hospital_name,last_updated_on,version,location_name,hospital_address,license_number|GA,type_2_npi,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",attester_name,,,,,,,,,,,,,,,,,,,
"Piedmont Columbus Regional - Northside",2026-04-01,3.0.0,"Piedmont Columbus Regional - Northside","100 Frist Court, Columbus, GA 31909",106-659,1407082308,TRUE,"Carey Kawano",,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,payer_name,plan_name,modifiers,standard_charge|negotiated_dollar,standard_charge|negotiated_percentage,standard_charge|negotiated_algorithm,median_amount,10th_percentile,90th_percentile,count,standard_charge|min,standard_charge|max,standard_charge|methodology,additional_generic_notes
"GLIDESHEATH SLENDER SS KIT, 0.021 GW, 7 FR, 10CM",SUP-80-1070,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"FIRST HEALTH [10303]","First Health",,356.4,80,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STARTER VASCULAR 150CM 15CM .035IN PTFE HEPARIN NEWTON",SUP-49-181,CDM,C1769,HCPCS,0272,RC,,,both,,,83.96,25.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ENDEAVOR SPRINT 15MM 142CM 3.5MM CORONARY STENT",SUP-ENSP35015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]","Cigna Open Access",,3154.54,56.9,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM BOVINE PERICARDIUM LEAFLET COBALT CHROMIUM",SUP-11400M25,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"BLUE CROSS [10001]","Blue Cross HMO",,17781.12,39.2,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UREA 15 GRAM ORAL POWDER PACKET",RX-179206,CDM,,,0250,RC,62530-0000-11,NDC,both,1,UN,27.36,8.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11.24,41.1,,,,,0,3.18,23.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAC-LOC 40CM 8CM 14FR DRNG ULTRATHANE HYDROPHILIC",SUP-G09500,CDM,C1729,HCPCS,0272,RC,,,both,,,801.82,240.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,93.25,681.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 30MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0312,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross PPO",,371.5,39.2,,957.42,570.23,957.42,28,110.22,805.55,"percent of total billed charges",
"FAT EMULSION 20 % IV RATE BASED",RX-40840048,CDM,,,0250,RC,00264-4460-10,NDC,both,500,ML,206.23,61.87,"AETNA [10100]","Aetna HMO/PPO",,163.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.98,175.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DAC 044 115CM",SUP-90760,CDM,S27200284,LOCAL,0272,RC,,,both,,,9626.67,2888,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1119.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1119.58,8182.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 15CC FINE FROZEN 1-4MM LATEX FREE",SUP-800113,CDM,S27800098,LOCAL,0278,RC,,,both,,,2614.50,784.35,"FIRST HEALTH [10303]","First Health",,2091.6,80,,,,,0,304.07,2222.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT TAPERED COMPONENT",SUP-G47481,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11935.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DEBAKEY ATRAUMATA 9.5INX2MM DISSECT STERILE",SUP-FB404R,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.96,80.99,"CIGNA [10200]",Cigna,,183.57,68,,,,,0,31.4,229.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP EASY LOAD DESIGN LOCK HANDLE SAFELY INSRT 3CM",SUP-KC-RUMI-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,135.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM AVENIR HELICAL 10 FINISH STERILE",SUP-10HFN-03004,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7033.31,68,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION",RX-7318,CDM,,,0250,RC,00264-5804-00,NDC,both,1000,ML,100.65,30.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,41.37,41.1,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 40MM 120MM 10MM .035IN VASCULAR VENOUS CATH",SUP-VENUL10040,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"KAISER [10500]",Kaiser,,14773.5,67,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MIDI 6 1/8-9IN OSTOMY 2 LAYER 2 SPOUT OUTLET CUT TO",SUP-14060,CDM,S27200284,LOCAL,0272,RC,,,both,,,295.63,88.69,"CIGNA [10200]","Cigna Local Plus",,158.16,53.5,,,,,0,34.38,251.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 65CM GUIDING PINNACLE DESTINATION",SUP-RSP04,CDM,C1887,HCPCS,0272,RC,,,both,,,769.50,230.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COENZYME Q10  50 MG CAPSULE",RX-35228,CDM,,,0637,RC,40093-0102-32,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC",082,MS-DRG,,,,,,,inpatient,,,77613.92,23284.18,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,30482.1,,"Case rate ($14,177.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,164.97, add-ons for qualifying new technology services are included. If operating cost exceeds $46,204.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,377.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,182.38. The transfer operating threshold is the transfer adjustment factor * $13,164.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $995.34. The transfer capital threshold is the transfer adjustment factor * $995.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,57000.58,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UHC [10700]","United Healthcare",,8298.63,63.3,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 100MM 120CM 7MM VASCULAR NICKEL",SUP-EVD35-07-100-120,CDM,C1876,HCPCS,0278,RC,,,both,,,7035.00,2110.5,"CIGNA [10200]",Cigna,,4783.8,68,,,,,0,818.17,5979.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006175282190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]","Cigna Local Plus",,676.98,,,,,,,147.16,1075.57,"percent of total billed charges",
"SET SPINAL IMPACTOR EJECTOR HOLDER SPINE CERVICAL ANTERIOR 7",SUP-11362,CDM,S27200284,LOCAL,0272,RC,,,both,,,2536.20,760.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,300.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,294.96,2155.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC",059,MS-DRG,,,,,,,inpatient,,,51090.24,15327.07,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,15673.41,,"Case rate ($7,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,147.54, add-ons for qualifying new technology services are included. If operating cost exceeds $40,187.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,922.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,156.99. The transfer operating threshold is the transfer adjustment factor * $7,147.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.39. The transfer capital threshold is the transfer adjustment factor * $540.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,30946.81,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC STATSEAL LARGE DISC POTASSIUM FERRATE",SUP-DL616,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"CIGNA [10200]",Cigna,,177.48,68,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4.1CM 5-3MM TORNADO SOFT .035IN STD SMALL",SUP-G10415,CDM,S27200284,LOCAL,0272,RC,,,both,,,730.54,219.16,"NOVANET [10819]",Novanet,,547.91,75,,,,,0,84.96,620.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 5.5MM EXPEDIUM PREBENT TITANIUM LINE",SUP-179771055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM ORTHOLOC FULL THREAD MIDFOOT CORTICAL 3",SUP-58803522,CDM,C1713,HCPCS,0278,RC,,,both,,,1506.60,451.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,175.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",175.22,1280.61,"percent of total billed charges",
"SPACER ALLOGRAFT C-ACS 11MMX14MM 6DEG 7MM",SUP-4W7407,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4692,68,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 22FR SILICONE MIC RADIOPAQUE FEED TUBE",SUP-8250-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"PHCS [10601]",PHCS,,1226.72,70,,,,,0,203.81,1489.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 36CM 4.8MM SOLID LAPAROSCOPIC",SUP-E2770-36,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.93,90.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,35.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35,255.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Bio-Med Multi-Stage 21f",PX-E27200396,CDM,E27200396,LOCAL,0272,RC,,,both,,,2162.60,648.78,"UHC [10700]","United Healthcare",,1368.93,63.3,,,,,0,251.51,1838.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 1.8MM Q-FIX MINI DISPOSABLE",SUP-72290125,CDM,S27200284,LOCAL,0272,RC,,,both,,,1385.10,415.53,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,569.28,41.1,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PYRIDOSTIGMINE BROMIDE 60 MG TABLET, IMMEDIATE RELEASE",RX-11239,CDM,,,0637,RC,00904-6622-61,NDC,both,1,UN,8.11,2.43,"CIGNA [10200]","Cigna Open Access",,4.61,56.9,,,,,0,0.94,6.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEPARATOR SURGICAL 7IN HORSLEY DURA STAINLESS STEEL",SUP-285325,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.34,73,"FIRST HEALTH [10303]","First Health",,194.67,80,,,,,0,28.3,206.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICS BALL BURR",SUP-110135,CDM,S27200284,LOCAL,0272,RC,,,both,,,578.34,173.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,237.7,41.1,,,,,0,67.26,491.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL SHAFT ALLOGRAFT FROZEN 200MM 10+ MM",SUP-450450,CDM,S27800098,LOCAL,0278,RC,,,both,,,11703.78,3511.13,"MULTIPLAN [10600]",Multiplan,,9948.21,85,,,,,0,1361.15,9948.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE 15IN 8FR UMBILICAL PVC NEONATE LUER LOCK HUB",SUP-8888160374,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.16,84.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,33.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.7,238.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC",083,MS-DRG,,,,,,,inpatient,,,49841.68,14952.5,"UHC [10700]","United Healthcare",,34809.86,,"Fee schedule rate ($34,809.86). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,34809.86,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 16MM 144CM 2.25MM CORONARY STENT",SUP-H7493952816220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]",Cigna,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X22X8MM RISE-L 6D NONSTERILE",SUP-193.422,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4068.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 130CM 150MM 5MM BALLOON DILATATION",SUP-LX3513051505F,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1001.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 12MM 140CM 3MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927412300,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE WIDE ACU-LOC 2 BONE RIGHT VOLAR DISTAL RADIAL",SUP-70-0361,CDM,C1713,HCPCS,0278,RC,,,both,,,5019.00,1505.7,"NOVANET [10819]",Novanet,,3764.25,75,,,,,0,583.71,4266.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 20MM 6FR 8MM .018IN BALLOON",SUP-39031-80201,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL 2MR CO2 O2 HIGH HUMIDITY SAMPLING LINE ADULT",SUP-704-3837-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,127.18,38.15,"CIGNA [10200]",Cigna,,86.48,68,,,,,0,14.79,108.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC",142,MS-DRG,,,,,,,inpatient,,,82442.56,24732.77,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,10199.64,,"Case rate ($9,902.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,195.20, add-ons for qualifying new technology services are included. If operating cost exceeds $42,234.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,077.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,207.36. The transfer operating threshold is the transfer adjustment factor * $9,195.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.20. The transfer capital threshold is the transfer adjustment factor * $695.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.",,,,0,9902.56,61871,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE GT VASCULAR STRAIGHT 180CM 25CM .018IN",SUP-RG*ES1818SA,CDM,C1887,HCPCS,0272,RC,,,both,,,1445.85,433.75,"MULTIPLAN [10600]",Multiplan,,1228.97,85,,,,,0,168.15,1228.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 59MM 80CM 8MM THIN VASCULAR COCR",SUP-1012624-59,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"BLUE CROSS [10001]","Blue Cross PPO",,3292.8,39.2,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 15.5X16CM 775CC STYLE 410FX HIGHLY COHESIVE",SUP-FX-410775,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"NOVANET [10819]",Novanet,,4173.75,75,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 80MM LCP DHHS STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.225,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"CIGNA [10200]","Cigna Open Access",,496.84,56.9,,1144.80,304.56,2275.09,66,101.55,742.2,"percent of total billed charges",
"STENT ZIPWIRE 20CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175260070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"BLUE CROSS [10001]","Blue Cross PPO",,390.99,39.2,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 5MM ENDOPATH XCEL BLADELESS",SUP-2B5LT,CDM,S27200284,LOCAL,0272,RC,,,both,,,919.46,275.84,"CIGNA [10200]","Cigna Open Access",,523.17,56.9,,,,,0,106.93,781.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175260070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"KAISER [10500]",Kaiser,,668.28,67,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM SEMIRIGID OPEN ANTERIOR SEG SEWING",SUP-5300M26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"BLUE CROSS [10001]","Blue Cross HMO",,5409.6,39.2,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 22CM 3CM 6FR .038IN 2",SUP-M006192131170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"MULTIPLAN [10600]",Multiplan,,1185.95,85,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTATIC  AGENT ARISTA ENT APPLICATOR",SUP-ENT00012,CDM,S27200284,LOCAL,0272,RC,,,both,,,899.91,269.97,"CIGNA [10200]","Cigna Local Plus",,481.45,53.5,,,,,0,104.66,764.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Connecting Drainage Bag",PX-E27200220,CDM,E27200220,LOCAL,0272,RC,,,both,,,79.20,23.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.55,41.1,,,,,0,9.21,67.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 40MM 4FR 5MM .018IN BALLOON",SUP-PCP050040130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 18CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192115010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"MULTIPLAN [10600]",Multiplan,,1020.49,85,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 21MM 19.6MM REGENT PYROLYTIC CARBON PTFE",SUP-21AGN-751,CDM,S27800098,LOCAL,0278,RC,,,both,,,31229.42,9368.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12835.29,41.1,,,,,0,3631.98,26545.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEARTRAIL III 100CM 6FR IL3.75 CURVE GUIDING PTFE",SUP-40-6377,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,67.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,inpatient,,,21091.49,6327.45,"BLUE CROSS [10001]","Blue Cross PPO",,19211.46,,,,,,,4827.22,19407.53,"case rate",
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,inpatient,,,84004.15,25201.24,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,11040.46,,"Case rate ($10,718.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,953.22, add-ons for qualifying new technology services are included. If operating cost exceeds $42,992.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,134.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,966.38. The transfer operating threshold is the transfer adjustment factor * $9,953.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.51. The transfer capital threshold is the transfer adjustment factor * $752.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,50450.69,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM 8MM RUBY POD COMPLEX OCCULUSION",SUP-RBYPOD8,CDM,S27800098,LOCAL,0278,RC,,,both,,,11661.00,3498.3,"NOVANET [10819]",Novanet,,8745.75,75,,,,,0,1356.17,9911.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 8MM NATURAL LORDOTIC CORTICOCANCELLOUS",SUP-018408,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 18 X 14 X 06MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-181406-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"FIRST HEALTH [10303]","First Health",,4968,80,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET HELICAL ULTRA 2 MM X 6 CM",SUP-M0035432060,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1065.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 200MM 5MM BALLOON DILATATION",SUP-PCU050200130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PHCS [10601]",PHCS,,861.84,70,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STAPLER ENDO GIA TRI-STAPLE TITANIUM 3 MM 3.5 MM 4 MM",SUP-SIGTRSB60AXT,CDM,S27200284,LOCAL,0272,RC,,,both,,,3079.43,923.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1265.65,41.1,,,,,0,358.14,2617.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM 11/13 TAPER 36MM HIP MODULAR BIOLOX DELTA",SUP-136536220,CDM,C1776,HCPCS,0278,RC,,,both,,,7290.36,2187.11,"MULTIPLAN [10600]",Multiplan,,6196.81,85,,,,,0,847.87,6196.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET HELICAL ULTRA 2 MM X 6 CM",SUP-M0035432060,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6227.22,68,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"175-260MM 9.0 -11.0 MM DIAM FLEXIGRAFT DUALLINK PRESUTURED T",SUP-FDL,CDM,S27800098,LOCAL,0278,RC,,,both,,,16487.14,4946.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6776.21,41.1,,,,,0,1917.45,14014.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7608,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Open Access",,3926.1,56.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3.5CM 2.5MM CEREPAK MINI FREEFORM",SUP-MCR092535,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"KAISER [10500]",Kaiser,,8861.32,67,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 800ML STYLE 7200 MEDIUM HEIGHT CENTERSCOPE",SUP-354-7216,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"FIRST HEALTH [10303]","First Health",,8280,80,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE GASTROSTOMY 14FR L1.5CM EXTENSION SET MIC-KEY ENFIT",SUP-8140-14-1.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"AETNA [10100]","Aetna HMO/PPO",,619.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 45MM 6.5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ145,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"BLUE CROSS [10001]","Blue Cross PPO",,3538.98,39.2,,3949.44,3949.44,3949.44,"1 through 10",1049.96,7673.8,"percent of total billed charges",
"STYLET PACING 59CM TAPERED",SUP-6543,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM TIMAX FULL THREAD CORTICAL ELBOW",SUP-815037022,CDM,S27200284,LOCAL,0272,RC,,,both,,,789.75,236.92,"KAISER [10500]",Kaiser,,529.13,67,,,,,0,91.85,671.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 38MM 144CM 3MM CORONARY STENT EVEROLIMUS",SUP-H7493926138300,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3544.88,41.1,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC",714,MS-DRG,,,,,,,inpatient,,,71757.27,21527.18,"UHC [10700]","United Healthcare",,30871.85,,"Fee schedule rate ($30,871.85). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,6559.11,30871.85,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 5.5CM 4FR CHECK-FLO PERFORMER MICROPUNCTURE .018IN",SUP-G27022,CDM,C1894,HCPCS,0272,RC,,,both,,,326.16,97.85,"FIRST HEALTH [10303]","First Health",,260.93,80,,,,,0,37.93,277.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCRYL RAPIDE 30MM 8MM ACL BIOABSORBABLE",SUP-231815,CDM,C1713,HCPCS,0278,RC,,,both,,,2349.00,704.7,"BLUE CROSS [10001]","Blue Cross HMO",,920.81,39.2,,957.42,156.86,7483.26,51,273.19,1996.65,"percent of total billed charges",
"SABER .035 3X120 135CM SL",SUP-48003012R,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"KAISER [10500]",Kaiser,,668.06,67,,,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 10 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION",RX-9809,CDM,,,0250,RC,00264-7622-00,NDC,both,1000,ML,100.65,30.19,"FIRST HEALTH [10303]","First Health",,80.52,80,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 21GA 3FR MERIT PAK .018IN 40CM MINI PEDAL",SUP-PAKM4NPD4,CDM,C1894,HCPCS,0272,RC,,,both,,,389.06,116.72,"AETNA [10100]","Aetna HMO/PPO",,309.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.25,330.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL COALITION ANTERIOR CERVICAL DISCECTOMY AND",SUP-384.106,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"CIGNA [10200]",Cigna,,7200,40,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS CORTICAL 30ML CRUSH 1-3MM",SUP-110130,CDM,S27800098,LOCAL,0278,RC,,,both,,,2483.25,744.97,"NOVANET [10819]",Novanet,,1862.44,75,,,,,0,288.8,2110.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X100 40CM SL",SUP-48005010P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"MULTIPLAN [10600]",Multiplan,,834.81,85,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 60MM 3MM .035IN BALLOON DILATATION NYBAX",SUP-39171-03067,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,853.74,68,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6.5FR 37CM LIEBERMAN MODIFICATION RADIOPAQUE",SUP-G12762,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 40MM 6MM BALLOON DILATATION HYDROPHILIC",SUP-606004022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"UHC [10700]","United Healthcare",,461.46,63.3,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 110CM 4FR .042IN 155D 9MM PIGTAIL",SUP-538455S,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,60.87,68,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE CHECKER 130CM 10CM 3MM BALLOON DILATATION",SUP-U8130310,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAYONET 9IN STR TIP DN621",SUP-DN6218,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"NOVANET [10819]",Novanet,,1215,75,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 20CM 5MM BALLOON DILATATION OTW LOW",SUP-G30903,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 80MM 10MM BALLOON DILATATION DURALYN",SUP-48010008S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR CODMAN MICROSENSOR METAL",SUP-626638US,CDM,C1729,HCPCS,0272,RC,,,both,,,9701.40,2910.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1149.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1128.27,8246.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2MM AXIUM PRIME HELIX DETACHABLE EXTRA",SUP-APB-2-3-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2557.34,28.62,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 120MM 5MM BILIARY SELF EXPANDING",SUP-SC5120L,CDM,C1876,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 2.25MM ULTRA LOW PROFILE BALLOON",SUP-1012404-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 5CM 7FR PIGTAIL PANCREATIC POLYMER RADIOPAQUE",SUP-M00537240,CDM,C2617,HCPCS,0278,RC,,,both,,,722.28,216.68,"BLUE CROSS [10001]","Blue Cross PPO",,283.13,39.2,,,,,0,84,613.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAXI LD 80CM 40MM 14MM BALLOON DILATATION DURALYN OTW 1",SUP-4171440S,CDM,C1725,HCPCS,0272,RC,,,both,,,1620.00,486,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12.5IN 15FR CORONARY SINUS ADULT RETROGRADE",SUP-94725,CDM,S27200284,LOCAL,0272,RC,,,both,,,793.01,237.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,363.99,45.9,,,,,0,92.23,674.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION 2 LUMEN OTW LOW PROFILE OPTA PRO",SUP-4196040X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 9MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140914,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]","Cigna Local Plus",,3742.77,31.5,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 300MM 3.5MM BALLOON DILATATION RAPID",SUP-47535300S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,832.28,41.1,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 1MM REUTER BOBBIN FLUOROPLASTIC LARGE LUMEN",SUP-145212-ENT,CDM,S27800098,LOCAL,0278,RC,,,both,,,69.93,20.98,"NOVANET [10819]",Novanet,,52.45,75,,,,,0,8.13,59.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X20MM COLOSSEUM 14MM MESH NONSTERILE LATEX",SUP-156.505,CDM,S27800098,LOCAL,0278,RC,,,both,,,28343.70,8503.11,"NOVANET [10819]",Novanet,,21257.78,75,,,,,0,3296.37,24092.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLI KIT SSL6 SAFESHEATH II 6FR 23CM",SUP-SSL6,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4.5MM 16MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.816,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"CIGNA [10200]","Cigna Open Access",,142.77,56.9,,1144.80,304.56,2275.09,66,29.18,213.27,"percent of total billed charges",
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 30MM 190CM 2MM",SUP-R51002003L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG WOUND 5X4IN URGOCLEAN AG SILVER ANTIMICROBIAL",SUP-603071,CDM,A6197,HCPCS,0272,RC,,,both,,,80.48,24.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.08,41.1,,,,,0,9.36,68.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 75CM 2CM 10MM BALLOON DILATATION PERIPHERAL",SUP-CQ75102,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATHETER 23CM 14FR 22GA BLUE FLEXTIP .035IN STRAIGHT PER",SUP-AK-01601,CDM,C1729,HCPCS,0272,RC,,,both,,,1085.40,325.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,128.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,126.23,922.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 12MM 3.25MM BALLOON DILATATION",SUP-H7493912412320,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Prep Fecal Microbiota Instill",PX-750000119,CDM,44705,CPT,0750,RC,,,both,,,669.23,200.77,"CIGNA [10200]","Cigna Open Access",,669.23,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,77.83,669.23,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,EXTREME",651,APR-DRG,,,,,,,inpatient,,,232974.11,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $28,390.55. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($146,266.86) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +1.5 CYL TORIC ACRYSOF IQ VIVITY",SUP-DFT315,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,100.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION",RX-179846,CDM,,,0250,RC,46287-0020-20,NDC,both,5,ML,179.80,53.94,"CIGNA [10200]","Cigna Open Access",,102.31,56.9,,,,,0,20.91,152.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENDOMAXX 100MM 90CM 19MM 24FR ESOPHAGEAL SILICONE",SUP-MAXX-1910,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]",Cigna,,6900,40,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 TWINFIX ULTRA COBRAID PEEK-OPTIMA STERILE",SUP-72202599,CDM,C1713,HCPCS,0278,RC,,,both,,,1724.63,517.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,791.61,45.9,,,,,0,200.57,1465.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE XS RIGID ROCKER SOLE HIGH ANKLE STRAP",SUP-79-81232,CDM,S27000186,LOCAL,0270,RC,,,both,,,53.59,16.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,36.44,68,,,,,0,6.23,45.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE 4 % TOPICAL PATCH",RX-112961,CDM,,,0250,RC,46581-0830-06,NDC,both,1,UN,13.62,4.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5.6,41.1,,,,,0,1.58,11.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE UBER FLEX 40MM 57CM 10MM .078IN VASCULAR",SUP-SR-1040-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT THORACENTESIS 7.5IN 8FR 18GA ARROW-CLARKE PLEURA-SEAL",SUP-AK-01000,CDM,C1729,HCPCS,0272,RC,,,both,,,385.41,115.62,"NOVANET [10819]",Novanet,,289.06,75,,,,,0,34.59,327.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 32MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-032,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5737.72,27,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 18IN BRAID TIE 12 STRAND PRECUT",SUP-A185H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 34X11MM HEDRON IA 8D 26MM STERILE LATEX FREE",SUP-1212.0611S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"FIRST HEALTH [10303]","First Health",,27720,80,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 5.5MM EXPEDIUM TITANIUM LINE PREBENT",SUP-179771045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"HC Dressing Wound Combiderm",PX-E27200107,CDM,E27200107,LOCAL,0272,RC,,,both,,,74.80,22.44,"CIGNA [10200]","Cigna Open Access",,42.56,56.9,,,,,0,8.7,63.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM 39.6MM 31.9MM MITRAL TRICUSPID 3D",SUP-460032MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"CIGNA [10200]",Cigna,,7741.8,68,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 64CM ENDOTAK RELIANCE ENDOCARDIUM 4 SITE 2 COIL",SUP-266,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"NOVANET [10819]",Novanet,,11385,75,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COALESCE 10X28X12MM STRAIGHT LORDOT",SUP-2000-00-101208,CDM,C1889,HCPCS,0278,RC,,,both,,,21420.00,6426,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5783.4,27,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR HEMI 3HL 54MM",SUP-430-98-054,CDM,C1776,HCPCS,0278,RC,,,both,,,16956.34,5086.9,"CIGNA [10200]",Cigna,,6782.54,40,,5873.17,5873.17,5873.17,"1 through 10",1972.02,14412.89,"percent of total billed charges",
"PASSER SURGICAL 60CM CATH STERILE LATEX FREE DISPOSABLE",SUP-8591-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,416.14,41.1,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE PHALANX 1.5",SUP-PRT-PHX-015,CDM,C1713,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,850.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",834.57,6099.6,"percent of total billed charges",
"SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE",RX-7319,CDM,,,0250,RC,64253-0111-30,NDC,both,10,ML,27.56,8.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.21,23.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 24FR POWERBALL UROLOGY ACMI CLASSIC",SUP-M0068802511,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"CIGNA [10200]","Cigna Local Plus",,255.85,53.5,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADMIN 150UM ASSORTED DEHP FREE FILTER SYR ALIQUOT SYSTEM",SUP-0396000F,CDM,S27200284,LOCAL,0272,RC,,,both,,,105.97,31.79,"CIGNA [10200]",Cigna,,72.06,68,,,,,0,12.32,90.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 31MMX12MMX15CM 22FR",SUP-TAC123115A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"MULTIPLAN [10600]",Multiplan,,155040,85,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 5CM MIDAS REX MR8 2MM BALL DISSECTING DIAMOND LP",SUP-MR8-LP05BA20D,CDM,S27200284,LOCAL,0272,RC,,,both,,,2179.13,653.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,258.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,253.43,1852.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.824,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,108.62,45.9,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 40MM 5MM VASCULAR DRUG ELUTE ACCEPTS .035IN",SUP-G38404,CDM,C1874,HCPCS,0278,RC,,,both,,,8114.33,2434.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,961.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,943.7,6897.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)MARKER SKIN PINK 5CM 15GA SMARTCLIP LITE 3-4MM SOFT TI",SUP-SMARTCLIPLT-PNK-5,CDM,A4648,HCPCS,0278,RC,,,both,,,2625.00,787.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175264190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 10.2CM .4MM JEWELERS IRIS CURVED STRAIGHT",SUP-14-1080,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,75.09,41.1,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 28CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155234180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,,,,,,,189.34,1383.8,"percent of total billed charges",
"ENV ABSORBABLE MEDIUM 2.7X2.5IN POLYARYLATE MINOCYCLINE",SUP-NMRM6122,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"BLUE CROSS [10001]","Blue Cross PPO",,2420.8,39.2,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 8MM 145CM 3.25MM CORONARY STENT",SUP-1125325-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross PPO",,2288.5,39.2,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMT BRIDLE PRO- 18 FR",SUP-4-4218,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"PHCS [10601]",PHCS,,498.96,70,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CHAMPIONIR DES SYSTEM US 6-120",SUP-412601200USRD,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 135CM 2CM 5FR 7MM 7.5MM BALLOON DILATATION",SUP-4207020X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 8MM 145CM 3.25MM CORONARY STENT",SUP-1125325-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23X9X11MM COALESCE LORDOTIC STRAIGHT STERILE",SUP-2000-00-091108,CDM,C1889,HCPCS,0278,RC,,,both,,,21420.00,6426,"PHCS [10601]",PHCS,,14994,70,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL 2.4MM HELIOCOID DISPOSABLE STERILE LATEX FREE",SUP-1608-002-103,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC",241,MS-DRG,,,,,,,inpatient,,,58839.08,17651.72,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,18463.15,,"Case rate ($8,587.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,974.09, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,984.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $7,984.64. The transfer operating threshold is the transfer adjustment factor * $7,974.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $602.88. The transfer capital threshold is the transfer adjustment factor * $602.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,40418.94,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN EXTERNAL FIXATION 40MM 6MM JET-X LONG TITANIUM NITRIDE",SUP-71066409,CDM,C1887,HCPCS,0272,RC,,,both,,,2153.25,645.97,"UHC [10700]","United Healthcare",,1363.01,63.3,,,,,0,250.42,1830.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Skin & Sq Tiss<=20scm",PX-510000007,CDM,11042,CPT,0761,RC,,,both,,,4376.70,1313.01,"KAISER [10500]",Kaiser,,2932.39,67,,,,,0,509.01,4376.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 ULTRA 5MM X 10CM",SUP-M0035425100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"NOVANET [10819]",Novanet,,10585.98,75,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2.5 X 4 HELICAL PICO COIL",SUP-10USH02504,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Local Plus",,3692.78,31.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIZISHOT 2 NEEDLE 22GA",SUP-NA-U401SX-4022-A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1096.09,68,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHEMOTHERAPY FOR ACUTE LEUKEMIA,MAJOR",695,APR-DRG,,,,,,,inpatient,,,22352.68,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $15,731.25. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($93,149.77) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 7FR 10MM SPACING S CURVE ATRIUM BIPOLAR",SUP-1944/52,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"NOVANET [10819]",Novanet,,1674.38,75,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC",352,MS-DRG,,,,,,,inpatient,,,73673.29,22101.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP 45CM 10MM WECK HEM-O-LOK ENDO10 XL POLYMER 1 PIECE",SUP-544990L,CDM,S27200284,LOCAL,0272,RC,,,both,,,18893.70,5668.11,"CIGNA [10200]","Cigna Open Access",,10750.52,56.9,,,,,0,2197.34,16059.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK,MAJOR",171,APR-DRG,,,,,,,inpatient,,,130477.03,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $13,450.25. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($68,274.95) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SUCTION ORCAPOD ORCA SEAL AIR WATER SILICONE FREE",SUP-SUV-629-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.20,24.06,"UHC [10700]","United Healthcare",,50.77,63.3,,,,,0,9.33,68.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC",352,MS-DRG,,,,,,,inpatient,,,73673.29,22101.99,"AETNA [10100]","Aetna HMO/PPO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GS 90, 80 CM, STRAIGHT, DISTAL",SUP-GS9080SD,CDM,C1887,HCPCS,0272,RC,,,both,,,3573.98,1072.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,415.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,415.65,3037.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION BARDEX LUBRICATH STATLOCK 16FR 350ML",SUP-304916,CDM,C1729,HCPCS,0272,RC,,,both,,,181.92,54.58,"UHC [10700]","United Healthcare",,115.16,63.3,,,,,0,21.16,154.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIRE RETINAL 2.5MM GROOVE CONCAVE SILICONE 9MM 7MM",SUP-S2999,CDM,S27800098,LOCAL,0278,RC,,,both,,,156.91,47.07,"BLUE CROSS [10001]","Blue Cross HMO",,61.51,39.2,,,,,0,18.25,133.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR HEAD AND NECK PROCEDURES WITH MCC",140,MS-DRG,,,,,,,inpatient,,,172534.24,51760.27,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,28309.97,,"Case rate ($26,457.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $24,567.97, add-ons for qualifying new technology services are included. If operating cost exceeds $57,607.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,239.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $24,600.46. The transfer operating threshold is the transfer adjustment factor * $24,567.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,857.46. The transfer capital threshold is the transfer adjustment factor * $1,857.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,7561,124529.7,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"RITONAVIR 100 MG TABLET",RX-100995,CDM,,,0637,RC,00054-0407-13,NDC,both,1,UN,35.00,10.5,"UHC [10700]","United Healthcare",,22.16,63.3,,,,,0,4.07,29.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MELATONIN 3 MG TABLET",RX-16830,CDM,,,0637,RC,20555-0036-00,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]",Cigna,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 6946M62 DUAL COIL PSSV DF4 QUATTRO",SUP-6946M62,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]","Cigna Open Access",,5752.62,33.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE 2 MG/ML INTRAVENOUS SYRINGE",RX-166018,CDM,J2270,HCPCS,0636,RC,00409-1890-01,NDC,both,1,ML,115.79,34.74,"MULTIPLAN [10600]",Multiplan,,98.42,85,,,,,0,2.54,98.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VICI VENOUS STENT 90MM 100MM 14MM ENDOPROSTHESIS",SUP-H74914090100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"UHC [10700]","United Healthcare",,8298.63,63.3,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 40MM COMPREHENSIVE 3.5MM SHOULDER VARIABLE",SUP-180562,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"BLUE CROSS [10001]","Blue Cross PPO",,609.95,39.2,,957.42,570.23,957.42,28,180.96,1322.6,"percent of total billed charges",
"KIT INSTR ACL HALL SAW BLADE DISPOSABLE TRANSTIBIAL",SUP-AR-1897S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1771.88,531.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,813.29,45.9,,,,,0,206.07,1506.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 36MM LCP STAINLESS STEEL CORTIEX PERIARTICULAR",SUP-02.204.036,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"KAISER [10500]",Kaiser,,661.01,67,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR 36CM 13-15FR ACCESS STAINLESS STEEL",SUP-M0062502091,CDM,C1894,HCPCS,0272,RC,,,both,,,815.04,244.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.79,692.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13177545,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,957.42,156.86,7483.26,51,348.9,2550,"percent of total billed charges",
"CAGE SPINAL 32X9X11MM COROENT 4D PEEK LARGE IMPACT",SUP-6711932,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA [10200]",Cigna,,6624,40,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 65CM 25CM 5FR .047IN COBRA 2",SUP-CG502,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOVIVE PLUS 15.0CC",SUP-203215,CDM,C1713,HCPCS,0278,RC,,,both,,,27090.00,8127,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11133.99,41.1,,,,,0,3150.57,23026.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH-PROFILE BOOST, 260CC",SUP-SMHB260,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5184.66,68,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 650CC",SUP-SSZ-F650,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,173.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X8MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7308,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"MULTIPLAN [10600]",Multiplan,,5865,85,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 16X3MM COLOSSEUM 0D 14MM NONSTERILE LATEX",SUP-156.553,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"CIGNA [10200]","Cigna Open Access",,1958.78,56.9,,,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 80MM 6MM BALLOON DILATATION DURALYN",SUP-48006008S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"NOVANET [10819]",Novanet,,941.63,75,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEVATOR SURGICAL L7 1/2IN TIP 6.5MM PERIOSTEAL SHARP/BLUNT",SUP-55-7026,CDM,S27200284,LOCAL,0272,RC,,,both,,,168.35,50.5,"NOVANET [10819]",Novanet,,126.26,75,,,,,0,19.58,143.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 4.0/20",SUP-434896,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"BLUE CROSS [10001]","Blue Cross HMO",,7742.2,39.2,,9776.84,9776.84,9776.84,"1 through 10",2296.98,16787.93,"percent of total billed charges",
"SPACER SPINAL 37X27X18MM 12D MEDIUM",SUP-7968218,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"CIGNA [10200]","Cigna Local Plus",,10796.81,31.5,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 100X14-18MM",SUP-400750,CDM,S27800098,LOCAL,0278,RC,,,both,,,4868.64,1460.59,"BLUE CROSS [10001]","Blue Cross HMO",,1908.51,39.2,,,,,0,566.22,4138.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SLEEP PNUEMO-OPT UPAT",SUP-AC2101300,CDM,S27200284,LOCAL,0272,RC,,,both,,,355.25,106.57,"AETNA [10100]","Aetna HMO/PPO",,282.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.32,301.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACURATE PRIME LOADING KIT XL",SUP-SYM-AC-009-C,CDM,S62400003,LOCAL,0624,RC,,,both,,,9660.00,2898,"NOVANET [10819]",Novanet,,7245,75,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 210500 SELECT 5MM SRVC FEE",SUP-210500,CDM,S27800098,LOCAL,0278,RC,,,both,,,3018.75,905.62,"AETNA [10100]","Aetna HMO/PPO",,2399.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,351.08,2565.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 120MM 28-14MM 13FR TRIVASCULAR OVATION PRIME",SUP-TV-IL1428120-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"AETNA [10100]","Aetna HMO/PPO",,26545.05,79.5,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRICATH 16FR STD URETHRAL NATURAL RUBBER HYDROGEL 5ML",SUP-0119L16,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.52,23.26,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.02,65.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 95X25MM 4 TONGUE DAVIS",SUP-45-5114,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.96,81.59,"PHCS [10601]",PHCS,,190.37,70,,,,,0,31.63,231.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 100MM 5MM BILIARY SELF EXPANDING",SUP-SC5100L,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6099.6,68,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASPIRATION NEEDLE, 5MMX42CM, 15 GAUGE NEEDLE 10/BOX",SUP-MY3015,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,89.39,41.1,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 10.25IN CARB-BITE RYDER INSRT NDL STAINLESS STEEL",SUP-121165,CDM,S27200284,LOCAL,0272,RC,,,both,,,626.45,187.93,"CIGNA [10200]","Cigna Local Plus",,335.15,53.5,,,,,0,72.86,532.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 13MM 140CM 3.5MM CORONARY STERILE LATEX",SUP-453935,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER BURR HOLE 13.5MM SPINE BENT",SUP-19-1019,CDM,C1713,HCPCS,0278,RC,,,both,,,1987.50,596.25,"KAISER [10500]",Kaiser,,1331.63,67,,,,,0,231.15,1689.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL 25CM END GRASPING TIP POSITIVE",SUP-705.43P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1279.31,383.79,"AETNA [10100]","Aetna HMO/PPO",,1017.05,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,148.78,1087.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG AUTOTRANSFUSION 400ML CARDIOPAT ORTHOPAT REPLACEMENT RBC",SUP-01200-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.68,40.4,"NOVANET [10819]",Novanet,,101.01,75,,,,,0,15.66,114.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,inpatient,,,30603.42,9181.03,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,6022.93,,"Case rate ($5,682.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,276.13, add-ons for qualifying new technology services are included. If operating cost exceeds $38,315.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,780.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,283.10. The transfer operating threshold is the transfer adjustment factor * $5,276.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.90. The transfer capital threshold is the transfer adjustment factor * $398.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,5682.01,22844.12,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 45MM 10MM 13FR 10FR TRIVASCULAR OVATION PRIME",SUP-TV-EX101045-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CIGNA [10200]",Cigna,,13356,40,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 4.0MM X 12.0MM",SUP-494001212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 18MM 140CM 2.25MM CORONARY STERILE",SUP-453943,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 1.7CM 14FR ENTERAL FEEDING TUBE RADIOPAQUE LOW",SUP-0120-14-1.7,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,92.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 25CM 9MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120925,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"NOVANET [10819]",Novanet,,8911.35,75,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 18CM 5FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552150,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,343.61,28.62,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENROUTE TRANSCAROTID STENT SYSTEM 6 X 40",SUP-SR-0640-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 15MM 135CM 5MM 8MM 7FR .035IN",SUP-BXA051502A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR RDC CURVE",SUP-G08578,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROYAL FLUSH 125CM 4FR .035IN PIGTAIL CURVE ANGIOGRAPHIC",SUP-G27864,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM 2.5MM SCR 1 LEVEL 1 STEP LOCK DYNATRAN BONE SPINE",SUP-48670114,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 12MM 144CM 2.5MM CORONARY STENT",SUP-H7493911412250,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3757.57,41.1,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 150CM 7FR .038IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145372170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,131.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 120CM 6MM 8FR STRAIGHT VASCULAR",SUP-AVSL06100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UHC [10700]","United Healthcare",,11564.91,63.3,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRESTIGE PLUS HELICAL PACK",SUP-PRES0615HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"CIGNA [10200]",Cigna,,4457.4,68,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.25/18",SUP-401747,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 19GA PREMARKED",SUP-SDAN2000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1294.38,388.31,"CIGNA [10200]","Cigna Local Plus",,692.49,53.5,,,,,0,150.54,1100.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 10MM2CM 190",SUP-R51010002L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,839.06,41.1,,,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 18MM .0145IN AXIUM PRIME 3D FRAME",SUP-FC-18-40-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"UHC [10700]","United Healthcare",,10460.64,63.3,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC THK1/16IN MEDIUM 7-8IN RIGHT THUMB CMC",SUP-92720503,CDM,S27000186,LOCAL,0270,RC,,,both,,,168.95,50.68,"UHC [10700]","United Healthcare",,106.95,63.3,,,,,0,19.65,143.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752720,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,414.1,45.9,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 80MM 2300MM 20MM 3.5MM ESOPHAGEAL NITINOL",SUP-ECBA-20-080-230,CDM,C1874,HCPCS,0278,RC,,,both,,,16425.45,4927.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6570.18,40,,,,,0,1910.28,13961.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADULT 14FT ETCO2 CANNULA ASSEMBLY WITH FITS-ALL AND REFLECTIVE",SUP-5114F-SE,CDM,S27000186,LOCAL,0270,RC,,,both,,,56.74,17.02,"PHCS [10601]",PHCS,,39.72,70,,,,,0,6.6,48.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 135CM 9MM 13MM 8FR .035IN",SUP-BXA092902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5266.3,27,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 12.5CM 3MM IBUR DISTAL BEND ROUND DIAMOND",SUP-8431-012-030D,CDM,S27200284,LOCAL,0272,RC,,,both,,,3045.45,913.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1251.68,41.1,,,,,0,354.19,2588.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 12MM 145CM 2.25MM CORONARY STENT",SUP-1145225-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]","Cigna Open Access",,3321.82,56.9,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X17MM LUMINARY 10-11MM SPINE",SUP-14717,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"FIRST HEALTH [10303]","First Health",,25200,80,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 160MM 12-14MM 12FR 10FR TRIVASCULAR OVATION",SUP-TV-IL1412160-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"KAISER [10500]",Kaiser,,22371.3,67,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 130MM 16MM REVERSE TRABECULAR METAL TIVANIUM",SUP-00434901613,CDM,C1776,HCPCS,0278,RC,,,both,,,17863.20,5358.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4823.06,27,,,,,0,2077.49,15183.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 3-0 PS-2 SPIRAL 60CM KNOTLESS",SUP-SXMP1B108,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"KAISER [10500]",Kaiser,,143.31,67,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 167MM 17MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-217,CDM,C1776,HCPCS,0278,RC,,,both,,,19885.95,5965.78,"NOVANET [10819]",Novanet,,14914.46,75,,,,,0,2312.74,16903.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 80MM 14MM 13FR 10FR TRIVASCULAR OVATION PRIME",SUP-TV-IL141480-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CIGNA [10200]","Cigna Local Plus",,10517.85,31.5,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM EVOLVE STAINLESS STEEL CORTICAL ELBOW",SUP-4973534L,CDM,C1713,HCPCS,0278,RC,,,both,,,1710.00,513,"FIRST HEALTH [10303]","First Health",,1368,80,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 4.75MM SOLERA COCR MOLYBDENUM CURVED",SUP-1475501045,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL CARMALT CURVE 9IN ARTERY CROSS SERRATE",SUP-16-3723,CDM,S27200284,LOCAL,0272,RC,,,both,,,643.06,192.92,"KAISER [10500]",Kaiser,,430.85,67,,,,,0,74.79,546.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUROFORM ATLAS STENT SYSTEM 4.0 X 21MM WITHOUT TIP ZERO (PM",SUP-M003UZAS40210,CDM,C1874,HCPCS,0278,RC,,,both,,,52885.22,15865.57,"CIGNA [10200]","Cigna Open Access",,17716.55,33.5,,,,,0,6150.55,44952.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 65MM 1.1MM WIRE PASS STERILE",SUP-1608002063,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 37MMX12MMX20CM 24FR",SUP-TAC123720A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"PHCS [10601]",PHCS,,127680,70,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL DURAL ADHERUS AUTOSPRAY LOW SWELL EXTENDED TIP",SUP-NUS-109,CDM,S27200284,LOCAL,0272,RC,,,both,,,5692.50,1707.75,"MULTIPLAN [10600]",Multiplan,,4838.63,85,,,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 8MM 145CM 3MM CORONARY STENT EVEROLIMUS",SUP-1145300-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross PPO",,2288.5,39.2,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR MYOSURE SEAL HYSTEROSCOPE OUTFLOW",SUP-40-902,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"CIGNA [10200]",Cigna,,53.24,68,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 32MM 144CM 2.75MM CORONARY STENT",SUP-H7493911432270,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2616.58,28.62,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SILVERHAWK MEC 110CM 6CM 3.5-5MM 2.7MM ATHERECTOMY",SUP-P4056,CDM,C1714,HCPCS,0272,RC,,,both,,,17955.00,5386.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7379.51,41.1,,,,,0,2088.17,15261.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 12MM 144CM 2.75MM CORONARY STENT",SUP-H7493952812270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Local Plus",,2977.28,53.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 42MM ENCORE",SUP-412-02-042,CDM,C1776,HCPCS,0278,RC,,,both,,,7338.63,2201.59,"KAISER [10500]",Kaiser,,4916.88,67,,,,,0,853.48,6237.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM 2MM CORONARY STENT BIOLINX",SUP-RONYX20008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LOCKING 4MM ASLS POLY RESORBABLE INNER THREAD SCR",SUP-08.025.032S,CDM,C1713,HCPCS,0278,RC,,,both,,,627.95,188.38,"CIGNA [10200]",Cigna,,427.01,68,,1831.33,1831.33,1831.33,16,73.03,533.76,"percent of total billed charges",
"BIT DRILL 2.5MM SOLID STERILE",SUP-829029070,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 20MM QUICKFIX TITANIUM T8 PARTIAL THREAD",SUP-AR-8724-20,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"FIRST HEALTH [10303]","First Health",,712.8,80,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN 125 MG CAPSULE",RX-11628,CDM,,,0637,RC,23155-0858-78,NDC,both,1,UN,15.39,4.62,"PHCS [10601]",PHCS,,10.77,70,,,,,0,1.79,13.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD XLNK BAR",SUP-6902530,CDM,C1713,HCPCS,0278,RC,,,both,,,745.20,223.56,"BLUE CROSS [10001]","Blue Cross HMO",,292.12,39.2,,957.42,156.86,7483.26,51,86.67,633.42,"percent of total billed charges",
"NIAGARA SINGLE USE GUIDEWIRE  1.7MM SS (QTY 1)",SUP-AC01-90064-G4,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.0MM X 24MM TI",SUP-VAN-20240-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"BLUE CROSS [10001]","Blue Cross PPO",,381.02,39.2,,957.42,570.23,957.42,28,113.04,826.2,"percent of total billed charges",
"SCR BONE 4.5MM 30MM EQUINOXE SHOULDER KIT COMPRESSION LOCK",SUP-320-20-30,CDM,C1713,HCPCS,0278,RC,,,both,,,648.00,194.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,297.43,45.9,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 6MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBH061502,CDM,C1874,HCPCS,0278,RC,,,both,,,23102.10,6930.63,"FIRST HEALTH [10303]","First Health",,18481.68,80,,,,,0,2686.77,19636.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 4CM 9MM BALLOON DILATATION",SUP-DR13594,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,565.95,41.1,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 45MM TITANIUM SPINE CORTICAL POLYAXIAL FIX",SUP-186727645,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"CATH STERLING SL 150CM 80MM 3.8FR 3MM BALLOON DILATATION OTW",SUP-H74939148308010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 2.25MM CORONARY RAPID EXCHANGE",SUP-ONYXNG22508UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA [10200]","Cigna Open Access",,1493.63,56.9,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 20MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"AETNA [10100]","Aetna HMO/PPO",,1139.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE 2 MG/ML INTRAVENOUS SYRINGE",RX-166018,CDM,J2270,HCPCS,0636,RC,00409-1890-01,NDC,both,1,ML,115.79,34.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.54,98.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP ENDOSCOPIC MANTIS TRUGRIP 235CM 2.8MM ANCHOR PRONG CLSR",SUP-M00521422,CDM,S27200284,LOCAL,0272,RC,,,both,,,2625.00,787.5,"CIGNA [10200]",Cigna,,1785,68,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 250MM 3.9-4.2FR 6MM BALLOON",SUP-PCU060250130,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"NOVANET [10819]",Novanet,,952.26,75,,,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS SURGICAL 20CM HARMONIC CURVE TIP ULTRASONIC",SUP-HAR1120,CDM,S27200284,LOCAL,0272,RC,,,both,,,3984.04,1195.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,463.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,463.34,3386.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARCTIC FRONT ADVANCE 95CM 23MM 10.5FR 28MM CRYOABLATION",SUP-2AF284,CDM,C2630,HCPCS,0272,RC,,,both,,,26460.00,7938,"KAISER [10500]",Kaiser,,17728.2,67,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.25MM X 8.0MM",SUP-493250812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 45MMX4.6MMX6.5CM 26F",SUP-TE4546A,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"MULTIPLAN [10600]",Multiplan,,53295,85,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 8MM 1MM BALLOON DILATATION PERCUTANEOUS",SUP-210-083-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"NOVANET [10819]",Novanet,,941.63,75,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 48MM 144CM 2.5MM CORONARY STENT",SUP-H7493941848250,CDM,C1874,HCPCS,0278,RC,,,both,,,5002.50,1500.75,"BLUE CROSS [10001]","Blue Cross PPO",,1960.98,39.2,,,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 14CM 3CM 4.8FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175197050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CIGNA [10200]","Cigna Local Plus",,572.85,,,,,,,124.53,910.13,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 12MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25012W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]","Cigna Open Access",,1920.38,56.9,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 9IN 10MM SENTINEL ROUND ECCENTRIC MONO FLUTE CUT",SUP-S8510,CDM,S27200284,LOCAL,0272,RC,,,both,,,1593.51,478.05,"AETNA [10100]","Aetna HMO/PPO",,1266.84,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.33,1354.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CHAMPIONIR DES SYSTEM US 6-60",SUP-412600600USRD,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEPIN NON-THREADED 2.5 X 200MM",SUP-MSG25200,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"PHCS [10601]",PHCS,,213.15,70,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 38MM 4MM CORONARY STENT EVEROLIMUS",SUP-1550400-38,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAX BONE 3.5GM WATER SOLUBLE MECHANICAL BARR ALKYLENE OXIDE",SUP-1503831,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.24,228.37,"CIGNA [10200]","Cigna Local Plus",,407.26,53.5,,,,,0,88.53,647.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 75CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR060201A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"KAISER [10500]",Kaiser,,12570.14,67,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 50MM 1.5MM SMARTPIN PLLA SELF REINFORCE STERILE",SUP-121550,CDM,S27200284,LOCAL,0272,RC,,,both,,,1160.08,348.02,"CIGNA [10200]",Cigna,,788.85,68,,,,,0,134.92,986.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 44-41MM COMPREHENSIVE STD SHOULDER E1",SUP-EP-115396,CDM,C1776,HCPCS,0278,RC,,,both,,,8854.00,2656.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3638.99,41.1,,6417.48,6417.48,6417.48,"1 through 10",1029.72,7525.9,"percent of total billed charges",
"ENDO SHEARS  W/UNIPOLAR CAUTERY 5MM",SUP-176643,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.90,70.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,107.82,45.9,,,,,0,27.32,199.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 19MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532G219,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4690.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",1327.29,9700.71,"percent of total billed charges",
"DRILL TWIST 38MM 1.1MM LORENZ STOP 5MM 1.5MM SCR MIDAS REX",SUP-1/1/7139,CDM,S27200284,LOCAL,0272,RC,,,both,,,1008.45,302.53,"UHC [10700]","United Healthcare",,638.35,63.3,,,,,0,117.28,857.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE MTF SMALL DIAMETER ANTERIOR TIBIALIS",SUP-430337,CDM,S27800098,LOCAL,0278,RC,,,both,,,10522.50,3156.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3011.54,28.62,,,,,0,1223.77,8944.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 20MM 2.5MM BALLOON DILATATION",SUP-2200-2520-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"MULTIPLAN [10600]",Multiplan,,4985.25,85,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752830,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,613.48,68,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAVVY 150CM 4CM 3.5-3FR 2MM BALLOON DILATATION DURALYN",SUP-435204X,CDM,C1725,HCPCS,0272,RC,,,both,,,2137.50,641.25,"FIRST HEALTH [10303]","First Health",,1710,80,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 100MM 130MM 5MM LONG VASCULAR NITINOL",SUP-SC5100LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1062.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 80MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171080870,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 8MM 11MM 8FR .035IN",SUP-BXA087901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6126.8,28.62,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 20MM 2MM BALLOON DILATATION HYDROPHILIC",SUP-2200-2020-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"UHC [10700]","United Healthcare",,3712.55,63.3,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 20MM 1.5MM 1.5MM 1.2MM BALLOON DILATATION RAPID",SUP-DC-RY1520UA1,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,671.98,68,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 20MM 75CM 9MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200092070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 80MM 3.5MM BALLOON DILATATION RAPID",SUP-47535080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE XS OVAL 240CM 1.9MM PROFILE LOOP FLEXIBLE ENDOSCOPIC",SUP-M00562531,CDM,S27200284,LOCAL,0272,RC,,,both,,,176.10,52.83,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MICROCATHETER INFUSION 160CM .021IN PHENOM STERILE LATEX",SUP-FG13160-0615-1S,CDM,C1769,HCPCS,0272,RC,,,both,,,7659.00,2297.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,907.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,890.74,6510.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYETHYLENE SUTURETAPE 1.3MM 36IN .5 CIRCLE TAPER NDL",SUP-AR-7500,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.73,95.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATHETERIZATION LUBRICATH 14FR 2000ML FOLEY DRNG BAG",SUP-899914,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.57,27.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.17,78.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOGRAPHY 6FR L100CM 0.038IN CORONARY POLYURETHAN",SUP-532649,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.83,25.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOTRACHEAL 8MM NASAL ORAL CUFF MURPHY EYE RADIOPAQUE",SUP-86113,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.46,17.54,"UHC [10700]","United Healthcare",,37.01,63.3,,,,,0,6.8,49.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK 8X1X2CM LARGE NASAL SLIMLINE RHINO ROCKET STERILE LATEX",SUP-11S-S0800-08AS,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.35,53.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE ARTHROSCOPIC TORPEDO SHAPE ELECTRD EDGE CONTROL APOLLO",SUP-AR-9831,CDM,S27200284,LOCAL,0272,RC,,,both,,,1850.63,555.19,"NOVANET [10819]",Novanet,,1387.97,75,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS SUTUPAK 3-0 18IN BRAID 12 STRAND",SUP-VCP104G,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.32,28.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TORCON NB ADVANTAGE 125CM 5FR BEACON SIMMONS 2 CURVE",SUP-G11517,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,161.49,68,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 20CM 4MM BALLOON DILATATION PERIPHERAL",SUP-G30952,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 90CM 100MM 2MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186201090,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 15CM 2.2MM MR8 MATCH HEAD STERILE DISPOSABLE",SUP-MR8-15MH22,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,536.49,45.9,,,,,0,135.93,993.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.25MM X 10.0MM",SUP-492251012,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION CURITY ADD-A-CATH 30CC INSRT PREFILL",SUP-5027,CDM,S27200284,LOCAL,0272,RC,,,both,,,45.68,13.7,"CIGNA [10200]","Cigna Open Access",,25.99,56.9,,,,,0,5.31,38.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp B1 Marow Smr",PX-305000088,CDM,0855T,CPT,0312,RC,,,both,,,104.00,31.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,47.74,45.9,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC",192,MS-DRG,,,,,,,inpatient,,,29091.05,8727.31,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,8108.9,,"Case rate ($3,982.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,697.90, add-ons for qualifying new technology services are included. If operating cost exceeds $36,737.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,661.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,702.79. The transfer operating threshold is the transfer adjustment factor * $3,697.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $279.58. The transfer capital threshold is the transfer adjustment factor * $279.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,3982.37,16010.84,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP EASY LOAD DESIGN LOCK HANDLE SAFELY INSRT 3.5CM",SUP-KC-RUMI-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"FIRST HEALTH [10303]","First Health",,916.67,80,,,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X12X6MM COHERE 7D LORDOSIS SCORIA PEEK LOW",SUP-1000-00-0614,CDM,C1889,HCPCS,0278,RC,,,both,,,6210.00,1863,"MULTIPLAN [10600]",Multiplan,,5278.5,85,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR DISPOSABLE 2.9/12.5MM SHORT BIOCOMPOSITE PUSHLOCK",SUP-AR-8923DSC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,173.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ONE STEP CENTESIS 10CM 5FR DRNG TEFLON PERCUTANEOUS 4",SUP-OSC-5F-10S,CDM,C1729,HCPCS,0272,RC,,,both,,,160.95,48.28,"NOVANET [10819]",Novanet,,120.71,75,,,,,0,18.72,136.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIABETES WITH CC",638,MS-DRG,,,,,,,inpatient,,,28949.95,8684.98,"AETNA [10100]","Aetna HMO/PPO",,16862,,"Fee schedule rate ($16,862.00). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,5559.19,22350.33,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER TISSUE 35CM 5MM ENSEAL G2 360D STRAIGHT ROTATING",SUP-NSLG2S35A,CDM,S27200284,LOCAL,0272,RC,,,both,,,3402.04,1020.61,"KAISER [10500]",Kaiser,,2279.37,67,,,,,0,395.66,2891.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 17.5MM S-ROM ZTT 20F 2XL HIP PROXIMAL",SUP-550540,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"NOVANET [10819]",Novanet,,8163.56,75,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL MEDIUM 6 FLUTE ROUND L50.8 MM OD3 MM STERILE",SUP-5300-010-509,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.08,49.82,"KAISER [10500]",Kaiser,,111.27,67,,,,,0,19.32,141.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 20MM REDAPT TITANIUM LOCK VARIABLE ANGLE",SUP-71354503,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 10MM PORTEX BLUSELECT CUFF STERILE LATEX FREE",SUP-101/815/100,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.48,103.04,"UHC [10700]","United Healthcare",,217.42,63.3,,,,,0,39.95,291.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 9.5MM 7MM NASAL ORAL TAPER CUFF MURPHY TIP",SUP-18770S,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.13,22.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,34.03,45.9,,,,,0,8.62,63.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 60MM 40CM 10MM 6FR BILIARY SELF EXPAND",SUP-G32006,CDM,C1876,HCPCS,0278,RC,,,both,,,4653.98,1396.19,"FIRST HEALTH [10303]","First Health",,3723.18,80,,,,,0,541.26,3955.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC STATSEAL LARGE DISC POTASSIUM FERRATE",SUP-DL616,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 20MM 4MM BALLOON DILATATION PEBAX",SUP-H74939032402080,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE PEDIATRIC 2.9MM",SUP-SB2900SS,CDM,S27200284,LOCAL,0272,RC,,,both,,,853.22,255.97,"NOVANET [10819]",Novanet,,639.92,75,,,,,0,99.23,725.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN VACUUM ASPIRATION PLASTIC CURVED ROUND TIP SEMIRIGID",SUP-21553,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.34,19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 9MM 80MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704980,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"CATH THREADER POWERCOIL 105CM 12MM 1.2MM MICRO SMALL THIN",SUP-H7493927012120,CDM,C1725,HCPCS,0272,RC,,,both,,,3300.00,990,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONQUEST 75CM 4CM 7MM BALLOON DILATATION PERIPHERAL",SUP-CQ7574,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"AETNA [10100]","Aetna HMO/PPO",,1062.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 4MM MEDIUM CARBIDE OVAL SOLID .31IN",SUP-5300010901,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.08,49.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE STRATAFIX MONOCRYL PLUS 4-0 PS-4 SPIRAL 45CM SUT",SUP-SXMP1B120,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"AETNA [10100]","Aetna HMO/PPO",,170.05,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BISACODYL 10 MG RECTAL SUPPOSITORY",RX-1080,CDM,,,0637,RC,00574-7050-12,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL SYMMETRY .3MM MICRO STRAIGHT 5.25INX9MM TISSUE",SUP-78-0075,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.82,182.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,249.81,41.1,,,,,0,70.69,516.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR ABDOMINAL VASCULAR PROCEDURES,EXTREME",169,APR-DRG,,,,,,,inpatient,,,288267.54,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $30,606.26. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($193,331.17) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENVEO R DELIVERY LOAD",SUP-LS-ENVEOR-34-US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2925.00,877.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1202.18,41.1,,,,,0,340.18,2486.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES,MINOR",098,APR-DRG,,,,,,,inpatient,,,55133.71,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,972.20. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($33,421.74) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL L HOOK 32CM 5MM UNIVERSAL PLUS",SUP-60-5272-132,CDM,S27200284,LOCAL,0272,RC,,,both,,,176.52,52.96,"KAISER [10500]",Kaiser,,118.27,67,,,,,0,20.53,150.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC ARREST AND SHOCK,MODERATE",196,APR-DRG,,,,,,,inpatient,,,33151.34,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $2,779.03. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"MILL+ COARSE BLADE",SUP-5420-CRS-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,4122.97,1236.89,"MULTIPLAN [10600]",Multiplan,,3504.52,85,,,,,0,479.5,3504.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEONATE WITH OTHER SIGNIFICANT PROBLEMS",794,MS-DRG,,,,,,,inpatient,,,7484.75,2245.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2-0 3/8 CIRCLE TAPER 38IN BRAID TIES",SUP-AR-7221,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.84,57.55,"FIRST HEALTH [10303]","First Health",,153.47,80,,,,,0,22.31,163.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 6 RIGHT MEDIAL LEFT LATERAL PARTIAL",SUP-5620-B-602,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"PHCS [10601]",PHCS,,5677.67,70,,,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 7FR ENDOCARDIUM BIPOLAR ACTIVE FIXATION",SUP-1999/52,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,264.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +6.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-PCB0000065,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-6 TTC-9 24IN 2 ARM MONOFILAMENT WHITE",SUP-6K02A,CDM,S27200284,LOCAL,0272,RC,,,both,,,309.57,92.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,210.51,68,,,,,0,36,263.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE TIBIAL 5MM LEGION 3-4 HEMI KNEE LEFT MEDIAL RIGHT",SUP-71421142,CDM,C1776,HCPCS,0278,RC,,,both,,,15369.75,4610.92,"CIGNA [10200]",Cigna,,6147.9,40,,5873.17,5873.17,5873.17,"1 through 10",1787.5,13064.29,"percent of total billed charges",
"RTRCTR ROUND 7CM GELPOINT VAGINAL",SUP-C2A15,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 19MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-219,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"PHCS [10601]",PHCS,,6881.36,70,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPLANT 14.5CM NATRELLE INSPIRA P4.8CM MODERATE PROFIL",SUP-MSZ-M520,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"FIRST HEALTH [10303]","First Health",,126.54,80,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE CAST SMALL CANVAS RUBBER ROCKER SOLE HOOP LOOP CLSR",SUP-2035-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.41,13.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COUNTSINK DRILL CANNULATED 2.5/3 MM SCR STERILE",SUP-03.333.201S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2980.80,894.24,"CIGNA [10200]","Cigna Local Plus",,1594.73,53.5,,,,,0,346.67,2533.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 14FR PIGTAIL CURVE DRNG FLEXIMA BILIARY FLEXIBLE",SUP-M001271620,CDM,C1729,HCPCS,0272,RC,,,both,,,615.60,184.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 3MM ROUND DIAMOND STERILE LATEX FREE",SUP-5820-012-030D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1164.70,349.41,"CIGNA [10200]",Cigna,,792,68,,,,,0,135.45,990,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC",096,MS-DRG,,,,,,,inpatient,,,75461.60,22638.48,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 3CM 18FR SILICONE MIC-KEY RADIOPAQUE LOW",SUP-8230-18-3.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,167.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC",848,MS-DRG,,,,,,,inpatient,,,24213.89,7264.17,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH 6MM SHORT HANDLE AORTIC",SUP-APU460,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"CIGNA [10200]",Cigna,,197.18,68,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEINMANN PIN SINGLE DIAMOND 2.4 MM X 229 MM",SUP-SPIN-SD-24229,CDM,S27000186,LOCAL,0270,RC,,,both,,,891.00,267.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT EXPRESS SD MONORAIL 15MM 90CM 7MM BILIARY STAINLESS",SUP-H74937911715900,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"CIGNA [10200]","Cigna Open Access",,2840.45,56.9,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH DRYSEAL FLEX 65CM 10FR 4MM 3.3MM INTRO HYDROPHILIC",SUP-GDSF1065,CDM,C1894,HCPCS,0272,RC,,,both,,,6858.60,2057.58,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Similac Probiotic Tri-Blend",PX-E27000265,CDM,E27000265,LOCAL,0270,RC,,,both,,,63.40,19.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,43.11,68,,,,,0,7.37,53.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ EXTRA STIFF VASCULAR 3MM FLOPPY STRAIGHT TAPER",SUP-G03290,CDM,C1769,HCPCS,0272,RC,,,both,,,133.81,40.14,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VIATRAC 14 PLUS 135CM 40MM 4MM .014IN LOW PROFILE",SUP-1008189-40,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"AETNA [10100]","Aetna HMO/PPO",,1126.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION COMPLETE CARE 16FR 5ML FOLEY DRNG BAG",SUP-300116A,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.80,35.34,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT ENDOVASCULAR 14CM 28.5MM 14.5MM 24-26MM 12-13.5MM GORE",SUP-RLT281414,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7429.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 50CMX.49MM 18/9MM HEMAGARD 2 BRANCH",SUP-HGK1809,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 133MM CEMENTLESS NECK ACCOLADE TMZF 132D 5.5 45",SUP-6020-5537,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"CIGNA [10200]","Cigna Open Access",,7645.29,33.5,,5302.19,4377.88,6578.61,27,2654.17,19398.49,"percent of total billed charges",
"(EVAL) BATWIRE IMPLANT KIT MODEL 1100",SUP-100066-102,CDM,C1769,HCPCS,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4.3MM 32MM POLARUS 3 HEXALOBE LOW PROFILE HUMERUS",SUP-3011-43032-S,CDM,C1713,HCPCS,0278,RC,,,both,,,1142.10,342.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,135.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,132.83,970.79,"percent of total billed charges",
"BINDER ABDOMINAL ABDOMEN 12IN CIRCUMFERENCE 45IN-62IN M",SUP-55476302,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.33,38.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT CLAMP 90MM STEALTH 5 SOFT TRACTION STERILE LATEX FREE",SUP-A0A04,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"CIGNA [10200]",Cigna,,106.49,68,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR STRAIGHT 145CM .038IN PTFE FIXED CORE",SUP-007042,CDM,C1769,HCPCS,0272,RC,,,both,,,87.00,26.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT CLAMP 90MM STEALTH 5 SOFT TRACTION STERILE LATEX FREE",SUP-A0A04,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"MULTIPLAN [10600]",Multiplan,,133.11,85,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE V-14 CONTROLWIRE VASCULAR SHORT TAPER STRAIGHT 182CM 8",SUP-H74939216718210,CDM,C1769,HCPCS,0272,RC,,,both,,,2295.00,688.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STPLR UNIVERSAL 45X3.5MM ENDO GIA TITANIUM ENDOSCOPIC",SUP-030422,CDM,S27200284,LOCAL,0272,RC,,,both,,,697.98,209.39,"FIRST HEALTH [10303]","First Health",,558.38,80,,,,,0,81.18,593.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC",020,MS-DRG,,,,,,,inpatient,,,453478.14,136043.44,"CIGNA [10200]",Cigna,,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 55.9%. Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"DRESSING FOAM ANTIMICROBIAL WITH SILVER MEPILEX BORDER POST-",SUP-498100,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.20,18.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25.98,41.1,,,,,0,7.35,53.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL FOGARTY 8MM 2 SOFTJAW ATRAUMATIC OCCLUSION",SUP-HCDSOFT8,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE MEDIUM STRAIGHT 1.5MM 2.3MM SCR 4 HOLE LOCK VARIAX",SUP-57-15301,CDM,C1713,HCPCS,0278,RC,,,both,,,3123.90,937.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1433.87,45.9,,,,,0,363.31,2655.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 1.3IN 2MM BULB POLYURETHANE TUBE WINGED",SUP-31002,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.30,27.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SWAN-GANZ CCOMBO VIP 110CM 8FR STD PULMONARY ARTERY",SUP-746F8,CDM,C1751,HCPCS,0272,RC,,,both,,,1782.30,534.69,"NOVANET [10819]",Novanet,,1336.73,75,,,,,0,207.28,1514.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 9MM TANNE UNIVERSAL TREPHINE STERILE","SUP-E3050 9.00",CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DXTERITY 100CM 6FR .056IN JUDKINS RIGHT 4 CURVE",SUP-DXT6JR40,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"PHCS [10601]",PHCS,,57.86,70,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPIDURAL TRAY 18GA CRAWFORD",SUP-332223,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.48,38.84,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TOTAL ABSCESSION BLUE SILK 30CM 12FR PIGTAIL CURVE DRNG",SUP-H787140008055,CDM,C1729,HCPCS,0272,RC,,,both,,,950.94,285.28,"FIRST HEALTH [10303]","First Health",,760.75,80,,,,,0,110.59,808.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 65CM 5FR MOT CURVE ANGIOGRAPHIC PEBAX",SUP-5591-A3,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BALLOON DISECT LAPAROSCOPIC KII 100MM 12MM 1 LATERAL",SUP-C0K16,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"PHCS [10601]",PHCS,,1312.5,70,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 289MM 4.3MM AXSOS CALIBRATE 4MM SMALL FRAGMENT",SUP-702742,CDM,S27200284,LOCAL,0272,RC,,,both,,,1010.39,303.12,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 6-0 C-1 30IN 2 ARM MONOFILAMENT BLUE",SUP-EP8706H,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.31,70.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,27.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.25,199.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EZ-BLADE SAW BLADE 25.40MM 1.27MM","SUP-EZ2513P.L62 STE",CDM,S27200284,LOCAL,0272,RC,,,both,,,720.90,216.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE QUILL 3-0 3/8 CIRCLE 30X30CM 26MM CLSR MONODERM 2 ARM",SUP-YA-1023Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,202.10,60.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,83.06,41.1,,,,,0,23.5,171.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PERMA-HAND SUTUPAK 4-0 24IN BRAID TIES 13 STRAND PRECUT",SUP-SA73H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL HARTMANN 5.5IN EAR SERRATE DELICATE 6X3MM",SUP-61-0111,CDM,S27200284,LOCAL,0272,RC,,,both,,,587.66,176.3,"PHCS [10601]",PHCS,,411.36,70,,,,,0,68.34,499.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 18.5X10X.4MM HALL SAGITTAL FINE TOOTH STERILE",SUP-5044-145,CDM,S27200284,LOCAL,0272,RC,,,both,,,220.28,66.08,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT POLYPROPYLENE PROLENE 4-0 RB-1 36IN 2 ARM MONOFILAMENT",SUP-8357H,CDM,S27200284,LOCAL,0272,RC,,,both,,,86.67,26,"CIGNA [10200]","Cigna Open Access",,49.32,56.9,,,,,0,10.08,73.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 200CM 5MM 5.5FR ULTRATOME XL BILIARY PANCREAS 3",SUP-M00535900,CDM,S27200284,LOCAL,0272,RC,,,both,,,999.05,299.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,118.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.19,849.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN FEMORAL LEFT 4 CURVE ANGIOGRAPHIC",SUP-H74908641222,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,35.15,45.9,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APIXABAN 2.5 MG TABLET",RX-161124,CDM,,,0250,RC,00003-0893-31,NDC,both,1,UN,45.84,13.75,"CIGNA [10200]","Cigna Local Plus",,24.52,53.5,,,,,0,5.33,38.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 22MM 140CM 2.25MM CORONARY STERILE",SUP-453949,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 2MM 22MM ORTHOLOC FULL THREAD MIDFOOT",SUP-58812722,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"AETNA [10100]","Aetna HMO/PPO",,676.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PANEL LIGHT SAPHLITE LARGE SOURCE",SUP-89-2716K,CDM,S27200284,LOCAL,0272,RC,,,both,,,3376.41,1012.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2295.96,68,,,,,0,392.68,2869.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALIPER SURGICAL 6IN 3.5MM 4MM 4.5MM AUSTIN STRUT MIDDLE EAR",SUP-61-0310,CDM,S27200284,LOCAL,0272,RC,,,both,,,672.87,201.86,"FIRST HEALTH [10303]","First Health",,538.3,80,,,,,0,78.25,571.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON DISECT LAPAROSCOPIC KII 100MM 12MM 2 LATERAL LOW",SUP-C0K15,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"NOVANET [10819]",Novanet,,1406.25,75,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL ENDOSCOPIC INSTR ENDOWRIST STPLR CANN DISPOSABLE",SUP-410351,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"KAISER [10500]",Kaiser,,116.58,67,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM STD CABLE TITANIUM COCR TROCHANTER REATTACHMENT",SUP-498.806S,CDM,S27200284,LOCAL,0272,RC,,,both,,,10336.20,3100.86,"CIGNA [10200]",Cigna,,7028.62,68,,,,,0,1202.1,8785.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 12.5CM 4MM IBUR DISTAL BEND ROUND DIAMOND",SUP-8431-013-040DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,2737.50,821.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,324.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 13CM 6MM STERLING 10000 RPM OVAL LARGE HUB",SUP-H9102,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII ALLOGRAFT 14MM 23MM",SUP-401214A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP SNAP-LIGHT 2 STAINLESS STEEL FIBER OPTIC",SUP-2217200,CDM,S27000186,LOCAL,0270,RC,,,both,,,268.40,80.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,182.51,68,,,,,0,31.21,228.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 20MM 2.5MM BALLOON DILATATION RAPID",SUP-47525020L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICRO ACCSS PL AWY SHTH 7F",SUP-6509945,CDM,C1887,HCPCS,0272,RC,,,both,,,3090.00,927,"FIRST HEALTH [10303]","First Health",,2472,80,,,,,0,359.37,2626.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPICILLIN 1 GRAM SOLUTION FOR INJECTION",RX-469,CDM,J0290,HCPCS,0636,RC,00781-3404-85,NDC,both,1,UN,65.20,19.56,"CIGNA [10200]","Cigna Local Plus",,3.19,,,,,,,1.28,55.42,"fee schedule",
"STENT ONYX FRONTIER 18MM 5MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG50018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LOCKING QUARTEX",SUP-1149.0001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2406.60,721.98,"AETNA [10100]","Aetna HMO/PPO",,1913.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1.5 KNEE LEFT CRUCIATE RETAIN SIGMA STERILE",SUP-940017,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6990.26,27,,,,,0,3010.99,22006.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP IDENTITY STEM/AUGMENTED GLENOID/PREMIUM POST/IDENTITY TI",SUP-98000900265,CDM,C1776,HCPCS,0278,RC,,,both,,,42525.00,12757.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11481.75,27,,,,,0,4945.66,36146.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMEDY SPECTRUM GV FEMORAL STEM LG",SUP-GVSTLG,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5409.18,28.62,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 12MM 3MM",SUP-SPL30012X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR ORTHOPEDIC 20MM 8MM PILOT HOLE CREATOR DISPOSABLE",SUP-PC-200,CDM,S27200284,LOCAL,0272,RC,,,both,,,5770.13,1731.04,"NOVANET [10819]",Novanet,,4327.6,75,,,,,0,671.07,4904.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 80CM 6CM 6MM BALLOON",SUP-G52346,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM STD TWIST",SUP-MFT-072-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,1409.40,422.82,"MULTIPLAN [10600]",Multiplan,,1197.99,85,,,,,0,163.91,1197.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 80CM 6CM 6MM BALLOON",SUP-G52346,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.47,41.1,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVATOR 20",SUP-AC4340-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1764.00,529.2,"PHCS [10601]",PHCS,,1234.8,70,,,,,0,205.15,1499.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X120 80CM SL",SUP-48006012N,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,118.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BULLET ALLOGRAFT REVISION DOWEL PREHYDRATE",SUP-PCD11,CDM,C1713,HCPCS,0278,RC,,,both,,,6744.75,2023.42,"BLUE CROSS [10001]","Blue Cross PPO",,2643.94,39.2,,957.42,570.23,957.42,28,784.41,5733.04,"percent of total billed charges",
"INSRT TIBIAL 4 9MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-409,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"CIGNA [10200]","Cigna Local Plus",,5259.33,53.5,,5372.07,4581.20,7242.98,23,1143.29,8355.94,"percent of total billed charges",
"INSRT TIBIAL LARGE 16MM KNEE DURATION POSTERIOR STABILIZE",SUP-6742-1-316,CDM,C1776,HCPCS,0278,RC,,,both,,,5709.75,1712.92,"BLUE CROSS [10001]","Blue Cross PPO",,2238.22,39.2,,3949.44,3949.44,3949.44,"1 through 10",664.04,4853.29,"percent of total billed charges",
"SPACER SPINAL 23MMX11MM ELEVATE STD PEEK TITANIUM STERILE",SUP-7771123,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 160CM 2.8-3.2FR .027IN MARKSMAN",SUP-FA-55160-1030,CDM,S27200284,LOCAL,0272,RC,,,both,,,7741.80,2322.54,"CIGNA [10200]","Cigna Open Access",,4405.08,56.9,,,,,0,900.37,6580.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 60MM 190CM 4MM",SUP-R51004006L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"AETNA [10100]","Aetna HMO/PPO",,1567.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16015540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6491.86,68,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST EXTERNAL FIXATION SHORT WIRE MRI SAFE NONSTERILE",SUP-03.311.070,CDM,S27800098,LOCAL,0278,RC,,,both,,,1499.55,449.86,"MULTIPLAN [10600]",Multiplan,,1274.62,85,,,,,0,174.4,1274.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 5-0 PS-2 18IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP495G,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.40,19.62,"UHC [10700]","United Healthcare",,41.4,63.3,,,,,0,7.61,55.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 36X28X19MM CHESAPEAKE 10D LORDOTIC",SUP-2013-21936L10,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"KAISER [10500]",Kaiser,,22964.65,67,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 15MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015015M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"KAISER [10500]",Kaiser,,960.58,67,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AMPHIRION DEEP 150CM 80MM 3.5MM BROAD TAPER BALLOON",SUP-AMP035080152,CDM,C1725,HCPCS,0272,RC,,,both,,,2422.50,726.75,"KAISER [10500]",Kaiser,,1623.08,67,,,,,0,281.74,2059.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP OSTEOTOM 46MM HEMISPHERE ACETABULAR CUP",SUP-705304620,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"CIGNA [10200]","Cigna Local Plus",,2421.62,53.5,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 6MM 3MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3006X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"KAISER [10500]",Kaiser,,352.76,67,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +27 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.270,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 90CM 80MM 2MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186200890,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Crrt Set Change",PX-801000002,CDM,9999114,LOCAL,0801,RC,,,both,,,1257.90,377.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.29,1069.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 9IN 8FR DRNG ALUMINUM",SUP-8888560805,CDM,C1729,HCPCS,0272,RC,,,both,,,220.35,66.1,"PHCS [10601]",PHCS,,154.25,70,,,,,0,25.63,187.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2MM AO CONNECTION LOCK 3MM SCR",SUP-AR-8944-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 30MM 12MM .035IN BALLOON DILATATION NYBAX",SUP-39171-12034,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AETNA [10100]","Aetna HMO/PPO",,998.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT WALKING CNFRM AUTO-MOLD 8-9 FOOT LEFT FOAM 2 DENSITY",SUP-AL241108,CDM,S27000186,LOCAL,0270,RC,,,both,,,903.15,270.94,"MULTIPLAN [10600]",Multiplan,,767.68,85,,,,,0,105.04,767.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIPHERAL CUTTING BALLOON 90CM 20MM 5MM BALLOON",SUP-M001PCB5020900,CDM,C1725,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"KAISER [10500]",Kaiser,,3120.53,67,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 10MM PORTEX BLUSELECT CUFF STERILE LATEX FREE",SUP-101/815/100,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.48,103.04,"CIGNA [10200]","Cigna Local Plus",,183.76,53.5,,,,,0,39.95,291.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP060100150 PLUS US D6L100UL1500",SUP-PCP060100150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP ADD-A-FOLEY COMPLETE CARE",SUP-A399400A,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.70,27.51,"MULTIPLAN [10600]",Multiplan,,77.95,85,,,,,0,10.66,77.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR STD STRAIGHT TAPER 260CM .035IN STAINLESS",SUP-G00656,CDM,C1769,HCPCS,0272,RC,,,both,,,133.81,40.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.56,113.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS LOC LARGE CARDIAC PERCUTANEOUS 3D STERILE",SUP-DS2C300-42,CDM,C1893,HCPCS,0272,RC,,,both,,,2250.00,675,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 014 150CM 12CM 4MM BALLOON DILATATION",SUP-U4150412,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SEMI-FLOATING 125CM 7FR 10MM SPACING PACING BIPOLAR",SUP-006242P,CDM,S27200284,LOCAL,0272,RC,,,both,,,923.40,277.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 014 150CM 12CM 4MM BALLOON DILATATION",SUP-U4150412,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL LARGE FREEZE DRIED SHAFT 126MM",SUP-72A003,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 2MM BALLOON DILATATION STERILE LATEX",SUP-582015022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 4-0 PS-2 18IN BLACK NONABSORBABLE",SUP-1667H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 15MM 3.5MM BALLOON DILATATION STERILE",SUP-235-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 FS-2 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8683G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 40MM 9MM .035IN BALLOON DILATATION NYBAX",SUP-39171-09044,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTDG STAPLE 60MM STERILE GIA LATEX FREE DISPOSABLE BLACK",SUP-GIA60XTC,CDM,S27200284,LOCAL,0272,RC,,,both,,,432.65,129.79,"NOVANET [10819]",Novanet,,324.49,75,,,,,0,50.32,367.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14.5IN 21FR VENT SUT RING EXTEND BODY",SUP-4949,CDM,S27200284,LOCAL,0272,RC,,,both,,,601.43,180.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,71.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.95,511.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 5 1/8IN LAMBOTTE SWISS PATTERN SURGICAL MINI",SUP-27-5706,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.07,43.22,"CIGNA [10200]","Cigna Local Plus",,77.08,53.5,,,,,0,16.76,122.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30X11MM HEDRON IA 8D 24MM STERILE LATEX FREE",SUP-1212.0111S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"MULTIPLAN [10600]",Multiplan,,29452.5,85,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM MASTER-SERIES PYROLYTIC CARBON PTFE",SUP-23AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"NOVANET [10819]",Novanet,,21839.42,75,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 8MM 6FR 3.5MM .07IN BALLOON",SUP-H7493918908350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOCRINE DISORDERS WITH CC",644,MS-DRG,,,,,,,inpatient,,,26077.98,7823.39,"AMBETTER EXCHANGE  [11102]",Ambetter,,6358.14,,"Case rate ($6,358.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,903.96, add-ons for qualifying new technology services are included. If operating cost exceeds $38,943.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,828.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $5,911.77. The transfer operating threshold is the transfer adjustment factor * $5,903.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $446.37. The transfer capital threshold is the transfer adjustment factor * $446.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,6358.14,25562.48,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 12MM 3MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012274-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 3/16IN 3/16IN BARD SILICONE 4 FREE FLOW",SUP-072223,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.71,37.11,"CIGNA [10200]",Cigna,,84.12,68,,,,,0,14.39,105.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATTAIN CLARITY BALLOON OCCLUSION VENOGRAM",SUP-6225,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,84.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERIVIEW FLEX 21G",SUP-NA-403D-2021,CDM,S27200284,LOCAL,0272,RC,,,both,,,6575.70,1972.71,"CIGNA [10200]",Cigna,,4471.48,68,,,,,0,764.75,5589.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 48MM 32MM XLPE HIP STERILE",SUP-71339548,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"PHCS [10601]",PHCS,,7788.38,70,,,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI 100CM 6FR MPB2 CURVE ANGIOGRAPHIC VESTAN",SUP-534649T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"NOVANET [10819]",Novanet,,65.25,75,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM NASAL 9IN HARDY BLADE BIVALVE 80X13MM",SUP-57-3556,CDM,S27200284,LOCAL,0272,RC,,,both,,,3050.55,915.16,"NOVANET [10819]",Novanet,,2287.91,75,,,,,0,354.78,2592.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 14CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175197180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,169.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDING LAUNCHER NYLON EBU3.5 CURVE L90 CM OD7 FR P",SUP-LA7EBU35D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT EXPEL TWIST-LOC 14CM 6FR SHORT LENGTH URETERAL",SUP-H7493936106140,CDM,C2617,HCPCS,0278,RC,,,both,,,1142.10,342.63,"PHCS [10601]",PHCS,,799.47,70,,,,,0,132.83,970.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 40CM .018IN NITINOL STAINLESS STEEL CORONARY",SUP-SGW-019-30,CDM,C1769,HCPCS,0272,RC,,,both,,,165.30,49.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DONEPEZIL 5 MG TABLET",RX-18786,CDM,,,0637,RC,00904-6477-61,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,3.57,56.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 5FR 21GA MERIT S-MAK .018IN STIFFENED DIL",SUP-S-MAK505,CDM,C1894,HCPCS,0272,RC,,,both,,,334.78,100.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT RETRIEVER 20MM 4MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0033PK43022001,CDM,S27200284,LOCAL,0272,RC,,,both,,,20045.55,6013.66,"AETNA [10100]","Aetna HMO/PPO",,15936.21,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2331.3,17038.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD REAMING 950MM 2.5MM BALL TIP EXT STERILE",SUP-351.707S,CDM,S27200284,LOCAL,0272,RC,,,both,,,910.85,273.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PROGREAT 150CM 90CM 2.4FR .021IN 750 PSI INTERVENTIONAL",SUP-MC*PV2415Y,CDM,C1887,HCPCS,0272,RC,,,both,,,2463.75,739.12,"NOVANET [10819]",Novanet,,1847.81,75,,,,,0,286.53,2094.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR STRAIGHT 150CM .035IN HYDROPHILIC FIX CORE",SUP-H2OSTDS35150,CDM,C1769,HCPCS,0272,RC,,,both,,,278.40,83.52,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",479,MS-DRG,,,,,,,inpatient,,,74518.26,22355.48,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,24791.37,,"Case rate ($11,530.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,707.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,746.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,191.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,721.35. The transfer operating threshold is the transfer adjustment factor * $10,707.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.52. The transfer capital threshold is the transfer adjustment factor * $809.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,54272.44,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAVVY 150CM 10CM 3.5-3FR 2MM BALLOON DILATATION DURALYN",SUP-435200X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEALER/DIVIDER LAPAROSCOPIC 44CM 5MM LIGASURE 180D 17.8MM 2",SUP-LF1844,CDM,S27200284,LOCAL,0272,RC,,,both,,,3386.18,1015.85,"CIGNA [10200]",Cigna,,2302.6,68,,,,,0,393.81,2878.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC",862,MS-DRG,,,,,,,inpatient,,,43300.62,12990.19,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,,,"Fee schedule rate ($0). Wage-adjusted base payment rate plus any adjustments related to capital costs, indirect medical education (IME), disproportionate share hospital (DSH) adjustors, new technology, hemophilia, sole community hospital (SCH) and Medicare Dependent Hospital (MDH) adjustors, transfers, and outliers.",,,,0,,,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MASK CPAP MEDIUM LEAK 1 ENTRAINMENT NEB ELBOW",SUP-73-1061734,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.58,61.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,24.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.03,175.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ROADRUNNER VASCULAR ANGLE SPRING COIL 300CM 5CM .018IN",SUP-G07640,CDM,C1769,HCPCS,0272,RC,,,both,,,927.37,278.21,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT WINGSPAN 15MM 4MM INTRACRANIAL HYDROPHILIC SELF EXPAND",SUP-M003WS0400150,CDM,C1874,HCPCS,0278,RC,,,both,,,51979.47,15593.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6159.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6045.21,44182.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OCCL 100CM 5FR 26FR BALLOON OCCLUSION 1 INFLATION PORT",SUP-M0062201080,CDM,C2628,HCPCS,0272,RC,,,both,,,1155.14,346.54,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL EPIDURAL 5IN 17GA TUOHY THIN WALL CENTIMETER MARK",SUP-AN-05505,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.39,24.12,"MULTIPLAN [10600]",Multiplan,,68.33,85,,,,,0,9.35,68.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM T10 FULL THREAD LOCK STARDRIVE",SUP-657014,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"FIRST HEALTH [10303]","First Health",,1189.47,80,,,,,0,172.92,1263.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC",495,MS-DRG,,,,,,,inpatient,,,141821.79,42546.54,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,23839.87,,"Case rate ($22,490.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,883.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,923.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,960.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $20,911.51. The transfer operating threshold is the transfer adjustment factor * $20,883.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.92. The transfer capital threshold is the transfer adjustment factor * $1,578.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,105855.94,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 8MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650908,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1555.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 3.5MM FRMLA END CUTTER STERILE",SUP-0375737000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2099.48,629.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,862.89,41.1,,,,,0,244.17,1784.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT WHITE KINEX CLLGN BIOACTIVE GLASS HYALURONIC",SUP-8115.0305S,CDM,C1713,HCPCS,0278,RC,,,both,,,5589.00,1676.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3800.52,68,,,,,0,650,4750.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 250MM 6MM BALLOON DILATATION RAPID",SUP-47560250M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,239.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SENSOR DUAL-FLEX UROLOGICAL 10CM 150CM 3CM .035IN",SUP-M0066703081,CDM,C1769,HCPCS,0272,RC,,,both,,,369.40,110.82,"FIRST HEALTH [10303]","First Health",,295.52,80,,,,,0,42.96,313.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pleur Drain W/Insrt Cath W/Img",PX-361000459,CDM,32557,CPT,0361,RC,,,both,,,5724.68,1717.4,"KAISER [10500]",Kaiser,,3835.54,67,,,,,0,665.78,4937,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X10MM STD XL PEEK PLATE FUSION",SUP-7861060,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13710.24,40,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLAMMATORY BOWEL DISEASE WITH MCC",385,MS-DRG,,,,,,,inpatient,,,44702.45,13410.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SENSOR DUAL-FLEX UROLOGICAL 10CM 150CM 3CM .035IN",SUP-M0066703081,CDM,C1769,HCPCS,0272,RC,,,both,,,369.40,110.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.96,313.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM RAYHACK CORTICAL ULNAR LOW PROFILE",SUP-40100956,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL 8 6MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630806,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]","Cigna Local Plus",,4135.08,31.5,,5372.07,4581.20,7242.98,23,1526.7,11158.16,"percent of total billed charges",
"CANN PERFUSION 15IN 34-48FR ATRIAL CAVAL VENOUS ADULT .5IN",SUP-93464,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.70,87.81,"CIGNA [10200]","Cigna Open Access",,166.55,56.9,,,,,0,34.04,248.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG GERMICIDAL 4X5IN AQUACEL AG",SUP-422299,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.99,21,"NOVANET [10819]",Novanet,,52.49,75,,,,,0,8.14,59.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIRANHA CERVICAL VARIABLE SCREW 4.25 MM X 16 MM",SUP-SK-CSV-425-16,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOGRAPHY 5FR L125CM ID0.047IN FL4 CURVE SOFT DIS",SUP-H749163912201,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.17,22.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.74,63.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5CMX10MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-3-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"AETNA [10100]","Aetna HMO/PPO",,1159.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH R2P METACROSS 200CM 80MM 5MM BALLOON DILATATION",SUP-BD-P50080ER,CDM,C1769,HCPCS,0272,RC,,,both,,,2028.75,608.62,"PHCS [10601]",PHCS,,1420.13,70,,,,,0,235.94,1724.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 7MM AXIUM 3D FRAME V01",SUP-FC-7-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,13765.50,4129.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3939.69,28.62,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 12.6CM MEMORYGEL P3.3CM MODERATE PROFILE SILTEX",SUP-3543007MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL 3.5MM 3.5MM SERFAS ENERGY 30D GRIZZLY",SUP-279351230,CDM,S27200284,LOCAL,0272,RC,,,both,,,931.50,279.45,"CIGNA [10200]","Cigna Open Access",,530.02,56.9,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO VASCULAR STRAIGHT 215CM .014IN HYDROPHILIC",SUP-SSFT215STR,CDM,C1769,HCPCS,0272,RC,,,both,,,4186.64,1255.99,"KAISER [10500]",Kaiser,,2805.05,67,,,,,0,486.91,3558.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETHRAL LUBRI-SIL IC 18FR FOLEY 3 WAY ROUND TIP 2",SUP-73018SI,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.23,33.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,45.3,41.1,,,,,0,12.82,93.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET TRANSFER 77X30IN MAXISLIDE FLITES LATEX FREE",SUP-NPA0500,CDM,S27000186,LOCAL,0270,RC,,,both,,,96.35,28.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,44.22,45.9,,,,,0,11.21,81.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHISEL SURGICAL 6.25IN 4MM V BALLENGER",SUP-63-0089,CDM,S27200284,LOCAL,0272,RC,,,both,,,415.43,124.63,"CIGNA [10200]","Cigna Open Access",,236.38,56.9,,,,,0,48.31,353.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OCCL 100CM 5FR 26FR BALLOON OCCLUSION 1 INFLATION PORT",SUP-M0062201080,CDM,C2628,HCPCS,0272,RC,,,both,,,1155.14,346.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,136.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,134.34,981.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 12D-30D LONG SMALL LOOP 24FR",SUP-WA22742S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3181.82,954.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2163.64,68,,,,,0,370.05,2704.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE NOVAGOLD ENDOSCOPIC 260CM 6CM .018IN TRITON BILIARY",SUP-M00552001,CDM,C1769,HCPCS,0272,RC,,,both,,,1460.03,438.01,"MULTIPLAN [10600]",Multiplan,,1241.03,85,,,,,0,169.8,1241.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X9-6.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-4809,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"CIGNA [10200]","Cigna Local Plus",,4673.03,31.5,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STARTER VASCULAR 1.5MM STD ROSEN CURVE 180CM 4CM .035",SUP-M001491561,CDM,C1769,HCPCS,0272,RC,,,both,,,254.04,76.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,30.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.54,215.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLATE TIBIAL ATTUNE 7 KNEE CEMENT REVISION ROTATE PLATFO",SUP-150660007,CDM,C1776,HCPCS,0278,RC,,,both,,,22629.60,6788.88,"KAISER [10500]",Kaiser,,15161.83,67,,,,,0,2631.82,19235.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY NAVIGUS NDL PASSIVE",SUP-9733068,CDM,S27200284,LOCAL,0272,RC,,,both,,,4478.10,1343.43,"AETNA [10100]","Aetna HMO/PPO",,3560.09,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,520.8,3806.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 150MM 130CM 7MM BILIARY SELF EXPANDING",SUP-SC7150L,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1062.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 118MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-240.039S,CDM,C1713,HCPCS,0278,RC,,,both,,,9565.33,2869.6,"PHCS [10601]",PHCS,,6695.73,70,,,,,0,1112.45,8130.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 NARROW KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508006401,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"AETNA [10100]","Aetna HMO/PPO",,20859.4,79.5,,10981.53,8986.79,12413.38,12,3051.51,22302.5,"percent of total billed charges",
"LENS IOL +17.5 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150175,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Local Plus",,184.58,53.5,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 2 X 2 COMPLEX FRAMING COIL",SUP-10CFR-02002,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4818.19,41.1,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) GUIDEWIRE VASCULAR .018INX200CM ARISTOTLE 18 SOFT",SUP-A18-200-001,CDM,C1769,HCPCS,0272,RC,,,both,,,4830.00,1449,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE AORTIC 19MM 14.8MM MASTER-SERIES PYROLYTIC CARBON",SUP-19AECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11647.69,40,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN 3-11.5GA LOCK DIAMOND TIP STYLET DELIVARY",SUP-975,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNARE SMALL OVAL 240CM 2.4MM CAPTIFLEX LOOP FLEXIBLE",SUP-M00562422,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.00,22.5,"UHC [10700]","United Healthcare",,47.48,63.3,,,,,0,8.72,63.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSOLE SHOE 12.5-14 XL MALE DARCO PEG-ASSIST REMOVABLE PEG",SUP-PTQM4,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.53,30.46,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 15IN 34-38FR VENOUS ATRIAL CAVAL ADULT 3/8IN",SUP-93463,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.70,87.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,199.04,68,,,,,0,34.04,248.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL .4-1MM ARTERY BLACK",SUP-B-1AB,CDM,S27200284,LOCAL,0272,RC,,,both,,,558.82,167.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT FIBERSNARE FIBERWIRE 2 26IN CLOSED LOOP STIFFEN GREEN 12",SUP-AR-7209SN,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.03,267.91,"FIRST HEALTH [10303]","First Health",,714.42,80,,,,,0,103.86,759.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 22MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-422,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"CIGNA [10200]",Cigna,,6684.75,68,,5873.17,5873.17,5873.17,"1 through 10",1143.29,8355.94,"percent of total billed charges",
"SET EXT 12IN MIC-KEY SECUR-LOK ENFIT LOW PROFILE CONTINUOUS",SUP-0141-12,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.91,20.97,"MULTIPLAN [10600]",Multiplan,,59.42,85,,,,,0,8.13,59.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ VASCULAR STRAIGHT 260CM .025IN PTFE STAINLESS",SUP-G04047,CDM,C1769,HCPCS,0272,RC,,,both,,,165.21,49.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.21,140.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA2-17-75-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,9177.00,2753.1,"CIGNA [10200]",Cigna,,6240.36,68,,,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AMPLATZER TORQVUE 80CM 12FR 45D EXCHANGE SYSTEM POLYMER",SUP-9-EITV12F45/80,CDM,C1773,HCPCS,0272,RC,,,both,,,4912.80,1473.84,"PHCS [10601]",PHCS,,3438.96,70,,,,,0,571.36,4175.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM BONE CEMENT PRSSZR HIGH VACUUM KIT BOWL CRTDG NOZZLE",SUP-0306705000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1096.08,328.82,"KAISER [10500]",Kaiser,,734.37,67,,,,,0,127.47,931.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR EXTERNAL FIXATION 70MM 3MM 2.5-3MM XCALIBER FOOT CORTEX",SUP-M314,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross PPO",,301.64,39.2,,957.42,570.23,957.42,28,89.49,654.08,"percent of total billed charges",
"BIT DRILL GOLD 110MM 2.5MM QUICK COUPLING STERILE",SUP-310.25S,CDM,S27200284,LOCAL,0272,RC,,,both,,,834.62,250.39,"NOVANET [10819]",Novanet,,625.97,75,,,,,0,97.07,709.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM TITANIUM SPINE CERVICAL SELF RETAINING",SUP-04.613.614,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,396.9,39.2,,957.42,570.23,957.42,28,117.75,860.63,"percent of total billed charges",
"E-CATH PLUS CATHETER-OVER-NEEDLE PNB CATHETER SYSTEM 18G X 3",SUP-211285-41E,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"CIGNA [10200]","Cigna Local Plus",,186.18,53.5,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC",357,MS-DRG,,,,,,,inpatient,,,60157.12,18047.14,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,14857.97,,"Case rate ($14,425.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,394.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,434.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,394.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,412.51. The transfer operating threshold is the transfer adjustment factor * $13,394.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,012.71. The transfer capital threshold is the transfer adjustment factor * $1,012.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,60157.12,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE 12IN MERITRANS BONDED PIGITAIL CABLE 1 WAY",SUP-K11-00099,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732058,CDM,C1776,HCPCS,0278,RC,,,both,,,9510.48,2853.14,"CIGNA [10200]","Cigna Local Plus",,5088.11,53.5,,5372.07,4581.20,7242.98,23,1106.07,8083.91,"percent of total billed charges",
"TIP ASPIR 12CM 2.49MM 2MM SONOPET IQ LARGE SOFT TISSUE",SUP-5500-25S-308,CDM,S27200284,LOCAL,0272,RC,,,both,,,6269.10,1880.73,"CIGNA [10200]","Cigna Open Access",,3567.12,56.9,,,,,0,729.1,5328.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CROSSTELLA 90CM 60MM 4-3.4FR 5MM BALLOON DILATATION",SUP-BD-F50060MR,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"MULTIPLAN [10600]",Multiplan,,1273.73,85,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 125CM 5FR 145D PIGTAIL CURVE ANGIOGRAPHIC",SUP-7529-53,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"UHC [10700]","United Healthcare",,51.82,63.3,,,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 41MM UNITRAX FEMORAL HIP MODULAR",SUP-6942-5-041,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA [10200]",Cigna,,2126.84,68,,5873.17,5873.17,5873.17,"1 through 10",363.75,2658.55,"percent of total billed charges",
"NDL BIOPSY 18GA 17GA 10CM BIOPINCE ULTRA FULL CORE CO-AXIAL",SUP-360-1080-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.84,161.35,"CIGNA [10200]","Cigna Local Plus",,287.74,53.5,,,,,0,62.55,457.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM CARBO-SEAL ASCENDING AORTA VALSALVA",SUP-CP-025,CDM,S27800098,LOCAL,0278,RC,,,both,,,29408.40,8822.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3484.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3420.2,24997.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 12MM 150MM KII ABDOMINAL ACCESS SYSTEM",SUP-CFS21,CDM,S27200284,LOCAL,0272,RC,,,both,,,119.63,35.89,"AETNA [10100]","Aetna HMO/PPO",,95.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 STD KNEE LEFT CRUCIATE RETAINING PERSONA",SUP-42502806401,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11876.08,41.1,,6417.48,6417.48,6417.48,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"AEON ENDOSTAPLER RELOAD 30MM GRAY",SUP-AESR30G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 5MM 75MM KII ADVANCE FIXATION RETENTION",SUP-CFS03,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"MULTIPLAN [10600]",Multiplan,,59.16,85,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 3-0 CT-1 SPIRAL 45CM SUT",SUP-SXMP1B429,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -4MM 28MM HIP BIOLOX DELTA V40",SUP-6570-0-028,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"BLUE CROSS [10001]","Blue Cross HMO",,3920,39.2,,5311.50,4717.44,5388.59,31,1163,8500,"percent of total billed charges",
"SHUNT NEUROSURGICAL BACTISEAL CSF 120CM PERITONEAL CATH",SUP-823074,CDM,S27800098,LOCAL,0278,RC,,,both,,,4520.33,1356.1,"CIGNA [10200]","Cigna Open Access",,2572.07,56.9,,,,,0,525.71,3842.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 36MM REUNION 2MM OFFSET SHOULDER CONCENTRIC",SUP-5573-C-3602,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4877.28,40,,,,,0,1418.07,10364.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27X24-32X19MM FRA 8D SPINE THORACOLUMBAR",SUP-10519,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]",Cigna,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN POSITIONING 7.3MM STAINLESS STEEL CRIMP STERILE",SUP-02.221.006S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,1831.33,1831.33,1831.33,16,189.34,1383.8,"percent of total billed charges",
"SPHINTOM 200CM 30MM 5.5FR ULTRATOME XL BILIARY PANCREAS 3",SUP-M00535920,CDM,S27200284,LOCAL,0272,RC,,,both,,,999.05,299.71,"CIGNA [10200]",Cigna,,679.35,68,,,,,0,116.19,849.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 110MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RELIEVA VORTEX IRRIGATION SINUS ENDOSCOPY",SUP-LC7065,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"UHC [10700]","United Healthcare",,640.91,63.3,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 16MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-316,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"KAISER [10500]",Kaiser,,6586.45,67,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL INSUFFLATION 150MM 14GA ENDOPATH SPRING LOAD BLUNT",SUP-PN150,CDM,S27200284,LOCAL,0272,RC,,,both,,,273.66,82.1,"FIRST HEALTH [10303]","First Health",,218.93,80,,,,,0,31.83,232.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 140MM 80CM 16MM BILIARY VENOUS DELIVERY",SUP-G57449,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"CIGNA [10200]","Cigna Local Plus",,4564.35,31.5,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL SHAVER 2.6MM FIBERTAK",SUP-AR-3657SD,CDM,S27200284,LOCAL,0272,RC,,,both,,,1063.13,318.94,"CIGNA [10200]","Cigna Open Access",,604.92,56.9,,,,,0,123.64,903.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 31X9X.38MM PRECISION MEDIUM LONG STAINLESS STEEL",SUP-2296-003-225,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"KAISER [10500]",Kaiser,,181.05,67,,,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DISPOSABLES CS FIBERTAK",SUP-AR-8991DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,2165.63,649.69,"CIGNA [10200]","Cigna Local Plus",,1158.61,53.5,,,,,0,251.86,1840.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM OZARK SPINE CERVICAL SELF START VARIABLE",SUP-8801-04016DA,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,1144.80,304.56,2275.09,66,117.75,860.63,"percent of total billed charges",
"CHISEL SURGICAL 6.75IN 8MM V BALLENGER",SUP-63-0091,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT HUMERAL EQUINOXE 1.5MM OFFSET SHOULDER TITANIUM",SUP-300-10-15,CDM,C1776,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FLOSWITCH 1050 PSI FLOW CONTROL 1 WAY HIGH PRESSURE",SUP-M001442011,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.60,17.88,"CIGNA [10200]",Cigna,,40.53,68,,,,,0,6.93,50.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR JR4.5 CURVE GUIDING CORONARY",SUP-LA8JR45,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"UHC [10700]","United Healthcare",,231.3,63.3,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HARVESTER 2.5CM SMALL EPIDERMAL GRAFT CELLUTOME STERILE",SUP-CT-H25,CDM,S27200284,LOCAL,0272,RC,,,both,,,3228.75,968.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2195.55,68,,,,,0,375.5,2744.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25X10X9MM 9MM CRESCENT 6D THORACOLUMBAR PEEK 4",SUP-9192509,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1962.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 113MM 30-12MM 7.7MM 20FR ZENITH RENU",SUP-G55382,CDM,C1874,HCPCS,0278,RC,,,both,,,43501.50,13050.45,"BLUE CROSS [10001]","Blue Cross PPO",,17052.59,39.2,,,,,0,5059.22,36976.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL RESTORIS 5 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-180605,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"CIGNA [10200]","Cigna Open Access",,3771.02,56.9,,5302.19,4377.88,6578.61,27,770.77,5633.33,"percent of total billed charges",
"XIENCE SKYPOINT DES 3.25 X 33 RX US",SUP-1804325-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 90CM 5FR STRAIGHT GUIDING DURAFORM",SUP-M003100640,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"NOVANET [10819]",Novanet,,1877.35,75,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 65CM 5FR PIGTAIL CURVE ANGIOGRAPHIC",SUP-5653510PIG-NB,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"NOVANET [10819]",Novanet,,78.3,75,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X8MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7008,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4692,68,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBTR LAPAROSCOPIC 8MM WECK VISTA LONG BLADELESS STERILE",SUP-470360,CDM,S27200284,LOCAL,0272,RC,,,both,,,274.05,82.21,"FIRST HEALTH [10303]","First Health",,219.24,80,,,,,0,31.87,232.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY 2-8-2MM SPACING 6FR 115CM 2MM",SUP-401926R,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 21.5X12.7X.3MM LARGE SAGITTAL STERILE",SUP-1200-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,146.16,43.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 8MM 6FR 1.2MM .07IN ULTRA LOW",SUP-H7493918908120,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"KAISER [10500]",Kaiser,,379.89,67,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE PIN ORTHOPEDIC TRUMATCH FEMORAL RIGHT STERILE ATTUNE",SUP-420946,CDM,S27200284,LOCAL,0272,RC,,,both,,,14138.10,4241.43,"CIGNA [10200]",Cigna,,9613.91,68,,,,,0,1644.26,12017.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS SHEET 45MMX20MMX7MM",SUP-4W0047,CDM,C1713,HCPCS,0278,RC,,,both,,,15559.50,4667.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1843.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1809.57,13225.58,"percent of total billed charges",
"GUIDE PIN ORTHOPEDIC TRUMATCH FEMORAL RIGHT STERILE ATTUNE",SUP-420946,CDM,S27200284,LOCAL,0272,RC,,,both,,,14138.10,4241.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9613.91,68,,,,,0,1644.26,12017.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP UNISTEP PLUS 68MM 135CM 10MM 160CM",SUP-M001711370,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"FIRST HEALTH [10303]","First Health",,6762,80,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FRACTURE OMNICURVE 11G 15MM",SUP-1032-115-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"FOL URETHRAL 13.35IN 16FR HEYMAN PLASTIC DILATION CATH",SUP-021116,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.13,65.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.25,184.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL FINE 7IN DRSG STD PATTERN SERRATE HANDLE",SUP-06-0018,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.94,16.18,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ADPTR FEMORAL PFC SIGMA +2/-2MM OFFSET KNEE BOLT STERILE",SUP-96-0784,CDM,C1776,HCPCS,0278,RC,,,both,,,1671.00,501.3,"BLUE CROSS [10001]","Blue Cross PPO",,655.03,39.2,,3949.44,3949.44,3949.44,"1 through 10",194.34,1420.35,"percent of total billed charges",
"CATH LUTONIX 75CM 60MM 6MM BALLOON DILATATION DRUG COATED",SUP-LX3575660V,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE NERVE STIM NIM XPAK PEDICLE",SUP-9450069,CDM,S27200284,LOCAL,0272,RC,,,both,,,1605.74,481.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,659.96,41.1,,,,,0,186.75,1364.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HI-FLO RENEGADE FATHOM 180CM 150CM 2.8-3FR 20CM MICRO",SUP-18457,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT ARTHROSCOPIC FIXATION FAST-FIX FLEX BENDER CANN SET",SUP-72205325,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER NERVOUS SYSTEM AND RELATED PROCEDURES,EXTREME",026,APR-DRG,,,,,,,inpatient,,,310619.37,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 24MM 2.5MM CORONARY STENT EVEROLIMUS PLATINUM",SUP-H7493926124250,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1022.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH PORTEX BLUPERC PERCUTANEOUS DILATION NDL SYR",SUP-101/562/000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2088.53,626.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 20CM 6MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120620,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"MULTIPLAN [10600]",Multiplan,,10099.53,85,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP PULSED LAVAGE INTERPULSE IRRIGATION PUMP SUCTION FEMORAL",SUP-210008000,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.44,28.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WRAP THERAPEUTIC HEAD",SUP-600,CDM,S27000186,LOCAL,0270,RC,,,both,,,728.19,218.46,"FIRST HEALTH [10303]","First Health",,582.55,80,,,,,0,84.69,618.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATH GUIDING RDND 1 CURVE 6FR .07IN 55CM CORONARY SOF",SUP-SA6RDND1K,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"FIRST HEALTH [10303]","First Health",,292.32,80,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 3/16IN STEINMANN 2 TROCAR POINT",SUP-163038000,CDM,C1713,HCPCS,0278,RC,,,both,,,203.00,60.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",23.61,172.55,"percent of total billed charges",
"VIABAHN BX BALLOON EXP ENDO 9MMX39MM 8FR 80CMCATH HEPARIN",SUP-BXB093901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5582.27,28.62,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BENTSON 22CM 15CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175261060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"FIRST HEALTH [10303]","First Health",,797.94,80,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX39MM 8FR 80CMCATH HEPARIN",SUP-BXB093901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]","Cigna Local Plus",,6144.01,31.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC",715,MS-DRG,,,,,,,inpatient,,,132254.08,39676.22,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,28258.61,,"Case rate ($13,878.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,886.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,926.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $12,903.81. The transfer operating threshold is the transfer adjustment factor * $12,886.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.30. The transfer capital threshold is the transfer adjustment factor * $974.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,65320.21,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 8FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0165SI08,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.82,19.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.54,55.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 20GA GRIESHABER SILICONE SOFT TIP STERILE",SUP-8065149520,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.61,53.58,"CIGNA [10200]","Cigna Open Access",,101.63,56.9,,,,,0,20.77,151.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER FEMORAL 11MM OMNIFIT UNIVERSAL DISTAL HIP CEMENTED",SUP-1067-0011,CDM,C1776,HCPCS,0278,RC,,,both,,,620.57,186.17,"NOVANET [10819]",Novanet,,465.43,75,,,,,0,72.17,527.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +6 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000060,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 13MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P413,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"MULTIPLAN [10600]",Multiplan,,7102.52,85,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX8-12MM CALIBER",SUP-194122,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"CIGNA [10200]","Cigna Local Plus",,9072,31.5,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR EXTRICATION AQUA 1.75IN PROCARE FLAT CONTOUR CERVICAL",SUP-79-83022,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.12,17.44,"KAISER [10500]",Kaiser,,38.94,67,,,,,0,6.76,49.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-0 TH-50 48IN NONABSORBABLE",SUP-0U01A,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.35,88.3,"MULTIPLAN [10600]",Multiplan,,250.2,85,,,,,0,34.23,250.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 69.6X45.8X25MM MBT 3+ MM KNEE CEMENT REVISION",SUP-1294-35-325,CDM,C1776,HCPCS,0278,RC,,,both,,,35980.56,10794.17,"UHC [10700]","United Healthcare",,22775.69,63.3,,8601.07,8395.67,8601.07,"1 through 10",4184.54,30583.48,"percent of total billed charges",
"CAP SYSTEM TKR POROUS PATELLA TIBIA",SUP-98000671003,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"AETNA [10100]","Aetna HMO/PPO",,17529.75,79.5,,10981.53,8986.79,12413.38,12,2564.42,18742.5,"percent of total billed charges",
"TRAY TIBIAL 80.6X53.1X4.8MM MBT 5MM KNEE CEMENTED REVISION",SUP-129435150,CDM,C1776,HCPCS,0278,RC,,,both,,,22385.16,6715.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2652.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2603.39,19027.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 15MM 3MM BALLOON DILATATION DURATRAC",SUP-NCEUP3015X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 32MM 0D E HIP X3 TRIDENT",SUP-623-00-32E,CDM,C1776,HCPCS,0278,RC,,,both,,,6242.04,1872.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,739.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,725.95,5305.73,"percent of total billed charges",
"SCR BONE 5MM 42MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.042TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"STEM FEMORAL 150MM 17MM CEMENTLESS TOTAL STABILIZED",SUP-5566-S-017,CDM,C1776,HCPCS,0278,RC,,,both,,,5447.65,1634.29,"CIGNA [10200]","Cigna Open Access",,3099.71,56.9,,5302.19,4377.88,6578.61,27,633.56,4630.5,"percent of total billed charges",
"(EVAL) ISOLATOR SYNERGY ENCOMPASS CLAMP - MODEL OLH",SUP-A001143-9,CDM,S62400003,LOCAL,0624,RC,,,both,,,34020.00,10206,"CIGNA [10200]",Cigna,,23133.6,68,,,,,0,3956.53,28917,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL RESTORIS 3 KNEE RIGHT MEDIAL LEFT LATERAL",SUP-180613,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"CIGNA [10200]","Cigna Local Plus",,3545.69,53.5,,5372.07,4581.20,7242.98,23,770.77,5633.33,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL FRONT LOAD BUTTON",SUP-786500,CDM,S27200284,LOCAL,0272,RC,,,both,,,3360.38,1008.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2285.06,68,,,,,0,390.81,2856.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 56MM 36MM XLPE HIP STERILE",SUP-71332756,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"KAISER [10500]",Kaiser,,7454.59,67,,,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.00 X 15 RX US",SUP-1804300-15,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20CM 14.5FR 15FR STRAIGHT POLYURETHANE GLIDEPATH",SUP-5397150,CDM,C1750,HCPCS,0278,RC,,,both,,,1875.00,562.5,"KAISER [10500]",Kaiser,,1256.25,67,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 21MM FREESTYLE PORCINE BIOPROSTHESIS COMPLETE",SUP-995CS-21MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,38430.00,11529,"KAISER [10500]",Kaiser,,25748.1,67,,,,,0,4469.41,32665.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 54.5X40X.8MM HALL STERNOTOMY REPEAT STERILE",SUP-00507122900,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.37,40.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.51,113.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 5ML 1-5MM CANCELLOUS ALLOGRAFT MILLED CHIP",SUP-400105,CDM,C1713,HCPCS,0278,RC,,,both,,,1619.03,485.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1100.94,68,,,,,0,188.29,1376.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemo IV Inf Add Hr",PX-335000002,CDM,96415,CPT,0335,RC,,,both,,,464.91,139.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,55.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.07,464.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 21FR .038IN FEMORAL ARTERIAL WIRE WOUND INTRO",SUP-ER21B,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ASCENDA 114CM 86CM 4FR .5MM INTRATHECAL SILICONE",SUP-8780,CDM,C1755,HCPCS,0278,RC,,,both,,,8769.90,2630.97,"BLUE CROSS [10001]","Blue Cross PPO",,3437.8,39.2,,,,,0,1019.94,7454.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI FIELDER XT-A 300CM",SUP-APW14R309S,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM FEMORAL 115MM PRIMARY CEMENT DISTAL BULLET TIP SYNERGY",SUP-71316010,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8505,40,,,,,0,2472.83,18073.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE 1.67FT TEMPERATURE CARE EXT PROBE LATEX FREE",SUP-2021700-001,CDM,S27000186,LOCAL,0270,RC,,,both,,,567.24,170.17,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM FEMORAL 127MM 13MM CEMENT GMRS COCR STRAIGHT HIP",SUP-6485-3-113,CDM,C1776,HCPCS,0278,RC,,,both,,,14800.50,4440.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4235.9,28.62,,,,,0,1721.3,12580.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 4X28+TRAK21+CAT7 3-PACK - US",SUP-SFP913130,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"HC Co2",PX-301000130,CDM,82374,CPT,0301,RC,,,both,,,70.00,21,"CIGNA [10200]","Cigna Open Access",,10.74,,,,,,,0.01,59.5,"fee schedule",
"DEVICE WATCHMAN 24MM 75CM 12FR 14FR CLSR PEBAX NITINOL",SUP-M635WU24060,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION IJS ELBOW BASE PLATE",SUP-IJS-ELB-BPA,CDM,C1776,HCPCS,0278,RC,,,both,,,33950.70,10185.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4023.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3948.47,28858.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXCATH CROSS TRANSSEPTAL SOLUTION ? FCC 65CM, 10F",SUP-900310,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Abd&Pelvis WO Cntrst",PX-352000028,CDM,74176,CPT,0352,RC,,,both,,,4731.01,1419.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,583.68,,,,,,,405,4021.36,"fee schedule",
"SCR BONE 4MM 40MM TALON DISTALFIX CORTICAL",SUP-HTN-U-4-40,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"CIGNA [10200]","Cigna Local Plus",,832.03,53.5,,3978.14,359.25,3978.14,24,180.87,1321.92,"percent of total billed charges",
"TUBE TRACH 10 STD 55MM 15MM 12MM PROVOX LIFE LARYTUBE",SUP-7417,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,812.54,68,,,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC RATCHET HANDLE STRAIGHT JAW ROTATION KNOB",SUP-5DSG,CDM,S27200284,LOCAL,0272,RC,,,both,,,1150.29,345.09,"FIRST HEALTH [10303]","First Health",,920.23,80,,,,,0,133.78,977.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 135CM 30MM 4MM .035IN BALLOON",SUP-AB35W04030135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,80.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER PACING LEAD ACUITY 11FR",SUP-7445,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRI-SIL 18FR URETHRAL BARD SILICONE 5CC 3 WAY FOLEY",SUP-70518SI,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.40,32.52,"CIGNA [10200]","Cigna Open Access",,61.68,56.9,,,,,0,12.61,92.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.50 X 28 RX US",SUP-1804250-28,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOTTLE DRNG VACUUM DRAIN LINE PLEURX 500ML",SUP-50-7205B,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"AETNA [10100]","Aetna HMO/PPO",,331.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC BREAST BIOPSY 14CM 9GA ATEC 20MM STD MRI DISPOSABLE","SUP-ATEC 0914-20MR",CDM,S27200284,LOCAL,0272,RC,,,both,,,2619.00,785.7,"FIRST HEALTH [10303]","First Health",,2095.2,80,,,,,0,304.59,2226.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO SELECT VASCULAR 300CM .014IN HYDROPHILIC SPRT",SUP-SSUP300PRE,CDM,C1769,HCPCS,0272,RC,,,both,,,5686.57,1705.97,"UHC [10700]","United Healthcare",,3599.6,63.3,,,,,0,661.35,4833.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 25MM 2.25MM ULTRA LOW PROFILE BALLOON",SUP-1012271-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 5.5IN WEITLANER 3X4 PRONG SHARP SELF RETAIN SURGICAL",SUP-24-2213,CDM,S27200284,LOCAL,0272,RC,,,both,,,297.11,89.13,"AETNA [10100]","Aetna HMO/PPO",,236.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.55,252.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 24CM 3CM 8FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155252050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]",Cigna,,837.05,68,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 135CM 7MM 30MM",SUP-38047-73013,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 30MM 80CM 12MM .079IN LARGE DIAMETER",SUP-SERB65-12-30-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 4 RIGHT DISTAL KNEE TOTAL",SUP-5540-A-402,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"BLUE CROSS [10001]","Blue Cross HMO",,1781.17,39.2,,5311.50,4717.44,5388.59,31,528.45,3862.24,"percent of total billed charges",
"MESH SURGICAL PARIETENE 20X20CM HERNIA VENTRAL BALANCE KNIT",SUP-PPM2020,CDM,C1781,HCPCS,0278,RC,,,both,,,640.71,192.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,75.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.51,544.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSELECT PLUS DEMINERALIZED BONE MATRIX 10CC P",SUP-359500,CDM,C1713,HCPCS,0278,RC,,,both,,,6900.00,2070,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3167.1,45.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txhep Port Perc W Hemo Eval Si",PX-323000029,CDM,75885,CPT,0320,RC,,,both,,,3213.00,963.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3213,,,,,,,113.41,3213,"fee schedule",
"GRAFT STENT 200MM 36MM VALIANT STRAIGHT ENDOVASCULAR",SUP-VAMF3636C200TU,CDM,C1874,HCPCS,0278,RC,,,both,,,102229.50,30668.85,"CIGNA [10200]","Cigna Local Plus",,32202.29,31.5,,,,,0,11889.29,86895.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP LAA EXCLUSION SYSTEM 35MM",SUP-ACH135,CDM,S27800098,LOCAL,0278,RC,,,both,,,8245.50,2473.65,"BLUE CROSS [10001]","Blue Cross PPO",,3232.24,39.2,,,,,0,958.95,7008.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ONYX 18 EMBOLIZATION DIMETHYL SULFOXIDE 1.5ML 1ML SYR",SUP-105-7100-060,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 28CM 10FR LARGE PROXIMAL PIGTAIL CURVE",SUP-M001235610,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,408.97,45.9,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 75CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR070201A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"NOVANET [10819]",Novanet,,14071.05,75,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 75CM 6MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR061001A,CDM,C1874,HCPCS,0278,RC,,,both,,,17545.50,5263.65,"BLUE CROSS [10001]","Blue Cross HMO",,6877.84,39.2,,9776.84,9776.84,9776.84,"1 through 10",2040.54,14913.68,"percent of total billed charges",
"SYSTEM PROMUS ELEMENT PLUS 8MM 144CM 3.5MM CORONARY STENT",SUP-H7493911408350,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"UHC [10700]","United Healthcare",,5787.2,63.3,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Surg Tx Abort Missed 1st Tr",PX-450000361,CDM,59820,CPT,0361,RC,,,both,,,8037.00,2411.1,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",3301.54,3301.54,3301.54,"1 through 10",934.7,6831.45,"fee schedule",
"GRAFT SKIN 8X4CM GRAFTJACKET ACELLULAR DERMAL MATRIX",SUP-GJ48,CDM,Q4107,HCPCS,0636,RC,,,both,,,17776.21,5332.86,"CIGNA [10200]","Cigna Open Access",,10114.66,56.9,,,,,0,247.92,15109.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Stnt 2+ Maj Cor Arty",PX-481000429,CDM,92930,CPT,0481,RC,,,both,,,46067.25,13820.17,"CIGNA [10200]",Cigna,,31325.73,68,,,,,0,4937,39157.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BNDG SETOPRESS 138X4IN STERILE COMPRESSION LATEX FREE",SUP-3505,CDM,S27000186,LOCAL,0270,RC,,,both,,,200.51,60.15,"UHC [10700]","United Healthcare",,126.92,63.3,,,,,0,23.32,170.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT NERVE 15MM 3MM AXOGUARD PORCINE EXTRACELLULAR MATRIX",SUP-AGX315,CDM,C1763,HCPCS,0278,RC,,,both,,,15366.30,4609.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1820.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1787.1,13061.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET VENTILATOR COAXIAL ELBOW ADPTR EXPIRATORY VALVE",SUP-260167,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4MM COOLCUT STERILE DISPOSABLE",SUP-AR-8400DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"UHC [10700]","United Healthcare",,317.64,63.3,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET VENTILATOR COAXIAL ELBOW ADPTR EXPIRATORY VALVE",SUP-260167,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAG SPEEDWHIP FIBERLOOP 2 NONABSORBABLE",SUP-AR-7264,CDM,S27200284,LOCAL,0272,RC,,,both,,,1063.13,318.94,"PHCS [10601]",PHCS,,744.19,70,,,,,0,123.64,903.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC",435,MS-DRG,,,,,,,inpatient,,,74505.71,22351.71,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,11734.95,,"Case rate ($11,393.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,579.32, add-ons for qualifying new technology services are included. If operating cost exceeds $43,619.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,181.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,593.31. The transfer operating threshold is the transfer adjustment factor * $10,579.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.85. The transfer capital threshold is the transfer adjustment factor * $799.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,45805.46,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB SKIN 10X6CM STRATTICE PORCINE DERMAL MATRIX FIRM PATCH",SUP-0610008,CDM,Q4130,HCPCS,0636,RC,,,both,,,10757.10,3227.13,"CIGNA [10200]","Cigna Open Access",,6120.79,56.9,,,,,0,1274.72,9143.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 8MMX8MMX6CM",SUP-TSB080806A,CDM,C1874,HCPCS,0278,RC,,,both,,,49140.00,14742,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5823.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5714.98,41769,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET GRAFT HARVEST ACL 11MM 10MM ALIGNMENT ROD CORE EXTRUDER",SUP-AR-1981-10S,CDM,S27200284,LOCAL,0272,RC,,,both,,,5126.70,1538.01,"CIGNA [10200]","Cigna Open Access",,2917.09,56.9,,,,,0,596.24,4357.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 90MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.890,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,630.85,45.9,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION LUBRI-SIL COMPLETE CARE CRITICORE 16FR",SUP-900916A,CDM,C1758,HCPCS,0272,RC,,,both,,,266.57,79.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,31.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31,226.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 12MM 5MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG50012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,858.6,28.62,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.430TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"CIGNA [10200]",Cigna,,1374.65,68,,1831.33,1831.33,1831.33,16,235.11,1718.32,"percent of total billed charges",
"SYSTEM SYNERGY XD MONORAIL 32MM 144CM 3.5MM CORONARY STENT",SUP-H7493941832350,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30MM STERILE LATEX FREE DISPOSABLE SUREFORM 8",SUP-488530,CDM,S27200284,LOCAL,0272,RC,,,both,,,3767.40,1130.22,"CIGNA [10200]","Cigna Open Access",,2143.65,56.9,,,,,0,438.15,3202.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 14CM 14.5MM 32MM EXCLUDER TRUNK",SUP-CXT321414,CDM,C1874,HCPCS,0278,RC,,,both,,,71175.90,21352.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,28470.36,40,,,,,0,8277.76,60499.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AMPLATZ 17CM 22FR ACCESS PTFE RENAL FIRM TAPER TIP",SUP-M0062601490,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"PHCS [10601]",PHCS,,234.22,70,,,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 9CM 18MM 18.5FR LOW PROFILE ESOPHAGEAL",SUP-M00516910,CDM,C1874,HCPCS,0278,RC,,,both,,,10022.00,3006.6,"CIGNA [10200]",Cigna,,6814.96,68,,,,,0,1165.56,8518.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 13CM SPLITTABLE SIDEPORT ROBUST VALVE",SUP-PLSH-1006,CDM,C1892,HCPCS,0272,RC,,,both,,,505.44,151.63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,59.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.78,429.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
UNGROUPABLE,999,MS-DRG,,,,,,,inpatient,,,50806.08,15241.82,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,5730.99,,"Case rate ($5,406.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,020.38, add-ons for qualifying new technology services are included. If operating cost exceeds $38,060.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,761.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,027.02. The transfer operating threshold is the transfer adjustment factor * $5,020.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $379.57. The transfer capital threshold is the transfer adjustment factor * $379.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,5406.59,21736.83,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH-PROFILE BOOST, 400CC",SUP-SMHB400,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5184.66,68,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.2MM TWIST STERILE",SUP-KM166-00-04,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.04,24.01,"CIGNA [10200]","Cigna Open Access",,45.54,56.9,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 12.5MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158103112,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"KAISER [10500]",Kaiser,,7486.95,67,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 20CM 37MM TAG THORACIC ACTIVE CONTROL",SUP-TGMR373720,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"KAISER [10500]",Kaiser,,77701.37,67,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 36MM REVISION MEDIUM LONG SHOULDER",SUP-520003036,CDM,C1776,HCPCS,0278,RC,,,both,,,29116.08,8734.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11966.71,41.1,,6417.48,6417.48,6417.48,"1 through 10",3386.2,24748.67,"percent of total billed charges",
"STENT HANAROSTENT 70MM 1800MM 10MM 2.33MM BILIARY NITINOL",SUP-SHS-10-070-180,CDM,C1874,HCPCS,0278,RC,,,both,,,6855.84,2056.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4661.97,68,,,,,0,797.33,5827.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 4X150 80CM SL",SUP-48004015N,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANNULA ARTHROSCOPIC L90 MM OD5.5 MM THREAD STERILE CLEAR",SUP-214110,CDM,S27200284,LOCAL,0272,RC,,,both,,,759.78,227.93,"CIGNA [10200]","Cigna Local Plus",,406.48,53.5,,,,,0,88.36,645.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER TUMARK BREAST BIOPSY VISION BREVERA PETITE STERILE",SUP-TUMARK-BREV-P-V-02,CDM,A4648,HCPCS,0278,RC,,,both,,,942.84,282.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,269.84,28.62,,,,,0,109.65,801.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 30MM 2MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG20030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD + VE",SUP-98000100209,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2930.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 10CM 21-26MM GORE TAG THORACIC ACTIVE CONTROL",SUP-TGM262110,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"MULTIPLAN [10600]",Multiplan,,98576.37,85,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Feeding Ng Levine",PX-E27200224,CDM,E27200224,LOCAL,0272,RC,,,both,,,52.32,15.7,"CIGNA [10200]",Cigna,,35.58,68,,,,,0,6.08,44.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 30MM 140CM 2.75MM CORONARY STERILE",SUP-453963,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Analyze 20-25 Cells",PX-312000062,CDM,88264,CPT,0311,RC,,,both,,,1835.40,550.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,154.76,,"Fee schedule rate ($154.76). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1560.09,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 8MM 2.5MM CORONARY STENT EVEROLIMUS",SUP-1550250-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 26MM 80CM 7MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU0800726,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"NOVANET [10819]",Novanet,,19608.75,75,,,,,0,3040.66,22223.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 8MM 2.5MM CORONARY STENT EVEROLIMUS",SUP-1550250-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 112MM PRIMARY ANTHOLOGY POROUS 131D 7 HIGH",SUP-71356107,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"AETNA [10100]","Aetna HMO/PPO",,26347.21,79.5,,10981.53,8986.79,12413.38,12,3854.32,28169.98,"percent of total billed charges",
"SYSTEM XIENCE SIERRA 38MM 2.75MM CORONARY STENT EVEROLIMUS",SUP-1550275-38,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEARTRAIL III 100CM 6FR IKARI RIGHT 2 CURVE GUIDING",SUP-40-6382,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"MULTIPLAN [10600]",Multiplan,,495.72,85,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 25CM 8FR PIGTAIL CURVE NEPHRSTMY FLEXIMA POLYURETHANE",SUP-M001271790,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 10X8X4MM FACET",SUP-609404,CDM,S27800098,LOCAL,0278,RC,,,both,,,3675.00,1102.5,"BLUE CROSS [10001]","Blue Cross PPO",,1440.6,39.2,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTMASTER 19MM 3.5MM CORONARY STENT STAINLESS STEEL",SUP-1012581-19,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"KAISER [10500]",Kaiser,,11072.09,67,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 12CM WIRE MANDREL HEMOSTASIS VALVE MICRO",SUP-CLI-101-15,CDM,C1894,HCPCS,0272,RC,,,both,,,295.80,88.74,"MULTIPLAN [10600]",Multiplan,,251.43,85,,,,,0,34.4,251.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET NDL 15MM 15GA EZ-IO STAINLESS STEEL 5GM STERILE LATEX",SUP-9018-VC-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1106.46,331.94,"FIRST HEALTH [10303]","First Health",,885.17,80,,,,,0,128.68,940.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 135CM 7MM 20MM",SUP-H74938047720130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3394.56,68,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 CTX 36IN BRAID COATED UNDYED ABSORBABLE",SUP-J979H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 60MM 13MM CEMENTLESS SMR TITANIUM MINI",SUP-1304.15.130,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CIGNA [10200]","Cigna Open Access",,4506.48,56.9,,5302.19,4377.88,6578.61,27,921.1,6732,"percent of total billed charges",
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC",190,MS-DRG,,,,,,,inpatient,,,33113.82,9934.15,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,7352.11,,"Case rate ($6,871.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,380.31, add-ons for qualifying new technology services are included. If operating cost exceeds $39,419.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,864.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,388.75. The transfer operating threshold is the transfer adjustment factor * $6,380.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $482.38. The transfer capital threshold is the transfer adjustment factor * $482.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,6871.13,27624.93,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BIOWICK INTERPOS BIORESORB",SUP-CM-6127,CDM,C1713,HCPCS,0278,RC,,,both,,,9729.00,2918.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2784.44,28.62,,,,,0,1131.48,8269.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 14MM PCM SPINE DISTRACTION NONSTERILE",SUP-7670214,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM BICARBONATE 50 MEQ/50 ML (8.4 %) INTRAVENOUS SYRINGE",RX-7309,CDM,,,0250,RC,76329-3352-01,NDC,both,50,ML,178.56,53.57,"CIGNA [10200]","Cigna Open Access",,101.6,56.9,,,,,0,20.77,151.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER LITHIUM EZ-IO SEAL BTTRY G3 POWER TRAINING 6.5X4.5",SUP-9059,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 4FR 6MM LOW PROFILE",SUP-39031-60401,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM PRECISION PERCUTANEOUS PHASE III",SUP-SC-2158-50,CDM,C1778,HCPCS,0278,RC,,,both,,,8914.80,2674.44,"BLUE CROSS [10001]","Blue Cross PPO",,3494.6,39.2,,,,,0,1036.79,7577.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZEBRA UROLOGICAL 150CM 3CM .032IN URO-GLIDE NITINOL",SUP-M0066701101,CDM,C1769,HCPCS,0272,RC,,,both,,,447.74,134.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP 100CM 6FR JL6 CURVE GUIDING STAINLESS",SUP-67001000,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"KAISER [10500]",Kaiser,,279.79,67,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 8- CM 22GA 5.2FR ULTRASOUND SHEATH BALL",SUP-G31521,CDM,S27200284,LOCAL,0272,RC,,,both,,,2340.00,702,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OCCL CARDIOVASCULAR 8MM 12-10MM 18MM DUCT SELF EXPANDABLE",SUP-9-PDA-007,CDM,C1817,HCPCS,0278,RC,,,both,,,34398.00,10319.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13759.2,40,,,,,0,4000.49,29238.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO SILVER 396MM 3.76MM 3.15MM SHOCKPULSE STERILE",SUP-SPL-PDBX376,CDM,S27200284,LOCAL,0272,RC,,,both,,,4740.81,1422.24,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 135MM 2MM AO DRIVE SCALE",SUP-703690,CDM,S27200284,LOCAL,0272,RC,,,both,,,1068.23,320.47,"UHC [10700]","United Healthcare",,676.19,63.3,,,,,0,124.24,908,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 21MM 2.5MM BALLOON DILATATION RAPID EXCHANGE",SUP-DC-RZ2521UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Acetylcholn Rcptr Bndng Antb",PX-301000691,CDM,86041,CPT,0301,RC,,,both,,,398.05,119.41,"AETNA [10100]","Aetna HMO/PPO",,316.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,338.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TRACER METRO DIRECT ENDOSCOPIC SPIRAL 480CM 5CM .035IN",SUP-G25686,CDM,C1769,HCPCS,0272,RC,,,both,,,1498.50,449.55,"FIRST HEALTH [10303]","First Health",,1198.8,80,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL 3.3MM ARTHROWAND COVAC 2O 20D HOOK",SUP-AC434001,CDM,S27200284,LOCAL,0272,RC,,,both,,,3692.25,1107.67,"CIGNA [10200]",Cigna,,2510.73,68,,,,,0,429.41,3138.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION MENISCAL ROOT REPAIR",SUP-AR-4550,CDM,S27200284,LOCAL,0272,RC,,,both,,,7208.78,2162.63,"CIGNA [10200]",Cigna,,4901.97,68,,,,,0,838.38,6127.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORD MONOPOLAR 10FT OLSEN 90D SPINE STRAIGHT PLUG STERILE",SUP-50-2111,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.55,69.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,27.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Pilonidal Cyst Smpl",PX-450000006,CDM,10080,CPT,0361,RC,,,both,,,3381.00,1014.3,"NOVANET [10819]",Novanet,,2535.75,75,,,,,0,393.21,3381,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM SPINE POLYAXIAL REVOLVE",SUP-185.456,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AETNA [10100]","Aetna HMO/PPO",,7589.75,79.5,,1521.93,481.35,16760.95,30,1110.3,8114.82,"percent of total billed charges",
"KIT CIRCUIT FISHER AND PAYKEL HEALTHCARE 1 LIMB O2 LIGHTWEIGHT",SUP-RT408,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.79,105.84,"PHCS [10601]",PHCS,,246.95,70,,,,,0,41.03,299.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE JOURNEY II WITH OXINIUM HEAD VERILA",SUP-71709000,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]",Cigna,,8820,40,,5873.17,5873.17,5873.17,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"CW001, 5MMX42CM EPIX ES SMK EVAC ANG SPT",SUP-CW001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC AVALUS 21MM 400 SERIES LATEX FREE",SUP-40021,CDM,S27800098,LOCAL,0278,RC,,,both,,,33390.00,10017,"CIGNA [10200]","Cigna Open Access",,11185.65,33.5,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 52.5MM TRIGEN LOW PROFILE FEMUR",SUP-71645052,CDM,C1713,HCPCS,0278,RC,,,both,,,2314.95,694.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1574.17,68,,,,,0,269.23,1967.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 20MM STAINLESS STEEL HIP OSTEOTOM SHORT CURVE MRI",SUP-47998602125,CDM,S27200284,LOCAL,0272,RC,,,both,,,996.30,298.89,"AETNA [10100]","Aetna HMO/PPO",,792.06,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAPIPLASTY SYSTEM ANATOMIC BIPLANAR IMPLANTS",SUP-SK12,CDM,C1713,HCPCS,0278,RC,,,both,,,24570.00,7371,"PHCS [10601]",PHCS,,17199,70,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Serpina1 Gene",PX-309000073,CDM,81332,CPT,0310,RC,,,both,,,505.00,151.5,"PHCS [10601]",PHCS,,353.5,70,,,,,0,0.51,429.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet/CT Tumor Ltd",PX-404000003,CDM,78814,CPT,0404,RC,,,both,,,7540.46,2262.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,876.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,876.96,7540.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 14MM PERSONA MEDIAL CONGRUENT 8-9 C-D KNEE",SUP-42522100514,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7327.97,68,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veno Ext Bil Si",PX-320000130,CDM,75822,CPT,0320,RC,,,both,,,2582.46,774.74,"CIGNA [10200]","Cigna Local Plus",,143.92,,,,,,,102.91,2582.46,"fee schedule",
"SET STENT 16CM 6FR SOF-FLEX SMALL 2 PIGTAIL CURVE COUDE",SUP-G14865,CDM,C2617,HCPCS,0278,RC,,,both,,,1028.70,308.61,"BLUE CROSS [10001]","Blue Cross PPO",,403.25,39.2,,,,,0,119.64,874.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tiss Cult Skin or Solid Tumor",PX-311000026,CDM,88233,CPT,0311,RC,,,both,,,1359.45,407.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,147.76,,"Fee schedule rate ($147.76). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1155.53,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS) SUGAR-FREE NO.20 ORAL",RX-172911,CDM,,,0250,RC,00574-0303-16,NDC,both,473,ML,139.83,41.95,"PHCS [10601]",PHCS,,97.88,70,,,,,0,16.26,118.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Hip W Anes",PX-361000354,CDM,27095,CPT,0361,RC,,,both,,,1108.00,332.4,"UHC [10700]","United Healthcare",,1108,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,128.86,1108,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION",RX-10266,CDM,,,0250,RC,70100-0424-01,NDC,both,1,UN,1281.08,384.32,"CIGNA [10200]","Cigna Open Access",,728.93,56.9,,,,,0,148.99,1088.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemo Inf Add Seq Dif Drug",PX-335000004,CDM,96417,CPT,0335,RC,,,both,,,713.33,214,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,713.33,,"Per diem ($830).",,,,0,82.96,713.33,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHALLOY NYLON ETHILON 5-0 PC-5 18IN MONOFILAMENT BLACK",SUP-1895G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Open Access",,14.23,56.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM VARIAX TORX TITANIUM FULL THREAD T10",SUP-40-35616,CDM,C1713,HCPCS,0278,RC,,,both,,,1211.11,363.33,"FIRST HEALTH [10303]","First Health",,968.89,80,,,,,0,140.85,1029.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 15CM FRANSEEN CANN SERRATE EDGE LUNG STERILE",SUP-G01266,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.10,58.23,"UHC [10700]","United Healthcare",,122.87,63.3,,,,,0,22.57,164.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I123 Datscan per Dose Up to 5mci",PX-343000027,CDM,A9584,HCPCS,0343,RC,,,both,,,11340.00,3402,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1318.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1318.84,9639,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE 25MMX10CM",SUP-7509010,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"BLUE CROSS [10001]","Blue Cross PPO",,2650.7,39.2,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM NARROW BLADE",SUP-7541123,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",348.9,2550,"percent of total billed charges",
"LINER ACETABULAR R3 20D 60MM 36MM XLPE HIP STERILE",SUP-71335760,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1318.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1293.98,9457.31,"percent of total billed charges",
"SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS",870,MS-DRG,,,,,,,inpatient,,,172930.99,51879.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,137206.14,,"Fee schedule rate ($137,206.14). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,10994,172373.38,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM PRIMARY CEMENT DISTAL BULLET TIP SYNERGY",SUP-71316010,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6085.33,28.62,,,,,0,2472.83,18073.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 75CM TRANSSEPTAL ACCESS SYSTEM ACQCROSS WATCHMAN TRUSEAL",SUP-900308,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX10MM VANGUARD SSK POLYETHYLENE KNEE",SUP-185100,CDM,C1776,HCPCS,0278,RC,,,both,,,14683.20,4404.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1707.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1707.66,12480.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE PHALANX 1.5",SUP-PRT-PHX-015,CDM,C1713,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"CIGNA [10200]","Cigna Open Access",,4083.14,56.9,,1144.80,304.56,2275.09,66,834.57,6099.6,"percent of total billed charges",
"BODY CALCAR 29MM RESTORATION +10MM OFFSET HIP MODULAR",SUP-6276-4-129,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2698.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2698.86,19725.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 22MM TITANIUM DISTAL RADIAL CORTICAL WRIST",SUP-CO-T2322,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"BLUE CROSS [10001]","Blue Cross PPO",,298.47,39.2,,957.42,570.23,957.42,28,88.55,647.19,"percent of total billed charges",
"JOINT FINGER SWANSON 4 METACARPOPHALANGEAL GROMMET HIGH",SUP-G4700004,CDM,C1776,HCPCS,0278,RC,,,both,,,4170.60,1251.18,"MULTIPLAN [10600]",Multiplan,,3545.01,85,,,,,0,485.04,3545.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 28MM 7MM FULL THREAD STEP",SUP-AR-1370TC,CDM,C1713,HCPCS,0272,RC,,,both,,,1850.63,555.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,760.61,41.1,,,,,0,760.61,1171.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 50MM 36MM XLPE HIP STERILE LATEX FREE",SUP-71935848,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.90,3024.27,"CIGNA [10200]",Cigna,,6855.01,68,,5873.17,5873.17,5873.17,"1 through 10",1172.41,8568.77,"percent of total billed charges",
"PLATE 85MM ATLANTIS VISION ELITE BONE SPINE",SUP-7200185,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME PATELLAR 9MM 38MM KNEE E PLUS 3 PEG STERILE",SUP-130-03-738,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 40MM BEVEL STERILE LATEX FREE MIS",SUP-SF3040,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"AETNA [10100]","Aetna HMO/PPO",,3949.56,79.5,,1521.93,481.35,16760.95,30,577.78,4222.8,"percent of total billed charges",
"CNTRLZR STEM 12MM C-STEM HIP FEMUR PMMA CEMENT VOID STERILE",SUP-961212500,CDM,C1776,HCPCS,0278,RC,,,both,,,842.40,252.72,"FIRST HEALTH [10303]","First Health",,673.92,80,,,,,0,97.97,716.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCKER SPINAL MANTIS PEDICLE REDUCTION",SUP-48289999,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"MULTIPLAN [10600]",Multiplan,,295.8,85,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 17MM 46MM SHOULDER AEQUALIS ASCEND FLEX COCR",SUP-DWF046,CDM,C1776,HCPCS,0278,RC,,,both,,,9475.00,2842.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3894.23,41.1,,6417.48,6417.48,6417.48,"1 through 10",1101.94,8053.75,"percent of total billed charges",
"SCR BONE 2.7MM 14MM STERNALOCK BLU STERNAL CANCELLOUS LOCK",SUP-73-2714,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,112.05,28.62,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prostatic Acid Phosphate",PX-301000354,CDM,84066,CPT,0301,RC,,,both,,,87.40,26.22,"CIGNA [10200]","Cigna Local Plus",,21.25,,,,,,,0.01,74.29,"fee schedule",
"ROD SPINAL 300MM 5.5MM RELINE STRAIGHT TITANIUM MAS",SUP-12355300,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 15MM CEMENTLESS MODULAR AML POROUS 52MM",SUP-155403150,CDM,C1776,HCPCS,0278,RC,,,both,,,15374.88,4612.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1821.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1788.1,13068.65,"percent of total billed charges",
"CATH GLIDECATH GLIDE TECHNOLOGY 100CM 25CM 5FR .047IN",SUP-CG510,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 9MM KNEE ONLAY MULTICOMPARTMENTAL RESTORIS",SUP-180704-1,CDM,C1776,HCPCS,0278,RC,,,both,,,4046.85,1214.05,"CIGNA [10200]",Cigna,,2751.86,68,,5873.17,5873.17,5873.17,"1 through 10",470.65,3439.82,"percent of total billed charges",
"SCREW BONE 1.3MM 7MM TITANIUM CORTICAL CRANIOFACIAL SELF TAP",SUP-400.687,CDM,C1713,HCPCS,0278,RC,,,both,,,650.92,195.28,"KAISER [10500]",Kaiser,,436.12,67,,,,,0,75.7,553.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR VIVACIT-E KK ELEVATED 56MM 36MM HIP",SUP-00885201236,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1214.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1192.31,8714.22,"percent of total billed charges",
"AUG FEMORAL 8MM PFC SIGMA 2.5 KNEE POSTERIOR TITANIUM CEMENT",SUP-96-0848,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"FIRST HEALTH [10303]","First Health",,4104.67,80,,,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 7.5MM EVOLVE +2MM ELBOW PROLINE MODULAR",SUP-496S275,CDM,C1776,HCPCS,0278,RC,,,both,,,14614.20,4384.26,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4182.58,28.62,,,,,0,1699.63,12422.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROXYZINE HCL 25 MG TABLET",RX-3774,CDM,,,0637,RC,63739-0486-10,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 7.5MM EVOLVE +2MM ELBOW PROLINE MODULAR",SUP-496S275,CDM,C1776,HCPCS,0278,RC,,,both,,,14614.20,4384.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3945.83,27,,,,,0,1699.63,12422.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL ADJUSTMENT HELIX LOCKING TOOL",SUP-A001HELX,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE REVISION HYBRID CONCELOC OXI WITH CEMENTE",SUP-71704640,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"AETNA [10100]","Aetna HMO/PPO",,18531.45,79.5,,10981.53,8986.79,12413.38,12,2710.95,19813.5,"percent of total billed charges",
"INSRT TIBIAL 6 10MM KNEE RIGHT E-PLUS EMPOWR 3D KNEE STERILE",SUP-342-10-706,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,776.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT SHOULDER TRABECULAR METAL REVERSE",SUP-98000971000,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"CIGNA [10200]","Cigna Open Access",,16250.85,33.5,,5302.19,4377.88,6578.61,27,5641.71,41233.5,"percent of total billed charges",
"I-GEL, SINGLE USE SUPRAGLOTTIC AIRWAY, SIZE 2",SUP-8202000,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.13,23.74,"MULTIPLAN [10600]",Multiplan,,67.26,85,,,,,0,9.2,67.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 58MM 36MM MARATHON HIP",SUP-121936058,CDM,C1776,HCPCS,0278,RC,,,both,,,8942.40,2682.72,"NOVANET [10819]",Novanet,,6706.8,75,,,,,0,1040,7601.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 345CC NATRELLE INSPIRA COHESIVE STERILE LATEX",SUP-SCM-345,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]","Cigna Local Plus",,4042.19,,,,,,,878.7,6422.18,"percent of total billed charges",
"CMPNT FEMORAL 6 KNEE RIGHT CRUCIATE RETAIN CEMENTLESS ATTUNE",SUP-150401206,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"UHC [10700]","United Healthcare",,18214.73,63.3,,8601.07,8395.67,8601.07,"1 through 10",3346.56,24458.96,"percent of total billed charges",
"TISSUE 330944 ACSR 9X14X14 SRVC FEE",SUP-330944,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD",SUP-98000700014,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STAPLER ENDO GIA TRI-STAPLE TITANIUM 3 MM 3.5 MM 4 MM",SUP-SIGTRS60AMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2843.70,853.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1305.26,45.9,,,,,0,330.72,2417.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 CURVE 15MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962023,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"BLUE CROSS [10001]","Blue Cross PPO",,3625.78,39.2,,3949.44,3949.44,3949.44,"1 through 10",1075.71,7862.03,"percent of total billed charges",
"BIT DRILL 2.5MM OASYS SPINE TETHER 3.5MM SCR STERILE",SUP-48560323,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"CIGNA [10200]",Cigna,,2690.35,68,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ASAHI SASUKE 145CM 3.3FR INFUSION STERILE LATEX FREE",SUP-SA145-33N,CDM,C1887,HCPCS,0272,RC,,,both,,,3262.50,978.75,"AETNA [10100]","Aetna HMO/PPO",,2593.69,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,379.43,2773.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE JOURNEY II WITH OXINIUM HEAD VERILA",SUP-71709000,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"UHC [10700]","United Healthcare",,13957.65,63.3,,8601.07,8395.67,8601.07,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"CATH FOGARTY 80CM 4FR 9MM ROUND EMBOLECTOMY STAINLESS STEEL",SUP-120804FP,CDM,C1757,HCPCS,0272,RC,,,both,,,310.76,93.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,211.32,68,,,,,0,36.14,264.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183762,CDM,C1776,HCPCS,0278,RC,,,both,,,13241.10,3972.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1539.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1539.94,11254.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT SHOULDER REVERSE","SUP-CON ALTIVATE SHOULDER",CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"UHC [10700]","United Healthcare",,28712.88,63.3,,8601.07,8395.67,8601.07,"1 through 10",5275.37,38556,"percent of total billed charges",
"LEAD PACING 80CM 4.1-2.6FR SPIRAL LEFT VENTRICLE CORONARY",SUP-4591,CDM,C1726,HCPCS,0272,RC,,,both,,,5607.00,1682.1,"KAISER [10500]",Kaiser,,3756.69,67,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 60CM 2FR 4.5MM EMBOLECTOMY .5ML 1 LUMEN BALLOON LATEX",SUP-E1601-26,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,246.35,41.1,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 11FR NONHEMOSTASIS GUIDING ELECTROPHYSIOLOGICAL",SUP-7097,CDM,C1894,HCPCS,0272,RC,,,both,,,3339.00,1001.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2270.52,68,,,,,0,388.33,2838.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 80CM 4FR 6MM EMBOLECTOMY ADHERENT CLOT",SUP-140806,CDM,C1757,HCPCS,0272,RC,,,both,,,1763.85,529.15,"PHCS [10601]",PHCS,,1234.7,70,,,,,0,205.14,1499.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR",RX-3781,CDM,,,0250,RC,54838-0511-80,NDC,both,473,ML,663.46,199.04,"FIRST HEALTH [10303]","First Health",,530.77,80,,,,,0,77.16,563.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD 25CM 14FR DRNG FLEXIMA METAL HYDROPHILIC REGULAR",SUP-M001271370,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP840D,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.36,38.81,"FIRST HEALTH [10303]","First Health",,103.49,80,,,,,0,15.04,109.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVONORGESTREL 1.5 MG TABLET",RX-99445,CDM,,,0637,RC,68180-0852-11,NDC,both,1,UN,138.20,41.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,93.98,68,,,,,0,16.07,117.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9.5FR .125IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLSX-1009.5,CDM,C1892,HCPCS,0272,RC,,,both,,,304.50,91.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,207.06,68,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB SKIN 16X6CM STRATTICE PORCINE DERMAL MATRIX FIRM PATCH",SUP-0616002,CDM,Q4130,HCPCS,0636,RC,,,both,,,16063.20,4818.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10441.08,65,,,,,0,1903.49,13653.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 11CM INPUT PS PEBAX HYDROPEL .038IN DDJ",SUP-080011,CDM,C1894,HCPCS,0272,RC,,,both,,,69.17,20.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.04,58.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB SKIN 16X6CM STRATTICE PORCINE DERMAL MATRIX FIRM PATCH",SUP-0616002,CDM,Q4130,HCPCS,0636,RC,,,both,,,16063.20,4818.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1903.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1903.49,13653.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 4FR 11CM GWIRE PRELUDE PRO .035IN STERILE RED",SUP-PRO-4F-11,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"UHC [10700]","United Healthcare",,47.91,63.3,,,,,0,8.8,64.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT",RX-164210,CDM,,,0250,RC,45802-0188-16,NDC,both,57,GR,31.55,9.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4.5MM 15MM ATLANTIS TITANIUM ANTERIOR CERVICAL",SUP-876-755,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION",RX-77411,CDM,,,0250,RC,72485-0110-10,NDC,both,3,ML,150.21,45.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE II PRO 15MM 4MM BALLOON DILATATION STERILE",SUP-240-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 6FT THERMOCOOL SF 3.5MM POROUS TIP",SUP-C5MHNAVMHS,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET BREAST BIOPSY 10CM LOCALIZER TAG NDL",SUP-09-0007S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2055.00,616.5,"MULTIPLAN [10600]",Multiplan,,1746.75,85,,,,,0,239,1746.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR",RX-6212,CDM,,,0250,RC,60687-0671-40,NDC,both,5,ML,46.22,13.87,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLUG DEFIB IS4/DF4 PORT",SUP-AC-IS4PP,CDM,C1883,HCPCS,0278,RC,,,both,,,453.60,136.08,"FIRST HEALTH [10303]","First Health",,362.88,80,,,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH",RX-27860,CDM,,,0250,RC,60505-7061-00,NDC,both,1,UN,12.54,3.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 150CM 40MM 3MM BALLOON DILATATION PEBAX",SUP-H74939032300410,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 2MM MEDIUM 100MM VITALLIUM 2 CABLE GRIP DALL-MILES BON",SUP-6704-3-081,CDM,C1713,HCPCS,0278,RC,,,both,,,5451.26,1635.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1560.15,28.62,,,,,0,633.98,4633.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE GT VASCULAR 60D 90D 25CM STD 180CM 2CM .016IN",SUP-RG*GW1618SP,CDM,C1769,HCPCS,0272,RC,,,both,,,2231.25,669.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,264.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.49,1896.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 140MM 125CM 7MM VASCULAR PERIPHERAL OTW",SUP-G38491,CDM,C1874,HCPCS,0278,RC,,,both,,,15906.62,4771.99,"BLUE CROSS [10001]","Blue Cross HMO",,6235.4,39.2,,9776.84,9776.84,9776.84,"1 through 10",1849.94,13520.63,"percent of total billed charges",
"SCR BONE 6.5MM 35MM CD HORIZON LEGACY TITANIUM SPINAL",SUP-75446535,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER",RX-41142,CDM,,,0250,RC,00597-0087-17,NDC,both,12.9,GR,1852.07,555.62,"FIRST HEALTH [10303]","First Health",,1481.66,80,,,,,0,215.4,1574.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GARM FACIAL SMALL CHEEK CHIN EAR 25.19IN SPRT ELASTIC",SUP-111825,CDM,S27000186,LOCAL,0270,RC,,,both,,,338.00,101.4,"CIGNA [10200]","Cigna Open Access",,192.32,56.9,,,,,0,39.31,287.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 2.25X10MM",SUP-PRV022510CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 NARROW KNEE LEFT CRUCIATE RETAINING PERSONA",SUP-42502206201,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"CIGNA [10200]","Cigna Local Plus",,9102.11,31.5,,5372.07,4581.20,7242.98,23,3360.56,24561.24,"percent of total billed charges",
"PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR",RX-6212,CDM,,,0250,RC,60687-0671-40,NDC,both,5,ML,46.22,13.87,"KAISER [10500]",Kaiser,,30.97,67,,,,,0,5.38,39.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 60MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4760,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS",RX-87834,CDM,,,0250,RC,70069-0651-01,NDC,both,5,ML,1232.15,369.64,"PHCS [10601]",PHCS,,862.51,70,,,,,0,143.3,1047.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BROWN 51MM 28MM SELF-CENTERING HIP FEMUR",SUP-103551000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,356.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CERVICAL SPINAL FUSION WITHOUT CC/MCC",473,MS-DRG,,,,,,,inpatient,,,100396.23,30118.87,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,16052.15,,"Case rate ($15,143.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,061.80, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,445.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $14,080.39. The transfer operating threshold is the transfer adjustment factor * $14,061.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,063.14. The transfer capital threshold is the transfer adjustment factor * $1,063.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,71276.19,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 6MM GORE STD WALL HEPARIN PROPATEN PTFE",SUP-H060040A,CDM,C1768,HCPCS,0278,RC,,,both,,,7562.40,2268.72,"BLUE CROSS [10001]","Blue Cross PPO",,2964.46,39.2,,,,,0,879.51,6428.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR GREEN 44MM 28MM RINGLOC ECCENTRIC HIP",SUP-11-165212,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"CIGNA [10200]","Cigna Local Plus",,3563.04,53.5,,5372.07,4581.20,7242.98,23,774.54,5660.9,"percent of total billed charges",
"TISSUE 800125 TRICORTICAL BLK 19-21MM",SUP-800125,CDM,S27800098,LOCAL,0278,RC,,,both,,,6109.95,1832.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,724.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,710.59,5193.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC",761,MS-DRG,,,,,,,inpatient,,,25916.12,7774.84,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,8520.2,,"Case rate ($8,153.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,570.89, add-ons for qualifying new technology services are included. If operating cost exceeds $40,610.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,954.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,580.91. The transfer operating threshold is the transfer adjustment factor * $7,570.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.40. The transfer capital threshold is the transfer adjustment factor * $572.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,25916.12,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 8.6CM PATCH SELF CENTER COMPOSITE",SUP-PCO8VP,CDM,C1781,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 2.7MM RIGIDFIX BONE TISSUE BONE",SUP-256868,CDM,C1713,HCPCS,0278,RC,,,both,,,4533.30,1359.99,"BLUE CROSS [10001]","Blue Cross HMO",,1777.05,39.2,,957.42,156.86,7483.26,51,527.22,3853.31,"percent of total billed charges",
"POD XL 4MMX30CM",SUP-RBYPODXL0430,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 12MM 10MM LAPIPLASTY TITANIUM METATARSAL SNAP",SUP-SK21,CDM,C1713,HCPCS,0278,RC,,,both,,,3727.50,1118.25,"PHCS [10601]",PHCS,,2609.25,70,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH METAL HEAD + VE",SUP-98000500307,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"MULTIPLAN [10600]",Multiplan,,21420,85,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT VASCULAR 4FR MERIT MINI ACCESS",SUP-417847,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"NOVANET [10819]",Novanet,,455.63,75,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC 11.25IN COTTON FOAM LARGE SHOULDER HUMERAL",SUP-79-97957,CDM,S27000186,LOCAL,0270,RC,,,both,,,512.49,153.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT NYLON DEKLENE II 7-0 XT-6.5 24IN MONOFILAMENT DOUBLE ARM",SUP-D-7506M1K,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.30,66.99,"UHC [10700]","United Healthcare",,141.35,63.3,,,,,0,25.97,189.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS FLO50 SUBASSEMBLY",SUP-MAP900,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.79,28.14,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHILON MULTIPASS 5-0 P-3 18IN MONOFILAMENT PLIABILIZE",SUP-698H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 15CM 4MM BALLOON DILATATION OTW LOW",SUP-G30950,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RUNWAY 100CM 6FR MP1 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389691380,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"FIRST HEALTH [10303]","First Health",,293.15,80,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 4CM 2MM BALLOON DILATATION",SUP-U815024,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PERFORMA 125CM 5FR 145D PIGTAIL CURVE ANGIOGRAPHIC",SUP-7529-53,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLICATION LOCK DELIVERY CATHETER",SUP-23000-I,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE VISIGLIDE ENDOSCOPIC STRAIGHT 2700MM .035IN .025IN",SUP-G-240-3527S,CDM,C1769,HCPCS,0272,RC,,,both,,,1288.95,386.68,"PHCS [10601]",PHCS,,902.27,70,,,,,0,149.9,1095.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENDO STITCH V-LOC 180 2-0 6IN CLSR ABSORBABLE RELOAD",SUP-VLOCA206L,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.01,84.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRESSING FOAM ANTIMICROBIAL WITH SILVER MEPILEX BORDER POST-",SUP-498200,CDM,S27200284,LOCAL,0272,RC,,,both,,,105.33,31.6,"CIGNA [10200]",Cigna,,71.62,68,,,,,0,12.25,89.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL STRAIGHT SELF CENTERING FORTIFY I",SUP-676.704,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT CHROMIC 1 CT 36IN MONOFILAMENT ABSORBABLE",SUP-915H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 8FR PIGTAIL CURVE DRNG FLEXIMA BILIARY FLEXIBLE",SUP-M001271540,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM IRRIGATION RAPID REFILL CONTINUOUS",SUP-M00566001,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.18,56.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,77.34,41.1,,,,,0,21.89,159.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,inpatient,,,34058.89,10217.67,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 3.25IN 18GA 20GA PAJUNK E-CATH 21GA",SUP-TDL104,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"UHC [10700]","United Healthcare",,333.27,63.3,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 15CM 34MM TAG THORACIC ACTIVE CONTROL",SUP-TGM343415,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,46388.88,40,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH ARTHROSCOPIC STRAIGHT LOW PROFILE SERIES 1 DESIGN",SUP-AR-11040XL,CDM,S27200284,LOCAL,0272,RC,,,both,,,7933.28,2379.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5394.63,68,,,,,0,922.64,6743.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 91MM 12FR ZENITH ABDOMINAL AORTIC",SUP-G32554,CDM,C1874,HCPCS,0278,RC,,,both,,,23360.40,7008.12,"PHCS [10601]",PHCS,,16352.28,70,,,,,0,2716.81,19856.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS INFINITI 100CM 6FR JL4.5 CURVE ANGIOGRAPHIC",SUP-534617T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"KAISER [10500]",Kaiser,,58.29,67,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 11IN 15FR RETROGRADE SOLID STYLET MULTIPORT",SUP-94535,CDM,S27200284,LOCAL,0272,RC,,,both,,,793.01,237.9,"AETNA [10100]","Aetna HMO/PPO",,630.44,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,92.23,674.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR WOLF RESECTOSCOPE",SUP-M0068802451,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,351.21,68,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 55MM TITANIUM REGULAR GASTROINTESTINAL",SUP-TLC55,CDM,S27200284,LOCAL,0272,RC,,,both,,,1876.45,562.93,"CIGNA [10200]",Cigna,,1275.99,68,,,,,0,218.23,1594.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 8MM 8FR ENDOPROSTHESIS HEPARIN",SUP-VBH081502,CDM,C1874,HCPCS,0278,RC,,,both,,,23102.10,6930.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2686.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2686.77,19636.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE-USE 1000 MICRON LASER",SUP-HLFDBX1000C,CDM,S27200284,LOCAL,0272,RC,,,both,,,5276.02,1582.81,"PHCS [10601]",PHCS,,3693.21,70,,,,,0,613.6,4484.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CORDIS STORQ VASCULAR STRAIGHT 180CM 10CM .035IN SLX",SUP-503456,CDM,C1769,HCPCS,0272,RC,,,both,,,314.77,94.43,"PHCS [10601]",PHCS,,220.34,70,,,,,0,36.61,267.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL LUMBAR ALIF ANTERIOR CONVEX 12 DEGRE",SUP-12419,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS [10001]","Blue Cross PPO",,7408.8,39.2,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 8MM REINFORCE CUFF MURPHY EYE LOW PRESSURE",SUP-DYNJAARC80,CDM,S27200284,LOCAL,0272,RC,,,both,,,295.80,88.74,"KAISER [10500]",Kaiser,,198.19,67,,,,,0,34.4,251.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FINASTERIDE 5 MG TABLET",RX-10037,CDM,,,0637,RC,00904-6830-61,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE WALLSTENT VASCULAR TAPER 500CM .035IN SUPER STIFF",SUP-H965180011,CDM,C1769,HCPCS,0272,RC,,,both,,,924.91,277.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,628.94,68,,,,,0,107.57,786.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI L 4MMX1MM MID FACE LEFT 4 HOLE BAR 2MM SCR BONE",SUP-55-08235,CDM,C1713,HCPCS,0278,RC,,,both,,,1648.88,494.66,"NOVANET [10819]",Novanet,,1236.66,75,,,,,0,191.76,1401.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI GAIA VASCULAR MICRO J 300CM CORONARY THIRD",SUP-AHW14R311P,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"NOVANET [10819]",Novanet,,850.5,75,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ANESTHESIA 21GA 4IN ANGLE MULTIPLE SURFACE INSULATE",SUP-ES-21100,CDM,S27200284,LOCAL,0272,RC,,,both,,,8107.50,2432.25,"PHCS [10601]",PHCS,,5675.25,70,,,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAMURAI VASCULAR 190CM J TIP",SUP-H74939302190J2,CDM,C1769,HCPCS,0272,RC,,,both,,,689.78,206.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.22,586.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EDS II 46CM 1.65MM .76MM DRNG SILICONE LUMBAR LUER LOCK",SUP-821706,CDM,C1729,HCPCS,0272,RC,,,both,,,1553.82,466.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,180.71,1320.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHORD-X 2-0 .5 CIRCLE 18MM 32MM 2 ARM LOOP PLEDG 3",SUP-CXL-20-1812-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"MULTIPLAN [10600]",Multiplan,,3187.5,85,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 12MM APTUS TRILOCK TITANIUM FOREFOOT MIDFOOT",SUP-A-5450.12/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"NOVANET [10819]",Novanet,,1208.93,75,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD 10CM OSCOR UNIVERSAL IMPLANTABLE BIPOLAR IS-1","SUP-355 914",CDM,S27200284,LOCAL,0272,RC,,,both,,,4947.30,1484.19,"PHCS [10601]",PHCS,,3463.11,70,,,,,0,575.37,4205.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 19MM 135CM 8MM THIN VASCULAR COCR",SUP-1012631-19,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"BLUE CROSS [10001]","Blue Cross HMO",,3292.8,39.2,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE ROUND 240MM 15MM 2.4MM CAPTIVATOR II STIFF BRAID WIRE",SUP-M00561233,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.04,23.71,"NOVANET [10819]",Novanet,,59.28,75,,,,,0,9.19,67.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 20MM 5MM .035IN BALLOON",SUP-AB35W05020135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,460.47,68,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN SUCTION 4MM 30CM TRIPORT II TIP POWER ASSISTED",SUP-PAL-402LL,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"KAISER [10500]",Kaiser,,428.73,67,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 10CM 5FR .035",SUP-M006192111090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"MULTIPLAN [10600]",Multiplan,,1268.57,85,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 27FR CUT STORZ 2 STEM",SUP-M0068802241,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,196.55,41.1,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR INSTR UROLOK II BALL FIT",SUP-M0067301401,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.45,37.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE FEEDING ORANGE 24IN 8FR POLYURETHANE RADIOPAQUE STRIPE",SUP-54-2480R,CDM,S27200284,LOCAL,0272,RC,,,both,,,57.43,17.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,26.36,45.9,,,,,0,6.68,48.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HAWKONE ATHERECTOMY H1-S",SUP-H1-S,CDM,C1714,HCPCS,0272,RC,,,both,,,20128.50,6038.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SOL DIALYSATE PHOXILLIUM PVC 5000ML 2 COMPARTMENT BAG",SUP-114905,CDM,S27200284,LOCAL,0272,RC,,,both,,,380.63,114.19,"UHC [10700]","United Healthcare",,240.94,63.3,,,,,0,44.27,323.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS SOLN DEX 2.5 % LOW CA+ 2.5 MEQ/L&MAG 0.5 MEQ/L",RX-27800,CDM,,,0250,RC,00941-0457-01,NDC,both,6000,ML,362.16,108.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ATLANTIS SR PRO MONORAIL 135CM 3.2FR 40MHZ ULTRASOUND",SUP-H749389420,CDM,C1753,HCPCS,0272,RC,,,both,,,4554.00,1366.2,"NOVANET [10819]",Novanet,,3415.5,75,,,,,0,529.63,3870.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW TPS THK.38MM MICRO LEFT INFERIOR BORDER",SUP-5100037902,CDM,S27200284,LOCAL,0272,RC,,,both,,,854.23,256.27,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE MAILMAN VASCULAR STRAIGHT SPRING COIL FLOPPY 300CM",SUP-H74912120012,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MAILMAN VASCULAR 182CM .014IN POLYMER HYDROPHILIC",SUP-H74912136011,CDM,C1769,HCPCS,0272,RC,,,both,,,589.03,176.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 12MM 6FR 5MM .07",SUP-H7493926712500,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 22CM 8FR LARGE PROXIMAL PIGTAIL CURVE URETERAL",SUP-M001235500,CDM,C2617,HCPCS,0278,RC,,,both,,,1093.50,328.05,"BLUE CROSS [10001]","Blue Cross PPO",,428.65,39.2,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM 6.8FR 11MM SPACING ENDOCARDIUM TRUE BIPOLAR",SUP-7122Q/65,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7057.69,41.1,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X300 80CM SL",SUP-48005030N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,707.89,68,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SHUNT CSF Y STAINLESS STEEL 1.8MM 1.2MM STERILE",SUP-901412,CDM,S27200284,LOCAL,0272,RC,,,both,,,8582.91,2574.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1017.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,998.19,7295.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 75MM AFFIXUS 3.6MM HIP FEMUR CORTICAL PROXIMAL",SUP-814501075,CDM,C1713,HCPCS,0278,RC,,,both,,,2868.75,860.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,339.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",333.64,2438.44,"percent of total billed charges",
"CLAMP SURGICAL 5.5IN FIXTR RING BLUNT TIP VASECTOMY",SUP-GU8160,CDM,S27200284,LOCAL,0272,RC,,,both,,,792.50,237.75,"PHCS [10601]",PHCS,,554.75,70,,,,,0,92.17,673.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 70X8X2CM PRECISION ARTISAN PLATNALOCK",SUP-SC-8216-70,CDM,C1778,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Open Access",,7386.75,33.5,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRI-SIL IC 20FR URETHRAL BACTI-GUARD SILICONE",SUP-70520SI,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.40,32.52,"AETNA [10100]","Aetna HMO/PPO",,86.18,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.61,92.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE GEL-FLOW NT THROMBIN-JMI GELATIN POWDER",SUP-00009-2250-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1443.74,433.12,"NOVANET [10819]",Novanet,,1082.81,75,,,,,0,167.91,1227.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E XLPE FEMUR PATELLA TIBIA CE",SUP-98000200090,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"NOVANET [10819]",Novanet,,17010,75,,,,,0,2637.68,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 81MM 12.2MM 7.6MM CUFF INNER CANN LOW PRESSURE",SUP-8FEN,CDM,S27200284,LOCAL,0272,RC,,,both,,,399.33,119.8,"CIGNA [10200]","Cigna Open Access",,227.22,56.9,,,,,0,46.44,339.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM 13MM CEMENTED BODY SECTION MRS POROUS STD",SUP-6485-3-013,CDM,C1776,HCPCS,0278,RC,,,both,,,12789.36,3836.81,"FIRST HEALTH [10303]","First Health",,10231.49,80,,,,,0,1487.4,10870.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HEARTSTRING III 4.3MM PROXIMAL SEAL AORTIC CUTTER",SUP-HSK-3043,CDM,S27200284,LOCAL,0272,RC,,,both,,,3809.28,1142.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,443.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,443.02,3237.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,inpatient,,,149949.56,44984.87,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,14732.09,,"Case rate ($13,768.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,784.81, add-ons for qualifying new technology services are included. If operating cost exceeds $45,824.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,348.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,801.72. The transfer operating threshold is the transfer adjustment factor * $12,784.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $966.59. The transfer capital threshold is the transfer adjustment factor * $966.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,64803.44,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 5X6IN MCCULLOCH NERVE ROOT",SUP-57-5761,CDM,S27200284,LOCAL,0272,RC,,,both,,,1273.56,382.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,150.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,148.12,1082.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 24MM TARGET 360D 2XL DETACHABLE",SUP-M0036182450,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ISOSORBIDE MONONITRATE 10 MG TABLET, IMMEDIATE RELEASE",RX-10356,CDM,,,0637,RC,81665-0102-10,NDC,both,1,UN,17.81,5.34,"MULTIPLAN [10600]",Multiplan,,15.14,85,,,,,0,2.07,15.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET",RX-184099,CDM,,,0637,RC,00310-1110-01,NDC,both,1,UN,173.34,52,"CIGNA [10200]",Cigna,,117.87,68,,,,,0,20.16,147.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 4MM BALLOON",SUP-U357548,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC",857,MS-DRG,,,,,,,inpatient,,,59768.28,17930.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,42510.92,,"Fee schedule rate ($42,510.92). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,59768.28,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE DUALMESH 34X26CM SOFT TISSUE BIOMATERIAL",SUP-1DLMC08,CDM,C1781,HCPCS,0278,RC,,,both,,,16284.00,4885.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6692.72,41.1,,,,,0,1893.83,13841.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 80CM 4FR REUT CURVE ANGIOGRAPHIC PEBAX",SUP-7714-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.05,30.01,"FIRST HEALTH [10303]","First Health",,80.04,80,,,,,0,11.64,85.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM QUICKFIX TITANIUM SHORT PARTIAL THREAD T15",SUP-AR-8740-40PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",155.43,1136.03,"percent of total billed charges",
"STENT ZILVER 635 30MM 125CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-G43820,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"AETNA [10100]","Aetna HMO/PPO",,3005.1,79.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.25CM NATRELLE INSPIRA P6.6CM EXTRA FULL",SUP-MSZ-X700,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 4.5MM CANNULATED SPINAL CREO MIS",SUP-6134.0045,CDM,S27000186,LOCAL,0270,RC,,,both,,,583.20,174.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,69.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 67MM 7MM VORTX 35 COIL PUSHABLE 5.5MM",SUP-373307,CDM,S27800098,LOCAL,0278,RC,,,both,,,3562.50,1068.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM ENCORE TITANIUM CANCELLOUS",SUP-010-55-045,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"MULTIPLAN [10600]",Multiplan,,258.83,85,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.5MM FIXOS CANNULATED",SUP-705251,CDM,S27200284,LOCAL,0272,RC,,,both,,,2059.65,617.89,"AETNA [10100]","Aetna HMO/PPO",,1637.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.54,1750.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309112,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"CIGNA [10200]","Cigna Open Access",,12650.34,33.5,,5302.19,4377.88,6578.61,27,4391.74,32097.87,"percent of total billed charges",
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 6FR 2.5MM .07",SUP-H7493926708250,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 10MM 13MM 8FR .035IN",SUP-BXA107901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"UHC [10700]","United Healthcare",,13550.88,63.3,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SMOOTH SHELL",SUP-SCM-295,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"MULTIPLAN [10600]",Multiplan,,6422.18,85,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET",RX-174917,CDM,J0751,HCPCS,0636,RC,61958-2002-01,NDC,both,1,UN,332.99,99.9,"CIGNA [10200]","Cigna Open Access",,191.78,,,,,,,39.46,283.04,"fee schedule",
"CATH SABERX 150CM 100MM 2MM BALLOON DILATATION RAPID",SUP-47520100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"FIRST HEALTH [10303]","First Health",,1276.56,80,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR NEROSTIMLTR OPTIMIZER IPG",SUP-10-B411-3-XX,CDM,C1824,HCPCS,0278,RC,,,both,,,131100.00,39330,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15535.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15246.93,111435,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 0 CT 36IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z358T,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 4MM DART-FIRE HEADED",SUP-DSDS1040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1069.20,320.76,"CIGNA [10200]","Cigna Local Plus",,572.02,53.5,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 CTX 36IN BRAID COATED UNDYED ABSORBABLE",SUP-J980H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TIGHTRAIL SUB-C .119IN DIL ROTATE STERILE LATEX FREE",SUP-560-009,CDM,C1773,HCPCS,0272,RC,,,both,,,12385.50,3715.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1440.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SCISSORS ENDOCUT L16.5 MM LAPAROSCOPIC STERILE DISPOSABL",SUP-85-3142,CDM,S27200284,LOCAL,0272,RC,,,both,,,232.50,69.75,"CIGNA [10200]","Cigna Local Plus",,124.39,53.5,,,,,0,27.04,197.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM INDEPENDENCE SPINE SELF DRILL VARIABLE",SUP-176.735,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"NOVANET [10819]",Novanet,,2205,75,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 310-375CC P4.8-6CM HIGH PROFILE ROUND STYLE 3000",SUP-350-3310,CDM,C1789,HCPCS,0278,RC,,,both,,,2475.00,742.5,"NOVANET [10819]",Novanet,,1856.25,75,,,,,0,287.84,2103.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 30IN 2 PORT 1 BLADDER PUMP LINE CNCT ATS STERILE",SUP-60707010500,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.78,62.03,"KAISER [10500]",Kaiser,,138.54,67,,,,,0,24.05,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVONORGESTREL 1.5 MG TABLET",RX-99445,CDM,,,0637,RC,68180-0852-11,NDC,both,1,UN,138.20,41.46,"FIRST HEALTH [10303]","First Health",,110.56,80,,,,,0,16.07,117.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 83MM 18GA 21GA E-CATH PLUS SONOPLEX",SUP-TDL142,CDM,C9812,HCPCS,0272,RC,,,both,,,611.55,183.46,"NOVANET [10819]",Novanet,,458.66,75,,,,,0,71.12,519.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 8MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640608,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Open Access",,6403.47,56.9,,5302.19,4377.88,6578.61,27,1308.83,9565.82,"percent of total billed charges",
"MINOCYCLINE 50 MG CAPSULE",RX-5111,CDM,,,0637,RC,00591-5694-01,NDC,both,1,UN,8.55,2.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.99,7.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE VOYANT MARYLAND 44CM 5MM LAPAROSCOPIC FUSION",SUP-EB216,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1463.06,45.9,,,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CEREBROVASCULAR DISORDERS WITH MCC",070,MS-DRG,,,,,,,inpatient,,,37516.25,11254.87,"AMBETTER EXCHANGE  [11102]",Ambetter,,10326.86,,"Case rate ($10,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,589.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,628.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,107.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,601.87. The transfer operating threshold is the transfer adjustment factor * $9,589.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $724.99. The transfer capital threshold is the transfer adjustment factor * $724.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,37516.25,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 18FR MEDIUM URETHRAL HYDROPHILIC",SUP-0174L18,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.47,22.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,52,68,,,,,0,8.89,65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIBRILLATOR 65CM 8FR OPTISURE ENDOCARDIUM 2 COIL DF1",SUP-LDA220-65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"FIRST HEALTH [10303]","First Health",,13737.6,80,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IBUPROFEN 200 MG TABLET",RX-3841,CDM,,,0637,RC,00904-7914-61,NDC,both,1,UN,6.27,1.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JAGWIRE DREAM TIP ENDOSCOPIC 260CM 5CM .025IN",SUP-M00556481,CDM,C1769,HCPCS,0272,RC,,,both,,,811.01,243.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,551.49,68,,,,,0,94.32,689.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 58MM STAINLESS STEEL T15 VARIABLE ANGLE SELF",SUP-02.127.158,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"NOVANET [10819]",Novanet,,849.53,75,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE CROSS-IT 100XT VASCULAR STRAIGHT 190CM 3CM",SUP-1003309H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X4MM COROENT 20D XL PEEK-OPTIMA",SUP-6200450,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"AETNA [10100]","Aetna HMO/PPO",,27249.1,79.5,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUR RND SKEETER OTO-FLEX 0.7MM CARB GRN",SUP-3155637,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 36CM HIP LEFT FEMUR AFFIXUS INTRAMEDULLARY 125D",SUP-814411360,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"PHCS [10601]",PHCS,,14519.93,70,,,,,0,2412.38,17631.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZIPWIRE VASCULAR 260CM 3CM .035IN NITINOL POLYMER",SUP-M00146316B1,CDM,C1769,HCPCS,0272,RC,,,both,,,339.13,101.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,40.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.44,288.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY UVA",SUP-CCWET0,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"NOVANET [10819]",Novanet,,648.75,75,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 5MM KII FIOS FIRST ENTRY ADVANCED",SUP-CFF01,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY UVA",SUP-CCWET0,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"FIRST HEALTH [10303]","First Health",,692,80,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAMURAI VASCULAR 300CM",SUP-H749393023002,CDM,C1769,HCPCS,0272,RC,,,both,,,689.78,206.93,"FIRST HEALTH [10303]","First Health",,551.82,80,,,,,0,80.22,586.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 80MM 17MM FINNED CEMENTLESS SMR TITANIUM",SUP-1304.15.170,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CIGNA [10200]",Cigna,,5385.6,68,,5873.17,5873.17,5873.17,"1 through 10",921.1,6732,"percent of total billed charges",
"SUT PLAIN MICROPOINT 5-0 G-3 18IN 2 ARM MONOFILAMENT",SUP-772G,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.58,54.17,"NOVANET [10819]",Novanet,,135.44,75,,,,,0,21,153.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 15CM 28MM TAG THORACIC ACTIVE CONTROL",SUP-TGM282815,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,47664.57,41.1,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE RETRIEVE ORTHOPEDIC 350MM 3.2MM",SUP-691.022S,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 2 CONTOUR 26IN 36- IN KNEE 2",SUP-79-96026,CDM,L1830,HCPCS,0274,RC,,,both,,,182.79,54.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.26,155.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 10FR 12IN DEAVER NATURAL RUBBER 5IN T TUBE",SUP-0099800,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.29,18.09,"FIRST HEALTH [10303]","First Health",,48.23,80,,,,,0,7.01,51.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC So Gsap Dna Cpy Nmbr&Mcrstl",PX-310000018,CDM,81458,CPT,0310,RC,,,both,,,5525.00,1657.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2535.98,45.9,,,,,0,5.53,4696.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BURN 48X4IN ACTICOAT FLEX 3 POLYESTER NANOCRYSTALLINE",SUP-66800434,CDM,S27200284,LOCAL,0272,RC,,,both,,,580.61,174.18,"NOVANET [10819]",Novanet,,435.46,75,,,,,0,67.52,493.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 6.35MM TSR2D PRECUT BENT",SUP-8371090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ARROW ADVANCER VASCULAR J SPRING 17 13/16IN .035IN",SUP-AW-04235,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"NOVANET [10819]",Novanet,,71.78,75,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS MULTIPASS 3-0 PS-1 18IN MONOFILAMENT",SUP-PDP683G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ALEXIS O 360D LARGE RIGID RING ATRAUMATIC SELF",SUP-C8403,CDM,S27200284,LOCAL,0272,RC,,,both,,,445.50,133.65,"UHC [10700]","United Healthcare",,282,63.3,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC or OP Cmplx 1st Hr",PX-360000017,CDM,9999169,LOCAL,0360,RC,,,both,,,17381.36,5214.41,"NOVANET [10819]",Novanet,,13036.02,75,,,,,0,2021.45,14774.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE LUNDERQUIST VASCULAR BENTSON STRAIGHT TAPER 300CM 11CM",SUP-G53971,CDM,C1769,HCPCS,0272,RC,,,both,,,1180.98,354.29,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,485.38,41.1,,,,,0,137.35,1003.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 17MM 135CM 7MM 20MM BILIARY STAINLESS STEEL",SUP-PXB35-07-17-135,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"CIGNA [10200]","Cigna Local Plus",,2336.35,53.5,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP 8MM INTERNAL LAPRO-CLIP TITANIUM LAPAROSCOPIC LIGATING",SUP-8886848808,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 15MM 140CM 4MM CORONARY",SUP-RSINT40015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,656.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP FULL OSTEOTOM 64MM HEMISPHERE ACETABULAR",SUP-705306420,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,536.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X12MM COROENT WIDE XL 100",SUP-6921250,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS [10001]","Blue Cross HMO",,9313.92,39.2,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE CROSS-IT 100XT VASCULAR J TAPER 190CM 3CM",SUP-1003309HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 14CM 23MM 18.5-21.5MM EXCLUDER",SUP-PLC231400,CDM,C1874,HCPCS,0278,RC,,,both,,,27997.20,8399.16,"NOVANET [10819]",Novanet,,20997.9,75,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 12/14 TAPER 32MM HIP OXINIUM ECHELON",SUP-71343212,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"BLUE CROSS [10001]","Blue Cross HMO",,6089.86,39.2,,5311.50,4717.44,5388.59,31,1806.76,13205.05,"percent of total billed charges",
"SCR BONE 9MM 45MM REVERE TITANIUM SPINE PEDICLE NONSTERILE",SUP-124.095,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA [10200]","Cigna Local Plus",,2590.79,53.5,,3978.14,359.25,3978.14,24,563.19,4116.21,"percent of total billed charges",
"GWIRE HI-TORQUE FLOPPY II VASCULAR J CURVE 300CM 2CM .014IN",SUP-22359MJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 40MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-05047,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR HEAD TITANIUM STD TAPER COMPREHENSIVE VERSA-DIAL",SUP-118001,CDM,C1776,HCPCS,0278,RC,,,both,,,9089.00,2726.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1077.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1057.05,7725.65,"percent of total billed charges",
"STENT DYNAMIC 110X11MM 25/40X8MM Y TRACHEOBRONCHIAL SILICONE",SUP-7067,CDM,C1887,HCPCS,0272,RC,,,both,,,1386.50,415.95,"FIRST HEALTH [10303]","First Health",,1109.2,80,,,,,0,161.25,1178.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT 7INX2MM OLIVECRONA DURA 2 END SURGICAL 3MM",SUP-57-3601,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.16,131.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.84,371.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ORTHOPEDIC 5MM 10MM 5MM END INTERNAL THREAD HEX TALON",SUP-HTN-10-C05,CDM,C1713,HCPCS,0278,RC,,,both,,,1320.30,396.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,897.8,68,,,,,0,153.55,1122.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE FLOPPY II VASCULAR STRAIGHT 190CM 30CM .014",SUP-22339M-903,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC .75CM 4.45X5.88CM ACCOLADE MRI LATITUDE NXT",SUP-L331,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11232,27,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 STD KNEE LEFT CRUCIATE RETAINING PERSONA",SUP-42502806401,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"BLUE CROSS [10001]","Blue Cross HMO",,11327.07,39.2,,5311.50,4717.44,5388.59,31,3360.56,24561.24,"percent of total billed charges",
"DRIVER NDL 54.7CM 8MM MEGA DA VINCI S/SI ENDOWRIST 30- D 1.3",SUP-420194,CDM,S27000186,LOCAL,0270,RC,,,both,,,1732.50,519.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,205.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,201.49,1472.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL SOFT/FIBRA 6MM 6MM .5 FORCE SPRING ATRAUMATIC",SUP-G-6052,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"MULTIPLAN [10600]",Multiplan,,192.27,85,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDEAVOR SPRINT 8MM 142CM 2.5MM CORONARY STENT",SUP-ENSP25008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,656.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR SHORT J 145CM 4CM .038IN",SUP-M001465181,CDM,C1769,HCPCS,0272,RC,,,both,,,494.10,148.23,"FIRST HEALTH [10303]","First Health",,395.28,80,,,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER BREAST 450CC DIA13.6CM P4.2CM SILICONE COHESIVE GEL SM",SUP-RSZ-4501S,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"FIRST HEALTH [10303]","First Health",,126.54,80,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 2.4MM CANNULATED ACROMIOCLAVICULAR REPAIR",SUP-AR-2257D-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,2165.63,649.69,"KAISER [10500]",Kaiser,,1450.97,67,,,,,0,251.86,1840.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 7.5IN RHOTON SURGICAL 4MM",SUP-NL3785-148,CDM,S27200284,LOCAL,0272,RC,,,both,,,921.13,276.34,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,107.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,107.13,782.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE NITREX VASCULAR 0D 60CM 7CM .018IN NITINOL TUNGSTEN",SUP-N180603,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 71CM TRANSSEPTAL AGILIS NXT ACQCROSS",SUP-900301,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MERIT MAK VASCULAR 40CM .018IN NITINOL PLATINUM",SUP-MAK001N,CDM,C1894,HCPCS,0272,RC,,,both,,,197.06,59.12,"KAISER [10500]",Kaiser,,132.03,67,,,,,0,22.92,167.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 420ML STYLE 10 SMOOTH NATRELLE SILICONE P3.8CM",SUP-10-420,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"MULTIPLAN [10600]",Multiplan,,3034.5,85,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CBL PCNG LD 301-CG",SUP-343586,CDM,C1883,HCPCS,0278,RC,,,both,,,408.90,122.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,47.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ERTAPENEM 1 G VIAL IV PUSH",RX-408330,CDM,J1335,HCPCS,0636,RC,55150-0282-09,NDC,both,1,UN,301.92,90.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,35.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.52,256.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC New Eval Visit Level 2",PX-510000172,CDM,99202,CPT,0761,RC,,,both,,,350.81,105.24,"PHCS [10601]",PHCS,,245.57,70,,,,,0,0.35,350.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRAILBLAZER 135CM 4FR 1.04MM ANGLE SPRT STERILE LATEX",SUP-ASC-035-135,CDM,C1887,HCPCS,0272,RC,,,both,,,1377.00,413.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ICD-VR VISIA MRI AF S US/OUS DF4",SUP-DVFC3D4,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"UHC [10700]","United Healthcare",,24687,63.3,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL BAYONET BIPOLAR STRAIGHT TIP LATEX FREE",SUP-1590-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,3261.60,978.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2217.89,68,,,,,0,379.32,2772.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 6.9MM 5MM NASAL ORAL TAPER CUFF MURPHY EYE",SUP-18750,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.76,19.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHIBOND EXCEL THK1.5MM 2-0 V-5 36IN 2 ARM BRAID FIRM",SUP-SX54H,CDM,S27200284,LOCAL,0272,RC,,,both,,,97.77,29.33,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,44.88,45.9,,,,,0,11.37,83.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 110CM 4FR .042IN 9MM PIGTAIL CURVE",SUP-538450S,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Rpr Wnd Surgical Secndry",PX-510000045,CDM,13160,CPT,0761,RC,,,both,,,14163.00,4248.9,"PHCS [10601]",PHCS,,6277,,"Case rate ($6,277). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,1647.16,12038.55,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 43IN 12FR FEED RIGID PORT DEHP FREE STYLET",SUP-8884711253,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.98,21.89,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IOTHALAMATE SODIUM 0.1 % INTRAVENOUS SOLUTION 0-10 MICROCURIES",RX-411742,CDM,A9554,HCPCS,0343,RC,08888-8878-42,NDC,both,1,UN,13286.75,3986.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8636.39,65,,,,,0,43.71,11293.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 4.5 MM HEADLESS SCR",SUP-P20-915-4500,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WEBSTER CS L 115CM 7FR 2-8-2MM SPACE FJ CURVE MAPPING",SUP-BD710FJ282RTS,CDM,C1730,HCPCS,0272,RC,,,both,,,2142.00,642.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1456.56,68,,,,,0,249.11,1820.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC CURVE TIP RELOAD AEON 60MMX3.25MM STERILE",SUP-AESC60R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4MM 15MM HELIX R SPINE SELF TAP FIX ANGLE",SUP-7804215,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 10.5IN 14FR 18MM CORONARY SINUS RETROGRADE",SUP-RC014T,CDM,S27200284,LOCAL,0272,RC,,,both,,,861.92,258.58,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANSTR SUCTION ARTEMIS",SUP-APCAN2,CDM,S27000186,LOCAL,0270,RC,,,both,,,2737.50,821.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,324.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH URI-CATH 3 WAY STPCOCK DRNG CLOSED SYSTEM",SUP-4195007,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.55,67.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MICROCATHETER CEREBROVASCULAR 115CM BENCHMARK 70 STERILE",SUP-BMK6F115,CDM,C1887,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"MULTIPLAN [10600]",Multiplan,,5718.38,85,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 16FR URETHRAL BACTI-GUARD RUBBER HYDROGEL 30",SUP-0167SI16,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.45,32.23,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT COLONIC WALLFLEX L9 CM OD22 MM SOFT ANCHOR LOCK DELIVE",SUP-M00555770,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 7.5MM ROUND STERILE LATEX FREE DISPOSABLE",SUP-5820110075,CDM,S27200284,LOCAL,0272,RC,,,both,,,1164.70,349.41,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH REDEL 115CM 6FR 10MM SPACE STD D CURVE",SUP-1079257S,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"NOVANET [10819]",Novanet,,2795.63,75,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EXTRACTION OUTAKE CATH SYR GLOVE TRANSPORT TUBE",SUP-CET300,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT PORCINE 3.9X2.4IN XENMATRIX AQUAPURE RECTANGLE",SUP-1160610,CDM,C1781,HCPCS,0278,RC,,,both,,,10078.14,3023.44,"UHC [10700]","United Healthcare",,6379.46,63.3,,,,,0,1172.09,8566.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 2MM PK DIEGO STRAIGHT TURBINATE SINUS SERRATE",SUP-7013-8033,CDM,S27200284,LOCAL,0272,RC,,,both,,,897.05,269.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 35LP 135CM 10CM 6FR 9MM .035IN BALLOON",SUP-G52289,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.47,41.1,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPLR TUBING OHMEDA O2 Y BLOCK",SUP-YB-CO-OHUO-OH,CDM,S27200284,LOCAL,0272,RC,,,both,,,594.30,178.29,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 5MM 78MM X25 LOCK LOW PROFILE STERILE",SUP-04.045.378S,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,217.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",217.47,1589.42,"percent of total billed charges",
"NDL ASPIRATION 4CM 21GA SPIN XTEND ALWAYS-ON TIP TRACKED",SUP-INS-5450,CDM,S27200284,LOCAL,0272,RC,,,both,,,5868.45,1760.53,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE STAINLESS STEEL 1.3 MM SCREWS 3 HOLE HEAD 8 HOLE SHAFT",SUP-221.333,CDM,C1713,HCPCS,0278,RC,,,both,,,2202.90,660.87,"CIGNA [10200]","Cigna Open Access",,1253.45,56.9,,1144.80,304.56,2275.09,66,256.2,1872.47,"percent of total billed charges",
"DIL VASCULAR 22FR 20CM RADIOPAQUE STD ACCEPTS .038IN GWIRE",SUP-G01472,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.44,31.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT NASAL 65X35MM SMALL ALUMINUM DENVER SEPTUM 2 PIECE",SUP-10-1800-05KS,CDM,S27000186,LOCAL,0270,RC,,,both,,,498.96,149.69,"FIRST HEALTH [10303]","First Health",,399.17,80,,,,,0,58.03,424.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 16.25MM 1.5MM AXIUS CORONARY INTERNAL",SUP-OF-1500,CDM,S27200284,LOCAL,0272,RC,,,both,,,813.05,243.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 6.5MM 70MM 16MM DARCO FOOT ANKLE HEAD",SUP-777657062,CDM,C1713,HCPCS,0278,RC,,,both,,,2617.50,785.25,"CIGNA [10200]",Cigna,,1779.9,68,,1831.33,1831.33,1831.33,16,304.42,2224.88,"percent of total billed charges",
"TUBE NASOGASTRIC 55IN 8FR ENTERAL RADIOPAQUE WEIGHT TIP",SUP-8884710826E,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.39,32.82,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR LEFT CORONARY",SUP-67018000,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"PHCS [10601]",PHCS,,292.32,70,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 57.9CM 20FR SILICONE .035IN MIC SECUR-LOK",SUP-0210-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT VASCULAR 40CM 6MM FLIXENE SLIDER GRADUATED WALL",SUP-25061,CDM,C1768,HCPCS,0278,RC,,,both,,,7430.33,2229.1,"MULTIPLAN [10600]",Multiplan,,6315.78,85,,,,,0,864.15,6315.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 4MM 7MM ANGLE SLIGHT 9IN SEMMES SURGICAL SPINAL FUSION",SUP-29-4951,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.98,94.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT CONTOUR 30CM 3CM 7FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006180235050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"KAISER [10500]",Kaiser,,697.86,67,,,,,0,121.14,885.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX PDS PLUS 1 CT-1 12IN KNOTLESS TISSUE CONTROL",SUP-SXPP1A435,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2.7MM 4.5MM 75MM EVOS MINI T8 LONG BONE SMALL BONE",SUP-72402775,CDM,C1713,HCPCS,0278,RC,,,both,,,456.52,136.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,53.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",53.09,388.04,"percent of total billed charges",
"DISECT ENDOSCOPIC RIGHT ANGLED TIP 5MM DISPOSABLE",SUP-3332,CDM,S27200284,LOCAL,0272,RC,,,both,,,334.95,100.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BINDER ABDOMINAL 12IN 4 PANEL HOOK LOOP CLSR 46-62IN MEDIUM",SUP-13652067,CDM,S27000186,LOCAL,0270,RC,,,both,,,88.65,26.59,"UHC [10700]","United Healthcare",,56.12,63.3,,,,,0,10.31,75.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTERIAL LINE 4.45CM 20GA ODSEC 22GA .018IN RADIAL",SUP-AK-04020-SPC,CDM,S27200284,LOCAL,0272,RC,,,both,,,221.85,66.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPEL APD TWIST-LOC 25CM 12FR DRNG FLEXITHANE METAL",SUP-H7493931012250,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,92.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH INSRT 8FR FIDELITY REINFORCED INTRO VESSEL DIL",SUP-0884-00-0019-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,955.80,286.74,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT EPIC 20MM 75CM 8MM VASCULAR METALLIC ILIAC ARTERY OTW",SUP-H74939200082070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"AETNA [10100]","Aetna HMO/PPO",,3291.3,79.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IDENTITY IMPRINT TKR KNEE POSTERIOR STABILIZE JIG",SUP-TPS-000-D002,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT LIFESTENT 40MM 130CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-EX060403CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"CIGNA [10200]","Cigna Open Access",,3929.55,33.5,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 4MM 110MM STERILE",SUP-144110,CDM,S27200284,LOCAL,0272,RC,,,both,,,505.44,151.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT INNOVA 80MM 75CM 7MM VASCULAR METAL SUPERFICIAL",SUP-H74939293078070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"AMERIGROUP MEDICAID [20100]",Amerigroup,,572.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 7MM PORTEX BLUSELECT UNCUFF STERILE LATEX FREE",SUP-101/816/070,CDM,S27200284,LOCAL,0272,RC,,,both,,,311.63,93.49,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER SPINAL 12X15MM FORTIFY 0D 12MM NO SPIKE NONSTERILE",SUP-151.001,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8666.6,27,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION 0.9% SODIUM CHLORIDE 500ML PRESERVATIVE FREE",SUP-06138-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE PLATINUM PLUS VASCULAR STRAIGHT SPRING COIL 300CM 5CM",SUP-H74917521,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXTR PRO 200CM 7-6FR 12-15MM SPECIMEN RETRIEVAL NATURAL",SUP-M00547010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CALIBER SPACER 10 X 22MM 9-13MM",SUP-194.422,CDM,S27800098,LOCAL,0278,RC,,,both,,,25200.00,7560,"MULTIPLAN [10600]",Multiplan,,21420,85,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 KS 30IN BRAID BLACK NONABSORBABLE",SUP-623H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE 6MM SPACE MINI 27MM TITANIUM 2MM SCR LOW PROFILE 2",SUP-443.176,CDM,C1713,HCPCS,0278,RC,,,both,,,3487.50,1046.25,"CIGNA [10200]",Cigna,,2371.5,68,,1831.33,1831.33,1831.33,16,405.6,2964.38,"percent of total billed charges",
"BLADE CHISEL 40X12MM THK1MM STRAIGHT SMALL",SUP-75100518,CDM,S27200284,LOCAL,0272,RC,,,both,,,1489.59,446.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT HUMERAL H+9MM 42MM AEQUALIS ASCEND FLEX 12.5D SHOULDER",SUP-DWF425B,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1069.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1049.92,7673.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 4CM 5FR ZIMMON PIGTAIL CURVE PANCREATIC",SUP-G21923,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"27.5 DIOPTER, TECNIS EYHANCE 1-PIECE IOL W/ SIMPLICITY DELIV",SUP-DIB00U0275,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,523.91,39.2,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Oasis Wound Matrix per Sq Cm",PX-E63600023,CDM,Q4102,HCPCS,0636,RC,,,both,,,55.00,16.5,"CIGNA [10200]","Cigna Local Plus",,31.95,,,,,,,6.52,55,"fee schedule",
"BURR SURGICAL 12.5CM 3MM IBUR DISTAL BEND ROUND DIAMOND",SUP-8431-013-030DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,3045.45,913.63,"AETNA [10100]","Aetna HMO/PPO",,2421.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,354.19,2588.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 7CM 10FR PROXIMAL BEND BILIARY 2 LAYER STERILE",SUP-PBD-421-1007,CDM,C2625,HCPCS,0278,RC,,,both,,,1387.85,416.35,"KAISER [10500]",Kaiser,,929.86,67,,,,,0,161.41,1179.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.6MM 14MM VIP SPINE CERVICAL ANTERIOR VARIABLE",SUP-171.314,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"AMERIGROUP MEDICAID [20100]",Amerigroup,,167.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",163.98,1198.5,"percent of total billed charges",
"CLIP SURGICAL FOGARTY 6MM 2 SOFTJAW SPRING ATRAUMATIC",SUP-CSOFT6,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.97,32.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,44.38,41.1,,,,,0,12.56,91.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP GRIPTION PINNACLE STERILE LATEX",SUP-121731052,CDM,C1776,HCPCS,0278,RC,,,both,,,8971.20,2691.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6100.42,68,,,,,0,1043.35,7625.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +27.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000275,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON DISECT LAPAROSCOPIC SPACEMAKER EXTRA VIEW",SUP-OMSXB2,CDM,C1727,HCPCS,0272,RC,,,both,,,2092.05,627.61,"AETNA [10100]","Aetna HMO/PPO",,1663.18,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,243.31,1778.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT STABILIT MX POWERCURVE VERTECOR LONG",SUP-MX-2100L-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,14904.00,4471.2,"CIGNA [10200]",Cigna,,10134.72,68,,,,,0,1733.34,12668.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32MM TITANIUM SELF TAP LOCK NONSTERILE AXSOS 3",SUP-661132,CDM,C1713,HCPCS,0278,RC,,,both,,,1377.32,413.2,"FIRST HEALTH [10303]","First Health",,1101.86,80,,,,,0,160.18,1170.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTERSINK 3.0MM HEADED",SUP-P20-910-3000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,461.02,45.9,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 6 HOLE BONE LEFT CLAVICLE",SUP-70-0296,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"BLUE CROSS [10001]","Blue Cross PPO",,2591.2,39.2,,957.42,570.23,957.42,28,768.77,5618.67,"percent of total billed charges",
"INSRT TIBIAL 4 11MM KNEE X3 POSTERIOR STABILIZED TRIATHLON",SUP-5532-G-411,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"PHCS [10601]",PHCS,,6095.33,70,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COSYNTROPIN 0.25 MG/ML IJ (WET SOLR VIAL)",RX-4159686,CDM,J0834,HCPCS,0636,RC,00548-5900-00,NDC,both,1,UN,643.32,193,"FIRST HEALTH [10303]","First Health",,514.66,80,,,,,0,24.26,546.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 11MM KNEE X3 POSTERIOR STABILIZED TRIATHLON",SUP-5532-G-411,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3996.79,45.9,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 134MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-226.571,CDM,C1713,HCPCS,0278,RC,,,both,,,2538.90,761.67,"PHCS [10601]",PHCS,,1777.23,70,,,,,0,295.27,2158.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 74.9X49.3X4.8MM MBT 4MM KNEE CEMENTED REVISION",SUP-129435140,CDM,C1776,HCPCS,0278,RC,,,both,,,22385.16,6715.55,"CIGNA [10200]","Cigna Open Access",,7499.03,33.5,,5302.19,4377.88,6578.61,27,2603.39,19027.39,"percent of total billed charges",
"SCR SET SPINE EVEREST GRAY",SUP-2901-10001,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"NOVANET [10819]",Novanet,,1804.95,75,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 8 KNEE LEFT DISTAL TOTAL STABILIZE",SUP-5540-A-801,CDM,C1776,HCPCS,0278,RC,,,both,,,6375.60,1912.68,"BLUE CROSS [10001]","Blue Cross HMO",,2499.24,39.2,,5311.50,4717.44,5388.59,31,741.48,5419.26,"percent of total billed charges",
"SCR BONE 5.5MM 40MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16025540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"LINER ACETABULAR 10D +4MM 48MM 32MM ALTRX HIP",SUP-1221-32-148,CDM,C1776,HCPCS,0278,RC,,,both,,,9259.80,2777.94,"CIGNA [10200]",Cigna,,6296.66,68,,5873.17,5873.17,5873.17,"1 through 10",1076.91,7870.83,"percent of total billed charges",
"SCREW BONE ORTHOLOC LONG L12 MM OD3.5 MM CORTEX ANKLE FOOT 3",SUP-58803512,CDM,C1713,HCPCS,0278,RC,,,both,,,1506.60,451.98,"BLUE CROSS [10001]","Blue Cross HMO",,590.59,39.2,,957.42,156.86,7483.26,51,175.22,1280.61,"percent of total billed charges",
"STEM FEMORAL COLLAR CATALYSTEM 8 STD OFFSET HIP STERILE",SUP-71314028,CDM,C1776,HCPCS,0278,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16025540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOLUTION? MP CS INSERT SIZE 5 STANDARD 10MM RIGHT",SUP-EIS5S10R,CDM,C1776,HCPCS,0278,RC,,,both,,,7569.30,2270.79,"BLUE CROSS [10001]","Blue Cross PPO",,2967.17,39.2,,3949.44,3949.44,3949.44,"1 through 10",880.31,6433.91,"percent of total billed charges",
"SCR BONE 6.5MM 60MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.407,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.21,68,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 NARROW 10MM KNEE POSTERIOR STABILIZE IDENTITY",SUP-TPS-020-102N,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,696.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 45MM CREO SPINE POLYAXIAL PREASSEMBLE",SUP-5119.1247,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"ALTIVATE REVERSE REVISION HUMERAL STEM, SZ 10X220MM",SUP-530-10-220,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1465.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Foam",PX-E27200111,CDM,E27200111,LOCAL,0272,RC,,,both,,,69.68,20.9,"CIGNA [10200]",Cigna,,47.38,68,,,,,0,8.1,59.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHOCARBAMOL 500 MG TABLET",RX-4971,CDM,,,0637,RC,76385-0123-01,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC SHORT 10MM SPACEMAKER BLUNT TIP BUILT IN",SUP-OMST10BTS,CDM,C1727,HCPCS,0272,RC,,,both,,,1677.75,503.32,"MULTIPLAN [10600]",Multiplan,,1426.09,85,,,,,0,195.12,1426.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE XSHORT 49MM 10 HOLE INTERMEDIATE VARIAX BONE RADIUS",SUP-54-25673,CDM,C1713,HCPCS,0278,RC,,,both,,,6820.79,2046.24,"NOVANET [10819]",Novanet,,5115.59,75,,,,,0,793.26,5797.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 44MM TI",SUP-SPL-35440-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,523.91,39.2,,957.42,570.23,957.42,28,155.43,1136.03,"percent of total billed charges",
"LISINOPRIL 2.5 MG TABLET",RX-13089,CDM,,,0637,RC,60687-0656-11,NDC,both,1,UN,6.27,1.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2.58,41.1,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM SYNAPSE TITANIUM SPINE CANCELLOUS",SUP-04.614.024,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"DEFIB CARDIAC 13MM 51X66MM EVERA MRI S PHYSIOCURVE",SUP-DDMC3D1,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"FIRST HEALTH [10303]","First Health",,32448,80,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.3MM 42MM POLARUS 3 HUMERUS LOCK LOW PROFILE",SUP-3011-43042,CDM,C1713,HCPCS,0278,RC,,,both,,,1190.70,357.21,"CIGNA [10200]","Cigna Local Plus",,637.02,53.5,,3978.14,359.25,3978.14,24,138.48,1012.1,"percent of total billed charges",
"LENS IOL 0 D +10 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.100,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 110MM 18 HOLE RESORBABLE BIOBRIDGE BONE RIB NONSTERILE",SUP-RRP1501,CDM,C1713,HCPCS,0278,RC,,,both,,,9204.60,2761.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1090.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1070.49,7823.91,"percent of total billed charges",
"STENT WALLSTENT 60MM 12MM 135CM ENDOPROSTHESIS ELGILOY",SUP-H74912044126010,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5865,68,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 4.5MM 32MM EVOS MINI CORTEX T8 DRIVER SELF",SUP-72402732,CDM,C1713,HCPCS,0278,RC,,,both,,,363.14,108.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,246.94,68,,,,,0,42.23,308.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP LIMIT HOLE MODULAR TITANIUM POROUS",SUP-PT-116048,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"MULTIPLAN [10600]",Multiplan,,8674.34,85,,,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 30MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75448530,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",441.36,3225.75,"percent of total billed charges",
"STEM FEMORAL 120MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 11",SUP-71357011,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"CIGNA [10200]",Cigna,,13256.46,40,,5873.17,5873.17,5873.17,"1 through 10",3854.32,28169.98,"percent of total billed charges",
"ORTHOLOC 3DI FOOT RECONSTRUCTION SYSTEM HALLUX PLATES - MTP",SUP-587110LT,CDM,C1713,HCPCS,0278,RC,,,both,,,12420.00,3726,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1471.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1444.45,10557,"percent of total billed charges",
"SCR BASEPLT 40MM 9.5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ240,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"KAISER [10500]",Kaiser,,6048.57,67,,,,,0,1049.92,7673.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 32MM 2 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.232,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 88MM RADIUS J 182X10.2X2.7MM STAINLESS STEEL 3.5MM SCR",SUP-245.924,CDM,C1713,HCPCS,0278,RC,,,both,,,4436.91,1331.07,"MULTIPLAN [10600]",Multiplan,,3771.37,85,,,,,0,516.01,3771.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 120MM FOOT ANKLE THREAD",SUP-4933-1-120,CDM,C1713,HCPCS,0278,RC,,,both,,,459.27,137.78,"CIGNA [10200]","Cigna Local Plus",,245.71,53.5,,3978.14,359.25,3978.14,24,53.41,390.38,"percent of total billed charges",
"CANN VACUUM ASPIRATION CURVED SEMI RIGID ROUNDED TIP TAPERED",SUP-20317,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.12,19.84,"MULTIPLAN [10600]",Multiplan,,56.2,85,,,,,0,7.69,56.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX 40MM 80CM 12MM 6FR .035IN BILIARY VASCULAR",SUP-ZBM12040,CDM,C1874,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"CIGNA [10200]",Cigna,,6803.4,68,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.5MM X 9MM TI",SUP-VAN-15090-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",113.04,826.2,"percent of total billed charges",
"HEMOSTATIC  AGENT ARISTA ENT APPLICATOR",SUP-ENT00012,CDM,S27200284,LOCAL,0272,RC,,,both,,,899.91,269.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,106.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.66,764.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 62MM STAINLESS STEEL 3.5MM SCR 3 HOLE SHARP HOOK LOW",SUP-02.113.103,CDM,C1713,HCPCS,0278,RC,,,both,,,3386.25,1015.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,393.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",393.82,2878.31,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 22CM 3CM 6FR .035IN",SUP-M006192131190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,165.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 64MM STAINLESS STEEL FULL THREAD FOOT",SUP-214.764,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,515.75,45.9,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM TRIATHLON 1 RIGHT MEDIAL LEFT LATERAL TOTAL",SUP-5545-A-102,CDM,C1776,HCPCS,0278,RC,,,both,,,6068.55,1820.56,"CIGNA [10200]",Cigna,,4126.61,68,,5873.17,5873.17,5873.17,"1 through 10",705.77,5158.27,"percent of total billed charges",
"SCR BONE 2.4MM 9MM LCP STAINLESS STEEL DISTAL RADIUS T8",SUP-212.809,CDM,C1713,HCPCS,0278,RC,,,both,,,802.87,240.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,545.95,68,,,,,0,93.37,682.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 122MM 8MM COMPREHENSIVE PPS SHOULDER",SUP-12-113558,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]",Cigna,,5040,40,,5873.17,5873.17,5873.17,"1 through 10",1465.38,10710,"percent of total billed charges",
"PLATE LONG TITANIUM ACU-LOC BONE RIGHT DISTAL VOLAR ULNAR",SUP-70-0048,CDM,C1713,HCPCS,0278,RC,,,both,,,5754.60,1726.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,681.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,669.26,4891.41,"percent of total billed charges",
"INSRT TIBIAL 3 8MM KNEE UNICONDYLAR RIGHT MEDIAL LEFT",SUP-102412308,CDM,C1776,HCPCS,0278,RC,,,both,,,10046.40,3013.92,"CIGNA [10200]",Cigna,,6831.55,68,,5873.17,5873.17,5873.17,"1 through 10",1168.4,8539.44,"percent of total billed charges",
"PLATE STD 31MM 3 HOLE LOCKING CURVATURE BONE RADIAL HEAD",SUP-70-0097,CDM,C1713,HCPCS,0278,RC,,,both,,,6458.40,1937.52,"CIGNA [10200]","Cigna Local Plus",,3455.24,53.5,,3978.14,359.25,3978.14,24,751.11,5489.64,"percent of total billed charges",
"SND1T6 AS SP ASPHER RESTOR REFERENCE",SUP-SND1T6,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA [10200]","Cigna Local Plus",,398.58,53.5,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 130MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355130,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 18MM EMBOLD NITINOL FIBER DETACHABLE",SUP-M001394240180500,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"UHC [10700]","United Healthcare",,5455.26,63.3,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 7.5X50MM POLYAXIAL 4S RELINE-O",SUP-13117550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"STENT ORSIRO 2.5/15",SUP-401742,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG TITANIUM ACU-LOC BONE RIGHT DISTAL VOLAR ULNAR",SUP-70-0048,CDM,C1713,HCPCS,0278,RC,,,both,,,5754.60,1726.38,"BLUE CROSS [10001]","Blue Cross HMO",,2255.8,39.2,,957.42,156.86,7483.26,51,669.26,4891.41,"percent of total billed charges",
"TUBE TRACH 5 EXTEND LENGTH 90MM 9.6MM SHILEY XLT UNCUFF SOFT",SUP-50XLTUD,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"PHCS [10601]",PHCS,,339.69,70,,,,,0,56.44,412.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 35MM COMPREHENSIVE 3.5MM SHOULDER FIX ANGLE",SUP-180554,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"KAISER [10500]",Kaiser,,1042.52,67,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 66MM PRESS FIT AEQUALIS ASCEND FLEX PTC 127.5D",SUP-DWF601A,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"KAISER [10500]",Kaiser,,8442,67,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 3.3MM 50MM TITANIUM T25 FULL THREAD TIBIAL LOCK",SUP-04.005.440,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,786.54,68,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 18MM 2MM CORONARY STENT COCR",SUP-1007821-18,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"MULTIPLAN [10600]",Multiplan,,2550,85,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE TITANIUM 25MM 8MM ACL PCL CANNULATED",SUP-AR-1381,CDM,C1713,HCPCS,0278,RC,,,both,,,807.98,242.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,93.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",93.97,686.78,"percent of total billed charges",
"SCR BONE 4.2MM 44MM R3CON NONSTERILE GORILLA PLATE SYSTEM",SUP-P50-453-4244,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,396.9,39.2,,957.42,570.23,957.42,28,117.75,860.63,"percent of total billed charges",
"SCR BONE 25MM INDEPENDENCE SPINE FIXED ANGLE",SUP-176.125,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,841.43,28.62,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X120 80CM SL",SUP-48005012N,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"NOVANET [10819]",Novanet,,747.83,75,,,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 42MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.042TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,1144.80,304.56,2275.09,66,189.34,1383.8,"percent of total billed charges",
"CMPNT FEMORAL 5N KNEE LEFT POSTERIOR STABILIZE LEGION",SUP-71421265,CDM,C1776,HCPCS,0278,RC,,,both,,,32536.35,9760.9,"KAISER [10500]",Kaiser,,21799.35,67,,,,,0,3783.98,27655.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 54MM TI",SUP-MTC-37540-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"BLUE CROSS [10001]","Blue Cross PPO",,488.98,39.2,,957.42,570.23,957.42,28,145.07,1060.29,"percent of total billed charges",
"BLOCK AUGMENTATION NEXGEN 6 HALF 5MM KNEE TIBIA PRECOAT",SUP-598800626,CDM,C1776,HCPCS,0278,RC,,,both,,,7158.06,2147.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4867.48,68,,,,,0,832.48,6084.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 450MM 5.5MM TSRH-3D TITANIUM PREBENT PRECUT",SUP-8370045,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",512.88,3748.5,"percent of total billed charges",
"LENS IOL +9.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000095,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM SOLERA CD HORIZON OSTEOGRIP TITANIUM",SUP-54840005545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION",RX-41463,CDM,,,0250,RC,63323-0186-01,NDC,both,10,ML,18.92,5.68,"CIGNA [10200]","Cigna Open Access",,10.77,56.9,,,,,0,2.2,16.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.4MM 40MM LCP STAINLESS STEEL 4MM PARTIAL",SUP-02.205.240,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"CIGNA [10200]","Cigna Open Access",,885.28,56.9,,1144.80,304.56,2275.09,66,180.95,1322.47,"percent of total billed charges",
"SMOOTH PEG LOCKING 6.0MM X 60MM TI",SUP-SPL-60600-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,743.58,45.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 4MM LORDOSIS TITANIUM",SUP-102064040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"DEVICE 20CM 8FR DRNG DIL",SUP-K12-08322,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"UHC [10700]","United Healthcare",,44.06,63.3,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP CAUT DA VINCI XI ENDOWRIST CAUT MONOPOLAR VESSEL SEALER",SUP-480322,CDM,S27000186,LOCAL,0270,RC,,,both,,,4105.50,1231.65,"CIGNA [10200]","Cigna Open Access",,2336.03,56.9,,,,,0,477.47,3489.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prealbumin",PX-301000368,CDM,84134,CPT,0301,RC,,,both,,,263.00,78.9,"CIGNA [10200]","Cigna Open Access",,32.1,,,,,,,0.01,223.55,"fee schedule",
"PIN FIXATION 9IN 1/8IN STEINMANN ORTHOPEDIC STAINLESS STEEL",SUP-KM169-29-18,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"CIGNA [10200]",Cigna,,43.25,68,,1831.33,1831.33,1831.33,16,7.4,54.07,"percent of total billed charges",
"STENT VICI VENOUS STENT 90MM 100CM 12MM ENDOPROSTHESIS",SUP-H74912090100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 65MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.065,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",24,175.41,"percent of total billed charges",
"SYSTEM AMPLATZER TORQVUE 90D 80CM 195CM 5FR .068IN .059IN",SUP-9-TVLP5F90/080,CDM,S27200284,LOCAL,0272,RC,,,both,,,5754.60,1726.38,"CIGNA [10200]","Cigna Open Access",,3274.37,56.9,,,,,0,669.26,4891.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,inpatient,,,30603.42,9181.03,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,5852.47,,"Case rate ($5,682.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,276.13, add-ons for qualifying new technology services are included. If operating cost exceeds $38,315.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,780.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,283.10. The transfer operating threshold is the transfer adjustment factor * $5,276.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.90. The transfer capital threshold is the transfer adjustment factor * $398.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,5682.01,22844.12,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 12FR .158IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLSX-1012,CDM,C1892,HCPCS,0272,RC,,,both,,,304.50,91.35,"PHCS [10601]",PHCS,,213.15,70,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM EVEREST SPINE POLYAXIAL CANNULATED",SUP-M5111-06535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 SH 27IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP784D,CDM,S27200284,LOCAL,0272,RC,,,both,,,127.77,38.33,"NOVANET [10819]",Novanet,,95.83,75,,,,,0,14.86,108.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 8MM STERNALOCK BLU STERNAL CANCELLOUS LOCK",SUP-73-2708,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"CIGNA [10200]","Cigna Open Access",,222.76,56.9,,1144.80,304.56,2275.09,66,45.53,332.78,"percent of total billed charges",
"RELOAD STPLR 2MM 2.5MM 3MM 60MM ENDO GIA VASCULAR MEDIUM",SUP-EGIA60AVM,CDM,S27200284,LOCAL,0272,RC,,,both,,,1459.46,437.84,"CIGNA [10200]",Cigna,,992.43,68,,,,,0,169.74,1240.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL ADHESIOLYSIS WITH CC",336,MS-DRG,,,,,,,inpatient,,,57144.78,17143.43,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,13472.8,,"Case rate ($13,080.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,146.03, add-ons for qualifying new technology services are included. If operating cost exceeds $45,185.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,300.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,162.09. The transfer operating threshold is the transfer adjustment factor * $12,146.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.30. The transfer capital threshold is the transfer adjustment factor * $918.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,57144.78,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN JUDKINS RIGHT 4 CURVE GUIDING",SUP-LA6JR40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 63MM STAINLESS STEEL 2.4MM SCR 6X4 HOLES 2",SUP-02.111.540,CDM,C1713,HCPCS,0278,RC,,,both,,,4041.68,1212.5,"AETNA [10100]","Aetna HMO/PPO",,3213.14,79.5,,1521.93,481.35,16760.95,30,470.05,3435.43,"percent of total billed charges",
"TUBE TRACH 6 74MM 10.8MM SHILEY UNCUFF DISPOSABLE INNER CANN",SUP-6UN75H,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.56,98.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,150.35,45.9,,,,,0,38.1,278.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM EPIC SUPRA THV",SUP-ESP100-23-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,36722.70,11016.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,14689.08,40,,,,,0,4270.85,31214.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 CROSSFT BC",SUP-CFBC-4502,CDM,C1713,HCPCS,0278,RC,,,both,,,3395.93,1018.78,"CIGNA [10200]","Cigna Open Access",,1932.28,56.9,,1144.80,304.56,2275.09,66,394.95,2886.54,"percent of total billed charges",
"SCR BONE 8.5MM 55MM CD HORIZON SPINAL FENESTRATE MULTIAXIAL",SUP-55840028555T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 32MM LCP STAINLESS STEEL SHORT THREAD",SUP-207.632,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,120.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",120.96,884.03,"percent of total billed charges",
"LENS IOL +27 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0270,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 4-0 P-12 3/8 CIRCLE 58CM CLSR SURGALLOY",SUP-VLOCM0033,CDM,S27200284,LOCAL,0272,RC,,,both,,,262.83,78.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,31.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.57,223.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 1.5MM X 11MM COCR",SUP-VAL-15110-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]","Cigna Open Access",,811.17,56.9,,1144.80,304.56,2275.09,66,165.8,1211.76,"percent of total billed charges",
"CATH MUSTANG 75CM 60MM 9MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171090670,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 6MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR060202A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2003.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIGMA FB OR RP CEMENTED/POROUS",SUP-CAP-DS-K-1,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Local Plus",,5953.5,31.5,,5372.07,4581.20,7242.98,23,2198.07,16065,"percent of total billed charges",
"GRAFT BONE GRAFTECH CANCELLOUS CORTICAL 30ML .5-3MM",SUP-T00070,CDM,S27800098,LOCAL,0278,RC,,,both,,,2840.25,852.07,"BLUE CROSS [10001]","Blue Cross HMO",,1113.38,39.2,,,,,0,330.32,2414.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 12MM 6FR 4.5MM",SUP-H7493926712450,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT HAND ACCESS 120MM BLUNT TIP AIRSEAL 12MM",SUP-IASB12-120,CDM,S27200284,LOCAL,0272,RC,,,both,,,756.65,226.99,"KAISER [10500]",Kaiser,,506.96,67,,,,,0,88,643.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 74MM 24MM 16FR ZENITH SPIRAL-Z Z-TRAK",SUP-G55246,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2509.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 56MM ACETABULAR SURGICAL",SUP-6210-0-815,CDM,S27200284,LOCAL,0272,RC,,,both,,,2463.75,739.12,"MULTIPLAN [10600]",Multiplan,,2094.19,85,,,,,0,286.53,2094.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX PROGRIP 5X3IN LEFT HERNIA PRECUT FLAP",SUP-TEM1208GL,CDM,C1781,HCPCS,0278,RC,,,both,,,1663.28,498.98,"BLUE CROSS [10001]","Blue Cross HMO",,652.01,39.2,,,,,0,193.44,1413.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 18.5MM 27MM MOSAIC CINCH PORCINE BIOPROSTHESIS",SUP-305C227,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"CIGNA [10200]","Cigna Local Plus",,8632.58,31.5,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 30MM 80CM 7MM VASCULAR NITINOL PERIPHERAL",SUP-1012529-30,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IMPL GLUTEUS MEDIUS",SUP-AR-2941GM-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,9201.15,2760.34,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1090.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1070.09,7820.98,"percent of total billed charges",
"ANCHOR SUT 4.75MM SWIVELOCK C TIGERTAPE CLOSED EYELET LOOP",SUP-AR-2324PCTT,CDM,C1713,HCPCS,0278,RC,,,both,,,3346.88,1004.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2275.88,68,,,,,0,389.24,2844.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TEMPO TEMPORARY PACING LEAD",SUP-T1106,CDM,S27200284,LOCAL,0272,RC,,,both,,,3112.50,933.75,"NOVANET [10819]",Novanet,,2334.38,75,,,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE CONNECTING DRNG BAG",SUP-M001229101,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.10,33.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.15,96.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER PRIME XP 110CM 8MM 7FR 8FR 2.5MM SPACE STRAIGHT",SUP-M004P4790THK20,CDM,C1733,HCPCS,0272,RC,,,both,,,12916.80,3875.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1502.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1502.22,10979.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 27FR STERILE DISPOSABLE BLACK CUT",SUP-27050F/6,CDM,S27200284,LOCAL,0272,RC,,,both,,,1113.89,334.17,"FIRST HEALTH [10303]","First Health",,891.11,80,,,,,0,129.55,946.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 25MM KNEE TOTAL STBL TRIATHLON",SUP-5537-G-525,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3851.81,28.62,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP MEDICAL L235CM L2.8MM 11MM OPENING HEMOSTATIC FIXING RE",SUP-M00522612,CDM,S27200284,LOCAL,0272,RC,,,both,,,1239.81,371.94,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE 39MM STAINLESS STEEL 2MM SCR 6 HOLE LC-DCP BONE FOOT",SUP-243.586,CDM,C1713,HCPCS,0278,RC,,,both,,,2931.60,879.48,"NOVANET [10819]",Novanet,,2198.7,75,,,,,0,340.95,2491.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER BEIGE 7CM 3.5MM DYONICS FULL RADIUS RESECTOR",SUP-7205305,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.00,84.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,116.31,41.1,,,,,0,32.91,240.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26MMX13MM CAPSTONE PEEK PTC LUMBAR INTERBODY",SUP-3992613,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"FIRST HEALTH [10303]","First Health",,17640,80,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 15MM 2-3MM AVANCE NERVE ALLOGRAFT",SUP-211215,CDM,C1762,HCPCS,0278,RC,,,both,,,17734.50,5320.35,"NOVANET [10819]",Novanet,,13300.88,75,,,,,0,2062.52,15074.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BUTTON 12MM 4CM PASSPORT BUTTON SILICONE CURVE HIP 1",SUP-AR-6592-12-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ROD SPINAL 70MM 5.5MM CD HORIZON CURVE COCRMO NONSTERILE",SUP-1555501070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL INSRT CURVED PLASTIC HANDLE TITANIUM TIP PLUG",SUP-TE-1000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1077.30,323.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAREON VIVITY",SUP-CNWET0,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,588.2,68,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 7IN STRAIGHT OPHTHALMIC NDL",SUP-MB607R,CDM,S27200284,LOCAL,0272,RC,,,both,,,795.10,238.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,94.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,92.47,675.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL",RX-230392,CDM,,,0250,RC,10310-0283-13,NDC,both,11.9,GR,32.94,9.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,22.4,68,,,,,0,3.83,28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X80 40CM SL",SUP-48003008P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASEPLT TIBIAL ATTUNE 5 KNEE CEMENT REVISION ROTATE PLATFORM",SUP-150660005,CDM,C1776,HCPCS,0278,RC,,,both,,,22629.60,6788.88,"NOVANET [10819]",Novanet,,16972.2,75,,,,,0,2631.82,19235.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION SLR PTCA DEB 4.5X20MM",SUP-SCA14U-450020D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 6.5MM 85MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.785S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,703.88,28.62,,,,,0,286.03,2090.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT WALKING GENESIS LARGE 3 STRAP ULTRA LIGHTWEIGHT LOW",SUP-BL515007,CDM,S27000186,LOCAL,0270,RC,,,both,,,434.91,130.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE SHORT 75MM STAINLESS STEEL 2.7/3.5MM SCR 3 HOLE TAPER",SUP-02.117.303S,CDM,C1713,HCPCS,0278,RC,,,both,,,6974.52,2092.36,"CIGNA [10200]","Cigna Open Access",,3968.5,56.9,,1144.80,304.56,2275.09,66,811.14,5928.34,"percent of total billed charges",
"SHEATH HEARTSPAN 15D FIX CURVE TAPER 60CM 8.5FR GUIDING",SUP-FCL-160-00,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 3.5MM 85MM STAINLESS STEEL T15 PARTIAL THREAD TIBIA",SUP-212429,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.25,337.57,"CIGNA [10200]","Cigna Open Access",,640.27,56.9,,1144.80,304.56,2275.09,66,130.87,956.46,"percent of total billed charges",
"CATH STERLING SL 150CM 100MM 2.5MM BALLOON DILATATION PEBAX",SUP-H74939148251010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CEFEPIME 2 G VIAL IV PUSH",RX-408309,CDM,J0692,HCPCS,0636,RC,44567-0241-10,NDC,both,1,UN,88.79,26.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.69,75.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23MMX10MM ELEVATE STD STERILE",SUP-7771023,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7776,27,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 27.5CM 3.5MM SKIMMER 15D SUBGLOTTIC 2 CURVED",SUP-1883523,CDM,S27200284,LOCAL,0272,RC,,,both,,,4429.80,1328.94,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,515.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,515.19,3765.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUROFORM ATLAS STENT SYSTEM 3.0 X 24MM WITHOUT TIP ZERO (PM",SUP-M003UZAS30240,CDM,C1874,HCPCS,0278,RC,,,both,,,52885.22,15865.57,"BLUE CROSS [10001]","Blue Cross HMO",,20731.01,39.2,,9776.84,9776.84,9776.84,"1 through 10",6150.55,44952.44,"percent of total billed charges",
"SPACER SPINAL 14X5MM HEDRON HEDRON IC 7D 8MM STERILE LATEX",SUP-1213.4075S,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross HMO",,4057.2,39.2,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYSORB 4-0 C-13 30IN BRAID COATED UNDYED ABSORBABLE",SUP-SL-691,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.47,21.74,"CIGNA [10200]","Cigna Open Access",,41.24,56.9,,,,,0,8.43,61.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PLUS PROFILE SOFTTOUCH",SUP-SSLP-360,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"FIRST HEALTH [10303]","First Health",,6044.4,80,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 24MM 140CM 3MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927424300,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"AMERIGROUP MEDICAID [20100]",Amerigroup,,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X11MM SABLE 22D STERILE LATEX FREE",SUP-1172.2035S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"BLUE CROSS [10001]","Blue Cross HMO",,13582.8,39.2,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 10MM STAINLESS STEEL CORTICAL LOCK TRIMED",SUP-LCBS2.7-10,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"BLUE CROSS [10001]","Blue Cross PPO",,333.4,39.2,,957.42,570.23,957.42,28,98.91,722.93,"percent of total billed charges",
"RESTRICT CEMENT MEDIUM UNIVERSAL",SUP-B000-0240,CDM,S27800098,LOCAL,0278,RC,,,both,,,620.57,186.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,177.61,28.62,,,,,0,72.17,527.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC COLD BIOPSY NDL 240CM 2.4FR 2.8MM RADIAL JAW",SUP-M00513331,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.37,38.51,"CIGNA [10200]","Cigna Open Access",,73.04,56.9,,,,,0,14.93,109.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 45MM BIO-MOORE II ENDO II HIP ACETABULAR",SUP-12-139014,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"BLUE CROSS [10001]","Blue Cross PPO",,1094.86,39.2,,3949.44,3949.44,3949.44,"1 through 10",324.83,2374.05,"percent of total billed charges",
"PATCH CARDIOVASCULAR THK.6MM RECTANGULAR REGULAR WALL 75X50",SUP-50P7506,CDM,C1768,HCPCS,0278,RC,,,both,,,2172.98,651.89,"AETNA [10100]","Aetna HMO/PPO",,1727.52,79.5,,,,,0,252.72,1847.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 55CM 7FR 10MM 12CM NEPHROMAX NEPHRSTMY HIGH PRESSURE",SUP-M0062101180,CDM,C1726,HCPCS,0272,RC,,,both,,,1970.78,591.23,"MULTIPLAN [10600]",Multiplan,,1675.16,85,,,,,0,229.2,1675.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUMP INFUSION 34MM INTERA 3000 HEPATIC ARTERY HIGH FLOW 30ML",SUP-AP03000H,CDM,C1891,HCPCS,0278,RC,,,both,,,82023.00,24606.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9539.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9539.27,69719.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175260070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"BLUE CROSS [10001]","Blue Cross HMO",,390.99,39.2,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752810,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"KAISER [10500]",Kaiser,,604.46,67,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +12.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.125,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 6FR 40D GUIDING DURAFORM PTFE",SUP-M003101420,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"KAISER [10500]",Kaiser,,1677.1,67,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 8X2.75IN 2 PORT 1 BLADDER WITHOUT SLEEVE ATS",SUP-60707010100,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.40,44.22,"CIGNA [10200]","Cigna Open Access",,83.87,56.9,,,,,0,17.14,125.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLGRAFT 50MM 90CM 7MM 9FR 116CM",SUP-M001705750,CDM,C1874,HCPCS,0278,RC,,,both,,,14165.70,4249.71,"CIGNA [10200]","Cigna Local Plus",,4462.2,31.5,,,,,0,1647.47,12040.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 15MM 4MM BALLOON DILATATION PACLITAXEL RADIOPAQUE",SUP-H7493960815400,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"FIRST HEALTH [10303]","First Health",,31122,80,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOBILIZER KNEE WRAP AROUND ABOVE KNEE OPEN PATELLA WINDOW",SUP-A142005,CDM,L1830,HCPCS,0274,RC,,,both,,,117.71,35.31,"KAISER [10500]",Kaiser,,78.87,67,,,,,0,13.69,100.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL G RIGHT CEMENTED POSTERIOR STABILIZED OPTION",SUP-00596401752,CDM,C1776,HCPCS,0278,RC,,,both,,,15346.80,4604.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1818.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1784.83,13044.78,"percent of total billed charges",
"HC Ld Recovery 1st Hour",PX-710000002,CDM,9999144,LOCAL,0710,RC,,,both,,,3269.70,980.91,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,387.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,380.27,2779.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 6MM GORE PROPATEN EPTFE HEPARIN THIN",SUP-HT066080A,CDM,C1768,HCPCS,0278,RC,,,both,,,18011.70,5403.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7402.81,41.1,,,,,0,2094.76,15309.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVOLUTION FLEXOR 9CM 22MM 27MM DUODENAL METAL CONTROL",SUP-G48026,CDM,C1876,HCPCS,0278,RC,,,both,,,17854.20,5356.26,"BLUE CROSS [10001]","Blue Cross PPO",,6998.85,39.2,,,,,0,2076.44,15176.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 STD KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-42500606001,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"MULTIPLAN [10600]",Multiplan,,19433.3,85,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DECA 4-4-4-29-4-4-4-4-4 MPA 120CM",SUP-901824,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"PHCS [10601]",PHCS,,2073.75,70,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUMARK CONIC 18GX12CM 10/BX",SUP-351262,CDM,A4648,HCPCS,0278,RC,,,both,,,961.70,288.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,653.96,68,,,,,0,111.85,817.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Psg W Cpap/Bipap Incomplt",PX-740000007,CDM,95811,CPT,0920,RC,,,both,,,6404.70,1921.41,"FIRST HEALTH [10303]","First Health",,5123.76,80,,,,,0,744.87,5444,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOX SV 150CM 60MM 4FR 6MM .018IN LARGE CRESCENT LOW",SUP-83981-02,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 30X10MM COSTAL CARTILAGE FROZEN",SUP-70B001,CDM,C1713,HCPCS,0278,RC,,,both,,,2088.75,626.62,"NOVANET [10819]",Novanet,,1566.56,75,,,,,0,242.92,1775.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CERES-C SPACER 12X15X7 10 DEG",SUP-SK-08-170-1007,CDM,S27800098,LOCAL,0278,RC,,,both,,,7590.00,2277,"AETNA [10100]","Aetna HMO/PPO",,6034.05,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 20MM 3.5MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012409-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 135CM 7MM 11MM 7FR .035IN",SUP-BXA077902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8798.44,41.1,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 27MM RESTORATION +0MM STD HIP MODULAR REVISION",SUP-6276-1-027,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"AETNA [10100]","Aetna HMO/PPO",,11501.12,79.5,,10981.53,8986.79,12413.38,12,1682.49,12296.8,"percent of total billed charges",
"COIL EMBOLIZATION 1CM 2MM AXIUM PRIME HELIX DETACHABLE EXTRA",SUP-APB-2-1-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"AETNA [10100]","Aetna HMO/PPO",,7103.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 14MM REVISION 20 GRIT BLAST SURFACE",SUP-197614140,CDM,C1776,HCPCS,0278,RC,,,both,,,17952.48,5385.74,"MULTIPLAN [10600]",Multiplan,,15259.61,85,,,,,0,2087.87,15259.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT XEMPLIFI DEMINERALIZE BONE MATRIX PUTTY 5ML",SUP-8103.0005S,CDM,S27800098,LOCAL,0278,RC,,,both,,,3750.00,1125,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1721.25,45.9,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 9X40 80CM SL",SUP-48009004N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,101.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ANTERIOR ASPHERIC SURFACE ABERRATION FREE ADVANCED",SUP-LI61AOR2850,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 150MM 3.9MM 4.2MM 3 FLUTE QUICK COUPLING 5MM ASLS",SUP-03.025.083,CDM,S27200284,LOCAL,0272,RC,,,both,,,1343.79,403.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,156.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,156.28,1142.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER INSTR 10X2.5IN WEINSTEIN STRINGER NONSTERILE",SUP-117-244,CDM,S27000186,LOCAL,0270,RC,,,both,,,309.72,92.92,"KAISER [10500]",Kaiser,,207.51,67,,,,,0,36.02,263.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RCRD CARDIAC 56.3X18.5X8MM CONFIRM 39MM SPACING ACTIVATED",SUP-DM2100,CDM,C1764,HCPCS,0278,RC,,,both,,,20128.50,6038.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2340.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL PLIF 17 DEGREE 7MM X 9MM X 28MM MOD-EX",SUP-1937928P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"AETNA [10100]","Aetna HMO/PPO",,27546.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 2-0 UCL 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z114H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"CIGNA [10200]","Cigna Local Plus",,14.45,53.5,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 35FR ANGLE 2 LEFT",SUP-M125135,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +17.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.175,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 1 MO-4 27IN MONOFILAMENT 1 STRAND BROWN",SUP-4925H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AETNA [10100]","Aetna HMO/PPO",,19.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 30FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0166SI30,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.21,20.46,"CIGNA [10200]",Cigna,,46.38,68,,,,,0,7.93,57.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL REUNION OD9 MM PRESS FIT TOTAL SHOULDER ARTHROP",SUP-5569-C-2009,CDM,C1776,HCPCS,0278,RC,,,both,,,10440.00,3132,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2987.93,28.62,,,,,0,1214.17,8874,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC .035IN 200CM KNIFE PRECUT GWIRE FUSION 7FR 6",SUP-G31539,CDM,S27200284,LOCAL,0272,RC,,,both,,,1680.00,504,"NOVANET [10819]",Novanet,,1260,75,,,,,0,195.38,1428,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 7.5CM 120CM 5MM 7FR ENDOPROSTHESIS",SUP-VBHR050702A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"KAISER [10500]",Kaiser,,14250.1,67,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTIGRAFT VG1 7D 1 PIECE LORDOSIS SOLID CENTRAL",SUP-VG1C-T46P,CDM,C1713,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"MULTIPLAN [10600]",Multiplan,,4985.25,85,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 105D XIA OFFSET PLATE TITANIUM SPINE",SUP-03820132,CDM,S27800098,LOCAL,0278,RC,,,both,,,3562.50,1068.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 30CM 7FR POLARIS ULTRA NAUTILUS ZIPWIRE .035IN 2",SUP-M006192145190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CIGNA [10200]","Cigna Local Plus",,746.45,,,,,,,162.27,1185.95,"percent of total billed charges",
"RING ANNULOPLASTY 24MM HOLDER CG FUTURE",SUP-638RL24,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5388.21,41.1,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK",RX-10049,CDM,J1450,HCPCS,0636,RC,25021-0184-82,NDC,both,100,ML,100.65,30.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68.44,68,,,,,0,2.63,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 10CM 10FR DUODENAL BEND BILIARY PLASTIC TEMPORARY",SUP-M00545620,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"CIGNA [10200]","Cigna Local Plus",,456.23,53.5,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTRA TWINFLEX TCH 69","SUP-392 290",CDM,C1893,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 20CM 150CM 6FR .038IN STD STRAIGHT LOW PROFILE",SUP-M006180520170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,837.05,68,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 65CM 5FR KA2 CURVE ANGIOGRAPHIC PEBAX",SUP-5582-43,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.44,55.33,"CIGNA [10200]","Cigna Local Plus",,98.68,53.5,,,,,0,21.45,156.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BIOLOGICAL 2X2IN INTEGRA BOVINE CLLGN GLYCOSAMINOGLYCAN",SUP-MWM2021,CDM,C9363,HCPCS,0278,RC,,,both,,,28085.27,8425.58,"FIRST HEALTH [10303]","First Health",,22468.22,80,,,,,0,3266.32,23872.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CIRCUIT EVAQUA 2 2 LIMB NO FILTER ADULT LATEX FREE",SUP-RT280,CDM,S27000186,LOCAL,0270,RC,,,both,,,276.23,82.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,32.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.13,234.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OLYMPUS EZDILATE BALLOON DILATOR 11-12-13",SUP-BD-410X-1355,CDM,C1726,HCPCS,0272,RC,,,both,,,1441.96,432.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,170.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.7,1225.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 15IN LARGE",SUP-D-497-LRG,CDM,S27000186,LOCAL,0270,RC,,,both,,,178.35,53.5,"CIGNA [10200]","Cigna Open Access",,101.48,56.9,,,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.7MM 16MM VARIAX TITANIUM LOW PROFILE HAND WRIST",SUP-53-17016E,CDM,C1713,HCPCS,0278,RC,,,both,,,734.83,220.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,87.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,85.46,624.61,"percent of total billed charges",
"BONE FENESTRATION PERFORATOR",SUP-P99-100-2010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"FIRST HEALTH [10303]","First Health",,803.52,80,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BMA NEEDLE 74285-01M 11 GAUGE X 11CM",SUP-7428501M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.00,513,"PHCS [10601]",PHCS,,1197,70,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT RESECTOSCOPE OES PRO 9MM 8FR WORKING ANTIBLOCKING",SUP-A42091A,CDM,S27800098,LOCAL,0278,RC,,,both,,,4515.00,1354.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2072.39,45.9,,,,,0,525.09,3837.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE IV FOR SCAPE",RX-411694,CDM,J2305,HCPCS,0636,RC,00338-1049-02,NDC,both,250,ML,203.85,61.15,"BLUE CROSS [10001]","Blue Cross PPO",,17.37,,,,,,,17.37,173.27,"fee schedule",
"SCR BONE 2.7MM 55MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.855,CDM,C1713,HCPCS,0278,RC,,,both,,,367.84,110.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,250.13,68,,,,,0,42.78,312.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE IV FOR SCAPE",RX-411694,CDM,J2305,HCPCS,0636,RC,00338-1049-02,NDC,both,250,ML,203.85,61.15,"KAISER [10500]",Kaiser,,136.58,67,,,,,0,17.37,173.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 150-180ML STYLE 68 SMOOTH ANTERIOR DIAPH VALVE",SUP-68-150,CDM,C1789,HCPCS,0278,RC,,,both,,,3202.50,960.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,372.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,372.45,2722.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-3 TH-26 36IN MONOFILAMENT 2 ARM UNDYED",SUP-3N08A,CDM,S27200284,LOCAL,0272,RC,,,both,,,276.95,83.08,"KAISER [10500]",Kaiser,,185.56,67,,,,,0,32.21,235.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 45MM COMPREHENSIVE 3.5MM SHOULDER FIX ANGLE",SUP-180556,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"NOVANET [10819]",Novanet,,1166.78,75,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 3CM 7FR .035IN PIGTAIL CURVE STRAIGHT LOW PROFILE",SUP-M006145374050,CDM,C2617,HCPCS,0278,RC,,,both,,,940.57,282.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,269.19,28.62,,,,,0,109.39,799.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 5FR 21GA MERIT MAK .018IN NITINOL GWIRE",SUP-MAK501N-PED,CDM,C1894,HCPCS,0272,RC,,,both,,,241.86,72.56,"AETNA [10100]","Aetna HMO/PPO",,192.28,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.13,205.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.430TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,239.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",235.11,1718.32,"percent of total billed charges",
"STENT VENOVO 120MM 120CM 18MM .035IN 3MM VASCULAR VENOUS",SUP-VENUL18120,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"CIGNA [10200]",Cigna,,9324,40,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 50MM SPINE POLYAXIAL REVOLVE",SUP-185.486,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1110.3,8114.82,"percent of total billed charges",
"ALTIVATE REVERSE REVISION HUMERAL STEM, SZ 10X175MM",SUP-530-10-175,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Local Plus",,3969,31.5,,5372.07,4581.20,7242.98,23,1465.38,10710,"percent of total billed charges",
"HC Rv Fem/Pop W Stent & Ather Sf Ea Add",PX-361000717,CDM,37276,CPT,0361,RC,,,both,,,17348.93,5204.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7883,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,17.35,14746.59,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.5 X 12MM POLYAXIAL SCREW",SUP-32535-012,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"AMERIGROUP MEDICAID [20100]",Amerigroup,,497.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",488.46,3570,"percent of total billed charges",
"HC Amino Acids 6/> Amino Acids Quantitative Ea Spe",PX-301000103,CDM,82139,CPT,0301,RC,,,both,,,453.70,136.11,"PHCS [10601]",PHCS,,317.59,70,,,,,0,0.01,385.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCPL SURGICAL MICRO POINT 128164M",SUP-28164MC-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1500.85,450.25,"CIGNA [10200]","Cigna Local Plus",,802.95,53.5,,,,,0,174.55,1275.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT CRUCIATE RETAINING GENESIS II",SUP-71421234,CDM,C1776,HCPCS,0278,RC,,,both,,,28831.95,8649.58,"MULTIPLAN [10600]",Multiplan,,24507.16,85,,,,,0,3353.16,24507.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Circumcision Neonate",PX-361000238,CDM,54160,CPT,0361,RC,,,both,,,3893.94,1168.18,"KAISER [10500]",Kaiser,,2608.94,67,,,,,0,452.87,3893.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LOCKING 5.5MM MATRIX FLAT SPINE COCR TITANIUM STEP",SUP-09.632.099,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"MULTIPLAN [10600]",Multiplan,,295.8,85,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFEPIME 2 G VIAL",RX-16371,CDM,J0692,HCPCS,0636,RC,44567-0241-10,NDC,both,1,UN,88.79,26.64,"MULTIPLAN [10600]",Multiplan,,75.47,85,,,,,0,5.69,75.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE 65CM 5FR .6CM RADIUS SMALL JUDKINS 3 CURVE",SUP-532523,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"NOVANET [10819]",Novanet,,78.3,75,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 22CM 9MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140922,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4883.42,41.1,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL COMFORT FLO PLUS LARGE HEAT HUMD WITH CONCHASMART",SUP-2412-11,CDM,S27000186,LOCAL,0270,RC,,,both,,,166.39,49.92,"FIRST HEALTH [10303]","First Health",,133.11,80,,,,,0,19.35,141.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 19MM 14.8MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-19MECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"BLUE CROSS [10001]","Blue Cross HMO",,11414.74,39.2,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SPECIMEN RETRIEVAL 120CM 2.6FR 8MM URETERAL STONE 2",SUP-M0063204010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Encephalitis St Louis Ab",PX-302000116,CDM,86653,CPT,0302,RC,,,both,,,160.55,48.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,20.75,,,,,,,0.01,136.47,"fee schedule",
"TUBE TRACH 12 STD 27MM PROVOX LIFE LARYTUBE SOFT SILICONE",SUP-7418,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"CIGNA [10200]","Cigna Open Access",,679.9,56.9,,,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCIVA VR DF4",SUP-D412,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"AETNA [10100]","Aetna HMO/PPO",,31005,79.5,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 20MM 150CM 8MM VASCULAR NICKEL",SUP-EVD35-08-020-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"KAISER [10500]",Kaiser,,4210.95,67,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 4CM 5MM BALLOON DILATATION",SUP-DR13554,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEMORAL VANGUARD 360 5MM OFFSET KNEE REVISION SYSTEM",SUP-185211,CDM,C1776,HCPCS,0278,RC,,,both,,,5978.16,1793.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2743.98,45.9,,,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 6X 38MM CATH 120CM ENDOVASCULAR",SUP-42638,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7200.84,41.1,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 500MM 5.5MM 2 HEXAGON STRAIGHT DEFORMITY DENALI",SUP-111-B55500,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 52MM TAN X25 LOCK STERILE LIGHT GREEN 4.2MM",SUP-04.045.052TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 90CM 7FR LCB CURVE GUIDING STAINLESS",SUP-77818090,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 650ML STYLE 9300 TEXTURED SELF SEALING PATCH",SUP-3549315,CDM,C1789,HCPCS,0278,RC,,,both,,,6720.00,2016,"CIGNA [10200]","Cigna Open Access",,3823.68,56.9,,5166.00,5166.00,5166.00,"1 through 10",781.54,5712,"percent of total billed charges",
"CMPNT FEMORAL 6 KNEE PERSONA STERILE LATEX FREE",SUP-42-5726-060-02,CDM,C1776,HCPCS,0278,RC,,,both,,,26429.76,7928.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3131.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3073.78,22465.3,"percent of total billed charges",
"GRAFT SKIN 5X5CM ALLOPATCH HD THK.8-1.7MM THICK ACELLULAR",SUP-471505,CDM,Q4128,HCPCS,0636,RC,,,both,,,10315.50,3094.65,"AETNA [10100]","Aetna HMO/PPO",,8200.82,79.5,,,,,0,80.43,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.0MM X 15.0MM",SUP-492001512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAUT ELECTROSURGICAL .5IN ACCU-TEMP 1205C HIGH VARIABLE",SUP-8443000,CDM,S27200284,LOCAL,0272,RC,,,both,,,153.81,46.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,63.22,41.1,,,,,0,17.89,130.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE PEEP 10 CMW 22MM 10CM TRUE THRESHOLD RESISTOR ADPTR",SUP-9010B,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.67,33.8,"NOVANET [10819]",Novanet,,84.5,75,,,,,0,13.1,95.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL PEDIATRIC MASK MANOMETER BAG RESVR O2 TUBE",SUP-530613030,CDM,S27000186,LOCAL,0270,RC,,,both,,,89.06,26.72,"CIGNA [10200]","Cigna Local Plus",,47.65,53.5,,,,,0,10.36,75.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 15MM 3.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP3515X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"UHC [10700]","United Healthcare",,333.27,63.3,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.455,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"PHCS [10601]",PHCS,,3389.82,70,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT SWIVELOCK SP KNOTLESS PEEK STERILE LATEX FREE",SUP-AR-2323KPSP,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Pta Cmplx Init",PX-361000706,CDM,37265,CPT,0361,RC,,,both,,,12247.10,3674.13,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6291,,"Case rate ($6,291). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1424.34,10410.04,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SHEATH GUIDE KINK RESISTANT STOPPER BRUSH",SUP-K-401,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,826.2,45.9,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 52CM .016IN FIRM KNOB CAP STRAIGHT RED WHITE",SUP-6583,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Stoma W Rmvl FB",PX-750000070,CDM,44390,CPT,0750,RC,,,both,,,2289.10,686.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2289.1,,"Fee schedule rate ($2,292.95).",,,,0,266.22,2289.1,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 10MM NATURAL LORDOTIC CORTICOCANCELLOUS",SUP-18410,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 44MM UNIVERS REVERS GLENOID PERIPHERAL LOCK",SUP-AR-9563-44,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,406.22,68,,,,,0,69.48,507.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 75MM STAINLESS STEEL 3.5MM SCREWS 3X5 HOLES T OBLIQUE",SUP-241.25,CDM,C1713,HCPCS,0278,RC,,,both,,,2831.85,849.55,"BLUE CROSS [10001]","Blue Cross PPO",,1110.09,39.2,,957.42,570.23,957.42,28,329.34,2407.07,"percent of total billed charges",
"DEVICE LESLIE PARACHUTE 120CM 5CM 11MM 3.1FR SPECIMEN",SUP-M0063203030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1464.48,439.34,"KAISER [10500]",Kaiser,,981.2,67,,,,,0,170.32,1244.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 6FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856140,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"NOVANET [10819]",Novanet,,822.5,75,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CIRCULATORY SYSTEM DIAGNOSES,MAJOR",207,APR-DRG,,,,,,,inpatient,,,49096.68,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $9,111.85. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($68,669.83) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 7.5MM 35MM RESURFACING GENESIS II",SUP-71932637,CDM,C1776,HCPCS,0278,RC,,,both,,,6882.75,2064.82,"BLUE CROSS [10001]","Blue Cross PPO",,2698.04,39.2,,3949.44,3949.44,3949.44,"1 through 10",800.46,5850.34,"percent of total billed charges",
"CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,EXTREME",166,APR-DRG,,,,,,,inpatient,,,315149.73,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $41,586.59. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($246,988.76) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Laryngeal Tube Non-Fenestrated",PX-E27000254,CDM,A7520,HCPCS,0270,RC,,,both,,,566.50,169.95,"AETNA [10100]","Aetna HMO/PPO",,450.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.47,481.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL ULTRA STRONG CURVE 3CM VEIN LIGHTWEIGHT",SUP-15-0730,CDM,S27200284,LOCAL,0272,RC,,,both,,,1659.75,497.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STYLET INTUB STAINLESS STEEL MEDIUM GLIDERITE ROD DISPOSABLE",SUP-0270-1093,CDM,S27200284,LOCAL,0272,RC,,,both,,,97.09,29.13,"AETNA [10100]","Aetna HMO/PPO",,77.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.29,82.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 15MM 3MM BALLOON DILATATION PEBAX",SUP-1400300-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL 0 D +20.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-SY60WF.205,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32MM TAN X25 LOCK STERILE LIGHT GREEN 4.2MM",SUP-04.045.032TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"RTRCTR 12IN DEAVER 3 FLEXIBLE STD HANDLE SATIN FINISH",SUP-23-7507,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.23,33.07,"KAISER [10500]",Kaiser,,73.85,67,,,,,0,12.82,93.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? BONE SCREW, 3.0MM X 14MM, 2 PACK",SUP-94-30-14-2S,CDM,C1713,HCPCS,0278,RC,,,both,,,1595.70,478.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",185.58,1356.35,"percent of total billed charges",
"CATH GLIDER 12MM 1.5MM BALLOON DILATATION LOW PROFILE PTCA",SUP-4100A-1512,CDM,C1725,HCPCS,0272,RC,,,both,,,2212.50,663.75,"KAISER [10500]",Kaiser,,1482.38,67,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 4.5FR 50CM 11CM RED HUB TUBING GWIRE ROTATING",SUP-PSI-4F-11-035ACT,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.9,41.1,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 10MM IPOLY XE POSTERIOR STABILIZE ITOTAL",SUP-TPS-020-1000,CDM,C1776,HCPCS,0278,RC,,,both,,,2130.00,639,"BLUE CROSS [10001]","Blue Cross PPO",,834.96,39.2,,3949.44,3949.44,3949.44,"1 through 10",247.72,1810.5,"percent of total billed charges",
"SUT SILK PERMA-HAND 2-0 30IN BRAID TIE 12 STRAND PRECUT",SUP-A305H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 38MM TITANIUM LEVEL 2 ASSURE BONE SPINE CERVICAL",SUP-110.238,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Open Access",,2509.29,56.9,,1144.80,304.56,2275.09,66,512.88,3748.5,"percent of total billed charges",
"BLADE SAW 105X19.5MM PRECISION THK1.33MM FALCON CRTDG LATEX",SUP-6725127105,CDM,S27200284,LOCAL,0272,RC,,,both,,,2580.23,774.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1060.47,41.1,,,,,0,300.08,2193.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CBL PCNG DISP",SUP-4043,CDM,S27200284,LOCAL,0272,RC,,,both,,,931.50,279.45,"NOVANET [10819]",Novanet,,698.63,75,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP NON POROUS FEMUR OXI HEAD ANTEVERTED LINER",SUP-71703326,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPLORER ST 100CM 5FR 5MM SPACE COURNAND CURVE",SUP-4542,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2573.61,45.9,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 150MM 5MM SCHANZ SELF DRILL CALCANEAL FRACTURE",SUP-AR-8954-01,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"CIGNA [10200]","Cigna Local Plus",,1203.75,53.5,,3978.14,359.25,3978.14,24,261.68,1912.5,"percent of total billed charges",
"HC ED Visit B Level 3 W Proc",PX-450000330,CDM,G0382,HCPCS,0450,RC,,,both,,,1257.00,377.1,"UHC [10700]","United Healthcare",,1257,,"Per diem ($2,260).",,,,0,67.13,1257,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 3MM RETRACTION SHARP ELASTIC STAY LONE STAR STAINLESS",SUP-3314-1G,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.05,27.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.59,77.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZTRK 90CM 6FR BLNOCC COR",SUP-6714,CDM,C2628,HCPCS,0272,RC,,,both,,,261.00,78.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,30.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .047IN RIGHT CORONARY",SUP-534570T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC DRN Lesion Ear Extrnl Cmplx",PX-450000301,CDM,69005,CPT,0450,RC,,,both,,,5935.00,1780.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5.94,.1,,,,,0,5.94,5044.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE 4X4CM AMNIOFIX AMNIOTIC MEMB DURABLE",SUP-APS-5440,CDM,Q4433,HCPCS,0636,RC,,,both,,,10101.60,3030.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cult Aerob Presump ID Wound",PX-306000026,CDM,87070,CPT,0306,RC,,,both,,,362.90,108.87,"NOVANET [10819]",Novanet,,272.18,75,,,,,0,0.01,308.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE SOFT TOUCH SMOOTH",SUP-SSF-295,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"NOVANET [10819]",Novanet,,5666.63,75,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM LOW PROFILE NONLOCK HEXALOBE",SUP-3025-35022,CDM,C1713,HCPCS,0278,RC,,,both,,,988.20,296.46,"KAISER [10500]",Kaiser,,662.09,67,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 20MM 120CM 9MM .079IN LARGE DIAMETER",SUP-SERB65-9-20-120,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,572.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR BICONVEX 26MM GENESIS II KNEE",SUP-71420568,CDM,C1776,HCPCS,0278,RC,,,both,,,6344.55,1903.36,"AETNA [10100]","Aetna HMO/PPO",,5043.92,79.5,,10981.53,8986.79,12413.38,12,737.87,5392.87,"percent of total billed charges",
"THORECON? AUXILERY CABLE PLATE KIT",SUP-94-1500-04-S,CDM,C1713,HCPCS,0278,RC,,,both,,,8507.70,2552.31,"KAISER [10500]",Kaiser,,5700.16,67,,,,,0,989.45,7231.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 100CM 5FR STRAIGHT ANGIOGRAPHIC POLYETHYLENE PERIPHERAL",SUP-G00159,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.19,73.86,"NOVANET [10819]",Novanet,,184.64,75,,,,,0,28.63,209.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP CLUSTER HOLE HA TRIDENT II PSL E",SUP-742-11-52E,CDM,C1776,HCPCS,0278,RC,,,both,,,9502.96,2850.89,"CIGNA [10200]","Cigna Open Access",,5407.18,56.9,,5302.19,4377.88,6578.61,27,1105.19,8077.52,"percent of total billed charges",
"STENT ONYX FRONTIER 22MM 2MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG20022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,858.6,28.62,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM FRMLA ROUND 6 FLUTED ARTHROSCOPIC STERILE",SUP-0375940000,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,38.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 8CM 2MM GATOR XTRA SHARP LARGE HUB STERILE",SUP-C9960A,CDM,S27200284,LOCAL,0272,RC,,,both,,,638.28,191.48,"UHC [10700]","United Healthcare",,404.03,63.3,,,,,0,74.23,542.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 4MM OXFORD ARCOM KNEE RIGHT MENISCAL PHASE 3",SUP-159569,CDM,C1776,HCPCS,0278,RC,,,both,,,8698.97,2609.69,"CIGNA [10200]","Cigna Open Access",,4949.71,56.9,,5302.19,4377.88,6578.61,27,1011.69,7394.12,"percent of total billed charges",
"INSRT TIBIAL 6 CURVE 15MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962063,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2647.19,28.62,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 15MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181550,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5322.63,28.62,,,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 16MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620916,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Local Plus",,6020.84,53.5,,5372.07,4581.20,7242.98,23,1308.83,9565.82,"percent of total billed charges",
"HC Kit Startup Cath Therm Als",PX-E27200182,CDM,E27200182,LOCAL,0272,RC,,,both,,,1361.80,408.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,926.02,68,,,,,0,158.38,1157.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL ROCHESTER-PEAN 8IN STRAIGHT",SUP-BH446R,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.10,57.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,130.63,68,,,,,0,22.34,163.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Venous 1st Br",PX-361000069,CDM,36011,CPT,0361,RC,,,both,,,713.64,214.09,"NOVANET [10819]",Novanet,,535.23,75,,,,,0,83,713.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 5CM 14FR MIC-KEY SECUR-LOK ENFIT SILICONE RADIOPAQUE",SUP-8140-14-5.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,357.59,45.9,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Somatostatin",PX-301000698,CDM,84307,CPT,0301,RC,,,both,,,180.00,54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.19,,"Fee schedule rate ($19.19). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,153,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 28MM 144CM 2.25MM",SUP-H7493941228220,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"FIRST HEALTH [10303]","First Health",,6210,80,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER SUPPORT L90CM DIA0.056IN COMPATIBLE GUIDEWIRE 0.035",SUP-P1VC-035ANG-090,CDM,C1894,HCPCS,0272,RC,,,both,,,1458.00,437.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,599.24,41.1,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 12X12.5CM 450CC STYLE 133S SMOOTH SUT TAB",SUP-133S-FX-12-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA [10200]","Cigna Open Access",,5300.24,56.9,,5166.00,5166.00,5166.00,"1 through 10",1083.33,7917.75,"percent of total billed charges",
"CUP HUMERAL 33MM UNIVERS REVERS +2 RIGHT SUT",SUP-AR-9502F-33LCPC,CDM,C1776,HCPCS,0278,RC,,,both,,,7576.20,2272.86,"PHCS [10601]",PHCS,,5303.34,70,,,,,0,881.11,6439.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.3MM STAINLESS STEEL 2MM SCR 2 HOLE HEAD 6 HOLE SHAFT",SUP-02.130.355,CDM,C1713,HCPCS,0278,RC,,,both,,,3465.00,1039.5,"PHCS [10601]",PHCS,,2425.5,70,,,,,0,402.98,2945.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 12MM 2.25MM BALLOON DILATATION PEBAX",SUP-1012271-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP SMF WITH OXINIUM HEAD R3 MULTI-HOLE",SUP-71705534,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6851.63,28.62,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE DESTINATION STRAIGHT 90CM 15CM 7FR GUIDING",SUP-RSC06,CDM,C1894,HCPCS,0272,RC,,,both,,,785.70,235.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,322.92,41.1,,,,,0,91.38,667.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 150D STD BARREL 94MM STAINLESS STEEL 5 HOLE",SUP-281.450,CDM,C1713,HCPCS,0278,RC,,,both,,,2156.11,646.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,255.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,250.76,1832.69,"percent of total billed charges",
"CATH CONQUEST 75CM 2CM 8MM 6FR BALLOON DILATATION PERIPHERAL",SUP-CQ7582,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"UHC [10700]","United Healthcare",,846,63.3,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 30MM LCP STAINLESS STEEL PROXIMAL FEMORAL",SUP-02.205.030,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"BLUE CROSS [10001]","Blue Cross PPO",,495.21,39.2,,957.42,570.23,957.42,28,146.92,1073.79,"percent of total billed charges",
"SCR BONE 5MM 6.2MM 28MM NCB PROTASUL-64 3.5MM CORTEX SELF",SUP-0203150028,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"BLUE CROSS [10001]","Blue Cross HMO",,727.65,39.2,,957.42,156.86,7483.26,51,215.88,1577.81,"percent of total billed charges",
"KIT INSTR JOINT PREPARATION ORTHOLOC 2 STERILE",SUP-9914PK01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1093.50,328.05,"KAISER [10500]",Kaiser,,732.65,67,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 8CM 9MM BALLOON DILATATION OTW LOW",SUP-G30980,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 12CM 1.92MM 1.5MM SONOPET IQ BARRACUDA SOFT TISSUE",SUP-5500-25S-310,CDM,S27200284,LOCAL,0272,RC,,,both,,,6794.31,2038.29,"CIGNA [10200]",Cigna,,4620.13,68,,,,,0,790.18,5775.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE INCISION ACMI CLASSIC",SUP-M0068805511,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"AETNA [10100]","Aetna HMO/PPO",,410.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 1.2CM 12FR RADIOPAQUE LOW PROFILE TAPER DISTAL TIP",SUP-0120-12-1.2,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"NOVANET [10819]",Novanet,,584.3,75,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXCISOR BIOPSY FISCHER LARGE CERVICAL CONE SHALLOW STERILE",SUP-900-155,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.28,60.98,"AETNA [10100]","Aetna HMO/PPO",,161.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.64,172.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC COBALT VR 1 CHMBR DF-1 PIN PLUG RADIOPAQUE",SUP-DVPB3D1,CDM,C1722,HCPCS,0278,RC,,,both,,,56385.00,16915.5,"AETNA [10100]","Aetna HMO/PPO",,44826.08,79.5,,,,,0,6557.58,47927.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 125CM 5FR BEACON SIMMONS 2 CURVE",SUP-G11517,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CIGNA [10200]","Cigna Local Plus",,127.06,53.5,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 10.5IN AMPUTATION",SUP-FH320R,CDM,S27200284,LOCAL,0272,RC,,,both,,,780.60,234.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,530.81,68,,,,,0,90.78,663.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR CERAMIC POROUS BIPOLAR PRIMARY HEAD INSRT",SUP-98B00100189,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2962.17,28.62,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 92CM 1MM 6FR 10MM SPACE REGULAR D CURVE",SUP-D6DR252CT,CDM,C1730,HCPCS,0272,RC,,,both,,,1400.60,420.18,"MULTIPLAN [10600]",Multiplan,,1190.51,85,,,,,0,162.89,1190.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL NOTTINGHAM ONE-STEP HYDROPLUS TAPER 70CM 4CM",SUP-M0062301100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1005.78,301.73,"KAISER [10500]",Kaiser,,673.87,67,,,,,0,116.97,854.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 2CM 6MM BALLOON",SUP-G52264,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PHCS [10601]",PHCS,,671.84,70,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTIFIER BIOPSY 14G",SUP-STAR1403,CDM,S27200284,LOCAL,0272,RC,,,both,,,640.49,192.15,"NOVANET [10819]",Novanet,,480.37,75,,,,,0,74.49,544.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE RIGHT CONSTRAIN LEGION OXINIUM",SUP-71421174,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"MULTIPLAN [10600]",Multiplan,,49158.9,85,,,,,0,6726.09,49158.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710512,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"BLUE CROSS [10001]","Blue Cross HMO",,5799.09,39.2,,5311.50,4717.44,5388.59,31,1720.5,12574.56,"percent of total billed charges",
"ROD SPINAL 50MM 5.5MM VIPER 2 PREBENT TITANIUM NONSTERILE",SUP-186788050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"BLADE MYRINGOTOMY 7IN NARROW NARROW SHAFT STERILE DISPOSABLE",SUP-1458275,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.95,20.98,"FIRST HEALTH [10303]","First Health",,55.96,80,,,,,0,8.14,59.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17.8MM 27-29MM ON-X HEART PROSTHETIC EXTEND STD",SUP-ONXAE-27/29,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"CIGNA [10200]","Cigna Open Access",,12663,33.5,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRESTIGE PLUS HELICAL PACK",SUP-PRES0412HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"PHCS [10601]",PHCS,,4588.5,70,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION BLUE 1.02MM PAPARELLA EAR ULTRASIL TAB",SUP-70241044,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.01,40.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.7,114.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.818,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,161.25,45.9,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 26MM 1 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800126,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,521.61,3812.25,"percent of total billed charges",
"NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC",987,MS-DRG,,,,,,,inpatient,,,114651.78,34395.53,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,22542.56,,"Case rate ($21,266.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $19,747.46, add-ons for qualifying new technology services are included. If operating cost exceeds $52,787.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,875.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $19,773.57. The transfer operating threshold is the transfer adjustment factor * $19,747.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,493.00. The transfer capital threshold is the transfer adjustment factor * $1,493.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,8593,100095.57,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 12MM XTEND SPINE VARIABLE ANGLE SELF DRILL",SUP-161.012,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"PHCS [10601]",PHCS,,987,70,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 2MM PRESTIGE PLUS HELICAL HELICAL XTRA",SUP-PRES0208HXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-593504022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 60MM 125CM 6MM 6FR VASCULAR NITINOL",SUP-G43822,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"PHCS [10601]",PHCS,,2646,70,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 18GA 10CM POWERGLIDE PRO BIOPATCH BASIC INSRT",SUP-F318107T,CDM,S27200284,LOCAL,0272,RC,,,both,,,575.67,172.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,68.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,66.95,489.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL COALITION AGX 0 D D10.5 MM W18 MM X H7 MM NONS",SUP-3128.1507,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT FEMORAL KNEE OXINIUM POROUS",SUP-71701018,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,9384.48,39.2,,3949.44,3949.44,3949.44,"1 through 10",2784.22,20349,"percent of total billed charges",
"(EVAL) CATHETER THE RINGER PERFUSION 20MM OD 4MM PERFUSION P",SUP-5888,CDM,C1725,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 4MM CANNULATED HEADLESS",SUP-MSN20009,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM AMPLATZER TORQVUE 90D 80CM 195CM 5FR .068IN .059IN",SUP-9-TVLP5F90/080,CDM,S27200284,LOCAL,0272,RC,,,both,,,5754.60,1726.38,"FIRST HEALTH [10303]","First Health",,4603.68,80,,,,,0,669.26,4891.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +20.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2050,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 15MM 2MM ULTRA LOW PROFILE BALLOON",SUP-1012270-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM CREO CREO AMP SPINE MODULAR NONSTERILE",SUP-1067.175,CDM,C1713,HCPCS,0278,RC,,,both,,,2437.50,731.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,283.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",283.48,2071.88,"percent of total billed charges",
"CATH EMERGE MONORAIL 144CM 15MM 6FR 1.5MM .07IN BALLOON",SUP-H7493918915150,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"NOVANET [10819]",Novanet,,425.25,75,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT JOHLIN 20CM 8.5FR PANCREATIC WEDGE PRELOAD INTRO",SUP-G26831,CDM,C2625,HCPCS,0278,RC,,,both,,,1368.90,410.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,159.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,159.2,1163.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM E HIP ELEVATE RIM X3 TRIDENT",SUP-643-00-36E,CDM,C1776,HCPCS,0278,RC,,,both,,,9915.30,2974.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4075.19,41.1,,6417.48,6417.48,6417.48,"1 through 10",1153.15,8428.01,"percent of total billed charges",
"CATH EXPO 100CM 5FR .045IN FEMORAL RIGHT 5 CURVE",SUP-H74908526032,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 11.9CM 6MM CEREPAK MICRO UNIFORM",SUP-FCX100611,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA [10200]","Cigna Local Plus",,4166.14,31.5,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE EYE 22MM STERILE POROUS MEDPOR OMNI DIRECTIONAL PORE",SUP-6322,CDM,S27800098,LOCAL,0278,RC,,,both,,,5016.30,1504.89,"MULTIPLAN [10600]",Multiplan,,4263.86,85,,,,,0,583.4,4263.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE HEXAGONAL 2.5CM 1.5CM 7FR SOFT ACUSNARE 1 PIECE BRAID",SUP-G22703,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.43,49.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,67.58,41.1,,,,,0,19.12,139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL STD 15MM KNEE GVF ROTATE PLATFORM LCS COMPLETE",SUP-129405415,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"FIRST HEALTH [10303]","First Health",,7730.76,80,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 64CM 7.8FR 9MM KT FIRM",SUP-6768,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18386,CDM,,,0637,RC,68084-0708-95,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI PROWATER VASCULAR 300CM 3CM .014IN CORONARY",SUP-AGH146300,CDM,C1769,HCPCS,0272,RC,,,both,,,769.50,230.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM LCP STAINLESS STEEL FULL THREAD CANCELLOUS",SUP-206.012,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"CIGNA [10200]","Cigna Local Plus",,146.39,53.5,,3978.14,359.25,3978.14,24,31.82,232.58,"percent of total billed charges",
"SET 85IN 4 LEAD GRAVITY FLOW LARGE BORE IRRIGATION Y",SUP-2C4013,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.22,65.47,"PHCS [10601]",PHCS,,152.75,70,,,,,0,25.38,185.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 40MM BEVEL STERILE LATEX FREE MIS",SUP-SF3040,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3378.24,68,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 38MM 144CM 4MM CORONARY STENT EVEROLIMUS",SUP-H7493926138400,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]",Cigna,,5865,68,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION VORTEX PEELPRO TITANIUM SILICONE",SUP-P5455K,CDM,C1788,HCPCS,0278,RC,,,both,,,6651.60,1995.48,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3053.08,45.9,,,,,0,773.58,5653.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 0 CT-2 30IN BRAID GREEN NONABSORBABLE",SUP-X412H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 300MM 3.2MM PERCUTANEOUS QUICK COUPLING CALIBRATED",SUP-324.212,CDM,S27000186,LOCAL,0270,RC,,,both,,,1272.35,381.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,147.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.97,1081.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM XIA SERRATO SPINE POLYAXIAL NONSTERILE 3",SUP-482615535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"HC Inj Wrist Arthgm",PX-361000045,CDM,25246,CPT,0361,RC,,,both,,,1061.98,318.59,"FIRST HEALTH [10303]","First Health",,849.58,80,,,,,0,123.51,1061.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CS2 STAINLESS STEEL 2.7MM SCR VARIABLE ANGLE LCP BONE",SUP-02.112.622,CDM,C1713,HCPCS,0278,RC,,,both,,,6005.21,1801.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,711.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",698.41,5104.43,"percent of total billed charges",
"LENS IOL 5 D +22.5 DIOPTER BICONVEX 13MM 6MM POSTERIOR CHMBR",SUP-ZA90030225,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,136.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC MEDIUM LEFT WRIST FOREARM PREFORM PAD",SUP-9101-05,CDM,S27000186,LOCAL,0270,RC,,,both,,,72.38,21.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,49.22,68,,,,,0,8.42,61.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +28.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.285,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13CM NATRELLE INSPIRA P6.2CM EXTRA FULL PROFILE",SUP-MSZ-X545,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AETNA [10100]","Aetna HMO/PPO",,125.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165CM 8.5-11MM OTSC 3MM NITINOL STERILE",SUP-100.03,CDM,C1760,HCPCS,0278,RC,,,both,,,3667.50,1100.25,"MULTIPLAN [10600]",Multiplan,,3117.38,85,,,,,0,426.53,3117.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTRUMENT MINI-HOHMANN RETRACTOR SMALL",SUP-INST-MHR-SM,CDM,S27000186,LOCAL,0270,RC,,,both,,,1755.00,526.5,"CIGNA [10200]","Cigna Open Access",,998.6,56.9,,,,,0,204.11,1491.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 TAPER 22MM HIP OXINIUM ECHELON",SUP-71342200,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6214.14,40,,,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 8MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT084050A,CDM,C1768,HCPCS,0278,RC,,,both,,,12827.10,3848.13,"CIGNA [10200]","Cigna Local Plus",,4040.54,31.5,,,,,0,1491.79,10903.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 20MM 140CM 2.5MM CORONARY STENT PLATINUM",SUP-H7493927420250,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROXYUREA 500 MG CAPSULE",RX-10236,CDM,,,0637,RC,00904-6939-61,NDC,both,1,UN,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX SAFE PERFORMAXX 40MM 80CM 9MM 6FR .035IN",SUP-ZBM09040,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"BLUE CROSS [10001]","Blue Cross HMO",,3921.96,39.2,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM 13MM CEMENT GMRS COCR STRAIGHT HIP",SUP-6485-3-113,CDM,C1776,HCPCS,0278,RC,,,both,,,14800.50,4440.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6083.01,41.1,,6417.48,6417.48,6417.48,"1 through 10",1721.3,12580.43,"percent of total billed charges",
"STPLR ENDOSCOPIC CURVE TIP RELOAD AEON 60MMX2.5MM STERILE",SUP-AESC60W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"AETNA [10100]","Aetna HMO/PPO",,1159.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 7MM THIN WALL PERIPHERAL GORE-TEX",SUP-ST0708,CDM,C1768,HCPCS,0278,RC,,,both,,,8535.30,2560.59,"CIGNA [10200]","Cigna Local Plus",,4566.39,53.5,,,,,0,992.66,7255.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006180241010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,491.47,45.9,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR 75X8MM THIN WALL FLUOROPASSIV",SUP-920875FT,CDM,C1768,HCPCS,0278,RC,,,both,,,1198.80,359.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,142.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.42,1018.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Elec Dual",PX-480000012,CDM,33217,CPT,0481,RC,,,both,,,8966.11,2689.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6291,,"Case rate ($6,291). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1042.76,8966.11,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE S-101 - EACH",SUP-666697-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,119.8,45.9,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 11MM 8.2MM 95MM TALON HIP DISTALFIX TECHNOLOGY LAG",SUP-SLN-011-095,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"MULTIPLAN [10600]",Multiplan,,4222.8,85,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 6MM GORE INTERING STD WALL PTFE RADIAL",SUP-IRS06040L,CDM,C1768,HCPCS,0278,RC,,,both,,,3974.40,1192.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1137.47,28.62,,,,,0,462.22,3378.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOLD CEMENT 60MM STAGEONE HIP SILICONE REINFORCEMENT SPACER",SUP-431184,CDM,C1713,HCPCS,0278,RC,,,both,,,7955.01,2386.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,942.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,925.17,6761.76,"percent of total billed charges",
"CATH SAFIRE COMFORTGRIP 115CM 5MM 7FR 2-5-2MM SPACING 1MM",SUP-402816,CDM,C1733,HCPCS,0272,RC,,,both,,,4222.80,1266.84,"MULTIPLAN [10600]",Multiplan,,3589.38,85,,,,,0,491.11,3589.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EDWARDS CAVAL PRESTENT LOADER",SUP-9600CP26L,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 100CM 5FR AR1 CURVE ANGIOGRAPHIC PEBAX",SUP-7528-13,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.74,23.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.16,66.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 9CM 4MM MIDAS REX LEGEND BALL FLUTED STERILE",SUP-9BA40,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.28,371.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,841.35,68,,,,,0,143.9,1051.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 130CM 80MM 6MM BALLOON DILATATION",SUP-ADM06008013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,956.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PCMKR CRD THK6MM SM 50X46MM","SUP-PM2160 CELL",CDM,C1785,HCPCS,0275,RC,,,both,,,9324.00,2797.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4279.72,45.9,,,,,0,1084.38,7925.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 90MM 32MM AXSOS STAINLESS STEEL 3.5MM HEXAGON",SUP-342090,CDM,C1713,HCPCS,0278,RC,,,both,,,299.63,89.89,"CIGNA [10200]",Cigna,,203.75,68,,1831.33,1831.33,1831.33,16,34.85,254.69,"percent of total billed charges",
"HC Revasc Lithotr-Stent Tib/Per",PX-481000130,CDM,C9773,HCPCS,0481,RC,,,both,,,28367.00,8510.1,"NOVANET [10819]",Novanet,,21275.25,75,,,,,0,3299.08,24111.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM VARIAX T8 FULL THREAD NONSTERILE",SUP-656418,CDM,C1713,HCPCS,0278,RC,,,both,,,779.22,233.77,"BLUE CROSS [10001]","Blue Cross PPO",,305.45,39.2,,957.42,570.23,957.42,28,90.62,662.34,"percent of total billed charges",
"TISSUE 330611 ACSR 6X11X11 SRVC FEE",SUP-330611,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM CLAW II ORTHOLOC CORTICAL ANKLE FOOT",SUP-40233530,CDM,C1713,HCPCS,0278,RC,,,both,,,1474.20,442.26,"PHCS [10601]",PHCS,,1031.94,70,,,,,0,171.45,1253.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Touch Prep Add Site",PX-312000040,CDM,88334,CPT,0312,RC,,,both,,,240.50,72.15,"FIRST HEALTH [10303]","First Health",,192.4,80,,,,,0,0.01,204.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM 32.9MM 26.9MM MITRAL FLEXIBLE HOLDER",SUP-4450M28,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"FIRST HEALTH [10303]","First Health",,9108,80,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM OPHTHALMIC EYE BARRAQUER 5MM PEDIATRIC",SUP-60-1962,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.10,83.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,33.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.46,237.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR070202A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2223.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 0 V-34 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J518H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP TRUNCATE OSTEOTOM 52MM HEMISPHERE",SUP-00705305210,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"UHC [10700]","United Healthcare",,2865.21,63.3,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 1IN SIGMA STRYKER",SUP-5627-10-500,CDM,S27200284,LOCAL,0272,RC,,,both,,,477.36,143.21,"CIGNA [10200]","Cigna Local Plus",,255.39,53.5,,,,,0,55.52,405.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 31MM LC-DCP HAND TITANIUM 4 HOLE 2.4MM SCR",SUP-449.924,CDM,C1713,HCPCS,0278,RC,,,both,,,3496.50,1048.95,"BLUE CROSS [10001]","Blue Cross HMO",,1370.63,39.2,,957.42,156.86,7483.26,51,406.64,2972.03,"percent of total billed charges",
"FRCP SURGICAL KOCHER STRAIGHT 5.5IN ARTERY 1X2 TEETH",SUP-SU2790,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.32,33.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.83,93.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mpi Spect Mult",PX-341000027,CDM,78452,CPT,0341,RC,,,both,,,6272.55,1881.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,562.27,,,,,,,562.27,5331.67,"fee schedule",
"STENT OMNILINK ELITE 29MM 135CM 7MM THIN VASCULAR COCR",SUP-1012630-29,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"AETNA [10100]","Aetna HMO/PPO",,6678,79.5,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HIWIRE VASCULAR ANGLE TAPER 180CM 22CM .035IN NITINOL",SUP-G36292,CDM,C1769,HCPCS,0272,RC,,,both,,,333.80,100.14,"FIRST HEALTH [10303]","First Health",,267.04,80,,,,,0,38.82,283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0175,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 8MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620208,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Open Access",,6403.47,56.9,,5302.19,4377.88,6578.61,27,1308.83,9565.82,"percent of total billed charges",
"PORT IMPLANTABLE INFUSION POWERPORT MRI SILICONE 9.6FR 1",SUP-1859600,CDM,C1788,HCPCS,0278,RC,,,both,,,2250.00,675,"MULTIPLAN [10600]",Multiplan,,1912.5,85,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 111MM 13MM PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51107130,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"CIGNA [10200]","Cigna Local Plus",,8642.1,31.5,,5372.07,4581.20,7242.98,23,3190.72,23319.95,"percent of total billed charges",
"LENS IOL +17.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0175,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA [10200]",Cigna,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X9MM SABLE 22D STERILE LATEX FREE",SUP-1172.2033S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4029.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL COMFORT FLO PLUS MEDIUM",SUP-2412-12,CDM,S27000186,LOCAL,0270,RC,,,both,,,166.39,49.92,"FIRST HEALTH [10303]","First Health",,133.11,80,,,,,0,19.35,141.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYMPHION INFINITY FLUID MANAGEMENT",SUP-FG-0204,CDM,S27200284,LOCAL,0272,RC,,,both,,,2617.50,785.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1075.79,41.1,,,,,0,304.42,2224.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM VARIAX NONSTERILE",SUP-657416,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",94.05,687.4,"percent of total billed charges",
"GRAFT ENDOVASCULAR 124MM 30MM ZENITH HANDL-B ONE-SHOT 2",SUP-G32543,CDM,C1874,HCPCS,0278,RC,,,both,,,62551.57,18765.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,17902.26,28.62,,,,,0,7274.75,53168.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CELOS OXIDIZED 4X4IN ABSORBABLE HEMOSTAT SURGICEL SNOW",SUP-2083,CDM,S27200284,LOCAL,0272,RC,,,both,,,1865.48,559.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,766.71,41.1,,,,,0,216.96,1585.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 17.5MM 5MM MODULUS ALIF STERILE",SUP-1350175P2,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD TITANIUM 4 HOLE GEMINUS BONE LEFT DISTAL VOLAR",SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,0278,RC,,,both,,,5161.20,1548.36,"NOVANET [10819]",Novanet,,3870.9,75,,,,,0,600.25,4387.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VENLAFAXINE 75 MG TABLET, IMMEDIATE RELEASE",RX-12206,CDM,,,0637,RC,68084-0856-11,NDC,both,1,UN,10.99,3.3,"AETNA [10100]","Aetna HMO/PPO",,8.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.28,9.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URINARY STONES WITHOUT MCC",694,MS-DRG,,,,,,,inpatient,,,41657.92,12497.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15517.53,,"Fee schedule rate ($15,517.53). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,4848.94,19494.82,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 50MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ350,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,654.16,68,,,,,0,111.88,817.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 9MM APTUS TRILOCK TITANIUM PHALANGEAL HAND",SUP-A-5250.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1096.09,68,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM AXIUM PRIME LATTICEFX 3D 10CM 6MM .0115IN",SUP-APB-6-10-3D-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,9591.00,2877.3,"NOVANET [10819]",Novanet,,7193.25,75,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Gwire Magic Torque 0.35in",PX-E27200324,CDM,C1769,HCPCS,0272,RC,,,both,,,372.90,111.87,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 82MM MALLEABLE SHAFT BEVEL 3MM SURGICAL MYRINGOTOMY",SUP-N0522,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.43,22.63,"NOVANET [10819]",Novanet,,56.57,75,,,,,0,8.77,64.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER BIPOLAR AQUAMAN MALLEABLE",SUP-23-301-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3607.50,1082.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2453.1,68,,,,,0,419.55,3066.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Abdomen W&WO Cntrst",PX-610000042,CDM,74183,CPT,0610,RC,,,both,,,5374.41,1612.32,"NOVANET [10819]",Novanet,,4030.81,75,,,,,0,625.04,4568.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK THERAPEUTIC HOT CERVICAL 3503",SUP-3503,CDM,S27000186,LOCAL,0270,RC,,,both,,,82.04,24.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.54,69.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 52MM 2 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800252,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM SWIVELOCK C CLOSED EYELET VENT",SUP-AR-2324BCCTT,CDM,C1713,HCPCS,0278,RC,,,both,,,3701.25,1110.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,430.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",430.46,3146.06,"percent of total billed charges",
"SCR BONE 3.5MM 16MM ORTHOLOC LONG CORTEX ANKLE FOOT 3DI",SUP-58803516,CDM,C1713,HCPCS,0278,RC,,,both,,,1506.60,451.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1024.49,68,,,,,0,175.22,1280.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 32CM FEMUR LEFT PROXIMAL TALON DISTALFIX",SUP-SLN-125-32L,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"CIGNA [10200]",Cigna,,6450.12,40,,1831.33,1831.33,1831.33,16,1875.37,13706.51,"percent of total billed charges",
"SCREW BONE 6MM 45MM VIPER PRIME SPINE POLYAXIAL EXTEND TAB N",SUP-186760245,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM TITANIUM T8 SELF TAP LOCK VARIABLE ANGLE",SUP-04.211.012,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"KAISER [10500]",Kaiser,,661.01,67,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM TITANIUM CORTICAL LOCKING NONSTERILE",SUP-CO-2720,CDM,C1713,HCPCS,0278,RC,,,both,,,696.60,208.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,82.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",81.01,592.11,"percent of total billed charges",
"SCR BONE 5.5MM 55MM INTERCONTINENTAL HA SPINE VARIABLE ANGLE",SUP-187.255S,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA [10200]","Cigna Local Plus",,1404.38,53.5,,3978.14,359.25,3978.14,24,305.29,2231.25,"percent of total billed charges",
"PLATE 232MM STAINLESS STEEL 2.7/3.5MM SCR 14 HOLE VARIABLE",SUP-02.118.213S,CDM,C1713,HCPCS,0278,RC,,,both,,,13144.50,3943.35,"PHCS [10601]",PHCS,,9201.15,70,,,,,0,1528.71,11172.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.3MM 30MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.520,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"FIRST HEALTH [10303]","First Health",,925.34,80,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.6MM 480MM KIRSCHNER STAINLESS STEEL TROCAR",SUP-02.606.001,CDM,C1713,HCPCS,0278,RC,,,both,,,413.25,123.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,281.01,68,,,,,0,48.06,351.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 15ML .1-2MM 80% CORTICAL 20% CANCELLOUS",SUP-400062,CDM,C1713,HCPCS,0278,RC,,,both,,,2030.63,609.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1380.83,68,,,,,0,236.16,1726.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRUT EXTERNAL FIXATION MAXFRAME SHORT ADJUSTABLE",SUP-03.312.811,CDM,C1713,HCPCS,0278,RC,,,both,,,7801.69,2340.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2232.84,28.62,,,,,0,907.34,6631.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 16MM CORE ALLOGRAFT CM2",SUP-PS60014,CDM,C1713,HCPCS,0278,RC,,,both,,,3341.25,1002.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,395.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,388.59,2840.06,"percent of total billed charges",
"ANCHOR SUT SWIVELOCK PEEK 17.9MM",SUP-AR-2326PSLC,CDM,C1713,HCPCS,0278,RC,,,both,,,2953.13,885.94,"CIGNA [10200]","Cigna Local Plus",,1579.92,53.5,,3978.14,359.25,3978.14,24,343.45,2510.16,"percent of total billed charges",
"WIRE FIXATION .9MM 229MM KIRSCHNER STAINLESS STEEL 2 END",SUP-262003900,CDM,C1713,HCPCS,0278,RC,,,both,,,228.38,68.51,"MULTIPLAN [10600]",Multiplan,,194.12,85,,,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 16IN 34FR VENOUS 90D STRAIGHT OPEN LIGHTHOUSE",SUP-TF034L90,CDM,S27200284,LOCAL,0272,RC,,,both,,,329.38,98.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,39.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.31,279.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS VISTA BRITE TIP 100CM 6FR XBRCA CURVE GUIDING",SUP-67012600,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"PHCS [10601]",PHCS,,292.32,70,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 56MM STAINLESS STEEL T8 SELF TAP LOCK",SUP-02.211.056,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,412.24,45.9,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 100MM ANTIROTATE STERILE FEMORAL NECK SYSTEM",SUP-04.168.500S,CDM,C1713,HCPCS,0278,RC,,,both,,,1642.20,492.66,"CIGNA [10200]","Cigna Open Access",,934.41,56.9,,1144.80,304.56,2275.09,66,190.99,1395.87,"percent of total billed charges",
"SCR BONE 4.5MM 3.9MM 36MM MULTILOC TITANIUM NIOBIUM ALUMINUM",SUP-04.019.036S,CDM,C1713,HCPCS,0278,RC,,,both,,,1747.20,524.16,"NOVANET [10819]",Novanet,,1310.4,75,,,,,0,203.2,1485.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CEMENTED EXETER V40 3 44MM OFFSET HIP",SUP-0580-1-443,CDM,C1776,HCPCS,0278,RC,,,both,,,17001.60,5100.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2014.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1977.29,14451.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 1.7-10MM CANCELLOUS ALLOGRAFT CHIPS FREEZE",SUP-400140,CDM,C1713,HCPCS,0278,RC,,,both,,,969.57,290.87,"CIGNA [10200]","Cigna Local Plus",,518.72,53.5,,3978.14,359.25,3978.14,24,112.76,824.13,"percent of total billed charges",
"ROD SPINAL 50MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000050,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross PPO",,635.04,39.2,,957.42,570.23,957.42,28,188.41,1377,"percent of total billed charges",
"SCR BONE 6.5MM 40MM CREO CREO AMP SPINE MODULAR",SUP-1067.1640,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1110.3,8114.82,"percent of total billed charges",
"SCR BONE 4.6MM VIP SPINE VARIABLE ANGLE",SUP-171.016,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"FIRST HEALTH [10303]","First Health",,1128,80,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM TRIDENT SECUR-FIT TITANIUM CANCELLOUS",SUP-2030-6525-1,CDM,C1713,HCPCS,0278,RC,,,both,,,571.90,171.57,"CIGNA [10200]",Cigna,,388.89,68,,1831.33,1831.33,1831.33,16,66.51,486.12,"percent of total billed charges",
"CNCT ROD 5.5MM 6MM SPINE TITANIUM EXT NONSTERILE",SUP-04.633.002,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Local Plus",,1905.94,53.5,,3978.14,359.25,3978.14,24,414.32,3028.13,"percent of total billed charges",
"PLATE TRITIUM 4 HOLE CABLE AUXILIARY BONE STERNAL NONSTERILE",SUP-86-500,CDM,C1713,HCPCS,0278,RC,,,both,,,4926.60,1477.98,"CIGNA [10200]","Cigna Local Plus",,2635.73,53.5,,3978.14,359.25,3978.14,24,572.96,4187.61,"percent of total billed charges",
"SCR BONE 3MM 12MM LOW PROFILE SCREWS TITANIUM ANKLE VARIABLE",SUP-AR-8933V-12,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross PPO",,555.66,39.2,,957.42,570.23,957.42,28,164.86,1204.88,"percent of total billed charges",
"PIN FIXATION SIGMA HIGH PERFORMANCE QUICK DRILL",SUP-950502072,CDM,C1713,HCPCS,0278,RC,,,both,,,1526.85,458.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,180.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",177.57,1297.82,"percent of total billed charges",
"SCR BONE 4.5MM 38MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.738,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"KAISER [10500]",Kaiser,,752.83,67,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 55MM REVERE SPINE PEDICLE",SUP-124.477,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA [10200]","Cigna Open Access",,2755.44,56.9,,1144.80,304.56,2275.09,66,563.19,4116.21,"percent of total billed charges",
"SCR BONE 7.5MM 55MM REVERE SPINE PEDICLE",SUP-124.477,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1385.95,28.62,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC",718,MS-DRG,,,,,,,inpatient,,,45243.20,13572.96,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,8581.28,,"Case rate ($8,331.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,736.21, add-ons for qualifying new technology services are included. If operating cost exceeds $40,775.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,966.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,746.44. The transfer operating threshold is the transfer adjustment factor * $7,736.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.89. The transfer capital threshold is the transfer adjustment factor * $584.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,39213.15,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CORPLEX 2X2 CM",SUP-CX-2020,CDM,Q4232,HCPCS,0636,RC,,,both,,,8404.20,2521.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5462.73,65,,,,,0,247.92,7143.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES 145CM 40MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939134254010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC CROME DR 2 CHMBR DF-1 PIN PLUG RADIOPAQUE",SUP-DDPC3D1,CDM,C1882,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6905.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 5MM CORONARY STENT",SUP-H7493941820500,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM COCR SPINE MULTIAXIAL CANNULATED 5.5 ROD",SUP-55840014540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"FIRST HEALTH [10303]","First Health",,7637.48,80,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 16 X 13 X 08MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-161308-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross HMO",,2434.32,39.2,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE",RX-122469,CDM,,,0250,RC,70092-1119-44,NDC,both,5,ML,59.92,17.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,24.63,41.1,,,,,0,6.97,50.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANSURETHRAL PROCEDURES WITH MCC",668,MS-DRG,,,,,,,inpatient,,,88844.31,26653.29,"CIGNA [10200]",Cigna,,38287.04,,"Fee schedule rate ($38,287.04). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,85252.32,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANSURETHRAL PROCEDURES WITH MCC",668,MS-DRG,,,,,,,inpatient,,,88844.31,26653.29,"PHCS [10601]",PHCS,,7561,,,,,,,7561,85252.32,"per diem","Estimated amount calculated based on 8 day length of stay."
"NDL SPINAL NIM-SPINE NDL PEDICLE",SUP-9450020,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE DESTINATION STRAIGHT 45CM 5CM 7FR GUIDING",SUP-RSR04,CDM,C1894,HCPCS,0272,RC,,,both,,,672.30,201.69,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CURET 4-0 8IN BRUNS OVAL CUP ANGLE TIP SURGICAL STAINLESS",SUP-240086,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MONODEK CAPIO TAPERCUT 0 48IN 2 ARM MONOFILAMENT PELVIC",SUP-M0068331371,CDM,S27200284,LOCAL,0272,RC,,,both,,,546.75,164.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOFT-VU 65CM 5FR HOOK 1 CURVE ANGIOGRAPHIC VISCERAL",SUP-H787107199035,CDM,C1887,HCPCS,0272,RC,,,both,,,190.36,57.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FLEXIMA 70CM 4FR URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002301,CDM,C1758,HCPCS,0272,RC,,,both,,,80.01,24,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ASAHI CHIKAI VASCULAR STRAIGHT 200CM 9CM .2/.26MM",SUP-WAIN-CKI-008-200,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FARAWAVE 12FR 31MM ABLATION PULSE FIELD STERILE LATEX",SUP-M004PF41M431,CDM,C1733,HCPCS,0272,RC,,,both,,,53235.00,15970.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"ACUTE ANXIETY AND STRESS SYNDROMES,MINOR",756,APR-DRG,,,,,,,inpatient,,,30071.51,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $3,186.92. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.5X15CM NATRELLE P5.8CM FULL PROJECTION FULL",SUP-MSZFF595,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH RED WHITE 9.5FR GROSHONG CENTRAL VENOUS 2 LUMEN",SUP-7742000,CDM,C1751,HCPCS,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STAPLER 2MM 2.5MM 3MM THK1.5-2.25MM 30MM ENDO GIA MED",SUP-SIG30AV,CDM,S27200284,LOCAL,0272,RC,,,both,,,1328.89,398.67,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STOCKING COMPRESSION SMALL TUBULAR SOFT TENSOGRIP",SUP-13200,CDM,S27000186,LOCAL,0270,RC,,,both,,,165.30,49.59,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO CATH 110CM 5FR .074IN .018-.038IN FLEXOR SHUTTLE TUOHY",SUP-G48194,CDM,C1894,HCPCS,0272,RC,,,both,,,1109.62,332.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RELIEVA SPIN 16MM 6MM 0D S-0 GUIDING SPHENOID SINUS",SUP-RSS0,CDM,S27200284,LOCAL,0272,RC,,,both,,,2400.00,720,"AETNA [10100]","Aetna HMO/PPO",,1908,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TEMNO EVOLUTION 15CM 10CM 18GA 17GA BIOPSY SOFT",SUP-CTT1815,CDM,S27200284,LOCAL,0272,RC,,,both,,,439.91,131.97,"CIGNA [10200]","Cigna Open Access",,250.31,56.9,,,,,0,51.16,373.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 15MM 3.5MM BALLOON DILATATION STERILE",SUP-235-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SLALOM 80CM 20MM 3.7FR 5MM 6.5MM BALLOON",SUP-4385020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 50MM LOW PROFILE SCREWS TITANIUM PARTIAL",SUP-AR-8945-50PT,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"KAISER [10500]",Kaiser,,949.73,67,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 10CM 5FR ANGLE BERENSTEIN CURVE",SUP-H787107221045,CDM,C1887,HCPCS,0272,RC,,,both,,,209.32,62.8,"MULTIPLAN [10600]",Multiplan,,177.92,85,,,,,0,24.34,177.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 14X3MM COLOSSEUM 3.5D 12MM NONSTERILE LATEX",SUP-156.263,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"MULTIPLAN [10600]",Multiplan,,2926.13,85,,,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ENDOSCOPIC NDL CYSTOTM STERILE DISPOSABLE 10FR 165FR",SUP-G30550,CDM,S27200284,LOCAL,0272,RC,,,both,,,2730.00,819,"AETNA [10100]","Aetna HMO/PPO",,2170.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,317.5,2320.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA CARDIOPLEGIA ANTEGRADE W/VENT",SUP-ANT-2012S,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.72,41.92,"NOVANET [10819]",Novanet,,104.79,75,,,,,0,16.25,118.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 90CM 20MM 3MM .014IN BALLOON DILATATION",SUP-AB14W030020090,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 FSL 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP588H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED II 100CM 5CM 9FR 23MM .035IN BALLOON DILATATION",SUP-611766,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"UHC [10700]","United Healthcare",,3366.32,63.3,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REFERENCE TOE DISPOSABLE INSTRUMENT SET SIZE 1-2","SUP-M03 S0002",CDM,S27200284,LOCAL,0272,RC,,,both,,,3337.50,1001.25,"AETNA [10100]","Aetna HMO/PPO",,2653.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,388.15,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EDM 35CM 15CM 2.8MM 1.5MM EXTERNAL DRNG STAINLESS STEEL",SUP-46118,CDM,C1729,HCPCS,0272,RC,,,both,,,1576.99,473.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,648.14,41.1,,,,,0,183.4,1340.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHNT HKM PRC VNTRC 70MM HP 175777",SUP-823008,CDM,S27800098,LOCAL,0278,RC,,,both,,,14545.20,4363.56,"MULTIPLAN [10600]",Multiplan,,12363.42,85,,,,,0,1691.61,12363.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN SUCTION MERCEDES 4MM 30CM MERCEDES TIP BENT POWER",SUP-PAL-404LLB,CDM,S27200284,LOCAL,0272,RC,,,both,,,623.70,187.11,"UHC [10700]","United Healthcare",,394.8,63.3,,,,,0,72.54,530.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL HEMI REVERSE INSTR TRABECULAR METAL",SUP-98000973001,CDM,C1776,HCPCS,0278,RC,,,both,,,23625.00,7087.5,"MULTIPLAN [10600]",Multiplan,,20081.25,85,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL 5MM LEGION KNEE POSTERIOR SCR",SUP-71421827,CDM,C1776,HCPCS,0278,RC,,,both,,,1224.72,367.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,142.43,1041.01,"percent of total billed charges",
"PIN DRILL 1/8IN VANGUARD QUICK RELEASE STERILE",SUP-32486265,CDM,S27200284,LOCAL,0272,RC,,,both,,,464.94,139.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 10X20 135CM SL",SUP-48010002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TYSHAK II 100CM 6CM 9FR 25MM BALLOON DILATATION DEHP",SUP-611946,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SODIUM CHLORIDE 7 % FOR NEBULIZATION",RX-82134,CDM,,,0250,RC,50190-0740-60,NDC,both,4,ML,12.54,3.76,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING MONORAIL 135CM 40MM 6FR 7MM 4FR BALLOON",SUP-H74939031704010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONVEY 100CM 7FR LEFTBU3.75 CURVE GUIDING HYDROPHILIC",SUP-H749392657150,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 1.5MM 8MM APTUS TITANIUM HEXADRIVE 4 HAND CORTICAL",SUP-A-5200.08/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 80MM 10MM BALLOON DILATATION DURALYN",SUP-48010008S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"MULTIPLAN [10600]",Multiplan,,1170.45,85,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP POLAR CUP WITH SMF STEM AND OXI HEAD",SUP-71703530,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,9384.48,39.2,,3949.44,3949.44,3949.44,"1 through 10",2784.22,20349,"percent of total billed charges",
"TUBE NASOGASTRIC 60IN 12FR 10FR .035IN 300CM NASOINTESTINAL",SUP-50-4602,CDM,S27200284,LOCAL,0272,RC,,,both,,,54.99,16.5,"CIGNA [10200]","Cigna Open Access",,31.29,56.9,,,,,0,6.4,46.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS CARDIOBAND FIT GUIDE SHEATH",SUP-25200GS,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MTRL SPLINTING THK1/8IN SMALL STATURE 24X18IN OPTIPERF",SUP-550549,CDM,S27000186,LOCAL,0270,RC,,,both,,,630.50,189.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,289.4,45.9,,,,,0,73.33,535.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 94MM PRESS FIT AEQUALIS ASCEND FLEX PTC 132.5D",SUP-DWF608B,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"MULTIPLAN [10600]",Multiplan,,10710,85,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rem Impl Drug Deliv Non-Biodeg",PX-361000515,CDM,11982,CPT,0361,RC,,,both,,,4282.83,1284.85,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,498.09,4282.83,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 20MM 3.8FR 5MM LOW PROFILE TAPER BALLOON",SUP-H74939032502080,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL CINCHLOCK SS ANATOMIC LABRUM RESTORATION SYSTEM",SUP-CAT02463,CDM,S27200284,LOCAL,0272,RC,,,both,,,1279.80,383.94,"KAISER [10500]",Kaiser,,857.47,67,,,,,0,148.84,1087.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT SPRT MEDTRONIC SMALL",SUP-FP9000S,CDM,S27000186,LOCAL,0270,RC,,,both,,,408.90,122.67,"MULTIPLAN [10600]",Multiplan,,347.57,85,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 20MM 6FR 2.25MM",SUP-H7493926720220,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,233.04,41.1,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CEREBROVASCULAR DISORDERS WITH MCC",070,MS-DRG,,,,,,,inpatient,,,37516.25,11254.87,"BLUE CROSS [10001]","Blue Cross HMO",,37516.25,,,,,,,7561,37516.25,"case rate",
"CATH LAUNCHER 100CM 6FR .071IN RBU4.5 CURVE GUIDING CORONARY",SUP-LA6RBU45,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 40MM 6FR 6MM BALLOON DILATATION PEBAX",SUP-H74939032604010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 12MM 5MM BALLOON DILATATION ZGLIDE PTFE",SUP-H7493918912500,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Ulnar Styloid",PX-450000117,CDM,25650,CPT,0450,RC,,,both,,,1347.00,404.1,"AETNA [10100]","Aetna HMO/PPO",,1070.87,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.13,1347,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION BROAD TAPER 4FR 4MM 150CM 80MM",SUP-AMP040080152,CDM,C1725,HCPCS,0272,RC,,,both,,,2422.50,726.75,"AETNA [10100]","Aetna HMO/PPO",,1925.89,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,281.74,2059.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NUCLEUS-X 110CM 4CM 18MM BALLOON DILATATION POLYAMIDE",SUP-612038,CDM,C1725,HCPCS,0272,RC,,,both,,,6566.52,1969.96,"FIRST HEALTH [10303]","First Health",,5253.22,80,,,,,0,763.69,5581.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 25MM 3.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3525X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 80CM 6CM 5MM BALLOON",SUP-G52339,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 27MM 3.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP3527X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 10X7CM CYTAL PORCINE BLADDER 3 LAYER",SUP-WSR0710,CDM,Q4166,HCPCS,0636,RC,,,both,,,14096.70,4229.01,"NOVANET [10819]",Novanet,,10572.53,75,,,,,0,53.69,11982.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 110CM 10CM 5FR 4MM 7.5MM BALLOON DILATATION",SUP-4194000L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 12MM 3.25MM BALLOON DILATATION STERILE",SUP-232-123-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRANSFORM 5MM 3MM BALLOON OCCLUSION 1 LUMEN SUPER",SUP-M003SSC03050,CDM,C1725,HCPCS,0272,RC,,,both,,,11760.02,3528.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7996.81,68,,,,,0,1367.69,9996.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 40MM 6MM BALLOON DILATATION DURALYN",SUP-48006004X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"FIRST HEALTH [10303]","First Health",,1004.4,80,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 12MM 6FR 2MM .07IN BALLOON",SUP-H7493918912200,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Elect Sngl",PX-480000013,CDM,33218,CPT,0481,RC,,,both,,,4375.00,1312.5,"KAISER [10500]",Kaiser,,2931.25,67,,,,,0,508.81,4375,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nongyn Cyto Prep",PX-311000003,CDM,88104,CPT,0311,RC,,,both,,,422.75,126.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,359.34,"per diem",
"STPLR ENDOSCOPIC RELOAD AEON 60MMX4MM STERILE LATEX FREE",SUP-AESR60P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS ELECTROSURGICAL 8MM HARMONIC ACE CURVE INSRT",SUP-400272,CDM,S27000186,LOCAL,0270,RC,,,both,,,3225.00,967.5,"KAISER [10500]",Kaiser,,2160.75,67,,,,,0,375.07,2741.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS MULTIPASS 2-0 PS-2 27IN BRAID ANTIBACTERIAL",SUP-VCP428H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UHC [10700]","United Healthcare",,15.83,63.3,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 22MM 2.25MM CORONARY STENT FULCRUM COCR",SUP-INT22522UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CIGNA [10200]","Cigna Local Plus",,1292.03,53.5,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 80CM 8FR 45MM BALLOON OCCLUSION VASCULAR",SUP-62080822F,CDM,C2628,HCPCS,0272,RC,,,both,,,741.31,222.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,504.09,68,,,,,0,86.21,630.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW PHTHALATE FREE",SUP-CG-09-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"PHCS [10601]",PHCS,,368.55,70,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HALYARD BALLARD 3.5MM 3MM 12IN 7FR 4MM SUCTION",SUP-197,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.21,33.06,"CIGNA [10200]","Cigna Open Access",,62.71,56.9,,,,,0,12.82,93.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 9IN CODMAN VERSATRU 1MM STD BIPOLAR",SUP-9009100ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,3198.15,959.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1467.95,45.9,,,,,0,371.94,2718.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 64MM 32MM MARATHON HIP",SUP-121932064,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"AETNA [10100]","Aetna HMO/PPO",,5751.55,79.5,,10981.53,8986.79,12413.38,12,841.39,6149.45,"percent of total billed charges",
"STOP DRILL 3.0MM X 70MM",SUP-DRLL-30070,CDM,S27000186,LOCAL,0270,RC,,,both,,,3781.20,1134.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1735.57,45.9,,,,,0,439.75,3214.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 100CM 15CM 4FR .041IN COBRA",SUP-CG410,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VEST 4 LARGE FRONT ZIP ADJUSTABLE SHOULDER STRAP CUP",SUP-111904,CDM,S27000186,LOCAL,0270,RC,,,both,,,403.16,120.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,274.15,68,,,,,0,46.89,342.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SHORT STEM RSA",SUP-71701430,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"CIGNA [10200]","Cigna Open Access",,15195.6,33.5,,5302.19,4377.88,6578.61,27,5275.37,38556,"percent of total billed charges",
"VIABAHN BX BALLOON EXP ENDO 6MMX19MM 7FR 80CMCATH HEPARIN",SUP-BXB061901A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Culture Genital",PX-306000038,CDM,87070,CPT,0306,RC,,,both,,,414.20,124.26,"PHCS [10601]",PHCS,,289.94,70,,,,,0,0.01,352.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRUGSORB PRIME AND INTEGRATION KIT","SUP-DSP 404",CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 100MM 5.5MM CD HORIZON CURVE TITANIUM CP4",SUP-1553201100,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 20MM TITANIUM PARTIAL THREAD LOW PROFILE",SUP-AR-8916VNC-20,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,324.55,28.62,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUTTY PROGENIX DBM 5ML",SUP-005005,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,1144.80,304.56,2275.09,66,434.96,3179,"percent of total billed charges",
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 7MM COCR",SUP-VAL-20070-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"NOVANET [10819]",Novanet,,1069.2,75,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION",RX-2367,CDM,J3490,HCPCS,0258,RC,00264-7387-50,NDC,both,2000,ML,113.22,33.97,"PHCS [10601]",PHCS,,79.25,70,,,,,0,13.17,96.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 5.5MM TPS THK.51MM 11.5MM RECIPROCATE",SUP-2296033410,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.50,90.15,"CIGNA [10200]","Cigna Open Access",,170.98,56.9,,,,,0,34.95,255.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 12IN MULTIPANEL PROCARE 36-65IN MEDIUM",SUP-79-89386,CDM,S27000186,LOCAL,0270,RC,,,both,,,61.60,18.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.16,52.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 26MM THORACIC 2 PASS SEWING WOVEN",SUP-M00202175126P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3046.80,914.04,"FIRST HEALTH [10303]","First Health",,2437.44,80,,,,,0,354.34,2589.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0257,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"NOVANET [10819]",Novanet,,710.78,75,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STAPLER TRI-STAPLE 2 MM L30 MM MEDIUM THICK TISSUE AR",SUP-SIG30AMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1098.77,329.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,451.59,41.1,,,,,0,127.79,933.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS LARGE PLUG CRUSHED 12MM",SUP-291298,CDM,S27800098,LOCAL,0278,RC,,,both,,,4805.85,1441.75,"BLUE CROSS [10001]","Blue Cross PPO",,1883.89,39.2,,,,,0,558.92,4084.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE MONORAIL 150CM 220MM 3MM BALLOON DILATATION",SUP-H74939185302210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5MM FORCE FIBER WIRE",SUP-3910-900-050,CDM,C1713,HCPCS,0278,RC,,,both,,,212.02,63.61,"FIRST HEALTH [10303]","First Health",,169.62,80,,,,,0,24.66,180.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 80MM 4FR 3MM ROUND LOW PROFILE TAPER",SUP-A2030-080,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL SF J-J CURVE ABLATION",SUP-D134803,CDM,C1732,HCPCS,0272,RC,,,both,,,21312.90,6393.87,"AETNA [10100]","Aetna HMO/PPO",,16943.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2478.69,18115.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 14FR 30CM RADIOPAQUE DRNG SILHOUETTE PEEL-AWAY",SUP-G08321,CDM,C1892,HCPCS,0272,RC,,,both,,,526.42,157.93,"KAISER [10500]",Kaiser,,352.7,67,,,,,0,61.22,447.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL 50 MCG/ML INJECTION SUPERORDERABLE (IV PREP ONLY)|DISCARDED DRUG NOT ADMINISTE",RX-409368,CDM,J3010,HCPCS,0636,RC,08888-8879-66,NDC,both,100,ML,422.80,126.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,JW,50.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.1,359.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER CURVED TIP RELOAD 45MM GRAY",SUP-AESC45G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1377.00,413.1,"FIRST HEALTH [10303]","First Health",,1101.6,80,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-512,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]","Cigna Local Plus",,4135.08,31.5,,5372.07,4581.20,7242.98,23,1526.7,11158.16,"percent of total billed charges",
"CLIP HEMOSTATIC 2.8MM REPOSITIONABLE DURACLIP 235CM 16MM",SUP-DC0235W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1053.00,315.9,"FIRST HEALTH [10303]","First Health",,842.4,80,,,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINE ANGIOGRAPHY 76.2CM 3.6MM 1.8MM 1200 PSI FEMALE TO MALE",SUP-91051302,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.77,17.63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.83,49.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 15CM ACHIEVE COAXIAL AUTOMATED PROGRAMMABLE",SUP-CA1815,CDM,S27200284,LOCAL,0272,RC,,,both,,,878.79,263.64,"UHC [10700]","United Healthcare",,556.27,63.3,,,,,0,102.2,746.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL MULTIPASS 6-0 PS-3 18IN BRAID COATED UNDYED",SUP-J499G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Local Plus",,13.38,53.5,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPIN ACCESS CATH 90D BRACHYTHERAPY OLYMPUS 190 SCOPE",SUP-INS-5910,CDM,S27200284,LOCAL,0272,RC,,,both,,,7452.00,2235.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,883.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW PHTHALATE FREE",SUP-CG-15-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPREME EP EXT. CABLE GREY  150 CM",SUP-401982,CDM,S27200284,LOCAL,0272,RC,,,both,,,248.00,74.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.84,210.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 31CM 5MM HARMONIC SCPL ULTRACISION",SUP-HBC05,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.41,432.72,"CIGNA [10200]",Cigna,,980.84,68,,,,,0,167.75,1226.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN STD JUDKINS RIGHT",SUP-534621T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"MULTIPLAN [10600]",Multiplan,,73.95,85,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 2.4MM",SUP-288301024,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"AETNA [10100]","Aetna HMO/PPO",,3145.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER PIN 7.5IN 1.6MM CANNULATED END CUT",SUP-14-3030,CDM,S27200284,LOCAL,0272,RC,,,both,,,966.01,289.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,443.4,45.9,,,,,0,112.35,821.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTNSL CUTLERY SPOON FINGER CONTOUR LIGHTWEIGHT STAINLESS",SUP-AA5553,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.30,21.69,"CIGNA [10200]","Cigna Local Plus",,38.68,53.5,,,,,0,8.41,61.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 0 18IN BRAID 12 STRAND COATED VIOLET ABSORBABLE",SUP-J906G,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.08,26.72,"AETNA [10100]","Aetna HMO/PPO",,70.82,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.36,75.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 135MM 2MM AO DRIVE SCALE",SUP-703690,CDM,S27200284,LOCAL,0272,RC,,,both,,,1068.23,320.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,126.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.24,908,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (PS) - SIZE 6",SUP-5555-2256,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"CIGNA [10200]","Cigna Open Access",,806.56,56.9,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 39FR RIGHT ANGLE ADJUSTABLE VALVE STYLET",SUP-126139,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.14,153.04,"CIGNA [10200]","Cigna Open Access",,290.27,56.9,,,,,0,59.33,433.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 10MM PRESTIGE PLUS HELICAL COMPLEX",SUP-PRES1040CPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"MULTIPLAN [10600]",Multiplan,,6158.25,85,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PSN MC VE ASF R 14MM 12/GH",SUP-42-5221-010-14,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1253.3,9159.96,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 15MM 145CM 4MM CORONARY STENT",SUP-1145400-15,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AETNA [10100]","Aetna HMO/PPO",,4641.21,79.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PATELLAR HEMI THK16-18MM WEDGE ALLOGRAFT FREEZE",SUP-400570,CDM,S27800098,LOCAL,0278,RC,,,both,,,5112.90,1533.87,"CIGNA [10200]","Cigna Local Plus",,2735.4,53.5,,,,,0,594.63,4345.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 345CC",SUP-SSZ-F345,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1013.47,68,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +9.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.095,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL 29MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-1511-11-201,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2014.9,14726.25,"percent of total billed charges",
"MICROCATHETER CEREBROVASCULAR 150CM 1.7-2.4FR .017IN",SUP-M003C1715450,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"FIRST HEALTH [10303]","First Health",,6175.39,80,,,,,0,897.75,6561.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 70CM 8MM GORE PROPATEN STD WALL",SUP-HAX01A,CDM,C1768,HCPCS,0278,RC,,,both,,,24412.50,7323.75,"BLUE CROSS [10001]","Blue Cross PPO",,9569.7,39.2,,,,,0,2839.17,20750.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC THK7.5MM 3.2MM 42.9X42.9MM ADAPTA SR ATRIUM",SUP-ADSR03,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"MULTIPLAN [10600]",Multiplan,,21114,85,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX15MM FRA 8D LORDOTIC NARROW WEDGE",SUP-15,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2198.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Russell Viper Venom Diluted",PX-305000059,CDM,85613,CPT,0305,RC,,,both,,,226.83,68.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,192.81,"per diem",
"CATH HEMOSTAR XK AIRGUARD 24CM 19CM 16FR STRAIGHT",SUP-5883690,CDM,C1750,HCPCS,0278,RC,,,both,,,1563.30,468.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,447.42,28.62,,,,,0,181.81,1328.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 8MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158102108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PHCS [10601]",PHCS,,7822.19,70,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 360MM FEMORAL EXPERT INTRAMEDULLARY ROUND",SUP-04.013.352S,CDM,C1713,HCPCS,0278,RC,,,both,,,8319.74,2495.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5657.42,68,,,,,0,967.59,7071.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE MEDIUM 230CM 2.8MM 15MM SNAREMASTER WIRE LOOP INTEGRAL",SUP-SD-240U-15,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.57,23.87,"KAISER [10500]",Kaiser,,53.31,67,,,,,0,9.25,67.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL ULTRAPRO 11X6CM PARTIAL ABSORBABLE LIGHTWEIGHT",SUP-UMS3,CDM,C1781,HCPCS,0278,RC,,,both,,,826.66,248,"CIGNA [10200]",Cigna,,562.13,68,,,,,0,96.14,702.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 135CM 2CM 5FR 5MM 7.5MM BALLOON DILATATION",SUP-4205020X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 36MM FLEX +9MM POLYETHYLENE",SUP-DWF362B,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"NOVANET [10819]",Novanet,,6771,75,,,,,0,1049.96,7673.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 0 CT-1 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8424H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR .083IN 25CM ROBUST VALVE SPLITTABLE WITHOUT",SUP-PLSX-2506,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"FIRST HEALTH [10303]","First Health",,313.2,80,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUMP INTRACARDIAC SUCTION ATRASUMP FLEXIBLE WEIGHTED TIP",SUP-SU-29602,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"AETNA [10100]","Aetna HMO/PPO",,159.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EXTERNAL DRNG ACCUDRAIN STERILE LATEX FREE DISPOSABLE",SUP-SP0234,CDM,C1729,HCPCS,0272,RC,,,both,,,2826.53,847.96,"UHC [10700]","United Healthcare",,1789.19,63.3,,,,,0,328.73,2402.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +8 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.080,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3.5MM 38MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.838.96,CDM,C1713,HCPCS,0278,RC,,,both,,,319.12,95.74,"MULTIPLAN [10600]",Multiplan,,271.25,85,,,,,0,37.11,271.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC MULTIPASS 5-0 P-3 18IN MONOFILAMENT BROWN",SUP-687G,CDM,S27200284,LOCAL,0272,RC,,,both,,,54.89,16.47,"CIGNA [10200]","Cigna Open Access",,31.23,56.9,,,,,0,6.38,46.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR ACTIS DUOFIX 6 STD OFFSET HIP STERILE",SUP-101011060,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"BLUE CROSS [10001]","Blue Cross PPO",,11946.69,39.2,,3949.44,3949.44,3949.44,"1 through 10",3544.39,25904.81,"percent of total billed charges",
"ANCHOR ORTHOPEDIC HEALIX 5.5MM ORTHOCORD NDL SHOULDER SMALL",SUP-222232,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,434.96,3179,"percent of total billed charges",
"CATH OPTA PRO 80CM 4CM 5FR 5MM 7.5MM BALLOON DILATATION",SUP-4195040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Estradiol Free Direct Measure",PX-301000677,CDM,82681,CPT,0301,RC,,,both,,,53.00,15.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,43.95,,,,,,,0.01,53,"fee schedule",
"CATH ULTRAVERSE 035 GEOALIGN 75CM 20MM 12MM BALLOON",SUP-U3575122,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BD NEXIVA 1.75IN 20GA IV BD VIALON PERIPHERAL CLOSED",SUP-383538,CDM,S27200284,LOCAL,0272,RC,,,both,,,45.33,13.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.27,38.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLIDESHEATH SLENDER SS KIT, 0.021 GW, 7 FR, 16CM",SUP-80-1670,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"MULTIPLAN [10600]",Multiplan,,378.68,85,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 30MM SPINE PEDICLE PLY NONSTERILE 4MM ROD",SUP-102045230,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"CATH IMPULSE 125CM 6FR IM CURVE ANGIOGRAPHIC CORONARY 2 WIRE",SUP-H749165992400,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"UHC [10700]","United Healthcare",,48.48,63.3,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 10 X 30 HELICAL FILLING COIL",SUP-10HFL-10030,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"NOVANET [10819]",Novanet,,6722.33,75,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST TAPER 18MM 9.5MM HEMICAP FOOT METATARSOPHALANGEAL INLAY",SUP-9095-0018-W,CDM,C1776,HCPCS,0278,RC,,,both,,,2250.00,675,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,643.95,28.62,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 13MM SPINE CERVICAL ANTERIOR SELF TAP",SUP-18008313,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 99MM TYPE 1 PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51109070,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"PHCS [10601]",PHCS,,19204.67,70,,,,,0,3190.72,23319.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CRISTACATH 115CM 3MM 7FR 1-3-1MM SPACE D CURVE",SUP-D7A20131RT,CDM,C1730,HCPCS,0272,RC,,,both,,,7086.30,2125.89,"KAISER [10500]",Kaiser,,4747.82,67,,,,,0,824.14,6023.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 131MM STAINLESS STEEL 2.7/3.5MM SCR 6 HOLE VARIABLE",SUP-02.107.506,CDM,C1713,HCPCS,0278,RC,,,both,,,6717.56,2015.27,"PHCS [10601]",PHCS,,4702.29,70,,,,,0,781.25,5709.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9.8FR 8FR 55CM HIGH FLEX DIL RADIOPAQUE CLOSED",SUP-G49045,CDM,C1894,HCPCS,0272,RC,,,both,,,472.23,141.67,"FIRST HEALTH [10303]","First Health",,377.78,80,,,,,0,54.92,401.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 50MM AXSOS STAINLESS STEEL 3.5MM FULL THREAD",SUP-340650,CDM,C1713,HCPCS,0278,RC,,,both,,,255.78,76.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,117.4,45.9,,,,,0,29.75,217.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 3X2CM AMNIOBAND 6SQ CM ALLOGRAFT",SUP-WC3023,CDM,Q4151,HCPCS,0636,RC,,,both,,,7063.88,2119.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,362.66,,,,,,,362.66,6004.3,"fee schedule",
"SULFACETAMIDE SODIUM 10 % EYE DROPS",RX-7359,CDM,,,0250,RC,24208-0670-04,NDC,both,15,ML,383.72,115.12,"CIGNA [10200]","Cigna Local Plus",,205.29,53.5,,,,,0,44.63,326.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 331311 ACSR 13X11X11 SRVC FEE",SUP-331311,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 60MM STAINLESS STEEL T15 METAPHYSEAL SELF TAP",SUP-02.127.160,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"CIGNA [10200]",Cigna,,770.24,68,,1831.33,1831.33,1831.33,16,131.73,962.8,"percent of total billed charges",
"BASEPLT TIBIAL ATTUNE 5 KNEE CEMENTED ROTATE PLATFORM",SUP-150610005,CDM,C1776,HCPCS,0278,RC,,,both,,,16694.55,5008.36,"CIGNA [10200]","Cigna Open Access",,5592.67,33.5,,5302.19,4377.88,6578.61,27,1941.58,14190.37,"percent of total billed charges",
"SABER .035 9X20 135CM SL",SUP-48009002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,353.05,41.1,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP COMPREHENSIVE STEM/COMPREHENSIVE GLENOID/VERSADIAL HEAD/",SUP-98000900059,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19937.61,41.1,,6417.48,6417.48,6417.48,"1 through 10",5641.71,41233.5,"percent of total billed charges",
"CATH ATTAIN GUIDING LEFT HEART LEAD DELIVERY SYSTEM LATEX",SUP-6216A,CDM,C1769,HCPCS,0272,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC MICROFIBRILLAR CLLGN SPONGE AVITENE",SUP-1050030,CDM,S27200284,LOCAL,0272,RC,,,both,,,272.40,81.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,185.23,68,,,,,0,31.68,231.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONCIERGE 100CM 6FR SBS4 MOD CURVE GUIDING STAINLESS",SUP-CGC6100SBS40-MSH,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CHISEL SURGICAL 6.75IN 6MM V BALLENGER",SUP-63-0090,CDM,S27200284,LOCAL,0272,RC,,,both,,,415.43,124.63,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 20MM 4MM BALLOON",SUP-U357542,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PDS II 7-0 BV-1 30IN 2 ARM MONOFILAMENT VIOLET",SUP-Z135H,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.03,60.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT ELITE VASCULAR STRAIGHT",SUP-1011881,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INFINITI THRULUMEN 100CM 6FR AMPLATZ LEFT 2 CURVE",SUP-534646T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BNDG 10YDX3IN UNNA-Z UNNA BOOT ZINC OXIDE PLASTIC WITHOUT",SUP-NONUNNA13,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.27,14.18,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAP WATER MEMB LATEX FREE DISPOSABLE D-FEND RPO PTFE",SUP-M1182629,CDM,S27000186,LOCAL,0270,RC,,,both,,,64.47,19.34,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CAP SYSTEM GENDER SOLUTIONS TKR PROLONG POROUS FEMUR PATELLA",SUP-98000255014,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"AETNA [10100]","Aetna HMO/PPO",,17529.75,79.5,,10981.53,8986.79,12413.38,12,2564.42,18742.5,"percent of total billed charges",
"ADPTR FEMORAL VANGUARD 360 2.5MM OFFSET KNEE REVISION SYSTEM",SUP-185210,CDM,C1776,HCPCS,0278,RC,,,both,,,5978.16,1793.45,"AETNA [10100]","Aetna HMO/PPO",,4752.64,79.5,,10981.53,8986.79,12413.38,12,695.26,5081.44,"percent of total billed charges",
"LEAD PACING 97CM 8.6FR VENTRICULAR HELIX ELECTRD DF-4 CNCT",SUP-6935M97,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4636.44,27,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 35MM 4.75MM CD HORIZON SOLERA PERCUTANEOUS CCM",SUP-641000035,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 36CM HIP RIGHT FEMUR AFFIXUS INTRAMEDULLARY 125D",SUP-814311360,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"BLUE CROSS [10001]","Blue Cross HMO",,8131.16,39.2,,957.42,156.86,7483.26,51,2412.38,17631.34,"percent of total billed charges",
"PLATE 0D SMALL FUSION MEDLINE UNITE BONE METATARSOPHALANGEAL",SUP-MPP1001L,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"BLUE CROSS [10001]","Blue Cross PPO",,4043.68,39.2,,957.42,570.23,957.42,28,1199.69,8768.18,"percent of total billed charges",
"BOLT ORTHOPEDIC 75MM FEMORAL NECK SYSTEM STERILE",SUP-04.168.275S,CDM,C1713,HCPCS,0278,RC,,,both,,,2435.70,730.71,"BLUE CROSS [10001]","Blue Cross HMO",,954.79,39.2,,957.42,156.86,7483.26,51,283.27,2070.35,"percent of total billed charges",
"VALVE AORTIC 20.2MM 18.8IN ATS OPEN PIVOT 20MM 2.56SQ CM STD",SUP-505DA20,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"MULTIPLAN [10600]",Multiplan,,20081.25,85,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 108MM 8MM SMALL SHELL ALTIVATE REVERSE SHOULDER",SUP-533-08-108,CDM,C1776,HCPCS,0278,RC,,,both,,,43175.16,12952.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5021.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5021.27,36698.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 142MM 30MM 25-27MM 20FR ZENITH TX2",SUP-G47445,CDM,C1874,HCPCS,0278,RC,,,both,,,98041.65,29412.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,26471.25,27,,,,,0,11402.24,83335.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 6MM 95MM LCP STAINLESS STEEL T8 CORTEX PELVIC",SUP-204.695,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"BLUE CROSS [10001]","Blue Cross HMO",,107.91,39.2,,957.42,156.86,7483.26,51,32.01,233.98,"percent of total billed charges",
"(EVAL) NAVCATH",SUP-5320,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER LIME GREEN 17MM 4.5MM DYONICS ORBIT INCISOR",SUP-7205320,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,41.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 10IN 22FR FEMORAL ARTERY 3/8IN THIN WALL T",SUP-TFA02225,CDM,S27200284,LOCAL,0272,RC,,,both,,,371.23,111.37,"CIGNA [10200]","Cigna Open Access",,211.23,56.9,,,,,0,43.17,315.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT FEMORAL KNEE PATELLA TIBIA HYBRID POSTERIOR BEARIN",SUP-98000244720,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"PHCS [10601]",PHCS,,17199,70,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 150MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"PHCS [10601]",PHCS,,1003.59,70,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PROGRESS 200T VASCULAR STRAIGHT 300CM 3CM",SUP-1011843,CDM,C1769,HCPCS,0272,RC,,,both,,,1036.80,311.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,122.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LASER ABLATION SYSTEM 10MM VISUALASE .4MM FIBER CORE TIP",SUP-9735560,CDM,S27200284,LOCAL,0272,RC,,,both,,,62700.00,18810,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7429.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 38MM 144CM 2.75MM CORONARY STENT",SUP-H7493911438270,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"FIRST HEALTH [10303]","First Health",,7314,80,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 22MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G322,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"MULTIPLAN [10600]",Multiplan,,7961.17,85,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC ELECTROSURGICAL MINERVA 1 STERILE LATEX FREE",SUP-MIN9770,CDM,S27200284,LOCAL,0272,RC,,,both,,,6210.00,1863,"KAISER [10500]",Kaiser,,4160.7,67,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 15MM STAINLESS STEEL 2.7MM SCR COMPRESSION INTERAXIS",SUP-40120015,CDM,C1713,HCPCS,0278,RC,,,both,,,6948.30,2084.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,823.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",808.09,5906.06,"percent of total billed charges",
"CATH SOUNDSTAR CRYSTAL ULTRASOUND",SUP-11510826,CDM,C1759,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11781,68,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 115CM 2.2FR 1CM TIPLESS STONE NCIRCLE UROLOGICAL",SUP-G18778,CDM,S27200284,LOCAL,0272,RC,,,both,,,1804.50,541.35,"CIGNA [10200]",Cigna,,1227.06,68,,,,,0,209.86,1533.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC ELECTROSURGICAL 10FT BEND-A-BEAM CORD 6IN STERILE",SUP-134006,CDM,S27200284,LOCAL,0272,RC,,,both,,,910.44,273.13,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,374.19,41.1,,,,,0,105.88,773.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE 0.5%-EPI 1:100,000 BUFFERED W/SOD BICARB 8.4% SYRINGE 10 ML",RX-411236,CDM,,,0250,RC,08888-8879-62,NDC,both,10,ML,18.92,5.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.2,16.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE MATRIX ASEPTIC 5X2.5CM",SUP-A42210,CDM,S27800098,LOCAL,0278,RC,,,both,,,9119.04,2735.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1060.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1060.54,7751.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.120 CLAREON",SUP-SY60WF.120,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Instant Wave Free Ratio Add",PX-481000373,CDM,93799,CPT,0481,RC,,,both,,,1734.36,520.31,"AETNA [10100]","Aetna HMO/PPO",,1378.82,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,201.71,1734.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NADOLOL 40 MG TABLET",RX-5331,CDM,,,0637,RC,76282-0348-01,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]",Cigna,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9 % INJECTION SOLUTION",RX-41463,CDM,,,0250,RC,63323-0186-01,NDC,both,10,ML,18.92,5.68,"KAISER [10500]",Kaiser,,12.68,67,,,,,0,2.2,16.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC REAMING 33MM PATELLA DISPOSABLE",SUP-8000-0033,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.00,675,"KAISER [10500]",Kaiser,,1507.5,67,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 22MM 10D E HIP CONSTRAIN TRIDENT",SUP-690-10-22E,CDM,C1776,HCPCS,0278,RC,,,both,,,17046.45,5113.93,"AETNA [10100]","Aetna HMO/PPO",,13551.93,79.5,,10981.53,8986.79,12413.38,12,1982.5,14489.48,"percent of total billed charges",
"LAPIPLASTY MINI INCISION SYSTEM",SUP-SK30,CDM,C1713,HCPCS,0278,RC,,,both,,,35248.50,10574.55,"BLUE CROSS [10001]","Blue Cross PPO",,13817.41,39.2,,957.42,570.23,957.42,28,4099.4,29961.23,"percent of total billed charges",
"HC Xr Foot 1v",PX-320000193,CDM,73620,CPT,0320,RC,,,both,,,463.91,139.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,54.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.47,394.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 200MM 4MM BALLOON DILATATION",SUP-PCU040200130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ARTHROSCOPIC GRAFT 10MM ACL STERILE DISPOSABLE",SUP-232110,CDM,S27200284,LOCAL,0272,RC,,,both,,,1665.00,499.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,684.32,41.1,,,,,0,193.64,1415.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 3MM CORONARY STENT PEBAX",SUP-H7493926032300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"KAISER [10500]",Kaiser,,3728.55,67,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CERTUS XT LK ABLATION PROBE 15",SUP-LK15XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,14524.50,4357.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1689.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1689.2,12345.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 30MM 29MM AEQUALIS REVERSED II 2MM OFFSET",SUP-DWE830,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"FIRST HEALTH [10303]","First Health",,7554.4,80,,,,,0,1098.22,8026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 10MM RETRACTA DETACHABLE .035IN",SUP-G34199,CDM,S27800098,LOCAL,0278,RC,,,both,,,4674.68,1402.4,"AETNA [10100]","Aetna HMO/PPO",,3716.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,543.67,3973.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 14CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155213180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"FIRST HEALTH [10303]","First Health",,1287.77,80,,,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET VENTILATOR COAXIAL ELBOW ADPTR EXPIRATORY VALVE",SUP-260167,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STELLAREX 135CM 150MM 6MM BALLOON DILATATION OTW DRUG",SUP-AB35SX060150135,CDM,C2623,HCPCS,0272,RC,,,both,,,11557.50,3467.25,"MULTIPLAN [10600]",Multiplan,,9823.88,85,,,,,0,1344.14,9823.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 40MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE REGENEATIONGRAFT 7CM X7CM",SUP-GS-5770,CDM,Q4186,HCPCS,0636,RC,,,both,,,60568.20,18170.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7177.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,406.44,51482.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +14.5 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SND1T4,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"MULTIPLAN [10600]",Multiplan,,633.25,85,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM 11/13 STD TAPER 28MM HIP MODULAR ULTAMET",SUP-875953,CDM,C1776,HCPCS,0278,RC,,,both,,,4754.10,1426.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3232.79,68,,,,,0,552.9,4040.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAPE FIBERWIRE 2 TAPER 7INX2MM BRAID BLUE",SUP-AR-7237-7,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23MMX8MM ELEVATE XLORDOTIC PEEK TITANIUM",SUP-8880823,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11520,40,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISIONS PV 90CM 100CM 8.5FR .035IN ULTRASOUND GLYDX",SUP-88901,CDM,C1753,HCPCS,0272,RC,,,both,,,6900.00,2070,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 520CC SMOOTH SHELL SURFACE COHESIVE GEL 1 LUMEN",SUP-SRF-520,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1569.95,28.62,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 80MM 80CM 10MM .035IN 3MM VASCULAR VENOUS",SUP-VENUM10080,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9062.55,41.1,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 29X6MM ITOTAL IPOLY XE STERILE",SUP-PAT0212906,CDM,C1776,HCPCS,0278,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,5302.19,4377.88,6578.61,27,0.01,0.01,"percent of total billed charges",
"TUBE 99MM 12.1MM 9MM 1 CANN CUFF LOW SECRETION LEVEL ROUND",SUP-9SCT,CDM,S27200284,LOCAL,0272,RC,,,both,,,383.32,115,"MULTIPLAN [10600]",Multiplan,,325.82,85,,,,,0,44.58,325.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC MEDIUM 8IN WRIST LEFT COCK UP CLSR VELCRO",SUP-5059-07,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.06,33.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,51.44,45.9,,,,,0,13.03,95.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PLATE 5 74X46MM STEMMED ANTERIOR POSTERIOR",SUP-00598800500,CDM,C1776,HCPCS,0278,RC,,,both,,,10113.60,3034.08,"UHC [10700]","United Healthcare",,6401.91,63.3,,8601.07,8395.67,8601.07,"1 through 10",1176.21,8596.56,"percent of total billed charges",
"CATH INFINITI THRULUMEN 100CM 6FR .057IN AMPLATZ RIGHT",SUP-534648T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"MULTIPLAN [10600]",Multiplan,,73.95,85,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20CM 13FR POLYURETHANE POWER-TRIALYSIS 3 LUMEN",SUP-5613200,CDM,C1752,HCPCS,0272,RC,,,both,,,1321.11,396.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,156.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,153.65,1122.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006175272170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"KAISER [10500]",Kaiser,,847.8,67,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 9.5CM 20MM 16.5-18.5MM EXCLUDER",SUP-PLC201000,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11198.88,40,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE DOUBLE DIAMOND 1.2MM X 89MM COCR",SUP-KWCC-DD-12089,CDM,S27000186,LOCAL,0270,RC,,,both,,,400.20,120.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,272.14,68,,,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 3 POSTERIOR KNEE TOTAL STABILIZED",SUP-5544-A-300,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"CIGNA [10200]",Cigna,,3244.27,68,,5873.17,5873.17,5873.17,"1 through 10",554.87,4055.34,"percent of total billed charges",
"INSRT TIBIAL 6 9MM KNEE X3 CONDYLAR STABILIZED PRIMARY",SUP-5531-G-609,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3849.46,41.1,,6417.48,6417.48,6417.48,"1 through 10",1089.28,7961.17,"percent of total billed charges",
"KNIFE OPHTHALMIC 1.4MM 20GA A-OK V-LANCE STRAIGHT CORNEAL",SUP-8065912001,CDM,S27200284,LOCAL,0272,RC,,,both,,,202.97,60.89,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATHETERIZATION BARDEX LUBRICATH STATLOCK 16FR 350ML",SUP-304916,CDM,C1729,HCPCS,0272,RC,,,both,,,181.92,54.58,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH METACROSS RX 135CM 20MM 5.7-3.9FR 6MM BALLOON",SUP-BD-L60020CR,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TAPE RADIOPAQUE 270MM LEMAITRE 20 STRIP STENT GUIDE",SUP-1102-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,502.20,150.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE JEJUNOSTOMY 14FR SILICONE MIC-KEY SECUR-LOK ENFIT BOLUS",SUP-8200-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 20MM 2.5MM",SUP-SPL25020X,CDM,C1725,HCPCS,0272,RC,,,both,,,546.75,164.02,"PHCS [10601]",PHCS,,382.73,70,,,,,0,63.59,464.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 57MM 36MM GLADIATOR HIP COCR XLPE UHMWPE",SUP-GLBP3657,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"AETNA [10100]","Aetna HMO/PPO",,11300.13,79.5,,10981.53,8986.79,12413.38,12,1653.09,12081.9,"percent of total billed charges",
"VALVE AORTIC 20MM SAPIEN 3 ULTRA RESILIA",SUP-S3URCM20A,CDM,S27800098,LOCAL,0278,RC,,,both,,,193800.00,58140,"BLUE CROSS [10001]","Blue Cross PPO",,75969.6,39.2,,,,,0,22538.94,164730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TOURNIQUET W4.125XL24IN SINGLE PORT SINGLE BLADDER CYLI",SUP-60-7075-104R,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.73,54.22,"NOVANET [10819]",Novanet,,135.55,75,,,,,0,21.02,153.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM DYNACLIP 8X8X8MM INTERNAL FIXATION",SUP-3000-00-080808,CDM,C1713,HCPCS,0278,RC,,,both,,,10591.50,3177.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1255.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1231.79,9002.78,"percent of total billed charges",
"LINER ACETABULAR 36MM +0MM HIP TRABECULAR METAL POLYETHYLENE",SUP-00434903600,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"NOVANET [10819]",Novanet,,6770.79,75,,,,,0,1049.92,7673.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT ENDOSCOPIC STRAIGHT JAW HAND SWITCH CORDLESS",SUP-SCD26,CDM,S27200284,LOCAL,0272,RC,,,both,,,2437.50,731.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,288.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT ENDOSCOPIC STRAIGHT JAW HAND SWITCH CORDLESS",SUP-SCD26,CDM,S27200284,LOCAL,0272,RC,,,both,,,2437.50,731.25,"CIGNA [10200]",Cigna,,1657.5,68,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 23FR .038IN FEMORAL ARTERIAL WIRE WOUND INTRO",SUP-ER23B,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"UHC [10700]","United Healthcare",,2620.62,63.3,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 68MM 3 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800368,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDEAVOR SPRINT 30MM 142CM 3.5MM CORONARY STENT",SUP-ENSP35030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,656.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 10MM 9FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEM10100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross HMO",,7161.84,39.2,,9776.84,9776.84,9776.84,"1 through 10",2124.8,15529.5,"percent of total billed charges",
"CATH TANGO 110CM 5FR 2MM SPACE COURNAND CURVE",SUP-M0044005420,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"FIRST HEALTH [10303]","First Health",,250.56,80,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.5MM CORTEX SCREW 50MM",SUP-214.05,CDM,C1713,HCPCS,0278,RC,,,both,,,345.22,103.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,98.8,28.62,,,,,0,40.15,293.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 11CM 5FR GEENEN PANCREATIC POLYETHYLENE",SUP-G27151,CDM,C2625,HCPCS,0278,RC,,,both,,,1231.20,369.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETERIZATION 16CM 18GA ARTERIAL LATEX FREE",SUP-SAC-01618-1A,CDM,S27200284,LOCAL,0272,RC,,,both,,,787.32,236.2,"NOVANET [10819]",Novanet,,590.49,75,,,,,0,91.57,669.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Iliac W Pta Add",PX-361000150,CDM,37222,CPT,0361,RC,,,both,,,7309.72,2192.92,"FIRST HEALTH [10303]","First Health",,5847.78,80,,,,,0,850.12,7309.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAMP 10GA STRAIGHT STEERABLE BALLOON RADIOPAQUE INFLATABLE",SUP-OT-0222,CDM,S27200284,LOCAL,0272,RC,,,both,,,4554.00,1366.2,"FIRST HEALTH [10303]","First Health",,3643.2,80,,,,,0,529.63,3870.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 300MM 3.5MM BALLOON DILATATION",SUP-48003530X,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDPN ORTHOPEDIC 7.6CM 1/8IN GENESIS II KNEE TROCAR STERILE",SUP-71210002,CDM,C1713,HCPCS,0278,RC,,,both,,,260.35,78.1,"MULTIPLAN [10600]",Multiplan,,221.3,85,,,,,0,30.28,221.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VESSEL SEALER EXTENDER",SUP-480422,CDM,S27200284,LOCAL,0272,RC,,,both,,,4528.70,1358.61,"AETNA [10100]","Aetna HMO/PPO",,3600.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,526.69,3849.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LOW PROFILE 35MM TITANIUM INTEGRATE LOCK MECHANISM",SUP-9790035,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM NAVITOR TRANSCATHETER SELF EXPAND INTRA",SUP-NVTR-27,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"CIGNA [10200]",Cigna,,54720,40,,,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISSECTOR LAPAROSCOPIC SONICISION 7 7 MM L13 CM CURVE JAW CO",SUP-SCD7A13,CDM,S27200284,LOCAL,0272,RC,,,both,,,2887.50,866.25,"CIGNA [10200]","Cigna Local Plus",,1544.81,53.5,,,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 P-3 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8699G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 15MM KNEE POSTERIOR STABILIZE HIGH",SUP-71421511,CDM,C1776,HCPCS,0278,RC,,,both,,,10774.35,3232.3,"CIGNA [10200]","Cigna Local Plus",,5764.28,53.5,,5372.07,4581.20,7242.98,23,1253.06,9158.2,"percent of total billed charges",
"CUFF TRNQT CYL 24X4IN 2 PORT TUBING LIMB PROTECTION SLEEVE",SUP-5921-024-235,CDM,S27200284,LOCAL,0272,RC,,,both,,,185.29,55.59,"FIRST HEALTH [10303]","First Health",,148.23,80,,,,,0,21.55,157.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT CYL 24X4IN 2 PORT TUBING LIMB PROTECTION SLEEVE",SUP-5921-024-235,CDM,S27200284,LOCAL,0272,RC,,,both,,,185.29,55.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,126,68,,,,,0,21.55,157.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 14MM PERSONA 10-12 G-H KNEE RIGHT TIBIA",SUP-42522401014,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1253.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 5MM 100MM KII ABDOMINAL LOW PROFILE Z",SUP-CTS29,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,47.33,68,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PYRIDOSTIGMINE BROMIDE 60 MG TABLET, IMMEDIATE RELEASE",RX-11239,CDM,,,0637,RC,00904-6622-61,NDC,both,1,UN,8.11,2.43,"CIGNA [10200]","Cigna Local Plus",,4.34,53.5,,,,,0,0.94,6.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 30MM MODULAR FLEXIBLE DISPOSABLE",SUP-00879000703,CDM,S27200284,LOCAL,0272,RC,,,both,,,1162.35,348.7,"CIGNA [10200]","Cigna Local Plus",,621.86,53.5,,,,,0,135.18,988,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 CURVE PLUS 8MM KNEE XLK FIX BEARING SIGMA",SUP-970470,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3198.16,28.62,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis D Quantification",PX-306000253,CDM,87523,CPT,0306,RC,,,both,,,279.00,83.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,38.56,,,,,,,0.01,237.15,"fee schedule",
"HC Brachytx Isodose Plan Simple",PX-333000064,CDM,77316,CPT,0333,RC,,,both,,,2249.39,674.82,"CIGNA [10200]",Cigna,,1529.59,68,,,,,0,261.6,2249.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 3MM BALL DISSECTING DIAMOND",SUP-MR8-9BA30D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.17,412.25,"FIRST HEALTH [10303]","First Health",,1099.34,80,,,,,0,159.82,1168.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 115CM 1.5FR 1CM 4 WIRE TIPLESS BASKET SPECIMEN",SUP-G46206,CDM,S27200284,LOCAL,0272,RC,,,both,,,2063.25,618.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,244.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.96,1753.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D C KNEE LEFT OSSEOTI KEEL",SUP-42535006401,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5657.62,41.1,,6417.48,6417.48,6417.48,"1 through 10",1600.93,11700.68,"percent of total billed charges",
"PATCH SURGICAL 5.5X4.3IN GROIN 2 LAYER MONOFILAMENT MEMORY",SUP-0010105,CDM,C1781,HCPCS,0278,RC,,,both,,,1175.00,352.5,"CIGNA [10200]","Cigna Local Plus",,628.63,53.5,,3096.73,1.00,3096.73,"1 through 10",136.65,998.75,"percent of total billed charges",
"HC Infect Agnt Detct Nucleic Acid Dna/Rna Covid19",PX-306000226,CDM,87635,CPT,0306,RC,,,both,,,252.33,75.7,"PHCS [10601]",PHCS,,176.63,70,,,,,0,0.25,214.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 5IN .6IN SHORTSHOT SAEED TRIVIEW 4 BAND HEMORRHOIDAL",SUP-G34063,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 10MM RELIANCE HIP FEMUR FRACTURE PRODUCTS F R",SUP-6259-8-100,CDM,C1776,HCPCS,0278,RC,,,both,,,810.00,243,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,371.79,45.9,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 26CM 150CM 7FR .035IN 3CM BLADDER LOOP",SUP-M006155243190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"NOVANET [10819]",Novanet,,1065.26,75,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG SURGICAL KEYHOLE PATCH SEMIRESORBABLE ISOELASTIC",SUP-PNP6X3,CDM,C1781,HCPCS,0278,RC,,,both,,,845.40,253.62,"NOVANET [10819]",Novanet,,634.05,75,,,,,0,98.32,718.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE SOFT TOUCH SMOOTH",SUP-SSF-415,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS [10001]","Blue Cross PPO",,2961.76,39.2,,16595.83,16595.83,16595.83,"1 through 10",878.7,6422.18,"percent of total billed charges",
"IMPL BREAST NATRELLE INSPIRA LOW PROFILE SILICONE SMOOTH",SUP-SCL-230,CDM,C1789,HCPCS,0278,RC,,,both,,,8004.00,2401.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,930.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,930.87,6803.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 11.5X12CM 290ML STYLE FF HIGHLY COHESIVE GEL",SUP-FF-410290,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"KAISER [10500]",Kaiser,,3728.55,67,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAUT BTTRY 5IN BOVIE HIGH TEMPERATURE LOOP TIP EXTEND SHAFT",SUP-AA09,CDM,S27200284,LOCAL,0272,RC,,,both,,,120.79,36.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.05,102.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION AQUALITE 0.9% SODIUM CHLORIDE 1.5L LATEX FREE",SUP-713836,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 CURVE 10MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962041,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"FIRST HEALTH [10303]","First Health",,7399.56,80,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL STRAIGHT SPAT 11IN VALLEYLAB STERILE",SUP-E3780-28,CDM,S27200284,LOCAL,0272,RC,,,both,,,163.73,49.12,"CIGNA [10200]",Cigna,,111.34,68,,,,,0,19.04,139.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 TAPER 36MM HIP OXINIUM ECHELON",SUP-71343600,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"CIGNA [10200]","Cigna Open Access",,5204.34,33.5,,5302.19,4377.88,6578.61,27,1806.76,13205.05,"percent of total billed charges",
"BASKET STONE RETRIEVAL 90CM 16MM 3FR SEGURA HEMISPHERE",SUP-M0063801020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"PHCS [10601]",PHCS,,1035.69,70,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX9MM FRA 8D 30D LORDOTIC NARROW",SUP-10209,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"MULTIPLAN [10600]",Multiplan,,16065,85,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 35MM ADJUSTABLE FULL FLEXIBLE RADIOPAQUE",SUP-AFR-35,CDM,S27800098,LOCAL,0278,RC,,,both,,,16909.83,5072.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2003.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1966.61,14373.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOCKING COMPRESSION SCREW 1.8MM X 10.0MM COCR",SUP-CMP-18010-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,594.86,45.9,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 150D STD BARREL 78MM STAINLESS STEEL 8 HOLE",SUP-281.440,CDM,C1713,HCPCS,0278,RC,,,both,,,2156.11,646.83,"NOVANET [10819]",Novanet,,1617.08,75,,,,,0,250.76,1832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 18IN ENDOLOOP VICRYL ABSORBABLE SUT BRAID ENDOSCOPIC",SUP-EJ10G,CDM,S27200284,LOCAL,0272,RC,,,both,,,822.04,246.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,377.32,45.9,,,,,0,95.6,698.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 0 CT-1 18IN CONTROL RELEASE MONOFILAMENT 8 STRAND",SUP-Z740D,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.02,66.91,"CIGNA [10200]","Cigna Local Plus",,119.32,53.5,,,,,0,25.94,189.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 19MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P319,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"KAISER [10500]",Kaiser,,5598.45,67,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006155234010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"MULTIPLAN [10600]",Multiplan,,1046.32,85,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HI-FLO RENEGADE 80CM 20CM 3-2.8FR .027IN MICRO INFUSION",SUP-M001182830,CDM,C1887,HCPCS,0272,RC,,,both,,,2100.00,630,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,248.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Delivery Rm Newborn Resus",PX-722000003,CDM,99465,CPT,0722,RC,,,both,,,1041.08,312.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,123.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.08,884.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 115CM 1.7FR 11MM NGAGE KIDNEY URETER NITINOL",SUP-G48295,CDM,S27200284,LOCAL,0272,RC,,,both,,,2063.25,618.97,"UHC [10700]","United Healthcare",,1306.04,63.3,,,,,0,239.96,1753.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSCONN ROD 30-42MM SPINE HEAD TO HEAD",SUP-102023102,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]",Cigna,,2422.5,68,,1831.33,1831.33,1831.33,16,414.32,3028.13,"percent of total billed charges",
"STENT EXPRESS SD MONORAIL 15MM 150CM 4MM BILIARY STAINLESS",SUP-H74937911415150,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"AETNA [10100]","Aetna HMO/PPO",,3968.64,79.5,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 75MM 32MM DARCO TITANIUM SHORT THREAD FOOT",SUP-DC003275,CDM,C1713,HCPCS,0278,RC,,,both,,,4629.90,1388.97,"AETNA [10100]","Aetna HMO/PPO",,3680.77,79.5,,1521.93,481.35,16760.95,30,538.46,3935.42,"percent of total billed charges",
"CBL PCNG BGE 12FT SAFE-CNCT",SUP-365888,CDM,C1883,HCPCS,0278,RC,,,both,,,408.90,122.67,"BLUE CROSS [10001]","Blue Cross HMO",,160.29,39.2,,6399.74,6399.74,6399.74,"1 through 10",47.56,347.57,"percent of total billed charges",
"STEM HUMERAL 115MM 6MM PRIMARY TURON",SUP-520-01-006,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"NOVANET [10819]",Novanet,,5940,75,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH UROMAX ULTRA QUADRA-FOLD ENCORE HIGH PRESSURE KINK",SUP-M0062251230,CDM,C1726,HCPCS,0272,RC,,,both,,,1904.70,571.41,"FIRST HEALTH [10303]","First Health",,1523.76,80,,,,,0,221.52,1619,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2-0 CT-1 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8423H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 5.5MM TITANIUM CONTOUR",SUP-101-65560,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Local Plus",,2359.35,53.5,,3978.14,359.25,3978.14,24,512.88,3748.5,"percent of total billed charges",
"LENS IOL 5 D +18.5 DIOPTER MODIFIED C BICONVEX 12.5MM 7MM",SUP-CZ70BD.185,CDM,V2632,HCPCS,0276,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE",318,MS-DRG,,,,,,,inpatient,,,145994.79,43798.44,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,15475.8,,"Case rate ($15,025.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,951.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,991.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,436.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $13,970.23. The transfer operating threshold is the transfer adjustment factor * $13,951.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,054.82. The transfer capital threshold is the transfer adjustment factor * $1,054.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,15025.05,59796.97,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE CONDYLAR CEMENT CONSTRAIN PERSONA",SUP-42504606201,CDM,C1776,HCPCS,0278,RC,,,both,,,42373.80,12712.14,"CIGNA [10200]","Cigna Local Plus",,13347.75,31.5,,5372.07,4581.20,7242.98,23,4928.07,36017.73,"percent of total billed charges",
"VESSEL SEALER EXTENDER",SUP-480422,CDM,S27200284,LOCAL,0272,RC,,,both,,,4528.70,1358.61,"CIGNA [10200]","Cigna Local Plus",,2422.85,53.5,,,,,0,526.69,3849.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 20MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-08027,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 55MM AFFIX II BONE LUMBAR SPINE",SUP-7577055,CDM,C1713,HCPCS,0278,RC,,,both,,,24141.60,7242.48,"CIGNA [10200]","Cigna Local Plus",,7604.6,31.5,,3978.14,359.25,3978.14,24,2807.67,20520.36,"percent of total billed charges",
"PLATE 60MM 3 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800360,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 55MM CENTERPULSE LEGACY 12/14 TAPER HIP FEMUR",SUP-451000055,CDM,C1776,HCPCS,0278,RC,,,both,,,2328.75,698.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,275.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,270.83,1979.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +7.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.075,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Ankle Trimal WO Manip",PX-450000165,CDM,27816,CPT,0450,RC,,,both,,,1347.00,404.1,"MULTIPLAN [10600]",Multiplan,,1144.95,85,,,,,0,67.13,1347,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE 0.5%-EPI 1:100,000 BUFFERED W/SOD BICARB 8.4% SYRINGE 10 ML",RX-411236,CDM,,,0250,RC,08888-8879-62,NDC,both,10,ML,18.92,5.68,"KAISER [10500]",Kaiser,,12.68,67,,,,,0,2.2,16.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INTROCAN SAFETY 2.5IN 22GA STRAIGHT IV POLYURETHANE",SUP-4251622-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,55.42,16.63,"UHC [10700]","United Healthcare",,35.08,63.3,,,,,0,6.45,47.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION",RX-77725,CDM,,,0250,RC,88880-8882-11,NDC,both,10,ML,12.54,3.76,"CIGNA [10200]","Cigna Open Access",,7.14,56.9,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 20IN 32FR STRAIGHT",SUP-8888570556,CDM,C1729,HCPCS,0272,RC,,,both,,,88.90,26.67,"MULTIPLAN [10600]",Multiplan,,75.57,85,,,,,0,10.34,75.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 10MM 3.25MM BALLOON DILATATION STERILE",SUP-232-103-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Guide Tiss Ablt",PX-402000038,CDM,76940,CPT,0402,RC,,,both,,,515.00,154.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,236.39,45.9,,,,,0,59.89,437.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM PRECISION .014IN TRIAL LINEAR STRAIGHT",SUP-SC-2218-50E,CDM,C1778,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) CATH TURNPIKE 150CM 2.2-3.1FR 1.6FR VASCULAR LOW PROF",SUP-5639,CDM,S27200284,LOCAL,0272,RC,,,both,,,4126.20,1237.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,488.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,479.88,3507.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veno Ext Uni Si",PX-320000129,CDM,75820,CPT,0320,RC,,,both,,,1743.69,523.11,"KAISER [10500]",Kaiser,,1168.27,67,,,,,0,93,1743.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SPINAL XLIF NEUROVISION DIL M5 DISPOSABLE",SUP-2029950,CDM,S27200284,LOCAL,0272,RC,,,both,,,5347.50,1604.25,"MULTIPLAN [10600]",Multiplan,,4545.38,85,,,,,0,621.91,4545.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3.5MM CEREPAK MICRO UNIFORM DETACHABLE",SUP-FCX100356,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"PHCS [10601]",PHCS,,9258.1,70,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VANSONNENBERG 25CM 12FR DRNG GLIDEX PERCUFLEX METAL",SUP-M001245130,CDM,C1729,HCPCS,0272,RC,,,both,,,729.00,218.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,495.72,68,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CORONARY 3.5MM 16MM .014IN OTW BALLOON EXPANDING",SUP-12745-16,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"CIGNA [10200]",Cigna,,6610.2,40,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR ROSCH INFERIOR MESENTRIC CURVE",SUP-10733401,CDM,C1887,HCPCS,0272,RC,,,both,,,108.75,32.62,"AETNA [10100]","Aetna HMO/PPO",,86.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.00MM X 15MM  SCOREFLEX  NC",SUP-640-154-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +18.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.185,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 60MM 3.5MM QUICK CONNECT NONSTERILE",SUP-03.133.109,CDM,S27200284,LOCAL,0272,RC,,,both,,,458.14,137.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,210.29,45.9,,,,,0,53.28,389.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM MINI-MONSTER SHORT THREAD CANNULATED",SUP-P20-540-038S,CDM,C1713,HCPCS,0278,RC,,,both,,,1876.88,563.06,"BLUE CROSS [10001]","Blue Cross PPO",,735.74,39.2,,957.42,570.23,957.42,28,218.28,1595.35,"percent of total billed charges",
"STEERABLE NEEDLES OSSEOFLEX SN STEERABLE NEEDLE (8G) (NEEDLE",SUP-OF-8241,CDM,S27200284,LOCAL,0272,RC,,,both,,,4560.90,1368.27,"CIGNA [10200]","Cigna Open Access",,2595.15,56.9,,,,,0,530.43,3876.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR MP9 NEUTRAL 40MM HXE+ HIP STERILE NONHOOD",SUP-931-40-756,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"MULTIPLAN [10600]",Multiplan,,5571.75,85,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X6MM AVS AS 4D 12MM PEEK CERVICAL INTERBODY",SUP-48322064,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 150MM 2.5MM BALLOON",SUP-H74939147251510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL 1-2.25MM ARTERY BLACK",SUP-B-3AB,CDM,S27200284,LOCAL,0272,RC,,,both,,,547.11,164.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,372.03,68,,,,,0,63.63,465.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RCRD CARDIAC 56.3X18.5X8MM CONFIRM 39MM SPACING ACTIVATED",SUP-DM2100,CDM,C1764,HCPCS,0278,RC,,,both,,,20128.50,6038.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2385.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X8MM CLYDESDALE PTC 0D PEEK TITANIUM",SUP-4980855,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8113.77,28.62,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25MMX10MM CRESCENT PEEK-OPTIMA VERTEBRAL BODY",SUP-9392510,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS [10001]","Blue Cross PPO",,6491.52,39.2,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 5 LEFT DISTAL KNEE",SUP-5541-A-501,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"CIGNA [10200]","Cigna Local Plus",,2552.48,53.5,,5372.07,4581.20,7242.98,23,554.87,4055.34,"percent of total billed charges",
"SCR BONE 2.4MM 8MM STAINLESS STEEL T8 SELF TAP LOCK VARIABLE",SUP-02.210.108TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1011.53,303.46,"CIGNA [10200]","Cigna Open Access",,575.56,56.9,,1144.80,304.56,2275.09,66,117.64,859.8,"percent of total billed charges",
"BIT DRILL 248MM 2.8MM QUICK COUPLING NONSTERILE",SUP-03.122.002,CDM,S27000186,LOCAL,0270,RC,,,both,,,1079.57,323.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,443.7,41.1,,,,,0,125.55,917.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000190,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X9MM 7D PEEK LUMBAR INTERBODY FUSION",SUP-21411-709,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3065.39,45.9,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER SHORT TIP RELOAD 30MM WHITE",SUP-ASR30WS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"NOVANET [10819]",Novanet,,1063.13,75,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 3001019 ZEVO 19MM 1 LVL",SUP-3001019,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"KAISER [10500]",Kaiser,,2814,67,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 80MM 9MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171090870,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,136.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEPHRSTMY PERCUTANEOUS ACCESS",SUP-M0064201100,CDM,C1726,HCPCS,0272,RC,,,both,,,1103.14,330.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,130.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",379.61,375.47,414.12,"1 through 10",128.3,937.67,"percent of total billed charges",
"CATH INQWIRE 150CM 3MM RADIUS J CURVE ANGIOGRAPHIC MOVABLE",SUP-6684-41,CDM,C1769,HCPCS,0272,RC,,,both,,,89.18,26.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,36.65,41.1,,,,,0,10.37,75.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM 1.1MM LATERAL WALL GORILLA BONE CALCANEUS LEFT",SUP-P53-102-L002,CDM,C1713,HCPCS,0278,RC,,,both,,,8254.13,2476.24,"CIGNA [10200]",Cigna,,5612.81,68,,1831.33,1831.33,1831.33,16,959.96,7016.01,"percent of total billed charges",
"TUBE SUCTION 4IN 10FR RHOTON STRAIGHT NEURO",SUP-58-6320,CDM,S27200284,LOCAL,0272,RC,,,both,,,439.91,131.97,"CIGNA [10200]","Cigna Local Plus",,235.35,53.5,,,,,0,51.16,373.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +2.5MM 32MM HIP C TAPER HIGH PERFORMANCE OFFSET",SUP-18-3225,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6800,68,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Device Cv W/Port < 5 Yrs",PX-361000497,CDM,36560,CPT,0361,RC,,,both,,,8548.00,2564.4,"NOVANET [10819]",Novanet,,6411,75,,,,,0,994.13,8239,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23X12X9MM COALESCE LORDOTIC STRAIGHT STERILE",SUP-2000-00-091208,CDM,C1889,HCPCS,0278,RC,,,both,,,21420.00,6426,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6130.4,28.62,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 130CM 60MM 5MM BALLOON DILATATION",SUP-LX351305605F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,797.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG THK1CM LARGE 15X10CM VERSATILE HIGHER TENSILE STRENGTH",SUP-M6275034/10,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.24,29.77,"CIGNA [10200]","Cigna Local Plus",,53.09,53.5,,,,,0,11.54,84.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MR DRILL BIT 7.5 X 1.5MM BALL FLTD",SUP-75BA15L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1441.80,432.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,661.79,45.9,,,,,0,167.68,1225.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE FEMORAL ANTHOLOGY +0 12/14 TAPER HIP TITANIUM MODULAR",SUP-71344247,CDM,C1776,HCPCS,0278,RC,,,both,,,1885.50,565.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,223.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,219.28,1602.68,"percent of total billed charges",
"GA-68-GOZETOTIDE INTRAVENOUS SOLUTION (2 MCI)",RX-411537,CDM,A9596,HCPCS,0343,RC,08888-8878-68,NDC,both,1,UN,24796.80,7439.04,"FIRST HEALTH [10303]","First Health",,19837.44,80,,,,,0,1181,21077.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL 6MM OFFSET LAMINA LEFT",SUP-7756074L,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,957.42,570.23,957.42,28,348.9,2550,"percent of total billed charges",
"HEAD FEMORAL STD 36MM HIP ENHANCED STABILITY PROVEN",SUP-6570-0-136,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"NOVANET [10819]",Novanet,,7500,75,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT HEMODIALYSIS SUPER HERO",SUP-SUPERHERO,CDM,C1750,HCPCS,0278,RC,,,both,,,27720.00,8316,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7933.46,28.62,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X22X7MM RISE-L 3D LORDOTIC NONSTERILE",SUP-193.604,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"MULTIPLAN [10600]",Multiplan,,29184.75,85,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 8-0 TG140-8 12IN 2 ARM BRAID COATED VIOLET",SUP-J548G,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.98,46.49,"PHCS [10601]",PHCS,,108.49,70,,,,,0,18.02,131.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM QUARTEX SPINE POLYAXIAL SHOULDER",SUP-1149.3728,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"BRA 52-53IN 3XL WIDE ADJUSTABLE SHOULDER STRAP HOOK LOOP",SUP-M5001-XXXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,183.57,55.07,"FIRST HEALTH [10303]","First Health",,146.86,80,,,,,0,21.35,156.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X8MM COROENT XL PEEK-OPTIMA LATERAL LUMBAR",SUP-6908850,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS [10001]","Blue Cross HMO",,9313.92,39.2,,8555.87,8555.87,8996.26,"1 through 10",2763.29,20196,"percent of total billed charges",
"LEAD ICD 64CM ENDOTAK RELIANCE ENDOCARDIAL STEROID SILICONE",SUP-148,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"NOVANET [10819]",Novanet,,11385,75,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG OTOPORE CYL FIRM BIORESORBABLE SOL WOUND EAR",SUP-5400020000,CDM,S27000186,LOCAL,0270,RC,,,both,,,759.38,227.81,"CIGNA [10200]",Cigna,,516.38,68,,,,,0,88.32,645.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SURGICAL CATARACT",SUP-SA60WF.245,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 3CM 10FR BILIARY 2 PIGTAIL GWIRE PUSHING CATH",SUP-ZSO-10-3,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"MULTIPLAN [10600]",Multiplan,,537.03,85,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 13MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532-P-113,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,990.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,971.79,7102.52,"percent of total billed charges",
"ESG PLASMALOOP - MEDIUM 30",SUP-WA22706S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3215.54,964.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,373.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,373.97,2733.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 15CM NATRELLE INSPIRA P4.9CM MODERATE PROFILE",SUP-SSZ-M600,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"PHCS [10601]",PHCS,,1043.28,70,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX PROGRIP 6X3.5IN HERNIA RECTANGULAR",SUP-TEM1509G,CDM,C1781,HCPCS,0278,RC,,,both,,,1781.25,534.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,817.59,45.9,,,,,0,207.16,1514.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 250CM 7.5FR BILIARY FLEXIMA TEFLON NASAL TUBE",SUP-M00540130,CDM,C2617,HCPCS,0272,RC,,,both,,,859.33,257.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,394.43,45.9,,,,,0,99.94,730.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ORTHOBLAST II CANCELLOUS DEMINERALIZED BONE",SUP-02-2110-050,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]",Cigna,,2550,68,,1831.33,1831.33,1831.33,16,436.13,3187.5,"percent of total billed charges",
"HC Tx Wnd Dehis Smpl",PX-510000043,CDM,12020,CPT,0761,RC,,,both,,,9320.00,2796,"UHC [10700]","United Healthcare",,5899.56,63.3,,,,,0,1083.92,7922,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis B Core Igm Ab",PX-302000145,CDM,86705,CPT,0302,RC,,,both,,,412.30,123.69,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,350.46,"per diem",
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR ANGLE COBRA 2",SUP-G08442,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"PHCS [10601]",PHCS,,166.24,70,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 THK14MM FIXED ULTRACONGRUENT PRIMARY GMK",SUP-02.07.0214FUC,CDM,C1776,HCPCS,0278,RC,,,both,,,4271.40,1281.42,"KAISER [10500]",Kaiser,,2861.84,67,,,,,0,496.76,3630.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9FR .118IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1009,CDM,C1894,HCPCS,0272,RC,,,both,,,298.32,89.5,"NOVANET [10819]",Novanet,,223.74,75,,,,,0,34.69,253.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 9.5-11.5MM 6 SHOOTER SAEED OPTI-VU 6 BAND NONSTERILE",SUP-G24654,CDM,S27200284,LOCAL,0272,RC,,,both,,,2107.50,632.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,249.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,245.1,1791.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 19GA 10.2CM SUPERCORE COAXIAL INTRO ECHOGENIC TIP",SUP-MCXS2015LY,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.64,44.89,"FIRST HEALTH [10303]","First Health",,119.71,80,,,,,0,17.4,127.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FELT CARDIOVASCULAR 1X1IN THK1.85MM PTFE LOW POROSITY",SUP-007021,CDM,C1768,HCPCS,0278,RC,,,both,,,188.79,56.64,"KAISER [10500]",Kaiser,,126.49,67,,,,,0,21.96,160.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 100CM 220MM 6MM BALLOON",SUP-LX1810062205F,CDM,C2623,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4962.83,41.1,,,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DSRCTOR 14MM CERVICAL PIN SCR CASPAR SURGICAL STERILE",SUP-R6398A,CDM,S27200284,LOCAL,0272,RC,,,both,,,515.73,154.72,"AETNA [10100]","Aetna HMO/PPO",,410.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.98,438.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FLEXIBLE 1.8MM STERILE LATEX FREE REUSABLE",SUP-AR-3610ND-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,978.08,293.42,"MULTIPLAN [10600]",Multiplan,,831.37,85,,,,,0,113.75,831.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP060200150 PLUS US D6L200UL1500",SUP-PCP060200150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"FIRST HEALTH [10303]","First Health",,984.96,80,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 34MM THORACIC 2 PASS SEWING WOVEN",SUP-M00202175134P0,CDM,L8670,HCPCS,0278,RC,,,both,,,3046.80,914.04,"BLUE CROSS [10001]","Blue Cross HMO",,1194.35,39.2,,,,,0,354.34,2589.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 50MM GORILLA R3CON LOCK",SUP-P50-353-4250,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",155.43,1136.03,"percent of total billed charges",
"PROBE CRYOABLATION L 17IN CRYOICE CRYOSPHERE MAX EXTENDED",SUP-CRYOSMAX-L,CDM,C9808,HCPCS,0272,RC,,,both,,,18270.00,5481,"MULTIPLAN [10600]",Multiplan,,15529.5,85,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Est Eval Visit Level 2",PX-510000177,CDM,99212,CPT,0761,RC,,,both,,,323.05,96.91,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.32,323.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL 13IN CANN 2 CONES",SUP-ER876,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.45,495.13,"CIGNA [10200]","Cigna Open Access",,939.11,56.9,,,,,0,191.95,1402.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 25.5IN 28FR FEMUR VEIN ADULT 3/8IN CNCT .038",SUP-96428,CDM,S27200284,LOCAL,0272,RC,,,both,,,1287.39,386.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,529.12,41.1,,,,,0,149.72,1094.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM ENDOCARDIUM 4 SITE 2 COIL PASSIVE FIXATION",SUP-0266,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]","Cigna Local Plus",,5409.18,31.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 100MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171081070,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AETNA [10100]","Aetna HMO/PPO",,933.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL 13IN CANN 2 CONES",SUP-ER876,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.45,495.13,"CIGNA [10200]","Cigna Local Plus",,882.99,53.5,,,,,0,191.95,1402.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EDWARDS EVOQUE TRICUSPID DELIVERY SYSTEM",SUP-9850TDS,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Antithrombin III Ag",PX-305000031,CDM,85301,CPT,0305,RC,,,both,,,516.75,155.02,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,439.24,"per diem",
"HC Tx Inhal Aero Sputum Rpeat",PX-410000005,CDM,94640,CPT,0410,RC,,,both,,,298.34,89.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,35.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",38.58,35.37,42.80,"1 through 10",34.7,298.34,"percent of total billed charges",
"SHELL ACETABULAR 56MM HIP RIGHT TITANIUM RESTORATION GAP II",SUP-2082-0056R,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,10981.53,8986.79,12413.38,12,2014.9,14726.25,"percent of total billed charges",
"DESMOPRESSIN 0.1 MG TABLET",RX-16052,CDM,,,0637,RC,60505-0257-01,NDC,both,1,UN,15.19,4.56,"FIRST HEALTH [10303]","First Health",,12.15,80,,,,,0,1.77,12.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 34MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.834,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"MULTIPLAN [10600]",Multiplan,,213.27,85,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) BRIOVAD BATTERY KIT",SUP-490025,CDM,Q0506,HCPCS,0624,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 8MM .021IN AZUR DETACHABLE .018IN",SUP-45-480815,CDM,S27800098,LOCAL,0278,RC,,,both,,,6037.50,1811.25,"CIGNA [10200]",Cigna,,4105.5,68,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 13.3MM 19MM 23MM 17.4MM ON-X 19 STD CYLINDRICAL",SUP-ONXAE-19,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10206,27,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SUPERORDERABLE",RX-408123315,CDM,J2270,HCPCS,0636,RC,70092-1519-48,NDC,both,30,ML,102.20,30.66,"CIGNA [10200]",Cigna,,24.45,,,,,,,7.62,86.87,"fee schedule",
"STEM HUMERAL 122MM 12MM COMPREHENSIVE PPS SHOULDER",SUP-12-113562,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"MULTIPLAN [10600]",Multiplan,,10710,85,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METOPROLOL TARTRATE 50 MG TABLET",RX-5009,CDM,,,0637,RC,65862-0063-01,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 46MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-46,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross PPO",,119.36,39.2,,957.42,570.23,957.42,28,35.41,258.83,"percent of total billed charges",
"SCREW 54840004550 MAS 4.5X50 CC",SUP-54840004550,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"NOVANET [10819]",Novanet,,7160.14,75,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR ACCEPTS .035IN GWIRE 7FR 20CM RADIOPAQUE",SUP-G00892,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX29MM 8FR 80CMCATH HEPARIN",SUP-BXB092901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]",Cigna,,7801.92,40,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP BIPOLAR GYRUS",SUP-WA22537D,CDM,S27200284,LOCAL,0272,RC,,,both,,,3215.53,964.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,381.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,373.97,2733.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ATLANTIS TITANIUM SPINAL CANCELLOUS",SUP-876-812,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G211,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"BLUE CROSS [10001]","Blue Cross HMO",,3671.5,39.2,,5311.50,4717.44,5388.59,31,1089.28,7961.17,"percent of total billed charges",
"BLADE SHAVER 8CM 2.9MM STERLING LARGE SPHERE SMALL JOINT",SUP-C9911A,CDM,S27200284,LOCAL,0272,RC,,,both,,,638.28,191.48,"FIRST HEALTH [10303]","First Health",,510.62,80,,,,,0,74.23,542.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 FS-1 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8684G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 4-0 P-12 3/8 CIRCLE 58CM CLSR SURGALLOY",SUP-VLOCM0033,CDM,S27200284,LOCAL,0272,RC,,,both,,,262.83,78.85,"MULTIPLAN [10600]",Multiplan,,223.41,85,,,,,0,30.57,223.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV",RX-156003,CDM,,,0250,RC,44567-0642-01,NDC,both,250,ML,476.59,142.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,55.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.43,405.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM CARPENTIER-EDWARDS PERIMOUNT MAGNA",SUP-3000TFX19MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13192.48,41.1,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE NAKAO SPIDER-NET STD 230CM 5.5X2.5CM SPECIMEN",SUP-00230A,CDM,S27000186,LOCAL,0270,RC,,,both,,,486.00,145.8,"KAISER [10500]",Kaiser,,325.62,67,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TWISTER WIRE 7.25IN BERRY DUROGRIP ROUND STERNUM TUNGSTEN",SUP-MD456R,CDM,S27000186,LOCAL,0270,RC,,,both,,,667.44,200.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,306.35,45.9,,,,,0,77.62,567.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 21MM 52MM SHOULDER SOFT TISSUE BALANCE",SUP-7122888,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"BLUE CROSS [10001]","Blue Cross HMO",,3104.64,39.2,,5311.50,4717.44,5388.59,31,921.1,6732,"percent of total billed charges",
"LINER ACETABULAR F 46MM COCR HIP MODULAR DUAL MOBILITY",SUP-626-00-46F,CDM,C1776,HCPCS,0278,RC,,,both,,,8517.60,2555.28,"UHC [10700]","United Healthcare",,5391.64,63.3,,8601.07,8395.67,8601.07,"1 through 10",990.6,7239.96,"percent of total billed charges",
"SCR BONE 5MM 60MM T2 TITANIUM FULL THREAD PROXIMAL FEMUR",SUP-1896-5060S,CDM,C1713,HCPCS,0278,RC,,,both,,,1297.80,389.34,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,150.93,1103.13,"percent of total billed charges",
"CATH MALECOT 35CM 24FR SUPRAPUBIC STENT LARGE OPEN NEPHRSTMY",SUP-M001224130,CDM,C1729,HCPCS,0272,RC,,,both,,,599.40,179.82,"UHC [10700]","United Healthcare",,379.42,63.3,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE 13",SUP-PCB0000210,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR SURGICAL",SUP-NF01,CDM,S27200284,LOCAL,0272,RC,,,both,,,168.62,50.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,114.66,68,,,,,0,19.61,143.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 300MM 3.5MM BALLOON DILATATION RAPID",SUP-47535300L,CDM,C1725,HCPCS,0272,RC,,,both,,,1890.00,567,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1285.2,68,,,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 3.5MM PRECUT",SUP-3603780,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS FLO50 SUBASSEMBLY",SUP-MAP900,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.79,28.14,"AETNA [10100]","Aetna HMO/PPO",,74.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.91,79.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 31.50CM 8MM SUTURECUT ENDOWRIST DA VINCI XI 38D",SUP-471296,CDM,S27000186,LOCAL,0270,RC,,,both,,,1446.12,433.84,"FIRST HEALTH [10303]","First Health",,1156.9,80,,,,,0,168.18,1229.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM PFC SIGMA 5 KNEE POSTERIOR TITANIUM CEMENT",SUP-960906,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,608,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC",251,MS-DRG,,,,,,,inpatient,,,118993.67,35698.1,"AETNA [10100]","Aetna HMO/PPO",,28119.02,,"Fee schedule rate ($28,119.02). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,9270.48,43633.42,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP OPHTHALMIC 25+ GA GRIESHABER MAXGRIP MICRO TEXTURE",SUP-705.13P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.84,388.75,"CIGNA [10200]",Cigna,,881.17,68,,,,,0,150.71,1101.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SUPERORDERABLE",RX-408123315,CDM,J2270,HCPCS,0636,RC,70092-1519-48,NDC,both,30,ML,102.20,30.66,"NOVANET [10819]",Novanet,,76.65,75,,,,,0,7.62,86.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC LOW PROFILE 55MM 5MM KII 2 PACK ACCESS",SUP-CTB23,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"CIGNA [10200]","Cigna Local Plus",,116.36,53.5,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SNARE AMPLATZ GOOSENECK 90D MICRO 175CM 2.3-3FR 2MM CATH",SUP-SK200,CDM,C1773,HCPCS,0272,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 6FR POWERPICC SHERLOCK 3 LUMEN MAXIMAL BARR",SUP-9386108D,CDM,C1752,HCPCS,0272,RC,,,both,,,1553.74,466.12,"CIGNA [10200]",Cigna,,1056.54,68,,,,,0,180.7,1320.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP MANIP LARGE CONTOUR TAPER POLYCARBONATE THIMBLE LIKE",SUP-LH-SCOLPO-LRG,CDM,S27200284,LOCAL,0272,RC,,,both,,,1352.70,405.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,157.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,157.32,1149.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 10CM MARIGEN FISH SKIN FENESTRATED 7CM STERILE",SUP-50200F03B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,27657.00,8297.1,"CIGNA [10200]",Cigna,,180.89,,,,,,,180.89,23508.45,"fee schedule",
"CEFAZOLIN 2 G VIAL IV PUSH (1 G VIAL)|DISCARDED DRUG NOT ADMINISTE",RX-408864,CDM,J0690,HCPCS,0636,RC,44567-0707-25,NDC,both,1,UN,14.95,4.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,JW,10.17,68,,,,,0,1.41,12.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 20CM 3CM 7FR .035IN PIGTAIL",SUP-M006180230190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 26CM 8FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251530,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"MULTIPLAN [10600]",Multiplan,,1046.32,85,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1MM 3-0 MINI JUGGERKNOT SOFT TISSUE 1 LOAD NDL",SUP-912082,CDM,C1713,HCPCS,0278,RC,,,both,,,2835.00,850.5,"MULTIPLAN [10600]",Multiplan,,2409.75,85,,,,,0,329.71,2409.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 75CM 7MM 20MM",SUP-38046-72075,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 0MM 12/14 STRAIGHT 28MM HIP ZIMALOY LEGACY VERS",SUP-00801802802,CDM,C1776,HCPCS,0278,RC,,,both,,,3322.20,996.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,393.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,386.37,2823.87,"percent of total billed charges",
"IMPL BREAST 600ML GEL SMOOTH MEMORYGEL SILICONE P5.6CM HIGH","SUP-3506004 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross HMO",,1481.76,39.2,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC",715,MS-DRG,,,,,,,inpatient,,,132254.08,39676.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,35670.91,,,,,,,7561,65320.21,"case rate",
"CATH VASCUTRAK 140CM 100MM 7FR 7MM .018IN SHORT BALLOON",SUP-V1870100,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,650.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY CHORDAL GUIDE DURAN ANCORE",SUP-620RG25,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"AETNA [10100]","Aetna HMO/PPO",,10422.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT WALKING GENESIS LARGE 3 STRAP ULTRA LIGHTWEIGHT LOW",SUP-BL515007,CDM,S27000186,LOCAL,0270,RC,,,both,,,434.91,130.47,"NOVANET [10819]",Novanet,,326.18,75,,,,,0,50.58,369.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE EMBOLIZATION YELLOW EMBOZENE 250UM MICRO SYR 2ML",SUP-01-0301-02502-11,CDM,S27800098,LOCAL,0278,RC,,,both,,,1620.00,486,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,743.58,45.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 15MM",SUP-SPL22515X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER 10MM CANNULATED ORTHOPEDIC TITANIUM",SUP-AR-8945W,CDM,C1713,HCPCS,0278,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC LARGE 1 PIECE AUTOSTOP BUCKLE 2 PRONG",SUP-563499,CDM,S27000186,LOCAL,0270,RC,,,both,,,668.90,200.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,79.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.79,568.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET GRAFT HARVEST 7MM FASTGRAFTER DISPOSABLE STERILE",SUP-SK27,CDM,S27200284,LOCAL,0272,RC,,,both,,,6865.50,2059.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,813.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,798.46,5835.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACC INTRDCR STD 11 FR LONG 7131",SUP-667131-300,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 5CM 8.5FR BILIARY FLEXIMA PLASTIC TEMPORARY DELIVERY",SUP-M00539250,CDM,C2625,HCPCS,0278,RC,,,both,,,755.24,226.57,"NOVANET [10819]",Novanet,,566.43,75,,,,,0,87.83,641.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC",828,MS-DRG,,,,,,,inpatient,,,97237.62,29171.29,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,22722.83,,"Case rate ($10,568.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,813.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,853.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,123.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,826.80. The transfer operating threshold is the transfer adjustment factor * $9,813.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $741.97. The transfer capital threshold is the transfer adjustment factor * $741.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,49744.14,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (7.5-8 MCI)",RX-411884,CDM,A9520,HCPCS,0343,RC,08888-8876-18,NDC,both,1,UN,4614.97,1384.49,"NOVANET [10819]",Novanet,,3461.23,75,,,,,0,536.72,4614.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT XEMPLIFI DEMINERALIZE BONE MATRIX GEL 5ML",SUP-8103.0105S,CDM,C1713,HCPCS,0278,RC,,,both,,,5692.50,1707.75,"FIRST HEALTH [10303]","First Health",,4554,80,,,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE 5 % TOPICAL PATCH",RX-28203,CDM,,,0250,RC,00591-3525-11,NDC,both,1,UN,80.00,24,"CIGNA [10200]",Cigna,,54.4,68,,,,,0,9.3,68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER FLEXIVA TRAC TIP 200UM FLEXSHIELD HOLMIUM",SUP-M0068403960,CDM,S27200284,LOCAL,0272,RC,,,both,,,3351.98,1005.59,"CIGNA [10200]",Cigna,,2279.35,68,,,,,0,389.84,2849.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 STD 17MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS6S17L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4769.65,45.9,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM DYNATRAN REFLEX HYBRID TITANIUM ANGLE FIX",SUP-48674014,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRODE DEFIBRILLATOR ONESTEP CODE-READY PEDIATRIC RESUSCI",SUP-8900-0215-40,CDM,S27000186,LOCAL,0270,RC,,,both,,,494.21,148.26,"NOVANET [10819]",Novanet,,370.66,75,,,,,0,57.48,420.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTERIAL 12IN 20FR 3/8IN EOPA BLUNT TIP INTRO NONVENT",SUP-77520,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,53.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.1,380.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SCLEROTHERAPY 25GA 1.8MM EXT CATH HEMOSTASIS DISPOSABLE",SUP-M00518111,CDM,S27200284,LOCAL,0272,RC,,,both,,,262.77,78.83,"CIGNA [10200]",Cigna,,178.68,68,,,,,0,30.56,223.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.0MM TI CORTEX SCRW SLF-TPNG WITH STARDRIVE RECESS 10MM",SUP-401.360.97,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,3978.14,359.25,3978.14,24,50.59,369.75,"percent of total billed charges",
"ROD SPINAL 95MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355095,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"CAP BIPOLAR HIP Z1 STEM METAL HEAD INSERT",SUP-98000100277,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"KAISER [10500]",Kaiser,,6934.5,67,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEOSTIGMINE METHYLSULFATE 5 MG/5 ML (1 MG/ML) INTRAVENOUS SYRINGE",RX-122897,CDM,J2710,HCPCS,0636,RC,69374-0902-05,NDC,both,5,ML,128.95,38.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.2,,,,,,,1.2,109.61,"fee schedule",
"COIL EMBOLIZATION 15CM 8MM .021IN AZUR DETACHABLE .018IN",SUP-45-480815,CDM,S27800098,LOCAL,0278,RC,,,both,,,6037.50,1811.25,"NOVANET [10819]",Novanet,,4528.13,75,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 15MM STAINLESS STEEL T6 CORTEX SELF TAP SELF",SUP-201.365.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"NOVANET [10819]",Novanet,,310.59,75,,,,,0,48.16,352,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM .02IN 2MM PENUMBRA COIL 400 RUBY",SUP-RBY4C0201,CDM,S27800098,LOCAL,0278,RC,,,both,,,4158.00,1247.4,"PHCS [10601]",PHCS,,2910.6,70,,,,,0,483.58,3534.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 14MM 4MM STAINLESS STEEL 1.1MM SHORT THREAD",SUP-02.226.014,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"BLUE CROSS [10001]","Blue Cross HMO",,644.92,39.2,,957.42,156.86,7483.26,51,191.34,1398.42,"percent of total billed charges",
"COIL EMBOLIZATION 14CM 20MM RETRACTA DETACHABLE .035IN",SUP-G34204,CDM,S27800098,LOCAL,0278,RC,,,both,,,4674.68,1402.4,"BLUE CROSS [10001]","Blue Cross PPO",,1832.47,39.2,,,,,0,543.67,3973.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (CR) - SIZE 8",SUP-5555-2208,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"MULTIPLAN [10600]",Multiplan,,1204.88,85,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 40MM",SUP-497-40-000,CDM,C1776,HCPCS,0278,RC,,,both,,,7869.52,2360.86,"CIGNA [10200]",Cigna,,5351.27,68,,5873.17,5873.17,5873.17,"1 through 10",915.23,6689.09,"percent of total billed charges",
"DEVICE PRESET 30MM 48MM 6MM THROMBECTOMY CLOSED RING HELICAL",SUP-PRE-6-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,34650.00,10395,"NOVANET [10819]",Novanet,,25987.5,75,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cor Arty Angio Si",PX-481000022,CDM,93454,CPT,0481,RC,,,both,,,9725.16,2917.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6002,,"Case rate ($6,002). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1131.04,9725.16,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 13MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-413,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"CIGNA [10200]",Cigna,,6684.75,68,,5873.17,5873.17,5873.17,"1 through 10",1143.29,8355.94,"percent of total billed charges",
"TRAY EPIDURAL 17GA 19GA 3.5IN 1.25IN 5ML SPRINGWOUND CLOSED",SUP-332079,CDM,S27200284,LOCAL,0272,RC,,,both,,,204.97,61.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,24.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.84,174.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 5MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650405,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"KAISER [10500]",Kaiser,,8795.26,67,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 30MM 2-3MM AVANCE NERVE ALLOGRAFT MULTIPLE",SUP-211230,CDM,C1762,HCPCS,0278,RC,,,both,,,29288.70,8786.61,"CIGNA [10200]","Cigna Local Plus",,9225.94,31.5,,,,,0,3406.28,24895.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO SD 90D UP STRAIGHT 1.8MM 3.8MM SHOULDER",SUP-AR-4068-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,1190.70,357.21,"FIRST HEALTH [10303]","First Health",,952.56,80,,,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 8MM GORE-TEX THIN WALL PTFE THIN WALLED",SUP-SRRT08030040L,CDM,C1768,HCPCS,0278,RC,,,both,,,6244.50,1873.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,739.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,726.24,5307.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT ALEXIS 360 DEGREE PROTECTION ULTIMATE VERSATILITY",SUP-HR004,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,209.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SURGICAL EP LAB STERILE DISPOSABLE LATEX FREE",SUP-DYNJ43533B,CDM,S27000186,LOCAL,0270,RC,,,both,,,597.64,179.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,406.4,68,,,,,0,69.51,507.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035476200,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]","Cigna Local Plus",,4446.11,31.5,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL EPIDURAL 22GA 3.5IN TUOHY PLASTIC HUB",SUP-183107,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.64,19.99,"NOVANET [10819]",Novanet,,49.98,75,,,,,0,7.75,56.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 RB-1 36IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8557,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.06,68.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,155.76,68,,,,,0,26.64,194.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC",379,MS-DRG,,,,,,,inpatient,,,23864.19,7159.26,"BLUE CROSS [10001]","Blue Cross PPO",,15562.72,,,,,,,3910.41,15721.55,"case rate",
"COIL EMBOLIZATION 1CM 1.5MM TARGET NANO HELICAL DETACHABLE",SUP-M0035431510,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3763.81,41.1,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE 40MM 57CM 10-8MM TAPER VASCULAR NITINOL",SUP-SR-100840-TCS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORD ELECTROSURGICAL MONOPOLAR ACTIVE BOVIE STERILE REUSABLE",SUP-C650-129A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1273.89,382.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,150.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,148.15,1082.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 16MM 144CM 2.75MM CORONARY STENT",SUP-H7493952816270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY PRO 69CM 7FR 130D GUIDING INNER STERILE LATEX",SUP-8102,CDM,C1887,HCPCS,0272,RC,,,both,,,1386.50,415.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,164.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.25,1178.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM LCP TITANIUM CORTICAL RADIAL SELF",SUP-402.872,CDM,C1713,HCPCS,0278,RC,,,both,,,358.70,107.61,"FIRST HEALTH [10303]","First Health",,286.96,80,,,,,0,41.72,304.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25X10X7MM VERTE-STACK CRESCENT 6D",SUP-9192507,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS [10001]","Blue Cross PPO",,6491.52,39.2,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X40 80CM SL",SUP-48003004N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"MULTIPLAN [10600]",Multiplan,,730.16,85,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronchodil Responsiveness",PX-460000002,CDM,94060,CPT,0460,RC,,,both,,,977.84,293.35,"NOVANET [10819]",Novanet,,733.38,75,,,,,0,113.72,831.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN FULL LENGTH WILLIAMS RIGHT CURVE",SUP-H74908641501,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.56,22.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.9,65.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZIPWIRE UROLOGICAL 150CM 3CM .035IN NITINOL",SUP-M006630205B1,CDM,S27200284,LOCAL,0272,RC,,,both,,,311.88,93.56,"PHCS [10601]",PHCS,,218.32,70,,,,,0,36.27,265.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 38MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.538,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 30CM 16FR TUNGSTEN SILICONE 2CM MIC-KEY",SUP-0270-16-2.0-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"FIRST HEALTH [10303]","First Health",,2106.24,80,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL GOLD 70MM 3.5MM SYNAPSE CURVE TITANIUM PREBENT",SUP-04.614.770,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 30MM 190CM 3MM",SUP-R51003003L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1340.79,68,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 19MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P319,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"NOVANET [10819]",Novanet,,6266.93,75,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIB 64CM 7.3FR RELIANCE 4-FRONT RIGHT VENTRICLE MP35N",SUP-673,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4098.6,27,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 10CM 7MM BALLOON",SUP-G52275,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UHC [10700]","United Healthcare",,607.53,63.3,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELAN 4 2-RING DISP OVAL BURR D4.0",SUP-GP382SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,1289.12,386.74,"UHC [10700]","United Healthcare",,816.01,63.3,,,,,0,149.92,1095.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM DRAINAGE LIMITORR 20 ML CSF CLOSED VOLUME LIMIT VALVE",SUP-INS9020,CDM,S27200284,LOCAL,0272,RC,,,both,,,2625.00,787.5,"MULTIPLAN [10600]",Multiplan,,2231.25,85,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 20MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171030270,CDM,C1726,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X21MM ENDOSKELETON TAS 12D 12MM STD TITANIUM",SUP-2312-0112,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8113.77,28.62,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE CONFLOW G 40GM",SUP-110043026,CDM,C1713,HCPCS,0278,RC,,,both,,,1872.08,561.62,"KAISER [10500]",Kaiser,,1254.29,67,,,,,0,217.72,1591.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30X24X17MM CHESAPEAKE 15D LORDOTIC",SUP-2013-21730L15,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"UHC [10700]","United Healthcare",,21696.45,63.3,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 14CM 26MM 14.5MM GORE EXCLUDER C3 TRUNK",SUP-RLT261414,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25769.7,41.1,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 115MM STAINLESS STEEL 3.5MM SCR 8 HOLE PRECONTOUR",SUP-02.112.085,CDM,C1713,HCPCS,0278,RC,,,both,,,5857.82,1757.35,"KAISER [10500]",Kaiser,,3924.74,67,,,,,0,681.26,4979.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR STD CEMENT 3 PEG ROTATE PLATFORM MOBILE",SUP-129409640,CDM,C1776,HCPCS,0278,RC,,,both,,,11978.40,3593.52,"CIGNA [10200]","Cigna Open Access",,4012.76,33.5,,5302.19,4377.88,6578.61,27,1393.09,10181.64,"percent of total billed charges",
"SMOOTH PEG LOCKING 3.5MM X 22MM TI",SUP-SPL-35220-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lipoprotein Hdl",PX-301000305,CDM,83718,CPT,0301,RC,,,both,,,150.55,45.16,"MULTIPLAN [10600]",Multiplan,,127.97,85,,,,,0,0.01,127.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 2.5MM 55MM AXSOS STAINLESS STEEL CORTICAL",SUP-338655,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"BLUE CROSS [10001]","Blue Cross PPO",,90.24,39.2,,957.42,570.23,957.42,28,26.77,195.67,"percent of total billed charges",
"LEVOCARNITINE 330 MG TABLET",RX-20952,CDM,,,0637,RC,54482-0144-07,NDC,both,1,UN,7.77,2.33,"KAISER [10500]",Kaiser,,5.21,67,,,,,0,0.9,6.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPROXIMATOR SURGICAL 16CM 2.5MM QUICKPASS TENDON SHUTTLE",SUP-AR-8090S,CDM,S27200284,LOCAL,0272,RC,,,both,,,722.93,216.88,"FIRST HEALTH [10303]","First Health",,578.34,80,,,,,0,84.08,614.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASE TIB STEM #1 RIGHT PEGLESS",SUP-2586-0-0001,CDM,C1776,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2850.39,45.9,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 9MM 29MM ASYMMETRIC TRIATHLON X3 KNEE STERILE",SUP-5551-G-299-E,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"KAISER [10500]",Kaiser,,3790.86,67,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HURRICANE 180CM 2CM 5.8FR 10MM 8 ATM BALLOON DILATATION",SUP-M00545950,CDM,C1726,HCPCS,0272,RC,,,both,,,1849.50,554.85,"KAISER [10500]",Kaiser,,1239.17,67,,,,,0,215.1,1572.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL HIGH TIBIAL OSTEOTOMY TITANIUM SCR",SUP-AR-13319,CDM,S27200284,LOCAL,0272,RC,,,both,,,612.36,183.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,71.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,71.22,520.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135D 48MM MINI TAPER HIGH OFFSET 43.2MM 150MM",SUP-L20312,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1841.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1841.86,13461.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16016550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"SCR BONE 8.5MM 45MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75448545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 29CM 16FR ATALA-SHEPARD COAXIAL BALLOON SET",SUP-G17273,CDM,C1726,HCPCS,0272,RC,,,both,,,798.90,239.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,328.35,41.1,,,,,0,92.91,679.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE WEB 1.5",SUP-PRT-WEB-015,CDM,C1713,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,850.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",834.57,6099.6,"percent of total billed charges",
"SCR BONE 4MM 36MM TITANIUM FULL THREAD CANNULATED",SUP-04.355.436,CDM,C1713,HCPCS,0278,RC,,,both,,,1848.23,554.47,"CIGNA [10200]","Cigna Local Plus",,988.8,53.5,,3978.14,359.25,3978.14,24,214.95,1571,"percent of total billed charges",
"CATH HALO XP 110CM 7FR 2-8-2MM SPACE TRICUSPID CURVE",SUP-D7T20282RT,CDM,C1731,HCPCS,0272,RC,,,both,,,7086.30,2125.89,"UHC [10700]","United Healthcare",,4485.63,63.3,,,,,0,824.14,6023.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 54MM STAINLESS STEEL 2MM SCR MINI FRAGMENT 7 HOLE LOW",SUP-247.349,CDM,C1713,HCPCS,0278,RC,,,both,,,4157.66,1247.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,483.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",483.54,3534.01,"percent of total billed charges",
"PIN FIXATION 150MM 3.2MM FLUTE CAS STERILE",SUP-20800000010,CDM,S27200284,LOCAL,0272,RC,,,both,,,963.90,289.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,114.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 55MM NAIL-EX TITANIUM FULL THREAD TIBIA 2 CORE",SUP-04.015.545,CDM,C1713,HCPCS,0278,RC,,,both,,,1313.17,393.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,152.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",152.72,1116.19,"percent of total billed charges",
"HC Perq Trancath Clsr Mitral Initial",PX-481000113,CDM,93590,CPT,0481,RC,,,both,,,29534.00,8860.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3499.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3434.8,25103.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM LOW PROFILE SCREWS STAINLESS STEEL FULL",SUP-AR-8827L-16,CDM,C1713,HCPCS,0278,RC,,,both,,,931.50,279.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,633.42,68,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 22B LARGE HIP PROXIMAL",SUP-521425,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4996.1,45.9,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 54MM 22MM CONSTRAINED",SUP-2099-2254,CDM,C1776,HCPCS,0278,RC,,,both,,,16939.50,5081.85,"CIGNA [10200]",Cigna,,6775.8,40,,5873.17,5873.17,5873.17,"1 through 10",1970.06,14398.58,"percent of total billed charges",
"SCR BONE 2.4MM 16MM LCP STAINLESS STEEL DISTAL RADIUS T8",SUP-212.816,CDM,C1713,HCPCS,0278,RC,,,both,,,802.87,240.86,"KAISER [10500]",Kaiser,,537.92,67,,,,,0,93.37,682.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 5.00 X 32MM",SUP-H7493942832500,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,722.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 8MM STAINLESS STEEL T8 SELF TAP LOCK VARIABLE",SUP-02.210.108TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1011.53,303.46,"MULTIPLAN [10600]",Multiplan,,859.8,85,,,,,0,117.64,859.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.7MM 75MM 18MM LOW PROFILE SCREWS TITANIUM 3.5MM",SUP-AR-8967-1875,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,860.63,45.9,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SURGICAL OSTEOPREP 2 PIN GRAFT PASS DRILL TIP STERILE",SUP-C8623,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERSACROSS SHEATH 63CM 55DEG D0",SUP-VXS0203,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FG GATEWAY OTW  US 3.00MM X 9MM",SUP-M0032072209300,CDM,C1725,HCPCS,0272,RC,,,both,,,9423.88,2827.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FILLER BONE VOID 90ML .1-4MM CANCELLOUS ALLOGRAFT FREEZE",SUP-400090,CDM,C1713,HCPCS,0278,RC,,,both,,,10246.50,3073.95,"NOVANET [10819]",Novanet,,7684.88,75,,,,,0,1191.67,8709.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 35CM 5.7FR ATRIUM VENTRICLE TRANSVENOUS BIPOLAR",SUP-407635,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1024.72,45.9,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 5.5MM 5.5MM EXPEDIUM SPINE TITANIUM END TO END",SUP-179777555,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross HMO",,1396.5,39.2,,957.42,156.86,7483.26,51,414.32,3028.13,"percent of total billed charges",
"HC Coxsackie Abs",PX-302000119,CDM,86658,CPT,0302,RC,,,both,,,306.80,92.04,"MULTIPLAN [10600]",Multiplan,,260.78,85,,,,,0,0.01,260.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE OLCOTT TORQUE STERILE DISPOSABLE ACCEPTS .014-.045IN",SUP-G17802,CDM,S27200284,LOCAL,0272,RC,,,both,,,105.27,31.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.24,89.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNAP(R) DRESSING KIT WITH FOAM -10 KIT CASE",SUP-SKTF15X15,CDM,S27200284,LOCAL,0272,RC,,,both,,,410.64,123.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,279.24,68,,,,,0,47.76,349.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.75/40",SUP-404674,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 17CM 31MM 14.5MM EXCLUDER C3 TRUNK",SUP-RLT311417,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS [10001]","Blue Cross HMO",,24578.4,39.2,,9776.84,9776.84,9776.84,"1 through 10",7292.01,53295,"percent of total billed charges",
"STENT EPIC 20MM 109CM 10MM 75CM VASCULAR NITINOL ILIAC",SUP-H74939200102070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO ENDOSCOPIC 10FR 6FR 205CM RADIOPAQUE GWIRE OASIS",SUP-G21739,CDM,C1876,HCPCS,0278,RC,,,both,,,737.10,221.13,"FIRST HEALTH [10303]","First Health",,589.68,80,,,,,0,85.72,626.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM WATCHMAN TRUSTEER 2 CURVE 17FR 12FR ACCESS PEBAX PTFE",SUP-M635TU90050,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"MULTIPLAN [10600]",Multiplan,,8797.5,85,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 CURVE PLUS 15MM KNEE XLK FIX BEARING SIGMA",SUP-970453,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"KAISER [10500]",Kaiser,,7486.95,67,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM 14.8MM MASTER-SERIES PYROLYTIC CARBON",SUP-19AGN-751,CDM,S27800098,LOCAL,0278,RC,,,both,,,31229.42,9368.83,"MULTIPLAN [10600]",Multiplan,,26545.01,85,,,,,0,3631.98,26545.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 0 18IN BRAID TIE 6 STRAND PRECUT BLACK",SUP-A186H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 120MM 4MM BALLOON DILATATION RAPID",SUP-47540120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1085.08,68,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X40 40CM SL",SUP-48006004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"NOVANET [10819]",Novanet,,736.6,75,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +13 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.130,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENICILLIN G DESENSITIZATION (10 MG/ML)",RX-410812,CDM,,,0636,RC,09999-9997-07,NDC,both,250,ML,100.65,30.19,"CIGNA [10200]","Cigna Local Plus",,53.85,53.5,,,,,0,11.93,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Outr/Acth Stimulation Test",PX-300000023,CDM,80400,CPT,0301,RC,,,both,,,637.45,191.23,"CIGNA [10200]","Cigna Local Plus",,71.76,,,,,,,0.01,541.83,"fee schedule",
"NDL BIOPSY 19GA 17.8CM TRUGUIDE COAXIAL DISPOSABLE",SUP-C2020A,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.96,27.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.69,78.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESTRICT CEMENT 24MM FEMORAL HIP",SUP-EBO0101,CDM,S27800098,LOCAL,0278,RC,,,both,,,1150.20,345.06,"NOVANET [10819]",Novanet,,862.65,75,,,,,0,133.77,977.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 80MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PHCS [10601]",PHCS,,1116.99,70,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA SMOOTH SHELL SURFACE SOFT TOUCH",SUP-SSF-520,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",878.7,6422.18,"percent of total billed charges",
"VALVE AORTIC 23MM CARPENTIER-EDWARDS PERIMOUNT MAGNA",SUP-3000TFX23MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13192.48,41.1,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT WALLFLEX 60CM 135CM 25-30",SUP-6507,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL BIT SCR BIO-TENODESIS 4MM",SUP-AR-1204D,CDM,C1713,HCPCS,0278,RC,,,both,,,978.08,293.42,"BLUE CROSS [10001]","Blue Cross HMO",,383.41,39.2,,957.42,156.86,7483.26,51,113.75,831.37,"percent of total billed charges",
"CMPNT FEMORAL 4 NARROW KNEE LEFT CEMENTED CRUCIATE RETAINING",SUP-150400124,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"CIGNA [10200]","Cigna Local Plus",,7053.91,31.5,,5372.07,4581.20,7242.98,23,2604.35,19034.35,"percent of total billed charges",
"SYSTEM XIENCE SIERRA 8MM 2.5MM CORONARY STENT EVEROLIMUS",SUP-1550250-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .018IN 4FR 5MM 135CM 4CM PTA LOW",SUP-G50237,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS DS 7FR 8MM XR CURVE ABLATION FLUTTER",SUP-D135901,CDM,C1733,HCPCS,0272,RC,,,both,,,5906.40,1771.92,"UHC [10700]","United Healthcare",,3738.75,63.3,,,,,0,686.91,5020.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Sld Level IV / Add on 88305",PX-312000090,CDM,0753T,CPT,0312,RC,,,both,,,100.00,30,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,41.1,41.1,,,,,0,11.85,85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Cardiopleg Retrograde 14",PX-E27200358,CDM,E27200358,LOCAL,0272,RC,,,both,,,437.80,131.34,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,200.95,45.9,,,,,0,50.92,372.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND MULTIPASS 3-0 FSL 30IN BRAID BLACK",SUP-675H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 245741FZ ASR 7X14X11 FZ SRVCFEE",SUP-245741FZ,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 28MM 7MM FULL THREAD STEP",SUP-AR-1370TC,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"CIGNA [10200]","Cigna Local Plus",,990.09,53.5,,3978.14,359.25,3978.14,24,215.23,1573.04,"percent of total billed charges",
"BIT DRILL 135MM 2.6MM SCALE AO",SUP-703691,CDM,S27200284,LOCAL,0272,RC,,,both,,,1068.23,320.47,"MULTIPLAN [10600]",Multiplan,,908,85,,,,,0,124.24,908,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE INFUSE RGBMP LARGE KIT CERVICAL SPINE LUMBAR",SUP-7510800,CDM,,,0278,RC,,,both,,,44761.50,13428.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17904.6,40,,,,,0,44.76,38047.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS MBA LARGE BORE",SUP-MAP400,CDM,S27200284,LOCAL,0272,RC,,,both,,,185.40,55.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,85.1,45.9,,,,,0,21.56,157.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPLANT 9.5-9.1CM MEMORYGEL P3-3.4CM MODERATE PROFILE",SUP-351-125SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX18MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183668,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1562.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1533.84,11210.36,"percent of total billed charges",
"CATH CXI 135CM 2.6FR SPRT ACCEPTS .018IN GWIRE",SUP-G23161,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM .02IN 3MM RUBY COMPLEX LARGE VOLUME",SUP-RBY4C0305,CDM,S27800098,LOCAL,0278,RC,,,both,,,4158.00,1247.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1908.52,45.9,,,,,0,483.58,3534.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RABINOV 30CM 27GA .016IN SIALOGRAPHY SUBMANDIBULAR DUCT",SUP-G01346,CDM,S27200284,LOCAL,0272,RC,,,both,,,347.91,104.37,"FIRST HEALTH [10303]","First Health",,278.33,80,,,,,0,40.46,295.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 7.5MM CANNULATED SURGICAL",SUP-6134.0075,CDM,C1713,HCPCS,0278,RC,,,both,,,583.20,174.96,"MULTIPLAN [10600]",Multiplan,,495.72,85,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 118MM CEMENTLESS NECK ACCOLADE TMZF 127D 2.5 40",SUP-6021-2530,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"CIGNA [10200]","Cigna Open Access",,7645.29,33.5,,5302.19,4377.88,6578.61,27,2654.17,19398.49,"percent of total billed charges",
"SUT MONOCRYL PLUS 4-0 PS-2 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP426H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.17,19.85,"KAISER [10500]",Kaiser,,44.33,67,,,,,0,7.7,56.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X12X6MM ENDOSKELETON TC 6D LORDOTIC SMALL",SUP-5146-1206-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross PPO",,4057.2,39.2,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 130MM 9MM REVERSE FRACTURE AEQUALIS SHOULDER",SUP-DWD902,CDM,C1776,HCPCS,0278,RC,,,both,,,16560.00,4968,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6624,40,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EDWARDS EVOQUE TRICUSPID DELIVERY SYSTEM",SUP-9850TDS,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 4CM 4FR PIGTAIL PANCREATIC POLYMER RADIOPAQUE",SUP-M00536880,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,434.69,68,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175270180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,169.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 135CM 2CM 5FR 6MM 7.5MM BALLOON DILATATION",SUP-4196020X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 56MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.556,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"CIGNA [10200]",Cigna,,745.57,68,,1831.33,1831.33,1831.33,16,127.51,931.96,"percent of total billed charges",
"CATH STERLING 200CM 60MM 5MM BALLOON DILATATION STERILE",SUP-H74939031506020,CDM,C1725,HCPCS,0272,RC,,,both,,,3740.00,1122,"NOVANET [10819]",Novanet,,2805,75,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN LEFT CORONARY BYPASS CURVE",SUP-DXT5LCB,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"CIGNA [10200]","Cigna Open Access",,39.6,56.9,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT ORTHOPEDIC 80MM FEMORAL NECK SYSTEM STERILE",SUP-04.168.280S,CDM,C1713,HCPCS,0278,RC,,,both,,,2435.70,730.71,"MULTIPLAN [10600]",Multiplan,,2070.35,85,,,,,0,283.27,2070.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.116,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,131.73,962.8,"percent of total billed charges",
"COIL EMBOLIZATION 30CM 11MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS11030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UHC [10700]","United Healthcare",,7420.72,63.3,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 7MM X 15CM",SUP-M0035477150,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"AETNA [10100]","Aetna HMO/PPO",,11221.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 65CM 5FR ROSCH INFERIOR MESENTRIC CURVE",SUP-H787117333015,CDM,C1887,HCPCS,0272,RC,,,both,,,526.50,157.95,"UHC [10700]","United Healthcare",,333.27,63.3,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP CLUSTER HOLE 12 SCALLOP SNAP FIT",SUP-00875704801,CDM,C1776,HCPCS,0278,RC,,,both,,,11012.40,3303.72,"NOVANET [10819]",Novanet,,8259.3,75,,,,,0,1280.74,9360.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS MONOPOLAR CURVED ENDOWRIST SP NONSTERILE REUSABLE 6",SUP-430100,CDM,S27000186,LOCAL,0270,RC,,,both,,,2772.00,831.6,"UHC [10700]","United Healthcare",,1754.68,63.3,,,,,0,322.38,2356.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PLASTIBELL 1.1CM CIRCUMCISION PLASTIC PEDIATRIC",SUP-HL9211,CDM,S27200284,LOCAL,0272,RC,,,both,,,51.82,15.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.03,44.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE SP 33M",SUP-TENDV-SP-33M-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"MULTIPLAN [10600]",Multiplan,,145350,85,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 12MM LCP STAINLESS STEEL DISTAL CORTICAL",SUP-201.762,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,170.52,39.2,,957.42,156.86,7483.26,51,50.59,369.75,"percent of total billed charges",
"PLATE 69MM 3 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-43F69V,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MIDFACE BURR HOLE 1.5MM SCREWS BONE TITANIUM 18.5MM",SUP-017308,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.70,405.81,"CIGNA [10200]",Cigna,,919.84,68,,1831.33,1831.33,1831.33,16,157.32,1149.8,"percent of total billed charges",
"BLADE SHAVER PELLO 60D 4MM",SUP-6290-112-040-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,2137.50,641.25,"PHCS [10601]",PHCS,,1496.25,70,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 48CM 15FR 1.9ML PALINDROME REVERSE TUNNEL HUB SNAP",SUP-8888541028P,CDM,C1750,HCPCS,0278,RC,,,both,,,2669.19,800.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,316.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,310.43,2268.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 3.5MM VERTEX PRECUT",SUP-7753740,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]","Cigna Open Access",,802.29,56.9,,1144.80,304.56,2275.09,66,163.98,1198.5,"percent of total billed charges",
"PROBE LITHO ELEC HYDRLC 3FRX120CM STRL DISP",SUP-E-3F,CDM,S27200284,LOCAL,0272,RC,,,both,,,1941.55,582.46,"AETNA [10100]","Aetna HMO/PPO",,1543.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,225.8,1650.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Cath Bowel Drainable",PX-E27000119,CDM,E27000119,LOCAL,0270,RC,,,both,,,215.60,64.68,"UHC [10700]","United Healthcare",,136.47,63.3,,,,,0,25.07,183.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 40MM 5MM BALLOON",SUP-U3513054,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 4.75MM PERCUTANEOUS CCM",SUP-641000065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"STENT VISI-PRO 57MM 80CM 7MM 60MM BILIARY STAINLESS STEEL",SUP-PXB35-07-57-080,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2969.56,68,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOFT TISSUE PROCEDURES WITH CC",501,MS-DRG,,,,,,,inpatient,,,54587.06,16376.12,"UHC [10700]","United Healthcare",,51037.53,,"Fee schedule rate ($51,037.53). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,51037.53,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 10FR LARGE REGULAR PIGTAIL CURVE URETERAL",SUP-M001245610,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,408.97,45.9,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOSURGERY 1.15MR 2.4MM CRYOPROBE FLEXIBLE ERBECRYO 2",SUP-20402-411,CDM,C2618,HCPCS,0272,RC,,,both,,,2530.50,759.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1040.04,41.1,,,,,0,294.3,2150.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 15D 10.5-12 13.5+ LARGE CONTACT CLSR",SUP-HS1005-14,CDM,S27000186,LOCAL,0270,RC,,,both,,,128.06,38.42,"MULTIPLAN [10600]",Multiplan,,108.85,85,,,,,0,14.89,108.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 22CM 5FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49964,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"FIRST HEALTH [10303]","First Health",,602.64,80,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CENTRAL VENOUS 28CM PALINDROME",SUP-8888145064,CDM,C1750,HCPCS,0278,RC,,,both,,,2487.65,746.29,"BLUE CROSS [10001]","Blue Cross PPO",,975.16,39.2,,,,,0,289.31,2114.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 21MM KNEE CONSTRAIN UHMWPE GENESIS II",SUP-71420532,CDM,C1776,HCPCS,0278,RC,,,both,,,18474.75,5542.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2189.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2148.61,15703.54,"percent of total billed charges",
"SCR BONE 3.5MM 42MM ORTHOLOC FULL THREAD CORTICAL ANKLE FOOT",SUP-58813542,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",89.49,654.08,"percent of total billed charges",
"SCR BONE 10MM 90MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704090,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"HEAD HUMERAL 24MM 42MM SHOULDER COMPREHENSIVE VERSA-DIAL",SUP-113036,CDM,C1776,HCPCS,0278,RC,,,both,,,9089.00,2726.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3735.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",1057.05,7725.65,"percent of total billed charges",
"CMPNT GLENOID 15D SMALL AUG CORTILOC SHOULDER LEFT",SUP-DWK403LA15S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"PHCS [10601]",PHCS,,7350,70,,,,,0,1221.15,8925,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO RENAL 2 CURVE 45CM 5FR 1.9MM GUIDING",SUP-G30117,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"PHCS [10601]",PHCS,,368.55,70,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8-6.5MM 45MM CREO SPINE 2 OUTER DIAMETER",SUP-5119.2247,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,957.42,570.23,957.42,28,601.85,4398.75,"percent of total billed charges",
"INSRT CLAMP 90MM STEALTH 5 SOFT STERILE LATEX FREE",SUP-A0A14,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN JUDKINS",SUP-CC77801200,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 16FR 20CM HYDROPHILIC RADIOPAQUE STERILE",SUP-G10206,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SKIN 8X4CM ALLOPATCH HD THK.8-1.7MM THICK ACELLULAR",SUP-471408,CDM,Q4128,HCPCS,0636,RC,,,both,,,11360.51,3408.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 15CM 8MM .0135IN AXIUM PRIME 3D FRAME",SUP-FC-8-15-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"AETNA [10100]","Aetna HMO/PPO",,13137.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X300 135CM SL",SUP-48007030R,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,121.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION VORTEX PEELPRO TITANIUM SILICONE",SUP-P5455K,CDM,C1788,HCPCS,0278,RC,,,both,,,6651.60,1995.48,"CIGNA [10200]","Cigna Local Plus",,3558.61,53.5,,,,,0,773.58,5653.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 24FR SILICONE INTERNAL RETENTION BALLOON RECESS DISTAL",SUP-8100-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,33.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL KNEE 9MM TRIATHLON 4 TIBIAL INSRT TOTAL STABILIZE PLUS",SUP-5537-T-409,CDM,C1776,HCPCS,0278,RC,,,both,,,656.10,196.83,"BLUE CROSS [10001]","Blue Cross PPO",,257.19,39.2,,3949.44,3949.44,3949.44,"1 through 10",76.3,557.69,"percent of total billed charges",
"PACEMKR CARDIAC ETRINSA 8 2 CHMBR IMPLANTABLE RATE",SUP-394931,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"MULTIPLAN [10600]",Multiplan,,35360,85,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 5MM SPACE A CURVE ELECTROPHYSIOLOGY",SUP-F65QA005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,372.86,41.1,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plt Lr Ea Unit",PX-390000022,CDM,P9031,HCPCS,0390,RC,,,both,,,1023.00,306.9,"AETNA [10100]","Aetna HMO/PPO",,813.29,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.97,869.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 90MM DHS/DCS STAINLESS STEEL CONDYLE HIP LAG",SUP-280.290S,CDM,C1713,HCPCS,0278,RC,,,both,,,2333.10,699.93,"NOVANET [10819]",Novanet,,1749.83,75,,,,,0,271.34,1983.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE READIGRAFT CANCELLOUS 15CC 4-10MM ALLOGRAFT","SUP-CAN15 410BP",CDM,S27800098,LOCAL,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET PACING 52CM TAPERED",SUP-6544,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE EXTERNAL FIXATION SALVATION FOOT ANKLE OPEN ROCKER",SUP-SEF02401,CDM,C1713,HCPCS,0278,RC,,,both,,,13703.40,4111.02,"KAISER [10500]",Kaiser,,9181.28,67,,,,,0,1593.71,11647.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 116MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 9",SUP-71357009,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"AETNA [10100]","Aetna HMO/PPO",,26347.21,79.5,,10981.53,8986.79,12413.38,12,3854.32,28169.98,"percent of total billed charges",
"CAP CMPNT GLENOID REVERSE EXT SHOULDER TRABECULAR METAL",SUP-98850090103,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"KAISER [10500]",Kaiser,,32501.7,67,,,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC West Nile Virus Rna Detect CSF",PX-306000150,CDM,87798,CPT,0306,RC,,,both,,,854.00,256.2,"UHC [10700]","United Healthcare",,31.58,,,,,,,0.01,725.9,"fee schedule",
"SCR BONE 3.5MM 16MM SPINE PLY NONSTERILE 4MM ROD",SUP-102035116,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"CATH FOGARTY 80CM 5FR 11MM ROUND EMBOLECTOMY STAINLESS STEEL",SUP-12A0805F,CDM,C1757,HCPCS,0272,RC,,,both,,,301.72,90.52,"MULTIPLAN [10600]",Multiplan,,256.46,85,,,,,0,35.09,256.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 97.5MM TYPE 1 PRESS FIT TAPERLOC MICROPLASTY",SUP-51108060,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"AETNA [10100]","Aetna HMO/PPO",,21811.02,79.5,,10981.53,8986.79,12413.38,12,3190.72,23319.95,"percent of total billed charges",
"SUT ETHILON MULTIPASS 5-0 FS-2 18IN MONOFILAMENT PLIABILIZED",SUP-661G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 80CM 4CM 5FR 7MM 7.5MM BALLOON DILATATION",SUP-4207040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL BREATHE-EASY STERILE",SUP-20-10500,CDM,S27200284,LOCAL,0272,RC,,,both,,,305.63,91.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,140.28,45.9,,,,,0,35.54,259.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRANSFORM 20MM 4MM BALLOON OCCLUSION 1 LUMEN COMPLIANT",SUP-M003SRC04200,CDM,C1725,HCPCS,0272,RC,,,both,,,11760.02,3528.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1393.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1367.69,9996.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50MMX10MM CLYDESDALE 6D PEEK-OPTIMA RADIOPAQUE",SUP-2968050,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Local Plus",,7541.1,31.5,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 100MM 10MM 8.5FR .035IN BILIARY UNCOVERED",SUP-M00570660,CDM,C1876,HCPCS,0278,RC,,,both,,,11927.41,3578.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3413.62,28.62,,,,,0,1387.16,10138.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16015540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"KAISER [10500]",Kaiser,,6396.39,67,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING MR8 DIAMOND LONG BALL L7 CM OD.6 MM",SUP-MR8-7BA06DL,CDM,S27200284,LOCAL,0272,RC,,,both,,,1142.51,342.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,524.41,45.9,,,,,0,132.87,971.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 34CM 7FR ATRIUM VENTRICLE BIPOLAR ACTIVE",SUP-1688TC/34,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"BLUE CROSS [10001]","Blue Cross PPO",,875.14,39.2,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 7 SLOT RIGHT TI",SUP-PHPF-S7R,CDM,C1713,HCPCS,0278,RC,,,both,,,17388.00,5216.4,"BLUE CROSS [10001]","Blue Cross HMO",,6816.1,39.2,,957.42,156.86,7483.26,51,2022.22,14779.8,"percent of total billed charges",
"COIL EMBOLIZATION 60CM 10-12MM POD",SUP-RBYPOD12,CDM,S27800098,LOCAL,0278,RC,,,both,,,11661.00,3498.3,"FIRST HEALTH [10303]","First Health",,9328.8,80,,,,,0,1356.17,9911.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 6FR .071IN INTERNAL MAMMARY ARTERY CURVE",SUP-LA6IMASHD,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 18MM MINI-MONSTER SHORT THREAD CANNULATED",SUP-P20-125-018S,CDM,C1713,HCPCS,0278,RC,,,both,,,1559.25,467.77,"CIGNA [10200]","Cigna Local Plus",,834.2,53.5,,3978.14,359.25,3978.14,24,181.34,1325.36,"percent of total billed charges",
"ELECTRD DEFIB ADULT 6.25X4.5IN MULTIFUNCTION",SUP-22770R,CDM,S27200284,LOCAL,0272,RC,,,both,,,153.53,46.06,"UHC [10700]","United Healthcare",,97.18,63.3,,,,,0,17.86,130.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RETRACTOR KII FIOS ALEXIS 5-9 CM MEDIUM L18 CM OD12 M",SUP-C8502,CDM,S27200284,LOCAL,0272,RC,,,both,,,1762.50,528.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,208.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP 5 UNIPOLAR/BIPOLAR - CEMENTED STEM/DEPUY",SUP-CAP-H-5,CDM,C1776,HCPCS,0278,RC,,,both,,,9030.00,2709,"KAISER [10500]",Kaiser,,6050.1,67,,,,,0,1050.19,7675.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 15MM 19MM 27.5MM 20.8MM EPIC MAX 11MM TISSUE",SUP-EMAX-19,CDM,S27800098,LOCAL,0278,RC,,,both,,,27990.90,8397.27,"UHC [10700]","United Healthcare",,17718.24,63.3,,,,,0,3255.34,23792.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"8MM HTR IMPLANT SYSTEM, STERILE",SUP-220-08-003,CDM,C1776,HCPCS,0278,RC,,,both,,,4830.00,1449,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 5FR .058IN JUDKINS RIGHT 4 CURVE GUIDING NYLON",SUP-LA5JR40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS",RX-11081,CDM,J3480,HCPCS,0636,RC,00990-7115-09,NDC,both,1000,ML,100.65,30.19,"KAISER [10500]",Kaiser,,67.44,67,,,,,0,0.24,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5-2.8MM 12MM ACUTRAK 2 TITANIUM MICRO FULL THREAD",SUP-AT2-C12,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,912.26,28.62,,,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE STC-18 105CM 20CM 3-2.4FR .021IN MICRO GUIDING",SUP-M001181250,CDM,C1887,HCPCS,0272,RC,,,both,,,2287.50,686.25,"KAISER [10500]",Kaiser,,1532.63,67,,,,,0,266.04,1944.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 35MM ATLANTIS VISION ELITE BONE ANTERIOR CERVICAL",SUP-7200035,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AETNA [10100]","Aetna HMO/PPO",,3505.95,79.5,,1521.93,481.35,16760.95,30,512.88,3748.5,"percent of total billed charges",
"TROCHLEAR COMPRESSION SCREW MALE 50MM",SUP-TCS-M-50,CDM,C1713,HCPCS,0278,RC,,,both,,,1506.60,451.98,"FIRST HEALTH [10303]","First Health",,1205.28,80,,,,,0,175.22,1280.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 8MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS08030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"FIRST HEALTH [10303]","First Health",,9378.48,80,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 100MM 130CM 6MM LONG VASCULAR NITINOL",SUP-SC6100LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4117.23,45.9,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE FEMORAL 55MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-151101207,CDM,C1776,HCPCS,0278,RC,,,both,,,16151.52,4845.46,"MULTIPLAN [10600]",Multiplan,,13728.79,85,,,,,0,1878.42,13728.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 9MM 31MM SYMMETRIC TRIATHLON X3 KNEE",SUP-5550-G-319,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"CIGNA [10200]","Cigna Local Plus",,2310.01,53.5,,5372.07,4581.20,7242.98,23,502.16,3670.1,"percent of total billed charges",
"CATH 70CM 145CM 5FR 20D .035IN URETERAL ANGLED TIP BEVELED",SUP-G14600,CDM,C1758,HCPCS,0272,RC,,,both,,,272.75,81.82,"NOVANET [10819]",Novanet,,204.56,75,,,,,0,31.72,231.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC",738,MS-DRG,,,,,,,inpatient,,,68404.17,20521.25,"CIGNA [10200]","Cigna Open Access",,16115.32,,"Fee schedule rate ($16,115.32). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,42874.33,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE CONNECTING 30CM FLEXIBLE KINK RESISTANT FEMALE LUER",SUP-M0067401010,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.57,31.37,"KAISER [10500]",Kaiser,,70.06,67,,,,,0,12.16,88.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL ATTUNE STERILE 3 KNEE LEFT CEMENTED POSTERIOR",SUP-150410103,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2653.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2604.35,19034.35,"percent of total billed charges",
"4F MICRO-INTRODUCER KIT",SUP-KIT-002-30,CDM,C1894,HCPCS,0272,RC,,,both,,,182.70,54.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE VASCULAR ANGLE 180CM 3CM .038IN NITINOL",SUP-GR3808,CDM,C1769,HCPCS,0272,RC,,,both,,,361.05,108.31,"PHCS [10601]",PHCS,,252.74,70,,,,,0,41.99,306.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 3 KNEE RIGHT CRUCIATE RETAIN CEMENTLESS AT",SUP-150401203,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7769.32,27,,,,,0,3346.56,24458.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 33CM 5MM ENDOPATH MACRO JAW STERILE",SUP-EBF01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1088.49,326.55,"MULTIPLAN [10600]",Multiplan,,925.22,85,,,,,0,126.59,925.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 8MM 2MM CORONARY STENT COCR",SUP-1007821-08,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 15MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50015,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9838.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 180CM 5CM 2.5CM RAPID EXCHANGE",SUP-M00510880,CDM,S27200284,LOCAL,0272,RC,,,both,,,2036.93,611.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,241.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,236.89,1731.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 2.5% DEXTROSE 2L LOW CALCIUM DIANEAL DIALYSIS PERITONEAL",SUP-5B9776,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.13,61.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,94.15,45.9,,,,,0,23.86,174.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL SMALL 12-14.4INX3IN ACTIMOVE MEDIUM DENSITY",SUP-72819-00026-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,48.20,14.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19.81,41.1,,,,,0,5.61,40.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR EBU3.5 CURVE GUIDING CORONARY",SUP-LA6EBU355,CDM,C1887,HCPCS,0272,RC,,,both,,,339.30,101.79,"MULTIPLAN [10600]",Multiplan,,288.41,85,,,,,0,39.46,288.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSELECT DEMINERALIZED BONE MATRIX 5CC",SUP-359050,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,3978.14,359.25,3978.14,24,434.96,3179,"percent of total billed charges",
"CPSL PH BRAVO CALIBRATION FREE REFLUX DELIVERY SYSTEM",SUP-FGS-0635,CDM,S27200284,LOCAL,0272,RC,,,both,,,2244.00,673.2,"MULTIPLAN [10600]",Multiplan,,1907.4,85,,,,,0,260.98,1907.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840007535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3923.76,41.1,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 5.5MM 5.5MM TOP NOTCH SPINE TITANIUM 2 OPEN",SUP-179771555,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2422.5,68,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) QUALBREATH SIZES S",SUP-QB-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,98.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 3CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175285010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,306.45,28.62,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 4 7MM KNEE AOX CRUCIATE RETAINING ROTATE PLATF",SUP-151630407,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"NOVANET [10819]",Novanet,,9845.44,75,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 90ML .1-4MM CANCELLOUS ALLOGRAFT FREEZE",SUP-400090,CDM,C1713,HCPCS,0278,RC,,,both,,,10246.50,3073.95,"BLUE CROSS [10001]","Blue Cross PPO",,4016.63,39.2,,957.42,570.23,957.42,28,1191.67,8709.53,"percent of total billed charges",
"SEAL ENDOSCOPIC INSTRUMEN 5-8MM DA VINCI XI UNIVERSAL",SUP-470361,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.43,49.33,"AETNA [10100]","Aetna HMO/PPO",,130.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.12,139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 110CM 4FR .042IN 155D 12MM PIGTAIL",SUP-538459V,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,41.09,45.9,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Respirat Syncytial Virus Ab",PX-302000158,CDM,86756,CPT,0302,RC,,,both,,,695.00,208.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,24.99,,,,,,,0.7,590.75,"fee schedule",
"SYSTEM PROMUS ELEMENT PLUS 16MM 144CM 2.25MM CORONARY STENT",SUP-H7493911416220,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1083.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 180MM RIGHT HINDFOOT NAIL-EX INTRAMEDULLARY",SUP-04.008.216S,CDM,C1713,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"NOVANET [10819]",Novanet,,6339.38,75,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFE-T-J VASCULAR 1.5MM ROSEN CURVE 145CM .035IN",SUP-G01382,CDM,C1769,HCPCS,0272,RC,,,both,,,133.81,40.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.56,113.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TIGHTRAIL MINI 20FR 6.1IN 9FR 15.9FR 9.2FR DIL ROTATE",SUP-540-009,CDM,C1773,HCPCS,0272,RC,,,both,,,12385.50,3715.65,"AETNA [10100]","Aetna HMO/PPO",,9846.47,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5-7MM 35MM CREO SPINE 2 OUTER DIAMETER",SUP-5119.2837,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 44MM STAINLESS STEEL T25 CONDYLAR VARIABLE",SUP-02.231.244,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,154.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,152.1,1111.66,"percent of total billed charges",
"GUIDE SIGNATURE SURGICAL TOTAL KNEE ARTHROPLASTY",SUP-42-422561,CDM,S27200284,LOCAL,0272,RC,,,both,,,7468.56,2240.57,"CIGNA [10200]",Cigna,,5078.62,68,,,,,0,868.59,6348.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PALMPUMP KIWI OMNICUP VACUUM EXTRACTION NEONATE",SUP-VAC-6000MT,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"CIGNA [10200]",Cigna,,207.06,68,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TACK 8MM 135 CM 6FR VASCULAR NITINOL RADIOPAQUE OTW 6",SUP-154150042,CDM,C1876,HCPCS,0278,RC,,,both,,,18238.50,5471.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7295.4,40,,,,,0,2121.14,15502.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +26 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030260,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"MULTIPLAN [10600]",Multiplan,,998.33,85,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION BLUE 4.8MM 1.32MM T EAR ULTRASIL MODIFY",SUP-70241072,CDM,S27800098,LOCAL,0278,RC,,,both,,,201.56,60.47,"NOVANET [10819]",Novanet,,151.17,75,,,,,0,23.44,171.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X18X11MM TRANSCONTINENTAL 6D SMALL PEEK",SUP-375.111CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"AETNA [10100]","Aetna HMO/PPO",,25042.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 24CM 7FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856190,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,129.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.45MM 2 1.5MM JUGGERKNOT MAXBRAID 1 LOAD RIGID",SUP-CM-99145BRN,CDM,C1713,HCPCS,0278,RC,,,both,,,3450.00,1035,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1583.55,45.9,,,,,0,401.24,2932.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE LORDOTIC ALLOGRAFT 14X14X6MM",SUP-645644,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 3.5MM CORONARY STENT",SUP-1125350-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3969.84,68,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACTOR, STRIPPED SCREW, 7 MM, 6"" LONG, SINGLE USE",SUP-SXT014-ST3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,351.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE DOPPLER HIGH SENSITIVITY NONDIRECTIONAL TRNSDUC 2MHZ",SUP-OP2-HS,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM 2.75MM 2.1-2.7FR CORONARY",SUP-RONYX27530UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]","Cigna Open Access",,1920.38,56.9,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 18MM 2.5MM CORONARY STENT FULCRUM COCR",SUP-INT25018UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CIGNA [10200]","Cigna Local Plus",,1292.03,53.5,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,inpatient,,,40298.87,12089.66,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,6375.1,,"Case rate ($5,958.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,532.44, add-ons for qualifying new technology services are included. If operating cost exceeds $38,572.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,800.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,539.76. The transfer operating threshold is the transfer adjustment factor * $5,532.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.28. The transfer capital threshold is the transfer adjustment factor * $418.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,5958.04,23953.91,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL SHAFT ALLOGRAFT FROZEN 200MM 10+ MM",SUP-450450,CDM,S27800098,LOCAL,0278,RC,,,both,,,11703.78,3511.13,"NOVANET [10819]",Novanet,,8777.84,75,,,,,0,1361.15,9948.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO ANL1 CURVE 55CM 5FR 1.9MM GUIDING",SUP-G56235,CDM,C1894,HCPCS,0272,RC,,,both,,,472.23,141.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,194.09,41.1,,,,,0,54.92,401.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE JOURNEY II COCR WITH XR INSERT AND",SUP-71709040,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIRE RETINAL 3.5MM GROOVE CONVEX SILICONE 7MM STERILE STYLE",SUP-9223,CDM,S27800098,LOCAL,0278,RC,,,both,,,229.68,68.9,"CIGNA [10200]","Cigna Open Access",,130.69,56.9,,,,,0,26.71,195.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL E LEFT OPTION LPS-FLEX GSF STERILE",SUP-00576401551,CDM,C1776,HCPCS,0278,RC,,,both,,,16934.40,5080.32,"BLUE CROSS [10001]","Blue Cross HMO",,6638.28,39.2,,5311.50,4717.44,5388.59,31,1969.47,14394.24,"percent of total billed charges",
"LENS IOL MONOFOCAL PRELOAD 1 PIECE UV BLOCK TECNIS ITEC",SUP-PCB0000240,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 16.1CM 8MM CEREPAK MICRO UNIFORM",SUP-FCX100816,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5435.82,41.1,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 22X10X11MM CASCADIA CONVEX ANATOMICALLY NARROW",SUP-6101-2102211NC-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2468.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 10CM 150CM 5FR .038IN 3CM BLADDER LOOP",SUP-M006155211170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CIGNA [10200]","Cigna Local Plus",,759.88,,,,,,,165.19,1207.29,"percent of total billed charges",
"BIT DRILL 4.3MM LONG CALIBRATED STERILE",SUP-03.313.701S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT THORACENTESIS 7.5IN 8FR 18GA ARROW-CLARKE PLEURA-SEAL",SUP-AK-01000,CDM,C1729,HCPCS,0272,RC,,,both,,,385.41,115.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 5FR .058IN AMPLATZ LEFT 1 CURVE GUIDING NYLON",SUP-LA5AL10,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 20MM 190CM 2MM",SUP-R51002002L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CRTDG RAPIDPOINT MEASUREMENT 405/500 400 TEST NONSTERILE",SUP-10313971,CDM,S27000186,LOCAL,0270,RC,,,both,,,4855.19,1456.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TAP 7.5MM SURGICAL CREO BEACON NONSTERILE REUSABLE",SUP-655.217,CDM,S27000186,LOCAL,0270,RC,,,both,,,534.60,160.38,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT STRATAFIX MONOCRYL PLUS ANTIBACTERIAL UNIDIRECTIONAL",SUP-SXMP1B106,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.03,65.41,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC T Cell Absolute Count W Ratio",PX-302000081,CDM,86360,CPT,0302,RC,,,both,,,630.43,189.13,"NOVANET [10819]",Novanet,,472.82,75,,,,,0,0.01,535.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EVOLUT FX DELIVERY 34 MM",SUP-D-EVOLUTFX-34,CDM,S27200284,LOCAL,0272,RC,,,both,,,14559.00,4367.7,"UHC [10700]","United Healthcare",,9215.85,63.3,,,,,0,1693.21,12375.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MICRO REGULAR .6MM MAXILLOFACIAL 6 HOLE STRAIGHT 1.5MM",SUP-25-306-06-09,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.35,445.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,172.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",172.86,1263.4,"percent of total billed charges",
"PLATE STRAIGHT 29X3.8X.8MM TITANIUM 1.5MM SCR 6 HOLE LOW",SUP-446.031,CDM,C1713,HCPCS,0278,RC,,,both,,,2790.90,837.27,"CIGNA [10200]",Cigna,,1897.81,68,,1831.33,1831.33,1831.33,16,324.58,2372.27,"percent of total billed charges",
"BALLOON CERVICAL DILATATION 40CM 18FR COOK SILICONE RIPENING",SUP-G48149,CDM,C1726,HCPCS,0272,RC,,,both,,,527.60,158.28,"FIRST HEALTH [10303]","First Health",,422.08,80,,,,,0,61.36,448.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Chest W/WO Cntrst",PX-610000014,CDM,71552,CPT,0610,RC,,,both,,,5765.38,1729.61,"PHCS [10601]",PHCS,,4035.77,70,,,,,0,670.51,4900.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ESOPHAGEAL PYLORIC 6FR 18-20MM 180CM 8CM FIXED WIRE",SUP-M00558380,CDM,C1726,HCPCS,0272,RC,,,both,,,1562.98,468.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,185.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",379.61,375.47,414.12,"1 through 10",181.77,1328.53,"percent of total billed charges",
"CORD ELECTROSURGICAL UNIVERSAL ACTIVE ADPTR NONSTERILE",SUP-G22092,CDM,S27200284,LOCAL,0272,RC,,,both,,,777.60,233.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,90.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 7MM .89MM SMALL STRAIGHT EAR FLUOROPLASTIC",SUP-14-0034,CDM,S27800098,LOCAL,0278,RC,,,both,,,76.24,22.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,51.84,68,,,,,0,8.87,64.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR JUDKINS LEFT CORONARY 5",SUP-534522T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GABAPENTIN 400 MG CAPSULE, IMMEDIATE RELEASE",RX-18307,CDM,,,0637,RC,00904-6667-61,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUBICON 135CM SPRT STRAIGHT TIP ACCEPTS .014IN GWIRE 4",SUP-H74939212014131,CDM,C1887,HCPCS,0272,RC,,,both,,,1449.90,434.97,"UHC [10700]","United Healthcare",,917.79,63.3,,,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30MM NONSTERILE LATEX FREE DISPOSABLE",SUP-470430,CDM,S27000186,LOCAL,0270,RC,,,both,,,1156.68,347,"PHCS [10601]",PHCS,,809.68,70,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUSHG FEMORAL STD MODULAR ROTATING HINGE",SUP-6481-2-110,CDM,C1776,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,791.78,45.9,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JADE OTW .018 150CM PTA BALLOONAND#59; 2.0X20MM",SUP-592002022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 34MM TI",SUP-SPL-35340-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,155.43,1136.03,"percent of total billed charges",
"BLADE 5 ANGLE LEFT RTRCTR DAVIS MCGIVOR MOUTH GAG RING",SUP-45-2143,CDM,S27200284,LOCAL,0272,RC,,,both,,,469.64,140.89,"CIGNA [10200]","Cigna Local Plus",,251.26,53.5,,,,,0,54.62,399.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Eus Exam",PX-750000097,CDM,45391,CPT,0750,RC,,,both,,,3622.00,1086.6,"PHCS [10601]",PHCS,,3622,,"Case rate ($6,277). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,421.24,3622,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 46MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.046S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL REVELATION 8 LEFT HIP",SUP-427-01-080,CDM,C1776,HCPCS,0278,RC,,,both,,,32703.43,9811.03,"KAISER [10500]",Kaiser,,21911.3,67,,,,,0,3803.41,27797.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 12 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502607402,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2709.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2658.93,19433.3,"percent of total billed charges",
"SHOE CAST MEDIUM CANVAS RUBBER ROCKER SOLE HOOP LOOP CLSR",SUP-2035-03,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.41,13.62,"CIGNA [10200]","Cigna Open Access",,25.84,56.9,,,,,0,5.28,38.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo 3d During Tee/Tte for Chd",PX-483000027,CDM,93319,CPT,0483,RC,,,both,,,1291.00,387.3,"CIGNA [10200]",Cigna,,877.88,68,,,,,0,150.14,1097.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 22MM GEMINUS COCR POLYAXIAL CANNULATED LOCK",SUP-PALS-25220-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1036.80,311.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,296.73,28.62,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 100MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355100,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE FUZEFIX MAX FULL THREAD L30 MM OD4.5 MM CANNULATE",SUP-FX-FT-4530,CDM,S27000186,LOCAL,0270,RC,,,both,,,3600.00,1080,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1479.6,41.1,,,,,0,418.68,3060,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 12CM 10FR CENTER BEND THIN WALL",SUP-M00534710,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,311.8,28.62,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 90CM 40MM 2MM .014IN BALLOON DILATATION",SUP-AB14W020040090,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"AETNA [10100]","Aetna HMO/PPO",,1101.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT 1.5 KNEE CEMENT ROTATE PLATFORM",SUP-129433115,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP POLAR CUP WITH SMF STEM AND OXI HEAD",SUP-71703530,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"MULTIPLAN [10600]",Multiplan,,20349,85,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 2 DISK NITINOL MESH SELF EXPANDING 18MM",SUP-9-ASD-018,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"FIRST HEALTH [10303]","First Health",,17000.64,80,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE INSUFLOW ENDOSCOPIC GAS CONDITION PORT STERILE LATEX",SUP-6198,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"NOVANET [10819]",Novanet,,364.5,75,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK",RX-116499,CDM,J2020,HCPCS,0636,RC,63323-0713-03,NDC,both,300,ML,274.64,82.39,"BLUE CROSS [10001]","Blue Cross HMO",,12.48,,,,,,,9.66,233.44,"fee schedule",
"APPLIER INTERNAL CLIP 15CM HORIZON TITANIUM MICRO ENDOSCOPIC",SUP-005200,CDM,S27200284,LOCAL,0272,RC,,,both,,,645.38,193.61,"KAISER [10500]",Kaiser,,432.4,67,,,,,0,75.06,548.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR/ELEV LAPAROSCOPIC STD VCARE CUP CERVICAL UTERINE",SUP-60-6085-201,CDM,S27200284,LOCAL,0272,RC,,,both,,,522.45,156.73,"CIGNA [10200]","Cigna Open Access",,297.27,56.9,,,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRI-SIL IC 60IN 14FR URETHRAL BACTI-GUARD SILICONE",SUP-0170SI14,CDM,S27200284,LOCAL,0272,RC,,,both,,,193.66,58.1,"MULTIPLAN [10600]",Multiplan,,164.61,85,,,,,0,22.52,164.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY UVA",SUP-CCWET0,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"MULTIPLAN [10600]",Multiplan,,735.25,85,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 10FT ABC THERMOGARD PLUS STERILE",SUP-7-382,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.94,15.88,"CIGNA [10200]","Cigna Local Plus",,28.32,53.5,,,,,0,6.16,45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE 130CM 80MM 7MM BALLOON DILATATION",SUP-LX181307805F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,797.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA 5D H KNEE RIGHT CEMENT STEM TIVANIUM",SUP-42532008302,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1271.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1271.59,9293.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 18MM HEMASHIELD GOLD STRAIGHT 2 VELOUR",SUP-M002020952180,CDM,C1768,HCPCS,0278,RC,,,both,,,3553.58,1066.07,"CIGNA [10200]",Cigna,,2416.43,68,,,,,0,413.28,3020.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXXCESS 6FR URETERAL OPEN END",SUP-M0064051160,CDM,C1758,HCPCS,0272,RC,,,both,,,746.25,223.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,507.45,68,,,,,0,86.79,634.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Tube Nasal/Orogast W Fl",PX-361000172,CDM,43752,CPT,0361,RC,,,both,,,1425.27,427.58,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,165.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.76,1425.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +24.5 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE",SUP-PCB0000245,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 60MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-583506022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chlamydia Trach & Neisseria Gonorr Dna Ampl Prb",PX-306000258,CDM,87494,CPT,0306,RC,,,both,,,566.86,170.06,"CIGNA [10200]",Cigna,,385.46,68,,,,,0,0.01,481.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 16CM 3MM BALLOON DILATATION HYDROPHILIC",SUP-G50332,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"FIRST HEALTH [10303]","First Health",,1889.94,80,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFEPIME 2 G VIAL",RX-16371,CDM,J0692,HCPCS,0636,RC,44567-0241-10,NDC,both,1,UN,88.79,26.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.69,75.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 6FR J CURVE ATRIUM MRI PASSIVE FIXATION",SUP-7736,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CIGNA [10200]","Cigna Local Plus",,1194.39,53.5,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732058,CDM,C1776,HCPCS,0278,RC,,,both,,,9510.48,2853.14,"CIGNA [10200]",Cigna,,6467.13,68,,5873.17,5873.17,5873.17,"1 through 10",1106.07,8083.91,"percent of total billed charges",
"STENT ZIPWIRE 28CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175254090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,157.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ENTEER VASCULAR 28D 2.5MM FLAT 300CM .014IN",SUP-ENW-SF-014-300,CDM,C1769,HCPCS,0272,RC,,,both,,,1620.00,486,"FIRST HEALTH [10303]","First Health",,1296,80,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 8MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR180830,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2162.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS POWERFLEX P3 80CM 40MM 12MM 7.5MM BALLOON",SUP-4202040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC .99CM MINI 5.23X7.03CM INOGEN EASYVIEW RIGHT",SUP-D012,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"MULTIPLAN [10600]",Multiplan,,34476,85,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 34MM SIMULUS ANNULUS POSTERIOR POLYESTER",SUP-800SC34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross PPO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CREO SPINE PREASSEMBLE THREAD",SUP-5119.1652,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"PLATE 17MM STAINLESS STEEL 2MM SCR MINI FRAGMENT SET 3 HOLE",SUP-243.13,CDM,C1713,HCPCS,0278,RC,,,both,,,1845.60,553.68,"CIGNA [10200]",Cigna,,1255.01,68,,1831.33,1831.33,1831.33,16,214.64,1568.76,"percent of total billed charges",
"2.5X8MM ABSORB RX IDE",SUP-1012458-08,CDM,C1874,HCPCS,0624,RC,,,both,,,10350.00,3105,"AETNA [10100]","Aetna HMO/PPO",,8228.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 10MM LCP STAINLESS STEEL CORTEX FOREFOOT",SUP-202.870,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",37.68,275.39,"percent of total billed charges",
"HC Ext Ecg>7d<15d Recording",PX-731000007,CDM,93246,CPT,0731,RC,,,both,,,383.00,114.9,"MULTIPLAN [10600]",Multiplan,,325.55,85,,,,,0,30.87,383,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 11 STD KNEE LEFT CRUCIATE RETAINING PERSONA",SUP-42502807001,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"FIRST HEALTH [10303]","First Health",,23116.46,80,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC Z THREAD 100MM 5MM KII FIOS FIRST ENTRY",SUP-CTF04,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"AETNA [10100]","Aetna HMO/PPO",,114.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 120CM 16MM 1MM FOREIGN BODY 0 TIP",SUP-M00513210,CDM,S27200284,LOCAL,0272,RC,,,both,,,1932.90,579.87,"KAISER [10500]",Kaiser,,1295.04,67,,,,,0,224.8,1642.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Consult Comprehensive 3",PX-312000035,CDM,88325,CPT,0312,RC,,,both,,,1691.00,507.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.19,,,,,,,0.01,1437.35,"fee schedule",
"STENT ORSIRO 3.0/9",SUP-401732,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 115CM 3FR 3.2FR 4 WIRE OCCLUSIVE BASKET CAPTURA",SUP-G32727,CDM,S27200284,LOCAL,0272,RC,,,both,,,1662.75,498.82,"KAISER [10500]",Kaiser,,1114.04,67,,,,,0,193.38,1413.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 17MM HELIX R SPINE SELF TAP VARIABLE ANGLE",SUP-7805117,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Skull>=4v",PX-320000018,CDM,70260,CPT,0320,RC,,,both,,,768.38,230.51,"PHCS [10601]",PHCS,,537.87,70,,,,,0,49.14,653.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 105MM COLLAR ACTIS DUOFIX 5 12/14 HIGH OFFSET",SUP-101012050,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"PHCS [10601]",PHCS,,21333.38,70,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 128MM 12MM PRESS FIT REUNION SHOULDER STERILE",SUP-5569-P-2012,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Open Access",,4221,33.5,,5302.19,4377.88,6578.61,27,1465.38,10710,"percent of total billed charges",
"SCR BONE 2MM 11MM LCP STAINLESS STEEL CORTEX T6 STARDRIVE",SUP-201.361.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"CIGNA [10200]","Cigna Local Plus",,221.55,53.5,,3978.14,359.25,3978.14,24,48.16,352,"percent of total billed charges",
"GUIDE PIN ORTHOPEDIC 3MM PERFORM 100MM HUMERAL",SUP-MWM100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1266.84,380.05,"PHCS [10601]",PHCS,,886.79,70,,,,,0,147.33,1076.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIALYZER HEMODIALYSIS 1.8SQ MR REVACLEAR 400 300ML 93ML",SUP-114746L,CDM,S27200284,LOCAL,0272,RC,,,both,,,524.29,157.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,240.65,45.9,,,,,0,60.97,445.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC",081,MS-DRG,,,,,,,inpatient,,,36309.01,10892.7,"CIGNA [10200]","Cigna Local Plus",,9241.7,,"Fee schedule rate ($9,241.70). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,5555.47,22335.37,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 15MM 140CM 2.25MM 2.1-2.7FR CORONARY",SUP-RONYX22515UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,439.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN SILICONE POLYMER INCISION FULL PERFORATED FLAT WOUND",SUP-00256900010,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.80,36.54,"UHC [10700]","United Healthcare",,77.1,63.3,,,,,0,14.17,103.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE RIGHT CRUCIATE RETAIN PERSONA PPS",SUP-42508606202,CDM,C1776,HCPCS,0278,RC,,,both,,,29326.50,8797.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3475.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3410.67,24927.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPINEPHRINE 0.1 MG/0.1 ML INJECTION, AUTO-INJECTOR",RX-182843,CDM,J0165,HCPCS,0636,RC,60842-0021-02,NDC,both,1,UN,1876.95,563.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1276.33,68,,,,,0,0.51,1595.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX59MM 8FR 80CMCATH HEPARIN",SUP-BXB095901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS [10001]","Blue Cross PPO",,7645.88,39.2,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CARDIOTHORACIC PROCEDURES WITH MCC",228,MS-DRG,,,,,,,inpatient,,,237640.85,71292.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,78880.01,,"Fee schedule rate ($78,880.01). The outlier threshold amount is ($224,410.00),  the outlier percentage is (46.51%).  The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1). Includes an add-on of $2,243.60 when RC 0681-0684 total amount is above $1.",,,,0,30689.02,144444.29,other,"IP STOPLOSS Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 55MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75447555,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"ROD SPINAL 90MM 3.5MM CAPITOL CURVE",SUP-111.89,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"COIL EMBOLIZATION 30CM 8MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0830CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross HMO",,2569.56,39.2,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 103MM COLLAR ACTIS DUOFIX 4 12/14 HIGH OFFSET",SUP-101012040,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8722.3,28.62,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANGINA PECTORIS",311,MS-DRG,,,,,,,inpatient,,,33115.21,9934.56,"BLUE CROSS [10001]","Blue Cross HMO",,16113.37,,,,,,,4353.92,17504.68,"case rate",
"BASE RTRCTR LEYLA REICHERT 1 MOUNT SELF RETAIN NONSTERILE",SUP-R2396,CDM,S27200284,LOCAL,0272,RC,,,both,,,2181.53,654.46,"AETNA [10100]","Aetna HMO/PPO",,1734.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,253.71,1854.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 CT-1 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J259H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 18MM 3.75MM EMBOLIZATION",SUP-PED2-375-18,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"NOVANET [10819]",Novanet,,60598.13,75,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 25MM 75CM 9MM 30MM",SUP-H74938046920750,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 180CC FULL PROFILE SMOOTH NATRELLE INSPIRA",SUP-SSF-180,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AETNA [10100]","Aetna HMO/PPO",,6006.62,79.5,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 22MM GELWEAVE VASCUTEK STRAIGHT THORACIC",SUP-733022,CDM,C1768,HCPCS,0278,RC,,,both,,,6831.00,2049.3,"CIGNA [10200]","Cigna Local Plus",,3654.59,53.5,,,,,0,794.45,5806.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH SMOKE EVAC 10FT VALLEYLAB STERILE LATEX FREE",SUP-E3810,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.80,34.14,"CIGNA [10200]","Cigna Local Plus",,60.88,53.5,,,,,0,13.23,96.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VISIGLIDE ENDOSCOPIC STRAIGHT 2700MM .035IN .025IN",SUP-G-240-2527S,CDM,C1769,HCPCS,0272,RC,,,both,,,1288.95,386.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,876.49,68,,,,,0,149.9,1095.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) IMPLANT DELIVERY SYSTEM WITH IMPLANT LOADING TOOL",SUP-FG-1001-02,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 34MM 10MM HEMASHIELD PLATINUM AORTIC",SUP-M00202175834P0,CDM,L8670,HCPCS,0278,RC,,,both,,,9685.32,2905.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1147.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,427.53,8232.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 60MM 2300MM 20MM ESOPHAGEAL METAL NITINOL",SUP-ECBA-20-060-230,CDM,C1874,HCPCS,0278,RC,,,both,,,16425.45,4927.63,"CIGNA [10200]","Cigna Open Access",,5502.53,33.5,,,,,0,1910.28,13961.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 9MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P709,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Local Plus",,4470.41,53.5,,5372.07,4581.20,7242.98,23,971.79,7102.52,"percent of total billed charges",
"COAGULATION AND PLATELET DISORDERS,MODERATE",661,APR-DRG,,,,,,,inpatient,,,49859.92,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $7,748.92. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($44,528.05) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 30CM 13FR POWER-TRIALYSIS STRAIGHT 3 LUMEN SHORT",SUP-5605300,CDM,C1752,HCPCS,0272,RC,,,both,,,1614.33,484.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH REDEL 110CM 1MM 4FR 5MM SPACE REGULAR D CURVE",SUP-D4S04DR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) TRISOL VALVE 60MM",SUP-DMS-14628,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GLIDESHEATH SLENDER SS KIT, 0.021 GW, 5 FR, 16CM",SUP-80-1650,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RESPONSE 120CM 6FR 10MM SPACING CRD CURVE",SUP-401210,CDM,C1730,HCPCS,0272,RC,,,both,,,704.70,211.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 48MM ZUK HEAD STERILE LATEX FREE MIS",SUP-00598304048,CDM,S27200284,LOCAL,0272,RC,,,both,,,830.25,249.07,"MULTIPLAN [10600]",Multiplan,,705.71,85,,,,,0,96.56,705.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 2MM BALLOON DILATATION OTW PTCA",SUP-DC-PY2012UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,117.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPIFIX 18 MM DISK ""Q"" CODED",SUP-GS-5180,CDM,Q4186,HCPCS,0636,RC,,,both,,,4733.40,1420.02,"PHCS [10601]",PHCS,,3313.38,70,,,,,0,406.44,4023.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT 7.5IN RHOTON LARGE STRAIGHT SPAT SURGICAL",SUP-58-6022,CDM,S27200284,LOCAL,0272,RC,,,both,,,524.07,157.22,"NOVANET [10819]",Novanet,,393.05,75,,,,,0,60.95,445.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 26X9X9MM 8D EIT PLIF STERILE LATEX FREE",SUP-PUI80906,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 29MM SJM TAILOR SILICONE FLEXIBLE SURE",SUP-TAB-29,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1434.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 7FR 19CM VESSEL ACCEPTS .035IN GWIRE",SUP-504407X,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.86,31.16,"CIGNA [10200]",Cigna,,70.62,68,,,,,0,12.08,88.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS 5-0 RB-2 30IN 2 ARM ANTIBACTERIAL VIOLET",SUP-PDP148H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.09,19.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.69,56.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 4MM 1.2MM 11MM 4MM STAINLESS STEEL SHORT THREAD",SUP-202.611,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,509.5,45.9,,,,,0,129.1,943.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 75MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.875,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"BLUE CROSS [10001]","Blue Cross PPO",,538.77,39.2,,957.42,570.23,957.42,28,159.84,1168.25,"percent of total billed charges",
"GRAFT BONE ALLOQUENT CORTICAL 12D ALLOGRAFT 28X26X12MM ALIF",SUP-3W4212,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8458.13,40,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG HYPERINFLATION PEDIATRIC 1L 7FT OXYGEN TUBING ELBOW MANO",SUP-900000624,CDM,S27000186,LOCAL,0270,RC,,,both,,,106.26,31.88,"KAISER [10500]",Kaiser,,71.19,67,,,,,0,12.36,90.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4.1CM 5-3MM TORNADO SOFT .035IN STD SMALL",SUP-G10415,CDM,S27200284,LOCAL,0272,RC,,,both,,,730.54,219.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,496.77,68,,,,,0,84.96,620.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 75CM .36MM FIRM TPR",SUP-124437,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"CIGNA [10200]","Cigna Open Access",,217.81,56.9,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 25MM 9MM BIOSURE",SUP-72202272,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 24F LARGE HIP PROXIMAL",SUP-550568,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"AETNA [10100]","Aetna HMO/PPO",,8653.38,79.5,,10981.53,8986.79,12413.38,12,1265.9,9252.04,"percent of total billed charges",
"CMPNT PATELLAR 9MM 33MM SYMMETRIC TRIATHLON X3 KNEE SUPERIOR",SUP-5550L339,CDM,C1776,HCPCS,0278,RC,,,both,,,4478.10,1343.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,530.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,520.8,3806.39,"percent of total billed charges",
"EXP TISSUE 11X11.5CM 350CC STYLE 133S SMOOTH SUT TAB",SUP-133S-FX-11-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA [10200]","Cigna Open Access",,5300.24,56.9,,5166.00,5166.00,5166.00,"1 through 10",1083.33,7917.75,"percent of total billed charges",
"CATH BLAZER PRIME XP 110CM 11CM 7FR 8FR 8MM 2.5MM SPACE STD",SUP-M004P4500TH0,CDM,C1733,HCPCS,0272,RC,,,both,,,11730.00,3519,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4821.03,41.1,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 206X13.5X4.2MM TITANIUM 4.5MM SCR LARGE",SUP-424.611,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.70,1106.91,"BLUE CROSS [10001]","Blue Cross PPO",,1446.36,39.2,,957.42,570.23,957.42,28,429.11,3136.25,"percent of total billed charges",
"STEM FEMORAL 235MM 25MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-325,CDM,C1776,HCPCS,0278,RC,,,both,,,18758.25,5627.47,"MULTIPLAN [10600]",Multiplan,,15944.51,85,,,,,0,2181.58,15944.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 20MM 6MM .035IN BALLOON",SUP-AB35W06020135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"FIRST HEALTH [10303]","First Health",,541.73,80,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.35IN 14FR HEYMAN PLASTIC COUDE TIP DILATION",SUP-021314,CDM,S27200284,LOCAL,0272,RC,,,both,,,242.30,72.69,"PHCS [10601]",PHCS,,169.61,70,,,,,0,28.18,205.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 34MM VOLT STAINLESS STEEL T8 CORTEX",SUP-02.527.134,CDM,C1713,HCPCS,0278,RC,,,both,,,1033.56,310.07,"KAISER [10500]",Kaiser,,692.49,67,,,,,0,120.2,878.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX EXTREME 80CM 4CM 5FR 5MM 7MM BALLOON",SUP-4156040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 23MM 18.5-21.5MM EXCLUDER",SUP-PLC231200,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"UHC [10700]","United Healthcare",,17722.23,63.3,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL LEGION 6 LEFT KNEE REVISION",SUP-71424006,CDM,C1776,HCPCS,0278,RC,,,both,,,23133.60,6940.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2741.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2690.44,19663.56,"percent of total billed charges",
"NAIL 9MM 285MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.337S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"BLUE CROSS [10001]","Blue Cross HMO",,3258.47,39.2,,957.42,156.86,7483.26,51,966.74,7065.57,"percent of total billed charges",
"LENS IOL 10 D +16 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z9002160,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"MULTIPLAN [10600]",Multiplan,,867.51,85,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR ITOTAL IPOLY XE CRUCIATE RETAIN PATIENT SPECIFIC",SUP-TCR1111111,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10710,40,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION AQUALITE WATER 1.5L STERILE LATEX FREE",SUP-07139-36,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 80MM 14MM VASCULAR NITINOL VENOUS ILIOFEMORAL",SUP-AB9U14080090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1226.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SIZING PATELLA ANTERIOR TMPLT STERILE",SUP-03.137.002S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1258.98,377.69,"PHCS [10601]",PHCS,,881.29,70,,,,,0,146.42,1070.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAMURAI VASCULAR 300CM J TIP",SUP-H74939302300J2,CDM,C1769,HCPCS,0272,RC,,,both,,,689.78,206.93,"PHCS [10601]",PHCS,,482.85,70,,,,,0,80.22,586.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 120MM 120CM 7MM VASCULAR PERIPHERAL SELF",SUP-PRB35-07-120-120,CDM,C1876,HCPCS,0278,RC,,,both,,,6930.00,2079,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1983.37,28.62,,,,,0,805.96,5890.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X7MM ADVANCED PARALLEL TRAPEZOIDAL",SUP-7607,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5630.4,68,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 20MM 10MM KNEE FASTTHREAD",SUP-AR-4020C-10,CDM,C1713,HCPCS,0278,RC,,,both,,,2323.13,696.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1066.32,45.9,,,,,0,270.18,1974.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID LOWER LEG REDUCTION KIT- STANDARD, WIDE",SUP-25102217,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"CIGNA [10200]","Cigna Local Plus",,671.69,53.5,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 19MM KNEE POSTERIOR STABILIZE BEARING",SUP-5532P419,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"FIRST HEALTH [10303]","First Health",,6684.72,80,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM EDWARDS SAPIEN 3 COMMANDER DELIVERY SYSTEM",SUP-9600CM29A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"BLUE CROSS [10001]","Blue Cross HMO",,72618,39.2,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 22MM AO QUICK 1.2MM SCREWS",SUP-60-10322,CDM,S27200284,LOCAL,0272,RC,,,both,,,724.63,217.39,"CIGNA [10200]",Cigna,,492.75,68,,,,,0,84.27,615.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 10CM 7MM THIN WALL PERIPHERAL GORE-TEX",SUP-ST0701,CDM,C1768,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE EMBOLIZATION GREEN EMBOZENE 700UM POLYZENE-F HYDROGEL",SUP-17020-S1,CDM,S27800098,LOCAL,0278,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,405.69,28.62,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW 54840004550 MAS 4.5X50 CC",SUP-54840004550,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS [10001]","Blue Cross HMO",,3742.37,39.2,,957.42,156.86,7483.26,51,1110.3,8114.82,"percent of total billed charges",
"HEAD FEMORAL +6MM 11/13 TAPER 28MM HIP M SPECIFICATION METAL",SUP-136518500,CDM,C1776,HCPCS,0278,RC,,,both,,,5716.65,1714.99,"CIGNA [10200]","Cigna Local Plus",,3058.41,53.5,,5372.07,4581.20,7242.98,23,664.85,4859.15,"percent of total billed charges",
"LINER ACETABULAR PMP EPLUS 34",SUP-932-34-750,CDM,C1776,HCPCS,0278,RC,,,both,,,16032.84,4809.85,"FIRST HEALTH [10303]","First Health",,12826.27,80,,,,,0,1864.62,13627.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REINFORCEMENT STAPLE LINE 60MM SOFT TISSUE ECHELON ENDOPATH",SUP-ECH60R,CDM,S27200284,LOCAL,0272,RC,,,both,,,5374.12,1612.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2466.72,45.9,,,,,0,625.01,4568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD FADER TIP 19CM 10FR DRNG PERCUFLEX LOCK PIGTAIL",SUP-M0064102030,CDM,C1729,HCPCS,0272,RC,,,both,,,713.85,214.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,293.39,41.1,,,,,0,83.02,606.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 55MM R3CON NONSTERILE GORILLA PLATE SYSTEM",SUP-P50-453-4255,CDM,C1713,HCPCS,0278,RC,,,both,,,1113.75,334.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,757.35,68,,,,,0,129.53,946.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP LIMIT HOLE OSSEOTI G7 E",SUP-110010244,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 11MM 6MM 4FR AMPLATZER .038IN NITINOL 2",SUP-9-AVP038-006,CDM,S27800098,LOCAL,0278,RC,,,both,,,7141.50,2142.45,"MULTIPLAN [10600]",Multiplan,,6070.28,85,,,,,0,830.56,6070.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR 14X9MM ENCAP TECHNOLOGY",SUP-C0914,CDM,C1768,HCPCS,0278,RC,,,both,,,4767.21,1430.16,"PHCS [10601]",PHCS,,3337.05,70,,,,,0,554.43,4052.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 51MM STAINLESS STEEL 2.4MM SCR 6 HOLE HEAD 3",SUP-02.111.530S,CDM,C1713,HCPCS,0278,RC,,,both,,,4217.63,1265.29,"AETNA [10100]","Aetna HMO/PPO",,3353.02,79.5,,1521.93,481.35,16760.95,30,490.51,3584.99,"percent of total billed charges",
"VALVE PULMONARY 10-21MM CRYOVALVE SG HEART WITHOUT CONDUIT",SUP-SGPV10-22-26,CDM,S27800098,LOCAL,0278,RC,,,both,,,145293.00,43587.9,"MULTIPLAN [10600]",Multiplan,,123499.05,85,,,,,0,16897.58,123499.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cleanser Saf-Clens Wound",PX-E27000081,CDM,E27000081,LOCAL,0270,RC,,,both,,,73.70,22.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.57,62.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER CHOCOLATE 40MM 2.5MM .014IN BALLOON DILATATION GUID",SUP-CB1415025040OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"PHCS [10601]",PHCS,,4008.9,70,,,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet Myocrd Perf Multi R&S W CT",PX-404000015,CDM,78431,CPT,0404,RC,,,both,,,5158.00,1547.4,"KAISER [10500]",Kaiser,,3455.86,67,,,,,0,599.88,5158,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYOSURE 1.8MM 54MM 140ML/MIN 300 MMHG 14MM 32CM 3MM",SUP-10-401,CDM,S27200284,LOCAL,0272,RC,,,both,,,5692.50,1707.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2612.86,45.9,,,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 16MM 144CM 4MM CORONARY STENT",SUP-H7493911416400,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA [10200]","Cigna Open Access",,5202.08,56.9,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 48CM 15FR 1.9ML PALINDROME REVERSE TUNNEL HUB SNAP",SUP-8888541028P,CDM,C1750,HCPCS,0278,RC,,,both,,,2669.19,800.76,"BLUE CROSS [10001]","Blue Cross HMO",,1046.32,39.2,,,,,0,310.43,2268.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM STAINLESS STEEL T15 CORTEX SELF TAP LOW",SUP-02.206.226,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"NOVANET [10819]",Novanet,,242.99,75,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 40MM PEGGED CORTILOC",SUP-DWE421,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"PHCS [10601]",PHCS,,6521.2,70,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN LOCK-OUT PUMP SET INFLAT SELF CONTAIN",SUP-ES2920,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"KAISER [10500]",Kaiser,,42009,67,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661140,CDM,C1713,HCPCS,0278,RC,,,both,,,1377.32,413.2,"PHCS [10601]",PHCS,,964.12,70,,,,,0,160.18,1170.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE 11IN VALLEYLAB STERILE ARGON",SUP-E3580-28,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.15,88.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,34.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.21,250.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 20X25MM ARTHREX DYNANITE NITINOL TITANIUM",SUP-AR-8719DS-2520,CDM,C1713,HCPCS,0278,RC,,,both,,,15835.50,4750.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1841.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1841.67,13460.18,"percent of total billed charges",
"BEARING 79/83MMX16MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183566,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"PHCS [10601]",PHCS,,9066.88,70,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G211,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6368.93,68,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17.5 DIOPTER HAPTIC C BICONVEX 13MM 6MM POSTERIOR",SUP-ZXR00U0175,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"MULTIPLAN [10600]",Multiplan,,633.25,85,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT ACM BREAK-AWAY MIX BOWL BASE CRTDG FEMORAL",SUP-0306-563-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,630.00,189,"NOVANET [10819]",Novanet,,472.5,75,,,,,0,73.27,535.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 12MM KII Z THREAD SLEEVE BALLOON",SUP-CFR71,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA [10200]","Cigna Open Access",,103.96,56.9,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT PARALLEL ALLOGRAFT 10MM TLIF",SUP-3W3310,CDM,S27800098,LOCAL,0278,RC,,,both,,,17139.60,5141.88,"BLUE CROSS [10001]","Blue Cross HMO",,6718.72,39.2,,,,,0,1993.34,14568.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SMOOTH SHELL",SUP-SCM-330,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3467.97,45.9,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR IMPLANTABLE INCEPTIV MRI STERILE LATEX FREE",SUP-977119,CDM,C1826,HCPCS,0278,RC,,,both,,,124830.00,37449,"PHCS [10601]",PHCS,,87381,70,,,,,0,14517.73,106105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp B1 Marow Smr",PX-305000088,CDM,0855T,CPT,0312,RC,,,both,,,104.00,31.2,"KAISER [10500]",Kaiser,,69.68,67,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 7CM 7FR DUODENAL BEND BILIARY PLASTIC TEMPORARY RAPID",SUP-M00545560,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"CIGNA [10200]","Cigna Open Access",,485.23,56.9,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.2MM 7MM APTUS TITANIUM 4MM HEAD HAND CORTICAL",SUP-A-5100.07/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"KAISER [10500]",Kaiser,,846.61,67,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM MITRAL SEMIRIGID MEMO 3D",SUP-SMD26,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"UHC [10700]","United Healthcare",,8080.25,63.3,,,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10MM 65MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712165,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"STRAP CLAVICLE XL HOOK LOOP CLSR",SUP-3002-05,CDM,S27000186,LOCAL,0270,RC,,,both,,,85.70,25.71,"CIGNA [10200]","Cigna Local Plus",,45.85,53.5,,,,,0,9.97,72.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST FIXATION 25MM 4.5MM KNEE BICORTICAL TITANIUM SELF TAP",SUP-AR-1365-25,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"NOVANET [10819]",Novanet,,637.88,75,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X15MM 9/11MM SPINE CORTICAL FROZEN DISTAL",SUP-4915,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"FIRST HEALTH [10303]","First Health",,13248,80,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT WALKING GENESIS LARGE 3 STRAP ULTRA LIGHTWEIGHT LOW",SUP-BL515007,CDM,S27000186,LOCAL,0270,RC,,,both,,,434.91,130.47,"CIGNA [10200]","Cigna Local Plus",,232.68,53.5,,,,,0,50.58,369.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 36MM UNIVERS REVERS +6MM SMALL SHOULDER",SUP-AR-9503S-06,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"NOVANET [10819]",Novanet,,2205,75,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE KORE FIBER CORTICAL BONE FIBER ALLOGRAFT STRIP",SUP-423302,CDM,C1713,HCPCS,0278,RC,,,both,,,13192.80,3957.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3562.06,27,,,,,0,1534.32,11213.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 4FR 11CM AVANTI+ MID LENGTH ENDOVASCULAR",SUP-402604A,CDM,C1894,HCPCS,0272,RC,,,both,,,50.03,15.01,"KAISER [10500]",Kaiser,,33.52,67,,,,,0,5.82,42.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 5-6MM 5-6MM RELINE-O SPINE OFFSET HOOK ROTATE",SUP-11104055,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross HMO",,1396.5,39.2,,957.42,156.86,7483.26,51,414.32,3028.13,"percent of total billed charges",
"GRAFT SOFT TISSUE 8X4CM ALLOPATCH DERMAL MATRIX ALLOGRAFT",SUP-WC0448,CDM,Q4128,HCPCS,0636,RC,,,both,,,11937.00,3581.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5341.81,44.75,,,,,0,80.43,10146.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM 30MM GELWEAVE VALSALVA MASTERS HP POROUS",SUP-29VAVGJ-515,CDM,S27800098,LOCAL,0278,RC,,,both,,,36805.86,11041.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4361.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4280.52,31284.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 50MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.121,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"NOVANET [10819]",Novanet,,642.98,75,,,,,0,99.7,728.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL DEXTILE 16X12CM LEFT ANATOMICAL 3D",SUP-DXT1612AL,CDM,C1781,HCPCS,0278,RC,,,both,,,1616.68,485,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,742.06,45.9,,,,,0,188.02,1374.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4.5MM TARGET TETRA DETACHABLE STERILE",SUP-TG5414510,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]","Cigna Local Plus",,4446.11,31.5,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 26MM 2.25MM CORONARY RAPID EXCHANGE",SUP-ONYXNG22526UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1204.88,45.9,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE ORTHOPEDIC VITALLIUM 2MM HOMOGENOUS DALL-MILES 2",SUP-6704-0-510,CDM,C1713,HCPCS,0278,RC,,,both,,,1440.74,432.22,"NOVANET [10819]",Novanet,,1080.56,75,,,,,0,167.56,1224.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAT SUCTION 56X36IN THE SUCTIONER FOAM ABSORBABLE",SUP-USA-X10,CDM,S27200284,LOCAL,0272,RC,,,both,,,671.90,201.57,"CIGNA [10200]","Cigna Open Access",,382.31,56.9,,,,,0,78.14,571.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME TALAR INFINITY 3 ANKLE ADAPTIS FLAT CUT NONSTERILE",SUP-33680033,CDM,C1776,HCPCS,0278,RC,,,both,,,36981.00,11094.3,"NOVANET [10819]",Novanet,,27735.75,75,,,,,0,4300.89,31433.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL GEMINI 9IN",SUP-54-7258,CDM,S27200284,LOCAL,0272,RC,,,both,,,215.76,64.73,"CIGNA [10200]","Cigna Local Plus",,115.43,53.5,,,,,0,25.09,183.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 60MM 120CM 9MM .079IN LARGE DIAMETER",SUP-SERB65-09-60-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 64.5X59.7MM KNEE LEFT BICRUCIATE STABILIZE",SUP-74022124,CDM,C1776,HCPCS,0278,RC,,,both,,,37771.65,11331.49,"BLUE CROSS [10001]","Blue Cross PPO",,14806.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",4392.84,32105.9,"percent of total billed charges",
"SPACER 4421405 GTECH CORT LORD LG 5MM",SUP-4421405,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 31CM 15FR 18GA .038IN POLYURETHANE CANNON II PLUS",SUP-CS-15362-VSP,CDM,C1750,HCPCS,0278,RC,,,both,,,2400.00,720,"PHCS [10601]",PHCS,,1680,70,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SMOOTH SHELL",SUP-SCM-310,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2162.38,28.62,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 5.5MM CHROMALOY PLUS CURVED",SUP-1556001090,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE EVERPOINT 6-0 BV 24IN 2 ARM MONOFILAMENT BLUE",SUP-8610H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 30MM TI",SUP-MTLS-37300-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,1144.80,304.56,2275.09,66,155.43,1136.03,"percent of total billed charges",
"LENS IOL 10 D +9.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200095,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"KAISER [10500]",Kaiser,,683.8,67,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP060100090 PLUS US D6L100UL900",SUP-PCP060100090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"FIRST HEALTH [10303]","First Health",,984.96,80,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 6 STD KNEE LEFT KEEL NONPOROUS",SUP-ETPKN6SL,CDM,C1776,HCPCS,0278,RC,,,both,,,11060.70,3318.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3165.57,28.62,,,,,0,1286.36,9401.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2-2.4MM CANNULATED DISPOSABLE",SUP-212-24-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.00,495,"FIRST HEALTH [10303]","First Health",,1320,80,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 10CM 6MM BALLOON DILATATION ILIAC",SUP-G34337,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MACH1 90CM 8FR JR4 CURVE GUIDING PTFE FEMORAL",SUP-H749343587080,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TURNPIKE 135CM 2.9FR 2.1FR VASCULAR MULTILAYER SHAFT",SUP-5621,CDM,C1887,HCPCS,0272,RC,,,both,,,4243.50,1273.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 70CM 145CM 5FR 20D .035IN URETERAL ANGLED TIP BEVELED",SUP-G14600,CDM,C1758,HCPCS,0272,RC,,,both,,,272.75,81.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEONATE WITH OTHER SIGNIFICANT PROBLEMS",794,MS-DRG,,,,,,,inpatient,,,7484.75,2245.42,"CIGNA [10200]","Cigna Local Plus",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET TITANIUM 5.5MM SPINE 1 INNER NONSTERILE VIPER",SUP-186715000,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,170.52,39.2,,957.42,570.23,957.42,28,50.59,369.75,"percent of total billed charges",
"CATH CONQUEST 75CM 2CM 8MM 6FR BALLOON DILATATION PERIPHERAL",SUP-CQ7582,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC NDL 160CM 2.8MM RADIAL JAW 4 35CM LARGE",SUP-M00513313,CDM,S27200284,LOCAL,0272,RC,,,both,,,171.30,51.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,116.48,68,,,,,0,19.92,145.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CARDIAC MNTR REVEAL LINQ INSERTABLE",SUP-LNQ11,CDM,C1764,HCPCS,0278,RC,,,both,,,17982.00,5394.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2091.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2091.31,15284.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +28 DIOPTER MODIFIED C BICONVEX 12.5MM 7MM",SUP-CZ70BD.280,CDM,V2632,HCPCS,0276,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,170.52,39.2,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC ITREVIA 7 VR-T DF-4 CNCT",SUP-393041,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"BLUE CROSS [10001]","Blue Cross HMO",,15288,39.2,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCK AUGMENTATION OSS 71/75MMX20MM KNEE TIBIA RIGHT MEDIAL",SUP-150431,CDM,C1776,HCPCS,0278,RC,,,both,,,8232.39,2469.72,"NOVANET [10819]",Novanet,,6174.29,75,,,,,0,957.43,6997.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DECA 5-5-5-24-3-3-3-3-3 MPA 120CM",SUP-901828,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2014.5,68,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII POSTERIOR STABILIZED HYB",SUP-71704535,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"KAISER [10500]",Kaiser,,14773.5,67,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 12X11.3CM 10.9CM MEMORYGEL COHESIVE III CPG 322",SUP-3341205,CDM,C1789,HCPCS,0278,RC,,,both,,,8107.50,2432.25,"KAISER [10500]",Kaiser,,5432.03,67,,,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL ETHI-PACK 4-0 18IN MONOFILAMENT TIES",SUP-DS32,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PHCS [10601]",PHCS,,17.5,70,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT CRUCIATE RETAIN JOURNEY II OXINIUM",SUP-74021163,CDM,C1776,HCPCS,0278,RC,,,both,,,37771.65,11331.49,"FIRST HEALTH [10303]","First Health",,30217.32,80,,,,,0,4392.84,32105.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR BED 32X12.5IN POSEY 6 MONTH 1 RESIDENT PAD OVER MATRS",SUP-8307,CDM,S27000186,LOCAL,0270,RC,,,both,,,223.33,67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.97,189.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11MM CORNERSTONE PSR 11MM PEEK-OPTIMA LIF",SUP-6287141,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"AETNA [10100]","Aetna HMO/PPO",,5309.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (OTW)  2.00MM X 10MM",SUP-H74939402102000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,641.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 29MM STD SEWING CUFF",SUP-M7-029,CDM,S27800098,LOCAL,0278,RC,,,both,,,22711.50,6813.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6132.11,27,,,,,0,2641.35,19304.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 28MM TI",SUP-MTC-37280-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"CIGNA [10200]",Cigna,,848.23,68,,1831.33,1831.33,1831.33,16,145.07,1060.29,"percent of total billed charges",
"BIOPSY A LA CARTE BFD BIOPSY (BONE FILLER DEVICE) (4 PACK) (",SUP-OF-0298,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 85MM TITANIUM PERIARTICULAR LOCK CANNULATED",SUP-04.205.085,CDM,C1713,HCPCS,0278,RC,,,both,,,1399.36,419.81,"FIRST HEALTH [10303]","First Health",,1119.49,80,,,,,0,162.75,1189.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752700,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,258.2,28.62,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION CURITY ADD-A-CATH 30CC INSRT PREFILL",SUP-5027,CDM,S27200284,LOCAL,0272,RC,,,both,,,45.68,13.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP ASPIR 25KHZ UNIVERSAL STRAIGHT SONOPET DISPOSABLE",SUP-5450800307,CDM,S27200284,LOCAL,0272,RC,,,both,,,4262.78,1278.83,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INTROCAN SAFETY 1.25IN 24GA STRAIGHT IV POLYURETHANE",SUP-4251623-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.55,16.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASKET STONE RETRIEVAL 90CM 1.3FR 6-11MM OPTIFLEX SMALL",SUP-M0063903000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1652.33,495.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 20CM 12FR 18GA .035IN POLYURETHANE ARROWG+ARD BLUE",SUP-AK-25122-F,CDM,C1752,HCPCS,0272,RC,,,both,,,936.36,280.91,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,inpatient,,,126140.57,37842.17,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL SMALL 65X55MM RIGHT KNEE MODULAR ROTATING",SUP-64811111,CDM,C1776,HCPCS,0278,RC,,,both,,,15373.80,4612.14,"CIGNA [10200]","Cigna Open Access",,5150.22,33.5,,5302.19,4377.88,6578.61,27,1787.97,13067.73,"percent of total billed charges",
"HEAD FEMORAL +4MM 12/14 TAPER 32MM HIP OXINIUM ECHELON",SUP-71343204,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"KAISER [10500]",Kaiser,,10408.68,67,,,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 5MM AVENIR 10 HELICAL FINISH STERILE",SUP-10HFN-05008,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA [10200]",Cigna,,7033.31,68,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CANTATA 135CM 2.8FR .025IN MICRO INTERVENTIONAL",SUP-G54535,CDM,S27200284,LOCAL,0272,RC,,,both,,,3142.43,942.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2136.85,68,,,,,0,365.46,2671.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PLUS PROFILE SILICONE",SUP-SCLP-190,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"NOVANET [10819]",Novanet,,5666.63,75,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 22MM 3.5MM CORONARY STENT FULCRUM COCR",SUP-INT35022UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"BLUE CROSS [10001]","Blue Cross HMO",,946.68,39.2,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) QUALIBRA ADVANCED XXXL",SUP-QADV-XXXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7.5CM 3.5MM CEREPAK FREEFORM DETACHABLE",SUP-SCR123575,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA [10200]","Cigna Local Plus",,4166.14,31.5,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 8.25IN OLSEN MIDAS TOUCH BAYONET",SUP-20-1440IMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,919.32,275.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,106.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,106.92,781.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 14MM 3FR GEMINI HELICAL",SUP-M0063302080,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"KAISER [10500]",Kaiser,,991.3,67,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FRONTRUNNER XP CTO 132CM 126CM 4.5FR ANGIOGRAPHIC",SUP-MGX39140,CDM,S27200284,LOCAL,0272,RC,,,both,,,1441.80,432.54,"UHC [10700]","United Healthcare",,912.66,63.3,,,,,0,167.68,1225.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL VASCULAR 190",SUP-1009660,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.50 X 08 RX US",SUP-1804250-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Wnd Rmvl Tis Non-Sel (Gp)",PX-420000034,CDM,97602,CPT,0420,RC,,,both,,,625.00,187.5,"FIRST HEALTH [10303]","First Health",,500,80,,,,,0,72.69,625,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 16MM 135CM 4MM .018IN BILIARY STAINLESS",SUP-G56619,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"PHCS [10601]",PHCS,,3528,70,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP TOTAL SHOULDER ANATOMIC",SUP-CP-UNIVERS-APEX,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"FIRST HEALTH [10303]","First Health",,21420,80,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 87.9MM THK1.27MM THK1.6MM 12.2MM RECIPROCATE HEAVY",SUP-5301-020-061S1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR SILICONE FEEDING TUBE PULL METHOD RETENTION",SUP-7180-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.81,228.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,90.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,88.6,647.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 38MM 2 LEVEL ARCHON BONE SPINE NONSTERILE",SUP-8787238,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 52CM .013IN BRADY SFT",SUP-6048,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVOLUTION 4CM 10MM 11MM BILIARY PLATINUM RADIOPACITY",SUP-G23127,CDM,C1876,HCPCS,0278,RC,,,both,,,8820.00,2646,"CIGNA [10200]",Cigna,,5997.6,68,,,,,0,1025.77,7497,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM MEDLINE UNITE NONSTERILE",SUP-MPSN3538,CDM,C1713,HCPCS,0278,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,460.4,39.2,,957.42,156.86,7483.26,51,136.59,998.33,"percent of total billed charges",
"VALVE AORTIC 25MM MASTERS HEMODYNAMIC PLUS MECHANICAL STD",SUP-25AHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"NOVANET [10819]",Novanet,,21839.42,75,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,,,0250,RC,00406-8315-23,NDC,both,1,UN,16.65,4.99,"FIRST HEALTH [10303]","First Health",,13.32,80,,,,,0,1.94,14.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 54MM TI",SUP-MTLS-37540-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SHUNT YELLOW MINOR VENTRICULAR ENLARGEMENT",SUP-903335A,CDM,C1729,HCPCS,0272,RC,,,both,,,9242.76,2772.83,"UHC [10700]","United Healthcare",,5850.67,63.3,,,,,0,1074.93,7856.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUCICLOVINE F-18 INTRAVENOUS SOLUTION (12-13 MCI)|DISCARDED DRUG NOT ADMINISTE",RX-411838,CDM,A9588,HCPCS,0343,RC,08888-8877-90,NDC,both,1,UN,638.44,191.53,"NOVANET [10819]",Novanet,JW,478.83,75,,,,,0,74.25,638.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 STD KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508605801,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"KAISER [10500]",Kaiser,,17579.62,67,,,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 40MM 130CM 8MM VASCULAR METAL SUPERFICIAL",SUP-H74939293084030,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross PPO",,1893.36,39.2,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 28MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.208,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,103.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,101.55,742.2,"percent of total billed charges",
"SUT MONOCRYL PLUS 5-0 P-3 18IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP493G,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.80,20.94,"UHC [10700]","United Healthcare",,44.18,63.3,,,,,0,8.12,59.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 8FR 18GA 16CM .032IN 2 LUMEN CATH GWIRE NDL SHARP",SUP-AK-42802-CDC,CDM,C1751,HCPCS,0272,RC,,,both,,,514.80,154.44,"UHC [10700]","United Healthcare",,325.87,63.3,,,,,0,59.87,437.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT POSTERIOR STABILIZE BEAD TRIATHLON",SUP-5516F601,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4956.11,28.62,,,,,0,2013.96,14719.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 26MM 140CM 3.5MM",SUP-RSINT35026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"AETNA [10100]","Aetna HMO/PPO",,4407.48,79.5,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 22MM TI",SUP-MTLS-37220-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,1144.80,304.56,2275.09,66,155.43,1136.03,"percent of total billed charges",
"PRGMR NEROSTIMLTR 22X10X4CM INTERSTIM 5L SACRAL",SUP-3037,CDM,C1787,HCPCS,0270,RC,,,both,,,13455.00,4036.5,"CIGNA [10200]","Cigna Open Access",,7655.9,56.9,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 18GA 50CM 11CM ORANGE HUB DIL GWIRE",SUP-PSI-7F-11-035-18G,CDM,C1894,HCPCS,0272,RC,,,both,,,102.23,30.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING SL 150CM 120MM 3.8FR 2MM BALLOON DILATATION",SUP-H74939148201210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DYNAMIC TIP 110CM 6FR 5MM SPACE LARGE 4 CURVE",SUP-200344,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DIAMONDBACK 180CM 30MM 1.75MM ATHERECTOMY PERIPHERAL",SUP-DBP-175SOLID180,CDM,C1724,HCPCS,0272,RC,,,both,,,22648.50,6794.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"BLADE SHAVER 2MM PK DIEGO STRAIGHT TURBINATE SINUS SERRATE",SUP-7013-8033,CDM,S27200284,LOCAL,0272,RC,,,both,,,897.05,269.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASKET SPECIMEN RETRIEVAL 6CM 3CM 3CM RAPID EXCHANGE LITHO",SUP-M00510890,CDM,S27200284,LOCAL,0272,RC,,,both,,,2036.93,611.08,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 32MM 144CM 2.75MM",SUP-H7493941232270,CDM,C1874,HCPCS,0278,RC,,,both,,,8245.50,2473.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,977.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,958.95,7008.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 12X18X60MM 10DEG POROUS EXTREME LATERAL LORDOTIC",SUP-1181260P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-03006,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"BLUE CROSS [10001]","Blue Cross HMO",,3513.54,39.2,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) HELO BLOOD RETURN SYSTEM (HELO BRS)",SUP-5001,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 0 .5 CIRCLE 4 DIAMOND SUTURETAK FIBERWIRE SMALL",SUP-AR-8934BCNF-00,CDM,C1713,HCPCS,0272,RC,,,both,,,2559.38,767.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1051.91,41.1,,,,,0,1051.91,1620.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE TALAR STERILE",SUP-351-90-24,CDM,C1713,HCPCS,0278,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",94.2,688.5,"percent of total billed charges",
"SUT PROLENE 7-0 BV175-6 24IN 2 ARM MONOFILAMENT 4 STRAND",SUP-M8735,CDM,S27200284,LOCAL,0272,RC,,,both,,,895.31,268.59,"FIRST HEALTH [10303]","First Health",,716.25,80,,,,,0,104.12,761.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION",RX-9748,CDM,J2597,HCPCS,0636,RC,43598-0931-11,NDC,both,1,ML,286.82,86.05,"CIGNA [10200]","Cigna Local Plus",,36.71,,,,,,,16.41,243.8,"fee schedule",
"PACK CATH 36CM 14.5FR PALINDROME 2 LUMEN SYMMETRIC TIP",SUP-8888119360P,CDM,C1750,HCPCS,0278,RC,,,both,,,2649.68,794.9,"MULTIPLAN [10600]",Multiplan,,2252.23,85,,,,,0,308.16,2252.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP 5CC ALLOGRAFT PUTTY",SUP-14100401,CDM,C1713,HCPCS,0278,RC,,,both,,,7458.76,2237.63,"CIGNA [10200]","Cigna Open Access",,4244.03,56.9,,1144.80,304.56,2275.09,66,867.45,6339.95,"percent of total billed charges",
"SYSTEM PROMUS PREMIER 20MM 144CM 4MM CORONARY STENT",SUP-H7493952820400,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,647.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR NELLCOR OXIMAX LOSAT ASSORTED FOREHEAD OXIMETER SPO2",SUP-MAX-N,CDM,S27000186,LOCAL,0270,RC,,,both,,,172.79,51.84,"CIGNA [10200]",Cigna,,117.5,68,,,,,0,20.1,146.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PLATE 3 66X42MM STEMMED NEXGEN PRECOAT TIVANIUM",SUP-00598003701,CDM,C1776,HCPCS,0278,RC,,,both,,,8643.60,2593.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5877.65,68,,,,,0,1005.25,7347.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 16MM XTEND SPINE VARIABLE ANGLE SELF DRILL",SUP-161.016,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,163.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",163.98,1198.5,"percent of total billed charges",
"HC Hpv Types 16 & 18 Only",PX-306000193,CDM,87625,CPT,0306,RC,,,both,,,249.85,74.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,212.37,"per diem",
"KNIFE ARTHROSCOPIC GRAFT 10MM ACL STERILE DISPOSABLE",SUP-232110,CDM,S27200284,LOCAL,0272,RC,,,both,,,1665.00,499.5,"CIGNA [10200]","Cigna Open Access",,947.39,56.9,,,,,0,193.64,1415.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVERLAY MATTRESS W34XL75IN THK3IN C600LB STATIC AIR EXPANSIO",SUP-1005ECPX060,CDM,S27000186,LOCAL,0270,RC,,,both,,,291.45,87.43,"AETNA [10100]","Aetna HMO/PPO",,231.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.9,247.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 70X12.5X.64MM STAINLESS STEEL RECIPROCATING 2",SUP-0277096275,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.41,87.12,"PHCS [10601]",PHCS,,203.29,70,,,,,0,33.77,246.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 90ML .5-5MM 80% CORTICAL 20% CANCELLOUS",SUP-400060,CDM,C1713,HCPCS,0278,RC,,,both,,,5938.83,1781.65,"CIGNA [10200]","Cigna Open Access",,3379.19,56.9,,1144.80,304.56,2275.09,66,690.69,5048.01,"percent of total billed charges",
"CAP COMPREHENSIVE SHORT STEM/TITANIUM GLENOID/TITANIUM HEAD",SUP-98B00900136,CDM,C1776,HCPCS,0278,RC,,,both,,,39375.00,11812.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10631.25,27,,,,,0,4579.31,33468.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 4-0 P-12 18IN CLSR ABSORBABLE CLEAR",SUP-VLOCL0023,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.73,70.42,"FIRST HEALTH [10303]","First Health",,187.78,80,,,,,0,27.3,199.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X7-4.1MM ROI-C 12MM LORDOTIC CERVICAL .38ML","SUP-MC 1443 P",CDM,S27800098,LOCAL,0278,RC,,,both,,,12171.00,3651.3,"UHC [10700]","United Healthcare",,7704.24,63.3,,,,,0,1415.49,10345.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SURGICAL CHECKPOINT FEMORAL",SUP-111644,CDM,S27200284,LOCAL,0272,RC,,,both,,,428.04,128.41,"CIGNA [10200]",Cigna,,291.07,68,,,,,0,49.78,363.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 0D E X3 TRIDENT STERILE LATEX FREE",SUP-723-00-36E,CDM,C1776,HCPCS,0278,RC,,,both,,,9332.25,2799.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4283.5,45.9,,,,,0,1085.34,7932.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL WHITE 28.9FR HOOK STERILE",SUP-8427.0925,CDM,S27200284,LOCAL,0272,RC,,,both,,,654.09,196.23,"NOVANET [10819]",Novanet,,490.57,75,,,,,0,76.07,555.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 9IN LAMBOTTE SURGICAL CURVE 1IN",SUP-28-9475,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.68,71.3,"CIGNA [10200]","Cigna Open Access",,135.24,56.9,,,,,0,27.64,202.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 45MM 6.5MM SPINE CORTICAL",SUP-55900106545,CDM,C1713,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1678.56,28.62,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 36FR VENOUS 1 STAGE DLP STERILE LATEX FREE",SUP-66136,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.63,85.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,131.1,45.9,,,,,0,33.22,242.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500005802,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"PHCS [10601]",PHCS,,16003.89,70,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 14MM NEXGEN LPS-FLEX 3-4 C-D KNEE PROLONG",SUP-596203014,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"AETNA [10100]","Aetna HMO/PPO",,6295.16,79.5,,10981.53,8986.79,12413.38,12,920.91,6730.67,"percent of total billed charges",
"GORE CARDIOFORM SEPTAL OCCLUDER 20MM 10FR",SUP-00733132631018,CDM,C1817,HCPCS,0278,RC,,,both,,,60826.50,18247.95,"PHCS [10601]",PHCS,,42578.55,70,,,,,0,7074.12,51702.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 50MM 2-3MM AVANCE NERVE ALLOGRAFT MULTIPLE",SUP-211250,CDM,C1762,HCPCS,0278,RC,,,both,,,45000.90,13500.27,"CIGNA [10200]","Cigna Open Access",,15075.3,33.5,,,,,0,5233.6,38250.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE VISCOSURGICAL HEALON DUET",SUP-10240016,CDM,S27200284,LOCAL,0272,RC,,,both,,,947.70,284.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,110.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 26MM 3.5MM CORONARY STENT FULCRUM COCR",SUP-INT35026UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"MULTIPLAN [10600]",Multiplan,,2052.75,85,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP CONSTRUCT 1 HIP WITH CERAMIC HEAD",SUP-CAP-STY-H1,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X10MM COROENT XL+ NONSTERILE LATEX FREE",SUP-6010850,CDM,C1889,HCPCS,0278,RC,,,both,,,23940.00,7182,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 550ML SMOOTH MEMORYGEL COHESIVE I SILICONE P5.5","SUP-3505504 BC",CDM,S27800098,LOCAL,0278,RC,,,both,,,3780.00,1134,"AETNA [10100]","Aetna HMO/PPO",,3005.1,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CENTER",SUP-5573-6540,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"NOVANET [10819]",Novanet,,1166.78,75,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 27MM PRECISION THK.38MM TAPER THIN MICRO",SUP-5100-137-233,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.38,176.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,241.82,41.1,,,,,0,68.43,500.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRACTURES OF FEMUR WITH MCC",533,MS-DRG,,,,,,,inpatient,,,64276.91,19283.07,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH C2 CRYOBALLOON PEAR ABLATION FOCAL STERILE LATEX FREE",SUP-FG-1024,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"ROD SPINAL 45MM 5.5MM CD HORIZON CURVE TITANIUM NONSTERILE",SUP-1553201045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"TUBE NASOGASTRIC 43IN 8FR SMOOTH BOLUS RADIOPAQUE STYLET",SUP-40-3438,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.52,22.06,"KAISER [10500]",Kaiser,,49.26,67,,,,,0,8.55,62.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTABLATOR ROTALINK PLUS 135CM .58IN 1.25MM ATHERECTOMY",SUP-H749236310020,CDM,C1724,HCPCS,0272,RC,,,both,,,8534.13,2560.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,992.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,992.52,7254.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 8MM 3MM HALL MICROPOWER MICRO100 MEDIUM SMALL",SUP-509122600,CDM,S27000186,LOCAL,0270,RC,,,both,,,361.92,108.58,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.09,307.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HALOPERIDOL 5 MG TABLET",RX-3583,CDM,,,0637,RC,70756-0004-11,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661038,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"PHCS [10601]",PHCS,,914,70,,,,,0,151.86,1109.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ VASCULAR 3CM STRAIGHT 180CM 8CM .035IN",SUP-G28781,CDM,C1769,HCPCS,0272,RC,,,both,,,247.86,74.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.83,210.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 36MM 2 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.236,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross PPO",,1728.72,39.2,,957.42,570.23,957.42,28,512.88,3748.5,"percent of total billed charges",
"PENICILLIN VK DESENSITIZATION ORAL (5 MG/ML)",RX-411687,CDM,,,0250,RC,08888-8877-43,NDC,both,20,ML,12.54,3.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"3.5 X 28MM ESPRIT BTK IDE",SUP-1202350-28,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE UROLOGICAL STRAIGHT 150CM 3CM .025IN PTFE FLEXIBLE TIP",SUP-M0066201070,CDM,C1769,HCPCS,0272,RC,,,both,,,93.35,28,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 12.75CM NATRELLE INSPIRA P6.2CM EXTRA FULL",SUP-MSZ-X525,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"5F DECA 2-8-2 CS 120CM",SUP-901530,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 81.5X12.5X1.19MM NARROW THICK STAINLESS STEEL",SUP-2108152000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SKIN OMEGA3 LYOPHILIZED ACELLULAR FISH SKIN STERILE",SUP-50200P04D0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,13800.00,4140,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL MONOFOCAL PRELOAD 1 PIECE UV BLOCK TECNIS ITEC",SUP-PCB0000240,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 3-2MM TORNADO MICROCOILS PLATINUM",SUP-G08261,CDM,S27800098,LOCAL,0278,RC,,,both,,,696.60,208.98,"BLUE CROSS [10001]","Blue Cross HMO",,273.07,39.2,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 32MM 1 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800132,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 1MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0105,CDM,S27800098,LOCAL,0278,RC,,,both,,,5451.00,1635.3,"PHCS [10601]",PHCS,,3815.7,70,,,,,0,633.95,4633.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +20 DIOPTER BICONVEX 10.7MM 6MM POSTERIOR CHMBR",SUP-AO60P2000,CDM,V2632,HCPCS,0276,RC,,,both,,,1036.80,311.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,120.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH DRUG DELIVERY 80 MINUTE IONTOPATCH WIRELESS SELF",SUP-A939650,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.05,14.71,"NOVANET [10819]",Novanet,,36.79,75,,,,,0,5.7,41.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17MM 27MM 25MM EPIC LINX SUPRA BIOPROSTHESIS",SUP-E100-27A-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,36722.70,11016.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10510.04,28.62,,,,,0,4270.85,31214.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +23 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.230,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"MULTIPLAN [10600]",Multiplan,,293.25,85,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 5MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620905,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1308.83,9565.82,"percent of total billed charges",
"FILLER BONE VOID 90ML .5-5MM 80% CORTICAL 20% CANCELLOUS",SUP-400060,CDM,C1713,HCPCS,0278,RC,,,both,,,5938.83,1781.65,"CIGNA [10200]",Cigna,,4038.4,68,,1831.33,1831.33,1831.33,16,690.69,5048.01,"percent of total billed charges",
"COUNTSINK DRILL DARCO ORTHOLOC ANKLE FUSION PLATING SYSTEM",SUP-98230532,CDM,S27200284,LOCAL,0272,RC,,,both,,,1239.30,371.79,"UHC [10700]","United Healthcare",,784.48,63.3,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL SMALL UNIVERSAL 12MM KNEE COCR POLYETHYLENE",SUP-198727212,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"CIGNA [10200]","Cigna Local Plus",,9307.11,31.5,,5372.07,4581.20,7242.98,23,3436.24,25114.41,"percent of total billed charges",
"STENT URETERAL 7FR L30CM SOFT WITHOUT GUIDEWIRE TRIA",SUP-M0061903350,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500005802,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"KAISER [10500]",Kaiser,,15318.01,67,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 100CM 1MM 4FR 5MM SPACE H CURVE ELECTROPHYSIOLOGY 10",SUP-F4QH005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"PHCS [10601]",PHCS,,635.04,70,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 13X13.5CM BREAST 500ML STYLE 133FV TEXTURE",SUP-133FV-13,CDM,C1789,HCPCS,0278,RC,,,both,,,5460.00,1638,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1562.65,28.62,,,,,0,635,4641,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID",RX-28188,CDM,,,0637,RC,00116-1061-04,NDC,both,118,ML,28.21,8.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,19.18,68,,,,,0,3.28,23.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE MATRISTEM MICROMATRIX PORCINE URINARY",SUP-MM0500,CDM,Q4118,HCPCS,0278,RC,,,both,,,5699.40,1709.82,"CIGNA [10200]","Cigna Local Plus",,6.84,,,,,,,6.84,4844.49,"fee schedule",
"COIL EMBOLIZATION 3CM 1.5MM DELTAXSFT 10 COIL",SUP-DLX100153,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"MULTIPLAN [10600]",Multiplan,,7694.88,85,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR CATALYSTEM 8 STD OFFSET HIP STERILE",SUP-71314028,CDM,C1776,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16929,27,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 16MM 144CM 4MM CORONARY STENT",SUP-H7493952816400,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Local Plus",,2977.28,53.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL PLIF 17 DEGREE 7MM X 11MM X 28MM MOD-EX",SUP-1937128P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"BLUE CROSS [10001]","Blue Cross PPO",,13582.8,39.2,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM NASAL 6IN LARGE HARTMANN-HALLE BLADE 32MM",SUP-66-0303,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.21,140.16,"CIGNA [10200]","Cigna Local Plus",,249.96,53.5,,,,,0,54.34,397.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER PROBE ISOSILK 96X5IN L TIP ANGLED TAPE STRIP GEL",SUP-PC1153,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.81,14.64,"PHCS [10601]",PHCS,,34.17,70,,,,,0,5.68,41.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 90ML .5-5MM 80% CORTICAL 20% CANCELLOUS",SUP-400060,CDM,C1713,HCPCS,0278,RC,,,both,,,5938.83,1781.65,"PHCS [10601]",PHCS,,4157.18,70,,,,,0,690.69,5048.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY 34MM 140CM 3MM CORONARY STENT",SUP-RSINT30034UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"FIRST HEALTH [10303]","First Health",,4435.2,80,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D 15.5D MODIFY L 13MM 6MM POSTERIOR CHMBR FOLDABLE",SUP-SY60WF.155,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM RELINE C SPINE MULTIAXIAL NONSTERILE",SUP-3903514,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,1144.80,304.56,2275.09,66,521.61,3812.25,"percent of total billed charges",
"SCR BONE 4.5MM 52MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.852,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"CIGNA [10200]","Cigna Open Access",,142.77,56.9,,1144.80,304.56,2275.09,66,29.18,213.27,"percent of total billed charges",
"INTRO SHEATH SAFESHEATH HS CURVE 60CM 7FR",SUP-WORLEY/B-60-07-HS,CDM,C1893,HCPCS,0272,RC,,,both,,,3345.00,1003.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2274.6,68,,,,,0,389.02,2843.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 156MM 16-10MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1610C156E,CDM,S27800098,LOCAL,0278,RC,,,both,,,38997.00,11699.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,11160.94,28.62,,,,,0,4535.35,33147.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4550,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Icd Gen Only Sq",PX-480000030,CDM,33241,CPT,0481,RC,,,both,,,6103.78,1831.13,"BLUE CROSS [10001]","Blue Cross PPO",,6103.78,,"Case rate ($27,529.22). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,709.87,6103.78,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BNDG TG FIX 25MR WHITE COMPRESSION LATEX WIDE MESH HIGHLY",SUP-568261,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.98,15.89,"PHCS [10601]",PHCS,,37.09,70,,,,,0,6.16,45.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 44MM 28MM F VIVACIT-E LUMEN STERILE LATEX FREE",SUP-110031012,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4256.69,41.1,,6417.48,6417.48,6417.48,"1 through 10",1204.51,8803.37,"percent of total billed charges",
"HC Heterophile Ab Screen",PX-302000058,CDM,86308,CPT,0302,RC,,,both,,,185.25,55.57,"MULTIPLAN [10600]",Multiplan,,157.46,85,,,,,0,0.19,157.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 15MM INDEPENDENCE 8D LARGE PEEK ALIF PLATE",SUP-376.715,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"CIGNA [10200]","Cigna Open Access",,11482.33,33.5,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOSARTAN 25 MG TABLET",RX-14823,CDM,,,0637,RC,50268-0504-11,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,,,0250,RC,00406-8315-23,NDC,both,1,UN,16.65,4.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7.64,45.9,,,,,0,1.94,14.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X18X10MM COROENT 10D XL PEEK-OPTIMA XLIF",SUP-6981060,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"CIGNA [10200]","Cigna Local Plus",,7484.4,31.5,,16168.95,16168.95,16168.95,"1 through 10",2763.29,20196,"percent of total billed charges",
"SCR BONE 6MM 55MM VIPER EXPEDIUM TITANIUM SPINE CORTICAL",SUP-186731655,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM 2 SWIVELOCK SP KNOTLESS SELF PUNCHING",SUP-AR-2324KBCSP,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,434.96,3179,"percent of total billed charges",
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE B CURVE",SUP-D7TCBL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3373.55,68,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla II Typing 1 Locus Lr",PX-309000085,CDM,81376,CPT,0310,RC,,,both,,,551.20,165.36,"CIGNA [10200]",Cigna,,268.88,,,,,,,46.99,468.52,"fee schedule",
"DEVICE CELERO BREAST BIOPSY VACUUM ASSIST SPRING LOAD CORE",SUP-CELERO-12,CDM,S27200284,LOCAL,0272,RC,,,both,,,1782.38,534.71,"CIGNA [10200]","Cigna Local Plus",,953.57,53.5,,,,,0,207.29,1515.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 3.5IN 18GA 20GA EPILONG TUOHY 1CM .2UM PLASTIC",SUP-0321152-51,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 15.8MM 7.75MM BEAVER CORNEAL STAINLESS",SUP-9722,CDM,S27200284,LOCAL,0272,RC,,,both,,,456.35,136.9,"CIGNA [10200]","Cigna Open Access",,259.66,56.9,,,,,0,53.07,387.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL LONG 140MM OVER SOLID AO CONNECTION 2MM",SUP-P99-100-2014,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,461.02,45.9,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 6MM 3.5MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012409-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH METAL HEAD + VE",SUP-98000500307,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2986.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2930.76,21420,"percent of total billed charges",
"CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION|DISCARDED DRUG NOT ADMINISTE",RX-9413,CDM,J0675,HCPCS,0636,RC,00009-0856-05,NDC,both,1,ML,845.04,253.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",JW,53.44,,,,,,,53.44,98.46,"fee schedule",
"PLATE 130MM TITANIUM 12 HOLE LOCKING ACUMED BONE MEDIAL",SUP-PL-LEM12,CDM,C1713,HCPCS,0278,RC,,,both,,,6755.10,2026.53,"AETNA [10100]","Aetna HMO/PPO",,5370.3,79.5,,1521.93,481.35,16760.95,30,785.62,5741.84,"percent of total billed charges",
"OPTRELL CATHETER 36 ELECTRODES, F-J CURVE",SUP-D142902,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"MULTIPLAN [10600]",Multiplan,,13489.5,85,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 4-0 KS 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J662H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 18MM STD SHELL DJO SURGICAL ALTIVATE",SUP-530-18-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5523.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5523.6,40370.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 16CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155214190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"MULTIPLAN [10600]",Multiplan,,1207.29,85,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 440MM LONG LINEAR CUTTER ECHELON FLEX POWERED",SUP-PLEE45A,CDM,S27200284,LOCAL,0272,RC,,,both,,,6690.40,2007.12,"KAISER [10500]",Kaiser,,4482.57,67,,,,,0,778.09,5686.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 1.5CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-24-1.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,92.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"26.0MM HEAD, RIGHT",SUP-TR-H260R-S,CDM,C1776,HCPCS,0278,RC,,,both,,,13489.50,4046.85,"AETNA [10100]","Aetna HMO/PPO",,10724.15,79.5,,10981.53,8986.79,12413.38,12,1568.83,11466.08,"percent of total billed charges",
"HC Ptca Mitral Valve",PX-480000046,CDM,92987,CPT,0481,RC,,,both,,,18690.43,5607.13,"CIGNA [10200]","Cigna Local Plus",,18690.43,,"Case rate ($20,211). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2173.7,18690.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bld Gases W Direct Meas O2 Sat",PX-301000199,CDM,82805,CPT,0301,RC,,,both,,,619.50,185.85,"NOVANET [10819]",Novanet,,464.63,75,,,,,0,19.23,526.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bld Gases W Direct Meas O2 Sat",PX-301000199,CDM,82805,CPT,0301,RC,,,both,,,619.50,185.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,70.89,,,,,,,19.23,526.58,"fee schedule",
"IMPL SPINAL 34X24X8MM BASE 10 TITANIUM NONSTERILE",SUP-6951810,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9809.68,28.62,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 355CC",SUP-RSZ-SHPX-355S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,19.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 88CM 5.3FR 2 CURVE LEFT HEART TRANSVENOUS",SUP-4296-88,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1604.72,28.62,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 10-0 BV75-4 5IN MONOFILAMENT BLACK NONABSORBABLE",SUP-2850G,CDM,S27200284,LOCAL,0272,RC,,,both,,,296.50,88.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,35.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.48,252.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK 143CM 12MM 4.5MM ROUND BALLOON DILATATION",SUP-1012454-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SMOOTH SHELL",SUP-SRM-405,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"AETNA [10100]","Aetna HMO/PPO",,4360.97,79.5,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 24IN KIRSCHNER THUNDERBOLT SPINE NITINOL",SUP-M070-KN224,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 44MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-44,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,35.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",35.41,258.83,"percent of total billed charges",
"CAP SYSTEM THR POROUS HIP STEM ENDO HEAD UNIPOLAR",SUP-98000100400,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Local Plus",,5537.25,53.5,,5372.07,4581.20,7242.98,23,1203.71,8797.5,"percent of total billed charges",
"CATH RENEGADE HI-FLO 105CM 10CM 20.8-30FR .027IN STRAIGHT",SUP-18-284,CDM,C1876,HCPCS,0278,RC,,,both,,,2162.10,648.63,"BLUE CROSS [10001]","Blue Cross PPO",,847.54,39.2,,,,,0,251.45,1837.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICROINTRODUCER 6FR 7CM GWIRE BEVEL A NDL SMOOTH DIL",SUP-0828960,CDM,C1894,HCPCS,0272,RC,,,both,,,455.54,136.66,"AETNA [10100]","Aetna HMO/PPO",,362.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.98,387.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL REVELATION 8 LEFT HIP",SUP-427-01-080,CDM,C1776,HCPCS,0278,RC,,,both,,,32703.43,9811.03,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3875.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3803.41,27797.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 22MM RSP SHOULDER LOCK GLENOID BASEPLT",SUP-506-03-122,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"FIRST HEALTH [10303]","First Health",,1244.56,80,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 2MM SPACE STD F CURVE",SUP-F6HF002RT,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,599.24,41.1,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 18MM AXSOS STAINLESS STEEL T15 FEMUR HUMERUS",SUP-371518,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"KAISER [10500]",Kaiser,,596.97,67,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 82MM 13MM 14FR ENDURANT II ABDOMEN AORTA",SUP-ETEW1313C82E,CDM,S27800098,LOCAL,0278,RC,,,both,,,28331.10,8499.33,"CIGNA [10200]",Cigna,,11332.44,40,,,,,0,3294.91,24081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0264,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"NOVANET [10819]",Novanet,,710.78,75,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CENTER",SUP-5573-6540,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"MULTIPLAN [10600]",Multiplan,,1322.35,85,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 5-0 FS-2 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8661G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 STD KNEE LEFT CRUCIATE RETAIN CEMENT PERSONA",SUP-42502605801,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"CIGNA [10200]","Cigna Local Plus",,7201.75,31.5,,5372.07,4581.20,7242.98,23,2658.93,19433.3,"percent of total billed charges",
"BLADE SHAVER PEACH 7CM 2.9MM DYONICS POWERMINI INCISOR PLUS",SUP-72201513,CDM,S27200284,LOCAL,0272,RC,,,both,,,461.70,138.51,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"V.A.C. VERAFLO CLEANSE CHOICE DRESSING MEDIUM 5-PACK",SUP-ULTVCC05MD.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1061.91,318.57,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR ATHERECTOMY 135CM 2MM ROTABLATOR ROTALINK PLUS",SUP-M0011402000,CDM,C1724,HCPCS,0272,RC,,,both,,,16525.50,4957.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BABYCARE",SUP-DYKL1421,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.40,23.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP PHACOEMULSIFICATION 25GA GRIESHABER REVOLUTION DSP 360D",SUP-337.84,CDM,S27200284,LOCAL,0272,RC,,,both,,,786.43,235.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL INSUFFLATION 120MM 14GA ENDOPATH ULTRA VERESS",SUP-UV120,CDM,S27200284,LOCAL,0272,RC,,,both,,,316.18,94.85,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 7-0 BV-1 24IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8702,CDM,S27200284,LOCAL,0272,RC,,,both,,,629.86,188.96,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE ACQUIRE S FRANSEEN 22GA BIOPSY ULTRASOUND FINE NDL",SUP-M00555640,CDM,S27200284,LOCAL,0272,RC,,,both,,,3051.38,915.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ASAHI SASUKE 145CM 3.3FR INFUSION STERILE LATEX FREE",SUP-SA145-33N,CDM,C1887,HCPCS,0272,RC,,,both,,,3262.50,978.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER DELIVERY MULTIPURPOSE SSPC",SUP-9182,CDM,C1887,HCPCS,0272,RC,,,both,,,3375.00,1012.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1387.13,41.1,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 CURVE 12.5MM KNEE GVF ROTATE PLATFORM PFC",SUP-972002,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"NOVANET [10819]",Novanet,,6937.09,75,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 40MM 5MM .014IN BALLOON DILATATION",SUP-AB14W050040150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,164.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 52MM STAINLESS STEEL 3.5MM SCR 3 HOLE T OBLIQUE RIGHT",SUP-241.931,CDM,C1713,HCPCS,0278,RC,,,both,,,2081.10,624.33,"NOVANET [10819]",Novanet,,1560.83,75,,,,,0,242.03,1768.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 45CM 5-8MM FLIXENE SLIDER GRADUATED WALL",SUP-25139,CDM,C1768,HCPCS,0278,RC,,,both,,,10206.27,3061.88,"FIRST HEALTH [10303]","First Health",,8165.02,80,,,,,0,1186.99,8675.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 31MM TITANIUM 4.8MM ENDOSCOPIC LINEAR CUTTER",SUP-EEA31,CDM,S27200284,LOCAL,0272,RC,,,both,,,1880.70,564.21,"UHC [10700]","United Healthcare",,1190.48,63.3,,,,,0,218.73,1598.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NERVE STIM RESPIRATORY",SUP-4340,CDM,C1778,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"AETNA [10100]","Aetna HMO/PPO",,16903.69,79.5,,,,,0,2472.83,18073.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 12/14 TAPER 28MM HIP COCR ARTICUL/EZE",SUP-136512000,CDM,C1776,HCPCS,0278,RC,,,both,,,2623.32,787,"CIGNA [10200]","Cigna Local Plus",,1403.48,53.5,,5372.07,4581.20,7242.98,23,305.09,2229.82,"percent of total billed charges",
"SET INTRO PEEL-AWAY PERCUTANEOUS STAINLESS STEEL 2 KNOB",SUP-G04495,CDM,C1892,HCPCS,0272,RC,,,both,,,818.10,245.43,"FIRST HEALTH [10303]","First Health",,654.48,80,,,,,0,95.15,695.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTEPLASE BOLUS FROM VIAL (100 MG VIAL)",RX-409108,CDM,J2997,HCPCS,0636,RC,50242-0085-25,NDC,both,1,UN,53118.96,15935.69,"KAISER [10500]",Kaiser,,35589.7,67,,,,,0,6294.6,45151.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM 13MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192113,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9499.39,40,,,,,0,2761.95,20186.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 40MM 3MM BALLOON",SUP-U357534,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 24CM 3CM 5FR .038IN STRAIGHT URETERAL",SUP-M006155222170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 100MM 21GA 20GA E-CATH PLUS SONOPLEX 18GA",SUP-261285-41E,CDM,C9812,HCPCS,0272,RC,,,both,,,382.80,114.84,"UHC [10700]","United Healthcare",,242.31,63.3,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 2.9MM 45CM RADIOPAQUE SMALL VALVE FLEXOR",SUP-G09601,CDM,C1894,HCPCS,0272,RC,,,both,,,468.67,140.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,192.62,41.1,,,,,0,54.51,398.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 140MM 5.5MM CREO STRAIGHT TITANIUM MIS NONSTERILE",SUP-1134.514,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"DRSG SILVER CELOS ETHYL SULPHONATE FIBER ANTIMICROBIAL",SUP-66800571,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.97,20.99,"AETNA [10100]","Aetna HMO/PPO",,55.63,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.14,59.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 10D G HIP X3 TRIDENT",SUP-723-10-36G,CDM,C1776,HCPCS,0278,RC,,,both,,,9332.25,2799.67,"PHCS [10601]",PHCS,,6532.58,70,,,,,0,1085.34,7932.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 32MM ORTHOLOC ANKLE 3DI TECHNOLOGY LOCKING",SUP-59215532,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,260.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",255.57,1867.88,"percent of total billed charges",
"SET NDL .75IN 2X2IN 20GA PORT ACCESS SYR PAD Y SITE 10ML",SUP-PA0031YN,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.87,28.76,"MULTIPLAN [10600]",Multiplan,,81.49,85,,,,,0,11.15,81.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX EXTREME 80CM 2CM 5FR 4MM LOW PROFILE TAPER",SUP-4154020S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SILVERHAWK 135CM 2.6CM 1.5-2MM .073IN ATHERECTOMY",SUP-P4028,CDM,C1714,HCPCS,0272,RC,,,both,,,18238.50,5471.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2161.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2121.14,15502.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +26.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.265,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 19GA 11CM 5CM ADJUSTABLE COAXIAL TEMNO",SUP-ACT2011,CDM,S27200284,LOCAL,0272,RC,,,both,,,473.85,142.15,"FIRST HEALTH [10303]","First Health",,379.08,80,,,,,0,55.11,402.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 30MM CEMENTED OMNIFIT HFX 132D 8 HIP",SUP-6070-0830A,CDM,C1776,HCPCS,0278,RC,,,both,,,7894.95,2368.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,918.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,918.18,6710.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 20MM 2.5MM BALLOON DILATATION",SUP-H7493912420250,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURECLIP REPOSITIONABLE 11MM 235CM",SUP-RC30141,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,105.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 100MM 16MM NEXGEN STRAIGHT KNEE ROTATE HINGE 145MM",SUP-00598801016,CDM,C1776,HCPCS,0278,RC,,,both,,,8049.54,2414.86,"MULTIPLAN [10600]",Multiplan,,6842.11,85,,,,,0,936.16,6842.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION BLUE 4.8MM 1.32MM T EAR SILICONE MODIFY",SUP-70245017,CDM,S27200284,LOCAL,0272,RC,,,both,,,152.90,45.87,"NOVANET [10819]",Novanet,,114.68,75,,,,,0,17.78,129.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +14 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-SY60WF.140,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD BIPOLAR 5FR VERSAPOINT SPRING TIP HYSTEROSCOPIC",SUP-WA47783A,CDM,S27200284,LOCAL,0272,RC,,,both,,,3439.80,1031.94,"FIRST HEALTH [10303]","First Health",,2751.84,80,,,,,0,400.05,2923.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 135CM 100MM 6MM BALLOON DILATATION PACLITAXEL",SUP-H74939419601010,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3544.88,41.1,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 6MM 2MM BALLOON DILATATION HYDROPHILIC",SUP-2200-2006-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"PHCS [10601]",PHCS,,4105.5,70,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +21 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.210,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 16MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P316,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Local Plus",,4470.41,53.5,,5372.07,4581.20,7242.98,23,971.79,7102.52,"percent of total billed charges",
"STENT SUPERA 20MM 120CM 7MM 6FR VASCULAR NITINOL PERIPHERAL",SUP-S-70-020-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1083.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 8- CM 19GA 5.2-4.2FR GASTROINTESTINAL",SUP-G52012,CDM,S27200284,LOCAL,0272,RC,,,both,,,2857.50,857.25,"AETNA [10100]","Aetna HMO/PPO",,2271.71,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,332.33,2428.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 20MM 5MM BALLOON DILATATION DURALYN",SUP-48005002X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UHC [10700]","United Healthcare",,794.73,63.3,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JAGWIRE DREAM TIP ENDOSCOPIC 260CM 5CM .025IN",SUP-M00556481,CDM,C1769,HCPCS,0272,RC,,,both,,,811.01,243.3,"UHC [10700]","United Healthcare",,513.37,63.3,,,,,0,94.32,689.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID UPPER LEG REDUCTION KIT- SHORT, WIDE",SUP-25302117,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"PHCS [10601]",PHCS,,878.85,70,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRI-STAPLE 2.0 RELOAD 45MM MEDIUM/THICK TISSUE PURPLE",SUP-SIG45AMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1328.81,398.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,903.59,68,,,,,0,154.54,1129.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 4-0 P-3 18IN BRAID BLACK NONABSORBABLE",SUP-641G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP APPLR TISSEEL GASLESS SPRAY QUICK CONNECT",SUP-601151,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 21GA ALWAYS-ON TIP TRACKED ANSO CYTOLOGY",SUP-INS-0392,CDM,S27200284,LOCAL,0272,RC,,,both,,,3912.30,1173.69,"CIGNA [10200]",Cigna,,2660.36,68,,,,,0,455,3325.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 15.5CM NATRELLE INSPIRA P6CM FULL PROFILE ROUND",SUP-MSZ-F770,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"MULTIPLAN [10600]",Multiplan,,134.45,85,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA SURG VELC STRP ZIP LG 38-40IN",SUP-958-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,347.48,104.24,"FIRST HEALTH [10303]","First Health",,277.98,80,,,,,0,40.41,295.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 6FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175260010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,491.47,45.9,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 25MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G325,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1109.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1089.28,7961.17,"percent of total billed charges",
"STEM FEMORAL 115MM 15MM PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51107150,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"UHC [10700]","United Healthcare",,17366.51,63.3,,8601.07,8395.67,8601.07,"1 through 10",3190.72,23319.95,"percent of total billed charges",
"BIT DRILL 15MM 3.2MM DISPOSABLE",SUP-31-323220,CDM,S27000186,LOCAL,0270,RC,,,both,,,896.67,269,"CIGNA [10200]","Cigna Open Access",,510.21,56.9,,,,,0,104.28,762.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM 15MM PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51107150,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"CIGNA [10200]","Cigna Local Plus",,8642.1,31.5,,5372.07,4581.20,7242.98,23,3190.72,23319.95,"percent of total billed charges",
"INSRT TIBIAL 3 7MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650307,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5395.3,41.1,,6417.48,6417.48,6417.48,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"HC Excsn Lesn Tr/Ext 3.1-4.0cm",PX-510000030,CDM,11404,CPT,0761,RC,,,both,,,4845.74,1453.72,"PHCS [10601]",PHCS,,4710,,"Case rate ($4,710). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,563.56,4710,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Tissue Back Soft Superfic",PX-360000052,CDM,21920,CPT,0360,RC,,,both,,,2787.94,836.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2787.94,,"Case rate ($23,244). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,324.24,2787.94,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR VIVACIT-E OSSEOTI HIP LINER STANDRD HEAD INSR",SUP-98000100039,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"BLUE CROSS [10001]","Blue Cross PPO",,11360.16,39.2,,3949.44,3949.44,3949.44,"1 through 10",3370.37,24633,"percent of total billed charges",
"STENT EXPRESS LD 37MM 135CM 9MM 7MM 6FR BILIARY METAL",SUP-H74938047740130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"BLUE CROSS [10001]","Blue Cross HMO",,1956.86,39.2,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH",RX-27472,CDM,,,0250,RC,00378-9104-16,NDC,both,1,UN,12.54,3.76,"UHC [10700]","United Healthcare",,7.94,63.3,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) INNOVALVE CRIMPER FOR TMVR TRANSCATHETER MITRAL VALVE",SUP-PRO-17269,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 24MM ACUMED TITANIUM CORTICAL ELBOW",SUP-CO-2724,CDM,C1713,HCPCS,0278,RC,,,both,,,696.60,208.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,199.37,28.62,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR 1",SUP-MTA4U0.050,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 24MM ACUMED TITANIUM CORTICAL ELBOW",SUP-CO-2724,CDM,C1713,HCPCS,0278,RC,,,both,,,696.60,208.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,319.74,45.9,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE FLOPPY II EXTRA SPORT VASCULAR STRAIGHT 190",SUP-22299M-901,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 30ML 1.7-10MM ALLOGRAFT CHIPS FREEZE",SUP-T00040,CDM,S27800098,LOCAL,0278,RC,,,both,,,2940.00,882,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,841.43,28.62,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR EXTRICATION 4.25IN 16-19IN CALIFORNIA PROCARE LARGE",SUP-79-83147,CDM,S27000186,LOCAL,0270,RC,,,both,,,82.74,24.82,"CIGNA [10200]","Cigna Open Access",,47.08,56.9,,,,,0,9.62,70.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX ECHO 2 15X10CM POSITION SYSTEM STERILE",SUP-1211015,CDM,C1781,HCPCS,0278,RC,,,both,,,21498.75,6449.62,"PHCS [10601]",PHCS,,15049.13,70,,,,,0,2500.3,18273.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 15ML 1.7-10MM CHIP FROZEN TRADITIONAL",SUP-T20035,CDM,S27800098,LOCAL,0278,RC,,,both,,,1795.50,538.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1220.94,68,,,,,0,208.82,1526.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM HELIX R SPINE SELF DRILL VARIABLE ANGLE",SUP-7801115,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 110MM 9.2MM 6MM ADJUSTABLE NECK FLANGE CLIP IN OBTR",SUP-75HA60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1619.19,485.76,"CIGNA [10200]","Cigna Open Access",,921.32,56.9,,,,,0,188.31,1376.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH DURAL 5X4IN DURAFORM CRANIAL BOVINE CLLGN MATRIX",SUP-801480US,CDM,S27800098,LOCAL,0278,RC,,,both,,,7955.98,2386.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5410.07,68,,,,,0,925.28,6762.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061755840,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,258.2,28.62,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSORB GT1 18MM 3MM CORONARY EVEROLIMUS ELUTING POLY L",SUP-1235300-18,CDM,C1874,HCPCS,0278,RC,,,both,,,8280.00,2484,"AMERIGROUP MEDICAID [20100]",Amerigroup,,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL SHAFT ALLOGRAFT FROZEN 50MM 10+ MM",SUP-450410,CDM,S27800098,LOCAL,0278,RC,,,both,,,4785.84,1435.75,"PHCS [10601]",PHCS,,3350.09,70,,,,,0,556.59,4067.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 40X14MM ENDOSKELETON TAS 12D 27MM XL TITANIUM",SUP-2312-0314-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,43942.50,13182.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5207.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5110.51,37351.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 5FR ANGLE KUMPE CURVE ANGIOGRAPHIC",SUP-10732703,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +28 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-AR40E00280,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"BLUE CROSS [10001]","Blue Cross HMO",,365.15,39.2,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 65CM 10MM PRESTIGE PLUS HELICAL PACK ULTRA",SUP-PRES1065HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"FIRST HEALTH [10303]","First Health",,6348,80,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER VASCULAR PROCEDURES WITH MCC",252,MS-DRG,,,,,,,inpatient,,,142770.90,42831.27,"PHCS [10601]",PHCS,,7561,,,,,,,7561,101844.41,"per diem","Estimated amount calculated based on 2 day length of stay."
"CANN PERFUSION 2IN VESSEL 3MM BLUNT TIP RADIOPAQUE BODY DLP",SUP-30023,CDM,S27200284,LOCAL,0272,RC,,,both,,,54.19,16.26,"CIGNA [10200]","Cigna Open Access",,30.83,56.9,,,,,0,6.3,46.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 1.2MM CROSS CUT FISSURE STERILE LATEX FREE",SUP-5820-066-012,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"AETNA [10100]","Aetna HMO/PPO",,870.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP FLEX-MINI 45MM CLSR POLYESTER LOW PROFILE",SUP-ACHM45,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6210,40,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 10CM 5.8FR 18FR BALLOON",SUP-M0062251170,CDM,C1726,HCPCS,0272,RC,,,both,,,1832.70,549.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARD 12FR URETHRAL NATURAL RUBBER SILICONE ELASTOMER 5",SUP-265712,CDM,S27200284,LOCAL,0272,RC,,,both,,,1.84,0.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRA 48-51IN 2XL HOOK LOOP CLSR WIDE ADJUSTABLE SHOULDER",SUP-M5001-XXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,183.57,55.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Ins Pacing Elect Lv Lead Add",PX-480000019,CDM,33225,CPT,0481,RC,,,both,,,7637.14,2291.14,"CIGNA [10200]","Cigna Local Plus",,7637.14,,"Case rate ($29,596). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,888.2,7637.14,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 4-0 P-3 18IN BRAID BLACK NONABSORBABLE",SUP-641G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 7X4CM SURGISIS PORCINE ACELLULAR CLLGN",SUP-G13181,CDM,C1763,HCPCS,0278,RC,,,both,,,6886.20,2065.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,800.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,800.87,5853.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 13- IN THUMB LEFT WRIST PALMAR",SUP-79-87490,CDM,S27000186,LOCAL,0270,RC,,,both,,,122.76,36.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,83.48,68,,,,,0,14.28,104.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 650CC COHESIVE NATRELLE INSPIRA STERILE LATEX",SUP-SCF-650,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AETNA [10100]","Aetna HMO/PPO",,6006.62,79.5,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 150MM 2.5MM QUICK CONNECT STERILE",SUP-03.133.104S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1095.44,328.63,"MULTIPLAN [10600]",Multiplan,,931.12,85,,,,,0,127.4,931.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .047IN RIGHT CORONARY",SUP-534570T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE RIGHT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F202,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"BLUE CROSS [10001]","Blue Cross HMO",,6718.89,39.2,,5311.50,4717.44,5388.59,31,1993.39,14569.03,"percent of total billed charges",
"HC Cor Arty/Grft Angio",PX-481000023,CDM,93455,CPT,0481,RC,,,both,,,11814.88,3544.46,"KAISER [10500]",Kaiser,,7915.97,67,,,,,0,1374.07,11062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIATHLON TRITANIUM BASEPLATE SIZE 2",SUP-5536-B-200,CDM,C1776,HCPCS,0278,RC,,,both,,,10139.04,3041.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1201.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1179.17,8618.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 50MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8840C-50,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]",Cigna,,908.82,68,,1831.33,1831.33,1831.33,16,155.43,1136.03,"percent of total billed charges",
"CLAREON UVA VIVITY TORIC AUTONOME",SUP-CCAET5,CDM,V2787,HCPCS,0276,RC,,,both,,,880.00,264,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,251.86,28.62,,,,,0,102.34,748,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 94MM 10MM PRESS FIT REUNION S SHOULDER",SUP-5567-P-3010,CDM,C1776,HCPCS,0278,RC,,,both,,,26525.52,7957.66,"NOVANET [10819]",Novanet,,19894.14,75,,,,,0,3084.92,22546.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sugars Single Ql",PX-300000045,CDM,84376,CPT,0301,RC,,,both,,,71.00,21.3,"NOVANET [10819]",Novanet,,53.25,75,,,,,0,0.01,60.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR STRAIGHT 260CM 7CM .035IN",SUP-M001465261,CDM,C1769,HCPCS,0272,RC,,,both,,,494.10,148.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,57.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH CHECK-FLO FLEXOR .018/.035IN ANL0 CURVE 90CM 4FR .059",SUP-G48188,CDM,C1894,HCPCS,0272,RC,,,both,,,842.40,252.72,"FIRST HEALTH [10303]","First Health",,673.92,80,,,,,0,97.97,716.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 63MM STAINLESS STEEL 2.4MM SCR 6 HOLE HEAD 4",SUP-02.111.541S,CDM,C1713,HCPCS,0278,RC,,,both,,,4447.05,1334.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,517.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",517.19,3779.99,"percent of total billed charges",
"CATH BLAZER PRIME XP 110CM 11CM 7FR 8FR 8MM 2.5MM SPACE STD",SUP-M004P4500TH0,CDM,C1733,HCPCS,0272,RC,,,both,,,11730.00,3519,"KAISER [10500]",Kaiser,,7859.1,67,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 24CM 12FR MAHURKAR POLYURETHANE 3 LUMEN STRAIGHT",SUP-8888102004HP,CDM,C1752,HCPCS,0272,RC,,,both,,,995.43,298.63,"CIGNA [10200]","Cigna Open Access",,566.4,56.9,,,,,0,115.77,846.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 11CMX12MM OSTEOTOM CUP NONSTERILE DISPOSABLE",SUP-SBLDCUP-2-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,599.24,41.1,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE INCORE PRECISION POST PLUG GUIDE CORRECTION LAPIDUS",SUP-ICLAP35P,CDM,C1713,HCPCS,0278,RC,,,both,,,3136.35,940.9,"BLUE CROSS [10001]","Blue Cross HMO",,1229.45,39.2,,957.42,156.86,7483.26,51,364.76,2665.9,"percent of total billed charges",
"FUZEFIX LAPILOCK KIT",SUP-FX-LL-7000,CDM,C1713,HCPCS,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 16MM 144CM 2.25MM CORONARY STENT PEBAX",SUP-H7493926016220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"MULTIPLAN [10600]",Multiplan,,4730.25,85,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 55D 35MM 4.75MM EMBOLIZATION 75% COCR",SUP-PED-475-35,CDM,S27800098,LOCAL,0278,RC,,,both,,,81396.00,24418.8,"AETNA [10100]","Aetna HMO/PPO",,64709.82,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9466.35,69186.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 25X20CM STRATTICE LIFECELL 500SQ CM",SUP-2025002P,CDM,Q4130,HCPCS,0636,RC,,,both,,,71193.00,21357.9,"CIGNA [10200]","Cigna Local Plus",,38088.26,53.5,,,,,0,8436.37,60514.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM PRESTIGE PLUS HELICAL COMPLEX XTRA",SUP-PRES0204CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.820,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"FIRST HEALTH [10303]","First Health",,281.05,80,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Exercise Test for Bronchospasm",PX-482000005,CDM,94617,CPT,0460,RC,,,both,,,191.00,57.3,"CIGNA [10200]",Cigna,,129.88,68,,,,,0,22.21,162.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR NEONATAL LNCS OXIMETER ADHESIVE CABLED TAPE MASIMO SE",SUP-1862,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.00,20.7,"AETNA [10100]","Aetna HMO/PPO",,54.86,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.58,58.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT FINGER SWANSON 4 METACARPOPHALANGEAL GROMMET HIGH",SUP-G4700004,CDM,C1776,HCPCS,0278,RC,,,both,,,4170.60,1251.18,"CIGNA [10200]","Cigna Open Access",,2373.07,56.9,,5302.19,4377.88,6578.61,27,485.04,3545.01,"percent of total billed charges",
"CATH SPRINTER FASTRAC 138CM 15MM 3.2-2.5-2.7FR 4MM BALLOON",SUP-SPR4015W,CDM,C1725,HCPCS,0272,RC,,,both,,,546.75,164.02,"NOVANET [10819]",Novanet,,410.06,75,,,,,0,63.59,464.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 9MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-509-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"BLUE CROSS [10001]","Blue Cross PPO",,4717.17,39.2,,3949.44,3949.44,3949.44,"1 through 10",1399.51,10228.56,"percent of total billed charges",
"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC",742,MS-DRG,,,,,,,inpatient,,,90441.84,27132.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,36422.61,,"Fee schedule rate ($36,422.61). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,53568.82,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 3.5MM RELINE-C PRE BENT TITANIUM NONSTERILE",SUP-3943050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER YELLOW 4.5MM ORBIT FULL RADIUS ARTHROSCOPIC",SUP-7205323,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 25.4MM .8MM LONG DIAMOND DISK STERILE",SUP-5130-130-250,CDM,S27200284,LOCAL,0272,RC,,,both,,,1027.32,308.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG WOUND 4X4IN CUTIMED EPIONA TISSUE 90% NATIVE CLLGN 10%",SUP-7322701,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.04,63.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC",621,MS-DRG,,,,,,,inpatient,,,99903.05,29970.91,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 7FR EXTRA BACKUP 3.5",SUP-77805400,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 3CM 1.5MM GALAXY G3 MINI STRETCH",SUP-GLM915030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"MULTIPLAN [10600]",Multiplan,,10099.53,85,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC LARGE HUB STERLING DRAGON 2500-6000 RPM",SUP-C9292,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL CRYOABLATION 17.5CM 17GA ICESPHERE 1.5CX 90D NONSTICK",SUP-FPRPR3573,CDM,C2618,HCPCS,0272,RC,,,both,,,13110.00,3933,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1524.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Euglobulin Lysis",PX-305000039,CDM,85360,CPT,0305,RC,,,both,,,584.00,175.2,"CIGNA [10200]","Cigna Local Plus",,18.5,,,,,,,0.01,496.4,"fee schedule",
"SIZER IMPL MEMORYSHAPE MEDIUM HEIGHT MODERATE PLUS PROFILE",SUP-RSZ-1155S,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.55,69.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,94.76,41.1,,,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPICILLIN 1 GRAM SOLUTION FOR INJECTION",RX-469,CDM,J0290,HCPCS,0636,RC,00781-3404-85,NDC,both,1,UN,65.20,19.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,44.34,68,,,,,0,1.28,55.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Decomprsn",PX-750000168,CDM,44408,CPT,0750,RC,,,both,,,3679.00,1103.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3311,,"Case rate ($3,311). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,427.87,3679,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Decomprsn",PX-750000168,CDM,44408,CPT,0750,RC,,,both,,,3679.00,1103.7,"UHC [10700]","United Healthcare",,3679,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,427.87,3679,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH AORTIC ROTATING 5.0MM X 20CM CLEANCUT STERILE",SUP-RCL50,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"AETNA [10100]","Aetna HMO/PPO",,181.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 28CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155244190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,165.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 23MM 143CM 2.25MM CORONARY EVEROLIMUS ELUTING",SUP-1009544-23,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6521.88,68,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 80CM 5MM 8MM 7FR .035IN",SUP-BXA052901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2311.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC LARGE 8IN 8-9IN WRIST LEFT LIGHTWEIGHT",SUP-92722202,CDM,L3908,HCPCS,0274,RC,,,both,,,148.86,44.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.31,126.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Liver Wedge",PX-361000501,CDM,47100,CPT,0361,RC,,,both,,,1980.00,594,"MULTIPLAN [10600]",Multiplan,,1683,85,,,,,0,230.27,1980,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM DARCO SHORT THREAD HEAD",SUP-777403832,CDM,C1713,HCPCS,0278,RC,,,both,,,1695.00,508.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,200.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,197.13,1440.75,"percent of total billed charges",
"SCR BONE 4MM 16MM SKYLINE TITANIUM 20- D SPINE SELF DRILL",SUP-186850016,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,396.9,39.2,,957.42,156.86,7483.26,51,117.75,860.63,"percent of total billed charges",
"HC Et Tube Endobronchial",PX-E27200242,CDM,9999115,LOCAL,0272,RC,,,both,,,730.95,219.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,85.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,85.01,621.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRIMONIDINE 0.2 % EYE DROPS",RX-17881,CDM,,,0250,RC,24208-0411-05,NDC,both,5,ML,114.04,34.21,"MULTIPLAN [10600]",Multiplan,,96.93,85,,,,,0,13.26,96.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL BEND 87MM STAINLESS STEEL 3.5MM SCR 4 HOLE",SUP-02.127.211,CDM,C1713,HCPCS,0278,RC,,,both,,,9039.00,2711.7,"FIRST HEALTH [10303]","First Health",,7231.2,80,,,,,0,1051.24,7683.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW LOCK SCR ANATOMIC VARIAX BONE RADIUS RIGHT",SUP-54-25384,CDM,C1713,HCPCS,0278,RC,,,both,,,6383.05,1914.91,"AETNA [10100]","Aetna HMO/PPO",,5074.52,79.5,,1521.93,481.35,16760.95,30,742.35,5425.59,"percent of total billed charges",
"SUB BONE GRAFT BBTRAUMA BONE BRIDGING TECHNOLOGIES VITOSS",SUP-2102-2201,CDM,C1713,HCPCS,0278,RC,,,both,,,3868.83,1160.65,"FIRST HEALTH [10303]","First Health",,3095.06,80,,,,,0,449.94,3288.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOGRAFT REVISION DOWEL 9MM",SUP-PCD9,CDM,C1713,HCPCS,0278,RC,,,both,,,6744.75,2023.42,"CIGNA [10200]","Cigna Open Access",,3837.76,56.9,,1144.80,304.56,2275.09,66,784.41,5733.04,"percent of total billed charges",
"STENT JOHLIN 20CM 8.5FR PANCREATIC WEDGE PRELOAD INTRO",SUP-G26831,CDM,C2625,HCPCS,0278,RC,,,both,,,1368.90,410.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,628.33,45.9,,,,,0,159.2,1163.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 50MM UNITRAX FEMORAL HIP MODULAR",SUP-6942-5-050,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA [10200]","Cigna Open Access",,1779.66,56.9,,5302.19,4377.88,6578.61,27,363.75,2658.55,"percent of total billed charges",
"GA-68-GOZETOTIDE INTRAVENOUS SOLUTION (5 MCI)",RX-411540,CDM,A9596,HCPCS,0343,RC,08888-8878-71,NDC,both,1,UN,24796.80,7439.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2938.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1181,21077.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL STD 17.5MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405417,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3971.68,41.1,,6417.48,6417.48,6417.48,"1 through 10",1123.86,8213.93,"percent of total billed charges",
"CATH BARD 12FR URETHRAL NATURAL RUBBER SILICONE ELASTOMER 5",SUP-265712,CDM,S27200284,LOCAL,0272,RC,,,both,,,1.84,0.55,"FIRST HEALTH [10303]","First Health",,1.47,80,,,,,0,0.21,1.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LASER FIBER 1000",SUP-HLFD1000C,CDM,S27200284,LOCAL,0272,RC,,,both,,,5750.00,1725,"KAISER [10500]",Kaiser,,3852.5,67,,,,,0,668.73,4887.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 46MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-46-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,670.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,658.03,4809.3,"percent of total billed charges",
"HC Ptca Aortic Valve",PX-480000045,CDM,92986,CPT,0481,RC,,,both,,,18690.43,5607.13,"CIGNA [10200]",Cigna,,18690.43,,"Case rate ($25,681). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2173.7,18690.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Biopatch",PX-E27200089,CDM,E27200089,LOCAL,0272,RC,,,both,,,32.47,9.74,"UHC [10700]","United Healthcare",,20.55,63.3,,,,,0,3.78,27.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 150CM 1.5FR .026-.039IN 15MM SPACE SPRT",SUP-518-065,CDM,C1887,HCPCS,0272,RC,,,both,,,972.00,291.6,"KAISER [10500]",Kaiser,,651.24,67,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 14FR 9FR SILICONE STD MIC LUER-LOK",SUP-0301-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,1540.13,462.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1047.29,68,,,,,0,179.12,1309.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Out of or Bedside Procedure",PX-361000431,CDM,361000431,LOCAL,0361,RC,,,both,,,5325.22,1597.57,"CIGNA [10200]",Cigna,,3621.15,68,,,,,0,619.32,4526.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL FUZEFIX MINI OD2.5 MM PROXIMAL HEADLESS NONS",SUP-CD-FX-2525,CDM,S27000186,LOCAL,0270,RC,,,both,,,2130.00,639,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,247.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER EMBOLIZATION 49MM 65CM VENA CAVA RADIOPAQUE PRELOAD",SUP-G34502,CDM,C1880,HCPCS,0278,RC,,,both,,,7621.05,2286.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5182.31,68,,,,,0,886.33,6477.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZEBRA UROLOGICAL 150CM 3CM .032IN URO-GLIDE NITINOL",SUP-M0066701111,CDM,C1769,HCPCS,0272,RC,,,both,,,432.13,129.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.26,367.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) GUIDEWIRE VASCULAR .014INX200CM ARISTOTLE 14 SOFT PRO",SUP-A14-200-001,CDM,C1769,HCPCS,0272,RC,,,both,,,3967.50,1190.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,470.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR061502A,CDM,C1874,HCPCS,0278,RC,,,both,,,24374.70,7312.41,"BLUE CROSS [10001]","Blue Cross HMO",,9554.88,39.2,,9776.84,9776.84,9776.84,"1 through 10",2834.78,20718.5,"percent of total billed charges",
"INSRT ARTICULAR 5-6 11MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934385,CDM,C1776,HCPCS,0278,RC,,,both,,,19429.20,5828.76,"BLUE CROSS [10001]","Blue Cross PPO",,7616.25,39.2,,3949.44,3949.44,3949.44,"1 through 10",2259.62,16514.82,"percent of total billed charges",
"EXP TISSUE 14.6X15.3CM BREAST 750ML STYLE 9300 TEXTURED SELF",SUP-3549316,CDM,C1789,HCPCS,0278,RC,,,both,,,9694.50,2908.35,"NOVANET [10819]",Novanet,,7270.88,75,,,,,0,1127.47,8240.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 80MM 8MM BILIARY PARTIAL COVER TRANSHEPATIC",SUP-7471,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 30MM 4-5MM AVANCE NERVE ALLOGRAFT",SUP-411230,CDM,C1762,HCPCS,0278,RC,,,both,,,29288.70,8786.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3406.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3406.28,24895.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X13MM PARALLEL SPINE CERVICAL",SUP-17913,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 100CM 5FR AL1 CURVE ANGIOGRAPHIC PEBAX",SUP-7527-13,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.74,23.62,"CIGNA [10200]",Cigna,,53.54,68,,,,,0,9.16,66.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 40MM 12MM .035IN BALLOON DILATATION NYBAX",SUP-39171-12044,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,482.72,41.1,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 20CC DBX ALLOGRAFT FREEZE DRY MIX",SUP-58200,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1839.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING 18FR STOMA L4CM JEJUNAL L45CM BALLOON 7-10ML GA",SUP-8270-18-4.0-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"UHC [10700]","United Healthcare",,1666.56,63.3,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 59MM 135CM 8MM THIN VASCULAR COCR",SUP-1012631-59,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"BLUE CROSS [10001]","Blue Cross PPO",,3292.8,39.2,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 2.5MM CORONARY STENT",SUP-H7493941820250,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 60MM 36MM MARATHON HIP",SUP-121936160,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1144.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1144.72,8366.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 25MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G325,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1089.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 6FR EBU3.75 CURVE GUIDING NYLON CORONARY",SUP-LA6EBU375A,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC BLUE MINI-BLADE 180D STRAIGHT 2 BEVEL SHARP",SUP-6900,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.08,14.42,"PHCS [10601]",PHCS,,33.66,70,,,,,0,5.59,40.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 16MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532-G-416,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"UHC [10700]","United Healthcare",,5511.92,63.3,,8601.07,8395.67,8601.07,"1 through 10",1012.7,7401.47,"percent of total billed charges",
"DEVICE PIPELINE 16MM 4.25MM EMBOLIZATION",SUP-PED2-425-16,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"PHCS [10601]",PHCS,,56558.25,70,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 8 SLOT LEFT TI",SUP-PHPF-S8L,CDM,C1713,HCPCS,0278,RC,,,both,,,17892.00,5367.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7353.61,41.1,,,,,0,2080.84,15208.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 15MM 140CM 3MM CORONARY STERILE LATEX",SUP-453940,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.3MM 42MM NAIL-EX TITANIUM FULL THREAD HUMERAL",SUP-04.005.532,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"FIRST HEALTH [10303]","First Health",,925.34,80,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE EMBOLIZATION YELLOW HYDROPEARL 200UM MICRO PEG",SUP-HP2S0200,CDM,S27800098,LOCAL,0278,RC,,,both,,,1927.50,578.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,884.72,45.9,,,,,0,224.17,1638.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 59MM 80CM 8MM 16SQ MM 8FR .035IN",SUP-BXAL085901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"AETNA [10100]","Aetna HMO/PPO",,15506.32,79.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL STD+ 12.5MM KNEE GVF POLYETHYLENE ROTATE",SUP-129405512,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"AETNA [10100]","Aetna HMO/PPO",,7682.44,79.5,,10981.53,8986.79,12413.38,12,1123.86,8213.93,"percent of total billed charges",
"PIN FIXATION TEMPORARY ANTERIOR CERVICAL PLATING SYSTEM",SUP-7786703,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 12X14X6MM CASCADIA 7D LORDOTIC TITANIUM POROUS",SUP-6101-2121406CL7-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 19MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-019,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,561.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,550.92,4026.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl FB Mscl Smpl",PX-450000065,CDM,20520,CPT,0450,RC,,,both,,,2379.00,713.7,"CIGNA [10200]",Cigna,,1833,,,,,,,67.13,2379,"case rate",
"DEVICE SPIRE CD HORIZON 45MM STABILIZATION SPINE PELVIS",SUP-9240100,CDM,S27800098,LOCAL,0278,RC,,,both,,,17798.40,5339.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7119.36,40,,,,,0,2069.95,15128.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 6X6CM TUTOPLAST THK.3-.5MM PERICARDIUM",SUP-938266,CDM,C1762,HCPCS,0278,RC,,,both,,,16263.30,4878.99,"UHC [10700]","United Healthcare",,10294.67,63.3,,,,,0,1891.42,13823.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAT TRANSFER 39X49IN HALFMATS HALF MAT AIR WEIGHT LIMIT 500",SUP-3230,CDM,S27100035,LOCAL,0271,RC,,,both,,,526.50,157.95,"FIRST HEALTH [10303]","First Health",,421.2,80,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 180CC FULL PROFILE SMOOTH NATRELLE INSPIRA",SUP-SSF-180,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"NOVANET [10819]",Novanet,,5666.63,75,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tangntl Bx Skin Single Les",PX-761000059,CDM,11102,CPT,0761,RC,,,both,,,1954.02,586.21,"CIGNA [10200]","Cigna Open Access",,1954.02,,"Per diem ($2,181).",,,,0,227.25,1954.02,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 1.8MM PILOT",SUP-320-0018,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"PHCS [10601]",PHCS,,1105.65,70,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 5.0 MM X 80 MM X 130 CM",SUP-IPU05008013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"MULTIPLAN [10600]",Multiplan,,6862.05,85,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 121MM TYPE 1 TAPERLOC MICROPLASTY PPS 133D 18",SUP-51106180,CDM,C1776,HCPCS,0278,RC,,,both,,,28567.35,8570.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3385.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3322.38,24282.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR SLIDER GDS VGTS",SUP-25129,CDM,C1768,HCPCS,0278,RC,,,both,,,9982.09,2994.63,"AETNA [10100]","Aetna HMO/PPO",,7935.76,79.5,,,,,0,1160.92,8484.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 5.5IN HOKE SPINE SURGICAL CURVE .5IN",SUP-28-4962,CDM,S27200284,LOCAL,0272,RC,,,both,,,197.40,59.22,"CIGNA [10200]","Cigna Local Plus",,105.61,53.5,,,,,0,22.96,167.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rheumatoid Factor Qual",PX-302000090,CDM,86430,CPT,0302,RC,,,both,,,236.00,70.8,"FIRST HEALTH [10303]","First Health",,188.8,80,,,,,0,0.01,200.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS RX 90CM 100MM 5.7-3.9FR 7MM BALLOON",SUP-BD-L70100MR,CDM,C1725,HCPCS,0272,RC,,,both,,,923.40,277.02,"AETNA [10100]","Aetna HMO/PPO",,734.1,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,107.39,784.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM ATLANTIS TITANIUM ANTERIOR CERVICAL SPINE",SUP-876-715,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"MESH SURGICAL PROGRIP 16X12CM INGUINAL LEFT SELF FIXATION",SUP-LPG1612AL,CDM,C1781,HCPCS,0278,RC,,,both,,,3591.45,1077.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2442.19,68,,,,,0,417.69,3052.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 14CM INFLATABLE NARROW",SUP-EN8914,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"KAISER [10500]",Kaiser,,42009,67,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 26CM 6FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49906,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"FIRST HEALTH [10303]","First Health",,602.64,80,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 217MM 34-38MM 33-34MM ZENITH ALPHA CAPTOR",SUP-G38190,CDM,C1874,HCPCS,0278,RC,,,both,,,96672.00,29001.6,"NOVANET [10819]",Novanet,,72504,75,,,,,0,11242.95,82171.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER FIDUCIAL 5MM .018IN LUMICOIL FIGURE 8 PLATINUM",SUP-M00553841,CDM,A4648,HCPCS,0278,RC,,,both,,,1387.72,416.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,161.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.39,1179.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL URETHRAL S-CURVE HYDROPHILIC SIDEPORT 37CM 24FR",SUP-G46250,CDM,S27200284,LOCAL,0272,RC,,,both,,,309.72,92.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,142.16,45.9,,,,,0,36.02,263.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 100MM 3MM BALLOON DILATATION DURALYN",SUP-48003010X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,853.74,68,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH 9MM PORTEX BLUPERC TUBE STERILE LATEX FREE",SUP-101/561/090,CDM,S27200284,LOCAL,0272,RC,,,both,,,2872.20,861.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,340.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.04,2441.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.3MM 36MM POLARUS 3 HEXALOBE LOW PROFILE HUMERUS",SUP-3011-43036-S,CDM,C1713,HCPCS,0278,RC,,,both,,,1142.10,342.63,"CIGNA [10200]","Cigna Local Plus",,611.02,53.5,,3978.14,359.25,3978.14,24,132.83,970.79,"percent of total billed charges",
"HC Mod Sedat 1st 15min < 5y",PX-371000007,CDM,99151,CPT,0371,RC,,,both,,,718.00,215.4,"BLUE CROSS [10001]","Blue Cross PPO",,0.72,.1,,,,,0,0.72,610.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII ALLOGRAFT 20MM 26MM",SUP-401320A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 188MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-224.601,CDM,C1713,HCPCS,0278,RC,,,both,,,3116.40,934.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,369.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",362.44,2648.94,"percent of total billed charges",
"STEM FEMORAL COLLAR ACTIS DUOFIX 1 STD OFFSET HIP STERILE",SUP-101011010,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12525.74,41.1,,6417.48,6417.48,6417.48,"1 through 10",3544.39,25904.81,"percent of total billed charges",
"BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET",RX-8958,CDM,,,0637,RC,00904-6938-06,NDC,both,1,UN,10.90,3.27,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.27,9.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM TAPER 32MM HIP MODULAR TYPE 1 BIOLOX DELTA",SUP-12-115116,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"CIGNA [10200]","Cigna Open Access",,5005.78,56.9,,5302.19,4377.88,6578.61,27,1023.15,7477.88,"percent of total billed charges",
"BRUSH CYTOLOGY ALWAYS-ON TIP TRACKED",SUP-INS-0352,CDM,S27200284,LOCAL,0272,RC,,,both,,,3912.30,1173.69,"CIGNA [10200]",Cigna,,2660.36,68,,,,,0,455,3325.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl/Bivalv Cast Arm/Leg",PX-450000208,CDM,29705,CPT,0361,RC,,,both,,,1142.16,342.65,"UHC [10700]","United Healthcare",,1142.16,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,132.83,1142.16,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR 14X14X11MM",SUP-345144,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2 38IN BRAID TIES MULTISTRAND LOWER KNOT",SUP-AR-7207,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,150.18,41.1,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 120MM 20MM VASCULAR NITINOL VENOUS ILIOFEMORAL",SUP-AB9U20120090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1203.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION LAPIPLASTY SPEEDPLATE RAPID COMPRESSION",SUP-SK53,CDM,C1713,HCPCS,0278,RC,,,both,,,22465.80,6739.74,"NOVANET [10819]",Novanet,,16849.35,75,,,,,0,2612.77,19095.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 330944 ACSR 9X14X14 SRVC FEE",SUP-330944,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP CEMENTED FEMUR OXINIUM HEAD R3 HIGHL",SUP-71705316,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Local Plus",,7541.1,31.5,,5372.07,4581.20,7242.98,23,2784.22,20349,"percent of total billed charges",
"VIABAHN BX BALLOON EXP ENDO 6MMX15MM 7FR 80CMCATH HEPARIN",SUP-BXB061501A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP 4 UNIPOLAR/BIPOLAR -  PRIMARY/REVISION STEM/DEPUY",SUP-CAP-H-4,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"AETNA [10100]","Aetna HMO/PPO",,8228.25,79.5,,10981.53,8986.79,12413.38,12,1203.71,8797.5,"percent of total billed charges",
"CASSETTE INFUSION PUMP GEN 2 PURGE",SUP-1000200,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Open Access",,3926.1,56.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP 4 UNIPOLAR/BIPOLAR -  PRIMARY/REVISION STEM/DEPUY",SUP-CAP-H-4,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Open Access",,5889.15,56.9,,5302.19,4377.88,6578.61,27,1203.71,8797.5,"percent of total billed charges",
"DEFIB CARDIAC VIVA CRT D QUAD S IS-4 DF1 US",SUP-DTBB1Q1,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA [10200]","Cigna Local Plus",,18181.8,31.5,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 150MM 18MM VASCULAR NITINOL ILIOFEMORAL VEIN SELF",SUP-AB9U18150090,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"PHCS [10601]",PHCS,,8211,70,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPIDURAL TRAY 18GA CRAWFORD",SUP-332223,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.48,38.84,"FIRST HEALTH [10303]","First Health",,103.58,80,,,,,0,15.06,110.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY 270CM 1MM .039IN SPYBITE 55D 4.1MM 1.2MM WORK",SUP-M00546270,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM PEEK-OPTIMA LOCK ROI-A BONE SPINE",SUP-IR2009T,CDM,C1713,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"MULTIPLAN [10600]",Multiplan,,29134.26,85,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE INZII UNIVERSAL XL ANGLE CYLINDRICAL 5MM SPECIMEN",SUP-CD003,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,38.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,inpatient,,,44667.96,13400.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23757.31,,"Fee schedule rate ($23,757.31). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,36550.47,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Fungi Defin ID Yeast",PX-306000068,CDM,87106,CPT,0306,RC,,,both,,,206.15,61.84,"CIGNA [10200]","Cigna Open Access",,22.7,,,,,,,0.21,175.23,"fee schedule",
"CATH SUPER TORQUE PLUS 100CM 6FR .051IN .042IN LEFT CORONARY",SUP-533672,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"UHC [10700]","United Healthcare",,52.1,63.3,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOXAZOSIN 1 MG TABLET, IMMEDIATE RELEASE",RX-9894,CDM,,,0637,RC,00904-5522-61,NDC,both,1,UN,6.27,1.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2.58,41.1,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9CM 3MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036123090,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 22MM DUODENAL NITINOL SOFT ANCHOR LOCK",SUP-M00555880,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO S1 GLIDESCOPE SPECTRUM MILLER DISPOSABLE",SUP-0270-1088,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.40,131.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,297.43,68,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Eopa Blunt Nonvent 22f",PX-E27200343,CDM,E27200343,LOCAL,0272,RC,,,both,,,342.10,102.63,"PHCS [10601]",PHCS,,239.47,70,,,,,0,39.79,290.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET MICRO BAYONET 7.25IN YASARGIL SYMMETRY OVAL CUP SHARP",SUP-58-3309,CDM,S27200284,LOCAL,0272,RC,,,both,,,740.26,222.08,"NOVANET [10819]",Novanet,,555.2,75,,,,,0,86.09,629.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 8MM 2.5MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012272-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Rmvl Snare",PX-750000094,CDM,45385,CPT,0750,RC,,,both,,,3930.04,1179.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,465.71,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,457.06,3930.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AIR/WATER DEFENDO BUTTON KIT SUCTION CLEAN BIOPSY",SUP-100305,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.07,15.92,"KAISER [10500]",Kaiser,,35.56,67,,,,,0,6.17,45.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ASR ALLOGRAFT FROZEN 14X11X5MM",SUP-245541FZ,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 40MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890006040,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 135CM EXCELSIOR XT-27 STRAIGHT",SUP-M003XT2735810,CDM,S27200284,LOCAL,0272,RC,,,both,,,8474.58,2542.37,"CIGNA [10200]",Cigna,,5762.71,68,,,,,0,985.59,7203.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 3-0 RB-1 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Y305H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,18.36,68,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE KNIFE 4IN KARLIN MICRO 2MM",SUP-46-3177,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.05,39.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.24,111.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C3",PX-302000025,CDM,86160,CPT,0302,RC,,,both,,,303.50,91.05,"BLUE CROSS [10001]","Blue Cross HMO",,0.3,.1,,,,,0,0.3,257.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL ARTHREX UNIVERS REVERS 7 SHOULDER STERILE",SUP-AR-9501-07P,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7178.76,68,,,,,0,1227.78,8973.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC",419,MS-DRG,,,,,,,inpatient,,,61213.47,18364.04,"CIGNA [10200]","Cigna Open Access",,14988.29,,"Fee schedule rate ($14,988.29). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",16375.13,16375.13,16375.13,"1 through 10",7561,39875.9,other,"IP DRG - Acute"
"CMPNT FEMORAL 9 NARROW KNEE RIGHT CRUCIATE RETAIN PERSONA",SUP-42502206602,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3360.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CARDIONYL 5-0 1 STRAND NONABSORBABLE",SUP-721222,CDM,S27200284,LOCAL,0272,RC,,,both,,,55.34,16.6,"CIGNA [10200]","Cigna Open Access",,31.49,56.9,,,,,0,6.44,47.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIGHT NARROW FLAT RTRCTR PHOTONGUIDE FIBEROPTIC STERILE",SUP-104008,CDM,S27200284,LOCAL,0272,RC,,,both,,,2343.75,703.12,"CIGNA [10200]","Cigna Open Access",,1333.59,56.9,,,,,0,272.58,1992.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 15MM 3MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT30015UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"BLUE CROSS [10001]","Blue Cross HMO",,946.68,39.2,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE LIGHT MAXCESS LIGHT GUIDE STERILE DISPOSABLE",SUP-3200220,CDM,S27000186,LOCAL,0270,RC,,,both,,,2973.75,892.12,"AETNA [10100]","Aetna HMO/PPO",,2364.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,345.85,2527.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 55MM 6.5MM MODULEX OSTEOGRIP SPINE",SUP-55900506555,CDM,C1713,HCPCS,0278,RC,,,both,,,4519.50,1355.85,"NOVANET [10819]",Novanet,,3389.63,75,,,,,0,525.62,3841.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC STD 16IN 25- IN KNEE ADJUSTABLE 3 PANEL",SUP-VP40105-010,CDM,L1830,HCPCS,0274,RC,,,both,,,160.08,48.02,"CIGNA [10200]","Cigna Local Plus",,85.64,53.5,,,,,0,18.62,136.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 14MM STAINLESS STEEL T8 SELF TAP LOCK",SUP-02.210.114TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1011.53,303.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",117.64,859.8,"percent of total billed charges",
"SPACER SPINAL 25X10X12MM VERTE-STACK CRESCENT 6D",SUP-9192512,CDM,S27800098,LOCAL,0278,RC,,,both,,,19235.66,5770.7,"PHCS [10601]",PHCS,,13464.96,70,,,,,0,2237.11,16350.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 20MM 144CM 3.5MM",SUP-H7493941220350,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"KAISER [10500]",Kaiser,,5200.88,67,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 30+ MM 14MM PERSONA TAPER KNEE TIBIA",SUP-42557000114,CDM,C1776,HCPCS,0278,RC,,,both,,,9648.96,2894.69,"PHCS [10601]",PHCS,,6754.27,70,,,,,0,1122.17,8201.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR .083IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1006,CDM,C1894,HCPCS,0272,RC,,,both,,,298.32,89.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,35.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.69,253.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL XS UNIVERSAL 16MM KNEE COCR POLYETHYLENE",SUP-198727116,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"BLUE CROSS [10001]","Blue Cross PPO",,11582.18,39.2,,3949.44,3949.44,3949.44,"1 through 10",3436.24,25114.41,"percent of total billed charges",
"LENS IOL 0 D +16.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.165,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 000 STRAIGHT OVAL 8IN SURGICAL SPINAL FUSION",SUP-29-5028,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.68,68.9,"CIGNA [10200]","Cigna Open Access",,130.69,56.9,,,,,0,26.71,195.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 10MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158105110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]","Cigna Open Access",,6358.32,56.9,,5302.19,4377.88,6578.61,27,1299.6,9498.37,"percent of total billed charges",
"CAP SYSTEM PREMIER G7 ACTIVE ARTICULATION THR XLPE CERAMIC H",SUP-98000500003,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3284.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3223.84,23562,"percent of total billed charges",
"KIT INTRO 4IN 6FR 18GA ARROW-FLEX .035IN PERCUTANEOUS",SUP-AK-09601,CDM,C1894,HCPCS,0272,RC,,,both,,,300.15,90.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,123.36,41.1,,,,,0,34.91,255.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 1 7MM",SUP-TPS-030-071S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLANER SURGICAL SP2 LARGE PATELLA BLADE",SUP-976748,CDM,S27200284,LOCAL,0272,RC,,,both,,,978.56,293.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,665.42,68,,,,,0,113.81,831.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE PIN KIT",SUP-AR-9507S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2940.00,882,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,341.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 30CM 14FR 22GA FLEXIMA POLYURETHANE 3 WAY STPCOCK 2",SUP-M001273070,CDM,C1729,HCPCS,0272,RC,,,both,,,1950.00,585,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1326,68,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 50CM 11CM GREEN HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-6F-11-035,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,54.43,68,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 51MM 28MM TANDEM HIP ACETABULAR COCR",SUP-71322051,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"NOVANET [10819]",Novanet,,6264.34,75,,,,,0,971.39,7099.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tcat Plmt&Rmvl Cerebrl Epd Perq",PX-361000562,CDM,33370,CPT,0361,RC,,,both,,,45298.00,13589.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5367.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1249,38503.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 125CM 6FR Q-CURVE 4.5 GUIDING PTFE FEMORAL LARGE",SUP-H749389692950,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"NOVANET [10819]",Novanet,,274.83,75,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 36MM LCP STAINLESS STEEL LONG THREAD FEMORAL",SUP-207.736,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,123.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,120.96,884.03,"percent of total billed charges",
"CATALYST HUMERAL STEM SHORT - 36MM X8MM",SUP-1230-7523-001,CDM,C1776,HCPCS,0278,RC,,,both,,,27713.70,8314.11,"UHC [10700]","United Healthcare",,17542.77,63.3,,8601.07,8395.67,8601.07,"1 through 10",3223.1,23556.65,"percent of total billed charges",
"DEVICE SYVEK NT CLSR PATCH HEMOSTATIC STERILE LATEX FREE",SUP-400-09-NT,CDM,S27200284,LOCAL,0272,RC,,,both,,,623.70,187.11,"NOVANET [10819]",Novanet,,467.78,75,,,,,0,72.54,530.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ADMIN AQUADEX FLEXFLOW POUCH LUER BLOOD CIRCUIT UF 500",SUP-A1650,CDM,S27200284,LOCAL,0272,RC,,,both,,,6210.00,1863,"MULTIPLAN [10600]",Multiplan,,5278.5,85,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD",SUP-98000500306,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,inpatient,,,24404.56,7321.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,12708.75,,,,,,,4944.46,19878.88,"case rate",
"GRAFT VASCULAR 40CM 6MM GORE INTERING STD WALL PTFE RADIAL",SUP-IRS06040L,CDM,C1768,HCPCS,0278,RC,,,both,,,3974.40,1192.32,"CIGNA [10200]","Cigna Open Access",,2261.43,56.9,,,,,0,462.22,3378.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 MEDIUM 32MM HIP ACETABULAR BIOLOX",SUP-877503202,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"CIGNA [10200]","Cigna Open Access",,5609.61,56.9,,5302.19,4377.88,6578.61,27,1146.57,8379.91,"percent of total billed charges",
"RING ANNULOPLASTY 30MM RIGID SADDLE SUT CUFF TITANIUM",SUP-RSAR-30,CDM,S27800098,LOCAL,0278,RC,,,both,,,14801.54,4440.46,"PHCS [10601]",PHCS,,10361.08,70,,,,,0,1721.42,12581.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 150CM 220MM 3MM BALLOON DILATATION",SUP-H74939031302210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 16MM 4.25MM EMBOLIZATION NEUROVASCULAR",SUP-PED-425-16,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8949.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HEAD BIPOLAR HIP",SUP-OSC365965,CDM,C1776,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Open Access",,2355.66,56.9,,5302.19,4377.88,6578.61,27,481.48,3519,"percent of total billed charges",
"BURR SURGICAL 3.8MM 3MM LONG NEURO STERILE",SUP-5130107030,CDM,S27200284,LOCAL,0272,RC,,,both,,,710.53,213.16,"CIGNA [10200]","Cigna Open Access",,404.29,56.9,,,,,0,82.63,603.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION",RX-109817,CDM,J0883,HCPCS,0636,RC,00143-9559-01,NDC,both,50,ML,1793.88,538.16,"CIGNA [10200]","Cigna Open Access",,81.23,,,,,,,46.62,1524.8,"fee schedule",
"RTRCTR ALEXIS 360D XL FLEXIBLE RING ATRAUMATIC SELF",SUP-C8304,CDM,S27200284,LOCAL,0272,RC,,,both,,,558.90,167.67,"AETNA [10100]","Aetna HMO/PPO",,444.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.5/22",SUP-401754,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 12MM 144CM 4.5MM CORONARY STENT",SUP-H7493941812450,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 485CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-485,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]","Cigna Local Plus",,4042.19,,,,,,,878.7,6422.18,"percent of total billed charges",
"GRAFT VASCULAR 40CM 8MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT083040A,CDM,C1768,HCPCS,0278,RC,,,both,,,10267.20,3080.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1216.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1194.08,8727.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL GWIRE .038MM 20CM 14FR VESSEL",SUP-JCD14-0-38-20,CDM,S27000186,LOCAL,0270,RC,,,both,,,59.16,17.75,"CIGNA [10200]","Cigna Local Plus",,31.65,53.5,,,,,0,6.88,50.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL GWIRE .038MM 20CM 14FR VESSEL",SUP-JCD14-0-38-20,CDM,S27000186,LOCAL,0270,RC,,,both,,,59.16,17.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.88,50.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (MR)  3.00MM X 10MM",SUP-H74939401103000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"FIRST HEALTH [10303]","First Health",,4333.2,80,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 6FR 8MM 4FR BALLOON",SUP-39031-80401,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION 14MM TIGHTROPE ROUND ACL ATTACHABLE",SUP-AR-1588TB-1,CDM,C1713,HCPCS,0278,RC,,,both,,,1685.25,505.57,"CIGNA [10200]","Cigna Open Access",,958.91,56.9,,1144.80,304.56,2275.09,66,195.99,1432.46,"percent of total billed charges",
"SYSTEM REBEL 24MM 140CM 3.5MM CORONARY STENT PLATINUM",SUP-H7493927424350,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"KAISER [10500]",Kaiser,,2512.5,67,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL 30CM 7FR .038IN URETERAL PERCUFLEX",SUP-M0061856310,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,313.86,28.62,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH 8FR 12CM",SUP-406253,CDM,C1894,HCPCS,0272,RC,,,both,,,156.60,46.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC",236,MS-DRG,,,,,,,inpatient,,,253424.13,76027.24,"UHC [10700]","United Healthcare",,122296.2,,"Fee schedule rate ($122,296.20). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,25983.38,122296.2,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ABLATION 7FR CORONARY SINUS 2-8-2MM SPACING D-F CUR",SUP-BD710DF282RTSR,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,991.44,68,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL COALITION ANTERIOR CERVICAL DISCECTOMY AND",SUP-384.106,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"AETNA [10100]","Aetna HMO/PPO",,14310,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL THK1.5MM 2-0 SH 36IN 2 ARM BRAID SOFT",SUP-SXP02H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UHC [10700]","United Healthcare",,15.83,63.3,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.160,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 3CM 20GA HAWKINS III FLEXSTRAND HARDWIRE",SUP-253030,CDM,A4648,HCPCS,0278,RC,,,both,,,310.59,93.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,142.56,45.9,,,,,0,36.12,264,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELLIPSE NEXT GENERATION VR 36",SUP-CD1411-36C,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"AETNA [10100]","Aetna HMO/PPO",,31005,79.5,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME TALAR INFINITY 3 ANKLE ADAPTIS FLAT CUT NONSTERILE",SUP-33680033,CDM,C1776,HCPCS,0278,RC,,,both,,,36981.00,11094.3,"BLUE CROSS [10001]","Blue Cross HMO",,14496.55,39.2,,5311.50,4717.44,5388.59,31,4300.89,31433.85,"percent of total billed charges",
"CAP POROUS COATED HIP SYSTEM WITH METAL HEAD",SUP-98000500305,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"MULTIPLAN [10600]",Multiplan,,20349,85,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAC-LOC 25CM 8.5FR DRNG ULTRATHANE AQ 6 SIDEPORT TROCAR",SUP-G09501,CDM,C1729,HCPCS,0272,RC,,,both,,,761.32,228.4,"MULTIPLAN [10600]",Multiplan,,647.12,85,,,,,0,88.54,647.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 5.5MM CORE THK.51MM 25MM LONG NARROW SAGITTAL",SUP-2296-033-414,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.84,87.25,"MULTIPLAN [10600]",Multiplan,,247.21,85,,,,,0,33.82,247.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 65CM 5FR RLG CURVE ANGIOGRAPHIC",SUP-G47064,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"AETNA [10100]","Aetna HMO/PPO",,167.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC",358,MS-DRG,,,,,,,inpatient,,,67768.60,20330.58,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,8931.4,,"Case rate ($8,671.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,051.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,091.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,990.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,062.50. The transfer operating threshold is the transfer adjustment factor * $8,051.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.76. The transfer capital threshold is the transfer adjustment factor * $608.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,40813.09,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 80MM 1.1MM LEGEND TAPERED STERILE",SUP-8TA11,CDM,S27200284,LOCAL,0272,RC,,,both,,,879.26,263.78,"AETNA [10100]","Aetna HMO/PPO",,699.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,102.26,747.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CRE 5.5CM 8-9-10MM BALLOON DILATATION PEBAX ADULT RAPID",SUP-M00558870,CDM,C1726,HCPCS,0272,RC,,,both,,,2085.75,625.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,242.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,242.57,1772.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL BLUE CD HORIZON MEDIUM NARROW BLADE 5.5/6MM ROD",SUP-5541123,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,3978.14,359.25,3978.14,24,348.9,2550,"percent of total billed charges",
"ROD SPINAL 65MM 3.5MM YUKON CONTOUR TITANIUM",SUP-7601-63565,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 18MM AMNIOBAND PLACENTAL ALLOGRAFT",SUP-WC3018,CDM,Q4151,HCPCS,0636,RC,,,both,,,4395.30,1318.59,"PHCS [10601]",PHCS,,3076.71,70,,,,,0,362.66,3736.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 31CM 5MM ENDO MINI-RETRACT CURVE JAW STRAIGHT HANDLE",SUP-174209,CDM,S27200284,LOCAL,0272,RC,,,both,,,488.51,146.55,"PHCS [10601]",PHCS,,341.96,70,,,,,0,56.81,415.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS SUTUPAK 3-0 18IN BRAID 12 STRAND",SUP-VCP104G,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.32,28.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.2,81.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 24FR SILICONE STD J MIC SECUR-LOK TRIMMABLE",SUP-0200-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"CIGNA [10200]",Cigna,,747.71,68,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 60MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.860,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,159.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",159.84,1168.25,"percent of total billed charges",
"STENT HANAROSTENT 100MM 1800MM 10MM 2.33MM BILIARY NITINOL",SUP-SHS-10-100-180,CDM,C1874,HCPCS,0278,RC,,,both,,,6855.84,2056.75,"MULTIPLAN [10600]",Multiplan,,5827.46,85,,,,,0,797.33,5827.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL WHITE 11CM UTAHLOOP SAFE-T-GAUGE",SUP-DLP-W11,CDM,S27200284,LOCAL,0272,RC,,,both,,,140.07,42.02,"PHCS [10601]",PHCS,,98.05,70,,,,,0,16.29,119.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 9 KNEE CEMENTED FIX BEARING STERILE",SUP-150600009,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"NOVANET [10819]",Novanet,,11253.04,75,,,,,0,1744.97,12753.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 23MM 4.5MM AEQUALIS REVERSED GLENOID TITANIUM",SUP-VDV223,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,714.2,45.9,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 80MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.128,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"CIGNA [10200]","Cigna Open Access",,487.8,56.9,,1144.80,304.56,2275.09,66,99.7,728.71,"percent of total billed charges",
"STENT UNISTEP PLUS WALLSTENT RP 90MM 75CM 6MM 100CM",SUP-M001711140,CDM,C1876,HCPCS,0278,RC,,,both,,,12592.50,3777.75,"CIGNA [10200]","Cigna Local Plus",,3966.64,31.5,,,,,0,1464.51,10703.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 82X12.7X1.2MM NARROW STAINLESS STEEL 2 CUT",SUP-2108-158,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"UHC [10700]","United Healthcare",,151.34,63.3,,,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 18MM 140CM .91-1.12MM 2.25MM CORONARY",SUP-RONYX22518W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"AETNA [10100]","Aetna HMO/PPO",,2683.13,79.5,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 22MM COLONIC ENTERAL ANCHOR LOCK",SUP-M00555780,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON ULTIMA 9-0 CA160-6 12IN 2 ARM MONOFILAMENT BLACK",SUP-9011G,CDM,S27200284,LOCAL,0272,RC,,,both,,,220.62,66.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.66,187.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 12MM 6FR 3.25MM",SUP-H7493926712320,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 45MM ENDOWRIST BLUE",SUP-41645B,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CROSSTELLA 90CM 40MM 4-3.4FR 5MM BALLOON DILATATION",SUP-BD-F50040MR,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PRELUDE ACT SHEATHS 8 FR 11CM 50CM LENGTH .038 GUIDEWIRE",SUP-PSI-8F-11-038ACT,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,54.43,68,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 200MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025200M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32MMX12MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2991232,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1883.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Nacl",PX-E27200280,CDM,E27200280,LOCAL,0272,RC,,,both,,,119.90,35.97,"AETNA [10100]","Aetna HMO/PPO",,95.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.94,101.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENDO ELECTROSURGICAL FLOATING BALL",SUP-12-201-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4105.5,68,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 CURVE PLUS 17.5MM KNEE XLK FIX BEARING SIGMA",SUP-970474,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4592.74,41.1,,6417.48,6417.48,6417.48,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"BIT DRILL 190MM 10MM LARGE QUICK COUPLING CANNULATED STERILE",SUP-360.05S,CDM,S27000186,LOCAL,0270,RC,,,both,,,3708.60,1112.58,"CIGNA [10200]",Cigna,,2521.85,68,,,,,0,431.31,3152.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP ACETABULAR 42MM 32MM PROSTALAC CEMENTED HIP ALL POLY",SUP-154142320,CDM,C1776,HCPCS,0278,RC,,,both,,,3955.08,1186.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1131.94,28.62,,,,,0,459.98,3361.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 4MM XCOARSE BALL DISSECTING DIAMOND",SUP-MR8-14BA40DX,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.17,412.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,162.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,159.82,1168.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 30MM 190CM 3MM",SUP-R51003003L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,810.39,41.1,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM INTERLOCK IDC 18 COIL SOFT 2D",SUP-M0033612020,CDM,S27800098,LOCAL,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VIA DEMINERALIZE MINERALIZE CORTICAL CANCELLOUS B",SUP-VCAX-100000,CDM,S27800098,LOCAL,0278,RC,,,both,,,20790.00,6237,"UHC [10700]","United Healthcare",,13160.07,63.3,,,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 20CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155230190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS [10001]","Blue Cross HMO",,556.77,39.2,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE LADDER 2.0",SUP-PRT-LDR-020,CDM,C1713,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2053.77,28.62,,,,,0,834.57,6099.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 110MM 18 HOLE RESORBABLE BIOBRIDGE BONE RIB NONSTERILE",SUP-RRP1501,CDM,C1713,HCPCS,0278,RC,,,both,,,9204.60,2761.38,"NOVANET [10819]",Novanet,,6903.45,75,,,,,0,1070.49,7823.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUADRA ASSURA MP CRT-D DF4 CONNECTOR",SUP-CD3369-40Q,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA [10200]","Cigna Local Plus",,18181.8,31.5,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 11 STD KNEE LEFT CRUCIATE RETAIN CEMENT",SUP-42502607001,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS [10001]","Blue Cross HMO",,8962.18,39.2,,5311.50,4717.44,5388.59,31,2658.93,19433.3,"percent of total billed charges",
"PLATE 38MM 2 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800238,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,957.42,570.23,957.42,28,521.61,3812.25,"percent of total billed charges",
"COLONOSCOPE ENDOSCOPIC PEDIATRIC SM DIA10.4MM PURPLE DISPOSA",SUP-ARV130,CDM,S27200284,LOCAL,0272,RC,,,both,,,216.11,64.83,"KAISER [10500]",Kaiser,,144.79,67,,,,,0,25.13,183.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chromosome Karyotype Study Addl",PX-311000069,CDM,88280,CPT,0311,RC,,,both,,,598.50,179.55,"CIGNA [10200]","Cigna Local Plus",,73.63,,,,,,,0.01,508.73,"fee schedule",
"LENS IOL 10 D +22 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z9002220,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,694.01,68,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.235,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"KAISER [10500]",Kaiser,,231.15,67,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CENTRIFUGAL PLATELET RICH PLASMA PROCESS ANGEL",SUP-976000501,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,262.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 144MM 12MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-103120,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6927,28.62,,,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT SIGMA 3 KNEE CEMENTED ROTATE",SUP-129433130,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"AMINOCAPROIC ACID 500 MG TABLET",RX-9063,CDM,,,0637,RC,69680-0115-30,NDC,both,1,UN,27.07,8.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.15,23.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE ENDOBRONCHIAL ZEPHYR OD 5.5- 8.5MM LOW PROFILE",SUP-EBV-TS-5.5-LP,CDM,S27800098,LOCAL,0278,RC,,,both,,,17112.00,5133.6,"CIGNA [10200]",Cigna,,6844.8,40,,,,,0,1990.13,14545.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 12MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE32512,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"KAISER [10500]",Kaiser,,56055.28,67,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 96MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 7X3",SUP-241.071,CDM,S27800098,LOCAL,0278,RC,,,both,,,2463.30,738.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,286.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,286.48,2093.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 43IN 12FR 3MM DISTAL TIP INTEGRATE CAMERA",SUP-461243E,CDM,S27200284,LOCAL,0272,RC,,,both,,,1887.60,566.28,"CIGNA [10200]","Cigna Local Plus",,1009.87,53.5,,,,,0,219.53,1604.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Breast Uni W Cntrst",PX-610000060,CDM,77048,CPT,0610,RC,,,both,,,4284.00,1285.2,"CIGNA [10200]",Cigna,,955,,"Per diem ($955). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,437.65,3641.4,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STYLET ASSORTED 40CM UNIVERSAL J STRAIGHT REPOSITIONING",SUP-DS06003/40,CDM,S27500001,LOCAL,0275,RC,,,both,,,453.60,136.08,"CIGNA [10200]",Cigna,,308.45,68,,,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL VIRTUS 6IN SPLINTER STAINLESS STEEL",SUP-30-4258,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.38,72.11,"NOVANET [10819]",Novanet,,180.29,75,,,,,0,27.96,204.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC",331,MS-DRG,,,,,,,inpatient,,,60802.64,18240.79,"AMBETTER EXCHANGE  [11102]",Ambetter,,10439.13,,"Case rate ($10,439.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,693.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,733.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,114.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $9,706.26. The transfer operating threshold is the transfer adjustment factor * $9,693.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $732.87. The transfer capital threshold is the transfer adjustment factor * $732.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,49133.95,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 3.25IN 9FR AORTIC ROOT ADULT 0-.9MG/KG 4",SUP-30401,CDM,S27200284,LOCAL,0272,RC,,,both,,,296.37,88.91,"CIGNA [10200]","Cigna Local Plus",,158.56,53.5,,,,,0,34.47,251.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 6MM EMBOLD PLATINUM TUNGSTUN NITINOL",SUP-M001394240060200,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"AETNA [10100]","Aetna HMO/PPO",,5419.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 120CM 150MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"AETNA [10100]","Aetna HMO/PPO",,1139.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 12MM OSS UHMWPE KNEE TIBIAL STD STERILE",SUP-150410,CDM,C1776,HCPCS,0278,RC,,,both,,,8317.26,2495.18,"CIGNA [10200]",Cigna,,5655.74,68,,5873.17,5873.17,5873.17,"1 through 10",967.3,7069.67,"percent of total billed charges",
"STENT UNIVERSA 24CM 7FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49913,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"KAISER [10500]",Kaiser,,504.71,67,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 25MM 3MM BALLOON DILATATION PEBAX",SUP-1400300-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS 5-0 P-3 18IN MULTIPASS ABSORBABLE",SUP-PDP493G,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.25,20.17,"KAISER [10500]",Kaiser,,45.06,67,,,,,0,7.82,57.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Bio-Med Multi-Stage 21f",PX-E27200396,CDM,E27200396,LOCAL,0272,RC,,,both,,,2162.60,648.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,256.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,251.51,1838.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 80X25.4X1.3MM LONG WIDE THICK SAGITTAL STERILE",SUP-2108111000,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"CIGNA [10200]","Cigna Local Plus",,127.91,53.5,,,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 30MM MODULAR FLEXIBLE DISPOSABLE",SUP-00879000703,CDM,S27200284,LOCAL,0272,RC,,,both,,,1162.35,348.7,"NOVANET [10819]",Novanet,,871.76,75,,,,,0,135.18,988,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PANEL LIGHT SAPHLITE LARGE SOURCE",SUP-89-2716K,CDM,S27200284,LOCAL,0272,RC,,,both,,,3376.41,1012.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,400.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,392.68,2869.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CROSSLEAD VASCULAR 300CM .035IN STERILE LATEX FREE",SUP-CLN03530A,CDM,C1769,HCPCS,0272,RC,,,both,,,1579.50,473.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,649.17,41.1,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 82MM 13MM 14FR ENDURANT II ABDOMEN AORTA",SUP-ETEW1313C82E,CDM,S27800098,LOCAL,0278,RC,,,both,,,28331.10,8499.33,"NOVANET [10819]",Novanet,,21248.33,75,,,,,0,3294.91,24081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DARUNAVIR 800 MG TABLET",RX-160155,CDM,,,0250,RC,59651-0086-30,NDC,both,1,UN,285.13,85.54,"FIRST HEALTH [10303]","First Health",,228.1,80,,,,,0,33.16,242.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -2MM 12/14 TAPER 36MM HIP CEMENTLESS M",SUP-136550000,CDM,C1776,HCPCS,0278,RC,,,both,,,3991.68,1197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1142.42,28.62,,,,,0,464.23,3392.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 15MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158105115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross HMO",,4380.42,39.2,,5311.50,4717.44,5388.59,31,1299.6,9498.37,"percent of total billed charges",
"KIT MICRO ACCSS PL AWY SHTH 7F",SUP-6509945,CDM,C1887,HCPCS,0272,RC,,,both,,,3090.00,927,"AMERIGROUP MEDICAID [20100]",Amerigroup,,366.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,359.37,2626.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 4.75MM LONGITUDE II STRAIGHT CCM",SUP-1475006120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET SURGICAL INSTR 10GA IVAS BEVEL STERILE LATEX FREE",SUP-0306-531-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,597.70,179.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,70.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.51,508.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH XXL QUADRA-FOLD 75CM 60MM 18MM BALLOON DILATATION",SUP-M001145590,CDM,C1725,HCPCS,0272,RC,,,both,,,1709.63,512.89,"FIRST HEALTH [10303]","First Health",,1367.7,80,,,,,0,198.83,1453.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOFT TISSUE PROCEDURES WITHOUT CC/MCC",502,MS-DRG,,,,,,,inpatient,,,89001.64,26700.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,26717.46,,"Fee schedule rate ($26,717.46). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,39294.9,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 30ML .1-4MM ALLOGRAFT CRUSH FREEZE",SUP-T00020,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 28MM 3.5MM CORONARY STENT EVEROLIMUS",SUP-1550350-28,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 6MM LCP STAINLESS STEEL DISTAL CORTICAL",SUP-201.756,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,3978.14,359.25,3978.14,24,50.59,369.75,"percent of total billed charges",
"CATHETER 115CM 7FR 2-12-2MM SPACING ISMUS CATH CURVE ELECTRO",SUP-D7R20P14CT,CDM,C1731,HCPCS,0272,RC,,,both,,,2100.00,630,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1428,68,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 25MM AEQUALIS PERFORM 15D SHOULDER WEDGE AUG",SUP-DWJ505,CDM,C1776,HCPCS,0278,RC,,,both,,,11340.00,3402,"KAISER [10500]",Kaiser,,7597.8,67,,,,,0,1318.84,9639,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 100MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355100,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"CABLE CATH 10FT 2 SENSOR EXT REDEL 10 PIN CNCT MALE TO MALE",SUP-C10MRMSTKDTCS,CDM,S27000186,LOCAL,0270,RC,,,both,,,2115.00,634.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,970.79,45.9,,,,,0,245.97,1797.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FRACTURE STABILIT LONG COMPLETE",SUP-3506,CDM,S27200284,LOCAL,0272,RC,,,both,,,16905.00,5071.5,"CIGNA [10200]","Cigna Open Access",,9618.95,56.9,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM ACTIVE ARTICULATION THR XLPE POROUS CUP 2 MOBILIT",SUP-98B00100193,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"BLUE CROSS [10001]","Blue Cross HMO",,6914.88,39.2,,5311.50,4717.44,5388.59,31,2051.53,14994,"percent of total billed charges",
"PROBE ARTHROSCOPIC MEASUREMENT 60D 220MM",SUP-AR-4070-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KETOROLAC 10 MG TABLET",RX-10371,CDM,,,0250,RC,60687-0104-11,NDC,both,1,UN,27.65,8.29,"PHCS [10601]",PHCS,,19.36,70,,,,,0,3.22,23.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OPTISEAL SIDEPORT  13 CM 6F",SUP-346978,CDM,C1893,HCPCS,0272,RC,,,both,,,486.00,145.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,56.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 6X38X28MM 15DEG ANTERIOR LUMBAR INTERFIXED 3DP M",SUP-1921045P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"AETNA [10100]","Aetna HMO/PPO",,27546.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 5CM 20GA GHIATAS BEADED STIFFENED SECTION",SUP-49520,CDM,A4648,HCPCS,0278,RC,,,both,,,182.79,54.84,"BLUE CROSS [10001]","Blue Cross HMO",,71.65,39.2,,,,,0,21.26,155.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM 34X16X2.5MM TITANIUM 2 LEVEL PREBENT SKYLINE BONE",SUP-186802034,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2998.8,68,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 8MM 32MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.522,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"CIGNA [10200]","Cigna Open Access",,658.15,56.9,,1144.80,304.56,2275.09,66,134.52,983.18,"percent of total billed charges",
"LINER ACETABULAR EMPHASYS 180D 3MM 64-66MM 52MM METAL HIP 2",SUP-472564052,CDM,C1776,HCPCS,0278,RC,,,both,,,16853.25,5055.97,"MULTIPLAN [10600]",Multiplan,,14325.26,85,,,,,0,1960.03,14325.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752540,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,106.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM TITANIUM ALUMINUM VANADIUM FEMUR",SUP-00493503201,CDM,C1713,HCPCS,0278,RC,,,both,,,607.50,182.25,"CIGNA [10200]","Cigna Open Access",,345.67,56.9,,1144.80,304.56,2275.09,66,70.65,516.38,"percent of total billed charges",
"SLEEVE LAPAROSCOPIC 5MM OPTICAL ACCESS SYSTEM 150MM KII",SUP-CFR10,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"CIGNA [10200]","Cigna Local Plus",,116.36,53.5,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII CRUCIATE RETAINING VERIL",SUP-71704565,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC",715,MS-DRG,,,,,,,inpatient,,,132254.08,39676.22,"AETNA [10100]","Aetna HMO/PPO",,42094.8,,"Fee schedule rate ($42,094.80). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,65320.21,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM VARIAX TITANIUM DISTAL RADIUS T7 DRIVE",SUP-53-27614E,CDM,C1713,HCPCS,0278,RC,,,both,,,762.05,228.61,"BLUE CROSS [10001]","Blue Cross HMO",,298.72,39.2,,957.42,156.86,7483.26,51,88.63,647.74,"percent of total billed charges",
"CATH GUIDER SOFTIP XF 90CM 6FR MP CURVE GUIDING DURAFORM",SUP-H965100460,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1028.79,41.1,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 115CM 1MM 7FR 2-8-2MM SPACE D CURVE ELECTROPHYSIOLOGY",SUP-D710DRP10CT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2534.7,68,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 75MM KNEE RIGHT CRUCIATE RETAIN CEMENT PRIMARY",SUP-183014,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5423.13,27,,,,,0,2335.96,17072.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 7CM 7FR PIGTAIL CURVE TAPER PANCREATIC",SUP-G22353,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.8CM NATRELLE BIOCELL P5.7CM HIGH PROFILE ROUND",SUP-MSZ20600,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"FIRST HEALTH [10303]","First Health",,126.54,80,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 3.00 X 28 MM",SUP-1212300-28,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]",Cigna,,6900,40,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESALAMINE 800 MG TABLET,DELAYED RELEASE",RX-96949,CDM,,,0637,RC,60687-0408-95,NDC,both,1,UN,61.99,18.6,"PHCS [10601]",PHCS,,43.39,70,,,,,0,7.21,52.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 6MM .021IN AZUR DETACHABLE .018IN",SUP-45-480610,CDM,S27800098,LOCAL,0278,RC,,,both,,,1333.26,399.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,611.97,45.9,,,,,0,155.06,1133.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION",RX-3037,CDM,J3010,HCPCS,0636,RC,00641-6028-01,NDC,both,5,ML,46.03,13.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,31.3,68,,,,,0,3.85,39.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veeg Ea 12-26hr Cont Mntr",PX-740000051,CDM,95716,CPT,0740,RC,,,both,,,6305.47,1891.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,747.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,733.33,5359.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 5MM 8.25IN STAINLESS STEEL GARRETT MALLEABLE",SUP-25-8024,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.12,22.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.62,63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 130MM 4.5MM RADENOID 40D ADENOID CURVED",SUP-1884507,CDM,S27200284,LOCAL,0272,RC,,,both,,,1941.00,582.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1319.88,68,,,,,0,225.74,1649.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ECHELON CONTOUR GST RELOAD (GREEN)",SUP-GCR40G,CDM,S27200284,LOCAL,0272,RC,,,both,,,2994.05,898.21,"CIGNA [10200]","Cigna Local Plus",,1601.82,53.5,,,,,0,348.21,2544.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X12X6MM ENDOSKELETON TC 6D LORDOTIC SMALL",SUP-5146-1206-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"AETNA [10100]","Aetna HMO/PPO",,8228.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 100MM 12MM NEXGEN STRAIGHT KNEE ROTATE HINGE 145MM",SUP-00598801012,CDM,C1776,HCPCS,0278,RC,,,both,,,8049.54,2414.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,936.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,936.16,6842.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT ORTHOPEDIC PROCARE PODOUS REGULAR FOOT LIGHTWEIGHT",SUP-79-90550,CDM,S27000186,LOCAL,0270,RC,,,both,,,291.54,87.46,"FIRST HEALTH [10303]","First Health",,233.23,80,,,,,0,33.91,247.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 20MM 4MM .035IN BALLOON DILATATION NYBAX",SUP-39171-04024,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,136.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR 44.5MM CARBIDE 4MM ROUND 8 FLUTE DENTAL",SUP-14-C0108,CDM,S27200284,LOCAL,0272,RC,,,both,,,120.15,36.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.97,102.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER TORQR 110CM 6FR 2-5-2MM SPACING JSN CURVE ELECTROPH",SUP-04122JMR,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 22CM 8FR .038IN PIGTAIL CURVE TAPER URETER GLIDEX",SUP-M001245630,CDM,C2617,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CIGNA [10200]","Cigna Local Plus",,922.88,,,,,,,200.62,1466.25,"percent of total billed charges",
"MARKER 18GA MAGSEED BREAST BIOPSY 12CM",SUP-SM18112001,CDM,A4648,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"MULTIPLAN [10600]",Multiplan,,3155.63,85,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE PATELLOFEMORAL LEFT CEMENTED PRECOAT",SUP-00592601201,CDM,C1776,HCPCS,0278,RC,,,both,,,15573.60,4672.08,"KAISER [10500]",Kaiser,,10434.31,67,,,,,0,1811.21,13237.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESPIRATORY NEOPLASMS WITH MCC",180,MS-DRG,,,,,,,inpatient,,,33272.18,9981.65,"CIGNA [10200]","Cigna Open Access",,19380.08,,"Fee schedule rate ($19,380.08). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,33272.18,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY",RX-11138,CDM,,,0637,RC,00574-7226-12,NDC,both,1,UN,47.56,14.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,21.83,45.9,,,,,0,5.53,40.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 80MM 6MM BALLOON",SUP-U3513068,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM 2.6-2FR .019IN EXCELSIOR",SUP-M0031441940,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"CIGNA [10200]",Cigna,,5249.08,68,,,,,0,897.75,6561.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex Bx",PX-750000076,CDM,45331,CPT,0750,RC,,,both,,,3094.10,928.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2795,,"Case rate ($2,795). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,359.84,3094.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 150MM 2300MM 20MM ESOPHAGEAL METAL NITINOL",SUP-ECBA-20-150-230,CDM,C1874,HCPCS,0278,RC,,,both,,,16425.45,4927.63,"CIGNA [10200]","Cigna Open Access",,5502.53,33.5,,,,,0,1910.28,13961.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYSORB 21IN LOOPED BRAIDED COATED VIOLET ABSORBABLE",SUP-EL21L,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.60,47.58,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,107.85,68,,,,,0,18.45,134.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SURFACE ARTICULAR PERSONA VIVACIT-E STD KNEE CEMENT",SUP-98000641500,CDM,C1776,HCPCS,0278,RC,,,both,,,19530.00,5859,"AETNA [10100]","Aetna HMO/PPO",,15526.35,79.5,,10981.53,8986.79,12413.38,12,2271.34,16600.5,"percent of total billed charges",
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,inpatient,,,25018.89,7505.67,"PHCS [10601]",PHCS,,7561,,,,,,,4835.9,19442.44,"per diem","Estimated amount calculated based on 2 day length of stay."
"STENT VISI-PRO 27MM 135CM 5MM 30MM BILIARY STAINLESS STEEL",SUP-PXB35-05-27-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"CIGNA [10200]","Cigna Local Plus",,2336.35,53.5,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X22X7MM RISE-L 3D LORDOTIC NONSTERILE",SUP-193.603,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"AETNA [10100]","Aetna HMO/PPO",,27296.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET VENTRICULAR ASSIST 2.5IN IMPELLA STERILE LATEX FREE",SUP-005042,CDM,S27800098,LOCAL,0278,RC,,,both,,,114000.00,34200,"UHC [10700]","United Healthcare",,72162,63.3,,,,,0,13258.2,96900,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARR GRAFT 8X3IN 1.5:1 DERMACARRIER II SKIN PLATEAU GROOVES",SUP-00219501200,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,49.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 STD KNEE LEFT POSTERIOR STABILIZE PERSONA",SUP-42500806001,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"KAISER [10500]",Kaiser,,19360.04,67,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 5MM 68MM NAIL-EX TITANIUM FEMORAL TIBIAL LOCKING",SUP-04.005.558,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"AMERIGROUP MEDICAID [20100]",Amerigroup,,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",134.52,983.18,"percent of total billed charges",
"ANGINA PECTORIS",311,MS-DRG,,,,,,,inpatient,,,33115.21,9934.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,11190.9,,,,,,,4353.92,17504.68,"case rate",
"LENS IOL 5 D +22 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2200,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 26MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ326,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.88,817.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 4MM CORONARY STENT",SUP-H7493941820400,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"MULTIPLAN [10600]",Multiplan,,2550,85,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 4MM 4.5MM 5MM XTHICK EEA BLACK 28MM",SUP-TRIEEA28XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2227.65,668.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,259.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.08,1893.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MEGA STATLOCK 6IN 229MM 8FR 17.4MM IAB 50ML 2 DEVICE",SUP-0684-00-0296-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,5980.99,1794.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2745.27,45.9,,,,,0,695.59,5083.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 20MM 130CM 7MM .035IN BILIARY SELF EXPANDING",SUP-EX070203CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3357.13,28.62,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo Small Intest Cntrl Bld",PX-750000206,CDM,44366,CPT,0750,RC,,,both,,,3668.65,1100.59,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,426.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,426.66,3668.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL 1-2.25MM ARTERY BLACK",SUP-B-3AB,CDM,S27200284,LOCAL,0272,RC,,,both,,,547.11,164.13,"CIGNA [10200]","Cigna Local Plus",,292.7,53.5,,,,,0,63.63,465.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYGNUS MATRIX (4 X 4) 16 SQ CM",SUP-585-010,CDM,Q4199,HCPCS,0636,RC,,,both,,,9832.50,2949.75,"PHCS [10601]",PHCS,,6882.75,70,,,,,0,298.85,8357.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ECHELON 14 155CM 150CM 2.4-1.9FR .017IN MICRO INFUSION",SUP-105-5092-150,CDM,S27200284,LOCAL,0272,RC,,,both,,,4650.60,1395.18,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1911.4,41.1,,,,,0,540.86,3953.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LCRML DCT MINI MONOKA SIL 40MM .64MM DIL PLG INSRTR 2M",SUP-S1.1500,CDM,S27200284,LOCAL,0272,RC,,,both,,,513.00,153.9,"FIRST HEALTH [10303]","First Health",,410.4,80,,,,,0,59.66,436.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 24FR CUT WOLF RESECTOSCOPE",SUP-M0068802431,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"KAISER [10500]",Kaiser,,320.41,67,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 7MM SPACE 70X7.5X2.2MM STAINLESS STEEL 2.7MM SCR 6",SUP-72442770,CDM,C1713,HCPCS,0278,RC,,,both,,,6184.13,1855.24,"CIGNA [10200]",Cigna,,4205.21,68,,1831.33,1831.33,1831.33,16,719.21,5256.51,"percent of total billed charges",
"IMPL BREAST NATRELLE INSPIRA SMOOTH SHELL SURFACE SOFT TOUCH",SUP-SSF-520,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS [10001]","Blue Cross HMO",,2961.76,39.2,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMEDY SPECTRUM GV FEMORAL STEM LG",SUP-GVSTLG,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Florbetaben F18 Diagnostic",PX-343000056,CDM,Q9983,HCPCS,0343,RC,,,both,,,4119.95,1235.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3090.11,,,,,,,479.15,3962.7,"fee schedule",
"ANCHOR SUT FULL THREAD CORKSCREW TAPE BIOCOMPOSITE 4.75MM",SUP-AR-1927BCT-475,CDM,C1713,HCPCS,0278,RC,,,both,,,2795.63,838.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1283.19,45.9,,,,,0,325.13,2376.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAUT 18IN 4.5FR 7.5FR CHOLANGIOGRAM SPRT TUBE MAXIMUM",SUP-20018-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,455.22,136.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,208.95,45.9,,,,,0,52.94,386.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Paravrt Jt L/S 1 Lvl",PX-510000138,CDM,64493,CPT,0761,RC,,,both,,,6149.00,1844.7,"MULTIPLAN [10600]",Multiplan,,5226.65,85,,,,,0,715.13,5226.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch W Valve Rmvl Ea Add",PX-750000147,CDM,31649,CPT,0750,RC,,,both,,,5006.00,1501.8,"KAISER [10500]",Kaiser,,3354.02,67,,,,,0,5.01,4617,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL KNEE IDENTITY IMPRINT THK8MM 6 NARROW TIBIAL INSRT",SUP-TPS-030-086N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Pyrophosphate Up to 25mci",PX-343000034,CDM,A9538,HCPCS,0343,RC,,,both,,,387.09,116.13,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,77.51,,,,,,,45.02,329.03,"fee schedule",
"OBLIQUE TLIF TI, 10X10X30MM 4",SUP-5400304,CDM,C1889,HCPCS,0278,RC,,,both,,,21225.60,6367.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2468.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 40MM MINI-MONSTER SHORT THREAD HEADLESS",SUP-P20-535-040S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"INSRT TIBIAL 5 CURVE 10MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962051,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"AETNA [10100]","Aetna HMO/PPO",,7353.31,79.5,,10981.53,8986.79,12413.38,12,1075.71,7862.03,"percent of total billed charges",
"OSTEOTOME 5INX10MM FLEXIBLE THIN SHAFT SURGICAL",SUP-270904011,CDM,S27200284,LOCAL,0272,RC,,,both,,,842.40,252.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,99.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.97,716.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 17MM 46MM SHOULDER SIMPLICITI",SUP-7122871,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"BLUE CROSS [10001]","Blue Cross HMO",,3927.45,39.2,,5311.50,4717.44,5388.59,31,1165.21,8516.15,"percent of total billed charges",
"BNDG TUBIGRIP 10MR COMPRESSION LATEX REUSABLE MULTIPURPOSE",SUP-1443,CDM,S27000186,LOCAL,0270,RC,,,both,,,189.83,56.95,"MULTIPLAN [10600]",Multiplan,,161.36,85,,,,,0,22.08,161.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX 1S REINFORCED TISSUE MATRIX, LONG-TERM RESORBABLE REI",SUP-F10266-2020G,CDM,C1781,HCPCS,0278,RC,,,both,,,39463.20,11838.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,11294.37,28.62,,,,,0,4589.57,33543.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG BONE CEMENT 30MM LARGE INTRAMEDULLARY CANAL STERILE",SUP-6215-5-021,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA [10200]","Cigna Open Access",,433.24,56.9,,1144.80,304.56,2275.09,66,88.55,647.19,"percent of total billed charges",
"SUT VICRYL 2-0 CTX 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J363H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732056,CDM,C1776,HCPCS,0278,RC,,,both,,,9510.48,2853.14,"PHCS [10601]",PHCS,,6657.34,70,,,,,0,1106.07,8083.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL 6.25IN SMILLIE LEFT CURVE MENISCUS",SUP-77-5001,CDM,S27200284,LOCAL,0272,RC,,,both,,,541.65,162.49,"AETNA [10100]","Aetna HMO/PPO",,430.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.99,460.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 240CM 5.5CM 7.5FR 6-8MM ESOPHAGUS PYLORUS",SUP-M00558660,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1121.34,68,,,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXAMETHASONE 4 MG TABLET",RX-2327,CDM,J8540,HCPCS,0637,RC,00054-8175-25,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.46,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE PLUS 100CM 6FR STD JUDKINS RIGHT 4 CURVE",SUP-533621,CDM,C1769,HCPCS,0272,RC,,,both,,,82.30,24.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.83,41.1,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 4MM 1.2MM 11MM 4MM STAINLESS STEEL SHORT THREAD",SUP-202.611,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,131.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,129.1,943.52,"percent of total billed charges",
"LOWER VASCULAR PROCEDURES,MODERATE",181,APR-DRG,,,,,,,inpatient,,,139004.32,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $15,945.60. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($64,540.82) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,MODERATE",281,APR-DRG,,,,,,,inpatient,,,45756.36,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEPTICEMIA AND DISSEMINATED INFECTIONS,MAJOR",720,APR-DRG,,,,,,,inpatient,,,37437.92,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $8,439.92. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($62,832.70) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X40 135CM SL",SUP-48003004R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BAG OSTOMY DRAINABLE DEEP CONVEX FLEXIBLE OVAL",SUP-40-7554-DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.09,33.33,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 1.7MM GRADUATE 2.4MM SCR",SUP-AR-8916-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRACE ORTHOPEDIC UNIVERSAL NARROW 24IN 17-23IN KNEE BAND",SUP-79-94040,CDM,S27000186,LOCAL,0270,RC,,,both,,,401.33,120.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Plc Cath Thorac Ea 2nd Ord",PX-361000084,CDM,36216,CPT,0361,RC,,,both,,,1189.73,356.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 40MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-593504022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TORCON NB ADVANTAGE 125CM 5FR VERT CURVE ANGIOGRAPHIC",SUP-G47180,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BOLT SPINAL 35MM 6.5MM DECADE LARGE PLATE EXTREME LATERAL",SUP-7146535,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",188.41,1377,"percent of total billed charges",
"CATH RANGER 150CM 200MM 7MM BALLOON DILATATION PACLITAXEL",SUP-H74939419702010,CDM,C2623,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5530.01,41.1,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 175MM CEMENT PROXIMAL GROOVE ECHELON COCR 12",SUP-71310312,CDM,C1776,HCPCS,0278,RC,,,both,,,44689.05,13406.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5295.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5197.34,37985.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 3.2MM 3CM 1.5CM RAPID EXCHANGE",SUP-M00510860,CDM,S27200284,LOCAL,0272,RC,,,both,,,2036.93,611.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,236.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,236.89,1731.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 0D E HIP CROSSFIRE TRIDENT",SUP-621-10-36E,CDM,C1776,HCPCS,0278,RC,,,both,,,5690.16,1707.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,661.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,661.77,4836.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 22MM RIGHT",SUP-TR-H220R-S,CDM,C1776,HCPCS,0278,RC,,,both,,,13489.50,4046.85,"BLUE CROSS [10001]","Blue Cross HMO",,5287.88,39.2,,5311.50,4717.44,5388.59,31,1568.83,11466.08,"percent of total billed charges",
"LENS IOL 10 D +12 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.120,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 15CM 28MM HEMASHIELD STRAIGHT PLATINUM 2",SUP-M00202175128P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3046.80,914.04,"NOVANET [10819]",Novanet,,2285.1,75,,,,,0,354.34,2589.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP GRIPTION PINNACLE STERILE LATEX",SUP-121731062,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"KAISER [10500]",Kaiser,,10866.36,67,,,,,0,1886.21,13785.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 95MM 5.5MM TSRH-2D CONTOUR PEDICLE TITANIUM",SUP-8370095,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER WEBSTER 60CM 1MM 6FR 2-8-2MM SPACE P CURVE ELECTROP",SUP-F6A-DP-282-RTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,2040.00,612,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,936.36,45.9,,,,,0,237.25,1734,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ VASCULAR 3CM 80CM 17CM .035IN EXTRA STIFF",SUP-G04003,CDM,C1769,HCPCS,0272,RC,,,both,,,252.21,75.66,"PHCS [10601]",PHCS,,176.55,70,,,,,0,29.33,214.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 4.50 X 24MM",SUP-H7493942824450,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross PPO",,2434.32,39.2,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEDSURG COMMIT BARD VASCULAR ACCESS PICCS AND MIDLINES",SUP-S1274108D6,CDM,C1751,HCPCS,0272,RC,,,both,,,2010.45,603.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1367.11,68,,,,,0,233.82,1708.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ST CLAIR 7.25IN ADENOID RING JAW 10X5MM",SUP-71-5018,CDM,S27200284,LOCAL,0272,RC,,,both,,,1750.20,525.06,"NOVANET [10819]",Novanet,,1312.65,75,,,,,0,203.55,1487.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO ANL1 CURVE 70CM 7FR 2.5MM GUIDING",SUP-G56227,CDM,C1894,HCPCS,0272,RC,,,both,,,558.09,167.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,229.37,41.1,,,,,0,64.91,474.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA 5D H KNEE RIGHT CEMENT STEM TIVANIUM",SUP-42532008302,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"UHC [10700]","United Healthcare",,6921.06,63.3,,8601.07,8395.67,8601.07,"1 through 10",1271.59,9293.68,"percent of total billed charges",
"CATH RUBICON 135CM 5.1FR 2.84FR 50MM SPACE GUIDING NYLON",SUP-H74939240035131,CDM,C1887,HCPCS,0272,RC,,,both,,,1449.90,434.97,"NOVANET [10819]",Novanet,,1087.43,75,,,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Skull>=4v",PX-320000018,CDM,70260,CPT,0320,RC,,,both,,,768.38,230.51,"CIGNA [10200]","Cigna Open Access",,68.73,,,,,,,49.14,653.12,"fee schedule",
"SYSTEM XIENCE SIERRA 38MM 4MM CORONARY STENT EVEROLIMUS",SUP-1550400-38,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.2MM 140MM STERILE",SUP-143140,CDM,C1713,HCPCS,0278,RC,,,both,,,1010.88,303.26,"MULTIPLAN [10600]",Multiplan,,859.25,85,,,,,0,117.57,859.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19.5 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6",SUP-ZCT225195,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXCATH 82CM 13MM 14FR 10FR CONTOUR ABLATION 2",SUP-10FCC13,CDM,C1766,HCPCS,0272,RC,,,both,,,7590.00,2277,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,882.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM DYNASTY LINEAGE BIOFOAM ACETABULAR",SUP-18080302,CDM,C1713,HCPCS,0278,RC,,,both,,,1101.60,330.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,749.09,68,,,,,0,128.12,936.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 2.4MM CANNULATED PASS WIRE STERILE LATEX FREE",SUP-AR-1594D-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,2323.13,696.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1066.32,45.9,,,,,0,270.18,1974.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM 3 HOLE POLY R3 STD",SUP-71335558,CDM,C1776,HCPCS,0278,RC,,,both,,,14345.10,4303.53,"FIRST HEALTH [10303]","First Health",,11476.08,80,,,,,0,1668.34,12193.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 114MM 7.5MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-00771100740,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"BLUE CROSS [10001]","Blue Cross PPO",,8192.65,39.2,,3949.44,3949.44,3949.44,"1 through 10",2430.63,17764.68,"percent of total billed charges",
"HC Dilation Esophagus Guide Wire",PX-750000056,CDM,43453,CPT,0750,RC,,,both,,,10136.00,3040.8,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1178.82,8615.6,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.180 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.180,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTAZIDIME 2 G/10ML IV (WET SOLR VIAL)",RX-4159476,CDM,J0713,HCPCS,0636,RC,00409-5084-11,NDC,both,1,UN,86.54,25.96,"FIRST HEALTH [10303]","First Health",,69.23,80,,,,,0,6.91,73.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 3MM 2.1 LOOP .035IN STAINLESS STEEL",SUP-G04044,CDM,S27800098,LOCAL,0278,RC,,,both,,,274.27,82.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,186.5,68,,,,,0,31.9,233.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LPT ANGLED GREAT TOE SIZE 2",SUP-487A002,CDM,C1776,HCPCS,0278,RC,,,both,,,11585.10,3475.53,"KAISER [10500]",Kaiser,,7762.02,67,,,,,0,1347.35,9847.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ENTEER 150CM 20X2.75X1MM .066IN BALLOON OCCLUSION",SUP-ENB-275-20-150,CDM,C1887,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"MULTIPLAN [10600]",Multiplan,,10263.75,85,,,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +1MM 12/14 TAPER 32MM HIP BIOLOX DELTA",SUP-136532310,CDM,C1776,HCPCS,0278,RC,,,both,,,6844.32,2053.3,"KAISER [10500]",Kaiser,,4585.69,67,,,,,0,795.99,5817.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 000 ANGLE OVAL 9IN BRUNS SPINE SURGICAL",SUP-29-5373,CDM,S27200284,LOCAL,0272,RC,,,both,,,253.00,75.9,"PHCS [10601]",PHCS,,177.1,70,,,,,0,29.42,215.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit B Level 2 W Proc",PX-450000328,CDM,G0381,HCPCS,0450,RC,,,both,,,714.00,214.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,714,,,,,,,67.13,714,"case rate",
"ALCON SURGICAL STANDARD EYE PACK",SUP-AS2277-19,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.14,30.34,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.76,85.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CRE STERI-FLATE INFLATION DISPOSABLE",SUP-M00550630,CDM,S27200284,LOCAL,0272,RC,,,both,,,340.52,102.16,"NOVANET [10819]",Novanet,,255.39,75,,,,,0,39.6,289.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 20IN 24FR ANGLE RIGHT",SUP-8888571034,CDM,C1729,HCPCS,0272,RC,,,both,,,1364.61,409.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,927.93,68,,,,,0,158.7,1159.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LSR BLK 4.25MM 1.8FR SLMLN",SUP-0644-007-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,3671.25,1101.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1508.88,41.1,,,,,0,426.97,3120.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP SOLID BACK TRITANIUM TRIDENT II F",SUP-700-04-56F,CDM,C1776,HCPCS,0278,RC,,,both,,,12895.96,3868.79,"CIGNA [10200]","Cigna Local Plus",,4062.23,31.5,,5372.07,4581.20,7242.98,23,1499.8,10961.57,"percent of total billed charges",
"BALL THERAPEUTIC SMALL SPHERE HAND FOREARM WRIST METAL",SUP-A83720,CDM,S27000186,LOCAL,0270,RC,,,both,,,151.90,45.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.67,129.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VG2 PRESERVON VERTIGRAFT CORTICAL CANCELLOUS",SUP-VG2C-T911,CDM,S27800098,LOCAL,0278,RC,,,both,,,8109.23,2432.77,"BLUE CROSS [10001]","Blue Cross HMO",,3178.82,39.2,,,,,0,943.1,6892.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 12MM 144CM 2.25MM CORONARY STENT EVEROLIMUS",SUP-H7493926112220,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"FIRST HEALTH [10303]","First Health",,6900,80,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP ADD-A-FOLEY COMPLETE CARE",SUP-A399400A,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.70,27.51,"NOVANET [10819]",Novanet,,68.78,75,,,,,0,10.66,77.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 7X 38MM CATH 120CM ENDOVASCULAR",SUP-42738,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2076.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 5-0 C-1 30IN BRAID BLACK NONABSORBABLE",SUP-K890H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 120MM 3.5MM BALLOON DILATATION PEBAX",SUP-H74939148351210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH NAVIGATOR 28CM 13-15FR ACCESS STAINLESS STEEL",SUP-M0062502060,CDM,C1894,HCPCS,0272,RC,,,both,,,895.54,268.66,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEON 12 NEONATAL EEG DEVICE CAN BE USED WITH ANY MULTI CHANN",SUP-TF01-MBS19,CDM,S27000186,LOCAL,0270,RC,,,both,,,729.00,218.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Splint Finger",PX-E27000165,CDM,E27000165,LOCAL,0270,RC,,,both,,,28.60,8.58,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 2-0 SH 48IN 2 ARM MONOFILAMENT BLUE",SUP-8533H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.96,20.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC",269,MS-DRG,,,,,,,inpatient,,,220739.83,66221.95,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION",RX-17405,CDM,J1815,HCPCS,0637,RC,00024-5926-05,NDC,both,3,ML,355.45,106.63,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Adhesive Housing",PX-E27000261,CDM,A7506,HCPCS,0270,RC,,,both,,,754.60,226.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PIN SCREW 3.2MMX89MM FLUTED DISP",SUP-GS901.089.032-4P,CDM,C1713,HCPCS,0278,RC,,,both,,,605.48,181.64,"CIGNA [10200]","Cigna Local Plus",,323.93,53.5,,3978.14,359.25,3978.14,24,70.42,514.66,"percent of total billed charges",
"CATH STERLING SL MONORAIL 150CM 120MM 2.5MM BALLOON",SUP-H74939147251210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mod Sedat Endo Svc > 5y",PX-371000013,CDM,G0500,HCPCS,0371,RC,,,both,,,359.29,107.79,"CIGNA [10200]","Cigna Open Access",,204.44,56.9,,,,,0,41.79,305.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION 130CM 2.4FR MICRO BERN INFUSION NITINOL 2",SUP-M001195340,CDM,C1887,HCPCS,0272,RC,,,both,,,3740.00,1122,"UHC [10700]","United Healthcare",,2367.42,63.3,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T TITANIUM 3MM SCR 4 HOLE LOW PROFILE BONE FOOT",SUP-AR-8952TT-04,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"COIL EMBOLIZATION 60CM .02IN 28MM PENUMBRA COIL 400 RUBY",SUP-RBY2C2860,CDM,S27800098,LOCAL,0278,RC,,,both,,,7098.00,2129.4,"CIGNA [10200]",Cigna,,4826.64,68,,,,,0,825.5,6033.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CASSETTE IRRIGATION ESSX HUMMER STERILE LATEX FREE",SUP-5290-075-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,563.76,169.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,258.77,45.9,,,,,0,65.57,479.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN RIGHT",SUP-77808400,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Guided Localization Stereo",PX-350000007,CDM,77011,CPT,0350,RC,,,both,,,1410.16,423.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,405,,"Per diem ($405). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,164,1410.16,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 5MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640405,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PHCS [10601]",PHCS,,7877.73,70,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 14.5MM 42X70X10MM GENTAMICIN PMMA REMEDY",SUP-RKINMD,CDM,C1776,HCPCS,0278,RC,,,both,,,4830.00,1449,"KAISER [10500]",Kaiser,,3236.1,67,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 80CM 80MM 7MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV07008008P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5489.64,68,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL J HOOK 11IN VALLEYLAB STERILE",SUP-E3782R-28ASP,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.42,71.23,"CIGNA [10200]","Cigna Local Plus",,127.02,53.5,,,,,0,27.61,201.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRICATH 16FR STD URETHRAL NATURAL RUBBER HYDROGEL 5ML",SUP-0119L16,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.52,23.26,"UHC [10700]","United Healthcare",,49.07,63.3,,,,,0,9.02,65.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIR STPLR TRIEEA33XT BLK EXTHK",SUP-TRIEEA33XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2254.95,676.48,"CIGNA [10200]",Cigna,,1533.37,68,,,,,0,262.25,1916.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 7FR .081IN EBU4 LEFT CURVE GUIDING NYLON",SUP-LA7EBU40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"UHC [10700]","United Healthcare",,231.3,63.3,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRD SURGICAL 10IN NARROW INGE LARGE PATTERN LAMINA ADULT 8",SUP-57-5506,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 4.75MM IMPL FLEXOR DIGITORUM LONGUS",SUP-AR-1547BC-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10831.28,3249.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1259.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1259.68,9206.59,"percent of total billed charges",
"SCR BONE 2.7MM 12MM VARIAX T8 FULL THREAD NONSTERILE",SUP-656412,CDM,C1713,HCPCS,0278,RC,,,both,,,779.22,233.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,223.01,28.62,,,,,0,90.62,662.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENYTOIN 50 MG CHEWABLE TABLET",RX-11018,CDM,,,0637,RC,60687-0156-95,NDC,both,1,UN,9.05,2.71,"CIGNA [10200]",Cigna,,6.15,68,,,,,0,1.05,7.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.8MM 200MM 25MM LCP ANKLE COMPRESSION THREAD",SUP-03.118.025,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",50.59,369.75,"percent of total billed charges",
"COIL EMBOLIZATION 14CM 16MM RETRACTA DETACHABLE .035IN",SUP-G34202,CDM,S27800098,LOCAL,0278,RC,,,both,,,4674.68,1402.4,"AETNA [10100]","Aetna HMO/PPO",,3716.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,543.67,3973.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT FX 26MM",SUP-EVOLUTFX-26,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"NOVANET [10819]",Novanet,,128250,75,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 5.0/26",SUP-434903,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"MULTIPLAN [10600]",Multiplan,,16787.93,85,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.75MM X 26.0MM",SUP-492752612,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UHC [10700]","United Healthcare",,512.73,63.3,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM REGENT FLEXCUFF 85D SUPRA ANNULAR",SUP-25AGFN-756,CDM,S27800098,LOCAL,0278,RC,,,both,,,31229.42,9368.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8937.86,28.62,,,,,0,3631.98,26545.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM ATLANTIS TITANIUM SPINE SELF DRILLING",SUP-3120416,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"PHCS [10601]",PHCS,,987,70,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 18MM CRANIOFACIAL TITANIUM 6 HOLE 2Y LOW PROFILE",SUP-421.516,CDM,C1713,HCPCS,0278,RC,,,both,,,3788.10,1136.43,"AETNA [10100]","Aetna HMO/PPO",,3011.54,79.5,,1521.93,481.35,16760.95,30,440.56,3219.89,"percent of total billed charges",
"LENS IOL 0 D +11.5 DIOPTER +6 CYL BICONVEX 13MM 6MM",SUP-SN6AT9,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +21.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM POST",SUP-ZA90030215,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LACOSAMIDE 200 MG/20 ML VIAL IV PUSH",RX-411152,CDM,C9254,HCPCS,0636,RC,70710-1359-01,NDC,both,20,ML,618.77,185.63,"NOVANET [10819]",Novanet,,464.08,75,,,,,0,46.62,525.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 3-0 PS-1 18IN MONOFILAMENT PLIABILIZE",SUP-1663H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 3-0 SH-1 36IN 2 ARM BRAID GREEN",SUP-X762H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM DCP LC-DCP STAINLESS STEEL PROXIMAL",SUP-204.238,CDM,C1713,HCPCS,0278,RC,,,both,,,177.48,53.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",20.64,150.86,"percent of total billed charges",
"ANCHOR SUTURE BIOCOMP PUSHLOCK",SUP-AR-1922BCM,CDM,C1713,HCPCS,0278,RC,,,both,,,3268.13,980.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2222.33,68,,,,,0,380.08,2777.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT NEUROSURGICAL CSF REGULAR HIGH PRESSURE UNITIZED KIT",SUP-46026,CDM,S27800098,LOCAL,0278,RC,,,both,,,9284.23,2785.27,"BLUE CROSS [10001]","Blue Cross PPO",,3639.42,39.2,,,,,0,1079.76,7891.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS BLOCK THK10MM ALLOGRAFT FREEZE DRIED",SUP-400292,CDM,S27800098,LOCAL,0278,RC,,,both,,,5415.12,1624.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1549.81,28.62,,,,,0,629.78,4602.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 300MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035300M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"KAISER [10500]",Kaiser,,1256.25,67,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 9MM KNEE BEARING POSTERIOR STABILIZE",SUP-5532-G-709-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"NOVANET [10819]",Novanet,,8559.45,75,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CASSETTE IRRIGATION ESSX HUMMER STERILE LATEX FREE",SUP-5290-075-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,563.76,169.13,"PHCS [10601]",PHCS,,394.63,70,,,,,0,65.57,479.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP GLOBAL UNITE REVER",SUP-OSC379179,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5275.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL HIP HEMIARTHROPLASTY (PARTIAL HIP CONSTRUCT)",SUP-CAP-LB-PH-1,CDM,C1776,HCPCS,0278,RC,,,both,,,6900.00,2070,"PHCS [10601]",PHCS,,4830,70,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL",RX-230392,CDM,,,0250,RC,10310-0283-13,NDC,both,11.9,GR,32.94,9.88,"UHC [10700]","United Healthcare",,20.85,63.3,,,,,0,3.83,28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OLYMPUS 4MM 90 DEG ROTATABLE SHAVER",SUP-SB4090RS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1541.46,462.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,707.53,45.9,,,,,0,179.27,1310.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS 75CM 4CM 14MM 7FR BALLOON DILATATION PERIPHERAL",SUP-AT75144,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 40MM 6FR 10MM .035IN LOW PROFILE BALLOON",SUP-B1100-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"FIRST HEALTH [10303]","First Health",,615.6,80,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 130MM 9 HOLE LOW PROFILE EXTENDED BONE LEFT OLECRANON",SUP-70-0314,CDM,C1713,HCPCS,0278,RC,,,both,,,7051.80,2115.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,820.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",820.12,5994.03,"percent of total billed charges",
"CATH APD 25CM 14FR LOOP DRNG FLEXIMA METAL HYDROPHILIC",SUP-M001271390,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM VERTEX MAX TITANIUM SPINAL MAS",SUP-6958712,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2856,68,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRESSING ANTIMICROBIAL 3.5 X 12 INCH AQUACEL AG ADVANTAGE",SUP-422606,CDM,S27200284,LOCAL,0272,RC,,,both,,,325.56,97.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.86,276.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SPINAL 27MM MIS LUMBAR",SUP-1135.0027,CDM,S27800098,LOCAL,0278,RC,,,both,,,1620.00,486,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,463.64,28.62,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 22.5MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962356,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"BLUE CROSS [10001]","Blue Cross PPO",,5685.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",1686.79,12328.23,"percent of total billed charges",
"KIT DRNG 20CMX7MM SILICONE FULL PERFORATED HUBLESS EVAC FLAT",SUP-0071430,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.52,22.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.55,62.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX PDS PLUS 1 CT-2 6IN UNIDIRECTIONAL SYMMETRIC",SUP-SXPP1A419,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"PHCS [10601]",PHCS,,168.21,70,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 34MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.534,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE HOLDING 8-11MM T2 NAIL ELASTIC INSRT STERILE",SUP-18061406S,CDM,S27200284,LOCAL,0272,RC,,,both,,,887.92,266.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,105.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.27,754.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP CEMENTED FEMUR WITH CERAMIC HEAD XLPE LINE",SUP-71701016,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2784.22,20349,"percent of total billed charges",
"GRAFT PORCINE 11X7.5IN XENMATRIX AQUAPURE RECTANGLE",SUP-1161928,CDM,C1781,HCPCS,0278,RC,,,both,,,43994.70,13198.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17597.88,40,,,,,0,5116.58,37395.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP GREEN 195MM RUSCH EQUIPLITE MILLER 3 STD",SUP-004650003,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.98,14.99,"FIRST HEALTH [10303]","First Health",,39.98,80,,,,,0,5.81,42.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE BREAST BIOPSY 145MM 11GA MAMMOTOME MR LONG BLADELESS",SUP-MRP11X,CDM,S27200284,LOCAL,0272,RC,,,both,,,2043.23,612.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1389.4,68,,,,,0,237.63,1736.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00230,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBTALAR DISTRACTION ARTHRODESIS WEDGE, 12 MM",SUP-PSBT-1206,CDM,S27800098,LOCAL,0278,RC,,,both,,,12851.25,3855.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5281.86,41.1,,,,,0,1494.6,10923.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 CURVE 10MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962021,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"UHC [10700]","United Healthcare",,5854.9,63.3,,8601.07,8395.67,8601.07,"1 through 10",1075.71,7862.03,"percent of total billed charges",
"SCR BONE 3MM 2MM 17MM 6MM STAINLESS STEEL 1.1MM LONG THREAD",SUP-02.226.117,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"CIGNA [10200]",Cigna,,1118.74,68,,1831.33,1831.33,1831.33,16,191.34,1398.42,"percent of total billed charges",
"STENT WALLFLEX 80MM 75CM 10MM 8.5FR .035IN BILIARY PERMALUME",SUP-M00574790,CDM,C1874,HCPCS,0278,RC,,,both,,,22050.00,6615,"PHCS [10601]",PHCS,,15435,70,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM 3.5MM SCR ELLI",SUP-682.104,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,460.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tavi/Tavr Bypass W Centl Art",PX-361000351,CDM,33369,CPT,0361,RC,,,both,,,45298.00,13589.4,"PHCS [10601]",PHCS,,31708.6,70,,,,,0,2491,38503.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEPHRSTMY 8.3FR REPLACEMENT 25CM JINRO PERCUTANEOUS",SUP-M0064202060,CDM,C1729,HCPCS,0272,RC,,,both,,,152.34,45.7,"FIRST HEALTH [10303]","First Health",,121.87,80,,,,,0,17.72,129.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HYDRAGLIDE XL 23IN 32FR STRAIGHT TAPER DRNG PVC",SUP-8032,CDM,C1729,HCPCS,0272,RC,,,both,,,57.61,17.28,"PHCS [10601]",PHCS,,40.33,70,,,,,0,6.7,48.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 90MM REGULAR LINEAR CUTTER RELOADABLE DIAL",SUP-TL90,CDM,S27200284,LOCAL,0272,RC,,,both,,,2160.20,648.06,"AETNA [10100]","Aetna HMO/PPO",,1717.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,251.23,1836.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3.5CM 2MM TARGET TETRA DETACHABLE STERILE",SUP-TG5412035,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 15.75IN 20FR DRNG",SUP-8888561043,CDM,C1729,HCPCS,0272,RC,,,both,,,221.42,66.43,"MULTIPLAN [10600]",Multiplan,,188.21,85,,,,,0,25.75,188.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 18IN BRAID TIE 12 STRAND PRECUT",SUP-A185H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 30CM 18FR SILICONE MIC SECUR-LOK LUER-SLIP",SUP-0250-18-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"KAISER [10500]",Kaiser,,1174.14,67,,,,,0,203.81,1489.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 2.5% DEXTROSE 132 MEQ/L SODIUM 95 MEQ/L CHLORIDE 2.5",SUP-044-30322,CDM,S27200284,LOCAL,0272,RC,,,both,,,54.20,16.26,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.3,46.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 15D 66MM 32MM MARATHON HIP STERILE",SUP-121932266,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"NOVANET [10819]",Novanet,,6083.21,75,,,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 3.50 X 32MM",SUP-H7493942832350,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"AMERIGROUP MEDICAID [20100]",Amerigroup,,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esoph Motility Study",PX-750000110,CDM,91010,CPT,0750,RC,,,both,,,2891.00,867.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,342.58,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,336.22,2457.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 1 STD SHORT 54IN MONOFILAMENT TIES YELLOWISH TAN",SUP-S115H,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.04,26.71,"UHC [10700]","United Healthcare",,56.36,63.3,,,,,0,10.36,75.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 22X9X11MM 8D",SUP-PUI81102,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7654.5,27,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 60MM 10MM BILIARY STERILE LATEX FREE DISPOSABLE",SUP-M00572320,CDM,C1876,HCPCS,0278,RC,,,both,,,10624.97,3187.49,"FIRST HEALTH [10303]","First Health",,8499.98,80,,,,,0,1235.68,9031.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 14MM SEPTAL SELF EXPANDING DELIVERY",SUP-9-ASD-014,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"KAISER [10500]",Kaiser,,14238.04,67,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 20CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006155230170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,168.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 44MM STAINLESS STEEL 2.4MM SCR MINI FRAGMENT MODULAR",SUP-247.375,CDM,C1713,HCPCS,0278,RC,,,both,,,2299.50,689.85,"MULTIPLAN [10600]",Multiplan,,1954.58,85,,,,,0,267.43,1954.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB ADULT 45MM ADHSV CONDUCTIVE RADIOLUCENT",SUP-8900-4005,CDM,S27000186,LOCAL,0270,RC,,,both,,,228.38,68.51,"MULTIPLAN [10600]",Multiplan,,194.12,85,,,,,0,26.56,334.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 25MM 2.25MM ULTRA LOW PROFILE BALLOON",SUP-1012271-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 18MM 140CM 4MM CORONARY STERILE LATEX",SUP-453948,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN EXTERNAL FIXATION 40MM 6MM JET-X LONG TITANIUM NITRIDE",SUP-71066409,CDM,C1887,HCPCS,0272,RC,,,both,,,2153.25,645.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,250.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,250.42,1830.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYPROPYLENE 10X6IN PERMANENT REINFORCE LOCK",SUP-F10244-0610P,CDM,C1781,HCPCS,0278,RC,,,both,,,3690.00,1107,"AMERIGROUP MEDICAID [20100]",Amerigroup,,437.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,429.15,3136.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 22MM SPINE PEDICLE PLY NONSTERILE 4MM ROD",SUP-102045222,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE ROUND SILICONE",SUP-SRF-295,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"PHCS [10601]",PHCS,,3839.85,70,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 24MM 140CM 3MM CORONARY STENT CARBOSIL",SUP-LUN300R24US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Tmj",PX-610000002,CDM,70336,CPT,0610,RC,,,both,,,3403.00,1020.9,"CIGNA [10200]","Cigna Local Plus",,752,,"Per diem ($752). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,395.77,2892.55,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VERISIGHT ICE CATHETER MITRAL",SUP-VSICE3D-R,CDM,C1759,HCPCS,0272,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STPLR 90X4.8MM DST SERIES TA TITANIUM THICK TISSUE",SUP-TA9048L,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.47,98.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cta Head W/WO Cntrst",PX-351000014,CDM,70496,CPT,0351,RC,,,both,,,4058.16,1217.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($377.70). Procedures 2 - 999, Per diem ($188.85).",,,,0,,,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FRCP 5.51IN OLSEN ADSON STRAIGHT BIPOLAR INSULATE",SUP-20-1080KI,CDM,S27200284,LOCAL,0272,RC,,,both,,,322.60,96.78,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 6FR 45CM 61CM SMOOTH TRANSITION STEERABLE",SUP-MAP645,CDM,S27200284,LOCAL,0272,RC,,,both,,,4071.00,1221.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET EPIDURAL 168MM 21GA 18GA SONOPLEX STIM INDWELL E CATH",SUP-271285-40E,CDM,C9812,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR .071IN RIGHT BACKUP 3.5 CURVE",SUP-LA6RBU35SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 125MMX2MM TITANIUM 7 HOLE LOCK LOW PROFILE VARIAX",SUP-40-20907,CDM,C1713,HCPCS,0278,RC,,,both,,,5059.08,1517.72,"NOVANET [10819]",Novanet,,3794.31,75,,,,,0,588.37,4300.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 45MM 10MM 13FR 10FR TRIVASCULAR OVATION PRIME",SUP-TV-EX101045-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"BLUE CROSS [10001]","Blue Cross PPO",,13088.88,39.2,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDER 20MM 2MM .014IN BALLOON DILATATION LOW PROFILE",SUP-4100A-2504,CDM,C1725,HCPCS,0272,RC,,,both,,,2212.50,663.75,"NOVANET [10819]",Novanet,,1659.38,75,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL TRIATHLON X3 5 H16 MM KNEE TOTAL STABILIZE PLU",SUP-5537-G-516-E,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"FIRST HEALTH [10303]","First Health",,10766.76,80,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 27MM DURAN ANCORE CHORDAL GUIDE",SUP-620BG27,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3539.7,27,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00225,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"MULTIPLAN [10600]",Multiplan,,929.48,85,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 UR-6 27IN BRAID COATED VIOLET ABSORBABLE",SUP-VCP603H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AETNA [10100]","Aetna HMO/PPO",,19.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERTORQUE THRULUMEN 100CM 6FR .079IN .051IN JUDKINS",SUP-532623,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"MULTIPLAN [10600]",Multiplan,,70.25,85,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 19GA FLEXISION STERILE LATEX FREE DISPOSABLE",SUP-490104,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"MULTIPLAN [10600]",Multiplan,,1593.75,85,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 64MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732064,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"NOVANET [10819]",Novanet,,12163.84,75,,,,,0,1886.21,13785.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT HAKIM CSF 120CM RIGHT ANGLE SIPHONGUARD UNITIZED",SUP-823146,CDM,S27800098,LOCAL,0278,RC,,,both,,,44384.89,13315.47,"CIGNA [10200]","Cigna Local Plus",,13981.24,31.5,,,,,0,5161.96,37727.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC",393,MS-DRG,,,,,,,inpatient,,,33120.72,9936.22,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,10218.19,,"Case rate ($9,920.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,211.91, add-ons for qualifying new technology services are included. If operating cost exceeds $42,251.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,078.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,224.09. The transfer operating threshold is the transfer adjustment factor * $9,211.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $696.47. The transfer capital threshold is the transfer adjustment factor * $696.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,33120.72,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 360 145CM 15MM .063IN 1.5MM ATHERECTOMY",SUP-DBP-CART-150CLA145,CDM,C1724,HCPCS,0272,RC,,,both,,,17250.00,5175,"AETNA [10100]","Aetna HMO/PPO",,13713.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Protime Mixing Studies",PX-305000058,CDM,85611,CPT,0305,RC,,,both,,,255.55,76.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.67,,,,,,,0.01,217.22,"fee schedule",
"STEM HUMERAL SHOULDER WITH NECK ANATOMIC ALTIVATE CS SIZE 1",SUP-520-08-018,CDM,C1776,HCPCS,0278,RC,,,both,,,34907.04,10472.11,"BLUE CROSS [10001]","Blue Cross HMO",,13683.56,39.2,,5311.50,4717.44,5388.59,31,4059.69,29670.98,"percent of total billed charges",
"PIRANHA CERVICAL VARIABLE SCREW 4.0 MM X 16 MM",SUP-SK-CSV-40-16,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"VIALIZE 2X12 CM",SUP-VL-0212,CDM,S27800098,LOCAL,0278,RC,,,both,,,11040.00,3312,"AETNA [10100]","Aetna HMO/PPO",,8776.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1283.95,9384,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM LCP STAINLESS STEEL FULL THREAD PROXIMAL",SUP-02.205.050,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"PHCS [10601]",PHCS,,884.3,70,,,,,0,146.92,1073.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL HIP STEM 96MM NK 33.5MM INSIGNIA 1 HIGH STEM HIGH",SUP-7000-6601,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"CIGNA [10200]",Cigna,,12229.56,40,,5873.17,5873.17,5873.17,"1 through 10",3555.74,25987.82,"percent of total billed charges",
"ACUSEAL 6MM X 50CM US",SUP-ECH060050A,CDM,C1768,HCPCS,0278,RC,,,both,,,11060.70,3318.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1310.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1286.36,9401.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 101MM 7MM MODULAR REMEDY STAINLESS STEEL PMMA",SUP-RSHSSM,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8190,40,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 1-2 15MM TIBIA KNEE CONSTRAIN UHMWPE GENESIS",SUP-71420964,CDM,C1776,HCPCS,0278,RC,,,both,,,18474.75,5542.42,"NOVANET [10819]",Novanet,,13856.06,75,,,,,0,2148.61,15703.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 22MM 1 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.122,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 3 KNEE CEMENT REVISION ROTATE PLATFORM",SUP-150660003,CDM,C1776,HCPCS,0278,RC,,,both,,,22629.60,6788.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2681.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2631.82,19235.16,"percent of total billed charges",
"COUNTSINK DRILL 5.5 MM HEADLESS SCR",SUP-P20-915-5500,CDM,S27200284,LOCAL,0272,RC,,,both,,,1279.80,383.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,151.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,148.84,1087.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR FIXATION 6.5MM SPEEDSCREW PEEK KNOTLESS",SUP-OM-8500,CDM,C1713,HCPCS,0278,RC,,,both,,,3291.75,987.52,"NOVANET [10819]",Novanet,,2468.81,75,,,,,0,382.83,2797.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 4-0 P-2 18IN BRAID ANTIBACTERIAL COATED",SUP-VCP504G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUSTAIN",SUP-EFSRN3PL,CDM,C1776,HCPCS,0278,RC,,,both,,,13075.50,3922.65,"CIGNA [10200]","Cigna Local Plus",,4118.78,31.5,,5372.07,4581.20,7242.98,23,1520.68,11114.18,"percent of total billed charges",
"PEG FIXATION 2.7MM 12MM THREAD TITANIUM NONSTERILE GEMINUS",SUP-TPNL-27120-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,623.70,187.11,"BLUE CROSS [10001]","Blue Cross HMO",,244.49,39.2,,957.42,156.86,7483.26,51,72.54,530.15,"percent of total billed charges",
"SHEATH NAVIGATOR 28CM 13-15FR ACCESS STAINLESS STEEL",SUP-M0062502071,CDM,C1894,HCPCS,0272,RC,,,both,,,815.04,244.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,96.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.79,692.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prostate Ndl Bx",PX-312000058,CDM,88305,CPT,0312,RC,,,both,,,8120.60,2436.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.63,,,,,,,0.01,6902.51,"fee schedule",
"DURASEAL EXACT SPINE SEALANT SYSTEM 3ML US BOX OF 5",SUP-206320,CDM,S27200284,LOCAL,0272,RC,,,both,,,6092.29,1827.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,708.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,708.53,5178.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 40MM TITANIUM LOCKING TRANSLATIONAL ATLANTIS BONE",SUP-6190040,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross HMO",,1728.72,39.2,,957.42,156.86,7483.26,51,512.88,3748.5,"percent of total billed charges",
"SCR BONE 2.7MM 20MM LOW PROFILE SCREWS STAINLESS STEEL T10",SUP-AR-8827-20,CDM,C1713,HCPCS,0278,RC,,,both,,,522.45,156.73,"MULTIPLAN [10600]",Multiplan,,444.08,85,,,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 1 CTX 30IN BRAID GREEN NONABSORBABLE",SUP-X865H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 100CM 25CM 5FR .047IN ANGLE",SUP-CG508,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 25MM FLEXIBLE SURE LOCK DELIVERY SYSTEM",SUP-TARP-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"MULTIPLAN [10600]",Multiplan,,10290.44,85,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC MEDIUM 7IN 6.75-7.5IN LEFT WRIST D RING",SUP-A611LM,CDM,S27000186,LOCAL,0270,RC,,,both,,,136.16,40.85,"CIGNA [10200]","Cigna Open Access",,77.48,56.9,,,,,0,15.84,115.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 65CM 1MM 6FR 2-8-2MM SPACING D CURVE ELECTROPHYSIOLOGY",SUP-D6A10DRP10RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"PHCS [10601]",PHCS,,2609.25,70,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 9MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P409,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2391.46,28.62,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 15CM 10FR DUODENAL BEND BILIARY",SUP-M00534360,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"KAISER [10500]",Kaiser,,729.93,67,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOMATRIX DEMINERALIZED BONE MATRIX CANCELLOUS 5",SUP-86XC0500,CDM,C1713,HCPCS,0278,RC,,,both,,,6403.20,1920.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1832.6,28.62,,,,,0,744.69,5442.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 25MM SIMULUS FULLY FLEXIBLE",SUP-700FC25,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3752.08,28.62,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hiv 1 Ab",PX-302000142,CDM,86701,CPT,0302,RC,,,both,,,436.05,130.81,"KAISER [10500]",Kaiser,,292.15,67,,,,,0,0.01,370.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esophagosc W/Band Varices",PX-750000200,CDM,43205,CPT,0750,RC,,,both,,,2075.00,622.5,"FIRST HEALTH [10303]","First Health",,1660,80,,,,,0,241.32,2075,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145363010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"KAISER [10500]",Kaiser,,647.82,67,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Binder Abdominal",PX-E27000058,CDM,E27000058,LOCAL,0270,RC,,,both,,,332.20,99.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,39.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.63,282.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE PACING S-101",SUP-6697,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.20,15.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL TORIC UV ABSORBENT CLAREON",SUP-CCW0T6,CDM,V2787,HCPCS,0276,RC,,,both,,,355.00,106.5,"MULTIPLAN [10600]",Multiplan,,301.75,85,,,,,0,41.29,301.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) CATHETER WALRUS 90CM 8FR STRAIGHT BALLOON DILATATION",SUP-BG8087-090,CDM,C1887,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1324.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD 16IN 8FR URETHRAL RUBBER FOLEY INTERMITTENT ALL",SUP-0094080,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.32,0.1,"PHCS [10601]",PHCS,,0.22,70,,,,,0,0.04,0.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 1ML DRY BIOCOMPATIBLE INLINE CPLR",SUP-TOR2510,CDM,S27800098,LOCAL,0278,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X10MM COROENT 10D XL+ WIDE PEEK NONSTERILE",SUP-6310250,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"NOVANET [10819]",Novanet,,17955,75,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADMIN 150UM ASSORTED DEHP FREE FILTER SYR ALIQUOT SYSTEM",SUP-0396000F,CDM,S27200284,LOCAL,0272,RC,,,both,,,105.97,31.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,72.06,68,,,,,0,12.32,90.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pretreat RBC Ab ID Enzyme",PX-302000210,CDM,86971,CPT,0302,RC,,,both,,,75.40,22.62,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,75.4,"per diem",
"APREPITANT 32 MG/4.4 ML (7.2 MG/ML) INTRAVENOUS EMULSION",RX-240358,CDM,C9145,HCPCS,0636,RC,47426-0401-01,NDC,both,4.4,ML,565.90,169.77,"CIGNA [10200]","Cigna Local Plus",,302.76,53.5,,332.79,119.80,366.27,66,67.06,481.02,"percent of total billed charges",
"CATH EXPO 100CM 5FR .045IN FULL LENGTH RIGHT CORONARY BYPASS",SUP-H749085261902,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM SPINE SHANK NONSTERILE MAS PLIF 3Z",SUP-7096530,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GRUENWALD BAYONET 6 3/8IN EAR SATIN FINISH",SUP-AU6130,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.04,49.51,"MULTIPLAN [10600]",Multiplan,,140.28,85,,,,,0,19.19,140.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM ROUND FLUTE",SUP-5540010040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1288.63,386.59,"NOVANET [10819]",Novanet,,966.47,75,,,,,0,149.87,1095.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY SIZE 32 OD37MM ID30MM MITRAL VALVE SEMI RI",SUP-SARP-32,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"FIRST HEALTH [10303]","First Health",,9685.12,80,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insrt/Pl Neurostim Gen Spinal",PX-361000476,CDM,63685,CPT,0361,RC,,,both,,,10158.00,3047.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8381,,"Case rate ($8,381). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1181.38,10158,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 11MM AVENIR 10 COIL STERILE LATEX",SUP-10CFR11030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"NOVANET [10819]",Novanet,,8792.33,75,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION REUTER BOBBIN",SUP-1066110,CDM,S27800098,LOCAL,0278,RC,,,both,,,201.32,60.4,"MULTIPLAN [10600]",Multiplan,,171.12,85,,,,,0,23.41,171.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.5IN 10FR PHILLIPS 1/56IN HOLLOW PLASTIC MALE",SUP-346110,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.46,41.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.99,116.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 15MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962333,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"BLUE CROSS [10001]","Blue Cross PPO",,5685.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",1686.79,12328.23,"percent of total billed charges",
"GORE CARDIOFORM ASD OCCLUDER 32MM 10FR",SUP-00733132636495,CDM,C1817,HCPCS,0278,RC,,,both,,,52321.50,15696.45,"BLUE CROSS [10001]","Blue Cross HMO",,20510.03,39.2,,,,,0,6084.99,44473.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PUBOVAGINAL MONARC FEMALE",SUP-72403830,CDM,C1771,HCPCS,0278,RC,,,both,,,8280.00,2484,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5630.4,68,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE PACING BEIGE 8FT SMALL LARGE ATRIAL VENTRICULAR SMALL",SUP-S-101-97,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.45,51.13,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 018 150CM 6CM 2MM BALLOON DILATATION",SUP-U815026,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) MOTIV SCAFFOLD 3.0MMX48MM","SUP-930030-48 (288)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) LAA - AMPLATZ CARDIAC PLUG 2-IDE-034",SUP-9-ACP2-IDE-034,CDM,S62400003,LOCAL,0624,RC,,,both,,,63452.40,19035.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA2-17-100-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,9177.00,2753.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 5X20 135CM SL",SUP-48005002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 112MM 3.5MM STAINLESS STEEL QUICK CONNECT 86MM",SUP-KM166-310-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,198.53,59.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEMCONC MINNTECH HEMOCOR HPH 1000 TUBE ADPTR SET PERFUSION",SUP-HPH-1000TS,CDM,S27200284,LOCAL,0272,RC,,,both,,,844.01,253.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE PLATINUM PLUS VASCULAR STRAIGHT SPRING COIL 180CM 5CM",SUP-H74917511,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHUTTLE ACCU-PASS 70D UP BEND ERGONOMIC HANDLE THUMB WHEEL",SUP-72200419,CDM,S27200284,LOCAL,0272,RC,,,both,,,961.07,288.32,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT DECOMPRESSION MICROBLADE IO-FLEX L5.5 MM SPINAL PROBE",SUP-IO-MBS5.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,9918.75,2975.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Semen Analysis",PX-301000452,CDM,G0027,HCPCS,0301,RC,,,both,,,257.00,77.1,"BLUE CROSS [10001]","Blue Cross PPO",,8.3,,"Fee schedule rate ($8.30).",,,,0,0.01,218.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +11.5 DIOPTER +6 CYL BICONVEX 13MM 6MM",SUP-SN6AT9,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 27MM SIMULUS FULLY FLEXIBLE",SUP-700FC27,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1524.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER HAPTIC C BICONVEX 13MM 6MM 1 PIECE",SUP-PCB0000165,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 18MM INFINITY SPINE MULTIAXIAL NONSTERILE LATEX",SUP-3604018,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 10.25IN CARB-BITE RYDER INSRT NDL STAINLESS STEEL",SUP-121165,CDM,S27200284,LOCAL,0272,RC,,,both,,,626.45,187.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,74.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.86,532.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO SD 90D LEFT CURVE 1.8MM 3.8MM THUMB PAD",SUP-AR-4068-90L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1190.70,357.21,"FIRST HEALTH [10303]","First Health",,952.56,80,,,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 10CM CANN SERRATE EDGE FRANSEEN LUNG STERILE",SUP-G01432,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.10,58.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,89.09,45.9,,,,,0,22.57,164.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732052,CDM,C1776,HCPCS,0278,RC,,,both,,,9510.48,2853.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6467.13,68,,,,,0,1106.07,8083.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP TRUNCATE OSTEOTOM 54MM HEMISPHERE",SUP-00705305410,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1860.35,41.1,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 NARROW KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508005601,CDM,C1776,HCPCS,0278,RC,,,both,,,29326.50,8797.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8393.24,28.62,,,,,0,3410.67,24927.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +10 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000100,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 100MM 5MM BALLOON DILATATION STERILE LATEX",SUP-595010022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"NOVANET [10819]",Novanet,,1093.5,75,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FIXATION UHMWPE ACL ATTACHABLE",SUP-AR-1588TN,CDM,C1713,HCPCS,0278,RC,,,both,,,1564.92,469.48,"BLUE CROSS [10001]","Blue Cross HMO",,613.45,39.2,,957.42,156.86,7483.26,51,182,1330.18,"percent of total billed charges",
"STPLR ENDOSCOPIC SHORT TIP RELOAD AEON 60MMX3.25MM STERILE",SUP-ASR60RS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"CIGNA [10200]","Cigna Open Access",,829.6,56.9,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE FEMORAL ANTHOLOGY +0 12/14 TAPER HIP TITANIUM MODULAR",SUP-71344247,CDM,C1776,HCPCS,0278,RC,,,both,,,1885.50,565.65,"CIGNA [10200]",Cigna,,1282.14,68,,5873.17,5873.17,5873.17,"1 through 10",219.28,1602.68,"percent of total billed charges",
"BLADE OPHTHALMIC 7.75MM TANNE UNIVERSAL TREPHINE UNIQUE HUB","SUP-E3050 7.75",CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,65.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.29,469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXCATH CROSS TRANSSEPTAL SOLUTION ? FCC 65CM, 10F",SUP-900310,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 32MM LCP STAINLESS STEEL DISTAL CORTEX RADIUS",SUP-201.782,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,1144.80,304.56,2275.09,66,50.59,369.75,"percent of total billed charges",
"SCR BONE 12.7MM 140MM 22MM DHS/DCS STAINLESS STEEL CONDYLAR",SUP-280.4,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,520.42,28.62,,,,,0,211.48,1545.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ 110CM 23CM 5FR PULMONARY ARTERY J TIP",SUP-TS258H5F,CDM,C1751,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENZOCAINE 10 % MUCOSAL GEL",RX-19690,CDM,,,0250,RC,50486-0550-32,NDC,both,7,GR,40.55,12.16,"AETNA [10100]","Aetna HMO/PPO",,32.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.72,34.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM CD HORIZON LEGACY TITANIUM SPINAL",SUP-75446545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X5MM OVAL PARALLEL SPINE CORTICAL",SUP-17105,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 15MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-015,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"MULTIPLAN [10600]",Multiplan,,4026.54,85,,,,,0,550.92,4026.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5CMX10MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-3-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"KAISER [10500]",Kaiser,,976.86,67,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 2.75MM BALLOON DILATATION RAPID EXCHANGE",SUP-DC-RZ2712UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"NOVANET [10819]",Novanet,,741.15,75,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PENUMBRA SYSTEM MAX SEPERATOR 139CM 143CM 6-4.3FR .041",SUP-4MAXC,CDM,C1757,HCPCS,0272,RC,,,both,,,11247.00,3374.1,"KAISER [10500]",Kaiser,,7535.49,67,,,,,0,1308.03,9559.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X22X12MM MODULUS 10D XL WIDE STERILE LATEX",SUP-1221245P2,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6800.11,28.62,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 100CM 5FR 1 CURVE ANGIOGRAPHIC",SUP-G47001,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"FIRST HEALTH [10303]","First Health",,168.42,80,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) HORIZONTAL ROD",SUP-5690,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 20GA 8CM POWERGLIDE PRO BIOPATCH BASIC INSRT",SUP-F320087T,CDM,S27200284,LOCAL,0272,RC,,,both,,,575.67,172.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH MAJOR ANOMALY,MODERATE",621,APR-DRG,,,,,,,inpatient,,,58980.30,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $10,623.85. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to (Final Base Payment plus Newborn Screen Add-on Amount $63.00) multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($55,917.98) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-2 Newborn; Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY,MODERATE",282,APR-DRG,,,,,,,inpatient,,,19385.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,469.55. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"GRASPER BULLETNOSE DISSECTING FORCEPS  ROTATING 5MM 32CM WIT",SUP-625117,CDM,S27000186,LOCAL,0270,RC,,,both,,,4108.33,1232.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ASCEND FLEX REVERSE",SUP-CAP-T-FLEXREV,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,12982.03,28.62,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 80CM 8MM 9FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM08100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross HMO",,7161.84,39.2,,9776.84,9776.84,9776.84,"1 through 10",2124.8,15529.5,"percent of total billed charges",
"EXP TISSUE 15X15.5CM 800CC STYLE 133S SMOOTH SUT TAB",SUP-133S-FX-15-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"BLUE CROSS [10001]","Blue Cross HMO",,3651.48,39.2,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 55.8CM 8MM DA VINCI S/SI ENDOWRIST",SUP-420172,CDM,S27000186,LOCAL,0270,RC,,,both,,,2126.25,637.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,873.89,41.1,,,,,0,247.28,1807.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Colon",PX-320000104,CDM,74270,CPT,0320,RC,,,both,,,1386.64,415.99,"FIRST HEALTH [10303]","First Health",,1109.31,80,,,,,0,161.27,1178.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACRANIAL PROCEDURES WITH MCC",037,MS-DRG,,,,,,,inpatient,,,149941.35,44982.4,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,21850.58,,"Case rate ($20,421.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $18,962.37, add-ons for qualifying new technology services are included. If operating cost exceeds $52,002.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,815.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,987.45. The transfer operating threshold is the transfer adjustment factor * $18,962.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,433.65. The transfer capital threshold is the transfer adjustment factor * $1,433.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,10994,96116.15,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ihc Antibody Multiplex per Spec",PX-312000059,CDM,88344,CPT,0312,RC,,,both,,,731.47,219.44,"CIGNA [10200]","Cigna Open Access",,297.99,,,,,,,0.01,621.75,"fee schedule",
"HEAD FEMORAL +0MM OFFSET TAPER 32MM HIP PRIMARY COCR V40",SUP-6260-9-132,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"KAISER [10500]",Kaiser,,2095.56,67,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COPE MAC-LOC 22CM 10.2FR PIGTAIL CURVE",SUP-G48162,CDM,C2617,HCPCS,0278,RC,,,both,,,996.22,298.87,"CIGNA [10200]",Cigna,,677.43,68,,,,,0,115.86,846.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERAPAMIL 80 MG TABLET, IMMEDIATE RELEASE",RX-8530,CDM,,,0637,RC,00591-0343-01,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 18MM INTERLOCK DETACHABLE ARM .018IN",SUP-M001363660,CDM,S27800098,LOCAL,0278,RC,,,both,,,3891.60,1167.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1113.78,28.62,,,,,0,452.59,3307.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 65CM 5FR HK MOD CURVE ANGIOGRAPHIC PEBAX",SUP-7603-20M65SH,CDM,S27200284,LOCAL,0272,RC,,,both,,,733.13,219.94,"CIGNA [10200]","Cigna Open Access",,417.15,56.9,,,,,0,85.26,623.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cortisol Blood Total Adrenal",PX-301000159,CDM,82533,CPT,0301,RC,,,both,,,357.50,107.25,"FIRST HEALTH [10303]","First Health",,286,80,,,,,0,0.01,303.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 18MM 140CM 2.25MM",SUP-RSINT22518UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3769.92,68,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SENSATION PLUS STATLOCK 6IN 258MM 8FR 17.4MM .027IN",SUP-0684-00-0576-01U,CDM,C1725,HCPCS,0272,RC,,,both,,,7006.26,2101.88,"UHC [10700]","United Healthcare",,4434.96,63.3,,,,,0,814.83,5955.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX EXTREME 80CM 4CM 5FR 5MM 7MM BALLOON",SUP-4156040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM DYONICS FLYER PLATINUM",SUP-72205292,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"CIGNA [10200]","Cigna Open Access",,414.8,56.9,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"600 SINGLE USE FLAT TIP HOLMIUM FIBER",SUP-HOL600SBX,CDM,S27200284,LOCAL,0272,RC,,,both,,,2397.50,719.25,"MULTIPLAN [10600]",Multiplan,,2037.88,85,,,,,0,278.83,2037.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION",RX-1222,CDM,J0665,HCPCS,0636,RC,00409-1559-19,NDC,both,30,ML,46.21,13.86,"CIGNA [10200]","Cigna Open Access",,4.28,,,,,,,1.75,39.28,"fee schedule",
"REFERENCE TOE 1ST MTP IMPLANT WITH GROMMETS  SIZE 1","SUP-M30 SE010",CDM,C1776,HCPCS,0278,RC,,,both,,,11937.00,3581.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1414.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1388.27,10146.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM CEMENT ACCOLADE C 127D 5 48MM OFFSET HIP",SUP-6057-0537D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1911.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1911.88,13973.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 45MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.845,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,630.85,45.9,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 60MM 5FR 7MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-07067,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 6FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175263070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,118.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 25MM FLEXIBLE SCR",SUP-71362925,CDM,S27200284,LOCAL,0272,RC,,,both,,,1538.19,461.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,706.03,45.9,,,,,0,178.89,1307.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET GRAFT HARVEST ACL 11MM 10MM ALIGNMENT ROD CORE EXTRUDER",SUP-AR-1981-10S,CDM,S27200284,LOCAL,0272,RC,,,both,,,5126.70,1538.01,"CIGNA [10200]","Cigna Local Plus",,2742.78,53.5,,,,,0,596.24,4357.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD + VE",SUP-98000100209,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"MULTIPLAN [10600]",Multiplan,,21420,85,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 38MM 22.2MM D HIP X3 STERILE LATEX FREE MDM",SUP-7236-2-244,CDM,C1776,HCPCS,0278,RC,,,both,,,8711.25,2613.37,"NOVANET [10819]",Novanet,,6533.44,75,,,,,0,1013.12,7404.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEART VALVE EPIC AORTIC 29MM",SUP-E100-29A-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,36722.70,11016.81,"CIGNA [10200]","Cigna Local Plus",,11567.65,31.5,,,,,0,4270.85,31214.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 4IN TUNGSTEN 20X12MM NONHEX",SUP-E15614,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.49,30.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46.12,45.9,,,,,0,11.69,85.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 13CM SPLITTABLE SIDEPORT ROBUST VALVE",SUP-PLSH-1006,CDM,C1892,HCPCS,0272,RC,,,both,,,505.44,151.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,343.7,68,,,,,0,58.78,429.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 45CM 8MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0845CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,842.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.75/26",SUP-401761,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEINMANN PIN SINGLE DIAMOND 2.4 MM X 229 MM",SUP-SPIN-SD-24229,CDM,S27000186,LOCAL,0270,RC,,,both,,,891.00,267.3,"UHC [10700]","United Healthcare",,564,63.3,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 41CM 5FR ROSCH",SUP-G10082,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,109.01,45.9,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN MULTIPASS 5-0 PC-1 18IN MONOFILAMENT YELLOWISH TAN",SUP-1915G,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.85,21.25,"CIGNA [10200]",Cigna,,48.18,68,,,,,0,8.24,60.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM NEXGEN LPS-FLEX 5-6MM EF KNEE UHMWPE",SUP-00596404012,CDM,C1776,HCPCS,0278,RC,,,both,,,6291.60,1887.48,"PHCS [10601]",PHCS,,4404.12,70,,,,,0,731.71,5347.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR ANGLE COBRA 2",SUP-G08442,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"FIRST HEALTH [10303]","First Health",,189.99,80,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG PETROLATUM 3YDX4IN XEROFORM 3% BISMUTH TRIBROMOPHENATE",SUP-SWD432000,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.73,34.12,"AETNA [10100]","Aetna HMO/PPO",,90.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.23,96.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR ANGLE KMP CURVE",SUP-G09469,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CIGNA [10200]",Cigna,,161.49,68,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION RAP-PAC ACL PCL DRILL GUIDE",SUP-014725,CDM,S27200284,LOCAL,0272,RC,,,both,,,1976.78,593.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,229.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.9,1680.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 80MM 4FR 6MM .018IN BALLOON",SUP-PCP060080130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,143.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X12MM MODULUS 10D XL WIDE STERILE LATEX",SUP-1221250P2,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"CIGNA [10200]","Cigna Local Plus",,7484.4,31.5,,16168.95,16168.95,16168.95,"1 through 10",2763.29,20196,"percent of total billed charges",
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FROZEN 40MMX5+ MM",SUP-450600,CDM,S27800098,LOCAL,0278,RC,,,both,,,4326.30,1297.89,"AETNA [10100]","Aetna HMO/PPO",,3439.41,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,503.15,3677.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE BGK0/2.5 POLYOLEFIN 5000ML NONPVC 2",SUP-110240,CDM,S27200284,LOCAL,0272,RC,,,both,,,332.60,99.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,136.7,41.1,,,,,0,38.68,282.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 34MM 140CM 3.5MM 2.1-2.7FR CORONARY",SUP-RONYX35034UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3618.75,1085.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,428.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,420.86,3075.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 CURVE PLUS 15MM KNEE XLK FIX BEARING SIGMA",SUP-970423,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"MULTIPLAN [10600]",Multiplan,,9498.37,85,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEMENT 17 F VASCULAR ACCESS SYSTEM 33CM",SUP-ELMNT17F33,CDM,C1887,HCPCS,0272,RC,,,both,,,6210.00,1863,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-9 CD 10MM KNEE LEFT CRUCIATE RETAINING",SUP-42512000410,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Open Access",,6131.78,56.9,,5302.19,4377.88,6578.61,27,1253.3,9159.96,"percent of total billed charges",
"CABLE CATH SAFIRE ELECTROPHYSIOLOGY GENRTR INTERFACE",SUP-402578,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLESEVELAM 625 MG TABLET",RX-28372,CDM,,,0637,RC,00713-0936-81,NDC,both,1,UN,19.90,5.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8.18,41.1,,,,,0,2.31,16.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIAFILL DEMINERAILIZED BONE FIBERS 12CC",SUP-VFB012,CDM,C1713,HCPCS,0272,RC,,,both,,,8280.00,2484,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3403.08,41.1,,,,,0,3403.08,5241.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 80MM 20MM VANGUARD 360 KNEE REVISION SPLINE",SUP-148310,CDM,C1776,HCPCS,0278,RC,,,both,,,11903.88,3571.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3214.05,27,,,,,0,1384.42,10118.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 8MM STAINLESS STEEL T4 SELF TAP LOCK VARIABLE",SUP-02.130.208,CDM,C1713,HCPCS,0278,RC,,,both,,,839.16,251.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,385.17,45.9,,,,,0,97.59,713.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 40MM 2.5MM BALLOON DILATATION RAPID",SUP-47525040L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 500ML 20% MANNITOL PLASTIC FLEXIBLE CNTNR",SUP-771503,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.55,43.66,"KAISER [10500]",Kaiser,,97.52,67,,,,,0,16.93,123.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prolact Rtf24 Qtr Btl",PX-E27000212,CDM,E27000212,LOCAL,0270,RC,,,both,,,214.50,64.35,"CIGNA [10200]","Cigna Open Access",,122.05,56.9,,,,,0,24.95,182.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 26CM 4.8FR URETERAL",SUP-M0061456080,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,72.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JAGWIRE ENDOSCOPIC STRAIGHT ROUND 260CM .025FR",SUP-M00557001,CDM,C1769,HCPCS,0272,RC,,,both,,,1418.31,425.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,582.93,41.1,,,,,0,164.95,1205.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PERFORM STEM HEMI",SUP-CAP1179,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2564.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP ACETABULAR 56MM PINNACLE HIP GRIPTION SECTOR SERIES",SUP-1217-32-056,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1886.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1886.21,13785.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR ALLOGRAFT 14X11X10MM SPINE",SUP-345041,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Addl Intracath Ablt Tx a Fib",PX-481000097,CDM,93657,CPT,0481,RC,,,both,,,15316.69,4595.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,15316.69,,"Case rate ($18,922). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1781.33,15316.69,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ILIVIA NEO DR-T DF1 HIGH ENERGY PROMRI TI AND CLS",SUP-429529,CDM,C1721,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"CIGNA [10200]",Cigna,,23310,40,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 115MM STAINLESS STEEL 5MM SCR BASIC FRAGMENT 6",SUP-427106S,CDM,C1713,HCPCS,0278,RC,,,both,,,1065.96,319.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,126.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,123.97,906.07,"percent of total billed charges",
"TUBE JEJUNOSTOMY 24FR SILICONE STD J MIC SECUR-LOK TRIMMABLE",SUP-0200-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"KAISER [10500]",Kaiser,,736.72,67,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE3.5MM 26MM MAXLOCK EXTREME DISTAL FIBULA ANKLE FOOT",SUP-MFT0113526,CDM,C1713,HCPCS,0278,RC,,,both,,,1239.30,371.79,"BLUE CROSS [10001]","Blue Cross PPO",,485.81,39.2,,957.42,570.23,957.42,28,144.13,1053.41,"percent of total billed charges",
"KIT INTRO 14FR IMPELLA LONG STERILE LATEX DISPOSABLE",SUP-0052-0039,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"AMERIGROUP MEDICAID [20100]",Amerigroup,,572.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alk Phosphatase Isoenzymes",PX-301000357,CDM,84080,CPT,0301,RC,,,both,,,207.10,62.13,"CIGNA [10200]","Cigna Open Access",,32.52,,,,,,,0.01,176.04,"fee schedule",
"SET STENT 24CM 8.5FR AMPLATZ PIGTAIL URETER AQ STAINLESS",SUP-G09709,CDM,C2625,HCPCS,0278,RC,,,both,,,1227.07,368.12,"KAISER [10500]",Kaiser,,822.14,67,,,,,0,142.71,1043.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE - AUGMENTED BASEPLATE AND POST",SUP-CAP-AR-UP-ABP,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,5372.07,4581.20,7242.98,23,348.9,2550,"percent of total billed charges",
"OVITEX CORE REINFORCED TISSUE MATRIX, LONG-TERM RESORBABLE R",SUP-F10264-1012G,CDM,C1781,HCPCS,0278,RC,,,both,,,6789.60,2036.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3116.43,45.9,,,,,0,789.63,5771.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 15MM 6.25MM ACL TENODESIS",SUP-AR-1562BC,CDM,C1713,HCPCS,0272,RC,,,both,,,2716.88,815.06,"UHC [10700]","United Healthcare",,1719.79,63.3,,5023.51,2672.93,6679.78,18,1116.64,1719.79,"percent of total billed charges",
"TUBE VENTILATION 9.5MM 4.5MM 9.5MM 1.14MM 9.5MM GOODE EAR T",SUP-1016010,CDM,S27800098,LOCAL,0278,RC,,,both,,,294.06,88.22,"MULTIPLAN [10600]",Multiplan,,249.95,85,,,,,0,34.2,249.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE WHOLEY .025-.038IN TORQUE",SUP-WWTD35001,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"FIRST HEALTH [10303]","First Health",,62.64,80,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ZEBRA 6F 105CM ACCESS SYSTEM BER",SUP-AC6074-105-30,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1039.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL TAN 80MM 10.35MM TFN-ADVANCED",SUP-04.038.380S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"AETNA [10100]","Aetna HMO/PPO",,3165.57,79.5,,1521.93,481.35,16760.95,30,463.09,3384.57,"percent of total billed charges",
"KIT CATH 15CM 13FR CURVE POLYURETHANE DUOGLIDE 2 LUMEN EXT",SUP-5624150,CDM,C1752,HCPCS,0278,RC,,,both,,,731.03,219.31,"BLUE CROSS [10001]","Blue Cross HMO",,286.56,39.2,,,,,0,85.02,621.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 13MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530G813,CDM,C1776,HCPCS,0278,RC,,,both,,,8868.13,2660.44,"MULTIPLAN [10600]",Multiplan,,7537.91,85,,,,,0,1031.36,7537.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 42MM NAIL-EX TITANIUM FULL THREAD HUMERAL",SUP-04.005.432S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"CIGNA [10200]",Cigna,,1017.88,68,,1831.33,1831.33,1831.33,16,174.09,1272.35,"percent of total billed charges",
"INSRT TIBIAL 7 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640706,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1308.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM OSSEOFLEX CD-H BONE CEMENT HYDRAULIC DELIVERY",SUP-OF-0348,CDM,S27200284,LOCAL,0272,RC,,,both,,,5326.80,1598.04,"NOVANET [10819]",Novanet,,3995.1,75,,,,,0,619.51,4527.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 65MM KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-183108,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8666.28,40,,,,,0,2519.72,18415.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 56MM STAINLESS STEEL 3.5MM SCREWS SMALL FRAGMENT SET 4",SUP-245.041,CDM,C1713,HCPCS,0278,RC,,,both,,,2589.30,776.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,741.06,28.62,,,,,0,301.14,2200.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 80MM 120CM 8MM VASCULAR PERIPHERAL SELF",SUP-PRB35-08-080-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross HMO",,2181.48,39.2,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 24CM 13.5FR CURVE STRAIGHT POLYURETHANE MAHURKAR",SUP-8888135244,CDM,C1752,HCPCS,0272,RC,,,both,,,860.01,258,"PHCS [10601]",PHCS,,602.01,70,,,,,0,100.02,731.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 8MM SMALL SHELL DJO SURGICAL ALTIVATE",SUP-533-08-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19520.21,41.1,,6417.48,6417.48,6417.48,"1 through 10",5523.6,40370.27,"percent of total billed charges",
"CATH COYOTE MONORAIL 150CM 100MM 4MM BALLOON DILATATION",SUP-H74939185401010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rem Auton Alg Insln Calc Setup",PX-761000090,CDM,0740T,HCPCS,0761,RC,,,both,,,127.00,38.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,127,,"Per diem ($1,793).",,,,0,14.77,127,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON SMALL TITANIUM NARROW BLADE",SUP-7541122,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",348.9,2550,"percent of total billed charges",
"GABAPENTIN 300 MG CAPSULE, IMMEDIATE RELEASE",RX-18308,CDM,,,0637,RC,00904-6666-61,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,3.57,56.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Neck/Thorax Lesion",PX-361000036,CDM,21501,CPT,0361,RC,,,both,,,6589.00,1976.7,"NOVANET [10819]",Novanet,,4941.75,75,,,,,0,766.3,6589,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC OP Vital Stim",PX-440000013,CDM,G0283,HCPCS,0440,RC,,,both,,,160.00,48,"AETNA [10100]","Aetna HMO/PPO",,127.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.61,160,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 90CM CORONARY VENOUS IS-1 EASYTRAK 2",SUP-4543,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]","Cigna Open Access",,3190.38,56.9,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Backup Battery Li Ion 11v",PX-E27400055,CDM,Q0506,HCPCS,0274,RC,,,both,,,2513.60,754.08,"KAISER [10500]",Kaiser,,1684.11,67,,,,,0,292.33,2136.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 3CM 4.8FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175251050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"NOVANET [10819]",Novanet,,803.06,75,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL MITRACLIP G4 CLIP GUIDE CATH",SUP-MCG40100,CDM,S27800098,LOCAL,0278,RC,,,both,,,188100.00,56430,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,75240,40,,,,,0,21876.03,159885,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 5.5IN 7FR AORTIC ROOT ADULT STD TIP INTRO DLP",SUP-11014L,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.11,91.23,"MULTIPLAN [10600]",Multiplan,,258.49,85,,,,,0,35.37,258.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 36MM UNIVERS REVERS +6MM SMALL SHOULDER",SUP-AR-9503S-06,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,841.43,28.62,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 23MM 8MM ACL TENODESIS STERILE",SUP-AR-1580BC,CDM,C1713,HCPCS,0278,RC,,,both,,,2716.88,815.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,777.57,28.62,,,,,0,315.97,2309.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 40MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50040,CDM,C1876,HCPCS,0278,RC,,,both,,,90294.33,27088.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,25842.24,28.62,,,,,0,10501.23,76750.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE AUGMENTATION THK6MM BIOIMPLANT PREHYDRATE EVANS",SUP-MWEV0006,CDM,C1713,HCPCS,0278,RC,,,both,,,12075.00,3622.5,"UHC [10700]","United Healthcare",,7643.48,63.3,,5023.51,2672.93,6679.78,18,1404.32,10263.75,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS 12CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192112010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"MULTIPLAN [10600]",Multiplan,,1020.49,85,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 57SQ CM 13MM 51X66MM COBALT XT VENTRICULAR",SUP-DVPA2D1,CDM,C1722,HCPCS,0278,RC,,,both,,,56385.00,16915.5,"FIRST HEALTH [10303]","First Health",,45108,80,,,,,0,6557.58,47927.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR SKIN DISORDERS WITHOUT MCC",596,MS-DRG,,,,,,,inpatient,,,27875.69,8362.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,17259.09,,,,,,,6714.82,26996.47,"case rate",
"GWIRE NITREX VASCULAR 45D 145CM 15CM .035IN NITINOL TUNGSTEN",SUP-N351452,CDM,C1769,HCPCS,0272,RC,,,both,,,362.50,108.75,"NOVANET [10819]",Novanet,,271.88,75,,,,,0,42.16,308.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERIT MAESTRO 130CM 2.8FR .024IN .038IN .021IN STRAIGHT",SUP-28MC28130ST,CDM,C1887,HCPCS,0272,RC,,,both,,,2301.00,690.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING SL 150CM 100MM 3.8FR 2MM BALLOON DILATATION",SUP-H74939148201010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MONOCRYL MULTIPASS 4-0 PC-3 18IN MONOFILAMENT UNDYED",SUP-Y845G,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.63,20.59,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK,MINOR",342,APR-DRG,,,,,,,inpatient,,,30334.36,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $3,663.00. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 20FR 56CM 40CM VALVE DIL PERFORMER CHECK-FLO AQ",SUP-G12830,CDM,C1894,HCPCS,0272,RC,,,both,,,2667.38,800.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Sensor Pulse Ox Adult",PX-E27000151,CDM,E27000151,LOCAL,0270,RC,,,both,,,135.11,40.53,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"3.0 X 38MM ESPRIT BTK IDE",SUP-1202300-38,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 3.5MM 38MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-38,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fluconazole",PX-301000068,CDM,80299,CPT,0301,RC,,,both,,,235.43,70.63,"AETNA [10100]","Aetna HMO/PPO",,187.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,200.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL H+0MM 39MM PERFORM .75 SHOULDER REVERSE",SUP-DWP4390,CDM,C1776,HCPCS,0278,RC,,,both,,,17388.00,5216.4,"CIGNA [10200]","Cigna Open Access",,5824.98,33.5,,5302.19,4377.88,6578.61,27,2022.22,14779.8,"percent of total billed charges",
"LENS IOL +19 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000190,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 30MM 120CM 7MM 6FR VASCULAR NITINOL PERIPHERAL",SUP-S-70-030-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross HMO",,3583.86,39.2,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMAKER CARDIAC THK6MM 59X55MM ALLURE RF IS-1 CONNECTOR CO",SUP-PM3222,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"CIGNA [10200]","Cigna Local Plus",,7273.48,31.5,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER ORTHOPEDIC 3.5 MM CANNULATED SCR",SUP-04.353.903.05,CDM,S27800098,LOCAL,0278,RC,,,both,,,251.05,75.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.2,213.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PULSE GENRTR WAVEWRITER ALPHA IMPLANTABLE",SUP-SC-1432,CDM,C1820,HCPCS,0278,RC,,,both,,,99750.00,29925,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11820.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11600.93,84787.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR",RX-78065,CDM,,,0637,RC,50458-0551-01,NDC,both,1,UN,56.74,17.02,"NOVANET [10819]",Novanet,,42.56,75,,,,,0,6.6,48.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDIGO CATHETER 6X 150CM STRAIGHT TRAX LIGHTNING BOLT ASPIRA",SUP-LITNGBT6XTX150,CDM,C1757,HCPCS,0272,RC,,,both,,,48132.00,14439.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5597.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5597.75,40912.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACURATE NE02TM TRANSFEMORAL DELIVE S STEM - CLINICAL",SUP-SYM-DS-008-C,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Muscle Test Cran Nrv Bil",PX-922000027,CDM,95868,CPT,0922,RC,,,both,,,1682.00,504.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,195.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,195.62,1429.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLIXIMAB-ABDA 100 MG/10ML IV (WET SOLR VIAL)",RX-415179659,CDM,Q5104,HCPCS,0636,RC,78206-0162-01,NDC,both,1,UN,4547.47,1364.24,"FIRST HEALTH [10303]","First Health",,3637.98,80,,,,,0,314.69,3865.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD MEDIUM SPINE MAS TO MAS",SUP-3602526,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,414.32,3028.13,"percent of total billed charges",
"SHOE POSTOPERATIVE MEDIUM XLONG FEMALE NAVY BLUE BREATHABLE",SUP-100347-030,CDM,S27000186,LOCAL,0270,RC,,,both,,,54.55,16.36,"FIRST HEALTH [10303]","First Health",,43.64,80,,,,,0,6.34,46.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 80MM 80CM 16MM .035IN 3MM VASCULAR VENOUS 3",SUP-VENUM16080,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY 20CM 20GA BARD MAX-CORE 2 TRIGGER ULTRA SHARP",SUP-MC2020,CDM,S27200284,LOCAL,0272,RC,,,both,,,254.04,76.21,"MULTIPLAN [10600]",Multiplan,,215.93,85,,,,,0,29.54,215.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 125MM 12MM PRIMARY CEMENT SATIN FINISH VERSYS",SUP-785001200,CDM,C1776,HCPCS,0278,RC,,,both,,,18721.08,5616.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2218.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2177.26,15912.92,"percent of total billed charges",
"STENT GORE VIABAHN 79MM 135CM 7MM 11MM 7FR .035IN",SUP-BXA077902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"CIGNA [10200]","Cigna Open Access",,7171.48,33.5,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER 13CM 5.5MM COOLCUT BONE CUTTER BONE CUTTING",SUP-AR-8550BC,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trichrome Stain O&P",PX-306000087,CDM,87209,CPT,0306,RC,,,both,,,224.20,67.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.52,,,,,,,0.01,190.57,"fee schedule",
"HC Perq Trancath Clsr Aortic Initial",PX-481000114,CDM,93591,CPT,0481,RC,,,both,,,29534.00,8860.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3434.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3434.8,25103.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Cholangiogram or Add Set",PX-320000214,CDM,74301,CPT,0320,RC,,,both,,,154.00,46.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,104.72,68,,,,,0,17.91,130.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Port Access Tray",PX-E27200278,CDM,E27200278,LOCAL,0272,RC,,,both,,,101.93,30.58,"PHCS [10601]",PHCS,,71.35,70,,,,,0,11.85,86.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intrvas Dplr Angio Init",PX-481000044,CDM,93571,CPT,0481,RC,,,both,,,2436.59,730.98,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,283.38,2071.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUSHER SURGICAL 177CM 16 COIL .016IN .020IN",SUP-401216,CDM,S27200284,LOCAL,0272,RC,,,both,,,1174.50,352.35,"UHC [10700]","United Healthcare",,743.46,63.3,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 5FR POWERLINE 2 LUMEN POWER INJECTABLE",SUP-0720515,CDM,C1751,HCPCS,0272,RC,,,both,,,2152.50,645.75,"PHCS [10601]",PHCS,,1506.75,70,,,,,0,250.34,1829.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 32MM TI",SUP-SPL-35320-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON SABRELOC 5-0 RD-1 18IN 2 ARM MONOFILAMENT BLACK",SUP-749G,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.65,34.99,"KAISER [10500]",Kaiser,,78.16,67,,,,,0,13.57,124.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 20MM PINNACLE GRIPTION TF DOME 4 POINT CUT",SUP-121720500,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"CIGNA [10200]","Cigna Open Access",,652.16,56.9,,1144.80,304.56,2275.09,66,133.3,974.23,"percent of total billed charges",
"CATH ESOPHAGUS PYLORIC 6FR 15-18MM 180CM 8CM FIXED WIRE HIGH",SUP-M00558370,CDM,C1726,HCPCS,0272,RC,,,both,,,1562.98,468.89,"AETNA [10100]","Aetna HMO/PPO",,1242.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,181.77,1328.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 20MM 3MM BALLOON DILATATION OTW NONCOMPLIANT",SUP-H74939206030270,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 5.5MM CD HORIZON CURVE TITANIUM NONSTERILE",SUP-1553201040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"SMOOTH PEG LOCKING 3.5MM X 65MM TI",SUP-SPL-35650-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 LEFT MEDIAL RIGHT LATERAL PARTIAL KNEE",SUP-5610-F-401,CDM,C1776,HCPCS,0278,RC,,,both,,,12002.52,3600.76,"UHC [10700]","United Healthcare",,7597.6,63.3,,8601.07,8395.67,8601.07,"1 through 10",1395.89,10202.14,"percent of total billed charges",
"STENT ZIPWIRE 20CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175270180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"BLUE CROSS [10001]","Blue Cross PPO",,572.36,39.2,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Assay of Prostaglandin",PX-301000695,CDM,84150,CPT,0301,RC,,,both,,,720.00,216,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,37.58,,"Fee schedule rate ($37.58). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,612,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 22FR 20CM RADIOPAQUE STD ACCEPTS .038IN GWIRE",SUP-G01472,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.44,31.03,"CIGNA [10200]","Cigna Local Plus",,55.34,53.5,,,,,0,12.03,87.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 32MM 0D C HIP X3 TRIDENT",SUP-723-00-32C,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"MULTIPLAN [10600]",Multiplan,,7263.8,85,,,,,0,993.86,7263.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING AIR ENTRAINER ADULT NONSTERILE LATEX FREE",SUP-RT008,CDM,S27000186,LOCAL,0270,RC,,,both,,,53.94,16.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.27,45.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRAVASTATIN 10 MG TABLET",RX-11110,CDM,,,0637,RC,00904-5891-61,NDC,both,1,UN,14.55,4.36,"MULTIPLAN [10600]",Multiplan,,12.37,85,,,,,0,1.69,12.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +28 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.280,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 20CM 10FR LARGE PROXIMAL PIGTAIL CURVE",SUP-M001235570,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"NOVANET [10819]",Novanet,,668.25,75,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOCKING COMPRESSION SCREW 1.8MM X 9.0MM COCR",SUP-CMP-18009-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,594.86,45.9,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT YELLOW 24X4IN STD LEG 1 FILL LINE POSITIVE LOCK",SUP-ASP-564008,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.63,46.99,"FIRST HEALTH [10303]","First Health",,125.3,80,,,,,0,18.22,133.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 30MM 190CM 2MM",SUP-R51002003L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,229.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 5-0 BB 36IN 2 ARM MONOFILAMENT BLUE",SUP-8580H,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.19,20.76,"PHCS [10601]",PHCS,,48.43,70,,,,,0,8.05,58.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 55X4.8MM TITANIUM REGULAR THICK TISSUE",SUP-017614,CDM,S27200284,LOCAL,0272,RC,,,both,,,1516.48,454.94,"UHC [10700]","United Healthcare",,959.93,63.3,,,,,0,176.37,1289.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING AIR ENTRAINER ADULT NONSTERILE LATEX FREE",SUP-RT008,CDM,S27000186,LOCAL,0270,RC,,,both,,,53.94,16.18,"NOVANET [10819]",Novanet,,40.46,75,,,,,0,6.27,45.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 122CM 8.6-11.3MM 6 SHOOTER UNIVERSAL SAEED OPTI-VU 6",SUP-G31917,CDM,S27200284,LOCAL,0272,RC,,,both,,,2122.50,636.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,872.35,41.1,,,,,0,246.85,1804.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM ALPHAVENT NONABSORBABLE STERILE",SUP-3911956547,CDM,C1713,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"NOVANET [10819]",Novanet,,2784.38,75,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 42X6X.4MM CRANIOFACIAL TITANIUM 22 HOLE STRUT 1MM",SUP-42004,CDM,C1713,HCPCS,0278,RC,,,both,,,3082.50,924.75,"PHCS [10601]",PHCS,,2157.75,70,,,,,0,358.49,2620.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR PULSE ATTESTA DR MRI IMPLANTABLE LONGEVITY",SUP-ATDRL1,CDM,C1785,HCPCS,0275,RC,,,both,,,15525.00,4657.5,"FIRST HEALTH [10303]","First Health",,12420,80,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 15MM 1.25MM BALLOON DILATATION OTW STERILE",SUP-47012015M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) OSCOR GUIDESTAR 10F SHEATH 50MM","SUP-D-1433-03-SI (50MM)",CDM,C1887,HCPCS,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCISSORS 5.75IN LAHEY CURVE MATTE FINISH SURGICAL",SUP-99251,CDM,S27000186,LOCAL,0270,RC,,,both,,,85.00,25.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT CLAMP 33MM STEALTH SOFT TRACTION STERILE LATEX FREE",SUP-G-3300,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]",Cigna,,153.82,68,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL LORDOTIC",SUP-345941,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 3 KNEE CEMENT REVISION ROTATE PLATFORM",SUP-150660003,CDM,C1776,HCPCS,0278,RC,,,both,,,22629.60,6788.88,"CIGNA [10200]",Cigna,,9051.84,40,,5873.17,5873.17,5873.17,"1 through 10",2631.82,19235.16,"percent of total billed charges",
"GRAFT BONE DEMINERALIZED BONE MATRIX 2.5ML PUTTY NONSTERILE",SUP-038025,CDM,C1713,HCPCS,0278,RC,,,both,,,2310.00,693,"KAISER [10500]",Kaiser,,1547.7,67,,,,,0,268.65,1963.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 60MM 8MM 9FR FLUENCY PLUS ENDOVASCULAR",SUP-FEM08060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross PPO",,7161.84,39.2,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 20MM 5.5MM EXPEDIUM SPINE ILIAC TITANIUM OPEN",SUP-179797020,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PHCS [10601]",PHCS,,2493.75,70,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 3CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175285110,CDM,C2617,HCPCS,0278,RC,,,both,,,1205.77,361.73,"KAISER [10500]",Kaiser,,807.87,67,,,,,0,140.23,1024.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT TAPERED COMPONENT",SUP-G47470,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"BLUE CROSS [10001]","Blue Cross PPO",,40230.37,39.2,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 38MM ONLAY ADVANCE METAL KNEE STERILE",SUP-KPON38MB,CDM,C1776,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,,10981.53,8986.79,12413.38,12,601.85,4398.75,"percent of total billed charges",
"SCREW NON-LOCKING 2.0MM X 22MM TI",SUP-VAN-20220-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Local Plus",,520.02,53.5,,3978.14,359.25,3978.14,24,113.04,826.2,"percent of total billed charges",
"LINER ACETABULAR MP6 NEUTRAL 36MM HXE-PLUS HIP STERILE",SUP-931-36-750,CDM,C1776,HCPCS,0278,RC,,,both,,,12087.14,3626.14,"AETNA [10100]","Aetna HMO/PPO",,9609.28,79.5,,10981.53,8986.79,12413.38,12,1405.73,10274.07,"percent of total billed charges",
"ROD SPINAL 90MM 5.5MM REVOLVE EXTRA LORDOTIC",SUP-185.89,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"GRAFT SOFT TISSUE 10X7CM CYTAL PORCINE URNARY BLADDER",SUP-WSM0710,CDM,Q4166,HCPCS,0636,RC,,,both,,,8812.13,2643.64,"CIGNA [10200]",Cigna,,53.69,,,,,,,53.69,7490.31,"fee schedule",
"STENT ONYX FRONTIER 8MM 2.75MM CORONARY RAPID EXCHANGE",SUP-ONYXNG27508UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2812.50,843.75,"BLUE CROSS [10001]","Blue Cross HMO",,1102.5,39.2,,9776.84,9776.84,9776.84,"1 through 10",327.09,2390.63,"percent of total billed charges",
"GRAFT BONE ALLOQUENT-S CERVICAL 5D ALLOGRAFT 5MM",SUP-3W5005,CDM,S27800098,LOCAL,0278,RC,,,both,,,6216.90,1865.07,"MULTIPLAN [10600]",Multiplan,,5284.37,85,,,,,0,723.03,5284.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 5CM 7FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22455,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 135CM 2.1FR TELEPORT HYDROPHILIC",SUP-221-13-1000U,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1387.13,41.1,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 16CM 5FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552140,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,142.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA ARTERIAL 14IN 24FR SOFT-FLOW 3/8IN ANGLE TIP SUTURE",SUP-6386,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 14 150CM 60MM 3MM TAPER BALLOON DILATATION JET",SUP-A2030-060,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION",RX-105633,CDM,,,0250,RC,63323-0468-37,NDC,both,30,ML,109.63,32.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOE POSTOPERATIVE MEDIUM MALE",SUP-100611-030,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.99,17.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,24.24,41.1,,,,,0,6.86,50.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET NDL 1IN 20GA PORT ACCESS KIT Y SITE HUBER ROTATE HEAD",SUP-PA0032YN,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.87,28.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.15,81.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 51MM STAINLESS STEEL 2.4MM SCR 6 HOLE HEAD 3",SUP-02.111.531S,CDM,C1713,HCPCS,0278,RC,,,both,,,4217.63,1265.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,499.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",490.51,3584.99,"percent of total billed charges",
"SPACER SPINAL 16X7MM COLONIAL 7D LORDOTIC 14MM XL TITANIUM",SUP-365.807CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-EXTENSIVE BURNS",935,MS-DRG,,,,,,,inpatient,,,29457.93,8837.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,29457.93,,"Fee schedule rate ($40,893.06). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,29457.93,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 30MM 4MM .035IN BALLOON DILATATION NYBAX",SUP-39171-04034,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 22GA 5.2FR 8- CM ECHOTIP PROCORE HIGH DEFINITION",SUP-G55736,CDM,S27200284,LOCAL,0272,RC,,,both,,,3195.00,958.5,"CIGNA [10200]","Cigna Open Access",,1817.96,56.9,,,,,0,371.58,2715.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC",760,MS-DRG,,,,,,,inpatient,,,33830.55,10149.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16331.58,,"Fee schedule rate ($16,331.58). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,6249.59,25126.04,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT PATIENT BLACK APB SMALL METASHANK SQUARE TOE",SUP-199649,CDM,S27000186,LOCAL,0270,RC,,,both,,,214.02,64.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.89,181.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC .99CM MINI 5.23X6.71CM INOGEN EASYVIEW",SUP-D010,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15600,40,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET HEANEY UTERINE TEETH SURGICAL",SUP-500-320,CDM,S27000186,LOCAL,0270,RC,,,both,,,321.64,96.49,"AETNA [10100]","Aetna HMO/PPO",,255.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.41,273.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CM 28MM 10MM THORAX 2 VELOUR 1 BRANCH",SUP-M00202175828P0,CDM,C1768,HCPCS,0278,RC,,,both,,,8540.68,2562.2,"CIGNA [10200]",Cigna,,5807.66,68,,,,,0,993.28,7259.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE 100CM 4FR HEADHUNTER 1 CURVE ANGIOGRAPHIC",SUP-532461,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"FIRST HEALTH [10303]","First Health",,83.52,80,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL TRANSCONTINENTAL BAYONET SPINE ANNULOTOMY",SUP-675.405S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1701.54,41.1,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URINARY STONES WITH MCC",693,MS-DRG,,,,,,,inpatient,,,47078.46,14123.54,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,8590.21,,"Case rate ($8,340.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,744.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,783.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,967.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,754.51. The transfer operating threshold is the transfer adjustment factor * $7,744.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.50. The transfer capital threshold is the transfer adjustment factor * $585.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,33530.49,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ORTHOPEDIC 5MM 10MM 5MM END INTERNAL THREAD HEX TALON",SUP-HTN-10-C05,CDM,C1713,HCPCS,0278,RC,,,both,,,1320.30,396.09,"CIGNA [10200]","Cigna Local Plus",,706.36,53.5,,3978.14,359.25,3978.14,24,153.55,1122.26,"percent of total billed charges",
"SUT POLYESTER SURGIDAC 2-0 21IN LOOPED BRAIDED COATED GREEN",SUP-ED-20-L,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,66.17,45.9,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Cerv Spine W/WO Cntrst",PX-612000007,CDM,72156,CPT,0612,RC,,,both,,,5854.43,1756.33,"KAISER [10500]",Kaiser,,3922.47,67,,,,,0,552.46,4976.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP THREE-HOLE CEMENTLESS EMPHASYS",SUP-471058300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"UHC [10700]","United Healthcare",,11365.52,63.3,,8601.07,8395.67,8601.07,"1 through 10",2088.17,15261.75,"percent of total billed charges",
"BLADE SAW 12.5X7.6MR HALL RECIPROCATE OR STERILE",SUP-505229100,CDM,S27200284,LOCAL,0272,RC,,,both,,,357.74,107.32,"CIGNA [10200]","Cigna Open Access",,203.55,56.9,,,,,0,41.61,304.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7606,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"MULTIPLAN [10600]",Multiplan,,5865,85,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CASSETTE IRRIGATION SUCTION STERILE LATEX FREE DISPOSABLE",SUP-5500-573-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 8CM 6FR 9MM .035IN BALLOON DILATATION",SUP-G52368,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) AUDIBLE FLOW INDICATOR (AFI) SYSTEM FOR HELO PE",SUP-30001,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 118CM 6FR EBU4 CURVE GUIDING STERILE LATEX",SUP-LA6EBU40Y,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL 90D BLADE 2.75IN 3/32IN EDGE SAFETY",SUP-E1455BNSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.24,14.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 6FR .071IN SHEPHERDS CROOK RIGHT 3.5 CURVE",SUP-LA6SCR35,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 75CM 20MM 6MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171060270,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT STENT 28CM 8FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001245660,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT LAPAROSCOPIC CUFF IMPLANTOR Y-TEC TUNNELOR LUKE INSRT",SUP-VP-211,CDM,S27200284,LOCAL,0272,RC,,,both,,,1571.40,471.42,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COLCHICINE 0.3 MG TABLET (PARTIAL OF 0.6 MG TABLET)",RX-409236,CDM,,,0637,RC,08888-8883-77,NDC,both,.5,UN,25.19,7.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PICK SURGICAL VEIN",SUP-6541,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC",242,MS-DRG,,,,,,,inpatient,,,128980.84,38694.25,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SAPPHIRE 3 CORONARY DILATATION CATHETER 1.0 X 10MM",SUP-54100-100-02,CDM,C1725,HCPCS,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MERIT MAK VASCULAR 60CM .018IN PLATINUM STAINLESS",SUP-MAK005-60,CDM,C1894,HCPCS,0272,RC,,,both,,,255.78,76.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,29.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.75,217.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT 14MM ALIF",SUP-3W3214,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8690.73,41.1,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP SYSTEM WITH CERAMIC HEAD",SUP-55500018,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"KAISER [10500]",Kaiser,,15195.6,67,,,,,0,2637.68,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 15MM 6.5MM G7 DOME HIP ACETABULAR LOW PROFILE",SUP-010000996,CDM,C1713,HCPCS,0278,RC,,,both,,,1174.50,352.35,"CIGNA [10200]","Cigna Open Access",,668.29,56.9,,1144.80,304.56,2275.09,66,136.59,998.33,"percent of total billed charges",
"IMPL BREAST SMOOTH HIGH PROFILE XTRA 355CC",SUP-SHPX355,CDM,C1789,HCPCS,0278,RC,,,both,,,6382.50,1914.75,"MULTIPLAN [10600]",Multiplan,,5425.13,85,,,,,0,742.28,5425.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 90CM 220MM 3MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186302290,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,881.28,68,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.105 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.105,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO AQUA 125CM 4FR 135D VERTEBRAL CURVE ANGIOGRAPHIC",SUP-SRD6108,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 12MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192012,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"AETNA [10100]","Aetna HMO/PPO",,18880.04,79.5,,10981.53,8986.79,12413.38,12,2761.95,20186.21,"percent of total billed charges",
"CURET 2MM SMALL 6.75IN SPRAGUE EAR SURGICAL",SUP-61-0015,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.05,81.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,31.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.41,229.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 16MM 43MM SHOULDER AEQUALIS ASCEND FLEX COCR",SUP-DWF043,CDM,C1776,HCPCS,0278,RC,,,both,,,9475.00,2842.5,"AETNA [10100]","Aetna HMO/PPO",,7532.63,79.5,,10981.53,8986.79,12413.38,12,1101.94,8053.75,"percent of total billed charges",
"IOFLUPANE I-123 INTRAVENOUS SOLUTION",RX-108781,CDM,A9584,HCPCS,0343,RC,08888-8878-37,NDC,both,1,UN,11340.00,3402,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1318.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1318.84,9639,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT 6 .5 CIRCLE 1.092IN .043IN REGULAR EYE REVERSE CUT",SUP-2164-06,CDM,S27200284,LOCAL,0272,RC,,,both,,,86.54,25.96,"CIGNA [10200]","Cigna Open Access",,49.24,56.9,,,,,0,10.06,73.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 45MM TSRH OSTEOGRIP THINLINE TITANIUM SPINE",SUP-83585459,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,736.68,28.62,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 32MM RESURFACING GENESIS II OXINIUM KNEE",SUP-71420576,CDM,C1776,HCPCS,0278,RC,,,both,,,6344.55,1903.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4314.29,68,,,,,0,737.87,5392.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alpha-Fetoprotein L3",PX-301000608,CDM,82107,CPT,0301,RC,,,both,,,193.06,57.92,"KAISER [10500]",Kaiser,,129.35,67,,,,,0,0.01,193.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MENISCAL CINCH CURVE SUTURING STERILE DISPOSABLE",SUP-AR-4500,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,261.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",261.02,1907.72,"percent of total billed charges",
"ROD SPINAL 240MM 3.5MM STD",SUP-3605240,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Screen Mrsa",PX-306000059,CDM,87081,CPT,0306,RC,,,both,,,290.70,87.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.1,,"Fee schedule rate ($7.10). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,247.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR POWER 45MM 45MM STD ECHELON 3000 340MM SHAFT",SUP-ECH45S,CDM,S27200284,LOCAL,0272,RC,,,both,,,8028.47,2408.54,"CIGNA [10200]","Cigna Open Access",,4568.2,56.9,,,,,0,933.71,6824.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM CONCERTO DETACHABLE HELIX",SUP-NV-3-4-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JAGWIRE DREAM TIP ENDOSCOPIC 450CM 5CM .025IN",SUP-M00556561,CDM,C1769,HCPCS,0272,RC,,,both,,,932.72,279.82,"NOVANET [10819]",Novanet,,699.54,75,,,,,0,108.48,792.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 310-375CC P4.8-6CM HIGH PROFILE ROUND STYLE 3000",SUP-350-3310,CDM,C1789,HCPCS,0278,RC,,,both,,,2475.00,742.5,"FIRST HEALTH [10303]","First Health",,1980,80,,,,,0,287.84,2103.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 26MM 140CM 2.75MM CORONARY STERILE",SUP-453957,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 5.5MM MATRIX CURVE SPINE PEDICLE POSTERIOR",SUP-04.636.030,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.5CM NATRELLE INSPIRA P6.7CM EXTRA FULL PROFILE",SUP-MSZ-X750,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"NOVANET [10819]",Novanet,,118.64,75,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (CR) - SIZE 8",SUP-5555-2208,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG VARIABLE ANGLE LOCKING 1.8MM X 18MM",SUP-SPLS-18180-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,165.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",165.8,1211.76,"percent of total billed charges",
"MTRL STRAPPING PILE LOOP FABRIC NYLON TRICOT THK1/8IN STD 10",SUP-A8097,CDM,S27000186,LOCAL,0270,RC,,,both,,,168.61,50.58,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOE ORTHOTIC 4-6 6.5-8.5 SMALL PROCARE OFF LOAD DIABETIC",SUP-79-81513,CDM,S27000186,LOCAL,0270,RC,,,both,,,237.16,71.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RED 72 132CM .085IN 2.16MM REPERFUSION LARGE BORE",SUP-RED72SDKIT,CDM,C1757,HCPCS,0272,RC,,,both,,,31027.50,9308.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SHOE CAST LARGE CANVAS RUBBER COMFO-EZE NONSLIP SOLE HEEL",SUP-2004-04,CDM,S27000186,LOCAL,0270,RC,,,both,,,72.30,21.69,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WEBSTER 92CM 1MM 5FR 10MM SPACE D CURVE",SUP-D508DP10RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3090.00,927,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH FLEXOR RAABE CHECK-FLO 70CM 9FR 3.2MM GUIDING AQ SOFT",SUP-G12606,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 6FR 4CM WITHOUT GWIRE DIL RADIOPAQUE MARKER",SUP-RSB605H,CDM,C1894,HCPCS,0272,RC,,,both,,,217.50,65.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RF MARINR 80CM 5FR 2-5-2MM SPACE 45MM CURVE ABLATION 4",SUP-076584,CDM,C1733,HCPCS,0272,RC,,,both,,,3562.50,1068.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHOCOLATE 135CM 40MM 4MM 5FR BALLOON DILATATION NITINOL",SUP-CB1413540040OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NAVITOR WITH RADIOPAQUE MARKERS 23MM",SUP-NVRO-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"PHCS [10601]",PHCS,,95760,70,,,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TIBIAL 80MM 15MM GMRS FLUTE KNEE PROXIMAL TITANIUM",SUP-6478-6-625,CDM,C1776,HCPCS,0278,RC,,,both,,,5999.55,1799.86,"KAISER [10500]",Kaiser,,4019.7,67,,,,,0,697.75,5099.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 80MM 10MM BILIARY STERILE LATEX FREE DISPOSABLE",SUP-M00572330,CDM,C1876,HCPCS,0278,RC,,,both,,,10624.97,3187.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1259.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1235.68,9031.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 345CC NATRELLE INSPIRA COHESIVE STERILE LATEX",SUP-SCM-345,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"NOVANET [10819]",Novanet,,5666.63,75,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE E CURVE",SUP-D7TCEL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,587.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM 11MM REINFORCEMENT SPACER STAGEONE",SUP-431191,CDM,C1776,HCPCS,0278,RC,,,both,,,9954.63,2986.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1179.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1157.72,8461.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM AXSOS LOCK NONSTERILE",SUP-661040,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"NOVANET [10819]",Novanet,,979.29,75,,,,,0,151.86,1109.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X8MM SUSTAIN SMALL OBLIQUE PEEK TITANIUM",SUP-304.088CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,18207.00,5462.1,"PHCS [10601]",PHCS,,12744.9,70,,,,,0,2117.47,15475.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 85MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000085,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]",Cigna,,1101.6,68,,1831.33,1831.33,1831.33,16,188.41,1377,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 24CM 3CM 6FR .035IN 2",SUP-M006192132180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,188.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 20MM 120CM 7.5MM 6FR VASCULAR NITINOL",SUP-S-75-020-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4196.41,45.9,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 5MM RELINE-O LORDOTIC COCR NONSTERILE",SUP-14450045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED-X 100CM 12X6CM 9FR 28MM .035IN BALLOON DILATATION",SUP-618451,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,630.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T 53MM TITANIUM 2X8 HOLE BONE HAND NONSTERILE",SUP-447.232,CDM,C1713,HCPCS,0278,RC,,,both,,,2461.20,738.36,"KAISER [10500]",Kaiser,,1649,67,,,,,0,286.24,2092.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 STD KNEE RIGHT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB6SR,CDM,C1776,HCPCS,0278,RC,,,both,,,17652.60,5295.78,"UHC [10700]","United Healthcare",,11174.1,63.3,,8601.07,8395.67,8601.07,"1 through 10",2053,15004.71,"percent of total billed charges",
"SCR INTERFERENCE HA 20MM 8MM ACL BIOSURE",SUP-72201775,CDM,C1713,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,669.11,1030.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 8-11 G-H",SUP-42512100912,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]",Cigna,,7327.97,68,,5873.17,5873.17,5873.17,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"SIZER IMPL 12.5CM NATRELLE INSPIRA P3.3CM LOW PLUS PROFILE",SUP-MSZ-LP280,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA [10200]",Cigna,,107.56,68,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII POSTERIOR STABILIZED CEM",SUP-71704510,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5409.18,28.62,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GALAFORM 3D 15.5X5.3CM MONOFILAMENT",SUP-FR3D01,CDM,C1781,HCPCS,0278,RC,,,both,,,8970.00,2691,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1043.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BROWN 50MM 28MM SELF-CENTERING HIP FEMUR",SUP-103550000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2083.74,68,,,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 160MM 15MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424048,CDM,C1776,HCPCS,0278,RC,,,both,,,12181.95,3654.58,"PHCS [10601]",PHCS,,8527.37,70,,,,,0,1416.76,10354.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM ENDOSCOPIC 20MM 3.9FR TRUETOME CENTER LUMEN TAPER",SUP-M00583080,CDM,S27200284,LOCAL,0272,RC,,,both,,,2190.68,657.2,"CIGNA [10200]","Cigna Local Plus",,1172.01,53.5,,,,,0,254.78,1862.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 12MM CEMENTLESS MODULAR AML POROUS 40MM",SUP-155402121,CDM,C1776,HCPCS,0278,RC,,,both,,,15374.88,4612.46,"KAISER [10500]",Kaiser,,10301.17,67,,,,,0,1788.1,13068.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN JUDKINS LEFT 3.5 CURVE",SUP-DXT5JL35,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA [10200]","Cigna Open Access",,47.03,56.9,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 CT-2 30IN BRAID GREEN NONABSORBABLE",SUP-X411H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET EXT 2.7CM 20FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-20-2.7,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SCHON XL 15CM HEMODIALYSIS SILICONE KINK RESISTANT TIP",SUP-H787108017015,CDM,C1752,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GUIDELINER 150CM 25CM 7FR .078IN .062IN INTERVENTIONAL",SUP-5572,CDM,C1887,HCPCS,0272,RC,,,both,,,2872.50,861.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Plc Stnt Sngl Maj Cor Arty 1 Les",PX-481000075,CDM,92928,CPT,0481,RC,,,both,,,29546.89,8864.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3436.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3436.3,25681,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CS1 STAINLESS STEEL 2.7MM SCR VARIABLE ANGLE LCP BONE",SUP-02.112.620,CDM,C1713,HCPCS,0278,RC,,,both,,,6189.30,1856.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,733.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,719.82,5260.91,"percent of total billed charges",
"SMOOTH PEG LOCKING 6.0MM X 70MM TI",SUP-SPL-60700-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross HMO",,635.04,39.2,,957.42,156.86,7483.26,51,188.41,1377,"percent of total billed charges",
"SYSTEM NORIAN SRS 10CM 10GA BONE CEMENT DELIVERY NDL STERILE",SUP-DLS-7103-01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.7MM 7MM VARIAX T5 LOCK NONSTERILE",SUP-662507,CDM,C1713,HCPCS,0278,RC,,,both,,,1075.03,322.51,"CIGNA [10200]","Cigna Open Access",,611.69,56.9,,1144.80,304.56,2275.09,66,125.03,913.78,"percent of total billed charges",
"DRAIN WOUND 5/16IN 24FR SILICONE TROCAR CHANNEL RADIOPAQUE",SUP-DYNJWE2234,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.25,33.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,50.6,45.9,,,,,0,12.82,93.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Redo Endovas Vena Cava Filter",PX-361000137,CDM,37192,CPT,0361,RC,,,both,,,10396.94,3119.08,"FIRST HEALTH [10303]","First Health",,8317.55,80,,,,,0,10.4,8837.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Punch Bx Skin Single Les",PX-761000061,CDM,11104,CPT,0761,RC,,,both,,,2635.92,790.78,"KAISER [10500]",Kaiser,,1766.07,67,,,,,0,306.56,2635.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 16X3MM COLOSSEUM 3.5D 14MM NONSTERILE LATEX",SUP-156.563,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"CIGNA [10200]","Cigna Local Plus",,1841.74,53.5,,,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enteroscopy WO Ileum W Ins Stnt",PX-750000230,CDM,44370,CPT,0750,RC,,,both,,,9903.00,2970.9,"BLUE CROSS [10001]","Blue Cross PPO",,5379.15,,"Case rate ($5,379.15). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1151.72,9903,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET INTUBATION SMALL GLIDERITE DISPOSABLE",SUP-0270-0916,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.38,16.91,"CIGNA [10200]",Cigna,,38.34,68,,,,,0,6.56,47.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Asp Bladder/Ins Supubic Cath",PX-361000232,CDM,51102,CPT,0361,RC,,,both,,,7686.64,2305.99,"CIGNA [10200]","Cigna Local Plus",,2587,,"Case rate ($2,587). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,893.96,7686.64,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE (RSP) MONOBLOCK REVISION HUMERAL STEM, 220MM, 6X220M",SUP-510-06-220,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"MULTIPLAN [10600]",Multiplan,,10710,85,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 10X100 40CM SL",SUP-48010010P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"NOVANET [10819]",Novanet,,736.6,75,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tavi/Tavr Perc Fem Approach",PX-361000343,CDM,33361,CPT,0481,RC,,,both,,,55614.16,16684.25,"UHC [10700]","United Healthcare",,3833,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,2491,47272.04,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 79MM 8.9MM UNCUFFED FENESTRATED INNER CANN SHILEY TRACH",SUP-10DCFN,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.84,87.85,"PHCS [10601]",PHCS,,204.99,70,,,,,0,34.06,248.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM IODIDE-123 CAPSULE",RX-156387,CDM,A9509,HCPCS,0343,RC,08888-8878-34,NDC,both,1,UN,2990.58,897.17,"PHCS [10601]",PHCS,,2093.41,70,,,,,0,0.01,2541.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Bone Marrow Img Ltd",PX-341000067,CDM,78102,CPT,0341,RC,,,both,,,1478.24,443.47,"CIGNA [10200]",Cigna,,298.28,,,,,,,171.92,1256.5,"fee schedule",
"SCR BONE 5MM 40MM CD HORIZON LEGACY TITANIUM SPINE SELF TAP",SUP-7542540,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC",432,MS-DRG,,,,,,,inpatient,,,46475.47,13942.64,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .018IN 5FR 5MM 120CM 10CM PTA OTW",SUP-435500L,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SHAVER MAROON 4MM DYONICS ELITE STONECUTTER STRAIGHT",SUP-72200728,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WAND ELECTROSURGICAL CABLATOR PROCIZE EZ VIEW PLASMA 3",SUP-EICA887501,CDM,S27200284,LOCAL,0272,RC,,,both,,,2348.33,704.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET CATH 4FR 65CM TRIFORCE FLEXOR PEEL-AWAY STRAIGHT TAPER",SUP-G56412,CDM,S27200284,LOCAL,0272,RC,,,both,,,2711.18,813.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMERGE MONORAIL 144CM 12MM 6FR 4MM .07IN BALLOON",SUP-H7493918912400,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 170CM 6CM 4MM BALLOON DILATATION HYDROPHILIC",SUP-G50336,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1606.45,68,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14IN 21FR AORTA 3/8IN STRAIGHT AUTO DILATE",SUP-EZS21TA,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"AETNA [10100]","Aetna HMO/PPO",,386.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SPECTRUM II 45D ANGLE RIGHT HOOK LOCK HANDLE SUT",SUP-C6380,CDM,S27200284,LOCAL,0272,RC,,,both,,,685.50,205.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,79.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,79.72,582.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER ETHIBOND 0 CT-2 18IN CONTROL RELEASE BRAID 8",SUP-CX27D,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.98,37.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,51.37,41.1,,,,,0,14.54,106.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLODERM (RTU) CONTOUR MEDIUM PERFORATED - THIN",SUP-CM1516P,CDM,Q4116,HCPCS,0636,RC,,,both,,,25263.00,7578.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16420.95,65,,,,,0,247.92,21473.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 14MM SPINE STOP LLIF",SUP-610.714,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2690.35,68,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTECH DOWEL ALLOGRAFT 15MM CERVICAL",SUP-4411215,CDM,S27800098,LOCAL,0278,RC,,,both,,,12335.82,3700.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1434.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1434.66,10485.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPINAL DISORDERS AND INJURIES WITH CC/MCC",052,MS-DRG,,,,,,,inpatient,,,60679.82,18203.95,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,11572.68,,"Case rate ($11,235.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,433.02, add-ons for qualifying new technology services are included. If operating cost exceeds $43,472.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,170.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,446.82. The transfer operating threshold is the transfer adjustment factor * $10,433.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.79. The transfer capital threshold is the transfer adjustment factor * $788.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,45172.01,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR MULTIPURPOSE A1",SUP-67027000,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,49.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEADACHES WITHOUT MCC",103,MS-DRG,,,,,,,inpatient,,,30826.86,9248.06,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,5498.88,,"Case rate ($5,187.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,817.06, add-ons for qualifying new technology services are included. If operating cost exceeds $37,856.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,746.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,823.43. The transfer operating threshold is the transfer adjustment factor * $4,817.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $364.19. The transfer capital threshold is the transfer adjustment factor * $364.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,5187.62,20856.49,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP LARGE 14IN ENDOSCOPIC HORIZON 12MM",SUP-438110,CDM,S27200284,LOCAL,0272,RC,,,both,,,13572.30,4071.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1578.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1578.46,11536.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC",717,MS-DRG,,,,,,,inpatient,,,89366.82,26810.05,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,12547.77,,"Case rate ($11,726.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,889.21, add-ons for qualifying new technology services are included. If operating cost exceeds $43,928.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,205.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,903.61. The transfer operating threshold is the transfer adjustment factor * $10,889.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.28. The transfer capital threshold is the transfer adjustment factor * $823.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,55195.04,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEMORAL TRIATHLON 2MM OFFSET KNEE TOTAL STABILIZE",SUP-5570-S-020,CDM,C1776,HCPCS,0278,RC,,,both,,,4573.30,1371.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,541.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,531.87,3887.31,"percent of total billed charges",
"STENT INNOVA 20MM 130CM 8MM VASCULAR SELF EXPAND RADIOPAQUE",SUP-H74939293080230,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"AETNA [10100]","Aetna HMO/PPO",,3839.85,79.5,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 NARROW KNEE RIGHT CRUCIATE RETAIN CEMENTLESS",SUP-150401226,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3409.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3346.56,24458.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NONTRAUMATIC STUPOR AND COMA WITH MCC",080,MS-DRG,,,,,,,inpatient,,,51729.23,15518.77,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,11901.19,,"Case rate ($11,227.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,425.53, add-ons for qualifying new technology services are included. If operating cost exceeds $43,465.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,170.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,439.32. The transfer operating threshold is the transfer adjustment factor * $10,425.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.22. The transfer capital threshold is the transfer adjustment factor * $788.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,45139.59,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT GLENOID SHORT STEM INSRT VERSA-DIAL",SUP-98B00900110,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"KAISER [10500]",Kaiser,,13718.25,67,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 8IN 40D UP CERVICAL 9X4MM MICRO-KERRISON EJECTOR",SUP-57-0694,CDM,S27200284,LOCAL,0272,RC,,,both,,,2535.15,760.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1041.95,41.1,,,,,0,294.84,2154.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 40MM 5MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171050470,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"MULTIPLAN [10600]",Multiplan,,998.33,85,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,inpatient,,,83832.58,25149.77,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,11461.51,,"Case rate ($11,127.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,332.80, add-ons for qualifying new technology services are included. If operating cost exceeds $43,372.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,163.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $10,346.46. The transfer operating threshold is the transfer adjustment factor * $10,332.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.21. The transfer capital threshold is the transfer adjustment factor * $781.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,52374.7,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR 10CM 5FR .035IN BLADDER LOOP LOW",SUP-M006155211090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"MULTIPLAN [10600]",Multiplan,,1158.33,85,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 48MM 32MM ALTRX HIP",SUP-1221-32-048,CDM,C1776,HCPCS,0278,RC,,,both,,,9128.70,2738.61,"FIRST HEALTH [10303]","First Health",,7302.96,80,,,,,0,1061.67,7759.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM SAPIEN 3 COMMANDER EDWARDS TRANSCATHETER",SUP-S3UCM223A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,76137.75,41.1,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE NERVE STIM MNTR STERILE",SUP-03.809.692S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3033.75,910.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,359.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,352.83,2578.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 9MM KNEE X3 BEARING POSTERIOR STABILIZE",SUP-5532-G-509,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3578.83,41.1,,6417.48,6417.48,6417.48,"1 through 10",1012.7,7401.47,"percent of total billed charges",
"ROD EXTERNAL FIXATION 500MM 11MM CARBON FIBER LARGE EXTERNAL",SUP-394.89,CDM,C1713,HCPCS,0278,RC,,,both,,,1581.53,474.46,"CIGNA [10200]","Cigna Local Plus",,846.12,53.5,,3978.14,359.25,3978.14,24,183.93,1344.3,"percent of total billed charges",
"HC Caregiver Training 1st 30 Min (Go)",PX-430000064,CDM,97550,CPT,0430,RC,,,both,,,90.21,27.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.49,90.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 4CM NASAL FIRMNESS NASOPORE STERILE LATEX FREE",SUP-5400030004,CDM,S27200284,LOCAL,0272,RC,,,both,,,1301.06,390.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,154.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,151.31,1105.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DISTRACTION 14MM TRIMLINE ANTERIOR CERVICAL",SUP-875-088,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 10CM 5MM BALLOON DILATATION",SUP-DR80510,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"NOVANET [10819]",Novanet,,1032.75,75,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ELECTROPHYSIOLOGY 110CM 6FR BARD EP XT 2-5-2MM SPAC",SUP-200794R,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"UHC [10700]","United Healthcare",,640.91,63.3,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG GERMICIDAL 4.75X4IN MAXORB EXTRA CALCIUM ALGINATE IONIC",SUP-MSC9445EP,CDM,S27200284,LOCAL,0272,RC,,,both,,,51.36,15.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,23.57,45.9,,,,,0,5.97,43.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CARTO XP THERMOCOOL SF 115CM 8FR 3.5MM DD CURVE",SUP-BNI35DDH,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"NOVANET [10819]",Novanet,,13546.58,75,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE-USE 1000 MICRON LASER",SUP-HLFDBX1000C,CDM,S27200284,LOCAL,0272,RC,,,both,,,5276.02,1582.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3587.69,68,,,,,0,613.6,4484.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM STAINLESS STEEL CORTICAL HAND FOOT SELF",SUP-201.648,CDM,C1713,HCPCS,0278,RC,,,both,,,391.94,117.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",45.58,333.15,"percent of total billed charges",
"CANN ENDOSCOPIC LIME GREEN 72MM 8MM CLEAR-TRAC SHOULDER",SUP-72200425,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.01,86.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,34.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.61,245.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL GREEN WHITE .7MM OTO-FLEX SKEETER DIAMOND",SUP-3155647,CDM,S27200284,LOCAL,0272,RC,,,both,,,1677.38,503.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,198.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,195.08,1425.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXS VECTA 71 132CM .082-.085IN .071IN ASPIRATION SCOUT",SUP-INC-11129-132,CDM,S27200284,LOCAL,0272,RC,,,both,,,16943.99,5083.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6963.98,41.1,,,,,0,1970.59,14402.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 28MM LCP STAINLESS STEEL DISTAL CORTEX RADIUS",SUP-201.778,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",50.59,369.75,"percent of total billed charges",
"SCR BONE 3.5MM 22MM INFINITY SPINE OCCIPITOCERVICAL UPPER",SUP-3603522,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 80MM 7MM .035IN BALLOON",SUP-AB35W07080135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"AETNA [10100]","Aetna HMO/PPO",,538.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 13MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G813,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"NOVANET [10819]",Novanet,,6530.71,75,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AMPHIRION DEEP 150CM 40MM 2MM BROAD TAPER BALLOON",SUP-AMP020040152,CDM,C1725,HCPCS,0272,RC,,,both,,,2422.50,726.75,"FIRST HEALTH [10303]","First Health",,1938,80,,,,,0,281.74,2059.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 87.5MM 3.1MM STAINLESS STEEL STERILE",SUP-180018000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INTELLANAV STABLEPOINT 4MM 8FR ABLATION RING ELECTRD",SUP-M004RFSDS96200,CDM,C2630,HCPCS,0272,RC,,,both,,,20160.00,6048,"PHCS [10601]",PHCS,,14112,70,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +5 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000050,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 40MM 7MM BALLOON DILATATION DURALYN",SUP-48007004X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC",191,MS-DRG,,,,,,,inpatient,,,24567.48,7370.24,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH KAYE 25CM 15CM 17FR 12MM NEPHRSTMY POLYETHELENE",SUP-G14343,CDM,C1729,HCPCS,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) AUDIBLE FLOW INDICATOR (AFI) SYSTEM FOR HELO PE",SUP-30001,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DETACHER COIL CEREPAK MECHANICAL DETACHMENT HANDLE",SUP-MDH1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1799.63,539.89,"UHC [10700]","United Healthcare",,1139.17,63.3,,,,,0,209.3,1529.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 STD KNEE LEFT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB5SL,CDM,C1776,HCPCS,0278,RC,,,both,,,17652.60,5295.78,"CIGNA [10200]","Cigna Open Access",,5913.62,33.5,,5302.19,4377.88,6578.61,27,2053,15004.71,"percent of total billed charges",
"STENT XACT 30MM 7-9MM TAPER VASCULAR NITINOL CAROTID ARTERY",SUP-82087-01,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"KAISER [10500]",Kaiser,,6271.2,67,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRIMARY KNEE/PARTIAL KNEES (KNEE CONSTRUCT)",SUP-CAP-LB-K-1,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"(EVAL) ARCHSINUS NASAL STENT",SUP-712-001,CDM,C2625,HCPCS,0272,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 22MM SPINE PEDICLE PLY NONSTERILE 4MM ROD",SUP-102045222,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"GRAFT SOFT TISSUE 15MM 2-3MM AVANCE NERVE ALLOGRAFT",SUP-211215,CDM,C1762,HCPCS,0278,RC,,,both,,,17734.50,5320.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5075.61,28.62,,,,,0,2062.52,15074.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 200MM 3MM BALLOON DILATATION DURALYN",SUP-48003020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 120MM 5MM BALLOON DILATATION RAPID",SUP-47550120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER DISORDERS OF NERVOUS SYSTEM,EXTREME",058,APR-DRG,,,,,,,inpatient,,,82264.12,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $16,498.51. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($105,256.92) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR LCB CURVE ANGIOGRAPHIC CORONARY 2",SUP-H749163911952,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS INFINITI 100CM 4FR AR MOD CURVE ANGIOGRAPHIC",SUP-538448,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT 12IN 1.75IN OSTOMY 2 PIECE DRAINABLE POUCH LOW PRESSURE",SUP-SQU416919,CDM,S27000186,LOCAL,0270,RC,,,both,,,236.62,70.99,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH GORE DRYSEAL FLEX 33CM 6.7MM 18FR INTRO HYDROPHILIC",SUP-GDSF1833,CDM,C1894,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4MM 26MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.426,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 17MM 46MM SHOULDER AEQUALIS ASCEND FLEX COCR 4",SUP-DWF146,CDM,C1776,HCPCS,0278,RC,,,both,,,10004.00,3001.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4591.84,45.9,,,,,0,1163.47,8503.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13177540,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,3978.14,359.25,3978.14,24,348.9,2550,"percent of total billed charges",
"SUT PLAIN LIGAPAK 0 54IN MONOFILAMENT DISPENSE REEL UNDYED",SUP-L104G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 8-11 E-F KNEE RIGHT TIBIA FIX",SUP-42522100813,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS [10001]","Blue Cross PPO",,4224.36,39.2,,3949.44,3949.44,3949.44,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"PACK 21X11IN THERAPEUTIC COLD PLIABLE SOFT OVERSIZE LATEX",SUP-3548D,CDM,S27000186,LOCAL,0270,RC,,,both,,,132.76,39.83,"AETNA [10100]","Aetna HMO/PPO",,105.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.44,112.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT AMSTERDAM 10FR INTRO PUSH GWIRE CATH PERCUFLEX",SUP-M00533920,CDM,C1894,HCPCS,0272,RC,,,both,,,593.81,178.14,"NOVANET [10819]",Novanet,,445.36,75,,,,,0,69.06,504.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 18GA SIDEKICK 2 10MM DEPLOYMENT",SUP-RFK-C101018S-ZK2-P,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.95,74.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.84,210.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM CROSSFT KNOTLESS BIOCOMPOSITE STERILE",SUP-CFKB-475S,CDM,C1713,HCPCS,0278,RC,,,both,,,4385.23,1315.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2012.82,45.9,,,,,0,510,3727.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN FEMORAL RIGHT 4 CURVE",SUP-H74908641022,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]","Cigna Local Plus",,40.97,53.5,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ASPIRATION ANTICOAGULATION LINE ELECTA ESSENTIAL CONCEPT",SUP-AAL,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,92.97,41.1,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 14CM 26MM 12MM 22-23MM 10-11MM GORE",SUP-RLT261214,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS [10001]","Blue Cross PPO",,24578.4,39.2,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM SKYLINE TITANIUM SPINE CERVICAL ANTERIOR",SUP-186862016,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,1144.80,304.56,2275.09,66,117.75,860.63,"percent of total billed charges",
"CMPNT GLENOID 35MM SMALL PEG PERFORM SHOULDER ALL POLY",SUP-DWE302,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6334.88,68,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Sel Opn Wnd<=20scm",PX-510000166,CDM,97597,CPT,0761,RC,,,both,,,1190.27,357.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,138.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,138.43,1190.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 18CM 5.5MM DYONICS LONG ABRADER ARTHROSCOPIC",SUP-72200082,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"CIGNA [10200]","Cigna Open Access",,331.84,56.9,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X2CM CYGNUS DUAL THK.2MM 6SQ CM AMNION",SUP-585-001,CDM,Q4282,HCPCS,0636,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.92,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 27MM DURAN ANCORE CHORDAL GUIDE",SUP-620BG27,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 46MM 28MM ALTRX HIP",SUP-122128046,CDM,C1776,HCPCS,0278,RC,,,both,,,11405.70,3421.71,"AETNA [10100]","Aetna HMO/PPO",,9067.53,79.5,,10981.53,8986.79,12413.38,12,1326.48,9694.85,"percent of total billed charges",
"HOOK SPINAL CD HORIZON SMALL TITANIUM NARROW BLADE RAMP 5.5",SUP-7541142,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,957.42,570.23,957.42,28,348.9,2550,"percent of total billed charges",
"INTRO SHEATH 6FR 4CM WITHOUT GWIRE DIL RADIOPAQUE MARKER",SUP-RSB605H,CDM,C1894,HCPCS,0272,RC,,,both,,,217.50,65.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,147.9,68,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC App Splint Fgr Dynamic",PX-450000195,CDM,29131,CPT,0450,RC,,,both,,,830.00,249,"CIGNA [10200]","Cigna Open Access",,830,,,,,,,67.13,830,"case rate",
"STEM FEMORAL 137MM CEMENT ACCOLADE C 127D 4 46MM OFFSET HIP",SUP-6057-0435D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"CIGNA [10200]","Cigna Open Access",,5507.15,33.5,,5302.19,4377.88,6578.61,27,1911.88,13973.36,"percent of total billed charges",
"SABER .035 6X20 40CM SL",SUP-48006002P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"PHCS [10601]",PHCS,,687.49,70,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTALBITAL 50 MG-ACETAMINOPHEN 325 MG-CAFFEINE 40 MG-CODEINE 30 MG CAP",RX-30350,CDM,,,0250,RC,00591-3220-01,NDC,both,1,UN,13.88,4.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5.7,41.1,,,,,0,1.61,11.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 36CM CARBOTHANE PALINDROME TAL VENATRAC 2 LUMEN",SUP-8888145039P,CDM,C1750,HCPCS,0278,RC,,,both,,,2876.79,863.04,"BLUE CROSS [10001]","Blue Cross HMO",,1127.7,39.2,,,,,0,334.57,2445.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 14MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240140200,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"BLUE CROSS [10001]","Blue Cross PPO",,2672.34,39.2,,,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CS3 TITANIUM 2.7MM SCR VARIABLE ANGLE LCP BONE",SUP-04.112.624S,CDM,C1713,HCPCS,0278,RC,,,both,,,7392.25,2217.67,"FIRST HEALTH [10303]","First Health",,5913.8,80,,,,,0,859.72,6283.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT CONFIDENCE HALF DOSE 5CC LATEX FREE",SUP-283905000,CDM,C1713,HCPCS,0278,RC,,,both,,,8424.90,2527.47,"CIGNA [10200]","Cigna Local Plus",,4507.32,53.5,,3978.14,359.25,3978.14,24,979.82,7161.17,"percent of total billed charges",
"STENT VIABAHN 15CM 75MM 8MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR081501A,CDM,C1874,HCPCS,0278,RC,,,both,,,21577.50,6473.25,"CIGNA [10200]",Cigna,,8631,40,,,,,0,2509.46,18340.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 7X 38MM CATH 120CM ENDOVASCULAR",SUP-42738,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"AETNA [10100]","Aetna HMO/PPO",,13928.64,79.5,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM GORILLA R3CON LOCK",SUP-P50-353-3514,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 90CM 5MM 8FR 2-5-2MM SPACE F CURVE",SUP-D8BTF5L252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"AETNA [10100]","Aetna HMO/PPO",,3944.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ERCP .035IN SHORT SWING TIP STAR TIP V 1950MM 2.5FR 2.1",SUP-PR-233Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,1249.34,374.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,145.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,145.3,1061.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM RELINE-O SPINE POLYAXIAL TRACTION",SUP-13117545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 MO-4 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP701D,CDM,S27200284,LOCAL,0272,RC,,,both,,,169.32,50.8,"MULTIPLAN [10600]",Multiplan,,143.92,85,,,,,0,19.69,143.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Beta-Amyloid 1-42 (Abeta 42)",PX-309000147,CDM,82234,CPT,0309,RC,,,both,,,563.00,168.9,"AETNA [10100]","Aetna HMO/PPO",,447.59,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,478.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X8MM COROENT 10D XL+ WIDE PEEK NONSTERILE",SUP-6308250,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS LORDOTIC BLOCK DENSE 14X11X7MM",SUP-T80057,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Allergen Ige Quant/Semi Ea",PX-302000005,CDM,86003,CPT,0302,RC,,,both,,,94.05,28.21,"PHCS [10601]",PHCS,,65.84,70,,,,,0,0.01,79.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 70MM 7.3MM LCP PARTIAL THREAD PROXIMAL MEDIAL",SUP-02.207.470,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,714.14,45.9,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .018IN 5FR 6MM 120CM 10CM PTA OTW",SUP-435600L,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PHCS [10601]",PHCS,,878.85,70,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 1.5% DEXTROSE 6000ML 1 BAG CNTNR LOW CALCIUM LUER",SUP-L5B9710,CDM,S27200284,LOCAL,0272,RC,,,both,,,413.69,124.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,49.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.11,351.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ETHAMBUTOL 400 MG TABLET",RX-9983,CDM,,,0637,RC,68084-0280-11,NDC,both,1,UN,8.17,2.45,"CIGNA [10200]","Cigna Open Access",,4.65,56.9,,,,,0,0.95,6.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 CURVE PLUS 10MM KNEE XLK FIX BEARING SIGMA",SUP-970481,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]","Cigna Local Plus",,5978.38,53.5,,5372.07,4581.20,7242.98,23,1299.6,9498.37,"percent of total billed charges",
"SCR BONE 3MM 26MM CHARLOTTE STAINLESS STEEL FOOT ANKLE",SUP-44110009,CDM,C1713,HCPCS,0278,RC,,,both,,,1672.50,501.75,"NOVANET [10819]",Novanet,,1254.38,75,,,,,0,194.51,1421.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL MONOFILAMENT ABSORBABLE LOW PROFILE",SUP-5954113,CDM,C1781,HCPCS,0278,RC,,,both,,,6720.00,2016,"BLUE CROSS [10001]","Blue Cross PPO",,2634.24,39.2,,,,,0,781.54,5712,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 65MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.435,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"FIRST HEALTH [10303]","First Health",,1107.3,80,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 700ML GEL ROUND SMOOTH MEMORYGEL COHESIVE I","SUP-3507001 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"FIRST HEALTH [10303]","First Health",,2940,80,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,inpatient,,,561084.65,168325.39,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,88498.7,,"Case rate ($85,921.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $79,783.54, add-ons for qualifying new technology services are included. If operating cost exceeds $112,823.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $7,414.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $79,889.05. The transfer operating threshold is the transfer adjustment factor * $79,783.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,032.02. The transfer capital threshold is the transfer adjustment factor * $6,032.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,85921.07,341950.2,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUITY WHISPER VIEW DS CS-J - EACH",SUP-664643-001,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,771.12,68,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 34MM 1 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-41F34V,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"NDL BIOPSY 15GA 22CM CENTIMETER MARK ADJUSTABLE STOP COLOR",SUP-MSPN2206,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,56.7,45.9,,,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 90MM 75CM 6MM 100CM",SUP-M001711140,CDM,C1876,HCPCS,0278,RC,,,both,,,12592.50,3777.75,"FIRST HEALTH [10303]","First Health",,10074,80,,,,,0,1464.51,10703.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 2.25MM BALLOON DILATATION RAPID EXCHANGE",SUP-DC-RZ2212UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"PHCS [10601]",PHCS,,691.74,70,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 350ML STYLE 6200 MEDIUM HEIGHT CENTERSCOPE",SUP-3546212,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2616.58,28.62,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2-2.4MM CANNULATED DISPOSABLE",SUP-212-24-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.00,495,"CIGNA [10200]","Cigna Open Access",,938.85,56.9,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 19MM KNEE X3 BEARING CRUCIATE RETAIN",SUP-5530-G-219,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"AETNA [10100]","Aetna HMO/PPO",,9073.02,79.5,,10981.53,8986.79,12413.38,12,1327.29,9700.71,"percent of total billed charges",
"SABER .035 6X200 80CM SL",SUP-48006020N,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"KAISER [10500]",Kaiser,,668.06,67,,,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEVELAMER CARBONATE 800 MG TABLET",RX-89201,CDM,,,0637,RC,50268-0720-11,NDC,both,1,UN,33.64,10.09,"NOVANET [10819]",Novanet,,25.23,75,,,,,0,3.91,28.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT STRATA II REGULAR CSF PROGRAMMABLE FLOW CONTROL",SUP-42866,CDM,S27800098,LOCAL,0278,RC,,,both,,,35307.22,10592.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14511.27,41.1,,,,,0,4106.23,30011.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SCR 90MM 4.5MM INTERTAN TROCHANTER TITANIUM LAG",SUP-71677090,CDM,C1713,HCPCS,0278,RC,,,both,,,6986.94,2096.08,"CIGNA [10200]",Cigna,,4751.12,68,,1831.33,1831.33,1831.33,16,812.58,5938.9,"percent of total billed charges",
"SHELL ACETABULAR 76MM 68MM HIP REVISION POROUS REDAPT THK4MM",SUP-71354244,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC",750,MS-DRG,,,,,,,inpatient,,,54616.21,16384.86,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,18640.33,,"Case rate ($9,154.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,500.55, add-ons for qualifying new technology services are included. If operating cost exceeds $41,540.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,024.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $8,511.79. The transfer operating threshold is the transfer adjustment factor * $8,500.55 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.68. The transfer capital threshold is the transfer adjustment factor * $642.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,43087.46,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Sm Bowel",PX-320000103,CDM,74250,CPT,0320,RC,,,both,,,1287.42,386.23,"FIRST HEALTH [10303]","First Health",,1029.94,80,,,,,0,131.63,1094.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THEOPHYLLINE ER 100 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27418,CDM,,,0637,RC,52244-0100-10,NDC,both,1,UN,23.36,7.01,"KAISER [10500]",Kaiser,,15.65,67,,,,,0,2.72,19.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 35CM AZUR HYDROPACK .018IN PERIPHERAL",SUP-45-880035,CDM,S27800098,LOCAL,0278,RC,,,both,,,9473.70,2842.11,"MULTIPLAN [10600]",Multiplan,,8052.65,85,,,,,0,1101.79,8052.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006175280190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]",Cigna,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 3.75 X 28 MM",SUP-1212375-28,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"MULTIPLAN [10600]",Multiplan,,14662.5,85,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 110MM STARDRIVE TITANIUM T25 CANNULATED SELF",SUP-04.003.032S,CDM,C1713,HCPCS,0278,RC,,,both,,,1544.51,463.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,179.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",179.63,1312.83,"percent of total billed charges",
"STIM/LOC NERVE IO-FLEX NEURO CHECK WIRE SPINE",SUP-IO-NCW,CDM,S27200284,LOCAL,0272,RC,,,both,,,7245.00,2173.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,842.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 6CM 5.8FR 18FR BALLOON",SUP-M0062251080,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"AETNA [10100]","Aetna HMO/PPO",,1361.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,199.16,1455.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL FEMUR DISTAL LATERAL STAINLESS STEEL LOCK AXSOS",SUP-370002,CDM,C1776,HCPCS,0278,RC,,,both,,,365.40,109.62,"CIGNA [10200]","Cigna Open Access",,207.91,56.9,,5302.19,4377.88,6578.61,27,42.5,310.59,"percent of total billed charges",
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.235,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER ULTRASOUND STEREOTACTIC GUIDED RIGID DEPLOYMENT",SUP-SMARK-ATEC-2S-13-12,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"CIGNA [10200]","Cigna Open Access",,380.01,56.9,,,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MICROPOINT 9-0 TG140-8 6IN 2 ARM MONOFILAMENT",SUP-1754G,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.81,61.14,"MULTIPLAN [10600]",Multiplan,,173.24,85,,,,,0,23.7,173.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX PDS PLUS 2-0 SH SPIRAL 6IN TAPER POINT",SUP-SXPP1B415,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.96,69.59,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,106.47,45.9,,,,,0,26.98,197.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY TORIC AUTONOME",SUP-CNAET3,CDM,V2787,HCPCS,0276,RC,,,both,,,880.00,264,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,102.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,102.34,748,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 4MM .6MM SMART STAPES PISTON RECONSTRUCTIVE",SUP-7014-5926,CDM,L8613,HCPCS,0278,RC,,,both,,,1801.20,540.36,"CIGNA [10200]","Cigna Local Plus",,963.64,53.5,,,,,0,209.48,1531.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC SHARP TIP UNIBODY SAMURAI FULL RADIUS",SUP-CAT02421,CDM,S27200284,LOCAL,0272,RC,,,both,,,1635.00,490.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,190.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,190.15,1389.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 14MM AXIUM 3D NEUROVASCULAR FRAME V01",SUP-FC-14-50-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"MULTIPLAN [10600]",Multiplan,,14046.68,85,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 3MM 18MM DCP STAINLESS STEEL MIDDLE PROXIMAL",SUP-200.818,CDM,C1713,HCPCS,0278,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL DUALMESH PLUS 15X10CM HERNIA BIOMATERIAL OVAL",SUP-1DLMCP03,CDM,C1781,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET, IMMEDIATE RELEASE",RX-9407,CDM,,,0637,RC,60687-0661-11,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BD NEXIVA DIFFUSICS 1IN 22GA 1.65MM 6.5ML/SEC 325 PSI",SUP-383591,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.16,17.75,"AETNA [10100]","Aetna HMO/PPO",,47.03,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.88,50.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 50MM 32MM ALTRX HIP",SUP-122132150,CDM,C1776,HCPCS,0278,RC,,,both,,,5531.40,1659.42,"CIGNA [10200]","Cigna Open Access",,3147.37,56.9,,5302.19,4377.88,6578.61,27,643.3,4701.69,"percent of total billed charges",
"SUT POLYESTER BRAID GREEN NONABSORBABLE",SUP-SXP52N,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.74,206.62,"CIGNA [10200]","Cigna Open Access",,391.89,56.9,,,,,0,80.1,585.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM AMPLATZER TORQVUE 90D 60CM 160CM 5FR .068IN .059IN",SUP-9-TVLP5F90/060,CDM,S27200284,LOCAL,0272,RC,,,both,,,5754.60,1726.38,"AETNA [10100]","Aetna HMO/PPO",,4574.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,669.26,4891.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 90ML .1-2MM 80% CORTICAL 20% CANCELLOUS",SUP-400071,CDM,C1713,HCPCS,0278,RC,,,both,,,5938.83,1781.65,"MULTIPLAN [10600]",Multiplan,,5048.01,85,,,,,0,690.69,5048.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 32MM 144CM 2.25MM",SUP-H7493941232220,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"AETNA [10100]","Aetna HMO/PPO",,6171.19,79.5,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 20MM 7MM BALLOON DILATATION STERILE LATEX",SUP-597002022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC",463,MS-DRG,,,,,,,inpatient,,,153569.89,46070.97,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH THERMOCOOL SF 115CM 8FR B CURVE ABLATION",SUP-D131601,CDM,C1732,HCPCS,0272,RC,,,both,,,10149.90,3044.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT SOLITAIRE PARAMETRIC 31MM 20MM 4MM 10MM SPACE 3-1",SUP-SFR4-4-20-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,40761.00,12228.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CAP ENDOSCP SEALING .7MM HOLE TRANSPARENT RIGID URETEROSCOPE",SUP-WA00387A,CDM,S27000186,LOCAL,0270,RC,,,both,,,86.03,25.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPTITORQUE 100CM 5FR RADIAL TIGER 4.5 CURVE",SUP-40-5012,CDM,C1769,HCPCS,0272,RC,,,both,,,313.20,93.96,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAMP SURGICAL 1-2.25MM ARTERY BLACK",SUP-B-3AB,CDM,S27200284,LOCAL,0272,RC,,,both,,,547.11,164.13,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 135CM 200MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171082010,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUT 5.5MM HEALICOIL KNOTLESS SELF TAP REGENESORB",SUP-72205136,CDM,C1713,HCPCS,0278,RC,,,both,,,3368.25,1010.47,"MULTIPLAN [10600]",Multiplan,,2863.01,85,,,,,0,391.73,2863.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE MEDIUM FEMALE",SUP-100612-030,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.99,17.7,"CIGNA [10200]","Cigna Local Plus",,31.56,53.5,,,,,0,6.86,50.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI CHIKAI VASCULAR STRAIGHT 200CM 9CM .2/.26MM",SUP-WAIN-CKI-008-200,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"NOVANET [10819]",Novanet,,2812.5,75,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 7MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650307,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UHC [10700]","United Healthcare",,8309.55,63.3,,8601.07,8395.67,8601.07,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"CMPNT FEMORAL 5 KNEE RIGHT CEMENT REVISION CONSTRAIN ATTUNE",SUP-1504-40-205,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"UHC [10700]","United Healthcare",,19062.16,63.3,,8601.07,8395.67,8601.07,"1 through 10",3502.26,25596.9,"percent of total billed charges",
"NEEDLE BIOPSY ASPIRATION ENDOSOPIC ULTRASOUND EXPECT 19GAX1.",SUP-M00550001,CDM,C1889,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASE RTRCTR LEYLA REICHERT 1 MOUNT SELF RETAIN NONSTERILE",SUP-R2396,CDM,S27200284,LOCAL,0272,RC,,,both,,,2181.53,654.46,"FIRST HEALTH [10303]","First Health",,1745.22,80,,,,,0,253.71,1854.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL PEDIATRIC PROSOFT SMALL NONSTERILE LATEX FREE",SUP-PROSOFT-PED-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.06,33.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,76.2,68,,,,,0,13.03,95.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 113MM TYPE 1 TAPERLOC MICROPLASTY TITANIUM PPS",SUP-51107140,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"CIGNA [10200]","Cigna Local Plus",,8642.1,31.5,,5372.07,4581.20,7242.98,23,3190.72,23319.95,"percent of total billed charges",
"INSRT TIBIAL 3 25MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962347,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"AETNA [10100]","Aetna HMO/PPO",,11530.52,79.5,,10981.53,8986.79,12413.38,12,1686.79,12328.23,"percent of total billed charges",
"HC CT Orbit/Ear/Fossa W/WO Cntrst",PX-351000007,CDM,70482,CPT,0351,RC,,,both,,,4432.17,1329.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,742,,,,,,,405,3767.34,"per diem",
"SET CLAMP FOGARTY HYDRAGRIP HYDRAJAW TRACTIONJAW 61MM",SUP-HYDRA61,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.27,84.38,"CIGNA [10200]","Cigna Open Access",,160.04,56.9,,,,,0,32.71,239.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER PELLO 3MM STRAIGHT",SUP-6290-112-033,CDM,S27200284,LOCAL,0272,RC,,,both,,,1837.50,551.25,"AETNA [10100]","Aetna HMO/PPO",,1460.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 560CC",SUP-RSZ-SHPX-560S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM 25MM HIP STERILE LATEX FREE",SUP-16-104158,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"CIGNA [10200]","Cigna Local Plus",,3765.33,53.5,,5372.07,4581.20,7242.98,23,818.52,5982.3,"percent of total billed charges",
"SCR BONE 2.7MM 8MM STERNALOCK BLU STERNAL CANCELLOUS LOCK",SUP-73-2708,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"CIGNA [10200]",Cigna,,266.22,68,,1831.33,1831.33,1831.33,16,45.53,332.78,"percent of total billed charges",
"LEAD ICD 65CM PAMIRA S",SUP-428769,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 2-0 GS-21 12IN CLSR ABSORBABLE GREEN",SUP-VLOCL0315,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,133.17,68,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 3CM 6FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006180223050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"PHCS [10601]",PHCS,,729.11,70,,,,,0,121.14,885.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER 6250V-EHXL ATTAIN COMMAND",SUP-6250V-EHXL,CDM,C1887,HCPCS,0272,RC,,,both,,,2602.50,780.75,"AETNA [10100]","Aetna HMO/PPO",,2068.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,302.67,2212.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 1.5CM WIRE LARGE RADIUS LOOP",SUP-R2015,CDM,S27200284,LOCAL,0272,RC,,,both,,,771.20,231.36,"PHCS [10601]",PHCS,,539.84,70,,,,,0,89.69,655.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT RETRIEVER 20MM 4MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0033PK42022001,CDM,S27200284,LOCAL,0272,RC,,,both,,,20045.55,6013.66,"NOVANET [10819]",Novanet,,15034.16,75,,,,,0,2331.3,17038.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2 OS-8 18IN CONTROL RELEASE BRAID 3 STRAND",SUP-VCP719T,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]",Cigna,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC AIRMESH 15D UNIVERSAL SHOULDER BREATHABLE",SUP-00052,CDM,S27000186,LOCAL,0270,RC,,,both,,,321.03,96.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,218.3,68,,,,,0,37.34,272.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Orbit/Ear/Fossa W/WO Cntrst",PX-351000007,CDM,70482,CPT,0351,RC,,,both,,,4432.17,1329.65,"FIRST HEALTH [10303]","First Health",,3545.74,80,,,,,0,405,3767.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 110CM 7.5CM 6FR .054IN .038IN PIGTAIL 155",SUP-7509-33,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"KAISER [10500]",Kaiser,,54.85,67,,,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH SURESTEP FOLEY TRAY SYSTEM BARDEX I C TEMPERATURE",SUP-A301216A,CDM,S27200284,LOCAL,0272,RC,,,both,,,322.60,96.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.52,274.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR COBRA 1 CURVE ANGIOGRAPHIC BRAID",SUP-M001314621,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"NOVANET [10819]",Novanet,,87.44,75,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 60CM DUAL COIL TACHYARRHYTHMIA SILGLIDE",SUP-359065,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]",Cigna,,6868.8,40,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 10MM 35MM ASYMMETRIC TRIATHLON X3 KNEE",SUP-5551-G-350-E,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"CIGNA [10200]","Cigna Open Access",,3219.4,56.9,,5302.19,4377.88,6578.61,27,658.03,4809.3,"percent of total billed charges",
"HC Ather/De Stnt Addl Br Cor Arty",PX-481000082,CDM,C9603,HCPCS,0481,RC,,,both,,,25789.00,7736.7,"CIGNA [10200]",Cigna,,25681,,"Case rate ($25,681). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2999.26,25681,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 12MM 2.5MM CORONARY STENT COCR",SUP-1007823-12,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM TARGET NANO HELICAL DETACHABLE",SUP-M0035452020,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"BLUE CROSS [10001]","Blue Cross PPO",,3589.81,39.2,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 10MM SMALL SHELL DJO SURGICAL ALTIVATE",SUP-533-10-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"CIGNA [10200]","Cigna Open Access",,15910.64,33.5,,5302.19,4377.88,6578.61,27,5523.6,40370.27,"percent of total billed charges",
"SYSTEM REBEL 16MM 140CM 2.5MM CORONARY STENT PLATINUM",SUP-H7493927416250,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Open Access",,2133.75,56.9,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS TESTICULAR SALINE FILLED INFUSION LINE NDL XS STERILE",SUP-4501323,CDM,L8699,HCPCS,0278,RC,,,both,,,14973.00,4491.9,"CIGNA [10200]","Cigna Open Access",,5015.96,33.5,,,,,0,1741.36,12727.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD .99CM 5.37X8.08CM",SUP-G138,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"BLUE CROSS [10001]","Blue Cross PPO",,22626.24,39.2,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM CD HORIZON SPINAL FENESTRATE MULTIAXIAL",SUP-55840025540T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"IMPL BREAST 480-510ML STYLE 68MP SMOOTH ANTERIOR DIAPH VALVE",SUP-68-480,CDM,C1789,HCPCS,0278,RC,,,both,,,2250.00,675,"AMERIGROUP MEDICAID [20100]",Amerigroup,,266.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 7MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS07030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"FIRST HEALTH [10303]","First Health",,9378.48,80,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veno Svc W Si",PX-320000132,CDM,75827,CPT,0320,RC,,,both,,,3762.17,1128.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,437.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.44,3762.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 20MM 5FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206060270,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 6.5X105MM STERILE STARDRIVE RECESS CANNULATED SHO",SUP-04.353.701S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"CIGNA [10200]","Cigna Local Plus",,1315.78,53.5,,3978.14,359.25,3978.14,24,286.03,2090.49,"percent of total billed charges",
"SCR BONE 12.7MM 8.2MM 70MM 22MM DHS/DCS STAINLESS STEEL",SUP-280.7,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"BLUE CROSS [10001]","Blue Cross PPO",,712.8,39.2,,957.42,570.23,957.42,28,211.48,1545.62,"percent of total billed charges",
"CATH POWERFLEX P3 135CM 2CM 5FR 9MM 7.5MM BALLOON DILATATION",SUP-4209020X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD EMG NIM-RESPONSE 4 CHANNEL DUAL PAIRED PIN SUBDERMAL",SUP-8227411,CDM,S27200284,LOCAL,0272,RC,,,both,,,1466.10,439.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,173.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,170.51,1246.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM STARDRIVE STAINLESS STEEL T15 CORTEX",SUP-02.206.216,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,38.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,37.68,275.39,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 22CM 3CM 6FR .035IN",SUP-M006192131190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,948.76,68,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 15MM 48MM SHOULDER SOFT TISSUE BALANCE",SUP-7122883,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"AETNA [10100]","Aetna HMO/PPO",,7965.11,79.5,,10981.53,8986.79,12413.38,12,1165.21,8516.15,"percent of total billed charges",
"INSRT TIBIAL 3 17.5MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962344,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"KAISER [10500]",Kaiser,,9717.55,67,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 209MM 36MM 31-32MM ZENITH ALPHA FLEXOR",SUP-G35356,CDM,C1874,HCPCS,0278,RC,,,both,,,88350.00,26505,"BLUE CROSS [10001]","Blue Cross PPO",,34633.2,39.2,,,,,0,10275.11,75097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 48MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.548,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"CIGNA [10200]","Cigna Open Access",,623.86,56.9,,1144.80,304.56,2275.09,66,127.51,931.96,"percent of total billed charges",
"COIL EMBOLIZATION 4CM 1.5MM TARGET NANO HELICAL DETACHABLE",SUP-M0035431540,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"BLUE CROSS [10001]","Blue Cross HMO",,3589.81,39.2,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM AZUR CX HYDROCOIL DETACHABLE LOOP",SUP-45-780204,CDM,S27800098,LOCAL,0278,RC,,,both,,,5275.05,1582.51,"PHCS [10601]",PHCS,,3692.54,70,,,,,0,613.49,4483.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 4-0 SH 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Y315H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"CIGNA [10200]","Cigna Open Access",,15.36,56.9,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRODUCER 19MM LOTUS LARGE NITINOL BOVINE PERICARDIAL B",SUP-H749NTR200,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME TALAR INFINITY 3 ANKLE ADAPTIS FLAT CUT NONSTERILE",SUP-33680033,CDM,C1776,HCPCS,0278,RC,,,both,,,36981.00,11094.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4300.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4300.89,31433.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT SOCKET RSP DJO SURGICAL +4MM STD HUMERAL HXE+ STERILE",SUP-509-00-432,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"BLUE CROSS [10001]","Blue Cross PPO",,3538.87,39.2,,3949.44,3949.44,3949.44,"1 through 10",1049.92,7673.56,"percent of total billed charges",
"PLATE L 32MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 2X3",SUP-249.688,CDM,C1713,HCPCS,0278,RC,,,both,,,2305.80,691.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,273.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,268.16,1959.93,"percent of total billed charges",
PROTEKDUO-31FR,SUP-5820-3118,CDM,S27200284,LOCAL,0272,RC,,,both,,,105450.00,31635,"CIGNA [10200]","Cigna Local Plus",,56415.75,53.5,,,,,0,12263.84,89632.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL2712,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,428.87,28.62,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0258,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,112.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",110.22,805.55,"percent of total billed charges",
"KIT TUBING 37FR VIVASIGHT LUNG LEFT DOUBLE LUMEN VIDEO",SUP-412371000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1326,68,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER GUIDING ADULT 8FR L100CM CORONARY BLUE NYLON PTFE X",SUP-5888100,CDM,C1725,HCPCS,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ADMIN AMIA CASSETTE AUTOMATE PERITONEAL DIALYSIS SYSTEM",SUP-5C5479,CDM,S27200284,LOCAL,0272,RC,,,both,,,258.25,77.47,"MULTIPLAN [10600]",Multiplan,,219.51,85,,,,,0,30.03,219.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 250MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560250S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"FIRST HEALTH [10303]","First Health",,1620,80,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARR GRAFT 8X4IN 3:1 DERMACARRIER II SKIN MESHGRAFT II",SUP-219513,CDM,S27200284,LOCAL,0272,RC,,,both,,,216.96,65.09,"AETNA [10100]","Aetna HMO/PPO",,172.48,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.23,184.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR MIKELSON CURVE ANGIOGRAPHIC VISCERA",SUP-M001314761,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ot Eval Mod Complex 45 Min",PX-430000036,CDM,97166,CPT,0434,RC,,,both,,,494.68,148.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,57.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.53,426,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 36X28X19MM CHESAPEAKE 10D LORDOTIC",SUP-2013-21936L10,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"NOVANET [10819]",Novanet,,25706.7,75,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENSIONER SURGICAL CERCLAGE STERILE LATEX FREE DISPOSABLE",SUP-AR-7820,CDM,S27200284,LOCAL,0272,RC,,,both,,,2165.63,649.69,"FIRST HEALTH [10303]","First Health",,1732.5,80,,,,,0,251.86,1840.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANSURETHRAL PROCEDURES WITHOUT CC/MCC",670,MS-DRG,,,,,,,inpatient,,,37883.74,11365.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,19400.38,,"Fee schedule rate ($19,400.38). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,6062.26,28533.25,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 6MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120615,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"FIRST HEALTH [10303]","First Health",,9505.44,80,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 80CM 200MM 5MM BALLOON DILATATION","SUP-ADM 050 200 08P",CDM,C2623,HCPCS,0272,RC,,,both,,,12730.50,3819.15,"KAISER [10500]",Kaiser,,8529.44,67,,,,,0,1480.56,10820.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 16FR DELIVERY LOAD",SUP-L-ENVPRO-16-US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2925.00,877.5,"UHC [10700]","United Healthcare",,1851.53,63.3,,,,,0,340.18,2486.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RADIUM RA-223 DICHLOR INTRAVENOUS SOLN",RX-162677,CDM,A9606,HCPCS,0344,RC,08888-8877-03,NDC,both,1,UN,10.00,3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.16,10,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH 26FR ENDOSCOPIC FIX INNER TUBE CERAMIC INSULATION",SUP-27040XA,CDM,S27200284,LOCAL,0272,RC,,,both,,,10613.44,3184.03,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE NASOGASTRIC 55IN 8FR RADIOPAQUE STRIPE WEIGHT TIP RIGID",SUP-8884720855E,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.09,21.03,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT POLYESTER ETHIBOND 0 MO-6 18IN CONTROL RELEASE BRAID 8",SUP-CX45D,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.15,44.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 120MM 8MM BALLOON",SUP-U3575812,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE X-PEDION VASCULAR 200CM 10CM .01IN PLATINUM STAINLESS",SUP-103-0605-200,CDM,C1769,HCPCS,0272,RC,,,both,,,2235.00,670.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FORMULA RESECTOR CUTTER,(BLACK/TAN)5.5MM ARTHROSCOPIC SHAVER",SUP-0375562000,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.94,39.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Myotomy Lwr Esophgl Transoral",PX-750000220,CDM,43497,CPT,0750,RC,,,both,,,6450.00,1935,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6450,,"Case rate ($6,891). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,750.14,6450,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM 5MM 2.1-2.7FR CORONARY STENT",SUP-RONYX50030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5754.00,1726.2,"PHCS [10601]",PHCS,,4027.8,70,,,,,0,669.19,4890.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS METAL GWIRE INSRT TOOL TORQUE DEVICE",SUP-MAP102,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.76,40.43,"CIGNA [10200]",Cigna,,91.64,68,,,,,0,15.67,114.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
".035 INTERLOCK DIAMOND 4MM",SUP-M001363910,CDM,C1725,HCPCS,0272,RC,,,both,,,2827.50,848.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DXTERITY 100CM 6FR .056IN AMPLATZ LEFT 1 CURVE",SUP-DXT6AL10,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PK 5.5CM ANTERIOR SINUS NASAL RAPID RHINO ADULT",SUP-RR550,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM SUCTION SUCTIONPRO 72 L570 MM OD14 FR CLOSED 1 LUMEN",SUP-Z110N-14EA,CDM,S27200284,LOCAL,0272,RC,,,both,,,197.47,59.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH CHECK-FLO FLEXOR .018-.038IN ANL0 CURVE 45CM 5FR .074",SUP-G44153,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSOLE SHOE 12.5-14 XL MALE PEGASSIST DARCO PRESSURE REDUCE",SUP-262825,CDM,S27000186,LOCAL,0270,RC,,,both,,,134.85,40.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) AMENDTS SYSTEM TSP37T",SUP-90-7001-137,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT DISPOSABLES CS FIBERTAK",SUP-AR-8991DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,2165.63,649.69,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN SUCTION SHORT CURVE 3MM 5.75IN STAINLESS STEEL SINUS",SUP-63-7562,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.61,80.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SKIN ALLOPATH 12X8CM THIN MESH",SUP-WC2812,CDM,Q4433,HCPCS,0636,RC,,,both,,,34691.71,10407.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CLEANSER WND ANTISEP GEL ANASEPT 3OZ",SUP-5003G,CDM,S27200284,LOCAL,0272,RC,,,both,,,183.80,55.14,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE GASTRO 20FR SILICONE LOW PROFILE TAPER DISTAL TIP",SUP-0120-20-2.3,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PIN FIXATION 1/8IN HEADLESS SQUARE END 3.5IN STAINLESS STEEL",SUP-7650-2038,CDM,S27200284,LOCAL,0272,RC,,,both,,,2947.50,884.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 8FR 50CM 4CM ORANGE HUB STAINLESS STEEL GWIRE",SUP-PSS-8F-4-035MT,CDM,C1894,HCPCS,0272,RC,,,both,,,208.80,62.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRODE BIPOLAR VAPORIZATION 26 FR SQUARE FITTING",SUP-MVVS,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.00,675,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SAFARI2 EXTRA SPRT VASCULAR XS CURVE 275X2.9X3.2CM",SUP-H74939598ESXS0,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT ZILVER 635 80MM 40CM 8MM BILIARY SELF EXPAND",SUP-G36011,CDM,C1876,HCPCS,0278,RC,,,both,,,4653.98,1396.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,551.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,541.26,3955.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 17X8MM 14MM LORDOTIC NARROW PROFILE",SUP-G6626748,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5104.62,41.1,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 12MM TITANIUM MULTIPLE HOLE OPEN DOOR PRECUT INTRINSIC",SUP-853-012,CDM,C1713,HCPCS,0278,RC,,,both,,,2624.40,787.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,310.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",305.22,2230.74,"percent of total billed charges",
"VALVE AORTIC 19MM MASTER-SERIES PYROLYTIC CARBON PTFE",SUP-19AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"FIRST HEALTH [10303]","First Health",,23295.38,80,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"30FR X 3CM OPTILUME DCB, 24FR X 3CM BASIC BALLOON AND INFLAT",SUP-OPTBDL7010B,CDM,C1726,HCPCS,0272,RC,,,both,,,16525.50,4957.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6791.98,41.1,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEPARATOR SURGICAL 7IN HORSLEY DURA STAINLESS STEEL",SUP-285325,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.34,73,"CIGNA [10200]","Cigna Open Access",,138.46,56.9,,,,,0,28.3,206.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 4CM 3MM GALAXY G3 MINI STRETCH",SUP-GLM930040,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"KAISER [10500]",Kaiser,,7960.81,67,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION",RX-7301,CDM,,,0250,RC,00409-7299-83,NDC,both,20,ML,112.50,33.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE MERIT MAK VASCULAR 60CM .018IN NITINOL PLATINUM",SUP-MAK001N-60,CDM,C1894,HCPCS,0272,RC,,,both,,,286.67,86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRIEVER16 CURVE CATHETER, 16F, 110 CM ( ONE TIME INVENTORY I",SUP-25-201-ISO,CDM,C1757,HCPCS,0272,RC,,,both,,,50400.00,15120,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"TUBE 30FR SILICONE INTERNAL RETENTION BALLOON RECESS DISTAL",SUP-8100-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 255CC",SUP-SSZ-M255,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR .071IN MULTIPURPOSE 1 CURVE GUIDING",SUP-LA6MB1SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL ENDOSCOPIC 17.75IN 5MM 15GA ASPIR PUNCTURE",SUP-90-5051L,CDM,S27200284,LOCAL,0272,RC,,,both,,,524.07,157.22,"AETNA [10100]","Aetna HMO/PPO",,416.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.95,445.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL YELLOW .8MM OTO-FLEX CARBIDE MALLEABLE",SUP-3155638,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC IPERIA 7 PROMRI DF4 IMPLANTABLE",SUP-393009,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA [10200]",Cigna,,23088,40,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22-24X27-32X9MM LUMINARY CC 30D BICONVEX",SUP-6909,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"PHCS [10601]",PHCS,,23284.8,70,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 3-0 FSLX 30IN MONOFILAMENT BLACK NONABSORBABLE",SUP-1673H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX22MM VANGUARD 360 POLYETHYLENE KNEE",SUP-183872,CDM,C1713,HCPCS,0278,RC,,,both,,,14945.40,4483.62,"KAISER [10500]",Kaiser,,10013.42,67,,,,,0,1738.15,12703.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS SURGICAL L5 1/2IN TISSUE HEMOSTATIC STANDARD LINE SE",SUP-32-4031,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.81,14.64,"KAISER [10500]",Kaiser,,32.7,67,,,,,0,5.68,41.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 7MM 8FR ENDOPROSTHESIS HEPARIN",SUP-VBH071502,CDM,C1874,HCPCS,0278,RC,,,both,,,23102.10,6930.63,"MULTIPLAN [10600]",Multiplan,,19636.79,85,,,,,0,2686.77,19636.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 55IN 10FR SMOOTH BOLUS RADIOPAQUE STYLET",SUP-40-3551,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.05,25.51,"AETNA [10100]","Aetna HMO/PPO",,67.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.89,72.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MITRACLIP G4 SYSTEM ONE (1) STEERABLE GUIDE CATHETER SGC0701",SUP-CDS0706-XTW,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE SMR TITANIUM L30 MM OD6.5 MM SHOULDER MODULAR REP",SUP-8420.15.030,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"CIGNA [10200]",Cigna,,1057.88,68,,1831.33,1831.33,1831.33,16,180.93,1322.35,"percent of total billed charges",
"INTRO SHEATH 22FR 20CM 13CM DIL PEEL-AWAY LARGE PERCUTANEOUS",SUP-G04096,CDM,C1892,HCPCS,0272,RC,,,both,,,382.71,114.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,157.29,41.1,,,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SUBSTITUTE 15CC 1-4MM CANCELLOUS CHIPS PUREBONE",SUP-PBC-1415,CDM,S27800098,LOCAL,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM VALOR HINDFOOT FUSION SYSTEM",SUP-4151150040,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"MULTIPLAN [10600]",Multiplan,,1466.25,85,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEIGHT EYELID THK1MM LOWER PROFILE GOLD CONTOUR .6GM",SUP-LL3006,CDM,L8699,HCPCS,0278,RC,,,both,,,1837.50,551.25,"CIGNA [10200]","Cigna Local Plus",,983.06,53.5,,,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 32MM 4.5MM CORONARY STENT PLATINUM",SUP-H7493926032450,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3828.47,41.1,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF MARINR 80CM 4MM 5FR 2-5-2MM SPACING SINGLE CURVE",SUP-076515,CDM,C1733,HCPCS,0272,RC,,,both,,,3562.50,1068.75,"NOVANET [10819]",Novanet,,2671.88,75,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP MEDIUM LARGE 8MM INTERNAL LAPRO-CLIP TITANIUM LIGATE",SUP-8886848882,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.42,67.03,"PHCS [10601]",PHCS,,156.39,70,,,,,0,25.98,189.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 4CM 8MM BALLOON DILATATION PERIPHERAL",SUP-G50268,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC LARGE 8.5IN 7.5-8.5IN WRIST LEFT LOOP LOCK",SUP-79-87297,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.33,14.8,"FIRST HEALTH [10303]","First Health",,39.46,80,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 28MM 140CM 4.5MM CORONARY STENT PLATINUM",SUP-H7493927428450,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Local Plus",,2006.25,53.5,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAMIVUDINE 10 MG/ML ORAL SOLUTION (NICU)",RX-410143,CDM,,,0250,RC,08888-8887-44,NDC,both,5,ML,17.42,5.23,"CIGNA [10200]","Cigna Open Access",,9.91,56.9,,,,,0,2.03,14.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 12MM 4MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG40012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2812.50,843.75,"CIGNA [10200]","Cigna Local Plus",,1504.69,53.5,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 8MM 3.5MM CORONARY STENT COCR RAPID",SUP-1007849-08,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHERRY FLAVOR (BULK) ORAL SYRUP",RX-246031,CDM,,,0637,RC,31722-0938-47,NDC,both,473,ML,127.93,38.38,"MULTIPLAN [10600]",Multiplan,,108.74,85,,,,,0,14.88,108.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 60MM 80CM 12MM BILIARY NITINOL",SUP-SERB65-12-60-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 34MM 2.7MM LCP CORTICAL FOREFOOT MIDFOOT STAINLESS",SUP-202.894,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"NOVANET [10819]",Novanet,,242.99,75,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 22GA 15CM FRANSEEN LUER LOCK HUB CROWN POINT TIP",SUP-FRA2215,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.66,17.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 018 150CM 10CM 2.5MM BALLOON DILATATION",SUP-U81502H10,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TAP 110MM SURGICAL 4MM CANCELLOUS SCR 60MM NONSTERILE",SUP-311.34,CDM,S27000186,LOCAL,0270,RC,,,both,,,1550.02,465.01,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BIOPSY 11.6CM 11GA PARALLAX CORE-ASSURE BONE VERTEBRAL",SUP-KP-CA-1102-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,899.10,269.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) MOTIV SCAFFOLD 2.5MMX12MM","SUP-930025-12 (70)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ZIPWIRE VASCULAR 260CM 3CM .035IN NITINOL POLYMER",SUP-M00146316B1,CDM,C1769,HCPCS,0272,RC,,,both,,,339.13,101.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 5CMX12MMX8MM VIEWSITE INTRO WORK CHANNEL SURGICAL",SUP-TC120805,CDM,S27200284,LOCAL,0272,RC,,,both,,,4795.50,1438.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT POLARIS ZIPWIRE 28CM 150CM 7FR .038IN 3CM BLADDER LOOP",SUP-M006155254170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SPINAL 12MM 3.5MM CODA ANTERIOR CERVICAL SELF DRILL",SUP-102250012,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5CMX12MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-5-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"CIGNA [10200]",Cigna,,991.44,68,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES 144CM 40MM 2MM BALLOON DILATATION NYBAX",SUP-H74939134204010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,881.28,68,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINE MNTR ADULT 2 PURPOSE CIRCUIT ETCO2 INTERMEDIATE FILTER",SUP-989803129751,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.32,40.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.74,115.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (OTW)  4.00MM X 6MM",SUP-H74939402064000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,629.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 62.5MM TRIGEN FEMUR LOW PROFILE",SUP-71645062,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"FIRST HEALTH [10303]","First Health",,1655.64,80,,,,,0,240.69,1759.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM OBTRYX URETHRAL SPRT FEMALE MIDURETHRAL",SUP-M0068505000,CDM,C1771,HCPCS,0278,RC,,,both,,,13183.07,3954.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5273.23,40,,,,,0,1533.19,11205.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND 24SQ CM 2.4X1.6IN CLLGN SILICONE PORCINE TENDON",SUP-TG-M4060,CDM,A2008,HCPCS,0636,RC,,,both,,,14436.87,4331.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9383.97,65,,,,,0,247.92,12271.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET BED SHORT REPROBED",SUP-36871003-2,CDM,S27000186,LOCAL,0270,RC,,,both,,,345.91,103.77,"NOVANET [10819]",Novanet,,259.43,75,,,,,0,40.23,294.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 80MM 10-14MM 13FR 10FR TRIVASCULAR OVATION PRIME",SUP-TV-IL141080-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"BLUE CROSS [10001]","Blue Cross PPO",,13088.88,39.2,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 51MM TITANIUM LEVEL 3 ASSURE BONE SPINE CERVICAL",SUP-110.351,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"BLUE CROSS [10001]","Blue Cross HMO",,2074.46,39.2,,957.42,156.86,7483.26,51,615.46,4498.2,"percent of total billed charges",
"AUG FEMORAL 8MM ATTUNE 5 KNEE POSTERIOR CEMENT REVISION",SUP-1549-05-002,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"AETNA [10100]","Aetna HMO/PPO",,4827.24,79.5,,10981.53,8986.79,12413.38,12,706.17,5161.2,"percent of total billed charges",
"CANN ARTHROSCOPIC 8.5MM 60MM SPORTPORT",SUP-72205350,CDM,S27200284,LOCAL,0272,RC,,,both,,,383.67,115.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,44.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.62,326.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CXI 150CM 2.6FR SPRT STAINLESS STEEL POLYMER",SUP-G50003,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 38MM 6MM E9000 OTOLOGY ROUND DIAMOND FINE",SUP-E6160,CDM,S27200284,LOCAL,0272,RC,,,both,,,463.08,138.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LUTONIX 035 130CM4X100MM 1/EACH",SUP-LX351304100,CDM,C1725,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATHETERIZATION 8IN 20GA ARTERY BIOPATH LATEX FREE",SUP-NA-04550-X1A,CDM,S27200284,LOCAL,0272,RC,,,both,,,939.60,281.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOFT-VU 65CM 10CM 5FR ANGLE BERENSTEIN CURVE",SUP-H787107221045,CDM,C1887,HCPCS,0272,RC,,,both,,,209.32,62.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH AVIATOR PLUS 142CM 30MM 4MM .014IN BALLOON DILATATION",SUP-4244030W,CDM,C1725,HCPCS,0272,RC,,,both,,,1438.80,431.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT VASC STR KNIT HEMSHLD GLD MICROVEL 24MMX30CM DBL VEL",SUP-M002020952240,CDM,C1768,HCPCS,0278,RC,,,both,,,3553.58,1066.07,"NOVANET [10819]",Novanet,,2665.19,75,,,,,0,413.28,3020.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 4.5IN VOLKMAN 6 PRONG FENESTRATED HANDLE SHARP",SUP-22-2606,CDM,S27200284,LOCAL,0272,RC,,,both,,,453.28,135.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,52.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.72,385.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER DIALYZER DIACAP PRO 13H DEHP FREE STERILE LATEX FREE",SUP-720DH13,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.53,52.06,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CARVEDILOL 12.5 MG TABLET, IMMEDIATE RELEASE",RX-15749,CDM,,,0637,RC,00904-7307-61,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 26.5CM 8FR NEPHRSTMY PERCUFLEX LOCK LOOP STERILE LATEX",SUP-M0064101110,CDM,C1729,HCPCS,0272,RC,,,both,,,616.49,184.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AMINO ACID 4.25 % NO.1 IN DEXTROSE 5 % INTRAVENOUS SOLUTION",RX-27927,CDM,J3490,HCPCS,0258,RC,00338-1133-03,NDC,both,1000,ML,231.38,69.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,27.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.91,196.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 27MM REVERE TITANIUM SPINE MONOAXIAL",SUP-124131,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING EXTERNAL FIXATION 150MM HALF TITANIUM DISTRACTION",SUP-03.311.315,CDM,C1713,HCPCS,0278,RC,,,both,,,3182.85,954.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,377.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",370.17,2705.42,"percent of total billed charges",
"CANN BONE CEMENT 15CM 18GA NDL ACCESS CHIBA",SUP-K12-08326,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.10,33.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.15,96.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TALON ORTHOPEDIC 900MM 3MM ROUND TIP",SUP-SLN-T34,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X9MM LUMINARY 10/11MM SPINE DEMINERALIZED",SUP-14709,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CIGNA [10200]","Cigna Open Access",,10552.5,33.5,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG BLACK 18X12.5CM GRANUFOAM SILVER SENSATRAC VAC",SUP-M8275096/10,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS DS REDEL 115CM 8MM 7FR 1-6-2MM SPACE B CURVE",SUP-D7TCB8L162RT,CDM,C1733,HCPCS,0272,RC,,,both,,,7810.80,2343.24,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC",315,MS-DRG,,,,,,,inpatient,,,28495.90,8548.77,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUTNER 22CM 30CM 12FR 14FR SUPRAPUBIC STAINLESS STEEL",SUP-G15261,CDM,C2627,HCPCS,0272,RC,,,both,,,516.05,154.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET CELL SAVER VACUUM LINE AUTOTRANSFUSION TUBING NONSTERILE",SUP-HAR-A-1000,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.79,29.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CELSIUS DS REDEL 115CM 8MM 7FR 1-6-2MM SPACE B CURVE",SUP-D7TCB8L162RT,CDM,C1733,HCPCS,0272,RC,,,both,,,7810.80,2343.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5311.34,68,,,,,0,908.4,6639.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX EXTREME 80CM 2CM 5FR 7MM 7MM BALLOON",SUP-4157020S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 8MM GORE-TEX THIN WALLED REMOVABLE RINGS",SUP-SRRT08040050L,CDM,C1768,HCPCS,0278,RC,,,both,,,7831.50,2349.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,928.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,910.8,6656.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 13CM MIDAS REX MR8 3MM MATCH HEAD DISSECTING ND STERILE",SUP-MR8-ND13MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,326.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYOSURE XL 25.25IN 4MM TISSUE REMOVAL 17OZ HANDHELD",SUP-50-501XL,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2835.9,41.1,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 105MM 13.3MM 8MM CUFF PROXIMAL EXT EXTEND LENGTH",SUP-80XLTCP,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"NOVANET [10819]",Novanet,,363.95,75,,,,,0,56.44,412.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BONE DISEASES AND ARTHROPATHIES WITH MCC",553,MS-DRG,,,,,,,inpatient,,,47774.24,14332.27,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,8603.89,,"Case rate ($8,041.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,466.64, add-ons for qualifying new technology services are included. If operating cost exceeds $40,506.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,946.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $7,476.51. The transfer operating threshold is the transfer adjustment factor * $7,466.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.51. The transfer capital threshold is the transfer adjustment factor * $564.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,32328.43,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 28MM STAINLESS STEEL FULL THREAD ORTHOPEDIC",SUP-214.728,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"PHCS [10601]",PHCS,,786.54,70,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55840017550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"SPACER ALLOGRAFT 12X14X6MM LORDOTIC SPINE CERVICAL CORTICAL",SUP-17006,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 10 8MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151621008,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"UHC [10700]","United Healthcare",,7123.72,63.3,,8601.07,8395.67,8601.07,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL LOOP 26FR CUT ACMI CLASSIC",SUP-M0068802541,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"FIRST HEALTH [10303]","First Health",,382.58,80,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR EXTERNAL FIXATION 50MM 3MM 2.5-3MM XCALIBER FOOT CORTEX",SUP-M310,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"CIGNA [10200]","Cigna Open Access",,437.85,56.9,,1144.80,304.56,2275.09,66,89.49,654.08,"percent of total billed charges",
"GRAFT SOFT TISSUE 2X1.5CM GRAFIX PRIME ALLOGRAFT",SUP-PS13015,CDM,Q4133,HCPCS,0636,RC,,,both,,,5464.80,1639.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2445.5,44.75,,,,,0,373.04,4645.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 CT-1 36IN BRAID COATED UNDYED ABSORBABLE",SUP-VCP946H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.28,41.1,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER CAPIO TAPERCUT 0 36IN 2 ARM MONOFILAMENT",SUP-M0068331141,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 40MM MATRIX TITANIUM T25 SPINE PEDICLE",SUP-04.639.640,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,1521.93,481.35,16760.95,30,441.36,3225.75,"percent of total billed charges",
"SYR 6MM 31GA 3/10ML INSULIN HYPODERMIC PERMANENT ATTACH NDL",SUP-328449,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.30,0.09,"KAISER [10500]",Kaiser,,0.2,67,,,,,0,0.03,0.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ATTAIN HYBRID VASCULAR STRAIGHT 108CM .018IN STABILITY",SUP-GWR419688,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transferrin",PX-301000419,CDM,84466,CPT,0301,RC,,,both,,,293.80,88.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.65,,,,,,,0.29,249.73,"fee schedule",
"STENT POLARIS 30CM 7FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552450,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"MULTIPLAN [10600]",Multiplan,,1020.49,85,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 35MM 6MM XIA 3 TITANIUM RADIOLUCENT",SUP-48238035,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL BLUE 28X36X7.9-12MM SYNFIX 10D MEDIUM PEEK",SUP-08.815.212S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL INTRO 14.9CM 17GA SUPERCORE COAXIAL ECHOGENIC",SUP-MCXS1820LX,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.64,44.89,"CIGNA [10200]","Cigna Local Plus",,80.06,53.5,,,,,0,17.4,127.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CELL SAVER VACUUM LINE AUTOTRANSFUSION TUBING NONSTERILE",SUP-HAR-A-1000,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.79,29.94,"MULTIPLAN [10600]",Multiplan,,84.82,85,,,,,0,11.61,84.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAFIRE TX COMFORTGRIP 110CM 8MM 7FR 2-5-2MM SPACING 1MM",SUP-402843,CDM,C1733,HCPCS,0272,RC,,,both,,,6555.00,1966.5,"PHCS [10601]",PHCS,,4588.5,70,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 157CM 2.4-2FR .017IN TREVO XP",SUP-90231,CDM,S27200284,LOCAL,0272,RC,,,both,,,7221.82,2166.55,"PHCS [10601]",PHCS,,5055.27,70,,,,,0,839.9,6138.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL BLUE 28X36X7.9-12MM SYNFIX 10D MEDIUM PEEK",SUP-08.815.212S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 40 SMALL KEEL AEQUALIS PERFORM SHOULDER",SUP-DWE503,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2666.24,28.62,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GALLANT DR ICD DF1 CONNECTOR",SUP-CDDRA500T,CDM,C1721,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6777.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 61CM TRANSSEPTAL AGILIS NXT ACQCROSS",SUP-900300,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PDS II 3-0 FS-1 27IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Z442H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MELOXICAM 7.5 MG TABLET",RX-20566,CDM,,,0637,RC,50268-0525-11,NDC,both,1,UN,15.58,4.67,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Rpr Sclp/Ax/Tr/Ext >30.0cm Int",PX-450000036,CDM,12037,CPT,0450,RC,,,both,,,4523.00,1356.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1862,,,,,,,67.13,4523,"case rate",
"HC Rpr Sclp/Ax/Tr/Ext >30.0cm Int",PX-450000036,CDM,12037,CPT,0450,RC,,,both,,,4523.00,1356.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,725,,,,,,,67.13,4523,"case rate",
"GRAFT AMNIOTIC 6.0 X 3.0 CM",SUP-NX-10-6030,CDM,Q4148,HCPCS,0636,RC,,,both,,,18144.00,5443.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"DEVICE STRATAFIX PDO 2-0 CT-1 SPIRAL 30CM SUT ABSORBABLE",SUP-SXPD1B401,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.13,55.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 185X70MM D OSCILLATING",SUP-KM33-114,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.65,24.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FIAGON FLEXTUBE 4MM","SUP-FFT-E 01 2106",CDM,S27000186,LOCAL,0270,RC,,,both,,,1629.00,488.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL INSUFFLATION 120MM 14GA ENDOPATH ULTRA VERESS STPCOCK",SUP-PN120,CDM,S27200284,LOCAL,0272,RC,,,both,,,264.41,79.32,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEAD RADIAL 10MM 24MM EXPLOR ELBOW MODULAR",SUP-11-210041,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3837.78,27,,,,,0,1653.09,12081.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 60MM 112CM 6MM 75CM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200066070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.838,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,27.52,201.14,"percent of total billed charges",
"INSRT TIBIAL 2.5 17.5MM KNEE XLK POSTERIOR LIPPED FIX",SUP-158102117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AETNA [10100]","Aetna HMO/PPO",,8883.77,79.5,,10981.53,8986.79,12413.38,12,1299.6,9498.37,"percent of total billed charges",
"SPACER SPINAL 14X11X8MM VERTE-STACK HYDROSORB PEEK ANATOMIC",SUP-6240841,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4541.33,68,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP LIMIT HOLE POROUS",SUP-11-106054,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4785.84,68,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABIL 8CM 200CM 10MM ENDOPROSTHESIS BILIARY",SUP-VSWVH1008,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,9776.84,9776.84,9776.84,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"WASHER 5.5MM CONTOUR ORTHOPEDIC",SUP-CSS50055A,CDM,C1713,HCPCS,0278,RC,,,both,,,858.60,257.58,"MULTIPLAN [10600]",Multiplan,,729.81,85,,,,,0,99.86,729.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 27CM 8MM AVENIR 18 COIL COMPLEX FRAME",SUP-18CFR-08027,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1520.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFE-T-J VASCULAR 3MM RADIUS J CURVE TAPER 145CM 6CM",SUP-G00488,CDM,C1769,HCPCS,0272,RC,,,both,,,147.81,44.34,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.19,125.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ROADRUNNER UNIGLIDE VASCULAR ANGLE TAPER 260CM 14CM",SUP-G30492,CDM,C1769,HCPCS,0272,RC,,,both,,,327.10,98.13,"MULTIPLAN [10600]",Multiplan,,278.04,85,,,,,0,38.04,278.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 30MM CEMENTLESS ACCOLADE TMZF 1 HIP",SUP-6021-0130,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"CIGNA [10200]","Cigna Local Plus",,7188.85,31.5,,5372.07,4581.20,7242.98,23,2654.17,19398.49,"percent of total billed charges",
"SCR BONE 4MM 32MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.432TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"BLUE CROSS [10001]","Blue Cross PPO",,792.45,39.2,,957.42,570.23,957.42,28,235.11,1718.32,"percent of total billed charges",
"SCREW SET EXPEDIUM VERSE SPINE UNITIZE 5.5 MM ROD",SUP-199721001S,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAROTID ARTERY STENT PROCEDURES WITH MCC",034,MS-DRG,,,,,,,inpatient,,,166453.99,49936.2,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,24730.5,,"Case rate ($24,010.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $22,295.09, add-ons for qualifying new technology services are included. If operating cost exceeds $55,334.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,067.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $22,324.57. The transfer operating threshold is the transfer adjustment factor * $22,295.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,685.62. The transfer capital threshold is the transfer adjustment factor * $1,685.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,113008.96,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO S1 LOW PROFILE QUICK CONNECT GLIDESCOPE",SUP-0270-1151,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.26,129.98,"NOVANET [10819]",Novanet,,324.95,75,,,,,0,50.39,368.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.0/40",SUP-404675,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Admin Chemo Artery Push",PX-331000005,CDM,96420,CPT,0331,RC,,,both,,,872.00,261.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,392,,"Per diem ($392).",,,,0,101.41,872,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prep Wnd Tr/Ext 100scm",PX-510000046,CDM,15002,CPT,0761,RC,,,both,,,1759.00,527.7,"MULTIPLAN [10600]",Multiplan,,1495.15,85,,,,,0,204.57,1759,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cdisloc Hip Arthro WO Anes",PX-450000142,CDM,27265,CPT,0450,RC,,,both,,,1064.00,319.2,"NOVANET [10819]",Novanet,,798,75,,,,,0,1.06,1064,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Wrist 2v",PX-320000070,CDM,73100,CPT,0320,RC,,,both,,,469.00,140.7,"KAISER [10500]",Kaiser,,314.23,67,,,,,0,40.79,398.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ko Sweedish Type",PX-E27400076,CDM,L1850,HCPCS,0274,RC,,,both,,,921.80,276.54,"BLUE CROSS [10001]","Blue Cross HMO",,361.35,39.2,,,,,0,107.21,783.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inf Disease Bact Vaginosis Rna",PX-309000142,CDM,81513,CPT,0310,RC,,,both,,,475.75,142.72,"CIGNA [10200]","Cigna Local Plus",,313.79,,,,,,,0.48,404.39,"fee schedule",
"HC Bronch W Trach/Bronch Dil",PX-750000012,CDM,31630,CPT,0750,RC,,,both,,,4511.04,1353.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2262,,"Case rate ($2,262). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,524.63,4511.04,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch W Dest Tumor Laser/Cryo",PX-750000018,CDM,31641,CPT,0750,RC,,,both,,,6667.30,2000.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4752,,"Case rate ($4,752). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,775.41,6667.3,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 10CM 7FR 10MM .035IN BALLOON",SUP-G52376,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"KAISER [10500]",Kaiser,,643.05,67,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON 100CM 5FR SIM1 CURVE",SUP-G08471,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL IRRIGATION UROMATIC 3% SORBITOL PLASTIC CNTNR 3000ML",SUP-2B7357,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.61,63.18,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC",578,MS-DRG,,,,,,,inpatient,,,197441.45,59232.43,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH THERMOCOOL SF 7.5FR D CURVE ABLATION UNIDIRECTIONAL",SUP-D131502,CDM,C1732,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"DAC 044 130CM",SUP-90761,CDM,S27200284,LOCAL,0272,RC,,,both,,,9626.67,2888,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MONOCRYL 2-0 CT-2 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Y333H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 80CM 20MM 4.8FR 9MM LOW PROFILE BALLOON",SUP-39032-90208,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NAIL 11.5MM 150MM RIGHT VALOR INTRAMEDULLARY SMALL SILVER",SUP-415101115R,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SYSTEM SPIDERFX 320CM 190CM 3.2-4.2FR 3MM EMBOLIC PROTECTION",SUP-SPD2-US-030-320,CDM,C1884,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]",Cigna,,4926.6,68,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM MANTIS SPINE PEDICLE POLYAXIAL",SUP-48285640,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,3978.14,359.25,3978.14,24,641.98,4692,"percent of total billed charges",
"ASSEMB LINER 40/41MM 26MM MULTIPOLAR HIP UHMWPE STERILE",SUP-500104026,CDM,C1776,HCPCS,0278,RC,,,both,,,2365.50,709.65,"BLUE CROSS [10001]","Blue Cross HMO",,927.28,39.2,,5311.50,4717.44,5388.59,31,275.11,2010.68,"percent of total billed charges",
"HC Nrv Condct 9-10 Studies",PX-922000023,CDM,95911,CPT,0922,RC,,,both,,,6810.24,2043.07,"CIGNA [10200]",Cigna,,4630.96,68,,,,,0,792.03,5788.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 10MM PORTEX BLUSELECT UNCUFF STERILE LATEX FREE",SUP-101/816/100,CDM,S27200284,LOCAL,0272,RC,,,both,,,311.63,93.49,"KAISER [10500]",Kaiser,,208.79,67,,,,,0,36.24,264.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FLAT CHUCK SKYLINE 12MM",SUP-286820012,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,468.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL HEMI REVERSE INSTR TRABECULAR METAL",SUP-98000973001,CDM,C1776,HCPCS,0278,RC,,,both,,,23625.00,7087.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9450,40,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 29MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-224.661,CDM,C1713,HCPCS,0278,RC,,,both,,,4352.80,1305.84,"BLUE CROSS [10001]","Blue Cross PPO",,1706.3,39.2,,957.42,570.23,957.42,28,506.23,3699.88,"percent of total billed charges",
"PLATE 14MM 16X16X2.5MM TITANIUM 1 LEVEL PREBENT SKYLINE BONE",SUP-186801016,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"FIRST HEALTH [10303]","First Health",,3360,80,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 20MM RETRACTA DETACHABLE .035IN",SUP-G34195,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"KAISER [10500]",Kaiser,,2843.15,67,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 20MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158104120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross PPO",,4380.42,39.2,,3949.44,3949.44,3949.44,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"DIL VASCULAR 5FR 20CM RADIOPAQUE GWIRE STERILE DISPOSABLE",SUP-G00972,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22.64,45.9,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP PRIMARY STEM 10MM STD",SUP-113650,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UHC [10700]","United Healthcare",,7975.8,63.3,,8601.07,8395.67,8601.07,"1 through 10",1465.38,10710,"percent of total billed charges",
"ROD SPINAL 110MM 5.5MM REVOLVE",SUP-185.310,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]",Cigna,,2998.8,68,,1831.33,1831.33,1831.33,16,512.88,3748.5,"percent of total billed charges",
"SCR BONE 5MM 36MM AEQUALIS TITANIUM HUMERAL PROXIMAL",SUP-7425036,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"NOVANET [10819]",Novanet,,935.55,75,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR NARROW LORDOTIC 12 DEGRE",SUP-12313,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS [10001]","Blue Cross PPO",,7408.8,39.2,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION 155CM 2.4FR MICRO BERN INFUSION NITINOL PTFE",SUP-M001195250,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"MULTIPLAN [10600]",Multiplan,,3187.5,85,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X23X12MM SOVEREIGN 8D",SUP-7968812,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"PHCS [10601]",PHCS,,23992.92,70,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X18X11MM TRANSCONTINENTAL 10D LORDOTIC",SUP-375.793,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6463.8,27,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 170MM FEMUR PROXIMAL TFN-ADVANCED INTRAMEDULLARY",SUP-04.037.242S,CDM,C1713,HCPCS,0278,RC,,,both,,,8273.93,2482.18,"FIRST HEALTH [10303]","First Health",,6619.14,80,,,,,0,962.26,7032.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREPHINE OPHTHALMIC TRABECULAR STERILE LATEX DISPOSABLE",SUP-AX1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR HA POROUS HIP STEM CUP LINER BIPOLAR",SUP-98000100106,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Local Plus",,5537.25,53.5,,5372.07,4581.20,7242.98,23,1203.71,8797.5,"percent of total billed charges",
"IMPL BREAST 300ML GEL ROUND SMOOTH MEMORYGEL SILICONE P3.1CM","SUP-3507300 MC",CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"CIGNA [10200]","Cigna Local Plus",,1909.95,,,,,,,415.19,3034.5,"percent of total billed charges",
"SHEATH FLEXOR RAABE 70CM 5FR 1.9MM GUIDING AQ CHECK-FLO",SUP-G13091,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"KAISER [10500]",Kaiser,,298.49,67,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS MULTIPASS 3-0 PS-1 18IN MONOFILAMENT",SUP-PDP683G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.48,45.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM 11/13 TAPER 40MM HIP M SPECIFICATION METAL",SUP-136541500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"BLUE CROSS [10001]","Blue Cross HMO",,4342.56,39.2,,5311.50,4717.44,5388.59,31,1288.37,9416.26,"percent of total billed charges",
"HC U1 Rnp/Snrnp Igg Ab",PX-302000048,CDM,86235,CPT,0302,RC,,,both,,,272.65,81.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,63.66,,,,,,,0.27,231.75,"fee schedule",
"SPACER ALLOGRAFT 23-27MMX17MM FRA 8D NARROW WEDGE SPINE",SUP-17,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]",Cigna,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 93MM AEQUALIS ASCEND FLEX PTC 132.5D 2B LONG",SUP-DWF612B,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS [10001]","Blue Cross HMO",,4939.2,39.2,,5311.50,4717.44,5388.59,31,1465.38,10710,"percent of total billed charges",
"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC",656,MS-DRG,,,,,,,inpatient,,,133265.07,39979.52,"BLUE CROSS [10001]","Blue Cross PPO",,78598.63,,,,,,,7561,92954.22,"case rate",
"PLATE BONE SHUNT .5MM 18.5MM LORENZ CRANIOMAXILLOFACIAL",SUP-017305,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.70,405.81,"CIGNA [10200]",Cigna,,919.84,68,,1831.33,1831.33,1831.33,16,157.32,1149.8,"percent of total billed charges",
"STENT SUPERA 40MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA [10200]","Cigna Local Plus",,4983.53,53.5,,,,,0,1083.33,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 29MM AEQUALIS PERFORM 15D SHOULDER WEDGE AUG",SUP-DWJ515,CDM,C1776,HCPCS,0278,RC,,,both,,,11340.00,3402,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3245.51,28.62,,,,,0,1318.84,9639,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805310,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]",Cigna,,613.48,68,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL PERCUFLEX PLUS HYDROPLUS",SUP-M006175255090,CDM,C2617,HCPCS,0278,RC,,,both,,,1294.14,388.24,"CIGNA [10200]",Cigna,,880.02,68,,,,,0,150.51,1100.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 3-0 FS-1 27IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Z442H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DEBAKEY ANGLE 11.75IN VASCULAR TISSUE 2MM",SUP-55-2017,CDM,S27200284,LOCAL,0272,RC,,,both,,,623.54,187.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,424.01,68,,,,,0,72.52,530.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 35MM 140CM 4MM CORONARY STERILE LATEX",SUP-453972,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION SLR PTCA DEB 3.5X15MM",SUP-SCA14U-350015D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 90MM REGULAR LINEAR CUTTER RELOADABLE DIAL",SUP-TL90,CDM,S27200284,LOCAL,0272,RC,,,both,,,2160.20,648.06,"FIRST HEALTH [10303]","First Health",,1728.16,80,,,,,0,251.23,1836.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEQ FRACTURE (INCLUSIVE OF STD FX STEM, HUMERAL HEAD AND CEMEN",SUP-CAP1003,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9062.55,41.1,,6417.48,6417.48,6417.48,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"STEM FEMORAL 119MM 10MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771101000,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8359.85,40,,,,,0,2430.63,17764.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trypsin",PX-301000259,CDM,83519,CPT,0301,RC,,,both,,,419.00,125.7,"CIGNA [10200]","Cigna Local Plus",,40.48,,,,,,,0.01,356.15,"fee schedule",
"OTITIS MEDIA AND URI WITHOUT MCC",153,MS-DRG,,,,,,,inpatient,,,22981.45,6894.43,"PHCS [10601]",PHCS,,7561,,,,,,,4579.09,18409.97,"per diem","Estimated amount calculated based on 3 day length of stay."
"HC IV Inf Ther Add Seq 1st Hr",PX-260000005,CDM,96367,CPT,0260,RC,,,both,,,423.28,126.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,49.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,49.23,423.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EPIDURAL EPILONG SOFT CATH",SUP-0431157-51,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.70,80.91,"MULTIPLAN [10600]",Multiplan,,229.25,85,,,,,0,31.37,229.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPN NC 10MM 6FR 1.5MM BALLOON DILATATION TWIN WALL",SUP-150-010-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"FIRST HEALTH [10303]","First Health",,6624,80,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION",RX-6451,CDM,,,0250,RC,65219-0054-09,NDC,both,15,ML,434.54,130.36,"NOVANET [10819]",Novanet,,325.91,75,,,,,0,50.54,369.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC AUTOMATIC HANDLE PAD 35CM 5MM DIRECT DRIVE",SUP-C4130,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +23 DIOPTER BICONVEX 13MM 6MM POSTERIOR CHAMBER",SUP-ZA90030230,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CIGNA [10200]","Cigna Open Access",,668.29,56.9,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEDGET SMALL MITRAL 2-0 CARDOPXYL",SUP-73P30CR,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.11,29.73,"NOVANET [10819]",Novanet,,74.33,75,,,,,0,11.53,84.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9.7CM 5MM CEREPAK MICRO UNIFORM DETACHABLE",SUP-FCX100509,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"NOVANET [10819]",Novanet,,9919.39,75,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 86MM PRESS FIT AEQUALIS ASCEND FLEX PTC 132.5D",SUP-DWF606B,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]",Cigna,,5040,40,,5873.17,5873.17,5873.17,"1 through 10",1465.38,10710,"percent of total billed charges",
"SCR BONE 3.5MM 6MM 18MM LCP TITANIUM FULL THREAD PROXIMAL",SUP-404.818,CDM,C1713,HCPCS,0278,RC,,,both,,,258.83,77.65,"KAISER [10500]",Kaiser,,173.42,67,,,,,0,30.1,220.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 26MMX3.8MMX4CM 20FR",SUP-TE2638A,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"PHCS [10601]",PHCS,,43890,70,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 60MM 130CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-EX060603CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"KAISER [10500]",Kaiser,,7859.1,67,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 24IN 29- IN KNEE CONTACT CLSR 3",SUP-79-80030,CDM,S27000186,LOCAL,0270,RC,,,both,,,130.85,39.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,53.78,41.1,,,,,0,15.22,111.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 5.5MM TSRH-2D CONTOUR PEDICLE TITANIUM",SUP-8370055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"CATH SABER 150CM 200MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030200M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"AETNA [10100]","Aetna HMO/PPO",,1490.63,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 12MM OLIF51 DIVERGENCE-L BONE SPINE",SUP-2150012,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1226.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"SCR BONE 3.5MM 80MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.128,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,101.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",99.7,728.71,"percent of total billed charges",
"PROBE SURGICAL IO-FLEX MICROBLADE SHAVER SPINE TIGHT DISTAL",SUP-IO-IP-TR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1599.75,479.92,"CIGNA [10200]","Cigna Open Access",,910.26,56.9,,,,,0,186.05,1359.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X11X14MM VERTEX PEEK-OPTIMA ANATOMIC",SUP-6240441,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3065.39,45.9,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SPINAL 16MM 3.5MM ANTERIOR CERVICAL SELF DRILL VARIABLE",SUP-102250016,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AMPLATZER TORQVUE 80CM 12FR 45D EXCHANGE SYSTEM POLYMER",SUP-9-EITV12F45/80,CDM,C1773,HCPCS,0272,RC,,,both,,,4912.80,1473.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3340.7,68,,,,,0,571.36,4175.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BENTSON 24CM 15CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175252060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"BLUE CROSS [10001]","Blue Cross HMO",,390.99,39.2,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL +0MM 3.5MM HIGH OFFSET SHOULDER REVERSE",SUP-DWF520,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"UHC [10700]","United Healthcare",,6380.64,63.3,,8601.07,8395.67,8601.07,"1 through 10",1172.3,8568,"percent of total billed charges",
"SYSTEM G7 THR E1 POROUS STEM CUP 2 MOBILITY AA LINER STD",SUP-98B00102504,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"PHCS [10601]",PHCS,,19404,70,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 16MM KNEE X3 CONDYLAR STABILIZE TRIATHLON",SUP-5531-G-216-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1399.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX 25X20CM OPEN POSITION SYSTEM STERILE",SUP-1222025,CDM,C1781,HCPCS,0278,RC,,,both,,,62700.00,18810,"MULTIPLAN [10600]",Multiplan,,53295,85,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 7FR AMPLATZ RIGHT 2",SUP-77811200,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL STEALTH 11MM 11MM VASCULAR SOFT WHITE",SUP-G-1100,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,71.88,45.9,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CYPHER 13MM 137CM 3.5MM CORONARY SIROLIMUS ELUTING",SUP-CXS13350,CDM,C1874,HCPCS,0278,RC,,,both,,,13110.00,3933,"PHCS [10601]",PHCS,,9177,70,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE GASTROSTOMY 14FR L1.5CM EXTENSION SET MIC-KEY ENFIT",SUP-8140-14-1.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,92.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADMIRAL XTREME 130CM 40MM 9MM BALLOON DILATATION",SUP-ADM090040130,CDM,C1725,HCPCS,0272,RC,,,both,,,1134.00,340.2,"MULTIPLAN [10600]",Multiplan,,963.9,85,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16025550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"SCR BONE 6.5MM 50MM CD HORIZON SPINAL FENESTRATE MULTIAXIAL",SUP-55840026550T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"CAGE SPINAL 14X11X5MM PTC PEEK TANTALUM TITANIUM CERVICAL",SUP-5030541,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS [10001]","Blue Cross PPO",,2617.94,39.2,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA MEDIAL CONGRUENT 6-7 E-F KNEE",SUP-42522100710,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UHC [10700]","United Healthcare",,6821.47,63.3,,8601.07,8395.67,8601.07,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"SCR BONE 5.5MM 45MM SOLERA CD HORIZON OSTEOGRIP TITANIUM",SUP-54840005545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 50MM STAINLESS STEEL T8 METAPHYSEAL SELF TAP",SUP-02.118.550,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,356.26,68,,,,,0,60.93,445.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTUNE RP CEMENTED",SUP-CAP-DS-K-2A,CDM,C1776,HCPCS,0278,RC,,,both,,,20790.00,6237,"BLUE CROSS [10001]","Blue Cross HMO",,8149.68,39.2,,5311.50,4717.44,5388.59,31,2417.88,17671.5,"percent of total billed charges",
"SMOOTH PEG LOCKING 3.5MM X 40MM TI",SUP-SPL-35400-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175252080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"FIRST HEALTH [10303]","First Health",,991.5,80,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X2CM GRAFIX CORE",SUP-PS12023,CDM,Q4132,HCPCS,0636,RC,,,both,,,6865.50,2059.65,"MULTIPLAN [10600]",Multiplan,,5835.68,85,,,,,0,286.88,5835.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11.4CM NATRELLE BIOCELL P3.7CM MODERATE PLUS",SUP-MSZ15265,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA [10200]","Cigna Local Plus",,84.63,53.5,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR SR4 CURVE GUIDING CORONARY",SUP-LA6SR40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 150MM 3.5MM BALLOON DILATATION PEBAX",SUP-H74939148351510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
HEMASORB,SUP-OS-401,CDM,S27200284,LOCAL,0272,RC,,,both,,,749.25,224.77,"CIGNA [10200]","Cigna Open Access",,426.32,56.9,,,,,0,87.14,636.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 14X26X55MM 10",SUP-6214155,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID H+3MM 36MM INSET 0MM STD SHOULDER REVERSE",SUP-2R1GLC0336,CDM,C1776,HCPCS,0278,RC,,,both,,,12816.75,3845.02,"CIGNA [10200]","Cigna Local Plus",,4037.28,31.5,,5372.07,4581.20,7242.98,23,1490.59,10894.24,"percent of total billed charges",
"STENT INLAY OPTIMA 26CM 7FR URETERAL PHREECOAT POLYMER",SUP-788726,CDM,C2617,HCPCS,0278,RC,,,both,,,834.30,250.29,"BLUE CROSS [10001]","Blue Cross HMO",,327.05,39.2,,,,,0,97.03,709.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 48MM TI",SUP-MTC-37480-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"CIGNA [10200]","Cigna Local Plus",,667.36,53.5,,3978.14,359.25,3978.14,24,145.07,1060.29,"percent of total billed charges",
"CATH SAPPHIRE NC PLUS 8MM 2.25MM BALLOON DILATATION STERILE",SUP-222-083-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Afo Ant Tib Tcf Prefab",PX-E27400059,CDM,L1932,HCPCS,0274,RC,,,both,,,1202.30,360.69,"KAISER [10500]",Kaiser,,805.54,67,,,,,0,139.83,1021.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Demo/Eval Pat Use Inhale",PX-410000012,CDM,94664,CPT,0410,RC,,,both,,,351.20,105.36,"FIRST HEALTH [10303]","First Health",,280.96,80,,,,,0,40.84,351.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Demo/Eval Pat Use Inhale",PX-410000012,CDM,94664,CPT,0410,RC,,,both,,,351.20,105.36,"AETNA [10100]","Aetna HMO/PPO",,279.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.84,351.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vasc Embol Occl Venous",PX-361000320,CDM,37241,CPT,0361,RC,,,both,,,13861.00,4158.3,"BLUE CROSS [10001]","Blue Cross PPO",,9549.81,,"Case rate ($9,549.81). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1612.03,11781.85,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vasc Embol Occl Venous",PX-361000320,CDM,37241,CPT,0361,RC,,,both,,,13861.00,4158.3,"UHC [10700]","United Healthcare",,10242,,"Case rate ($10,242). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1612.03,11781.85,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vasc Embol Occl Venous",PX-361000320,CDM,37241,CPT,0361,RC,,,both,,,13861.00,4158.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1642.53,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1612.03,11781.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLITTER SURGICAL FACIAL UNIVERSITY BLADE DISPOSABLE",SUP-8801279,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 150CM 80MM 2.5MM BALLOON DILATATION",SUP-48002508X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 4X40 80CM SL",SUP-48004004N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT FIBERWIRE 2 T-8 38IN 2 ARM BRAID MULTISTRAND LOWER KNOT",SUP-AR-7206,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"CIGNA [10200]","Cigna Open Access",,114.35,56.9,,,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH 12IN 7MM TNLR POLYMER VASCULAR RADIOPAQUE SMOOTH",SUP-9009-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,557.28,167.18,"CIGNA [10200]","Cigna Local Plus",,298.14,53.5,,,,,0,64.81,473.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE ADPTR V40 TITANIUM ALUMINA CERAMIC",SUP-17-0000E,CDM,C1776,HCPCS,0278,RC,,,both,,,1152.59,345.78,"MULTIPLAN [10600]",Multiplan,,979.7,85,,,,,0,134.05,979.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 85MM 5.5MM CREO LATERAL HEAD LEFT NONSTERILE",SUP-1175.5527,CDM,C1713,HCPCS,0278,RC,,,both,,,12061.20,3618.36,"BLUE CROSS [10001]","Blue Cross PPO",,4727.99,39.2,,957.42,570.23,957.42,28,1402.72,10252.02,"percent of total billed charges",
"CMPNT FEMORAL 7 STD KNEE RIGHT CRUCIATE RETAINING PERSONA",SUP-42502806202,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"BLUE CROSS [10001]","Blue Cross HMO",,11327.07,39.2,,5311.50,4717.44,5388.59,31,3360.56,24561.24,"percent of total billed charges",
"STENT URETERAL 4.8FR L24CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902120,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION",RX-32700,CDM,J0585,HCPCS,0636,RC,00023-1145-01,NDC,both,1,UN,3929.44,1178.83,"BLUE CROSS [10001]","Blue Cross HMO",,757.58,,,,,,,654.82,3340.02,"fee schedule",
"STENT ZILVER 635 40MM 80CM 14MM 6FR .035IN BILIARY NITINOL",SUP-G36234,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,439.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28MMX10MM X-PAC LORDOTIC",SUP-EI2502L,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AETNA [10100]","Aetna HMO/PPO",,22538.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pyruvate",PX-301000387,CDM,84210,CPT,0301,RC,,,both,,,452.20,135.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.5,,"Fee schedule rate ($15.50). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,384.37,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pyruvate",PX-301000387,CDM,84210,CPT,0301,RC,,,both,,,452.20,135.66,"CIGNA [10200]",Cigna,,31.86,,,,,,,0.01,384.37,"fee schedule",
"GRAFT VASCULAR 30CM 26MM GELWEAVE VASCUTEK STRAIGHT THORACIC",SUP-733026,CDM,C1768,HCPCS,0278,RC,,,both,,,6831.00,2049.3,"CIGNA [10200]",Cigna,,4645.08,68,,,,,0,794.45,5806.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SLEEVE 6MM 5.5MM CD HORIZON SOLERA VOYAGER NONSTERILE",SUP-6550016,CDM,S27000186,LOCAL,0270,RC,,,both,,,1788.75,536.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,208.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,208.03,1520.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM AVENIR 10 HELICAL FINISH STERILE",SUP-10HFN-04008,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4747.48,45.9,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 22FR STD URETHRAL NATURAL RUBBER",SUP-0167L22,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.13,23.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.09,66.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE RAPTOR 200CM 1.9MM SPECIMEN RETRIEVAL HYBRID JAW",SUP-00711178,CDM,S27200284,LOCAL,0272,RC,,,both,,,972.00,291.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,399.49,41.1,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8840-14,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT MICRORAPTOR KNOTLESS RIGID REGENESORB",SUP-72205020,CDM,C1713,HCPCS,0278,RC,,,both,,,3570.75,1071.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,423.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",415.28,3035.14,"percent of total billed charges",
"KIT CATH 20GA 10CM POWERGLIDE PRO REINFORCE TIP BASIC",SUP-F120100T,CDM,C1751,HCPCS,0272,RC,,,both,,,558.98,167.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.01,475.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 1.5MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES0156CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR CEMENTLESS STD Z1 TITANIUM ALLOY 3",SUP-611201030,CDM,C1776,HCPCS,0278,RC,,,both,,,28967.40,8690.22,"MULTIPLAN [10600]",Multiplan,,24622.29,85,,,,,0,3368.91,24622.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH 1 90CM 7FR .081IN STRAIGHT TIP CURVE GUIDING PTFE",SUP-M001197480,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"MULTIPLAN [10600]",Multiplan,,507.56,85,,,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 25MM .0145IN AXIUM PRIME 3D FRAME",SUP-FC-25-50-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"CIGNA [10200]","Cigna Local Plus",,5205.53,31.5,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLITTER KIT  5019  M-4 HV 15-L CE MK",SUP-5019,CDM,S27200284,LOCAL,0272,RC,,,both,,,27090.00,8127,"CIGNA [10200]",Cigna,,18421.2,68,,,,,0,3150.57,23026.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 8 KNEE PRIMARY BEAD PA",SUP-5526-B-800,CDM,C1776,HCPCS,0278,RC,,,both,,,15783.75,4735.12,"MULTIPLAN [10600]",Multiplan,,13416.19,85,,,,,0,1835.65,13416.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYPROPYLENE MONOFILAMENT BLUE NONABSORBABLE",SUP-85550H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"NOVANET [10819]",Novanet,,18.75,75,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST LARGE WEDGE FREEZE DRIED",SUP-40A001,CDM,S27800098,LOCAL,0278,RC,,,both,,,3977.85,1193.35,"NOVANET [10819]",Novanet,,2983.39,75,,,,,0,462.62,3381.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Exc Lesn Mal Trunk/Arm >4.0 Cm",PX-361000542,CDM,11606,CPT,0361,RC,,,both,,,4903.00,1470.9,"CIGNA [10200]",Cigna,,3287,,"Case rate ($3,287). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,570.22,4903,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 2.9 MM SHORT PUSHLOCK DISPOSABLE KIT",SUP-AR-2923DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"CIGNA [10200]",Cigna,,1012.1,68,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PYROCARBON HEMI SHOULDER",SUP-CAP1109,CDM,C1776,HCPCS,0278,RC,,,both,,,50400.00,15120,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,20160,40,,,,,0,5861.52,42840,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYOSURE 1.8MM 54MM 140ML/MIN 300 MMHG 14MM 32CM 3MM",SUP-10-401,CDM,S27200284,LOCAL,0272,RC,,,both,,,5692.50,1707.75,"CIGNA [10200]","Cigna Local Plus",,3045.49,53.5,,,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ACCLARENT 2 BALLOON INFLATION TYVEK 30ML HIGH",SUP-SM-ID-S3040H-TB,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM .02IN 6MM PENUMBRA COIL 400 RUBY",SUP-RBY4C0620,CDM,S27800098,LOCAL,0278,RC,,,both,,,6258.00,1877.4,"AETNA [10100]","Aetna HMO/PPO",,4975.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,727.81,5319.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 15MM CRANIOFACIAL TITANIUM 5 HOLE Y LOW PROFILE",SUP-421.515,CDM,C1713,HCPCS,0278,RC,,,both,,,1792.50,537.75,"MULTIPLAN [10600]",Multiplan,,1523.63,85,,,,,0,208.47,1523.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD 20FR URETHRAL NATURAL RUBBER SILICONE ELASTOMER 5",SUP-265720,CDM,S27200284,LOCAL,0272,RC,,,both,,,1.84,0.55,"UHC [10700]","United Healthcare",,1.16,63.3,,,,,0,0.21,1.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP SMALL ALLOGRAFT COMPRESSIBLE SPONGE",SUP-13810809,CDM,C1713,HCPCS,0278,RC,,,both,,,7197.47,2159.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,852.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,837.07,6117.85,"percent of total billed charges",
"INSRT TIBIAL 1.5 12.5MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158120112,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"FIRST HEALTH [10303]","First Health",,8939.64,80,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION SLR PTCA DEB 2.5X20MM",SUP-SCA14U-250020D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CM 7MM CLLGN",SUP-AG750,CDM,C1768,HCPCS,0278,RC,,,both,,,26327.70,7898.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7108.48,27,,,,,0,3061.91,22378.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 51X22MM CROSSLOCK LOW PROFILE DVR BONE RADIUS",SUP-131821050,CDM,C1713,HCPCS,0278,RC,,,both,,,9263.25,2778.97,"BLUE CROSS [10001]","Blue Cross PPO",,3631.19,39.2,,957.42,570.23,957.42,28,1077.32,7873.76,"percent of total billed charges",
"STENT GORE VIABAHN 19MM 80CM 7MM 11MM 7FR .035IN",SUP-BXA071901A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL CARDIOBLATE BP2 STERILE DISPOSABLE",SUP-60831,CDM,S27200284,LOCAL,0272,RC,,,both,,,17250.00,5175,"NOVANET [10819]",Novanet,,12937.5,75,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 4-0 PC-3 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J845G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORTHOLOC 3DI FOOT RECONSTRUCTION SYSTEM HALLUX PLATES - MTP",SUP-587220LT,CDM,C1713,HCPCS,0278,RC,,,both,,,12420.00,3726,"CIGNA [10200]",Cigna,,4968,40,,1831.33,1831.33,1831.33,16,1444.45,10557,"percent of total billed charges",
"BLADE SAW 3.937X.984IN STRYKER PERFORMANCE SERIES THK.05IN",SUP-6125-127-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION SORBITOL MANNITOL FLEXIBLE CNTNR 3L LATEX",SUP-07981-08,CDM,S27200284,LOCAL,0272,RC,,,both,,,112.93,33.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.13,95.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 7.6MM 1.27MM MODIFY T PC SILICONE 6MM",SUP-510-111C,CDM,S27800098,LOCAL,0278,RC,,,both,,,282.38,84.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,192.02,68,,,,,0,32.84,240.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX14MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183624,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"MULTIPLAN [10600]",Multiplan,,11210.36,85,,,,,0,1533.84,11210.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 4MM .5MM SMART STAPES PISTON FLUOROPLASTIC",SUP-7014-5921,CDM,L8613,HCPCS,0278,RC,,,both,,,1822.13,546.64,"CIGNA [10200]","Cigna Open Access",,1036.79,56.9,,,,,0,211.91,1548.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 55MM EVOLVE STAINLESS STEEL CANCELLOUS ELBOW",SUP-4983555N,CDM,C1713,HCPCS,0278,RC,,,both,,,785.70,235.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,91.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",91.38,667.85,"percent of total billed charges",
"GRAFT BONE ALLOQUENT PARALLEL ALLOGRAFT 8MM TLIF",SUP-3W3308,CDM,S27800098,LOCAL,0278,RC,,,both,,,17139.60,5141.88,"KAISER [10500]",Kaiser,,11483.53,67,,,,,0,1993.34,14568.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet Not Otherwise Specified",PX-404000011,CDM,G0235,HCPCS,0404,RC,,,both,,,9966.87,2990.06,"CIGNA [10200]",Cigna,,3647,,"Per diem ($3,647). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,982.43,8808,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ABLATION NEUWAVE 2 RESECTION CLIP",SUP-RCPK,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,39.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.46,288.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5-6MM 45MM CREO SPINE 2 OUTER DIAMETER",SUP-5119.2747,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Buprenorphine",PX-301000550,CDM,80348,CPT,0301,RC,,,both,,,129.00,38.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,87.72,68,,,,,0,0.01,129,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION BARDEX LUBRICATH 18FR 350ML URINE METER",SUP-304918,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.92,54.58,"NOVANET [10819]",Novanet,,136.44,75,,,,,0,21.16,154.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL COCHLEAR 4MM BAHA TITANIUM ABUTMENT B1300",SUP-92129,CDM,L8690,HCPCS,0278,RC,,,both,,,9625.50,2887.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2754.82,28.62,,,,,0,1119.45,8181.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 28MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.828,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",40.86,298.61,"percent of total billed charges",
"(EVAL) PACKAGED ACCESSORIES",SUP-ES0542,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10-5MM TORNADO PLATINUM .018IN CATH",SUP-G47518,CDM,S27800098,LOCAL,0278,RC,,,both,,,931.42,279.43,"BLUE CROSS [10001]","Blue Cross PPO",,365.12,39.2,,,,,0,108.32,791.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 100MM 12MM BALLOON",SUP-U35751210,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP 20D MEDIUM HEART 8IN TITANIUM LIGATE",SUP-237081,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"AETNA [10100]","Aetna HMO/PPO",,1341.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE RIGHT TOTAL STABILIZE TRIATHLON COCR",SUP-5512-F-802,CDM,C1776,HCPCS,0278,RC,,,both,,,32652.90,9795.87,"UHC [10700]","United Healthcare",,20669.29,63.3,,8601.07,8395.67,8601.07,"1 through 10",3797.53,27754.97,"percent of total billed charges",
"LENS IOL +21 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.210,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 20MM 140CM 2.5MM CORONARY STENT PLATINUM",SUP-H7493927420250,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"FIRST HEALTH [10303]","First Health",,3000,80,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8-6.5MM 45MM CREO SPINE 2 OUTER DIAMETER",SUP-5119.2247,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,601.85,4398.75,"percent of total billed charges",
"ELECTRD DEFIB RESUSCITATION COMPLETE AMBULATORY CARE ONESTEP",SUP-8900-0214-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,575.59,172.68,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRICLIP NT CLIP DELIVERY SYS CLIN",SUP-TCDS0203-NT,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT DECOMPRESSION 8.5FR MARCON PIGTAIL CURVE",SUP-G21709,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACK 24IN THERAPEUTIC MOIST HEAT THERMAL COLOR CODED TABS",SUP-561727,CDM,S27000186,LOCAL,0270,RC,,,both,,,239.16,71.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GD CS WORLEY","SUP-361 683",CDM,C1892,HCPCS,0272,RC,,,both,,,2325.00,697.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 6.5MM 20MM TRIDENT SECUR-FIT TITANIUM CANCELLOUS",SUP-2030-6520-1,CDM,C1713,HCPCS,0278,RC,,,both,,,571.90,171.57,"CIGNA [10200]",Cigna,,388.89,68,,1831.33,1831.33,1831.33,16,66.51,486.12,"percent of total billed charges",
"PLATE 42MM STAINLESS STEEL 2.4MM SCR 6 HEAD 2 SHAFT HOLES 2",SUP-02.111.521,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,1466.08,39.2,,957.42,570.23,957.42,28,434.96,3179,"percent of total billed charges",
"STEM FEMORAL 170MM 16MM COLLAR CEMENTLESS LOW PROFILE NECK",SUP-3L92506,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4532.58,28.62,,,,,0,1841.86,13461.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH BLUE 10FT CARTO 3 HYPERTONICS 34 PIN TO LEMO 10",SUP-CB3410CT,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OXCARBAZEPINE 300 MG TABLET",RX-21061,CDM,,,0637,RC,60687-0722-11,NDC,both,1,UN,13.86,4.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MARINR 110CM 4MM 7FR 2-5-2MM SPACE MULTICURVE ABLATION",SUP-ARV120,CDM,S27200284,LOCAL,0272,RC,,,both,,,216.11,64.83,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH XXL 75CM 40MM 5.8FR 16MM .035IN BALLOON DILATATION",SUP-M001145520,CDM,C1725,HCPCS,0272,RC,,,both,,,1709.63,512.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE 108MM RADIUS CURVE 104X10.2X2.7MM STAINLESS STEEL 3.5",SUP-245.878,CDM,C1713,HCPCS,0278,RC,,,both,,,4488.04,1346.41,"CIGNA [10200]",Cigna,,3051.87,68,,1831.33,1831.33,1831.33,16,521.96,3814.83,"percent of total billed charges",
"CATH ARMADA 14 150CM 200MM 4MM TAPER BALLOON DILATATION JET",SUP-A2040-200,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 40MM TITANIUM 1.5MM SCREW 4X8 HOLE T BONE HAND NONSTER",SUP-446.234,CDM,C1713,HCPCS,0278,RC,,,both,,,2736.30,820.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1860.68,68,,,,,0,318.23,2325.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XACT 30MM 10MM STRAIGHT VASCULAR NITINOL CAROTID",SUP-82098-01,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1109.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 28MM 140CM 4.5MM CORONARY STENT PLATINUM",SUP-H7493927428450,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"FIRST HEALTH [10303]","First Health",,3000,80,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 85X25X1.19MM WIDE THICK STAINLESS STEEL SAGITTAL",SUP-2108151000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,130.27,68,,,,,0,22.28,162.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAC-LOC 40CM 12FR DRNG ULTRATHANE HYDROPHILIC BILIARY",SUP-G09499,CDM,C1729,HCPCS,0272,RC,,,both,,,801.82,240.55,"AETNA [10100]","Aetna HMO/PPO",,637.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,93.25,681.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 16MM LCP STAINLESS STEEL T25 PROXIMAL MEDIAL",SUP-212.202,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"MULTIPLAN [10600]",Multiplan,,742.2,85,,,,,0,101.55,742.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT EVEROLIMUS ELUTING CORONARY STENT SYSTEM 4.5",SUP-1804450-28,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 F 36MM E1 HIP HIGH WALL",SUP-010000936,CDM,C1776,HCPCS,0278,RC,,,both,,,12282.00,3684.6,"CIGNA [10200]",Cigna,,4912.8,40,,5873.17,5873.17,5873.17,"1 through 10",1428.4,10439.7,"percent of total billed charges",
"GRAFT STENT 200MM 36MM VALIANT STRAIGHT ENDOVASCULAR",SUP-VAMF3636C200TU,CDM,C1874,HCPCS,0278,RC,,,both,,,102229.50,30668.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11889.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11889.29,86895.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERSACROSS SHEATH 63CM 45DEG D1",SUP-VXS0202,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 34MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.434TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"MULTIPLAN [10600]",Multiplan,,1718.32,85,,,,,0,235.11,1718.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 6-9 G-H KNEE LEFT VIVACIT-E",SUP-42512400910,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]",Cigna,,7327.97,68,,5873.17,5873.17,5873.17,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"CMPNT FEMORAL 3 KNEE RIGHT MEDIAL LEFT LATERAL RESTORIS",SUP-180513,CDM,C1776,HCPCS,0278,RC,,,both,,,12440.70,3732.21,"FIRST HEALTH [10303]","First Health",,9952.56,80,,,,,0,1446.85,10574.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fetal Fibronectin",PX-301000190,CDM,82731,CPT,0301,RC,,,both,,,729.60,218.88,"MULTIPLAN [10600]",Multiplan,,620.16,85,,,,,0,0.73,620.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CELL SAVER VACUUM LINE AUTOTRANSFUSION TUBING NONSTERILE",SUP-HAR-A-1000,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.79,29.94,"CIGNA [10200]","Cigna Local Plus",,53.39,53.5,,,,,0,11.61,84.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 4 1/8IN 8.5FR 7-7.5FR ARROWG+ARD BLUE ARROW-FLEX",SUP-AK-29803-CDC,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TRANSITION HA SPINE PEDICLE POLYAXIAL",SUP-152.764S,CDM,C1713,HCPCS,0278,RC,,,both,,,10791.60,3237.48,"UHC [10700]","United Healthcare",,6831.08,63.3,,5023.51,2672.93,6679.78,18,1255.06,9172.86,"percent of total billed charges",
"EXP TISSUE BREAST 375CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP120RH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"MULTIPLAN [10600]",Multiplan,,10117.13,85,,,,,0,1384.26,10117.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 8MM 2.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP2508X,CDM,C1725,HCPCS,0272,RC,,,both,,,534.60,160.38,"MULTIPLAN [10600]",Multiplan,,454.41,85,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM STAINLESS STEEL T8 METAPHYSEAL SELF TAP",SUP-02.118.512,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"KAISER [10500]",Kaiser,,351.02,67,,,,,0,60.93,445.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERTORQUE PLUS 110CM 6FR .079IN .051IN 155D PIGTAIL",SUP-533654S,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER ANGIOPLASTY L150CM BALLOON L120MM DIA5MM COMPATIBLE",SUP-1013468-120,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BALLOON DILATATION BROAD TAPER 4FR 4MM 150CM 80MM",SUP-AMP040080152,CDM,C1725,HCPCS,0272,RC,,,both,,,2422.50,726.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT NASAL C-FLEX DOYLE BIVALVE SET",SUP-1524075,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.95,74.38,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 21.5X12.7X.3MM LARGE SAGITTAL STERILE",SUP-1200-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,146.16,43.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCHIZOPHRENIA AND OTHER SEVERE PSYCHOTIC DISORDERS,MAJOR",750,APR-DRG,,,,,,,inpatient,,,51780.25,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $6,607.26. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($34,004.28) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"FEEDER INFANT HABERMAN MINI-SPECIALNEEDS SILICONE BISPHENOL",SUP-6100093S,CDM,S27200284,LOCAL,0272,RC,,,both,,,97.12,29.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,44.58,45.9,,,,,0,11.3,82.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOPURINOL 100 MG TABLET",RX-310,CDM,,,0637,RC,60687-0677-11,NDC,both,1,UN,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER BEIGE 3.5MM DYONICS ELITE STRAIGHT FULL RADIUS",SUP-7210751,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 9X 59MM CATH 120CM ENDOVASCULAR",SUP-42959,CDM,C1874,HCPCS,0278,RC,,,both,,,18881.10,5664.33,"BLUE CROSS [10001]","Blue Cross PPO",,7401.39,39.2,,,,,0,2195.87,16048.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE SOFTTOUCH SMOOTH",SUP-SSF-265,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]",Cigna,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4+ 10MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS4P10L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"CIGNA [10200]","Cigna Local Plus",,5559.4,53.5,,5372.07,4581.20,7242.98,23,1208.52,8832.69,"percent of total billed charges",
"HC US Quan Tis Charac WO Dx US",PX-402000065,CDM,0689T,CPT,0402,RC,,,both,,,147.00,44.1,"CIGNA [10200]",Cigna,,99.96,68,,,,,0,17.1,147,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 40CM 16FR .038IN DRNG ULTRATHANE HYDROPHILIC BILIARY 32",SUP-G09205,CDM,C1729,HCPCS,0272,RC,,,both,,,963.82,289.15,"NOVANET [10819]",Novanet,,722.87,75,,,,,0,112.09,819.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INFUSION SYNCHROMED REFILL STERILE LATEX FREE",SUP-8551,CDM,A4220,HCPCS,0272,RC,,,both,,,278.40,83.52,"KAISER [10500]",Kaiser,,186.53,67,,,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOBILIZER KNEE WRAP EZ",SUP-01259B22OP,CDM,L1830,HCPCS,0274,RC,,,both,,,232.81,69.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,158.31,68,,,,,0,27.08,197.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prolact+4 10ml Qtr Btl",PX-E27000206,CDM,E27000206,LOCAL,0270,RC,,,both,,,89.10,26.73,"KAISER [10500]",Kaiser,,59.7,67,,,,,0,10.36,75.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC if Herpes Smpx Antigen",PX-306000206,CDM,87290,CPT,0306,RC,,,both,,,251.00,75.3,"MULTIPLAN [10600]",Multiplan,,213.35,85,,,,,0,0.25,213.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 650ML GEL SMOOTH MEMORYGEL SILICONE P5.7CM HIGH","SUP-3506504 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1735.02,45.9,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NUCLEUS-X 110CM 4CM 25MM BALLOON DILATATION POLYAMIDE",SUP-612029,CDM,C1725,HCPCS,0272,RC,,,both,,,6566.52,1969.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2698.84,41.1,,,,,0,763.69,5581.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.3MM 10MM STAINLESS STEEL T4 CORTEX SELF TAP SELF",SUP-02.130.010,CDM,C1713,HCPCS,0278,RC,,,both,,,345.91,103.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,235.22,68,,,,,0,40.23,294.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM 11/13 TAPER 28MM HIP BIOLOX DELTA CERAMIC",SUP-136528220,CDM,C1776,HCPCS,0278,RC,,,both,,,12385.50,3715.65,"FIRST HEALTH [10303]","First Health",,9908.4,80,,,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR PREPARATION OF TC 99M-SODIUM THIOSULFATE SOLUTION",RX-123715,CDM,A9541,HCPCS,0343,RC,08888-8878-22,NDC,both,1,UN,738.32,221.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,87.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,85.87,738.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Emg Thoracic Paraspinal",PX-922000030,CDM,95869,CPT,0922,RC,,,both,,,531.99,159.6,"CIGNA [10200]",Cigna,,361.75,68,,,,,0,61.87,452.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 89.5X25X.89MM MEDIUM LONG WIDE SAGITTAL 2 CUT",SUP-2108102000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"CIGNA [10200]","Cigna Local Plus",,102.5,53.5,,,,,0,22.28,162.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 8-9 C-D KNEE",SUP-42512100512,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Local Plus",,5765.38,53.5,,5372.07,4581.20,7242.98,23,1253.3,9159.96,"percent of total billed charges",
"HC Xe133 Dx per 10mci",PX-343000022,CDM,A9558,HCPCS,0343,RC,,,both,,,755.00,226.5,"KAISER [10500]",Kaiser,,505.85,67,,,,,0,87.81,641.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM 22.5MM MASTERS HP MECHANICAL ROTATABLE STD",SUP-25MHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3386.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Trach Uncuffed",PX-E27200237,CDM,E27200237,LOCAL,0272,RC,,,both,,,373.07,111.92,"KAISER [10500]",Kaiser,,249.96,67,,,,,0,43.39,317.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 16MM LCP STAINLESS STEEL CORTICAL T6 STARDRIVE",SUP-201.366.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"BLUE CROSS [10001]","Blue Cross HMO",,162.34,39.2,,957.42,156.86,7483.26,51,48.16,352,"percent of total billed charges",
"STENT ZILVER 518 60MM 125CM 5MM 5FR .018IN BILIARY NITINOL",SUP-G31354,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,495.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X100 40CM SL",SUP-48003010P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"KAISER [10500]",Kaiser,,658.03,67,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 27FR CUT STORZ 1 STEM",SUP-M0068802041,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,219.5,45.9,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.75 X 18 RX US",SUP-1804275-18,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM SOLERA COCR TITANIUM SPINE MULTIAXIAL",SUP-54840007550,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"MULTIPLAN [10600]",Multiplan,,8114.82,85,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 30-32MM TITANIUM 4.75MM SCR MULTISPAN XLNK BONE SPINAL",SUP-5442130,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross HMO",,1893.36,39.2,,957.42,156.86,7483.26,51,561.73,4105.5,"percent of total billed charges",
"SCR BONE 2MM 3.5MM 6MM DCP STAINLESS STEEL CORTEX HAND FOOT",SUP-201.806,CDM,C1713,HCPCS,0278,RC,,,both,,,358.09,107.43,"MULTIPLAN [10600]",Multiplan,,304.38,85,,,,,0,41.65,304.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Blood Typing Abo",PX-302000192,CDM,86900,CPT,0302,RC,,,both,,,184.60,55.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10.61,,,,,,,2.02,156.91,"fee schedule",
"BIT DRILL 130MM 4.2MM T2 AO COUPLING CENTER TIPPED",SUP-18064280S,CDM,S27000186,LOCAL,0270,RC,,,both,,,147.00,44.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,99.96,68,,,,,0,17.1,124.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veni >=3 Yr W Phys",PX-300000008,CDM,36410,CPT,0300,RC,,,both,,,210.00,63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,105,50,,,,,0,24.89,178.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE WIGGLE VASCULAR STRAIGHT RIBBON 190CM 30CM",SUP-22299M-W30,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT/GRAFT ENDOPROSTHESIS 7CM 14.5MM EXCLUDER ILIAC EXT AAA",SUP-PXL161407,CDM,C1874,HCPCS,0278,RC,,,both,,,19530.00,5859,"PHCS [10601]",PHCS,,13671,70,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN OMEGA3 MARIGEN 4SQ CM MICRO FISH SKIN STERILE",SUP-50200P00B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1698.26,44.75,,,,,0,180.89,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 48MM 32MM MARATHON",SUP-121932448,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"MULTIPLAN [10600]",Multiplan,,6894.31,85,,,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 61MM STEALTH FOGARTY ATRAUMAX 3 SOFT STERILE",SUP-G-6150,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"FIRST HEALTH [10303]","First Health",,180.96,80,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 39X15MM HEDRON IA 8D 29MM STERILE LATEX FREE",SUP-1212.1115S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"MULTIPLAN [10600]",Multiplan,,29452.5,85,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET HELICAL ULTRA 2MM X 1CM",SUP-M0035432010,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"BLUE CROSS [10001]","Blue Cross HMO",,3589.81,39.2,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISPOSABLE HANDPIECE 3-PACK",SUP-MIN3PAK,CDM,S27200284,LOCAL,0272,RC,,,both,,,6210.00,1863,"KAISER [10500]",Kaiser,,4160.7,67,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR AL2 CURVE ANGIOGRAPHIC TRILON PERIPHERAL",SUP-H74908641981,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"CIGNA [10200]",Cigna,,48.22,68,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON IQ UVA",SUP-CC60WF,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,345.41,28.62,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM 4.5MM 2.1-2.7FR CORONARY",SUP-RONYX45022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5754.00,1726.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2641.09,45.9,,,,,0,669.19,4890.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION CONCERTO 3D V01",SUP-PV-10-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE PRIME 33MM 143CM 3.5MM CORONARY STENT",SUP-1011734-33,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"UHC [10700]","United Healthcare",,6071.1,63.3,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Eps Icd Generator W Test",PX-481000060,CDM,93641,CPT,0481,RC,,,both,,,3043.83,913.15,"KAISER [10500]",Kaiser,,2039.37,67,,,,,0,354,3043.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PUBOURETHRAL BLUE MESH CLEAR DESARA 1000UM TAPER",SUP-CAL-DS01B,CDM,C1771,HCPCS,0278,RC,,,both,,,6030.60,1809.18,"CIGNA [10200]","Cigna Open Access",,3431.41,56.9,,,,,0,701.36,5126.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 100CM 5FR SIM2 CURVE ANGIOGRAPHIC SLX CEREBRAL",SUP-451531H0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"CIGNA [10200]","Cigna Open Access",,59.4,56.9,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 8MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBJ081002,CDM,C1874,HCPCS,0278,RC,,,both,,,21218.40,6365.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8720.76,41.1,,,,,0,2467.7,18035.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 25MM LCP STAINLESS STEEL PROXIMAL FEMORAL",SUP-02.205.025,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"NOVANET [10819]",Novanet,,947.46,75,,,,,0,146.92,1073.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Nontunl Cvc >=5yr",PX-361000110,CDM,36556,CPT,0361,RC,,,both,,,7972.91,2391.87,"FIRST HEALTH [10303]","First Health",,6378.33,80,,,,,0,927.25,7883,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TYSHAK II 100CM 5CM 9FR 23MM BALLOON DILATATION",SUP-611941,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"AETNA [10100]","Aetna HMO/PPO",,3021.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,442.08,3231.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 30FR RIGHT VENT DLP STERILE LATEX FREE",SUP-67530,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.59,90.48,"CIGNA [10200]","Cigna Open Access",,171.6,56.9,,,,,0,35.07,256.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 7FR 3MM 240CM BRISTLE STERILE DISPOSABLE RED",SUP-G22108,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"AETNA [10100]","Aetna HMO/PPO",,145.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC CROME 2 CHMBR DF-1 PIN PLUG IS4 INLINE CNCT",SUP-DTPC2Q1,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"AETNA [10100]","Aetna HMO/PPO",,61175.25,79.5,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175262180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"MULTIPLAN [10600]",Multiplan,,1241.09,85,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 30MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840005530,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]",Cigna,,6491.86,68,,1831.33,1831.33,1831.33,16,1110.3,8114.82,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL J HOOK LOCK SHEATH MONOPOLAR LATEX",SUP-5600140,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"PHCS [10601]",PHCS,,237.51,70,,,,,0,39.46,288.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION",RX-9266,CDM,J0702,HCPCS,0636,RC,00517-0720-01,NDC,both,5,ML,498.60,149.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,185.82,,,,,,,72.78,423.81,"fee schedule",
"SYSTEM XIENCE ALPINE 38MM 145CM 2.75MM CORONARY STENT",SUP-1145275-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PHCS [10601]",PHCS,,4086.6,70,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 12MM 1.25MM",SUP-SPL12512X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"FIRST HEALTH [10303]","First Health",,421.2,80,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 40MMX8MMX20CM 26FR",SUP-TAC084020A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,74966.4,41.1,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION 22MM 3S HEMI IMPL LARGE NONSTERILE LATEX FREE",SUP-101-00-003,CDM,C1776,HCPCS,0278,RC,,,both,,,8280.00,2484,"PHCS [10601]",PHCS,,5796,70,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH XXL 75CM 40MM 5.8FR 14MM .035IN BALLOON DILATATION",SUP-M001145140,CDM,C1725,HCPCS,0272,RC,,,both,,,1709.63,512.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1162.55,68,,,,,0,198.83,1453.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT STRAIGHT RETRACTION 40MM MARS 26MM",SUP-632.464S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2880.00,864,"AETNA [10100]","Aetna HMO/PPO",,2289.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.94,2448,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 2 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022212,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6648.84,40,,,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 28MM 143CM 2.25MM CORONARY EVEROLIMUS ELUTING",SUP-1009544-28,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"CIGNA [10200]","Cigna Local Plus",,5131.19,53.5,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Incision Bx Skin Ea Addl",PX-761000064,CDM,11107,CPT,0761,RC,,,both,,,2168.00,650.4,"CIGNA [10200]",Cigna,,2168,,"Per diem ($2,606).",,,,0,2.17,2168,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 18MM CEMENTLESS TOTAL STABILIZED",SUP-5566-S-018,CDM,C1776,HCPCS,0278,RC,,,both,,,5447.65,1634.29,"CIGNA [10200]","Cigna Local Plus",,2914.49,53.5,,5372.07,4581.20,7242.98,23,633.56,4630.5,"percent of total billed charges",
"RELIANCE DF4 NON-GORE, PASSIVE FIXATION SINGLE COIL 59 CM, I",SUP-0262,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4344.52,28.62,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS 115CM 4MM 7FR 2-5-2MM SPACE F CURVE ABLATION",SUP-D7TCFL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2039.01,41.1,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 65MM TITANIUM LOCK TRANSLATIONAL ATLANTIS BONE SPINE",SUP-6190065,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR VIVACIT-E II 52MM 36MM HIP NEUTRAL",SUP-00885101036,CDM,C1776,HCPCS,0278,RC,,,both,,,7996.80,2399.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,947.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,930.03,6797.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 3.5MM LORDOSIS TITANIUM",SUP-102063060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BACTISEAL 120CM 14CM DRNG VENTRICLE DISTAL KIT SHUNT",SUP-823072,CDM,S27800098,LOCAL,0278,RC,,,both,,,4862.22,1458.67,"BLUE CROSS [10001]","Blue Cross HMO",,1905.99,39.2,,,,,0,565.48,4132.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC UNIVERSAL 22IN 25IN 19IN KNEE THIGH 3 PANEL",SUP-ORT2411022,CDM,S27000186,LOCAL,0270,RC,,,both,,,141.38,42.41,"CIGNA [10200]","Cigna Local Plus",,75.64,53.5,,,,,0,16.44,120.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 60MM 40MM ALTRX HIP",SUP-122140160,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"BLUE CROSS [10001]","Blue Cross HMO",,5410.95,39.2,,5311.50,4717.44,5388.59,31,1605.34,11732.93,"percent of total billed charges",
"GWIRE VICTORY VASCULAR 300CM 18IN HYDROPHILIC PERIPHERAL",SUP-H74939473300300,CDM,C1769,HCPCS,0272,RC,,,both,,,2617.50,785.25,"PHCS [10601]",PHCS,,1832.25,70,,,,,0,304.42,2224.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 38CM 135CM 9MM VASCULAR COVER BALLOON",SUP-LSMU1350938,CDM,C1874,HCPCS,0278,RC,,,both,,,15870.00,4761,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1880.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 4-5 C-D KNEE",SUP-42522100312,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS [10001]","Blue Cross HMO",,4224.36,39.2,,5311.50,4717.44,5388.59,31,1253.3,9159.96,"percent of total billed charges",
"HC Immuno Tumr Ag Other Ag Qn",PX-302000060,CDM,86316,CPT,0302,RC,,,both,,,358.15,107.44,"MULTIPLAN [10600]",Multiplan,,304.43,85,,,,,0,0.01,304.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 7FR 5MM SPACE D CURVE ELECTROPHYSIOLOGY",SUP-D7DR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"AETNA [10100]","Aetna HMO/PPO",,1842.41,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CRIMPER ACTIVATOR",SUP-DMS-28829,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 14X26X60MM 10",SUP-6214160,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]",Cigna,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE .4MM UNIVERSAL NEURO III 2Y CRANIOMAXILLOFACIAL",SUP-53-34608,CDM,C1713,HCPCS,0278,RC,,,both,,,2048.33,614.5,"CIGNA [10200]","Cigna Local Plus",,1095.86,53.5,,3978.14,359.25,3978.14,24,238.22,1741.08,"percent of total billed charges",
"FILFRM URETHRAL 13IN 3FR STRAIGHT PVC PLASTIC STERILE LATEX",SUP-342103,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.96,28.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.93,79.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR EXTRA BACKUP LAD",SUP-67006100,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"KAISER [10500]",Kaiser,,279.79,67,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 40MM 5.5MM DECADE LARGE PLATE EXTREME LATERAL",SUP-7145540,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",188.41,1377,"percent of total billed charges",
"CAP END T25 STARDRIVE HINDFOOT ARTHRODESIS NAIL EX SPIRAL",SUP-04.008.000S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 60CM 6MM 2 VELOUR KNITTED STRAIGHT TUBE",SUP-M002020952060,CDM,C1768,HCPCS,0278,RC,,,both,,,3748.95,1124.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2549.29,68,,,,,0,436,3186.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 8MM 2.25MM CORONARY STENT COCR",SUP-1007822-08,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"MULTIPLAN [10600]",Multiplan,,2550,85,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT WALKING GENESIS SMALL 3 STRAP ULTRA LIGHTWEIGHT LOW",SUP-BL515003,CDM,S27000186,LOCAL,0270,RC,,,both,,,434.91,130.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.58,369.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 16MM 3.75MM EMBOLIZATION NEUROVASCULAR",SUP-PED-375-16,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,31626.45,41.1,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 15MM 5.5MM FOOT ANKLE VENT",SUP-AR-1555PS,CDM,C1713,HCPCS,0278,RC,,,both,,,2480.63,744.19,"MULTIPLAN [10600]",Multiplan,,2108.54,85,,,,,0,288.5,2108.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 60MM 80CM 8MM VASCULAR PERIPHERAL SELF",SUP-1012530-60,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mra Spine Canal W/WO Cntrst",PX-612000010,CDM,72159,CPT,0612,RC,,,both,,,4041.00,1212.3,"KAISER [10500]",Kaiser,,2707.47,67,,,,,0,469.97,3434.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER BROWN 5.5MM ACROMIONIZER DYONICS STRAIGHT",SUP-7205327,CDM,S27200284,LOCAL,0272,RC,,,both,,,314.00,94.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,36.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.52,266.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP FEM N/POROUS SIZE 3 RIGHT",SUP-2154-0-0003,CDM,C1776,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3800.52,45.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PCMKR CRD THK6MM 50X47MM","SUP-PM2272 CELL",CDM,C1785,HCPCS,0275,RC,,,both,,,9324.00,2797.2,"MULTIPLAN [10600]",Multiplan,,7925.4,85,,,,,0,1084.38,7925.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID .1-4MM CANCELLOUS ALLOGRAFT CHIPS FREEZE",SUP-400080,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM ALLOGRAFT 16MMX15MM",SUP-310116,CDM,S27800098,LOCAL,0278,RC,,,both,,,4858.98,1457.69,"BLUE CROSS [10001]","Blue Cross HMO",,1904.72,39.2,,,,,0,565.1,4130.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 5-0 PS-2 18IN MONOFILAMENT PLIABILIZE",SUP-CX14D,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.66,41.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,93.61,68,,,,,0,16.01,117.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X3 HUMERAL INSERT - 36MM X 10MM STANDARD",SUP-5571-S-3610,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"UHC [10700]","United Healthcare",,6380.64,63.3,,8601.07,8395.67,8601.07,"1 through 10",1172.3,8568,"percent of total billed charges",
"CATH AGENT 20MM 2.75MM BALLOON DILATATION PACLITAXEL",SUP-H7493960820270,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4609.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 28MM 144CM 2.5MM CORONARY STENT",SUP-H7493911428250,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross HMO",,3583.86,39.2,,9776.84,9776.84,9776.84,"1 through 10",1063.27,7771.13,"percent of total billed charges",
"CANN INNER SHILEY XLT 6 95MM 11MM 6MM ADULT EXTEND LENGTH",SUP-60XLTIN,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.83,1.45,"UHC [10700]","United Healthcare",,3.06,63.3,,,,,0,0.56,4.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT PL SITEMARK 51CM 47CM 9FR 7FR RIGHT SIDE",SUP-410176,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1525.84,41.1,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 220MM 4.6MM 3/16IN SQUARE CANNULATED 7MM MONSTER",SUP-P99-110-4622,CDM,S27200284,LOCAL,0272,RC,,,both,,,1279.80,383.94,"FIRST HEALTH [10303]","First Health",,1023.84,80,,,,,0,148.84,1087.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE LEGACY DBM 10CC ALLOGRAFT NONSTERILE LATEX FREE",SUP-420810,CDM,C1713,HCPCS,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1777.3,28.62,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 38MM 144CM 4MM CORONARY STENT EVEROLIMUS",SUP-H7493926138400,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"AETNA [10100]","Aetna HMO/PPO",,6856.88,79.5,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D D KNEE RIGHT CEMENT KEEL",SUP-42536006702,CDM,C1776,HCPCS,0278,RC,,,both,,,10619.10,3185.73,"MULTIPLAN [10600]",Multiplan,,9026.24,85,,,,,0,1235,9026.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 1.3MM LAPIDUS 3 HOLE COMPRESSION MEDIAL WALL",SUP-P53-106-R101,CDM,C1713,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"CIGNA [10200]","Cigna Local Plus",,4522.09,53.5,,3978.14,359.25,3978.14,24,983.03,7184.63,"percent of total billed charges",
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000110,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Protein Total Other",PX-301000380,CDM,84157,CPT,0301,RC,,,both,,,182.00,54.6,"UHC [10700]","United Healthcare",,3.6,,,,,,,2.48,154.7,"fee schedule",
"STENT VIABAHN 2.5CM 120CM 6MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR060202A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"KAISER [10500]",Kaiser,,11326.35,67,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 60MM 80CM 8MM VASCULAR PERIPHERAL 3 WAVE PEAK",SUP-PRB35-08-060-080,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AETNA [10100]","Aetna HMO/PPO",,4424.18,79.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT COATED VICRYL PLUS 3-0 PSL 27IN BRAID ANTIBACTERIAL",SUP-VCP502H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UHC [10700]","United Healthcare",,15.83,63.3,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 4MM X 28MM - US",SUP-90313,CDM,S27200284,LOCAL,0272,RC,,,both,,,35649.18,10694.75,"CIGNA [10200]",Cigna,,24241.44,68,,,,,0,4146,30301.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CASTING 4IN 10: BOOT TCC-EZ XL",SUP-TCC24024,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.43,23.23,"KAISER [10500]",Kaiser,,51.88,67,,,,,0,9.01,65.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WATCHMAN PROCEDURE -FXD CURVE SYSTEM",SUP-WMFLXPROFXDPERPROC,CDM,C1894,HCPCS,0272,RC,,,both,,,6900.00,2070,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,802.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 100MM 120CM 6MM VASCULAR PERIPHERAL SELF",SUP-PRB35-06-100-120,CDM,C1876,HCPCS,0278,RC,,,both,,,7098.00,2129.4,"BLUE CROSS [10001]","Blue Cross HMO",,2782.42,39.2,,,,,0,825.5,6033.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 1000-1180UM 5 VIAL CONTOUR PVA",SUP-M0017601151,CDM,S27800098,LOCAL,0278,RC,,,both,,,1377.00,413.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,163.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 130CM 200MM 6MM BALLOON DILATATION",SUP-ADM06020013P,CDM,C2623,HCPCS,0272,RC,,,both,,,12730.50,3819.15,"MULTIPLAN [10600]",Multiplan,,10820.93,85,,,,,0,1480.56,10820.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER 6250VC ATTAIN COMMAND",SUP-6250VC,CDM,C1887,HCPCS,0272,RC,,,both,,,6451.50,1935.45,"KAISER [10500]",Kaiser,,4322.51,67,,,,,0,750.31,5483.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.5/35",SUP-404670,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 28MM HIP BIOLOX DELTA V40",SUP-6570-0-128,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"PHCS [10601]",PHCS,,7000,70,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RAMIPRIL 2.5 MG CAPSULE",RX-11260,CDM,,,0637,RC,65862-0475-01,NDC,both,1,UN,9.09,2.73,"CIGNA [10200]","Cigna Local Plus",,4.86,53.5,,,,,0,1.06,7.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 345CC",SUP-SSZ-F345,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,176.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION SMART PORT FLUOROMAX VORTEX",SUP-CT80STPD,CDM,C1788,HCPCS,0278,RC,,,both,,,2274.00,682.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,264.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,264.47,1932.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE RIGHT POSTERIOR STABILIZE BEAD",SUP-5516F202,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2052.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2013.96,14719.4,"percent of total billed charges",
"CATH WEBSTER 60CM 5FR 2-8-2MM SPACE P CURVE",SUP-F5ADPP10RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2040.00,612,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,241.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,237.25,1734,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS ETHIGUARD 0 CTX-B 36IN BRAID ANTIBACTERIAL",SUP-VCPB978H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORCLTR SURGICAL 335MM 4.75MM DISPOSABLE",SUP-49700113,CDM,S27200284,LOCAL,0272,RC,,,both,,,2628.58,788.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,305.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.7,2234.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION LCS SIGMA HIP THREAD HEAD STERILE",SUP-9505-02-303,CDM,S27200284,LOCAL,0272,RC,,,both,,,1938.75,581.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,225.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,225.48,1647.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 2CM 6MM 7FR BALLOON DILATATION",SUP-V186020,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,650.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS SOLN DEX 1.5 % CA+ 3.5 MEQ/L&LOW MAG 0.5 MEQ/L",RX-27797,CDM,,,0250,RC,00941-0426-52,NDC,both,2000,ML,211.26,63.38,"CIGNA [10200]","Cigna Open Access",,120.21,56.9,,,,,0,24.57,179.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE  VIATORR TIPS ENDOPROSTHESIS WITH CONTROLLED EXPANSION,",SUP-PTB6106275,CDM,C1874,HCPCS,0278,RC,,,both,,,33364.80,10009.44,"KAISER [10500]",Kaiser,,22354.42,67,,,,,0,3880.33,28360.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS STREAMLINE 15MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-M003SFD040150,CDM,C1874,HCPCS,0278,RC,,,both,,,85681.49,25704.45,"FIRST HEALTH [10303]","First Health",,68545.19,80,,,,,0,9964.76,72829.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 135CM 150MM 4MM .035IN BALLOON",SUP-AB35W04150135,CDM,C1725,HCPCS,0272,RC,,,both,,,1061.91,318.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,436.45,41.1,,,,,0,123.5,902.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 3X32+PRO14 2-PACK - US",SUP-91316,CDM,S27200284,LOCAL,0272,RC,,,both,,,24624.97,7387.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2918.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2863.88,20931.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 30MM 3MM BALLOON DILATATION DURALYN",SUP-48003003S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"FIRST HEALTH [10303]","First Health",,1004.4,80,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25MM M-CLASS HALL THK1.47MM STAINLESS STEEL",SUP-T250-147-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,521.80,156.54,"PHCS [10601]",PHCS,,365.26,70,,,,,0,60.69,443.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 11MM KNEE X3 POSTERIOR STABILIZED PRIMARY",SUP-5532-G-311,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"NOVANET [10819]",Novanet,,6530.71,75,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ROCHESTER-PEAN CURVE 6.25IN STD LINE STAINLESS",SUP-32-4071,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.29,16.89,"CIGNA [10200]","Cigna Local Plus",,30.12,53.5,,,,,0,6.55,47.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 25MM 2.75MM ULTRA LOW PROFILE BALLOON",SUP-1012273-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REVOLVE BREAST BIOPSY STERILE DISPOSABLE",SUP-RV0002,CDM,S27200284,LOCAL,0272,RC,,,both,,,6147.90,1844.37,"CIGNA [10200]",Cigna,,4180.57,68,,,,,0,715,5225.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFTS FOR INJURIES WITH CC/MCC",904,MS-DRG,,,,,,,inpatient,,,175649.32,52694.8,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,24379.38,,"Case rate ($22,784.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $21,156.92, add-ons for qualifying new technology services are included. If operating cost exceeds $54,196.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,981.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $21,184.90. The transfer operating threshold is the transfer adjustment factor * $21,156.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,599.57. The transfer capital threshold is the transfer adjustment factor * $1,599.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,107239.83,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET XL 360 SOFT 5MM X 15CM",SUP-M0036125150,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM VARIAX TORX TITANIUM FULL THREAD T10",SUP-40-35616,CDM,C1713,HCPCS,0278,RC,,,both,,,1211.11,363.33,"MULTIPLAN [10600]",Multiplan,,1029.44,85,,,,,0,140.85,1029.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 50MM 28MM XLPE HIP",SUP-71334950,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4581.4,41.1,,6417.48,6417.48,6417.48,"1 through 10",1296.39,9474.91,"percent of total billed charges",
"STNT WLSTNT 60MM 194CM 8MM 8FR",SUP-6962,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,170.52,39.2,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +29.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200295,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,118.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Quest Yeast Susceptibility",PX-306000245,CDM,87186,CPT,0306,RC,,,both,,,1074.00,322.2,"CIGNA [10200]",Cigna,,19.03,,,,,,,0.01,912.9,"fee schedule",
"FRCP SURGICAL PETIT-POINT MIXTER ANGLE RIGHT 5.25IN GALL",SUP-140218,CDM,S27000186,LOCAL,0270,RC,,,both,,,265.00,79.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,31.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.82,225.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13CM NATRELLE INSPIRA P6.2CM EXTRA FULL PROFILE",SUP-MSZ-X545,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA [10200]","Cigna Open Access",,90,56.9,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 20MM 6FR 5.5MM 4FR BALLOON",SUP-H74939031552010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC .75CM 4.45X5.88CM ESSENTIO PACESAFE",SUP-L131,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"FIRST HEALTH [10303]","First Health",,33280,80,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PRECISION 12D ALLOGRAFT 16MM",SUP-421666,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 12MM ATTUNE 5 KNEE DISTAL CEMENT REVISION",SUP-154705003,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"CIGNA [10200]","Cigna Local Plus",,3248.52,53.5,,5372.07,4581.20,7242.98,23,706.17,5161.2,"percent of total billed charges",
"NAIL 11MM 300MM HIP RIGHT FEMUR AFFIXUS INTRAMEDULLARY 130D",SUP-814511300,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"FIRST HEALTH [10303]","First Health",,16594.2,80,,,,,0,2412.38,17631.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Salivary Gland",PX-341000081,CDM,78230,CPT,0341,RC,,,both,,,1730.90,519.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,205.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,201.3,1471.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TALON ORTHOPEDIC 600MM 3MM TROCAR TIP",SUP-SLN-T35,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL TAPERCUT 5-0 V-5 30IN 2 ARM BRAID GREEN",SUP-X934H,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.71,18.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,28.78,45.9,,,,,0,7.29,53.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS THK12MM ALLOGRAFT BLOCK FREEZE DRIED",SUP-400293,CDM,S27800098,LOCAL,0278,RC,,,both,,,5547.60,1664.28,"PHCS [10601]",PHCS,,3883.32,70,,,,,0,645.19,4715.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR SHUTTLE 80CM 6FR 2.2MM GUIDING HYDROPHILIC",SUP-G13539,CDM,C1894,HCPCS,0272,RC,,,both,,,1109.62,332.89,"KAISER [10500]",Kaiser,,743.45,67,,,,,0,129.05,943.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 14X26X55MM",SUP-6214055,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"FIRST HEALTH [10303]","First Health",,19152,80,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE PROTEAN BONE ULNA DISTAL",SUP-PRT-FSP-DU,CDM,C1713,HCPCS,0278,RC,,,both,,,5996.10,1798.83,"BLUE CROSS [10001]","Blue Cross PPO",,2350.47,39.2,,957.42,570.23,957.42,28,697.35,5096.69,"percent of total billed charges",
"HC Wound Cytal 6-Layer 5x5cm",PX-E63600042,CDM,Q4166,HCPCS,0636,RC,,,both,,,345.40,103.62,"CIGNA [10200]",Cigna,,53.69,,,,,,,40.93,293.59,"fee schedule",
"CATH COYOTE 150CM 100MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939186251010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR J STRAIGHT 27.7IN .035IN STAINLESS STEEL 2",SUP-8817231001,CDM,C1887,HCPCS,0272,RC,,,both,,,97.97,29.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,66.62,68,,,,,0,11.39,83.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR ADULT INVOS OXIMETER KIT",SUP-PMSENS71-A-20,CDM,S27000186,LOCAL,0270,RC,,,both,,,946.61,283.98,"KAISER [10500]",Kaiser,,634.23,67,,,,,0,110.09,804.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 6FR GLIDESHEATH .035IN HYDROPHILIC SPRING J",SUP-RM*BF6M10MA,CDM,C1894,HCPCS,0272,RC,,,both,,,368.01,110.4,"PHCS [10601]",PHCS,,257.61,70,,,,,0,42.8,312.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM RELINE 2C SPINE MODULAR SHANK NONSTERILE",SUP-16185540,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,348.9,2550,"percent of total billed charges",
"SCR BONE 4MM 35MM RELINE-O 2S SPINE POLYAXIAL NONSTERILE",SUP-13014035,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA [10200]",Cigna,,3292.97,68,,1831.33,1831.33,1831.33,16,563.19,4116.21,"percent of total billed charges",
"BASEPLT TIBIAL ATTUNE 6 KNEE CEMENT REVISION ROTATE PLATFORM",SUP-1506-60-006,CDM,C1776,HCPCS,0278,RC,,,both,,,22629.60,6788.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9051.84,40,,,,,0,2631.82,19235.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT MICRO NONSTERILE DISPOSABLE",SUP-AR-1320BCNF,CDM,C1713,HCPCS,0278,RC,,,both,,,2559.38,767.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1174.76,45.9,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Burn 2nd Degree 5-10%",PX-510000059,CDM,16025,CPT,0761,RC,,,both,,,1913.08,573.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1793,,"Per diem ($1,793).",,,,0,222.49,1913.08,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 150MM THREAD MR SAFE DISTRACTION",SUP-03.311.115,CDM,C1713,HCPCS,0278,RC,,,both,,,521.56,156.47,"CIGNA [10200]","Cigna Open Access",,296.77,56.9,,1144.80,304.56,2275.09,66,60.66,443.33,"percent of total billed charges",
"LENS IOL 5 D +1 DIOPTER MODIFIED C BICONVEX 12.5MM 5.5MM",SUP-MA30AC,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross PPO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 22IN 5FR PORT ANTICLOG RADIOPAQUE BOW TIP",SUP-20-C1225,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.97,23.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.3,67.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 7MM TRI-LOCK APTUS TITANIUM HEXADRIVE 6 TAPER",SUP-A-5450.07/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 18FR TUNGSTEN SILICONE 2.5CM MIC-KEY",SUP-8270-18-2.5-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"CIGNA [10200]",Cigna,,1790.3,68,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT 5 KNEE CEMENT ROTATE PLATFORM",SUP-129431150,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"GRAFT STENT 80MM 16-14MM 14MM 11FR TRIVASCULAR OVATION PRIME",SUP-TV-IL141680-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"BLUE CROSS [10001]","Blue Cross HMO",,13088.88,39.2,,9776.84,9776.84,9776.84,"1 through 10",3883.26,28381.5,"percent of total billed charges",
"HEAD HUMERAL 19MM 50MM SHOULDER SIMPLICITI",SUP-7122874,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"KAISER [10500]",Kaiser,,6712.73,67,,,,,0,1165.21,8516.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 70MM VALOR HINDFOOT FUSION SYSTEM",SUP-4151150070,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"NOVANET [10819]",Novanet,,1293.75,75,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8MM 300MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-408-300,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 8MM 12-10MM 18MM DUCT SELF EXPANDABLE",SUP-9-PDA-007,CDM,C1817,HCPCS,0278,RC,,,both,,,34398.00,10319.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4076.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4000.49,29238.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 10CM MARIGEN FISH SKIN FENESTRATED 7CM STERILE",SUP-50200F03B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,27657.00,8297.1,"AETNA [10100]","Aetna HMO/PPO",,21987.32,79.5,,,,,0,180.89,23508.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 80MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,974.92,68,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR 44.5MM CARBIDE 3MM ROUND 6 FLUTE DENTAL",SUP-14-C0107,CDM,S27200284,LOCAL,0272,RC,,,both,,,120.15,36.04,"CIGNA [10200]","Cigna Open Access",,68.37,56.9,,,,,0,13.97,102.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Particle Agglutination Ea",PX-302000089,CDM,86403,CPT,0302,RC,,,both,,,547.00,164.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.97,,"Fee schedule rate ($11.97). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.91,464.95,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP LIMIT HOLE COLOR CODED OSSEOTI G7",SUP-110010247,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,5311.50,4717.44,5388.59,31,2014.9,14726.25,"percent of total billed charges",
"SHELL ACETABULAR 58MM HIP LIMIT HOLE COLOR CODED OSSEOTI G7",SUP-110010247,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,inpatient,,,81192.97,24357.89,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,14686.95,,"Case rate ($13,726.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,745.64, add-ons for qualifying new technology services are included. If operating cost exceeds $45,785.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,345.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,762.50. The transfer operating threshold is the transfer adjustment factor * $12,745.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $963.63. The transfer capital threshold is the transfer adjustment factor * $963.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,13726.12,55185.02,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT PL SITEMARK 58CM 54CM 9FR 7FR 115D GUIDING",SUP-410182,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"FIRST HEALTH [10303]","First Health",,2970,80,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL CANCELLOUS 7D ALLOGRAFT 14MM",SUP-3W5214,CDM,S27800098,LOCAL,0278,RC,,,both,,,21094.92,6328.48,"UHC [10700]","United Healthcare",,13353.08,63.3,,,,,0,2453.34,17930.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MR DRILL BIT 7.5 X 1.5MM BALL FLTD",SUP-75BA15L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1441.80,432.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,167.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.68,1225.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 4-0 PC-1 18IN MONOFILAMENT BLUE",SUP-8619G,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.79,20.34,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,46.1,68,,,,,0,7.88,57.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 4CM 8MM BALLOON DILATATION",SUP-DR8084,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"PHCS [10601]",PHCS,,963.9,70,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X12MM LUMINARY 10-11MM SPINE",SUP-14712,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"UHC [10700]","United Healthcare",,19939.5,63.3,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR GRAY 45MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103545000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"CIGNA [10200]",Cigna,,2083.74,68,,5873.17,5873.17,5873.17,"1 through 10",356.38,2604.67,"percent of total billed charges",
"SHOE POSTOPERATIVE XL FEMALE SUEDE RUBBER BOTTOM WOOD SOLE",SUP-2007-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.43,23.23,"UHC [10700]","United Healthcare",,49.01,63.3,,,,,0,9.01,65.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 10CM 10FR DUODENAL BEND BILIARY PLASTIC TEMPORARY",SUP-M00545620,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,391.42,45.9,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 301MM STAINLESS STEEL 4.5MM SCR 14 HOLE 4 COLUMN",SUP-02.124.415,CDM,C1713,HCPCS,0278,RC,,,both,,,11799.00,3539.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1398.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1372.22,10029.15,"percent of total billed charges",
"CATH FIRMAP 154CM 8.5FR 60MM 60MM MAPPING 64 ELECTRD TOPERA",SUP-USAR064060,CDM,C1732,HCPCS,0272,RC,,,both,,,30870.00,9261,"FIRST HEALTH [10303]","First Health",,24696,80,,,,,0,3590.18,26239.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INJECTION 1000ML 5% DEXTROSE USP LIFE FLEXIBLE CNTNR",SUP-792209,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"NOVANET [10819]",Novanet,,60.75,75,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLACK USA ELITE SYSTEM USA SERIES",SUP-VE-F,CDM,S27200284,LOCAL,0272,RC,,,both,,,1214.65,364.39,"UHC [10700]","United Healthcare",,768.87,63.3,,,,,0,141.26,1032.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +30 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.300,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE XL FEMALE SUEDE RUBBER BOTTOM WOOD SOLE",SUP-2007-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.43,23.23,"AETNA [10100]","Aetna HMO/PPO",,61.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.01,65.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 36CM 13.5FR 12FR .038IN STAINLESS STEEL SILICONE",SUP-8833074001,CDM,C1752,HCPCS,0272,RC,,,both,,,1698.35,509.5,"MULTIPLAN [10600]",Multiplan,,1443.6,85,,,,,0,197.52,1443.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM PRESTIGE PLUS HELICAL HELICAL XTRA",SUP-PRES0206HXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 400MM 11MM CARBON FIBER MR CONDITIONAL",SUP-394.87,CDM,C1713,HCPCS,0278,RC,,,both,,,1581.53,474.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,183.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",183.93,1344.3,"percent of total billed charges",
"PLATE 32MM TITANIUM LEVEL 2 ASSURE BONE SPINE CERVICAL",SUP-110.232,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"KAISER [10500]",Kaiser,,2954.7,67,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRESSING ANTIMICROBIAL 3.5 X 6 INCH AQUACEL AG ADVANTAGE",SUP-422604,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.29,69.09,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH INTRO ORANGE 23CM 7FR BRITE TIP CANN INTERVENTIONAL",SUP-401723M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"PHCS [10601]",PHCS,,73.08,70,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 100CM 6FR 12MM AMPLATZER .086IN TYPE II",SUP-9-AVP2-012,CDM,S27800098,LOCAL,0278,RC,,,both,,,6589.50,1976.85,"FIRST HEALTH [10303]","First Health",,5271.6,80,,,,,0,766.36,5601.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP 2 - SPECIALTY",SUP-CAP-DJO-H-2,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2911.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2857.49,20884.5,"percent of total billed charges",
"CATH IMAGER II 65CM 5FR STRAIGHT URETERAL STAINLESS STEEL",SUP-M0064003021,CDM,C1758,HCPCS,0272,RC,,,both,,,149.15,44.74,"UHC [10700]","United Healthcare",,94.41,63.3,,,,,0,17.35,126.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLINDAMYCIN 150 MG/ML INJECTION SOLUTION",RX-82303,CDM,J0736,HCPCS,0636,RC,00009-0870-26,NDC,both,2,ML,22.53,6.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5.13,,,,,,,2.13,19.15,"fee schedule",
"RELOAD STPLR 3-0 4IN ENDO STITCH V-LOC POLYBUTESTER LOAD",SUP-VLOCN304L,CDM,S27200284,LOCAL,0272,RC,,,both,,,249.43,74.83,"PHCS [10601]",PHCS,,174.6,70,,,,,0,29.01,212.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Phosphorus Urine",PX-301000360,CDM,84105,CPT,0301,RC,,,both,,,132.05,39.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.07,,"Fee schedule rate ($6.07). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,112.24,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 8FR LARGE REGULAR PIGTAIL CURVE URETERAL GLIDEX",SUP-M001245500,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"NOVANET [10819]",Novanet,,668.25,75,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR EXTRICATION 2.25IN 16-19IN CALIFORNIA PROCARE LARGE",SUP-79-83127,CDM,S27000186,LOCAL,0270,RC,,,both,,,82.74,24.82,"PHCS [10601]",PHCS,,57.92,70,,,,,0,9.62,70.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 3MM MATCH HEAD SYMMETRIC DISSECTING SP",SUP-MR8-SP14MH30T,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1876.29,68,,,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE PIN ORTHOPEDIC 100MM DECADE SPINE XLIF",SUP-7141112,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE SUCTION/IRRIGATION 10FT UNIVERSAL PLUS HI FLO PISTOL",SUP-60-6010-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,825.82,247.75,"MULTIPLAN [10600]",Multiplan,,701.95,85,,,,,0,96.04,701.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM GORILLA R3CON LOCK",SUP-P50-353-3512,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"PHCS [10601]",PHCS,,935.55,70,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 135CM 7MM 11MM 7FR .035IN",SUP-BXA072902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"FIRST HEALTH [10303]","First Health",,15603.84,80,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CITATION TMZF HA 3 SHORT HIP RIGHT",SUP-6265-5213,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"NOVANET [10819]",Novanet,,18316.46,75,,,,,0,2840.27,20758.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 4.5MM 38MM EVOS MINI CORTEX T8 DRIVER SELF",SUP-72402738,CDM,C1713,HCPCS,0278,RC,,,both,,,363.14,108.94,"CIGNA [10200]","Cigna Local Plus",,194.28,53.5,,3978.14,359.25,3978.14,24,42.23,308.67,"percent of total billed charges",
"CATH LAUNCHER 100CM 7FR .081IN AMPLATZ LEFT 1 CURVE GUIDING",SUP-LA7AL10,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 150MM 5MM BALLOON DILATATION RAPID",SUP-47550150L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 250MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050250M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 9MM BALLOON",SUP-U357596,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATH 4FR 18GA 20CM 1 LUMEN MIDLINE MAXIMAL BARR",SUP-4154108D,CDM,C1752,HCPCS,0272,RC,,,both,,,899.10,269.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 5-0 C-1 18IN 2 ARM MONOFILAMENT BLUE",SUP-8717H,CDM,S27200284,LOCAL,0272,RC,,,both,,,150.18,45.05,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Interrog Dev Eval in Person",PX-480000078,CDM,0521T,CPT,0480,RC,,,both,,,579.79,173.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX RADIANZ 190CM 20MM 6MM .018IN BALLOON DILATATION",SUP-R51006002L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VIEWFLEX X ICE CATHETER SENSOR ENABLED",SUP-ICE-VF-SE-2D-01,CDM,C1759,HCPCS,0272,RC,,,both,,,16905.00,5071.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"KIT ARTHROSCOPIC 6.25MM FLEXOR HALLUCIS LONGUS",SUP-AR-1562BC-CP,CDM,S27200284,LOCAL,0272,RC,,,both,,,10831.28,3249.38,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Specific Gravity Non Urine",PX-301000527,CDM,84315,CPT,0301,RC,,,both,,,77.90,23.37,"MULTIPLAN [10600]",Multiplan,,66.22,85,,,,,0,0.08,66.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TFNT30 PANOPTIX TORIC",SUP-TFNT30,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,387.86,45.9,,,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fo Pip Dip Jnt/Sprng Pre Ots",PX-E27400036,CDM,L3925,HCPCS,0274,RC,,,both,,,119.90,35.97,"BLUE CROSS [10001]","Blue Cross HMO",,47,39.2,,,,,0,13.94,101.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM PRESTIGE PLUS HELICAL EXTRA PACK",SUP-PRES0103HXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CENTRAL LINE DRESSING CHANGE KIT",SUP-78861,CDM,S27200284,LOCAL,0272,RC,,,both,,,235.34,70.6,"AETNA [10100]","Aetna HMO/PPO",,187.1,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.37,200.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL LEGION 6 L 5DX5P KNEE SCR",SUP-71421751,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,1144.80,304.56,2275.09,66,2014.9,14726.25,"percent of total billed charges",
"LENS IOL +14.5 DIOPTER HAPTIC C BICONVEX 13MM 6MM 1 PIECE",SUP-PCB0000145,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX13MM FRA 8D LORDOTIC NARROW WEDGE",SUP-10013,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5409.18,28.62,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 400MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.161S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"BLUE CROSS [10001]","Blue Cross HMO",,4867.99,39.2,,957.42,156.86,7483.26,51,1444.25,10555.59,"percent of total billed charges",
"SCR BONE 4.5MM 13MM ATLANTIS TITANIUM ANTERIOR CERVICAL",SUP-3125213,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"FIRST HEALTH [10303]","First Health",,1128,80,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Genotype Hiv 1 Oth Region",PX-306000210,CDM,87906,CPT,0306,RC,,,both,,,1337.60,401.28,"NOVANET [10819]",Novanet,,1003.2,75,,,,,0,0.01,1136.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Progr Dev Eval Pcmkr Sngl Lead",PX-480000050,CDM,93279,CPT,0480,RC,,,both,,,266.00,79.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,30.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.94,266,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM PRESTIGE PLUS HELICAL COMPLEX XTRA",SUP-PRES0101CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 4X13MM ANTERIOR CERVICAL VARIABLE ANGLE SELF TA",SUP-18008513,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,117.75,860.63,"percent of total billed charges",
"HC Excis of Anal Lesion",PX-750000153,CDM,46922,CPT,0750,RC,,,both,,,8537.00,2561.1,"CIGNA [10200]","Cigna Open Access",,2090,,"Case rate ($2,090). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,992.85,7256.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esoph Imped Func Test>1hr",PX-750000152,CDM,91038,CPT,0750,RC,,,both,,,7093.00,2127.9,"CIGNA [10200]","Cigna Local Plus",,3794.76,53.5,,,,,0,824.92,6029.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR TRILOGY STD NEUTRAL 11.9MM 64MM 36MM",SUP-00630506436,CDM,C1776,HCPCS,0278,RC,,,both,,,9937.38,2981.21,"NOVANET [10819]",Novanet,,7453.04,75,,,,,0,1155.72,8446.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE-O MOD SHANK, 5.5X55MM TRACTION",SUP-13175555,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,3978.14,359.25,3978.14,24,348.9,2550,"percent of total billed charges",
"CATH CHOLANGIOGRAM 60CM 4FR ARROW-KARLAN 2 LUMEN 3WAY",SUP-CS-01700,CDM,S27200284,LOCAL,0272,RC,,,both,,,879.66,263.9,"UHC [10700]","United Healthcare",,556.82,63.3,,,,,0,102.3,747.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL CURVE SPAT 11IN VALLEYLAB STERILE",SUP-E3781R-28ASP,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.42,71.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.61,201.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 25MMX4.8MM EEA TITANIUM THIN VASCULAR TISSUE",SUP-110214L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1850.10,555.03,"KAISER [10500]",Kaiser,,1239.57,67,,,,,0,215.17,1572.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION",RX-9681,CDM,J0770,HCPCS,0636,RC,42023-0131-01,NDC,both,1,UN,226.52,67.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,154.03,68,,,,,0,14.19,192.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRIAD 14X11X7MM CERVICAL SPINE",SUP-5750007,CDM,S27800098,LOCAL,0278,RC,,,both,,,5841.00,1752.3,"NOVANET [10819]",Novanet,,4380.75,75,,,,,0,679.31,4964.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 3CM 7FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145370010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"BLUE CROSS [10001]","Blue Cross PPO",,379.02,39.2,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 7FR 90CM .028IN CLOSED TIP URINARY DIVERSION",SUP-5230600,CDM,C2617,HCPCS,0278,RC,,,both,,,2007.23,602.17,"BLUE CROSS [10001]","Blue Cross HMO",,786.83,39.2,,,,,0,233.44,1706.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM PRESTIGE PLUS HELICAL EXTRA PACK",SUP-PRES0103HXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 18MM AXIUM 3D NEUROVASCULAR FRAME V01",SUP-FC-18-50-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4461.89,27,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 6MM 38MM 14MM STAINLESS STEEL 2.5MM FLUTE",SUP-121838,CDM,C1713,HCPCS,0278,RC,,,both,,,2006.40,601.92,"CIGNA [10200]","Cigna Open Access",,1141.64,56.9,,1144.80,304.56,2275.09,66,233.34,1705.44,"percent of total billed charges",
"STENT ICAST STENT DIAMETER 7X 59MM CATH 120CM ENDOVASCULAR",SUP-42759,CDM,C1874,HCPCS,0278,RC,,,both,,,18881.10,5664.33,"CIGNA [10200]","Cigna Local Plus",,5947.55,31.5,,,,,0,2195.87,16048.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 4.5MM X 26.0MM",SUP-494502612,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1 2 CURVE ULTRABRAID SUTUREFIX STERILE LATEX FREE",SUP-72204687,CDM,C1713,HCPCS,0278,RC,,,both,,,1771.88,531.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,206.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",206.07,1506.1,"percent of total billed charges",
"(EVAL) QUALI BRA ADVANCED M",SUP-QADV-M,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM AXSOS 3 TITANIUM CORTICAL NONSTERILE",SUP-661426,CDM,C1713,HCPCS,0278,RC,,,both,,,289.54,86.86,"CIGNA [10200]",Cigna,,196.89,68,,1831.33,1831.33,1831.33,16,33.67,246.11,"percent of total billed charges",
"LENS IOL +11.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.115,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR E1 POROUS CUP LINER INSRT",SUP-98B00100191,CDM,C1776,HCPCS,0278,RC,,,both,,,15180.00,4554,"PHCS [10601]",PHCS,,10626,70,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PILOT 150 VASCULAR J CURVE 190CM 3CM .014IN",SUP-1010481-HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 20CM 12MM INTERLOCK FIBERED IDC DETACHABLE",SUP-M001361610,CDM,S27800098,LOCAL,0278,RC,,,both,,,2079.00,623.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,595.01,28.62,,,,,0,241.79,1767.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ORTHOLOC FULL THREAD CANCELLOUS ANKLE FOOT",SUP-58934012,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"CIGNA [10200]","Cigna Open Access",,437.85,56.9,,1144.80,304.56,2275.09,66,89.49,654.08,"percent of total billed charges",
"SHELL ACETABULAR 64MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701064,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1345.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1320.06,9647.93,"percent of total billed charges",
"STENT ZIPWIRE 28CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175254080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,146.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ca VI Psp&Sp1 Antb SjãGren",PX-310000051,CDM,0472U,CPT,0310,RC,,,both,,,260.00,78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,119.34,45.9,,,,,0,25.11,221,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 250MM 5MM BALLOON",SUP-U3575525,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 40MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206080470,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 30MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45030,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"BLUE CROSS [10001]","Blue Cross HMO",,32545.69,39.2,,9776.84,9776.84,9776.84,"1 through 10",9655.77,70571.01,"percent of total billed charges",
"CATH EMERGE MONORAIL 144CM 12MM 6FR 1.5MM .07IN BALLOON",SUP-H7493919012150,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,233.04,41.1,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 F 40MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30104006,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1192.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOCEL PRO CELLULAR BONE MATRIX 1CC SMALL",SUP-5016001,CDM,C1713,HCPCS,0278,RC,,,both,,,3967.50,1190.25,"KAISER [10500]",Kaiser,,2658.23,67,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 10D G 9.4MM 36MM X3 HIP",SUP-623-10-36G,CDM,C1776,HCPCS,0278,RC,,,both,,,6879.60,2063.88,"AETNA [10100]","Aetna HMO/PPO",,5469.28,79.5,,10981.53,8986.79,12413.38,12,800.1,5847.66,"percent of total billed charges",
"LARYNSCP INTUB 3 PREASSEMBLE BLADE STD HANDLE LED LIGHT",SUP-040-04-0130U,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.42,18.73,"AETNA [10100]","Aetna HMO/PPO",,49.62,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.26,53.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM GORILLA NONSTERILE R3CON NONLOCK PLATE",SUP-P50-453-3514,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]",Cigna,,660.96,68,,1831.33,1831.33,1831.33,16,113.04,826.2,"percent of total billed charges",
"MESH SURGICAL PARIETENE DS 25X20CM COMPOSITE ABSORBABLE FILM",SUP-PPDS2520,CDM,C1781,HCPCS,0278,RC,,,both,,,6915.11,2074.53,"KAISER [10500]",Kaiser,,4633.12,67,,,,,0,765.93,5877.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +9.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.095,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175270180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"MULTIPLAN [10600]",Multiplan,,1241.09,85,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) WISE PULSE GENERATOR BATTERY","SUP-MODEL 3100",CDM,S62400003,LOCAL,0624,RC,,,both,,,31500.00,9450,"CIGNA [10200]","Cigna Open Access",,17923.5,56.9,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 3MM EMBOLD PLATINUM TUNGSTUN NITINOL",SUP-M001394240030120,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,792.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 220MM 2.6MM AO SCALE",SUP-703901,CDM,S27200284,LOCAL,0272,RC,,,both,,,1207.71,362.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.46,1026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 2.5CM 1.5MM GALAXY G3 MINI STRETCH",SUP-GLM915025,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"UHC [10700]","United Healthcare",,7521.18,63.3,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARM RTRCTR FUKUSHIMA-DAY EXT ADJUSTABLE NONSTERILE STAINLESS",SUP-R9104,CDM,S27200284,LOCAL,0272,RC,,,both,,,7709.30,2312.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,913.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,896.59,6552.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 12MM 3MM CORONARY STENT EVEROLIMUS",SUP-1550300-12,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 15MM STRAIGHT CONICAL MODULAR RESTORATION",SUP-6276-7-115,CDM,C1776,HCPCS,0278,RC,,,both,,,11080.37,3324.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3171.2,28.62,,,,,0,1288.65,9418.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 40MM 8MM BALLOON DILATATION PEBAX",SUP-H74939032804010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.50 X 15 RX US",SUP-1804250-15,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Short Somatosensory Test Tr/Hd",PX-922000010,CDM,95927,CPT,0922,RC,,,both,,,888.00,266.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,105.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.27,754.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Compres Band Rosidal W<3""/Yd",PX-E27000284,CDM,E27000284,LOCAL,0270,RC,,,both,,,121.00,36.3,"CIGNA [10200]","Cigna Open Access",,68.85,56.9,,,,,0,14.07,102.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plt Pheresis Ea Unit",PX-390000009,CDM,P9034,HCPCS,0390,RC,,,both,,,3019.00,905.7,"NOVANET [10819]",Novanet,,2264.25,75,,,,,0,351.11,2566.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PARALLEL FLEXOR 55CM 14FR ENDOSCOPIC HYDROPHILIC",SUP-G56443,CDM,C1894,HCPCS,0272,RC,,,both,,,1396.44,418.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,165.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.41,1186.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH AORTIC ROTATING 4.8MM X 20CM CLEANCUT STERILE",SUP-RCL-48,CDM,S27200284,LOCAL,0272,RC,,,both,,,238.82,71.65,"UHC [10700]","United Healthcare",,151.17,63.3,,,,,0,27.77,203,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE 100CM 5FR .0395IN SIDEWINDER SIM 1 CURVE",SUP-532501,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"PHCS [10601]",PHCS,,73.08,70,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 20MM 2 HOLE CASCADIA CAYMAN BONE SPINE NONSTERILE",SUP-7908-42F203,CDM,C1713,HCPCS,0278,RC,,,both,,,31594.50,9478.35,"CIGNA [10200]","Cigna Open Access",,10584.16,33.5,,1144.80,304.56,2275.09,66,3674.44,26855.33,"percent of total billed charges",
"LARYNSCP VIDEO S1 LOW PROFILE QUICK CONNECT GLIDESCOPE",SUP-0270-1151,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.26,129.98,"FIRST HEALTH [10303]","First Health",,346.61,80,,,,,0,50.39,368.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM TKR PATELLOFEMORAL",SUP-98000661000,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5409.18,28.62,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SURGICAL 4.7X3.1IN SPRING OPEN BIORESORBABLE SELF",SUP-5950030,CDM,C1781,HCPCS,0278,RC,,,both,,,2250.00,675,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,261.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 15CM 12FR POWER-TRIALYSIS SLIM-CATH 3 LUMEN KINK",SUP-5865150,CDM,C1752,HCPCS,0272,RC,,,both,,,1649.25,494.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,195.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,191.81,1401.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 26MM HIP PRIMARY TAPER OFFSET COCR LFIT",SUP-6260-9-226,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,363.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 24MM LCP STAINLESS STEEL CORTICAL FOREFOOT",SUP-202.884,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,148.71,45.9,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC30ST-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,19530.00,5859,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8026.83,41.1,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM PRECEPT",SUP-8847120,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 18MM 135CM 7MM 3.3-3.5FR 6FR LOW",SUP-1011505-18,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"BLUE CROSS [10001]","Blue Cross HMO",,2469.6,39.2,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Lung Perfsn Diff",PX-341000033,CDM,78597,CPT,0341,RC,,,both,,,2819.08,845.72,"UHC [10700]","United Healthcare",,982.43,,,,,,,236.17,2396.22,"fee schedule",
"CMPNT FEMORAL 11 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502607002,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"AETNA [10100]","Aetna HMO/PPO",,18175.85,79.5,,10981.53,8986.79,12413.38,12,2658.93,19433.3,"percent of total billed charges",
"STENT SURPASS EVOLVE 17MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDS32517,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"KAISER [10500]",Kaiser,,55626.56,67,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Boot Heel Lift",PX-E27000066,CDM,E27000066,LOCAL,0270,RC,,,both,,,365.20,109.56,"CIGNA [10200]",Cigna,,248.34,68,,,,,0,42.47,310.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Actvty Dirct 15min (Go)",PX-430000019,CDM,97530,CPT,0430,RC,,,both,,,183.84,55.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.38,183.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? DOUBLE CABLE PLATE KIT",SUP-94-1300-04,CDM,C1713,HCPCS,0278,RC,,,both,,,10867.50,3260.25,"MULTIPLAN [10600]",Multiplan,,9237.38,85,,,,,0,1263.89,9237.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SHORT STEM RSA",SUP-71701430,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"CIGNA [10200]",Cigna,,18144,40,,5873.17,5873.17,5873.17,"1 through 10",5275.37,38556,"percent of total billed charges",
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 65MM COCR",SUP-VAL-35650-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"BLUE CROSS [10001]","Blue Cross HMO",,823.2,39.2,,957.42,156.86,7483.26,51,244.23,1785,"percent of total billed charges",
"GRAFT ENDOVASCULAR 93MM 20-16MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1620C93E,CDM,S27800098,LOCAL,0278,RC,,,both,,,30006.90,9002.07,"UHC [10700]","United Healthcare",,18994.37,63.3,,,,,0,3489.8,25505.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLAZER PRIME 8FR/10MM=P4790THN4",SUP-M004P4790THN4,CDM,C1733,HCPCS,0272,RC,,,both,,,12420.00,3726,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1471.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 60MM 120CM 5MM 6FR VASCULAR PERIPHERAL",SUP-S-50-060-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1192.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 300CM PRESSURE VERRATA PLUS STERILE LATEX","SUP-10300 P",CDM,C1769,HCPCS,0272,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.6MM KIRSCHNER TROCHAR TIP NONSTERILE",SUP-233500008,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,153.47,39.2,,957.42,570.23,957.42,28,45.53,332.78,"percent of total billed charges",
"PLATE 47MM STAINLESS STEEL 2.4MM SCR 4X3 HOLE LCP BONE RIGHT",SUP-242.464,CDM,C1713,HCPCS,0278,RC,,,both,,,4922.87,1476.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,583.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,572.53,4184.44,"percent of total billed charges",
"RING ANNULOPLASTY 32MM TRICUSPID 3 RADIAL MARKER POLISH WIRE",SUP-900SFC32,CDM,S27800098,LOCAL,0278,RC,,,both,,,14490.00,4347,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4147.04,28.62,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.50 X 15 RX US",SUP-1804250-15,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"CATH SUPER TORQUE 110CM 6FR .051IN .042IN PIGTAIL CURVE",SUP-532650S,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 100MM 6MM BALLOON DILATATION RAPID",SUP-47560100L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 430CC 12.9CM 4.4CM PROJECTION MODERATE PLUS P",SUP-SMPB430,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"BLUE CROSS [10001]","Blue Cross PPO",,2988.8,39.2,,16595.83,16595.83,16595.83,"1 through 10",886.73,6480.83,"percent of total billed charges",
"CATH EVERCROSS CROSSTEC 135CM 100MM 6MM .035IN BALLOON",SUP-AB35W06100135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,278.31,41.1,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RIVAL CHECKER 80CM 4CM 5MM BALLOON DILATATION 2 LUMEN",SUP-RV8054,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 15CM 120CM 6MM 6FR ENDOPROSTHESIS HEPARIN",SUP-VBJ061502,CDM,C1874,HCPCS,0278,RC,,,both,,,24462.90,7338.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2898.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2845.04,20793.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 4.8FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006145352190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,518.65,45.9,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,inpatient,,,151155.63,45346.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,58539,,,,,,,8593,107196.03,"case rate",
"APPL INTERNAL CLIP SMALL 9IN TITANIUM ENDOSCOPIC LIGATING",SUP-133650,CDM,S27200284,LOCAL,0272,RC,,,both,,,379.23,113.77,"UHC [10700]","United Healthcare",,240.05,63.3,,,,,0,44.1,322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CTRL ANGIOGRAPHY 3 CLOCKWISE COUNT ROTATION SPINR .014-.038",SUP-3X-GW,CDM,S27200284,LOCAL,0272,RC,,,both,,,1987.50,596.25,"FIRST HEALTH [10303]","First Health",,1590,80,,,,,0,231.15,1689.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL MICRO NDL STRAIGHT 4IN TUNGSTEN",SUP-E16514,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.10,61.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,24.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.97,175.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM SPINE CERVICAL ANTERIOR SELF DRILL",SUP-7741115,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,1144.80,304.56,2275.09,66,117.75,860.63,"percent of total billed charges",
"CAGE SPINAL 55X12MM 10D XL PEEK-OPTIMA PLATE FUSION",SUP-7871250,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3986.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 40MM 2 LEVEL ARCHON BONE SPINE NONSTERILE",SUP-8787240,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Local Plus",,2359.35,53.5,,3978.14,359.25,3978.14,24,512.88,3748.5,"percent of total billed charges",
"GRAFT ENDOVASCULAR 14CM 14.5MM 12-13.5MM GORE EXCLUDER",SUP-PLC141400,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"CIGNA [10200]","Cigna Local Plus",,8819.12,31.5,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752540,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,613.48,68,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 140MM 80CM 10MM 6FR .035IN BILIARY",SUP-G50140,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"MULTIPLAN [10600]",Multiplan,,5176.5,85,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fibrin Degradation Products",PX-305000040,CDM,85362,CPT,0305,RC,,,both,,,343.20,102.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,291.72,"per diem",
"HC Pre-Pooled Cryoprecipitate, Each Unit",PX-390000025,CDM,P9012,HCPCS,0390,RC,,,both,,,399.85,119.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,46.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.5,339.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cholesterol Body Fluid",PX-301000145,CDM,82465,CPT,0301,RC,,,both,,,120.00,36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3.92,,,,,,,0.01,102,"fee schedule",
"HC Hdr Rdncl Skn Surf Brachytx 1 Chnl",PX-342000016,CDM,77767,CPT,0342,RC,,,both,,,6024.59,1807.38,"AETNA [10100]","Aetna HMO/PPO",,4789.55,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,408.8,5120.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Icd Gen Only Sq",PX-480000030,CDM,33241,CPT,0481,RC,,,both,,,6103.78,1831.13,"BLUE CROSS [10001]","Blue Cross HMO",,6103.78,,"Case rate ($25,005.81). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,709.87,6103.78,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sensor Lnop Oximeter",PX-E27000150,CDM,E27000150,LOCAL,0270,RC,,,both,,,290.40,87.12,"UHC [10700]","United Healthcare",,183.82,63.3,,,,,0,33.77,246.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Factor VIII Vw Ag",PX-305000021,CDM,85246,CPT,0305,RC,,,both,,,348.67,104.6,"MULTIPLAN [10600]",Multiplan,,296.37,85,,,,,0,0.01,296.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHLOROTHIAZIDE SODIUM 500 MG/18ML IV (WET SOLR VIAL)",RX-4159526,CDM,J1205,HCPCS,0636,RC,25021-0305-66,NDC,both,1,UN,239.15,71.74,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,113.35,,,,,,,28.34,203.28,"fee schedule",
"TIROFIBAN 12.5 MG/250 ML (50 MCG/ML)-0.9 % SODIUM CHLORIDE INTRAVENOUS",RX-122431,CDM,J3246,HCPCS,0636,RC,25208-0002-02,NDC,both,250,ML,1442.35,432.7,"FIRST HEALTH [10303]","First Health",,1153.88,80,,,,,0,202.8,1226,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC 2 POUCH PACK 1 POWDER STD APPLR TIP PVC",SUP-PCUS003,CDM,A6250,HCPCS,0272,RC,,,both,,,1348.71,404.61,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 9IN 9.5MM SENTINEL ECCENTRIC MONOFLUTE CUTTING",SUP-S8595,CDM,S27200284,LOCAL,0272,RC,,,both,,,1593.51,478.05,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cann Coronary Sinus 13f",PX-E27200383,CDM,E27200383,LOCAL,0272,RC,,,both,,,62.70,18.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Bx Breast Stereotc Clip Plc Add",PX-361000307,CDM,19082,CPT,0361,RC,,,both,,,4316.06,1294.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT POLARIS 22CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155231050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS [10001]","Blue Cross HMO",,482.54,39.2,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 300MM 5.5MM EXPEDIUM Z TITANIUM NONSTERILE",SUP-179798300,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,414.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",414.32,3028.13,"percent of total billed charges",
"TISSUE 210500 SELECT 5MM SRVC FEE",SUP-210500,CDM,S27800098,LOCAL,0278,RC,,,both,,,3018.75,905.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,357.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,351.08,2565.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 24CM 8FR URETERAL FLEXITHANE",SUP-H7493936108240,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"BLUE CROSS [10001]","Blue Cross PPO",,485.81,39.2,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 45MM 26MM UHR UNIVERSAL ACETABULAR HIP COCR",SUP-UH1-45-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"CIGNA [10200]","Cigna Open Access",,2456.81,56.9,,5302.19,4377.88,6578.61,27,502.16,3670.1,"percent of total billed charges",
"CANN ARTHROSCOPIC 5.5MM COMPLETE SYSTEM 72MM CLEAR-TRAC",SUP-72200907,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,24.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET, IMMEDIATE RELEASE",RX-9408,CDM,,,0637,RC,60687-0836-11,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAXX 15CM 10MM NEPHRSTMY PTFE SET",SUP-G47649,CDM,C1726,HCPCS,0272,RC,,,both,,,2279.25,683.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SIEGEL TAVR DELIVERY SYSTEM - HANDLE, BALLOON CATHETE",SUP-30-1-0226,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE JOURNEY VASCULAR 185CM 7CM .014IN INCONEL NITINOL",SUP-M001391270,CDM,C1769,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS,MINOR",344,APR-DRG,,,,,,,inpatient,,,27771.38,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $3,814.95. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,349.84) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"HIV WITH OR WITHOUT OTHER RELATED CONDITION",977,MS-DRG,,,,,,,inpatient,,,44546.33,13363.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 32X6MM ITOTAL IPOLY XE STERILE",SUP-PAT0213206,CDM,C1776,HCPCS,0278,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MONODERM QUILL SRS 2-0 12MM 3/8 CIRCLE 30CM 2 ARM CLEAR",SUP-YA-1024Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,202.10,60.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,83.06,41.1,,,,,0,23.5,171.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2 38IN BRAID TIES MULTISTRAND LOWER KNOT",SUP-AR-7233,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.84,57.55,"KAISER [10500]",Kaiser,,128.53,67,,,,,0,22.31,163.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIBUCAINE 1 % TOPICAL OINTMENT",RX-2412,CDM,,,0637,RC,00536-1211-95,NDC,both,28,GR,36.99,11.1,"AETNA [10100]","Aetna HMO/PPO",,29.41,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.3,31.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE URETHROTOME LANCET",SUP-A3555,CDM,S27200284,LOCAL,0272,RC,,,both,,,1892.55,567.76,"CIGNA [10200]",Cigna,,1286.93,68,,,,,0,220.1,1608.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 3.2MM INTERTAN LAG SCR",SUP-71674540,CDM,S27200284,LOCAL,0272,RC,,,both,,,5071.85,1521.55,"UHC [10700]","United Healthcare",,3210.48,63.3,,,,,0,589.86,4311.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Cytp Oth Prp / Add on 88161",PX-311000084,CDM,0833T,CPT,0311,RC,,,both,,,104.00,31.2,"CIGNA [10200]","Cigna Local Plus",,55.64,53.5,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GARM FACIAL MEDIUM SPRT ELASTIC FACIOPLASTY",SUP-111826,CDM,S27000186,LOCAL,0270,RC,,,both,,,408.64,122.59,"PHCS [10601]",PHCS,,286.05,70,,,,,0,47.52,347.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUARD PIN STD WHITE 3/8IN JURGAN PIN BALL 6 BALL REFILL",SUP-W062,CDM,C1713,HCPCS,0278,RC,,,both,,,417.60,125.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,49.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",48.57,354.96,"percent of total billed charges",
"LENS IOL 0 D +8 DIOPTER MODIFY L BICONVEX 13MM 6MM POSTERIOR",SUP-CC60WF.080,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT XEMPLIFI DEMINERALIZE BONE MATRIX GEL 5ML",SUP-8103.0105S,CDM,C1713,HCPCS,0278,RC,,,both,,,5692.50,1707.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,674.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,662.04,4838.63,"percent of total billed charges",
"HC IV Push Add Seq New Drug",PX-260000008,CDM,96375,CPT,0260,RC,,,both,,,404.05,121.21,"NOVANET [10819]",Novanet,,303.04,75,,,,,0,46.99,404.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sm/Rnp Abs",PX-302000047,CDM,86235,CPT,0302,RC,,,both,,,202.35,60.7,"NOVANET [10819]",Novanet,,151.76,75,,,,,0,0.2,172,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 90CM 6FR STRAIGHT GUIDING DURAFORM",SUP-H965100500,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1148.94,45.9,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTICROSS 6HD 135CM 1.18MM ULTRASOUND CORONARY STERILE",SUP-H74939354090,CDM,C1753,HCPCS,0272,RC,,,both,,,5037.00,1511.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3425.16,68,,,,,0,585.8,4281.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 8MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS08020,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM 27MM 33MM TRIFECTA GLIDE 15MM ANNULUS",SUP-TFGT-27A,CDM,S27800098,LOCAL,0278,RC,,,both,,,38367.00,11510.1,"KAISER [10500]",Kaiser,,25705.89,67,,,,,0,4462.08,32611.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SUCTION SMART THERMAL DRAPE PISTON HEAT DEVICE",SUP-7013-1013,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.28,73.88,"CIGNA [10200]",Cigna,,167.47,68,,,,,0,28.64,209.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS LACTATED RINGERS 1L VIAFLEX LATEX FREE",SUP-2B2324X,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT AORTIC 4.5CM 26MM EXCLUDER CONFORMABLE ACTIVE CONTROL",SUP-CXA260005,CDM,C1874,HCPCS,0278,RC,,,both,,,27612.90,8283.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3211.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3211.38,23470.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 12MM KII FIOS FIRST ENTRY Z THREAD",SUP-CTF73,CDM,S27200284,LOCAL,0272,RC,,,both,,,201.00,60.3,"MULTIPLAN [10600]",Multiplan,,170.85,85,,,,,0,23.38,170.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM VUEPOINT II SPINE FAVORED ANGLE",SUP-8975512,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CIGNA [10200]","Cigna Open Access",,2389.8,56.9,,1144.80,304.56,2275.09,66,488.46,3570,"percent of total billed charges",
"GRAFT BONE OSTEOAMP LARGE ALLOGRAFT COMPRESSIBLE SPONGE 50",SUP-13812209,CDM,C1713,HCPCS,0278,RC,,,both,,,15333.74,4600.12,"NOVANET [10819]",Novanet,,11500.31,75,,,,,0,1783.31,13033.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST TRICORTICAL THK7MM WEDGE ALLOGRAFT",SUP-400398,CDM,S27800098,LOCAL,0278,RC,,,both,,,3916.44,1174.93,"NOVANET [10819]",Novanet,,2937.33,75,,,,,0,455.48,3328.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 100MM 75CM 5MM VASCULAR METAL SUPERFICIAL",SUP-H74939293051070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross PPO",,1893.36,39.2,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY TRANSPLANT",652,MS-DRG,,,,,,,inpatient,,,91630.23,27489.07,"CIGNA [10200]",Cigna,,17330.13,,"Fee schedule rate ($17,330.13). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,38588.35,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR PRESSURE NIFOMETER 60- CM 2O SMALL NEGATIVE",SUP-1034002,CDM,S27000186,LOCAL,0270,RC,,,both,,,125.57,37.67,"UHC [10700]","United Healthcare",,79.49,63.3,,,,,0,14.6,106.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 46MM LCP STAINLESS STEEL T25 CONDYLAR",SUP-02.231.246,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"NOVANET [10819]",Novanet,,980.87,75,,,,,0,152.1,1111.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 30MM 6FR 3.5MM .07IN BALLOON",SUP-H7493918930350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 4.75MM ULTRATAPE ULTRABRAID SMOOTH REGENESORB",SUP-72203697,CDM,C1713,HCPCS,0278,RC,,,both,,,3037.50,911.25,"BLUE CROSS [10001]","Blue Cross HMO",,1190.7,39.2,,957.42,156.86,7483.26,51,353.26,2581.88,"percent of total billed charges",
"MONOFILAMENT SELF-FIXATING POLYESTER MESH WITH POLYLACTIC AC",SUP-LPG1510AR,CDM,C1781,HCPCS,0278,RC,,,both,,,3206.70,962.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,379.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,372.94,2725.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 20MM 31MM 29MM BIOCOR FLEXFIT PORCINE",SUP-B100-31M-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,30744.00,9223.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3575.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3575.53,26132.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP CLUSTER HOLE HA TRIDENT II PSL E",SUP-742-11-54E,CDM,C1776,HCPCS,0278,RC,,,both,,,9502.96,2850.89,"PHCS [10601]",PHCS,,6652.07,70,,,,,0,1105.19,8077.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIATORR 6CM 2CM 10MM ENDOPROSTHESIS NITINOL",SUP-PTB106275,CDM,C1874,HCPCS,0278,RC,,,both,,,29206.80,8762.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11682.72,40,,,,,0,3396.75,24825.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EXOFIN FUSION 22CM SKIN CLSR 2-OCTYL CYANOACRYLATE",SUP-EF70401,CDM,S27200284,LOCAL,0272,RC,,,both,,,518.40,155.52,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,237.95,45.9,,,,,0,60.29,440.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 5MM TARGET 360D STD PLATINUM",SUP-M0035465200,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS [10001]","Blue Cross PPO",,5532.94,39.2,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 8MM BABY GORILLA LOCK",SUP-P50-053-2008,CDM,C1713,HCPCS,0278,RC,,,both,,,1316.25,394.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,895.05,68,,,,,0,153.08,1118.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 36IN 8FR ANTICLOG RADIOPAQUE SMOOTH BOLUS",SUP-40-7368,CDM,S27200284,LOCAL,0272,RC,,,both,,,115.84,34.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.47,98.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 100MM 120CM 6MM 6FR VASCULAR PERIPHERAL",SUP-S-60-100-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2879.74,28.62,,,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US BPP WO Nonstress Test",PX-402000046,CDM,76819,CPT,0402,RC,,,both,,,1494.35,448.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,173.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.93,1270.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP CEMENTED STEM WITH BIOLOX DELTA HEAD R3 MH",SUP-71705325,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6463.8,27,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 45MM 28MM TANDEM HIP ACETABULAR COCR",SUP-71322045,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"AETNA [10100]","Aetna HMO/PPO",,6640.2,79.5,,10981.53,8986.79,12413.38,12,971.39,7099.58,"percent of total billed charges",
"PLUG BONE CEMENT 30MM LARGE INTRAMEDULLARY CANAL STERILE",SUP-6215-5-021,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"NOVANET [10819]",Novanet,,571.05,75,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 10FT CARTO 3 34 PIN HYPERTRONIC ELECTROPHYSIOLOGY",SUP-D128624,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"AETNA [10100]","Aetna HMO/PPO",,2677.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPLATZER TALISMAN DELIVERY SHEATH 9F 80",SUP-9-TDS-09F45-80,CDM,S27200284,LOCAL,0272,RC,,,both,,,5154.30,1546.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,599.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,599.45,4381.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 4.4MM ORTHOLOC FOOT ANKLE 3DI TECHNOLOGY",SUP-77706514,CDM,S27200284,LOCAL,0272,RC,,,both,,,1166.40,349.92,"CIGNA [10200]",Cigna,,793.15,68,,,,,0,135.65,991.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN IRRIGATION 18GA 50MM 10MM",SUP-AC0004,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"NOVANET [10819]",Novanet,,78.3,75,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo Submucosal Dissection",PX-750000219,CDM,C9779,HCPCS,0750,RC,,,both,,,3923.00,1176.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,464.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,456.24,3923,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM TRICUSPID 1 SEAM 2 WRAP ANATOMIC",SUP-4900T26,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"CIGNA [10200]","Cigna Open Access",,4276.28,33.5,,,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC SURGILAV PLUS SET MULTIORIFICE TIP SPLASH SHIELD",SUP-207-559,CDM,S27200284,LOCAL,0272,RC,,,both,,,337.68,101.3,"UHC [10700]","United Healthcare",,213.75,63.3,,,,,0,39.27,287.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 17MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181750,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"KAISER [10500]",Kaiser,,12460.39,67,,,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 28CM 3CM 6FR .038IN 2",SUP-M006192134170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,640.41,45.9,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 71MM STAINLESS STEEL LARGE FRAGMENT SET 4 HOLE",SUP-222.04,CDM,C1713,HCPCS,0278,RC,,,both,,,1376.03,412.81,"CIGNA [10200]","Cigna Open Access",,782.96,56.9,,1144.80,304.56,2275.09,66,160.03,1169.63,"percent of total billed charges",
"PLATE STRAIGHT 29X3.8X.8MM TITANIUM 1.5MM SCR 6 HOLE LOW",SUP-446.031,CDM,C1713,HCPCS,0278,RC,,,both,,,2790.90,837.27,"NOVANET [10819]",Novanet,,2093.18,75,,,,,0,324.58,2372.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE? II PRO SZ PTCA BALLOON SEMI-COMPLIANT 1.25 MM X 5",SUP-212-053-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PERFORM XL STEM UPCHARGE",SUP-CAP1203,CDM,C1776,HCPCS,0278,RC,,,both,,,6900.00,2070,"FIRST HEALTH [10303]","First Health",,5520,80,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +7.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-MA60AC.750,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 150MM 4MM BALLOON DILATATION",SUP-PCU040150130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING G7 -3MM OFFSET TAPER HIP TITANIUM TYPE 1",SUP-650-1065,CDM,C1776,HCPCS,0278,RC,,,both,,,1539.00,461.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,182.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE RAD DIST VOLAR STND 4HLR","SUP-GMN-RTS-4HL RIGHT",CDM,C1713,HCPCS,0278,RC,,,both,,,5161.20,1548.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3509.62,68,,,,,0,600.25,4387.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12MM NATURAL LARGE LORDOTIC",SUP-19412,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT WALKING J WALKER MEDIUM LEG FOREFOOT ANKLE ALUMINUM",SUP-BL210005,CDM,S27000186,LOCAL,0270,RC,,,both,,,243.34,73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,111.69,45.9,,,,,0,28.3,206.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 23GA MVR STERILE DISPOSABLE",SUP-8065912301,CDM,S27200284,LOCAL,0272,RC,,,both,,,244.12,73.24,"MULTIPLAN [10600]",Multiplan,,207.5,85,,,,,0,28.39,207.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM DELTAXSFT 10 COIL",SUP-DLX100204,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2590.91,28.62,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rom Measurement Hnd (Gp)",PX-420000011,CDM,95852,CPT,0420,RC,,,both,,,252.89,75.87,"FIRST HEALTH [10303]","First Health",,202.31,80,,,,,0,29.41,252.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 5MM MEDIUM CARBIDE ROUND ZIMMER RSC",SUP-5300-10-513,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.08,49.82,"FIRST HEALTH [10303]","First Health",,132.86,80,,,,,0,19.32,141.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 110CM 6CM 5FR 6MM 7.5MM BALLOON DILATATION",SUP-4196060L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL CANNULATED 7.5MM STERILE",SUP-AR-1218-75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PERFECTPASSER SMARTSTITCH SUTURING DISPOSABLE",SUP-OM-8010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1348.65,404.59,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,619.03,45.9,,,,,0,156.85,1146.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 7-12 G-H KNEE RIGHT TIBIA",SUP-42521200610,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5491.52,68,,,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM 1.6MM KIRSCHNER STAINLESS STEEL 2 TROCAR",SUP-292.56,CDM,C1713,HCPCS,0278,RC,,,both,,,71.86,21.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,20.57,28.62,,,,,0,8.36,61.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 2CM 5MM 6FR BALLOON DILATATION",SUP-V185020,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT CHORD-X 2-0 .5 CIRCLE 18MM 2 ARM LOOP PLEDG 3 CHORDAL 20",SUP-CXL-20-1812-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 70X27MM STD OSCILLATING ERGONOMIC LIGHTWEIGHT",SUP-519.170S,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ROD SPINAL 240MM 3.2MM STD",SUP-3602240,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Occult Blood Feces Immunoassy",PX-301000119,CDM,82274,CPT,0301,RC,,,both,,,120.00,36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.72,,"Fee schedule rate ($16.72). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.68,102,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE 15X12CM PREPERITONEAL KNIT WEB SYNECOR",SUP-GKWR1215,CDM,C1781,HCPCS,0278,RC,,,both,,,6423.90,1927.17,"CIGNA [10200]","Cigna Open Access",,3655.2,56.9,,11235.02,819.42,11235.02,"1 through 10",747.1,5460.32,"percent of total billed charges",
"OTITIS MEDIA AND URI WITH MCC",152,MS-DRG,,,,,,,inpatient,,,34029.10,10208.73,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,7663.27,,"Case rate ($7,333.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,809.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,896.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,818.43. The transfer operating threshold is the transfer adjustment factor * $6,809.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $514.83. The transfer capital threshold is the transfer adjustment factor * $514.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7333.27,29482.89,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM PRIMARY CEMENT DISTAL BULLET TIP SYNERGY",SUP-71316211,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"BLUE CROSS [10001]","Blue Cross HMO",,8334.9,39.2,,5311.50,4717.44,5388.59,31,2472.83,18073.13,"percent of total billed charges",
"BLADE MORCELLATION 20MM STERILE",SUP-53-000020,CDM,C1782,HCPCS,0272,RC,,,both,,,2325.00,697.5,"CIGNA [10200]",Cigna,,1581,68,,,,,0,270.4,1976.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR STRAIGHT 260CM 3CM .018IN",SUP-M001467320,CDM,C1769,HCPCS,0272,RC,,,both,,,1539.00,461.7,"NOVANET [10819]",Novanet,,1154.25,75,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 85MM 20MM ASNIS III STAINLESS STEEL",SUP-326085,CDM,C1713,HCPCS,0278,RC,,,both,,,1904.40,571.32,"BLUE CROSS [10001]","Blue Cross PPO",,746.52,39.2,,957.42,570.23,957.42,28,221.48,1618.74,"percent of total billed charges",
"MESH SURGICAL OVITEX PRS LONG TERM RESORBABLE 3 LAYER",SUP-P20363-2025G,CDM,C1781,HCPCS,0278,RC,,,both,,,47575.08,14272.52,"KAISER [10500]",Kaiser,,31875.3,67,,,,,0,5532.98,40438.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16015545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4382,45.9,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 90MM 6MM DISTAFLO SMALL BEAD MINI CUFF",SUP-DFX9006SC,CDM,C1768,HCPCS,0278,RC,,,both,,,10339.63,3101.89,"BLUE CROSS [10001]","Blue Cross HMO",,4053.13,39.2,,,,,0,1202.5,8788.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 80MM 75CM 8MM 8FR .035IN BILIARY METAL",SUP-M00574640,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK NASAL DRSG SINU-KNIT",SUP-RR600,CDM,S27200284,LOCAL,0272,RC,,,both,,,389.78,116.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,178.91,45.9,,,,,0,45.33,331.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60MMX4.8MM TITANIUM THICK TISSUE 2 ROW LINEAR",SUP-TX60G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1871.98,561.59,"CIGNA [10200]","Cigna Open Access",,1065.16,56.9,,,,,0,217.71,1591.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT HAKIM CSF 120CM 14CM UNITIZED DISTAL CATH",SUP-823834,CDM,S27800098,LOCAL,0278,RC,,,both,,,34085.02,10225.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4039.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3964.09,28972.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN EXTRA",SUP-77806100,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF ENHANCR II 110CM 4MM 7FR 2-5-2MM SPACE 55MM SINGLE",SUP-31745523,CDM,C1733,HCPCS,0272,RC,,,both,,,3375.00,1012.5,"NOVANET [10819]",Novanet,,2531.25,75,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 12.7MM 9MM SHILEY CUFF DISPOSABLE INNER CANN",SUP-9CN90A,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.97,110.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,249.54,68,,,,,0,42.68,311.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL MULTIPASS 6-0 PS-3 18IN BRAID COATED UNDYED",SUP-J499G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALEXIS CES 17CM",SUP-GTB17,CDM,S27200284,LOCAL,0272,RC,,,both,,,2700.00,810,"AETNA [10100]","Aetna HMO/PPO",,2146.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC",435,MS-DRG,,,,,,,inpatient,,,74505.71,22351.71,"UHC [10700]","United Healthcare",,45805.46,,"Fee schedule rate ($45,805.46). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,45805.46,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR STAINLESS STEEL WIDE .56MM 35 STAPLE STERILE",SUP-050284,CDM,S27200284,LOCAL,0272,RC,,,both,,,160.95,48.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,19.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.72,136.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE REGENESORB 25MM 9MM 9MM FULL LENGTH SOLID",SUP-72204404,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,793.93,28.62,,,,,0,322.62,2357.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 20MM OPTILINK T25 SELF TAP VARIABLE ANGLE",SUP-42.231.220,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,160.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",157.3,1149.66,"percent of total billed charges",
"CATH LIVEWIRE 115CM 6FR 1MM 2-5-2MM SPACE ELECTROPHYSIOLOGY",SUP-401575R,CDM,C1730,HCPCS,0272,RC,,,both,,,2812.50,843.75,"NOVANET [10819]",Novanet,,2109.38,75,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 80CM 11MM 16SQ MM 8FR .035IN",SUP-BXA112901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"KAISER [10500]",Kaiser,,13068.22,67,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.50 X 28 MM  RX FDA",SUP-1203350-28,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"NOVANET [10819]",Novanet,,12937.5,75,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 56MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.546S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,177.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,174.09,1272.35,"percent of total billed charges",
"STENT EVERFLEX ENTRUST 120MM 150CM 8MM VASCULAR NICKEL",SUP-EVD35-08-120-150,CDM,C1876,HCPCS,0278,RC,,,both,,,7665.00,2299.5,"BLUE CROSS [10001]","Blue Cross HMO",,3004.68,39.2,,,,,0,891.44,6515.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 31X9X.38MM PRECISION MEDIUM LONG STAINLESS STEEL",SUP-2296-003-225,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,111.06,41.1,,,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT RETRIEVER 20MM 3MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0033PK32021001,CDM,S27200284,LOCAL,0272,RC,,,both,,,20045.55,6013.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2375.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2331.3,17038.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET SPINE LOCKING XLNK MAS CNCT",SUP-7752529,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"MULTIPLAN [10600]",Multiplan,,295.8,85,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 120MM 118CM 7MM 75CM VASCULAR NITINOL ILIAC",SUP-H74939200071270,CDM,C1876,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,511.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 80MM 14MM VASCULAR NITINOL VENOUS ILIOFEMORAL",SUP-AB9U14080090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"PHCS [10601]",PHCS,,7245,70,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR STD 37MM 3 PEG KNEE SERIES A",SUP-184768,CDM,C1776,HCPCS,0278,RC,,,both,,,4824.48,1447.34,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2214.44,45.9,,,,,0,561.09,4100.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPLATZ RENAL SHEATH 26FX17CM",SUP-M0062601520,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,39.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG LEAD IS-1 MR CONDITIONAL PORT IMAGEREADY",SUP-7145,CDM,S27800098,LOCAL,0278,RC,,,both,,,2232.50,669.75,"CIGNA [10200]",Cigna,,1518.1,68,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TWISTER PLUS 160CM 15MM 2MM SPECIMEN RETRIEVAL",SUP-TWIST15-PED,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRUSH CYTOLOGY 8FR 200CMX2.1MM RAPID EXCHANGE COMBO CATH",SUP-M00545000,CDM,S27200284,LOCAL,0272,RC,,,both,,,873.34,262,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROCHLORPERAZINE MALEATE 5 MG TABLET",RX-6583,CDM,Q0164,HCPCS,0637,RC,50268-0684-11,NDC,both,1,UN,8.10,2.43,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL 2.84IN 3/32IN EDGE STD PTFE ELECTRD",SUP-E1465B,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.24,14.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW FEATHERRASP SM STERILE LATEX FREE DISPOSABLE",SUP-SN31,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Chemo Intralesional 1-7 Lesions",PX-331000007,CDM,96405,CPT,0331,RC,,,both,,,389.36,116.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Tcat Plmt&Rmvl Cerebrl Epd Perq",PX-361000562,CDM,33370,CPT,0361,RC,,,both,,,45298.00,13589.4,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1249,38503.3,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cont Aero Aao Ea Add Hr",PX-410000008,CDM,94645,CPT,0410,RC,,,both,,,632.85,189.85,"PHCS [10601]",PHCS,,443,70,,,,,0,73.6,537.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Targeted Genomic Seq Analysis",PX-301000564,CDM,81445,CPT,0310,RC,,,both,,,5525.00,1657.5,"MULTIPLAN [10600]",Multiplan,,4696.25,85,,,,,0,0.01,4696.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROCAINAMIDE 100 MG/ML INJECTION SOLUTION",RX-6562,CDM,J2690,HCPCS,0636,RC,14789-0901-07,NDC,both,10,ML,4528.80,1358.64,"NOVANET [10819]",Novanet,,3396.6,75,,,,,0,4.25,3849.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vitamin D 1 25 Dihydroxy",PX-301000178,CDM,82652,CPT,0301,RC,,,both,,,421.20,126.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.42,,"Fee schedule rate ($40.42). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",121.29,121.29,121.29,"1 through 10",0.42,358.02,"fee schedule",
"HC Dest Lumb/Sac Facet Jnt",PX-510000155,CDM,64635,CPT,0761,RC,,,both,,,3281.00,984.3,"CIGNA [10200]","Cigna Local Plus",,2051,,"Per diem ($2,051).",,,,0,381.58,3281,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rheumatoid Factor Qual",PX-302000090,CDM,86430,CPT,0302,RC,,,both,,,236.00,70.8,"CIGNA [10200]",Cigna,,13.51,,,,,,,0.01,200.6,"fee schedule",
"HC RBC Washed Ea Unit",PX-390000007,CDM,P9022,HCPCS,0390,RC,,,both,,,1602.00,480.6,"CIGNA [10200]","Cigna Local Plus",,857.07,53.5,,,,,0,186.31,1361.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Home Mgmt Train Ea 15min (Gp)",PX-420000029,CDM,97535,CPT,0420,RC,,,both,,,207.28,62.18,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,207.28,,"Per diem ($239.55).",,,,0,24.11,207.28,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemoglobin Fetal Qual",PX-301000227,CDM,83033,CPT,0301,RC,,,both,,,228.00,68.4,"PHCS [10601]",PHCS,,159.6,70,,,,,0,0.23,193.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drain Absc Pelvic Tansrectal",PX-361000505,CDM,45000,CPT,0361,RC,,,both,,,6320.00,1896,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,735.02,5469,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Access Av Dial Grft for Eval",PX-361000434,CDM,36901,CPT,0361,RC,,,both,,,4893.23,1467.97,"BLUE CROSS [10001]","Blue Cross PPO",,3634.7,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,569.08,4159.25,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cystoscopy W Insert Stent",PX-361000342,CDM,52332,CPT,0361,RC,,,both,,,8387.42,2516.23,"NOVANET [10819]",Novanet,,6290.57,75,,,,,0,975.46,7883,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTRIAXONE 250 MG SOLUTION FOR INJECTION",RX-9489,CDM,J0696,HCPCS,0636,RC,00409-7337-11,NDC,both,1,UN,18.92,5.68,"CIGNA [10200]","Cigna Open Access",,1.25,,,,,,,0.5,16.08,"fee schedule",
"HC Thera Cytopheresis",PX-361000107,CDM,36512,CPT,0390,RC,,,both,,,12324.44,3697.33,"MULTIPLAN [10600]",Multiplan,,10475.77,85,,,,,0,1433.33,10475.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Consult Comprehensive 1",PX-312000033,CDM,88325,CPT,0312,RC,,,both,,,1094.00,328.2,"BLUE CROSS [10001]","Blue Cross PPO",,169.72,,"Fee schedule rate ($169.72).",,,,0,0.01,929.9,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC T Cell Absolute Cd4 Count",PX-302000082,CDM,86361,CPT,0302,RC,,,both,,,313.30,93.99,"CIGNA [10200]","Cigna Open Access",,58.92,,,,,,,0.01,266.31,"fee schedule",
"HC Hydroxyprogesterone",PX-301000239,CDM,83498,CPT,0301,RC,,,both,,,307.80,92.34,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,261.63,"per diem",
"HC Vn Screen Sars Cov-2 Covid-19",PX-300000412,CDM,86408,CPT,0300,RC,,,both,,,228.00,68.4,"CIGNA [10200]","Cigna Local Plus",,92.69,,,,,,,27.02,193.8,"fee schedule",
"HC ED Visit Level 5 W Proc",PX-450000320,CDM,99285,CPT,0450,RC,,,both,,,2982.77,894.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,725,,,,,,,419.55,2535.35,"case rate",
"CATH ELCA 135CM 6FR 1.7MM .014IN ATHERECTOMY RAPID EXCHANGE",SUP-117-016,CDM,C1885,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pack Perf Tub Waste Bag",PX-E27200271,CDM,E27200271,LOCAL,0272,RC,,,both,,,514.80,154.44,"CIGNA [10200]","Cigna Open Access",,292.92,56.9,,,,,0,59.87,437.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Angio Visc Sel Si",PX-323000017,CDM,75726,CPT,0323,RC,,,both,,,8240.91,2472.27,"UHC [10700]","United Healthcare",,8240.91,,,,,,,121.77,8240.91,"fee schedule",
"HC Propoxyphene",PX-301000571,CDM,80367,CPT,0301,RC,,,both,,,83.00,24.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Afo Spiral Plastic Pf",PX-E27400079,CDM,L1951,HCPCS,0274,RC,,,both,,,2768.70,830.61,"NOVANET [10819]",Novanet,,2076.53,75,,,,,0,322,2353.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 15MM 145CM 3MM CORONARY STENT",SUP-1145300-15,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross HMO",,2288.5,39.2,,9776.84,9776.84,9776.84,"1 through 10",678.96,4962.3,"percent of total billed charges",
"HC Brace Hf CK Glv W/Fgr Pf",PX-E27400086,CDM,L3912,HCPCS,0274,RC,,,both,,,312.40,93.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,36.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.33,265.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Spine Lumbosacral Complt >=6v",PX-320000046,CDM,72114,CPT,0320,RC,,,both,,,1245.01,373.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,144.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.68,1058.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC H Pylori Stool Ag Eia",PX-306000102,CDM,87338,CPT,0306,RC,,,both,,,419.90,125.97,"FIRST HEALTH [10303]","First Health",,335.92,80,,,,,0,0.01,356.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0329,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]","Cigna Open Access",,539.24,56.9,,1144.80,304.56,2275.09,66,110.22,805.55,"percent of total billed charges",
"COIL EMBOLIZATION 7CM 5MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140507,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]","Cigna Open Access",,3980.4,33.5,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Pta Cmplx Init",PX-361000723,CDM,37282,CPT,0361,RC,,,both,,,14777.16,4433.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6019.63,,"Case rate ($6,019.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,1718.58,12560.59,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 50MM 7.5MM MODULEX OSTEOGRIP SPINE",SUP-55900507550,CDM,C1713,HCPCS,0278,RC,,,both,,,4519.50,1355.85,"BLUE CROSS [10001]","Blue Cross HMO",,1771.64,39.2,,957.42,156.86,7483.26,51,525.62,3841.58,"percent of total billed charges",
"CATH STABLEMAPR SM 110CM 5FR 2-10-2MM SPACING",SUP-04130DS,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 7-0 TG140-8 18IN 2 ARM BRAID COATED VIOLET",SUP-J546G,CDM,S27200284,LOCAL,0272,RC,,,both,,,152.85,45.85,"MULTIPLAN [10600]",Multiplan,,129.92,85,,,,,0,17.78,129.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 C NEUTRAL 32MM ARCOMXL HIP",SUP-010000730,CDM,C1776,HCPCS,0278,RC,,,both,,,8101.98,2430.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,960.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,942.26,6886.68,"percent of total billed charges",
"LEAD PACING 55CM RIGHT VENTRICLE DF-4 TRIPOLAR SCR DEFIB",SUP-6935M55,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4914.63,28.62,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +10MM 22MM HIP C TAPER COCR LFIT",SUP-06-2210,CDM,C1776,HCPCS,0278,RC,,,both,,,4188.30,1256.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,487.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,487.1,3560.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELLIPSE NEXT GENERATION DR 36",SUP-CD2411-36C,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4806.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hiv-1 Genotype Dna Reverse",PX-306000179,CDM,87901,CPT,0306,RC,,,both,,,3095.10,928.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,128.83,,"Fee schedule rate ($128.83). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,2630.84,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK",RX-121729,CDM,J3475,HCPCS,0636,RC,44567-0420-24,NDC,both,50,ML,100.65,30.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4.33,,,,,,,0.24,85.55,"fee schedule",
"STEM FEMORAL 115MM 14MM PRESS FIT UNIVERSAL FLUTE KNEE",SUP-867428,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"BLUE CROSS [10001]","Blue Cross PPO",,3175.44,39.2,,3949.44,3949.44,3949.44,"1 through 10",942.1,6885.51,"percent of total billed charges",
"HC Hbb Full Gene Sequence",PX-309000140,CDM,81364,CPT,0310,RC,,,both,,,1536.00,460.8,"NOVANET [10819]",Novanet,,1152,75,,,,,0,0.01,1305.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tte Cong W Contr Cmplt",PX-483000019,CDM,C8923,HCPCS,0480,RC,,,both,,,2274.00,682.2,"PHCS [10601]",PHCS,,1591.8,70,,,,,0,264.47,2274,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS VOICE PROLARYN VOCAL CORD INJECTABLE CALCIUM HA",SUP-8044M0K5,CDM,C1878,HCPCS,0278,RC,,,both,,,4692.00,1407.6,"PHCS [10601]",PHCS,,3284.4,70,,,,,0,545.68,3988.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Impacted Cerumen",PX-450000304,CDM,69210,CPT,0361,RC,,,both,,,1527.04,458.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,180.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,177.59,1527.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Ren Arty 1st Ord Uni",PX-361000091,CDM,36251,CPT,0361,RC,,,both,,,7964.58,2389.37,"CIGNA [10200]","Cigna Open Access",,6428,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,926.28,7883,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION SUPERORDERABLE",RX-408848,CDM,J7510,HCPCS,0636,RC,,,both,5,ML,12.54,3.76,"UHC [10700]","United Healthcare",,5.37,,,,,,,0.8,10.66,"fee schedule",
"HC Pth Related Protein Pth-Rp",PX-301000257,CDM,83519,CPT,0301,RC,,,both,,,419.00,125.7,"PHCS [10601]",PHCS,,293.3,70,,,,,0,0.01,356.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immunology Unlstd Proc",PX-302000225,CDM,86849,CPT,0302,RC,,,both,,,332.00,99.6,"FIRST HEALTH [10303]","First Health",,265.6,80,,,,,0,0.01,282.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 120CM 3FR 16MM 4 WIRE STONE",SUP-M0063901030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1416.61,424.98,"PHCS [10601]",PHCS,,991.63,70,,,,,0,164.75,1204.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE REVERSE REVISION HUMERAL STEM, SZ 14X175MM",SUP-530-14-175,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1465.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 6FR STRAIGHT RIGHT VENTRICLE MRI PASSIVE",SUP-7731,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,264.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -2.5MM 32MM HIP C TAPER NECK COCR LFIT",SUP-S-1400-HH31,CDM,C1776,HCPCS,0278,RC,,,both,,,4188.30,1256.49,"CIGNA [10200]","Cigna Open Access",,2383.14,56.9,,5302.19,4377.88,6578.61,27,487.1,3560.06,"percent of total billed charges",
"SYSTEM TENDYNE TMVR SYSTEM LP35M","SUP-TENDYNE TENDYNE 35M SYSTEM",CDM,S27800098,LOCAL,0278,RC,,,both,,,319200.00,95760,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,91355.04,28.62,,,,,0,37122.96,271320,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 36MM AEQUALIS SHOULDER COCR REVERSE CENTER 25",SUP-DWD180,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"CIGNA [10200]",Cigna,,4877.2,40,,5873.17,5873.17,5873.17,"1 through 10",1418.05,10364.05,"percent of total billed charges",
"SCR BONE 3.5MM 26MM SPINE PLY SHAFT NONSTERILE 4MM ROD",SUP-102035726,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 6FR 40D GUIDING DURAFORM PTFE",SUP-M003101420,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"AETNA [10100]","Aetna HMO/PPO",,1989.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE ABSORBABLE VICRYL MICROPOINT 7-0 TG160-8 L18 IN 2 ARM",SUP-J576G,CDM,S27200284,LOCAL,0272,RC,,,both,,,152.85,45.85,"MULTIPLAN [10600]",Multiplan,,129.92,85,,,,,0,17.78,129.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM BIRMINGHAM BICEPS FIXATION STERILE LATEX FREE",SUP-AR-1662S-1,CDM,C1713,HCPCS,0278,RC,,,both,,,5071.50,1521.45,"BLUE CROSS [10001]","Blue Cross HMO",,1988.03,39.2,,957.42,156.86,7483.26,51,589.82,4310.78,"percent of total billed charges",
"LENS IOL SY60WF.095 CLAREON",SUP-SY60WF.095,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 111MM TRI-LOCK BPS GRIPTION 8 STD OFFSET HIP",SUP-101204080,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6620.03,41.1,,6417.48,6417.48,6417.48,"1 through 10",1873.26,13691.05,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 28CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006155244170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,965.83,68,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 6MM X 10CM",SUP-M0035476100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4039.61,28.62,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11.25CM NATRELLE INSPIRA P4.5CM FULL PROFILE",SUP-MSZ-F295,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,65.01,41.1,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMAKER CARDIAC 33GM 16.6ML CONNECTOR W4.45XH6.17IN D0.75I",SUP-U228,CDM,C2621,HCPCS,0275,RC,,,both,,,25200.00,7560,"CIGNA [10200]","Cigna Open Access",,8442,33.5,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH AORTIC ROTATING 4.0MM X 20CM CLEANCUT STERILE",SUP-RCL-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"KAISER [10500]",Kaiser,,153.01,67,,,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT 16CM X 20CM CORTIVA DERMIS",SUP-DH1620,CDM,S27800098,LOCAL,0278,RC,,,both,,,52332.15,15699.64,"NOVANET [10819]",Novanet,,39249.11,75,,,,,0,6086.23,44482.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEO-LINE BONE GRAFT DELIVERY DEVICE",SUP-LS-1015-150,CDM,S27200284,LOCAL,0272,RC,,,both,,,4688.55,1406.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1926.99,41.1,,,,,0,545.28,3985.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 600MM 4.75MM CD HORIZON STRAIGHT COCRMO PLUS LINE",SUP-1476200600,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 LEFT KNEE CRUCIATE RETAINING CEMENTED",SUP-5510-F-301,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"BLUE CROSS [10001]","Blue Cross PPO",,6427.96,39.2,,3949.44,3949.44,3949.44,"1 through 10",1907.07,13938.17,"percent of total billed charges",
"COIL EMBOLIZATION 24CM 8MM CEREPAK FREEFORM DETACHABLE",SUP-SCR120824,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5290.34,40,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM CREO CREO AMP SPINE MODULAR NONSTERILE",SUP-1067.1230,CDM,C1713,HCPCS,0278,RC,,,both,,,2812.50,843.75,"FIRST HEALTH [10303]","First Health",,2250,80,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 360D 25KHZ LONG SUPER PAYNER ULTRASONIC SONOPET",SUP-5450800302,CDM,S27200284,LOCAL,0272,RC,,,both,,,5827.74,1748.32,"AETNA [10100]","Aetna HMO/PPO",,4633.05,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,677.77,4953.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC20ST-LK,CDM,S27200284,LOCAL,0272,RC,,,both,,,17640.00,5292,"AETNA [10100]","Aetna HMO/PPO",,14023.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE NARROW SAGITTAL MICS SURGICAL DISPOSABLE",SUP-116171,CDM,S27200284,LOCAL,0272,RC,,,both,,,2287.50,686.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,271.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,266.04,1944.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT LEAD SPLICE 6.1FR 8.3FR CAPSURE 10.7FR TRANSVENOUS",SUP-5867-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,174.00,52.2,"CIGNA [10200]","Cigna Local Plus",,93.09,53.5,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 0D 2SHORT 1.3MM 2 HOLE DORSIFLEXION PRIMARY GORILLA",SUP-P53-103-L004,CDM,C1713,HCPCS,0278,RC,,,both,,,8159.25,2447.77,"PHCS [10601]",PHCS,,5711.48,70,,,,,0,948.92,6935.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X7MM HEDRON HEDRON IC 7D 10MM STERILE LATEX",SUP-1213.6077S,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1226.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 2 13MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-213,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1164.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1143.29,8355.94,"percent of total billed charges",
"SCR BONE 2.7MM 14MM AXSOS STAINLESS STEEL FULL THREAD",SUP-349614,CDM,C1713,HCPCS,0278,RC,,,both,,,233.86,70.16,"NOVANET [10819]",Novanet,,175.4,75,,,,,0,27.2,198.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR HEADFRAME LONG RING STERILE DISPOSABLE",SUP-DHRSL5,CDM,S27200284,LOCAL,0272,RC,,,both,,,12489.48,3746.84,"MULTIPLAN [10600]",Multiplan,,10616.06,85,,,,,0,1452.53,10616.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 2-0 P-14 3/8 CIRCLE 23IN 24MM CLSR PREMIUM",SUP-VLOCM0135,CDM,S27200284,LOCAL,0272,RC,,,both,,,262.83,78.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,108.02,41.1,,,,,0,30.57,223.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT EDGE ACCUVAC",SUP-E2450HS,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.66,32,"CIGNA [10200]",Cigna,,72.53,68,,,,,0,12.4,90.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 200MM CEMENT EXT PROSTALAC 3 HIP LEFT LATEX",SUP-154123000,CDM,C1776,HCPCS,0278,RC,,,both,,,18814.32,5644.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2188.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2188.11,15992.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MIDAS REX MR8 5MM BALL SYMMETRICAL DISSECTING",SUP-MR8-9BA50T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1444.64,433.39,"NOVANET [10819]",Novanet,,1083.48,75,,,,,0,168.01,1227.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX13MM FRA 8D 30D NARROW SPINE LUMBAR",SUP-213,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"AETNA [10100]","Aetna HMO/PPO",,15025.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUROLOGICAL EYE DISORDERS",123,MS-DRG,,,,,,,inpatient,,,43843.81,13153.14,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,5102.38,,"Case rate ($4,953.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,599.91, add-ons for qualifying new technology services are included. If operating cost exceeds $37,639.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,729.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,605.99. The transfer operating threshold is the transfer adjustment factor * $4,599.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $347.78. The transfer capital threshold is the transfer adjustment factor * $347.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4953.77,19916.29,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"TESTES PROCEDURES WITH CC/MCC",711,MS-DRG,,,,,,,inpatient,,,54422.83,16326.85,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,13830.76,,"Case rate ($12,925.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,002.61, add-ons for qualifying new technology services are included. If operating cost exceeds $45,042.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,289.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,018.48. The transfer operating threshold is the transfer adjustment factor * $12,002.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.46. The transfer capital threshold is the transfer adjustment factor * $907.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,54422.83,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"TESTES PROCEDURES WITH CC/MCC",711,MS-DRG,,,,,,,inpatient,,,54422.83,16326.85,"BLUE CROSS [10001]","Blue Cross PPO",,54422.83,,,,,,,7561,54422.83,"case rate",
"SYSTEM XIENCE ALPINE 23MM 145CM 2.5MM CORONARY STENT",SUP-1125250-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"KAISER [10500]",Kaiser,,3911.46,67,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 142MM 30MM 25-27MM 20FR ZENITH TX2",SUP-G47445,CDM,C1874,HCPCS,0278,RC,,,both,,,98041.65,29412.49,"MULTIPLAN [10600]",Multiplan,,83335.4,85,,,,,0,11402.24,83335.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 7MMX39MM 7FR 80CMCATH HEPARIN",SUP-BXB073901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS [10001]","Blue Cross PPO",,7645.88,39.2,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 7MMX39MM 7FR 80CMCATH HEPARIN",SUP-BXB073901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2311.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 8MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBJ081002,CDM,C1874,HCPCS,0278,RC,,,both,,,21218.40,6365.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2514.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2467.7,18035.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 80MM 4FR 5MM .018IN BALLOON",SUP-PCP050080130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UHC [10700]","United Healthcare",,779.35,63.3,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 8IN 40D UP CERVICAL 9X5MM MICRO-KERRISON EJECTOR",SUP-57-0695,CDM,S27200284,LOCAL,0272,RC,,,both,,,2535.15,760.54,"PHCS [10601]",PHCS,,1774.61,70,,,,,0,294.84,2154.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 19FR .25IN BLAKE SILICONE 4 CHANNEL .75",SUP-072225,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.15,37.24,"MULTIPLAN [10600]",Multiplan,,105.53,85,,,,,0,14.44,105.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 85MM STAINLESS STEEL LARGE FRAGMENT SET 4 HOLE ANGLED",SUP-240.54,CDM,C1713,HCPCS,0278,RC,,,both,,,9574.16,2872.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6510.43,68,,,,,0,1113.47,8138.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175253080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"FIRST HEALTH [10303]","First Health",,991.5,80,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM EVOLVE STAINLESS STEEL CORTICAL ELBOW",SUP-4972712L,CDM,C1713,HCPCS,0278,RC,,,both,,,1710.00,513,"FIRST HEALTH [10303]","First Health",,1368,80,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 330611 ACSR 6X11X11 SRVC FEE",SUP-330611,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 15MM 135CM 7MM 11MM 7FR .035IN",SUP-BXA071502A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR RESPIRATORY PAD LEVEL SARNS DISPOSABLE",SUP-195240,CDM,S27000186,LOCAL,0270,RC,,,both,,,156.60,46.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,64.36,41.1,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 2.4MM",SUP-288301024,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"UHC [10700]","United Healthcare",,2504.4,63.3,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL GENESIS II 2 RIGHT KNEE CEMENT TITANIUM",SUP-71420180,CDM,C1776,HCPCS,0278,RC,,,both,,,16725.60,5017.68,"KAISER [10500]",Kaiser,,11206.15,67,,,,,0,1945.19,14216.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 135CM 6MM 8MM 7FR .035IN",SUP-BXA067902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2536.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SUCTION BRONCHOSCOPE STERILE DISPOSABLE",SUP-MAJ-209,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.71,29.91,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.6,84.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN JUDKINS LEFT 4 CURVE GUIDING",SUP-LA6JL40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 20-38CMX3-10MM GRACILIS TENDON ALLOGRAFT",SUP-430300,CDM,C1762,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"CIGNA [10200]",Cigna,,5911.92,68,,,,,0,1011.11,7389.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATROPINE 1 % EYE DROPS",RX-736,CDM,,,0637,RC,70069-0582-01,NDC,both,5,ML,327.08,98.12,"CIGNA [10200]","Cigna Local Plus",,174.99,53.5,,,,,0,38.04,278.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM CEMENT SUMMIT 6 12/14 HIGH OFFSET TAPER",SUP-157013120,CDM,C1776,HCPCS,0278,RC,,,both,,,18219.60,5465.88,"NOVANET [10819]",Novanet,,13664.7,75,,,,,0,2118.94,15486.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD COMPONENT UNITRAX 43MM END",SUP-6942-6-043,CDM,C1776,HCPCS,0278,RC,,,both,,,16025.25,4807.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6410.1,40,,,,,0,1863.74,13621.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 15CM 11.5FR FULL SILICONE HEMO-CATH SAFETY SCPL",SUP-MCDLTSL15,CDM,C1750,HCPCS,0278,RC,,,both,,,988.20,296.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,117.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 10MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630510,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"BLUE CROSS [10001]","Blue Cross HMO",,5145.88,39.2,,5311.50,4717.44,5388.59,31,1526.7,11158.16,"percent of total billed charges",
"DRAPE SLUSH MACH EQUIPMENT",SUP-29-33009,CDM,S27000186,LOCAL,0270,RC,,,both,,,93.15,27.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,63.34,68,,,,,0,10.83,79.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONFIRM MART-1/MELAN A (A103) PRIMARY AN",SUP-790-2990,CDM,S27000186,LOCAL,0270,RC,,,both,,,66.58,19.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,30.56,45.9,,,,,0,7.74,56.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 6MM ENDOWRIST SP NONSTERILE LATEX FREE REUSABLE",SUP-431200,CDM,S27000186,LOCAL,0270,RC,,,both,,,2324.70,697.41,"CIGNA [10200]",Cigna,,1580.8,68,,,,,0,270.36,1976,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR HEMI 2HL 48MM",SUP-430-98-048,CDM,C1776,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,3949.44,3949.44,3949.44,"1 through 10",641.98,4692,"percent of total billed charges",
"INSRT TIBIAL 4 CURVE 12.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962042,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"PHCS [10601]",PHCS,,6474.62,70,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 13MM CONDYLAR STABILIZE BEARING TRIATHLON",SUP-5531-G-313-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4813.44,40,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CIRCUIT EVAQUA 2 2 LIMB HEAT INFANT",SUP-RT266,CDM,S27000186,LOCAL,0270,RC,,,both,,,324.51,97.35,"NOVANET [10819]",Novanet,,243.38,75,,,,,0,37.74,275.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 4.5X5MM FOR SMALL STATURE MIDLINE LOCK OPEN TUL",SUP-13450000,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",40.47,295.8,"percent of total billed charges",
"SODIUM CHLORIDE 1 GRAM TABLET SUPERORDERABLE",RX-409669,CDM,,,0637,RC,77333-0844-25,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Islet Cell Ab",PX-302000075,CDM,86341,CPT,0302,RC,,,both,,,240.50,72.15,"UHC [10700]","United Healthcare",,21.21,,,,,,,0.01,204.43,"fee schedule",
"STEM FEMORAL 195MM 16MM RESTORATION HA STRAIGHT CONICAL HIP",SUP-6276-7-116,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,5873.17,5873.17,5873.17,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"STEM HUMERAL 108MM 6MM MONOBLOCK RSP",SUP-510-00-006,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]",Cigna,,5040,40,,5873.17,5873.17,5873.17,"1 through 10",1465.38,10710,"percent of total billed charges",
"HEAD BIPOLAR 46MM 26MM UHR UNIVERSAL ACETABULAR HIP COCR",SUP-UH1-46-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"CIGNA [10200]","Cigna Open Access",,2456.81,56.9,,5302.19,4377.88,6578.61,27,502.16,3670.1,"percent of total billed charges",
"HEAD FEMORAL +3MM 11/13 TAPER 40MM HIP M SPECIFICATION METAL",SUP-136543500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"FIRST HEALTH [10303]","First Health",,8862.36,80,,,,,0,1288.37,9416.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 CURVE 10MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962041,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1096.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM NEXGEN LPS-FLEX 5-6 C-D KNEE PROLONG",SUP-596204110,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"PHCS [10601]",PHCS,,5542.91,70,,,,,0,920.91,6730.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 9.5MM S-ROM ZTT 22B SMALL HIP PROXIMAL",SUP-521423,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1265.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM 11/13 TAPER 40MM HIP M SPECIFICATION METAL",SUP-136543500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"PHCS [10601]",PHCS,,7754.57,70,,,,,0,1288.37,9416.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE REVISION HYBRID CONCELOC OXI WITH CEMENTE",SUP-71704640,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"FIRST HEALTH [10303]","First Health",,18648,80,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER FEMORAL CATHCART ARTICUL/EZE -3MM 12/14 TAPER HIP",SUP-136308000,CDM,C1776,HCPCS,0278,RC,,,both,,,1650.00,495,"KAISER [10500]",Kaiser,,1105.5,67,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARROW-CLARK VECTORFLOW ARROW SIMPLICITY MICROPUNCTURE",SUP-CS-15272-VFM,CDM,C1750,HCPCS,0278,RC,,,both,,,2850.00,855,"NOVANET [10819]",Novanet,,2137.5,75,,,,,0,331.46,2422.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM LOW PROFILE NECK VERTICAL GROOVE CORAIL2",SUP-3L92510,CDM,C1776,HCPCS,0278,RC,,,both,,,28658.70,8597.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8202.12,28.62,,,,,0,3333.01,24359.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 14MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-414-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]","Cigna Local Plus",,3790.58,31.5,,5372.07,4581.20,7242.98,23,1399.51,10228.56,"percent of total billed charges",
"COUNTSINK DRILL CANNULATED LARGE QUICK COUPLING 6.5 MM 7.5",SUP-03.333.214,CDM,S27000186,LOCAL,0270,RC,,,both,,,2965.05,889.51,"FIRST HEALTH [10303]","First Health",,2372.04,80,,,,,0,344.84,2520.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E FEMUR PATELLA TIBIA CEMENT",SUP-98000200280,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6293.7,27,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM ENDOCARDIUM 4 SITE 2 COIL PASSIVE FIXATION",SUP-0266,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS [10001]","Blue Cross HMO",,6731.42,39.2,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG MIDFACE 6 HOLE 2Y 1.5MM SCREWS BONE TITANIUM",SUP-01-7112,CDM,C1713,HCPCS,0278,RC,,,both,,,1441.80,432.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,170.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,167.68,1225.53,"percent of total billed charges",
"MESH SURGICAL PROCEED 6X4IN HERNIA TISSUE SEPARATING",SUP-PCDN1,CDM,C1781,HCPCS,0278,RC,,,both,,,2882.42,864.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,824.95,28.62,,,,,0,335.23,2450.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 42MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661042,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,599.33,45.9,,,,,0,151.86,1109.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH-PROFILE BOOST, 500CC",SUP-SMHB500,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"NOVANET [10819]",Novanet,,5718.38,75,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TACTIFLEX ABLATION CATHETER, SENSOR ENABLED",SUP-A-TFSE-D-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL 37CM XL CIRCULAR 2 ROW SEAL 5.2MMX1.5-2.2MM",SUP-ECS29B,CDM,S27200284,LOCAL,0272,RC,,,both,,,6267.91,1880.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL 4 12MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-412-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1352.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, OFFSET HUMERAL HEAD, 42X16",SUP-520-42-316,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"CIGNA [10200]",Cigna,,6180.38,68,,5873.17,5873.17,5873.17,"1 through 10",1057.03,7725.48,"percent of total billed charges",
"SURFACE ARTICULAR 18MM PERSONA 6-9 C-D KNEE RIGHT VIVACIT-E",SUP-42-5226-005-18,CDM,C1776,HCPCS,0278,RC,,,both,,,13634.40,4090.32,"CIGNA [10200]","Cigna Local Plus",,4294.84,31.5,,5372.07,4581.20,7242.98,23,1585.68,11589.24,"percent of total billed charges",
"STEM HUMERAL 111MM CORE SET PROXIMAL FILL UNIVERS REVERS",SUP-AR-9501-06CPC,CDM,C1776,HCPCS,0278,RC,,,both,,,16560.00,4968,"NOVANET [10819]",Novanet,,12420,75,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX 10X6IN MONOFILAMENT SCAFFOLD FULL",SUP-1191525,CDM,C1781,HCPCS,0278,RC,,,both,,,37341.99,11202.6,"FIRST HEALTH [10303]","First Health",,29873.59,80,,,,,0,4342.87,31740.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 11MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530P611,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3835.36,45.9,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +6MM OFFSET 32MM HIP TYPE 1 MODULAR COCR G7",SUP-110025134,CDM,C1776,HCPCS,0278,RC,,,both,,,9255.66,2776.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1076.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1076.43,7867.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 25MM RESTORATION +20MM HIP MODULAR REVISION",SUP-6276-1-225,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6369.31,28.62,,,,,0,2588.23,18916.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOLUTION? MP CS INSERT SIZE 5 STANDARD 10MM LEFT",SUP-EIS5S10L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4270.87,41.1,,6417.48,6417.48,6417.48,"1 through 10",1208.52,8832.69,"percent of total billed charges",
"BEARING 87/91MMX14MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183584,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"PHCS [10601]",PHCS,,9066.88,70,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 STD KNEE LEFT CRUCIATE RETAIN CEMENT PERSONA",SUP-42502605401,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"NOVANET [10819]",Novanet,,17147.03,75,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL PFC SIGMA 3 KNEE TITANIUM CEMENT KEEL FIX BEARIN",SUP-864181,CDM,C1776,HCPCS,0278,RC,,,both,,,15404.25,4621.27,"NOVANET [10819]",Novanet,,11553.19,75,,,,,0,1791.51,13093.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT SURGICAL TANDEM CUSTOM HIP PROC BIPOLAR LOW DEMAND",SUP-71701440,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"PHCS [10601]",PHCS,,6762,70,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 17.5MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158121117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"KAISER [10500]",Kaiser,,7486.95,67,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-71933650,CDM,C1776,HCPCS,0278,RC,,,both,,,22273.65,6682.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2639.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2590.43,18932.6,"percent of total billed charges",
"INSRT TIBIAL 5 8MM KNEE POSTERIOR STABILIZE IDENTITY IMPRINT",SUP-TPS-020-085S,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"PHCS [10601]",PHCS,,4115.16,70,,,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 14GA RIGID NDL RADIOPAQUE GEL MARK ULTRACOR BREAST",SUP-GMUTC005SS,CDM,A4648,HCPCS,0278,RC,,,both,,,526.34,157.9,"CIGNA [10200]","Cigna Local Plus",,281.59,53.5,,,,,0,61.21,447.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 15MM 3.3-3.6FR 5MM BALLOON",SUP-1008193-15,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"FIRST HEALTH [10303]","First Health",,1134,80,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 20CM PUMP SET",SUP-ES8920,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC",072,MS-DRG,,,,,,,inpatient,,,38490.61,11547.18,"CIGNA [10200]","Cigna Open Access",,8298.54,,"Fee schedule rate ($8,298.54). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,4690.75,18858.87,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN 125 MG CAPSULE",RX-11628,CDM,,,0637,RC,23155-0858-78,NDC,both,1,UN,15.39,4.62,"KAISER [10500]",Kaiser,,10.31,67,,,,,0,1.79,13.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE AUG 3CC ALLOGRAFT AUG INJECTABLE KIT",SUP-K30003010,CDM,C1734,HCPCS,0278,RC,,,both,,,23052.69,6915.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2731.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2681.03,19594.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 14MM AXIUM 3D NEUROVASCULAR FRAME V01",SUP-FC-14-50-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6791.98,41.1,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP LOCKING SCREW 4.75X25MM",SUP-180502,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"FIRST HEALTH [10303]","First Health",,1244.56,80,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE DCP LC-DCP FOOT NONSTERILE 73MM STAINLESS STEEL SMALL",SUP-241.36,CDM,C1713,HCPCS,0278,RC,,,both,,,1113.59,334.08,"CIGNA [10200]","Cigna Open Access",,633.63,56.9,,1144.80,304.56,2275.09,66,129.51,946.55,"percent of total billed charges",
"LENS IOL 5 D +14 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-AR40E00140,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,633.42,68,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE RESERVE 5MM",SUP-270050,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 15MM 140CM 2.75MM 2.1-2.7FR CORONARY",SUP-RONYX27515UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 4-0 PC-1 18IN MONOFILAMENT PLIABILIZED",SUP-1854G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON UVA TORIC AUTONOME",SUP-CCA0T6,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,43.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 18GA 3.5IN NDL SYR CATH WING PERIFIX HUSTEAD",SUP-332249,CDM,C1755,HCPCS,0278,RC,,,both,,,116.60,34.98,"NOVANET [10819]",Novanet,,87.45,75,,,,,0,13.56,99.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ULTRAFLEX 30MM 14MM 18FR 4.1MM TRACHEOBRONCHIAL DISTAL",SUP-M00576320,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 133MM CEMENTLESS NECK ACCOLADE TMZF 127D 5.5 49",SUP-6021-5537,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"UHC [10700]","United Healthcare",,14446.17,63.3,,8601.07,8395.67,8601.07,"1 through 10",2654.17,19398.49,"percent of total billed charges",
"BEARING 71/75MMX10MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183540,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"FIRST HEALTH [10303]","First Health",,10362.14,80,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 22GA ACCURIAN STRAIGHT SHARP 5MM",SUP-AC0017,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"FIRST HEALTH [10303]","First Health",,83.52,80,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS SOLN DEX 1.5 % CA+ 3.5 MEQ/L&LOW MAG 0.5 MEQ/L",RX-27797,CDM,,,0250,RC,00941-0426-52,NDC,both,2000,ML,211.26,63.38,"MULTIPLAN [10600]",Multiplan,,179.57,85,,,,,0,24.57,179.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC",810,MS-DRG,,,,,,,inpatient,,,43309.90,12992.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16965.39,,"Fee schedule rate ($16,965.39). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,6492.12,26101.16,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 75CM 40MM 4MM BALLOON DILATATION DRUG COATED",SUP-LX3575440V,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"UHC [10700]","United Healthcare",,4258.51,63.3,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25MM THK1.37MM STAINLESS STEEL SAGITTAL 2 CUT",SUP-4125-137-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,393.85,118.15,"CIGNA [10200]","Cigna Open Access",,224.1,56.9,,,,,0,45.8,334.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL COMPOSIX KUGEL 7X5.4IN VENTRAL HERNIA PATCH",SUP-0010212,CDM,C1781,HCPCS,0278,RC,,,both,,,3890.67,1167.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1785.82,45.9,,,,,0,452.48,3307.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC",278,MS-DRG,,,,,,,inpatient,,,253785.70,76135.71,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,70304.85,,"Case rate ($34,527.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $32,061.10, add-ons for qualifying new technology services are included. If operating cost exceeds $65,100.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,805.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $32,103.50. The transfer operating threshold is the transfer adjustment factor * $32,061.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,423.98. The transfer capital threshold is the transfer adjustment factor * $2,423.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,162510.78,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION",RX-119387,CDM,,,0250,RC,00574-0521-76,NDC,both,240,ML,149.45,44.83,"PHCS [10601]",PHCS,,104.62,70,,,,,0,17.38,127.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM EDWARDS INTUITY ELITE STERILE LATEX FREE",SUP-8300KITB27A,CDM,S27800098,LOCAL,0278,RC,,,both,,,68400.00,20520,"CIGNA [10200]","Cigna Open Access",,22914,33.5,,,,,0,7954.92,58140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 20CM 2MM BALLOON DILATATION HYDROPHILIC",SUP-G50319,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"NOVANET [10819]",Novanet,,1771.82,75,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE 10CM",SUP-7509141,CDM,S27800098,LOCAL,0278,RC,,,both,,,17640.00,5292,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7056,40,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135D 47MM MINI TAPER HIGH OFFSET 43.2MM 145MM",SUP-L20311,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"BLUE CROSS [10001]","Blue Cross HMO",,6208.15,39.2,,5311.50,4717.44,5388.59,31,1841.86,13461.55,"percent of total billed charges",
"LAMIVUDINE 10 MG/ML ORAL SOLUTION (NICU)",RX-410143,CDM,,,0250,RC,08888-8887-44,NDC,both,5,ML,17.42,5.23,"NOVANET [10819]",Novanet,,13.07,75,,,,,0,2.03,14.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONNECTIVE TISSUE DISORDERS WITH MCC",545,MS-DRG,,,,,,,inpatient,,,74257.79,22277.34,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,33097.38,,"Case rate ($15,394.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,294.50, add-ons for qualifying new technology services are included. If operating cost exceeds $47,334.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,462.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $14,313.40. The transfer operating threshold is the transfer adjustment factor * $14,294.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,080.73. The transfer capital threshold is the transfer adjustment factor * $1,080.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,61891.12,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"AFTERCARE WITH CC/MCC",949,MS-DRG,,,,,,,inpatient,,,69874.09,20962.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,23616.73,,"Fee schedule rate ($23,616.73). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,2462,38264.95,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX10MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183740,CDM,C1776,HCPCS,0278,RC,,,both,,,13241.10,3972.33,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3575.1,27,,,,,0,1539.94,11254.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 58MM UNITRAX HIP FEMORAL MODULAR EXETER V40",SUP-6942-5-058,CDM,C1776,HCPCS,0278,RC,,,both,,,4291.80,1287.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,508.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,499.14,3648.03,"percent of total billed charges",
"HEAD FEMORAL -3.5MM 12/14 SMALL 36MM HIP ACETABULAR BIOLOX",SUP-00877503601,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"BLUE CROSS [10001]","Blue Cross HMO",,3864.62,39.2,,5311.50,4717.44,5388.59,31,1146.57,8379.91,"percent of total billed charges",
"CMPNT FEMORAL 7 KNEE RIGHT POSTERIOR STABILIZE BEAD",SUP-5516-F-702,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"BLUE CROSS [10001]","Blue Cross PPO",,6788.24,39.2,,3949.44,3949.44,3949.44,"1 through 10",2013.96,14719.4,"percent of total billed charges",
"SHELL ACETABULAR 56MM HIP MULTIHOLE R3 STD STERILE",SUP-71338667,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"KAISER [10500]",Kaiser,,10644.46,67,,,,,0,1847.69,13504.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PEFORM FX REV LAT BASEPLASTE",SUP-CAP1125,CDM,C1776,HCPCS,0278,RC,,,both,,,61110.00,18333,"KAISER [10500]",Kaiser,,40943.7,67,,,,,0,7107.09,51943.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 4-5 C-D KNEE",SUP-42512100312,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"MULTIPLAN [10600]",Multiplan,,9159.96,85,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 4-5 C-D KNEE",SUP-42512100312,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Open Access",,6131.78,56.9,,5302.19,4377.88,6578.61,27,1253.3,9159.96,"percent of total billed charges",
"HEAD FEMORAL +6MM OFFSET 28MM HIP TYPE 1 COCR G7",SUP-163638,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"CIGNA [10200]","Cigna Local Plus",,2595.12,53.5,,5372.07,4581.20,7242.98,23,564.14,4123.1,"percent of total billed charges",
"CMPNT FEMORAL 7 KNEE RIGHT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F702,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"BLUE CROSS [10001]","Blue Cross PPO",,6718.89,39.2,,3949.44,3949.44,3949.44,"1 through 10",1993.39,14569.03,"percent of total billed charges",
"INSRT TIBIAL 4 25MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G425,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"KAISER [10500]",Kaiser,,6275.27,67,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 3MM OXFORD ARCOM KNEE RIGHT MENISCAL PHASE 3",SUP-159575,CDM,C1776,HCPCS,0278,RC,,,both,,,5270.22,1581.07,"CIGNA [10200]","Cigna Local Plus",,2819.57,53.5,,5372.07,4581.20,7242.98,23,612.93,4479.69,"percent of total billed charges",
"AUG TIBIAL 10MM TRIATHLON 6 RIGHT MEDIAL LEFT LATERAL TOTAL",SUP-5546-A-602,CDM,C1776,HCPCS,0278,RC,,,both,,,4252.25,1275.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1216.99,28.62,,,,,0,494.54,3614.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 55MM 9MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113609,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5178.6,41.1,,6417.48,6417.48,6417.48,"1 through 10",1465.38,10710,"percent of total billed charges",
"SURFACE ARTICULAR 13MM PERSONA MEDIAL CONGRUENT 12 G-H KNEE",SUP-42512101013,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Open Access",,6131.78,56.9,,5302.19,4377.88,6578.61,27,1253.3,9159.96,"percent of total billed charges",
"INSRT TIBIAL 2 CURVE 15MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962013,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"UHC [10700]","United Healthcare",,5854.9,63.3,,8601.07,8395.67,8601.07,"1 through 10",1075.71,7862.03,"percent of total billed charges",
"LINER ACETABULAR G7 G NEUTRAL 40MM E1 HIP",SUP-010000865,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"CIGNA [10200]","Cigna Local Plus",,5484.83,53.5,,5372.07,4581.20,7242.98,23,1192.31,8714.22,"percent of total billed charges",
"LINER ACETABULAR G7 G NEUTRAL 40MM E1 HIP",SUP-010000865,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"PHCS [10601]",PHCS,,7176.41,70,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE FEMORAL TANDEM +0MM 12/14 TAPER HIP UNIPOLAR",SUP-71326600,CDM,C1776,HCPCS,0278,RC,,,both,,,1212.57,363.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,824.55,68,,,,,0,141.02,1030.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 30MM SECUR-FIT MAX 7 STERILE",SUP-6051-0730S,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"UHC [10700]","United Healthcare",,9905.94,63.3,,8601.07,8395.67,8601.07,"1 through 10",1820,13301.82,"percent of total billed charges",
"AUG TIBIAL 5MM MBT 2 KNEE REVISION STEP WEDGE STERILE LATEX",SUP-129456120,CDM,C1776,HCPCS,0278,RC,,,both,,,9889.08,2966.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6724.57,68,,,,,0,1150.1,8405.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM MBT 2 KNEE REVISION STEP WEDGE STERILE LATEX",SUP-129456120,CDM,C1776,HCPCS,0278,RC,,,both,,,9889.08,2966.72,"CIGNA [10200]",Cigna,,6724.57,68,,5873.17,5873.17,5873.17,"1 through 10",1150.1,8405.72,"percent of total billed charges",
"INSRT TIBIAL SMALL 13MM KNEE DURATION POSTERIOR STABILIZE",SUP-6742-1-113,CDM,C1776,HCPCS,0278,RC,,,both,,,5709.75,1712.92,"PHCS [10601]",PHCS,,3996.83,70,,,,,0,664.04,4853.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 22F LARGE HIP PROXIMAL",SUP-550546,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"CIGNA [10200]",Cigna,,7401.63,68,,5873.17,5873.17,5873.17,"1 through 10",1265.9,9252.04,"percent of total billed charges",
"LINER ACETABULAR DYNASTY STD 36MM A-CLASS STERILE GROUP E",SUP-DLXPGE36,CDM,C1776,HCPCS,0278,RC,,,both,,,12771.90,3831.57,"BLUE CROSS [10001]","Blue Cross HMO",,5006.58,39.2,,5311.50,4717.44,5388.59,31,1485.37,10856.12,"percent of total billed charges",
"TRAY TIBIAL INFINITY 4 LONG",SUP-33650014,CDM,C1776,HCPCS,0278,RC,,,both,,,29049.30,8714.79,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7843.31,27,,,,,0,3378.43,24691.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY HUMERAL SMR TI6AL4V REVERSE LOCKING SCR ELECTIVE",SUP-1352.15.010,CDM,C1776,HCPCS,0278,RC,,,both,,,10440.00,3132,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1214.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1214.17,8874,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 13MM CEMENTLESS SECUR-FIT PLUS HYDROXYAPATITE 9",SUP-6054-0913S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4626.55,28.62,,,,,0,1880.04,13740.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 60MM ARCOS B STD OFFSET HIP FEMORAL TITANIUM",SUP-11301302,CDM,C1776,HCPCS,0278,RC,,,both,,,39453.12,11835.94,"BLUE CROSS [10001]","Blue Cross HMO",,15465.62,39.2,,5311.50,4717.44,5388.59,31,4588.4,33535.15,"percent of total billed charges",
"INSRT ACETABULAR 36MM I HIP ELEVATE RIM X3 TRIDENT",SUP-643-00-36I,CDM,C1776,HCPCS,0278,RC,,,both,,,9915.30,2974.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2837.76,28.62,,,,,0,1153.15,8428.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAL PALINDROME 23CM",SUP-8888123400,CDM,C1750,HCPCS,0278,RC,,,both,,,2703.75,811.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,773.81,28.62,,,,,0,314.45,2298.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL STD+ KNEE RIGHT LCS COMPLETE POROCOAT",SUP-129403050,CDM,C1776,HCPCS,0278,RC,,,both,,,28683.90,8605.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11473.56,40,,,,,0,3335.94,24381.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL XS KNEE LEFT TAPER FEMALE ANTIROTATION TAB LPS",SUP-198713105,CDM,C1776,HCPCS,0278,RC,,,both,,,77842.62,23352.79,"AETNA [10100]","Aetna HMO/PPO",,61884.88,79.5,,10981.53,8986.79,12413.38,12,9053.1,66166.23,"percent of total billed charges",
"INSRT TIBIAL 3 STD 10MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS3S10L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1231.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL SHOULDER RESURFACE COPELAND HA 3",SUP-11114643,CDM,C1776,HCPCS,0278,RC,,,both,,,16174.80,4852.44,"BLUE CROSS [10001]","Blue Cross HMO",,6340.52,39.2,,5311.50,4717.44,5388.59,31,1881.13,13748.58,"percent of total billed charges",
"CAP CONSTRUCT HIP PARTIAL ANTHOLOGY AFIT WITH OXINIUM HEAD A",SUP-71703320,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6851.63,28.62,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP BIOFOAM DYNASTY",SUP-DSBFGB48,CDM,C1776,HCPCS,0278,RC,,,both,,,18918.90,5675.67,"CIGNA [10200]","Cigna Open Access",,6337.83,33.5,,5302.19,4377.88,6578.61,27,2200.27,16081.07,"percent of total billed charges",
"INSRT TIBIAL 3-4 13MM KNEE XLPE POSTERIOR STABILIZE LEGION",SUP-71453248,CDM,C1776,HCPCS,0278,RC,,,both,,,14831.55,4449.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4004.52,27,,,,,0,1724.91,12606.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 13MM KNEE XLPE POSTERIOR STABILIZE LEGION",SUP-71453248,CDM,C1776,HCPCS,0278,RC,,,both,,,14831.55,4449.46,"KAISER [10500]",Kaiser,,9937.14,67,,,,,0,1724.91,12606.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP CERAMIC R3 DELTA POROUS R3 XLPE LINER",SUP-71703415,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross HMO",,9384.48,39.2,,5311.50,4717.44,5388.59,31,2784.22,20349,"percent of total billed charges",
"STEM FEMORAL 145MM PRESS FIT BASIC SUMMIT 5 12/14 TAPER HIP",SUP-157005110,CDM,C1776,HCPCS,0278,RC,,,both,,,9090.75,2727.22,"BLUE CROSS [10001]","Blue Cross PPO",,3563.57,39.2,,3949.44,3949.44,3949.44,"1 through 10",1057.25,7727.14,"percent of total billed charges",
"CMPNT FEMORAL 5 NARROW KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-42500005801,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6172.93,27,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL MEDIUM NEUTRAL KNEE COCRMO UHMWPE CONNECTION",SUP-16-2840/05,CDM,C1776,HCPCS,0278,RC,,,both,,,10553.00,3165.9,"BLUE CROSS [10001]","Blue Cross PPO",,4136.78,39.2,,3949.44,3949.44,3949.44,"1 through 10",1227.31,8970.05,"percent of total billed charges",
"CMPNT FEMORAL 5 NARROW KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-42500005801,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"UHC [10700]","United Healthcare",,14472.09,63.3,,8601.07,8395.67,8601.07,"1 through 10",2658.93,19433.3,"percent of total billed charges",
"INSRT TIBIAL 10 14MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151621014,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4625.35,41.1,,6417.48,6417.48,6417.48,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"SHELL BIPOLAR 45MM LEGACY HIP METAL MULTIPOLAR STERILE",SUP-00500104500,CDM,C1776,HCPCS,0278,RC,,,both,,,2969.40,890.82,"FIRST HEALTH [10303]","First Health",,2375.52,80,,,,,0,345.34,2523.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REUNION TSA - PRESS-FIT HUMERAL STEM 17MM",SUP-5569-P-2017,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEM POR RT SZ 8",SUP-427-02-080,CDM,C1776,HCPCS,0278,RC,,,both,,,32703.43,9811.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8829.93,27,,,,,0,3803.41,27797.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -2.5MM OFFSET C TAPER 36MM HIP TRITANIUM LFIT",SUP-06-3697,CDM,C1776,HCPCS,0278,RC,,,both,,,7962.60,2388.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,943.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,926.05,6768.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 17.5MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158106117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"KAISER [10500]",Kaiser,,7486.95,67,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 20MM PRESS FIT FLUTED TRIATHLON KNEE",SUP-5566-S-020,CDM,C1776,HCPCS,0278,RC,,,both,,,5447.65,1634.29,"CIGNA [10200]","Cigna Open Access",,3099.71,56.9,,5302.19,4377.88,6578.61,27,633.56,4630.5,"percent of total billed charges",
"LINER ACETABULAR PINNACLE 15D 66MM 32MM MARATHON HIP STERILE",SUP-121932266,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"AETNA [10100]","Aetna HMO/PPO",,6448.21,79.5,,10981.53,8986.79,12413.38,12,943.3,6894.31,"percent of total billed charges",
"STEM FEMORAL 155MM 10.5MM CEMENTLESS MODULAR AML POROUS 40MM",SUP-155401106,CDM,C1776,HCPCS,0278,RC,,,both,,,15374.88,4612.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4151.22,27,,,,,0,1788.1,13068.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 38MM ONLAY ADVANCE METAL KNEE STERILE",SUP-KPON38MB,CDM,C1776,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,5873.17,5873.17,5873.17,"1 through 10",601.85,4398.75,"percent of total billed charges",
"BEARING 71/75MMX10MM VANGUARD ARCOM KNEE POSTERIOR STABILIZE",SUP-VE183640,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"AETNA [10100]","Aetna HMO/PPO",,10484.98,79.5,,10981.53,8986.79,12413.38,12,1533.84,11210.36,"percent of total billed charges",
"AUG TIBIAL 10MM TRIATHLON 2 RIGHT MEDIAL LEFT LATERAL",SUP-5612-A-210,CDM,C1776,HCPCS,0278,RC,,,both,,,9878.04,2963.41,"MULTIPLAN [10600]",Multiplan,,8396.33,85,,,,,0,1148.82,8396.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 15MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962353,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"MULTIPLAN [10600]",Multiplan,,12328.23,85,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 9MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P109,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS [10001]","Blue Cross HMO",,3275.51,39.2,,5311.50,4717.44,5388.59,31,971.79,7102.52,"percent of total billed charges",
"UPCH - TRUMATCH GL",SUP-OSC371062,CDM,C1776,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,5873.17,5873.17,5873.17,"1 through 10",441.36,3225.75,"percent of total billed charges",
"CMPNT PATELLAR 9MM 33MM SYMMETRIC TRIATHLON X3 KNEE",SUP-5550-G-339,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"PHCS [10601]",PHCS,,3022.44,70,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 25D MEDIUM AUG CORTILOC SHOULDER RIGHT",SUP-DWK404RA25S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"UHC [10700]","United Healthcare",,6646.5,63.3,,8601.07,8395.67,8601.07,"1 through 10",1221.15,8925,"percent of total billed charges",
"INSRT TIBIAL 5 16MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-516,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4040.34,41.1,,6417.48,6417.48,6417.48,"1 through 10",1143.29,8355.94,"percent of total billed charges",
"STEM HUMERAL 122MM 8MM COMPREHENSIVE PPS SHOULDER",SUP-12-113558,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5040,40,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 6.5MM EVOLVE +4MM ELBOW PROLINE MODULAR",SUP-496S465,CDM,C1776,HCPCS,0278,RC,,,both,,,14614.20,4384.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1731.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1699.63,12422.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 13MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532P713,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,990.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,971.79,7102.52,"percent of total billed charges",
"INSRT TIBIAL 2 25MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962327,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"MULTIPLAN [10600]",Multiplan,,12328.23,85,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 12/14 TAPER 32MM HIP CEMENTLESS SLEEVE",SUP-136532720,CDM,C1776,HCPCS,0278,RC,,,both,,,12408.96,3722.69,"AETNA [10100]","Aetna HMO/PPO",,9865.12,79.5,,10981.53,8986.79,12413.38,12,1443.16,10547.62,"percent of total billed charges",
"BASEPLT TIBIAL ATTUNE 8 KNEE CEMENTED ROTATE PLATFORM",SUP-150610008,CDM,C1776,HCPCS,0278,RC,,,both,,,16694.55,5008.36,"NOVANET [10819]",Novanet,,12520.91,75,,,,,0,1941.58,14190.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP ACETABULAR 56MM PINNACLE HIP GRIPTION SECTOR SERIES",SUP-1217-32-056,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"CIGNA [10200]","Cigna Open Access",,5433.18,33.5,,5302.19,4377.88,6578.61,27,1886.21,13785.68,"percent of total billed charges",
"BASEPLT TIBIAL TRIATHLON 2 KNEE REVISION",SUP-5612-B-200,CDM,C1776,HCPCS,0278,RC,,,both,,,26089.56,7826.87,"UHC [10700]","United Healthcare",,16514.69,63.3,,8601.07,8395.67,8601.07,"1 through 10",3034.22,22176.13,"percent of total billed charges",
"STEM FEMORAL 145MM 11MM COLLAR CEMENTLESS LOW PROFILE NECK",SUP-3L92501,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"PHCS [10601]",PHCS,,11085.98,70,,,,,0,1841.86,13461.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 17MM 44MM SHOULDER SHORT STEM ARTICULATION 24MM",SUP-2N2HE17044,CDM,C1776,HCPCS,0278,RC,,,both,,,12775.07,3832.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1513.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1485.74,10858.81,"percent of total billed charges",
"CMPNT PATELLAR 10MM 36MM SYMMETRIC TRIATHLON X3 KNEE STERILE",SUP-5550-G-360-E,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3847.44,68,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HUMERAL CUP - 40MM DIA X 4MM THK",SUP-5570-4004,CDM,C1776,HCPCS,0278,RC,,,both,,,7980.00,2394,"BLUE CROSS [10001]","Blue Cross PPO",,3128.16,39.2,,3949.44,3949.44,3949.44,"1 through 10",928.07,6783,"percent of total billed charges",
"SET STENT 30CM 7FR 2.1FR POLARIS ULTRA NAUTILUS ZIPWIRE .035",SUP-M006192145180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,729.75,45.9,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RAMROD CLASSIC 24CM 4.5FR KIDNEY BLADDER CURL URETERAL",SUP-5604524,CDM,C2617,HCPCS,0278,RC,,,both,,,692.15,207.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,317.7,45.9,,,,,0,80.5,588.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175270080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"MULTIPLAN [10600]",Multiplan,,1053.47,85,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR ELECTROSURGICAL 4FT 3/8IN 7/8IN PENADAPT 45D PENCIL",SUP-PA2010,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.57,43.67,"PHCS [10601]",PHCS,,101.9,70,,,,,0,16.93,123.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 40MM COMPREHENSIVE TITANIUM SHOULDER FIX",SUP-180505,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"NOVANET [10819]",Novanet,,1166.78,75,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC",909,MS-DRG,,,,,,,inpatient,,,41193.05,12357.91,"BLUE CROSS [10001]","Blue Cross HMO",,30135.38,,,,,,,7561,38325.59,"case rate",
"SCR BONE 3.5MM 24MM RELINE C SPINE FAVOR ANGLE NONSTERILE",SUP-3913524,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,957.42,156.86,7483.26,51,521.61,3812.25,"percent of total billed charges",
"SCR BONE 5MM 50MM ARTHREX TITANIUM T15 LARGE FULL THREAD",SUP-AR-8750-50H,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2422.5,68,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT QUILL SRS PDS 2 CT-1 T-8 36X36CM ABSORBABLE",SUP-RX-1062Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.81,62.64,"CIGNA [10200]","Cigna Open Access",,118.81,56.9,,,,,0,24.28,177.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Elec Sngl",PX-480000011,CDM,33216,CPT,0481,RC,,,both,,,8966.11,2689.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7066,,"Case rate ($7,066). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1042.76,8966.11,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 65CM 6FR COBRA CURVE RENAL TORCON STAINLESS STEEL INNER",SUP-G14408,CDM,C1758,HCPCS,0272,RC,,,both,,,274.92,82.48,"PHCS [10601]",PHCS,,192.44,70,,,,,0,31.97,233.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 6X4CM VIALIZE PLACENTAL MEMB ALLOGRAFT",SUP-VL-4060,CDM,,,0278,RC,,,both,,,11040.00,3312,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1308.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.04,9384,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC",206,MS-DRG,,,,,,,inpatient,,,36918.01,11075.4,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,6246.34,,"Case rate ($5,837.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,420.70, add-ons for qualifying new technology services are included. If operating cost exceeds $38,460.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,791.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,427.87. The transfer operating threshold is the transfer adjustment factor * $5,420.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $409.83. The transfer capital threshold is the transfer adjustment factor * $409.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,5837.7,23470.09,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPN NC 10MM 2MM BALLOON DILATATION PLATINUM IRIDIUM",SUP-200-010-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"MULTIPLAN [10600]",Multiplan,,7038,85,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Facial Bn>=3v",PX-320000009,CDM,70150,CPT,0320,RC,,,both,,,787.88,236.36,"PHCS [10601]",PHCS,,551.52,70,,,,,0,54.88,669.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION",RX-3497,CDM,J1596,HCPCS,0636,RC,00143-9681-01,NDC,both,2,ML,21.74,6.52,"CIGNA [10200]","Cigna Local Plus",,3.99,,,,,,,1.79,18.48,"fee schedule",
"OVITEX LPR 9 CM CIRCLE",SUP-F10244-0909L,CDM,C1781,HCPCS,0278,RC,,,both,,,7268.46,2180.54,"BLUE CROSS [10001]","Blue Cross PPO",,2849.24,39.2,,,,,0,845.32,6178.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 40X30CM SELF GRIP RESORBING",SUP-TSB4030,CDM,C1781,HCPCS,0278,RC,,,both,,,105450.00,31635,"CIGNA [10200]","Cigna Local Plus",,33216.75,31.5,,3096.73,1.00,3096.73,"1 through 10",12263.84,89632.5,"percent of total billed charges",
"MESH SURGICAL PHASIX 6X4IN MONOFILAMENT SCAFFOLD FULL",SUP-1190200,CDM,C1781,HCPCS,0278,RC,,,both,,,8400.00,2520,"BLUE CROSS [10001]","Blue Cross HMO",,3292.8,39.2,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER CELEROMARK BREAST BIOPSY","SUP-CELERO MARK -2S",CDM,A4648,HCPCS,0278,RC,,,both,,,628.56,188.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,179.89,28.62,,,,,0,73.1,534.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 14CM 28.5MM 12MM 24-26MM 10-11MM GORE",SUP-RLT281214,CDM,C1725,HCPCS,0272,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,42636,68,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 4.4MM ORTHOLOC FOOT ANKLE 3DI TECHNOLOGY",SUP-77706514,CDM,S27200284,LOCAL,0272,RC,,,both,,,1166.40,349.92,"CIGNA [10200]","Cigna Local Plus",,624.02,53.5,,,,,0,135.65,991.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752550,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS [10001]","Blue Cross HMO",,353.65,39.2,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD RVOT KIT MOND",SUP-4150/65,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"BLUE CROSS [10001]","Blue Cross HMO",,225.44,39.2,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 23MM 52MM OFFSET 4MM TOTAL SHOULDER REPLACEMENT",SUP-5552-E-5223,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2601.21,28.62,,,,,0,1057.03,7725.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM CEMENT BASIC SUMMIT 8 12/14 TAPER HIP",SUP-157006150,CDM,C1776,HCPCS,0278,RC,,,both,,,8135.10,2440.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,946.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,946.11,6914.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX ECHO 2 11CM POSITION SYSTEM STERILE",SUP-1210011,CDM,C1781,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 0 CT-1 45CM SUT ABSORBABLE",SUP-SXPP1A401,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM 12/14 TAPER 32MM HIP COCR SPECTRON EF",SUP-71303203,CDM,C1776,HCPCS,0278,RC,,,both,,,8145.45,2443.63,"NOVANET [10819]",Novanet,,6109.09,75,,,,,0,947.32,6923.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMB LINER 47/48/49MM 28MM MULTIPOLAR HIP UHMWPE STERILE",SUP-500104728,CDM,C1776,HCPCS,0278,RC,,,both,,,2365.50,709.65,"KAISER [10500]",Kaiser,,1584.89,67,,,,,0,275.11,2010.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE PLUS 100CM 6FR .044IN .042IN JUDKINS RIGHT",SUP-533687,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.83,41.1,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION SIGMA HIGH PERFORMANCE THREAD HEAD",SUP-950502089,CDM,C1713,HCPCS,0278,RC,,,both,,,1526.85,458.05,"CIGNA [10200]","Cigna Open Access",,868.78,56.9,,1144.80,304.56,2275.09,66,177.57,1297.82,"percent of total billed charges",
"INSERT TIBIAL 10 7MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151621007,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1308.83,9565.82,"percent of total billed charges",
"SCR BONE 4MM 16MM SYNAPSE TITANIUM 50D T15 SPINE CANCELLOUS",SUP-04.614.116,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ROCHESTER-PEAN CURVE 7.25IN ARTERY HEMOSTATIC",SUP-BH445R,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.35,26.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,60.76,68,,,,,0,10.39,75.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 15MM 4MM CORONARY STENT COCR RAPID",SUP-1007850-15,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 20MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE50020,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22589.44,27,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 10 KNEE RIGHT CEMENTED POSTERIOR STABILIZE",SUP-150410210,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"CIGNA [10200]","Cigna Open Access",,7501.77,33.5,,5302.19,4377.88,6578.61,27,2604.35,19034.35,"percent of total billed charges",
"FORCEPS SURGICAL L4.3IN TEETH DIA0.5MM STAINLESS STEEL SERRA",SUP-E1553,CDM,S27200284,LOCAL,0272,RC,,,both,,,2931.90,879.57,"CIGNA [10200]",Cigna,,1993.69,68,,,,,0,340.98,2492.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 30MM 3.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3530X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4545,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 100-300UM LC BEAD",SUP-VE220GS,CDM,S27800098,LOCAL,0278,RC,,,both,,,10812.30,3243.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1281.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1257.47,9190.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLAMMATORY BOWEL DISEASE WITH CC",386,MS-DRG,,,,,,,inpatient,,,34543.87,10363.16,"UHC [10700]","United Healthcare",,24347.95,,"Fee schedule rate ($24,347.95). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",24751.96,24751.96,24751.96,"1 through 10",6056.05,24347.95,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN"
"INFLAMMATORY BOWEL DISEASE WITH CC",386,MS-DRG,,,,,,,inpatient,,,34543.87,10363.16,"CIGNA [10200]",Cigna,,12801.25,,"Fee schedule rate ($12,801.25). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,6056.05,24347.95,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Autolog Prp Not Diab Ulcer",PX-761000094,CDM,G0460,HCPCS,0761,RC,,,both,,,2665.00,799.5,"NOVANET [10819]",Novanet,,1998.75,75,,,,,0,309.94,2606,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 3MM FACET TISSUE SHIM",SUP-609003,CDM,S27800098,LOCAL,0278,RC,,,both,,,3150.00,945,"AETNA [10100]","Aetna HMO/PPO",,2504.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,366.35,2677.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULUS CERVICAL, 7X19X16MM",SUP-67940070P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SURGIDAC SURGIWIP 2-0 V-20 48IN BRAID COATED GREEN",SUP-EDW-51,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"CIGNA [10200]","Cigna Local Plus",,77.13,53.5,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 28CM 8FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001245660,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,200.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 25KHZ UNIVERSAL ULTRASONIC LARGE DIAMETER SOFT",SUP-5450800306,CDM,S27200284,LOCAL,0272,RC,,,both,,,4359.43,1307.83,"MULTIPLAN [10600]",Multiplan,,3705.52,85,,,,,0,507,3705.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL CURVE 5IN SHARP POINTED SMOOTH JAW VASECTOMY",SUP-GU8161,CDM,S27200284,LOCAL,0272,RC,,,both,,,640.14,192.04,"PHCS [10601]",PHCS,,448.1,70,,,,,0,74.45,544.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR 12X150MM KII FIOS ADV FIX",SUP-CFB71,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,124.24,68,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE CONCENTRATE 20 MG/ML ORAL SYRINGE SUPERORDERABLE (FOR ORAL USE ONLY)",RX-410317,CDM,,,0250,RC,68094-0056-01,NDC,both,.5,ML,25.19,7.56,"CIGNA [10200]",Cigna,,17.13,68,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 13.5X12.5CM 445ML STYLE 410 GEL TEXTURED",SUP-MX-410445,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +10 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.100,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 40CM 29FR 3/8IN ADULT 3 STAGE VENOUS RETURN",SUP-RTS-11029,CDM,S27200284,LOCAL,0272,RC,,,both,,,589.68,176.9,"CIGNA [10200]",Cigna,,400.98,68,,,,,0,68.58,501.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Felbamate",PX-301000678,CDM,80167,CPT,0301,RC,,,both,,,52.00,15.6,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,44.2,"per diem",
"HC Drug Assay Felbamate",PX-301000678,CDM,80167,CPT,0301,RC,,,both,,,52.00,15.6,"CIGNA [10200]","Cigna Local Plus",,41.01,,,,,,,0.01,44.2,"fee schedule",
"HC Rmvl Tunl Cvc W Port",PX-450000231,CDM,36590,CPT,0361,RC,,,both,,,5591.61,1677.48,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1718,,"Case rate ($1,718). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,650.3,5591.61,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 500ML STYLE 20 SMOOTH NATRELLE SILICONE P5.2CM",SUP-20-500,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"CIGNA [10200]","Cigna Local Plus",,1909.95,,,,,,,415.19,3034.5,"percent of total billed charges",
"HC Inj Paravrt Jt C/T 1 Lvl",PX-510000132,CDM,64490,CPT,0761,RC,,,both,,,6149.00,1844.7,"AETNA [10100]","Aetna HMO/PPO",,4888.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,715.13,5226.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTITIS MEDIA AND URI WITH MCC",152,MS-DRG,,,,,,,inpatient,,,34029.10,10208.73,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,7773.27,,"Case rate ($7,333.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,809.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,849.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,896.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,818.43. The transfer operating threshold is the transfer adjustment factor * $6,809.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $514.83. The transfer capital threshold is the transfer adjustment factor * $514.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7333.27,29482.89,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM SUMMIT POROCOAT 7 12/14 HIGH OFFSET TAPER",SUP-157011135,CDM,C1776,HCPCS,0278,RC,,,both,,,25247.25,7574.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2991.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2936.26,21460.16,"percent of total billed charges",
"CATH STERLING SL 150CM 80MM 3.8FR 3MM BALLOON DILATATION OTW",SUP-H74939148308010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 5X5CM ALLOPATCH HD THK.4-.7MM THIN ACELLULAR",SUP-470505,CDM,Q4128,HCPCS,0636,RC,,,both,,,10101.60,3030.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1197.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.43,8586.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 106X25MM 5 TONGUE DAVIS",SUP-45-5115,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.96,81.59,"CIGNA [10200]","Cigna Local Plus",,145.5,53.5,,,,,0,31.63,231.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE BIOPSY NAVIGUS TRAJECTORY KIT",SUP-9733066,CDM,S27200284,LOCAL,0272,RC,,,both,,,8882.92,2664.88,"CIGNA [10200]",Cigna,,6040.39,68,,,,,0,1033.08,7550.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DURASEAL EXACT SPINE SEALANT SYSTEM 3ML US BOX OF 5",SUP-206320,CDM,S27200284,LOCAL,0272,RC,,,both,,,6092.29,1827.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4142.76,68,,,,,0,708.53,5178.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 3 POROUS TRABECULAR METAL FIXED MIS BONE TIBIAL",SUP-00595403701,CDM,C1713,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA [10200]","Cigna Local Plus",,5350,53.5,,3978.14,359.25,3978.14,24,1163,8500,"percent of total billed charges",
"PLATE CURVE 230MM STAINLESS STEEL 4.5MM SCR 10 HOLE 4 COLUMN",SUP-02.124.410S,CDM,C1713,HCPCS,0278,RC,,,both,,,13765.64,4129.69,"MULTIPLAN [10600]",Multiplan,,11700.79,85,,,,,0,1600.94,11700.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 10MM KNEE LEFT E-PLUS EMPOWR 3D KNEE STERILE",SUP-341-10-707,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"PHCS [10601]",PHCS,,4588.5,70,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 80MM 4FR 2.5MM ROUND LOW PROFILE TAPER",SUP-A2025-080,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"AETNA [10100]","Aetna HMO/PPO",,1062.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vrtplsty Lumb/Sac W Img",PX-361000376,CDM,22511,CPT,0361,RC,,,both,,,9378.00,2813.4,"AETNA [10100]","Aetna HMO/PPO",,7455.51,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1090.66,9378,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 375ML GEL ROUND SMOOTH COHESIVE I SILICONE P4CM","SUP-3503751 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"FIRST HEALTH [10303]","First Health",,2940,80,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 6CM 5FR ZIMMON PIGTAIL CURVE PANCREATIC",SUP-G21924,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 3.5MM PRECUT",SUP-3603760,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"STEM HUMERAL 122MM 8MM COMPREHENSIVE PPS SHOULDER",SUP-12-113558,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Local Plus",,3969,31.5,,5372.07,4581.20,7242.98,23,1465.38,10710,"percent of total billed charges",
"LENS IOL 5 D +17.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM POST",SUP-ZA9003-17.5,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CIGNA [10200]",Cigna,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 122MM 12MM COMPREHENSIVE POROUS STD SHOULDER",SUP-113652,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3402,27,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE FLEXIGRAFT PATELLAR LIGAMENT QUADRICEP",SUP-FWPLQ,CDM,S27800098,LOCAL,0278,RC,,,both,,,22911.53,6873.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6186.11,27,,,,,0,2664.61,19474.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 36MM TRICUSPID LOW PROFILE TRI-AD",SUP-900SFC36,CDM,S27800098,LOCAL,0278,RC,,,both,,,14490.00,4347,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3912.3,27,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRACTOR SURGICAL DISPOSABLE RICHARDSON EASTMAN DOUBLE ENDE",SUP-NF09,CDM,S27200284,LOCAL,0272,RC,,,both,,,419.34,125.8,"MULTIPLAN [10600]",Multiplan,,356.44,85,,,,,0,48.77,356.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 260MM 8MM",SUP-81B002,CDM,C1762,HCPCS,0278,RC,,,both,,,8852.70,2655.81,"CIGNA [10200]","Cigna Open Access",,5037.19,56.9,,,,,0,1029.57,7524.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 6IN 5FR 21GA S-MAK .018IN PLATINUM COIL TIP",SUP-S-MAK501N15BT,CDM,C1894,HCPCS,0272,RC,,,both,,,380.02,114.01,"NOVANET [10819]",Novanet,,285.02,75,,,,,0,44.2,323.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE ESC 10D +4MM 52MM 32MM GVF",SUP-121832752,CDM,C1776,HCPCS,0278,RC,,,both,,,20472.48,6141.74,"KAISER [10500]",Kaiser,,13716.56,67,,,,,0,2380.95,17401.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 CTX 36IN BRAID ANTIBACTERIAL COATED UNDYED",SUP-VCP978H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION HEXAGON KIT",SUP-531-78-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"CIGNA [10200]",Cigna,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH PERCUTANEOUS PASSIVE TIP",SUP-9731115,CDM,S27200284,LOCAL,0272,RC,,,both,,,3939.90,1181.97,"CIGNA [10200]","Cigna Open Access",,2241.8,56.9,,,,,0,458.21,3348.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 135CM 2.7FR DRAGONFLY OPTIS 20MM HYDROPHILIC",SUP-C408646,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM MITRAL VALVE BAND CG FUTURE",SUP-638RL30,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UHC [10700]","United Healthcare",,8298.63,63.3,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 96MM 32MM 7.7MM 20FR ZENITH FLEX Z-TRAK",SUP-G48428,CDM,C1874,HCPCS,0278,RC,,,both,,,48686.90,14606.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,13934.19,28.62,,,,,0,5662.29,41383.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPREME 120CM 6FR 5MM SPACE DAMATO CURVE",SUP-401445,CDM,C1730,HCPCS,0272,RC,,,both,,,245.52,73.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,166.95,68,,,,,0,28.55,208.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR PREPARATION OF TC-99M-EXAMETAZIME INTRAVENOUS SOLUTION",RX-186705,CDM,A9521,HCPCS,0343,RC,08888-8878-39,NDC,both,1,UN,9958.79,2987.64,"BLUE CROSS [10001]","Blue Cross PPO",,1997.63,,,,,,,1158.21,8464.97,"fee schedule",
"HC Emg 1 Ext",PX-922000001,CDM,95860,CPT,0922,RC,,,both,,,1218.00,365.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.65,1035.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ivp W/WO Tomo",PX-320000116,CDM,74400,CPT,0320,RC,,,both,,,1879.00,563.7,"AETNA [10100]","Aetna HMO/PPO",,1493.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,175.55,1597.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS 135CM 40MM 10MM .035IN BALLOON DILATATION",SUP-AB35W10040135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"UHC [10700]","United Healthcare",,428.64,63.3,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACTOR, BROKEN SCREW, 3 MM, 6"" LONG, SINGLE USE",SUP-SXT004-BR3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"KAISER [10500]",Kaiser,,1984.88,67,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 20CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155220190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"MULTIPLAN [10600]",Multiplan,,1207.29,85,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +20.5 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z9002205,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"BLUE CROSS [10001]","Blue Cross HMO",,400.08,39.2,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 23CM 15FR 16FR .038IN POLYURETHANE ARROW SIMPLICITY",SUP-CS-15282-SPM,CDM,C1750,HCPCS,0278,RC,,,both,,,2850.00,855,"BLUE CROSS [10001]","Blue Cross HMO",,1117.2,39.2,,,,,0,331.46,2422.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH BLUPERC PERCUTANEOUS DILATION STERILE LATEX FREE",SUP-101/561/070,CDM,S27200284,LOCAL,0272,RC,,,both,,,2872.20,861.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1953.1,68,,,,,0,334.04,2441.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 8MM HEMASHIELD GOLD STRAIGHT MICROVEL 2",SUP-M002020954080,CDM,C1768,HCPCS,0278,RC,,,both,,,3508.58,1052.57,"FIRST HEALTH [10303]","First Health",,2806.86,80,,,,,0,408.05,2982.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC ITREVIA 7 VR-T DF-4 CNCT",SUP-393041,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"CIGNA [10200]",Cigna,,15600,40,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +24 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2400,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tte 2d Fu/Ltd",PX-483000006,CDM,93308,CPT,0483,RC,,,both,,,1015.18,304.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,465.97,45.9,,,,,0,118.07,862.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL 4.6 X 300MM CANNULATED 3/16  SQ. CONNECTION",SUP-P99-110-4630,CDM,S27000186,LOCAL,0270,RC,,,both,,,2085.00,625.5,"AETNA [10100]","Aetna HMO/PPO",,1657.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,242.49,1772.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 129MM STAINLESS STEEL 2.7/3.5MM SCR 7 HOLE LCP",SUP-02.112.115S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bone Survey",PX-320000199,CDM,77074,CPT,0320,RC,,,both,,,954.96,286.49,"FIRST HEALTH [10303]","First Health",,763.97,80,,,,,0,70.03,811.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 6MM 7D XL CERVICAL PEEK",SUP-365.706,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,791.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Gastrin",PX-301000201,CDM,82941,CPT,0301,RC,,,both,,,281.00,84.3,"UHC [10700]","United Healthcare",,15.87,,,,,,,0.01,238.85,"fee schedule",
"HC Dbrd Bn<=20scm",PX-510000009,CDM,11044,CPT,0761,RC,,,both,,,8357.33,2507.2,"FIRST HEALTH [10303]","First Health",,6685.86,80,,,,,0,971.96,7103.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pulm Rhb W Cont Oximetry Mntr",PX-948000003,CDM,94626,CPT,0948,RC,,,both,,,301.15,90.34,"NOVANET [10819]",Novanet,,225.86,75,,,,,0,35.02,301.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL VOCAL CORD PROLARYN GEL WATER BASE INJECTABLE TEMPORARY",SUP-8602M0K5,CDM,C1878,HCPCS,0278,RC,,,both,,,4933.50,1480.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1411.97,28.62,,,,,0,573.77,4193.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETA HOODED PMP E+ MP11",SUP-932-44-764,CDM,C1776,HCPCS,0278,RC,,,both,,,16186.99,4856.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6652.85,41.1,,6417.48,6417.48,6417.48,"1 through 10",1882.55,13758.94,"percent of total billed charges",
"TUBE JEJUNOSTOMY 12FR SILICONE MIC-KEY SECUR-LOK ENFIT BOLUS",SUP-8200-12LV,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"PHCS [10601]",PHCS,,769.71,70,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 10FR PIGTAIL CURVE DRNG FLEXIMA BILIARY FLEXIBLE",SUP-M001271600,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prcrd Drg 0-5yr or W Anomly",PX-450000388,CDM,33018,CPT,0450,RC,,,both,,,5785.00,1735.5,"UHC [10700]","United Healthcare",,2260,,"Per diem ($2,260).",,,,0,67.13,4917.25,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW CENTER 6.5MM - 24MM",SUP-5573-6524,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,184.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,180.93,1322.35,"percent of total billed charges",
"NAIL 11MM 315MM TIBIAL TN ADVANCED INTRAMEDULLARY MR",SUP-04.043.325S,CDM,C1713,HCPCS,0278,RC,,,both,,,9579.13,2873.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2741.55,28.62,,,,,0,1114.05,8142.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 20MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50020,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"UHC [10700]","United Healthcare",,52554.65,63.3,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TNLR SURGICAL SHEATH ON-Q 12IN 16GA STERILE LATEX FREE",SUP-T16X12,CDM,S27200305,LOCAL,0272,RC,,,both,,,250.93,75.28,"MULTIPLAN [10600]",Multiplan,,213.29,85,,,,,0,29.18,213.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.3MM 230MM KIRSCHNER FLOURO BAND 1 END TROCAR",SUP-P99-194-2323,CDM,C1713,HCPCS,0278,RC,,,both,,,518.40,155.52,"CIGNA [10200]",Cigna,,352.51,68,,1831.33,1831.33,1831.33,16,60.29,440.64,"percent of total billed charges",
"LENS IOL SY60WF.295 CLAREON",SUP-SY60WF.295,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SHUNT ACCU-FLO CSF CATH 3 WAY PLASTIC STERILE",SUP-45105,CDM,S27800098,LOCAL,0278,RC,,,both,,,2171.03,651.31,"AETNA [10100]","Aetna HMO/PPO",,1725.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,252.49,1845.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 20MM 52MM OFFSET 4MM TOTAL SHOULDER REPLACEMENT",SUP-5552-E-5220,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"CIGNA [10200]",Cigna,,6180.38,68,,5873.17,5873.17,5873.17,"1 through 10",1057.03,7725.48,"percent of total billed charges",
"CATH JADE 150CM 80MM 4MM BALLOON DILATATION OTW STERILE",SUP-594008022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLUTION",RX-158314,CDM,,,0250,RC,42192-0608-05,NDC,both,5,ML,45.38,13.61,"CIGNA [10200]","Cigna Open Access",,25.82,56.9,,,,,0,5.28,38.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM INSPIRIS RESILIA BOVINE PERICARDIUM",SUP-11500A29,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5375.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA MEDIAL CONGRUENT 12 G-H KNEE",SUP-42512101010,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AETNA [10100]","Aetna HMO/PPO",,8567.25,79.5,,10981.53,8986.79,12413.38,12,1253.3,9159.96,"percent of total billed charges",
"HOOK 6.25INX2MM SKIN RETRACTION 2 PRONG SHARP JOSEPH",SUP-20-5002,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.72,41.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,93.65,68,,,,,0,16.02,117.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 3-0 SH 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-G122H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X9MM DIVERGENCE 12MM LORDOTIC NUCLEUS PULPOSUS",SUP-G6626529,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"NOVANET [10819]",Novanet,,9315,75,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.5MM X 14MM TI",SUP-VAN-15140-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"FIRST HEALTH [10303]","First Health",,777.6,80,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM AZUR CX HYDROCOIL DETACHABLE LOOP",SUP-45-780202,CDM,S27800098,LOCAL,0278,RC,,,both,,,5275.05,1582.51,"CIGNA [10200]","Cigna Open Access",,3001.5,56.9,,,,,0,613.49,4483.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM ORTHOLOC FULL THREAD FOOT ANKLE CORTICAL",SUP-58813514,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"CIGNA [10200]","Cigna Local Plus",,411.68,53.5,,3978.14,359.25,3978.14,24,89.49,654.08,"percent of total billed charges",
"SCR BONE 3.5MM 14MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0235,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,112.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",110.22,805.55,"percent of total billed charges",
"KIT NEROSTIMLTR BLUE 50CM NEVRO 5MM SPACING LEAD STERILE",SUP-LEAD1058-50B,CDM,C1778,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]",Cigna,,2550,68,,6217.33,6217.33,6217.33,"1 through 10",436.13,3187.5,"percent of total billed charges",
"SCR BONE 5MM 70MM TRIGEN FEMUR LOW PROFILE",SUP-71645070,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"FIRST HEALTH [10303]","First Health",,1655.64,80,,,,,0,240.69,1759.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 15.5",SUP-DIB00U0265,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 7CM MR8 3MM BALL FINE GRIT DISSECTING DIAMOND",SUP-MR8-7BA30DF,CDM,S27200284,LOCAL,0272,RC,,,both,,,1142.51,342.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,135.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,132.87,971.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 18FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0118L18,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.96,26.39,"FIRST HEALTH [10303]","First Health",,70.37,80,,,,,0,10.23,74.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC XL 4IN FINGER SPRING EXT ASSIST WIRE-FOAM",SUP-501D,CDM,S27000186,LOCAL,0270,RC,,,both,,,85.87,25.76,"KAISER [10500]",Kaiser,,57.53,67,,,,,0,9.99,72.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 120MM 4FR 5MM .018IN BALLOON",SUP-PCP050120130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PHCS [10601]",PHCS,,861.84,70,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH ENDOSCOPIC HANDPIECE",SUP-E-SOSHTH,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.68,23.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.15,66.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 35MM 4.75MM SOLERA CURVED COCR MOLYBDENUM",SUP-1475501035,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]",Cigna,,2998.8,68,,1831.33,1831.33,1831.33,16,512.88,3748.5,"percent of total billed charges",
"CATH SABER 90CM 150MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARD 70CM 5FR URETERAL POLYURETHANE CONE TIP ADPTR KINK",SUP-138008,CDM,C1758,HCPCS,0272,RC,,,both,,,103.05,30.91,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 7-0 BV-1 18IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8701,CDM,S27200284,LOCAL,0272,RC,,,both,,,644.96,193.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC",271,MS-DRG,,,,,,,inpatient,,,180964.81,54289.44,"CIGNA [10200]",Cigna,,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 55.9%. Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL .25IN TRIATHLON PEG",SUP-6541-4-525,CDM,S27000186,LOCAL,0270,RC,,,both,,,1672.50,501.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DIREXION 105CM 2.4-3FR .021IN MICRO INFUSION NITINOL",SUP-M001195290,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT FRACTURE STABILIT MX LONG BASE VERTEBRAL AUGMENTATION",SUP-MX-1100L-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,13413.60,4024.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MTRL SPLINTING THK1/8IN 24X18IN PERFORATE OPTIPERF",SUP-A96321,CDM,S27000186,LOCAL,0270,RC,,,both,,,707.05,212.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 40.5MM SAFEDGE THK.025IN STERNUM SAGITTAL CUT EDGE",SUP-2108125000,CDM,S27200284,LOCAL,0272,RC,,,both,,,258.22,77.47,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE JEJUNOSTOMY 30CM 16FR TUNGSTEN SILICONE MIC-KEY",SUP-0270-16-2.7-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MENTOR MEMORY SHAPE BREAST IMPLANT TH TALL HEIGHT HIGH PROFI",SUP-334-1054,CDM,C1789,HCPCS,0278,RC,,,both,,,7583.10,2274.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2170.28,28.62,,,,,0,881.91,6445.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 15MM ENDO GIA TITANIUM EXTRA THICK TISSUE",SUP-SIGRADXT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2947.73,884.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2004.46,68,,,,,0,342.82,2505.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM PFC SIGMA TC3 3 KNEE LEFT TITANIUM CEMENTED",SUP-960862,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1468.45,28.62,,,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 133MM CEMENTLESS NECK ACCOLADE TMZF 132D 5.5 45",SUP-6020-5537,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2704.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2654.17,19398.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.6MM 12MM STD SPINE VARIABLE ANGLE SELF DRILL",SUP-184.152,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,431.46,45.9,,,,,0,109.32,799,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACEL 110CM 2MM 5FR 10CM 1CM SPACE RIGHT HEART CURVE",SUP-401763,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 12/14 TAPER 28MM HIP OXINIUM ECHELON",SUP-71342804,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"NOVANET [10819]",Novanet,,11651.51,75,,,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 8FR PIGTAIL NEPHROURETERAL PERCUFLEX METAL",SUP-M001221390,CDM,C2617,HCPCS,0278,RC,,,both,,,811.20,243.36,"CIGNA [10200]","Cigna Local Plus",,433.99,,,,,,,94.34,689.52,"percent of total billed charges",
"HC Mra Chest W Cntrst",PX-610000015,CDM,71555,CPT,0610,RC,,,both,,,3987.00,1196.1,"NOVANET [10819]",Novanet,,2990.25,75,,,,,0,463.69,3388.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 96MM 1.5MM NONSTERILE",SUP-310.507,CDM,S27000186,LOCAL,0270,RC,,,both,,,945.76,283.73,"NOVANET [10819]",Novanet,,709.32,75,,,,,0,109.99,803.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 6X6CM TUTOPLAST THK.3-.5MM PERICARDIUM",SUP-938266,CDM,C1762,HCPCS,0278,RC,,,both,,,16263.30,4878.99,"BLUE CROSS [10001]","Blue Cross PPO",,6375.21,39.2,,,,,0,1891.42,13823.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 7-9 C-D KNEE LEFT CONDYLAR",SUP-42512800512,CDM,C1776,HCPCS,0278,RC,,,both,,,16308.84,4892.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1896.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1896.72,13862.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TRACH 8FR CIAGLIA BLUE RHINO SHILEY PERCUTANEOUS EZ",SUP-G12565,CDM,C1769,HCPCS,0272,RC,,,both,,,3288.30,986.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,382.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,382.43,2795.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 11MM ECHO FX COCR STD OFFSET HIP STERILE",SUP-12151311,CDM,C1776,HCPCS,0278,RC,,,both,,,8941.02,2682.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2558.92,28.62,,,,,0,1039.84,7599.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 3-0 SH 36IN 2 ARM MONOFILAMENT VIOLET",SUP-Y527H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 5FR MP CURVE GUIDING DURAFORM",SUP-M003101630,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"NOVANET [10819]",Novanet,,1877.35,75,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dhea",PX-301000174,CDM,82626,CPT,0301,RC,,,both,,,167.70,50.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.12,,,,,,,0.17,142.55,"fee schedule",
"HC Analysis Dev Icd Sys",PX-480000059,CDM,93289,CPT,0480,RC,,,both,,,419.42,125.83,"MULTIPLAN [10600]",Multiplan,,356.51,85,,,,,0,48.78,419.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Virus Culture Cmv",PX-306000092,CDM,87252,CPT,0306,RC,,,both,,,407.00,122.1,"NOVANET [10819]",Novanet,,305.25,75,,,,,0,0.01,345.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachythrpy Grid",PX-E27200042,CDM,E27200042,LOCAL,0272,RC,,,both,,,363.00,108.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,166.62,45.9,,,,,0,42.22,308.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION 4MM DISTAL RADIAL ADJUSTABLE",SUP-390.051,CDM,S27200284,LOCAL,0272,RC,,,both,,,4616.51,1384.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2118.98,45.9,,,,,0,536.9,3924.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 32MM SIMUPLUS FLEXIBLE LUMEN STERILE LATEX",SUP-7700FB32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 40MM 6MM BALLOON DILATATION HYDROPHILIC",SUP-606004022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"FIRST HEALTH [10303]","First Health",,583.2,80,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 24CM 12FR .035IN POLYURETHANE MAHURKAR 3 LUMEN HIGH",SUP-8888345637HP,CDM,C1752,HCPCS,0272,RC,,,both,,,732.69,219.81,"MULTIPLAN [10600]",Multiplan,,622.79,85,,,,,0,85.21,622.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION",RX-9815,CDM,J7042,HCPCS,0636,RC,00990-7941-09,NDC,both,1000,ML,100.65,30.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,,,,,,,0.74,85.55,"fee schedule",
"HC Special Teletx Port Plan",PX-333000012,CDM,77321,CPT,0333,RC,,,both,,,2365.34,709.6,"NOVANET [10819]",Novanet,,1774.01,75,,,,,0,275.09,2365.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transferase Alanine Amino",PX-301000418,CDM,84460,CPT,0301,RC,,,both,,,106.50,31.95,"KAISER [10500]",Kaiser,,71.36,67,,,,,0,0.11,90.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 15X10CM CYTAL PORCINE BLADDER BURN",SUP-BMM1015,CDM,Q4166,HCPCS,0636,RC,,,both,,,15866.14,4759.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7100.1,44.75,,,,,0,53.69,13486.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Cslt Mat Prp",PX-312000072,CDM,0839T,CPT,0312,RC,,,both,,,104.00,31.2,"CIGNA [10200]","Cigna Local Plus",,55.64,53.5,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 490CC",SUP-RSZ-SHPX-490S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH REDEL 115CM 1MM 6FR 2-5-2MM SPACE G CURVE",SUP-F6DG252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2040.00,612,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1387.2,68,,,,,0,237.25,1734,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYRINGE KIT",SUP-H96560181141,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.07,39.02,"NOVANET [10819]",Novanet,,97.55,75,,,,,0,15.13,110.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BNDG 10YDX4IN CALAMINE DOME PASTE TENDERWRAP UNNA BOOT",SUP-8036-,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.38,16.01,"PHCS [10601]",PHCS,,37.37,70,,,,,0,6.21,45.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM SWIVELOCK FIBERLINK SUTURETAPE",SUP-AR-1665KBCSL,CDM,C1713,HCPCS,0278,RC,,,both,,,6230.70,1869.21,"BLUE CROSS [10001]","Blue Cross HMO",,2442.43,39.2,,957.42,156.86,7483.26,51,724.63,5296.1,"percent of total billed charges",
"PLATE 100D STD L 5MMX.6MM MIDFACE LEFT 5 HOLE BAR 1.7MM SCR",SUP-55-06762,CDM,C1713,HCPCS,0278,RC,,,both,,,1606.72,482.02,"CIGNA [10200]","Cigna Local Plus",,859.6,53.5,,3978.14,359.25,3978.14,24,186.86,1365.71,"percent of total billed charges",
"ANCHOR SUT 4.5MM HEALIX ADVANCE CORD PEEK-OPTIMA",SUP-222303,CDM,C1713,HCPCS,0278,RC,,,both,,,2977.50,893.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,352.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",346.28,2530.88,"percent of total billed charges",
"SCR BONE 4MM 50MM LCP STAINLESS STEEL SHORT THREAD SMALL",SUP-207.650,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"CIGNA [10200]",Cigna,,707.23,68,,1831.33,1831.33,1831.33,16,120.96,884.03,"percent of total billed charges",
"LEAD PACING 65CM 7FR ENDOCARDIAL 2 COIL TRUE BIPOLAR",SUP-7170Q/65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"MULTIPLAN [10600]",Multiplan,,14596.2,85,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 10.5MM 5MM 4FR AMPLATZER .038IN NITINOL",SUP-9-AVP038-005,CDM,S27800098,LOCAL,0278,RC,,,both,,,7141.50,2142.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3277.95,45.9,,,,,0,830.56,6070.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 33MM FLEXIBLE SURE LOCK DELIVERY SYSTEM",SUP-TARP-33,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"FIRST HEALTH [10303]","First Health",,9685.12,80,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SMALL INTERNAL HORIZON TITANIUM ENDOSCOPIC LIGATING",SUP-001201,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.48,18.44,"CIGNA [10200]",Cigna,,41.81,68,,,,,0,7.15,52.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS ZIPWIRE 24CM 3CM 6FR .035IN PIGTAIL CURVE",SUP-M0061265720,CDM,C2617,HCPCS,0278,RC,,,both,,,1483.43,445.03,"NOVANET [10819]",Novanet,,1112.57,75,,,,,0,172.52,1260.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Bn/Jnt Img 3 Phase",PX-341000024,CDM,78315,CPT,0341,RC,,,both,,,3278.75,983.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,388.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,381.32,2786.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Platelet Antibody",PX-302000009,CDM,86022,CPT,0302,RC,,,both,,,174.20,52.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,65.21,,,,,,,0.01,148.07,"fee schedule",
"SYSTEM SYNERGY XD MONORAIL 28MM 144CM 3.5MM CORONARY STENT",SUP-H7493941828350,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM NAIL-EX TITANIUM FULL THREAD TIBIA 2 CORE",SUP-04.015.540,CDM,C1713,HCPCS,0278,RC,,,both,,,1313.17,393.95,"MULTIPLAN [10600]",Multiplan,,1116.19,85,,,,,0,152.72,1116.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION",RX-121669,CDM,J1308,HCPCS,0636,RC,63323-0739-11,NDC,both,2,ML,18.92,5.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.94,,"Fee schedule rate ($0.94). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",17.20,17.20,17.20,"1 through 10",0.93,16.08,"fee schedule",
"HC Xr Spine Lumb/Thor 2+ V",PX-320000042,CDM,72080,CPT,0320,RC,,,both,,,686.11,205.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,216.45,,,,,,,38.7,583.19,"fee schedule",
"REFERENCE TOE 1ST MTP IMPLANT WITH GROMMETS  SIZE 2","SUP-M30 SE020",CDM,C1776,HCPCS,0278,RC,,,both,,,11937.00,3581.1,"KAISER [10500]",Kaiser,,7997.79,67,,,,,0,1388.27,10146.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Spine Lumbosacral >=4v",PX-320000045,CDM,72110,CPT,0320,RC,,,both,,,1142.39,342.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,135.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.2,971.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 100X14-18MM",SUP-400750,CDM,S27800098,LOCAL,0278,RC,,,both,,,4868.64,1460.59,"NOVANET [10819]",Novanet,,3651.48,75,,,,,0,566.22,4138.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esoph WO Egd Dil",PX-750000055,CDM,43450,CPT,0750,RC,,,both,,,9134.50,2740.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1718,,"Case rate ($1,718). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1062.34,7764.33,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAPAVERINE 30 MG/ML INJECTION SOLUTION",RX-6030,CDM,J2440,HCPCS,0637,RC,00517-4002-25,NDC,both,2,ML,375.18,112.55,"MULTIPLAN [10600]",Multiplan,,318.9,85,,,,,0,43.63,318.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CLEANERXT 65CM 7FR 15MM THROMBECTOMY ROTATIONAL 1",SUP-700015,CDM,S27200284,LOCAL,0272,RC,,,both,,,5382.00,1614.6,"FIRST HEALTH [10303]","First Health",,4305.6,80,,,,,0,625.93,4574.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tte Cong W Contr Cmplt",PX-483000019,CDM,C8923,HCPCS,0480,RC,,,both,,,2274.00,682.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2274,,"Case rate ($5,284). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,264.47,2274,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Cslt Mat Prp",PX-312000072,CDM,0839T,CPT,0312,RC,,,both,,,104.00,31.2,"UHC [10700]","United Healthcare",,65.83,63.3,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752620,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,258.2,28.62,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 135D STD BARREL 62X19X5.8MM STAINLESS STEEL 4.5MM",SUP-281.131S,CDM,C1713,HCPCS,0278,RC,,,both,,,3765.33,1129.6,"BLUE CROSS [10001]","Blue Cross HMO",,1476.01,39.2,,957.42,156.86,7483.26,51,437.91,3200.53,"percent of total billed charges",
"SCR BONE 6MM 40MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712640,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 159MM STAINLESS STEEL 4.5MM SCR 6 HOLE 4 COLUMN",SUP-02.124.406S,CDM,C1713,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"BLUE CROSS [10001]","Blue Cross PPO",,4138.34,39.2,,957.42,570.23,957.42,28,1227.78,8973.45,"percent of total billed charges",
"ANCHOR SUT 5MM 2 3/8 CIRCLE BIO-CORKSCREW FIBERWIRE ROTATOR",SUP-AR-1920BNF,CDM,C1713,HCPCS,0278,RC,,,both,,,2126.25,637.87,"BLUE CROSS [10001]","Blue Cross HMO",,833.49,39.2,,957.42,156.86,7483.26,51,247.28,1807.31,"percent of total billed charges",
"HC MRI Cerv Spine WO Cntrst",PX-612000001,CDM,72141,CPT,0612,RC,,,both,,,3910.59,1173.18,"KAISER [10500]",Kaiser,,2620.1,67,,,,,0,360.71,3324,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 7MM LONG ROUND HEAD DIAMOND POINT STERILE",SUP-5130012070,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.07,262.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,359.24,41.1,,,,,0,101.65,742.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL 5MM LEGION KNEE POSTERIOR SCR",SUP-71421827,CDM,C1776,HCPCS,0278,RC,,,both,,,1224.72,367.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,350.51,28.62,,,,,0,142.43,1041.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Tissue Back Soft Deep",PX-360000053,CDM,21925,CPT,0360,RC,,,both,,,3285.23,985.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3279,,"Case rate ($3,279). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,382.07,3285.23,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 80MM 7MM BALLOON DILATATION HYDROPHILIC",SUP-607008022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,84.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 8.25MM 9CM TWIST-IN SHOULDER OBTR THREAD",SUP-AR-6540,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 135CM 80MM 8MM .035IN BALLOON DILATATION NYBAX",SUP-39171-08081,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY,MODERATE",343,APR-DRG,,,,,,,inpatient,,,47067.79,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,953.71. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($33,881.18) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Serpina1 Gene",PX-309000073,CDM,81332,CPT,0310,RC,,,both,,,505.00,151.5,"CIGNA [10200]",Cigna,,96.03,,,,,,,0.51,429.25,"fee schedule",
"SUT PROLENE 1 XLH 30IN 2 ARM MONOFILAMENT BLUE NONABSORBABLE",SUP-8190G,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.96,27.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,62.53,68,,,,,0,10.69,78.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 80MM 125CM 6MM 5FR .018IN VASCULAR NITINOL",SUP-G43773,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"FIRST HEALTH [10303]","First Health",,3343.2,80,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 8.2FR SPRINT QUATTRO SECURE RIGHT VENTRICLE STEROID",SUP-6935,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"FIRST HEALTH [10303]","First Health",,13737.6,80,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemo Non-Horm Anti-Neo Sq/Im",PX-331000001,CDM,96401,CPT,0331,RC,,,both,,,427.13,128.14,"CIGNA [10200]","Cigna Local Plus",,427.13,,"Per diem ($449).",,,,0,49.68,427.13,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 4.8FR L12CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902060,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,,,,,,,189.34,1383.8,"percent of total billed charges",
"4F QUAD 5-5-5 MPA 120CM",SUP-901477,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pretreat RBC Ab ID Densitysep",PX-302000211,CDM,86972,CPT,0302,RC,,,both,,,289.88,86.96,"MULTIPLAN [10600]",Multiplan,,246.4,85,,,,,0,0.01,246.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 100MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.415,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.21,68,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Fem Grft Evasc Aa Rpr",PX-360000042,CDM,34813,CPT,0361,RC,,,both,,,5771.71,1731.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,671.25,5771.71,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Uc Acid Stph Aureus Amplified",PX-306000219,CDM,87641,CPT,0306,RC,,,both,,,416.00,124.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,31.58,,,,,,,0.01,353.6,"fee schedule",
"HC Cocaine Confirmation",PX-301000511,CDM,80353,CPT,0301,RC,,,both,,,208.00,62.4,"PHCS [10601]",PHCS,,145.6,70,,,,,0,0.01,208,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Blood Component Product Noc",PX-390000026,CDM,P9099,HCPCS,0390,RC,,,both,,,1564.00,469.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,185.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.56,1329.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Manip Chst Wall Subq",PX-410000014,CDM,94668,CPT,0410,RC,,,both,,,253.84,76.15,"CIGNA [10200]","Cigna Open Access",,253.84,,"Per diem ($309).",,,,0,29.52,253.84,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revasc Lithotr-Stent Tib/Per",PX-481000130,CDM,C9773,HCPCS,0481,RC,,,both,,,28367.00,8510.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7461.64,,"Case rate ($7,461.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,3299.08,24111.95,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Resp Virus 12-25 Targets",PX-306000225,CDM,87633,CPT,0306,RC,,,both,,,1656.80,497.04,"CIGNA [10200]",Cigna,,916.92,,,,,,,0.01,1479.54,"fee schedule",
"PACK DURAGEN DURAL REGMAX  3X3",SUP-DRM1033,CDM,S27800098,LOCAL,0278,RC,,,both,,,8187.26,2456.18,"BLUE CROSS [10001]","Blue Cross PPO",,3209.41,39.2,,,,,0,952.18,6959.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATROPINE 1% EYE DROP SUPERORDERABLE",RX-408736,CDM,,,0637,RC,70069-0582-01,NDC,both,5,ML,327.08,98.12,"PHCS [10601]",PHCS,,228.96,70,,,,,0,38.04,278.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA SMOOTH SHELL SURFACE SOFT TOUCH",SUP-SSM-210,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"NOVANET [10819]",Novanet,,5666.63,75,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 28MM 144CM 3.5MM",SUP-H7493941228350,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CIGNA [10200]","Cigna Open Access",,4416.86,56.9,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR 6MM 31GA 3/10ML INSULIN HYPODERMIC PERMANENT ATTACH NDL",SUP-328449,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.30,0.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.03,0.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 13X10.6CM BREAST 340-420CC TEXTURE INTEGRATE PORT",SUP-ALLOX2-13E,CDM,C1789,HCPCS,0278,RC,,,both,,,12420.00,3726,"NOVANET [10819]",Novanet,,9315,75,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 695CC",SUP-SSZ-F695,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1013.47,68,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 22CM 150CM 7FR .038IN 3CM BLADDER LOOP",SUP-M006155251170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR SKIN WIDE 35 COUNT STERILE LATEX FREE VISISTAT",SUP-528235,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.15,20.44,"PHCS [10601]",PHCS,,47.71,70,,,,,0,7.93,57.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 18MM LOW PROFILE SCREWS TITANIUM T10 FULL",SUP-AR-8933-18,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,408.97,45.9,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 26CM 6FR .038",SUP-M006192133120,CDM,C2617,HCPCS,0278,RC,,,both,,,1528.96,458.69,"BLUE CROSS [10001]","Blue Cross PPO",,599.35,39.2,,,,,0,177.82,1299.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER PLATE LARGE BB-TAK THREAD",SUP-AR-8970-09T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) VERISIGHT ICE CATHETER TRICUSPID",SUP-VSICE3D,CDM,C1759,HCPCS,0272,RC,,,both,,,21420.00,6426,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"FLEXIBLE LOCK CATHETER",SUP-3680,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DUODENOSCOPE FLEXIBLE 1240MM 15.1MM 11.3MM 4.2MM EXALT MODEL",SUP-M00542421,CDM,C1748,HCPCS,0272,RC,,,both,,,18459.00,5537.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH SABERX 90CM 40MM 2.5MM BALLOON DILATATION RAPID",SUP-47525040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STY LD 52CM .016IN FIRM PCMKR",SUP-6036,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061802210,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,104.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 4.5MM 50MM HAND INNATE INTRAMEDULLARY ANATOMIC",SUP-EXINN924550,CDM,C1713,HCPCS,0278,RC,,,both,,,5002.50,1500.75,"PHCS [10601]",PHCS,,3501.75,70,,,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 2.9MM MAGNUM MINI ABRADER DISPOSABLE",SUP-72201518,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER BIPOLAR 44/45/46MM 28MM LEGACY HIP UHMWPE ASSEMB",SUP-00500104428,CDM,C1776,HCPCS,0278,RC,,,both,,,2365.50,709.65,"MULTIPLAN [10600]",Multiplan,,2010.68,85,,,,,0,275.11,2010.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT GWIRE 145CM .014IN STEERABLE CINCH QR DISPOSABLE ATW",SUP-502144,CDM,C1769,HCPCS,0272,RC,,,both,,,769.50,230.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immuno Tumr Ag Other Ag Qn",PX-302000060,CDM,86316,CPT,0302,RC,,,both,,,358.15,107.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,32.73,,,,,,,0.01,304.43,"fee schedule",
"GRAFT SOFT TISSUE 4X4CM VIALIZE PLACENTAL MEMB ALLOGRAFT",SUP-VL-4040,CDM,,,0278,RC,,,both,,,10281.00,3084.3,"CIGNA [10200]","Cigna Open Access",,5849.89,56.9,,,,,0,10.28,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL NDL STERILE LATEX FREE DISPOSABLE",SUP-30677CN-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1455.30,436.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,172.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.25,1237.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL NDL 45D 2.13IN VALLEYLAB STERILE",SUP-E1652,CDM,S27200284,LOCAL,0272,RC,,,both,,,187.40,56.22,"CIGNA [10200]","Cigna Local Plus",,100.26,53.5,,,,,0,21.79,159.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT MONORAIL 37MM 135CM 10MM ENDOPROSTHESIS",SUP-M001719060,CDM,C1876,HCPCS,0278,RC,,,both,,,16615.20,4984.56,"CIGNA [10200]","Cigna Open Access",,5566.09,33.5,,,,,0,1932.35,14122.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY 10CM 10GA 12GA ARROW ONCONTROL BONE LESION 14CM",SUP-9463-VC-006,CDM,C1830,HCPCS,0272,RC,,,both,,,3237.50,971.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2201.5,68,,,,,0,376.52,2751.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP INTERNAL MAKO",SUP-111331,CDM,S27200284,LOCAL,0272,RC,,,both,,,899.10,269.73,"CIGNA [10200]","Cigna Local Plus",,481.02,53.5,,,,,0,104.57,764.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE ARISTA MPH PLANT STARCH BIONERT 3GM",SUP-SM0002USA,CDM,S27200284,LOCAL,0272,RC,,,both,,,1247.61,374.28,"CIGNA [10200]","Cigna Local Plus",,667.47,53.5,,,,,0,145.1,1060.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 6MM GORE INTERING STD WALL PTFE RADIAL",SUP-IRS06040L,CDM,C1768,HCPCS,0278,RC,,,both,,,3974.40,1192.32,"BLUE CROSS [10001]","Blue Cross HMO",,1557.96,39.2,,,,,0,462.22,3378.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA SURG VELC STRP ZIP SM 30-32IN",SUP-958-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,333.99,100.2,"CIGNA [10200]","Cigna Local Plus",,178.68,53.5,,,,,0,38.84,283.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 245741FZ ASR 7X14X11 FZ SRVCFEE",SUP-245741FZ,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE COMPRESSION 25X20MM STAINLESS STEEL FOOT ANKLE",SUP-43110008,CDM,C1713,HCPCS,0278,RC,,,both,,,3682.50,1104.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2504.1,68,,,,,0,428.27,3130.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 24CM 7FR .038",SUP-M006192142120,CDM,C2617,HCPCS,0278,RC,,,both,,,1498.34,449.5,"BLUE CROSS [10001]","Blue Cross PPO",,587.35,39.2,,,,,0,174.26,1273.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT VITRECTOMY PERFLUORO-N-OCTANE PROCEDURAL LIQUID PURIFY",SUP-8065900164,CDM,C1784,HCPCS,0278,RC,,,both,,,3845.92,1153.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1765.28,45.9,,,,,0,447.28,3269.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL CURVE 5IN SHARP POINTED SMOOTH JAW VASECTOMY",SUP-GU8161,CDM,S27200284,LOCAL,0272,RC,,,both,,,640.14,192.04,"CIGNA [10200]","Cigna Local Plus",,342.47,53.5,,,,,0,74.45,544.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 54MM TI",SUP-SPL-60540-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Local Plus",,866.7,53.5,,3978.14,359.25,3978.14,24,188.41,1377,"percent of total billed charges",
"SCR BONE 2.4MM 12MM LCP TITANIUM DISTAL VOLAR RADIUS LOCKING",SUP-04.210.112,CDM,C1713,HCPCS,0278,RC,,,both,,,1063.69,319.11,"PHCS [10601]",PHCS,,744.58,70,,,,,0,123.71,904.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT SURGICAL 97.5MM 1.2MM RICHARDS T STAINLESS STEEL TUBE",SUP-130549,CDM,S27200284,LOCAL,0272,RC,,,both,,,2084.55,625.36,"CIGNA [10200]",Cigna,,1417.49,68,,,,,0,242.43,1771.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION",RX-3769,CDM,J3410,HCPCS,0636,RC,00517-4201-01,NDC,both,1,ML,230.74,69.22,"NOVANET [10819]",Novanet,,173.06,75,,,,,0,0.3,196.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 80MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.780S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,291.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",286.03,2090.49,"percent of total billed charges",
"SHEATH VIZIGO 17MM SMALL CURVE 71CM 11.5FR 8.5FR INTRO",SUP-D138501,CDM,C1766,HCPCS,0272,RC,,,both,,,6824.10,2047.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,808.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,793.64,5800.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Cath Crico",PX-E27200146,CDM,E27200146,LOCAL,0272,RC,,,both,,,741.40,222.42,"PHCS [10601]",PHCS,,518.98,70,,,,,0,86.22,630.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Brachial Plex Sngl",PX-510000118,CDM,64415,CPT,0761,RC,,,both,,,3659.40,1097.82,"AETNA [10100]","Aetna HMO/PPO",,2909.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,425.59,3659.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK",RX-9627,CDM,J0736,HCPCS,0636,RC,00781-3290-91,NDC,both,50,ML,114.16,34.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.73,,"Fee schedule rate ($6.73). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.4,97.04,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 12MM 5.5MM ACL RECONSTRUCTION",SUP-AR-1655PS-12,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1030.17,45.9,,,,,0,261.02,1907.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 14MM 3.5MM EMBOLIZATION NEUROVASCULAR",SUP-PED-350-14,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"CIGNA [10200]","Cigna Local Plus",,24239.25,31.5,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 28MM 6MM SHOULDER 13STERILE TITANIUM SHORT",SUP-2N2SN06280,CDM,C1776,HCPCS,0278,RC,,,both,,,17039.41,5111.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1981.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1981.68,14483.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 105MM CEMENTED EXT PROSTALAC 1 HIGH OFFSET HIP",SUP-154106000,CDM,C1776,HCPCS,0278,RC,,,both,,,18814.32,5644.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2188.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2188.11,15992.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Galactose Transferase Qn",PX-301000535,CDM,82775,CPT,0301,RC,,,both,,,328.90,98.67,"CIGNA [10200]","Cigna Local Plus",,46.35,,,,,,,0.01,279.57,"fee schedule",
"HC Dil Intracranial Vspasm Diff",PX-361000257,CDM,61642,CPT,0361,RC,,,both,,,7313.71,2194.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,850.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.31,7313.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25X5.5X.38MM MICRO OSCILLATING SAGITTAL STERILE",SUP-2296003524,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,32.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL BLUNT TIP 3.0MM X 70MM",SUP-DRLL-BT-30070,CDM,S27000186,LOCAL,0270,RC,,,both,,,3781.20,1134.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,448.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.75,3214.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 19MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181950,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"PHCS [10601]",PHCS,,13018.32,70,,,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 8FR .088IN AMPLATZ",SUP-588847,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX SMALL - L 11MM X",SUP-T600412,CDM,S27800098,LOCAL,0278,RC,,,both,,,4347.00,1304.1,"PHCS [10601]",PHCS,,3042.9,70,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM 2.5MM 2.1-2.7FR CORONARY",SUP-RONYX25022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CIGNA [10200]","Cigna Open Access",,2112.41,56.9,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 18MM 2MM AXIUS CORONARY ARTERY INTERNAL",SUP-OF-2000,CDM,S27200284,LOCAL,0272,RC,,,both,,,813.05,243.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,552.87,68,,,,,0,94.56,691.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL 2.5MR ETCO2 O2 NONINTUBATE SIDESTREAM PEDIATRIC",SUP-989803144461,CDM,S27000186,LOCAL,0270,RC,,,both,,,132.81,39.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.45,112.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC",053,MS-DRG,,,,,,,inpatient,,,39987.42,11996.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8832.38,,"Fee schedule rate ($8,832.38). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,6074.03,24420.27,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM ORTHOLOC FULL THREAD MIDFOOT CORTICAL 3",SUP-58803522,CDM,C1713,HCPCS,0278,RC,,,both,,,1506.60,451.98,"CIGNA [10200]","Cigna Local Plus",,806.03,53.5,,3978.14,359.25,3978.14,24,175.22,1280.61,"percent of total billed charges",
"SCR BONE 5MM 47.5MM TRIGEN FEMUR LOW PROFILE",SUP-71645047,CDM,C1713,HCPCS,0278,RC,,,both,,,2314.95,694.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1574.17,68,,,,,0,269.23,1967.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 4 STD KNEE RIGHT KEEL NONPOROUS",SUP-ETPKN4SR,CDM,C1776,HCPCS,0278,RC,,,both,,,11060.70,3318.21,"UHC [10700]","United Healthcare",,7001.42,63.3,,8601.07,8395.67,8601.07,"1 through 10",1286.36,9401.6,"percent of total billed charges",
"SYSTEM SPIDERFX 320CM 190CM 3.2-4.2FR 7MM EMBOLIC PROTECTION",SUP-SPD2-US-070-320,CDM,C1884,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"KAISER [10500]",Kaiser,,4854.15,67,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 15CM 19GA 5FR 4 SIDEPORT CATH HOLLOW STYLET PROC",SUP-G10100,CDM,S27200284,LOCAL,0272,RC,,,both,,,369.66,110.9,"AETNA [10100]","Aetna HMO/PPO",,293.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.99,314.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYNX CONTROL 5FR CLSR 10ML 2 MODE BALLOON CATH SEAL",SUP-MX5060,CDM,C1760,HCPCS,0278,RC,,,both,,,1680.00,504,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,480.82,28.62,,,,,0,195.38,1428,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 40MM 5.5MM ARMADA SPINE TITANIUM FIX CROSS",SUP-8450140,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1019.59,28.62,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERPICC SHERLOCK 3CG 5FR CENTRAL VENOUS 3 LUMEN",SUP-1385108QD,CDM,C1751,HCPCS,0272,RC,,,both,,,1872.23,561.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,221.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,217.74,1591.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 50MM 32MM ALTRX HIP",SUP-122132050,CDM,C1776,HCPCS,0278,RC,,,both,,,5307.67,1592.3,"FIRST HEALTH [10303]","First Health",,4246.14,80,,,,,0,617.28,4511.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT BIPOLAR HIP OSTEO",SUP-CAP-H-B-O,CDM,C1776,HCPCS,0278,RC,,,both,,,10660.50,3198.15,"BLUE CROSS [10001]","Blue Cross HMO",,4178.92,39.2,,5311.50,4717.44,5388.59,31,1239.82,9061.43,"percent of total billed charges",
"TISSUE 280012 UNCRT DWL 12 MM SRVC FEE",SUP-280012,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,1466.08,39.2,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 7 HOLE SHAFT LCP BONE RADIUS RIGHT",SUP-02.110.007S,CDM,C1713,HCPCS,0278,RC,,,both,,,9722.79,2916.84,"CIGNA [10200]","Cigna Local Plus",,5201.69,53.5,,3978.14,359.25,3978.14,24,1130.76,8264.37,"percent of total billed charges",
"NDL BONE BIOPSY REVOLVE ACCESS TROCAR TIP 8GA",SUP-685.027S,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM RAYHACK CORTICAL ULNAR LOW PROFILE",SUP-40100956,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,349.48,45.9,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 63MM REGENEREX KNEE PRIMARY CRUCIATE RETAINING P",SUP-141271,CDM,C1776,HCPCS,0278,RC,,,both,,,11964.60,3589.38,"KAISER [10500]",Kaiser,,8016.28,67,,,,,0,1391.48,10169.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Strep a W Dir Optic Obv",PX-306000172,CDM,87880,CPT,0306,RC,,,both,,,240.35,72.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14.88,,,,,,,8.12,204.3,"fee schedule",
"STENT MARDIS 26CM 7FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251430,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"MULTIPLAN [10600]",Multiplan,,1046.32,85,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 25MM RESTORATION +20MM HIP MODULAR REVISION",SUP-6276-1-225,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2637.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2588.23,18916.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR ORTHOPEDIC 23MM LONG BRIDGE POST NONSTERILE LATEX FREE",SUP-323.1033,CDM,C1713,HCPCS,0278,RC,,,both,,,25389.00,7616.7,"AETNA [10100]","Aetna HMO/PPO",,20184.26,79.5,,1521.93,481.35,16760.95,30,2952.74,21580.65,"percent of total billed charges",
"BIT DRILL 290MM 13MM 3 FLUTE CANNULATED QUICK COUPLING",SUP-351.27,CDM,S27000186,LOCAL,0270,RC,,,both,,,3349.50,1004.85,"AETNA [10100]","Aetna HMO/PPO",,2662.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,389.55,2847.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 17.5MM S-ROM ZTT 22F 2XL HIP PROXIMAL",SUP-550751,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1289.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1265.9,9252.04,"percent of total billed charges",
"HC Rv Inframlr W Pta Cmplx Init",PX-361000739,CDM,37298,CPT,0361,RC,,,both,,,19230.05,5769.01,"PHCS [10601]",PHCS,,13461.04,70,,,,,0,19.23,16345.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175280010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,126.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL SHAFT ALLOGRAFT FROZEN 150MM",SUP-T20657,CDM,S27800098,LOCAL,0278,RC,,,both,,,6795.81,2038.74,"CIGNA [10200]",Cigna,,4621.15,68,,,,,0,790.35,5776.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 66MM 32MM MARATHON HIP",SUP-121932166,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2321.35,28.62,,,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT CONFIDENCE HALF DOSE 5CC LATEX FREE",SUP-283905000,CDM,C1713,HCPCS,0278,RC,,,both,,,8424.90,2527.47,"MULTIPLAN [10600]",Multiplan,,7161.17,85,,,,,0,979.82,7161.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL OLIF25 2 HOLE BONE SPINE STERILE",SUP-2140001,CDM,C1713,HCPCS,0278,RC,,,both,,,17250.00,5175,"NOVANET [10819]",Novanet,,12937.5,75,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RAMROD QUADRA-COIL 22-28CM 6FR KIDNEY BLADDER CURL",SUP-5001960,CDM,C2617,HCPCS,0278,RC,,,both,,,721.79,216.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,83.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,83.94,613.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 30MM 154CM 12MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200123020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"KAISER [10500]",Kaiser,,2773.8,67,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM REDUCED",SUP-R5-027,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"AETNA [10100]","Aetna HMO/PPO",,17529.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 20CM 7FR 2 PIGTAIL CURVE",SUP-M0061921400,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 LEFT KNEE CEMENTED CRUCIATE RETAINING",SUP-5510F201,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1943.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1907.07,13938.17,"percent of total billed charges",
"HC Filter Transfusion Blood",PX-E27200337,CDM,E27200337,LOCAL,0272,RC,,,both,,,52.80,15.84,"FIRST HEALTH [10303]","First Health",,42.24,80,,,,,0,6.14,44.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 694758  LEAD-QUADRIPOLAR RV/SVC 58C",SUP-6947-58,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"NOVANET [10819]",Novanet,,12879,75,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 12MM CEMENTRALIZER HIP FEMUR PMMA CEMENT SUMMIT",SUP-137621000,CDM,C1776,HCPCS,0278,RC,,,both,,,846.45,253.93,"BLUE CROSS [10001]","Blue Cross PPO",,331.81,39.2,,3949.44,3949.44,3949.44,"1 through 10",98.44,719.48,"percent of total billed charges",
"CATH TAKERU 8MM 2MM BALLOON DILATATION OTW PTCA",SUP-DC-PY2008UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,671.98,68,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM PFC SIGMA TC3 2 KNEE LEFT TITANIUM CEMENTED",SUP-960822,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"KAISER [10500]",Kaiser,,3437.66,67,,,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL ATTUNE STERILE 8 KNEE LEFT CEMENTED POSTERIOR",SUP-150410108,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"AETNA [10100]","Aetna HMO/PPO",,17802.71,79.5,,10981.53,8986.79,12413.38,12,2604.35,19034.35,"percent of total billed charges",
"FUROSEMIDE 20 MG TABLET",RX-3294,CDM,,,0637,RC,00054-8297-25,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,3.35,53.5,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT FLITES XL LOOP DISPOSABLE",SUP-MFA2100-XL,CDM,S27000186,LOCAL,0270,RC,,,both,,,231.56,69.47,"AETNA [10100]","Aetna HMO/PPO",,184.09,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.93,196.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR CERAMIC POROUS BIPOLAR PRIMARY HEAD INSRT",SUP-98B00100189,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross PPO",,4057.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"BLADE SAW 25X9MM THK.015MM MEDIUM LONG STAINLESS STEEL",SUP-2296-033-111,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.84,87.25,"UHC [10700]","United Healthcare",,184.1,63.3,,,,,0,33.82,247.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 43IN 8FR SMOOTH BOLUS RADIOPAQUE STYLET",SUP-40-3438,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.52,22.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.55,62.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 5.5MM MATRIX CURVE SPINE PEDICLE POSTERIOR",SUP-04.636.030,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PROFILE SILICONE SMOOTH",SUP-SCL-320,CDM,C1789,HCPCS,0278,RC,,,both,,,8004.00,2401.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2290.74,28.62,,,,,0,930.87,6803.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION SWIVELOCK PEEK MENISCAL ROOT REPAIR",SUP-AR-4550P,CDM,C1713,HCPCS,0278,RC,,,both,,,10106.78,3032.03,"FIRST HEALTH [10303]","First Health",,8085.42,80,,,,,0,1175.42,8590.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 8MM HEMASHIELD GOLD STRAIGHT MICROVEL 2",SUP-M002020954080,CDM,C1768,HCPCS,0278,RC,,,both,,,3508.58,1052.57,"PHCS [10601]",PHCS,,2456.01,70,,,,,0,408.05,2982.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Abdomen 1v",PX-320000220,CDM,74018,CPT,0320,RC,,,both,,,552.96,165.89,"BLUE CROSS [10001]","Blue Cross PPO",,69.15,,"Fee schedule rate ($69.15).",69.40,69.14,69.40,"1 through 10",34.01,470.02,"fee schedule",
"CATH ATTAIN CLARITY BALLOON OCCLUSION VENOGRAM",SUP-6225,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,495.72,68,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 25X20X5MM DEMINERALIZED CANCELLOUS BONE",SUP-0W1025,CDM,S27800098,LOCAL,0278,RC,,,both,,,7521.00,2256.3,"PHCS [10601]",PHCS,,5264.7,70,,,,,0,874.69,6392.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 6MM MOUNTAINEER TITANIUM SPINE",SUP-188362006,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"KIT CATH UROMAX ULTRA QUADRA-FOLD ENCORE HIGH PRESSURE KINK",SUP-M0062251360,CDM,C1726,HCPCS,0272,RC,,,both,,,2024.93,607.48,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,832.25,41.1,,,,,0,235.5,1721.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMT BRIDLE PRO- 16 FR",SUP-4-4216,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"CIGNA [10200]","Cigna Open Access",,405.58,56.9,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 C NEUTRAL 32MM E1 HIP",SUP-010000847,CDM,C1776,HCPCS,0278,RC,,,both,,,12282.00,3684.6,"MULTIPLAN [10600]",Multiplan,,10439.7,85,,,,,0,1428.4,10439.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER HUMERAL 36MM SMR +6MM SHOULDER UHMWPE REVISION REVERSE",SUP-1360.50.820,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"CIGNA [10200]",Cigna,,1999.2,68,,5873.17,5873.17,5873.17,"1 through 10",341.92,2499,"percent of total billed charges",
"SCR BONE 3.5MM 22MM VARIAX LOCK NONSTERILE",SUP-657322,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"BLUE CROSS [10001]","Blue Cross HMO",,582.84,39.2,,957.42,156.86,7483.26,51,172.92,1263.81,"percent of total billed charges",
"KIT ARTHROSCOPIC L7 MM FLEXOR HALLUCIS LONGUS",SUP-AR-1570BC-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10831.28,3249.38,"BLUE CROSS [10001]","Blue Cross PPO",,4245.86,39.2,,957.42,570.23,957.42,28,1259.68,9206.59,"percent of total billed charges",
"LENS IOL 0 D +15 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.150,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 126D 65MM HIP NECK SEG",SUP-17296426,CDM,C1776,HCPCS,0278,RC,,,both,,,29432.09,8829.63,"PHCS [10601]",PHCS,,20602.46,70,,,,,0,3422.95,25017.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FLOSWITCH 1050 PSI FLOW CONTROL 1 WAY HIGH PRESSURE",SUP-M001442001,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.22,18.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.35,53.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR ANGIOGRAPHY NAMIC 3 200 PSI 5/16IN 28 THREAD ORIGINAL",SUP-H965914000311,CDM,S27000186,LOCAL,0270,RC,,,both,,,119.17,35.75,"MULTIPLAN [10600]",Multiplan,,101.29,85,,,,,0,13.86,101.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL 15X6MM MOBI-C 13MM CERVICAL TITANIUM COCRMO UHMWPE","SUP-MB 3356",CDM,S27800098,LOCAL,0278,RC,,,both,,,33075.00,9922.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13593.83,41.1,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 8MM 32MM 3 PEG ONLAY ADVANCE ALL POLY KNEE",SUP-KPONTP32,CDM,C1776,HCPCS,0278,RC,,,both,,,4195.20,1258.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,497.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,487.9,3565.92,"percent of total billed charges",
"HC Inj Cerv/Thorac Sngl WO Img",PX-510000203,CDM,62320,CPT,0761,RC,,,both,,,4263.00,1278.9,"FIRST HEALTH [10303]","First Health",,3410.4,80,,,,,0,4.26,3623.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sensor Neurological Bis Quatro",PX-E27000205,CDM,E27000205,LOCAL,0270,RC,,,both,,,194.37,58.31,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SMALL PERIPHERAL CUTTING BALLOON 142CM 1.5CM 4MM",SUP-M001PCBO4015140F0,CDM,C1725,HCPCS,0272,RC,,,both,,,4854.15,1456.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,MODERATE",607,APR-DRG,,,,,,,inpatient,,,200449.63,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $32,452.78. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to (Final Base Payment plus Newborn Screen Add-on Amount $63.00) multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($123,519.41) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 Newborn; Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 30MM 9MM FASTTHREAD",SUP-AR-4030C-09,CDM,C1713,HCPCS,0278,RC,,,both,,,2323.13,696.94,"CIGNA [10200]","Cigna Open Access",,1321.86,56.9,,1144.80,304.56,2275.09,66,270.18,1974.66,"percent of total billed charges",
"GRAFT SKIN 7X3CM OMEGA3 WOUND FENESTRATE",SUP-50200F02B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,9170.10,2751.03,"CIGNA [10200]",Cigna,,180.89,,,,,,,180.89,7794.59,"fee schedule",
"RETRIEVER SUT 10.1IN HEWSON DRILL GUIDE ACCESS LIGAMENT",SUP-71111579,CDM,S27200284,LOCAL,0272,RC,,,both,,,797.53,239.26,"CIGNA [10200]","Cigna Local Plus",,426.68,53.5,,,,,0,92.75,677.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD 25CM 12FR LOOP DRNG FLEXIMA METAL HYDROPHILIC",SUP-M001271380,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000165,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM TRILOGY HIP SELF TAP STERILE",SUP-625006560,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,118.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,115.87,846.86,"percent of total billed charges",
"ENV TISSUE 6.9X9.5CM CORMATRIX CANGAROO ECM XL PORCINE SOFT",SUP-CMCV-009-XLG,CDM,S27800098,LOCAL,0278,RC,,,both,,,6796.50,2038.95,"BLUE CROSS [10001]","Blue Cross PPO",,2664.23,39.2,,,,,0,790.43,5777.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 3-0 CT-1 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-810H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.6MM 14MM COALITION SPINE SELF TAP VARIABLE ANGLE",SUP-184.114,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"AMERIGROUP MEDICAID [20100]",Amerigroup,,111.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",109.32,799,"percent of total billed charges",
"CATH ROTABLATOR ROTALINK PLUS 135CM .58IN 1.75MM ATHERECTOMY",SUP-H749236310040,CDM,C1724,HCPCS,0272,RC,,,both,,,8534.13,2560.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1011.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,992.52,7254.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 2-0 CT-1 SPIRAL 15CM SUT",SUP-SXPP1B409,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.96,69.59,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,106.47,45.9,,,,,0,26.98,197.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 8X8X2MM FUSEFORCE HAND STERILE",SUP-FFNS-0808,CDM,C1713,HCPCS,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Local Plus",,3691.5,53.5,,3978.14,359.25,3978.14,24,802.47,5865,"percent of total billed charges",
"GRAFT ENDOVASCULAR 80MM 10MM 9FR FLUENCY PLUS CARBON EPTFE 2",SUP-FEM10080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 16MM 144CM 2.5MM CORONARY STENT",SUP-H7493952816250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AETNA [10100]","Aetna HMO/PPO",,4424.18,79.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY SERRATE 9IN WITTNER FINE STRAIGHT UTERUS",SUP-52-6870,CDM,S27200284,LOCAL,0272,RC,,,both,,,2485.13,745.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1140.67,45.9,,,,,0,289.02,2112.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING COMPRESSION 1500MM FLOWTRON EXCEL SYSTEM",SUP-SP057,CDM,S27000186,LOCAL,0270,RC,,,both,,,103.36,31.01,"CIGNA [10200]","Cigna Open Access",,58.81,56.9,,,,,0,12.02,87.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 10MM NATURAL LARGE LORDOTIC",SUP-19410,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 16CM 2MM BALLOON DILATATION HYDROPHILIC",SUP-G50318,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1606.45,68,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 3.50 X 28MM",SUP-H7493942828350,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2850.39,45.9,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADMIRAL XTREME 130CM 120MM 5MM BALLOON DILATATION",SUP-ADM050120130,CDM,C1725,HCPCS,0272,RC,,,both,,,1134.00,340.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,771.12,68,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +7 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000070,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 7.25IN 4.5MM STAINLESS STEEL FREER 2 END SHARP",SUP-656620,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.01,32.7,"PHCS [10601]",PHCS,,76.31,70,,,,,0,12.68,92.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 34MM TITANIUM TIBIA CANCELLOUS DISTAL T15 DRIVE",SUP-816140034,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"HC Pt Eval High Complex 45 Min",PX-420000155,CDM,97163,CPT,0424,RC,,,both,,,535.54,160.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,63.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.28,455.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 20IN GIGLI SPIRAL WIRE",SUP-210483,CDM,S27200284,LOCAL,0272,RC,,,both,,,193.14,57.94,"CIGNA [10200]","Cigna Open Access",,109.9,56.9,,,,,0,22.46,164.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 35MM 9MM DELTA ACL CANNULATED",SUP-AR-5035TC-09,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"CIGNA [10200]",Cigna,,1258.43,68,,1831.33,1831.33,1831.33,16,215.23,1573.04,"percent of total billed charges",
"CATH JADE 150CM 240MM 4MM BALLOON DILATATION STERILE LATEX",SUP-594024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"PHCS [10601]",PHCS,,1020.6,70,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM TRABECULAR METAL REVERSE PLUS ORTHOPEDIC SHOULDER",SUP-98000900084,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"BLUE CROSS [10001]","Blue Cross PPO",,19015.92,39.2,,3949.44,3949.44,3949.44,"1 through 10",5641.71,41233.5,"percent of total billed charges",
"STENT ICAST STENT DIAMETER 5X 38MM CATH 80CM ENDOVASCULAR",SUP-48538,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"BLUE CROSS [10001]","Blue Cross HMO",,6867.96,39.2,,9776.84,9776.84,9776.84,"1 through 10",2037.61,14892.26,"percent of total billed charges",
"CAP STEM HUMERAL REVISION INSRT COMPREHENSIVE E1 SHOULDER",SUP-98000900081,CDM,C1776,HCPCS,0278,RC,,,both,,,51660.00,15498,"CIGNA [10200]",Cigna,,20664,40,,5873.17,5873.17,5873.17,"1 through 10",6008.06,43911,"percent of total billed charges",
"GRAFT SKIN 4X4CM ALLOPATCH THK.4-.8MM THIN ACELLULAR DERMIS",SUP-WC0404,CDM,Q4128,HCPCS,0636,RC,,,both,,,5871.28,1761.38,"AETNA [10100]","Aetna HMO/PPO",,4667.67,79.5,,,,,0,80.43,4990.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TIBIAL 14MM INBONE RIGHT LEFT TOP MODULAR",SUP-200011901,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,,10981.53,8986.79,12413.38,12,434.96,3179,"percent of total billed charges",
"BIT DRILL 1.8MM FLEXIBLE ALL SUT ANCHOR SYSTEM DISPOSABLE",SUP-Y18D,CDM,S27200284,LOCAL,0272,RC,,,both,,,733.54,220.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,498.81,68,,,,,0,85.31,623.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 15MM 145CM 3MM CORONARY STENT",SUP-1125300-15,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]","Cigna Local Plus",,3123.33,53.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX SEPRA 14X12IN MONOFILAMENT RESORBABLE",SUP-1203035,CDM,C1781,HCPCS,0278,RC,,,both,,,110019.12,33005.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13037.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12795.22,93516.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 100MM 120CM 8MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200091020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]",Cigna,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 59MM 75CM 6MM 100CM",SUP-M001712060,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"FIRST HEALTH [10303]","First Health",,6762,80,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 155CM 8MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200084020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 30MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE50030,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"PHCS [10601]",PHCS,,58565.22,70,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 14GA RIGID NDL 1 MICROFIBER PAD RADIOPAQUE INTERWOVEN",SUP-SMUC13H,CDM,A4648,HCPCS,0278,RC,,,both,,,630.67,189.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,180.5,28.62,,,,,0,73.35,536.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 150MM 130CM 6MM VASCULAR METAL SUPERFICIAL",SUP-H74939293061530,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +31 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60AT.310,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross PPO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 5.5MM ES2 RADIUS TITANIUM HEXAGONAL",SUP-482806045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"HC Intro Cath Aorta",PX-361000081,CDM,36200,CPT,0361,RC,,,both,,,4155.54,1246.66,"FIRST HEALTH [10303]","First Health",,3324.43,80,,,,,0,483.29,4155.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 15MM 145CM 2.5MM CORONARY STENT",SUP-1125250-15,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"FIRST HEALTH [10303]","First Health",,4670.4,80,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 18MM COCR",SUP-VAL-25180-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]","Cigna Open Access",,811.17,56.9,,1144.80,304.56,2275.09,66,165.8,1211.76,"percent of total billed charges",
"SET TRANSFER 6IN TWIST CLAMP MINICAP PERITONEUM PEDIATRIC",SUP-5C4482A,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.17,194.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,297.51,45.9,,,,,0,75.38,550.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 100CM 5FR SIM1 CURVE ANGIOGRAPHIC STAINLESS",SUP-510035SIM1,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"AETNA [10100]","Aetna HMO/PPO",,86.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.25/18",SUP-401747,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX MEDIUM C9 8MM X",SUP-T600209,CDM,S27800098,LOCAL,0278,RC,,,both,,,3150.00,945,"AETNA [10100]","Aetna HMO/PPO",,2504.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,366.35,2677.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM .02IN 4MM PENUMBRA COIL 400 RUBY",SUP-RBY4C0415,CDM,S27800098,LOCAL,0278,RC,,,both,,,5838.00,1751.4,"KAISER [10500]",Kaiser,,3911.46,67,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 33MM 26.1MM MASTERS SERIES 85D STD SUPRA",SUP-33MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"KAISER [10500]",Kaiser,,19509.88,67,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 30CM MIC-KEY SECUR-LOK ENFIT CNCT GASTRO",SUP-0144-12,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.91,20.97,"NOVANET [10819]",Novanet,,52.43,75,,,,,0,8.13,59.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 150MM 120CM 6.5MM 6FR VASCULAR NITINOL",SUP-S-65-150-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA [10200]",Cigna,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 120MM 3.5MM BALLOON DILATATION PEBAX",SUP-H74939148351210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 170MM 130CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-EX061703CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2459.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 75CM 8.6FR CARDIAC 2 DEFIBRILLATION COIL ACTIVE",SUP-6947-75,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]","Cigna Open Access",,5752.62,33.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 8.5IN COTTLE 2 END SEPTUM",SUP-67-1623,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.41,87.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,33.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.77,246.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 4FR 2-8-2MM SPACE REGULAR P CURVE",SUP-D4S10PR282RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"MULTIPLAN [10600]",Multiplan,,3168.38,85,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Internal Jugular Puncture",PX-E27200290,CDM,E27200290,LOCAL,0272,RC,,,both,,,132.00,39.6,"FIRST HEALTH [10303]","First Health",,105.6,80,,,,,0,15.35,112.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45MM LINEAR CUTTER ARTICULATION TRIGGER LOCK",SUP-PSE45A,CDM,S27200284,LOCAL,0272,RC,,,both,,,5656.21,1696.86,"FIRST HEALTH [10303]","First Health",,4524.97,80,,,,,0,657.82,4807.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET PRESSURE MONITOR QUICK CHAMBER SYRINGE SIDE PORTED NEEDL",SUP-0295-004-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTECH CANCELLOUS CORTICAL 30ML .5-3MM",SUP-T00070,CDM,S27800098,LOCAL,0278,RC,,,both,,,2840.25,852.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,336.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,330.32,2414.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X8MM HEDRON C 7D 14MM STERILE LATEX FREE",SUP-1211.4618S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2850.39,45.9,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT R 34MM STERILE",SUP-EVOLUTR-34-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20263.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 STANDARD 5MMX15CM",SUP-M0035465150,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS [10001]","Blue Cross PPO",,5532.94,39.2,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT GLAUCOMA EX-PRESS 2.64MM 50UM VERTICAL CHANNEL",SUP-47053,CDM,C1783,HCPCS,0278,RC,,,both,,,7723.86,2317.16,"NOVANET [10819]",Novanet,,5792.9,75,,,,,0,898.28,6565.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 24CM 5FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552220,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"MULTIPLAN [10600]",Multiplan,,1020.49,85,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE CHIBA 18 GA X 9 CM",SUP-MCN1803,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2.7MM 18MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656318,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"KAISER [10500]",Kaiser,,894.58,67,,,,,0,155.28,1134.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 8CM 2.9MM STERLING LARGE SPHERE SMALL JOINT",SUP-C9911A,CDM,S27200284,LOCAL,0272,RC,,,both,,,638.28,191.48,"NOVANET [10819]",Novanet,,478.71,75,,,,,0,74.23,542.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 100MM 4MM BALLOON",SUP-LX1813041004F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"KAISER [10500]",Kaiser,,4507.43,67,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR MEDIUM CEMENT 3 PEG LOW PROFILE LCS",SUP-129409430,CDM,C1776,HCPCS,0278,RC,,,both,,,7055.25,2116.57,"PHCS [10601]",PHCS,,4938.68,70,,,,,0,820.53,5996.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 18FR TUNGSTEN SILICONE 2.5CM MIC-KEY",SUP-0270-18-2.5-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1790.3,68,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 6.8FR 10MM SPACING J ATRIUM BIPOLAR ACTIVE",SUP-1782TC/52,CDM,C1898,HCPCS,0275,RC,,,both,,,1786.00,535.8,"KAISER [10500]",Kaiser,,1196.62,67,,,,,0,207.71,1518.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 59MM 135CM 6MM THIN VASCULAR COCR",SUP-1012629-59,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"NOVANET [10819]",Novanet,,6300,75,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL ADULT REGULAR CONTOUR 3IN ATLAS PROCARE 2",SUP-79-83285,CDM,S27000186,LOCAL,0270,RC,,,both,,,245.69,73.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.57,208.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 12MM 2.75MM BALLOON DILATATION PEBAX",SUP-1400275-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOXCROSS 135CM 20MM 8MM BALLOON DILATATION JETCOAT",SUP-10338-20,CDM,C1725,HCPCS,0272,RC,,,both,,,1539.00,461.7,"AETNA [10100]","Aetna HMO/PPO",,1223.51,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT AMSTERDAM 10FR INTRO PUSH GWIRE CATH PERCUFLEX",SUP-M00533920,CDM,C1894,HCPCS,0272,RC,,,both,,,593.81,178.14,"AETNA [10100]","Aetna HMO/PPO",,472.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.06,504.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 20MM 125CM 6MM 6FR VASCULAR ILIAC ARTERY",SUP-G43819,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,447.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SITAGLIPTIN PHOSPHATE 50 MG TABLET",RX-77616,CDM,,,0637,RC,00006-0112-01,NDC,both,1,UN,49.90,14.97,"UHC [10700]","United Healthcare",,31.59,63.3,,,,,0,5.8,42.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 7.75IN WEITLANER BLUNT SELF RETAINING 2X3 PRONG",SUP-BV201R,CDM,S27200284,LOCAL,0272,RC,,,both,,,699.35,209.8,"CIGNA [10200]","Cigna Open Access",,397.93,56.9,,,,,0,81.33,594.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNQT SURGICAL 42IN ATS",SUP-60-7075-157R,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"CIGNA [10200]","Cigna Local Plus",,39.56,53.5,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 6.5X50MM MIDLINE SYSTEM POLYAXIAL CORTICAL 4S R",SUP-14616550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"DEFIBRILLATOR CRT-D GALLANT BIPOLAR DF4 HF",SUP-CDHFA500D,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"AETNA [10100]","Aetna HMO/PPO",,61175.25,79.5,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAFLEX 15CM 66CM 7.5FR .025IN IAB CARDIOTHANE II",SUP-IAB-06840-U,CDM,S27200284,LOCAL,0272,RC,,,both,,,12385.50,3715.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1440.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY FEMORAL BLUE 75MM 20MM RECLAIM ARTICUL/EZE 40MM OFFSET",SUP-197520075,CDM,C1776,HCPCS,0278,RC,,,both,,,22082.76,6624.83,"BLUE CROSS [10001]","Blue Cross PPO",,8656.44,39.2,,3949.44,3949.44,3949.44,"1 through 10",2568.22,18770.35,"percent of total billed charges",
"SYSTEM SWARTZ LAMP 90 CURVE 90CM 8.5FR INTRO TRANSSEPTAL",SUP-407358,CDM,C1893,HCPCS,0272,RC,,,both,,,1291.06,387.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,530.63,41.1,,,,,0,150.15,1097.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 5.5MM EXPEDIUM PREBENT TITANIUM LINE",SUP-179771055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 40MM 75CM 20MM 100CM",SUP-H965404300,CDM,C1876,HCPCS,0278,RC,,,both,,,4410.00,1323,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,512.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 58MM HIP ACETABULAR MODULAR COCRMO BIO-MOORE",SUP-12-139040,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"PHCS [10601]",PHCS,,1955.1,70,,,,,0,324.83,2374.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 5% DEXTROSE EXCEL 1L LATEX FREE",SUP-L5100,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"AETNA [10100]","Aetna HMO/PPO",,64.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT SHOULDER TRABECULAR METAL REVERSE",SUP-98000971000,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"FIRST HEALTH [10303]","First Health",,38808,80,,,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"13F AGILIS INTRODUCER, MEDIUM CURL",SUP-SI-1371-M,CDM,C1766,HCPCS,0272,RC,,,both,,,8970.00,2691,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6099.6,68,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"13F AGILIS INTRODUCER, MEDIUM CURL",SUP-SI-1371-M,CDM,C1766,HCPCS,0272,RC,,,both,,,8970.00,2691,"AETNA [10100]","Aetna HMO/PPO",,7131.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +13.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.135,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,197.05,28.62,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.220,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,197.05,28.62,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 25MM 7FR FUSION OMNI-TOME BILE PANCREATIC DOME TIP",SUP-G31903,CDM,S27200284,LOCAL,0272,RC,,,both,,,2197.50,659.25,"CIGNA [10200]","Cigna Local Plus",,1175.66,53.5,,,,,0,255.57,1867.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 12MM ORTHOLOC TITANIUM NITRIDE FOREFOOT LOCKING",SUP-5201020012,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,204.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,200.62,1466.25,"percent of total billed charges",
"BLADE LARYNGOSCOPE SPECTRUM LOPRO 2 TITANIUM GLIDESCOPE DISP",SUP-0270-0877,CDM,S27200284,LOCAL,0272,RC,,,both,,,414.99,124.5,"CIGNA [10200]","Cigna Open Access",,236.13,56.9,,,,,0,48.26,352.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 4X.7X.05IN SYSTEM 6 SAGITTAL HEAVY DUTY BEVELED",SUP-6118127100,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.30,93.99,"KAISER [10500]",Kaiser,,209.91,67,,,,,0,36.44,266.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 120MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.419,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"KAISER [10500]",Kaiser,,927.37,67,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRN6PR,CDM,C1776,HCPCS,0278,RC,,,both,,,13075.50,3922.65,"UHC [10700]","United Healthcare",,8276.79,63.3,,8601.07,8395.67,8601.07,"1 through 10",1520.68,11114.18,"percent of total billed charges",
"VALVE AORTIC 14MM 19MM BIOCOR FLEXFIT LOW PROFILE SUPRA",SUP-BSP100-19,CDM,S27800098,LOCAL,0278,RC,,,both,,,32715.90,9814.77,"PHCS [10601]",PHCS,,22901.13,70,,,,,0,3804.86,27808.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONTOUR 150-250 2 VIALS BX/2",SUP-M0017600221,CDM,S27800098,LOCAL,0278,RC,,,both,,,1458.00,437.4,"CIGNA [10200]","Cigna Local Plus",,780.03,53.5,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 80MM 80CM 8MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM08080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"MULTIPLAN [10600]",Multiplan,,15529.5,85,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 6MM CANNULATED REAMER STERILE",SUP-AR-1218-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UNITE ORTHOPEDIC 150MM 1.6MM NONTHREAD LATEX FREE",SUP-MSG16150,CDM,S27000186,LOCAL,0270,RC,,,both,,,174.00,52.2,"AETNA [10100]","Aetna HMO/PPO",,138.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 40CM 7FR ENDOCARDIUM BIPOLAR ACTIVE FIXATION",SUP-1999/40,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"BLUE CROSS [10001]","Blue Cross PPO",,875.14,39.2,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP050100090 PLUS US D5L100UL900",SUP-PCP050100090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UHC [10700]","United Healthcare",,779.35,63.3,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 145MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.451,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"BLUE CROSS [10001]","Blue Cross PPO",,542.58,39.2,,957.42,570.23,957.42,28,160.97,1176.51,"percent of total billed charges",
"SUBSTITUTE BONE GRAFT FIBERGRAFT LARGE 11 CC MORSEL BIOACTIV",SUP-77000110,CDM,C1713,HCPCS,0278,RC,,,both,,,9563.40,2869.02,"NOVANET [10819]",Novanet,,7172.55,75,,,,,0,1112.22,8128.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 22CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006175271170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 5MMX59MM 7FR 135CMCATH HEPARIN",SUP-BXB055902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UHC [10700]","United Healthcare",,12346.54,63.3,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT ELITE VASCULAR STRAIGHT",SUP-1011883,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 4IN ALM BLUNT SELF RETAINING SURGICAL",SUP-BV011R,CDM,S27200284,LOCAL,0272,RC,,,both,,,393.24,117.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.73,334.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLOWGUARD 14CM 16FR HEMODIALYSIS PEEL AWAY VALVE",SUP-DCVP1600,CDM,C1894,HCPCS,0272,RC,,,both,,,261.00,78.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 445CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRM-445,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"AETNA [10100]","Aetna HMO/PPO",,4360.97,79.5,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIZISHOT 2 NEEDLE 22GA",SUP-NA-U401SX-4022-A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,739.86,45.9,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 27CM 8MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-08027,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"FIRST HEALTH [10303]","First Health",,9378.48,80,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 439888 ATTAIN PERFORMA",SUP-439888,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"PHCS [10601]",PHCS,,3924.9,70,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO BALKIN CURVE 40CM 8FR 2.9MM GUIDING",SUP-G10385,CDM,C1894,HCPCS,0272,RC,,,both,,,405.25,121.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,166.56,41.1,,,,,0,47.13,344.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE 10CM 2.5CM 9FR INTRO STAINLESS STEEL",SUP-RSS902,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"MULTIPLAN [10600]",Multiplan,,66.56,85,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE THRUWAY VASCULAR 300CM 3CM .014IN PERIPHERAL STRAIGHT",SUP-M001492981,CDM,C1769,HCPCS,0272,RC,,,both,,,564.98,169.49,"KAISER [10500]",Kaiser,,378.54,67,,,,,0,65.71,480.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BD NEXIVA DIFFUSICS 1IN 20GA 1.65MM 10ML/SEC 325 PSI",SUP-383592,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.16,17.75,"MULTIPLAN [10600]",Multiplan,,50.29,85,,,,,0,6.88,50.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZINC SULFATE 1 MG/ML ORAL LIQUID",RX-408890,CDM,,,0637,RC,08888-8884-07,NDC,both,100,ML,12.54,3.76,"MULTIPLAN [10600]",Multiplan,,10.66,85,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 36X28X17MM CHESAPEAKE 15D LORDOTIC",SUP-2013-21736L15,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"BLUE CROSS [10001]","Blue Cross PPO",,13436.04,39.2,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 38MM GENESIS II UHMWPE KNEE RESURFACING",SUP-71926225,CDM,C1776,HCPCS,0278,RC,,,both,,,6882.75,2064.82,"CIGNA [10200]",Cigna,,4680.27,68,,5873.17,5873.17,5873.17,"1 through 10",800.46,5850.34,"percent of total billed charges",
"CAGE SPINAL 12X14X9MM CASCADIA 12D TITANIUM POROUS CERVICAL",SUP-6101-2121409CL12-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BENTSON 22CM 15CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175261060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"CIGNA [10200]","Cigna Open Access",,567.54,,,,,,,116,847.82,"percent of total billed charges",
"SYSTEM CRYO/CUFF IC UNIVERSAL 45- IN COMPRESSION THERAPY",SUP-51A14A,CDM,S27000186,LOCAL,0270,RC,,,both,,,649.78,194.93,"CIGNA [10200]","Cigna Open Access",,369.72,56.9,,,,,0,75.57,552.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL 29MM ATTUNE KNEE POROCOAT REVISION PARTIAL COA",SUP-151111101,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTRA 45CM 8.7FR 7.3FR RIGHT CURVE GUIDING PEBAX","SUP-375 535",CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 30MM 135CM 8MM VASCULAR NITINOL",SUP-1012536-30,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 90MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.890,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,934.6,68,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM ALLOGRAFT 8MM",SUP-310108,CDM,S27800098,LOCAL,0278,RC,,,both,,,3139.50,941.85,"CIGNA [10200]",Cigna,,2134.86,68,,,,,0,365.12,2668.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 12CM 6MM .035IN BILIARY SELF EXPAND GWIRE",SUP-G23812,CDM,C1876,HCPCS,0278,RC,,,both,,,13275.60,3982.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5310.24,40,,,,,0,1543.95,11284.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 5MM 44MM 7.3MM SHILEY PEDIATRIC UNCUFF TAPE TIE",SUP-5.0PEF,CDM,S27200284,LOCAL,0272,RC,,,both,,,395.85,118.75,"UHC [10700]","United Healthcare",,250.57,63.3,,,,,0,46.04,336.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TUBING VIVASIGHT 2 LUMEN ENDOBRONCHIAL TUBE",SUP-412391000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"UHC [10700]","United Healthcare",,1234.35,63.3,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM 1.6MM KIRSCHNER STAINLESS STEEL 2 TROCAR",SUP-292.56,CDM,C1713,HCPCS,0278,RC,,,both,,,71.86,21.56,"FIRST HEALTH [10303]","First Health",,57.49,80,,,,,0,8.36,61.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR 30CM 3CM 7FR .035IN 2 FLOPPY PIGTAIL",SUP-M006180235090,CDM,C2617,HCPCS,0278,RC,,,both,,,1294.14,388.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,594.01,45.9,,,,,0,150.51,1100.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS ENDOSCOPIC L230CM DIA2.4MM OPENING 9MM LONG GRIPPER",SUP-M00527551,CDM,S27200284,LOCAL,0272,RC,,,both,,,625.73,187.72,"FIRST HEALTH [10303]","First Health",,500.58,80,,,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE 14MM 4.5MM EMBOLIZATION",SUP-PED2-450-14,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"UHC [10700]","United Healthcare",,51144.82,63.3,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ERCP STD GWIRE CONTOUR 210CM 5FR BILIARY STERILE",SUP-M00530850,CDM,S27200284,LOCAL,0272,RC,,,both,,,407.60,122.28,"CIGNA [10200]",Cigna,,277.17,68,,,,,0,47.4,346.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ERCP STD GWIRE CONTOUR 210CM 5FR BILIARY STERILE",SUP-M00530850,CDM,S27200284,LOCAL,0272,RC,,,both,,,407.60,122.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,277.17,68,,,,,0,47.4,346.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 32MM 144CM 3MM CORONARY STENT",SUP-H7493952832300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL COMPREHENSIVE +5MM STD SHOULDER REVERSE",SUP-110031400,CDM,C1776,HCPCS,0278,RC,,,both,,,8473.20,2541.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1004.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,985.43,7202.22,"percent of total billed charges",
"MATRIX TISSUE 8X6CM BOVINE PERICARDIUM RESORBABLE SUTURABLE",SUP-BP10608,CDM,Q4432,HCPCS,0636,RC,,,both,,,4159.87,1247.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2828.71,68,,,,,0,247.92,3535.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAUTERY ESURG RAM AARON 593D FN LO",SUP-AA04,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.82,20.65,"AETNA [10100]","Aetna HMO/PPO",,54.71,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8,58.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT MEDIUM 6.25 CC MATRIX BIOAC",SUP-74000063,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7038,68,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING OXFORD KNEE LEFT MEDIAL RIGHT LATERAL",SUP-154720,CDM,C1776,HCPCS,0278,RC,,,both,,,11195.94,3358.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4601.53,41.1,,6417.48,6417.48,6417.48,"1 through 10",1302.09,9516.55,"percent of total billed charges",
"BURR SURGICAL 5MM ACORN STERILE",SUP-5620030050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1066.37,319.91,"KAISER [10500]",Kaiser,,714.47,67,,,,,0,124.02,906.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPIDCROSS 170CM 80MM 2MM .014IN BALLOON DILATATION",SUP-A14BX020080170,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,164.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 12MM 6FR 2MM .07",SUP-H7493926712200,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 10X22X50MM 5DEG LORDOTIC MODULUS XLW",SUP-1223050P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 20MM 144CM 2.5MM CORONARY STENT",SUP-H7493952820250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"NOVANET [10819]",Novanet,,4173.75,75,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO 55CM 6FR 2.2MM GUIDING RAABE",SUP-G11638,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"PHCS [10601]",PHCS,,311.85,70,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mmr Vaccine Sc",PX-771000009,CDM,90707,CPT,0636,RC,,,both,,,275.14,82.54,"NOVANET [10819]",Novanet,,206.36,75,,,,,0,11.97,233.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 35X18X9MM TRANSCONTINENTAL 10D LORDOTIC",SUP-375.392,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6851.63,28.62,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE-USE 270 MICRON LASER",SUP-HLFDBX0270C,CDM,S27200284,LOCAL,0272,RC,,,both,,,2546.00,763.8,"FIRST HEALTH [10303]","First Health",,2036.8,80,,,,,0,296.1,2164.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP ALLOGRAFT STRIP 50X20X7MM POSTEROLATERAL",SUP-15120501,CDM,C1713,HCPCS,0278,RC,,,both,,,18721.08,5616.32,"KAISER [10500]",Kaiser,,12543.12,67,,,,,0,2177.26,15912.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BARD INLAY 22CM 6FR 2 PIGTAIL CURVE URETERAL",SUP-778622,CDM,C2625,HCPCS,0278,RC,,,both,,,625.73,187.72,"KAISER [10500]",Kaiser,,419.24,67,,,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA MEDIAL CONGRUENT 4-5 C-D KNEE",SUP-42512100313,CDM,C1776,HCPCS,0278,RC,,,both,,,9466.80,2840.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1121.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1100.99,8046.78,"percent of total billed charges",
"MARKER TUMARK BREAST BIOPSY PROFESSIONAL X BREVERA PETITE",SUP-TUMARK-BREV-P-X-02,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"KAISER [10500]",Kaiser,,447.46,67,,,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR ANGLE 150CM .018IN HYDROPHILIC FIX CORE",SUP-H2OSTDA18150,CDM,C1769,HCPCS,0272,RC,,,both,,,408.47,122.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,277.76,68,,,,,0,47.51,347.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 80MM 125CM 10MM VASCULAR HIWIRE NITINOL",SUP-G43793,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"MULTIPLAN [10600]",Multiplan,,3552.15,85,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 36X15MM ENDOSKELETON TAS 12D LORDOTIC 24MM LARGE",SUP-2312-0215-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,43942.50,13182.75,"FIRST HEALTH [10303]","First Health",,35154,80,,,,,0,5110.51,37351.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Ather Cmplx Ea Add",PX-361000732,CDM,37291,CPT,0361,RC,,,both,,,8353.79,2506.14,"BLUE CROSS [10001]","Blue Cross PPO",,8.35,.1,,,,,0,8.35,7883,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR ACETABULAR 35MM 6.5MM HIP CANCELLOUS GAP",SUP-2080-0035,CDM,C1713,HCPCS,0278,RC,,,both,,,632.74,189.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,430.26,68,,,,,0,73.59,537.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRANSITION VENTILATOR NASAL INTERFACE HIGH FLOW L OPTIFL",SUP-OJR416VT,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER TORIC POSTERIOR CHMBR FOLDABLE",SUP-SA6AT4,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"MULTIPLAN [10600]",Multiplan,,293.25,85,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 10 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION",RX-9809,CDM,,,0250,RC,00264-7622-00,NDC,both,1000,ML,100.65,30.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY INSTR 446X49X88MM 2 TELESCOPE",SUP-WA05990A,CDM,S27000186,LOCAL,0270,RC,,,both,,,1913.03,573.91,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PLAIN 1 STD SHORT 54IN MONOFILAMENT TIES YELLOWISH TAN",SUP-S115H,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.04,26.71,"KAISER [10500]",Kaiser,,59.66,67,,,,,0,10.36,75.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SENTAI SAMURAI RC VASCULAR 190CM 24CM .014IN STAINLESS",SUP-H749393061902,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,660.96,68,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 40MM 120CM 6MM 8FR STRAIGHT VASCULAR",SUP-AVSL06040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross PPO",,7161.84,39.2,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 7CM 5FR PIGTAIL CURVE PANCREATIC",SUP-M00537420,CDM,C2625,HCPCS,0278,RC,,,both,,,1411.18,423.35,"CIGNA [10200]","Cigna Local Plus",,754.98,53.5,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION TRANSSEPTAL",SUP-5140-6217,CDM,S27200284,LOCAL,0272,RC,,,both,,,13455.00,4036.5,"PHCS [10601]",PHCS,,9418.5,70,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11.75CM NATRELLE INSPIRA P5.9CM EXTRA FULL",SUP-MSZ-X420,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.69,42.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,65.49,45.9,,,,,0,16.59,121.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC",243,MS-DRG,,,,,,,inpatient,,,99724.14,29917.24,"UHC [10700]","United Healthcare",,62213.76,,"Fee schedule rate ($62,213.76). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,13218.1,62213.76,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL URETERAL HYDROPLUS 70CM 16FR STERILE",SUP-M0062401150,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.52,130.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,294.79,68,,,,,0,50.42,368.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 12MM MREYE 4 LOOP .035IN PLATINUM",SUP-G47895,CDM,S27800098,LOCAL,0278,RC,,,both,,,766.50,229.95,"KAISER [10500]",Kaiser,,513.56,67,,,,,0,89.14,651.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHNT HKM PRC VNTRC 70MM HP 175777",SUP-823008,CDM,S27800098,LOCAL,0278,RC,,,both,,,14545.20,4363.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4162.84,28.62,,,,,0,1691.61,12363.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROCLAIM ELITE 5 WITH PATIENT CONTROLLER",SUP-3660,CDM,C1820,HCPCS,0278,RC,,,both,,,89632.50,26889.75,"NOVANET [10819]",Novanet,,67224.38,75,,,,,0,10424.26,76187.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,,,0637,RC,00032-0047-70,NDC,both,1,UN,25.19,7.56,"CIGNA [10200]",Cigna,,17.13,68,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 18B LARGE HIP PROXIMAL",SUP-521485,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"NOVANET [10819]",Novanet,,8163.56,75,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 25CM 10FR 21GA FLEXIMA POLYURETHANE HYDROPHILIC",SUP-M001271990,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 2CM 3MM BALLOON DILATATION HYDROPHILIC",SUP-G50327,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"NOVANET [10819]",Novanet,,1771.82,75,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 1.4MM ORTHOLOC TEMPORARY",SUP-5882000014,CDM,C1713,HCPCS,0278,RC,,,both,,,785.70,235.71,"CIGNA [10200]","Cigna Local Plus",,420.35,53.5,,3978.14,359.25,3978.14,24,91.38,667.85,"percent of total billed charges",
"HEAD HUMERAL SHOULDER RESURFACE COPELAND HA 5",SUP-11-114645,CDM,C1776,HCPCS,0278,RC,,,both,,,16174.80,4852.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1916.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1881.13,13748.58,"percent of total billed charges",
"VALVE AORTIC 29MM INSPIRIS RESILIA BOVINE PERICARDIUM",SUP-11500A29,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,12247.2,27,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.5MM X 8.0MM",SUP-493500812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT THR HIP E1 POROUS CUP 2 MOBILITY AA STD LINER INSRT",SUP-98000100046,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"NOVANET [10819]",Novanet,,20790,75,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Sl Sp Grpiii / Add on 88319",PX-312000096,CDM,0759T,CPT,0312,RC,,,both,,,100.00,30,"CIGNA [10200]",Cigna,,68,68,,,,,0,11.85,85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esoph Flex Trnsoral Muc Rsct",PX-750000123,CDM,43211,CPT,0750,RC,,,both,,,4531.00,1359.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,526.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,526.96,4531,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 18 X 14 X 08MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-181408-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"AMERIGROUP MEDICAID [20100]",Amerigroup,,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 67X45MM PFC SIGMA 2.5 KNEE CEMENT MODULAR PLUS",SUP-860127,CDM,C1776,HCPCS,0278,RC,,,both,,,16046.64,4813.99,"CIGNA [10200]","Cigna Local Plus",,5054.69,31.5,,5372.07,4581.20,7242.98,23,1866.22,13639.64,"percent of total billed charges",
"CATH NANOCROSS 150CM 120MM 6MM .014IN BALLOON DILATATION",SUP-AB14W060120150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 67.5MM KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-183130,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"BLUE CROSS [10001]","Blue Cross PPO",,8492.95,39.2,,3949.44,3949.44,3949.44,"1 through 10",2519.72,18415.85,"percent of total billed charges",
"MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY",RX-114231,CDM,,,0250,RC,00472-1738-03,NDC,both,1,UN,59.59,17.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.93,50.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 125CM 5FR JR6 CURVE ANGIOGRAPHIC PEBAX",SUP-7523-83,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.74,23.62,"CIGNA [10200]","Cigna Open Access",,44.8,56.9,,,,,0,9.16,66.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 3CM 6FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175264050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"BLUE CROSS [10001]","Blue Cross PPO",,419.73,39.2,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Rmvl FB",PX-750000088,CDM,45379,CPT,0750,RC,,,both,,,2212.15,663.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2212.15,,"Case rate ($2,262). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,257.27,2212.15,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPHENHYDRAMINE 50MG/ML SUPERORDERABLE",RX-4082508,CDM,J1200,HCPCS,0636,RC,00641-0376-25,NDC,both,1,ML,18.92,5.68,"BLUE CROSS [10001]","Blue Cross PPO",,0.89,,,,,,,0.83,16.08,"fee schedule",
"SUT PROLENE MULTIPASS 3-0 PS-1 18IN MONOFILAMENT BLUE",SUP-8663G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 34CM KLEPPINGER CABLE",SUP-BC3310,CDM,S27200284,LOCAL,0272,RC,,,both,,,961.88,288.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.87,817.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Total Protein",PX-301000378,CDM,84155,CPT,0301,RC,,,both,,,150.10,45.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13.03,,,,,,,0.15,127.59,"fee schedule",
"CMPNT PATELLAR 2.4MM COUNTSINK TIVANIUM ALLOY",SUP-DSDS1028,CDM,C1776,HCPCS,0278,RC,,,both,,,1069.20,320.76,"NOVANET [10819]",Novanet,,801.9,75,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SAFEGUARD RADIAL STD LOW PROFILE 26CM COMPRESSION",SUP-SGR26,CDM,S27000186,LOCAL,0270,RC,,,both,,,261.00,78.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,119.8,45.9,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Psa Free",PX-301000377,CDM,84154,CPT,0301,RC,,,both,,,205.20,61.56,"CIGNA [10200]","Cigna Open Access",,40.46,,,,,,,0.21,174.42,"fee schedule",
"SUB BONE GRAFT 10CM MASTERGRAFT SPINE STRIP 12ML",SUP-7800310,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"UHC [10700]","United Healthcare",,6551.55,63.3,,5023.51,2672.93,6679.78,18,1203.71,8797.5,"percent of total billed charges",
"(EVAL) SUPIRA INTRODUCER",SUP-FG-03957,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MACH1 90CM 8FR AL.75ST CURVE GUIDING PTFE FEMORAL",SUP-H749343581910,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ROTAPRO 135CM .58IN 2.25MM ATHERECTOMY PRECONNECT BURR",SUP-H749394672250,CDM,C1724,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH INJECTION GOLD PROBE 210CM 7FR 25GA .24MM 2.8MM",SUP-M00560150,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 26CM 4.8FR URETERAL",SUP-M0061456080,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"CIGNA [10200]","Cigna Open Access",,355.76,,,,,,,72.72,531.45,"percent of total billed charges",
"BRACE ORTHOPEDIC MEDIUM 8IN 7.25-8IN WRIST RIGHT LIGHTWEIGHT",SUP-92722101,CDM,L3908,HCPCS,0274,RC,,,both,,,148.86,44.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,42.6,28.62,,,,,0,17.31,126.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? BONE SCREW, 2.7MM X 14MM, 4 PACK",SUP-94-27-14-4S,CDM,C1713,HCPCS,0278,RC,,,both,,,2947.50,884.25,"KAISER [10500]",Kaiser,,1974.83,67,,,,,0,342.79,2505.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 52MM CATHCART BALL HIP FEMORAL ORTHOCHROME",SUP-136352000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE PT VASCULAR J 185CM 35CM .014IN FLOPPY",SUP-H7491216001J1,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 36CM HIP LEFT FEMUR AFFIXUS INTRAMEDULLARY 125D",SUP-814411360,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8297.1,40,,,,,0,2412.38,17631.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLS-2508 CLASSICSHEATH LONG",SUP-398724,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"KAISER [10500]",Kaiser,,352.76,67,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 62.5MM KNEE LEFT CRUCIATE RETAINING CEMENTED",SUP-183026,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2380.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2335.96,17072.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 12MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424025,CDM,C1776,HCPCS,0278,RC,,,both,,,11747.25,3524.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1392.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1366.21,9985.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ULTRAFLEX 30MM 15MM 14MM 24FR 95CM 4MM",SUP-M00576570,CDM,C1874,HCPCS,0278,RC,,,both,,,19467.00,5840.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2306.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2264.01,16546.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VEST 1 FRONT ZIP ADJUSTABLE SHOULDER STRAP CUP POSTOPERATIVE",SUP-111901,CDM,S27000186,LOCAL,0270,RC,,,both,,,945.03,283.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,109.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,109.91,803.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CAPTIVATOR ENDOSCOPIC ACCESS PORT HANDLE BAND CLLGN",SUP-M00561600,CDM,S27200284,LOCAL,0272,RC,,,both,,,2510.63,753.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,291.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,291.99,2134.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 34CM HIP LEFT FEMUR GAMMA3 INTRAMEDULLARY 125D R2",SUP-3325-0340S,CDM,C1713,HCPCS,0278,RC,,,both,,,18618.45,5585.53,"AETNA [10100]","Aetna HMO/PPO",,14801.67,79.5,,1521.93,481.35,16760.95,30,2165.33,15825.68,"percent of total billed charges",
"COIL EMBOLIZATION 8CM 3MM TARGET TETRA DETACHABLE STERILE",SUP-TG5413080,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS [10001]","Blue Cross PPO",,5532.94,39.2,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FLEXSEGMENT PALMAZ GENESIS SLALOM 23MM 135CM 6MM .014",SUP-PG24608BSX,CDM,C1876,HCPCS,0278,RC,,,both,,,6554.03,1966.21,"BLUE CROSS [10001]","Blue Cross HMO",,2569.18,39.2,,,,,0,762.23,5570.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 4.25% DEXTROSE 6000ML 1 BAG CNTNR LOW CALCIUM LUER",SUP-L5B9712,CDM,S27200284,LOCAL,0272,RC,,,both,,,463.00,138.9,"PHCS [10601]",PHCS,,324.1,70,,,,,0,53.85,393.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14 EXTREME LATERAL INTERBODY FUSION 2 HOLE DECADE BONE",SUP-7140214,CDM,C1713,HCPCS,0278,RC,,,both,,,13800.00,4140,"FIRST HEALTH [10303]","First Health",,11040,80,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM TRIATHLON 4 RIGHT MEDIAL LEFT LATERAL TOAL",SUP-5546-A-402,CDM,C1776,HCPCS,0278,RC,,,both,,,4252.25,1275.67,"CIGNA [10200]","Cigna Local Plus",,2274.95,53.5,,5372.07,4581.20,7242.98,23,494.54,3614.41,"percent of total billed charges",
"SCR BONE 5MM 57.5MM T2 TITANIUM FULL THREAD FEMUR HUMERUS",SUP-1896-5057S,CDM,C1713,HCPCS,0278,RC,,,both,,,1279.15,383.74,"FIRST HEALTH [10303]","First Health",,1023.32,80,,,,,0,148.77,1087.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 7/8MM MINI STEP DIL RADIALLY",SUP-MS101008,CDM,S27200284,LOCAL,0272,RC,,,both,,,1244.24,373.27,"MULTIPLAN [10600]",Multiplan,,1057.6,85,,,,,0,144.71,1057.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER HUMERAL 36MM UNIVERS REVERS +9MM SHOULDER TITANIUM",SUP-AR-9555-09,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"NOVANET [10819]",Novanet,,2205,75,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH UROMAX ULTRA QUADRA-FOLD ENCORE HIGH PRESSURE KINK",SUP-M0062251230,CDM,C1726,HCPCS,0272,RC,,,both,,,1904.70,571.41,"NOVANET [10819]",Novanet,,1428.53,75,,,,,0,221.52,1619,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 88MM RADIUS J 182X10.2X2.7MM STAINLESS STEEL 3.5MM SCR",SUP-245.934,CDM,C1713,HCPCS,0278,RC,,,both,,,4436.91,1331.07,"CIGNA [10200]","Cigna Local Plus",,2373.75,53.5,,3978.14,359.25,3978.14,24,516.01,3771.37,"percent of total billed charges",
"SCR SET SPINE EVEREST GRAY",SUP-2901-10001,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"BLUE CROSS [10001]","Blue Cross PPO",,943.39,39.2,,957.42,570.23,957.42,28,279.89,2045.61,"percent of total billed charges",
"DEVICE PIPELINE 16MM 4.5MM EMBOLIZATION",SUP-PED2-450-16,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"FIRST HEALTH [10303]","First Health",,64638,80,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 260X17.5X5.2MM STAINLESS STEEL 4.5MM CORTICAL",SUP-226.641,CDM,C1713,HCPCS,0278,RC,,,both,,,4175.05,1252.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1194.9,28.62,,,,,0,485.56,3548.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH REFERENCE CARTO 3 EXTERNAL",SUP-CREFP6,CDM,S27000186,LOCAL,0270,RC,,,both,,,3142.50,942.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1291.57,41.1,,,,,0,365.47,2671.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG 108MM STAINLESS STEEL 2.7/3.5MM SCR 4 HOLE",SUP-02.117.404S,CDM,C1713,HCPCS,0278,RC,,,both,,,6974.52,2092.36,"MULTIPLAN [10600]",Multiplan,,5928.34,85,,,,,0,811.14,5928.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE HEXAGONAL 2.5CM 1.5CM 7FR SOFT ACUSNARE 1 PIECE BRAID",SUP-G22703,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.43,49.33,"CIGNA [10200]",Cigna,,111.81,68,,,,,0,19.12,139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 35MM 12MM DELTA ACL CANNULATED",SUP-AR-5035TC-12,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,529.65,28.62,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM .0165IN PROWLER SELECT",SUP-MC1755M2U,CDM,C1887,HCPCS,0272,RC,,,both,,,7390.38,2217.11,"AETNA [10100]","Aetna HMO/PPO",,5875.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,859.5,6281.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 100CM 8FR JR4 CURVE GUIDING PTFE FEMORAL",SUP-H749343586920,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"MULTIPLAN [10600]",Multiplan,,311.47,85,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 18X7MM HEDRON C 7D 15MM STERILE LATEX FREE",SUP-1211.5817S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Open Access",,3533.49,56.9,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN AIMING GUIDE 2.0MM",SUP-PRT-AIM-20,CDM,S27000186,LOCAL,0270,RC,,,both,,,1312.20,393.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,155.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,152.61,1115.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 20X20CM STRATTICE LIFECELL 400SQ CM",SUP-2020002P,CDM,Q4130,HCPCS,0636,RC,,,both,,,62949.60,18884.88,"AETNA [10100]","Aetna HMO/PPO",,50044.93,79.5,,,,,0,7459.53,53507.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 10FR DRNG FLEXIMA BILIARY METAL AND FLEXIBLE",SUP-M001271550,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 19MM 80CM 5MM 8MM 7FR .035IN",SUP-BXA051901A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3.5MM 13MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.813.96,CDM,C1713,HCPCS,0278,RC,,,both,,,319.12,95.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,91.33,28.62,,,,,0,37.11,271.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .035IN 5FR 5MM 80CM 6CM PTA 2 LUMEN",SUP-4205060S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUTURE HEALIX ADVANCE PEEK-OPTIMA OD5.5 MM ORTHOCORD",SUP-222308,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"CIGNA [10200]","Cigna Open Access",,1813.69,56.9,,1144.80,304.56,2275.09,66,370.71,2709.38,"percent of total billed charges",
"COIL EMBOLIZATION 19CM 10MM AZUR CX DETACHABLE SOFT SOLID",SUP-45-751019,CDM,S27800098,LOCAL,0278,RC,,,both,,,7672.80,2301.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,909.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,892.35,6521.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 10X11MM ARTHREX DYNANITE NITINOL TITANIUM",SUP-AR-8717DS-1110,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"MULTIPLAN [10600]",Multiplan,,8768.18,85,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 7FR 40D GUIDING DURAFORM PTFE",SUP-M003101430,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 5FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G00983,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PERFORMA 100CM 6FR AR MOD CURVE ANGIOGRAPHIC PEBAX",SUP-7506-11,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.74,23.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRESSING ANTIMICROBIAL 3.5 X 4 INCH AQUACEL AG ADVANTAGE",SUP-422603,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.99,57.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TISSUE REGENEATIONGRAFT 4CM X 4CM",SUP-GS-5440,CDM,Q4186,HCPCS,0636,RC,,,both,,,19070.10,5721.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"MALLET SURGICAL 7 9/16IN 1.5IN STAINLESS STEEL 2LB",SUP-250404,CDM,S27000186,LOCAL,0270,RC,,,both,,,703.16,210.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Nerve Stimulator",PX-E27200245,CDM,9999121,LOCAL,0272,RC,,,both,,,332.80,99.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RONGEUR 8IN 40D UP 9MM OPEN MICRO 4MM SYMMETRY KERRISON",SUP-57-0694-BD,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEPARATOR THROMBECTOMY 200CM .03IN 5MAX REPERFUSION CATH",SUP-3MAXS,CDM,C1757,HCPCS,0272,RC,,,both,,,18774.00,5632.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SUB BONE GRAFT 50X25X8MM SIGNAFUSE GLASS CLLGN TYPE 1",SUP-SGFS-010,CDM,C1713,HCPCS,0278,RC,,,both,,,12972.00,3891.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1508.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1508.64,11026.2,"percent of total billed charges",
"DEVICE PRESSURE MNTR INTRAABDOMINAL KIT FOLEY CATH STERILE",SUP-BRDIAP001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1419.40,425.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,165.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.08,1206.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAP MULTICHAMBER LATEX FREE OPTIMIZER SPECIMEN POLYP",SUP-CAP132,CDM,S27000186,LOCAL,0270,RC,,,both,,,65.25,19.57,"CIGNA [10200]","Cigna Open Access",,37.13,56.9,,,,,0,7.59,55.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTMASTER 26MM 2.8MM CORONARY STENT STAINLESS STEEL",SUP-1012580-26,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1921.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER QUICKPASS SUTURELASSO 90D SMALL STRAIGHT 7MM CANN",SUP-AR-6068-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,559.29,41.1,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 80MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"KAISER [10500]",Kaiser,,960.58,67,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 8MM SALVATION STEP MIDFOOT NAIL",SUP-SMN10018,CDM,S27200284,LOCAL,0272,RC,,,both,,,3292.50,987.75,"UHC [10700]","United Healthcare",,2084.15,63.3,,,,,0,382.92,2798.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACARBOSE 25 MG TABLET",RX-22148,CDM,,,0637,RC,64380-0758-06,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 LEFT KNEE CRUCIATE RETAINING CEMENTED",SUP-5510-F-801,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6559.14,40,,,,,0,1907.07,13938.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY 9CM 18GA SUPERCORE STERILE LATEX FREE",SUP-701118090,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.65,103.09,"PHCS [10601]",PHCS,,240.56,70,,,,,0,39.97,292.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 52MM 3 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800352,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"HC Trypsin",PX-301000259,CDM,83519,CPT,0301,RC,,,both,,,419.00,125.7,"NOVANET [10819]",Novanet,,314.25,75,,,,,0,0.01,356.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL S-ROM +6MM 11/13 TAPER 36MM HIP M SPECIFICATION",SUP-136533000,CDM,C1776,HCPCS,0278,RC,,,both,,,6875.85,2062.75,"AETNA [10100]","Aetna HMO/PPO",,5466.3,79.5,,10981.53,8986.79,12413.38,12,799.66,5844.47,"percent of total billed charges",
"PEG FIXATION 2.7MM 22MM RADIUS FOSSA DISTAL VOLAR HIGH",SUP-HCLP-27220-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 30CM CRYOARTERY FEMORAL ARTERY",SUP-R020-30,CDM,C1768,HCPCS,0278,RC,,,both,,,42210.00,12663,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5001.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4909.02,35878.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE RAPTOR 200CM 1.9MM SPECIMEN RETRIEVAL HYBRID JAW",SUP-00711178,CDM,S27200284,LOCAL,0272,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Local Plus",,520.02,53.5,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXCATH CROSS TRANSSEPTAL SOLUTION ? FCC 65CM, 10F",SUP-900310,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 STD KNEE RIGHT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB7SR,CDM,C1776,HCPCS,0278,RC,,,both,,,17652.60,5295.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2091.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2053,15004.71,"percent of total billed charges",
"PEG FIXATION 2.7MM 16MM THREAD NONLOCK TITANIUM NONSTERILE",SUP-TPNL-27160-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,623.70,187.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,286.28,45.9,,,,,0,72.54,530.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP 30D SMALL 9 3/8IN TITANIUM ENDOSCOPIC",SUP-MCS20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1092.07,327.62,"CIGNA [10200]","Cigna Local Plus",,584.26,53.5,,,,,0,127.01,928.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 40MM 5.4FR 5MM BALLOON DILATATION 2",SUP-BD-L50040CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.214,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"MULTIPLAN [10600]",Multiplan,,742.2,85,,,,,0,101.55,742.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 4MM20CM 190",SUP-R51004020L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"MULTIPLAN [10600]",Multiplan,,2118.1,85,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 150MM 18GA 20GA SONOLONG SONOLONG SONO",SUP-511187-31C,CDM,C9814,HCPCS,0272,RC,,,both,,,518.40,155.52,"AETNA [10100]","Aetna HMO/PPO",,412.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.29,440.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE SIMPLEX GENTAMICIN 20ML 40GM HIGH VISCOSITY",SUP-6195-1-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,1728.52,518.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,201.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,201.03,1469.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSRT FEMORAL VENOUS CANN BIO-MEDICUS NEXTGEN 25FR",SUP-96600-125,CDM,S27200284,LOCAL,0272,RC,,,both,,,3022.88,906.86,"UHC [10700]","United Healthcare",,1913.48,63.3,,,,,0,351.56,2569.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IV LIFECARE 5% DEXTROSE 50ML LATEX FREE",SUP-07923-13,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN SX ENDO HEPARIN 35 RO 11MMX5CM 10FR 120CMCATH",SUP-VBHR110502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"BLUE CROSS [10001]","Blue Cross HMO",,7354.47,39.2,,9776.84,9776.84,9776.84,"1 through 10",2181.95,15947.19,"percent of total billed charges",
"PROTEK DUO",SUP-5190-0020,CDM,S27200284,LOCAL,0272,RC,,,both,,,111150.00,33345,"UHC [10700]","United Healthcare",,70357.95,63.3,,,,,0,12926.75,94477.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL STEALTH 6MM 6MM VASCULAR .75 FORCE SPRING",SUP-A1604,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 124MM 26MM ZENITH HANDL-B ONE-SHOT 2 BRANCH",SUP-G32541,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"AETNA [10100]","Aetna HMO/PPO",,49846.5,79.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM 16MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-216.035,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,52.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",52.23,381.7,"percent of total billed charges",
"HOOK SPINAL 4.5MM LAMINA LEFT OFFSET",SUP-7756073L,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 21MM 16.7MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-21MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11968,41.1,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 2.4MM TEMPORARY",SUP-58820024,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM G7 ACTIVE ARTICULATION THR E1 CERAMIC HIP 2 MOBIL",SUP-98000100158,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"PHCS [10601]",PHCS,,20286,70,,,,,0,3370.37,24633,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EVOLUT FX DELIVERY LOAD 23-29 MM",SUP-L-EVOLUTFX-2329,CDM,S27200284,LOCAL,0272,RC,,,both,,,2925.00,877.5,"PHCS [10601]",PHCS,,2047.5,70,,,,,0,340.18,2486.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Punct Ventric Cath Subdur",PX-361000468,CDM,61107,CPT,0361,RC,,,both,,,4773.34,1432,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4773.34,,"Case rate ($5,284). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,4.77,4773.34,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2-0 TS 14IN 2 ARM MONOFILAMENT BLUE",SUP-8571G,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.67,20.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,28.22,41.1,,,,,0,7.99,58.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 130CM 2.9FR .025IN TRINAV LV EXPANDAB",SUP-XPS-25130-35,CDM,C1982,HCPCS,0272,RC,,,both,,,50292.90,15087.87,"CIGNA [10200]","Cigna Open Access",,28616.66,56.9,,,,,0,5849.06,42748.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 6FT 18FR URETHRAL BACTI-GUARD HYDROGEL 5CC",SUP-129418,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.68,42.8,"MULTIPLAN [10600]",Multiplan,,121.28,85,,,,,0,16.59,121.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.25 X 18 RX US",SUP-1804225-18,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM GLUCONATE 10% TOPICAL",RX-411652,CDM,J0612,HCPCS,0636,RC,63323-0360-01,NDC,both,10,ML,75.61,22.68,"FIRST HEALTH [10303]","First Health",,60.49,80,,,,,0,3.52,64.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7609,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"FIRST HEALTH [10303]","First Health",,5520,80,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BARD INLAY 26CM 6FR 2 PIGTAIL CURVE URETERAL",SUP-778626,CDM,C2625,HCPCS,0278,RC,,,both,,,625.73,187.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,72.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CARTO XP LASSO 115CM 7FR 15MM 6MM SPACE D CURVE",SUP-DLN1215CT,CDM,C1732,HCPCS,0272,RC,,,both,,,11350.50,3405.15,"UHC [10700]","United Healthcare",,7184.87,63.3,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT AORTIC VALVE 14FR COMMANDER SAPIEN 3 20MM TRANSCATHETER",SUP-9600CM20A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,76137.75,41.1,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMINOCAPROIC ACID 500 MG TABLET",RX-9063,CDM,,,0637,RC,69680-0115-30,NDC,both,1,UN,27.07,8.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.15,23.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 16MM KNEE POSTERIOR STABILIZE BEARING",SUP-5532P716,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2391.46,28.62,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 5MM CANNULATED GS",SUP-86PS1005,CDM,C1713,HCPCS,0278,RC,,,both,,,2535.00,760.5,"MULTIPLAN [10600]",Multiplan,,2154.75,85,,,,,0,294.82,2154.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL SMALL 65X55MM KNEE LEFT MODULAR ROTATE HINGE",SUP-64811110,CDM,C1776,HCPCS,0278,RC,,,both,,,25203.15,7560.94,"KAISER [10500]",Kaiser,,16886.11,67,,,,,0,2931.13,21422.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE RADIUS DISTAL VOLAR TWO COLUMN RIGHT 6X4 HOLE STE",SUP-02.111.540S,CDM,C1713,HCPCS,0278,RC,,,both,,,4447.05,1334.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,526.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,517.19,3779.99,"percent of total billed charges",
"SCR BONE 2.7MM 16MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.816,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"MULTIPLAN [10600]",Multiplan,,298.61,85,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +24.5 DIOPTER MODIFIY C BICONVEX 13MM 6MM",SUP-ZMA00U0245,CDM,V2632,HCPCS,0276,RC,,,both,,,6175.50,1852.65,"BLUE CROSS [10001]","Blue Cross PPO",,2420.8,39.2,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIPOLAR HIP WITH FRACTURE OR CEMENTED STEM",SUP-55500033,CDM,C1776,HCPCS,0278,RC,,,both,,,6900.00,2070,"AETNA [10100]","Aetna HMO/PPO",,5485.5,79.5,,10981.53,8986.79,12413.38,12,802.47,5865,"percent of total billed charges",
"HEAD UNIPOLAR 49MM CENTERPULSE LEGACY 12/14 TAPER HIP FEMUR",SUP-451000049,CDM,C1776,HCPCS,0278,RC,,,both,,,2398.65,719.59,"BLUE CROSS [10001]","Blue Cross PPO",,940.27,39.2,,3949.44,3949.44,3949.44,"1 through 10",278.96,2038.85,"percent of total billed charges",
"SCR BONE 2.4MM 18MM TITANIUM T8 LOCK VARIABLE ANGLE TUBE",SUP-04.210.118TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1056.89,317.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,718.69,68,,,,,0,122.92,898.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR ATHERECTOMY 135CM 1.25MM ROTABLATOR ROTALINK PLUS",SUP-M0011401250,CDM,C1724,HCPCS,0272,RC,,,both,,,16525.50,4957.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1958.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)GWIRE R350 VASCULAR 200CM STRAIGHT 350CM 5CM .013IN NI",SUP-7390,CDM,C1769,HCPCS,0272,RC,,,both,,,1611.90,483.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,187.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 15MM 41MM SHOULDER AEQUALIS ASCEND FLEX COCR",SUP-DWF041,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CIGNA [10200]","Cigna Open Access",,4506.48,56.9,,5302.19,4377.88,6578.61,27,921.1,6732,"percent of total billed charges",
"PACK SURGICAL EZ-IO SOFT SIDE INTRAOSSEOUS VASCULAR ACCESS",SUP-9065,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +14.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1450,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 2.3MM LONG TAPER DISSECTING",SUP-MR8-14TA23L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1416.29,424.89,"AETNA [10100]","Aetna HMO/PPO",,1125.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.71,1203.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 120MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560120S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH X-FORCE U30 4CM 6FR 6MM BALLOON DILATATION TUNGSTEN",SUP-997604,CDM,C1726,HCPCS,0272,RC,,,both,,,1909.58,572.87,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MORPHINE 15 MG IMMEDIATE RELEASE TABLET",RX-5178,CDM,,,0250,RC,00054-0235-24,NDC,both,1,UN,12.54,3.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLING ORTHOPEDIC LARGE 1 PIECE AUTOSTOP BUCKLE 2 PRONG",SUP-563499,CDM,S27000186,LOCAL,0270,RC,,,both,,,668.90,200.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARD BARDEX 16FR URETHRAL SILICONE ELASTOMER NATURAL",SUP-0166V16S,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.59,28.08,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE SHORT 40MM STAINLESS STEEL 2.7MM SCR VARIABLE ANGLE",SUP-02.211.410,CDM,C1713,HCPCS,0278,RC,,,both,,,4702.49,1410.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1345.85,28.62,,,,,0,546.9,3997.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOLTR TRANSCATHETER AORTIC VALVE-23MM - THE 23MM EVOLTR TRA",SUP-EVOLUTR-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46170,27,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOCKING COMPRESSION SCREW 1.8MM X 6.0MM COCR",SUP-CMP-18006-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE KIWI OMNICUP MEDIUM LOW PROFILE VACUUM EXTRACTION",SUP-VAC-6000M,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"NOVANET [10819]",Novanet,,182.7,75,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 29MM TORNIER AEQUALIS PERFORM +3MM SHOULDER",SUP-DWJ512,CDM,C1776,HCPCS,0278,RC,,,both,,,11340.00,3402,"KAISER [10500]",Kaiser,,7597.8,67,,,,,0,1318.84,9639,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 18MM TARGET 360D 2XL DETACHABLE",SUP-M0036181850,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 16MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-616,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"MULTIPLAN [10600]",Multiplan,,8355.94,85,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LIVEWIRE 115CM 2MM 6FR 5MM SPACING ELECTROPHYSIOLOGY",SUP-401934,CDM,C1730,HCPCS,0272,RC,,,both,,,2625.00,787.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRASPER BULLETNOSE DISSECTING FORCEPS  ROTATING 5MM 32CM WIT",SUP-625117,CDM,S27000186,LOCAL,0270,RC,,,both,,,4108.33,1232.5,"CIGNA [10200]","Cigna Open Access",,2337.64,56.9,,,,,0,477.8,3492.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 19MM REVISION 20 GRIT BLAST SURFACE",SUP-197619140,CDM,C1776,HCPCS,0278,RC,,,both,,,17952.48,5385.74,"FIRST HEALTH [10303]","First Health",,14361.98,80,,,,,0,2087.87,15259.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDING LAUNCHER NYLON EBU3.5 CURVE L90 CM OD7 FR P",SUP-LA7EBU35D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,inpatient,,,84889.64,25466.89,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,32032.64,,"Case rate ($15,731.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,607.84, add-ons for qualifying new technology services are included. If operating cost exceeds $47,647.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,486.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,627.16. The transfer operating threshold is the transfer adjustment factor * $14,607.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,104.42. The transfer capital threshold is the transfer adjustment factor * $1,104.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,74043.98,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 130CM 60MM 5MM BALLOON DILATATION",SUP-LX351305605F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"NOVANET [10819]",Novanet,,5045.63,75,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 2.5MM CEREPAK FREEFORM DETACHABLE",SUP-SCR122505,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA [10200]",Cigna,,5290.34,40,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIRAL MENINGITIS WITHOUT CC/MCC",076,MS-DRG,,,,,,,inpatient,,,30054.41,9016.32,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,5272.33,,"Case rate ($5,118.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,753.12, add-ons for qualifying new technology services are included. If operating cost exceeds $37,792.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,741.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,759.41. The transfer operating threshold is the transfer adjustment factor * $4,753.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $359.36. The transfer capital threshold is the transfer adjustment factor * $359.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,5118.77,20579.66,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"POINTER MRI 1.5MM ELECTROMAGNETIC MALLEABLE 10 TIME USE",SUP-8000050001,CDM,S27200284,LOCAL,0272,RC,,,both,,,15180.00,4554,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +7.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.750,CDM,V2632,HCPCS,0276,RC,,,both,,,3712.50,1113.75,"AETNA [10100]","Aetna HMO/PPO",,2951.44,79.5,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.255 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.255,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM ENDOSKELETON TCS TITANIUM STD SPINE",SUP-5301-3514,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-507,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UHC [10700]","United Healthcare",,8309.55,63.3,,8601.07,8395.67,8601.07,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"CMPNT GLENOID XL VAULTLOCK ARTHREX UNIVERS STERILE",SUP-AR-9106-04,CDM,C1776,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5865,68,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 0 CT-2 30IN BRAID GREEN NONABSORBABLE",SUP-X412H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE NERVE STIM NIM XPAK PEDICLE",SUP-9450069,CDM,S27200284,LOCAL,0272,RC,,,both,,,1605.74,481.72,"NOVANET [10819]",Novanet,,1204.31,75,,,,,0,186.75,1364.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 11.4CM COHESIVE I MEMORYGEL P5.8CM ULTRA HIGH","SUP-3505480 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"PHCS [10601]",PHCS,,3670.8,70,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCK AUGMENTATION NEXGEN 3 HALF 10MM KNEE TIBIA PRECOAT",SUP-598800327,CDM,C1776,HCPCS,0278,RC,,,both,,,7158.06,2147.42,"CIGNA [10200]",Cigna,,4867.48,68,,5873.17,5873.17,5873.17,"1 through 10",832.48,6084.35,"percent of total billed charges",
"DISECT LAPAROSCOPIC CURVE JAW CORDLESS ULTRASONIC",SUP-SCD7A39,CDM,S27200284,LOCAL,0272,RC,,,both,,,2887.50,866.25,"MULTIPLAN [10600]",Multiplan,,2454.38,85,,,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL PEDIATRIC MEDIUM O2 RESVR BAG MASK TUBE LATEX",SUP-530613000,CDM,S27000186,LOCAL,0270,RC,,,both,,,57.00,17.1,"NOVANET [10819]",Novanet,,42.75,75,,,,,0,6.63,48.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 1.35MM 18MM 9MM LCP STAINLESS STEEL FEMORAL",SUP-207.718,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,123.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",120.96,884.03,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL LOOP T CONE 15CM 10MM ULTRACLEAN",SUP-60-5180-102,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.76,44.33,"FIRST HEALTH [10303]","First Health",,118.21,80,,,,,0,17.18,125.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALBENDAZOLE 200 MG TABLET",RX-8979,CDM,,,0637,RC,42799-0110-02,NDC,both,1,UN,865.26,259.58,"CIGNA [10200]",Cigna,,588.38,68,,,,,0,100.63,735.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER DS NAV 115CM 8MM 7FR 1-7-4MM SPACE D-F CURVE",SUP-BN7TCDF8L,CDM,C1732,HCPCS,0272,RC,,,both,,,16477.20,4943.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1952.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1916.3,14005.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 52MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 6",SUP-244.06,CDM,C1713,HCPCS,0278,RC,,,both,,,3031.80,909.54,"AETNA [10100]","Aetna HMO/PPO",,2410.28,79.5,,1521.93,481.35,16760.95,30,352.6,2577.03,"percent of total billed charges",
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 12MM 6FR 5MM .07",SUP-H7493926712500,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AETNA [10100]","Aetna HMO/PPO",,450.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 12MM 145CM 2.5MM CORONARY STENT",SUP-1145250-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PHCS [10601]",PHCS,,4086.6,70,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 40MM 150CM 6MM VASCULAR NICKEL",SUP-EVD35-06-040-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"BLUE CROSS [10001]","Blue Cross PPO",,2463.72,39.2,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TNLR SURGICAL 15CM PLASTIC HICKMAN BROVIAC LEONARD CATH",SUP-0601930,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"FIRST HEALTH [10303]","First Health",,583.2,80,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT ALEXIS FLEXIBLE RETRACTION RING ATRAUMATIC SELF",SUP-C8313,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"CIGNA [10200]","Cigna Local Plus",,167.56,53.5,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intravasc Litho Fem/Pop",PX-361000720,CDM,37279,CPT,0361,RC,,,both,,,6377.03,1913.11,"PHCS [10601]",PHCS,,4463.92,70,,,,,0,6.38,6377.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC",822,MS-DRG,,,,,,,inpatient,,,99189.17,29756.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,19196.25,,,,,,,7468.49,35151.98,"case rate",
"(EVAL) MICROATHETER PLATO .017X127 CM 90 ANGLE",SUP-PL17-160-090,CDM,C1887,HCPCS,0272,RC,,,both,,,6555.00,1966.5,"MULTIPLAN [10600]",Multiplan,,5571.75,85,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502605602,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6172.93,27,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 20MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51103200,CDM,C1776,HCPCS,0278,RC,,,both,,,27004.32,8101.3,"BLUE CROSS [10001]","Blue Cross HMO",,10585.69,39.2,,5311.50,4717.44,5388.59,31,3140.6,22953.67,"percent of total billed charges",
"SPHERE GLENOID 39MM STD COCR CANNULATED",SUP-DWJ1017302,CDM,C1776,HCPCS,0278,RC,,,both,,,18544.68,5563.4,"CIGNA [10200]",Cigna,,7417.87,40,,5873.17,5873.17,5873.17,"1 through 10",2156.75,15762.98,"percent of total billed charges",
"COIL EMBOLIZATION 15CM 5MM TARGET XL LARGE HELICAL",SUP-M0036115150,CDM,S27800098,LOCAL,0278,RC,,,both,,,12419.24,3725.77,"NOVANET [10819]",Novanet,,9314.43,75,,,,,0,1444.36,10556.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL MONOFILAMENT ABSORBABLE LOW PROFILE",SUP-5954113,CDM,C1781,HCPCS,0278,RC,,,both,,,6720.00,2016,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4569.6,68,,,,,0,781.54,5712,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 145MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.945,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"BLUE CROSS [10001]","Blue Cross HMO",,538.77,39.2,,957.42,156.86,7483.26,51,159.84,1168.25,"percent of total billed charges",
"SOL INJECTION 1000ML 5% DEXTROSE USP LIFE FLEXIBLE CNTNR",SUP-792209,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"UHC [10700]","United Healthcare",,51.27,63.3,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D F KNEE LEFT OSSEOTI KEEL",SUP-42535007501,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5657.62,41.1,,6417.48,6417.48,6417.48,"1 through 10",1600.93,11700.68,"percent of total billed charges",
"DEVICE EZDILATE 15 ATM INFLATION 60CC BALLOON SYR LOCK",SUP-MAJ-1740,CDM,S27000186,LOCAL,0270,RC,,,both,,,304.50,91.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,36.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION",RX-27838,CDM,J3490,HCPCS,0258,RC,00264-5802-00,NDC,both,1000,ML,100.65,30.19,"MULTIPLAN [10600]",Multiplan,,85.55,85,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 120CM 7.5CM 8MM VASCULAR HEPARIN CATH",SUP-VBJR080702A,CDM,C1874,HCPCS,0278,RC,,,both,,,22163.40,6649.02,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2626.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2577.6,18838.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION",RX-185242,CDM,,,0250,RC,49502-0806-32,NDC,both,3,ML,333.05,99.91,"MULTIPLAN [10600]",Multiplan,,283.09,85,,,,,0,38.73,283.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSUFLOW PORT 8MM",SUP-4100-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"AETNA [10100]","Aetna HMO/PPO",,804.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Campylobacter Antibody",PX-302000229,CDM,86625,CPT,0302,RC,,,both,,,872.90,261.87,"PHCS [10601]",PHCS,,611.03,70,,,,,0,0.01,741.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 15MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71933735,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"KAISER [10500]",Kaiser,,8154.97,67,,,,,0,1415.56,10345.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION",RX-43717,CDM,,,0250,RC,76329-6300-05,NDC,both,4,ML,227.95,68.38,"PHCS [10601]",PHCS,,159.57,70,,,,,0,26.51,193.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL H+9MM 42MM AEQUALIS ASCEND FLEX 12.5D SHOULDER",SUP-DWF425B,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"BLUE CROSS [10001]","Blue Cross PPO",,3538.87,39.2,,3949.44,3949.44,3949.44,"1 through 10",1049.92,7673.56,"percent of total billed charges",
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET RETROGRADE LOW",SUP-AR-1204AF-110,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"KAISER [10500]",Kaiser,,1714.78,67,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Manip Chst Wall Subq",PX-410000014,CDM,94668,CPT,0410,RC,,,both,,,253.84,76.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,29.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.52,253.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 20CM 3CM 7FR .035IN 2",SUP-M006192140180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"CIGNA [10200]",Cigna,,1081.11,68,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Cholangiogram or Add Set",PX-320000214,CDM,74301,CPT,0320,RC,,,both,,,154.00,46.2,"CIGNA [10200]","Cigna Open Access",,87.63,56.9,,,,,0,17.91,130.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 13MM 51X73MM CLARIA MRI CRT-D SURESCAN",SUP-DTMA1D4,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"BLUE CROSS [10001]","Blue Cross HMO",,22626.24,39.2,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RIFAXIMIN 200 MG TABLET",RX-39063,CDM,,,0637,RC,65649-0301-03,NDC,both,1,UN,53.98,16.19,"FIRST HEALTH [10303]","First Health",,43.18,80,,,,,0,6.28,45.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 5 LR 30IN 2 ARM BRAID BLACK",SUP-485T,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE RIGHT TOTAL STABILIZE TRIATHLON COCR",SUP-5512-F-802,CDM,C1776,HCPCS,0278,RC,,,both,,,32652.90,9795.87,"MULTIPLAN [10600]",Multiplan,,27754.97,85,,,,,0,3797.53,27754.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL HIP STEM 96MM NK 33.5MM INSIGNIA 1 HIGH STEM HIGH",SUP-7000-6601,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"NOVANET [10819]",Novanet,,22930.43,75,,,,,0,3555.74,25987.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 194MM 26-34MM 30MM 20FR ZENITH TX2",SUP-G47473,CDM,C1874,HCPCS,0278,RC,,,both,,,98041.65,29412.49,"UHC [10700]","United Healthcare",,62060.36,63.3,,,,,0,11402.24,83335.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"26 MM EDWARDS SAPIEN 3 ULTRA TRANSCATHETER HEART VALVE (THV)",SUP-S3UCM26A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,74100,40,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAINLESS STEEL CARDIAC 3 FINGER HEART RETRACTOR - SMALL",SUP-OS-CFR-S-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,1603.80,481.14,"NOVANET [10819]",Novanet,,1202.85,75,,,,,0,186.52,1363.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 20CM 7FR URETERAL",SUP-M0061456170,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"MULTIPLAN [10600]",Multiplan,,531.45,85,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GS 90, 80 CM, STRAIGHT, DISTAL",SUP-GS9080SD,CDM,C1887,HCPCS,0272,RC,,,both,,,3573.98,1072.19,"NOVANET [10819]",Novanet,,2680.49,75,,,,,0,415.65,3037.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 48MM X25 LOCK INTRAMEDULLARY NAIL",SUP-04.045.048S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,1831.33,1831.33,1831.33,16,189.34,1383.8,"percent of total billed charges",
"SPLINT TRACTION UNIVERSAL LEG OPEN TOE STRAP FOAM VELCRO",SUP-8130-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,156.17,46.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSTRUMENT CLAMP EM UNIVERSAL  - MAXIMUM 10 USES",SUP-8000060021,CDM,S27200284,LOCAL,0272,RC,,,both,,,16242.60,4872.78,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CURET 4 STRAIGHT OVAL 8IN SURGICAL SPINAL FUSION",SUP-29-5034,CDM,S27200284,LOCAL,0272,RC,,,both,,,353.39,106.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dgtz Gls Mcrscp Cytp Smears / Add on 88104",PX-311000078,CDM,0827T,CPT,0311,RC,,,both,,,104.00,31.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOTRACHEAL 6.5MM HIGH VOLUME LOW PRESSURE TAPER CUFF",SUP-HUD512613,CDM,S27200284,LOCAL,0272,RC,,,both,,,391.60,117.48,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ZIPWIRE STIFF .038IN ANGLED TIP BX 5",SUP-M0066802261,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE PIRANHA TI6AL4V ELI L35 MM X H2 MM SPINE CERVICAL",SUP-P2-0035,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 38MM 144CM 3.5MM CORONARY STENT PEBAX",SUP-H7493926038350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AETNA [10100]","Aetna HMO/PPO",,4424.18,79.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RETROMAX PLUS 26CM 7-14FR THIN WALL PIGTAIL CURVE",SUP-M0061451490,CDM,C2617,HCPCS,0278,RC,,,both,,,1557.47,467.24,"PHCS [10601]",PHCS,,1090.23,70,,,,,0,181.13,1323.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH GREEN 24CM 12.5FR MAHURKAR ELITE DOUBLE-D LARGE",SUP-8888233424,CDM,C1752,HCPCS,0272,RC,,,both,,,1178.06,353.42,"CIGNA [10200]",Cigna,,801.08,68,,,,,0,137.01,1001.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 10.3MM 18MM 16.8MM ATS OPEN PIVOT AP360 HEART",SUP-505DA18,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"FIRST HEALTH [10303]","First Health",,18900,80,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Proc Spine Unlisted",PX-510000066,CDM,22899,CPT,0761,RC,,,both,,,6795.00,2038.5,"KAISER [10500]",Kaiser,,4552.65,67,,,,,0,790.26,5775.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG PERITONEAL PLEURAL STARTER 1 INSRT TRAY CATH ASPIRA",SUP-4992509,CDM,S27200284,LOCAL,0272,RC,,,both,,,5430.65,1629.19,"KAISER [10500]",Kaiser,,3638.54,67,,,,,0,631.58,4616.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 60MM TI",SUP-SPL-60600-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"FIRST HEALTH [10303]","First Health",,1296,80,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL BIT SCR BIO-TENODESIS 4MM",SUP-AR-1204D,CDM,C1713,HCPCS,0278,RC,,,both,,,978.08,293.42,"MULTIPLAN [10600]",Multiplan,,831.37,85,,,,,0,113.75,831.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-6 THC-9 30IN 2 ARM MONOFILAMENT WHITE",SUP-6M24A,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,37.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 45MM 2.1MM CARBIDE TAPERED SIDE CUTTING",SUP-1607002109,CDM,S27000186,LOCAL,0270,RC,,,both,,,93.87,28.16,"FIRST HEALTH [10303]","First Health",,75.1,80,,,,,0,10.92,79.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 45MM TSRH OSTEOGRIP TITANIUM SPINE NONSTERILE",SUP-83545451,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"FIRST HEALTH [10303]","First Health",,2059.2,80,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTDG GRSP ATRAUMATIC 38CM 5MM DIRECT DRIVE 20MM STERILE",SUP-C4120,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL RIBFIX TITAN NONSTERILE LATEX FREE REUSABLE",SUP-323.8003,CDM,S27000186,LOCAL,0270,RC,,,both,,,4098.60,1229.58,"CIGNA [10200]","Cigna Open Access",,2332.1,56.9,,,,,0,476.67,3483.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 28MM 145CM 3MM CORONARY STENT",SUP-1145300-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"KAISER [10500]",Kaiser,,3911.46,67,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC TRIFECTA GLIDE 23",SUP-TFGT-23A,CDM,S27800098,LOCAL,0278,RC,,,both,,,38367.00,11510.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15768.84,41.1,,,,,0,4462.08,32611.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lyme Western Blot",PX-302000101,CDM,86617,CPT,0302,RC,,,both,,,486.40,145.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,413.44,"per diem",
"BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET",RX-34711,CDM,,,0637,RC,60687-0481-11,NDC,both,1,UN,18.70,5.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.17,15.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 70MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661070,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,154.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",151.86,1109.86,"percent of total billed charges",
"INFU-STAT PRESSURE INFUSOR BAGAND#59; 1000CC",SUP-MTM310,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.20,15.66,"PHCS [10601]",PHCS,,36.54,70,,,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 5/64IN STEINMANN 1 END TROCAR POINT",SUP-1611-18-000,CDM,C1713,HCPCS,0278,RC,,,both,,,139.20,41.76,"CIGNA [10200]","Cigna Local Plus",,74.47,53.5,,3978.14,359.25,3978.14,24,16.19,118.32,"percent of total billed charges",
"CRTDG NOVOSTITCH 0 SUT",SUP-CTXR002,CDM,C1713,HCPCS,0278,RC,,,both,,,3570.75,1071.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1021.95,28.62,,,,,0,415.28,3035.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM ELLIPSE POSTERIOR",SUP-182.224,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"AMERIGROUP MEDICAID [20100]",Amerigroup,,497.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",488.46,3570,"percent of total billed charges",
"SCR BONE 5.5MM 55MM CREO AMP HA SPINE CANNULATED MODULAR",SUP-1067.4556S,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Local Plus",,2006.25,53.5,,3978.14,359.25,3978.14,24,436.13,3187.5,"percent of total billed charges",
"BLADE SAW 90X13MM M-CLASS HALL THK1.27MM STAINLESS STEEL",SUP-T130-127-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,553.72,166.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,64.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.4,470.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC",309,MS-DRG,,,,,,,inpatient,,,25811.57,7743.47,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,4768.94,,"Case rate ($4,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,237.60, add-ons for qualifying new technology services are included. If operating cost exceeds $37,277.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,702.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.21. The transfer operating threshold is the transfer adjustment factor * $4,237.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $320.38. The transfer capital threshold is the transfer adjustment factor * $320.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",13505.11,4848.35,20711.08,"1 through 10",4563.58,18347.62,other,"IP DRG"
"CAP SYSTEM THR VIVACIT-E OSSEOTI CERAMIC CEMENT STEM HEAD",SUP-98000100232,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"BLUE CROSS [10001]","Blue Cross PPO",,10866.24,39.2,,3949.44,3949.44,3949.44,"1 through 10",3223.84,23562,"percent of total billed charges",
"SYSTEM SYNERGY 16MM 144CM 2.25MM CORONARY STENT EVEROLIMUS",SUP-H7493926116220,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]",Cigna,,5865,68,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE ABSORBABLE 12.5X8CM PORCINE GELATIN SURGIFOAM THK2MM",SUP-1975,CDM,S27200284,LOCAL,0272,RC,,,both,,,318.57,95.57,"MULTIPLAN [10600]",Multiplan,,270.78,85,,,,,0,37.05,270.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE CINCH LONG FOR X-TACK ENDOSCOPIC HELIX TRACKING SYSTE",SUP-M00505550,CDM,S27200284,LOCAL,0272,RC,,,both,,,1478.25,443.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,175.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,171.92,1256.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE STAINLESS STEEL L18 MM OD5 MM CONDYLAR SELF TAP V",SUP-42.231.018S,CDM,C1713,HCPCS,0278,RC,,,both,,,2101.05,630.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,601.32,28.62,,,,,0,244.35,1785.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH ENDOSCP 4MM 11.8MM ROUND EDGE STERILE LATEX FREE",SUP-D-201-11304,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.26,63.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.45,178.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL BLUNT TIP 3.5MM X 70MM",SUP-DRLL-BT-35070,CDM,S27000186,LOCAL,0270,RC,,,both,,,3781.20,1134.36,"KAISER [10500]",Kaiser,,2533.4,67,,,,,0,439.75,3214.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL TISSUE ALLOGRAFT BLOCK 45MM",SUP-800126,CDM,S27800098,LOCAL,0278,RC,,,both,,,10833.69,3250.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4972.66,45.9,,,,,0,1259.96,9208.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH 7.5IN 4.8MM DISPOSABLE AORTIC",SUP-APU548,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"NOVANET [10819]",Novanet,,217.48,75,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Snrpn/Ube3a Gene",PX-309000072,CDM,81331,CPT,0310,RC,,,both,,,7823.00,2346.9,"CIGNA [10200]","Cigna Open Access",,112.35,,,,,,,7.82,6649.55,"fee schedule",
"CMPNT FEMORAL 57.5MM KNEE LEFT CRUCIATE RETAINING CEMENTED",SUP-183022,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"BLUE CROSS [10001]","Blue Cross PPO",,7873.58,39.2,,3949.44,3949.44,3949.44,"1 through 10",2335.96,17072.81,"percent of total billed charges",
"SCR BONE 5MM 80MM LCP DHHS STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.225,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"KAISER [10500]",Kaiser,,585.03,67,,,,,0,101.55,742.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 130MM 5.5MM REVOLVE XLORDOTIC",SUP-185.930,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 21.5X10.7CM ALLODERM SELECT 164SQ CM THK1.6-.4",SUP-CL1518P,CDM,Q4116,HCPCS,0636,RC,,,both,,,30870.00,9261,"UHC [10700]","United Healthcare",,247.92,,,,,,,247.92,26239.5,"fee schedule",
"ELECTRD ELECTROSURGICAL 31CM 5MM HARMONIC SCPL ULTRACISION",SUP-HBC05,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.41,432.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,662.07,45.9,,,,,0,167.75,1226.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch Unlstd Proc",PX-750000192,CDM,31899,CPT,0750,RC,,,both,,,3924.00,1177.2,"MULTIPLAN [10600]",Multiplan,,3335.4,85,,,,,0,456.36,3924,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cftr Gene Com Variants",PX-309000015,CDM,81220,CPT,0310,RC,,,both,,,692.00,207.6,"NOVANET [10819]",Novanet,,519,75,,,,,0,0.01,692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC",024,MS-DRG,,,,,,,inpatient,,,151880.69,45564.21,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,25964.36,,"Case rate ($24,265.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $22,532.40, add-ons for qualifying new technology services are included. If operating cost exceeds $55,572.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,085.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,562.19. The transfer operating threshold is the transfer adjustment factor * $22,532.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,703.56. The transfer capital threshold is the transfer adjustment factor * $1,703.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,7561,114211.83,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thc Confirmation",PX-301000509,CDM,80349,CPT,0301,RC,,,both,,,224.00,67.2,"NOVANET [10819]",Novanet,,168,75,,,,,0,0.01,224,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERLOOP FIBERTAG SWAGE STRAIGHT NDL NONABSORBABLE",SUP-AR-7266,CDM,S27200284,LOCAL,0272,RC,,,both,,,1063.13,318.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,487.98,45.9,,,,,0,123.64,903.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL TRIATHLON D CONE KNEE TRITANIUM SYMMETRIC STERILE",SUP-5549-A-140,CDM,C1776,HCPCS,0278,RC,,,both,,,22087.80,6626.34,"KAISER [10500]",Kaiser,,14798.83,67,,,,,0,2568.81,18774.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM 11.3MM CEMENTED OFFSET CONDYLAR",SUP-6097-0835,CDM,C1776,HCPCS,0278,RC,,,both,,,10292.40,3087.72,"KAISER [10500]",Kaiser,,6895.91,67,,,,,0,1197.01,8748.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BLOOD WARMING ADMIN LEVEL 1 HOTLINE INTRAVENOUS",SUP-L-70NI,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.48,21.14,"NOVANET [10819]",Novanet,,52.86,75,,,,,0,8.2,59.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 1MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN01003,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"UHC [10700]","United Healthcare",,6547.18,63.3,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 3DMAX 5.3X3.1IN ABDOMINAL LEFT MONOFILAMENT",SUP-0117310,CDM,C1781,HCPCS,0278,RC,,,both,,,951.60,285.48,"CIGNA [10200]","Cigna Local Plus",,509.11,53.5,,3096.73,1.00,3096.73,"1 through 10",110.67,808.86,"percent of total billed charges",
"KIT SNARE AMPLATZ GOOSENECK 120CM 4FR 10MM 1 CATH CABLE LOOP",SUP-GN1000,CDM,C1773,HCPCS,0272,RC,,,both,,,2062.50,618.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,847.69,41.1,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 12MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-212-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3444.02,28.62,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB ADULT 45MM ADHSV CONDUCTIVE RADIOLUCENT",SUP-8900-4005,CDM,S27000186,LOCAL,0270,RC,,,both,,,263.18,78.95,"FIRST HEALTH [10303]","First Health",,210.54,80,,,,,0,26.56,334.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH VERSACROSS 1 LARGE CURVE 72CM 230CM GUIDING CNCT",SUP-VSTK0020,CDM,C1766,HCPCS,0272,RC,,,both,,,11212.50,3363.75,"NOVANET [10819]",Novanet,,8409.38,75,,,,,0,1304.01,9530.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH 1 55CM 7FR .081IN RENAL DOUBLE CURVE 1 GUIDING",SUP-M001197960,CDM,C1887,HCPCS,0272,RC,,,both,,,972.00,291.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 6MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0100600,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"NOVANET [10819]",Novanet,,3811.39,75,,,,,0,591.02,4319.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN AL1 CURVE ANGIOGRAPHIC",SUP-H74908641962,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUBE DEMINERALIZED BONE CANCELLOUS 9MM Q-PACK",SUP-4W0009,CDM,C1713,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"MULTIPLAN [10600]",Multiplan,,2868.75,85,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 6FR L20CM FIRM TRI LAYER DESIGN RAW COLORANT",SUP-M0061902200,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 3.5X20MM",SUP-PRV035020CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cmv Dna Quant",PX-306000126,CDM,87497,CPT,0306,RC,,,both,,,731.50,219.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,67.39,,,,,,,0.73,621.78,"fee schedule",
"PLATE 1.9H 62MM 3 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009362,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAC 136CM 3.9FR .038IN GUIDING DISTAL ACCESS STERILE",SUP-90721,CDM,S27200284,LOCAL,0272,RC,,,both,,,9626.67,2888,"FIRST HEALTH [10303]","First Health",,7701.34,80,,,,,0,1119.58,8182.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 100MM 20G SONOPLEX II FACETT S TIP",SUP-001285-95,CDM,C9812,HCPCS,0272,RC,,,both,,,132.68,39.8,"AETNA [10100]","Aetna HMO/PPO",,105.48,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.43,112.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12IN 22FR ARTERIAL 3/8IN RADIOPAQUE 1 PIECE",SUP-77422,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,205.63,45.9,,,,,0,52.1,380.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 194MM STAINLESS STEEL 3.5MM SCR 8 HOLE LCP BONE RIGHT",SUP-02.104.008,CDM,C1713,HCPCS,0278,RC,,,both,,,8280.00,2484,"FIRST HEALTH [10303]","First Health",,6624,80,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? X CABLE PLATE KIT",SUP-94-1200-08,CDM,C1713,HCPCS,0278,RC,,,both,,,11488.50,3446.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7812.18,68,,,,,0,1336.11,9765.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT POSTERIOR STABILIZE GENESIS II",SUP-71421217,CDM,C1776,HCPCS,0278,RC,,,both,,,29077.65,8723.29,"CIGNA [10200]","Cigna Local Plus",,9159.46,31.5,,5372.07,4581.20,7242.98,23,3381.73,24716,"percent of total billed charges",
"SEALER/DIVIDER LAPAROSCOPIC 44CM 5MM LIGASURE RETRACTABLE L",SUP-LF5644,CDM,S27200284,LOCAL,0272,RC,,,both,,,4171.05,1251.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,485.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,485.09,3545.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM FASTTHREAD 20MM 17.9MM 3.9MM 6MM IMPL BIOCOMPOSITE",SUP-AR-1360FT-BC,CDM,C1713,HCPCS,0278,RC,,,both,,,14453.78,4336.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5781.51,40,,,,,0,1680.97,12285.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER SMOKE EVACUATOR STRYKEVAC VIROSAFE .25 IN 3/8 IN 7/8",SUP-VSSV304,CDM,S27200284,LOCAL,0272,RC,,,both,,,1912.59,573.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,226.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,222.43,1625.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CSGWORL19M SAFESHTH GDE",SUP-CSGWORL19M,CDM,C1892,HCPCS,0272,RC,,,both,,,2437.50,731.25,"UHC [10700]","United Healthcare",,1542.94,63.3,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM",RX-103884,CDM,,,0637,RC,74300-0081-94,NDC,both,113,GR,40.51,12.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CURET OBLONG 7.5IN ANTRUM SURGICAL STAINLESS STEEL 9.5X3.7MM",SUP-440402,CDM,S27200284,LOCAL,0272,RC,,,both,,,675.95,202.78,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXTR STONE 115CM 2.2FR 8MM NGAGE KIDNEY URETER NITINOL",SUP-G48297,CDM,S27200284,LOCAL,0272,RC,,,both,,,2063.25,618.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC",508,MS-DRG,,,,,,,inpatient,,,64547.71,19364.31,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 6CM 6FR 9MM .035IN BALLOON DILATATION",SUP-G52367,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP BIPOLAR 6MM ENDOWRIST SP NONSTERILE LATEX FREE REUSABLE",SUP-431150,CDM,S27000186,LOCAL,0270,RC,,,both,,,3228.75,968.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL RAPIDE MULTIPASS 5-0 PC-3 18IN BRAID",SUP-VR844,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.27,21.68,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC",862,MS-DRG,,,,,,,inpatient,,,43300.62,12990.19,"CIGNA [10200]",Cigna,,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LEAD 49CM 9FR SAFESHEATH CSG WORLEY JUMBO CURVE",SUP-CSG/WRLY/BCOR-1-09,CDM,C1892,HCPCS,0272,RC,,,both,,,3345.00,1003.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SENSOR DUAL-FLEX UROLOGICAL 10CM ANGLE 150CM 3CM .038",SUP-M0066703021,CDM,C1769,HCPCS,0272,RC,,,both,,,372.19,111.66,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 12MM MICRO FUSHIA",SUP-AT2-C12-S,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1463.06,45.9,,,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000195,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL RESTORIS 8 KNEE RIGHT MEDIAL ONLAY",SUP-180618,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"MULTIPLAN [10600]",Multiplan,,5633.33,85,,,,,0,770.77,5633.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 35FR LEFT ANGLE ADJUSTABLE VALVE STYLET 2",SUP-125035,CDM,S27200284,LOCAL,0272,RC,,,both,,,439.99,132,"CIGNA [10200]","Cigna Open Access",,250.35,56.9,,,,,0,51.17,373.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 STD KNEE CONDYLAR CEMENT CONSTRAIN PERSONA",SUP-42504605802,CDM,C1776,HCPCS,0278,RC,,,both,,,42373.80,12712.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5021.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4928.07,36017.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175264080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"BLUE CROSS [10001]","Blue Cross PPO",,485.84,39.2,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE DUCKBILL 25MM 7FR ACUSNARE 1 PIECE GRADUATED MARK",SUP-G22649,CDM,S27200284,LOCAL,0272,RC,,,both,,,282.75,84.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,192.27,68,,,,,0,32.88,240.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 5CMX12MMX8MM VIEWSITE INTRO WORK CHANNEL SURGICAL",SUP-TC120805,CDM,S27200284,LOCAL,0272,RC,,,both,,,4795.50,1438.65,"MULTIPLAN [10600]",Multiplan,,4076.18,85,,,,,0,557.72,4076.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 9IN 1.5MM SMALL DISPOSABLE",SUP-801277,CDM,S27200284,LOCAL,0272,RC,,,both,,,3441.00,1032.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,400.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,400.19,2924.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PT GRAPHIX VASCULAR STRAIGHT INTERMEDIATE 300CM .014IN",SUP-H74914914011,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"NOVANET [10819]",Novanet,,425.25,75,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR VIVACIT-E JJ ELEVATED 54MM 36MM HIP",SUP-00885201136,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"BLUE CROSS [10001]","Blue Cross HMO",,4018.79,39.2,,5311.50,4717.44,5388.59,31,1192.31,8714.22,"percent of total billed charges",
"CATH SAPPHIRE II PRO 10MM 1.75MM BALLOON DILATATION STERILE",SUP-217-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UHC [10700]","United Healthcare",,512.73,63.3,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC GREEN BEAVER OPTIMUM 15D STRAIGHT STAB",SUP-374891,CDM,S27200284,LOCAL,0272,RC,,,both,,,175.09,52.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.36,148.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 9MM KNEE BEARING CRUCIATE RETAIN TRIATHLON",SUP-5530-G-709-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1327.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25 DIOPTER 13MM 6MM POSTERIOR CHMBR 1 PIECE",SUP-SN60WF.250,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX CORE REINFORCED TISSUE MATRIX, LONG-TERM RESORBABLE R",SUP-F10264-2020G,CDM,C1781,HCPCS,0278,RC,,,both,,,20664.00,6199.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2448.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2403.22,17564.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 8MM 38MM TITANIUM CORTEX SELF TAP LARGE",SUP-414.838,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,32.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,32.01,233.98,"percent of total billed charges",
"BLADE REAMER 41MM PILOT HOLE KNEE PATELLA STAINLESS STEEL",SUP-597909541,CDM,S27200284,LOCAL,0272,RC,,,both,,,1129.14,338.74,"AETNA [10100]","Aetna HMO/PPO",,897.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.32,959.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 40MM 5FR 7MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206070470,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 80MM 2MM .014IN BALLOON DILATATION",SUP-AB14W020080150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"FIRST HEALTH [10303]","First Health",,1108.08,80,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST EXTERNAL FIXATION JET-X 4MMX6.25MM FREEDOM",SUP-71067382,CDM,C1887,HCPCS,0272,RC,,,both,,,7563.78,2269.13,"KAISER [10500]",Kaiser,,5067.73,67,,,,,0,879.67,6429.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED + VE",SUP-98000200252,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"KAISER [10500]",Kaiser,,16461.9,67,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 80CM 23CM GRAY HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-5F-23-035,CDM,C1894,HCPCS,0272,RC,,,both,,,117.45,35.23,"UHC [10700]","United Healthcare",,74.35,63.3,,,,,0,13.66,99.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 5CM MIDAS REX MR8 3MM BALL DISSECTING DIAMOND LP",SUP-MR8-LP05BA30D,CDM,S27200284,LOCAL,0272,RC,,,both,,,2179.13,653.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,253.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,253.43,1852.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS TESTICULAR 13ML SALINE FILL INFUSION LINE NDL MEDIUM 4",SUP-450-1327,CDM,L8699,HCPCS,0278,RC,,,both,,,14973.00,4491.9,"MULTIPLAN [10600]",Multiplan,,12727.05,85,,,,,0,1741.36,12727.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5-6 11MM KNEE XLPE POSTERIOR STABILIZED HIGH",SUP-71453222,CDM,C1776,HCPCS,0278,RC,,,both,,,13420.50,4026.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5368.2,40,,,,,0,1560.8,11407.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CLEANER15 135CM 7FR 15MM THROMBECTOMY SINUSOIDAL WIRE",SUP-700115,CDM,S27200284,LOCAL,0272,RC,,,both,,,7893.60,2368.08,"KAISER [10500]",Kaiser,,5288.71,67,,,,,0,918.03,6709.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 6MM REINFORCE CUFF MURPHY EYE LOW PRESSURE",SUP-DYNJAARC60,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.86,46.46,"NOVANET [10819]",Novanet,,116.15,75,,,,,0,18.01,131.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM TRIATHLON 4 RIGHT LATERAL LEFT MEDIAL KNEE",SUP-5546-A-401,CDM,C1776,HCPCS,0278,RC,,,both,,,4252.25,1275.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1216.99,28.62,,,,,0,494.54,3614.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 80CM 2CM 6MM BALLOON",SUP-G52344,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"KAISER [10500]",Kaiser,,643.05,67,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM INSET SHOULDER LOCK REVERSE",SUP-2R1PT45035,CDM,C1713,HCPCS,0278,RC,,,both,,,865.08,259.52,"CIGNA [10200]","Cigna Local Plus",,462.82,53.5,,3978.14,359.25,3978.14,24,100.61,735.32,"percent of total billed charges",
"PLATE T OBLIQUE ANGLE 63X10X1.5MM TITANIUM 3.5MM SCR SMALL",SUP-441.24,CDM,C1713,HCPCS,0278,RC,,,both,,,1547.91,464.37,"FIRST HEALTH [10303]","First Health",,1238.33,80,,,,,0,180.02,1315.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC SUTUPAK 2-0 18IN MONOFILAMENT 12 STRAND PRECUT",SUP-SG13T,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.67,51.8,"AETNA [10100]","Aetna HMO/PPO",,137.27,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.08,146.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repo Cannula Ecmo Perc Peripheral>=6",PX-361000366,CDM,33958,CPT,0481,RC,,,both,,,7589.00,2276.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,882.6,7589,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repo Cannula Ecmo Perc Peripheral>=6",PX-361000366,CDM,33958,CPT,0481,RC,,,both,,,7589.00,2276.7,"NOVANET [10819]",Novanet,,5691.75,75,,,,,0,882.6,7589,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 13MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530-G-513,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CIGNA [10200]",Cigna,,5921.17,68,,5873.17,5873.17,5873.17,"1 through 10",1012.7,7401.47,"percent of total billed charges",
"INSRT TIBIAL 7 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640706,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7652.65,68,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 2 SAMPLE SITE 3 TRNSDUC TUBE SNAP TAB",SUP-PXVP23X3,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT WALLFLEX 100MM 8MM BIL",SUP-7465,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,35.76,41.1,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM SOLERA CD HORIZON SPINE MULTIAXIAL",SUP-54850016535,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"KAISER [10500]",Kaiser,,4391.85,67,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL GOLD 70MM 3.5MM SYNAPSE CURVE TITANIUM PREBENT",SUP-04.614.770,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"PEG FIXATION 18MM WRIST VOLAR THREAD LOCK TORX",SUP-TPEG-18,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"CIGNA [10200]",Cigna,,578.34,68,,1831.33,1831.33,1831.33,16,98.91,722.93,"percent of total billed charges",
"PROBE ELECTROSURGICAL 3MM OPES 90D LOW PROFILE ASPIRATE",SUP-AR-9703A-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"CIGNA [10200]","Cigna Local Plus",,796.28,53.5,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX 30MM 80CM 10MM 6FR .035IN BILIARY CATH",SUP-ZBM10030,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4592.3,45.9,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 2IN 20GA 18GA CONTIPLEX TUOHYL ULTRA 360",SUP-331640,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.28,68.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,27.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.55,194.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET VENTRICULAR ASSIST 2.5IN IMPELLA STERILE LATEX FREE",SUP-005042,CDM,S27800098,LOCAL,0278,RC,,,both,,,114000.00,34200,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13509,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13258.2,96900,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CEMENTED EXETER V40 1 44MM OFFSET HIP",SUP-0580-1-441,CDM,C1776,HCPCS,0278,RC,,,both,,,17001.60,5100.48,"MULTIPLAN [10600]",Multiplan,,14451.36,85,,,,,0,1977.29,14451.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYSORB 3-0 C-14 30IN BRAID COATED UNDYED ABSORBABLE",SUP-SL-693,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.62,31.09,"UHC [10700]","United Healthcare",,65.59,63.3,,,,,0,12.05,88.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 145D STD BARREL 142X19X5.8MM STAINLESS STEEL 4.5MM",SUP-281.308,CDM,C1713,HCPCS,0278,RC,,,both,,,4545.38,1363.61,"BLUE CROSS [10001]","Blue Cross HMO",,1781.79,39.2,,957.42,156.86,7483.26,51,528.63,3863.57,"percent of total billed charges",
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN EXTRA",SUP-67006600,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,171.63,41.1,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL 2 18IN MONOFILAMENT TIE 12 STRAND SILVER",SUP-DS24,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.11,21.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.15,59.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP IRRIGATION XMAX MICROMAX EMAX 2 PLUS SHORT ATTACH",SUP-IRR-CLIP-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 124MM 30MM ZENITH HANDL-B ONE-SHOT 2",SUP-G32543,CDM,C1874,HCPCS,0278,RC,,,both,,,62551.57,18765.47,"KAISER [10500]",Kaiser,,41909.55,67,,,,,0,7274.75,53168.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNR SM OVL 240CM 2.4MM SNS",SUP-6269,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"FIRST HEALTH [10303]","First Health",,69.6,80,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 18 9 X 30 COMPLEX FRAMING COIL",SUP-18CFR-09030,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1549.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM TSRH OSTEOGRIP THINLINE TITANIUM SPINE 2",SUP-83575401,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1750.32,68,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Amniocentesis Thpy Reduce Fld",PX-720000004,CDM,59001,CPT,0720,RC,,,both,,,21498.00,6449.4,"KAISER [10500]",Kaiser,,14403.66,67,,,,,0,1729.39,18273.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Not Feeynolm<=2.5cm",PX-450000019,CDM,12001,CPT,0361,RC,,,both,,,738.00,221.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,87.45,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,85.83,738,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE SP 35M",SUP-TENDV-SP-35M-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"MULTIPLAN [10600]",Multiplan,,145350,85,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) 20 FR. THORAGUARD CHEST TUBE KIT (BOX OF 10)",SUP-TGCT120020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"AETNA [10100]","Aetna HMO/PPO",,1255.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUARD BURR LONG",SUP-137501100,CDM,S27000186,LOCAL,0270,RC,,,both,,,770.96,231.29,"CIGNA [10200]",Cigna,,524.25,68,,,,,0,89.66,655.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 31MM SJM TAILOR SILICONE FLEXIBLE SURE",SUP-TAB-31,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"CIGNA [10200]",Cigna,,4842.56,40,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.8MM 200MM 10MM LCP ANKLE COMPRESSION THREAD",SUP-03.118.010,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immunodiffusion Nos",PX-302000067,CDM,86329,CPT,0302,RC,,,both,,,508.00,152.4,"FIRST HEALTH [10303]","First Health",,406.4,80,,,,,0,0.51,431.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BENTSON 28CM 15CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175274060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"CIGNA [10200]","Cigna Local Plus",,533.63,,,,,,,116,847.82,"percent of total billed charges",
"4F QUAD 5-5-5 MPA 120CM",SUP-901477,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X18X8MM COROENT XL PEEK TLIF RADIOLUCENT",SUP-6908855,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6800.11,28.62,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 14FR URETHRAL SILICONE 10ML FOLEY 2 WAY COUDE TIP",SUP-DYND11591,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.36,38.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,inpatient,,,149949.56,44984.87,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 P-3 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8695G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 CURVE 15MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962053,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"CIGNA [10200]","Cigna Open Access",,5262.94,56.9,,5302.19,4377.88,6578.61,27,1075.71,7862.03,"percent of total billed charges",
".035 INTERLOCK 2D 10MM X 20CM",SUP-M001363600,CDM,C1725,HCPCS,0272,RC,,,both,,,3891.60,1167.48,"FIRST HEALTH [10303]","First Health",,3113.28,80,,,,,0,452.59,3307.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEDG CARDIOVASCULAR 3/8X3/16IN THK1/16IN LARGE TEFLON SOFT",SUP-L-705,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.57,21.17,"MULTIPLAN [10600]",Multiplan,,59.98,85,,,,,0,8.21,59.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 80MM 6MM BALLOON DILATATION HYDROPHILIC",SUP-606008022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,495.72,68,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB ADULT MULTIFUNCTION STAT PADZ HIGH VISCOSITY",SUP-8900-4004,CDM,S27000186,LOCAL,0270,RC,,,both,,,155.30,46.59,"KAISER [10500]",Kaiser,,104.05,67,,,,,0,18.06,132.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL 2.0MM X 124MM",SUP-DRLL-20124,CDM,S27000186,LOCAL,0270,RC,,,both,,,1417.50,425.25,"CIGNA [10200]","Cigna Open Access",,806.56,56.9,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23MMX7MM ELEVATE XLORDOTIC STERILE",SUP-7770723,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11836.8,41.1,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 20MM PERSONA 3-5+ C-D KNEE RIGHT CONDYLAR",SUP-42522800420,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 100CM 5FR JR4 CURVE ANGIOGRAPHIC",SUP-G47021,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"CIGNA [10200]","Cigna Open Access",,119.79,56.9,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 18MM OSS UHMWPE KNEE TIBIAL STD STERILE",SUP-150413,CDM,C1776,HCPCS,0278,RC,,,both,,,8317.26,2495.18,"AETNA [10100]","Aetna HMO/PPO",,6612.22,79.5,,10981.53,8986.79,12413.38,12,967.3,7069.67,"percent of total billed charges",
"HEAD FEMORAL +8MM 12/14 TAPER 36MM HIP COCR SPECTRON EF",SUP-71303608,CDM,C1776,HCPCS,0278,RC,,,both,,,10236.15,3070.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2929.59,28.62,,,,,0,1190.46,8700.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 44MM 6.5MM REUNION FOOT ANKLE CENTER STERILE",SUP-5573-6544,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",180.93,1322.35,"percent of total billed charges",
"WIRE WITH OLIVE - DIA 2.0 X 450 MM",SUP-4933-8-040,CDM,C1713,HCPCS,0278,RC,,,both,,,756.70,227.01,"CIGNA [10200]","Cigna Open Access",,430.56,56.9,,1144.80,304.56,2275.09,66,88,643.2,"percent of total billed charges",
"RING ANNULOPLASTY CHORDAL GUIDE DURAN ANCORE",SUP-620RG25,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FUSION 170CM 5FR PUSHING DOME TIP PLASTIC STENT STERILE",SUP-G31550,CDM,C1894,HCPCS,0272,RC,,,both,,,639.90,191.97,"MULTIPLAN [10600]",Multiplan,,543.92,85,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 90CM 6FR AR2 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H74938969180,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AETNA [10100]","Aetna HMO/PPO",,291.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORTIVA SILHOUETTE 16X20 CM",SUP-UTD1620,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ORTHOPEDIC 11MM INDEPENDENCE",SUP-376.411,CDM,C1776,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"UHC [10700]","United Healthcare",,21696.45,63.3,,8601.07,8395.67,8601.07,"1 through 10",3986.25,29134.26,"percent of total billed charges",
"INSRT HUMERAL H+6MM 36MM AEQUALIS ASCEND FLEX 17.5D SHOULDER",SUP-DWF361A,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1049.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1049.92,7673.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.122,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"CIGNA [10200]","Cigna Local Plus",,605.99,53.5,,3978.14,359.25,3978.14,24,131.73,962.8,"percent of total billed charges",
"FRCP BIPOLAR 10IN MARS BAYONET 1MM",SUP-632.678S,CDM,S27200284,LOCAL,0272,RC,,,both,,,6810.30,2043.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,807.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,792.04,5788.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH IRIS STERILE LATEX FREE DISPOSABLE",SUP-220180518,CDM,S27200284,LOCAL,0272,RC,,,both,,,2157.21,647.16,"AETNA [10100]","Aetna HMO/PPO",,1714.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,250.88,1833.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 30CM 7FR URETERAL",SUP-M0061456220,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,178.94,28.62,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ASPIRATION 15MM 21GA 1.8MM .5MM EXCELON TRANSBRONCHIAL",SUP-M00564121,CDM,S27200284,LOCAL,0272,RC,,,both,,,664.10,199.23,"NOVANET [10819]",Novanet,,498.08,75,,,,,0,77.23,564.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 5.5MM COOLCUT 12 FLUTE OVAL STERILE",SUP-AR-8550OBT,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"NOVANET [10819]",Novanet,,376.35,75,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8-6.5MM 45MM CREO SPINE 2 OUTER DIAMETER",SUP-5119.2247,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP REVISION TRITANIUM F",SUP-509-02-60F,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"CIGNA [10200]","Cigna Local Plus",,6009.12,53.5,,5372.07,4581.20,7242.98,23,1306.28,9547.2,"percent of total billed charges",
"COIL EMBOLIZATION 6CM 3MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS03006,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1389.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TISSUE CLOSURE SEALANT 100SQ FT EVICEL FIBRIN 5ML",SUP-3905,CDM,S25000001,LOCAL,0250,RC,,,both,,,2156.49,646.95,"UHC [10700]","United Healthcare",,1365.06,63.3,,,,,0,250.8,1833.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM SOLERA COCR SPINE MULTIAXIAL",SUP-54840007540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Local Plus",,5107.56,53.5,,3978.14,359.25,3978.14,24,1110.3,8114.82,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 15MM 145CM 3.25MM CORONARY STENT",SUP-1125325-15,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM 16X16X2.5MM TITANIUM 1 LEVEL PREBENT SKYLINE BONE",SUP-186801016,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"NOVANET [10819]",Novanet,,3150,75,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 140MM 120CM 14MM .035IN VASCULAR VENOUS CATH",SUP-VENUL14140,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"KAISER [10500]",Kaiser,,15617.7,67,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPANSURE DILATOR",SUP-ESD125-35-67-70-N,CDM,C1893,HCPCS,0272,RC,,,both,,,1458.00,437.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.3/4F DUO-DECA 18-2-2-2 S 120CM",SUP-904220,CDM,C1731,HCPCS,0272,RC,,,both,,,8970.00,2691,"KAISER [10500]",Kaiser,,6009.9,67,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EPILONG 35IN 20GA EPIDURAL STEEL CLOSE TIP 6 LATERAL",SUP-041151-37R,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.35,53.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,121.28,68,,,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER BURR HOLE 7MM MEDPOR LOW PROFILE TITANIUM TAB STERILE",SUP-53-34507,CDM,C1713,HCPCS,0278,RC,,,both,,,1858.35,557.5,"CIGNA [10200]",Cigna,,1263.68,68,,1831.33,1831.33,1831.33,16,216.13,1579.6,"percent of total billed charges",
"SCR BONE 30MM ARTHREX CENTRAL MODULAR STERILE",SUP-AR-9561-30S,CDM,C1713,HCPCS,0278,RC,,,both,,,4029.60,1208.88,"PHCS [10601]",PHCS,,2820.72,70,,,,,0,468.64,3425.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 5FR 5MM SPACE L CURVE ELECTROPHYSIOLOGY",SUP-F5QF252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"UHC [10700]","United Healthcare",,574.26,63.3,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM TRILOGY HIP SELF TAP STERILE",SUP-625006560,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"MULTIPLAN [10600]",Multiplan,,846.86,85,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOLVAPTAN 30 MG TABLET",RX-97894,CDM,,,0637,RC,67877-0636-33,NDC,both,1,UN,2064.07,619.22,"CIGNA [10200]","Cigna Open Access",,1174.46,56.9,,,,,0,240.05,1754.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD REAMER 16.5MM STAINLESS STEEL RIA STERILE DISPOSABLE",SUP-352.259S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2560.05,768.01,"KAISER [10500]",Kaiser,,1715.23,67,,,,,0,297.73,2176.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BRACHYTHERAPY INTERFACE CONTROL SYSTEM BRACHYBALLOON",SUP-610-898,CDM,S27200284,LOCAL,0272,RC,,,both,,,584.62,175.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,69.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.99,496.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 BV-1 30IN 2 ARM MONOFILAMENT BLUE",SUP-8709H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WRAP THERAPEUTIC RAPR ROUND LEG HYPERTHERMIA HYPOTHERMIA",SUP-8001061540,CDM,S27000186,LOCAL,0270,RC,,,both,,,362.79,108.84,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMERGE MONORAIL 144CM 30MM 6FR 2MM .07IN BALLOON",SUP-H7493918930200,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) DISPOSABLE WEIGHT",SUP-5675,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cysto W/Biopsy(S)",PX-361000473,CDM,0505T,CPT,0361,RC,,,both,,,24262.00,7278.6,"NOVANET [10819]",Novanet,,18196.5,75,,,,,0,2821.67,20622.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC 2XL 27-31IN 19.75-22IN KNEE LEFT COMPACT",SUP-24960,CDM,S27000186,LOCAL,0270,RC,,,both,,,2058.38,617.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,845.99,41.1,,,,,0,239.39,1749.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14CM NATRELLE BIOCELL P3.8CM MODERATE PROFILE",SUP-MSZ10420,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,65.01,41.1,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 12X14X7MM CASCADIA 12D TITANIUM POROUS CERVICAL",SUP-6101-2121407CL12-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM TOMCAT SPINE SELF DRILL VARIABLE ANGLE",SUP-RT10-D3514,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 40MM 9MM BALLOON",SUP-U357594,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 150MM 120CM 8MM VASCULAR PERIPHERAL SELF",SUP-PRB35-08-150-120,CDM,C1876,HCPCS,0278,RC,,,both,,,7560.00,2268,"NOVANET [10819]",Novanet,,5670,75,,,,,0,879.23,6426,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 6.35MM TSR2D PRECUT BENT",SUP-8371080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"PLATE BONE 25MMX.5MM LORENZ SMALL CRANIOMAXILLOFACIAL",SUP-017351,CDM,C1713,HCPCS,0278,RC,,,both,,,1657.50,497.25,"CIGNA [10200]",Cigna,,1127.1,68,,1831.33,1831.33,1831.33,16,192.77,1408.88,"percent of total billed charges",
"SPACER ALLOGRAFT 21-26X27-32X19MM LUMINARY CC 30D BICONVEX",SUP-6919,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"NOVANET [10819]",Novanet,,24948,75,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 60MM 135CM 6MM 5FR VASCULAR NITINOL LOW",SUP-5F060603CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"BLUE CROSS [10001]","Blue Cross HMO",,4598.16,39.2,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 54MM",SUP-626-00-54I,CDM,S27800098,LOCAL,0278,RC,,,both,,,9500.40,2850.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2719.01,28.62,,,,,0,1104.9,8075.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 48MM CAYMAN SPINE SELF START NONSTERILE",SUP-4501-15548,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]",Cigna,,1101.6,68,,1831.33,1831.33,1831.33,16,188.41,1377,"percent of total billed charges",
"CATH PUREWICK URETHRAL NATURAL (LATEX-FREE)",SUP-PWF030F,CDM,S27000186,LOCAL,0270,RC,,,both,,,64.38,19.31,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SKIN 16X8CM ALLODERM THK1.04-2.28MM IMPL REGENERATIVE",SUP-102128,CDM,Q4116,HCPCS,0636,RC,,,both,,,23347.80,7004.34,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH ULTRAVERSE 018 150CM 22CM 4MM BALLOON DILATATION",SUP-U8150422,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POS STENT 45CM 4.8FR URETERAL",SUP-M0061802001,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.15,26.44,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW .37IN MICROCHOICE .79IN THK.03IN OSCILLATING",SUP-KM-3005,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL PROC 10CM 18GA TROCAR",SUP-G01458,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.46,43.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC",872,MS-DRG,,,,,,,inpatient,,,31833.40,9550.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 34CM 14MM FRAMING .035IN",SUP-45-651434,CDM,S27800098,LOCAL,0278,RC,,,both,,,8538.75,2561.62,"AETNA [10100]","Aetna HMO/PPO",,6788.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,993.06,7257.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 42X4IN ATS CYL PORT STERILE DISPOSABLE",SUP-60707510700,CDM,S27200284,LOCAL,0272,RC,,,both,,,227.12,68.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,154.44,68,,,,,0,26.41,193.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.0MM X 10MM TI",SUP-VAN-20100-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"BLUE CROSS [10001]","Blue Cross HMO",,381.02,39.2,,957.42,156.86,7483.26,51,113.04,826.2,"percent of total billed charges",
"PASSER CURVE WORM SUT ARTHROSCOPY STERILE",SUP-AR-1268,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 100MM 1.4MM KIRSCHNER FOOT SMOOTH NONSTERILE",SUP-45-80200,CDM,C1713,HCPCS,0278,RC,,,both,,,160.78,48.23,"FIRST HEALTH [10303]","First Health",,128.62,80,,,,,0,18.7,136.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL BECK COOLEY LARGE MEDIUM CURVE STRAIGHT 6IN",SUP-55-5037,CDM,S27200284,LOCAL,0272,RC,,,both,,,1191.92,357.58,"MULTIPLAN [10600]",Multiplan,,1013.13,85,,,,,0,138.62,1013.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS MULTIPASS 3-0 PS-2 27IN BRAID COATED UNDYED",SUP-VCP427H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"KAISER [10500]",Kaiser,,16.75,67,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 65MM 9.4MM 5MM CUFFLESS DISPOSABLE INNER CANN SHILEY",SUP-4DCFS,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM ULNAR SIZE 5 L115MM LEFT CEMENTED CONSTRAINED NEXEL",SUP-840001511,CDM,C1776,HCPCS,0278,RC,,,both,,,31971.49,9591.45,"BLUE CROSS [10001]","Blue Cross HMO",,12532.82,39.2,,5311.50,4717.44,5388.59,31,3718.28,27175.77,"percent of total billed charges",
"STBL ORTHOPEDIC XL AIRMESH KNEE LATERAL LEFT LOW PROFILE J",SUP-11045,CDM,L1830,HCPCS,0274,RC,,,both,,,227.07,68.12,"CIGNA [10200]",Cigna,,154.41,68,,,,,0,26.41,193.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SURGICAL 4MM HOFFER BAYONET",SUP-1564-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.60,562.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,770.87,41.1,,,,,0,218.13,1594.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM OBTRYX II PRECISIONBLUE ADVANTAGE THK.66MM 1182UM 22",SUP-M0068505110,CDM,C1788,HCPCS,0278,RC,,,both,,,13183.00,3954.9,"CIGNA [10200]","Cigna Local Plus",,4152.65,31.5,,,,,0,1533.18,11205.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 40MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.140,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,131.73,962.8,"percent of total billed charges",
"CATH BARDEX IC 26FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0165SI26,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.82,19.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.54,55.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL RENAL AMPLATZ FIRM KINK RESISTANT GRADUATED TAPER 35CM",SUP-M0062601040,CDM,C1894,HCPCS,0272,RC,,,both,,,362.44,108.73,"AETNA [10100]","Aetna HMO/PPO",,288.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.15,308.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 451666A PG 16X26X26 SRVC FEE F",SUP-451666A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 14MM STD SHELL DJO SURGICAL ALTIVATE",SUP-530-14-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,18997.78,40,,,,,0,5523.6,40370.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD SENTUS PROMRI LEFT VENTRICULAR OTW QUADRIPOLAR",SUP-406081,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]",Cigna,,3812.76,68,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VISIGLIDE ENDOSCOPIC ANGLE 450CM 7CM .025IN",SUP-G-240-2545A,CDM,C1769,HCPCS,0272,RC,,,both,,,1288.95,386.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,876.49,68,,,,,0,149.9,1095.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD RVOT KIT MOND",SUP-4140/52,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,66.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 120MM 4FR 2.5MM ROUND LOW PROFILE TAPER",SUP-A2025-120,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 60MM 125CM 6MM 5FR VASCULAR NITINOL ILIAC",SUP-G43772,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"CIGNA [10200]",Cigna,,2841.72,68,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET NDL 1IN 20GA PORT ACCESS KIT Y SITE HUBER ROTATE HEAD",SUP-PA0032YN,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.87,28.76,"NOVANET [10819]",Novanet,,71.9,75,,,,,0,11.15,81.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 43IN 8FR NASOINTESTINAL RADIOPAQUE ANTICLOG",SUP-40-5438,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.88,26.66,"CIGNA [10200]","Cigna Local Plus",,47.55,53.5,,,,,0,10.34,75.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE WHISPER ES VASCULAR STRAIGHT 300CM 3CM .014",SUP-1011835H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 100MM 20MM 3MM VASCULAR VENOUS ILIOFEMORAL VEIN",SUP-VENUM20100,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2762.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Methadone Confirmation",PX-301000510,CDM,80358,CPT,0301,RC,,,both,,,386.65,115.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,45.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.39,328.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 46CM LEFT TROCHANTERIC INTRAMEDULLARY 130D LONG",SUP-456.367S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1619.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1589.87,11619.86,"percent of total billed charges",
"HC Ercp Ablation",PX-750000143,CDM,43278,CPT,0750,RC,,,both,,,3239.00,971.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3239,,"Case rate ($6,891). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,376.7,3239,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Creatinine Blood",PX-301000166,CDM,82565,CPT,0301,RC,,,both,,,67.60,20.28,"FIRST HEALTH [10303]","First Health",,54.08,80,,,,,0,0.07,57.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 300-500UM 2ML LABEL LC BEAD BLUE",SUP-VE420GS,CDM,S27800098,LOCAL,0278,RC,,,both,,,10812.30,3243.69,"BLUE CROSS [10001]","Blue Cross PPO",,4238.42,39.2,,,,,0,1257.47,9190.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,inpatient,,,21091.49,6327.45,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,4972.04,,"Case rate ($4,827.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,482.40, add-ons for qualifying new technology services are included. If operating cost exceeds $37,522.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,720.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,488.33. The transfer operating threshold is the transfer adjustment factor * $4,482.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.89. The transfer capital threshold is the transfer adjustment factor * $338.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",12562.56,12562.56,12562.56,"1 through 10",4827.22,19407.53,other,"IP DRGs"
"CATH SOFT-VU 90CM 5FR STRAIGHT ANGIOGRAPHIC RADIOPAQUE FLUSH",SUP-H787107086045,CDM,C1887,HCPCS,0272,RC,,,both,,,190.36,57.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.14,161.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REINFORCEMENT STAPLE LINE BIOABSORBABLE STERILE GORE",SUP-12BSGUSS60G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1323.00,396.9,"FIRST HEALTH [10303]","First Health",,1058.4,80,,,,,0,153.86,1124.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 3DEMIN ALLOGRAFT STRIP PLIABLE OSTEOCONDUCTIVE",SUP-109771,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"CIGNA [10200]",Cigna,,7014.54,68,,1831.33,1831.33,1831.33,16,1199.69,8768.18,"percent of total billed charges",
"IMPL BREAST NATRELLE INSPIRA LOW PLUS PROFILE SOFTTOUCH",SUP-SSLP-190,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]","Cigna Open Access",,4299.08,56.9,,5166.00,5166.00,5166.00,"1 through 10",878.7,6422.18,"percent of total billed charges",
"SCR BONE 5MM 40MM NAIL-EX TITANIUM FULL THREAD TIBIA 2 CORE",SUP-04.015.530,CDM,C1713,HCPCS,0278,RC,,,both,,,1313.17,393.95,"CIGNA [10200]",Cigna,,892.96,68,,1831.33,1831.33,1831.33,16,152.72,1116.19,"percent of total billed charges",
"HC Sol D5 Nacl",PX-E27200282,CDM,E27200282,LOCAL,0272,RC,,,both,,,119.90,35.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,81.53,68,,,,,0,13.94,101.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 75MM 6.5MM DRI-LOK THREAD",SUP-3910075650,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"CIGNA [10200]",Cigna,,118.32,68,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION HI-FLO 105CM 2.8-3FR .027IN MICRO INFUSION",SUP-M001195490,CDM,C1887,HCPCS,0272,RC,,,both,,,4416.00,1324.8,"NOVANET [10819]",Novanet,,3312,75,,,,,0,513.58,3753.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VOLT, HD GRID X, AGILIS 13F SMALL, ICE SE",SUP-K-VOLT-HDI-S,CDM,C1732,HCPCS,0272,RC,,,both,,,74100.00,22230,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8780.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8617.83,62985,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3.5MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN03506,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"FIRST HEALTH [10303]","First Health",,9378.48,80,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 8MM 115MM LCP STAINLESS STEEL CORTEX CONDYLE",SUP-214.915,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,170.52,39.2,,957.42,156.86,7483.26,51,50.59,369.75,"percent of total billed charges",
"5FR X 7CM STIFFEN FLUENT TRANSITIONLESS MICRO-INTRODUCER KIT",SUP-KIT-039-04,CDM,C1887,HCPCS,0272,RC,,,both,,,281.88,84.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,115.85,41.1,,,,,0,32.78,239.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTRA 39CM 7FR 130D GUIDING STERILE LATEX FREE",SUP-443627,CDM,C1893,HCPCS,0272,RC,,,both,,,1800.00,540,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,213.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE CRANIOFACIAL TITANIUM 6 HOLE STRUT LOW PROFILE",SUP-421.522,CDM,C1713,HCPCS,0278,RC,,,both,,,3127.50,938.25,"AETNA [10100]","Aetna HMO/PPO",,2486.36,79.5,,1521.93,481.35,16760.95,30,363.73,2658.38,"percent of total billed charges",
"HC Tcat Ins 1chmbr Ldls Pm Ra",PX-481000390,CDM,0823T,CPT,0481,RC,,,both,,,29836.00,8950.8,"BLUE CROSS [10001]","Blue Cross HMO",,10743.75,,"Case rate ($10,743.75). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3469.93,25360.6,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 31X12-15MM MAGNIFY-S 8D LORDOTIC 25MM EXPAND",SUP-1126.0112,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"CIGNA [10200]","Cigna Local Plus",,13494.6,31.5,,,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYNXGRIP GRIP 5FR CLSR 10ML VASCULAR BALLOON CATH",SUP-MX5021,CDM,C1760,HCPCS,0278,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 3CM 8FR .038IN PIGTAIL CURVE STRAIGHT LOW",SUP-M006180243010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CIGNA [10200]",Cigna,,728.1,68,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 0 OS-2 MINI QUICKANCHOR PLUS ETHIBOND",SUP-212133,CDM,C1713,HCPCS,0278,RC,,,both,,,4843.80,1453.14,"MULTIPLAN [10600]",Multiplan,,4117.23,85,,,,,0,563.33,4117.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT CONSTRAIN LEGION OXINIUM",SUP-71421163,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23769.77,41.1,,6417.48,6417.48,6417.48,"1 through 10",6726.09,49158.9,"percent of total billed charges",
"LENS IOL +23 DIOPTER +2.25 CYL MODIFY C BICONVEX 13MM 6MM",SUP-DIU225U230,CDM,V2787,HCPCS,0276,RC,,,both,,,445.00,133.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,127.36,28.62,,,,,0,51.75,378.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC",272,MS-DRG,,,,,,,inpatient,,,121931.81,36579.54,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,16786.59,,"Case rate ($15,836.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,705.18, add-ons for qualifying new technology services are included. If operating cost exceeds $47,744.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,493.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $14,724.63. The transfer operating threshold is the transfer adjustment factor * $14,705.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,111.78. The transfer capital threshold is the transfer adjustment factor * $1,111.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 106%.",,,,0,7561,74537.39,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL CANCELLOUS 5D ALLOGRAFT 12MM",SUP-3W5012,CDM,S27800098,LOCAL,0278,RC,,,both,,,6216.90,1865.07,"BLUE CROSS [10001]","Blue Cross HMO",,2437.02,39.2,,,,,0,723.03,5284.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 4 X 8 COMPLEX PICO COIL",SUP-10USC04008,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3742.21,28.62,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATHETER THE RINGER PERFUSION 20MM OD 3.5MM PERFUSION",SUP-5886,CDM,C1725,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC",216,MS-DRG,,,,,,,inpatient,,,491349.83,147404.95,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,130469.12,,"Case rate ($60,683.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $56,348.56, add-ons for qualifying new technology services are included. If operating cost exceeds $89,388.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $5,642.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $56,423.08. The transfer operating threshold is the transfer adjustment factor * $56,348.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,260.23. The transfer capital threshold is the transfer adjustment factor * $4,260.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 215%.",,,,0,60683.31,285618.63,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 38MM 144CM 2.5MM CORONARY STENT",SUP-H7493941838250,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MONOKA 3MM MEDIUM LACRIMAL DUCT PEEK-OPTIMA SILICONE",SUP-S1-1810U,CDM,S27200284,LOCAL,0272,RC,,,both,,,931.50,279.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,108.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW COUNTERSINK 2.0MM",SUP-P20-910-2000,CDM,C1713,HCPCS,0278,RC,,,both,,,1004.40,301.32,"PHCS [10601]",PHCS,,703.08,70,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PG PRO 2.8FR/165CM/STRAIGHT",SUP-PGP28165STR,CDM,C1887,HCPCS,0272,RC,,,both,,,4022.70,1206.81,"FIRST HEALTH [10303]","First Health",,3218.16,80,,,,,0,467.84,3419.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 32CM FEMUR RIGHT PROXIMAL TALON DISTALFIX",SUP-SLN-125-32R,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1910.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1875.37,13706.51,"percent of total billed charges",
"CMPNT PATELLAR OVAL 35MM RESURFACE GENESIS II KNEE",SUP-71421035,CDM,C1776,HCPCS,0278,RC,,,both,,,7162.20,2148.66,"BLUE CROSS [10001]","Blue Cross PPO",,2807.58,39.2,,3949.44,3949.44,3949.44,"1 through 10",832.96,6087.87,"percent of total billed charges",
"CATH BARDEX IC 18FR URETHRAL BACTI-GUARD RUBBER HYDROGEL 5CC",SUP-0168SI18,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.14,33.04,"FIRST HEALTH [10303]","First Health",,88.11,80,,,,,0,12.81,93.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENSITE PRECISION NAVX SE PATCH",SUP-EN0020-P,CDM,S27000186,LOCAL,0270,RC,,,both,,,6900.00,2070,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3167.1,45.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT OSSEOPERM MENDEC PMMA INJECTOR MIX CNTNR",SUP-OP-0001,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,434.96,3179,"percent of total billed charges",
"LEAD QUAD ATTAIN STABILITY - 88 CM",SUP-4798-88CM,CDM,C1900,HCPCS,0278,RC,,,both,,,11626.50,3487.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1377.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1352.16,9882.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 13SQ CM THERASKIN ALLOGRAFT CRYOPRESERVE",SUP-101TSS,CDM,Q4121,HCPCS,0636,RC,,,both,,,7824.60,2347.38,"MULTIPLAN [10600]",Multiplan,,6650.91,85,,,,,0,141.84,6650.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183562,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"MULTIPLAN [10600]",Multiplan,,11009.78,85,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM 37.6MM 30MM MITRAL TRICUSPID FLEXIBLE",SUP-460030MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"UHC [10700]","United Healthcare",,7206.71,63.3,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM PRESS FIT BASIC SUMMIT 4 12/14 TAPER HIP",SUP-157005100,CDM,C1776,HCPCS,0278,RC,,,both,,,9090.75,2727.22,"MULTIPLAN [10600]",Multiplan,,7727.14,85,,,,,0,1057.25,7727.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM 21.4MM REGENT PYROLYTIC CARBON PTFE",SUP-23AGN-751,CDM,S27800098,LOCAL,0278,RC,,,both,,,31229.42,9368.83,"FIRST HEALTH [10303]","First Health",,24983.54,80,,,,,0,3631.98,26545.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 29MM 47.5MM TENDYNE 2.2SQ CM 29L REPOSITIONABLE","SUP-TENDYNE 29L SYSTEM",CDM,S27800098,LOCAL,0278,RC,,,both,,,319200.00,95760,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37825.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37122.96,271320,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 10FR 63CM HEMOSTASIS SWARTZ SL1 CURVE",SUP-406969,CDM,C1893,HCPCS,0272,RC,,,both,,,1920.00,576,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRAPE WOUND 30.5X26CM VAC ADHSV STERILE DISPOSABLE",SUP-M6275009/10.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.81,15.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MFLD INJECTION ACIST CVI SALINE CONTRAST PORT SPIKE TUBE",SUP-014613,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.25,71.77,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SYNTHETIC ETHIBOND EXCEL 2-0 V-7 36IN 2 ARM BRAID FIRM",SUP-PXX79N,CDM,S27200284,LOCAL,0272,RC,,,both,,,745.06,223.52,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BALLOON DILATATION .035IN 5FR 5MM 80CM 4CM PERIPHERAL 2",SUP-4155040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RESPIRATORY FAILURE,MODERATE",133,APR-DRG,,,,,,,inpatient,,,35701.66,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $6,551.80. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($42,205.76) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 1MM ELITE ROUND FLUTE 5 STEP NOTCH STERILE",SUP-5820-010-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACEMKR CARDIAC .75CM 4.45X5.88CM ESSENTIO PACESAFE",SUP-L131,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,17097.6,41.1,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 75MM KNEE LEFT CRUCIATE RETAIN CEMENT PRIMARY",SUP-183034,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"AETNA [10100]","Aetna HMO/PPO",,15968.1,79.5,,10981.53,8986.79,12413.38,12,2335.96,17072.81,"percent of total billed charges",
"CORTICAL SCREW 4MM X 42MM",SUP-HTN-U-4-42,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"CIGNA [10200]","Cigna Open Access",,884.91,56.9,,1144.80,304.56,2275.09,66,180.87,1321.92,"percent of total billed charges",
"SHEET TRANSFER 77X60IN MAXISLIDE FLITES PREMIUM LATEX FREE",SUP-NPAV5000,CDM,S27000186,LOCAL,0270,RC,,,both,,,203.06,60.92,"CIGNA [10200]","Cigna Open Access",,115.54,56.9,,,,,0,23.62,172.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 6 74MM 10.8MM SHILEY UNCUFF REUSABLE INNER CANN",SUP-6UN75R,CDM,S27200284,LOCAL,0272,RC,,,both,,,484.06,145.22,"PHCS [10601]",PHCS,,338.84,70,,,,,0,56.3,411.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER SUT 10.1IN HEWSON DRILL GUIDE ACCESS LIGAMENT",SUP-71111579,CDM,S27200284,LOCAL,0272,RC,,,both,,,797.53,239.26,"CIGNA [10200]","Cigna Open Access",,453.79,56.9,,,,,0,92.75,677.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT GLENOID STD SHORT STEM INSRT REGENEREX",SUP-98B00900111,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"FIRST HEALTH [10303]","First Health",,23940,80,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT CEMENTED POSTERIOR STABILIZE SIGMA",SUP-196040500,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1185,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1163,8500,"percent of total billed charges",
"BURR SHAVER 13CM 5.5MM COOLCUT FLUSHCUT 6 FLUTE OVAL STERILE",SUP-AR-8550FOS,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 14 X 12 X 08MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-141208-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"KAISER [10500]",Kaiser,,4160.7,67,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 3MM BALLOON",SUP-U357538,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 36IN 8FR ANTICLOG RADIOPAQUE BOW TIP BOLUS",SUP-40-9368,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.39,27.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,62.83,68,,,,,0,10.74,78.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 16MM 144CM 4MM CORONARY STENT",SUP-H7493911416400,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"MULTIPLAN [10600]",Multiplan,,7771.13,85,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 6-9 C-D KNEE RIGHT VIVACIT-E",SUP-42522400510,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3084.21,28.62,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 18 9 X 30 COMPLEX FRAMING COIL",SUP-18CFR-09030,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"PHCS [10601]",PHCS,,9152.85,70,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 6MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBH061502,CDM,C1874,HCPCS,0278,RC,,,both,,,23102.10,6930.63,"NOVANET [10819]",Novanet,,17326.58,75,,,,,0,2686.77,19636.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTIGRAFT CERVICAL LARGE PARALLEL 14X14.5X7MM",SUP-VG2C-DR7P,CDM,S27800098,LOCAL,0278,RC,,,both,,,6077.73,1823.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,706.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,706.84,5166.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER CURVED TIP RELOAD 45MM PURPLE",SUP-AESC45P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"UHC [10700]","United Healthcare",,897.28,63.3,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 167MM 18MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-118,CDM,C1776,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7200.84,41.1,,6417.48,6417.48,6417.48,"1 through 10",2037.61,14892.26,"percent of total billed charges",
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 355CC",SUP-RSZ-SHPX-355S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,76.24,45.9,,,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SPECIMEN RETRIEVAL 120CM 3FR HOOK PRONG GRASP RETRACT",SUP-M0063701150,CDM,S27200284,LOCAL,0272,RC,,,both,,,1376.11,412.83,"PHCS [10601]",PHCS,,963.28,70,,,,,0,160.04,1169.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION .25IN .25IN BARD SILICONE 4 FREE FLOW CHANNEL",SUP-072231,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.37,37.61,"KAISER [10500]",Kaiser,,84,67,,,,,0,14.58,106.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 14X12CM BREAST 500ML STYLE 133SV TEXTURED SUT TAB",SUP-133SX-14-T,CDM,C1789,HCPCS,0278,RC,,,both,,,6510.00,1953,"AMERIGROUP MEDICAID [20100]",Amerigroup,,771.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,757.11,5533.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRALOCK LAPILOCK KIT",SUP-IL-LL-7000,CDM,C1713,HCPCS,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross HMO",,11113.2,39.2,,957.42,156.86,7483.26,51,3297.11,24097.5,"percent of total billed charges",
"INSRT ARTICULAR 5-6 C-H STD 74X46X17MM KNEE PROLONG NEXGEN",SUP-90595204017,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"CIGNA [10200]",Cigna,,5331.05,68,,5873.17,5873.17,5873.17,"1 through 10",911.77,6663.81,"percent of total billed charges",
"NDL PROC 10CM 18GA TROCAR",SUP-G01458,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.46,43.04,"MULTIPLAN [10600]",Multiplan,,121.94,85,,,,,0,16.68,121.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 12MM 144CM 2.25MM CORONARY STENT",SUP-H7493952812220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AETNA [10100]","Aetna HMO/PPO",,4424.18,79.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 93MM STAINLESS STEEL 3.5MM SCR 4 HOLE LIMIT",SUP-239.954S,CDM,C1713,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"BLUE CROSS [10001]","Blue Cross HMO",,3408.05,39.2,,957.42,156.86,7483.26,51,1011.11,7389.9,"percent of total billed charges",
"3.3/4F DUO-DECA 2-8-2 S 120CM",SUP-903256,CDM,C1731,HCPCS,0272,RC,,,both,,,8970.00,2691,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1062.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM SWIVELOCK C CLOSE EYELET TAPE LOOP VENT",SUP-AR-2324BCCT,CDM,C1713,HCPCS,0278,RC,,,both,,,3701.25,1110.37,"MULTIPLAN [10600]",Multiplan,,3146.06,85,,,,,0,430.46,3146.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +7.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.075,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 8MM LCP STAINLESS STEEL SMALL BONE SELF",SUP-202.208,CDM,C1713,HCPCS,0278,RC,,,both,,,748.44,224.53,"CIGNA [10200]","Cigna Local Plus",,400.42,53.5,,3978.14,359.25,3978.14,24,87.04,636.17,"percent of total billed charges",
"BOOT WALKING J WALKER MEDIUM LEG FOREFOOT ANKLE ALUMINUM",SUP-BL210005,CDM,S27000186,LOCAL,0270,RC,,,both,,,243.34,73,"CIGNA [10200]",Cigna,,165.47,68,,,,,0,28.3,206.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 10-12 G-H KNEE LEFT VIVACIT-E",SUP-42512401012,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4429.11,41.1,,6417.48,6417.48,6417.48,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"INSRT TIBIAL 5 15MM KNEE GVF STABILIZE ROTATE PLATFORM PFC",SUP-962153,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"PHCS [10601]",PHCS,,7143.57,70,,,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RENAL FAILURE WITHOUT CC/MCC",684,MS-DRG,,,,,,,inpatient,,,23649.13,7094.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11916.56,,"Fee schedule rate ($11,916.56). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,3723.71,14970.88,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE EVANS CANCELLOUS CORTICAL WEDGE ALLOGRAFT FREEZE",SUP-403108,CDM,S27800098,LOCAL,0278,RC,,,both,,,7331.11,2199.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,868.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,852.61,6231.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 9MM COCR",SUP-VAL-20090-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]",Cigna,,969.41,68,,1831.33,1831.33,1831.33,16,165.8,1211.76,"percent of total billed charges",
"INTRO SHEATH 26FR 20CM 13CM DIL PEEL-AWAY LARGE PERCUTANEOUS",SUP-G06447,CDM,C1892,HCPCS,0272,RC,,,both,,,382.71,114.81,"PHCS [10601]",PHCS,,267.9,70,,,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL DIA10MM HOLLOW FOR MULTILOC HUMERAL NAILING SYSTEM",SUP-03.019.003,CDM,S27200284,LOCAL,0272,RC,,,both,,,2158.80,647.64,"PHCS [10601]",PHCS,,1511.16,70,,,,,0,251.07,1834.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB PEDIATRIC MULTIFUNCTION PAD PEDI-PADZ",SUP-8900-2065,CDM,S27000186,LOCAL,0270,RC,,,both,,,328.58,98.57,"AETNA [10100]","Aetna HMO/PPO",,261.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.21,279.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60X3.5MM TITANIUM ENDOSCOPIC LINEAR CUTTER",SUP-TA6035S,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.55,176.56,"NOVANET [10819]",Novanet,,441.41,75,,,,,0,68.45,500.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 40MM 100CM 12MM 75CM",SUP-H965402110,CDM,C1876,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINERAL OIL ORAL",RX-5086,CDM,,,0250,RC,48433-0202-30,NDC,both,30,ML,15.10,4.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.76,12.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH 8IN 4.5MM CLEANCUT PERFECTCUT BULLET TIP ROTATE CUT",SUP-RCL45,CDM,S27200284,LOCAL,0272,RC,,,both,,,238.82,71.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,109.62,45.9,,,,,0,27.77,203,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ENDOSCOPIC MICRO SICKLE",SUP-28164MS-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1500.85,450.25,"CIGNA [10200]",Cigna,,1020.58,68,,,,,0,174.55,1275.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER RELOAD 30MM WHITE",SUP-AESR30W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"UHC [10700]","United Healthcare",,846,63.3,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 12MM 140CM .91-1.12MM 3.5MM CORONARY",SUP-RONYX35012W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"KAISER [10500]",Kaiser,,3644.13,67,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 1.6MM TPS ELITE 5 STEP NOTCH CROSS CUT FISSURE",SUP-5820-066-016,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,129.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 1 STD SHORT 54IN MONOFILAMENT TIES YELLOWISH TAN",SUP-S115H,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.04,26.71,"FIRST HEALTH [10303]","First Health",,71.23,80,,,,,0,10.36,75.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET",RX-31864,CDM,,,0250,RC,00406-0523-23,NDC,both,1,UN,31.21,9.36,"NOVANET [10819]",Novanet,,23.41,75,,,,,0,3.63,26.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 14 HIGH OFFSET HIP",SUP-71935586,CDM,C1776,HCPCS,0278,RC,,,both,,,36760.50,11028.15,"MULTIPLAN [10600]",Multiplan,,31246.43,85,,,,,0,4275.25,31246.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,inpatient,,,162263.37,48679.01,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,18529.81,,"Case rate ($17,990.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $16,705.04, add-ons for qualifying new technology services are included. If operating cost exceeds $49,744.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,644.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $16,727.13. The transfer operating threshold is the transfer adjustment factor * $16,705.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,262.98. The transfer capital threshold is the transfer adjustment factor * $1,262.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,84674.24,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Stool Culture",PX-300000402,CDM,300000402,LOCAL,0300,RC,,,both,,,173.25,51.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,117.81,68,,,,,0,20.53,147.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 130MM 4.2MM T2 AO COUPLING CENTER TIPPED",SUP-18064280S,CDM,S27000186,LOCAL,0270,RC,,,both,,,147.00,44.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,67.47,45.9,,,,,0,17.1,124.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BNDG 10YDX4IN CALAMINE ZINC OXIDE PLASTIC LIGHT COMPRESSION",SUP-NONUNNA4,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.98,15.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,36.03,68,,,,,0,6.16,45.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 5CM 5FR STRAIGHT PANCREATIC",SUP-M00537520,CDM,C2625,HCPCS,0278,RC,,,both,,,1411.18,423.35,"CIGNA [10200]",Cigna,,959.6,68,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCK AUGMENTATION ASCENT MAXIM 83MMX16MM KNEE TIBIA RIGHT",SUP-141796,CDM,C1776,HCPCS,0278,RC,,,both,,,9255.66,2776.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3804.08,41.1,,6417.48,6417.48,6417.48,"1 through 10",1076.43,7867.31,"percent of total billed charges",
"SIZER IMPL 11.25CM NATRELLE INSPIRA P4.5CM FULL PROFILE",SUP-SSZ-F295,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CIGNA [10200]","Cigna Local Plus",,797.36,53.5,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 3-0 RB-1 SPIRAL 16CM SUT",SUP-SXMP2B402,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.02,66.91,"PHCS [10601]",PHCS,,156.11,70,,,,,0,25.94,189.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (0-0.5 MCI)",RX-184865,CDM,A9520,HCPCS,0343,RC,08888-8878-35,NDC,both,1,UN,4614.97,1384.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2307.49,50,,,,,0,536.72,3922.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 150CM 120MM 7MM BALLOON DILATATION PACLITAXEL",SUP-H74939419701210,CDM,C2623,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1083.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO MICRO STRAIGHT BRAID MATRS STITCH SUT",SUP-AR-8703,CDM,S27200284,LOCAL,0272,RC,,,both,,,1190.70,357.21,"UHC [10700]","United Healthcare",,753.71,63.3,,,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 100MM 17GA 19GA TUOHY SOFT CLOSED TIP CATH DRY",SUP-TAL901,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.40,83.52,"AETNA [10100]","Aetna HMO/PPO",,221.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablt Perc Liver Tmr Rf",PX-361000179,CDM,47382,CPT,0361,RC,,,both,,,7662.58,2298.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,908.02,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,891.16,7662.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 4MM RELINE-C PRE BENT TITANIUM NONSTERILE",SUP-3944040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachythrpy Grid",PX-E27200042,CDM,E27200042,LOCAL,0272,RC,,,both,,,363.00,108.9,"FIRST HEALTH [10303]","First Health",,290.4,80,,,,,0,42.22,308.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAA - AMPLATZ CARDIAC PLUG 2-IDE-034",SUP-9-ACP2-IDE-034,CDM,S62400003,LOCAL,0624,RC,,,both,,,63452.40,19035.72,"CIGNA [10200]","Cigna Open Access",,36104.42,56.9,,,,,0,7379.51,53934.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 5 EXTEND LENGTH 90MM 9.6MM SHILEY XLT UNCUFF SOFT",SUP-50XLTUD,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"MULTIPLAN [10600]",Multiplan,,412.48,85,,,,,0,56.44,412.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE",RX-177637,CDM,J1171,HCPCS,0636,RC,76045-0009-05,NDC,both,.5,ML,44.00,13.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1.85,,,,,,,0.58,37.4,"fee schedule",
"SPLINT ORTHOPEDIC SMALL 8IN THUMB LEFT WRIST D RING CLSR",SUP-A125105,CDM,S27000186,LOCAL,0270,RC,,,both,,,115.80,34.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.47,98.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM LOCK STERILE",SUP-2361-5040S,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.05,506.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,482.83,28.62,,,,,0,196.2,1433.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 650ML GEL SMOOTH MEMORYGEL SILICONE P5.7CM HIGH","SUP-3506504 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross PPO",,1481.76,39.2,,16595.83,16595.83,16595.83,"1 through 10",439.61,3213,"percent of total billed charges",
"STENT ZILVER 518 20MM 125CM 9MM 5FR .018IN VASCULAR NITINOL",SUP-G43784,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1918.16,45.9,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 PS-2 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8687H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILFRM URETHRAL 13IN 5FR STRAIGHT PLASTIC STERILE LATEX FREE",SUP-342105,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.96,28.19,"CIGNA [10200]",Cigna,,63.89,68,,,,,0,10.93,79.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 8.7IN SILVERGLIDE PRECISION 1.5MM",SUP-6720220015,CDM,S27200284,LOCAL,0272,RC,,,both,,,7079.81,2123.94,"FIRST HEALTH [10303]","First Health",,5663.85,80,,,,,0,823.38,6017.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 54MM 47MM HIP 2 MOBILITY",SUP-121854047,CDM,C1776,HCPCS,0278,RC,,,both,,,15870.00,4761,"BLUE CROSS [10001]","Blue Cross HMO",,6221.04,39.2,,5311.50,4717.44,5388.59,31,1845.68,13489.5,"percent of total billed charges",
"DIL VASCULAR 7FR 20CM AQ DECREASE FRICTION RADIOPAQUE",SUP-G10208,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"CIGNA [10200]",Cigna,,45.49,68,,,,,0,7.78,56.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 48MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.448TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"PHCS [10601]",PHCS,,1415.09,70,,,,,0,235.11,1718.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER SOLTIVE 940UM THULIUM DISPOSABLE",SUP-TFL-FBX940S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4497.56,1349.27,"UHC [10700]","United Healthcare",,2846.96,63.3,,,,,0,523.07,3822.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER ENDOSCOPIC 25MM 6MM TREVO XP PROVUE STERILE LATEX",SUP-90186,CDM,S27200284,LOCAL,0272,RC,,,both,,,47273.94,14182.18,"AETNA [10100]","Aetna HMO/PPO",,37582.78,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5497.96,40182.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SPINAL 20MM THK1.9MM ANTERIOR CERVICAL 1 LEVEL",SUP-18009120,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM TITANIUM CORTICAL NONSTERILE AXSOS 3",SUP-661420,CDM,C1713,HCPCS,0278,RC,,,both,,,289.54,86.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,33.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",33.67,246.11,"percent of total billed charges",
"HEAD FEMORAL +0MM 11/13 TAPER 44MM HIP M SPECIFICATION METAL",SUP-136562500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"CIGNA [10200]","Cigna Local Plus",,5926.7,53.5,,5372.07,4581.20,7242.98,23,1288.37,9416.26,"percent of total billed charges",
"SCR GUIDE GOLD 33MM M/G KNEE STAINLESS STEEL HEAD",SUP-00579104400,CDM,C1713,HCPCS,0278,RC,,,both,,,34083.00,10224.9,"NOVANET [10819]",Novanet,,25562.25,75,,,,,0,3963.85,28970.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PROGRESS 80 VASCULAR STRAIGHT 300CM 3CM .014",SUP-1011839,CDM,C1769,HCPCS,0272,RC,,,both,,,1036.80,311.04,"NOVANET [10819]",Novanet,,777.6,75,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 35MM 4.75MM CD HORIZON SOLERA COCRMO CAP",SUP-641003035,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 31X9X11MM TLX 20D STERILE LATEX FREE",SUP-5902931P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE SURGISIS BIODESIGN .2MM RECTOVAGINAL",SUP-G48651,CDM,C1763,HCPCS,0278,RC,,,both,,,6994.19,2098.26,"FIRST HEALTH [10303]","First Health",,5595.35,80,,,,,0,813.42,5945.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 22CM 150CM 5FR .038IN 3CM BLADDER LOOP",SUP-M006155221170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CIGNA [10200]","Cigna Open Access",,808.17,,,,,,,165.19,1207.29,"percent of total billed charges",
"BLADE SAW 27X.38MM TPS SHORT LONG MICRO THIN RECIPROCATING",SUP-5100337233,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.38,176.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH POWERFLEX P3 110CM 10CM 5FR 6MM 7.5MM BALLOON",SUP-4206000L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC",099,MS-DRG,,,,,,,inpatient,,,46755.41,14026.62,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ACUTRAK ORTHOPEDIC 6IN .054IN STAINLESS STEEL 1 TROCAR",SUP-WS-1406ST,CDM,C1769,HCPCS,0272,RC,,,both,,,287.10,86.13,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE JEJUNOSTOMY 45CM 18FR SILICONE MIC SECUR-LOK UNIVERSAL",SUP-0250-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE AMPLATZ SUPER STIFF VASCULAR 3MM J 260CM 7CM .035IN",SUP-46-502,CDM,C1769,HCPCS,0272,RC,,,both,,,494.10,148.23,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHTH 7FR HMSTS CLS LNG",SUP-6273,CDM,C1894,HCPCS,0272,RC,,,both,,,139.20,41.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,94.66,68,,,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 5.5MM TWINFIX ULTRA TITANIUM STERILE COBRAID",SUP-72202897,CDM,C1713,HCPCS,0278,RC,,,both,,,2155.13,646.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,250.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",250.64,1831.86,"percent of total billed charges",
"SCR BONE 6.5MM 30MM REFLECTION FULL THREAD HIP ACETABULAR",SUP-71336530,CDM,C1713,HCPCS,0278,RC,,,both,,,1341.36,402.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,912.12,68,,,,,0,156,1140.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 15MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25015W,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nephleometry",PX-301000322,CDM,83883,CPT,0301,RC,,,both,,,414.00,124.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.55,,"Fee schedule rate ($14.55). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,351.9,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRT ACCESSORY SUTRURESLEEVE KIT-USFGI",SUP-DSA0006,CDM,S27200284,LOCAL,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP UNISTEP PLUS 68MM 135CM 10MM 160CM",SUP-M001711370,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"KAISER [10500]",Kaiser,,5663.18,67,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Ureter Stnt Perc Si",PX-361000211,CDM,50382,CPT,0361,RC,,,both,,,8063.12,2418.94,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,937.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,937.74,6853.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK ULTRA 18MM 5MM CORONARY STENT XCELON",SUP-1003382-18,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 H 36MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30103608,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4705.68,45.9,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRACTOR ALEXIS 360D X-SMALL ORTHO WOUND PROTECTOR ULTIMATE",SUP-HR000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.205,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP OPHTHALMIC 23GA GRIESHABER REVOLUTION RETINAL INTERNAL",SUP-706.44,CDM,S27200284,LOCAL,0272,RC,,,both,,,984.07,295.22,"CIGNA [10200]",Cigna,,669.17,68,,,,,0,114.45,836.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vasopressin (Adh)",PX-301000437,CDM,84588,CPT,0301,RC,,,both,,,324.00,97.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,23,,,,,,,0.01,275.4,"fee schedule",
"FORTIFY ASSURA NEXT GENERATION DR 40",SUP-CD2357-40C,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4806.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP LIGATION RESOLUTION 360 ULTRA 235CM BRAID ROTATION",SUP-M00521401,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1096.09,68,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"11.0 DIOPTER, TECNIS EYHANCE 1-PIECE IOL W/ SIMPLICITY DELIV",SUP-DIB00U0110,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,523.91,39.2,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM HEALIX ADVANCE CORD PEEK-OPTIMA",SUP-222303,CDM,C1713,HCPCS,0278,RC,,,both,,,2977.50,893.25,"BLUE CROSS [10001]","Blue Cross HMO",,1167.18,39.2,,957.42,156.86,7483.26,51,346.28,2530.88,"percent of total billed charges",
"KIT INSTR DISPOSABLE 3.9MM KNOTLESS CORKSCREW",SUP-AR-1941DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,2323.13,696.94,"FIRST HEALTH [10303]","First Health",,1858.5,80,,,,,0,270.18,1974.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE LEFT POSTERIOR STABILIZE BEAD TRIATHLON",SUP-5516F801,CDM,C1776,HCPCS,0278,RC,,,both,,,23001.30,6900.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9200.52,40,,,,,0,2675.05,19551.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR 260CM 8CM .018IN GLIDEX",SUP-M001466020,CDM,C1769,HCPCS,0272,RC,,,both,,,1539.00,461.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,182.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 5.5MM VIPER 2 PREBENT TITANIUM NONSTERILE",SUP-186788045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"MESH HERNIA POLYGLYCOLIC ACID 20X20IN RESORBABLE REINFORCE",SUP-F10254-2020G,CDM,C1781,HCPCS,0278,RC,,,both,,,20664.00,6199.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2448.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2403.22,17564.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD 5MM BIPOLAR IS-1",SUP-6162,CDM,C1883,HCPCS,0278,RC,,,both,,,2625.00,787.5,"PHCS [10601]",PHCS,,1837.5,70,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esoph Flex Trnsoral Muc Rsct",PX-750000123,CDM,43211,CPT,0750,RC,,,both,,,4531.00,1359.3,"AETNA [10100]","Aetna HMO/PPO",,3602.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,526.96,4531,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE ENFORM 8X16CM INTRAPERITONEAL BIOMATERIAL",SUP-GBFR0816,CDM,C1781,HCPCS,0278,RC,,,both,,,15952.80,4785.84,"AETNA [10100]","Aetna HMO/PPO",,12682.48,79.5,,,,,0,1855.31,13559.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 1CM 14FR RADIOPAQUE LOW PROFILE TAPER DISTAL TIP",SUP-0120-14-1.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"PHCS [10601]",PHCS,,545.34,70,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 57MM 80CM 7MM 60MM BILIARY STAINLESS STEEL",SUP-PXB35-07-57-080,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"AETNA [10100]","Aetna HMO/PPO",,3471.77,79.5,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR EXTRA BACKUP 4.5",SUP-67005800,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"PHCS [10601]",PHCS,,292.32,70,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VEST COMPRESSION 2IN LARGE FABRIC 2 REINFORCED FRONT PANEL",SUP-2-8003BG-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,437.40,131.22,"PHCS [10601]",PHCS,,306.18,70,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 55IN 8FR RADIOPAQUE STRIPE WEIGHT TIP RIGID",SUP-8884720855E,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.09,21.03,"FIRST HEALTH [10303]","First Health",,56.07,80,,,,,0,8.15,59.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PHACOEMULSIFICATION .9MM INTREPID MICROSMOOTH ULTRA",SUP-8065750517,CDM,S27200284,LOCAL,0272,RC,,,both,,,266.57,79.97,"AETNA [10100]","Aetna HMO/PPO",,211.92,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31,226.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 37MM LOCK STERILE",SUP-2361-5037S,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.05,506.11,"KAISER [10500]",Kaiser,,1130.32,67,,,,,0,196.2,1433.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 145MM STAINLESS STEEL 3.5MM SCREWS 8 HOLE LCP BONE",SUP-239.959,CDM,C1713,HCPCS,0278,RC,,,both,,,9810.83,2943.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2807.86,28.62,,,,,0,1141,8339.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ENVEO R DELIVERY SYSTEM INFLOW OUTFLOW CONE BACKPLATE",SUP-ENVEOR-US,CDM,S27200284,LOCAL,0272,RC,,,both,,,14559.00,4367.7,"PHCS [10601]",PHCS,,10191.3,70,,,,,0,1693.21,12375.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 8MM GORE PROPATEN EPTFE HEPARIN STRETCH",SUP-HT087080A,CDM,C1768,HCPCS,0278,RC,,,both,,,18559.80,5567.94,"BLUE CROSS [10001]","Blue Cross PPO",,7275.44,39.2,,,,,0,2158.5,15775.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BUTTON 8MM 6CM PASSPORT BUTTON SILICONE CURVE HIP 1",SUP-AR-6592-08-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"PHCS [10601]",PHCS,,204.62,70,,,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOUND 34FR URETHRAL CURVE VAN BUREN 10.75IN",SUP-51-6334,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.11,39.33,"PHCS [10601]",PHCS,,91.78,70,,,,,0,15.25,111.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 80CM 1MM 5FR 5-1-5MM SPACE P2 CURVE",SUP-D510P2R5155RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"AETNA [10100]","Aetna HMO/PPO",,2963.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"I-GEL, SINGLE USE SUPRAGLOTTIC AIRWAY, SIZE 1",SUP-8201000,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.13,23.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.2,67.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lyme Western Blot",PX-302000101,CDM,86617,CPT,0302,RC,,,both,,,486.40,145.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,55.01,,,,,,,0.01,413.44,"fee schedule",
"BRACE ORTHOPEDIC SMALL 8IN WRIST RIGHT REMOVABLE PALMAR STAY",SUP-92722001,CDM,L3908,HCPCS,0274,RC,,,both,,,148.86,44.66,"BLUE CROSS [10001]","Blue Cross PPO",,58.35,39.2,,,,,0,17.31,126.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 12D ALLOGRAFT 10MM ALIF",SUP-3W4210,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"FIRST HEALTH [10303]","First Health",,16916.26,80,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 47CM 14MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181447,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"CIGNA [10200]","Cigna Open Access",,6230.2,33.5,,,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP070100150 PLUS US D7L100UL1500",SUP-PCP070100150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"NOVANET [10819]",Novanet,,923.4,75,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 100CM 4FR 5MM SPACING F CURVE ELECTROPHYSIOLOGY FIXED",SUP-112436RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"FIRST HEALTH [10303]","First Health",,1854,80,,,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TYSHAK II 100CM 5CM 9FR 25MM .035IN BALLOON DILATATION",SUP-611945,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"PHCS [10601]",PHCS,,2660.85,70,,,,,0,442.08,3231.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 60MM 13.5MM 10FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEL14060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"MULTIPLAN [10600]",Multiplan,,15529.5,85,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE CRESCENT 165CM 2MM 25MM SNAREMASTER 2 WIRE ENDOSCOPIC",SUP-SD-221L-25,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.82,51.85,"UHC [10700]","United Healthcare",,109.4,63.3,,,,,0,20.1,146.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SIGMA HP UNI",SUP-OSC2754,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"CIGNA [10200]","Cigna Local Plus",,5556.6,31.5,,5372.07,4581.20,7242.98,23,2051.53,14994,"percent of total billed charges",
"FILLER BONE VOID 90CC 1.7-10MM CANCELLOUS ALLOGRAFT FREEZE",SUP-400160,CDM,C1713,HCPCS,0278,RC,,,both,,,7182.90,2154.87,"NOVANET [10819]",Novanet,,5387.18,75,,,,,0,835.37,6105.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SHEATH 60CM 5FR MICROPUNCTURE STAINLESS STEEL",SUP-G07324,CDM,C1894,HCPCS,0272,RC,,,both,,,251.26,75.38,"UHC [10700]","United Healthcare",,159.05,63.3,,,,,0,29.22,213.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPELLA RP PUMP SET",SUP-004334,CDM,S27800098,LOCAL,0278,RC,,,both,,,142500.00,42750,"PHCS [10601]",PHCS,,99750,70,,,,,0,16572.75,121125,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHASIX UMBILICAL MEDIUM CIRCLE W/ STRAP (6.4CM)",SUP-1230008,CDM,C1781,HCPCS,0278,RC,,,both,,,10701.90,3210.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4912.17,45.9,,,,,0,1244.63,9096.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM PFC SIGMA 2 KNEE LEFT TITANIUM STERILE LATEX",SUP-96-0822,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"KAISER [10500]",Kaiser,,3437.66,67,,,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ENDOSCP SEALING .7MM HOLE TRANSPARENT RIGID URETEROSCOPE",SUP-WA00387A,CDM,S27000186,LOCAL,0270,RC,,,both,,,86.03,25.81,"CIGNA [10200]","Cigna Open Access",,48.95,56.9,,,,,0,10.01,73.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 60MM 6FR 9MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-09067,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 150CM 10CM 7MM BALLOON DILATATION ILIAC",SUP-G34342,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TROCAR LAPAROSCOPIC 55MM 5MM KII Z THREAD SLEEVE OPTICAL",SUP-CTR05,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADMIRAL XTREME 130CM 150MM 7MM BALLOON DILATATION",SUP-ADM070150130,CDM,C1725,HCPCS,0272,RC,,,both,,,1638.75,491.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSTR BIOPSY 10CM 18GA BARD MARQUEE CORE ENHANCE TROCAR TIP",SUP-MQ1810,CDM,S27200284,LOCAL,0272,RC,,,both,,,514.35,154.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 4.9FR CHLGM RX KT",SUP-7127,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 60MM 2.5MM BALLOON DILATATION DURALYN",SUP-48002506S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PUNCH ARTHROSCOPIC STD KNOTLESS DISPOSABLE CROSSFT 4.75/5.5",SUP-CFK-DBP4755,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT POLYSORB SURGIWIP 0 SK 48IN BRAID COATED VIOLET",SUP-ELW-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.04,51.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRACE ORTHOPEDIC SMALL 7.5IN 5.5-6.5IN THUMB WRIST RIGHT",SUP-79-87303,CDM,S27000186,LOCAL,0270,RC,,,both,,,132.15,39.64,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DXTERITY 100CM 5FR .047IN 3D RIGHT CURVE DIAGNOSTIC",SUP-DXT53DRC,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG HEEL 24X18.5CM 5 LAYER SELF ADHERENT ABSORBENT SHOWER",SUP-283250,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.78,22.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 90CM 300MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020300S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PATCH VASCULAR 16X10CM XENOSURE BOVINE PERICARDIUM STERILE",SUP-E10P16,CDM,C1768,HCPCS,0278,RC,,,both,,,6065.10,1819.53,"BLUE CROSS [10001]","Blue Cross HMO",,2377.52,39.2,,,,,0,705.37,5155.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 100MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520100S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"UHC [10700]","United Healthcare",,1010.08,63.3,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Fetal Doplr Velocimerty",PX-402000063,CDM,76821,CPT,0402,RC,,,both,,,349.26,104.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,41.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.62,349.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cannula Sharp Rf Needle",PX-E27200047,CDM,E27200047,LOCAL,0272,RC,,,both,,,226.60,67.98,"FIRST HEALTH [10303]","First Health",,181.28,80,,,,,0,26.35,192.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 30CM 6FR 2 PIGTAIL CURVE",SUP-M0061921350,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"BLUE CROSS [10001]","Blue Cross HMO",,445.16,39.2,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM SURGICAL TRITOME 3 EDGE RELEASE STERILE LATEX FREE",SUP-SN21,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"KAISER [10500]",Kaiser,,2487.38,67,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890006535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 14CM 12MM EXCLUDER GORE CONTRALATERAL LEG",SUP-PLC121400,CDM,C1874,HCPCS,0278,RC,,,both,,,27997.20,8399.16,"MULTIPLAN [10600]",Multiplan,,23797.62,85,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 FULL THREAD CORKSCREW FIBERWIRE SHOULDER",SUP-AR-1927PSF-3,CDM,C1713,HCPCS,0278,RC,,,both,,,2362.50,708.75,"BLUE CROSS [10001]","Blue Cross PPO",,926.1,39.2,,957.42,570.23,957.42,28,274.76,2008.13,"percent of total billed charges",
"SCR BONE 3.5MM 16MM GEMINUS TITANIUM CORTEX LOCK NONSTERILE",SUP-COLS-35160-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,631.80,189.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,73.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",73.48,537.03,"percent of total billed charges",
"LINER ACETABULAR PINNACLE 54MM 47MM HIP 2 MOBILITY",SUP-121854047,CDM,C1776,HCPCS,0278,RC,,,both,,,15870.00,4761,"BLUE CROSS [10001]","Blue Cross PPO",,6221.04,39.2,,3949.44,3949.44,3949.44,"1 through 10",1845.68,13489.5,"percent of total billed charges",
"HC Fva Non-Ophthalmic",PX-320000200,CDM,C9733,HCPCS,0320,RC,,,both,,,2593.80,778.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,307.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,301.66,2204.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STEERABLEBALLOON CA",SUP-ARC10SB-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,18270.00,5481,"PHCS [10601]",PHCS,,12789,70,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Pelvis Complete",PX-402000027,CDM,76856,CPT,0402,RC,,,both,,,1238.23,371.47,"NOVANET [10819]",Novanet,,928.67,75,,,,,0,114.92,1052.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.5MM X 6MM TI",SUP-VAN-15060-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,113.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",113.04,826.2,"percent of total billed charges",
"RELOAD STPLR 4.2MM ECHELON ENDOPATH VERY THICK TISSUE BLACK",SUP-GST60T,CDM,S27200284,LOCAL,0272,RC,,,both,,,3907.19,1172.16,"UHC [10700]","United Healthcare",,2473.25,63.3,,,,,0,454.41,3321.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP SECTOR POROCOAT PINNACLE STERILE",SUP-121722058,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"CIGNA [10200]","Cigna Local Plus",,3590.26,53.5,,5372.07,4581.20,7242.98,23,780.46,5704.15,"percent of total billed charges",
"SET OPHTHALMIC 155CM .051CM .081CM C-LINE .064CM ROUND",SUP-8590450,CDM,S27200284,LOCAL,0272,RC,,,both,,,797.04,239.11,"CIGNA [10200]",Cigna,,541.99,68,,,,,0,92.7,677.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 4CMX2CMX.2-.4MM DERMAMATRIX ACELLULAR DERMAL",SUP-19407,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 4.8FR L10CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902050,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HI-FLO RENEGADE FATHOM 180CM 150CM 2.8-3FR 20CM MICRO",SUP-M001184570,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"FIRST HEALTH [10303]","First Health",,3000,80,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETERAL 10FR 50CM .038IN .050IN DUAL LUMEN GWIRE",SUP-M0064051000,CDM,C1758,HCPCS,0272,RC,,,both,,,551.53,165.46,"NOVANET [10819]",Novanet,,413.65,75,,,,,0,64.14,468.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSUFLOW PORT 12MM",SUP-4100-12,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Hemodialysis",PX-E27200057,CDM,C1750,HCPCS,0272,RC,,,both,,,1500.40,450.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,616.66,41.1,,,,,0,174.5,1275.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 575ML GEL SMOOTH MEMORYGEL SILICONE P4.5CM","SUP-3505751 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,427.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT HUMD LOW FLOW AEROSOL NONSTERILE LATEX FREE",SUP-PF-ADPC-LOW,CDM,S27000186,LOCAL,0270,RC,,,both,,,1220.40,366.12,"KAISER [10500]",Kaiser,,817.67,67,,,,,0,141.93,1037.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIHEXYPHENIDYL 2 MG TABLET",RX-8166,CDM,,,0637,RC,70954-0212-10,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION",RX-22185,CDM,J1451,HCPCS,0636,RC,70710-1478-01,NDC,both,1.5,ML,9054.00,2716.2,"PHCS [10601]",PHCS,,6337.8,70,,,,,0,1254,7695.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION",RX-113697,CDM,,,0250,RC,00121-0431-30,NDC,both,30,ML,14.72,4.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.71,12.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 135CM 40MM 6MM BALLOON DILATATION PACLITAXEL OTW",SUP-H74939419600410,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"NOVANET [10819]",Novanet,,6468.75,75,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) WISE RECEIVER ELECTRODE","SUP-MODEL 1000",CDM,S62400003,LOCAL,0624,RC,,,both,,,47250.00,14175,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5495.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5495.18,40162.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE BREAST STYLE 410 690CC STERILE LATEX",SUP-MSZFX690,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,73.14,41.1,,,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 142MM 30MM 25-27MM 20FR ZENITH TX2",SUP-G47445,CDM,C1874,HCPCS,0278,RC,,,both,,,98041.65,29412.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,40295.12,41.1,,,,,0,11402.24,83335.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD SUT ASSISTANT 3-0 ES-9 48IN 1 STITCH ENDO STITCH",SUP-170071,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"MULTIPLAN [10600]",Multiplan,,122.54,85,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SOLYX ADVANTAGE 9CM URETHRAL SPRT POLYPROPYLENE",SUP-M0068507001,CDM,C1771,HCPCS,0278,RC,,,both,,,15346.98,4604.09,"MULTIPLAN [10600]",Multiplan,,13044.93,85,,,,,0,1784.85,13044.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 6 74MM 10.8MM SHILEY UNCUFF REUSABLE INNER CANN",SUP-6UN75R,CDM,S27200284,LOCAL,0272,RC,,,both,,,484.06,145.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,198.95,41.1,,,,,0,56.3,411.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 35.5X5MM TITANIUM VASCULAR 30 HELICAL",SUP-174006,CDM,S27200284,LOCAL,0272,RC,,,both,,,2153.48,646.04,"CIGNA [10200]","Cigna Local Plus",,1152.11,53.5,,,,,0,250.45,1883.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR ANGLE 260CM .018IN HYDROPHILIC FIX CORE",SUP-H2OSTDA18260EX,CDM,C1769,HCPCS,0272,RC,,,both,,,408.47,122.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,167.88,41.1,,,,,0,47.51,347.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 80MM 130CM 7MM VASCULAR METAL SUPERFICIAL",SUP-H74939293078030,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"FIRST HEALTH [10303]","First Health",,3864,80,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX 4-0 TH-18 36IN 2 ARM MONOFILAMENT UNDYED",SUP-4N02A,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.28,86.78,"NOVANET [10819]",Novanet,,216.96,75,,,,,0,33.64,245.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX14MM VERTE-STACK CAPSTONE PEEK-OPTIMA END",SUP-2961422,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"CIGNA [10200]","Cigna Local Plus",,5007.74,31.5,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL GOLD 110MM 2.5MM QUICK COUPLING STERILE",SUP-310.25S,CDM,S27200284,LOCAL,0272,RC,,,both,,,834.62,250.39,"MULTIPLAN [10600]",Multiplan,,709.43,85,,,,,0,97.07,709.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 300MM 10MM TFN-ADVANCED TAPER LARGE QUICK COUPLING",SUP-03.037.021,CDM,S27200284,LOCAL,0272,RC,,,both,,,2801.40,840.42,"AETNA [10100]","Aetna HMO/PPO",,2227.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,325.8,2381.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 38MM ORTHOLOC ANKLE 3DI TECHNOLOGY LOCKING",SUP-59215538,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,255.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",255.57,1867.88,"percent of total billed charges",
"INTRO SHEATH 8FR 2.5CM 25CM DIL MINI GWIRE KINK RESISTANT",SUP-RSS805,CDM,C1894,HCPCS,0272,RC,,,both,,,178.35,53.5,"FIRST HEALTH [10303]","First Health",,142.68,80,,,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 120MM 118CM 6MM 75CM VASCULAR NITINOL ILIAC",SUP-H74939200061270,CDM,C1876,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,501.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 13MM HELIX R SPINE SELF TAP FIX ANGLE",SUP-7806213,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Voriconazole",PX-301000626,CDM,80285,CPT,0301,RC,,,both,,,314.93,94.48,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,267.69,"per diem",
"ELECTRD DEFIB 42IN MEDI-TRACE CADENCE OVAL FOAM GEL",SUP-22550R,CDM,S27200284,LOCAL,0272,RC,,,both,,,153.53,46.06,"NOVANET [10819]",Novanet,,115.15,75,,,,,0,17.86,130.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OXYMETAZOLINE 0.05 % NASAL MIST",RX-117367,CDM,,,0250,RC,41100-0015-11,NDC,both,15,ML,48.59,14.58,"CIGNA [10200]",Cigna,,33.04,68,,,,,0,5.65,41.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FIXATION ATTACHABLE OPEN",SUP-AR-1588TN-1,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CGUARD PRIME CAROTID STENT SYSTEM 135CM 9MM LENGTH  30MM",SUP-CND0930,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"CIGNA [10200]",Cigna,,8303.4,40,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RECIP SAWBLADE 8X50X1MM",SUP-351-91-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 24CM 13MM AZUR CX DETACHABLE SOFT SOLID",SUP-45-751324,CDM,S27800098,LOCAL,0278,RC,,,both,,,7672.80,2301.84,"CIGNA [10200]","Cigna Local Plus",,4104.95,53.5,,,,,0,892.35,6521.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL MONOFILAMENT LIGHTWEIGHT ABSORBABLE LOW",SUP-5954680,CDM,C1781,HCPCS,0278,RC,,,both,,,2940.00,882,"AMERIGROUP MEDICAID [20100]",Amerigroup,,348.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION",RX-20472,CDM,,,0250,RC,72485-0508-01,NDC,both,10,ML,41.00,12.3,"MULTIPLAN [10600]",Multiplan,,34.85,85,,,,,0,4.77,34.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE MICROCENTRIFUGE 38MM 10MM NATURAL POLYPROPYLENE",SUP-22364111,CDM,S27200284,LOCAL,0272,RC,,,both,,,241.43,72.43,"UHC [10700]","United Healthcare",,152.83,63.3,,,,,0,28.08,205.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 5.5MM 6.35MM EXPEDIUM SPINE TITANIUM 2 OPEN TOP",SUP-179971555,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"KAISER [10500]",Kaiser,,2386.88,67,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 20MM LCP STAINLESS STEEL SHORT THREAD SMALL",SUP-207.620,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"NOVANET [10819]",Novanet,,780.03,75,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 3.2MM 12MM 7% NIOBIUM 6% ALUMINUM TITANIUM",SUP-04.601.112,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"CATH ATLAS 75CM 2CM 7FR 14MM BALLOON DILATATION SHAFT",SUP-AT75142,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"NOVANET [10819]",Novanet,,1546.88,75,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD EMG NEUROVISION M5 15MM NDL MODULE PROBE",SUP-8050015,CDM,S27200284,LOCAL,0272,RC,,,both,,,6210.00,1863,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP LUBRICATH STATLOCK 16FR URINE",SUP-A902916,CDM,S27200284,LOCAL,0272,RC,,,both,,,155.90,46.77,"UHC [10700]","United Healthcare",,98.68,63.3,,,,,0,18.13,132.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brace Hf CK Glv W/Fgr Pf",PX-E27400086,CDM,L3912,HCPCS,0274,RC,,,both,,,312.40,93.72,"CIGNA [10200]",Cigna,,212.43,68,,,,,0,36.33,265.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 50CM 12CM 2 DISTAL GWIRE HEMOSTASIS VALVE",SUP-406701,CDM,C1894,HCPCS,0272,RC,,,both,,,95.70,28.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,39.33,41.1,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840005545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 60MM 5FR 7MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-07067,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPLANT 12CM NATRELLE INSPIRA P4CM MODERATE PROFILE RO",SUP-MSZ-M310,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 2-0 SH 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Y317H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 11CMX10MM OSTEOTOM CUP NONSTERILE DISPOSABLE",SUP-SBLDCUP-1-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"UHC [10700]","United Healthcare",,922.91,63.3,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION TENSIONTIGHT STERILE DISPOSABLE",SUP-AR-2350,CDM,C1713,HCPCS,0278,RC,,,both,,,6339.38,1901.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1814.33,28.62,,,,,0,737.27,5388.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aspergillus Ag Eia",PX-306000098,CDM,87305,CPT,0306,RC,,,both,,,1041.20,312.36,"PHCS [10601]",PHCS,,728.84,70,,,,,0,0.01,885.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEARTRAIL III 100CM 6FR IL3.75 CURVE GUIDING PTFE",SUP-40-6377,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC",788,MS-DRG,,,,,,,inpatient,,,42726.41,12817.92,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 6FR 4.5MM .07",SUP-H7493926708450,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EUPHORA 142CM 20MM 3.75MM BALLOON DILATATION",SUP-NCEUP37520X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LIGHTNING FLASH CATHETER, 115CM",SUP-LITNGFHT115H1,CDM,C1757,HCPCS,0272,RC,,,both,,,60795.00,18238.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SUT NUROLON 2-0 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-C522D,CDM,S27200284,LOCAL,0272,RC,,,both,,,127.14,38.14,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"3.0MM PHALANX LNTRAMEDULLARY NAIL 3MM X 37.5MM TI",SUP-IHFN-PHX-30037,CDM,C1713,HCPCS,0278,RC,,,both,,,8052.30,2415.69,"BLUE CROSS [10001]","Blue Cross PPO",,3156.5,39.2,,957.42,570.23,957.42,28,936.48,6844.46,"percent of total billed charges",
"INSTR ORTHOPEDIC 20MM 11MM PILOT HOLE CREATOR",SUP-PC-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,5770.13,1731.04,"KAISER [10500]",Kaiser,,3865.99,67,,,,,0,671.07,4904.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION",RX-103889,CDM,J2003,HCPCS,0636,RC,63323-0495-07,NDC,both,5,ML,32.54,9.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1.17,,,,,,,1.17,27.66,"fee schedule",
"CATH LUTONIX 035 130CM 150MM 6MM BALLOON DILATATION",SUP-LX3513061505F,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3473.98,41.1,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 36MM COMPREHENSIVE +3MM SHOULDER VIVACIT-E",SUP-110031425,CDM,C1776,HCPCS,0278,RC,,,both,,,7755.60,2326.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5273.81,68,,,,,0,901.98,6592.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR 2.9MM GUIDE DRILL BIT OBTR SOFT ANCHOR JUGGERKNOT",SUP-912057,CDM,C1713,HCPCS,0278,RC,,,both,,,2992.50,897.75,"AETNA [10100]","Aetna HMO/PPO",,2379.04,79.5,,1521.93,481.35,16760.95,30,348.03,2543.63,"percent of total billed charges",
"CATH PCP070150150 PLUS US D7L150UL1500",SUP-PCP070150150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PHCS [10601]",PHCS,,861.84,70,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25MM HALL THK1.19MM OSCILLATING REPLACEMENT",SUP-STK250-119-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,298.41,89.52,"NOVANET [10819]",Novanet,,223.81,75,,,,,0,34.71,253.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 22MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.422,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,497.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,488.46,3570,"percent of total billed charges",
"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC",241,MS-DRG,,,,,,,inpatient,,,58839.08,17651.72,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,9102.76,,"Case rate ($8,587.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,974.09, add-ons for qualifying new technology services are included. If operating cost exceeds $41,013.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,984.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $7,984.64. The transfer operating threshold is the transfer adjustment factor * $7,974.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $602.88. The transfer capital threshold is the transfer adjustment factor * $602.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,40418.94,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 31MM TITANIUM CURVE CIRCLE 2 STAGGER LOW",SUP-111989,CDM,S27200284,LOCAL,0272,RC,,,both,,,2138.85,641.65,"CIGNA [10200]","Cigna Open Access",,1217.01,56.9,,,,,0,248.75,1818.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.444,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,573.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",563.19,4116.21,"percent of total billed charges",
"STENT MARDIS ZIPWIRE 26CM 3CM 6FR .038IN PIGTAIL CURVE",SUP-M0061265330,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"FIRST HEALTH [10303]","First Health",,1136.27,80,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE AXIOFILL HUMAN PLACENTAL EXTRACELLULAR MATRIX",SUP-PCM-1000,CDM,Q4433,HCPCS,0636,RC,,,both,,,15807.90,4742.37,"PHCS [10601]",PHCS,,11065.53,70,,,,,0,247.92,13436.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 CT 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP752D,CDM,S27200284,LOCAL,0272,RC,,,both,,,127.90,38.37,"CIGNA [10200]",Cigna,,86.97,68,,,,,0,14.87,108.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 20MM 144CM 3.5MM CORONARY STENT",SUP-H7493952820350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1592.7,28.62,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 275CC",SUP-SSZ-M275,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,173.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 4MM SURGICAL REVERE 6.35MM ROD",SUP-634.213,CDM,C1713,HCPCS,0278,RC,,,both,,,583.20,174.96,"CIGNA [10200]","Cigna Local Plus",,312.01,53.5,,3978.14,359.25,3978.14,24,67.83,495.72,"percent of total billed charges",
"CATH 92CM 1MM 6FR 5MM SPACE REGULAR D CURVE",SUP-D6DR005CT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,274.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 44MM 28MM F VIVACIT-E LUMEN STERILE LATEX FREE",SUP-110031012,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7042.69,68,,,,,0,1204.51,8803.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 8MM TI",SUP-VAN-25080-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"NOVANET [10819]",Novanet,,729,75,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U150,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"FIRST HEALTH [10303]","First Health",,596,80,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 40MM 9MM BALLOON",SUP-U3513094,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 25MM 3.5MM BALLOON DILATATION PEBAX",SUP-1012276-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 600MM 11MM CARBON FIBER MR CONDITIONAL",SUP-394.91,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP3PL,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"BLUE CROSS [10001]","Blue Cross HMO",,8428.74,39.2,,5311.50,4717.44,5388.59,31,2500.67,18276.62,"percent of total billed charges",
"REAMER SURGICAL HOLLOW 2 MM SCREWS REMOVAL NONSTERILE",SUP-309.200,CDM,S27200284,LOCAL,0272,RC,,,both,,,2173.50,652.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC MRI Thorac Spine W/WO Cntrst",PX-612000008,CDM,72157,CPT,0612,RC,,,both,,,5553.36,1666.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($683.51). Procedures 2 - 999, Per diem ($341.76).",,,,0,,,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GERALD STRAIGHT NARROW 7IN TISSUE 1X2 TEETH",SUP-285125,CDM,S27000186,LOCAL,0270,RC,,,both,,,179.48,53.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 3-0 V-7 48IN 2 ARM MONOFILAMENT BLUE",SUP-D6175,CDM,S27200284,LOCAL,0272,RC,,,both,,,720.72,216.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMERGE MONORAIL 144CM 20MM 6FR 1.5MM .07IN BALLOON",SUP-H7493918920150,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 3MM TPS ELITE OSTEON ROUND FLUTE 5 NOTCH SOFT",SUP-5820-010-130,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NERVOUS SYSTEM NEOPLASMS WITHOUT MCC",055,MS-DRG,,,,,,,inpatient,,,44962.19,13488.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIPHERAL CUTTING BALLOON 90CM 20MM 7MM BALLOON",SUP-M001PCB7020900,CDM,C1725,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC",358,MS-DRG,,,,,,,inpatient,,,67768.60,20330.58,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PREVENA PLUS -125 MMHG NEGATIVE PRESSURE 0.019% IONIC",SUP-PRE4001US.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4255.58,1276.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1953.31,45.9,,,,,0,494.92,3617.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 9.75INX8MM LAMBOTTE CURVED SURGICAL",SUP-FL781R,CDM,S27200284,LOCAL,0272,RC,,,both,,,298.50,89.55,"AETNA [10100]","Aetna HMO/PPO",,237.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.72,253.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT REPAIR EYELET ZONE SPECIFIC II NITINOL MENISCUS",SUP-8570,CDM,S27200284,LOCAL,0272,RC,,,both,,,224.03,67.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.05,190.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U175,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"KAISER [10500]",Kaiser,,499.15,67,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR ACCENT SR 52X52MM 12.8ML 23GM 1 CHMBR STORED EGMS",SUP-PM1210,CDM,C1786,HCPCS,0275,RC,,,both,,,9576.00,2872.8,"UHC [10700]","United Healthcare",,6061.61,63.3,,,,,0,1113.69,8139.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Pseudoaneurysm Perc Extrem",PX-361000067,CDM,36002,CPT,0361,RC,,,both,,,1572.38,471.71,"CIGNA [10200]",Cigna,,1572.38,,"Case rate ($2,497). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,182.87,1572.38,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ANTERIOR CHMBR",SUP-MTA5UO,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 2.8MM TWIST STERILE",SUP-KM166-10-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"UHC [10700]","United Healthcare",,65.31,63.3,,,,,0,12,87.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hood Oxygen",PX-E27000193,CDM,E27000193,LOCAL,0270,RC,,,both,,,89.10,26.73,"NOVANET [10819]",Novanet,,66.83,75,,,,,0,10.36,75.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE VITAMIN E POLY LINERS INSERTS",SUP-CAP-U-VE,CDM,C1776,HCPCS,0278,RC,,,both,,,1875.00,562.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION HI-FLO FATHOM-16 130CM 180CM 2.8-3FR .027IN",SUP-M001195710,CDM,C1887,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4926.6,68,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 18X5MM COLONIAL 7D LORDOTIC 15MM 2XL TITANIUM",SUP-365.065CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-207.014,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"BLUE CROSS [10001]","Blue Cross PPO",,107.26,39.2,,957.42,570.23,957.42,28,31.82,232.58,"percent of total billed charges",
"STENT ORSIRO 2.25/22",SUP-401753,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE ESC 10D +4MM 52MM 32MM GVF",SUP-121832752,CDM,C1776,HCPCS,0278,RC,,,both,,,20472.48,6141.74,"AETNA [10100]","Aetna HMO/PPO",,16275.62,79.5,,10981.53,8986.79,12413.38,12,2380.95,17401.61,"percent of total billed charges",
"KIT TKR 30MM LPS TITANIUM MALE TO FEMALE TAPER ANTIROTATION",SUP-198707030,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 465CC",SUP-RSZ-MPX-465S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"KAISER [10500]",Kaiser,,111.28,67,,,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII CRUCIATE RETAINING HYBRI",SUP-71704525,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"MULTIPLAN [10600]",Multiplan,,18742.5,85,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 129MM 22MM PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51-107220,CDM,C1776,HCPCS,0278,RC,,,both,,,30643.20,9192.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8770.08,28.62,,,,,0,3563.8,26046.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT FEMORAL KNEE PATELLA TIBIA POSTERIOR STABILIZE CEM",SUP-98000641521,CDM,C1776,HCPCS,0278,RC,,,both,,,20790.00,6237,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8316,40,,,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 40MM 80CM 8MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM08040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"FIRST HEALTH [10303]","First Health",,14616,80,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 56MM 36MM MARATHON HIP",SUP-121936056,CDM,C1776,HCPCS,0278,RC,,,both,,,8942.40,2682.72,"CIGNA [10200]","Cigna Open Access",,5088.23,56.9,,5302.19,4377.88,6578.61,27,1040,7601.04,"percent of total billed charges",
"SET .195IN 81IN REGULATE CLAMP CATH ADPTR TUBE DRIP CHMBR",SUP-2C4040,CDM,S27200284,LOCAL,0272,RC,,,both,,,71.71,21.51,"PHCS [10601]",PHCS,,50.2,70,,,,,0,8.34,60.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 70MM ALLOGRAFT 3-4MM NERVE",SUP-311270,CDM,C1762,HCPCS,0278,RC,,,both,,,62029.80,18608.94,"AETNA [10100]","Aetna HMO/PPO",,49313.69,79.5,,,,,0,7214.07,52725.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 55MM 20MM 75CM ENDOPROSTHESIS VENOUS CATH",SUP-H74912044205570,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"KAISER [10500]",Kaiser,,5778.75,67,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 80MM 12MM BALLOON",SUP-U35130128,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 120MM 5FR 4MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-04121,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 64MM 36MM ALTRX HIP",SUP-122136164,CDM,C1776,HCPCS,0278,RC,,,both,,,11405.70,3421.71,"NOVANET [10819]",Novanet,,8554.28,75,,,,,0,1326.48,9694.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE EMBOLIZATION GREEN HYDROPEARL 800UM MICRO PEG PREFILL",SUP-HP2S0800,CDM,S27800098,LOCAL,0278,RC,,,both,,,1927.50,578.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,228.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,224.17,1638.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch W Tracheal Dil W Stent",PX-750000013,CDM,31631,CPT,0750,RC,,,both,,,7321.00,2196.3,"CIGNA [10200]",Cigna,,3287,,"Case rate ($3,287). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,7.32,7311,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch W Tracheal Dil W Stent",PX-750000013,CDM,31631,CPT,0750,RC,,,both,,,7321.00,2196.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,851.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.32,7311,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Blood Pump Kit Lifesparc",PX-E27200442,CDM,E27200442,LOCAL,0272,RC,,,both,,,73931.00,22179.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,50273.08,68,,,,,0,8598.18,62841.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 24CM 8MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120824,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1407.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 10MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036121040,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 NARROW KNEE RIGHT POSTERIOR STABILIZE",SUP-42500206202,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"AETNA [10100]","Aetna HMO/PPO",,22971.99,79.5,,10981.53,8986.79,12413.38,12,3360.56,24561.24,"percent of total billed charges",
"GRAFT BONE UNICORTICAL DOWEL ALLOGRAFT FREEZE DRIED 30-40MM",SUP-400204,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"MULTIPLAN [10600]",Multiplan,,3606.98,85,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT FX 34MM",SUP-EVOLUTFX-34,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"KAISER [10500]",Kaiser,,114570,67,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DEMINERALIZED BONE MATRIX 1ML PUTTY STERILE",SUP-038010,CDM,C1713,HCPCS,0278,RC,,,both,,,1160.90,348.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,137.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",135.01,986.77,"percent of total billed charges",
"CATH ADVANCE 150CM 6CM 3MM BALLOON DILATATION ILIAC",SUP-G34320,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X13X7MM COROENT SMALL LORDOTIC PLUS PEEK",SUP-6807815,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 2 LR 20IN BRAID GREEN NONABSORBABLE",SUP-X406T,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Special Dosimetry",PX-333000016,CDM,77331,CPT,0333,RC,,,both,,,1139.76,341.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,523.15,45.9,,,,,0,132.55,1139.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 87.5MM 3.9MM STAINLESS STEEL STERILE",SUP-180022000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Dplr Fu/Ltd",PX-483000013,CDM,93321,CPT,0483,RC,,,both,,,877.78,263.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,360.77,41.1,,,,,0,46.29,746.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION KIRSCHNER RADIAN SPINE FACET SCR SYSTEM",SUP-5526061,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.7MM 22MM DISTAL VOLAR RADIUS FOSSA THREADED",SUP-TPNL-27220-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,623.70,187.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,72.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",72.54,530.15,"percent of total billed charges",
"CATH NC TREK NEO 12MM 145CM 3.75MM BALLOON DILATATION",SUP-1400375-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 3.75MM ULTRA LOW PROFILE BALLOON",SUP-1012277-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2MM 150MM KIRSCHNER STAINLESS STEEL SET TROCAR",SUP-71161020,CDM,C1713,HCPCS,0278,RC,,,both,,,65.09,19.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,44.26,68,,,,,0,7.57,55.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 100MM 10MM BALLOON",SUP-U35751010,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR RAABE 90CM 5FR 1.9MM GUIDING AQ CHECK-FLO",SUP-G13069,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"KAISER [10500]",Kaiser,,298.49,67,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3DMAX MID MESH LARGE LEFT",SUP-0116311,CDM,C1781,HCPCS,0278,RC,,,both,,,1881.75,564.52,"KAISER [10500]",Kaiser,,1260.77,67,,,,,0,218.85,1599.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 120MM 6MM BALLOON DILATATION RAPID",SUP-47560120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BIOPSY 22.1CM 13GA 16GA OSTEO-SITE M2 BONE STAINLESS",SUP-G36409,CDM,S27200284,LOCAL,0272,RC,,,both,,,931.50,279.45,"CIGNA [10200]","Cigna Open Access",,530.02,56.9,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rf Ablt Nrv Si Joint",PX-510000536,CDM,64625,CPT,0761,RC,,,both,,,4688.00,1406.4,"AETNA [10100]","Aetna HMO/PPO",,3726.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,545.21,3984.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Assembly Suct Anticoag Line",PX-E27200355,CDM,E27200355,LOCAL,0272,RC,,,both,,,82.50,24.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.59,70.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC D-Dimer Quant",PX-305000042,CDM,85379,CPT,0305,RC,,,both,,,322.05,96.61,"AETNA [10100]","Aetna HMO/PPO",,256.03,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",269.51,256.03,269.51,"1 through 10",6.9,273.74,"percent of total billed charges",
"TUBE JEJUNOSTOMY 3CM 18FR SILICONE MIC-KEY SECUR-LOK",SUP-0230-18-3.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"FIRST HEALTH [10303]","First Health",,1154.28,80,,,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 6MM 3MM BALLOON DILATATION HYDROPHILIC",SUP-2200-3006-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"NOVANET [10819]",Novanet,,4398.75,75,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL BIT ORTHOPEDIC CANNULATED 2.1MM",SUP-DRLL-DIP-21,CDM,S27000186,LOCAL,0270,RC,,,both,,,1815.00,544.5,"CIGNA [10200]","Cigna Local Plus",,971.03,53.5,,,,,0,211.08,1542.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN PIGTAIL CURVE FULL LENGTH",SUP-H74908526402,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"MULTIPLAN [10600]",Multiplan,,65.09,85,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC D-Dimer Quant",PX-305000042,CDM,85379,CPT,0305,RC,,,both,,,322.05,96.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9.16,,,,,,,6.9,273.74,"fee schedule",
"SMOOTH MODERATE HIGH-PROFILE BOOST, 470CC",SUP-SMHB470,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"CIGNA [10200]","Cigna Open Access",,4338.34,56.9,,5166.00,5166.00,5166.00,"1 through 10",886.73,6480.83,"percent of total billed charges",
"HC Tcat Ins or Rplc Perm Ldls Pm Rv",PX-481000116,CDM,33274,CPT,0481,RC,,,both,,,30137.23,9041.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3571.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2795,25616.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 152MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-224.581,CDM,C1713,HCPCS,0278,RC,,,both,,,2744.70,823.41,"MULTIPLAN [10600]",Multiplan,,2333,85,,,,,0,319.21,2333,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC",266,MS-DRG,,,,,,,inpatient,,,302248.71,90674.61,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 100CM 5FR HH1 CURVE ANGIOGRAPHIC STAINLESS",SUP-510038HH1,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ORTHOPEDIC 300MM 2.8MM THREAD STERILE",SUP-03.333.015S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1178.79,353.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SODIUM CHLORIDE 3 % IV INFUSION",RX-409429,CDM,,,0258,RC,00338-0054-03,NDC,both,500,ML,100.65,30.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS",208,MS-DRG,,,,,,,inpatient,,,77977.80,23393.34,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM 40DEG BIPOLAR CONVEX SERRATED",SUP-BB4040XC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1434.01,430.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Rv Iliac W Pta Add",PX-361000150,CDM,37222,CPT,0361,RC,,,both,,,7309.72,2192.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS 0 54IN BRAIDED COATED ANTIBACTERIAL UNDYED",SUP-ETVCP608H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GAUGE DEPTH 2 MM 2.4 MM SCR",SUP-319.006,CDM,S27200284,LOCAL,0272,RC,,,both,,,6589.22,1976.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE ARTHROSCOPIC LARGE HUB 2 SERRATE STERLING CUDA",SUP-C9254,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 18GA 8CM POWERGLIDE PRO BIOPATCH FULL INSRT",SUP-F318088T,CDM,C1751,HCPCS,0272,RC,,,both,,,884.36,265.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) WISE DELIVERY CATHETER","SUP-MODEL 2000",CDM,S62400003,LOCAL,0624,RC,,,both,,,13800.00,4140,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCREW NON-LOCKING 2.0MM X 6MM TI",SUP-VAN-20060-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,113.04,826.2,"percent of total billed charges",
"CMPNT TALAR INBONE 4 DOME ANKLE SULCUS",SUP-220220904,CDM,C1776,HCPCS,0278,RC,,,both,,,23719.50,7115.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2810.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2758.58,20161.58,"percent of total billed charges",
"PLATE 122MM STAINLESS STEEL 2.7/3.5MM SCR 6 HOLE LCP BONE",SUP-02.112.142,CDM,C1713,HCPCS,0278,RC,,,both,,,3144.75,943.42,"MULTIPLAN [10600]",Multiplan,,2673.04,85,,,,,0,365.73,2673.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) INTREPID MITRAL VALVE 42MM RECOVERABLE CLINICAL IMPLA",SUP-INTPD-V4-42A,CDM,S62400003,LOCAL,0624,RC,,,both,,,256500.00,76950,"NOVANET [10819]",Novanet,,192375,75,,,,,0,29830.95,218025,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Suction",PX-E27200071,CDM,E27200071,LOCAL,0272,RC,,,both,,,97.42,29.23,"NOVANET [10819]",Novanet,,73.07,75,,,,,0,11.33,82.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 70MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.870,CDM,C1713,HCPCS,0278,RC,,,both,,,1757.70,527.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,204.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",204.42,1494.05,"percent of total billed charges",
"STENT AGILE 62MM 14MM ESOPHAGEAL FULL COVER STERILE LATEX",SUP-M00517400,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2124.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HYDRA JAGWIRE ENDOSCOPIC STRAIGHT 450CM .035IN PTFE",SUP-M00556041,CDM,C1769,HCPCS,0272,RC,,,both,,,1422.36,426.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.42,1209.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IRR SUCTION 8MM DA VINCI SI ENDOWRIST ONE DISPOSABLE",SUP-410299,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.00,495,"FIRST HEALTH [10303]","First Health",,1320,80,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Onc Pan-Tum Dna&Rna Gnrj Seq",PX-310000035,CDM,0211U,CPT,0310,RC,,,both,,,16910.00,5073,"UHC [10700]","United Healthcare",,7609.5,,,,,,,16.91,16910,"fee schedule",
"SYSTEM SYNERGY 16MM 144CM 2.25MM CORONARY STENT PEBAX",SUP-H7493926016220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Local Plus",,2977.28,53.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3-4MM CANNULATED",SUP-210-40-001,CDM,S27000186,LOCAL,0270,RC,,,both,,,1650.00,495,"MULTIPLAN [10600]",Multiplan,,1402.5,85,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE CONNECT 250T VASCULAR 195CM .018IN DURASTEEL",SUP-1012594,CDM,C1769,HCPCS,0272,RC,,,both,,,1417.50,425.25,"UHC [10700]","United Healthcare",,897.28,63.3,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 9MM KNEE X3 BEARING CRUCIATE RETAIN TRIATHLON",SUP-5530-G-509-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"AETNA [10100]","Aetna HMO/PPO",,9073.02,79.5,,10981.53,8986.79,12413.38,12,1327.29,9700.71,"percent of total billed charges",
"GRAFT BONE RADIUS ULNA SHAFT ALLOGRAFT FREEZE DRIED 100",SUP-400830,CDM,S27800098,LOCAL,0278,RC,,,both,,,5361.30,1608.39,"CIGNA [10200]","Cigna Local Plus",,2868.3,53.5,,,,,0,623.52,4557.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 6MM 1.14MM 6.5MM GOODE T EAR C-FLEX SOFT",SUP-1066016,CDM,S27800098,LOCAL,0278,RC,,,both,,,193.14,57.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,22.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.46,164.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Int/Ext Hem 1 Group",PX-750000240,CDM,46255,CPT,0750,RC,,,both,,,7114.00,2134.2,"CIGNA [10200]","Cigna Open Access",,3307,,"Case rate ($3,307). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,827.36,7114,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Breast Stereotc Clip Plc",PX-361000306,CDM,19081,CPT,0361,RC,,,both,,,4876.58,1462.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,577.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,567.15,4876.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Breast Stereotc Clip Plc",PX-361000306,CDM,19081,CPT,0361,RC,,,both,,,4876.58,1462.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2292.95,,"Case rate ($2,292.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,567.15,4876.58,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Stent Cmplx Ea Add",PX-361000728,CDM,37287,CPT,0361,RC,,,both,,,10928.93,3278.68,"BLUE CROSS [10001]","Blue Cross HMO",,10.93,.1,,,,,0,10.93,9289.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SPECTRUM II SMALL CRESCENT 15MM 3MM HOOK ERGONOMIC",SUP-C6385,CDM,S27200284,LOCAL,0272,RC,,,both,,,685.50,205.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,79.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,79.72,582.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 44MM ASNIS III TITANIUM PARTIAL THREAD REVERSE",SUP-604644,CDM,C1713,HCPCS,0278,RC,,,both,,,1319.00,395.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,156.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",153.4,1121.15,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 12MM 145CM 3.5MM CORONARY STENT",SUP-1125350-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AETNA [10100]","Aetna HMO/PPO",,4641.21,79.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 94MM 10MM PRESS FIT REUNION S SHOULDER",SUP-5567-P-3010,CDM,C1776,HCPCS,0278,RC,,,both,,,26525.52,7957.66,"PHCS [10601]",PHCS,,18567.86,70,,,,,0,3084.92,22546.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER/DIVIDER LAPAROSCOPIC 44CM 5MM LIGASURE XP MARYLAND",SUP-LXMJ44L,CDM,S27200284,LOCAL,0272,RC,,,both,,,4041.68,1212.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1661.13,41.1,,,,,0,470.05,3435.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ CCOMBO 110CM 7.5FR STD PULMONARY ARTERY",SUP-774F75,CDM,C1751,HCPCS,0272,RC,,,both,,,1782.30,534.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,207.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,207.28,1514.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL RESTORIS 4 KNEE RIGHT MEDIAL LEFT LATERAL",SUP-180614,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"FIRST HEALTH [10303]","First Health",,5301.96,80,,,,,0,770.77,5633.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 5.5MM CREO CURVE TITANIUM MIS NONSTERILE",SUP-1134.7060,CDM,C1713,HCPCS,0278,RC,,,both,,,1966.50,589.95,"KAISER [10500]",Kaiser,,1317.56,67,,,,,0,228.7,1671.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC",797,MS-DRG,,,,,,,inpatient,,,50780.54,15234.16,"UHC [10700]","United Healthcare",,9753,,"Case rate ($9,753). Includes a variable per diem for days 3-99999: RC 0111:0169 @ $3,376; RC 0172:0178 @ $3,376; RC 0190:0219 @ $3,376.",,,,0,5018,13341.95,"per diem","Estimated amount calculated based on 4 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 5.5MM CURVE NONSTERILE",SUP-1555501055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 9-0 BV100-3 5IN MONOFILAMENT COATED VIOLET",SUP-V402G,CDM,S27200284,LOCAL,0272,RC,,,both,,,199.67,59.9,"NOVANET [10819]",Novanet,,149.75,75,,,,,0,23.22,169.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 5X5CM PURAPLY 25SQ CM ANTIMICROBIAL","SUP-PURAPLYAM-COM 5X5",CDM,Q4196,HCPCS,0636,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,271.63,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 STANDARD 3MMX6CM",SUP-M0035463060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3810.95,27,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X6MM HEDRON C 7D 14MM STERILE LATEX FREE",SUP-1211.4616S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Open Access",,3533.49,56.9,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 12MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-312-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"FIRST HEALTH [10303]","First Health",,9626.88,80,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 9-0 BV100-3 5IN MONOFILAMENT COATED VIOLET",SUP-V402G,CDM,S27200284,LOCAL,0272,RC,,,both,,,199.67,59.9,"MULTIPLAN [10600]",Multiplan,,169.72,85,,,,,0,23.22,169.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 28MM 143CM 2.5MM CORONARY EVEROLIMUS ELUTING",SUP-1009539-28,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"BLUE CROSS [10001]","Blue Cross HMO",,3759.67,39.2,,9776.84,9776.84,9776.84,"1 through 10",1115.43,8152.35,"percent of total billed charges",
"TUBE TRACH 5.5MM 46MM 7.9MM SHILEY PEDIATRIC UNCUFF TAPE TIE",SUP-5.5PEF,CDM,S27200284,LOCAL,0272,RC,,,both,,,395.85,118.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,46.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.04,336.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO MULTIPURPOSE CURVE 55CM 7FR 2.5MM",SUP-G49043,CDM,C1894,HCPCS,0272,RC,,,both,,,472.23,141.67,"AETNA [10100]","Aetna HMO/PPO",,375.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.92,401.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 6MM TARGET 360D STD PLATINUM",SUP-M0035466150,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 60MM 80CM 9MM .079IN LARGE DIAMETER",SUP-SERB65-09-60-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2554.34,45.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC App Cast Knee-Toe",PX-450000200,CDM,29405,CPT,0361,RC,,,both,,,813.00,243.9,"PHCS [10601]",PHCS,,569.1,70,,,,,0,94.55,813,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 8MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640508,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4625.35,41.1,,6417.48,6417.48,6417.48,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"COIL EMBOLIZATION 12CM 3MM INTERLOCK IDC 18 COIL OCCLUSION",SUP-M001361510,CDM,S27800098,LOCAL,0278,RC,,,both,,,1984.50,595.35,"CIGNA [10200]","Cigna Local Plus",,1061.71,53.5,,,,,0,230.8,1686.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE RIGHT CEMENT REVISION CONSTRAIN ATTUNE",SUP-1504-40-205,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12376.85,41.1,,6417.48,6417.48,6417.48,"1 through 10",3502.26,25596.9,"percent of total billed charges",
"CANN ARTHROSCOPIC 7MM 7CM TWIST-IN 3 DAM SIDEPORT LUER LOCK",SUP-AR-6570TD,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"MULTIPLAN [10600]",Multiplan,,248.47,85,,,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH 13CM 18FR INTRO",SUP-G28327,CDM,C1894,HCPCS,0272,RC,,,both,,,378.19,113.46,"NOVANET [10819]",Novanet,,283.64,75,,,,,0,43.98,321.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 3.5MM FRMLA SMALL JOINT FULL RADIUS STERILE",SUP-0375636000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1498.50,449.55,"CIGNA [10200]",Cigna,,1018.98,68,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUSHG FEMORAL KNEE POLYETHYLENE AUXILIARY",SUP-150477,CDM,C1770,HCPCS,0278,RC,,,both,,,1722.00,516.6,"MULTIPLAN [10600]",Multiplan,,1463.7,85,,,,,0,200.27,1463.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 2 3/8IN SAMPLEMASTER SHARP BEVEL",SUP-41220,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA [10200]","Cigna Local Plus",,97.74,53.5,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT 16CM X 20CM CORTIVA DERMIS",SUP-DH1620,CDM,S27800098,LOCAL,0278,RC,,,both,,,52332.15,15699.64,"FIRST HEALTH [10303]","First Health",,41865.72,80,,,,,0,6086.23,44482.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 6FR 28CM WITHOUT GWIRE POLARIS ULTRA",SUP-M0061921340,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"BLUE CROSS [10001]","Blue Cross HMO",,445.16,39.2,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 6FR EBU3.75 CURVE GUIDING NYLON CORONARY",SUP-LA6EBU375A,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AETNA [10100]","Aetna HMO/PPO",,311.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tee Plc Only",PX-483000010,CDM,93313,CPT,0483,RC,,,both,,,2122.00,636.6,"CIGNA [10200]","Cigna Open Access",,1207.42,56.9,,,,,0,246.79,1803.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lipoprotein A",PX-301000299,CDM,83695,CPT,0301,RC,,,both,,,164.75,49.42,"CIGNA [10200]","Cigna Open Access",,31.5,,,,,,,0.16,140.04,"fee schedule",
"MESH SURGICAL GORE ENFORM 16X20CM INTRAPERITONEAL",SUP-GBFR1620,CDM,C1781,HCPCS,0278,RC,,,both,,,36477.00,10943.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14992.05,41.1,,,,,0,4242.28,31005.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG CONTOUR 162MM STAINLESS STEEL 19 HOLE LOW PROFILE",SUP-4953110R,CDM,C1713,HCPCS,0278,RC,,,both,,,8521.50,2556.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1009.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,991.05,7243.28,"percent of total billed charges",
"GRAFT SOFT TISSUE 30X10MM COSTAL CARTILAGE FROZEN",SUP-70B001,CDM,C1713,HCPCS,0278,RC,,,both,,,2088.75,626.62,"AETNA [10100]","Aetna HMO/PPO",,1660.56,79.5,,1521.93,481.35,16760.95,30,242.92,1775.44,"percent of total billed charges",
"CATH IMAGER II 65CM 5FR COBRA 2 CURVE ANGIOGRAPHIC BRAID",SUP-M001314671,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"UHC [10700]","United Healthcare",,73.8,63.3,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ARROW ARROW ADVANCER VASCULAR J CURVE STRAIGHT 26.75IN",SUP-AW-14725,CDM,C1769,HCPCS,0272,RC,,,both,,,105.79,31.74,"NOVANET [10819]",Novanet,,79.34,75,,,,,0,12.3,89.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 59MM 80CM 10MM THIN VASCULAR COCR",SUP-1012626-59,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"AETNA [10100]","Aetna HMO/PPO",,6678,79.5,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 26.5CM 8FR NEPHRSTMY PERCUFLEX LOCK LOOP STERILE LATEX",SUP-M0064101110,CDM,C1729,HCPCS,0272,RC,,,both,,,616.49,184.95,"FIRST HEALTH [10303]","First Health",,493.19,80,,,,,0,71.7,524.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 9CM 7FR .035IN GENTLE CURVE BILIARY",SUP-G21685,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS [10001]","Blue Cross HMO",,247.67,39.2,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS HONOR METAL GWIRE INSRT TOOL",SUP-MAP301,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.19,61.86,"PHCS [10601]",PHCS,,144.33,70,,,,,0,23.98,175.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL KNEE ATTUNE FB - CEMENTED",SUP-009504191,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"NOVANET [10819]",Novanet,,21262.5,75,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 59CM ENDOTAK RELIANCE 4-SITE ENDOCARDIUM GORE",SUP-285,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS [10001]","Blue Cross HMO",,5950.56,39.2,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR LNCS NEO-3 3FT ASSORTED OXIMETER LOW NOISE CABLED SOL",SUP-2320,CDM,S27000186,LOCAL,0270,RC,,,both,,,4.95,1.48,"NOVANET [10819]",Novanet,,3.71,75,,,,,0,0.58,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL ARTICUL/EZE CERAMIC +5 OD40 MM",SUP-473440050,CDM,C1776,HCPCS,0278,RC,,,both,,,17961.30,5388.39,"CIGNA [10200]",Cigna,,7184.52,40,,5873.17,5873.17,5873.17,"1 through 10",2088.9,15267.11,"percent of total billed charges",
"GWIRE DREAMWIRE ENDOSCOPIC ANGLE STD 260CM .035IN ENDOGLIDE",SUP-M00556111,CDM,C1769,HCPCS,0272,RC,,,both,,,1422.36,426.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,168.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.42,1209.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530G211,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"NOVANET [10819]",Novanet,,6530.71,75,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Onc Pan-Tum Dna&Rna Gnrj Seq",PX-310000035,CDM,0211U,CPT,0310,RC,,,both,,,16910.00,5073,"BLUE CROSS [10001]","Blue Cross HMO",,16.91,.1,,,,,0,16.91,16910,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 11MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530G811,CDM,C1776,HCPCS,0278,RC,,,both,,,8868.13,2660.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6030.33,68,,,,,0,1031.36,7537.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Euglobulin Lysis",PX-305000039,CDM,85360,CPT,0305,RC,,,both,,,584.00,175.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.83,,"Fee schedule rate ($8.83). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,496.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 75CM .36MM SFT TPR",SUP-121197,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"BLUE CROSS [10001]","Blue Cross HMO",,150.06,39.2,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE OXFEM NP TIBIA CONCL PATELLA J2ASMD INSER",SUP-71704652,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6671.32,28.62,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 24MM TITANIUM SPINE CANCELLOUS SELF TAP 2",SUP-489.145,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ERTAPENEM SODIUM 1 G/10ML IJ (WET SOLR VIAL)",RX-41531922,CDM,J1335,HCPCS,0636,RC,55150-0282-09,NDC,both,1,UN,301.92,90.58,"NOVANET [10819]",Novanet,,226.44,75,,,,,0,21.52,256.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TYSHAK II 100CM 6CM 8FR 20MM BALLOON DILATATION DEHP",SUP-611934,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"NOVANET [10819]",Novanet,,2850.91,75,,,,,0,442.08,3231.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 345CC",SUP-SSZ-F345,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CIGNA [10200]","Cigna Local Plus",,797.36,53.5,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 18MM 145CM 2.25MM CORONARY STENT",SUP-1145225-18,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]","Cigna Local Plus",,3123.33,53.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE COLPASSIST PESSARY VAGINAL 2 END POSITION FLAT SUT",SUP-M0068318210,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LASSO 7FR 25-15MM D CURVE ELECTROPHYSIOLOGY 12 POLE",SUP-LN122515CT,CDM,C1732,HCPCS,0272,RC,,,both,,,11260.80,3378.24,"NOVANET [10819]",Novanet,,8445.6,75,,,,,0,1309.63,9571.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 34X11MM HEDRON IA 8D 26MM STERILE LATEX FREE",SUP-1212.0611S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"PHCS [10601]",PHCS,,24255,70,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 19GA 15CM TEMNO EVOLUTION 2 NOTCH COAXIAL",SUP-CTT2015,CDM,S27200284,LOCAL,0272,RC,,,both,,,442.26,132.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.43,375.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Progr Dev Eval Icd Subq Lead",PX-481000106,CDM,93260,CPT,0480,RC,,,both,,,438.70,131.61,"CIGNA [10200]","Cigna Local Plus",,234.7,53.5,,,,,0,51.02,438.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM AEQUALIS TITANIUM HUMERAL PROXIMAL",SUP-7425040,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"PHCS [10601]",PHCS,,873.18,70,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 345CC",SUP-SSZ-F345,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"MULTIPLAN [10600]",Multiplan,,1266.84,85,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT CRUCIATE RETAIN CEMENTLESS ATTUNE",SUP-150401105,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"CIGNA [10200]","Cigna Open Access",,9639.71,33.5,,5302.19,4377.88,6578.61,27,3346.56,24458.96,"percent of total billed charges",
"POD XL 16MMX55CM",SUP-RBYPODXL1655,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"NOVANET [10819]",Novanet,,14127.75,75,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 150CM 4.8FR .035IN 3CM STD STRAIGHT URETERAL",SUP-M006145351190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CIGNA [10200]",Cigna,,768.37,68,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRICLIP NT CLIP DELIVERY SYS CLIN",SUP-TCDS0203-NT,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS 1 XLH 48IN MONOFILAMENT ANTIBACTERIAL VIOLET",SUP-PDP881G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.48,45.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 20MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-220,CDM,C1776,HCPCS,0278,RC,,,both,,,17822.70,5346.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4812.13,27,,,,,0,2072.78,15149.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 66X51X13MM VISIA AF MRI SURESCAN",SUP-DVFB1D1,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"KAISER [10500]",Kaiser,,26130,67,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 014 150CM 10CM 4MM BALLOON DILATATION",SUP-U4150410,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 300MM 2.8MM THREAD STERILE",SUP-03.333.015S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1178.79,353.64,"AETNA [10100]","Aetna HMO/PPO",,937.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,137.09,1001.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 19GA 5.2-4.2FR 0-8CM ULTRASOUND CONTOUR",SUP-G31520,CDM,S27200284,LOCAL,0272,RC,,,both,,,2407.50,722.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1105.04,45.9,,,,,0,279.99,2046.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE LP 33S",SUP-TENDV-LP-33S-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"NOVANET [10819]",Novanet,,128250,75,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Vad Complt Tunl W Port",PX-361000118,CDM,36582,CPT,0361,RC,,,both,,,5946.72,1784.02,"NOVANET [10819]",Novanet,,4460.04,75,,,,,0,691.6,5946.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 13MM 1.3MM CORTICAL CRANIOFACIAL TITANIUM SELF",SUP-400.693,CDM,C1713,HCPCS,0278,RC,,,both,,,650.92,195.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,77.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,75.7,553.28,"percent of total billed charges",
"LINER ACETABULAR G7 B 32MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30123202,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6971.37,68,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 22GA 20CM FRANSEEN CLEAR LUER LOCK HUB CROWN",SUP-FRA2220,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,82.24,41.1,,,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 B 32MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30123202,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"FIRST HEALTH [10303]","First Health",,8201.62,80,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL NASAL 16MM 4MM PROPEL 370 MCG MINI MOMETASONE FUROATE",SUP-60011,CDM,C2625,HCPCS,0278,RC,,,both,,,6679.20,2003.76,"NOVANET [10819]",Novanet,,5009.4,75,,,,,0,776.79,5677.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 380MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.058S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"UHC [10700]","United Healthcare",,7860.81,63.3,,5023.51,2672.93,6679.78,18,1444.25,10555.59,"percent of total billed charges",
"HEAD UNIPOLAR 52MM CENTERPULSE LEGACY 12/14 TAPER HIP FEMUR",SUP-451000052,CDM,C1776,HCPCS,0278,RC,,,both,,,2398.65,719.59,"KAISER [10500]",Kaiser,,1607.1,67,,,,,0,278.96,2038.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LASER FIBER 1000",SUP-HLFD1000C,CDM,S27200284,LOCAL,0272,RC,,,both,,,5750.00,1725,"CIGNA [10200]","Cigna Open Access",,3271.75,56.9,,,,,0,668.73,4887.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR 16CM 5FR .035IN BLADDER LOOP LOW",SUP-M006155214090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,926.66,68,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FIBERTAG FIXATION",SUP-AR-1588RTT2-IB,CDM,C1713,HCPCS,0278,RC,,,both,,,5252.63,1575.79,"FIRST HEALTH [10303]","First Health",,4202.1,80,,,,,0,610.88,4464.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN",RX-163725,CDM,,,0250,RC,00942-0641-04,NDC,both,1000,ML,100.65,30.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,41.37,41.1,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3-4MM CANNULATED",SUP-210-40-001,CDM,S27000186,LOCAL,0270,RC,,,both,,,1650.00,495,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,191.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 26CM 7FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49914,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"FIRST HEALTH [10303]","First Health",,602.64,80,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 235MM 24MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-324,CDM,C1776,HCPCS,0278,RC,,,both,,,18758.25,5627.47,"FIRST HEALTH [10303]","First Health",,15006.6,80,,,,,0,2181.58,15944.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Upr Ext Arty Uni",PX-921000009,CDM,93931,CPT,0921,RC,,,both,,,1125.51,337.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,765.35,68,,,,,0,130.9,956.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 80CM 40MM 9MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV09004008P,CDM,C1725,HCPCS,0272,RC,,,both,,,10281.00,3084.3,"NOVANET [10819]",Novanet,,7710.75,75,,,,,0,1195.68,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ICD-DR DDBB1D1 EVERA XT IS1/DF1 US",SUP-DDBB1D1,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"UHC [10700]","United Healthcare",,25674.48,63.3,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 44MM X25 LOCK INTRAMEDULLARY NAIL",SUP-04.045.044S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 80CM 6MM 8MM 7FR .035IN",SUP-BXA062901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]","Cigna Open Access",,6534.11,33.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP FEM N/POROUS SIZE 6 RIGHT",SUP-2154-0-0006,CDM,C1776,HCPCS,0278,RC,,,both,,,10151.40,3045.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2905.33,28.62,,,,,0,1180.61,8628.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nongyn Cyto Prep",PX-311000003,CDM,88104,CPT,0311,RC,,,both,,,422.75,126.82,"KAISER [10500]",Kaiser,,283.24,67,,,,,0,0.01,359.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 55MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16025555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet Myocrd Perf Multi R&S W CT",PX-404000015,CDM,78431,CPT,0404,RC,,,both,,,5158.00,1547.4,"CIGNA [10200]","Cigna Open Access",,3053,,"Per diem ($3,053). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,599.88,5158,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +7.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.075,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC 16.5-17.5IN FABRIC 15D LARGE UNIVERSAL",SUP-08505,CDM,L3670,HCPCS,0274,RC,,,both,,,389.33,116.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,102.83,,,,,,,45.28,330.93,"fee schedule",
"STENT CONTOUR ZIPWIRE 30CM 150CM 7FR .035IN PIGTAIL CURVE",SUP-M006180235180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"FIRST HEALTH [10303]","First Health",,1168.09,80,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DRNG 28FR 21IN PLEUR-EVAC STRAIGHT SOFT THERMOSENSITIVE",SUP-DSTC-28S,CDM,C1729,HCPCS,0272,RC,,,both,,,53.94,16.18,"MULTIPLAN [10600]",Multiplan,,45.85,85,,,,,0,6.27,45.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM 3 HOLE EMPHASYS",SUP-471046300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"BLUE CROSS [10001]","Blue Cross PPO",,7038.36,39.2,,3949.44,3949.44,3949.44,"1 through 10",2088.17,15261.75,"percent of total billed charges",
"SCR BONE 5.5MM 40MM EVEREST SPINE CANNULATED POLYAXIAL MIS",SUP-M5111-05540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAFCILLIN SODIUM 1 G/4ML IJ (WET SOLR VIAL)",RX-4155333,CDM,J2290,HCPCS,0636,RC,44567-0221-10,NDC,both,1,UN,99.66,29.9,"KAISER [10500]",Kaiser,,66.77,67,,,,,0,2.91,84.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 30MM T2 ALPHA LOCK STERILE",SUP-2360-5030S,CDM,C1713,HCPCS,0278,RC,,,both,,,1542.56,462.77,"CIGNA [10200]",Cigna,,1048.94,68,,1831.33,1831.33,1831.33,16,179.4,1311.18,"percent of total billed charges",
"ANCHOR SUT 6MM 2 8MM TENOLOK HI-FI 2 EXPAND GUIDE PIN DRILL",SUP-T60S80,CDM,C1713,HCPCS,0278,RC,,,both,,,8016.83,2405.05,"CIGNA [10200]",Cigna,,5451.44,68,,1831.33,1831.33,1831.33,16,932.36,6814.31,"percent of total billed charges",
"DEVICE AUTOCAP RX LOCKING BIOPSY CAP OLYMPUS COMPATIBLE ERCP",SUP-M00545101,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.46,44.24,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 4MM DART-FIRE HEADED",SUP-DSDS1040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1069.20,320.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INQUIRY 110CM 1MM 6FR 2-5-2MM SPACE LARGE CURVE",SUP-81809,CDM,C1730,HCPCS,0272,RC,,,both,,,2100.00,630,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ADX GUIDEWIRE PTFE 035 X 180CM FC ST BENTSON",SUP-H7878141351801,CDM,C1769,HCPCS,0272,RC,,,both,,,121.80,36.54,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STPLR 2-0 6IN ENDO STITCH V-LOC POLYBUTESTER LOAD",SUP-VLOCN206L,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.01,84.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 14 150CM 200MM 4MM TAPER BALLOON DILATATION JET",SUP-A2040-200,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BLOOD SAMPLING SAFEDRAW PM",SUP-688496,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 110CM 7FR .081IN JUDKINS RIGHT 3.5 CURVE",SUP-LA7JR35,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM FEMORAL 127D 6 30MM CONDYLAR STABILIZED NECK OMNIFIT",SUP-6097-0630,CDM,C1776,HCPCS,0278,RC,,,both,,,10292.40,3087.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4230.18,41.1,,6417.48,6417.48,6417.48,"1 through 10",1197.01,8748.54,"percent of total billed charges",
"CATH 5.75IN 16FR URETHRAL STAINLESS STEEL FEMALE NONSTERILE",SUP-475-636,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.39,103.02,"CIGNA [10200]","Cigna Local Plus",,183.71,53.5,,,,,0,39.94,291.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SUT SAF-T-PEXY BIOSYN LOW PROFILE ANCHOR PRELOAD NDL T",SUP-98701,CDM,S27200284,LOCAL,0272,RC,,,both,,,957.34,287.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,393.47,41.1,,,,,0,111.34,813.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.426,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Scrotum",PX-402000029,CDM,76870,CPT,0402,RC,,,both,,,1541.85,462.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,110.22,,,,,,,105.35,1310.57,"fee schedule",
"HC US Scrotum",PX-402000029,CDM,76870,CPT,0402,RC,,,both,,,1541.85,462.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,105.35,,,,,,,105.35,1310.57,"fee schedule",
"HC US Scrotum",PX-402000029,CDM,76870,CPT,0402,RC,,,both,,,1541.85,462.55,"MULTIPLAN [10600]",Multiplan,,1310.57,85,,,,,0,105.35,1310.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC GREEN 76MM OBTR TROCAR SEAL STERILE",SUP-012421,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 175MM 24MM 19MM STD NECK S-ROM CERAMIC 135D",SUP-523196,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"CIGNA [10200]",Cigna,,7780.5,40,,5873.17,5873.17,5873.17,"1 through 10",2262.18,16533.56,"percent of total billed charges",
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR",RX-27633,CDM,,,0637,RC,60505-2807-07,NDC,both,1,UN,9.88,2.96,"CIGNA [10200]","Cigna Local Plus",,5.29,53.5,,,,,0,1.15,8.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC",826,MS-DRG,,,,,,,inpatient,,,278940.49,83682.15,"UHC [10700]","United Healthcare",,136573.05,,"Fee schedule rate ($136,573.05). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,29016.67,136573.05,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INTRODUCER",SUP-MAJ1820,CDM,S27200284,LOCAL,0272,RC,,,both,,,549.50,164.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,65.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,63.91,467.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 19MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532-P-119,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS [10001]","Blue Cross PPO",,3275.51,39.2,,3949.44,3949.44,3949.44,"1 through 10",971.79,7102.52,"percent of total billed charges",
"CATH SABERX 90CM 20MM 2.5MM BALLOON DILATATION RAPID",SUP-47525020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,655.83,41.1,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO GRAY 23CM 5FR BRITE TIP CANN INTERVENTIONAL",SUP-401523M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"NOVANET [10819]",Novanet,,78.3,75,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CARDIONYL 4-0 .5C 2 ARM BLUE NONABSORBABLE",SUP-721932,CDM,S27200284,LOCAL,0272,RC,,,both,,,55.34,16.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,22.74,41.1,,,,,0,6.44,47.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR FR4 CURVE ANGIOGRAPHIC VENTRICULAR 2",SUP-H74916391022,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"FIRST HEALTH [10303]","First Health",,61.26,80,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET IMPL 68MM KNEE LEFT FUSION NAIL MODULAR STERILE",SUP-15-0028/07,CDM,C1713,HCPCS,0278,RC,,,both,,,43703.48,13111.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5082.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",5082.71,37147.96,"percent of total billed charges",
"CUTTER SURGICAL ACUITY UNIVERSAL SPIRAL",SUP-7060,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx/Exc Lymph Node Super Open",PX-361000504,CDM,38500,CPT,0361,RC,,,both,,,7566.00,2269.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,896.57,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.57,7566,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 45MM CENTERPULSE LEGACY 12/14 TAPER HIP FEMUR",SUP-451000045,CDM,C1776,HCPCS,0278,RC,,,both,,,2328.75,698.62,"KAISER [10500]",Kaiser,,1560.26,67,,,,,0,270.83,1979.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 38CM 10FR 2CM BASKET RAPID ATRAUMATIC TIPLESS",SUP-G32862,CDM,S27200284,LOCAL,0272,RC,,,both,,,1266.03,379.81,"CIGNA [10200]","Cigna Open Access",,720.37,56.9,,,,,0,147.24,1076.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC De Revasc Cto Addl Art/Br/Grft",PX-481000092,CDM,C9608,HCPCS,0481,RC,,,both,,,25789.00,7736.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12474,,"Case rate ($12,474). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,2795,25681,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP PRIMARY MODULAR MULTIHOLE",SUP-00620205220,CDM,C1776,HCPCS,0278,RC,,,both,,,17500.14,5250.04,"KAISER [10500]",Kaiser,,11725.09,67,,,,,0,2035.27,14875.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +26 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00260,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"BLUE CROSS [10001]","Blue Cross HMO",,428.65,39.2,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 12MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS12030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"FIRST HEALTH [10303]","First Health",,9378.48,80,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.6MM 229MM KIRSCHNER STAINLESS STEEL 1 END",SUP-18600369,CDM,C1713,HCPCS,0278,RC,,,both,,,119.63,35.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,81.35,68,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9CM 3.5MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY123509,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"BLUE CROSS [10001]","Blue Cross PPO",,4657.67,39.2,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 80MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171030810,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 34MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25034W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"AETNA [10100]","Aetna HMO/PPO",,2683.13,79.5,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (OTW)  3.50MM X 15MM",SUP-H74939402153500,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,641.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 30MM 120CM 6MM VASCULAR PERIPHERAL SELF",SUP-PRB35-06-030-120,CDM,C1876,HCPCS,0278,RC,,,both,,,4347.00,1304.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2955.96,68,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 90MM 75CM 14MM 9FR 100CM",SUP-H965403130,CDM,C1876,HCPCS,0278,RC,,,both,,,7140.00,2142,"AETNA [10100]","Aetna HMO/PPO",,5676.3,79.5,,,,,0,830.38,6069,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX CORE REINFORCED TISSUE MATRIX, LONG-TERM RESORBABLE R",SUP-F10264-2020G,CDM,C1781,HCPCS,0278,RC,,,both,,,20664.00,6199.2,"AETNA [10100]","Aetna HMO/PPO",,16427.88,79.5,,,,,0,2403.22,17564.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 15MM 3.75MM BALLOON DILATATION STERILE",SUP-237-153-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM LCP STAINLESS STEEL FULL THREAD PROXIMAL",SUP-02.205.050,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"KAISER [10500]",Kaiser,,846.4,67,,,,,0,146.92,1073.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X14MM COROENT XL PEEK TLIF",SUP-6914850,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2815.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX10MM VANGUARD ARCOM KNEE POSTERIOR STABILIZE",SUP-VE183640,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1533.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1533.84,11210.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION ENDOBUTTON 1.2MM ACCESS PACK GUIDE",SUP-72202799,CDM,C1713,HCPCS,0278,RC,,,both,,,2488.50,746.55,"NOVANET [10819]",Novanet,,1866.38,75,,,,,0,289.41,2115.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH C-FLEX 70CM 7FR URETERAL TAPER TIP 1 LUMEN RADIOPAQUE",SUP-M0064001520,CDM,C1758,HCPCS,0272,RC,,,both,,,325.47,97.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.85,276.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 3.25MM BALLOON DILATATION PTCA",SUP-DC-RZ3212UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"NOVANET [10819]",Novanet,,741.15,75,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 60MM 75CM 7MM VASCULAR METAL SUPERFICIAL",SUP-H74939293076070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"AMERIGROUP MEDICAID [20100]",Amerigroup,,572.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC 130CM 1.2MM COREDX MINI STERILE DISPOSABLE",SUP-M00515220,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 20CM 150CM 8FR .035IN PIGTAIL CURVE",SUP-M006180240180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"BLUE CROSS [10001]","Blue Cross PPO",,572.36,39.2,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONCIERGE 100CM 5FR SBS4.5 MOD CURVE GUIDING STAINLESS",SUP-CGC5100SBS45SH-M,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"MULTIPLAN [10600]",Multiplan,,378.68,85,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 12MM 3.2-2.4-2.6FR 1.5MM BALLOON",SUP-SPR1512W,CDM,C1725,HCPCS,0272,RC,,,both,,,607.50,182.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,71.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT LOWAX 90MM 22MM COLONIC NITINOL RECTAL",SUP-CNJF-22-090-230,CDM,C1876,HCPCS,0278,RC,,,both,,,15104.24,4531.27,"CIGNA [10200]",Cigna,,6041.7,40,,,,,0,1756.62,12838.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 100MM 125CM 6MM BILIARY NITINOL SELF",SUP-G50165,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"AETNA [10100]","Aetna HMO/PPO",,4841.55,79.5,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 KS 30IN BRAID BLACK NONABSORBABLE",SUP-623H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 21X4.8MM TITANIUM XL CIRCULAR LARGE",SUP-EEAXL21,CDM,S27200284,LOCAL,0272,RC,,,both,,,2269.80,680.94,"PHCS [10601]",PHCS,,1588.86,70,,,,,0,263.98,1929.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE STD 240CMX27MM 2.4MM CAPTIFLEX POLYPECTOMY OVAL",SUP-M00562402,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.00,22.5,"CIGNA [10200]","Cigna Open Access",,42.68,56.9,,,,,0,8.72,63.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 CT-1 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J344H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT MEGALOADER HD SCORPION",SUP-AR-13999HDN,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL KNIFE 24FR STERILE DISPOSABLE TUIP",SUP-M0068802371,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,61.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL MICRO NDL STRAIGHT 2.5IN TUNGSTEN",SUP-E16512,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.10,61.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.97,175.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX LARGE - L 21MM X",SUP-T600612,CDM,S27800098,LOCAL,0278,RC,,,both,,,4347.00,1304.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2955.96,68,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 9CM 8.5FR BILIARY POLYETHYLENE TAPERED",SUP-G21621,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 3.5X3CM MARIGEN OMEGA3 ALLOGRAFT WOUND FENESTRATE",SUP-50200F01B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,5754.60,1726.38,"NOVANET [10819]",Novanet,,4315.95,75,,,,,0,180.89,4891.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 3.1CC DARK BLUE 15MM SYNFIX 18D SMALL",SUP-08.815.174S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ EXTRA STIFF VASCULAR 3MM FLOPPY STRAIGHT TAPER",SUP-G03290,CDM,C1769,HCPCS,0272,RC,,,both,,,133.81,40.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,90.99,68,,,,,0,15.56,113.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 6 RIGHT DISTAL KNEE",SUP-5541-A-602,CDM,C1776,HCPCS,0278,RC,,,both,,,5742.83,1722.85,"KAISER [10500]",Kaiser,,3847.7,67,,,,,0,667.89,4881.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE GDE HV WSP RS3 CSJ",SUP-4588,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,466.07,41.1,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ENROUTE VASCULAR .014IN 5CM 95CM 15CM PTFE HYDROPHILIC",SUP-SR-014-GW,CDM,C1769,HCPCS,0272,RC,,,both,,,1458.00,437.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X3IN DURAGEN CRANIUM BOVINE CLLGN MATRIX",SUP-DURS3391,CDM,,,0278,RC,,,both,,,7552.19,2265.66,"BLUE CROSS [10001]","Blue Cross HMO",,7.55,.1,,,,,0,7.55,6419.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55840006555,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,1831.33,1831.33,1831.33,16,441.36,3225.75,"percent of total billed charges",
"LINER ACETABULAR GG ELEVATE 48MM 32MM VIVACIT-E HIP STERILE",SUP-885200832,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1214.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ADMIN 125IN .2UM 20 GTT/ML 29ML INTRAVENOUS ALARIS",SUP-11532269,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.38,21.11,"CIGNA [10200]","Cigna Open Access",,40.05,56.9,,,,,0,8.19,59.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC",258,MS-DRG,,,,,,,inpatient,,,145506.57,43651.97,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,39686.84,,"Case rate ($19,490.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $18,098.38, add-ons for qualifying new technology services are included. If operating cost exceeds $51,138.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,750.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $18,122.31. The transfer operating threshold is the transfer adjustment factor * $18,098.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,368.33. The transfer capital threshold is the transfer adjustment factor * $1,368.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 203.62%.",,,,0,7561,91736.75,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET",RX-165120,CDM,,,0637,RC,66993-0456-30,NDC,both,1,UN,83.63,25.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,34.37,41.1,,,,,0,9.73,71.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZER VASCULAR J 260CM 1.5MM .035IN STAINLESS",SUP-9-GW-002,CDM,C1769,HCPCS,0272,RC,,,both,,,461.70,138.51,"UHC [10700]","United Healthcare",,292.26,63.3,,,,,0,53.7,392.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061802230,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"MULTIPLAN [10600]",Multiplan,,766.85,85,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 12X14X22MM SANTORINI 7D PEEK CORPECTOMY",SUP-1703-22214L,CDM,S27800098,LOCAL,0278,RC,,,both,,,39793.32,11938,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4627.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4627.96,33824.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COAG SUCTION 6IN 10FR 3/8IN VALLEYLAB POLYOLEFIN PLASTIC",SUP-E3310NSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.39,24.72,"UHC [10700]","United Healthcare",,52.15,63.3,,,,,0,9.58,70.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR CANCELLOUS CORTICAL ALLOGRAFT 11",SUP-341011,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 65CM 20MM PRESTIGE PLUS HELICAL COMPLEX 18",SUP-PRES2065COM18,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2271,28.62,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 29.5X7X.38MM PRECISION LONG MICRO NARROW THIN",SUP-2296003115,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"MULTIPLAN [10600]",Multiplan,,229.69,85,,,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE CHIBA 18 GA X 9 CM",SUP-MCN1803,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"CIGNA [10200]","Cigna Open Access",,70.29,56.9,,,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOVIVE PLUS 10.0CC",SUP-203210,CDM,C1713,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"MULTIPLAN [10600]",Multiplan,,17403.75,85,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT YELLOW 24X4IN STD LEG 2 FILL LINE POSITIVE LOCK",SUP-ASP-564009,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.90,51.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.11,146.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL CORTICAL THK3-12MM THIRDS ALLOGRAFT STRUT",SUP-450486,CDM,S27800098,LOCAL,0278,RC,,,both,,,5249.52,1574.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1502.41,28.62,,,,,0,610.52,4462.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 6.5MM 2 FULL THREAD CORKSCREW FIBERWIRE 2 VENT",SUP-AR-1927BCF-65,CDM,C1713,HCPCS,0278,RC,,,both,,,2638.13,791.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,306.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",306.81,2242.41,"percent of total billed charges",
"TUBE 62MM 9.4MM 5MM CUFFED LOW PRESSURE FENESTRATED INNER",SUP-4DFEN,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.46,95.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,37.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.15,271.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 10-0 CS160-6 12IN 2 ARM MONOFILAMENT BLACK",SUP-9000G,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.29,68.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,155.92,68,,,,,0,26.67,194.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 30MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ330,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"BLUE CROSS [10001]","Blue Cross HMO",,377.1,39.2,,5311.50,4717.44,5388.59,31,111.88,817.7,"percent of total billed charges",
"CATH EVOLUT PRO 107CM 7.6CM 14FR 18FR 88.6CM DELIVERY SYSTEM",SUP-D-EVPROP2329US,CDM,S27200284,LOCAL,0272,RC,,,both,,,14559.00,4367.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6682.58,45.9,,,,,0,1693.21,12375.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 30MM TSRH OSTEOGRIP TITANIUM THIN SPINE",SUP-83545309,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"PHCS [10601]",PHCS,,1801.8,70,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG SURGICAL 1.6X1.3IN MONOFILAMENT FULL RESORBABLE PATCH",SUP-1190601,CDM,C1781,HCPCS,0278,RC,,,both,,,3563.25,1068.97,"FIRST HEALTH [10303]","First Health",,2850.6,80,,,,,0,414.41,3028.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 6IN DUROGRIP BABY CRILE-WOOD SERRATE NDL TUNGSTEN",SUP-BM013R,CDM,S27000186,LOCAL,0270,RC,,,both,,,268.22,80.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,31.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.19,227.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ELUVIA 80MM 130CM 7MM VASCULAR DRUG ELUTE DELIVERY",SUP-H74939294700810,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 12MM 144CM 2.5MM CORONARY STENT",SUP-H7493952812250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2554.34,45.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 60MM TSRH OSTEOGRIP TITANIUM THIN SPINE",SUP-83575609,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,299.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",299.36,2187.9,"percent of total billed charges",
"PK PAPYRUS 5.0/20",SUP-434898,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5652.59,28.62,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 8MM 140CM 3.5MM CORONARY STENT",SUP-LUN350R08US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 36CM HIP LEFT FEMUR AFFIXUS INTRAMEDULLARY 130D",SUP-814609360,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"CIGNA [10200]",Cigna,,8297.1,40,,1831.33,1831.33,1831.33,16,2412.38,17631.34,"percent of total billed charges",
"KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC",695,MS-DRG,,,,,,,inpatient,,,41840.17,12552.05,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,7591.7,,"Case rate ($7,095.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,588.24, add-ons for qualifying new technology services are included. If operating cost exceeds $39,627.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,880.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,596.96. The transfer operating threshold is the transfer adjustment factor * $6,588.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $498.10. The transfer capital threshold is the transfer adjustment factor * $498.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7095.05,28525.23,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 18-14MM 14MM 11FR TRIVASCULAR OVATION",SUP-TV-IL1418100-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9015.3,27,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cardiovsn Elect Intrnl",PX-480000036,CDM,92961,CPT,0481,RC,,,both,,,986.88,296.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,452.98,45.9,,,,,0,114.77,986.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 9MM 140CM 3MM CORONARY",SUP-RSINT30009UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1586.69,28.62,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 100MM 1800MM 8MM 2.33MM BILIARY METAL",SUP-SHS-08-100-180,CDM,C1874,HCPCS,0278,RC,,,both,,,6855.84,2056.75,"NOVANET [10819]",Novanet,,5141.88,75,,,,,0,797.33,5827.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WINGSPAN 15MM 4MM INTRACRANIAL HYDROPHILIC SELF EXPAND",SUP-M003WS0400150,CDM,C1874,HCPCS,0278,RC,,,both,,,51979.47,15593.84,"CIGNA [10200]","Cigna Local Plus",,16373.53,31.5,,,,,0,6045.21,44182.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 80MM 80CM 7MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM07080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4932.9,27,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 22MM 4.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG45022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2887.50,866.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,335.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM SPINAL POLYAXIAL",SUP-8456550,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"FIRST HEALTH [10303]","First Health",,3874.08,80,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"C2 IVL CATHETER, 2.5 X 12 MM",SUP-C2IVL2512,CDM,C1761,HCPCS,0272,RC,,,both,,,29610.00,8883,"CIGNA [10200]","Cigna Open Access",,16848.09,56.9,,,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI CHIKAI VASCULAR STRAIGHT 200CM 30CM .36MM",SUP-WAIN-CKI-200,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"FIRST HEALTH [10303]","First Health",,3000,80,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"I-GEL, SINGLE USE SUPRAGLOTTIC AIRWAY, SIZE 4",SUP-8204000,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.19,23.76,"NOVANET [10819]",Novanet,,59.39,75,,,,,0,9.21,67.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +22 DIOPTER MODIFIED C BICONVEX 12.5MM 7MM",SUP-CZ70BD.220,CDM,V2632,HCPCS,0276,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 8.75IN MALIS STRAIGHT TIP NDL TITANIUM BAYONET .4MM",SUP-80-1515,CDM,S27200284,LOCAL,0272,RC,,,both,,,2164.95,649.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1472.17,68,,,,,0,251.78,1840.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 57SQ CM 13MM 51X66MM COBALT TITANIUM",SUP-DDPA2D1,CDM,C1721,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6905.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTOURA BREAST TISSUE EXPANDER HIGH PROJECTION 300CC",SUP-TEXP110RH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"UHC [10700]","United Healthcare",,8713.56,63.3,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM INTERLOCK IDC OCCLUSION SYSTEM",SUP-M001363550,CDM,S27800098,LOCAL,0278,RC,,,both,,,3891.60,1167.48,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1786.24,45.9,,,,,0,452.59,3307.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +15 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.150,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]",Cigna,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 30MM CLEVERCUT3V PRELOAD DISTAL TIP STERILE",SUP-KD-VC631Q-07301S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2817.75,845.32,"KAISER [10500]",Kaiser,,1887.89,67,,,,,0,327.7,2395.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 4X4IN CUTIMED EPIONA TISSUE 90% NATIVE CLLGN 10%",SUP-7322701,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.04,63.01,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,86.33,41.1,,,,,0,24.43,178.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL LMD 10  IN N S 500ML",SUP-07419-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,244.21,73.26,"UHC [10700]","United Healthcare",,154.58,63.3,,,,,0,28.4,207.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD MARLEX 14X10IN GROIN MONOFILAMENT GOLD",SUP-0112660,CDM,C1781,HCPCS,0278,RC,,,both,,,1498.50,449.55,"KAISER [10500]",Kaiser,,1004,67,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RECTAL RESECTION WITHOUT CC/MCC",334,MS-DRG,,,,,,,inpatient,,,90693.67,27208.1,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,20687.77,,"Case rate ($10,159.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,434.24, add-ons for qualifying new technology services are included. If operating cost exceeds $42,473.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,095.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $9,446.72. The transfer operating threshold is the transfer adjustment factor * $9,434.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.27. The transfer capital threshold is the transfer adjustment factor * $713.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,47820.13,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SUPIRA CATHETER",SUP-FG-03242,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE METRX ORTHOPEDIC MEDIUM 30CM .062IN REUSABLE",SUP-955-519,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN IRRIGATION 9/64IN 20GA BD VISITEC 55D ANTERIOR CHMBR",SUP-585061,CDM,S27200284,LOCAL,0272,RC,,,both,,,962.60,288.78,"KAISER [10500]",Kaiser,,644.94,67,,,,,0,111.95,818.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 25X9X12MM COROENT 8D LARGE CONTOUR PEEK LUMBAR",SUP-6612925,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4739.47,28.62,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.7MM CANNULATED",SUP-CSS07237SQ,CDM,S27200284,LOCAL,0272,RC,,,both,,,1506.60,451.98,"AETNA [10100]","Aetna HMO/PPO",,1197.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,175.22,1280.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 125CM EPXT OCTAPOLAR EASY MATE",SUP-200774P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC",868,MS-DRG,,,,,,,inpatient,,,32172.67,9651.8,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 111MM TYPE 1 TAPERLOC MICROPLASTY PPS 133D 13",SUP-51106130,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3251.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3190.72,23319.95,"percent of total billed charges",
"RING RTRCTR LONE STAR NORYL PLASTIC 2 PEEL POUCH SELF RETAIN",SUP-3308G,CDM,S27200284,LOCAL,0272,RC,,,both,,,642.25,192.67,"KAISER [10500]",Kaiser,,430.31,67,,,,,0,74.69,545.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 22MM AO QUICK 1.2MM SCREWS",SUP-60-10322,CDM,S27200284,LOCAL,0272,RC,,,both,,,724.63,217.39,"CIGNA [10200]","Cigna Open Access",,412.31,56.9,,,,,0,84.27,615.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN JUDKINS RIGHT 3.5 CURVE",SUP-DXT5JR35,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"KAISER [10500]",Kaiser,,55.38,67,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-3 TH-26 36IN MONOFILAMENT WHITE",SUP-3N07A,CDM,S27200284,LOCAL,0272,RC,,,both,,,255.93,76.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,30.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.76,217.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH X-FORCE N30 15CM 7FR 10MM 30 ATM STRAIGHT BALLOON",SUP-995101,CDM,C1726,HCPCS,0272,RC,,,both,,,1931.25,579.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1313.25,68,,,,,0,224.6,1641.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG BLACK 26X15CM GRANUFOAM VAC THK1.6CM THIN PRECUT",SUP-M8275081/5.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,441.46,132.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,202.63,45.9,,,,,0,51.34,375.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BREAST BIOPSY 10CM LOCALIZER 20 APPLR",SUP-09-0007,CDM,S27200284,LOCAL,0272,RC,,,both,,,2055.00,616.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,243.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239,1746.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 CT-1 36IN BRAID COATED UNDYED ABSORBABLE",SUP-J944H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 8MM TRI-LOCK APTUS TITANIUM HEXADRIVE 6 TAPER",SUP-A-5450.08/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXCELSIOR SL-10 PRE-SHAPED 45 150CM",SUP-M0031681900,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3543.13,45.9,,,,,0,897.75,6561.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11.75CM NATRELLE INSPIRA P3.1CM LOW PLUS PROFILE",SUP-MSZ-LP235,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,72.6,45.9,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 3-0 KS 30IN MONOFILAMENT BLACK NONABSORBABLE",SUP-627H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG HEMOSTATIC 5X5IN QUIKCLOT CONTROL+ 4 PLY STERILE LATEX",SUP-4000,CDM,S27200284,LOCAL,0272,RC,,,both,,,497.06,149.12,"CIGNA [10200]",Cigna,,338,68,,,,,0,57.81,422.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 6-0 P-1 18IN MONOFILAMENT UNDYED NONABSORBABLE",SUP-689G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 90CM 3FR ODEC16MM 4 WIRE STONE",SUP-M0063901020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1416.61,424.98,"CIGNA [10200]","Cigna Local Plus",,757.89,53.5,,,,,0,164.75,1204.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -4MM 32MM HIP BIOLOX DELTA V40",SUP-6570-0-032,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"BLUE CROSS [10001]","Blue Cross PPO",,3920,39.2,,3949.44,3949.44,3949.44,"1 through 10",1163,8500,"percent of total billed charges",
"CATH TREK 25MM 3.25MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012408-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 16MM 2MM 3.5MM CORTEX CRANIOMAXILLOFACIAL TITANIUM",SUP-401.816.96,CDM,C1713,HCPCS,0278,RC,,,both,,,319.12,95.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",37.11,271.25,"percent of total billed charges",
"CATH NC EUPHORA 142CM 6MM 3.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP3506X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,233.04,41.1,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 3MM 440MM INTRAMEDULLARY ELASTIC TITANIUM PEDIATRIC",SUP-475.930S,CDM,C1713,HCPCS,0278,RC,,,both,,,1982.40,594.72,"KAISER [10500]",Kaiser,,1328.21,67,,,,,0,230.55,1685.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Cytp Slctv / Add on 88112",PX-311000081,CDM,0830T,CPT,0311,RC,,,both,,,104.00,31.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.74,41.1,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 25MM 3.75MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012410-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP050250090 PLUS US D5L250UL900",SUP-PCP050250090,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"PHCS [10601]",PHCS,,888.78,70,,,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 14.7MM 21MM 26MM 19.4MM ON-X 21 STD CYLINDRICAL",SUP-ONXAE-21,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"MULTIPLAN [10600]",Multiplan,,32130,85,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM CEMENTLESS OFFSET ACCOLADE TMZF 127D 5 48",SUP-6021-0537,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"BLUE CROSS [10001]","Blue Cross PPO",,6134.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",1820,13301.82,"percent of total billed charges",
"PENIS PROCEDURES WITH CC/MCC",709,MS-DRG,,,,,,,inpatient,,,78096.88,23429.06,"CIGNA [10200]",Cigna,,30512.94,,"Fee schedule rate ($30,512.94). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,67942.01,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION AQUALITE 0.9% SODIUM CHLORIDE 1.5L LATEX FREE",SUP-713836,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPR LD SFSHTH INR CATH SLF SL",SUP-410195,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR 180CM 3CM .014IN GLIDEX",SUP-M001467400,CDM,C1769,HCPCS,0272,RC,,,both,,,1539.00,461.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,182.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 80MM 12MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171120870,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEIGHT EYELID THK1MM GOLD CONTOUR .8GM SPHERICAL CURVATURE",SUP-LL3008,CDM,L8699,HCPCS,0278,RC,,,both,,,1875.00,562.5,"BLUE CROSS [10001]","Blue Cross HMO",,735,39.2,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHARGER 12.0 X60  75CM",SUP-H74939206120670,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2.5 X 3 HELICAL PICO COIL",SUP-10USH02503,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-03008,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"BLUE CROSS [10001]","Blue Cross HMO",,3513.54,39.2,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL SHAFT ALLOGRAFT FROZEN 70MM 10+ MM",SUP-450420,CDM,S27800098,LOCAL,0278,RC,,,both,,,5402.70,1620.81,"CIGNA [10200]","Cigna Local Plus",,2890.44,53.5,,,,,0,628.33,4592.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DAC 044 136CM",SUP-90762,CDM,S27200284,LOCAL,0272,RC,,,both,,,9626.67,2888,"NOVANET [10819]",Novanet,,7220,75,,,,,0,1119.58,8182.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPLICATIONS OF TREATMENT WITHOUT CC/MCC",921,MS-DRG,,,,,,,inpatient,,,30472.67,9141.8,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,4398.3,,"Case rate ($4,270.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,965.16, add-ons for qualifying new technology services are included. If operating cost exceeds $37,004.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,681.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,970.40. The transfer operating threshold is the transfer adjustment factor * $3,965.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $299.79. The transfer capital threshold is the transfer adjustment factor * $299.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4270.19,17168.01,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET",RX-31684,CDM,,,0637,RC,50268-0758-11,NDC,both,1,UN,25.19,7.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.56,45.9,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEIZURES WITH MCC",100,MS-DRG,,,,,,,inpatient,,,37993.84,11398.15,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,12734.95,,"Case rate ($12,014.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,155.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,195.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,225.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,170.65. The transfer operating threshold is the transfer adjustment factor * $11,155.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $843.44. The transfer capital threshold is the transfer adjustment factor * $843.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,37993.84,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840007535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4382,45.9,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,inpatient,,,32839.80,9851.94,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,9331.62,,"Case rate ($4,340.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,030.25, add-ons for qualifying new technology services are included. If operating cost exceeds $37,069.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,686.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,035.58. The transfer operating threshold is the transfer adjustment factor * $4,030.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $304.71. The transfer capital threshold is the transfer adjustment factor * $304.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,4340.29,17449.82,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 10CM 28MM TAG THORACIC ACTIVE CONTROL",SUP-TGM282810,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13742.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 217MM 38MM 33-34MM ZENITH ALPHA FLEXOR",SUP-G35360,CDM,C1874,HCPCS,0278,RC,,,both,,,88350.00,26505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10469.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10275.11,75097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 30MM 80CM 6MM 8FR STRAIGHT VASCULAR",SUP-AVSM06030,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"MULTIPLAN [10600]",Multiplan,,15529.5,85,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW TPS THK.38MM MICRO RIGHT INFERIOR BORDER",SUP-5100037901,CDM,S27200284,LOCAL,0272,RC,,,both,,,854.23,256.27,"KAISER [10500]",Kaiser,,572.33,67,,,,,0,99.35,726.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 24FR URETHRAL SILASTIC 30CC 2 WAY 2 STAGGER DRNG EYE",SUP-33424,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.11,15.03,"KAISER [10500]",Kaiser,,33.57,67,,,,,0,5.83,42.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000110,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT ORTHOPEDIC 16MM SIDEKICK CIRCULAR FIXTR",SUP-RR1600,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"CIGNA [10200]","Cigna Local Plus",,186.18,53.5,,3978.14,359.25,3978.14,24,40.47,295.8,"percent of total billed charges",
"KIT CATH ADULT 55CM 15.5FR POLYURETHANE BIOFLO DURAMAX",SUP-H787103028095,CDM,C1750,HCPCS,0278,RC,,,both,,,1212.60,363.78,"KAISER [10500]",Kaiser,,812.44,67,,,,,0,141.03,1030.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC LARGE 17X12IN ARM HEAVY DUTY ICE BAG",SUP-8011-03,CDM,S27000186,LOCAL,0270,RC,,,both,,,108.58,32.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,44.63,41.1,,,,,0,12.63,92.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM STAINLESS STEEL T25 SELF TAP LOCK VARIABLE",SUP-02.231.234,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"CIGNA [10200]","Cigna Local Plus",,699.69,53.5,,3978.14,359.25,3978.14,24,152.1,1111.66,"percent of total billed charges",
"CAP SYSTEM VANGUARD TKR FEMUR PATELLA TIBIA ARTICULAR SURFAC",SUP-98000600087,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Local Plus",,5953.5,31.5,,5372.07,4581.20,7242.98,23,2198.07,16065,"percent of total billed charges",
"CANN PERFUSION 17IN 26FR VENOUS ADULT 3/8IN CNCT 1 STAGE DLP",SUP-67526,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.59,90.48,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GATEWAY 135CM 15MM 1.5MM BALLOON DILATATION HYDROPHILIC",SUP-M0032072215150,CDM,C1725,HCPCS,0272,RC,,,both,,,9423.88,2827.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,MODERATE",049,APR-DRG,,,,,,,inpatient,,,227891.60,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $10,035.69. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($35,905.21) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 ALL other APRDRG- IP DRG OUTLIER; Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 19MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-519,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"CIGNA [10200]","Cigna Open Access",,5593.57,56.9,,5302.19,4377.88,6578.61,27,1143.29,8355.94,"percent of total billed charges",
"HC Grad Compression Gauntlet",PX-E27100007,CDM,S8428,HCPCS,0292,RC,,,both,,,210.00,63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.42,178.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX 20MM 80CM 10MM 6FR .035IN BILIARY CATH",SUP-ZBM10020,CDM,C1874,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2863.43,28.62,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AERO 15MM 110CM 6MM TRACHEOBRONCHIAL FULLY COVER",SUP-AERO615,CDM,C1874,HCPCS,0278,RC,,,both,,,16215.00,4864.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1921.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1885.8,13782.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 157MM 28MM 22FR VALIANT CAPTIVIA SINUSOIDAL",SUP-VAMF2828C150TU,CDM,C1874,HCPCS,0278,RC,,,both,,,96985.50,29095.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11492.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11279.41,82437.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 28MM AEQUALIS TITANIUM HUMERAL PROXIMAL",SUP-7425028,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,147.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",145.07,1060.29,"percent of total billed charges",
"SYSTEM VALLEYLAB SMOKE EVAC LAPAROSCOPIC",SUP-SEL7010,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.21,44.76,"KAISER [10500]",Kaiser,,99.97,67,,,,,0,17.35,126.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPEL APD TWIST-LOC 15CM 10FR SHORT LENGTH PIGTAIL",SUP-H7493931110150,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"AETNA [10100]","Aetna HMO/PPO",,618.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE LARGE MALE BEIGE CANVAS RUBBER CLOSED",SUP-2041-03,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.42,14.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,21.77,45.9,,,,,0,5.51,40.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 30CM 6FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251350,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS [10001]","Blue Cross PPO",,482.54,39.2,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE WALKING LARGE STD FOOT ANKLE 1 PIECE 2 LAYER MEMORY",SUP-SL8001-07,CDM,S27000186,LOCAL,0270,RC,,,both,,,228.03,68.41,"MULTIPLAN [10600]",Multiplan,,193.83,85,,,,,0,26.52,193.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR 30CM 6FR .038IN BLADDER LOOP LOW",SUP-M006155235120,CDM,C2617,HCPCS,0278,RC,,,both,,,1325.65,397.69,"FIRST HEALTH [10303]","First Health",,1060.52,80,,,,,0,154.17,1126.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER DIAGNOSTIC 4FR 110CM 145DEG GUIDEWIRE 0.035IN NYLON",SUP-538457V,CDM,C1769,HCPCS,0272,RC,,,both,,,89.52,26.86,"NOVANET [10819]",Novanet,,67.14,75,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MERIT LAUREATE VASCULAR ANGLE 260CM 3CM .035IN NITINOL",SUP-LWSTDA35260EX,CDM,C1769,HCPCS,0272,RC,,,both,,,295.80,88.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,201.14,68,,,,,0,34.4,251.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RED 43 REPERFUSION CATHETER 138 CM",SUP-RED43138,CDM,C1757,HCPCS,0272,RC,,,both,,,16767.00,5030.1,"MULTIPLAN [10600]",Multiplan,,14251.95,85,,,,,0,1950,14251.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE UNICORTICAL DOWEL ALLOGRAFT FREEZE DRIED 16-40MM",SUP-400230,CDM,S27800098,LOCAL,0278,RC,,,both,,,4413.24,1323.97,"AETNA [10100]","Aetna HMO/PPO",,3508.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,513.26,3751.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 46MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.046S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"TUBE ENDOTRACHEAL SHILEY EVAC TAPERGUARD OD11.8 MM ID8.0 MM",SUP-18880S,CDM,S27200284,LOCAL,0272,RC,,,both,,,159.85,47.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,65.7,41.1,,,,,0,18.59,135.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 58CM .016IN KNOB CAP KT",SUP-6059,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABRE VENOUS SELF-EXPADING STENT16X100X90",SUP-AB9T16100090,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.270 CLAREON",SUP-SY60WF.270,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 60CM 8MM GORE STD WALL HEPARIN PROPATEN PTFE",SUP-H080060A,CDM,C1768,HCPCS,0278,RC,,,both,,,11378.10,3413.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4676.4,41.1,,,,,0,1323.27,9671.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN OMEGA3 MARIGEN 16MM CIRCULAR FISH SKIN STERILE",SUP-50200S16B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,180.89,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 10MM RADIUS 110CM .035IN STAINLESS STEEL",SUP-G26957,CDM,C1769,HCPCS,0272,RC,,,both,,,700.57,210.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,83.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.48,595.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZIPWIRE BENTSON UROLOGICAL STRAIGHT 150CM 8CM .035IN",SUP-M0066802241,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING SCR IN ELECTRD ACTIVE FIXATION BIPOLAR IS 1 CNCT",SUP-1688TC/58,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"MULTIPLAN [10600]",Multiplan,,1897.63,85,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.3MM 20MM DISTAL VOLAR RADIUS FOSSA THREADED",SUP-TPLS-23200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,680.40,204.12,"CIGNA [10200]",Cigna,,462.67,68,,1831.33,1831.33,1831.33,16,79.13,578.34,"percent of total billed charges",
"GUIDEWIRE PACING LEAD 65CM FINISHING WIRE SUPPORTRAK LV-1",SUP-6681,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"FIRST HEALTH [10303]","First Health",,907.2,80,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL DURAL DURAGEN 4X 5IN SQUARE CALLAGEN DURAMATRIX REPAIR",SUP-DMR45,CDM,,,0278,RC,,,both,,,11364.99,3409.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1346.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.36,9660.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 170MM 2.4MM SCR LCP BONE WRIST STERILE",SUP-242.003S,CDM,C1713,HCPCS,0278,RC,,,both,,,17470.72,5241.22,"UHC [10700]","United Healthcare",,11058.97,63.3,,5023.51,2672.93,6679.78,18,2031.84,14850.11,"percent of total billed charges",
"GWIRE SYNCHRO2 VASCULAR STD STRAIGHT 215CM .014IN",SUP-SSTD215STR,CDM,C1769,HCPCS,0272,RC,,,both,,,4186.64,1255.99,"NOVANET [10819]",Novanet,,3139.98,75,,,,,0,486.91,3558.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN OMEGA3 LYOPHILIZED ACELLULAR FISH SKIN STERILE",SUP-50200P04D0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,13800.00,4140,"AETNA [10100]","Aetna HMO/PPO",,10971,79.5,,,,,0,180.89,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 20CMX.49MM 20MM HEMAGARD STRAIGHT POLYESTER",SUP-HGK0020-20,CDM,C1768,HCPCS,0278,RC,,,both,,,1926.00,577.8,"KAISER [10500]",Kaiser,,1290.42,67,,,,,0,223.99,1637.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 SH 2 ARM BRAID GREEN WHITE STERILE",SUP-10X82N,CDM,S27200284,LOCAL,0272,RC,,,both,,,384.12,115.24,"FIRST HEALTH [10303]","First Health",,307.3,80,,,,,0,44.67,326.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 24/26FR STERILE DISPOSABLE",SUP-27040GP1-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3100.64,930.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2108.44,68,,,,,0,360.6,2635.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 244CM REPROCESSED STERILE LATEX FREE REUSABLE",SUP-05508SPR,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,195.23,68,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AXS INFINITY LS PLUS LONG 70CM 8FR .091IN INTRO",SUP-INC-11196-70,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTERIAL LINE 5IN 20GA 18GA .025IN RADIAL ARTERY CATH",SUP-AK-04510-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.12,72.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.93,204.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 3-0 SH-1 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-G182H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UHC [10700]","United Healthcare",,15.83,63.3,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 110CM 6FR PIGTAIL CURVE ANGIOGRAPHIC PERIPHERAL",SUP-H74916599402,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GASTROJEJUNOSTOMY TUBE 14FR STOMA L2.5CM JEJUNAL L30CM S",SUP-8270-14-2.5-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,3027.60,908.28,"FIRST HEALTH [10303]","First Health",,2422.08,80,,,,,0,352.11,2573.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CASSETTE WOUND DRNG VAC VERALINK NONSTERILE DISPOSABLE",SUP-ULTLNK0500.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE EMBOLIZATION RED EMBOGOLD 500-700UM GELATIN 2% GOLD",SUP-S610EG,CDM,S27800098,LOCAL,0278,RC,,,both,,,2175.00,652.5,"NOVANET [10819]",Novanet,,1631.25,75,,,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 85MM 2-6MM VORTX 18 COIL PLATINUM FIBER",SUP-M0013812061,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CARDIONYL 5-0 12MM MONOFILAMENT NONABSORBABLE",SUP-721202,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.11,20.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,31.72,45.9,,,,,0,8.04,58.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 28.5X5.5MM THK.4MM THK.6MM SMALL BONE OSCILLATE",SUP-KM-3001,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"NOVANET [10819]",Novanet,,46.33,75,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FALCON PRECISION CARTRIDGE 90MM",SUP-6725127090,CDM,S27200284,LOCAL,0272,RC,,,both,,,2580.23,774.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,305.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,300.08,2193.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET",RX-31864,CDM,,,0250,RC,00406-0523-23,NDC,both,1,UN,31.21,9.36,"AETNA [10100]","Aetna HMO/PPO",,24.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.63,26.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP MONOPOLAR 230X4MM 2.75MM 3.2MM COAGRASPER HEMOSTASIS",SUP-FD-411UR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.83,513.25,"CIGNA [10200]","Cigna Open Access",,973.46,56.9,,,,,0,198.97,1454.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 20CM ACHIEVE LIGHTWEIGHT AUTOMATE",SUP-A1820,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.39,103.02,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,157.62,45.9,,,,,0,39.94,291.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 8FR 200CMX2.1MM RAPID EXCHANGE COMBO CATH",SUP-M00545000,CDM,S27200284,LOCAL,0272,RC,,,both,,,873.34,262,"CIGNA [10200]",Cigna,,593.87,68,,,,,0,101.57,742.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.5/26",SUP-401763,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,inpatient,,,27970.34,8391.1,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,8418.05,,"Case rate ($7,867.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,305.36, add-ons for qualifying new technology services are included. If operating cost exceeds $40,345.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,934.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,315.02. The transfer operating threshold is the transfer adjustment factor * $7,305.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $552.32. The transfer capital threshold is the transfer adjustment factor * $552.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,27970.34,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 90CM 6MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT067090A,CDM,C1768,HCPCS,0278,RC,,,both,,,19240.20,5772.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5506.55,28.62,,,,,0,2237.64,16354.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 4N 8MM",SUP-TPS-030-084N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 105MM 13.3MM 8MM CUFFLESS DISTAL EXT EXTEND LENGTH SOFT",SUP-80XLTUD,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,329.98,68,,,,,0,56.44,412.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 125CM 6FR 145D PIGTAIL CURVE ANGIOGRAPHIC",SUP-7569-53,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.74,23.62,"MULTIPLAN [10600]",Multiplan,,66.93,85,,,,,0,9.16,66.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG VALU-BAGS BUTT-FLAP 8MM UNIVERSAL U FRAME UROLOGY",SUP-CMS-999,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.10,21.03,"AETNA [10100]","Aetna HMO/PPO",,55.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.15,59.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE MNTR CENTURION STERILE LATEX FREE",SUP-CUHG1-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,553.73,166.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,376.54,68,,,,,0,64.4,470.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 28MMX8MMX20CM 22FR",SUP-TAC082820A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"MULTIPLAN [10600]",Multiplan,,155040,85,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 207MM 38MM 24FR VALIANT CAPTIVIA SINUSOIDAL",SUP-VAMF3838C200TU,CDM,C1874,HCPCS,0278,RC,,,both,,,102229.50,30668.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,27601.97,27,,,,,0,11889.29,86895.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TANGENT 4D ALLOGRAFT FREEZE DRIED WEDGE IMPACTED",SUP-171426,CDM,S27800098,LOCAL,0278,RC,,,both,,,12572.49,3771.75,"NOVANET [10819]",Novanet,,9429.37,75,,,,,0,1462.18,10686.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 4-0 P-12 18IN CLSR ABSORBABLE CLEAR",SUP-VLOCL0023,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.73,70.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,96.47,41.1,,,,,0,27.3,199.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 70X12.5X.64MM STAINLESS STEEL RECIPROCATING 2",SUP-0277096275,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.41,87.12,"UHC [10700]","United Healthcare",,183.83,63.3,,,,,0,33.77,246.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC HANDLE AEON MEDIUM STERILE LATEX FREE",SUP-AESH160,CDM,S27200284,LOCAL,0272,RC,,,both,,,1134.00,340.2,"KAISER [10500]",Kaiser,,759.78,67,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MINITAPE CURVE NDL ASSEMB BLUE NONABSORBABLE",SUP-72205434,CDM,S27200284,LOCAL,0272,RC,,,both,,,484.79,145.44,"PHCS [10601]",PHCS,,339.35,70,,,,,0,56.38,412.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW PHTHALATE FREE",SUP-CG-09-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTNSL CUTLERY SPOON FINGER CONTOUR LIGHTWEIGHT STAINLESS",SUP-AA5555,CDM,S27200284,LOCAL,0272,RC,,,both,,,97.18,29.15,"NOVANET [10819]",Novanet,,72.89,75,,,,,0,11.3,82.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW PHTHALATE FREE",SUP-CG-09-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 135X30MM EIKON LT LOW PROFILE NONCONDUCTIVE SURGICAL",SUP-C135,CDM,S27200284,LOCAL,0272,RC,,,both,,,7832.88,2349.86,"CIGNA [10200]",Cigna,,5326.36,68,,,,,0,910.96,6657.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CXI 150CM 2.3FR SPRT STAINLESS STEEL HYDROPHILIC",SUP-G18373,CDM,S27200284,LOCAL,0272,RC,,,both,,,1522.72,456.82,"CIGNA [10200]","Cigna Open Access",,866.43,56.9,,,,,0,177.09,1294.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 4X4IN MELGISORB SILVER CALCIUM ALGINATE HIGH",SUP-565976,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.72,23.92,"PHCS [10601]",PHCS,,55.8,70,,,,,0,9.27,67.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG SILVER CELOS ETHYL SULPHONATE FIBER ANTIMICROBIAL",SUP-66800571,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.97,20.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,32.12,45.9,,,,,0,8.14,59.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH SURGICAL RAIL 6MM",SUP-6975406,CDM,S27200284,LOCAL,0272,RC,,,both,,,3656.25,1096.87,"KAISER [10500]",Kaiser,,2449.69,67,,,,,0,425.22,3107.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 30MMX3.5MM PI TITANIUM MEDIUM THICK TISSUE",SUP-4907T,CDM,S27200284,LOCAL,0272,RC,,,both,,,392.20,117.66,"CIGNA [10200]","Cigna Local Plus",,209.83,53.5,,,,,0,45.61,333.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH KOALA INTRAUTERINE PRESSURE SENSOR TIP LUMEN LATEX FREE",SUP-IPC-5000E,CDM,S27200284,LOCAL,0272,RC,,,both,,,252.30,75.69,"CIGNA [10200]","Cigna Local Plus",,134.98,53.5,,,,,0,29.34,214.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE TAPE BROADBAND 5 BLACK WHITE CUTTING CORELESS SINGLE",SUP-110045775,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,241.66,45.9,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE TAPE BROADBAND 5 BLACK WHITE CUTTING CORELESS SINGLE",SUP-110045775,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"CIGNA [10200]","Cigna Open Access",,299.58,56.9,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAVER ULTRASONIC MICRO HOOK AND TUBESET NEXUS BONESCALPEL",SUP-110-31-1210,CDM,S27200284,LOCAL,0272,RC,,,both,,,4021.71,1206.51,"FIRST HEALTH [10303]","First Health",,3217.37,80,,,,,0,467.72,3418.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 3.5MM PRESTIGE PLUS HELICAL HELICAL",SUP-PRES0355CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 36IN 8FR STD TIP RIGID PORT RADIOPAQUE",SUP-8884720825E,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.01,31.8,"FIRST HEALTH [10303]","First Health",,84.81,80,,,,,0,12.33,90.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BALLOON DILATATION ARCADIA 15MM STEERABLE LOCK CEMENT",SUP-ARC15SB-LK,CDM,S27200284,LOCAL,0272,RC,,,both,,,17640.00,5292,"PHCS [10601]",PHCS,,12348,70,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY 10CM 20GA 19GA MISSION TRUGUIDE 10MM 20MM BLUNT",SUP-2010MSK,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"MULTIPLAN [10600]",Multiplan,,347.57,85,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT HAND ACCESS 120MM OBTR OPTICAL TIP AUTOMATIC VENT LOW",SUP-IAS12-120,CDM,S27200284,LOCAL,0272,RC,,,both,,,760.06,228.02,"FIRST HEALTH [10303]","First Health",,608.05,80,,,,,0,88.39,646.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE RUMI II KOH-EFFICIENT 4CM UTERINE CERVIX STERILE",SUP-KC-RUMI-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,1091.28,327.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,126.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,126.92,927.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AERO 30MM 62CM 10MM 16FR GEOMETRIC TRACHEOBRONCHIAL",SUP-90129-208,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"PHCS [10601]",PHCS,,12075,70,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,inpatient,,,71618.94,21485.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,21452.29,,,,,,,7561,39283.22,"case rate",
"GRAFT SOFT TISSUE FLEXIGRAFT TENDON ALLOGRAFT CONNECT",SUP-FCON,CDM,S27800098,LOCAL,0278,RC,,,both,,,8433.87,2530.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3871.15,45.9,,,,,0,980.86,7168.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3MM CEREPAK XTRASOFT FREEFORM",SUP-XCR120308,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"MULTIPLAN [10600]",Multiplan,,11241.97,85,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 15CM 12FR POWER-TRIALYSIS SLIM-CATH 3 LUMEN KINK",SUP-5865150,CDM,C1752,HCPCS,0272,RC,,,both,,,1649.25,494.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,195.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,191.81,1401.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON DEKLENE II 7-0 XT-6.5 24IN MONOFILAMENT DOUBLE ARM",SUP-D-7506M1K,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.30,66.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.97,189.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC30ST-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,19530.00,5859,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13280.4,68,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA IRRIGATION IO-FLEX IPSI",SUP-IO-IC,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"AETNA [10100]","Aetna HMO/PPO",,269.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.46,288.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SHORT 25MM INTERNAL STRAIGHT",SUP-PL544S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BERMAN 110CM 7FR 11MM .038IN ANGIOGRAPHIC 1.25ML 2",SUP-AI-07137,CDM,S27200284,LOCAL,0272,RC,,,both,,,2332.50,699.75,"CIGNA [10200]","Cigna Local Plus",,1247.89,53.5,,,,,0,271.27,1982.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 29.5X7MM STRYKER THK.38MM MICRO OSCILLATE SAGITTAL",SUP-SM-3115,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 8.5MM CUFF MURPHY EYE REINFORCE KINK",SUP-DYNJAARC85,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.56,83.87,"NOVANET [10819]",Novanet,,209.67,75,,,,,0,32.51,237.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEPHRSTMY 12FR LOCK REGULAR DUROMETER 25CM FLEXIMA",SUP-M001271880,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 40MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45040,CDM,C1874,HCPCS,0278,RC,,,both,,,90294.33,27088.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,37110.97,41.1,,,,,0,10501.23,76750.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 0D TRUDI SURGICAL STERILE LATEX FREE DISPOSABLE",SUP-TDC0005,CDM,S27200284,LOCAL,0272,RC,,,both,,,2437.50,731.25,"FIRST HEALTH [10303]","First Health",,1950,80,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT RED 18X4IN 10.5-16.5IN ATS 750/1200 CYL 1 PORT 1",SUP-60707515300,CDM,S27200284,LOCAL,0272,RC,,,both,,,211.85,63.55,"FIRST HEALTH [10303]","First Health",,169.48,80,,,,,0,24.64,180.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 5MM KII Z THREAD SLEEVE NONBLADE",SUP-CTR03,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"KAISER [10500]",Kaiser,,104.92,67,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL .7MM ROUND DIAMOND REINFORCE TIP QUICK CONNECT",SUP-5452012007,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLUX PROTEIIIOS GROWTH FACTOR L",SUP-IFLX-GF-050,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4443.26,28.62,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 28MM 143CM 2.75MM CORONARY EVEROLIMUS ELUTING",SUP-1009540-28,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"CIGNA [10200]","Cigna Open Access",,5457.28,56.9,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIPASE-PROTEASE-AMYLASE (PORK) 3,000-9,500-15,000 UNIT CAPSULE,DEL REL",RX-111147,CDM,,,0637,RC,00032-0045-70,NDC,both,1,UN,10.94,3.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.27,9.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2MM 2MM .018IN HELICAL STRAIGHT PLATINUM",SUP-M0013120021,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"CIGNA [10200]",Cigna,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 70MM PRESS FIT AEQUALIS ASCEND FLEX PTC 127.5D",SUP-DWF602A,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"KAISER [10500]",Kaiser,,8442,67,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 3.5IN 17GA 19GA PERIFIX TUOHY BPA DEHP PVC",SUP-332086,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.45,61.03,"CIGNA [10200]",Cigna,,138.35,68,,,,,0,23.66,172.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ROCHESTER-PEAN STRAIGHT 6.25IN ARTERY",SUP-BH442R,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.71,57.81,"NOVANET [10819]",Novanet,,144.53,75,,,,,0,22.41,163.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13CM NATRELLE INSPIRA P4.3CM MODERATE PROFILE",SUP-MSZ-M375,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AETNA [10100]","Aetna HMO/PPO",,125.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"Bien-Air 40deg Curved Adenoid, Double Serrated, Convex, 4.0m",SUP-1600572,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,582.59,41.1,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL 6MM SAPHENOUS VEIN RENAL ARTERY .75 SPRING",SUP-A1801,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 20CM OCCL GLDEWIRE NEPHRSTMY INTRO PERCUTANEOUS",SUP-M0067001220,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.79,81.54,"AETNA [10100]","Aetna HMO/PPO",,216.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.61,231.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX21MM FRA 8D 30D NARROW SPINE LUMBAR",SUP-221,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6.7MM 6MM INTERLOCK VORTX FIBERED IDC 18",SUP-M0013822061,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANISTER SUCTION ENGN NS",SUP-PAPS3,CDM,S27200284,LOCAL,0272,RC,,,both,,,2737.50,821.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,318.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR IMC CURVE ANGIOGRAPHIC TRILON BRACHIAL",SUP-H749085262031,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"FIRST HEALTH [10303]","First Health",,56.73,80,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 11.5X9X.38MM PRECISION SHORT MEDIUM STAINLESS",SUP-2296003411,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"CIGNA [10200]","Cigna Open Access",,153.76,56.9,,,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPLR ANASTOMOSIS 2MM FLOW ULTRASONIC DOPPLER IMPLANTABLE 20",SUP-GEM2752-FC,CDM,S27200284,LOCAL,0272,RC,,,both,,,7569.30,2270.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,896.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,880.31,6433.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 35FR ANGLE 2 RIGHT",SUP-M126135,CDM,S27200284,LOCAL,0272,RC,,,both,,,520.51,156.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,353.95,68,,,,,0,60.54,442.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VORTIOXETINE 10 MG TABLET",RX-164866,CDM,,,0250,RC,64764-0730-30,NDC,both,1,UN,81.63,24.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,55.51,68,,,,,0,9.49,69.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPLICATED PEPTIC ULCER WITH MCC",380,MS-DRG,,,,,,,inpatient,,,65490.26,19647.08,"PHCS [10601]",PHCS,,7561,,,,,,,7561,48935.31,"per diem","Estimated amount calculated based on 4 day length of stay."
"COIL EMBOLIZATION 4IN 3IN FREEFORM MINI",SUP-MCR093040,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA [10200]","Cigna Open Access",,4430.66,33.5,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 135CM 2.1FR ASAHI CORSAIR PRO XS",SUP-CSR135-21S,CDM,C1887,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3988.2,68,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 135CM 7MM 11MM 7FR .035IN",SUP-BXA072902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]",Cigna,,7801.92,40,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 23CM 6FR CHECK-FLO FLEXOR .018IN RADIAL ARTERY",SUP-G11605,CDM,C1894,HCPCS,0272,RC,,,both,,,312.33,93.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 6FR 80CM 23CM GWIRE HEMOSTASIS VALVE SIDEPORT",SUP-406724,CDM,C1894,HCPCS,0272,RC,,,both,,,243.60,73.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FLUCONAZOLE 100 MG TABLET",RX-10044,CDM,,,0637,RC,50268-0337-11,NDC,both,1,UN,36.03,10.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM IRRIGATION RAPID REFILL CONTINUOUS",SUP-M00566001,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.18,56.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLINDAMYCIN HCL 150 MG CAPSULE",RX-1740,CDM,,,0637,RC,68084-0243-11,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 50X27MM STD OSCILLATE ERGONOMIC LIGHTWEIGHT THK.6",SUP-519.100S,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"CIGNA [10200]","Cigna Open Access",,290.36,56.9,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE CURVED HARMONIC SYNERGY SURGICAL",SUP-SNGCB,CDM,S27200284,LOCAL,0272,RC,,,both,,,1862.06,558.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,216.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,216.56,1582.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 2-0 P-14 12IN CLSR ABSORBABLE UNDYED",SUP-VLOCM0115,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CURET 3MM LARGE 6.75IN SPRAGUE EAR SURGICAL",SUP-61-0016,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.05,81.01,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR 44.5MM CARBIDE 5MM ROUND 8 FLUTE DENTAL",SUP-14-C0109,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.55,40.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE WIGGLE VASCULAR STRAIGHT RIBBON 190CM 30CM",SUP-22299M-W30,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"REAMER SURGICAL 9MM CANNULATED COLLAR PIN SET CORING STERILE",SUP-AR-1223S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAMP EXTERNAL FIXATION 4 POSITION MULTIPIN MRI SAFE LG",SUP-390.004,CDM,S27200284,LOCAL,0272,RC,,,both,,,4675.30,1402.59,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AGENT HEMOSTATIC 4X3IN BICOL CLLGN ABSORBABLE MICROFIBRILLAR",SUP-801460,CDM,S27200284,LOCAL,0272,RC,,,both,,,1033.59,310.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRIVER DRILL ZDRIVE STERILE LATEX FREE DISPOSABLE",SUP-70-2001,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DXTERITY 100CM 6FR .056IN JUDKINS LEFT 3.5 CURVE",SUP-DXT6JL35,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ARTHROSCOPIC CLEAR 75MM THREADED OBTR 8.5MM",SUP-214120,CDM,S27200284,LOCAL,0272,RC,,,both,,,163.21,48.96,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TORCON NB ADVANTAGE BEACON 65CM 5FR LEV1 CURVE",SUP-G11194,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR/ELEV LAPAROSCOPIC STD VCARE CUP CERVICAL UTERINE",SUP-60-6085-201,CDM,S27200284,LOCAL,0272,RC,,,both,,,522.45,156.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COUNTSINK DRILL 4MM STAINLESS STEEL REUSABLE",SUP-MSD07040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL SURGICAL 2.9 MM SHORT PUSHLOCK DISPOSABLE KIT",SUP-AR-2923DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMAGER II 65CM 5FR COBRA 2 CURVE ANGIOGRAPHIC VISCERAL",SUP-M001314681,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.04,22.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 125MM 2MM TWIST STERILE",SUP-KM166-10-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FIBER LASER ACCUTRAC 200UM FLEXSHIELD HOLMIUM FLEXIBLE",SUP-M0068404110,CDM,S27200284,LOCAL,0272,RC,,,both,,,3351.98,1005.59,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 6-0 C-1 30IN 2 ARM MONOFILAMENT BLUE",SUP-8706H,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.57,52.07,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MINOCYCLINE HCL 100 MG/5ML IV (WET SOLR VIAL)",RX-41510612,CDM,,,0250,RC,70842-0160-01,NDC,both,1,UN,1560.31,468.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE STAINLESS STEEL RADIAL OSTEOTOM 12MM MRI STERILE LATEX",SUP-47998602129,CDM,S27200284,LOCAL,0272,RC,,,both,,,1162.35,348.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SLIP-CATH BEACON TIP SHUTTLE FLEXOR 135CM 5FR ANGLE",SUP-G48154,CDM,S27200284,LOCAL,0272,RC,,,both,,,708.75,212.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INSTR ACL HALL SAW BLADE DISPOSABLE TRANSTIBIAL",SUP-AR-1897S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1771.88,531.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC",416,MS-DRG,,,,,,,inpatient,,,80503.46,24151.04,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAVER BLADES STRAIGHT SHAFT 4MM DOUBLE SERRATED STERILE",SUP-1600540-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INSRT SPINAL NDL DIL FISHMOUTH SPEAR PUNCH PERCUTANEOUS",SUP-AR-1941PK,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PDS II MULTIPASS 5-0 P-3 18IN MONOFILAMENT UNDYED",SUP-Z493G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TROCAR LAPAROSCOPIC 100MM 12MM KII FIOS FIRST ENTRY ADVANCE",SUP-CFF73,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Hemoconcentrator Perf",PX-E27200356,CDM,E27200356,LOCAL,0272,RC,,,both,,,498.30,149.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE MYOSURE XL 25.25IN 4MM TISSUE REMOVAL 17OZ HANDHELD",SUP-50-501XL,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
FACEPLATE,SUP-06001-I,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,,41.1,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"REAMER SURGICAL FUZEFIX MINI OD2.5 MM PROXIMAL HEADLESS NONS",SUP-CD-FX-2525,CDM,S27000186,LOCAL,0270,RC,,,both,,,2130.00,639,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HARVESTER BONE YELLOW AVITUS 8MM CUT TIP FILTER DEPTH MARK",SUP-BH-110,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"KIT GASTRO MIC MIC-KEY HALYARD STERILE LATEX FREE DISPOSABLE",SUP-98432,CDM,S27200284,LOCAL,0272,RC,,,both,,,1649.78,494.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC",409,MS-DRG,,,,,,,inpatient,,,121020.17,36306.05,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 29MM 24.2MM MASTERS 85D RING ANNULUS PYROLYTIC",SUP-29MECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AETNA [10100]","Aetna HMO/PPO",,23149.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 48MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-48-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"BLUE CROSS [10001]","Blue Cross HMO",,2217.94,39.2,,5311.50,4717.44,5388.59,31,658.03,4809.3,"percent of total billed charges",
"SUT PDS PLUS MULTIPASS 5-0 P-3 18IN ANTIBACTERIAL VIOLET",SUP-PDP463G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]",Cigna,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY 10CM 18GA BARD MARQUEE CORE ENHANCE TROCAR TIP",SUP-MQ1810,CDM,S27200284,LOCAL,0272,RC,,,both,,,514.35,154.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,59.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.82,437.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL WIDENING COUNTSINK 3MM",SUP-92140,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,199.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 4MM 120MM ARCHIMIS AUTOGRAFT",SUP-AD1CH40120,CDM,S27200284,LOCAL,0272,RC,,,both,,,7583.10,2274.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,898.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,881.91,6445.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM LOW PROFILE SCREWS TITANIUM T15 FULL",SUP-AR-8935-34,CDM,C1713,HCPCS,0278,RC,,,both,,,486.00,145.8,"BLUE CROSS [10001]","Blue Cross PPO",,190.51,39.2,,957.42,570.23,957.42,28,56.52,413.1,"percent of total billed charges",
"SET FEEDING 18FR L3.5CM TUBE JEJUNAL EXTENSION MIC-KEY ENFIT",SUP-8230-18-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,981.14,68,,,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 18 X 14 X 07MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-181407-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"NOVANET [10819]",Novanet,,4657.5,75,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 35MM 5/6-5.5MM LATERAL SPINE SIDE LOAD STERILE",SUP-5554235,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,414.32,3028.13,"percent of total billed charges",
"CATH ATLAS 120CM 4CM 12MM BALLOON DILATATION PERIPHERAL",SUP-AT120124,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,847.69,41.1,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 8 SLOT RIGHT TI",SUP-PHPF-S8R,CDM,C1713,HCPCS,0278,RC,,,both,,,17892.00,5367.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7353.61,41.1,,,,,0,2080.84,15208.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 40CM 32FR VENOUS 90D 1 STAGE WIRE REINFORCE",SUP-TF032L90,CDM,S27200284,LOCAL,0272,RC,,,both,,,277.18,83.15,"UHC [10700]","United Healthcare",,175.45,63.3,,,,,0,32.24,235.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 9CM 5MM MIDAS REX LEGEND BALL DIAMOND COARSE",SUP-9BA50DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.17,412.25,"MULTIPLAN [10600]",Multiplan,,1168.04,85,,,,,0,159.82,1168.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR 26CM 5CM 5FR .035IN 2",SUP-M006192133080,CDM,C2617,HCPCS,0278,RC,,,both,,,1319.25,395.77,"CIGNA [10200]",Cigna,,897.09,68,,,,,0,153.43,1121.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR 49MM MULTIPOLAR HIP METAL STERILE",SUP-500104900,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2MM FAST ULNA ANATOMIC ANATOMIC VOLAR PLATING",SUP-FDB20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABLE, 12X30MM, 10-17MM, 22%C2%B0",SUP-1172.4234S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14241.15,41.1,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR AR1 CURVE GUIDING CORONARY SIDEHOLE",SUP-LA7AR10SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET LIFT 185X90CM HANDYTUBE MEDIUM LONG SLIDE WITHOUT",SUP-3711015,CDM,S27000186,LOCAL,0270,RC,,,both,,,337.13,101.14,"UHC [10700]","United Healthcare",,213.4,63.3,,,,,0,39.21,286.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 52CM .014IN LIMBER ACC",SUP-6039,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 86MM TITANIUM 3 HOLE AXSOS 3 BONE HUMERUS LEFT",SUP-627203,CDM,C1713,HCPCS,0278,RC,,,both,,,11951.63,3585.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1389.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1389.97,10158.89,"percent of total billed charges",
"STENT PERIPHERAL L12MM DIA5MM CATHETER L80CM GUIDE 6FR BILIA",SUP-1011492-12,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 30CM PRECISION 2X8 SPLITTER",SUP-SC-3400-30,CDM,C1883,HCPCS,0278,RC,,,both,,,7590.00,2277,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3483.81,45.9,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 18MM RETRACTA DETACHABLE .035IN",SUP-G34194,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"CIGNA [10200]","Cigna Open Access",,2414.55,56.9,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP HUMERAL 36MM UNIVERS REVERS +2 SHOULDER RIGHT SUT",SUP-AR-9502F-36RCPC,CDM,C1776,HCPCS,0278,RC,,,both,,,7980.00,2394,"CIGNA [10200]","Cigna Open Access",,4540.62,56.9,,5302.19,4377.88,6578.61,27,928.07,6783,"percent of total billed charges",
"SYSTEM JOT DX CARDIAC MNTR IMPLANTABLE RCRD REMOTE",SUP-DM4500,CDM,C1764,HCPCS,0278,RC,,,both,,,23940.00,7182,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 4MM COOLCUT 8 FLUTE ROUND STERILE",SUP-AR-8400RBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"AETNA [10100]","Aetna HMO/PPO",,398.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 80MM 4MM BALLOON",SUP-LX181304804F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"MULTIPLAN [10600]",Multiplan,,5718.38,85,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 16MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G816,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"BLUE CROSS [10001]","Blue Cross PPO",,3920,39.2,,3949.44,3949.44,3949.44,"1 through 10",1163,8500,"percent of total billed charges",
"PLATE 24MM LEVEL 1 CONSTRAIN PYRENEES BONE SPINE CERVICAL",SUP-208-41F24,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"AMERIGROUP MEDICAID [20100]",Amerigroup,,497.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",488.46,3570,"percent of total billed charges",
"SHEATH FLEXOR CHECK-FLO MULTIPURPOSE CURVE 45CM 5FR 1.9MM",SUP-G29981,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 5.5MM TSRH-3D PEDICLE TITANIUM PRECUT",SUP-8370030,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"BLADE SAW 15.9MM THK.38MM THK.69MM 90D OFFSET SAGITTAL 14.3",SUP-2296-003-109S2,CDM,S27200284,LOCAL,0272,RC,,,both,,,667.44,200.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,453.86,68,,,,,0,77.62,567.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 80CM 5FR 2MM SPACING D CURVE ELECTROPHYSIOLOGY",SUP-107875S,CDM,C1730,HCPCS,0272,RC,,,both,,,4388.40,1316.52,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STAPLE INTERNAL MEDIUM THICK CATRIDGE STERILE GIA TRI-STAPLE",SUP-GIA80MTC,CDM,S27200284,LOCAL,0272,RC,,,both,,,587.66,176.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOUND 20FR URETHRAL CURVE VAN BUREN 10.75IN",SUP-51-6320,CDM,S27200284,LOCAL,0272,RC,,,both,,,320.33,96.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 16FR 20CM 15.5CM DIL PEEL-AWAY ACCEPTS .038IN",SUP-G02997,CDM,C1894,HCPCS,0272,RC,,,both,,,382.71,114.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CESAREAN SECTION WITH STERILIZATION WITH CC",784,MS-DRG,,,,,,,inpatient,,,44261.10,13278.33,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE CATH YUEH CENTESIS 10CM",SUP-G09490,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.55,41.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES",321,MS-DRG,,,,,,,inpatient,,,160403.77,48121.13,"PHCS [10601]",PHCS,,,70,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150230,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Local Plus",,184.58,53.5,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM GLUCONATE 10% TOPICAL",RX-411652,CDM,J0612,HCPCS,0636,RC,63323-0360-01,NDC,both,10,ML,75.61,22.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8.55,,,,,,,3.52,64.27,"fee schedule",
"CMPNT FEMORAL 7- KNEE RIGHT PRESS FIT EMPOWR KNEE STERILE BP",SUP-353-04-107,CDM,C1776,HCPCS,0278,RC,,,both,,,15979.64,4793.89,"NOVANET [10819]",Novanet,,11984.73,75,,,,,0,1858.43,13582.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM ON-X CONFORM-X CUFF MECHANICAL",SUP-ONXACE/19,CDM,S27800098,LOCAL,0278,RC,,,both,,,21780.00,6534,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2533.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2533.01,18513,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT 3 .5 CIRCLE REGULAR .984IN .024IN TAPER POINT FREE",SUP-212903,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.09,21.63,"FIRST HEALTH [10303]","First Health",,57.67,80,,,,,0,8.38,61.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 31CM 5MM HARMONIC SCPL ULTRACISION",SUP-HBC05,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.41,432.72,"MULTIPLAN [10600]",Multiplan,,1226.05,85,,,,,0,167.75,1226.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL H+6MM 42MM AEQUALIS ASCEND FLEX 12.5D SHOULDER",SUP-DWF424B,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"BLUE CROSS [10001]","Blue Cross HMO",,3538.98,39.2,,5311.50,4717.44,5388.59,31,1049.96,7673.8,"percent of total billed charges",
"CATH LEMAITRE 80CM 5FR 13MM EMBOLECTOMY 15ML STERILE LATEX",SUP-E1601-58,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"AETNA [10100]","Aetna HMO/PPO",,476.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 6941041 ANATOMIC 10X14X11 SRVCFEE",SUP-6941041,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XACT 30MM 8MM STRAIGHT VASCULAR NICKEL TITANIUM",SUP-82092-01,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"PHCS [10601]",PHCS,,6552,70,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG VACUUM BOTTLE PERITONEAL CATH SELF ADHSV DRSG BLUE",SUP-50-7500B,CDM,C1729,HCPCS,0272,RC,,,both,,,558.90,167.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,229.71,41.1,,,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TRIA 26CM 6FR URETERAL SOFT",SUP-M0061903230,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5.5FR 5CM 80CM DENNY MODIFICATION SET PEEL-AWAY",SUP-G11558,CDM,C1892,HCPCS,0272,RC,,,both,,,745.77,223.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,88.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.73,633.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2.5MM DELTAXSFT 10 COIL",SUP-DLX100254,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"BLUE CROSS [10001]","Blue Cross HMO",,3548.7,39.2,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6CM 60CM RADIOPAQUE GWIRE ACCUSTICK II NITINOL",SUP-M001207111,CDM,C1769,HCPCS,0272,RC,,,both,,,400.20,120.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,47.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 44MM X25 LOCK INTRAMEDULLARY NAIL",SUP-04.045.044S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 345CC",SUP-SSZ-M345,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1013.47,68,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL STD",SUP-500DM31,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6378.75,27,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMUR HEAD FREEZE DRIED PROXIMAL",SUP-24A001,CDM,S27800098,LOCAL,0278,RC,,,both,,,5733.90,1720.17,"CIGNA [10200]",Cigna,,3899.05,68,,,,,0,666.85,4873.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEPHRSTMY 10FR CONNECT TUBE INTRO STPCOCK FLOPPY TIP",SUP-H749393411025K1,CDM,C1729,HCPCS,0272,RC,,,both,,,1441.80,432.54,"KAISER [10500]",Kaiser,,966.01,67,,,,,0,167.68,1225.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VESSEL SEALER EXTENDER",SUP-480422,CDM,S27200284,LOCAL,0272,RC,,,both,,,4528.70,1358.61,"PHCS [10601]",PHCS,,3170.09,70,,,,,0,526.69,3849.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 48MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-48-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2597.02,45.9,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG CHEST TUBE FENESTRATED DRAPE NDL DRIVER SCISSORS",SUP-17100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1144.80,343.44,"UHC [10700]","United Healthcare",,724.66,63.3,,,,,0,133.14,973.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175263080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,146.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP ELECTROSURGICAL CARDIOBLATE LOW PROFILE FIBRILLATION",SUP-49341,CDM,S27200284,LOCAL,0272,RC,,,both,,,16560.00,4968,"MULTIPLAN [10600]",Multiplan,,14076,85,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 4MM EMBOLD PLATINUM TUNGSTUN NITINOL",SUP-M001394240040080,CDM,S27800098,LOCAL,0278,RC,,,both,,,6127.20,1838.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4166.5,68,,,,,0,712.59,5208.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 210MM 3.5-4MM .014IN BALLOON DILATATION",SUP-AB14W040210150,CDM,C1725,HCPCS,0272,RC,,,both,,,1638.75,491.62,"UHC [10700]","United Healthcare",,1037.33,63.3,,,,,0,190.59,1392.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 13X1IN RIBBON 2 END MALLEABLE STAINLESS STEEL SPINE",SUP-22-0252,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.81,18.84,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EPS EXT CABLE B/T/Q BLU 150 US",SUP-401981R,CDM,S27000186,LOCAL,0270,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 12FR 4.1MM 80CM VALVE RADIOPAQUE BAND GWIRE",SUP-G49487,CDM,C1894,HCPCS,0272,RC,,,both,,,657.72,197.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUMP INTRACARDIAC SUCTION 15IN 20FR DLP .25IN PERICARDIAL",SUP-12010,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.52,37.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FOX SV 150CM 20MM 4FR 6MM .018IN LARGE CRESCENT LOW",SUP-83979-02,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET CATH 4FR 65CM TRIFORCE FLEXOR PEEL-AWAY CURVE TAPER DOWN",SUP-G56415,CDM,S27200284,LOCAL,0272,RC,,,both,,,2711.18,813.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 40CM 40MM 9MM .035IN BALLOON DILATATION NYBAX",SUP-39171-09044,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT PROC 7 TRIATHLON CR DISPOSABLE FEMORAL",SUP-5555-2207,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"FIRST HEALTH [10303]","First Health",,1134,80,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 8MM CANNULATED COLLAR PIN SET CORING STERILE",SUP-AR-1222S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 60MM KNEE RIGHT CRUCIATE RETAINING CEMENTED",SUP-183004,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"NOVANET [10819]",Novanet,,15064.25,75,,,,,0,2335.96,17072.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 50MM ACETABULAR FLEXIBLE SCR STERILE",SUP-71362950,CDM,S27200284,LOCAL,0272,RC,,,both,,,1538.19,461.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,182.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,178.89,1307.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 120MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,974.92,68,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY SIMULUS SEMIRIGID",SUP-800SC30,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UHC [10700]","United Healthcare",,8298.63,63.3,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 2 CONTOUR 20IN 36- IN KNEE 2",SUP-79-96019,CDM,L1830,HCPCS,0274,RC,,,both,,,121.54,36.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,55.79,45.9,,,,,0,14.14,103.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC BLUE 2.3MM MAXTORQUE STAINLESS STEEL",SUP-CSS04023,CDM,C1769,HCPCS,0272,RC,,,both,,,234.90,70.47,"KAISER [10500]",Kaiser,,157.38,67,,,,,0,27.32,199.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT SUT RETENTION SLOT NDL HOLDER OCTOBASE RTRCTR",SUP-28707,CDM,S27200284,LOCAL,0272,RC,,,both,,,409.25,122.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BENIGN PROSTATIC HYPERTROPHY WITH MCC",725,MS-DRG,,,,,,,inpatient,,,40871.92,12261.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG PLEURAL PLEURAL CATH PLEURX STERILE DISPOSABLE",SUP-50-7000B,CDM,C1729,HCPCS,0272,RC,,,both,,,4899.00,1469.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MENINGOCOCCAL A CONJ VACC 2 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION",RX-170284,CDM,,,0636,RC,58160-0958-01,NDC,both,1,UN,949.02,284.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CMPNT FEMORAL 7 NARROW KNEE RIGHT POSTERIOR STABILIZE",SUP-42500206202,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11876.08,41.1,,6417.48,6417.48,6417.48,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"INSRT HUMERAL 33MM UNIVERS REVERS +3MM SHOULDER LINER",SUP-AR-9503XS-03C,CDM,C1776,HCPCS,0278,RC,,,both,,,4305.60,1291.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1232.26,28.62,,,,,0,500.74,3659.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE SCLERAL ROUND SILICONE STYLE 72 BUCKLING",SUP-92-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.92,30.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46.32,45.9,,,,,0,11.74,85.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 2.7CM 20FR RADIOPAQUE LOW PROFILE PROXIMAL ANTIREFLUX",SUP-0120-20-2.7,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"NOVANET [10819]",Novanet,,584.3,75,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 3 RIGHT DISTAL KNEE TOTAL",SUP-5540-A-302,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"AETNA [10100]","Aetna HMO/PPO",,3612.33,79.5,,10981.53,8986.79,12413.38,12,528.45,3862.24,"percent of total billed charges",
"SPHERE EMBOLIZATION YELLOW HYDROPEARL 200UM MICRO PEG",SUP-HP2S0200,CDM,S27800098,LOCAL,0278,RC,,,both,,,1927.50,578.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,551.65,28.62,,,,,0,224.17,1638.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GROSHONG SURECUFF VITACUFF PEEL-APART 9.5FR CENTRAL",SUP-7726954,CDM,C1751,HCPCS,0272,RC,,,both,,,1890.00,567,"NOVANET [10819]",Novanet,,1417.5,75,,,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OT Routine Visit",PX-431000003,CDM,G0152,HCPCS,0431,RC,,,outpatient,,,261.00,78.3,"KAISER [10500]",Kaiser,,174.87,67,,,,,0,174.87,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Lwr Ext WO Cntrst",PX-359000004,CDM,73700,CPT,0352,RC,,,both,,,2107.53,632.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,742,,,,,,,245.11,1933,"per diem",
"SCR BONE 3.5MM 34MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0268,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,271.23,28.62,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL GRAY 65MM 5.5MM CURVED CONTOUR CONTOUR",SUP-101-65565,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2024.19,45.9,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 20CM 3CM 7FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155240050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]",Cigna,,837.05,68,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR RUST 41MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103541000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2083.74,68,,,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 30MM 120CM 6MM 6FR VASCULAR PERIPHERAL",SUP-S-60-030-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1192.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TACTIFLEX SE BID CURVE F UNIFIED",SUP-A-TFSE-F-X,CDM,C2630,HCPCS,0272,RC,,,both,,,25061.40,7518.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2969.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2914.64,21302.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Jada Sys 2.0 Vac Hemorrhage Cntrl",PX-E27200439,CDM,E27200439,LOCAL,0272,RC,,,both,,,5780.59,1734.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,672.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,672.28,4913.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM 65MM STOP QUICK COUPLING NONSTERILE",SUP-388.394,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 60MM 10MM PRESS FIT REMOVABLE TRUNION SUT HOLE",SUP-AR-9100-10S,CDM,C1776,HCPCS,0278,RC,,,both,,,10713.60,3214.08,"AETNA [10100]","Aetna HMO/PPO",,8517.31,79.5,,10981.53,8986.79,12413.38,12,1245.99,9106.56,"percent of total billed charges",
"INSRT ACETABULAR 36MM 10D H HIP X3 TRIDENT 11.2MM",SUP-723-10-36H,CDM,C1776,HCPCS,0278,RC,,,both,,,9332.25,2799.67,"MULTIPLAN [10600]",Multiplan,,7932.41,85,,,,,0,1085.34,7932.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 60MM 6MM BALLOON DILATATION STERILE LATEX",SUP-596006022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS",876,MS-DRG,,,,,,,inpatient,,,64549.52,19364.86,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,51544.55,,"Case rate ($23,974.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $22,261.68, add-ons for qualifying new technology services are included. If operating cost exceeds $55,301.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,065.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $22,291.12. The transfer operating threshold is the transfer adjustment factor * $22,261.68 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,683.09. The transfer capital threshold is the transfer adjustment factor * $1,683.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,2182.7,64549.52,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.322,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"NOVANET [10819]",Novanet,,3150,75,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 40MM 8MM 8FR BILIARY PLATINOL METAL RAPID",SUP-M00570600,CDM,C1876,HCPCS,0278,RC,,,both,,,11927.41,3578.22,"BLUE CROSS [10001]","Blue Cross PPO",,4675.54,39.2,,,,,0,1387.16,10138.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE WIRE SAW 20IN STAINLESS STEEL GIGLI STILLE NONSTERILE",SUP-260-106,CDM,S27000186,LOCAL,0270,RC,,,both,,,512.41,153.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,210.6,41.1,,,,,0,59.59,435.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ganglioside Monosialic Acd Abs",PX-301000265,CDM,83520,CPT,0301,RC,,,both,,,354.35,106.3,"MULTIPLAN [10600]",Multiplan,,301.2,85,,,,,0,0.35,301.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC",578,MS-DRG,,,,,,,inpatient,,,197441.45,59232.43,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,10263.54,,"Case rate ($9,964.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,252.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,292.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,081.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,265.04. The transfer operating threshold is the transfer adjustment factor * $9,252.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $699.56. The transfer capital threshold is the transfer adjustment factor * $699.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,9964.6,46900.45,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.5CM NATRELLE INSPIRA P2.7CM LOW PROFILE ROUND",SUP-MSZ-L320,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.69,42.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,97.03,68,,,,,0,16.59,121.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOQUE TRICUSPID VALVE REPLACEMENT SYSTEM (44 MM VALVE)",SUP-EVQ1A2US44,CDM,S27800098,LOCAL,0278,RC,,,both,,,245100.00,73530,"MULTIPLAN [10600]",Multiplan,,208335,85,,,,,0,28505.13,208335,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT RICKHAM 70MM 2O PRECISION NO CATH PROGRAMMABLE",SUP-NS0567,CDM,S27800098,LOCAL,0278,RC,,,both,,,6819.27,2045.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4637.1,68,,,,,0,793.08,5796.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL WHITE YELLOW .8MM OTO-FLEX SKEETER DIAMOND LOW",SUP-3155648,CDM,S27200284,LOCAL,0272,RC,,,both,,,2145.00,643.5,"NOVANET [10819]",Novanet,,1608.75,75,,,,,0,249.46,1823.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 150MM 2.5MM BALLOON DILATATION",SUP-48002515X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ROADRUNNER VASCULAR 480CM .018IN BILE PANCREATIC",SUP-G22419,CDM,C1769,HCPCS,0272,RC,,,both,,,1417.50,425.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE INCISION CIRCON",SUP-M0068805111,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"CIGNA [10200]","Cigna Open Access",,293.88,56.9,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION",RX-18908,CDM,,,0250,RC,72485-0105-01,NDC,both,2,ML,181.20,54.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,123.22,68,,,,,0,21.07,154.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 5.5MM REINFORCE CUFF MURPHY EYE LOW",SUP-DYNJAARC55,CDM,S27200284,LOCAL,0272,RC,,,both,,,312.04,93.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,212.19,68,,,,,0,36.29,265.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCP CLAC PLXS US ECHO TIP 138-140CM 20 G X 6FR",SUP-G4927,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,791.78,45.9,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 5.5MM REVOLVE",SUP-185.290,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1262.14,28.62,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE SCLERAL 2.5MM GROOVED SILICONE STERILE",SUP-92-28,CDM,S27800098,LOCAL,0278,RC,,,both,,,241.95,72.58,"FIRST HEALTH [10303]","First Health",,193.56,80,,,,,0,28.14,205.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTRA TWINFLEX TCH 59","SUP-392 289",CDM,C1893,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 8.5IN ULTRA TIP KNIFE HANDLE KARLIN 1.5MM SURGICAL",SUP-46-3178,CDM,S27200284,LOCAL,0272,RC,,,both,,,1207.63,362.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL BALL UNIVERSAL 12CM 3MM STERILE",SUP-B0312,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.17,46.85,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,MINOR",030,APR-DRG,,,,,,,inpatient,,,144624.26,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $13,816.55. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%.",,,,0,,,other,"SOI-1 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Swan Ganz Standard",PX-E27200074,CDM,C1751,HCPCS,0272,RC,,,both,,,1033.69,310.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE ELECTROSURGICAL SOMNOPLASTY RC20 HNDPC 1120411005",SUP-7201017,CDM,S27200284,LOCAL,0272,RC,,,both,,,1504.33,451.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 8.5FR 18MM 145CM 60CM GUIDING GWIRE HEMOSTASIS",SUP-406965,CDM,C1893,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 45MM 1.7MM STEIGER CARBIDE CYLINDRICAL HEAD",SUP-1607-002-116,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.62,57.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RETRACTOR SURGICAL L15.2CM BLADE W6.3CM D7.6CM Z DOANE",SUP-78-5998,CDM,S27200284,LOCAL,0272,RC,,,both,,,475.47,142.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOE POSTOPERATIVE 4-6 SMALL FEMALE BEIGE CANVAS RUBBER",SUP-2041-07,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.42,14.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.51,40.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 2IN 18GA ROSEN EAR 60MM",SUP-61-1038,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.91,23.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,36.22,45.9,,,,,0,9.18,67.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL RAPIDE MULTIPASS 4-0 PS-2 27IN BRAID COATED",SUP-VR426,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.27,20.48,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,31.34,45.9,,,,,0,7.94,58.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +8 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.080,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,158.36,45.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 75MM TITANIUM LINEAR CUTTER",SUP-NTLC75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1307.75,392.32,"CIGNA [10200]",Cigna,,889.27,68,,,,,0,152.09,1111.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND 5CMX6CM SALERA MINI MEMB",SUP-WC4056,CDM,S27800098,LOCAL,0278,RC,,,both,,,19845.00,5953.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5679.64,28.62,,,,,0,2307.97,16868.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 2 RIGHT DISTAL KNEE",SUP-5542-A-202,CDM,C1776,HCPCS,0278,RC,,,both,,,5009.55,1502.86,"BLUE CROSS [10001]","Blue Cross PPO",,1963.74,39.2,,3949.44,3949.44,3949.44,"1 through 10",582.61,4258.12,"percent of total billed charges",
"ALTIVATE REVERSE REVISION HUMERAL STEM, SZ 6X220MM",SUP-530-06-220,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"AETNA [10100]","Aetna HMO/PPO",,10017,79.5,,10981.53,8986.79,12413.38,12,1465.38,10710,"percent of total billed charges",
"TUBE JEJUNOSTOMY 3.5CM 18FR SILICONE MIC-KEY SECUR-LOK",SUP-0230-18-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"CIGNA [10200]","Cigna Local Plus",,771.92,53.5,,,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 125CC P2.8CM MODERATE PLUS PROFILE ROUND GEL",SUP-350-1251BC,CDM,C1789,HCPCS,0278,RC,,,both,,,4823.10,1446.93,"KAISER [10500]",Kaiser,,3231.48,67,,,,,0,560.93,4099.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX29MM 8FR 135CMCATH HEPARIN",SUP-BXB092902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UHC [10700]","United Healthcare",,12346.54,63.3,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAPE 36INX2MM REVERSE CUT NDL CLSR BLUE WHITE",SUP-AR-7288,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"NOVANET [10819]",Novanet,,1116.29,75,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLIDE HER 2 PATHWAY 4 IN 1 PARAFFIN EMBED CONTROL",SUP-781-2991,CDM,S27000186,LOCAL,0270,RC,,,both,,,226.46,67.94,"CIGNA [10200]","Cigna Open Access",,128.86,56.9,,,,,0,26.34,192.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GIRAFFE 45D 2MM 5.25IN FRONTAL SINUS 2 ACTION",SUP-63-8840,CDM,S27200284,LOCAL,0272,RC,,,both,,,3430.28,1029.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1574.5,45.9,,,,,0,398.94,2915.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PTCA CATHETER 2.0 X 15NM (620-154-1U) SCOREFLEX NC SCORING",SUP-SD36003-05,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"UHC [10700]","United Healthcare",,0.01,63.3,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 MO-4 27IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCPP71D,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.65,53.89,"FIRST HEALTH [10303]","First Health",,143.72,80,,,,,0,20.89,152.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVRTB ENDOSCOPIC 50CM 19.5MM 10-11.7MM 16.7MM TAPERED TIP",SUP-00711149,CDM,S27000186,LOCAL,0270,RC,,,both,,,4657.50,1397.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,551.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ELECTROPHYSIOLOGY 2-8-2MM SPACING CSL CURVE 5FR 65C",SUP-401864R,CDM,C1730,HCPCS,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG ALGINATE 16X8IN ACTICOAT POLYETHYLENE NANOCRYSTALLINE",SUP-20301,CDM,S27200284,LOCAL,0272,RC,,,both,,,357.51,107.25,"CIGNA [10200]",Cigna,,243.11,68,,,,,0,41.58,303.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2 LR 20IN MONOFILAMENT 3 STRAND BLUE",SUP-3846T,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.63,32.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,74.55,68,,,,,0,12.75,93.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 11MM KNEE POSTERIOR STABILIZE BEARING",SUP-5532P711,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"MULTIPLAN [10600]",Multiplan,,7102.52,85,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR STD AMPLATZ LEFT 1 CURVE",SUP-534645T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,59.16,68,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 28CM 8FR 2.1FR POLARIS ULTRA NAUTILUS ZIPWIRE .035",SUP-M006192154180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,188.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN ADULT MAYFIELD RED O RING SECURE FIT RIGID FIXATION 13MM",SUP-A1083,CDM,S27200284,LOCAL,0272,RC,,,both,,,4362.94,1308.88,"FIRST HEALTH [10303]","First Health",,3490.35,80,,,,,0,507.41,3708.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW PHTHALATE FREE",SUP-CG-15-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,216.39,41.1,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 RB-1 36IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8557,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.06,68.72,"UHC [10700]","United Healthcare",,144.99,63.3,,,,,0,26.64,194.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 12MM ENDOPATH XCEL BLUNT TIP",SUP-H12LP,CDM,S27200284,LOCAL,0272,RC,,,both,,,1189.82,356.95,"AETNA [10100]","Aetna HMO/PPO",,945.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,138.38,1011.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 10MM PORTEX BLUSELECT CUFF STERILE LATEX FREE",SUP-101/815/100,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.48,103.04,"MULTIPLAN [10600]",Multiplan,,291.96,85,,,,,0,39.95,291.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LANTHANUM 500 MG CHEWABLE TABLET",RX-39975,CDM,,,0637,RC,66993-0422-47,NDC,both,1,UN,48.96,14.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.69,41.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 100MM 5MM ENDOPATH XCEL OPTIVIEW",SUP-2CB5LT,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.80,153.24,"CIGNA [10200]",Cigna,,347.34,68,,,,,0,59.41,434.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 4-0 KS 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J662H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 60MM 5MM LCP PROXIMAL FEMORAL STAINLESS STEEL",SUP-02.205.260,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"PHCS [10601]",PHCS,,1089.1,70,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SV VASCULAR 180CM 5CM .018IN PTFE PLATINUM NICKEL",SUP-503558,CDM,C1769,HCPCS,0272,RC,,,both,,,400.20,120.06,"MULTIPLAN [10600]",Multiplan,,340.17,85,,,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 1 BACKWARD DOWN OFFSET 9.5IN KARLIN LUMBAR HANDLE",SUP-46-3138,CDM,S27200284,LOCAL,0272,RC,,,both,,,1195.16,358.55,"MULTIPLAN [10600]",Multiplan,,1015.89,85,,,,,0,139,1015.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAMINAR IMPLANT SIZE (18MM)",SUP-FG-6033,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 13MM 57SQ CM 51X71MM COBALT SURESCAN TITANIUM",SUP-DTPA2D1,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"KAISER [10500]",Kaiser,,51556.5,67,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 7 SLOT RIGHT TI",SUP-PHPF-S7R,CDM,C1713,HCPCS,0278,RC,,,both,,,17388.00,5216.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7146.47,41.1,,,,,0,2022.22,14779.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FUNNEL GRAFT KELLER FUNNEL 2 HYDROPHILIC TRANSPARENT CONE",SUP-HA-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1108.08,332.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,128.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,128.87,941.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SPINAL 5.8MM SPINEJACK",SUP-0909-000-042,CDM,C1062,HCPCS,0278,RC,,,both,,,24560.17,7368.05,"CIGNA [10200]","Cigna Local Plus",,7736.45,31.5,,,,,0,2856.35,20876.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 57MM TITANIUM LEVEL 3 ZEVO BONE SPINE CERVICAL",SUP-3003057,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"CIGNA [10200]","Cigna Open Access",,3011.15,56.9,,1144.80,304.56,2275.09,66,615.46,4498.2,"percent of total billed charges",
"CATH PCP060200090 PLUS US D6L200UL900",SUP-PCP060200090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lt Hrt Cath Txsptl Punc",PX-481000030,CDM,93462,CPT,0481,RC,,,both,,,14303.21,4290.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1694.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1663.46,12157.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 300MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030300S,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT VALLEYLAB ACCUVAC",SUP-E2515HS,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.47,21.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.2,59.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 5MM PRESTIGE PLUS HELICAL HELICAL",SUP-PRES0520HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"NOVANET [10819]",Novanet,,4916.25,75,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COSYNTROPIN 0.25 MG/ML IJ (WET SOLR VIAL)",RX-4159686,CDM,J0834,HCPCS,0636,RC,00548-5900-00,NDC,both,1,UN,643.32,193,"CIGNA [10200]","Cigna Local Plus",,55.52,,,,,,,24.26,546.82,"fee schedule",
"INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP",RX-70693,CDM,J1815,HCPCS,0637,RC,00002-7511-01,NDC,both,10,ML,773.80,232.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,526.18,68,,,,,0,51.7,657.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS MULTIPASS 4-0 PC-1 18IN BRAID ANTIBACTERIAL",SUP-VCP835G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.28,41.1,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 51MM 3 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.351,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3598.56,68,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SPINAL 25GA PENCAN GLASS OB SYR SSK BKG",SUP-560603,CDM,C1755,HCPCS,0278,RC,,,both,,,133.20,39.96,"NOVANET [10819]",Novanet,,99.9,75,,,,,0,15.49,113.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9.8FR 8FR 55CM HIGH FLEX DIL RADIOPAQUE CLOSED",SUP-G49045,CDM,C1894,HCPCS,0272,RC,,,both,,,472.23,141.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,55.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.92,401.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL ULTRAPRO 4.7X2.4IN 4IN ONLAY UNDERLAY PATCH",SUP-UHSL,CDM,C1781,HCPCS,0278,RC,,,both,,,2028.70,608.61,"PHCS [10601]",PHCS,,1420.09,70,,,,,0,235.94,1724.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.5CM NATRELLE INSPIRA P5.7CM FULL PROFILE ROUND",SUP-MSZ-F560,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"UHC [10700]","United Healthcare",,100.13,63.3,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 20MM AZUR DETACHABLE HYDROGEL",SUP-45-452020,CDM,S27800098,LOCAL,0278,RC,,,both,,,1974.75,592.42,"MULTIPLAN [10600]",Multiplan,,1678.54,85,,,,,0,229.66,1678.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PLUMEPORT UNIVERSAL SMOKE EVAC LAPAROSCOPIC PLUME",SUP-PP010,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.11,42.93,"MULTIPLAN [10600]",Multiplan,,121.64,85,,,,,0,16.64,121.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM ATTUNE 8 KNEE DISTAL CEMENT REVISION STERILE",SUP-154708002,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"CIGNA [10200]","Cigna Local Plus",,3248.52,53.5,,5372.07,4581.20,7242.98,23,706.17,5161.2,"percent of total billed charges",
"NAIL 11MM 36CM HIP RIGHT FEMUR AFFIXUS INTRAMEDULLARY 125D",SUP-814311360,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8297.1,40,,,,,0,2412.38,17631.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 5MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0510,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4598.16,68,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +27.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000275,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION CONCERTO 3D V01",SUP-PV-10-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIDAS BURR",SUP-F3/9TA30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"NOVANET [10819]",Novanet,,876.62,75,,,,,0,135.93,993.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 12 STD KNEE RIGHT CRUCIATE RETAIN PERSONA COCR",SUP-42502807402,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"UHC [10700]","United Healthcare",,18290.9,63.3,,8601.07,8395.67,8601.07,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"PLATE CURVE 159MM STAINLESS STEEL 4.5MM SCR 6 HOLE 4 COLUMN",SUP-02.124.406,CDM,C1713,HCPCS,0278,RC,,,both,,,9798.00,2939.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1161.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1139.51,8328.3,"percent of total billed charges",
"STEM TALAR 1 LARGE 10MM ANKLE",SUP-200347901,CDM,C1776,HCPCS,0278,RC,,,both,,,7424.40,2227.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,879.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,863.46,6310.74,"percent of total billed charges",
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 12MM 144CM 2.75MM",SUP-H7493941212270,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"BLUE CROSS [10001]","Blue Cross PPO",,3042.9,39.2,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SPINAL 4.75IN 22GA SPROTTE PENCIL POINT TIP LATERAL EYE",SUP-03115130C,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.68,68.9,"CIGNA [10200]",Cigna,,156.18,68,,,,,0,26.71,195.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 60MM 5.5MM XL",SUP-5485560,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"BLUE CROSS [10001]","Blue Cross PPO",,1152.48,39.2,,957.42,570.23,957.42,28,341.92,2499,"percent of total billed charges",
"DRAIN INCISION 1/8IN 49IN SILICONE ROUND 10IN HOLE PATTERN",SUP-0070310,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.90,17.67,"PHCS [10601]",PHCS,,41.23,70,,,,,0,6.85,50.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 9 132D",SUP-6720-0937,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"BLUE CROSS [10001]","Blue Cross HMO",,9393.12,39.2,,5311.50,4717.44,5388.59,31,2786.79,20367.74,"percent of total billed charges",
"SCR BONE 3MM 4MM 1.2MM 25MM 10MM STAINLESS STEEL LONG THREAD",SUP-202.725,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,131.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",129.1,943.52,"percent of total billed charges",
"CATHETER ANGIOGRAPHY 6FR L100CM ID0.056IN FR5 CURVE SOFT DIS",SUP-H74916599030,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"AETNA [10100]","Aetna HMO/PPO",,60.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM REVERE TITANIUM SPINE PEDICLE NONSTERILE",SUP-124.056,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"KAISER [10500]",Kaiser,,3244.54,67,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -6MM OFFSET 28MM HIP TYPE 1 COCR G7",SUP-163660,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"CIGNA [10200]","Cigna Local Plus",,2595.12,53.5,,5372.07,4581.20,7242.98,23,564.14,4123.1,"percent of total billed charges",
"SPACER ALLOGRAFT 12.5X15X11MM PARALLEL SPINE",SUP-17311,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 31X8-11MM MAGNIFY-S 8D 25MM EXPAND STANDALONE",SUP-1126.0108,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11566.8,27,,,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 2 STD KNEE LEFT KEEL NONPOROUS",SUP-ETPKN2SL,CDM,C1776,HCPCS,0278,RC,,,both,,,15193.80,4558.14,"FIRST HEALTH [10303]","First Health",,12155.04,80,,,,,0,1767.04,12914.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-02003,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UHC [10700]","United Healthcare",,7420.72,63.3,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 445CC NATRELLE INSPIRA COHESIVE STERILE",SUP-SCX-445,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]",Cigna,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 485CC",SUP-SSZ-M485,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CIGNA [10200]","Cigna Open Access",,848.04,56.9,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 6MM BALLOON DILATATION STERILE LATEX",SUP-596004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"MULTIPLAN [10600]",Multiplan,,1239.3,85,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +29 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.290,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ELECTROPHYSIOLOGY 2-8-2MM SPACING CSL CURVE 5FR 65C",SUP-401864R,CDM,C1730,HCPCS,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 13X12CM BREAST 400ML STYLE 133MV TEXTURED STERILE",SUP-133MV-13,CDM,C1789,HCPCS,0278,RC,,,both,,,5460.00,1638,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,635,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,635,4641,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT 1:1 SILICONE CARDIAC DRNG 4 CHANNEL RADIOPAQUE SOLID",SUP-BCC1,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.73,70.42,"CIGNA [10200]","Cigna Local Plus",,125.58,53.5,,,,,0,27.3,199.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 55CM 7FR .078IN ADULT RENAL CURVE",SUP-77821255,CDM,C1887,HCPCS,0272,RC,,,both,,,304.50,91.35,"PHCS [10601]",PHCS,,213.15,70,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 35CM 4MM ARTEGRAFT BOVINE CAROTID",SUP-AG535,CDM,C1768,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH SURGICAL 7.75MM BARRON CORNEAL NONVACUUM 4 GUIDE POST",SUP-K20-2077,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,219.72,41.1,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE UNIVERSAL FIFTH METATARSAL FRACTURE SYSTEM HOOK BONE",SUP-AR-8956-01,CDM,C1713,HCPCS,0278,RC,,,both,,,9121.80,2736.54,"CIGNA [10200]",Cigna,,6202.82,68,,1831.33,1831.33,1831.33,16,1060.87,7753.53,"percent of total billed charges",
"STENT PROTEGE EVERFLEX 80MM 120CM 5MM .079IN BILIARY NITINOL",SUP-PRB35-05-080-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"FIRST HEALTH [10303]","First Health",,4452,80,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 5/64IN STEINMANN 1 END TROCAR POINT",SUP-1611-18-000,CDM,C1713,HCPCS,0278,RC,,,both,,,139.20,41.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,94.66,68,,,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 108MM 8MM SMALL SHELL ALTIVATE REVERSE SHOULDER",SUP-533-08-108,CDM,C1776,HCPCS,0278,RC,,,both,,,43175.16,12952.55,"AETNA [10100]","Aetna HMO/PPO",,34324.25,79.5,,10981.53,8986.79,12413.38,12,5021.27,36698.89,"percent of total billed charges",
"SUT ETHILON 10-0 BV75-4 5IN MONOFILAMENT BLACK NONABSORBABLE",SUP-2850G,CDM,S27200284,LOCAL,0272,RC,,,both,,,296.50,88.95,"CIGNA [10200]","Cigna Open Access",,168.71,56.9,,,,,0,34.48,252.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 23CM 14.5FR 360D STD 2 BRANCH STRAIGHT POLYURETHANE",SUP-5733730,CDM,S27200284,LOCAL,0272,RC,,,both,,,1897.50,569.25,"FIRST HEALTH [10303]","First Health",,1518,80,,,,,0,220.68,1612.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5-6 14MM KNEE RIGHT UHMWPE CONGRUENT CONSENSUS",SUP-2042-0-5614,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,414.32,3028.13,"percent of total billed charges",
"STENT COTTON-LEUNG 5CM 10FR GENTLE CURVE BILIARY",SUP-G22622,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 55MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840007555,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"BLADE INTRAMEDULLARY L85MM DIA10.35MM GOLD TITANIUM CANNULAT",SUP-04.038.385S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"MULTIPLAN [10600]",Multiplan,,3384.57,85,,,,,0,463.09,3384.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL LARGE+ KNEE LEFT CEMENT LCS COMPLETE COCR",SUP-129402070,CDM,C1776,HCPCS,0278,RC,,,both,,,20635.65,6190.69,"FIRST HEALTH [10303]","First Health",,16508.52,80,,,,,0,2399.93,17540.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG 1L ASPIRA PLEURAL DISPOSABLE",SUP-4992301,CDM,S27200284,LOCAL,0272,RC,,,both,,,277.53,83.26,"UHC [10700]","United Healthcare",,175.68,63.3,,,,,0,32.28,235.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL 5MM LEGION 7-8 LONG KNEE POSTERIOR",SUP-71421807,CDM,C1776,HCPCS,0278,RC,,,both,,,11043.45,3313.03,"PHCS [10601]",PHCS,,7730.42,70,,,,,0,1284.35,9386.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS 135CM 100MM 7MM .035IN BALLOON DILATATION",SUP-AB35W07100135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,460.47,68,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINE MNTR 2MR LOFLO SIDESTREAM STRAIGHT INTUBATE MALE LUER",SUP-989803144571,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.78,43.73,"NOVANET [10819]",Novanet,,109.34,75,,,,,0,16.95,123.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE MNTR 12IN TRUWAVE 30ML 3 WAY STPCOCK FLUSH",SUP-PX12N,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.05,31.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,72.11,68,,,,,0,12.33,90.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 19MM 27MM 24MM HANCOCK II CINCH 35MM",SUP-T510C27,CDM,S27800098,LOCAL,0278,RC,,,both,,,21420.00,6426,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8568,40,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR",RX-14100,CDM,,,0637,RC,51079-0924-01,NDC,both,1,UN,19.99,6,"MULTIPLAN [10600]",Multiplan,,16.99,85,,,,,0,2.32,16.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON SMALL TITANIUM NARROW BLADE RAMP 5.5",SUP-7541142,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"MULTIPLAN [10600]",Multiplan,,2550,85,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 2 ACTION ROTATE RATCHET HANDLE 32CM 5MM",SUP-97-1089RC,CDM,S27200284,LOCAL,0272,RC,,,both,,,3597.53,1079.26,"KAISER [10500]",Kaiser,,2410.35,67,,,,,0,418.39,3057.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 20MM 4FR 6MM .018IN BALLOON",SUP-PCP060020130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM VERTEX MAX TITANIUM SPINE MULTIAXIAL",SUP-6958730,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"DX DEFL 10 POLE AUTO ID",SUP-D135303,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"FIRST HEALTH [10303]","First Health",,2982,80,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 11MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-111-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1425.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TM REVERSE STEM 14MM X 130MM",SUP-00434901413,CDM,C1776,HCPCS,0278,RC,,,both,,,17863.20,5358.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7145.28,40,,,,,0,2077.49,15183.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SPINAL MAXCESS 4 ACCESS",SUP-3241000,CDM,S27200284,LOCAL,0272,RC,,,both,,,11730.00,3519,"CIGNA [10200]","Cigna Local Plus",,6275.55,53.5,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX PRS LONG-TERM RESORBABLE, 25CM CIRCLE",SUP-P20463-2525G,CDM,C1781,HCPCS,0278,RC,,,both,,,66467.70,19940.31,"FIRST HEALTH [10303]","First Health",,53174.16,80,,,,,0,7730.19,56497.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE CATH YUEH CENTESIS 10CM",SUP-G09490,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.55,41.86,"FIRST HEALTH [10303]","First Health",,111.64,80,,,,,0,16.23,118.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mayo Glutamic Acid Decarboxylase (Gad65) Antibody Assay,Serum",PX-302000236,CDM,86341,CPT,0302,RC,,,both,,,106.00,31.8,"NOVANET [10819]",Novanet,,79.5,75,,,,,0,0.01,90.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM TAPER 36MM HIP MODULAR TYPE 1 BIOLOX DELTA",SUP-12-115122,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"MULTIPLAN [10600]",Multiplan,,7477.88,85,,,,,0,1023.15,7477.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 14MM LEIBINGER UNIVERSAL 2 TITANIUM",SUP-5020414,CDM,C1713,HCPCS,0278,RC,,,both,,,458.02,137.41,"BLUE CROSS [10001]","Blue Cross HMO",,179.54,39.2,,957.42,156.86,7483.26,51,53.27,389.32,"percent of total billed charges",
"GARM COMPRESSION 2XL CHEST 50-52IN VEST VELCRO SHOULDER",SUP-2-8003-XXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP 2A - ACTIS STEM AND STANDARD CUP",SUP-CAP-DS-H-2A,CDM,C1776,HCPCS,0278,RC,,,both,,,24885.00,7465.5,"BLUE CROSS [10001]","Blue Cross HMO",,9754.92,39.2,,5311.50,4717.44,5388.59,31,2894.13,21152.25,"percent of total billed charges",
"SCR BONE 11MM 7MM 85MM 80MM INTERTAN HIP TROCHANTER KIT",SUP-71677085,CDM,C1713,HCPCS,0278,RC,,,both,,,6986.94,2096.08,"CIGNA [10200]",Cigna,,4751.12,68,,1831.33,1831.33,1831.33,16,812.58,5938.9,"percent of total billed charges",
"COIL EMBOLIZATION 8CM 4MM CONCERTO 3D",SUP-PV-4-8-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT 14MM ALIF",SUP-3W3214,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5709.24,27,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD CONTOUR TITANIUM 2.3MM CORTICAL SCR 5 HOLE LOCK 7",SUP-VLBPL-5-7,CDM,C1713,HCPCS,0278,RC,,,both,,,8176.50,2452.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,950.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",950.93,6950.03,"percent of total billed charges",
"STENT 12CM 10FR BILIARY FLEXIMA PLASTIC TEMPORARY DELIVERY",SUP-M00539330,CDM,C2625,HCPCS,0278,RC,,,both,,,755.24,226.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,89.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.83,641.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 65MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75446565,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"KIT JEJUNOSTOMY 22CM 16FR TUNGSTEN SILICONE 1.7CM MIC-KEY",SUP-0270-16-1.7-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 7MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620507,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT ELECTROSURGICAL 2.5IN ACE BLADE SOFT TISSUE E CNCT",SUP-ME7251E,CDM,S27200284,LOCAL,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA 5D J KNEE LEFT CEMENT STEM TIVANIUM",SUP-42-5320-088-01,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1295.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1271.59,9293.68,"percent of total billed charges",
"TRAY CATH GREEN 24CM 12FR 18GA MAHURKAR .035IN J CURVE",SUP-8888103004HP,CDM,C1752,HCPCS,0272,RC,,,both,,,1178.06,353.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,540.73,45.9,,,,,0,137.01,1001.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X2CM ALLOPATCH DERMAL MATRIX ALLOGRAFT",SUP-WC0222,CDM,Q4128,HCPCS,0636,RC,,,both,,,3166.80,950.04,"CIGNA [10200]","Cigna Local Plus",,80.43,,,,,,,80.43,2691.78,"fee schedule",
"HC Colonoscopy W Rmvl Hot Bx",PX-750000093,CDM,45384,CPT,0750,RC,,,both,,,4713.82,1414.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2292.95,,"Case rate ($2,292.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,548.22,4713.82,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) NEO IPG MODEL 2102",SUP-100054-201,CDM,C1825,HCPCS,0278,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Trach Cuffed Fenestrated",PX-E27200229,CDM,E27200229,LOCAL,0272,RC,,,both,,,311.43,93.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,36.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.22,264.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txhep Port Perc W Hemo Eval Si",PX-323000029,CDM,75885,CPT,0320,RC,,,both,,,3213.00,963.9,"KAISER [10500]",Kaiser,,2152.71,67,,,,,0,113.41,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit B Level 4",PX-450000331,CDM,G0383,HCPCS,0450,RC,,,both,,,1807.00,542.1,"PHCS [10601]",PHCS,,1264.9,70,,,,,0,67.13,1807,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Nephrostomy Tube W Fl",PX-361000219,CDM,50389,CPT,0361,RC,,,both,,,1947.47,584.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,230.78,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,226.49,1947.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Brachial Plex Sngl",PX-510000118,CDM,64415,CPT,0761,RC,,,both,,,3659.40,1097.82,"NOVANET [10819]",Novanet,,2744.55,75,,,,,0,425.59,3659.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Outr/Aso Scn W/Reflex to Titer",PX-300000031,CDM,86063,CPT,0302,RC,,,both,,,35.10,10.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.06,,"Fee schedule rate ($6.06). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,29.84,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 5CM 7FR DUODENAL BEND BILIARY FLEXIMA PLASTIC",SUP-M00539200,CDM,C2625,HCPCS,0278,RC,,,both,,,755.24,226.57,"CIGNA [10200]","Cigna Local Plus",,404.05,53.5,,,,,0,87.83,641.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC M/Phmtrc Alys Ishquant/Semiq",PX-312000068,CDM,88374,CPT,0312,RC,,,both,,,981.00,294.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,116.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,875.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ON-Q C-BLOC SELECT-A-FLOW 5ML/HR DRUG DELIVERY 400ML",SUP-CB001,CDM,C9804,HCPCS,0272,RC,,,both,,,1591.33,477.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT PROC ECTRA II PROBE RETROGRADE TRIANGLE KNIFE HAND PAD",SUP-4116,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 0 CT-1 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8424H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 30X6MM CRANIOFACIAL TITANIUM 16 HOLE STRUT 1MM",SUP-42001,CDM,C1713,HCPCS,0278,RC,,,both,,,2932.50,879.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,347.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",341.05,2492.63,"percent of total billed charges",
"KIT CATHETERIZATION 4FR 25GA 2IN .018IN 2 LUMEN SPRING GWIRE",SUP-AK-12402,CDM,C1751,HCPCS,0272,RC,,,both,,,278.40,83.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACIFIC PLUS 130CM 120MM 4FR 5MM .018IN BALLOON",SUP-PCP050120130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH COYOTE MONORAIL 150CM 100MM 3MM BALLOON DILATATION",SUP-H74939185301010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE JEJUNOSTOMY 45CM 18FR SILICONE MIC SECUR-LOK UNIVERSAL",SUP-0260-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,2567.55,770.26,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MAJOR",625,APR-DRG,,,,,,,inpatient,,,109877.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $14,976.12. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to (Final Base Payment plus Newborn Screen Add-on Amount $63.00) multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($81,066.34) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-3 Newborn; Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG BLACK 18X12.5CM GRANUFOAM SENSATRAC VAC THK3.3CM",SUP-M8275052/5.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,371.16,111.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,152.55,41.1,,,,,0,43.17,315.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR EMPHASYS +4MM NEUTRAL 50MM 36MM AOX HIP",SUP-472250436,CDM,C1776,HCPCS,0278,RC,,,both,,,14038.05,4211.41,"CIGNA [10200]","Cigna Local Plus",,4421.99,31.5,,5372.07,4581.20,7242.98,23,1632.63,11932.34,"percent of total billed charges",
"STENT ZIPWIRE 30CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175265170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,580.81,45.9,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM 5MM 2.1-2.7FR CORONARY STENT",SUP-RONYX50030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5754.00,1726.2,"NOVANET [10819]",Novanet,,4315.5,75,,,,,0,669.19,4890.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 16MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1650CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2271,28.62,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT CATH 3FT PKG SOURCING4",SUP-0653,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4344.52,28.62,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 57MM TITANIUM 2.4MM SCREW 8 HOLE BONE LEFT HAND NONSTE",SUP-449.917,CDM,C1713,HCPCS,0278,RC,,,both,,,3706.50,1111.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1701.28,45.9,,,,,0,431.07,3150.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM THK5-30MM ALLOGRAFT FROZEN",SUP-450910,CDM,S27800098,LOCAL,0278,RC,,,both,,,14899.86,4469.96,"UHC [10700]","United Healthcare",,9431.61,63.3,,,,,0,1732.85,12664.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 4MM 7FR 1-7-4MM SPACING D CURVE ABLATION",SUP-NS7TCDL174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9337.08,68,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 28MM LCP STAINLESS STEEL DISTAL RADIAL",SUP-02.210.128,CDM,C1713,HCPCS,0278,RC,,,both,,,959.36,287.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,274.57,28.62,,,,,0,111.57,815.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 2IN 20GA 18GA CONTIPLEX TUOHYL ULTRA 360",SUP-331640,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.28,68.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.55,194.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 73X25X1.24MM WIDE THICK STAINLESS STEEL SAGITTAL",SUP-2108110000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"CIGNA [10200]","Cigna Local Plus",,102.5,53.5,,,,,0,22.28,162.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 24MM 5MM STAINLESS STEEL SHORT THREAD FOOT HAND",SUP-02.226.024,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,194.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",191.34,1398.42,"percent of total billed charges",
"DEVICE SERTERA 14GA BREAST BIOPSY PERCUTANEOUS SPRING LOAD",SUP-SERTERA-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,746.42,223.93,"KAISER [10500]",Kaiser,,500.1,67,,,,,0,86.81,634.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 120MM 4FR 2MM .018IN BALLOON",SUP-PCP020120130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"KAISER [10500]",Kaiser,,824.9,67,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL SHAFT SMALL FREEZE DRIED 100-125MM",SUP-72A002,CDM,S27800098,LOCAL,0278,RC,,,both,,,3360.00,1008,"FIRST HEALTH [10303]","First Health",,2688,80,,,,,0,390.77,2856,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.2MM X 6MM COCR",SUP-VAN-12006-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 4MM CANNULATED",SUP-AR-8943-05,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 9CM 3MM LEGEND MATCH HEAD STERILE",SUP-9MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1184.63,355.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,486.88,41.1,,,,,0,137.77,1006.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 2MM PRECISION ROUND EXTEND",SUP-5540009320,CDM,S27200284,LOCAL,0272,RC,,,both,,,1777.20,533.16,"MULTIPLAN [10600]",Multiplan,,1510.62,85,,,,,0,206.69,1510.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X8X7MM RISE NONSTERILE",SUP-193.001,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"NOVANET [10819]",Novanet,,21262.5,75,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR 53MM MULTIPOLAR HIP METAL STERILE",SUP-500105300,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD INTICA 7 DF-1 CONNECTION HF-T QP",SUP-404629,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6839.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 65CM RVOT KIT MOND STAINLESS STEEL MEDIUM",SUP-4141/65,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"NOVANET [10819]",Novanet,,431.33,75,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 2MM CRANIOFACIAL TITANIUM SELF TAPPING LOW",SUP-400.856,CDM,C1713,HCPCS,0278,RC,,,both,,,615.60,184.68,"CIGNA [10200]",Cigna,,418.61,68,,1831.33,1831.33,1831.33,16,71.59,523.26,"percent of total billed charges",
"CATH STERLING SL MONORAIL 150CM 80MM 3.8FR 2MM LOW PROFILE",SUP-39147-20801,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"UHC [10700]","United Healthcare",,948.55,63.3,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 30CM 3CM 7FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155245050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,837.05,68,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 24MM 144CM 2.25MM",SUP-H7493941224220,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,902.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 400ML STYLE 20 GEL SMOOTH NATRELLE MATRIX",SUP-20-400,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"CIGNA [10200]","Cigna Open Access",,2031.33,56.9,,5166.00,5166.00,5166.00,"1 through 10",415.19,3034.5,"percent of total billed charges",
"ANGINA PECTORIS",311,MS-DRG,,,,,,,inpatient,,,33115.21,9934.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6331.14,,"Fee schedule rate ($6,331.14). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,4353.92,17504.68,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 28CM 3CM 7FR .035IN 2",SUP-M006192144180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"BLUE CROSS [10001]","Blue Cross HMO",,623.23,39.2,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL SF J-J CURVE ABLATION",SUP-D134803,CDM,C1732,HCPCS,0272,RC,,,both,,,21312.90,6393.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2525.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2478.69,18115.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME PATELLAR 41MM PFC SIGMA LARGE OVAL KNEE UHMWPE CEMENTED",SUP-960103,CDM,C1776,HCPCS,0278,RC,,,both,,,4723.05,1416.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2167.88,45.9,,,,,0,549.29,4014.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 135CM MAMBA FLEX STERILE LATEX",SUP-H7493928713540,CDM,C1725,HCPCS,0272,RC,,,both,,,4071.00,1221.3,"UHC [10700]","United Healthcare",,2576.94,63.3,,,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL CANNULATED 6.5/7.5 MM SCR STERILE",SUP-03.333.204S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2718.60,815.58,"UHC [10700]","United Healthcare",,1720.87,63.3,,,,,0,316.17,2310.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 28CM 8FR LARGE PROXIMAL PIGTAIL CURVE URETERAL",SUP-M001231390,CDM,C2617,HCPCS,0278,RC,,,both,,,931.50,279.45,"KAISER [10500]",Kaiser,,624.11,67,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 8-0 TG140-8 12IN 2 ARM BRAID COATED VIOLET",SUP-J599G,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.98,46.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.02,131.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL TAN 95MM 10.35MM TFN-ADVANCED",SUP-04.038.395S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"MULTIPLAN [10600]",Multiplan,,3384.57,85,,,,,0,463.09,3384.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 17MMX8MMX6CM",SUP-TSB081706A,CDM,C1874,HCPCS,0278,RC,,,both,,,49140.00,14742,"BLUE CROSS [10001]","Blue Cross HMO",,19262.88,39.2,,9776.84,9776.84,9776.84,"1 through 10",5714.98,41769,"percent of total billed charges",
"CATH IMPRESS 100CM 5FR HH1 CURVE ANGIOGRAPHIC STAINLESS",SUP-510038HH1,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"KAISER [10500]",Kaiser,,72.86,67,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 10CM 6MM BALLOON DILATATION",SUP-DR135610,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 14MM SEPTAL SELF EXPANDING DELIVERY",SUP-9-ASD-014,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"CIGNA [10200]",Cigna,,8500.32,40,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN READIGRAFT CRYOSKIN 125SQ CM FIBROBLAST",SUP-SK-N,CDM,Q4433,HCPCS,0636,RC,,,both,,,2536.95,761.08,"PHCS [10601]",PHCS,,1775.87,70,,,,,0,247.92,2156.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR071002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2520.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 55MM AFFIX II BONE LUMBAR SPINE",SUP-7577055,CDM,C1713,HCPCS,0278,RC,,,both,,,24141.60,7242.48,"CIGNA [10200]","Cigna Open Access",,8087.44,33.5,,1144.80,304.56,2275.09,66,2807.67,20520.36,"percent of total billed charges",
"CATH ULTRAVERSE 035 GEOALIGN 75CM 200MM 4MM BALLOON",SUP-U3575420,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 40MM 800MM 12MM VASCULAR VENOUS",SUP-VENUM12040,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC",420,MS-DRG,,,,,,,inpatient,,,94491.45,28347.43,"CIGNA [10200]",Cigna,,44673.9,,"Fee schedule rate ($44,673.90). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,94491.45,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCOUT.SINGLE-USE HANDPIECE.STERILE.ETO",SUP-HPSU-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"UHC [10700]","United Healthcare",,1305.56,63.3,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTMASTER 26MM 2.8MM CORONARY STENT STAINLESS STEEL",SUP-1012580-26,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4729.6,28.62,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 19CM 5MM COOLCUT 8 FLUTE CONCAVE CURVE HIP",SUP-AR-6500VBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.01,257.7,"UHC [10700]","United Healthcare",,543.75,63.3,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FREEZOR MAX 90CM 8MM 9FR 3-5-2MM SPACE 55MM MEDIUM",SUP-209F3,CDM,C1733,HCPCS,0272,RC,,,both,,,11730.00,3519,"AETNA [10100]","Aetna HMO/PPO",,9325.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Asp Breast Cyst",PX-361000015,CDM,19000,CPT,0361,RC,,,both,,,1679.93,503.98,"CIGNA [10200]","Cigna Open Access",,1679.93,,"Case rate ($2,090). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,195.38,1679.93,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 8MM MOUNTAINEER TITANIUM SPINE",SUP-188362008,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIA MATRIX (4 X 4) 16 SQ CM",SUP-585-006,CDM,Q4309,HCPCS,0636,RC,,,both,,,114000.00,34200,"AETNA [10100]","Aetna HMO/PPO",,90630,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.92,96900,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plas Shoe Insert Jnt",PX-E27400080,CDM,L2180,HCPCS,0274,RC,,,both,,,309.10,92.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,141.88,45.9,,,,,0,35.95,262.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ecmo/Ecls Rem Cann Prc 6+",PX-481000121,CDM,33966,CPT,0481,RC,,,both,,,2783.00,834.9,"BLUE CROSS [10001]","Blue Cross HMO",,2783,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,323.66,2783,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Brain Functional",PX-611000004,CDM,70554,CPT,0611,RC,,,both,,,3373.00,1011.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,583.68,,,,,,,392.28,2867.05,"fee schedule",
"STEM FEMORAL 75MM 10MM PRESS FIT UNIVERSAL FLUTE KNEE",SUP-867410,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"NOVANET [10819]",Novanet,,6075.45,75,,,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MECLIZINE 12.5 MG TABLET",RX-12024,CDM,,,0637,RC,50268-0522-11,NDC,both,1,UN,6.27,1.88,"PHCS [10601]",PHCS,,4.39,70,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins/Rep Card Sys Gen/Elect",PX-480000082,CDM,0408T,CPT,0481,RC,,,both,,,37328.00,11198.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5284,,"Case rate ($5,284). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,4341.25,31728.8,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER CHOCOLATE 150CM 120MM 3MM .014IN BALLOON DILATATION",SUP-CB1415030120OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,678.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 114MM 7.5MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771100700,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"FIRST HEALTH [10303]","First Health",,16719.7,80,,,,,0,2430.63,17764.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPTIP 35CM 8FR DRNG FLEXIMA POLYURETHANE HYDROPHILIC",SUP-M001281560,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 16GA 15CM 1.6MM OSTYCUT 2 PART SELF LOCK",SUP-17820070,CDM,S27200284,LOCAL,0272,RC,,,both,,,498.96,149.69,"PHCS [10601]",PHCS,,349.27,70,,,,,0,58.03,424.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING G7 -3MM OFFSET TAPER HIP TITANIUM TYPE 1",SUP-650-1065,CDM,C1776,HCPCS,0278,RC,,,both,,,1539.00,461.7,"FIRST HEALTH [10303]","First Health",,1231.2,80,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 5MM 100MM KII ABDOMINAL ADVANCE FIXATION",SUP-CFS02,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"MULTIPLAN [10600]",Multiplan,,59.16,85,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH MICROBIOLOGY 1MM 1.8MM 110CM STERILE DISPOSABLE",SUP-130,CDM,S27200284,LOCAL,0272,RC,,,both,,,151.03,45.31,"FIRST HEALTH [10303]","First Health",,120.82,80,,,,,0,17.56,128.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM PRECEPT",SUP-8847070,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross PPO",,1728.72,39.2,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 G 40MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30104007,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"MULTIPLAN [10600]",Multiplan,,8714.22,85,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 12MM 144CM 5MM CORONARY STENT",SUP-H7493941812500,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Endomyocardial",PX-480000061,CDM,93505,CPT,0481,RC,,,both,,,8983.92,2695.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1044.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1044.83,7636.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 7.5IN WIDE CUSHING JARIT CONVEX EDGE WIDE",SUP-285-375,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.96,80.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,110.95,41.1,,,,,0,31.4,229.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 36MM X25 LOCK INTRAMEDULLARY NAIL",SUP-04.045.036S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 26MM 1 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800126,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 480CC 12.2CM 5.8CM PROJECTION HIGH PROFILE SM",SUP-SHPB480,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"NOVANET [10819]",Novanet,,5718.38,75,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LACOSAMIDE 100 MG TABLET",RX-96969,CDM,,,0637,RC,00904-7245-68,NDC,both,1,UN,18.76,5.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7.71,41.1,,,,,0,2.18,15.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 140MM 80CM 8MM 6FR .035IN BILIARY",SUP-G50134,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"AETNA [10100]","Aetna HMO/PPO",,4841.55,79.5,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 28CM 6FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251340,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,837.05,68,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 800102 CANC CRUSHED 1-10MM 5CC",SUP-800102,CDM,S27800098,LOCAL,0278,RC,,,both,,,992.25,297.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,283.98,28.62,,,,,0,115.4,843.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 12MM 2.50MM BALLOON DILATATION PEBAX",SUP-1400250-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 4MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012411-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 18FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0168L18,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.78,22.73,"AETNA [10100]","Aetna HMO/PPO",,60.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.81,64.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 4MM X 28MM - US",SUP-90313,CDM,S27200284,LOCAL,0272,RC,,,both,,,35649.18,10694.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,24241.44,68,,,,,0,4146,30301.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIB 58CM 8.6FR TENSI-LOCK SPRINT QUATTRO SECURE HELIX",SUP-6935-58,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"UHC [10700]","United Healthcare",,10869.88,63.3,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 3MM DOG BONE SUTURELASSO KNOTLESS",SUP-AR-2371BL,CDM,C1713,HCPCS,0278,RC,,,both,,,13584.38,4075.31,"FIRST HEALTH [10303]","First Health",,10867.5,80,,,,,0,1579.86,11546.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fluorescent Ab Titer Ea",PX-302000054,CDM,86256,CPT,0302,RC,,,both,,,340.10,102.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.65,,"Fee schedule rate ($12.65). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,289.09,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL COALITION ANTERIOR CERVICAL DISCECTOMY AND",SUP-384.106,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2133,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.2MM 14MM APTUS TITANIUM HAND ELBOW HEXADRIVE 4",SUP-A-5100.14/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,519.34,41.1,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR IMPLANTABLE CHRONIC PAIN RS2",SUP-97715,CDM,C1820,HCPCS,0278,RC,,,both,,,85500.00,25650,"MULTIPLAN [10600]",Multiplan,,72675,85,,,,,0,9943.65,72675,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 24MM LCP TITANIUM DISTAL VOLAR RADIUS LOCKING",SUP-04.210.124,CDM,C1713,HCPCS,0278,RC,,,both,,,1063.69,319.11,"CIGNA [10200]","Cigna Open Access",,605.24,56.9,,1144.80,304.56,2275.09,66,123.71,904.14,"percent of total billed charges",
"TROCAR LAPAROSCOPIC Z THREAD 100MM 12MM KII FIOS FIRST ENTRY",SUP-CTF74,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 42MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.842,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",29.18,213.27,"percent of total billed charges",
"STENT POLARIS LOOP URETERAL",SUP-M0061902330,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 5MM BALLOON DILATATION STERILE LATEX",SUP-595015022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH II SSL9",SUP-398356,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"NOVANET [10819]",Novanet,,394.88,75,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 5CM 14FR MIC-KEY SECUR-LOK ENFIT SILICONE RADIOPAQUE",SUP-8140-14-5.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CIGNA [10200]",Cigna,,529.76,68,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 9MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P309,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Open Access",,4754.51,56.9,,5302.19,4377.88,6578.61,27,971.79,7102.52,"percent of total billed charges",
"PLATE MEDIUM TITANIUM 4/5.5MM SCR LOW PROFILE RECONSTRUCTION",SUP-SP01003L,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,957.42,570.23,957.42,28,2014.9,14726.25,"percent of total billed charges",
"NAIL 10MM 380MM RIGHT TROCHANTERIC INTRAMEDULLARY 130D LONG",SUP-456.358S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"FIRST HEALTH [10303]","First Health",,10936.34,80,,,,,0,1589.87,11619.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X18X9MM TRANSCONTINENTAL 10D LORDOTIC",SUP-375.782,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross HMO",,9384.48,39.2,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 114MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 8",SUP-71357008,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"PHCS [10601]",PHCS,,23198.81,70,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FLOSWITCH 1050 PSI FLOW CONTROL 1 WAY HIGH PRESSURE",SUP-M001442001,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.22,18.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,29.02,45.9,,,,,0,7.35,53.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER BREAST BIOPSY CELERO SYSTEM",SUP-SMARK-CELERO,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"FIRST HEALTH [10303]","First Health",,534.28,80,,,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP ACETABULAR 58MM PINNACLE HIP STERILE 100 SERIES",SUP-121701058,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"BLUE CROSS [10001]","Blue Cross PPO",,4449.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",1320.06,9647.93,"percent of total billed charges",
"SHEATH PINNACLE 10CM 2.5CM 7FR INTRO STAINLESS STEEL",SUP-RSS702,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"MULTIPLAN [10600]",Multiplan,,66.56,85,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 5.5MM ES2 RADIUS TITANIUM HEXAGONAL",SUP-482806055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE COMPRESSION M L12IN FOR 14-15IN CALF NEOPRENE DURABLE",SUP-VP40103-030,CDM,S27000186,LOCAL,0270,RC,,,both,,,67.69,20.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.87,57.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION KIRSCHNER L203 MM OD.9 MM 1 TROCAR NONSTERILE",SUP-KWIR-ST-09203,CDM,S27200284,LOCAL,0272,RC,,,both,,,426.30,127.89,"FIRST HEALTH [10303]","First Health",,341.04,80,,,,,0,49.58,362.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET",RX-24216,CDM,,,0637,RC,00904-7440-61,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM FULL THREAD 1.3MM CORKSCREW SUTURETAPE",SUP-AR-1927BCT,CDM,C1713,HCPCS,0278,RC,,,both,,,2795.63,838.69,"MULTIPLAN [10600]",Multiplan,,2376.29,85,,,,,0,325.13,2376.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 36MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.212,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"FIRST HEALTH [10303]","First Health",,698.54,80,,,,,0,101.55,742.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 7 HIP",SUP-PRTLE027,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXERCISER HAND C10-100 LB 3 SPRING RESISTIVE LATEX FREE",SUP-A8461,CDM,S27000186,LOCAL,0270,RC,,,both,,,151.03,45.31,"CIGNA [10200]","Cigna Open Access",,85.94,56.9,,,,,0,17.56,128.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175273180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"MULTIPLAN [10600]",Multiplan,,1241.09,85,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 27MM CARPENTIER-EDWARDS PERIMOUNT MAGNA HEART",SUP-7300TFX27MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,62370.00,18711,"CIGNA [10200]",Cigna,,24948,40,,,,,0,7253.63,53014.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ABLATION 20CM 14GA CERTUS",SUP-LN20,CDM,C2618,HCPCS,0272,RC,,,both,,,14524.50,4357.35,"PHCS [10601]",PHCS,,10167.15,70,,,,,0,1689.2,12345.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRICUSPID WIRE DELIVERY CATHETER, MEDIUM",SUP-26000-02,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 10.5MM 5MM 4FR AMPLATZER .038IN NITINOL",SUP-9-AVP038-005,CDM,S27800098,LOCAL,0278,RC,,,both,,,7141.50,2142.45,"NOVANET [10819]",Novanet,,5356.13,75,,,,,0,830.56,6070.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP MULTIHOLE R3 STD STERILE",SUP-71338664,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"AETNA [10100]","Aetna HMO/PPO",,12630.36,79.5,,10981.53,8986.79,12413.38,12,1847.69,13504.16,"percent of total billed charges",
"INSRT ARTICULAR 5-6 E-F 17MM KNEE FIX BEARING PROLONG NEXGEN",SUP-00596204017,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"MULTIPLAN [10600]",Multiplan,,6730.67,85,,,,,0,920.91,6730.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 7FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175270110,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"BLUE CROSS [10001]","Blue Cross PPO",,485.84,39.2,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 30MM 5.5MM .014IN LOW PROFILE",SUP-1008195-30,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"PHCS [10601]",PHCS,,992.25,70,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X18X10MM COROENT XL PEEK-OPTIMA LUMBAR",SUP-6910855,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"FIRST HEALTH [10303]","First Health",,19008,80,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins/Rplc Pcmkr Gen Only Sngl",PX-480000007,CDM,33212,CPT,0481,RC,,,both,,,6607.65,1982.29,"AETNA [10100]","Aetna HMO/PPO",,5253.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,768.47,6607.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORD, HI FREQ, W/8MM PLUG, 300CM",SUP-277KB-HN,CDM,S27000186,LOCAL,0270,RC,,,both,,,1714.05,514.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,786.75,45.9,,,,,0,199.34,1456.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3.33MM LARGE REGULAR PIGTAIL CURVE URETERAL",SUP-M001274050,CDM,C2617,HCPCS,0278,RC,,,both,,,1053.00,315.9,"BLUE CROSS [10001]","Blue Cross HMO",,412.78,39.2,,,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM DCP LC-DCP STAINLESS STEEL PROXIMAL",SUP-204.22,CDM,C1713,HCPCS,0278,RC,,,both,,,117.28,35.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,13.64,99.69,"percent of total billed charges",
"SNARE 2.8CM ROUND 240CM 2.4MM CAPTIVATOR II LOOP SHEATH",SUP-M00561243,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.04,23.71,"CIGNA [10200]",Cigna,,53.75,68,,,,,0,9.19,67.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -2MM 36MM CERAMIC ARTICUL/EZE",SUP-473436920,CDM,C1776,HCPCS,0278,RC,,,both,,,14072.55,4221.76,"NOVANET [10819]",Novanet,,10554.41,75,,,,,0,1636.64,11961.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 15MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25015W,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 125MM CEMENT EXETER V40 ORTHINOX 1 37.5MM",SUP-0580-3-371,CDM,C1776,HCPCS,0278,RC,,,both,,,17001.60,5100.48,"CIGNA [10200]","Cigna Open Access",,5695.54,33.5,,5302.19,4377.88,6578.61,27,1977.29,14451.36,"percent of total billed charges",
"INSRT TIBIAL 6 6MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710606,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6080.17,41.1,,6417.48,6417.48,6417.48,"1 through 10",1720.5,12574.56,"percent of total billed charges",
"PRECEPT TI ROD, 300MM STRAIGHT",SUP-8848300,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2998.8,68,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 68MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.568,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"MULTIPLAN [10600]",Multiplan,,931.96,85,,,,,0,127.51,931.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEXA PROMRI 60 LEAD",SUP-420768,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 40MM 7MM 8FR FLUENCY PLUS CARBON EPTFE 2",SUP-FEM07040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]",Cigna,,7308,40,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL INSUFFLATION 15CM 14GA PNEUMOPERITONEUM BAND INDCTR",SUP-60-6050-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,163.47,49.04,"UHC [10700]","United Healthcare",,103.48,63.3,,,,,0,19.01,138.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18385,CDM,,,0637,RC,42806-0410-60,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 80MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540080L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 16MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-1517-10-516,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"MULTIPLAN [10600]",Multiplan,,12574.56,85,,,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE VASCULAR STRAIGHT 182CM .014IN POLYMER",SUP-H74912133012,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 200MM 3MM BALLOON DILATATION RAPID",SUP-47530200L,CDM,C1725,HCPCS,0272,RC,,,both,,,1890.00,567,"MULTIPLAN [10600]",Multiplan,,1606.5,85,,,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORPLEX 2X3 CM",SUP-CX-2030,CDM,Q4232,HCPCS,0636,RC,,,both,,,9204.60,2761.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1090.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.92,7823.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 20MM 80CM 7MM VASCULAR NITINOL PERIPHERAL",SUP-1012529-20,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM CONCERTO 3D",SUP-PV-6-20-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"KAISER [10500]",Kaiser,,3004.95,67,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM .021-.027IN AZUR CX DETACHABLE",SUP-45-780620,CDM,S27800098,LOCAL,0278,RC,,,both,,,5278.50,1583.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1510.71,28.62,,,,,0,613.89,4486.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 6-9 C-D KNEE LEFT VIVACIT-E",SUP-42512400510,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4429.11,41.1,,6417.48,6417.48,6417.48,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"HC Apc Resistance",PX-305000036,CDM,85307,CPT,0305,RC,,,both,,,514.80,154.44,"CIGNA [10200]","Cigna Open Access",,33.7,,,,,,,0.01,437.58,"fee schedule",
"CATH SABERX 200CM 80MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560080L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 80MM 4MM BALLOON",SUP-U3513048,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.6V 38MM 2 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18006238,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,3978.14,359.25,3978.14,24,521.61,3812.25,"percent of total billed charges",
"BRACE, WALKING LARGE  AIR",SUP-01P-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,754.27,226.28,"KAISER [10500]",Kaiser,,505.36,67,,,,,0,87.72,641.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 20MM 5MM CORONARY STENT PLATINUM",SUP-H7493926020500,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"PHCS [10601]",PHCS,,6520.5,70,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00205,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"CIGNA [10200]","Cigna Local Plus",,585.02,53.5,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT BROWN 34X4.125IN 22.5-32IN ATS 2200 CYL 1 PORT 1",SUP-60707515600,CDM,S27200284,LOCAL,0272,RC,,,both,,,282.96,84.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,32.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.91,240.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 80CM 6MM 8FR STRAIGHT VASCULAR",SUP-AVSM06100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7308,40,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"Assay of Feces Porphyrins",PX-301000710,CDM,84126,CPT,0301,RC,,,both,,,348.00,104.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,295.8,"per diem",
"CATH ULTRAVERSE 035 GEOALIGN 130CM 80MM 9MM BALLOON",SUP-U3513098,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 300ML GEL ROUND SMOOTH MEMORYGEL SILICONE P3.1CM","SUP-3507300 MC",CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1638.63,45.9,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 3.25MM CORONARY STENT",SUP-1145325-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"FIRST HEALTH [10303]","First Health",,4670.4,80,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS INFINITI 100CM 5FR MPB2 CURVE ANGIOGRAPHIC",SUP-534539T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"CIGNA [10200]",Cigna,,63.6,68,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY UVA",SUP-CCWET0,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,397.04,45.9,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 120CM 2.4FR 12MM 4 WIRE STONE KINK",SUP-M0063901010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1495.67,448.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,614.72,41.1,,,,,0,173.95,1271.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 4FR 21GA MERIT MAK .018IN STD GWIRE NDL MINI",SUP-MAK401N,CDM,C1894,HCPCS,0272,RC,,,both,,,217.50,65.25,"AETNA [10100]","Aetna HMO/PPO",,172.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 150MM 2.5MM BALLOON DILATATION RAPID",SUP-47525150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1085.08,68,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 36X3.5X.9MM TITANIUM 1.5MM SCR 7 HOLE LCP BONE LEFT",SUP-446.63.96,CDM,C1713,HCPCS,0278,RC,,,both,,,3271.80,981.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,936.39,28.62,,,,,0,380.51,2781.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 10CM 26MM GORE TAG THORACIC ACTIVE CONTROL",SUP-TGM262610,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"KAISER [10500]",Kaiser,,77701.37,67,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X18X1.19MM SAGITTAL 2 CUT STERILE",SUP-4118-119-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,393.85,118.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.8,334.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 15X12MM 3/32IN COVIDIEN STERILE",SUP-E1560,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.35,27.4,"CIGNA [10200]",Cigna,,62.12,68,,,,,0,10.62,77.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE 4 MEQ/L POTASSIUM 1.2 MEQ/L MAGNESIUM 140",SUP-110411,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"KAISER [10500]",Kaiser,,139.9,67,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 200MM 5.5MM RELINE STRAIGHT TITANIUM MULTIAXIAL",SUP-12355200,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 5-0 P-3 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8698G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT RICKHAM 70MM 2O PRECISION NO CATH PROGRAMMABLE",SUP-NS0567,CDM,S27800098,LOCAL,0278,RC,,,both,,,6819.27,2045.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3130.04,45.9,,,,,0,793.08,5796.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 18MM 9MM STD WALL THIN WALL 2 BRANCH",SUP-SBT1802D,CDM,C1768,HCPCS,0278,RC,,,both,,,8611.20,2583.36,"UHC [10700]","United Healthcare",,5450.89,63.3,,,,,0,1001.48,7319.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 12MM 4MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG40012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2812.50,843.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,333.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM TRIATHLON 5 LEFT MEDIAL RIGHT LATERAL TOTAL",SUP-5545-A-501,CDM,C1776,HCPCS,0278,RC,,,both,,,6068.55,1820.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,705.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,705.77,5158.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOLOIST 110CM 6FR 5MM SPACING JSN CURVE",SUP-307F1,CDM,C1733,HCPCS,0272,RC,,,both,,,10005.00,3001.5,"KAISER [10500]",Kaiser,,6703.35,67,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 115CM 7FR 2-5-2MM SPACE F CURVE LARGE DOME MAPPING 4",SUP-D7FL252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,5326.80,1598.04,"NOVANET [10819]",Novanet,,3995.1,75,,,,,0,619.51,4527.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 92CM 1MM 6FR 2-5-2MM SPACING F CURVE ELECTROPHYSIOLOGY",SUP-D610FR252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2534.7,68,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 15.5CM MEMORYGEL P6CM HIGH PROFILE ROUND BREAST",SUP-RSZ8004S,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"CIGNA [10200]","Cigna Open Access",,87.76,56.9,,,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +19 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.190,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 8MM MREYE PLATINUM FIBER 2 LOOP",SUP-G42463,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"NOVANET [10819]",Novanet,,625.67,75,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 6X 22MM CATH 120CM ENDOVASCULAR",SUP-42622,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 6.25MM SWIVELOCK TENODESIS SHOULDER BICEPS CLOSED",SUP-AR-1662BC,CDM,C1713,HCPCS,0272,RC,,,both,,,3228.75,968.62,"UHC [10700]","United Healthcare",,2043.8,63.3,,5023.51,2672.93,6679.78,18,1327.02,2043.8,"percent of total billed charges",
"STENT URETERAL 7FR L28CM SOFT WITHOUT GUIDEWIRE TRIA",SUP-M0061903340,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 12 EXTREME LATERAL INTERBODY FUSION 4 HOLE DECADE BONE",SUP-7140412,CDM,C1713,HCPCS,0278,RC,,,both,,,13800.00,4140,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3726,27,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER PACING LEAD ACUITY 11FR",SUP-667467-001,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 29.5X7MM PRECISION THK.38MM LONG MICRO NARROW THIN",SUP-2296003115,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.00,18.6,"CIGNA [10200]",Cigna,,42.16,68,,,,,0,7.21,52.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND 24X20CM SILICONE PORCINE THERAGENESIS 2 LAYER",SUP-TG-M200240,CDM,A2008,HCPCS,0636,RC,,,both,,,49083.30,14724.99,"CIGNA [10200]","Cigna Open Access",,27928.4,56.9,,,,,0,247.92,41720.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 5 LEFT DISTAL KNEE",SUP-5540-A-501,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"NOVANET [10819]",Novanet,,3407.86,75,,,,,0,528.45,3862.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE MASR CANCELLOUS CORTICAL LORDOTIC",SUP-645641,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 57MM TITANIUM 2.4MM SCREW 8 HOLE BONE RIGHT HAND NONST",SUP-449.916,CDM,C1713,HCPCS,0278,RC,,,both,,,3706.50,1111.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,439.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,431.07,3150.53,"percent of total billed charges",
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR RDC CURVE",SUP-G08578,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,97.61,41.1,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 150MM 75CM 6MM VASCULAR RADIOPAQUE SELF EXPAND",SUP-H74939293061570,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hdr Ntrstl Icav Brachytx 2-12 Chnl Sd",PX-342000022,CDM,77771,CPT,0342,RC,,,both,,,6027.68,1808.3,"CIGNA [10200]",Cigna,,4098.82,68,,,,,0,408.8,5123.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY 2-5-2MM SPACING 7FR 95CM 2MM DUO",SUP-401914R,CDM,C1731,HCPCS,0272,RC,,,both,,,2100.00,630,"MULTIPLAN [10600]",Multiplan,,1785,85,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 20X20MM FORTIFY 0D 20MM FOOTPRINT LOWER",SUP-151.451,CDM,S27800098,LOCAL,0278,RC,,,both,,,3172.50,951.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,368.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,368.96,2696.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 8MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630508,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1555.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT ELITE VASCULAR J CURVE",SUP-1011880J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKING COILS XL 45CM",SUP-RBYPCXL45,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 7MM CONCERTO DETACHABLE HELIX PERIPHE",SUP-NV-7-30-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SUTURETAPE TIGERLINK 1.3MM BLACK WHITE LATEX FREE",SUP-AR-7535T,CDM,S27200284,LOCAL,0272,RC,,,both,,,722.93,216.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,331.82,45.9,,,,,0,84.08,614.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE AMNIOBAND PLACENTAL ALLOGRAFT DEHYDRATE",SUP-WC3160,CDM,S27800098,LOCAL,0278,RC,,,both,,,16086.04,4825.81,"AETNA [10100]","Aetna HMO/PPO",,12788.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1870.81,13673.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BENCHMARK 95CM .07IN STRAIGHT DELIVERY SYSTEM LATEX",SUP-BMK6F95,CDM,S27200284,LOCAL,0272,RC,,,both,,,6727.50,2018.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,797.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 2CM WIRE LARGE RADIUS LOOP UNIVERSAL",SUP-R2020,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.17,46.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.16,132.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +30 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000300,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD ILIVIA 7 DR-T",SUP-404623,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,11608.27,28.62,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP PRESS FIT WITH COCR HEAD R3 XLPE LINER",SUP-71703313,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32.5MM T2 TITANIUM FULL THREAD FEMUR HUMERUS",SUP-1896-5032S,CDM,C1713,HCPCS,0278,RC,,,both,,,1279.15,383.74,"CIGNA [10200]",Cigna,,869.82,68,,1831.33,1831.33,1831.33,16,148.77,1087.28,"percent of total billed charges",
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 15MM COCR",SUP-VAL-20150-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,408.01,28.62,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR COBRA 2 CURVE ANGIOGRAPHIC VISCERAL",SUP-M001314661,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPIDERFX 320CM 190CM 3.2-4.2FR 6MM EMBOLIC PROTECTION",SUP-SPD2-US-060-320,CDM,C1884,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"MULTIPLAN [10600]",Multiplan,,6158.25,85,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X12MM 10D XL PEEK-OPTIMA PLATE FUSION",SUP-7871250,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"MULTIPLAN [10600]",Multiplan,,29134.26,85,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 35CM ENDOCARDIUM MYOCARDIUM RIGHT VENTRICLE IS-1",SUP-4046,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross PPO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 380MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.059S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CIGNA [10200]","Cigna Local Plus",,3911.78,31.5,,3978.14,359.25,3978.14,24,1444.25,10555.59,"percent of total billed charges",
"CATH BARDEX LUBRICATH 22FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0103L22,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.74,25.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,34.83,41.1,,,,,0,9.86,72.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 80MM 8MM .035IN LOW PROFILE BALLOON",SUP-B1080-080,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"MULTIPLAN [10600]",Multiplan,,654.08,85,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 8MM 72MM STAINLESS STEEL CORTICAL SELF TAP",SUP-214.872,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,170.62,68,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE POLYPECTOMY ENDOSCOPIC",SUP-M00562550,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL RESTORELLE SMARTMESH 24X8CM NONPALPABLE",SUP-501440,CDM,C1781,HCPCS,0278,RC,,,both,,,6982.80,2094.84,"BLUE CROSS [10001]","Blue Cross PPO",,2737.26,39.2,,,,,0,812.1,5935.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 12MM AXIUM 3D NEUROVASCULAR FRAME V01",SUP-FC-12-50-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6610.2,40,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 170MM PERFORM 13 LONG SHOULDER STERILE LATEX",SUP-PFX13170,CDM,C1776,HCPCS,0278,RC,,,both,,,42493.50,12748.05,"NOVANET [10819]",Novanet,,31870.13,75,,,,,0,4941.99,36119.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINE MNTR 2MR LOFLO SIDESTREAM STRAIGHT INTUBATE MALE LUER",SUP-989803144571,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.78,43.73,"MULTIPLAN [10600]",Multiplan,,123.91,85,,,,,0,16.95,123.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROLENE 4X1.8IN KNIT NONABSORBABLE PRESHAPE",SUP-PMSK,CDM,C1781,HCPCS,0278,RC,,,both,,,594.43,178.33,"FIRST HEALTH [10303]","First Health",,475.54,80,,,,,0,69.13,505.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM VUEPOINT II SPINE MULTIAXIAL NONSTERILE",SUP-8975310,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,1144.80,304.56,2275.09,66,441.36,3225.75,"percent of total billed charges",
"HC MRI Fetal Addl Gestation",PX-610000054,CDM,74713,CPT,0610,RC,,,both,,,1846.00,553.8,"AETNA [10100]","Aetna HMO/PPO",,1846,,"Per diem ($2,816). Each eligible service on a given day will be paid its own per diem rate.",,,,0,214.69,1846,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH-PROFILE BOOST, 700CC",SUP-SMHB700,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"BLUE CROSS [10001]","Blue Cross HMO",,2988.8,39.2,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Dil Schatzki Ring W Bx Forceps",PX-750000241,CDM,43499,CPT,0750,RC,,,both,,,5311.00,1593.3,"BLUE CROSS [10001]","Blue Cross PPO",,5311,,"Case rate ($5,500.90). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,617.67,5311,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 4-0 PS-2 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP426H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.17,19.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.7,56.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALARM WC POSEY SELF RELEASE BELT DISPOSABLE",SUP-8399L,CDM,S27100035,LOCAL,0271,RC,,,both,,,219.68,65.9,"UHC [10700]","United Healthcare",,139.06,63.3,,,,,0,25.55,186.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR AMPLATZ LEFT 1.5",SUP-67003800,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,171.63,41.1,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE STEMS/WEDGES/AUGMENTS",SUP-CAP-U-SWA,CDM,C1776,HCPCS,0278,RC,,,both,,,2250.00,675,"BLUE CROSS [10001]","Blue Cross HMO",,882,39.2,,5311.50,4717.44,5388.59,31,261.68,1912.5,"percent of total billed charges",
"CLAREON PANOPTIX TORIC",SUP-CNWTT3,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,397.04,45.9,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DEX 5    .5 SALINE 1000ML",SUP-792609,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061802410,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"NOVANET [10819]",Novanet,,676.64,75,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12.2CM 6MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR180612,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"FIRST HEALTH [10303]","First Health",,9505.44,80,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 6FR 7MM 4FR BALLOON",SUP-39031-70401,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,174.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 80MM 8MM BALLOON",SUP-U3513088,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 8MM RETRACTA DETACHABLE .035IN",SUP-G34189,CDM,S27800098,LOCAL,0278,RC,,,both,,,4308.98,1292.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1233.23,28.62,,,,,0,501.13,3662.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Breast Uni WO Cntrst",PX-610000058,CDM,77046,CPT,0610,RC,,,both,,,4260.00,1278,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,504.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,495.44,3621,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 18CM NARROW BASE INFRAPUBIC NARROW CORPORA",SUP-EN8818,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7429.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 14MM XTEND SPINE FIX ANGLE SELF TAP",SUP-161.714,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,inpatient,,,145350.75,43605.22,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,48769.56,,"Case rate ($23,951.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $22,240.37, add-ons for qualifying new technology services are included. If operating cost exceeds $55,280.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,063.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,269.78. The transfer operating threshold is the transfer adjustment factor * $22,240.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,681.48. The transfer capital threshold is the transfer adjustment factor * $1,681.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 203.62%.",,,,0,7561,112731.6,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL 12MM 2 SOFT SPRING",SUP-G-1200,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]",Cigna,,153.82,68,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 80MM 120CM 10MM 9FR STRAIGHT VASCULAR",SUP-AVSL10080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UHC [10700]","United Healthcare",,11564.91,63.3,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, NEUTRAL HUMERAL HEAD, 40X14",SUP-520-40-214,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"PHCS [10601]",PHCS,,6362.16,70,,,,,0,1057.03,7725.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 11X.5IN COBB SPINE",SUP-26-4913,CDM,S27200284,LOCAL,0272,RC,,,both,,,499.77,149.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYR INFLATION 3 WAY STPCOCK DILATION GRADUATED NONSTERILE",SUP-G27112,CDM,S27200284,LOCAL,0272,RC,,,both,,,401.94,120.58,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM FEMORAL 109MM 12MM PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51107120,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"CIGNA [10200]",Cigna,,10974.1,40,,5873.17,5873.17,5873.17,"1 through 10",3190.72,23319.95,"percent of total billed charges",
"CAP LINER ACETABULAR R3 XLPE COCR NONPOROUS HIP",SUP-71703312,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6851.63,28.62,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 220CM 11.5-14MM OTSC 3MM NITINOL",SUP-100.07,CDM,C1760,HCPCS,0278,RC,,,both,,,4754.10,1426.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2182.13,45.9,,,,,0,552.9,4040.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE",325,MS-DRG,,,,,,,inpatient,,,199674.97,59902.49,"BLUE CROSS [10001]","Blue Cross PPO",,79255.31,,,,,,,19914.3,93730.84,"case rate",
"STENT EPIC 100MM 120CM 8MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200091020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"AMERIGROUP MEDICAID [20100]",Amerigroup,,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK",RX-16162,CDM,J3475,HCPCS,0636,RC,00409-6727-23,NDC,both,100,ML,100.65,30.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68.44,68,,,,,0,0.12,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TALON 160CM 2.5MM SPECIMEN RETRIEVAL STAINLESS STEEL",SUP-00711175,CDM,S27200284,LOCAL,0272,RC,,,both,,,1134.00,340.2,"NOVANET [10819]",Novanet,,850.5,75,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9MM 45MM REVERE TITANIUM SPINE PEDICLE NONSTERILE",SUP-124.095,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1385.95,28.62,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO ANL1 CURVE 70CM 8FR 2.9MM GUIDING",SUP-G56228,CDM,C1894,HCPCS,0272,RC,,,both,,,558.09,167.43,"AETNA [10100]","Aetna HMO/PPO",,443.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.91,474.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT ISP AIRGUARD CHRONOFLEX",SUP-1708061,CDM,C1788,HCPCS,0278,RC,,,both,,,1905.00,571.5,"CIGNA [10200]","Cigna Local Plus",,1019.18,53.5,,,,,0,221.55,1619.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH II SS10",SUP-398348,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TM REVERSE STEM 10MM X130MM",SUP-00434901013,CDM,C1776,HCPCS,0278,RC,,,both,,,17863.20,5358.96,"PHCS [10601]",PHCS,,12504.24,70,,,,,0,2077.49,15183.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 10.5IN WRIST RIGHT ADJUSTABLE",SUP-VP30001-240,CDM,S27000186,LOCAL,0270,RC,,,both,,,92.74,27.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.79,78.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 1.9MM 150CM BRONCHOSCOPE BULLET TIP WIRE",SUP-M00516151,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.01,40.5,"CIGNA [10200]","Cigna Open Access",,76.82,56.9,,,,,0,15.7,114.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8MM 210MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-408-210,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 5CM 20GA GHIATAS BEADED STIFFENED SECTION",SUP-49520,CDM,A4648,HCPCS,0278,RC,,,both,,,182.79,54.84,"CIGNA [10200]",Cigna,,124.3,68,,,,,0,21.26,155.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 23FR 55.7CM MICRA HYDROPHILIC",SUP-MI2355A,CDM,C1894,HCPCS,0272,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP IODINE SSI 6OZ 3 7/16X2",SUP-6G,CDM,S27000186,LOCAL,0270,RC,,,both,,,60.73,18.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,27.88,45.9,,,,,0,7.06,51.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL MIXED OSTEONICS HIP",SUP-CAP-MH-F-O,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4443.26,28.62,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 30CM ANKLE DYNANAIL XL INTRAMEDULLARY NITINOL",SUP-1200-01-1230,CDM,C1713,HCPCS,0278,RC,,,both,,,83106.00,24931.8,"CIGNA [10200]","Cigna Local Plus",,26178.39,31.5,,3978.14,359.25,3978.14,24,9665.23,70640.1,"percent of total billed charges",
"WISE SYSTEM SYSTEM PRICE",SUP-M7000,CDM,C1740,HCPCS,0278,RC,,,both,,,360810.00,108243,"NOVANET [10819]",Novanet,,270607.5,75,,,,,0,41962.2,306688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 2.5X2.5MM APPLEBAUM INCUS HA PARTIAL",SUP-140972,CDM,L8613,HCPCS,0278,RC,,,both,,,2680.88,804.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,317.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,232.31,2278.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 P-3 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8699G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 110CM 6FR .079IN .057IN 145D PIGTAIL",SUP-534653S,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"UHC [10700]","United Healthcare",,55.07,63.3,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT,DISP,22MM,NON-HTD,PASSIVE",SUP-989805664611,CDM,S27200284,LOCAL,0272,RC,,,both,,,167.17,50.15,"CIGNA [10200]","Cigna Open Access",,95.12,56.9,,,,,0,19.44,142.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 7FR 10MM SPACING VENTRICLE BIPOLAR PASSIVE",SUP-1948/58,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,259.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL OVITEX PRS LONG TERM RESORBABLE 3 LAYER",SUP-P20163-2020G,CDM,C1781,HCPCS,0278,RC,,,both,,,43738.38,13121.51,"BLUE CROSS [10001]","Blue Cross HMO",,17145.44,39.2,,,,,0,5086.77,37177.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM ALLOGRAFT 12MM",SUP-310112,CDM,S27800098,LOCAL,0278,RC,,,both,,,3139.50,941.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,365.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,365.12,2668.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 8MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158120108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]",Cigna,,7598.69,68,,5873.17,5873.17,5873.17,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"PLATE 145MM STAINLESS STEEL 3.5MM SCREWS 8 HOLE LCP BONE",SUP-239.959,CDM,C1713,HCPCS,0278,RC,,,both,,,9810.83,2943.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4032.25,41.1,,,,,0,1141,8339.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30MMX4.8MM TITANIUM THICK TISSUE 2 ROW",SUP-TX30G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1810.13,543.04,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUTURE PASSER WITH GUIDE SUTURE PASSING PUNCTURE CLOSURE DEV",SUP-RSG-14F,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.80,52.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FILTER LN SET CAPNGRPHY OXMTR MICROSTRM AD PED",SUP-XS04624,CDM,S27000186,LOCAL,0270,RC,,,both,,,133.12,39.94,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,inpatient,,,149949.56,44984.87,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.8MM SHOULDER RESTORATION SYSTEM Y-KNOT SPADE",SUP-Y28D,CDM,S27200284,LOCAL,0272,RC,,,both,,,954.26,286.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN RADIOFREQUENCY 15CM 18GA SIDEKICK 2 ERGONOMIC HUB",SUP-RFK-C151018S-ZK2-P,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.95,74.38,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TURBO-ELITE 150CM 2MM .08IN .081IN ATHERECTOMY",SUP-420-006,CDM,C1885,HCPCS,0272,RC,,,both,,,18868.50,5660.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"STEM FEMORAL 124MM CEMENT ACCOLADE C 132D 2 35MM OFFSET HIP",SUP-6058-0230D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1948.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1911.88,13973.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 74MM 10.8MM 6.4MM UNCUFFED NONFENESTRATED INNER CANN",SUP-6DCFS,CDM,S27200284,LOCAL,0272,RC,,,both,,,420.04,126.01,"PHCS [10601]",PHCS,,294.03,70,,,,,0,48.85,357.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 19MM KNEE X3 CONDYLAR STABILIZED PRIMARY",SUP-5531G319,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1109.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1089.28,7961.17,"percent of total billed charges",
"STENT HERCULINK ELITE 18MM 80CM 7MM 3.3-3.5FR VASCULAR COCR",SUP-1011504-18,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"MULTIPLAN [10600]",Multiplan,,5355,85,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 D 36MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30123604,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"UHC [10700]","United Healthcare",,6489.53,63.3,,8601.07,8395.67,8601.07,"1 through 10",1192.31,8714.22,"percent of total billed charges",
"RING ANNULOPLASTY 34MM MITRAL CARPENTIER-EDWARDS PHYSIO II",SUP-520034MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"PHCS [10601]",PHCS,,9660,70,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X21MM LUMINARY CC BICONVEX SPINE",SUP-6821,CDM,S27800098,LOCAL,0278,RC,,,both,,,34524.00,10357.2,"NOVANET [10819]",Novanet,,25893,75,,,,,0,4015.14,29345.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 36MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.115,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"CIGNA [10200]","Cigna Local Plus",,458.66,53.5,,3978.14,359.25,3978.14,24,99.7,728.71,"percent of total billed charges",
"TRAY CATHETERIZATION LUBRICATH 14FR 2000ML FOLEY DRNG BAG",SUP-899914,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.57,27.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,38.05,41.1,,,,,0,10.17,78.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG 17X6CM VAC GRANUFOAM THK1.9CM POLYURETHANE FOAM",SUP-M8275042/10.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,376.72,113.02,"FIRST HEALTH [10303]","First Health",,301.38,80,,,,,0,43.81,320.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE DRILL TAN 3.2MM SURESHOT PIN",SUP-71631436,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 4.8FR .035IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856080,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"FIRST HEALTH [10303]","First Health",,877.33,80,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +16.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.165,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA D KNEE LEFT NONPOROUS REVISION FIXATION",SUP-42542006701,CDM,C1776,HCPCS,0278,RC,,,both,,,16335.06,4900.52,"PHCS [10601]",PHCS,,11434.54,70,,,,,0,1899.77,13884.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 95D 238MM TI6AL4V PERIPROSTHETIC 9 HOLE NCB BONE FEMUR",SUP-0202264009,CDM,C1713,HCPCS,0278,RC,,,both,,,13144.50,3943.35,"MULTIPLAN [10600]",Multiplan,,11172.83,85,,,,,0,1528.71,11172.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG SPECIMEN RETRIEVAL 10MM INZII MONARCH UNIVERSAL",SUP-CD001,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"PHCS [10601]",PHCS,,213.15,70,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT 2XL BARIATRIC",SUP-MAA8010-XXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,4692.14,1407.64,"KAISER [10500]",Kaiser,,3143.73,67,,,,,0,545.7,3988.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 87CM LEFT VENTRICULAR QUADRIPOLAR OTW THREAD",SUP-406082,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"PHCS [10601]",PHCS,,3924.9,70,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 12.7CM 3.5MM STAINLESS STEEL STRAIGHT SHANK",SUP-231803506,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC",190,MS-DRG,,,,,,,inpatient,,,33113.82,9934.15,"BLUE CROSS [10001]","Blue Cross HMO",,25429.24,,,,,,,6871.13,27624.93,"case rate",
"DEVICE ZIPTIGHT ZIPLOOP FIXATION TITANIUM ANKLE KNOTLESS LOW",SUP-909853,CDM,S27200284,LOCAL,0272,RC,,,both,,,8355.90,2506.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,990.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC",288,MS-DRG,,,,,,,inpatient,,,80069.72,24020.92,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN HOCKEY STICK 1 CURVE GUIDING",SUP-LA7HSI,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 7FR .081IN SHORT AMPLATZ LEFT 1 CURVE GUIDING",SUP-LA7SAL10,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT STAINLESS STEEL 2 18IN MONOFILAMENT TIE 12 STRAND SILVER",SUP-DS24,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.11,21.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SHAVER 3MM 10 FLUTE OVAL",SUP-AR-9300OBT,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE STD CONTOUR TITANIUM 3 HOLE ANATOMIC GRAFT WINDOW BONE",SUP-AR-8916VSR-03,CDM,C1713,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"AETNA [10100]","Aetna HMO/PPO",,4360.97,79.5,,1521.93,481.35,16760.95,30,637.96,4662.68,"percent of total billed charges",
"BLADE SHAVER SLATE 4.5MM INCISOR PLUS ELITE LONG CURVED",SUP-72200494,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"AETNA [10100]","Aetna HMO/PPO",,463.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN HOCKEY STICK 1 CURVE GUIDING",SUP-LA6HSISH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 22MM COLONIC ENTERAL ANCHOR LOCK",SUP-M00555780,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 43MM TITANIUM LEVEL 2 ZEVO BONE SPINE CERVICAL",SUP-3002043,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 150MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UHC [10700]","United Healthcare",,907.53,63.3,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 6MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBH061502,CDM,C1874,HCPCS,0278,RC,,,both,,,23102.10,6930.63,"PHCS [10601]",PHCS,,16171.47,70,,,,,0,2686.77,19636.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 1.3FR 6-11MM OPTIFLEX SMALL",SUP-M0063903000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1652.33,495.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,195.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,192.17,1404.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM .02IN 3MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0320,CDM,S27800098,LOCAL,0278,RC,,,both,,,6258.00,1877.4,"CIGNA [10200]","Cigna Local Plus",,3348.03,53.5,,,,,0,727.81,5319.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL RESTORELLE SMARTMESH 27X4CM NONPALPABLE Y FLAT",SUP-501430,CDM,C1781,HCPCS,0278,RC,,,both,,,8645.70,2593.71,"FIRST HEALTH [10303]","First Health",,6916.56,80,,,,,0,1005.49,7348.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIA FORM+, 1.0 CC",SUP-VCAFX-010000,CDM,S27800098,LOCAL,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X6MM COLONIAL 7D LORDOTIC 14MM XL TITANIUM",SUP-365.806CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chromo Analyss 15-20 Cell Band",PX-311000035,CDM,88262,CPT,0311,RC,,,both,,,1561.30,468.39,"AETNA [10100]","Aetna HMO/PPO",,1241.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1327.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 72.5MM KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-183113,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"CIGNA [10200]","Cigna Open Access",,7258.01,33.5,,5302.19,4377.88,6578.61,27,2519.72,18415.85,"percent of total billed charges",
"KIT NEUROSURGICAL INTRACEPT 120D STERILE LATEX FREE","SUP-RLV AK05",CDM,S27200284,LOCAL,0272,RC,,,both,,,12420.00,3726,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1471.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 4.0/40",SUP-404677,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 25MM 3.3MM MODULAR STERILE",SUP-21073325,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STYLET .016-.032IN 140CM LOCK LEAD EXTRACTION THREADABLE",SUP-G26550,CDM,C1773,HCPCS,0272,RC,,,both,,,4692.00,1407.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4.5MM 14MM OZARK SPINE CERVICAL SELF TAP VARIABLE",SUP-8801-04514CA,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Arm/Hnd Bi (Go)",PX-510000547,CDM,29584,CPT,0430,RC,,,both,,,891.00,267.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,215,,"Per diem ($215).",,,,0,103.62,891,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VIVIGEN MIS CELLULAR BONE MATRIX ALLOGRAFT",SUP-BL-1900-001,CDM,C1713,HCPCS,0278,RC,,,both,,,12357.07,3707.12,"BLUE CROSS [10001]","Blue Cross HMO",,4843.97,39.2,,957.42,156.86,7483.26,51,1437.13,10503.51,"percent of total billed charges",
"SLING PATIENT 2XL BARIATRIC",SUP-MAA8010-XXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,4692.14,1407.64,"AETNA [10100]","Aetna HMO/PPO",,3730.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,545.7,3988.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC15ST-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,19530.00,5859,"FIRST HEALTH [10303]","First Health",,15624,80,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEPHRSTMY 6.3FR PERCUTANEOUS ACCESS PIGTAIL CATH 20CM",SUP-M0064202000,CDM,C1729,HCPCS,0272,RC,,,both,,,123.71,37.11,"PHCS [10601]",PHCS,,86.6,70,,,,,0,14.39,105.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 60MM 14MM 10FR FLUENCY PLUS FLARE ENDOVASCULAR",SUP-FEM14060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5228.87,28.62,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 8FR L24CM FIRM TRI LAYER DESIGN RAW COLORANT",SUP-M0061902420,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SHORT NARROW RADIUS RIGHT DISTAL VOLAR 48.9X21.6MM",SUP-DVRANSR,CDM,S27200284,LOCAL,0272,RC,,,both,,,7607.25,2282.17,"PHCS [10601]",PHCS,,5325.08,70,,,,,0,884.72,6466.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 21GA .087IN 45CM 10CM SPRING STRAIGHT WIRE",SUP-20-1060,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 3MM15CM 190",SUP-R51003015L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"NOVANET [10819]",Novanet,,1531.13,75,,,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0215,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM ATRIAL VENTRICULAR BIPOLAR SCR IN ELECTRD",SUP-407665,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"AETNA [10100]","Aetna HMO/PPO",,1774.84,79.5,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 7IN STRAIGHT BONE LUER SURGICAL",SUP-30-5217,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.40,408.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,161.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.21,1156.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Disco Cerv/Thorac Ea",PX-510000107,CDM,62291,CPT,0761,RC,,,both,,,1524.00,457.2,"PHCS [10601]",PHCS,,1066.8,70,,,,,0,1.52,1524,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM TARGET NANO HELICAL DETACHABLE",SUP-M0035431010,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"NOVANET [10819]",Novanet,,6868.26,75,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9.5MM 45MM CREO SPINE PREASSEMBLE THREAD",SUP-5119.1947,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 6-9 C-D KNEE LEFT VIVACIT-E",SUP-42512400510,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1253.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAMOTRIGINE 25 MG TABLET",RX-13981,CDM,,,0637,RC,00904-7007-61,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 32MM 144CM 2.25MM CORONARY STENT",SUP-H7493941832220,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,9776.84,9776.84,9776.84,"1 through 10",348.9,2550,"percent of total billed charges",
"SPACER FEMORAL 20MM MP FEMUR PROXIMAL COCRMO LEG LENGTHENER",SUP-172-950/20,CDM,C1776,HCPCS,0278,RC,,,both,,,2285.10,685.53,"NOVANET [10819]",Novanet,,1713.83,75,,,,,0,265.76,1942.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS SOLN 4.25 % DEX LOW CA+ 2.5 MEQ/L-MG 0.5 MEQ/L",RX-27804,CDM,,,0250,RC,00941-0459-01,NDC,both,6000,ML,301.80,90.54,"MULTIPLAN [10600]",Multiplan,,256.53,85,,,,,0,35.1,256.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +28 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030280,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER FEMORAL 20MM MP FEMUR PROXIMAL COCRMO LEG LENGTHENER",SUP-172-950/20,CDM,C1776,HCPCS,0278,RC,,,both,,,2285.10,685.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,270.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,265.76,1942.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE ANALZR 8X2IN CAPTURE-R READY-ID EXTEND I D POSITIVE",SUP-0006455,CDM,C1713,HCPCS,0278,RC,,,both,,,110.20,33.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,74.94,68,,,,,0,12.82,93.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 10FT CARTO 3 HYPERTONICS 20 PIN TO LEMO 25 PIN",SUP-CG2025CT,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1545.68,45.9,,,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 7MM 9.5MM 225MM HUMERAL RIGHT MULTILOC INTRAMEDULLARY",SUP-04.016.225S,CDM,C1713,HCPCS,0278,RC,,,both,,,11172.76,3351.83,"CIGNA [10200]","Cigna Local Plus",,5977.43,53.5,,3978.14,359.25,3978.14,24,1299.39,9496.85,"percent of total billed charges",
"GRAFT VASCULAR 80CM 8MM GORE INTERING THIN WALL PTFE RADIAL",SUP-IRST08080080L,CDM,C1768,HCPCS,0278,RC,,,both,,,11605.80,3481.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3321.58,28.62,,,,,0,1349.75,9864.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM .02IN 6MM PENUMBRA COIL 400 RUBY",SUP-RBY4C0630,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.00,2003.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4541.04,68,,,,,0,776.65,5676.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 80MM 80CM 5MM 6FR .035IN BILIARY NITINOL",SUP-G36015,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"KAISER [10500]",Kaiser,,2532.6,67,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMR SMALL-R CONNECTOR +4 WITH SCREW TI6AI4V",SUP-1374.15.314,CDM,C1776,HCPCS,0278,RC,,,both,,,1770.00,531,"AMERIGROUP MEDICAID [20100]",Amerigroup,,209.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,205.85,1504.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 7MM STD WALL GORE-TEX LINE STERILE LATEX",SUP-V07040L,CDM,C1768,HCPCS,0278,RC,,,both,,,2775.00,832.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,794.21,28.62,,,,,0,322.73,2358.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) QUALIBREATH 5 XXL  SIZE",SUP-QB5XXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,96.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 1.7MM GRADUATE 2.4MM SCR",SUP-AR-8916-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"FIRST HEALTH [10303]","First Health",,511.92,80,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.150 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.150,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 40CM 11CM 10FR 2CM PIGTAIL CURVE DRNG",SUP-RBDC-10-038,CDM,C1729,HCPCS,0272,RC,,,both,,,558.90,167.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 11CMX20MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-8-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000280,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 53CM J SOLIA S",SUP-107237,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,260.3,68,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 20MM 75CM 8MM VASCULAR METALLIC ILIAC ARTERY OTW",SUP-H74939200082070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 20FR SILICONE UNIVERSAL FEEDING PORT CNCT MEDICATION",SUP-0100-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"CIGNA [10200]","Cigna Local Plus",,149.74,53.5,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX 11CM OPEN POSITION SYSTEM STERILE",SUP-1220011,CDM,C1781,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT 2:1 SILICONE CARDIAC DRNG 4 CHANNEL RADIOPAQUE SOLID",SUP-BCC2,CDM,S27200284,LOCAL,0272,RC,,,both,,,252.07,75.62,"FIRST HEALTH [10303]","First Health",,201.66,80,,,,,0,29.32,214.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT LARGE 12.5 CC MATRIX BIOACT",SUP-74000125,CDM,C1713,HCPCS,0278,RC,,,both,,,18113.76,5434.13,"KAISER [10500]",Kaiser,,12136.22,67,,,,,0,2106.63,15396.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2MM 20MM BLUNT SMOOTH LOCK DVR NONSTERILE",SUP-P20000,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"FIRST HEALTH [10303]","First Health",,874.8,80,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 75CM 10MM 110CM VASCULAR NITINOL ILIAC",SUP-H74939200104070,CDM,C1876,HCPCS,0278,RC,,,both,,,4515.00,1354.5,"CIGNA [10200]","Cigna Local Plus",,2415.53,53.5,,,,,0,525.09,3837.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 24MM 2MM LCP CORTICAL STAINLESS STEEL SELF TAPPING",SUP-201.374.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"FIRST HEALTH [10303]","First Health",,331.3,80,,,,,0,48.16,352,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3522,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,174.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",174.28,1273.73,"percent of total billed charges",
"SHUNT CARDIOVASCULAR 18MM 2MM FLO-THRU INTRALUMINAL",SUP-FT12200,CDM,S27200284,LOCAL,0272,RC,,,both,,,763.91,229.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,313.97,41.1,,,,,0,88.84,649.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON DEKLENE II 7-0 XT-6.5 24IN MONOFILAMENT DOUBLE ARM",SUP-D-7506M2K,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.18,96.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.35,273,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Protein S Total",PX-305000034,CDM,85305,CPT,0305,RC,,,both,,,293.55,88.06,"CIGNA [10200]","Cigna Local Plus",,25.54,,,,,,,0.01,249.52,"fee schedule",
"STENT AEROMINI 115MM 15MM 8MM 12.5FR TRACHEOBRONCHIAL TAPER",SUP-AERO815,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 9 SLOT LEFT TI",SUP-PHPF-C9L,CDM,C1713,HCPCS,0278,RC,,,both,,,21924.00,6577.2,"MULTIPLAN [10600]",Multiplan,,18635.4,85,,,,,0,2549.76,18635.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA EXTRA FULL PROFILE SOFT TOUCH",SUP-SSX-700,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AETNA [10100]","Aetna HMO/PPO",,6006.62,79.5,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 90D 5.5MM TSRH-3D OPEN OFFSET TITANIUM POSTERIOR",SUP-8379124,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,414.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",414.32,3028.13,"percent of total billed charges",
"CATH SABER 150CM 120MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,166.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM 13.8MM CEMENT CONDYLAR STABILIZE OMNIFIT",SUP-6097-1040,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1948.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1911.88,13973.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE RTI ANTERIOR TIBIALIS TENDON ALLOGRAFT",SUP-453017,CDM,C1762,HCPCS,0278,RC,,,both,,,13800.00,4140,"UHC [10700]","United Healthcare",,8735.4,63.3,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER TISSUE 45CM 5MM ENSEAL G2 CURVE ARTICULATE ETHICON",SUP-NSLG2C45A,CDM,S27200284,LOCAL,0272,RC,,,both,,,3679.46,1103.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,436.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,427.92,3127.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP060150150 PLUS US D6L150UL1500",SUP-PCP060150150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AETNA [10100]","Aetna HMO/PPO",,978.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM TITANIUM SELF TAP LOCK NONSTERILE AXSOS 3",SUP-661134,CDM,C1713,HCPCS,0278,RC,,,both,,,1377.32,413.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,936.58,68,,,,,0,160.18,1170.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HMII BATT HOLSTER-PCTRL,EP14",SUP-104234,CDM,Q0498,HCPCS,0274,RC,,,both,,,2883.60,865.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,335.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,335.36,2451.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IOL LENS 6.0 DIOPTER",SUP-SA60WF.060,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN AMPLATZ",SUP-77804200,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT MEDIAL RIGHT LATERAL RESTORIS",SUP-180504,CDM,C1776,HCPCS,0278,RC,,,both,,,12440.70,3732.21,"AETNA [10100]","Aetna HMO/PPO",,9890.36,79.5,,10981.53,8986.79,12413.38,12,1446.85,10574.6,"percent of total billed charges",
"BASEPLT TIBIAL ATTUNE 7 KNEE CEMENT ROTATE PLATFORM STERILE",SUP-150680007,CDM,C1776,HCPCS,0278,RC,,,both,,,17225.85,5167.75,"FIRST HEALTH [10303]","First Health",,13780.68,80,,,,,0,2003.37,14641.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.6MM 14MM COALITION SPINE SELF TAP VARIABLE ANGLE",SUP-184.114,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,109.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",109.32,799,"percent of total billed charges",
"SPACER SPINAL 55X20X12MM PIVOX 6D LATERAL OLIF25",SUP-2111355,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"UHC [10700]","United Healthcare",,16749.18,63.3,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPCOCK ENDOSCOPIC UNIVERSAL LUER LOCK STERILE DISPOSABLE",SUP-00102.1,CDM,S27200284,LOCAL,0272,RC,,,both,,,894.73,268.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,104.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.06,760.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT GREEN 44X4IN EXPRESSAIRE XLONG LEG 1 FILL LINE 1",SUP-A70107012,CDM,S27200284,LOCAL,0272,RC,,,both,,,473.57,142.07,"MULTIPLAN [10600]",Multiplan,,402.53,85,,,,,0,55.08,402.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZONISAMIDE 100 MG CAPSULE",RX-27780,CDM,,,0637,RC,60687-0230-11,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]",Cigna,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE EMERALD VASCULAR 260CM 7CM .035IN HEPARIN PTFE",SUP-502555,CDM,C1769,HCPCS,0272,RC,,,both,,,134.42,40.33,"MULTIPLAN [10600]",Multiplan,,114.26,85,,,,,0,15.63,114.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP 40MM 75CM 7MM 100CM ENDOPROSTHESIS METAL",SUP-M001711180,CDM,C1876,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"AETNA [10100]","Aetna HMO/PPO",,5896.91,79.5,,,,,0,862.66,6304.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM 3DX TSRH OSTEOGRIP THINLINE TITANIUM",SUP-83555359,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]",Cigna,,6491.86,68,,1831.33,1831.33,1831.33,16,1110.3,8114.82,"percent of total billed charges",
"PISTON OSSICULAR 4.5MM .5MM RICHARDS PLATINUM FLUOROPLASTIC",SUP-140816,CDM,L8613,HCPCS,0278,RC,,,both,,,1209.90,362.97,"NOVANET [10819]",Novanet,,907.43,75,,,,,0,140.71,1028.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 34MM 140CM .91-1.12MM 2.75MM CORONARY",SUP-RONYX27534W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2496.5,45.9,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC",829,MS-DRG,,,,,,,inpatient,,,127470.32,38241.1,"BLUE CROSS [10001]","Blue Cross PPO",,78011.08,,,,,,,10994,92259.36,"case rate",
"CATH LAUNCHER 100CM 7FR EBU3 CURVE GUIDING LEFT CORONARY",SUP-LA7EBU30SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 8MM STAINLESS STEEL T8 SELF TAP LOCK VARIABLE",SUP-02.210.108TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1011.53,303.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.5,28.62,,,,,0,117.64,859.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 4-0 P-3 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J494G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esophagosc W/Sclero Inject",PX-750000199,CDM,43204,CPT,0750,RC,,,both,,,2075.00,622.5,"CIGNA [10200]",Cigna,,2075,,"Case rate ($2,497). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,241.32,2075,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SUPERORDERABLE",RX-408123315,CDM,J2270,HCPCS,0636,RC,70092-1519-48,NDC,both,30,ML,102.20,30.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.72,,"Fee schedule rate ($10.72). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.62,86.87,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 124MM 30MM ZENITH HANDL-B ONE-SHOT 2",SUP-G32543,CDM,C1874,HCPCS,0278,RC,,,both,,,62551.57,18765.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25020.63,40,,,,,0,7274.75,53168.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR PREPARATION OF TC 99M-SODIUM THIOSULFATE SOLUTION",RX-123715,CDM,A9541,HCPCS,0343,RC,08888-8878-22,NDC,both,1,UN,738.32,221.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,87.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,85.87,738.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENDO STITCH V-LOC 180 0 8IN CLSR ABSORBABLE RELOAD",SUP-VLOCA008L,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.99,98.4,"KAISER [10500]",Kaiser,,219.75,67,,,,,0,38.15,278.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 26CM 7FR .035",SUP-M006192143090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"BLUE CROSS [10001]","Blue Cross PPO",,585.03,39.2,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 77MMX2.6MM STAINLESS STEEL 2.7MM SCR 8 HOLE LC-DCP",SUP-242.208,CDM,C1713,HCPCS,0278,RC,,,both,,,2429.70,728.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,695.38,28.62,,,,,0,282.57,2065.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EYE90 MICROSPHERES UNIT DOSE GEN II",SUP-P-0556,CDM,C1889,HCPCS,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EYE90 MICROSPHERES UNIT DOSE GEN II",SUP-P-0556,CDM,C1889,HCPCS,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2MM 17MM LOCK SMOOTH TITANIUM",SUP-SPLS-20170-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,639.90,191.97,"CIGNA [10200]",Cigna,,435.13,68,,1831.33,1831.33,1831.33,16,74.42,543.92,"percent of total billed charges",
"TUBE TRACH 8 79MM 12.2MM SHILEY UNCUFF DISPOSABLE INNER CANN",SUP-8UN85H,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.56,98.27,"FIRST HEALTH [10303]","First Health",,262.05,80,,,,,0,38.1,278.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 10 STD 36MM PROVOX LIFE LARYTUBE",SUP-7416,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"MULTIPLAN [10600]",Multiplan,,1015.67,85,,,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR COBRA 2 CURVE ANGIOGRAPHIC VISCERAL",SUP-H787107091085,CDM,C1887,HCPCS,0272,RC,,,both,,,236.64,70.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,160.92,68,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 90CM 9FR ENDOTAK RELIANCE ENDOCARDIAL STEROID",SUP-149,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]","Cigna Open Access",,5085.3,33.5,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 6CM 5FR 7MM .035IN BALLOON",SUP-G52273,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.47,41.1,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 4.8MM TWIST STERILE",SUP-KM166-10-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"MULTIPLAN [10600]",Multiplan,,87.7,85,,,,,0,12,87.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ARTHROSCOPIC TORPEDO SHAPE ELECTRD EDGE CONTROL APOLLO",SUP-AR-9831,CDM,S27200284,LOCAL,0272,RC,,,both,,,1850.63,555.19,"CIGNA [10200]","Cigna Open Access",,1053.01,56.9,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP CATH BALLOON TIP ENDOSCOPIC KRONNER MANIPUJECTOR 33CM",SUP-6003,CDM,S27200284,LOCAL,0272,RC,,,both,,,326.25,97.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.94,277.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NEW LOCK OVERLAP ATLANTIS VISION BONE SPINAL",SUP-7200167,CDM,C1713,HCPCS,0278,RC,,,both,,,4620.00,1386,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3141.6,68,,,,,0,537.31,3927,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VITALYST PUMP 1D",SUP-H749396760010,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 11MM KNEE BEARING POSTERIOR STABILIZE",SUP-5532-G-711-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4690.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",1327.29,9700.71,"percent of total billed charges",
"DIL VASCULAR 14FR 70CM PLASTIC NATURAL RUBBER TAPERED",SUP-DMS-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,292.96,41.1,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 3-0 P-12 12IN CLSR ABSORBABLE PREMIUM",SUP-VLOCL0014,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,80.49,41.1,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 62MM NONFENESTRATE CUFF DISPOSABLE INNER CANN SMOOTH",SUP-4DCT,CDM,S27200284,LOCAL,0272,RC,,,both,,,325.99,97.8,"UHC [10700]","United Healthcare",,206.35,63.3,,,,,0,37.91,277.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 22MM AO QUICK 1.2MM SCREWS",SUP-60-10322,CDM,S27200284,LOCAL,0272,RC,,,both,,,724.63,217.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,297.82,41.1,,,,,0,84.27,615.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +20.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2050,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 190CM 3CM",SUP-1020014,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 15CM 7FR 6MM .018IN BALLOON DILATATION",SUP-V1860150,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"KAISER [10500]",Kaiser,,3675.29,67,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA CARDIOPLEGIA ANTEGRADE W/VENT",SUP-ANT-2012S,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.72,41.92,"CIGNA [10200]","Cigna Open Access",,79.5,56.9,,,,,0,16.25,118.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET TRANSFER 77X45IN 29IN MAXITUBE FLITES",SUP-NPA0750,CDM,S27000186,LOCAL,0270,RC,,,both,,,144.56,43.37,"FIRST HEALTH [10303]","First Health",,115.65,80,,,,,0,16.81,122.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 12.5IN 1.5IN HARRINGTON LAMB HANDLE STAINLESS STEEL",SUP-200-175,CDM,S27000186,LOCAL,0270,RC,,,both,,,831.87,249.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,98.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,96.75,707.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 5MM 6FR A CURVE ELECTROPHYSIOLOGY 10 PIN CNCT",SUP-F6QA005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,372.86,41.1,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM .02IN 4MM PENUMBRA COIL 400 RUBY",SUP-RBY4C0415,CDM,S27800098,LOCAL,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross HMO",,2288.5,39.2,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY SOFT TISSUE",SUP-4382SP,CDM,S27200284,LOCAL,0272,RC,,,both,,,238.73,71.62,"CIGNA [10200]","Cigna Local Plus",,127.72,53.5,,,,,0,27.76,202.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X28MM BENGAL 12MM STD LORDOTIC THORACOLUMBAR",SUP-177306128,CDM,S27800098,LOCAL,0278,RC,,,both,,,15950.04,4785.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1890.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1854.99,13557.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER OLECRANON LOW PROFILE FIXATION ORTHOPEDIC STERILE",SUP-OSW,CDM,C1713,HCPCS,0278,RC,,,both,,,2062.50,618.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",239.87,1753.13,"percent of total billed charges",
"SCR BONE 5.5MM 45MM SOLERA CD HORIZON SPINE MULTIAXIAL",SUP-54850015545,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"PHCS [10601]",PHCS,,4588.5,70,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 NANO 1MM X 3CM",SUP-M0035421030,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"AETNA [10100]","Aetna HMO/PPO",,11221.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD DISS HANDTIGHT IS-1 DF4 CNCT SOLIA S STERILE",SUP-401298,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"MULTIPLAN [10600]",Multiplan,,347.57,85,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CROSSTELLA 150CM 40MM 4-3.4FR 4MM BALLOON DILATATION",SUP-BD-F40040LR,CDM,C1725,HCPCS,0272,RC,,,both,,,1559.25,467.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1060.29,68,,,,,0,181.34,1325.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X19MM LUMINARY CC BICONVEX SPINE",SUP-16819,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3941.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X11X8MM PTC TANTALUM PEEK ANATOMIC CERVICAL",SUP-5030841,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,791.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NUCLEUS-X 110CM 6CM 18MM BALLOON DILATATION POLYAMIDE",SUP-612039,CDM,C1725,HCPCS,0272,RC,,,both,,,6566.52,1969.96,"KAISER [10500]",Kaiser,,4399.57,67,,,,,0,763.69,5581.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM STAINLESS STEEL T15 TIBIA PROXIMAL SELF",SUP-02.127.120,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,770.24,68,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM ADVANCED CONVEX SPINE",SUP-17812,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]","Cigna Open Access",,4711.32,56.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP MEDIUM LARGE INTERNAL HEM-O-LOK POLYMER ENDOSCOPIC",SUP-544230,CDM,S27200284,LOCAL,0272,RC,,,both,,,439.14,131.74,"CIGNA [10200]","Cigna Local Plus",,234.94,53.5,,,,,0,51.07,373.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 10MM 11FR ENDOPROSTHESIS HEPARIN",SUP-VBH100502,CDM,C1874,HCPCS,0278,RC,,,both,,,22087.80,6626.34,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2568.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2568.81,18774.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4F GEN 1.5 TACK ENDOVASCULAR SYSTEM, 150CM",SUP-CS1502,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 60MM 5FR 4MM LOW PROFILE TAPER BALLOON",SUP-39206-04061,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS 75CM 4CM 14MM 7FR BALLOON DILATATION PERIPHERAL",SUP-AT75144,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1402.5,68,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.5MM X 12.0MM",SUP-492501212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 112MM 21.7MM 11MM MODULAR REMEDY GENTAMICIN",SUP-RHSTMD,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Open Access",,5778.75,33.5,,5302.19,4377.88,6578.61,27,2006.18,14662.5,"percent of total billed charges",
"SYSTEM TIGHTROPE II FIBERTAPE FIXATION BONE TENDON BONE",SUP-AR-1588BTB-IB,CDM,C1713,HCPCS,0278,RC,,,both,,,4673.03,1401.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3177.66,68,,,,,0,543.47,3972.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FIXATION TITANIUM UHMWPE ACL RIGHT STERILE",SUP-AR-1588RT,CDM,C1713,HCPCS,0278,RC,,,both,,,2756.25,826.87,"CIGNA [10200]","Cigna Open Access",,1568.31,56.9,,1144.80,304.56,2275.09,66,320.55,2342.81,"percent of total billed charges",
"ELECTRD DEFIB SILVER WHITE 6X4.25IN PADPRO ZOLL A CARBON",SUP-2001Z-C,CDM,S27000186,LOCAL,0270,RC,,,both,,,1336.50,400.95,"UHC [10700]","United Healthcare",,846,63.3,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 1.7MM ATRIUM ENDOCARDIUM VENTRICLE BIPOLAR",SUP-4470,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"AETNA [10100]","Aetna HMO/PPO",,1774.84,79.5,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 17MM MODULAR RESTORATION BOWED CONICAL",SUP-6276-7-217,CDM,C1776,HCPCS,0278,RC,,,both,,,11695.32,3508.6,"PHCS [10601]",PHCS,,8186.72,70,,,,,0,1360.17,9941.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"F/G WINGSPAN STENT SYSTEM  4.0 X 20MM",SUP-M003WS0400200,CDM,C1874,HCPCS,0278,RC,,,both,,,51979.47,15593.84,"BLUE CROSS [10001]","Blue Cross HMO",,20375.95,39.2,,9776.84,9776.84,9776.84,"1 through 10",6045.21,44182.55,"percent of total billed charges",
"BIT DRILL 3.5MM FIXOS CANNULATED",SUP-705251,CDM,S27200284,LOCAL,0272,RC,,,both,,,2059.65,617.89,"CIGNA [10200]","Cigna Local Plus",,1101.91,53.5,,,,,0,239.54,1750.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Submuc Inj",PX-750000080,CDM,45335,CPT,0750,RC,,,both,,,2388.48,716.54,"CIGNA [10200]",Cigna,,2388.48,,"Case rate ($2,497). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,277.78,2388.48,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Apheresis Therapeutic Wbc",PX-361000392,CDM,36511,CPT,0390,RC,,,both,,,6474.00,1942.2,"CIGNA [10200]",Cigna,,4402.32,68,,,,,0,752.93,5502.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTCLAW 145CM 5FR .035IN 32MM THROMBECTOMY TACTILE",SUP-FD0660-02,CDM,C1757,HCPCS,0272,RC,,,both,,,25168.50,7550.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2982.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2927.1,21393.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ERCP RAPID EXCHANGE TAPER TIP 210CM BILIARY ACCEPTS",SUP-M00545770,CDM,S27200284,LOCAL,0272,RC,,,both,,,590.25,177.07,"KAISER [10500]",Kaiser,,395.47,67,,,,,0,68.65,501.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656318,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"NOVANET [10819]",Novanet,,1001.4,75,,,,,0,155.28,1134.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 36MM 28MM UNIVERS REVERS +4 TAPER LATERALIZE",SUP-AR-9564-2836-LAT,CDM,C1776,HCPCS,0278,RC,,,both,,,9763.50,2929.05,"MULTIPLAN [10600]",Multiplan,,8298.98,85,,,,,0,1135.5,8298.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER WEBSTER 60CM 1MM 6FR 2-8-2MM SPACE P CURVE ELECTROP",SUP-F6A-DP-282-RTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,2040.00,612,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,241.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,237.25,1734,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xe133 Dx per 10mci",PX-343000022,CDM,A9558,HCPCS,0343,RC,,,both,,,755.00,226.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,89.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.81,641.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Surg Path Level 4 Kid Bx",PX-312000010,CDM,88305,CPT,0312,RC,,,both,,,413.40,124.02,"FIRST HEALTH [10303]","First Health",,330.72,80,,,,,0,0.01,351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULUS ALIF BOLT, 5.0X25MM FIXATION",SUP-1450250,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",188.41,1377,"percent of total billed charges",
"HC Ins/Rplc Pcmkr Atrial",PX-480000002,CDM,33206,CPT,0481,RC,,,both,,,7221.57,2166.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7221.57,,"Case rate ($10,216.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,839.87,7221.57,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 1.5 MM 2 MM CORTEX SCREWS NONSTERILE",SUP-310.880,CDM,S27200284,LOCAL,0272,RC,,,both,,,1828.50,548.55,"FIRST HEALTH [10303]","First Health",,1462.8,80,,,,,0,212.65,1554.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 25X14-18MM",SUP-400716,CDM,S27800098,LOCAL,0278,RC,,,both,,,3783.96,1135.19,"CIGNA [10200]","Cigna Local Plus",,2024.42,53.5,,,,,0,440.07,3216.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cholesterol Ldl",PX-301000549,CDM,83721,CPT,0301,RC,,,both,,,116.00,34.8,"MULTIPLAN [10600]",Multiplan,,98.6,85,,,,,0,0.01,98.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 11.4CM 19MM ECHOGENIC TRU-CORE II COAXIAL",SUP-MCXS2016TY,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.00,28.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.05,80.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID MEDIUM VAULTLOCK ARTHREX UNIVERS STERILE",SUP-AR-9106-02,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3766.57,41.1,,6417.48,6417.48,6417.48,"1 through 10",1065.82,7789.74,"percent of total billed charges",
"STENT AGILE 15CM 23MM 18.5FR ESOPHAGEAL PARTIAL COVER",SUP-M00517740,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PHCS [10601]",PHCS,,12789,70,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X6MM COALITION MIS 7D 12MM TITANIUM STERILE",SUP-1136.2476,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6900,40,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Sulfr Colloid Filtered Up to 20mci",PX-343000014,CDM,A9541,HCPCS,0343,RC,,,both,,,746.77,224.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,88.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.85,746.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SURGICAL 27GA SMALL LARYNGEAL INJECTOR STERILE",SUP-1650050,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.44,73.93,"FIRST HEALTH [10303]","First Health",,197.15,80,,,,,0,28.66,209.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Vent Lt Heart Dlp 20f",PX-E27200330,CDM,E27200330,LOCAL,0272,RC,,,both,,,170.50,51.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.83,144.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plt Lr Ea Unit",PX-390000022,CDM,P9031,HCPCS,0390,RC,,,both,,,1023.00,306.9,"MULTIPLAN [10600]",Multiplan,,869.55,85,,,,,0,118.97,869.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Everolimus Assay",PX-301000457,CDM,80169,CPT,0301,RC,,,both,,,394.25,118.27,"MULTIPLAN [10600]",Multiplan,,335.11,85,,,,,0,0.01,335.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC",256,MS-DRG,,,,,,,inpatient,,,66754.53,20026.36,"AETNA [10100]","Aetna HMO/PPO",,31945.99,,"Fee schedule rate ($31,945.99). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,49571.89,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7606,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"AETNA [10100]","Aetna HMO/PPO",,5485.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2MM 152MM KIRSCHNER STAINLESS STEEL TOP TRAY",SUP-KW20SS,CDM,S27000186,LOCAL,0270,RC,,,both,,,546.75,164.02,"KAISER [10500]",Kaiser,,366.32,67,,,,,0,63.59,464.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SKATER 40CM 10FR PIGTAIL CURVE DRNG BILIARY LOCK",SUP-755310040,CDM,C1729,HCPCS,0272,RC,,,both,,,651.24,195.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,77.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.74,553.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 CURVE PLUS 12.5MM KNEE XLK FIX BEARING",SUP-970422,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3198.16,28.62,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Estradiol",PX-301000181,CDM,82670,CPT,0301,RC,,,both,,,399.95,119.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.9,,"Fee schedule rate ($29.90). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.4,339.96,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRIMARY HIP 1",SUP-CAP-S-H-1,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"AETNA [10100]","Aetna HMO/PPO",,19032.3,79.5,,10981.53,8986.79,12413.38,12,2784.22,20349,"percent of total billed charges",
"SCR BONE LOCKING CANNULATED 5MM 85MM LCP STAINLESS STEEL",SUP-02.205.085,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"CIGNA [10200]","Cigna Local Plus",,675.85,53.5,,3978.14,359.25,3978.14,24,146.92,1073.79,"percent of total billed charges",
"GRAFT BONE MEDIUM 7.5GM PUTTY",SUP-MSBG0750,CDM,S27800098,LOCAL,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]",Cigna,,5865,68,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit B Level 2",PX-450000327,CDM,G0381,HCPCS,0450,RC,,,both,,,714.00,214.2,"FIRST HEALTH [10303]","First Health",,571.2,80,,,,,0,67.13,714,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR WHITE 53MM 28MM RINGLOC BIO-MOORE II HIP",SUP-11165230,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"CIGNA [10200]",Cigna,,4528.72,68,,5873.17,5873.17,5873.17,"1 through 10",774.54,5660.9,"percent of total billed charges",
"HEMOSTASIS CLIP 12MM 2300MM LENGTH",SUP-SCA-23-230-12,CDM,S27200284,LOCAL,0272,RC,,,both,,,972.00,291.6,"UHC [10700]","United Healthcare",,615.28,63.3,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502605602,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS [10001]","Blue Cross PPO",,8962.18,39.2,,3949.44,3949.44,3949.44,"1 through 10",2658.93,19433.3,"percent of total billed charges",
"HC Factor X",PX-305000024,CDM,85260,CPT,0305,RC,,,both,,,687.70,206.31,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,584.55,"per diem",
"IMMOB ORTHOPEDIC 2XL 44X6IN SHOULDER VELPEAU PADDED WRIST",SUP-9008-05,CDM,S27000186,LOCAL,0270,RC,,,both,,,103.62,31.09,"CIGNA [10200]","Cigna Local Plus",,55.44,53.5,,,,,0,12.05,88.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM MITRAL CARPENTIER-EDWARDS PHYSIO II",SUP-520028MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,15180.00,4554,"UHC [10700]","United Healthcare",,9608.94,63.3,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM TITANIUM 2.4MM SCR 6X3 HOLE 2 COLUMN VARIABLE",SUP-04.111.630,CDM,C1713,HCPCS,0278,RC,,,both,,,4217.63,1265.29,"CIGNA [10200]",Cigna,,2867.99,68,,1831.33,1831.33,1831.33,16,490.51,3584.99,"percent of total billed charges",
"SET BREAST BIOPSY 145MM 11GA MAMMOTOME UNIVERSAL MR TARGET",SUP-MRU11X,CDM,S27200284,LOCAL,0272,RC,,,both,,,1866.08,559.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,766.96,41.1,,,,,0,217.03,1586.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTNR 9 5/8INX6 3/8IN LARGE VISCERAL STERILE LATEX FREE",SUP-3206,CDM,S27200284,LOCAL,0272,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 2.5MM 30CM SMALL VALVE RADIOPAQUE BAND",SUP-G08246,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR AL2 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H74938969690,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"UHC [10700]","United Healthcare",,231.96,63.3,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 32CM FEMUR RIGHT PROXIMAL TALON DISTALFIX",SUP-SLN-125-32R,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"BLUE CROSS [10001]","Blue Cross PPO",,6321.12,39.2,,957.42,570.23,957.42,28,1875.37,13706.51,"percent of total billed charges",
"TOTAL HIP 6 UNIPOLAR/BIPOLAR - FX STEM/DEPUY",SUP-CAP-H-6,CDM,C1776,HCPCS,0278,RC,,,both,,,6720.00,2016,"CIGNA [10200]","Cigna Open Access",,3823.68,56.9,,5302.19,4377.88,6578.61,27,781.54,5712,"percent of total billed charges",
"SCR BONE LOCKING CANNULATED 5MM 75MM LCP STAINLESS STEEL",SUP-02.205.075,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"MULTIPLAN [10600]",Multiplan,,1073.79,85,,,,,0,146.92,1073.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Test Inhal Bronchl",PX-924000001,CDM,95070,CPT,0924,RC,,,both,,,1027.78,308.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,121.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,119.53,873.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIBRILLATOR CRT-D GALLANT BIPOLAR DF4 HF",SUP-CDHFA500D,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,20776.5,27,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C-Reactive Protein",PX-302000014,CDM,86140,CPT,0302,RC,,,both,,,292.60,87.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.44,,"Fee schedule rate ($5.44). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",16.32,5.44,27.20,16,0.29,248.71,"fee schedule",
"COIL EMBOLIZATION 30CM 5MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0530,CDM,S27800098,LOCAL,0278,RC,,,both,,,8832.00,2649.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4053.89,45.9,,,,,0,1027.16,7507.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SUPERORDERABLE",RX-408844,CDM,J1171,HCPCS,0636,RC,76045-0009-05,NDC,both,.5,ML,44.00,13.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.58,37.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PRIME HD DBM .5CC ALLOGRAFT LATEX FREE",SUP-421005,CDM,C1713,HCPCS,0278,RC,,,both,,,506.25,151.87,"KAISER [10500]",Kaiser,,339.19,67,,,,,0,58.88,430.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESONATE EL VR DF4",SUP-D432,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4621.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 8CM 7FR 12MM .035IN BALLOON",SUP-G52300,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.47,41.1,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26MMX14MM VERTE-STACK CAPSTONE PEEK-OPTIMA END",SUP-2961426,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1883.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 20MM 140CM 2.5MM CORONARY STENT PLATINUM",SUP-H7493927420250,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"AMERIGROUP MEDICAID [20100]",Amerigroup,,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 9MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G809,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4945.81,41.1,,6417.48,6417.48,6417.48,"1 through 10",1399.51,10228.56,"percent of total billed charges",
"CATH NC TREK NEO 145CM 6MM 2.50MM BALLOON DILATATION PEBAX",SUP-1400250-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PATELLA THK16-18MM WEDGE ALLOGRAFT STRIP FREEZE",SUP-400585,CDM,S27800098,LOCAL,0278,RC,,,both,,,6412.86,1923.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1835.36,28.62,,,,,0,745.82,5450.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 70CM 15MM 4FR 6 WIRE STONE UROLOGY",SUP-GU6359,CDM,S27200284,LOCAL,0272,RC,,,both,,,479.36,143.81,"CIGNA [10200]","Cigna Local Plus",,256.46,53.5,,,,,0,55.75,407.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 200MM 6MM BALLOON",SUP-U35130620,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 240MM 3MM BALLOON DILATATION STERILE LATEX",SUP-583024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR RINGLOC +3MM 23 36MM E-POLY HIP STERILE",SUP-EP-108223,CDM,C1776,HCPCS,0278,RC,,,both,,,14076.00,4222.8,"CIGNA [10200]","Cigna Open Access",,4715.46,33.5,,5302.19,4377.88,6578.61,27,1637.04,11964.6,"percent of total billed charges",
"SAFESHEATH INTRDCR FR12 - EACH",SUP-667119-001,CDM,C1892,HCPCS,0272,RC,,,both,,,607.50,182.25,"UHC [10700]","United Healthcare",,384.55,63.3,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE XLORDOTIC 17MM LEVEL 1 VIP BONE SPINE CERVICAL",SUP-171.167,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",521.61,3812.25,"percent of total billed charges",
"GRAFT BONE CANCELLOUS BLOCK THK25MM ALLOGRAFT FREEZE DRIED",SUP-400285,CDM,S27800098,LOCAL,0278,RC,,,both,,,7588.62,2276.59,"NOVANET [10819]",Novanet,,5691.47,75,,,,,0,882.56,6450.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 10MM CANNULATED COLLAR PIN SET CORING",SUP-AR-1224S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 37.5MM TRIGEN FEMUR LOW PROFILE",SUP-71645037,CDM,C1713,HCPCS,0278,RC,,,both,,,2846.25,853.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1306.43,45.9,,,,,0,331.02,2419.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST TRICORTICAL THK10-12MM WEDGE",SUP-400402,CDM,S27800098,LOCAL,0278,RC,,,both,,,4719.60,1415.88,"CIGNA [10200]","Cigna Open Access",,2685.45,56.9,,,,,0,548.89,4011.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 5MM ACCESS SYSTEM 55MM KII Z THREAD LOW",SUP-CTS28,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"MULTIPLAN [10600]",Multiplan,,59.16,85,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Fetal Addl Gestation",PX-610000054,CDM,74713,CPT,0610,RC,,,both,,,1846.00,553.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,683,,"Per diem ($683). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,214.69,1846,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 300MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030300M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"MULTIPLAN [10600]",Multiplan,,1593.75,85,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 5 LEFT DISTAL KNEE",SUP-5540-A-501,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"PHCS [10601]",PHCS,,3180.67,70,,,,,0,528.45,3862.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX SAFE PERFORMAXX 40MM 80CM 8MM 6FR .035IN",SUP-ZBM08040,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1185.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155244050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS [10001]","Blue Cross PPO",,482.54,39.2,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-71422342,CDM,C1776,HCPCS,0278,RC,,,both,,,29720.25,8916.07,"BLUE CROSS [10001]","Blue Cross PPO",,11650.34,39.2,,3949.44,3949.44,3949.44,"1 through 10",3456.47,25262.21,"percent of total billed charges",
"DEVICE 5-14FR SECUREMENT","SUP-680ME 5F-14F",CDM,S27200284,LOCAL,0272,RC,,,both,,,81.43,24.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.47,69.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FEMORAL IDENTITY IMPRINT 3 KNEE POSTERIOR STABILIZE",SUP-TPS-101-F03S,CDM,C1776,HCPCS,0278,RC,,,both,,,11716.20,3514.86,"CIGNA [10200]",Cigna,,4686.48,40,,5873.17,5873.17,5873.17,"1 through 10",1362.59,9958.77,"percent of total billed charges",
"CATH IMAGER II 65CM 5FR COBRA 2 CURVE ANGIOGRAPHIC VISCERAL",SUP-M001314681,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.04,22.81,"AETNA [10100]","Aetna HMO/PPO",,60.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.84,64.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E CEMENT SURFACE",SUP-98000674105,CDM,C1776,HCPCS,0278,RC,,,both,,,19530.00,5859,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5273.1,27,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036129300,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 20MM 4MM BALLOON DILATATION DURATRAC",SUP-NCEUP4020X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPTIP APD 25CM 10FR DRNG FLEXIMA METAL POLYURETHANE",SUP-M001281350,CDM,C1729,HCPCS,0272,RC,,,both,,,631.80,189.54,"MULTIPLAN [10600]",Multiplan,,537.03,85,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 8X38X28MM 15DEG ANTERIOR LUMBAR INTERFIXED 3DP M",SUP-1921046P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9355.5,27,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE 14X13X11MM",SUP-331341,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 6X38X28MM 20 DEGREE",SUP-1921049P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"BLUE CROSS [10001]","Blue Cross PPO",,13582.8,39.2,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURETTE UTERINE 11IN SIMS",SUP-52-8153,CDM,S27200284,LOCAL,0272,RC,,,both,,,187.31,56.19,"AETNA [10100]","Aetna HMO/PPO",,148.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.78,159.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 40MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.840,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"NOVANET [10819]",Novanet,,1030.81,75,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 7-0 CC 24IN 2 ARM BLUE NONABSORBABLE",SUP-EP8704H,CDM,S27200284,LOCAL,0272,RC,,,both,,,248.18,74.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,113.91,45.9,,,,,0,28.86,210.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 6MM BALLOON DILATATION STERILE LATEX",SUP-596015022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,599.24,41.1,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 65CM 8MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0865CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"CIGNA [10200]",Cigna,,5395.8,68,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP CLUSTER HOLE HA TRIDENT II PSL G",SUP-742-11-60G,CDM,C1776,HCPCS,0278,RC,,,both,,,9502.96,2850.89,"CIGNA [10200]",Cigna,,6462.01,68,,5873.17,5873.17,5873.17,"1 through 10",1105.19,8077.52,"percent of total billed charges",
"CATH RUNWAY 100CM 6FR JL4 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389696680,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTDG ANALZR RED HMS PLUS 0-.9MG/KG HEPARIN ASSAY 4 CHANNEL",SUP-304-01POR,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.04,37.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.66,107.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CAPSTONE ALLOGRAFT FREEZE DRIED 22MMX10MM",SUP-9441022,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"AETNA [10100]","Aetna HMO/PPO",,13713.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 110CM 4FR .042IN 155D 9MM PIGTAIL",SUP-538455S,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,36.79,41.1,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRS INCUBATOR 104F 40C COTTON TRANSPORT PEDIATRIC LATEX",SUP-HNICU-200,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.92,41.08,"FIRST HEALTH [10303]","First Health",,109.54,80,,,,,0,15.92,116.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 7X 59MM CATH 80CM ENDOVASCULAR",SUP-48759,CDM,C1874,HCPCS,0278,RC,,,both,,,18881.10,5664.33,"PHCS [10601]",PHCS,,13216.77,70,,,,,0,2195.87,16048.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 800106 CANC CRUSHED 1-10MM 90CC",SUP-800106,CDM,S27800098,LOCAL,0278,RC,,,both,,,7810.11,2343.03,"CIGNA [10200]","Cigna Open Access",,4443.95,56.9,,,,,0,908.32,6638.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 15MM ATLANTIS TITANIUM ANTERIOR CERVICAL",SUP-876-755,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 NARROW KNEE RIGHT CEMENTED CRUCIATE",SUP-150400226,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"KAISER [10500]",Kaiser,,15003.54,67,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM MAMBA FLEX STERILE LATEX",SUP-H7493928715000,CDM,C1887,HCPCS,0272,RC,,,both,,,4312.50,1293.75,"FIRST HEALTH [10303]","First Health",,3450,80,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 7CM 5FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22076,CDM,C2625,HCPCS,0272,RC,,,both,,,631.80,189.54,"FIRST HEALTH [10303]","First Health",,505.44,80,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POUCH SURGICAL TISSUE 6X4IN LAPSAC DRAWSTRING 200ML STERILE",SUP-G16495,CDM,S27200284,LOCAL,0272,RC,,,both,,,438.99,131.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,52.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.05,373.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 0 CT-1 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J340H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 45D BALL COOLCUT STERILE SMALL JOINT",SUP-AR-9808SJ-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,978.08,293.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,665.09,68,,,,,0,113.75,831.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X8MM COROENT 10D XL+ PEEK NONSTERILE LATEX",SUP-6308850,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2784.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT MONOLITHIC 14MM PLIF",SUP-3W3114,CDM,S27800098,LOCAL,0278,RC,,,both,,,12487.62,3746.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4995.05,40,,,,,0,1452.31,10614.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD",SUP-98000700014,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"MULTIPLAN [10600]",Multiplan,,20349,85,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS SURGICAL 20CM HARMONIC CURVE TIP ULTRASONIC",SUP-HAR1120,CDM,S27200284,LOCAL,0272,RC,,,both,,,3984.04,1195.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,472.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,463.34,3386.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ACOLYTE CATHETER","SUP-FG 01412",CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMALL PERIPHERAL CUTTING BALLOON 142CM 1.5CM 3.5MM",SUP-M001PCBO3515140F0,CDM,C1725,HCPCS,0272,RC,,,both,,,4854.15,1456.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,575.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,564.54,4126.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lymph Vessel X-Ray Arms/Legs",PX-323000039,CDM,75803,CPT,0320,RC,,,both,,,2624.56,787.37,"CIGNA [10200]","Cigna Open Access",,429.9,,,,,,,305.24,2624.56,"fee schedule",
"CATH EUPHORA 142CM 12MM 2MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2012X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 STD KNEE LEFT CRUCIATE RETAINING PERSONA",SUP-42502806601,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"CIGNA [10200]",Cigna,,11558.23,40,,5873.17,5873.17,5873.17,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"INSRT ARTICULAR 7-8 18MM KNEE POSTERIOR STABILIZE HIGH",SUP-71421526,CDM,C1776,HCPCS,0278,RC,,,both,,,10774.35,3232.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1276.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1253.06,9158.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 7MM CANNULATED REAMER STERILE",SUP-AR-1218-70,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4.3MM QUADCUT",SUP-1884380HR,CDM,S27200284,LOCAL,0272,RC,,,both,,,2190.00,657,"NOVANET [10819]",Novanet,,1642.5,75,,,,,0,254.7,1861.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Nails >5",PX-510000035,CDM,11721,CPT,0761,RC,,,both,,,664.60,199.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,78.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.29,664.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ostomy Pouch",PX-E27000139,CDM,E27000139,LOCAL,0270,RC,,,both,,,92.40,27.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,37.98,41.1,,,,,0,10.75,78.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 2.5MM BD BEAVER BD XSTAR 55D CRESCENT",SUP-373807,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.62,32.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,73.86,68,,,,,0,12.63,92.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM 14.8MM MASTER-SERIES PYROLYTIC CARBON",SUP-19AGN-751,CDM,S27800098,LOCAL,0278,RC,,,both,,,31229.42,9368.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8937.86,28.62,,,,,0,3631.98,26545.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 24IN 2 PORT 1 BLADDER WITHOUT SLEEVE ATS STERILE",SUP-60707010400,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"MULTIPLAN [10600]",Multiplan,,62.86,85,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON PANOPTIX TORIC UVA",SUP-CCWTT5,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,100.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 1 CTX 36IN BRAID COATED UNDYED ABSORBABLE",SUP-J977H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"NOVANET [10819]",Novanet,,20.25,75,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE FLEXIBLE 600MM 5MM 2.2MM AMBU ASCOPE 4 AVIEW 85",SUP-477001000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"NOVANET [10819]",Novanet,,1462.5,75,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUTTLE ACCU-PASS 1 MONOFILAMENT SUT STERILE",SUP-72201361,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 150MM 11MM CARBON FIBER MR CONDITIONAL",SUP-394.82,CDM,S27800098,LOCAL,0278,RC,,,both,,,1342.58,402.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,384.25,28.62,,,,,0,156.14,1141.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM 9FR ENDOCARDIUM 1 COIL 2 COIL IS-1 DF-1",SUP-0181,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7057.69,41.1,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 40MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR40,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEXA PROMRI S 60 LEAD",SUP-402265,CDM,C1898,HCPCS,0275,RC,,,both,,,15180.00,4554,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txcath Plc Stent Intrathor Carotid/Innom",PX-361000386,CDM,37218,CPT,0361,RC,,,both,,,10287.00,3086.1,"BLUE CROSS [10001]","Blue Cross PPO",,10.29,.1,,,,,0,10.29,8743.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 80CM 60MM 5MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV05006008P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"PHCS [10601]",PHCS,,5651.1,70,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLIABILIZE MONOFILAMENT ETHILON MULTIPASS 4-0 P-3 18IN",SUP-699H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 18CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061751990,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"FIRST HEALTH [10303]","First Health",,721.74,80,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 24MM 1 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-41F24V,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,957.42,570.23,957.42,28,521.61,3812.25,"percent of total billed charges",
"ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION",880,MS-DRG,,,,,,,inpatient,,,33042.32,9912.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8661,,"Fee schedule rate ($8,661.00). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,1958,23946.43,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 7CM MIDAS REX MR8 1.5MM F1 TAPER DISSECTING STERILE",SUP-MR8-F1/7TA15,CDM,S27200284,LOCAL,0272,RC,,,both,,,955.31,286.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.1,812.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SURGICAL 4.7X3.1IN VENTRAL 2 LAYER MONOFILAMENT SELF",SUP-0010211,CDM,C1781,HCPCS,0278,RC,,,both,,,2329.79,698.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1069.37,45.9,,,,,0,270.95,1980.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL COCHLEAR 8MM 4MM DERMALOCK BAHA TITANIUM HA 1 STAGE",SUP-93330,CDM,L8690,HCPCS,0278,RC,,,both,,,21042.00,6312.6,"KAISER [10500]",Kaiser,,14098.14,67,,,,,0,2447.18,17885.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM 4MM 2.1-2.7FR CORONARY STENT",SUP-RONYX40022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"BLUE CROSS [10001]","Blue Cross PPO",,1455.3,39.2,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Tube Duodeno W Fl",PX-750000105,CDM,49451,CPT,0750,RC,,,both,,,7334.52,2200.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,853,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,853,6234.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cta Coronaries W Cntrst",PX-352000035,CDM,75574,CPT,0352,RC,,,both,,,1518.10,455.43,"CIGNA [10200]","Cigna Local Plus",,446,,"Per diem ($446). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,176.56,1518.1,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.75CM NATRELLE INSPIRA P6.2CM EXTRA FULL",SUP-MSZ-X525,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"UHC [10700]","United Healthcare",,100.13,63.3,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUNAV CRYSTAL 9FR ULTRASOUND STERILE LATEX FREE",SUP-11510825,CDM,C1759,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 14MM PERSONA 3-5 C-D KNEE RIGHT VIVACIT-E",SUP-42522600414,CDM,C1776,HCPCS,0278,RC,,,both,,,13634.40,4090.32,"MULTIPLAN [10600]",Multiplan,,11589.24,85,,,,,0,1585.68,11589.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC INTERVERTEBRAL 19X6MM MOBI-C 15MM SPINE CERVICAL COCRMO","SUP-MB 3596",CDM,S27800098,LOCAL,0278,RC,,,both,,,33075.00,9922.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8930.25,27,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL SOFT CURVED PRONG KINK RESISTANT TUBING UNIQUE",SUP-N4902,CDM,S27000186,LOCAL,0270,RC,,,both,,,97.44,29.23,"NOVANET [10819]",Novanet,,73.08,75,,,,,0,11.33,82.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135CM 120MM 6MM .035IN LOW PROFILE BALLOON",SUP-B2060-120,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH ARTHROSCOPIC 15D UP TIP XL STRAIGHT SERIES 1 DESIGN",SUP-AR-11240XL,CDM,S27200284,LOCAL,0272,RC,,,both,,,7933.28,2379.98,"PHCS [10601]",PHCS,,5553.3,70,,,,,0,922.64,6743.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM CONCERTO 3D",SUP-PV-2-4-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"KAISER [10500]",Kaiser,,3004.95,67,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 80% CANCELLOUS 20% CORTICAL 30CC ALLOGRAFT 4-10MM",SUP-800118,CDM,S27800098,LOCAL,0278,RC,,,both,,,2777.25,833.17,"FIRST HEALTH [10303]","First Health",,2221.8,80,,,,,0,322.99,2360.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aldolase",PX-301000093,CDM,82085,CPT,0301,RC,,,both,,,178.25,53.47,"PHCS [10601]",PHCS,,124.78,70,,,,,0,0.01,151.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS 20CM HONOR METAL GWIRE INSRT TOOL BONDED",SUP-MAP350,CDM,S27200284,LOCAL,0272,RC,,,both,,,193.75,58.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.53,164.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 30D BUTTON HIGH FREQUENCY",SUP-WA22557C,CDM,S27200284,LOCAL,0272,RC,,,both,,,3629.21,1088.76,"MULTIPLAN [10600]",Multiplan,,3084.83,85,,,,,0,422.08,3084.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MICROPOINT 10-0 TG140-8 6IN 2 ARM MONOFILAMENT",SUP-1757G,CDM,S27200284,LOCAL,0272,RC,,,both,,,216.59,64.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.19,184.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 11MM CATALYFT PL40 SHORT",SUP-6069113,CDM,S27800098,LOCAL,0278,RC,,,both,,,39060.00,11718,"UHC [10700]","United Healthcare",,24724.98,63.3,,,,,0,4542.68,33201,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM 16MM PRESS FIT UNIVERSAL FLUTE KNEE",SUP-867430,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,959.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 0D TRUDI SURGICAL STERILE LATEX FREE DISPOSABLE",SUP-TDC0005,CDM,S27200284,LOCAL,0272,RC,,,both,,,2437.50,731.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1001.81,41.1,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 8MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS08030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3165.24,27,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOBILIZER KNEE WRAP AROUND ABOVE KNEE OPEN PATELLA WINDOW",SUP-A142005,CDM,L1830,HCPCS,0274,RC,,,both,,,117.71,35.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,54.03,45.9,,,,,0,13.69,100.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)MARKER SKIN PINK 5CM 15GA SMARTCLIP LITE 3-4MM SOFT TI",SUP-SMARTCLIPLT-PNK-5,CDM,A4648,HCPCS,0278,RC,,,both,,,2625.00,787.5,"AETNA [10100]","Aetna HMO/PPO",,2086.88,79.5,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE IRON MAN VASCULAR STRAIGHT 300CM 3CM .014IN",SUP-1001311,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE TAPE BROADBAND 5 BLACK WHITE CUTTING CORELESS SINGLE",SUP-110045775,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X8MM COROENT 10D XL+ PEEK NONSTERILE LATEX",SUP-6308855,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"UHC [10700]","United Healthcare",,15154.02,63.3,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 169.9MM 18GA 1.25MM VENOM CURVE 150MM",SUP-0406-860-225,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 13MM PRIMARY CEMENT SATIN FINISH VERSYS",SUP-785001300,CDM,C1776,HCPCS,0278,RC,,,both,,,18721.08,5616.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5357.97,28.62,,,,,0,2177.26,15912.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HIP FEM P2 POROUS OFFSZ13",SUP-425-97-013,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,12180.23,28.62,,,,,0,4949.55,36174.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 3INX10MM OSTEOTOM THIN MRI STERILE LATEX FREE",SUP-47998602121,CDM,S27200284,LOCAL,0272,RC,,,both,,,996.30,298.89,"KAISER [10500]",Kaiser,,667.52,67,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 30MM 130CM 4MM LONG BILIARY NITINOL SELF",SUP-SC430LV,CDM,C1876,HCPCS,0278,RC,,,both,,,6210.00,1863,"AETNA [10100]","Aetna HMO/PPO",,4936.95,79.5,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER FIBERTAPE STRAIGHT CERCLAGE TROCHANTERIC SUT",SUP-AR-7823,CDM,S27200284,LOCAL,0272,RC,,,both,,,1771.88,531.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,209.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,206.07,1506.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9FR 35MM 35CM KINK RESISTANT CANN",SUP-401935M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL SOMER CURVE TO SIDE 9.5IN UTERUS SERRATE",SUP-52-5035,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ALTIVATE ANATOMIC, ALL-POLY PEGGED GLENOID, SIZE 38, E-PLUS",SUP-521-07-238,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3766.57,41.1,,6417.48,6417.48,6417.48,"1 through 10",1065.82,7789.74,"percent of total billed charges",
"REVERSE PSI KIT (HUMERAL AND GLENOID)",SUP-1235-7152-003,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"AETNA [10100]","Aetna HMO/PPO",,5485.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP IDENTITY STEM/AUGMENTED GLENOID/PREMIUM POST/IDENTITY HE",SUP-98000900262,CDM,C1776,HCPCS,0278,RC,,,both,,,33075.00,9922.5,"MULTIPLAN [10600]",Multiplan,,28113.75,85,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)MARKER SKIN GREEN 5CM SOFT TISSUE DELIVERY SYSTEM STER",SUP-SMARTCLIPLT-GRN-5,CDM,A4648,HCPCS,0278,RC,,,both,,,2625.00,787.5,"BLUE CROSS [10001]","Blue Cross PPO",,1029,39.2,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 15MM AEQUALIS HA REVERSED 25MM STD POST",SUP-DWD170,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"KAISER [10500]",Kaiser,,6326.81,67,,,,,0,1098.22,8026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY NDL STREAMLINE CATH POSITION MARKER 100CM 1.8MM",SUP-M00515191,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.48,104.84,"CIGNA [10200]",Cigna,,237.65,68,,,,,0,40.64,297.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 20MM 3.2-2.4-2.6FR 2MM BALLOON",SUP-SPR2020W,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE HEXAGONAL 230CM 2.4MM TRAXTION OLYMPUS ACTIVE CORD",SUP-00711113,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE SHUNT .5MM 18.5MM LORENZ CRANIOMAXILLOFACIAL",SUP-017305,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.70,405.81,"PHCS [10601]",PHCS,,946.89,70,,,,,0,157.32,1149.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 25MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50025,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"BLUE CROSS [10001]","Blue Cross PPO",,32545.69,39.2,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNETOS MATRIX .25-1MM LARGE ALLOGRAFT FLEX",SUP-703-058-US,CDM,C1713,HCPCS,0278,RC,,,both,,,20997.90,6299.37,"CIGNA [10200]","Cigna Open Access",,7034.3,33.5,,1144.80,304.56,2275.09,66,2442.06,17848.22,"percent of total billed charges",
"MESH SURGICAL GALASHAPE 18.5X6.4CM SOFT TISSUE SCAFFOLD",SUP-FR3D04,CDM,C1781,HCPCS,0278,RC,,,both,,,17640.00,5292,"MULTIPLAN [10600]",Multiplan,,14994,85,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LASER ABLATION SYSTEM 3MM VISUALASE 1.65MM TIP CATH STERILE",SUP-9735559,CDM,S27200284,LOCAL,0272,RC,,,both,,,62700.00,18810,"MULTIPLAN [10600]",Multiplan,,53295,85,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LUTONIX 035 DRUG COATED PTA BALLOON",SUP-LX351307150,CDM,C2623,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"NOVANET [10819]",Novanet,,10091.25,75,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,inpatient,,,149949.56,44984.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,35388.7,,,,,,,7561,64803.44,"case rate",
"CATH NAVISTAR 115CM 4MM 7FR 1-7-4MM SPACE F CURVE ABLATION",SUP-118331S,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"NOVANET [10819]",Novanet,,10298.25,75,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP 20D MEDIUM HEART 8IN TITANIUM LIGATE",SUP-237081,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"UHC [10700]","United Healthcare",,1068.19,63.3,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.7MM 32MM CHARLOTTE LISFRANC RECONSTRUCTION",SUP-43503732,CDM,C1713,HCPCS,0278,RC,,,both,,,6147.90,1844.37,"FIRST HEALTH [10303]","First Health",,4918.32,80,,,,,0,715,5225.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 305CC P4.9CM MODERATE PLUS PROFILE TALL HEIGHT",SUP-334-1159,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA [10200]","Cigna Open Access",,5202.08,56.9,,5166.00,5166.00,5166.00,"1 through 10",1063.27,7771.13,"percent of total billed charges",
"HC Hepatitis D Quantification",PX-306000253,CDM,87523,CPT,0306,RC,,,both,,,279.00,83.7,"CIGNA [10200]","Cigna Local Plus",,94.25,,,,,,,0.01,237.15,"fee schedule",
"PAD THERAPEUTIC 11.34X10.85IN WRAP ON EXTEND HOSE CONTINUOUS",SUP-11-0680-9-00000,CDM,S27000187,LOCAL,0270,RC,,,both,,,157.38,47.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.3,133.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM OZARK SPINE CERVICAL SELF START FIX ANGLE",SUP-8801-14012DA,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-FLO RENEGADE FATHOM VASCULAR 115CM 10CM .016IN",SUP-M001184520,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"FIRST HEALTH [10303]","First Health",,3000,80,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 58MM 80CM 9MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU0800958,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10458,40,,,,,0,3040.66,22223.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAYONET 8IN STR TIP DN6214",SUP-DN6214,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CGUARD PRIME CAROTID STENT SYSTEM 135CM 9MM LENGTH  30MM",SUP-CND0930,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"CIGNA [10200]","Cigna Open Access",,6954.1,33.5,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SCR SOLERA SPINAL TITANIUM BREAKOFF 4.75 MM ROD",SUP-5440030,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"CIGNA [10200]","Cigna Open Access",,1369.36,56.9,,1144.80,304.56,2275.09,66,279.89,2045.61,"percent of total billed charges",
"HOOK SPINAL BLUE CD HORIZON MEDIUM NARROW BLADE 5.5/6MM ROD",SUP-5541123,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",348.9,2550,"percent of total billed charges",
"HC Mayo Glutamic Acid Decarboxylase (Gad65) Antibody Assay,Serum",PX-302000236,CDM,86341,CPT,0302,RC,,,both,,,106.00,31.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,21.21,,,,,,,0.01,90.1,"fee schedule",
"STENT WALLFLEX 12CM 230CM 25-30MM 10FR 270CM COLONIC NITINOL",SUP-M00565060,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR GRAY 43MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103543000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"NOVANET [10819]",Novanet,,2298.24,75,,,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 350ML STYLE 7200 MEDIUM HEIGHT CENTERSCOPE",SUP-354-7212,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"UHC [10700]","United Healthcare",,6551.55,63.3,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMINO ACID 4.25 % NO.1 IN DEXTROSE 5 % INTRAVENOUS SOLUTION",RX-27927,CDM,J3490,HCPCS,0258,RC,00338-1089-04,NDC,both,2000,ML,452.70,135.81,"AETNA [10100]","Aetna HMO/PPO",,359.9,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.65,384.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +13 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150130,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"FIRST HEALTH [10303]","First Health",,276,80,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDPN ORTHOPEDIC 5IN 1/8IN GENESIS II KNEE TROCAR TIP",SUP-71210003,CDM,C1713,HCPCS,0278,RC,,,both,,,260.35,78.1,"NOVANET [10819]",Novanet,,195.26,75,,,,,0,30.28,221.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NAVIFLEX 202.5CM 10FR DELIVERY RAPID EXCHANGE CATH",SUP-M00533580,CDM,C1887,HCPCS,0272,RC,,,both,,,667.20,200.16,"KAISER [10500]",Kaiser,,447.02,67,,,,,0,77.6,567.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablt Perc Liver Tmr Ire",PX-361000742,CDM,47384,CPT,0361,RC,,,both,,,16726.00,5017.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1945.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1945.23,14217.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST ALLOGRAFT WEDGE 10-12MM",SUP-P00204,CDM,S27800098,LOCAL,0278,RC,,,both,,,4830.00,1449,"AETNA [10100]","Aetna HMO/PPO",,3839.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ASAHI SASUKE 145CM 3.3FR INFUSION STERILE LATEX FREE",SUP-SA145-33N,CDM,C1887,HCPCS,0272,RC,,,both,,,3262.50,978.75,"KAISER [10500]",Kaiser,,2185.88,67,,,,,0,379.43,2773.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUARD BURR LONG",SUP-137501100,CDM,S27000186,LOCAL,0270,RC,,,both,,,770.96,231.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY TIBIAL INFINITY 2 STD",SUP-33650002,CDM,S27200284,LOCAL,0272,RC,,,both,,,29049.30,8714.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH RANGER 150CM 120MM 6MM BALLOON DILATATION PACLITAXEL",SUP-H74939419601210,CDM,C2623,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM INTEGRITY 9MM 3MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT30009UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,280.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OXYMETAZOLINE 0.05 % NASAL MIST",RX-117367,CDM,,,0250,RC,41100-0015-11,NDC,both,15,ML,48.59,14.58,"PHCS [10601]",PHCS,,34.01,70,,,,,0,5.65,41.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS SMALL PLUG CRUSHED 12MM",SUP-291286,CDM,S27800098,LOCAL,0278,RC,,,both,,,4805.85,1441.75,"CIGNA [10200]","Cigna Local Plus",,2571.13,53.5,,,,,0,558.92,4084.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 100MM 4FR 3MM LOW PROFILE",SUP-39147-30101,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 7MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBJ070502,CDM,C1874,HCPCS,0278,RC,,,both,,,18622.80,5586.84,"KAISER [10500]",Kaiser,,12477.28,67,,,,,0,2165.83,15829.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOLD CEMENT 60MM STAGEONE HIP SILICONE REINFORCEMENT SPACER",SUP-431184,CDM,C1713,HCPCS,0278,RC,,,both,,,7955.01,2386.5,"FIRST HEALTH [10303]","First Health",,6364.01,80,,,,,0,925.17,6761.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28MMX10MM X-PAC LORDOTIC",SUP-EI2502L,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross HMO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 480MM 6MM XIA 3 TITANIUM NONSTERILE",SUP-48232480,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 20MM 130CM 7MM .035IN BILIARY SELF EXPANDING",SUP-EX070203CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"KAISER [10500]",Kaiser,,7859.1,67,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE POWERTURN FLEX VASCULAR STRAIGHT 300CM 3CM",SUP-1044593,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR THK.36MM ULTRATHIN TAPER 3X1IN KNIT",SUP-M00202019530P0,CDM,C1768,HCPCS,0278,RC,,,both,,,995.73,298.72,"KAISER [10500]",Kaiser,,667.14,67,,,,,0,115.8,846.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3-0 NANO CORKSCREW FT 2 NDL 1.35MM K WIRE",SUP-AR-1317FT,CDM,C1713,HCPCS,0278,RC,,,both,,,3346.88,1004.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,396.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",389.24,2844.85,"percent of total billed charges",
"HC Bx Salivary Gland Ndl",PX-361000170,CDM,42400,CPT,0361,RC,,,both,,,2874.83,862.45,"BLUE CROSS [10001]","Blue Cross HMO",,2490.09,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,334.34,2874.83,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 28MM 144CM 3.5MM CORONARY STENT",SUP-H7493952828350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 45D HOOK 8.5IN 3/32IN STERILE EDGE",SUP-E1511,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.38,44.21,"NOVANET [10819]",Novanet,,110.54,75,,,,,0,17.14,125.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Virus Ab Nos",PX-302000169,CDM,86790,CPT,0302,RC,,,both,,,593.75,178.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13.52,,"Fee schedule rate ($13.52). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,504.69,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT DOUBLE-J 24CM 100CM 6FR .028IN URETERAL SILICONE PTFE",SUP-5202800,CDM,C2617,HCPCS,0278,RC,,,both,,,1212.57,363.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.02,1030.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 117MM 11MM PRIMARY STD OFFSET PRESS FIT",SUP-00786401100,CDM,S27800098,LOCAL,0278,RC,,,both,,,30164.40,9049.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8633.05,28.62,,,,,0,3508.12,25639.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER ACCUTRAC 200UM FLEXSHIELD HOLMIUM FLEXIBLE",SUP-M0068404112,CDM,S27200284,LOCAL,0272,RC,,,both,,,3284.22,985.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,389.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,381.95,2791.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Et Tube Endobronchial",PX-E27200242,CDM,9999115,LOCAL,0272,RC,,,both,,,730.95,219.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,85.01,621.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 12MM ENDOPATH XCEL BLADELESS",SUP-B12XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1082.48,324.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,128.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,125.89,920.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) GUIDEWIRE VASCULAR .024INX200CM ARISTOTLE 24 SOFT",SUP-A24-200-001,CDM,C1769,HCPCS,0272,RC,,,both,,,5692.50,1707.75,"UHC [10700]","United Healthcare",,3603.35,63.3,,,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP UNISTEP PLUS 60MM 100CM 8MM 6FR",SUP-M001711280,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"KAISER [10500]",Kaiser,,5663.18,67,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 130D STD BARREL 80MM STAINLESS STEEL 3 HOLE",SUP-121125,CDM,S27800098,LOCAL,0278,RC,,,both,,,5149.13,1544.74,"CIGNA [10200]","Cigna Open Access",,2929.85,56.9,,,,,0,598.84,4376.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3.5MM 22MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.822.96,CDM,C1713,HCPCS,0278,RC,,,both,,,319.12,95.74,"NOVANET [10819]",Novanet,,239.34,75,,,,,0,37.11,271.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 13MM COROENT INTERLOCK II SPINE SELF TAP",SUP-1903013,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPTIP 35CM 14FR DRNG FLEXIMA POLYURETHANE HYDROPHILIC",SUP-M001281590,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 69CM ATRIUM VENTRICLE BIPOLAR FIXED SCR IN",SUP-383069,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"PHCS [10601]",PHCS,,1562.75,70,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 11MM ECHO FX COCR STD OFFSET HIP STERILE",SUP-12151311,CDM,C1776,HCPCS,0278,RC,,,both,,,8941.02,2682.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6079.89,68,,,,,0,1039.84,7599.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 12 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502607402,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"CIGNA [10200]",Cigna,,9145.08,40,,5873.17,5873.17,5873.17,"1 through 10",2658.93,19433.3,"percent of total billed charges",
"GRAFT BONE ILIAC CREST TRICORTICAL THK13-15MM WEDGE",SUP-400407,CDM,S27800098,LOCAL,0278,RC,,,both,,,5261.94,1578.58,"MULTIPLAN [10600]",Multiplan,,4472.65,85,,,,,0,611.96,4472.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 14.5MM 42X70X10MM GENTAMICIN PMMA REMEDY",SUP-RKINMD,CDM,C1776,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross HMO",,1893.36,39.2,,5311.50,4717.44,5388.59,31,561.73,4105.5,"percent of total billed charges",
"CATH SWAN-GANZ CCO VIP 110CM 7.5FR ARTERIAL LINE AMC",SUP-139HF75P,CDM,C1751,HCPCS,0272,RC,,,both,,,973.54,292.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,115.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.22,827.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FEVER AND INFLAMMATORY CONDITIONS",864,MS-DRG,,,,,,,inpatient,,,36826.81,11048.04,"CIGNA [10200]",Cigna,,11639.52,,"Fee schedule rate ($11,639.52). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,5506.46,22138.35,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.9H 32MM 2 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009232,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR COBRA 1 CURVE ANGIOGRAPHIC VISCERAL",SUP-10719701,CDM,C1887,HCPCS,0272,RC,,,both,,,104.23,31.27,"NOVANET [10819]",Novanet,,78.17,75,,,,,0,12.12,88.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 300MM 17MM LARGE QUICK COUPLING CANNULATED",SUP-357.394,CDM,S27200284,LOCAL,0272,RC,,,both,,,4178.92,1253.68,"FIRST HEALTH [10303]","First Health",,3343.14,80,,,,,0,486.01,3552.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 014 150CM 12CM 2.5MM BALLOON DILATATION",SUP-U41502H12,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 120MM 120CM 6MM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200061220,CDM,C1876,HCPCS,0278,RC,,,both,,,4620.00,1386,"BLUE CROSS [10001]","Blue Cross PPO",,1811.04,39.2,,,,,0,537.31,3927,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC",357,MS-DRG,,,,,,,inpatient,,,60157.12,18047.14,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,15434.97,,"Case rate ($14,425.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,394.79, add-ons for qualifying new technology services are included. If operating cost exceeds $46,434.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,394.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,412.51. The transfer operating threshold is the transfer adjustment factor * $13,394.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,012.71. The transfer capital threshold is the transfer adjustment factor * $1,012.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,60157.12,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SHORT 25MM INTERNAL CURVED",SUP-PL548S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION SWIVELOCK PEEK MENISCAL ROOT REPAIR",SUP-AR-4550P,CDM,C1713,HCPCS,0278,RC,,,both,,,10106.78,3032.03,"MULTIPLAN [10600]",Multiplan,,8590.76,85,,,,,0,1175.42,8590.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM HELIX R SPINE SELF TAP FIX ANGLE",SUP-7804215,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,396.9,39.2,,957.42,570.23,957.42,28,117.75,860.63,"percent of total billed charges",
"PLATE T OBLIQUE ANGLE 63X10X1.5MM TITANIUM 3.5MM SCR SMALL",SUP-441.24,CDM,C1713,HCPCS,0278,RC,,,both,,,1547.91,464.37,"CIGNA [10200]","Cigna Local Plus",,828.13,53.5,,3978.14,359.25,3978.14,24,180.02,1315.72,"percent of total billed charges",
"GRAFT ENDOVASCULAR 124MM 23-13MM 18FR ENDURANT II ABDOMEN",SUP-ETBF2313C124E,CDM,S27800098,LOCAL,0278,RC,,,both,,,60782.40,18234.72,"MULTIPLAN [10600]",Multiplan,,51665.04,85,,,,,0,7068.99,51665.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.3MM SUT GUIDE STERILE",SUP-8757,CDM,S27200284,LOCAL,0272,RC,,,both,,,1058.02,317.41,"CIGNA [10200]","Cigna Open Access",,602.01,56.9,,,,,0,123.05,899.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION ENDOBUTTON 12MM 4MM ARTHROSCOPIC STERILE",SUP-013186,CDM,C1713,HCPCS,0278,RC,,,both,,,1271.70,381.51,"CIGNA [10200]","Cigna Local Plus",,680.36,53.5,,3978.14,359.25,3978.14,24,147.9,1080.95,"percent of total billed charges",
"CEMENT BONE SIMPLEX GENTAMICIN 20ML 40GM HIGH VISCOSITY",SUP-6195-1-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,1728.52,518.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,494.7,28.62,,,,,0,201.03,1469.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE C SCREW, 3.5X12MM MA",SUP-3903512,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMNION PATCH 2X2",SUP-RA-831,CDM,V2790,HCPCS,0278,RC,,,both,,,6175.50,1852.65,"FIRST HEALTH [10303]","First Health",,4940.4,80,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 8MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR080202A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2223.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HYDRA JAGWIRE DREAM TIP ENDOSCOPIC ROUND ANGLE 260CM",SUP-M00556031,CDM,C1769,HCPCS,0272,RC,,,both,,,1422.36,426.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,168.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.42,1209.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 66MM HIP MULTIHOLE RIM TRITANIUM X3 MDM",SUP-509-02-66H,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"PHCS [10601]",PHCS,,7862.4,70,,,,,0,1306.28,9547.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTAPRO 135CM .58IN 2.5MM ATHERECTOMY PRECONNECT BURR",SUP-H749394672500,CDM,C1724,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1594.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDO QUILL 2 .5 CIRCLE TAPER POINT 70CM MONOFILAMENT",SUP-VLP-2010,CDM,S27200284,LOCAL,0272,RC,,,both,,,150.19,45.06,"CIGNA [10200]","Cigna Local Plus",,80.35,53.5,,,,,0,17.47,127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Iontophoresis 15min (Gp)",PX-420000018,CDM,97033,CPT,0420,RC,,,both,,,226.67,68,"KAISER [10500]",Kaiser,,151.87,67,,,,,0,26.36,226.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 146MM CANNULATED SURGICAL 3.5MM CANNULATED SCR",SUP-311.39,CDM,S27000186,LOCAL,0270,RC,,,both,,,3740.00,1122,"UHC [10700]","United Healthcare",,2367.42,63.3,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 1.14MM SHEPARD EAR GROMMET TAB POLYETHYLENE",SUP-14-6031,CDM,S27800098,LOCAL,0278,RC,,,both,,,95.19,28.56,"BLUE CROSS [10001]","Blue Cross HMO",,37.31,39.2,,,,,0,11.07,80.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40026W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"FIRST HEALTH [10303]","First Health",,4351.2,80,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 15MM 1.25MM BALLOON DILATATION RAPID",SUP-47512015M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL URETERAL TAPER NOTTINGHAM ONE-STEP 70CM 4CM 6-10FR",SUP-M0062301000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1005.78,301.73,"FIRST HEALTH [10303]","First Health",,804.62,80,,,,,0,116.97,854.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 10.5IN 14FR SILICONE Y PORT GRADUATE SHAFT OPEN DISTAL",SUP-8884715148E,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.71,111.81,"CIGNA [10200]","Cigna Local Plus",,199.4,53.5,,,,,0,43.35,316.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP SECTOR POROCOAT PINNACLE",SUP-121722056,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"CIGNA [10200]","Cigna Open Access",,3818.42,56.9,,5302.19,4377.88,6578.61,27,780.46,5704.15,"percent of total billed charges",
"CATH LAUNCHER 100CM 8FR .09IN EXTRA BACKUP LEFT 3.5 CURVE",SUP-LA8EBU35SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 20MM 29MM MOSAIC ULTRA CINCH RING PORCINE STENT",SUP-305U229,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"KAISER [10500]",Kaiser,,18361.35,67,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 18MM REVISION 20 GRIT BLAST SURFACE",SUP-197618140,CDM,C1776,HCPCS,0278,RC,,,both,,,17952.48,5385.74,"NOVANET [10819]",Novanet,,13464.36,75,,,,,0,2087.87,15259.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM VARIAX T10 FULL THREAD NONSTERILE LOCK",SUP-657426,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"BLUE CROSS [10001]","Blue Cross HMO",,317.01,39.2,,957.42,156.86,7483.26,51,94.05,687.4,"percent of total billed charges",
"CMPNT FEMORAL STANDARD+ KNEE LEFT STABILIZE CEMENT ROTATE",SUP-129412050,CDM,C1776,HCPCS,0278,RC,,,both,,,31285.80,9385.74,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12858.46,41.1,,6417.48,6417.48,6417.48,"1 through 10",3638.54,26592.93,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 16CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155214180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"BLUE CROSS [10001]","Blue Cross PPO",,631.01,39.2,,,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 5.5MM MATRIX CURVE SPINE PEDICLE POSTERIOR",SUP-04.636.030,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS SELECT 150CM 4MM 3.2FR .052-.059IN 45D 15MM",SUP-518-087,CDM,C1887,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.8MM 5MM STERILETRAC TITANIUM MIDFACE SELF TAP",SUP-91-1805,CDM,C1713,HCPCS,0278,RC,,,both,,,400.20,120.06,"CIGNA [10200]","Cigna Local Plus",,214.11,53.5,,3978.14,359.25,3978.14,24,46.54,340.17,"percent of total billed charges",
"STEM HUMERAL 170MM PERFORM 15 LONG SHOULDER STERILE LATEX",SUP-PFX15170,CDM,C1776,HCPCS,0278,RC,,,both,,,42493.50,12748.05,"PHCS [10601]",PHCS,,29745.45,70,,,,,0,4941.99,36119.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75444540,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"TRAY CATH 70CM POWERPICC 2 LUMEN GWIRE INTRO NDL CUFF",SUP-3386355,CDM,C1751,HCPCS,0272,RC,,,both,,,929.88,278.96,"AETNA [10100]","Aetna HMO/PPO",,739.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.15,790.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 NARROW KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-71933653,CDM,C1776,HCPCS,0278,RC,,,both,,,22273.65,6682.09,"MULTIPLAN [10600]",Multiplan,,18932.6,85,,,,,0,2590.43,18932.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 CURVE PLUS 15MM KNEE XLK FIX BEARING SIGMA",SUP-970483,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3198.16,28.62,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 60MM 5MM BALLOON DILATATION DURALYN",SUP-48005006X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PHCS [10601]",PHCS,,878.85,70,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 240MM 3MM BALLOON DILATATION HYDROPHILIC",SUP-593024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 13.5X12.7CM 395ML STYLE CPG 312 COHESIVE III GEL",SUP-3541358,CDM,C1789,HCPCS,0278,RC,,,both,,,7590.00,2277,"CIGNA [10200]","Cigna Open Access",,4318.71,56.9,,5166.00,5166.00,5166.00,"1 through 10",882.72,6451.5,"percent of total billed charges",
"STENT POLARIS 22CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006155231010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,565.01,45.9,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 45CM 5MM PKS 360D 1 FINGER ROTATION MICRO JAW",SUP-3640,CDM,S27200284,LOCAL,0272,RC,,,both,,,2355.00,706.5,"FIRST HEALTH [10303]","First Health",,1884,80,,,,,0,273.89,2001.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM PEDICLE TITANIUM BIFID BLADE",SUP-7541103,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 4-0 PC-1 18IN MONOFILAMENT BLUE",SUP-8619G,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.79,20.34,"NOVANET [10819]",Novanet,,50.84,75,,,,,0,7.88,57.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 29MM 3 PEG OPTETRAK POLYETHYLENE KNEE STERILE",SUP-200-02-29,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 14CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061751970,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]","Cigna Local Plus",,482.67,,,,,,,104.92,766.85,"percent of total billed charges",
"SUT VICRYL PLUS 0 MO-4 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP701D,CDM,S27200284,LOCAL,0272,RC,,,both,,,169.32,50.8,"CIGNA [10200]","Cigna Open Access",,96.34,56.9,,,,,0,19.69,143.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI STRAIGHT 4MMX1MM MANDIBLE 4 HOLE 2MM SCR BONE",SUP-55-10505,CDM,C1713,HCPCS,0278,RC,,,both,,,825.55,247.66,"CIGNA [10200]","Cigna Open Access",,469.74,56.9,,1144.80,304.56,2275.09,66,96.01,701.72,"percent of total billed charges",
"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION",RX-10266,CDM,,,0250,RC,70100-0424-01,NDC,both,1,UN,1281.08,384.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,148.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,148.99,1088.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 F 44MM COCR HIP 2 MOBILITY",SUP-110024464,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"MULTIPLAN [10600]",Multiplan,,11009.78,85,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 111MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 8",SUP-223.581,CDM,C1713,HCPCS,0278,RC,,,both,,,2001.30,600.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,232.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",232.75,1701.11,"percent of total billed charges",
"SCR BONE 5MM 38MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.528S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1017.88,68,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NAVITOR LARGE LOADING STENT GUIDE LEAFLET LOADING",SUP-NVTR-LS-LG+,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"MULTIPLAN [10600]",Multiplan,,3187.5,85,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM 30X16X2.5MM TITANIUM 2 LEVEL PREBENT SKYLINE BONE",SUP-186802030,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Open Access",,2509.29,56.9,,1144.80,304.56,2275.09,66,512.88,3748.5,"percent of total billed charges",
"STEM FEMORAL 101MM TYPE 1 PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51108080,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"CIGNA [10200]",Cigna,,10974.1,40,,5873.17,5873.17,5873.17,"1 through 10",3190.72,23319.95,"percent of total billed charges",
"GRAFT BONE OSTEOSELECT DEMINERALIZED BONE MATRIX 1CC",SUP-359010,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"CIGNA [10200]","Cigna Open Access",,645.25,56.9,,1144.80,304.56,2275.09,66,131.88,963.9,"percent of total billed charges",
"HC Inj Paravrt Jt C/T 2 Lvl Bi",PX-510000135,CDM,64491,CPT,0761,RC,,,both,,,3365.42,1009.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,391.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,391.4,2860.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEDSURG COMMIT BARD VASCULAR ACCESS PICCS AND MIDLINES",SUP-F418108PT,CDM,C1751,HCPCS,0272,RC,,,both,,,955.07,286.52,"PHCS [10601]",PHCS,,668.55,70,,,,,0,111.07,811.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 75MM AXSOS STAINLESS STEEL T15 FEMUR HUMERUS",SUP-371575,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,103.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",103.62,757.35,"percent of total billed charges",
"HEAD HUMERAL 15MM 41MM SHOULDER SIMPLICITI",SUP-7122869,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"AETNA [10100]","Aetna HMO/PPO",,7965.11,79.5,,10981.53,8986.79,12413.38,12,1165.21,8516.15,"percent of total billed charges",
"BIT DRILL 100MM 2.4MM STAINLESS STEEL QUICK COUPLING",SUP-310.53,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SHUNT ACCU-FLO STRAIGHT CSF RADIOPAQUE CATH PLASTIC",SUP-45103,CDM,S27800098,LOCAL,0278,RC,,,both,,,755.57,226.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,89.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.87,642.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROXIMAL HUMERUS SUTURE PLATE TI",SUP-PHP-SP,CDM,C1713,HCPCS,0278,RC,,,both,,,6624.00,1987.2,"BLUE CROSS [10001]","Blue Cross PPO",,2596.61,39.2,,957.42,570.23,957.42,28,770.37,5630.4,"percent of total billed charges",
"CATH WOLVERINE CUTTING BALLOON (OTW)  4.00MM X 6MM",SUP-H74939402064000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"NOVANET [10819]",Novanet,,4062.38,75,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RELIEVA TRACT 40MM 16MM BALLOON DILATATION STERILE",SUP-RT1640A,CDM,C1726,HCPCS,0272,RC,,,both,,,4795.50,1438.65,"FIRST HEALTH [10303]","First Health",,3836.4,80,,,,,0,557.72,4076.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT INSUFFLATION THERMOFLATOR ADPTR PATIENT CONNECTION TUBE",SUP-20400034,CDM,S27200284,LOCAL,0272,RC,,,both,,,1224.72,367.42,"AETNA [10100]","Aetna HMO/PPO",,973.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,142.43,1041.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 6MM 2.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP2506X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 62.5MM KNEE RIGHT CRUCIATE RETAINING CEMENTED",SUP-183006,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2380.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2335.96,17072.81,"percent of total billed charges",
"STENT DYNAMIC 110X15MM 25/40X12MM Y TRACHEOBRONCHIAL",SUP-M00570690,CDM,C1875,HCPCS,0278,RC,,,both,,,22226.40,6667.92,"KAISER [10500]",Kaiser,,14891.69,67,,,,,0,2584.93,18892.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 46MM 28MM TANDEM HIP COCR",SUP-71322046,CDM,C1776,HCPCS,0278,RC,,,both,,,7003.50,2101.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2004.4,28.62,,,,,0,814.51,5952.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX 1S PERMANENT, 25X30 CM",SUP-F10246-2530P,CDM,C1781,HCPCS,0278,RC,,,both,,,60858.00,18257.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7211.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7077.79,51729.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT BBTRAUMA BONE BRIDGING TECHNOLOGIES VITOSS",SUP-2102-2201,CDM,C1713,HCPCS,0278,RC,,,both,,,3868.83,1160.65,"MULTIPLAN [10600]",Multiplan,,3288.51,85,,,,,0,449.94,3288.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET DIAGNOSTIC EXPLORA ENDOMETRIAL UTERINE 3MM BIOPSY",SUP-MX120,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.16,24.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.56,69.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"D652/1-110 CATHETER",SUP-333959,CDM,S27500001,LOCAL,0275,RC,,,both,,,408.90,122.67,"MULTIPLAN [10600]",Multiplan,,347.57,85,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE LEUKEMIA WITHOUT CC/MCC",836,MS-DRG,,,,,,,inpatient,,,19406.20,5821.86,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,7791.57,,"Case rate ($7,564.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,024.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,063.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,913.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,033.56. The transfer operating threshold is the transfer adjustment factor * $7,024.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.07. The transfer capital threshold is the transfer adjustment factor * $531.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,19406.2,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINR 110CM 4MM 7FR 2-5-2MM SPACE MULTICURVE ABLATION",SUP-ARV120,CDM,S27200284,LOCAL,0272,RC,,,both,,,216.11,64.83,"PHCS [10601]",PHCS,,151.28,70,,,,,0,25.13,183.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER II XP 8MM 7FR 8FR 8MM SPACE STD CURVE STRAIGHT",SUP-M0044500TH0,CDM,C1733,HCPCS,0272,RC,,,both,,,11840.40,3552.12,"NOVANET [10819]",Novanet,,8880.3,75,,,,,0,1377.04,10064.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASC WOVEN SIZE 8X30CM",SUP-175208P,CDM,C1768,HCPCS,0278,RC,,,both,,,4417.31,1325.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1264.23,28.62,,,,,0,513.73,3754.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATHETER THE RINGER PERFUSION 20MM OD 4.5MM PERFUSION",SUP-5890,CDM,C1725,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 60MM ORTHOLOC LOCK",SUP-59215560,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"NOVANET [10819]",Novanet,,1648.13,75,,,,,0,255.57,1867.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 8IN STARDUST CURVE DELICATE JAW ROUND HANDLE",SUP-278103,CDM,S27200284,LOCAL,0272,RC,,,both,,,2069.85,620.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,850.71,41.1,,,,,0,240.72,1759.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 126MM 13.5MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771101320,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"BLUE CROSS [10001]","Blue Cross PPO",,8192.65,39.2,,3949.44,3949.44,3949.44,"1 through 10",2430.63,17764.68,"percent of total billed charges",
"STEM FEMORAL 102MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 2",SUP-71357002,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"NOVANET [10819]",Novanet,,24855.86,75,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,,,0250,RC,00406-8315-23,NDC,both,1,UN,16.65,4.99,"CIGNA [10200]","Cigna Local Plus",,8.91,53.5,,,,,0,1.94,14.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 72MM 2.2MM FJ 2000 BUNION 20MM",SUP-P65-105-2220-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2730.00,819,"CIGNA [10200]",Cigna,,1856.4,68,,,,,0,317.5,2320.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 47MM UNITRAX HIP MODULAR ENDOPROSTHESIS",SUP-6942-5-047,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1435.61,45.9,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR CLEVERCAP HYBRID TUBE BACK FLOW VALVE",SUP-20325-201,CDM,S27000186,LOCAL,0270,RC,,,both,,,190.97,57.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,87.66,45.9,,,,,0,22.21,162.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADMIRAL XTREME 130CM 80MM 4MM BALLOON DILATATION",SUP-ADM040080130,CDM,C1725,HCPCS,0272,RC,,,both,,,1134.00,340.2,"KAISER [10500]",Kaiser,,759.78,67,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL F KNEE LEFT LPS-FLEX GENDER SOLUTIONS NEXG",SUP-00576201651,CDM,C1776,HCPCS,0278,RC,,,both,,,20412.00,6123.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5841.91,28.62,,,,,0,2373.92,17350.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE REGENEATION GRAFT 2CM X 3CM",SUP-GS-5230,CDM,Q4186,HCPCS,0636,RC,,,both,,,8252.40,2475.72,"CIGNA [10200]","Cigna Open Access",,406.44,,,,,,,406.44,7014.54,"fee schedule",
"ROD SPINAL 50CM 5.5MM CD HORIZON LEGACY LONG TITANIUM IV",SUP-869-022,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PRIMOPAC INFINITI AVANTI+ 4FR 155D MICRO JL4 JR4",SUP-538494P,CDM,S27200284,LOCAL,0272,RC,,,both,,,232.73,69.82,"CIGNA [10200]",Cigna,,158.26,68,,,,,0,27.07,197.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 6X38X28MM 20 DEGREE",SUP-1921049P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA [10200]",Cigna,,13860,40,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 16CM 12FR MAHURKAR 3 LUMEN CURVE EXT HIGH PRESSURE",SUP-8888101002HP,CDM,C1752,HCPCS,0272,RC,,,both,,,995.43,298.63,"UHC [10700]","United Healthcare",,630.11,63.3,,,,,0,115.77,846.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 16MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-716,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"NOVANET [10819]",Novanet,,10093.84,75,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 8MM AZUR CX DETACHABLE SOFT SOLID",SUP-45-750812,CDM,S27800098,LOCAL,0278,RC,,,both,,,7672.80,2301.84,"PHCS [10601]",PHCS,,5370.96,70,,,,,0,892.35,6521.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 8MM 6FR 1.5MM .07IN BALLOON",SUP-H7493919008150,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.00MM X 20MM  SCOREFLEX  NC",SUP-640-204-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM TROUGH BONE SPINE",SUP-8530000,CDM,C1713,HCPCS,0278,RC,,,both,,,2624.40,787.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,310.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,305.22,2230.74,"percent of total billed charges",
"BURR SHAVER 150MM 4MM XPS ASB 15D CURVED SINUS CUT",SUP-1884075HSE,CDM,S27200284,LOCAL,0272,RC,,,both,,,3562.50,1068.75,"FIRST HEALTH [10303]","First Health",,2850,80,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 6MM THORACIC KNIT HEMASHIELD GOLD",SUP-M002020951060,CDM,C1768,HCPCS,0278,RC,,,both,,,2540.03,762.01,"CIGNA [10200]","Cigna Local Plus",,1358.92,53.5,,,,,0,295.41,2159.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG AUTOTRANSFUSION 400ML CARDIOPAT ORTHOPAT REPLACEMENT RBC",SUP-01200-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.68,40.4,"KAISER [10500]",Kaiser,,90.24,67,,,,,0,15.66,114.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BONE BIOPSY REVOLVE ACCESS TROCAR TIP 11GA",SUP-685.030S,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMIPENEM-CILASTATIN 500 MG/10ML IV (WET SOLR VIAL)",RX-4159603,CDM,J0743,HCPCS,0636,RC,44567-0705-01,NDC,both,1,UN,226.52,67.96,"CIGNA [10200]","Cigna Open Access",,38.19,,,,,,,16.68,192.54,"fee schedule",
"CATH DIREXION 130CM 2.4-3FR .021IN .035IN MICRO STRAIGHT",SUP-M001195210,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,436.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 14MM LCP TITANIUM DISTAL VOLAR RADIUS LOCKING",SUP-04.210.114,CDM,C1713,HCPCS,0278,RC,,,both,,,1063.69,319.11,"FIRST HEALTH [10303]","First Health",,850.95,80,,,,,0,123.71,904.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED 100CM 9CM 9FR 26MM .035IN BALLOON DILATATION",SUP-611682,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3616.27,68,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STABLEMAPR SM 110CM 5FR 2-10-2MM SPACING",SUP-04402SM,CDM,C1731,HCPCS,0272,RC,,,both,,,5520.00,1656,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2268.72,41.1,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 172MM STAINLESS STEEL 2.7/3.5MM SCR 8 HOLE VARIABLE",SUP-02.118.007,CDM,C1713,HCPCS,0278,RC,,,both,,,9766.40,2929.92,"MULTIPLAN [10600]",Multiplan,,8301.44,85,,,,,0,1135.83,8301.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 17.5MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158105117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1299.6,9498.37,"percent of total billed charges",
"HC Cortisol Blood Total",PX-301000158,CDM,82533,CPT,0301,RC,,,both,,,341.90,102.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,57.85,,,,,,,0.01,290.62,"fee schedule",
"COUNTSINK DRILL 4MM CANNULATED HEADLESS",SUP-MSN20009,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HYPERGLIDE X-PEDION 150CM 20MM 2.2-2.8FR 4MM .01IN 4MM",SUP-104-4127,CDM,C1725,HCPCS,0272,RC,,,both,,,8790.60,2637.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1022.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1022.35,7472.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN AMPLATZ LEFT 2 CURVE GUIDING",SUP-LA6AL20,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"KAISER [10500]",Kaiser,,244.82,67,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIDAZOLAM 1 MG/ML INJECTION SOLUTION",RX-93519,CDM,J2250,HCPCS,0636,RC,00641-6281-01,NDC,both,2,ML,44.00,13.2,"CIGNA [10200]","Cigna Open Access",,0.74,,,,,,,0.33,37.4,"fee schedule",
"STENT ADVANIX 5CM 4FR PIGTAIL CURVE PANCREATIC POLYMER",SUP-M00537370,CDM,C2625,HCPCS,0278,RC,,,both,,,1411.18,423.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,647.73,45.9,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NUT EXTERNAL FIXATION HEX MRI SAFE NONSTERILE",SUP-03.311.061.10,CDM,S27800098,LOCAL,0278,RC,,,both,,,66.83,20.05,"KAISER [10500]",Kaiser,,44.78,67,,,,,0,7.77,56.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRA 91CM 80CM SHUNT STAINLESS STEEL SILICONE",SUP-903345A,CDM,C1729,HCPCS,0272,RC,,,both,,,9425.47,2827.64,"KAISER [10500]",Kaiser,,6315.06,67,,,,,0,1096.18,8011.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 26MM RESURFACE GENESIS II KNEE",SUP-71420580,CDM,C1776,HCPCS,0278,RC,,,both,,,6344.55,1903.36,"CIGNA [10200]","Cigna Local Plus",,3394.33,53.5,,5372.07,4581.20,7242.98,23,737.87,5392.87,"percent of total billed charges",
"COIL EMBOLIZATION 50CM 7MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0750CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"CIGNA [10200]","Cigna Open Access",,4515.02,56.9,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYNTHETIC TISSUE SCAFFOLD STRIP .5X8CM",SUP-31053,CDM,C1763,HCPCS,0278,RC,,,both,,,10591.50,3177.45,"FIRST HEALTH [10303]","First Health",,8473.2,80,,,,,0,1231.79,9002.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 4965-15  LEAD-UNI EPI STEROID 15CM",SUP-4965-15,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"FIRST HEALTH [10303]","First Health",,4485.6,80,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 24MM 8MM STAINLESS STEEL LONG THREAD FOOT HAND",SUP-02.226.124,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"CIGNA [10200]",Cigna,,1118.74,68,,1831.33,1831.33,1831.33,16,191.34,1398.42,"percent of total billed charges",
"HC Surg Path Gross Micro Level 6",PX-312000018,CDM,88309,CPT,0312,RC,,,both,,,1129.70,338.91,"BLUE CROSS [10001]","Blue Cross PPO",,381.56,,"Fee schedule rate ($381.56).",,,,0,0.01,960.25,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM VANGUARD TKR E1 FEMUR PATELLA TIBIA CEMENT INSRT",SUP-98B00200138,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"BLUE CROSS [10001]","Blue Cross HMO",,9631.44,39.2,,5311.50,4717.44,5388.59,31,2857.49,20884.5,"percent of total billed charges",
"COIL EMBOLIZATION 3CM 1.5MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES0153CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 5MM 1.35MM TRIUNE EAR SILICONE BLUE",SUP-510-121,CDM,S27800098,LOCAL,0278,RC,,,both,,,245.41,73.62,"KAISER [10500]",Kaiser,,164.42,67,,,,,0,28.54,208.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 NARROW KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-42500006201,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6543.3,28.62,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BICALUTAMIDE 50 MG TABLET",RX-15746,CDM,,,0637,RC,16714-0816-01,NDC,both,1,UN,68.99,20.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.02,58.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM CARBO-SEAL ASCENDING AORTA VALSALVA",SUP-CP-025,CDM,S27800098,LOCAL,0278,RC,,,both,,,29408.40,8822.52,"UHC [10700]","United Healthcare",,18615.52,63.3,,,,,0,3420.2,24997.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE POLY-L-LACTIC ACID 20MM 9MM TIBIAL ACL",SUP-AR-1586RB-09,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 1/8IN 1 PIECE HEADLESS FLUTED SQUARE END 3.5IN",SUP-BMA-S90010S,CDM,S27200284,LOCAL,0272,RC,,,both,,,603.61,181.08,"CIGNA [10200]","Cigna Local Plus",,322.93,53.5,,,,,0,70.2,513.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RTRCTR LEYLA COUPLING NONSTERILE BRAIN",SUP-R2382,CDM,S27200284,LOCAL,0272,RC,,,both,,,7649.13,2294.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,889.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,889.59,6501.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX11MM FRA 8D LORDOTIC NARROW WEDGE",SUP-10011,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 55MM 5MM KII Z THREAD SLEEVE SHIELD",SUP-CTB05,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,106.49,68,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 25MM CEMENTED OMNIFIT HFX 132D 5 HIP",SUP-6070-0525A,CDM,C1776,HCPCS,0278,RC,,,both,,,7894.95,2368.48,"BLUE CROSS [10001]","Blue Cross PPO",,3094.82,39.2,,3949.44,3949.44,3949.44,"1 through 10",918.18,6710.71,"percent of total billed charges",
"VICTORY 14 300 CM 12G 1-PACK",SUP-H74939470300120,CDM,C1769,HCPCS,0272,RC,,,both,,,2370.00,711,"UHC [10700]","United Healthcare",,1500.21,63.3,,,,,0,275.63,2014.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL STD 17.5MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405417,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"CIGNA [10200]","Cigna Open Access",,5498.5,56.9,,5302.19,4377.88,6578.61,27,1123.86,8213.93,"percent of total billed charges",
"PIN FIXATION DETACHABLE PLATE TEMPORARY NONSTERILE",SUP-389.873,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 120MM 2.5MM BALLOON DILATATION PEBAX",SUP-H74939148251210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCRP OPHTHALMIC 25GA CURVE",SUP-338.25P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1210.46,363.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.78,1028.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLONAZEPAM 0.25 MG DISINTEGRATING TABLET",RX-35626,CDM,,,0637,RC,62332-0365-06,NDC,both,1,UN,12.91,3.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8.78,68,,,,,0,1.5,10.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 18CM 28.5MM 12MM 24-26MM 10-11MM GORE",SUP-RLT281218,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS [10001]","Blue Cross HMO",,24578.4,39.2,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER PROSTATE SPACEOAR VUE RECTUM ANTERIOR HYDROGEL",SUP-SV-2101,CDM,C1889,HCPCS,0278,RC,,,both,,,29297.84,8789.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7910.42,27,,,,,0,3407.34,24903.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 12MM 144CM 3.5MM",SUP-H7493941212350,CDM,C1874,HCPCS,0278,RC,,,both,,,8245.50,2473.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2359.86,28.62,,,,,0,958.95,7008.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR AMPLATZ RIGHT 2",SUP-67011200,CDM,C1887,HCPCS,0272,RC,,,both,,,83.52,25.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.71,70.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LD 26MM 6.4MM 3.4MM SIL SL","SUP-109 185",CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"KAISER [10500]",Kaiser,,256.48,67,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16015545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AETNA [10100]","Aetna HMO/PPO",,7589.75,79.5,,1521.93,481.35,16760.95,30,1110.3,8114.82,"percent of total billed charges",
"CATH NC TREK NEO 15MM 145CM 5MM BALLOON DILATATION HYDROCOAT",SUP-1400500-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC RELOAD AEON 60MMX4MM STERILE LATEX FREE",SUP-AESR60P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY 5MM SPACING JSN CURVE 5FR 120CM",SUP-401223R,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 80MM 120CM 10MM 159CM VASCULAR NITINOL ILIAC",SUP-H74939200108020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Open Access",,2355.66,56.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AQUAFLO HYDROGEL WOUND DRESSING DISC 3IN",SUP-8884476139,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.31,17.79,"CIGNA [10200]","Cigna Open Access",,33.75,56.9,,,,,0,6.9,50.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 52MM STAINLESS STEEL 2MM SCREW MINI FRAGMENT SET 7 HOL",SUP-247.347,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 100MM 5.5MM CD HORIZON LEGACY TITANIUM PREBENT",SUP-8690100,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2.5CM 2.5MM GALAXY G3 XTRASOFT",SUP-GLX122525,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]","Cigna Local Plus",,3742.77,31.5,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 24MM LCP DCP STAINLESS STEEL CORTICAL",SUP-201.824,CDM,C1713,HCPCS,0278,RC,,,both,,,358.09,107.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,243.5,68,,,,,0,41.65,304.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 40MM 130CM 7MM VASCULAR METAL SUPERFICIAL",SUP-H74939293074030,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"KAISER [10500]",Kaiser,,3236.1,67,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X300 80CM SL",SUP-48005030N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,121.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA G KNEE LEFT 2 PEG TIVANIUM STERILE",SUP-42530007901,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"KAISER [10500]",Kaiser,,9503.96,67,,,,,0,1649.72,12057.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 20IN 28FR STRAIGHT",SUP-8888570549,CDM,C1729,HCPCS,0272,RC,,,both,,,94.36,28.31,"UHC [10700]","United Healthcare",,59.73,63.3,,,,,0,10.97,80.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 7 HOLE SHAFT LCP BONE RADIUS RIGHT",SUP-02.110.007S,CDM,C1713,HCPCS,0278,RC,,,both,,,9722.79,2916.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4462.76,45.9,,,,,0,1130.76,8264.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT Q-FIX MINITAPE 2 PRELOAD BLUE COBRAID WHITE",SUP-72205860,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.00,945,"CIGNA [10200]",Cigna,,2142,68,,1831.33,1831.33,1831.33,16,366.35,2677.5,"percent of total billed charges",
"SCR BONE 3.5MM 20MM CORTEX SELF TAP STARDRIVE",SUP-02.200.020,CDM,C1713,HCPCS,0278,RC,,,both,,,240.38,72.11,"CIGNA [10200]","Cigna Open Access",,136.78,56.9,,1144.80,304.56,2275.09,66,27.96,204.32,"percent of total billed charges",
"CANN ARTERIAL 20FR 12IN 1 PIECE BLUNT TIP INTRO ELONGATED",SUP-77420,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"AETNA [10100]","Aetna HMO/PPO",,356.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.1,380.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL AEQUALIS ASCEND FLEX +0MM 0MM CENTER OFFSET",SUP-DWF500,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"BLUE CROSS [10001]","Blue Cross PPO",,3951.36,39.2,,3949.44,3949.44,3949.44,"1 through 10",1172.3,8568,"percent of total billed charges",
"LUBIPROSTONE 8 MCG CAPSULE",RX-91534,CDM,,,0637,RC,00254-3028-02,NDC,both,1,UN,25.25,7.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.94,21.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 22CM 8FR LARGE PROXIMAL PIGTAIL CURVE URETERAL",SUP-M001235500,CDM,C2617,HCPCS,0278,RC,,,both,,,1093.50,328.05,"NOVANET [10819]",Novanet,,820.13,75,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 28MMX3.5MM TITANIUM STD CIRCULAR LINEAR",SUP-EEA2835,CDM,S27200284,LOCAL,0272,RC,,,both,,,1978.05,593.41,"MULTIPLAN [10600]",Multiplan,,1681.34,85,,,,,0,230.05,1681.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 5FR .058IN EXTRA BACKUP 4 LEFT CURVE GUIDING",SUP-LA5EBU40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THREAD PROTECTORS - SET OF 5",SUP-105558,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"UHC [10700]","United Healthcare",,220.28,63.3,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TANDEMLIFE KIT- V24/A15",SUP-5840-2415,CDM,S27200284,LOCAL,0272,RC,,,both,,,71250.00,21375,"NOVANET [10819]",Novanet,,53437.5,75,,,,,0,8286.38,60562.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X12MM ALEUTIAN 7D SMALL PEEK ACDF",SUP-403-21412L,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVOLUTION 10CM 230CM 25MM 30MM COLONIC CONTROLLED",SUP-G48038,CDM,C1876,HCPCS,0278,RC,,,both,,,17854.20,5356.26,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5109.87,28.62,,,,,0,2076.44,15176.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM TSRH OSTEOGRIP TITANIUM SHORT SPINE",SUP-83565558,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.10,1106.73,"BLUE CROSS [10001]","Blue Cross PPO",,1446.13,39.2,,957.42,570.23,957.42,28,429.04,3135.74,"percent of total billed charges",
"CATH ARMADA 35 135MM 20MM 7FR 14MM .035IN LOW PROFILE",SUP-B2140-020,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"AETNA [10100]","Aetna HMO/PPO",,611.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 23MM 3.5MM CORONARY STENT EVEROLIMUS",SUP-1550350-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM OFFSET 32MM HIP MODULAR TYPE 1 SKIRT COCR",SUP-163668,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"MULTIPLAN [10600]",Multiplan,,4123.1,85,,,,,0,564.14,4123.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PACING 37CM BIPOLAR IS-1",SUP-6984M,CDM,C1883,HCPCS,0278,RC,,,both,,,1069.20,320.76,"NOVANET [10819]",Novanet,,801.9,75,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 10FR POLYURETHANE SILICONE TEFLON Y ADPTR ADJUST A",SUP-50-7361,CDM,S27200284,LOCAL,0272,RC,,,both,,,396.39,118.92,"CIGNA [10200]",Cigna,,269.55,68,,,,,0,46.1,336.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE MONORAIL 150CM 100MM 3MM BALLOON DILATATION",SUP-H74939185301010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EMBOTRAP III 5 MM X 22MM",SUP-ET309522,CDM,C1757,HCPCS,0272,RC,,,both,,,40320.00,12096,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4777.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4689.22,34272,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19 DIOPTER +4.5 ADD MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT450U190,CDM,V2632,HCPCS,0276,RC,,,both,,,3712.50,1113.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,431.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP UNISTEP PLUS 90MM 75CM 12MM 8FR 100CM",SUP-H965402130,CDM,C1876,HCPCS,0278,RC,,,both,,,7140.00,2142,"MULTIPLAN [10600]",Multiplan,,6069,85,,,,,0,830.38,6069,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 5FR SIDEWINDER 2 CURVE ANGIOGRAPHIC",SUP-H787107090075,CDM,C1887,HCPCS,0272,RC,,,both,,,190.36,57.11,"MULTIPLAN [10600]",Multiplan,,161.81,85,,,,,0,22.14,161.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC",179,MS-DRG,,,,,,,inpatient,,,31813.55,9544.06,"BLUE CROSS [10001]","Blue Cross HMO",,17332.38,,,,,,,4683.31,18828.95,"case rate",
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.5MM X 8.0MM",SUP-492500812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 110MM 10 HOLE BONE CLAVICLE LEFT SUPERIOR NONSTERILE",SUP-133525110,CDM,C1713,HCPCS,0278,RC,,,both,,,14334.75,4300.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5891.58,41.1,,,,,0,1667.13,12184.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 80CM 5FR CHG-B CURVE",SUP-G13560,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"KAISER [10500]",Kaiser,,159.12,67,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD INTICA 7 DF-1 CONNECTION HF-T QP",SUP-404629,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"UHC [10700]","United Healthcare",,36536.76,63.3,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE SCOPE 10.2X3.7X7CM RECHARGEABLE SMART UNIVERSAL CHRG",SUP-71910,CDM,S27200284,LOCAL,0272,RC,,,both,,,1123.31,336.99,"AETNA [10100]","Aetna HMO/PPO",,893.03,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,130.64,954.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTALINK 135CM 1.5MM ATHERECTOMY BURR EXCHANGE",SUP-H749393001500,CDM,C1724,HCPCS,0272,RC,,,both,,,13282.50,3984.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASKET SPECIMEN RETRIEVAL 90CM 3FR 13MM STONE FLATWIRE 0 TIP",SUP-039790,CDM,S27200284,LOCAL,0272,RC,,,both,,,1016.51,304.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SENSOR DUAL-FLEX UROLOGICAL 10CM 150CM 3CM .035IN",SUP-M0066703011,CDM,C1769,HCPCS,0272,RC,,,both,,,372.19,111.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER GASTROENTERITIS, NAUSEA AND VOMITING,MAJOR",249,APR-DRG,,,,,,,inpatient,,,36996.78,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $7,397.06. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($42,106.08) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,MAJOR",323,APR-DRG,,,,,,,inpatient,,,203452.32,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $19,268.87. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($81,959.53) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 20IN 36FR STRAIGHT",SUP-8888570564,CDM,C1729,HCPCS,0272,RC,,,both,,,88.88,26.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX 035 130CM 40MM 6MM BALLOON DILATATION",SUP-LX351306405F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE CHECKER 130CM 15CM 5MM BALLOON DILATATION",SUP-U8130515,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS STREAMLINE 50MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-M003SFD050500,CDM,C1874,HCPCS,0278,RC,,,both,,,93183.77,27955.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,37273.51,40,,,,,0,10837.27,79206.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL BENTSON 22-30CM 15CM 4.8FR .035IN STRAIGHT",SUP-M006180155060,CDM,C2617,HCPCS,0278,RC,,,both,,,1003.67,301.1,"NOVANET [10819]",Novanet,,752.75,75,,,,,0,116.73,853.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 9IN LAMBOTTE SURGICAL CURVE 1IN",SUP-28-9475,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.68,71.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,97.69,41.1,,,,,0,27.64,202.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC COLD BIOPSY NDL 240CM 2.4FR 2.8MM RADIAL JAW",SUP-M00513331,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.37,38.51,"PHCS [10601]",PHCS,,89.86,70,,,,,0,14.93,109.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH-PROFILE BOOST, 435CC",SUP-SMHB435,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,903.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX14MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183564,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"CIGNA [10200]","Cigna Open Access",,4460.83,56.9,,5302.19,4377.88,6578.61,27,911.77,6663.81,"percent of total billed charges",
"LEAD ICD 70CM ENDOTAK RELIANCE G ENDOCARDIAL STEROID",SUP-186,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"UHC [10700]","United Healthcare",,9608.94,63.3,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 15D 64MM 32MM MARATHON HIP STERILE",SUP-121932264,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"FIRST HEALTH [10303]","First Health",,6488.76,80,,,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 47.5MM T2 TITANIUM FULL THREAD FEMUR HUMERUS",SUP-1896-5047S,CDM,C1713,HCPCS,0278,RC,,,both,,,1279.15,383.74,"CIGNA [10200]","Cigna Open Access",,727.84,56.9,,1144.80,304.56,2275.09,66,148.77,1087.28,"percent of total billed charges",
"CAGE SPINAL 50X22X4MM COROENT 20D XL PEEK-OPTIMA",SUP-6200450,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"PHCS [10601]",PHCS,,23992.92,70,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CORONARY 15MM 3MM EVEROLIMUS ELUTING COCR XIENCE V 143",SUP-1009541-15,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"CIGNA [10200]","Cigna Open Access",,5457.28,56.9,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM OPHTHALMIC SOLID BLADE CLOSED EYE LIEBERMAN 15MM",SUP-60-2005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1330.91,399.27,"FIRST HEALTH [10303]","First Health",,1064.73,80,,,,,0,154.78,1131.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +14 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.140,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 60MM 6MM BALLOON",SUP-LX181306605F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4574.7,68,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 11MM 8.2MM 75MM TALON PROXIMAL FEMUR DISTALFIX",SUP-SLN-011-075,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"CIGNA [10200]","Cigna Open Access",,2826.79,56.9,,1144.80,304.56,2275.09,66,577.78,4222.8,"percent of total billed charges",
"STEM HUMERAL 70MM 8MM EQUINOXE STERILE",SUP-300-30-08,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"BLUE CROSS [10001]","Blue Cross HMO",,5409.6,39.2,,5311.50,4717.44,5388.59,31,1604.94,11730,"percent of total billed charges",
"RED 43 REPERFUSION CATHETER 138 CM AND PENUMBRA ASPIRATION T",SUP-RED43KIT138,CDM,C1757,HCPCS,0272,RC,,,both,,,17608.50,5282.55,"NOVANET [10819]",Novanet,,13206.38,75,,,,,0,2047.87,14967.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 58MM 32MM ZENITH FLEX Z-TRAK MAIN BODY",SUP-G55216,CDM,C1874,HCPCS,0278,RC,,,both,,,14138.10,4241.43,"MULTIPLAN [10600]",Multiplan,,12017.39,85,,,,,0,1644.26,12017.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 6.5MM EVOLVE +4MM ELBOW PROLINE MODULAR",SUP-496S465,CDM,C1776,HCPCS,0278,RC,,,both,,,14614.20,4384.26,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6006.44,41.1,,6417.48,6417.48,6417.48,"1 through 10",1699.63,12422.07,"percent of total billed charges",
"AMPICILLIN 500 MG CAPSULE",RX-466,CDM,,,0250,RC,00781-2145-01,NDC,both,1,UN,6.27,1.88,"PHCS [10601]",PHCS,,4.39,70,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTDG ANALZR RED HMS PLUS 0-.9MG/KG HEPARIN ASSAY 4 CHANNEL",SUP-304-01POR,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.04,37.81,"FIRST HEALTH [10303]","First Health",,100.83,80,,,,,0,14.66,107.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM OASYS TITANIUM LOW PROFILE SPINE",SUP-48552312,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3292.97,68,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 140MM 12MM 7FR BILIARY VENOUS SELF EXPAND",SUP-G57435,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"NOVANET [10819]",Novanet,,10867.5,75,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 68MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-214.868,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,71.81,28.62,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH ADULT 55CM 15.5FR DURATHANE DURAFLOW EMBOSAFE BASIC",SUP-H787103012115,CDM,C1750,HCPCS,0278,RC,,,both,,,1104.50,331.35,"NOVANET [10819]",Novanet,,828.38,75,,,,,0,128.45,938.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINR ACTB G7 G 36MM E1 HIP HW",SUP-010000937,CDM,C1776,HCPCS,0278,RC,,,both,,,12282.00,3684.6,"CIGNA [10200]","Cigna Local Plus",,3868.83,31.5,,5372.07,4581.20,7242.98,23,1428.4,10439.7,"percent of total billed charges",
"PACEMKR CARDIAC COBALT DR 2 CHMBR DF-1 PIN PLUG RADIOPAQUE",SUP-DDPB3D1,CDM,C1882,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"FIRST HEALTH [10303]","First Health",,46620,80,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Extract Nuc Ag Ea Ab",PX-302000038,CDM,86235,CPT,0302,RC,,,both,,,348.65,104.59,"UHC [10700]","United Healthcare",,16.14,,,,,,,0.35,296.35,"fee schedule",
"CAP HYBRID TOTAL KNEE SYSTEM (EITHER POROUS FEMUR OR TIBIA)",SUP-98000200398,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2762.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2710.95,19813.5,"percent of total billed charges",
"HC Afo Spiral Plastic Pf",PX-E27400079,CDM,L1951,HCPCS,0274,RC,,,both,,,2768.70,830.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1270.83,45.9,,,,,0,322,2353.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PROC 1 TRIATHLON PS DISPOSABLE FEMORAL",SUP-5555-2251,CDM,C1776,HCPCS,0278,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,405.69,28.62,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 100MM 161CM 8MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200081020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 51MM 1.5MM 6 FLUTE STRAIGHT ORAL CARBIDE",SUP-04-C0306,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.21,18.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.24,52.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 1.6MM TPS ELITE 5 STEP NOTCH CROSS CUT FISSURE",SUP-5820-066-016,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"PHCS [10601]",PHCS,,766.47,70,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYSORB SURGITIE 2-0 21IN BRAID LOOP COATED VIOLET",SUP-EL-22-LN,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.68,42.8,"FIRST HEALTH [10303]","First Health",,114.14,80,,,,,0,16.59,121.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 150MM 2300MM 20MM ESOPHAGEAL METAL NITINOL",SUP-ECBA-20-150-230,CDM,C1874,HCPCS,0278,RC,,,both,,,16425.45,4927.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1910.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1910.28,13961.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 28MM 144CM 3.5MM",SUP-H7493941228350,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5278.5,68,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Collect Bld Vad Imp",PX-450000232,CDM,36591,CPT,0260,RC,,,both,,,524.59,157.38,"BLUE CROSS [10001]","Blue Cross PPO",,359.87,68.6,,,,,0,61.01,524.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 4.75IN SNAGFREE SATIN FINISH NDL FINE STERILE",SUP-66355,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.53,17.56,"CIGNA [10200]","Cigna Open Access",,33.3,56.9,,,,,0,6.81,49.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE-USE 600 MICRON LASER",SUP-HLFDBX0600C,CDM,S27200284,LOCAL,0272,RC,,,both,,,2652.88,795.86,"NOVANET [10819]",Novanet,,1989.66,75,,,,,0,308.53,2254.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPTIP 35CM 10FR DRNG FLEXIMA POLYURETHANE HYDROPHILIC",SUP-M001281570,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 32-36MM LAPIPLASTY FULL THREAD SHORT STERILE",SUP-SK37,CDM,C1713,HCPCS,0278,RC,,,both,,,3967.50,1190.25,"NOVANET [10819]",Novanet,,2975.63,75,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL TRITANIUM 0 D L23 MM X W11 MM X H9 MM SOLID TIP",SUP-48951090,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"MULTIPLAN [10600]",Multiplan,,18742.5,85,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SNAPLOC OLYMPUS LOCKING GWIRE",SUP-G59683,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,207.06,68,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL CANNULATED 3 MM SCR",SUP-44112004,CDM,S27200284,LOCAL,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 10CM 5MM BALLOON",SUP-G52261,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AETNA [10100]","Aetna HMO/PPO",,763.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 26CM 3CM 8FR .038IN 2 PIGTAIL",SUP-M006192153010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]","Cigna Open Access",,683.13,,,,,,,139.63,1020.49,"percent of total billed charges",
"BAND ANNULOPLASTY 85MM 43.7MM 35MM DURAN ANCORE 37.7MM 2",SUP-620BG35,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"AETNA [10100]","Aetna HMO/PPO",,10422.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 4.7MM BARD SILICONE 4 FREE FLOW CHANNEL",SUP-072189,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.84,36.85,"CIGNA [10200]","Cigna Local Plus",,65.72,53.5,,,,,0,14.29,104.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD 5MM BIPOLAR IS-1",SUP-6162,CDM,C1883,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA [10200]",Cigna,,1785,68,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Rmvl FB",PX-750000088,CDM,45379,CPT,0750,RC,,,both,,,2212.15,663.64,"UHC [10700]","United Healthcare",,2212.15,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,257.27,2212.15,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (MR) 10MM X 4.00",SUP-H74939401104000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,641.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 100X12-13MM",SUP-400751,CDM,S27800098,LOCAL,0278,RC,,,both,,,4868.64,1460.59,"CIGNA [10200]","Cigna Local Plus",,2604.72,53.5,,,,,0,566.22,4138.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 8MM STAINLESS STEEL T8 CORTEX TUBE STARDRIVE",SUP-201.758TS,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,218.61,45.9,,,,,0,55.39,404.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +1.5MM 12/14 TAPER 36MM HIP SLEEVE TOTAL",SUP-136536710,CDM,C1776,HCPCS,0278,RC,,,both,,,13002.36,3900.71,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3510.64,27,,,,,0,1512.17,11052.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT CRUCIATE RETAIN GENESIS II LEGION",SUP-71421227,CDM,C1776,HCPCS,0278,RC,,,both,,,28831.95,8649.58,"CIGNA [10200]","Cigna Open Access",,9658.7,33.5,,5302.19,4377.88,6578.61,27,3353.16,24507.16,"percent of total billed charges",
"SYSTEM EXOFIN FUSION 60CM SKIN CLSR 2-OCTYL CYANOACRYLATE",SUP-EF70466,CDM,S27200284,LOCAL,0272,RC,,,both,,,769.50,230.85,"CIGNA [10200]","Cigna Local Plus",,411.68,53.5,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE 0.5%-EPI 1:100,000 BUFFERED W/SOD BICARB 8.4% SYRINGE 10 ML",RX-411236,CDM,,,0250,RC,08888-8879-62,NDC,both,10,ML,18.92,5.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.2,16.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SHEATH GUIDE KINK RESISTANT STOPPER BRUSH",SUP-K-401,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"FIRST HEALTH [10303]","First Health",,1440,80,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL ULTRAPRO 12X12IN PARTIAL ABSORBABLE",SUP-UML1,CDM,C1781,HCPCS,0278,RC,,,both,,,1985.63,595.69,"PHCS [10601]",PHCS,,1389.94,70,,,,,0,230.93,1687.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 12MM 2.25MM BALLOON DILATATION PEBAX",SUP-1400225-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFTOUCH 80CM 4FR .041IN .035IN 11MM PIGTAIL CURL",SUP-4408-2M80,CDM,S27200284,LOCAL,0272,RC,,,both,,,518.40,155.52,"NOVANET [10819]",Novanet,,388.8,75,,,,,0,60.29,440.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) AMPLATZ EXTRA STIFF GUIDE WIRE (COOK MEDICAL)",SUP-G03460,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 2-5-2MM SPACE F CURVE",SUP-F6QRF252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,107.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 5FR 28CM WITHOUT GWIRE POLARIS ULTRA",SUP-M0061921240,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"CIGNA [10200]","Cigna Open Access",,646.17,,,,,,,132.07,965.28,"percent of total billed charges",
"BLADE SHAVER BEIGE 3.5MM BONECUTTER FULL RADIUS SHARP",SUP-7210486,CDM,S27200284,LOCAL,0272,RC,,,both,,,691.09,207.33,"CIGNA [10200]","Cigna Open Access",,393.23,56.9,,,,,0,80.37,587.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE REDUCTION 150MM 1.25MM STAINLESS STEEL THREAD TIP SMALL",SUP-02.111.500.01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,384.98,115.49,"CIGNA [10200]",Cigna,,261.79,68,,,,,0,44.77,327.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? BONE SCREW, 3.0MM X 14MM, 2 PACK",SUP-94-30-14-2S,CDM,C1713,HCPCS,0278,RC,,,both,,,1595.70,478.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1085.08,68,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 10MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158106110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AETNA [10100]","Aetna HMO/PPO",,8883.77,79.5,,10981.53,8986.79,12413.38,12,1299.6,9498.37,"percent of total billed charges",
"CANN NASAL COMFORT FLO PLUS MEDIUM",SUP-2412-12,CDM,S27000186,LOCAL,0270,RC,,,both,,,166.39,49.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.35,141.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM 18MM PRESS FIT UNIVERSAL FLUTE KNEE",SUP-867432,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,942.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE TAPER TIP",SUP-02.107.302,CDM,C1713,HCPCS,0278,RC,,,both,,,5840.44,1752.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3971.5,68,,,,,0,679.24,4964.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AMPLATZ 88CM 8FR .038IN GUIDING TEFLON RENAL DIL",SUP-T8.038880NSARD,CDM,C1887,HCPCS,0272,RC,,,both,,,246.99,74.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,101.51,41.1,,,,,0,28.72,209.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 1.3 MM SCREWS 4 HOLE HEAD 8 HOLE SHAFT",SUP-221.334,CDM,C1713,HCPCS,0278,RC,,,both,,,2228.10,668.43,"NOVANET [10819]",Novanet,,1671.08,75,,,,,0,259.13,1893.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINE ANGIOGRAPHY 76.20CM 3.6MM 1.8MM 1200 PSI FEMALE LUER",SUP-H965910513031,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.21,20.46,"CIGNA [10200]",Cigna,,46.38,68,,,,,0,7.93,57.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC",091,MS-DRG,,,,,,,inpatient,,,55863.17,16758.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,34862.33,,"Fee schedule rate ($34,862.33). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,10893.81,43797.87,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pacing Hrt Rhythm",PX-481000052,CDM,93618,CPT,0480,RC,,,both,,,4831.00,1449.3,"KAISER [10500]",Kaiser,,3236.77,67,,,,,0,561.85,4831,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 40MM 75CM 7MM VASCULAR METAL SUPERFICIAL",SUP-H74939293074070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]",Cigna,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 70MM 32MM NCB TITANIUM ALUMINUM VANADIUM",SUP-0203152070,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 13MM RELIANCE HIP FEMUR STERILE",SUP-6259-8-130,CDM,C1776,HCPCS,0278,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,231.82,28.62,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS 90CM 4MM 8FR 2-5-2MM SPACE B CURVE ABLATION 10",SUP-D8BTBL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"AETNA [10100]","Aetna HMO/PPO",,3944.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PARTIAL SHOULDER",SUP-PHC-HEMI,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"NOVANET [10819]",Novanet,,15356.25,75,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DBM FIBER CRUNCH",SUP-FF-10,CDM,C1713,HCPCS,0278,RC,,,both,,,6900.00,2070,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1974.78,28.62,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE AXIOFILL HUMAN PLACENTAL EXTRACELLULAR MATRIX",SUP-PCM-1000,CDM,Q4433,HCPCS,0636,RC,,,both,,,15807.90,4742.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7255.83,45.9,,,,,0,247.92,13436.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM ORTHOLOC FULL THREAD FOOT ANKLE CORTICAL",SUP-58813512,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross HMO",,301.64,39.2,,957.42,156.86,7483.26,51,89.49,654.08,"percent of total billed charges",
"UPCHARGE REVERSED FX STEM",SUP-CAP-T-1058,CDM,C1776,HCPCS,0278,RC,,,both,,,3750.00,1125,"NOVANET [10819]",Novanet,,2812.5,75,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 13.75X4IN ACTICOAT POLYURETHANE NANOCRYSTALLINE",SUP-66800057,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.41,86.22,"CIGNA [10200]",Cigna,,195.44,68,,,,,0,33.43,244.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 59CM ENDOCARDIUM 2 COIL IS-1 CNCT BIPOLAR",SUP-180,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1997.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NUVISION ICE CATHETER,  10F",SUP-FG12080,CDM,C1759,HCPCS,0272,RC,,,both,,,20160.00,6048,"KAISER [10500]",Kaiser,,13507.2,67,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 13MM RESONATE SPINE SELF DRILL VARIBLE ANGLE",SUP-1194.7213,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 90CM 4MM 8FR 2-5-2MM SPACE D CURVE",SUP-D8BTCDL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"UHC [10700]","United Healthcare",,3140.38,63.3,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SECURMARK BIOPSY SITE F USE WITH CELERO 12 2ND SHAP",SUP-SMARK-CELERO-2S,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,79.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 30CM 3CM 5FR .038IN 2",SUP-M006192125170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"FIRST HEALTH [10303]","First Health",,1116.18,80,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +31 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000310,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175262070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"FIRST HEALTH [10303]","First Health",,797.94,80,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 45MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890006045,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"GWIRE ZIPWIRE VASCULAR 180CM 3CM .035IN NITINOL POLYMER",SUP-M00146152B1,CDM,C1769,HCPCS,0272,RC,,,both,,,486.00,145.8,"NOVANET [10819]",Novanet,,364.5,75,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemo Cns",PX-331000006,CDM,96450,CPT,0331,RC,,,both,,,872.12,261.64,"CIGNA [10200]","Cigna Local Plus",,449,,"Per diem ($449).",,,,0,101.43,872.12,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 60MM 100CM 12MM 75CM",SUP-40212,CDM,C1876,HCPCS,0278,RC,,,both,,,6210.00,1863,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,722.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 7CM 5FR 21GA MICROPUNCTURE .18IN HEMOSTASIS VALVE",SUP-G02988,CDM,C1894,HCPCS,0272,RC,,,both,,,394.28,118.28,"PHCS [10601]",PHCS,,276,70,,,,,0,45.85,335.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2MM 18MM FOSSA RADIUS DISTAL VOLAR SMOOTH LOCK",SUP-SPLS-20180-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,639.90,191.97,"KAISER [10500]",Kaiser,,428.73,67,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.816,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CIGNA [10200]","Cigna Open Access",,199.9,56.9,,1144.80,304.56,2275.09,66,40.86,298.61,"percent of total billed charges",
"STENT SOLUS 7CM 210CM 10FR 5FR .035IN 2 PIGTAIL CURVE",SUP-G25673,CDM,C2625,HCPCS,0278,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross HMO",,482.63,39.2,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE STERILE EDGE DISPOSABLE",SUP-E1512,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.38,44.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.14,125.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 115CM 2.2FR 11MM MULTIWIRE BASKET KINK RESISTANT",SUP-G48296,CDM,S27200284,LOCAL,0272,RC,,,both,,,2063.25,618.97,"CIGNA [10200]","Cigna Open Access",,1173.99,56.9,,,,,0,239.96,1753.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 62MM 32MM MARATHON HIP",SUP-121932062,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,857.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,841.39,6149.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ 110CM 6FR .018IN PRESSURE MNTR HEPARIN PVC",SUP-497527,CDM,C1751,HCPCS,0272,RC,,,both,,,350.18,105.05,"UHC [10700]","United Healthcare",,221.66,63.3,,,,,0,40.73,297.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REUNION TSA - PRESS-FIT HUMERAL STEM 8MM",SUP-5569-P-2008,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]",Cigna,,5040,40,,5873.17,5873.17,5873.17,"1 through 10",1465.38,10710,"percent of total billed charges",
"CATHETER 6248V-90L ATTAIN SELECT II",SUP-6248V-90L,CDM,C1887,HCPCS,0272,RC,,,both,,,2272.50,681.75,"KAISER [10500]",Kaiser,,1522.58,67,,,,,0,264.29,1931.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 6.5X50MM MIDLINE SYSTEM POLYAXIAL CORTICAL 4S R",SUP-14616550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM 1.7-2.4FR .017IN",SUP-M003C1775450,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Wrap Polar Pad Universal Xl",PX-E27000184,CDM,E27000184,LOCAL,0270,RC,,,both,,,213.40,64.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 14GA 13CM MAGNUM ULTRA SHARP TIP DISPOSABLE",SUP-MN1413,CDM,S27200284,LOCAL,0272,RC,,,both,,,176.96,53.09,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET BIOPSY 15CM 14GA QUICK-CORE SOFT TISSUE NDL COAXIAL",SUP-G10149,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 100CM 5FR BERN CURVE ANGIOGRAPHIC STAINLESS",SUP-510038BER,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM STAINLESS STEEL CORTEX SELF TAP LOW",SUP-02.206.016,CDM,C1713,HCPCS,0278,RC,,,both,,,321.55,96.46,"FIRST HEALTH [10303]","First Health",,257.24,80,,,,,0,37.4,273.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 4FR 5MM SPACE REGULAR F CURVE",SUP-D4S04FR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"NOVANET [10819]",Novanet,,1738.13,75,,,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITX CATHETER ACCESS KIT",SUP-50-7280A,CDM,C1729,HCPCS,0272,RC,,,both,,,469.80,140.94,"KAISER [10500]",Kaiser,,314.77,67,,,,,0,54.64,399.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE 2CM MIC-KEY",SUP-8270-18-2.0-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 13IN DEAVER 5 SURGICAL 2IN",SUP-SU3305,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.10,61.83,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 250MM 2.8MM QUICK COUPLING STOP CALIBRATED 95MM",SUP-03.113.024,CDM,S27200284,LOCAL,0272,RC,,,both,,,827.82,248.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TORCON NB ADVANTAGE 125CM 5FR BEACON SIMMONS 2 CURVE",SUP-G11517,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRAIN INCS XPR THRX 1 CHMBR 1 TUBE",SUP-17.0091,CDM,S27200284,LOCAL,0272,RC,,,both,,,317.46,95.24,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 70X25.4X.6MM WIDE STAINLESS STEEL SAGITTAL DUAL",SUP-2108100000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PRUITT 24CM 12FR OCCLUSION AORTA STERILE LATEX FREE",SUP-E2100-12,CDM,C2628,HCPCS,0272,RC,,,both,,,4478.10,1343.43,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET",RX-174917,CDM,J0751,HCPCS,0636,RC,61958-2002-01,NDC,both,1,UN,332.99,99.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,39.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.46,283.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 6-0 C-1 18IN 2 ARM BRAID BLACK",SUP-706G,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.79,29.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.26,82.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 STANDARD 13MM X 30CM",SUP-M0035461330,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX10MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183640,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"CIGNA [10200]",Cigna,,5275.46,40,,5873.17,5873.17,5873.17,"1 through 10",1533.84,11210.36,"percent of total billed charges",
"STENT GORE VIABAHN 39MM 135CM 5MM 8MM 7FR .035IN",SUP-BXA053902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"FIRST HEALTH [10303]","First Health",,15603.84,80,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 21MM 3.25MM BALLOON DILATATION PTCA",SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"AETNA [10100]","Aetna HMO/PPO",,785.62,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM EPIC SUPRA THV",SUP-ESP100-27-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,36722.70,11016.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10510.04,28.62,,,,,0,4270.85,31214.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 17MM HELIX R SPINE SELF TAP VARIABLE ANGLE",SUP-7805117,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]",Cigna,,688.5,68,,1831.33,1831.33,1831.33,16,117.75,860.63,"percent of total billed charges",
"CATH DIAMONDBACK 360 145CM 7MM .052IN 1.25MM ATHERECTOMY",SUP-DBP-EX-125SOL145,CDM,C1724,HCPCS,0272,RC,,,both,,,23278.50,6983.55,"MULTIPLAN [10600]",Multiplan,,19786.73,85,,,,,0,2707.29,19786.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.3-12.2CM NATRELLE BIOCELL P4.2-4.5CM MODERATE",SUP-SZ68330,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,139.77,45.9,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER GD 100CM 6FR RWY IM CRV",SUP-H74938969260,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AETNA [10100]","Aetna HMO/PPO",,291.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 7CM 5FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22076,CDM,C2625,HCPCS,0272,RC,,,both,,,631.80,189.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,259.67,41.1,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS",998,MS-DRG,,,,,,,inpatient,,,36599.36,10979.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9745,,,,,,,4182.11,11132.13,"case rate",
"CATH CORDIS SABER 90CM 30MM 10MM BALLOON DILATATION DURALYN",SUP-48010003S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,565.95,41.1,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 75X12X.8MM LONG STAINLESS STEEL RECIPROCATING 2",SUP-0277096325,CDM,S27200284,LOCAL,0272,RC,,,both,,,303.46,91.04,"AETNA [10100]","Aetna HMO/PPO",,241.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.29,257.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 43CM 15FR PALINDROME RT REVERSE TUNNEL 23CM STERILE",SUP-8888541023P,CDM,C1750,HCPCS,0278,RC,,,both,,,2669.19,800.76,"FIRST HEALTH [10303]","First Health",,2135.35,80,,,,,0,310.43,2268.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 10X4IN ANTIMICROBIAL BACK FILM MULTILAYER ABSORBENT",SUP-498450,CDM,S27200284,LOCAL,0272,RC,,,both,,,219.24,65.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.5,186.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 18MM STD SHELL DJO SURGICAL ALTIVATE",SUP-530-18-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"AETNA [10100]","Aetna HMO/PPO",,37758.08,79.5,,10981.53,8986.79,12413.38,12,5523.6,40370.27,"percent of total billed charges",
"GRAFT ENDOVASCULAR 12CM 12MM EXCLUDER GORE CONTRALATERAL LEG",SUP-PLC121200,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8012.8,28.62,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 4MM TRAUMAONE LORENZ TITANIUM MIDFACE SELF",SUP-916104,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,112.05,28.62,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR 30CM 3CM 7FR .035IN 2 FLOPPY PIGTAIL",SUP-M006180235090,CDM,C2617,HCPCS,0278,RC,,,both,,,1294.14,388.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.51,1100.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE DRILL 2.4MM UNIVERSAL NONSTERILE",SUP-323.202,CDM,S27100035,LOCAL,0271,RC,,,both,,,3884.98,1165.49,"MULTIPLAN [10600]",Multiplan,,3302.23,85,,,,,0,451.82,3302.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAFIRE COMFORTGRIP 115CM 4MM 7FR 2-5-2MM SPACE 1MM",SUP-402811,CDM,C1733,HCPCS,0272,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 29MM INTRALUMINAL ENDOSCOPIC LINEAR CUTTER",SUP-ECS29A,CDM,S27200284,LOCAL,0272,RC,,,both,,,6267.91,1880.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,742.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,728.96,5327.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 55MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0320,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"NOVANET [10819]",Novanet,,710.78,75,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 24CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805320,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,106.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMEDY SPECTRUM GV FEMORAL STEM SM",SUP-GVSTSM,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"KAISER [10500]",Kaiser,,12663,67,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT ULNAR 3IN COONRAD/MORREY XS ELBOW RIGHT TIVANIUM",SUP-32810504302,CDM,C1776,HCPCS,0278,RC,,,both,,,31147.20,9344.16,"BLUE CROSS [10001]","Blue Cross PPO",,12209.7,39.2,,3949.44,3949.44,3949.44,"1 through 10",3622.42,26475.12,"percent of total billed charges",
"SIZER IMPL 12.75CM NATRELLE INSPIRA P5.3CM FULL PROFILE",SUP-SSZ-F450,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"KAISER [10500]",Kaiser,,998.57,67,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS LOOP URETERAL",SUP-M0061902330,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X21X10MM COUGAR LS LORDOTIC LATERAL NONSTERILE",SUP-189150810,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6463.8,27,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 23X9X10MM COROENT 12D LARGE PEEK MAS PLIF",SUP-6121023,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6806.16,41.1,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SPECIMEN RETRIEVAL 58CM 5FR GRASPING 4 PRONG",SUP-GF558,CDM,S27000186,LOCAL,0270,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 65MM TI",SUP-MTC-37650-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"CIGNA [10200]","Cigna Local Plus",,667.36,53.5,,3978.14,359.25,3978.14,24,145.07,1060.29,"percent of total billed charges",
"CMPNT FEMORAL 8 KNEE LEFT CEMENTED POSTERIOR STABILIZE",SUP-5515F801,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"MULTIPLAN [10600]",Multiplan,,8500,85,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PREDNISONE 2.5 MG TABLET",RX-6495,CDM,J7512,HCPCS,0636,RC,59651-0485-01,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,0.09,,,,,,,0.03,5.33,"fee schedule",
"CATH ADVANCE PLIAFORM STARCAST 80CM 4CM 5MM BALLOON",SUP-G52338,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"NOVANET [10819]",Novanet,,719.83,75,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 36MM 24MM +2.5 ECCENTRIC GLENOSPHERE TAPER",SUP-AR-9564-2436-INF,CDM,C1776,HCPCS,0278,RC,,,both,,,9763.50,2929.05,"KAISER [10500]",Kaiser,,6541.55,67,,,,,0,1135.5,8298.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 4.75MM PERCUTANEOUS CCM",SUP-641000065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 7MM BALLOON",SUP-U357578,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 15MM MASTERS HP STD MECHANICAL CUFF",SUP-15AHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,60064.20,18019.26,"CIGNA [10200]",Cigna,,24025.68,40,,,,,0,6985.47,51054.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 20MM MONTEREY SPINE LUMBAR ANTERIOR NONSTERILE",SUP-480115020,CDM,S27800098,LOCAL,0278,RC,,,both,,,1620.00,486,"FIRST HEALTH [10303]","First Health",,1296,80,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP OPHTHALMIC 25+ GA GRIESHABER MAXGRIP MICRO TEXTURE",SUP-705.13P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.84,388.75,"AETNA [10100]","Aetna HMO/PPO",,1030.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.71,1101.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 55X3.5MM TITANIUM REGULAR ENDOSCOPIC LINEAR",SUP-017612,CDM,S27200284,LOCAL,0272,RC,,,both,,,1516.48,454.94,"CIGNA [10200]","Cigna Local Plus",,811.32,53.5,,,,,0,176.37,1289.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 4.5MM 7MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.507.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"BLUE CROSS [10001]","Blue Cross PPO",,233.82,39.2,,957.42,570.23,957.42,28,69.37,507.01,"percent of total billed charges",
"DISORDERS OF THE BILIARY TRACT WITH CC",445,MS-DRG,,,,,,,inpatient,,,26490.58,7947.17,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 5.0MM X 22.0MM",SUP-495002212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 8FR 15CM RADIOPAQUE GWIRE STERILE DISPOSABLE",SUP-G00999,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CARTO XP THERMOCOOL SF 7.5FR B-B CURVE",SUP-BNI35BBH,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"BIT DRILL BLUE GOLD 330MM 3.2MM EXPERT 3 FLUTE QUICK",SUP-03.010.060S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1808.10,542.43,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4MM 52MM QUICKFIX TITANIUM T15 SHORT THREAD",SUP-AR-8740-52PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 42CM 12MM DELTAFILL 18",SUP-DLF181242,CDM,S27800098,LOCAL,0278,RC,,,both,,,16974.00,5092.2,"BLUE CROSS [10001]","Blue Cross PPO",,6653.81,39.2,,,,,0,1974.08,14427.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Collagen Cross Links",PX-301000154,CDM,82523,CPT,0301,RC,,,both,,,148.00,44.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.61,,"Fee schedule rate ($19.61). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,125.8,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) OCCLUDER CARDIOVASCULAR 10X22-25MM 28MM 35MM HEMOSTAS",SUP-9-ACP2-010-028,CDM,C1817,HCPCS,0278,RC,,,both,,,96900.00,29070,"MULTIPLAN [10600]",Multiplan,,82365,85,,,,,0,11269.47,82365,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 6MM TITANIUM SPINE CORTEX SELF TAP STARDRIVE",SUP-401.356.99,CDM,C1713,HCPCS,0278,RC,,,both,,,526.50,157.95,"CIGNA [10200]","Cigna Local Plus",,281.68,53.5,,3978.14,359.25,3978.14,24,61.23,447.53,"percent of total billed charges",
"SLEEVE IRRIGATION ELITE 12CM",SUP-5407-010-470,CDM,S27200284,LOCAL,0272,RC,,,both,,,585.74,175.72,"CIGNA [10200]","Cigna Open Access",,333.29,56.9,,,,,0,68.12,497.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 16MM 144CM 2.75MM CORONARY STENT EVEROLIMUS",SUP-H7493926116270,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]",Cigna,,5865,68,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITAZOXANIDE 500 MG TABLET",RX-39254,CDM,,,0637,RC,67546-0111-14,NDC,both,1,UN,657.34,197.2,"CIGNA [10200]","Cigna Open Access",,374.03,56.9,,,,,0,76.45,558.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135MM 30MM 3.8-3.4FR 8MM LOW PROFILE",SUP-39031-80301,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LARGE 116MM TITANIUM 4 HOLE SHAFT 2 COMPRESSION SLOT",SUP-59202030,CDM,C1713,HCPCS,0278,RC,,,both,,,14993.70,4498.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6162.41,41.1,,,,,0,1743.77,12744.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM ATTUNE .75 UNIVERSAL KNEE REVISION",SUP-152303001,CDM,C1776,HCPCS,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Local Plus",,3691.5,53.5,,5372.07,4581.20,7242.98,23,802.47,5865,"percent of total billed charges",
"SHEATH HEARTSPAN 15D FIX CURVE TAPER 60CM 8.5FR GUIDING",SUP-FCL-160-00,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 63CM EPSILA EV SUBSTERNAL QUADRIPOLAR PASSIVE",SUP-EV240163,CDM,C1896,HCPCS,0278,RC,,,both,,,33957.00,10187.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3949.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3949.2,28863.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 60MM SOLERA CD HORIZON OSTEOGRIP TITANIUM",SUP-54840005560,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,1144.80,304.56,2275.09,66,441.36,3225.75,"percent of total billed charges",
"PROS OSSICULAR 2X2.5MM APPLEBAUM INCUS HA PARTIAL CANNULATED",SUP-140970,CDM,L8613,HCPCS,0278,RC,,,both,,,2680.88,804.26,"CIGNA [10200]","Cigna Local Plus",,1434.27,53.5,,,,,0,232.31,2278.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 17CM 3MM BALLOON DILATATION OTW LOW",SUP-G30945,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SNIPER 150CM 2.2-2.9FR 6- MM .02IN 900- PSI BALLOON",SUP-SBC0629-STR-150,CDM,C2628,HCPCS,0272,RC,,,both,,,33295.50,9988.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATHETER GUIDING NONSTERILE LATEX FREE 50 USES",SUP-490207,CDM,S27000186,LOCAL,0270,RC,,,both,,,348.00,104.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PUNCH SHORT HANDLE 4MM HANCOCK AORTIC",SUP-APU440,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PIN FIXATION 9IN 3/16IN STEINMANN SHORT THREAD 1 END TROCAR",SUP-161718000,CDM,S27000186,LOCAL,0270,RC,,,both,,,777.60,233.28,"FIRST HEALTH [10303]","First Health",,622.08,80,,,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 21MM MODULAR RESTORATION BOWED CONICAL",SUP-6276-7-221,CDM,C1776,HCPCS,0278,RC,,,both,,,11695.32,3508.6,"CIGNA [10200]","Cigna Open Access",,3917.93,33.5,,5302.19,4377.88,6578.61,27,1360.17,9941.02,"percent of total billed charges",
"RAIL EXTERNAL FIXATION TRUELOK KIT ROCKER NONSTERILE LATEX",SUP-56-24000,CDM,C1713,HCPCS,0278,RC,,,both,,,8264.20,2479.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3793.27,45.9,,,,,0,961.13,7024.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 25CM 120CM 8MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR082502A,CDM,C1874,HCPCS,0278,RC,,,both,,,40635.00,12190.5,"CIGNA [10200]","Cigna Open Access",,13612.73,33.5,,,,,0,4725.85,34539.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC MEDIUM 15X8.5IN SHOULDER FRONT REAR STRAP",SUP-VP20105-030,CDM,L3670,HCPCS,0274,RC,,,both,,,59.94,17.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,17.15,28.62,,,,,0,6.97,59.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BONE 105MM INTERTAN 105MMX100MM TROCHANTERIC TITANIUM",SUP-7167-7105,CDM,S27200284,LOCAL,0272,RC,,,both,,,6986.94,2096.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,812.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,812.58,5938.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 16MM 43MM SHOULDER AEQUALIS ASCEND FLEX COCR",SUP-DWF043,CDM,C1776,HCPCS,0278,RC,,,both,,,9475.00,2842.5,"MULTIPLAN [10600]",Multiplan,,8053.75,85,,,,,0,1101.94,8053.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL 120D PERFORATE BLADE",SUP-3722087,CDM,S27200284,LOCAL,0272,RC,,,both,,,809.84,242.95,"AETNA [10100]","Aetna HMO/PPO",,643.82,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.18,688.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 36MM 24MM +4MM SHOULDER LATERALIZE",SUP-AR-9564-2436-LAT,CDM,C1776,HCPCS,0278,RC,,,both,,,9763.50,2929.05,"CIGNA [10200]","Cigna Local Plus",,5223.47,53.5,,5372.07,4581.20,7242.98,23,1135.5,8298.98,"percent of total billed charges",
"SCR BONE 3.5MM 18MM VARIAX NONSTERILE",SUP-657418,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"NOVANET [10819]",Novanet,,606.53,75,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC INTERVERTEBRAL 18MM 6MM PRESTIGE LP CERVICAL SPINE",SUP-6972860,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",3297.11,24097.5,"percent of total billed charges",
"DRESSING HYDROCOLLOID AQUACEL AG L25 CM X W9 CM STERILE LATE",SUP-413555,CDM,S27200284,LOCAL,0272,RC,,,both,,,298.10,89.43,"CIGNA [10200]",Cigna,,202.71,68,,,,,0,34.67,253.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 100CM 4FR SIDEWINDER I CURVE ANGIOGRAPHIC NEON",SUP-451430H0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X7-14MM ELSA 20MM",SUP-1122.0045,CDM,S27800098,LOCAL,0278,RC,,,both,,,50400.00,15120,"FIRST HEALTH [10303]","First Health",,40320,80,,,,,0,5861.52,42840,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pth Related Protein",PX-301000256,CDM,83519,CPT,0301,RC,,,both,,,316.61,94.98,"CIGNA [10200]","Cigna Open Access",,40.48,,,,,,,0.01,269.12,"fee schedule",
"SYSTEM XIENCE SIERRA 15MM 3MM CORONARY STENT EVEROLIMUS",SUP-1550300-15,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 54MM TITANIUM 2.4MM SCR 6 HOLE HEAD 3 HOLE SHAFT 2",SUP-04.111.630S,CDM,C1713,HCPCS,0278,RC,,,both,,,4602.30,1380.69,"PHCS [10601]",PHCS,,3221.61,70,,,,,0,535.25,3911.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TIBIAL 18MM INBONE ANKLE PLASMA BASE",SUP-200009902,CDM,C1776,HCPCS,0278,RC,,,both,,,2743.00,822.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,325.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,319.01,2331.55,"percent of total billed charges",
"DEVICE MENISCAL CINCH CURVE SUTURING STERILE DISPOSABLE",SUP-AR-4500,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1030.17,45.9,,,,,0,261.02,1907.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON ENDOSCOPIC MAXFORCE 3CM 2.8MM 8MM 5FR BILIARY",SUP-6742,CDM,C1726,HCPCS,0272,RC,,,both,,,217.50,65.25,"MULTIPLAN [10600]",Multiplan,,184.88,85,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 24FR SILICONE RADIOPAQUE BOLUS ENTERAL FEED INTERNAL",SUP-0110-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,190.32,68,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY NDL 240CM 2.4MM RADIAL JAW 4 LARGE CAPACITY",SUP-M00513334,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.01,24,"UHC [10700]","United Healthcare",,50.65,63.3,,,,,0,9.31,68.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REUNION TSA - CEMENTED HUMERAL STEM 11MM",SUP-5569-C-2011,CDM,C1776,HCPCS,0278,RC,,,both,,,10440.00,3132,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7099.2,68,,,,,0,1214.17,8874,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE",RX-31576,CDM,,,0250,RC,60687-0596-33,NDC,both,1,UN,61.24,18.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.12,52.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 12MM 1.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP1512X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PASSER QUICKPASS SUTURELASSO 90D SMALL TIGHT CURVE 7MM CANN",SUP-AR-6068-90T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SIDE RAIL EXTENSION MARKED",SUP-50237-001ES,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 48MM PERSONA 3.5MM HEX STERILE LATEX FREE",SUP-00590103548,CDM,S27200284,LOCAL,0272,RC,,,both,,,846.86,254.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SPECIMEN RETRIEVAL 2.4MM STONE STENT REM GRASPING SHARP",SUP-FG-53SX-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,4665.71,1399.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GARM COMPRESSION 50-60HZ 25VA SMALL UNIVERSAL CALF VELCRO SC",SUP-DVT5,CDM,S27000186,LOCAL,0270,RC,,,both,,,68.99,20.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FG GATEWAY OTW  US 4.00MM X 15MM",SUP-M0032072215400,CDM,C1725,HCPCS,0272,RC,,,both,,,9423.88,2827.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3873.21,41.1,,,,,0,1096,8010.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 21MM +20MM HIP MODULAR REVISION BOLT",SUP-6276-1-221,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"KAISER [10500]",Kaiser,,9692.77,67,,,,,0,1682.49,12296.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR FR4 CURVE ANGIOGRAPHIC VENTRICULAR 2",SUP-H74916599022,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"KAISER [10500]",Kaiser,,51.31,67,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM ORTHOLOC LONG CORTICAL ANKLE FOOT 3DI",SUP-58803530,CDM,C1713,HCPCS,0278,RC,,,both,,,1506.60,451.98,"PHCS [10601]",PHCS,,1054.62,70,,,,,0,175.22,1280.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aspergillus Ab",PX-302000096,CDM,86606,CPT,0302,RC,,,both,,,257.45,77.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,218.83,"per diem",
"CATH IMPULSE 110CM 6FR 145D PIGTAIL CURVE ANGIOGRAPHIC",SUP-H74916599410,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,35.15,45.9,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PROTECTIVE STAINLESS STEEL HOFFMANN XPRESS BLUNT TIP",SUP-5027-1-050,CDM,S27000186,LOCAL,0270,RC,,,both,,,339.82,101.95,"CIGNA [10200]","Cigna Local Plus",,181.8,53.5,,,,,0,39.52,288.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VERSACROSS VASCULAR 1 CURVE 93CM 180CM 24MM",SUP-VXAK0045,CDM,S27200284,LOCAL,0272,RC,,,both,,,6969.00,2090.7,"AETNA [10100]","Aetna HMO/PPO",,5540.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,810.49,5923.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 6.5MM HIGH VOLUME LOW PRESSURE TAPER CUFF",SUP-HUD512613,CDM,S27200284,LOCAL,0272,RC,,,both,,,391.60,117.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,266.29,68,,,,,0,45.54,332.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 1.5MM TARGET NANO 360D DETACHABLE",SUP-M0035421530,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FLUENCY PLUS PUZZLE 40MM 80CM 7MM 8FR TRACHEOBRONCHIAL",SUP-FTM07040,CDM,C1874,HCPCS,0278,RC,,,both,,,15014.40,4504.32,"KAISER [10500]",Kaiser,,10059.65,67,,,,,0,1746.17,12762.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 25MM 2.25MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP22525X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,233.04,41.1,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 52MM 32MM XLPE HIP",SUP-71337652,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"CIGNA [10200]",Cigna,,7565.85,68,,5873.17,5873.17,5873.17,"1 through 10",1293.98,9457.31,"percent of total billed charges",
"GRAFT VASCULAR 50CM 26MM 12/10/8/8MM HEMASHIELD PLATINUM",SUP-M00202175726AP0,CDM,L8670,HCPCS,0278,RC,,,both,,,12385.91,3715.77,"PHCS [10601]",PHCS,,8670.14,70,,,,,0,427.53,10528.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE ULTIMA 10-0 CS160-6 CTC-6 4IN 2 ARM MONOFILAMENT",SUP-9090G,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.32,85.6,"NOVANET [10819]",Novanet,,213.99,75,,,,,0,33.18,242.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tte 2d Fu/Ltd",PX-483000006,CDM,93308,CPT,0483,RC,,,both,,,1015.18,304.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,189.48,,"Fee schedule rate ($189.48).",,,,0,118.07,862.9,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 6MM APTUS TRILOCK TITANIUM PHALANGEAL HAND",SUP-A-5250.06/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1096.09,68,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +12.5 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.125,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 40MM 28MM D VIVACIT-E LUMEN STERILE LATEX FREE",SUP-110031010,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1227.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1204.51,8803.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 2MM 9MM LCP STAINLESS STEEL CORTICAL SELF TAPPING",SUP-201.359.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,49.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",48.16,352,"percent of total billed charges",
"CUTTER ENDOSCOPIC AGGRESSIVE SMALL JOINT STERILE 2.5MM",SUP-0275628000,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"MULTIPLAN [10600]",Multiplan,,273.62,85,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 75CM KIT STIFF QUICKSITE LEFT HEART TAPER 15CM",SUP-4078S/75/15,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"MULTIPLAN [10600]",Multiplan,,488.84,85,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revise Hepatic Shunt (Tips)",PX-361000130,CDM,37183,CPT,0361,RC,,,both,,,33723.54,10117.06,"BLUE CROSS [10001]","Blue Cross HMO",,7166.56,,"Case rate ($7,166.56). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3922.05,28665.01,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revise Hepatic Shunt (Tips)",PX-361000130,CDM,37183,CPT,0361,RC,,,both,,,33723.54,10117.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5284,,"Case rate ($5,284). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3922.05,28665.01,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revise Hepatic Shunt (Tips)",PX-361000130,CDM,37183,CPT,0361,RC,,,both,,,33723.54,10117.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3996.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3922.05,28665.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Collar Cerv Unv Contr",PX-E27400067,CDM,L0120,HCPCS,0274,RC,,,both,,,34.10,10.23,"CIGNA [10200]",Cigna,,23.19,68,,,,,0,3.97,28.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mpi Spect Sngl",PX-341000026,CDM,78451,CPT,0341,RC,,,both,,,5294.69,1588.41,"CIGNA [10200]",Cigna,,548.09,,,,,,,391.88,4500.49,"fee schedule",
"HYOSCYAMINE 0.125 MG DISINTEGRATING TABLET",RX-29822,CDM,,,0637,RC,42192-0338-01,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 43MM JNOTCH STOP TWIST 5MM 1.1MM",SUP-72-2011,CDM,S27200284,LOCAL,0272,RC,,,both,,,1755.00,526.5,"CIGNA [10200]","Cigna Open Access",,998.6,56.9,,,,,0,204.11,1491.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CAPSURE STRAIGHT 37CM FIXATION STAINLESS STEEL PEEK",SUP-0113230,CDM,S27200284,LOCAL,0272,RC,,,both,,,2100.00,630,"UHC [10700]","United Healthcare",,1329.3,63.3,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 3.6MM RAD55 CURVE 30K",SUP-1883655BRC,CDM,S27200284,LOCAL,0272,RC,,,both,,,3898.50,1169.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,461.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,453.4,3313.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD PLEXA PROMRI S 75",SUP-402267,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7057.69,41.1,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dhea Sulfate",PX-301000175,CDM,82627,CPT,0301,RC,,,both,,,244.40,73.32,"UHC [10700]","United Healthcare",,20.01,,,,,,,0.01,207.74,"fee schedule",
"BINDER ABDOMINAL 10IN LARGE",SUP-U2-710,CDM,S27000186,LOCAL,0270,RC,,,both,,,208.80,62.64,"CIGNA [10200]",Cigna,,141.98,68,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SYRINGE 1ML 2ML TRAUMA TRAUMACEM V+",SUP-03.702.150S,CDM,S27200284,LOCAL,0272,RC,,,both,,,821.02,246.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,97.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,95.48,697.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION",RX-34814,CDM,,,0250,RC,24208-0631-10,NDC,both,10,ML,633.28,189.98,"CIGNA [10200]","Cigna Open Access",,360.34,56.9,,,,,0,73.65,538.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL STRAIGHT SPAT 11IN VALLEYLAB STERILE",SUP-E3780-28,CDM,S27200284,LOCAL,0272,RC,,,both,,,163.73,49.12,"CIGNA [10200]","Cigna Local Plus",,87.6,53.5,,,,,0,19.04,139.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLF TORIC AUTONOME",SUP-CNA0T4,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"NOVANET [10819]",Novanet,,277.5,75,,,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (6-6.5 MCI)",RX-411881,CDM,A9520,HCPCS,0343,RC,08888-8876-15,NDC,both,1,UN,4614.97,1384.49,"BLUE CROSS [10001]","Blue Cross PPO",,4614.97,,,,,,,536.72,4614.97,"fee schedule",
"KIT CATH UROMAX ULTRA QUADRA-FOLD ENCORE HIGH PRESSURE KINK",SUP-M0062251240,CDM,C1726,HCPCS,0272,RC,,,both,,,1904.70,571.41,"PHCS [10601]",PHCS,,1333.29,70,,,,,0,221.52,1619,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE CASCADIA SPINE MODULAR NONSTERILE INTERBODY SYSTEM",SUP-7901-1S12,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,743.58,45.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN STERILE WATER INTRAVENOUS SOLN",RX-181766,CDM,J1806,HCPCS,0636,RC,44567-0811-10,NDC,both,250,ML,721.81,216.54,"FIRST HEALTH [10303]","First Health",,577.45,80,,,,,0,85.53,613.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN STERILE WATER INTRAVENOUS SOLN",RX-181766,CDM,J1806,HCPCS,0636,RC,44567-0811-10,NDC,both,250,ML,721.81,216.54,"KAISER [10500]",Kaiser,,483.61,67,,,,,0,85.53,613.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 3CM 18FR SILICONE MIC-KEY SECUR-LOK",SUP-0230-18-3.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"KAISER [10500]",Kaiser,,966.71,67,,,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, OFFSET HUMERAL HEAD, 42X16",SUP-520-42-316,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4171.76,45.9,,,,,0,1057.03,7725.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ VASCULAR STRAIGHT 260CM .035IN STAINLESS STEEL",SUP-G03562,CDM,C1769,HCPCS,0272,RC,,,both,,,247.86,74.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,101.87,41.1,,,,,0,28.83,210.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X6MM DIVERGENCE 12MM LORDOTIC NUCLEUS PULPOSUS",SUP-G6626526,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"PHCS [10601]",PHCS,,8694,70,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 80CM 4FR .042IN .038IN PIGTAIL FLUSH",SUP-7749-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.75,58.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,80.45,41.1,,,,,0,22.77,166.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL BIOVER LARGE VEIN 2 POLYCARBONATE STERILE","SUP-GEM TKLV-2",CDM,S27200284,LOCAL,0272,RC,,,both,,,616.41,184.92,"FIRST HEALTH [10303]","First Health",,493.13,80,,,,,0,71.69,523.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 8.5FR 18GA 16CM .032IN 4 LUMEN INDWELL GWIRE NDL",SUP-CDC-42854-XP1A,CDM,C1751,HCPCS,0272,RC,,,both,,,1229.58,368.87,"KAISER [10500]",Kaiser,,823.82,67,,,,,0,143,1045.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PRESET 40MM 52MM 5MM THROMBECTOMY CLOSED RING HELICAL",SUP-PRE-5-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,34650.00,10395,"CIGNA [10200]","Cigna Open Access",,19715.85,56.9,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175272090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"CIGNA [10200]","Cigna Local Plus",,711.69,,,,,,,154.71,1130.72,"percent of total billed charges",
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 10.5",SUP-DIB00U0105,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED II 100CM 6CM 8FR 20MM .035IN BALLOON DILATATION",SUP-611759,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"KAISER [10500]",Kaiser,,3563.09,67,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Mark Thor for Rt Perq",PX-361000452,CDM,32553,CPT,0360,RC,,,both,,,8006.06,2401.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4031,,"Case rate ($4,031). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,8.01,6805.15,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL FIBRA STEALTH 6MM VASCULAR .5 FORCE SPRING",SUP-A1652,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]","Cigna Local Plus",,121.02,53.5,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 14MM SKYLINE TITANIUM SPINE SELF DRILL VARIABLE",SUP-186850014,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 50MM DCP LC-DCP STAINLESS STEEL FULL THREAD",SUP-206.050,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"KAISER [10500]",Kaiser,,183.33,67,,,,,0,31.82,232.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X8MM COALITION AGX 7D 8MM NONSTERILE LATEX",SUP-3128.1278,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.5 X 14MM POLYAXIAL SCREW",SUP-32535-014,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PHCS [10601]",PHCS,,2940,70,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK",RX-155785,CDM,J1953,HCPCS,0636,RC,43598-0635-52,NDC,both,100,ML,139.64,41.89,"BLUE CROSS [10001]","Blue Cross PPO",,2.33,,,,,,,2.33,118.69,"fee schedule",
"GWIRE AMPLATZ STIFF VASCULAR 145CM 8CM .035IN STAINLESS",SUP-THSF-35-145-ASG,CDM,C1769,HCPCS,0272,RC,,,both,,,347.91,104.37,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dgtz Gls Mcrscp Pth Cslt Ea",PX-312000075,CDM,0842T,CPT,0312,RC,,,both,,,104.00,31.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VASCUTRAK 140CM 8CM 5MM 6FR BALLOON DILATATION",SUP-V185080,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RAMIPRIL 2.5 MG CAPSULE",RX-11260,CDM,,,0637,RC,65862-0475-01,NDC,both,1,UN,9.09,2.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY PROC 10CM TRU-CLOSE THORACIC VENT STERILE 13FR",SUP-TV13-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.00,513,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Progr Dev Eval Icd Subq Lead",PX-481000106,CDM,93260,CPT,0480,RC,,,both,,,438.70,131.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AXS VECTA 074  INTERMEDIATE CATHETER (132CM)",SUP-INC-11597-132,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"HC Dressing Wound Prisma",PX-E27200118,CDM,E27200118,LOCAL,0272,RC,,,both,,,94.57,28.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MONOCRYL MULTIPASS 3-0 PS-1 27IN MONOFILAMENT UNDYED",SUP-Y936H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET .195IN 81IN REGULATE CLAMP CATH ADPTR TUBE DRIP CHMBR",SUP-2C4040,CDM,S27200284,LOCAL,0272,RC,,,both,,,71.71,21.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 3.5MM 16MM VERTEX MAX TITANIUM SPINE MULTIAXIAL",SUP-6958716,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2856,68,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dihydrotestosterone (Dht)",PX-301000572,CDM,82642,CPT,0301,RC,,,both,,,71.50,21.45,"CIGNA [10200]","Cigna Open Access",,64.42,,,,,,,0.01,64.42,"fee schedule",
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 12MM 1.25MM",SUP-SPL12512X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"KAISER [10500]",Kaiser,,352.76,67,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL TRIATHLON X3 2 H10 MM KNEE POSTERIOR STABILIZE",SUP-5532-G-210-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1327.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DEMINERALIZED BONE MATRIX 1ML PUTTY STERILE",SUP-038010,CDM,C1713,HCPCS,0278,RC,,,both,,,1160.90,348.27,"BLUE CROSS [10001]","Blue Cross HMO",,455.07,39.2,,957.42,156.86,7483.26,51,135.01,986.77,"percent of total billed charges",
"PYRAZINAMIDE 100 MG/ML ORAL SUSPENSION",RX-408887,CDM,,,0637,RC,08888-8884-04,NDC,both,30,ML,238.33,71.5,"CIGNA [10200]",Cigna,,162.06,68,,,,,0,27.72,202.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS LIFECARE 5% DEXTROSE QUAD PACK 100ML LATEX",SUP-07923-37,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"AETNA [10100]","Aetna HMO/PPO",,64.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Prisma",PX-E27200118,CDM,E27200118,LOCAL,0272,RC,,,both,,,94.57,28.37,"FIRST HEALTH [10303]","First Health",,75.66,80,,,,,0,11,80.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Prisma",PX-E27200118,CDM,E27200118,LOCAL,0272,RC,,,both,,,94.57,28.37,"CIGNA [10200]","Cigna Local Plus",,50.59,53.5,,,,,0,11,80.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 3CM 75CM 8-9-10MM PULMONARY BALLOON",SUP-M00550330,CDM,C1726,HCPCS,0272,RC,,,both,,,2278.65,683.59,"MULTIPLAN [10600]",Multiplan,,1936.85,85,,,,,0,265.01,1936.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 30CM 10IN CHECK-FLO FLEXOR LARGE VALVE ASSEMB",SUP-G13032,CDM,C1894,HCPCS,0272,RC,,,both,,,476.85,143.05,"MULTIPLAN [10600]",Multiplan,,405.32,85,,,,,0,55.46,405.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 59MM 80CM 8MM 16SQ MM 8FR .035IN",SUP-BXAL085901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2311.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOCYCLINE 50 MG CAPSULE",RX-5111,CDM,,,0637,RC,00591-5694-01,NDC,both,1,UN,8.55,2.56,"CIGNA [10200]","Cigna Local Plus",,4.57,53.5,,,,,0,0.99,7.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERTAPE TIGERWIRE 2 TAPER 7INX2MM BRAID BLACK WHITE",SUP-AR-7237-7T,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 600-720ML TEXTURED LOW POLE PLUS LATERAL EXT FULL",SUP-LPP-FH15,CDM,C1789,HCPCS,0278,RC,,,both,,,8349.00,2504.7,"MULTIPLAN [10600]",Multiplan,,7096.65,85,,,,,0,970.99,7096.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM SKYLINE TITANIUM 20- D SPINE SELF DRILL",SUP-186850016,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PROC VENACURE EVLT NEVERTOUCH DIRECT NDL SMA 905 CNCT 1",SUP-11403101,CDM,C1888,HCPCS,0272,RC,,,both,,,4532.61,1359.78,"AETNA [10100]","Aetna HMO/PPO",,3603.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,527.14,3852.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17CM 7MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140717,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]",Cigna,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 83MM 12MM COMPREHENSIVE POROUS MINI SHOULDER",SUP-113632,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UHC [10700]","United Healthcare",,7975.8,63.3,,8601.07,8395.67,8601.07,"1 through 10",1465.38,10710,"percent of total billed charges",
"XPNDR TISS",SUP-3611-ES74-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,12558.00,3767.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 150MM 5MM BALLOON DILATATION RAPID",SUP-47550150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT PRESSURE MNTR TRNSDUC 1 WAY 3 WAY STPCOCK ROTATING MALE",SUP-K11-00392A,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.22,27.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 6-0 BV 30IN 2 ARM MONOFILAMENT BLUE",SUP-8776H,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.68,53.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BETHANECHOL CHLORIDE 10 MG TABLET",RX-1043,CDM,,,0637,RC,00832-0511-89,NDC,both,1,UN,10.07,3.02,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SERFAS ENERGY,HOOK3.5MM SOFT TISSUE ABLATOR SOFT TISSUE ABL",SUP-0279350501,CDM,S27200284,LOCAL,0272,RC,,,both,,,939.60,281.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"APPL BAND RAPIDPORT EZ ACCESS PORT ADJUSTABLE LAP-BAND AP",SUP-C-20390,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LASER ABLATION SYSTEM 15MM VISUALASE VCLAS 1.85MM CATH",SUP-9735561,CDM,S27200284,LOCAL,0272,RC,,,both,,,62700.00,18810,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"STENT ZILVER 518 30MM 125CM 5MM 5FR SLOT BILIARY NITINOL OTW",SUP-G31351,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,495.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 85MM STAINLESS STEEL LARGE FRAGMENT SET 4 HOLE ANGLED",SUP-240.44,CDM,C1713,HCPCS,0278,RC,,,both,,,9574.16,2872.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6510.43,68,,,,,0,1113.47,8138.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE CARDIOFORM SEPTAL OCCLUDER 30MM 10FR",SUP-00733132631032,CDM,C1817,HCPCS,0278,RC,,,both,,,60826.50,18247.95,"MULTIPLAN [10600]",Multiplan,,51702.53,85,,,,,0,7074.12,51702.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 100D TUBULAR 73X9.2X1.3MM TIMAX 3.5MM SCR SMALL",SUP-143556,CDM,C1713,HCPCS,0278,RC,,,both,,,1154.25,346.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,136.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",134.24,981.11,"percent of total billed charges",
"CATH EMERGE MONORAIL 144CM 12MM 6FR 2MM .07IN BALLOON",SUP-H7493918912200,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"FIRST HEALTH [10303]","First Health",,453.6,80,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 15MM 7FR 3 ELECTROPHYSIOLOGY 20 POLE DEFLECTABLE CARTO",SUP-D7L2015CT,CDM,C1731,HCPCS,0272,RC,,,both,,,10950.30,3285.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1297.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1273.52,9307.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTITORQUE 110CM 6FR 3.5MM JACKY RADIAL CURVE",SUP-40-6023,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"CIGNA [10200]","Cigna Local Plus",,167.56,53.5,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GA-68-GOZETOTIDE INTRAVENOUS SOLUTION (5 MCI)",RX-411540,CDM,A9596,HCPCS,0343,RC,08888-8878-71,NDC,both,1,UN,24796.80,7439.04,"UHC [10700]","United Healthcare",,4665.55,,,,,,,1181,21077.28,"fee schedule",
"HC Cors&Graft Angio W Lt Hrt Cath",PX-481000027,CDM,93459,CPT,0481,RC,,,both,,,20792.02,6237.61,"MULTIPLAN [10600]",Multiplan,,17673.22,85,,,,,0,1566.32,17673.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 BV 30IN 2 ARM MONOFILAMENT BLUE",SUP-8776H,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.68,53.3,"FIRST HEALTH [10303]","First Health",,142.14,80,,,,,0,20.66,151.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 11CMX12MM OSTEOTOM CUP NONSTERILE DISPOSABLE",SUP-SBLDCUP-2-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"FIRST HEALTH [10303]","First Health",,1166.4,80,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT AIRGUARD CHRONOFLEX",SUP-1708060,CDM,C1788,HCPCS,0278,RC,,,both,,,1905.00,571.5,"CIGNA [10200]","Cigna Local Plus",,1019.18,53.5,,,,,0,221.55,1619.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +7.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.075,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 18 25 X 50 COMPLEX FRAMING COIL",SUP-18CFR-25050,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"NOVANET [10819]",Novanet,,9806.63,75,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 163MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 12",SUP-223.621,CDM,C1713,HCPCS,0278,RC,,,both,,,2423.40,727.02,"MULTIPLAN [10600]",Multiplan,,2059.89,85,,,,,0,281.84,2059.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 15CM 5MM BALLOON DILATATION",SUP-U8150515,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 12MM SEPTAL SELF EXPANDING DELIVERY",SUP-9-ASD-012,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"BLUE CROSS [10001]","Blue Cross HMO",,8330.31,39.2,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 16MM 8MM STD WALL THIN WALL 2 BRANCH",SUP-SBT1601D,CDM,C1768,HCPCS,0278,RC,,,both,,,6893.10,2067.93,"FIRST HEALTH [10303]","First Health",,5514.48,80,,,,,0,801.67,5859.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 160MM 4.75MM STRAIGHT PERCUTANEOUS CCM PLUS",SUP-1476006160,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"HC Sol Dialysate 106.5meq/Cl 100meq/Na 4meq",PX-E25000002,CDM,E25000002,LOCAL,0250,RC,,,both,,,56.45,16.93,"FIRST HEALTH [10303]","First Health",,45.16,80,,,,,0,6.57,47.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Transducer IV Transpac",PX-E27200186,CDM,E27200186,LOCAL,0272,RC,,,both,,,147.40,44.22,"AETNA [10100]","Aetna HMO/PPO",,117.18,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.14,125.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 4CM 4MM BALLOON DILATATION",SUP-U815044,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PIN DRILL 1/8IN VANGUARD QUICK RELEASE STERILE",SUP-32486265,CDM,S27200284,LOCAL,0272,RC,,,both,,,464.94,139.48,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SINGLE USE INSTRUMENTS - FEMORAL KIT (PS) - SIZE 6",SUP-5555-2256,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BLAZER DX-20 100CM 7FR 2-8-2-60MM SPACE SUPER LARGE",SUP-M00420SL28600,CDM,C1731,HCPCS,0272,RC,,,both,,,11557.50,3467.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO GWIRE 10CM 4FR 21GA MERIT S-MAK .018IN STAINLESS STEEL",SUP-S-MAK401,CDM,C1894,HCPCS,0272,RC,,,both,,,295.80,88.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEEDLE PROCEDURE STAINLESS STEEL ADULT BRK1 CURVE L98 CM OD1",SUP-407207,CDM,S27200284,LOCAL,0272,RC,,,both,,,1547.10,464.13,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MATRIX TISSUE 21.5X10.7CM ALLODERM SELECT THK2-2.8MM CONTOUR",SUP-CL1519P,CDM,Q4116,HCPCS,0636,RC,,,both,,,31380.30,9414.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SCR BONE 4MM 16MM SKYLINE TITANIUM 20- D SPINE SELF DRILL",SUP-186850016,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,396.9,39.2,,957.42,570.23,957.42,28,117.75,860.63,"percent of total billed charges",
"SPACER ALLOGRAFT 30X10MM LUMINARY 10-11MM SPINE",SUP-14710,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3732.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIFLUFOLASTAT F-18 IV SYRINGE (11-12 MCI)",RX-411828,CDM,A9595,HCPCS,0343,RC,08888-8877-82,NDC,both,1,UN,16868.88,5060.66,"NOVANET [10819]",Novanet,,12651.66,75,,,,,0,696,14338.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 150MM 3MM BALLOON DILATATION",SUP-H74939147301510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESALAMINE 1,000 MG RECTAL SUPPOSITORY",RX-40369,CDM,,,0637,RC,16714-0245-30,NDC,both,1,UN,141.37,42.41,"FIRST HEALTH [10303]","First Health",,113.1,80,,,,,0,16.44,120.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemodialysis I/P 1 Eval",PX-801000004,CDM,90935,CPT,0801,RC,,,both,,,2636.00,790.8,"MULTIPLAN [10600]",Multiplan,,2240.6,85,,,,,0,58.62,2240.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC F2 Gene",PX-309000025,CDM,81240,CPT,0310,RC,,,both,,,867.00,260.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,736.95,"per diem",
"SCR BONE 4.5MM 8MM 14MM STAINLESS STEEL STD CORTEX LARGE",SUP-214.014,CDM,C1713,HCPCS,0278,RC,,,both,,,464.78,139.43,"BLUE CROSS [10001]","Blue Cross PPO",,182.19,39.2,,957.42,570.23,957.42,28,54.05,395.06,"percent of total billed charges",
"OVRTB ENDOSCOPIC 1320MM 13.2MM 11MM 1 BALLOON ENTEROSCOPE",SUP-ST-SB1,CDM,S27000186,LOCAL,0270,RC,,,both,,,1952.03,585.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,895.98,45.9,,,,,0,227.02,1659.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET THROMBECTOMY 145CM 3-4FR 1.5MM ANGIOJET ULTRA SOLENT",SUP-111303-001,CDM,C1757,HCPCS,0272,RC,,,both,,,27058.50,8117.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,18399.78,68,,,,,0,3146.9,22999.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 63MM STAINLESS STEEL MINI FRAGMENT SET .25 TUBULAR 8",SUP-242.08,CDM,C1713,HCPCS,0278,RC,,,both,,,1158.95,347.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,531.96,45.9,,,,,0,134.79,985.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 3 STD KNEE LEFT KEEL NONPOROUS",SUP-ETPKN3SL,CDM,C1776,HCPCS,0278,RC,,,both,,,11060.70,3318.21,"BLUE CROSS [10001]","Blue Cross PPO",,4335.79,39.2,,3949.44,3949.44,3949.44,"1 through 10",1286.36,9401.6,"percent of total billed charges",
"DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN",RX-163725,CDM,,,0250,RC,00942-0641-04,NDC,both,1000,ML,100.65,30.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS HONOR METAL GWIRE INSRT TOOL",SUP-MAP301,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.19,61.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,23.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.98,175.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER DX-20 100CM 7FR 2-8-2-60MM SPACE SUPER LARGE",SUP-M00420SL28600,CDM,C1731,HCPCS,0272,RC,,,both,,,11557.50,3467.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1369.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1344.14,9823.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 85X25X1.19MM WIDE THICK STAINLESS STEEL SAGITTAL",SUP-2108151000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.28,162.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 59CM ENDOTAK RELIANCE 4-SITE ENDOCARDIUM GORE",SUP-285,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]",Cigna,,6072,40,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FIBERTAG FIXATION ACL RIGHT DISPOSABLE",SUP-AR-1588RTT,CDM,C1713,HCPCS,0278,RC,,,both,,,3803.63,1141.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,450.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,442.36,3233.09,"percent of total billed charges",
"PACKING COILS XL 55CM",SUP-RBYPCXL55,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7534.8,40,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADDITIONAL LEVEL ACCESS INSTRUMENTS BOX OF 5","SUP-RLV AKA05",CDM,S27200284,LOCAL,0272,RC,,,both,,,4588.50,1376.55,"NOVANET [10819]",Novanet,,3441.38,75,,,,,0,533.64,3900.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 80MM 2.5MM BALLOON",SUP-H74939147258010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 5-0 RB-1 30IN 2 ARM MONOFILAMENT VIOLET",SUP-Z320H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.00,19.8,"AETNA [10100]","Aetna HMO/PPO",,52.47,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.68,56.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM CLAW CHARLOTTE STAINLESS STEEL LOCK",SUP-40122718,CDM,C1713,HCPCS,0278,RC,,,both,,,1344.60,403.38,"PHCS [10601]",PHCS,,941.22,70,,,,,0,156.38,1142.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FIBERTAG FIXATION ACL RIGHT DISPOSABLE",SUP-AR-1588RTT,CDM,C1713,HCPCS,0278,RC,,,both,,,3803.63,1141.09,"CIGNA [10200]",Cigna,,2586.47,68,,1831.33,1831.33,1831.33,16,442.36,3233.09,"percent of total billed charges",
"GRAFT BONE ALLOQUENT 12D ALLOGRAFT 22MM ALIF",SUP-3W4222,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"PHCS [10601]",PHCS,,14801.72,70,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC",939,MS-DRG,,,,,,,inpatient,,,155639.55,46691.86,"AMBETTER EXCHANGE  [11102]",Ambetter,,22507.8,,"Case rate ($22,507.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,900.02, add-ons for qualifying new technology services are included. If operating cost exceeds $53,939.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,962.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $20,927.66. The transfer operating threshold is the transfer adjustment factor * $20,900.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,580.14. The transfer capital threshold is the transfer adjustment factor * $1,580.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,105937.69,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR OPHTHALMIC .5MM CORNEAL RUST RING REMOVAL LATEX FREE",SUP-AB05,CDM,S27200284,LOCAL,0272,RC,,,both,,,576.23,172.87,"KAISER [10500]",Kaiser,,386.07,67,,,,,0,67.02,489.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 2.5MM CORONARY STENT EVEROLIMUS",SUP-H7493926132250,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]","Cigna Open Access",,4907.63,56.9,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EMBOL-X GLIDE XL 11IN 24FR 35-40MM EMBOLIZATION",SUP-EXGF24XLD,CDM,C1884,HCPCS,0272,RC,,,both,,,3007.50,902.25,"PHCS [10601]",PHCS,,2105.25,70,,,,,0,349.77,2556.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH",RX-27472,CDM,,,0250,RC,00378-9104-16,NDC,both,1,UN,12.54,3.76,"NOVANET [10819]",Novanet,,9.41,75,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROPEL 370 MCG NASAL MOMETASONE FUROATE",SUP-70011,CDM,C2625,HCPCS,0278,RC,,,both,,,6679.20,2003.76,"CIGNA [10200]","Cigna Local Plus",,3573.37,53.5,,,,,0,776.79,5677.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO GWIRE 10CM 4FR 21GA MERIT S-MAK .018IN STAINLESS STEEL",SUP-S-MAK401,CDM,C1894,HCPCS,0272,RC,,,both,,,295.80,88.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,201.14,68,,,,,0,34.4,251.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vasc Embol Occl Organ",PX-361000322,CDM,37243,CPT,0361,RC,,,both,,,34449.05,10334.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4082.21,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4006.42,29281.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR RAABE 70CM 5FR 1.9MM GUIDING AQ CHECK-FLO",SUP-G13091,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"NOVANET [10819]",Novanet,,334.13,75,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 5CM 7FR PANCREATIC POLYETHYLENE PUSH CATH DRAIN",SUP-G21374,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,180.82,28.62,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANT BREAST DISORDERS WITH CC",598,MS-DRG,,,,,,,inpatient,,,46065.48,13819.64,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,7333.31,,"Case rate ($7,017.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,516.25, add-ons for qualifying new technology services are included. If operating cost exceeds $39,555.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,874.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,524.86. The transfer operating threshold is the transfer adjustment factor * $6,516.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $492.66. The transfer capital threshold is the transfer adjustment factor * $492.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7017.52,28213.49,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT SL II SITEMARK 57.7CM 54CM 9FR 7FR STRAIGHT",SUP-DS2C011,CDM,C1887,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"FIRST HEALTH [10303]","First Health",,3008.4,80,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PRESET 40MM 52MM 5MM THROMBECTOMY CLOSED RING HELICAL",SUP-PRE-5-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,34650.00,10395,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14241.15,41.1,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) QUALIBREATH",SUP-QB-XS,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,380.71,45.9,,,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 12MM 145CM 3.75MM BALLOON DILATATION",SUP-1400375-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER SURGICAL ACUITY UNIVERSAL SPIRAL",SUP-7060,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ATLAS 75CM 6CM 12MM 7FR BALLOON DILATATION PERIPHERAL",SUP-AT75126,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 150CM 40MM 2.5MM BALLOON DILATATION",SUP-48002504X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 5.75IN 16FR URETHRAL STAINLESS STEEL FEMALE NONSTERILE",SUP-475-636,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.39,103.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONDUCTR 110CM 7FR 2-5-2MM SPACING ELECTROPHYSIOLOGY",SUP-7856042,CDM,C1733,HCPCS,0272,RC,,,both,,,4554.00,1366.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE AORTIC 19MM 29MM 27MM BIOCOR FLEXFIT LOW PROFILE",SUP-B100-29A-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,30744.00,9223.2,"BLUE CROSS [10001]","Blue Cross HMO",,12051.65,39.2,,,,,0,3575.53,26132.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 120MM 6FR 7MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206071210,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC",446,MS-DRG,,,,,,,inpatient,,,35958.41,10787.52,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,11033.35,,"Case rate ($5,131.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,765.22, add-ons for qualifying new technology services are included. If operating cost exceeds $37,804.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,742.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,771.52. The transfer operating threshold is the transfer adjustment factor * $4,765.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.27. The transfer capital threshold is the transfer adjustment factor * $360.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,5131.79,20632.03,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 770CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-770,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"MULTIPLAN [10600]",Multiplan,,6422.18,85,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 80CM 4FR .042IN .038IN PIGTAIL FLUSH",SUP-7749-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.75,58.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,89.85,45.9,,,,,0,22.77,166.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Startup Cath Therm Als",PX-E27200182,CDM,E27200182,LOCAL,0272,RC,,,both,,,1361.80,408.54,"FIRST HEALTH [10303]","First Health",,1089.44,80,,,,,0,158.38,1157.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 2.5MM CORONARY STENT",SUP-H7493941820250,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM ORTHOLOC FULL THREAD MIDFOOT CORTICAL 3",SUP-58813516,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross PPO",,301.64,39.2,,957.42,570.23,957.42,28,89.49,654.08,"percent of total billed charges",
"SCR BONE 3.5MM 16MM ORTHOLOC FULL THREAD MIDFOOT CORTICAL 3",SUP-58813516,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"KAISER [10500]",Kaiser,,515.57,67,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 9MM KNEE XLPE POSTERIOR STABILIZE LEGION",SUP-71453247,CDM,C1776,HCPCS,0278,RC,,,both,,,14831.55,4449.46,"MULTIPLAN [10600]",Multiplan,,12606.82,85,,,,,0,1724.91,12606.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 15CM 120CM 6MM 6FR ENDOPROSTHESIS HEPARIN",SUP-VBJ061502,CDM,C1874,HCPCS,0278,RC,,,both,,,24462.90,7338.87,"KAISER [10500]",Kaiser,,16390.14,67,,,,,0,2845.04,20793.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 138MM 13MM PRIMARY PRESS FIT TIVANIUM 12/14 45",SUP-786401320,CDM,C1776,HCPCS,0278,RC,,,both,,,30164.40,9049.32,"FIRST HEALTH [10303]","First Health",,24131.52,80,,,,,0,3508.12,25639.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR070202A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7710.94,41.1,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 8FR PIGTAIL NEPHROURETERAL PERCUFLEX METAL",SUP-M001221360,CDM,C2617,HCPCS,0278,RC,,,both,,,811.20,243.36,"CIGNA [10200]",Cigna,,551.62,68,,,,,0,94.34,689.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 64CM ENDOTAK RELIANCE ENDOCARDIAL STEROID SILICONE",SUP-158,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]","Cigna Open Access",,5085.3,33.5,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 45D COOLCUT STERILE ABLATOR",SUP-AR-9802M-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,931.50,279.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,108.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 5.5MM COOLCUT 8 FLUTE ROUND STERILE",SUP-AR-8550RBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,59.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE 17GA 10MM RADIOFREQUENCY ELECTROTHERAPY OSTEOCOOL 2MM",SUP-OCP210,CDM,S27200284,LOCAL,0272,RC,,,both,,,25389.00,7616.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3008.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2952.74,21580.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 150MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-150-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10782.00,3234.6,"NOVANET [10819]",Novanet,,8086.5,75,,,,,0,1083.33,9164.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARCADIA 20MM BALLOON DILATATION HIGH PRESSURE RESHEATH",SUP-ARC20SB,CDM,S27200284,LOCAL,0272,RC,,,both,,,6555.00,1966.5,"CIGNA [10200]",Cigna,,4457.4,68,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION (HIE THERAPY ONLY)",RX-411797,CDM,J1815,HCPCS,0637,RC,00002-7510-01,NDC,both,10,ML,2265.00,679.5,"AETNA [10100]","Aetna HMO/PPO",,1800.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.7,1925.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grad Compression Thigh 40-50",PX-E27100014,CDM,A6535,HCPCS,0292,RC,,,both,,,336.60,100.98,"CIGNA [10200]","Cigna Open Access",,191.53,56.9,,,,,0,39.15,286.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 44MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 5",SUP-244.05,CDM,C1713,HCPCS,0278,RC,,,both,,,3031.80,909.54,"KAISER [10500]",Kaiser,,2031.31,67,,,,,0,352.6,2577.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 3MM BALLOON DILATATION STERILE LATEX",SUP-583012022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 200CM 300MM 2.5MM BALLOON DILATATION RAPID",SUP-47525300L,CDM,C1725,HCPCS,0272,RC,,,both,,,1890.00,567,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN",RX-163725,CDM,,,0250,RC,00942-0641-04,NDC,both,1000,ML,100.65,30.19,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP ENDOSCOPIC NDL 160CM 2.8MM RADIAL JAW 4 35CM LARGE",SUP-M00513313,CDM,S27200284,LOCAL,0272,RC,,,both,,,171.30,51.39,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE CATH 60CM REPOSITIONING LUER LOCK ADPTR HEMOSTASIS",SUP-406501,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.90,18.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPTA PRO 80CM 4CM 5FR 6MM 7.5MM BALLOON DILATATION",SUP-4196040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL 20CM 18GA 2 PART TROCAR PROC DISPOSABLE STD NEPHRSTMY",SUP-G14255,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.52,51.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) ACOLYTE CATHETER","SUP-FG 01412",CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Trauma Response Lvl III W/O Pre-Notification",PX-683000002,CDM,TTARU,HCPCS,0450,RC,,,both,,,9037.35,2711.2,"UHC [10700]","United Healthcare",,2260,,"Per diem ($2,260).",,,,0,67.13,7681.75,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"DILTIAZEM HCL 100 MG/100 ML (1 MG/ML) IN SOD CHLORIDE,ISO-OSM IV SOLN",RX-180353,CDM,,,0250,RC,44567-0662-01,NDC,both,100,ML,231.88,69.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.97,197.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 4 STD KNEE LEFT KEEL NONPOROUS",SUP-ETPKN4SL,CDM,C1776,HCPCS,0278,RC,,,both,,,15193.80,4558.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1767.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1767.04,12914.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 5MM CURVE BAYONET RIGHT 9.5IN HARDY SYMMETRY SURGICAL",SUP-58-7526,CDM,S27200284,LOCAL,0272,RC,,,both,,,680.72,204.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,80.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,79.17,578.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL NASAL 16MM 4MM PROPEL 370 MCG MINI MOMETASONE FUROATE",SUP-60011,CDM,C2625,HCPCS,0278,RC,,,both,,,6679.20,2003.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3065.75,45.9,,,,,0,776.79,5677.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 35X15MM CONTINENTAL 15D 24MM MEDIUM PEEK",SUP-364.615CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LACRIMAL 130MM .7-.8MM BOWMAN GERMAN SILVER 2 END",SUP-OB510,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.28,36.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,49.85,41.1,,,,,0,14.1,103.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE ESC 10D +4MM 52MM 32MM GVF",SUP-121832752,CDM,C1776,HCPCS,0278,RC,,,both,,,20472.48,6141.74,"NOVANET [10819]",Novanet,,15354.36,75,,,,,0,2380.95,17401.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKING COILS XL 55CM",SUP-RBYPCXL55,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"BLUE CROSS [10001]","Blue Cross HMO",,7384.1,39.2,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUR SURGICAL DIA4MM STAINLESS STEEL EGG 10 FLUTE",SUP-1607002035,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +13 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000130,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM EDWARDS SAPIEN ASCENDRA PLUS TRANSAPICAL",SUP-9355ASP29A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,76137.75,41.1,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION 16FR SURESTEP BARDEX IC COMPLETE CARE",SUP-A300316A,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.29,41.79,"MULTIPLAN [10600]",Multiplan,,118.4,85,,,,,0,16.2,118.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 38MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR38,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3752.08,28.62,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Sacroiliac Jt <3v",PX-320000050,CDM,72200,CPT,0320,RC,,,both,,,374.86,112.46,"PHCS [10601]",PHCS,,262.4,70,,,,,0,39.75,318.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL STARTER SCREW METTAN",SUP-71631448,CDM,S27200284,LOCAL,0272,RC,,,both,,,1647.30,494.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1120.16,68,,,,,0,191.58,1400.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 18MM 2.75MM CORONARY STENT EVEROLIMUS",SUP-1550275-18,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +9.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.095,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HTC VITRECTOMY CORRECTION LENS THUMBSCREW COVER FULL",SUP-40211,CDM,S27200284,LOCAL,0272,RC,,,both,,,1731.38,519.41,"CIGNA [10200]","Cigna Local Plus",,926.29,53.5,,,,,0,201.36,1471.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SENSOR 22CM 7FR .035IN URETERAL PERCUFLEX PLUS",SUP-M006175271090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"CIGNA [10200]",Cigna,,904.58,68,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.104,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"CIGNA [10200]",Cigna,,582.96,68,,1831.33,1831.33,1831.33,16,99.7,728.71,"percent of total billed charges",
"HC Xr Clavicle Complt",PX-320000060,CDM,73000,CPT,0320,RC,,,both,,,619.96,185.99,"CIGNA [10200]","Cigna Open Access",,54.12,,,,,,,38.7,526.97,"fee schedule",
"COIL EMBOLIZATION 4.1CM 4MM INTERLOCK FIBERED IDC VORTX 18",SUP-M001361750,CDM,S27800098,LOCAL,0278,RC,,,both,,,1984.50,595.35,"PHCS [10601]",PHCS,,1389.15,70,,,,,0,230.8,1686.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 20CM 4MM BALLOON DILATATION ILIAC",SUP-G35527,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PHCS [10601]",PHCS,,671.84,70,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS",RX-41412,CDM,,,0637,RC,57896-0181-05,NDC,both,15,ML,12.83,3.85,"CIGNA [10200]","Cigna Local Plus",,6.86,53.5,,,,,0,1.49,10.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 5IN 2.8MM ACU-LOC 2 QUICK RELEASE",SUP-80-0387,CDM,S27200284,LOCAL,0272,RC,,,both,,,704.70,211.41,"CIGNA [10200]",Cigna,,479.2,68,,,,,0,81.96,599,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 24MM MITRAL SEMIRIGID MEMO 3D",SUP-SMD24,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"PHCS [10601]",PHCS,,8935.5,70,,,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 26MM DCP STAINLESS STEEL CORTEX SELF TAPPING",SUP-202.826,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,238.89,68,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH RED 150CM RESPONSE ELECTROPHYSIOLOGY HEXAPOLAR",SUP-401977R,CDM,S27000186,LOCAL,0270,RC,,,both,,,729.00,218.7,"FIRST HEALTH [10303]","First Health",,583.2,80,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE XPRESS ULTRA 1.5MM BALL SUPER SLEEK PROFILE 8MM 2.5FR",SUP-ULF-206,CDM,C1726,HCPCS,0272,RC,,,both,,,11364.30,3409.29,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Bronch Ebus Ivntj Perph Les",PX-750000183,CDM,31654,CPT,0750,RC,,,both,,,5344.42,1603.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 11CMX12MM OSTEOTOM CUP NONSTERILE DISPOSABLE",SUP-SBLDCUP-2-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASKET STONE RETRIEVAL 120CM 11MM 3FR GEMINI HELICAL",SUP-M0063301060,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 10.5FR .138IN 25CM ROBUST VALVE SPLITTABLE",SUP-PLSX-2510.5,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE L70MM DIA3MM THREAD L25MM SELF DRILLING GALAXY FI",SUP-M315,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,353.2,45.9,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 3MM 3.2MM DORNHOFFER PORP CURVE MALLEUS",SUP-70141014,CDM,C1713,HCPCS,0278,RC,,,both,,,2274.53,682.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,264.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",264.53,1933.35,"percent of total billed charges",
"CMPNT FEMORAL 4 NARROW KNEE RIGHT CEMENTED CRUCIATE",SUP-150400224,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"KAISER [10500]",Kaiser,,15003.54,67,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 6",SUP-249.682,CDM,C1713,HCPCS,0278,RC,,,both,,,2429.70,728.91,"AETNA [10100]","Aetna HMO/PPO",,1931.61,79.5,,1521.93,481.35,16760.95,30,282.57,2065.25,"percent of total billed charges",
"HC Immunoassay Tumor Ca 15-3 (27-29)",PX-302000055,CDM,86300,CPT,0302,RC,,,both,,,202.35,60.7,"UHC [10700]","United Healthcare",,18.73,,,,,,,0.01,172,"fee schedule",
"GLIMEPIRIDE 2 MG TABLET",RX-16356,CDM,,,0637,RC,50268-0359-11,NDC,both,1,UN,6.27,1.88,"PHCS [10601]",PHCS,,4.39,70,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.2MM IFUSE IMPL SYSTEM STEINMANN SACROILIAC",SUP-500078,CDM,S27000186,LOCAL,0270,RC,,,both,,,3326.40,997.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1526.82,45.9,,,,,0,386.86,2827.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 100MM 80CM 5MM 6FR .035IN BILIARY",SUP-G50112,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"NOVANET [10819]",Novanet,,4567.5,75,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plasma Cryoprecipitate Reduc",PX-390000014,CDM,P9044,HCPCS,0390,RC,,,both,,,735.80,220.74,"NOVANET [10819]",Novanet,,551.85,75,,,,,0,85.57,625.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURECLIP REPOSITIONABLE 11MM 235CM",SUP-RC30141,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"NOVANET [10819]",Novanet,,668.25,75,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM ATLANTIS TITANIUM SPINAL CANCELLOUS",SUP-876-814,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"DEVICE PIPELINE FLEX 35MM 5MM EMBOLIZATION NEUROVASCULAR 48",SUP-PED-500-35,CDM,S27800098,LOCAL,0278,RC,,,both,,,81396.00,24418.8,"CIGNA [10200]","Cigna Open Access",,27267.66,33.5,,,,,0,9466.35,69186.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NAVITOR SMALL LOADING",SUP-NVTR-LS-SM,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"PHCS [10601]",PHCS,,2625,70,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPIDCROSS 170CM 100MM 4MM .014IN BALLOON DILATATION",SUP-A14BX040100170,CDM,S27200284,LOCAL,0272,RC,,,both,,,1385.10,415.53,"NOVANET [10819]",Novanet,,1038.83,75,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Pta Sf Init",PX-361000721,CDM,37280,CPT,0361,RC,,,both,,,14777.16,4433.15,"KAISER [10500]",Kaiser,,9900.7,67,,,,,0,1718.58,12560.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg WO Vid 2-12 Hr Unmntr",PX-740000040,CDM,95705,CPT,0740,RC,,,both,,,4168.00,1250.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,493.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.17,3542.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH GREEN 30CM 12.5FR MAHURKAR ELITE DOUBLE-D LARGE",SUP-8888231330,CDM,C1752,HCPCS,0272,RC,,,both,,,995.43,298.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,409.12,41.1,,,,,0,115.77,846.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.7MM 22MM DISTAL VOLAR RADIUS FOSSA THREADED",SUP-TPNL-27220-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,623.70,187.11,"FIRST HEALTH [10303]","First Health",,498.96,80,,,,,0,72.54,530.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +2.5 MMM 36MM HIP BIOLOX DELTA V40",SUP-6570-0-536,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"UHC [10700]","United Healthcare",,6330,63.3,,8601.07,8395.67,8601.07,"1 through 10",1163,8500,"percent of total billed charges",
"DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC",446,MS-DRG,,,,,,,inpatient,,,35958.41,10787.52,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,5491.02,,"Case rate ($5,131.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,765.22, add-ons for qualifying new technology services are included. If operating cost exceeds $37,804.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,742.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,771.52. The transfer operating threshold is the transfer adjustment factor * $4,765.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.27. The transfer capital threshold is the transfer adjustment factor * $360.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,5131.79,20632.03,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERLINK 0 36IN LOOP BLUE 1.5IN NONABSORBABLE",SUP-AR-7258,CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"CIGNA [10200]","Cigna Open Access",,314.56,56.9,,,,,0,64.29,469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOPLASTY L150CM BALLOON L150MM DIA6MM PERIPHERAL",SUP-1013470-150,CDM,S27200284,LOCAL,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE POLYPECTOMY ENDOSCOPIC",SUP-M00562550,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE DERMATOME ACCULAN GB230R GB231R STERILE DISPOSABLE",SUP-GB228R,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.43,20.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,46.53,68,,,,,0,7.96,58.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 11MM KNEE POSTERIOR STABILIZE HIGH",SUP-71421509,CDM,C1776,HCPCS,0278,RC,,,both,,,10774.35,3232.3,"UHC [10700]","United Healthcare",,6820.16,63.3,,8601.07,8395.67,8601.07,"1 through 10",1253.06,9158.2,"percent of total billed charges",
"KIT CATH 28CM 14.5FR CARBOTHANE PALINDROME 2 LUMEN SIDE SLOT",SUP-8888145016P,CDM,C1750,HCPCS,0278,RC,,,both,,,2876.79,863.04,"CIGNA [10200]","Cigna Local Plus",,1539.08,53.5,,,,,0,334.57,2445.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 16CM 23MM 12MM 19-21MM 10-11MM GORE",SUP-RLT231216,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16929,27,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 90MM 28MM 20MM AFX2 2 BRANCH 30MM",SUP-BEA28-90/I20-30,CDM,C1874,HCPCS,0278,RC,,,both,,,84559.50,25367.85,"MULTIPLAN [10600]",Multiplan,,71875.58,85,,,,,0,9834.27,71875.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 2-0 CP-2 18IN CONTROL RELEASE MONOFILAMENT 8",SUP-Z762D,CDM,S27200284,LOCAL,0272,RC,,,both,,,268.76,80.63,"MULTIPLAN [10600]",Multiplan,,228.45,85,,,,,0,31.26,228.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG PETROLATUM 18X3IN VASELINE CISION GAUZE NONADHERENT",SUP-8884424600,CDM,S27200284,LOCAL,0272,RC,,,both,,,105.63,31.69,"PHCS [10601]",PHCS,,73.94,70,,,,,0,12.28,89.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 NARROW KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500006402,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"MULTIPLAN [10600]",Multiplan,,19433.3,85,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AEROSTAT 33CM 6-20FR 6FR TAPER CHOLANGIOGRAM RIGID TIP",SUP-C1002,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"CIGNA [10200]","Cigna Open Access",,414.8,56.9,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM ATTUNE 5 KNEE DISTAL CEMENT REVISION STERILE",SUP-154705001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"BLUE CROSS [10001]","Blue Cross PPO",,2380.22,39.2,,3949.44,3949.44,3949.44,"1 through 10",706.17,5161.2,"percent of total billed charges",
"BLADE 2.9MM 75 DEG STD SERRATED DS",SUP-SB2975SC,CDM,S27200284,LOCAL,0272,RC,,,both,,,987.42,296.23,"CIGNA [10200]","Cigna Open Access",,561.84,56.9,,,,,0,114.84,839.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 200MM 5MM 5.5MM STEINMANN STAINLESS STEEL",SUP-293.74,CDM,C1713,HCPCS,0278,RC,,,both,,,791.78,237.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,226.61,28.62,,,,,0,92.08,673.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)MARKER SKIN PINK 5CM 15GA SMARTCLIP LITE 3-4MM SOFT TI",SUP-SMARTCLIPLT-PNK-5,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA [10200]",Cigna,,1836,68,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 30CM 3CM 6FR .038IN 2 PIGTAIL",SUP-M006192135010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"NOVANET [10819]",Novanet,,900.44,75,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 2-0 CT 36IN MONOFILAMENT ABSORBABLE",SUP-913H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"FIRST HEALTH [10303]","First Health",,21.6,80,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701050,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3248.51,28.62,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 6FR .07IN GUIDING",SUP-H749389696480,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AETNA [10100]","Aetna HMO/PPO",,291.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LOCKING CREO SPINAL MIS NONSTERILE",SUP-1134.001,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,601.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM .91-1.12MM 3.5MM CORONARY",SUP-RONYX35008W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"MULTIPLAN [10600]",Multiplan,,4623.15,85,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERSTICK TIGERWIRE 2 50IN 1 END STIFFEN MONOFILAMENT",SUP-AR-7209T,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FACE 10X8X6MM TISSUE",SUP-609406,CDM,S27800098,LOCAL,0278,RC,,,both,,,3864.00,1159.2,"FIRST HEALTH [10303]","First Health",,3091.2,80,,,,,0,449.38,3284.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE KORE FIBER CORTICAL BONE FIBER 10CC ALLOGRAFT",SUP-423210,CDM,C1713,HCPCS,0278,RC,,,both,,,14296.80,4289.04,"BLUE CROSS [10001]","Blue Cross PPO",,5604.35,39.2,,957.42,570.23,957.42,28,1662.72,12152.28,"percent of total billed charges",
"HC Egd W/Drain Pseudocyst",PX-750000217,CDM,43240,CPT,0750,RC,,,both,,,2701.20,810.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,320.09,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,314.15,2701.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TIBIAL 16MM PROPHECY INBONE ANKLE PLASMA TOP",SUP-200011902,CDM,C1776,HCPCS,0278,RC,,,both,,,2520.00,756,"CIGNA [10200]","Cigna Local Plus",,1348.2,53.5,,5372.07,4581.20,7242.98,23,293.08,2142,"percent of total billed charges",
"PLATE STAINLESS STEEL 1.3 MM SCREWS 12 HOLE STRAIGHT BONE",SUP-221.312,CDM,C1713,HCPCS,0278,RC,,,both,,,2202.90,660.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,261.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",256.2,1872.47,"percent of total billed charges",
"CATH CANTATA 150CM 2.8FR .025IN MICRO INTERVENTIONAL",SUP-G54536,CDM,S27200284,LOCAL,0272,RC,,,both,,,3142.43,942.73,"CIGNA [10200]","Cigna Local Plus",,1681.2,53.5,,,,,0,365.46,2671.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 200MM 5.5MM RELINE STRAIGHT TITANIUM MULTIAXIAL",SUP-12355200,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"BURR SURGICAL 51MM 3.1MM MEDIUM ROUND CARBIDE STERILE",SUP-04-C0107,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.66,29,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,39.73,41.1,,,,,0,11.24,82.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 190MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-240.043S,CDM,C1713,HCPCS,0278,RC,,,both,,,9779.78,2933.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2798.97,28.62,,,,,0,1137.39,8312.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 NARROW KNEE LEFT CRUCIATE RETAINING PERSONA",SUP-42502206401,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"AETNA [10100]","Aetna HMO/PPO",,22971.99,79.5,,10981.53,8986.79,12413.38,12,3360.56,24561.24,"percent of total billed charges",
"CATH Z-MED II 100CM 3CM 9FR 22MM .035IN BALLOON DILATATION",SUP-611760,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,630.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 500MM 6-9MM TFN-ADVANCED CANNULATED STEP LARGE",SUP-03.037.022,CDM,S27200284,LOCAL,0272,RC,,,both,,,3177.30,953.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,376.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,369.52,2700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD OSTOMY 2IN 2IN 1 PLASTIC EYELET LOOP DURABLE DISPOSABLE",SUP-616,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.10,33.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,51.91,45.9,,,,,0,13.15,96.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tavi/Tavr Bypass W Centl Art",PX-361000351,CDM,33369,CPT,0361,RC,,,both,,,45298.00,13589.4,"UHC [10700]","United Healthcare",,3833,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,2491,38503.3,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 9X11X25MM 15",SUP-5891255,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11520,40,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM TRILOGY TIVANIUM ALLOY HIP ACETABULAR",SUP-00625006525,CDM,C1713,HCPCS,0278,RC,,,both,,,691.60,207.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,470.29,68,,,,,0,80.43,587.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 5.5X45MM MIDLINE SYSTEM POLYAXIAL CORTICAL 4S R",SUP-14615545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"PROBE SURGICAL MALLEABLE CURVED GRADUATED SIMS 13IN 4MM",SUP-EO012R,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.38,43.01,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 20GA 2.25MM ACCUCATH ACE DOT",SUP-AC1202252,CDM,S27200284,LOCAL,0272,RC,,,both,,,446.88,134.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT ORTHOPEDIC MEDIUM 6.75-7.5IN RIGHT WRIST THUMB SPICA",SUP-A6156,CDM,S27000186,LOCAL,0270,RC,,,both,,,224.55,67.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.12,190.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, ALL-POLY PEGGED GLENOID, SIZE 38, E-PLUS",SUP-521-07-238,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"AETNA [10100]","Aetna HMO/PPO",,7285.7,79.5,,10981.53,8986.79,12413.38,12,1065.82,7789.74,"percent of total billed charges",
"CAGE SPINAL 50MMX10MM CLYDESDALE 6D PEEK-OPTIMA RADIOPAQUE",SUP-2968050,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6851.63,28.62,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 60MM 3 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800360,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EP XT 110CM 6FR 2-5-2MM SPACE LARGE 4 CURVE",SUP-M0042007940,CDM,C1730,HCPCS,0272,RC,,,both,,,3967.50,1190.25,"AETNA [10100]","Aetna HMO/PPO",,3154.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 14MM PRIMARY SECUR-FIT PLUS HA 7 35MM HIP",SUP-6070-1035A,CDM,C1776,HCPCS,0278,RC,,,both,,,9473.94,2842.18,"UHC [10700]","United Healthcare",,5997,63.3,,8601.07,8395.67,8601.07,"1 through 10",1101.82,8052.85,"percent of total billed charges",
"CATH HYPERGLIDE X-PEDION 150CM 15MM 2.2-2.8FR 4MM .01IN 4MM",SUP-104-4112,CDM,C1725,HCPCS,0272,RC,,,both,,,9232.20,2769.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1094.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1073.7,7847.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ZEPHYR 2.8MM 4 DELIVERY SYSTEM FLEXIBLE EMPHASYS",SUP-EDC-TS-4.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,3898.50,1169.55,"CIGNA [10200]","Cigna Open Access",,2218.25,56.9,,,,,0,453.4,3313.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 20MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560020L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 8FR .09IN JUDKINS RIGHT 3.5 CURVE GUIDING",SUP-LA8JR35,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Jo-1 Igg Muscle Ab",PX-302000041,CDM,86235,CPT,0302,RC,,,both,,,424.00,127.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.42,.1,,,,,0,0.42,360.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CENTRAL LINE DRESSING CHANGE 132",SUP-03-5837,CDM,S27000186,LOCAL,0270,RC,,,both,,,86.21,25.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.03,73.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG PERFUSION HEMOCONCENTRATION WASTE",SUP-020585504,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"CIGNA [10200]","Cigna Local Plus",,93.09,53.5,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TACK 6MM 135CM 6FR VASCULAR NITINOL RADIOPAQUE OTW 6",SUP-156135062,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"PHCS [10601]",PHCS,,10143,70,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 90CM 135CM 25-30MM 10FR COLONIC NITINOL",SUP-M00565080,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AZITHROMYCIN 2 MG/ML INJ (NICU/PEDS)",RX-408335,CDM,J0133,HCPCS,0636,RC,08888-8887-90,NDC,both,1,ML,18.92,5.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12.87,68,,,,,0,0.05,16.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVOLUTION 10CM 8MM 20MM 25MM ESOPHAGEAL SILICONE",SUP-G48031,CDM,C1876,HCPCS,0278,RC,,,both,,,14283.00,4284.9,"CIGNA [10200]",Cigna,,5713.2,40,,,,,0,1661.11,12140.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 20MM 80CM 10MM VASCULAR NITINOL ILIAC",SUP-G43864,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]",Cigna,,2570.4,68,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 150MM 16MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U16150090,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1364.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 60MM 120CM 9MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200096020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 120MM 125CM 5MM 8FR BILIARY",SUP-G50163,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"MULTIPLAN [10600]",Multiplan,,5176.5,85,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 32MM 140CM 4MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927432400,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE 40MM 57CM 8-6MM TAPER VASCULAR NITINOL",SUP-SR-080640-TCS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 75CM 7MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200074070,CDM,C1876,HCPCS,0278,RC,,,both,,,4515.00,1354.5,"CIGNA [10200]","Cigna Local Plus",,2415.53,53.5,,,,,0,525.09,3837.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 9CM 10FR PROXIMAL BEND BILIARY 2 LAYER STERILE",SUP-PBD-421-1009,CDM,C1876,HCPCS,0278,RC,,,both,,,1387.85,416.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,161.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.41,1179.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 150MM 14MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U14150090,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"PHCS [10601]",PHCS,,8211,70,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 15MM 4MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT40015UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CIGNA [10200]",Cigna,,1642.2,68,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH THERMOCOOL SF 115CM 8FR D-J CURVE ABLATION",SUP-BDI35DJRT,CDM,C2630,HCPCS,0272,RC,,,both,,,11350.50,3405.15,"UHC [10700]","United Healthcare",,7184.87,63.3,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 20MM 135CM 8MM 160CM",SUP-M001711250,CDM,C1876,HCPCS,0278,RC,,,both,,,8728.50,2618.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2498.1,28.62,,,,,0,1015.12,7419.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAPLACE 26F SHEATH CATHETER",SUP-TTVR-SC-2633,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 57MM 75CM 9MM 60MM",SUP-H74938046960750,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX 30MM 135CM 6MM VASCULAR NITINOL CAROTID",SUP-PC0630RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"AMERIGROUP MEDICAID [20100]",Amerigroup,,899.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 9MM 4MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT40009UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CIGNA [10200]",Cigna,,1642.2,68,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PERIPHERAL L12MM DIA5MM CATHETER L80CM GUIDE 6FR BILIA",SUP-1011492-12,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BILIARY 8MM 6FR 24MM 135CM .035IN MEDIUM BALLOON",SUP-H739PG2480BPX3,CDM,C1876,HCPCS,0278,RC,,,both,,,6553.97,1966.19,"FIRST HEALTH [10303]","First Health",,5243.18,80,,,,,0,762.23,5570.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ETHOSUXIMIDE 250 MG CAPSULE",RX-9989,CDM,,,0637,RC,69452-0152-20,NDC,both,1,UN,10.78,3.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH AMPLATZER TORQVUE 80CM 12FR 45D EXCHANGE SYSTEM POLYMER",SUP-9-EITV12F45/80,CDM,C1773,HCPCS,0272,RC,,,both,,,4912.80,1473.84,"NOVANET [10819]",Novanet,,3684.6,75,,,,,0,571.36,4175.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL 25CM ABLATION 13GA",SUP-NWSR25,CDM,C1886,HCPCS,0272,RC,,,both,,,14524.50,4357.35,"AETNA [10100]","Aetna HMO/PPO",,11546.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1689.2,12345.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALVIMOPAN 12 MG CAPSULE",RX-91870,CDM,,,0637,RC,00591-2312-45,NDC,both,1,UN,783.59,235.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,322.06,41.1,,,,,0,91.13,666.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Parathyroid Planar Img",PX-341000007,CDM,78070,CPT,0341,RC,,,both,,,2241.53,672.46,"CIGNA [10200]","Cigna Open Access",,509.39,,,,,,,260.69,1905.3,"fee schedule",
"CINCH SUTURE FOR OVERSTITCH SUTURING SYSTEM",SUP-M00505530,CDM,S27200284,LOCAL,0272,RC,,,both,,,1343.22,402.97,"CIGNA [10200]","Cigna Open Access",,764.29,56.9,,,,,0,156.22,1141.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 21GA FLEXISION STERILE LATEX FREE DISPOSABLE",SUP-490103,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,860.63,45.9,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 16FR SILICONE MIC-KEY SECUR-LOK ENFIT BOLUS",SUP-8200-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"CIGNA [10200]","Cigna Open Access",,625.66,56.9,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TIGHTRAIL MINI 11FR 6.1IN 23FR 18FR 11.2FR DIL",SUP-540-011,CDM,C1773,HCPCS,0272,RC,,,both,,,12385.50,3715.65,"FIRST HEALTH [10303]","First Health",,9908.4,80,,,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET, IMMEDIATE RELEASE",RX-33228,CDM,,,0637,RC,60687-0803-11,NDC,both,1,UN,9.54,2.86,"UHC [10700]","United Healthcare",,6.04,63.3,,,,,0,1.11,8.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 6 RIGHT DISTAL KNEE",SUP-5542-A-602,CDM,C1776,HCPCS,0278,RC,,,both,,,6011.46,1803.44,"KAISER [10500]",Kaiser,,4027.68,67,,,,,0,699.13,5109.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER SUPPORT L150CM DIA0.0375IN COMPATIBLE GUIDEWIRE 0.0",SUP-P1VC-014STR-150,CDM,C1894,HCPCS,0272,RC,,,both,,,1458.00,437.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,599.24,41.1,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PRIMEWIRE PRESTIGE PLUS VASCULAR STRAIGHT 185CM",SUP-9185,CDM,C1769,HCPCS,0272,RC,,,both,,,4140.00,1242,"MULTIPLAN [10600]",Multiplan,,3519,85,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 100CM 7-5FR 8.5MM .035IN CORONARY VENOUS LEFT",SUP-4544,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"AETNA [10100]","Aetna HMO/PPO",,4457.57,79.5,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RX BILIARY SYSTEM 15CM 7FR BILIARY PLASTIC TEMPORARY",SUP-M00545590,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,244.06,28.62,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZIPWIRE UROLOGICAL 150CM 3CM .035IN NITINOL",SUP-M006630222B1,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 26MM 10MM HEMASHIELD PLATINUM 1 BRANCH",SUP-M00202175826P0,CDM,C1768,HCPCS,0278,RC,,,both,,,8352.73,2505.82,"BLUE CROSS [10001]","Blue Cross PPO",,3274.27,39.2,,,,,0,971.42,7099.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 26MM 10MM HEMASHIELD PLATINUM 1 BRANCH",SUP-M00202175826P0,CDM,C1768,HCPCS,0278,RC,,,both,,,8352.73,2505.82,"FIRST HEALTH [10303]","First Health",,6682.18,80,,,,,0,971.42,7099.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC",410,MS-DRG,,,,,,,inpatient,,,126850.28,38055.08,"AETNA [10100]","Aetna HMO/PPO",,29872.58,,"Fee schedule rate ($29,872.58). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,46354.49,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT WALLFLEX 40MM 194CM 10MM",SUP-7089,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE BENTSON VASCULAR STRAIGHT TAPER 260CM 20CM .035IN PTFE",SUP-G01063,CDM,C1769,HCPCS,0272,RC,,,both,,,204.36,61.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,23.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.77,173.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE LUNDERQUIST VASCULAR STRAIGHT 260CM 15CM .035IN",SUP-G31453,CDM,C1769,HCPCS,0272,RC,,,both,,,1013.31,303.99,"MULTIPLAN [10600]",Multiplan,,861.31,85,,,,,0,117.85,861.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE BENTSON VASCULAR STRAIGHT TAPER 260CM 20CM .035IN PTFE",SUP-G01063,CDM,C1769,HCPCS,0272,RC,,,both,,,204.36,61.31,"NOVANET [10819]",Novanet,,153.27,75,,,,,0,23.77,173.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VICI VENOUS STENT 90MM 100MM 14MM ENDOPROSTHESIS",SUP-H74914090100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"NOVANET [10819]",Novanet,,9832.5,75,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM SYNAPSE TITANIUM 40D SPINE CORTEX",SUP-04.614.334,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVED 314MM STAINLESS STEEL 4.5MM SCR 14 HOLE LOCKING",SUP-02.001.324,CDM,C1713,HCPCS,0278,RC,,,both,,,10034.81,3010.44,"CIGNA [10200]","Cigna Open Access",,5709.81,56.9,,1144.80,304.56,2275.09,66,1167.05,8529.59,"percent of total billed charges",
"CATH VASCUTRAK 140CM 8CM 3MM BALLOON DILATATION HYDROPHILIC",SUP-V143080,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"FIRST HEALTH [10303]","First Health",,4388.4,80,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA 38IN SEMI SLIGHTLY CONTOURED FRONT HOOK AND EYE CLSR",SUP-2-8125-38,CDM,S27000186,LOCAL,0270,RC,,,both,,,313.20,93.96,"PHCS [10601]",PHCS,,219.24,70,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW RADIOPAQUE",SUP-CG-05-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"NOVANET [10819]",Novanet,,394.88,75,,,,,0,394.88,394.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 12X19MM FORTIFY 12MM NONSTERILE LATEX FREE",SUP-151.051,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3733.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOOTPRINT PEEL-AWAY 1.9FR IV POLYURETHANE PERIPHERAL 2",SUP-P2PIC1.9-C,CDM,C1751,HCPCS,0272,RC,,,both,,,704.70,211.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,81.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.96,599,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM OPTIFIX FIXATION POLY-DL-LACTIDE 15 ABSORBABLE SMOOTH",SUP-0113127,CDM,S27200284,LOCAL,0272,RC,,,both,,,524.88,157.46,"AETNA [10100]","Aetna HMO/PPO",,417.28,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.04,446.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.0MM PHALANX LNTRAMEDULLARY NAIL 3MM X 32.5MM TI",SUP-IHFN-PHX-30032,CDM,C1713,HCPCS,0278,RC,,,both,,,8052.30,2415.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,954.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",936.48,6844.46,"percent of total billed charges",
"GRAFT SOFT TISSUE 12X8CM AXIS TUTOPLAST DERMIS ALLOGRAFT",SUP-939812,CDM,C1762,HCPCS,0278,RC,,,both,,,21892.50,6567.75,"CIGNA [10200]","Cigna Open Access",,7333.99,33.5,,,,,0,2546.1,18608.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 60MM 80CM 14MM BILIARY VENOUS DELIVERY",SUP-G57444,CDM,C1876,HCPCS,0278,RC,,,both,,,13800.00,4140,"BLUE CROSS [10001]","Blue Cross HMO",,5409.6,39.2,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM LCP",SUP-02.211.020,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"MULTIPLAN [10600]",Multiplan,,763.41,85,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX LPR 12 CM CIRCLE",SUP-F10244-1212L,CDM,C1781,HCPCS,0278,RC,,,both,,,12924.53,3877.36,"NOVANET [10819]",Novanet,,9693.4,75,,,,,0,1503.12,10985.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH OTOLOGIC 2.5X2.5CM EPIFILM EAR LAMINA FILM RESORBABLE",SUP-1417000,CDM,C1763,HCPCS,0278,RC,,,both,,,1581.53,474.46,"PHCS [10601]",PHCS,,1107.07,70,,,,,0,183.93,1344.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VTC 25CM 8FR PIGTAIL CURVE NEPHRSTMY METAL POLYURETHANE",SUP-M001245260,CDM,C1887,HCPCS,0272,RC,,,both,,,729.00,218.7,"FIRST HEALTH [10303]","First Health",,583.2,80,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO SD 25D TIGHT RIGHT CURVE 1.8MM 3.8MM",SUP-AR-4068-25TR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1190.70,357.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,138.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INTROCAN SAFETY 2.5IN 22GA STRAIGHT IV POLYURETHANE",SUP-4251622-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,55.42,16.63,"CIGNA [10200]","Cigna Local Plus",,29.65,53.5,,,,,0,6.45,47.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2.5MM TARGET TETRA DETACHABLE STERILE",SUP-TG5412560,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"MULTIPLAN [10600]",Multiplan,,11997.44,85,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 1/8IN STEINMANN 2 END TROCAR POINT",SUP-1627-38-000,CDM,C1713,HCPCS,0278,RC,,,both,,,102.95,30.88,"BLUE CROSS [10001]","Blue Cross HMO",,40.36,39.2,,957.42,156.86,7483.26,51,11.97,87.51,"percent of total billed charges",
"IMP MAM MED MOD HIGH PROJ 685C",SUP-3341452,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"MULTIPLAN [10600]",Multiplan,,7771.13,85,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL IDENTITY IMPRINT 4 NARROW H7 MM KNEE POSTERIOR",SUP-TPS-020-074N,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"PHCS [10601]",PHCS,,4115.16,70,,,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 11 HOLE CLUSTER GORILLA BONE FIBULA LEFT",SUP-P53-203-L011,CDM,C1713,HCPCS,0278,RC,,,both,,,9468.53,2840.56,"CIGNA [10200]","Cigna Open Access",,5387.59,56.9,,1144.80,304.56,2275.09,66,1101.19,8048.25,"percent of total billed charges",
"EXPORT ASPIRATION CATHETER 6FR",SUP-ADVANCE,CDM,C1757,HCPCS,0272,RC,,,both,,,2250.00,675,"NOVANET [10819]",Novanet,,1687.5,75,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 7FR ENDOCARDIUM TRUE BIPOLAR ACTIVE",SUP-7171Q/58,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]","Cigna Local Plus",,5409.18,31.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP040250150 PLUS US D4L250UL1500",SUP-PCP040250150,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,147.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 25CM 12FR PIGTAIL CURVE DRNG POLYURETHANE",SUP-RLC-12-038MB,CDM,C1729,HCPCS,0272,RC,,,both,,,537.19,161.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,365.29,68,,,,,0,62.48,456.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDEPATH 40CM 14.5FR STD STRAIGHT HEMODIALYSIS",SUP-5393190R,CDM,C1750,HCPCS,0278,RC,,,both,,,2062.50,618.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,239.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL GENESIS II 4 LEFT KNEE CEMENT TITANIUM",SUP-71420166,CDM,C1776,HCPCS,0278,RC,,,both,,,14593.50,4378.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4176.66,28.62,,,,,0,1697.22,12404.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 3.5 X 8 COMPLEX PICO COIL",SUP-10USC03508,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"CIGNA [10200]","Cigna Local Plus",,4118.78,31.5,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM FILTERWIRE EZ .014IN 110UM 190CM 2.25-3.5MM EMBOLIC",SUP-H749390711900,CDM,C1884,HCPCS,0272,RC,,,both,,,9844.09,2953.23,"KAISER [10500]",Kaiser,,6595.54,67,,,,,0,1144.87,8367.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 15CM 7.5FR .038IN PIGTAIL CURVE DRNG",SUP-RLC15-7-038MB,CDM,C1729,HCPCS,0272,RC,,,both,,,537.19,161.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,63.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.48,456.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 150CM 2.1-2.7FR .0175 .0157IN",SUP-221-15-1000U,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1387.13,41.1,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 3.5MM OASYS TITANIUM OCCIPITOCERVICOTHORACIC",SUP-48552070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"CATH STERLING 135CM 40MM 6FR 4MM BALLOON DILATATION PEBAX",SUP-39032-40401,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"FIRST HEALTH [10303]","First Health",,1198.8,80,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC",656,MS-DRG,,,,,,,inpatient,,,133265.07,39979.52,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,20341.79,,"Case rate ($19,749.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $18,338.57, add-ons for qualifying new technology services are included. If operating cost exceeds $51,378.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,768.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $18,362.82. The transfer operating threshold is the transfer adjustment factor * $18,338.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,386.49. The transfer capital threshold is the transfer adjustment factor * $1,386.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,92954.22,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"AMMONIUM LACTATE 12 % LOTION",RX-10380,CDM,,,0637,RC,00904-5984-26,NDC,both,226,GR,240.24,72.07,"NOVANET [10819]",Novanet,,180.18,75,,,,,0,27.94,204.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.5MM X 6MM TI",SUP-VAN-15060-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",113.04,826.2,"percent of total billed charges",
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 26MM 140CM 2.5MM",SUP-RSINT25026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]",Cigna,,3769.92,68,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 7MMX15MM 7FR 80CMCATH HEPARIN",SUP-BXB071501A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 30MM STEALTH 1 SOFT TRACTION STERILE LATEX FREE",SUP-A0A01,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 4MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-04004,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"BLUE CROSS [10001]","Blue Cross PPO",,3513.54,39.2,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 STD KNEE RIGHT CRUCIATE RETAIN PERSONA COCR",SUP-42502805802,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11558.23,40,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER BIPOLAR 12.5IN .283IN DISSECT DISPOSABLE AQUAMANTYS",SUP-23-317-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,4416.00,1324.8,"UHC [10700]","United Healthcare",,2795.33,63.3,,,,,0,513.58,3753.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM TARGET XL LARGE HELICAL",SUP-M0036119300,CDM,S27800098,LOCAL,0278,RC,,,both,,,12419.24,3725.77,"CIGNA [10200]","Cigna Open Access",,4160.45,33.5,,,,,0,1444.36,10556.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE .6MM 4.6CM UNIVERSAL NEURO III MEDIUM ROUND",SUP-92-00664,CDM,C1713,HCPCS,0278,RC,,,both,,,11536.80,3461.04,"BLUE CROSS [10001]","Blue Cross PPO",,4522.43,39.2,,957.42,570.23,957.42,28,1341.73,9806.28,"percent of total billed charges",
"CUFF TRNQT PLUM 12X3.5IN 2 FILL LINE POSITIVE LOCK CNCT",SUP-ASP-564003,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.06,39.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,89.12,68,,,,,0,15.24,111.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT STRATAMR REGULAR",SUP-42965MR,CDM,S27800098,LOCAL,0278,RC,,,both,,,42777.00,12833.1,"AETNA [10100]","Aetna HMO/PPO",,34007.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4974.97,36360.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BACTISEAL 120CM 14CM DRNG VENTRICLE DISTAL KIT SHUNT",SUP-823072,CDM,S27800098,LOCAL,0278,RC,,,both,,,4862.22,1458.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3306.31,68,,,,,0,565.48,4132.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHNT HKM PRC VNTRC 70MM HP 175777",SUP-823008,CDM,S27800098,LOCAL,0278,RC,,,both,,,14545.20,4363.56,"NOVANET [10819]",Novanet,,10908.9,75,,,,,0,1691.61,12363.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CERES-C SPACER 12X15X7 10 DEG",SUP-SK-08-170-1007,CDM,S27800098,LOCAL,0278,RC,,,both,,,7590.00,2277,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5161.2,68,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE 14MM 4MM EMBOLIZATION",SUP-PED2-400-14,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"BLUE CROSS [10001]","Blue Cross PPO",,31672.62,39.2,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 36MM SIMULUS ANNULUS POSTERIOR POLYESTER",SUP-800SC36,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"FIRST HEALTH [10303]","First Health",,10488,80,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ALLOGRAFT BLOCK 9MM",SUP-320109,CDM,S27800098,LOCAL,0278,RC,,,both,,,3412.50,1023.75,"BLUE CROSS [10001]","Blue Cross PPO",,1337.7,39.2,,,,,0,396.87,2900.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 425ML P5CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-4254BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3565.92,68,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOQUE TRICUSPID VALVE REPLACEMENT SYSTEM (56 MM VALVE)",SUP-EVQ1A2US56,CDM,S27800098,LOCAL,0278,RC,,,both,,,245100.00,73530,"AETNA [10100]","Aetna HMO/PPO",,194854.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28505.13,208335,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 38MM SIMULUS ANNULUS POSTERIOR POLYESTER",SUP-800SC38,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5388.21,41.1,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NONABSORBABLE POLYPROPLENE",SUP-M0068332341,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 155MM 32MM ZENITH ALPHA 7.1MM CYLINDRICAL",SUP-G35347,CDM,C1874,HCPCS,0278,RC,,,both,,,89041.07,26712.32,"UHC [10700]","United Healthcare",,56363,63.3,,,,,0,10355.48,75684.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X14X12MM FORTIFY I 3.5D NO SPIKE FOOTPRINT",SUP-137.311,CDM,S27800098,LOCAL,0278,RC,,,both,,,31320.00,9396,"CIGNA [10200]","Cigna Open Access",,10492.2,33.5,,,,,0,3642.52,26622,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X9X6MM ARCH PARALLEL FREEZE DRY OPEN DOOR",SUP-15114,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myeloperoxidase",PX-301000706,CDM,83876,CPT,0301,RC,,,both,,,88.00,26.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.12,,"Fee schedule rate ($18.12). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,88,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 32MM 140CM 4MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927432400,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE STIM 5IN 20GA INTERSTIM FORAMEN STERILE LATEX FREE",SUP-041839,CDM,S27200284,LOCAL,0272,RC,,,both,,,453.60,136.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,186.43,41.1,,,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 20 MEQ POTASSIUM CHLORIDE 5% DEXTROSE 0.9%",SUP-0710709,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"PHCS [10601]",PHCS,,56.7,70,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2.5MM AXIUM PRIME HELIX DETACHABLE",SUP-APB-2.5-3-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"PHCS [10601]",PHCS,,6254.85,70,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE SOFT TOUCH SMOOTH",SUP-SSF-770,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2162.38,28.62,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 15MM MASTERS HP STD MECHANICAL CUFF",SUP-15AHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,60064.20,18019.26,"UHC [10700]","United Healthcare",,38020.64,63.3,,,,,0,6985.47,51054.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL THK3-6MM ALLOGRAFT STRUT FREEZE DRIED 60",SUP-400600,CDM,S27800098,LOCAL,0278,RC,,,both,,,5729.76,1718.93,"FIRST HEALTH [10303]","First Health",,4583.81,80,,,,,0,666.37,4870.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL LUMBAR ALIF ANTERIOR CONVEX 12 DEGRE",SUP-2419,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 1.5MM TARGET NANO HELICAL DETACHABLE",SUP-M0035431540,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"AETNA [10100]","Aetna HMO/PPO",,7280.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX8MM VERTE-STACK CAPSTONE PEEK-OPTIMA END",SUP-2960822,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"CIGNA [10200]","Cigna Open Access",,5325.7,33.5,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SNARE AMPLATZ GOOSENECK 120CM 6FR 30MM 1 CATH CABLE LOOP",SUP-GN3000,CDM,C1773,HCPCS,0272,RC,,,both,,,2062.50,618.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 24CM 5FR UNIVERSA 2 PIGTAIL CURVE URETER AQ",SUP-G23397,CDM,C2617,HCPCS,0278,RC,,,both,,,535.41,160.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,153.23,28.62,,,,,0,62.27,455.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 15.5CM NATRELLE INSPIRA P5CM MODERATE PROFILE",SUP-MSZ-M640,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER BIPOLAR 44MM 28MM TANDEM HIP COCR UHMW POLYETHYLENE",SUP-71322044,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"UHC [10700]","United Healthcare",,5287.1,63.3,,8601.07,8395.67,8601.07,"1 through 10",971.39,7099.58,"percent of total billed charges",
"CATH RANGER 135CM 80MM 7MM BALLOON DILATATION PACLITAXEL OTW",SUP-H74939419700810,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"MULTIPLAN [10600]",Multiplan,,7331.25,85,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER FEMORAL ARTICUL/EZE +10MM 12/14 TAPER HIP ORTHOCHROME",SUP-136314000,CDM,C1776,HCPCS,0278,RC,,,both,,,1650.00,495,"BLUE CROSS [10001]","Blue Cross PPO",,646.8,39.2,,3949.44,3949.44,3949.44,"1 through 10",191.9,1402.5,"percent of total billed charges",
"SPACER SPINAL 45X22X10MM COROENT XL WIDE PEEK LUMBAR",SUP-6910245,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"CIGNA [10200]",Cigna,,9504,40,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 31MM 26.1MM MASTERS SERIES 85D PYROLYTIC CARBON",SUP-31AECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11968,41.1,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 25CM 10FR PIGTAIL CURVE NEPHRSTMY FLEXIMA POLYURETHANE",SUP-M001271780,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 10MM NESTER PLATINUM FIBER 4.5 LOOP",SUP-G47325,CDM,S27800098,LOCAL,0278,RC,,,both,,,890.92,267.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,254.98,28.62,,,,,0,103.61,757.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45MM LINEAR CUTTER ARTICULATION TRIGGER LOCK",SUP-PSE45A,CDM,S27200284,LOCAL,0272,RC,,,both,,,5656.21,1696.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,670.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,657.82,4807.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT R 34MM STERILE",SUP-EVOLUTR-34-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS [10001]","Blue Cross PPO",,67032,39.2,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT R 34MM STERILE",SUP-EVOLUTR-34-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]","Cigna Open Access",,57285,33.5,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOQUE TRICUSPID VALVE REPLACEMENT SYSTEM (48 MM VALVE)",SUP-EVQ1A2US48,CDM,S27800098,LOCAL,0278,RC,,,both,,,245100.00,73530,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,28505.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28505.13,208335,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 25X9X12MM COROENT 8D LARGE CONTOUR PEEK LUMBAR",SUP-6612925,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4471.2,27,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VALVE AORTIC 13MM 19MM AVALUS ULTRA 19MM BOVINE PERIC",SUP-400U19,CDM,S27800098,LOCAL,0278,RC,,,both,,,36225.00,10867.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14888.48,41.1,,,,,0,4212.97,30791.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 6X3CM PRO3 THICK AMNIOTIC UMBILICAL CORD",SUP-P01-AMC-0306,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2.5MM AVENIR 10 COIL FINISH COMPLEX",SUP-10CFN-02504,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"KAISER [10500]",Kaiser,,7854.48,67,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 135CM 8MM 16SQ MM 7FR .035IN",SUP-BXAL082902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS [10001]","Blue Cross PPO",,7645.88,39.2,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP 3 HOLE EMPHASYS",SUP-471052300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2088.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2088.17,15261.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"30ATM INFLATION DEVICES AND ANGIOPLASTY PACKSBASIXCOMPAK30 INF",SUP-IN4530,CDM,S27200284,LOCAL,0272,RC,,,both,,,264.13,79.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,31.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.72,224.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 22MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532-G-322,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"BLUE CROSS [10001]","Blue Cross HMO",,4473.74,39.2,,5311.50,4717.44,5388.59,31,1327.29,9700.71,"percent of total billed charges",
"BEARING 63/67MMX10MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183520,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"AETNA [10100]","Aetna HMO/PPO",,6232.63,79.5,,10981.53,8986.79,12413.38,12,911.77,6663.81,"percent of total billed charges",
"SUT ETHIBOND 4-0 C-1 30IN 2 ARM BRAID GREEN NONABSORBABLE",SUP-X726H,CDM,S27200284,LOCAL,0272,RC,,,both,,,161.78,48.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,74.26,45.9,,,,,0,18.82,137.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 4-0 P-12 3/8 CIRCLE 58CM CLSR SURGALLOY",SUP-VLOCM0033,CDM,S27200284,LOCAL,0272,RC,,,both,,,262.83,78.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,108.02,41.1,,,,,0,30.57,223.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 115CM 1MM 6FR 5MM SPACE A CURVE ELECTROPHYSIOLOGY",SUP-F6QA005CT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,372.86,41.1,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 10CM 5FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552110,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"PHCS [10601]",PHCS,,840.41,70,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUCTION/IRRIGATION STRYKEFLOW2 DISPOSABLE TIP",SUP-250-070-520,CDM,S27200284,LOCAL,0272,RC,,,both,,,564.30,169.29,"MULTIPLAN [10600]",Multiplan,,479.66,85,,,,,0,65.63,479.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 500MM 5.5MM CD HORIZON STRAIGHT COCRMO NONSTERILE",SUP-1555000500,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross HMO",,555.66,39.2,,957.42,156.86,7483.26,51,164.86,1204.88,"percent of total billed charges",
"COLLAR CERVICAL PEDIATRIC 1 22-33IN",SUP-100277-000,CDM,S27000186,LOCAL,0270,RC,,,both,,,307.63,92.29,"PHCS [10601]",PHCS,,215.34,70,,,,,0,35.78,261.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 54MM TI",SUP-SPL-60540-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,188.41,1377,"percent of total billed charges",
"SCR BONE 3.2MM 14MM HEXAGON ANKLE CORTICAL LAG",SUP-HEX3.2-14,CDM,C1713,HCPCS,0278,RC,,,both,,,729.00,218.7,"CIGNA [10200]",Cigna,,495.72,68,,1831.33,1831.33,1831.33,16,84.78,619.65,"percent of total billed charges",
"SUT VICRYL PLUS 0 OS-4 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP694H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 240CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-240,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PHCS [10601]",PHCS,,5288.85,70,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 130MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355130,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"SCR BONE 3.5MM 44MM STARDRIVE STAINLESS STEEL T15 SELF TAP",SUP-02.127.144,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,131.73,962.8,"percent of total billed charges",
"COMPONENT FEMORAL 4 RIGHT MEDIAL LEFT LATERAL PARTIAL KNEE R",SUP-5610-F-402,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"KAISER [10500]",Kaiser,,6701.41,67,,,,,0,1163.24,8501.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 100MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,169.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 50MM 28MM HIP 2 MOBILITY BIRMINGHAM HIP",SUP-74121650,CDM,C1776,HCPCS,0278,RC,,,both,,,6582.60,1974.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,780.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,765.56,5595.21,"percent of total billed charges",
"BLADE LARYNSCP C-MAC S D HYPERANGULATE VIDEO DISPOSABLE",SUP-051216-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,191.40,57.42,"UHC [10700]","United Healthcare",,121.16,63.3,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 55MM LOW PROFILE SCREWS TITANIUM PARTIAL",SUP-AR-8945-55PT,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR TUBING HUB SIDE ARM POLYURETHANE 4FR CATH 8IN RED",SUP-VA-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.10,33.93,"FIRST HEALTH [10303]","First Health",,90.48,80,,,,,0,13.15,96.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 50CM PRECISION INFINION 16 LEAD",SUP-SC-2316-50,CDM,C1897,HCPCS,0278,RC,,,both,,,17640.00,5292,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5048.57,28.62,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 14GA 11CM 20MM ACHIEVE SAMPLE NOTCH ECHOGENIC",SUP-A1411,CDM,S27200284,LOCAL,0272,RC,,,both,,,338.00,101.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RASP SURGICAL 2.4MM HELIOCOID DISPOSABLE STERILE LATEX FREE",SUP-1608-002-103,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,MAJOR",279,APR-DRG,,,,,,,inpatient,,,50186.53,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $7,995.04. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($35,682.71) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ROADRUNNER VASCULAR ANGLE SPRING COIL 180CM 5CM .018IN",SUP-G07557,CDM,C1769,HCPCS,0272,RC,,,both,,,846.37,253.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOFT-VU 65CM 5FR 1.8MM STRAIGHT FLUSH CURVE",SUP-H787107086035,CDM,C1887,HCPCS,0272,RC,,,both,,,190.36,57.11,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT ASSURANT COBALT 30MM 80CM 9MM BILIARY COCR 2 LUMEN",SUP-ASC930SV,CDM,C1876,HCPCS,0278,RC,,,both,,,6444.60,1933.38,"MULTIPLAN [10600]",Multiplan,,5477.91,85,,,,,0,749.51,5477.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC EVERA MRI SURESCAN DF-1 PIN PLUG XT DR",SUP-DDMB1D1,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"CIGNA [10200]",Cigna,,16224,40,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ANGIOGRAPHY INJECTOR STERILE PULSE SPRAY DISPOSABLE",SUP-12300801,CDM,S27200284,LOCAL,0272,RC,,,both,,,609.12,182.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,414.2,68,,,,,0,70.84,517.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM EVOLVE STAINLESS STEEL CORTICAL ELBOW",SUP-4972712L,CDM,C1713,HCPCS,0278,RC,,,both,,,1710.00,513,"BLUE CROSS [10001]","Blue Cross HMO",,670.32,39.2,,957.42,156.86,7483.26,51,198.87,1453.5,"percent of total billed charges",
"CATH 14FR URETHRAL SILICONE 10ML FOLEY 2 WAY COUDE TIP",SUP-DYND11591,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.36,38.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,87.96,68,,,,,0,15.04,109.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.440TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,578.57,28.62,,,,,0,235.11,1718.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RENAL FAILURE WITH CC",683,MS-DRG,,,,,,,inpatient,,,27646.67,8294,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,5812.92,,"Case rate ($5,432.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,044.58, add-ons for qualifying new technology services are included. If operating cost exceeds $38,084.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,763.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,051.25. The transfer operating threshold is the transfer adjustment factor * $5,044.58 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $381.39. The transfer capital threshold is the transfer adjustment factor * $381.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,5432.64,21841.58,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE NOVAGOLD ENDOSCOPIC STRAIGHT 480CM .018IN BILIARY",SUP-M00552011,CDM,C1769,HCPCS,0272,RC,,,both,,,1460.03,438.01,"KAISER [10500]",Kaiser,,978.22,67,,,,,0,169.8,1241.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 28MM 144CM 4.5MM CORONARY STENT",SUP-H7493941828450,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 6 RIGHT DISTAL KNEE",SUP-5541-A-602,CDM,C1776,HCPCS,0278,RC,,,both,,,5742.83,1722.85,"AETNA [10100]","Aetna HMO/PPO",,4565.55,79.5,,10981.53,8986.79,12413.38,12,667.89,4881.41,"percent of total billed charges",
"STEM HUMERAL 98MM 14MM PRESS FIT REUNION S SHOULDER",SUP-5567P3014,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Local Plus",,5433.75,31.5,,5372.07,4581.20,7242.98,23,2006.18,14662.5,"percent of total billed charges",
"MESH SURGICAL VERTESSA LITE 26X5CM 4CM LIGHTWEIGHT FLEXIBLE",SUP-CAL-VLY2654,CDM,C1781,HCPCS,0278,RC,,,both,,,6285.90,1885.77,"CIGNA [10200]","Cigna Open Access",,3576.68,56.9,,11235.02,819.42,11235.02,"1 through 10",731.05,5343.02,"percent of total billed charges",
"CMPNT FEMORAL 3 59X53MM RIGHT KNEE TOTAL STABILIZED",SUP-5512-F-302,CDM,C1776,HCPCS,0278,RC,,,both,,,20599.49,6179.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5561.86,27,,,,,0,2395.72,17509.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rem Contraceptive Capsule",PX-761000072,CDM,11976,CPT,0761,RC,,,both,,,1523.00,456.9,"CIGNA [10200]","Cigna Open Access",,1523,,"Per diem ($2,181).",,,,0,177.12,1523,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 59CM ENDOCARDIUM 4 SITE 2 COIL PASSIVE FIXATION",SUP-0265,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS [10001]","Blue Cross PPO",,6731.42,39.2,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE CUTTER 3.5MM STRAIGHT ARTHROSCOPIC STERILE DISPOSABLE",SUP-7205308,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.00,84.9,"CIGNA [10200]","Cigna Open Access",,161.03,56.9,,,,,0,32.91,240.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 12X22X60MM 5DEG LORDOTIC TITANIUM ALLOY MODULUS",SUP-1223260P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Local Plus",,8930.25,31.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 7-0 C-1 30IN 2 ARM MONOFILAMENT BLUE",SUP-8708H,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.76,52.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM BIOPSY SHARKCORE FINE OD22 GA NEEDLE",SUP-DSC-22-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,2865.00,859.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CIRCUIT BREATHING LOW FLOW DELIVERY TUBE WATER PATH VAPOR",SUP-PF-DPC-LOW,CDM,S27000186,LOCAL,0270,RC,,,both,,,849.12,254.74,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LANTERN 115CM 3CM 2.6-2.95FR .025IN 45D MICRO DELIVERY",SUP-PXSLIMLAN115T45,CDM,S27200284,LOCAL,0272,RC,,,both,,,4071.00,1221.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PIN EXTERNAL FIXATION 40MM 6MM JET-X LONG TITANIUM NITRIDE",SUP-71066409,CDM,C1887,HCPCS,0272,RC,,,both,,,2153.25,645.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"6F DECA 2-8-2 MPD-SL. 110CM",SUP-901718,CDM,C1730,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.75MM X 18.0MM",SUP-492751812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FOGARTY 80CM 5FR 8MM EMBOLECTOMY ADHERENT CLOT",SUP-140808,CDM,C1757,HCPCS,0272,RC,,,both,,,1763.85,529.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONVEY 100CM 7FR AR1 CURVE GUIDING HYDROPHILIC FEMORAL",SUP-H74939265170,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FIBER LASER MOSES 80HZ 60W 2J 200UM D/F/L LITHOTRIPSY",SUP-AC-10030100,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 15MM 3MM 1.5MM 1.2MM BALLOON DILATATION RAPID",SUP-DC-RY3015UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,117.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 3.3MM 36MM STARDRIVE NAIL-EX TITANIUM 7%",SUP-04.005.426,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"AMERIGROUP MEDICAID [20100]",Amerigroup,,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",134.52,983.18,"percent of total billed charges",
"CATH NC TREK 143CM 20MM 4MM ROUND BALLOON DILATATION",SUP-1012453-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 18MM 145CM 2.25MM CORONARY STENT",SUP-1145225-18,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross PPO",,2288.5,39.2,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .047IN JUDKINS RIGHT",SUP-534525T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 2.25MM CORONARY RAPID EXCHANGE",SUP-ONYXNG22508UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,305.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-150440105,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"MULTIPLAN [10600]",Multiplan,,25596.9,85,,,,,0,3502.26,25596.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR 1.5MM BONE TAMP GUIDE SLEEVE RADIOLUCENCY SUPERIOR",SUP-AR-4151DS,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1204.88,45.9,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 91X10.1X3.7MM STAINLESS STEEL 3.5MM SCR 7",SUP-02.100.107,CDM,C1713,HCPCS,0278,RC,,,both,,,4318.02,1295.41,"MULTIPLAN [10600]",Multiplan,,3670.32,85,,,,,0,502.19,3670.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 16CM 9FR SHEATH PEEL AWAY SPLIT",SUP-00491114A,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,183.1,41.1,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +24.5 DIOPTER MODIFIY C BICONVEX 13MM 6MM",SUP-ZMA00U0245,CDM,V2632,HCPCS,0276,RC,,,both,,,6175.50,1852.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,718.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 25MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-825,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"BLUE CROSS [10001]","Blue Cross HMO",,5275.71,39.2,,5311.50,4717.44,5388.59,31,1565.22,11439.68,"percent of total billed charges",
"SHUNT NEUROSURGICAL CSF 87CM LUMBOPERITONEAL CATH T STERILE",SUP-44520,CDM,S27800098,LOCAL,0278,RC,,,both,,,6715.22,2014.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1921.9,28.62,,,,,0,780.98,5707.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 8 HOLE LOW PROFILE STRAIGHT BONE RIGHT CLAVICLE",SUP-70-0299,CDM,S27800098,LOCAL,0278,RC,,,both,,,6610.20,1983.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,783.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 4.0MM X 15.0MM",SUP-494001512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PNEUMOTHORAX WITHOUT CC/MCC",201,MS-DRG,,,,,,,inpatient,,,26856.90,8057.07,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) DELIVERY DEVICE GEN II (50-200MG)",SUP-P-1075,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EUPHORA 142CM 6MM 1.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP1506X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SALIVARY GLAND PROCEDURES",139,MS-DRG,,,,,,,inpatient,,,68260.63,20478.19,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 18MM 140CM 3MM 2.1-2.7FR CORONARY STENT",SUP-RONYX30018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3309.38,992.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,392.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,384.88,2812.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRESSING FOAM MEPILEX TRANSFER SAFETAC SILVER THIN L8 IN X W",SUP-394890,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.61,51.78,"PHCS [10601]",PHCS,,120.83,70,,,,,0,20.07,146.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.7MM 8MM VARIAX T5 NONSTERILE",SUP-662608,CDM,C1713,HCPCS,0278,RC,,,both,,,843.70,253.11,"CIGNA [10200]","Cigna Local Plus",,451.38,53.5,,3978.14,359.25,3978.14,24,98.12,717.15,"percent of total billed charges",
"VIABAHN SX ENDO HEPARIN 35 RO 9MMX10CM 8FR 120CMCATH",SUP-VBHR091002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8507.52,40,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM SENSAR INTRAOCULAR LENS, BICONVEX, 21.5 DIOPTER",SUP-AR40E00215,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"CIGNA [10200]","Cigna Local Plus",,498.35,53.5,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 15MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDS32515,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9655.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MONTEREY AL STAND-ALONE ANTERIOR LUMBAR ANTERIOR LUMBAR CAGE",SUP-480114531,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14241.15,41.1,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BIOPSY 11.5CM 20GA 19GA QUICK-CORE ECHOTIP 20MM SOFT",SUP-G08788,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INFLATION INDEFLATOR PLUS 30 .096IN CORONARY ROTATE",SUP-1000185,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 86CM KIT STIFF QUICKSITE LEFT HEART TAPER 15CM",SUP-4078S/86/15,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"FIRST HEALTH [10303]","First Health",,460.08,80,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO PEEL-AWAY SAFE-T-J PERCUTANEOUS STAINLESS STEEL 2",SUP-G04500,CDM,C1892,HCPCS,0272,RC,,,both,,,417.51,125.25,"NOVANET [10819]",Novanet,,313.13,75,,,,,0,48.56,354.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MONARQ TTVR SYSTEM LARGE IMPLANT",SUP-DWG-4710,CDM,S62400003,LOCAL,0624,RC,,,both,,,182400.00,54720,"KAISER [10500]",Kaiser,,122208,67,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM VANGUARD TKR KNEE CEMENT",SUP-98B00200127,CDM,C1776,HCPCS,0278,RC,,,both,,,19530.00,5859,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7812,40,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 12MM 145CM 2.5MM CORONARY STENT",SUP-1125250-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross PPO",,2288.5,39.2,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LOCKING 7 HOLE DISTAL MEDIAL TIBIAL 98MM STAINLESS",SUP-223.571,CDM,C1713,HCPCS,0278,RC,,,both,,,1913.10,573.93,"BLUE CROSS [10001]","Blue Cross HMO",,749.94,39.2,,957.42,156.86,7483.26,51,222.49,1626.14,"percent of total billed charges",
"SPACER SPINAL 25X10X12MM VERTE-STACK CRESCENT 6D",SUP-9192512,CDM,S27800098,LOCAL,0278,RC,,,both,,,19235.66,5770.7,"FIRST HEALTH [10303]","First Health",,15388.53,80,,,,,0,2237.11,16350.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR CERAMIC BIPOLAR STD HEAD",SUP-98B00100103,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"FIRST HEALTH [10303]","First Health",,7728,80,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAPAROTOMY TRAY",SUP-SBA21LPUHQ,CDM,S27200284,LOCAL,0272,RC,,,both,,,675.14,202.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,78.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.52,573.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PEN 19CM ISOLATOR TRANSPOLAR",SUP-MAX1,CDM,S27200284,LOCAL,0272,RC,,,both,,,12420.00,3726,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1444.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 6.0 MM X 60 MM X 130 CM",SUP-IPU06006013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,956.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00200,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,501.92,45.9,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM LOW PROFILE SCREWS TITANIUM T15 FULL",SUP-AR-8935-24,CDM,C1713,HCPCS,0278,RC,,,both,,,486.00,145.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,57.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,56.52,413.1,"percent of total billed charges",
"VALVE CATH REPLACEMENT RADIOPAQUE ROCKET INDWELL PLEURAL",SUP-R54410-00-VV,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,37.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 20MM 7MM STAINLESS STEEL LONG THREAD FOOT HAND",SUP-02.226.120,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"BLUE CROSS [10001]","Blue Cross PPO",,644.92,39.2,,957.42,570.23,957.42,28,191.34,1398.42,"percent of total billed charges",
"AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC",474,MS-DRG,,,,,,,inpatient,,,146293.47,43888.04,"AETNA [10100]","Aetna HMO/PPO",,80770.91,,"Fee schedule rate ($80,770.91). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,8593,125335.51,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL 3.5 X 160MM CANNULATED 3/16 SQ. CONNECTION",SUP-P99-110-3516,CDM,S27000186,LOCAL,0270,RC,,,both,,,1004.40,301.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4545,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T 53MM TITANIUM 2X8 HOLE BONE HAND NONSTERILE",SUP-447.232,CDM,C1713,HCPCS,0278,RC,,,both,,,2461.20,738.36,"BLUE CROSS [10001]","Blue Cross HMO",,964.79,39.2,,957.42,156.86,7483.26,51,286.24,2092.02,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 18MM 145CM 3.25MM CORONARY STENT",SUP-1145325-18,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"FIRST HEALTH [10303]","First Health",,4670.4,80,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502606602,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2709.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 4FR 100CM TRIFORCE FLEXOR PEEL-AWAY STRAIGHT CURVE",SUP-G56417,CDM,S27200284,LOCAL,0272,RC,,,both,,,2711.18,813.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,EXTREME",045,APR-DRG,,,,,,,inpatient,,,85470.59,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $21,566.63. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($119,119.75) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 180CM 63CM HEMOSTASIS VALVE SUPER STIFF",SUP-406948,CDM,C1893,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONTROL CHEMISTRY 1ML LEVEL 1 ASSAYED LIQUID HUMAN WHOLE",SUP-171,CDM,C1895,HCPCS,0278,RC,,,both,,,362.79,108.84,"KAISER [10500]",Kaiser,,243.07,67,,,,,0,42.19,308.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEURAL EFFUSION WITH MCC",186,MS-DRG,,,,,,,inpatient,,,52193.67,15658.1,"AMBETTER EXCHANGE  [11102]",Ambetter,,9667.47,,"Case rate ($9,667.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,976.90, add-ons for qualifying new technology services are included. If operating cost exceeds $42,016.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,060.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $8,988.77. The transfer operating threshold is the transfer adjustment factor * $8,976.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $678.70. The transfer capital threshold is the transfer adjustment factor * $678.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",17360.30,17360.30,17360.30,"1 through 10",7561,38867.43,other,"INPATIENT DRG"
"ACCESS 6719  PIN PLUG ASSY KIT DF-1 PORT",SUP-6719,CDM,S27800098,LOCAL,0278,RC,,,both,,,348.00,104.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,41.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 7X9MM ARTHREX DYNANITE NITINOL TITANIUM STERILE",SUP-AR-8717DS-0907,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4239.67,41.1,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 E 36MM LONGEVITY HIP STERILE LUMEN LATEX",SUP-20123605,CDM,C1776,HCPCS,0278,RC,,,both,,,8101.98,2430.59,"PHCS [10601]",PHCS,,5671.39,70,,,,,0,942.26,6886.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 14CM 6MM LEGEND CYL FLUTED LARGE BORE 7.9MM",SUP-14CY60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.28,371.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,146.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.9,1051.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TF (-T) LOADING SYSTEM LHR-0081",SUP-LHR-0081,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 36CM FEMUR META-NAIL INTRAMEDULLARY RETROGRADE",SUP-71653036,CDM,C1713,HCPCS,0278,RC,,,both,,,15941.76,4782.53,"MULTIPLAN [10600]",Multiplan,,13550.5,85,,,,,0,1854.03,13550.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM ORTHOLOC FULL THREAD CORTICAL ANKLE FOOT",SUP-58813510,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"CIGNA [10200]",Cigna,,523.26,68,,1831.33,1831.33,1831.33,16,89.49,654.08,"percent of total billed charges",
"PIN ALIGNMENT 200MM 2.5MM AEQUALIS SHOULDER GLENOID STERILE",SUP-DWD063,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"PHCS [10601]",PHCS,,1089.2,70,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 6.5MM BARREL DIAMOND EXTRA COURSE",SUP-5130-020-160,CDM,S27200284,LOCAL,0272,RC,,,both,,,955.23,286.57,"AETNA [10100]","Aetna HMO/PPO",,759.41,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.09,811.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PLUS PROFILE SILICONE",SUP-SCLP-190,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]","Cigna Local Plus",,4042.19,,,,,,,878.7,6422.18,"percent of total billed charges",
"SYSTEM RESOLUTE INTEGRITY 34MM 140CM 3MM CORONARY STENT",SUP-RSINT30034UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,644.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTEFILL ALLOGRAFT FREEZE DRIED 20X15-17X15MM",SUP-12015,CDM,S27800098,LOCAL,0278,RC,,,both,,,15456.00,4636.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4423.51,28.62,,,,,0,1797.53,13137.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 18MM 4.5MM EMBOLIZATION NEUROVASCULAR",SUP-PED-450-18,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"BLUE CROSS [10001]","Blue Cross PPO",,30164.4,39.2,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYCLOPENTOLATE 1 % EYE DROPS",RX-2025,CDM,,,0250,RC,24208-0735-01,NDC,both,2,ML,102.72,30.82,"FIRST HEALTH [10303]","First Health",,82.18,80,,,,,0,11.95,87.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 85MM 20MM ASNIS III STAINLESS STEEL HIP SELF",SUP-326085S,CDM,C1713,HCPCS,0278,RC,,,both,,,1904.40,571.32,"CIGNA [10200]",Cigna,,1294.99,68,,1831.33,1831.33,1831.33,16,221.48,1618.74,"percent of total billed charges",
"CATH CORDIS SABER 150CM 200MM 2.5MM BALLOON DILATATION",SUP-48002520X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRACKER NAVIGATION COPILOT Q 360D STERILE LATEX FREE",SUP-5502-100-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,10225.80,3067.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1211.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1189.26,8691.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC",379,MS-DRG,,,,,,,inpatient,,,23864.19,7159.26,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,4145.03,,"Case rate ($3,910.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,631.08, add-ons for qualifying new technology services are included. If operating cost exceeds $36,670.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,656.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,635.88. The transfer operating threshold is the transfer adjustment factor * $3,631.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $274.53. The transfer capital threshold is the transfer adjustment factor * $274.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,3910.41,15721.55,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC",379,MS-DRG,,,,,,,inpatient,,,23864.19,7159.26,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,7962.38,,"Case rate ($3,910.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,631.08, add-ons for qualifying new technology services are included. If operating cost exceeds $36,670.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,656.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,635.88. The transfer operating threshold is the transfer adjustment factor * $3,631.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $274.53. The transfer capital threshold is the transfer adjustment factor * $274.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,3910.41,15721.55,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 12MM 144CM 4MM",SUP-H7493941212400,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"KAISER [10500]",Kaiser,,5200.88,67,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOPROSTHESIS STENT AORTOILIAC L59MM DIA8MM VIABAHN V",SUP-BXBL085902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS [10001]","Blue Cross PPO",,7645.88,39.2,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT",SUP-G47439,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,29372.28,28.62,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 5MM 6FR ENDOPROSTHESIS HEPARIN",SUP-VBJR051502A,CDM,C1874,HCPCS,0278,RC,,,both,,,25143.30,7542.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6788.69,27,,,,,0,2924.17,21371.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 24CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155242180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 4.6MM SUREFORM 45 STERILE LATEX FREE DISPOSABLE",SUP-48345T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40030W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"PHCS [10601]",PHCS,,3807.3,70,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 8FR 8MM ENDOPROSTHESIS HEPARIN",SUP-VBHR080502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"NOVANET [10819]",Novanet,,14071.05,75,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 37MM 135CM 7MM VASCULAR BALLOON EXPANDABLE",SUP-LSMU1350737,CDM,C1874,HCPCS,0278,RC,,,both,,,15870.00,4761,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1880.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 18MM 140CM 3MM CORONARY",SUP-RSINT30018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"BLUE CROSS [10001]","Blue Cross HMO",,2173.25,39.2,,9776.84,9776.84,9776.84,"1 through 10",644.77,4712.4,"percent of total billed charges",
"INSRT TIBIAL 4 10MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620410,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]",Cigna,,7652.65,68,,5873.17,5873.17,5873.17,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"SET JEJUNOSTOMY 100CM 10.2FR 16FR CAREY-ALZATE-COONS .038IN",SUP-G02956,CDM,S27200284,LOCAL,0272,RC,,,both,,,1832.85,549.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,753.3,41.1,,,,,0,213.16,1557.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 52CM 20FR 8FR NEPHRSTMY PERCUFLEX STENTING",SUP-M001224200,CDM,C1729,HCPCS,0272,RC,,,both,,,599.40,179.82,"UHC [10700]","United Healthcare",,379.42,63.3,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 217MM 34-38MM 33-34MM ZENITH ALPHA CAPTOR",SUP-G38190,CDM,C1874,HCPCS,0278,RC,,,both,,,96672.00,29001.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,38668.8,40,,,,,0,11242.95,82171.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC",461,MS-DRG,,,,,,,inpatient,,,226474.50,67942.35,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,35287.29,,"Case rate ($34,259.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $31,812.27, add-ons for qualifying new technology services are included. If operating cost exceeds $64,851.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,787.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $31,854.34. The transfer operating threshold is the transfer adjustment factor * $31,812.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,405.16. The transfer capital threshold is the transfer adjustment factor * $2,405.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.",,,,0,7561,161249.51,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TOURGUIDE 180D 45CM 9MM 7FR CATH HYDROPHILIC",SUP-TG0704509,CDM,C1887,HCPCS,0272,RC,,,both,,,4209.00,1262.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,498.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,489.51,3577.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 23MM 145CM 2.75MM CORONARY STENT",SUP-1145275-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1670.84,28.62,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URETHRAL STRICTURE",697,MS-DRG,,,,,,,inpatient,,,52373.15,15711.94,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,14374.17,,"Case rate ($6,685.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,208.09, add-ons for qualifying new technology services are included. If operating cost exceeds $39,247.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,851.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,216.30. The transfer operating threshold is the transfer adjustment factor * $6,208.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $469.36. The transfer capital threshold is the transfer adjustment factor * $469.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,6685.66,26879.25,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 35CM 20FR NEPHRSTMY DRNG STERILE LATEX FREE",SUP-M0064101020,CDM,C1729,HCPCS,0272,RC,,,both,,,551.53,165.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,226.68,41.1,,,,,0,64.14,468.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 4.00 X 32MM",SUP-H7493942832400,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2850.39,45.9,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR 24CM 5CM 6FR .035IN 2",SUP-M006192132080,CDM,C2617,HCPCS,0278,RC,,,both,,,1319.25,395.77,"PHCS [10601]",PHCS,,923.48,70,,,,,0,153.43,1121.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH DURAL 3X3IN DUREPAIR CRANIAL BOVINE CLLGN MATRIX",SUP-62105,CDM,,,0278,RC,,,both,,,6563.00,1968.9,"CIGNA [10200]","Cigna Open Access",,3734.35,56.9,,,,,0,6.56,5578.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR ANGLE 150CM .038IN HYDROPHILIC FIX CORE",SUP-H2OSTDA38150,CDM,C1769,HCPCS,0272,RC,,,both,,,278.40,83.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,32.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 194MM 100MM 8MM 9FR BILIARY PERMALUME",SUP-M00547460,CDM,C1874,HCPCS,0278,RC,,,both,,,17194.52,5158.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2037.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1999.72,14615.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 18MM 140CM 3MM CORONARY STERILE LATEX",SUP-453946,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 40MMX8MMX15CM 26FR",SUP-TAC084015A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,49248,27,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 75CM 7MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR071501A,CDM,C1874,HCPCS,0278,RC,,,both,,,21577.50,6473.25,"CIGNA [10200]","Cigna Local Plus",,6796.91,31.5,,,,,0,2509.46,18340.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC",857,MS-DRG,,,,,,,inpatient,,,59768.28,17930.48,"BLUE CROSS [10001]","Blue Cross HMO",,49161.97,,,,,,,7561,59768.28,"case rate",
"SUT VICRYL RAPIDE MULTIPASS 4-0 PS-2 18IN BRAID COATED",SUP-VR496,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.87,20.06,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FILTER PERFUSION SENTRY PRIMEGARD 20UM MICRO STANDALONE",SUP-5343,CDM,S27200284,LOCAL,0272,RC,,,both,,,1449.90,434.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TACTIFLEX SE UNID CURVE F",SUP-A-TFSE-F,CDM,C2630,HCPCS,0272,RC,,,both,,,25061.40,7518.42,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"BIT DRILL 160MM 3.5MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.68,CDM,S27000186,LOCAL,0270,RC,,,both,,,2271.60,681.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE GLDEWIRE GLIDE TECHNOLOGY VASCULAR STD STRAIGHT 180CM",SUP-GS3503,CDM,C1769,HCPCS,0272,RC,,,both,,,426.30,127.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT ORTHOPEDIC LARGE 8IN WRIST LEFT BLACK",SUP-A120107,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.46,17.54,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT TRACH CARE PROVOX TRUTONE PLUS 9 PULMONARY BASE",SUP-6139,CDM,S27000186,LOCAL,0270,RC,,,both,,,8264.52,2479.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE WIRE SAW 1.4MM 20IN 6 TWISTED WIRE GIGLI",SUP-FH415,CDM,S27000186,LOCAL,0270,RC,,,both,,,75.71,22.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SUPREME 120CM 6FR 5MM SPACING DAO CURVE",SUP-401445,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 125MM 2.5MM SPS AXSOS STD AO LOCK PLATE SYSTEM",SUP-700347,CDM,S27000186,LOCAL,0270,RC,,,both,,,147.00,44.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CIRCUIT HUMD AEROSOL HIGH FLOW HIGH VELOCITY THERAPY 2.0",SUP-HVT-ADPC-HIGH,CDM,S27000186,LOCAL,0270,RC,,,both,,,1412.10,423.63,"MULTIPLAN [10600]",Multiplan,,1200.29,85,,,,,0,164.23,1200.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE ORTHOPEDIC VITALLIUM 2MM HIP HOMOGENOUS GRIP",SUP-6704-0-210,CDM,C1713,HCPCS,0278,RC,,,both,,,2144.61,643.38,"FIRST HEALTH [10303]","First Health",,1715.69,80,,,,,0,249.42,1822.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 24IN 29- IN KNEE CONTACT CLSR 3",SUP-79-80030,CDM,S27000186,LOCAL,0270,RC,,,both,,,130.85,39.25,"CIGNA [10200]",Cigna,,88.98,68,,,,,0,15.22,111.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG PRESSURE INFUSER 1000ML WITH HOOK INFU-SURG REPROCESSED",SUP-4010HR,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.59,15.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6,43.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPLEX AORTIC ARCH PROCEDURES",209,MS-DRG,,,,,,,inpatient,,,404524.58,121357.37,"CIGNA [10200]","Cigna Local Plus",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 44%. Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP070200090 PLUS US D7L200UL900",SUP-PCP070200090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 6FR .071IN EXTRA BACKUP 4.5 LEFT CURVE GUIDING",SUP-LA6EBU45SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL DIA11.5MM HOLLOW FOR 9.5MM MULTILOC PROXIMAL HUMER",SUP-03.019.004,CDM,S27200284,LOCAL,0272,RC,,,both,,,2383.50,715.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 40MM 9MM BALLOON",SUP-U357594,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BONE MARROW ASPIRATION 11GAUGE 11CM NEEDLE W/SIDE HOLES-STER",SUP-710.111.99S,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.80,262.44,"FIRST HEALTH [10303]","First Health",,699.84,80,,,,,0,101.74,743.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION",RX-14953,CDM,,,0250,RC,81033-0104-05,NDC,both,5,ML,143.41,43.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.68,121.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 26FR 8.6MM MINOP BLUNT OBTR TIP SHEATH DEPTH SCALE",SUP-FH641SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,2070.45,621.13,"KAISER [10500]",Kaiser,,1387.2,67,,,,,0,240.79,1759.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REPROCESSED CATHETER EAGLE EYE 150CM 5FR 20MM 20MHZ SHORT TA",SUP-85900PSTR,CDM,C1753,HCPCS,0272,RC,,,both,,,3341.25,1002.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1373.25,41.1,,,,,0,388.59,2840.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE 43CM 5MM CENTIMETER MARKING PALPATION ENDOSCOPIC",SUP-26178T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAPROXEN 250 MG TABLET, IMMEDIATE RELEASE",RX-5391,CDM,,,0637,RC,65162-0188-10,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 STD KNEE LEFT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB6SL,CDM,C1776,HCPCS,0278,RC,,,both,,,17652.60,5295.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4766.2,27,,,,,0,2053,15004.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 18MM LAG NONSTERILE",SUP-S30-18S-11,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT WALKING CNFRM AUTO-MOLD 10-11 FOOT LEFT FOAM 2 DENSITY",SUP-AL241110,CDM,S27000186,LOCAL,0270,RC,,,both,,,903.15,270.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,371.19,41.1,,,,,0,105.04,767.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 24MM TITANIUM SPINE CANCELLOUS SELF TAP 2",SUP-489.145,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 3CM 1.5MM GALAXY G3 MINI STRETCH",SUP-GLM915030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"NOVANET [10819]",Novanet,,8911.35,75,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE TOTAL LEGION GII PS OXI NP TIB HI DMD INS",SUP-71704572,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS [10001]","Blue Cross HMO",,8643.6,39.2,,5311.50,4717.44,5388.59,31,2564.42,18742.5,"percent of total billed charges",
"KIT CATH SOFT 5FR LATEX FREE PEDIATRIC",SUP-CKF155L,CDM,S27200284,LOCAL,0272,RC,,,both,,,51.24,15.37,"AETNA [10100]","Aetna HMO/PPO",,40.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.96,43.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 18-20MM 0-34MM COREVALVE EVOLUT 23MM HEART",SUP-MCS-P4-23-AOA-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"UHC [10700]","United Healthcare",,108243,63.3,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING ANESTHESIA SAMPLE PORT BAG FILTER MASK 72",SUP-DF475-6121Z,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.86,18.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25.42,41.1,,,,,0,7.19,52.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 75CM 1.3MM VECTRIS SURESCAN 4MM SPACE 1X8",SUP-977A275,CDM,C1778,HCPCS,0278,RC,,,both,,,13800.00,4140,"CIGNA [10200]","Cigna Open Access",,4623,33.5,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 8.25MM 9CM PARTIAL THREAD OBTR TRANSLUCENT",SUP-AR-6575-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 175MM 8MM SMALL SHELL REVISION ALTIVATE REVERSE",SUP-533-08-175,CDM,C1776,HCPCS,0278,RC,,,both,,,43228.40,12968.52,"AETNA [10100]","Aetna HMO/PPO",,34366.58,79.5,,10981.53,8986.79,12413.38,12,5027.46,36744.14,"percent of total billed charges",
"SLEEVE CENTERING 13.5MM S-ROM ZTT 14B LARGE HIP PROXIMAL",SUP-550502,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4473.63,41.1,,6417.48,6417.48,6417.48,"1 through 10",1265.9,9252.04,"percent of total billed charges",
"GRAFT BONE MDII ALLOGRAFT 26MMX16MM",SUP-401316,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE BIOPSY 6MM BRONCHIAL",SUP-HU-VS-6,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOTHYROXINE 125 MCG TABLET",RX-4424,CDM,,,0637,RC,51079-0443-01,NDC,both,1,UN,6.27,1.88,"FIRST HEALTH [10303]","First Health",,5.02,80,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY 13CM 14GA BARD MARQUEE CORE ENHANCE TROCAR TIP",SUP-MQ1413,CDM,S27200284,LOCAL,0272,RC,,,both,,,514.35,154.3,"PHCS [10601]",PHCS,,360.05,70,,,,,0,59.82,437.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 4MM 1.2MM 28MM 6MM STAINLESS STEEL SHORT THREAD",SUP-202.628,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"PHCS [10601]",PHCS,,777.01,70,,,,,0,129.1,943.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 100MM 130CM 7MM LONG VASCULAR NITINOL",SUP-SC7100LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"AETNA [10100]","Aetna HMO/PPO",,7131.15,79.5,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 108MM RADIUS CURVE 104X10.2X2.7MM STAINLESS STEEL 3.5",SUP-245.878,CDM,C1713,HCPCS,0278,RC,,,both,,,4488.04,1346.41,"MULTIPLAN [10600]",Multiplan,,3814.83,85,,,,,0,521.96,3814.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM 1.25MM PERI-LOC VLP KIRSCHNER STAINLESS",SUP-71161012,CDM,C1713,HCPCS,0278,RC,,,both,,,390.54,117.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,45.42,331.96,"percent of total billed charges",
"SHELL ACETABULAR HEMI 3HL 52MM",SUP-430-98-052,CDM,C1776,HCPCS,0278,RC,,,both,,,16956.34,5086.9,"FIRST HEALTH [10303]","First Health",,13565.07,80,,,,,0,1972.02,14412.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 5 LEFT DISTAL KNEE",SUP-5541-A-501,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,565.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,554.87,4055.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM DVR RADIUS CORTICAL DISTAL LOCK 3 LEAD",SUP-131227112,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,523.91,39.2,,957.42,570.23,957.42,28,155.43,1136.03,"percent of total billed charges",
"CATH LAUNCHER 100CM 6FR .071IN EXTRA BACKUP 3.75 LEFT CURVE",SUP-LA6EBU375SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 11MM KNEE XLPE POSTERIOR STABILIZE HIGH",SUP-71453212,CDM,C1776,HCPCS,0278,RC,,,both,,,13420.50,4026.15,"CIGNA [10200]","Cigna Open Access",,4495.87,33.5,,5302.19,4377.88,6578.61,27,1560.8,11407.43,"percent of total billed charges",
"LOTUS VALVE SYSTEM 25MM REPRISE III",SUP-H749LTVR3CL250,CDM,S62400003,LOCAL,0624,RC,,,both,,,142500.00,42750,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16886.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16572.75,121125,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 100MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.900,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,162.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",159.84,1168.25,"percent of total billed charges",
"PAD POSITIONING W8.6XL95.9CM LEG HOLDER 2 SPECIAL FOAM SECUR",SUP-R-S4133-V,CDM,S27000186,LOCAL,0270,RC,,,both,,,220.19,66.06,"KAISER [10500]",Kaiser,,147.53,67,,,,,0,25.61,187.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM CLAW CHARLOTTE STAINLESS STEEL LOCK",SUP-40122720,CDM,C1713,HCPCS,0278,RC,,,both,,,1344.60,403.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,914.33,68,,,,,0,156.38,1142.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 30CM 3CM 6FR .035IN PIGTAIL",SUP-M006180225190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]","Cigna Local Plus",,676.98,,,,,,,147.16,1075.57,"percent of total billed charges",
"PLATE 72MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 5",SUP-223.551,CDM,C1713,HCPCS,0278,RC,,,both,,,1770.30,531.09,"NOVANET [10819]",Novanet,,1327.73,75,,,,,0,205.89,1504.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 129MM STAINLESS STEEL 2.7/3.5MM SCR 7 HOLE LCP",SUP-02.112.114S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,1831.33,1831.33,1831.33,16,434.96,3179,"percent of total billed charges",
"PROSTATECTOMY WITHOUT CC/MCC",667,MS-DRG,,,,,,,inpatient,,,56410.72,16923.22,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,7170.6,,"Case rate ($6,861.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,371.67, add-ons for qualifying new technology services are included. If operating cost exceeds $39,411.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,863.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,380.10. The transfer operating threshold is the transfer adjustment factor * $6,371.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.73. The transfer capital threshold is the transfer adjustment factor * $481.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,6861.82,32296.62,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION",RX-225383,CDM,J0248,HCPCS,0636,RC,61958-2901-02,NDC,both,1,UN,2615.60,784.68,"UHC [10700]","United Healthcare",,1346,,,,,,,622.5,2223.26,"fee schedule",
"CATH 40MM 3CM BALLOON DILATATION",SUP-613705,CDM,C1725,HCPCS,0272,RC,,,both,,,2251.50,675.45,"KAISER [10500]",Kaiser,,1508.51,67,,,,,0,261.85,1913.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COAG SUCTION 6IN 10FR 3/8IN VALLEYLAB POLYOLEFIN PLASTIC",SUP-E3310,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.69,22.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,50.11,68,,,,,0,8.57,62.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 45MM 28MM TANDEM HIP ACETABULAR COCR",SUP-71322045,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"BLUE CROSS [10001]","Blue Cross PPO",,3274.16,39.2,,3949.44,3949.44,3949.44,"1 through 10",971.39,7099.58,"percent of total billed charges",
"HC NM Radrx Thrpy IV Admin",PX-342000012,CDM,79101,CPT,0342,RC,,,both,,,1444.31,433.29,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,592.6,,,,,,,84.19,1227.66,"fee schedule",
"STENT ABSOLUTE PRO 100MM 135CM 8MM VASCULAR NITINOL",SUP-1012536-100,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Open Access",,2355.66,56.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16026555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SALIVA SUBSTITUTE COMBO NO.9 MOUTHWASH",RX-166704,CDM,,,0250,RC,48582-0802-20,NDC,both,237,ML,37.27,11.18,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15.32,41.1,,,,,0,4.33,31.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM AXSOS STAINLESS STEEL T15 FEMUR HUMERUS",SUP-371540,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA [10200]",Cigna,,605.88,68,,1831.33,1831.33,1831.33,16,103.62,757.35,"percent of total billed charges",
"COMPONENT FEMORAL 4 KNEE LEFT CRUCIATE RETAINING PFC SIGMA P",SUP-940014,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3067.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3010.99,22006.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX PDS PLUS 2-0 SH SPIRAL 5IN ABSORBABLE",SUP-256643,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.38,69.41,"AETNA [10100]","Aetna HMO/PPO",,183.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.91,196.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 1IN 20GA 90D INFUSION 1 HAND CLAMP UNIVERSAL LUER LOCK",SUP-H787LG201005,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.74,26.62,"PHCS [10601]",PHCS,,62.12,70,,,,,0,10.32,75.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAYONET 8IN STR TIP DN6214",SUP-DN6214,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,743.58,45.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.5MM X 12MM TI",SUP-VAN-15120-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Local Plus",,520.02,53.5,,3978.14,359.25,3978.14,24,113.04,826.2,"percent of total billed charges",
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 24MM COCR",SUP-VAL-20240-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"KAISER [10500]",Kaiser,,955.15,67,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 7MM 0MM ELBOW",SUP-TR-S0700-S,CDM,C1776,HCPCS,0278,RC,,,both,,,15145.50,4543.65,"FIRST HEALTH [10303]","First Health",,12116.4,80,,,,,0,1761.42,12873.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 4MM COOLCUT 8 FLUTE OVAL STERILE DISPOSABLE",SUP-AR-8400OBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"PHCS [10601]",PHCS,,351.26,70,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LASER CYCLO G6 MICROPULSE P3 CURVE TIP SWEEP MOTION",SUP-15522,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"AETNA [10100]","Aetna HMO/PPO",,1639.69,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 80MM 120CM 7MM 8FR STRAIGHT VASCULAR",SUP-AVSL07080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UHC [10700]","United Healthcare",,11564.91,63.3,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM .91-1.12MM 2.25MM CORONARY",SUP-RONYX22522W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]","Cigna Local Plus",,1805.63,53.5,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACETAZOLAMIDE 250 MG TABLET, IMMEDIATE RELEASE",RX-113,CDM,,,0637,RC,50268-0054-11,NDC,both,1,UN,21.07,6.32,"FIRST HEALTH [10303]","First Health",,16.86,80,,,,,0,2.45,17.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 47MM 26MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-47-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"NOVANET [10819]",Novanet,,3238.33,75,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 122.3CM 15FR ARGYLE SWAN NECK CURL CATH PRESTERNAL",SUP-8888121132,CDM,C1750,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CALCAR 29MM RESTORATION +30MM OFFSET HIP MODULAR",SUP-6276-4-329,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"MULTIPLAN [10600]",Multiplan,,19725.14,85,,,,,0,2698.86,19725.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 STD KNEE LEFT CRUCIATE RETAIN CEMENT PERSONA",SUP-42502606001,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9145.08,40,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 144MM 12MM PRESS FIT FULL PROFILE TAPERLOC PPS",SUP-51-101120,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9947.57,41.1,,6417.48,6417.48,6417.48,"1 through 10",2814.85,20572.84,"percent of total billed charges",
"KIT ANGIOGRAPHY AT-P54 IN PREMIUM HAND CONTROLLER",SUP-014644,CDM,S27000186,LOCAL,0270,RC,,,both,,,313.20,93.96,"CIGNA [10200]","Cigna Local Plus",,167.56,53.5,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-1504-40-106,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"PHCS [10601]",PHCS,,21079.8,70,,,,,0,3502.26,25596.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR TRABECULAR METAL CERAMIC HEAD",SUP-98786420000,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1635.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE REVERSED FX STEM",SUP-CAP-T-1058,CDM,C1776,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]",Cigna,,2550,68,,5873.17,5873.17,5873.17,"1 through 10",436.13,3187.5,"percent of total billed charges",
"LINER ACETABULAR EMPHASYS 48MM 36MM AOX ELEVATE",SUP-472248236,CDM,C1776,HCPCS,0278,RC,,,both,,,14038.05,4211.41,"BLUE CROSS [10001]","Blue Cross PPO",,5502.92,39.2,,3949.44,3949.44,3949.44,"1 through 10",1632.63,11932.34,"percent of total billed charges",
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 3 HIP",SUP-PRTLE023,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"KAISER [10500]",Kaiser,,12663,67,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT POSITIONING SHOULDER SUSPENSION KIT COBANT WRAP ARM",SUP-72200195,CDM,S27000186,LOCAL,0270,RC,,,both,,,558.90,167.67,"NOVANET [10819]",Novanet,,419.18,75,,,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CIRCUIT 480CM SET COAXIAL NONHEAT ELBOW ADPTR HAMILTON-C",SUP-260168,CDM,S27000186,LOCAL,0270,RC,,,both,,,522.98,156.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,240.05,45.9,,,,,0,60.82,444.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL GENESIS II 2 KNEE LEFT CEMENTED",SUP-71420162,CDM,C1776,HCPCS,0278,RC,,,both,,,16725.60,5017.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6690.24,40,,,,,0,1945.19,14216.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 16MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P316,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"NOVANET [10819]",Novanet,,6266.93,75,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SPIRE CD HORIZON 45MM STABILIZATION SPINE PELVIS",SUP-9240100,CDM,S27800098,LOCAL,0278,RC,,,both,,,17798.40,5339.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7315.14,41.1,,,,,0,2069.95,15128.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT XL 20 CC MATRIX BIOACTIVE S",SUP-74000200,CDM,C1713,HCPCS,0278,RC,,,both,,,27720.00,8316,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11088,40,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN FEMORAL RIGHT 3.5 CURVE",SUP-864101,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]","Cigna Open Access",,43.57,56.9,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE INFUSE RHBMP-2 2XS KIT LUMBAR SPINE LUMBAR",SUP-7510050,CDM,,,0278,RC,,,both,,,8128.20,2438.46,"BLUE CROSS [10001]","Blue Cross HMO",,8.13,.1,,,,,0,8.13,6908.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X20X8MM PIVOX 0D LATERAL OLIF25",SUP-2110145,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"MULTIPLAN [10600]",Multiplan,,22491,85,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PYROCARBON HEMI SHOULDER",SUP-CAP1109,CDM,C1776,HCPCS,0278,RC,,,both,,,50400.00,15120,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,14424.48,28.62,,,,,0,5861.52,42840,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP 10CC 2-4MM ALLOGRAFT GRANULE",SUP-12700501,CDM,C1713,HCPCS,0278,RC,,,both,,,12431.25,3729.37,"AETNA [10100]","Aetna HMO/PPO",,9882.84,79.5,,1521.93,481.35,16760.95,30,1445.75,10566.56,"percent of total billed charges",
"HEAD FEMORAL S-ROM +6MM 11/13 TAPER 36MM HIP M SPECIFICATION",SUP-136533000,CDM,C1776,HCPCS,0278,RC,,,both,,,6875.85,2062.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1967.87,28.62,,,,,0,799.66,5844.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 4 ML TOPICAL SYRINGE",RX-182423,CDM,,,0250,RC,00338-9564-01,NDC,both,4,ML,1610.81,483.24,"CIGNA [10200]","Cigna Local Plus",,861.78,53.5,,,,,0,187.34,1369.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC",940,MS-DRG,,,,,,,inpatient,,,107549.87,32264.96,"AMBETTER EXCHANGE  [11102]",Ambetter,,14495.94,,"Case rate ($14,495.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,460.46, add-ons for qualifying new technology services are included. If operating cost exceeds $46,500.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,399.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,478.26. The transfer operating threshold is the transfer adjustment factor * $13,460.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.68. The transfer capital threshold is the transfer adjustment factor * $1,017.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,68228.13,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,inpatient,,,34412.37,10323.71,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,11942.91,,"Case rate ($5,554.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,158.05, add-ons for qualifying new technology services are included. If operating cost exceeds $38,197.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,771.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $5,164.87. The transfer operating threshold is the transfer adjustment factor * $5,158.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.97. The transfer capital threshold is the transfer adjustment factor * $389.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,5554.84,22332.87,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR CHEST TRAUMA WITH MCC",183,MS-DRG,,,,,,,inpatient,,,53642.01,16092.6,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,9917.12,,"Case rate ($9,490.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,812.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,851.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,048.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $8,823.82. The transfer operating threshold is the transfer adjustment factor * $8,812.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.24. The transfer capital threshold is the transfer adjustment factor * $666.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",9917.09,9917.09,9917.09,"1 through 10",7561,38154.18,other,"IP DRG"
"XIENCE SKYPOINT DES 3.00 X 08 RX US",SUP-1804300-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +11.5 DIOPTER +6 CYLINDER MODIFIED C BICONVEX 13MM",SUP-ZCT600U115,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"NOVANET [10819]",Novanet,,258.75,75,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrombin Time",PX-305000063,CDM,85670,CPT,0305,RC,,,both,,,137.75,41.32,"PHCS [10601]",PHCS,,96.43,70,,,,,0,0.01,117.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC",806,MS-DRG,,,,,,,inpatient,,,32369.79,9710.94,"CIGNA [10200]",Cigna,,9954,,"Case rate ($9,954). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,5018,11132.13,other,"IP NVD Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Ribbon Mesalt",PX-E27200122,CDM,E27200122,LOCAL,0272,RC,,,both,,,40.73,12.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.74,34.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC",434,MS-DRG,,,,,,,inpatient,,,29343.78,8803.13,"AMBETTER EXCHANGE  [11102]",Ambetter,,4419.68,,"Case rate ($4,419.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,103.97, add-ons for qualifying new technology services are included. If operating cost exceeds $37,143.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,692.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,109.40. The transfer operating threshold is the transfer adjustment factor * $4,103.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $310.28. The transfer capital threshold is the transfer adjustment factor * $310.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,4419.68,17769.04,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,inpatient,,,159071.74,47721.52,"BLUE CROSS [10001]","Blue Cross HMO",,125208.63,,,,,,,7561,159071.74,"case rate",
"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC",434,MS-DRG,,,,,,,inpatient,,,29343.78,8803.13,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,4618.57,,"Case rate ($4,419.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,103.97, add-ons for qualifying new technology services are included. If operating cost exceeds $37,143.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,692.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,109.40. The transfer operating threshold is the transfer adjustment factor * $4,103.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $310.28. The transfer capital threshold is the transfer adjustment factor * $310.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,4419.68,17769.04,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 18MM 50MM SHOULDER DJO SURGICAL ALTIVATE",SUP-520-50-218,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"BLUE CROSS [10001]","Blue Cross HMO",,3562.81,39.2,,5311.50,4717.44,5388.59,31,1057.03,7725.48,"percent of total billed charges",
"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC",963,MS-DRG,,,,,,,inpatient,,,88505.50,26551.65,"CIGNA [10200]","Cigna Open Access",,30000.72,,"Fee schedule rate ($30,000.72). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,10994,68178.24,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 46MM 75CM 6MM 100CM",SUP-M001712040,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3473.98,41.1,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC",658,MS-DRG,,,,,,,inpatient,,,88621.47,26586.44,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,10203.46,,"Case rate ($9,625.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,938.31, add-ons for qualifying new technology services are included. If operating cost exceeds $41,977.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,057.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $8,950.13. The transfer operating threshold is the transfer adjustment factor * $8,938.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $675.78. The transfer capital threshold is the transfer adjustment factor * $675.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,45306.35,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CRADLE SUPPORT INTPD-TF-S",SUP-INTPD-TF-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.50 X 18 MM  RX FDA",SUP-1203350-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 120MM 13.5MM 10FR FLUENCY PLUS ENDOVASCULAR",SUP-FEL14120,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UHC [10700]","United Healthcare",,11564.91,63.3,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC",091,MS-DRG,,,,,,,inpatient,,,55863.17,16758.95,"CIGNA [10200]","Cigna Open Access",,19272.54,,"Fee schedule rate ($19,272.54). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,10893.81,43797.87,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"I-GEL, SINGLE USE SUPRAGLOTTIC AIRWAY, SIZE 2.5",SUP-8225000,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.13,23.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.2,67.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE WALKING 10-13 11-14 LARGE LOW PROFILE 1 PIECE",SUP-79-95077,CDM,S27000186,LOCAL,0270,RC,,,both,,,294.76,88.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,200.44,68,,,,,0,34.28,250.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR RINGLOC 24 36MM ARCOMXL HIP STERILE HIGH",SUP-XL-105914,CDM,C1776,HCPCS,0278,RC,,,both,,,9937.38,2981.21,"BLUE CROSS [10001]","Blue Cross PPO",,3895.45,39.2,,3949.44,3949.44,3949.44,"1 through 10",1155.72,8446.77,"percent of total billed charges",
"RTRCTR ALEXIS O 360D LARGE RIGID RING ATRAUMATIC UNIQUE C",SUP-G6313,CDM,S27200284,LOCAL,0272,RC,,,both,,,445.50,133.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 15CM 120CM 18MM 18.5FR FLARE LOW PROFILE",SUP-M00516720,CDM,C1874,HCPCS,0278,RC,,,both,,,10076.00,3022.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1194.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1171.84,8564.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.9MM 2 OSTEORAPTOR ULTRABRAID COBRAID BLUE",SUP-72201994,CDM,C1713,HCPCS,0278,RC,,,both,,,2567.25,770.17,"CIGNA [10200]","Cigna Open Access",,1460.77,56.9,,1144.80,304.56,2275.09,66,298.57,2182.16,"percent of total billed charges",
"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC",741,MS-DRG,,,,,,,inpatient,,,84838.68,25451.6,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,19019.29,,"Case rate ($8,846.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,214.28, add-ons for qualifying new technology services are included. If operating cost exceeds $41,253.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,003.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,225.15. The transfer operating threshold is the transfer adjustment factor * $8,214.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $621.04. The transfer capital threshold is the transfer adjustment factor * $621.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,41636.42,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN JUDKINS",SUP-77801000,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE II PRO 15MM 1.5MM BALLOON DILATATION STERILE",SUP-215-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 18.5X10MM MICRO 100 MICROPOWER THK.4MM STRAIGHT",SUP-502316300,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.65,53.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE EAGLE INFLATION 20ML UROLOGICAL NITINOL GWIRE",SUP-325130,CDM,C1726,HCPCS,0272,RC,,,both,,,578.18,173.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL SURGICAL 6IN AUSTIN INTEGRA 16MM LIGHT CURVE INNER EAR",SUP-3722056,CDM,S27200284,LOCAL,0272,RC,,,both,,,638.36,191.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,75.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.24,542.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 36MM LCP STAINLESS STEEL CORTIEX PERIARTICULAR",SUP-02.204.036,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"NOVANET [10819]",Novanet,,739.94,75,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE GLENOID EQUINOXE SHOULDER SMALL REVERSE",SUP-320-35-01,CDM,C1776,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5865,68,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP UNIPOLAR LOW END CEMENTED FEMORAL CO",SUP-71700025,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"CIGNA [10200]","Cigna Local Plus",,5168.1,53.5,,5372.07,4581.20,7242.98,23,1123.46,8211,"percent of total billed charges",
"CATH SAPPHIRE II PRO 10MM 3.25MM BALLOON DILATATION STERILE",SUP-232-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR SURGICAL 22CM COSEAL 2 LUMEN MALLEABLE SEAL EXTEND",SUP-934034,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.79,104.64,"CIGNA [10200]","Cigna Local Plus",,186.6,53.5,,,,,0,40.56,296.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 3.5MM 2 STRAIGHT 5.75IN BUCK EAR SHARP SURGICAL",SUP-380203,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.07,40.22,"MULTIPLAN [10600]",Multiplan,,113.96,85,,,,,0,15.59,113.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 120MM 2.5MM BALLOON DILATATION PEBAX",SUP-H74939148251210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC STD 24IN 25- IN KNEE 1 PANEL FINGER POCKET",SUP-VP40101-070,CDM,L1830,HCPCS,0274,RC,,,both,,,132.94,39.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,90.4,68,,,,,0,15.46,113,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.7MM 6MM VARIAX T5 LOCK NONSTERILE",SUP-662506,CDM,C1713,HCPCS,0278,RC,,,both,,,1075.03,322.51,"CIGNA [10200]","Cigna Open Access",,611.69,56.9,,1144.80,304.56,2275.09,66,125.03,913.78,"percent of total billed charges",
"STEM EXT 50MM 14MM ATTUNE KNEE CEMENT REVISION STERILE",SUP-151214050,CDM,C1776,HCPCS,0278,RC,,,both,,,5230.20,1569.06,"AETNA [10100]","Aetna HMO/PPO",,4158.01,79.5,,10981.53,8986.79,12413.38,12,608.27,4445.67,"percent of total billed charges",
"GWIRE JAGWIRE ENDOSCOPIC STRAIGHT TRIM 260CM .035IN BILIARY",SUP-5664,CDM,C1769,HCPCS,0272,RC,,,both,,,811.01,243.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.32,689.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 13MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530G713,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1031.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1012.7,7401.47,"percent of total billed charges",
"MESH SURGICAL PHASIX 15X10CM OPEN POSITION SYSTEM STERILE",SUP-1221015,CDM,C1781,HCPCS,0278,RC,,,both,,,21697.20,6509.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5858.24,27,,,,,0,2523.38,18442.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 53MM UNITRAX FEMORAL HIP MODULAR",SUP-6942-5-053,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"KAISER [10500]",Kaiser,,2095.56,67,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309012,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15104.88,40,,,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT THROMBECTOMY JET STERILE LATEX FREE DISPOSABLE",SUP-5MAXJETDKIT,CDM,C1757,HCPCS,0272,RC,,,both,,,17608.50,5282.55,"UHC [10700]","United Healthcare",,11146.18,63.3,,,,,0,2047.87,14967.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP LOCKING REAMER IRR ASPIR INTRAMEDULLARY BONE HARVEST",SUP-352.260S,CDM,S27200284,LOCAL,0272,RC,,,both,,,557.69,167.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,64.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.86,474.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 10MM R3CON LOCK",SUP-P50-353-2710,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,1144.80,304.56,2275.09,66,155.43,1136.03,"percent of total billed charges",
"STENT VIABAHN 5CM 75CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR060501A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"BLUE CROSS [10001]","Blue Cross HMO",,7354.47,39.2,,9776.84,9776.84,9776.84,"1 through 10",2181.95,15947.19,"percent of total billed charges",
"SYSTEM PROMUS PREMIER 28MM 144CM 2.75MM CORONARY STENT",SUP-H7493952828270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,647.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATTAIN COMMAND SUREVALVE 50CM 9FR 7.2FR STRAIGHT",SUP-6250V-50S,CDM,C1887,HCPCS,0272,RC,,,both,,,2602.50,780.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,302.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,302.67,2212.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 10MM RELINE C SPINE MULTIAXIAL NONSTERILE LATEX",SUP-3904010,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,3978.14,359.25,3978.14,24,521.61,3812.25,"percent of total billed charges",
"SCR BONE 2.7MM 26MM LCP",SUP-02.211.026,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,106.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",104.45,763.41,"percent of total billed charges",
"SUT GORE-TEX CV-0 TH-50 48IN NONABSORBABLE",SUP-0U01A,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.35,88.3,"KAISER [10500]",Kaiser,,197.21,67,,,,,0,34.23,250.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 80CM 40MM 9MM .035IN BALLOON",SUP-AB35W09040080,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"MULTIPLAN [10600]",Multiplan,,575.59,85,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Neurostim Non Recharge FB",PX-E27800015,CDM,C1767,HCPCS,0278,RC,,,both,,,1.00,0.3,"BLUE CROSS [10001]","Blue Cross PPO",,0.39,39.2,,,,,0,0.12,0.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAXI LD 80CM 4CM 7FR 20MM LARGE DIAMETER BALLOON",SUP-4172040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1620.00,486,"UHC [10700]","United Healthcare",,1025.46,63.3,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENTED TSA",SUP-S2A,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"UHC [10700]","United Healthcare",,16948.58,63.3,,8601.07,8395.67,8601.07,"1 through 10",3113.93,22758.75,"percent of total billed charges",
"CATH BARDEX IC 24FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0167SI24,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.45,32.23,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLUG OCCLUSION 12X5.3MM 3MM MVP PTFE MECHANICALLY DETACHABLE",SUP-MVP-3Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,10695.00,3208.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE PLATINUM PLUS VASCULAR 260CM 8CM .018IN GLIDEX",SUP-M001466020,CDM,C1769,HCPCS,0272,RC,,,both,,,1539.00,461.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC",565,MS-DRG,,,,,,,inpatient,,,39169.44,11750.83,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 80MM 2MM BALLOON DILATATION OTW STERILE",SUP-592008022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE NC PLUS 8MM 3.75MM BALLOON DILATATION",SUP-237-083-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 15MM 2.5MM BALLOON DILATATION DRUG COATED",SUP-H7493960815250,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"AETNA [10100]","Aetna HMO/PPO",,30927.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 CT-1 TAPERPOINT 27IN BRAID ANTIBACTERIAL",SUP-VCP259H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LATERAL LUMBAR ANCHOR 22MM",SUP-1219.0022,CDM,C1713,HCPCS,0278,RC,,,both,,,3277.50,983.25,"CIGNA [10200]","Cigna Open Access",,1864.9,56.9,,1144.80,304.56,2275.09,66,381.17,2785.88,"percent of total billed charges",
"COIL EMBOLIZATION 26CM 10MM .021IN AZUR FRAMING ELECTRICAL",SUP-45-681026,CDM,S27800098,LOCAL,0278,RC,,,both,,,5464.80,1639.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3716.06,68,,,,,0,635.56,4645.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Irrig Blad Smpl",PX-450000270,CDM,51700,CPT,0361,RC,,,both,,,1458.58,437.57,"PHCS [10601]",PHCS,,1021.01,70,,,,,0,1.46,1458.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 16MM 144CM 2.75MM",SUP-H7493941216270,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"AETNA [10100]","Aetna HMO/PPO",,6171.19,79.5,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Protime",PX-305000057,CDM,85610,CPT,0305,RC,,,both,,,130.20,39.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6.75,,,,,,,0.13,110.67,"fee schedule",
"CATH DXTERITY 100CM 5FR .047IN AMPLATZ LEFT 2 CURVE",SUP-DXT5AL20,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA [10200]","Cigna Local Plus",,44.22,53.5,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INFUSION 118IN SMARTSITE TEXIUM ALARIS 20 GTT",SUP-10013361T,CDM,S27200284,LOCAL,0272,RC,,,both,,,51.50,15.45,"AETNA [10100]","Aetna HMO/PPO",,40.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.99,43.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 11.5X10.8CM 255ML GEL TEXTURE ORIENTATION MARK",SUP-3341155,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"AETNA [10100]","Aetna HMO/PPO",,7268.29,79.5,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 64CM .016IN FIRM STERILE LATEX FREE DISPOSABLE",SUP-6971,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 16MM TITANIUM CERVICAL SPINE LOCKING NONSTERILE",SUP-04.617.816,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183762,CDM,C1776,HCPCS,0278,RC,,,both,,,13241.10,3972.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5296.44,40,,,,,0,1539.94,11254.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TIGHTRAIL SUB-C .171IN DIL ROTATE STERILE LATEX FREE",SUP-560-013,CDM,C1773,HCPCS,0272,RC,,,both,,,12385.50,3715.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PCP050150150 PLUS US D5L150UL1500",SUP-PCP050150150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RING ANNULOPLASTY 28MM TRICUSPID CONTOUR 3D TITANIUM",SUP-690R28,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross PPO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 17MM 5.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE52517,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"MULTIPLAN [10600]",Multiplan,,71114.91,85,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGSEED PRO 12CM",SUP-MS2-17-1-12,CDM,A4648,HCPCS,0278,RC,,,both,,,3829.50,1148.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,445.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,445.37,3255.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 60MM 125CM 9MM 5FR VASCULAR NITINOL ILIAC",SUP-G43787,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,486.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP MULTIHOLE TRITANIUM TRIDENT II E",SUP-709-04-52E,CDM,C1776,HCPCS,0278,RC,,,both,,,17958.91,5387.67,"NOVANET [10819]",Novanet,,13469.18,75,,,,,0,2088.62,15265.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM LCP STAINLESS STEEL SHORT THREAD SMALL",SUP-207.616,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,123.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",120.96,884.03,"percent of total billed charges",
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 4.0MM X 18.0MM",SUP-494001812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UHC [10700]","United Healthcare",,512.73,63.3,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 9.5-11.5MM 6 SHOOTER SAEED OPTI-VU 6 BAND NONSTERILE",SUP-G24654,CDM,S27200284,LOCAL,0272,RC,,,both,,,2107.50,632.25,"CIGNA [10200]",Cigna,,1433.1,68,,,,,0,245.1,1791.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROLENE 6X4IN HERNIA PATCH SOFT FLAT STERILE",SUP-0117010,CDM,C1781,HCPCS,0278,RC,,,both,,,460.08,138.02,"KAISER [10500]",Kaiser,,308.25,67,,,,,0,53.51,391.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 60MM 7MM BALLOON DILATATION DURALYN",SUP-48007006S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM",RX-9969,CDM,,,0637,RC,00093-3541-43,NDC,both,42.5,GR,2257.83,677.35,"MULTIPLAN [10600]",Multiplan,,1919.16,85,,,,,0,262.59,1919.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 12CM 180CM 20MM 10.5FR ESOPHAGEAL",SUP-G57348,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"FIRST HEALTH [10303]","First Health",,14071.68,80,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC MRI SURESCAN VENTRICULAR 1 CHMBR EV4 LATEX",SUP-DVEA3E4,CDM,C1722,HCPCS,0278,RC,,,both,,,118275.00,35482.5,"AETNA [10100]","Aetna HMO/PPO",,94028.63,79.5,,,,,0,13755.38,100533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.00 X 38 MM  RX FDA",SUP-1203300-38,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"KAISER [10500]",Kaiser,,11557.5,67,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE QUILL 2-0 3/8 CIRCLE 14X14CM 26MM CLSR PDO 2 ARM",SUP-RA1020Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.40,39.42,"FIRST HEALTH [10303]","First Health",,105.12,80,,,,,0,15.28,111.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION",317,MS-DRG,,,,,,,inpatient,,,321245.51,96373.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,126889.71,,"Fee schedule rate ($126,889.71). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,195219.05,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"LOTUS VALVE SYSTEM: 21MM REPRISE III",SUP-H749LTVR3CL210,CDM,S62400003,LOCAL,0624,RC,,,both,,,142500.00,42750,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,65407.5,45.9,,,,,0,16572.75,121125,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 92CM 1MM 6FR 5MM SPACE REGULAR D CURVE",SUP-D6DR005CT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"NOVANET [10819]",Novanet,,1738.13,75,,,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 72MM X25 LOCK LOW PROFILE STERILE",SUP-04.045.372S,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"PHCS [10601]",PHCS,,1308.93,70,,,,,0,217.47,1589.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL OPTIFLOW 2 JUNIOR",SUP-OJR520,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 90CM 5FR PIGTAIL CURVE TAPER ANGIOGRAPHIC SLX",SUP-451503F5,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.91,41.1,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM .91-1.12MM 2.25MM CORONARY",SUP-RONYX22530W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,965.93,28.62,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 12MM 145CM 2.25MM CORONARY STENT",SUP-1145225-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AETNA [10100]","Aetna HMO/PPO",,4641.21,79.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC CLEAR 75MM THREADED OBTR 8.5MM",SUP-214120,CDM,S27200284,LOCAL,0272,RC,,,both,,,163.21,48.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,110.98,68,,,,,0,18.98,138.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE 2.8MM MEDIUM OVAL 240CM 2.4MM SENSATION FLEXIBLE SHORT",SUP-M00562673,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.43,23.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,31.82,41.1,,,,,0,9.01,65.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE LUGE VASCULAR STRAIGHT 300CM 3CM .014IN STAINLESS",SUP-H74912100010,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"FIRST HEALTH [10303]","First Health",,453.6,80,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER YELLOW 4.5MM 4.5MM DYONICS LONG CURVED CONCAVE",SUP-7205335,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,239.7,41.1,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COAGULATION DISORDERS",813,MS-DRG,,,,,,,inpatient,,,31920.82,9576.25,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,9887.3,,"Case rate ($9,461.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,785.67, add-ons for qualifying new technology services are included. If operating cost exceeds $41,825.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,046.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,797.29. The transfer operating threshold is the transfer adjustment factor * $8,785.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $664.24. The transfer capital threshold is the transfer adjustment factor * $664.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",10055.58,10055.58,10055.58,"1 through 10",7561,31920.82,other,"IP DRG"
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,inpatient,,,2338.83,701.65,"AMBETTER EXCHANGE  [11102]",Ambetter,,2338.83,,"Case rate ($3,715.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,449.64, add-ons for qualifying new technology services are included. If operating cost exceeds $36,489.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,642.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.1. The base transfer operating payment is the transfer adjustment factor * $3,454.20. The transfer operating threshold is the transfer adjustment factor * $3,449.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.81. The transfer capital threshold is the transfer adjustment factor * $260.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,2338.83,2338.83,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 80MM TITANIUM LOCK ATLANTIS TRANSLATIONAL BONE SPINE",SUP-6190080,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE",RX-4457,CDM,J2003,HCPCS,0636,RC,00409-9137-11,NDC,both,5,ML,160.98,48.29,"FIRST HEALTH [10303]","First Health",,128.78,80,,,,,0,0.58,136.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBLIQUE TLIF TI, 10X10X25MM 4",SUP-5400254,CDM,C1889,HCPCS,0278,RC,,,both,,,21225.60,6367.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6074.77,28.62,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM TSRH OSTEOGRIP TITANIUM SHORT POST SPINE",SUP-83565451,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"BLUE CROSS [10001]","Blue Cross PPO",,1009.01,39.2,,957.42,570.23,957.42,28,299.36,2187.9,"percent of total billed charges",
"CATH DORADO CHECKER 80CM 2CM 8MM BALLOON DILATATION",SUP-DR8082,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CPS DIRECT SL II SITEMARK 57.7CM 54CM 9FR 7FR WIDE",SUP-DS2C014,CDM,C1887,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC",806,MS-DRG,,,,,,,inpatient,,,32369.79,9710.94,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 100CM 25CM 5FR .047IN",SUP-CG506,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SUPER TORQUE PLUS 100CM 6FR AL3 CURVE",SUP-533647,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"UHC [10700]","United Healthcare",,52.1,63.3,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM .0125IN AXIUM DETACHABLE HELIX SM",SUP-NV-6-20-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ACCESS 50.5CM 10FR 16GA TRANSJUGULAR INTRAHEPATIC 38.5CM",SUP-G29769,CDM,C1887,HCPCS,0272,RC,,,both,,,3740.00,1122,"UHC [10700]","United Healthcare",,2367.42,63.3,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIB 65CM PLEXA PROMRI DF-1 180MM SD 65/15 STERILE",SUP-414001,CDM,C1896,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]","Cigna Local Plus",,5409.18,31.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL INSUFFLATION 100MM 14GA STEP VERRES PNEUMOPERITONEUM",SUP-S100000,CDM,S27200284,LOCAL,0272,RC,,,both,,,350.96,105.29,"FIRST HEALTH [10303]","First Health",,280.77,80,,,,,0,40.82,298.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION",RX-28282,CDM,,,0637,RC,00088-2220-33,NDC,both,10,ML,582.18,174.65,"NOVANET [10819]",Novanet,,436.64,75,,,,,0,67.71,494.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRA-THIN/SDS 135CM 20MM 5.3FR 4MM .035IN STD BALLOON",SUP-M001175580,CDM,C1725,HCPCS,0272,RC,,,both,,,1012.50,303.75,"AETNA [10100]","Aetna HMO/PPO",,804.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL HOOK TAB HEADSTRAP QUICK RELEASE BUCKLE UNIVERSAL",SUP-OPT1046,CDM,S27000186,LOCAL,0270,RC,,,both,,,264.70,79.41,"KAISER [10500]",Kaiser,,177.35,67,,,,,0,30.78,225,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 9FR SMALL RIGHT VENTRICLE TRANSVENOUS 1",SUP-5038S-58,CDM,C1779,HCPCS,0275,RC,,,both,,,2232.50,669.75,"AETNA [10100]","Aetna HMO/PPO",,1774.84,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 STD KNEE LEFT CRUCIATE RETAIN PERSONA COCR",SUP-42502806001,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"UHC [10700]","United Healthcare",,18290.9,63.3,,8601.07,8395.67,8601.07,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"CNCT ROD 5.5MM 5.5MM EXPEDIUM SPINE TITANIUM END TO END",SUP-179777555,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"NOVANET [10819]",Novanet,,2671.88,75,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM EDWARDS SAPIEN 3 COMMANDER DELIVERY SYSTEM",SUP-9600CM23A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,50017.5,27,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 70CM INFINION 16 CONTACT LEAD CX",SUP-SC-2317-70,CDM,C1897,HCPCS,0278,RC,,,both,,,17640.00,5292,"NOVANET [10819]",Novanet,,13230,75,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 50MM 14MM ATTUNE KNEE CEMENT REVISION STERILE",SUP-151214050,CDM,C1776,HCPCS,0278,RC,,,both,,,5230.20,1569.06,"KAISER [10500]",Kaiser,,3504.23,67,,,,,0,608.27,4445.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE NERVE STIM BIPOLAR SIDE BY SIDE",SUP-8225401,CDM,S27200284,LOCAL,0272,RC,,,both,,,1308.96,392.69,"CIGNA [10200]","Cigna Local Plus",,700.29,53.5,,,,,0,152.23,1112.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 20MM 3.5MM BALLOON DILATATION RAPID",SUP-47535020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,655.83,41.1,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AINTREE RAPI-FIT 56CM 19FR 4.7MM LARGE AIRWAY EXCHANGE",SUP-G10789,CDM,S27200284,LOCAL,0272,RC,,,both,,,532.17,159.65,"CIGNA [10200]","Cigna Local Plus",,284.71,53.5,,,,,0,61.89,452.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Complement Functional Activity",PX-302000032,CDM,86161,CPT,0302,RC,,,both,,,380.00,114,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,18.88,,,,,,,0.01,323,"fee schedule",
"STEM FEMORAL 119MM TYPE 1 TAPERLOC MICROPLASTY TITANIUM PPS",SUP-51107170,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3251.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3190.72,23319.95,"percent of total billed charges",
"TRAY CATH 4FR 20CM POWERMIDLINE MICROEZ FLEXURA STATLOCK",SUP-P4154108D,CDM,C1751,HCPCS,0272,RC,,,both,,,1098.85,329.65,"PHCS [10601]",PHCS,,769.2,70,,,,,0,127.8,934.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 45MMX12MMX20CM 26FR",SUP-TAC124520A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21614.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATTAIN GUIDING LEFT HEART LEAD DELIVERY SYSTEM LATEX",SUP-6216A,CDM,C1769,HCPCS,0272,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM CREO SPINE PREASSEMBLE THREAD",SUP-5119.1647,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,1521.93,481.35,16760.95,30,441.36,3225.75,"percent of total billed charges",
"CATH INFINITI THRULUMEN 110CM 5FR 145D PIGTAIL CURVE",SUP-534552S,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,63.6,68,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD LARGE TSRH TITANIUM SPINAL 3DX",SUP-8351522,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AETNA [10100]","Aetna HMO/PPO",,7589.75,79.5,,1521.93,481.35,16760.95,30,1110.3,8114.82,"percent of total billed charges",
"TOOL LEAD DELIVERY 35CM 65D EPICARDIUM LEAD PLACEMENT 18CM",SUP-10626,CDM,C1898,HCPCS,0275,RC,,,both,,,6555.00,1966.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,762.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRELUDE SNAP SPLITTABLE SHEAT",SUP-PLS-1006,CDM,C1892,HCPCS,0272,RC,,,both,,,518.40,155.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 7FR .081IN HOCKEY STICK 1 CURVE GUIDING",SUP-LA7HSISH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE V-LOC 1 GS-21 18IN CLSR NONABSORBABLE BLUE",SUP-VLOCN0327,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.33,69.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FOXCROSS 135CM 20MM 8MM BALLOON DILATATION JETCOAT",SUP-10338-20,CDM,C1725,HCPCS,0272,RC,,,both,,,1539.00,461.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DIAMONDBACK 360 145CM 2MM ATHERECTOMY DIAMOND",SUP-DBP-200SOLID145,CDM,C1724,HCPCS,0272,RC,,,both,,,21388.50,6416.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH ADVANCE 35LP 80CM 14CM 5FR 4MM .035IN BALLOON",SUP-G52336,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"THIN LOOP, 7CM LONGER THAN STANDARD",SUP-VXRU1L,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.00,675,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT NEPHRSTMY 10FR 21GA NDL CATH DIL CONNECT TUBE 25CM VTC",SUP-M001245310,CDM,C1729,HCPCS,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Mnt Reassess Indv Ea 15min",PX-942000005,CDM,97803,CPT,0942,RC,,,both,,,81.19,24.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET INTRO 40CM 4FR MICROPUNCTURE PUSH-PLUS .018IN NITINOL",SUP-G48003,CDM,C1894,HCPCS,0272,RC,,,both,,,208.80,62.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT MICROINTRODUCER 45CM 5FR 21GA .018IN 10CM PERCUTANEOUS",SUP-06597016,CDM,C1894,HCPCS,0272,RC,,,both,,,238.38,71.51,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER ALLOGRAFT 14X11X10MM ALLOCRAFT 5D LORDOSIS CORTICAL",SUP-6183-7-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 8MM 2MM CORONARY STENT COCR",SUP-1007821-08,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 5.5IN WEITLANER 17MM BLUNT 3X4 PRONG STAINLESS STEEL",SUP-205151,CDM,S27100035,LOCAL,0271,RC,,,both,,,546.67,164,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,250.92,45.9,,,,,0,63.58,464.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 36MM LCP STAINLESS STEEL SHORT THREAD",SUP-207.636,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,297.66,28.62,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AWL SURGICAL FORTIFY I SELF CENTER BENT",SUP-676.705,CDM,S27000186,LOCAL,0270,RC,,,both,,,2010.00,603,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,826.11,41.1,,,,,0,233.76,1708.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 CURVE 15MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-96-2033,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"FIRST HEALTH [10303]","First Health",,7399.56,80,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE SOFT TOUCH SMOOTH",SUP-SSF-560,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2162.38,28.62,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 40MM HIP BIOLOX DELTA FMP SYSTEM",SUP-400-03-403,CDM,S27200284,LOCAL,0272,RC,,,both,,,16953.92,5086.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1971.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1971.74,14410.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 150MM 5MM .018IN BALLOON",SUP-R51005015L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,241.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 580CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRX-580,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"CIGNA [10200]","Cigna Open Access",,2258.36,56.9,,5166.00,5166.00,5166.00,"1 through 10",461.59,3373.65,"percent of total billed charges",
"FRCP OPHTHALMIC 23GA GRIESHABER REVOLUTION RETINAL INTERNAL",SUP-706.44,CDM,S27200284,LOCAL,0272,RC,,,both,,,984.07,295.22,"CIGNA [10200]","Cigna Open Access",,559.94,56.9,,,,,0,114.45,836.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 45CM 16FR SILICONE MIC SECUR-LOK UNIVERSAL",SUP-0250-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,804.37,45.9,,,,,0,203.81,1489.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENTAMICIN 0.1 % TOPICAL CREAM",RX-3423,CDM,,,0250,RC,45802-0056-35,NDC,both,15,GR,310.60,93.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,36.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.12,264.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 131MM STAINLESS STEEL 2.7/3.5MM SCR 6 HOLE VARIABLE",SUP-02.107.506,CDM,C1713,HCPCS,0278,RC,,,both,,,6717.56,2015.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1922.57,28.62,,,,,0,781.25,5709.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH CUFF CRICO 9CM MELKER PERCUTANEOUS 7.2MM 5MM",SUP-G47662,CDM,C1769,HCPCS,0272,RC,,,both,,,2752.50,825.75,"KAISER [10500]",Kaiser,,1844.18,67,,,,,0,320.12,2339.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30X24X17MM CHESAPEAKE 15D LORDOTIC",SUP-2013-21730L15,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9254.41,27,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 150MM 3.8FR 4MM BALLOON DILATATION",SUP-H74939148401510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM PRESTIGE PLUS HELICAL HELICAL XTRA",SUP-PRES0206HXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC PULSED LAVAGE INTERPULSE FAN SPRAY COAXIAL SET SUCTION",SUP-0210-118-200,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.47,105.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.99,299.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 90X25.4X1.27MM PRIMECUT OSCILLATING",SUP-5271-561,CDM,S27200284,LOCAL,0272,RC,,,both,,,536.38,160.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,364.74,68,,,,,0,62.38,455.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 3INX20MM OSTEOTOM THIN MRI STERILE LATEX FREE",SUP-47998602123,CDM,S27200284,LOCAL,0272,RC,,,both,,,996.30,298.89,"KAISER [10500]",Kaiser,,667.52,67,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 10MM 11FR ENDOPROSTHESIS HEPARIN",SUP-VBH100502,CDM,C1874,HCPCS,0278,RC,,,both,,,22087.80,6626.34,"BLUE CROSS [10001]","Blue Cross PPO",,8658.42,39.2,,,,,0,2568.81,18774.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 40CMX.49MM 22MM KNIT REVERSE LOCKNIT",SUP-HGK0022-40,CDM,C1768,HCPCS,0278,RC,,,both,,,2588.55,776.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,306.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,301.05,2200.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Graft Epifix per Sq Cm",PX-E63600024,CDM,Q4186,HCPCS,0636,RC,,,both,,,918.25,275.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,108.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.81,780.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 5MM LEIBINGER UNIVERSAL 2 TITANIUM",SUP-5020405,CDM,C1713,HCPCS,0278,RC,,,both,,,458.02,137.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,131.09,28.62,,,,,0,53.27,389.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 CT-1 36IN BRAID ANTIBACTERIAL COATED",SUP-VCP344H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 24MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.206,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"KAISER [10500]",Kaiser,,585.03,67,,,,,0,101.55,742.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM ORTHOLOC FULL THREAD CORTEX ANKLE FOOT 3",SUP-58813528,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",89.49,654.08,"percent of total billed charges",
"GWIRE ORTHOPEDIC 1.45MM NITINOL BLUNT",SUP-286705320,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP ULTRASONIC 20MM BONESCALPEL STD BLUNT STERILE LATEX FREE",SUP-MXB-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,3265.32,979.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ECHELON 10 150CM 1.7-2.1FR .017IN 45D MICRO INFUSION",SUP-145-5091-150,CDM,C1769,HCPCS,0272,RC,,,both,,,5016.30,1504.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE II PRO 15MM 2.75MM BALLOON DILATATION STERILE",SUP-227-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABERX RADIANZ 5MM3CM 190",SUP-R51005003L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 80CM 20MM 3.8FR 8MM LOW PROFILE BALLOON",SUP-H74939032802080,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 100MM 5MM VASCULAR DRUG ELUTE ACCEPTS .035",SUP-G38414,CDM,C1874,HCPCS,0278,RC,,,both,,,11921.66,3576.5,"NOVANET [10819]",Novanet,,8941.25,75,,,,,0,1386.49,10133.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMILORIDE 5 MG TABLET",RX-391,CDM,,,0637,RC,00574-0292-01,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM CD HORIZON VOYAGER SPINE NONSTERILE",SUP-55850046545,CDM,C1713,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"BLUE CROSS [10001]","Blue Cross PPO",,2907.66,39.2,,957.42,570.23,957.42,28,862.66,6304.88,"percent of total billed charges",
"STENT ZIPWIRE 26CM 3CM 4.8FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006145352190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CIGNA [10200]",Cigna,,768.37,68,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG VAC PEEL AND PLACE SMALL",SUP-EZ5SML,CDM,S27200284,LOCAL,0272,RC,,,both,,,813.55,244.06,"PHCS [10601]",PHCS,,569.49,70,,,,,0,94.62,691.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR MPA2 CURVE ANGIOGRAPHIC PERIPHERAL",SUP-H749163911212,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"NOVANET [10819]",Novanet,,57.44,75,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 80MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"NOVANET [10819]",Novanet,,1196.78,75,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL LEAD TUNNLR",SUP-6888,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"NOVANET [10819]",Novanet,,5175,75,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 15MM STRAIGHT CONICAL MODULAR RESTORATION",SUP-6276-7-115,CDM,C1776,HCPCS,0278,RC,,,both,,,11080.37,3324.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1313.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1288.65,9418.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4N NARROW KNEE LEFT POSTERIOR STABILIZE LEGION",SUP-71421264,CDM,C1776,HCPCS,0278,RC,,,both,,,32536.35,9760.9,"CIGNA [10200]","Cigna Open Access",,10899.68,33.5,,5302.19,4377.88,6578.61,27,3783.98,27655.9,"percent of total billed charges",
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR JUDKINS LEFT 3.5",SUP-67001200,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"UHC [10700]","United Healthcare",,264.34,63.3,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SPECTRA OPTIA TPE EXCHANGE AUTOTRANSFUSION TUBING",SUP-12220,CDM,S27200284,LOCAL,0272,RC,,,both,,,3033.89,910.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2063.05,68,,,,,0,352.84,2578.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 CURVE PLUS 15MM KNEE XLK FIX BEARING SIGMA",SUP-970473,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]",Cigna,,7598.69,68,,5873.17,5873.17,5873.17,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"LENS IOL 10 D +15.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.155,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION",RX-176571,CDM,Q9968,HCPCS,0636,RC,00517-0374-01,NDC,both,10,ML,2123.59,637.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,956.5,,,,,,,251.65,1805.05,"fee schedule",
"CAP CONSTRUCT TOTAL KNEE LEGION GII POSTERIOR STABILIZED OXI",SUP-71704590,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2564.42,18742.5,"percent of total billed charges",
"CATH OPTA PRO 80CM 20MM 6MM BALLOON DILATATION DURALYN OTW 2",SUP-4196020S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION JET-X FREEDOM 10.5-5MM BAR TO PIN MR",SUP-71064001,CDM,C1713,HCPCS,0278,RC,,,both,,,7563.78,2269.13,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2164.75,28.62,,,,,0,879.67,6429.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MERSILENE 3-0 FS-1 18IN BRAID WHITE NONABSORBABLE",SUP-R647H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCUFLEX STENT 6F X 20CM W/O WIRE",SUP-M0061453590,CDM,C2617,HCPCS,0272,RC,,,both,,,633.10,189.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,75.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 120MM 130CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-EX061203CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS [10001]","Blue Cross PPO",,5950.56,39.2,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 4-0 PS-2 27IN MONOFILAMENT UNDYED",SUP-Y426H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 60MM 9MM PRESS FIT REMOVABLE TRUNION SUT HOLE",SUP-AR-9100-09S,CDM,C1776,HCPCS,0278,RC,,,both,,,10713.60,3214.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4917.54,45.9,,,,,0,1245.99,9106.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION KIRSCHNER THREAD BLUNT TIP",SUP-6133.0399S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PREFACE ANTERIOR CURVE 62CM 8FR .11IN GUIDING BRAID",SUP-301803A,CDM,C1893,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14X6MM COALITION AGX BONE SPINE",SUP-1128.1206,CDM,C1713,HCPCS,0278,RC,,,both,,,12420.00,3726,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3554.6,28.62,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0261,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]",Cigna,,644.44,68,,1831.33,1831.33,1831.33,16,110.22,805.55,"percent of total billed charges",
"FRCP SURGICAL ALLIS TESSA GRASP DISPOSABLE",SUP-NF06,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.15,63.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.79,181.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.0MM X 15.0MM",SUP-493001512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER II XP 8MM 7FR 8FR 8MM SPACE STD CURVE STRAIGHT",SUP-M0044500TH0,CDM,C1733,HCPCS,0272,RC,,,both,,,11840.40,3552.12,"KAISER [10500]",Kaiser,,7933.07,67,,,,,0,1377.04,10064.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mra Chest W&WO Cntrst",PX-610000017,CDM,71555,CPT,0610,RC,,,both,,,4592.46,1377.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1248,,,,,,,534.1,3903.59,"per diem",
"ANCHOR SUT 1.3MM FIBERTAK SUTURETAPE BLUE WHITE GLENOID",SUP-AR-3602,CDM,C1713,HCPCS,0278,RC,,,both,,,2795.63,838.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,800.11,28.62,,,,,0,325.13,2376.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM .02IN 5MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0530,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.00,2003.4,"BLUE CROSS [10001]","Blue Cross PPO",,2617.78,39.2,,,,,0,776.65,5676.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
FACEPLATE,SUP-06001-I,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .62IN 5FR .056IN LONG",SUP-5562700L,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"KAISER [10500]",Kaiser,,279.79,67,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 13CM 6MM STERLING 10000 RPM OVAL LARGE HUB",SUP-H9102,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 60MM 10MM BALLOON DILATATION DURALYN",SUP-48010006S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"NOVANET [10819]",Novanet,,1032.75,75,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 15MM 1.50MM BALLOON DILATATION PEBAX",SUP-1400150-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 178MM 28-32MM ZENITH ALPHA 7.1MM",SUP-G38075,CDM,C1874,HCPCS,0278,RC,,,both,,,89876.46,26962.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,24266.64,27,,,,,0,10452.63,76394.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 57MM TRIGEN FEMUR LOW PROFILE",SUP-71645057,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,245.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,240.69,1759.12,"percent of total billed charges",
"SPACER SPINAL 23MMX10MM ELEVATE STD STERILE",SUP-7771023,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"UHC [10700]","United Healthcare",,18230.4,63.3,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 6.5MM 2 FULL THREAD BIO-CORKSCREW ROTATOR CUFF 2",SUP-AR-1925BF,CDM,C1713,HCPCS,0278,RC,,,both,,,1099.80,329.94,"CIGNA [10200]",Cigna,,747.86,68,,1831.33,1831.33,1831.33,16,127.91,934.83,"percent of total billed charges",
"INSRT TIBIAL 8 7MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650807,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"BLUE CROSS [10001]","Blue Cross HMO",,5145.88,39.2,,5311.50,4717.44,5388.59,31,1526.7,11158.16,"percent of total billed charges",
"SOL INTRAVENOUS 0.9% SODIUM CHLORIDE 50ML LIFECARE LATEX",SUP-07984-36,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,55.08,68,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG BODY SHROUD",SUP-SP3160,CDM,S27000186,LOCAL,0270,RC,,,both,,,168.22,50.47,"MULTIPLAN [10600]",Multiplan,,142.99,85,,,,,0,19.56,142.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM QUICKFIX TITANIUM SHORT PARTIAL THREAD T15",SUP-AR-8740-26PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,523.91,39.2,,957.42,156.86,7483.26,51,155.43,1136.03,"percent of total billed charges",
"COIL EMBOLIZATION 30CM 3.5MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES3530CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"BLUE CROSS [10001]","Blue Cross PPO",,2840.04,39.2,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ARROW ADVANCER VASCULAR 26 13/16IN .035IN 1 END MARK",SUP-AW-14735,CDM,C1769,HCPCS,0272,RC,,,both,,,84.91,25.47,"UHC [10700]","United Healthcare",,53.75,63.3,,,,,0,9.88,72.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP RIGHT ANGLE MULTIPLE ACUCLIP LATEX",SUP-OMSA8,CDM,S27200284,LOCAL,0272,RC,,,both,,,944.95,283.48,"CIGNA [10200]","Cigna Local Plus",,505.55,53.5,,,,,0,109.9,803.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 485CC NATRELLE INSPIRA COHESIVE STERILE",SUP-TCM-485,CDM,C1789,HCPCS,0278,RC,,,both,,,8280.00,2484,"KAISER [10500]",Kaiser,,5547.6,67,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 50.8MM 1.5MM MEDIUM 6 FLUTE ROUND STRYKER",SUP-5300010503,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.08,49.82,"AETNA [10100]","Aetna HMO/PPO",,132.03,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.32,141.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 10MM ENDOPROSTHESIS GORE-TEX",SUP-VBC101002A,CDM,C1874,HCPCS,0278,RC,,,both,,,19435.50,5830.65,"CIGNA [10200]","Cigna Local Plus",,6122.18,31.5,,,,,0,2260.35,16520.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ELECTROPHYSIOLOGY BLUE 92CM 6FR 2-8-2MM SPACING D C",SUP-D610DRP10CTR,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 2-0 P-12 6IN CLSR ABSORBABLE PREMIUM REVERSE",SUP-VLOCM0005,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.00,51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ATTACH ENDOSCP 4MM 11.35MM ROUND EDGE STERILE LATEX FREE",SUP-D-201-10704,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.26,63.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ATLAS 75CM 4CM 20MM 9FR BALLOON DILATATION PERIPHERAL",SUP-AT75204,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER NAVY BLUE 4.5MM TURBOWHISKER DYONICS STRAIGHT",SUP-7205316,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 1.5MM 10MM APTUS TRILOCK TITANIUM PHALANGEAL HAND",SUP-A-5250.10/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2.7MM 20MM DARCO TITANIUM FOOT LOCK",SUP-DC2825020,CDM,C1713,HCPCS,0278,RC,,,both,,,1036.80,311.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,120.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",120.58,881.28,"percent of total billed charges",
"CATH TORCON NB ADVANTAGE BEACON 100CM 5FR JB1 CURVE",SUP-G08472,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"PHCS [10601]",PHCS,,166.24,70,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION",RX-1090,CDM,,,0250,RC,01490-0039-08,NDC,both,236,ML,19.30,5.79,"KAISER [10500]",Kaiser,,12.93,67,,,,,0,2.24,16.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 25MM SOLERA CD HORIZON OSTEOGRIP TITANIUM",SUP-54840004525,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2732.31,28.62,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16017535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SUPERORDERABLE",RX-40814984,CDM,,,0250,RC,63323-0462-37,NDC,both,30,ML,118.01,35.4,"CIGNA [10200]","Cigna Open Access",,67.15,56.9,,,,,0,13.72,100.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC",957,MS-DRG,,,,,,,inpatient,,,299460.93,89838.28,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,48684.7,,"Case rate ($47,266.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $43,890.34, add-ons for qualifying new technology services are included. If operating cost exceeds $76,930.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $4,700.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $43,948.38. The transfer operating threshold is the transfer adjustment factor * $43,890.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,318.32. The transfer capital threshold is the transfer adjustment factor * $3,318.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,222470.6,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 70MM TI",SUP-SPL-35700-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30MMX4.8MM TITANIUM THICK TISSUE 2 ROW",SUP-TX30G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1810.13,543.04,"KAISER [10500]",Kaiser,,1212.79,67,,,,,0,210.52,1538.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE PATIENT SPECIFIC INSTRUMENTATION PSI GUIDE PIN",SUP-CAP-U-PSI,CDM,C1776,HCPCS,0278,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL 44MM COMPREHENSIVE STD SHOULDER COCR REVERSE",SUP-115370,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6854.4,68,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 60X22X7MM RISE-L 3D LORDOTIC NONSTERILE",SUP-193.606,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CIGNA [10200]","Cigna Open Access",,11502.23,33.5,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR DURALOC 52MM 32MM ENDURON HIP STERILE",SUP-1242-12-527,CDM,C1776,HCPCS,0278,RC,,,both,,,16479.96,4943.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1916.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1916.62,14007.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY ALLIGATOR JAW FENESTRATE CUP 115CM 5MM ENDOJAW",SUP-FB-211D.A,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.94,65.38,"UHC [10700]","United Healthcare",,137.96,63.3,,,,,0,25.35,185.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 28MM 4MM CORONARY STENT EVEROLIMUS",SUP-1550400-28,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEINMANN PIN SINGLE DIAMOND 2.4 MM X 229 MM",SUP-SPIN-SD-24229,CDM,S27000186,LOCAL,0270,RC,,,both,,,891.00,267.3,"KAISER [10500]",Kaiser,,596.97,67,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 60MM 120CM 4.5MM 6FR VASCULAR NITINOL",SUP-S-45-060-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"FIRST HEALTH [10303]","First Health",,8049.6,80,,,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL EIT 8 D L28 MM X W10 MM X H8 MM STERILE LATEX FR",SUP-TUI80828,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3297.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Guide Wire",PX-E27200130,CDM,C1769,HCPCS,0272,RC,,,both,,,135.99,40.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,92.47,68,,,,,0,15.82,115.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brca1&2 Gen Full Seq Dup/Del",PX-310000039,CDM,81162,CPT,0310,RC,,,both,,,4300.00,1290,"BLUE CROSS [10001]","Blue Cross PPO",,2331.47,,"Fee schedule rate ($2,331.47).",,,,0,0.01,4300,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE WHISPER MS VASCULAR STRAIGHT 300CM 3CM .014",SUP-1005359H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Natural Killer Total Count",PX-302000079,CDM,86357,CPT,0302,RC,,,both,,,333.45,100.03,"CIGNA [10200]",Cigna,,83.01,,,,,,,0.01,283.43,"fee schedule",
"INSRT TIBIAL XS S1 S2 SMALL 10MM DISTAL BEARING MODULAR",SUP-64813210,CDM,C1776,HCPCS,0278,RC,,,both,,,4114.66,1234.4,"CIGNA [10200]","Cigna Open Access",,2341.24,56.9,,5302.19,4377.88,6578.61,27,478.53,3497.46,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 24CM 7FR .035",SUP-M006192142090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,176.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE RIGHT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517-F-302,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"FIRST HEALTH [10303]","First Health",,13712.02,80,,,,,0,1993.39,14569.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAVITOR WITH RADIOPAQUE MARKERS 25MM",SUP-NVRO-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"BLUE CROSS [10001]","Blue Cross HMO",,53625.6,39.2,,,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 6MMX79MM 7FR 80CMCATH HEPARIN",SUP-BXB067901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"CIGNA [10200]","Cigna Open Access",,7171.48,33.5,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.75CM NATRELLE INSPIRA P4.9CM MODERATE PROFILE",SUP-MSZ-M560,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"UHC [10700]","United Healthcare",,100.13,63.3,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAPE SLUSH MACH EQUIPMENT",SUP-29-33009,CDM,S27000186,LOCAL,0270,RC,,,both,,,93.15,27.94,"CIGNA [10200]",Cigna,,63.34,68,,,,,0,10.83,79.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GATEWAY 135CM 20MM 2MM BALLOON DILATATION HYDROPHILIC",SUP-M0032072220200,CDM,C1725,HCPCS,0272,RC,,,both,,,9423.88,2827.16,"KAISER [10500]",Kaiser,,6314,67,,,,,0,1096,8010.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 3.5CM 20FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-20-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"FIRST HEALTH [10303]","First Health",,623.25,80,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9FR 11CM MINI GWIRE NO OBTR HEXCUSPID VALVE",SUP-504609X,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 7X4CM ALLODERM THICK ACELLULAR DERMAL MATRIX",SUP-102033,CDM,Q4116,HCPCS,0636,RC,,,both,,,5161.20,1548.36,"CIGNA [10200]","Cigna Open Access",,2936.72,56.9,,,,,0,247.92,4387.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 110MM 4.75MM STRAIGHT PERCUTANEOUS COCR",SUP-1476006110,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Open Access",,2509.29,56.9,,1144.80,304.56,2275.09,66,512.88,3748.5,"percent of total billed charges",
"IN.PACT 018 5.0 MM X 100 MM X 130 CM",SUP-IPU05010013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"MULTIPLAN [10600]",Multiplan,,6862.05,85,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 100MM 194CM 8MM 8FR BILIARY PLATINOL METAL",SUP-M00570630,CDM,C1876,HCPCS,0278,RC,,,both,,,11927.41,3578.22,"KAISER [10500]",Kaiser,,7991.36,67,,,,,0,1387.16,10138.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPTIP APD 25CM 12FR DRNG FLEXIMA METAL POLYURETHANE",SUP-M001281380,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL, SIZE 2 ANTI-ROTATION NOTCH",SUP-200178002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR RINGLOC 10D 24 36MM ARCOMXL HIP",SUP-XL105894,CDM,C1776,HCPCS,0278,RC,,,both,,,9937.38,2981.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1177.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1155.72,8446.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 65CM 5FR C3 CURVE ANGIOGRAPHIC",SUP-G06828,CDM,S27200284,LOCAL,0272,RC,,,both,,,631.80,189.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT PERITONEOVENOUS DENVER PERCUTANEOUS 25-40ML/MIN AMPLE",SUP-42-2020,CDM,S27200284,LOCAL,0272,RC,,,both,,,15525.00,4657.5,"CIGNA [10200]","Cigna Open Access",,8833.73,56.9,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.50 X 28 RX US",SUP-1804250-28,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPISTAXIS WITHOUT MCC",151,MS-DRG,,,,,,,inpatient,,,22642.27,6792.68,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,4689.63,,"Case rate ($4,553.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,227.81, add-ons for qualifying new technology services are included. If operating cost exceeds $37,267.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,701.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,233.40. The transfer operating threshold is the transfer adjustment factor * $4,227.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4553.04,18305.23,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 14MM LCP TITANIUM DISTAL VOLAR RADIUS LOCKING",SUP-04.210.114,CDM,C1713,HCPCS,0278,RC,,,both,,,1063.69,319.11,"CIGNA [10200]","Cigna Open Access",,605.24,56.9,,1144.80,304.56,2275.09,66,123.71,904.14,"percent of total billed charges",
"GRAFT SOFT TISSUE 3X2CM EPICORD PURION PLUS AMNIOTIC",SUP-EC-5230,CDM,Q4187,HCPCS,0636,RC,,,both,,,9004.50,2701.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5852.93,65,,,,,0,659.55,7653.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEMORAL PFC SIGMA NEUTRAL KNEE BOLT STERILE",SUP-960783,CDM,C1776,HCPCS,0278,RC,,,both,,,1671.00,501.3,"NOVANET [10819]",Novanet,,1253.25,75,,,,,0,194.34,1420.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA MEDIAL CONGRUENT 12 J KNEE",SUP-42-5121-011-10,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1253.3,9159.96,"percent of total billed charges",
"SHEATH ENDO-SCRUB 2 30D 4MM ENDOSCOPIC CLEANING KARL STORZ",SUP-1912010,CDM,S27200284,LOCAL,0272,RC,,,both,,,542.70,162.81,"PHCS [10601]",PHCS,,379.89,70,,,,,0,63.12,461.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 110CM 4CM 5FR 4MM 7.5MM BALLOON DILATATION",SUP-4204040L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON PLUS DEMINERALIZED BONE MATRIX 10ML PASTE",SUP-T45010,CDM,C1713,HCPCS,0278,RC,,,both,,,6210.00,1863,"FIRST HEALTH [10303]","First Health",,4968,80,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVRTB ENDOSCOPIC 50CM 19.5MM 8.6-10MM 16.7MM TAPER TIP",SUP-BX00711148,CDM,S27000186,LOCAL,0270,RC,,,both,,,1687.50,506.25,"NOVANET [10819]",Novanet,,1265.63,75,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN JUDKINS RIGHT 5 CURVE",SUP-DXT6JR50,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"UHC [10700]","United Healthcare",,52.32,63.3,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 6MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBH061002,CDM,C1874,HCPCS,0278,RC,,,both,,,19939.50,5981.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5706.68,28.62,,,,,0,2318.96,16948.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35LL 135CM 250MM 6MM .035IN LOW PROFILE BALLOON",SUP-B2060-250,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"PHCS [10601]",PHCS,,538.65,70,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 2.5CM 10CM WITHOUT MINI GWIRE DIL PINNACLE",SUP-RSS704,CDM,C1894,HCPCS,0272,RC,,,both,,,73.95,22.18,"FIRST HEALTH [10303]","First Health",,59.16,80,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KT CATH SELECTRA ACC KT",SUP-375518,CDM,C1893,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EVAC SMOKE ADAPTIVE PHOTONBLADE",SUP-PB2SE,CDM,S27200284,LOCAL,0272,RC,,,both,,,3012.75,903.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 77.5X11.2MM RECIPROCATE SURGICAL STERILE",SUP-KM-325R,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.49,33.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,MINOR",313,APR-DRG,,,,,,,inpatient,,,107097.37,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $8,867.46. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($41,718.64) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP AND FEMUR FRACTURE REPAIR,EXTREME",308,APR-DRG,,,,,,,inpatient,,,140574.35,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $25,476.90. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($83,664.80) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRI-SIL IC 20FR URETHRAL BACTI-GUARD SILICONE",SUP-70520SI,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.40,32.52,"CIGNA [10200]","Cigna Open Access",,61.68,56.9,,,,,0,12.61,92.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMB AUTOTRANSFUSION SYSTEM 2 LUMEN SUCTION BRAT 2",SUP-007005001,CDM,S27200284,LOCAL,0272,RC,,,both,,,152.25,45.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,69.88,45.9,,,,,0,17.71,129.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) GUIDEWIRE VASCULAR .018INX200CM ARISTOTLE 18 SUPPORT",SUP-A18-200-003,CDM,C1769,HCPCS,0272,RC,,,both,,,4830.00,1449,"NOVANET [10819]",Novanet,,3622.5,75,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006175282180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA [10200]",Cigna,,992.87,68,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 28MM STARDRIVE STAINLESS STEEL T8 METAPHYSEAL",SUP-02.118.528,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,356.26,68,,,,,0,60.93,445.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 45CM .013IN EXTRA SOFT STIFFNESS KNOB CAP",SUP-5003,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 10CM 7FR DUODENAL BEND BILIARY PLASTIC TEMPORARY RAPID",SUP-M00545570,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"NOVANET [10819]",Novanet,,639.58,75,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 35MM TSRH OSTEOGRIP THINLINE SPINE",SUP-83585359,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"CIGNA [10200]","Cigna Local Plus",,1377.09,53.5,,3978.14,359.25,3978.14,24,299.36,2187.9,"percent of total billed charges",
"SUT VICRYL 2 BP-1 27IN BRAID COATED CUSTOM VIOLET ABSORBABLE",SUP-D5961,CDM,S27200284,LOCAL,0272,RC,,,both,,,1241.20,372.36,"UHC [10700]","United Healthcare",,785.68,63.3,,,,,0,144.35,1055.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 65CM 5FR CB2 CURVE ANGIOGRAPHIC STAINLESS STEEL",SUP-565382CB2,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"FIRST HEALTH [10303]","First Health",,87,80,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUTURE BONE ARTHROSCOPIC DELIVERY",SUP-4403,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT ENDOSCOPIC 8.5MM SINGLE-SITE",SUP-428065,CDM,S27200284,LOCAL,0272,RC,,,both,,,1154.25,346.27,"CIGNA [10200]","Cigna Open Access",,656.77,56.9,,,,,0,134.24,981.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 5 KNEE POSTERIOR TOTAL STABILIZE",SUP-5544-A-600,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,565.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,554.87,4055.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 3.937X.984IN STRYKER PERFORMANCE SERIES THK.05IN",SUP-6125-127-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER DX-20 100CM 7FR 2-8-2-60MM SPACE SUPER LARGE",SUP-M00420SL28600,CDM,C1731,HCPCS,0272,RC,,,both,,,11557.50,3467.25,"PHCS [10601]",PHCS,,8090.25,70,,,,,0,1344.14,9823.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR FL3 CURVE ANGIOGRAPHIC TRILON FEMORAL",SUP-H7490864120A2,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.17,22.55,"KAISER [10500]",Kaiser,,50.36,67,,,,,0,8.74,63.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC",438,MS-DRG,,,,,,,inpatient,,,40794.08,12238.22,"CIGNA [10200]","Cigna Local Plus",,16822.03,,"Fee schedule rate ($16,822.03). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,40655.56,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CXI 65CM 2.3FR ANGLE SPRT PLATINUM STAINLESS STEEL",SUP-G18370,CDM,C1887,HCPCS,0272,RC,,,both,,,1522.72,456.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,625.84,41.1,,,,,0,177.09,1294.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON 6 6 NUROLON 3-0 SH 18IN CONTROL RELEASE BRAID 8",SUP-C513D,CDM,S27200284,LOCAL,0272,RC,,,both,,,120.76,36.23,"CIGNA [10200]","Cigna Local Plus",,64.61,53.5,,,,,0,14.04,102.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD BIPOLAR 24FR BALL COAGULATION STERILE LATEX FREE",SUP-26040NB-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3144.38,943.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,365.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,365.69,2672.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL TWIST 70MM 3.5MM SCP",SUP-829032070,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 90CM 40MM 2MM .014IN BALLOON DILATATION",SUP-AB14W020040090,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"NOVANET [10819]",Novanet,,1038.83,75,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR BROAD LORDOTIC 12 DEGREE",SUP-012415,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Local Plus",,5953.5,31.5,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 2 KNEE PRIMARY BEAD PA",SUP-5526-B-200,CDM,C1776,HCPCS,0278,RC,,,both,,,15783.75,4735.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6313.5,40,,,,,0,1835.65,13416.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM ROUND COARSE TRANSNASAL DIAMOND STERILE",SUP-TN30RCD,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"CIGNA [10200]",Cigna,,1876.29,68,,,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 6FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006145361190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"NOVANET [10819]",Novanet,,847.46,75,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CRANIOTOMY INTEGRA WITHOUT PREP SOL STERILE LATEX FREE",SUP-INSHITHND,CDM,S27200284,LOCAL,0272,RC,,,both,,,3495.90,1048.77,"KAISER [10500]",Kaiser,,2342.25,67,,,,,0,406.57,2971.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 7-0 BV175-8 24IN 2 ARM MONOFILAMENT",SUP-8747H,CDM,S27200284,LOCAL,0272,RC,,,both,,,258.69,77.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,30.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.09,219.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +10.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.105,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 5FR POWERLINE 2 LUMEN POWER INJECTABLE",SUP-0720515,CDM,C1751,HCPCS,0272,RC,,,both,,,2152.50,645.75,"MULTIPLAN [10600]",Multiplan,,1829.63,85,,,,,0,250.34,1829.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 150MM 4FR 2.5MM .018IN BALLOON",SUP-PCP025150130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,837.22,68,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 135CM EXCELSIOR XT-27 STRAIGHT",SUP-M003XT2735820,CDM,S27200284,LOCAL,0272,RC,,,both,,,8474.58,2542.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5762.71,68,,,,,0,985.59,7203.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 24CM 3CM 7FR .035IN PIGTAIL",SUP-M006180232090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,380.72,28.62,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCOPIC UPHOLD MESH SPRT SYSTEM VAGINAL APICAL",SUP-M0068318170,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC",480,MS-DRG,,,,,,,inpatient,,,107563.30,32268.99,"CIGNA [10200]",Cigna,,38186.08,,"Fee schedule rate ($38,186.08). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,85027.51,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Kidney Img Morpohlogy",PX-341000043,CDM,78700,CPT,0341,RC,,,both,,,2034.67,610.4,"CIGNA [10200]","Cigna Open Access",,302.65,,,,,,,2.03,1729.47,"fee schedule",
"CATH MACH1 55CM 8FR .091IN LIMA CURVE GUIDING PTFE",SUP-M001198620,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,69.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER CURVED TIP RELOAD 30MM ORANGE",SUP-ASR30RC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"AETNA [10100]","Aetna HMO/PPO",,1126.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 90MM 13MM AEQUALIS FLEX REVIVE SHOULDER DISTAL",SUP-ARS741803,CDM,C1776,HCPCS,0278,RC,,,both,,,16704.00,5011.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1942.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1942.68,14198.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE LARYNSCP BRITEPRO SOLO MILLER 4 METAL BLADE OVERMOULD",SUP-040-344U,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.63,21.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 150CM 250MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035250M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PORT HAND ACCESS 120MM OBTR OPTICAL TIP AUTOMATIC VENT LOW",SUP-IAS12-120,CDM,S27200284,LOCAL,0272,RC,,,both,,,760.06,228.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 4.3MM XLONG CALIBRATED STERILE",SUP-03.313.702S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AUG TIBIAL 10MM TRIATHLON 3 KNEE RIGHT MEDIAL LEFT LATERAL",SUP-5612-A-310,CDM,C1776,HCPCS,0278,RC,,,both,,,9878.04,2963.41,"KAISER [10500]",Kaiser,,6618.29,67,,,,,0,1148.82,8396.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.5CM NATRELLE INSPIRA P2.5CM LOW PROFILE ROUND",SUP-MSZ-L260,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.69,42.81,"FIRST HEALTH [10303]","First Health",,114.15,80,,,,,0,16.59,121.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 34MM 23MM FREESTYLE ROOT PORCINE BIOPROSTHESIS",SUP-FR995-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,38430.00,11529,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10376.1,27,,,,,0,4469.41,32665.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 22CM 3CM 5FR .038IN BLADDER LOOP STRAIGHT LOW",SUP-M006155221010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,565.01,45.9,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,inpatient,,,47595.94,14278.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,21586.34,,"Fee schedule rate ($21,586.34). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7055.99,33210.45,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 49MM ACU-LOC 2 BONE RIGHT PROXIMAL DISTAL VOLAR",SUP-70-0351,CDM,C1713,HCPCS,0278,RC,,,both,,,6651.60,1995.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,788.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",773.58,5653.86,"percent of total billed charges",
"FRCP BIPOLAR 10.2CM .4MM JEWELERS IRIS CURVED STRAIGHT",SUP-14-1080,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA [10200]","Cigna Open Access",,103.96,56.9,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 40MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.840,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"MULTIPLAN [10600]",Multiplan,,1168.25,85,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM CEMENTLESS SUMMIT DUOFIX 5 12/14 STD",SUP-157002110,CDM,C1776,HCPCS,0278,RC,,,both,,,15590.88,4677.26,"NOVANET [10819]",Novanet,,11693.16,75,,,,,0,1813.22,13252.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +2.5MM 32MM HIP C TAPER NECK PRIMARY COCR LFIT",SUP-S-1400-HH32,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,363.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM CD HORIZON SPINAL FENESTRATE MULTIAXIAL",SUP-55840025550T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"PLATE NARROW 42MM STAINLESS STEEL 2.4MM SCR 6 HOLE HEAD 2",SUP-02.111.521S,CDM,C1713,HCPCS,0278,RC,,,both,,,4102.05,1230.61,"NOVANET [10819]",Novanet,,3076.54,75,,,,,0,477.07,3486.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WATER FOR INJECTION, STERILE 100 % INTRAVENOUS SOLUTION",RX-28400,CDM,,,0250,RC,00338-0013-04,NDC,both,1000,ML,100.65,30.19,"NOVANET [10819]",Novanet,,75.49,75,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 10CM 4MM 5FR BALLOON DILATATION",SUP-DR135410,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"FIRST HEALTH [10303]","First Health",,1101.6,80,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NOVII FETAL MONITOR PATCH",SUP-107-PT-004-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,380.44,114.13,"NOVANET [10819]",Novanet,,285.33,75,,,,,0,44.25,323.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 44-36MM COMPREHENSIVE +3MM SHOULDER E1",SUP-EP-115395,CDM,C1776,HCPCS,0278,RC,,,both,,,8854.00,2656.2,"BLUE CROSS [10001]","Blue Cross PPO",,3470.77,39.2,,3949.44,3949.44,3949.44,"1 through 10",1029.72,7525.9,"percent of total billed charges",
"TRAY INSTR 446X49X88MM 2 TELESCOPE",SUP-WA05990A,CDM,S27000186,LOCAL,0270,RC,,,both,,,1913.03,573.91,"AETNA [10100]","Aetna HMO/PPO",,1520.86,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,222.49,1626.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICKSTICK 25CM 10FR LOOP DRNG FLEXIMA HYDROPHILIC",SUP-M001271470,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE STRAIGHT/ROTATION 2.0",SUP-PRT-STR-020,CDM,C1713,HCPCS,0278,RC,,,both,,,6624.00,1987.2,"MULTIPLAN [10600]",Multiplan,,5630.4,85,,,,,0,770.37,5630.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC",269,MS-DRG,,,,,,,inpatient,,,220739.83,66221.95,"AMBETTER EXCHANGE  [11102]",Ambetter,,26196.76,,"Case rate ($26,196.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $24,325.47, add-ons for qualifying new technology services are included. If operating cost exceeds $57,365.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,221.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $24,357.64. The transfer operating threshold is the transfer adjustment factor * $24,325.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,839.12. The transfer capital threshold is the transfer adjustment factor * $1,839.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,123300.55,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 100MM 5MM ENDOPATH XCEL OPTIVIEW",SUP-2CB5LT,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.80,153.24,"AETNA [10100]","Aetna HMO/PPO",,406.09,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.41,434.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.5X70MM LORDOSED ROD",SUP-30100-070,CDM,S27800098,LOCAL,0278,RC,,,both,,,1410.00,423,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,958.8,68,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 6.2MM 65MM 32MM NCB PROTASUL-64 3.5MM PARTIAL",SUP-0203152065,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"SCR BONE 8MM 90MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704890,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +14 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-SY60WF.140,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 26-42MM LARGE BALLOON OCCLUSION TAG THORAX TRILOBE",SUP-BCL2645,CDM,C1725,HCPCS,0272,RC,,,both,,,4843.80,1453.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,573.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,563.33,4117.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR .09IN EXTRA BACKUP LEFT 3.5 CURVE",SUP-LA8EBU35,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22.5 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150225,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"MULTIPLAN [10600]",Multiplan,,293.25,85,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PLGA TRICALCIUM PHOSPHATE 30MM 9MM ACL",SUP-231825,CDM,C1713,HCPCS,0272,RC,,,both,,,2349.00,704.7,"UHC [10700]","United Healthcare",,1486.92,63.3,,5023.51,2672.93,6679.78,18,965.44,1486.92,"percent of total billed charges",
"SCR INTERFERENCE BIOCOMPOSITE 28MM 10MM BLUNT FULL THREAD",SUP-AR-1400TC,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,219.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,215.23,1573.04,"percent of total billed charges",
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 6 SLOT LEFT TI",SUP-PHPF-C6L,CDM,C1713,HCPCS,0278,RC,,,both,,,18144.00,5443.2,"CIGNA [10200]","Cigna Local Plus",,5715.36,31.5,,3978.14,359.25,3978.14,24,2110.15,15422.4,"percent of total billed charges",
"DRSG WOUND 4X4CM V+PAD HEMOSTATIC NON INVASIVE",SUP-3935,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASKET SPECIMEN RETRIEVAL 6CM 200CM 3CM 5FR 8 WIRE",SUP-G21910,CDM,S27200284,LOCAL,0272,RC,,,both,,,2805.00,841.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1287.5,45.9,,,,,0,326.22,2384.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK VITRECTOMY INFINITI ANTERIOR STERILE DISPOSABLE",SUP-8065750157,CDM,S27200284,LOCAL,0272,RC,,,both,,,1232.09,369.63,"CIGNA [10200]","Cigna Open Access",,701.06,56.9,,,,,0,143.29,1047.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR ACETABULAR X3 TRITANIUM 40MM 6.5MM HIP CANCELLOUS DRIVE",SUP-2080-0040,CDM,C1713,HCPCS,0278,RC,,,both,,,632.74,189.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",73.59,537.83,"percent of total billed charges",
"LENS IOL +12 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.120,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ORTHOPEDIC LARGE LUMBOSACRAL 2 STRAP COMPRESSION PAD",SUP-79-89357,CDM,S27000186,LOCAL,0270,RC,,,both,,,145.81,43.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.96,123.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHOCOLATE 120CM 80MM 5MM .014IN BALLOON DILATATION",SUP-CB1812050080OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"UHC [10700]","United Healthcare",,3625.19,63.3,,,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 8X4CM ALLOPATCH THK.4-.8MM ACELLULAR DERMAL",SUP-WC0418,CDM,Q4128,HCPCS,0636,RC,,,both,,,10948.85,3284.65,"CIGNA [10200]","Cigna Local Plus",,80.43,,,,,,,80.43,9306.52,"fee schedule",
"GRAFT BONE FEMORAL SHAFT FREEZE DRIED",SUP-27A005,CDM,S27800098,LOCAL,0278,RC,,,both,,,5002.50,1500.75,"KAISER [10500]",Kaiser,,3351.68,67,,,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 140MM 125CM 10MM 6FR .035IN BILIARY",SUP-G50179,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CIGNA [10200]",Cigna,,4141.2,68,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Allevyn",PX-E27200104,CDM,E27200104,LOCAL,0272,RC,,,both,,,80.68,24.2,"CIGNA [10200]",Cigna,,54.86,68,,,,,0,9.38,68.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 95MM 28MM AFX VELA STRATA AORTIC EXT AAA STERILE",SUP-A28-28/C95V,CDM,C1874,HCPCS,0278,RC,,,both,,,35406.00,10621.8,"FIRST HEALTH [10303]","First Health",,28324.8,80,,,,,0,4117.72,30095.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SSPC NXT Y",SUP-9287,CDM,C1887,HCPCS,0272,RC,,,both,,,3375.00,1012.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,399.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 60CM 5MM GORE STD WALL HEPARIN PROPATEN PTFE",SUP-H050060A,CDM,C1768,HCPCS,0278,RC,,,both,,,11378.10,3413.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1348.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1323.27,9671.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HI-FLO RENEGADE FATHOM 180CM 135CM 2.8-3FR 20CM MICRO",SUP-M001184550,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 2MM 45MM ENDO GIA MEDIUM THICK TISSUE REINFORCE",SUP-SIGTRSB45AMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2325.23,697.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR SL4.5 CURVE GUIDING NYLON CORONARY",SUP-LA6SL45,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER CHEMOTHERAPY,MAJOR",696,APR-DRG,,,,,,,inpatient,,,65523.19,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $7,107.60. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($71,496.60) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH CHECK-FLO FLEXOR ANL1 CURVE 90CM 5FR .074IN GUIDING",SUP-G29988,CDM,S27200284,LOCAL,0272,RC,,,both,,,842.40,252.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TREVO NXT 3X32+TRAK21+CAT5L 3-PACK - US",SUP-SFP913100,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"GRAFT HUMAN TISSUE 2X3CM SELF EXPANDING EPICORD",SUP-EX-5230,CDM,Q4187,HCPCS,0636,RC,,,both,,,9591.00,2877.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INPACT ADMIRAL 80CM 250MM 5MM BALLOON DILATATION","SUP-ADM 050 250 08P",CDM,C2623,HCPCS,0272,RC,,,both,,,14007.00,4202.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL SURGICAL 130MM CANNULATED AO CONNECTION 2.6MM",SUP-P99-110-2613,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,682.99,68,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO 330MM 3.3MM SWISS LITHOCLAST ULTRASOUND FLEXIBLE",SUP-M0068407140,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2.5X2.5CM BIODESIGN COOK OTOLOGIC REPAIR",SUP-G44451,CDM,C1763,HCPCS,0278,RC,,,both,,,2212.50,663.75,"BLUE CROSS [10001]","Blue Cross HMO",,867.3,39.2,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 41-44MM TITANIUM 4.75MM SCR MULTISPAN XLNK BONE SPINE",SUP-5442141,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross PPO",,1893.36,39.2,,957.42,570.23,957.42,28,561.73,4105.5,"percent of total billed charges",
"SHELL ACETABULAR 62MM HIP CLUSTER HOLE 12 SCALLOP SNAP FIT",SUP-00875706201,CDM,C1776,HCPCS,0278,RC,,,both,,,11012.40,3303.72,"CIGNA [10200]",Cigna,,7488.43,68,,5873.17,5873.17,5873.17,"1 through 10",1280.74,9360.54,"percent of total billed charges",
"KIT PROC 1 TRIATHLON CR DISPOSABLE FEMORAL",SUP-5555-2201,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM 11/13 TAPER 40MM HIP M SPECIFICATION METAL",SUP-136541500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"PHCS [10601]",PHCS,,7754.57,70,,,,,0,1288.37,9416.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP 3 HOLE POLY POROUS R3 STD STERILE",SUP-71335548,CDM,C1776,HCPCS,0278,RC,,,both,,,14345.10,4303.53,"UHC [10700]","United Healthcare",,9080.45,63.3,,8601.07,8395.67,8601.07,"1 through 10",1668.34,12193.34,"percent of total billed charges",
"EXCELSIOR SL-10 150CM 2 TIP",SUP-M0031681890,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"MULTIPLAN [10600]",Multiplan,,6561.35,85,,,,,0,897.75,6561.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD PLEXA PROMRI S 65",SUP-402266,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS [10001]","Blue Cross HMO",,6731.42,39.2,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 18MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40018W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"CIGNA [10200]",Cigna,,3698.52,68,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTITORQUE 110CM 6FR 3.5MM JACKY RADIAL CURVE",SUP-40-6023,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"KAISER [10500]",Kaiser,,209.84,67,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 100CM 8FR LCB CURVE GUIDING STAINLESS",SUP-588818,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM LOW PROFILE NECK VERTICAL GROOVE CORAIL2",SUP-3L92510,CDM,C1776,HCPCS,0278,RC,,,both,,,28658.70,8597.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3333.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3333.01,24359.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 100CM 5FR MULTIPURPOSE SHORT TIP CURVE",SUP-M001314011,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"AETNA [10100]","Aetna HMO/PPO",,92.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 48MM SHOULDER REVISION SMR COCR MOLYBDENUM",SUP-1322.09.480,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5385.6,68,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INJECTION 5% DEXTROSE LACTATED RINGERS USP LIFE 1000ML",SUP-792909,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"AETNA [10100]","Aetna HMO/PPO",,64.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 140MM CANNULATED SQUARE CONNECTION 2.9MM",SUP-P99-110-2914,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"CIGNA [10200]","Cigna Open Access",,571.5,56.9,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOQUE TRICUSPID VALVE REPLACEMENT SYSTEM (48 MM VALVE)",SUP-EVQ1A2US48,CDM,S27800098,LOCAL,0278,RC,,,both,,,245100.00,73530,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,98040,40,,,,,0,28505.13,208335,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE NDL 9GA DISPOSABLE EVIVA","SUP-EVIVA NG09L",CDM,S27200284,LOCAL,0272,RC,,,both,,,90.31,27.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET BREAST BIOPSY 9GA STD INTRO LOCALIZATION ATEC 0914-20MR","SUP-ILS 0914-20",CDM,S27200284,LOCAL,0272,RC,,,both,,,1571.40,471.42,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 7.5MM 50MM CREO CREO AMP SPINE MODULAR NONSTERILE",SUP-1067.175,CDM,C1713,HCPCS,0278,RC,,,both,,,2437.50,731.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,288.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",283.48,2071.88,"percent of total billed charges",
"CATH MAC-LOC 40CM 10.2FR DRNG ULTRATHANE HYDROPHILIC BILIARY",SUP-G09498,CDM,C1729,HCPCS,0272,RC,,,both,,,801.82,240.55,"NOVANET [10819]",Novanet,,601.37,75,,,,,0,93.25,681.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.240,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",188.41,1377,"percent of total billed charges",
"CATH HURRICANE 180CM 2CM 5.8FR 4MM 12 ATM BALLOON DILATATION",SUP-M00545890,CDM,C1726,HCPCS,0272,RC,,,both,,,1849.50,554.85,"KAISER [10500]",Kaiser,,1239.17,67,,,,,0,215.1,1572.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 45CM 12MM TARGET XL 360D STD LARGE",SUP-M0036101240,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 110CM 6FR ULT4T-40 CURVE ANGIOGRAPHIC PEBAX",SUP-6110381ULT4-T40,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.84,61.75,"CIGNA [10200]",Cigna,,139.97,68,,,,,0,23.94,174.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END 0MM T25 STARDRIVE TITANIUM NIOBIUM ALUMINUM STERILE",SUP-04.019.000S,CDM,C1713,HCPCS,0278,RC,,,both,,,1372.14,411.64,"FIRST HEALTH [10303]","First Health",,1097.71,80,,,,,0,159.58,1166.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE RIB FREEZE DRIED WHOLE",SUP-51A001,CDM,S27800098,LOCAL,0278,RC,,,both,,,2092.50,627.75,"CIGNA [10200]","Cigna Local Plus",,1119.49,53.5,,,,,0,243.36,1778.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 14X26X60MM",SUP-6214060,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,9384.48,39.2,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE COROLENE 7-0 MULTI",SUP-20P05B,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.70,80.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,123.79,45.9,,,,,0,31.37,229.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MULTIFLEX PENTALUMEN TORQUE-LINE 110CM 7FR STD",SUP-41223-02,CDM,C1751,HCPCS,0272,RC,,,both,,,343.22,102.97,"MULTIPLAN [10600]",Multiplan,,291.74,85,,,,,0,39.92,291.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Airway Laryngeal",PX-E27000037,CDM,E27000037,LOCAL,0270,RC,,,both,,,42.81,12.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,19.65,45.9,,,,,0,4.98,36.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.3MM 20MM CENTRONAIL TITANIUM LOW PROFILE FOOT",SUP-99-T774020,CDM,C1713,HCPCS,0278,RC,,,both,,,1492.91,447.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1015.18,68,,,,,0,173.63,1268.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS 5-0 RB-1 30IN 2 ARM ANTIBACTERIAL VIOLET",SUP-PDP320H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]",Cigna,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 5MM 68MM NAIL-EX TITANIUM FEMORAL TIBIAL LOCKING",SUP-04.005.558,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,134.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",134.52,983.18,"percent of total billed charges",
"STEM EXT 120MM 15MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424028,CDM,C1776,HCPCS,0278,RC,,,both,,,11747.25,3524.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3362.06,28.62,,,,,0,1366.21,9985.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM MASTERS HP STD MECHANICAL CUFF",SUP-19AHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]","Cigna Open Access",,9754.94,33.5,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC",239,MS-DRG,,,,,,,inpatient,,,141174.97,42352.49,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,62164.39,,"Case rate ($30,529.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $28,348.81, add-ons for qualifying new technology services are included. If operating cost exceeds $61,388.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,525.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $28,386.30. The transfer operating threshold is the transfer adjustment factor * $28,348.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,143.31. The transfer capital threshold is the transfer adjustment factor * $2,143.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,10994,141174.97,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X8MM SUSTAIN SMALL OBLIQUE PEEK TITANIUM",SUP-304.088CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,18207.00,5462.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7483.08,41.1,,,,,0,2117.47,15475.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 1-2 11MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934379,CDM,C1776,HCPCS,0278,RC,,,both,,,18947.25,5684.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2245.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2203.57,16105.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 20MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0307,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]",Cigna,,644.44,68,,1831.33,1831.33,1831.33,16,110.22,805.55,"percent of total billed charges",
"LEAD ICD 64CM ENDOTAK RELIANCE G ENDOCARDIAL STEROID",SUP-175,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 11CM 5FR GEENEN PANCREATIC POLYETHYLENE",SUP-G27151,CDM,C2625,HCPCS,0278,RC,,,both,,,1231.20,369.36,"PHCS [10601]",PHCS,,861.84,70,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT FEMORAL 40MM GMRS KNEE",SUP-64956040,CDM,C1776,HCPCS,0278,RC,,,both,,,16025.25,4807.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1863.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1863.74,13621.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grad Compression Knee 30-40",PX-E27100010,CDM,A6531,HCPCS,0292,RC,,,both,,,122.10,36.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.2,103.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL SPIN GUARD FEMORAL METATARSOPHALANGEAL",SUP-P01-900-1902,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,226.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COPE MAC-LOC 26CM 8.5FR PIGTAIL CURVE",SUP-G48180,CDM,C2617,HCPCS,0278,RC,,,both,,,980.02,294.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,116.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.98,833.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPILONG SOFT TRAY 17G X 3.5     (90MM) NEEDLE WITH 1CM GRADU",SUP-TAL151,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"CIGNA [10200]","Cigna Open Access",,188.11,56.9,,,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP OPHTHALMIC MALYUGIN 7MM RING",SUP-MAL-0002-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1147.50,344.25,"MULTIPLAN [10600]",Multiplan,,975.38,85,,,,,0,133.45,975.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM 16MM DCP LC-DCP STAINLESS STEEL",SUP-216.050,CDM,C1713,HCPCS,0278,RC,,,both,,,496.85,149.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,228.05,45.9,,,,,0,57.78,422.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP HUMERAL 33MM UNIVERS REVERS +2MM SHOULDER LEFT CALCIUM",SUP-AR-9502F-33RCPC,CDM,C1776,HCPCS,0278,RC,,,both,,,7576.20,2272.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3477.48,45.9,,,,,0,881.11,6439.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,inpatient,,,119319.61,35795.88,"BLUE CROSS [10001]","Blue Cross PPO",,86093.62,,,,,,,7561,101818.13,"case rate",
"TRAY CATH 5FR 6FR POWERPICC 3 LUMEN MAXIMAL BARR SHERLOCK",SUP-9385108QD,CDM,C1751,HCPCS,0272,RC,,,both,,,1689.60,506.88,"AETNA [10100]","Aetna HMO/PPO",,1343.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,196.5,1436.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ONE-STEP 7CM 5FR 19GA STRAIGHT DRNG PERCUTANEOUS 4 HOLE",SUP-OSC-5F-7LT,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.35,53.5,"CIGNA [10200]","Cigna Local Plus",,95.42,53.5,,,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 4 ML TOPICAL SYRINGE",RX-182423,CDM,,,0250,RC,00338-9564-01,NDC,both,4,ML,1610.81,483.24,"UHC [10700]","United Healthcare",,1019.64,63.3,,,,,0,187.34,1369.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Picc Triple Lumen",PX-E27200068,CDM,C1751,HCPCS,0272,RC,,,both,,,1205.97,361.79,"PHCS [10601]",PHCS,,844.18,70,,,,,0,140.25,1025.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 120MM 3.8FR 2MM BALLOON DILATATION",SUP-H74939148201210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 90CM 5FR 1.9MM FLEXOR SHUTTLE TUOHY BORST CHECK",SUP-G31133,CDM,C1894,HCPCS,0272,RC,,,both,,,1173.69,352.11,"AETNA [10100]","Aetna HMO/PPO",,933.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.5,997.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC",862,MS-DRG,,,,,,,inpatient,,,43300.62,12990.19,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE INQWIRE VASCULAR BENTSON STRAIGHT 180CM 15CM .035IN",SUP-IQ35F180BC,CDM,C1769,HCPCS,0272,RC,,,both,,,92.74,27.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL 5 D +24 DIOPTER MODIFIED C BICONVEX 12.5MM 7MM",SUP-CZ70BD.240,CDM,V2632,HCPCS,0276,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGSEED PRO 7CM",SUP-MS2-17-1-07,CDM,A4648,HCPCS,0278,RC,,,both,,,3829.50,1148.85,"CIGNA [10200]","Cigna Local Plus",,2048.78,53.5,,,,,0,445.37,3255.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORTHOLOC? 3DI FOOT RECONSTRUCTION SYSTEM MEDIAL COLUMN PLATE",SUP-58150001,CDM,C1713,HCPCS,0278,RC,,,both,,,14386.50,4315.95,"NOVANET [10819]",Novanet,,10789.88,75,,,,,0,1673.15,12228.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 6FR STRAIGHT GUIDING DURAFORM",SUP-M003101500,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,296.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Amino Acids 6/> Amino Acids Quantitative Ea Spe",PX-301000103,CDM,82139,CPT,0301,RC,,,both,,,453.70,136.11,"CIGNA [10200]","Cigna Local Plus",,37.11,,,,,,,0.01,385.65,"fee schedule",
"HC Mra Pelvis WO Cntrst",PX-610000022,CDM,72198,CPT,0610,RC,,,both,,,4288.00,1286.4,"CIGNA [10200]","Cigna Local Plus",,752,,"Per diem ($752). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,498.69,3644.8,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14X12.9CM NATRELLE P6.5CM EXTRA MODERATE HEIGHT",SUP-MSZMX520,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 1",SUP-71357101,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"PHCS [10601]",PHCS,,23198.81,70,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG VARIABLE ANGLE LOCKING 1.8MM X 16MM",SUP-SPLS-18160-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,408.01,28.62,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intrpul Srf Admin Physcn W Ett",PX-460000008,CDM,94610,CPT,0460,RC,,,both,,,277.56,83.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,127.4,45.9,,,,,0,32.28,235.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESPIRATORY NEOPLASMS WITHOUT CC/MCC",182,MS-DRG,,,,,,,inpatient,,,61119.45,18335.83,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIRROR LARYNGEAL 18MM 3 STATIONARY OCTAGONAL HANDLE",SUP-73-4818,CDM,S27000186,LOCAL,0270,RC,,,both,,,65.60,19.68,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 40CM 16MM .0145IN AXIUM PRIME 3D FRAME",SUP-FC-16-40-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"CIGNA [10200]","Cigna Open Access",,5536.04,33.5,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR FL3.5 CURVE ANGIOGRAPHIC FEMORAL 2",SUP-H74916599212,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,52.07,68,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM ATLANTIS TITANIUM SPINAL CANCELLOUS",SUP-876-816,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"PLATE 40MM TITANIUM LOCKING ATLANTIS VISION BONE ANTERIOR",SUP-976-140,CDM,C1713,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"KAISER [10500]",Kaiser,,3929.55,67,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY 10CM 18GA BARD MARQUEE CORE DISPOSABLE",SUP-MQK1810,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,67.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE 20MM 8MM BIOSURE REGENESORB",SUP-72204398,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"NOVANET [10819]",Novanet,,2080.52,75,,,,,0,322.62,2357.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 CURVE 10MM KNEE GVF ROTATE PLATFORM PFC",SUP-972001,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"BLUE CROSS [10001]","Blue Cross HMO",,3625.78,39.2,,5311.50,4717.44,5388.59,31,1075.71,7862.03,"percent of total billed charges",
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 100X12-13MM",SUP-400751,CDM,S27800098,LOCAL,0278,RC,,,both,,,4868.64,1460.59,"CIGNA [10200]","Cigna Open Access",,2770.26,56.9,,,,,0,566.22,4138.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 6MM 3.75MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012410-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Head/Brain W/WO Cntrst",PX-351000004,CDM,70470,CPT,0351,RC,,,both,,,3265.19,979.56,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($536.40). Procedures 2 - 999, Per diem ($268.20).",536.40,536.40,536.40,"1 through 10",,,"per diem",
"DEVICE NOVASURE ABLATION ENDOMETRIAL STERILE DISPOSABLE",SUP-NS2000,CDM,S27200284,LOCAL,0272,RC,,,both,,,6785.00,2035.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) OSCOR GUIDESTAR 10F SHEATH 22MM","SUP-D-1433-02-SI (22MM)",CDM,C1887,HCPCS,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL RUSSIAN 8IN TISSUE MATTE FINISH STAINLESS",SUP-129392,CDM,S27000186,LOCAL,0270,RC,,,both,,,98.31,29.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ASTATO 30 VASCULAR 180CM 15CM .33-.45MM SLIP-COAT PTFE",SUP-PAGH18M071,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 12MM 6FR 4.5MM",SUP-H7493926712450,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DILATOR 4FR/.035",SUP-48-149,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.00,1.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CROSSWALK 90CM 4.2FR 3.2FR .039FR .037FR MICRO SPRT",SUP-PSC35090A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Drng Vacuum Bottle Pleurx",PX-HHE27200401,CDM,C1729,LOCAL,0272,RC,,,outpatient,,,422.00,126.6,"UHC [10700]","United Healthcare",,267.13,63.3,,,,,0,49.08,358.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 10MM AXIUM 3D NEUROVASCULAR FRAME V01",SUP-FC-10-40-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4461.89,27,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BIO DBM PUTTY PLUS DEMINERALIZED BONE MATRIX 10CC",SUP-7777010,CDM,C1713,HCPCS,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]",Cigna,,4692,68,,1831.33,1831.33,1831.33,16,802.47,5865,"percent of total billed charges",
"STENT ONYX FRONTIER 26MM 2MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG20026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PEEK-OPTIMA 15MM 5MM RADIOLUCENT G-FORCE",SUP-86PS0515,CDM,C1713,HCPCS,0278,RC,,,both,,,3037.50,911.25,"CIGNA [10200]",Cigna,,2065.5,68,,1831.33,1831.33,1831.33,16,353.26,2581.88,"percent of total billed charges",
"TRAY TIBIAL 74.9X49.3X4.8MM MBT 4MM KNEE CEMENTED REVISION",SUP-129435140,CDM,C1776,HCPCS,0278,RC,,,both,,,22385.16,6715.55,"BLUE CROSS [10001]","Blue Cross HMO",,8774.98,39.2,,5311.50,4717.44,5388.59,31,2603.39,19027.39,"percent of total billed charges",
"HC Microsatellite Instability",PX-309000061,CDM,81301,CPT,0310,RC,,,both,,,2072.00,621.6,"CIGNA [10200]","Cigna Local Plus",,766.83,,,,,,,0.01,1761.2,"fee schedule",
"CAP LOCKING CREO SPINAL THREAD NONSTERILE",SUP-1119.0010,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 4FR 8CM CENTRAL VENOUS SPECTRUM 2 LUMEN CURVE NDL",SUP-G43991,CDM,C1751,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL COCHLEAR 8MM 4MM DERMALOCK BAHA TITANIUM HA 1 STAGE",SUP-93330,CDM,L8690,HCPCS,0278,RC,,,both,,,21042.00,6312.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8648.26,41.1,,,,,0,2447.18,17885.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM ATS SPINE MULTIAXIAL 4.75MM ROD",SUP-54840046540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS [10001]","Blue Cross PPO",,3742.37,39.2,,957.42,570.23,957.42,28,1110.3,8114.82,"percent of total billed charges",
"GRAFT SKIN 10X5CM REPLIFORM PELVIC FLOOR ACELLULAR DERMAL",SUP-M0068202450,CDM,C1762,HCPCS,0278,RC,,,both,,,9918.09,2975.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2838.56,28.62,,,,,0,1153.47,8430.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLATE, GLENOSPHERE, INSERT, TRAY, STEM, SCREWS, DISPOSAB",SUP-CAP-E-RSA1,CDM,C1776,HCPCS,0278,RC,,,both,,,49140.00,14742,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,14063.87,28.62,,,,,0,5714.98,41769,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 41CM 5FR ROSCH",SUP-G10082,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CIGNA [10200]",Cigna,,161.49,68,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADHSV SKIN CLSR 2 OCTYL CYANOACRYLATE DERMABOND MINI LIQUID",SUP-DHVM12,CDM,S27200284,LOCAL,0272,RC,,,both,,,308.17,92.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,141.45,45.9,,,,,0,35.84,261.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ARTHROSCOPIC .034IN TROCAR TIP LASER LINE",SUP-AR-8737-39,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"MULTIPLAN [10600]",Multiplan,,162.69,85,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 6MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620906,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Open Access",,6403.47,56.9,,5302.19,4377.88,6578.61,27,1308.83,9565.82,"percent of total billed charges",
"STENT CONTOUR 26CM 4.8FR .035IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856080,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,745.73,68,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 9FR 20CM HYDROPHILIC RADIOPAQUE STERILE",SUP-G10290,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"KAISER [10500]",Kaiser,,44.82,67,,,,,0,7.78,56.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION",RX-1090,CDM,,,0250,RC,00536-1286-36,NDC,both,237,ML,25.34,7.6,"CIGNA [10200]","Cigna Open Access",,14.42,56.9,,,,,0,2.95,21.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 CURVE PLUS 8MM KNEE XLK FIX BEARING SIGMA",SUP-970470,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 4.5CM 18FR RADIOPAQUE LOW PROFILE PROXIMAL ANTIREFLUX",SUP-0120-18-4.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"NOVANET [10819]",Novanet,,584.3,75,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ENDOSCOPIC BLADE SHARP TIP SICKLE CURVE 7.5IN NASAL",SUP-63-7580,CDM,S27200284,LOCAL,0272,RC,,,both,,,539.38,161.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,221.69,41.1,,,,,0,62.73,458.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN EXTRA BACKUP 4.5 LEFT CURVE",SUP-LA6EBU45,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 83MM 10MM COMPREHENSIVE POROUS MINI SHOULDER",SUP-113630,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"NOVANET [10819]",Novanet,,9450,75,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 2.5MM GALAXY G3 XTRASOFT NEUROVASCULAR",SUP-GLX122505,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3400.57,28.62,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PER-Q-CATH 20CM 4FR 20GA 17GA CENTRAL VENOUS 1 LUMEN",SUP-4144202,CDM,C1751,HCPCS,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 75CM .4MM FIRM TPR",SUP-124208,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"FIRST HEALTH [10303]","First Health",,306.24,80,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR GUIDE SPEAR STEP DRILL TROCAR DISPOSABLE STERILE 3",SUP-AR-1934DS-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CIGNA [10200]","Cigna Open Access",,774.3,56.9,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM KNEE 100MM 14MM GENESIS II LONG TITANIUM",SUP-71420632,CDM,C1776,HCPCS,0278,RC,,,both,,,11540.25,3462.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3302.82,28.62,,,,,0,1342.13,9809.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 12X8IN MEPITEL SILICONE NONADHESIVE LATEX FREE",SUP-292005,CDM,S27200284,LOCAL,0272,RC,,,both,,,175.39,52.62,"CIGNA [10200]",Cigna,,119.27,68,,,,,0,20.4,149.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,,,0637,RC,77333-0951-25,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM DIVERGENCE-L SPINE",SUP-2150125,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,188.41,1377,"percent of total billed charges",
"LINER ACETABULAR PINNACLE NEUTRAL 66MM 36MM MARATHON HIP",SUP-121936066,CDM,C1776,HCPCS,0278,RC,,,both,,,8942.40,2682.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1059.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1040,7601.04,"percent of total billed charges",
"CMPNT PATELLAR 11MM 39MM SYMMETRIC TRIATHLON X3 KNEE",SUP-5550L391,CDM,C1776,HCPCS,0278,RC,,,both,,,4478.10,1343.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,520.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,520.8,3806.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON ULTIMA 10-0 CS160-6 6IN 2 ARM MONOFILAMENT BLACK",SUP-9001G,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.51,73.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.67,209.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 10MM INTERLOCK FIBERED IDC 18 COIL",SUP-M001361590,CDM,S27800098,LOCAL,0278,RC,,,both,,,2079.00,623.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,241.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,241.79,1767.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 39MM 135CM 10MM 13MM 8FR .035IN",SUP-BXA103902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8016.47,41.1,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE HEMO-SEAL 4-0 C-1 30IN 2 ARM MONOFILAMENT BLUE",SUP-9706H,CDM,S27200284,LOCAL,0272,RC,,,both,,,432.46,129.74,"PHCS [10601]",PHCS,,302.72,70,,,,,0,50.3,367.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Stim Hrt Pacing Post IV Inf",PX-481000057,CDM,93623,CPT,0481,RC,,,both,,,5711.11,1713.33,"CIGNA [10200]","Cigna Open Access",,5711.11,,"Case rate ($19,750). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,664.2,5711.11,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Sulfr Colloid Filtered Up to 20mci",PX-343000014,CDM,A9541,HCPCS,0343,RC,,,both,,,746.77,224.03,"KAISER [10500]",Kaiser,,500.34,67,,,,,0,86.85,746.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 29MM 4.5MM AEQUALIS SHOULDER TITANIUM LOCK",SUP-DWD029,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"PHCS [10601]",PHCS,,1089.2,70,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL HIP 22MM 34MM OR3O 2 MOBILITY LINER STERILE LATEX FREE",SUP-71358254,CDM,C1776,HCPCS,0278,RC,,,both,,,10743.30,3222.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4931.17,45.9,,,,,0,1249.45,9131.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 14MM SKYLINE TITANIUM LARGE DIAMETER SPINE",SUP-186864014,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]",Cigna,,958.8,68,,1831.33,1831.33,1831.33,16,163.98,1198.5,"percent of total billed charges",
"BLADE SAW 90X25X1.27MM OSCILLATING AGGRESSIVE K2000",SUP-K7-2590-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.11,68.43,"UHC [10700]","United Healthcare",,144.39,63.3,,,,,0,26.53,193.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 50CM CARBOTHANE PALINDROME TAL VENATRAC 2 LUMEN",SUP-8888145042P,CDM,C1750,HCPCS,0278,RC,,,both,,,2876.79,863.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1320.45,45.9,,,,,0,334.57,2445.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF ENHANCR II 110CM 4MM 7FR 2-5-2MM SPACE 45MM SINGLE",SUP-FND-019-05,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,161.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL LONG BAYONET STRAIGHT BIPOLAR",SUP-675.170S,CDM,S27200284,LOCAL,0272,RC,,,both,,,7438.20,2231.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,865.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,865.06,6322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP MEDIUM LARGE INTERNAL HEM-O-LOK POLYMER ENDOSCOPIC",SUP-544230,CDM,S27200284,LOCAL,0272,RC,,,both,,,439.14,131.74,"UHC [10700]","United Healthcare",,277.98,63.3,,,,,0,51.07,373.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV POSITIONING WAFFLE UNIVERSAL FOOT HEEL CUSTOM",SUP-5450CXXX060,CDM,S27000186,LOCAL,0270,RC,,,both,,,238.82,71.65,"KAISER [10500]",Kaiser,,160.01,67,,,,,0,27.77,203,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Radial Artery",PX-E27200178,CDM,E27200178,LOCAL,0272,RC,,,both,,,67.10,20.13,"KAISER [10500]",Kaiser,,44.96,67,,,,,0,7.8,57.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Radial Artery",PX-E27200178,CDM,E27200178,LOCAL,0272,RC,,,both,,,67.10,20.13,"AETNA [10100]","Aetna HMO/PPO",,53.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.8,57.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Stoma W Resect",PX-750000163,CDM,44403,CPT,0750,RC,,,both,,,3326.05,997.81,"NOVANET [10819]",Novanet,,2494.54,75,,,,,0,386.82,3326.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP PRIMARY STEM 16MM MINI",SUP-113636,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1465.38,10710,"percent of total billed charges",
"LEAD 5076-85  LEAD-BIPOLAR SIL SCREW-IN",SUP-5076-85,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"PHCS [10601]",PHCS,,1562.75,70,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC 55.4CM 8MM DA VINCI S/SI ENDOWRIST COBRA",SUP-420190,CDM,S27000186,LOCAL,0270,RC,,,both,,,1732.50,519.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,712.06,41.1,,,,,0,201.49,1472.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 59CM ENDOCARDIUM 4 SITE 2 COIL CARDIOVERTER",SUP-0275,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]","Cigna Open Access",,5752.62,33.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD EEG CERIBELL MEDIUM HEADBAND NONSTERILE LATEX FREE",SUP-C152,CDM,S27200284,LOCAL,0272,RC,,,both,,,4167.60,1250.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1712.88,41.1,,,,,0,484.69,3542.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POLYMER INTREPID TRANSFORMER I/A HANDPIECE (SINGLE USE)",SUP-8065752885,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.64,69.19,"CIGNA [10200]","Cigna Open Access",,131.23,56.9,,,,,0,26.82,196.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 56MM 36MM ALTRX HIP",SUP-122136056,CDM,C1776,HCPCS,0278,RC,,,both,,,6186.60,1855.98,"CIGNA [10200]","Cigna Open Access",,3520.18,56.9,,5302.19,4377.88,6578.61,27,719.5,5258.61,"percent of total billed charges",
"SURFACE ARTICULAR 14MM PERSONA 10-12 G-H KNEE RIGHT TIBIA",SUP-42522401014,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4946.38,45.9,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 24MM 144CM 2.75MM CORONARY STENT",SUP-H7493941824270,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE-O MOD SHANK, 5.5X55MM TRACTION",SUP-13175555,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,1831.33,1831.33,1831.33,16,348.9,2550,"percent of total billed charges",
"SCR BONE 44MM 4MM LCP CORTICAL PERIARTICULAR TIBIAL",SUP-02.204.044,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"BLUE CROSS [10001]","Blue Cross PPO",,386.74,39.2,,957.42,570.23,957.42,28,114.74,838.59,"percent of total billed charges",
"COIL EMBOLIZATION 15CM 6MM .021IN AZUR DETACHABLE .018IN",SUP-45-480615,CDM,S27800098,LOCAL,0278,RC,,,both,,,1459.46,437.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,992.43,68,,,,,0,169.74,1240.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 50MM LCP STAINLESS STEEL FULL THREAD CONDYLAR",SUP-02.207.050,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",189.34,1383.8,"percent of total billed charges",
"NAIL 12MM 360MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.257S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CIGNA [10200]","Cigna Local Plus",,3911.78,31.5,,3978.14,359.25,3978.14,24,1444.25,10555.59,"percent of total billed charges",
"SCR BONE 2.5MM 16MM MINI-MONSTER SHORT THREAD CANNULATED",SUP-P20-125-016S,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,164.86,1204.88,"percent of total billed charges",
"SCR BONE 4MM 19MM HELIX R SPINE SELF TAP FIX ANGLE",SUP-7804219,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 5/64IN STEINMANN 1 END TROCAR POINT",SUP-1611-18-000,CDM,C1713,HCPCS,0278,RC,,,both,,,139.20,41.76,"KAISER [10500]",Kaiser,,93.26,67,,,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM VARIAX T10 FULL THREAD FOOT ANKLE LOCK",SUP-657310,CDM,C1713,HCPCS,0278,RC,,,both,,,1961.70,588.51,"BLUE CROSS [10001]","Blue Cross HMO",,768.99,39.2,,957.42,156.86,7483.26,51,228.15,1667.45,"percent of total billed charges",
"CAP END 0MM T40 HEXAGON FEMUR PROXIMAL EXTEND STARDRIVE",SUP-04.038.000S,CDM,C1713,HCPCS,0278,RC,,,both,,,1539.97,461.99,"CIGNA [10200]","Cigna Open Access",,876.24,56.9,,1144.80,304.56,2275.09,66,179.1,1308.97,"percent of total billed charges",
"CAP ORTHOPEDIC 1MM 10MM 5MM END INTERNAL THREAD HEX TALON",SUP-HTN-10-C01,CDM,C1713,HCPCS,0278,RC,,,both,,,1320.30,396.09,"PHCS [10601]",PHCS,,924.21,70,,,,,0,153.55,1122.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 TWINFIX ULTRA ULTRABRAID PRELOAD COBRAID",SUP-72202613,CDM,C1713,HCPCS,0278,RC,,,both,,,2039.63,611.89,"FIRST HEALTH [10303]","First Health",,1631.7,80,,,,,0,237.21,1733.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TIBIAL GREEN STRIPE 74X50MM NEXGEN 6 WEDGE KNEE",SUP-00598800600,CDM,C1713,HCPCS,0278,RC,,,both,,,15836.88,4751.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4532.52,28.62,,,,,0,1841.83,13461.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 20MM LCP TITANIUM DISTAL VOLAR RADIUS LOCKING",SUP-04.210.120,CDM,C1713,HCPCS,0278,RC,,,both,,,1063.69,319.11,"CIGNA [10200]","Cigna Local Plus",,569.07,53.5,,3978.14,359.25,3978.14,24,123.71,904.14,"percent of total billed charges",
"SCR BONE 2.4MM 26MM LCP TITANIUM DISTAL VOLAR RADIUS LOCKING",SUP-04.210.126,CDM,C1713,HCPCS,0278,RC,,,both,,,1063.69,319.11,"NOVANET [10819]",Novanet,,797.77,75,,,,,0,123.71,904.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI L 4MMX1MM MID FACE LEFT 4 HOLE BAR 2MM SCR BONE",SUP-55-08235,CDM,C1713,HCPCS,0278,RC,,,both,,,1648.88,494.66,"CIGNA [10200]",Cigna,,1121.24,68,,1831.33,1831.33,1831.33,16,191.76,1401.55,"percent of total billed charges",
"ANCHOR SUT 5MM 2 TWINFIX ULTRABRAID SHOULDER PRELOAD NDL",SUP-7210708,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 62MM STAINLESS STEEL 3.5MM SCR 3 HOLE SHARP HOOK LOW",SUP-02.113.103S,CDM,C1713,HCPCS,0278,RC,,,both,,,3724.88,1117.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2532.92,68,,,,,0,433.2,3166.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.9MM 2 OSTEORAPTOR ULTRABRAID COBRAID BLUE WHITE",SUP-72201995,CDM,C1713,HCPCS,0278,RC,,,both,,,2666.25,799.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1813.05,68,,,,,0,310.08,2266.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 450MM 11MM HOFFMANN 3 VECTRAN CARBON",SUP-4922-8-450,CDM,C1713,HCPCS,0278,RC,,,both,,,3401.70,1020.51,"CIGNA [10200]",Cigna,,2313.16,68,,1831.33,1831.33,1831.33,16,395.62,2891.45,"percent of total billed charges",
"SCREW BONE 2MM 14MM DCP STAINLESS STEEL SMALL BONE SELF TAPP",SUP-201.884,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"CIGNA [10200]","Cigna Open Access",,401.34,56.9,,1144.80,304.56,2275.09,66,82.03,599.55,"percent of total billed charges",
"PLATE 42X41X1MM ORBITAL FLOOR LEFT MESH EMBED EXT BONE",SUP-81031,CDM,C1713,HCPCS,0278,RC,,,both,,,8317.26,2495.18,"PHCS [10601]",PHCS,,5822.08,70,,,,,0,967.3,7069.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 22MM 2 HOLE CASCADIA CAYMAN BONE SPINE NONSTERILE",SUP-7908-42F223,CDM,C1713,HCPCS,0278,RC,,,both,,,31594.50,9478.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3674.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",3674.44,26855.33,"percent of total billed charges",
"PLATE 22MM 2 HOLE CASCADIA CAYMAN BONE SPINE NONSTERILE",SUP-7908-42F223,CDM,C1713,HCPCS,0278,RC,,,both,,,31594.50,9478.35,"CIGNA [10200]","Cigna Open Access",,10584.16,33.5,,1144.80,304.56,2275.09,66,3674.44,26855.33,"percent of total billed charges",
"PIN FIXATION 10MM 1.6MM UNITE THREAD TEMPORARY",SUP-MPPF1610T,CDM,C1713,HCPCS,0278,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 22MM LCP STAINLESS STEEL SMALL BONE SELF",SUP-202.222,CDM,C1713,HCPCS,0278,RC,,,both,,,748.44,224.53,"MULTIPLAN [10600]",Multiplan,,636.17,85,,,,,0,87.04,636.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 245MM TI6AL4V PERIPROSTHETIC 9 HOLE NCB BONE FEMUR",SUP-0202263109,CDM,C1713,HCPCS,0278,RC,,,both,,,13144.50,3943.35,"CIGNA [10200]","Cigna Open Access",,4403.41,33.5,,1144.80,304.56,2275.09,66,1528.71,11172.83,"percent of total billed charges",
"SCR INTERFERENCE REGENESORB 20MM 6MM SOLID OPEN ARCHITECTURE",SUP-72204391,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,328.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,322.62,2357.93,"percent of total billed charges",
"SCR BONE 6.5MM 50MM ASSEMB",SUP-11-4650*,CDM,C1713,HCPCS,0278,RC,,,both,,,6210.00,1863,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,722.22,5278.5,"percent of total billed charges",
"SCR BONE 5MM 80MM VALOR ORTHOPEDIC",SUP-4151150080,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"KAISER [10500]",Kaiser,,1155.75,67,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 75MM STAINLESS STEEL T25 VARIABLE ANGLE SELF",SUP-02.231.275,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,152.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",152.1,1111.66,"percent of total billed charges",
"SCR BONE 6.5MM 35MM SPINE POLYAXIAL REVOLVE",SUP-185.463,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4382,45.9,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 46MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.546,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"MULTIPLAN [10600]",Multiplan,,931.96,85,,,,,0,127.51,931.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICONAZOLE NITRATE 2 % TOPICAL OINTMENT",RX-13651,CDM,,,0250,RC,84389-0135-51,NDC,both,71,GR,364.42,109.33,"NOVANET [10819]",Novanet,,273.32,75,,,,,0,42.38,309.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORTICAL SCREW 4MM X 46MM",SUP-HTN-U-4-46,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"KAISER [10500]",Kaiser,,1041.98,67,,,,,0,180.87,1321.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE STAINLESS STEEL L18 MM OD5 MM CONDYLAR SELF TAP V",SUP-42.231.018S,CDM,C1713,HCPCS,0278,RC,,,both,,,2101.05,630.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1428.71,68,,,,,0,244.35,1785.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.7MM 6MM VARIAX T5 LOCK NONSTERILE",SUP-662506,CDM,C1713,HCPCS,0278,RC,,,both,,,1075.03,322.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,125.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",125.03,913.78,"percent of total billed charges",
"SHEET SYNTHETIC 50X38X3MM MEDPOR NEURO",SUP-9562,CDM,C1713,HCPCS,0278,RC,,,both,,,7877.73,2363.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,933.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,916.18,6696.07,"percent of total billed charges",
"SCR BONE 3.5MM 20MM SECUR-FIT X-TRA TITANIUM T15 CORTICAL",SUP-131218020,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"CIGNA [10200]","Cigna Local Plus",,422.52,53.5,,3978.14,359.25,3978.14,24,91.85,671.29,"percent of total billed charges",
"HC Xr Finger(S)>=2v",PX-320000074,CDM,73140,CPT,0320,RC,,,both,,,507.16,152.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,60.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,49.66,431.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Analysis Antitachy Pcmkr Sys",PX-480000064,CDM,93724,CPT,0480,RC,,,both,,,367.00,110.1,"CIGNA [10200]","Cigna Local Plus",,196.35,53.5,,,,,0,42.68,367,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 90MM 16MM DCP LC-DCP STAINLESS STEEL",SUP-216.090,CDM,C1713,HCPCS,0278,RC,,,both,,,302.06,90.62,"CIGNA [10200]","Cigna Local Plus",,161.6,53.5,,3978.14,359.25,3978.14,24,35.13,256.75,"percent of total billed charges",
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 48MM COCR",SUP-VAL-35480-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"BLUE CROSS [10001]","Blue Cross HMO",,823.2,39.2,,957.42,156.86,7483.26,51,244.23,1785,"percent of total billed charges",
"PLATE 67MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 7",SUP-249.683,CDM,C1713,HCPCS,0278,RC,,,both,,,2429.70,728.91,"KAISER [10500]",Kaiser,,1627.9,67,,,,,0,282.57,2065.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 22MM TITANIUM DISTAL RADIAL WRIST HAND",SUP-CO-N2322,CDM,C1713,HCPCS,0278,RC,,,both,,,720.90,216.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,206.32,28.62,,,,,0,83.84,612.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM LOW PROFILE SCREWS STAINLESS STEEL SHORT",SUP-AR-8840C-40,CDM,C1713,HCPCS,0278,RC,,,both,,,1770.00,531,"FIRST HEALTH [10303]","First Health",,1416,80,,,,,0,205.85,1504.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 49MM TITANIUM 2.4MM SCREWS 7X2 HOLES VARIABLE ANGLE 2",SUP-04.111.720,CDM,C1713,HCPCS,0278,RC,,,both,,,4126.20,1237.86,"CIGNA [10200]","Cigna Open Access",,2347.81,56.9,,1144.80,304.56,2275.09,66,479.88,3507.27,"percent of total billed charges",
"SCR BONE 2.7MM 40MM LCP",SUP-02.211.040,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,257.04,28.62,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T OBLIQUE ANGLE 63MM STAINLESS STEEL 3.5MM SCR SMALL",SUP-241.24,CDM,C1713,HCPCS,0278,RC,,,both,,,2710.95,813.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,321.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,315.28,2304.31,"percent of total billed charges",
"SCR BONE 4MM 26MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-207.026,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,125.59,45.9,,,,,0,31.82,232.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.3MM 20MM DISTAL VOLAR RADIUS FOSSA THREADED",SUP-TPLS-23200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,680.40,204.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,80.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",79.13,578.34,"percent of total billed charges",
"SCR BONE 3.5MM 12MM GEMINUS TITANIUM CORTICAL DISTAL VOLAR",SUP-PANL-35120-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,623.70,187.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,424.12,68,,,,,0,72.54,530.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 5.5MM CREO CURVE TITANIUM MIS NONSTERILE",SUP-1134.7045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"ROD SPINAL 45MM 5.5MM CREO CURVE TITANIUM MIS NONSTERILE",SUP-1134.7045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"SCR BONE 4.5MM 72MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.572,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"CIGNA [10200]",Cigna,,745.57,68,,1831.33,1831.33,1831.33,16,127.51,931.96,"percent of total billed charges",
"SCR BONE 4MM 26MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-207.026,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"BLUE CROSS [10001]","Blue Cross PPO",,107.26,39.2,,957.42,570.23,957.42,28,31.82,232.58,"percent of total billed charges",
"SCR BONE 4.5MM 30MM AXSOS STAINLESS STEEL 3.5MM FULL THREAD",SUP-340630,CDM,C1713,HCPCS,0278,RC,,,both,,,255.78,76.73,"CIGNA [10200]",Cigna,,173.93,68,,1831.33,1831.33,1831.33,16,29.75,217.41,"percent of total billed charges",
"HC Susceptibility Enzyme",PX-306000082,CDM,87185,CPT,0306,RC,,,both,,,104.98,31.49,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,89.23,"per diem",
"HC Eia Shiga-Like Toxin Ag Ql/Sq",PX-306000204,CDM,87427,CPT,0306,RC,,,both,,,178.60,53.58,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,151.81,"per diem",
"SCR BONE 6.5MM 8.2MM 100MM TITANIUM T25 SELF TAP TIP",SUP-04.003.030S,CDM,C1713,HCPCS,0278,RC,,,both,,,1442.45,432.73,"CIGNA [10200]",Cigna,,980.87,68,,1831.33,1831.33,1831.33,16,167.76,1226.08,"percent of total billed charges",
"PLATE 314MM STAINLESS STEEL 4.5MM SCR 14 HOLE CURVED LOCKING",SUP-02.001.304,CDM,C1713,HCPCS,0278,RC,,,both,,,10034.81,3010.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1167.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1167.05,8529.59,"percent of total billed charges",
"PLATE 66MM 4 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800466,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"SCR BONE 3MM 8MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0301,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"NOVANET [10819]",Novanet,,710.78,75,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET PERICARDIOCENTESIS 40CM 8.3FR 18GA PERICARDIAL SAC",SUP-G02433,CDM,C1729,HCPCS,0272,RC,,,both,,,1096.74,329.02,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.55,932.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.6MM 65MM KIRSCHNER NONSTERILE",SUP-WIRE-1.6/065,CDM,S27000186,LOCAL,0270,RC,,,both,,,174.00,52.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 40MM 4FR 7MM .018IN BALLOON",SUP-PCP070040130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UHC [10700]","United Healthcare",,779.35,63.3,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STATLOCK UNIVERSAL PLUS LARGE 12-14FR SECUREMENT FOAM",SUP-VUPD1214,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.96,25.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,35.33,41.1,,,,,0,10,73.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTALINK 135CM 1.75MM ATHERECTOMY BURR EXCHANGE",SUP-H749393001750,CDM,C1724,HCPCS,0272,RC,,,both,,,13282.50,3984.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5459.11,41.1,,,,,0,1544.75,11290.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 15MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158103115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UHC [10700]","United Healthcare",,7073.49,63.3,,8601.07,8395.67,8601.07,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"CATH ADVANCE 35LP 80CM 14CM 5FR 6MM .035IN BALLOON",SUP-G52350,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM XIA SERRATO SPINE POLYAXIAL NONSTERILE 3",SUP-482616550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL REVERSE LINEAR SPACER NONPOROUS SHOULDER",SUP-98000900507,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2381.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY BREAK AWAY 49CM 8FR MULTIPURPOSE CURVE GUIDING",SUP-7074,CDM,C1887,HCPCS,0272,RC,,,both,,,1386.50,415.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,942.82,68,,,,,0,161.25,1178.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH GORE DRYSEAL 28CM 18FR 6.8MM 6MM INTRO HYDROPHILIC",SUP-DSL1828,CDM,C1894,HCPCS,0272,RC,,,both,,,2475.00,742.5,"KAISER [10500]",Kaiser,,1658.25,67,,,,,0,287.84,2103.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5F DECA 4-4-4-29-5-5-5-5-5 MPA 120CM",SUP-901582,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2014.5,68,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT FEMORAL KNEE OXINIUM POROUS",SUP-71701018,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6851.63,28.62,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +29 DIOPTER BICONVEX 13MM 6MM POSTERIOR CHMBR",SUP-MA60AC.290,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +20.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.205,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9MM 70MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704970,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"INSRT TIBIAL 8 9MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G809,CDM,C1776,HCPCS,0278,RC,,,both,,,8868.13,2660.44,"AETNA [10100]","Aetna HMO/PPO",,7050.16,79.5,,10981.53,8986.79,12413.38,12,1031.36,7537.91,"percent of total billed charges",
"STENT ASCERTA 30CM 7FR URETERAL FIRM STERILE LATEX FREE",SUP-M0061456540,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"NOVANET [10819]",Novanet,,468.93,75,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STBL SURGICAL ASSISTANT STABLESOFT",SUP-401-212S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.00,495,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,678.15,41.1,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Iontophoresis 15min (Gp)",PX-420000018,CDM,97033,CPT,0420,RC,,,both,,,226.67,68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,215,,"Per diem ($215).",,,,0,26.36,226.67,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON SMALL TITANIUM NARROW BLADE",SUP-7541122,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Open Access",,1707,56.9,,1144.80,304.56,2275.09,66,348.9,2550,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 12MM 145CM 3MM CORONARY STENT",SUP-1125300-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3969.84,68,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VASCURE FOR VASCULAR REPAIR FIVE PACK 1 X 10 CM",SUP-CMCV-014-609,CDM,C1768,HCPCS,0278,RC,,,both,,,3457.50,1037.25,"MULTIPLAN [10600]",Multiplan,,2938.88,85,,,,,0,402.11,2938.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLATE TIBIAL ATTUNE 8 KNEE REVISION CEMENT ROTATE PLATFO",SUP-150660008,CDM,C1776,HCPCS,0278,RC,,,both,,,22629.60,6788.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9051.84,40,,,,,0,2631.82,19235.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 590CC P4.2CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-590,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"KAISER [10500]",Kaiser,,5062.19,67,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DEMINERALIZED CANCELLOUS CUBE 12X12X12MM",SUP-4104-K1212DC,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502605602,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"PHCS [10601]",PHCS,,16003.89,70,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ORTHOPEDIC 5MM 10MM 5MM END INTERNAL THREAD HEX TALON",SUP-HTN-10-C05,CDM,C1713,HCPCS,0278,RC,,,both,,,1320.30,396.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,156.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,153.55,1122.26,"percent of total billed charges",
"SHEATH AMPLATZER TORQVUE 2 120CM 6FR INTRO POLYMER PTFE",SUP-9-TV2-06F120,CDM,S27200284,LOCAL,0272,RC,,,both,,,5754.60,1726.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,669.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,669.26,4891.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 11MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P111,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,990.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,971.79,7102.52,"percent of total billed charges",
"GRAFT SOFT TISSUE 12X2CM PRO3 THIN AMNIOTIC PLACENTAL MEMB",SUP-P01-AMP-0212,CDM,S27800098,LOCAL,0278,RC,,,both,,,12997.88,3899.36,"CIGNA [10200]","Cigna Open Access",,4354.29,33.5,,,,,0,1511.65,11048.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Observation Carve-Out Blood Transfusion",PX-762000017,CDM,G0378,HCPCS,0762,RC,,,both,,,66.00,19.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,66,,,,,,,7.68,66,"case rate",
"INSRT TIBIAL 9 6MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620906,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"FIRST HEALTH [10303]","First Health",,9003.12,80,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LASER 25GA ILLUMINATED PIK RADIO FREQUENCY ID",SUP-8065751572,CDM,S27200284,LOCAL,0272,RC,,,both,,,950.62,285.19,"AETNA [10100]","Aetna HMO/PPO",,755.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,110.56,808.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 6.5MM 2 FULL THREAD CORKSCREW FIBERWIRE TITANIUM",SUP-AR-1929SF-3,CDM,C1713,HCPCS,0278,RC,,,both,,,1929.38,578.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1311.98,68,,,,,0,224.39,1639.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 250MM 3.5MM BALLOON DILATATION RAPID",SUP-47535250S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,832.28,41.1,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 10CM 5MM BALLOON",SUP-G52261,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.64,68,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPS AIM, MEDIGUIDE (135DEG INNER CATH)",SUP-DS2M054,CDM,C1887,HCPCS,0272,RC,,,both,,,15835.50,4750.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10768.14,68,,,,,0,1841.67,13460.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER YELLOW 180MM 4.5MM DYONICS LONG STRAIGHT LONG",SUP-7205341,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"UHC [10700]","United Healthcare",,369.17,63.3,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 4MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-04007,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"KAISER [10500]",Kaiser,,7854.48,67,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL PLIF HL 22 DEGREE 11MM X 9MM X 28MM MOD-EX",SUP-1931928P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"UHC [10700]","United Healthcare",,21933.45,63.3,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"M AC611 HFNC FEP CONNECT 20 PK",SUP-73-1134191,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.51,57.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.27,162.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +19.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.195,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM ATTUNE 3 KNEE DISTAL CEMENT REVISION STERILE",SUP-154703001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"PHCS [10601]",PHCS,,4250.4,70,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL TROUTMAN-BARRAQUER 45D .12MM 3IN ANGLED 2X3",SUP-60-1463,CDM,S27200284,LOCAL,0272,RC,,,both,,,1402.60,420.78,"UHC [10700]","United Healthcare",,887.85,63.3,,,,,0,163.12,1192.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE HI-FLO 150CM 10CM 3-2.8FR .027IN MICRO",SUP-M001182900,CDM,C1887,HCPCS,0272,RC,,,both,,,2100.00,630,"UHC [10700]","United Healthcare",,1329.3,63.3,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL TAPERCUT 5 V-56 30IN MONOFILAMENT 4",SUP-M435G,CDM,S27200284,LOCAL,0272,RC,,,both,,,132.05,39.61,"PHCS [10601]",PHCS,,92.44,70,,,,,0,15.36,112.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO PERCUTANEOUS 7 FR CATH LATEX FREE",SUP-AK-09701,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.93,88.48,"PHCS [10601]",PHCS,,206.45,70,,,,,0,34.3,250.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT POSTERIOR STABILIZE BEAD TRIATHLON",SUP-5516F601,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2052.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2013.96,14719.4,"percent of total billed charges",
"STENT CONTOUR 28CM 6FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856150,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE RX 30MM 135CM 8/6MM 6FR TAPER VASCULAR NITINOL",SUP-SECX-8-6-30-135,CDM,C1876,HCPCS,0278,RC,,,both,,,12420.00,3726,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5104.62,41.1,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 14MM 9MM STD NECK S-ROM CERAMIC 135D",SUP-523251,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"CIGNA [10200]","Cigna Open Access",,6516.17,33.5,,5302.19,4377.88,6578.61,27,2262.18,16533.56,"percent of total billed charges",
"STEM HUMERAL 108MM 12MM SMALL SHELL ALTIVATE REVERSE",SUP-533-12-108,CDM,C1776,HCPCS,0278,RC,,,both,,,43175.16,12952.55,"KAISER [10500]",Kaiser,,28927.36,67,,,,,0,5021.27,36698.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER LIME GREEN 4.5MM INCISOR STRAIGHT STERILE",SUP-7205313,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"FIRST HEALTH [10303]","First Health",,278.4,80,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 190ML GEL ROUND SMOOTH MEMORYGEL COHESIVE I","SUP-3507190 MC",CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"CIGNA [10200]","Cigna Open Access",,2031.33,56.9,,5166.00,5166.00,5166.00,"1 through 10",415.19,3034.5,"percent of total billed charges",
"GRAFT SKIN 6X4CM ENVERSE DEHYDRATED COMPLETE HUMAN PLACENTAL",SUP-EN-4060,CDM,Q4258,HCPCS,0636,RC,,,both,,,11040.00,3312,"PHCS [10601]",PHCS,,7728,70,,,,,0,241.31,9384,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 CURVE PLUS 15MM KNEE XLK FIX BEARING SIGMA",SUP-970433,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"MULTIPLAN [10600]",Multiplan,,9498.37,85,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? TOWER CABLE PLATE KIT",SUP-94-1600-05,CDM,C1713,HCPCS,0278,RC,,,both,,,9501.30,2850.39,"MULTIPLAN [10600]",Multiplan,,8076.11,85,,,,,0,1105,8076.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8MM 150MM HUMERUS LEFT PROXIMAL T2 INTRAMEDULLARY",SUP-1832-1035S,CDM,C1713,HCPCS,0278,RC,,,both,,,11873.11,3561.93,"AETNA [10100]","Aetna HMO/PPO",,9439.12,79.5,,1521.93,481.35,16760.95,30,1380.84,10092.14,"percent of total billed charges",
"STENT MARDIS ZIPWIRE 22CM 3CM 6FR .038IN PIGTAIL CURVE",SUP-M0061265310,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"NOVANET [10819]",Novanet,,1065.26,75,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP XL ALLOGRAFT COMPRESSIBLE SPONGE 50X20X7",SUP-13812509,CDM,C1713,HCPCS,0278,RC,,,both,,,18721.06,5616.32,"NOVANET [10819]",Novanet,,14040.8,75,,,,,0,2177.26,15912.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-2 THX-36 36IN MONOFILAMENT WHITE",SUP-2N07B,CDM,S27200284,LOCAL,0272,RC,,,both,,,227.65,68.29,"FIRST HEALTH [10303]","First Health",,182.12,80,,,,,0,26.48,193.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.6CM NATRELLE BIOCELL P3.5CM MODERATE PROFILE",SUP-MSZ10300,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"KAISER [10500]",Kaiser,,105.98,67,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG PRESSURE INFUSION 1L NYLON INFUSOR DUAL PRESSURE RELIEF",SUP-PIB1000,CDM,S27000186,LOCAL,0270,RC,,,both,,,95.00,28.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,64.6,68,,,,,0,11.05,80.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 96MM 32MM 7.7MM 20FR ZENITH FLEX Z-TRAK",SUP-G48428,CDM,C1874,HCPCS,0278,RC,,,both,,,48686.90,14606.07,"NOVANET [10819]",Novanet,,36515.18,75,,,,,0,5662.29,41383.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG BONE CEMENT 30MM LARGE INTRAMEDULLARY CANAL STERILE",SUP-6215-5-021,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,349.48,45.9,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROPARACAINE 0.5 % EYE DROPS",RX-6644,CDM,,,0250,RC,70069-0601-01,NDC,both,15,ML,275.22,82.57,"NOVANET [10819]",Novanet,,206.42,75,,,,,0,32.01,233.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 38MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ338,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"BLUE CROSS [10001]","Blue Cross PPO",,377.1,39.2,,3949.44,3949.44,3949.44,"1 through 10",111.88,817.7,"percent of total billed charges",
"CRTDG WOUND 5.2X2.3IN SNAP THK1IN 125 MMHG SMALL INDCTR",SUP-SNPA125US,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"FIRST HEALTH [10303]","First Health",,816.48,80,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 3MM 30MM 4.8MM SHILEY NEONATE UNCUFF TAPE TIE",SUP-3.0NEF,CDM,S27200284,LOCAL,0272,RC,,,both,,,395.85,118.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,269.18,68,,,,,0,46.04,336.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 6FR .07IN KIESZ LEFT 3 HORIZONTAL CURVE GUIDING",SUP-H749389696110,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) STERILE TRICUSPID VALVE 170MM",SUP-ES0366-04,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 2-0 GS-21 .5 CIRCLE 9IN TAPER POINT",SUP-VLOCL0345,CDM,S27200284,LOCAL,0272,RC,,,both,,,405.94,121.78,"PHCS [10601]",PHCS,,284.16,70,,,,,0,47.21,345.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 40CM 7FR ATRIUM VENTRICLE BIPOLAR ACTIVE",SUP-1688TC/40,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"FIRST HEALTH [10303]","First Health",,1786,80,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fna Bx W/Fluor Gdn 1st Les",PX-361000479,CDM,10007,CPT,0361,RC,,,both,,,3171.00,951.3,"KAISER [10500]",Kaiser,,2124.57,67,,,,,0,368.79,2740.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 0-5CM ULTRASOUND HIGH DEFINITION DIMPLE",SUP-G52011,CDM,S27200284,LOCAL,0272,RC,,,both,,,1747.50,524.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,802.1,45.9,,,,,0,203.23,1485.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR ENDOSCOPIC FLOSEAL STERILE DISPOSABLE",SUP-110860,CDM,S27200284,LOCAL,0272,RC,,,both,,,624.75,187.42,"NOVANET [10819]",Novanet,,468.56,75,,,,,0,72.66,531.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM PRECISION ROUND",SUP-5820009040,CDM,S27200284,LOCAL,0272,RC,,,both,,,3587.85,1076.35,"MULTIPLAN [10600]",Multiplan,,3049.67,85,,,,,0,417.27,3049.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION",RX-10224,CDM,J1171,HCPCS,0636,RC,00409-2634-10,NDC,both,1,ML,497.10,149.13,"UHC [10700]","United Healthcare",,27,,,,,,,11.66,422.54,"fee schedule",
"COIL EMBOLIZATION 15CM 8MM CEREPAK FREEFORM DETACHABLE",SUP-SCR120815,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"FIRST HEALTH [10303]","First Health",,10580.68,80,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 62MM 32MM MARATHON HIP",SUP-121932062,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"BLUE CROSS [10001]","Blue Cross PPO",,2835.98,39.2,,3949.44,3949.44,3949.44,"1 through 10",841.39,6149.45,"percent of total billed charges",
"HC ED Visit Level 2 W Proc",PX-450000314,CDM,99282,CPT,0450,RC,,,both,,,1194.97,358.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1194.97,,"Per diem ($1,469).",,,,0,67.13,1194.97,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X10X10MM SABLE 15D STERILE LATEX FREE",SUP-1172.2124S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA [10200]","Cigna Local Plus",,10914.75,31.5,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 450MM 2.8MM FLUTE TIP STERILE",SUP-03.333.006S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1347.19,404.16,"UHC [10700]","United Healthcare",,852.77,63.3,,,,,0,156.68,1145.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2/0 CARDIOXYL W/ PLEDGET 3 X 7MM 25MM",SUP-73P30CM,CDM,S27200284,LOCAL,0272,RC,,,both,,,645.98,193.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.13,549.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2/0 CARDIOXYL W/ PLEDGET 3 X 7MM 25MM",SUP-73P30CM,CDM,S27200284,LOCAL,0272,RC,,,both,,,645.98,193.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.13,549.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 2.5FR UMBILICAL POLYURETHANE 1 LUMEN RADIOPAQUE SMOOTH",SUP-P1UVC-2530,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.20,41.76,"AETNA [10100]","Aetna HMO/PPO",,110.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA D KNEE RIGHT NONPOROUS REVISION",SUP-42542006702,CDM,C1776,HCPCS,0278,RC,,,both,,,16335.06,4900.52,"BLUE CROSS [10001]","Blue Cross HMO",,6403.34,39.2,,5311.50,4717.44,5388.59,31,1899.77,13884.8,"percent of total billed charges",
"CATH PACIFIC PLUS 90CM 40MM 4FR 5MM BALLOON DILATATION",SUP-PCP050040090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UHC [10700]","United Healthcare",,779.35,63.3,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TANGO 110CM 5FR 2MM SPACE COURNAND CURVE",SUP-M0044005420,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,128.73,41.1,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM INTERLOCK IDC OCCLUSION SYSTEM",SUP-M0013613060,CDM,S27800098,LOCAL,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.6V 38MM 2 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18006238,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM CARPENTIER-EDWARDS PERIMOUNT MAGNA",SUP-3000TFX19MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"CIGNA [10200]","Cigna Local Plus",,10111.03,31.5,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 2.7MM 44MM LCP STAINLESS STEEL CORTICAL SELF TAPP",SUP-202.963,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"CIGNA [10200]","Cigna Open Access",,184.35,56.9,,1144.80,304.56,2275.09,66,37.68,275.39,"percent of total billed charges",
"GLIDESHEATH SLENDER SS KIT, 0.021 GW, 5 FR, 10CM",SUP-80-1050,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 NARROW KNEE RIGHT POSTERIOR STABILIZE",SUP-42500206002,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3424.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3360.56,24561.24,"percent of total billed charges",
"HEAD FEMORAL +3MM 11/13 TAPER 44MM HIP M SPECIFICATION METAL",SUP-136563500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"BLUE CROSS [10001]","Blue Cross HMO",,4342.56,39.2,,5311.50,4717.44,5388.59,31,1288.37,9416.26,"percent of total billed charges",
"TRAY THORACENTESIS 4.75IN 8FR 18GA ARROW-CLARKE PLEURA-SEAL",SUP-AK-01000,CDM,C1729,HCPCS,0272,RC,,,both,,,297.41,89.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,202.24,68,,,,,0,34.59,252.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 38MM TITANIUM T25 SELF TAP LOCK STARDRIVE",SUP-412.213S,CDM,C1713,HCPCS,0278,RC,,,both,,,1220.18,366.05,"CIGNA [10200]",Cigna,,829.72,68,,1831.33,1831.33,1831.33,16,141.91,1037.15,"percent of total billed charges",
"SCR BONE 3.5MM 50MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-50,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENROUTE TRANSCAROTID NEUROPROTECTION SYSTEM PLUS",SUP-SR-250-NPS,CDM,C1884,HCPCS,0272,RC,,,both,,,23530.50,7059.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2788.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2736.6,20000.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER 55CM 8FR 40MM VASCULAR ENDOSCOPIC LATEX FREE INDY",SUP-G51835,CDM,C1773,HCPCS,0272,RC,,,both,,,3607.50,1082.25,"KAISER [10500]",Kaiser,,2417.03,67,,,,,0,419.55,3066.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.25 X 23 RX US",SUP-1804325-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET",RX-99694,CDM,,,0250,RC,00115-1365-30,NDC,both,1,UN,96.85,29.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,39.81,41.1,,,,,0,11.26,82.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC HOOK TRIANGLE PACK ENDOTRAC PLANTAR",SUP-3056,CDM,S27200284,LOCAL,0272,RC,,,both,,,2101.05,630.31,"CIGNA [10200]","Cigna Local Plus",,1124.06,53.5,,,,,0,244.35,1785.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 15.7IN 5FR .018IN MERIT MAK STD COAXIAL STAINLESS",SUP-MAK501,CDM,C1894,HCPCS,0272,RC,,,both,,,197.06,59.12,"KAISER [10500]",Kaiser,,132.03,67,,,,,0,22.92,167.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 33CM 5MM LYONS CORD",SUP-942005PK,CDM,S27200284,LOCAL,0272,RC,,,both,,,2466.60,739.98,"PHCS [10601]",PHCS,,1726.62,70,,,,,0,286.87,2096.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 65CM 24MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES2465CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"FIRST HEALTH [10303]","First Health",,6348,80,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 135CM 6MM 8MM 7FR .035IN",SUP-BXA067902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"AETNA [10100]","Aetna HMO/PPO",,17018.88,79.5,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW ACU-LOC 2 BONE LEFT DISTAL VOLAR RADIAL STERILE",SUP-70-0358,CDM,C1713,HCPCS,0278,RC,,,both,,,6654.91,1996.47,"BLUE CROSS [10001]","Blue Cross HMO",,2608.72,39.2,,957.42,156.86,7483.26,51,773.97,5656.67,"percent of total billed charges",
"STENT VISI-PRO 37MM 80CM 6MM 40MM BILIARY STAINLESS STEEL",SUP-PXB35-06-37-080,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"MULTIPLAN [10600]",Multiplan,,3711.95,85,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? DISPOSABLE POWER DRIVER BIT",SUP-94-DRIVERBIT-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"FIRST HEALTH [10303]","First Health",,583.2,80,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT MONORAIL 31MM 135CM 10MM ENDOPROSTHESIS",SUP-M001719050,CDM,C1876,HCPCS,0278,RC,,,both,,,16615.20,4984.56,"BLUE CROSS [10001]","Blue Cross PPO",,6513.16,39.2,,,,,0,1932.35,14122.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR",023,MS-DRG,,,,,,,inpatient,,,244377.61,73313.28,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,38033.58,,"Case rate ($35,545.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $33,006.31, add-ons for qualifying new technology services are included. If operating cost exceeds $66,045.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,877.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $33,049.96. The transfer operating threshold is the transfer adjustment factor * $33,006.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,495.44. The transfer capital threshold is the transfer adjustment factor * $2,495.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,7561,167301.84,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 7 16MM KNEE AOX CRUCIATE RETAIN ROTATE PLATFOR",SUP-151630716,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]","Cigna Local Plus",,4135.08,31.5,,5372.07,4581.20,7242.98,23,1526.7,11158.16,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 28CM 5FR .038",SUP-M006192124120,CDM,C2617,HCPCS,0278,RC,,,both,,,1528.96,458.69,"BLUE CROSS [10001]","Blue Cross PPO",,599.35,39.2,,,,,0,177.82,1299.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR",RX-36982,CDM,,,0637,RC,57237-0114-90,NDC,both,1,UN,21.20,6.36,"UHC [10700]","United Healthcare",,13.42,63.3,,,,,0,2.47,18.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADAPTOR LEAD B-IS-15 15CM OSCOR",SUP-B-IS-15,CDM,C1883,HCPCS,0278,RC,,,both,,,1875.00,562.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET SUCTION PLASTIC CANN SEMIRIGID CONE FILTER SEALING CAP",SUP-MX416,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.50,54.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.11,154.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 30MM LCP STAINLESS STEEL DISTAL FIBULA T8",SUP-202.230,CDM,C1713,HCPCS,0278,RC,,,both,,,748.44,224.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,88.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,87.04,636.17,"percent of total billed charges",
"GIRDLE COMPRESSION 2XL ABOVE KNEE LENGTH POWERKNIT 12.75",SUP-4-4012B-2XL,CDM,S27000186,LOCAL,0270,RC,,,both,,,607.50,182.25,"CIGNA [10200]","Cigna Local Plus",,325.01,53.5,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 28CM 6FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856150,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"MULTIPLAN [10600]",Multiplan,,932.16,85,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ndl Emg Non-Extremity",PX-922000013,CDM,95887,CPT,0922,RC,,,both,,,214.34,64.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,88.09,41.1,,,,,0,24.93,182.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12MM NATURAL LARGE LORDOTIC",SUP-19412,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25X6MM STD TOOTH AGGRESSIVE CALIBRATE THK.6MM CUT",SUP-532.061S,CDM,S27200284,LOCAL,0272,RC,,,both,,,605.07,181.52,"AETNA [10100]","Aetna HMO/PPO",,481.03,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.37,514.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL LORNA-EDNA 5.5IN TOWEL",SUP-17-5714,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"NOVANET [10819]",Novanet,,46.33,75,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 30ML .1-4MM ALLOGRAFT CRUSH FROZEN",SUP-T20025,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"NOVANET [10819]",Novanet,,2805,75,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1.5 X 4 HELICAL PICO COIL",SUP-10USH01504,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X20X12MM PIVOX 6D LATERAL OLIF25",SUP-2111355,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3135.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF CONDUCTR 110CM 55-75MM 7FR 2-5-2MM SPACING ABLATION",SUP-787544,CDM,C1733,HCPCS,0272,RC,,,both,,,3967.50,1190.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1630.64,41.1,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 59CM ENDOCARDIUM 4 SITE 2 COIL CARDIOVERTER",SUP-0275,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"KAISER [10500]",Kaiser,,11505.24,67,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAROTID SINUS LEAD","SUP-MODEL 1036",CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SENTAI HORNET 10 VASCULAR 190CM 15CM .008IN STAINLESS",SUP-H749393041902,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TAKERU 21MM 3.25MM BALLOON DILATATION PTCA",SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL GERALD STRAIGHT NARROW 7IN TISSUE 1X2 TEETH",SUP-285125,CDM,S27000186,LOCAL,0270,RC,,,both,,,179.48,53.84,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD EMG I-PAS III BEVEL SPRINGLESS DISPOSABLE STERILE",SUP-2010037,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.00,495,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NAVICROSS 135CM 30D 12MM SPRT STAINLESS STEEL",SUP-NC35131,CDM,C1887,HCPCS,0272,RC,,,both,,,1462.05,438.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Hep B Surface Antigen Quan",PX-306000246,CDM,87467,CPT,0306,RC,,,both,,,226.00,67.8,"CIGNA [10200]","Cigna Open Access",,128.59,56.9,,,,,0,0.01,192.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 NARROW KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500006602,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS [10001]","Blue Cross HMO",,8962.18,39.2,,5311.50,4717.44,5388.59,31,2658.93,19433.3,"percent of total billed charges",
"LENS IOL +29.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.295,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AMPLATZER TORQVUE 80CM 12FR 45D EXCHANGE SYSTEM POLYMER",SUP-9-EITV12F45/80,CDM,C1773,HCPCS,0272,RC,,,both,,,4912.80,1473.84,"AETNA [10100]","Aetna HMO/PPO",,3905.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,571.36,4175.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.230,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 FSL 30IN BRAID BLACK NONABSORBABLE",SUP-679H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TITANIUM TIBIA CANCELLOUS OPENING WEDGE",SUP-AR-13280-40,CDM,C1713,HCPCS,0278,RC,,,both,,,1968.75,590.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,903.66,45.9,,,,,0,228.97,1673.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP PAT ROUND SZ #2/7.5MM",SUP-2764-1-7502,CDM,C1776,HCPCS,0278,RC,,,both,,,1875.00,562.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,218.06,1593.75,"percent of total billed charges",
"SCR BONE 3MM 12MM LOW PROFILE SCREWS TITANIUM ANKLE VARIABLE",SUP-AR-8933V-12,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,164.86,1204.88,"percent of total billed charges",
"SA60WF.230 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.230,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 140MM 125CM 6MM 6FR BILIARY",SUP-G50167,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,708.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cognitive Trn 1st 15 Min (Gp)",PX-420000176,CDM,97129,CPT,0420,RC,,,both,,,173.00,51.9,"NOVANET [10819]",Novanet,,129.75,75,,,,,0,20.12,173,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT GLENOID REVERSE BONE MODEL SHOULDER TRABECULAR MET",SUP-98850090011,CDM,C1776,HCPCS,0278,RC,,,both,,,51660.00,15498,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6121.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6008.06,43911,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 100MM STAINLESS STEEL LARGE FRAGMENT SET 5 HOLE SPOON",SUP-240.05,CDM,C1713,HCPCS,0278,RC,,,both,,,1823.25,546.97,"PHCS [10601]",PHCS,,1276.28,70,,,,,0,212.04,1549.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 7MM AXIUM 3D FRAME V01",SUP-FC-7-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,13765.50,4129.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1600.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QDOT MICRO D CURVE ABLATION UNIDIRECTIONAL",SUP-D139401,CDM,C1732,HCPCS,0272,RC,,,both,,,22560.30,6768.09,"FIRST HEALTH [10303]","First Health",,18048.24,80,,,,,0,2623.76,19176.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Lung Ventil&Perfsn Diff",PX-341000034,CDM,78598,CPT,0341,RC,,,both,,,2819.08,845.72,"BLUE CROSS [10001]","Blue Cross HMO",,789.39,,"Fee schedule rate ($789.39).",,,,0,327.86,2396.22,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D +3 CYL BICONVEX TORIC 13MM 6MM POSTERIOR CHMBR 1",SUP-SV25T5,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA [10200]",Cigna,,506.6,68,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC SPRINTER FASTRAC 138CM 27MM 3-1.9FR 4MM BALLOON",SUP-NCSP4027X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE LCP DHHS ORTHOPEDIC SPADE 230MM 2.5MM THREAD",SUP-900.723,CDM,C1769,HCPCS,0272,RC,,,both,,,338.60,101.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ULTRABRAID 2-0 24IN COBRAID BLUE WHITE NONABSORBABLE",SUP-72204328,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.57,52.07,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GYNECOLOGIC PROCEDURES FOR LEIOMYOMA,MODERATE",519,APR-DRG,,,,,,,inpatient,,,107181.82,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $8,172.42. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%.",,,,0,,,other,"SOI-2 Shortstay; Zero final payments for the item or service in the 15 months prior to posting the file."
"HEART FAILURE AND SHOCK WITH CC",292,MS-DRG,,,,,,,inpatient,,,20714.23,6214.27,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 12MM SPINE",SUP-610.712,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"MULTIPLAN [10600]",Multiplan,,495.72,85,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 40CM 7FR ATRIUM VENTRICLE BIPOLAR ACTIVE",SUP-1688TC/40,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,264.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON DISECT LAPAROSCOPIC KII OVAL",SUP-C0K11,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1",SUP-179715640,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",441.36,3225.75,"percent of total billed charges",
"STENT POLARIS SENSOR DUAL-FLEX 12CM 5FR .035IN URETERAL",SUP-M006155212090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,161.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM ULNAR SIZE 5 L115MM LEFT CEMENTED CONSTRAINED NEXEL",SUP-840001511,CDM,C1776,HCPCS,0278,RC,,,both,,,31971.49,9591.45,"BLUE CROSS [10001]","Blue Cross PPO",,12532.82,39.2,,3949.44,3949.44,3949.44,"1 through 10",3718.28,27175.77,"percent of total billed charges",
"CMPNT FEMORAL 9 KNEE LEFT CEMENTED CRUCIATE RETAINING ATTUNE",SUP-150400109,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"UHC [10700]","United Healthcare",,14174.99,63.3,,8601.07,8395.67,8601.07,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"CATH WEBSTER 110CM 1MM 5FR 5MM SPACE ELECTROPHYSIOLOGY FIX",SUP-F5QA005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"UHC [10700]","United Healthcare",,574.26,63.3,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE ADPTR -2.5MM UNIVERSAL C TAPER TITANIUM",SUP-19-0325T,CDM,C1776,HCPCS,0278,RC,,,both,,,1304.10,391.23,"FIRST HEALTH [10303]","First Health",,1043.28,80,,,,,0,151.67,1108.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 20MM SPINE PLY NONSTERILE 4MM ROD",SUP-102040120,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"SHEATH HEARTSPAN 55D FIX CURVE TAPER 101.5CM 8.5FR GUIDING",SUP-FCL-160-10,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 15MM 145CM 3MM CORONARY STENT",SUP-1125300-15,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE",RX-116491,CDM,,,0250,RC,76329-3302-01,NDC,both,50,ML,183.47,55.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,84.21,45.9,,,,,0,21.34,155.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM ATTUNE 4 KNEE DISTAL CEMENT REVISION STERILE",SUP-154704002,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"KAISER [10500]",Kaiser,,4068.24,67,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 80MM 80CM 10MM VASCULAR PERIPHERAL SELF",SUP-1012532-80,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross HMO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IOFLUPANE I-123 INTRAVENOUS SOLUTION",RX-108781,CDM,A9584,HCPCS,0343,RC,08888-8878-37,NDC,both,1,UN,11340.00,3402,"AETNA [10100]","Aetna HMO/PPO",,9015.3,79.5,,,,,0,1318.84,9639,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 63MM 3 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-43F63V,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,3978.14,359.25,3978.14,24,641.98,4692,"percent of total billed charges",
"STENT ZILVER FLEX 35 120MM 125CM 9MM 6FR .035IN BILIARY",SUP-G50175,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1742.96,28.62,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 300MM 6MM BALLOON DILATATION RAPID",SUP-47560300M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"PHCS [10601]",PHCS,,1417.5,70,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 13-16X15MM HIGHLY ELASTIC STAPLES SMALL FOREFOOT",SUP-ES-15X13X16,CDM,C1713,HCPCS,0278,RC,,,both,,,8590.50,2577.15,"NOVANET [10819]",Novanet,,6442.88,75,,,,,0,999.08,7301.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE+ 20MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405720,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"NOVANET [10819]",Novanet,,7247.59,75,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DOVER 16IN 18FR URETHRAL SILICONE NONPOROUS 5CC 2 WAY",SUP-8888760518,CDM,S27200284,LOCAL,0272,RC,,,both,,,422.30,126.69,"PHCS [10601]",PHCS,,295.61,70,,,,,0,49.11,358.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 140MM 3MM MIDAS REX LEGEND MATCH HEAD",SUP-14MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1184.63,355.39,"MULTIPLAN [10600]",Multiplan,,1006.94,85,,,,,0,137.77,1006.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 120MM 20GA SONOPLEX II NANOLINE 1 SHOT",SUP-001285-72,CDM,C9812,HCPCS,0272,RC,,,both,,,132.68,39.8,"KAISER [10500]",Kaiser,,88.9,67,,,,,0,15.43,112.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 15CM 23MM ESOPHAGEAL FULL COVER CATH DIAMETER",SUP-M00517780,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]","Cigna Local Plus",,5755.05,31.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 4IN 8GA ORIGINAL JAMSHIDI BONE MARROW ASPIRATION",SUP-DJ4008X,CDM,S27200284,LOCAL,0272,RC,,,both,,,153.25,45.97,"UHC [10700]","United Healthcare",,97.01,63.3,,,,,0,17.82,130.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 12.75CM NATRELLE INSPIRA P4.2CM MODERATE PROFILE",SUP-SRM-360,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"BLUE CROSS [10001]","Blue Cross HMO",,2150.32,39.2,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 12.5X11CM 400CC AEROFORM P8CM SMALL",SUP-BR125-400,CDM,C1789,HCPCS,0278,RC,,,both,,,16118.40,4835.52,"CIGNA [10200]","Cigna Local Plus",,5077.3,,,,,,,1874.57,13700.64,"percent of total billed charges",
"CATH PACIFIC XTREME 130CM 250MM 7MM BALLOON DILATATION",SUP-PCU070250130,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"FIRST HEALTH [10303]","First Health",,1015.74,80,,,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +6MM OFFSET 32MM HIP TYPE 1 MODULAR COCR G7",SUP-110025134,CDM,C1776,HCPCS,0278,RC,,,both,,,9255.66,2776.7,"BLUE CROSS [10001]","Blue Cross PPO",,3628.22,39.2,,3949.44,3949.44,3949.44,"1 through 10",1076.43,7867.31,"percent of total billed charges",
"VALVE AORTIC 23-26MM 0-43MM COREVALVE 29MM HEART PORCINE",SUP-MCS-P3-29-AOA-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"UHC [10700]","United Healthcare",,108243,63.3,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 34X21X2MM TITANIUM 1 LEVEL CLOVERLEAF CAUDAL HOLE LOCK",SUP-450.126,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,,1521.93,481.35,16760.95,30,521.61,3812.25,"percent of total billed charges",
"INTRO LEAD 50CM 9FR 18GA WORLEY CSG BRAID CORE SHEATH GWIRE",SUP-WOR-CSG-B2-09,CDM,C1892,HCPCS,0272,RC,,,both,,,2730.00,819,"AETNA [10100]","Aetna HMO/PPO",,2170.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,317.5,2320.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD SUT ASSISTANT 3-0 ES-9 7IN 1 STITCH ENDO STITCH",SUP-170072,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"UHC [10700]","United Healthcare",,91.25,63.3,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 20FR BALLOON GASTRO",SUP-00802526273902,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL H+6MM 36MM 39MM SHOULDER CONSTRAIN COMBINATION",SUP-AR-9503-3639-3C,CDM,C1776,HCPCS,0278,RC,,,both,,,4305.60,1291.68,"BLUE CROSS [10001]","Blue Cross HMO",,1687.8,39.2,,5311.50,4717.44,5388.59,31,500.74,3659.76,"percent of total billed charges",
"HC Egd W/Drain Pseudocyst",PX-750000217,CDM,43240,CPT,0750,RC,,,both,,,2701.20,810.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2701.2,,"Case rate ($3,279). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,314.15,2701.2,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 150MM 2300MM 20MM ESOPHAGEAL METAL NITINOL",SUP-ECBA-20-150-230,CDM,C1874,HCPCS,0278,RC,,,both,,,16425.45,4927.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6570.18,40,,,,,0,1910.28,13961.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABRE VENOUS SELF-EXPADING STENT16X100X90",SUP-AB9T16100090,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY DRNG 12FR FLEXIBLE STAYFIX SMALL SECUREMENT DEVICE",SUP-RLC-NV-12-SFX,CDM,C1729,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NUCLEUS-X 110CM 5CM 28MM BALLOON DILATATION POLYAMIDE",SUP-612033,CDM,C1725,HCPCS,0272,RC,,,both,,,6566.52,1969.96,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO ENDOSCOPIC 9FR 5.5FR 195CM 1 ACTION STENT RADIOPAQUE",SUP-G31527,CDM,C1769,HCPCS,0272,RC,,,both,,,1085.40,325.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP ASPIR 12CM 1.92MM 1.5MM SONOPET IQ STD SOFT TISSUE",SUP-5500-25S-307,CDM,S27200284,LOCAL,0272,RC,,,both,,,6210.09,1863.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAMP SURGICAL OCHSNER CLASSIC 5/8IN 10IN AORTA 1X2 TEETH",SUP-38-1025,CDM,S27200284,LOCAL,0272,RC,,,both,,,796.96,239.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Maskset Brainlab",PX-E27000192,CDM,9999119,LOCAL,0270,RC,,,both,,,1400.30,420.09,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRIAL SHOULDER 30MM ECLIPSE SMALL GLENOID CAGE SCR",SUP-AR-9301-01,CDM,C1776,HCPCS,0278,RC,,,both,,,9080.40,2724.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2598.81,28.62,,,,,0,1056.05,7718.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 42MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR42,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross PPO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 12MM 6FR 5.5MM",SUP-H7493926712550,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"KAISER [10500]",Kaiser,,379.89,67,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840005550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,8114.82,"percent of total billed charges",
"BASKET SPECIMEN RETRIEVAL 180CM 5CM 2.5CM RAPID EXCHANGE",SUP-M00510880,CDM,S27200284,LOCAL,0272,RC,,,both,,,2036.93,611.08,"FIRST HEALTH [10303]","First Health",,1629.54,80,,,,,0,236.89,1731.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 3MM 1.8MM 160CM 3 RING HANDLE BRISTLE CATH",SUP-60314,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.41,38.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,88,68,,,,,0,15.05,110,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 16MM 144CM 2.5MM CORONARY STENT",SUP-H7493911416250,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"UHC [10700]","United Healthcare",,5787.2,63.3,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CORTICAL LORDOTIC BLOCK 14X11X9MM",SUP-340941,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 345CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-345,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS [10001]","Blue Cross PPO",,2961.76,39.2,,16595.83,16595.83,16595.83,"1 through 10",878.7,6422.18,"percent of total billed charges",
"GRAFT SKIN GRAFTJACKET XPRESS ACELLULAR DERMAL MATRIX SOFT",SUP-GJX,CDM,Q4113,HCPCS,0636,RC,,,both,,,12447.60,3734.28,"FIRST HEALTH [10303]","First Health",,9958.08,80,,,,,0,1475.04,10580.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Shave Ext Lesn 1.1-2.0cm",PX-510000020,CDM,11302,CPT,0761,RC,,,both,,,713.18,213.95,"PHCS [10601]",PHCS,,499.23,70,,,,,0,82.94,713.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 20MM 9MM BALLOON DILATATION OTW NONCOMPLIANT",SUP-H74939206090270,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ROCHESTER-PEAN CURVE 7.25IN ARTERY HEMOSTATIC",SUP-BH445R,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.35,26.8,"CIGNA [10200]","Cigna Local Plus",,47.8,53.5,,,,,0,10.39,75.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 65CM 5FR KA2 CURVE ANGIOGRAPHIC PEBAX",SUP-5582-43,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.44,55.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,75.8,41.1,,,,,0,21.45,156.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 20MM 29MM MOSAIC CINCH RING PORCINE STENT",SUP-305C229,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"AETNA [10100]","Aetna HMO/PPO",,21786.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 3DEMIN ALLOGRAFT BOAT PLIABLE OSTEOCONDUCTIVE",SUP-109781,CDM,C1713,HCPCS,0278,RC,,,both,,,27562.50,8268.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7441.88,27,,,,,0,3205.52,23428.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BD NEXIVA DIFFUSICS 1IN 22GA 1.65MM 6.5ML/SEC 325 PSI",SUP-383591,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.16,17.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,40.23,68,,,,,0,6.88,50.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.220,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 5 X 6 COMPLEX PICO COIL",SUP-10USC05006,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5374.03,41.1,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 3MM SPAT VARIABLE LENGTH SHAFT INTEGRATE SUCTION",SUP-PS210-030S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,257.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE OXIMETER 300CM SPO2 LNC-10",SUP-2027263-002,CDM,S27000186,LOCAL,0270,RC,,,both,,,1007.75,302.32,"CIGNA [10200]","Cigna Open Access",,573.41,56.9,,,,,0,117.2,856.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 4.1MM ECHELON ENDOPATH THICK TISSUE 2MM GREEN",SUP-GST45G,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT MONORAIL 31MM 135CM 10MM ENDOPROSTHESIS",SUP-M001719050,CDM,C1876,HCPCS,0278,RC,,,both,,,16615.20,4984.56,"CIGNA [10200]",Cigna,,6646.08,40,,,,,0,1932.35,14122.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR JR4.5 CURVE GUIDING CORONARY",SUP-LA7JR45SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"KAISER [10500]",Kaiser,,262.31,67,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,inpatient,,,88435.94,26530.78,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,11467.22,,"Case rate ($10,717.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,951.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,991.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,134.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,964.65. The transfer operating threshold is the transfer adjustment factor * $9,951.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.38. The transfer capital threshold is the transfer adjustment factor * $752.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,7561,50441.93,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 25CM 120CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR072502A,CDM,C1874,HCPCS,0278,RC,,,both,,,40635.00,12190.5,"FIRST HEALTH [10303]","First Health",,32508,80,,,,,0,4725.85,34539.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablt Pulm Tumor Perc Cryo",PX-361000470,CDM,32994,CPT,0361,RC,,,both,,,9566.00,2869.8,"BLUE CROSS [10001]","Blue Cross PPO",,6755.86,,"Case rate ($6,755.86). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1112.53,9566,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 18CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175199190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]",Cigna,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM CORTICAL RAYHACK GENERATION II",SUP-40100912,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"MULTIPLAN [10600]",Multiplan,,647.19,85,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.438TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,235.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",235.11,1718.32,"percent of total billed charges",
"TRAY INTRO BLUE RHINO G2 SHILEY 7.5MM 8.5MM 9MM PERCUTANEOUS",SUP-G57721,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTAROLINE FOSAMIL 600 MG VIAL",RX-107671,CDM,J0712,HCPCS,0636,RC,00456-0600-01,NDC,both,1,UN,1554.03,466.21,"BLUE CROSS [10001]","Blue Cross HMO",,295.8,,,,,,,184.15,1320.93,"fee schedule",
"ROD EXTERNAL FIXATION AEQUALIS REVERSED DISPOSABLE",SUP-DWD163,CDM,C1776,HCPCS,0278,RC,,,both,,,447.00,134.1,"FIRST HEALTH [10303]","First Health",,357.6,80,,,,,0,51.99,379.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE 24FR INCISION STORZ 1 STEM",SUP-M0068805011,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,212.27,41.1,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tacrolimus (Prograf)",PX-301000057,CDM,80197,CPT,0301,RC,,,both,,,732.45,219.73,"CIGNA [10200]","Cigna Local Plus",,30.21,,,,,,,0.73,622.58,"fee schedule",
"CATH LAUNCHER 8FR .09IN JUDKINS RIGHT 5 CURVE GUIDING NYLON",SUP-LA8JR50,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 85MM X40 RECONSTRUCTION STERILE",SUP-04.046.685S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 45X2MM ENDO GIA ROTICULATOR TITANIUM VASCULAR",SUP-030453,CDM,S27200284,LOCAL,0272,RC,,,both,,,1550.99,465.3,"MULTIPLAN [10600]",Multiplan,,1318.34,85,,,,,0,180.38,1318.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 28CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805240,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,414.1,45.9,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM ASSURE TITANIUM ANTERIOR CERVICAL SPINE",SUP-110.016,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"NOVANET [10819]",Novanet,,1057.5,75,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BENCHMARK 105CM .07IN STRAIGHT DELIVERY SYSTEM LATEX",SUP-BMK6F105,CDM,S27200284,LOCAL,0272,RC,,,both,,,6727.50,2018.25,"PHCS [10601]",PHCS,,4709.25,70,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SEEKER 90CM SPRT HYDROPHILIC PERIPHERAL RADIOPAQUE",SUP-SK9035M,CDM,C1887,HCPCS,0272,RC,,,both,,,1498.50,449.55,"MULTIPLAN [10600]",Multiplan,,1273.73,85,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LEAD 49CM 9FR SAFESHEATH CSG WORLEY JUMBO CURVE",SUP-CSG/WRLY/BCOR-1-09,CDM,C1892,HCPCS,0272,RC,,,both,,,3345.00,1003.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,396.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,389.02,2843.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 21MM REVISION 20 GRIT BLAST SURFACE",SUP-197621140,CDM,C1776,HCPCS,0278,RC,,,both,,,17952.48,5385.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2127.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2087.87,15259.61,"percent of total billed charges",
"BLADE SAW 30X10.2X.97MM MINI-DRIVER II FINE SAGITTAL STERILE",SUP-K144,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.61,54.18,"MULTIPLAN [10600]",Multiplan,,153.52,85,,,,,0,21,153.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOANCHOR AORTIC HELI-FX W/AP",SUP-SA-85,CDM,S27800098,LOCAL,0278,RC,,,both,,,27197.10,8159.13,"BLUE CROSS [10001]","Blue Cross HMO",,10661.26,39.2,,,,,0,3163.02,23117.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORD MONOPOLAR 10FT OLSEN 90D SPINE STRAIGHT PLUG STERILE",SUP-50-2111,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.55,69.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,156.77,68,,,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19 DIOPTER POSTERIOR CHMBR FOLDABLE ASPHERIC UV",SUP-CCA0T0,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 5FR 5MM SPACE D CURVE ELECTROPHYSIOLOGY",SUP-F5QD005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"AETNA [10100]","Aetna HMO/PPO",,721.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER BURR HOLE 7MM UNIVERSAL NEURO II CRANIOMAXILLOFACIAL",SUP-53-05507,CDM,C1713,HCPCS,0278,RC,,,both,,,1690.88,507.26,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,196.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",196.65,1437.25,"percent of total billed charges",
"SCR BONE 5.5MM 40MM UNIVERS REVERS POROUS GLENOID PERIPHERAL",SUP-AR-9563-40,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"CIGNA [10200]","Cigna Local Plus",,319.6,53.5,,3978.14,359.25,3978.14,24,69.48,507.77,"percent of total billed charges",
"SCR BONE 4MM 40MM LCP STAINLESS STEEL LONG THREAD FEMORAL",SUP-207.740,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,123.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,120.96,884.03,"percent of total billed charges",
"LENS IOL +16.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.165,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 12MM 3.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3512X,CDM,C1725,HCPCS,0272,RC,,,both,,,558.90,167.67,"UHC [10700]","United Healthcare",,353.78,63.3,,,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1/3 TUBE 123MM STAINLESS STEEL 10 HOLE LOCK BONE ANKLE",SUP-AR-8943T-10,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,957.42,570.23,957.42,28,348.9,2550,"percent of total billed charges",
"CATH JADE 135CM 150MM 6MM BALLOON DILATATION HYDROPHILIC",SUP-606015022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZOOM 55 REPERFUSION CATHETER",SUP-ICRC055137,CDM,S27200284,LOCAL,0272,RC,,,both,,,17146.50,5143.95,"CIGNA [10200]","Cigna Local Plus",,9173.38,53.5,,,,,0,1994.14,14574.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM FOOT LOCKING",SUP-58803518,CDM,C1713,HCPCS,0278,RC,,,both,,,1506.60,451.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,431.19,28.62,,,,,0,175.22,1280.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 140MM 125CM 7MM VASCULAR PERIPHERAL OTW",SUP-G38491,CDM,C1874,HCPCS,0278,RC,,,both,,,15906.62,4771.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1849.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1849.94,13520.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL UNIVERSAL 22INX3IN DELUXE MEDIUM DENSITY",SUP-1022-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,56.90,17.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.62,48.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 40MM COMPREHENSIVE +3MM SHOULDER PROLONG",SUP-110031423,CDM,C1776,HCPCS,0278,RC,,,both,,,5354.40,1606.32,"CIGNA [10200]","Cigna Open Access",,3046.65,56.9,,5302.19,4377.88,6578.61,27,622.72,4551.24,"percent of total billed charges",
"STEM FEMORAL 140MM 10MM COLLARLESS CEMENTLESS LOW PROFILE",SUP-L20310,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"UHC [10700]","United Healthcare",,10024.9,63.3,,8601.07,8395.67,8601.07,"1 through 10",1841.86,13461.55,"percent of total billed charges",
"PLATE SHORT 72MM STAINLESS STEEL 2.7/3.5MM SCR 1 HOLE",SUP-02.117.601,CDM,C1713,HCPCS,0278,RC,,,both,,,6541.75,1962.52,"AETNA [10100]","Aetna HMO/PPO",,5200.69,79.5,,1521.93,481.35,16760.95,30,760.81,5560.49,"percent of total billed charges",
"HEAD FEMORAL +1.5MM 12/14 TAPER 28MM HIP SLEEVE TOTAL",SUP-136528710,CDM,C1776,HCPCS,0278,RC,,,both,,,11785.20,3535.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4843.72,41.1,,6417.48,6417.48,6417.48,"1 through 10",1370.62,10017.42,"percent of total billed charges",
"SHELL ACETABULAR 48MM HIP LIMIT HOLE MODULAR TITANIUM POROUS",SUP-PT-116048,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"FIRST HEALTH [10303]","First Health",,8164.08,80,,,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADHESIVE SKIN CLOSURE SYSTEM MESH EXOFIN FUSION 6CM",SUP-EF70406,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"PHCS [10601]",PHCS,,237.51,70,,,,,0,39.46,288.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS LARGE BLOCK 20X20MM",SUP-800101,CDM,S27800098,LOCAL,0278,RC,,,both,,,5255.04,1576.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1503.99,28.62,,,,,0,611.16,4466.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 13MM 360MM HIP RIGHT FEMUR AFFIXUS INTRAMEDULLARY 125D",SUP-814313360,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5600.54,27,,,,,0,2412.38,17631.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 35 SMALL PEG AEQUALIS CORTILOC SHOULDER",SUP-DWE402,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"KAISER [10500]",Kaiser,,6241.72,67,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 4-0 STD ANGLE MICRO 9IN HOLLOW HANDLE SURGICAL 3X2.1MM",SUP-RN0987,CDM,S27200284,LOCAL,0272,RC,,,both,,,842.56,252.77,"CIGNA [10200]","Cigna Local Plus",,450.77,53.5,,,,,0,97.99,716.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 CURVE PLUS 10MM KNEE XLK FIX BEARING SIGMA",SUP-970481,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UHC [10700]","United Healthcare",,7073.49,63.3,,8601.07,8395.67,8601.07,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"SCR BONE 3.5MM 24MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.108,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,582.96,68,,,,,0,99.7,728.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Urinalysis Non-Auto W Micro",PX-307000001,CDM,81000,CPT,0307,RC,,,both,,,129.00,38.7,"PHCS [10601]",PHCS,,90.3,70,,,,,0,2.15,109.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Urinalysis Non-Auto W Micro",PX-307000001,CDM,81000,CPT,0307,RC,,,both,,,129.00,38.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.15,,,,,,,2.15,109.65,"fee schedule",
"HC Rmvl Endovas Vena Cava Filter",PX-361000138,CDM,37193,CPT,0361,RC,,,both,,,12925.66,3877.7,"BLUE CROSS [10001]","Blue Cross HMO",,4025.22,,"Case rate ($4,025.22). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1503.25,10986.81,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 190ML GEL ROUND SMOOTH MEMORYGEL COHESIVE I","SUP-3507190 MC",CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2427.6,68,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM 4MM 2.1-2.7FR CORONARY STENT",SUP-RONYX40008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BIOLOGICAL 2.22X2IN PURACOL PLUS SQUARE SILVER CLLGN",SUP-MSC8722EP,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.94,19.18,"FIRST HEALTH [10303]","First Health",,51.15,80,,,,,0,7.44,54.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION",RX-103889,CDM,J2003,HCPCS,0636,RC,63323-0495-07,NDC,both,5,ML,32.54,9.76,"KAISER [10500]",Kaiser,,21.8,67,,,,,0,1.17,27.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN AMPLATZ RIGHT 1",SUP-534641T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"AETNA [10100]","Aetna HMO/PPO",,69.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL SILVER 6.1CM 3.2MM BLACK MAX STRAIGHT FLUTE",SUP-SIL-15,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.80,262.44,"KAISER [10500]",Kaiser,,586.12,67,,,,,0,101.74,743.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INTELLANAV STABLEPOINT 4MM 8FR ABLATION RING ELECTRD",SUP-M004RFSDS96200,CDM,C2630,HCPCS,0272,RC,,,both,,,20160.00,6048,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2388.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 110MM SURGICAL 3.5MM CORTEX SCR NONSTERILE",SUP-311.32,CDM,S27000186,LOCAL,0270,RC,,,both,,,1550.02,465.01,"NOVANET [10819]",Novanet,,1162.52,75,,,,,0,180.27,1317.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 55MM PROXIMATE TITANIUM VASCULAR ENDOSCOPIC",SUP-TVR55,CDM,S27200284,LOCAL,0272,RC,,,both,,,1198.64,359.59,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ALLERGIC REACTIONS WITH MCC",915,MS-DRG,,,,,,,inpatient,,,59678.23,17903.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 20MM 12MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171120270,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 74X46X12MM NEXGEN LCCK 5-6 C-D STD KNEE",SUP-599404112,CDM,C1776,HCPCS,0278,RC,,,both,,,16256.40,4876.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4389.23,27,,,,,0,1890.62,13817.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 7CM 5FR PANCREATIC POLYETHYLENE PUSH CATH",SUP-G22210,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"FIRST HEALTH [10303]","First Health",,984.96,80,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTRIAXONE 2 G VIAL - INTRAMUSCULAR",RX-408316,CDM,J0696,HCPCS,0636,RC,00409-7335-21,NDC,both,1,UN,26.21,7.86,"FIRST HEALTH [10303]","First Health",,20.97,80,,,,,0,4.01,22.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 5MM 1MM BALLOON DILATATION PERCUTANEOUS",SUP-210-053-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"NOVANET [10819]",Novanet,,941.63,75,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP3PR,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5805.51,27,,,,,0,2500.67,18276.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 100MM 2MM VARIAX STOP 4.5MM NONSTERILE",SUP-703818,CDM,C1713,HCPCS,0278,RC,,,both,,,629.37,188.81,"BLUE CROSS [10001]","Blue Cross HMO",,246.71,39.2,,957.42,156.86,7483.26,51,73.2,534.96,"percent of total billed charges",
"COIL EMBOLIZATION 2CM 1.5MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-01502,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1225.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 60MM 4MM BALLOON DILATATION OTW STERILE",SUP-584006022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEPILEX BORDER HEEL 22X23CM 8.7X9.1IN",SUP-282790,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.30,24.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,54.6,68,,,,,0,9.34,68.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 6FR 22CM DUAL DUROMETER STRAIGHT FLEXIBLE TIP",SUP-M0061921310,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"BLUE CROSS [10001]","Blue Cross HMO",,445.16,39.2,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 7CM 10FR 2 PIGTAIL CURVE TAPER BILIARY",SUP-G21977,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY 400ML GEL P5.1CM HIGH PROFILE ROUND 12.3CM",SUP-RSZ-4004,CDM,S27200284,LOCAL,0272,RC,,,both,,,127.64,38.29,"UHC [10700]","United Healthcare",,80.8,63.3,,,,,0,14.84,108.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS LIGAPAK 2-0 54IN BRAID REEL ANTIBACTERIAL",SUP-VCP286G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PHCS [10601]",PHCS,,17.5,70,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 47CM 26MM ABDOMEN THORAX WOVEN SOFT",SUP-M00202175426T0,CDM,L8670,HCPCS,0278,RC,,,both,,,13481.36,4044.41,"CIGNA [10200]",Cigna,,5392.54,40,,,,,0,427.53,11459.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 26CM 3CM 8FR .038IN PIGTAIL CURVE",SUP-M006180543170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]",Cigna,,837.05,68,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 3.5CM 18FR GUIDING BALLOON LOW PROFILE",SUP-8117,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,431.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.3/4F DUO-DECA 2-5-2 S 120CM",SUP-903273,CDM,C1731,HCPCS,0272,RC,,,both,,,8970.00,2691,"PHCS [10601]",PHCS,,6279,70,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X18X7MM RISE-L NONSTERILE",SUP-193.305,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"NOVANET [10819]",Novanet,,25751.25,75,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 40MM 3.8FR 7MM LOW PROFILE BALLOON",SUP-H749392032704010,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1018.98,68,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
CABLE,SUP-05001-I,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,,41.1,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WIRE FIXATION .8MM 70MM KIRSCHNER TITANIUM TROCAR POINT",SUP-492.08,CDM,C1713,HCPCS,0278,RC,,,both,,,70.16,21.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",8.16,59.64,"percent of total billed charges",
"CAP CONSTRUCT TOTAL KNEE LEGION GII POSTERIOR STABILIZED HYB",SUP-71704530,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9062.55,41.1,,6417.48,6417.48,6417.48,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"SUT PDS II 2-0 STP-10 27IN 2 ARM MONOFILAMENT VIOLET",SUP-Z997G,CDM,S27200284,LOCAL,0272,RC,,,both,,,202.71,60.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,83.31,41.1,,,,,0,23.58,172.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 6CM 7FR BILIARY POLYETHYLENE TAPERED TIP",SUP-G27143,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC G6pd Enzyme Screen",PX-301000579,CDM,82960,CPT,0301,RC,,,both,,,72.00,21.6,"UHC [10700]","United Healthcare",,5.45,,,,,,,0.01,61.2,"fee schedule",
"BURR SURGICAL 48MM 1MM E9000 ROUND STAINLESS STEEL 6 FLUTE",SUP-E8210,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP MONOPOLAR 230X4MM 2.75MM 3.2MM COAGRASPER HEMOSTASIS",SUP-FD-411UR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.83,513.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1163.36,68,,,,,0,198.97,1454.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.2MM COMPREHENSIVE CENTRAL SCR REVERSE SHOULDER",SUP-405883,CDM,S27200284,LOCAL,0272,RC,,,both,,,1556.00,466.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,184.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOLD CEMENT STAGEONE -6 HIP SILICONE SPACER NECK ADPTR",SUP-431188,CDM,S27200284,LOCAL,0272,RC,,,both,,,2193.75,658.12,"UHC [10700]","United Healthcare",,1388.64,63.3,,,,,0,255.13,1864.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY 300ML GEL P3.7CM MODERATE PLUS PROFILE ROUND",SUP-RSZ-3001,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA [10200]","Cigna Open Access",,90,56.9,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 31CM 5MM HARMONIC SCPL ULTRACISION",SUP-HBC05,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.41,432.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,592.83,41.1,,,,,0,167.75,1226.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MDM EKG CARDIOMESSENGER NS LF",SUP-401831,CDM,S27000186,LOCAL,0270,RC,,,both,,,2437.50,731.25,"MULTIPLAN [10600]",Multiplan,,2071.88,85,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 20MM TRILOGY TIVANIUM HIP CORTICAL ACETABULAR",SUP-00625006520,CDM,C1713,HCPCS,0278,RC,,,both,,,691.60,207.48,"BLUE CROSS [10001]","Blue Cross HMO",,271.11,39.2,,957.42,156.86,7483.26,51,80.43,587.86,"percent of total billed charges",
"GWIRE VIPERWIRE ADVANCE VASCULAR 335CM .018IN PERIPHERAL",SUP-VPR-GW-FLEX18,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUMARK CONIC 18GX12CM 10/BX",SUP-351262,CDM,A4648,HCPCS,0278,RC,,,both,,,961.70,288.51,"FIRST HEALTH [10303]","First Health",,769.36,80,,,,,0,111.85,817.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,inpatient,,,83097.72,24929.32,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,62994.22,,"Case rate ($30,937.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $28,727.24, add-ons for qualifying new technology services are included. If operating cost exceeds $61,766.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,553.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $28,765.23. The transfer operating threshold is the transfer adjustment factor * $28,727.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,171.92. The transfer capital threshold is the transfer adjustment factor * $2,171.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,83097.72,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION",RX-28282,CDM,,,0637,RC,00088-2220-33,NDC,both,10,ML,582.18,174.65,"CIGNA [10200]",Cigna,,395.88,68,,,,,0,67.71,494.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 5FR 2-5-2MM SPACE A CURVE",SUP-F5QRA252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"UHC [10700]","United Healthcare",,574.26,63.3,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 84MM X25 LOCK LOW PROFILE STERILE",SUP-04.045.084S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 11MM KNEE X3 CONDYLAR STABILIZED PRIMARY",SUP-5531G411,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1109.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1089.28,7961.17,"percent of total billed charges",
"HC Rpr Face/Ax/Ext Add 5cm Cmplx",PX-450000054,CDM,13133,CPT,0361,RC,,,both,,,1753.02,525.91,"KAISER [10500]",Kaiser,,1174.52,67,,,,,0,1.75,1753.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 65MM 9.4MM 15MM 5MM CUFFLESS REUSABLE INNER CANN",SUP-4CFN,CDM,S27200284,LOCAL,0272,RC,,,both,,,312.85,93.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHUTTLE IDEAL STRAIGHT CRESCENT SUT",SUP-251007,CDM,S27200284,LOCAL,0272,RC,,,both,,,2618.78,785.63,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE VASCULAR .014IN 300CM 2CM STRAIGHT RADIOPAQUE MARKER",SUP-H74938951022,CDM,C1769,HCPCS,0272,RC,,,both,,,672.30,201.69,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 72CM 21FR TANDEMHEART VENOUS DIL INTRO",SUP-5140-6217,CDM,S27200284,LOCAL,0272,RC,,,both,,,62700.00,18810,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SLEEVE ORTHOPEDIC THK1/8IN LARGE 13IN NEOPRENE KNEE EXTRA",SUP-79-82007,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.72,17.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PK 8X1.5X2CM LARGE NASAL 2 COMPRESS BACTERIOSTATIC AIRWAY",SUP-7089-0837,CDM,S27200284,LOCAL,0272,RC,,,both,,,869.54,260.86,"MULTIPLAN [10600]",Multiplan,,739.11,85,,,,,0,101.13,739.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Arthro Shldr Si",PX-322000001,CDM,73040,CPT,0322,RC,,,both,,,1394.28,418.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,162.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.15,1185.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dpyd Gene Common Variants",PX-309000132,CDM,81232,CPT,0310,RC,,,both,,,942.40,282.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,274.98,,,,,,,0.01,801.04,"fee schedule",
"HC Washing Sperm",PX-301000680,CDM,58323,CPT,0301,RC,,,both,,,591.00,177.3,"FIRST HEALTH [10303]","First Health",,472.8,80,,,,,0,70.03,591,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 62.5MM KNEE LEFT CRUCIATE RETAINING CEMENTED",SUP-183026,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2335.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2335.96,17072.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE S+ 4 KNEE CEMENT FIX BEARING",SUP-150670004,CDM,C1776,HCPCS,0278,RC,,,both,,,15487.05,4646.11,"BLUE CROSS [10001]","Blue Cross PPO",,6070.92,39.2,,3949.44,3949.44,3949.44,"1 through 10",1801.14,13163.99,"percent of total billed charges",
"HC Xr Abdomen 1v",PX-320000220,CDM,74018,CPT,0320,RC,,,both,,,552.96,165.89,"CIGNA [10200]","Cigna Local Plus",,47.56,,,,,,,34.01,470.02,"fee schedule",
"STENT AEROMINI 115MM 15MM 8MM 12.5FR TRACHEOBRONCHIAL TAPER",SUP-AERO815,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,9776.84,9776.84,9776.84,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"PLATE 91MM STAINLESS STEEL 5 HOLE LOCK MODULAR LOW PROFILE",SUP-AR-8943BR-05,CDM,C1713,HCPCS,0278,RC,,,both,,,6410.10,1923.03,"BLUE CROSS [10001]","Blue Cross PPO",,2512.76,39.2,,957.42,570.23,957.42,28,745.49,5448.59,"percent of total billed charges",
"HEAD BIPOLAR 44MM ENCORE",SUP-412-02-044,CDM,C1776,HCPCS,0278,RC,,,both,,,7338.63,2201.59,"PHCS [10601]",PHCS,,5137.04,70,,,,,0,853.48,6237.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 75CM 60MM 9MM BALLOON DILATATION DRUG COATED",SUP-LX3575960V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1001.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 26MM CG FUTURE EYELET DESIGN CROSS",SUP-638BL26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1524.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER QUICKPASS SUTURELASSO 90D SMALL RIGHT CURVE 8.25MM",SUP-AR-6068-90R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,161.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL BEND 87MM STAINLESS STEEL 3.5MM SCR 4 HOLE",SUP-02.127.211,CDM,C1713,HCPCS,0278,RC,,,both,,,9039.00,2711.7,"BLUE CROSS [10001]","Blue Cross HMO",,3543.29,39.2,,957.42,156.86,7483.26,51,1051.24,7683.15,"percent of total billed charges",
"KIT CATH 16GA 18GA 16CM .032IN CATH GWIRE NDL SYR SHARP",SUP-AK-04306-SP,CDM,C1751,HCPCS,0272,RC,,,both,,,234.90,70.47,"FIRST HEALTH [10303]","First Health",,187.92,80,,,,,0,27.32,199.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X6MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7106,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +23 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-CC60WF.230,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 48MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.638,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"NOVANET [10819]",Novanet,,867.51,75,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 16MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532-G-516,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2492.12,28.62,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 80MM 80CM 16MM .035IN 3MM VASCULAR VENOUS 3",SUP-VENUM16080,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8820,40,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 40MMX12MMX15CM 26FR",SUP-TAC124015A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21614.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXCHG HEAT/MOISTURE 2 MODE SYSTEM FILTER ROTATABLE COLLAR",SUP-19912,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.96,1.49,"NOVANET [10819]",Novanet,,3.72,75,,,,,0,0.58,4.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 28MM 4MM CORONARY STENT COCR RAPID",SUP-1007850-28,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE ROUND",SUP-02.107.202S,CDM,C1713,HCPCS,0278,RC,,,both,,,6423.90,1927.17,"KAISER [10500]",Kaiser,,4304.01,67,,,,,0,747.1,5460.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT NEUROSURGICAL ULTRA SMALL 90CM CSF SNAP ASSEMB DOME",SUP-46560,CDM,S27800098,LOCAL,0278,RC,,,both,,,10727.02,3218.11,"BLUE CROSS [10001]","Blue Cross PPO",,4204.99,39.2,,,,,0,1247.55,9117.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 520CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-520,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS [10001]","Blue Cross PPO",,2961.76,39.2,,16595.83,16595.83,16595.83,"1 through 10",878.7,6422.18,"percent of total billed charges",
"CATH ADVANCE PLIAFORM STARCAST 80CM 4CM 7MM BALLOON",SUP-G52352,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEARTMATE 3? LVAD SURGICAL ACCESSORIES SPARES KIT (APICAL CU",SUP-10006827,CDM,S27200284,LOCAL,0272,RC,,,both,,,11488.50,3446.55,"AETNA [10100]","Aetna HMO/PPO",,9133.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1336.11,9765.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502605602,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2658.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO SMALL STYLET SURESIGHT",SUP-321900010,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.00,26.1,"PHCS [10601]",PHCS,,60.9,70,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 8FR L20CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902400,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CROSSLEAD VASCULAR 300CM .035IN STERILE LATEX FREE",SUP-CLN03530A,CDM,C1769,HCPCS,0272,RC,,,both,,,1579.50,473.85,"MULTIPLAN [10600]",Multiplan,,1342.58,85,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT PATELLAR 1 FULL 10MM 41MM PRIMARY NEXGEN TRABECULA",SUP-00587806541,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.16,2973.35,"UHC [10700]","United Healthcare",,6273.76,63.3,,8601.07,8395.67,8601.07,"1 through 10",1152.67,8424.49,"percent of total billed charges",
"CATH MACH1 100CM 8FR ART3.5 CURVE GUIDING PTFE FEMORAL",SUP-H749343584980,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 100CM 40MM 7MM BALLOON",SUP-LX181007405F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,797.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 45CM 6MM FLIXENE SLIDER GRADUATED WALL",SUP-25050,CDM,C1768,HCPCS,0278,RC,,,both,,,8200.03,2460.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5576.02,68,,,,,0,953.66,6970.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPEEDBRIDGE SWIVELOCK 4.75MM IMPL BIOCOMPOSITE",SUP-AR-2600SBS-10,CDM,C1713,HCPCS,0278,RC,,,both,,,15576.75,4673.02,"CIGNA [10200]","Cigna Local Plus",,4906.68,31.5,,3978.14,359.25,3978.14,24,1811.58,13240.24,"percent of total billed charges",
"SCISSORS 4.5IN IRIS STRAIGHT SATIN FINISH SURGICAL STERILE",SUP-66450,CDM,S27200284,LOCAL,0272,RC,,,both,,,44.00,13.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18.08,41.1,,,,,0,5.12,37.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PREVENA PEEL AND PLACE PATCH STRIPS VAC 13CM NEGATIVE",SUP-PRE1101US,CDM,S27200284,LOCAL,0272,RC,,,both,,,3522.60,1056.78,"CIGNA [10200]","Cigna Open Access",,2004.36,56.9,,,,,0,409.68,2994.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 20MM SMR TITANIUM SHOULDER MODULAR SYSTEM",SUP-8420.15.010,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"BLUE CROSS [10001]","Blue Cross PPO",,609.83,39.2,,957.42,570.23,957.42,28,180.93,1322.35,"percent of total billed charges",
"SHEATH PERFORMER 63CM 14FR GUIDING MULLINS DESIGN",SUP-G12239,CDM,C1894,HCPCS,0272,RC,,,both,,,963.82,289.15,"KAISER [10500]",Kaiser,,645.76,67,,,,,0,112.09,819.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 FLEXOR 30MM 125CM 6MM 5FR LOW PROFILE",SUP-G43770,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,486.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPEEDBRIDGE SWIVELOCK 4.75MM IMPL BIOCOMPOSITE",SUP-AR-2600SBS-10,CDM,C1713,HCPCS,0278,RC,,,both,,,15576.75,4673.02,"PHCS [10601]",PHCS,,10903.73,70,,,,,0,1811.58,13240.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 15X15.5CM 750CC STYLE 133S SMOOTH SUT TAB",SUP-133S-FV-15-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA [10200]",Cigna,,6334.2,68,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP 2.5MM XL VESSEL CLSR GRIPPIER ANASTOCLIP",SUP-4007-04,CDM,S27200284,LOCAL,0272,RC,,,both,,,3442.50,1032.75,"PHCS [10601]",PHCS,,2409.75,70,,,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL INTERTAN 10X24X130DG",SUP-71934480,CDM,C1713,HCPCS,0278,RC,,,both,,,12096.00,3628.8,"PHCS [10601]",PHCS,,8467.2,70,,,,,0,1406.76,10281.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC",807,MS-DRG,,,,,,,inpatient,,,29558.07,8867.42,"CIGNA [10200]","Cigna Local Plus",,7833,,"Case rate ($7,833). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,4182.11,11132.13,other,"IP NVD Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 14MM 3.25MM EMBOLIZATION",SUP-PED2-325-14,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,21815.33,27,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE LARGE FEMALE",SUP-100612-040,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.99,17.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,40.11,68,,,,,0,6.86,50.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 9MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-509-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3444.02,28.62,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 3CMX6MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-9-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"KAISER [10500]",Kaiser,,976.86,67,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE GRAFT 12CC DEMINERALIZED CORTICAL FIBER ACCELERATE",SUP-T50212,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 100MM 19GA 20GA SONOLONG SONOLONG SONO",SUP-531187-31A,CDM,C9814,HCPCS,0272,RC,,,both,,,461.70,138.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,54.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.7,392.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC",027,MS-DRG,,,,,,,inpatient,,,164317.86,49295.36,"AMBETTER EXCHANGE  [11102]",Ambetter,,15649.71,,"Case rate ($15,649.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,531.81, add-ons for qualifying new technology services are included. If operating cost exceeds $47,571.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,480.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $14,551.03. The transfer operating threshold is the transfer adjustment factor * $14,531.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,098.68. The transfer capital threshold is the transfer adjustment factor * $1,098.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,15649.71,73658.59,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE PT VASCULAR J 185CM 35CM .014IN FLOPPY",SUP-H7491216001J1,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM COCR SPINAL MULTIAXIAL CANNULATED",SUP-54840014535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4382,45.9,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 22CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006155231010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULE EMG NEUROVISION M5 NEXT GENERATION",SUP-8020015,CDM,S27200284,LOCAL,0272,RC,,,both,,,6210.00,1863,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2850.39,45.9,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 23MM 3MM CORONARY STENT EVEROLIMUS",SUP-1550300-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 2.5CM 6CM GWIRE DIL RADIOPAQUE KINK",SUP-RSB711,CDM,C1894,HCPCS,0272,RC,,,both,,,191.40,57.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 15CM 2.5MM STD DRNG VENTRICLE BARIUM IMPREGNATED PLAINT",SUP-41103,CDM,C1729,HCPCS,0272,RC,,,both,,,1470.15,441.04,"UHC [10700]","United Healthcare",,930.6,63.3,,,,,0,170.98,1249.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PLASMABUTTON LARGE HIGH FREQUENCY",SUP-WA22603S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3091.82,927.55,"UHC [10700]","United Healthcare",,1957.12,63.3,,,,,0,359.58,2628.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE SCREW HEADED THREADED 6-KANT/HEXAGONAL 3.20MM L-33.00M","SUP-GS901.033.032 STE",CDM,S27200284,LOCAL,0272,RC,,,both,,,789.75,236.92,"PHCS [10601]",PHCS,,552.83,70,,,,,0,91.85,671.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM PERSONA EF KNEE LEFT MEDIAL HALF BLOCK",SUP-42555805310,CDM,C1776,HCPCS,0278,RC,,,both,,,7236.72,2171.02,"BLUE CROSS [10001]","Blue Cross HMO",,2836.79,39.2,,5311.50,4717.44,5388.59,31,841.63,6151.21,"percent of total billed charges",
"STEM FEMORAL SHORT STRAIGHT NECK PROFEMUR TL CLASSIC 8 HIP",SUP-PRTLS028,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.3MM 2MM SCR MESH APTUS TRILOCK BONE HAND",SUP-A-4655.56,CDM,S27200284,LOCAL,0272,RC,,,both,,,8790.60,2637.18,"AETNA [10100]","Aetna HMO/PPO",,6988.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1022.35,7472.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
UNGROUPABLE,999,MS-DRG,,,,,,,inpatient,,,50806.08,15241.82,"CIGNA [10200]",Cigna,,11428.42,,"Fee schedule rate ($11,428.42). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,5406.59,21736.83,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CADENCE PRECISION INFLATION 1ML SYR INJECTOR THREAD",SUP-103-0304,CDM,S27200284,LOCAL,0272,RC,,,both,,,3592.50,1077.75,"AETNA [10100]","Aetna HMO/PPO",,2856.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,417.81,3053.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 26MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-026,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5737.72,27,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ca Ionized POC",PX-301000125,CDM,82330,CPT,0301,RC,,,both,,,202.95,60.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.36,,"Fee schedule rate ($14.36). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",19.05,19.05,19.05,"1 through 10",0.2,172.51,"fee schedule",
"FRCP BIPOLAR GREEN 4IN .4MM JEWELERS IRIS STRAIGHT NONSTICK",SUP-14-3000,CDM,S27200284,LOCAL,0272,RC,,,both,,,190.53,57.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.16,161.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPLANT 16CM NATRELLE INSPIRA P5.2CM MODERATE PROFILE",SUP-MSZ-M685,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,72.6,45.9,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ASAHI TORNUS 135CM 2.1FR .014IN BRAID THREAD GUIDING",SUP-82380-01,CDM,C1887,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"NOVANET [10819]",Novanet,,4114.13,75,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 24MM 140CM 2.75MM CORONARY STENT",SUP-LUN275R24US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII CRUCIATE RETAINING OXINI",SUP-71704580,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Local Plus",,6945.75,31.5,,5372.07,4581.20,7242.98,23,2564.42,18742.5,"percent of total billed charges",
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,inpatient,,,32839.80,9851.94,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,4600.71,,"Case rate ($4,340.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,030.25, add-ons for qualifying new technology services are included. If operating cost exceeds $37,069.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,686.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,035.58. The transfer operating threshold is the transfer adjustment factor * $4,030.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $304.71. The transfer capital threshold is the transfer adjustment factor * $304.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,4340.29,17449.82,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 11.3MM 8MM 2 CHANNEL EMG REINFORCED LOW",SUP-8229308,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"NOVANET [10819]",Novanet,,2805,75,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 4 7MM KNEE AOX CRUCIATE RETAINING ROTATE PLATF",SUP-151630407,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"MULTIPLAN [10600]",Multiplan,,11158.16,85,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Instill Anticarcinogen Blad",PX-510000100,CDM,51720,CPT,0361,RC,,,both,,,2014.00,604.2,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1249,1922,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 2.5IN E-Z CLEAN PTFE NDL MICROFINE",SUP-0118A,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.41,37.32,"MULTIPLAN [10600]",Multiplan,,105.75,85,,,,,0,14.47,105.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ON-Q PAINBUSTER 5IN 17GA DELIVERY TNLR SHEATH",SUP-T17X5,CDM,S27200305,LOCAL,0272,RC,,,both,,,250.93,75.28,"MULTIPLAN [10600]",Multiplan,,213.29,85,,,,,0,29.18,213.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.3MM 19MM THREAD LOCK TITANIUM NONSTERILE",SUP-TPLS-23190-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,680.40,204.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,79.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",79.13,578.34,"percent of total billed charges",
"TACTIFLEX SE UNID CURVE D UNIFIED",SUP-A-TFSE-D-X,CDM,C2630,HCPCS,0272,RC,,,both,,,25061.40,7518.42,"AETNA [10100]","Aetna HMO/PPO",,19923.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2914.64,21302.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS,MODERATE",405,APR-DRG,,,,,,,inpatient,,,43903.73,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $8,625.38. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($35,289.67) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION FUZEFIX MAX FT STANDARD OD1.1 MM NONSTERILE",SUP-CD-FX-0011,CDM,S27000186,LOCAL,0270,RC,,,both,,,261.00,78.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL LOOP 10X10MM 3/32IN VALLEYLAB",SUP-E1559,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.35,27.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 0-8CM 19GA 4.8FR PROCORE ECHOTIP ULTRASOUND HIGH",SUP-G53585,CDM,S27200284,LOCAL,0272,RC,,,both,,,3195.00,958.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACIFIC PLUS 130CM 20MM 4FR 7MM .018IN BALLOON",SUP-PCP070020130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 17IN 21FR PERCUTANEOUS FEMORAL ARTERIAL ADULT",SUP-96530-021,CDM,S27200284,LOCAL,0272,RC,,,both,,,1903.58,571.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IMPL FIXATION 2.8MM MAGNUM2 KNOTLESS",SUP-OM1502,CDM,C1713,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]","Cigna Open Access",,1920.38,56.9,,1144.80,304.56,2275.09,66,392.51,2868.75,"percent of total billed charges",
"LEAD PACING 65CM 7FR ENDOCARDIAL 2 COIL TRUE BIPOLAR",SUP-7170Q/65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS [10001]","Blue Cross HMO",,6731.42,39.2,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 535CC STERILE ARTOURA ULTRA HIGH PROFILE ROUND",SUP-TEXP120RUH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"UHC [10700]","United Healthcare",,8713.56,63.3,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 118CM 6FR EBU3.75 CURVE GUIDING STERILE LATEX",SUP-LA6EBU375Y,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"KAISER [10500]",Kaiser,,244.82,67,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FROZEN 60MMX5+ MM",SUP-450610,CDM,S27800098,LOCAL,0278,RC,,,both,,,4607.82,1382.35,"NOVANET [10819]",Novanet,,3455.87,75,,,,,0,535.89,3916.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 2CMX16MM FLAT TIP OSTEOTOM Z NONSTERILE DISPOSABLE",SUP-SBLDZ-1-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"CIGNA [10200]","Cigna Open Access",,829.6,56.9,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KETAMINE 10 MG/ML INJECTION SOLUTION SUPERORDERABLE (STATUS EPILEPTICUS)",RX-410194,CDM,,,0250,RC,55150-0438-01,NDC,both,20,ML,207.45,62.23,"MULTIPLAN [10600]",Multiplan,,176.33,85,,,,,0,24.13,176.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LAPIDUS NO STEP BONE TARSOMETATARSAL NONSTERILE",SUP-MPP2000U,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7014.54,68,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 5CM BLURR COOLCUT BLADE",SUP-AR-8500BL,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.01,257.7,"MULTIPLAN [10600]",Multiplan,,730.16,85,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROPHILIC WIRE STANDARD , 0.035"""", 400CM, STRAIGHT",SUP-GR3541,CDM,C1769,HCPCS,0272,RC,,,both,,,615.60,184.68,"KAISER [10500]",Kaiser,,412.45,67,,,,,0,71.59,523.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON CABLE BLUE 2.5MM FEMUR TITANIUM ALUMINUM VANADIUM",SUP-47223206001,CDM,C1713,HCPCS,0278,RC,,,both,,,1912.50,573.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1300.5,68,,,,,0,222.42,1625.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM CONCERTO 3D",SUP-PV-3-6-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 4 KNEE POSTERIOR TOTAL STABILIZE",SUP-5544-A-400,CDM,C1776,HCPCS,0278,RC,,,both,,,6699.90,2009.97,"NOVANET [10819]",Novanet,,5024.93,75,,,,,0,779.2,5694.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 65MM 2MM MINI QUICK COUPLING NONSTERILE",SUP-310.201,CDM,S27000186,LOCAL,0270,RC,,,both,,,503.50,151.05,"CIGNA [10200]","Cigna Local Plus",,269.37,53.5,,,,,0,58.56,427.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tavi/Tavr Bypass W Centl Art",PX-361000351,CDM,33369,CPT,0361,RC,,,both,,,45298.00,13589.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6019.63,,"Fee schedule rate ($6,019.63).",,,,0,2491,38503.3,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036122030,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,EXTREME",622,APR-DRG,,,,,,,inpatient,,,215803.55,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $24,854.08. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to (Final Base Payment plus Newborn Screen Add-on Amount $63.00) multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($129,077.28) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-4 Newborn; Zero final payments for the item or service in the 15 months prior to posting the file."
"BOTTLE DRNG EVACUATE LUER LOCK NDL FREE DEHP FREE ACCEL 2000",SUP-622298,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.22,43.27,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RESOLVE 25CM 14FR PIGTAIL CURVE DRNG POLYURETHANE",SUP-RLC-14-038,CDM,C1729,HCPCS,0272,RC,,,both,,,531.36,159.41,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE GLDEWIRE GT VASCULAR 180CM .018IN STD FLEXIBLE TIP SET",SUP-RG*ES1818SP,CDM,C1769,HCPCS,0272,RC,,,both,,,1445.85,433.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CIRCUIT BREATHING HOSE BAG GAS ELBOW MASK 72IN ADULT 3L",SUP-AFNX2004,CDM,S27000186,LOCAL,0270,RC,,,both,,,64.35,19.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET EXT 2.5CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-24-2.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ARTHROSCOPIC 5.2MM 120MM DRAGONWING LARGE AUTOGRAFT",SUP-AD5CH52120,CDM,S27200284,LOCAL,0272,RC,,,both,,,8273.10,2481.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LEAD ICD 70CM ENDOTAK RELIANCE G ENDOCARDIAL STEROID",SUP-176,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6072,40,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE UBER FLEX 30MM 57CM 8MM .065IN VASCULAR",SUP-SR-0830-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION 8X11MM MEDIUM COMBINATION MR SAFE",SUP-390.037,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC LARGE XL SHOULDER GEL COLD",SUP-02815,CDM,S27000186,LOCAL,0270,RC,,,both,,,156.95,47.08,"KAISER [10500]",Kaiser,,105.16,67,,,,,0,18.25,133.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE MORCELLATION 12MM STERILE",SUP-53-000012,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 12/14 TAPER 28MM HIP CEMENTLESS BIOLOX",SUP-136528320,CDM,C1776,HCPCS,0278,RC,,,both,,,12268.20,3680.46,"BLUE CROSS [10001]","Blue Cross HMO",,4809.13,39.2,,5311.50,4717.44,5388.59,31,1426.79,10427.97,"percent of total billed charges",
"DEVICE SAFEGUARD 12CM COMPRESSION PRESSURE ASSISTED",SUP-82050,CDM,S27200284,LOCAL,0272,RC,,,both,,,453.60,136.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,53.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 12MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424025,CDM,C1776,HCPCS,0278,RC,,,both,,,11747.25,3524.17,"CIGNA [10200]",Cigna,,4698.9,40,,5873.17,5873.17,5873.17,"1 through 10",1366.21,9985.16,"percent of total billed charges",
"CATH LAUNCHER 100CM 6FR .071IN EXTRA BACKUP 4 LEFT CURVE",SUP-LA6EBU40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM SYNAPSE TITANIUM 40D SPINE CORTEX",SUP-04.614.334,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,441.36,3225.75,"percent of total billed charges",
"CATH REDEL 115CM 1MM 6FR 2-5-2MM SPACE G CURVE",SUP-F6DG252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2040.00,612,"AETNA [10100]","Aetna HMO/PPO",,1621.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,237.25,1734,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 38MM NCB PROTASUL-64 3.5MM SELF TAP 2 LEAD",SUP-0203150038,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,215.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",215.88,1577.81,"percent of total billed charges",
"CATH LUTONIX 100CM 40MM 8MM BALLOON DILATATION DRUG COATED",SUP-LX35100840V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"PHCS [10601]",PHCS,,5916.75,70,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Npwt <=50 Sq Cm (Go)",PX-430000027,CDM,97605,CPT,0430,RC,,,both,,,753.00,225.9,"AETNA [10100]","Aetna HMO/PPO",,598.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.57,640.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE FEMORAL 40MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-1511-01-204,CDM,C1776,HCPCS,0278,RC,,,both,,,16151.52,4845.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4360.91,27,,,,,0,1878.42,13728.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 32X21X2MM TITANIUM 1 LEVEL CLOVERLEAF CAUDAL HOLE LOCK",SUP-450.124,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,521.61,3812.25,"percent of total billed charges",
"PULMONARY EMBOLISM WITHOUT MCC",176,MS-DRG,,,,,,,inpatient,,,31732.94,9519.88,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,5143.27,,"Case rate ($4,993.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,636.77, add-ons for qualifying new technology services are included. If operating cost exceeds $37,676.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,732.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,642.90. The transfer operating threshold is the transfer adjustment factor * $4,636.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.56. The transfer capital threshold is the transfer adjustment factor * $350.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4993.47,20075.9,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA NATURAL TIBIA 5D C KNEE LEFT STEM",SUP-42532006401,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5018.59,45.9,,,,,0,1271.59,9293.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TYSHAK NUCLEUS 100CM 4CM 7FR 16MM BALLOON DILATATION",SUP-612090,CDM,C1725,HCPCS,0272,RC,,,both,,,5345.43,1603.63,"FIRST HEALTH [10303]","First Health",,4276.34,80,,,,,0,621.67,4543.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins/Plc Flow Dir Cath",PX-481000033,CDM,93503,CPT,0481,RC,,,both,,,2448.46,734.54,"NOVANET [10819]",Novanet,,1836.35,75,,,,,0,284.76,2448.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RAINS 48MM 38MM 4MM 3.2MM STD NASAL FRONTAL SINUS",SUP-7089-0932,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.04,111.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,252.99,68,,,,,0,43.27,316.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 7-0 BV-1 30IN 2 ARM MONOFILAMENT VIOLET",SUP-Z135H,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.03,60.01,"FIRST HEALTH [10303]","First Health",,160.02,80,,,,,0,23.26,170.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 7-0 BV-1 30IN 2 ARM MONOFILAMENT VIOLET",SUP-Z135H,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.03,60.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,23.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.26,170.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 X-1 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J458H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Ven Single Stage Dlp 24fr",PX-E27200371,CDM,E27200371,LOCAL,0272,RC,,,both,,,210.10,63.03,"PHCS [10601]",PHCS,,147.07,70,,,,,0,24.43,178.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO CYBERWAND RENAL BLADDER ULTRASONIC STERILE",SUP-CW-USLRBP,CDM,S27200284,LOCAL,0272,RC,,,both,,,4583.05,1374.91,"CIGNA [10200]","Cigna Open Access",,2607.76,56.9,,,,,0,533.01,3895.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIC PEG REPLACEMENT FEEDING ADAPTER  20FR",SUP-0135-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.86,20.36,"CIGNA [10200]",Cigna,,46.14,68,,,,,0,7.89,57.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER HUMERAL SMR UHMWPE +3 MM OD36 MM SHOULDER REVISION REV",SUP-1360.50.815,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"CIGNA [10200]","Cigna Open Access",,1672.86,56.9,,5302.19,4377.88,6578.61,27,341.92,2499,"percent of total billed charges",
"BASEPLT TIBIAL JOURNEY 8 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022218,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"MULTIPLAN [10600]",Multiplan,,14128.79,85,,,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +6MM 11/13 TAPER 44MM HIP M SPECIFICATION METAL",SUP-136564500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"BLUE CROSS [10001]","Blue Cross HMO",,4342.56,39.2,,5311.50,4717.44,5388.59,31,1288.37,9416.26,"percent of total billed charges",
"VALVE AORTIC 19MM EDWARDS INTUITY ELITE STERILE LATEX FREE",SUP-8300KITB19A,CDM,S27800098,LOCAL,0278,RC,,,both,,,68400.00,20520,"PHCS [10601]",PHCS,,47880,70,,,,,0,7954.92,58140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSRT SPINAL NDL DIL FISHMOUTH SPEAR PUNCH PERCUTANEOUS",SUP-AR-1941PK,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"CIGNA [10200]",Cigna,,1740.38,68,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 45MM COMMON ILLIAC SEG 41MM EXTERNAL",SUP-G60344,CDM,C1874,HCPCS,0278,RC,,,both,,,68399.94,20519.98,"CIGNA [10200]",Cigna,,27359.98,40,,,,,0,7954.91,58139.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT SPRT MEDTRONIC SMALL",SUP-FP9000S,CDM,S27000186,LOCAL,0270,RC,,,both,,,408.90,122.67,"CIGNA [10200]","Cigna Local Plus",,218.76,53.5,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035473060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1641.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM LCP STAINLESS STEEL LONG THREAD LONG",SUP-207.726,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,707.23,68,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 15.2CM .045IN KIRSCHNER STAINLESS STEEL BOTH",SUP-00018607400,CDM,C1713,HCPCS,0278,RC,,,both,,,119.63,35.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,81.35,68,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION FATHOM 155CM 180CM 2.4-3FR .021IN MICRO",SUP-M001195620,CDM,C1887,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"MULTIPLAN [10600]",Multiplan,,6158.25,85,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 5MM TRAUMAONE MANDIBLE SELF DRILL CROSS DRIVE",SUP-41-2205,CDM,C1713,HCPCS,0278,RC,,,both,,,664.20,199.26,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,190.09,28.62,,,,,0,77.25,564.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY CHORDAL GUIDE DURAN ANCORE",SUP-620RG25,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"MULTIPLAN [10600]",Multiplan,,11143.5,85,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Sclp/Ax/Tr/Ext 7.6-12.5int",PX-450000033,CDM,12034,CPT,0450,RC,,,both,,,1661.00,498.3,"AETNA [10100]","Aetna HMO/PPO",,1320.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.13,1661,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP CLUSTER HOLE SNAP FIT INTEGRATED",SUP-00875705201,CDM,C1776,HCPCS,0278,RC,,,both,,,11012.40,3303.72,"UHC [10700]","United Healthcare",,6970.85,63.3,,8601.07,8395.67,8601.07,"1 through 10",1280.74,9360.54,"percent of total billed charges",
"EPIFIX MESH 3.5X3.5 CM",SUP-ES-3300,CDM,Q4186,HCPCS,0636,RC,,,both,,,8618.10,2585.43,"CIGNA [10200]","Cigna Local Plus",,406.44,,,,,,,406.44,7325.39,"fee schedule",
"PLATE BONE RIGID CONTOURABLE MESH LOW PROFILE 100X100MM",SUP-421.534S,CDM,C1713,HCPCS,0278,RC,,,both,,,13096.20,3928.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3748.13,28.62,,,,,0,1523.09,11131.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X22X10MM COROENT WIDE XL PEEK-OPTIMA LORDOTIC",SUP-6920855,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2815.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 120MM 1.5MM BALLOON DILATATION RAPID",SUP-47515120L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXCISOR BIOPSY FISCHER SMALL WIDE CONE",SUP-900-157,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.28,60.98,"MULTIPLAN [10600]",Multiplan,,172.79,85,,,,,0,23.64,172.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 135CM .035IN STRAIGHT SPRT",SUP-518-080,CDM,C1887,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 7.5MM 6FR VASCULAR NITINOL",SUP-S-75-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"NOVANET [10819]",Novanet,,6856.88,75,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC",964,MS-DRG,,,,,,,inpatient,,,59010.67,17703.2,"BLUE CROSS [10001]","Blue Cross PPO",,37835.37,,"Fee schedule rate ($37,835.37). Includes an add-on of $3,218.50 when RC 0681-0684 total amount is above $1.",,,,0,7561,38221.51,other,"IP DRG + TRAUMA Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cholesterol Body Fluid",PX-301000145,CDM,82465,CPT,0301,RC,,,both,,,120.00,36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4.57,,"Fee schedule rate ($4.57). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,102,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 26CM 7FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552430,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,816.39,68,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175250090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,154.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 10MM KNEE RIGHT E-PLUS EMPOWR 3D KNEE STERILE",SUP-342-10-708,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,776.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,762.35,5571.75,"percent of total billed charges",
"RELOAD STPLR 45X4.8MM DST SERIES TA TITANIUM THICK TISSUE",SUP-TA4548L,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.89,114.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,45.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.53,325.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Screening Clo Test",PX-306000060,CDM,87081,CPT,0306,RC,,,both,,,260.00,78,"NOVANET [10819]",Novanet,,195,75,,,,,0,0.01,221,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ VASCULAR STRAIGHT 260CM .025IN PTFE STAINLESS",SUP-G04047,CDM,C1769,HCPCS,0272,RC,,,both,,,165.21,49.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,19.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.21,140.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP BARDEX IC COMPLETE CARE",SUP-A300416A,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.07,41.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.06,117.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL LEAD RETRIEVAL ONE-TIE LEAD EXTRACTION COMPRESSION",SUP-G31929,CDM,S27200284,LOCAL,0272,RC,,,both,,,1639.25,491.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,673.73,41.1,,,,,0,190.64,1393.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROCKET IPC DRAINAGE KIT INCLUDES 2L BAG AND DRESSING PACK",SUP-R51401H,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"MULTIPLAN [10600]",Multiplan,,310.59,85,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 4.5 MM HEADLESS SCR",SUP-P20-915-4500,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"UHC [10700]","United Healthcare",,635.79,63.3,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1.5 X 2.5 COMPLEX PICO COIL",SUP-10USC0152H,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5374.03,41.1,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL NAVISTAR 115CM 8FR 3.5MM FJ CURVE",SUP-D132704,CDM,C1732,HCPCS,0272,RC,,,both,,,19845.00,5953.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"STYLET LEAD 45CM .014IN SOFT LONG TAPER STERILE LATEX FREE",SUP-5012,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OCTARAY 2-5-2-5-2MM SPACE F CURVE ELECTROPHYSIOLOGY",SUP-D160905,CDM,C1732,HCPCS,0272,RC,,,both,,,15407.70,4622.31,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CARR GRAFT 8X3IN 3:1 DERMACARRIER II SKIN MESHER STERILE",SUP-00219501300,CDM,S27200284,LOCAL,0272,RC,,,both,,,215.33,64.6,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEALER/DIVIDER LAPAROSCOPIC 37CM 5MM LIGASURE XP MARYLAND",SUP-LXMJ37S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ALLIS 6IN TISSUE 4X5 TEETH STD PATTERN",SUP-50-0215,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.51,20.85,"CIGNA [10200]","Cigna Open Access",,39.55,56.9,,,,,0,8.08,59.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 20MM 144CM 4MM CORONARY STENT",SUP-H7493952820400,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"KAISER [10500]",Kaiser,,3728.55,67,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB CONGR 14MM LEFT .5",SUP-2041-0-1214,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,414.32,3028.13,"percent of total billed charges",
"DEVICE V-LOC 90 4-0 P-12 3/8 CIRCLE 58CM CLSR SURGALLOY",SUP-VLOCM0033,CDM,S27200284,LOCAL,0272,RC,,,both,,,262.83,78.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,30.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.57,223.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH R2P DESTINATION SLENDER 75CM 6FR GUIDING STERILE",SUP-GS-R6ST1C75W,CDM,C1894,HCPCS,0272,RC,,,both,,,2216.25,664.87,"AETNA [10100]","Aetna HMO/PPO",,1761.92,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,257.75,1883.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM EDWARDS SAPIEN 3 TRANSCATHETER ULTRA LOW",SUP-S3USTA123A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"FIRST HEALTH [10303]","First Health",,148200,80,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 5MM EMBOLD PLATINUM TUNGSTUN NITINOL",SUP-M001394240050150,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"NOVANET [10819]",Novanet,,5112.9,75,,,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA D KNEE LEFT 2 PEG TIVANIUM STERILE",SUP-42530006701,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"FIRST HEALTH [10303]","First Health",,11348.02,80,,,,,0,1649.72,12057.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM OASYS TITANIUM LOW PROFILE SPINE",SUP-48552312,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,563.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",563.19,4116.21,"percent of total billed charges",
"STENT SC530L COMPLETE SE LONG US 5 x 30 x 130",SUP-SC530LV,CDM,C1876,HCPCS,0278,RC,,,both,,,5347.50,1604.25,"AETNA [10100]","Aetna HMO/PPO",,4251.26,79.5,,,,,0,621.91,4545.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 13MM PRIMARY CEMENT SATIN FINISH VERSYS",SUP-785001300,CDM,C1776,HCPCS,0278,RC,,,both,,,18721.08,5616.32,"NOVANET [10819]",Novanet,,14040.81,75,,,,,0,2177.26,15912.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6.5FR 11CM MINI GWIRE AVANTI+ .038IN GREEN",SUP-504656X,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"NOVANET [10819]",Novanet,,58.73,75,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 14CM 3MM MR8 MATCH HEAD DIAMOND",SUP-MR8-14MH30D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1358.37,407.51,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MAJOR SMALL BOWEL PROCEDURES,MAJOR",230,APR-DRG,,,,,,,inpatient,,,152217.03,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $21,387.52. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($118,340.56) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 10X60 40CM SL",SUP-48010006P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 018 150CM 10CM 4MM BALLOON DILATATION",SUP-U8150410,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 5FR 11CM NO MINI GWIRE NO OBTR HEXCUSPID VALVE",SUP-504605A,CDM,C1894,HCPCS,0272,RC,,,both,,,72.65,21.79,"AETNA [10100]","Aetna HMO/PPO",,57.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.45,61.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR SILICONE RADIOPAQUE EXTERNAL RETENTION RING",SUP-8180-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.81,228.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,313.1,41.1,,,,,0,88.6,647.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 300MM 4MM BALLOON",SUP-U3575430,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 1.5IN 20GA INFUSION 2 LUMEN PORT LOW PROFILE SMALL",SUP-0682015,CDM,S27200284,LOCAL,0272,RC,,,both,,,45.68,13.7,"CIGNA [10200]","Cigna Open Access",,25.99,56.9,,,,,0,5.31,38.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM SOLERA CD HORIZON OSTEOGRIP TITANIUM COCR",SUP-54840004040,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AETNA [10100]","Aetna HMO/PPO",,7589.75,79.5,,1521.93,481.35,16760.95,30,1110.3,8114.82,"percent of total billed charges",
"HC Rv Tib/Prneal W Pta Cmplx Ea Add",PX-361000724,CDM,37283,CPT,0361,RC,,,both,,,6735.46,2020.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1249,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,6.74,6735.46,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VTC 25CM 12FR PIGTAIL CURVE NEPHRSTMY METAL",SUP-M001245280,CDM,C1729,HCPCS,0272,RC,,,both,,,729.00,218.7,"PHCS [10601]",PHCS,,510.3,70,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 30MM SOLERA COCR SPINAL MULTIAXIAL CANNULATED",SUP-54840004530,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AETNA [10100]","Aetna HMO/PPO",,7589.75,79.5,,1521.93,481.35,16760.95,30,1110.3,8114.82,"percent of total billed charges",
"SYSTEM FRONTIER ONYX 18MM 3.5MM CORONARY STENT LARGE VESSEL",SUP-ONYXNG35018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2662.50,798.75,"AETNA [10100]","Aetna HMO/PPO",,2116.69,79.5,,,,,0,309.65,2263.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 10MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-210-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"PHCS [10601]",PHCS,,8423.52,70,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLATE SET SCREW LOCKING NUT (STD SHORT)",SUP-2R1GN51650,CDM,C1713,HCPCS,0278,RC,,,both,,,756.22,226.87,"CIGNA [10200]","Cigna Local Plus",,404.58,53.5,,3978.14,359.25,3978.14,24,87.95,642.79,"percent of total billed charges",
"CATH ANGIOSCULPT XL 137CM 100MM 5MM RECTANGLE HELIX BALLOON",SUP-2237-50100,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TREK 145CM 20MM 2.75MM BALLOON DILATATION PEBAX",SUP-1012273-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 150CM 15CM 7MM BALLOON DILATATION OTW LOW",SUP-G30968,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FIBER LASER 2.6MR FLEXIVA PULSE TRACTIP 550UM HIGH POWER",SUP-M006L8405930,CDM,S27200284,LOCAL,0272,RC,,,both,,,3122.85,936.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ORTHOPEDIC 150MM 1.4MM",SUP-03.333.002,CDM,C1769,HCPCS,0272,RC,,,both,,,517.91,155.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NAIL 9MM 330MM TIBIAL TN ADVANCED INTRAMEDULLARY MR",SUP-04.043.130S,CDM,C1713,HCPCS,0278,RC,,,both,,,9579.13,2873.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1135.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1114.05,8142.26,"percent of total billed charges",
"HEAD FEMORAL -3MM OFFSET 28MM HIP MODULAR TYPE 1 BIOLOX",SUP-650-1159,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"CIGNA [10200]",Cigna,,6703.93,68,,5873.17,5873.17,5873.17,"1 through 10",1146.57,8379.91,"percent of total billed charges",
"INSRT TIBIAL 3 17.5MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158123117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"KAISER [10500]",Kaiser,,7486.95,67,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 4.5CM 18FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-18-4.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"UHC [10700]","United Healthcare",,493.14,63.3,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Biofdbk Train Any Method (Gn)",PX-440000001,CDM,90901,CPT,0440,RC,,,both,,,449.00,134.7,"UHC [10700]","United Healthcare",,331,,"Per diem ($331).",,,,0,52.22,426,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 30MM 154CM 7MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200073020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM ACIST NAVVUS TRNSDUC",SUP-014667,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1541.25,41.1,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 40MM 125CM 10MM 5FR VASCULAR NITINOL ILIAC",SUP-G43791,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"MULTIPLAN [10600]",Multiplan,,3552.15,85,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Corset Lumbar",PX-E27400002,CDM,E27400002,LOCAL,0274,RC,,,both,,,191.40,57.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,22.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT DELTA CSF REGULAR CONTOURED LOW PRESSURE STERILE",SUP-42322,CDM,S27800098,LOCAL,0278,RC,,,both,,,7576.75,2273.02,"PHCS [10601]",PHCS,,5303.73,70,,,,,0,881.18,6440.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +24.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.245,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (MR) 6MM X 3.25",SUP-H74939401063250,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"MULTIPLAN [10600]",Multiplan,,4604.03,85,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT  RAD GRACILIS 3X260 FZ",SUP-50R501,CDM,C1713,HCPCS,0278,RC,,,both,,,6537.75,1961.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,774.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,760.34,5557.09,"percent of total billed charges",
"CAP SYSTEM THR VIVACIT-E CERAMIC HIP STEM CUP LINER HEAD PRE",SUP-98000100021,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"PHCS [10601]",PHCS,,17640,70,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 20MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171030270,CDM,C1726,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PHCS [10601]",PHCS,,822.15,70,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 15MM 3.5MM BALLOON DILATATION STERILE",SUP-235-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anaplsma Phgcytophlm Amp Prb",PX-306000247,CDM,87468,CPT,0306,RC,,,both,,,744.80,223.44,"NOVANET [10819]",Novanet,,558.6,75,,,,,0,0.01,633.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 71MM STAINLESS STEEL LARGE FRAGMENT SET 5 HOLE",SUP-222.05,CDM,C1713,HCPCS,0278,RC,,,both,,,1340.87,402.26,"NOVANET [10819]",Novanet,,1005.65,75,,,,,0,155.94,1139.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 6MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR061002A,CDM,C1874,HCPCS,0278,RC,,,both,,,17545.50,5263.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2079.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2040.54,14913.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTED TOTAL KNEE SYSTEM INCLUDING CONSTRAINED WITH ON",SUP-98000200376,CDM,C1776,HCPCS,0278,RC,,,both,,,27090.00,8127,"CIGNA [10200]","Cigna Local Plus",,8533.35,31.5,,5372.07,4581.20,7242.98,23,3150.57,23026.5,"percent of total billed charges",
"LENS IOL 5 D +17.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-ZMA00U0175,CDM,V2632,HCPCS,0276,RC,,,both,,,6175.50,1852.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,731.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F301,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2031.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1993.39,14569.03,"percent of total billed charges",
"TRNSDUC PRESSURE 12IN MERITRANS 3 WAY STPCOCK FEMALE LUER",SUP-K11-00280,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"UHC [10700]","United Healthcare",,82.61,63.3,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SEROSAFUSE IMPLANTABLE FASTNER",SUP-R2275,CDM,S27800098,LOCAL,0278,RC,,,both,,,34618.50,10385.55,"FIRST HEALTH [10303]","First Health",,27694.8,80,,,,,0,4026.13,29425.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 74MM 13MM 5.4MM 14FR ZENITH SPIRAL-Z",SUP-G55232,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2509.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI MIRACLEBROS 6 PTCA GUIDE WIRE 180 CM",SUP-AG14M060,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,466.07,41.1,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEXGEN LPS-FLEX FIXED PROLONG ART SUR EF 3-412MM",SUP-596203212,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"BLUE CROSS [10001]","Blue Cross HMO",,3104.03,39.2,,5311.50,4717.44,5388.59,31,920.91,6730.67,"percent of total billed charges",
"SYSTEM CRYO/CUFF XLONG 42-54IN COMPRESSION THERAPY SHOULDER",SUP-12AXL01,CDM,S27200284,LOCAL,0272,RC,,,both,,,317.81,95.34,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.96,270.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL 4.6 X 300MM CANNULATED 3/16  SQ. CONNECTION",SUP-P99-110-4630,CDM,S27000186,LOCAL,0270,RC,,,both,,,2085.00,625.5,"FIRST HEALTH [10303]","First Health",,1668,80,,,,,0,242.49,1772.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 8MM 144CM 2.5MM CORONARY STENT",SUP-H7493952808250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Local Plus",,2977.28,53.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 36MM COMPREHENSIVE STD SHOULDER VIVACIT-E",SUP-110031424,CDM,C1776,HCPCS,0278,RC,,,both,,,7755.60,2326.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5273.81,68,,,,,0,901.98,6592.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 8FR PIGTAIL CURVE DRNG FLEXIMA BILIARY FLEXIBLE",SUP-M001271540,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.5/15",SUP-401745,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 0D F HIP X3 TRIDENT",SUP-723-00-36F,CDM,C1776,HCPCS,0278,RC,,,both,,,9332.25,2799.67,"CIGNA [10200]","Cigna Local Plus",,4992.75,53.5,,5372.07,4581.20,7242.98,23,1085.34,7932.41,"percent of total billed charges",
"GRAFT STENT 55MM 20MM 17FR AFX ACTIVESEAL STRATA STRAIGHT","SUP-I20-20/C55F SA",CDM,C1874,HCPCS,0278,RC,,,both,,,23373.00,7011.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9606.3,41.1,,,,,0,2718.28,19867.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 15IN 29FR VENOUS ADULT 3/8IN CNCT 3 STAGE",SUP-91429,CDM,S27200284,LOCAL,0272,RC,,,both,,,465.75,139.72,"CIGNA [10200]","Cigna Open Access",,265.01,56.9,,,,,0,54.17,395.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHIELD CONTAMINATION YELLOW 80CM TWISTLOCK CATH-GARD",SUP-ST-09875,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.71,33.51,"FIRST HEALTH [10303]","First Health",,89.37,80,,,,,0,12.99,94.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 7 SLOT LEFT TI",SUP-PHPF-C7L,CDM,C1713,HCPCS,0278,RC,,,both,,,20664.00,6199.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5579.28,27,,,,,0,2403.22,17564.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2MM 150MM KIRSCHNER STAINLESS STEEL SET TROCAR",SUP-71161020,CDM,C1713,HCPCS,0278,RC,,,both,,,65.09,19.53,"BLUE CROSS [10001]","Blue Cross HMO",,25.52,39.2,,957.42,156.86,7483.26,51,7.57,55.33,"percent of total billed charges",
"STENT GORE VIABAHN 29MM 80CM 5MM 8MM 7FR .035IN",SUP-BXA052901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"MULTIPLAN [10600]",Multiplan,,16579.08,85,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC 10IN COTTON FOAM SMALL SHOULDER HUMERAL",SUP-79-97953,CDM,S27000186,LOCAL,0270,RC,,,both,,,512.49,153.75,"CIGNA [10200]","Cigna Open Access",,291.61,56.9,,,,,0,59.6,435.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 25CM 8FR PIGTAIL CURVE NEPHRSTMY FLEXIMA POLYURETHANE",SUP-M001271790,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,MODERATE",198,APR-DRG,,,,,,,inpatient,,,33713.45,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488.00. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.20. DRG Reimbursement is equal to $3,804.55. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%.",,,,0,,,other,"SOI-2 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE,MODERATE",140,APR-DRG,,,,,,,inpatient,,,23679.89,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,697.77. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"GASTROINTESTINAL HEMORRHAGE WITH CC",378,MS-DRG,,,,,,,inpatient,,,37226.65,11167.99,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 100MM 3.5MM BALLOON DILATATION RAPID",SUP-47535100S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP COLONOSCOPE BLUE 11MM ENDOCUFF VISION MEDIUM PLASTIC 1",SUP-ARV110,CDM,S27200284,LOCAL,0272,RC,,,both,,,216.11,64.83,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN AMPLATZ",SUP-67004400,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOLDER TUBE MINI PURPLE NEOBAR ENDOTRACHEAL GENTLE",SUP-N709-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,135.02,40.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOFT-VU 100CM 5FR OMNI FLUSH CURVE ANGIOGRAPHIC",SUP-H787107322055,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER",RX-41142,CDM,,,0250,RC,00597-0087-17,NDC,both,12.9,GR,1852.07,555.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT PRESSURE MNTR 3 WAY STPCOCK TRNSDUC 3 FLUSH DEVICE",SUP-PX3X3272,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOR BLADDER PROCEDURES WITH CC",663,MS-DRG,,,,,,,inpatient,,,75418.74,22625.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,24237.66,,,,,,,9429.89,44383.76,"case rate",
"FILLER BONE VOID DBX ALLOGRAFT FREEZE DRIED MIX 5CC",SUP-058050,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SENSOR DUAL-FLEX 22CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175261120,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,904.58,68,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR BENTSON 22CM 15CM 6FR .035IN STRAIGHT URETERAL",SUP-M006180221060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"CIGNA [10200]","Cigna Local Plus",,533.63,,,,,,,116,847.82,"percent of total billed charges",
"EPIFIX 2X2 CM ""Q"" CODED",SUP-GS-5220,CDM,Q4186,HCPCS,0636,RC,,,both,,,6803.40,2041.02,"CIGNA [10200]","Cigna Local Plus",,406.44,,,,,,,406.44,5782.89,"fee schedule",
"GRAFTON PUTTY 2CC",SUP-T43103,CDM,S27800098,LOCAL,0278,RC,,,both,,,2499.00,749.7,"BLUE CROSS [10001]","Blue Cross HMO",,979.61,39.2,,,,,0,290.63,2124.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP 5 SCR HOLE CLUSTER METAL HA",SUP-502-11-56F,CDM,C1776,HCPCS,0278,RC,,,both,,,9525.45,2857.63,"FIRST HEALTH [10303]","First Health",,7620.36,80,,,,,0,1107.81,8096.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 28MM 140CM 4MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927428400,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"NOVANET [10819]",Novanet,,2812.5,75,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 8 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022218,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"CIGNA [10200]","Cigna Open Access",,5568.4,33.5,,5302.19,4377.88,6578.61,27,1933.15,14128.79,"percent of total billed charges",
"NDL BRACHYTHERAPY 20CM 17GA APPLR SEED ULTRA SHARP TIP",SUP-917205,CDM,C1715,HCPCS,0272,RC,,,both,,,159.04,47.71,"KAISER [10500]",Kaiser,,106.56,67,,,,,0,18.5,135.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 12 STD OFFSET HIP",SUP-71935572,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9864.1,27,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 142MM 11MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-104110,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2868.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2814.85,20572.84,"percent of total billed charges",
"SCR BONE 2MM 12MM BABY GORILLA LOCK",SUP-P50-053-2012,CDM,C1713,HCPCS,0278,RC,,,both,,,1316.25,394.87,"MULTIPLAN [10600]",Multiplan,,1118.81,85,,,,,0,153.08,1118.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TRANSEND VASCULAR 205CM 2CM .014IN SCITANIUM ICE",SUP-M001468070,CDM,C1769,HCPCS,0272,RC,,,both,,,3942.52,1182.76,"PHCS [10601]",PHCS,,2759.76,70,,,,,0,458.52,3351.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 8MM MREYE PLATINUM FIBER 2 LOOP",SUP-G42463,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,567.27,68,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 80MM STAINLESS STEEL FULL THREAD FEMUR",SUP-208.472,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"NOVANET [10819]",Novanet,,1038.1,75,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.5X80MM LORDOSED ROD",SUP-30100-080,CDM,S27800098,LOCAL,0278,RC,,,both,,,1410.00,423,"BLUE CROSS [10001]","Blue Cross PPO",,552.72,39.2,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.00MM X 20MM  SCOREFLEX  NC",SUP-630-204-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE CAST 12.5IN 5IN LARGE NONSKID SOLE",SUP-SA901007,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.55,17.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.81,49.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 4-6 SMALL FEMALE BEIGE CANVAS RUBBER",SUP-2041-07,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.42,14.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19.49,41.1,,,,,0,5.51,40.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMANTADINE HCL 100 MG CAPSULE",RX-364,CDM,,,0637,RC,50268-0069-11,NDC,both,1,UN,17.52,5.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11.91,68,,,,,0,2.04,14.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM AVENIR FITMORE MULTIPOLAR STD THR CERAMIC BIPOLAR",SUP-98000100016,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross PPO",,4057.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"STENT CONTOUR ZIPWIRE 30CM 3CM 7FR .035IN STD PIGTAIL CURVE",SUP-M006180235190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 90CM 220MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939186252290,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L19 MM OD3.5 MM SPINE CERVICAL ANTERIOR SELF DRIL",SUP-18008119,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE WHISPER VIEW VASCULAR CS J CURVE EXTRA DISTAL SPRT",SUP-4639,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,771.12,68,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LEMAITRE 80CM 3FR 6MM .018IN C.2ML EMBOLECTOMY 1 LUMEN",SUP-E1651-38,CDM,C1757,HCPCS,0272,RC,,,both,,,963.90,289.17,"AETNA [10100]","Aetna HMO/PPO",,766.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 CT-2 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP332H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SUPIRA CATHETER",SUP-FG-03242,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE PROTECTION RIGID 8-13 MM NAIL STERILE",SUP-03.043.036S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1633.13,489.94,"KAISER [10500]",Kaiser,,1094.2,67,,,,,0,189.93,1388.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BIOPSY 9CM 20GA 19GA QUICK-CORE ECHOTIP 5.5CM SOFT",SUP-G27019,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 25 5/8IN 7FR 8FR SUPER ARROW-FLEX PERCUTANEOUS 3",SUP-CL-07765,CDM,C1894,HCPCS,0272,RC,,,both,,,875.61,262.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,103.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,101.83,744.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 32CM 15.5FR BIOFLO 2 VALVE SHEATH BASIC DIALYSIS",SUP-H965103028051,CDM,C1750,HCPCS,0278,RC,,,both,,,2137.50,641.25,"KAISER [10500]",Kaiser,,1432.13,67,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 11MM TITANIUM SPINAL SELF TAPPING VARIABLE",SUP-3125311,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,647.19,45.9,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 2.5MM 1ML SYR EMBOCUBE GELATIN 100MG",SUP-EC25100,CDM,S27800098,LOCAL,0278,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT MCCABE 14MM ANGLED SURGICAL",SUP-MB189R,CDM,S27000186,LOCAL,0270,RC,,,both,,,794.37,238.31,"FIRST HEALTH [10303]","First Health",,635.5,80,,,,,0,92.39,675.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thyroid Stim Immunoglobin",PX-301000415,CDM,84445,CPT,0301,RC,,,both,,,275.60,82.68,"UHC [10700]","United Healthcare",,45.77,,,,,,,0.01,234.26,"fee schedule",
"HC Ercp Bal Dil Ampulla/Bil Duc",PX-750000142,CDM,43277,CPT,0750,RC,,,both,,,5278.11,1583.43,"NOVANET [10819]",Novanet,,3958.58,75,,,,,0,613.84,5278.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Pta Sf Init",PX-361000704,CDM,37263,CPT,0361,RC,,,both,,,12247.10,3674.13,"CIGNA [10200]","Cigna Local Plus",,6044,,"Case rate ($6,044). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1424.34,10410.04,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sn Routine O&A",PX-551000010,CDM,G0493,HCPCS,0551,RC,,,outpatient,,,236.00,70.8,"MULTIPLAN [10600]",Multiplan,,200.6,85,,,,,0,158.12,200.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Hand 2v",PX-320000072,CDM,73120,CPT,0320,RC,,,both,,,529.21,158.76,"PHCS [10601]",PHCS,,370.45,70,,,,,0,37.14,449.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C-Reactive Protein",PX-302000014,CDM,86140,CPT,0302,RC,,,both,,,292.60,87.78,"KAISER [10500]",Kaiser,,196.04,67,,,,,0,0.29,248.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION",RX-7876,CDM,J3411,HCPCS,0636,RC,72603-0139-01,NDC,both,2,ML,85.27,25.58,"FIRST HEALTH [10303]","First Health",,68.22,80,,,,,0,4.24,72.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Strep a W Dir Optic Obv",PX-306000172,CDM,87880,CPT,0306,RC,,,both,,,240.35,72.1,"CIGNA [10200]","Cigna Local Plus",,36.37,,,,,,,8.12,204.3,"fee schedule",
"HC Collect Bld Est Cath Nos",PX-450000233,CDM,36592,CPT,0260,RC,,,both,,,365.69,109.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,365.69,,"Per diem ($558).",,,,0,42.53,365.69,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 30CM 3MM BALLOON DILATATION",SUP-U8150330,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ADPTR AEROSOL AEROGEN",SUP-AAA-2,CDM,S27000186,LOCAL,0270,RC,,,both,,,133.11,39.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL 7CM MR8 1MM BALL FINE GRIT DISSECTING DIAMOND",SUP-MR8-7BA10DF,CDM,S27200284,LOCAL,0272,RC,,,both,,,1142.51,342.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH Z-MED II 100CM 4CM 9FR 25MM BALLOON DILATATION",SUP-611769,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER 5.5MM ULTRAFRR STEALTH STERILE LATEX FREE",SUP-SDPS-C011,CDM,S27200284,LOCAL,0272,RC,,,both,,,1044.90,313.47,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEMOSTAT ABSORBABLE SURGICEL NU-KNIT LATEX FREE STERILE",SUP-1943S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1487.17,446.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNIFE OPHTHALMIC GREEN BEAVER OPTIMUM 15D STRAIGHT STAB",SUP-374891,CDM,S27200284,LOCAL,0272,RC,,,both,,,175.09,52.53,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE LARYNGOSCOPE SPECTRUM LOPRO 1 TITANIUM GLIDESCOPE DISP",SUP-0270-0876,CDM,S27200284,LOCAL,0272,RC,,,both,,,414.99,124.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOE POSTOPERATIVE 5-6.5 SMALL UNIVERSAL MALE SUEDE RUBBER",SUP-2007-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.43,23.23,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT MICROINTRODUCER 7CM 5FR MICROEZ STAINLESS STEEL GWIRE",SUP-0828950,CDM,C1894,HCPCS,0272,RC,,,both,,,455.54,136.66,"AETNA [10100]","Aetna HMO/PPO",,362.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.98,387.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 5MM BALL DISSECTING SYMMETRICAL",SUP-MR8-14BA50T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1495.26,448.58,"AETNA [10100]","Aetna HMO/PPO",,1188.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.9,1270.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 11MM 3FR GEMINI HELICAL URETERAL",SUP-M0063301120,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,175.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 6FR 55CM POWERPICC 3 LUMEN FULL MICROINTRODUCER",SUP-3386108,CDM,C1751,HCPCS,0272,RC,,,both,,,984.15,295.24,"UHC [10700]","United Healthcare",,622.97,63.3,,,,,0,114.46,836.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS04008,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]",Cigna,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 6.35MM TSRH-3D TITANIUM PREBENT PRECUT",SUP-8371050,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 14GA 11GA 22.1CM OSTEO-SITE STAINLESS STEEL",SUP-G36406,CDM,S27200284,LOCAL,0272,RC,,,both,,,931.50,279.45,"UHC [10700]","United Healthcare",,589.64,63.3,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX14MM VANGUARD ARCOM KNEE CRUCIATE RETAINING",SUP-183444,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"BLUE CROSS [10001]","Blue Cross HMO",,3073.19,39.2,,5311.50,4717.44,5388.59,31,911.77,6663.81,"percent of total billed charges",
"PUNCH 2.5MM STD HANDLE STERILE LATEX FREE DISPOSABLE AORTIC",SUP-APU425,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"CIGNA [10200]","Cigna Open Access",,164.99,56.9,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 17IN 21FR FEMUR ARTERY ADULT 3/8IN CNCT 1",SUP-96570-021,CDM,S27200284,LOCAL,0272,RC,,,both,,,2120.63,636.19,"MULTIPLAN [10600]",Multiplan,,1802.54,85,,,,,0,246.63,1802.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 28CM 8.5FR AMPLATZ RB PIGTAIL CURVE URETER AQ",SUP-G09711,CDM,C2625,HCPCS,0272,RC,,,both,,,1227.07,368.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,504.33,41.1,,,,,0,142.71,1043.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 75CM 4CM 6MM BALLOON DILATATION PERIPHERAL",SUP-CQ7564,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"AETNA [10100]","Aetna HMO/PPO",,1062.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 80MM 4FR 7MM .018IN BALLOON",SUP-PCP070080130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"KAISER [10500]",Kaiser,,824.9,67,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500005802,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6172.93,27,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM SOLERA COCR SPINAL MULTIAXIAL CANNULATED",SUP-54840006525,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1110.3,8114.82,"percent of total billed charges",
"CATH OPTA PRO 110CM 4CM 5FR 9MM 7.5MM BALLOON DILATATION",SUP-4199040L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR EXTERNAL FIXATION 170MM 5MM SCHANZ XLONG STAINLESS STEEL",SUP-294.55,CDM,C1713,HCPCS,0278,RC,,,both,,,609.53,182.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,279.77,45.9,,,,,0,70.89,518.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grad Compression Waist 30-40",PX-E27100016,CDM,A6540,HCPCS,0292,RC,,,both,,,630.30,189.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,259.05,41.1,,,,,0,73.3,535.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT CONTRACTURE SMALL FOOT ANKLE SOLE LATEX FREE FLEECE 7-9",SUP-4306B,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP LIMIT HOLE COLOR CODED OSSEOTI G7",SUP-110010243,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.7MM 85MM 18MM LOW PROFILE SCREWS TITANIUM 3.5MM",SUP-AR-8967-1885,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,536.63,28.62,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 97MM CEMENT SUMMIT 2 12/14 STD OFFSET TAPER HIP",SUP-157003080,CDM,C1776,HCPCS,0278,RC,,,both,,,18219.60,5465.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2118.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2118.94,15486.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER NOVOSTITCH 0 MENISCAL MENISCAL SUT REPAIR SYSTEM",SUP-CTXA004,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) HEARTBEAM AIMIGO VECG DEVICE (W/ CHARGING CABLE AND DOC","SUP-SN A000112",CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 2-0 UCL 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z114H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,18.36,68,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 2IN 18GA 20GA PAJUNK SONOLONG TUOHY",SUP-TDL106,CDM,C9814,HCPCS,0272,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 12MM 140CM .91-1.12MM 2.25MM CORONARY",SUP-RONYX22512W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"BLUE CROSS [10001]","Blue Cross HMO",,1323,39.2,,9776.84,9776.84,9776.84,"1 through 10",392.51,2868.75,"percent of total billed charges",
"EXP TISSUE 535CC STERILE ARTOURA ULTRA HIGH PROFILE ROUND",SUP-TEXP120RUH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1631.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",1600.93,11700.68,"percent of total billed charges",
"CAP CEMENTED TOTAL KNEE SYSTEM INCLUDING CONSTRAINED WITH ON",SUP-98000200376,CDM,C1776,HCPCS,0278,RC,,,both,,,27090.00,8127,"CIGNA [10200]","Cigna Open Access",,9075.15,33.5,,5302.19,4377.88,6578.61,27,3150.57,23026.5,"percent of total billed charges",
"CATH CPS DIRECT SL II SITEMARK 50.7CM 47CM 9FR 7FR 135D",SUP-DS2C003,CDM,C1887,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"PHCS [10601]",PHCS,,2632.35,70,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 10CM 5FR 2 PIGTAIL CURVE TAPER BILIARY",SUP-G22122,CDM,C2625,HCPCS,0278,RC,,,both,,,1328.40,398.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,380.19,28.62,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 155MM 3.5MM PERI-LOC SHORT QUICK CONNECT STERILE",SUP-71173504,CDM,S27200284,LOCAL,0272,RC,,,both,,,1354.73,406.42,"NOVANET [10819]",Novanet,,1016.05,75,,,,,0,157.56,1151.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT LAPAROSCOPIC CURVE JAW CORDLESS ULTRASONIC",SUP-SCD7A48,CDM,S27200284,LOCAL,0272,RC,,,both,,,3112.50,933.75,"NOVANET [10819]",Novanet,,2334.38,75,,,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 7MM 7CM TWIST-IN 3 DAM SIDEPORT LUER LOCK",SUP-AR-6570TDNV,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"FIRST HEALTH [10303]","First Health",,233.86,80,,,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 74MM FENESTRATE CUFFLESS DISPOSABLE INNER CANN ROUND",SUP-6DCFN,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.84,87.85,"NOVANET [10819]",Novanet,,219.63,75,,,,,0,34.06,248.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM IV SOLUTION (0-30 MCI)",RX-123842,CDM,A9503,HCPCS,0343,RC,08888-8877-48,NDC,both,1,UN,298.45,89.53,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,125.7,,,,,,,15.15,253.68,"fee schedule",
"MATRIX TISSUE 16X8CM SURGIMEND PRS THK1MM SEMIOVAL BOVINE",SUP-606-004-103,CDM,C9358,HCPCS,0278,RC,,,both,,,12934.40,3880.32,"CIGNA [10200]","Cigna Open Access",,7359.67,56.9,,,,,0,12.93,10994.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Pelvis Complete",PX-402000027,CDM,76856,CPT,0402,RC,,,both,,,1238.23,371.47,"KAISER [10500]",Kaiser,,829.61,67,,,,,0,114.92,1052.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 180CM 40MM 4FR 2MM .018IN BALLOON",SUP-PCP020040180,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BREAST BIOPSY 5CM LOCALIZER 20 APPLR",SUP-09-0029,CDM,A4648,HCPCS,0278,RC,,,both,,,2055.00,616.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1397.4,68,,,,,0,239,1746.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6",SUP-ZCT225205,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,98.74,28.62,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sn Routine T&E",PX-551000011,CDM,G0495,HCPCS,0551,RC,,,outpatient,,,236.00,70.8,"MULTIPLAN [10600]",Multiplan,,200.6,85,,,,,0,158.12,200.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REFERENCE TOE 1ST MTP IMPLANT WITH GROMMETS  SIZE 2","SUP-M30 SE020",CDM,C1776,HCPCS,0278,RC,,,both,,,11937.00,3581.1,"BLUE CROSS [10001]","Blue Cross HMO",,4679.3,39.2,,5311.50,4717.44,5388.59,31,1388.27,10146.45,"percent of total billed charges",
"CATH ARMADA 35 135CM 60MM 8MM .035IN LOW PROFILE BALLOON",SUP-B2080-060,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"MULTIPLAN [10600]",Multiplan,,654.08,85,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 85MM STAINLESS STEEL 3.5MM SCREWS SMALL FRAGMENT SET 3",SUP-241.061,CDM,C1713,HCPCS,0278,RC,,,both,,,2429.70,728.91,"AETNA [10100]","Aetna HMO/PPO",,1931.61,79.5,,1521.93,481.35,16760.95,30,282.57,2065.25,"percent of total billed charges",
"SHUNT NEUROSURGICAL CSF 87CM LUMBOPERITONEAL CATH T STERILE",SUP-44520,CDM,S27800098,LOCAL,0278,RC,,,both,,,6715.22,2014.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,795.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,780.98,5707.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STATION DOCKING FOUR POSITION VERSION FOR NOVA STATSTRIP GLU",SUP-53402,CDM,S27000186,LOCAL,0270,RC,,,both,,,8280.00,2484,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3403.08,41.1,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEMORAL VANGUARD 360 2.5MM OFFSET KNEE REVISION SYSTEM",SUP-185210,CDM,C1776,HCPCS,0278,RC,,,both,,,5978.16,1793.45,"FIRST HEALTH [10303]","First Health",,4782.53,80,,,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STEERABLEBALLOON CA",SUP-ARC10SB-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,18270.00,5481,"CIGNA [10200]",Cigna,,12423.6,68,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER CAPIO TAPERCUT 0 36IN 2 ARM MONOFILAMENT",SUP-M0068331141,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ETHAMBUTOL 400 MG TABLET",RX-9983,CDM,,,0637,RC,68084-0280-11,NDC,both,1,UN,8.17,2.45,"KAISER [10500]",Kaiser,,5.47,67,,,,,0,0.95,6.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM TITANIUM CORTICAL",SUP-PANL-35280-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,899.10,269.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,106.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,104.57,764.24,"percent of total billed charges",
"SPRT 42-44IN 2XL PAD SHOULDER STRAP REMOVABLE DRAIN BULB",SUP-46518-05LF,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 14CM 150CM 5FR .038IN 3CM BLADDER LOOP",SUP-M006155213170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,406.5,28.62,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMB TUBE 520MM REAMER IRR ASPIR DRIVE SHAFT",SUP-314.746S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3089.55,926.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1418.1,45.9,,,,,0,359.31,2626.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL GENESIS II 6 RIGHT KNEE CEMENT TITANIUM",SUP-71420188,CDM,C1776,HCPCS,0278,RC,,,both,,,14593.50,4378.05,"CIGNA [10200]",Cigna,,5837.4,40,,5873.17,5873.17,5873.17,"1 through 10",1697.22,12404.48,"percent of total billed charges",
"SIZER IMPL 12CM MEMORYGEL BOOST P4.1CM MODERATE PLUS PROFILE",SUP-RSZMPB340S,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT WALLFLEX 6CM 230CM 25-30",SUP-6504,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"KAISER [10500]",Kaiser,,204.02,67,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL COALITION AGX 0 D D10.5 MM W18 MM X H7 MM NONS",SUP-3128.1507,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN FULL LENGTH RIGHT CORONARY BYPASS",SUP-H749085261902,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]","Cigna Open Access",,43.57,56.9,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL 5MM LEGION 5 KNEE SCR",SUP-71421664,CDM,C1776,HCPCS,0278,RC,,,both,,,11995.65,3598.69,"BLUE CROSS [10001]","Blue Cross PPO",,4702.29,39.2,,3949.44,3949.44,3949.44,"1 through 10",1395.09,10196.3,"percent of total billed charges",
"CABLE 22-PIN SENSOR ENABLED DIAGNOSTIC CATHETER CABLE",SUP-D-AVSE-CBL22,CDM,S27000186,LOCAL,0270,RC,,,both,,,2362.50,708.75,"PHCS [10601]",PHCS,,1653.75,70,,,,,0,274.76,2008.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LANTERN 135CM .025IN MICRO DELIVERY SYSTEM HIGH FLOW",SUP-PXSLIMLAN135STR,CDM,S27200284,LOCAL,0272,RC,,,both,,,4071.00,1221.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1868.59,45.9,,,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL 6MM LAMINA",SUP-7756074,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 45D HOOK 8.5IN 3/32IN STERILE EDGE",SUP-E1511,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.38,44.21,"KAISER [10500]",Kaiser,,98.74,67,,,,,0,17.14,125.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 100CM 5FR NEWT3 CURVE ANGIOGRAPHIC STAINLESS",SUP-510038N3,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"AETNA [10100]","Aetna HMO/PPO",,83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 109MM COLLAR ACTIS DUOFIX 7 12/14 HIGH OFFSET",SUP-101012070,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"PHCS [10601]",PHCS,,21333.38,70,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 4.75MM CD HORIZON SOLERA COCRMO CAP",SUP-641003070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"BLADE SAW 80X25.4MM THK1.3MM LONG WIDE STAINLESS STEEL",SUP-2108118,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 5MM LEIBINGER UNIVERSAL 2 TITANIUM",SUP-5020405,CDM,C1713,HCPCS,0278,RC,,,both,,,458.02,137.41,"CIGNA [10200]","Cigna Local Plus",,245.04,53.5,,3978.14,359.25,3978.14,24,53.27,389.32,"percent of total billed charges",
"GRAFT SKIN 4X4CM ALLOPATCH THK.4-.8MM THIN ACELLULAR DERMIS",SUP-WC0404,CDM,Q4128,HCPCS,0636,RC,,,both,,,5871.28,1761.38,"PHCS [10601]",PHCS,,4109.9,70,,,,,0,80.43,4990.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 15MM 9.4MM 6.5MM SHILEY TAPERGUARD ADULT FLEXIBLE",SUP-4CN65A,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.97,110.09,"CIGNA [10200]","Cigna Local Plus",,196.33,53.5,,,,,0,42.68,311.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLARED SECUR-FIT HYDROXYAPATITE 6 HIP",SUP-S-2337-HF06,CDM,C1776,HCPCS,0278,RC,,,both,,,16482.96,4944.89,"CIGNA [10200]","Cigna Open Access",,5521.79,33.5,,5302.19,4377.88,6578.61,27,1916.97,14010.52,"percent of total billed charges",
"SET ADMIN 124IN 60 GTT SMALLBORE 13.1ML INTRAVENOUS",SUP-1194802,CDM,S27200284,LOCAL,0272,RC,,,both,,,199.49,59.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,81.99,41.1,,,,,0,23.2,169.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER TORQR 110CM 6FR 2-5-2MM SPACING JSN CURVE ELECTROPH",SUP-04122JMR,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"NOVANET [10819]",Novanet,,234.9,75,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 22CM 3CM 5FR .035IN",SUP-M006192121190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,948.76,68,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 120MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171081210,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veno Ext Bil Si",PX-320000130,CDM,75822,CPT,0320,RC,,,both,,,2582.46,774.74,"NOVANET [10819]",Novanet,,1936.85,75,,,,,0,102.91,2582.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 35MM RESURFACE GENESIS II",SUP-71420578,CDM,C1776,HCPCS,0278,RC,,,both,,,6344.55,1903.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,751.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,737.87,5392.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT FINGER SWANSON 1 METACARPOPHALANGEAL GROMMET HIGH",SUP-4700001,CDM,C1776,HCPCS,0278,RC,,,both,,,5733.90,1720.17,"KAISER [10500]",Kaiser,,3841.71,67,,,,,0,666.85,4873.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP 1CC 2MM ALLOGRAFT GRANULE",SUP-12600201,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",348.9,2550,"percent of total billed charges",
"CATH CHRG 75CM 30MM 5FR 7MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206070370,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FOGARTY 80CM 6FR 10MM EMBOLECTOMY ADHERENT CLOT",SUP-1408010,CDM,C1757,HCPCS,0272,RC,,,both,,,1763.85,529.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LIGHTNING FLASH CATHETER 100CM XTORQ + LIGHTNING FLASH ASPIR",SUP-LITNGFXT100H1,CDM,C1757,HCPCS,0272,RC,,,both,,,60795.00,18238.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH TREK 145CM 25MM 3.5MM BALLOON DILATATION PEBAX",SUP-1012276-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT ABSORB GT1 28MM 3.5MM CORONARY EVEROLIMUS ELUTING POLY",SUP-1235350-28,CDM,C1874,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]",Cigna,,5630.4,68,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 STD 12MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS4S12L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"UHC [10700]","United Healthcare",,6577.76,63.3,,8601.07,8395.67,8601.07,"1 through 10",1208.52,8832.69,"percent of total billed charges",
"TRNSDUC PRESSURE 12IN MERITRANS 3 WAY STPCOCK FEMALE LUER",SUP-K11-00280,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"KAISER [10500]",Kaiser,,87.44,67,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 9 KNEE CEMENT FIX BEARING STERILE",SUP-150670009,CDM,C1776,HCPCS,0278,RC,,,both,,,15487.05,4646.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6194.82,40,,,,,0,1801.14,13163.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 55MM TSRH OSTEOGRIP TITANIUM THIN SPINE",SUP-83555559,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"MULTIPLAN [10600]",Multiplan,,2187.9,85,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Foot 2v",PX-320000089,CDM,73620,CPT,0320,RC,,,both,,,463.91,139.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,53.77,,,,,,,33.47,394.32,"fee schedule",
"PLATE MINI STRAIGHT 1MM MAXILLOFACIAL 4 HOLE LOCK NEUTRAL",SUP-55-10504,CDM,C1713,HCPCS,0278,RC,,,both,,,723.57,217.07,"FIRST HEALTH [10303]","First Health",,578.86,80,,,,,0,84.15,615.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 40MM 9MM BALLOON",SUP-U3513094,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.5MM 22MM PARTIAL THREAD RADIUS DISTAL VOLAR",SUP-TP22000,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,501.92,45.9,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 300MM 2.5MM .018IN BALLOON",SUP-R51002530L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"PHCS [10601]",PHCS,,1744.32,70,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD 7753900 PRE-CUT 3.5MM X 100 CCM+",SUP-7753900,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"BLUE CROSS [10001]","Blue Cross PPO",,552.72,39.2,,957.42,570.23,957.42,28,163.98,1198.5,"percent of total billed charges",
"HC Hexagonal Phase Confirm Reflx",PX-305000070,CDM,85598,CPT,0305,RC,,,both,,,287.30,86.19,"CIGNA [10200]",Cigna,,39.56,,,,,,,0.01,244.21,"fee schedule",
"BLADE SAW 90X25X1.19MM SAGITTAL SYSTEM 6 STERILE",SUP-6125119090,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.60,90.48,"PHCS [10601]",PHCS,,211.12,70,,,,,0,35.08,256.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT ORTHOPEDIC 34MM ARCOS TROCHANTER LATERAL COCRMO MODULAR",SUP-11-302134,CDM,C1713,HCPCS,0278,RC,,,both,,,3906.78,1172.03,"KAISER [10500]",Kaiser,,2617.54,67,,,,,0,454.36,3320.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Leptospira Ab",PX-302000152,CDM,86720,CPT,0302,RC,,,both,,,394.25,118.27,"KAISER [10500]",Kaiser,,264.15,67,,,,,0,0.39,335.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 110CM 5FR 5MM SPACE ELECTROPHYSIOLOGY 4 PIN FIX",SUP-F5QF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,372.86,41.1,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH II SS10.5",SUP-398349,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE KYPHX KYPHON 3 BONE BIOPSY SPINE",SUP-F05A,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NANOCROSS 150CM 60MM 5MM .014IN BALLOON DILATATION",SUP-AB14W050060150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) ADAPTER CATHETER BARB FLUSHING",SUP-OTS01312,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EVERCROSS BEVEL 360 80CM 20MM 12MM .035IN BALLOON",SUP-AB35W12020080,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PERFORMA 125CM 5FR JL3.5 CURVE ANGIOGRAPHIC PEBAX",SUP-7521-53,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 6.5MM 40MM 15MM ES2 SPINE CANNULATED LOW PROFILE 6",SUP-482804640,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"S MEGATRON US MR 5.00 X 24MM",SUP-H7493942824500,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,722.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE LCP ANKLE FOOT STAINLESS STEEL 8 HOLE 2.4 MM SCR",SUP-249.678,CDM,C1713,HCPCS,0278,RC,,,both,,,2299.50,689.85,"MULTIPLAN [10600]",Multiplan,,1954.58,85,,,,,0,267.43,1954.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 53CM 5.3FR J ATRIAL TRANSVENOUS BIPOLAR TINED",SUP-4592-53,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,664.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 34MM 140CM .91-1.12MM 2.25MM CORONARY",SUP-RONYX22534W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"BLUE CROSS [10001]","Blue Cross HMO",,1323,39.2,,9776.84,9776.84,9776.84,"1 through 10",392.51,2868.75,"percent of total billed charges",
"RCC,SELF INFLAT, LONG,SMOOTH, MD, RIGID",SUP-RSR-M014S-L,CDM,S27200284,LOCAL,0272,RC,,,both,,,659.83,197.95,"NOVANET [10819]",Novanet,,494.87,75,,,,,0,76.74,560.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 90ML .5-5MM 80% CORTICAL 20% CANCELLOUS",SUP-400060,CDM,C1713,HCPCS,0278,RC,,,both,,,5938.83,1781.65,"CIGNA [10200]","Cigna Local Plus",,3177.27,53.5,,3978.14,359.25,3978.14,24,690.69,5048.01,"percent of total billed charges",
"3-0 STRATAFIX SPIRAL MONOCRYL PLUS DYED 23CM SH",SUP-SXMP1B452,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.59,67.08,"AETNA [10100]","Aetna HMO/PPO",,177.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26,190.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 6MM ANSPACH FLUTE BALL",SUP-LHD-6B-M,CDM,S27200284,LOCAL,0272,RC,,,both,,,578.34,173.5,"KAISER [10500]",Kaiser,,387.49,67,,,,,0,67.26,491.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X18X9MM TRANSCONTINENTAL 10D LORDOTIC",SUP-375.592,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"FIRST HEALTH [10303]","First Health",,19152,80,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 7X4CM AXIS TUTOPLAST DERMIS ALLOGRAFT",SUP-939247,CDM,C1762,HCPCS,0278,RC,,,both,,,10294.80,3088.44,"KAISER [10500]",Kaiser,,6897.52,67,,,,,0,1197.29,8750.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 STD 12MM KNEE LEFT CRUCIATE SUB EVOLUTION MP",SUP-EIS3S12L,CDM,C1776,HCPCS,0278,RC,,,both,,,7569.30,2270.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,896.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,880.31,6433.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .035IN 5FR 4MM 110CM 10CM PTA 2",SUP-4204000L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.7MM 18MM DISTAL VOLAR RADIUS FOSSA HIGH",SUP-HCLP-27180-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,957.42,156.86,7483.26,51,80.07,585.23,"percent of total billed charges",
"SENSOR NEONATE LNCS NEO-3 3FT OXIMETER ADHSV SPO2 STERILE",SUP-2604,CDM,S27000186,LOCAL,0270,RC,,,both,,,148.77,44.63,"UHC [10700]","United Healthcare",,94.17,63.3,,,,,0,17.3,126.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 90MM 230CM 22-27MM DUODENAL NITINOL DELIVERY",SUP-M00565020,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 240CM 5.5CM 7.5FR 6-8MM ESOPHAGEAL",SUP-M00558450,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,195.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",379.61,375.47,414.12,"1 through 10",191.78,1401.68,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX OTW CORONARY STENT  2.00 X 22MM",SUP-RONYX20022W,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,9776.84,9776.84,9776.84,"1 through 10",521.61,3812.25,"percent of total billed charges",
"HC Xr Optic Foramina",PX-320000012,CDM,70190,CPT,0320,RC,,,both,,,336.00,100.8,"CIGNA [10200]",Cigna,,59.25,,,,,,,0.34,285.6,"fee schedule",
"SUT MERSILENE SABRELOC 5-0 RD-1 18IN 2 ARM BRAID WHITE",SUP-746G,CDM,S27200284,LOCAL,0272,RC,,,both,,,168.40,50.52,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EVERCROSS CROSSTEC 80CM 30MM 10MM .035IN BALLOON",SUP-AB35W10030080,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT NEPHRSTMY 12FR 21GA NDL CATH DIL CONNECT TUBE 25CM VTC",SUP-M001245320,CDM,C1729,HCPCS,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG 10X4IN ANTIMICROBIAL BACK FILM MULTILAYER ABSORBENT",SUP-498450,CDM,S27200284,LOCAL,0272,RC,,,both,,,219.24,65.77,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE 105MM 13.3MM 8MM CUFFLESS DISTAL EXT EXTEND LENGTH SOFT",SUP-80XLTUD,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,56.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.44,412.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.35MM 100MM TFN-ADVANCED TITANIUM ALUMINUM",SUP-04.038.200S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,957.42,156.86,7483.26,51,434.96,3179,"percent of total billed charges",
"SUT EPTFE GORE-TEX CV-2 TH-26 48IN MONOFILAMENT DOUBLE ARM",SUP-2U02A,CDM,S27200284,LOCAL,0272,RC,,,both,,,284.20,85.26,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,33.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.05,241.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30MMX7MM CRESCENT LORDOTIC",SUP-293007,CDM,S27800098,LOCAL,0278,RC,,,both,,,24290.28,7287.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6951.88,28.62,,,,,0,2824.96,20646.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 28MMX8MMX20CM 22FR",SUP-TAC082820A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"PHCS [10601]",PHCS,,127680,70,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 65X61MM KNEE RIGHT CEMENTED CRUCIATE",SUP-960088,CDM,C1776,HCPCS,0278,RC,,,both,,,27588.96,8276.69,"NOVANET [10819]",Novanet,,20691.72,75,,,,,0,3208.6,23450.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT BIPOLAR HIP OSTEO",SUP-CAP-H-B-O,CDM,C1776,HCPCS,0278,RC,,,both,,,10660.50,3198.15,"UHC [10700]","United Healthcare",,6748.1,63.3,,8601.07,8395.67,8601.07,"1 through 10",1239.82,9061.43,"percent of total billed charges",
"SCR BONE 4MM 20MM LCP STAINLESS STEEL CORTICAL PERIARTICULAR",SUP-02.204.020,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,116.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",114.74,838.59,"percent of total billed charges",
"NAIL 10MM 340MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.055S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1471.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1444.25,10555.59,"percent of total billed charges",
"GRAFT BONE GRAFTON DEMINERALIZED BONE MATRIX 15CC LARGE",SUP-T44135,CDM,C1713,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"PHCS [10601]",PHCS,,6520.5,70,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EXTERNAL DRNG 14CM VENTRICULAR DISTAL CATH RIGHT ANGLE",SUP-823088,CDM,C1729,HCPCS,0272,RC,,,both,,,4870.09,1461.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,566.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,566.39,4139.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 38MM 2.7MM LCP CORTICAL FOREFOOT MIDFOOT STAINLESS",SUP-202.898,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"CIGNA [10200]","Cigna Open Access",,184.35,56.9,,1144.80,304.56,2275.09,66,37.68,275.39,"percent of total billed charges",
"SPACER SPINAL PLIF 17 DEGREE 7MM X 11MM X 28MM MOD-EX",SUP-1937128P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"UHC [10700]","United Healthcare",,21933.45,63.3,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUILD-A-BOOT (BARIATRIC SIZE)",SUP-BAB09B,CDM,S27000186,LOCAL,0270,RC,,,both,,,326.25,97.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,134.09,41.1,,,,,0,37.94,277.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG VALU-BAGS BUTT-FLAP 8MM UNIVERSAL U FRAME UROLOGY",SUP-CMS-999,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.10,21.03,"UHC [10700]","United Healthcare",,44.37,63.3,,,,,0,8.15,59.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC HOT BIOPSY ALLIGATOR JAW 230CM 2.8MM ENDOJAW",SUP-FD-210U,CDM,S27200284,LOCAL,0272,RC,,,both,,,152.27,45.68,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STELLAREX 135CM 80MM 6MM BALLOON DILATATION ENDURACOAT",SUP-AB35SX060080135,CDM,C2623,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT POLYESTER POLYDEK 1 KC-6 30IN BRAID GREEN NONABSORBABLE",SUP-69-546,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG 12X4IN ANTIMICROBIAL BACK FILM MULTILAYER ABSORBENT",SUP-498600,CDM,S27200284,LOCAL,0272,RC,,,both,,,250.56,75.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SMART ABLATE DISPOSABLE CABLES",SUP-M4900633,CDM,S27000186,LOCAL,0270,RC,,,both,,,3052.50,915.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PORT STRAIGHT RETRACTION 70MM MARS 26MM",SUP-632.467S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2880.00,864,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL ADSON .5 CURVE 7.25IN ARTERY SERRATE STD",SUP-16-4119,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.44,54.13,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CAGE SPINAL 16X14X8MM ENDOSKELETON TCS 6D MEDIUM LORDOTIC",SUP-5366-1408,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"BLUE CROSS [10001]","Blue Cross PPO",,7056,39.2,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DILATOR LACHRYMAL 40X.64MM MNK MN 2MM",SUP-SI-1500,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 4MM 7FR 1-7-4MM SPACING B CURVE ABLATION",SUP-NS7TCBL174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"UHC [10700]","United Healthcare",,8691.72,63.3,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL TAPERFILL 13 STD OFFSET HIP STERILE LATEX FREE",SUP-425-96-013,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"BLUE CROSS [10001]","Blue Cross HMO",,5409.6,39.2,,5311.50,4717.44,5388.59,31,1604.94,11730,"percent of total billed charges",
"STEM FEMORAL 167MM 12MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-212,CDM,C1776,HCPCS,0278,RC,,,both,,,19885.95,5965.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2356.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2312.74,16903.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemdnr Nrv Muscle Facial Trig",PX-761000055,CDM,64615,CPT,0761,RC,,,both,,,2899.73,869.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,343.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,337.24,2740.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX OTW CORONARY STENT  2.00 X 22MM",SUP-RONYX20022W,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 7FR .081IN MULTIPURPOSE 1 CURVE GUIDING NYLON",SUP-LA7MP1,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"FIRST HEALTH [10303]","First Health",,313.2,80,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BTTRY SURGICAL DRIVER PACK STERILE DISPOSABLE BTTRY POWERED",SUP-05.000.007.01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3829.50,1148.85,"CIGNA [10200]",Cigna,,2604.06,68,,,,,0,445.37,3255.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD LARGE TSRH TITANIUM SPINAL 3DX",SUP-8351522,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1110.3,8114.82,"percent of total billed charges",
"STENT COVERA 60MM 80CM 9MM 8FR STRAIGHT VASCULAR",SUP-AVSM09060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2124.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061802210,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]",Cigna,,613.48,68,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM FULL THREAD HEALICOIL ULTRABRAID SHOULDER",SUP-72203704,CDM,C1713,HCPCS,0278,RC,,,both,,,2868.75,860.62,"BLUE CROSS [10001]","Blue Cross HMO",,1124.55,39.2,,957.42,156.86,7483.26,51,333.64,2438.44,"percent of total billed charges",
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,,,0637,RC,77333-0938-25,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SENSOR BED 32X12.5IN POSEY 6 MONTH 1 RESIDENT PAD OVER MATRS",SUP-8307,CDM,S27000186,LOCAL,0270,RC,,,both,,,223.33,67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOLDER TUBE MACRO PEACH NEOBAR ENDOTRACHEAL GENTLE",SUP-602-N715F-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.02,40.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPO 100CM 5FR .045IN AMPLATZ RIGHT 2 CURVE",SUP-H74908526862,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS POWERFLEX P3 80CM 20MM 5FR 10MM 7.5MM BALLOON",SUP-4200020S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 45MM 1MM CARBIDE CROSS CUT FISSURE FAST",SUP-0277-010-062,CDM,S27000186,LOCAL,0270,RC,,,both,,,262.31,78.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CAP: BIPOLAR HIP Z1 STEM / CERAMIC HEAD",SUP-98000100276,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"PHCS [10601]",PHCS,,7245,70,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC",267,MS-DRG,,,,,,,inpatient,,,289642.88,86892.86,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,30417.48,,"Case rate ($29,531.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $27,422.03, add-ons for qualifying new technology services are included. If operating cost exceeds $60,461.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,455.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $27,458.29. The transfer operating threshold is the transfer adjustment factor * $27,422.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,073.24. The transfer capital threshold is the transfer adjustment factor * $2,073.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.",,,,0,7561,138996.32,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135CM 40MM 8MM .035IN LOW PROFILE BALLOON",SUP-B2080-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4635,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,,1521.93,481.35,16760.95,30,348.9,2550,"percent of total billed charges",
"LENS IOL 10 D +15.5 DIOPTER 13MM 6MM POSTERIOR CHMBR 3 PIECE",SUP-Z900200155,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,468.46,45.9,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 100MM 12MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U12100090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1203.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE LARGE MALE",SUP-100611-040,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.99,17.7,"CIGNA [10200]",Cigna,,40.11,68,,,,,0,6.86,50.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2 MMM 5MM SPINE STERILE LATEX FREE CENTERPIECE",SUP-8532065,CDM,C1713,HCPCS,0278,RC,,,both,,,443.23,132.97,"CIGNA [10200]",Cigna,,301.4,68,,1831.33,1831.33,1831.33,16,51.55,376.75,"percent of total billed charges",
"SUT NYLON DEKLENE II 5-0 XT-1 36IN MONOFILAMENT DOUBLE ARM",SUP-D-7061A,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.90,36.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL ADSON 120MM TISSUE 1X2 TEETH DELICATE SERRATE",SUP-MG275R,CDM,S27200284,LOCAL,0272,RC,,,both,,,309.72,92.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN NASAL NASAL INTERFACE BLENDER TRANSITION KIT OPTIFLOW",SUP-OJR416B,CDM,S27000186,LOCAL,0270,RC,,,both,,,520.02,156.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CMPNT FEMORAL 7 KNEE RIGHT MEDIAL LEFT LATERAL RESTORIS",SUP-180517,CDM,C1776,HCPCS,0278,RC,,,both,,,12440.70,3732.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4976.28,40,,,,,0,1446.85,10574.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2-0 RB-1 36IN 2 ARM MONOFILAMENT BLUE",SUP-8559H,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.76,19.13,"FIRST HEALTH [10303]","First Health",,51.01,80,,,,,0,7.42,54.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 11MM",SUP-9790915,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1815.99,45.9,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 7CM MR8 4MM BALL DISSECTING CARBIDE",SUP-MR8-7BA40C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1089.86,326.96,"UHC [10700]","United Healthcare",,689.88,63.3,,,,,0,126.75,926.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 50.8MM 1.5MM MEDIUM 6 FLUTE ROUND STRYKER",SUP-5300010503,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.08,49.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,112.93,68,,,,,0,19.32,141.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 23MM MITRAL TRICUSPID FULL FLEXIBLE BAND",SUP-700FF23,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1524.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 16MM CORE ALLOGRAFT CM2",SUP-PS60014,CDM,C1713,HCPCS,0278,RC,,,both,,,3341.25,1002.37,"FIRST HEALTH [10303]","First Health",,2673,80,,,,,0,388.59,2840.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 8.25IN OLSEN MIDAS TOUCH BAYONET",SUP-20-1440IMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,919.32,275.8,"UHC [10700]","United Healthcare",,581.93,63.3,,,,,0,106.92,781.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC RIGHT ATRIUM RIGHT VENTRICLE DR TYPE IS-1 DF-1",SUP-D013,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16670.16,41.1,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS HONOR METAL GWIRE INSRT TOOL TORQUE DEVICE",SUP-MAP302,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.63,64.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,88.21,41.1,,,,,0,24.96,182.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE PT VASCULAR 182CM .014IN STAINLESS STEEL",SUP-H7491216001J2,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"KAISER [10500]",Kaiser,,379.89,67,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 16MM 25MM 23MM EPIC LINX SUPRA BIOPROSTHESIS",SUP-E100-25A-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,36722.70,11016.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4351.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4270.85,31214.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PEEK-OPTIMA 15MM 5MM RADIOLUCENT G-FORCE",SUP-86PS0515,CDM,C1713,HCPCS,0278,RC,,,both,,,3037.50,911.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1394.21,45.9,,,,,0,353.26,2581.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL +12MM 44MM STD LATERAL OFFSET 160MM 18MM 13MM",SUP-563618,CDM,C1776,HCPCS,0278,RC,,,both,,,11104.56,3331.37,"BLUE CROSS [10001]","Blue Cross PPO",,4352.99,39.2,,3949.44,3949.44,3949.44,"1 through 10",1291.46,9438.88,"percent of total billed charges",
"STEM HUMERAL 10MM UNIVERS APEX OPTIFIT",SUP-AR-9100-10M,CDM,C1776,HCPCS,0278,RC,,,both,,,26302.50,7890.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7527.78,28.62,,,,,0,3058.98,22357.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22.5 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6",SUP-ZCT225225,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"NOVANET [10819]",Novanet,,258.75,75,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X15MM 9/11MM SPINE CORTICAL FROZEN DISTAL",SUP-4915,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"KAISER [10500]",Kaiser,,11095.2,67,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE PACING S-101",SUP-6697,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.20,15.66,"CIGNA [10200]",Cigna,,35.5,68,,,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C02 Membrane Diffuse Capacity",PX-460000013,CDM,94729,CPT,0460,RC,,,both,,,849.77,254.93,"MULTIPLAN [10600]",Multiplan,,722.3,85,,,,,0,98.83,722.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 60MM 800MM 14MM VASCULAR VENOUS",SUP-VENUM14060,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"PHCS [10601]",PHCS,,15435,70,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 6X9X6MM ARCH 7.5D SPINE FREEZE DRY NOTCH",SUP-015206,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 20MM 4MM BALLOON DILATATION STERILE",SUP-240-203-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +12 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.120,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE POLY L LACTIC ACID 28MM 7MM FULL THREAD ACL",SUP-AR-1370TB,CDM,C1713,HCPCS,0278,RC,,,both,,,1207.71,362.31,"FIRST HEALTH [10303]","First Health",,966.17,80,,,,,0,140.46,1026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPN NC 20MM 3MM 35 ATM BALLOON DILATATION THIN WALL LOW",SUP-300-020-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"AMERIGROUP MEDICAID [20100]",Amerigroup,,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 28CM 7FR URETERAL FIRM",SUP-M0061456530,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,74.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 180CM 150MM 4FR 2MM .018IN BALLOON",SUP-PCP020150180,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE RIB SEG THK1-20MM ALLOGRAFT FREEZE DRIED 50-130",SUP-400650,CDM,S27800098,LOCAL,0278,RC,,,both,,,3604.50,1081.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,427.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,419.2,3063.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 54MM TITANIUM 3 LEVEL ASSURE BONE SPINE CERVICAL",SUP-110.354,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"AETNA [10100]","Aetna HMO/PPO",,4207.14,79.5,,1521.93,481.35,16760.95,30,615.46,4498.2,"percent of total billed charges",
"SCR BONE 6.5MM 105MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.416,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"CIGNA [10200]","Cigna Local Plus",,740.51,53.5,,3978.14,359.25,3978.14,24,160.97,1176.51,"percent of total billed charges",
"CATH 35CM 14FR PIGTAIL CURVE DRNG FLEXIMA BILIARY REGULAR",SUP-M001271590,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION",RX-113540,CDM,,,0250,RC,51754-5001-01,NDC,both,50,ML,100.65,30.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46.2,45.9,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUITY WHISPER VIEW ES CS-J - EACH",SUP-664641-001,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"NOVANET [10819]",Novanet,,850.5,75,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL REVISION INSRT COMPREHENSIVE E1 SHORT SHOUL",SUP-98000900083,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"KAISER [10500]",Kaiser,,30391.2,67,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 9MM APTUS TITANIUM 6MM WRIST CORTICAL 2",SUP-A-5450.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"MULTIPLAN [10600]",Multiplan,,1370.12,85,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CREO SPINE POLYAXIAL PREASSEMBLE",SUP-5119.1642,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,3978.14,359.25,3978.14,24,441.36,3225.75,"percent of total billed charges",
"STEMLESS ANATOMIC PSI KIT (HUMERAL ONLY)",SUP-1235-7151-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"NOVANET [10819]",Novanet,,4528.13,75,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OSCILLATING LARGE 9.5MMX71MMX0.9MM",SUP-ZO-7277,CDM,S27200284,LOCAL,0272,RC,,,both,,,255.78,76.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.75,217.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC",166,MS-DRG,,,,,,,inpatient,,,100065.18,30019.55,"UHC [10700]","United Healthcare",,100065.18,,"Fee schedule rate ($109,125.89). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,100065.18,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD MONOPOLAR YELLOW 24FR UROLOGICAL CUTTING LOOP 1",SUP-27050G/6,CDM,S27200284,LOCAL,0272,RC,,,both,,,1097.98,329.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP SCIS ENDOCT",SUP-3142,CDM,S27200284,LOCAL,0272,RC,,,both,,,238.70,71.61,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BALSAM PERU-CASTOR OIL TOPICAL OINTMENT",RX-184845,CDM,,,0250,RC,58980-0780-21,NDC,both,56.7,GR,235.74,70.72,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE NEB ENGSTROM CARESTATION",SUP-15055602000,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.10,17.43,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) 20F DRYSEAL FLEX INTRODUCER SHEATH (GORE)",SUP-DSF2033,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CPS DIRECT« UPSIZED, WIDE 54CM-DS2C028",SUP-DS2C028,CDM,C1893,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRIVER PHP T10",SUP-DRVR-PHP-T10,CDM,S27000186,LOCAL,0270,RC,,,both,,,1539.00,461.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CBL PCNG CNCT DF4 MDTRNC SYS",SUP-4161,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH HI-FLO RENEGADE 105CM 10CM 3-2.8FR .027IN MICRO",SUP-M001182840,CDM,C1887,HCPCS,0272,RC,,,both,,,2100.00,630,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE NITREX VASCULAR 45D 260CM 15CM .035IN NITINOL TUNGSTEN",SUP-N352601,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VASCUTRAK 140CM 15CM 7FR 6MM .018IN BALLOON DILATATION",SUP-V1860150,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AIRWAY ESOPHAGEAL 1.5 STD 4MM 3MM PEDIATRIC LMA UNIQUE",SUP-125015,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.20,15.66,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP SMALL CHEVRON HEART INTERNAL WECK HEMOCLIP TANTALUM",SUP-523335,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.36,26.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PERFORMA 80CM 5FR HK3 MOD CURVE ANGIOGRAPHIC PEBAX",SUP-5585-E3,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"5.5MM TI CURVED ROD 65MM",SUP-04.636.065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW QUARTEX 3.5X18MM",SUP-1149.3518,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"BLUE CROSS [10001]","Blue Cross HMO",,1646.4,39.2,,957.42,156.86,7483.26,51,488.46,3570,"percent of total billed charges",
"DIL VASCULAR 20FR 20CM RADIOPAQUE STERILE DISPOSABLE STD",SUP-G01471,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.44,31.03,"KAISER [10500]",Kaiser,,69.3,67,,,,,0,12.03,87.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 8MM 32MM 3 PEG ONLAY ADVANCE ALL POLY KNEE",SUP-KPONTP32,CDM,C1776,HCPCS,0278,RC,,,both,,,4195.20,1258.56,"NOVANET [10819]",Novanet,,3146.4,75,,,,,0,487.9,3565.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 28CM 6FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251340,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"KAISER [10500]",Kaiser,,824.74,67,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 20IN 36FR STRAIGHT DRNG PVC THORACIC 6 EYELET FIRM",SUP-15036,CDM,C1729,HCPCS,0272,RC,,,both,,,60.26,18.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,24.77,41.1,,,,,0,7.01,51.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 10FT 2 SENSOR EXT REDEL 10 PIN CNCT MALE TO MALE",SUP-C10MRMSTKDTCS,CDM,S27000186,LOCAL,0270,RC,,,both,,,2115.00,634.5,"UHC [10700]","United Healthcare",,1338.8,63.3,,,,,0,245.97,1797.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIA MATRIX (4 X 6) 24 SQ CM",SUP-585-007,CDM,Q4309,HCPCS,0636,RC,,,both,,,171000.00,51300,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20263.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.92,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 11MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G111,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1012.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 150MM SCHANZ STAINLESS STEEL CONDYLAR HIP SELF",SUP-294.784,CDM,C1713,HCPCS,0278,RC,,,both,,,1042.88,312.86,"CIGNA [10200]","Cigna Local Plus",,557.94,53.5,,3978.14,359.25,3978.14,24,121.29,886.45,"percent of total billed charges",
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS,EXTREME",344,APR-DRG,,,,,,,inpatient,,,96792.06,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $12,175.71. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($123,831.26) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 30MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDS40030,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,23761.67,28.62,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR EXTRA THICK 45MM ENDO GIA ARTICULATING STERILE",SUP-SIG45AXT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1469.99,441,"AMERIGROUP MEDICAID [20100]",Amerigroup,,174.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,170.96,1249.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC .75CM 4.45X5.88CM ESSENTIO PACESAFE",SUP-L131,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4838.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET XL 360 SOFT 5MM X 15CM",SUP-M0036125150,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD 20CM 6FR DRNG FLEXIMA METAL HYDROPHILIC REGULAR",SUP-M001271280,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 10MM OLIF51 DIVERGENCE-L BONE SPINE",SUP-2150010,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2962.17,28.62,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH THERMOCOOL SF 115CM 8FR B-B CURVE ABLATION",SUP-BDI35BBRT,CDM,C2630,HCPCS,0272,RC,,,both,,,11350.50,3405.15,"UHC [10700]","United Healthcare",,7184.87,63.3,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 47CM 14MM PRESTIGE PLUS HELICAL COMPLEX 18",SUP-PRES1447COM18,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"NOVANET [10819]",Novanet,,5951.25,75,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROCKET IPC DRAINAGE KIT INCLUDES BOTTLE AND DRESSING PACK 10",SUP-R51411H,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 305CC P4.9CM MODERATE PLUS PROFILE TALL HEIGHT",SUP-334-1159,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross PPO",,3583.86,39.2,,16595.83,16595.83,16595.83,"1 through 10",1063.27,7771.13,"percent of total billed charges",
"HANDLE BTTRY SMART AA THERMAL PISTON HEAT DEVICE",SUP-70131012,CDM,S27000186,LOCAL,0270,RC,,,both,,,671.33,201.4,"CIGNA [10200]","Cigna Local Plus",,359.16,53.5,,,,,0,78.08,570.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE SMALL HEXAGON 240CMX13MM 2.4MM CAPTIVATOR STIFF",SUP-M00562451,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.33,36.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,49.87,41.1,,,,,0,14.11,103.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM KNEE 100MM 16/13MM ENDO-MODEL SL FEMALE TAPER MODULAR",SUP-15-8517/54,CDM,C1776,HCPCS,0278,RC,,,both,,,16271.03,4881.31,"BLUE CROSS [10001]","Blue Cross PPO",,6378.24,39.2,,3949.44,3949.44,3949.44,"1 through 10",1892.32,13830.38,"percent of total billed charges",
"STENT POLARIS 16CM 3CM 5FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155214050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"MULTIPLAN [10600]",Multiplan,,1046.32,85,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 11MM KNEE XLPE CRUCIATE RETAINING HIGH",SUP-71453112,CDM,C1776,HCPCS,0278,RC,,,both,,,15556.05,4666.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4452.14,28.62,,,,,0,1809.17,13222.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA 5D H KNEE LEFT CEMENT STEM TIVANIUM",SUP-42532008301,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"NOVANET [10819]",Novanet,,8200.31,75,,,,,0,1271.59,9293.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X22X7MM RISE-L NONSTERILE",SUP-193.404,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9270.45,27,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX10MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183520,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1534.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1506.4,11009.78,"percent of total billed charges",
"7F DUO-DECA 2-8-2 MPD-L 100CM",SUP-901685,CDM,C1731,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"NOVANET [10819]",Novanet,,5045.63,75,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Platelet Aggregation Ea",PX-305000055,CDM,85576,CPT,0305,RC,,,both,,,377.15,113.14,"BLUE CROSS [10001]","Blue Cross HMO",,31.94,,"Fee schedule rate ($31.94).",,,,0,10.19,320.58,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.5MM TI MULTILOC SCREW LENGTH 44MM-STERILE",SUP-04.019.044S,CDM,C1713,HCPCS,0278,RC,,,both,,,1747.20,524.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,801.96,45.9,,,,,0,203.2,1485.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP LIMIT HOLE MODULAR TITANIUM POROUS",SUP-PT-116048,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"PHCS [10601]",PHCS,,7143.57,70,,,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONTROL ACT HEPCON CLOTTRAC ABNORMAL HIGH RANGE VIAL",SUP-550-08,CDM,S27000186,LOCAL,0270,RC,,,both,,,62.81,18.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.3,53.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 32MM HIP C TAPER HIGH PERFORMANCE OFFSET",SUP-18-3205,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"MULTIPLAN [10600]",Multiplan,,8500,85,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR ANGLE 260CM 3CM .035IN HYDROPHILIC STIFF",SUP-LWSTFA35260EX,CDM,C1769,HCPCS,0272,RC,,,both,,,295.80,88.74,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,121.57,41.1,,,,,0,34.4,251.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 5MM COOLCUT FLUSHCUT 6 FLUTE OVAL",SUP-AR-8500FOS,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,381.7,68,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ILIAC CREST WEDGE (TRICORTICAL BLOCKS), (ACF), PARALLEL: 9MM",SUP-400404,CDM,S27800098,LOCAL,0278,RC,,,both,,,4173.12,1251.94,"BLUE CROSS [10001]","Blue Cross HMO",,1635.86,39.2,,,,,0,485.33,3547.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006175283190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"NOVANET [10819]",Novanet,,949.04,75,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX PROGRIP 5.5X3.5IN LEFT FLAP SELF FIX",SUP-TEM1409GL,CDM,C1781,HCPCS,0278,RC,,,both,,,1948.20,584.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,230.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,226.58,1655.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 19MM KNEE X3 BEARING CRUCIATE RETAIN",SUP-5530-G-719,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"AETNA [10100]","Aetna HMO/PPO",,9073.02,79.5,,10981.53,8986.79,12413.38,12,1327.29,9700.71,"percent of total billed charges",
"LINER ACETABULAR R3 20D 58MM 36MM XLPE HIP STERILE",SUP-71335758,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"CIGNA [10200]","Cigna Open Access",,6330.84,56.9,,5302.19,4377.88,6578.61,27,1293.98,9457.31,"percent of total billed charges",
"KIT PEG 12FR LIDOCAINE POVIDONE IODINE TRACTION REMOVABLE",SUP-50-6012,CDM,S27200284,LOCAL,0272,RC,,,both,,,973.42,292.03,"UHC [10700]","United Healthcare",,616.17,63.3,,,,,0,113.21,827.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERTORQUE THRULUMEN 100CM 6FR .079IN .051IN SMALL",SUP-532619,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"UHC [10700]","United Healthcare",,52.32,63.3,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Quadratus Lumborum (Ql) Block",PX-361000650,CDM,64999,CPT,0361,RC,,,both,,,2896.00,868.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,343.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,336.8,2896,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAFT SCRDRVR 100MM 3.5MM LARGE HEXAGONAL QUICK COUPLING",SUP-314.15,CDM,S27000186,LOCAL,0270,RC,,,both,,,726.57,217.97,"UHC [10700]","United Healthcare",,459.92,63.3,,,,,0,84.5,617.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 48MM 28MM ALTRX HIP STERI",SUP-122128148,CDM,C1776,HCPCS,0278,RC,,,both,,,9128.70,2738.61,"BLUE CROSS [10001]","Blue Cross PPO",,3578.45,39.2,,3949.44,3949.44,3949.44,"1 through 10",1061.67,7759.4,"percent of total billed charges",
"DRIVER NDL 31.50CM 8MM SUTURECUT ENDOWRIST DA VINCI XI 38D",SUP-471296,CDM,S27000186,LOCAL,0270,RC,,,both,,,1446.12,433.84,"AETNA [10100]","Aetna HMO/PPO",,1149.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.18,1229.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AERO 20MM 63CM 10MM 16FR GEOMETRIC TRACHEOBRONCHIAL",SUP-90129-207,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"NOVANET [10819]",Novanet,,12937.5,75,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 6FR .071IN JL4 CURVE GUIDING CORONARY",SUP-LA6JL40A,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dtap Vaccine < 7 Yrs Im",PX-771000015,CDM,90700,CPT,0636,RC,,,both,,,113.27,33.98,"KAISER [10500]",Kaiser,,75.89,67,,,,,0,13.42,96.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET .28IN 85IN 4 LEAD 3Y CNCT SIGHT CHMBR LARGE BORE",SUP-1523901,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.63,40.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,90.87,68,,,,,0,15.54,113.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOLUTION D 10 W 500ML",SUP-0793003,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.29,41.1,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS 4.5IN IRIS STRAIGHT SATIN FINISH SURGICAL STERILE",SUP-66450,CDM,S27200284,LOCAL,0272,RC,,,both,,,44.00,13.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,20.2,45.9,,,,,0,5.12,37.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER 6227DEF04 ATTAIN GLOBAL",SUP-6227DEF04,CDM,C1887,HCPCS,0272,RC,,,both,,,4830.00,1449,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HIWIRE SAFE-T-J VASCULAR STD TAPER 180CM 7CM .021IN",SUP-G01793,CDM,C1769,HCPCS,0272,RC,,,both,,,156.51,46.95,"NOVANET [10819]",Novanet,,117.38,75,,,,,0,18.2,133.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DRILL 1.5MM TENDON",SUP-72202189,CDM,C1769,HCPCS,0272,RC,,,both,,,1017.36,305.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,418.13,41.1,,,,,0,118.32,864.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Compres Band Comprilan W>=3""<5""/Yd",PX-E27000280,CDM,A6443,HCPCS,0270,RC,,,both,,,118.00,35.4,"MULTIPLAN [10600]",Multiplan,,100.3,85,,,,,0,0.28,100.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 9 STD OFFSET HIP",SUP-71935569,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,14613.48,40,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 25.4MM WHEEL DISSECTING",SUP-MR8-9MC254,CDM,S27200284,LOCAL,0272,RC,,,both,,,1416.29,424.89,"CIGNA [10200]","Cigna Local Plus",,757.72,53.5,,,,,0,164.71,1203.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 20MM 1.5MM BALLOON DILATATION RAPID",SUP-47515020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PREVAIL DCB 2.75X15MM",SUP-PRV027515CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 40MM 12MM BALLOON",SUP-U3575124,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MAJOR BLADDER PROCEDURES WITH CC",654,MS-DRG,,,,,,,inpatient,,,155565.33,46669.6,"CIGNA [10200]",Cigna,,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 55.9%. Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNGOSCOPE SPECTRUM LOPRO 4 GLIDESCOPE DISPOSABLE",SUP-0270-0939,CDM,S27200284,LOCAL,0272,RC,,,both,,,3000.00,900,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"4.00MM X 10MM  SCOREFLEX  NC",SUP-640-104-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STETH ESOPHAGEAL 9FR TEMPERATURE PROBE 400 SERIES DISPOSABLE",SUP-M1024205VY,CDM,S27200284,LOCAL,0272,RC,,,both,,,57.00,17.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RADPICC RADSTIC 70CM 3FR IV TUNGSTEN POLYURETHANE 1",SUP-3163155,CDM,C1751,HCPCS,0272,RC,,,both,,,379.32,113.8,"KAISER [10500]",Kaiser,,254.14,67,,,,,0,44.11,322.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 NARROW 8MM KNEE POSTERIOR STABILIZE IDENTITY",SUP-TPS-020-086N,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"CIGNA [10200]","Cigna Open Access",,3345.04,56.9,,5302.19,4377.88,6578.61,27,683.7,4996.98,"percent of total billed charges",
"ROD SPINAL 90MM 5.5MM CD HORIZON STRAIGHT COCR PRECUT",SUP-1555006090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"STENT EPIC 60MM 120CM 7MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200076020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]",Cigna,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 25MM PRIMARY HFX OMNIFIT 132D 6 HIP",SUP-6070-0625A,CDM,C1776,HCPCS,0278,RC,,,both,,,7894.95,2368.48,"CIGNA [10200]","Cigna Local Plus",,4223.8,53.5,,5372.07,4581.20,7242.98,23,918.18,6710.71,"percent of total billed charges",
"SCR INTERFERENCE BIOCOMPOSITE 35MM 11MM DELTA ACL CANNULATED",SUP-AR-5035TC-11,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"CIGNA [10200]","Cigna Open Access",,1053.01,56.9,,1144.80,304.56,2275.09,66,215.23,1573.04,"percent of total billed charges",
"SUT PROLENE 6-0 C-1 30IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8706,CDM,S27200284,LOCAL,0272,RC,,,both,,,562.13,168.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE STERNAL TITANIUM CUT EDGE NDL CRIMP STERILE",SUP-401-096,CDM,S27200284,LOCAL,0272,RC,,,both,,,4533.30,1359.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT ORTHOPEDIC SMALL 8IN WRIST LEFT BLACK",SUP-A120105,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.29,17.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 6FR 21GA 40CM 23CM MANDREL WIRE ANGLE FLOPPY",SUP-PID6F7018NTPD,CDM,C1894,HCPCS,0272,RC,,,both,,,535.49,160.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION",RX-27838,CDM,J3490,HCPCS,0258,RC,00264-5802-00,NDC,both,1000,ML,100.65,30.19,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"I-GEL, SINGLE USE SUPRAGLOTTIC AIRWAY, SIZE 1",SUP-8201000,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.13,23.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CENTRIFUGAL PLATELET RICH PLASMA PROCESS ANGEL",SUP-976000501,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1504.5,68,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC YELLOW 6MM 20GA VISITEC GRIZZARD STRAIGHT",SUP-585021,CDM,S27200284,LOCAL,0272,RC,,,both,,,140.77,42.23,"CIGNA [10200]","Cigna Local Plus",,75.31,53.5,,,,,0,16.37,119.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - TIBIAL KIT (PS) - SIZE 5",SUP-5555-2365,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 4IN 4FR 21GA MAK .018IN PLATINUM COIL TIP NITINOL",SUP-MAK401NEBT,CDM,C1894,HCPCS,0272,RC,,,both,,,250.56,75.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,102.98,41.1,,,,,0,29.14,212.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 60CM 7MM THORAX KNIT SOFT FLEXIBLE SEAL",SUP-M002020952070,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X12MM COROENT WIDE XL 100",SUP-6921250,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"PHCS [10601]",PHCS,,16632,70,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MERSILENE MULTIPASS 4-0 P-3 18IN BRAID WHITE",SUP-R691G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC",842,MS-DRG,,,,,,,inpatient,,,52367.36,15710.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16378.58,,"Fee schedule rate ($16,378.58). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,6267.57,25198.37,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 1 CT-1 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Y341H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 345241FZ L-ASR 12X14X11 FZ SRVCFE",SUP-345241FZ,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER FIRSTPASS ST SELF CAPTURE SUT",SUP-224038,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"CIGNA [10200]",Cigna,,1096.09,68,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +27 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.270,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,316.02,45.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 2.5MM20CM 190",SUP-R51002520L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"AETNA [10100]","Aetna HMO/PPO",,1981.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PROC 1 TRIATHLON CR DISPOSABLE TIBIAL",SUP-5555-2321,CDM,C1776,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPAT SURGICAL 7X5/8IN DAVIS BRAIN MALLEABLE",SUP-22-0063,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.11,41.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.95,116.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 60MM 80CM 9MM VASCULAR PERIPHERAL SELF",SUP-1012531-60,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP MONOPOLAR 32CM 5MM ACCU-SPIN MARYLAND 23MM CURVE",SUP-97-1067RC,CDM,S27200284,LOCAL,0272,RC,,,both,,,3590.03,1077.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL NERVE BLOCK 100MM 20G SONOPLEX II FACETT S TIP",SUP-001285-95,CDM,C9812,HCPCS,0272,RC,,,both,,,132.68,39.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH ZURPAZ .032IN MEDIUM SYMMETRIC CURVE 92CM 72CM 8.5FR",SUP-M004USMC85100,CDM,C1894,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ROPINIROLE 1 MG TABLET, IMMEDIATE RELEASE",RX-21689,CDM,,,0637,RC,00904-6374-61,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ORTHOPEDIC 1.45MM NITINOL BLUNT",SUP-286705320,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL 36CM CLEANCOAT PTFE DISPOSABLE WIRE",SUP-E3773-36C,CDM,S27200284,LOCAL,0272,RC,,,both,,,251.00,75.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE REAMER 26MM PILOT HOLE KNEE PATELLA STAINLESS STEEL",SUP-597909526,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.02,350.41,"CIGNA [10200]",Cigna,,794.25,68,,,,,0,135.84,992.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 42MM DARCO FULL THREAD HEAD",SUP-777404202,CDM,C1713,HCPCS,0278,RC,,,both,,,1695.00,508.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,197.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",197.13,1440.75,"percent of total billed charges",
"CANN NASAL PRONG RETENTION UNOBTRUSIVE PRONG OPTIFLOW",SUP-OJR410,CDM,S27000186,LOCAL,0270,RC,,,both,,,404.77,121.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,185.79,45.9,,,,,0,47.07,344.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOGA SURGICAL STERI-SHIELD XL HYTREL ZIPPER DISPOSABLE",SUP-400851000,CDM,S27000186,LOCAL,0270,RC,,,both,,,415.76,124.73,"CIGNA [10200]",Cigna,,282.72,68,,,,,0,48.35,353.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKAGED RADIAL STEM 9MM X -2MM",SUP-ALN-RST-09M2,CDM,C1776,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"PHCS [10601]",PHCS,,9954.63,70,,,,,0,1653.89,12087.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 7CM MR8 3MM BALL COARSE GRIT DISSECTING DIAMOND",SUP-MR8-7BA30DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1142.51,342.75,"FIRST HEALTH [10303]","First Health",,914.01,80,,,,,0,132.87,971.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 3 X 8 COMPLEX PICO COIL",SUP-10USC03008,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"UHC [10700]","United Healthcare",,8276.79,63.3,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 20X20IN RESORBABLE GRID 1",SUP-F10256-2020G,CDM,C1781,HCPCS,0278,RC,,,both,,,39463.20,11838.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10655.06,27,,,,,0,4589.57,33543.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 21.3IN 14FR SUCTION ADULT 2 SWIVEL ELBOW CLOSED",SUP-2276,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.24,44.77,"CIGNA [10200]",Cigna,,101.48,68,,,,,0,17.36,126.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 80MM TITANIUM FULL THREAD LOCK STERILE T2 NAIL",SUP-1896-5080S,CDM,C1713,HCPCS,0278,RC,,,both,,,1279.15,383.74,"CIGNA [10200]",Cigna,,869.82,68,,1831.33,1831.33,1831.33,16,148.77,1087.28,"percent of total billed charges",
"STENT GORE VIABAHN 79MM 135CM 9MM 13MM 8FR .035IN",SUP-BXA097902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"CIGNA [10200]","Cigna Local Plus",,6743.33,31.5,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lso Ortholine",PX-E27400064,CDM,L0631,HCPCS,0274,RC,,,both,,,3290.10,987.03,"KAISER [10500]",Kaiser,,2204.37,67,,,,,0,382.64,2796.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 60MM VIPER EXPEDIUM TITANIUM SPINE CORTICAL",SUP-186727760,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"PLATE 110MM STAINLESS STEEL 3.5MM SCREWS 7 HOLE LCP BONE",SUP-02.112.083S,CDM,C1713,HCPCS,0278,RC,,,both,,,6280.93,1884.28,"KAISER [10500]",Kaiser,,4208.22,67,,,,,0,730.47,5338.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM ACCOLADE HFX 127D 5 48MM OFFSET HIP",SUP-6077-0537,CDM,C1776,HCPCS,0278,RC,,,both,,,8983.80,2695.14,"UHC [10700]","United Healthcare",,5686.75,63.3,,8601.07,8395.67,8601.07,"1 through 10",1044.82,7636.23,"percent of total billed charges",
"STENT WALLSTENT 90MM 14MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044149070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1022.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch Dx",PX-750000004,CDM,31622,CPT,0750,RC,,,both,,,6015.80,1804.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2292.95,,"Case rate ($2,292.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,699.64,6015.8,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acapella",PX-E27000029,CDM,E27000029,LOCAL,0270,RC,,,both,,,319.49,95.85,"KAISER [10500]",Kaiser,,214.06,67,,,,,0,37.16,271.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 73.2MM 3MM LONG CARBIDE ROUND RSCB STERILE",SUP-5300020509,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.18,81.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,31.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.54,230.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 70CM 4-7MM GORE-TEX STD WALL TAPER PERIPHERAL",SUP-S47070,CDM,C1768,HCPCS,0278,RC,,,both,,,7231.20,2169.36,"BLUE CROSS [10001]","Blue Cross PPO",,2834.63,39.2,,,,,0,840.99,6146.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FARAWAVE 12FR 35MM ABLATION PULSE FIELD STERILE LATEX",SUP-M004PF41M432,CDM,C1733,HCPCS,0272,RC,,,both,,,53235.00,15970.5,"MULTIPLAN [10600]",Multiplan,,45249.75,85,,,,,0,6191.23,45249.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .035IN 5FR 5MM 110CM 8CM PTA 2 LUMEN",SUP-4205080L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 16MM GUIDED GROWTH PLATE QUAD-PLATE BONE NONSTERILE",SUP-GPQ800CE,CDM,C1713,HCPCS,0278,RC,,,both,,,2433.68,730.1,"FIRST HEALTH [10303]","First Health",,1946.94,80,,,,,0,283.04,2068.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 19MM KNEE X3 BEARING CRUCIATE RETAIN",SUP-5530-G-219,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]","Cigna Local Plus",,6105.74,53.5,,5372.07,4581.20,7242.98,23,1327.29,9700.71,"percent of total billed charges",
"SHELL ACETABULAR 46MM 3 HOLE EMPHASYS",SUP-471046300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"BLUE CROSS [10001]","Blue Cross HMO",,7038.36,39.2,,5311.50,4717.44,5388.59,31,2088.17,15261.75,"percent of total billed charges",
"SYSTEM REGULAR 6FR INTRO NINITOL ECHOGENIC NDL FIXED CORE",SUP-70-6160,CDM,C1894,HCPCS,0272,RC,,,both,,,304.50,91.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,207.06,68,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 131MM CORE SET PROXIMAL FILL UNIVERS REVERS",SUP-AR-9501-11CPC,CDM,C1776,HCPCS,0278,RC,,,both,,,10713.60,3214.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4403.29,41.1,,6417.48,6417.48,6417.48,"1 through 10",1245.99,9106.56,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 24CM 3CM 7FR .038IN 2",SUP-M006192142170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"FIRST HEALTH [10303]","First Health",,1116.18,80,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lgh Vari Regional Mutation",PX-309000039,CDM,81263,CPT,0310,RC,,,both,,,1512.00,453.6,"KAISER [10500]",Kaiser,,1013.04,67,,,,,0,0.01,1285.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 9MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P509,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,990.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 1026X50MM",SUP-6210050,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Local Plus",,7541.1,31.5,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 350ML STYLE 6200 MEDIUM HEIGHT CENTERSCOPE",SUP-3546212,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1063.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERLINK 0 36IN LOOP BLUE 1.5IN NONABSORBABLE",SUP-AR-7258,CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"PHCS [10601]",PHCS,,386.98,70,,,,,0,64.29,469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Zonisamide",PX-301000081,CDM,80203,CPT,0301,RC,,,both,,,348.40,104.52,"CIGNA [10200]","Cigna Local Plus",,29.15,,,,,,,0.01,296.14,"fee schedule",
"PLANER SURGICAL SP2 MEDIUM PATELLA BLADE",SUP-976747,CDM,S27200284,LOCAL,0272,RC,,,both,,,978.56,293.57,"PHCS [10601]",PHCS,,684.99,70,,,,,0,113.81,831.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASE TI BOLT 6.0X20.0MM FIXED",SUP-6956201,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"CIGNA [10200]","Cigna Local Plus",,1572.9,53.5,,3978.14,359.25,3978.14,24,341.92,2499,"percent of total billed charges",
"HC Avul Nail Plate Smpl",PX-510000036,CDM,11730,CPT,0761,RC,,,both,,,2956.01,886.8,"BLUE CROSS [10001]","Blue Cross PPO",,2740.57,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,343.78,2740.57,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LEMAITRE 80CM 6FR 13.5MM EMBOLECTOMY 16ML STERILE LATEX",SUP-E1601-68,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"AETNA [10100]","Aetna HMO/PPO",,476.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCOPIC EMR KIT 165CM 13.9MM RIM DYE SPRAY CATH",SUP-K-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1489.02,446.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,176.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.17,1265.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 90CM 4MM 8FR 2-5-2MM SPACE C CURVE ABLATION 10",SUP-D8BRCG252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,5326.80,1598.04,"FIRST HEALTH [10303]","First Health",,4261.44,80,,,,,0,619.51,4527.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,inpatient,,,38328.21,11498.46,"PHCS [10601]",PHCS,,7561,,,,,,,7561,31709.94,"per diem","Estimated amount calculated based on 3 day length of stay."
"HC Vitamin D 25 Hydroxy",PX-301000121,CDM,82306,CPT,0301,RC,,,both,,,262.50,78.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46.56,,,,,,,0.26,223.13,"fee schedule",
"HC Belt/Vest Elec/Combo Vad Rep",PX-E27400005,CDM,Q0499,HCPCS,0274,RC,,,both,,,2033.82,610.15,"CIGNA [10200]","Cigna Open Access",,1157.24,56.9,,,,,0,236.53,1728.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 45MM COCR SPINE MULTIAXIAL 5.5MM ROD",SUP-55840004545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"4 PACK REVOLVE FAT PROCESSING SYSTEM",SUP-RV0004,CDM,S27200284,LOCAL,0272,RC,,,both,,,3341.25,1002.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,388.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,388.59,2840.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Sacroiliac Joint>=3v",PX-320000051,CDM,72202,CPT,0320,RC,,,both,,,603.85,181.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,64.77,,"Fee schedule rate ($64.77).",,,,0,44.96,513.27,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CPIO",SUP-M0068331141,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG 600ML TRU-CLOSE GRAVITY TUBE 20IN",SUP-TC600,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"MULTIPLAN [10600]",Multiplan,,66.56,85,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE RELINE L50 MM OD5.5 MM SPINE POLYAXIAL 2 FULL CAN",SUP-16215550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"SCR BONE 5.5MM 45MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13175545,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 10MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650810,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"FIRST HEALTH [10303]","First Health",,10501.8,80,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Iabp",PX-E27200059,CDM,E27200059,LOCAL,0272,RC,,,both,,,4138.20,1241.46,"KAISER [10500]",Kaiser,,2772.59,67,,,,,0,481.27,3517.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RELIEVA SPIN RELIEVA VORTEX 2 M-110 16MM 6MM",SUP-RS0616M,CDM,S27200284,LOCAL,0272,RC,,,both,,,11557.50,3467.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7859.1,68,,,,,0,1344.14,9823.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD REAMING 1150MM 2.5MM BALL TIP INTRAMEDULLARY NAIL",SUP-351.708S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1100.39,330.12,"AETNA [10100]","Aetna HMO/PPO",,874.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.98,935.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echogr Transrec/Pros Vol Stdy",PX-402000031,CDM,76873,CPT,0402,RC,,,both,,,1190.00,357,"PHCS [10601]",PHCS,,833,70,,,,,0,138.4,1011.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP ELECTROSURGICAL ISOLATOR SYNERGY SHORT JAW LEFT CURVE",SUP-OSL2,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,9857.93,56.9,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 6 PACK KOBYGARD SURGICAL STERILE DISPOSABLE",SUP-380-0006,CDM,S27200284,LOCAL,0272,RC,,,both,,,6844.80,2053.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3141.76,45.9,,,,,0,796.05,5818.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERTORQUE PLUS 100CM 6FR JR4 MOD CURVE ANGIOGRAPHIC",SUP-533628,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.52,22.06,"AETNA [10100]","Aetna HMO/PPO",,58.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.55,62.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY INTRO BLUE RHINO G2 SHILEY 7.5MM 8.5MM 9MM PERCUTANEOUS",SUP-G57721,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC M/Phmtrc Alys Ishquant/Semiq",PX-312000068,CDM,88374,CPT,0312,RC,,,both,,,981.00,294.3,"MULTIPLAN [10600]",Multiplan,,833.85,85,,,,,0,0.01,875.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 20X20IN RESORBABLE GRID 1",SUP-F10256-2020G,CDM,C1781,HCPCS,0278,RC,,,both,,,39463.20,11838.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,11294.37,28.62,,,,,0,4589.57,33543.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAFCILLIN 1 GRAM INJECTION VIAL",RX-5333,CDM,J2290,HCPCS,0636,RC,55150-0122-15,NDC,both,1,UN,109.48,32.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.52,,"Fee schedule rate ($3.52). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,93.06,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 14 X 12 X 06MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-141206-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"NOVANET [10819]",Novanet,,4657.5,75,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Cerv Spine W/WO Cntrst",PX-352000010,CDM,72127,CPT,0352,RC,,,both,,,3543.36,1063.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,419.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,405,3011.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TANDEM 2 DUO ANCHOR SYSTEM XL",SUP-PNO610-623,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 4.5MM CUFF MURPHY EYE RADIOPAQUE VITAL",SUP-8045RTC,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.28,14.18,"CIGNA [10200]",Cigna,,32.15,68,,,,,0,5.5,40.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CANTATA 150CM 2.5FR .021IN MICRO INTERVENTIONAL",SUP-G54532,CDM,S27200284,LOCAL,0272,RC,,,both,,,2774.93,832.48,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1140.5,41.1,,,,,0,322.72,2358.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND VA.C VERAFLO CLEANSE MEDIUM DISPOSABLE",SUP-ULTVCL05MD,CDM,S27200284,LOCAL,0272,RC,,,both,,,1015.74,304.72,"PHCS [10601]",PHCS,,711.02,70,,,,,0,118.13,863.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 9/64IN STEINMANN 2 END TROCAR POINT",SUP-1628-38-000,CDM,C1713,HCPCS,0278,RC,,,both,,,102.95,30.88,"BLUE CROSS [10001]","Blue Cross HMO",,40.36,39.2,,957.42,156.86,7483.26,51,11.97,87.51,"percent of total billed charges",
"RTRCTR 70X23MM SMITH-BUIE SWIVEL BLADE SELF RETAINING SPREAD",SUP-50-7420,CDM,S27200284,LOCAL,0272,RC,,,both,,,1909.50,572.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,222.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,222.07,1623.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X7MM ANATOMIC 11MM PEEK RADIOPAQUE CERVICAL",SUP-4240741,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 10FR 11CM NO MINI GWIRE NO OBTR HEXCUSPID VALVE",SUP-504610A,CDM,C1894,HCPCS,0272,RC,,,both,,,72.65,21.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,29.86,41.1,,,,,0,8.45,61.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER BALLOON DILATION ATLAS GOLD LARGE DIAMETER L80 CM L",SUP-ATG80244,CDM,C1725,HCPCS,0272,RC,,,both,,,4312.50,1293.75,"NOVANET [10819]",Novanet,,3234.38,75,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 3CM 2MM GALAXY G3 MINI STRETCH",SUP-GLM920030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"MULTIPLAN [10600]",Multiplan,,10099.53,85,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM MREYE PLATINUM FIBER 4.2 LOOP",SUP-G42454,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"BLUE CROSS [10001]","Blue Cross HMO",,327.01,39.2,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 22CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175271180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"BLUE CROSS [10001]","Blue Cross PPO",,572.36,39.2,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 1 MO-6 36IN MONOFILAMENT SINGLE ARM CUSTOM BLUE",SUP-D6731,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.24,83.47,"UHC [10700]","United Healthcare",,176.13,63.3,,,,,0,32.36,236.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 92CM 4MM 6FR 2-5-2MM SPACE E CURVE",SUP-D6TCEL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"AETNA [10100]","Aetna HMO/PPO",,3944.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRY 80X12-13MM",SUP-400741,CDM,S27800098,LOCAL,0278,RC,,,both,,,4545.72,1363.72,"FIRST HEALTH [10303]","First Health",,3636.58,80,,,,,0,528.67,3863.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STIM PROXIMATE GENITOURINARY HANDSET NONSTERILE LATEX",SUP-TH90G01,CDM,C1787,HCPCS,0270,RC,,,both,,,12516.60,3754.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8511.29,68,,,,,0,1455.68,10639.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION .7MM 80MM KIRSCHNER STAINLESS STEEL",SUP-WIRE-0.7/080,CDM,S27000186,LOCAL,0270,RC,,,both,,,174.00,52.2,"NOVANET [10819]",Novanet,,130.5,75,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 130MM 4.2MM AO COUPLING REPROCESSED STERILE",SUP-1806-4280S,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.49,61.05,"PHCS [10601]",PHCS,,142.44,70,,,,,0,23.67,172.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X12X6MM ENDOSKELETON TC 6D SMALL INTERBODY",SUP-5146-1206,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA [10200]",Cigna,,4541.33,68,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 100MM 6MM BALLOON DILATATION DURALYN",SUP-48006010X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890005545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"BIT DRILL 2.7MM 2.7/3MM SCR ANKLE FRACTURE MANAGEMENT SYSTEM",SUP-AR-8827D-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM CD HORIZON REDUCTION MULTIAXIAL",SUP-55890007550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI-TREK II 20MM 5FR 1.5MM BALLOON DILATATION",SUP-1012402-20A,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 12MMX7MM AVS-AS 4D PEEK-OPTIMA ALIF",SUP-48322074,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,inpatient,,,88435.94,26530.78,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,23041.61,,"Case rate ($10,717.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,951.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,991.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,134.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,964.65. The transfer operating threshold is the transfer adjustment factor * $9,951.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.38. The transfer capital threshold is the transfer adjustment factor * $752.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 215%.",,,,0,7561,50441.93,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 45MM RELINE-O 2S SPINE POLYAXIAL NONSTERILE",SUP-13014545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.7MM 11MM VARIAX T5 LOCK NONSTERILE",SUP-662511,CDM,C1713,HCPCS,0278,RC,,,both,,,1075.03,322.51,"PHCS [10601]",PHCS,,752.52,70,,,,,0,125.03,913.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL REVELATION 8 LEFT HIP",SUP-427-01-080,CDM,C1776,HCPCS,0278,RC,,,both,,,32703.43,9811.03,"NOVANET [10819]",Novanet,,24527.57,75,,,,,0,3803.41,27797.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY PINK 100MM 18GA SURE-GRIP PLATINUM CURVE",SUP-PMF18-100-10CS,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.83,52.15,"PHCS [10601]",PHCS,,121.68,70,,,,,0,20.22,147.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 20MM 33MM 31MM BIOCOR FLEXFIT LOW PROFILE",SUP-B100-33M-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,30744.00,9223.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8798.93,28.62,,,,,0,3575.53,26132.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL MEDIUM 16MM KNEE DURATION POSTERIOR STABILIZE",SUP-6742-1-216,CDM,C1776,HCPCS,0278,RC,,,both,,,5709.75,1712.92,"KAISER [10500]",Kaiser,,3825.53,67,,,,,0,664.04,4853.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cystatin C",PX-301000460,CDM,82610,CPT,0301,RC,,,both,,,487.35,146.2,"CIGNA [10200]","Cigna Local Plus",,40.74,,,,,,,0.01,414.25,"fee schedule",
"CATH IMPULSE 100CM 6FR AL1 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916599960,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT DRNG 35CM 10FR FLEXIMA POLYURETHANE BILIARY DUROMETER",SUP-M001271660,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 220MM 2.6MM AO SCALE",SUP-703901,CDM,S27200284,LOCAL,0272,RC,,,both,,,1207.71,362.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,821.24,68,,,,,0,140.46,1026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR PRESSURE MONITOR ACUMEN IQ L84 IN",SUP-AIQS85,CDM,S27200284,LOCAL,0272,RC,,,both,,,2760.00,828,"UHC [10700]","United Healthcare",,1747.08,63.3,,,,,0,320.99,2346,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET TITANIUM SPINE BREAK OFF NONSTERILE 5.5 MM ROD",SUP-5540030,CDM,S27200284,LOCAL,0272,RC,,,both,,,2406.60,721.98,"CIGNA [10200]",Cigna,,1636.49,68,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 450ML STYLE 7200 MEDIUM HEIGHT CENTERSCOPE",SUP-3549213,CDM,C1789,HCPCS,0278,RC,,,both,,,9694.50,2908.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1148.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",1127.47,8240.33,"percent of total billed charges",
"ROD SPINAL 85MM 6MM CURVE TITANIUM SOFT NORMALIZE NONSTERILE",SUP-498.143,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 15.6CM MEMORYGEL BOOST P5.1CM MODERATE PLUS",SUP-RSZMPB730S,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,73.14,41.1,,,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revsc Tib/per W/Litho",PX-481000129,CDM,C9772,HCPCS,0481,RC,,,both,,,19534.29,5860.29,"KAISER [10500]",Kaiser,,13087.97,67,,,,,0,2271.84,16604.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 4X250 80CM SL",SUP-48004025N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"NOVANET [10819]",Novanet,,780.76,75,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 10 12MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151621012,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS [10001]","Blue Cross PPO",,4411.53,39.2,,3949.44,3949.44,3949.44,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"LINER ACETABULAR PINNACLE NEUTRAL 66MM 36MM ALTRX HIP",SUP-122136066,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross HMO",,4057.2,39.2,,5311.50,4717.44,5388.59,31,1203.71,8797.5,"percent of total billed charges",
"STENT C-FLEX 5CM 10FR 2 PIGTAIL CURVE BILIARY PLASTIC",SUP-M00532040,CDM,C2617,HCPCS,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT Q-FIX MINITAPE NDL STERILE LATEX FREE",SUP-72205695,CDM,C1713,HCPCS,0278,RC,,,both,,,3003.75,901.12,"PHCS [10601]",PHCS,,2102.63,70,,,,,0,349.34,2553.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 5MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620205,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"NOVANET [10819]",Novanet,,8440.43,75,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MINITAPE COBRAID NDL NONABSORBABLE",SUP-72205427,CDM,S27200284,LOCAL,0272,RC,,,both,,,484.79,145.44,"KAISER [10500]",Kaiser,,324.81,67,,,,,0,56.38,412.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 2CM 2.5MM BALLOON DILATATION HYDROPHILIC",SUP-G50320,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"UHC [10700]","United Healthcare",,1495.42,63.3,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 100MM 2MM .014IN BALLOON DILATATION NYBAX",SUP-39186-20101,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 6MM 1.14MM 6MM GOODE 6MM EAR SILICONE",SUP-24752,CDM,S27200284,LOCAL,0272,RC,,,both,,,356.70,107.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,42.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.48,303.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 15.5X13.5CM BREAST 800ML STYLE 133SV TEXTURED SUT",SUP-133SX-16-T,CDM,C1789,HCPCS,0278,RC,,,both,,,6510.00,1953,"FIRST HEALTH [10303]","First Health",,5208,80,,,,,0,757.11,5533.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 1 CTX 30IN BRAID GREEN NONABSORBABLE",SUP-X865H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRIMARY TT REVERSE SHOULDER",SUP-SMRTTREV,CDM,C1776,HCPCS,0278,RC,,,both,,,54652.50,16395.75,"MULTIPLAN [10600]",Multiplan,,46454.63,85,,,,,0,6356.09,46454.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIAZEPAM 2.5 MG RECTAL KIT",RX-87865,CDM,,,0250,RC,68682-0650-20,NDC,both,1,UN,586.42,175.93,"PHCS [10601]",PHCS,,410.49,70,,,,,0,68.2,498.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL COMPREHENSIVE +6MM STD SHOULDER REVERSE",SUP-110031405,CDM,C1776,HCPCS,0278,RC,,,both,,,8224.80,2467.44,"KAISER [10500]",Kaiser,,5510.62,67,,,,,0,956.54,6991.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE EXTERNAL FIXATION SALVATION FOOT ANKLE OPEN ROCKER",SUP-SEF02401,CDM,C1713,HCPCS,0278,RC,,,both,,,13703.40,4111.02,"CIGNA [10200]",Cigna,,5481.36,40,,1831.33,1831.33,1831.33,16,1593.71,11647.89,"percent of total billed charges",
"SCR BONE 5.5MM 34MM ORTHOLOC TITANIUM CORTICAL SELF TAP",SUP-59225534,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"BLUE CROSS [10001]","Blue Cross HMO",,390.55,39.2,,957.42,156.86,7483.26,51,115.87,846.86,"percent of total billed charges",
"KNEE CONSTRUCT 1",SUP-CAP-MI-K-1,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7250.04,41.1,,6417.48,6417.48,6417.48,"1 through 10",2051.53,14994,"percent of total billed charges",
"STEM FEMORAL 105MM 16MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-016,CDM,C1776,HCPCS,0278,RC,,,both,,,5684.52,1705.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,673.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,661.11,4831.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY 20CM 18GA BARD MARQUEE CORE DISPOSABLE",SUP-MQK1820,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"FIRST HEALTH [10303]","First Health",,466.56,80,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 1MM 1.7MM 120CM RING HANDLE STERILE",SUP-133R,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.52,22.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.78,64.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 80CM 9MM 9FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM09100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PHCS [10601]",PHCS,,12789,70,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 58CM 8.2FR SPRINT QUATTRO RIGHT VENTRICLE",SUP-6944-58,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2034.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +15 DIOPTER TORIC POSTERIOR CHMBR FOLDABLE ASPHERIC",SUP-SA6AT3,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,40.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL UTERINE HEGAR 2 END 5/6MM",SUP-52-3505,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,56.2,68,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 26MM 140CM 2.5MM CORONARY STERILE LATEX",SUP-453956,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 20MM 1 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-41F20V,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",521.61,3812.25,"percent of total billed charges",
"STENT ACCULINK 30MM 132CM 5MM STRAIGHT VASCULAR NITINOL",SUP-1011337-30,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6238.98,41.1,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 70CM PRECISION PERCUTANEOUS PHASE III",SUP-SC-2158-70,CDM,C1778,HCPCS,0278,RC,,,both,,,8914.80,2674.44,"CIGNA [10200]",Cigna,,6062.06,68,,6217.33,6217.33,6217.33,"1 through 10",1036.79,7577.58,"percent of total billed charges",
"MATRIX TISSUE 19.3X9.6CM ALLODERM SELECT THK.4-2.4MM THICK",SUP-CM1519P,CDM,Q4116,HCPCS,0636,RC,,,both,,,24847.20,7454.16,"CIGNA [10200]","Cigna Open Access",,14138.06,56.9,,,,,0,247.92,21120.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES0310CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BICALUTAMIDE 50 MG TABLET",RX-15746,CDM,,,0637,RC,16714-0816-01,NDC,both,1,UN,68.99,20.7,"AETNA [10100]","Aetna HMO/PPO",,54.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.02,58.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 58-71MM REVERE TRANSVERSE ADJUSTABLE TITANIUM SPINE",SUP-124.916,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"AMERIGROUP MEDICAID [20100]",Amerigroup,,572.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",561.73,4105.5,"percent of total billed charges",
"LINER ACETABULAR PINNACLE NEUTRAL 66MM 36MM ALTRX HIP",SUP-122136066,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"NOVANET [10819]",Novanet,,7762.5,75,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 18X5.5MM THK.38MM THK.43MM THIN SMALL BONE",SUP-KM3-412,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.65,24.19,"CIGNA [10200]",Cigna,,54.84,68,,,,,0,9.38,68.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 70MM LCP",SUP-212.326,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.25,337.57,"CIGNA [10200]",Cigna,,765.17,68,,1831.33,1831.33,1831.33,16,130.87,956.46,"percent of total billed charges",
"GRAFT SOFT TISSUE 240MM SEMITENDINOSUS",SUP-81B003,CDM,C1762,HCPCS,0278,RC,,,both,,,6537.75,1961.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1871.1,28.62,,,,,0,760.34,5557.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X22X14MM XL PEEK",SUP-6914260,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6415.2,27,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR STD CEMENT 3 PEG ROTATE PLATFORM MOBILE",SUP-129409840,CDM,C1776,HCPCS,0278,RC,,,both,,,4131.72,1239.52,"BLUE CROSS [10001]","Blue Cross PPO",,1619.63,39.2,,3949.44,3949.44,3949.44,"1 through 10",480.52,3511.96,"percent of total billed charges",
"SUT CHROMIC 1 CT-1 36IN MONOFILAMENT ABSORBABLE",SUP-925H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 12IN LARGE 4 PANEL ELASTIC HOOK LOOP CLSR",SUP-55476303,CDM,S27000186,LOCAL,0270,RC,,,both,,,137.81,41.34,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,56.64,41.1,,,,,0,16.03,117.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 6MM DIAPASON TITANIUM UNION THORACOLUMBAR",SUP-665080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 8MM 85MM STAINLESS STEEL 3.5MM FULL THREAD",SUP-218.085,CDM,C1713,HCPCS,0278,RC,,,both,,,485.35,145.6,"NOVANET [10819]",Novanet,,364.01,75,,,,,0,56.45,412.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2MM 1MM 13 MICRO STRAIGHT 7.5IN SURGICAL NONSTERILE",SUP-RN6213,CDM,S27200284,LOCAL,0272,RC,,,both,,,686.88,206.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,79.88,583.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM 3.5MM SCR ELLI",SUP-682.104,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"CIGNA [10200]","Cigna Local Plus",,2116.67,53.5,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 10MM 3.5MM BALLOON DILATATION STERILE",SUP-235-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 8IN SPETZLER-MALIS 1.5MM 2 IRRIGATE DISPOSABLE",SUP-6770-200-015,CDM,S27200284,LOCAL,0272,RC,,,both,,,3282.98,984.89,"AETNA [10100]","Aetna HMO/PPO",,2609.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,381.81,2790.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 6 HOLE LOCKING BONE ANTERIOR LATERAL",SUP-70-0122,CDM,C1713,HCPCS,0278,RC,,,both,,,6651.60,1995.48,"FIRST HEALTH [10303]","First Health",,5321.28,80,,,,,0,773.58,5653.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM 3DX TSRH OSTEOGRIP THINLINE TITANIUM",SUP-83545409,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"MULTIPLAN [10600]",Multiplan,,2187.9,85,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SCR VERTEX M6 POSTERIOR SPINE TITANIUM",SUP-6950315,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"NOVANET [10819]",Novanet,,1804.95,75,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prostatic Acid Phosphate",PX-301000354,CDM,84066,CPT,0301,RC,,,both,,,87.40,26.22,"MULTIPLAN [10600]",Multiplan,,74.29,85,,,,,0,0.01,74.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT 20CM MASTERGRAFT SPINE STRIP",SUP-7800320,CDM,C1713,HCPCS,0278,RC,,,both,,,17643.78,5293.13,"AETNA [10100]","Aetna HMO/PPO",,14026.81,79.5,,1521.93,481.35,16760.95,30,2051.97,14997.21,"percent of total billed charges",
"NAIL 9MM 40.5CM TIBIAL NAIL-EX INTRAMEDULLARY CANNULATED",SUP-04.004.361S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"CIGNA [10200]",Cigna,,5652.45,68,,1831.33,1831.33,1831.33,16,966.74,7065.57,"percent of total billed charges",
"TUBE SUCTION 11.5IN YANKAUER SATIN FINISH",SUP-170120,CDM,S27000186,LOCAL,0270,RC,,,both,,,205.49,61.65,"FIRST HEALTH [10303]","First Health",,164.39,80,,,,,0,23.9,174.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL 20MM LEGION 5 KNEE DISTAL HINGE",SUP-71422105,CDM,C1776,HCPCS,0278,RC,,,both,,,10536.30,3160.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3015.49,28.62,,,,,0,1225.37,8955.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 25X9X9MM COROENT 8D LARGE CONTOUR PEEK LUMBAR",SUP-6609925,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1925.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC",917,MS-DRG,,,,,,,inpatient,,,36486.30,10945.89,"BLUE CROSS [10001]","Blue Cross PPO",,36486.3,,,,,,,7561,36486.3,"case rate",
"TRAY NERVE BLOCK 2IN 18GA 20GA PAJUNK E-CATH 21GA CONTINUOUS",SUP-TDL103,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"CIGNA [10200]",Cigna,,358.02,68,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIVER KIDNEY MICROWAVE ABLATION PROBE, 17 GUAGE, 15 CM",SUP-LK15,CDM,C2618,HCPCS,0272,RC,,,both,,,14524.50,4357.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1721.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1689.2,12345.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 2.8 SONICANCHOR STERILE LATEX FREE DISPOSABLE",SUP-1910-1270S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2110.50,633.15,"CIGNA [10200]","Cigna Local Plus",,1129.12,53.5,,,,,0,245.45,1793.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP HUMERAL 33MM UNIVERS REVERS +2MM SHOULDER LEFT CALCIUM",SUP-AR-9502F-33RCPC,CDM,C1776,HCPCS,0278,RC,,,both,,,7576.20,2272.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,881.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,881.11,6439.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 28-14MM 13FR TRIVASCULAR OVATION PRIME",SUP-TV-IL1428100-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13723.29,41.1,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colposcopy Entire Vagina",PX-510000543,CDM,57420,CPT,0761,RC,,,both,,,1873.53,562.06,"PHCS [10601]",PHCS,,1311.47,70,,,,,0,217.89,1873.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULE SPINAL M5 NERVE MAP NDL MON",SUP-8050215,CDM,S27200284,LOCAL,0272,RC,,,both,,,6686.40,2005.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,792.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,777.63,5683.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 54MM 28MM XLPE HIP",SUP-71337554,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"CIGNA [10200]",Cigna,,7579.93,68,,5873.17,5873.17,5873.17,"1 through 10",1296.39,9474.91,"percent of total billed charges",
"CANNULA RAM  MICRO PREEMIE",SUP-N4900,CDM,S27000186,LOCAL,0270,RC,,,both,,,97.44,29.23,"AETNA [10100]","Aetna HMO/PPO",,77.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.33,82.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PSN FEM CR PPS TIV STD SZ 4 L",SUP-42-5786-056-01,CDM,C1776,HCPCS,0278,RC,,,both,,,33106.50,9931.95,"PHCS [10601]",PHCS,,23174.55,70,,,,,0,3850.29,28140.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 30MM 80CM 9MM .079IN LARGE DIAMETER",SUP-SERB65-09-30-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"NOVANET [10819]",Novanet,,4173.75,75,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM ATTUNE 4 KNEE DISTAL CEMENT REVISION STERILE",SUP-154704002,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"NOVANET [10819]",Novanet,,4554,75,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 25MMX4.8MM EEA TITANIUM THIN VASCULAR TISSUE",SUP-110214L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1850.10,555.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 135CM 40MM 5FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-06041,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT JEJUNOSTOMY 30CM 16FR SILICONE MIC RADIOPAQUE FEED TUBE",SUP-8250-16-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET ENDOTRACHEAL 10MM 4MM VIVASIGHT 2 LUMEN NONSTERILE LATEX",SUP-412351000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"FIRST HEALTH [10303]","First Health",,1560,80,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH ADULT 40CM 15.5FR DURATHANE DURAFLOW EMBOSAFE BASIC",SUP-H787103012055,CDM,C1750,HCPCS,0278,RC,,,both,,,1104.50,331.35,"PHCS [10601]",PHCS,,773.15,70,,,,,0,128.45,938.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR .09IN EXTRA BACKUP 3.75 LEFT CURVE",SUP-LA8EBU375D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 6CM 6FR 9MM .035IN BALLOON",SUP-G52287,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.47,41.1,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55840006555,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 159MM STAINLESS STEEL 4.5MM SCR 6 HOLE 4 COLUMN",SUP-02.124.407S,CDM,C1713,HCPCS,0278,RC,,,both,,,13248.28,3974.48,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3577.04,27,,,,,0,1540.77,11261.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Perm Gen Mult Lead",PX-480000023,CDM,33229,CPT,0481,RC,,,both,,,9268.04,2780.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9268.04,,"Case rate ($12,174). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1077.87,9268.04,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 5.5MM RELINE LORDOTIC TITANIUM MULTIAXIAL",SUP-11355040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"RELOAD SUT ASSISTANT 0 ES-9 48IN NONABSORBABLE NONMUTAGENIC",SUP-170003,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"KAISER [10500]",Kaiser,,96.59,67,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP FLEXV 45MM CLSR 1 HAND SMALL FOOTPRINT SUT",SUP-ACHV45,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3353.4,27,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT PRO+ 26MM",SUP-EVPROPLUS-26US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS [10001]","Blue Cross PPO",,67032,39.2,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 15IN 34-38FR VENOUS ATRIAL CAVAL ADULT 3/8IN",SUP-93463,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.70,87.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,134.35,45.9,,,,,0,34.04,248.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 120MM 4FR 2.5MM .018IN BALLOON",SUP-PCP025120130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"FIRST HEALTH [10303]","First Health",,984.96,80,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF URETHRAL AMS 800 OCCLUSIVE URINARY CONTROL SYSTEM",SUP-720157-01,CDM,C1815,HCPCS,0278,RC,,,both,,,53550.00,16065,"AETNA [10100]","Aetna HMO/PPO",,42572.25,79.5,,,,,0,6227.87,45517.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYGNUS MATRIX (4 X 4) 16 SQ CM",SUP-585-010,CDM,Q4199,HCPCS,0636,RC,,,both,,,9832.50,2949.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4400.04,44.75,,,,,0,298.85,8357.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA2-17-100-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,9177.00,2753.1,"MULTIPLAN [10600]",Multiplan,,7800.45,85,,,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL RESTORELLE SMARTMESH 30X30CM ULTRA LIGHTWEIGHT",SUP-501330,CDM,C1781,HCPCS,0278,RC,,,both,,,11812.80,3543.84,"AETNA [10100]","Aetna HMO/PPO",,9391.18,79.5,,,,,0,1373.83,10040.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 100MM X25 LOCK LOW PROFILE STERILE",SUP-04.045.400S,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"FIRST HEALTH [10303]","First Health",,1495.92,80,,,,,0,217.47,1589.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ERTAPENEM 1 G VIAL IV PUSH",RX-408330,CDM,J1335,HCPCS,0636,RC,55150-0282-09,NDC,both,1,UN,301.92,90.58,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.53,,"Fee schedule rate ($21.53). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.52,256.63,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN AMPLATZ LEFT 2 CURVE ANGIOGRAPHIC",SUP-08461-98,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"MULTIPLAN [10600]",Multiplan,,60.27,85,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 2.8 SONICANCHOR STERILE LATEX FREE DISPOSABLE",SUP-1910-1270S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2110.50,633.15,"CIGNA [10200]","Cigna Open Access",,1200.87,56.9,,,,,0,245.45,1793.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSRT PERCUTANEOUS KNOTLESS SUTURETAK",SUP-AR-1938PK,CDM,C1713,HCPCS,0278,RC,,,both,,,2795.63,838.69,"FIRST HEALTH [10303]","First Health",,2236.5,80,,,,,0,325.13,2376.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ACCESS ASCENDA 2 ATTACH COLLET SPINAL SEG REVISION CATH",SUP-8782,CDM,C1755,HCPCS,0278,RC,,,both,,,4843.80,1453.14,"NOVANET [10819]",Novanet,,3632.85,75,,,,,0,563.33,4117.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON 10-O CU-8",SUP-8065202001,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.98,94.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,144.12,45.9,,,,,0,36.52,266.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RETROMAX PLUS 26CM 7-14FR THIN WALL PIGTAIL CURVE",SUP-M0061451490,CDM,C2617,HCPCS,0278,RC,,,both,,,1557.47,467.24,"FIRST HEALTH [10303]","First Health",,1245.98,80,,,,,0,181.13,1323.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X10MM CASCADIA 0D PARALLEL TITANIUM POROUS",SUP-6101-2184510LP-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,42048.72,12614.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4890.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4890.27,35741.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 90MM 22MM 16MM AFX2 2 BRANCH 30MM AAA STERILE",SUP-BEA22-90/I16-30,CDM,C1874,HCPCS,0278,RC,,,both,,,84559.50,25367.85,"CIGNA [10200]",Cigna,,33823.8,40,,,,,0,9834.27,71875.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT MONOLITHIC 12MM PLIF",SUP-3W3112,CDM,S27800098,LOCAL,0278,RC,,,both,,,12487.62,3746.29,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5132.41,41.1,,,,,0,1452.31,10614.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 70MM LCP",SUP-212.326,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.25,337.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,322.05,28.62,,,,,0,130.87,956.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MITRACLIP G4 CDS XTW REPAIR-MR CLINICAL",SUP-CDS0704-XTW,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]",Cigna,,68400,40,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 15MM 140CM 4MM CORONARY",SUP-RSINT40015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"BLUE CROSS [10001]","Blue Cross PPO",,2173.25,39.2,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 30CM 3CM 7FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006180235050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"NOVANET [10819]",Novanet,,781.19,75,,,,,0,121.14,885.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 13MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532-G-513,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CIGNA [10200]","Cigna Local Plus",,4658.57,53.5,,5372.07,4581.20,7242.98,23,1012.7,7401.47,"percent of total billed charges",
"CATH EVERCROSS CROSSTEC 135CM 20MM 3MM .035IN BALLOON",SUP-AB35W03020135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,278.31,41.1,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 5 1/8IN 7FR BARON REGULAR THUMB PLATE CUT OFF 3",SUP-62-2220,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.24,37.87,"PHCS [10601]",PHCS,,88.37,70,,,,,0,14.68,107.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS09030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PHCS [10601]",PHCS,,8206.17,70,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE TITANIUM 20MM 7MM 1.5MM ACL PCL CANNULATED",SUP-7207001,CDM,C1713,HCPCS,0278,RC,,,both,,,1342.66,402.8,"CIGNA [10200]","Cigna Open Access",,763.97,56.9,,1144.80,304.56,2275.09,66,156.15,1141.26,"percent of total billed charges",
"ANCHOR SUT 2.6MM 1.7MM FIBERTAK FIBERTAPE SUTURETAPE SELF",SUP-AR-3652TSP,CDM,C1713,HCPCS,0278,RC,,,both,,,3701.25,1110.37,"KAISER [10500]",Kaiser,,2479.84,67,,,,,0,430.46,3146.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 10FR .131IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1010,CDM,C1894,HCPCS,0272,RC,,,both,,,321.03,96.31,"KAISER [10500]",Kaiser,,215.09,67,,,,,0,37.34,272.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CORDIS AQUATRACK VASCULAR ANGLE SHORT TAPER 150CM 5IN",SUP-C3515SSA,CDM,C1769,HCPCS,0272,RC,,,both,,,383.67,115.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,45.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.62,326.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HI-FLO RENEGADE 135CM 38CM 3-2.8FR .027IN MICRO",SUP-M001183010,CDM,C1887,HCPCS,0272,RC,,,both,,,4726.50,1417.95,"NOVANET [10819]",Novanet,,3544.88,75,,,,,0,549.69,4017.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE ULTRA THIN 50X38X.85MM POLYETHYLENE",SUP-7210,CDM,C1713,HCPCS,0278,RC,,,both,,,3382.50,1014.75,"CIGNA [10200]","Cigna Local Plus",,1809.64,53.5,,3978.14,359.25,3978.14,24,393.38,2875.13,"percent of total billed charges",
"INSRT TIBIAL 4 12MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-1517-10-412,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"BLUE CROSS [10001]","Blue Cross HMO",,5799.09,39.2,,5311.50,4717.44,5388.59,31,1720.5,12574.56,"percent of total billed charges",
"CAGE SPINAL 14X12X6MM COHERE 7D LORDOSIS SCORIA PEEK LOW",SUP-1000-00-0614,CDM,C1889,HCPCS,0278,RC,,,both,,,6210.00,1863,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM PERCUTANEOUS LORDOTIC",SUP-11-4045,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 45D JJ 54MM 28MM LONGEVITY HIP CONSTRAINED",SUP-00875801128,CDM,C1776,HCPCS,0278,RC,,,both,,,18074.70,5422.41,"CIGNA [10200]",Cigna,,7229.88,40,,5873.17,5873.17,5873.17,"1 through 10",2102.09,15363.5,"percent of total billed charges",
"STENT GORE VIABAHN 79MM 135CM 10MM 13MM 8FR .035IN",SUP-BXA107902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2536.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 300MM 5MM 2.9MM CANNULATED LARGE QUICK COUPLING",SUP-310.63S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2534.40,760.32,"KAISER [10500]",Kaiser,,1698.05,67,,,,,0,294.75,2154.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TRIA 30CM 6FR URETERAL SOFT",SUP-M0061903250,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 16MM ACUMED TITANIUM DISTAL RADIAL WRIST HAND",SUP-CO-N2316,CDM,C1713,HCPCS,0278,RC,,,both,,,720.90,216.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,85.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",83.84,612.77,"percent of total billed charges",
"SCR BONE 4.5MM 35MM TRIGEN FEMUR LOW PROFILE",SUP-71645435,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"KAISER [10500]",Kaiser,,1386.6,67,,,,,0,240.69,1759.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 260X17.5X5.2MM STAINLESS STEEL 4.5MM CORTICAL",SUP-226.641,CDM,C1713,HCPCS,0278,RC,,,both,,,4175.05,1252.51,"NOVANET [10819]",Novanet,,3131.29,75,,,,,0,485.56,3548.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 58CM .013IN BRADY SFT",SUP-6046,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RUBY XL COIL 24MMX55CM",SUP-RBYXL2455,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5391.15,28.62,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE 110CM 6FR .051IN .042IN PIGTAIL CURVE",SUP-532650S,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WASHER 7MM ORTHOPEDIC TITANIUM 4MM QUICKFIX SCR",SUP-AR-8740W,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTIMED SORBION SORBACT 4X8",SUP-7269809,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.14,49.84,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ARTHROSCOPIC 6MM 7CM TWIST-IN 3 DAM SIDEPORT LUER LOCK",SUP-AR-6535TD,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE DOPPLER HIGH SENSITIVITY NONDIRECTIONAL TRNSDUC 2MHZ",SUP-OP2-HS,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EUPHORA 142CM 12MM 3.75MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP37512X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BOTTLE DRNG SET UNIQUE FLOW CONTROL EMPTY OUT PORT",SUP-R514110000,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX 75CM 60MM 9MM BALLOON DILATATION DRUG COATED",SUP-LX3575960V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN NASAL NASAL INTERFACE BLENDER TRANSITION KIT OPTIFLOW",SUP-OJR416B,CDM,S27000186,LOCAL,0270,RC,,,both,,,520.02,156.01,"FIRST HEALTH [10303]","First Health",,416.02,80,,,,,0,60.48,442.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTOURA BREAST TISSUE EXPANDER HIGH PROJECTION 600 CC",SUP-TEXP140RH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"UHC [10700]","United Healthcare",,8713.56,63.3,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 15MM PINNACLE GRIPTION TF DOME 4 POINT CUT",SUP-121715500,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"CIGNA [10200]","Cigna Local Plus",,613.19,53.5,,3978.14,359.25,3978.14,24,133.3,974.23,"percent of total billed charges",
"TRAY TIBIAL 64.6X42.6X15MM MBT 2+ MM KNEE CEMENTED REVISION",SUP-129435215,CDM,C1776,HCPCS,0278,RC,,,both,,,35980.56,10794.17,"CIGNA [10200]","Cigna Local Plus",,11333.88,31.5,,5372.07,4581.20,7242.98,23,4184.54,30583.48,"percent of total billed charges",
"CATH STERLING 80CM 40MM 3.8FR 6MM LOW PROFILE TAPER BALLOON",SUP-39032-60408,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"MULTIPLAN [10600]",Multiplan,,1273.73,85,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 34MM NAIL-EX TITANIUM FULL THREAD HUMERUS TIBIA",SUP-04.005.424,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,134.52,983.18,"percent of total billed charges",
"SUT SURGITIE 0 21IN LIGATE LOOP ABSORBABLE",SUP-SGL-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"AETNA [10100]","Aetna HMO/PPO",,114.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MITRL VAL INTPDMVL54C INTREPID 54MM CLIN",SUP-INTPDMVL54C,CDM,S62400003,LOCAL,0624,RC,,,both,,,256500.00,76950,"AMERIGROUP MEDICAID [20100]",Amerigroup,,30395.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29830.95,218025,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM BOVINE PERICARDIUM LEAFLET COBALT CHROMIUM",SUP-11400M25,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"PHCS [10601]",PHCS,,31752,70,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 55MM VIPER EXPEDIUM TITANIUM SPINE CORTICAL",SUP-186731655,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|DISCARDED DRUG NOT ADMINISTE",RX-21900,CDM,J0289,HCPCS,0636,RC,00469-3051-30,NDC,both,1,UN,1921.31,576.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,JW,1306.49,68,,,,,0,125.17,1633.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM STERNALOCK BLU STERNAL CANCELLOUS LOCK",SUP-73-2714,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,153.47,39.2,,957.42,570.23,957.42,28,45.53,332.78,"percent of total billed charges",
"CMPNT FEMORAL 5 KNEE RIGHT PATELLOFEMORAL JOINT CEMENT",SUP-00592601502,CDM,C1776,HCPCS,0278,RC,,,both,,,15573.60,4672.08,"CIGNA [10200]","Cigna Local Plus",,4905.68,31.5,,5372.07,4581.20,7242.98,23,1811.21,13237.56,"percent of total billed charges",
"SCR BONE 2.7MM 58MM STAINLESS STEEL T8 SELF TAP LOCK",SUP-02.211.058,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,106.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,104.45,763.41,"percent of total billed charges",
"GWIRE SENSOR UROLOGICAL ANGLE 150CM 3CM .035IN NITINOL",SUP-M0066703061,CDM,C1769,HCPCS,0272,RC,,,both,,,355.45,106.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,241.71,68,,,,,0,41.34,302.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Screen Collection",PX-300000001,CDM,99000,CPT,0300,RC,,,both,,,57.00,17.1,"FIRST HEALTH [10303]","First Health",,45.6,80,,,,,0,0.06,48.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL DECOMPRESSION 3.25IN 14GA RUG TUBE OPEN HEX CAP SHOCK",SUP-TM-303,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.43,20.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.84,57.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656018,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"CIGNA [10200]","Cigna Open Access",,759.73,56.9,,1144.80,304.56,2275.09,66,155.28,1134.92,"percent of total billed charges",
"NEO IMPLANTABLE PULSE GENERATOR","SUP-MODEL 2102",CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 19MM RESTORATION +20MM HIP MODULAR",SUP-6276-1-219,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1714.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1682.49,12296.8,"percent of total billed charges",
"SCR BONE 6.5MM 35MM REFLECTION FULL THREAD HIP ACETABULAR",SUP-71336535,CDM,C1713,HCPCS,0278,RC,,,both,,,1341.36,402.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,383.9,28.62,,,,,0,156,1140.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VESUVIUS PUTTY DBM PUTTY 100 5CC",SUP-4104-K5050DP,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"CIGNA [10200]","Cigna Local Plus",,2307.19,53.5,,3978.14,359.25,3978.14,24,501.54,3665.63,"percent of total billed charges",
"PIN FIXATION 3/32IN THREADED DIAMOND POINT ONE END 9IN",SUP-KM169-39-33,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"CIGNA [10200]","Cigna Local Plus",,34.03,53.5,,3978.14,359.25,3978.14,24,7.4,54.07,"percent of total billed charges",
"DIABETES WITH CC",638,MS-DRG,,,,,,,inpatient,,,28949.95,8684.98,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,5809.35,,"Case rate ($5,559.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,162.08, add-ons for qualifying new technology services are included. If operating cost exceeds $38,201.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,772.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,168.90. The transfer operating threshold is the transfer adjustment factor * $5,162.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $390.28. The transfer capital threshold is the transfer adjustment factor * $390.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",6015.02,5958.00,6015.02,"1 through 10",5559.19,22350.33,other,"IP DRG"
"(COMM) PLATE H 6 HOLE BONE NONSTERILE LATEX FREE",SUP-115.102.06,CDM,C1713,HCPCS,0278,RC,,,both,,,2857.50,857.25,"CIGNA [10200]",Cigna,,1943.1,68,,1831.33,1831.33,1831.33,16,332.33,2428.88,"percent of total billed charges",
"GWIRE TRANSEND VASCULAR 205CM 2CM .014IN SCITANIUM ICE",SUP-M001468080,CDM,C1769,HCPCS,0272,RC,,,both,,,3942.52,1182.76,"NOVANET [10819]",Novanet,,2956.89,75,,,,,0,458.52,3351.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3/32IN THREADED DIAMOND POINT ONE END 9IN",SUP-KM169-39-33,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"CIGNA [10200]","Cigna Open Access",,36.19,56.9,,1144.80,304.56,2275.09,66,7.4,54.07,"percent of total billed charges",
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.75MM X 12.0MM",SUP-493751212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.5MM TRA",SUP-58850025,CDM,S27000186,LOCAL,0270,RC,,,both,,,1069.20,320.76,"KAISER [10500]",Kaiser,,716.36,67,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 10 8MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151621008,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"FIRST HEALTH [10303]","First Health",,9003.12,80,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 59MM 135CM 8MM THIN VASCULAR COCR",SUP-1012631-59,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3452.4,41.1,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .047IN JUDKINS RIGHT 4",SUP-534521T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"UHC [10700]","United Healthcare",,59.2,63.3,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEROPENEM-VABORBACTAM 2 G/21ML IV (WET SOLR VIAL)",RX-415180291,CDM,J2186,HCPCS,0636,RC,70842-0120-01,NDC,both,1,UN,1343.01,402.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,259.91,,,,,,,159.15,1141.56,"fee schedule",
"ROD REAMER 950MM 3MM OFFSET BALL TIP STERILE",SUP-351.71S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.17,412.25,"NOVANET [10819]",Novanet,,1030.63,75,,,,,0,159.82,1168.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 3MM PRESTIGE PLUS HELICAL COMPLEX",SUP-PRES0307CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 40MM 80CM 12MM .079IN LARGE DIAMETER",SUP-SERB65-12-40-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,647.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP HEMOSTATIC 30 CRTDG SUPERFINE BLUE GEM TITANIUM",SUP-GEM1521,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.50,30.45,"KAISER [10500]",Kaiser,,68.01,67,,,,,0,11.8,86.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION",RX-38488,CDM,,,0250,RC,70954-0600-10,NDC,both,120,ML,741.97,222.59,"KAISER [10500]",Kaiser,,497.12,67,,,,,0,86.29,630.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PROTRACK VASCULAR 13CM PIGTAIL SPIRAL TAPER 230CM 207",SUP-PTW-25-230,CDM,C1769,HCPCS,0272,RC,,,both,,,1458.00,437.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,991.44,68,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brace Hf CK Glv W/Fgr Pf",PX-E27400086,CDM,L3912,HCPCS,0274,RC,,,both,,,312.40,93.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,89.41,28.62,,,,,0,36.33,265.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 3CM 7FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22454,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"NOVANET [10819]",Novanet,,473.85,75,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 31X12-15MM MAGNIFY-S 8D LORDOTIC 25MM EXPAND",SUP-1126.0112,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"NOVANET [10819]",Novanet,,32130,75,,,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI CORSAIR PRO MICROCATHETER (5 IN SAME PO) 2.6FR, 135CM",SUP-CSR135-26P-5,CDM,C1887,HCPCS,0272,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 12MM 3.5MM BALLOON DILATATION PACLITAXEL",SUP-H7493960812350,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"CIGNA [10200]",Cigna,,26453.7,68,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 6.5IN TUNGSTEN 20X15MM NONHEX",SUP-E15626,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.49,30.15,"CIGNA [10200]","Cigna Local Plus",,53.76,53.5,,,,,0,11.69,85.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPAT ELECTROSURGICAL 33CM PKS PLASMASPATULA LAPAROSCOPIC",SUP-952005PK,CDM,S27200284,LOCAL,0272,RC,,,both,,,2400.00,720,"PHCS [10601]",PHCS,,1680,70,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 8IN 40D UP MICRO THIN 4MM KERRISON CERAMIC CONVERT",SUP-58-4200J-BD,CDM,S27200284,LOCAL,0272,RC,,,both,,,5017.40,1505.22,"UHC [10700]","United Healthcare",,3176.01,63.3,,,,,0,583.52,4264.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 87/91MMX16MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183586,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"CIGNA [10200]","Cigna Local Plus",,4194.28,53.5,,5372.07,4581.20,7242.98,23,911.77,6663.81,"percent of total billed charges",
"SYSTEM PROMUS PREMIER 38MM 144CM 3.5MM CORONARY STENT",SUP-H7493952838350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONTOUR STENT 8FX24CM W/O WIRE",SUP-M0061802420,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS [10001]","Blue Cross PPO",,353.65,39.2,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MOTIV SCAFFOLD 2.5MMX12MM","SUP-930025-12 (70)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 2MM PRESTIGE PLUS HELICAL HELICAL XTRA",SUP-PRES0208HXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 159MM AVENIR MULLER PROTASUL-64WF HA 6 41.66MM",SUP-106010006,CDM,C1776,HCPCS,0278,RC,,,both,,,12868.50,3860.55,"KAISER [10500]",Kaiser,,8621.9,67,,,,,0,1496.61,10938.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DEX 5    .5 SALINE 1000ML",SUP-792609,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QDOT MICRO D CURVE ABLATION UNIDIRECTIONAL",SUP-D139401,CDM,C1732,HCPCS,0272,RC,,,both,,,22560.30,6768.09,"AETNA [10100]","Aetna HMO/PPO",,17935.44,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2623.76,19176.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER ETHIBOND 0 CT-2 18IN CONTROL RELEASE BRAID 8",SUP-CX27D,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.98,37.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.54,106.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 150-180ML STYLE 68 SMOOTH ANTERIOR DIAPH VALVE",SUP-68-150,CDM,C1789,HCPCS,0278,RC,,,both,,,3202.50,960.75,"BLUE CROSS [10001]","Blue Cross HMO",,1255.38,39.2,,,,,0,372.45,2722.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA 30CM 3CM 8FR .038IN STRAIGHT URETHRAL",SUP-M006192155170,CDM,C2617,HCPCS,0278,RC,,,both,,,1357.24,407.17,"CIGNA [10200]",Cigna,,922.92,68,,,,,0,157.85,1153.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET VACUUM 9MM PLASTIC CANN STRAIGHT ROUND TIP SEMIRIGID",SUP-21552,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.34,19,"CIGNA [10200]","Cigna Open Access",,36.04,56.9,,,,,0,7.37,53.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE CONNECTING 14.5FR PLASTIC FITTING HIGH PRESSURE FMRA",SUP-G09435,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.43,20.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.84,57.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 250MM 6MM BALLOON DILATATION DURALYN",SUP-48006025X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM TRICUSPID 1 SEAM 2 WRAP ANATOMIC",SUP-4900T28,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"BLUE CROSS [10001]","Blue Cross HMO",,5003.88,39.2,,,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG AUTOTRANSFUSION 400ML CARDIOPAT ORTHOPAT REPLACEMENT RBC",SUP-01200-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.68,40.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.66,114.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM 3 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.345,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"MULTIPLAN [10600]",Multiplan,,4498.2,85,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 200MM 120CM 7MM VASCULAR PERIPHERAL SELF",SUP-PRB35-07-200-120,CDM,C1876,HCPCS,0278,RC,,,both,,,11625.00,3487.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1351.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1351.99,9881.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.122,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"CIGNA [10200]",Cigna,,770.24,68,,1831.33,1831.33,1831.33,16,131.73,962.8,"percent of total billed charges",
"KIT PEG 14FR SILICONE RADIOPAQUE EXTERNAL RETENTION RING",SUP-8180-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.81,228.54,"PHCS [10601]",PHCS,,533.27,70,,,,,0,88.6,647.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 2MM CONCERTO DETACHABLE HELIX PERIPHER",SUP-NV-2-8-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG VAC PEEL AND PLACE LARGE",SUP-EZ5LRG,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.99,371.4,"PHCS [10601]",PHCS,,866.59,70,,,,,0,143.98,1052.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SPINAL 27MM MIS LUMBAR",SUP-1135.0027,CDM,S27800098,LOCAL,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Open Access",,921.78,56.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 165CM 1.9-2.8FR .019IN PROGREAT",SUP-CC*M1916SN,CDM,C1725,HCPCS,0272,RC,,,both,,,5230.20,1569.06,"AETNA [10100]","Aetna HMO/PPO",,4158.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,608.27,4445.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16025545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"CATH COYOTE 150CM 100MM 4MM .014IN BALLOON DILATATION NYBAX",SUP-39186-40101,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 11MM KNEE BEARING CRUCIATE RETAIN TRIATHLON",SUP-5530-G-311-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]","Cigna Open Access",,6493.77,56.9,,5302.19,4377.88,6578.61,27,1327.29,9700.71,"percent of total billed charges",
"GRAFT ENDOVASCULAR 74MM 24MM 16FR ZENITH SPIRAL-Z Z-TRAK",SUP-G55246,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"KAISER [10500]",Kaiser,,14186.78,67,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC HIP GEL BAG COMPRESSION NONSTERILE LATEX",SUP-H-24-6-IP,CDM,S27000186,LOCAL,0270,RC,,,both,,,377.61,113.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,256.77,68,,,,,0,43.92,320.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 220CC FULL PROFILE SMOOTH NATRELLE INSPIRA",SUP-SSF-220,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2162.38,28.62,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 5 % AND 0.9 % NACL IV BOLUS",RX-400294,CDM,,,0258,RC,00338-0089-04,NDC,both,1000,ML,100.65,30.19,"KAISER [10500]",Kaiser,,67.44,67,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X10MM CASCADIA 0D PARALLEL TITANIUM POROUS",SUP-6101-2184510LP-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,42048.72,12614.62,"FIRST HEALTH [10303]","First Health",,33638.98,80,,,,,0,4890.27,35741.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 115MM 6MM UNIVERS II SHOULDER STERILE",SUP-AR-9100-06P,CDM,C1776,HCPCS,0278,RC,,,both,,,10713.60,3214.08,"CIGNA [10200]","Cigna Local Plus",,5731.78,53.5,,5372.07,4581.20,7242.98,23,1245.99,9106.56,"percent of total billed charges",
"STEM FEMORAL 105MM CEMENTED EXT PROSTALAC 1 HIGH OFFSET HIP",SUP-154106000,CDM,C1776,HCPCS,0278,RC,,,both,,,18814.32,5644.3,"BLUE CROSS [10001]","Blue Cross HMO",,7375.21,39.2,,5311.50,4717.44,5388.59,31,2188.11,15992.17,"percent of total billed charges",
"DEVICE STRATAFIX PDS PLUS 3-0 SH SPIRAL 6IN CLSR ABSORBABLE",SUP-SXPP1B420,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.96,69.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,157.73,68,,,,,0,26.98,197.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 20MM 31IN 29IN EPIC 31IN 3 SEPARATE PORCINE",SUP-E100-31M-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,24570.00,7371,"CIGNA [10200]","Cigna Local Plus",,7739.55,31.5,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 45CM 5.3FR J ATRIUM TRANSVENOUS BIPOLAR TINE",SUP-4574-45,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,638.94,28.62,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.9H 52MM 3 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009352,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM G7 DOME HIP ACETABULAR LOW PROFILE",SUP-010000998,CDM,C1713,HCPCS,0278,RC,,,both,,,1174.50,352.35,"CIGNA [10200]","Cigna Local Plus",,628.36,53.5,,3978.14,359.25,3978.14,24,136.59,998.33,"percent of total billed charges",
"HOOK SPINAL CD HORIZON SMALL TITANIUM NARROW BLADE",SUP-7541122,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,957.42,570.23,957.42,28,348.9,2550,"percent of total billed charges",
"HC Ldl Cholesterol",PX-301000306,CDM,83721,CPT,0301,RC,,,both,,,107.90,32.37,"MULTIPLAN [10600]",Multiplan,,91.72,85,,,,,0,0.01,91.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tcat Plmt&Rmvl Cerebrl Epd Perq",PX-361000562,CDM,33370,CPT,0361,RC,,,both,,,45298.00,13589.4,"PHCS [10601]",PHCS,,31708.6,70,,,,,0,1249,38503.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR OSSEOTI E1 CERAMIC HIP CEMENT FIX STEM CUP LI",SUP-98000100193,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3284.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3223.84,23562,"percent of total billed charges",
"SUT PROLENE HEMO-SEAL 5-0 BV-1 24IN 2 ARM MONOFILAMENT BLUE",SUP-9702H,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.81,68.94,"MULTIPLAN [10600]",Multiplan,,195.34,85,,,,,0,26.73,195.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 35X18X9MM TRANSCONTINENTAL 10D LORDOTIC",SUP-375.392,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"NOVANET [10819]",Novanet,,17955,75,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 37MMX8MMX15CM 24FR",SUP-TAC083715A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,52202.88,28.62,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 57MM 80CM 8MM 60MM BILIARY STAINLESS STEEL",SUP-PXB35-08-57-080,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1249.84,28.62,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 9.5MM S-ROM ZTT 24F SMALL HIP PROXIMAL",SUP-550567,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"NOVANET [10819]",Novanet,,8163.56,75,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 14CM 5FR 3MM .035IN D BALLOON",SUP-G52250,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"KAISER [10500]",Kaiser,,643.05,67,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 11 12MM KNEE N2VAC POSTERIOR STABILIZE BEARING",SUP-82-3-1112,CDM,C1776,HCPCS,0278,RC,,,both,,,7890.15,2367.04,"BLUE CROSS [10001]","Blue Cross PPO",,3092.94,39.2,,3949.44,3949.44,3949.44,"1 through 10",917.62,6706.63,"percent of total billed charges",
"CATH INTRATHECAL SPINE PROXIMAL KIT PUMP REVISION SEG",SUP-8596SC,CDM,C1755,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ASAHI CORSAIR SHINKA-SHAFT 150CM 2.6-2.8FR .018IN .015",SUP-CSW150-26N,CDM,C1887,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"FIRST HEALTH [10303]","First Health",,4692,80,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bag Autotransfusion",PX-E27200032,CDM,E27200032,LOCAL,0272,RC,,,both,,,554.40,166.32,"UHC [10700]","United Healthcare",,350.94,63.3,,,,,0,64.48,471.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 3-0 RB-1 27IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y215H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +22.5 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z900200225,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"BLUE CROSS [10001]","Blue Cross PPO",,400.08,39.2,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 12IN MULTIPANEL PROCARE 36-65IN MEDIUM",SUP-79-89386,CDM,S27000186,LOCAL,0270,RC,,,both,,,61.60,18.48,"FIRST HEALTH [10303]","First Health",,49.28,80,,,,,0,7.16,52.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TRANSEND VASCULAR STRAIGHT 135CM 2CM .018IN SCITANIUM",SUP-M001468120,CDM,C1769,HCPCS,0272,RC,,,both,,,2062.50,618.75,"UHC [10700]","United Healthcare",,1305.56,63.3,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 11MM",SUP-7080510,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"CIGNA [10200]","Cigna Local Plus",,2116.67,53.5,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Varicella Zoster Virus Dna CSF",PX-306000168,CDM,87799,CPT,0306,RC,,,both,,,959.50,287.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,67.39,,,,,,,0.96,815.58,"fee schedule",
"OVERSTITCH ENDOSCOPIC SUTURE SYSTEM",SUP-M00505410,CDM,S27200284,LOCAL,0272,RC,,,both,,,8797.50,2639.25,"NOVANET [10819]",Novanet,,6598.13,75,,,,,0,1023.15,7477.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Renal Cyst Study Translumb",PX-320000123,CDM,74470,CPT,0320,RC,,,both,,,1197.00,359.1,"KAISER [10500]",Kaiser,,801.99,67,,,,,0,68.87,1197,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 150MM 120CM 7MM VASCULAR PERIPHERAL SELF",SUP-PRB35-07-150-120,CDM,C1876,HCPCS,0278,RC,,,both,,,7560.00,2268,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,895.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,879.23,6426,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 24MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.824,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",40.86,298.61,"percent of total billed charges",
"LINER ACETABULAR PINNACLE NEUTRAL 58MM 40MM ALTRX HIP",SUP-122140058,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"BLUE CROSS [10001]","Blue Cross PPO",,5410.95,39.2,,3949.44,3949.44,3949.44,"1 through 10",1605.34,11732.93,"percent of total billed charges",
"STENT INNOVA 40MM 130CM 5MM VASCULAR SUPERFICIAL FEMORAL",SUP-H74939293054030,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"CIGNA [10200]","Cigna Local Plus",,2696.4,53.5,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM 22MM 17MM STD NECK S-ROM CERAMIC 135D",SUP-523395,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"AETNA [10100]","Aetna HMO/PPO",,15463.74,79.5,,10981.53,8986.79,12413.38,12,2262.18,16533.56,"percent of total billed charges",
"CANN OPHTHALMIC 4MM 27GA BD VISITEC ANGLED ANTERIOR CHMBR",SUP-8065420120,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.76,14.93,"FIRST HEALTH [10303]","First Health",,39.81,80,,,,,0,5.79,42.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM 16MM PRESS FIT LEGION KNEE",SUP-71424029,CDM,C1776,HCPCS,0278,RC,,,both,,,11747.25,3524.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1392.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1366.21,9985.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK EMBOLECTOMY STROKE FAST PACK STROKE STERILE LATEX FREE",SUP-M0033PK62523001,CDM,S27200284,LOCAL,0272,RC,,,both,,,20045.55,6013.66,"NOVANET [10819]",Novanet,,15034.16,75,,,,,0,2331.3,17038.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 17.8MM 31-33MM 36MM 23.4MM ON-X 31/33 STD",SUP-ONXM-31/33,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10206,27,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.3MM 52MM TITANIUM ALUMINUM NIOBIUM T25 FULL",SUP-04.005.542S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,177.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",174.09,1272.35,"percent of total billed charges",
"HC Prosth Ext Train Ea 15min (Go)",PX-430000050,CDM,97761,CPT,0430,RC,,,both,,,160.37,48.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,160.37,,"Per diem ($254).",,,,0,18.65,160.37,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE DIRECTINJECT HA 10CC",SUP-79-45910,CDM,C1713,HCPCS,0278,RC,,,both,,,24853.44,7456.03,"CIGNA [10200]","Cigna Open Access",,8325.9,33.5,,1144.80,304.56,2275.09,66,2890.46,21125.42,"percent of total billed charges",
"SCR BONE 3.5MM 32MM VERTEX MAX TITANIUM SPINE MULTIAXIAL",SUP-6958732,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CIGNA [10200]",Cigna,,2856,68,,1831.33,1831.33,1831.33,16,488.46,3570,"percent of total billed charges",
"CAGE SPINAL 13MM CENTERPIECE B",SUP-436013B,CDM,S27800098,LOCAL,0278,RC,,,both,,,39060.00,11718,"MULTIPLAN [10600]",Multiplan,,33201,85,,,,,0,4542.68,33201,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 22CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006155231170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CIGNA [10200]","Cigna Local Plus",,759.88,,,,,,,165.19,1207.29,"percent of total billed charges",
"HC Egd W Closure Fistula",PX-750000246,CDM,43999,CPT,0750,RC,,,both,,,3172.51,951.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,368.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,368.96,3172.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL PRE BENT TITANIUM 35MM X 110MM RELINE-C",SUP-3943110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"GWIRE HI-TORQUE PILOT 200 VASCULAR STRAIGHT 190CM 3CM .014IN",SUP-1010482-H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GERALD 9.25IN TISSUE SERRATE DRSG",SUP-55-9004,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.91,101.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,156.02,45.9,,,,,0,39.53,288.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 30CM 10FR 3.3MM PERFORMER ACCEPTS .038IN GWIRE",SUP-G08686,CDM,C1894,HCPCS,0272,RC,,,both,,,289.54,86.86,"PHCS [10601]",PHCS,,202.68,70,,,,,0,33.67,246.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 50CM CARBOTHANE PALINDROME TAL VENATRAC 2 LUMEN",SUP-8888145042P,CDM,C1750,HCPCS,0278,RC,,,both,,,2876.79,863.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,823.34,28.62,,,,,0,334.57,2445.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 14MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0101400,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2332.57,45.9,,,,,0,591.02,4319.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DRNG PURPLE 250CM 7FR PIGTAIL CURVE NASOBILIARY 5",SUP-G21586,CDM,C1729,HCPCS,0272,RC,,,both,,,1239.30,371.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,842.72,68,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR HD 28CM 11-13FR ACCESS STAINLESS STEEL",SUP-M0062502210,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"MULTIPLAN [10600]",Multiplan,,833.57,85,,,,,0,114.05,833.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY THRULUMEN 40CM 4FR 9MM EMBOLECTOMY STAINLESS",SUP-12TLW404F,CDM,C1757,HCPCS,0272,RC,,,both,,,746.58,223.97,"AETNA [10100]","Aetna HMO/PPO",,593.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.83,634.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Innovamatrix Ac, per Sq Cm",PX-E63600050,CDM,A2001,HCPCS,0636,RC,,,both,,,767.80,230.34,"NOVANET [10819]",Novanet,,575.85,75,,,,,0,90.98,652.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL LEGION 8 KNEE RIGHT JOURNEY LOCK",SUP-71933582,CDM,C1776,HCPCS,0278,RC,,,both,,,25949.70,7784.91,"UHC [10700]","United Healthcare",,16426.16,63.3,,8601.07,8395.67,8601.07,"1 through 10",3017.95,22057.25,"percent of total billed charges",
"ROD SPINAL 9CM 5.5MM TSRH SILO STD PEDICLE TITANIUM PREBENT",SUP-8370090,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"MULTIPLAN [10600]",Multiplan,,3748.5,85,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROLL 24INX6IN VINYL POSITIONING PEDIATRIC TUMBLE FORMS 2",SUP-2794B,CDM,S27000186,LOCAL,0270,RC,,,both,,,806.11,241.83,"MULTIPLAN [10600]",Multiplan,,685.19,85,,,,,0,93.75,685.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25.5 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE",SUP-PCB0000255,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC 2XL CONTOUR 48-52IN SHOULDER CONTACT CLSR",SUP-79-84039,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.42,14.83,"MULTIPLAN [10600]",Multiplan,,42.01,85,,,,,0,5.75,42.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 15MM 4MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG40015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"KAISER [10500]",Kaiser,,1758.75,67,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 30MM GRIPTION TF HIP ACETABULAR POLYAXIAL",SUP-121730800,CDM,C1713,HCPCS,0278,RC,,,both,,,933.12,279.94,"KAISER [10500]",Kaiser,,625.19,67,,,,,0,108.52,793.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT POSTERIOR STABILIZE BEAD TRIATHLON",SUP-5516F301,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2052.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2013.96,14719.4,"percent of total billed charges",
"LENS IOL +23 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00230,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAVER SYS IRRIGTN CLIPS",SUP-SSA-106,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"CIGNA [10200]",Cigna,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON SABRELOC 5-0 RD-1 18IN 2 ARM MONOFILAMENT BLACK",SUP-749G,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.65,34.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,53.54,45.9,,,,,0,13.57,124.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HERMETIC 80CM 1.5MM .7MM DRNG LUMBAR CLOSED TIP LUER",SUP-INS5010,CDM,C1729,HCPCS,0272,RC,,,both,,,3102.68,930.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,360.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,360.84,2637.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 85MM 2MM STD JACOBS CHUCK BASIC SET ARTICULATED",SUP-310.20,CDM,S27000186,LOCAL,0270,RC,,,both,,,496.69,149.01,"UHC [10700]","United Healthcare",,314.4,63.3,,,,,0,57.77,422.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 80MM 120CM 8MM VASCULAR PERIPHERAL SELF",SUP-PRB35-08-080-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Local Plus",,2977.28,53.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X17MM LUMINARY CC BICONVEX SPINE",SUP-16817,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3941.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12IN 22FR ARTERIAL 3/8IN RADIOPAQUE 1 PIECE",SUP-77422,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,304.64,68,,,,,0,52.1,380.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 25MM 2.5MM ULTRA LOW PROFILE BALLOON",SUP-1012272-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABIL 6CM 40CM 8MM ENDOPROSTHESIS GORE-TEX NITINOL",SUP-VH0806040,CDM,C1874,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Open Access",,7386.75,33.5,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSRT SPINAL NDL DIL FISHMOUTH SPEAR PUNCH PERCUTANEOUS",SUP-AR-1941PK,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"CIGNA [10200]","Cigna Open Access",,1456.29,56.9,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC BLACK BEAVER MINI-BLADE 60D GRINDLESS SHARP",SUP-BEAVER6600,CDM,S27200284,LOCAL,0272,RC,,,both,,,640.63,192.19,"AETNA [10100]","Aetna HMO/PPO",,509.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.51,544.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG BONE CEMENT 16MM MEDIUM INTRAMEDULLARY CANAL STERILE",SUP-130611,CDM,C1713,HCPCS,0278,RC,,,both,,,1029.51,308.85,"NOVANET [10819]",Novanet,,772.13,75,,,,,0,119.73,875.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA B KNEE RIGHT NONPOROUS REVISION",SUP-42542006102,CDM,C1776,HCPCS,0278,RC,,,both,,,16335.06,4900.52,"BLUE CROSS [10001]","Blue Cross PPO",,6403.34,39.2,,3949.44,3949.44,3949.44,"1 through 10",1899.77,13884.8,"percent of total billed charges",
"(EVAL) QUALIBREATH 5 XXL  SIZE",SUP-QB5XXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP ENDOSCOPIC SERRATE JAW SPRING SHEATH 230CM .8MM .76MM",SUP-BX00711889,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE NC PLUS 8MM 4MM BALLOON DILATATION STERILE",SUP-240-083-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PASSER SUTURELASSO 45D 1 RIGHT CURVE 10YD 1.5MM ERGONOMIC",SUP-AR-6069-45R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TORCON NB ADVANTAGE BEACON TIP 100CM 5FR ANGLE SIMMONS",SUP-G08420,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 9X20 135CM SL",SUP-48009002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"AETNA [10100]","Aetna HMO/PPO",,682.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 12MM 5FR 2MM BALLOON DILATATION PEBAX",SUP-1012403-12,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 4.5IN 11FR FRAZIER ANGLE STAINLESS STEEL THUMB",SUP-70-1081,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.14,57.34,"NOVANET [10819]",Novanet,,143.36,75,,,,,0,22.23,162.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +11 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000110,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT STEMLESS SHOULDER","SUP-CON STEMLESS HEMI",CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.6MM 150MM KIRSCHNER MONSTER HINDFOOT SCR",SUP-P99-192-1615,CDM,C1713,HCPCS,0278,RC,,,both,,,146.16,43.85,"FIRST HEALTH [10303]","First Health",,116.93,80,,,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.2MM X 6MM COCR",SUP-VAN-12006-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",150.72,1101.6,"percent of total billed charges",
"SPACER ALLOGRAFT 12.5X15X6MM ADVANCED PARALLEL TRAPEZOID",SUP-17606,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]",Cigna,,5630.4,68,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Stent Sf Ea Add",PX-361000709,CDM,37268,CPT,0361,RC,,,both,,,13927.30,4178.19,"CIGNA [10200]","Cigna Open Access",,6428,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,13.93,11838.21,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER FIBERTAPE SMALL CERCLAGE STRAIGHT SUT DISPOSABLE",SUP-AR-7825,CDM,S27200284,LOCAL,0272,RC,,,both,,,1771.88,531.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,209.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,206.07,1506.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 47MM ATLANTIS VISION BONE SPINE",SUP-7200047,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]",Cigna,,2998.8,68,,1831.33,1831.33,1831.33,16,512.88,3748.5,"percent of total billed charges",
"CAP END FLUSH TALON DISTALFIX 15.5MM",SUP-SLN-155-000,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TISSUE CLSR OMNIPAQUE SEAL CONFLUENT SURGICAL CRANIAL 5",SUP-202050,CDM,S27200284,LOCAL,0272,RC,,,both,,,6803.15,2040.94,"AETNA [10100]","Aetna HMO/PPO",,5408.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,791.21,5782.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 5-0 PS-2 18IN MONOFILAMENT PLIABILIZE",SUP-1666G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 12MM 144CM 2.5MM CORONARY STENT",SUP-H7493941812250,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE RX 30MM 135CM 8/6MM 6FR TAPER VASCULAR NITINOL",SUP-SECX-8-6-30-135,CDM,C1876,HCPCS,0278,RC,,,both,,,12420.00,3726,"AETNA [10100]","Aetna HMO/PPO",,9873.9,79.5,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ECHELON 14 155CM 150CM 2.4-1.9FR .017IN MICRO INFUSION",SUP-105-5092-150,CDM,S27200284,LOCAL,0272,RC,,,both,,,4650.60,1395.18,"CIGNA [10200]","Cigna Open Access",,2646.19,56.9,,,,,0,540.86,3953.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 20MM NONBIOABSORBABLE CLAW CHARLOTTE BONE NONSTERILE",SUP-40120020,CDM,C1713,HCPCS,0278,RC,,,both,,,6948.30,2084.49,"MULTIPLAN [10600]",Multiplan,,5906.06,85,,,,,0,808.09,5906.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIKING 110CM 6FR 5MM SPACE JOSEPHSON CURVE",SUP-M0044005040,CDM,C1730,HCPCS,0272,RC,,,both,,,1558.44,467.53,"NOVANET [10819]",Novanet,,1168.83,75,,,,,0,181.25,1324.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAXCESS-C SCREW, 12MM DISTRACTION",SUP-7670212,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR FL4 CURVE ANGIOGRAPHIC FEMORAL 2 WIRE",SUP-H74916599220,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,52.07,68,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 113MM 12-28MM Z-TRAK ZENITH RENU",SUP-G55376,CDM,C1874,HCPCS,0278,RC,,,both,,,46197.90,13859.37,"UHC [10700]","United Healthcare",,29243.27,63.3,,,,,0,5372.82,39268.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER BALLOON DILATION ATLAS GOLD LARGE DIAMETER L80 CM L",SUP-ATG80224,CDM,C1725,HCPCS,0272,RC,,,both,,,4312.50,1293.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,501.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 1 KNEE LEFT DISTAL TOTAL",SUP-5541-A-101,CDM,C1776,HCPCS,0278,RC,,,both,,,6699.90,2009.97,"MULTIPLAN [10600]",Multiplan,,5694.92,85,,,,,0,779.2,5694.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 3 GBQ MICROSPHERES YTTRIUM 90",SUP-SIR-Y001,CDM,C2616,HCPCS,0278,RC,,,both,,,104566.50,31369.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,41826.6,40,,,,,0,12161.08,88881.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAUMATIC INJURY WITHOUT MCC",914,MS-DRG,,,,,,,inpatient,,,37001.92,11100.58,"AMBETTER EXCHANGE  [11102]",Ambetter,,5492.82,,"Case rate ($5,492.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,100.45, add-ons for qualifying new technology services are included. If operating cost exceeds $38,140.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,767.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $5,107.19. The transfer operating threshold is the transfer adjustment factor * $5,100.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $385.62. The transfer capital threshold is the transfer adjustment factor * $385.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,5492.82,22083.48,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 14MM PYRENEES +2.3MM SPINAL",SUP-201-90105,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1815.99,45.9,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 6FR LEFT CORONARY BYPASS CURVE ANGIOGRAPHIC",SUP-8641195,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Adalimumab",PX-301000621,CDM,80145,CPT,0301,RC,,,both,,,544.35,163.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,462.7,"per diem",
"GWIRE NIT-VU ENDOSCOPIC MICRO 80CM 5CM .018IN HIGH",SUP-05800113,CDM,C1769,HCPCS,0272,RC,,,both,,,675.00,202.5,"NOVANET [10819]",Novanet,,506.25,75,,,,,0,78.5,573.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 30MM 4MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT40030UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"AETNA [10100]","Aetna HMO/PPO",,1919.93,79.5,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 92CM 1MM 6FR 5MM SPACE REGULAR D CURVE",SUP-D6DR005CT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"MULTIPLAN [10600]",Multiplan,,1969.88,85,,,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 80MM 80CM 9MM .079IN LARGE DIAMETER",SUP-SERB65-09-80-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]",Cigna,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 440CC P3.8CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-440,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 30MM 75CM 8MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200083070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840006560,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION",RX-10289,CDM,J1815,HCPCS,0637,RC,00002-8215-01,NDC,both,10,ML,404.15,121.24,"AETNA [10100]","Aetna HMO/PPO",,321.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47,343.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 2.4MM INTREPID ANGLE BEVEL STAB MICRO",SUP-8065992445,CDM,S27200284,LOCAL,0272,RC,,,both,,,288.75,86.62,"AETNA [10100]","Aetna HMO/PPO",,229.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.58,245.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN CHAMP 1.5 CURVE GUIDING NYLON",SUP-LA6CHAMP15,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT POLYPROPYLENE PROLENE 0 CTX 30IN MONOFILAMENT BLUE",SUP-8454H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND 2 MH 30IN BRAID BLACK NONABSORBABLE",SUP-K846H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH AXS VECTA 46 160CM .046IN ASPIRATION INTERMEDIATE",SUP-INC-11814-160,CDM,S27200284,LOCAL,0272,RC,,,both,,,9911.85,2973.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 90CM 80MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ATLAS 120CM 4CM 14MM BALLOON DILATATION PERIPHERAL",SUP-AT120144,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COAGULATION AND PLATELET DISORDERS,MINOR",661,APR-DRG,,,,,,,inpatient,,,35711.00,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,598.39. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CESAREAN SECTION WITHOUT STERILIZATION,EXTREME",540,APR-DRG,,,,,,,inpatient,,,102300.46,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $12,377.35. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($83,828.19) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR 180CM 3CM .025IN MEDIGLIDE",SUP-M001466100,CDM,C1769,HCPCS,0272,RC,,,both,,,1539.00,461.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Nrv Condct =>13 Studies",PX-922000025,CDM,95913,CPT,0922,RC,,,both,,,10036.11,3010.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HYDROCORTISONE 1 % TOPICAL CREAM",RX-3726,CDM,,,0250,RC,45802-0438-03,NDC,both,28,GR,25.19,7.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH R2P METACROSS 200CM 100MM 3MM BALLOON DILATATION",SUP-BD-P30100ER,CDM,C1725,HCPCS,0272,RC,,,both,,,2028.75,608.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EPIFIX MESH 3.5X3.5 CM",SUP-ES-3300,CDM,Q4186,HCPCS,0636,RC,,,both,,,8618.10,2585.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONVEY 5FR .058IN CONTRALATERAL SPRT 4 CURVE GUIDING",SUP-H749392285750,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AETNA [10100]","Aetna HMO/PPO",,291.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 4 PREASSEMBLE BLADE STD HANDLE LED LIGHT",SUP-040-04-0140U,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.42,18.73,"UHC [10700]","United Healthcare",,39.51,63.3,,,,,0,7.26,53.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE LESLIE PARACHUTE 120CM 5CM 11MM 3.1FR SPECIMEN",SUP-M0063203030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1464.48,439.34,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,995.85,68,,,,,0,170.32,1244.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 60MM 8MM 8FR BILIARY RAPID EXCHANGE DELIVERY",SUP-M00570610,CDM,C1876,HCPCS,0278,RC,,,both,,,11927.41,3578.22,"FIRST HEALTH [10303]","First Health",,9541.93,80,,,,,0,1387.16,10138.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE HEARTMATE 3 VENTRICULAR ASSIST CTRL STERILE LATEX",SUP-106531US,CDM,Q0481,HCPCS,0274,RC,,,both,,,37422.00,11226.6,"FIRST HEALTH [10303]","First Health",,29937.6,80,,,,,0,4352.18,31808.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 40MM 135CM 8MM 160CM",SUP-M001711270,CDM,C1876,HCPCS,0278,RC,,,both,,,4410.00,1323,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2998.8,68,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 12MM KII FIRST ENTRY FLAT BLADE Z",SUP-CTF71,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"UHC [10700]","United Healthcare",,115.65,63.3,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 3.4MM QUADCUT M4 STRAIGHTSHOT M4 LATEX",SUP-1883480EM,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT THERAPEUTIC PREVENA INCISION MANAGEMENT SYSTEM PEEL",SUP-PRE1001US,CDM,S27200284,LOCAL,0272,RC,,,both,,,3522.60,1056.78,"CIGNA [10200]",Cigna,,2395.37,68,,,,,0,409.68,2994.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 110MM 10 HOLE BONE CLAVICLE LEFT SUPERIOR NONSTERILE",SUP-133525110,CDM,C1713,HCPCS,0278,RC,,,both,,,14334.75,4300.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1667.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1667.13,12184.54,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL 7/8IN BLADE 15FT 3/8IN PLUMEPEN",SUP-PLPUL2520,CDM,S27200284,LOCAL,0272,RC,,,both,,,277.08,83.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,32.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.22,235.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 5MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640705,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS [10001]","Blue Cross HMO",,4411.53,39.2,,5311.50,4717.44,5388.59,31,1308.83,9565.82,"percent of total billed charges",
"CATH ADVANCE PLIAFORM STARCAST 135CM 10CM 7MM BALLOON",SUP-G52275,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"NOVANET [10819]",Novanet,,719.83,75,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175282010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,126.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUARTET, WIDE SPACING - 1458QL/86",SUP-1458QL/86,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"FIRST HEALTH [10303]","First Health",,4485.6,80,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 3.5MM 2 STRAIGHT 5.75IN BUCK EAR SHARP SURGICAL",SUP-380203,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.07,40.22,"CIGNA [10200]",Cigna,,91.17,68,,,,,0,15.59,113.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIMPLE PNEUMONIA AND PLEURISY WITH CC",194,MS-DRG,,,,,,,inpatient,,,25896.69,7769.01,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,5298.98,,"Case rate ($4,999.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,641.95, add-ons for qualifying new technology services are included. If operating cost exceeds $37,681.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,732.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $4,648.09. The transfer operating threshold is the transfer adjustment factor * $4,641.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.95. The transfer capital threshold is the transfer adjustment factor * $350.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,4999.04,20098.34,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 3-0 T-43 18IN BRAID TIES MULTISTRAND LOWER",SUP-AR-7227-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"NOVANET [10819]",Novanet,,150.73,75,,,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 28CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006180234010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"NOVANET [10819]",Novanet,,803.06,75,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR VACUUM 14MM VACRET PLASTIC ASPIR PUMP BERKELEY",SUP-003696,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.67,36.8,"MULTIPLAN [10600]",Multiplan,,104.27,85,,,,,0,14.27,104.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STYLET ASSORTED 100CM UNIVERSAL J STRAIGHT REPOSITION 1",SUP-DS06002/100,CDM,S27200284,LOCAL,0272,RC,,,both,,,896.51,268.95,"AETNA [10100]","Aetna HMO/PPO",,712.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.26,762.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC",854,MS-DRG,,,,,,,inpatient,,,64962.71,19488.81,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,12766.16,,"Case rate ($12,394.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,508.98, add-ons for qualifying new technology services are included. If operating cost exceeds $44,548.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,252.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $11,524.20. The transfer operating threshold is the transfer adjustment factor * $11,508.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.13. The transfer capital threshold is the transfer adjustment factor * $870.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,58336.53,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CONTROL CHEMISTRY 1ML LEVEL 1 ASSAYED LIQUID HUMAN WHOLE",SUP-171,CDM,C1895,HCPCS,0278,RC,,,both,,,362.79,108.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,42.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.19,308.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 1.5 X 6 HELICAL FINISHING COIL",SUP-10HFN-01506,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"FIRST HEALTH [10303]","First Health",,8274.48,80,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X4CM ACTISHIELD AMNIOTIC BARR MEMB",SUP-AM204X04,CDM,V2790,HCPCS,0278,RC,,,both,,,12420.00,3726,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5104.62,41.1,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 8MM MREYE 2 LOOP PLATINUM ARTERIAL",SUP-G42423,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,238.75,28.62,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 5 9MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530-G-509,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"AETNA [10100]","Aetna HMO/PPO",,6922.55,79.5,,10981.53,8986.79,12413.38,12,1012.7,7401.47,"percent of total billed charges",
"COIL EMBOLIZATION 2CM 2MM AZUR HYDROCOIL DETACHABLE 18D .018",SUP-45-480202,CDM,S27800098,LOCAL,0278,RC,,,both,,,5361.30,1608.39,"BLUE CROSS [10001]","Blue Cross HMO",,2101.63,39.2,,,,,0,623.52,4557.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL FIXATION GREEN 170MM 11MM 130D RIGHT TROCHANTERIC",SUP-456.318S,CDM,C1713,HCPCS,0278,RC,,,both,,,8753.89,2626.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1037.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1018.08,7440.81,"percent of total billed charges",
"CAP KIT REPLACEMENT COMPREHENSIVE VERSA-DIAL STRAIGHT SHOULD",SUP-98B00900101,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"UHC [10700]","United Healthcare",,18942.53,63.3,,8601.07,8395.67,8601.07,"1 through 10",3480.28,25436.25,"percent of total billed charges",
"PIN FIXATION TEMPORARY SPINE STERILE DISPOSABLE",SUP-201-90000,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ENDOWRIST SP ROUND TOOTH 6MM SURGICAL NONSTERILE",SUP-431301,CDM,S27000186,LOCAL,0270,RC,,,both,,,1968.90,590.67,"NOVANET [10819]",Novanet,,1476.68,75,,,,,0,228.98,1673.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.102,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"NOVANET [10819]",Novanet,,642.98,75,,,,,0,99.7,728.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 75CM 3CM 12-15MM PULMONARY RADIOPAQUE",SUP-M00550350,CDM,C1726,HCPCS,0272,RC,,,both,,,2278.65,683.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,936.53,41.1,,,,,0,265.01,1936.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EXOFIN FUSION 60CM SKIN CLSR 2-OCTYL CYANOACRYLATE",SUP-EF70466,CDM,S27200284,LOCAL,0272,RC,,,both,,,769.50,230.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Eps Icd Generator W Test",PX-481000060,CDM,93641,CPT,0481,RC,,,both,,,3043.83,913.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,360.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,354,3043.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION",RX-88011,CDM,Q2009,HCPCS,0636,RC,00069-5471-01,NDC,both,2,ML,27.69,8.31,"UHC [10700]","United Healthcare",,5.22,,,,,,,3.28,23.54,"fee schedule",
"HC Cult Fungi Pres ID Hair/Sk/Na",PX-306000065,CDM,87101,CPT,0306,RC,,,both,,,164.00,49.2,"KAISER [10500]",Kaiser,,109.88,67,,,,,0,0.01,139.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFOXITIN SODIUM 2 G/20ML IV (WET SOLR VIAL)",RX-4159463,CDM,J0694,HCPCS,0636,RC,44567-0246-25,NDC,both,1,UN,180.75,54.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,122.91,68,,,,,0,11.14,153.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fill Portable Pump",PX-260000010,CDM,96521,CPT,0260,RC,,,both,,,1203.30,360.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,602.61,50.08,,,,,0,139.94,1022.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM REFLECTION FULL THREAD HIP ACETABULAR",SUP-71336540,CDM,C1713,HCPCS,0278,RC,,,both,,,1341.36,402.41,"BLUE CROSS [10001]","Blue Cross HMO",,525.81,39.2,,957.42,156.86,7483.26,51,156,1140.16,"percent of total billed charges",
"SYSTEM PROMUS PREMIER 28MM 144CM 4MM CORONARY STENT",SUP-H7493952828400,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AETNA [10100]","Aetna HMO/PPO",,4424.18,79.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM CD HORIZON SPINE MULTIAXIAL FENESTRATE",SUP-55840024540T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640512,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7652.65,68,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CEMENTED EXETER V40 4 37.5MM OFFSET HIP",SUP-0580-1-374,CDM,C1776,HCPCS,0278,RC,,,both,,,17001.60,5100.48,"MULTIPLAN [10600]",Multiplan,,14451.36,85,,,,,0,1977.29,14451.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 40X54.6MM HALL THK.4MM STAINLESS STEEL OSCILLATE",SUP-5059-279,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.57,30.17,"KAISER [10500]",Kaiser,,67.38,67,,,,,0,11.7,85.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1 KNEE LEFT CEMENTED POSTERIOR STABILIZE",SUP-5515F101,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA [10200]",Cigna,,6800,68,,5873.17,5873.17,5873.17,"1 through 10",1163,8500,"percent of total billed charges",
"APPL INTERNAL CLIP 2.5MM XL VESSEL CLSR ANASTOCLIP",SUP-4008-08,CDM,S27200284,LOCAL,0272,RC,,,both,,,9791.10,2937.33,"MULTIPLAN [10600]",Multiplan,,8322.44,85,,,,,0,1138.7,8322.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.2MM KIRSCHNER TEMPORARY",SUP-DC4212,CDM,C1713,HCPCS,0278,RC,,,both,,,550.80,165.24,"CIGNA [10200]","Cigna Local Plus",,294.68,53.5,,3978.14,359.25,3978.14,24,64.06,468.18,"percent of total billed charges",
"SCR BONE 2.7MM 48MM STAINLESS STEEL T8 SELF TAP LOCK",SUP-02.211.048,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"MULTIPLAN [10600]",Multiplan,,763.41,85,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 16MM 3.5MM EMBOLIZATION",SUP-PED2-350-16,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"FIRST HEALTH [10303]","First Health",,64638,80,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 30MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.442,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"KAISER [10500]",Kaiser,,3244.54,67,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBRANT 5CC 12MM OPEN ALLOGRAFT 1 LEVEL PAK",SUP-IFLX-FBG-SM-DC,CDM,S27800098,LOCAL,0278,RC,,,both,,,18616.50,5584.95,"BLUE CROSS [10001]","Blue Cross PPO",,7297.67,39.2,,,,,0,2165.1,15824.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 113MM 12-28MM Z-TRAK ZENITH RENU",SUP-G55376,CDM,C1874,HCPCS,0278,RC,,,both,,,46197.90,13859.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5474.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5372.82,39268.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG TIP PATIENT STARTER",SUP-50-0071,CDM,S27200284,LOCAL,0272,RC,,,both,,,2557.50,767.25,"AETNA [10100]","Aetna HMO/PPO",,2033.21,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,297.44,2173.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 16MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036121650,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIGESTIVE MALIGNANCY WITH CC",375,MS-DRG,,,,,,,inpatient,,,40215.22,12064.57,"UHC [10700]","United Healthcare",,30166.21,,"Fee schedule rate ($30,166.21). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7503.22,30166.21,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 7CM 8.5FR CENTER BEND THIN WALL",SUP-M00534630,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"CIGNA [10200]","Cigna Open Access",,619.9,56.9,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDIUM IN-111 OXYQUINOLINE INTRAVENOUS SOLUTION 0-0.5 MCI",RX-155677,CDM,A9547,HCPCS,0343,RC,08888-8878-40,NDC,both,1,UN,11022.18,3306.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2453.35,,,,,,,1281.88,9368.85,"fee schedule",
"CIRCUIT BREATHING EXPANDABLE SAMPLE PORT LATEX FREE BAG MALE",SUP-KNCF3756121Z,CDM,S27000186,LOCAL,0270,RC,,,both,,,67.01,20.1,"MULTIPLAN [10600]",Multiplan,,56.96,85,,,,,0,7.79,56.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 7FR ENDOCARDIUM BIPOLAR ACTIVE FIXATION",SUP-1999/52,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CIGNA [10200]","Cigna Open Access",,1270.29,56.9,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 19MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-019,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2518.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +31 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000310,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM COMPREHENSIVE 3.5MM SHOULDER CENTRAL",SUP-115399,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CIGNA [10200]",Cigna,,1058.08,68,,1831.33,1831.33,1831.33,16,180.96,1322.6,"percent of total billed charges",
"MESH SURGICAL RESTORELLE SMARTMESH 30X30CM ULTRA LIGHTWEIGHT",SUP-501330,CDM,C1781,HCPCS,0278,RC,,,both,,,11812.80,3543.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4725.12,40,,,,,0,1373.83,10040.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.475,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA [10200]",Cigna,,3292.97,68,,1831.33,1831.33,1831.33,16,563.19,4116.21,"percent of total billed charges",
"AUG FEMORAL 10MM TRIATHLON 1 KNEE LEFT DISTAL TOTAL",SUP-5541-A-101,CDM,C1776,HCPCS,0278,RC,,,both,,,6699.90,2009.97,"CIGNA [10200]",Cigna,,4555.93,68,,5873.17,5873.17,5873.17,"1 through 10",779.2,5694.92,"percent of total billed charges",
"SCR BONE 2.7MM 16MM DARCO TITANIUM FOOT LOCK",SUP-DC2825016,CDM,C1713,HCPCS,0278,RC,,,both,,,1036.80,311.04,"NOVANET [10819]",Novanet,,777.6,75,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1 KNEE LEFT CEMENTED POSTERIOR STABILIZE",SUP-5515F101,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"BLUE CROSS [10001]","Blue Cross HMO",,3920,39.2,,5311.50,4717.44,5388.59,31,1163,8500,"percent of total billed charges",
"AMVIE EDGE SR-T",SUP-460164,CDM,C1786,HCPCS,0275,RC,,,both,,,14490.00,4347,"AETNA [10100]","Aetna HMO/PPO",,11519.55,79.5,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE BIOPSY PREP+ STERILE DISPOSABLE",SUP-5420-PRP-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,5558.21,1667.46,"AETNA [10100]","Aetna HMO/PPO",,4418.78,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,646.42,4724.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X60 135CM SL",SUP-48007006R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,101.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sars Cov-2 Antibody Qn",PX-302000239,CDM,86413,CPT,0302,RC,,,both,,,228.00,68.4,"KAISER [10500]",Kaiser,,152.76,67,,,,,0,13.35,193.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 30MM 80CM 9MM .079IN LARGE DIAMETER",SUP-SERB65-09-30-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 1.5IN 21GA 25GA EPILONG TUOHY .2UM METAL STEEL",SUP-0131156-51,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.70,80.91,"CIGNA [10200]",Cigna,,183.4,68,,,,,0,31.37,229.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONDUIT VALVE 25MM ATS OPEN PIVOT MECHANICAL GRAFT STERILE",SUP-502AG25,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"CIGNA [10200]","Cigna Open Access",,8864.1,33.5,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONDUIT VALVE 25MM ATS OPEN PIVOT MECHANICAL GRAFT STERILE",SUP-502AG25,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"PHCS [10601]",PHCS,,18522,70,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13176550,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 4MM AZUR DETACHABLE .035IN HYDROGEL",SUP-45-450415,CDM,S27800098,LOCAL,0278,RC,,,both,,,8514.60,2554.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3908.2,45.9,,,,,0,990.25,7237.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 10CM 6MM FLIXENE STD WALL ARTERIOVENOUS PTFE",SUP-25053,CDM,C1768,HCPCS,0278,RC,,,both,,,2591.03,777.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,307.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,301.34,2202.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESVR SHUNT BURRHOLE PROGAV 2 PEDIATRIC",SUP-FX445T,CDM,S27800098,LOCAL,0278,RC,,,both,,,18201.71,5460.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4914.46,27,,,,,0,2116.86,15471.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTHROCARE WAND 90 DEGREE",SUP-ASHA4250-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1377.81,413.34,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,936.91,68,,,,,0,160.24,1171.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL MONOFILAMENT ABSORBABLE LOW PROFILE",SUP-5954810,CDM,C1781,HCPCS,0278,RC,,,both,,,5208.00,1562.4,"CIGNA [10200]",Cigna,,3541.44,68,,,,,0,605.69,4426.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT SCORPION SUREFIRE ROTATOR CUFF",SUP-AR-13991N,CDM,S27000186,LOCAL,0270,RC,,,both,,,1190.70,357.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,809.68,68,,,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 28MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.518S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"CIGNA [10200]",Cigna,,1017.88,68,,1831.33,1831.33,1831.33,16,174.09,1272.35,"percent of total billed charges",
"ADPTR FEEDING SET 20FR ENDOVIVE ENFIT Y PORT",SUP-M00501261,CDM,S27000186,LOCAL,0270,RC,,,both,,,65.25,19.57,"CIGNA [10200]",Cigna,,44.37,68,,,,,0,7.59,55.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH 27FR ENDOSCOPIC OUTER 2 STPCOCK ROTATE NONSTERILE",SUP-A22021A,CDM,C1894,HCPCS,0272,RC,,,both,,,10209.17,3062.75,"MULTIPLAN [10600]",Multiplan,,8677.79,85,,,,,0,1187.33,8677.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 100CM 5FR .035IN C1",SUP-G08623,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"UHC [10700]","United Healthcare",,150.33,63.3,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREPARATION OF TC-99M-TETROFOSMIN 1.38 MG IV SOLUTION",RX-169822,CDM,A9502,HCPCS,0343,RC,08888-8878-17,NDC,both,1,UN,206.95,62.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,140.73,68,,,,,0,24.07,206.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 140MM 28-14MM 13FR TRIVASCULAR OVATION PRIME",SUP-TV-IL1428140-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3956.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVETIRACETAM 500 MG/5 ML VIAL",RX-77195,CDM,J1953,HCPCS,0636,RC,00409-1886-22,NDC,both,5,ML,35.22,10.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.33,29.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 6.7IN SEWALL HANDHELD SURGICAL 70X13MM",SUP-N3324,CDM,S27200284,LOCAL,0272,RC,,,both,,,1357.80,407.34,"KAISER [10500]",Kaiser,,909.73,67,,,,,0,157.91,1154.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL CANNULATED 5.5 MM SCR",SUP-AR-1218-55,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL CARDIO-GRIP DEBAKEY ANGLED 7IN PERIPHERAL",SUP-320250,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.00,228.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,90.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,88.5,646.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 15MM TORNIER AEQUALIS PERFORM SHOULDER PRESS",SUP-DWJ002,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"BLUE CROSS [10001]","Blue Cross PPO",,3538.98,39.2,,3949.44,3949.44,3949.44,"1 through 10",1049.96,7673.8,"percent of total billed charges",
"CATH EVERCROSS CROSSTEC 135CM 80MM 4MM .035IN BALLOON",SUP-AB35W04080135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"PHCS [10601]",PHCS,,474.01,70,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BUTTON 4CM 8MM PASSPORT CURVE HIP SILICONE 1 PIECE MOLD",SUP-AR-6592-08-40,CDM,S27000186,LOCAL,0270,RC,,,both,,,292.32,87.7,"PHCS [10601]",PHCS,,204.62,70,,,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US BPP W Nonstress Test",PX-402000023,CDM,76818,CPT,0402,RC,,,both,,,1663.12,498.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure count. Procedure 1, Fee schedule rate ($216.88). Procedures 2 - 999, Fee schedule rate ($108.44).",,,,0,,,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 80MM 2.3MM MIDAS REX LEGEND TAPE STERILE",SUP-F2/8TA23,CDM,S27200284,LOCAL,0272,RC,,,both,,,974.03,292.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EDWARDS EVOQUE VALVE (EVOQUE VALVE)48 MM",SUP-9850EV48,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MACH 1 55CM 6FR .07IN RENAL DOUBLE CURVE 1 GUIDING PTFE",SUP-M001196960,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE BENTSON VASCULAR STD 180CM 6CM .035IN STAINLESS STEEL",SUP-G01290,CDM,C1769,HCPCS,0272,RC,,,both,,,178.26,53.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COUPLER ANSTM 4MM RNG PIN ULTSNC",SUP-GEM2756-FC,CDM,S27200284,LOCAL,0272,RC,,,both,,,7569.30,2270.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LINE ANGIOGRAPHY 76.2CM 3.6MM 1.8MM 1200 PSI FEMALE TO MALE",SUP-91051302,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.77,17.63,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM TACKING L235CM ENDOSCOPIC HELIX DISPOSABLE X-TACK",SUP-M00505510,CDM,S27200284,LOCAL,0272,RC,,,both,,,5706.30,1711.89,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL DEBAKEY STRAIGHT 14IN VASCULAR TISSUE FLUTE",SUP-55-2065,CDM,S27200284,LOCAL,0272,RC,,,both,,,851.39,255.42,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MICROCATHETER CEREBROVASCULAR 150CM 2.6-2FR .019IN EXCELSIOR",SUP-M0031441910,CDM,S27200284,LOCAL,0272,RC,,,both,,,7801.42,2340.43,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EVERCROSS CROSSTEC 135CM 150MM 6MM .035IN BALLOON",SUP-AB35W06150135,CDM,C1725,HCPCS,0272,RC,,,both,,,1061.91,318.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,722.1,68,,,,,0,123.5,902.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONE IRRIGATION VISI-FLOW STOMA",SUP-022736,CDM,S27000186,LOCAL,0270,RC,,,both,,,44.02,13.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.12,37.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONE IRRIGATION VISI-FLOW STOMA",SUP-022736,CDM,S27000186,LOCAL,0270,RC,,,both,,,44.02,13.21,"AETNA [10100]","Aetna HMO/PPO",,35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.12,37.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER IRRIGATION PUMP PACK FLUSH",SUP-7501355,CDM,S27200284,LOCAL,0272,RC,,,both,,,46.34,13.9,"MULTIPLAN [10600]",Multiplan,,39.39,85,,,,,0,5.39,39.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM DARCO TITANIUM FOOT NONLOCK",SUP-DC2825120,CDM,C1713,HCPCS,0278,RC,,,both,,,567.00,170.1,"CIGNA [10200]",Cigna,,385.56,68,,1831.33,1831.33,1831.33,16,65.94,481.95,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL KNIFE SHORT LENGTH 230CM 1.7MM .9MM",SUP-KD-612U,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE FATHOM VASCULAR STRAIGHT 200CM 10CM .014IN PERIPHERAL",SUP-M001508100,CDM,C1769,HCPCS,0272,RC,,,both,,,1815.00,544.5,"FIRST HEALTH [10303]","First Health",,1452,80,,,,,0,211.08,1542.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X9MM ENDOSKELETON TC 6D 14MM MEDIUM CERVICAL",SUP-5166-1409-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross PPO",,4057.2,39.2,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL ORBITAL HA 20MM I O I",SUP-I00020S,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITROGLYCERIN 2 % TRANSDERMAL OINTMENT",RX-5606,CDM,,,0250,RC,00281-0326-08,NDC,both,1,GR,19.05,5.71,"CIGNA [10200]",Cigna,,12.95,68,,,,,0,2.22,16.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT STEM 80MM 17MM 1 AXIS PRESS FIT CEMENTED KNEE FEMORAL",SUP-6478-6-410,CDM,C1776,HCPCS,0278,RC,,,both,,,4905.90,1471.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,570.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,570.56,4170.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 08.0",SUP-DIB00U0080,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 22FR TUNGSTEN SILICONE MIC-KEY",SUP-0270-22-3.5-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0175,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT VALEO 36MM 120CM 7MM 6FR .035IN BILIARY SELF",SUP-EV07362CD,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"PHCS [10601]",PHCS,,6279,70,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 66MM 32MM 10D HIP CROSSFIRE OMNIFIT STERILE",SUP-2041C-3266,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"BLUE CROSS [10001]","Blue Cross PPO",,2758.9,39.2,,3949.44,3949.44,3949.44,"1 through 10",818.52,5982.3,"percent of total billed charges",
"PATCH SURGICAL SMALL CIRCLE 3IN VENTRAL 2 LAYER MONOFILAMENT",SUP-0010213,CDM,C1781,HCPCS,0278,RC,,,both,,,1828.07,548.42,"NOVANET [10819]",Novanet,,1371.05,75,,,,,0,212.6,1553.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 8CM 9MM BALLOON DILATATION OTW LOW",SUP-G30980,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 12MM 2.25MM BALLOON DILATATION PEBAX",SUP-1012404-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +6 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.060,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X22X10MM COROENT XL PEEK CERVICAL INTERBODY",SUP-6910250,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"NOVANET [10819]",Novanet,,17820,75,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 20MM 144CM 4MM",SUP-H7493941220400,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,902.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL 3MR ETCO2 O2 NONINTUBATE ADULT LOFLO NONSTERILE",SUP-989803144501,CDM,S27000186,LOCAL,0270,RC,,,both,,,132.81,39.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,60.96,45.9,,,,,0,15.45,112.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 22GA ACCURIAN STRAIGHT SHARP 10MM",SUP-AC0019,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP ACETABULAR 50MM CLUSTER HOLE MODULAR HIP",SUP-620205022,CDM,C1776,HCPCS,0278,RC,,,both,,,13372.20,4011.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3610.49,27,,,,,0,1555.19,11366.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 10MM 2.75MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP27510X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 100CM 11FR 15MM AIRWAY EXCHANGE 2 LUMEN TIP",SUP-G57627,CDM,S27200284,LOCAL,0272,RC,,,both,,,785.70,235.71,"CIGNA [10200]","Cigna Local Plus",,420.35,53.5,,,,,0,91.38,667.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ES-2 STARTER KIT",SUP-900-00036,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 10MM 2.75MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP27510X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"KAISER [10500]",Kaiser,,352.76,67,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT/GRAFT ENDOPROSTHESIS 15CM 31MM 14.5MM EXCLUDER",SUP-PXT311415,CDM,C1874,HCPCS,0278,RC,,,both,,,51439.50,15431.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5982.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5982.41,43723.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 70X40MM ARTHROFLEX THK1MM DECELLULARIZE",SUP-AFLEX401,CDM,Q4125,HCPCS,0636,RC,,,both,,,13196.25,3958.87,"PHCS [10601]",PHCS,,9237.38,70,,,,,0,1563.76,11216.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC THK.31IN MODIFIED ELLIPSE 1.69X1.93IN ALTRUA",SUP-S602,CDM,C1785,HCPCS,0275,RC,,,both,,,17250.00,5175,"PHCS [10601]",PHCS,,12075,70,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXERCISER HAND ROLYAN BLACK PLASTIC RUBBER LIGHTWEIGHT FRAME",SUP-A3488,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.81,15.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,21.7,41.1,,,,,0,6.14,44.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 50MM ARCOS A STD OFFSET HIP FEMUR PROXIMAL PPS",SUP-11-301300,CDM,C1776,HCPCS,0278,RC,,,both,,,39453.12,11835.94,"NOVANET [10819]",Novanet,,29589.84,75,,,,,0,4588.4,33535.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Proc Surgical Path Unlistd",PX-312000051,CDM,88399,CPT,0312,RC,,,both,,,253.65,76.09,"KAISER [10500]",Kaiser,,169.95,67,,,,,0,0.01,215.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT AORTIC 3.3CM 23MM",SUP-PLA230300,CDM,S27800098,LOCAL,0278,RC,,,both,,,19725.30,5917.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5645.38,28.62,,,,,0,2294.05,16766.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 28.9X1.02MM THK.64MM SHORT NARROW THIN STAINLESS",SUP-2108-140-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.94,69.58,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,157.72,68,,,,,0,26.97,197.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR MEDIUM 45MM ENDO GIA VASCULAR ARTICULATING",SUP-EGIA45AVM,CDM,S27200284,LOCAL,0272,RC,,,both,,,1211.76,363.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,824,68,,,,,0,140.93,1030,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM LCP STAINLESS STEEL CORTICAL T25 STARDRIVE",SUP-02.204.030,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,670.87,68,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM TKR POROUS PATELLA TIBIA",SUP-98000671003,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC THK.31IN MODIFIED ELLIPSE 1.69X1.93IN ALTRUA",SUP-S602,CDM,C1785,HCPCS,0275,RC,,,both,,,17250.00,5175,"UHC [10700]","United Healthcare",,10919.25,63.3,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCOPIC UPHOLD MESH SPRT SYSTEM VAGINAL APICAL",SUP-M0068318170,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 100CM 11FR 15MM AIRWAY EXCHANGE 2 LUMEN TIP",SUP-G57627,CDM,S27200284,LOCAL,0272,RC,,,both,,,785.70,235.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,93.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,91.38,667.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT DOUBLE-J 12CM 100CM 6FR .028IN URETERAL SILICONE PTFE",SUP-5201800,CDM,C2617,HCPCS,0278,RC,,,both,,,1212.57,363.77,"FIRST HEALTH [10303]","First Health",,970.06,80,,,,,0,141.02,1030.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCOPIC UPHOLD MESH SPRT SYSTEM VAGINAL APICAL",SUP-M0068318170,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X3 HUMERAL INSERT - 32MM X 4 CONSTRAINED",SUP-5571-C-3204,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"PHCS [10601]",PHCS,,7056,70,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CHAMPIONIR DES SYSTEM US 5-60",SUP-412500600USRD,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM .0135IN AXIUM PRIME 3D FRAME",SUP-FC-9-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4461.89,27,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR WHITE 55MM 28MM RINGLOC ECCENTRIC HIP",SUP-11-165234,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"KAISER [10500]",Kaiser,,4462.12,67,,,,,0,774.54,5660.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR ANGLE MULTIPURPOSE B CURVE",SUP-H787107349015,CDM,C1887,HCPCS,0272,RC,,,both,,,236.64,70.99,"PHCS [10601]",PHCS,,165.65,70,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1 KNEE RIGHT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517-F-102,CDM,C1776,HCPCS,0278,RC,,,both,,,22765.05,6829.51,"CIGNA [10200]","Cigna Open Access",,7626.29,33.5,,5302.19,4377.88,6578.61,27,2647.58,19350.29,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL BLACK 11CM 3MM UTAHBALL SHAFT",SUP-DBL-311,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,53.64,41.1,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 7.5MM BALL DISSECTING",SUP-MR8-9BA75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1187.46,356.24,"NOVANET [10819]",Novanet,,890.6,75,,,,,0,138.1,1009.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC",517,MS-DRG,,,,,,,inpatient,,,83996.53,25198.96,"CIGNA [10200]","Cigna Open Access",,16863.75,,"Fee schedule rate ($16,863.75). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,44865.49,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM STAINLESS STEEL T15 CORTEX SELF TAP LOW",SUP-02.206.220S,CDM,C1713,HCPCS,0278,RC,,,both,,,725.76,217.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,333.12,45.9,,,,,0,84.41,616.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla Class I & II Ab Qual",PX-302000220,CDM,86828,CPT,0302,RC,,,both,,,929.10,278.73,"BLUE CROSS [10001]","Blue Cross PPO",,82.01,,"Fee schedule rate ($82.01).",,,,0,57.17,789.74,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 4MM BALL DISSECTING DIAMOND",SUP-MR8-14BA40D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.17,412.25,"CIGNA [10200]","Cigna Local Plus",,735.18,53.5,,,,,0,159.82,1168.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 08.0",SUP-DIB00U0080,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,523.91,39.2,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 27MM 135CM 7MM 30MM BILIARY STAINLESS STEEL",SUP-PXB35-07-27-135,CDM,C1876,HCPCS,0278,RC,,,both,,,4347.00,1304.1,"MULTIPLAN [10600]",Multiplan,,3694.95,85,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Transparent",PX-E27200100,CDM,E27200100,LOCAL,0272,RC,,,both,,,162.36,48.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,19.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.88,138.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
RADIOTHERAPY,849,MS-DRG,,,,,,,inpatient,,,163131.53,48939.46,"BLUE CROSS [10001]","Blue Cross HMO",,62201.42,,,,,,,10994,67572.22,"case rate",
"KIT ABLATION STAR POWERCURVE SHORT BLISTER TRAY TUMOR",SUP-RF-1015S-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,22680.00,6804,"CIGNA [10200]","Cigna Open Access",,12904.92,56.9,,,,,0,2637.68,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 27MM 135CM 7MM 30MM BILIARY STAINLESS STEEL",SUP-PXB35-07-27-135,CDM,C1876,HCPCS,0278,RC,,,both,,,4347.00,1304.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1995.27,45.9,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 20CM 7FR 2 PIGTAIL CURVE",SUP-M0061921400,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"PHCS [10601]",PHCS,,794.93,70,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM TPS ROUND DIAMOND 5 STEP NOTCH NUMBER",SUP-5820-012-030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"FIRST HEALTH [10303]","First Health",,875.97,80,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ld Recovery 1st Hour",PX-710000002,CDM,9999144,LOCAL,0710,RC,,,both,,,3269.70,980.91,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1343.85,41.1,,,,,0,380.27,2779.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 6 12MM KNEE AOX REVISION CRUCIATE SUBSTITUTE R",SUP-151710612,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"CIGNA [10200]",Cigna,,5917.44,40,,5873.17,5873.17,5873.17,"1 through 10",1720.5,12574.56,"percent of total billed charges",
"SLING ORTHOPEDIC ARM ELEV CUTAWAY FOAM ADULT BLUE",SUP-8874-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,86.57,25.97,"PHCS [10601]",PHCS,,60.6,70,,,,,0,10.07,73.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 4CM 5FR ZIMMON PIGTAIL CURVE PANCREATIC",SUP-G21923,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 3MM BALLOON DILATATION OTW STERILE",SUP-593004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"KAISER [10500]",Kaiser,,976.86,67,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 2-0 FSL 36IN MONOFILAMENT ABSORBABLE",SUP-Y932H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROGESTERONE MICRONIZED 100 MG CAPSULE",RX-23122,CDM,,,0637,RC,70700-0162-01,NDC,both,1,UN,25.19,7.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.35,41.1,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ULTRAFLEX 12CM 9CM 18-23MM ESOPHAGEAL PTFE COVER",SUP-M00513740,CDM,C1874,HCPCS,0278,RC,,,both,,,11762.09,3528.63,"NOVANET [10819]",Novanet,,8821.57,75,,,,,0,1367.93,9997.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 14MM ORTHOLOC TITANIUM NITRIDE FOREFOOT LOCKING",SUP-5201020014,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CIGNA [10200]","Cigna Open Access",,981.53,56.9,,1144.80,304.56,2275.09,66,200.62,1466.25,"percent of total billed charges",
"STENT RETROMAX PLUS 28CM 7-14FR THIN WALL PIGTAIL CURVE",SUP-M0061451500,CDM,C2617,HCPCS,0278,RC,,,both,,,1557.47,467.24,"MULTIPLAN [10600]",Multiplan,,1323.85,85,,,,,0,181.13,1323.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Ren Arty >=2nd Ord",PX-361000093,CDM,36253,CPT,0361,RC,,,both,,,8002.05,2400.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6291,,"Case rate ($6,291). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,930.64,8002.05,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Ren Arty >=2nd Ord",PX-361000093,CDM,36253,CPT,0361,RC,,,both,,,8002.05,2400.61,"CIGNA [10200]","Cigna Open Access",,6428,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,930.64,8002.05,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cr Adenovirus 40-41 Ag, Eia",PX-300000040,CDM,87301,CPT,0302,RC,,,both,,,88.00,26.4,"BLUE CROSS [10001]","Blue Cross PPO",,0.09,.1,,,,,0,0.09,74.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cr Adenovirus 40-41 Ag, Eia",PX-300000040,CDM,87301,CPT,0302,RC,,,both,,,88.00,26.4,"KAISER [10500]",Kaiser,,58.96,67,,,,,0,0.09,74.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txcath Plc Stent Ea Add Vein",PX-361000327,CDM,37239,CPT,0361,RC,,,both,,,8118.63,2435.59,"KAISER [10500]",Kaiser,,5439.48,67,,,,,0,944.2,8118.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alcohols Biomarkers 1or 2",PX-301000506,CDM,80321,CPT,0301,RC,,,both,,,380.95,114.28,"CIGNA [10200]","Cigna Open Access",,251.75,,,,,,,0.38,323.81,"fee schedule",
"HC Rv Fem/Pop W Ather Sf Init",PX-361000712,CDM,37271,CPT,0361,RC,,,both,,,17083.20,5124.96,"FIRST HEALTH [10303]","First Health",,13666.56,80,,,,,0,1986.78,14520.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Hrt W/O Cntrst W Ca Test",PX-352000032,CDM,75571,CPT,0352,RC,,,both,,,300.00,90,"KAISER [10500]",Kaiser,,201,67,,,,,0,34.89,300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 80CM 2CM 8MM BALLOON",SUP-G52358,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALAMINE 8 %-ZINC OXIDE 8 % LOTION",RX-28055,CDM,,,0637,RC,00904-2533-21,NDC,both,177,ML,14.47,4.34,"KAISER [10500]",Kaiser,,9.69,67,,,,,0,1.68,12.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLER INTERNAL 33MM TITANIUM 4.8MM XL ANVIL ENDOSCOPIC LIN",SUP-EEAXL33,CDM,S27200284,LOCAL,0272,RC,,,both,,,2546.25,763.87,"CIGNA [10200]","Cigna Open Access",,1448.82,56.9,,,,,0,296.13,2164.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP 6701 CDI SENSOR ARTERIAL",SUP-6701,CDM,S27800098,LOCAL,0278,RC,,,both,,,174.00,52.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.5MM X 20MM TI",SUP-VAN-15200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,278.19,28.62,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR EXTRA BACKUP LAD",SUP-67006400,CDM,C1894,HCPCS,0272,RC,,,both,,,417.60,125.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,171.63,41.1,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45MM LINEAR CUTTER ARTICULATION TRIGGER LOCK",SUP-PSE45A,CDM,S27200284,LOCAL,0272,RC,,,both,,,5656.21,1696.86,"CIGNA [10200]",Cigna,,3846.22,68,,,,,0,657.82,4807.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Complement Functional Activity",PX-302000032,CDM,86161,CPT,0302,RC,,,both,,,380.00,114,"UHC [10700]","United Healthcare",,10.8,,,,,,,0.01,323,"fee schedule",
"HC Gastric Band Adjustment",PX-361000268,CDM,S2083,HCPCS,0361,RC,,,both,,,899.29,269.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,104.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.59,764.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN SX ENDO HEPARIN 35 RO 10MMX5CM 8FR 120CMCATH",SUP-VBHR100502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5369.51,28.62,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 12MM 1.5MM",SUP-SPL15012X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 34MM 140CM 4MM CORONARY",SUP-RSINT40034UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]",Cigna,,3769.92,68,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 35MM ENDOPATH ECHELON TITANIUM VASCULAR TISSUE",SUP-VASECR35,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE DCP LC-DCP 81MM STAINLESS STEEL SMALL FRAGMENT SET 7",SUP-241.37,CDM,C1713,HCPCS,0278,RC,,,both,,,1113.59,334.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,131.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,129.51,946.55,"percent of total billed charges",
"GRAFT BONE MAGNETOS 1CC 1-2MM ALLOGRAFT GRANULE PUTTY GOLD",SUP-703-029-US,CDM,C1713,HCPCS,0278,RC,,,both,,,2550.00,765,"BLUE CROSS [10001]","Blue Cross PPO",,999.6,39.2,,957.42,570.23,957.42,28,296.57,2167.5,"percent of total billed charges",
"SCR BONE 2MM 28MM ACUTRAK 2 STD",SUP-AT2-S28-S,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,377.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",370.71,2709.38,"percent of total billed charges",
"SURFACE ARTICULAR 14MM PERSONA MEDIAL CONGRUENT 8-9 C-D KNEE",SUP-42522100514,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS [10001]","Blue Cross PPO",,4224.36,39.2,,3949.44,3949.44,3949.44,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"SHEATH ZURPAZ .032IN MEDIUM ASYMMETRIC CURVE 92CM 72CM 8.5FR",SUP-M004USMCA85200,CDM,C1894,HCPCS,0272,RC,,,both,,,7714.20,2314.26,"NOVANET [10819]",Novanet,,5785.65,75,,,,,0,897.16,6557.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC LONG 6IN .062IN",SUP-AR-8941-6,CDM,C1769,HCPCS,0272,RC,,,both,,,365.40,109.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II VASCULAR J",SUP-1009664J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 150MM 10MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U10150090,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"BLUE CROSS [10001]","Blue Cross HMO",,4598.16,39.2,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 8CM 10MM 7FR BALLOON DILATATION",SUP-DR80108,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"KAISER [10500]",Kaiser,,922.59,67,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 16MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G816,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA [10200]","Cigna Open Access",,5690,56.9,,5302.19,4377.88,6578.61,27,1163,8500,"percent of total billed charges",
"SCR BONE 6.5MM 105MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.701S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"CIGNA [10200]",Cigna,,1672.39,68,,1831.33,1831.33,1831.33,16,286.03,2090.49,"percent of total billed charges",
"PRIMIDONE 250 MG TABLET",RX-6544,CDM,,,0637,RC,50268-0687-11,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000110,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE C TI ROD, 3.5X60MM PRE BENT",SUP-3943060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.5MM 15MM FULL THREAD LOCK SCR TIMAX ALPS",SUP-FP15,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"BLUE CROSS [10001]","Blue Cross HMO",,428.65,39.2,,957.42,156.86,7483.26,51,127.17,929.48,"percent of total billed charges",
"GWIRE HI-TORQUE WINN VASCULAR TAPER 190CM .014IN DURASTEEL",SUP-1012474,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"PHCS [10601]",PHCS,,674.73,70,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 11MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G611,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1109.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1089.28,7961.17,"percent of total billed charges",
"CATH MARINR 90CM 7FR 2-5-2MM SPACING 65MM REACH MC CURVE",SUP-072322M,CDM,C1730,HCPCS,0272,RC,,,both,,,2437.50,731.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,288.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 7FR MP CURVE GUIDING DURAFORM",SUP-M003101470,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,296.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 8CM 10MM 7FR BALLOON DILATATION",SUP-DR80108,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,160.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 12.5MM 7MM 4FR AMPLATZER .038IN NITINOL",SUP-9-AVP038-007,CDM,S27800098,LOCAL,0278,RC,,,both,,,7141.50,2142.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4856.22,68,,,,,0,830.56,6070.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 200MM 6FR 6MM .014IN BALLOON",SUP-2249-60200,CDM,C1725,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6334.2,68,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAMURAI VASCULAR 190CM J TIP",SUP-H74939302190J2,CDM,C1769,HCPCS,0272,RC,,,both,,,689.78,206.93,"PHCS [10601]",PHCS,,482.85,70,,,,,0,80.22,586.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC",277,MS-DRG,,,,,,,inpatient,,,187730.38,56319.11,"CIGNA [10200]","Cigna Open Access",,50683.42,,"Fee schedule rate ($50,683.42). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,134841.73,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC AUTOMATIC HANDLE PAD 35CM 5MM DIRECT DRIVE",SUP-C4130,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL SYMMETRY .4-1MM VESSEL 1",SUP-B-1VB,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.30,176.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,241.79,41.1,,,,,0,68.42,500.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 2CM 7MM BALLOON DILATATION",SUP-DR8072,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,160.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000030,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",188.41,1377,"percent of total billed charges",
"STEM FEMORAL 195MM 14MM MODULAR RESTORATION HA STRAIGHT CONE",SUP-6276-7-114,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"GRAFT VASCULAR 45CM 4-7MM STD WALL TAPER PERIPHERAL GORE-TEX",SUP-S47045,CDM,C1768,HCPCS,0278,RC,,,both,,,4692.00,1407.6,"CIGNA [10200]","Cigna Local Plus",,2510.22,53.5,,,,,0,545.68,3988.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 117MM STAINLESS STEEL 3.5MM SCR 6 HOLE VARIABLE ANGLE",SUP-02.127.220S,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1226.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"DISECT LAPAROSCOPIC 56.1CM 5MM DA VINCI S/SI ENDOWRIST",SUP-420143,CDM,S27200284,LOCAL,0272,RC,,,both,,,27090.00,8127,"CIGNA [10200]",Cigna,,18421.2,68,,,,,0,3150.57,23026.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 28CM 4.8FR URETERAL FIRM STERILE LATEX FREE",SUP-M0061456430,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"NOVANET [10819]",Novanet,,468.93,75,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT LAPAROSCOPIC 56.1CM 5MM DA VINCI S/SI ENDOWRIST",SUP-420143,CDM,S27200284,LOCAL,0272,RC,,,both,,,27090.00,8127,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3150.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3150.57,23026.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDELINER 145CM 20CM 6FR .07IN .056IN INTERVENTIONAL",SUP-5571,CDM,C1887,HCPCS,0272,RC,,,both,,,2775.00,832.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STPLR MEDIUM THICK CURVE 45MM TRI-STAPLE 2 STERILE",SUP-SIG45CTAMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1522.40,456.72,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE ZIP 16CM SKIN CLSR STERILE LATEX FREE DISPOSABLE",SUP-PS1160,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR AMPLATZ LEFT 2",SUP-67004000,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) NUVISION NON?NAV ICE CATHETER",SUP-M60,CDM,C1759,HCPCS,0272,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) ES-2 STARTER KIT",SUP-900-00036,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAMP SURGICAL VASCU-STATT II 75-80GM CLAMPING PRESSURE MIDI",SUP-1001-532,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.36,32.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BONE CEMENT STABILIT WITHOUT NDL VERTEBROPLASTY",SUP-VP-0010A,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 80CM 80MM 3.8FR 6MM BALLOON DILATATION OTW",SUP-39032-60808,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 14CM 7FR 18GA PEEL-AWAY 3MM .038IN TRANSSEPTAL",SUP-405108,CDM,C1892,HCPCS,0272,RC,,,both,,,261.00,78.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 90X19-13MM M-CLASS HALL THK1.19MM BEVEL COARSE",SUP-TN193-119-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,569.35,170.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE AORTIC 19MM 27MM 33MM TRIFECTA GLIDE 15MM ANNULUS",SUP-TFGT-27A,CDM,S27800098,LOCAL,0278,RC,,,both,,,38367.00,11510.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15346.8,40,,,,,0,4462.08,32611.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 122MM STAINLESS STEEL 2.7/3.5MM SCR 6 HOLE LCP BONE",SUP-02.112.142,CDM,C1713,HCPCS,0278,RC,,,both,,,3144.75,943.42,"NOVANET [10819]",Novanet,,2358.56,75,,,,,0,365.73,2673.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ndl Asp Absc/Hema/Bulla/Cyst",PX-510000004,CDM,10160,CPT,0761,RC,,,both,,,7071.53,2121.46,"BLUE CROSS [10001]","Blue Cross PPO",,2740.57,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,822.42,6010.8,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB CONGRU 10MM LFT 1-2",SUP-2041-0-1210,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"FIRST HEALTH [10303]","First Health",,2850,80,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 6MM LEIBINGER UNIVERSAL TITANIUM MANDIBULAR",SUP-5020406,CDM,C1713,HCPCS,0278,RC,,,both,,,458.02,137.41,"BLUE CROSS [10001]","Blue Cross PPO",,179.54,39.2,,957.42,570.23,957.42,28,53.27,389.32,"percent of total billed charges",
"CATH EUPHORA 142CM 10MM 2.75MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP27510X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRACTOR ABDOMINAL RIBBON TISSUE HAND HELD MALLEABLE 8IN LE",SUP-22-0017,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.04,24.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.72,41.1,,,,,0,9.54,69.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER HAPTIC C BICONVEX 13MM 6MM POSTERIOR",SUP-ZXR00U0205,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"NOVANET [10819]",Novanet,,558.75,75,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL MITRACLIP BUNDLE SGC0301 1 CDS0601 XTR",SUP-MBR0201,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]",Cigna,,68400,40,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL TLIF ANTERIOR 10X11X34MM 8DEG LORDOTIC MODULUS",SUP-1101348P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"MULTIPLAN [10600]",Multiplan,,24097.5,85,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTERNALBRACE FIXATION ULNAR COLLATERAL LIGAMENT",SUP-AR-7715,CDM,C1713,HCPCS,0278,RC,,,both,,,8541.86,2562.56,"CIGNA [10200]",Cigna,,5808.46,68,,1831.33,1831.33,1831.33,16,993.42,7260.58,"percent of total billed charges",
"LENS IOL 10 D +6 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.060,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"E-CATH TRAY 18G X 4'' (100MM) INDWELLING CATHETER SONOPLEX 2",SUP-TDL135,CDM,S27200284,LOCAL,0272,RC,,,both,,,603.45,181.03,"AETNA [10100]","Aetna HMO/PPO",,479.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.18,512.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 240MM 17MM REVISION MONOLITHIC REDAPT ROCKTITE",SUP-71354706,CDM,C1776,HCPCS,0278,RC,,,both,,,51237.90,15371.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,21058.78,41.1,,6417.48,6417.48,6417.48,"1 through 10",5958.97,43552.22,"percent of total billed charges",
"SYSTEM BONE CEMENT 10CM DELIVERY NDL 8GA STERILE NORIAN SRS",SUP-DLS-7083-01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 12MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0101200,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3455.66,68,,,,,0,591.02,4319.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 60MM 120MM 12MM .035IN 3MM VASCULAR VENOUS",SUP-VENUL12060,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC INTERVERTEBRAL 16MM 7MM PRESTIGE LP CERVICAL SPINE",SUP-6972670,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 5MMX39MM 7FR 80CMCATH HEPARIN",SUP-BXB053901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"FIRST HEALTH [10303]","First Health",,15603.84,80,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5-6MM 35MM CREO SPINE 2 OUTER DIAMETER",SUP-5119.2737,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 1.7CM 14FR ENTERAL FEEDING TUBE RADIOPAQUE LOW",SUP-0120-14-1.7,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CIGNA [10200]",Cigna,,529.76,68,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNQT VASCULAR 7.5IN 4 TUBE 1 WIRE SNARE SET QUICK TIE CAP",SUP-79013,CDM,S27200284,LOCAL,0272,RC,,,both,,,112.30,33.69,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RETRACTOR ABDOMINAL RIBBON TISSUE HAND HELD MALLEABLE 8IN LE",SUP-22-0017,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.04,24.61,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE ARTHROSCOPIC ENDOBLADE PLANTAR FASCIA RELEASE SYSTEM",SUP-AR-8856DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,6484.28,1945.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 10CMX6CMX.8MM DERMACELL AWM DERMIS",SUP-DCELL157,CDM,Q4122,HCPCS,0636,RC,,,both,,,27984.79,8395.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"TUBE GASTRO 20FR SILICONE LOW PROFILE TAPER DISTAL TIP",SUP-0120-20-2.3,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOBRONCHIAL 41FR RIGHT ADJUSTABLE VALVE RADIOPAQUE 2",SUP-126141,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.14,153.04,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL 0 D +13.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.135,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Open Access",,196.31,56.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) BRIOVAD BATTERY KIT",SUP-490025,CDM,Q0506,HCPCS,0624,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,11781,68,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY 2-5-2MM SPACING 1MM 6FR 115CM 4MM",SUP-401600R,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"AETNA [10100]","Aetna HMO/PPO",,804.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 1-2 13MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934380,CDM,C1776,HCPCS,0278,RC,,,both,,,18947.25,5684.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2245.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2203.57,16105.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 100CM 8FR 16MM AMPLATZER II .086IN",SUP-9-AVP2-016,CDM,S27800098,LOCAL,0278,RC,,,both,,,6589.50,1976.85,"AETNA [10100]","Aetna HMO/PPO",,5238.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,766.36,5601.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM 6.5MM LEGACY TITANIUM SPINAL MULTIAXIAL",SUP-7576535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Local Plus",,5107.56,53.5,,3978.14,359.25,3978.14,24,1110.3,8114.82,"percent of total billed charges",
"INSRT TIBIAL 7-8 13MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71933742,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1415.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1415.56,10345.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 55MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-207.055,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,31.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",31.82,232.58,"percent of total billed charges",
"SCR BONE 6.5MM 35MM 6.5MM LEGACY TITANIUM SPINAL MULTIAXIAL",SUP-7576535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"FIRST HEALTH [10303]","First Health",,7637.48,80,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORMULA BARREL BUR 12-FLUTE,(TAN/TAN)5.5MM ARTHROSCOPIC SHAV",SUP-0375951012,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"CIGNA [10200]","Cigna Local Plus",,172.22,53.5,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 106MM PRIMARY ANTHOLOGY POROUS 131D 4 STD",SUP-71356004,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13621.01,41.1,,6417.48,6417.48,6417.48,"1 through 10",3854.32,28169.98,"percent of total billed charges",
"DRAIN INCISION CLOSED WOUND SUCTION 4 FREE FLOW CHANNEL",SUP-072213,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.84,31.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,43.09,41.1,,,,,0,12.19,89.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 27CM 14.5FR 360D STD 2 BRANCH STRAIGHT POLYURETHANE",SUP-5733270,CDM,S27200284,LOCAL,0272,RC,,,both,,,1897.50,569.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1290.3,68,,,,,0,220.68,1612.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 5 LEFT MEDIAL RIGHT LATERAL PARTIAL",SUP-5620-B-501,CDM,C1776,HCPCS,0278,RC,,,both,,,6899.26,2069.78,"MULTIPLAN [10600]",Multiplan,,5864.37,85,,,,,0,802.38,5864.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,inpatient,,,34412.37,10323.71,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXABILITY SENSOR ENABLED ENSITE PRECISION MEDIGUIDE",SUP-A-FASE-JJ,CDM,C2630,HCPCS,0272,RC,,,both,,,12765.00,3829.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 130CM 20MM 6MM BALLOON",SUP-U3513062,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EZ STEER DS NAV 115CM 8MM 7FR 1-7-4MM SPACING F-J CURVE",SUP-BN7TCFJ8L,CDM,C1732,HCPCS,0272,RC,,,both,,,16477.20,4943.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"ELECTRD ELECTROSURGICAL BALL STERILE DISPOSABLE COAGULATION",SUP-27054N-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1113.89,334.17,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Tube Trach Neonatal",PX-E27200234,CDM,E27200234,LOCAL,0272,RC,,,both,,,212.30,63.69,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LEAD PACING 25CM ATRIAL VENTRICULAR BIPOLAR SCR IN ELECTRD",SUP-407625,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,259.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SUBSTITUTE 15CC 4-10MM CANCELLOUS CHIPS PUREBONE",SUP-PBC-41015,CDM,S27800098,LOCAL,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 54MM 32MM MARATHON",SUP-121932454,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"NOVANET [10819]",Novanet,,6083.21,75,,,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 7MM TI",SUP-VAN-25070-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,446.15,45.9,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ileoscopy Stoma W Bal Dil",PX-750000159,CDM,44381,CPT,0750,RC,,,both,,,4055.00,1216.5,"FIRST HEALTH [10303]","First Health",,3244,80,,,,,0,471.6,4055,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 FULL THREAD CORKSCREW FIBERWIRE 2 PEEK 14",SUP-AR-1927PSF-45,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"NOVANET [10819]",Novanet,,1683.29,75,,,,,0,261.02,1907.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 5MM BALLOON DILATATION STERILE LATEX",SUP-595012022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM DELTAXSFT 10 COIL DETACHABLE",SUP-DLX100406,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4155.24,45.9,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED II 100CM 6CM 9FR 22MM .035IN BALLOON DILATATION",SUP-611763,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"NOVANET [10819]",Novanet,,3988.53,75,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC L100MM DIA5MM BLADELESS WITH STABILITY S",SUP-B5LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,64.36,41.1,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 50MM COCR",SUP-VAL-35500-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"CIGNA [10200]",Cigna,,1428,68,,1831.33,1831.33,1831.33,16,244.23,1785,"percent of total billed charges",
"TI CERVICAL SPINE LOCKING",SUP-450.354,CDM,S27000186,LOCAL,0270,RC,,,both,,,5520.00,1656,"UHC [10700]","United Healthcare",,3494.16,63.3,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 42MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.042TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 30CM 14FR TUNGSTEN SILICONE 2.7CM MIC-KEY",SUP-0270-14-2.7-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,3027.60,908.28,"FIRST HEALTH [10303]","First Health",,2422.08,80,,,,,0,352.11,2573.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GARMENT CMPR CALF SEQ REPROC",SUP-MSALP1R,CDM,S27000186,LOCAL,0270,RC,,,both,,,75.26,22.58,"KAISER [10500]",Kaiser,,50.42,67,,,,,0,8.75,63.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SPRAY 100MM COSEAL SEAL 2 SPRAY HEAD 2 LUMEN CNCT HOSE",SUP-0600021,CDM,S25000001,LOCAL,0250,RC,,,both,,,540.38,162.11,"FIRST HEALTH [10303]","First Health",,432.3,80,,,,,0,62.85,459.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERLOOP 4-0 3/8 CIRCLE 10IN TAPER NDL BLUE 17.9MM",SUP-AR-7229-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 7MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620907,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS LOC SMALL CARDIAC PERCUTANEOUS 3D STERILE",SUP-DS2C100-42,CDM,C1893,HCPCS,0272,RC,,,both,,,2250.00,675,"AETNA [10100]","Aetna HMO/PPO",,1788.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK 143CM 8MM 4MM ROUND BALLOON DILATATION",SUP-1012453-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 24FR KNIFE LATEX FREE TUIP UROLOGY",SUP-M0068802571,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"KAISER [10500]",Kaiser,,346.04,67,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE PT VASCULAR J INTERMEDIATE 182CM .014IN",SUP-H7491216101J1,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3+ 10MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS3P10R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"CIGNA [10200]","Cigna Open Access",,5912.71,56.9,,5302.19,4377.88,6578.61,27,1208.52,8832.69,"percent of total billed charges",
"COIL EMBOLIZATION 6CM 2.5MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-02506,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7033.31,68,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER SMALL 5-24MM GRAFT MULTIPACK PLASTIC LATEX FREE",SUP-M002363200201,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.75,26.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.32,75.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 RIGHT KNEE CRUCIATE RETAINING CEMENTED",SUP-5510-F-202,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"CIGNA [10200]","Cigna Open Access",,5493.28,33.5,,5302.19,4377.88,6578.61,27,1907.07,13938.17,"percent of total billed charges",
"PASSER SUTURELASSO SD 45D LEFT CURVE 1.8MM 3.8MM THUMB PAD",SUP-AR-4068-45L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1190.70,357.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,489.38,41.1,,,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 100CM 5FR 1 CURVE ANGIOGRAPHIC SLX NYLON CEREBRAL",SUP-451535H0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,70.99,68,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 48MM STAINLESS STEEL FULL THREAD FOOT",SUP-214.748,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"PHCS [10601]",PHCS,,786.54,70,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 385CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-385,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PHCS [10601]",PHCS,,5288.85,70,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 8.5FR 18GA ARROW-FLEX .035IN PERCUTANEOUS",SUP-AK-09803-CDC,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INQUIRY 110CM 6FR ELECTROPHYSIOLOGY PUSH AND PULL",SUP-81105,CDM,C1730,HCPCS,0272,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VISIGLIDE 2 ENDOSCOPIC 4500MM 70MM .025IN FLUORINE",SUP-G-260-2545A,CDM,C1769,HCPCS,0272,RC,,,both,,,1288.95,386.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,152.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,149.9,1095.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 6X34X24MM 20 DEGREE",SUP-1921009P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA [10200]",Cigna,,13860,40,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL FINE 7IN DRSG STD PATTERN SERRATE HANDLE",SUP-06-0018,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.94,16.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,24.76,45.9,,,,,0,6.27,45.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 10X9MM PRECISION THK.51MM MEDIUM STAINLESS STEEL",SUP-2296-003-529,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"CIGNA [10200]","Cigna Local Plus",,144.57,53.5,,,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Potassium Urine 24hr",PX-301000367,CDM,84133,CPT,0301,RC,,,both,,,137.00,41.1,"KAISER [10500]",Kaiser,,91.79,67,,,,,0,0.01,116.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 3002041 ZEVO 41MM 2 LVL",SUP-3002041,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]",Cigna,,2998.8,68,,1831.33,1831.33,1831.33,16,512.88,3748.5,"percent of total billed charges",
"MD DOUBLE ARTERIAL CLAMP","SUP-GEM TKM-2",CDM,S27200284,LOCAL,0272,RC,,,both,,,582.39,174.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,67.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.73,495.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB ADULT 6.25X4.5IN MULTIFUNCTION ADHSV",SUP-22660R-,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.30,46.29,"MULTIPLAN [10600]",Multiplan,,131.16,85,,,,,0,17.95,131.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Hrt Morphology Congenital",PX-352000034,CDM,75573,CPT,0352,RC,,,both,,,1482.48,444.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,742,,,,,,,172.41,1482.48,"per diem",
"ADPTR LEAD 15CM BRADY 5.38MM IS-1 UNIPOLAR CNCT EXT LOW",SUP-6161,CDM,C1883,HCPCS,0278,RC,,,both,,,1875.00,562.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP LOCKING REAMER IRR ASPIR INTRAMEDULLARY BONE HARVEST",SUP-352.260S,CDM,S27200284,LOCAL,0272,RC,,,both,,,557.69,167.31,"CIGNA [10200]","Cigna Open Access",,317.33,56.9,,,,,0,64.86,474.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 47CM 14.5FR 15FR STRAIGHT POLYURETHANE GLIDEPATH",SUP-5397420,CDM,C1750,HCPCS,0278,RC,,,both,,,1875.00,562.5,"CIGNA [10200]","Cigna Open Access",,1066.88,56.9,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mod Sed Oth Phys Add 15min",PX-371000012,CDM,99157,CPT,0371,RC,,,both,,,151.32,45.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,69.46,45.9,,,,,0,17.6,128.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.3MM 150MM KIRSCHNER",SUP-P99-192-2315,CDM,C1713,HCPCS,0278,RC,,,both,,,146.16,43.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",17,124.24,"percent of total billed charges",
"HC Potassium Urine 24hr",PX-301000367,CDM,84133,CPT,0301,RC,,,both,,,137.00,41.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.06,,"Fee schedule rate ($5.06). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,116.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM YUKON SPINE OCCIPITOCERVICOTHORACIC",SUP-7601-03514,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"SCR BONE 4MM 50MM SOLERA CD HORIZON OSTEOGRIP TITANIUM COCR",SUP-54840004050,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"KAISER [10500]",Kaiser,,6396.39,67,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Potassium Urine 24hr",PX-301000367,CDM,84133,CPT,0301,RC,,,both,,,137.00,41.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7.44,,,,,,,0.01,116.45,"fee schedule",
"GWIRE 2O VASCULAR STRAIGHT 180CM .035IN HYDROPHILIC FIX CORE",SUP-H2OSTFS35180,CDM,C1769,HCPCS,0272,RC,,,both,,,348.00,104.4,"PHCS [10601]",PHCS,,243.6,70,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMNIOFIX INJECTABLE 40MG",SUP-AI-5050,CDM,Q4433,HCPCS,0636,RC,,,both,,,5002.50,1500.75,"NOVANET [10819]",Novanet,,3751.88,75,,,,,0,247.92,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17.5 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6",SUP-ZCT225175,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WATCHDOG (20-PACK)",SUP-H74939343021,CDM,C1725,HCPCS,0272,RC,,,both,,,422.82,126.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,287.52,68,,,,,0,49.17,359.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 15CM 6.5FR AIRGUARD VALVE STERILE",SUP-5515160,CDM,C1894,HCPCS,0272,RC,,,both,,,753.30,225.99,"AETNA [10100]","Aetna HMO/PPO",,598.87,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 24MM FUSION ACUTRAK 2.4MM 24MM SCR",SUP-ATF-024,CDM,S27200284,LOCAL,0272,RC,,,both,,,1657.50,497.25,"CIGNA [10200]","Cigna Local Plus",,886.76,53.5,,,,,0,192.77,1408.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPN NC 15MM 2.5MM BALLOON DILATATION CORONARY ACCEPTS 6",SUP-250-015-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"UHC [10700]","United Healthcare",,5241.24,63.3,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM PFC SIGMA TC3 4 KNEE LEFT TITANIUM CEMENTED",SUP-960880,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"AETNA [10100]","Aetna HMO/PPO",,4079.02,79.5,,10981.53,8986.79,12413.38,12,596.72,4361.21,"percent of total billed charges",
"HC Cors&Graft Angio W Rt Hrt Cath",PX-481000025,CDM,93457,CPT,0481,RC,,,both,,,19920.17,5976.05,"CIGNA [10200]","Cigna Local Plus",,8706,,"Case rate ($8,706). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1566.32,16932.14,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CALCAR 25MM RESTORATION +30MM OFFSET HIP MODULAR",SUP-6276-4-325,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6265.63,27,,,,,0,2698.86,19725.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LIVEWIRE 7FR MEDIUM CURL CURVE ELECTROPHYSIOLOGY DUO",SUP-401908,CDM,C1731,HCPCS,0272,RC,,,both,,,6348.00,1904.4,"AETNA [10100]","Aetna HMO/PPO",,5046.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,738.27,5395.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ldh Isoenzymes",PX-301000294,CDM,83625,CPT,0301,RC,,,both,,,97.50,29.25,"CIGNA [10200]",Cigna,,28.14,,,,,,,0.01,82.88,"fee schedule",
"HC Thora WO Img Guid",PX-361000280,CDM,32554,CPT,0361,RC,,,both,,,1947.78,584.33,"AETNA [10100]","Aetna HMO/PPO",,1548.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,226.53,1947.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trichomonas Vag Dirct Probe",PX-306000145,CDM,87660,CPT,0306,RC,,,both,,,607.05,182.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.46,,"Fee schedule rate ($21.46). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.61,515.99,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trichomonas Vag Dirct Probe",PX-306000145,CDM,87660,CPT,0306,RC,,,both,,,607.05,182.11,"CIGNA [10200]","Cigna Open Access",,44.11,,,,,,,0.61,515.99,"fee schedule",
"HC Cult Fungi Pres ID Blood",PX-306000067,CDM,87103,CPT,0306,RC,,,both,,,308.25,92.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.58,,"Fee schedule rate ($13.58). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,262.01,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Calprotectin",PX-301000521,CDM,83993,CPT,0301,RC,,,both,,,488.80,146.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.61,,"Fee schedule rate ($20.61). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.49,415.48,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERCROSS 130CM 80CM 2.4-3.2FR .017-.018IN 90D MICRO",SUP-5304,CDM,C1887,HCPCS,0272,RC,,,both,,,3740.00,1122,"NOVANET [10819]",Novanet,,2805,75,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 80MM 120CM 4.5MM 6FR VASCULAR NITINOL",SUP-S-45-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"MULTIPLAN [10600]",Multiplan,,7771.13,85,,,,,0,1063.27,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATHLETIS 135CM 40MM 8MM BALLOON DILATATION STERILE",SUP-H74939347080410,CDM,C1725,HCPCS,0272,RC,,,both,,,1449.90,434.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,985.93,68,,,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 40MM VIPER TITANIUM SPINE CORTICAL POLYAXIAL",SUP-186727740,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"STEM FEMORAL 117MM TRI-LOCK BPS GRIPTION 11 12/14 STD OFFSET",SUP-101204110,CDM,C1776,HCPCS,0278,RC,,,both,,,29153.25,8745.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3390.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3390.52,24780.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL STANDARD+ 20MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405520,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6571.15,68,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP CEMENTED FEMUR WITH OXINIUM HEAD XLPE CUP",SUP-71701003,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"AETNA [10100]","Aetna HMO/PPO",,19032.3,79.5,,10981.53,8986.79,12413.38,12,2784.22,20349,"percent of total billed charges",
"SCR BONE 5MM 75MM STAINLESS STEEL SELF TAP VARIABLE ANGLE",SUP-42.231.275,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"KAISER [10500]",Kaiser,,906.2,67,,,,,0,157.3,1149.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 11MM KNEE POSTERIOR STABILIZE UHMWPE",SUP-71420832,CDM,C1776,HCPCS,0278,RC,,,both,,,9998.10,2999.43,"MULTIPLAN [10600]",Multiplan,,8498.39,85,,,,,0,1162.78,8498.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 15MMX12MMX6CM",SUP-TSB121506A,CDM,C1874,HCPCS,0278,RC,,,both,,,49140.00,14742,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13267.8,27,,,,,0,5714.98,41769,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM NAIL-EX TITANIUM FULL THREAD HUMERAL",SUP-04.005.420S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,687.07,45.9,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ULTRA FINE NDL POINT TIP HIGHLY INSULATED EXTENDED",SUP-PS200-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2198.10,659.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,903.42,41.1,,,,,0,255.64,1868.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 180MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-409-180,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER INDEN 15MM 15DEG 26X34",SUP-3135.0715,CDM,S27800098,LOCAL,0278,RC,,,both,,,30870.00,9261,"PHCS [10601]",PHCS,,21609,70,,,,,0,3590.18,26239.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL HIP CONSTRUCT 2",SUP-CAP-SN-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1144.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1123.46,8211,"percent of total billed charges",
"BIT DRILL 88MM 1.5MM K WIRE ATTACH THREAD HOLE NONSTERILE",SUP-03.130.300,CDM,S27200284,LOCAL,0272,RC,,,both,,,576.07,172.82,"PHCS [10601]",PHCS,,403.25,70,,,,,0,67,489.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT NSC STRATA LUMBOPERITONEAL KIT LATEX FREE",SUP-44430,CDM,S27800098,LOCAL,0278,RC,,,both,,,41594.87,12478.46,"CIGNA [10200]",Cigna,,16637.95,40,,,,,0,4837.48,35355.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE OTSC 4MM 165CM 12MM 3.2MM ENDOSCOPIC TISSUE ANCHOR",SUP-200.1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3742.50,1122.75,"CIGNA [10200]","Cigna Open Access",,2129.48,56.9,,,,,0,435.25,3181.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12IN 18FR 3/18IN ARTERY THIN 1 PIECE",SUP-77418,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"CIGNA [10200]",Cigna,,304.64,68,,,,,0,52.1,380.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 STD 12MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS6S12L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"BLUE CROSS [10001]","Blue Cross HMO",,4073.43,39.2,,5311.50,4717.44,5388.59,31,1208.52,8832.69,"percent of total billed charges",
"(EVAL) EDWARDS PASCAL PRECISION TRANSCATHETER VALVE REPAIR S",SUP-20000STCL,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 65CM 4FR CB2 CURVE ANGIOGRAPHIC STAINLESS STEEL",SUP-465382CB2,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 1IN BREISKY 4IN 2 SLIGHT CURVE BLADE VAGINAL SURGICAL",SUP-52-2602,CDM,S27200284,LOCAL,0272,RC,,,both,,,908.98,272.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PREVAIL DCB 3.0X15MM",SUP-PRV030015CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 10CMX6CMX.8MM DERMACELL AWM DERMIS",SUP-DCELL157,CDM,Q4122,HCPCS,0636,RC,,,both,,,27984.79,8395.44,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SUT STAINLESS STEEL 4-0 V-26 TS 14IN 2 ARM MONOFILAMENT 2",SUP-540G,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.05,21.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Eeg WO Vid Ea 12-26hr Cont",PX-740000045,CDM,95710,CPT,0740,RC,,,both,,,7006.08,2101.82,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRICUSPID WIRE DELIVERY CATHETER, MEDIUM",SUP-26000-02,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,39.2,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 9.7CM 5MM CEREPAK MICRO UNIFORM DETACHABLE",SUP-FCX100509,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1538.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM SYNAPSE TITANIUM 50D T15 SPINE",SUP-04.614.026,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"HC Tracheostomy/Laryngectomy Shower Protector",PX-E27000255,CDM,A7523,HCPCS,0270,RC,,,both,,,330.00,99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE NONLOCK STD HEAD CANNULATED NONSTERILE SMALL",SUP-1437660,CDM,S27200284,LOCAL,0272,RC,,,both,,,1968.75,590.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"Bien-Air 40deg Curved Adenoid, Double Serrated, Convex, 4.0m",SUP-1600572,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AEON ENDOSTAPLER CURVED TIP RELOAD 30MM ORANGE",SUP-ASR30RC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GUARDWIRE 200CM 2.5CM .014IN 3-6IN .070IN .036IN",SUP-GEZ6200US,CDM,C1884,HCPCS,0272,RC,,,both,,,10488.00,3146.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 75CM 60MM 6MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171060670,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INDAPAMIDE 2.5 MG TABLET",RX-3879,CDM,,,0637,RC,62559-0511-01,NDC,both,1,UN,7.79,2.34,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR .071IN 3 DIMENSIONAL RIGHT CURVE",SUP-LA63DRCSH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X2IN DURAGEN CRANIAL DURA BOVINE CLLGN",SUP-ID-2205,CDM,,,0278,RC,,,both,,,3479.82,1043.95,"PHCS [10601]",PHCS,,2435.87,70,,,,,0,3.48,2957.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MISOPROSTOL 25 MCG TABLET (PARTIAL OF 100 MCG TABLET)",RX-4010628,CDM,,,0637,RC,08888-8887-85,NDC,both,.25,UN,6.27,1.88,"CIGNA [10200]",Cigna,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 6 14MM KNEE AOX FIX BEARING CRUCIATE RETAIN AT",SUP-151620614,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"MULTIPLAN [10600]",Multiplan,,9565.82,85,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDEAVOR SPRINT 24MM 142CM 3MM CORONARY STENT",SUP-ENSP30024UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5817.00,1745.1,"BLUE CROSS [10001]","Blue Cross PPO",,2280.26,39.2,,,,,0,676.52,4944.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX PERMALUME 40MM 194CM 10MM 8.5FR .035IN",SUP-M00570360,CDM,C1874,HCPCS,0278,RC,,,both,,,9360.00,2808,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1109.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR .09IN RIGHT BACKUP 4 CURVE GUIDING",SUP-LA8RBU40,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"AETNA [10100]","Aetna HMO/PPO",,290.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 11/13 TAPER 44MM HIP M SPECIFICATION",SUP-136566500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3170.51,28.62,,,,,0,1288.37,9416.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LITHO SURGICAL 1950MM 2 SHEATH PREASSEMBLE DISTAL WIRE GUIDE",SUP-BML-V232QR-26,CDM,S27200284,LOCAL,0272,RC,,,both,,,2442.00,732.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,284,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,284,2075.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +14.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.145,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Npwt <=50 Sq Cm Disp (Go)",PX-430000033,CDM,97607,CPT,0430,RC,,,both,,,934.00,280.2,"BLUE CROSS [10001]","Blue Cross PPO",,371.22,,"Per diem ($371.22).",,,,0,108.62,793.9,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEPERIDINE 50 MG TABLET",RX-4908,CDM,,,0637,RC,42806-0050-30,NDC,both,1,UN,185.50,55.65,"MULTIPLAN [10600]",Multiplan,,157.68,85,,,,,0,21.57,157.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH PORTEX STERILE LATEX FREE DISPOSABLE",SUP-101/596/080,CDM,S27200284,LOCAL,0272,RC,,,both,,,3247.05,974.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1490.4,45.9,,,,,0,377.63,2759.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 35MM 4.75MM CD HORIZON SOLERA PERCUTANEOUS CCM",SUP-641000035,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"PLATE NARROW 8 HOLE LOW PROFILE STRAIGHT BONE RIGHT CLAVICLE",SUP-70-0299,CDM,S27800098,LOCAL,0278,RC,,,both,,,6610.20,1983.06,"AETNA [10100]","Aetna HMO/PPO",,5255.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY FIXATION GOLD 115MM 11MM HELICAL",SUP-456.308S,CDM,C1713,HCPCS,0278,RC,,,both,,,4361.08,1308.32,"PHCS [10601]",PHCS,,3052.76,70,,,,,0,507.19,3706.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2/0 CARDIOXYL W/ PLEDGET 3 X 5MM 18MM",SUP-73P30AG,CDM,S27200284,LOCAL,0272,RC,,,both,,,645.98,193.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.13,549.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM AFFIX II BONE LUMBAR SPINE",SUP-7577045,CDM,S27800098,LOCAL,0278,RC,,,both,,,24141.60,7242.48,"PHCS [10601]",PHCS,,16899.12,70,,,,,0,2807.67,20520.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18386,CDM,,,0637,RC,68084-0708-95,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,3.35,53.5,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 39MM 135CM 10MM LOW PROFILE THIN",SUP-1012633-39,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"CIGNA [10200]","Cigna Local Plus",,4494,53.5,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 10MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240100200,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"BLUE CROSS [10001]","Blue Cross HMO",,2672.34,39.2,,,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,inpatient,,,37647.37,11294.21,"PHCS [10601]",PHCS,,3437,,,,,,,1476,24035.17,"per diem","Estimated amount calculated based on 1 day length of stay."
"INSTR BIOPSY PINK 16CM 18GA BARD MAX-CORE ANGLE 22MM",SUP-MC1816,CDM,S27200284,LOCAL,0272,RC,,,both,,,254.04,76.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.54,215.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 24CM 3CM 7FR .035IN 2",SUP-M006192142180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"NOVANET [10819]",Novanet,,1192.4,75,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL CORTICAL THK3-12MM HALVED ALLOGRAFT STRUT",SUP-450481,CDM,S27800098,LOCAL,0278,RC,,,both,,,7973.64,2392.09,"BLUE CROSS [10001]","Blue Cross HMO",,3125.67,39.2,,,,,0,927.33,6777.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 10MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620210,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"NOVANET [10819]",Novanet,,8440.43,75,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT POSTERIOR STABILIZE CEMENT LEGION",SUP-71423237,CDM,C1776,HCPCS,0278,RC,,,both,,,21886.20,6565.86,"FIRST HEALTH [10303]","First Health",,17508.96,80,,,,,0,2545.37,18603.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN IRRIGATION 25MM 19GA BISHOP-HARMON 30D STAINLESS STEEL",SUP-E4922,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.74,53.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,122.22,68,,,,,0,20.9,152.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE RIGHT PROXIMAL TIBIAL 82MM STAINLESS STEEL 4.5MM SCR",SUP-240.036,CDM,C1713,HCPCS,0278,RC,,,both,,,8587.74,2576.32,"NOVANET [10819]",Novanet,,6440.81,75,,,,,0,998.75,7299.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 56MM 9MM 5.4MM 4.7MM ZENITH SPIRAL-Z",SUP-G55219,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"NOVANET [10819]",Novanet,,15880.73,75,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 3-0 V-20 .5 CIRCLE 12IN 26MM CLSR SURGALLOY",SUP-VLOCL0614,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Deoxyribonuclease Ab",PX-302000035,CDM,86215,CPT,0302,RC,,,both,,,149.50,44.85,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,127.08,"per diem",
"BASEPLT TIBIAL ATTUNE 7 KNEE CEMENTED FIX BEARING STERILE",SUP-150600007,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"BLUE CROSS [10001]","Blue Cross PPO",,5881.59,39.2,,3949.44,3949.44,3949.44,"1 through 10",1744.97,12753.44,"percent of total billed charges",
"KIT SURGICAL OSTEOCOOL BONE ACCESS 8GA",SUP-OCN003,CDM,S27200284,LOCAL,0272,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KT ASCP FX 25MM 8MM BICEPTOR",SUP-72202358,CDM,C1713,HCPCS,0278,RC,,,both,,,2895.75,868.72,"PHCS [10601]",PHCS,,2027.03,70,,,,,0,336.78,2461.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 10.5IN 26FR SILICONE Y PORT GRADUATE SHAFT OPEN DISTAL",SUP-8884720265E,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.71,111.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,253.44,68,,,,,0,43.35,316.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 12/14 TAPER 32MM HIP BIOLOX DELTA",SUP-1365-32-320,CDM,C1776,HCPCS,0278,RC,,,both,,,12268.20,3680.46,"FIRST HEALTH [10303]","First Health",,9814.56,80,,,,,0,1426.79,10427.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 12MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0303,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross HMO",,371.5,39.2,,957.42,156.86,7483.26,51,110.22,805.55,"percent of total billed charges",
"GRAFT ENDOVASCULAR 12CM 14.5MM 26MM EXCLUDER TRUNK",SUP-CXT261412,CDM,C1874,HCPCS,0278,RC,,,both,,,71175.90,21352.77,"BLUE CROSS [10001]","Blue Cross PPO",,27900.95,39.2,,,,,0,8277.76,60499.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DOVER 16IN 18FR URETHRAL SILICONE NONPOROUS 30CC FOLEY",SUP-8887630187,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.36,43.01,"CIGNA [10200]","Cigna Open Access",,81.57,56.9,,,,,0,16.67,121.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX 1S REINFORCED TISSUE MATRIX, LONG-TERM RESORBABLE REI",SUP-F10266-1620G,CDM,C1781,HCPCS,0278,RC,,,both,,,31570.56,9471.17,"AETNA [10100]","Aetna HMO/PPO",,25098.6,79.5,,,,,0,3671.66,26834.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL RAPIDE 5-0 P-1 18IN BRAID COATED UNDYED",SUP-VR490,CDM,S27200284,LOCAL,0272,RC,,,both,,,71.48,21.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.31,60.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAX NEURON SELECT 105CM 9CM 6FR .04IN .035IN .038IN 1",SUP-PNS6F105H1,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 6-9 C-D KNEE RIGHT TIBIA",SUP-42521400512,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,939.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP CLUSTER HOLE HA TRIDENT II PSL E",SUP-742-11-54E,CDM,C1776,HCPCS,0278,RC,,,both,,,9502.96,2850.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1105.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1105.19,8077.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 5.5IN 12GA AORTIC ROOT STD INTRO FLANGE TIP",SUP-10012,CDM,S27200284,LOCAL,0272,RC,,,both,,,163.64,49.09,"PHCS [10601]",PHCS,,114.55,70,,,,,0,19.03,139.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 V-5 36IN 2 ARM BRAID 1 STRAND FIRM",SUP-PX17H,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.67,73.1,"CIGNA [10200]","Cigna Open Access",,138.65,56.9,,,,,0,28.34,207.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Proc Dx Unlisted",PX-320000172,CDM,76499,CPT,0320,RC,,,both,,,1329.98,398.99,"UHC [10700]","United Healthcare",,216.45,,,,,,,154.68,1130.48,"fee schedule",
"BLADE SHAVER 4MM PK DIEGO STRAIGHT SINUS SERRATE",SUP-7013-8000,CDM,S27200284,LOCAL,0272,RC,,,both,,,897.05,269.11,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMERGE MONORAIL 144CM 30MM 6FR 4MM .07IN BALLOON",SUP-H7493918930400,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL INTRAVENOUS FIRSTCHOICE 5% DEXTROSE 40 MEQ POTASSIUM",SUP-07904-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE 79MM 12.2MM 7.6MM TAPER DISTAL TIP DISPOSABLE INNER",SUP-8PERC,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.62,111.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT IMPL TITAN INFLATABLE PENILE PROS TUBE STERILE LATEX",SUP-519150,CDM,S27200284,LOCAL,0272,RC,,,both,,,4671.30,1401.39,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INPACT ADMIRAL 130CM 80MM 7MM BALLOON DILATATION",SUP-ADM07008013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC",271,MS-DRG,,,,,,,inpatient,,,180964.81,54289.44,"CIGNA [10200]","Cigna Local Plus",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 44%. Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 3-0 KS 30IN BRAID BLACK NONABSORBABLE",SUP-622H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPO 100CM 5FR .045IN LEFT CORONARY BYPASS CURVE",SUP-H749085261952,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EUPHORA 142CM 6MM 2.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2506X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL 3-0 CT-1 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J338H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WAND ESURG 195MM 3MM MULTIVAC 50D",SUP-72290004,CDM,S27200284,LOCAL,0272,RC,,,both,,,3476.25,1042.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE CORNERSTONE SR CORTICAL BLOCK 11X11X9MM",SUP-200911,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 15MM 140CM 3.5MM CORONARY STENT",SUP-LUN350R15US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRACTOR 12X55MM 8 1/2 CONCAVE BLADE CURVED DOWN OBWEGESER",SUP-7537,CDM,S27200284,LOCAL,0272,RC,,,both,,,908.58,272.57,"KAISER [10500]",Kaiser,,608.75,67,,,,,0,105.67,772.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROXYUREA 100 MG/ML ORAL SUSPENSION",RX-408879,CDM,,,0637,RC,08888-8885-95,NDC,both,50,ML,107.03,32.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.45,90.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 4.75MM CD HORIZON SOLERA COCRMO CAP",SUP-641003030,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"MARROW CELLU 74279-02M 12 GAUGE X 3.5",SUP-7427902M,CDM,S27200284,LOCAL,0272,RC,,,both,,,6718.88,2015.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3083.97,45.9,,,,,0,781.41,5711.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 11MM TITANIUM SPINAL",SUP-G6623511,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"PHCS [10601]",PHCS,,1312.5,70,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.3/4F DUO-DECA 2-10-2 S120CM",SUP-903257,CDM,C1731,HCPCS,0272,RC,,,both,,,8970.00,2691,"NOVANET [10819]",Novanet,,6727.5,75,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TADALAFIL 5 MG TABLET",RX-37400,CDM,,,0637,RC,43547-0049-03,NDC,both,1,UN,46.54,13.96,"PHCS [10601]",PHCS,,32.58,70,,,,,0,5.41,39.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PALMAZ GENESIS AVIATOR FLEXSEGMENT 14MM 135CM 4MM 17MM",SUP-PG1540BAX,CDM,C1876,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"FIRST HEALTH [10303]","First Health",,5934,80,,,,,0,862.66,6304.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 20CM PUMP SET",SUP-ES2820,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"MULTIPLAN [10600]",Multiplan,,53295,85,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTRUMENT SURGICAL RELINE FENESTRATE REPLACEABLE TIP NONSTE",SUP-1729023,CDM,S27000186,LOCAL,0270,RC,,,both,,,1395.23,418.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,948.76,68,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 25CM TWIST LOCK ROTATING SUT WING SUPER",SUP-15-966B,CDM,C1894,HCPCS,0272,RC,,,both,,,177.22,53.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.61,150.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 SURGALLOY 3-0 P-12 18IN CLSR ABSORBABLE",SUP-VLOCM0024,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.73,70.42,"CIGNA [10200]",Cigna,,159.62,68,,,,,0,27.3,199.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP LARGE 2 FLAP ENTRAINMENT ELBOW FOREHEAD PAD GRAB",SUP-989805610101,CDM,S27000186,LOCAL,0270,RC,,,both,,,208.37,62.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,24.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.23,177.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT CONSTRAIN LEGION OXINIUM",SUP-71421166,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"FIRST HEALTH [10303]","First Health",,46267.2,80,,,,,0,6726.09,49158.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUCICLOVINE F-18 INTRAVENOUS SOLUTION (12-13 MCI)",RX-411838,CDM,A9588,HCPCS,0343,RC,08888-8877-90,NDC,both,1,UN,755.00,226.5,"NOVANET [10819]",Novanet,,566.25,75,,,,,0,87.81,755,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 12CM 6MM BALLOON DILATATION OTW LOW",SUP-G30961,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY NERVE BLOCK 83MM 18GA 21GA E-CATH PLUS SONOPLEX",SUP-TDL142,CDM,C9812,HCPCS,0272,RC,,,both,,,611.55,183.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,280.7,45.9,,,,,0,71.12,519.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT POSTERIOR STABILIZE CEMENT LEGION",SUP-71423237,CDM,C1776,HCPCS,0278,RC,,,both,,,21886.20,6565.86,"PHCS [10601]",PHCS,,15320.34,70,,,,,0,2545.37,18603.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD 641000045 45MM PERC ROD 4.75MM CCM",SUP-641000045,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AETNA [10100]","Aetna HMO/PPO",,3505.95,79.5,,1521.93,481.35,16760.95,30,512.88,3748.5,"percent of total billed charges",
"STEM FEMORAL 124MM 12.5MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-00771101200,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"CIGNA [10200]","Cigna Local Plus",,6583.38,31.5,,5372.07,4581.20,7242.98,23,2430.63,17764.68,"percent of total billed charges",
"GWIRE STBL XS VASCULAR 180CM 3CM .014IN STEERABLE SUPER SOFT",SUP-527914,CDM,C1769,HCPCS,0272,RC,,,both,,,613.25,183.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,417.01,68,,,,,0,71.32,521.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.45 % IV BOLUS",RX-400292,CDM,,,0250,RC,00264-7802-10,NDC,both,500,ML,100.65,30.19,"FIRST HEALTH [10303]","First Health",,80.52,80,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEPARATOR THROMBECTOMY INDIGO",SUP-SEP7,CDM,C1757,HCPCS,0272,RC,,,both,,,11005.50,3301.65,"FIRST HEALTH [10303]","First Health",,8804.4,80,,,,,0,1279.94,9354.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 15MM GEMINUS TITANIUM DISTAL VOLAR RADIUS",SUP-PANL-35150-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,623.70,187.11,"MULTIPLAN [10600]",Multiplan,,530.15,85,,,,,0,72.54,530.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR 5X2CM ENCAP TECHNOLOGY PERICARDIAL",SUP-C0205,CDM,C1768,HCPCS,0278,RC,,,both,,,2874.38,862.31,"KAISER [10500]",Kaiser,,1925.83,67,,,,,0,334.29,2443.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 60MM 4FR 2.5MM ROUND TAPER LOW PROFILE",SUP-A2025-060,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP RIM CLUSTER HOLE TRITANIUM X3 MDM",SUP-502-03-56E,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"AETNA [10100]","Aetna HMO/PPO",,8321.12,79.5,,10981.53,8986.79,12413.38,12,1217.29,8896.8,"percent of total billed charges",
"BLADE SAW 25.5X5.5MM HALL MICROPOWER MICRO100 .6MM THK.4MM",SUP-5023-132,CDM,S27200284,LOCAL,0272,RC,,,both,,,225.94,67.78,"CIGNA [10200]","Cigna Open Access",,128.56,56.9,,,,,0,26.28,192.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 7MM 2MM STERILE",SUP-TR-S0702-S,CDM,C1776,HCPCS,0278,RC,,,both,,,15145.50,4543.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6224.8,41.1,,6417.48,6417.48,6417.48,"1 through 10",1761.42,12873.68,"percent of total billed charges",
"KNEE CONSTRUCT 3 UNICONDYLAR KNEE SYSTEM",SUP-CAP-STY-K3,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7767.9,41.1,,6417.48,6417.48,6417.48,"1 through 10",2198.07,16065,"percent of total billed charges",
"CATH MUSTANG 75CM 80MM 10MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171100870,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,136.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.25MM X 8.0MM",SUP-492250812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER TORQR 80CM 5FR 2MM SPACING DAO CURVE ELECTROPHYSIOL",SUP-04120DS,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"NOVANET [10819]",Novanet,,234.9,75,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 13CM 4.5MM STERLING 10000 RPM SPHERE LARGE HUB",SUP-H9111,CDM,S27000186,LOCAL,0270,RC,,,both,,,293.76,88.13,"CIGNA [10200]","Cigna Open Access",,167.15,56.9,,,,,0,34.16,249.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PROSTREAM VASCULAR 175CM 12CM .035IN TEFLON STAINLESS",SUP-41278-01,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 100MM 2.5MM BALLOON DILATATION RAPID",SUP-47525100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 240MM 6MM BALLOON DILATATION STERILE LATEX",SUP-596024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE CATH TEAL 6FT 4 ELECTROGRAM CONDUCTOR",SUP-C6TMRMST4SA,CDM,S27000186,LOCAL,0270,RC,,,both,,,2115.00,634.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 13.25CM NATRELLE INSPIRA P6.3CM EXTRA FULL",SUP-MSZ-X560,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT",005,MS-DRG,,,,,,,inpatient,,,1082957.65,324887.29,"AETNA [10100]","Aetna HMO/PPO",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $208,489. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 79.5%. Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,,,other,"IP STOP LOSS Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 11CM 4MM RAD 12 XPS 360D 5000 RPM SINUS CURVED",SUP-1884012,CDM,S27200284,LOCAL,0272,RC,,,both,,,1902.00,570.6,"UHC [10700]","United Healthcare",,1203.97,63.3,,,,,0,221.2,1616.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 10MM STAINLESS STEEL CORTICAL TRIMED CLAVICLE",SUP-HEX2.7-10,CDM,C1713,HCPCS,0278,RC,,,both,,,729.00,218.7,"CIGNA [10200]","Cigna Open Access",,414.8,56.9,,1144.80,304.56,2275.09,66,84.78,619.65,"percent of total billed charges",
"CAGE SPINAL TLIF ANTERIOR 8X11X34MM 8DEG LORDOTIC ALLOY MODU",SUP-1081348P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 20MM 2.5MM BALLOON DILATATION STERILE",SUP-225-203-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIXER BONE CEMENT REVOLUTION FEMUR STERILE LATEX FREE",SUP-0606-565-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,783.88,235.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,533.04,68,,,,,0,91.17,666.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 5FR 135CM POWERPICC 2 LUMEN GWIRE NITINOL",SUP-3275335,CDM,C1751,HCPCS,0272,RC,,,both,,,711.67,213.5,"UHC [10700]","United Healthcare",,450.49,63.3,,,,,0,82.77,604.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR ANGLE KUMPE CURVE ANGIOGRAPHIC",SUP-H787107327015,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.165 CLAREON",SUP-SY60WF.165,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) IMPLANT DELIVERY SYSTEM WITH IMPLANT LOADING TOOL",SUP-FG-1001-04,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 14X26X55MM 10",SUP-6214155,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"NOVANET [10819]",Novanet,,17955,75,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X15MM LUMINARY 10-11MM SPINE",SUP-14715,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8505,27,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 8CM 180CM 18MM 10.5FR ESOPHAGEAL",SUP-G57310,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"KAISER [10500]",Kaiser,,11785.03,67,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VANSONNENBERG SUMP 35CM 12FR LOOP DRNG FLEXIMA",SUP-M001273030,CDM,C1729,HCPCS,0272,RC,,,both,,,1053.00,315.9,"KAISER [10500]",Kaiser,,705.51,67,,,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ARTHROSCOPIC SUT RETRIEVAL",SUP-16.1018,CDM,S27200284,LOCAL,0272,RC,,,both,,,6652.15,1995.64,"FIRST HEALTH [10303]","First Health",,5321.72,80,,,,,0,773.65,5654.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM TRILOGY TIVANIUM HIP CORTICAL ACETABULAR",SUP-00625006535,CDM,C1713,HCPCS,0278,RC,,,both,,,691.60,207.48,"BLUE CROSS [10001]","Blue Cross HMO",,271.11,39.2,,957.42,156.86,7483.26,51,80.43,587.86,"percent of total billed charges",
"(EVAL) SUPIRA CATHETER",SUP-FG-04444,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 220MM 2.5MM BALLOON DILATATION PEBAX",SUP-H74939032252210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 85MM SHORT THREAD ANKLE FOOT CANNULATED",SUP-MSD01070085S,CDM,C1713,HCPCS,0278,RC,,,both,,,2235.00,670.5,"KAISER [10500]",Kaiser,,1497.45,67,,,,,0,259.93,1899.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC UNIVERSAL STD 52- IN SHOULDER ADJUSTABLE",SUP-79-84100,CDM,S27000186,LOCAL,0270,RC,,,both,,,53.68,16.1,"CIGNA [10200]",Cigna,,36.5,68,,,,,0,6.24,45.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 22MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-022,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"BLUE CROSS [10001]","Blue Cross HMO",,8330.31,39.2,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 18X9MM COALITION MIS 7D 15MM",SUP-3136.4109,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"NOVANET [10819]",Novanet,,13500,75,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR 44.5MM CARBIDE 7.9MM 4MM OVAL 8 FLUTE DENTAL",SUP-14-C0901,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.29,44.19,"PHCS [10601]",PHCS,,103.1,70,,,,,0,17.13,125.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP BASEPLT TIBIAL ATTUNE CEMENT ROTATE PLATFORM",SUP-OSC372206,CDM,C1776,HCPCS,0278,RC,,,both,,,20790.00,6237,"CIGNA [10200]","Cigna Local Plus",,6548.85,31.5,,5372.07,4581.20,7242.98,23,2417.88,17671.5,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL ROLLER BALL 3MM 26FR CIRCON CLASSIC",SUP-M0068802561,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"KAISER [10500]",Kaiser,,346.04,67,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 12MM 145CM 2.75MM CORONARY STENT",SUP-1145275-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 56MM 11MM 5.4MM 4.7MM ZENITH SPIRAL-Z",SUP-G55225,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5717.06,27,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIPHERAL CUTTING BALLOON 90CM 20MM 5MM BALLOON",SUP-M001PCB5020900,CDM,C1725,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"UHC [10700]","United Healthcare",,2948.2,63.3,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835L-12,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",155.43,1136.03,"percent of total billed charges",
"SUT POLYSORB 3-0 SK 48IN BRAID COATED VIOLET ABSORBABLE",SUP-EL-450,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.26,54.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.96,153.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT 13CM 5.5MM AGGRESSIVE SURGICAL STERILE DISPOSABLE",SUP-AR-8550DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"MULTIPLAN [10600]",Multiplan,,426.53,85,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Hip WO Anes",PX-361000047,CDM,27093,CPT,0361,RC,,,both,,,1086.44,325.93,"UHC [10700]","United Healthcare",,1086.44,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,126.35,1086.44,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 24CM PROXIMAL HUMERAL NAIL-EX INTRAMEDULLARY",SUP-04.001.428S,CDM,C1713,HCPCS,0278,RC,,,both,,,9216.74,2765.02,"PHCS [10601]",PHCS,,6451.72,70,,,,,0,1071.91,7834.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 550MM 1.3MM KIRSCHNER ES2 SPINE NITINOL BLUNT",SUP-48280232,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 8CM 180CM 20MM 10.5FR ESOPHAGEAL",SUP-G57341,CDM,C1874,HCPCS,0278,RC,,,both,,,18118.80,5435.64,"KAISER [10500]",Kaiser,,12139.6,67,,,,,0,2107.22,15400.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CORTICAL CANCELLOUS BLOCK FREEZE",SUP-245041,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BILIARY 5MM 15MM 150CM SMALL PREMOUNT BALLOON EXPAND",SUP-37911-51515,CDM,C1876,HCPCS,0278,RC,,,both,,,6210.00,1863,"NOVANET [10819]",Novanet,,4657.5,75,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X8MM CLYDESDALE PTC 0D PEEK TITANIUM",SUP-4980850,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX PERMALUME 40MM 194CM 10MM 8.5FR .035IN",SUP-M00570360,CDM,C1874,HCPCS,0278,RC,,,both,,,9360.00,2808,"BLUE CROSS [10001]","Blue Cross PPO",,3669.12,39.2,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE HUMERAL 8MM COMPREHENSIVE SHOULDER POSITIONING",SUP-113576,CDM,C1776,HCPCS,0278,RC,,,both,,,1518.10,455.43,"CIGNA [10200]","Cigna Local Plus",,812.18,53.5,,5372.07,4581.20,7242.98,23,176.56,1290.39,"percent of total billed charges",
"GRAFT VASCULAR 70CM 8MM GORE PROPATEN STD WALL",SUP-HAX01A,CDM,C1768,HCPCS,0278,RC,,,both,,,24412.50,7323.75,"CIGNA [10200]","Cigna Open Access",,8178.19,33.5,,,,,0,2839.17,20750.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"ENDOCRINE DISORDERS WITH MCC",643,MS-DRG,,,,,,,inpatient,,,41516.82,12455.05,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,21953.35,,"Case rate ($10,210.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,481.47, add-ons for qualifying new technology services are included. If operating cost exceeds $42,521.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,098.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $9,494.01. The transfer operating threshold is the transfer adjustment factor * $9,481.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.85. The transfer capital threshold is the transfer adjustment factor * $716.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,41052.09,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 8MM 144CM 2.75MM CORONARY STENT",SUP-H7493952808270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1592.7,28.62,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DAPTOMYCIN 500 MG VIAL IV PUSH",RX-408642,CDM,J0878,HCPCS,0636,RC,71288-0016-15,NDC,both,1,UN,226.52,67.96,"NOVANET [10819]",Novanet,,169.89,75,,,,,0,17.48,226.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 3MM 1.5MM 1.2MM BALLOON DILATATION RAPID",SUP-DC-RY3012UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 80MM 2MM BALLOON DILATATION DURALYN",SUP-48002008X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 6-5.6MM 260MM 90MM XCALIBER OSTEOTITE HA",SUP-99-612690,CDM,C1713,HCPCS,0278,RC,,,both,,,986.18,295.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,670.6,68,,,,,0,114.69,838.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 120MM 120CM 18MM .035IN 3MM VASCULAR VENOUS",SUP-VENUL18120,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"BLUE CROSS [10001]","Blue Cross HMO",,9137.52,39.2,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPENDIX PROCEDURES WITHOUT CC/MCC",399,MS-DRG,,,,,,,inpatient,,,57452.94,17235.88,"BLUE CROSS [10001]","Blue Cross HMO",,26278.64,,,,,,,7100.65,33420.66,"case rate",
"PLATE 116MM STAINLESS STEEL 2.7/3.5MM SCR 4 HOLE TAPER TIP",SUP-02.107.204S,CDM,C1713,HCPCS,0278,RC,,,both,,,6595.85,1978.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3027.5,45.9,,,,,0,767.1,5606.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 130CM 40MM 4MM BALLOON DILATATION",SUP-ADM04004013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"KAISER [10500]",Kaiser,,5408.91,67,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 105MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.905,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"PHCS [10601]",PHCS,,962.09,70,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 21MM 16.7MM MASTER-SERIES PYROLYTIC CARBON",SUP-21AECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11647.69,40,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC",072,MS-DRG,,,,,,,inpatient,,,38490.61,11547.18,"BLUE CROSS [10001]","Blue Cross HMO",,17359.92,,,,,,,4690.75,18858.87,"case rate",
"IMPL BREAST SMOOTH MOD + PROF XTRA 295CC",SUP-SMPX295,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"PHCS [10601]",PHCS,,5216.4,70,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immobilizer Shoulder",PX-E27000114,CDM,L3670,HCPCS,0274,RC,,,both,,,135.30,40.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,92,68,,,,,0,15.74,115.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 8MM 4.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP4508X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 24MM 75CM 6MM 100CM",SUP-M001712000,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,983.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 12MM 3.75MM BALLOON DILATATION STERILE",SUP-237-123-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 3 X 4 COMPLEX PICO COIL",SUP-10USC03004,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"FIRST HEALTH [10303]","First Health",,10460.4,80,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 3MM 1.5MM 1.2MM BALLOON DILATATION RAPID",SUP-DC-RY3012UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"UHC [10700]","United Healthcare",,625.53,63.3,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 62MM 32MM MARATHON",SUP-121932462,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5515.45,68,,,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM TRICUSPID CONTOUR 3D TITANIUM",SUP-690R26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 8-0 TG160-6 12IN 2 ARM BRAID COATED VIOLET",SUP-J975G,CDM,S27200284,LOCAL,0272,RC,,,both,,,199.77,59.93,"CIGNA [10200]","Cigna Open Access",,113.67,56.9,,,,,0,23.23,169.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Cath Fecal Mgmt Instaflo",PX-E27000120,CDM,E27000120,LOCAL,0270,RC,,,both,,,1096.70,329.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,129.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.55,932.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Breast WO Cntrst Bi",PX-610000059,CDM,77047,CPT,0614,RC,,,both,,,4692.54,1407.76,"MULTIPLAN [10600]",Multiplan,,3988.66,85,,,,,0,545.74,3988.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY INTRO XPANDER ONE-STEP KYPHOPAK KYPHX FIRST FRACTURE",SUP-KPT1005,CDM,C1894,HCPCS,0272,RC,,,both,,,11021.40,3306.42,"MULTIPLAN [10600]",Multiplan,,9368.19,85,,,,,0,1281.79,9368.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 100MM 3MM BALLOON DILATATION",SUP-H74939147301010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 34CM LEFT TROCHANTERIC INTRAMEDULLARY 130D",SUP-456.355S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1619.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1589.87,11619.86,"percent of total billed charges",
"PLATE BROAD 206X17.5X5.2MM STAINLESS STEEL 4.5MM SCR LARGE",SUP-226.611,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR .071IN JUDKINS RIGHT 4.5 CURVE GUIDING",SUP-LA6JR45,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT STEM 80MM 14MM 1 AXIS PRESS FIT CEMENT KNEE VITALLIUM",SUP-6478-6-399,CDM,C1776,HCPCS,0278,RC,,,both,,,3364.45,1009.33,"FIRST HEALTH [10303]","First Health",,2691.56,80,,,,,0,391.29,2859.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL JOINT PACK (TJUHR)215",SUP-SOP21TJU10,CDM,S27200284,LOCAL,0272,RC,,,both,,,976.86,293.06,"KAISER [10500]",Kaiser,,654.5,67,,,,,0,113.61,830.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 60MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.124,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,99.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",99.7,728.71,"percent of total billed charges",
"TOTAL JOINT PACK (TJUHR)215",SUP-SOP21TJU10,CDM,S27200284,LOCAL,0272,RC,,,both,,,976.86,293.06,"AETNA [10100]","Aetna HMO/PPO",,776.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.61,830.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM 13.5MM NECK SECUR-FIT MAX HA 127D 11 51MM",SUP-6052-1140S,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"PHCS [10601]",PHCS,,15975.23,70,,,,,0,2654.17,19398.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK INSTR PROSTEP STERILE MIS",SUP-57S1MI07,CDM,S27200284,LOCAL,0272,RC,,,both,,,2077.50,623.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1412.7,68,,,,,0,241.61,1765.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 24MM 75CM 6MM 100CM",SUP-M001712000,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"BLUE CROSS [10001]","Blue Cross PPO",,3313.38,39.2,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 11MM PRIMARY SECUR-FIT PLUS HA 7 30MM HIP",SUP-6054-0711S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"KAISER [10500]",Kaiser,,10830.84,67,,,,,0,1880.04,13740.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 12MM 140CM .91-1.12MM 3MM CORONARY",SUP-RONYX30012W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"FIRST HEALTH [10303]","First Health",,4351.2,80,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND MULTIPASS 5-0 PC-3 18IN BRAID BLACK",SUP-1925G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSORB GT1 8MM 3MM CORONARY EVEROLIMUS ELUTING POLY L",SUP-1235300-08,CDM,C1874,HCPCS,0278,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross HMO",,3245.76,39.2,,9776.84,9776.84,9776.84,"1 through 10",962.96,7038,"percent of total billed charges",
"SCR BONE 4.5MM 40MM SOLERA CD HORIZON OSTEOGRIP TITANIUM",SUP-54840004540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"MULTIPLAN [10600]",Multiplan,,8114.82,85,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20GA 8CM POWERGLIDE 1.3IN .014IN 5ML/SEC FULL",SUP-M020081,CDM,C1751,HCPCS,0272,RC,,,both,,,607.50,182.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,71.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 18FR STD URETHRAL RUBBER HYDROGEL MALE",SUP-0102L18,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.57,27.77,"UHC [10700]","United Healthcare",,58.6,63.3,,,,,0,10.77,78.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 5FR 21GA MERIT MAK .018IN NITINOL GWIRE",SUP-MAK501N-PED,CDM,C1894,HCPCS,0272,RC,,,both,,,241.86,72.56,"NOVANET [10819]",Novanet,,181.4,75,,,,,0,28.13,205.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ORTHOCORD 2 MO-6 TAPER BRAID HIGH STRENGTH BLUE VIOLET",SUP-223115,CDM,S27200284,LOCAL,0272,RC,,,both,,,718.23,215.47,"CIGNA [10200]",Cigna,,488.4,68,,,,,0,83.53,610.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 1.7MM 120CM SUPERTRAX",SUP-AKI00100-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,620.46,186.14,"NOVANET [10819]",Novanet,,465.35,75,,,,,0,72.16,527.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK LAPAROSCOPIC 8MM ENDOWRIST PERMANENT CAUT GRASPING",SUP-470183,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,120.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 80CM 4CM 5FR 6MM 7.5MM BALLOON DILATATION",SUP-4196040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.3MM 36MM POLARUS 3 HEXALOBE LOW PROFILE HUMERUS",SUP-3011-43036-S,CDM,C1713,HCPCS,0278,RC,,,both,,,1142.10,342.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,135.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,132.83,970.79,"percent of total billed charges",
"SCR BASEPLT 22MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ322,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"FIRST HEALTH [10303]","First Health",,769.6,80,,,,,0,111.88,817.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 8MM KNEE LEFT MEDIAL RIGHT LATERAL X3 PARTIAL",SUP-5630-G-608,CDM,C1776,HCPCS,0278,RC,,,both,,,5309.55,1592.86,"NOVANET [10819]",Novanet,,3982.16,75,,,,,0,617.5,4513.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 6-5.6MM 260MM 90MM XCALIBER OSTEOTITE HA",SUP-99-612690,CDM,C1713,HCPCS,0278,RC,,,both,,,986.18,295.85,"KAISER [10500]",Kaiser,,660.74,67,,,,,0,114.69,838.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLIDESHEATH SLENDER A KIT, 0.021 GW, 5 FR, 10CM",SUP-60-1050,CDM,C1894,HCPCS,0272,RC,,,both,,,761.40,228.42,"AETNA [10100]","Aetna HMO/PPO",,605.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Candida Ab",PX-302000105,CDM,86628,CPT,0302,RC,,,both,,,58.49,17.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.61,,"Fee schedule rate ($12.61). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,49.72,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRITANIUM SYMMETRIC METAL BACKED PATELLA S39X11",SUP-5556-L-391,CDM,C1776,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 15FTX5IN ROLL FIBERGLASS ORTHO-GLASS LATEX",SUP-OG-5L2,CDM,S27000186,LOCAL,0270,RC,,,both,,,614.99,184.5,"MULTIPLAN [10600]",Multiplan,,522.74,85,,,,,0,71.52,522.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 4-0 PC-3 18IN MONOFILAMENT BLUE",SUP-8634G,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.79,20.34,"PHCS [10601]",PHCS,,47.45,70,,,,,0,7.88,57.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 0 54IN MONOFILAMENT TIES YELLOWISH TAN ABSORBABLE",SUP-S104H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 3DEMIN ALLOGRAFT BOAT PLIABLE OSTEOCONDUCTIVE",SUP-109785,CDM,C1713,HCPCS,0278,RC,,,both,,,16422.00,4926.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1946.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1909.88,13958.7,"percent of total billed charges",
"BLADE 3INX20MM OSTEOTOM THIN MRI STERILE LATEX FREE",SUP-47998602123,CDM,S27200284,LOCAL,0272,RC,,,both,,,996.30,298.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,118.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION TRANSEND 130CM 165CM 2.4FR .014IN MICRO BERN",SUP-M001195840,CDM,C1887,HCPCS,0272,RC,,,both,,,6382.50,1914.75,"FIRST HEALTH [10303]","First Health",,5106,80,,,,,0,742.28,5425.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +23 DIOPTER 13MM 6MM POSTERIOR CHMBR 3 PIECE",SUP-Z9002230,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,501.92,45.9,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INTELLANAV ST 110CM 7FR 4MM 2.5MM SPACE STD CURVE",SUP-M004R5031TH0,CDM,C1733,HCPCS,0272,RC,,,both,,,14145.00,4243.5,"MULTIPLAN [10600]",Multiplan,,12023.25,85,,,,,0,1645.06,12023.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +27 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.270,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 5IN .25IN STD STAINLESS STEEL TWIST NONSTERILE",SUP-KM166-00-08,CDM,C1713,HCPCS,0278,RC,,,both,,,80.04,24.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,9.31,68.03,"percent of total billed charges",
"HC Lithium",PX-301000046,CDM,80178,CPT,0301,RC,,,both,,,243.20,72.96,"KAISER [10500]",Kaiser,,162.94,67,,,,,0,0.01,206.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM WIDE BLADE LIPPED 5.5",SUP-7541213,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,1831.33,1831.33,1831.33,16,348.9,2550,"percent of total billed charges",
"COIL EMBOLIZATION 50CM 10MM INTERLOCK FIBERED IDC 18 COIL",SUP-M001361920,CDM,S27800098,LOCAL,0278,RC,,,both,,,4843.80,1453.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,573.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,563.33,4117.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 6-5.6MM 260MM 90MM XCALIBER OSTEOTITE HA",SUP-99-612690,CDM,C1713,HCPCS,0278,RC,,,both,,,986.18,295.85,"BLUE CROSS [10001]","Blue Cross PPO",,386.58,39.2,,957.42,570.23,957.42,28,114.69,838.25,"percent of total billed charges",
"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC",576,MS-DRG,,,,,,,inpatient,,,235566.99,70670.1,"CIGNA [10200]","Cigna Local Plus",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 44%. Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 2.9 MM PUSHLOCK",SUP-AR-1923DL,CDM,S27200284,LOCAL,0272,RC,,,both,,,807.98,242.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 6FR .071IN JUDKINS RIGHT 4.5 CURVE GUIDING",SUP-LA6JR45,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOTRACHEAL 5MM NASAL ORAL UNCUFF REINFORCE MURPHY TIP",SUP-5-12910,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.11,36.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAPPHIRE? II PRO SZ PTCA BALLOON SEMI-COMPLIANT 1.25 MM X 10",SUP-212-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BOTTLE DRNG DISCHARGE PACK ROCKET IPC 1000ML NONSTERILE",SUP-R51411-DP,CDM,S27200284,LOCAL,0272,RC,,,both,,,556.88,167.06,"MULTIPLAN [10600]",Multiplan,,473.35,85,,,,,0,64.77,473.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 3.5MM 106MM STAINLESS STEEL 3.5MM SCREWS SMALL",SUP-245.19,CDM,C1713,HCPCS,0278,RC,,,both,,,3288.60,986.58,"FIRST HEALTH [10303]","First Health",,2630.88,80,,,,,0,382.46,2795.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CSGWORLEY 109M SAFESHTH GDE",SUP-CSGWORLEY109M,CDM,C1892,HCPCS,0272,RC,,,both,,,2437.50,731.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,288.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HIP FEM P2 POROUS OFFSZ14",SUP-425-97-014,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"CIGNA [10200]","Cigna Open Access",,14257.08,33.5,,5302.19,4377.88,6578.61,27,4949.55,36174.68,"percent of total billed charges",
"COIL EMBOLIZATION 20CM 15MM INTERLOCK FIBERED IDC 35 COIL",SUP-M001363640,CDM,S27800098,LOCAL,0278,RC,,,both,,,3891.60,1167.48,"BLUE CROSS [10001]","Blue Cross PPO",,1525.51,39.2,,,,,0,452.59,3307.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT CEMENTED CRUCIATE RETAINING ATTUNE",SUP-150400105,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"CIGNA [10200]","Cigna Open Access",,7501.77,33.5,,5302.19,4377.88,6578.61,27,2604.35,19034.35,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 12MM 140CM .91-1.12MM 3MM CORONARY",SUP-RONYX30012W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,644.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 18.8CM RIBFIX TITAN NONSTERILE LATEX FREE REUSABLE",SUP-323.8001,CDM,S27000186,LOCAL,0270,RC,,,both,,,4422.90,1326.87,"AETNA [10100]","Aetna HMO/PPO",,3516.21,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,514.38,3759.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM CORTICAL RAYHACK GENERATION II",SUP-40100918,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"CIGNA [10200]","Cigna Local Plus",,407.35,53.5,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 60MM 3.5MM ANKLE",SUP-58850035,CDM,S27000186,LOCAL,0270,RC,,,both,,,1069.20,320.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,727.06,68,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Infusion Dual Luman Elite",PX-E27200291,CDM,C1751,HCPCS,0272,RC,,,both,,,12888.70,3866.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1527.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1498.96,10955.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 50MM 7.5MM MODULEX OSTEOGRIP SPINE",SUP-55900507550,CDM,C1713,HCPCS,0278,RC,,,both,,,4519.50,1355.85,"PHCS [10601]",PHCS,,3163.65,70,,,,,0,525.62,3841.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 118MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 10",SUP-71357010,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8948.11,27,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) STERILE TRICUSPID VALVE 160MM",SUP-ES0366-03,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 5.5IN 5MM ROUND",SUP-KM-AM35U,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE PEEP 5CM 2O SAFETY HOLE",SUP-9005B,CDM,S27000186,LOCAL,0270,RC,,,both,,,66.99,20.1,"CIGNA [10200]","Cigna Open Access",,38.12,56.9,,,,,0,7.79,56.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0255,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X6MM VERTE-STACK CORNERSTONE PSR",SUP-6240641,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS [10001]","Blue Cross HMO",,2617.94,39.2,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) VIAL",RX-20887,CDM,J3379,HCPCS,0636,RC,00143-9785-01,NDC,both,5,ML,63.42,19.03,"FIRST HEALTH [10303]","First Health",,50.74,80,,,,,0,5.83,53.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 73.5X12.5MM HALL RECIPROCATE STERILE",SUP-505217300,CDM,S27200284,LOCAL,0272,RC,,,both,,,323.12,96.94,"AETNA [10100]","Aetna HMO/PPO",,256.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.58,274.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 5MM 48MM STAINLESS STEEL CORTICAL SELF TAP",SUP-202.848,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,41.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",40.86,298.61,"percent of total billed charges",
"SYSTEM CARBOJET PULSED LAVAGE CO2 TUBE SET",SUP-25-100-2001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID COMPRESSION ANKLET (STD)",SUP-RSANK001,CDM,S27000186,LOCAL,0270,RC,,,both,,,170.52,51.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EUPHORA 142CM 27MM 3.75MM BALLOON DILATATION",SUP-NCEUP37527X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 5FR 20CM HYDROPHILIC RADIOPAQUE STERILE",SUP-G10283,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 95X19.5X1.27MM HALL OSCILLATING STERILE",SUP-507112300,CDM,S27200284,LOCAL,0272,RC,,,both,,,254.04,76.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SKIN 20X11CM FLEXHD THK.7-1.4MM THIN MEDIUM ALLOGRAFT",SUP-SF2000,CDM,Q4128,HCPCS,0636,RC,,,both,,,24052.14,7215.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"STENT VISI-PRO 27MM 80CM 8MM 30MM BILIARY STAINLESS STEEL",SUP-PXB35-08-27-080,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"CIGNA [10200]",Cigna,,2969.56,68,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE SMR TITANIUM L40 MM OD6.5 MM SHOULDER REVISION",SUP-8420.15.050,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,714.07,45.9,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE SMALL HEXAGON CAPTIVATOR STIFF ENDOSCOPIC POLYPECTOMY",SUP-M00562450,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.33,36.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,82.5,68,,,,,0,14.11,103.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Bn<=20scm",PX-510000009,CDM,11044,CPT,0761,RC,,,both,,,8357.33,2507.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,990.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,971.96,7103.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTAZIDIME 1 G VIAL",RX-9474,CDM,J0713,HCPCS,0636,RC,44567-0235-25,NDC,both,1,UN,40.77,12.23,"BLUE CROSS [10001]","Blue Cross HMO",,3.66,,,,,,,3.45,34.65,"fee schedule",
"STPLR INTERNAL 4MM TITANIUM 12MM UNIVERSAL VASCULAR LINEAR",SUP-030449,CDM,S27200284,LOCAL,0272,RC,,,both,,,671.17,201.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,456.4,68,,,,,0,78.06,570.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM EXTEND BODY 5.5MM ROD",SUP-7541173,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,858.6,28.62,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 48MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.848,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"KAISER [10500]",Kaiser,,168.11,67,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 26FR STD URETHRAL NATURAL RUBBER",SUP-0167L26,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.13,23.44,"UHC [10700]","United Healthcare",,49.46,63.3,,,,,0,9.09,66.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 45MM ECHELON ENDOSCOPIC LINEAR CUTTER",SUP-ECR45M,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METOCLOPRAMIDE 10 MG TABLET",RX-5005,CDM,,,0637,RC,60687-0631-11,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]",Cigna,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARBAMAZEPINE 200 MG TABLET, IMMEDIATE RELEASE",RX-1357,CDM,,,0637,RC,68084-0444-11,NDC,both,1,UN,6.27,1.88,"PHCS [10601]",PHCS,,4.39,70,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBO ELITE 125CM 2.3MM .091IN ATHERECTOMY PERIPHERAL",SUP-423-135,CDM,C1885,HCPCS,0272,RC,,,both,,,18868.50,5660.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2194.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2194.41,16038.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD 641003040 40MM CAPPED ROD 4.75MM CCM",SUP-641003040,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"3 PIECE ENDURANT II BUNDLE",SUP-ENDURANTII3,CDM,S27800098,LOCAL,0278,RC,,,both,,,108300.00,32490,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12833.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12595.29,92055,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL CERVICAL 8X14X12MM 7DEG LORDOTIC PEEK COHERE",SUP-4081427P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"MULTIPLAN [10600]",Multiplan,,5278.5,85,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX 6X4IN MONOFILAMENT SCAFFOLD FULL",SUP-1190200,CDM,C1781,HCPCS,0278,RC,,,both,,,8400.00,2520,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2404.08,28.62,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"29.0 DIOPTER, SENSAR MONOFOCAL 3-PIECE FOLDABLE IOL, MODEL A",SUP-AR40E00290,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"BLUE CROSS [10001]","Blue Cross PPO",,365.15,39.2,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG LINGEMAN CYSTO LIEBEL",SUP-LG2000N,CDM,S27000186,LOCAL,0270,RC,,,both,,,65.38,19.61,"FIRST HEALTH [10303]","First Health",,52.3,80,,,,,0,7.6,55.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Outr/Thin Prep Imager Pap Scre",PX-300000042,CDM,88175,CPT,0311,RC,,,both,,,91.00,27.3,"UHC [10700]","United Healthcare",,23.95,,,,,,,0.01,91,"fee schedule",
"PLATE 99MM STAINLESS STEEL 2.7/3.5MM SCR 5 HOLE LCP BONE",SUP-02.112.140,CDM,C1713,HCPCS,0278,RC,,,both,,,3076.50,922.95,"BLUE CROSS [10001]","Blue Cross PPO",,1205.99,39.2,,957.42,570.23,957.42,28,357.8,2615.03,"percent of total billed charges",
"STENT URETERAL 6FR 26CM WITHOUT GWIRE POLARIS ULTRA",SUP-M0061921330,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,325.01,28.62,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 30MM 140CM 2.75MM",SUP-RSINT27530UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"PHCS [10601]",PHCS,,3880.8,70,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM CEMENT AVENIR PROTASUL-S30 7 42.55MM STD",SUP-01.06010.207,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 30CM POLYURETHANE POWER-TRIALYSIS 3 LUMEN POWER",SUP-5603300,CDM,C1752,HCPCS,0272,RC,,,both,,,1245.78,373.73,"CIGNA [10200]","Cigna Local Plus",,666.49,53.5,,,,,0,144.88,1058.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTP W4TR01 PERCEPTA QUAD CRTP MRI US",SUP-W4TR01,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"MULTIPLAN [10600]",Multiplan,,19626.84,85,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla Class I & II Ab Qual",PX-302000220,CDM,86828,CPT,0302,RC,,,both,,,929.10,278.73,"KAISER [10500]",Kaiser,,622.5,67,,,,,0,57.17,789.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 30MM 5MM .035IN BALLOON DILATATION NYBAX",SUP-39171-05031,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UHC [10700]","United Healthcare",,743.46,63.3,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE RIGHT POSTERIOR STABILIZE BEAD",SUP-5514-F-402,CDM,C1776,HCPCS,0278,RC,,,both,,,18717.30,5615.19,"CIGNA [10200]","Cigna Open Access",,6270.3,33.5,,5302.19,4377.88,6578.61,27,2176.82,15909.71,"percent of total billed charges",
"NITROGLYCERIN 2 % TRANSDERMAL OINTMENT",RX-5606,CDM,,,0250,RC,00281-0326-08,NDC,both,1,GR,19.05,5.71,"PHCS [10601]",PHCS,,13.34,70,,,,,0,2.22,16.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAPLACE TTVR TRICUSPID VALVE LARGE",SUP-TTVR-L-85X53,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cors&Angio W Lt Hrt Cath",PX-481000026,CDM,93458,CPT,0481,RC,,,both,,,18905.42,5671.63,"AETNA [10100]","Aetna HMO/PPO",,15029.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1566.32,16069.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Wnd Dehis W Packing",PX-510000044,CDM,12021,CPT,0761,RC,,,both,,,5428.00,1628.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1793,,"Per diem ($1,793).",,,,0,631.28,4710,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Gammaglobulin Ige",PX-301000195,CDM,82785,CPT,0301,RC,,,both,,,170.30,51.09,"NOVANET [10819]",Novanet,,127.73,75,,,,,0,0.17,144.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID UPPER LEG REDUCTION KIT- STANDARD, REGULAR",SUP-25301217,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 90CM 200MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050200S,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP ENDOSCOPIC NDL 240CM 2.8MM RADIAL JAW 4 JUMBO STERILE",SUP-M00513373,CDM,S27200284,LOCAL,0272,RC,,,both,,,293.49,88.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"REAMER SURGICAL 6.5MM PILOT HEAD STERILE",SUP-AR-1451,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 100MM 2.5MM BALLOON DILATATION RAPID",SUP-47525100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 4CM 5.8FR 12FR BALLOON",SUP-M0062251000,CDM,C1726,HCPCS,0272,RC,,,both,,,1670.40,501.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 95MM 5MM XLONG CARBIDE ROUND 8 FLUTED LINVATEC",SUP-5300030513,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.18,81.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM MULTI-LINK MINI VISION 23MM 2.5MM CORONARY STENT COCR",SUP-1007823-23,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X22X10MM MODULUS 15D XL WIDE STERILE LATEX",SUP-1225055P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,29925.00,8977.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8564.54,28.62,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 8 HOLE LOW PROFILE STRAIGHT BONE RIGHT CLAVICLE",SUP-70-0299,CDM,S27800098,LOCAL,0278,RC,,,both,,,6610.20,1983.06,"NOVANET [10819]",Novanet,,4957.65,75,,,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IVABRADINE 5 MG TABLET",RX-170267,CDM,,,0637,RC,55513-0800-60,NDC,both,1,UN,47.32,14.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,21.72,45.9,,,,,0,5.5,40.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 13CM 31MM 14.5MM EXCLUDER C3 TRUNK",SUP-RLT311413,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"NOVANET [10819]",Novanet,,47025,75,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 4-0 PS-1 SPIRAL 30CM SUT",SUP-SXMP2B150,CDM,S27200284,LOCAL,0272,RC,,,both,,,219.64,65.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,100.81,45.9,,,,,0,25.54,186.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR 44.5MM CARBIDE 7.9MM 4MM OVAL 8 FLUTE DENTAL",SUP-14-C0901,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.29,44.19,"AETNA [10100]","Aetna HMO/PPO",,117.1,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.13,125.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 13.6CM 8MM CEREPAK XL UNIFORM DETACHABLE",SUP-FCX180813,CDM,S27800098,LOCAL,0278,RC,,,both,,,15872.28,4761.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6523.51,41.1,,,,,0,1845.95,13491.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thaw Ffp Ea Unit",PX-302000203,CDM,86927,CPT,0302,RC,,,both,,,318.00,95.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,29.76,,,,,,,0.01,270.3,"fee schedule",
"TUBE SUCTION 2IN 24GA ROSEN EAR 60MM",SUP-61-1042,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.91,23.67,"AETNA [10100]","Aetna HMO/PPO",,62.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.18,67.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 250MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030250M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,770.63,41.1,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 6 X 6 HELICAL FINISHING COIL",SUP-10HFN-06006,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"KAISER [10500]",Kaiser,,6929.88,67,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM VANGUARD TKR E1 FEMUR PATELLA TIBIA CEMENT STEM B",SUP-98000800027,CDM,C1776,HCPCS,0278,RC,,,both,,,19530.00,5859,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8026.83,41.1,,6417.48,6417.48,6417.48,"1 through 10",2271.34,16600.5,"percent of total billed charges",
"EXP TISSUE 13.5X11.7CM BREAST 550CC STYLE 8200 SUT TAB CPX4",SUP-3548214,CDM,C1789,HCPCS,0278,RC,,,both,,,9694.50,2908.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1127.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1127.47,8240.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 8MM 144CM 3MM CORONARY STENT",SUP-H7493911408300,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross HMO",,3583.86,39.2,,9776.84,9776.84,9776.84,"1 through 10",1063.27,7771.13,"percent of total billed charges",
"STENT GORE VIABAHN 79MM 80CM 8MM 16SQ MM 8FR .035IN",SUP-BXAL087901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2489.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 30CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006175285070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"BLUE CROSS [10001]","Blue Cross PPO",,390.99,39.2,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE LEFT CRUCIATE RETAIN ATTUNE POROCOAT",SUP-150401108,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3409.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3346.56,24458.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 RIGHT KNEE CRUCIATE RETAINING CEMENTED",SUP-5510-F-402,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"PHCS [10601]",PHCS,,11478.5,70,,,,,0,1907.07,13938.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 15MM 48MM SHOULDER REUNION STD RADIUS STERILE",SUP-5552-S-4815,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"CIGNA [10200]","Cigna Open Access",,5171.53,56.9,,5302.19,4377.88,6578.61,27,1057.03,7725.48,"percent of total billed charges",
"FIBEROS 5CC",SUP-FB050,CDM,C1713,HCPCS,0278,RC,,,both,,,4140.00,1242,"AMERIGROUP MEDICAID [20100]",Amerigroup,,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",481.48,3519,"percent of total billed charges",
"SUT SILK PERMA-HAND 3-0 SH 30IN BRAID BLACK NONABSORBABLE",SUP-K832H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LACRIMAL 5IN BOWMAN STAINLESS STEEL 2 ENDED SET",SUP-360-270,CDM,S27000186,LOCAL,0270,RC,,,both,,,751.52,225.46,"NOVANET [10819]",Novanet,,563.64,75,,,,,0,87.4,638.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 12 EXTREME LATERAL INTERBODY FUSION 4 HOLE DECADE BONE",SUP-7140412,CDM,C1713,HCPCS,0278,RC,,,both,,,13800.00,4140,"NOVANET [10819]",Novanet,,10350,75,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 30CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006175285070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,118.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASC HEMA PLATINUM 26X30",SUP-175426P,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 16MM 144CM 4MM CORONARY STENT EVEROLIMUS",SUP-H7493926116400,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4275.59,45.9,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT EXTERNAL FIXATION 100MM FEMORAL NECK SYSTEM STERILE",SUP-04.168.300S,CDM,C1713,HCPCS,0278,RC,,,both,,,2435.70,730.71,"BLUE CROSS [10001]","Blue Cross HMO",,954.79,39.2,,957.42,156.86,7483.26,51,283.27,2070.35,"percent of total billed charges",
"HC Apc Resistance",PX-305000036,CDM,85307,CPT,0305,RC,,,both,,,514.80,154.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13.79,,,,,,,0.01,437.58,"fee schedule",
"GRAFT ENDOVASCULAR 82MM 30MM 25-27MM 20FR ZENITH TX2",SUP-G47447,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"CIGNA [10200]","Cigna Open Access",,34380.55,33.5,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 20MM 4D RIGHT ELBOW",SUP-TR-H200R-S,CDM,C1776,HCPCS,0278,RC,,,both,,,13489.50,4046.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1598.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1568.83,11466.08,"percent of total billed charges",
"PACEMKR CARDIAC 7.5MM 52.3X45.4MM ADAPTA DR MVP ATRIUM",SUP-ADDRL1,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"BLUE CROSS [10001]","Blue Cross PPO",,16307.2,39.2,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETHRAL BARDEX IC 22FR FOLEY 2 WAY SILVER HYDROGEL 5ML",SUP-0165SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.82,19.45,"KAISER [10500]",Kaiser,,43.43,67,,,,,0,7.54,55.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDURANT II AUI 2-PIECE CASE",SUP-ENDURANTIIAUI2,CDM,S27800098,LOCAL,0278,RC,,,both,,,108300.00,32490,"FIRST HEALTH [10303]","First Health",,86640,80,,,,,0,12595.29,92055,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM VARIAX T8 FULL THREAD NONSTERILE",SUP-656416,CDM,C1713,HCPCS,0278,RC,,,both,,,779.22,233.77,"CIGNA [10200]","Cigna Local Plus",,416.88,53.5,,3978.14,359.25,3978.14,24,90.62,662.34,"percent of total billed charges",
"CATH MACH1 90CM 8FR JL4 CURVE GUIDING PTFE FEMORAL",SUP-H749343582010,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,150.61,41.1,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD BIPOLAR CELONPROBREATH STERILE LATEX FREE DISPOSABLE",SUP-WB990310,CDM,S27200284,LOCAL,0272,RC,,,both,,,1406.44,421.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,166.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,163.57,1195.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FRACTURE STABILIT FIRST SHORT",SUP-3353,CDM,S27200284,LOCAL,0272,RC,,,both,,,21105.00,6331.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2500.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2454.51,17939.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 20X16CM ALLODERM THICK READY TO USE",SUP-1520320,CDM,Q4116,HCPCS,0636,RC,,,both,,,57884.40,17365.32,"UHC [10700]","United Healthcare",,247.92,,,,,,,247.92,49201.74,"fee schedule",
"SPACER ALLOGRAFT 12X14X10MM LORDOTIC SPINE CERVICAL CORTICAL",SUP-17010,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE WALLSTENT VASCULAR TAPER 500CM .035IN SUPER STIFF",SUP-H965180011,CDM,C1769,HCPCS,0272,RC,,,both,,,924.91,277.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 4MM 8.25IN STAINLESS STEEL GARRETT MALLEABLE",SUP-25-8022,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.12,22.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 122MM 2.7MM AO OVER",SUP-703897,CDM,S27200284,LOCAL,0272,RC,,,both,,,1068.23,320.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPHINTOM 450MM 20MM 4.4FR DREAMTOME DREAMWIRE BILIARY RAPID",SUP-M00584060,CDM,C1769,HCPCS,0272,RC,,,both,,,3112.43,933.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE GLDEWIRE GOLD VASCULAR 70D 180CM 8CM .014IN",SUP-GM1402,CDM,C1769,HCPCS,0272,RC,,,both,,,2175.00,652.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,257.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 23MM 2MM CORONARY STENT COCR",SUP-1007821-23,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR ACTIS DUOFIX 4 STD OFFSET HIP STERILE",SUP-101011040,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12190.5,40,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT FIBERTAK 2 LOAD NDL",SUP-AR-3730SP,CDM,C1713,HCPCS,0278,RC,,,both,,,3346.88,1004.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,389.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",389.24,2844.85,"percent of total billed charges",
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE ROUND SILICONE",SUP-SRF-335,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3730.14,68,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL 220CM 2.3MM FIAPC FLEXIBLE STRAIGHT",SUP-20132-214,CDM,S27200284,LOCAL,0272,RC,,,both,,,1900.50,570.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,872.33,45.9,,,,,0,221.03,1615.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 20MM 120CM 7MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200072020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN AIMING GUIDE 2.5MM",SUP-PRT-AIM-25,CDM,S27000186,LOCAL,0270,RC,,,both,,,1514.70,454.41,"CIGNA [10200]",Cigna,,1030,68,,,,,0,176.16,1287.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD INTICA 7 DF-1 CONNECTION HF-T QP",SUP-404629,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,15584.4,27,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19 DIOPTER +4.5 ADD MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT450U190,CDM,V2632,HCPCS,0276,RC,,,both,,,3712.50,1113.75,"AETNA [10100]","Aetna HMO/PPO",,2951.44,79.5,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 330ML STYLE 10 SMOOTH NATRELLE SILICONE P3.6CM",SUP-10-330,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,415.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC REAMING 36MM PATELLA DISPOSABLE",SUP-8000-0036,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.00,675,"AETNA [10100]","Aetna HMO/PPO",,1788.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT FLOWABLE 5CC OSTEOAMP SELECT",SUP-OAFL-05,CDM,C1713,HCPCS,0278,RC,,,both,,,12209.90,3662.97,"KAISER [10500]",Kaiser,,8180.63,67,,,,,0,1420.01,10378.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 100MM 116CM 6MM 75CM VASCULAR NITINOL ILIAC",SUP-H74939200061070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 28MM LCP STAINLESS STEEL DISTAL RADIAL SELF",SUP-212.828,CDM,C1713,HCPCS,0278,RC,,,both,,,802.87,240.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,229.78,28.62,,,,,0,93.37,682.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE WIRE GWR419588 ATTAIN HYBRID 108CM",SUP-GWR419588,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME PATELLAR 9MM 35MM KNEE E PLUS 3 PEG STERILE",SUP-130-03-735,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,5311.50,4717.44,5388.59,31,348.9,2550,"percent of total billed charges",
"GRAFT BONE MAGNETOS BCP 20CC 1-2MM ALLOGRAFT GRANULE",SUP-703-045-US,CDM,C1713,HCPCS,0278,RC,,,both,,,21420.00,6426,"UHC [10700]","United Healthcare",,13558.86,63.3,,5023.51,2672.93,6679.78,18,2491.15,18207,"percent of total billed charges",
"SET INTRO 17.75IN 10FR 8FR SUPER ARROW-FLEX PERCUTANEOUS",SUP-CL-07045,CDM,C1894,HCPCS,0272,RC,,,both,,,767.88,230.36,"NOVANET [10819]",Novanet,,575.91,75,,,,,0,89.3,652.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH PLEURA STARTER PLEURX 1000ML",SUP-158431,CDM,C1729,HCPCS,0272,RC,,,both,,,8280.00,2484,"MULTIPLAN [10600]",Multiplan,,7038,85,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 48MM T10 FULL THREAD STARDRIVE NONSTERILE",SUP-657448,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",94.05,687.4,"percent of total billed charges",
"NDL LOCALIZATION 12.5CM 20GA HAWKINS III FLEXSTRAND HARDWIRE",SUP-253125,CDM,A4648,HCPCS,0278,RC,,,both,,,310.59,93.18,"MULTIPLAN [10600]",Multiplan,,264,85,,,,,0,36.12,264,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Infusion for Proxis",PX-E27200061,CDM,C1751,HCPCS,0272,RC,,,both,,,1730.30,519.09,"FIRST HEALTH [10303]","First Health",,1384.24,80,,,,,0,201.23,1470.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC SMALL 24IN 14-16IN KNEE CONTOUR POSTERIOR",SUP-1010247,CDM,L1830,HCPCS,0274,RC,,,both,,,189.49,56.85,"FIRST HEALTH [10303]","First Health",,151.59,80,,,,,0,22.04,161.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC SMARTVEST WRAP SMALL NONSTERILE LATEX FREE",SUP-SW-15/25-1,CDM,S27000186,LOCAL,0270,RC,,,both,,,437.40,131.22,"PHCS [10601]",PHCS,,306.18,70,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 22MM 3MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG30022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"PHCS [10601]",PHCS,,1890,70,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR RINGLOC +3MM 23 36MM ARCOMXL HIP HIGH WALL",SUP-XL-108323,CDM,C1776,HCPCS,0278,RC,,,both,,,9937.38,2981.21,"KAISER [10500]",Kaiser,,6658.04,67,,,,,0,1155.72,8446.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 12 EXTREME LATERAL INTERBODY FUSION 4 HOLE DECADE BONE",SUP-7140412,CDM,C1713,HCPCS,0278,RC,,,both,,,13800.00,4140,"CIGNA [10200]",Cigna,,5520,40,,1831.33,1831.33,1831.33,16,1604.94,11730,"percent of total billed charges",
"CATH INFINITI THRULUMEN 100CM 5FR .048IN .047IN AMPLATZ LEFT",SUP-534546T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"KAISER [10500]",Kaiser,,62.67,67,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT FIBERTAK 2 LOAD NDL",SUP-AR-3730SP,CDM,C1713,HCPCS,0278,RC,,,both,,,3346.88,1004.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,396.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,389.24,2844.85,"percent of total billed charges",
"KIT TRANSPORT LIGHTWEIGHT CARRY CASE FOR STAT STRIP HOSPITAL",SUP-53425,CDM,S27000186,LOCAL,0270,RC,,,both,,,891.00,267.3,"KAISER [10500]",Kaiser,,596.97,67,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 45MM STEALTH 2 LATIS STERILE LATEX FREE",SUP-A0C02,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]","Cigna Open Access",,128.71,56.9,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTMASTER 16MM 4.5MM CORONARY STENT STAINLESS STEEL",SUP-1012583-16,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1958.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 6 74MM 10.8MM SHILEY UNCUFF DISPOSABLE INNER CANN",SUP-6UN75H,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.56,98.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,222.74,68,,,,,0,38.1,278.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 E 36MM E1 HIP HIGH WALL",SUP-010000935,CDM,C1776,HCPCS,0278,RC,,,both,,,12282.00,3684.6,"UHC [10700]","United Healthcare",,7774.51,63.3,,8601.07,8395.67,8601.07,"1 through 10",1428.4,10439.7,"percent of total billed charges",
"HC Knee Orthosis",PX-E27400075,CDM,L1847,HCPCS,0274,RC,,,both,,,1447.60,434.28,"BLUE CROSS [10001]","Blue Cross HMO",,567.46,39.2,,,,,0,168.36,1230.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 5CM 10FR .035IN 2 PIGTAIL CURVE BILIARY",SUP-G21975,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,180.82,28.62,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL NDL STERILE LATEX FREE DISPOSABLE",SUP-30677CN-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1455.30,436.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.25,1237.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 60X8-15MM ELSA 6D 20MM",SUP-1122.016,CDM,S27800098,LOCAL,0278,RC,,,both,,,50400.00,15120,"CIGNA [10200]","Cigna Local Plus",,15876,31.5,,,,,0,5861.52,42840,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ARTHROSCOPIC ASPIRATE ABLATOR APOLLORF SMALL JOINT 50D",SUP-AR-9845,CDM,S27200284,LOCAL,0272,RC,,,both,,,1968.75,590.62,"PHCS [10601]",PHCS,,1378.13,70,,,,,0,228.97,1673.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE STEELCORE VASCULAR STRAIGHT 190CM 3CM .018IN",SUP-1007709,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM 51X16X2.5MM TITANIUM 3 LEVEL PREBENT SKYLINE BONE",SUP-186803051,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1514.57,28.62,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LINER BIPOLAR TANDEM HIP",SUP-71701455,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Local Plus",,5537.25,53.5,,5372.07,4581.20,7242.98,23,1203.71,8797.5,"percent of total billed charges",
"SYSTEM MULTI-LINK ULTRA 38MM 5MM CORONARY STENT XCELON",SUP-1003382-38,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +21.5 DIOPTER MODIFIED C BICONVEX MULTIPIECE",SUP-MA60AC.215,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 240MM 20MM REVISION MONOLITHIC REDAPT ROCKTITE",SUP-71354709,CDM,C1776,HCPCS,0278,RC,,,both,,,51237.90,15371.37,"BLUE CROSS [10001]","Blue Cross HMO",,20085.26,39.2,,5311.50,4717.44,5388.59,31,5958.97,43552.22,"percent of total billed charges",
"CHMBR HUMD 2 FLOAT MECHANISM AUTOFILL CONSISTENT",SUP-MR290HFV,CDM,S27000186,LOCAL,0270,RC,,,both,,,94.72,28.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.02,80.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP PHACOEMULSIFICATION 12MM .9MM OZIL 45D MINIFLARE",SUP-8065751177,CDM,S27200284,LOCAL,0272,RC,,,both,,,597.29,179.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,70.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.46,507.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE OTSC 4MM 165CM 12MM 3.2MM ENDOSCOPIC TISSUE ANCHOR",SUP-200.1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3742.50,1122.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,435.25,3181.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 22MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0285,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"NOVANET [10819]",Novanet,,710.78,75,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 26CM 3CM 8FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155253050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 39MM MITRAL TRICUSPID FULL FLEXIBLE BAND",SUP-700FF39,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Open Access",,4391.85,33.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSOLE SHOE 12.5-14 XL MALE DARCO PEG-ASSIST REMOVABLE PEG",SUP-PTQM4,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.53,30.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,41.73,41.1,,,,,0,11.81,86.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 28MM TI",SUP-SPL-35280-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]",Cigna,,908.82,68,,1831.33,1831.33,1831.33,16,155.43,1136.03,"percent of total billed charges",
"STEM HUMERAL SHOULDER WITH NECK ANATOMIC ALTIVATE CS SIZE 2",SUP-520-08-021,CDM,C1776,HCPCS,0278,RC,,,both,,,34907.04,10472.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9990.39,28.62,,,,,0,4059.69,29670.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Spirometry Breathing Capacity",PX-460000001,CDM,94010,CPT,0460,RC,,,both,,,630.76,189.23,"UHC [10700]","United Healthcare",,399.27,63.3,,,,,0,73.36,536.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 26CM 150CM 8FR .035IN 3CM BLADDER LOOP",SUP-M006155253180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"BLUE CROSS [10001]","Blue Cross HMO",,631.01,39.2,,,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 105MM 32MM STAINLESS STEEL ORTHOPEDIC",SUP-71128105,CDM,C1713,HCPCS,0278,RC,,,both,,,2479.50,743.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,288.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",288.37,2107.58,"percent of total billed charges",
"SCR BONE 6.5MM 30MM TITANIUM DOME HIP ACETABULAR CANCELLOUS",SUP-103533,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,677.48,68,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC App Inters Rad Cmplx",PX-342000005,CDM,77778,CPT,0333,RC,,,both,,,8183.73,2455.12,"AETNA [10100]","Aetna HMO/PPO",,6506.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,408.8,6956.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.812,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"MULTIPLAN [10600]",Multiplan,,298.61,85,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.3MM 35MM TITANIUM FOOT TIBIA LOCK LOW PROFILE",SUP-99-T774035,CDM,C1713,HCPCS,0278,RC,,,both,,,1492.91,447.87,"BLUE CROSS [10001]","Blue Cross PPO",,585.22,39.2,,957.42,570.23,957.42,28,173.63,1268.97,"percent of total billed charges",
"STENT POLARIS 20CM 3CM 5FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155220050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"FIRST HEALTH [10303]","First Health",,984.77,80,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 9MM CANNULATED ACL LOW PROFILE STERILE",SUP-AR-1409LP,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X2CM NEOX CORD 1K THK1MM 6SQ CM AMNIOTIC",SUP-163599,CDM,Q4148,HCPCS,0636,RC,,,both,,,8935.50,2680.65,"KAISER [10500]",Kaiser,,5986.79,67,,,,,0,332.85,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 4-0 PS-2 SPIRAL 12IN",SUP-SXMP1B117,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.03,65.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.36,185.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM CHARLOTTE CLAW FOOT HEXAGONAL LOCKING",SUP-40133524,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,1831.33,1831.33,1831.33,16,189.34,1383.8,"percent of total billed charges",
"GRAFT VASCULAR 30CM 14MM HEMASHIELD PLATINUM STRAIGHT",SUP-M00202175414P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE LEFT LATERAL FEMORAL CORTICAL THK3-15MM THIRD",SUP-450971,CDM,S27800098,LOCAL,0278,RC,,,both,,,5775.30,1732.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,684.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,671.67,4909.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FEMORAL IDENTITY IMPRINT 6 NARROW KNEE POSTERIOR",SUP-TPS-101-F06N,CDM,C1776,HCPCS,0278,RC,,,both,,,11716.20,3514.86,"PHCS [10601]",PHCS,,8201.34,70,,,,,0,1362.59,9958.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 9CM 18MM 18.5FR LOW PROFILE ESOPHAGEAL",SUP-M00516910,CDM,C1874,HCPCS,0278,RC,,,both,,,10022.00,3006.6,"NOVANET [10819]",Novanet,,7516.5,75,,,,,0,1165.56,8518.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +9 DIOPTER MODIFY L BICONVEX 13MM 6MM POSTERIOR",SUP-CC60WF.090,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 14.3MM 29.5MM ATS OPEN PIVOT STD TITANIUM",SUP-500FA29,CDM,S27800098,LOCAL,0278,RC,,,both,,,25011.00,7503.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10279.52,41.1,,,,,0,2908.78,21259.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8MM 165MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-408-165,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,957.42,570.23,957.42,28,2014.9,14726.25,"percent of total billed charges",
"COIL EMBOLIZATION 20CM 6MM .0125IN AXIUM DETACHABLE HELIX SM",SUP-NV-6-20-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40MM 3MM .035IN 2D HELIX PLATINUM FIBER",SUP-M0013723041,CDM,S27800098,LOCAL,0278,RC,,,both,,,769.50,230.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WARFARIN 1.25 MG TABLET (PARTIAL OF 2.5 MG TABLET)",RX-408648,CDM,,,0637,RC,08888-8886-81,NDC,both,1.25,ME,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.300 CLAREON",SUP-SY60WF.300,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 28CM 4.8FR URETERAL FIRM STERILE LATEX FREE",SUP-M0061456430,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WARFARIN 1.25 MG TABLET (PARTIAL OF 2.5 MG TABLET)",RX-408648,CDM,,,0637,RC,08888-8886-81,NDC,both,1.25,ME,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,3.57,56.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 45CM PK COIL LP STERILE LATEX FREE",SUP-RBYPCLP45,CDM,S27800098,LOCAL,0278,RC,,,both,,,8832.00,2649.6,"CIGNA [10200]",Cigna,,6005.76,68,,,,,0,1027.16,7507.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drsg Wound Normlgel Ag 1.5oz",PX-E27200317,CDM,E27200317,LOCAL,0272,RC,,,both,,,123.42,37.03,"CIGNA [10200]","Cigna Local Plus",,66.03,53.5,,,,,0,14.35,104.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 4MM 8.25IN STAINLESS STEEL GARRETT MALLEABLE",SUP-25-8022,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.12,22.24,"CIGNA [10200]","Cigna Open Access",,42.17,56.9,,,,,0,8.62,63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 280014 UNCRT DWL 14MM SRVC FEE",SUP-280014,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Charger Elec/Combo Vad, Rep",PX-E27400014,CDM,Q0495,HCPCS,0274,RC,,,both,,,31785.72,9535.72,"AETNA [10100]","Aetna HMO/PPO",,25269.65,79.5,,,,,0,3696.68,27017.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 28MM 8MM DELTA TAPER SHOULDER",SUP-AR-5028C-08,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"CIGNA [10200]",Cigna,,1258.43,68,,1831.33,1831.33,1831.33,16,215.23,1573.04,"percent of total billed charges",
"STENT WALLFLEX 12CM 9CM 18MM 18.5FR LOW PROFILE ESOPHAGEAL",SUP-M00516910,CDM,C1874,HCPCS,0278,RC,,,both,,,10022.00,3006.6,"AETNA [10100]","Aetna HMO/PPO",,7967.49,79.5,,,,,0,1165.56,8518.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL VISTA TX HEIGHT ADJUSTMENT TECHNOLOGY",SUP-100084-000,CDM,S27000186,LOCAL,0270,RC,,,both,,,413.34,124,"CIGNA [10200]","Cigna Open Access",,235.19,56.9,,,,,0,48.07,351.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE OPHTHALMIC .9MM ALCON FMS ABS INTREPID 45D BALANCE",SUP-8065752918,CDM,S27200284,LOCAL,0272,RC,,,both,,,833.00,249.9,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT DRSG VAC PEEL AND PLACE SMALL",SUP-EZ5SML,CDM,S27200284,LOCAL,0272,RC,,,both,,,813.55,244.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO BIOPSY 10CM 19GA 20GA ACHIEVE UNIVERSAL COAXIAL",SUP-PP1910,CDM,S27200284,LOCAL,0272,RC,,,both,,,114.41,34.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER OLIVE 5MM DYONICS ELITE STRAIGHT FULL RADIUS",SUP-7210909,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRODE ELECTROTHERAPY VITALSTIM ADULT",SUP-966032,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.34,40.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 10CM 5FR 21GA 3FR MERIT PAK .018IN 40CM PEDAL",SUP-PAKS5NPD4,CDM,C1894,HCPCS,0272,RC,,,both,,,497.02,149.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS MULTIPASS 3-0 PS-2 18IN BRAID ANTIBACTERIAL",SUP-VCP497H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE MERIT LAUREATE VASCULAR STRAIGHT 180CM 3CM .035IN",SUP-LWSTDS35180,CDM,C1769,HCPCS,0272,RC,,,both,,,278.40,83.52,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACIFIC PLUS 130CM 60MM 4FR 4MM LOW PROFILE BALLOON",SUP-PCP040060130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,143.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1",SUP-179712035,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",441.36,3225.75,"percent of total billed charges",
"CAGE SPINAL XLIF 10MM X 18MM X 55MM 10 DEGREE LORDOTIC TITAN",SUP-1181055P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM FRMLA 12D LONG AGGRESSIVE PLUS ARTHROSCOPIC",SUP-0385544000,CDM,S27200284,LOCAL,0272,RC,,,both,,,494.10,148.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,57.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 90CM 5FR PIGTAIL CURVE TAPER ANGIOGRAPHIC SLX",SUP-451503F5,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"AETNA [10100]","Aetna HMO/PPO",,83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FIXATION ACL RIGHT 2 LOAD PASS SUT",SUP-AR-1588RT-J,CDM,C1713,HCPCS,0278,RC,,,both,,,2913.75,874.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,338.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",338.87,2476.69,"percent of total billed charges",
"INSERT TIBIAL 6 8MM KNEE AOX CRUCIATE RETAIN ROTATE PLATFORM",SUP-151630608,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]","Cigna Local Plus",,4135.08,31.5,,5372.07,4581.20,7242.98,23,1526.7,11158.16,"percent of total billed charges",
"INSRT TIBIAL 3 15MM KNEE AOX STABILIZE ROTATE PLATFORM SIGMA",SUP-196192133,CDM,C1776,HCPCS,0278,RC,,,both,,,13386.00,4015.8,"CIGNA [10200]","Cigna Local Plus",,4216.59,31.5,,5372.07,4581.20,7242.98,23,1556.79,11378.1,"percent of total billed charges",
"HC Actinothrpy/Ultraviolet Light",PX-940000014,CDM,96900,CPT,0940,RC,,,both,,,139.00,41.7,"CIGNA [10200]","Cigna Open Access",,79.09,56.9,,,,,0,16.17,139,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MICROPOINT 9-0 TG140-8 12IN 2 ARM MONOFILAMENT",SUP-7717G,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.46,43.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,59.78,41.1,,,,,0,16.92,123.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER BURR HOLE .4MM 10MM UNIVERSAL NEURO III",SUP-53-34510,CDM,C1713,HCPCS,0278,RC,,,both,,,1858.37,557.51,"FIRST HEALTH [10303]","First Health",,1486.7,80,,,,,0,216.13,1579.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2 .5 CIRCLE STRAIGHT DIAMOND POINT 38IN BRAID",SUP-AR-7201,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.73,95.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,131.41,41.1,,,,,0,37.18,271.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 24FR CUT OLYMPUS OES PRO",SUP-M0068802611,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,325.19,68,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 4MM TITANIUM 12MM UNIVERSAL VASCULAR LINEAR",SUP-030449,CDM,S27200284,LOCAL,0272,RC,,,both,,,671.17,201.35,"FIRST HEALTH [10303]","First Health",,536.94,80,,,,,0,78.06,570.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 8MM RIGHT MEDIAL LEFT LATERAL X3 PARTIAL KNEE",SUP-5630-G-228,CDM,C1776,HCPCS,0278,RC,,,both,,,4514.33,1354.3,"CIGNA [10200]",Cigna,,3069.74,68,,5873.17,5873.17,5873.17,"1 through 10",525.02,3837.18,"percent of total billed charges",
"HC Study Ext Artery 1-2 Lvls Bi",PX-920000003,CDM,93922,CPT,0921,RC,,,both,,,1568.21,470.46,"CIGNA [10200]","Cigna Local Plus",,838.99,53.5,,,,,0,180.05,1332.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 26MM TI",SUP-SPL-35260-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Aorta Ivc Ltd",PX-921000016,CDM,93979,CPT,0921,RC,,,both,,,1081.48,324.44,"BLUE CROSS [10001]","Blue Cross PPO",,348.06,,"Fee schedule rate ($348.06).",,,,0,125.78,919.26,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL SYMBOTEX 3.3X2.3MM 12CM 2 SIDE COMPOSITE",SUP-SYM12,CDM,C1781,HCPCS,0278,RC,,,both,,,3229.65,968.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1482.41,45.9,,,,,0,375.61,2745.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM LAPIPLASTY BIPLANAR 16X4.3MM 12MM 3MM 3MM INTERNAL",SUP-SK23,CDM,C1713,HCPCS,0278,RC,,,both,,,44068.50,13220.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18112.15,41.1,,,,,0,5125.17,37458.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 115CMX10MM 1.2MM MINI HELIX 3 WIRE",SUP-FG-52D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVD 33CM 1.5FR EXTERNAL DRNG CSF VENTRICULAR HERMETIC",SUP-50318,CDM,C1729,HCPCS,0272,RC,,,both,,,2604.38,781.31,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SUPERORDERABLE",RX-4087309,CDM,,,0250,RC,51754-5001-01,NDC,both,50,ML,79.28,23.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 50MM ACETABULAR FLEXIBLE SCR STERILE",SUP-71362950,CDM,S27200284,LOCAL,0272,RC,,,both,,,1538.19,461.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL LOOP 24FR CUT OLYMPUS OES PRO",SUP-M0068802611,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Gastric Band Adjustment",PX-361000268,CDM,S2083,HCPCS,0361,RC,,,both,,,899.29,269.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ORTHOPEDIC 220MM 1.6MM",SUP-03.333.003,CDM,S27000186,LOCAL,0270,RC,,,both,,,562.63,168.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAFIRE TX COMFORTGRIP 110CM 8MM 7FR 1MM 2-5-2MM SPACE",SUP-402841,CDM,C1733,HCPCS,0272,RC,,,both,,,6555.00,1966.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 12.7MM 85MM DHS/DCS STAINLESS STEEL CONDYLE HIP LAG",SUP-280.285S,CDM,C1713,HCPCS,0278,RC,,,both,,,2333.10,699.93,"FIRST HEALTH [10303]","First Health",,1866.48,80,,,,,0,271.34,1983.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM SUMMIT POROCOAT 10 12/14 STD OFFSET TAPER",SUP-157001180,CDM,C1776,HCPCS,0278,RC,,,both,,,25247.25,7574.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2991.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2936.26,21460.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION HI-FLO 105CM 2.8-3FR .027IN MICRO INFUSION",SUP-M001195460,CDM,C1887,HCPCS,0272,RC,,,both,,,4416.00,1324.8,"NOVANET [10819]",Novanet,,3312,75,,,,,0,513.58,3753.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X5MM VERTE-STACK CORNERSTONE PSR",SUP-6240541,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"AETNA [10100]","Aetna HMO/PPO",,5309.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT MONORAIL 21MM 135CM 8MM ENDOPROSTHESIS METAL",SUP-M001719010,CDM,C1876,HCPCS,0278,RC,,,both,,,10479.00,3143.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4306.87,41.1,,,,,0,1218.71,8907.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC RBC Ag Not Abo/Rh(D) Ea",PX-302000196,CDM,86905,CPT,0302,RC,,,both,,,92.30,27.69,"FIRST HEALTH [10303]","First Health",,73.84,80,,,,,0,0.01,78.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14IN 24FR VENOUS ANGLE RIGHT OPEN LIGHTHOUSE",SUP-TF024L90,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.48,58.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,80.34,41.1,,,,,0,22.73,166.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 14MM PERSONA 4-11 E-F KNEE RIGHT TIBIA",SUP-42522200514,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1253.3,9159.96,"percent of total billed charges",
"STEM FEMORAL ACCOLADE II 5 127D",SUP-6721-0535,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9848.4,41.1,,6417.48,6417.48,6417.48,"1 through 10",2786.79,20367.74,"percent of total billed charges",
"CATH AGENT 20MM 3.5MM BALLOON DILATATION PACLITAXEL",SUP-H7493960820350,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"PHCS [10601]",PHCS,,27231.75,70,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 110CM 5FR 5MM SPACE ELECTROPHYSIOLOGY STEERABLE 4",SUP-81483R,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,991.44,68,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY FEMORAL 105MM 24MM RECLAIM 45MM 12/14 OFFSET MINI TAPER",SUP-197524105,CDM,C1776,HCPCS,0278,RC,,,both,,,22082.76,6624.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2616.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2568.22,18770.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM 14MM PRESS FIT UNIVERSAL FLUTE KNEE",SUP-867428,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2318.39,28.62,,,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 140MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 10",SUP-245.101,CDM,C1713,HCPCS,0278,RC,,,both,,,3324.30,997.29,"AETNA [10100]","Aetna HMO/PPO",,2642.82,79.5,,1521.93,481.35,16760.95,30,386.62,2825.66,"percent of total billed charges",
"INSRT TIBIAL 6+ KNEE LEFT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB6PL,CDM,C1776,HCPCS,0278,RC,,,both,,,17652.60,5295.78,"CIGNA [10200]",Cigna,,7061.04,40,,5873.17,5873.17,5873.17,"1 through 10",2053,15004.71,"percent of total billed charges",
"SPACER ALLOGRAFT 11MMX14MM 6 DEGREE CERVICAL CANCELLOUS",SUP-4W7206,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Open Access",,3926.1,56.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE AMS 700CX MS PUMP 21CM INFLATABLE PRECONNECT CYL",SUP-72404238,CDM,C1813,HCPCS,0278,RC,,,both,,,76351.50,22905.45,"CIGNA [10200]","Cigna Open Access",,25577.75,33.5,,,,,0,8879.68,64898.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Carpal Tunnel Therapeutic",PX-510000202,CDM,20526,CPT,0761,RC,,,both,,,895.13,268.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,895.13,,"Case rate ($1,729.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,104.1,895.13,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION",RX-93084,CDM,J0282,HCPCS,0636,RC,63323-0616-03,NDC,both,3,ML,18.92,5.68,"BLUE CROSS [10001]","Blue Cross PPO",,2.51,,,,,,,2.24,16.08,"fee schedule",
"MICROCATHETER CEREBROVASCULAR 135CM MAMBA FLEX STERILE LATEX",SUP-H7493928713540,CDM,C1725,HCPCS,0272,RC,,,both,,,4071.00,1221.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 40MM 3MM BALLOON DILATATION OTW STERILE",SUP-583004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT RETRIEVAL 76CM 7FR 3 LOOP RADIOPAQUE PLATINUM STRAND",SUP-380911330,CDM,C1773,HCPCS,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPRT 40-42IN XL PAD SHOULDER STRAP REMOVABLE DRAIN BULB",SUP-46518-04LF,CDM,S27000186,LOCAL,0270,RC,,,both,,,418.38,125.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET 1.5IN 19GA ANGLE DOWN INFUSION Y INJECTION SITE POWER",SUP-0671915,CDM,S27200284,LOCAL,0272,RC,,,both,,,54.64,16.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAMP SURGICAL SYMMETRY .4-1MM VESSEL 1",SUP-B-1VB,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.30,176.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VERIPATH 50CM 7FR .078IN LIMA CURVE GUIDING STAINLESS",SUP-1005597-07,CDM,C1887,HCPCS,0272,RC,,,both,,,382.80,114.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,45.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM STARDRIVE STAINLESS STEEL T8 METAPHYSEAL",SUP-02.118.514,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",60.93,445.32,"percent of total billed charges",
"STEM RADIAL 8MM 2MM ELBOW HEAD STERILE",SUP-TR-S0802-S,CDM,C1776,HCPCS,0278,RC,,,both,,,15145.50,4543.65,"PHCS [10601]",PHCS,,10601.85,70,,,,,0,1761.42,12873.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH",RX-27860,CDM,,,0250,RC,60505-7061-00,NDC,both,1,UN,12.54,3.76,"PHCS [10601]",PHCS,,8.78,70,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARGATROBAN 1 MG/ML IN 0.9% SODIUM CHLORIDE IV SOLUTION SUPERORDERABLE",RX-408837,CDM,J0883,HCPCS,0636,RC,00143-9559-01,NDC,both,50,ML,1793.88,538.16,"BLUE CROSS [10001]","Blue Cross HMO",,46.62,,,,,,,46.62,1524.8,"fee schedule",
"DEVICE ZIP 16CM SKIN CLSR STERILE LATEX FREE DISPOSABLE",SUP-PS1160,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,249.68,41.1,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 8MMX79MM 8FR 80CMCATH HEPARIN",SUP-BXBL087901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"FIRST HEALTH [10303]","First Health",,17125.92,80,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 22MM LCP STAINLESS STEEL LONG THREAD FEMORAL",SUP-207.722,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"CIGNA [10200]","Cigna Local Plus",,556.42,53.5,,3978.14,359.25,3978.14,24,120.96,884.03,"percent of total billed charges",
"FRCP SPECIMEN RETRIEVAL 90CM 3FR HOOK PRONG GRASP MINI THROW",SUP-M0063701000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1376.11,412.83,"FIRST HEALTH [10303]","First Health",,1100.89,80,,,,,0,160.04,1169.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM LOW PROFILE NECK VERTICAL GROOVE CORAIL2",SUP-L20316,CDM,C1776,HCPCS,0278,RC,,,both,,,28658.70,8597.61,"BLUE CROSS [10001]","Blue Cross PPO",,11234.21,39.2,,3949.44,3949.44,3949.44,"1 through 10",3333.01,24359.9,"percent of total billed charges",
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,inpatient,,,47595.94,14278.78,"AMBETTER EXCHANGE  [11102]",Ambetter,,7055.99,,"Case rate ($7,055.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,551.96, add-ons for qualifying new technology services are included. If operating cost exceeds $39,591.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,877.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,560.62. The transfer operating threshold is the transfer adjustment factor * $6,551.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $495.36. The transfer capital threshold is the transfer adjustment factor * $495.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7055.99,33210.45,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET TPR .016 45CM",SUP-6035,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 8 HOLE STRAIGHT BONE LEFT CLAVICLE",SUP-70-0298,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"AETNA [10100]","Aetna HMO/PPO",,5255.11,79.5,,1521.93,481.35,16760.95,30,768.77,5618.67,"percent of total billed charges",
"CMPNT GLENOID 48MM PEG REUNION X3 STERILE LATEX FREE TOTAL",SUP-5542-P-0048,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3710.39,41.1,,6417.48,6417.48,6417.48,"1 through 10",1049.92,7673.56,"percent of total billed charges",
"SEAL TISSUE CLSR VISTASEAL FIBRIN HUMAN 2ML",SUP-VST02,CDM,S25000001,LOCAL,0250,RC,,,both,,,1459.86,437.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,169.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.78,1240.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 13MM 12FR ENDOPROSTHESIS HEPARIN",SUP-VBH131002A,CDM,C1874,HCPCS,0278,RC,,,both,,,20160.00,6048,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8064,40,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL 11MM 2 KNEE ALL POLYETHYLENE CONDYLAR STABILIZE",SUP-5534-A-211,CDM,C1776,HCPCS,0278,RC,,,both,,,13872.45,4161.73,"UHC [10700]","United Healthcare",,8781.26,63.3,,8601.07,8395.67,8601.07,"1 through 10",1613.37,11791.58,"percent of total billed charges",
"CATH ADVANCE 150CM 2CM 5MM BALLOON DILATATION ILIAC",SUP-G34328,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER HUMERAL 42MM AEQUALIS +9MM SHOULDER REVERSE STERILE",SUP-DWB932,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"CIGNA [10200]","Cigna Local Plus",,4829.98,53.5,,5372.07,4581.20,7242.98,23,1049.96,7673.8,"percent of total billed charges",
"SCR BONE 2.4MM 22MM LCP STAINLESS STEEL DISTAL RADIUS T8",SUP-02.210.122,CDM,C1713,HCPCS,0278,RC,,,both,,,959.36,287.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,111.57,815.46,"percent of total billed charges",
"SCREW NON-LOCKING 2.5MM X 12MM TI",SUP-VAN-25120-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,113.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",113.04,826.2,"percent of total billed charges",
"HC Hla I Typing Complete Lr",PX-309000081,CDM,81372,CPT,0310,RC,,,both,,,1427.00,428.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1.43,.1,,,,,0,1.43,1212.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 22MM LCP STAINLESS STEEL DISTAL RADIUS T8",SUP-02.210.122,CDM,C1713,HCPCS,0278,RC,,,both,,,959.36,287.81,"CIGNA [10200]","Cigna Open Access",,545.88,56.9,,1144.80,304.56,2275.09,66,111.57,815.46,"percent of total billed charges",
"STPLR INTERNAL TITANIUM XL LINEAR CUTTER SQUEEZE HANDLE",SUP-EEAORVIL25A,CDM,S27200284,LOCAL,0272,RC,,,both,,,706.81,212.04,"AETNA [10100]","Aetna HMO/PPO",,561.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,82.2,600.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR EMPHASYS 52MM 28MM AOX HIP MOBILE BEARING",SUP-473252028,CDM,C1776,HCPCS,0278,RC,,,both,,,18106.20,5431.86,"CIGNA [10200]",Cigna,,7242.48,40,,5873.17,5873.17,5873.17,"1 through 10",2105.75,15390.27,"percent of total billed charges",
"HEMOSTAT ABSORBABLE 2X1IN SURGICEL FIBRILLAR STERILE",SUP-1961,CDM,S27200284,LOCAL,0272,RC,,,both,,,867.83,260.35,"NOVANET [10819]",Novanet,,650.87,75,,,,,0,100.93,737.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH XXL 75CM 60MM 5.8FR 14MM .035IN BALLOON DILATATION",SUP-M001145320,CDM,C1725,HCPCS,0272,RC,,,both,,,1709.63,512.89,"KAISER [10500]",Kaiser,,1145.45,67,,,,,0,198.83,1453.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Arm/Hnd Lt",PX-510000098,CDM,29584,CPT,0761,RC,,,both,,,802.84,240.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,802.84,,"Case rate ($1,729.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,93.37,802.84,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE INQWIRE VASCULAR 1.5MM RADIUS J CURVE ROSEN 180CM .035",SUP-IQ35F180J1O5RS,CDM,C1769,HCPCS,0272,RC,,,both,,,101.79,30.54,"PHCS [10601]",PHCS,,71.25,70,,,,,0,11.84,86.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5MM 2 3/8 CIRCLE BIO-CORKSCREW FIBERWIRE ROTATOR",SUP-AR-1920BNF,CDM,C1713,HCPCS,0278,RC,,,both,,,2126.25,637.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,251.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",247.28,1807.31,"percent of total billed charges",
"CATH NANOCROSS 150CM 60MM 4MM .014IN BALLOON DILATATION",SUP-AB14W040060150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"KAISER [10500]",Kaiser,,928.02,67,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM TSRH-3D TITANIUM SHORT POST POSTERIOR",SUP-8372650,CDM,C1713,HCPCS,0278,RC,,,both,,,2361.60,708.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,274.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",274.65,2007.36,"percent of total billed charges",
"INSRT ARTICULAR 5-6 11MM KNEE POSTERIOR STABILIZE UHMWPE",SUP-71420832,CDM,C1776,HCPCS,0278,RC,,,both,,,9998.10,2999.43,"FIRST HEALTH [10303]","First Health",,7998.48,80,,,,,0,1162.78,8498.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION AVENIR STERILE LATEX FREE DISPOSABLE",SUP-10CFN03504,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AETNA [10100]","Aetna HMO/PPO",,9319.86,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI L 8MMX1MM MID FACE RIGHT 4 HOLE BAR 2MM SCR BONE",SUP-55-08232,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"SCR BONE 5.5MM 25MM SOLERA COCR SPINAL MULTIAXIAL CANNULATED",SUP-54840005525,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1110.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1110.3,8114.82,"percent of total billed charges",
"HC Hla Class II Phenotype Qual",PX-302000267,CDM,86831,CPT,0302,RC,,,both,,,481.00,144.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,245.67,,,,,,,0.01,408.85,"fee schedule",
"CATH HYPERGLIDE X-PEDION 150CM 15MM 2.8-2.2FR 5MM .01IN 4MM",SUP-104-4515,CDM,C1725,HCPCS,0272,RC,,,both,,,9273.60,2782.08,"UHC [10700]","United Healthcare",,5870.19,63.3,,,,,0,1078.52,7882.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 7MM INTERTAN COMPRESSION SCR STARTER",SUP-71674570,CDM,S27200284,LOCAL,0272,RC,,,both,,,2127.38,638.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,874.35,41.1,,,,,0,247.41,1808.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 710-1000UM 5 VIAL CONTOUR PVA",SUP-M0017600851,CDM,S27800098,LOCAL,0278,RC,,,both,,,1377.00,413.1,"KAISER [10500]",Kaiser,,922.59,67,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER CURVED TIP RELOAD 30MM WHITE",SUP-ASR30WC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"KAISER [10500]",Kaiser,,949.73,67,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 22-30CM 3CM 7FR .035IN",SUP-M006180157190,CDM,C2617,HCPCS,0278,RC,,,both,,,1271.86,381.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,364.01,28.62,,,,,0,147.92,1081.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 15CM ACHIEVE COAXIAL INTRO AUTOMATED",SUP-CA2015,CDM,S27200284,LOCAL,0272,RC,,,both,,,967.46,290.24,"FIRST HEALTH [10303]","First Health",,773.97,80,,,,,0,112.52,822.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL O2 DELIVERY TUBE MINIMIZE RESISTANCE INFANT",SUP-BC2745-20,CDM,S27000186,LOCAL,0270,RC,,,both,,,70.91,21.27,"UHC [10700]","United Healthcare",,44.89,63.3,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ENDOSCOPIC 5MM 250MM CURVE ARM 1",SUP-428071,CDM,S27000186,LOCAL,0270,RC,,,both,,,6900.00,2070,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4692,68,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO BALKIN CURVE 40CM 7FR 2.5MM GUIDING",SUP-G32225,CDM,C1894,HCPCS,0272,RC,,,both,,,432.22,129.67,"NOVANET [10819]",Novanet,,324.17,75,,,,,0,50.27,367.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 12MM 2.5MM CORONARY STENT EVEROLIMUS",SUP-1550250-12,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON DISECT LAPAROSCOPIC SPACEMAKER PLUS PREPERITONEAL",SUP-SMBTTOVL,CDM,C1726,HCPCS,0272,RC,,,both,,,3258.30,977.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2215.64,68,,,,,0,378.94,2769.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OCCL 100CM 5FR 26FR BALLOON OCCLUSION 1 INFLATION PORT",SUP-M0062201080,CDM,C2628,HCPCS,0272,RC,,,both,,,1155.14,346.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,136.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,134.34,981.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA STD TKR VIVACIT-E FEMUR PATELLA TIBIA CEM",SUP-98000647502,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"BLUE CROSS [10001]","Blue Cross PPO",,8890.56,39.2,,3949.44,3949.44,3949.44,"1 through 10",2637.68,19278,"percent of total billed charges",
"STENT 28CM 3CM 4.8FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175254050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"MULTIPLAN [10600]",Multiplan,,910.13,85,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVISION OF HIP OR KNEE REPLACEMENT WITH MCC",466,MS-DRG,,,,,,,inpatient,,,153376.94,46013.08,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,65747.7,,"Case rate ($32,289.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $29,982.91, add-ons for qualifying new technology services are included. If operating cost exceeds $63,022.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,648.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $30,022.56. The transfer operating threshold is the transfer adjustment factor * $29,982.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,266.85. The transfer capital threshold is the transfer adjustment factor * $2,266.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 203.62%.",,,,0,32289.41,151976.86,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X2CM NUSHIELD MEMB",SUP-NO-1240,CDM,Q4160,HCPCS,0636,RC,,,both,,,6555.00,1966.5,"MULTIPLAN [10600]",Multiplan,,5571.75,85,,,,,0,776.77,6555,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE REAMER 51MM PILOT HOLE KNEE PATELLA STAINLESS STEEL",SUP-597909551,CDM,S27200284,LOCAL,0272,RC,,,both,,,1129.14,338.74,"MULTIPLAN [10600]",Multiplan,,959.77,85,,,,,0,131.32,959.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID",RX-42219,CDM,,,0250,RC,08888-8883-90,NDC,both,7.5,ML,12.54,3.76,"PHCS [10601]",PHCS,,8.78,70,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH ENDOSCP 4MM 11.35MM ROUND EDGE STERILE LATEX FREE",SUP-D-201-10704,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.26,63.08,"CIGNA [10200]",Cigna,,142.98,68,,,,,0,24.45,178.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 13CM 8FR CHECK-FLO PERFORMER RADIOPAQUE TIP",SUP-G07856,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE BONE SAGITTAL L 70X12.5",SUP-BR2108-155,CDM,S27200284,LOCAL,0272,RC,,,both,,,157.47,47.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,72.28,45.9,,,,,0,18.31,133.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR CATH TUOHY BORST PEEL OPEN STERILE DISPOSABLE",SUP-11274TB/6,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 18MM 2.25MM AXIUS CORONARY INTERNAL",SUP-OF-2250,CDM,S27200284,LOCAL,0272,RC,,,both,,,813.05,243.91,"KAISER [10500]",Kaiser,,544.74,67,,,,,0,94.56,691.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 60CM 8MM STRAIGHT FUSION BIOLINE POLYESTER 2",SUP-M00201503068B0,CDM,C1768,HCPCS,0278,RC,,,both,,,10631.52,3189.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1259.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1236.45,9036.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FUSION QUATTRO 200CM 6.6FR 8.5-15MM SPECIMEN RETRIEVAL",SUP-G48225,CDM,S27800098,LOCAL,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC App Rigid Leg Cast",PX-510000074,CDM,29445,CPT,0761,RC,,,both,,,3729.02,1118.71,"CIGNA [10200]","Cigna Open Access",,2181,,"Per diem ($2,181).",,,,0,433.69,3169.67,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC",261,MS-DRG,,,,,,,inpatient,,,72451.35,21735.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,17052.31,,"Fee schedule rate ($17,052.31). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,7561,55195.04,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM 20.4MM MASTER-SERIES PYROLYTIC CARBON PTFE",SUP-25ATJ-503,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]","Cigna Open Access",,9754.94,33.5,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 12FR BALLOON 2-3ML SILICONE SECURELOK RIGHT",SUP-0200-12LV,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"AETNA [10100]","Aetna HMO/PPO",,874.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM MEDIUM BARREL",SUP-5120017040,CDM,S27200284,LOCAL,0272,RC,,,both,,,765.94,229.78,"KAISER [10500]",Kaiser,,513.18,67,,,,,0,89.08,651.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL TAN 100MM 10.35MM TFN-ADVANCED",SUP-04.038.400S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"BLUE CROSS [10001]","Blue Cross HMO",,1560.89,39.2,,957.42,156.86,7483.26,51,463.09,3384.57,"percent of total billed charges",
"INSRT TIBIAL 6 10MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650610,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5395.3,41.1,,6417.48,6417.48,6417.48,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"SCR BONE 5MM 57MM TRIGEN FEMUR LOW PROFILE",SUP-71645057,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"MULTIPLAN [10600]",Multiplan,,1759.12,85,,,,,0,240.69,1759.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lactoferrin Stool",PX-301000295,CDM,83630,CPT,0301,RC,,,both,,,657.40,197.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.8,,"Fee schedule rate ($15.80). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,558.79,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR TRILOGY STD NEUTRAL 6.8MM 50/52/54MM 36MM",SUP-00630505036,CDM,C1776,HCPCS,0278,RC,,,both,,,6497.40,1949.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4418.23,68,,,,,0,755.65,5522.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL BEND 147MM STAINLESS STEEL 3.5MM SCR 8 HOLE",SUP-02.127.230S,CDM,C1713,HCPCS,0278,RC,,,both,,,11005.50,3301.65,"AETNA [10100]","Aetna HMO/PPO",,8749.37,79.5,,1521.93,481.35,16760.95,30,1279.94,9354.68,"percent of total billed charges",
"STENT COVERA 60MM 80CM 8MM 8FR STRAIGHT VASCULAR COVER",SUP-AVSM08060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL NEONATE PROSOFT NONSTERILE LATEX FREE DISPOSABLE",SUP-PROSOFT-NEO,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.06,33.62,"UHC [10700]","United Healthcare",,70.93,63.3,,,,,0,13.03,95.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 15MM 145CM 3.25MM CORONARY STENT",SUP-1145325-15,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER FEMORAL 14MM ACCOLADE UNIVERSAL DISTAL HIP CEMENTED",SUP-1067-0014,CDM,C1776,HCPCS,0278,RC,,,both,,,620.57,186.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,72.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.17,527.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE WHISPER VIEW VASCULAR 190CM .014IN CORONARY SINUS",SUP-4635,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"KAISER [10500]",Kaiser,,759.78,67,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 5MMX59MM 7FR 80CMCATH HEPARIN",SUP-BXB055901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"PHCS [10601]",PHCS,,13653.36,70,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28X10X10MM COALESCE LORDOTIC STRAIGHT STERILE",SUP-2000-00-101008,CDM,C1889,HCPCS,0278,RC,,,both,,,21420.00,6426,"FIRST HEALTH [10303]","First Health",,17136,80,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE TITANIUM 20MM 7MM ACL PCL CANNULATED",SUP-AR-1370,CDM,C1713,HCPCS,0278,RC,,,both,,,807.98,242.39,"BLUE CROSS [10001]","Blue Cross HMO",,316.73,39.2,,957.42,156.86,7483.26,51,93.97,686.78,"percent of total billed charges",
"RIFAMPIN (10 MG/ML) ORAL SUSPENSION",RX-408547,CDM,,,0637,RC,08888-8886-45,NDC,both,1,ML,12.54,3.76,"NOVANET [10819]",Novanet,,9.41,75,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STATLOCK SECUREMENT PERCUTANEOUS SHEATH INTRO",SUP-0684-00-0493,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.58,49.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,68.05,41.1,,,,,0,19.26,140.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK 8X1.5X2CM STD SEPTUM NASAL AIRWAY DRAWSTRING COMPRESSED",SUP-440410,CDM,S27200284,LOCAL,0272,RC,,,both,,,254.91,76.47,"MULTIPLAN [10600]",Multiplan,,216.67,85,,,,,0,29.65,216.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXIBLE ARGON ELECTRODE 6",SUP-E3530-6,CDM,S27200284,LOCAL,0272,RC,,,both,,,197.49,59.25,"CIGNA [10200]",Cigna,,134.29,68,,,,,0,22.97,167.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 8MM INFINITY SPINE OCCIPITOCERVICAL",SUP-3600408,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOABLATION 10CM STAINLESS STEEL MALLEABLE",SUP-CRYOF,CDM,C9808,HCPCS,0272,RC,,,both,,,15870.00,4761,"AETNA [10100]","Aetna HMO/PPO",,12616.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 8MM 26MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.416S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,687.07,45.9,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 0 Q-FIX NEEDLES SUT STERILE LATEX FREE DISPOSABLE",SUP-72205691,CDM,C1713,HCPCS,0278,RC,,,both,,,3003.75,901.12,"KAISER [10500]",Kaiser,,2012.51,67,,,,,0,349.34,2553.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC L7 MM FLEXOR HALLUCIS LONGUS",SUP-AR-1570BC-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10831.28,3249.38,"CIGNA [10200]",Cigna,,7365.27,68,,1831.33,1831.33,1831.33,16,1259.68,9206.59,"percent of total billed charges",
"INSRT TIBIAL 6 16MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-616-E,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"CIGNA [10200]","Cigna Open Access",,4508.58,33.5,,5302.19,4377.88,6578.61,27,1565.22,11439.68,"percent of total billed charges",
"SHEATH CLEARPETRA 15CM 20FR 18FR ACCESS NEPHRSTMY",SUP-90121815,CDM,C1894,HCPCS,0272,RC,,,both,,,3157.50,947.25,"MULTIPLAN [10600]",Multiplan,,2683.88,85,,,,,0,367.22,2683.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM NEXGEN LPS-FLEX 5-6MM GH KNEE UHMWPE",SUP-00596404210,CDM,C1776,HCPCS,0278,RC,,,both,,,6291.60,1887.48,"CIGNA [10200]","Cigna Local Plus",,3366.01,53.5,,5372.07,4581.20,7242.98,23,731.71,5347.86,"percent of total billed charges",
"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",555,MS-DRG,,,,,,,inpatient,,,48597.28,14579.18,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN 3 DIMENSIONAL RIGHT CURVE",SUP-LA63DRCSH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE WHISPER VIEW VASCULAR 3MM 190CM .014IN",SUP-4636,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 9X100 135CM SL",SUP-48009010R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,584.13,68,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING URETHRAL BLUE DESARA TRANSVAGINAL STAINLESS STEEL",SUP-CAL-DS01BTV,CDM,C1771,HCPCS,0278,RC,,,both,,,6203.10,1860.93,"KAISER [10500]",Kaiser,,4156.08,67,,,,,0,721.42,5272.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 80CM 10MM 13MM 8FR .035IN",SUP-BXA102901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]",Cigna,,7801.92,40,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC",485,MS-DRG,,,,,,,inpatient,,,119941.43,35982.43,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,20618.43,,"Case rate ($20,017.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $18,587.97, add-ons for qualifying new technology services are included. If operating cost exceeds $51,627.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,787.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $18,612.56. The transfer operating threshold is the transfer adjustment factor * $18,587.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,405.34. The transfer capital threshold is the transfer adjustment factor * $1,405.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,94218.41,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 28CM 10.2FR RB AMPLATZ PIGTAIL CURVE URETER",SUP-G09715,CDM,C2625,HCPCS,0278,RC,,,both,,,1227.07,368.12,"BLUE CROSS [10001]","Blue Cross HMO",,481.01,39.2,,,,,0,142.71,1043.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER CURVED TIP RELOAD 45MM GRAY",SUP-AESC45G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1377.00,413.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,163.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC QUANTUM TTC 320CM 3CM 10MM 6.8-4.5FR BILIARY",SUP-G22767,CDM,C1726,HCPCS,0272,RC,,,both,,,3045.00,913.5,"AETNA [10100]","Aetna HMO/PPO",,2420.78,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,354.13,2588.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH ENDO-SCRUB 2 30D 4MM ENDOSCOPIC CLEANING STERILE",SUP-1912051,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.84,161.35,"NOVANET [10819]",Novanet,,403.38,75,,,,,0,62.55,457.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXS CATALYST 5 132CM .058IN GUIDING DISTAL ACCESS",SUP-M003IC0581320,CDM,S27200284,LOCAL,0272,RC,,,both,,,13688.22,4106.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1622.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1591.94,11634.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 5X1CM GAUZE MEROGEL SEPTUM PK STERILE LATEX",SUP-1517100,CDM,S27000186,LOCAL,0270,RC,,,both,,,467.29,140.19,"MULTIPLAN [10600]",Multiplan,,397.2,85,,,,,0,54.35,397.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 16FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G01212,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"KAISER [10500]",Kaiser,,33.05,67,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 150MM 130CM 6MM 6FR .035IN HELICAL VASCULAR",SUP-EX061503CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20128.50,6038.55,"FIRST HEALTH [10303]","First Health",,16102.8,80,,,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 2.5MM CEREPAK XTRASOFT FREEFORM",SUP-XCR122505,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1538.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 75CM 6MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200064070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 45CM 4-6MM ADVANTA VXT STD WALL SHORT TAPER",SUP-22114,CDM,C1768,HCPCS,0278,RC,,,both,,,3440.10,1032.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,400.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,400.08,2924.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 10MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240100200,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"PHCS [10601]",PHCS,,4772.04,70,,,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOBRONCHIAL ARNDT PEDIATRIC 65CM 7FR STD 1 LUMEN CATH",SUP-G44114,CDM,S27200284,LOCAL,0272,RC,,,both,,,1942.50,582.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 135CM 60MM 4MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171040610,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BD NEXIVA DIFFUSICS .75IN 24GA 1.22MM 3ML/SEC 325 PSI",SUP-383590,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.16,17.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH HEMOSTASIS VALVE TEAR AWAY SIDEPORT SAFESHEATH",SUP-HLS2510,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIQUIFIX PRECISION OPEN",SUP-72014033,CDM,S27200284,LOCAL,0272,RC,,,both,,,2925.00,877.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,346.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,340.18,2486.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL ETHI-PACK 4-0 18IN MONOFILAMENT TIES",SUP-DS32,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AETNA [10100]","Aetna HMO/PPO",,19.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDEAVOR SPRINT 18MM 142CM 3MM CORONARY STENT",SUP-ENSP30018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"BLUE CROSS [10001]","Blue Cross HMO",,2173.25,39.2,,9776.84,9776.84,9776.84,"1 through 10",644.77,4712.4,"percent of total billed charges",
"CATH HEARTRAIL III 100CM 6FR IKARI LEFT 4 CURVE GUIDING",SUP-40-6373,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,239.7,41.1,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 100MM 2.7MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.26,CDM,S27000186,LOCAL,0270,RC,,,both,,,496.69,149.01,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,204.14,41.1,,,,,0,57.77,422.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM 3 HOLE BIOFOAM DYNASTY",SUP-DBFPGE54,CDM,C1776,HCPCS,0278,RC,,,both,,,18194.40,5458.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7277.76,40,,,,,0,2116.01,15465.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC RBC Lr Ea Unit",PX-390000004,CDM,P9016,HCPCS,0390,RC,,,both,,,1383.50,415.05,"AETNA [10100]","Aetna HMO/PPO",,1099.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.9,1175.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 20MM CANNULATED PROXIMAL 1.6MM KWIRE",SUP-03.211.120,CDM,S27200284,LOCAL,0272,RC,,,both,,,2436.00,730.8,"CIGNA [10200]","Cigna Local Plus",,1303.26,53.5,,,,,0,283.31,2070.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 60X22X14MM 10D XL WIDE PEEK LORDOTIC",SUP-6921460,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9504,40,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 75CM 60MM 12MM BALLOON DILATATION ARTERIOVENOUS",SUP-LX35751260V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"NOVANET [10819]",Novanet,,6339.38,75,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 13MM 140CM 3MM CORONARY STERILE LATEX",SUP-453934,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE SPINAL FENESTRATED RELINE MAS",SUP-10001117,CDM,S27000186,LOCAL,0270,RC,,,both,,,1008.45,302.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.28,857.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH DURAL 2X2IN DUREPAIR",SUP-62100,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Perq Trancath Septal Rdct",PX-481000099,CDM,93583,CPT,0481,RC,,,both,,,25853.00,7755.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3063.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2491,25681,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM ARTHREX CORKSCREW FT SUTURETAPE PEEK",SUP-AR-1927PST-475,CDM,C1713,HCPCS,0278,RC,,,both,,,2480.63,744.19,"BLUE CROSS [10001]","Blue Cross HMO",,972.41,39.2,,957.42,156.86,7483.26,51,288.5,2108.54,"percent of total billed charges",
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR NARROW LORDOTIC 12 DEGRE",SUP-12321,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"KAISER [10500]",Kaiser,,12663,67,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM SAPPHIRE SPINE SELF DRILL VARIABLE ANGLE",SUP-27240-014,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"FIRST HEALTH [10303]","First Health",,1128,80,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EASYTRAK 3",SUP-4550,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross PPO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM WIDE BLADE RAMP 5.5MM",SUP-7541133,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,957.42,570.23,957.42,28,348.9,2550,"percent of total billed charges",
"ROD SPINAL 6MM PRECEPT PREBENT LORDOTIC",SUP-8847160,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Local Plus",,2359.35,53.5,,3978.14,359.25,3978.14,24,512.88,3748.5,"percent of total billed charges",
"MESH SURGICAL VICRYL 6X6IN ABSORBABLE STERILE POLYGLACTIN",SUP-VWMM,CDM,C1781,HCPCS,0278,RC,,,both,,,2471.17,741.35,"PHCS [10601]",PHCS,,1729.82,70,,,,,0,287.4,2100.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 200MM 4MM BALLOON DILATATION RAPID",SUP-47540200M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,235.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X5MM VERTE-STACK CORNERSTONE PSR",SUP-6240541,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA [10200]",Cigna,,4541.33,68,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 140MM 22-14MM 15MM 12FR TRIVASCULAR OVATION",SUP-TV-IL1422140-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3883.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB 7 13MM KN BRNG POST STAB",SUP-5532-G-713-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"BLUE CROSS [10001]","Blue Cross PPO",,4473.74,39.2,,3949.44,3949.44,3949.44,"1 through 10",1327.29,9700.71,"percent of total billed charges",
"KIT CATH 19CM 14.5FR 360D STD 2 BRANCH STRAIGHT POLYURETHANE",SUP-5733690,CDM,S27200284,LOCAL,0272,RC,,,both,,,1897.50,569.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,220.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,220.68,1612.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 12MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620812,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"KAISER [10500]",Kaiser,,7540.11,67,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 150CM 200MM 5MM BALLOON DILATATION PACLITAXEL",SUP-H74939419502010,CDM,C2623,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1594.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID ARM REDUCTION KIT- LONG, REGULAR",SUP-25401217,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"UHC [10700]","United Healthcare",,794.73,63.3,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL LOCK HOLE COMPRESSION SLOT PRECONTOUR",SUP-AR-2652CR,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE EXAMINATION BFLEX SLIM 3.8 SINGLE USE X2",SUP-0570-0448,CDM,S27200284,LOCAL,0272,RC,,,both,,,1990.50,597.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,818.1,41.1,,,,,0,231.5,1691.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 10MM 1.9FR BAGLEY HELICAL 3 WIRE",SUP-M0063401210,CDM,S27200284,LOCAL,0272,RC,,,both,,,1247.08,374.12,"CIGNA [10200]","Cigna Open Access",,709.59,56.9,,,,,0,145.04,1060.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SPECIMEN RETRIEVAL 240CM 5.5FR 3 PRONG HOOKED GRASPING",SUP-G25080,CDM,S27200284,LOCAL,0272,RC,,,both,,,1239.30,371.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,146.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 5FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552240,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]",Cigna,,816.39,68,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Paravrt Jt L/S 2 Lvl",PX-510000140,CDM,64494,CPT,0761,RC,,,both,,,3490.00,1047,"MULTIPLAN [10600]",Multiplan,,2966.5,85,,,,,0,405.89,2966.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X4MM VERTE-STACK CORNERSTONE PSR 14MM",SUP-6278444,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 15MM 5MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG50015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA [10200]","Cigna Open Access",,1493.63,56.9,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22-24X27-32X9MM LUMINARY CC BICONVEX SPINE",SUP-6809,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3941.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 102MM 25-14MM 18FR ENDURANT II ENDOVASCULAR",SUP-ETUF2514C102E,CDM,S27800098,LOCAL,0278,RC,,,both,,,60782.40,18234.72,"MULTIPLAN [10600]",Multiplan,,51665.04,85,,,,,0,7068.99,51665.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 7.5FR 10.5FR SUBCUTANEOUS DF-1 CNCT",SUP-6996SQ58,CDM,C1896,HCPCS,0278,RC,,,both,,,12420.00,3726,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5104.62,41.1,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 100CM 5FR JL2 CURVE ANGIOGRAPHIC NO",SUP-G47012,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"CIGNA [10200]","Cigna Open Access",,119.79,56.9,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PREFACE MULTIPURPOSE CURVE 62CM 8FR .11IN GUIDING 2",SUP-301803M,CDM,C1893,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR ANGLE 80CM .035IN HYDROPHILIC FIXED CORE",SUP-H2OSTDA3580,CDM,C1769,HCPCS,0272,RC,,,both,,,278.40,83.52,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STELLAREX 135CM 150MM 4MM BALLOON DILATATION OTW DRUG",SUP-AB35SX040150135,CDM,C2623,HCPCS,0272,RC,,,both,,,11557.50,3467.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TRANSFORM 10MM 3MM BALLOON OCCLUSION 1 LUMEN COMPLIANT",SUP-M003SRC03100,CDM,C1725,HCPCS,0272,RC,,,both,,,11760.02,3528.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE TRACH 12 STD 27MM PROVOX LIFE LARYTUBE SOFT SILICONE",SUP-7418,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 3.5MM TRIM-IT",SUP-AR-4160-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM FEMORAL 119MM 10MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771101020,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"BLUE CROSS [10001]","Blue Cross HMO",,8192.65,39.2,,5311.50,4717.44,5388.59,31,2430.63,17764.68,"percent of total billed charges",
"TAMP 10MM 3MM INFLATABLE BALLOON SURGICAL BONE KYPHX EXACT",SUP-K17A,CDM,S27200284,LOCAL,0272,RC,,,both,,,6587.78,1976.33,"KAISER [10500]",Kaiser,,4413.81,67,,,,,0,766.16,5599.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5+ 10MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS5P10L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"CIGNA [10200]","Cigna Open Access",,5912.71,56.9,,5302.19,4377.88,6578.61,27,1208.52,8832.69,"percent of total billed charges",
"SIZER IMPL MEMORYSHAPE MEDIUM HEIGHT MODERATE PLUS PROFILE",SUP-RSZ-1255S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,895.05,45.9,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2 X 4 COMPLEX PICO COIL",SUP-10USC02004,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"BLUE CROSS [10001]","Blue Cross HMO",,5125.6,39.2,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO ORANGE 90CM 7FR BRITE TIP CANN INTERVENTIONAL",SUP-401790M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 135D STD BARREL 78MM STAINLESS STEEL 4 HOLE",SUP-281.140S,CDM,C1713,HCPCS,0278,RC,,,both,,,3765.33,1129.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,446.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",437.91,3200.53,"percent of total billed charges",
"STENT COTTON-LEUNG 12CM 10FR .035IN GENTLE CURVE BILIARY",SUP-G21810,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,180.82,28.62,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4MM TORPEDO CURVE",SUP-AR-8400CTD,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.01,257.7,"NOVANET [10819]",Novanet,,644.26,75,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFARI2 VASCULAR SMALL CURVE 275X4.2X4.2CM .035IN (COM",SUP-H74939406S1,CDM,C1769,HCPCS,0272,RC,,,both,,,1498.50,449.55,"UHC [10700]","United Healthcare",,948.55,63.3,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 22CM 3CM 5FR .035IN 2",SUP-M006192121180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"CIGNA [10200]",Cigna,,1081.11,68,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC",856,MS-DRG,,,,,,,inpatient,,,97608.55,29282.56,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,30190.97,,"Case rate ($28,215.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $26,200.34, add-ons for qualifying new technology services are included. If operating cost exceeds $59,240.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,362.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $26,234.99. The transfer operating threshold is the transfer adjustment factor * $26,200.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,980.87. The transfer capital threshold is the transfer adjustment factor * $1,980.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,8593,97608.55,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TRUCLEAR INCISOR PLUS 7MM 4MM REMOVAL TISSUE WINDOW",SUP-7209509,CDM,C1782,HCPCS,0272,RC,,,both,,,3724.88,1117.46,"CIGNA [10200]",Cigna,,2532.92,68,,,,,0,433.2,3166.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULAR HEAD - OPEN SUPERIOR CONNECTOR, 5.5-6.35",SUP-1175.6355,CDM,C1776,HCPCS,0278,RC,,,both,,,16215.00,4864.5,"BLUE CROSS [10001]","Blue Cross HMO",,6356.28,39.2,,5311.50,4717.44,5388.59,31,1885.8,13782.75,"percent of total billed charges",
"TRNSDUC PRESSURE 12IN MERITRANS MEDALLION MARQUIS WING",SUP-K11-00098B,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"KAISER [10500]",Kaiser,,52.46,67,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 6-8 SMALL MALE NYLON MESH ROCKER",SUP-798504,CDM,S27000186,LOCAL,0270,RC,,,both,,,61.07,18.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.1,51.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM HIP ACETABULAR CANCELLOUS PRIMARY",SUP-2020-6535-1,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,88.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",88.55,647.19,"percent of total billed charges",
"3.5MM X 40MM S4 CATHETER",SUP-FG63091-3540,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NANOCROSS 90CM 20MM 5MM .014IN BALLOON DILATATION",SUP-AB14W050020090,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC QUANTUM APEX 143CM 12MM 2.75MM BALLOON DILATATION",SUP-H7493912412270,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LORAZEPAM 1 MG TABLET",RX-4573,CDM,,,0250,RC,00093-3426-01,NDC,both,1,UN,12.54,3.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH GORE DRYSEAL FLEX 65CM 12FR 4.7MM 4MM INTRO",SUP-GDSF1265,CDM,C1894,HCPCS,0272,RC,,,both,,,6858.60,2057.58,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LEAD NEROSTIMLTR 50CM PRECISION STRAIGHT PERCUTANEOUS LINEAR",SUP-SC-2218-50,CDM,C1778,HCPCS,0278,RC,,,both,,,8914.80,2674.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6062.06,68,,,,,0,1036.79,7577.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE CATH RELIEVA SIDEKICK SINUS GUIDE",SUP-SDKKLP,CDM,S27200284,LOCAL,0272,RC,,,both,,,445.50,133.65,"CIGNA [10200]","Cigna Local Plus",,238.34,53.5,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN OMEGA3 MARIGEN 19SQ CM MICRO FISH SKIN STERILE",SUP-50200P02D0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,7969.50,2390.85,"KAISER [10500]",Kaiser,,5339.57,67,,,,,0,180.89,6774.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X7MM COALITION AGX 7D 8MM NONSTERILE LATEX",SUP-3128.1277,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRAIL SIZE 2 7MM",SUP-TPS-030-072S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 60MM KNEE RIGHT CRUCIATE RETAINING CEMENTED",SUP-183004,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"FIRST HEALTH [10303]","First Health",,16068.53,80,,,,,0,2335.96,17072.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY NAVIGUS NDL PASSIVE",SUP-9733068,CDM,S27200284,LOCAL,0272,RC,,,both,,,4478.10,1343.43,"NOVANET [10819]",Novanet,,3358.58,75,,,,,0,520.8,3806.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 5.2MMX1.5-2.2MM 22MM 25 3D GRIP SURFACE POWER",SUP-CDH25P,CDM,S27200284,LOCAL,0272,RC,,,both,,,8613.25,2583.97,"UHC [10700]","United Healthcare",,5452.19,63.3,,,,,0,1001.72,7321.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 55MM LCP STAINLESS STEEL FULL THREAD CONDYLAR",SUP-02.207.055,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 105MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.443,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,164.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,160.97,1176.51,"percent of total billed charges",
"CATH BLAZER II HTD 110CM 4MM 7FR 2.5MM SPACE ASYMMETRIC 4",SUP-M0045031THN40,CDM,C1733,HCPCS,0272,RC,,,both,,,8107.50,2432.25,"NOVANET [10819]",Novanet,,6080.63,75,,,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ORAL CARE ENCORE TONGUE SUSPENSION ADJUSTABLE KNOTLESS",SUP-FG0002,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"DEVICE TIGHTROPE II FIXATION BONE TO BONE FLIP SUT",SUP-AR-1588BTB-2J,CDM,C1713,HCPCS,0278,RC,,,both,,,3948.53,1184.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1130.07,28.62,,,,,0,459.21,3356.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 79MM STAINLESS STEEL 2.7MM SCR 3 HOLE CONTOUR SHAFT",SUP-02.118.400S,CDM,C1713,HCPCS,0278,RC,,,both,,,4398.75,1319.62,"MULTIPLAN [10600]",Multiplan,,3738.94,85,,,,,0,511.57,3738.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE COROLENE 6-0 C-1",SUP-20S07D,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.94,20.08,"AETNA [10100]","Aetna HMO/PPO",,53.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.79,56.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esophagoscopy W Eus Exam",PX-750000024,CDM,43231,CPT,0750,RC,,,both,,,3661.48,1098.44,"BLUE CROSS [10001]","Blue Cross PPO",,3634.7,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,425.83,3661.48,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 15MM REVISION MODULAR ARCOS STS TITANIUM",SUP-11-300815,CDM,C1776,HCPCS,0278,RC,,,both,,,20372.94,6111.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2369.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2369.37,17317,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 5.9X3.9IN XENMATRIX AB RECTANGLE DERMAL CLLGN",SUP-1151015,CDM,C1781,HCPCS,0278,RC,,,both,,,25080.30,7524.09,"BLUE CROSS [10001]","Blue Cross HMO",,9831.48,39.2,,,,,0,2916.84,21318.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X2CM AMNIOFIX POSTERIOR",SUP-APS-5230,CDM,Q4433,HCPCS,0636,RC,,,both,,,5485.50,1645.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2454.76,44.75,,,,,0,247.92,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 200MM 5MM BALLOON DILATATION",SUP-PCU050200130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AETNA [10100]","Aetna HMO/PPO",,978.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 20MM 135CM 5MM .018IN BILIARY STAINLESS",SUP-G56624,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,586.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 20MM KNEE GVF STABILIZE ROTATE PLATFORM PFC",SUP-962115,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"PHCS [10601]",PHCS,,7143.57,70,,,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SPYGLASS IRRIGATION",SUP-M00546451,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.95,47.08,"FIRST HEALTH [10303]","First Health",,125.56,80,,,,,0,18.25,133.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 210MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-409-210,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,2014.9,14726.25,"percent of total billed charges",
"SCR BONE 2.7MM 16MM MEDLINE UNITE FOOT ANKLE NONLOCK",SUP-MPSN2716,CDM,C1713,HCPCS,0278,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,336.14,28.62,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esophagosc W/Submucosal Inj",PX-750000198,CDM,43201,CPT,0750,RC,,,both,,,2077.85,623.35,"NOVANET [10819]",Novanet,,1558.39,75,,,,,0,241.65,2077.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL TITAN INFLATABLE PENILE PROS TUBE STERILE LATEX",SUP-519150,CDM,S27200284,LOCAL,0272,RC,,,both,,,4671.30,1401.39,"NOVANET [10819]",Novanet,,3503.48,75,,,,,0,543.27,3970.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,inpatient,,,30603.42,9181.03,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,12216.32,,"Case rate ($5,682.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,276.13, add-ons for qualifying new technology services are included. If operating cost exceeds $38,315.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,780.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,283.10. The transfer operating threshold is the transfer adjustment factor * $5,276.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $398.90. The transfer capital threshold is the transfer adjustment factor * $398.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,5682.01,22844.12,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 20MM 130CM 6MM .035IN VASCULAR SELF",SUP-EX060203CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"UHC [10700]","United Healthcare",,7425.09,63.3,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 15CM 11.5FR PRECURVE POLYURETHANE DUO-FLOW",SUP-MCDLT116IJ-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,701.46,210.44,"KAISER [10500]",Kaiser,,469.98,67,,,,,0,81.58,596.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 35MM 3.5MM VERTEX SELECT PRECUT",SUP-7753735,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"GRAFT BONE CORTICAL WEDGE ALLOGRAFT 20MM",SUP-4578120,CDM,S27800098,LOCAL,0278,RC,,,both,,,19921.48,5976.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7968.59,40,,,,,0,2316.87,16933.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 CURVE 10MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962031,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"UHC [10700]","United Healthcare",,5854.9,63.3,,8601.07,8395.67,8601.07,"1 through 10",1075.71,7862.03,"percent of total billed charges",
"HC Test Physcl Perf Ea 15min (Go)",PX-430000029,CDM,97750,CPT,0430,RC,,,both,,,259.29,77.79,"CIGNA [10200]",Cigna,,259.29,,"Per diem ($369).",,,,0,30.16,259.29,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 97MM TRI-LOCK BPS GRIPTION 1 HIGH OFFSET HIP",SUP-101214010,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"BLUE CROSS [10001]","Blue Cross PPO",,6313.99,39.2,,3949.44,3949.44,3949.44,"1 through 10",1873.26,13691.05,"percent of total billed charges",
"PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION",RX-32855,CDM,J2430,HCPCS,0636,RC,61703-0326-18,NDC,both,10,ML,339.60,101.88,"MULTIPLAN [10600]",Multiplan,,288.66,85,,,,,0,33.71,288.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ALEXIS KII 14CM EXTRACTION SPECIMEN CONTAINMENT BAG",SUP-GTK14,CDM,S27200284,LOCAL,0272,RC,,,both,,,2812.50,843.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,327.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 48MM T10 FULL THREAD STARDRIVE NONSTERILE",SUP-657448,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,231.45,28.62,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 100MM 130CM 7MM LONG VASCULAR NITINOL",SUP-SC7100LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6099.6,68,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SURGITIE 0 18IN LIGATING LOOP ANCHORED ABSORBABLE",SUP-SGL-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.14,32.44,"FIRST HEALTH [10303]","First Health",,86.51,80,,,,,0,12.58,91.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 5MM KII BLUNT TIP BALLOON STERILE",SUP-C0Q20,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"CIGNA [10200]",Cigna,,97.61,68,,,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR AVENIR COMPLETE 3 HIP STERILE LATEX FREE",SUP-574203030,CDM,C1776,HCPCS,0278,RC,,,both,,,23461.20,7038.36,"BLUE CROSS [10001]","Blue Cross HMO",,9196.79,39.2,,5311.50,4717.44,5388.59,31,2728.54,19942.02,"percent of total billed charges",
"NDL BIOPSY 17GA 5.1CM TRU-CORE II COAXIAL INTRO ECHOGENIC",SUP-MCXS1810TX,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.64,44.89,"CIGNA [10200]",Cigna,,101.76,68,,,,,0,17.4,127.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM TITANIUM LEVEL 3 ASSURE BONE SPINE CERVICAL",SUP-110.345,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"AETNA [10100]","Aetna HMO/PPO",,4207.14,79.5,,1521.93,481.35,16760.95,30,615.46,4498.2,"percent of total billed charges",
"NDL BIOPSY PRECISIONPOINT TRANSPERINEAL ACC SYS",SUP-P1001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,188.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 4X40 40CM SL",SUP-48004004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"KAISER [10500]",Kaiser,,658.03,67,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 3 WAY STPCOCK TRNSDUC FLUSH DEVICE",SUP-PX260,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.53,31.06,"KAISER [10500]",Kaiser,,69.37,67,,,,,0,12.04,88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nfct Ds Bv&Vaginitis Rtpcr Amp Dna Markers",PX-310000029,CDM,81515,CPT,0310,RC,,,both,,,500.00,150,"NOVANET [10819]",Novanet,,375,75,,,,,0,0.01,425,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175252080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"BLUE CROSS [10001]","Blue Cross HMO",,485.84,39.2,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 24MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR24,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"PHCS [10601]",PHCS,,9177,70,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hbb Full Gene Sequence",PX-309000140,CDM,81364,CPT,0310,RC,,,both,,,1536.00,460.8,"UHC [10700]","United Healthcare",,292.12,,,,,,,0.01,1305.6,"fee schedule",
"CATH NC TREK NEO 145CM 6MM 2MM BALLOON DILATATION PEBAX",SUP-1400200-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAP WATER ANESTHETIC GAS MNTR LATEX FREE REUSABLE HEW-PAC",SUP-989803110871,CDM,S27000186,LOCAL,0270,RC,,,both,,,127.09,38.13,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PK 4X2.4CM THK.3CM NASAL EPISTAXIS SOFT ATRAUMATIC PLACEMENT",SUP-XG-102,CDM,S27200284,LOCAL,0272,RC,,,both,,,866.70,260.01,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 7IN SMITH SUCTION NERVE",SUP-58-5000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1207.63,362.29,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM RESOLUTE ONYX 34MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40034W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,632.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 150MM 5FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-06151,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-211-E,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"CIGNA [10200]","Cigna Local Plus",,4239.41,31.5,,5372.07,4581.20,7242.98,23,1565.22,11439.68,"percent of total billed charges",
"LINER ACETABULAR 0D D 7.9MM 28MM X3 HIP",SUP-623-00-28D,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"CIGNA [10200]","Cigna Open Access",,4862.47,56.9,,5302.19,4377.88,6578.61,27,993.86,7263.8,"percent of total billed charges",
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 10.0",SUP-DIB00U0100,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM CLUSTER HOLE PRIMARY HEMISPHERICAL",SUP-502-03-46B,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"FIRST HEALTH [10303]","First Health",,8373.46,80,,,,,0,1217.29,8896.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850016550,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"MULTIPLAN [10600]",Multiplan,,5571.75,85,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 12/14 TAPER 36MM HIP SLEEVE TOTAL",SUP-136536740,CDM,C1776,HCPCS,0278,RC,,,both,,,13002.36,3900.71,"AETNA [10100]","Aetna HMO/PPO",,10336.88,79.5,,10981.53,8986.79,12413.38,12,1512.17,11052.01,"percent of total billed charges",
"CATH LUTONIX 75CM 40MM 8MM BALLOON DILATATION DRUG COATED",SUP-LX3575840V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5747.7,68,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CARTO 3 THERMOCOOL SF 7.5FR F-F CURVE ELECTROPHYSIOLOGY",SUP-BNI35FFCT,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2140.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 26MM SPINE PEDICLE PLY NONSTERILE 4MM ROD",SUP-102045226,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR JUDKINS LEFT 3.5 CURVE",SUP-534518T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,63.6,68,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL ZIPWIRE 22-30CM 3CM 6FR .035IN PIGTAIL",SUP-M006180156180,CDM,C2617,HCPCS,0278,RC,,,both,,,1466.59,439.98,"CIGNA [10200]",Cigna,,997.28,68,,,,,0,170.56,1246.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"14MM AMPLATZER MUSCULAR VSD OCCLUDER",SUP-9-VSD-MUSC-014,CDM,C1817,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]","Cigna Open Access",,21004.5,33.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 2 CONTOUR 20IN 36- IN KNEE 2",SUP-79-96019,CDM,L1830,HCPCS,0274,RC,,,both,,,121.54,36.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,82.65,68,,,,,0,14.14,103.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COPE MAC-LOC 24CM 10.2FR PIGTAIL CURVE",SUP-G48164,CDM,C2617,HCPCS,0278,RC,,,both,,,996.22,298.87,"NOVANET [10819]",Novanet,,747.17,75,,,,,0,115.86,846.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 KNEE RIGHT PRESS FIT EMPOWR 3D KNEE STERILE",SUP-243-02-109,CDM,C1776,HCPCS,0278,RC,,,both,,,27824.45,8347.33,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7512.6,27,,,,,0,3235.98,23650.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM ADVANCED LORDOTIC SPINE",SUP-017712,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"AMERIGROUP MEDICAID [20100]",Amerigroup,,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 152MM 16MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-104160,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"PHCS [10601]",PHCS,,16942.34,70,,,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 29MM RESTORATION +30MM HIP PROXIMAL MODULAR",SUP-6276-1-329,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"FIRST HEALTH [10303]","First Health",,17803.8,80,,,,,0,2588.23,18916.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 2.25MM BALLOON DILATATION PEBAX",SUP-1012271-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER BIPOLAR 47/48/49MM 26MM LEGACY HIP UHMWPE STERILE",SUP-00500104726,CDM,C1776,HCPCS,0278,RC,,,both,,,2365.50,709.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1608.54,68,,,,,0,275.11,2010.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE COUGAR XT VASCULAR J 190CM .014IN HYDRO-TRACK EXTRA",SUP-CGRXT190HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,486.00,145.8,"KAISER [10500]",Kaiser,,325.62,67,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 12X3.5IN ATS CYL PORT STERILE DISPOSABLE",SUP-60707510200,CDM,S27200284,LOCAL,0272,RC,,,both,,,150.82,45.25,"AETNA [10100]","Aetna HMO/PPO",,119.9,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.54,128.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (PS) - SIZE 2",SUP-5555-2252,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"FIRST HEALTH [10303]","First Health",,1134,80,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 60MM 7FR 14MM .035IN LOW PROFILE BALLOON",SUP-B1140-060,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IMMOB ORTHOPEDIC SMALL 32-36IN 32-36IN SHOULDER ELASTIC RIB",SUP-79-84033,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.42,14.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET",RX-5604,CDM,,,0250,RC,68462-0639-25,NDC,both,1,UN,6.27,1.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL TUNNELING 338MM 3.1MM STAINLESS STEEL 6996SQ LEAD",SUP-6996T,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION",RX-155345,CDM,,,0250,RC,68094-0750-59,NDC,both,5,ML,41.47,12.44,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC RBC Lr Ea Unit",PX-390000004,CDM,P9016,HCPCS,0390,RC,,,both,,,1383.50,415.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC TREK 143CM 20MM 4.5MM ROUND BALLOON DILATATION",SUP-1012454-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-120629,CDM,,,0250,RC,45802-0143-00,NDC,both,1,UN,12.54,3.76,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BARE (2) AND COVERED (5) SLIDERS",SUP-4764-02,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AUG FEMORAL 4MM ATTUNE 6 KNEE DISTAL CEMENT REVISION STERILE",SUP-154706001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"CIGNA [10200]",Cigna,,4128.96,68,,5873.17,5873.17,5873.17,"1 through 10",706.17,5161.2,"percent of total billed charges",
"SPACER SPINAL 14X6MM COLONIAL 12MM LARGE PARALLEL TITANIUM",SUP-365.306CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPLICATED PEPTIC ULCER WITH MCC",380,MS-DRG,,,,,,,inpatient,,,65490.26,19647.08,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,12536.8,,"Case rate ($12,171.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,302.20, add-ons for qualifying new technology services are included. If operating cost exceeds $44,341.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,236.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $11,317.14. The transfer operating threshold is the transfer adjustment factor * $11,302.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.50. The transfer capital threshold is the transfer adjustment factor * $854.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,48935.31,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE 15IN 5FR 18GA 21GA UMBILICAL POLYURETHANE",SUP-8888160556,CDM,S27200284,LOCAL,0272,RC,,,both,,,305.39,91.62,"MULTIPLAN [10600]",Multiplan,,259.58,85,,,,,0,35.52,259.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 12MM 2.5MM BALLOON DILATATION STERILE",SUP-225-123-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUVOXAMINE 50 MG TABLET, IMMEDIATE RELEASE",RX-10085,CDM,,,0637,RC,60505-0165-01,NDC,both,1,UN,12.95,3.88,"CIGNA [10200]",Cigna,,8.81,68,,,,,0,1.51,11.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOCKWAVE C2+ IVL CATHETER 4.0X12 MM",SUP-C2PIVL4012,CDM,C1761,HCPCS,0272,RC,,,both,,,29610.00,8883,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,20134.8,68,,,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cdisloc I-P W Manip W Anes",PX-450000134,CDM,26775,CPT,0450,RC,,,both,,,9333.00,2799.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1261,,,,,,,9.33,7933.05,"case rate",
"STENT EVERFLEX 200MM 120CM 6MM VASCULAR PERIPHERAL SELF",SUP-PRB35-06-200-120,CDM,C1876,HCPCS,0278,RC,,,both,,,11625.00,3487.5,"MULTIPLAN [10600]",Multiplan,,9881.25,85,,,,,0,1351.99,9881.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TRUCLEAR INCISOR PLUS 7MM 4MM REMOVAL TISSUE WINDOW",SUP-7209509,CDM,C1782,HCPCS,0272,RC,,,both,,,3724.88,1117.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1530.93,41.1,,,,,0,433.2,3166.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PROSTREAM VASCULAR 175CM 9CM .035IN TEFLON STAINLESS",SUP-41277-01,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM COLLAR SECUR-FIT TITANIUM HA 132D 4 C",SUP-S-2337-HF04,CDM,C1776,HCPCS,0278,RC,,,both,,,24037.65,7211.29,"BLUE CROSS [10001]","Blue Cross PPO",,9422.76,39.2,,3949.44,3949.44,3949.44,"1 through 10",2795.58,20432,"percent of total billed charges",
"SUT PDS II 4-0 SH 18IN CONTROL RELEASE MONOFILAMENT 8 STRAND",SUP-Z773D,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.75,62.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,inpatient,,,32919.14,9875.74,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS SAPIEN 3 ULTRA RESILIA TRANSCATHETER HEART VA",SUP-9755RSL23A,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68400,40,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THYROID (PORK) 30 MG TABLET",RX-122841,CDM,,,0637,RC,00456-0458-01,NDC,both,1,UN,6.27,1.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2.58,41.1,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 89MM TITANIUM 4 HOLE VARIAX BONE RIGHT OLECRANON ELBOW",SUP-629364,CDM,C1713,HCPCS,0278,RC,,,both,,,7272.88,2181.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2081.5,28.62,,,,,0,845.84,6181.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20GA 10CM POWERGLIDE MIDLINE STERILE LATEX FREE",SUP-M120100,CDM,C1751,HCPCS,0272,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MONARCH 13IN INFLATION POLYCARBONATE 20ML DIGITAL",SUP-IN2330,CDM,S27200284,LOCAL,0272,RC,,,both,,,504.14,151.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,59.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.63,428.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ethylene Glycol",PX-301000186,CDM,82693,CPT,0301,RC,,,both,,,312.54,93.76,"NOVANET [10819]",Novanet,,234.41,75,,,,,0,0.01,265.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINE GAS SUPPLY 2.1MR 10MM NEOPUFF LONG UNIQUE CNCT RESUS T",SUP-900RD009,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.42,14.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.51,40.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFAZOLIN 1 G VIAL IV PUSH",RX-408310,CDM,J0690,HCPCS,0636,RC,44567-0707-25,NDC,both,1,UN,18.92,5.68,"CIGNA [10200]","Cigna Open Access",,4.45,,,,,,,1.41,16.08,"fee schedule",
"CATH CHRG 135CM 200MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-08201,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BONE CEMENT STABILIT LONG VERTEBRAL LOCK DELIVERY",SUP-1426,CDM,S27200284,LOCAL,0272,RC,,,both,,,1607.45,482.23,"PHCS [10601]",PHCS,,1125.22,70,,,,,0,186.95,1366.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VIPERWIRE ADVANCE VASCULAR 475CM .014IN PERIPHERAL",SUP-VPR-GW-EL14,CDM,C1769,HCPCS,0272,RC,,,both,,,1539.00,461.7,"MULTIPLAN [10600]",Multiplan,,1308.15,85,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ab ID",PX-302000184,CDM,86870,CPT,0302,RC,,,both,,,729.30,218.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.3,,,,,,,0.01,619.91,"fee schedule",
"HC Erector Spinae Plane (Esp) Block",PX-361000647,CDM,64999,CPT,0361,RC,,,both,,,2899.73,869.92,"KAISER [10500]",Kaiser,,1942.82,67,,,,,0,337.24,2899.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Band Ligat",PX-750000172,CDM,45350,CPT,0750,RC,,,both,,,4085.00,1225.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3311,,"Case rate ($3,311). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,475.09,4085,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 6.5MM 55MM TSRH OSTEOGRIP TITANIUM SPINE PEDICLE",SUP-83565551,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,305.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",299.36,2187.9,"percent of total billed charges",
"HC I123 Iodide Dx per 100 Uci",PX-343000007,CDM,A9516,HCPCS,0343,RC,,,both,,,324.00,97.2,"NOVANET [10819]",Novanet,,243,75,,,,,0,37.68,275.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN SL5 CURVE GUIDING CORONARY",SUP-LA7SL50SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPN NC 15MM 3MM BALLOON DILATATION CORONARY ACCEPTS 6FR",SUP-300-015-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3403.08,41.1,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE 1 SLOT LEFT TI",SUP-PHPF-1L,CDM,C1713,HCPCS,0278,RC,,,both,,,15732.00,4719.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1864.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1829.63,13372.2,"percent of total billed charges",
"SCR INTERFERENCE TITANIUM 20MM 7MM ACL PCL CANNULATED",SUP-AR-1370,CDM,C1713,HCPCS,0278,RC,,,both,,,807.98,242.39,"NOVANET [10819]",Novanet,,605.99,75,,,,,0,93.97,686.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM EVEREST SPINE POLYAXIAL CANNULATED MIS",SUP-M5111-06545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6491.86,68,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK ENDOSCOPIC HARMONIC SYNERGY COMBINATION BLADE",SUP-SNGHK2,CDM,S27200284,LOCAL,0272,RC,,,both,,,1862.06,558.62,"CIGNA [10200]","Cigna Open Access",,1059.51,56.9,,,,,0,216.56,1582.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 8MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140820,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"UHC [10700]","United Healthcare",,7521.18,63.3,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUPERCORE ECHOGENIC 9CM 4.2CM 20GA 19GA BIOPSY",SUP-701220090,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.53,140.26,"CIGNA [10200]","Cigna Local Plus",,250.13,53.5,,,,,0,54.37,397.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 33MM TITANIUM ENDOSCOPIC LINEAR CUTTER",SUP-EEA33,CDM,S27200284,LOCAL,0272,RC,,,both,,,1911.00,573.3,"PHCS [10601]",PHCS,,1337.7,70,,,,,0,222.25,1624.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 12MM QUICKFIX TITANIUM T8 PARTIAL THREAD",SUP-AR-8724-12,CDM,C1713,HCPCS,0278,RC,,,both,,,1028.70,308.61,"NOVANET [10819]",Novanet,,771.53,75,,,,,0,119.64,874.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ATTAIN HYBRID VASCULAR STRAIGHT 108CM .018IN STABILITY",SUP-GWR419688,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 2 6MM",SUP-TPS-030-062S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"UHC [10700]","United Healthcare",,512.73,63.3,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 21MM 2.75MM BALLOON DILATATION PTCA",SUP-DC-RZ2721UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"PHCS [10601]",PHCS,,691.74,70,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 60MM 16MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-1513-16-060,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"BLUE CROSS [10001]","Blue Cross PPO",,3240.35,39.2,,3949.44,3949.44,3949.44,"1 through 10",961.36,7026.27,"percent of total billed charges",
"SCR BONE 2.7MM 30MM LCP STAINLESS STEEL SUPERIOR ANTERIOR",SUP-02.211.030,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,610.73,68,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 4-0 PS-1 18IN MONOFILAMENT UNDYED",SUP-Y682H,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.63,20.59,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.98,58.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABRE VENOUS SELF-EXPADING STENT16X150X90",SUP-AB9T16150090,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 8MM SWIVELOCK TENODESIS SHOULDER BICEPS CLOSED",SUP-AR-1662BCC-8,CDM,C1713,HCPCS,0278,RC,,,both,,,3425.63,1027.69,"FIRST HEALTH [10303]","First Health",,2740.5,80,,,,,0,398.4,2911.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 3-0 DE-14 18IN BRAID TIES MULTISTRAND LOWER",SUP-AR-7225,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"CIGNA [10200]","Cigna Open Access",,114.35,56.9,,,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 12-14MM 13FR 10FR TRIVASCULAR OVATION",SUP-TV-IL1412100-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"UHC [10700]","United Healthcare",,21135.87,63.3,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 24CM 5FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49897,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,87.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT GLENOID SHOULDER SIG",SUP-98B00901102,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"NOVANET [10819]",Novanet,,22443.75,75,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABRE VENOUS SELF-EXPADING STENT16X150X90",SUP-AB9T16150090,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 16MM 144CM 4.5MM CORONARY STENT",SUP-H7493926016450,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA [10200]","Cigna Open Access",,5300.24,56.9,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHARKCORE LG FNB BIOPSY SYSTEM WITH NEEDLE - 19 GUAGE",SUP-DSL-19-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,4933.50,1480.05,"MULTIPLAN [10600]",Multiplan,,4193.48,85,,,,,0,573.77,4193.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Vulva Peri Abscess",PX-450000282,CDM,56405,CPT,0361,RC,,,both,,,1183.72,355.12,"BLUE CROSS [10001]","Blue Cross HMO",,1183.72,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,137.67,1183.72,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK",RX-5018,CDM,J1836,HCPCS,0636,RC,00338-1055-48,NDC,both,100,ML,100.65,30.19,"NOVANET [10819]",Novanet,,75.49,75,,,,,0,1.75,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP GRIPTION PINNACLE STERILE LATEX",SUP-121731054,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"AETNA [10100]","Aetna HMO/PPO",,12893.67,79.5,,10981.53,8986.79,12413.38,12,1886.21,13785.68,"percent of total billed charges",
"CATH DXTERITY 100CM 6FR .056IN AMPLATZ LEFT 1 CURVE",SUP-DXT6AL10,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"UHC [10700]","United Healthcare",,52.32,63.3,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Aa&/Strd Paracervical Nerve",PX-761000135,CDM,64435,CPT,0761,RC,,,both,,,1318.00,395.4,"FIRST HEALTH [10303]","First Health",,1054.4,80,,,,,0,153.28,1318,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nucleic Acid Rev Trans/Amp Pro",PX-306000220,CDM,87538,CPT,0306,RC,,,both,,,781.00,234.3,"AETNA [10100]","Aetna HMO/PPO",,620.9,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,663.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL INSUFFLATION 120MM 13GA VERRES PNEUMOPERITONEUM LATEX",SUP-C2201,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.10,33.93,"PHCS [10601]",PHCS,,79.17,70,,,,,0,13.15,96.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH HEARTSPAN MR0 CURVE 63CM 8.5FR GUIDING PEBAX STEEL",SUP-FCB8563MR0,CDM,C1894,HCPCS,0272,RC,,,both,,,1432.08,429.62,"AETNA [10100]","Aetna HMO/PPO",,1138.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.55,1217.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 7.5FR VENTRICLE CS SVC COIL TRANSVENE",SUP-6937A-58,CDM,C1896,HCPCS,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Open Access",,3926.1,56.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM DYNACLIP 18X18X18MM INTERNAL FIXATION",SUP-3000-00-181818,CDM,C1713,HCPCS,0278,RC,,,both,,,12627.00,3788.1,"CIGNA [10200]","Cigna Local Plus",,3977.51,31.5,,3978.14,359.25,3978.14,24,1468.52,10732.95,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL 100MM APCAPPLICATOR FILTER RIGID",SUP-20132-256,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE 100CM 6FR CAS3 CURVE ANGIOGRAPHIC",SUP-532686,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA [10200]","Cigna Open Access",,47.03,56.9,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPREME EXTENSION CABLE BLUE  150 CM",SUP-401981,CDM,S27200284,LOCAL,0272,RC,,,both,,,248.00,74.4,"AETNA [10100]","Aetna HMO/PPO",,197.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.84,215.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE HUMERAL 10MM COMPREHENSIVE SHOULDER POSITIONING",SUP-113578,CDM,C1776,HCPCS,0278,RC,,,both,,,1518.10,455.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1032.31,68,,,,,0,176.56,1290.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +25 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-CC60WF.250,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW LOWPROFILE 6.5X20MM",SUP-010-55-020,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,36.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,35.41,258.83,"percent of total billed charges",
"NAIL 7MM 220MM HUMERAL NAIL-EX INTRAMEDULLARY CANNULATED",SUP-04.001.224S,CDM,C1713,HCPCS,0278,RC,,,both,,,9216.74,2765.02,"UHC [10700]","United Healthcare",,5834.2,63.3,,5023.51,2672.93,6679.78,18,1071.91,7834.23,"percent of total billed charges",
"SUT ETHIBOND EXCEL 2-0 V-7 36IN 2 ARM BRAID FIRM PLEDG WHITE",SUP-PX64H,CDM,S27200284,LOCAL,0272,RC,,,both,,,90.60,27.18,"CIGNA [10200]",Cigna,,61.61,68,,,,,0,10.54,77.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE 20MM 7MM CANNULATED PROPEL STERILE",SUP-C8700,CDM,C1713,HCPCS,0278,RC,,,both,,,1016.15,304.84,"BLUE CROSS [10001]","Blue Cross HMO",,398.33,39.2,,957.42,156.86,7483.26,51,118.18,863.73,"percent of total billed charges",
"PROS OSSICULAR 4MM .6MM SMART STAPES PISTON RECONSTRUCTIVE",SUP-7014-5926,CDM,L8613,HCPCS,0278,RC,,,both,,,1801.20,540.36,"BLUE CROSS [10001]","Blue Cross PPO",,706.07,39.2,,,,,0,209.48,1531.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 6FR 10MM SPACE STD D CURVE",SUP-1079257S,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"UHC [10700]","United Healthcare",,2359.51,63.3,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM 17MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192117,CDM,C1776,HCPCS,0278,RC,,,both,,,955.80,286.74,"BLUE CROSS [10001]","Blue Cross HMO",,374.67,39.2,,5311.50,4717.44,5388.59,31,111.16,812.43,"percent of total billed charges",
"STENT GORE VIABAHN 29MM 80CM 11MM 16SQ MM 8FR .035IN",SUP-BXA112901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UHC [10700]","United Healthcare",,12346.54,63.3,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 5.5MM CD HORIZON LEGACY TITANIUM PREBENT CP",SUP-8690090,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"MULTIPLAN [10600]",Multiplan,,3748.5,85,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 10FR PIGTAIL URETERAL PERCUFLEX METAL",SUP-M001221420,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"FIRST HEALTH [10303]","First Health",,712.8,80,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM CORKSCREW FT 3 PLAY PEEK STERILE LATEX",SUP-AR-1927PSF-475,CDM,C1713,HCPCS,0278,RC,,,both,,,2480.63,744.19,"BLUE CROSS [10001]","Blue Cross HMO",,972.41,39.2,,957.42,156.86,7483.26,51,288.5,2108.54,"percent of total billed charges",
"HOLDER 4.5IN OLSEN-HEGAR DELICATE NDL TUNGSTEN CARBIDE",SUP-32-159,CDM,S27200284,LOCAL,0272,RC,,,both,,,684.69,205.41,"KAISER [10500]",Kaiser,,458.74,67,,,,,0,79.63,581.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Manual Ea 15min (Go)",PX-430000017,CDM,97140,CPT,0430,RC,,,both,,,276.79,83.04,"KAISER [10500]",Kaiser,,185.45,67,,,,,0,32.19,276.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 80CM 11MM 16SQ MM 8FR .035IN",SUP-BXA112901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]",Cigna,,7801.92,40,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25MM THK1.37MM STAINLESS STEEL SAGITTAL 2 CUT",SUP-4125-137-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,393.85,118.15,"CIGNA [10200]","Cigna Local Plus",,210.71,53.5,,,,,0,45.8,334.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 42MM GORILLA R3CON LOCK",SUP-P50-353-4242,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM X3 MODULAR DUAL MOBILITY LINER",SUP-626-00-36C,CDM,C1776,HCPCS,0278,RC,,,both,,,8517.60,2555.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3500.73,41.1,,6417.48,6417.48,6417.48,"1 through 10",990.6,7239.96,"percent of total billed charges",
"BLADE OSTEOTOM LATARJET",SUP-AR-7000-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1063.13,318.94,"CIGNA [10200]","Cigna Open Access",,604.92,56.9,,,,,0,123.64,903.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 64MM STAINLESS STEEL FULL THREAD FOOT",SUP-214.764,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"PHCS [10601]",PHCS,,786.54,70,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 19MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G419,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"UHC [10700]","United Healthcare",,5928.73,63.3,,8601.07,8395.67,8601.07,"1 through 10",1089.28,7961.17,"percent of total billed charges",
"STBL SURGICAL OCTOPUS 4 TISSUE 2 VACUUM TUBE REINFORCE ARM",SUP-29400,CDM,S27200284,LOCAL,0272,RC,,,both,,,7915.68,2374.7,"NOVANET [10819]",Novanet,,5936.76,75,,,,,0,920.59,6728.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 10CM 3MM BALLOON DILATATION HYDROPHILIC",SUP-V1430100,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"NOVANET [10819]",Novanet,,4114.13,75,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RED 62 138CM THROMBECTOMY",SUP-RED62S,CDM,C1757,HCPCS,0272,RC,,,both,,,16767.00,5030.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1986.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1950,14251.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 3 HOLE PIN DORSAL ULNAR PIN PLATE BONE",SUP-DUP3,CDM,C1713,HCPCS,0278,RC,,,both,,,4278.00,1283.4,"FIRST HEALTH [10303]","First Health",,3422.4,80,,,,,0,497.53,3636.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 27CM 11MM .0135IN MICRUSFRAME MICRO",SUP-MFR141127,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1381.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 6 X 10 HELICAL FILLING COIL",SUP-10HFL-06010,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4114.06,45.9,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 4MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG40008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1836,68,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON RETRIEVAL 12-15MM EXTR PRO RX-S BILIARY DISTAL ABOVE",SUP-M00547310,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 27CM 11MM .0135IN MICRUSFRAME MICRO",SUP-MFR141127,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"NOVANET [10819]",Novanet,,8911.35,75,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 15MM 2MM BALLOON DILATATION STERILE",SUP-220-153-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TRANSFORM 10MM 4MM BALLOON OCCLUSION 1 LUMEN COMPLIANT",SUP-M003SRC04100,CDM,C1725,HCPCS,0272,RC,,,both,,,11760.02,3528.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 90CM 200MM 5MM BALLOON DILATATION RAPID EXCHANGE",SUP-47550200S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Rplc Ureter Stnt Bi W Si",PX-361000212,CDM,50382,CPT,0361,RC,,,both,,,8959.02,2687.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1041.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1041.93,7615.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTFR BIOPSY SITE 13CM EVIVA",SUP-SMARK-EVIVA-13,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"CIGNA [10200]","Cigna Local Plus",,357.3,53.5,,,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 20FR SILICONE STD J MIC SECUR-LOK TRIMMABLE",SUP-0200-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"CIGNA [10200]","Cigna Open Access",,625.66,56.9,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEART FAILURE AND SHOCK WITHOUT CC/MCC",293,MS-DRG,,,,,,,inpatient,,,25754.65,7726.39,"PHCS [10601]",PHCS,,7561,,,,,,,3510.94,14115.47,"per diem","Estimated amount calculated based on 3 day length of stay."
"(EVAL) BRIOVAD PATIENT SUPPORT KIT",SUP-490023,CDM,Q0508,HCPCS,0624,RC,,,both,,,114837.90,34451.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13608.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13355.65,97612.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPIDERFX .014IN 190CM 4MM EMBOLIC PROTECTION NITINOL",SUP-SPDRX-US-040,CDM,C1884,HCPCS,0272,RC,,,both,,,8280.00,2484,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3800.52,45.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 5 1/8IN LAMBOTTE SWISS PATTERN SURGICAL MINI",SUP-27-5708,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.07,40.82,"FIRST HEALTH [10303]","First Health",,108.86,80,,,,,0,15.82,115.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY THORACENTESIS/PARACENTESIS 8FR THORA-PARA POLYURETHANE",SUP-TPT1000,CDM,C1729,HCPCS,0272,RC,,,both,,,210.80,63.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.52,179.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 56MM 32MM MARATHON HIP",SUP-121932156,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"BLUE CROSS [10001]","Blue Cross HMO",,3179.49,39.2,,5311.50,4717.44,5388.59,31,943.3,6894.31,"percent of total billed charges",
"CAGE SPINAL 32X21MM ENDOSKELETON TAS 12D 10MM STD TITANIUM",SUP-2312-0110,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"MULTIPLAN [10600]",Multiplan,,24097.5,85,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 150CM .025IN STD TIP FIXED CORE J 3CM EMERALD",SUP-502524,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR PREPARATION OF TC-99M-EXAMETAZIME INTRAVENOUS SOLUTION",RX-186705,CDM,A9521,HCPCS,0343,RC,08888-8878-39,NDC,both,1,UN,9958.79,2987.64,"UHC [10700]","United Healthcare",,1809.03,,,,,,,1158.21,8464.97,"fee schedule",
"GWIRE HI-FLO RENEGADE FATHOM VASCULAR 115CM 20CM .016IN",SUP-M001184530,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"UHC [10700]","United Healthcare",,2373.75,63.3,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL 2.1MM HELICOID ELITE SHORT TIP",SUP-5820080021,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"AETNA [10100]","Aetna HMO/PPO",,870.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 72.5MM KNEE RIGHT POSTERIOR STABILIZE OPEN BOX",SUP-184513,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"FIRST HEALTH [10303]","First Health",,19860.62,80,,,,,0,2887.24,21101.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 7 KNEE CEMENTED ROTATE PLATFORM",SUP-150610007,CDM,C1776,HCPCS,0278,RC,,,both,,,16694.55,5008.36,"BLUE CROSS [10001]","Blue Cross HMO",,6544.26,39.2,,5311.50,4717.44,5388.59,31,1941.58,14190.37,"percent of total billed charges",
"PLATE SMALL 1.5MM 5-8MM GRAFT LAPIDUS 4 HOLE COMPRESSION",SUP-P53-106-L002,CDM,C1713,HCPCS,0278,RC,,,both,,,9848.03,2954.41,"AETNA [10100]","Aetna HMO/PPO",,7829.18,79.5,,1521.93,481.35,16760.95,30,1145.33,8370.83,"percent of total billed charges",
"HC Esophagoscopy W Eus Exam",PX-750000024,CDM,43231,CPT,0750,RC,,,both,,,3661.48,1098.44,"KAISER [10500]",Kaiser,,2453.19,67,,,,,0,425.83,3661.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Post OP Limbguard Bk",PX-E27400095,CDM,L5450,HCPCS,0274,RC,,,both,,,2143.90,643.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,249.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,249.34,1822.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35942,CDM,,,0637,RC,00245-5317-89,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 30CM 7FR .035",SUP-M006192145090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"CIGNA [10200]",Cigna,,1014.85,68,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 2-5-2MM SPACE F CURVE",SUP-F6DF252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2040.00,612,"KAISER [10500]",Kaiser,,1366.8,67,,,,,0,237.25,1734,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL OVITEX 22X18IN PERMANENT GRID 1 SMOOTH SIDE",SUP-F10246-1822P,CDM,C1781,HCPCS,0278,RC,,,both,,,39068.57,11720.57,"CIGNA [10200]","Cigna Local Plus",,12306.6,31.5,,3096.73,1.00,3096.73,"1 through 10",4543.67,33208.28,"percent of total billed charges",
"SCRDRVR SMALL HEXAGON LCP HOLDING SLEEVE SURGICAL NONSTERILE",SUP-314.02,CDM,S27000186,LOCAL,0270,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 15CM 5FR 21GA MERIT S-MAK .018IN STIFFENED DIL",SUP-S-MAK501N-15,CDM,C1894,HCPCS,0272,RC,,,both,,,380.02,114.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,45.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.2,323.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X11-20MM ELSA 15-30D 20MM",SUP-1122.2055,CDM,S27800098,LOCAL,0278,RC,,,both,,,50400.00,15120,"AETNA [10100]","Aetna HMO/PPO",,40068,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5861.52,42840,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 80MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16028580,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 100D L 12MMX.8MM MID FACE RIGHT 6 HOLE 1.7MM SCR BONE",SUP-55-07767,CDM,C1713,HCPCS,0278,RC,,,both,,,1659.08,497.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,196.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",192.95,1410.22,"percent of total billed charges",
"BLADE .75IN RTRCTR HENLY 1 CENTER SELF RETAIN NONSTERILE",SUP-205540,CDM,S27200284,LOCAL,0272,RC,,,both,,,593.33,178,"PHCS [10601]",PHCS,,415.33,70,,,,,0,69,504.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC",614,MS-DRG,,,,,,,inpatient,,,119151.48,35745.44,"UHC [10700]","United Healthcare",,63991.79,,"Fee schedule rate ($63,991.79). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,63991.79,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 28FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0165SI28,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.82,19.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.54,55.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 32MM HIP C TAPER COBALT CHROME LFIT",SUP-06-3200,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA [10200]",Cigna,,2126.84,68,,5873.17,5873.17,5873.17,"1 through 10",363.75,2658.55,"percent of total billed charges",
"STENT VIABAHN 15CM 120MM 8MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR081502A,CDM,C1874,HCPCS,0278,RC,,,both,,,21577.50,6473.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2556.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2509.46,18340.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW CANN MINI-MON 2.0X16MM",SUP-P20-120-016S,CDM,C1713,HCPCS,0278,RC,,,both,,,1559.25,467.77,"MULTIPLAN [10600]",Multiplan,,1325.36,85,,,,,0,181.34,1325.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO FUCHSIA 23CM 10FR BRITE TIP SILICONE CANN",SUP-401023M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"NOVANET [10819]",Novanet,,78.3,75,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25X1.27MM INTREX",SUP-00507132400,CDM,S27200284,LOCAL,0272,RC,,,both,,,323.12,96.94,"FIRST HEALTH [10303]","First Health",,258.5,80,,,,,0,37.58,274.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIRE RETINAL 2.5MM GROOVE CONCAVE SILICONE 9MM STERILE STYLE",SUP-9216,CDM,S27800098,LOCAL,0278,RC,,,both,,,175.64,52.69,"BLUE CROSS [10001]","Blue Cross HMO",,68.85,39.2,,,,,0,20.43,149.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SURGICAL SPRING OPEN BIORESORBABLE SELF EXPAND VENTRIO",SUP-5950020,CDM,C1781,HCPCS,0278,RC,,,both,,,2520.00,756,"BLUE CROSS [10001]","Blue Cross HMO",,987.84,39.2,,,,,0,293.08,2142,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 65CM 12MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1265CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,922.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SMALL 2.6MM INTERNAL LIGACLIP EXTRA TITANIUM",SUP-LT100,CDM,S27200284,LOCAL,0272,RC,,,both,,,46.04,13.81,"CIGNA [10200]",Cigna,,31.31,68,,,,,0,5.35,39.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRONG CPAP CURVE INFANT SEPTUM CUT AWAY SOFT SILICONE NASAL",SUP-BC4540-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,68.73,20.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT CHROMIC 2-0 CT-1 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-811H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC",451,MS-DRG,,,,,,,inpatient,,,153195.27,45958.58,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDOMETHACIN 25 MG CAPSULE, IMMEDIATE RELEASE",RX-3897,CDM,,,0637,RC,50268-0430-11,NDC,both,1,UN,6.27,1.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT STRATAFIX PDS PLUS 1 MO-4 SPIRAL 14IN ABSORBABLE",SUP-SXPP2B400,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL 12D 30D BUTTON 12CM 24-28FR STERILE",SUP-A22251C,CDM,S27200284,LOCAL,0272,RC,,,both,,,702.99,210.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 6FR WITHOUT MINI WIRE AVANTI+ STD",SUP-504606A,CDM,C1894,HCPCS,0272,RC,,,both,,,72.65,21.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Adhesive Cement Ostomy",PX-E27000032,CDM,E27000032,LOCAL,0270,RC,,,both,,,59.40,17.82,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP GRASPING RAT TOOTH 1.85MM 19MM REUSABLE",SUP-FG-14P-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BARE (2) AND COVERED (5) SLIDERS",SUP-4764-02,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM 25MM 33MM 26.3MM EPIC MAX 14MM TISSUE",SUP-EMAX-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,27990.90,8397.27,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3316.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3255.34,23792.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 52MM STAINLESS STEEL T8 ELBOW METAPHYSEAL",SUP-02.118.552,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,149.94,28.62,,,,,0,60.93,445.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 FIBERTAK SWIVELOCK C TIGERTAIL 2 LOAD",SUP-AR-2323BCT-2,CDM,C1713,HCPCS,0278,RC,,,both,,,3346.88,1004.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,396.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,389.24,2844.85,"percent of total billed charges",
"STENT COTTON-LEUNG 12CM 10FR .035IN GENTLE CURVE BILIARY",SUP-G21810,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA [10200]","Cigna Local Plus",,338.01,,,,,,,73.48,537.03,"percent of total billed charges",
"KIT CATH 18GA 10CM POWERGLIDE PRO BIOPATCH FULL INSRT",SUP-F318108T,CDM,C1751,HCPCS,0272,RC,,,both,,,884.36,265.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,104.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,102.85,751.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLIPIZIDE 5 MG TABLET, IMMEDIATE RELEASE",RX-10117,CDM,,,0637,RC,51079-0810-01,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORTICAL STRUTS (12 EACH): 40-80MM L X 1-3MM W: FREEZE-DRIED",SUP-400602,CDM,S27800098,LOCAL,0278,RC,,,both,,,6566.04,1969.81,"CIGNA [10200]",Cigna,,4464.91,68,,,,,0,763.63,5581.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE NONABSORBABLE ULTRABRAID UHMWPE 2 L38 IN BRAIDED PREC",SUP-72202965,CDM,C1713,HCPCS,0278,RC,,,both,,,176.18,52.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,119.8,68,,,,,0,20.49,149.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 8IN 40D UP CERVICAL 9X6MM MICRO-KERRISON BLACK",SUP-57-0696-BD,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"NOVANET [10819]",Novanet,,2805,75,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SPINAL 16MM 4MM CODA ANTERIOR CERVICAL SELF TAP VARIABLE",SUP-102254016,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM ATTUNE 4 KNEE DISTAL CEMENT REVISION STERILE",SUP-154704001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4128.96,68,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY SOFT TISSUE LATEX FREE HAZARDOUS",SUP-32-ST1SF,CDM,S27200284,LOCAL,0272,RC,,,both,,,175.57,52.67,"AETNA [10100]","Aetna HMO/PPO",,139.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.42,149.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETER ADULT 14.5FR L45CM INSERTION L28CM POLYURETHANE",SUP-8888145041P,CDM,C1750,HCPCS,0278,RC,,,both,,,2876.79,863.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,340.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.57,2445.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 16MM CONCERTO DETACHABLE",SUP-PV-16-40-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"KAISER [10500]",Kaiser,,3004.95,67,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 5MM EXCALIBUR COOLCUT STERILE DISPOSABLE",SUP-AR-8500EX,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"KAISER [10500]",Kaiser,,336.21,67,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CITATION TMZF HA 6 SHORT HIP LEFT",SUP-6265-5206,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"PHCS [10601]",PHCS,,17095.37,70,,,,,0,2840.27,20758.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AMPLATZ 17CM 18FR ACCESS PTFE RENAL FIRM TAPER TIP",SUP-M0062601470,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,137.52,41.1,,,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACELLUAIR LIQUIT AMNION 1ML ROOM TEMP",SUP-RA-931RT,CDM,V2790,HCPCS,0278,RC,,,both,,,10591.50,3177.45,"KAISER [10500]",Kaiser,,7096.31,67,,,,,0,1231.79,9002.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION",RX-160048,CDM,,,0250,RC,00121-0945-10,NDC,both,10,ML,31.58,9.47,"CIGNA [10200]","Cigna Local Plus",,16.9,53.5,,,,,0,3.67,26.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 14MM SKYLINE TITANIUM OVERSIZE SPINE CERVICAL",SUP-186854014,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"MULTIPLAN [10600]",Multiplan,,1198.5,85,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 15MM SECUR-FIT PLUS 11 HIP STERILE",SUP-6054-1115S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4364.67,27,,,,,0,1880.04,13740.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 54MM TI",SUP-SPL-35540-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROPHECY½ INFINITY PROPHECY½ INFINITY",SUP-PROPINF,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"MULTIPLAN [10600]",Multiplan,,8797.5,85,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 14MM RESONATE SPINE SELF DRILL VARIBLE ANGLE",SUP-1194.7214,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",117.75,860.63,"percent of total billed charges",
"CATH ADVANCE PLIAFORM STARCAST 135CM 8CM 4MM BALLOON",SUP-G52253,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 12MM 3.5MM EMBOLIZATION",SUP-PED2-350-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9574.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL LARGE KNEE RIGHT CEMENT LCS COMPLETE COCR",SUP-129401060,CDM,C1776,HCPCS,0278,RC,,,both,,,20635.65,6190.69,"MULTIPLAN [10600]",Multiplan,,17540.3,85,,,,,0,2399.93,17540.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 180CM 120MM 4FR 3MM LOW PROFILE COAXIAL",SUP-PCP030120180,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"NOVANET [10819]",Novanet,,923.4,75,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 8MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0278,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]",Cigna,,644.44,68,,1831.33,1831.33,1831.33,16,110.22,805.55,"percent of total billed charges",
"SPACER ALLOGRAFT 12X14X12MM LORDOTIC SPINE CERVICAL CORTICAL",SUP-17012,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 10X80 80CM SL",SUP-48010008N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,99.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 22GA 1.25MM ACCUCATH ACE DOT",SUP-AC1221252,CDM,S27200284,LOCAL,0272,RC,,,both,,,295.37,88.61,"FIRST HEALTH [10303]","First Health",,236.3,80,,,,,0,34.35,251.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 77MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 6",SUP-223.56,CDM,C1713,HCPCS,0278,RC,,,both,,,1963.50,589.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,561.95,28.62,,,,,0,228.36,1668.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X18X9MM TRANSCONTINENTAL 10D LORDOTIC",SUP-375.782,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Local Plus",,7541.1,31.5,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Upgrade Impl Pcmkr Sys",PX-480000009,CDM,33214,CPT,0481,RC,,,both,,,11250.00,3375,"UHC [10700]","United Healthcare",,11250,,"Case rate ($18,789). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1308.38,11250,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF ENHANCR II 110CM 4MM 7FR 2-5-2MM SPACE 45MM SINGLE",SUP-FND-019-05,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"UHC [10700]","United Healthcare",,861.39,63.3,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.432,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"CIGNA [10200]","Cigna Open Access",,787.57,56.9,,1144.80,304.56,2275.09,66,160.97,1176.51,"percent of total billed charges",
"LENS IOL +26 DIOPTER 12.5MM 5.5MM ANTERIOR CHMBR 1 PIECE",SUP-MTA3U0.260,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]",Cigna,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SHORT STEM TSA",SUP-71701426,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"MULTIPLAN [10600]",Multiplan,,22758.75,85,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM VERTEX MAX TITANIUM SPINE MULTIAXIAL",SUP-6958710,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1927.8,45.9,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT MONORAIL 36MM 135CM 8MM ENDOPROSTHESIS METAL",SUP-M001719030,CDM,C1876,HCPCS,0278,RC,,,both,,,16615.20,4984.56,"MULTIPLAN [10600]",Multiplan,,14122.92,85,,,,,0,1932.35,14122.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET THORACENTESIS 30IN 15GA PORTEX MALE ADPTR SLIDE CLAMP",SUP-PTX465348,CDM,C1729,HCPCS,0272,RC,,,both,,,48.66,14.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.66,41.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MITRACLIP G4 SYSTEM ONE (1) STEERABLE GUIDE CATHETER SGC0701",SUP-CDS0706-NT,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,28.62,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PACKAGED ACCESSORIES",SUP-ES0542,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR INTERFERENCE TITANIUM 25MM 8MM ACL PCL CANNULATED",SUP-AR-1381,CDM,C1713,HCPCS,0278,RC,,,both,,,807.98,242.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,549.43,68,,,,,0,93.97,686.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STOCKING COMPRESSION LARGE TUBULAR SOFT TENSOGRIP",SUP-13202,CDM,S27000186,LOCAL,0270,RC,,,both,,,494.42,148.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,58.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.5,420.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STOCKING COMPRESSION LARGE TUBULAR SOFT TENSOGRIP",SUP-13202,CDM,S27000186,LOCAL,0270,RC,,,both,,,494.42,148.33,"KAISER [10500]",Kaiser,,331.26,67,,,,,0,57.5,420.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM 2.5MM 2.1-2.7FR CORONARY",SUP-RONYX25022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"PHCS [10601]",PHCS,,2598.75,70,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X17MM LUMINARY 10/11MM SPINE",SUP-4717,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3663.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 24FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0119SI24,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.53,33.46,"AETNA [10100]","Aetna HMO/PPO",,88.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.97,94.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +24.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.245,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X20 135CM SL",SUP-48007002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"FIRST HEALTH [10303]","First Health",,687.21,80,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX 20MM 135CM 6MM VASCULAR NITINOL CAROTID",SUP-PC0620RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"CIGNA [10200]","Cigna Local Plus",,4060.65,53.5,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.5/18",SUP-401748,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 4-0 P-2 18IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Z504G,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.37,23.51,"KAISER [10500]",Kaiser,,52.51,67,,,,,0,9.11,66.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 100MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171081010,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PHCS [10601]",PHCS,,822.15,70,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 34CM FEMUR RIGHT PROXIMAL TALON DISTALFIX",SUP-SLN-125-34R,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"MULTIPLAN [10600]",Multiplan,,13706.51,85,,,,,0,1875.37,13706.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 8MM AXIUM 3D FRAME V01",SUP-FC-8-20-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6610.2,40,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD SUT ASSISTANT 0 ES-9 7IN COATED ENDO STITCH BRALON",SUP-170010,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cpap Generator Infant Flow",PX-E27000100,CDM,E27000100,LOCAL,0270,RC,,,both,,,361.89,108.57,"UHC [10700]","United Healthcare",,229.08,63.3,,,,,0,42.09,307.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 30X6IN STRONG PRECUT PADDED LIGHTWEIGHT",SUP-OG-6PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,148.82,44.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOFT-VU 100CM 5FR ANGLE VERTEBRAL CURVE ANGIOGRAPHIC 2",SUP-H787107087025,CDM,C1887,HCPCS,0272,RC,,,both,,,190.36,57.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE GLDEWIRE ENDOSCOPIC 3MM STD J 400CM 3MM .035IN",SUP-GR3538,CDM,C1769,HCPCS,0272,RC,,,both,,,615.60,184.68,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CARDIOFLON 2/0  1/2KL 18MM  DA 75CM PLEDGET TD3X7",SUP-19P30T,CDM,S27200284,LOCAL,0272,RC,,,both,,,865.35,259.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cntrl Mtr Evoked Pot Upr/Lwr",PX-922000018,CDM,95939,CPT,0922,RC,,,both,,,812.00,243.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PTCA CATHETER 2.0 X 15NM (620-154-1U) SCOREFLEX NC SCORING",SUP-SD36003-05,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 17GA 5.1CM TRU-CORE II COAXIAL INTRO ECHOGENIC",SUP-MCXS1810TX,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.64,44.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,61.5,41.1,,,,,0,17.4,127.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AXS INFINITY LS LONG 80CM 8FR .088IN INTRO STERILE",SUP-GEN-10800-80,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"NOVANET [10819]",Novanet,,2805,75,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 61MM 28MM UHR UNIVERSAL HIP FEMUR COCR UHMWPE",SUP-UH1-61-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"BLUE CROSS [10001]","Blue Cross HMO",,2217.94,39.2,,5311.50,4717.44,5388.59,31,658.03,4809.3,"percent of total billed charges",
"SHEATH ACCESS CLEARPETRA L13 CM OD16 FR ID14 FR NEPHROSTOMY",SUP-90121413,CDM,C1894,HCPCS,0272,RC,,,both,,,1935.00,580.5,"PHCS [10601]",PHCS,,1354.5,70,,,,,0,225.04,1644.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 15MM 145CM 2.75MM CORONARY STENT",SUP-1145275-15,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"FIRST HEALTH [10303]","First Health",,4670.4,80,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +32 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60AT.320,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 2MM 22MM DCP STAINLESS STEEL SMALL BONE SELF TAPP",SUP-201.892,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"MULTIPLAN [10600]",Multiplan,,599.55,85,,,,,0,82.03,599.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL LINEAR CUTTER LAPAROSCOPIC 100X3.8MM TITANIUM",SUP-GIA10038L,CDM,S27200284,LOCAL,0272,RC,,,both,,,766.99,230.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,315.23,41.1,,,,,0,89.2,651.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH LONG 95CM .079IN 10.7FR INTRO RADIAL",SUP-107F-079-95,CDM,C1894,HCPCS,0272,RC,,,both,,,8093.70,2428.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5503.72,68,,,,,0,941.3,6879.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 15ML .212-.85MM DEMINERALIZED CORTICAL",SUP-420117,CDM,C1713,HCPCS,0278,RC,,,both,,,2543.63,763.09,"MULTIPLAN [10600]",Multiplan,,2162.09,85,,,,,0,295.82,2162.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE RX BILIARY SYSTEM LOCKING BIOPSY CAP STERILE",SUP-M00545261,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.67,24.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.61,70.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 62MM 32MM XLPE HIP",SUP-71337662,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"FIRST HEALTH [10303]","First Health",,8901,80,,,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 108MM 30MM ZENITH LOW PROFILE MAIN BODY 2",SUP-G51023,CDM,C1874,HCPCS,0624,RC,,,both,,,25867.80,7760.34,"CIGNA [10200]",Cigna,,17590.1,68,,,,,0,3008.43,21987.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 300MM 5MM BALLOON",SUP-U3575530,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 1 54IN BRAID ANTIBACTERIAL COATED VIOLET",SUP-VCP617H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.28,41.1,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 24CM 12FR MAHURKAR 3 LUMEN STRAIGHT EXT HIGH",SUP-8888101004HP,CDM,C1752,HCPCS,0272,RC,,,both,,,995.43,298.63,"KAISER [10500]",Kaiser,,666.94,67,,,,,0,115.77,846.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 26MM 140CM 2.75MM CORONARY STERILE",SUP-453957,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 70CM INFINION PERCUTANEOUS 16 LEAD",SUP-SC-2316-70,CDM,C1897,HCPCS,0278,RC,,,both,,,17640.00,5292,"CIGNA [10200]","Cigna Local Plus",,5556.6,31.5,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEMOSTAR XK AIRGUARD 28CM 23CM 16FR STRAIGHT",SUP-5883730,CDM,C1750,HCPCS,0278,RC,,,both,,,1563.30,468.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,447.42,28.62,,,,,0,181.81,1328.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR NEVRO IMPLANATABLE PULSE GENRTR STERILE",SUP-ACCK7100,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,71.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 65CM PLEXA PROMRI S DF-1",SUP-413997,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"PHCS [10601]",PHCS,,10626,70,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 18MM 2.75MM CORONARY STENT COCR",SUP-1007847-18,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ENDOSCOPIC I TYPE I JET MULTIFUNCTIONAL PROBE",SUP-20150-261,CDM,C1889,HCPCS,0272,RC,,,both,,,4312.50,1293.75,"PHCS [10601]",PHCS,,3018.75,70,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 10CM 3MM BALLOON DILATATION HYDROPHILIC",SUP-V1430100,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"KAISER [10500]",Kaiser,,3675.29,67,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 8FR .088IN AMPLATZ",SUP-588847,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.35MM 14MM CSLP TITANIUM STD SPINE CANCELLOUS",SUP-488.814,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,117.75,860.63,"percent of total billed charges",
"SCR BONE 7.5MM 50MM TRANSITION HA SPINE PEDICLE POLYAXIAL",SUP-152.776S,CDM,C1713,HCPCS,0278,RC,,,both,,,10791.60,3237.48,"CIGNA [10200]","Cigna Open Access",,6140.42,56.9,,1144.80,304.56,2275.09,66,1255.06,9172.86,"percent of total billed charges",
"CATH SUPER TORQUE PLUS 100CM 6FR STD JUDKINS LEFT 4 CURVE",SUP-533620,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"CIGNA [10200]","Cigna Local Plus",,44.03,53.5,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHALANX CORONAL TRANSFIXION SCREW 1.5MM X 14.0MM COCR",SUP-PTS-15014-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.90,337.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,765.61,68,,,,,0,130.94,957.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 9IN 10FR DRNG",SUP-8888561019,CDM,C1729,HCPCS,0272,RC,,,both,,,221.15,66.34,"PHCS [10601]",PHCS,,154.81,70,,,,,0,25.72,187.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK",RX-5018,CDM,J1836,HCPCS,0636,RC,00338-1055-48,NDC,both,100,ML,100.65,30.19,"BLUE CROSS [10001]","Blue Cross PPO",,1.75,,,,,,,1.75,85.55,"fee schedule",
"SCR BONE 3MM 8MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0278,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"NOVANET [10819]",Novanet,,710.78,75,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 6FR 15CM RADIOPAQUE GWIRE STERILE DISPOSABLE",SUP-G00944,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"FIRST HEALTH [10303]","First Health",,39.46,80,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC MICRO MESH TOOTH POSITION MARKER STREAMLINE",SUP-M00513324,CDM,C1889,HCPCS,0278,RC,,,both,,,80.01,24,"CIGNA [10200]","Cigna Local Plus",,42.81,53.5,,16168.95,16168.95,16168.95,"1 through 10",9.31,68.01,"percent of total billed charges",
"SCR BONE 3.5MM 40MM T10 FULL THREAD LOCK STARDRIVE",SUP-657340,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1011.05,68,,,,,0,172.92,1263.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET ANGLE 2 OVAL 8IN SURGICAL SPINAL FUSION",SUP-29-4942,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.68,68.9,"PHCS [10601]",PHCS,,160.78,70,,,,,0,26.71,195.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL SF F-F CURVE ABLATION",SUP-D134802,CDM,C1732,HCPCS,0272,RC,,,both,,,21312.90,6393.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2478.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2478.69,18115.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENROUTE ENFLATE TRANSCAROTID RX BALLOON DILATATION CATHETER",SUP-SR-4535-BC,CDM,C1725,HCPCS,0272,RC,,,both,,,2625.00,787.5,"NOVANET [10819]",Novanet,,1968.75,75,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH R2P DESTINATION SLENDER 75CM 6FR GUIDING STERILE",SUP-GS-R6ST1C75W,CDM,C1894,HCPCS,0272,RC,,,both,,,2216.25,664.87,"FIRST HEALTH [10303]","First Health",,1773,80,,,,,0,257.75,1883.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA D KNEE LEFT NONPOROUS REVISION FIXATION",SUP-42542006701,CDM,C1776,HCPCS,0278,RC,,,both,,,16335.06,4900.52,"BLUE CROSS [10001]","Blue Cross HMO",,6403.34,39.2,,5311.50,4717.44,5388.59,31,1899.77,13884.8,"percent of total billed charges",
"SCR BONE 10MM 40MM SI-LOK SPINE WASHER STERILE LATEX FREE",SUP-1202.6040S,CDM,C1713,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4657.5,27,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20GA 10CM POWERGLIDE 1.3IN .014IN 5ML/SEC FULL",SUP-M020101,CDM,C1751,HCPCS,0272,RC,,,both,,,607.50,182.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,70.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 5",SUP-245.15,CDM,C1713,HCPCS,0278,RC,,,both,,,2467.50,740.25,"AETNA [10100]","Aetna HMO/PPO",,1961.66,79.5,,1521.93,481.35,16760.95,30,286.97,2097.38,"percent of total billed charges",
"SCR BONE 10.5MM 85MM GAMMA3 TITANIUM TROCHANTER HIP LAG",SUP-3060-0085S,CDM,C1713,HCPCS,0278,RC,,,both,,,3471.30,1041.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2360.48,68,,,,,0,403.71,2950.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL THK1.5MM 2-0 V-5 36IN 2 ARM BRAID FIRM",SUP-SX54H,CDM,S27200284,LOCAL,0272,RC,,,both,,,97.77,29.33,"KAISER [10500]",Kaiser,,65.51,67,,,,,0,11.37,83.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 40MM T10 FULL THREAD LOCK STARDRIVE",SUP-657340,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"FIRST HEALTH [10303]","First Health",,1189.47,80,,,,,0,172.92,1263.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 7CM 7FR DUODENAL BEND BILIARY PLASTIC TEMPORARY RAPID",SUP-M00545560,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,99.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 55MM CD HORIZON LEGACY TITANIUM ANGLE REVERSE",SUP-75448555,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",441.36,3225.75,"percent of total billed charges",
"CANN OPHTHALMIC 25GA SILICONE DISPOSABLE",SUP-8065149525,CDM,S27200284,LOCAL,0272,RC,,,both,,,201.93,60.58,"MULTIPLAN [10600]",Multiplan,,171.64,85,,,,,0,23.48,171.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 3-0 SH-1 18IN CONTROL RELEASE BRAID 8",SUP-C003D,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.00,30.3,"CIGNA [10200]",Cigna,,68.68,68,,,,,0,11.75,85.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1",SUP-179712045,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNETOS 5CC 1-2MM ALLOGRAFT GRANULE PUTTY GOLD",SUP-703-035-US,CDM,C1713,HCPCS,0278,RC,,,both,,,10867.50,3260.25,"PHCS [10601]",PHCS,,7607.25,70,,,,,0,1263.89,9237.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 3MM BALLOON DILATATION STERILE LATEX",SUP-593015022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 2.1MM STRAIGHT 2 SERRATE ENTELLUS MEDICAL HNDPC",SUP-SSB-12200-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 42MM LEVEL 2 TRANSLATIONAL BONE SPINE",SUP-201-42D42,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REUNION TSA - SR 4MM OFFSET HUMERAL HEAD 48X21",SUP-5552-E-4821,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"NOVANET [10819]",Novanet,,6816.6,75,,,,,0,1057.03,7725.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT OSTEOMATRIX+ 2 STRIP 18CC STERILE",SUP-OMP-18,CDM,C1713,HCPCS,0278,RC,,,both,,,6776.66,2033,"CIGNA [10200]","Cigna Open Access",,3855.92,56.9,,1144.80,304.56,2275.09,66,788.13,5760.16,"percent of total billed charges",
"HC Tbs Techl Prep&Transmis Data",PX-320000272,CDM,77090,CPT,0320,RC,,,both,,,404.00,121.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6.03,,"Fee schedule rate ($6.03).",,,,0,6.03,343.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .035IN 7MM 135CM 40MM PERIPHERAL",SUP-10337-40,CDM,C1725,HCPCS,0272,RC,,,both,,,1539.00,461.7,"UHC [10700]","United Healthcare",,974.19,63.3,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 8MM RIGHT MEDIAL LEFT LATERAL X3 PARTIAL KNEE",SUP-5630-G-428,CDM,C1776,HCPCS,0278,RC,,,both,,,5309.55,1592.86,"NOVANET [10819]",Novanet,,3982.16,75,,,,,0,617.5,4513.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Impl Cardiac Event Record",PX-361000058,CDM,33285,CPT,0361,RC,,,both,,,15025.48,4507.64,"NOVANET [10819]",Novanet,,11269.11,75,,,,,0,1747.46,12771.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 75MM TITANIUM ENDOSCOPIC LINEAR CUTTER SAFETY",SUP-TLC75,CDM,S27200284,LOCAL,0272,RC,,,both,,,2800.28,840.08,"CIGNA [10200]","Cigna Open Access",,1593.36,56.9,,,,,0,325.67,2380.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERCI 95CM 8FR GUIDING SILICONE BALLOON STERILE LATEX",SUP-90073,CDM,C1725,HCPCS,0272,RC,,,both,,,9696.36,2908.91,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEAD FEMORAL 0MM 36MM HIP ORTHINOX V40",SUP-6364-2-136,CDM,C1776,HCPCS,0278,RC,,,both,,,4778.25,1433.47,"BLUE CROSS [10001]","Blue Cross HMO",,1873.07,39.2,,5311.50,4717.44,5388.59,31,555.71,4061.51,"percent of total billed charges",
"SUT ETHILON MULTIPASS 6-0 P-1 18IN MONOFILAMENT PLIABILIZE",SUP-697G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR 42MM MULTIPOLAR HIP METAL STERILE",SUP-500104200,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,5372.07,4581.20,7242.98,23,434.96,3179,"percent of total billed charges",
"GRAFT BONE VIVIGEN FORMABLE CELLULAR BONE MATRIX 5CC MEDIUM",SUP-BL-1600-002,CDM,C1713,HCPCS,0278,RC,,,both,,,15732.00,4719.6,"BLUE CROSS [10001]","Blue Cross PPO",,6166.94,39.2,,957.42,570.23,957.42,28,1829.63,13372.2,"percent of total billed charges",
"CATH SOFT-VU 110CM 5FR PIGTAIL CURVE ANGIOGRAPHIC RADIOPAQUE",SUP-H787107085065,CDM,C1887,HCPCS,0272,RC,,,both,,,218.37,65.51,"FIRST HEALTH [10303]","First Health",,174.7,80,,,,,0,25.4,185.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH SAFESHEATH II INTRO HEMOSTASIS",SUP-7469,CDM,C1894,HCPCS,0272,RC,,,both,,,261.00,78.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,30.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 8MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640708,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1308.83,9565.82,"percent of total billed charges",
"MARKER FIDUCIAL 5MM .018IN LUMICOIL FIGURE 8 PLATINUM",SUP-M00553841,CDM,A4648,HCPCS,0278,RC,,,both,,,1387.72,416.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,636.96,45.9,,,,,0,161.39,1179.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 150MM 2MM BALLOON DILATATION DURALYN",SUP-48002015S,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH CHECK-FLO ANL0 CURVE STRAIGHT 90CM 5FR .074IN GUIDING",SUP-G48189,CDM,C1894,HCPCS,0272,RC,,,both,,,842.40,252.72,"UHC [10700]","United Healthcare",,533.24,63.3,,,,,0,97.97,716.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LD/ADP LV-1 BP TO IS-1 BP 17CM",SUP-4403,CDM,C1883,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.0MM X 10.0MM",SUP-492001012,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUMP INTRACARDIAC SUCTION 15IN 20FR DLP .25IN PERICARDIAL",SUP-12010,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.52,37.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,86.03,68,,,,,0,14.71,107.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X10X6MM SABLE 8D STERILE LATEX FREE",SUP-1172.2110S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"BLUE CROSS [10001]","Blue Cross PPO",,13582.8,39.2,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 16X10CM STRATTICE LIFECELL 160SQ CM",SUP-1016002P,CDM,Q4130,HCPCS,0636,RC,,,both,,,25181.10,7554.33,"CIGNA [10200]",Cigna,,17123.15,68,,,,,0,2983.96,21403.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP .8CM UNIVERSAL LARGE 12X2CM",SUP-R2008,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.67,49.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.27,140.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOUND 26FR URETHRAL CURVE VAN BUREN 10.75IN",SUP-51-6326,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.21,101.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,230.66,68,,,,,0,39.45,288.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM 20.4MM HEMODYNAMIC PLUS STD CUFF MR",SUP-23AHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AETNA [10100]","Aetna HMO/PPO",,23149.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE 3MM TAPERED ELITE SURGICAL",SUP-5820-071-030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"FIRST HEALTH [10303]","First Health",,875.97,80,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXFIT SEAMLESS BRA FRONT CLOSURE-40 D/E-BLACK","SUP-B01G-40 D/E-B",CDM,S27000186,LOCAL,0270,RC,,,both,,,200.45,60.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,92.01,45.9,,,,,0,23.31,170.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN 500 MG VIAL",RX-8443,CDM,J3373,HCPCS,0636,RC,00409-4332-11,NDC,both,1,UN,73.94,22.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.75,62.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOGRAPHIC SOFT-VU SOS OMNI 0 CURVE L80 CM OD4 FR",SUP-H787107140235,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"MULTIPLAN [10600]",Multiplan,,184.88,85,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 22IN 8FR STYLET ANTICLOG BOW TIP BOLUS",SUP-40-9228,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.39,27.72,"CIGNA [10200]","Cigna Open Access",,52.57,56.9,,,,,0,10.74,78.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER MARINR 90CM 2MM 7FR 2-5-2MM SPACE 2XL CURVE ABLATIO",SUP-072302,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 15CM 8.5FR BILIARY PLASTIC DUODENAL BEND",SUP-M00534300,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,129.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 4MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-04004,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2565.24,28.62,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROGRIP 20X15CM RESORBABLE SELF GRIP PLA",SUP-PP2015G,CDM,C1781,HCPCS,0278,RC,,,both,,,3700.65,1110.19,"CIGNA [10200]",Cigna,,2516.44,68,,,,,0,430.39,3145.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Protein Electrophoresis Other",PX-301000382,CDM,84166,CPT,0301,RC,,,both,,,289.50,86.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.29,.1,,,,,0,0.29,246.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH 9MM PORTEX PREFIT PERCUTANEOUS STERILE LATEX FREE",SUP-101/815/090,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.48,103.04,"UHC [10700]","United Healthcare",,217.42,63.3,,,,,0,39.95,291.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE MALLEABLE CONTOURABLE MESH LOW PROFILE 100X100MM",SUP-421.533S,CDM,C1713,HCPCS,0278,RC,,,both,,,15000.60,4500.18,"PHCS [10601]",PHCS,,10500.42,70,,,,,0,1744.57,12750.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 70MM LCP STAINLESS STEEL PROXIMAL FEMORAL",SUP-02.205.070,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"CIGNA [10200]",Cigna,,859.03,68,,1831.33,1831.33,1831.33,16,146.92,1073.79,"percent of total billed charges",
"DEVICE STAYFIX 12-22FR DRNG FIXATION FASTEN SHOWERCAP",SUP-685ME,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.43,24.43,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MORCLTR SURGICAL 335MM 4.75MM DISPOSABLE",SUP-49700113,CDM,S27200284,LOCAL,0272,RC,,,both,,,2628.58,788.57,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROS PENILE TITAN LOCK-OUT INFLATABLE SELF CONTAIN FLUID",SUP-519300,CDM,C1813,HCPCS,0278,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,39.2,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH CHECK-FLO ANL0 CURVE STRAIGHT 90CM 5FR .074IN GUIDING",SUP-G48189,CDM,C1894,HCPCS,0272,RC,,,both,,,842.40,252.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,99.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.97,716.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 7MM CONCERTO DETACHABLE HELIX PERIPHE",SUP-NV-7-30-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"KAISER [10500]",Kaiser,,3004.95,67,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 26CM 6FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49906,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,345.76,45.9,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X24MM COLOSSEUM 12MM CURVE MESH NONSTERILE",SUP-156.206,CDM,S27800098,LOCAL,0278,RC,,,both,,,28343.70,8503.11,"CIGNA [10200]","Cigna Local Plus",,8928.27,31.5,,,,,0,3296.37,24092.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 135CM MAMBA FLEX STERILE LATEX",SUP-H7493928713540,CDM,C1725,HCPCS,0272,RC,,,both,,,4071.00,1221.3,"AETNA [10100]","Aetna HMO/PPO",,3236.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 4MM STRAIGHT TITANIUM",SUP-102014120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC ELATION 100CM 3CM 10-11-12MM PULMONARY 3",SUP-P10L30,CDM,C1726,HCPCS,0272,RC,,,both,,,2137.50,641.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,248.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"O.R. PROCEDURES FOR OBESITY WITH CC",620,MS-DRG,,,,,,,inpatient,,,95553.19,28665.96,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,10522.37,,"Case rate ($9,926.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,217.67, add-ons for qualifying new technology services are included. If operating cost exceeds $42,257.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,078.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $9,229.86. The transfer operating threshold is the transfer adjustment factor * $9,217.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $696.90. The transfer capital threshold is the transfer adjustment factor * $696.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,46722.36,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 255CC P4.7CM MODERATE PLUS PROFILE MEDIUM HEIGHT",SUP-334-1105,CDM,C1789,HCPCS,0278,RC,,,both,,,8107.50,2432.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3721.34,45.9,,,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GAR047 CO2 SOURCE TUBING",SUP-K10037012,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.08,20.12,"KAISER [10500]",Kaiser,,44.94,67,,,,,0,7.8,57.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER VASCULAR PROCEDURES WITH MCC",252,MS-DRG,,,,,,,inpatient,,,142770.90,42831.27,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,22611.86,,"Case rate ($21,638.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,092.48, add-ons for qualifying new technology services are included. If operating cost exceeds $53,132.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,901.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $20,119.05. The transfer operating threshold is the transfer adjustment factor * $20,092.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,519.09. The transfer capital threshold is the transfer adjustment factor * $1,519.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,101844.41,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 6CM 7MM BALLOON",SUP-M0062251090,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"FIRST HEALTH [10303]","First Health",,1369.98,80,,,,,0,199.16,1455.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CAROTID BARD JAVID TAPER 27.5CM TYPE 1852 KINK",SUP-007714,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"PHCS [10601]",PHCS,,510.3,70,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 40 75CM 8CM 6MM BALLOON DILATATION PERIPHERAL",SUP-CQF7568,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SKIN INFANT AIRLIFE CARE PLUS THRMOMTR NONSTERILE",SUP-6600-0628-700,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.53,85.66,"MULTIPLAN [10600]",Multiplan,,242.7,85,,,,,0,33.21,242.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 60CM 5MM GORE STD WALL HEPARIN PROPATEN PTFE",SUP-H050060A,CDM,C1768,HCPCS,0278,RC,,,both,,,11378.10,3413.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1348.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1323.27,9671.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 154MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT SET 8",SUP-240.041,CDM,C1713,HCPCS,0278,RC,,,both,,,8796.40,2638.92,"NOVANET [10819]",Novanet,,6597.3,75,,,,,0,1023.02,7476.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK-83/2,5M STERILE",SUP-115489,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.80,114.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,44.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ON-Q PAINBUSTER 2ML/HR PAIN PUMP 100ML 2 DAY DELIVERY",SUP-P100X2,CDM,C9804,HCPCS,0272,RC,,,both,,,694.09,208.23,"AETNA [10100]","Aetna HMO/PPO",,551.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.72,589.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.7MM 2.6 KNOTLESS TIGERTAPE FIBERTAK LOOP SELF",SUP-AR-3653TTSP,CDM,C1713,HCPCS,0278,RC,,,both,,,3839.85,1151.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,446.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",446.57,3263.87,"percent of total billed charges",
"RTRCTR 13IN RIBBON HOLLOW GRIP HANDLE MALLEABLE BLADE",SUP-201225,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.44,161.23,"UHC [10700]","United Healthcare",,340.2,63.3,,,,,0,62.5,456.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM CD HORIZON LEGACY TITANIUM SPINAL",SUP-75447540,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"KAISER [10500]",Kaiser,,3244.54,67,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 145MM 3.2MM QUICK COUPLING STERILE",SUP-310.31S,CDM,S27000186,LOCAL,0270,RC,,,both,,,825.55,247.66,"KAISER [10500]",Kaiser,,553.12,67,,,,,0,96.01,701.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTIX-PPP ARTIX PRICE PER PROCEDURE",SUP-ARTIX-PPP,CDM,C1757,HCPCS,0272,RC,,,both,,,47250.00,14175,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CANN RADIOFREQUENCY YELLOW 145MM 20GA SURE-GRIP BEVEL CURVE",SUP-PMF20-145-10CS,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.04,53.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ADHESIVE SKIN CLOSURE SYSTEM MESH EXOFIN FUSION 30CM",SUP-EF70430,CDM,S27200284,LOCAL,0272,RC,,,both,,,615.60,184.68,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE SPEAKING AQUA 22MM 15MM PMV LOW PROFILE TRACHEA RUBBER",SUP-PMV007,CDM,S27000186,LOCAL,0270,RC,,,both,,,909.87,272.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIPHENHYDRAMINE 25 MG TABLET",RX-2505,CDM,,,0637,RC,68094-0018-59,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 30CM 7MM CONCERTO DETACHABLE HELIX PERIPHE",SUP-NV-7-30-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X11MM 9-11MM SPINE CORTICAL FROZEN",SUP-4911,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"NOVANET [10819]",Novanet,,12420,75,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL PREP SCRUB CARE EXIDINE 2% CHG 30OZ BOTTLE ANTIMICROBIAL",SUP-4CHG2-FM,CDM,S27000186,LOCAL,0270,RC,,,both,,,56.84,17.05,"AETNA [10100]","Aetna HMO/PPO",,45.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.61,48.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tavi/Tavr Bypassperc per Art",PX-361000349,CDM,33367,CPT,0361,RC,,,both,,,45298.00,13589.4,"BLUE CROSS [10001]","Blue Cross PPO",,9549.81,,"Case rate ($9,549.81). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2491,38503.3,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT 200MM 11MM STAGEONE SELECT HIP STAINLESS",SUP-431196,CDM,C1776,HCPCS,0278,RC,,,both,,,9954.63,2986.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4569.18,45.9,,,,,0,1157.72,8461.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 10 STD 27MM PROVOX LIFE LARYTUBE SOFT COMPATIBLE",SUP-7415,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"PHCS [10601]",PHCS,,836.44,70,,,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP - HIP CONSTRUCT 4A: BIPOLAR/PRESS FIT STEM -PRESS",SUP-CAP-H-4A,CDM,C1776,HCPCS,0278,RC,,,both,,,9240.00,2772,"FIRST HEALTH [10303]","First Health",,7392,80,,,,,0,1074.61,7854,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL IHF 1.4MM",SUP-DRLL-IHF-14,CDM,S27000186,LOCAL,0270,RC,,,both,,,996.30,298.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,457.3,45.9,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 3-0 CTX 27IN MONOFILAMENT ABSORBABLE",SUP-873H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 75CM 7MM 30MM",SUP-38046-73075,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"NOVANET [10819]",Novanet,,3622.5,75,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 370MM TIBIA T2 INTRAMEDULLARY STD LOCK TITANIUM",SUP-1822-0937S,CDM,C1713,HCPCS,0278,RC,,,both,,,14406.10,4321.83,"PHCS [10601]",PHCS,,10084.27,70,,,,,0,1675.43,12245.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VOID FILLER SYNTHETIC NANOSS 3D PLUS 10CC",SUP-90-400-251004,CDM,C1713,HCPCS,0278,RC,,,both,,,12765.00,3829.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1512.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1484.57,10850.25,"percent of total billed charges",
"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC",522,MS-DRG,,,,,,,inpatient,,,100547.02,30164.11,"CIGNA [10200]","Cigna Local Plus",,21852.55,,"Fee schedule rate ($21,852.55). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,61828.37,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 80MM LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.080S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,1831.33,1831.33,1831.33,16,189.34,1383.8,"percent of total billed charges",
"CATH METACROSS 135CM 200MM 5.7FR 6MM BALLOON DILATATION 2",SUP-BD-L60200CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"KAISER [10500]",Kaiser,,643.1,67,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDOMETHACIN 50 MG RECTAL SUPPOSITORY",RX-3901,CDM,,,0637,RC,69344-0102-33,NDC,both,1,UN,1641.60,492.48,"MULTIPLAN [10600]",Multiplan,,1395.36,85,,,,,0,190.92,1395.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 5.5MM CREO CURVE TITANIUM NONSTERILE",SUP-1119.7065,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,512.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",512.88,3748.5,"percent of total billed charges",
"DEVICE ACAPELLA DH PEP MOUTHPC",SUP-26-21-1530,CDM,S27000186,LOCAL,0270,RC,,,both,,,323.03,96.91,"CIGNA [10200]","Cigna Local Plus",,172.82,53.5,,,,,0,37.57,274.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 13MM KNEE XLPE POSTERIOR STABILIZE LEGION",SUP-71453248,CDM,C1776,HCPCS,0278,RC,,,both,,,14831.55,4449.46,"UHC [10700]","United Healthcare",,9388.37,63.3,,8601.07,8395.67,8601.07,"1 through 10",1724.91,12606.82,"percent of total billed charges",
"SEALER BIPOLAR 12.5IN .283IN DISSECT DISPOSABLE AQUAMANTYS",SUP-23-317-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,4416.00,1324.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1814.98,41.1,,,,,0,513.58,3753.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Stoma W Inj",PX-750000164,CDM,44404,CPT,0750,RC,,,both,,,2630.79,789.24,"BLUE CROSS [10001]","Blue Cross PPO",,2630.79,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,305.96,2630.79,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR JL4.5 CURVE GUIDING CORONARY",SUP-LA7JL45SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL E 68X61.5MM KNEE LEFT SET SCR CEMENT REVISION",SUP-00599401591,CDM,C1776,HCPCS,0278,RC,,,both,,,41440.14,12432.04,"KAISER [10500]",Kaiser,,27764.89,67,,,,,0,4819.49,35224.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DAT015 AS UVA VIVITY",SUP-DAT015,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"CIGNA [10200]","Cigna Open Access",,480.81,56.9,,,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE COMPRESSION MEDIUM THIGH HIGH SCD EXPRESS",SUP-9530,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.33,61.9,"CIGNA [10200]","Cigna Local Plus",,110.39,53.5,,,,,0,24,175.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM CHARLOTTE CLAW FOOT HEXAGONAL LOCKING",SUP-40133522,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"EPL 7F DEC 2/5 2M 115 MEDSWP",SUP-401582R,CDM,S27200284,LOCAL,0272,RC,,,both,,,2625.00,787.5,"PHCS [10601]",PHCS,,1837.5,70,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL FUZEFIX MINI OD2.5 MM PROXIMAL HEADLESS NONS",SUP-CD-FX-2525,CDM,S27000186,LOCAL,0270,RC,,,both,,,2130.00,639,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,252.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 24MM 20D OBLIQUE FULL AUG STERILE LATEX FREE",SUP-AR-9580-2420,CDM,C1776,HCPCS,0278,RC,,,both,,,11571.30,3471.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3124.25,27,,,,,0,1345.74,9835.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTIGRAFT CERVICAL LARGE PARALLEL 14X14.5X9MM",SUP-VG2C-DR9P,CDM,S27800098,LOCAL,0278,RC,,,both,,,6077.73,1823.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,720.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,706.84,5166.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE DESTINATION STRAIGHT 65CM 35CM 8FR GUIDING",SUP-54-86501,CDM,C1887,HCPCS,0272,RC,,,both,,,769.50,230.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 22CM FEMUR PROXIMAL TALON DISTALFIX",SUP-SLN-120-220,CDM,C1713,HCPCS,0278,RC,,,both,,,13227.30,3968.19,"BLUE CROSS [10001]","Blue Cross PPO",,5185.1,39.2,,957.42,570.23,957.42,28,1538.33,11243.21,"percent of total billed charges",
"COIL EMBOLIZATION 10CM 4MM CONCERTO 3D",SUP-PV-4-10-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0256,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross HMO",,371.5,39.2,,957.42,156.86,7483.26,51,110.22,805.55,"percent of total billed charges",
"HC Morpho Anlys in Situ Manual",PX-310000003,CDM,88369,CPT,0310,RC,,,both,,,529.10,158.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,150.41,,,,,,,0.01,449.74,"fee schedule",
"CATH R2P METACROSS 200CM 80MM 7MM BALLOON DILATATION",SUP-BD-P70080ER,CDM,C1769,HCPCS,0272,RC,,,both,,,2028.75,608.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,833.82,41.1,,,,,0,235.94,1724.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo Small Intest Cntrl Bld",PX-750000206,CDM,44366,CPT,0750,RC,,,both,,,3668.65,1100.59,"MULTIPLAN [10600]",Multiplan,,3118.35,85,,,,,0,426.66,3668.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 80CM 8FR STRAIGHT URETERAL PERCUFLEX HYDROPLUS CLOSED",SUP-M0061602350,CDM,C2617,HCPCS,0278,RC,,,both,,,1537.95,461.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1045.81,68,,,,,0,178.86,1307.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3.5MM 12/14 SHORT NECK TAPER 36MM BIOLOX DELTA",SUP-PHA04414,CDM,C1776,HCPCS,0278,RC,,,both,,,14234.70,4270.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1686.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1655.5,12099.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD SMALL 5.5MM TSRH-3D OPEN OFFSET TITANIUM POSTERIOR",SUP-8379120,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"FIRST HEALTH [10303]","First Health",,2850,80,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 25MM TITANIUM CIRCLE LINEAR CUTTER SQUEEZE",SUP-EEAORVIL25,CDM,S27200284,LOCAL,0272,RC,,,both,,,637.79,191.34,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,292.75,45.9,,,,,0,74.17,542.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 40MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025040M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"KAISER [10500]",Kaiser,,960.58,67,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850017540,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross HMO",,2569.56,39.2,,957.42,156.86,7483.26,51,762.35,5571.75,"percent of total billed charges",
"INSRT ARTICULAR 5-6 21MM KNEE POSTERIOR STABILIZE UHMWPE",SUP-71420840,CDM,C1776,HCPCS,0278,RC,,,both,,,11416.05,3424.81,"FIRST HEALTH [10303]","First Health",,9132.84,80,,,,,0,1327.69,9703.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTAZIDIME 2 G/10ML IV (WET SOLR VIAL)",RX-4159476,CDM,J0713,HCPCS,0636,RC,00409-5084-11,NDC,both,1,UN,86.54,25.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,15.73,,,,,,,6.91,73.56,"fee schedule",
"STENT EPIC 120MM 75CM 8MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200081270,CDM,C1876,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"MULTIPLAN [10600]",Multiplan,,3665.63,85,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DICLOXACILLIN 250 MG CAPSULE",RX-2414,CDM,,,0637,RC,00093-3123-01,NDC,both,1,UN,7.56,2.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3.47,45.9,,,,,0,0.88,6.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 5CM 4FR STRAIGHT PANCREATIC POLYMER NO LEAD",SUP-M00537480,CDM,C2625,HCPCS,0278,RC,,,both,,,1411.18,423.35,"CIGNA [10200]","Cigna Local Plus",,754.98,53.5,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 36MM 2 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-42F36V,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 4MM X 10CM",SUP-M0035474100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS RX 135CM 120MM 5.7-3.9FR 5MM BALLOON",SUP-BD-L50120CR,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.5,41.1,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VOID FILLER SYNTHETIC NANOSS 3D PLUS 10CC",SUP-90-400-251004,CDM,C1713,HCPCS,0278,RC,,,both,,,12765.00,3829.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1484.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1484.57,10850.25,"percent of total billed charges",
"CATH OPN NC 20MM 4.5MM 35 ATM BALLOON DILATATION THIN WALL",SUP-450-020-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"NOVANET [10819]",Novanet,,6210,75,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 240MM 2MM BALLOON DILATATION STERILE LATEX",SUP-582024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 15MM 3.5MM BALLOON DILATATION STERILE",SUP-235-153-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 7X 38MM CATH 120CM ENDOVASCULAR",SUP-42738,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"FIRST HEALTH [10303]","First Health",,14016.24,80,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC",863,MS-DRG,,,,,,,inpatient,,,38004.56,11401.37,"AETNA [10100]","Aetna HMO/PPO",,18775.49,,"Fee schedule rate ($18,775.49). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,6190.04,24886.63,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 7MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650807,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5250.9,40,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 170MM FEMUR PROXIMAL TFN-ADVANCED LATERAL RELIEF",SUP-04.037.042S,CDM,C1713,HCPCS,0278,RC,,,both,,,8273.93,2482.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5626.27,68,,,,,0,962.26,7032.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM CREO SPINE POLYAXIAL FENESTRATE THREAD",SUP-5192.1547,CDM,C1713,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1925.41,28.62,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PERIPHERAL L60MM DIA8MM CATHETER L80CM ILIAC LIFESTAR",SUP-VIUS08060,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rubeola Ab",PX-302000162,CDM,86765,CPT,0302,RC,,,both,,,265.05,79.51,"KAISER [10500]",Kaiser,,177.58,67,,,,,0,0.01,225.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32MM AFFIXUS 3.5MM HIP FEMUR CORTICAL HEXAGONAL",SUP-814550032,CDM,C1713,HCPCS,0278,RC,,,both,,,2081.25,624.37,"PHCS [10601]",PHCS,,1456.88,70,,,,,0,242.05,1769.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vest Spu Sml 22-33 In",PX-E27000215,CDM,E27000215,LOCAL,0270,RC,,,both,,,466.00,139.8,"CIGNA [10200]","Cigna Local Plus",,249.31,53.5,,,,,0,54.2,396.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELIANCE 4 FRONT PASSIVE FIXATION SINGLE COIL 70CM",SUP-0650,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6238.98,41.1,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"O.R. PROCEDURES FOR OBESITY WITH MCC",619,MS-DRG,,,,,,,inpatient,,,114444.88,34333.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,26044.35,,"Fee schedule rate ($26,044.35). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,10994,84300.53,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 320MM FEMORAL PROXIMAL TFN-ADVANCED INTRAMEDULLARY",SUP-04.037.253S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"PHCS [10601]",PHCS,,8692.84,70,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.75MM X 12.0MM",SUP-493751212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE RIB SEG THK1-20MM ALLOGRAFT FROZEN 50-300X5-30MM",SUP-450010,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 3MM MATCH HEAD DISSECTING DIAMOND",SUP-MR8-9MH30D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1326.78,398.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,157.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.3,1127.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 37MM 26.1MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-37MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]",Cigna,,11647.69,40,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.145 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.145,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL RESTORIS 5 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-180605,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"CIGNA [10200]","Cigna Local Plus",,3545.69,53.5,,5372.07,4581.20,7242.98,23,770.77,5633.33,"percent of total billed charges",
"POST OP BRA 34C BLACK","SUP-B0G134C B",CDM,S27000186,LOCAL,0270,RC,,,both,,,373.23,111.97,"CIGNA [10200]",Cigna,,253.8,68,,,,,0,43.41,317.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PROGRESS 40 VASCULAR STRAIGHT 190CM 3CM .014",SUP-1011836,CDM,C1769,HCPCS,0272,RC,,,both,,,1036.80,311.04,"KAISER [10500]",Kaiser,,694.66,67,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 3.3MM 36MM STARDRIVE NAIL-EX TITANIUM 7%",SUP-04.005.426,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,134.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",134.52,983.18,"percent of total billed charges",
"GWIRE SAFE-T-J VASCULAR 3MM RADIUS J CURVE TAPER 145CM 6CM",SUP-G00488,CDM,C1769,HCPCS,0272,RC,,,both,,,147.81,44.34,"PHCS [10601]",PHCS,,103.47,70,,,,,0,17.19,125.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 FULL THREAD CORKSCREW II FIBERWIRE 3",SUP-AR-1928SF-3,CDM,C1713,HCPCS,0278,RC,,,both,,,1929.38,578.81,"BLUE CROSS [10001]","Blue Cross PPO",,756.32,39.2,,957.42,570.23,957.42,28,224.39,1639.97,"percent of total billed charges",
"SCR BONE 2.4MM 20MM LCP TITANIUM DISTAL HUMERAL CORTICAL",SUP-401.770,CDM,C1713,HCPCS,0278,RC,,,both,,,455.87,136.76,"CIGNA [10200]",Cigna,,309.99,68,,1831.33,1831.33,1831.33,16,53.02,387.49,"percent of total billed charges",
"TUBE FEEDING ORANGE 16IN 6.5FR ENTERAL POLYURETHANE HUB END",SUP-ENFPU1665LD,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.55,17.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.81,49.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fibrinolysis Act Nos Analyte",PX-305000069,CDM,85397,CPT,0305,RC,,,both,,,135.20,40.56,"UHC [10700]","United Healthcare",,27.77,,,,,,,0.01,114.92,"fee schedule",
"STENT ONYX FRONTIER 12MM 3.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG35012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"MULTIPLAN [10600]",Multiplan,,2231.25,85,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 240MM 2MM BALLOON DILATATION STERILE LATEX",SUP-582024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 480-510ML STYLE 68MP SMOOTH ANTERIOR DIAPH VALVE",SUP-68-480,CDM,C1789,HCPCS,0278,RC,,,both,,,2250.00,675,"CIGNA [10200]","Cigna Local Plus",,1203.75,,,,,,,261.68,1912.5,"percent of total billed charges",
"STENT EVERFLEX 20MM 120CM 6MM VASCULAR PERIPHERAL SELF",SUP-PRB35-06-020-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"FIRST HEALTH [10303]","First Health",,4452,80,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 NARROW KNEE LEFT CRUCIATE RETAIN CEMENT",SUP-42-5020-064-01,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2709.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 35MM VIVACIT-E ALL POLY KNEE LATEX FREE",SUP-42540200035,CDM,C1776,HCPCS,0278,RC,,,both,,,5322.66,1596.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,630.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,619.03,4524.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENCIL SMOKE EVAC 70MM NEPTUNE ROCKER SWITCH COATED SUCTION",SUP-0703-047-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"AETNA [10100]","Aetna HMO/PPO",,193.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM EDWARDS SAPIEN ASCENDRA PLUS TRANSAPICAL",SUP-9355ASP29A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"FIRST HEALTH [10303]","First Health",,148200,80,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 175MM 12MM SMALL SHELL REVISION ALTIVATE",SUP-533-12-175,CDM,C1776,HCPCS,0278,RC,,,both,,,43228.40,12968.52,"BLUE CROSS [10001]","Blue Cross HMO",,16945.53,39.2,,5311.50,4717.44,5388.59,31,5027.46,36744.14,"percent of total billed charges",
"REAMER SURGICAL CENTERING PIN 4.5 MM SCREWS NONSTERILE",SUP-309.470,CDM,S27000186,LOCAL,0270,RC,,,both,,,961.31,288.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.8,817.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 5FR 3MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206030410,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GUARD PIN YELLOW JURGAN PIN BALL .054IN KIRSCHNER WIRE W",SUP-W045-YL,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.50,21.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 7FR ELECTROPHYSIOLOGY DUO DECAPOLAR",SUP-D139801,CDM,C1731,HCPCS,0272,RC,,,both,,,7086.30,2125.89,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 6.5MM 60MM TITANIUM TIBIA CANCELLOUS OPENING WEDGE",SUP-AR-13280-60,CDM,C1713,HCPCS,0278,RC,,,both,,,1968.75,590.62,"CIGNA [10200]","Cigna Open Access",,1120.22,56.9,,1144.80,304.56,2275.09,66,228.97,1673.44,"percent of total billed charges",
"IMPL BREAST 480-510ML STYLE 68MP SMOOTH ANTERIOR DIAPH VALVE",SUP-68-480,CDM,C1789,HCPCS,0278,RC,,,both,,,2250.00,675,"KAISER [10500]",Kaiser,,1507.5,67,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH RADIFOCUS 100CM 5FR SIM3 CURVE ANGIOGRAPHIC",SUP-CG512,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASCOPE 4 BRONCHO REGULAR SAMPLER SET",SUP-477501000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2010.00,603,"FIRST HEALTH [10303]","First Health",,1608,80,,,,,0,233.76,1708.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 3.5MM OASYS OCCIPITOCERVICOTHORACIC SPINE",SUP-48552050,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross PPO",,1728.72,39.2,,957.42,570.23,957.42,28,512.88,3748.5,"percent of total billed charges",
"BINDER ABDOMINAL 9IN ELASTIC PANEL CONTACT CLSR PROCARE",SUP-79-89071,CDM,S27000186,LOCAL,0270,RC,,,both,,,44.46,13.34,"FIRST HEALTH [10303]","First Health",,35.57,80,,,,,0,5.17,37.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT",RX-2888,CDM,,,0250,RC,00574-4024-11,NDC,both,1,GR,54.70,16.41,"AETNA [10100]","Aetna HMO/PPO",,43.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.36,46.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 9X40 40CM SL",SUP-48009004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"UHC [10700]","United Healthcare",,621.69,63.3,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET THORACENTESIS 10CM 5FR STRAIGHT 1 STEP VALVE CENTESIS",SUP-TAPS-5F-10LT,CDM,C1729,HCPCS,0272,RC,,,both,,,365.40,109.62,"PHCS [10601]",PHCS,,255.78,70,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 4FR 135CM POWERPICC 1 LUMEN MAXIMAL BARR NURSING",SUP-3174335,CDM,C1751,HCPCS,0272,RC,,,both,,,792.67,237.8,"MULTIPLAN [10600]",Multiplan,,673.77,85,,,,,0,92.19,673.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUMP INTRACARDIAC SUCTION ATRASUMP FLEXIBLE WEIGHTED TIP",SUP-SU-29602,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RONGEUR 9IN FULL CURVE HANDLE 8MM LEKSELL 2 ACTION SURGICAL",SUP-31-5308,CDM,S27200284,LOCAL,0272,RC,,,both,,,1635.83,490.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STY LD 59CM .016IN FIRM KNOB",SUP-6604,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER BIPOLAR AQUAMAN MALLEABLE",SUP-23-301-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3607.50,1082.25,"AETNA [10100]","Aetna HMO/PPO",,2867.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,419.55,3066.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 15MM 3.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG35015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2662.50,798.75,"KAISER [10500]",Kaiser,,1783.88,67,,,,,0,309.65,2263.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL DUALMESH PLUS 10X7.5CM SOFT TISSUE BIOMATERIAL",SUP-1DLMCP05,CDM,C1781,HCPCS,0278,RC,,,both,,,2655.00,796.5,"KAISER [10500]",Kaiser,,1778.85,67,,,,,0,308.78,2256.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERWIRE 2 38IN BRAID BLACK WHITE NONABSORBABLE",SUP-AR-7203,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.11,63.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,86.36,41.1,,,,,0,24.44,178.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RAMROD CLASSIC 24CM 6FR KIDNEY BLADDER CURL URETERAL",SUP-5606024,CDM,C2617,HCPCS,0278,RC,,,both,,,910.00,273,"BLUE CROSS [10001]","Blue Cross HMO",,356.72,39.2,,,,,0,105.83,773.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 150MM 120CM 6MM VASCULAR PERIPHERAL SELF",SUP-PRB35-06-150-120,CDM,C1876,HCPCS,0278,RC,,,both,,,7560.00,2268,"PHCS [10601]",PHCS,,5292,70,,,,,0,879.23,6426,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL KNEE 12.5MM PFC TC3 SIGMA 4 TIBIAL FIX BEARING INSERT",SUP-961541,CDM,C1776,HCPCS,0278,RC,,,both,,,676.35,202.9,"CIGNA [10200]","Cigna Local Plus",,361.85,53.5,,5372.07,4581.20,7242.98,23,78.66,574.9,"percent of total billed charges",
"HAND PROCEDURES FOR INJURIES",906,MS-DRG,,,,,,,inpatient,,,67276.32,20182.9,"AMBETTER EXCHANGE  [11102]",Ambetter,,12184.67,,"Case rate ($12,184.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,314.29, add-ons for qualifying new technology services are included. If operating cost exceeds $44,353.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,237.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,329.26. The transfer operating threshold is the transfer adjustment factor * $11,314.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.42. The transfer capital threshold is the transfer adjustment factor * $855.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,57349.7,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM ARTHREX SWIVELOCK 2 LOAD PEEK STERILE",SUP-AR-2324PSLC-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,3110.63,933.19,"CIGNA [10200]","Cigna Local Plus",,1664.19,53.5,,,,,0,361.77,2644.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 50MM 15MM CEMENTED TOTAL STABILIZED TRIATHLON",SUP-5560-S-115,CDM,C1776,HCPCS,0278,RC,,,both,,,4271.90,1281.57,"PHCS [10601]",PHCS,,2990.33,70,,,,,0,496.82,3631.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM OFFSET 28MM HIP MODULAR TYPE 1 BIOLOX",SUP-650-1159,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"CIGNA [10200]","Cigna Local Plus",,5274.42,53.5,,5372.07,4581.20,7242.98,23,1146.57,8379.91,"percent of total billed charges",
"CANN ARTHROSCOPIC 8.5MM COMPLETE SYSTEM 45MM CLEAR-TRAC",SUP-72200904,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"CIGNA [10200]","Cigna Local Plus",,111.71,53.5,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRICUSPID GUIDE CATHETER",SUP-29000,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 8X40 135CM SL",SUP-48008004R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,353.05,41.1,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 27.5MM VICTORY SPINE SELF TAP NONSTERILE",SUP-1236.4027,CDM,C1713,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]",Cigna,,2295,68,,1831.33,1831.33,1831.33,16,392.51,2868.75,"percent of total billed charges",
"HC Q Fever (Coxiella) Ab",PX-302000109,CDM,86638,CPT,0302,RC,,,both,,,320.15,96.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,272.13,"per diem",
"FRCP SPECIMEN RETRIEVAL 58CM 5FR GRASPING 4 PRONG",SUP-GF558,CDM,S27000186,LOCAL,0270,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 80CM 6FR 13MM ROUND EMBOLECTOMY STAINLESS STEEL",SUP-120806F,CDM,C1757,HCPCS,0272,RC,,,both,,,376.01,112.8,"UHC [10700]","United Healthcare",,238.01,63.3,,,,,0,43.73,319.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1.5CM 2MM GALAXY G3 XTRASOFT NEUROVASCULAR",SUP-GLX120201,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1381.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL DUALMESH 24X18CM SOFT TISSUE BIOMATERIAL",SUP-1DLMC06,CDM,C1781,HCPCS,0278,RC,,,both,,,8894.10,2668.23,"CIGNA [10200]","Cigna Open Access",,5060.74,56.9,,11235.02,819.42,11235.02,"1 through 10",1034.38,7559.99,"percent of total billed charges",
"GRAFT BONE CORTICAL BONE FIBER 2.5CC ALLOGRAFT MOLDABLE",SUP-423202,CDM,C1713,HCPCS,0278,RC,,,both,,,3967.50,1190.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,470.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,461.42,3372.38,"percent of total billed charges",
"SCR BONE 4MM 38MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.438TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,239.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",235.11,1718.32,"percent of total billed charges",
"SET DRILL 2.4MM TRANSFIX II ACL GRAFT PASS WIRE PIN STERILE",SUP-AR-1978S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1292.76,387.83,"UHC [10700]","United Healthcare",,818.32,63.3,,,,,0,150.35,1098.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE SHEET 4X10CM DEHYDRATED AMNION/CHORION ME",SUP-APS-5610,CDM,Q4433,HCPCS,0636,RC,,,both,,,26970.30,8091.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12069.21,44.75,,,,,0,247.92,22924.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL TISSUE ALLOGRAFT BLOCK 60MM",SUP-800129,CDM,S27800098,LOCAL,0278,RC,,,both,,,15794.10,4738.23,"AETNA [10100]","Aetna HMO/PPO",,12556.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1836.85,13424.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 90MM STEALTH 5 FIBRA STERILE LATEX FREE",SUP-A0G14,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 25MM X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-325,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"PHCS [10601]",PHCS,,9420.92,70,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLATOR AIRWAY ENDOTRACHEAL TUBE STD MANOMETER AIR VENT",SUP-8199,CDM,S27200284,LOCAL,0272,RC,,,both,,,1547.26,464.18,"FIRST HEALTH [10303]","First Health",,1237.81,80,,,,,0,179.95,1315.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 27CM 8MM AVENIR 18 COIL COMPLEX FRAME",SUP-18CFR-08027,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"MULTIPLAN [10600]",Multiplan,,11114.18,85,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE  VIATORR TIPS ENDOPROSTHESIS WITH CONTROLLED EXPANSION,",SUP-PTB6106275,CDM,C1874,HCPCS,0278,RC,,,both,,,33364.80,10009.44,"BLUE CROSS [10001]","Blue Cross HMO",,13079,39.2,,9776.84,9776.84,9776.84,"1 through 10",3880.33,28360.08,"percent of total billed charges",
"LEAD ICD 64CM ENDOTAK RELIANCE 4 SITE ENDOCARDIAL STEROID",SUP-276,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"KAISER [10500]",Kaiser,,10170.6,67,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 55CM RIGHT VENTRICLE DF-4 TRIPOLAR SCR DEFIB",SUP-6935M55,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7057.69,41.1,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN IRRIGATION 25MM 19GA BISHOP-HARMON 30D STAINLESS STEEL",SUP-E4922,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.74,53.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,82.5,45.9,,,,,0,20.9,152.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI FIELDER XT-R 190CM",SUP-APW14R005S,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"MULTIPLAN [10600]",Multiplan,,963.9,85,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 3X32+TRAK21 2-PACK - US",SUP-91312,CDM,S27200284,LOCAL,0272,RC,,,both,,,24624.97,7387.49,"NOVANET [10819]",Novanet,,18468.73,75,,,,,0,2863.88,20931.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 22CM 5FR .035",SUP-M006192121090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"CIGNA [10200]","Cigna Open Access",,849.19,,,,,,,173.57,1268.57,"percent of total billed charges",
"KIT CATH 75CM 15FR CARBOTHANE 2.5ML PALINDROME TNLR SEAL CAP",SUP-8888541055P,CDM,C1750,HCPCS,0278,RC,,,both,,,2669.19,800.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,316.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,310.43,2268.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 30MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE45030,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,34386.15,41.1,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 30MM 4MM BALLOON DILATATION DURALYN",SUP-48004003X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"KAISER [10500]",Kaiser,,841.19,67,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) QUALIBREATH",SUP-QB-XS,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"FIRST HEALTH [10303]","First Health",,663.55,80,,,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 100MM 16MM NEXGEN STRAIGHT KNEE ROTATE HINGE 145MM",SUP-00598801016,CDM,C1776,HCPCS,0278,RC,,,both,,,8049.54,2414.86,"CIGNA [10200]","Cigna Local Plus",,4306.5,53.5,,5372.07,4581.20,7242.98,23,936.16,6842.11,"percent of total billed charges",
"MTRL SPLINTING THK1/8IN SMALL STATURE 24X18IN OPTIPERF",SUP-550549,CDM,S27000186,LOCAL,0270,RC,,,both,,,630.50,189.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,428.74,68,,,,,0,73.33,535.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 95MM STAINLESS STEEL 2.4/3.5MM SCR 5 HOLE SHAFT LCP",SUP-02.110.105,CDM,C1713,HCPCS,0278,RC,,,both,,,8550.14,2565.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2447.05,28.62,,,,,0,994.38,7267.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 40MM 5.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE52540,CDM,C1876,HCPCS,0278,RC,,,both,,,90839.19,27251.76,"CIGNA [10200]","Cigna Local Plus",,28614.34,31.5,,,,,0,10564.6,77213.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Fem Art Perc Bio-Med 21f",PX-E27200381,CDM,E27200381,LOCAL,0272,RC,,,both,,,1442.10,432.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,661.92,45.9,,,,,0,167.72,1225.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX CORE REINFORCED TISSUE MATRIX, LONG-TERM RESORBABLE R",SUP-F10264-0610G,CDM,C1781,HCPCS,0278,RC,,,both,,,3690.00,1107,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2509.2,68,,,,,0,429.15,3136.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARCADIA 20MM BALLOON DILATATION HIGH PRESSURE RESHEATH",SUP-ARC20SB,CDM,S27200284,LOCAL,0272,RC,,,both,,,6555.00,1966.5,"NOVANET [10819]",Novanet,,4916.25,75,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 16MM 2.4FR SEGURA HEMISPHERE",SUP-M0063801060,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DIAMONDBACK 360 145CM 30MM .079IN 2MM .014IN",SUP-DBP-CART-200SOL145,CDM,C1724,HCPCS,0272,RC,,,both,,,17250.00,5175,"PHCS [10601]",PHCS,,12075,70,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 270MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.334S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5652.45,68,,,,,0,966.74,7065.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM INTERLOCK IDC OCCLUSION SYSTEM",SUP-M001363550,CDM,S27800098,LOCAL,0278,RC,,,both,,,3891.60,1167.48,"CIGNA [10200]",Cigna,,2646.29,68,,,,,0,452.59,3307.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ORTHOCORD 2 MO-7 36IN BRAIDED BLUE VIOLET NONABSORBABLE",SUP-223114,CDM,S27200284,LOCAL,0272,RC,,,both,,,517.05,155.11,"FIRST HEALTH [10303]","First Health",,413.64,80,,,,,0,60.13,439.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 8MM 7FR 1-7-4MM SPACE J CURVE ABLATION",SUP-NS7TCJ8L174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"AETNA [10100]","Aetna HMO/PPO",,12616.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30MMX10MM VERTE-STACK CRESCENT LUMBAR",SUP-293010,CDM,S27800098,LOCAL,0278,RC,,,both,,,24290.28,7287.08,"BLUE CROSS [10001]","Blue Cross HMO",,9521.79,39.2,,,,,0,2824.96,20646.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TISSUE CLSR PROGEL PLEURA SEAL ADHSV AIR LEAK 4ML",SUP-PGPS002,CDM,S27200284,LOCAL,0272,RC,,,both,,,8119.23,2435.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5521.08,68,,,,,0,944.27,6901.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC ELECTROSURGICAL 10FT BEND-A-BEAM CORD 6IN STERILE",SUP-134006,CDM,S27200284,LOCAL,0272,RC,,,both,,,910.44,273.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,107.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.88,773.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 20MM PINNACLE GRIPTION TF DOME 4 POINT CUT",SUP-121720500,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"MULTIPLAN [10600]",Multiplan,,974.23,85,,,,,0,133.3,974.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM SMR TITANIUM SHOULDER MODULAR",SUP-8420.15.020,CDM,C1713,HCPCS,0278,RC,,,both,,,550.80,165.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,374.54,68,,,,,0,64.06,468.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Maternity Care Procedure Unlisted",PX-361000670,CDM,59899,CPT,0361,RC,,,both,,,6106.00,1831.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1249,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,710.13,6106,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 60X18X11MM TRANSCONTINENTAL 0D CORONAL TAPER",SUP-375.893,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6463.8,27,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ORTHOPEDIC LARGE LUMBOSACRAL 2 STRAP COMPRESSION PAD",SUP-79-89357,CDM,S27000186,LOCAL,0270,RC,,,both,,,145.81,43.74,"KAISER [10500]",Kaiser,,97.69,67,,,,,0,16.96,123.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 10CM 8MM 6FR BALLOON DILATATION",SUP-DR135810,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"KAISER [10500]",Kaiser,,922.59,67,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Test Sleep Attnd Incomplt",PX-740000003,CDM,95807,CPT,0920,RC,,,both,,,6574.00,1972.2,"CIGNA [10200]","Cigna Open Access",,1451,,"Per diem ($1,451).",,,,0,764.56,5587.9,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL ARTICUL/EZE CERAMIC +5 OD40 MM",SUP-473440050,CDM,C1776,HCPCS,0278,RC,,,both,,,17961.30,5388.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4849.55,27,,,,,0,2088.9,15267.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 10MM 2.5MM BALLOON DILATATION STERILE",SUP-225-103-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3DMAX MID MESH LARGE LEFT",SUP-0116311,CDM,C1781,HCPCS,0278,RC,,,both,,,1881.75,564.52,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,863.72,45.9,,,,,0,218.85,1599.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-2-2-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1385.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 5/64IN THREAD 9IN STEINMANN NONSTERILE",SUP-KM169-39-56,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"FIRST HEALTH [10303]","First Health",,50.89,80,,,,,0,7.4,54.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR LNCS NEO-3 3FT ASSORTED OXIMETER LOW NOISE CABLED SOL",SUP-2320,CDM,S27000186,LOCAL,0270,RC,,,both,,,82.65,24.79,"NOVANET [10819]",Novanet,,61.99,75,,,,,0,0.58,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 20MM 2.5MM .014IN BALLOON DILATATION",SUP-AB14W030020150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"PHCS [10601]",PHCS,,969.57,70,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BN 2.3MM 10MM LEIBINGER UNV 2",SUP-50-23410,CDM,C1713,HCPCS,0278,RC,,,both,,,559.22,167.77,"CIGNA [10200]",Cigna,,380.27,68,,1831.33,1831.33,1831.33,16,65.04,475.34,"percent of total billed charges",
"LENS IOL 5 D +14 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-AR40E00140,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"CIGNA [10200]","Cigna Open Access",,530.02,56.9,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK12MM 51X74MM GALLANT HF IS-1 IS-4 DF-4 CNCT",SUP-CDHFA500Q,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"MULTIPLAN [10600]",Multiplan,,65407.5,85,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 8MM 86MM 10.9MM PER-FIT OBTR DIL INNER CANN",SUP-536080,CDM,S27200284,LOCAL,0272,RC,,,both,,,1079.41,323.82,"AETNA [10100]","Aetna HMO/PPO",,858.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,125.54,917.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER SUT 30MM 7MM TIP CUTTING DISPOSABLE",SUP-691.002S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"CIGNA [10200]",Cigna,,1147.5,68,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION ARCHON ACP SPINE TEMPORARY",SUP-8789733,CDM,C1713,HCPCS,0278,RC,,,both,,,1424.81,427.44,"NOVANET [10819]",Novanet,,1068.61,75,,,,,0,165.71,1211.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 8MM CR VERTEBRAL LORDOTIC CRESCENT NONSTERILE",SUP-889.924,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Hip Bil 3-4v",PX-320000207,CDM,73522,CPT,0320,RC,,,both,,,647.10,194.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.72,550.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 32MM 1 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-41F32V,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transducer Truwave Dpt",PX-E27200342,CDM,E27200342,LOCAL,0272,RC,,,both,,,63.80,19.14,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE AMPLATZ VASCULAR STRAIGHT 145CM .035IN PTFE STAINLESS",SUP-G09954,CDM,C1769,HCPCS,0272,RC,,,both,,,239.16,71.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION",RX-186564,CDM,,,0250,RC,00264-4500-00,NDC,both,1000,ML,241.44,72.43,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dressing Sasorb Mextra 9x13in",PX-E27200409,CDM,E27200409,LOCAL,0272,RC,,,both,,,39.81,11.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Xr Sacroiliac Jt <3v",PX-320000050,CDM,72200,CPT,0320,RC,,,both,,,374.86,112.46,"AETNA [10100]","Aetna HMO/PPO",,298.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.75,318.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL TAN 110MM 10.35MM TFN-ADVANCED",SUP-04.038.410S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"AETNA [10100]","Aetna HMO/PPO",,3165.57,79.5,,1521.93,481.35,16760.95,30,463.09,3384.57,"percent of total billed charges",
"STENT GEENEN 5CM 7FR PANCREATIC POLYETHYLENE PUSH CATH DRAIN",SUP-G21374,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA [10200]","Cigna Local Plus",,338.01,,,,,,,73.48,537.03,"percent of total billed charges",
"KIT ENDOSCOPIC EMR KIT 165CM 13.9MM RIM DYE SPRAY CATH",SUP-K-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1489.02,446.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,173.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.17,1265.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER CANNULATED SURGICAL THREAD WASHER",SUP-314.464,CDM,S27000186,LOCAL,0270,RC,,,both,,,1672.20,501.66,"NOVANET [10819]",Novanet,,1254.15,75,,,,,0,194.48,1421.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE V-14 CONTROLWIRE VASCULAR SHORT TAPER 300CM 8CM .014IN",SUP-H74939216730020,CDM,C1769,HCPCS,0272,RC,,,both,,,753.30,225.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,89.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM TI HARD ROD 100MM",SUP-498.104,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"CATH LEMAITRE 80CM 6FR 13.5MM EMBOLECTOMY 16ML STERILE LATEX",SUP-E1601-68,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,71.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ELECTROSURGICAL 32CM 5MM ULTRACISION TITANIUM CURVED",SUP-HC325,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.41,432.72,"NOVANET [10819]",Novanet,,1081.81,75,,,,,0,167.75,1226.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH XXL 75CM 40MM 5.8FR 14MM .035IN BALLOON DILATATION",SUP-M001145140,CDM,C1725,HCPCS,0272,RC,,,both,,,1709.63,512.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,198.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,198.83,1453.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FROZEN 120MMX5+ MM",SUP-450633,CDM,S27800098,LOCAL,0278,RC,,,both,,,5547.60,1664.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,657.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,645.19,4715.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION",RX-227101,CDM,,,0250,RC,00517-9305-01,NDC,both,1,ML,170.16,51.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,115.71,68,,,,,0,19.79,144.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTMASTER 16MM 2.8MM CORONARY STENT STAINLESS STEEL",SUP-1012580-16,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"CIGNA [10200]",Cigna,,6610.2,40,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 37MM FULL FLEXIBLE MARKER SIMULUS",SUP-700FF37,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"FIRST HEALTH [10303]","First Health",,10488,80,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 10CM 5FR ANGLE BERENSTEIN CURVE",SUP-H787107221025,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,147.9,68,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE POSITIONING 22X20X8IN TUMBLE FORMS 2 VELCRO VINYL",SUP-2795C,CDM,S27000186,LOCAL,0270,RC,,,both,,,1124.69,337.41,"NOVANET [10819]",Novanet,,843.52,75,,,,,0,130.8,955.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 6MM 16MM TITANIUM 2.5MM FULL THREAD CORTEX",SUP-404.816,CDM,C1713,HCPCS,0278,RC,,,both,,,258.83,77.65,"CIGNA [10200]","Cigna Local Plus",,138.47,53.5,,3978.14,359.25,3978.14,24,30.1,220.01,"percent of total billed charges",
"CATH DAC 125CM 3.9FR .038IN GUIDING DISTAL ACCESS STERILE",SUP-90720,CDM,S27200284,LOCAL,0272,RC,,,both,,,9626.67,2888,"CIGNA [10200]","Cigna Local Plus",,5150.27,53.5,,,,,0,1119.58,8182.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 171MM CEMENT AVENIR PROTASUL-S30 8 43.66MM STD",SUP-01.06010.208,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 3 8.75IN BARNHILL ADENOID SURGICAL 16MM",SUP-71-3616,CDM,S27200284,LOCAL,0272,RC,,,both,,,299.98,89.99,"FIRST HEALTH [10303]","First Health",,239.98,80,,,,,0,34.89,254.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL 12D ALLOGRAFT 28X26X12MM ALIF",SUP-3W4212,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"AETNA [10100]","Aetna HMO/PPO",,16810.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? TOWER CABLE PLATE KIT",SUP-94-1600-05,CDM,C1713,HCPCS,0278,RC,,,both,,,9501.30,2850.39,"BLUE CROSS [10001]","Blue Cross HMO",,3724.51,39.2,,957.42,156.86,7483.26,51,1105,8076.11,"percent of total billed charges",
"INSRT TIBIAL 1.5 CURVE PLUS 8MM KNEE XLK FIX BEARING SIGMA",SUP-970420,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PHCS [10601]",PHCS,,7822.19,70,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 11MM KNEE BEARING CRUCIATE RETAIN TRIATHLON",SUP-5530-G-311-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"BLUE CROSS [10001]","Blue Cross HMO",,4473.74,39.2,,5311.50,4717.44,5388.59,31,1327.29,9700.71,"percent of total billed charges",
"CATH SUPER TORQUE 100CM 6FR .051IN .042IN INTERNAL MAMMARY",SUP-532660,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT ENDOSCP ELLIPSYS S 21 GAX7 CM ECHO-TIP MICROPUNCTURE NDL",SUP-K21-00022,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC",002,MS-DRG,,,,,,,inpatient,,,337005.87,101101.76,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES,MINOR",143,APR-DRG,,,,,,,inpatient,,,27022.55,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $3,240.66. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%.",,,,0,,,other,"SOI-1 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CSGWORBC19M SAFESHTH GDE",SUP-CSGWORBC19M,CDM,C1892,HCPCS,0272,RC,,,both,,,2887.50,866.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 1.5MM 9MM APTUS TRILOCK TITANIUM PHALANGEAL HAND",SUP-A-5250.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTTER SUT REMOVAL MENISCAL CINCH KNOT PUSHER 2-0 FIBERWIRE",SUP-AR-4515,CDM,S27200284,LOCAL,0272,RC,,,both,,,1063.13,318.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ASAHI TORNUS 135CM 2.1FR .014IN BRAID THREAD GUIDING",SUP-82380-01,CDM,C1887,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD SUT ASSISTANT 10MM 3-0 ES-9 7IN 1 STITCH ENDO STITCH",SUP-170070,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT SNARE AMPLATZ GOOSENECK 120CM 4FR 10MM 1 CATH CABLE LOOP",SUP-GN1000,CDM,C1773,HCPCS,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT STIMULATOR PROXIMATE GENITOURINARY HANDSET NONSTERILE LA",SUP-TH90Q01,CDM,C1787,HCPCS,0270,RC,,,both,,,12420.00,3726,"AETNA [10100]","Aetna HMO/PPO",,9873.9,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC LARGE 7.75-8.5IN LEFT WRIST THUMB SPICA",SUP-A6157,CDM,S27000186,LOCAL,0270,RC,,,both,,,224.55,67.36,"MULTIPLAN [10600]",Multiplan,,190.87,85,,,,,0,26.12,190.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ARTHROSCOPIC STAINLESS STEEL 3.4MM HOOK 90D 5MM MARK",SUP-AR-10010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1428.84,428.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,169.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.17,1214.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK PHACOEMULSIFICATION .9MM INFINITI KELMAN 45D MINI",SUP-8065751722,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"CIGNA [10200]","Cigna Open Access",,414.8,56.9,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 400741  L SR SRVC FEE",SUP-400741,CDM,S27800098,LOCAL,0278,RC,,,both,,,4975.00,1492.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,589.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,578.59,4228.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 500MM 1.6MM KIRSCHNER BLUNT NITINOL",SUP-685.007,CDM,C1713,HCPCS,0278,RC,,,both,,,3326.40,997.92,"CIGNA [10200]","Cigna Local Plus",,1779.62,53.5,,3978.14,359.25,3978.14,24,386.86,2827.44,"percent of total billed charges",
"MENTOR MEMORYSHAPE BREAST IMPLANT TALL HEIGHT HIGH PROFILE S",SUP-334-1204,CDM,C1789,HCPCS,0278,RC,,,both,,,7583.10,2274.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,881.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,881.91,6445.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest Nrv Other Periph",PX-510000159,CDM,64640,CPT,0761,RC,,,both,,,8394.00,2518.2,"KAISER [10500]",Kaiser,,5623.98,67,,,,,0,976.22,7134.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL RAPIDE MULTIPASS 5-0 PC-1 18IN BRAID COATED",SUP-VR834,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.27,21.68,"FIRST HEALTH [10303]","First Health",,57.82,80,,,,,0,8.41,61.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH",RX-27696,CDM,,,0250,RC,00378-6470-16,NDC,both,1,UN,115.56,34.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,78.58,68,,,,,0,13.44,98.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TRIA 30CM 6FR URETERAL SOFT",SUP-M0061903250,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 14CM 14FR 18GA PEEL-AWAY 3MM .038IN TRANSSEPTAL",SUP-405136,CDM,C1892,HCPCS,0272,RC,,,both,,,261.00,78.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 8MM GORE STD WALL HEPARIN PROPATEN PTFE",SUP-H080040A,CDM,C1768,HCPCS,0278,RC,,,both,,,7562.40,2268.72,"CIGNA [10200]","Cigna Local Plus",,4045.88,53.5,,,,,0,879.51,6428.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISTAL BICEPS REPAIR STERILE KIT BLUE",SUP-DBR-BLU-01,CDM,C1713,HCPCS,0278,RC,,,both,,,10488.00,3146.4,"NOVANET [10819]",Novanet,,7866,75,,,,,0,1219.75,8914.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE LARGE XLONG FEMALE NAVY BLUE BREATHABLE",SUP-100347-040,CDM,S27000186,LOCAL,0270,RC,,,both,,,54.55,16.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.34,46.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 90MM 9MM 5.4MM 14FR ZENITH SPIRAL-Z",SUP-G55221,CDM,C1874,HCPCS,0278,RC,,,both,,,20160.00,6048,"BLUE CROSS [10001]","Blue Cross PPO",,7902.72,39.2,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC",761,MS-DRG,,,,,,,inpatient,,,25916.12,7774.84,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,8397.9,,"Case rate ($8,153.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,570.89, add-ons for qualifying new technology services are included. If operating cost exceeds $40,610.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,954.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,580.91. The transfer operating threshold is the transfer adjustment factor * $7,570.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.40. The transfer capital threshold is the transfer adjustment factor * $572.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,25916.12,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 10MM TITANIUM CRANIOFACIAL CORTICAL SELF",SUP-400360,CDM,S27800098,LOCAL,0278,RC,,,both,,,3937.14,1181.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,466.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,457.89,3346.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST TRICORTICAL THK10-12MM WEDGE",SUP-400402,CDM,S27800098,LOCAL,0278,RC,,,both,,,4719.60,1415.88,"BLUE CROSS [10001]","Blue Cross HMO",,1850.08,39.2,,,,,0,548.89,4011.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SUT 2 MAXBRAID",SUP-CM0222N,CDM,S27200284,LOCAL,0272,RC,,,both,,,631.80,189.54,"CIGNA [10200]","Cigna Open Access",,359.49,56.9,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 10CM 7MM BALLOON DILATATION PERIPHERAL",SUP-G50264,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest L/S Facet Jnt Add",PX-510000157,CDM,64636,CPT,0761,RC,,,both,,,1988.00,596.4,"FIRST HEALTH [10303]","First Health",,1590.4,80,,,,,0,231.2,1988,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX 12X10IN MONOFILAMENT SCAFFOLD FULL",SUP-1190500,CDM,C1781,HCPCS,0278,RC,,,both,,,63441.00,19032.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7517.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7378.19,53924.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC CLLGN POWDER SACHET STIMULEN 1GM",SUP-ST9501,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.27,41.48,"NOVANET [10819]",Novanet,,103.7,75,,,,,0,16.08,117.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER 13MM LCP ORTHOPEDIC STAINLESS STEEL 7.3MM CANNULATED",SUP-219.990,CDM,C1713,HCPCS,0278,RC,,,both,,,192.44,57.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,22.38,163.57,"percent of total billed charges",
"SET .28IN 85IN 4 LEAD 3Y CNCT SIGHT CHMBR LARGE BORE",SUP-1523901,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.63,40.09,"NOVANET [10819]",Novanet,,100.22,75,,,,,0,15.54,113.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 8CM 6FR 9MM .035IN BALLOON",SUP-G52288,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.47,41.1,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 87/91MMX16MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183586,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"MULTIPLAN [10600]",Multiplan,,6663.81,85,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 8 X 30 HELICAL FILLING COIL",SUP-10HFL-08030,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2565.24,28.62,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 20CM 5MM BALLOON DILATATION PERIPHERAL",SUP-G30958,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Debrisoft",PX-E27200435,CDM,E27200435,LOCAL,0272,RC,,,both,,,73.70,22.11,"CIGNA [10200]","Cigna Open Access",,41.94,56.9,,,,,0,8.57,62.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM AVENIR 10 COIL FINISH COMPLEX",SUP-10CFN-02006,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS [10001]","Blue Cross HMO",,4595.46,39.2,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 16CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155214180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"PHCS [10601]",PHCS,,1126.8,70,,,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) SYSTEM AVEIR PACEMKR LEADLESS VR RET CATH TRI LOOP",SUP-LSCR111,CDM,S27200284,LOCAL,0272,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8675.1,45.9,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 8MM 3.25MM CORONARY STENT EVEROLIMUS",SUP-1550325-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 216MM 4.3MM AXSOS SHORT LOCK NONSTERILE REUSABLE",SUP-705043,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BUTTON 4CM 8MM PASSPORT CURVE HIP SILICONE 1 PIECE MOLD",SUP-AR-6592-08-40,CDM,S27000186,LOCAL,0270,RC,,,both,,,292.32,87.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC",262,MS-DRG,,,,,,,inpatient,,,57910.24,17373.07,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,10413.67,,"Case rate ($10,110.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,388.16, add-ons for qualifying new technology services are included. If operating cost exceeds $42,427.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,091.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,400.58. The transfer operating threshold is the transfer adjustment factor * $9,388.16 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $709.79. The transfer capital threshold is the transfer adjustment factor * $709.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.",,,,0,7561,47586.56,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PT2 VASCULAR 185CM 2CM .014IN STAINLESS STEEL NITINOL",SUP-H74938931030,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMR GLENOSPHERE 36MM",SUP-1374.09.111,CDM,C1776,HCPCS,0278,RC,,,both,,,9183.90,2755.17,"CIGNA [10200]",Cigna,,6245.05,68,,5873.17,5873.17,5873.17,"1 through 10",1068.09,7806.32,"percent of total billed charges",
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II VASCULAR J",SUP-1009667J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ld Routine Delivery Charge",PX-722000001,CDM,9999147,LOCAL,0722,RC,,,both,,,4023.46,1207.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,476.78,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,467.93,3419.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 60MM STEALTH 3 SOFT STERILE LATEX FREE",SUP-A0A13,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"FIRST HEALTH [10303]","First Health",,125.28,80,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 280MM 11MM LARGE QUICK COUPLING CANNULATED TAPERED",SUP-357.404,CDM,S27200284,LOCAL,0272,RC,,,both,,,2883.30,864.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,335.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,335.33,2450.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA2-17-75-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,9177.00,2753.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1087.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE DOUBLE DIAMOND 1.2MM X 89MM COCR",SUP-KWCC-DD-12089,CDM,S27000186,LOCAL,0270,RC,,,both,,,400.20,120.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,47.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 7CM 14.5MM 12-13.5MM GORE EXCLUDER ILIAC",SUP-PLL161407,CDM,C1874,HCPCS,0278,RC,,,both,,,19725.30,5917.59,"PHCS [10601]",PHCS,,13807.71,70,,,,,0,2294.05,16766.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HALO90 BARRX 160CM 40X13",SUP-90-9200,CDM,C1886,HCPCS,0272,RC,,,both,,,16532.40,4959.72,"NOVANET [10819]",Novanet,,12399.3,75,,,,,0,1922.72,14052.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rad Tx Del Lvl 3",PX-333000071,CDM,77412,CPT,0333,RC,,,both,,,3045.45,913.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3045.45,,"Per diem ($3,244).",,,,0,354.19,3045.45,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE AUGMENTATION 16MM CORTICAL INTERSPINOUS PROCESS",SUP-4578116,CDM,S27800098,LOCAL,0278,RC,,,both,,,19921.48,5976.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8187.73,41.1,,,,,0,2316.87,16933.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 11MM 8.2MM 120MM TALON PROXIMAL FEMUR DISTALFIX",SUP-SLN-011-120,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,588.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,577.78,4222.8,"percent of total billed charges",
"CATH RED 68 132CM THROMBECTOMY NO CE",SUP-RED68,CDM,C1757,HCPCS,0272,RC,,,both,,,16767.00,5030.1,"PHCS [10601]",PHCS,,11736.9,70,,,,,0,1950,14251.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR DEFIB CROME PIN PLUG MRI HIGH FREQUENCY CRT-D",SUP-DTPC2D1,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,31626.45,41.1,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 120MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171081210,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,482.72,41.1,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER 14MM ORTHOPEDIC TITANIUM CANCELLOUS SCR STERILE",SUP-AR-1349M,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,243.41,28.62,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 520CC",SUP-SSZ-M520,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,612.55,41.1,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +23.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.235,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,396.9,39.2,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACC INTRDCR STD 11 FR LONG 7131",SUP-667131-300,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,358.02,68,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 16CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175198190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS [10001]","Blue Cross HMO",,496.03,39.2,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM ULNAR SIZE 5 L115MM LEFT CEMENTED CONSTRAINED NEXEL",SUP-840001511,CDM,C1776,HCPCS,0278,RC,,,both,,,31971.49,9591.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12788.6,40,,,,,0,3718.28,27175.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE URETHROTOME SEMICIRCLE",SUP-A3558,CDM,S27200284,LOCAL,0272,RC,,,both,,,1892.55,567.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1286.93,68,,,,,0,220.1,1608.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 100MM 22MM DHS/DCS STAINLESS STEEL LARGE",SUP-280,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"FIRST HEALTH [10303]","First Health",,1454.7,80,,,,,0,211.48,1545.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPN NC 10MM 2MM BALLOON DILATATION PLATINUM IRIDIUM",SUP-200-010-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"UHC [10700]","United Healthcare",,5241.24,63.3,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T 32MM TITANIUM 1.3MM SCR 4X8 HOLE PRECONTOURED LOW",SUP-421.334,CDM,C1713,HCPCS,0278,RC,,,both,,,2450.70,735.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1124.87,45.9,,,,,0,285.02,2083.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL MONOFILAMENT LIGHTWEIGHT ABSORBABLE LOW",SUP-5954610,CDM,C1781,HCPCS,0278,RC,,,both,,,4032.00,1209.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,477.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,468.92,3427.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X2CM VIALIZE PLACENTAL MEMB ALLOGRAFT",SUP-VL-2030,CDM,,,0278,RC,,,both,,,7431.30,2229.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,880.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.43,6316.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 190MM 11MM SHORT CARBON FIBER BRIDGE",SUP-394.796,CDM,S27800098,LOCAL,0278,RC,,,both,,,4945.09,1483.53,"KAISER [10500]",Kaiser,,3313.21,67,,,,,0,575.11,4203.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 3MM SURGICAL NONSTERILE SINGLE USE",SUP-3606030,CDM,S27000186,LOCAL,0270,RC,,,both,,,1837.50,551.25,"AETNA [10100]","Aetna HMO/PPO",,1460.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Tum Loc Spect 1 Area 1 Day",PX-341000050,CDM,78803,CPT,0341,RC,,,both,,,3308.44,992.53,"PHCS [10601]",PHCS,,2315.91,70,,,,,0,384.77,3308.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 46MM QUICKFIX TITANIUM T15 SHORT THREAD",SUP-AR-8740-46PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 150CM 200MM 4MM BALLOON DILATATION PACLITAXEL",SUP-H74939419402010,CDM,C2623,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1594.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 14FR PIGTAIL CURVE DRNG FLEXIMA BILIARY REGULAR",SUP-M001271590,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS EVOQUE VALVE (EVOQUE VALVE)48 MM",SUP-9850EV48CL,CDM,S62400003,LOCAL,0624,RC,,,both,,,216600.00,64980,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25667.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25190.58,184110,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prekallikrein",PX-305000028,CDM,85292,CPT,0305,RC,,,both,,,1164.00,349.2,"CIGNA [10200]","Cigna Local Plus",,41.65,,,,,,,0.01,989.4,"fee schedule",
"SCR BONE 6.5MM 35MM EVEREST SPINE POLYAXIAL",SUP-2911-06535,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"BLUE CROSS [10001]","Blue Cross PPO",,1898.3,39.2,,957.42,570.23,957.42,28,563.19,4116.21,"percent of total billed charges",
"SCR BONE 3.5MM 40MM ORTHOLOC CLAW II STAINLESS STEEL 15D",SUP-40233540,CDM,C1713,HCPCS,0278,RC,,,both,,,1474.20,442.26,"MULTIPLAN [10600]",Multiplan,,1253.07,85,,,,,0,171.45,1253.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MERSILENE MULTIPASS 4-0 P-3 18IN BRAID WHITE",SUP-R691G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.25/26",SUP-401759,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC DRN Mouth Lesion Cmplx",PX-450000245,CDM,40801,CPT,0450,RC,,,both,,,4068.00,1220.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,694.48,,,,,,,67.13,4068,"case rate",
"CMPNT FEMORAL 9 NARROW KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-42500006601,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS [10001]","Blue Cross PPO",,8962.18,39.2,,3949.44,3949.44,3949.44,"1 through 10",2658.93,19433.3,"percent of total billed charges",
"INSRT TIBIAL 2 16MM KNEE X3 CRUCIATE SUBSTITUTING REVISION",SUP-5531G216,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6368.93,68,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 15MM INDEPENDENCE 8D SMALL PEEK ALIF PLATE",SUP-376.115,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4061.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 8MM STAINLESS STEEL T8 CORTEX TUBE STARDRIVE",SUP-201.758TS,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,56.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,55.39,404.84,"percent of total billed charges",
"SPACER SPINAL COALITION ANTERIOR CERVICAL DISCECTOMY AND",SUP-384.106,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"BLUE CROSS [10001]","Blue Cross HMO",,7056,39.2,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH CUFF CRICO UNIVERSAL 9CM MELKER 7.2MM 5MM",SUP-G47665,CDM,C1769,HCPCS,0272,RC,,,both,,,3839.85,1151.95,"PHCS [10601]",PHCS,,2687.9,70,,,,,0,446.57,3263.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16026545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"COMPONENT FEM POROUS RT SZ12",SUP-427-02-120,CDM,C1776,HCPCS,0278,RC,,,both,,,32703.43,9811.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3875.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3803.41,27797.92,"percent of total billed charges",
"INSRT TIBIAL 6 20MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158126120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PHCS [10601]",PHCS,,7822.19,70,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 4CM 18FR SILICONE MIC-KEY SECUR-LOK",SUP-0230-18-4.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"AETNA [10100]","Aetna HMO/PPO",,1147.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U235,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"NOVANET [10819]",Novanet,,558.75,75,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 190MM 5.5MM RELINE STRAIGHT TITANIUM MAS",SUP-12355190,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 8MM MREYE PLATINUM FIBER 2 LOOP",SUP-G42463,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,97.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MOTIV SCAFFOLD 3.0MMX60MM","SUP-930030-60 (360)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR .035IN 145CM GOLD TIP STEERABLE TORQUE DEVICE",SUP-50120,CDM,C1769,HCPCS,0272,RC,,,both,,,705.51,211.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNARE SMALL OVAL 240CM 2.4MM CAPTIFLEX LOOP FLEXIBLE",SUP-M00562422,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.00,22.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH HEARTRAIL III 100CM 5FR IR1 CURVE GUIDING PTFE CORONARY",SUP-40-5380,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INFINITI THRULUMEN 100CM 6FR .079IN .057IN JUDKINS LEFT",SUP-534620T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC US Retroperitoneal Ltd",PX-402000011,CDM,76775,CPT,0402,RC,,,both,,,1265.37,379.61,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure count. Procedure 1, Fee schedule rate ($103.01). Procedures 2 - 999, Fee schedule rate ($51.50).",103.00,103.00,103.00,"1 through 10",,,"fee schedule",
"SNARE 20MM ROUND 240MM 2.4MM CAPTIVATOR II STIFF BRAID WIRE",SUP-M00561241,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.70,40.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ARTERIAL BLUE 2X.1X.15IN CORONARY VEIN POLYPROPYLENE NO",SUP-82609,CDM,S27200284,LOCAL,0272,RC,,,both,,,114.71,34.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 3.5MM 42MM STAINLESS STEEL T15 SELF TAP VARIABLE",SUP-02.127.142,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"NOVANET [10819]",Novanet,,849.53,75,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 3.5MM 2 STRAIGHT 5.75IN BUCK EAR SHARP SURGICAL",SUP-380203,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.07,40.22,"PHCS [10601]",PHCS,,93.85,70,,,,,0,15.59,113.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PRELUDESYNC 29CM COMPRESSION 20ML RADIAL BAND SOFT",SUP-SRB29MED,CDM,S27000186,LOCAL,0270,RC,,,both,,,217.50,65.25,"NOVANET [10819]",Novanet,,163.13,75,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHOCKWAVE M5 60MM 110CM 3.5MM 7MM BALLOON DILATATION",SUP-M5PIVL3560,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"PHCS [10601]",PHCS,,15214.5,70,,,,,0,2527.78,18474.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL CANNULATED 6.5/7.3 MM SCR",SUP-310.78,CDM,S27200284,LOCAL,0272,RC,,,both,,,2341.80,702.54,"PHCS [10601]",PHCS,,1639.26,70,,,,,0,272.35,1990.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESTRICT CEMENT 24MM FEMORAL HIP",SUP-EBO0101,CDM,S27800098,LOCAL,0278,RC,,,both,,,1150.20,345.06,"CIGNA [10200]",Cigna,,782.14,68,,,,,0,133.77,977.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 770CC",SUP-SSZ-F770,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"KAISER [10500]",Kaiser,,998.57,67,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE EXTRA SPORT VASCULAR J CURVE 300CM 3CM .014",SUP-22235MJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 8X22X55MM 5DEG LORDOTIC TITANIUM ALLOY MODULUS X",SUP-1223855P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7654.5,27,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM VARIAX TITANIUM ELBOW SELF TAPPING",SUP-614716,CDM,C1713,HCPCS,0278,RC,,,both,,,1023.92,307.18,"NOVANET [10819]",Novanet,,767.94,75,,,,,0,119.08,870.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POUCH SURGICAL TISSUE 8X5IN LAPSAC DRAWSTRING COLOR CODED",SUP-G16496,CDM,S27200284,LOCAL,0272,RC,,,both,,,877.54,263.26,"KAISER [10500]",Kaiser,,587.95,67,,,,,0,102.06,745.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ETHAMBUTOL 100 MG TABLET",RX-9982,CDM,,,0637,RC,68180-0280-01,NDC,both,1,UN,6.27,1.88,"PHCS [10601]",PHCS,,4.39,70,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 5X5CM SOLID SHEET NONSTERILE LATEX FREE",SUP-PAC25,CDM,Q4201,HCPCS,0636,RC,,,both,,,7521.00,2256.3,"CIGNA [10200]","Cigna Open Access",,204.57,,,,,,,204.57,6392.85,"fee schedule",
"SET BREAST BIOPSY 10CM LOCALIZER 20 APPLR",SUP-09-0007,CDM,S27200284,LOCAL,0272,RC,,,both,,,2055.00,616.5,"CIGNA [10200]","Cigna Local Plus",,1099.43,53.5,,,,,0,239,1746.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 LEFT KNEE POSTERIOR STABILIZED CEMENTED",SUP-5515-F-701,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"UHC [10700]","United Healthcare",,6330,63.3,,8601.07,8395.67,8601.07,"1 through 10",1163,8500,"percent of total billed charges",
"RTRCTR 2 7/8INX7/8IN BUIE-SMITH SELF RETAINING SWIVEL SHORT",SUP-SU290,CDM,S27200284,LOCAL,0272,RC,,,both,,,1405.35,421.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,163.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,163.44,1194.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM NASAL 6IN MEDIUM HARTMANN-HALLE BLADE 30MM",SUP-66-0302,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.21,140.16,"AETNA [10100]","Aetna HMO/PPO",,371.43,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.34,397.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Guide DRN Perc Plc Cath Si",PX-402000003,CDM,75989,CPT,0402,RC,,,both,,,2467.97,740.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,287.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,277,2097.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN JUDKINS RIGHT 5 CURVE",SUP-DXT6JR50,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.97,41.1,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN FEMORAL RIGHT 5 CURVE",SUP-864103,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"NOVANET [10819]",Novanet,,53.18,75,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFT TOUCH",SUP-SSM-255,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",878.7,6422.18,"percent of total billed charges",
"CAP LOCKING MATRIX TITANIUM 1 STEP 5.5 MM MATRIX SPINAL",SUP-04.632.000,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"FIRST HEALTH [10303]","First Health",,278.4,80,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX16MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183546,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"KAISER [10500]",Kaiser,,5252.65,67,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.0 PLY SCRW 3.5X24",SUP-102035124,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,inpatient,,,27970.34,8391.1,"CIGNA [10200]","Cigna Open Access",,13918.32,,"Fee schedule rate ($13,918.32). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,27970.34,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"AERVIA NEONATAL SUPRAGLOTTIC AIRWAY DEVICE, VARIETY",SUP-AVVARIETY,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.47,70.34,"KAISER [10500]",Kaiser,,157.09,67,,,,,0,27.27,199.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ERLOTINIB 10 MG/ML ORAL SUSPENSION",RX-408878,CDM,,,0637,RC,08888-8885-94,NDC,both,75,ML,8114.65,2434.39,"NOVANET [10819]",Novanet,,6085.99,75,,,,,0,943.73,6897.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR CEMENTLESS STD Z1 TITANIUM ALLOY 5",SUP-611201050,CDM,C1776,HCPCS,0278,RC,,,both,,,28967.40,8690.22,"MULTIPLAN [10600]",Multiplan,,24622.29,85,,,,,0,3368.91,24622.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 63MM HIP ANTIROTATION FIN EQUATORIAL TEETH",SUP-75100461,CDM,C1776,HCPCS,0278,RC,,,both,,,18389.70,5516.91,"MULTIPLAN [10600]",Multiplan,,15631.25,85,,,,,0,2138.72,15631.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH DRILL 1.5NM QUICK COUPLING TORQUE LIMITING NONSTERILE",SUP-511.773,CDM,S27000186,LOCAL,0270,RC,,,both,,,14078.90,4223.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1668.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1637.38,11967.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pacu Cc 1st Hr",PX-710000007,CDM,9999177,LOCAL,0710,RC,,,both,,,1124.58,337.37,"AETNA [10100]","Aetna HMO/PPO",,894.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,130.79,955.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-28,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 0 SH 30IN BRAID BLACK NONABSORBABLE",SUP-K834H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT FLITES PASSIVE LOOP",SUP-MFA2100-S-L1,CDM,S27000186,LOCAL,0270,RC,,,both,,,231.51,69.45,"CIGNA [10200]",Cigna,,157.43,68,,,,,0,26.92,196.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.2MM 5MM CORTICAL 4 HANDLE",SUP-A-5100.05/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"AETNA [10100]","Aetna HMO/PPO",,1004.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DEMINERALIZED BONE MATRIX CANCELLOUS ALLOGRAFT",SUP-7777005,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"AETNA [10100]","Aetna HMO/PPO",,3428.44,79.5,,1521.93,481.35,16760.95,30,501.54,3665.63,"percent of total billed charges",
"FAT EMULSION 20 % INTRAVENOUS",RX-10014,CDM,,,0250,RC,00264-4460-30,NDC,both,250,ML,162.22,48.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.87,137.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN STD JUDKINS RIGHT",SUP-534621T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,39.93,45.9,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR RUST 41MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103541000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"PHCS [10601]",PHCS,,2145.02,70,,,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFT TOUCH",SUP-SSM-520,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"FIRST HEALTH [10303]","First Health",,6044.4,80,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP CIRCUMCISION 26MM MALE",SUP-51-9926,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"PHCS [10601]",PHCS,,1035.69,70,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC F5 Gene",PX-309000026,CDM,81241,CPT,0310,RC,,,both,,,769.60,230.88,"KAISER [10500]",Kaiser,,515.63,67,,,,,0,0.01,654.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30X13MM HEDRON IA 15D 24MM STERILE LATEX FREE",SUP-1212.0213S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"MULTIPLAN [10600]",Multiplan,,29452.5,85,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 3MM BALLOON DILATATION STERILE LATEX",SUP-583015022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DARUNAVIR 800 MG TABLET",RX-160155,CDM,,,0250,RC,59651-0086-30,NDC,both,1,UN,285.13,85.54,"AETNA [10100]","Aetna HMO/PPO",,226.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.16,242.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE",RX-11019,CDM,,,0637,RC,00071-3740-66,NDC,both,1,UN,8.76,2.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.02,7.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 8 HIP",SUP-PRTLE028,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"AETNA [10100]","Aetna HMO/PPO",,15025.5,79.5,,10981.53,8986.79,12413.38,12,2198.07,16065,"percent of total billed charges",
"SHAVER SYS IRRIGTN CLIPS",SUP-SSA-106,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM CONCERTO DETACHABLE",SUP-NV-4-10-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH 5.6MM STD HANDLE AORTIC",SUP-APU456,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,33.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALEXIS CES 17CM",SUP-GTB17,CDM,S27200284,LOCAL,0272,RC,,,both,,,2700.00,810,"CIGNA [10200]",Cigna,,1836,68,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL KNIFE 2300MM 2.8MM DUALKNIFEJ",SUP-KD-655U,CDM,S27200284,LOCAL,0272,RC,,,both,,,5520.35,1656.1,"NOVANET [10819]",Novanet,,4140.26,75,,,,,0,642.02,4692.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR HYPERTRONICS 115CM 4MM 7FR 1-7-4MM SPACE C",SUP-NS7TCCL174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5643.44,41.1,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 60MM 32MM MARATHON",SUP-121932460,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,961.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE RETRIEVAL SYSTEM",SUP-TENDV-RS-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 80CM 10MM 9FR STRAIGHT VASCULAR",SUP-AVSM10100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]","Cigna Open Access",,6120.45,33.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOPROSTHESIS STENT AORTOILIAC L79MM DIA8MM VIABAHN V",SUP-BXBL087902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8562.96,40,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM GRAVES VAGINAL 105X33MM",SUP-EL196R,CDM,S27200284,LOCAL,0272,RC,,,both,,,183.74,55.12,"PHCS [10601]",PHCS,,128.62,70,,,,,0,21.37,156.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 10CM 7FR PIGTAIL PANCREATIC POLYMER",SUP-M00537290,CDM,C2617,HCPCS,0278,RC,,,both,,,722.28,216.68,"BLUE CROSS [10001]","Blue Cross PPO",,283.13,39.2,,,,,0,84,613.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 16X26X55MM",SUP-6216055,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2784.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Transneph Stnt Bi W Si",PX-361000218,CDM,50387,CPT,0361,RC,,,both,,,6400.07,1920.02,"NOVANET [10819]",Novanet,,4800.05,75,,,,,0,744.33,5440.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN INNER SHILEY XLT 6 95MM 11MM 6MM ADULT EXTEND LENGTH",SUP-60XLTIN,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.83,1.45,"FIRST HEALTH [10303]","First Health",,3.86,80,,,,,0,0.56,4.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 8.25IN JACOBSON IMPREGNATE LOCK NDL TUNGSTEN CARBIDE",SUP-55-2525,CDM,S27200284,LOCAL,0272,RC,,,both,,,1551.07,465.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,711.94,45.9,,,,,0,180.39,1318.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPANDER BREAST TISSUE SUTURE TABS SMOOTH MEDIUM HEIGHT 800C",SUP-SCPX156MH,CDM,C1789,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"CIGNA [10200]",Cigna,,5911.92,68,,,,,0,1011.11,7389.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Evasc Stnt Rpr Thrc/Aa X Crsg Br",PX-481000136,CDM,33895,CPT,0481,RC,,,both,,,45298.00,13589.4,"BLUE CROSS [10001]","Blue Cross PPO",,9549.81,,"Case rate ($9,549.81). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2491,38503.3,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CENTRALIZER DIST 9MM ENCORE",SUP-400-03-000,CDM,C1713,HCPCS,0278,RC,,,both,,,1315.68,394.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,376.55,28.62,,,,,0,153.01,1118.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATRIX-C UNION CERVICAL ALLOGRAFT SPACER 13 X 16 X 7MM 7",SUP-X094-3010,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING RTRCTR GEN II NORYL WITHOUT STAYS KIT TEKNA DISPOSABLE",SUP-3301G,CDM,S27200284,LOCAL,0272,RC,,,both,,,746.66,224,"AETNA [10100]","Aetna HMO/PPO",,593.59,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.84,634.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 30MM CREO MIS SPINE POLYAXIAL TULIP REDUCTION",SUP-1134.01,CDM,C1713,HCPCS,0278,RC,,,both,,,3555.00,1066.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,421.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",413.45,3021.75,"percent of total billed charges",
"COIL EMBOLIZATION 8CM 5MM INTERLOCK IDC OCCLUSION SYSTEM",SUP-M0013615080,CDM,S27800098,LOCAL,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD 25CM 10FR PIGTAIL CURVE DRNG PERCUFLEX GLIDEX METAL",SUP-M001245081,CDM,C1729,HCPCS,0272,RC,,,both,,,850.50,255.15,"PHCS [10601]",PHCS,,595.35,70,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REGENT AORTIC VALVE, W/ FLEXCUFF, 19MM ROTATABLE",SUP-19AGFN-756,CDM,S27800098,LOCAL,0278,RC,,,both,,,31229.42,9368.83,"MULTIPLAN [10600]",Multiplan,,26545.01,85,,,,,0,3631.98,26545.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 2.75MM CORONARY STENT PEBAX",SUP-H7493926032270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752710,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS [10001]","Blue Cross PPO",,353.65,39.2,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 22CM 5FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49896,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"NOVANET [10819]",Novanet,,564.98,75,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 20MM 125CM 4MM 5FR BILIARY NITINOL SELF",SUP-G31437,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"MULTIPLAN [10600]",Multiplan,,3552.15,85,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL 2 18IN MONOFILAMENT TIE 12 STRAND SILVER",SUP-DS24,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.11,21.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,32.18,45.9,,,,,0,8.15,59.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF CONDUCTR 55-75CM 7FR 2-5-2MM SPACING 55-75MM REACH",SUP-2ACH15,CDM,C1730,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"PHCS [10601]",PHCS,,4105.5,70,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 18LP 80CM 2CM 4FR 7MM .018IN BALLOON DILATATION",SUP-G50254,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 32MM HIP BIOLOX DELTA BIOLOX OPTION G7",SUP-6501056,CDM,C1776,HCPCS,0278,RC,,,both,,,13896.60,4168.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3752.08,27,,,,,0,1616.17,11812.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 8.5-10 LARGE FEMALE BEIGE CANVAS RUBBER",SUP-2041-09,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.42,14.23,"PHCS [10601]",PHCS,,33.19,70,,,,,0,5.51,40.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 7CM 7FR DUODENAL BEND BILIARY PLASTIC TEMPORARY RAPID",SUP-M00545560,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,101.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 40MM 80CM 6MM VASCULAR PERIPHERAL SELF",SUP-1012528-40,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]",Cigna,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 45MM 12MM ZENITH ILIAC BRANCH 58MM",SUP-G60346,CDM,C1874,HCPCS,0278,RC,,,both,,,68399.94,20519.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8105.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7954.91,58139.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-105634,CDM,,,0250,RC,00409-9045-16,NDC,both,30,ML,36.01,10.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14.8,41.1,,,,,0,4.19,30.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.5MM X 10.0MM",SUP-492501012,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WEDGE POSITIONING 22X12X9IN DEVON FOAM BODY ALIGNMENT 30322",SUP-31143392,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.90,23.37,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CORPLEX 15MM DISC",SUP-CX-0015,CDM,Q4232,HCPCS,0636,RC,,,both,,,4029.60,1208.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEAD FEMORAL 0MM 26MM HIP C TAPER COCR LFIT",SUP-06-2600,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"KAISER [10500]",Kaiser,,2095.56,67,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR LICOX 2 LUMEN O2 TEMPERATURE CATH STERILE",SUP-IP2P,CDM,S27200284,LOCAL,0272,RC,,,both,,,16849.80,5054.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1996.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1959.63,14322.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 30MM 125CM 12MM 6FR .035IN BILIARY NITINOL",SUP-G36238,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]",Cigna,,2570.4,68,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Legionella Direct Ifa",PX-302000052,CDM,86255,CPT,0302,RC,,,both,,,228.00,68.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.72,,,,,,,0.23,193.8,"fee schedule",
"CATH DXTERITY 100CM 5FR .047IN JUDKINS RIGHT 4 CURVE",SUP-DXT5JR40,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +26 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT225260,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP: FX STEMS (+) CENT",SUP-OSC368806,CDM,C1776,HCPCS,0278,RC,,,both,,,4830.00,1449,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T 1MM TITANIUM 1.5MM SCR 3 HOLE HEAD 7 HOLE SHAFT LOCK",SUP-04.130.252S,CDM,C1713,HCPCS,0278,RC,,,both,,,3330.60,999.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2264.81,68,,,,,0,387.35,2831.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 12MM CEMENTRALIZER HIP FEMUR PMMA CEMENT SUMMIT",SUP-137621000,CDM,C1776,HCPCS,0278,RC,,,both,,,846.45,253.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,388.52,45.9,,,,,0,98.44,719.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 64.6X42.6X25MM MBT 2+ MM KNEE CEMENTED REVISION",SUP-129435225,CDM,C1776,HCPCS,0278,RC,,,both,,,35980.56,10794.17,"CIGNA [10200]",Cigna,,14392.22,40,,5873.17,5873.17,5873.17,"1 through 10",4184.54,30583.48,"percent of total billed charges",
"HC Osteocalcin",PX-301000519,CDM,83937,CPT,0301,RC,,,both,,,191.00,57.3,"CIGNA [10200]",Cigna,,65.67,,,,,,,0.01,162.35,"fee schedule",
"INTRO LEAD 13CM 7FR TEAR AWAY SAFESHEATH HEMOSTASIS VALVE",SUP-HLS-1007M,CDM,C1894,HCPCS,0272,RC,,,both,,,391.50,117.45,"FIRST HEALTH [10303]","First Health",,313.2,80,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN JUDKINS LEFT 5 CURVE GUIDING",SUP-LA6JL50,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION",RX-2357,CDM,,,0250,RC,00990-7930-09,NDC,both,1000,ML,100.65,30.19,"NOVANET [10819]",Novanet,,75.49,75,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION",RX-1685,CDM,,,0250,RC,00409-4093-09,NDC,both,10,ML,179.69,53.91,"CIGNA [10200]","Cigna Local Plus",,96.13,53.5,,,,,0,20.9,152.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC MEDIUM 3-3.5IN HAND RIGHT REST FINGER",SUP-81096148,CDM,L3807,HCPCS,0274,RC,,,both,,,499.85,149.95,"FIRST HEALTH [10303]","First Health",,399.88,80,,,,,0,58.13,424.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis B Core Igm Ab",PX-302000145,CDM,86705,CPT,0302,RC,,,both,,,412.30,123.69,"CIGNA [10200]","Cigna Local Plus",,25.89,,,,,,,0.01,350.46,"fee schedule",
"BLADE SAW 25.5X13.8MM THK.4MM THK.6MM SMALL BONE OSCILLATE",SUP-KM-3171,CDM,S27200284,LOCAL,0272,RC,,,both,,,401.51,120.45,"UHC [10700]","United Healthcare",,254.16,63.3,,,,,0,46.7,341.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 0.045IN 6IN TROCAR SMOOTH NONSTERILE LATEX","SUP-P06 N0322",CDM,S27000186,LOCAL,0270,RC,,,both,,,454.41,136.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,52.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.85,386.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUADRA ASSURA MP CRT-D DF4 CONNECTOR",SUP-CD3369-40Q,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"AETNA [10100]","Aetna HMO/PPO",,45887.4,79.5,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 10MM NATURAL LARGE LORDOTIC",SUP-19410,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PSEUDOEPHEDRINE 30 MG TABLET",RX-6714,CDM,,,0637,RC,00904-6990-61,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 4.5MM 24MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.524.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,69.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",69.37,507.01,"percent of total billed charges",
"NAIL 10MM 165MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-410-165,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,3978.14,359.25,3978.14,24,2014.9,14726.25,"percent of total billed charges",
"CMPNT PATELLAR 32MM PERSONA ALL POLY KNEE LATEX FREE",SUP-42540000032,CDM,C1776,HCPCS,0278,RC,,,both,,,4667.16,1400.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,553.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,542.79,3967.09,"percent of total billed charges",
"SCR INTERFERENCE PEEK-OPTIMA 15MM 5.5MM FOOT ANKLE VENT",SUP-AR-1555PS,CDM,C1713,HCPCS,0278,RC,,,both,,,2480.63,744.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,293.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,288.5,2108.54,"percent of total billed charges",
"INSRT TIBIAL 3 17.5MM KNEE GVF STABILIZE ROTATE PLATFORM PFC",SUP-962134,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1209.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 120CM 7.5CM 8MM VASCULAR HEPARIN CATH",SUP-VBJR080702A,CDM,C1874,HCPCS,0278,RC,,,both,,,22163.40,6649.02,"CIGNA [10200]","Cigna Local Plus",,6981.47,31.5,,,,,0,2577.6,18838.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIBRILLATOR CARDIAC MOMENTUM HEARTLOGIC ENDURALIFE D.99 CM",SUP-D120,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"UHC [10700]","United Healthcare",,24687,63.3,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32MM TITANIUM T25 SELF TAP LOCK STARDRIVE",SUP-412.210S,CDM,C1713,HCPCS,0278,RC,,,both,,,1220.18,366.05,"BLUE CROSS [10001]","Blue Cross PPO",,478.31,39.2,,957.42,570.23,957.42,28,141.91,1037.15,"percent of total billed charges",
"HEAD FEMORAL -2.5MM 32MM HIP C TAPER HIGH PERFORMANCE OFFSET",SUP-18-32-3,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4590,45.9,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BONE CEMENT 10GA VERTEPORT PRECISE CIONTROL TACTILE",SUP-306410000,CDM,S27200284,LOCAL,0272,RC,,,both,,,612.17,183.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,72.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,71.2,520.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM VERTEX MAX TITANIUM SPINAL MAS",SUP-6958712,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,497.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,488.46,3570,"percent of total billed charges",
"SCR BONE 2.4MM 9MM LCP STAINLESS STEEL DISTAL CORTEX RADIUS",SUP-201.759,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",50.59,369.75,"percent of total billed charges",
"PLATE 40MM TITANIUM 2 LEVEL ASSURE BONE SPINE CERVICAL",SUP-110.24,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,957.42,156.86,7483.26,51,521.61,3812.25,"percent of total billed charges",
"PLATE STD 49MM 2.3MM SCR ACU-LOC 2 BONE LEFT PROXIMAL DISTAL",SUP-70-0350,CDM,C1713,HCPCS,0278,RC,,,both,,,6651.60,1995.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,788.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,773.58,5653.86,"percent of total billed charges",
"KIT 17GA 75MM ACTIVE TIP PROBE INTRO TUBE ELECTROTHERAPY",SUP-CRK-17-75-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 14MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-414-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3249.07,27,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 12MM 140CM 3MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927412300,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1721.25,45.9,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 345841FZ L-ASR 8X14X11 FZ SRVCFEE",SUP-345841FZ,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT VASCULAR J CURVE 190CM",SUP-1001780J-HC,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT XEMPLIFI DEMINERALIZE BONE MATRIX PLUS 3ML",SUP-8103.0203S,CDM,C1713,HCPCS,0278,RC,,,both,,,3018.75,905.62,"CIGNA [10200]",Cigna,,2052.75,68,,1831.33,1831.33,1831.33,16,351.08,2565.94,"percent of total billed charges",
"GWIRE ASAHI MIRACLEBROS 4.5 VASCULAR STRAIGHT 300CM 11CM",SUP-14936-01,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,114.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING INGEVITY+ STEROID STAINLESS STEEL SILICONE RUBBE",SUP-7840,CDM,C1898,HCPCS,0275,RC,,,both,,,2250.00,675,"FIRST HEALTH [10303]","First Health",,1800,80,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL BONE FIBER 2.5CC ALLOGRAFT MOLDABLE",SUP-423202,CDM,C1713,HCPCS,0278,RC,,,both,,,3967.50,1190.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,461.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",461.42,3372.38,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 30CM 8MM THORACIC AORTA WOVEN EXCLUSIVE",SUP-IGW0008-30,CDM,C1768,HCPCS,0278,RC,,,both,,,2830.73,849.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1299.31,45.9,,,,,0,329.21,2406.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 8MM 2.75MM CORONARY STENT EVEROLIMUS",SUP-1550275-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM MULTIPOLAR THR CERAMIC CEMENTED STEM CUP LINER HE",SUP-98000100701,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2764.69,28.62,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METER GLUCOSE W3.1XH5.8IN D1.2IN 1.75 HOSPITAL WITH 2D BARCO",SUP-53398,CDM,S27000186,LOCAL,0270,RC,,,both,,,5865.00,1759.5,"NOVANET [10819]",Novanet,,4398.75,75,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL GENESIS II 6 RIGHT KNEE CEMENT TITANIUM",SUP-71420188,CDM,C1776,HCPCS,0278,RC,,,both,,,14593.50,4378.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1729.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1697.22,12404.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRIDGE CYSTOURETHROSCOPE 1 WAY NONSTERILE LATEX FREE",SUP-A20971A,CDM,S27000186,LOCAL,0270,RC,,,both,,,8592.36,2577.71,"CIGNA [10200]",Cigna,,5842.8,68,,,,,0,999.29,7303.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENYTOIN 50 MG CHEWABLE TABLET",RX-11018,CDM,,,0637,RC,60687-0156-95,NDC,both,1,UN,9.05,2.71,"MULTIPLAN [10600]",Multiplan,,7.69,85,,,,,0,1.05,7.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 80MM 120CM 5MM 6FR VASCULAR PERIPHERAL",SUP-S-50-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1170.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT TOE LPT 2 REGULAR GREAT TOE",SUP-487S002,CDM,C1776,HCPCS,0278,RC,,,both,,,11585.10,3475.53,"UHC [10700]","United Healthcare",,7333.37,63.3,,8601.07,8395.67,8601.07,"1 through 10",1347.35,9847.34,"percent of total billed charges",
"RETRIEVER SURGICAL 30X12MM",SUP-691.004S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"UHC [10700]","United Healthcare",,1068.19,63.3,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 120MM 2.5MM BALLOON",SUP-H74939147251210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM ATTUNE 5 KNEE DISTAL CEMENT REVISION STERILE",SUP-1547-05-002,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"CIGNA [10200]","Cigna Local Plus",,3248.52,53.5,,5372.07,4581.20,7242.98,23,706.17,5161.2,"percent of total billed charges",
"LENS IOL 0 D +11.5 DIOPTER +6 CYL BICONVEX 13MM 6MM",SUP-SN6AT9,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,98.74,28.62,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 9MM KNEE POSTERIOR STABILIZE BEARING",SUP-5532P809,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3835.36,45.9,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SECONDARY DELIVERY CATHETER, DISTAL",SUP-4850-03,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD SUT ASSISTANT 0 ES-9 7IN 1 STITCH ENDO STITCH",SUP-170054,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD SUT ASSISTANT 0 ES-9 48IN COATED ENDO STITCH BRALON",SUP-170012,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE LAPAROSCOPIC 12MM ACCESS SYSTEM 150MM KII ABDOMEN Z",SUP-CTS21,CDM,S27200284,LOCAL,0272,RC,,,both,,,119.63,35.89,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 40MM 3MM BALLOON",SUP-U357534,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOFT-VU 65CM 4FR ANGLE BERENSTEIN CURVE ANGIOGRAPHIC",SUP-H787107140095,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER DISORDERS OF NERVOUS SYSTEM,MODERATE",058,APR-DRG,,,,,,,inpatient,,,46298.61,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $6,451.85. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($35,278.29) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR HOCKEY STICK CURVE",SUP-67027900,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cann Retrograde Gundry 15fr",PX-E27200353,CDM,E27200353,LOCAL,0272,RC,,,both,,,521.40,156.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SODIUM CHLORIDE 0.9 % CHILLED IV SOLUTION",RX-409037,CDM,J7030,HCPCS,0258,RC,88880-8882-34,NDC,both,1000,ML,100.65,30.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT ORTHOPEDIC MEDIUM RIGHT WRIST FOREARM PREFORM PAD",SUP-9101-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,72.38,21.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BALLOON DILATATION 120MM .018IN LOW PROFILE 4FR 2.5MM",SUP-83969-02,CDM,C1725,HCPCS,0272,RC,,,both,,,3037.50,911.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH DESTINO BRAIDED FLEXSTEER 9MM STRAIGHT 45CM 63CM 6.5F",SUP-PSS0655509,CDM,C1887,HCPCS,0272,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WIRE FIXATION 2.8MM 200MM 25MM LCP ANKLE COMPRESSION THREAD",SUP-03.118.025,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,170.52,39.2,,957.42,156.86,7483.26,51,50.59,369.75,"percent of total billed charges",
"STENT ICAST 38MM 120CM 10MM VASCULAR STAINLESS STEEL PTFE",SUP-42038,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4730.48,27,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR STRAIGHT SPRING COIL 180CM 5CM",SUP-H74917511,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP GLOBAL UNITE REVER",SUP-OSC379179,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"MULTIPLAN [10600]",Multiplan,,38556,85,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 55MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.855,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"KAISER [10500]",Kaiser,,920.85,67,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0310,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"BLUE CROSS [10001]","Blue Cross PPO",,2650.7,39.2,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW MA 3.5 X 22MM",SUP-8975322,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 7 KNEE CEMENTED PRIMARY",SUP-5520B700,CDM,C1776,HCPCS,0278,RC,,,both,,,7151.76,2145.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4863.2,68,,,,,0,831.75,6079,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 60CC FINE 1-4MM LATEX FREE",SUP-800111,CDM,S27800098,LOCAL,0278,RC,,,both,,,6399.75,1919.92,"CIGNA [10200]",Cigna,,4351.83,68,,,,,0,744.29,5439.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 10MM NATURAL STD PARALLEL CERVICAL",SUP-18310,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED DUAL MOBILITY HIP SYSTEM + CER HD + OSS LH",SUP-98000500330,CDM,C1776,HCPCS,0278,RC,,,both,,,31500.00,9450,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3732.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3663.45,26775,"percent of total billed charges",
"SYSTEM PROMUS ELEMENT PLUS 32MM 144CM 2.5MM CORONARY STENT",SUP-H7493911632250,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"AETNA [10100]","Aetna HMO/PPO",,7268.29,79.5,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 7.5MM 5MM MAGILL CURVE NASAL ORAL 2 CUFF",SUP-86394,CDM,S27200284,LOCAL,0272,RC,,,both,,,399.33,119.8,"KAISER [10500]",Kaiser,,267.55,67,,,,,0,46.44,339.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50MMX8MM CLYDESDALE 0D PEEK-OPTIMA RADIOPAQUE",SUP-2969850,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross HMO",,9384.48,39.2,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 16MM RETRACTA DETACHABLE .035IN",SUP-G34202,CDM,S27800098,LOCAL,0278,RC,,,both,,,4674.68,1402.4,"BLUE CROSS [10001]","Blue Cross PPO",,1832.47,39.2,,,,,0,543.67,3973.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 7X4CM SUSPEND TUTOPLAST FASCIA LATA",SUP-937201,CDM,C1762,HCPCS,0278,RC,,,both,,,12123.30,3636.99,"CIGNA [10200]",Cigna,,4849.32,40,,,,,0,1409.94,10304.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12.5MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962362,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"BLUE CROSS [10001]","Blue Cross HMO",,5685.49,39.2,,5311.50,4717.44,5388.59,31,1686.79,12328.23,"percent of total billed charges",
"ASAHI PROWATERFLEX PTCA GUIDE WIRE 180 CM",SUP-AGH147000,CDM,C1769,HCPCS,0272,RC,,,both,,,769.50,230.85,"NOVANET [10819]",Novanet,,577.13,75,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ROI-C PEEK-OPTIMA 7 D D12 MM W14 MM X H9 MM .53",SUP-MC1445P,CDM,S27800098,LOCAL,0278,RC,,,both,,,24570.00,7371,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7031.93,28.62,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) INSERTABLE CARDIAC MONITOR SYSTEM","SUP-M302 - LUX-DX II",CDM,C1764,HCPCS,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 7FR .081IN EBU4 LEFT CURVE GUIDING NYLON",SUP-LA7EBU40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"KAISER [10500]",Kaiser,,244.82,67,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP MULTIHOLE PRIMARY MODULAR STERILE",SUP-620206220,CDM,C1776,HCPCS,0278,RC,,,both,,,17500.14,5250.04,"BLUE CROSS [10001]","Blue Cross PPO",,6860.05,39.2,,3949.44,3949.44,3949.44,"1 through 10",2035.27,14875.12,"percent of total billed charges",
"SCR BONE 5.5MM 50MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840005550,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]",Cigna,,6491.86,68,,1831.33,1831.33,1831.33,16,641.98,8114.82,"percent of total billed charges",
"INSRT ARTICULAR 3-4 13MM KNEE POSTERIOR STABILIZE HIGH",SUP-71421510,CDM,C1776,HCPCS,0278,RC,,,both,,,10774.35,3232.3,"BLUE CROSS [10001]","Blue Cross HMO",,4223.55,39.2,,5311.50,4717.44,5388.59,31,1253.06,9158.2,"percent of total billed charges",
"INSRT TIBIAL 14.5MM 42X70X10MM GENTAMICIN PMMA REMEDY",SUP-RKINMD,CDM,C1776,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2216.97,45.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH HEMOSTASIS VALVE TEAR AWAY SIDEPORT SAFESHEATH",SUP-HLS2509,CDM,C1894,HCPCS,0272,RC,,,both,,,411.51,123.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,47.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.86,349.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 80MM 3.8-3.4FR 2.5MM TAPER",SUP-39147-25801,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 80MM 3.8-3.4FR 2.5MM TAPER",SUP-39147-25801,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANDESARTAN 16 MG TABLET",RX-23231,CDM,,,0637,RC,62332-0343-30,NDC,both,1,UN,15.37,4.61,"CIGNA [10200]","Cigna Local Plus",,8.22,53.5,,,,,0,1.79,13.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 140MM 125CM 6MM 6FR BILIARY",SUP-G50167,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"AETNA [10100]","Aetna HMO/PPO",,4841.55,79.5,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 4.8FR L30CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902150,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mod Sedat Endo Svc > 5y",PX-371000013,CDM,G0500,HCPCS,0371,RC,,,both,,,359.29,107.79,"PHCS [10601]",PHCS,,251.5,70,,,,,0,41.79,305.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 V-5 30IN 2 ARM BRAID 10 STRAND GREEN",SUP-10X52,CDM,S27200284,LOCAL,0272,RC,,,both,,,879.17,263.75,"FIRST HEALTH [10303]","First Health",,703.34,80,,,,,0,102.25,747.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPPORT ATHLT MED",SUP-281824,CDM,S27000186,LOCAL,0270,RC,,,both,,,53.59,16.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.23,45.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 6.3X2.4IN XENMATRIX AQUAPURE RECTANGLE",SUP-1160616,CDM,C1781,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"CIGNA [10200]",Cigna,,6450.12,40,,,,,0,1875.37,13706.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 6CMX9MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-10-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"MULTIPLAN [10600]",Multiplan,,1239.3,85,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LINER ACETABULAR XLPE HIP CUSTOM KIT CAPITATE",SUP-71701013,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"NOVANET [10819]",Novanet,,17955,75,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALLET SURGICAL 7 9/16IN 1.5IN STAINLESS STEEL 2LB",SUP-250404,CDM,S27000186,LOCAL,0270,RC,,,both,,,703.16,210.95,"UHC [10700]","United Healthcare",,445.1,63.3,,,,,0,81.78,597.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE RUBBER PLASTIC CHEST DRNG SEAL FLUTTER TAPER END",SUP-373460,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.64,67.99,"PHCS [10601]",PHCS,,158.65,70,,,,,0,26.36,192.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL RAPIDE MULTIPASS 2-0 CT-1 36IN BRAID",SUP-VR945,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL PTEYE PARATHYROID DETECTION SYSTEM DISPOSABLE",SUP-PTEYE-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3960.60,1188.18,"PHCS [10601]",PHCS,,2772.42,70,,,,,0,460.62,3366.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH 3.5MM AORTIC",SUP-APU535,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"FIRST HEALTH [10303]","First Health",,231.98,80,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE LOCALIZATION 20CM 20GA GHIATAS BREAST BEADED NDL 7CM",SUP-47720,CDM,A4648,HCPCS,0278,RC,,,both,,,182.79,54.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,124.3,68,,,,,0,21.26,155.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 52MM COCR",SUP-VAL-35520-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,248.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,244.23,1785,"percent of total billed charges",
"NDL ENDOSCOPIC .035IN 200CM KNIFE PRECUT GWIRE FUSION 7FR 6",SUP-G31539,CDM,S27200284,LOCAL,0272,RC,,,both,,,1680.00,504,"MULTIPLAN [10600]",Multiplan,,1428,85,,,,,0,195.38,1428,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 18MM CRANIOFACIAL TITANIUM 6 HOLE 2Y LOW PROFILE",SUP-421.516,CDM,C1713,HCPCS,0278,RC,,,both,,,3788.10,1136.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,448.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,440.56,3219.89,"percent of total billed charges",
"CAGE SPINAL ROI-C PEEK-OPTIMA 7 D D12 MM W14 MM X H9 MM .53",SUP-MC1445P,CDM,S27800098,LOCAL,0278,RC,,,both,,,24570.00,7371,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10098.27,41.1,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 140MM 125CM 6MM 6FR BILIARY",SUP-G50167,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CIGNA [10200]","Cigna Open Access",,3465.21,56.9,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STAT TACK FIXATION TITANIUM 15 TACK SHORT SHAFT",SUP-OMS-TTSS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1468.21,440.46,"FIRST HEALTH [10303]","First Health",,1174.57,80,,,,,0,170.75,1247.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM TRANSITION HA SPINE PEDICLE POLYAXIAL",SUP-152.775S,CDM,C1713,HCPCS,0278,RC,,,both,,,10791.60,3237.48,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4435.35,41.1,,,,,0,1255.06,9172.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXIMA 70CM 7FR URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002031,CDM,C1758,HCPCS,0272,RC,,,both,,,82.25,24.67,"PHCS [10601]",PHCS,,57.58,70,,,,,0,9.57,69.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPLATZER PFO OCCLUDER 35MM",SUP-9-PFO-035,CDM,C1817,HCPCS,0278,RC,,,both,,,56668.50,17000.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6715.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6590.55,48168.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 28MM SPINE PLY NONSTERILE 4MM ROD",SUP-102040128,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,3978.14,359.25,3978.14,24,441.36,3225.75,"percent of total billed charges",
"RONGEUR 8IN 40D UP 9MM OPEN MICRO 4MM SYMMETRY KERRISON",SUP-57-0694-BD,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VOYAGER NC 8MM 2.5MM SHORT ROUND TAPER BALLOON",SUP-1011752-08,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,299.62,41.1,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006175270070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,285.46,28.62,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH X-FORCE U30 6CM 6FR 4MM BALLOON DILATATION PERCUTANEOUS",SUP-998406,CDM,C1726,HCPCS,0272,RC,,,both,,,1854.00,556.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,761.99,41.1,,,,,0,215.62,1575.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 89MM 10.9MM 8MM 1 CANN CUFF SMOOTH ROUND TIP OBTR",SUP-8SCT,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.54,64.36,"UHC [10700]","United Healthcare",,135.8,63.3,,,,,0,24.95,182.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 1 CT 45CM SUT ABSORBABLE KNOTLESS",SUP-SXPP1A405,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"CIGNA [10200]",Cigna,,163.4,68,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM G7 ACTIVE ARTICULATION THR E1 CERAMIC HIP CEMENT",SUP-98000100187,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8294.08,28.62,,,,,0,3370.37,24633,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR BROAD LORDOTIC 12 DEGREE",SUP-12417,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS [10001]","Blue Cross PPO",,7408.8,39.2,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ACCESS 10CM 4FR MICROPUNCTURE NITINOL TRANSITIONLESS",SUP-G53578,CDM,C1887,HCPCS,0272,RC,,,both,,,300.24,90.07,"UHC [10700]","United Healthcare",,190.05,63.3,,,,,0,34.92,255.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM ALLOGRAFT 12MM",SUP-310112,CDM,S27800098,LOCAL,0278,RC,,,both,,,3139.50,941.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,372.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,365.12,2668.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC BEAVER 3MM NDL CUT EDGE",SUP-375910,CDM,S27200284,LOCAL,0272,RC,,,both,,,456.76,137.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,187.73,41.1,,,,,0,53.12,388.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM DCP LC-DCP STAINLESS STEEL FULL THREAD",SUP-206.030,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,32.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",31.82,232.58,"percent of total billed charges",
"STENT WALLSTENT 90MM 18MM 75CM ENDOPROSTHESIS VENOUS CATH",SUP-H74912044189070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"BLUE CROSS [10001]","Blue Cross PPO",,3381,39.2,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD SENTUS PROMRI LEFT VENTRICULAR OTW QUADRIPOLAR",SUP-406081,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,664.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 8CM 8MM BALLOON DILATATION 2 LUMEN",SUP-G52361,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.47,41.1,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 15FTX4IN WRIST IMMOB WRINKLE FREE STRETCH",SUP-OG-4L2,CDM,S27000186,LOCAL,0270,RC,,,both,,,518.81,155.64,"KAISER [10500]",Kaiser,,347.6,67,,,,,0,60.34,440.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +26.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000265,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TACTIFLEX SE BID CURVE F-J UNIFIED",SUP-A-TFSE-FJ-X,CDM,C2630,HCPCS,0272,RC,,,both,,,23940.00,7182,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2784.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,P9041,HCPCS,0636,RC,44206-0310-50,NDC,both,500,ML,1358.64,407.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,607.99,44.75,,,,,0,123.78,1154.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 8 LEVEL NEW LOCK ATLANTIS VISION BONE SPINAL",SUP-7200085,CDM,C1713,HCPCS,0278,RC,,,both,,,4620.00,1386,"CIGNA [10200]","Cigna Open Access",,2628.78,56.9,,1144.80,304.56,2275.09,66,537.31,3927,"percent of total billed charges",
"PLATE CURVE 336MM TITANIUM 4.5MM SCR 16 HOLE VARIABLE ANGLE",SUP-04.124.416S,CDM,C1713,HCPCS,0278,RC,,,both,,,15619.25,4685.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1816.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1816.52,13276.36,"percent of total billed charges",
"ROD SPINAL 100MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355100,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pump Blood Centrifugal Revolut",PX-E27200328,CDM,E27200328,LOCAL,0272,RC,,,both,,,566.50,169.95,"AETNA [10100]","Aetna HMO/PPO",,450.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.88,481.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Initial Care Training 30 M (Gn)",PX-440000025,CDM,G0539,HCPCS,0440,RC,,,both,,,70.00,21,"CIGNA [10200]","Cigna Open Access",,70,,"Per diem ($309).",,,,0,0.07,70,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 29.5X7MM PRECISION THK.51MM MICRO LONG NARROW",SUP-2296-033-115,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.84,87.25,"CIGNA [10200]","Cigna Open Access",,165.49,56.9,,,,,0,33.82,247.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 11CMX16MM OSTEOTOM CUP NONSTERILE DISPOSABLE",SUP-SBLDCUP-4-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,669.22,45.9,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR FL3 CURVE ANGIOGRAPHIC TRILON FEMORAL",SUP-H7490864120A2,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.17,22.55,"AETNA [10100]","Aetna HMO/PPO",,59.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.74,63.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION T 5MM 1.14MM 5MM TOUMA EAR GROMMET C-FLEX",SUP-1066012,CDM,S27800098,LOCAL,0278,RC,,,both,,,103.40,31.02,"FIRST HEALTH [10303]","First Health",,82.72,80,,,,,0,12.03,87.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION",RX-22185,CDM,J1451,HCPCS,0636,RC,70710-1478-01,NDC,both,1.5,ML,9054.00,2716.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5885.1,65,,,,,0,1254,7695.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH CLICKLINE 36CM 5MM ENDOSCOPIC METAL INSULATE OUTER",SUP-33300,CDM,C1894,HCPCS,0272,RC,,,both,,,2455.35,736.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1009.15,41.1,,,,,0,285.56,2087.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP LIGATION RESOLUTION 360 ULTRA 235CM BRAID ROTATION",SUP-M00521402,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"MULTIPLAN [10600]",Multiplan,,1370.12,85,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 95MM 20MM ASNIS III STAINLESS STEEL SMALL",SUP-326095S,CDM,C1713,HCPCS,0278,RC,,,both,,,1904.40,571.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1294.99,68,,,,,0,221.48,1618.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR STRAIGHT 145CM 15CM .038IN HEPARIN FIX CORE",SUP-G00793,CDM,C1769,HCPCS,0272,RC,,,both,,,215.33,64.6,"UHC [10700]","United Healthcare",,136.3,63.3,,,,,0,25.04,183.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Icd Gen Sngl Lead Sys",PX-480000033,CDM,33262,CPT,0481,RC,,,both,,,19976.15,5992.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19976.15,,"Case rate ($35,023). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,2323.23,19976.15,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 135X30MM ONETRAC LX 2 SMOKE EVACUATION CHANNEL",SUP-C100210,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"CIGNA [10200]","Cigna Open Access",,1066.88,56.9,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOPLASTY L80CM BALLOON L40MM DIA4MM HYDROPHOBIC",SUP-1008190-15,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"UHC [10700]","United Healthcare",,897.28,63.3,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 70CM ENDOTAK RELIANCE G ENDOCARDIAL STEROID",SUP-186,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 124MM 28-16MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1628C124E,CDM,C1876,HCPCS,0278,RC,,,both,,,31342.50,9402.75,"CIGNA [10200]","Cigna Open Access",,10499.74,33.5,,,,,0,3645.13,26641.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 95MM 4MM LORDOSIS TITANIUM",SUP-102064095,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THOMASMEDICAL INTRDCR FR7 LONG - EACH",SUP-666273-001,CDM,C1894,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Iabp Perc",PX-360000032,CDM,33968,CPT,0361,RC,,,both,,,1436.37,430.91,"CIGNA [10200]","Cigna Open Access",,1436.37,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,167.05,1436.37,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Bn Age Study",PX-320000179,CDM,77072,CPT,0320,RC,,,both,,,383.34,115,"PHCS [10601]",PHCS,,268.34,70,,,,,0,26.69,325.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPREME 65CM 2MM 5FR 2-8-2MM SPACE CSL CURVE",SUP-401864,CDM,C1730,HCPCS,0272,RC,,,both,,,1692.00,507.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,200.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,196.78,1438.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 6-14FR TITANIUM GREENFIELD SET INTRO VENA CAVA",SUP-M001503350,CDM,S27200284,LOCAL,0272,RC,,,both,,,303.80,91.14,"KAISER [10500]",Kaiser,,203.55,67,,,,,0,35.33,258.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH ADULT 55CM 15.5FR POLYURETHANE BIOFLO DURAMAX",SUP-H787103028095,CDM,C1750,HCPCS,0278,RC,,,both,,,1212.60,363.78,"NOVANET [10819]",Novanet,,909.45,75,,,,,0,141.03,1030.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HMII GOGEAR CON BG-PCTL,EP14,L",SUP-106449,CDM,Q0499,HCPCS,0274,RC,,,both,,,2373.30,711.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,281.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,276.01,2017.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE IV FOR SCAPE",RX-411694,CDM,J2305,HCPCS,0636,RC,00338-1049-02,NDC,both,250,ML,203.85,61.15,"MULTIPLAN [10600]",Multiplan,,173.27,85,,,,,0,17.37,173.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE JOURNEY II COCR WITH XR INSERT AND",SUP-71709040,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]",Cigna,,7560,40,,5873.17,5873.17,5873.17,"1 through 10",2198.07,16065,"percent of total billed charges",
"ROD SPINAL 70MM PRECEPT",SUP-8847070,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"AETNA [10100]","Aetna HMO/PPO",,3505.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 2-0 STP-10 27IN 2 ARM MONOFILAMENT VIOLET",SUP-Z997G,CDM,S27200284,LOCAL,0272,RC,,,both,,,202.71,60.81,"MULTIPLAN [10600]",Multiplan,,172.3,85,,,,,0,23.58,172.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 110MM 7 HOLE LOW PROFILE BONE RIGHT OLECRANON",SUP-70-0307,CDM,C1713,HCPCS,0278,RC,,,both,,,7051.80,2115.54,"BLUE CROSS [10001]","Blue Cross HMO",,2764.31,39.2,,957.42,156.86,7483.26,51,820.12,5994.03,"percent of total billed charges",
"HC Jo-1 Igg Muscle Ab",PX-302000041,CDM,86235,CPT,0302,RC,,,both,,,424.00,127.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,28.2,,,,,,,0.42,360.4,"fee schedule",
"HC Dbrd Nails >5",PX-510000035,CDM,11721,CPT,0761,RC,,,both,,,664.60,199.38,"BLUE CROSS [10001]","Blue Cross PPO",,664.6,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,77.29,664.6,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plas Shoe Insert Jnt",PX-E27400080,CDM,L2180,HCPCS,0274,RC,,,both,,,309.10,92.73,"KAISER [10500]",Kaiser,,207.1,67,,,,,0,35.95,262.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE TRANSPAC IV SAFESET RESVR",SUP-46115-39,CDM,S27200284,LOCAL,0272,RC,,,both,,,120.93,36.28,"MULTIPLAN [10600]",Multiplan,,102.79,85,,,,,0,14.06,102.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 20CM CENTRAL VENOUS 3 LUMEN OXIMETRY CONTINUOUS SCVO2",SUP-XA3820SAFKT,CDM,C1751,HCPCS,0272,RC,,,both,,,2887.50,866.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,335.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRL MIC TPS MED 3.5X21.5MM",SUP-5120100035,CDM,S27200284,LOCAL,0272,RC,,,both,,,506.17,151.85,"CIGNA [10200]",Cigna,,344.2,68,,,,,0,58.87,430.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 420MM FEMORAL EXPERT INTRAMEDULLARY ROUND",SUP-04.013.464S,CDM,C1713,HCPCS,0278,RC,,,both,,,8657.78,2597.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1025.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1006.9,7359.11,"percent of total billed charges",
"CATH CROSSTELLA 90CM 40MM 4-3.4FR 5MM BALLOON DILATATION",SUP-BD-F50040MR,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"UHC [10700]","United Healthcare",,948.55,63.3,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Belt Leg",PX-E27000053,CDM,E27000053,LOCAL,0270,RC,,,both,,,38.50,11.55,"FIRST HEALTH [10303]","First Health",,30.8,80,,,,,0,4.48,32.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 2MM AXIUM PRIME HELIX DETACHABLE EXTRA",SUP-APB-2-8-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3672.49,41.1,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION",RX-9080,CDM,,,0250,RC,59651-0026-75,NDC,both,75,ML,407.12,122.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,47.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.35,346.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 300MM 6MM BALLOON DILATATION RAPID",SUP-47560300M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,235.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM QUADLINK 11MM IMPL",SUP-AR-1288QIS-110,CDM,C1713,HCPCS,0278,RC,,,both,,,15757.88,4727.36,"BLUE CROSS [10001]","Blue Cross PPO",,6177.09,39.2,,957.42,570.23,957.42,28,1832.64,13394.2,"percent of total billed charges",
"MESALAMINE 800 MG TABLET,DELAYED RELEASE",RX-96949,CDM,,,0637,RC,60687-0408-95,NDC,both,1,UN,61.99,18.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.21,52.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.5MM STARDRIVE CORTEX SCREW SELF-TAPPING 24MM",SUP-02.200.024,CDM,C1713,HCPCS,0278,RC,,,both,,,240.38,72.11,"CIGNA [10200]",Cigna,,163.46,68,,1831.33,1831.33,1831.33,16,27.96,204.32,"percent of total billed charges",
"SUT VICRYL PLUS SUTUPAK 4-0 18IN BRAID 12 STRAND",SUP-VCP103G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UHC [10700]","United Healthcare",,15.83,63.3,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II MULTIPASS 5-0 PS-2 18IN MONOFILAMENT UNDYED",SUP-Z495G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 70MM STAINLESS STEEL 3.5MM FLUTE CANNULATED",SUP-02.231.670,CDM,C1713,HCPCS,0278,RC,,,both,,,1631.85,489.55,"CIGNA [10200]","Cigna Open Access",,928.52,56.9,,1144.80,304.56,2275.09,66,189.78,1387.07,"percent of total billed charges",
"CATH METACROSS RX 135CM 60MM 5.7-3.9FR 5MM BALLOON",SUP-BD-L50060CR,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCISSORS LAPAROSCOPIC 31.75CM 8MM DA VINCI XI HOT SHEARS",SUP-470179,CDM,S27000186,LOCAL,0270,RC,,,both,,,2520.00,756,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE PROCEED VASCULAR 170T ANGLE 300CM .014IN",SUP-1030902,CDM,C1769,HCPCS,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 7FR .081IN EBU4 LEFT CURVE GUIDING NYLON",SUP-LA7EBU40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE AMPLATZ SUPER STIFF UROLOGICAL J 145CM 3CM .038IN PTFE",SUP-M0066401071,CDM,C1769,HCPCS,0272,RC,,,both,,,250.91,75.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 300MM 4MM BALLOON DILATATION RAPID",SUP-47540300M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL 12CM LEGEND 3MM 2 FLUTE MATCH HEAD DISSECTING BURR",SUP-T12MH30M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 120CM 6FR 5MM SPACE JOSEPHSON CURVE ELECTROPHYSIOLOGY",SUP-200624S,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Ablt Pulm Tumor Perc Cryo",PX-361000470,CDM,32994,CPT,0361,RC,,,both,,,9566.00,2869.8,"MULTIPLAN [10600]",Multiplan,,8131.1,85,,,,,0,1112.53,9566,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE PLUS 125CM 6FR JL4 CURVE ANGIOGRAPHIC",SUP-SR3056,CDM,S27200284,LOCAL,0272,RC,,,both,,,314.24,94.27,"NOVANET [10819]",Novanet,,235.68,75,,,,,0,36.55,267.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Somatostatin",PX-301000698,CDM,84307,CPT,0301,RC,,,both,,,180.00,54,"CIGNA [10200]","Cigna Open Access",,40.22,,,,,,,0.01,153,"fee schedule",
"AVENIR 10 5 X 6 HELICAL FINISHING COIL",SUP-10HFN-05006,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7033.31,68,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR ZEPHYR XL DR DUAL CHMBR RATE RESPONSIVE EXTENDED",SUP-5826,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"KAISER [10500]",Kaiser,,27872,67,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 150MM .062IN TROCAR TIP DISPOSABLE",SUP-AR-8941K,CDM,C1769,HCPCS,0272,RC,,,both,,,130.50,39.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pathogen Test Platelets",PX-300000416,CDM,P9100,HCPCS,0300,RC,,,both,,,313.00,93.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,143.67,45.9,,,,,0,0.31,266.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR RUST 41MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103541000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"CIGNA [10200]",Cigna,,2083.74,68,,5873.17,5873.17,5873.17,"1 through 10",356.38,2604.67,"percent of total billed charges",
"INTRO SHTH 11FR HMSTS EP",SUP-6270,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT LARGE EXTREMITY HEELBO ELBOW HEEL DISPOSABLE WHITE",SUP-D12039,CDM,S27000186,LOCAL,0270,RC,,,both,,,102.98,30.89,"MULTIPLAN [10600]",Multiplan,,87.53,85,,,,,0,11.98,87.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 8MM 2.25MM CORONARY STENT EVEROLIMUS",SUP-1550225-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUR RND SKEETER OTO-FLEX 0.6MM CARB BLK",SUP-3155626,CDM,S27200284,LOCAL,0272,RC,,,both,,,2002.50,600.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,919.15,45.9,,,,,0,232.89,1702.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 20CMX15CMX1MM GORE-TEX",SUP-1415020010,CDM,C1781,HCPCS,0278,RC,,,both,,,8804.40,2641.32,"AETNA [10100]","Aetna HMO/PPO",,6999.5,79.5,,,,,0,1023.95,7483.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LINER ACETABULAR XLPE HIP CUSTOM KIT CAPITATE",SUP-71701012,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6463.8,27,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FG GATEWAY OTW  US 1.50MM X 9MM",SUP-M0032072209150,CDM,C1725,HCPCS,0272,RC,,,both,,,9423.88,2827.16,"FIRST HEALTH [10303]","First Health",,7539.1,80,,,,,0,1096,8010.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHALLOY NYLON ETHILON 5-0 PC-5 18IN MONOFILAMENT BLACK",SUP-1895G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 15MM 6.5MM G7 DOME HIP ACETABULAR LOW PROFILE",SUP-010000996,CDM,C1713,HCPCS,0278,RC,,,both,,,1174.50,352.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALIPER SURGICAL 3.5IN 2- MM CASTROVIEJO",SUP-60-1931,CDM,S27200284,LOCAL,0272,RC,,,both,,,709.24,212.77,"CIGNA [10200]",Cigna,,482.28,68,,,,,0,82.48,602.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROYAL FLUSH PLUS 100CM 5FR PIGTAIL CURVE ANGIOGRAPHIC",SUP-G58543,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.17,61.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.98,175.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 60MM STAINLESS STEEL T8 SELF TAP LOCK",SUP-02.211.060,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,104.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",104.45,763.41,"percent of total billed charges",
"BURR ATHERECTOMY 135CM 2.5MM ROTABLATOR ROTALINK PLUS",SUP-M0011402500,CDM,C1724,HCPCS,0272,RC,,,both,,,16525.50,4957.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11237.34,68,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION",RX-9791,CDM,J3480,HCPCS,0636,RC,00264-7625-00,NDC,both,1000,ML,100.65,30.19,"FIRST HEALTH [10303]","First Health",,80.52,80,,,,,0,0.24,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cellutome Harvester",PX-E27200297,CDM,E27200297,LOCAL,0272,RC,,,both,,,3364.90,1009.47,"UHC [10700]","United Healthcare",,2129.98,63.3,,,,,0,391.34,2860.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 8MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650408,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"BLUE CROSS [10001]","Blue Cross PPO",,5145.88,39.2,,3949.44,3949.44,3949.44,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"GWIRE CHOICE PT VASCULAR J 300CM .014IN STAINLESS STEEL",SUP-H7491215501J2,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HERMETIC PLUS DRNG CSF ANTIREFLUX VALVE NEEDLELESS",SUP-INS-8301,CDM,S27200284,LOCAL,0272,RC,,,both,,,2317.50,695.25,"MULTIPLAN [10600]",Multiplan,,1969.88,85,,,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 2.25MM CORONARY RAPID EXCHANGE",SUP-ONYXNG22508UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM SPINE PLY NONSTERILE 4MM ROD",SUP-102035110,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR REGULAR 30X3.5MM DST SERIES TA TITANIUM",SUP-TA3035L,CDM,S27200284,LOCAL,0272,RC,,,both,,,275.79,82.74,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,126.59,45.9,,,,,0,32.07,234.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SNARE BARD 20MM 2 SHEATH RETRIEVAL KINK RESISTANT",SUP-SRK30,CDM,C1773,HCPCS,0272,RC,,,both,,,3375.00,1012.5,"MULTIPLAN [10600]",Multiplan,,2868.75,85,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT SMALL INLINE CODMAN CERTAS PLUS SIPHONGUARD",SUP-828814PL,CDM,S27800098,LOCAL,0278,RC,,,both,,,36453.69,10936.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,14581.48,40,,,,,0,4239.56,30985.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 4CM 5MM BALLOON DILATATION ILIAC",SUP-G34329,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 55MM 12MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113612,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5178.6,41.1,,6417.48,6417.48,6417.48,"1 through 10",1465.38,10710,"percent of total billed charges",
"DIL UTERINE HANK 2 END 10.75IN 25/26FR",SUP-52-3725,CDM,S27000186,LOCAL,0270,RC,,,both,,,184.96,55.49,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR VANSCHIE 4",SUP-G13783,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.56,87.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MERSILENE 2-0 FS 18IN BRAID WHITE NONABSORBABLE",SUP-R665H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 8FR 18GA 25CM SPLITTABLE HEMOSTATIC VALVE NDL",SUP-CLS-2508,CDM,C1892,HCPCS,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXCISOR BIOPSY .472X.354IN FISCHER 74D 12MM SMALL CONE",SUP-900-150,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.28,60.98,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Traceostoma Button",PX-E27000256,CDM,A7524,HCPCS,0270,RC,,,both,,,800.80,240.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 9.5FR 14CM HEMOSTASIS PEEL AWAY .038IN",SUP-405148,CDM,C1892,HCPCS,0272,RC,,,both,,,356.70,107.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,42.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.48,303.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 9CM 5FR STRAIGHT PANCREATIC POLYMER RADIOPAQUE",SUP-M00536310,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"BLUE CROSS [10001]","Blue Cross HMO",,250.59,39.2,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABLE, 12X26MM, 7-14MM, 15%C2%B0",SUP-1172.4121S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9355.5,27,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT STD PRECHAMBER MEDIUM HIGH PRESSURE RANGE",SUP-823009,CDM,S27800098,LOCAL,0278,RC,,,both,,,6094.49,1828.35,"BLUE CROSS [10001]","Blue Cross PPO",,2389.04,39.2,,,,,0,708.79,5180.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM SPINE PLY NONSTERILE 4MM ROD",SUP-102040126,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 2CM 9MM BALLOON DILATATION OTW LOW PROFILE",SUP-G30922,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 30.5",SUP-DIB00U0305,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 110MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 6",SUP-71357106,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"CIGNA [10200]",Cigna,,13256.46,40,,5873.17,5873.17,5873.17,"1 through 10",3854.32,28169.98,"percent of total billed charges",
"SPHERE GLENOID 42MM TORNIER AEQUALIS PERFORM STD SHOULDER",SUP-DWJ014,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"KAISER [10500]",Kaiser,,8169.31,67,,,,,0,1418.05,10364.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY DRNG 12FR FLEXIBLE STAYFIX SMALL SECUREMENT DEVICE",SUP-RLC-NV-12-SFX,CDM,C1729,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grad Compression Thight 20-30",PX-E27100024,CDM,A6533,HCPCS,0292,RC,,,both,,,191.40,57.42,"CIGNA [10200]","Cigna Open Access",,108.91,56.9,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL KNIFE 24FR STERILE DISPOSABLE TUIP",SUP-M0068802371,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,212.27,41.1,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ENDARTERECTOMY 12MM 14MM 2 COAXIAL METAL RING",SUP-E4500-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,15835.50,4750.65,"AETNA [10100]","Aetna HMO/PPO",,12589.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1841.67,13460.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PERFORM STEM RSA-PERF REV STD",SUP-CAP1188,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"MULTIPLAN [10600]",Multiplan,,38556,85,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 26MM SAPIEN 3 ULTRA RESILIA",SUP-S3URCM26A,CDM,S27800098,LOCAL,0278,RC,,,both,,,193800.00,58140,"BLUE CROSS [10001]","Blue Cross PPO",,75969.6,39.2,,,,,0,22538.94,164730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Lung Ventil&Perfsn",PX-341000032,CDM,78582,CPT,0341,RC,,,both,,,2819.08,845.72,"KAISER [10500]",Kaiser,,1888.78,67,,,,,0,327.86,2396.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752710,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"MULTIPLAN [10600]",Multiplan,,766.85,85,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 3CM 4FR PIGTAIL PANCREATIC POLYMER RADIOPAQUE",SUP-M00536870,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"KAISER [10500]",Kaiser,,428.3,67,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC QUANTUM TTC 320CM 3CM 8MM 6.8-4.5FR BILIARY",SUP-G22766,CDM,C1726,HCPCS,0272,RC,,,both,,,3045.00,913.5,"FIRST HEALTH [10303]","First Health",,2436,80,,,,,0,354.13,2588.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM SWIVELOCK C CLOSED EYELET VENT",SUP-AR-2324BCCTT,CDM,C1713,HCPCS,0278,RC,,,both,,,3701.25,1110.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,438.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,430.46,3146.06,"percent of total billed charges",
"SLEEVE OFFSET +7.0MM ENCORE",SUP-411-00-700,CDM,C1776,HCPCS,0278,RC,,,both,,,947.54,284.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,112.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,110.2,805.41,"percent of total billed charges",
"STEM FEMORAL MONOBLOCK 7",SUP-510-00-007,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3606.12,28.62,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 2MM CONCERTO DETACHABLE HELIX PERIPHER",SUP-NV-2-8-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X6MM ENDOSKELETON TCS 6D 12MM SMALL TITANIUM",SUP-5346-1206-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,23310.00,6993,"AETNA [10100]","Aetna HMO/PPO",,18531.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 25X9X15MM CONCORDE 10D THORACOLUMBAR CFRP INLINE",SUP-187855215,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1962.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 5FR 10MM SPACE D CURVE",SUP-F5QD010RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,372.86,41.1,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASTECTOMY FOR MALIGNANCY WITH CC/MCC",582,MS-DRG,,,,,,,inpatient,,,163503.95,49051.18,"CIGNA [10200]",Cigna,,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 55.9%. Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 19.5MM THK.38MM 41MM MICRO OSCILLATE SAGITTAL 2",SUP-5400-003-254,CDM,S27200284,LOCAL,0272,RC,,,both,,,430.48,129.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL ENDOSCOPIC CRE 240CM 5.5CM 7.5FR 10-12MM ESOPHAGUS",SUP-M00558680,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ASAHI FIELDER XT-R 190CM",SUP-APW14R005S,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 150CM 60MM 4MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013466-060,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GO2VENT (100% FIO2 ONLY, NO ENTRAINMENT) WITH MANOMETER AND 10",SUP-64-6001,CDM,S27200284,LOCAL,0272,RC,,,both,,,469.80,140.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WEBSTER COMPLI REDEL 110CM 1MM 5FR 2-5-2MM SPACE A",SUP-F5CQA252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,inpatient,,,159071.74,47721.52,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 20MM 4MM BALLOON DILATATION PACLITAXEL RADIOPAQUE",SUP-H7493960820400,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"BEARING OXFORD KNEE LEFT MEDIAL RIGHT LATERAL",SUP-154720,CDM,C1776,HCPCS,0278,RC,,,both,,,11195.94,3358.78,"BLUE CROSS [10001]","Blue Cross HMO",,4388.81,39.2,,5311.50,4717.44,5388.59,31,1302.09,9516.55,"percent of total billed charges",
"CATH SABERX 200CM 120MM 1.5MM BALLOON DILATATION RAPID",SUP-47515120L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X13MM LUMINARY CC BICONVEX SPINE",SUP-6813,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"CIGNA [10200]",Cigna,,13305.6,40,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATHLETIC SUPPORTER MALE 38 TO 44IN KNITTED STRETCH ELASTIC",SUP-2570-01L,CDM,S27000186,LOCAL,0270,RC,,,both,,,216.89,65.07,"MULTIPLAN [10600]",Multiplan,,184.36,85,,,,,0,25.22,184.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM TSRH OSTEOGRIP TITANIUM SHORT POST SPINE",SUP-83565451,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1181.47,45.9,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 CURVE PLUS 20MM KNEE XLK FIX BEARING SIGMA",SUP-970455,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"KAISER [10500]",Kaiser,,7486.95,67,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 27MM SJM TAILOR SILICONE FLEXIBLE SURE",SUP-TAB-27,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"CIGNA [10200]",Cigna,,4842.56,40,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 4.0MM X 8.0MM",SUP-494000812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE CONNECTING 40CM 14FR PVC DRNG BAG CNCT STPCOCK STERILE",SUP-G02327,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.36,35.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,79.8,68,,,,,0,13.65,99.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXIVA PULSE ID 242",SUP-M006L8406910,CDM,S27200284,LOCAL,0272,RC,,,both,,,2856.45,856.93,"FIRST HEALTH [10303]","First Health",,2285.16,80,,,,,0,332.21,2427.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5F DECA 4-4-4-29-4-4-4-4-4 MPA 120CM",SUP-901580,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"KAISER [10500]",Kaiser,,1984.88,67,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL CEMENT HEAD POROUS STD SHOULDER GLENOID",SUP-98000900025,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11004.53,41.1,,6417.48,6417.48,6417.48,"1 through 10",3113.93,22758.75,"percent of total billed charges",
"PIN FIXATION 2.5IN ANKLE STERILE",SUP-351-90-22,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"CIGNA [10200]","Cigna Local Plus",,455.02,53.5,,3978.14,359.25,3978.14,24,98.91,722.93,"percent of total billed charges",
"COIL EMBOLIZATION 3CM 1MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES0103CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE EMERALD VASCULAR 3MM RADIUS 150CM 7CM .035IN PTFE",SUP-502521,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"FIRST HEALTH [10303]","First Health",,76.56,80,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP REVERSE SHOULDER: SHORT STEM RSA W/ AUGMENTS",SUP-71701432,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19937.61,41.1,,6417.48,6417.48,6417.48,"1 through 10",5641.71,41233.5,"percent of total billed charges",
"CMPNT FEMORAL 5 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-71422345,CDM,C1776,HCPCS,0278,RC,,,both,,,29720.25,8916.07,"CIGNA [10200]","Cigna Open Access",,9956.28,33.5,,5302.19,4377.88,6578.61,27,3456.47,25262.21,"percent of total billed charges",
"SCR BONE 4.5MM 15MM INSET SHOULDER LOCK PERPENDICULAR",SUP-2R1PT45015,CDM,C1713,HCPCS,0278,RC,,,both,,,865.08,259.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,100.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",100.61,735.32,"percent of total billed charges",
"LARYNSCP VIDEO S3 GLIDESCOPE SPECTRUM MACINTOSH DISPOSABLE",SUP-0270-1085,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"CIGNA [10200]",Cigna,,236.64,68,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL WEIL-BLAKESLEY 45D UP 1 4MM 4.5IN SINUS",SUP-3711041,CDM,S27200284,LOCAL,0272,RC,,,both,,,3720.68,1116.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1707.79,45.9,,,,,0,432.72,3162.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTECH DEMINERALIZED BONE FIBER 3CC ALLOGRAFT",SUP-T50103,CDM,C1713,HCPCS,0278,RC,,,both,,,4761.00,1428.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2185.3,45.9,,,,,0,553.7,4046.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBERFUSE ALLOGRAFT",SUP-420605,CDM,C1713,HCPCS,0278,RC,,,both,,,9018.30,2705.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6132.44,68,,,,,0,1048.83,7665.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TI LOW PROFILE TRANSCONNECTOR 42MM-55MM FOR 6.0MM RODS",SUP-497.798,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"NOVANET [10819]",Novanet,,2812.5,75,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 6MM AVENIR 10 HELICAL FINISH STERILE",SUP-10HFN-06008,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4747.48,45.9,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 7MM KNEE POSTERIOR STABILIZE IDENTITY IMPRINT",SUP-TPS-020-075S,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"BLUE CROSS [10001]","Blue Cross PPO",,2304.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",683.7,4996.98,"percent of total billed charges",
"HEAD FEMORAL -4 32MM HIP BIOLOX DELTA FMP SYSTEM",SUP-400-03-321,CDM,C1776,HCPCS,0278,RC,,,both,,,16953.92,5086.18,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6968.06,41.1,,6417.48,6417.48,6417.48,"1 through 10",1971.74,14410.83,"percent of total billed charges",
"12MM AMPLATZER MUSCULAR VSD OCCLUDER",SUP-9-VSD-MUSC-012,CDM,C1817,HCPCS,0278,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM 32MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-217.055,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,52.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",52.23,381.7,"percent of total billed charges",
"CAGE SPINAL 50X18X10MM COROENT 10 XL PEEK",SUP-6981050,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS [10001]","Blue Cross PPO",,9313.92,39.2,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE CAST SMALL CANVAS RUBBER ROCKER SOLE HOOP LOOP CLSR",SUP-2035-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.41,13.62,"CIGNA [10200]","Cigna Local Plus",,24.29,53.5,,,,,0,5.28,38.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 25MM FLEXIBLE SCR",SUP-71362925,CDM,S27200284,LOCAL,0272,RC,,,both,,,1538.19,461.46,"CIGNA [10200]",Cigna,,1045.97,68,,,,,0,178.89,1307.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHTH 10.5FR 1 SYS LNG",SUP-8004,CDM,C1892,HCPCS,0272,RC,,,both,,,252.30,75.69,"KAISER [10500]",Kaiser,,169.04,67,,,,,0,29.34,214.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENAZOPYRIDINE 100 MG TABLET",RX-6193,CDM,,,0637,RC,10135-0620-01,NDC,both,1,UN,8.00,2.4,"FIRST HEALTH [10303]","First Health",,6.4,80,,,,,0,0.93,6.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC BALANCE 13IN THERABAND PREINFLATE",SUP-81510445,CDM,S27000186,LOCAL,0270,RC,,,both,,,256.65,76.99,"UHC [10700]","United Healthcare",,162.46,63.3,,,,,0,29.85,218.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 36MM MITRAL VALVE STIFFNESS COMPOSITE LOW",SUP-638RL36,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 75CM 7FR BANDER .038IN 5MM PIGTAIL CURVE URETER",SUP-G18070,CDM,C2617,HCPCS,0272,RC,,,both,,,959.04,287.71,"UHC [10700]","United Healthcare",,607.07,63.3,,,,,0,111.54,815.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 28MM 9MM BLUNT FULL THREAD",SUP-AR-1390TC,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"FIRST HEALTH [10303]","First Health",,1480.5,80,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ONE STEP 15CM 5FR DRNG TEFLON 4 SIDEHOLE INTRO NDL SLIP",SUP-OSC-5F-15S,CDM,C1729,HCPCS,0272,RC,,,both,,,160.95,48.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,109.45,68,,,,,0,18.72,136.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP TOTAL SHOULDER: SHORT STEM TSA W/ AUGMENTS",SUP-71701428,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"CIGNA [10200]",Cigna,,11970,40,,5873.17,5873.17,5873.17,"1 through 10",3480.28,25436.25,"percent of total billed charges",
"PLATE EXTERNAL FIXATION SALVATION FOOT ANKLE OPEN ROCKER",SUP-SEF02401,CDM,C1713,HCPCS,0278,RC,,,both,,,13703.40,4111.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5632.1,41.1,,,,,0,1593.71,11647.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 100MM 2MM .014IN BALLOON DILATATION NYBAX",SUP-39186-20101,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 124MM 28-16MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1628C124E,CDM,C1876,HCPCS,0278,RC,,,both,,,31342.50,9402.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8462.48,27,,,,,0,3645.13,26641.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 2-0 GS-21 .5 CIRCLE 9IN TAPER POINT",SUP-VLOCL0345,CDM,S27200284,LOCAL,0272,RC,,,both,,,405.94,121.78,"AETNA [10100]","Aetna HMO/PPO",,322.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.21,345.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 10CM 3.3MM 2 PIGTAIL CURVE BILIARY PLASTIC",SUP-M00532290,CDM,C2617,HCPCS,0278,RC,,,both,,,447.93,134.38,"FIRST HEALTH [10303]","First Health",,358.34,80,,,,,0,52.09,380.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER CHOCOLATE 150MM 40MM 3MM .014IN BALLOON DILATATION",SUP-CB1415030040OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE PT VASCULAR 300CM .014IN STAINLESS STEEL",SUP-H7491215401J2,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32.5MM TRIGEN FEMUR LOW PROFILE",SUP-71645032,CDM,C1713,HCPCS,0278,RC,,,both,,,2314.95,694.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,662.54,28.62,,,,,0,269.23,1967.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cleanser Wound Debrisoft Lolly",PX-E27200436,CDM,E27200436,LOCAL,0272,RC,,,both,,,73.70,22.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.57,62.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PLA HA 20MM 7MM ACL TAPERED BIOCOMPATIBLE",SUP-72201771,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X20X12MM PIVOX 6D LATERAL OLIF25",SUP-2111355,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"FIRST HEALTH [10303]","First Health",,21168,80,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM FETAL PILLOW DELIVERY BALLOON CEPHALIC ELEVATION",SUP-FP-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,5649.95,1694.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,669.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,657.09,4802.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Biliary DRN Extrnl",PX-361000400,CDM,47533,CPT,0361,RC,,,both,,,6602.46,1980.74,"CIGNA [10200]",Cigna,,6602.46,,"Case rate ($10,015). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,767.87,6602.46,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"AXS UNIVERSAL ASPIRATION TUBING",SUP-077.0193,CDM,S27200284,LOCAL,0272,RC,,,both,,,2460.00,738,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE LESLIE PARACHUTE 120CM 11MM 3.1FR SPECIMEN RETRIEVAL",SUP-M0063203020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1464.48,439.34,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT E-LUMINEXX SAFE PERFORMAXX 60MM 80CM 10MM 6FR .035IN",SUP-ZBM10060,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"UHC [10700]","United Healthcare",,6333.17,63.3,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 4MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS04015,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AETNA [10100]","Aetna HMO/PPO",,9319.86,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 14MM TIMESH CENTERPIECE CRANIAL TITANIUM OPEN",SUP-853014WM,CDM,C1713,HCPCS,0278,RC,,,both,,,2624.40,787.32,"BLUE CROSS [10001]","Blue Cross HMO",,1028.76,39.2,,957.42,156.86,7483.26,51,305.22,2230.74,"percent of total billed charges",
"CATH RANGER 135CM 60MM 7MM BALLOON DILATATION PACLITAXEL OTW",SUP-H74939419700610,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1003.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 20X30CM SELF GRIP RESORBING",SUP-TSB3030,CDM,C1781,HCPCS,0278,RC,,,both,,,62700.00,18810,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7292.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLUX SPARC 2CC",SUP-IFLX-CM-02,CDM,S27800098,LOCAL,0278,RC,,,both,,,7555.50,2266.65,"PHCS [10601]",PHCS,,5288.85,70,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARCADIA 20MM 10GA BALLOON DILATATION HIGH PRESSURE",SUP-ARC20ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,5978.16,1793.45,"CIGNA [10200]","Cigna Open Access",,3401.57,56.9,,,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLUX SPARC 5CC",SUP-IFLX-CM-05,CDM,S27800098,LOCAL,0278,RC,,,both,,,15007.50,4502.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6003,40,,,,,0,1745.37,12756.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 18-20MM EVOLUT FX+ 23MM ANNULUS",SUP-EVFXPLUS-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,182400.00,54720,"PHCS [10601]",PHCS,,127680,70,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 5FR 20CM PER-Q-CATH PLUS 2 LUMEN RADIOPAQUE INTRO",SUP-4245202,CDM,C1751,HCPCS,0272,RC,,,both,,,487.62,146.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,56.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.71,414.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MX523 ETHBOND 2-0",SUP-MX523,CDM,S27200284,LOCAL,0272,RC,,,both,,,175.94,52.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.46,149.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 24FR STERILE DISPOSABLE COAGULATE",SUP-27050NP-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1459.48,437.84,"NOVANET [10819]",Novanet,,1094.61,75,,,,,0,169.74,1240.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 8MM 140CM 4MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927408400,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"AMERIGROUP MEDICAID [20100]",Amerigroup,,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 4MM SURGICAL REVERE 6.35MM ROD",SUP-634.213,CDM,C1713,HCPCS,0278,RC,,,both,,,583.20,174.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,67.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",67.83,495.72,"percent of total billed charges",
"SCR BONE 7.3MM 115MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.915,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CIGNA [10200]",Cigna,,934.6,68,,1831.33,1831.33,1831.33,16,159.84,1168.25,"percent of total billed charges",
"HC NM Lung Perfsn Diff",PX-341000033,CDM,78597,CPT,0341,RC,,,both,,,2819.08,845.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,982.43,,,,,,,236.17,2396.22,"fee schedule",
"BUSHG TIBIAL OSS KNEE POLYETHYLENE LOW FRICTION INTERFACE",SUP-150476,CDM,C1770,HCPCS,0278,RC,,,both,,,2460.00,738,"NOVANET [10819]",Novanet,,1845,75,,,,,0,286.1,2091,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 68MM 3 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800368,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"HC Cann Bio-Med Multi-Stage 19f",PX-E27200397,CDM,E27200397,LOCAL,0272,RC,,,both,,,2162.60,648.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,888.83,41.1,,,,,0,251.51,1838.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 19MM 14.8MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-19MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"MULTIPLAN [10600]",Multiplan,,24751.35,85,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON UVA VIVITY AUTONOME",SUP-CCAET0,CDM,V2788,HCPCS,0276,RC,,,both,,,880.00,264,"BLUE CROSS [10001]","Blue Cross HMO",,344.96,39.2,,,,,0,102.34,748,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP 5 SCR HOLE CLUSTER TRITANIUM",SUP-702-04-58F,CDM,C1776,HCPCS,0278,RC,,,both,,,12551.10,3765.33,"FIRST HEALTH [10303]","First Health",,10040.88,80,,,,,0,1459.69,10668.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHARGER 3.0 X20  135CM",SUP-H74939206030210,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL CRYOABLATION 17.5CM 14GA ICEPEARL 2.1CX STRAIGHT IMAGE",SUP-FPRPR3603,CDM,C2618,HCPCS,0272,RC,,,both,,,13110.00,3933,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT PRESS FIT EMPOWR 3D KNEE STERILE",SUP-243-01-106,CDM,C1776,HCPCS,0278,RC,,,both,,,27824.45,8347.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7963.36,28.62,,,,,0,3235.98,23650.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 14X4MM COLOSSEUM 3.5D 12MM NONSTERILE LATEX",SUP-156.264,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,407.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM GORILLA R3CON LOCK",SUP-P50-353-3516,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,523.91,39.2,,957.42,156.86,7483.26,51,155.43,1136.03,"percent of total billed charges",
"GRAFT ENDOVASCULAR 124MM 16-13MM 14FR ENDURANT II ABDOMEN",SUP-ETLW1613C124E,CDM,S27800098,LOCAL,0278,RC,,,both,,,30315.60,9094.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3525.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3525.7,25768.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA2-17-100-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,9177.00,2753.1,"UHC [10700]","United Healthcare",,5809.04,63.3,,,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV",RX-122733,CDM,,,0250,RC,00338-0112-20,NDC,both,250,ML,157.30,47.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,106.96,68,,,,,0,18.29,133.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 24MM LCP STAINLESS STEEL CORTICAL FOREFOOT",SUP-202.884,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"MULTIPLAN [10600]",Multiplan,,275.39,85,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL KNEE TRIATHLON 3D BUMPER HINGE",SUP-5612-4-003,CDM,C1776,HCPCS,0278,RC,,,both,,,6003.00,1800.9,"BLUE CROSS [10001]","Blue Cross PPO",,2353.18,39.2,,3949.44,3949.44,3949.44,"1 through 10",698.15,5102.55,"percent of total billed charges",
"ELECTRD EEG CERIBELL MEDIUM HEADBAND NONSTERILE LATEX FREE",SUP-C152,CDM,S27200284,LOCAL,0272,RC,,,both,,,4167.60,1250.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2833.97,68,,,,,0,484.69,3542.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TR BAND LARGE 29CM COMPRESSION RADIAL ARTERY 2",SUP-TRB29-LRG,CDM,S27000186,LOCAL,0270,RC,,,both,,,252.30,75.69,"PHCS [10601]",PHCS,,176.61,70,,,,,0,29.34,214.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM CONCERTO 3D",SUP-PV-2-4-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM QUICKFIX TITANIUM T15 SHORT THREAD",SUP-AR-8740-30PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA PERFUSION BIO-MEDICUS OD19 FR",SUP-96570-019,CDM,S27200284,LOCAL,0272,RC,,,both,,,2120.63,636.19,"UHC [10700]","United Healthcare",,1342.36,63.3,,,,,0,246.63,1802.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP MEDIUM LARGE INTERNAL HORIZON TITANIUM ENDOSCOPIC",SUP-003200,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.62,29.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,67.74,68,,,,,0,11.59,84.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45 REPOSABLE DA VINCI SI ENDOWRIST",SUP-410298,CDM,S27000186,LOCAL,0270,RC,,,both,,,1134.00,340.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,131.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 80MM 3.2MM ORTHOSOFT STRAIGHT CAS",SUP-20800000011,CDM,S27200284,LOCAL,0272,RC,,,both,,,963.90,289.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,442.43,45.9,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPANDER BREAST TISSUE 600CC SUTURE TAB MODERATE HEIGHT EXTR",SUP-133P-MX-14-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9991.20,2997.36,"CIGNA [10200]","Cigna Local Plus",,5345.29,,,,,,,1161.98,8492.52,"percent of total billed charges",
"LEAD NEROSTIMLTR 70CM PRECISION .014IN TRIAL LINEAR STRAIGHT",SUP-SC-2218-70E,CDM,C1778,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER PACING LEAD ACUITY 8FR",SUP-7442,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 40MX19.5MMX.4MM STERILE",SUP-KM-3231,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25.39,41.1,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MONOFOCAL PRELOAD 1 PIECE UV BLOCK TECNIS ITEC",SUP-PCB0000270,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 60MM 13.5MM 10FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEL14060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UHC [10700]","United Healthcare",,11564.91,63.3,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 19MM 150CM 5MM BILIARY STAINLESS",SUP-37912-51915,CDM,C1876,HCPCS,0278,RC,,,both,,,3967.50,1190.25,"BLUE CROSS [10001]","Blue Cross PPO",,1555.26,39.2,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER YELLOW 4.5MM DYONICS STRAIGHT FULL RADIUS",SUP-7205306,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.00,84.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,129.9,45.9,,,,,0,32.91,240.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE REAMER 26MM PILOT HOLE KNEE PATELLA STAINLESS STEEL",SUP-597909526,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.02,350.41,"KAISER [10500]",Kaiser,,782.57,67,,,,,0,135.84,992.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 14LP 170CM 12CM 4FR 4MM .014IN BALLOON",SUP-G50338,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"AETNA [10100]","Aetna HMO/PPO",,1878.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +15.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.155,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"MULTIPLAN [10600]",Multiplan,,293.25,85,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM .0115IN AXIUM PRIME LATTICEFX 3D",SUP-APB-4-6-3D-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,9591.00,2877.3,"PHCS [10601]",PHCS,,6713.7,70,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.828,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,160.92,68,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 20CM 34MM GORE TAG THORACIC ACTIVE CONTROL",SUP-TGM343420,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13742.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 12MM 135CM 6.5MM 3.3-3.5FR 6FR LOW",SUP-1011502-12,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"AETNA [10100]","Aetna HMO/PPO",,5008.5,79.5,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Breast MR Clip Plc",PX-361000310,CDM,19085,CPT,0361,RC,,,both,,,5365.30,1609.59,"NOVANET [10819]",Novanet,,4023.98,75,,,,,0,623.98,5365.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL THK1.5MM 2-0 V-5 36IN 2 ARM BRAID FIRM",SUP-SX54H,CDM,S27200284,LOCAL,0272,RC,,,both,,,97.77,29.33,"FIRST HEALTH [10303]","First Health",,78.22,80,,,,,0,11.37,83.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 18MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ318,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"MULTIPLAN [10600]",Multiplan,,817.7,85,,,,,0,111.88,817.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 18LP 80CM 2CM 4FR 7MM .018IN BALLOON DILATATION",SUP-G50254,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENICILLIN G DESENSITIZATION (10 MG/ML)",RX-410812,CDM,,,0636,RC,09999-9997-07,NDC,both,250,ML,100.65,30.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,50.33,50,,,,,0,11.93,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXXCESS 6FR URETERAL OPEN END",SUP-M0064051160,CDM,C1758,HCPCS,0272,RC,,,both,,,746.25,223.87,"PHCS [10601]",PHCS,,522.38,70,,,,,0,86.79,634.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW TITANIUM 4 HOLE GEMINUS BONE RADIAL RIGHT",SUP-GMN-RTN-4HL,CDM,C1713,HCPCS,0278,RC,,,both,,,5161.20,1548.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,611.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",600.25,4387.02,"percent of total billed charges",
"SLEEVE LAPAROSCOPIC 5MM 100MM KII ABDOMINAL LOW PROFILE Z",SUP-CTS29,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"FIRST HEALTH [10303]","First Health",,55.68,80,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Brst Ndl Perc WO Guide",PX-361000563,CDM,19100,CPT,0361,RC,,,both,,,2480.00,744,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2292.95,,"Fee schedule rate ($2,292.95).",,,,0,288.42,2480,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Declot Impl Vad/Cath",PX-361000121,CDM,36593,CPT,0361,RC,,,both,,,1572.38,471.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,186.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,182.87,1572.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1.5MM DELTAXSFT 10 COIL",SUP-DLX100152,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6155.9,68,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 5.5MM TITANIUM PREBENT",SUP-8052120,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1262.14,28.62,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Klhl11 Antb Sr/CSF Asy Qual",PX-310000048,CDM,0432U,CPT,0310,RC,,,both,,,72.00,21.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,48.96,68,,,,,0,8.53,61.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE ANGLE 1.5MM MANDIBLE 4 HOLE BAR 2/2.3MM SCR BONE",SUP-55-15524,CDM,C1713,HCPCS,0278,RC,,,both,,,2846.03,853.81,"CIGNA [10200]","Cigna Local Plus",,1522.63,53.5,,3978.14,359.25,3978.14,24,330.99,2419.13,"percent of total billed charges",
"FRCP SURGICAL ADSON 4.75IN TISSUE 1X2 TEETH TUNGSTEN CARBIDE",SUP-122500,CDM,S27000186,LOCAL,0270,RC,,,both,,,474.17,142.25,"AETNA [10100]","Aetna HMO/PPO",,376.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.15,403.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 10MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158122110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4592.74,41.1,,6417.48,6417.48,6417.48,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"HC Drug Test Definitiv 8-14 Class",PX-301000671,CDM,G0481,HCPCS,0301,RC,,,both,,,313.00,93.9,"PHCS [10601]",PHCS,,219.1,70,,,,,0,0.31,266.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSSEOFLEX CONVENIENCE PACKS OSSEOFLEX SB 10GA/4ML STRAIGHT S",SUP-OCP-0014,CDM,S27200284,LOCAL,0272,RC,,,both,,,12054.30,3616.29,"UHC [10700]","United Healthcare",,7630.37,63.3,,,,,0,1401.92,10246.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 30FR RIGHT VENT DLP STERILE LATEX FREE",SUP-67530,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.59,90.48,"UHC [10700]","United Healthcare",,190.91,63.3,,,,,0,35.07,256.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL HARTMANN 5.5IN EAR SERRATE DELICATE 6X3MM",SUP-61-0111,CDM,S27200284,LOCAL,0272,RC,,,both,,,587.66,176.3,"FIRST HEALTH [10303]","First Health",,470.13,80,,,,,0,68.34,499.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM SEMIRIGID OPEN ANTERIOR SEG SEWING",SUP-5300M26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1635.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 24MM 144CM 2.5MM CORONARY STENT PEBAX",SUP-H7493926024250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tubing Press Monitor Sep",PX-E27200272,CDM,E27200272,LOCAL,0272,RC,,,both,,,414.70,124.41,"KAISER [10500]",Kaiser,,277.85,67,,,,,0,48.23,352.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (OTW)  2.00MM X 15MM",SUP-H74939402152000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,641.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Yttrium 90 Ibritumomab Mci",PX-344000005,CDM,A9543,HCPCS,0344,RC,,,both,,,29229.00,8768.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3463.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3399.33,29229,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 11MM X 14MM",SUP-4W7405,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 135CM 30MM 7MM .035IN BALLOON",SUP-AB35W07030135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"UHC [10700]","United Healthcare",,428.64,63.3,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB 60IN 1 CNCT STANDARDIZATION MULTIFUNCTION",SUP-PEDIATRIC-ZOLL,CDM,S27000186,LOCAL,0270,RC,,,both,,,177.52,53.26,"AETNA [10100]","Aetna HMO/PPO",,141.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.65,150.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X11MM 9-11MM SPINE CORTICAL FROZEN",SUP-4911,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4471.2,27,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL KOCHER-OCHSNER STRAIGHT 160MM 1X2 TEETH",SUP-BH642R,CDM,S27000186,LOCAL,0270,RC,,,both,,,205.67,61.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,94.4,45.9,,,,,0,23.92,174.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 9MM 33MM METAL BACKED SYMMETRIC RESURFACING",SUP-5556-L-339,CDM,C1776,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Local Plus",,2359.35,53.5,,5372.07,4581.20,7242.98,23,512.88,3748.5,"percent of total billed charges",
"CATH BARDEX IC 24FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0166SI24,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.21,20.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,31.31,45.9,,,,,0,7.93,57.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALCON SURGICAL STANDARD EYE PACK",SUP-AS2277-19,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.14,30.34,"CIGNA [10200]","Cigna Local Plus",,54.11,53.5,,,,,0,11.76,85.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.185,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 5.25IN 9GA AORTIC ROOT ADULT STD VENT LINE",SUP-24009,CDM,S27200284,LOCAL,0272,RC,,,both,,,253.90,76.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,172.65,68,,,,,0,29.53,215.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 2IN 22GA ROSEN EAR 60MM",SUP-61-1041,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.91,23.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.18,67.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Arm/Hnd Bi",PX-510000095,CDM,29584,CPT,0761,RC,,,both,,,892.05,267.61,"FIRST HEALTH [10303]","First Health",,713.64,80,,,,,0,103.75,892.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA STD TKR FEMUR TIBIA",SUP-98000900255,CDM,C1776,HCPCS,0278,RC,,,both,,,36225.00,10867.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9780.75,27,,,,,0,4212.97,30791.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MR DRILL BIT 7.5 X 2.5MM BALL FLTD",SUP-75BA25L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1328.40,398.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,154.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Abdomen WO Cntrst",PX-610000040,CDM,74181,CPT,0610,RC,,,both,,,3907.20,1172.16,"MULTIPLAN [10600]",Multiplan,,3321.12,85,,,,,0,436.01,3321.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 30IN 2 PORT 1 BLADDER PUMP LINE CNCT ATS STERILE",SUP-60707010500,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.78,62.03,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.05,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT LAPAROSCOPIC CURVE JAW CORDLESS ULTRASONIC 26CM",SUP-SCDA26,CDM,S27200284,LOCAL,0272,RC,,,both,,,2887.50,866.25,"PHCS [10601]",PHCS,,2021.25,70,,,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lymph Choriomeningitiss Ab",PX-302000153,CDM,86727,CPT,0302,RC,,,both,,,88.00,26.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.72,,,,,,,0.01,74.8,"fee schedule",
"BAYONET 9IN STR TIP DN621",SUP-DN6218,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"PHCS [10601]",PHCS,,1134,70,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Stent Cmplx Ea Add",PX-361000728,CDM,37287,CPT,0361,RC,,,both,,,10928.93,3278.68,"NOVANET [10819]",Novanet,,8196.7,75,,,,,0,10.93,9289.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 25MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE45025,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"CIGNA [10200]",Cigna,,33465.84,40,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 4CM 2MM BALLOON DILATATION",SUP-U815024,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN SUCTION 3MM 30CM POWER ASSISTED LIPOPLASTY DISPOSABLE",SUP-PAL-302LL,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"CIGNA [10200]","Cigna Open Access",,364.1,56.9,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 100MM 3.5MM BALLOON DILATATION RAPID",SUP-47535100L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH URETHRAL BARDEX IC 22FR FOLEY 2 WAY COUNCIL TIP 2",SUP-0196SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.25,42.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2MM 14MM APTUS TITANIUM 6MM HEAD HAND CORTICAL LOCK",SUP-A-5450.14/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN BONE CEMENT 15CM 18GA NDL ACCESS CHIBA",SUP-K12-08326,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.10,33.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 5X5CM GRAFIX PRIME PLACENTAL MEMBRANE ALLO",SUP-PS13055,CDM,Q4133,HCPCS,0636,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"EMTRICITABINE 200 MG CAPSULE",RX-36252,CDM,,,0637,RC,61958-0601-01,NDC,both,1,UN,81.12,24.34,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 11.5CM NATRELLE INSPIRA P5.8CM EXTRA FULL PROFILE",SUP-MSZ-X400,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXP TISSUE 15.5X13.5CM BREAST 800ML STYLE 133SV TEXTURED SUT",SUP-133SX-16-T,CDM,C1789,HCPCS,0278,RC,,,both,,,6510.00,1953,"CIGNA [10200]","Cigna Local Plus",,3482.85,,,,,,,757.11,5533.5,"percent of total billed charges",
"CATH BLAZER PRIME XP 110CM 8MM 7FR 8FR 2.5MM SPACE STRAIGHT",SUP-M004P4790THK20,CDM,C1733,HCPCS,0272,RC,,,both,,,12916.80,3875.04,"MULTIPLAN [10600]",Multiplan,,10979.28,85,,,,,0,1502.22,10979.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POUCH SURGICAL TISSUE 6X4IN LAPSAC DRAWSTRING 200ML STERILE",SUP-G16495,CDM,S27200284,LOCAL,0272,RC,,,both,,,438.99,131.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,298.51,68,,,,,0,51.05,373.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Stnt Sngl Maj Cor Arty 1 Les",PX-481000075,CDM,92928,CPT,0481,RC,,,both,,,29546.89,8864.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,13394.16,,"Fee schedule rate ($13,394.16).",,,,0,3436.3,25681,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mnt Subq Ea 15min Reassess",PX-942000009,CDM,G0270,HCPCS,0942,RC,,,both,,,75.00,22.5,"CIGNA [10200]",Cigna,,51,68,,,,,0,8.72,75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4N NARROW KNEE LEFT POSTERIOR STABILIZE LEGION",SUP-71421264,CDM,C1776,HCPCS,0278,RC,,,both,,,32536.35,9760.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13014.54,40,,,,,0,3783.98,27655.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 36MM ORTHOLOC FULL THREAD CORTICAL ANKLE FOOT",SUP-58813536,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,523.26,68,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 30ML .1-4MM ALLOGRAFT CRUSH FROZEN",SUP-T20025,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 100CM 40MM 9MM BALLOON DILATATION DRUG COATED",SUP-LX35100940V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,983.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 4MM TRAUMAONE LORENZ TITANIUM MIDFACE SELF",SUP-916104,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 60MM 75CM 16MM 9FR 100CM",SUP-40332,CDM,C1876,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,797.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X60 135CM SL",SUP-48007006R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,101.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 32MM 0D F HIP X3 TRIDENT",SUP-623-00-32F,CDM,C1776,HCPCS,0278,RC,,,both,,,6242.04,1872.61,"FIRST HEALTH [10303]","First Health",,4993.63,80,,,,,0,725.95,5305.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADMIRAL XTREME 130CM 120MM 5MM BALLOON DILATATION",SUP-ADM050120130,CDM,C1725,HCPCS,0272,RC,,,both,,,1134.00,340.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,466.07,41.1,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CM 28MM 10MM THORAX 2 VELOUR 1 BRANCH",SUP-M00202175828P0,CDM,C1768,HCPCS,0278,RC,,,both,,,8540.68,2562.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3510.22,41.1,,,,,0,993.28,7259.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 18 16 X 50 COMPLEX FRAMING COIL",SUP-18CFR-16050,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5374.03,41.1,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC INTERPULSE BONE CLEANING TIP SUCTION PULSED LAVAGE",SUP-0210-110-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.14,99.04,"KAISER [10500]",Kaiser,,221.19,67,,,,,0,38.4,280.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 90MM 230CM 22-27MM DUODENAL NITINOL DELIVERY",SUP-M00565020,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 107MM TRI-LOCK BPS GRIPTION 6 STD OFFSET HIP",SUP-101204060,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"UHC [10700]","United Healthcare",,10195.81,63.3,,8601.07,8395.67,8601.07,"1 through 10",1873.26,13691.05,"percent of total billed charges",
"CATH SOFT-VU 100CM 5FR SIDEWINDER 2 CURVE ANGIOGRAPHIC",SUP-H787107090075,CDM,C1887,HCPCS,0272,RC,,,both,,,190.36,57.11,"AETNA [10100]","Aetna HMO/PPO",,151.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.14,161.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 2CM 2.5MM BALLOON DILATATION HYDROPHILIC",SUP-G50320,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"KAISER [10500]",Kaiser,,1582.83,67,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION SLR PTCA DEB 2.5X20MM",SUP-SCA14U-250020D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 150MM 5MM BALLOON DILATATION STERILE LATEX",SUP-585015022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PALACOS MV+G PRO 80",SUP-5081291,CDM,C1713,HCPCS,0278,RC,,,both,,,3829.50,1148.85,"AETNA [10100]","Aetna HMO/PPO",,3044.45,79.5,,1521.93,481.35,16760.95,30,445.37,3255.08,"percent of total billed charges",
"CATH ATTAIN COMMAND SUREVALVE 45CM 9FR 7.2FR .035IN",SUP-6250V-MPR,CDM,C1887,HCPCS,0272,RC,,,both,,,2602.50,780.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1069.63,41.1,,,,,0,302.67,2212.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TIBIAL YELLOW STRIPE 66X42MM NEXGEN 3 WEDGE KNEE",SUP-598800300,CDM,C1713,HCPCS,0278,RC,,,both,,,15836.88,4751.06,"KAISER [10500]",Kaiser,,10610.71,67,,,,,0,1841.83,13461.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trcran Dplr Intrcr Ltd",PX-921000004,CDM,93888,CPT,0921,RC,,,both,,,1592.00,477.6,"CIGNA [10200]","Cigna Open Access",,905.85,56.9,,,,,0,1.59,1353.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4MM SABRE COOLCUT CURVE SOFT TISSUE",SUP-AR-8400CSR,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"CIGNA [10200]",Cigna,,381.7,68,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 12X40 40CM SL",SUP-48012004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 5MM CENTRAL THREAD 300MM STEINMANN STAINLESS",SUP-293.940,CDM,C1713,HCPCS,0278,RC,,,both,,,791.78,237.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,226.61,28.62,,,,,0,92.08,673.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 17GA 10CM BIOPINCE ULTRA FULL CORE CO-AXIAL",SUP-360-1080-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.84,161.35,"AETNA [10100]","Aetna HMO/PPO",,427.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.55,457.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X11X8MM CRYSTAL 7D SMALL CERVICAL ANTERIOR",SUP-21411-708,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA [10200]","Cigna Local Plus",,3572.95,53.5,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOGRAPHY 6FR L100CM ID0.056IN FR5 CURVE SOFT DIS",SUP-H74916599030,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"KAISER [10500]",Kaiser,,51.31,67,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 1 BACKWARD DOWN OFFSET 9.5IN KARLIN LUMBAR HANDLE",SUP-46-3138,CDM,S27200284,LOCAL,0272,RC,,,both,,,1195.16,358.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,812.71,68,,,,,0,139,1015.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM ACCOLADE HFX 127D 5 48MM OFFSET HIP",SUP-6077-0537,CDM,C1776,HCPCS,0278,RC,,,both,,,8983.80,2695.14,"NOVANET [10819]",Novanet,,6737.85,75,,,,,0,1044.82,7636.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED + VE",SUP-98000200231,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"BLUE CROSS [10001]","Blue Cross HMO",,10866.24,39.2,,5311.50,4717.44,5388.59,31,3223.84,23562,"percent of total billed charges",
"LENS IOL 0 D +21 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.210,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 45MM CREO CREO AMP SPINE MODULAR NONSTERILE",SUP-1067.1245,CDM,C1713,HCPCS,0278,RC,,,both,,,2437.50,731.25,"NOVANET [10819]",Novanet,,1828.13,75,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 7FR 40D GUIDING DURAFORM PTFE",SUP-M003101430,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"NOVANET [10819]",Novanet,,1877.35,75,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 26CM 3CM 8FR .038IN 2",SUP-M006192153170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"MULTIPLAN [10600]",Multiplan,,1185.95,85,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTASIS CLIP 12MM 2300MM LENGTH",SUP-SCA-23-230-12,CDM,S27200284,LOCAL,0272,RC,,,both,,,972.00,291.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 6-0 PC-1 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J833G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE R/O II HI-FLO 4CM 8FR INTRO DIL KINK",SUP-RSB804H,CDM,C1894,HCPCS,0272,RC,,,both,,,226.20,67.86,"FIRST HEALTH [10303]","First Health",,180.96,80,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR REFLECTION 20D C 44MM 22MM XLPE HIP",SUP-71333302,CDM,C1776,HCPCS,0278,RC,,,both,,,20487.60,6146.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2382.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2382.71,17414.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER CURVED TIP RELOAD 60MM PURPLE",SUP-AESC60P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"FIRST HEALTH [10303]","First Health",,1166.4,80,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK VITRECTOMY 23GA CONSTELLATION TOTAL PLUS 5000 CPM 3 WAY",SUP-8065751058,CDM,S27200284,LOCAL,0272,RC,,,both,,,3082.28,924.68,"AETNA [10100]","Aetna HMO/PPO",,2450.41,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,358.47,2619.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET NAVIGATION VIPER PRIME SPINE STERILE",SUP-286750200S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.00,675,"CIGNA [10200]",Cigna,,1530,68,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 10CM 10FR 2 PIGTAIL CURVE BILIARY POLYETHYLENE",SUP-G21637,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"FIRST HEALTH [10303]","First Health",,505.44,80,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 32MM 0D C HIP X3 TRIDENT",SUP-723-00-32C,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2445.77,28.62,,,,,0,993.86,7263.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GASTRO MIC MIC-KEY HALYARD STERILE LATEX FREE DISPOSABLE",SUP-98432,CDM,S27200284,LOCAL,0272,RC,,,both,,,1649.78,494.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,757.25,45.9,,,,,0,191.87,1402.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODEL-TRANSEND .010",SUP-M003468020,CDM,C1769,HCPCS,0272,RC,,,both,,,3942.52,1182.76,"MULTIPLAN [10600]",Multiplan,,3351.14,85,,,,,0,458.52,3351.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS POWERFLEX P3 80CM 20MM 12MM 7.5MM BALLOON",SUP-4202020S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Paste Karaya",PX-E27100019,CDM,E27100019,LOCAL,0271,RC,,,both,,,40.70,12.21,"CIGNA [10200]","Cigna Local Plus",,21.77,53.5,,,,,0,4.73,34.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG EQUIPMENT BLACK RED HEARTMATE II CONSOLIDATE NONSTERILE",SUP-104233,CDM,Q0499,HCPCS,0274,RC,,,both,,,2373.30,711.99,"BLUE CROSS [10001]","Blue Cross HMO",,930.33,39.2,,,,,0,276.01,2017.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Legion Pneumophilia Ag If",PX-306000097,CDM,87278,CPT,0306,RC,,,both,,,215.00,64.5,"KAISER [10500]",Kaiser,,144.05,67,,,,,0,0.01,182.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immuniz Intranasal/Oral 1st",PX-771000025,CDM,90473,CPT,0771,RC,,,both,,,77.10,23.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.97,77.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 59CM 6FR STRAIGHT ATRIUM MRI POSITIVE FIXATION",SUP-7742,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"BLUE CROSS [10001]","Blue Cross HMO",,875.14,39.2,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acetylcholn Rcptr Blckg Antb",PX-301000692,CDM,86042,CPT,0301,RC,,,both,,,398.05,119.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,28.94,,,,,,,0.01,338.34,"fee schedule",
"HC Fsh (Follicle Stim Hormone)",PX-301000214,CDM,83001,CPT,0301,RC,,,both,,,420.50,126.15,"CIGNA [10200]","Cigna Local Plus",,40.88,,,,,,,0.01,357.43,"fee schedule",
"STEM KNEE 130MM 20/16MM ENDO-MODEL SL MALE TAPER MODULAR",SUP-15-8523/58,CDM,C1776,HCPCS,0278,RC,,,both,,,16271.03,4881.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4656.77,28.62,,,,,0,1892.32,13830.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Perianal Abscess Supfcl",PX-450000264,CDM,46050,CPT,0361,RC,,,both,,,4068.00,1220.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1718,,"Case rate ($1,718). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,473.11,4068,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fmr1 Gene Detection",PX-309000028,CDM,81243,CPT,0310,RC,,,both,,,2368.35,710.5,"UHC [10700]","United Healthcare",,51.34,,,,,,,0.01,2013.1,"fee schedule",
"MATRIX OI BLOCK- 10MM",SUP-441010,CDM,S27800098,LOCAL,0278,RC,,,both,,,8383.50,2515.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3848.03,45.9,,,,,0,975,7125.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT CINCHLOCK FLEX KNOTLESS INSRT FRICTION GRIP",SUP-CAT02643,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,1831.33,1831.33,1831.33,16,434.96,3179,"percent of total billed charges",
"KIT ANGIOGRAPHY AT-P65 HAND CTRL STPCOCK TUBING STERILE",SUP-014645,CDM,S27200284,LOCAL,0272,RC,,,both,,,502.20,150.66,"CIGNA [10200]","Cigna Open Access",,285.75,56.9,,,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE",RX-108028,CDM,J1652,HCPCS,0636,RC,55150-0232-00,NDC,both,.6,ML,471.91,141.57,"CIGNA [10200]",Cigna,,35.48,,,,,,,12.59,401.12,"fee schedule",
"SCR BONE 4MM 12MM OZARK SPINE CERVICAL SELF START FIX ANGLE",SUP-8801-14012DA,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,1144.80,304.56,2275.09,66,117.75,860.63,"percent of total billed charges",
"PLATE 9 HOLE ALPS BONE HUMERUS LEFT POSTEROLATERAL",SUP-131218302,CDM,C1713,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1251,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1227.78,8973.45,"percent of total billed charges",
"LEAD PACING 110CM ATRIUM VENTRICLE BIPOLAR FIXED SCR IN",SUP-3830110,CDM,C1898,HCPCS,0275,RC,,,both,,,2850.00,855,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1308.15,45.9,,,,,0,331.46,2422.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 80MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1085.08,68,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XACT 40MM 136CM 8-6MM TAPER VASCULAR NITINOL CAROTID",SUP-82090-01,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"KAISER [10500]",Kaiser,,6271.2,67,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Cath Tunl Mech",PX-361000122,CDM,36595,CPT,0361,RC,,,both,,,8180.70,2454.21,"AETNA [10100]","Aetna HMO/PPO",,6503.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,951.42,7883,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRS INCUBATOR 104F 40C COTTON TRANSPORT PEDIATRIC LATEX",SUP-HNICU-200,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.92,41.08,"CIGNA [10200]",Cigna,,93.11,68,,,,,0,15.92,116.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 130MM 4.75MM STRAIGHT PERCUTANEOUS CCM PLUS",SUP-1476006130,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",512.88,3748.5,"percent of total billed charges",
"PROBE ESOPHAGEAL RECTAL TEMPERATURE STERI-PROBE THRMOMTR",SUP-491B,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.82,20.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,31.59,45.9,,,,,0,8,58.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE SMALL TABLE FIXATION 16X13MM COCR",SUP-128698,CDM,C1713,HCPCS,0278,RC,,,both,,,2973.30,891.99,"FIRST HEALTH [10303]","First Health",,2378.64,80,,,,,0,345.79,2527.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRINGER INSTR 6X2.5IN BAR",SUP-51-0006,CDM,S27000186,LOCAL,0270,RC,,,both,,,314.68,94.4,"MULTIPLAN [10600]",Multiplan,,267.48,85,,,,,0,36.6,267.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 15MM MODULAR CONICAL DISTAL HIP",SUP-6276-7-015,CDM,C1776,HCPCS,0278,RC,,,both,,,10468.22,3140.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2996,28.62,,,,,0,1217.45,8897.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla Class I Phenotype Qual",PX-302000266,CDM,86830,CPT,0302,RC,,,both,,,481.00,144.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,408.85,"per diem",
"PUNCH 6MM SHORT HANDLE AORTIC",SUP-APU460,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,119.18,41.1,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PCMKR CRD THK6MM 59X55MM ALR","SUP-PM3222 CELL",CDM,C2621,HCPCS,0275,RC,,,both,,,15444.00,4633.2,"FIRST HEALTH [10303]","First Health",,12355.2,80,,,,,0,1796.14,13127.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BRONCHOSCOPIC 15MM 21GA WANG TRANSBRONCHIAL CENTRAL",SUP-MW319,CDM,S27200284,LOCAL,0272,RC,,,both,,,411.86,123.56,"PHCS [10601]",PHCS,,288.3,70,,,,,0,47.9,350.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VEST SPU 23-33- IN SMALL CHEST WRAP DISPOSABLE",SUP-P300630005,CDM,S27000186,LOCAL,0270,RC,,,both,,,548.99,164.7,"AETNA [10100]","Aetna HMO/PPO",,436.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,63.85,466.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X17MM LUMINARY CC BICONVEX SPINE",SUP-16817,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3941.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT FLITES LARGE LOOP DISPOSABLE",SUP-MFA2000-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,232.70,69.81,"FIRST HEALTH [10303]","First Health",,186.16,80,,,,,0,27.06,197.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 80MM 9MM 9FR FLUENCY PLUS ENDOVASCULAR",SUP-FEM09080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2124.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 20MM 6MM BALLOON DILATATION DURALYN",SUP-48006002S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AETNA [10100]","Aetna HMO/PPO",,998.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRAZOSIN 5 MG CAPSULE",RX-6470,CDM,,,0637,RC,60687-0572-33,NDC,both,1,UN,20.70,6.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.41,17.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC No Pt Prsnt Train Initial 30 (Gp)",PX-420000190,CDM,G0541,HCPCS,0420,RC,,,both,,,70.00,21,"KAISER [10500]",Kaiser,,46.9,67,,,,,0,0.07,70,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE BGK0/2.5 POLYOLEFIN 5000ML NONPVC 2",SUP-110240,CDM,S27200284,LOCAL,0272,RC,,,both,,,332.60,99.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,226.17,68,,,,,0,38.68,282.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EDM 35CM 15CM 2.8MM 1.5MM EXTERNAL DRNG STAINLESS STEEL",SUP-46118,CDM,C1729,HCPCS,0272,RC,,,both,,,1576.99,473.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,183.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.4,1340.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLF TORIC AUTONOME",SUP-CNA0T3,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 20MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158101120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1299.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sensor Flo Trac Vigileo",PX-E27200200,CDM,E27200200,LOCAL,0272,RC,,,both,,,1268.30,380.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,147.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.5,1078.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 675CC P5CM MODERATE PLUS PROFILE COHESIVE GEL",SUP-SMPB675,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"AETNA [10100]","Aetna HMO/PPO",,6061.48,79.5,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAPAROTOMY TRAY",SUP-SBA21LPUHQ,CDM,S27200284,LOCAL,0272,RC,,,both,,,675.14,202.54,"CIGNA [10200]",Cigna,,459.1,68,,,,,0,78.52,573.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 60MM 12MM 10FR FLUENCY PLUS FLARE ENDOVASCULAR",SUP-FEM12060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5228.87,28.62,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BULLET ALLOGRAFT REVISION DOWEL PREHYDRATE",SUP-PCD12,CDM,C1713,HCPCS,0278,RC,,,both,,,6744.75,2023.42,"PHCS [10601]",PHCS,,4721.33,70,,,,,0,784.41,5733.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM MEDIUM ROUND FLUTED STERILE",SUP-5120010040,CDM,S27200284,LOCAL,0272,RC,,,both,,,668.25,200.47,"FIRST HEALTH [10303]","First Health",,534.6,80,,,,,0,77.72,568.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VXSK-180J RF WIRE 63CM/55DEG/D1 SHEATH",SUP-VXSK0104,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,731.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE B22K4/0 PHOXILLIUM PVC 5000ML 2 COMPARTMENT",SUP-114906,CDM,S27200284,LOCAL,0272,RC,,,both,,,369.18,110.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,169.45,45.9,,,,,0,42.94,313.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JET THROMBECTOMY STERILE LATEX FREE",SUP-5MAXJETD,CDM,C1757,HCPCS,0272,RC,,,both,,,16767.00,5030.1,"KAISER [10500]",Kaiser,,11233.89,67,,,,,0,1950,14251.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VLV SHNT CERTAS INLN SPHGRD",SUP-828804PL,CDM,S27800098,LOCAL,0278,RC,,,both,,,38643.57,11593.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4494.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4494.25,32847.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rad Tx Del Lvl 1 Sd",PX-333000068,CDM,77402,CPT,0333,RC,,,both,,,1665.36,499.61,"MULTIPLAN [10600]",Multiplan,,1415.56,85,,,,,0,193.68,1665.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 60MM KNEE LEFT POSTERIOR STABILIZE OPEN BOX",SUP-184524,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2941.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2887.24,21101.91,"percent of total billed charges",
"ENV TISSUE 6.9X8CM CANGAROO LARGE SOFT SUPPLE POCKET NO",SUP-CMCV-010-LRG,CDM,S27800098,LOCAL,0278,RC,,,both,,,31027.50,9308.25,"BLUE CROSS [10001]","Blue Cross PPO",,12162.78,39.2,,,,,0,3608.5,26373.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER SLIMLINE 550UM 1 INCISION SLING",SUP-M0068409250,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txcath Plc Stent Init Vein",PX-361000325,CDM,37238,CPT,0361,RC,,,both,,,16222.38,4866.71,"PHCS [10601]",PHCS,,11355.67,70,,,,,0,1886.66,13789.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ANGLE 8.75IN MISKIMON CEREBELLAR",SUP-24-2810,CDM,S27200284,LOCAL,0272,RC,,,both,,,536.63,160.99,"CIGNA [10200]","Cigna Open Access",,305.34,56.9,,,,,0,62.41,456.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 12X14X21MM SANTORINI 7D PEEK CORPECTOMY",SUP-1703-22114L,CDM,S27800098,LOCAL,0278,RC,,,both,,,39793.32,11938,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4715.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4627.96,33824.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 4MM E9000 ROUND CARBIDE ROUND HEAD LSO",SUP-E8240LSO,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)MARKER SKIN PINK 10CM 15GA SMARTCLIP LITE 3-4MM SOFT T",SUP-SMARTCLIPLT-PNK-10,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"KAISER [10500]",Kaiser,,1809,67,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM GEMINUS TITANIUM CORTICAL DISTAL VOLAR",SUP-PANL-35120-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,623.70,187.11,"CIGNA [10200]","Cigna Open Access",,354.89,56.9,,1144.80,304.56,2275.09,66,72.54,530.15,"percent of total billed charges",
"PYRIDOSTIGMINE BROMIDE 60 MG TABLET, IMMEDIATE RELEASE",RX-11239,CDM,,,0637,RC,00904-6622-61,NDC,both,1,UN,8.11,2.43,"CIGNA [10200]",Cigna,,5.51,68,,,,,0,0.94,6.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP SPECTRUM 1 STERILE DISPOSABLE",SUP-0270-0967,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER HUMERAL 36MM UNIVERS REVERS +9MM SHOULDER TITANIUM",SUP-AR-9555-09,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"FIRST HEALTH [10303]","First Health",,2352,80,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 3.75 X 18 MM",SUP-1212375-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross PPO",,6762,39.2,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemostatic Agent",PX-E27200131,CDM,E27200131,LOCAL,0272,RC,,,both,,,320.10,96.03,"FIRST HEALTH [10303]","First Health",,256.08,80,,,,,0,37.23,272.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST 59MM 80CM 8MM TRACHEOBRONCHIAL STAINLESS STEEL",SUP-48859,CDM,C1874,HCPCS,0278,RC,,,both,,,18881.10,5664.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2237.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2195.87,16048.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 6MM NESTER 7.4 LOOP SOFT RADIOPACITY",SUP-G26989,CDM,S27800098,LOCAL,0278,RC,,,both,,,696.60,208.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,82.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 150MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"FIRST HEALTH [10303]","First Health",,1276.56,80,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION SLR PTCA DEB 2.0X30MM",SUP-SCA14U-200030D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 8MM 3.5MM CORONARY STENT EVEROLIMUS",SUP-1550350-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT AORTIC 4.5CM 36MM EXCLUDER CONFORMABLE ACTIVE CONTROL",SUP-CXA360005,CDM,C1874,HCPCS,0278,RC,,,both,,,27612.90,8283.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3211.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3211.38,23470.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 30MM 9.6MM CONDYLAR STABILIZED NECK OMNIFIT EON",SUP-6098-0630,CDM,C1776,HCPCS,0278,RC,,,both,,,10292.40,3087.72,"CIGNA [10200]","Cigna Open Access",,5856.38,56.9,,5302.19,4377.88,6578.61,27,1197.01,8748.54,"percent of total billed charges",
"SHEATH 12IN 7MM TNLR POLYMER VASCULAR RADIOPAQUE SMOOTH",SUP-9009-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,557.28,167.18,"PHCS [10601]",PHCS,,390.1,70,,,,,0,64.81,473.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 17MM 46MM SHOULDER AEQUALIS ASCEND FLEX COCR",SUP-DWF046,CDM,C1776,HCPCS,0278,RC,,,both,,,9475.00,2842.5,"AETNA [10100]","Aetna HMO/PPO",,7532.63,79.5,,10981.53,8986.79,12413.38,12,1101.94,8053.75,"percent of total billed charges",
"SCR BONE 1.5MM 11MM STAINLESS STEEL T4 CORTEX SELF TAP",SUP-02.214.111,CDM,C1713,HCPCS,0278,RC,,,both,,,418.99,125.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,284.91,68,,,,,0,48.73,356.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER SHEATH 5FR 10CM MICRO ACCESS TEAR AWAY SET PEEL-A",SUP-INT-106-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"PHCS [10601]",PHCS,,91.35,70,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)MARKER SKIN GREEN 10CM 15GA SMARTCLIP LITE 3-4MM SOFT",SUP-SMARTCLIPLT-GRN-10,CDM,A4648,HCPCS,0278,RC,,,both,,,2625.00,787.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD MEDIUM SPINE ROD TO ROD",SUP-3602536,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,414.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",414.32,3028.13,"percent of total billed charges",
"INSRT TIBIAL 5 9MM KNEE X3 BEARING POSTERIOR STABILIZE",SUP-5532-G-509,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"FIRST HEALTH [10303]","First Health",,6966.09,80,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE RIGHT CRUCIATE RETAINING PERSONA",SUP-42502806202,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3424.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3360.56,24561.24,"percent of total billed charges",
"WRAP THERAPEUTIC 112-137CM SMARTVEST XL HIGH FREQUENCY CHEST",SUP-SW-44/54-1,CDM,S27000186,LOCAL,0270,RC,,,both,,,437.40,131.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF MARINR 110CM 4MM 7FR 2-5-2MM SPACING 55-75MM REACH",SUP-075402,CDM,C1733,HCPCS,0272,RC,,,both,,,3967.50,1190.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1630.64,41.1,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 8CM 6FR 10MM .035IN BALLOON",SUP-G52295,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"MULTIPLAN [10600]",Multiplan,,815.8,85,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION",RX-32700,CDM,J0585,HCPCS,0636,RC,00023-1145-01,NDC,both,1,UN,3929.44,1178.83,"CIGNA [10200]","Cigna Local Plus",,1749.9,,,,,,,654.82,3340.02,"fee schedule",
"CMPNT FEMORAL 9 STD KNEE RIGHT CRUCIATE RETAIN PERSONA PPS",SUP-42508606602,CDM,C1776,HCPCS,0278,RC,,,both,,,29326.50,8797.95,"UHC [10700]","United Healthcare",,18563.67,63.3,,8601.07,8395.67,8601.07,"1 through 10",3410.67,24927.53,"percent of total billed charges",
"SPLINT ORTHOPEDIC UNIVERSAL 7IN WRIST COCK UP 2 PIECE",SUP-79-87010,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.42,14.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.75,42.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM OFFSET 36MM HIP TYPE 1 COCR G7",SUP-11363663,CDM,C1776,HCPCS,0278,RC,,,both,,,5296.44,1588.93,"CIGNA [10200]",Cigna,,3601.58,68,,5873.17,5873.17,5873.17,"1 through 10",615.98,4501.97,"percent of total billed charges",
"STENT TEMPTIP 24CM 10FR LARGE PROXIMAL PIGTAIL CURVE",SUP-M001231410,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA [10200]",Cigna,,605.88,68,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER 3992612 26MM X 12MM",SUP-3992612,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"PHCS [10601]",PHCS,,14857.92,70,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTEPLASE 2 MG INTRA-CATHETER SOLUTION",RX-31310,CDM,J2997,HCPCS,0636,RC,50242-0041-64,NDC,both,1,UN,1117.67,335.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,500.16,44.75,,,,,0,132.44,950.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL RADIOLOGY GOLD 20CM 17GA 1.2MM KNURL SOFT TISSUE",SUP-MTNW887825,CDM,A4648,HCPCS,0278,RC,,,both,,,1665.00,499.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,764.24,45.9,,,,,0,193.64,1415.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC UNIVERSAL 54X5IN SHOULDER 2 STRAP SLING",SUP-4442-00,CDM,L3670,HCPCS,0274,RC,,,both,,,77.34,23.2,"BLUE CROSS [10001]","Blue Cross HMO",,30.32,39.2,,,,,0,8.99,77.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 16MM 23MM MOSAIC ULTRA CINCH RING PORCINE STENT",SUP-305U223,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3247.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY CUT-AWAY 8FR GUIDING INNER",SUP-7041,CDM,C1887,HCPCS,0272,RC,,,both,,,1579.50,473.85,"KAISER [10500]",Kaiser,,1058.27,67,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309011,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"CIGNA [10200]",Cigna,,15104.88,40,,5873.17,5873.17,5873.17,"1 through 10",4391.74,32097.87,"percent of total billed charges",
"CATH EZ STEER REDEL 115CM 4MM 7FR 1-7-4MM SPACE D-D CURVE",SUP-BD7TCDD4L,CDM,C1733,HCPCS,0272,RC,,,both,,,6113.40,1834.02,"UHC [10700]","United Healthcare",,3869.78,63.3,,,,,0,710.99,5196.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 560CC",SUP-SSZ-F560,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"PHCS [10601]",PHCS,,1043.28,70,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 15X15CM 10MM RESORBABLE PLA POLYPROPYLENE",SUP-PP1515G,CDM,C1781,HCPCS,0278,RC,,,both,,,3217.95,965.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,381.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,374.25,2735.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 24CM 10FR LARGE PROXIMAL PIGTAIL CURVE",SUP-M001231410,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,255,28.62,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 45MM 16MM CHARLOTTE STAINLESS STEEL SHORT",SUP-44174516,CDM,C1713,HCPCS,0278,RC,,,both,,,4961.10,1488.33,"FIRST HEALTH [10303]","First Health",,3968.88,80,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 80MM 14MM 13FR 10FR TRIVASCULAR OVATION PRIME",SUP-TV-IL141480-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CIGNA [10200]","Cigna Open Access",,11185.65,33.5,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +2.5MM OFFSET C TAPER 28MM HIP HIGH PERFORMANCE",SUP-18-2825,CDM,C1776,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,656.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,644.77,4712.4,"percent of total billed charges",
"INSRT TIBIAL 5 25MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962367,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1718.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE STD VASCULAR STRAIGHT 190CM 2CM .014IN",SUP-22318H,CDM,C1769,HCPCS,0272,RC,,,both,,,502.20,150.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,59.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 24MM ALIGN COCR SIDE LOAD HYBRID ADJUSTABLE LOCK",SUP-ALN-RHI-240,CDM,C1776,HCPCS,0278,RC,,,both,,,10681.20,3204.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4902.67,45.9,,,,,0,1242.22,9079.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X6MM LORDOTIC SPINE CERVICAL CORTICAL",SUP-17006,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 96MM 12MM PRESS FIT REUNION SHOULDER",SUP-5567-P-3012,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7089.75,41.1,,6417.48,6417.48,6417.48,"1 through 10",2006.18,14662.5,"percent of total billed charges",
"ANCHOR SUT 2 V5 ETHIBOND GII QUICKANCHOR PLUS ROTATOR CUFF",SUP-212035,CDM,C1713,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,797.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,782.41,5718.38,"percent of total billed charges",
"SUT ULTRATAPE COBRAID WIDE LOW PROFILE BLUE NONABSORBABLE",SUP-72203897,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR AVENIR COMPLETE 0 HIP STERILE LATEX FREE",SUP-574203000,CDM,C1776,HCPCS,0278,RC,,,both,,,26190.36,7857.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10764.24,41.1,,6417.48,6417.48,6417.48,"1 through 10",3045.94,22261.81,"percent of total billed charges",
"SCR BONE 3.5MM 65MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0276,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"KAISER [10500]",Kaiser,,634.96,67,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM AXSOS STAINLESS STEEL HUMERUS FEMUR TIBIA",SUP-371530,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"NOVANET [10819]",Novanet,,668.25,75,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Leishmania Antibody",PX-302000261,CDM,86717,CPT,0302,RC,,,both,,,259.00,77.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.86,,"Fee schedule rate ($12.86). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.26,220.15,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE DESTINATION STRAIGHT 45CM 35CM 7FR GUIDING",SUP-54-74501,CDM,C1887,HCPCS,0272,RC,,,both,,,672.30,201.69,"MULTIPLAN [10600]",Multiplan,,571.46,85,,,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 4MM UNIVERSAL NEURO III CRANIOMAXILLOFACIAL",SUP-56-15034,CDM,C1713,HCPCS,0278,RC,,,both,,,584.37,175.31,"NOVANET [10819]",Novanet,,438.28,75,,,,,0,67.96,496.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 4.8FR L20CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902100,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOGUARD 100UM 180CM .014IN 6MM EMBOLIC PROTECTION",SUP-601814RMC,CDM,C1884,HCPCS,0272,RC,,,both,,,6520.50,1956.15,"CIGNA [10200]","Cigna Open Access",,3710.16,56.9,,,,,0,758.33,5542.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 60MM 3.8-3.4FR 5MM LOW PROFILE",SUP-H74939031506010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHEATHLESS EAUCATH 100CM 7.5FR .081IN AL.75 CURVE",SUP-G6AL07-0-L115,CDM,C1887,HCPCS,0272,RC,,,both,,,1125.90,337.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,133.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,130.94,957.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROPAFENONE 150 MG TABLET, IMMEDIATE RELEASE",RX-11146,CDM,,,0250,RC,59651-0256-01,NDC,both,1,UN,8.23,2.47,"PHCS [10601]",PHCS,,5.76,70,,,,,0,0.96,7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PCMKR CRD THK6MM SM 50X47MM","SUP-PM1240 CELL",CDM,C1786,HCPCS,0275,RC,,,both,,,9324.00,2797.2,"MULTIPLAN [10600]",Multiplan,,7925.4,85,,,,,0,1084.38,7925.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9.5MM 80MM RELINE-O 2S SPINE ILIAC POLYAXIAL",SUP-13019580,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES 143CM 20MM 3MM .014IN BALLOON DILATATION OTW",SUP-39134-30201,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REFERENCE TOE IMPLANT SIZER","SUP-M03 S0001",CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"UHC [10700]","United Healthcare",,1068.19,63.3,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT THROMBOLYTIC 6FR JETI STERILE DISPOSABLE",SUP-WV6203A,CDM,S27200284,LOCAL,0272,RC,,,both,,,23562.00,7068.6,"UHC [10700]","United Healthcare",,14914.75,63.3,,,,,0,2740.26,20027.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 19MM 135CM 7MM THIN VASCULAR COCR",SUP-1012630-19,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"CIGNA [10200]",Cigna,,5712,68,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 45MM 16MM CHARLOTTE STAINLESS STEEL SHORT",SUP-44174516,CDM,C1713,HCPCS,0278,RC,,,both,,,4961.10,1488.33,"CIGNA [10200]","Cigna Local Plus",,2654.19,53.5,,3978.14,359.25,3978.14,24,576.98,4216.94,"percent of total billed charges",
"CATH LAUNCHER 100CM 7FR .081IN JUDKINS LEFT 3.5 CURVE",SUP-LA7JL35,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AETNA [10100]","Aetna HMO/PPO",,311.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plmt Uret Stnt New Acc Sep Cath",PX-361000419,CDM,50695,CPT,0361,RC,,,both,,,7552.00,2265.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6891,,"Case rate ($6,891). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,878.3,7552,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plmt Uret Stnt New Acc Sep Cath",PX-361000419,CDM,50695,CPT,0361,RC,,,both,,,7552.00,2265.6,"BLUE CROSS [10001]","Blue Cross PPO",,4431.65,,"Case rate ($4,431.65). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,878.3,7552,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plmt Uret Stnt New Acc Sep Cath",PX-361000419,CDM,50695,CPT,0361,RC,,,both,,,7552.00,2265.6,"MULTIPLAN [10600]",Multiplan,,6419.2,85,,,,,0,878.3,7552,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 10.5IN 24FR SILICONE Y PORT GRADUATE SHAFT OPEN DISTAL",SUP-8884720247,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.27,54.38,"PHCS [10601]",PHCS,,126.89,70,,,,,0,21.08,154.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAFIRE COMFORTGRIP 115CM 4MM 7FR 2-5-2MM SPACE 1MM",SUP-402810,CDM,C1733,HCPCS,0272,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Salivary Gland",PX-341000081,CDM,78230,CPT,0341,RC,,,both,,,1730.90,519.27,"CIGNA [10200]","Cigna Local Plus",,312.88,,,,,,,201.3,1471.27,"fee schedule",
"SURFACE ARTICULAR 10MM PERSONA MEDIAL CONGRUENT 12 J KNEE",SUP-42-5121-011-10,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1253.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE",447,MS-DRG,,,,,,,inpatient,,,313650.24,94095.07,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,42689.76,,"Case rate ($41,446.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $38,485.76, add-ons for qualifying new technology services are included. If operating cost exceeds $71,525.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $4,291.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $38,536.66. The transfer operating threshold is the transfer adjustment factor * $38,485.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,909.71. The transfer capital threshold is the transfer adjustment factor * $2,909.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,10994,195075.99,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 25MM 2MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2025X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"AETNA [10100]","Aetna HMO/PPO",,418.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.00 X 33 RX US",SUP-1804300-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER PROBE 96X5IN FOLDED TAPE STRIP INTRAOPERATIVE STERILE",SUP-PC1308,CDM,S27200284,LOCAL,0272,RC,,,both,,,44.58,13.37,"PHCS [10601]",PHCS,,31.21,70,,,,,0,5.18,37.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AIRWAY 4-7MM ENDOBRONCHIAL ZEPHYR",SUP-EBV-TS-4.0,CDM,S27800098,LOCAL,0278,RC,,,both,,,17112.00,5133.6,"CIGNA [10200]",Cigna,,6844.8,40,,,,,0,1990.13,14545.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 4FR 100CM TRIFORCE FLEXOR PEEL-AWAY STRAIGHT CURVE",SUP-G56417,CDM,S27200284,LOCAL,0272,RC,,,both,,,2711.18,813.35,"CIGNA [10200]","Cigna Open Access",,1542.66,56.9,,,,,0,315.31,2304.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH VASCULAR 8X1CM BOVINE PERICARDIAL",SUP-DP1X6,CDM,C1768,HCPCS,0278,RC,,,both,,,1263.68,379.1,"KAISER [10500]",Kaiser,,846.67,67,,,,,0,146.97,1074.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX LPR 15 CM CIRCLE",SUP-F10244-1515L,CDM,C1781,HCPCS,0278,RC,,,both,,,18437.08,5531.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4978.01,27,,,,,0,2144.23,15671.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Neuro CSF Prion Prtn Qual",PX-301000631,CDM,0035U,CPT,0301,RC,,,both,,,1444.95,433.48,"MULTIPLAN [10600]",Multiplan,,1228.21,85,,,,,0,0.01,1228.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE NDL 9 INSRT PALETTE STERILE BURR HOLE TRNSDUC 8863",SUP-UA1346,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"CIGNA [10200]",Cigna,,177.48,68,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 4-0 P-3 18IN MONOFILAMENT UNDYED",SUP-691G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7+ KNEE CONDYLAR CEMENT CONSTRAIN PERSONA COCR",SUP-42-5046-062-12,CDM,C1776,HCPCS,0278,RC,,,both,,,49172.76,14751.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,14073.24,28.62,,,,,0,5718.79,41796.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP MULTIHOLE COLOR CODED OSSEOTI G7 D",SUP-110010263,CDM,C1776,HCPCS,0278,RC,,,both,,,20755.98,6226.79,"BLUE CROSS [10001]","Blue Cross PPO",,8136.34,39.2,,3949.44,3949.44,3949.44,"1 through 10",2413.92,17642.58,"percent of total billed charges",
"PLATE 52MM STAINLESS STEEL 2.4MM SCR MINI FRAGMENT SET 6",SUP-249.676,CDM,C1713,HCPCS,0278,RC,,,both,,,2299.50,689.85,"CIGNA [10200]",Cigna,,1563.66,68,,1831.33,1831.33,1831.33,16,267.43,1954.58,"percent of total billed charges",
"BLADE CHISEL 40X10MM THK1MM STRAIGHT SMALL",SUP-75100517,CDM,S27200284,LOCAL,0272,RC,,,both,,,1489.59,446.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,612.22,41.1,,,,,0,173.24,1266.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR AXONICS PERIPHERAL NERVE EVALUATION LEAD",SUP-1701,CDM,C1897,HCPCS,0278,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM PFC SIGMA TC3 4 KNEE RIGHT TITANIUM CEMENTED",SUP-960883,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"PHCS [10601]",PHCS,,3591.59,70,,,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VIA CANCELLOUS DEMINERALIZE CORTICAL BONE 2.5CC",SUP-VCAFX-025000,CDM,S27800098,LOCAL,0278,RC,,,both,,,6037.50,1811.25,"PHCS [10601]",PHCS,,4226.25,70,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Protein Electrophoresis Other",PX-301000382,CDM,84166,CPT,0301,RC,,,both,,,289.50,86.85,"PHCS [10601]",PHCS,,202.65,70,,,,,0,0.29,246.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 18GA SIDEKICK 2 10MM DEPLOYMENT",SUP-RFK-C101018S-ZK2-P,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.95,74.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.84,210.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 8MM 6FR 1.25MM .07IN BALLOON",SUP-H7493919008120,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"2.5 X 18MM ESPRIT BTK IDE",SUP-1202250-18,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT CARDIONYL 4-0 .5C 2 ARM BLUE NONABSORBABLE",SUP-721932,CDM,S27200284,LOCAL,0272,RC,,,both,,,55.34,16.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT NASAL C-FLEX DOYLE BIVALVE SET",SUP-1524075,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.95,74.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR SET TITANIUM 5.5MM SPINE 1 INNER NONSTERILE VIPER",SUP-186715000,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 11CM 7FR STRAIGHT PANCREATIC POLYMER",SUP-M00536560,CDM,C2617,HCPCS,0278,RC,,,both,,,722.28,216.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,206.72,28.62,,,,,0,84,613.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 360CC NATRELLE INSPIRA COHESIVE STERILE LATEX",SUP-SCM-360,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]",Cigna,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE SIMPLEX HV 20ML 40GM STERILE",SUP-6194-1-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,658.29,197.49,"BLUE CROSS [10001]","Blue Cross PPO",,258.05,39.2,,,,,0,76.56,559.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP IDENTITY STEM/AUGMENTED GLENOID/PREMIUM POST/IDENTITY TI",SUP-98000900265,CDM,C1776,HCPCS,0278,RC,,,both,,,42525.00,12757.5,"NOVANET [10819]",Novanet,,31893.75,75,,,,,0,4945.66,36146.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CS2 STAINLESS STEEL 2.7MM SCR VARIABLE ANGLE LCP BONE",SUP-02.112.622,CDM,C1713,HCPCS,0278,RC,,,both,,,6005.21,1801.56,"CIGNA [10200]",Cigna,,4083.54,68,,1831.33,1831.33,1831.33,16,698.41,5104.43,"percent of total billed charges",
"CMPNT FEMORAL 9 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502606602,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS [10001]","Blue Cross HMO",,8962.18,39.2,,5311.50,4717.44,5388.59,31,2658.93,19433.3,"percent of total billed charges",
"SCR DISTRACTION 14MM CASPAR CERVICAL PIN STERILE",SUP-0024-LDR,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"UHC [10700]","United Healthcare",,2373.75,63.3,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONVEY 100CM 7FR LEFTBU3.75 CURVE GUIDING HYDROPHILIC",SUP-H749392657150,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"FIRST HEALTH [10303]","First Health",,293.15,80,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS",208,MS-DRG,,,,,,,inpatient,,,77977.80,23393.34,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,24793.27,,"Fee schedule rate ($24,793.27). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,10994,68549.83,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 150MM 2.5MM QUICK CONNECT STERILE",SUP-03.133.104S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1095.44,328.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,450.23,41.1,,,,,0,127.4,931.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PROC ECTRA II PROBE RETROGRADE TRIANGLE KNIFE HAND PAD",SUP-4116,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 4IN 5FR 21GA MAK .018IN PLATINUM COIL TIP NITINOL",SUP-MAK501NBT,CDM,C1894,HCPCS,0272,RC,,,both,,,250.56,75.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,102.98,41.1,,,,,0,29.14,212.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 10X38X28MM 15DEG",SUP-1921047P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"AETNA [10100]","Aetna HMO/PPO",,27546.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE SHOULDER : HUMERAL STEM, HUMERAL TRAY, POLY LINE",SUP-SI-RSA,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"CIGNA [10200]","Cigna Open Access",,15195.6,33.5,,5302.19,4377.88,6578.61,27,5275.37,38556,"percent of total billed charges",
"SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL",RX-29676,CDM,,,0250,RC,10939-0955-85,NDC,both,44,ML,12.54,3.76,"PHCS [10601]",PHCS,,8.78,70,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL SMALL+ 15MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405215,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3971.68,41.1,,6417.48,6417.48,6417.48,"1 through 10",1123.86,8213.93,"percent of total billed charges",
"IMPLANT BREAST 450CC DIA12.8CM P5.1CM SILICONE GEL SMOOTH RO",SUP-350-4504BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1500.83,28.62,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOCKWAVE C2+ IVL CATHETER 3.0X12 MM",SUP-C2PIVL3012,CDM,C1761,HCPCS,0272,RC,,,both,,,29610.00,8883,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12169.71,41.1,,,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SIEGEL TAVR 8FR MSHEATH EXPANDABLE INTRODUCER SET",SUP-30-1-0508,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X10MM DIVERGENCE 12MM LORDOTIC NUCLEUS",SUP-G6626520,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"CIGNA [10200]","Cigna Local Plus",,3912.3,31.5,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM ARTISAN MRI",SUP-SC-8416-50,CDM,C1778,HCPCS,0278,RC,,,both,,,30240.00,9072,"CIGNA [10200]","Cigna Open Access",,10130.4,33.5,,,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5F X 30CM TEARAWAY INTRODUCER",SUP-INT-106-31,CDM,C1894,HCPCS,0272,RC,,,both,,,216.49,64.95,"PHCS [10601]",PHCS,,151.54,70,,,,,0,25.18,184.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LEMAITRE 80CM 3FR 6MM .018IN C.2ML EMBOLECTOMY 1 LUMEN",SUP-E1651-38,CDM,C1757,HCPCS,0272,RC,,,both,,,963.90,289.17,"PHCS [10601]",PHCS,,674.73,70,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +9 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000090,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 22MM LOW PROFILE SCREWS STAINLESS STEEL T10",SUP-AR-8827-22,CDM,C1713,HCPCS,0278,RC,,,both,,,522.45,156.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,149.53,28.62,,,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150210,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 40MM 5MM .035IN LOW PROFILE BALLOON",SUP-B1050-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 26MM LCP",SUP-02.211.026,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"NOVANET [10819]",Novanet,,673.6,75,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 100MM 6MM .035IN BALLOON",SUP-AB35W06100135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,460.47,68,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH SURGICAL 140MM 22MM DURAPRO 5MM BALL REMOVAL",SUP-6262.2351S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 60MM 125CM 5MM 5FR .018IN BILIARY NITINOL",SUP-G31354,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"BLUE CROSS [10001]","Blue Cross PPO",,1638.17,39.2,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 8X4IN RESORBABLE GRID 1 SMOOTH",SUP-F10256-0408G,CDM,C1781,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM LOW PROFILE NECK VERTICAL GROOVE CORAIL2",SUP-L20315,CDM,C1776,HCPCS,0278,RC,,,both,,,28658.70,8597.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3333.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3333.01,24359.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSCONN ROD 60-70MM ADJUSTABLE ARCH",SUP-8450260,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1382.35,28.62,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSCONN ROD 21-26MM MATRIX 2 SPINE PEDICLE POSTERIOR",SUP-04.633.321,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Open Access",,2027.06,56.9,,1144.80,304.56,2275.09,66,414.32,3028.13,"percent of total billed charges",
"SET STENT PURPLE 8CM 5FR ZIMMON PIGTAIL CURVE PANCREATIC",SUP-G21926,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,506.02,41.1,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ION 24MM 144CM 2.5MM CORONARY STENT TRANSLUTE",SUP-H7493902424250,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"UHC [10700]","United Healthcare",,5787.2,63.3,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COENZYME Q10  50 MG CAPSULE",RX-35228,CDM,,,0637,RC,40093-0102-32,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 200CM 300MM 2MM BALLOON DILATATION RAPID",SUP-47520300L,CDM,C1725,HCPCS,0272,RC,,,both,,,1740.00,522,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT EXTERNAL DRNG CSF REPLACEMENT COLL NATUS EDS 3",SUP-821732C,CDM,S27000186,LOCAL,0270,RC,,,both,,,362.88,108.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DIAMONDBACK 360 145CM 20MM 2MM 6FR 2MM ATHERECTOMY",SUP-DBP-200CLASS145,CDM,C1724,HCPCS,0272,RC,,,both,,,21388.50,6416.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH PERIPHERAL CUTTING BALLOON 135CM 20MM 7MM BALLOON",SUP-M001PCB70201350,CDM,C1725,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GLIPIZIDE 5 MG TABLET, IMMEDIATE RELEASE",RX-10117,CDM,,,0637,RC,51079-0810-01,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE ULTRA FINE NDL POINT TIP HIGHLY INSULATED EXTENDED",SUP-PS200-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2198.10,659.43,"CIGNA [10200]","Cigna Local Plus",,1175.98,53.5,,,,,0,255.64,1868.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC",816,MS-DRG,,,,,,,inpatient,,,21595.68,6478.7,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,7982.58,,"Case rate ($3,920.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,640.30, add-ons for qualifying new technology services are included. If operating cost exceeds $36,679.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,657.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,645.11. The transfer operating threshold is the transfer adjustment factor * $3,640.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.22. The transfer capital threshold is the transfer adjustment factor * $275.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,3920.33,15761.45,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 110MM ACCOLADE HFX 127D 1 38MM OFFSET HIP",SUP-6077-0130,CDM,C1776,HCPCS,0278,RC,,,both,,,8983.80,2695.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1064.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1044.82,7636.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT RIBFIX TITAN EXTRATHORACIC BUTTON WASHER TITANIUM",SUP-323.3002,CDM,C1713,HCPCS,0278,RC,,,both,,,21760.20,6528.06,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8943.44,41.1,,,,,0,2530.71,18496.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON SABRELOC 5-0 RD-1 18IN 2 ARM MONOFILAMENT BLACK",SUP-749G,CDM,S27200284,LOCAL,0272,RC,,,both,,,146.68,44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEALER/DIVIDER LAPAROSCOPIC 37CM 5MM LIGASURE XP MARYLAND",SUP-LXMJ37L,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 48MM 4MM E9000 MEDIUM LONG ROUND DIAMOND",SUP-E6240,CDM,S27200284,LOCAL,0272,RC,,,both,,,463.08,138.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4.5MM 50MM TSRH OSTEOGRIP THINLINE TITANIUM SPINE",SUP-83545509,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1181.47,45.9,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5+ 10MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS5P10R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1231.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTILUME 3CM 30FR BALLOON PACLITAXEL",SUP-OPTBDL7004B,CDM,C1726,HCPCS,0272,RC,,,both,,,14455.50,4336.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1712.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",379.61,375.47,414.12,"1 through 10",1681.17,12287.18,"percent of total billed charges",
"HC Bronch W Bronchl Alveolar Lav",PX-750000006,CDM,31624,CPT,0750,RC,,,both,,,4023.02,1206.91,"KAISER [10500]",Kaiser,,2695.42,67,,,,,0,467.88,4023.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 20CC 50CC CALCIUM SULFATE STIMULAN RAPID",SUP-620-020,CDM,C1713,HCPCS,0278,RC,,,both,,,10080.00,3024,"UHC [10700]","United Healthcare",,6380.64,63.3,,5023.51,2672.93,6679.78,18,1172.3,8568,"percent of total billed charges",
"TAPE RADIOPAQUE 30CM GLOW N TELL VASCUTAPE CENTIMETER",SUP-1100-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,502.20,150.66,"CIGNA [10200]",Cigna,,341.5,68,,,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 6.35MM TSRH-2D CONTOUR PEDICLE TITANIUM",SUP-8371070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"IMPL BREAST 650CC SMOOTH SHELL SURFACE NATRELLE INSPIRA FULL",SUP-SRF-650,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"BLUE CROSS [10001]","Blue Cross HMO",,1555.85,39.2,,,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X7MM RISE NONSTERILE",SUP-193.101,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 10MM 2.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2510X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 70X12.5X.8MM STAINLESS STEEL 2 SIDED RECIPROCATING",SUP-0277096276,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.41,87.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,34.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.77,246.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL IHF 1.4MM",SUP-DRLL-IHF-14,CDM,S27000186,LOCAL,0270,RC,,,both,,,996.30,298.89,"CIGNA [10200]","Cigna Local Plus",,533.02,53.5,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC STATSEAL SMALL DISC POTASSIUM FERRATE",SUP-DS614,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SAPPHIRE 3 CORONARY DILATATION CATHETER 1.25 X 15MM",SUP-54125-150-02,CDM,C1725,HCPCS,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM LEGEND 9MM BALL DIAMOND DISSECTING",SUP-14BA90D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1468.94,440.68,"PHCS [10601]",PHCS,,1028.26,70,,,,,0,170.84,1248.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROSUVASTATIN 20 MG TABLET",RX-35135,CDM,,,0637,RC,60687-0256-11,NDC,both,1,UN,27.01,8.1,"MULTIPLAN [10600]",Multiplan,,22.96,85,,,,,0,3.14,22.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BICORTICAL ILIUM THK3+ MM ALLOGRAFT FREEZE DRIED",SUP-400310,CDM,S27800098,LOCAL,0278,RC,,,both,,,4868.64,1460.59,"AETNA [10100]","Aetna HMO/PPO",,3870.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,566.22,4138.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vad Cable Disply Mod to Pwr Mod",PX-E27400010,CDM,Q0486,HCPCS,0274,RC,,,both,,,2025.00,607.5,"CIGNA [10200]",Cigna,,1377,68,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 200MM 135CM 6MM 6FR .035IN HELICAL VASCULAR",SUP-EX062003CL,CDM,C1876,HCPCS,0278,RC,,,both,,,22018.50,6605.55,"CIGNA [10200]","Cigna Open Access",,7376.2,33.5,,,,,0,2560.75,18715.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 25MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G425,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"NOVANET [10819]",Novanet,,7024.56,75,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 14MM COLLAR CEMENTLESS LOW PROFILE NECK",SUP-3L93714,CDM,C1776,HCPCS,0278,RC,,,both,,,28658.70,8597.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3396.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3333.01,24359.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COAGULATION DISORDERS",813,MS-DRG,,,,,,,inpatient,,,31920.82,9576.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,24318.97,,,,,,,7561,31920.82,"case rate",
"KIT ENDOSCOPIC EMR KIT 165CM 18MM RIM DYE SPRAY CATH",SUP-K-008,CDM,S27200284,LOCAL,0272,RC,,,both,,,1489.02,446.71,"FIRST HEALTH [10303]","First Health",,1191.22,80,,,,,0,173.17,1265.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 1.5MM X 8MM COCR",SUP-VAL-15080-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,654.35,45.9,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL WHITE 3MM TAPER ROUTER",SUP-5407FA3030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1009.26,302.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.38,857.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 5.2MMX1.5-2.2MM 29MM 26 3D GRIP SURFACE POWER",SUP-CDH29P,CDM,S27200284,LOCAL,0272,RC,,,both,,,8613.48,2584.04,"AETNA [10100]","Aetna HMO/PPO",,6847.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1001.75,7321.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL LOCK HOLE COMPRESSION SLOT PRECONTOUR",SUP-AR-2652CR,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,441.36,3225.75,"percent of total billed charges",
"CAP TOTAL SHOULDER: SHORT STEM TSA W/ AUGMENTS",SUP-71701428,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8079.75,27,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP PRIMARY STEM 16MM MINI",SUP-113636,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"MULTIPLAN [10600]",Multiplan,,10710,85,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 95MM 36MM 8.5MM 22FR ZENITH FLEX Z-TRAK",SUP-G48432,CDM,C1874,HCPCS,0278,RC,,,both,,,53285.40,15985.62,"CIGNA [10200]","Cigna Local Plus",,16784.9,31.5,,,,,0,6197.09,45292.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 10MM KNEE GVF UHMWPE STABILIZE ROTATE",SUP-972101,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"CIGNA [10200]","Cigna Open Access",,5806.7,56.9,,5302.19,4377.88,6578.61,27,1186.85,8674.34,"percent of total billed charges",
"BUTTON 1.7CM 14FR ENTERAL FEEDING TUBE RADIOPAQUE LOW",SUP-0120-14-1.7,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,90.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATORVASTATIN 10 MG TABLET",RX-19176,CDM,,,0637,RC,68084-0097-11,NDC,both,1,UN,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) DILATOR KIT INTPD-TF-DK",SUP-INTPDTFDKG,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC",699,MS-DRG,,,,,,,inpatient,,,31433.45,9430.03,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,6484.98,,"Case rate ($6,296.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,846.36, add-ons for qualifying new technology services are included. If operating cost exceeds $38,886.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,824.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,854.09. The transfer operating threshold is the transfer adjustment factor * $5,846.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $442.01. The transfer capital threshold is the transfer adjustment factor * $442.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,6296.1,25313.09,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 5CM 7FR .035IN GENTLE CURVE BILIARY",SUP-G21681,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,290,45.9,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HALYARD BALLARD 21.3IN 14FR 22MM 15MM SUCTION",SUP-2210,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.78,22.43,"NOVANET [10819]",Novanet,,56.09,75,,,,,0,8.7,63.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.250 CLAREON",SUP-SY60WF.250,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VISIGLIDE 2 ENDOSCOPIC 4500MM 70MM .035IN FLUORINE",SUP-G-260-3545S,CDM,C1769,HCPCS,0272,RC,,,both,,,1288.95,386.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH COYOTE 150CM 80MM 3.5MM BALLOON DILATATION NYBAX",SUP-H74939186350810,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 75CM 80MM 5MM BALLOON DILATATION OTW NONCOMPLIANT",SUP-H74939206050870,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ELECTROPHYSIOLOGY 2MM SPACING 6FR 115CM 2MM DECAPOLAR",SUP-401923R,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SENSOR NEONATAL LNCS OXIMETER ADHESIVE CABLED TAPE MASIMO SE",SUP-1862,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.00,20.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 9.5FR .125IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1009.5,CDM,C1894,HCPCS,0272,RC,,,both,,,255.78,76.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ANGIOGUARD 100UM 180CM .014IN 6MM EMBOLIC PROTECTION",SUP-601814RMC,CDM,C1884,HCPCS,0272,RC,,,both,,,6520.50,1956.15,"KAISER [10500]",Kaiser,,4368.74,67,,,,,0,758.33,5542.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM ADVANCED LORDOTIC TRAPEZOIDAL",SUP-7712,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"AETNA [10100]","Aetna HMO/PPO",,6582.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC",521,MS-DRG,,,,,,,inpatient,,,110850.82,33255.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,25889.2,,"Fee schedule rate ($25,889.20). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,7561,83798.36,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.838,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"CIGNA [10200]","Cigna Local Plus",,126.6,53.5,,3978.14,359.25,3978.14,24,27.52,201.14,"percent of total billed charges",
"CATH ENTEER 135CM 20X3.75X1.5MM .066IN FLAT BALLOON",SUP-ENB-375-20-135,CDM,C1887,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"AETNA [10100]","Aetna HMO/PPO",,9599.63,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 100MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,589.25,41.1,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 8MM 72MM STAINLESS STEEL CORTICAL SELF TAP",SUP-214.872,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,115.17,45.9,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 125ML GEL ROUND SMOOTH MEMORYGEL SILICONE P2.8CM",SUP-3501251BC,CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,435.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 24IN 8FR SUCTION",SUP-8888256529,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.16,19.85,"MULTIPLAN [10600]",Multiplan,,56.24,85,,,,,0,7.69,56.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRECEPT TI ROD, 95MM PREBENT LORDOTIC",SUP-8847095,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 80MM 16MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U16080090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4253.85,41.1,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 10FR LARGE REGULAR PIGTAIL CURVE URETERAL",SUP-M001245600,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,105.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Impacted Cerumen",PX-450000304,CDM,69210,CPT,0361,RC,,,both,,,1527.04,458.11,"KAISER [10500]",Kaiser,,1023.12,67,,,,,0,177.59,1527.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 20MM 1 HOLE CASCADIA CAYMAN BONE SPINE LEFT NONSTERILE",SUP-7908-41F20L,CDM,C1713,HCPCS,0278,RC,,,both,,,31594.50,9478.35,"PHCS [10601]",PHCS,,22116.15,70,,,,,0,3674.44,26855.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U185,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA [10200]","Cigna Local Plus",,398.58,53.5,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 STD KNEE LEFT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB6SL,CDM,C1776,HCPCS,0278,RC,,,both,,,17652.60,5295.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7255.22,41.1,,6417.48,6417.48,6417.48,"1 through 10",2053,15004.71,"percent of total billed charges",
"CATH STERLING MONORAIL 135CM 60MM 3.8-3.4FR 5MM LOW PROFILE",SUP-H74939031506010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 7 KNEE CEMENT FIX BEARING STERILE",SUP-150670007,CDM,C1776,HCPCS,0278,RC,,,both,,,15487.05,4646.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6365.18,41.1,,6417.48,6417.48,6417.48,"1 through 10",1801.14,13163.99,"percent of total billed charges",
"SUT PDS II 3-0 SH 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z316H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 50MM 36MM XLPE HIP STERILE LATEX FREE",SUP-71935848,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.90,3024.27,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1194.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1172.41,8568.77,"percent of total billed charges",
"CATH 35CM 8FR DRNG FLEXIMA METAL BILIARY RADIOPAQUE FIRM",SUP-M001272640,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR POWER 60MM 60MM LONG ECHELON 3000 440MM SHAFT",SUP-ECH60L,CDM,S27200284,LOCAL,0272,RC,,,both,,,9634.19,2890.26,"KAISER [10500]",Kaiser,,6454.91,67,,,,,0,1120.46,8189.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 25MM 2MM ULTRA LOW PROFILE BALLOON",SUP-1012270-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 3-0 SH 36IN 2 ARM BRAID GREEN NONABSORBABLE",SUP-X522H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC",871,MS-DRG,,,,,,,inpatient,,,47206.78,14162.03,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FARAWAVE NAV 115CM 12FR 35MM ABLATION OTW 20 ELECTRD",SUP-M004PF41M412,CDM,C1733,HCPCS,0272,RC,,,both,,,53235.00,15970.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"KIT CATH 16GA 22GA 8IN .032IN 1 LUMEN INTEGRAL SUT WING",SUP-AK-04210,CDM,C1751,HCPCS,0272,RC,,,both,,,149.64,44.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE VERSACORE VASCULAR 260CM .035IN STAINLESS",SUP-1012068-09,CDM,C1769,HCPCS,0272,RC,,,both,,,793.80,238.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 2X1.5CM GRAFIX PRIME ALLOGRAFT",SUP-PS13015,CDM,Q4133,HCPCS,0636,RC,,,both,,,5464.80,1639.44,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASHIR ENDOVASCULAR CATHETER",SUP-7201,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 35 SMALL KEEL AEQUALIS PERFORM SHOULDER",SUP-DWE502,CDM,C1776,HCPCS,0278,RC,,,both,,,9315.60,2794.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4275.86,45.9,,,,,0,1083.4,7918.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 145MM 23/16MM 18FR ENDURANT II ABDOMINAL",SUP-ETBF2316C145E,CDM,C1876,HCPCS,0278,RC,,,both,,,58443.53,17533.06,"MULTIPLAN [10600]",Multiplan,,49677,85,,,,,0,6796.98,49677,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE EXPLOR LOCK",SUP-11-210099,CDM,S27800098,LOCAL,0278,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,317.52,39.2,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 9.5IN MEYERDING 3IN 2 MEDIUM TEETH EDGE SURGICAL 1IN",SUP-23-6302,CDM,S27200284,LOCAL,0272,RC,,,both,,,311.98,93.59,"FIRST HEALTH [10303]","First Health",,249.58,80,,,,,0,36.28,265.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 2.7 MM CORTICAL SCR NONSTERILE",SUP-310.87,CDM,S27200284,LOCAL,0272,RC,,,both,,,1828.50,548.55,"FIRST HEALTH [10303]","First Health",,1462.8,80,,,,,0,212.65,1554.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +28.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.285,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAPE BLUNT NDL CLSR STERNAL NONABSORBABLE",SUP-AR-7289,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL SHALLCROSS FULL CURVE 8IN CYSTIC DUCT",SUP-SU10510,CDM,S27200284,LOCAL,0272,RC,,,both,,,466.97,140.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 24IN 8FR SUCTION",SUP-8888256529,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.16,19.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PDS II 3-0 SH 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z316H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE EKG 3 LEAD 12 PIN CNCT TRUNK SHIELD 2.7MR NONSTERILE",SUP-M1669A,CDM,S27000186,LOCAL,0270,RC,,,both,,,394.81,118.44,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATHETERIZATION 16FR SURESTEP BARDEX IC COMPLETE CARE",SUP-A300316A,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.29,41.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EZ STEER REDEL 115CM 4MM 7FR 1-7-4MM SPACE D-D CURVE",SUP-BD7TCDD4L,CDM,C1733,HCPCS,0272,RC,,,both,,,6113.40,1834.02,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Impl Cardiac Event Record",PX-361000058,CDM,33285,CPT,0361,RC,,,both,,,15025.48,4507.64,"CIGNA [10200]",Cigna,,7680,,"Case rate ($7,680). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1747.46,12771.66,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL SF J-J CURVE ABLATION",SUP-D134803,CDM,C1732,HCPCS,0272,RC,,,both,,,21312.90,6393.87,"NOVANET [10819]",Novanet,,15984.68,75,,,,,0,2478.69,18115.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SPINAL MAXCESS 4 ACCESS",SUP-3241000,CDM,S27200284,LOCAL,0272,RC,,,both,,,11730.00,3519,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1390.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SYNETURE V-LOC 2-0 GS-21 9IN CLSR ABSORBABLE BLUE",SUP-VLOCN0345,CDM,S27200284,LOCAL,0272,RC,,,both,,,503.82,151.15,"FIRST HEALTH [10303]","First Health",,403.06,80,,,,,0,58.59,428.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 144MM 12MM PRESS FIT FULL PROFILE TAPERLOC PPS",SUP-51-101120,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"PHCS [10601]",PHCS,,16942.34,70,,,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER MVP SPECTRUM 45D RIGHT HOOK EXTENDED LENGTH ERGONOMIC",SUP-C6410EL,CDM,S27200284,LOCAL,0272,RC,,,both,,,1972.80,591.84,"CIGNA [10200]",Cigna,,1341.5,68,,,,,0,229.44,1676.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND VAC VERAFLO MEDIUM KIT DISPOSABLE",SUP-ULTVFL05MD,CDM,S27200284,LOCAL,0272,RC,,,both,,,884.93,265.48,"AETNA [10100]","Aetna HMO/PPO",,703.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,102.92,752.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 24MM T2 TITANIUM FULL THREAD FEMUR HUMERUS",SUP-1896-4024S,CDM,C1713,HCPCS,0278,RC,,,both,,,1299.56,389.87,"CIGNA [10200]",Cigna,,883.7,68,,1831.33,1831.33,1831.33,16,151.14,1104.63,"percent of total billed charges",
"STENT POLARIS 28CM 3CM 5FR .038IN BLADDER LOOP STRAIGHT LOW",SUP-M006155224010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"NOVANET [10819]",Novanet,,923.22,75,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL ORANGE 125MM 2MM QUICK COUPLE 2.7MM LOCKING SCR",SUP-03.119.014,CDM,S27200284,LOCAL,0272,RC,,,both,,,629.69,188.91,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT SPINAL MAXCESS 4 ACCESS",SUP-3241000,CDM,S27200284,LOCAL,0272,RC,,,both,,,11730.00,3519,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR EASY RADIAL LEFT CURVE GUIDING",SUP-LA6ERADL,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE VISI-BLACK 5-0 C-1 24IN 2 ARM MONOFILAMENT BLUE",SUP-8725H,CDM,S27200284,LOCAL,0272,RC,,,both,,,150.18,45.05,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE WHOLEY VASCULAR J 145CM .035IN ATRAUMATIC EXT",SUP-WWIJ35145,CDM,C1769,HCPCS,0272,RC,,,both,,,510.30,153.09,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM FEMORAL 135MM CEMENTLESS NECK ACCOLADE TMZF 127D 6 49MM",SUP-6021-0637,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2704.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2654.17,19398.49,"percent of total billed charges",
"SLEEVE CENTERING 9.5MM S-ROM ZTT 24F SMALL HIP PROXIMAL",SUP-550747,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"AETNA [10100]","Aetna HMO/PPO",,8653.38,79.5,,10981.53,8986.79,12413.38,12,1265.9,9252.04,"percent of total billed charges",
"CANN ARTERIAL 20FR 12IN 1 PIECE BLUNT TIP INTRO ELONGATED",SUP-77420,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,205.63,45.9,,,,,0,52.1,380.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE ULTIMA 10-0 CS160-6 CTC-6 4IN 2 ARM MONOFILAMENT",SUP-9090G,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.32,85.6,"CIGNA [10200]","Cigna Open Access",,162.35,56.9,,,,,0,33.18,242.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR INJECTION MEDRAD STELLANT FLEX 2 SPIKE 200ML",SUP-FLEXD-200-SPK,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.23,30.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46.92,45.9,,,,,0,11.89,86.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT TRIVASCULAR OVATION PRIME PTFE DELIVERY CATH",SUP-TV-AI01-E,CDM,S27200284,LOCAL,0272,RC,,,both,,,801.90,240.57,"KAISER [10500]",Kaiser,,537.27,67,,,,,0,93.26,681.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL ATTUNE STERILE 3 KNEE RIGHT CEMENTED POSTERIOR",SUP-150410203,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"BLUE CROSS [10001]","Blue Cross PPO",,8778.19,39.2,,3949.44,3949.44,3949.44,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"SCR BASEPLT 20MM AEQUALIS FLEX REVIVE SHOULDER",SUP-ARS655102,CDM,C1713,HCPCS,0278,RC,,,both,,,4330.00,1299,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,503.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",503.58,3680.5,"percent of total billed charges",
"STENT SUPERA 100MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-100-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"MULTIPLAN [10600]",Multiplan,,8552.7,85,,,,,0,1063.27,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Periph Ins Impl Vad",PX-361000120,CDM,36585,CPT,0361,RC,,,both,,,7533.44,2260.03,"CIGNA [10200]",Cigna,,3951,,"Case rate ($3,951). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,876.14,7533.44,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 38MM 140CM .91-1.12MM 3.5MM CORONARY",SUP-RONYX35038W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"CIGNA [10200]","Cigna Open Access",,3094.79,56.9,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EMPHASYS THR CERAMIC ON POLYETHYLENE",SUP-OSC382182,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"PHCS [10601]",PHCS,,16317,70,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Scr Mammo Bi Incl Cad",PX-403000006,CDM,77067,CPT,0403,RC,,,both,,,722.12,216.64,"CIGNA [10200]",Cigna,,252,,"Per diem ($252).",,,,0,83.98,613.8,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 16.25MM 1.5MM AXIUS CORONARY INTERNAL",SUP-OF-1500,CDM,S27200284,LOCAL,0272,RC,,,both,,,813.05,243.91,"CIGNA [10200]",Cigna,,552.87,68,,,,,0,94.56,691.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",477,MS-DRG,,,,,,,inpatient,,,125782.25,37734.67,"BLUE CROSS [10001]","Blue Cross PPO",,85283.88,,,,,,,7561,100860.5,"case rate",
"HC Dgtz Gls Mcrscp B1 Marow Smr",PX-305000088,CDM,0855T,CPT,0312,RC,,,both,,,104.00,31.2,"PHCS [10601]",PHCS,,72.8,70,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 3.2FR 115CM BIOPSY SET STRAIGHT TIP OCCLUSIVE",SUP-G14919,CDM,S27200284,LOCAL,0272,RC,,,both,,,721.71,216.51,"AMERIGROUP MEDICAID [20100]",Amerigroup,,85.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,83.93,613.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 25MM 29MM AEQUALIS 2MM LATERAL OFFSET",SUP-DWE825,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6421.24,68,,,,,0,1098.22,8026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 80CM .018IN STAINLESS STEEL MANDRELL SS TIP",SUP-06507210,CDM,C1769,HCPCS,0272,RC,,,both,,,200.54,60.16,"KAISER [10500]",Kaiser,,134.36,67,,,,,0,23.32,170.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HALOPERIDOL LACTATE 5 MG/ML INJECTION SUPERORDERABLE",RX-409467,CDM,J1630,HCPCS,0636,RC,63323-0474-00,NDC,both,1,ML,54.27,16.28,"BLUE CROSS [10001]","Blue Cross HMO",,0.93,,,,,,,0.86,46.13,"fee schedule",
"AUG TIBIAL 10MM PERSONA EF KNEE LEFT MEDIAL HALF BLOCK",SUP-42555805310,CDM,C1776,HCPCS,0278,RC,,,both,,,7236.72,2171.02,"CIGNA [10200]",Cigna,,4920.97,68,,5873.17,5873.17,5873.17,"1 through 10",841.63,6151.21,"percent of total billed charges",
"SCR BONE 4.5MM 35MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840004535,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,1144.80,304.56,2275.09,66,441.36,3225.75,"percent of total billed charges",
"(EVAL) SELUTION DEB 2.75X25",SUP-SCA14U-275025D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45MMX8MM CLYDESDALE 6D PEEK-OPTIMA RADIOPAQUE",SUP-2968845,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOLO PLUS HYBRID GUIDEWIRE  0.035"" STRAIGHT TIP (TRITON)",SUP-HW35SS,CDM,C1769,HCPCS,0272,RC,,,both,,,442.18,132.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAPPHIRE? II PRO SZ PTCA BALLOON SEMI-COMPLIANT 1.25 MM X 10",SUP-212-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CRYOPRESERVED SKIN 115.52 SQ CM 7.6CM X 15.2CM CRYOPRESER",SUP-104TSXLR,CDM,Q4121,HCPCS,0636,RC,,,both,,,21690.90,6507.27,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CMPNT GLENOID 36MM +6MM GLENOSPHERE COLOR CODED",SUP-115316,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5011.32,41.1,,6417.48,6417.48,6417.48,"1 through 10",1418.05,10364.05,"percent of total billed charges",
"BLADE OPHTHALMIC 8MM TANNE UNIVERSAL TREPHINE UNIQUE HUB","SUP-E3050 8.00",CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,375.92,68,,,,,0,64.29,469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC",427,MS-DRG,,,,,,,inpatient,,,310602.19,93180.66,"AMBETTER EXCHANGE  [11102]",Ambetter,,44777.41,,"Case rate ($44,777.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $41,578.86, add-ons for qualifying new technology services are included. If operating cost exceeds $74,618.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $4,525.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,633.85. The transfer operating threshold is the transfer adjustment factor * $41,578.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,143.56. The transfer capital threshold is the transfer adjustment factor * $3,143.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,210754.25,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE FIBER 9CC ALLOGRAFT",SUP-T50309,CDM,C1713,HCPCS,0278,RC,,,both,,,13524.00,4057.2,"KAISER [10500]",Kaiser,,9061.08,67,,,,,0,1572.84,11495.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) OCCL CARDIOVASCULAR 7.5X15-17MM 20MM 26MM HEMOSTASIS",SUP-9-ACP2-007-020,CDM,C1817,HCPCS,0278,RC,,,both,,,102600.00,30780,"MULTIPLAN [10600]",Multiplan,,87210,85,,,,,0,11932.38,87210,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM TRIATHLON 3 RIGHT LATERAL LEFT MEDIAL TOTAL",SUP-5545-A-301,CDM,C1776,HCPCS,0278,RC,,,both,,,4327.60,1298.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,512.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,503.3,3678.46,"percent of total billed charges",
"CATH ADVANCE PLIAFORM STARCAST 135CM 4CM 10MM BALLOON",SUP-G52293,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX12MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183722,CDM,C1776,HCPCS,0278,RC,,,both,,,13241.10,3972.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1569.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1539.94,11254.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 8MM 145CM 3.25MM CORONARY STENT",SUP-1125325-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2679.64,45.9,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIMETHYL FUMARATE 240 MG CAPSULE,DELAYED RELEASE",RX-162311,CDM,,,0250,RC,16729-0417-12,NDC,both,1,UN,561.20,168.36,"PHCS [10601]",PHCS,,392.84,70,,,,,0,65.27,477.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THIOGUANINE 20 MG/ML ORAL SUSPENSION",RX-408888,CDM,,,0637,RC,08888-8884-05,NDC,both,30,ML,36235.62,10870.69,"UHC [10700]","United Healthcare",,22937.15,63.3,,,,,0,4214.2,30800.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 24X10X17-13.7MM LUMINARY BULLET NOSE",SUP-15817,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"MULTIPLAN [10600]",Multiplan,,16065,85,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 9.5IN LUMBAR CERVICAL NERVE RETRACTION HANDLE KARLIN",SUP-46-3141,CDM,S27200284,LOCAL,0272,RC,,,both,,,1095.61,328.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,129.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.42,931.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 3 GBQ MICROSPHERES YTTRIUM 90",SUP-SIR-Y001,CDM,C2616,HCPCS,0278,RC,,,both,,,104566.50,31369.95,"MULTIPLAN [10600]",Multiplan,,88881.53,85,,,,,0,12161.08,88881.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX SPIRAL MONOCRYL PLUS 4-0 PS-2 SPIRAL 70CM",SUP-SXMP1B119,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"NOVANET [10819]",Novanet,,160.43,75,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 12MM T8 FULL THREAD LOCK STARDRIVE NONSTERILE",SUP-656012,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"BLUE CROSS [10001]","Blue Cross HMO",,523.4,39.2,,957.42,156.86,7483.26,51,155.28,1134.92,"percent of total billed charges",
"PLATE LARGE OLIF25 2 HOLE BONE SPINE STERILE",SUP-2140002,CDM,C1713,HCPCS,0278,RC,,,both,,,17250.00,5175,"AETNA [10100]","Aetna HMO/PPO",,13713.75,79.5,,1521.93,481.35,16760.95,30,2006.18,14662.5,"percent of total billed charges",
"INDIUM IN-111 OXYQUINOLINE INTRAVENOUS SOLUTION 0-0.5 MCI",RX-155677,CDM,A9547,HCPCS,0343,RC,08888-8878-40,NDC,both,1,UN,11022.18,3306.65,"BLUE CROSS [10001]","Blue Cross PPO",,2453.35,,,,,,,1281.88,9368.85,"fee schedule",
"KIT GASTRO 16FR 18GA NDL SCPL INTRO SYR HEMOSTAT MIC-KEY 11",SUP-98437,CDM,S27200284,LOCAL,0272,RC,,,both,,,1649.78,494.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,678.06,41.1,,,,,0,191.87,1402.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 65CM 5FR ROSCH INFERIOR MESENTRIC CURVE",SUP-H787117334015,CDM,C1887,HCPCS,0272,RC,,,both,,,704.05,211.21,"UHC [10700]","United Healthcare",,445.66,63.3,,,,,0,81.88,598.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CROSSWALK 135CM 4.2FR 3.2FR .039FR .037FR MICRO SPRT",SUP-PSC35135A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1498.50,449.55,"MULTIPLAN [10600]",Multiplan,,1273.73,85,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR COBRA 2 CURVE ANGIOGRAPHIC VISCERAL",SUP-10719708,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 16MM 8MM STD WALL THIN WALL 2 BRANCH",SUP-SBT1601D,CDM,C1768,HCPCS,0278,RC,,,both,,,6893.10,2067.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3163.93,45.9,,,,,0,801.67,5859.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30X2.5MM VASCULAR CRTDG LOADING UNIT TITANIUM",SUP-010911L,CDM,S27200284,LOCAL,0272,RC,,,both,,,738.32,221.5,"CIGNA [10200]","Cigna Local Plus",,395,53.5,,,,,0,85.87,627.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035423080,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]",Cigna,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 22CM 9MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140922,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1407.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 12CM 3CM 4.8FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175196050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,124.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 200MM 5MM .014IN BALLOON DILATATION",SUP-AB14W050200150,CDM,C1725,HCPCS,0272,RC,,,both,,,1638.75,491.62,"PHCS [10601]",PHCS,,1147.13,70,,,,,0,190.59,1392.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM REFLECTION R3 CONTOUR HIP ACETABULAR",SUP-71332530,CDM,C1713,HCPCS,0278,RC,,,both,,,1287.90,386.37,"CIGNA [10200]",Cigna,,875.77,68,,1831.33,1831.33,1831.33,16,149.78,1094.72,"percent of total billed charges",
"GRAFT BONE CORTICAL FEMORAL THK3MM HALVE FROZEN TRADITIONAL",SUP-T20675,CDM,S27800098,LOCAL,0278,RC,,,both,,,6109.95,1832.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1748.67,28.62,,,,,0,710.59,5193.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 60MM 20MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U20060090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"AETNA [10100]","Aetna HMO/PPO",,8228.25,79.5,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 5.6MM ASNIS II LARGE CANNULATED AO FIT 8MM SCR",SUP-702611,CDM,S27200284,LOCAL,0272,RC,,,both,,,2838.15,851.44,"UHC [10700]","United Healthcare",,1796.55,63.3,,,,,0,330.08,2412.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GATEWAY 135CM 9MM 4MM BALLOON DILATATION HYDROPHILIC",SUP-M0032072209400,CDM,C1725,HCPCS,0272,RC,,,both,,,9423.88,2827.16,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1096,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1096,8010.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X8MM 10D LORDOTIC",SUP-6980850,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"CIGNA [10200]","Cigna Open Access",,7959.6,33.5,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Culture Respiratory",PX-306000042,CDM,87070,CPT,0306,RC,,,both,,,479.75,143.92,"BLUE CROSS [10001]","Blue Cross PPO",,11.01,,"Fee schedule rate ($11.01).",,,,0,0.01,407.79,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 25MM TITANIUM LOCKING VENTURE BONE ANTERIOR CERVICAL",SUP-9790025,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"AMERIGROUP MEDICAID [20100]",Amerigroup,,497.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",488.46,3570,"percent of total billed charges",
"SHELL ACETABULAR 48MM HIP LIMIT HOLE POROUS RANAWAT/BURSTEIN",SUP-11-106048,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,818.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 12CM 5FR 2 PIGTAIL CURVE BILIARY POLYETHYLENE",SUP-G22437,CDM,C2625,HCPCS,0278,RC,,,both,,,1328.40,398.52,"BLUE CROSS [10001]","Blue Cross HMO",,520.73,39.2,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cold Agglut Titer",PX-302000019,CDM,86157,CPT,0302,RC,,,both,,,214.50,64.35,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,182.33,"per diem",
"HEAD FEMORAL +3.5MM 12/14 LARGE 36MM HIP ACETABULUM BIOLOX",SUP-00877503603,CDM,C1776,HCPCS,0278,RC,,,both,,,8526.00,2557.8,"NOVANET [10819]",Novanet,,6394.5,75,,,,,0,991.57,7247.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 CURVE 10MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962041,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1075.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) IMPLANT DELIVERY SYSTEM 49-18",SUP-FG-1001-05,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 19GA 10.2CM SUPERCORE COAXIAL INTRO ECHOGENIC TIP",SUP-MCXS2015LY,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.64,44.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA",955,MS-DRG,,,,,,,inpatient,,,419460.64,125838.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Fee schedule rate ($0). The outlier threshold amount is ($224,410.00),  the outlier percentage is (63.7%).  The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1). Includes an add-on of $3,230.48 when RC 0681-0684 total amount is above $1.",,,,0,,,other,"IP STOPLOSS Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPRT ORTHOPEDIC LARGE 20.5-23IN KNEE NEOPRENE SLEEVE OPEN",SUP-NE7702-04,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.70,30.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STELLAREX 135CM 80MM 5MM BALLOON DILATATION ENDURACOAT",SUP-AB35SX050080135,CDM,C2623,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH HERO ACCESS CMPNT LATEX FREE",SUP-HEROACK,CDM,S27200284,LOCAL,0272,RC,,,both,,,3864.00,1159.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER DISORDERS OF NERVOUS SYSTEM,MAJOR",058,APR-DRG,,,,,,,inpatient,,,42338.71,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $10,145.47. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($60,816.70) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR FL5 CURVE ANGIOGRAPHIC FEMORAL 2 WIRE",SUP-H74916599242,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"UHC [10700]","United Healthcare",,48.48,63.3,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 33MM FOGARTY FIBRA ATRAUMATIC OCCLUSION STERILE",SUP-G-3355,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,153.82,68,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 9MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71934436,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"MULTIPLAN [10600]",Multiplan,,10345.86,85,,,,,0,1415.56,10345.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 70MM LCP STAINLESS STEEL FULL THREAD PROXIMAL",SUP-212.126,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"CIGNA [10200]","Cigna Open Access",,487.8,56.9,,1144.80,304.56,2275.09,66,99.7,728.71,"percent of total billed charges",
"CONDUIT VALVE 21MM ATS OPEN PIVOT AORTIC MECHANICAL GRAFT",SUP-502AG21,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3135.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 CTX 36IN BRAID COATED UNDYED ABSORBABLE",SUP-J980H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VALVE AORTIC 20MM SAPIEN 3 EDWARDS HEART TRANSCATHETE",SUP-9750TFX20A,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19887.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 126MM 13.5MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771101300,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"BLUE CROSS [10001]","Blue Cross PPO",,8192.65,39.2,,3949.44,3949.44,3949.44,"1 through 10",2430.63,17764.68,"percent of total billed charges",
"TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION",RX-11565,CDM,J3260,HCPCS,0636,RC,39822-0412-06,NDC,both,1,UN,471.91,141.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,36.47,,"Fee schedule rate ($36.47). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.47,401.12,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Ganglion Sphenopalat",PX-361000423,CDM,64505,CPT,0361,RC,,,both,,,2996.00,898.8,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,3,2996,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 60MM 10MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171100610,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"KAISER [10500]",Kaiser,,786.92,67,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC High Mw Kininogen",PX-305000029,CDM,85293,CPT,0305,RC,,,both,,,857.00,257.1,"BLUE CROSS [10001]","Blue Cross PPO",,24.18,,"Fee schedule rate ($24.18).",,,,0,0.01,728.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYSORB 3-0 C-14 30IN BRAID COATED UNDYED ABSORBABLE",SUP-SL-693,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.62,31.09,"FIRST HEALTH [10303]","First Health",,82.9,80,,,,,0,12.05,88.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC",439,MS-DRG,,,,,,,inpatient,,,25336.85,7601.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7587.62,,"Fee schedule rate ($7,587.62). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,5218.02,20978.69,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT GLENOID SHORT STEM STD HEAD INSRT POLYETHYLENE",SUP-98B00900109,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3172.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3113.93,22758.75,"percent of total billed charges",
"SPRT ORTHOPEDIC LARGE XL 9IN LUMBOSACRAL ELASTIC COMPRESSION",SUP-79-89241,CDM,S27000186,LOCAL,0270,RC,,,both,,,292.06,87.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,120.04,41.1,,,,,0,33.97,248.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Methylmalonic Acid",PX-301000344,CDM,83918,CPT,0301,RC,,,both,,,628.90,188.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.15,,,,,,,0.01,534.57,"fee schedule",
"SPECLM EAR 6.5MM ROUND EBONY FINISH STAINLESS STEEL",SUP-130665,CDM,S27200284,LOCAL,0272,RC,,,both,,,535.98,160.79,"KAISER [10500]",Kaiser,,359.11,67,,,,,0,62.33,455.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR SMALL DIAMETER SHORT 30MM SIGNIA VASCULAR CURVE",SUP-SIGSDS30CTV,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 150MM 4FR 3.5MM LOW PROFILE COAXIAL",SUP-PCP035150130,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +17 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1700,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 5FR 21GA MERIT MAK .018IN STD STAINLESS STEEL",SUP-MAK505,CDM,C1894,HCPCS,0272,RC,,,both,,,230.55,69.16,"FIRST HEALTH [10303]","First Health",,184.44,80,,,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 47MM SHOULDER EQUINOXE SHORT STERILE LATEX FREE",SUP-310-01-47,CDM,C1776,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3988.2,68,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 80MM 190CM 2MM",SUP-R51002008L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,233.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 1.27MM FLUOROPLASTIC COLLAR BUTTON",SUP-1013302,CDM,S27800098,LOCAL,0278,RC,,,both,,,70.23,21.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.17,59.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 45IN 8FR SIDEPORT WEIGHTED STYLET FLEXIFLO",SUP-00473,CDM,S27000186,LOCAL,0270,RC,,,both,,,73.95,22.18,"FIRST HEALTH [10303]","First Health",,59.16,80,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION RELINE MAS NITINOL SPINE BLUNT THREAD",SUP-10000607,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 170MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT SET 6",SUP-222.657,CDM,C1713,HCPCS,0278,RC,,,both,,,9026.30,2707.89,"MULTIPLAN [10600]",Multiplan,,7672.36,85,,,,,0,1049.76,7672.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NEURON 120CM THROMBECTOMY",SUP-PNS5F120BER,CDM,C1757,HCPCS,0272,RC,,,both,,,1012.50,303.75,"UHC [10700]","United Healthcare",,640.91,63.3,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUGMENTED BASEPLATE, GLENOSPHERE, INSERT, TRAY, STEM, SCREWS",SUP-CAP-E-RSA2,CDM,C1776,HCPCS,0278,RC,,,both,,,52290.00,15687,"BLUE CROSS [10001]","Blue Cross PPO",,20497.68,39.2,,3949.44,3949.44,3949.44,"1 through 10",6081.33,44446.5,"percent of total billed charges",
"CAP CONSTRUCT HIP DUAL MOBILITY CEMENTED OR3O WITH OXI HEAD",SUP-71703498,CDM,C1776,HCPCS,0278,RC,,,both,,,30240.00,9072,"MULTIPLAN [10600]",Multiplan,,25704,85,,,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 188MM LCP BOARD METAPHYSEAL STAINLESS STEEL 10",SUP-226.601,CDM,C1713,HCPCS,0278,RC,,,both,,,3612.00,1083.6,"CIGNA [10200]",Cigna,,2456.16,68,,1831.33,1831.33,1831.33,16,420.08,3070.2,"percent of total billed charges",
"HC Lgh Gene Rearrange Amp Meth",PX-309000037,CDM,81261,CPT,0310,RC,,,both,,,1046.90,314.07,"UHC [10700]","United Healthcare",,178.19,,,,,,,0.01,889.87,"fee schedule",
"LENS IOL 10 D +9 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200090,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,118.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIDAXOMICIN 200 MG TABLET",RX-110360,CDM,,,0637,RC,52015-0080-01,NDC,both,1,UN,1180.49,354.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,139.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,137.29,1003.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 19MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G519,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4110,41.1,,6417.48,6417.48,6417.48,"1 through 10",1163,8500,"percent of total billed charges",
"HC MRI Upr Ext Nonjnt W&WO Cntrst",PX-610000026,CDM,73220,CPT,0610,RC,,,both,,,4522.07,1356.62,"CIGNA [10200]","Cigna Open Access",,799,,"Per diem ($799). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,525.92,3843.76,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SPINAL L70MM 2.1H ANTERIOR CERVICAL TITANIUM ALLOY LEV",SUP-18002470,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 30CM 32MM ABDOMEN THORAX SUT RETENTION",SUP-733032,CDM,C1768,HCPCS,0278,RC,,,both,,,7104.24,2131.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2033.23,28.62,,,,,0,826.22,6038.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG HEMOSTATIC 5X5IN QUIKCLOT CONTROL+ 4 PLY STERILE LATEX",SUP-4000,CDM,S27200284,LOCAL,0272,RC,,,both,,,497.06,149.12,"AETNA [10100]","Aetna HMO/PPO",,395.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.81,422.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BALL 37CM 6FR NONSTERILE REUSABLE",SUP-257F6,CDM,S27000186,LOCAL,0270,RC,,,both,,,868.40,260.52,"MULTIPLAN [10600]",Multiplan,,738.14,85,,,,,0,100.99,738.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 150MM 6FR 7MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-07151,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 9MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531-G-509,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"BLUE CROSS [10001]","Blue Cross PPO",,3671.5,39.2,,3949.44,3949.44,3949.44,"1 through 10",1089.28,7961.17,"percent of total billed charges",
"STENT ZILVER VENA 140MM 80CM 16MM BILIARY VENOUS DELIVERY",SUP-G57449,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4147.04,28.62,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE STERILE EDGE DISPOSABLE",SUP-E1512,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.38,44.21,"CIGNA [10200]",Cigna,,100.22,68,,,,,0,17.14,125.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY TRICUSPID 28MM",SUP-900SFC28,CDM,S27800098,LOCAL,0278,RC,,,both,,,14490.00,4347,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5796,40,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 12MM 140CM 3.5MM CORONARY STENT",SUP-LUN350R12US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENZONATATE 100 MG CAPSULE",RX-988,CDM,,,0637,RC,68084-0214-11,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Removal Perm Ccm-D System Pulse Generator Only",PX-481000414,CDM,0919T,CPT,0481,RC,,,both,,,5605.00,1681.5,"AETNA [10100]","Aetna HMO/PPO",,4455.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,651.86,5605,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 150MM .9MM NONTHREAD NONSTERILE LATEX FREE",SUP-MSG09150,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"CIGNA [10200]","Cigna Open Access",,99.01,56.9,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xtra Bowl Set 225ml",PX-E27200339,CDM,E27200339,LOCAL,0272,RC,,,both,,,354.20,106.26,"CIGNA [10200]","Cigna Open Access",,201.54,56.9,,,,,0,41.19,301.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 180MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-05181,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 16MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-716,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1565.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUTURING 10MM 2-0 ES-9 7IN SINGLE STITCH ENDO STITCH",SUP-170051,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,98.03,68,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT HS FIBER ULTRALOOP #2 66CM NON-ABSORABLE 1.25IN MINITAPE",SUP-72205445,CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"KAISER [10500]",Kaiser,,370.4,67,,,,,0,64.29,469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BULLET ALLOGRAFT REVISION DOWEL PREHYDRATE",SUP-PCD11,CDM,C1713,HCPCS,0278,RC,,,both,,,6744.75,2023.42,"FIRST HEALTH [10303]","First Health",,5395.8,80,,,,,0,784.41,5733.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 NARROW KNEE LEFT CRUCIATE RETAINING PERSONA",SUP-42502206401,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"MULTIPLAN [10600]",Multiplan,,24561.24,85,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC CURVE TIP RELOAD AEON 45MMX2.5MM STERILE",SUP-AESC45W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"CIGNA [10200]","Cigna Open Access",,806.56,56.9,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 6.5IN 9MM 5MM SAYRE 2 END BLUNT PERIOSTEAL",SUP-26-3751,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.92,53.98,"CIGNA [10200]",Cigna,,122.35,68,,,,,0,20.92,152.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPANDER BREAST TISSUE SMOOTH SURFACE WITH SUTURE TABS MEDIU",SUP-SCPX135MH,CDM,C1789,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"UHC [10700]","United Healthcare",,5503.3,63.3,,,,,0,1011.11,7389.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 80MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-08081,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 FLEXOR 20MM 125CM 5MM 7FR BILIARY NITINOL",SUP-G31350,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"KAISER [10500]",Kaiser,,2799.93,67,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURNPIKE 135CM 2.9FR SPIRAL GUIDING MULTILAYER SHAFT",SUP-5640,CDM,C1887,HCPCS,0272,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL ARTHREX UNIVERS REVERS 10 SHOULDER STERILE",SUP-AR-9501-10S,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1251,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1227.78,8973.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE PIN ORTHOPEDIC 444MM 3.2MM VERSANAIL HIP THREAD",SUP-281001175,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 59MM 135CM 6MM 160CM",SUP-M001712070,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"CIGNA [10200]","Cigna Open Access",,4809.47,56.9,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 14MM 13FR 10FR TRIVASCULAR OVATION PRIME",SUP-TV-IL1414100-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13723.29,41.1,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 17CM 6MM BALLOON DILATATION",SUP-DR135617,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"KAISER [10500]",Kaiser,,922.59,67,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 20MM EDWARDS SAPIEN 3 TRANSCATHETER ULTRA LOW",SUP-S3USTA120A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21544.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 200MM 4MM BALLOON DILATATION DURALYN",SUP-48004020X,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUP FEEDING MEDICINE GRADUATED LATEX FREE REUSABLE STAINLESS",SUP-2,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.87,23.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT TISSUE CLSR PRIMA DUPLOJECT TISSEEL PREFILL SYR FROZEN",SUP-1506079,CDM,S27200284,LOCAL,0272,RC,,,both,,,1280.04,384.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR INTERFERENCE BIOCOMPOSITE 10MM 7MM ACL TENODESIS STERILE",SUP-AR-1670BC,CDM,C1713,HCPCS,0278,RC,,,both,,,2716.88,815.06,"PHCS [10601]",PHCS,,1901.82,70,,,,,0,315.97,2309.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR ACTIS DUOFIX 3 HIGH OFFSET HIP STERILE",SUP-101012030,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8722.3,28.62,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 47CM 26MM ABDOMEN THORAX WOVEN SOFT",SUP-M00202175426T0,CDM,L8670,HCPCS,0278,RC,,,both,,,13481.36,4044.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3639.97,27,,,,,0,427.53,11459.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR JUDKINS RIGHT 3.5 CURVE",SUP-534519T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"AETNA [10100]","Aetna HMO/PPO",,74.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC No Pt Prsnt Train Add 15 (Gp)",PX-420000191,CDM,G0542,HCPCS,0420,RC,,,both,,,37.00,11.1,"NOVANET [10819]",Novanet,,27.75,75,,,,,0,0.04,37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE PT VASCULAR J 185CM 35CM .014IN FLOPPY",SUP-H7491216001J1,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"FIRST HEALTH [10303]","First Health",,453.6,80,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 8.25MM 7CM PARTIAL THREAD ROTATOR CUFF",SUP-AR-6566,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"CIGNA [10200]",Cigna,,155.3,68,,,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TGS GUIDEWIRE",SUP-8000-060-009,CDM,C1769,HCPCS,0272,RC,,,both,,,1762.50,528.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,724.39,41.1,,,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 26CM 6FR .035",SUP-M006192133090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,427.13,28.62,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 120MM 3.8-3.4FR 3.5MM LOW",SUP-39147-35121,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 35MM 9MM DELTA ACL CANNULATED",SUP-AR-5035TC-09,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,849.44,45.9,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Pta Sf Init",PX-361000704,CDM,37263,CPT,0361,RC,,,both,,,12247.10,3674.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1451.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1424.34,10410.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00165,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,743.58,68,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REINFORCEMENT STAPLE LINE UNIVERSAL 6 FIRING 3 GEL TUBE","SUP-PSD 4506-UN",CDM,S27200284,LOCAL,0272,RC,,,both,,,1256.85,377.05,"MULTIPLAN [10600]",Multiplan,,1068.32,85,,,,,0,146.17,1068.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 12CM SONOPET IQ BONE MICRO CLAW 1.6X2MM STERILE",SUP-5500-25B-315,CDM,S27200284,LOCAL,0272,RC,,,both,,,7162.61,2148.78,"NOVANET [10819]",Novanet,,5371.96,75,,,,,0,833.01,6088.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CRE 240CM 5.5CM 7.5FR 10-12MM BALLOON DILATATION PEBAX",SUP-M00558470,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"PHCS [10601]",PHCS,,1154.32,70,,,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP TUBE 16MM CRANIOFIX 2 CRANIAL FLAP TITANIUM SECURE",SUP-FF491T,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.77,401.03,"MULTIPLAN [10600]",Multiplan,,1136.25,85,,,,,0,155.47,1136.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 240MM 5MM BALLOON DILATATION STERILE LATEX",SUP-585024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17MM 27MM 25MM BIOCOR FLEXFIT STENTED LOW",SUP-B100-27A-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,30744.00,9223.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8798.93,28.62,,,,,0,3575.53,26132.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0347,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"MULTIPLAN [10600]",Multiplan,,805.55,85,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP EXTERNAL FIXATION STIMULATION",SUP-675705S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2610.00,783,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1774.8,68,,,,,0,303.54,2218.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 80CM 5FR SOS OMNI 3 CURVE ANGIOGRAPHIC VISCERAL",SUP-H787107204065,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"KAISER [10500]",Kaiser,,145.73,67,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT 7.5IN RHOTON 45D BALL SURGICAL 4MM",SUP-58-6072,CDM,S27200284,LOCAL,0272,RC,,,both,,,524.07,157.22,"CIGNA [10200]","Cigna Open Access",,298.2,56.9,,,,,0,60.95,445.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 11MM 1MM CORTICAL CRANIOFACIAL TITANIUM SELF",SUP-400.531,CDM,C1713,HCPCS,0278,RC,,,both,,,550.80,165.24,"FIRST HEALTH [10303]","First Health",,440.64,80,,,,,0,64.06,468.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSELECT PLUS DEMINERALIZED BONE MATRIX 5CC",SUP-359450,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,511.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,501.54,3665.63,"percent of total billed charges",
"SUT MONOCRYL MULTIPASS 6-0 P-3 18IN MONOFILAMENT UNDYED",SUP-Y492G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-707,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1526.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD SURGICAL ADDSTAT FIBER",SUP-744200,CDM,S27200284,LOCAL,0272,RC,,,both,,,3221.33,966.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,381.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,374.64,2738.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 42MM STAINLESS STEEL 2.4MM SCR 6X2 HOLE 2 COLUMN",SUP-02.111.520,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",434.96,3179,"percent of total billed charges",
"SCR BONE 3.5MM 24MM DARCO TITANIUM FOOT LOCK",SUP-DC2820024,CDM,C1713,HCPCS,0278,RC,,,both,,,1223.10,366.93,"KAISER [10500]",Kaiser,,819.48,67,,,,,0,142.25,1039.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Icd Elect Thoracotomy",PX-360000025,CDM,33243,CPT,0361,RC,,,both,,,10760.85,3228.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5391,,"Case rate ($5,391). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1251.49,10760.85,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV",RX-156003,CDM,,,0250,RC,44567-0642-01,NDC,both,250,ML,476.59,142.98,"UHC [10700]","United Healthcare",,301.68,63.3,,,,,0,55.43,405.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.240,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"NOVANET [10819]",Novanet,,1215,75,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 28MM 144CM 2.25MM CORONARY STENT",SUP-H7493952828220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 110MM 21GA SONOTAP II CORNERSTONE BEVEL TIP",SUP-1285-3F110,CDM,C9812,HCPCS,0272,RC,,,both,,,138.33,41.5,"NOVANET [10819]",Novanet,,103.75,75,,,,,0,16.09,117.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE IRRIGATION POLY STERILE",SUP-111695,CDM,S27200284,LOCAL,0272,RC,,,both,,,370.62,111.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ANTEPARTUM WITHOUT O.R. PROCEDURE,EXTREME",566,APR-DRG,,,,,,,inpatient,,,37533.10,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $8,689.51. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($40,245.97) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"DISPOSABLE LOOP LIMB SLING",SUP-VIG22001-L1,CDM,S27000186,LOCAL,0270,RC,,,both,,,145.43,43.63,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM 4MM DRNG SILICONE 100ML CENTER HOLE FLAT BULB",SUP-6649,CDM,S27200284,LOCAL,0272,RC,,,both,,,329.12,98.74,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH HEARTSPAN ML2 CURVE 81CM 8.5FR GUIDING PEBAX STEEL",SUP-FCB8581ML2,CDM,C1894,HCPCS,0272,RC,,,both,,,1432.08,429.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE LITHO 403MM 3.3MM SWISS LITHOCLAST ULTRASOUND FLEXIBLE",SUP-M0068407160,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRANSURETHRAL PROCEDURES WITHOUT CC/MCC",670,MS-DRG,,,,,,,inpatient,,,37883.74,11365.12,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,6244.13,,"Case rate ($6,062.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,629.21, add-ons for qualifying new technology services are included. If operating cost exceeds $38,668.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,807.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,636.66. The transfer operating threshold is the transfer adjustment factor * $5,629.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.60. The transfer capital threshold is the transfer adjustment factor * $425.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,6062.26,28533.25,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH II SS6",SUP-398339,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"NOVANET [10819]",Novanet,,394.88,75,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Feeynolm<=2.5cm",PX-450000025,CDM,12011,CPT,0361,RC,,,both,,,910.55,273.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,910.55,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,105.9,910.55,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOLD CEMENT SURESPACE SMALL FEMORAL SPACER",SUP-SSF1060,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"PHCS [10601]",PHCS,,9949.8,70,,,,,0,1653.09,12081.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE MYRINGOTOMY 10.5MM 6.3MM MICRO STAINLESS STEEL SPEAR",SUP-14-58233,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.22,49.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,75.38,45.9,,,,,0,19.1,139.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 4MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0430,CDM,S27800098,LOCAL,0278,RC,,,both,,,8832.00,2649.6,"MULTIPLAN [10600]",Multiplan,,7507.2,85,,,,,0,1027.16,7507.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEQUALIS PERFORM GLENOID (CORTILOC)- S30",SUP-DWE401,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"KAISER [10500]",Kaiser,,6241.72,67,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL UTERINE HEGAR 2 END 11/12MM",SUP-52-3511,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.18,83.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,33.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.47,237.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 12.5CM STAINLESS STEEL 2.7/3.5MM SCR 7 HOLE LCP BONE",SUP-02.112.144,CDM,C1713,HCPCS,0278,RC,,,both,,,3194.63,958.39,"BLUE CROSS [10001]","Blue Cross PPO",,1252.29,39.2,,957.42,570.23,957.42,28,371.54,2715.44,"percent of total billed charges",
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 60X12-13MM",SUP-400731,CDM,S27800098,LOCAL,0278,RC,,,both,,,4264.20,1279.26,"PHCS [10601]",PHCS,,2984.94,70,,,,,0,495.93,3624.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 71MM VANGUARD 360 KNEE POROUS PRIMARY REVISION",SUP-185203,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,5873.17,5873.17,5873.17,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"CMPNT FEMORAL 67.5MM KNEE LEFT POSTERIOR STABILIZE OPEN BOX",SUP-184530,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9930.31,40,,,,,0,2887.24,21101.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 59MM 135CM 6MM 8MM 7FR .035IN",SUP-BXA065902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8016.47,41.1,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE SIMPLEX HV 20ML 40GM STERILE",SUP-6194-1-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,658.29,197.49,"FIRST HEALTH [10303]","First Health",,526.63,80,,,,,0,76.56,559.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 12IN LARGE",SUP-U2-712,CDM,S27000186,LOCAL,0270,RC,,,both,,,226.20,67.86,"CIGNA [10200]","Cigna Open Access",,128.71,56.9,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARMSLING, (ULTRASLING) MED.",SUP-11-0138-3-13130,CDM,S27000186,LOCAL,0270,RC,,,both,,,373.06,111.92,"AETNA [10100]","Aetna HMO/PPO",,296.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.39,317.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 20MM 5MM 3.9FR AUTOTOME BILIARY CANNULATED RAPID",SUP-M00545190,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) KIT INTRO 50CM 8.9MM 25FR AVEIR HYDROPHILIC COATED IN",SUP-LSN25501,CDM,C1894,HCPCS,0272,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION",RX-4455,CDM,J2003,HCPCS,0636,RC,00409-4283-11,NDC,both,5,ML,43.79,13.14,"NOVANET [10819]",Novanet,,32.84,75,,,,,0,2.33,37.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS LAPAROSCOPIC 54.5CM 8MM DA VINCI S/SI ENDOWRIST",SUP-420007,CDM,S27200284,LOCAL,0272,RC,,,both,,,13455.00,4036.5,"CIGNA [10200]","Cigna Open Access",,7655.9,56.9,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SANDN LG OSC SAW BLADE 19.5MM X 71",SUP-72204158,CDM,S27200284,LOCAL,0272,RC,,,both,,,414.70,124.41,"FIRST HEALTH [10303]","First Health",,331.76,80,,,,,0,48.23,352.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 135CM 100MM 5MM .035IN BALLOON",SUP-AB35W05100135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,460.47,68,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 17X10MM DIVERGENCE 14MM LORDOTIC NUCLEUS",SUP-G6626740,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"FIRST HEALTH [10303]","First Health",,9936,80,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 56MM 32MM MARATHON HIP",SUP-121932056,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"AETNA [10100]","Aetna HMO/PPO",,5751.55,79.5,,10981.53,8986.79,12413.38,12,841.39,6149.45,"percent of total billed charges",
"SET SPECTRA OPTIA TPE EXCHANGE AUTOTRANSFUSION TUBING",SUP-12220,CDM,S27200284,LOCAL,0272,RC,,,both,,,3033.89,910.17,"CIGNA [10200]","Cigna Local Plus",,1623.13,53.5,,,,,0,352.84,2578.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"E-CATH PLUS CATHETER-OVER-NEEDLE PNB CATHETER SYSTEM 18G X 3",SUP-211285-41E,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"MULTIPLAN [10600]",Multiplan,,295.8,85,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER BREAST IMPLANT RESTERILIZABLE GEL SMOOTH ROUND MODERAT",SUP-RSZMPB265,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,73.14,41.1,,,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDIGO CATHETER 6X 150CM STRAIGHT TRAX LIGHTNING BOLT ASPIRA",SUP-LITNGBT6XTX150,CDM,C1757,HCPCS,0272,RC,,,both,,,48132.00,14439.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,32729.76,68,,,,,0,5597.75,40912.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH UHP-L BREAST IMPLANTS 1240 CC",SUP-350-51240L,CDM,A4648,HCPCS,0278,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG ACETABULAR 15MM 46MM RESTORATION WEDGE HIP",SUP-5096-4615,CDM,C1776,HCPCS,0278,RC,,,both,,,12461.40,3738.42,"KAISER [10500]",Kaiser,,8349.14,67,,,,,0,1449.26,10592.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 3.9MM 38MM TITANIUM FULL THREAD SELF CUT",SUP-04.019.038,CDM,C1713,HCPCS,0278,RC,,,both,,,1592.14,477.64,"MULTIPLAN [10600]",Multiplan,,1353.32,85,,,,,0,185.17,1353.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 11 STD KNEE LEFT CRUCIATE RETAIN PERSONA",SUP-42508607001,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"NOVANET [10819]",Novanet,,19678.68,75,,,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 8MM .8MM GOLDENBERG TORP EAR HEAD PLASTIPORE",SUP-14-0917,CDM,C1713,HCPCS,0278,RC,,,both,,,2968.65,890.59,"CIGNA [10200]","Cigna Local Plus",,1588.23,53.5,,3978.14,359.25,3978.14,24,345.25,2523.35,"percent of total billed charges",
"COIL EMBOLIZATION 16CM 5MM .021-.027IN AZUR CX DETACHABLE",SUP-45-780516,CDM,S27800098,LOCAL,0278,RC,,,both,,,5275.05,1582.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,625.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,613.49,4483.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHROMIUM CHLORIDE 0.4 MCG/ML INTRAVENOUS SOLUTION",RX-408352,CDM,,,0250,RC,08888-8886-05,NDC,both,1,ML,18.92,5.68,"UHC [10700]","United Healthcare",,11.98,63.3,,,,,0,2.2,16.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 6.35MM TSRH-2D CONTOUR PEDICLE TITANIUM",SUP-8371030,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,inpatient,,,64156.26,19246.88,"CIGNA [10200]","Cigna Open Access",,16154.83,,"Fee schedule rate ($16,154.83). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,36712.7,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI PROWATERFLEX VASCULAR STRAIGHT 300CM 20CM .014IN",SUP-AGH147300,CDM,C1769,HCPCS,0272,RC,,,both,,,769.50,230.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUTTED PINS","SUP-GP007.075.032 STE",CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"AETNA [10100]","Aetna HMO/PPO",,1758.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 22MM 31MM 41MM 28MM MOSAIC CINCH RING HEART",SUP-310C31,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7843.31,28.62,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 2.5MM 1ML SYR EMBOCUBE GELATIN 50MG",SUP-EC2550,CDM,S27800098,LOCAL,0278,RC,,,both,,,526.50,157.95,"CIGNA [10200]","Cigna Open Access",,299.58,56.9,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 40MM 80CM 9MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM09040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"MULTIPLAN [10600]",Multiplan,,15529.5,85,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GALASHAPE 3D 21X7.5CM SOFT TISSUE SCAFFOLD",SUP-SH3D05,CDM,C1781,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]",Cigna,,5630.4,68,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 315MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.034.343S,CDM,C1713,HCPCS,0278,RC,,,both,,,8166.56,2449.97,"CIGNA [10200]",Cigna,,5553.26,68,,1831.33,1831.33,1831.33,16,949.77,6941.58,"percent of total billed charges",
"SCR BONE 4.5MM 64MM STAINLESS STEEL FULL THREAD FOOT",SUP-214.764,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"CIGNA [10200]","Cigna Local Plus",,601.14,53.5,,3978.14,359.25,3978.14,24,130.68,955.09,"percent of total billed charges",
"INSRT TIBIAL 4 STD KNEE LEFT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB4SL,CDM,C1776,HCPCS,0278,RC,,,both,,,17652.60,5295.78,"FIRST HEALTH [10303]","First Health",,14122.08,80,,,,,0,2053,15004.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 6CM 5FR 7MM .035IN BALLOON",SUP-G52273,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +12.5 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.125,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Local Plus",,184.58,53.5,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAVER BLADES STRAIGHT SHAFT 4MM DOUBLE SERRATED STERILE",SUP-1600540-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"NOVANET [10819]",Novanet,,1063.13,75,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 100CM 9FR 18MM AMPLATZER .098IN DELIVERY",SUP-9-AVP2-018,CDM,S27800098,LOCAL,0278,RC,,,both,,,6589.50,1976.85,"CIGNA [10200]","Cigna Open Access",,3749.43,56.9,,,,,0,766.36,5601.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL PROFILE SUBTALAR DYNANAIL HELIX 6.5",SUP-3100-01-0007,CDM,S27200284,LOCAL,0272,RC,,,both,,,5037.00,1511.1,"NOVANET [10819]",Novanet,,3777.75,75,,,,,0,585.8,4281.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR ORTHOPEDIC KNOT PUSHER SUT CUTTER PORTAL SKID",SUP-AR-5845,CDM,S27200284,LOCAL,0272,RC,,,both,,,1732.50,519.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,712.06,41.1,,,,,0,201.49,1472.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 5MM 2MM 90D SMALL STRAIGHT OBLONG 7.5IN FRONTAL SINUS",SUP-63-8815,CDM,S27200284,LOCAL,0272,RC,,,both,,,660.07,198.02,"KAISER [10500]",Kaiser,,442.25,67,,,,,0,76.77,561.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC",330,MS-DRG,,,,,,,inpatient,,,92120.58,27636.17,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,31970.46,,"Case rate ($14,869.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,807.78, add-ons for qualifying new technology services are included. If operating cost exceeds $46,847.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,425.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,826.04. The transfer operating threshold is the transfer adjustment factor * $13,807.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,043.94. The transfer capital threshold is the transfer adjustment factor * $1,043.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,69988.65,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT REPAIR EYELET ZONE SPECIFIC II NITINOL MENISCUS",SUP-8570,CDM,S27200284,LOCAL,0272,RC,,,both,,,224.03,67.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.05,190.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM MEDIUM ROUND DIAMOND",SUP-509126400,CDM,S27200284,LOCAL,0272,RC,,,both,,,525.85,157.75,"CIGNA [10200]",Cigna,,357.58,68,,,,,0,61.16,446.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X7MM DIVERGENCE 12MM LORDOTIC NUCLEUS PULPOSUS",SUP-G6626527,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"PHCS [10601]",PHCS,,8694,70,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13177545,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,348.9,2550,"percent of total billed charges",
"BLADE 10MM REUSABLE HANDLE ACL PCL SURGICAL PARALLEL GRAFT",SUP-AR-2285-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,429.35,128.8,"MULTIPLAN [10600]",Multiplan,,364.95,85,,,,,0,49.93,364.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 26MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ326,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"NOVANET [10819]",Novanet,,721.5,75,,,,,0,111.88,817.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 22CM 8FR .035",SUP-M006192151090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"FIRST HEALTH [10303]","First Health",,1193.94,80,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR THICK TISSUE 80X4.8MM GIA TITANIUM LINEAR",SUP-GIA8048L,CDM,S27200284,LOCAL,0272,RC,,,both,,,489.73,146.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,58.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.96,416.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 2.7MM 3 FLUTED QUICK COUPLING NONSTERILE",SUP-315.28,CDM,S27000186,LOCAL,0270,RC,,,both,,,732.56,219.77,"CIGNA [10200]","Cigna Open Access",,416.83,56.9,,,,,0,85.2,622.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SUPER TORQUE MB 65CM 5FR .0395IN PIGTAIL CURVE",SUP-532598C,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,139.77,45.9,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 10CM 10MM GORE EXCLUDER ILIAC BRANCH",SUP-CEB231010A,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7429.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA POWERTRAC 142CM 20MM 4.5MM BALLOON",SUP-NCEUP4520X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"PHCS [10601]",PHCS,,368.55,70,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 9MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P409,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Local Plus",,4470.41,53.5,,5372.07,4581.20,7242.98,23,971.79,7102.52,"percent of total billed charges",
"BLADE SAW 90X25X1.19MM INTREX",SUP-507132300,CDM,S27200284,LOCAL,0272,RC,,,both,,,323.12,96.94,"CIGNA [10200]",Cigna,,219.72,68,,,,,0,37.58,274.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM VANGUARD TKR FEMUR PATELLA TIBIA ARTICULAR SURFAC",SUP-98000600087,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2198.07,16065,"percent of total billed charges",
"HC Ileoscopy Stoma W Stent",PX-750000160,CDM,44384,CPT,0750,RC,,,both,,,7444.00,2233.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,882.11,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,865.74,6327.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC IV Inf Hydrat Add Hr",PX-260000002,CDM,96361,CPT,0260,RC,,,both,,,294.17,88.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,147.32,50.08,,,,,0,34.21,294.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 8MM 2.50MM BALLOON DILATATION PEBAX",SUP-1400250-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM PINNACLE PRECISION ACCESS SYSTEM 45CM 10CM 5FR 21-19",SUP-70-5165,CDM,C1894,HCPCS,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OSTEOTOM 9IN LAMBOTTE SYMMETRY SURGICAL CURVE 1.25IN",SUP-28-9480,CDM,S27200284,LOCAL,0272,RC,,,both,,,252.56,75.77,"CIGNA [10200]","Cigna Open Access",,143.71,56.9,,,,,0,29.37,214.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Oxcarbazepine",PX-301000079,CDM,80183,CPT,0301,RC,,,both,,,140.41,42.12,"PHCS [10601]",PHCS,,98.29,70,,,,,0,0.01,119.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Removal Tooth Root Residual",PX-450000362,CDM,D7250,HCPCS,0450,RC,,,both,,,706.00,211.8,"UHC [10700]","United Healthcare",,706,,"Per diem ($2,260).",,,,0,67.13,706,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intro Long G Tube W Fl Si",PX-320000113,CDM,74340,CPT,0320,RC,,,both,,,377.00,113.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,174.11,,"Fee schedule rate ($174.11).",,,,0,43.85,320.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 CURVE PLUS 10MM KNEE XLK FIX BEARING SIGMA",SUP-970441,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1299.6,9498.37,"percent of total billed charges",
"SPHERE EMBOLIZATION YELLOW EMBOZENE 250UM MICRO SYR 2ML",SUP-01-0301-02502-11,CDM,S27800098,LOCAL,0278,RC,,,both,,,1620.00,486,"FIRST HEALTH [10303]","First Health",,1296,80,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON RETRIEVAL EXTR PRO RX 200CM 6-7FR 15-18MM BILIARY 3",SUP-M00547050,CDM,C1889,HCPCS,0278,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 5MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0530,CDM,S27800098,LOCAL,0278,RC,,,both,,,8832.00,2649.6,"MULTIPLAN [10600]",Multiplan,,7507.2,85,,,,,0,1027.16,7507.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN ADULT DORO STRONG PROTECTIVE CAP FURROWED GRIP UNIQUE",SUP-3006-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.04,27.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.82,79.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 7.5CM 120CM 5MM 7FR ENDOPROSTHESIS",SUP-VBHR050702A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"MULTIPLAN [10600]",Multiplan,,18078.48,85,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP LIGATION RESOLUTION 360 ULTRA 235CM BRAID ROTATION",SUP-M00521401,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"KAISER [10500]",Kaiser,,1079.97,67,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 FS-1 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8684G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 CROSSFT BC",SUP-CFBC-4502,CDM,C1713,HCPCS,0278,RC,,,both,,,3395.93,1018.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,402.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",394.95,2886.54,"percent of total billed charges",
"SUT VICRYL MULTIPASS 4-0 PC-5 18IN BRAID COATED UNDYED",SUP-J823G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"NOVANET [10819]",Novanet,,18.75,75,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nrv Condct 1-2 Studies",PX-922000019,CDM,95907,CPT,0922,RC,,,both,,,1022.50,306.75,"FIRST HEALTH [10303]","First Health",,818,80,,,,,0,118.92,869.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 120MM 32MM STAINLESS STEEL ORTHOPEDIC",SUP-209.92,CDM,C1713,HCPCS,0278,RC,,,both,,,1574.24,472.27,"MULTIPLAN [10600]",Multiplan,,1338.1,85,,,,,0,183.08,1338.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL L270MM DIA12MM NONSTERILE 3 FLUTED CANNULATED LARG",SUP-03.010.439,CDM,S27200284,LOCAL,0272,RC,,,both,,,2926.35,877.9,"PHCS [10601]",PHCS,,2048.45,70,,,,,0,340.33,2487.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 10-11 E-F KNEE RIGHT",SUP-42522600810,CDM,C1776,HCPCS,0278,RC,,,both,,,13634.40,4090.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1615.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1585.68,11589.24,"percent of total billed charges",
"CMPNT FEMORAL 6 STD KNEE RIGHT POSTERIOR STABILIZE PERSONA",SUP-42500806002,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"PHCS [10601]",PHCS,,20226.91,70,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT SCROTAL WHITE BAUER AND BLACK XL COTTON SUSPENSORY LEG",SUP-201352,CDM,S27000186,LOCAL,0270,RC,,,both,,,127.48,38.24,"KAISER [10500]",Kaiser,,85.41,67,,,,,0,14.83,108.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET IMPL ARTHREX FIBERTAK BICEPS STERILE LATEX FREE",SUP-AR-3671,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.00,945,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,373.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,366.35,2677.5,"percent of total billed charges",
"CATH SUPERTORQUE 100CM 6FR .051IN .042IN JUDKINS LEFT",SUP-532624,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA [10200]","Cigna Local Plus",,44.22,53.5,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM BICARBONATE 650 MG TABLET",RX-7312,CDM,,,0637,RC,77333-0827-25,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOCYCLINE HCL 100 MG/5ML IV (WET SOLR VIAL)",RX-41510612,CDM,,,0250,RC,70842-0160-01,NDC,both,1,UN,1560.31,468.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,716.18,45.9,,,,,0,181.46,1326.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2-0 TS 14IN 2 ARM MONOFILAMENT BLUE",SUP-8571G,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.67,20.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.99,58.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 1.7-10MM CANCELLOUS ALLOGRAFT CHIPS FREEZE",SUP-400145,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.88,493.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,755.46,45.9,,,,,0,191.42,1399,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 12MM 6FR 3.25MM .07IN BALLOON",SUP-H7493918912320,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"FIRST HEALTH [10303]","First Health",,453.6,80,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONCIERGE GUIDE CATHETER 7F 100CM 2 SIDE HOLES SUPER BACK UP",SUP-CGC7100SBS45SH-M,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,183.1,41.1,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 5MM BALLOON DILATATION STERILE LATEX",SUP-595004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"UHC [10700]","United Healthcare",,922.91,63.3,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.4MM X 445MM TRILOGY PROBE KIT",SUP-M0068403530,CDM,S27200284,LOCAL,0272,RC,,,both,,,5531.45,1659.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,655.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,643.31,4701.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD REAMER 14.5MM RIA 2 STERILE",SUP-03.404.025S,CDM,S27200284,LOCAL,0272,RC,,,both,,,6005.07,1801.52,"KAISER [10500]",Kaiser,,4023.4,67,,,,,0,698.39,5104.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 5FR 25CM RADIOPAQUE GWIRE STERILE DISPOSABLE",SUP-G06587,CDM,S27200284,LOCAL,0272,RC,,,both,,,169.65,50.89,"CIGNA [10200]","Cigna Local Plus",,90.76,53.5,,,,,0,19.73,144.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM 2.75MM 2.1-2.7FR CORONARY",SUP-RONYX27508UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"AETNA [10100]","Aetna HMO/PPO",,2683.13,79.5,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 180CM 8CM 6FR 10-12MM ESOPHAGEAL FIX WIRE",SUP-M00558350,CDM,C1726,HCPCS,0272,RC,,,both,,,1562.98,468.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1062.83,68,,,,,0,181.77,1328.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 135CM 2.1FR ASAHI CORSAIR PRO XS",SUP-CSR135-21S,CDM,C1887,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"AETNA [10100]","Aetna HMO/PPO",,4662.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM 9FR ENDOCARDIAL DF4-LLHO CNCT 1 COIL TINE",SUP-263,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"KAISER [10500]",Kaiser,,10170.6,67,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING EXTERNAL FIXATION 180MM MAXFRAME FULL ALUMINUM",SUP-03.312.180,CDM,C1713,HCPCS,0278,RC,,,both,,,7632.50,2289.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3503.32,45.9,,,,,0,887.66,6487.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION SUB-Q TITANIUM SILICONE 9.6FR 1",SUP-0602230,CDM,C1788,HCPCS,0278,RC,,,both,,,928.72,278.62,"KAISER [10500]",Kaiser,,622.24,67,,,,,0,108.01,789.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE BENTSON VASCULAR 6CM STD STRAIGHT TAPER 180CM 15CM",SUP-G01431,CDM,C1769,HCPCS,0272,RC,,,both,,,178.26,53.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.73,151.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 8X6CM SUSPEND TUTOPLAST FASCIA LATA",SUP-937268,CDM,C1762,HCPCS,0278,RC,,,both,,,3238.30,971.49,"NOVANET [10819]",Novanet,,2428.73,75,,,,,0,376.61,2752.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC 7.5MM 42.9X43.3MM ADAPTA SR ATRIUM VENTRICLE",SUP-ADSR06,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2888.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE NONPVC PRISMASOL BGK 2/3.5 STERILE LATEX FREE",SUP-110243S,CDM,S27200284,LOCAL,0272,RC,,,both,,,332.60,99.78,"CIGNA [10200]","Cigna Open Access",,189.25,56.9,,,,,0,38.68,282.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR 50CM LINEAR PERCUTANEOUS 3-6 LEAD TRIAL SUT",SUP-SC-2366-50E,CDM,C1778,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,6217.33,6217.33,6217.33,"1 through 10",641.98,4692,"percent of total billed charges",
"RHINOLARYNGOSCOPE FLEXIBLE 300MM 3MM 3.5MM AMBU ASCOPE 4",SUP-510101000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 360MM TIBIAL TN ADVANCED INTRAMEDULLARY MR",SUP-04.043.340S,CDM,C1713,HCPCS,0278,RC,,,both,,,9579.13,2873.74,"KAISER [10500]",Kaiser,,6418.02,67,,,,,0,1114.05,8142.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS LAPAROSCOPIC 5MM DA VINCI SI SINGLE-SITE CURVE",SUP-428057,CDM,S27000186,LOCAL,0270,RC,,,both,,,1004.40,301.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-105634,CDM,,,0250,RC,63323-0462-17,NDC,both,10,ML,71.05,21.31,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC TREK NEO 12MM 145CM 6MM BALLOON DILATATION HYDROCOAT",SUP-1400600-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CNTNR TRANSPEC DEVICE PERFORATED COMPRESSION PLATE SPECIMEN",SUP-600101,CDM,S27000186,LOCAL,0270,RC,,,both,,,171.52,51.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE 20/30 INDEFLATOR 30 ATM INFLATION 20CC STERILE LATEX",SUP-1000184,CDM,C1769,HCPCS,0272,RC,,,both,,,321.90,96.57,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE ELECTROSURGICAL 4MR HIGH FREQUENCY MONOPOLAR VALLEYLAB",SUP-A00012A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1303.13,390.94,"KAISER [10500]",Kaiser,,873.1,67,,,,,0,151.55,1107.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 11MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530-G-511,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"UHC [10700]","United Healthcare",,5511.92,63.3,,8601.07,8395.67,8601.07,"1 through 10",1012.7,7401.47,"percent of total billed charges",
"SHOE CAST LARGE CANVAS RUBBER COMFO-EZE NONSLIP SOLE HEEL",SUP-2004-04,CDM,S27000186,LOCAL,0270,RC,,,both,,,72.30,21.69,"NOVANET [10819]",Novanet,,54.23,75,,,,,0,8.41,61.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fo Pip Dip Jnt/Sprng Pre Ots",PX-E27400036,CDM,L3925,HCPCS,0274,RC,,,both,,,119.90,35.97,"NOVANET [10819]",Novanet,,89.93,75,,,,,0,13.94,101.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SPINAL SACRAL ANTERIOR 3 HOLE/1 HOLE SIDE 27MM VICTORY",SUP-1236.7027,CDM,C1713,HCPCS,0278,RC,,,both,,,29610.00,8883,"PHCS [10601]",PHCS,,20727,70,,,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 14MM SPINE STERILE REUSABLE",SUP-650.114,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 90CM 6FR LCB CURVE GUIDING PTFE FEMORAL LARGE",SUP-H74938969250,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"NOVANET [10819]",Novanet,,274.83,75,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.50 X 18 RX US",SUP-1804250-18,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA 32-35IN SMALL HOOK LOOP CLSR WIDE ADJUSTABLE SHOULDER",SUP-M5001-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,161.39,48.42,"NOVANET [10819]",Novanet,,121.04,75,,,,,0,18.77,137.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 2.50 X 38 MM",SUP-1212250-38,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Open Access",,5778.75,33.5,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 34MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40034W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"PHCS [10601]",PHCS,,3807.3,70,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 9 1/5INX9 1/5IN SELF ADHERENT ABSORBENT PAD MOISTURE",SUP-282400,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.52,26.26,"UHC [10700]","United Healthcare",,55.4,63.3,,,,,0,10.18,74.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIFLUFOLASTAT F-18 IV SYRINGE (13-14 MCI)",RX-411830,CDM,A9595,HCPCS,0343,RC,08888-8877-84,NDC,both,1,UN,16868.88,5060.66,"BLUE CROSS [10001]","Blue Cross HMO",,10035.93,,,,,,,696,14338.55,"fee schedule",
"STY LD 45CM FIRM BLNT",SUP-130011,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,45.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DISTRACTION 14MM CASPAR STERILE",SUP-73-2592-S5,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 11MM KII ADVANCE FIXATION SLEEVE",SUP-CFB33,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,75.09,41.1,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3510,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,177.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,174.28,1273.73,"percent of total billed charges",
"STENT WALLFLEX 80MM 3.2MM 10MM 8FR BILIARY PLATINOL METAL",SUP-7065,CDM,C1887,HCPCS,0272,RC,,,both,,,1386.50,415.95,"MULTIPLAN [10600]",Multiplan,,1178.53,85,,,,,0,161.25,1178.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Toxoplasm Gondii Qpcr Wb 2200",PX-306000166,CDM,87799,CPT,0306,RC,,,both,,,1038.00,311.4,"NOVANET [10819]",Novanet,,778.5,75,,,,,0,1.04,882.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 100MM 130CM 5MM 6FR .035IN VASCULAR NITINOL",SUP-EX051003CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"FIRST HEALTH [10303]","First Health",,12144,80,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 3MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012407-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 50CM 5FR COIL THROMBECTOMY VASCULAR GRAFT",SUP-160245F,CDM,C1757,HCPCS,0272,RC,,,both,,,3003.23,900.97,"AETNA [10100]","Aetna HMO/PPO",,2387.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,349.28,2552.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 110CM 6FR .056IN MULTIPURPOSE A CURVE",SUP-DXT6MPASHA,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP GRIPTION PINNACLE STERILE LATEX",SUP-121731058,CDM,C1776,HCPCS,0278,RC,,,both,,,8971.20,2691.36,"FIRST HEALTH [10303]","First Health",,7176.96,80,,,,,0,1043.35,7625.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL INSIGNIA 3 35.5 STANDARD OFFSET L101 MM L32.5 M",SUP-7000-5503,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12565.87,41.1,,6417.48,6417.48,6417.48,"1 through 10",3555.74,25987.82,"percent of total billed charges",
"AZITHROMYCIN 600 MG TABLET",RX-17387,CDM,,,0637,RC,69452-0173-13,NDC,both,1,UN,70.62,21.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,32.41,45.9,,,,,0,8.21,60.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 360D 7.5MM TREPHINE RADIAL VACUUM BARRON STAINLESS",SUP-K20-2056,CDM,S27200284,LOCAL,0272,RC,,,both,,,599.40,179.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,71.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 62X20MM 2 TONGUE DAVIS-CROWE",SUP-45-5112,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.96,81.59,"CIGNA [10200]","Cigna Local Plus",,145.5,53.5,,,,,0,31.63,231.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 120MM 1.5MM BALLOON DILATATION RAPID",SUP-47515120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"KAISER [10500]",Kaiser,,1069.12,67,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRESSING OPTICELL 18X.75IN FORZAGEL",SUP-MSC9818EPZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,37.58,45.9,,,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 4.5MM 7MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.507.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,69.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",69.37,507.01,"percent of total billed charges",
"STENT DOUBLE-J 16CM 100CM 8.5FR .028IN URETERAL SILICONE",SUP-5209000,CDM,C2617,HCPCS,0278,RC,,,both,,,1212.57,363.77,"KAISER [10500]",Kaiser,,812.42,67,,,,,0,141.02,1030.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE EXTRA SPORT VASCULAR J CURVE 300CM 3CM .014",SUP-22235MJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE 20MM 8MM BIOSURE REGENESORB",SUP-72204398,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,322.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",322.62,2357.93,"percent of total billed charges",
"BRA SURG VELC STRP ZIP LG 38-40IN",SUP-958-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,347.48,104.24,"PHCS [10601]",PHCS,,243.24,70,,,,,0,40.41,295.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SENSATION PLUS STATLOCK 6IN 229MM 7.5FR 16MM IAB 40CC",SUP-0684-00-0568-01,CDM,C1725,HCPCS,0272,RC,,,both,,,7006.26,2101.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,830.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,814.83,5955.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 14MM TI",SUP-VAN-25140-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,113.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",113.04,826.2,"percent of total billed charges",
"FILLER BONE VOID 5CC DBX ALLOGRAFT PASTE FREEZE DRIED",SUP-028050,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1721.25,45.9,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 65CM 5FR RIM CURVE ANGIOGRAPHIC",SUP-G47063,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"UHC [10700]","United Healthcare",,133.26,63.3,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Emg 3 Ext",PX-922000003,CDM,95863,CPT,0922,RC,,,both,,,934.00,280.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,108.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.62,793.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEMOSPRAY 220CM 7FR ENDOSCOPIC HEMOSTAT 2.8MM MINIMUM",SUP-G56572,CDM,C1052,HCPCS,0272,RC,,,both,,,17250.00,5175,"KAISER [10500]",Kaiser,,11557.5,67,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION .25IN OCEAN SLIDE CLAMP SUCTION CONTROL",SUP-2012-320,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.83,87.25,"FIRST HEALTH [10303]","First Health",,232.66,80,,,,,0,33.82,247.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 5MM OXFORD ARCOM KNEE LEFT MENISCAL PHASE 3",SUP-159556,CDM,C1776,HCPCS,0278,RC,,,both,,,5270.22,1581.07,"NOVANET [10819]",Novanet,,3952.67,75,,,,,0,612.93,4479.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 15MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE32515,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,23944.81,28.62,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 18X8MM COALITION MIS 7D 15MM",SUP-3136.4108,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"AETNA [10100]","Aetna HMO/PPO",,14310,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR ACTIS DUOFIX 11 HIGH OFFSET HIP STERILE",SUP-101012110,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"BLUE CROSS [10001]","Blue Cross PPO",,11946.69,39.2,,3949.44,3949.44,3949.44,"1 through 10",3544.39,25904.81,"percent of total billed charges",
"GRAFT SKIN 2X2CM ALLOPATCH THK.4-.8MM ACELLULAR DERMAL",SUP-WC0202,CDM,Q4128,HCPCS,0636,RC,,,both,,,2293.50,688.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1026.34,44.75,,,,,0,80.43,1949.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 103MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 8",SUP-223.58,CDM,C1713,HCPCS,0278,RC,,,both,,,2142.00,642.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,249.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",249.11,1820.7,"percent of total billed charges",
"CATH SONOPLEX FIXOCATH 21GA 18GA 20GA INTERVENTIONAL INDWELL",SUP-201285-41E,CDM,C9812,HCPCS,0272,RC,,,both,,,348.00,104.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,236.64,68,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 6MM TITANIUM T4 HAND SELF TAP VARIABLE ANGLE",SUP-04.130.206,CDM,C1713,HCPCS,0278,RC,,,both,,,925.34,277.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,629.23,68,,,,,0,107.62,786.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 75MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.410,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",160.97,1176.51,"percent of total billed charges",
"CAGE SPINAL 14X11X7MM COROENT 5D SMALL PEEK NONSTERILE LATEX",SUP-6807714,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LORAZEPAM 0.5 MG TABLET",RX-4572,CDM,,,0250,RC,00093-3425-01,NDC,both,1,UN,12.54,3.76,"NOVANET [10819]",Novanet,,9.41,75,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM REVERE CURVED",SUP-132.145,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 75CM .36MM FIRM TPR",SUP-124437,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,109.56,28.62,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X11MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7311,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"PHCS [10601]",PHCS,,4830,70,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP7PR,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"BLUE CROSS [10001]","Blue Cross HMO",,8428.74,39.2,,5311.50,4717.44,5388.59,31,2500.67,18276.62,"percent of total billed charges",
"MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC",427,MS-DRG,,,,,,,inpatient,,,310602.19,93180.66,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,46120.73,,"Case rate ($44,777.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $41,578.86, add-ons for qualifying new technology services are included. If operating cost exceeds $74,618.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $4,525.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,633.85. The transfer operating threshold is the transfer adjustment factor * $41,578.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,143.56. The transfer capital threshold is the transfer adjustment factor * $3,143.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,210754.25,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATH NUVISION NAV 10FR ULTRASOUND STERILE LATEX FREE",SUP-FG11656,CDM,C1759,HCPCS,0272,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 12/14 40MM HIP TOTAL STABILIZED TAPER",SUP-136540720,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"UHC [10700]","United Healthcare",,9497.56,63.3,,8601.07,8395.67,8601.07,"1 through 10",1744.97,12753.44,"percent of total billed charges",
"STENT HANAROSTENT 60MM 2300MM 20MM ESOPHAGEAL METAL NITINOL",SUP-ECBA-20-060-230,CDM,C1874,HCPCS,0278,RC,,,both,,,16425.45,4927.63,"BLUE CROSS [10001]","Blue Cross HMO",,6438.78,39.2,,9776.84,9776.84,9776.84,"1 through 10",1910.28,13961.63,"percent of total billed charges",
"SUT STRATAFIX 3-0 FS SPIRAL 30CM KNOTLESS TISSUE CONTROL 2",SUP-SXMD2B412,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.33,57.7,"CIGNA [10200]","Cigna Open Access",,109.44,56.9,,,,,0,22.37,163.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV",RX-9801,CDM,J3480,HCPCS,0258,RC,00264-7635-00,NDC,both,1000,ML,100.65,30.19,"FIRST HEALTH [10303]","First Health",,80.52,80,,,,,0,0.02,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 220CM 10.5-12MM OTSC 6MM NITINOL",SUP-100.3,CDM,C1760,HCPCS,0278,RC,,,both,,,4133.10,1239.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,480.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,480.68,3513.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1 KNEE LEFT TOTAL STABILIZE TRIATHLON COCR",SUP-5512-F-101,CDM,C1776,HCPCS,0278,RC,,,both,,,32652.90,9795.87,"CIGNA [10200]","Cigna Local Plus",,10285.66,31.5,,5372.07,4581.20,7242.98,23,3797.53,27754.97,"percent of total billed charges",
"BENZOCAINE 6 MG-MENTHOL 10 MG LOZENGES",RX-41085,CDM,,,0637,RC,78112-0011-06,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 150MM 3.2MM FLUTE CAS STERILE",SUP-20800000010,CDM,S27200284,LOCAL,0272,RC,,,both,,,963.90,289.17,"PHCS [10601]",PHCS,,674.73,70,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 25MMX.5MM LORENZ SMALL CRANIOMAXILLOFACIAL",SUP-017351,CDM,C1713,HCPCS,0278,RC,,,both,,,1657.50,497.25,"KAISER [10500]",Kaiser,,1110.53,67,,,,,0,192.77,1408.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 30CM 3MM BALLOON DILATATION",SUP-U8150330,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 15.5CM 9FR PEEL-AWAY PERCUTANEOUS STERILE",SUP-G01697,CDM,C1894,HCPCS,0272,RC,,,both,,,382.71,114.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,157.29,41.1,,,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.5MM 12MM FULL THREAD FOOT LOCKING SCR F3",SUP-FP12,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",127.17,929.48,"percent of total billed charges",
"SYSTEM SYNERGY XD MONORAIL 38MM 144CM 2.5MM CORONARY STENT",SUP-H7493941838250,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.467,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3292.97,68,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 15CM 28MM HEMASHIELD STRAIGHT PLATINUM 2",SUP-M00202175128P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3046.80,914.04,"KAISER [10500]",Kaiser,,2041.36,67,,,,,0,354.34,2589.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT BIORAPTOR SHOULDER KNOTLESS INNER LOCK PLUG",SUP-72202403,CDM,C1713,HCPCS,0278,RC,,,both,,,2212.88,663.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1015.71,45.9,,,,,0,257.36,1880.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.2MM X 12MM COCR",SUP-VAN-12012-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +8 DIOPTER MODIFY L BICONVEX 13MM 6MM POSTERIOR",SUP-CC60WF.080,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM ROUND DIAMOND STERILE LATEX FREE",SUP-5820-012-040D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1164.70,349.41,"CIGNA [10200]","Cigna Local Plus",,623.11,53.5,,,,,0,135.45,990,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 7MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650307,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5250.9,40,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 80CM 2CM 5FR 8MM 7.5MM BALLOON DILATATION",SUP-4198020S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION 4 POSITION MULTIPIN MRI SAFE LG",SUP-390.004,CDM,S27200284,LOCAL,0272,RC,,,both,,,4675.30,1402.59,"NOVANET [10819]",Novanet,,3506.48,75,,,,,0,543.74,3974.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR AL2 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H74938969690,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +14.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-ZA90030145,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CIGNA [10200]","Cigna Local Plus",,628.36,53.5,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPANDER TISSUE NATRELLE MAGNA-FINDER FOURTE P5.2 CM MODERAT",SUP-133S-MV-12-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"NOVANET [10819]",Novanet,,6986.25,75,,,,,0,6986.25,6986.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 90CM RAABE MODIFICATION RADIOPAQUE BAND",SUP-G11634,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"MULTIPLAN [10600]",Multiplan,,378.68,85,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X6MM ADVANCED PARALLEL TRAPEZOID",SUP-17606,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross HMO",,3245.76,39.2,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 80MM 80CM 8MM 8FR STRAIGHT VASCULAR COVER",SUP-AVSM08080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross PPO",,7161.84,39.2,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STEERABLEBALLOON CA",SUP-ARC30SB-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,18270.00,5481,"FIRST HEALTH [10303]","First Health",,14616,80,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE CR CEMENTED HIGH DEMAND INSERT LEGION GEN",SUP-71704505,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2198.07,16065,"percent of total billed charges",
"SCREW NON-LOCKING 2.5MM X 14MM TI",SUP-VAN-25140-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Open Access",,553.07,56.9,,1144.80,304.56,2275.09,66,113.04,826.2,"percent of total billed charges",
"SLEEVE TIBIAL ALL KNEE ROTATING HINGE",SUP-6481-2-140,CDM,S27000186,LOCAL,0270,RC,,,both,,,2966.25,889.87,"FIRST HEALTH [10303]","First Health",,2373,80,,,,,0,344.97,2521.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM LOW PROFILE SCREWS TITANIUM T15 FULL",SUP-AR-8935-38,CDM,C1713,HCPCS,0278,RC,,,both,,,696.60,208.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,319.74,45.9,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP BARDEX IC COMPLETE CARE",SUP-A300416A,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.07,41.42,"FIRST HEALTH [10303]","First Health",,110.46,80,,,,,0,16.06,117.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20GA 8CM POWERGLIDE PRO REINFORCE TIP BASIC STERILE",SUP-F120080T,CDM,C1751,HCPCS,0272,RC,,,both,,,558.98,167.69,"KAISER [10500]",Kaiser,,374.52,67,,,,,0,65.01,475.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10D MODIFY C BICONVEX 13MM 6MM POSTERIOR CHMBR",SUP-MA60AC,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 2MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES0212CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,762.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 2.4MM TEMPORARY",SUP-58820024,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ALLIS 12IN TISSUE 5X6 TEETH STD PATTERN",SUP-50-0226,CDM,S27200284,LOCAL,0272,RC,,,both,,,671.33,201.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,456.5,68,,,,,0,78.08,570.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG NASAL 8CM HEMOPORE SINUS CHITOSAN LACTATE BIORESORBABLE",SUP-5400020208,CDM,S27200284,LOCAL,0272,RC,,,both,,,1775.01,532.5,"CIGNA [10200]",Cigna,,1207.01,68,,,,,0,206.43,1508.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 150MM 3MM BALLOON DILATATION RAPID",SUP-47530150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 64CM ENDOTAK RELIANCE ENDOCARDIAL STEROID SILICONE",SUP-158,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1765.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Prosthetic Voice",PX-444000003,CDM,92597,CPT,0444,RC,,,both,,,850.03,255.01,"FIRST HEALTH [10303]","First Health",,680.02,80,,,,,0,98.86,722.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Clozaril",PX-301000065,CDM,80159,CPT,0301,RC,,,both,,,370.50,111.15,"NOVANET [10819]",Novanet,,277.88,75,,,,,0,0.01,314.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ostomy Wafer",PX-E27000141,CDM,E27000141,LOCAL,0270,RC,,,both,,,80.30,24.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.34,68.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lymphang Pelvis/Abd Bi Si",PX-323000027,CDM,75807,CPT,0320,RC,,,both,,,6091.05,1827.31,"BLUE CROSS [10001]","Blue Cross PPO",,6091.05,,"Fee schedule rate ($9,495.99).",,,,0,325.8,6091.05,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 13MM 140CM 3MM CORONARY STERILE LATEX",SUP-453934,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR 28CM 11-13FR ACCESS STAINLESS STEEL",SUP-M0062502000,CDM,C1894,HCPCS,0272,RC,,,both,,,895.54,268.66,"FIRST HEALTH [10303]","First Health",,716.43,80,,,,,0,104.15,761.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA PERFUSION ADULT PEDIATRIC 34FR L12-15IN CONNECTION S",SUP-67534,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.59,90.48,"CIGNA [10200]","Cigna Open Access",,171.6,56.9,,,,,0,35.07,256.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 92MM STAINLESS STEEL 2.7MM SCR 4 HOLE VARIABLE ANGLE",SUP-02.118.402S,CDM,C1713,HCPCS,0278,RC,,,both,,,4562.97,1368.89,"BLUE CROSS [10001]","Blue Cross HMO",,1788.68,39.2,,957.42,156.86,7483.26,51,530.67,3878.52,"percent of total billed charges",
"WAND ELECTROSURGICAL 3.75MM AMBIENT SUPER MULTIVAC 50D IFS",SUP-ASHA4830-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 165CM DUALKNIFE J STERILE CERAMIC 2",SUP-KD-655L,CDM,S27200284,LOCAL,0272,RC,,,both,,,5520.35,1656.1,"FIRST HEALTH [10303]","First Health",,4416.28,80,,,,,0,642.02,4692.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 0MM 36MM HIP COCR LFIT V40",SUP-6260-9-136,CDM,C1776,HCPCS,0278,RC,,,both,,,6224.40,1867.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,737.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,723.9,5290.74,"percent of total billed charges",
"SPHERE GLENOID 22.3MM 36MM EQUINOXE SHOULDER SMALL REVERSE",SUP-320-31-36,CDM,C1776,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CIGNA [10200]",Cigna,,5278.5,68,,5873.17,5873.17,5873.17,"1 through 10",902.78,6598.13,"percent of total billed charges",
"SCR BONE 3MM 4MM 1.2MM 24MM 10MM STAINLESS STEEL LONG THREAD",SUP-202.724,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,317.69,28.62,,,,,0,129.1,943.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 22FR 18FR DIL HALYARD STERILE LATEX FREE",SUP-98433,CDM,S27200284,LOCAL,0272,RC,,,both,,,1649.78,494.93,"CIGNA [10200]",Cigna,,1121.85,68,,,,,0,191.87,1402.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALL THERAPEUTIC SMALL SPHERE HAND FOREARM WRIST METAL",SUP-A83720,CDM,S27000186,LOCAL,0270,RC,,,both,,,151.90,45.57,"PHCS [10601]",PHCS,,106.33,70,,,,,0,17.67,129.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO 570MM 1MM SWISS LITHOCLAST PNEUMATIC LATEX FREE",SUP-M0068407330,CDM,S27200284,LOCAL,0272,RC,,,both,,,1680.60,504.18,"CIGNA [10200]","Cigna Local Plus",,899.12,53.5,,,,,0,195.45,1428.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,inpatient,,,55488.36,16646.51,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,9103.26,,"Case rate ($8,838.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,206.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,246.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,002.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,217.65. The transfer operating threshold is the transfer adjustment factor * $8,206.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.47. The transfer capital threshold is the transfer adjustment factor * $620.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,35533.09,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 8CM 7MM BALLOON DILATATION ILIAC",SUP-G34341,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GUIDEWIRE RESTOR3D METATARSOPHALANGEAL STERILE LATEX FRE",SUP-4103-G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 73X25X1.24MM WIDE THICK STAINLESS STEEL SAGITTAL",SUP-2108110000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"CIGNA [10200]","Cigna Open Access",,109.01,56.9,,,,,0,22.28,162.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 56CM 19GA PROC TRANSSEPTAL 50D HEARTSPAN",SUP-FND01900,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERCROSS 130CM 80CM 2.4-3.2FR .017-.018IN 90D MICRO",SUP-5304,CDM,C1887,HCPCS,0272,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 15MM 2.75MM BALLOON DILATATION STERILE",SUP-227-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UHC [10700]","United Healthcare",,512.73,63.3,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 97MM CEMENT SUMMIT 2 12/14 STD OFFSET TAPER HIP",SUP-157003080,CDM,C1776,HCPCS,0278,RC,,,both,,,18219.60,5465.88,"PHCS [10601]",PHCS,,12753.72,70,,,,,0,2118.94,15486.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 74.9X49.3X4.8MM MBT 4MM KNEE CEMENTED REVISION",SUP-129435140,CDM,C1776,HCPCS,0278,RC,,,both,,,22385.16,6715.55,"NOVANET [10819]",Novanet,,16788.87,75,,,,,0,2603.39,19027.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SENSOR DUAL-FLEX 28CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006175284120,CDM,C2617,HCPCS,0278,RC,,,both,,,1294.14,388.24,"MULTIPLAN [10600]",Multiplan,,1100.02,85,,,,,0,150.51,1100.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +6 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR 1",SUP-MTA4U0.060,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,316.02,45.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 34MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-034,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"NOVANET [10819]",Novanet,,15938.1,75,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X7MM COLONIAL 7D LORDOTIC 14MM XL TITANIUM",SUP-365.807CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE NEUROSCOUT VASCULAR 205CM 43CM .014IN STAINLESS STEEL",SUP-601414,CDM,C1769,HCPCS,0272,RC,,,both,,,4071.00,1221.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,482.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Chest 3v",PX-324000011,CDM,71047,CPT,0324,RC,,,both,,,426.52,127.96,"KAISER [10500]",Kaiser,,285.77,67,,,,,0,46.01,362.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +14 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.140,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 STANDARD 9MM X 30CM",SUP-M0035469300,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS [10001]","Blue Cross HMO",,5532.94,39.2,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 8MM STD SHELL DJO SURGICAL ALTIVATE",SUP-530-08-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"NOVANET [10819]",Novanet,,35620.83,75,,,,,0,5523.6,40370.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 3CM 5FR STRAIGHT PANCREATIC POLYMER RADIOPAQUE",SUP-M00536250,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"BLUE CROSS [10001]","Blue Cross HMO",,250.59,39.2,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lipid Panel",PX-301000010,CDM,80061,CPT,0301,RC,,,both,,,327.75,98.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,47.53,,,,,,,0.33,278.59,"fee schedule",
"SCR BONE 4MM 17MM ATLANTIS TITANIUM SPINE CERVICAL ANTERIOR",SUP-3120217,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 13.6CM 8MM CEREPAK XL UNIFORM DETACHABLE",SUP-FCX180813,CDM,S27800098,LOCAL,0278,RC,,,both,,,15872.28,4761.68,"MULTIPLAN [10600]",Multiplan,,13491.44,85,,,,,0,1845.95,13491.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BILIARY 10MM 8.5FR 40MM FULLY COVERED TRANSHEPATIC WAL",SUP-M00574770,CDM,C1874,HCPCS,0278,RC,,,both,,,22050.00,6615,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 22MM 140CM 4MM CORONARY",SUP-RSINT40022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3769.92,68,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM TITANIUM 5 LEVEL ATLANTIS VISION ELITE BONE SPINE",SUP-7200090,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"COMPONENT FEMORAL 3 NARROW KNEE RIGHT CEMENTED CRUCIATE RETA",SUP-150400223,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9203.67,41.1,,6417.48,6417.48,6417.48,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"PLATE MINI STRAIGHT 4MMX1MM MANDIBLE 4 HOLE 2MM SCR BONE",SUP-55-10505,CDM,C1713,HCPCS,0278,RC,,,both,,,825.55,247.66,"BLUE CROSS [10001]","Blue Cross PPO",,323.62,39.2,,957.42,570.23,957.42,28,96.01,701.72,"percent of total billed charges",
"CATH 23IN 32FR ANGLE RIGHT TAPER DRNG PVC THORAX 5 EYELET",SUP-8132,CDM,C1729,HCPCS,0272,RC,,,both,,,89.63,26.89,"UHC [10700]","United Healthcare",,56.74,63.3,,,,,0,10.42,76.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 30MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"PHCS [10601]",PHCS,,1890,70,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP 6 UNIPOLAR/BIPOLAR - FX STEM/DEPUY",SUP-CAP-H-6,CDM,C1776,HCPCS,0278,RC,,,both,,,6720.00,2016,"BLUE CROSS [10001]","Blue Cross HMO",,2634.24,39.2,,5311.50,4717.44,5388.59,31,781.54,5712,"percent of total billed charges",
"SCR BONE 3MM 4MM 1.2MM 23MM 10MM STAINLESS STEEL LONG THREAD",SUP-202.723,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"MULTIPLAN [10600]",Multiplan,,943.52,85,,,,,0,129.1,943.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR050202A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"FIRST HEALTH [10303]","First Health",,15009.12,80,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.7MM 50MM 18MM LOW PROFILE SCREWS TITANIUM 3.5MM",SUP-AR-8967-1850,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"KAISER [10500]",Kaiser,,1256.25,67,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 100MM 130CM 7MM VASCULAR METAL SUPERFICIAL",SUP-H74939293071030,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1382.35,28.62,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TRILOGY HEART VALVE (SIZE 23)",SUP-TRILOGY-THV-S,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,91570.5,45.9,,,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE OSTEOCONDUCTIVE MATRIX DEMINERALIZED",SUP-OCMP2,CDM,C1713,HCPCS,0278,RC,,,both,,,1458.00,437.4,"CIGNA [10200]","Cigna Open Access",,829.6,56.9,,1144.80,304.56,2275.09,66,169.57,1239.3,"percent of total billed charges",
"CATH PIONEER PLUS 120CM 6FR .014IN CURVE ULTRASOUND REENTRY",SUP-PPLUS120,CDM,C1753,HCPCS,0272,RC,,,both,,,20128.50,6038.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2385.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 31CM 15FR 18GA .038IN POLYURETHANE CANNON II PLUS",SUP-CS-15362-VSP,CDM,C1750,HCPCS,0278,RC,,,both,,,2400.00,720,"MULTIPLAN [10600]",Multiplan,,2040,85,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POUCH 6.9X4.3IN OSTOMY FISTULA REMOTE DRNG ATTACH TAP CLSR",SUP-839262,CDM,S27000186,LOCAL,0270,RC,,,both,,,119.56,35.87,"CIGNA [10200]","Cigna Open Access",,68.03,56.9,,,,,0,13.9,101.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 58MM 26MM UHR UNIVERSAL ACETABULAR HIP COCR",SUP-UH1-58-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"BLUE CROSS [10001]","Blue Cross PPO",,1692.57,39.2,,3949.44,3949.44,3949.44,"1 through 10",502.16,3670.1,"percent of total billed charges",
"SCR BONE 5.5MM 40MM COCR SPINE MULTIAXIAL CANNULATED 5.5MM",SUP-55840015540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"TIP INSRT PERSONA BEARING PARTIAL KNEE SYSTEM DISPOSABLE",SUP-42529900301,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 200MM 5.5MM RELINE STRAIGHT TITANIUM MULTIAXIAL",SUP-12355200,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DBM T44125 5CC ORTHOBLEND LARGE DEFGRAFT",SUP-T44125,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1979.44,45.9,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X7MM ENDOSKELETON TC 6D 12MM SMALL TITANIUM",SUP-5146-1207-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4253.85,41.1,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPRAPUBIC STAMEY MALECOT 12FR 25CM CONNECTING TUBE",SUP-81012,CDM,C2627,HCPCS,0272,RC,,,both,,,371.93,111.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,44.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.26,316.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 15MM 21MM BIOCOR FLEXFIT LOW PROFILE SUPRA",SUP-BSP100-21,CDM,S27800098,LOCAL,0278,RC,,,both,,,32715.90,9814.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13086.36,40,,,,,0,3804.86,27808.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR SKIN 20MM WIDE ENDOSCOPIC LINEAR CUTTER RELOADABLE",SUP-070614,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.01,84.3,"AETNA [10100]","Aetna HMO/PPO",,223.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.68,238.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16015540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1110.3,8114.82,"percent of total billed charges",
"STEM FEMORAL 115MM 20MM PRESS FIT UNIVERSAL FLUTE KNEE",SUP-867433,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,959.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,942.1,6885.51,"percent of total billed charges",
"SHEATH HEARTSPAN 55D FIX CURVE TAPER 79.4CM 8.5FR GUIDING",SUP-FCL-160-07,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH 30D 230MM 22FR 4MM ENDOSCOPIC PERCUTANEOUS FRCP",SUP-A3342,CDM,S27200284,LOCAL,0272,RC,,,both,,,2234.25,670.27,"AETNA [10100]","Aetna HMO/PPO",,1776.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.84,1899.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 10MM KNEE LEFT E-PLUS EMPOWR 3D KNEE STERILE",SUP-341-10-704,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,762.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING DRNG 30CM 12FR SILICONE SOFT PLIABLE T",SUP-SU130-1238,CDM,S27200284,LOCAL,0272,RC,,,both,,,2175.00,652.5,"FIRST HEALTH [10303]","First Health",,1740,80,,,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR MYOSURE HYSTEROSCOPE OUTFLOW CHANNEL",SUP-40-250,CDM,S27200284,LOCAL,0272,RC,,,both,,,31468.50,9440.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3659.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3659.79,26748.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SMALL CHEVRON HEART INTERNAL WECK HEMOCLIP TANTALUM",SUP-523335,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.36,26.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,40.1,45.9,,,,,0,10.16,74.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Rmvl Snare",PX-750000040,CDM,43251,CPT,0750,RC,,,both,,,2979.73,893.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,353.1,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,346.54,2979.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mog-Igg1 Antb Flo Cytmtry Ea",PX-302000256,CDM,86363,CPT,0302,RC,,,both,,,1219.00,365.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,1036.15,"per diem",
"HC Mog-Igg1 Antb Flo Cytmtry Ea",PX-302000256,CDM,86363,CPT,0302,RC,,,both,,,1219.00,365.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,144.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1036.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Absc Fgr Smpl",PX-450000119,CDM,26010,CPT,0450,RC,,,both,,,909.00,272.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,107.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.91,909,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 30X4IN WRIST PRECUT FIBERGLASS ORTHO-GLASS",SUP-OG-430PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,102.16,30.65,"NOVANET [10819]",Novanet,,76.62,75,,,,,0,11.88,86.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TFCC MENDER STRAIGHT CURVE SUTURING NDL WIRE LOOP",SUP-7210752,CDM,S27200284,LOCAL,0272,RC,,,both,,,993.14,297.94,"FIRST HEALTH [10303]","First Health",,794.51,80,,,,,0,115.5,844.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 STD 10MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS8S10R,CDM,C1776,HCPCS,0278,RC,,,both,,,7569.30,2270.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,896.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,880.31,6433.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT REPAIR PERITONEAL 62CM 3 CUFF COIL TUNNEL CATH EXXTENDED",SUP-CF-5570,CDM,C1750,HCPCS,0278,RC,,,both,,,3742.50,1122.75,"PHCS [10601]",PHCS,,2619.75,70,,,,,0,435.25,3181.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PVAC GOLD ABLATION LATEX FREE",SUP-990078,CDM,S62400003,LOCAL,0624,RC,,,both,,,27090.00,8127,"PHCS [10601]",PHCS,,18963,70,,,,,0,3150.57,23026.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM YUKON SPINE OCCIPITOCERVICOTHORACIC",SUP-7601-03512,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 7MM CEREPAK MICRO UNIFORM DETACHABLE",SUP-FCX100730,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA [10200]","Cigna Open Access",,4430.66,33.5,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE 2.3CM MIC-KEY",SUP-8270-18-2.3-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"AETNA [10100]","Aetna HMO/PPO",,2093.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP SMALL ALLOGRAFT COMPRESSIBLE SPONGE 30",SUP-13810709,CDM,C1713,HCPCS,0278,RC,,,both,,,10952.67,3285.8,"MULTIPLAN [10600]",Multiplan,,9309.77,85,,,,,0,1273.8,9309.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM SYNAPSE TITANIUM 50D T15 SPINE",SUP-04.614.018,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"CATH TREK 25MM 3MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012407-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.822,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",27.52,201.14,"percent of total billed charges",
"CATH EMERGE MONORAIL 144CM 12MM 6FR 1.25MM .07IN ULTRA LOW",SUP-H7493918912120,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 48MM 32MM MARATHON",SUP-121932448,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"CIGNA [10200]",Cigna,,5515.45,68,,5873.17,5873.17,5873.17,"1 through 10",943.3,6894.31,"percent of total billed charges",
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 24MM 144CM 2.75MM",SUP-H7493941224270,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,919.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR ENDOSCOPIC 34CM SURGIFLO STERILE LATEX FREE DISPOSABLE",SUP-MS1995,CDM,S27000186,LOCAL,0270,RC,,,both,,,589.48,176.84,"AETNA [10100]","Aetna HMO/PPO",,468.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.56,501.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD PACING 100CM 6FR BARD NBIH 1CM PROXIMAL BIPOLAR",SUP-007152P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1822.50,546.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,215.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,211.96,1549.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 FULL THREAD CROSSFT BC SADDLE TIP LOADED",SUP-CFBC-5502N,CDM,C1713,HCPCS,0272,RC,,,both,,,3467.25,1040.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1425.04,41.1,,,,,0,1425.04,2194.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION VORTEX PEELPRO TITANIUM SILICONE",SUP-P5455K,CDM,C1788,HCPCS,0278,RC,,,both,,,6651.60,1995.48,"FIRST HEALTH [10303]","First Health",,5321.28,80,,,,,0,773.58,5653.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAHURKAR ELITE DOUBLE-D 20CM 12FR LARGE HEMODIALYSIS",SUP-8888221120,CDM,C1752,HCPCS,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM UNIVERS REVERS POROUS GLENOID PERIPHERAL",SUP-AR-9563-40,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"MULTIPLAN [10600]",Multiplan,,507.77,85,,,,,0,69.48,507.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 360MM RIGHT TROCHANTERIC INTRAMEDULLARY 130D LONG",SUP-456.356S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"KAISER [10500]",Kaiser,,9159.18,67,,,,,0,1589.87,11619.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 11CM TOUCH NARROW BASE",SUP-EN2811,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE THINFLAP STD CRANIOFACIAL TITANIUM 6 HOLE CURVED",SUP-191050,CDM,C1713,HCPCS,0278,RC,,,both,,,1912.50,573.75,"KAISER [10500]",Kaiser,,1281.38,67,,,,,0,222.42,1625.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Hip Uni W Pelvis 2-3v",PX-320000204,CDM,73502,CPT,0320,RC,,,both,,,526.67,158,"PHCS [10601]",PHCS,,368.67,70,,,,,0,58.01,447.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemo Extend IV Infus W/Pump",PX-335000006,CDM,G0498,HCPCS,0335,RC,,,both,,,1831.05,549.31,"NOVANET [10819]",Novanet,,1373.29,75,,,,,0,212.95,1556.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT BULKING POLYDIMETHYLSILOXANE PVP POLYPROPYLENE 2.5ML",SUP-MPQ-2.5,CDM,L8606,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"AETNA [10100]","Aetna HMO/PPO",,2951.44,79.5,,,,,0,176.81,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Td Vaccine No Prsrv >/= 7 Im",PX-771000017,CDM,90714,CPT,0636,RC,,,both,,,99.03,29.71,"NOVANET [10819]",Novanet,,74.27,75,,,,,0,11.97,99.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Needle Nerve Stimuplex",PX-E27200254,CDM,E27200254,LOCAL,0272,RC,,,both,,,118.80,35.64,"KAISER [10500]",Kaiser,,79.6,67,,,,,0,13.82,100.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla II Typing 1 Allele Hr",PX-309000092,CDM,81383,CPT,0310,RC,,,both,,,424.00,127.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.58,,"Fee schedule rate ($114.58). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.24,387.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Perc Bile Duct Stent Exist Access",PX-361000405,CDM,47538,CPT,0361,RC,,,both,,,12296.60,3688.98,"CIGNA [10200]","Cigna Local Plus",,7882,,"Case rate ($7,882). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1430.09,10452.11,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Slp Stdy Unatnd W Hrt/O2/Resp Efft",PX-920000007,CDM,95806,CPT,0920,RC,,,both,,,1399.00,419.7,"CIGNA [10200]",Cigna,,1399,,"Per diem ($1,733).",,,,0,162.7,1399,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Minor Proc Basic 1st Hr",PX-361000356,CDM,361000356,LOCAL,0361,RC,,,both,,,4374.00,1312.2,"NOVANET [10819]",Novanet,,3280.5,75,,,,,0,508.7,3717.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mra Neck WO/W Cntrst",PX-610000011,CDM,70549,CPT,0615,RC,,,both,,,4931.70,1479.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,584.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,573.56,4191.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Glucagon",PX-301000202,CDM,82943,CPT,0301,RC,,,both,,,293.80,88.14,"PHCS [10601]",PHCS,,205.66,70,,,,,0,0.01,249.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Adalimumab",PX-301000621,CDM,80145,CPT,0301,RC,,,both,,,544.35,163.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,60.67,,,,,,,0.01,462.7,"fee schedule",
"DRILL SURGICAL QUICK RELEASE ACCESS 15/64IN",SUP-110003481,CDM,S27200284,LOCAL,0272,RC,,,both,,,1556.00,466.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1058.08,68,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 56MM STAINLESS STEEL 3.5MM SCREWS SMALL FRAGMENT SET 4",SUP-245.041,CDM,C1713,HCPCS,0278,RC,,,both,,,2589.30,776.79,"CIGNA [10200]",Cigna,,1760.72,68,,1831.33,1831.33,1831.33,16,301.14,2200.91,"percent of total billed charges",
"HC Ihc Antibody Multiplex per Spec",PX-312000059,CDM,88344,CPT,0312,RC,,,both,,,731.47,219.44,"CIGNA [10200]","Cigna Local Plus",,297.99,,,,,,,0.01,621.75,"fee schedule",
"CATH SABERX RADIANZ 190CM 100MM 8MM .018IN BALLOON",SUP-R51008010L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"FIRST HEALTH [10303]","First Health",,1633.2,80,,,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Picc Line",PX-450000229,CDM,36584,CPT,0361,RC,,,both,,,7009.87,2102.96,"FIRST HEALTH [10303]","First Health",,5607.9,80,,,,,0,815.25,7009.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 60CM RVOT KIT MOND STAINLESS STEEL MEDIUM",SUP-4141/60,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"BLUE CROSS [10001]","Blue Cross HMO",,225.44,39.2,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 8IN 40D UP MICRO THIN 4MM KERRISON CERAMIC CONVERT",SUP-58-4200J-BD,CDM,S27200284,LOCAL,0272,RC,,,both,,,5017.40,1505.22,"KAISER [10500]",Kaiser,,3361.66,67,,,,,0,583.52,4264.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X250 80CM SL",SUP-48005025N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"FIRST HEALTH [10303]","First Health",,832.81,80,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Ankle Trimall W Manip",PX-450000166,CDM,27818,CPT,0450,RC,,,both,,,2528.88,758.66,"FIRST HEALTH [10303]","First Health",,2023.1,80,,,,,0,67.13,2528.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER BURR HOLE 17MM MATRIXNEURO MIDFACE CRANIOFACIAL",SUP-04.503.023,CDM,C1713,HCPCS,0278,RC,,,both,,,3753.60,1126.08,"BLUE CROSS [10001]","Blue Cross PPO",,1471.41,39.2,,957.42,570.23,957.42,28,436.54,3190.56,"percent of total billed charges",
"SUT VICRYL RAPIDE MULTIPASS 5-0 P-3 18IN BRAID COATED UNDYED",SUP-VR493,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.98,20.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.14,59.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC",520,MS-DRG,,,,,,,inpatient,,,88042.13,26412.64,"AMBETTER EXCHANGE  [11102]",Ambetter,,9266.76,,"Case rate ($9,266.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,604.81, add-ons for qualifying new technology services are included. If operating cost exceeds $41,644.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,032.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,616.19. The transfer operating threshold is the transfer adjustment factor * $8,604.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.57. The transfer capital threshold is the transfer adjustment factor * $650.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,43615.9,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCRP OPHTHALMIC 27GA CURVE MEMB DISPOSABLE",SUP-338.27,CDM,S27200284,LOCAL,0272,RC,,,both,,,1368.90,410.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,162.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,159.2,1163.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mlh1 Gene Dup/Delete Variants",PX-309000054,CDM,81294,CPT,0310,RC,,,both,,,2420.00,726,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,581.98,,,,,,,2.42,2057,"fee schedule",
"HC Compression Bandage Rosidal",PX-E27000090,CDM,E27000090,LOCAL,0270,RC,,,both,,,133.10,39.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.48,113.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Particle Agglutination Ea",PX-302000089,CDM,86403,CPT,0302,RC,,,both,,,547.00,164.1,"FIRST HEALTH [10303]","First Health",,437.6,80,,,,,0,6.91,464.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM VARIAX TORX TITANIUM FULL THREAD T10",SUP-40-35618,CDM,C1713,HCPCS,0278,RC,,,both,,,1211.11,363.33,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,555.9,45.9,,,,,0,140.85,1029.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 3MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140303,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]","Cigna Local Plus",,3742.77,31.5,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 24FR POWERBALL STORZ 1 STEM",SUP-M0068802011,CDM,S27200284,LOCAL,0272,RC,,,both,,,956.45,286.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.24,812.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE CONNECTING 30CM FLEXIBLE KINK RESISTANT FEMALE LUER",SUP-M0067401010,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.57,31.37,"PHCS [10601]",PHCS,,73.2,70,,,,,0,12.16,88.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS EVOQUE VALVE (EVOQUE VALVE) 48 MM",SUP-9850EV48PCL,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"KAISER [10500]",Kaiser,,133665,67,,,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0329,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,644.44,68,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM TRICUSPID 1 SEAM 2 WRAP ANATOMIC",SUP-4900T30,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"BLUE CROSS [10001]","Blue Cross HMO",,5003.88,39.2,,,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIPWIRE STIFF .025IN ANGLED TIP BX 5",SUP-M0066802171,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL CANCELLOUS 5D ALLOGRAFT 12MM",SUP-3W5012,CDM,S27800098,LOCAL,0278,RC,,,both,,,6216.90,1865.07,"NOVANET [10819]",Novanet,,4662.68,75,,,,,0,723.03,5284.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR AMPLATZ LEFT 1.5",SUP-67003800,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,48.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE REGENESORB 25MM 10MM SOLID OPEN",SUP-72204408,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"MULTIPLAN [10600]",Multiplan,,2357.93,85,,,,,0,322.62,2357.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION .25IN .25IN BARD SILICONE 4 FREE FLOW CHANNEL",SUP-072231,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.37,37.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,57.54,45.9,,,,,0,14.58,106.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 115CM 5MM 5FR ELECTROPHYSIOLOGY 4 POLE 12 PIN",SUP-D1085413,CDM,C1730,HCPCS,0272,RC,,,both,,,1425.60,427.68,"NOVANET [10819]",Novanet,,1069.2,75,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR CONTRALATERAL 2 CURVE ANGIOGRAPHIC",SUP-M001314581,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"AETNA [10100]","Aetna HMO/PPO",,92.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 80CM 5FR SOS OMNI 3 CURVE ANGIOGRAPHIC VISCERAL",SUP-H787107204065,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"AETNA [10100]","Aetna HMO/PPO",,172.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM 85MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE",SUP-02.117.602,CDM,C1713,HCPCS,0278,RC,,,both,,,6541.75,1962.52,"BLUE CROSS [10001]","Blue Cross PPO",,2564.37,39.2,,957.42,570.23,957.42,28,760.81,5560.49,"percent of total billed charges",
"CAP CONSTRUCT HIP CEMENTED STEM WITH BIOLOX DELTA HEAD R3 MH",SUP-71705325,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Local Plus",,7541.1,31.5,,5372.07,4581.20,7242.98,23,2784.22,20349,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL LOOP 28FR CUT OLYMPUS OES PRO",SUP-M0068802631,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,325.19,68,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BREAST BIOPSY 10CM LOCALIZER 20 APPLR",SUP-09-0007,CDM,S27200284,LOCAL,0272,RC,,,both,,,2055.00,616.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,243.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239,1746.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X8MM ADVANCED LORDOTIC SPINE",SUP-017708,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"FIRST HEALTH [10303]","First Health",,6624,80,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X18X11MM TRANSCONTINENTAL 6D LORDOTIC XS",SUP-375.911,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"UHC [10700]","United Healthcare",,15154.02,63.3,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 20CM TEMNO EVOLUTION COAXIAL INTRO SOFT",SUP-CTT2020,CDM,S27200284,LOCAL,0272,RC,,,both,,,369.23,110.77,"UHC [10700]","United Healthcare",,233.72,63.3,,,,,0,42.94,313.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER 7MM SPS ORTHOPEDIC TITANIUM .8MM 3.5/2.7MM SCR",SUP-619905,CDM,C1713,HCPCS,0278,RC,,,both,,,232.12,69.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,106.54,45.9,,,,,0,27,197.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP PHACOEMULSIFICATION .9MM ABS 45D MICRO MINIFLARED",SUP-8065750853,CDM,S27200284,LOCAL,0272,RC,,,both,,,597.29,179.19,"UHC [10700]","United Healthcare",,378.08,63.3,,,,,0,69.46,507.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"I-GEL, SINGLE USE SUPRAGLOTTIC AIRWAY, SIZE 1",SUP-8201000,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.13,23.74,"NOVANET [10819]",Novanet,,59.35,75,,,,,0,9.2,67.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 130MM 4MM STERLING TAPERED LARGE HUB",SUP-H9121,CDM,S27200284,LOCAL,0272,RC,,,both,,,412.21,123.66,"KAISER [10500]",Kaiser,,276.18,67,,,,,0,47.94,350.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 20MM 2.75MM BALLOON DILATATION PACLITAXEL",SUP-H7493960820270,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,17856.25,45.9,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 30CM SMALL VALVE ASSEMB RADIOPAQUE BAND",SUP-G08867,CDM,C1894,HCPCS,0272,RC,,,both,,,415.08,124.52,"NOVANET [10819]",Novanet,,311.31,75,,,,,0,48.27,352.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STARTER VASCULAR 3MM RADIUS J CURVE STRAIGHT 150CM",SUP-M001491701,CDM,C1769,HCPCS,0272,RC,,,both,,,92.19,27.66,"KAISER [10500]",Kaiser,,61.77,67,,,,,0,10.72,78.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 30D .35IN 24FR STERILE",SUP-A22205C,CDM,S27200284,LOCAL,0272,RC,,,both,,,710.34,213.1,"PHCS [10601]",PHCS,,497.24,70,,,,,0,82.61,603.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIOFLON 2/0 1/2KL 18MM DA 75CM PLEDGET TD3X7",SUP-19S30T,CDM,S27200284,LOCAL,0272,RC,,,both,,,97.88,29.36,"AETNA [10100]","Aetna HMO/PPO",,77.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.38,83.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL CARDIO-GRIP DEBAKEY 45D 4.75IN BULLDOG RING",SUP-320-185,CDM,S27200284,LOCAL,0272,RC,,,both,,,721.06,216.32,"MULTIPLAN [10600]",Multiplan,,612.9,85,,,,,0,83.86,612.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ehrlichia Antibody",PX-302000130,CDM,86666,CPT,0302,RC,,,both,,,162.50,48.75,"AETNA [10100]","Aetna HMO/PPO",,129.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,138.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 6.3X3.1IN XENMATRIX AB RECTANGLE DERMAL CLLGN",SUP-1150816,CDM,C1781,HCPCS,0278,RC,,,both,,,20829.69,6248.91,"BLUE CROSS [10001]","Blue Cross HMO",,8165.24,39.2,,,,,0,2422.49,17705.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 36CM CLEANCOAT PTFE STAINLESS STEEL",SUP-E3771-36C,CDM,S27200284,LOCAL,0272,RC,,,both,,,251.00,75.3,"MULTIPLAN [10600]",Multiplan,,213.35,85,,,,,0,29.19,213.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 260MM STAINLESS STEEL 9 HOLE CABLE BMP BONE ORTHOPEDIC",SUP-350819,CDM,C1713,HCPCS,0278,RC,,,both,,,11695.50,3508.65,"BLUE CROSS [10001]","Blue Cross PPO",,4584.64,39.2,,957.42,570.23,957.42,28,1360.19,9941.18,"percent of total billed charges",
"AUG TIBIAL 67MMX15MM VANGUARD 360 KNEE LEFT MEDIAL RIGHT",SUP-185242,CDM,C1776,HCPCS,0278,RC,,,both,,,7577.58,2273.27,"CIGNA [10200]","Cigna Local Plus",,4054.01,53.5,,5372.07,4581.20,7242.98,23,881.27,6440.94,"percent of total billed charges",
"LIFESPARC PUMP KIT",SUP-5800-0000,CDM,S27200284,LOCAL,0272,RC,,,both,,,74100.00,22230,"CIGNA [10200]","Cigna Open Access",,42162.9,56.9,,,,,0,8617.83,62985,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC SURGIFLO MATRIX",SUP-2994,CDM,S27200284,LOCAL,0272,RC,,,both,,,1372.75,411.82,"FIRST HEALTH [10303]","First Health",,1098.2,80,,,,,0,159.65,1166.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-0 THX-36 36IN MONOFILAMENT UNDYED",SUP-0N07B,CDM,S27200284,LOCAL,0272,RC,,,both,,,227.65,68.29,"AETNA [10100]","Aetna HMO/PPO",,180.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.48,193.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 42X4IN ATS CYL PORT STERILE DISPOSABLE",SUP-60707510700,CDM,S27200284,LOCAL,0272,RC,,,both,,,227.12,68.14,"PHCS [10601]",PHCS,,158.98,70,,,,,0,26.41,193.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 14X14.5CM 535ML STYLE FF HIGHLY COHESIVE GEL",SUP-FF-410535,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 9IN SLIGHT CURVE 5MM LEKSELL 2 ACTION SURGICAL",SUP-31-5105,CDM,S27200284,LOCAL,0272,RC,,,both,,,1192.40,357.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,138.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,138.68,1013.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VISIGI 3D STD 40FR GASTRIC LAVAGE BULB CALIBRATE",SUP-5540B,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 27MM 80CM 9MM 30MM BILIARY STAINLESS STEEL",SUP-PXB35-09-27-080,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"BLUE CROSS [10001]","Blue Cross HMO",,1711.86,39.2,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE GRAFT 12CC DEMINERALIZED CORTICAL FIBER ACCELERATE",SUP-T50212,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,957.42,156.86,7483.26,51,2014.9,14726.25,"percent of total billed charges",
"DISECT BIPOLAR ENDOWRIST 8MM CURVE CAUT",SUP-420344,CDM,S27000186,LOCAL,0270,RC,,,both,,,2025.00,607.5,"CIGNA [10200]","Cigna Local Plus",,1083.38,53.5,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL 3MM OPES 90D LOW PROFILE ASPIRATE",SUP-AR-9703A-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"CIGNA [10200]","Cigna Open Access",,846.89,56.9,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP FLEX-MINI 50MM CLSR POLYESTER LOW PROFILE",SUP-ACHM50,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"CIGNA [10200]","Cigna Local Plus",,4890.38,31.5,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE 9MM 230CM 2.4MM EXACTO COLD BRAID WIRE CLEAN CUT",SUP-BX00711115,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.70,28.71,"NOVANET [10819]",Novanet,,71.78,75,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 15CM 6.6FR MYOCARDIUM UNIPOLAR FIX SCR IS-1",SUP-5071-15,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"AETNA [10100]","Aetna HMO/PPO",,4457.57,79.5,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 8.2MM 6MM FULL MAGILL CURVE NASAL ORAL",SUP-86389,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.54,17.86,"NOVANET [10819]",Novanet,,44.66,75,,,,,0,6.92,50.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 STANDARD 9MM X 30CM",SUP-M0035469300,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]","Cigna Open Access",,4728.4,33.5,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB CONGRUENT 3/4 LF 12",SUP-2041-0-3412,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Local Plus",,1905.94,53.5,,5372.07,4581.20,7242.98,23,414.32,3028.13,"percent of total billed charges",
"CANN ENDOSCOPIC LIME GREEN 72MM 8MM CLEAR-TRAC SHOULDER",SUP-72200425,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.01,86.7,"KAISER [10500]",Kaiser,,193.64,67,,,,,0,33.61,245.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER/10 DEGREE HOODED-NEUTRAL MP10",SUP-932-44-760,CDM,C1776,HCPCS,0278,RC,,,both,,,16186.99,4856.1,"BLUE CROSS [10001]","Blue Cross HMO",,6345.3,39.2,,5311.50,4717.44,5388.59,31,1882.55,13758.94,"percent of total billed charges",
"SHELL ACETABULAR 50MM HIP LIMIT HOLE COLOR CODED POROUS G7 D",SUP-010000662,CDM,C1776,HCPCS,0278,RC,,,both,,,10120.92,3036.28,"NOVANET [10819]",Novanet,,7590.69,75,,,,,0,1177.06,8602.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 16MM LCP STAINLESS STEEL DISTAL RADIUS T8",SUP-212.816,CDM,C1713,HCPCS,0278,RC,,,both,,,802.87,240.86,"BLUE CROSS [10001]","Blue Cross HMO",,314.73,39.2,,957.42,156.86,7483.26,51,93.37,682.44,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 33MM 145CM 2.75MM CORONARY STENT",SUP-1125275-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"NOVANET [10819]",Novanet,,4378.5,75,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM 16X16X2.5MM TITANIUM 1 LEVEL PREBENT SKYLINE BONE",SUP-186801016,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"AETNA [10100]","Aetna HMO/PPO",,3339,79.5,,1521.93,481.35,16760.95,30,488.46,3570,"percent of total billed charges",
"CATH 14FR URETHRAL SILICONE 10ML FOLEY 2 WAY COUDE TIP",SUP-DYND11591,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.36,38.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.04,109.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 38MM 145CM 2.75MM CORONARY STENT",SUP-1145275-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]",Cigna,,3969.84,68,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL ARTHREX UNIVERS REVERS UNIVERS APEX 11 SHOULDER",SUP-AR-9501-11S,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"MULTIPLAN [10600]",Multiplan,,8973.45,85,,,,,0,1227.78,8973.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 5.5MM CREO CURVE TITANIUM NONSTERILE",SUP-1119.7040,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM AXSOS STAINLESS STEEL T20 FEMUR HUMERUS",SUP-371340,CDM,C1713,HCPCS,0278,RC,,,both,,,991.44,297.43,"BLUE CROSS [10001]","Blue Cross HMO",,388.64,39.2,,957.42,156.86,7483.26,51,115.3,842.72,"percent of total billed charges",
"KIT EXTERNAL FIXATION HOFFMANN 3 MOSQUITO B SCPL CLAMP SELF",SUP-4922-9-941S,CDM,S27200284,LOCAL,0272,RC,,,both,,,47081.79,14124.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19350.62,41.1,,,,,0,5475.61,40019.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR DYNASTY A-CLASS STD 28MM POLY BIOFOAM HIP",SUP-DLXPGB28,CDM,C1776,HCPCS,0278,RC,,,both,,,7507.20,2252.16,"PHCS [10601]",PHCS,,5255.04,70,,,,,0,873.09,6381.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM TIMAX T15 CORTEX SELF TAP LOCK TAPER",SUP-816135020,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,189.34,1383.8,"percent of total billed charges",
"DEFIB CARDIAC .99CM 5.37X7.36CM RESONATE PHYSIOLOGIC SENSOR",SUP-D532,CDM,C1722,HCPCS,0278,RC,,,both,,,56385.00,16915.5,"UHC [10700]","United Healthcare",,35691.71,63.3,,,,,0,6557.58,47927.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.113,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,101.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,99.7,728.71,"percent of total billed charges",
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.120,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 15CM FRANSEEN CANN SERRATE EDGE LUNG STERILE",SUP-G01266,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.10,58.23,"CIGNA [10200]","Cigna Open Access",,110.44,56.9,,,,,0,22.57,164.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRACTURES OF FEMUR WITHOUT MCC",534,MS-DRG,,,,,,,inpatient,,,30880.39,9264.12,"AETNA [10100]","Aetna HMO/PPO",,15166.77,,"Fee schedule rate ($15,166.77). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,5000.29,20103.33,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 5MM 90MM NAIL-EX TITANIUM FULL THREAD FEMORAL TIB",SUP-04.005.580,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"BLUE CROSS [10001]","Blue Cross PPO",,453.42,39.2,,957.42,570.23,957.42,28,134.52,983.18,"percent of total billed charges",
"WRAP THERAPEUTIC 25-30IN SMARTVEST SMALL HIGH FREQUENCY",SUP-SW-25/30-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 220MM 4MM BALLOON DILATATION NYBAX",SUP-39186-40221,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.50,708.75,"KAISER [10500]",Kaiser,,1582.88,67,,,,,0,274.76,2008.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING .48MM ATRIAL UNIPOLAR TEMPORARY STREAMLINE 3MM",SUP-6492F,CDM,C1898,HCPCS,0275,RC,,,both,,,304.50,91.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,35.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 217MM 17MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-417,CDM,C1776,HCPCS,0278,RC,,,both,,,19885.95,5965.78,"UHC [10700]","United Healthcare",,12587.81,63.3,,8601.07,8395.67,8601.07,"1 through 10",2312.74,16903.06,"percent of total billed charges",
"HC Neuromuscular Junction Test",PX-740000034,CDM,95937,CPT,0740,RC,,,both,,,387.00,116.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,263.16,68,,,,,0,45.01,387,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 24IN 6FR SUCTION",SUP-8888256545,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.16,19.85,"FIRST HEALTH [10303]","First Health",,52.93,80,,,,,0,7.69,56.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 159MM STAINLESS STEEL 4.5MM SCR 6 HOLE 4 COLUMN",SUP-02.124.407,CDM,C1713,HCPCS,0278,RC,,,both,,,9798.00,2939.4,"PHCS [10601]",PHCS,,6858.6,70,,,,,0,1139.51,8328.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 40MM CREO CREO AMP SPINE MODULAR NONSTERILE",SUP-1067.1840,CDM,C1713,HCPCS,0278,RC,,,both,,,2812.50,843.75,"AETNA [10100]","Aetna HMO/PPO",,2235.94,79.5,,1521.93,481.35,16760.95,30,327.09,2390.63,"percent of total billed charges",
"SURFACE ARTICULAR 12MM PERSONA 6-9 E-F KNEE RIGHT TIBIA",SUP-42521400712,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"PHCS [10601]",PHCS,,5653.03,70,,,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM 32X16X2.5MM TITANIUM 2 LEVEL PREBENT SKYLINE BONE",SUP-186802032,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross PPO",,1728.72,39.2,,957.42,570.23,957.42,28,512.88,3748.5,"percent of total billed charges",
"CATH ARMADA 35 80CM 20MM 5FR 6MM .035IN LOW PROFILE BALLOON",SUP-B1060-020,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 375ML GEL ROUND SMOOTH COHESIVE I SILICONE P4CM","SUP-3503751 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"CIGNA [10200]",Cigna,,2499,68,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (OTW)  2.00MM X 15MM",SUP-H74939402152000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"MULTIPLAN [10600]",Multiplan,,4604.03,85,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER FLEXIVA 365UM FLEXSHIELD HIGH POWER POLISH",SUP-M0068403921,CDM,S27200284,LOCAL,0272,RC,,,both,,,2258.15,677.44,"KAISER [10500]",Kaiser,,1512.96,67,,,,,0,262.62,1919.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) QUALIBRA ADVANCED 5XLPLUS",SUP-QADV-5XL-PLUS,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM RIGHT VENTRICLE IS-1 CNCT BIPOLAR FIXATION","SUP-365 501",CDM,C1777,HCPCS,0278,RC,,,both,,,17250.00,5175,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6900,40,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 28MM 2.75MM CORONARY STENT COCR",SUP-1007847-28,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 10CM 5.8FR 12FR BALLOON",SUP-M0062251150,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"KAISER [10500]",Kaiser,,1147.36,67,,,,,0,199.16,1455.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM COCR SPINE MULTIAXIAL CANNULATED",SUP-54840016535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"MULTIPLAN [10600]",Multiplan,,8114.82,85,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 6.8FR 11MM SPACING ENDOCARDIUM TRUE BIPOLAR",SUP-7122Q/52,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"KAISER [10500]",Kaiser,,11505.24,67,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE SYNTHETIC MATRIX INJECTION STEM CELL NUCLEAR FIELD",SUP-NC-1000,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"NOVANET [10819]",Novanet,,4631.63,75,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE RIGHT PRESS FIT EMPOWR KNEE STERILE BP",SUP-353-02-106,CDM,C1776,HCPCS,0278,RC,,,both,,,15979.64,4793.89,"PHCS [10601]",PHCS,,11185.75,70,,,,,0,1858.43,13582.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEPTIC ARTHRITIS WITH CC",549,MS-DRG,,,,,,,inpatient,,,35913.08,10773.92,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,7825.32,,"Case rate ($7,488.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,953.43, add-ons for qualifying new technology services are included. If operating cost exceeds $39,993.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,907.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $6,962.62. The transfer operating threshold is the transfer adjustment factor * $6,953.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $525.71. The transfer capital threshold is the transfer adjustment factor * $525.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7488.34,30106.36,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"ENT BUR 4MM FLUTED BALL TS SHORT ANSPACH",SUP-SA-FB4,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"KAISER [10500]",Kaiser,,1155.75,67,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 15MM 140CM 2.25MM 2.1-2.7FR CORONARY",SUP-RONYX22515UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"BLUE CROSS [10001]","Blue Cross HMO",,1455.3,39.2,,9776.84,9776.84,9776.84,"1 through 10",431.76,3155.63,"percent of total billed charges",
"COMPONENT TIBIAL PERSONA NONPOROUS E KNEE LEFT REVISION FIXA",SUP-42542007101,CDM,C1776,HCPCS,0278,RC,,,both,,,23892.50,7167.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6838.03,28.62,,,,,0,2778.7,20308.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT RETRIEVER 20MM 3MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0033PK32021001,CDM,S27200284,LOCAL,0272,RC,,,both,,,20045.55,6013.66,"CIGNA [10200]",Cigna,,13630.97,68,,,,,0,2331.3,17038.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM TARGET HELICAL PLATINUM DETACHABLE",SUP-M0035434080,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1085.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 1.5 X 3 COMPLEX FINISHING COIL",SUP-10CFN-01503,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1363.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 7FR 40D GUIDING DURAFORM PTFE",SUP-M003101430,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"FIRST HEALTH [10303]","First Health",,2002.5,80,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL HIP C TAPER COBALT CHROME LFIT",SUP-06-2805,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"BLUE CROSS [10001]","Blue Cross HMO",,1226.06,39.2,,5311.50,4717.44,5388.59,31,363.75,2658.55,"percent of total billed charges",
"STENT EPIC 100MM 75CM 9MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200091070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross PPO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 35MM CONDYLAR STABILIZED NECK OMNIFIT HFX 132D",SUP-6098-0835,CDM,C1776,HCPCS,0278,RC,,,both,,,10292.40,3087.72,"CIGNA [10200]","Cigna Open Access",,5856.38,56.9,,5302.19,4377.88,6578.61,27,1197.01,8748.54,"percent of total billed charges",
"CATH PACIFIC XTREME 90CM 150MM 3.9-4.2FR 5MM BALLOON",SUP-PCU050150090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN JUDKINS LEFT 4 CURVE GUIDING",SUP-LA7JL40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,266.22,68,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH INSRT 8FR FIDELITY REINFORCED INTRO VESSEL DIL",SUP-0884-00-0019-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,955.80,286.74,"NOVANET [10819]",Novanet,,716.85,75,,,,,0,111.16,812.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WARFARIN 0.5 MG TABLET (PARTIAL OF 1 MG TABLET)",RX-408647,CDM,,,0637,RC,08888-8886-80,NDC,both,.5,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 110CM 5FR .047IN .047IN PIGTAIL",SUP-534550S,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"PHCS [10601]",PHCS,,65.47,70,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CLEANER15 135CM 7FR 15MM THROMBECTOMY SINUSOIDAL WIRE",SUP-700115,CDM,S27200284,LOCAL,0272,RC,,,both,,,7893.60,2368.08,"UHC [10700]","United Healthcare",,4996.65,63.3,,,,,0,918.03,6709.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 9CM 135CM 22-27MM 10FR COLONIC DELIVERY",SUP-M00565140,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESTRICT CEMENT SMALL UNIVERSAL DISTAL DISPOSABLE INSRT",SUP-B000-1185,CDM,S27800098,LOCAL,0278,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 345MM TIBIAL TN ADVANCED INTRAMEDULLARY MR",SUP-04.043.135S,CDM,C1713,HCPCS,0278,RC,,,both,,,9579.13,2873.74,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3937.02,41.1,,,,,0,1114.05,8142.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 60MM 12MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U12060090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"PHCS [10601]",PHCS,,7245,70,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 1 127D",SUP-6721-0127,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6469.75,27,,,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 12MM 4MM CORONARY STENT COCR RAPID",SUP-1007850-12,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL WEIL-BLAKESLEY 2 5MM STRAIGHT 7.5IN NASAL",SUP-63-2011,CDM,S27200284,LOCAL,0272,RC,,,both,,,1801.88,540.56,"CIGNA [10200]","Cigna Open Access",,1025.27,56.9,,,,,0,209.56,1531.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22.5 DIOPTER UV ABSORBENT CLAREON AUTONOME",SUP-CCA0T0.225,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALACYCLOVIR 500 MG TABLET",RX-13133,CDM,,,0637,RC,63739-0077-10,NDC,both,1,UN,8.23,2.47,"KAISER [10500]",Kaiser,,5.51,67,,,,,0,0.96,7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 270090 RESERVE 9MM SRVC FEE",SUP-270090,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 20X9CM AMNIOFIX PURION ALLOGRAFT SHEET",SUP-APS-5920,CDM,Q4433,HCPCS,0636,RC,,,both,,,56252.70,16875.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,25819.99,45.9,,,,,0,247.92,47814.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 62MM 32MM MARATHON HIP",SUP-121932062,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,857.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,841.39,6149.45,"percent of total billed charges",
"SYSTEM ENVEO R DELIVERY LOAD",SUP-LS-ENVEOR-34-US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2925.00,877.5,"KAISER [10500]",Kaiser,,1959.75,67,,,,,0,340.18,2486.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 12/14 TAPER 28MM HIP OXINIUM",SUP-71342812,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"NOVANET [10819]",Novanet,,11651.51,75,,,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION ACTIVENT SHEEHY",SUP-1026145,CDM,S27800098,LOCAL,0278,RC,,,both,,,194.76,58.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.65,165.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 7-0 24IN 2 ARM MONOFILAMENT 4 STRAND",SUP-EPM8704,CDM,S27200284,LOCAL,0272,RC,,,both,,,984.31,295.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.48,836.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 5X4IN RESTORE TRIACT SILVER CONTACT LAYER LATEX",SUP-509341,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.64,19.69,"CIGNA [10200]","Cigna Open Access",,37.35,56.9,,,,,0,7.63,55.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLATE TIBIAL ATTUNE 8 KNEE REVISION CEMENT ROTATE PLATFO",SUP-150660008,CDM,C1776,HCPCS,0278,RC,,,both,,,22629.60,6788.88,"UHC [10700]","United Healthcare",,14324.54,63.3,,8601.07,8395.67,8601.07,"1 through 10",2631.82,19235.16,"percent of total billed charges",
"CABLE CATH 10FT CARTO 3 34 PIN HYPERTRONIC ELECTROPHYSIOLOGY",SUP-D128624,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"FIRST HEALTH [10303]","First Health",,2694,80,,,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 10MM X 30CM",SUP-M0035471030,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1672.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D +4.5 CYL MODIFY L 13MM 6MM POSTERIOR CHMBR 1",SUP-CNW0T7,CDM,V2787,HCPCS,0276,RC,,,both,,,355.00,106.5,"CIGNA [10200]","Cigna Local Plus",,189.93,53.5,,,,,0,41.29,301.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GALASHAPE 15.5X5.3CM SOFT TISSUE SCAFFOLD",SUP-FR3D02,CDM,C1781,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,7120.58,10966.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION TROCAR END PERFORATION RADIOPAQUE STRIPE 3/16",SUP-DC7032,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.90,17.67,"CIGNA [10200]",Cigna,,40.05,68,,,,,0,6.85,50.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.7MM 65MM 18MM LOW PROFILE SCREWS TITANIUM 3.5MM",SUP-AR-8967-1865,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"FIRST HEALTH [10303]","First Health",,1500,80,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 375CC",SUP-SSZ-M375,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"UHC [10700]","United Healthcare",,943.42,63.3,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16026555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"NAIL 11.5MM 200MM VALOR",SUP-415101120L,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR ANGLE 80CM .035IN HYDROPHILIC FIX CORE",SUP-H2OSTFA3580,CDM,C1769,HCPCS,0272,RC,,,both,,,278.40,83.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,32.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP MEDIUM CHEVRON INTERNAL WECK HORIZON TITANIUM 24 CRTDG",SUP-002204,CDM,S27200284,LOCAL,0272,RC,,,both,,,286.06,85.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,194.52,68,,,,,0,33.27,243.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION LIFECARE 0.9% SODIUM CHLORIDE 2L LATEX FREE",SUP-07972-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +10 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1000,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM 13 HOLE STRAIGHT LOCKING BONE STERNAL",SUP-460.046,CDM,C1713,HCPCS,0278,RC,,,both,,,8424.90,2527.47,"UHC [10700]","United Healthcare",,5332.96,63.3,,5023.51,2672.93,6679.78,18,979.82,7161.17,"percent of total billed charges",
"MATRIX TISSUE 4X4CM AMNIOBAND PLACENTAL ALLOGRAFT",SUP-WC3044,CDM,Q4151,HCPCS,0636,RC,,,both,,,16148.97,4844.69,"MULTIPLAN [10600]",Multiplan,,13726.62,85,,,,,0,362.66,13726.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TANDEMLIFE KIT- V24/A15",SUP-5840-2415,CDM,S27200284,LOCAL,0272,RC,,,both,,,71250.00,21375,"AETNA [10100]","Aetna HMO/PPO",,56643.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8286.38,60562.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 130CM 40MM 4MM BALLOON DILATATION",SUP-LX351304405F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"PHCS [10601]",PHCS,,4709.25,70,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NEOMAGIC 6CM 1.9FR VASCULAR PERIPHERAL INTRAVENOUS 1",SUP-1943-1606,CDM,C1751,HCPCS,0272,RC,,,both,,,239.25,71.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.82,203.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 5MM 40MM VIPER PRIME SPINE CORTICAL FIX POLYAXIAL",SUP-186750440,CDM,C1713,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"KAISER [10500]",Kaiser,,4854.15,67,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8-6.5MM 80MM CREO SPINE PREASSEMBLE 2 OUTER",SUP-5119.2282,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 12.5X11CM 400CC AEROFORM P8CM SMALL",SUP-BR125-400,CDM,C1789,HCPCS,0278,RC,,,both,,,16118.40,4835.52,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4351.97,27,,,,,0,1874.57,13700.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SMART CONTROL MICROMARKER 100MM 120CM 6MM VASCULAR",SUP-C06100ML,CDM,C1876,HCPCS,0278,RC,,,both,,,4657.50,1397.25,"CIGNA [10200]","Cigna Local Plus",,2491.76,53.5,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE 6X16X1 CORTIVIA",SUP-DH2616,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 40CM 20/10MM 2 VELOUR KNITTED",SUP-M002020852010,CDM,C1768,HCPCS,0278,RC,,,both,,,4778.66,1433.6,"PHCS [10601]",PHCS,,3345.06,70,,,,,0,555.76,4061.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR KL4H CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389696150,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"UHC [10700]","United Healthcare",,231.96,63.3,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)MARKER SKIN PINK 10CM 15GA SMARTCLIP LITE 3-4MM SOFT T",SUP-SMARTCLIPLT-PNK-10,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA [10200]","Cigna Open Access",,1536.3,56.9,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT 12IN 1.75IN OSTOMY 2 PIECE DRAINABLE POUCH LOW PRESSURE",SUP-SQU416919,CDM,S27000186,LOCAL,0270,RC,,,both,,,236.62,70.99,"AETNA [10100]","Aetna HMO/PPO",,188.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.52,201.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PCMKR CRD THK6MM SM 50X41MM","SUP-PM1160 CELL",CDM,C1786,HCPCS,0275,RC,,,both,,,9324.00,2797.2,"KAISER [10500]",Kaiser,,6247.08,67,,,,,0,1084.38,7925.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 46MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.217,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"BLUE CROSS [10001]","Blue Cross PPO",,342.29,39.2,,957.42,570.23,957.42,28,101.55,742.2,"percent of total billed charges",
"CATH COYOTE ES 145CM 40MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939134254010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAPAROTOMY TRAY",SUP-SBA21LPUHQ,CDM,S27200284,LOCAL,0272,RC,,,both,,,675.14,202.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,459.1,68,,,,,0,78.52,573.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK VITRECTOMY 25+ GA TOTAL PLUS CONSTELLATION 5000 CPM",SUP-8065751462,CDM,S27200284,LOCAL,0272,RC,,,both,,,3742.50,1122.75,"AETNA [10100]","Aetna HMO/PPO",,2975.29,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,435.25,3181.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 439014 PG 14X26 SRVC FEE FD",SUP-439014,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 25CM 12FR MAC-LOC SUPRAPUBIC ULTRATHANE NDL OBTR",SUP-G30404,CDM,C2627,HCPCS,0272,RC,,,both,,,1219.86,365.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.87,1036.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 10MM REUSABLE HANDLE ACL PCL SURGICAL PARALLEL GRAFT",SUP-AR-2285-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,429.35,128.8,"UHC [10700]","United Healthcare",,271.78,63.3,,,,,0,49.93,364.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT MRI AIRGUARD CHRONOFLEX",SUP-1808001,CDM,C1788,HCPCS,0278,RC,,,both,,,1905.00,571.5,"NOVANET [10819]",Novanet,,1428.75,75,,,,,0,221.55,1619.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM PRESTIGE PLUS HELICAL ULTRA",SUP-PRES0310CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 150MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171081510,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,482.72,41.1,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 46MM 28MM MARATHON HIP",SUP-121928146,CDM,C1776,HCPCS,0278,RC,,,both,,,9125.25,2737.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2611.65,28.62,,,,,0,1061.27,7756.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +8 DIOPTER +1.5 CYL BICONVEX 13MM 6MM POSTERIOR",SUP-SN6AT3.080,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMAKER CARDIAC THK6MM 59X55MM ALLURE RF IS-1 CONNECTOR CO",SUP-PM3222,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9490.15,41.1,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,inpatient,,,29665.36,8899.61,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,4415.55,,"Case rate ($4,286.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,980.71, add-ons for qualifying new technology services are included. If operating cost exceeds $37,020.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,682.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,985.97. The transfer operating threshold is the transfer adjustment factor * $3,980.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $300.96. The transfer capital threshold is the transfer adjustment factor * $300.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4286.94,17235.34,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 12MM 5MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012280-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 15MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDS32515,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA [10200]","Cigna Open Access",,27813.28,33.5,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X8MM CLYDESDALE PTC 0D PEEK TITANIUM",SUP-4980855,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7654.5,27,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X12.7X1.19MM OSCILLATING",SUP-6113-119-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Split Blood Ea Unit",PX-302000216,CDM,86985,CPT,0302,RC,,,both,,,226.20,67.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.23,.1,,,,,0,0.23,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 8-4MM TORNADO PLATINUM STERILE ACCEPTS",SUP-G10411,CDM,S27800098,LOCAL,0278,RC,,,both,,,730.54,219.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,209.08,28.62,,,,,0,84.96,620.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 45-65MM 5MM RELINE-O SPINE LOW PROFILE ADJUSTABLE",SUP-10050445,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross HMO",,1396.5,39.2,,957.42,156.86,7483.26,51,414.32,3028.13,"percent of total billed charges",
"LEAD PACING 46CM 6.8FR 10MM SPACING J ATRIUM BIPOLAR ACTIVE",SUP-1782TC/46,CDM,C1898,HCPCS,0275,RC,,,both,,,1786.00,535.8,"CIGNA [10200]","Cigna Local Plus",,955.51,53.5,,,,,0,207.71,1518.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIPHERAL CUTTING BALLOON 90CM 20MM 7MM BALLOON",SUP-M001PCB7020900,CDM,C1725,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1914.23,41.1,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER INFINITY MRI GUIDED RIGID DEPLOYMENT DEVICE SECURMARK",SUP-SMARK-M-SS2,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,79.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +22.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2250,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 12MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45012,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA [10200]","Cigna Open Access",,27813.28,33.5,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 12MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45012,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"UHC [10700]","United Healthcare",,52554.65,63.3,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Lymphedema Full Leg",PX-E27000189,CDM,E27000189,LOCAL,0270,RC,,,both,,,1430.87,429.26,"NOVANET [10819]",Novanet,,1073.15,75,,,,,0,166.41,1216.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 44MM 2 LEVEL ARCHON BONE SPINE NONSTERILE",SUP-8787244,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,957.42,156.86,7483.26,51,521.61,3812.25,"percent of total billed charges",
"PLATE 3 POROUS TRABECULAR METAL FIXED MIS BONE TIBIAL",SUP-00595403701,CDM,C1713,HCPCS,0278,RC,,,both,,,10000.00,3000,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6800,68,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 26MM GELWEAVE VASCUTEK STRAIGHT THORACIC",SUP-733026,CDM,C1768,HCPCS,0278,RC,,,both,,,6831.00,2049.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4645.08,68,,,,,0,794.45,5806.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE OFFSET +3.5MM ENCORE",SUP-411-00-350,CDM,C1776,HCPCS,0278,RC,,,both,,,947.54,284.26,"CIGNA [10200]","Cigna Open Access",,539.15,56.9,,5302.19,4377.88,6578.61,27,110.2,805.41,"percent of total billed charges",
"STEM FEMORAL 100MM 12MM CEMENTED TOTAL STABILIZED TRIATHLON",SUP-5560-S-212,CDM,C1776,HCPCS,0278,RC,,,both,,,4271.90,1281.57,"AETNA [10100]","Aetna HMO/PPO",,3396.16,79.5,,10981.53,8986.79,12413.38,12,496.82,3631.12,"percent of total billed charges",
"AVENIR 10, 1 X 4 COMPLEX PICO COIL",SUP-10USC01004,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"AETNA [10100]","Aetna HMO/PPO",,10395.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG ACETABULAR 20MM 62MM RESTORATION WEDGE HIP",SUP-5096-6220,CDM,C1776,HCPCS,0278,RC,,,both,,,12461.40,3738.42,"PHCS [10601]",PHCS,,8722.98,70,,,,,0,1449.26,10592.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X14MM CLYDESDALE 6D PEEK CAGE INTERBODY",SUP-2968455,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"NOVANET [10819]",Novanet,,17820,75,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plasminogen Activator Inihibit",PX-305000044,CDM,85400,CPT,0305,RC,,,both,,,402.80,120.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,12.13,,,,,,,0.4,342.38,"fee schedule",
"PLATE 40MM ATLANTIS VISION ELITE BONE SPINE",SUP-7200040,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Open Access",,2509.29,56.9,,1144.80,304.56,2275.09,66,512.88,3748.5,"percent of total billed charges",
"SYSTEM PROMUS PREMIER 12MM 144CM 2.5MM CORONARY STENT",SUP-H7493952812250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"MULTIPLAN [10600]",Multiplan,,4730.25,85,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 23X9X9MM CONCORDE PARALLEL BULLET NOSE",SUP-187823109,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4471.2,27,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.00 X 18 MM  RX FDA",SUP-1203300-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6900,40,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM 3 HOLE POLY R3 STD",SUP-71335558,CDM,C1776,HCPCS,0278,RC,,,both,,,14345.10,4303.53,"UHC [10700]","United Healthcare",,9080.45,63.3,,8601.07,8395.67,8601.07,"1 through 10",1668.34,12193.34,"percent of total billed charges",
"SCR BONE EQUINOXE SHOULDER GLENOSPHERE LOCK REVERSE",SUP-320-15-05,CDM,C1713,HCPCS,0278,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 42MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.442TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"PHCS [10601]",PHCS,,1415.09,70,,,,,0,235.11,1718.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BARR ADHESION 4X3IN ABSORBABLE CONTROL BEYOND CLSR GYNECARE",SUP-4350,CDM,C1765,HCPCS,0278,RC,,,both,,,2316.00,694.8,"NOVANET [10819]",Novanet,,1737,75,,,,,0,269.35,1968.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 100MM 16MM LCP STAINLESS STEEL CANCELLOUS",SUP-216.100,CDM,C1713,HCPCS,0278,RC,,,both,,,302.06,90.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,35.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,35.13,256.75,"percent of total billed charges",
"NDL BIOPSY 22GA 9IN CHIBA CENTIMETER MARKING STOP",SUP-MCN2203,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 8- CM 19GA 5.2-4.2FR GASTROINTESTINAL",SUP-G52012,CDM,S27200284,LOCAL,0272,RC,,,both,,,2857.50,857.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1943.1,68,,,,,0,332.33,2428.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 41 SHORT DISTAL SCR GRADUATE 4.3MM STERILE",SUP-211201406,CDM,S27200284,LOCAL,0272,RC,,,both,,,2700.00,810,"FIRST HEALTH [10303]","First Health",,2160,80,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD LUBRI-SIL IC 12FR URETHRAL BACTI-GUARD SILICONE",SUP-1758SI12,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.35,24.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.46,69.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR",RX-14100,CDM,,,0637,RC,51079-0924-01,NDC,both,1,UN,19.99,6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.32,16.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GEMFIBROZIL 600 MG TABLET",RX-3378,CDM,,,0637,RC,60687-0224-11,NDC,both,1,UN,11.65,3.49,"CIGNA [10200]",Cigna,,7.92,68,,,,,0,1.35,9.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROLENE 4X1.8IN KNIT NONABSORBABLE PRESHAPE",SUP-PMSK,CDM,C1781,HCPCS,0278,RC,,,both,,,594.43,178.33,"KAISER [10500]",Kaiser,,398.27,67,,,,,0,69.13,505.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +12 DIOPTER MODIFIED C BICONVEX 12.5MM 7MM",SUP-CZ70BD.120,CDM,V2632,HCPCS,0276,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,170.52,39.2,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 103X12X3.8MM STAINLESS STEEL 4.5MM SCR LARGE",SUP-224.06,CDM,C1713,HCPCS,0278,RC,,,both,,,2820.98,846.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,334.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",328.08,2397.83,"percent of total billed charges",
"SCR BONE 7MM 40MM EXPEDIUM TITANIUM SPINE 1 INNIE POLYAXIAL",SUP-179712740,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1385.95,28.62,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 400641  L SR SRVC FEE",SUP-400641,CDM,S27800098,LOCAL,0278,RC,,,both,,,4975.00,1492.5,"FIRST HEALTH [10303]","First Health",,3980,80,,,,,0,578.59,4228.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MENINGOCO C,Y,W-135 VACC 1 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION",RX-170285,CDM,,,0636,RC,58160-0959-01,NDC,both,.5,ML,532.93,159.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,63.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,63.15,452.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 124MM 16-16MM 14FR ENDURANT II ABDOMEN",SUP-ETLW1616C124E,CDM,S27800098,LOCAL,0278,RC,,,both,,,17730.00,5319,"CIGNA [10200]","Cigna Open Access",,5939.55,33.5,,,,,0,2062,15070.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 38MM 3MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG30038UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2643.75,793.12,"AETNA [10100]","Aetna HMO/PPO",,2101.78,79.5,,,,,0,307.47,2247.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT HAKIM CSF 120CM RIGHT ANGLE SIPHONGUARD UNITIZED",SUP-823146,CDM,S27800098,LOCAL,0278,RC,,,both,,,44384.89,13315.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5259.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5161.96,37727.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PREDNISONE 2.5 MG TABLET",RX-6495,CDM,J7512,HCPCS,0636,RC,59651-0485-01,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,0.06,,,,,,,0.03,5.33,"fee schedule",
"CIRCAID UPPER LEG REDUCTION KIT- LONG, WIDE",SUP-25302317,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 SH-1 30IN 2 ARM MONOFILAMENT BLUE",SUP-8526H,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.76,19.13,"CIGNA [10200]","Cigna Local Plus",,34.11,53.5,,,,,0,7.42,54.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35LL 135CM 250MM 5FR 4MM .035IN LOW PROFILE",SUP-B2040-250,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"UHC [10700]","United Healthcare",,487.09,63.3,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM STD TWIST",SUP-MFT-072-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,1409.40,422.82,"NOVANET [10819]",Novanet,,1057.05,75,,,,,0,163.91,1197.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE RX BILIARY SYSTEM LOCKING BIOPSY CAP STERILE",SUP-4527,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,652.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT PL SITEMARK 58CM 54CM 9FR 7FR WIDE CURVE",SUP-410184,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,431.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM LEVEL 1 EXTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.114,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1202.04,28.62,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION",RX-38303,CDM,J0132,HCPCS,0636,RC,55150-0259-30,NDC,both,30,ML,482.45,144.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,43.2,,,,,,,27.27,410.08,"fee schedule",
"STENT ZIPWIRE 20CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175270190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,362.15,28.62,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC",415,MS-DRG,,,,,,,inpatient,,,92948.19,27884.46,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,13204.46,,"Case rate ($12,819.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,904.11, add-ons for qualifying new technology services are included. If operating cost exceeds $44,943.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,282.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,919.86. The transfer operating threshold is the transfer adjustment factor * $11,904.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $900.01. The transfer capital threshold is the transfer adjustment factor * $900.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,60339.37,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 100MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.442,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"PHCS [10601]",PHCS,,968.89,70,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 59MM 135CM 10MM 13MM 8FR .035IN",SUP-BXA105902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]",Cigna,,7801.92,40,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR CANCELLOUS CORTICAL LORDOTIC",SUP-345841,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTSITE 43CM 2.8MM 1.9MM GUIDING STERILE LATEX FREE",SUP-C304-HIS,CDM,C1887,HCPCS,0272,RC,,,both,,,2610.00,783,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1774.8,68,,,,,0,303.54,2218.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 71MMX5MM VANGUARD 360 UNIVERSAL KNEE REVISION",SUP-185223,CDM,C1776,HCPCS,0278,RC,,,both,,,7577.58,2273.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5152.75,68,,,,,0,881.27,6440.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 28MM COCR",SUP-VAL-25280-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]",Cigna,,969.41,68,,1831.33,1831.33,1831.33,16,165.8,1211.76,"percent of total billed charges",
"TRAY TIBIAL PFC SIGMA 4 KNEE COCR CEMENTED MODULAR FIX",SUP-158140000,CDM,C1776,HCPCS,0278,RC,,,both,,,8603.28,2580.98,"CIGNA [10200]","Cigna Local Plus",,4602.75,53.5,,5372.07,4581.20,7242.98,23,1000.56,7312.79,"percent of total billed charges",
"CATH CHRG 75CM 40MM 6FR 9MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206090470,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC",372,MS-DRG,,,,,,,inpatient,,,26409.63,7922.89,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,6523.33,,"Case rate ($6,333.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,880.92, add-ons for qualifying new technology services are included. If operating cost exceeds $38,920.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,826.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $5,888.70. The transfer operating threshold is the transfer adjustment factor * $5,880.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $444.63. The transfer capital threshold is the transfer adjustment factor * $444.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,6333.33,25462.72,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 24MM REUNION PERIPHERAL STERILE",SUP-5572-4524,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"MULTIPLAN [10600]",Multiplan,,1322.35,85,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 18MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.818,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",29.18,213.27,"percent of total billed charges",
"DUODENOSCOPE FLEXIBLE EXALT MODEL D DISPOSABLE",SUP-M00542423,CDM,C1748,HCPCS,0272,RC,,,both,,,18459.00,5537.7,"PHCS [10601]",PHCS,,12921.3,70,,,,,0,2146.78,15690.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Absc Fgr Smpl",PX-450000119,CDM,26010,CPT,0450,RC,,,both,,,909.00,272.7,"NOVANET [10819]",Novanet,,681.75,75,,,,,0,0.91,909,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM T2 TITANIUM FULL THREAD FEMUR HUMERUS",SUP-1896-4026S,CDM,C1713,HCPCS,0278,RC,,,both,,,1299.56,389.87,"BLUE CROSS [10001]","Blue Cross PPO",,509.43,39.2,,957.42,570.23,957.42,28,151.14,1104.63,"percent of total billed charges",
"VALVE SUCTION EVIS OES OSF AMP NONSTERILE REUSABLE",SUP-MB-197,CDM,S27200284,LOCAL,0272,RC,,,both,,,811.86,243.56,"MULTIPLAN [10600]",Multiplan,,690.08,85,,,,,0,94.42,690.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bilimask",PX-E27200039,CDM,E27200039,LOCAL,0272,RC,,,both,,,67.10,20.13,"CIGNA [10200]",Cigna,,45.63,68,,,,,0,7.8,57.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Culture Stool",PX-306000002,CDM,87045,CPT,0306,RC,,,both,,,286.90,86.07,"CIGNA [10200]","Cigna Local Plus",,20.77,,,,,,,4.26,243.87,"fee schedule",
"HC Culture Stool",PX-306000002,CDM,87045,CPT,0306,RC,,,both,,,286.90,86.07,"MULTIPLAN [10600]",Multiplan,,243.87,85,,,,,0,4.26,243.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D +5.25 CYL MODIFY L 13MM 6MM POSTERIOR CHMBR 1",SUP-CCW0T8,CDM,V2787,HCPCS,0276,RC,,,both,,,355.00,106.5,"CIGNA [10200]","Cigna Local Plus",,189.93,53.5,,,,,0,41.29,301.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP OCCL BALLOON AUDIO INDCTR ALERT ELECTROSURGERY DEVICE",SUP-KC-ARCH-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"UHC [10700]","United Healthcare",,725.32,63.3,,,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 24FR BLADDER TUMOR RESECTION",SUP-M0065051611,CDM,S27200284,LOCAL,0272,RC,,,both,,,446.34,133.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,183.45,41.1,,,,,0,51.91,379.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE ROUND SILICONE",SUP-SRF-265,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"CIGNA [10200]",Cigna,,3730.14,68,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE ENDOSCOPIC 1.5MM STD J 350CM .035IN",SUP-GR3533,CDM,C1769,HCPCS,0272,RC,,,both,,,534.60,160.38,"NOVANET [10819]",Novanet,,400.95,75,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPEL TWIST-LOC APD 30CM 16FR DRNG FLEXITHANE METAL",SUP-H7493932016300,CDM,C1729,HCPCS,0272,RC,,,both,,,761.40,228.42,"FIRST HEALTH [10303]","First Health",,609.12,80,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.3MM 17MM LOCK THREAD TITANIUM",SUP-TPLS-23170-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,680.40,204.12,"CIGNA [10200]","Cigna Open Access",,387.15,56.9,,1144.80,304.56,2275.09,66,79.13,578.34,"percent of total billed charges",
"DRSG NASAL WHITE 4CM NASOPORE OTOPORE STD SINUS FOAM FIRM",SUP-5400020004,CDM,S27200284,LOCAL,0272,RC,,,both,,,1124.90,337.47,"AETNA [10100]","Aetna HMO/PPO",,894.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,130.83,956.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 30MM CEMENTLESS ACCOLADE TMZF 1 HIP",SUP-6021-0130,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"UHC [10700]","United Healthcare",,14446.17,63.3,,8601.07,8395.67,8601.07,"1 through 10",2654.17,19398.49,"percent of total billed charges",
"VXSK-230J RF WIRE 63CM/45DEG/D1 SHEATH",SUP-VXSK0112,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,731.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 25CM 14FR .038IN DRNG HYDROPHILIC ULTRATHANE 6 SIDEPORT",SUP-G09504,CDM,C1729,HCPCS,0272,RC,,,both,,,761.32,228.4,"KAISER [10500]",Kaiser,,510.08,67,,,,,0,88.54,647.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BALL 10CM 5MM ULTRACLEAN STERILE",SUP-60-5181-103,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.19,57.36,"FIRST HEALTH [10303]","First Health",,152.95,80,,,,,0,22.24,162.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON PLUS DEMINERALIZED BONE MATRIX 10ML PASTE",SUP-T45010,CDM,C1713,HCPCS,0278,RC,,,both,,,6210.00,1863,"AETNA [10100]","Aetna HMO/PPO",,4936.95,79.5,,1521.93,481.35,16760.95,30,722.22,5278.5,"percent of total billed charges",
"COIL EMBOLIZATION 50CM 20MM TARGET XL 360D STD LARGE",SUP-M0036102050,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING UNITRAX +5MM HIP C TAPER NECK",SUP-6942-7-075,CDM,C1776,HCPCS,0278,RC,,,both,,,855.82,256.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,581.96,68,,,,,0,99.53,727.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cyclosporine",PX-301000038,CDM,80158,CPT,0301,RC,,,both,,,275.50,82.65,"NOVANET [10819]",Novanet,,206.63,75,,,,,0,0.28,234.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 40MM 125CM 14MM 6FR .035IN BILIARY NITINOL",SUP-G36244,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross PPO",,1481.76,39.2,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE XPRESS ULTRA 1.5MM BALL SUPER SLEEK PROFILE 20MM 2.5",SUP-ULF-105,CDM,C1726,HCPCS,0272,RC,,,both,,,11364.30,3409.29,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 10IN 24FR FEMORAL ARTERY 3/8IN THIN WALL T 2",SUP-TFA02425H,CDM,S27200284,LOCAL,0272,RC,,,both,,,371.26,111.38,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OBTR ENDOSCOPIC 26FR RESECTOSCOPY DEFLECTABLE TIP",SUP-A22086A,CDM,S27200284,LOCAL,0272,RC,,,both,,,4111.37,1233.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRASCORE GEOALIGN 130CM 150MM 6MM BALLOON DILATATION",SUP-US35130615,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET DIL S-CURVE HYDROPHILIC SIDEPORT 37CM 8-20FR URETHRAL",SUP-G32789,CDM,S27200284,LOCAL,0272,RC,,,both,,,1746.00,523.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 44.5MM 1.5MM 4MM STOP J LATCH NONSTERILE",SUP-317.64,CDM,S27000186,LOCAL,0270,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET TUBING DUALWAVE CASSETTE OUTFLOW ARTHROSCOPY PUMP",SUP-AR-6430,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,167.72,45.9,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 9IN LAMBOTTE SPINE SURGICAL CURVE .5IN",SUP-28-9462,CDM,S27200284,LOCAL,0272,RC,,,both,,,232.99,69.9,"CIGNA [10200]","Cigna Local Plus",,124.65,53.5,,,,,0,27.1,198.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 0 MO-5 18IN CONTROL RELEASE BRAID 8 STRAND COATED",SUP-J801D,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.39,52.32,"CIGNA [10200]","Cigna Open Access",,99.23,56.9,,,,,0,20.28,148.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 60MM 2.5MM .014IN BALLOON DILATATION",SUP-AB14W025060150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"UHC [10700]","United Healthcare",,876.77,63.3,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 80MM 16MM DARCO FOOT ANKLE HEAD",SUP-777758062,CDM,C1713,HCPCS,0278,RC,,,both,,,2827.50,848.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1297.82,45.9,,,,,0,328.84,2403.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CRYO/CUFF UNIVERSAL COMPRESSION THERAPY ADULT ANKLE",SUP-10A,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,inpatient,,,2338.83,701.65,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,2338.83,,"Case rate ($3,715.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,449.64, add-ons for qualifying new technology services are included. If operating cost exceeds $36,489.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,642.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.1. The base transfer operating payment is the transfer adjustment factor * $3,454.20. The transfer operating threshold is the transfer adjustment factor * $3,449.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $260.81. The transfer capital threshold is the transfer adjustment factor * $260.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,2338.83,2338.83,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONCIERGE 100CM 6FR SBS3.5 MOD CURVE GUIDING STAINLESS",SUP-CGC6100SBS35-MSH,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDOMETHACIN 50 MG RECTAL SUPPOSITORY",RX-3901,CDM,,,0637,RC,69344-0102-33,NDC,both,1,UN,1641.60,492.48,"NOVANET [10819]",Novanet,,1231.2,75,,,,,0,190.92,1395.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROLAMINE SALICYLATE 10 % TOPICAL CREAM",RX-27680,CDM,,,0637,RC,41167-0057-23,NDC,both,85,GR,25.66,7.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.98,21.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 30MM 5MM E9000 ROUND 10 FLUTE CARBIDE CUT LOW",SUP-E8050LSO,CDM,S27200284,LOCAL,0272,RC,,,both,,,453.28,135.98,"MULTIPLAN [10600]",Multiplan,,385.29,85,,,,,0,52.72,385.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE RIB SEG THK1-20MM ALLOGRAFT FROZEN 50-300X5-30MM",SUP-450010,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40022W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2496.5,45.9,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 125MMX2MM TITANIUM 7 HOLE LOCK LOW PROFILE VARIAX",SUP-40-20907,CDM,C1713,HCPCS,0278,RC,,,both,,,5059.08,1517.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2322.12,45.9,,,,,0,588.37,4300.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANSTR WOUND DRNG ABTHERA 1X LARGE NEGATIVE PRESSURE",SUP-370620.S,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.00,26.1,"UHC [10700]","United Healthcare",,55.07,63.3,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER URETERAL LASER 3 FR 115CM",SUP-G15020,CDM,C1758,HCPCS,0272,RC,,,both,,,119.19,35.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",11.23,7.03,11.23,"1 through 10",13.86,101.31,"percent of total billed charges",
"COIL EMBOLIZATION 8CM 3.5MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035423580,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]",Cigna,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 60ML 4-10MM FREEZE DRY",SUP-08A021,CDM,S27800098,LOCAL,0278,RC,,,both,,,4968.00,1490.4,"CIGNA [10200]",Cigna,,3378.24,68,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 30CM MIC-KEY SECUR-LOK LOW PROFILE BOLUS FEED CNCT",SUP-0143-12,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.91,20.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,32.09,45.9,,,,,0,8.13,59.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 8IN 40D UP CERVICAL 9X5MM MICRO-KERRISON EJECTOR",SUP-57-0695,CDM,S27200284,LOCAL,0272,RC,,,both,,,2535.15,760.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1041.95,41.1,,,,,0,294.84,2154.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL ALLOGRAFT FROZEN 200-500MM 10+ MM",SUP-450455,CDM,S27800098,LOCAL,0278,RC,,,both,,,13132.08,3939.62,"UHC [10700]","United Healthcare",,8312.61,63.3,,,,,0,1527.26,11162.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Progr Dev Eval Imp Loop Record",PX-480000056,CDM,93285,CPT,0480,RC,,,both,,,304.55,91.36,"CIGNA [10200]","Cigna Open Access",,173.29,56.9,,,,,0,35.42,304.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EXTERNAL DRNG ACCUDRAIN HERMETIC LUMBAR CLOSED TIP CATH",SUP-31240,CDM,C1729,HCPCS,0272,RC,,,both,,,3977.09,1193.13,"MULTIPLAN [10600]",Multiplan,,3380.53,85,,,,,0,462.54,3380.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALL THERAPEUTIC SMALL SPHERE HAND FOREARM WRIST METAL",SUP-A83720,CDM,S27000186,LOCAL,0270,RC,,,both,,,151.90,45.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,69.72,45.9,,,,,0,17.67,129.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 CURVE PLUS 20MM KNEE XLK FIX BEARING SIGMA",SUP-970435,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PHCS [10601]",PHCS,,7822.19,70,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM PFC SIGMA TC3 3 KNEE LEFT TITANIUM CEMENTED",SUP-960860,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"BLUE CROSS [10001]","Blue Cross HMO",,2011.29,39.2,,5311.50,4717.44,5388.59,31,596.72,4361.21,"percent of total billed charges",
"SCR BONE 3.5MM 20MM LOW PROFILE SCREWS TITANIUM T15 FULL",SUP-AR-8935-20,CDM,C1713,HCPCS,0278,RC,,,both,,,104.40,31.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,70.99,68,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDING 120CM 6FR .066IN .057IN GUIDEZILLA STRAIGHT",SUP-H7493924215050,CDM,S27200284,LOCAL,0272,RC,,,both,,,3112.50,933.75,"CIGNA [10200]","Cigna Local Plus",,1665.19,53.5,,,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHEATHLESS EAUCATH 100CM 7.5FR .081IN PB3.5 CURVE",SUP-G6AL07-0-L127,CDM,C1887,HCPCS,0272,RC,,,both,,,1125.90,337.77,"NOVANET [10819]",Novanet,,844.43,75,,,,,0,130.94,957.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TISSUE LORDOTIC ALLOGRAFT ANTERIOR SEPTAL",SUP-345844,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 11MM DCP STAINLESS STEEL CORTICAL SELF",SUP-200.811,CDM,C1713,HCPCS,0278,RC,,,both,,,365.40,109.62,"CIGNA [10200]","Cigna Local Plus",,195.49,53.5,,3978.14,359.25,3978.14,24,42.5,310.59,"percent of total billed charges",
"SCR BONE 2.5MM 18MM GEMINUS COCR DISTAL VOLAR RADIUS",SUP-PALS-25180-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1036.80,311.04,"NOVANET [10819]",Novanet,,777.6,75,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JETSTREAM 1.6MM ATHERECTOMY 1 CUTTER",SUP-112260-001,CDM,C1724,HCPCS,0272,RC,,,both,,,19530.00,5859,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8026.83,41.1,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE TIBIAL 10MM LEGION 3-4 HEMI KNEE LEFT MEDIAL RIGHT",SUP-71423034,CDM,C1776,HCPCS,0278,RC,,,both,,,15245.55,4573.66,"CIGNA [10200]",Cigna,,6098.22,40,,5873.17,5873.17,5873.17,"1 through 10",1773.06,12958.72,"percent of total billed charges",
"SYSTEM SHILEY BRONCHO-CATH STD CPAP ADJUSTABLE VALVE 2",SUP-85006,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.23,58.57,"PHCS [10601]",PHCS,,136.66,70,,,,,0,22.71,165.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ASPIRATION ANTICOAGULATION LINE ELECTA ESSENTIAL CONCEPT",SUP-AAL,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]","Cigna Open Access",,128.71,56.9,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GIRAFFE 45D 2MM 5.25IN FRONTAL SINUS 2 ACTION",SUP-63-8845,CDM,S27200284,LOCAL,0272,RC,,,both,,,3430.28,1029.08,"PHCS [10601]",PHCS,,2401.2,70,,,,,0,398.94,2915.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 40CMX.49MM 16MM KNITTED REVERSE LOCKNIT",SUP-HGK0016-40,CDM,C1768,HCPCS,0278,RC,,,both,,,2588.55,776.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,740.84,28.62,,,,,0,301.05,2200.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Transperi Pros Inters",PX-361000240,CDM,55875,CPT,0361,RC,,,both,,,7679.62,2303.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7679.62,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,893.14,7679.62,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immobilizer Shoulder Uni",PX-E27400084,CDM,L3650,HCPCS,0274,RC,,,both,,,48.40,14.52,"CIGNA [10200]","Cigna Open Access",,27.54,56.9,,,,,0,5.63,42.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANDESARTAN 4 MG TABLET",RX-23229,CDM,,,0637,RC,33342-0114-07,NDC,both,1,UN,15.37,4.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7.05,45.9,,,,,0,1.79,13.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR",RX-14100,CDM,,,0637,RC,51079-0924-01,NDC,both,1,UN,19.99,6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9.18,45.9,,,,,0,2.32,16.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Jada Sys 2.0 Vac Hemorrhage Cntrl",PX-E27200439,CDM,E27200439,LOCAL,0272,RC,,,both,,,5780.59,1734.18,"UHC [10700]","United Healthcare",,3659.11,63.3,,,,,0,672.28,4913.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PENCIL 10FT VALLEYLAB EDGE SMOKE",SUP-SEP5000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLACK 24-26FR USA ELITE SYSTEM",SUP-RB,CDM,S27200284,LOCAL,0272,RC,,,both,,,807.60,242.28,"PHCS [10601]",PHCS,,565.32,70,,,,,0,93.92,686.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL SHAFT ALLOGRAFT FROZEN 70MM 10+ MM",SUP-450420,CDM,S27800098,LOCAL,0278,RC,,,both,,,5402.70,1620.81,"PHCS [10601]",PHCS,,3781.89,70,,,,,0,628.33,4592.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 12/14 TAPER 36MM HIP SLEEVE TOTAL",SUP-136536720,CDM,C1776,HCPCS,0278,RC,,,both,,,13002.36,3900.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3721.28,28.62,,,,,0,1512.17,11052.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR .09IN JUDKINS LEFT 4 CURVE GUIDING",SUP-LA8JL40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 4X250 135CM SL",SUP-48004025R,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"MULTIPLAN [10600]",Multiplan,,884.86,85,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP REVERSE STEM/COMPREHENSIVE GLENOID/VITAMIN E/AUGMENTED B",SUP-98000900031,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"UHC [10700]","United Healthcare",,30706.83,63.3,,8601.07,8395.67,8601.07,"1 through 10",5641.71,41233.5,"percent of total billed charges",
"PLATE TIBIAL 7 KNEE TRABECULAR METAL MIS STERILE",SUP-00595405701,CDM,C1713,HCPCS,0278,RC,,,both,,,13555.74,4066.72,"KAISER [10500]",Kaiser,,9082.35,67,,,,,0,1576.53,11522.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH ADULT 55CM 15.5FR DURATHANE DURAFLOW EMBOSAFE BASIC",SUP-H787103012115,CDM,C1750,HCPCS,0278,RC,,,both,,,1104.50,331.35,"CIGNA [10200]","Cigna Open Access",,628.46,56.9,,,,,0,128.45,938.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 114MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 8",SUP-71357008,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3927.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 17MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE40017,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"CIGNA [10200]","Cigna Local Plus",,26354.35,31.5,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 3DEMIN ALLOGRAFT STRIP PLIABLE OSTEOCONDUCTIVE",SUP-109775,CDM,C1713,HCPCS,0278,RC,,,both,,,8970.00,2691,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1062.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1043.21,7624.5,"percent of total billed charges",
"CLAREONPANOPTIX PROTORIC(BLF)",SUP-PXYWT4,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"BLUE CROSS [10001]","Blue Cross HMO",,358.68,39.2,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING ORANGE 20IN 5FR ENTERAL POLYURETHANE HUB END",SUP-ENFPU2050LD,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.84,17.65,"CIGNA [10200]","Cigna Local Plus",,31.48,53.5,,,,,0,6.84,50.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 42X4IN POSTERIOR STABILIZED ATS DURABLE STERILE",SUP-60707010700,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"FIRST HEALTH [10303]","First Health",,59.16,80,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Compres Band Rosidal W>=3""<5""Yd",PX-E27000283,CDM,A6452,HCPCS,0270,RC,,,both,,,121.00,36.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.66,102.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM FILTERWIRE EZ .014IN 110UM 190CM 2.25-3.5MM EMBOLIC",SUP-H749390711900,CDM,C1884,HCPCS,0272,RC,,,both,,,9844.09,2953.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4045.92,41.1,,,,,0,1144.87,8367.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X9X6MM ARCH 7.5D SPINE FREEZE DRIED NOTCH",SUP-15212,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 3CM 4.8FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175255050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,126.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL CANCELLOUS ALLOGRAFT RING 6MM",SUP-270060,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 60MM 44MM XLPE HIP",SUP-71331096,CDM,C1776,HCPCS,0278,RC,,,both,,,15193.80,4558.14,"UHC [10700]","United Healthcare",,9617.68,63.3,,8601.07,8395.67,8601.07,"1 through 10",1767.04,12914.73,"percent of total billed charges",
"RELIANCE DF4 NON-GORE, PASSIVE FIXATION SINGLE COIL 59 CM, I",SUP-0262,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"PHCS [10601]",PHCS,,10626,70,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 3.5MM PRECUT",SUP-3603740,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"SYSTEM VENASEAL CLSR",SUP-257965,CDM,S27200284,LOCAL,0272,RC,,,both,,,5368.20,1610.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3650.38,68,,,,,0,624.32,4562.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 31X12-15MM MAGNIFY-S 8D LORDOTIC 25MM EXPAND",SUP-1126.0112,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"PHCS [10601]",PHCS,,29988,70,,,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 20MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"FIRST HEALTH [10303]","First Health",,1276.56,80,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 81MM 12.2MM 7.6MM CUFF INNER CANN LOW PRESSURE",SUP-8FEN,CDM,S27200284,LOCAL,0272,RC,,,both,,,399.33,119.8,"CIGNA [10200]",Cigna,,271.54,68,,,,,0,46.44,339.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX EXTREME 80CM 4CM 5FR 5MM 7MM BALLOON",SUP-4156040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROPARACAINE 0.5 % EYE DROPS",RX-6644,CDM,,,0250,RC,70069-0601-01,NDC,both,15,ML,275.22,82.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,32.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.01,233.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 25MM VALOR HINDFOOT FUSION SYSTEM",SUP-4151150025,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CIGNA [10200]","Cigna Open Access",,981.53,56.9,,1144.80,304.56,2275.09,66,200.62,1466.25,"percent of total billed charges",
"HOLDER 6.5IN SWEDEN DELICATE INSRT NDL TUNGSTEN CARBIDE 5-0",SUP-32-460,CDM,S27200284,LOCAL,0272,RC,,,both,,,955.64,286.69,"MULTIPLAN [10600]",Multiplan,,812.29,85,,,,,0,111.14,812.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,,,0250,RC,72888-0141-35,NDC,both,16,GR,587.03,176.11,"CIGNA [10200]","Cigna Local Plus",,314.06,53.5,,,,,0,68.27,498.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11MM NATURAL LARGE LORDOTIC",SUP-19411,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 115CM 3.2FR 3FR 4 WIRE SHEATH TIP OCCLUSIVE",SUP-G32824,CDM,S27200284,LOCAL,0272,RC,,,both,,,1662.75,498.82,"AETNA [10100]","Aetna HMO/PPO",,1321.89,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,193.38,1413.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 2MM ELITE ROUND TAPER EXTEND STERILE",SUP-5820-103-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1066.37,319.91,"CIGNA [10200]",Cigna,,725.13,68,,,,,0,124.02,906.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 10MM RADIUS 110CM .035IN STAINLESS STEEL",SUP-G26957,CDM,C1769,HCPCS,0272,RC,,,both,,,700.57,210.17,"KAISER [10500]",Kaiser,,469.38,67,,,,,0,81.48,595.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 29MM 135CM 6MM THIN VASCULAR COCR",SUP-1012629-29,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"AMERIGROUP MEDICAID [20100]",Amerigroup,,995.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 00 STRAIGHT OVAL 8IN SURGICAL SPINAL FUSION",SUP-29-5029,CDM,S27200284,LOCAL,0272,RC,,,both,,,353.39,106.02,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE EXTRA SPORT VASCULAR STRAIGHT 300CM 3CM .014",SUP-22235M,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE EVERPOINT 6-0 C-1 30IN 2 ARM MONOFILAMENT 4",SUP-EPM8706,CDM,S27200284,LOCAL,0272,RC,,,both,,,734.16,220.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC US Retroperitoneal Complete",PX-402000010,CDM,76770,CPT,0402,RC,,,both,,,1285.72,385.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure count. Procedure 1, Fee schedule rate ($240.89). Procedures 2 - 999, Fee schedule rate ($120.45).",,,,0,,,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SILVERHAWK MEC 113CM 9CM 4.5-6.5MM ATHERECTOMY",SUP-P4055,CDM,C1714,HCPCS,0272,RC,,,both,,,17955.00,5386.5,"FIRST HEALTH [10303]","First Health",,14364,80,,,,,0,2088.17,15261.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 120MM 3MM TAPER BALLOON DILATATION JET",SUP-A2030-120,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 60CM 8MM PROPATEN THIN WALL GORE-TEX HEPARIN",SUP-IRTH086060A,CDM,C1768,HCPCS,0278,RC,,,both,,,15890.70,4767.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6356.28,40,,,,,0,1848.09,13507.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL STD OFFSET 36MM HIP TYPE 1 COCR G7",SUP-11363662,CDM,C1776,HCPCS,0278,RC,,,both,,,5296.44,1588.93,"BLUE CROSS [10001]","Blue Cross PPO",,2076.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",615.98,4501.97,"percent of total billed charges",
"CATH CORDIS SABER 90CM 80MM 2.5MM BALLOON DILATATION DURALYN",SUP-48002508S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PHCS [10601]",PHCS,,878.85,70,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 20CM 6FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552300,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"NOVANET [10819]",Novanet,,900.44,75,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIBRILLATOR CRT-D GALLANT BIPOLAR DF1HF",SUP-CDHFA500B,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"CIGNA [10200]","Cigna Local Plus",,24239.25,31.5,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 4 RIGHT DISTAL KNEE TOTAL",SUP-5540-A-402,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"NOVANET [10819]",Novanet,,3407.86,75,,,,,0,528.45,3862.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 3CM 6FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006180223050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"NOVANET [10819]",Novanet,,781.19,75,,,,,0,121.14,885.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Neck/Soft Tiss W/WO Cntrst",PX-351000013,CDM,70492,CPT,0351,RC,,,both,,,3189.70,956.91,"CIGNA [10200]","Cigna Open Access",,475,,"Per diem ($475). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,370.96,2711.25,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 3.5MM 190MM TITANIUM 3.5MM SCREWS SMALL FRAGMENT SET 6",SUP-245.06,CDM,C1713,HCPCS,0278,RC,,,both,,,4012.76,1203.83,"BLUE CROSS [10001]","Blue Cross PPO",,1573,39.2,,957.42,570.23,957.42,28,466.68,3410.85,"percent of total billed charges",
"STEM FEMORAL 145MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309111,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4391.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT 17GA 50MM ELECTROTHERAPY COOLIEF STERILE LATEX FREE",SUP-CRK-17-50-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CARTIFORM 25X20MM",SUP-ABS-1102-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7292.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 90MM STEALTH 5 FIBRA STERILE LATEX FREE",SUP-A0G14,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]",Cigna,,153.82,68,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 80MM 125CM 7MM 6FR VASCULAR NITINOL",SUP-G43828,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Open Access",,2150.82,56.9,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 150CM 40MM 4MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013466-040,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 46MM ASNIS III TITANIUM PARTIAL THREAD REVERSE",SUP-604646,CDM,C1713,HCPCS,0278,RC,,,both,,,1319.00,395.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,153.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",153.4,1121.15,"percent of total billed charges",
"PLATE 80MM TITANIUM LOCK ATLANTIS TRANSLATIONAL BONE SPINE",SUP-6190080,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"LANOLIN-MINERAL OIL LOTION",RX-2787,CDM,,,0637,RC,00904-4299-09,NDC,both,236,ML,14.85,4.45,"CIGNA [10200]","Cigna Local Plus",,7.94,53.5,,,,,0,1.73,12.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM TRIATHLON 6 RIGHT MEDIAL LEFT LATERAL TOTAL",SUP-5546-A-602,CDM,C1776,HCPCS,0278,RC,,,both,,,4252.25,1275.67,"KAISER [10500]",Kaiser,,2849.01,67,,,,,0,494.54,3614.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NEURON SELECT 130CM 9CM 5FR .04IN BERENSTEIN CURVE",SUP-PNS5F130BER,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"UHC [10700]","United Healthcare",,640.91,63.3,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fna W CT Init",PX-361000481,CDM,10009,CPT,0361,RC,,,both,,,3291.17,987.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1729.39,,"Case rate ($1,729.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,382.76,2797.49,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE SYNTHETIC CALCIUM PHOSPHATE CALCIUM SULFATE 10ML",SUP-87SR0410,CDM,C1713,HCPCS,0278,RC,,,both,,,18062.10,5418.63,"FIRST HEALTH [10303]","First Health",,14449.68,80,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH 7FR DIL 1 ACCESS",SUP-1000440,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"KAISER [10500]",Kaiser,,1256.25,67,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.9MM PUSHLOCK HIP CANNULATED SUT FIRST TECHNIQUE",SUP-AR-1923PS,CDM,C1713,HCPCS,0278,RC,,,both,,,2835.00,850.5,"CIGNA [10200]",Cigna,,1927.8,68,,1831.33,1831.33,1831.33,16,329.71,2409.75,"percent of total billed charges",
"HC Xr Mastoid<3v per Side",PX-320000006,CDM,70120,CPT,0320,RC,,,both,,,348.00,104.4,"KAISER [10500]",Kaiser,,233.16,67,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVISION OF HIP OR KNEE REPLACEMENT WITH CC",467,MS-DRG,,,,,,,inpatient,,,134114.11,40234.23,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Ext Complete",PX-402000032,CDM,76881,CPT,0402,RC,,,both,,,1433.29,429.99,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure count. Procedure 1, Fee schedule rate ($35.68). Procedures 2 - 999, Fee schedule rate ($17.84).",,,,0,,,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA POWERTRAC 142CM 8MM 2.25MM BALLOON",SUP-NCEUP22508X,CDM,C1725,HCPCS,0272,RC,,,both,,,534.60,160.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC TREK NEO 12MM 145CM 3.25MM BALLOON DILATATION",SUP-1400325-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER 6238TEL TELESCOPE 7 FR SOFT TIP",SUP-6238TEL,CDM,C1887,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PHCS [10601]",PHCS,,861.84,70,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 22CM 5FR UNIVERSA 2 PIGTAIL CURVE URETER AQ",SUP-G23396,CDM,C2617,HCPCS,0278,RC,,,both,,,535.41,160.62,"BLUE CROSS [10001]","Blue Cross PPO",,209.88,39.2,,,,,0,62.27,455.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE SMALL OVAL 240CM 2.4MM SENSATION LOOP SHORT THROW",SUP-M00562692,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.45,37.63,"AETNA [10100]","Aetna HMO/PPO",,99.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.59,106.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 26FR 5MM ACMI CLASSIC",SUP-M0068804521,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"AETNA [10100]","Aetna HMO/PPO",,410.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 53CM J SOLIA S",SUP-107237,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,44.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35LL 135CM 200MM 6FR 6MM .035IN LOW PROFILE",SUP-B2060-200,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"MULTIPLAN [10600]",Multiplan,,654.08,85,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 101MMX2MM 5 HOLE VARIAX BONE FOOT FIBULA DISTAL",SUP-40-20905,CDM,C1713,HCPCS,0278,RC,,,both,,,4488.59,1346.58,"PHCS [10601]",PHCS,,3142.01,70,,,,,0,522.02,3815.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 700ML GEL SMOOTH MEMORYGEL SILICONE P5.8CM HIGH","SUP-3507004 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"PHCS [10601]",PHCS,,2646,70,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL BIOVER MEDIUM VEIN 1 POLYCARBONATE STERILE",SUP-TKMV-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,338.43,101.53,"UHC [10700]","United Healthcare",,214.23,63.3,,,,,0,39.36,287.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR DYNASTY A-CLASS 15D 36MM POLY GROUP G",SUP-DLXPLG36,CDM,C1776,HCPCS,0278,RC,,,both,,,12771.90,3831.57,"AETNA [10100]","Aetna HMO/PPO",,10153.66,79.5,,10981.53,8986.79,12413.38,12,1485.37,10856.12,"percent of total billed charges",
"HC US Ext Complete",PX-402000032,CDM,76881,CPT,0402,RC,,,both,,,1433.29,429.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,17.3,,,,,,,17.3,1218.3,"fee schedule",
"CATH SPIN ACCESS CATH 90D BRACHYTHERAPY OLYMPUS 190 SCOPE",SUP-INS-5910,CDM,S27200284,LOCAL,0272,RC,,,both,,,7452.00,2235.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3062.77,41.1,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X6MM ENDOSKELETON TC 6D 14MM MEDIUM CERVICAL",SUP-5166-1406-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"AETNA [10100]","Aetna HMO/PPO",,8228.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VG2 PRESERVON VERTIGRAFT CORTICAL CANCELLOUS",SUP-VG2C-T810P,CDM,S27800098,LOCAL,0278,RC,,,both,,,5865.00,1759.5,"CIGNA [10200]","Cigna Local Plus",,3137.78,53.5,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 150MM 2.5MM BALLOON DILATATION RAPID",SUP-47525150L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET SUPERORDERABLE",RX-409435,CDM,,,0637,RC,37000-0024-10,NDC,both,1,UN,12.54,3.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA MIV 110CM 6FR PIGTAIL ST CURVE ANGIOGRAPHIC",SUP-6RPS110,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.84,61.75,"MULTIPLAN [10600]",Multiplan,,174.96,85,,,,,0,23.94,174.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONDUIT VALVE 29MM KONECT AORTIC RESILIA",SUP-11060A29,CDM,S27800098,LOCAL,0278,RC,,,both,,,79800.00,23940,"CIGNA [10200]","Cigna Open Access",,26733,33.5,,,,,0,9280.74,67830,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER FR7 OSCOR",SUP-6089,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,302.94,68,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION",RX-24916,CDM,,,0250,RC,76204-0900-11,NDC,both,3,ML,12.59,3.78,"CIGNA [10200]",Cigna,,8.56,68,,,,,0,1.46,10.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID SMALL REVISION METAL BACK SMR SHOULDER",SUP-1375.21.005,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"CIGNA [10200]","Cigna Open Access",,5136.77,56.9,,5302.19,4377.88,6578.61,27,1049.92,7673.56,"percent of total billed charges",
"PACK VITRECTOMY ACCURUS TOTAL PLUS PROBE 2500",SUP-8065741017,CDM,S27200284,LOCAL,0272,RC,,,both,,,2134.13,640.24,"PHCS [10601]",PHCS,,1493.89,70,,,,,0,248.2,1814.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC MEDIUM SHOULDER ELASTIC FOAM",SUP-A111006,CDM,L3670,HCPCS,0274,RC,,,both,,,58.03,17.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.75,58.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH GORE DRYSEAL 28CM 18FR 6.8MM 6MM INTRO HYDROPHILIC",SUP-DSL1828,CDM,C1894,HCPCS,0272,RC,,,both,,,2475.00,742.5,"NOVANET [10819]",Novanet,,1856.25,75,,,,,0,287.84,2103.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 60MM 16MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U16060090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"UHC [10700]","United Healthcare",,6551.55,63.3,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM .021IN AZUR DETACHABLE .018IN",SUP-45-480410,CDM,S27800098,LOCAL,0278,RC,,,both,,,5678.70,1703.61,"KAISER [10500]",Kaiser,,3804.73,67,,,,,0,660.43,4826.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 235MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.145S,CDM,C1713,HCPCS,0278,RC,,,both,,,9346.95,2804.08,"FIRST HEALTH [10303]","First Health",,7477.56,80,,,,,0,1087.05,7944.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 15IN 30FR VENOUS ADULT 3/8IN CONNECTION SITE",SUP-66130,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.63,85.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,117.39,41.1,,,,,0,33.22,242.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL SMALL 28MM HIP BIOLOX DELTA",SUP-PHA04402,CDM,C1776,HCPCS,0278,RC,,,both,,,14234.70,4270.41,"UHC [10700]","United Healthcare",,9010.57,63.3,,8601.07,8395.67,8601.07,"1 through 10",1655.5,12099.5,"percent of total billed charges",
"GRAFT BONE ALPHAGRAFT DEMINERALIZED BONE MATRIX FIBER 5CC",SUP-1008-050,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross PPO",,1470,39.2,,957.42,570.23,957.42,28,436.13,3187.5,"percent of total billed charges",
"SCR BONE 8.5MM 50MM SPINE POLYAXIAL REVOLVE",SUP-185.486,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1110.3,8114.82,"percent of total billed charges",
"CATH TRUE DILATATION 110CM 4.5CM 21MM BALLOON DILATATION OTW",SUP-0214512,CDM,C1725,HCPCS,0272,RC,,,both,,,7590.00,2277,"AMERIGROUP MEDICAID [20100]",Amerigroup,,899.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 16-14MM 14MM 11FR TRIVASCULAR OVATION",SUP-TV-IL1416100-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13723.29,41.1,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ema Each Ig Class",PX-302000253,CDM,86231,CPT,0302,RC,,,both,,,258.70,77.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.36,,"Fee schedule rate ($11.36). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,219.9,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mra Pelvis W&WO Cntrst",PX-610000023,CDM,72198,CPT,0610,RC,,,both,,,4406.00,1321.8,"PHCS [10601]",PHCS,,3084.2,70,,,,,0,512.42,3745.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 26X9X10MM 8D EIT PLIF STERILE LATEX FREE",SUP-PUI81006,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"MULTIPLAN [10600]",Multiplan,,24097.5,85,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM TITANIUM LEGACY XLNK CD HORIZON BONE SPINE",SUP-8110714,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]",Cigna,,2422.5,68,,1831.33,1831.33,1831.33,16,414.32,3028.13,"percent of total billed charges",
"(EVAL) EDWARDS PASCAL PRECISION TRANSCATHETER VALVE REPAIR S",SUP-20000ISMCL,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"CIGNA [10200]","Cigna Local Plus",,91485,53.5,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 10CM 14.5MM GORE EXCLUDER ILIAC BRANCH",SUP-CEB231410A,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"NOVANET [10819]",Novanet,,47025,75,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL .038IN 18CM 7FR VESSEL",SUP-DIL-600-07,CDM,C1894,HCPCS,0272,RC,,,both,,,95.23,28.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.08,80.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BARR ADHESION 4X3IN ABSORBABLE CONTROL BEYOND CLSR GYNECARE",SUP-4350,CDM,C1765,HCPCS,0272,RC,,,both,,,2316.00,694.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,951.88,41.1,,,,,0,951.88,1466.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Frozen Section 1st Block",PX-312000037,CDM,88331,CPT,0312,RC,,,both,,,569.50,170.85,"BLUE CROSS [10001]","Blue Cross PPO",,53.15,,"Fee schedule rate ($53.15).",,,,0,0.01,484.08,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SUPERORDERABLE",RX-40814984,CDM,,,0250,RC,63323-0462-37,NDC,both,30,ML,118.01,35.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,54.17,45.9,,,,,0,13.72,100.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE PASSER WITH GUIDE SUTURE PASSING PUNCTURE CLOSURE DEV",SUP-RSG-14F,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.80,52.44,"PHCS [10601]",PHCS,,122.36,70,,,,,0,20.33,148.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Avul Nail Plate Smpl",PX-510000036,CDM,11730,CPT,0761,RC,,,both,,,2956.01,886.8,"BLUE CROSS [10001]","Blue Cross HMO",,2490.09,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,343.78,2740.57,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Carnitine Quant Ea Specimen",PX-301000133,CDM,82379,CPT,0301,RC,,,both,,,1202.70,360.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.71,,"Fee schedule rate ($17.71). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1022.3,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 NARROW KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-71933649,CDM,C1776,HCPCS,0278,RC,,,both,,,22273.65,6682.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6013.89,27,,,,,0,2590.43,18932.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR",276,MS-DRG,,,,,,,inpatient,,,217382.44,65214.73,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,38935.97,,"Case rate ($37,259.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $34,597.79, add-ons for qualifying new technology services are included. If operating cost exceeds $67,637.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,997.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $34,643.54. The transfer operating threshold is the transfer adjustment factor * $34,597.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,615.76. The transfer capital threshold is the transfer adjustment factor * $2,615.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,10994,175368.69,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 9-0 V100-3 5IN MONOFILAMENT BLACK NONABSORBABLE",SUP-2894G,CDM,S27200284,LOCAL,0272,RC,,,both,,,238.83,71.65,"CIGNA [10200]","Cigna Open Access",,135.89,56.9,,,,,0,27.78,203.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSELECT DEMINERALIZED BONE MATRIX 10ML",SUP-359100,CDM,C1713,HCPCS,0278,RC,,,both,,,5602.80,1680.84,"MULTIPLAN [10600]",Multiplan,,4762.38,85,,,,,0,651.61,4762.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 16MM MODULAR REVISION RESTORATION BOW",SUP-6276-7-216,CDM,C1776,HCPCS,0278,RC,,,both,,,11695.32,3508.6,"CIGNA [10200]","Cigna Open Access",,3917.93,33.5,,5302.19,4377.88,6578.61,27,1360.17,9941.02,"percent of total billed charges",
"PLATE STD CURVE .6MM MIDFACE 6 HOLE BAR 1.7MM SCR BONE",SUP-5505188,CDM,C1713,HCPCS,0278,RC,,,both,,,1721.95,516.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,790.38,45.9,,,,,0,200.26,1463.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ORTHOPEDIC WRIST HOOK ARMBRD MBRACE M4200 RADIAL",SUP-140-0250-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,69.60,20.88,"FIRST HEALTH [10303]","First Health",,55.68,80,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 5MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBHR050502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2223.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 77.5MM TRIGEN FEMUR LOW PROFILE",SUP-71645077,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"CIGNA [10200]",Cigna,,1407.29,68,,1831.33,1831.33,1831.33,16,240.69,1759.12,"percent of total billed charges",
"ROD SPINAL 70MM 4.75MM CD HORIZON SOLERA PERCUTANEOUS CCM",SUP-641000070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"IMPL BREAST 415CC SMOOTH SHELL SURFACE NATRELLE INSPIRA FULL",SUP-SRF-415,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3730.14,68,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 26CM 3CM 6FR .035IN PIGTAIL CURVE",SUP-M006180223070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,118.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 32MM VIVACIT-E ALL POLY KNEE",SUP-42540200032,CDM,C1776,HCPCS,0278,RC,,,both,,,5322.66,1596.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1523.35,28.62,,,,,0,619.03,4524.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 9.5MM 5MM S-ROM ZTT 14D SMALL HIP POROUS",SUP-550503,CDM,C1776,HCPCS,0278,RC,,,both,,,6466.32,1939.9,"CIGNA [10200]",Cigna,,4397.1,68,,5873.17,5873.17,5873.17,"1 through 10",752.03,5496.37,"percent of total billed charges",
"RING ANNULOPLASTY 32MM RECONSTRUCTION VALVULAR RETRACTION",SUP-680R32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"FIRST HEALTH [10303]","First Health",,10488,80,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP MULTIHOLE TRIDENT E HEMISPHERE",SUP-508-11-52E,CDM,C1776,HCPCS,0278,RC,,,both,,,11233.20,3369.96,"PHCS [10601]",PHCS,,7863.24,70,,,,,0,1306.42,9548.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 19MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P319,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"PHCS [10601]",PHCS,,5849.13,70,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Nacl",PX-E27200280,CDM,E27200280,LOCAL,0272,RC,,,both,,,119.90,35.97,"FIRST HEALTH [10303]","First Health",,95.92,80,,,,,0,13.94,101.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 15CM 180CM 20MM 10.5MM ESOPHAGEAL",SUP-G57357,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7035.84,40,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM 13MM PRESS FIT REDUCE PROXIMAL PROFILE",SUP-192413,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"BLUE CROSS [10001]","Blue Cross PPO",,9309.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",2761.95,20186.21,"percent of total billed charges",
"CAGE SPINAL 28X10X11MM 8D EIT TLIF STERILE LATEX FREE",SUP-TUI81128,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AETNA [10100]","Aetna HMO/PPO",,22538.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL HIP 2",SUP-CAP-S-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]",Cigna,,7038,68,,5873.17,5873.17,5873.17,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"SUT SILK PERMA-HAND 2 MH 30IN BRAID BLACK NONABSORBABLE",SUP-K846H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +12.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.125,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Local Plus",,184.58,53.5,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM LCP STAINLESS STEEL FULL THREAD CANCELLOUS",SUP-206.026,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"FIRST HEALTH [10303]","First Health",,218.9,80,,,,,0,31.82,232.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 13MM APTUS TRILOCK TITANIUM PHALANGEAL HAND",SUP-A-5250.13/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VENLAFAXINE ER 37.5 MG TAB/CAP,EXTENDED RELEASE 24 HR SUPERORDERABLE",RX-409943,CDM,,,0637,RC,68084-0698-11,NDC,both,1,UN,18.82,5.65,"FIRST HEALTH [10303]","First Health",,15.06,80,,,,,0,2.19,16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.5X8MM ABSORB RX IDE",SUP-1012458-08,CDM,C1874,HCPCS,0624,RC,,,both,,,10350.00,3105,"CIGNA [10200]",Cigna,,7038,68,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 32MM 140CM 4MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927432400,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,436.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BANDAGE ELASTIC 6  LATEX FREE",SUP-24096,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.46,14.84,"CIGNA [10200]","Cigna Local Plus",,26.46,53.5,,,,,0,5.75,42.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER/DIVIDER LAPAROSCOPIC 23CM 5MM LIGASURE XP MARYLAND",SUP-LXMJ23S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 67.5MM TITANIUM LOCKING ATLANTIS VISION BONE ANTERIOR",SUP-976-167,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1876.04,28.62,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPROXIMATOR SURGICAL 5.75IN BAILEY RIB SHARP TEETH",SUP-54-2530,CDM,S27200284,LOCAL,0272,RC,,,both,,,1265.71,379.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,860.68,68,,,,,0,147.2,1075.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP PULSED LAVAGE INTERPULSE SHORT COAXIAL FAN SPRAY STERILE",SUP-0210018100,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.71,24.51,"NOVANET [10819]",Novanet,,61.28,75,,,,,0,9.5,69.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT 24MM MINI STAINLESS STEEL ROTATOR CUFF STERILE",SUP-902963,CDM,S27200284,LOCAL,0272,RC,,,both,,,680.40,204.12,"CIGNA [10200]","Cigna Open Access",,387.15,56.9,,,,,0,79.13,578.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PROFILE SILICONE SMOOTH",SUP-SCL-260,CDM,C1789,HCPCS,0278,RC,,,both,,,8004.00,2401.2,"MULTIPLAN [10600]",Multiplan,,6803.4,85,,,,,0,930.87,6803.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM ARTHREX TITANIUM T15 LARGE FULL THREAD",SUP-AR-8750-50H,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"KAISER [10500]",Kaiser,,2386.88,67,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ldh Body Fluid",PX-301000293,CDM,83615,CPT,0301,RC,,,both,,,147.25,44.17,"UHC [10700]","United Healthcare",,5.44,,,,,,,0.15,125.16,"fee schedule",
"LEAD PACING 52CM 6FR 2MM 17MM SPACE SMALL STRAIGHT VENTRICLE",SUP-5054-52,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"BLUE CROSS [10001]","Blue Cross HMO",,875.14,39.2,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 20MM 3.5MM BALLOON DILATATION STERILE",SUP-235-203-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0310,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"CIGNA [10200]","Cigna Open Access",,3847.58,56.9,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.205,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ACETABULAR 50MM DURALOC DYNAMIC HIP LOCK STERILE LATEX",SUP-124950000,CDM,C1776,HCPCS,0278,RC,,,both,,,1878.00,563.4,"BLUE CROSS [10001]","Blue Cross PPO",,736.18,39.2,,3949.44,3949.44,3949.44,"1 through 10",218.41,1596.3,"percent of total billed charges",
"RETRIEVER SURGICAL 30X12MM",SUP-691.004S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"NOVANET [10819]",Novanet,,1265.63,75,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 6FR 5.5MM .07",SUP-H7493926708550,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OLBT 180CM 10MM 5.8FR 4MM",SUP-6765,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER SOLTIVE 150UM THULIUM BALL TIP DISPOSABLE",SUP-TFL-FBX150BS,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL COMPOSIX L/P 14.2X10.2IN VENTRAL HERNIA PATCH",SUP-0134114,CDM,C1781,HCPCS,0278,RC,,,both,,,6791.40,2037.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,804.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,789.84,5772.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNQT SURGICAL 42IN ATS",SUP-60-7075-157R,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"CIGNA [10200]",Cigna,,50.29,68,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 65CM 11FR 8FR SUPER ARROW-FLEX PERCUTANEOUS 3 WAY",SUP-CL-71165,CDM,C1894,HCPCS,0272,RC,,,both,,,960.66,288.2,"UHC [10700]","United Healthcare",,608.1,63.3,,,,,0,111.72,816.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR SILICONE RADIOPAQUE EXTERNAL RETENTION RING",SUP-8180-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.81,228.54,"UHC [10700]","United Healthcare",,482.23,63.3,,,,,0,88.6,647.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.6MM 14MM VIP SPINE SELF DRILL VARIABLE ANGLE",SUP-171.014,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]",Cigna,,958.8,68,,1831.33,1831.33,1831.33,16,163.98,1198.5,"percent of total billed charges",
"SUT PROLENE 4-0 RB-1 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8871H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Local Plus",,13.38,53.5,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TITAN TOUCH INFRAPUBIC ZERO ANGLE 24CM",SUP-ES2824,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"NOVANET [10819]",Novanet,,47025,75,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 1.45MM NITINOL SHARP",SUP-286705330,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXI-TIP 50CM 5-10FR .04IN .05IN STD URETERAL 2 LUMEN",SUP-G17013,CDM,C1758,HCPCS,0272,RC,,,both,,,351.48,105.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,41.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.88,298.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 3CM 8FR .038IN PIGTAIL CURVE STRAIGHT LOW",SUP-M006180243010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"PHCS [10601]",PHCS,,749.52,70,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 26MM 140CM 2.5MM",SUP-RSINT25026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1586.69,28.62,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEUROSURGICAL 15MM LASER DIFFUSE",SUP-NEUROKIT-600-T15,CDM,S27200284,LOCAL,0272,RC,,,both,,,68400.00,20520,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,46512,68,,,,,0,7954.92,58140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 15ML 85% BTCP 15% HA MASTERGRAFT GRANULE",SUP-7600115,CDM,C1713,HCPCS,0278,RC,,,both,,,5840.51,1752.15,"CIGNA [10200]","Cigna Local Plus",,3124.67,53.5,,3978.14,359.25,3978.14,24,679.25,4964.43,"percent of total billed charges",
"STENT ZIPWIRE 22CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175261180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,173.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 24FR 5/16IN SILICONE RADIOPAQUE 4 FREE FLOW",SUP-072234,CDM,S27200284,LOCAL,0272,RC,,,both,,,114.93,34.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,78.15,68,,,,,0,13.37,97.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL 50 MCG/HR TRANSDERMAL PATCH",RX-27906,CDM,,,0250,RC,47781-0426-11,NDC,both,1,UN,208.12,62.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,85.54,41.1,,,,,0,24.2,176.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 30GA 5MM AIR INJECTION",SUP-60-1149,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.13,24.64,"CIGNA [10200]",Cigna,,55.85,68,,,,,0,9.55,69.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 12FR CATH STERILE LATEX FREE DISPOSABLE",SUP-DIL-600-12,CDM,C1894,HCPCS,0272,RC,,,both,,,66.99,20.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.79,56.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 130CM 250MM 6MM BALLOON DILATATION",SUP-ADM06025013P,CDM,C2623,HCPCS,0272,RC,,,both,,,14007.00,4202.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5756.88,41.1,,,,,0,1629.01,11905.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 210MM 2.5-2MM .014IN BALLOON DILATATION",SUP-AB14W025210150,CDM,C1725,HCPCS,0272,RC,,,both,,,1638.75,491.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,194.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,190.59,1392.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC ANATOMIC SOCKET FLIPCUTTER II SHORT KNEE",SUP-AR-1204AS-80,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1174.76,45.9,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INDIGO CAT LIGHTNING 100CM 12FR THROMBECTOMY HTORQ",SUP-LITNG12HTORQ100,CDM,C1757,HCPCS,0272,RC,,,both,,,42147.00,12644.1,"UHC [10700]","United Healthcare",,26679.05,63.3,,,,,0,4901.7,35824.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MONARCH INFLATION 3 WAY STPCOCK SYR EXT TUBE DIGITAL",SUP-K05-L3-L4B,CDM,S27200284,LOCAL,0272,RC,,,both,,,720.90,216.27,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,296.29,41.1,,,,,0,83.84,612.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSCOR BIPOLAR IMPLANTABLE LEAD ADAPTOR-BLV/BIS-4403",SUP-BLV/BIS-4403,CDM,C1883,HCPCS,0278,RC,,,both,,,3630.00,1089,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,430.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,422.17,3085.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET M6 SPINE OCCIPITOCERVICAL UPPER THORACIC INFINITY",SUP-3600215,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"CIGNA [10200]",Cigna,,236.64,68,,1831.33,1831.33,1831.33,16,40.47,295.8,"percent of total billed charges",
"HC Copper",PX-301000156,CDM,82525,CPT,0301,RC,,,both,,,237.05,71.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.28,,"Fee schedule rate ($13.28). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",18.69,18.69,18.69,"1 through 10",0.24,201.49,"fee schedule",
"CATH ADVANCE 18LP 80CM 6CM 4FR 6MM .018IN BALLOON DILATATION",SUP-G50248,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23MMX7MM ELEVATE XLORDOTIC STERILE",SUP-7770723,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11520,40,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LINER ACETABULAR R3 XLPE COCR NONPOROUS HIP",SUP-71703312,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"UHC [10700]","United Healthcare",,15154.02,63.3,,8601.07,8395.67,8601.07,"1 through 10",2784.22,20349,"percent of total billed charges",
"CAP LINER ACETABULAR R3 XLPE COCR NONPOROUS HIP",SUP-71703312,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X11MM 8D CONVEX LORDOTIC WEDGE",SUP-10611,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8505,27,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS",RX-24932,CDM,J2916,HCPCS,0636,RC,00143-9570-01,NDC,both,5,ML,288.11,86.43,"NOVANET [10819]",Novanet,,216.08,75,,,,,0,11.77,244.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sclerotx Fluid Collection Perq",PX-361000461,CDM,49185,CPT,0361,RC,,,both,,,3706.12,1111.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,439.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.02,3706.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 650CC",SUP-RSZ-SHPX-650S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,76.24,45.9,,,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 15FTX1IN ROLL FIBERGLASS ORTHO-GLASS LATEX",SUP-OG-1L2,CDM,S27000186,LOCAL,0270,RC,,,both,,,225.50,67.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.23,191.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Hand>=3v",PX-320000073,CDM,73130,CPT,0320,RC,,,both,,,513.25,153.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,60.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.49,436.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 6MM 10MM 4MM DUCT TYPE II SELF EXPANDING",SUP-9-PDA2-04-06,CDM,C1817,HCPCS,0278,RC,,,both,,,15444.00,4633.2,"CIGNA [10200]","Cigna Open Access",,5173.74,33.5,,,,,0,1796.14,13127.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SCIS LAPSCP LOGI-CUT SH 330MM",SUP-120-7000,CDM,S27200284,LOCAL,0272,RC,,,both,,,320.70,96.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.3,272.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cntrst Bath Ea 15min (Go)",PX-430000012,CDM,97034,CPT,0430,RC,,,both,,,151.00,45.3,"MULTIPLAN [10600]",Multiplan,,128.35,85,,,,,0,17.56,151,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TRANSEND VASCULAR 205CM 2CM .014IN SCITANIUM ICE",SUP-M001468070,CDM,C1769,HCPCS,0272,RC,,,both,,,3942.52,1182.76,"FIRST HEALTH [10303]","First Health",,3154.02,80,,,,,0,458.52,3351.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 6MM UNIVERS APEX OPTIFIT SHOULDER",SUP-AR-9100-06M,CDM,C1776,HCPCS,0278,RC,,,both,,,26302.50,7890.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7101.68,27,,,,,0,3058.98,22357.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL EZ-IO ARROW VASCULAR ACCESS",SUP-9058,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 85MM STAINLESS STEEL T25 SELF TAP LOCK VARIABLE",SUP-02.231.285,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"FIRST HEALTH [10303]","First Health",,1046.26,80,,,,,0,152.1,1111.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH SUREFLEX 94CM 180CM LARGE 91CM 71CM 50MM 8.5FR",SUP-TSK85-32-BD-71L,CDM,C1766,HCPCS,0272,RC,,,both,,,6134.10,1840.23,"UHC [10700]","United Healthcare",,3882.89,63.3,,,,,0,713.4,5213.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL EZ-IO ARROW VASCULAR ACCESS",SUP-9058,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 37FR LEFT ANGLE ADJUSTABLE VALVE STYLET 2",SUP-125037,CDM,S27200284,LOCAL,0272,RC,,,both,,,439.99,132,"KAISER [10500]",Kaiser,,294.79,67,,,,,0,51.17,373.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ON-Q C-BLOC SELECT-A-FLOW 5ML/HR DRUG DELIVERY 400ML",SUP-CB001,CDM,C9804,HCPCS,0272,RC,,,both,,,1591.33,477.4,"CIGNA [10200]",Cigna,,1082.1,68,,,,,0,185.07,1352.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 80MM 1.5MM BALLOON DILATATION RAPID",SUP-47515080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 105D XIA OFFSET PLATE TITANIUM SPINE",SUP-03820132,CDM,S27800098,LOCAL,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Open Access",,2027.06,56.9,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NUT ORTHOPEDIC MRI SAFE NONSTERILE",SUP-03.311.062,CDM,S27800098,LOCAL,0278,RC,,,both,,,1313.42,394.03,"PHCS [10601]",PHCS,,919.39,70,,,,,0,140.82,1116.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE WIRE SAW 51CM HANDLE STAINLESS STEEL GIGLI STERILE",SUP-00280800200,CDM,S27000186,LOCAL,0270,RC,,,both,,,241.95,72.58,"CIGNA [10200]",Cigna,,164.53,68,,,,,0,28.14,205.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROPOFOL 10 MG/ML IV EMULSION (ANESTHESIA OSM) 20 ML",RX-408976,CDM,J2704,HCPCS,0636,RC,63323-0269-29,NDC,both,20,ML,100.65,30.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4.56,,,,,,,2.1,85.55,"fee schedule",
"SHELL ACETABULAR 60MM HIP POROCOAT PINNACLE 300 SERIES",SUP-121703060,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"MULTIPLAN [10600]",Multiplan,,5704.15,85,,,,,0,780.46,5704.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 2.4X1.2IN 12 TPI THK.025IN OSCILLATING HEAVY DUTY",SUP-5305-010-124S2,CDM,S27200284,LOCAL,0272,RC,,,both,,,955.80,286.74,"KAISER [10500]",Kaiser,,640.39,67,,,,,0,111.16,812.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4.5CM 2.5MM GALAXY G3 MINI FREEFORM",SUP-MCR092545,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3570.98,27,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIVIGEN CELLULAR BONE MATRIX 10CC CRYO",SUP-BL-1500-003,CDM,C1713,HCPCS,0278,RC,,,both,,,21168.00,6350.4,"AETNA [10100]","Aetna HMO/PPO",,16828.56,79.5,,1521.93,481.35,16760.95,30,2461.84,17992.8,"percent of total billed charges",
"HC Kit Admin Dialysis M100",PX-E27200140,CDM,E27200140,LOCAL,0272,RC,,,both,,,1037.30,311.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET STENT PURPLE 10CM 5FR ZIMMON PIGTAIL CURVE PANCREATIC",SUP-G21689,CDM,C2625,HCPCS,0272,RC,,,both,,,1328.40,398.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ABDOMINAL PAIN,MAJOR",251,APR-DRG,,,,,,,inpatient,,,31702.94,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,768.83. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($34,777.27) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRICATH 16FR STD URETHRAL RUBBER 5CC FOLEY",SUP-119416M,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.53,30.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CONCUSSION WITH CC",089,MS-DRG,,,,,,,inpatient,,,63358.35,19007.5,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.2MM 5MM CORTICAL 4 HANDLE",SUP-A-5100.05/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RUNWAY 100CM 6FR AR1 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H74938969660,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL TWIST 50MM 1MM LORENZ 5MM STOP MANDIBLE",SUP-01-7142,CDM,S27000186,LOCAL,0270,RC,,,both,,,680.40,204.12,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PUNCH 6MM SHORT HANDLE AORTIC",SUP-APU460,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,133.1,45.9,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MAXFIRE FIXATION MENISCUS REPAIR ZIPLOOP TECHNOLOGY",SUP-900339,CDM,C1713,HCPCS,0278,RC,,,both,,,3307.50,992.25,"FIRST HEALTH [10303]","First Health",,2646,80,,,,,0,384.66,2811.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT NRV HUM AVANCE 3-4X30MM",SUP-311230,CDM,C1762,HCPCS,0278,RC,,,both,,,29288.70,8786.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7907.95,27,,,,,0,3406.28,24895.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE GT VASCULAR 90D 180CM 25CM .018IN HYDROPHILIC",SUP-RG*GE1818SP,CDM,C1769,HCPCS,0272,RC,,,both,,,1445.85,433.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,171.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.15,1228.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 13MM DIVERGENCE TITANIUM SPINAL CERVICAL",SUP-G7733513,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,536.63,28.62,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.35IN 18FR HEYMAN PLASTIC COUDE TIP DILATION",SUP-021318,CDM,S27200284,LOCAL,0272,RC,,,both,,,242.30,72.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,111.22,45.9,,,,,0,28.18,205.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 28CM 14.5FR 15FR STRAIGHT POLYURETHANE GLIDEPATH",SUP-5397230,CDM,C1750,HCPCS,0278,RC,,,both,,,1875.00,562.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 4 KNEE CEMENTED PRIMARY",SUP-5520-B-400,CDM,C1776,HCPCS,0278,RC,,,both,,,7151.76,2145.53,"CIGNA [10200]",Cigna,,4863.2,68,,5873.17,5873.17,5873.17,"1 through 10",831.75,6079,"percent of total billed charges",
"STENT VIABAHN 2.5CM 75CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR060201A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"NOVANET [10819]",Novanet,,14071.05,75,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER BURR HOLE .4MM 14MM UNIVERSAL NEURO III",SUP-53-34514,CDM,C1713,HCPCS,0278,RC,,,both,,,1858.37,557.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1263.69,68,,,,,0,216.13,1579.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL SF 8FR F-J CURVE ABLATION",SUP-D134804,CDM,C1732,HCPCS,0272,RC,,,both,,,21312.90,6393.87,"MULTIPLAN [10600]",Multiplan,,18115.97,85,,,,,0,2478.69,18115.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 3DMAX 6.2X4.1IN ABDOMINAL LEFT MONOFILAMENT",SUP-0117311,CDM,C1781,HCPCS,0278,RC,,,both,,,1008.80,302.64,"CIGNA [10200]","Cigna Open Access",,574.01,56.9,,11235.02,819.42,11235.02,"1 through 10",117.32,857.48,"percent of total billed charges",
"SCR BONE 7MM 60MM MATRIX TITANIUM SPINE THREADED POLYAXIAL",SUP-04.606.760,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRB 13GA MAMTM ELT BRSTBIO",SUP-MEP13,CDM,S27200284,LOCAL,0272,RC,,,both,,,2021.12,606.34,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1374.36,68,,,,,0,235.06,1717.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM VENTURE TITANIUM LOW PROFILE SPINE",SUP-9790315,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,396.9,39.2,,957.42,156.86,7483.26,51,117.75,860.63,"percent of total billed charges",
"PLATE T 58MM STAINLESS STEEL 2.4MM SCR MINI FRAGMENT SET 3X7",SUP-249.615,CDM,C1713,HCPCS,0278,RC,,,both,,,3883.32,1165,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,451.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",451.63,3300.82,"percent of total billed charges",
"BALLOON KPA20 CATHETER 20MM UNIPEDICULAR",SUP-KPA20,CDM,S27200284,LOCAL,0272,RC,,,both,,,20790.00,6237,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9542.61,45.9,,,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aqaprn-4 Antb Flo Cytmtry Ea",PX-302000252,CDM,86053,CPT,0302,RC,,,both,,,751.45,225.43,"KAISER [10500]",Kaiser,,503.47,67,,,,,0,0.01,638.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION KIRSCHNER NITINOL BEVEL BLUNT",SUP-8801069,CDM,C1713,HCPCS,0278,RC,,,both,,,3326.40,997.92,"FIRST HEALTH [10303]","First Health",,2661.12,80,,,,,0,386.86,2827.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP OPHTHALMIC MALYUGIN 7MM RING",SUP-MAL-0002-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1147.50,344.25,"PHCS [10601]",PHCS,,803.25,70,,,,,0,133.45,975.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP PERFORMATRAK FOAM LARGE NASAL ORAL 1 ENTRAINMENT E",SUP-73-1019480EA,CDM,S27000186,LOCAL,0270,RC,,,both,,,225.23,67.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,103.38,45.9,,,,,0,26.19,191.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP GRIPTION PINNACLE STERILE LATEX",SUP-121731060,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"PHCS [10601]",PHCS,,11352.92,70,,,,,0,1886.21,13785.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TRILOGY HEART VALVE (SIZE 27)",SUP-TRILOGY-THV-L,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,23201.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 0D F HIP X3 TRIDENT",SUP-723-00-36F,CDM,C1776,HCPCS,0278,RC,,,both,,,9332.25,2799.67,"MULTIPLAN [10600]",Multiplan,,7932.41,85,,,,,0,1085.34,7932.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 650ML GEL ROUND SMOOTH MEMORYGEL SILICONE P4.7CM","SUP-3506501 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"CIGNA [10200]","Cigna Open Access",,2091.08,56.9,,5166.00,5166.00,5166.00,"1 through 10",427.4,3123.75,"percent of total billed charges",
"STEM FEMORAL ACCOLADE II 7 127D",SUP-6721-0737,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9848.4,41.1,,6417.48,6417.48,6417.48,"1 through 10",2786.79,20367.74,"percent of total billed charges",
"STENT WALLFLEX 80MM 75CM 8MM 8FR .035IN BILIARY METAL",SUP-M00574640,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM SUMMIT POROCOAT 5 12/14 HIGH OFFSET TAPER",SUP-157011110,CDM,C1776,HCPCS,0278,RC,,,both,,,25247.25,7574.17,"AETNA [10100]","Aetna HMO/PPO",,20071.56,79.5,,10981.53,8986.79,12413.38,12,2936.26,21460.16,"percent of total billed charges",
"LINER ACETABULAR EMPHASYS +4MM NEUTRAL 56-58MM 40MM AOX",SUP-472256440,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,5302.19,4377.88,6578.61,27,2014.9,14726.25,"percent of total billed charges",
"DRILL SURGICAL STD 2.7MM CANNULATED PROXIMAL LATERAL",SUP-00236020527,CDM,S27000186,LOCAL,0270,RC,,,both,,,2137.50,641.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,878.51,41.1,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR -3MM TAPER HIP ADPTR ENDO II",SUP-139248,CDM,C1776,HCPCS,0278,RC,,,both,,,3198.00,959.4,"CIGNA [10200]","Cigna Open Access",,1819.66,56.9,,5302.19,4377.88,6578.61,27,371.93,2718.3,"percent of total billed charges",
"SET CATH 16FR 15GA 30CM 1 WAY STPCOCK CONNECT TUBE LOCK NDL",SUP-G55825,CDM,C2627,HCPCS,0272,RC,,,both,,,450.36,135.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,53.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.38,382.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 75MM ANTIROTATE STERILE FEMORAL NECK SYSTEM",SUP-04.168.475S,CDM,C1713,HCPCS,0278,RC,,,both,,,1642.20,492.66,"CIGNA [10200]","Cigna Local Plus",,878.58,53.5,,3978.14,359.25,3978.14,24,190.99,1395.87,"percent of total billed charges",
"COIL EMBOLIZATION 40CM 10MM INTERLOCK FIBERED IDC 35 COIL",SUP-M001363800,CDM,S27800098,LOCAL,0278,RC,,,both,,,5181.90,1554.57,"CIGNA [10200]",Cigna,,3523.69,68,,,,,0,602.65,4404.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 20MM 2.5MM BALLOON DILATATION",SUP-48002502X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"KAISER [10500]",Kaiser,,841.19,67,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO MICRO STRAIGHT BRAID MATRS STITCH SUT",SUP-AR-8703,CDM,S27200284,LOCAL,0272,RC,,,both,,,1190.70,357.21,"CIGNA [10200]","Cigna Open Access",,677.51,56.9,,,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 12MM 3MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012274-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT FLOWABLE 10CC OSTEOAMP SELECT",SUP-OAFL-10,CDM,C1713,HCPCS,0278,RC,,,both,,,18909.45,5672.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7563.78,40,,,,,0,2199.17,16073.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY TORIC",SUP-CNWET5,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,397.04,45.9,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 FREEDOM H 36MM E1 HIP CONSTRAIN",SUP-010000986,CDM,C1776,HCPCS,0278,RC,,,both,,,19199.88,5759.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2275.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2232.95,16319.9,"percent of total billed charges",
"SCR BONE 6.5MM 45MM PINNACLE HIP ACETABULAR CANCELLOUS",SUP-121745500,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"KAISER [10500]",Kaiser,,767.92,67,,,,,0,133.3,974.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANSTR SUCTION PENUMBRA ENGINE INDIGO",SUP-IAPS3,CDM,S27200284,LOCAL,0272,RC,,,both,,,2700.00,810,"FIRST HEALTH [10303]","First Health",,2160,80,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Icd Elect",PX-480000031,CDM,33244,CPT,0481,RC,,,both,,,8654.86,2596.46,"CIGNA [10200]","Cigna Local Plus",,8654.86,,"Case rate ($13,926). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1006.56,8654.86,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 9X 38MM CATH 120CM ENDOVASCULAR",SUP-42938,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"UHC [10700]","United Healthcare",,11090.35,63.3,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 110CM 4FR .042IN 155D 12MM PIGTAIL",SUP-538459V,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"PHCS [10601]",PHCS,,62.66,70,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr DXA Bn Density Axial",PX-320000183,CDM,77080,CPT,0320,RC,,,both,,,990.58,297.17,"AETNA [10100]","Aetna HMO/PPO",,787.51,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.53,841.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X9MM ENDOSKELETON TC 6D 12MM SMALL CERVICAL",SUP-5146-1209-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7038,68,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 44MM MINI-MONSTER SHORT THREAD CANNULATED",SUP-P20-140-044S,CDM,C1713,HCPCS,0278,RC,,,both,,,1599.75,479.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,189.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",186.05,1359.79,"percent of total billed charges",
"EXP TISSUE BREAST 850CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP140RUH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"UHC [10700]","United Healthcare",,7534.28,63.3,,,,,0,1384.26,10117.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 4FR 8CM CENTRAL VENOUS SPECTRUM 2 LUMEN CURVE NDL",SUP-G43991,CDM,C1751,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Abd Cmplt 2+V W Pa Chest",PX-320000096,CDM,74022,CPT,0320,RC,,,both,,,1032.14,309.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,54.88,,,,,,,54.88,877.32,"fee schedule",
"POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV",RX-9801,CDM,J3480,HCPCS,0258,RC,00264-7635-00,NDC,both,1000,ML,100.65,30.19,"MULTIPLAN [10600]",Multiplan,,85.55,85,,,,,0,0.02,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SCR SOLERA SPINAL TITANIUM BREAKOFF 4.75 MM ROD",SUP-5440030,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"MULTIPLAN [10600]",Multiplan,,2045.61,85,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 20MM 6FR 2.25MM .07IN BALLOON",SUP-H7493918920220,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AETNA [10100]","Aetna HMO/PPO",,450.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Brain Perfsn W Cntrst WO CT/Cta",PX-351000020,CDM,70473,CPT,0351,RC,,,both,,,1352.72,405.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,448,,,,,,,157.32,1352.72,"fee schedule",
"GRAFT VASCULAR 80CM 4-7MM GORE STD WALL TAPER HEPARIN",SUP-H470080A,CDM,C1768,HCPCS,0278,RC,,,both,,,15732.00,4719.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4502.5,28.62,,,,,0,1829.63,13372.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insitu Hybrid Ea Probe Manual",PX-312000049,CDM,88368,CPT,0312,RC,,,both,,,1041.20,312.36,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,885.02,"per diem",
"STENT GORE VIABAHN 39MM 135CM 9MM 13MM 8FR .035IN",SUP-BXA093902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7801.92,40,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .047IN JUDKINS LEFT 4.5",SUP-534517T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"MULTIPLAN [10600]",Multiplan,,79.5,85,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan",PX-302000263,CDM,86581,CPT,0302,RC,,,both,,,167.70,50.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,114.04,68,,,,,0,0.01,142.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pacing Hrt Rhythm",PX-481000052,CDM,93618,CPT,0480,RC,,,both,,,4831.00,1449.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4831,,"Case rate ($16,234). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,561.85,4831,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 10.5IN 14FR 18MM CORONARY SINUS RETROGRADE",SUP-RC014T,CDM,S27200284,LOCAL,0272,RC,,,both,,,861.92,258.58,"CIGNA [10200]","Cigna Open Access",,490.43,56.9,,,,,0,100.24,732.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION",RX-10330,CDM,Q9958,HCPCS,0636,RC,00019-0862-50,NDC,both,250,ML,500.00,150,"FIRST HEALTH [10303]","First Health",,400,80,,,,,0,35,425,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MONITOR CARDIAC INSERTABLE ASSERT-IQ",SUP-DM5300,CDM,C1764,HCPCS,0278,RC,,,both,,,23940.00,7182,"MULTIPLAN [10600]",Multiplan,,20349,85,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM PFC SIGMA 5 KNEE POSTERIOR TITANIUM CEMENT",SUP-960906,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,596.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR NEROSTIMLTR OPTIMIZER SMART MINI",SUP-10-B501-3-XX,CDM,C1824,HCPCS,0278,RC,,,both,,,148200.00,44460,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17561.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17235.66,125970,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 20MM 2.5MM BALLOON DILATATION DURALYN",SUP-48002502S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM 27MM BIOCOR FLEXFIT LOW PROFILE SUPRA",SUP-BSP100-27,CDM,S27800098,LOCAL,0278,RC,,,both,,,32715.90,9814.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13086.36,40,,,,,0,3804.86,27808.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE PSI KIT (GLENOID ONLY)",SUP-1235-7152-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"MULTIPLAN [10600]",Multiplan,,5131.88,85,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bag Effluent",PX-E27000045,CDM,E27000045,LOCAL,0270,RC,,,both,,,51.70,15.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,21.25,41.1,,,,,0,6.01,43.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 20MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158106120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1299.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .014IN 4FR 4MM 142CM 1.5CM",SUP-4244015W,CDM,C1725,HCPCS,0272,RC,,,both,,,1438.80,431.64,"MULTIPLAN [10600]",Multiplan,,1222.98,85,,,,,0,167.33,1222.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 8.5MM HEAD FRONT CUT MEDULLARY NONSTERILE",SUP-352.085,CDM,S27200284,LOCAL,0272,RC,,,both,,,2176.73,653.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,257.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,253.15,1850.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 20MM UNIVERS REVERS POROUS GLENOID PERIPHERAL",SUP-AR-9562-20NL,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"FIRST HEALTH [10303]","First Health",,477.9,80,,,,,0,69.48,507.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Lwr Ext Nonjnt WO Cntrst",PX-610000031,CDM,73718,CPT,0610,RC,,,both,,,4076.82,1223.05,"MULTIPLAN [10600]",Multiplan,,3465.3,85,,,,,0,430.75,3465.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"0.014IN DIA X 205CM LENGTH PORTAL STEERABLE HYDROPHILIC GUID",SUP-PORT-14-200-1,CDM,C1887,HCPCS,0272,RC,,,both,,,4133.10,1239.93,"AETNA [10100]","Aetna HMO/PPO",,3285.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,480.68,3513.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX LARGE - L 21MM X",SUP-T600612,CDM,S27800098,LOCAL,0278,RC,,,both,,,4347.00,1304.1,"CIGNA [10200]","Cigna Open Access",,2473.44,56.9,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL OVITEX PRS LONG TERM RESORBABLE 3 LAYER",SUP-P20263-1122G,CDM,C1781,HCPCS,0278,RC,,,both,,,25070.09,7521.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7175.06,28.62,,,,,0,2915.65,21309.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM TKR CEMENT FLEX",SUP-98000670100,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Open Access",,6331.5,33.5,,5302.19,4377.88,6578.61,27,2198.07,16065,"percent of total billed charges",
"GRAFT BONE READIGRAFT CANCELLOUS 30ML 4-10MM FREEZE DRIED","SUP-CAN30 410BP",CDM,S27800098,LOCAL,0278,RC,,,both,,,2783.63,835.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,329.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,323.74,2366.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD SENTUS PROMRI LEFT VENTRICULAR OTW QUADRIPOLAR",SUP-406081,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"AETNA [10100]","Aetna HMO/PPO",,4457.57,79.5,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 12MM 140CM 3MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927412300,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,436.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 14MM 200MM SUPRACONDYLAR T2 INTRAMEDULLARY",SUP-1826-1420S,CDM,C1713,HCPCS,0278,RC,,,both,,,11554.33,3466.3,"CIGNA [10200]","Cigna Open Access",,3870.7,33.5,,1144.80,304.56,2275.09,66,1343.77,9821.18,"percent of total billed charges",
"SCR BONE 3MM 14MM DART-FIRE TITANIUM SMALL PARTIAL THREAD",SUP-D1N30014S,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Ctrl Blood",PX-750000091,CDM,45382,CPT,0750,RC,,,both,,,3655.67,1096.7,"AETNA [10100]","Aetna HMO/PPO",,2906.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,425.15,3655.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 24MM 144CM 3MM CORONARY STENT EVEROLIMUS",SUP-H7493926124300,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 58MM HIP ACETABULAR MODULAR COCRMO BIO-MOORE",SUP-12-139040,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"NOVANET [10819]",Novanet,,2094.75,75,,,,,0,324.83,2374.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Spine Thorac>=4v",PX-320000041,CDM,72074,CPT,0320,RC,,,both,,,718.34,215.5,"BLUE CROSS [10001]","Blue Cross PPO",,105.88,,"Fee schedule rate ($105.88).",,,,0,51.75,610.59,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 4MM COOLCUT 8 FLUTE OVAL STERILE DISPOSABLE",SUP-AR-8400OBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"NOVANET [10819]",Novanet,,376.35,75,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GALASHAPE 18.5X6.4CM SOFT TISSUE SCAFFOLD",SUP-FR3D04,CDM,C1781,HCPCS,0278,RC,,,both,,,17640.00,5292,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7056,40,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX10MM VANGUARD ARCOM KNEE POSTERIOR STABILIZE",SUP-183640,CDM,C1776,HCPCS,0278,RC,,,both,,,8259.30,2477.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,978.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,960.56,7020.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPPORT ARTHRITIS SM LEFT WRIST SOFT FOAM PADDED FLANNEL FLE",SUP-A918-LS,CDM,S27000186,LOCAL,0270,RC,,,both,,,272.31,81.69,"AETNA [10100]","Aetna HMO/PPO",,216.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.67,231.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 7CM 8.25MM TWIST-IN 3 DAM TRANSLUCENT",SUP-AR-6530TD,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,134.17,45.9,,,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 90CM 5FR OMNI CURVE ANGIOGRAPHIC VISCERAL",SUP-10732202,CDM,C1887,HCPCS,0272,RC,,,both,,,218.37,65.51,"FIRST HEALTH [10303]","First Health",,174.7,80,,,,,0,25.4,185.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 20MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158103120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross PPO",,4380.42,39.2,,3949.44,3949.44,3949.44,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 15MM 140CM 2MM CORONARY STENT BIOLINX",SUP-RONYX20015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,1466.08,39.2,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 13CM 9FR 3.2MM FLEXOR CHECK-FLO SMALL VALVE",SUP-G07857,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 13X12.2CM 495ML STYLE CPG 323 GEL COHESIVE III",SUP-3341302,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"FIRST HEALTH [10303]","First Health",,7314,80,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 4-6 SMALL FEMALE BEIGE CANVAS RUBBER",SUP-2041-07,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.42,14.23,"MULTIPLAN [10600]",Multiplan,,40.31,85,,,,,0,5.51,40.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HIWIRE VASCULAR ANGLE TAPER 180CM 15CM .035IN NITINOL",SUP-G36284,CDM,C1769,HCPCS,0272,RC,,,both,,,257.94,77.38,"PHCS [10601]",PHCS,,180.56,70,,,,,0,30,219.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JEIL POWER DRIVER, SINGLE USE",SUP-111-ED-050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"FIRST HEALTH [10303]","First Health",,1166.4,80,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fna W Fluoro Ea Addl",PX-361000480,CDM,10008,CPT,0361,RC,,,both,,,4962.00,1488.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,588,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,577.08,4217.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT FLITES C600LB XL GENERAL PURPOSE CLIP",SUP-MFA1000M-XL,CDM,S27000186,LOCAL,0270,RC,,,both,,,268.70,80.61,"KAISER [10500]",Kaiser,,180.03,67,,,,,0,31.25,228.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 9MM THK.6MM 35MM SAGITTAL OSCILLATE LATEX FREE",SUP-350S90-06,CDM,S27200284,LOCAL,0272,RC,,,both,,,866.70,260.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRESSING ANTIMICROBIAL 3.5 X 14 INCH AQUACEL AG ADVANTAGE",SUP-422607,CDM,S27200284,LOCAL,0272,RC,,,both,,,325.56,97.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT STENT 22CM 6FR .038IN PIGTAIL CURVE TAPER URETER GLIDEX",SUP-M001245730,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2.2MM 4MM RELIEVE SPINE SELF DRILL NONSTERILE LATEX",SUP-136.404,CDM,C1713,HCPCS,0278,RC,,,both,,,1077.30,323.19,"KAISER [10500]",Kaiser,,721.79,67,,,,,0,125.29,915.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 6MM 10MM 4MM DUCT TYPE II SELF EXPANDING",SUP-9-PDA2-04-06,CDM,C1817,HCPCS,0278,RC,,,both,,,15444.00,4633.2,"CIGNA [10200]",Cigna,,6177.6,40,,,,,0,1796.14,13127.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 18CM 10MM KNITTED BIFURCATED",SUP-85180,CDM,C1768,HCPCS,0278,RC,,,both,,,3669.12,1100.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1050.1,28.62,,,,,0,426.72,3118.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 12 STD KNEE RIGHT CRUCIATE RETAIN PERSONA COCR",SUP-42502807402,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3424.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION AQUALITE 0.9% SODIUM CHLORIDE 1.5L LATEX FREE",SUP-713836,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grad Compression Knee 30-40",PX-E27100010,CDM,A6531,HCPCS,0292,RC,,,both,,,122.10,36.63,"NOVANET [10819]",Novanet,,91.58,75,,,,,0,14.2,103.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT ACCESS DA VINCI SP 2.7-4CM SMALL KIT INCISION",SUP-430073,CDM,S27200284,LOCAL,0272,RC,,,both,,,3741.25,1122.37,"FIRST HEALTH [10303]","First Health",,2993,80,,,,,0,435.11,3180.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.160,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 3.5CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-24-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,357.59,45.9,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 7CM 10FR CENTER BEND THIN WALL",SUP-M00534690,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,311.8,28.62,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Culture Stool",PX-306000002,CDM,87045,CPT,0306,RC,,,both,,,286.90,86.07,"KAISER [10500]",Kaiser,,192.22,67,,,,,0,4.26,243.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS ZIPWIRE 26CM 3CM 6FR .038IN PIGTAIL CURVE",SUP-M0061265330,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,165.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +19.5 DIOPTER MODIFIED C BICONVEX 12.5MM 7MM",SUP-CZ70BD.195,CDM,V2632,HCPCS,0276,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL HEAD FROZEN 40MM",SUP-24B002,CDM,S27800098,LOCAL,0278,RC,,,both,,,5733.90,1720.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,679.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,666.85,4873.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY 16CM 20GA 19GA MISSION TRUGUIDE 10MM 20MM BLUNT",SUP-2016MSK,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,278.05,68,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 18X7MM COALITION AGX 7D 10.5MM NONSTERILE",SUP-3128.1577,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 40MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520040M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"UHC [10700]","United Healthcare",,1010.08,63.3,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM CEMENT BASIC SUMMIT 8 12/14 TAPER HIP",SUP-157006150,CDM,C1776,HCPCS,0278,RC,,,both,,,8135.10,2440.53,"BLUE CROSS [10001]","Blue Cross PPO",,3188.96,39.2,,3949.44,3949.44,3949.44,"1 through 10",946.11,6914.84,"percent of total billed charges",
"GRAFT VASCULAR 50CM 7MM FLIXENE 1 SLIDER GDS GRADUATED WALL",SUP-25059,CDM,C1768,HCPCS,0278,RC,,,both,,,8102.19,2430.66,"MULTIPLAN [10600]",Multiplan,,6886.86,85,,,,,0,942.28,6886.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR MEDIUM 11MM 35MM ASYMMETRIC DURACON DURATION",SUP-6642-2-100,CDM,C1776,HCPCS,0278,RC,,,both,,,3753.60,1126.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1074.28,28.62,,,,,0,436.54,3190.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 28MM 2 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.228,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1262.14,28.62,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT MONOLITHIC 14MM PLIF",SUP-3W3114,CDM,S27800098,LOCAL,0278,RC,,,both,,,12487.62,3746.29,"KAISER [10500]",Kaiser,,8366.71,67,,,,,0,1452.31,10614.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN EXTRA BACKUP 4.5 LEFT CURVE",SUP-LA6EBU45,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL PFC SIGMA TC3 2 60X56MM KNEE LEFT CEMENTED",SUP-960081,CDM,C1776,HCPCS,0278,RC,,,both,,,27588.96,8276.69,"BLUE CROSS [10001]","Blue Cross HMO",,10814.87,39.2,,5311.50,4717.44,5388.59,31,3208.6,23450.62,"percent of total billed charges",
"PHYSIO FLEX MITRAL ANNULOPLASTY RING",SUP-5300,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1635.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 111MM 6MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771100600,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"UHC [10700]","United Healthcare",,13229.46,63.3,,8601.07,8395.67,8601.07,"1 through 10",2430.63,17764.68,"percent of total billed charges",
"SCR BONE 6.5MM 150MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.452,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,635.32,45.9,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM LARGE ALLOGRAFT BLOCK FREEZE",SUP-T00220,CDM,S27800098,LOCAL,0278,RC,,,both,,,6109.95,1832.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1748.67,28.62,,,,,0,710.59,5193.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 22-30CM 6FR URETERAL",SUP-M0061456300,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,74.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 15MM 6FR 5.5MM",SUP-H7493926715550,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 60MM 5FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206060670,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM SPINAL POLYAXIAL",SUP-8456550,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1385.95,28.62,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CORTICAL FREEZE DRIED BLOCK",SUP-340841,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 8MM STERNALOCK BLU STERNAL CANCELLOUS LOCK",SUP-73-2708,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,179.7,45.9,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR",SUP-SSR75-01,CDM,A4648,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYNCHRO 2/14 200 CM STANDARD PRESHAPED",SUP-M00326420,CDM,C1769,HCPCS,0272,RC,,,both,,,4186.64,1255.99,"KAISER [10500]",Kaiser,,2805.05,67,,,,,0,486.91,3558.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 20MM 6FR 4.5MM 4FR BALLOON",SUP-39031-45201,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 8IN 40D UP CERVICAL 9X5MM MICRO-KERRISON EJECTOR",SUP-57-0695,CDM,S27200284,LOCAL,0272,RC,,,both,,,2535.15,760.54,"FIRST HEALTH [10303]","First Health",,2028.12,80,,,,,0,294.84,2154.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 4MM X 28MM - US",SUP-90313,CDM,S27200284,LOCAL,0272,RC,,,both,,,35649.18,10694.75,"FIRST HEALTH [10303]","First Health",,28519.34,80,,,,,0,4146,30301.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK",RX-11076,CDM,J3480,HCPCS,0636,RC,00990-7075-26,NDC,both,100,ML,100.65,30.19,"KAISER [10500]",Kaiser,,67.44,67,,,,,0,0.24,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ENDOSCOPIC 11GA IVAS ACCESS LATEX FREE",SUP-306330000,CDM,S27200284,LOCAL,0272,RC,,,both,,,701.97,210.59,"UHC [10700]","United Healthcare",,444.35,63.3,,,,,0,81.64,596.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR 24CM 3CM 8FR .035IN 2 FLOPPY PIGTAIL",SUP-M006180242090,CDM,C2617,HCPCS,0278,RC,,,both,,,1294.14,388.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.51,1100.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 2.5% DEXTROSE 3000ML LOW CALCIUM DIANEAL DIALYSIS",SUP-5B9758,CDM,S27200284,LOCAL,0272,RC,,,both,,,347.89,104.37,"AETNA [10100]","Aetna HMO/PPO",,276.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.46,295.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESPIRATORY NEOPLASMS WITHOUT CC/MCC",182,MS-DRG,,,,,,,inpatient,,,61119.45,18335.83,"AMBETTER EXCHANGE  [11102]",Ambetter,,4675.87,,"Case rate ($4,675.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,341.86, add-ons for qualifying new technology services are included. If operating cost exceeds $37,381.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,710.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,347.60. The transfer operating threshold is the transfer adjustment factor * $4,341.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.27. The transfer capital threshold is the transfer adjustment factor * $328.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,4675.87,18799.02,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 60MM 80CM 12MM BILIARY VENOUS DELIVERY",SUP-G57433,CDM,C1876,HCPCS,0278,RC,,,both,,,13800.00,4140,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1604.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER BREAST BIOPSY TUMARK PROFESSIONAL X EVIVA STD STERILE",SUP-TUMARK-E13-S-X-02,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"CIGNA [10200]",Cigna,,454.14,68,,,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D D KNEE RIGHT OSSEOTI KEEL",SUP-42535006702,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"BLUE CROSS [10001]","Blue Cross HMO",,5396.08,39.2,,5311.50,4717.44,5388.59,31,1600.93,11700.68,"percent of total billed charges",
"SCR BONE 14MM 2.4MM CORTICAL HAND TITANIUM SELF TAPPING",SUP-401.514.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"MULTIPLAN [10600]",Multiplan,,507.01,85,,,,,0,69.37,507.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 40MM 3.2MM 10MM 8.5FR .035IN BILIARY RAPID",SUP-M00570720,CDM,C1874,HCPCS,0278,RC,,,both,,,9158.00,2747.4,"CIGNA [10200]","Cigna Open Access",,5210.9,56.9,,,,,0,1065.08,7784.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cyp2d6 Gene Com Variants",PX-309000021,CDM,81226,CPT,0310,RC,,,both,,,725.00,217.5,"KAISER [10500]",Kaiser,,485.75,67,,,,,0,0.01,725,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REUNION TSA - PRESS-FIT HUMERAL STEM 8MM",SUP-5569-P-2008,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS [10001]","Blue Cross PPO",,4939.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",1465.38,10710,"percent of total billed charges",
"COIL EMBOLIZATION 30CM 12MM .0135IN MICRUSFRAME MICRO",SUP-MFR141230,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"BLUE CROSS [10001]","Blue Cross HMO",,4657.67,39.2,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP MULTIHOLE TRIDENT E HEMISPHERE",SUP-508-11-52E,CDM,C1776,HCPCS,0278,RC,,,both,,,11233.20,3369.96,"CIGNA [10200]",Cigna,,7638.58,68,,5873.17,5873.17,5873.17,"1 through 10",1306.42,9548.22,"percent of total billed charges",
"6F HEXA 2-5-2-5-2 MPA 120CM",SUP-901133,CDM,C1730,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 300MM 6MM BALLOON",SUP-LX1813063005F,CDM,C2623,HCPCS,0272,RC,,,both,,,18270.00,5481,"UHC [10700]","United Healthcare",,11564.91,63.3,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 90MM 5 HOLE LOW PROFILE BONE RIGHT OLECRANON ELBOW",SUP-70-0305,CDM,C1713,HCPCS,0278,RC,,,both,,,7051.80,2115.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,835.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,820.12,5994.03,"percent of total billed charges",
"SCR BONE 4MM 6MM 16MM TITANIUM FULL THREAD CANCELLOUS SMALL",SUP-406.016,CDM,C1713,HCPCS,0278,RC,,,both,,,294.76,88.43,"CIGNA [10200]","Cigna Open Access",,167.72,56.9,,1144.80,304.56,2275.09,66,34.28,250.55,"percent of total billed charges",
"HC Set Rad Ther Field Int",PX-333000005,CDM,77285,CPT,0333,RC,,,both,,,1628.16,488.45,"KAISER [10500]",Kaiser,,1090.87,67,,,,,0,189.36,1628.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM FETAL PILLOW DELIVERY BALLOON CEPHALIC ELEVATION",SUP-FP-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,5649.95,1694.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3841.97,68,,,,,0,657.09,4802.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERCI 95CM 9FR GUIDING SILICONE BALLOON STERILE LATEX",SUP-90074,CDM,C1725,HCPCS,0272,RC,,,both,,,9696.36,2908.91,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE 13MM CUFF LOW PRESSURE SHILEY TRACH 10 LATEX FREE",SUP-10LPC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1040.12,312.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC",522,MS-DRG,,,,,,,inpatient,,,100547.02,30164.11,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE Y 2MM SCR 6 HOLE VLP MINI-MOD BONE",SUP-74442010,CDM,C1887,HCPCS,0272,RC,,,both,,,5770.13,1731.04,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER CHOCOLATE 150CM 80MM 2.5MM .014IN BALLOON DILATATIO",SUP-CB1415025080OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 018 150CM 8CM 2.5MM BALLOON DILATATION",SUP-U81502H8,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Intro GI Tube Long",PX-361000173,CDM,44500,CPT,0361,RC,,,both,,,2973.36,892.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1729.39,,"Case rate ($1,729.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,345.8,2973.36,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Potassium Body Fluid",PX-301000363,CDM,84132,CPT,0301,RC,,,both,,,107.00,32.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7.49,,,,,,,0.11,90.95,"fee schedule",
"CATH SABERX 200CM 300MM 6MM BALLOON DILATATION RAPID",SUP-47560300L,CDM,C1725,HCPCS,0272,RC,,,both,,,1890.00,567,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,219.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 24MM TARGET 360D 2XL DETACHABLE",SUP-M0036182450,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.185 CLAREON",SUP-SY60WF.185,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 11MM KNEE X3 CONDYLAR STABILIZED PRIMARY",SUP-5531G411,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"KAISER [10500]",Kaiser,,6275.27,67,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRT-D DTBA1D1 VIVA XT IS1/DF1 US",SUP-DTBA1D1,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"PHCS [10601]",PHCS,,40404,70,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 92CM 1MM 6FR 2MM SPACE D CURVE ELECTROPHYSIOLOGY",SUP-D608DR002CT,CDM,C1730,HCPCS,0272,RC,,,both,,,1997.50,599.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,236.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,232.31,1697.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 135CM 8MM 30MM",SUP-H74938047830130,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]",Cigna,,2570.4,68,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL ADULT MEDIUM O2 RESVR BAG MASK LATEX FREE",SUP-520611000,CDM,S27000186,LOCAL,0270,RC,,,both,,,57.07,17.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.64,48.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM SPINE MULTIAXIAL",SUP-8806550A,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"KAISER [10500]",Kaiser,,6396.39,67,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 28CM 3CM 5FR .035IN 2 PIGTAIL",SUP-M006192124050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"NOVANET [10819]",Novanet,,900.44,75,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SPECIMEN RETRIEVAL EXTRA STRENGTH STONE 3 PRONG HOOK",SUP-M0063701230,CDM,S27200284,LOCAL,0272,RC,,,both,,,1376.11,412.83,"PHCS [10601]",PHCS,,963.28,70,,,,,0,160.04,1169.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 30MM 2MM ULTRA LOW PROFILE BALLOON",SUP-1012270-30,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 7MM TARGET XL 360D STD LARGE",SUP-M0036107200,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 12IN .25IN PVC 3 SPRING EVAC TROCAR Y CNCT TUBE",SUP-0043620,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.12,19.84,"UHC [10700]","United Healthcare",,41.85,63.3,,,,,0,7.69,56.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR DYNASTY A-CLASS STD 28MM POLY BIOFOAM HIP",SUP-DLXPGB28,CDM,C1776,HCPCS,0278,RC,,,both,,,7507.20,2252.16,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,873.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,873.09,6381.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 10D E HIP X3 TRIDENT",SUP-623-10-36E,CDM,C1776,HCPCS,0278,RC,,,both,,,6879.60,2063.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3157.74,45.9,,,,,0,800.1,5847.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYNTHETIC TISSUE SCAFFOLD PATCH 6X9 CM",SUP-31049,CDM,C1763,HCPCS,0278,RC,,,both,,,19782.00,5934.6,"MULTIPLAN [10600]",Multiplan,,16814.7,85,,,,,0,2300.65,16814.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENV TISSUE 6.9X6.5CM CANGAROO MEDIUM SOFT SUPPLE POCKET NO",SUP-CMCV-010-MED,CDM,S27800098,LOCAL,0278,RC,,,both,,,31027.50,9308.25,"FIRST HEALTH [10303]","First Health",,24822,80,,,,,0,3608.5,26373.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL IDENTITY IMPRINT 3 H10 MM KNEE POSTERIOR STABI",SUP-TPS-020-103S,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"KAISER [10500]",Kaiser,,3938.8,67,,,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 15D 58MM 32MM MARATHON HIP STERILE",SUP-121932258,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"KAISER [10500]",Kaiser,,5434.34,67,,,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inf Agent Detect Dna Cov Rsv 4 Targets",PX-306000238,CDM,87637,CPT,0306,RC,,,both,,,1135.00,340.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,127.03,,"Fee schedule rate ($127.03).",,,,0,127.03,964.75,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 60MM 4MM TAPER BALLOON DILATATION JET",SUP-A2040-060,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HARVESTER 9MM GRAFT QUADPRO",SUP-AR-2386-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,3346.88,1004.06,"MULTIPLAN [10600]",Multiplan,,2844.85,85,,,,,0,389.24,2844.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Sclp/Ax/Tr/Ext <=2.5 Int",PX-450000031,CDM,12031,CPT,0450,RC,,,both,,,920.57,276.17,"CIGNA [10200]","Cigna Open Access",,920.57,,,,,,,67.13,920.57,"case rate",
"HC Antithrombin III Ag",PX-305000031,CDM,85301,CPT,0305,RC,,,both,,,516.75,155.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,38.39,,,,,,,0.01,439.24,"fee schedule",
"VIABAHN BX BALLOON EXP ENDO 8MMX79MM 8FR 135CMCATH HEPARIN",SUP-BXB087902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"UHC [10700]","United Healthcare",,13550.88,63.3,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tiss Cult Skin or Solid Tumor",PX-311000026,CDM,88233,CPT,0311,RC,,,both,,,1359.45,407.83,"BLUE CROSS [10001]","Blue Cross PPO",,179.8,,"Fee schedule rate ($179.80).",,,,0,0.01,1155.53,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Txcath",PX-361000140,CDM,37200,CPT,0361,RC,,,both,,,3423.00,1026.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,405.63,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,398.09,3423,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES",769,MS-DRG,,,,,,,inpatient,,,68348.04,20504.41,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,11215.67,,"Case rate ($10,481.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,733.18, add-ons for qualifying new technology services are included. If operating cost exceeds $42,772.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,117.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,746.06. The transfer operating threshold is the transfer adjustment factor * $9,733.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.88. The transfer capital threshold is the transfer adjustment factor * $735.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,49335.4,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 28CM 4.8FR .035IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856090,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"NOVANET [10819]",Novanet,,822.5,75,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 90MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.440,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"NOVANET [10819]",Novanet,,1038.1,75,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 40MM SMALL PEG PERFORM SHOULDER ALL POLY",SUP-DWE303,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"UHC [10700]","United Healthcare",,5897.03,63.3,,8601.07,8395.67,8601.07,"1 through 10",1083.45,7918.6,"percent of total billed charges",
"HC Alpha1 Antitrypsin Phenotype",PX-301000096,CDM,82104,CPT,0301,RC,,,both,,,981.35,294.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13.01,,,,,,,0.01,834.15,"fee schedule",
"KIT INTRO 4IN 5FR 21GA S-MAK .018IN PLATINUM COIL TIP",SUP-S-MAK501NBT,CDM,C1894,HCPCS,0272,RC,,,both,,,334.78,100.43,"KAISER [10500]",Kaiser,,224.3,67,,,,,0,38.93,284.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 32MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.832,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",40.86,298.61,"percent of total billed charges",
"CATH C315HIS02 RIGHTSITE",SUP-C315HIS02,CDM,C1887,HCPCS,0272,RC,,,both,,,2175.00,652.5,"PHCS [10601]",PHCS,,1522.5,70,,,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TPAK 10 GAUGE DECOMPRESSION NEEDLE",SUP-TM-310,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.12,20.44,"CIGNA [10200]","Cigna Open Access",,38.76,56.9,,,,,0,7.92,57.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grad Compression Thight 20-30",PX-E27100024,CDM,A6533,HCPCS,0292,RC,,,both,,,191.40,57.42,"CIGNA [10200]","Cigna Local Plus",,102.4,53.5,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM",RX-16299,CDM,,,0637,RC,00904-5354-31,NDC,both,28,GR,27.30,8.19,"KAISER [10500]",Kaiser,,18.29,67,,,,,0,3.17,23.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 2.7/3.5/4 MM SCR FUSION MEDLINE UNITE BONE FOOT LEFT",SUP-MPP8201L,CDM,C1713,HCPCS,0278,RC,,,both,,,11005.50,3301.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1304.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1279.94,9354.68,"percent of total billed charges",
"CANN NASAL INFANT PROSOFT NONSTERILE LATEX FREE DISPOSABLE",SUP-PROSOFT-INF,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.06,33.62,"CIGNA [10200]","Cigna Open Access",,63.76,56.9,,,,,0,13.03,95.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 103MM 14-25MM 18FR ENDURANT IIS 2 BRANCH",SUP-ESBF2514C103E,CDM,S27800098,LOCAL,0278,RC,,,both,,,60782.40,18234.72,"AETNA [10100]","Aetna HMO/PPO",,48322.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7068.99,51665.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"7F DECA 7-7-7 PV24 110CM",SUP-901645,CDM,C1730,HCPCS,0272,RC,,,both,,,5692.50,1707.75,"KAISER [10500]",Kaiser,,3813.98,67,,,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 28.2MM 26.8IN ATS OPEN PIVOT 28MM 4.59SQ CM STD",SUP-505DA26,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9450,40,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 ULTRA 5MM X 10CM",SUP-M0035425100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5801.12,41.1,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 50MM REFLECTION HIP SPHERICAL HEAD",SUP-71332550,CDM,C1713,HCPCS,0278,RC,,,both,,,1287.90,386.37,"FIRST HEALTH [10303]","First Health",,1030.32,80,,,,,0,149.78,1094.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 3MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140303,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"KAISER [10500]",Kaiser,,7960.81,67,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OLBT 180CM 10MM 5.8FR 4MM",SUP-6765,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Virus Ab Nos",PX-302000169,CDM,86790,CPT,0302,RC,,,both,,,593.75,178.12,"KAISER [10500]",Kaiser,,397.81,67,,,,,0,0.01,504.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Nasal Bn>=3v",PX-320000010,CDM,70160,CPT,0320,RC,,,both,,,604.70,181.41,"UHC [10700]","United Healthcare",,216.45,,,,,,,46.53,514,"fee schedule",
"SCR BONE 4.5MM 15MM HELIX R SPINE SELF TAP FIX ANGLE",SUP-7806215,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,396.9,39.2,,957.42,570.23,957.42,28,117.75,860.63,"percent of total billed charges",
"CATH NC SPRINTER FASTRAC 138CM 6MM 2.4/2.6-1.9FR 3.75MM",SUP-NCSP37506X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO AQUA 125CM 4FR STRAIGHT ANGIOGRAPHIC NYLON",SUP-SRD6667,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,78.67,41.1,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 33MM SIMULUS FULLY FLEXIBLE",SUP-700FC33,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Open Access",,4391.85,33.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 210MM PERFORM 9 XLONG SHOULDER STERILE LATEX",SUP-PFX09210,CDM,C1776,HCPCS,0278,RC,,,both,,,51351.30,15405.39,"MULTIPLAN [10600]",Multiplan,,43648.61,85,,,,,0,5972.16,43648.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KETOCONAZOLE 2 % TOPICAL CREAM",RX-10368,CDM,,,0250,RC,00168-0099-15,NDC,both,15,GR,194.36,58.31,"PHCS [10601]",PHCS,,136.05,70,,,,,0,22.6,165.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 20FR 20CM COONS TAPER STERILE DISPOSABLE",SUP-G04264,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.61,54.78,"PHCS [10601]",PHCS,,127.83,70,,,,,0,21.24,155.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM DARCO TITANIUM FOOT LOCK",SUP-DC2825018,CDM,C1713,HCPCS,0278,RC,,,both,,,1036.80,311.04,"NOVANET [10819]",Novanet,,777.6,75,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 15MM 3.5MM BALLOON DILATATION PACLITAXEL",SUP-H7493960815350,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,17856.25,45.9,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 6.35MM TSRH-2D CONTOUR PEDICLE TITANIUM",SUP-8371070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 135CM 5MM 20MM",SUP-H74938047520130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2291.33,45.9,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 1.8MM PILOT",SUP-320-0018,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,724.99,45.9,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) BAROSTIM NEO IPG MODEL 2102",SUP-100054-202,CDM,C1825,HCPCS,0278,RC,,,both,,,179550.00,53865,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20881.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20881.67,152617.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 11.5CM 4MM CEREPAK MICRO UNIFORM",SUP-FCX100412,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"UHC [10700]","United Healthcare",,8371.96,63.3,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM EXCELSIOR XT-27 1 TIP",SUP-M003XT2750910,CDM,S27200284,LOCAL,0272,RC,,,both,,,8474.58,2542.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1004.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,985.59,7203.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035424060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"MULTIPLAN [10600]",Multiplan,,11997.44,85,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTALBITAL 50 MG-ACETAMINOPHEN 325 MG-CAFFEINE 40 MG-CODEINE 30 MG CAP",RX-30350,CDM,,,0250,RC,00591-3220-01,NDC,both,1,UN,13.88,4.16,"CIGNA [10200]","Cigna Open Access",,7.9,56.9,,,,,0,1.61,11.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION COMPLETE CARE ADD-A-FOLEY STATLOCK 2L",SUP-399400A,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.39,22.92,"UHC [10700]","United Healthcare",,48.35,63.3,,,,,0,8.88,64.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY 2-5-2MM SPACING 1MM 6FR 115CM 4MM",SUP-401606R,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL RUSSIAN 6IN TISSUE",SUP-07-1515,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.21,22.86,"PHCS [10601]",PHCS,,53.35,70,,,,,0,8.86,64.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR AL2 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916599982,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"NOVANET [10819]",Novanet,,57.44,75,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 55MM 8MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113608,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"KAISER [10500]",Kaiser,,8442,67,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ON-Q PAINBUSTER 2ML/HR PAIN PUMP 100ML 2 DAY DELIVERY",SUP-P100X2,CDM,C9804,HCPCS,0272,RC,,,both,,,694.09,208.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,285.27,41.1,,,,,0,80.72,589.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.3MM 38MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.528,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"BLUE CROSS [10001]","Blue Cross HMO",,453.42,39.2,,957.42,156.86,7483.26,51,134.52,983.18,"percent of total billed charges",
"SCR BONE 7.3MM 65MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-02.207.465,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,714.14,45.9,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT 17GA 50MM ELECTROTHERAPY COOLIEF STERILE LATEX FREE",SUP-CRK-17-50-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TS STAGE",SUP-PRO-6994,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL OXFORD C KNEE LEFT MEDIAL COCRMO",SUP-154722,CDM,C1776,HCPCS,0278,RC,,,both,,,11195.94,3358.78,"MULTIPLAN [10600]",Multiplan,,9516.55,85,,,,,0,1302.09,9516.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 125CM 6FR PIGTAIL CURVE ANGIOGRAPHIC PERIPHERAL",SUP-H749165992152,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP IRRIGATION INTERPULSE LONG COAXIAL FEMORAL CANAL STERILE",SUP-0210-007-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.99,28.2,"PHCS [10601]",PHCS,,65.79,70,,,,,0,10.93,79.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 22CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155231180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 30MM 125CM 10MM 6FR .035IN VASCULAR NITINOL",SUP-G43840,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1735.02,45.9,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM CEMENT AVENIR PROTASUL-S30 2 39.17MM STD",SUP-106010202,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,5873.17,5873.17,5873.17,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"KIT CATH ADULT 55CM 15.5FR DURATHANE DURAFLOW EMBOSAFE BASIC",SUP-H787103012115,CDM,C1750,HCPCS,0278,RC,,,both,,,1104.50,331.35,"KAISER [10500]",Kaiser,,740.02,67,,,,,0,128.45,938.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X120 80CM SL",SUP-48003012N,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,118.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 3MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012274-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 30MM 6FR 3.25MM",SUP-H7493926730320,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"NOVANET [10819]",Novanet,,425.25,75,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LOCKING CREO SPINAL MIS NONSTERILE",SUP-1134.001,CDM,C1713,HCPCS,0278,RC,,,both,,,707.94,212.38,"MULTIPLAN [10600]",Multiplan,,601.75,85,,,,,0,50.59,601.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX10MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183740,CDM,C1776,HCPCS,0278,RC,,,both,,,13241.10,3972.33,"CIGNA [10200]",Cigna,,5296.44,40,,5873.17,5873.17,5873.17,"1 through 10",1539.94,11254.94,"percent of total billed charges",
"SCR BONE 7MM 2MM DCP SMALL BONE STAINLESS STEEL SELF TAPPING",SUP-201.877,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"BLUE CROSS [10001]","Blue Cross HMO",,276.5,39.2,,957.42,156.86,7483.26,51,82.03,599.55,"percent of total billed charges",
"CATH DXTERITY 100CM 5FR .047IN AMPLATZ LEFT 2 CURVE",SUP-DXT5AL20,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 40MM COCR SPINE MULTIAXIAL 5.5MM ROD",SUP-55840006040,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM .0115IN AXIUM PRIME LATTICEFX 3D",SUP-APB-4-10-3D-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,10074.00,3022.2,"CIGNA [10200]",Cigna,,6850.32,68,,,,,0,1171.61,8562.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR RINGLOC 25 +3MM 40MM ARCOMXL HIP STERILE",SUP-XL-108525,CDM,C1776,HCPCS,0278,RC,,,both,,,7249.14,2174.74,"PHCS [10601]",PHCS,,5074.4,70,,,,,0,843.07,6161.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SENTAI FIGHTER VASCULAR 300CM SPECIALITY CROSS",SUP-H749393033002,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,660.96,68,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.5MM X 15.0MM",SUP-493501512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 2MM SPACE A CURVE ELECTROPHYSIOLOGY",SUP-1086259RT,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"KAISER [10500]",Kaiser,,976.86,67,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DIL AMPLATZ FIRM KINK RESISTANT GRADUATED TAPER 35CM",SUP-M0062601000,CDM,C1894,HCPCS,0272,RC,,,both,,,1670.40,501.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,686.53,41.1,,,,,0,194.27,1419.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PREVENA PLUS NEGATIVE PRESSURE STANDALONE EXTEND",SUP-PRE4010.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"FIRST HEALTH [10303]","First Health",,2700,80,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 25CM 14FR PIGTAIL CURVE DRNG POLYURETHANE",SUP-RLC-14-038MB,CDM,C1729,HCPCS,0272,RC,,,both,,,537.19,161.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRIVER NDL 55.1CM 5MM DA VINCI S/SI ENDOWRIST 30- D .9CM",SUP-420117,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 10MM 2MM",SUP-SPL20010X,CDM,C1725,HCPCS,0272,RC,,,both,,,577.13,173.14,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2MM 11MM APTUS TRI-LOCK TITANIUM FOOT HAND WRIST",SUP-A-5450.11/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUFF TRNQT CYL 24X4IN 2 PORT TUBING LIMB PROTECTION SLEEVE",SUP-5921-024-235,CDM,S27200284,LOCAL,0272,RC,,,both,,,185.29,55.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ROUTER SURGICAL TAPER OD2.3 MM BLUE RED",SUP-5407FA2023,CDM,S27200284,LOCAL,0272,RC,,,both,,,1009.26,302.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT WALLFLEX 80MM 10MM BILIARY PARTIAL COVER TRANSHEPATIC",SUP-7474,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +29 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.290,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,197.05,28.62,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH VERSACROSS 45D 0 CURVE PIGTAIL 81CM 230CM 8.5FR",SUP-VXSK0037,CDM,C1893,HCPCS,0272,RC,,,both,,,6175.50,1852.65,"AETNA [10100]","Aetna HMO/PPO",,4909.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP 3 HOLE EMPHASYS",SUP-471054300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2127.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2088.17,15261.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Intermediate Procedure",PX-450000382,CDM,450000382,LOCAL,0361,RC,,,both,,,1687.35,506.2,"AETNA [10100]","Aetna HMO/PPO",,1341.44,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,196.24,1434.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 53MM TITANIUM 3 LEVEL ZEVO BONE SPINE CERVICAL",SUP-3003053,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (CR) - SIZE 8",SUP-5555-2208,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"UHC [10700]","United Healthcare",,897.28,63.3,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X14X7MM ENDOSKELETON TC 6D MEDIUM LORDOTIC",SUP-5166-1407,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"PHCS [10601]",PHCS,,4674.89,70,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) LEADLESS DR PM 19.5F 38.0 MM RV",SUP-LSP202V,CDM,C1786,HCPCS,0275,RC,,,both,,,44100.00,13230,"CIGNA [10200]","Cigna Local Plus",,13891.5,31.5,,,,,0,5128.83,37485,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN JUDKINS RIGHT 6 CURVE",SUP-DXT6JR60,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 7CM 7FR CENTER BEND BILIARY PLASTIC",SUP-M00534570,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"KAISER [10500]",Kaiser,,729.93,67,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 30MM 2.25MM CORONARY RAPID EXCHANGE",SUP-ONYXNG22530UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"KAISER [10500]",Kaiser,,1758.75,67,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK CATH 45CM 14.5FR 14FR PALINDROME TAL VENATRAC 2 LUMEN 2",SUP-8888128454P,CDM,C1750,HCPCS,0278,RC,,,both,,,2649.68,794.9,"MULTIPLAN [10600]",Multiplan,,2252.23,85,,,,,0,308.16,2252.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X11X10MM VERTEX PEEK-OPTIMA ANATOMIC",SUP-6240041,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,791.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URETEROSCOPE FLEXIBLE 9.5FR 7.7FR 3.6FR LITHOVUE STD",SUP-M0067913500,CDM,C1747,HCPCS,0272,RC,,,both,,,10350.00,3105,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1203.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL THK3-6MM ALLOGRAFT STRUT FREEZE DRIED 60",SUP-400600,CDM,S27800098,LOCAL,0278,RC,,,both,,,5729.76,1718.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2629.96,45.9,,,,,0,666.37,4870.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 25MM 9.5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ225,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3710.39,41.1,,6417.48,6417.48,6417.48,"1 through 10",1049.92,7673.56,"percent of total billed charges",
"SNR SM OVL 240CM 2.4MM SNS",SUP-6269,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"AETNA [10100]","Aetna HMO/PPO",,69.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETERAL LEVEEN INFLATOR GAUGE HIGH PRESSURE .038IN 5.8",SUP-M0062251220,CDM,C1726,HCPCS,0272,RC,,,both,,,2024.93,607.48,"MULTIPLAN [10600]",Multiplan,,1721.19,85,,,,,0,235.5,1721.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE LEAD DISP 12 LEAD SZ 7L",SUP-LS-20B,CDM,S27000186,LOCAL,0270,RC,,,both,,,8939.09,2681.73,"PHCS [10601]",PHCS,,6257.36,70,,,,,0,1039.62,7598.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 20MM 3.75MM BALLOON DILATATION",SUP-NCEUP37520X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 20MM EDWARDS SAPIEN 3 TRANSCATHETER ULTRA LOW",SUP-S3USTA120A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"NOVANET [10819]",Novanet,,138937.5,75,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 24X10X9-5.7MM LUMINARY BULLET NOSE",SUP-15809,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC IPERIA 7 PROMRI DF-1 IMPLANTABLE",SUP-393007,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA [10200]",Cigna,,23088,40,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUSPIRONE 5 MG TABLET",RX-9324,CDM,,,0637,RC,00904-7122-61,NDC,both,1,UN,6.27,1.88,"FIRST HEALTH [10303]","First Health",,5.02,80,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 40MM VIPER 2 TITANIUM SPINE CANNULATED EXTEND",SUP-186760040,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"SUT PROLENE 6-0 P-3 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8695G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHNT HKM PRC VNTRC 70MM HP 175777",SUP-823008,CDM,S27800098,LOCAL,0278,RC,,,both,,,14545.20,4363.56,"AETNA [10100]","Aetna HMO/PPO",,11563.43,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1691.61,12363.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER CONNECTING PLATES 30MM TRUELOK",SUP-54-11660,CDM,C1713,HCPCS,0278,RC,,,both,,,756.86,227.06,"CIGNA [10200]","Cigna Local Plus",,404.92,53.5,,3978.14,359.25,3978.14,24,88.02,643.33,"percent of total billed charges",
"BALL THERAPEUTIC SMALL SPHERE HAND FOREARM WRIST METAL",SUP-A83720,CDM,S27000186,LOCAL,0270,RC,,,both,,,151.90,45.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOLDER 8.25IN JACOBSON IMPREGNATE LOCK NDL TUNGSTEN CARBIDE",SUP-55-2525,CDM,S27200284,LOCAL,0272,RC,,,both,,,1551.07,465.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRACE ORTHOPEDIC XL 24IN 22-24IN KNEE 2 AXIS 1 PIECE HINGE",SUP-79-94258,CDM,S27000186,LOCAL,0270,RC,,,both,,,428.91,128.67,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEALER BIPOLAR AQUAMAN EDIDURAL VIEN",SUP-23-121-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT INNOVA 100MM 75CM 6MM VASCULAR METAL SUPERFICIAL",SUP-H74939293061070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1382.35,28.62,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PICK SURGICAL 13CM 1.5MM 45D XL POWERPICK POWER TROCAR",SUP-AR-8150PX-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.01,257.7,"AETNA [10100]","Aetna HMO/PPO",,682.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL 2.8 X 160MM SOLID MEASURING LONG AO",SUP-P99-100-2816,CDM,S27000186,LOCAL,0270,RC,,,both,,,1004.40,301.32,"NOVANET [10819]",Novanet,,753.3,75,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 36CM HIP LEFT FEMUR AFFIXUS INTRAMEDULLARY 125D",SUP-814411360,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"AETNA [10100]","Aetna HMO/PPO",,16490.49,79.5,,1521.93,481.35,16760.95,30,2412.38,17631.34,"percent of total billed charges",
"SHEATH HEARTSPAN 120D FIX CURVE TAPER 79.4CM 8.5FR GUIDING",SUP-FCL-160-09,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prolact Rtf24 Qtr Btl",PX-E27000212,CDM,E27000212,LOCAL,0270,RC,,,both,,,214.50,64.35,"NOVANET [10819]",Novanet,,160.88,75,,,,,0,24.95,182.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PREGABALIN 25 MG CAPSULE",RX-42162,CDM,,,0637,RC,60687-0473-11,NDC,both,1,UN,14.51,4.35,"MULTIPLAN [10600]",Multiplan,,12.33,85,,,,,0,1.69,12.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY INTRO EXPRESS KYPHOPAK FIRST FRACTURE 10/2",SUP-KPE1001-CDS,CDM,C1894,HCPCS,0272,RC,,,both,,,13098.00,3929.4,"UHC [10700]","United Healthcare",,8291.03,63.3,,,,,0,1523.3,11133.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE MARKER 4 X 4 BIOZORB",SUP-F0404,CDM,A4648,HCPCS,0278,RC,,,both,,,7935.00,2380.5,"CIGNA [10200]","Cigna Open Access",,4515.02,56.9,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.9MM X 350MM TRILOGY PROBE KIT",SUP-M0068403540,CDM,S27200284,LOCAL,0272,RC,,,both,,,5531.45,1659.43,"CIGNA [10200]","Cigna Open Access",,3147.4,56.9,,,,,0,643.31,4701.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLS-2507 CLASSICSHEATH LONG",SUP-398723,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"NOVANET [10819]",Novanet,,394.88,75,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR ANGIOGRAPHY LATEX FREE MARK 7 ARTERION","SUP-ART 700 SYR",CDM,S27200284,LOCAL,0272,RC,,,both,,,73.29,21.99,"CIGNA [10200]",Cigna,,49.84,68,,,,,0,8.52,62.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 60MM 5FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206060670,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPO 100CM 6FR .056IN FEMORAL RIGHT 4 CURVE",SUP-H74908641022,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN RADIOFREQUENCY 10CM 18GA SIDEKICK 2 10MM DEPLOYMENT",SUP-RFK-C101018S-ZK2-P,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.95,74.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT TRACH 9MM PORTEX PREFIT PERCUTANEOUS STERILE LATEX FREE",SUP-101/815/090,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.48,103.04,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD PACING 115CM 5FR BARD 1CM PROXIMAL BIPOLAR DISTAL",SUP-006225P,CDM,S27200284,LOCAL,0272,RC,,,both,,,5508.96,1652.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC",082,MS-DRG,,,,,,,inpatient,,,77613.92,23284.18,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DOYEN STRAIGHT 9IN INTESTINE SERRATE",SUP-50-1673,CDM,S27200284,LOCAL,0272,RC,,,both,,,1105.49,331.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MATRIX TISSUE 16X10CM STRATTICE LIFECELL 160SQ CM",SUP-1016002P,CDM,Q4130,HCPCS,0636,RC,,,both,,,25181.10,7554.33,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"EXTRAOCULAR PROCEDURES EXCEPT ORBIT",115,MS-DRG,,,,,,,inpatient,,,74074.89,22222.47,"CIGNA [10200]",Cigna,,,68,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Elastogel",PX-E27200110,CDM,E27200110,LOCAL,0272,RC,,,both,,,24.20,7.26,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL BIT ASSY, CARBIDE, HUDSON END, 5 MM, SINGLE USE",SUP-SBT004,CDM,S27000186,LOCAL,0270,RC,,,both,,,2212.50,663.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE UROLOGICAL STRAIGHT 150CM .038IN PTFE MOVABLE CORE",SUP-M0066201030,CDM,C1769,HCPCS,0272,RC,,,both,,,118.41,35.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT EVOLUTION FLEXOR 8MM 230MM 25MM 30MM COLONIC CONTROL",SUP-G48028,CDM,C1876,HCPCS,0278,RC,,,both,,,17854.20,5356.26,"FIRST HEALTH [10303]","First Health",,14283.36,80,,,,,0,2076.44,15176.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR 28CM 11-13FR ACCESS STAINLESS STEEL",SUP-M0062502011,CDM,C1894,HCPCS,0272,RC,,,both,,,815.04,244.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,554.23,68,,,,,0,94.79,692.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 150MM 7MM BALLOON DILATATION HYDROPHILIC",SUP-607015022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"UHC [10700]","United Healthcare",,461.46,63.3,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE MATRIX ALLOGRAFT STRIP",SUP-T42280,CDM,S27800098,LOCAL,0278,RC,,,both,,,16146.00,4843.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1877.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1877.78,13724.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 4-0 PS-2 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J496G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 3-5 C-D KNEE RIGHT VIVACIT-E",SUP-42522600410,CDM,C1776,HCPCS,0278,RC,,,both,,,12351.00,3705.3,"PHCS [10601]",PHCS,,8645.7,70,,,,,0,1436.42,10498.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE FEEDING TUBE ENFIT FARRELL ENTERAL GASTRIC PRESSURE",SUP-43-4100,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.63,16.99,"CIGNA [10200]","Cigna Local Plus",,30.3,53.5,,,,,0,6.59,48.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +13.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000135,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 16FR SILICONE MIC FEED TUBE INTERNAL",SUP-8260-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,2567.55,770.26,"PHCS [10601]",PHCS,,1797.29,70,,,,,0,298.61,2182.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 160MM 10MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424043,CDM,C1776,HCPCS,0278,RC,,,both,,,12181.95,3654.58,"NOVANET [10819]",Novanet,,9136.46,75,,,,,0,1416.76,10354.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION YELLOW HOFFMANN II MRI STRAIGHT CURVED",SUP-4921-0-000,CDM,C1713,HCPCS,0278,RC,,,both,,,16150.55,4845.16,"NOVANET [10819]",Novanet,,12112.91,75,,,,,0,1878.31,13727.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X10MM COROENT 10D XL+ WIDE PEEK NONSTERILE",SUP-6310250,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"PHCS [10601]",PHCS,,16758,70,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 370CC",SUP-SMPX370,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"CIGNA [10200]","Cigna Local Plus",,3986.82,,,,,,,866.67,6334.2,"percent of total billed charges",
"CATH STELLAREX 135CM 80MM 5MM BALLOON DILATATION ENDURACOAT",SUP-AB35SX050080135,CDM,C2623,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"MULTIPLAN [10600]",Multiplan,,7917.75,85,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA MIV 110CM 5FR PIGTAIL LT CURVE ANGIOGRAPHIC",SUP-5RPL110-NB,CDM,S27200284,LOCAL,0272,RC,,,both,,,197.93,59.38,"PHCS [10601]",PHCS,,138.55,70,,,,,0,23.02,168.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immunoassay Non Infect Ab/Ag",PX-301000243,CDM,83516,CPT,0301,RC,,,both,,,146.90,44.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,18.14,,,,,,,0.01,124.87,"fee schedule",
"BLADE 8.25MM HANNA SURGICAL",SUP-17171D825,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"CIGNA [10200]",Cigna,,517.75,68,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLENOSPHERE - 32MM DIA X 2MM THK CONCENTRIC",SUP-5573-C-3202,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"NOVANET [10819]",Novanet,,9144.9,75,,,,,0,1418.07,10364.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VXSK-180J RF WIRE 63CM/90DEG/D1 SHEATH",SUP-VXSK0106,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"MULTIPLAN [10600]",Multiplan,,5249.18,85,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QDOT MICRO F CURVE ABLATION UNIDIRECTIONAL",SUP-D139402,CDM,C1732,HCPCS,0272,RC,,,both,,,22560.30,6768.09,"KAISER [10500]",Kaiser,,15115.4,67,,,,,0,2623.76,19176.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 8MM 48MM STAINLESS STEEL STD CORTEX LARGE",SUP-214.048,CDM,C1713,HCPCS,0278,RC,,,both,,,464.78,139.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,55.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,54.05,395.06,"percent of total billed charges",
"INTRO LEAD 75CM 5FR .046IN WORLEY ERGONOMIC WING HUB BRAID",SUP-57538CSHK-WOR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1010.88,303.26,"AETNA [10100]","Aetna HMO/PPO",,803.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.57,859.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOR BLADDER PROCEDURES WITHOUT CC/MCC",664,MS-DRG,,,,,,,inpatient,,,54205.43,16261.63,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,6948.57,,"Case rate ($6,493.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,030.10, add-ons for qualifying new technology services are included. If operating cost exceeds $39,069.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,837.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,038.08. The transfer operating threshold is the transfer adjustment factor * $6,030.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.91. The transfer capital threshold is the transfer adjustment factor * $455.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,6493.99,30565.29,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM GRAY FLEXIBLE BLADE SURGICAL 6MMX67MM STERILE",SUP-6210-0-720,CDM,S27200284,LOCAL,0272,RC,,,both,,,1377.10,413.13,"CIGNA [10200]",Cigna,,936.43,68,,,,,0,160.16,1170.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 12MM MATRIXNEURO CRANIOMAXILLOFACIAL TITANIUM 2",SUP-04.503.062,CDM,C1713,HCPCS,0278,RC,,,both,,,1101.60,330.48,"NOVANET [10819]",Novanet,,826.2,75,,,,,0,128.12,936.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL ULTRAPRO 12X12IN PARTIAL ABSORBABLE",SUP-UML1,CDM,C1781,HCPCS,0278,RC,,,both,,,1985.63,595.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,568.29,28.62,,,,,0,230.93,1687.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS .115IN DUOSTAT ROTATE",SUP-23245,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,67.94,41.1,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 55MM TSRH OSTEOGRIP THINLINE SPINAL",SUP-83585559,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4382,45.9,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE LOCALIZATION 20CM 20GA GHIATAS BREAST BEAD NDL 9CM",SUP-47920,CDM,A4648,HCPCS,0278,RC,,,both,,,182.79,54.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.26,155.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP SMALL ADULT FULL 2 FLAP FOREHEAD SPRT HEADSTRAP",SUP-1012623,CDM,S27000186,LOCAL,0270,RC,,,both,,,211.50,63.45,"CIGNA [10200]","Cigna Local Plus",,113.15,53.5,,,,,0,24.6,179.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 45MM 3MM SHORT CARBIDE ROUND STERILE",SUP-0277010230,CDM,S27200284,LOCAL,0272,RC,,,both,,,262.31,78.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,120.4,45.9,,,,,0,30.51,222.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CLOTTRIEVER 16FR THROMBECTOMY",SUP-51-101,CDM,C1894,HCPCS,0272,RC,,,both,,,13800.00,4140,"PHCS [10601]",PHCS,,9660,70,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 100MM 120CM 7MM VASCULAR PERIPHERAL SELF",SUP-PRB35-07-100-120,CDM,C1876,HCPCS,0278,RC,,,both,,,7098.00,2129.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2031.45,28.62,,,,,0,825.5,6033.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 18MM 145CM 2.5MM CORONARY STENT",SUP-1125250-18,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3969.84,68,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN MULTIPURPOSE A CURVE",SUP-DXT6MPA,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.97,41.1,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE DISTAL RADIAL CORTICAL WRIST HAND LOCKING THREADED",SUP-CO-T2318,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"BLUE CROSS [10001]","Blue Cross PPO",,298.47,39.2,,957.42,570.23,957.42,28,88.55,647.19,"percent of total billed charges",
"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC",981,MS-DRG,,,,,,,inpatient,,,173901.28,52170.38,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 5X4CM BOVINE PERICARDIUM RESORBABLE SUTURABLE",SUP-BP10405,CDM,Q4432,HCPCS,0636,RC,,,both,,,3501.53,1050.46,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SEEKER 135CM SPRT HYDROPHILIC PERIPHERAL RADIOPAQUE",SUP-SK13518,CDM,C1887,HCPCS,0272,RC,,,both,,,6382.50,1914.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET .241IN 77IN NONVENT PIERCE PIN LARGE BORE TUBE SIGHT",SUP-06544-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.20,15.66,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2.7MM 16MM VARIAX TITANIUM T7 FULL THREAD RADIUS",SUP-53-27616E,CDM,C1713,HCPCS,0278,RC,,,both,,,762.05,228.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,90.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",88.63,647.74,"percent of total billed charges",
"CATH SABERX 150CM 20MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.7MM 16MM VARIAX TITANIUM LOW PROFILE HAND WRIST",SUP-53-17016E,CDM,C1713,HCPCS,0278,RC,,,both,,,734.83,220.45,"CIGNA [10200]",Cigna,,499.68,68,,1831.33,1831.33,1831.33,16,85.46,624.61,"percent of total billed charges",
"SIZER IMPL 13.7CM NATRELLE BIOCELL P4.5CM MODERATE PLUS",SUP-MSZ15457,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 10 5MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151621005,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"NOVANET [10819]",Novanet,,8440.43,75,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)MARKER SKIN GREEN 7.5CM SOFT TISSUE DELIVERY SYSTEM ST",SUP-SMARTCLIPLT-GRN-7.5,CDM,A4648,HCPCS,0278,RC,,,both,,,2625.00,787.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DEMINERALIZED BONE MATRIX 10ML PUTTY PRETREATED",SUP-T43110,CDM,C1713,HCPCS,0278,RC,,,both,,,4185.00,1255.5,"BLUE CROSS [10001]","Blue Cross HMO",,1640.52,39.2,,957.42,156.86,7483.26,51,486.72,3557.25,"percent of total billed charges",
"TRAY TIBIAL OXFORD D KNEE LEFT MEDIAL UNICOMPARTMENTAL",SUP-154724,CDM,C1776,HCPCS,0278,RC,,,both,,,11195.94,3358.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4601.53,41.1,,6417.48,6417.48,6417.48,"1 through 10",1302.09,9516.55,"percent of total billed charges",
"STENT ADVANIX NAVIFLEX 7CM 7FR DUODENAL BEND BILIARY PLASTIC",SUP-M00534210,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"PHCS [10601]",PHCS,,762.62,70,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5-3MM TORNADO PLATINUM FIBER .035IN CATH",SUP-G47520,CDM,S27800098,LOCAL,0278,RC,,,both,,,931.42,279.43,"BLUE CROSS [10001]","Blue Cross HMO",,365.12,39.2,,,,,0,108.32,791.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 11MM LCP STAINLESS STEEL SMALL BONE T6",SUP-201.881,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,83.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,82.03,599.55,"percent of total billed charges",
"COIL EMBOLIZATION 45CM 12MM TARGET XL 360D STD LARGE",SUP-M0036101240,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 25CM 14FR PIGTAIL CURVE DRNG POLYURETHANE",SUP-RLC-14-038,CDM,C1729,HCPCS,0272,RC,,,both,,,531.36,159.41,"PHCS [10601]",PHCS,,371.95,70,,,,,0,61.8,451.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 100MM SPINAL LOCKING POST",SUP-8461100,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,279.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",279.89,2045.61,"percent of total billed charges",
"GWIRE ORTHOPEDIC 300MM 2.8MM THREAD",SUP-03.333.015.04,CDM,S27200284,LOCAL,0272,RC,,,both,,,1123.33,337,"KAISER [10500]",Kaiser,,752.63,67,,,,,0,130.64,954.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 10CM 5MM 6FR BALLOON DILATATION",SUP-V1850100,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"UHC [10700]","United Healthcare",,3472.32,63.3,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 12MM EXCLUDER GORE CONTRALATERAL LEG",SUP-PLC121200,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"CIGNA [10200]","Cigna Local Plus",,8819.12,31.5,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 150MM 130CM 6MM OFFSET CROWN VASCULAR",SUP-SC6150LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1062.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 25X9X10MM COROENT 8D LARGE CONTOUR PEEK LUMBAR",SUP-6610925,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4739.47,28.62,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOTALOL 80 MG TABLET",RX-11421,CDM,,,0637,RC,50268-0724-11,NDC,both,1,UN,11.67,3.5,"CIGNA [10200]",Cigna,,7.94,68,,,,,0,1.36,9.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING OXFORD KNEE LEFT MEDIAL RIGHT LATERAL",SUP-154720,CDM,C1776,HCPCS,0278,RC,,,both,,,11195.94,3358.78,"KAISER [10500]",Kaiser,,7501.28,67,,,,,0,1302.09,9516.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 8CMX4CMX.2-.75MM DERMACELL DERMIS",SUP-DCELL154,CDM,Q4122,HCPCS,0636,RC,,,both,,,15278.81,4583.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1810.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1810.54,12986.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALEXIS CES 17CM",SUP-GTB17,CDM,S27200284,LOCAL,0272,RC,,,both,,,2700.00,810,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,314.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DANDY APPLY REMOVING",SUP-FF003R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC ELIM PET 230CM 4CM 15MM PYLORIC BALLOON",SUP-848,CDM,C1726,HCPCS,0272,RC,,,both,,,607.50,182.25,"AETNA [10100]","Aetna HMO/PPO",,482.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 13MM KNEE POSTERIOR STABILIZED PRIMARY",SUP-5532P313,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]",Cigna,,5682.01,68,,5873.17,5873.17,5873.17,"1 through 10",971.79,7102.52,"percent of total billed charges",
"SCR BONE 2.7MM 8MM LCP STAINLESS STEEL SMALL BONE SELF",SUP-202.208,CDM,C1713,HCPCS,0278,RC,,,both,,,748.44,224.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,343.53,45.9,,,,,0,87.04,636.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STBL SURGICAL OCTOPUS EVOLUTION TISSUE",SUP-TS2000,CDM,S27000186,LOCAL,0270,RC,,,both,,,9240.48,2772.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1074.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1074.67,7854.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE PREBENT 94MM TITANIUM RIBFIX TITAN BONE EXTRATHORACIC",SUP-323.4094,CDM,C1713,HCPCS,0278,RC,,,both,,,23398.20,7019.46,"NOVANET [10819]",Novanet,,17548.65,75,,,,,0,2721.21,19888.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION AZUR DETACHMENT CTRL",SUP-45-4001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1405.35,421.6,"MULTIPLAN [10600]",Multiplan,,1194.55,85,,,,,0,163.44,1194.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pulse Ox O2 Sat Mult",PX-460000016,CDM,94761,CPT,0460,RC,,,both,,,153.00,45.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.79,130.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL SHOULDER 36MM SMR ECCENTRICAL GLENOSPHERE STERILE",SUP-1376.09.031,CDM,C1776,HCPCS,0278,RC,,,both,,,9183.90,2755.17,"PHCS [10601]",PHCS,,6428.73,70,,,,,0,1068.09,7806.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT SIGMA 3 KNEE CEMENTED ROTATE",SUP-129433130,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOSURGICAL 100MM SURGIFROST STAINLESS STEEL",SUP-60SF2,CDM,S27200284,LOCAL,0272,RC,,,both,,,14490.00,4347,"PHCS [10601]",PHCS,,10143,70,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM PARALLEL SPINE",SUP-17312,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esrd Emergency Dialysis Tx",PX-829000001,CDM,G0257,HCPCS,0829,RC,,,both,,,3128.80,938.64,"PHCS [10601]",PHCS,,2190.16,70,,,,,0,363.88,2659.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 15MM KNEE POSTERIOR STABILIZE HIGH",SUP-71421518,CDM,C1776,HCPCS,0278,RC,,,both,,,10774.35,3232.3,"CIGNA [10200]","Cigna Open Access",,6130.61,56.9,,5302.19,4377.88,6578.61,27,1253.06,9158.2,"percent of total billed charges",
"REG VACUUM 0-300 MMHG CONTINUOUS INTERMITTENT TUBING NIPPLE",SUP-VR-CIUT-OMD,CDM,S27200284,LOCAL,0272,RC,,,both,,,2452.58,735.77,"KAISER [10500]",Kaiser,,1643.23,67,,,,,0,285.24,2084.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 71X40X14IN FORTIFY 2.5V 500OHM 60 PPM",SUP-CD2231-40Q,CDM,C1721,HCPCS,0278,RC,,,both,,,63000.00,18900,"CIGNA [10200]","Cigna Open Access",,21105,33.5,,,,,0,7326.9,53550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 7FR 40D GUIDING DURAFORM PTFE",SUP-M003101430,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"KAISER [10500]",Kaiser,,1677.1,67,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 15MM 4MM 1.5MM 1.2MM BALLOON DILATATION RAPID",SUP-DC-RY4015UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,117.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 24.4MM LUMEN 33MM 5.5MM CURVE CIRCLE",SUP-ESECS33A,CDM,S27200284,LOCAL,0272,RC,,,both,,,7603.89,2281.17,"FIRST HEALTH [10303]","First Health",,6083.11,80,,,,,0,884.33,6463.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ENDOSCOPIC GF UM20 BILIARY ULTRASOUND BALLOON STERILE",SUP-MAJ-233,CDM,C1726,HCPCS,0272,RC,,,both,,,246.56,73.97,"NOVANET [10819]",Novanet,,184.92,75,,,,,0,28.67,209.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 12CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175196190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]",Cigna,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR SUREFORM 60 BLUE",SUP-48360B,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.25,543.37,"UHC [10700]","United Healthcare",,1146.52,63.3,,,,,0,210.65,1539.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETENE 12X8CM LEFT SELF GRIP ANATOMIC",SUP-PP1208DL,CDM,C1781,HCPCS,0278,RC,,,both,,,1892.63,567.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1286.99,68,,,,,0,220.11,1608.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESOMEPRAZOLE MAGNESIUM DR 40 MG GRANULES DELAYED RELEASE FOR SUSP",RX-78616,CDM,,,0250,RC,68382-0849-93,NDC,both,1,UN,61.37,18.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,41.73,68,,,,,0,7.14,52.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM TITANIUM SELF TAP LOCK NONSTERILE AXSOS 3",SUP-661134,CDM,C1713,HCPCS,0278,RC,,,both,,,1377.32,413.2,"CIGNA [10200]",Cigna,,936.58,68,,1831.33,1831.33,1831.33,16,160.18,1170.72,"percent of total billed charges",
"PLATE CURVE 195MM STAINLESS STEEL 4.5MM SCR 8 HOLE 4 COLUMN",SUP-02.124.408,CDM,C1713,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"FIRST HEALTH [10303]","First Health",,8004,80,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Cytp Smears / Add on 88104",PX-311000078,CDM,0827T,CPT,0311,RC,,,both,,,104.00,31.2,"CIGNA [10200]","Cigna Local Plus",,55.64,53.5,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TALON ORTHOPEDIC 900MM 3MM TROCAR TIP",SUP-SLN-T33,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE MYRINGOTOMY RICHARDS SICKLE BLADE FLAT HANDLE STERILE",SUP-130715,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.44,30.43,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SELEGILINE 5 MG CAPSULE",RX-17280,CDM,,,0637,RC,70954-0504-10,NDC,both,1,UN,11.58,3.47,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHIBOND 4-0 C-1 30IN 2 ARM BRAID GREEN NONABSORBABLE",SUP-X726H,CDM,S27200284,LOCAL,0272,RC,,,both,,,161.78,48.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP ELECTROSURGICAL LONG BAYONET STRAIGHT BIPOLAR",SUP-675.170S,CDM,S27200284,LOCAL,0272,RC,,,both,,,7438.20,2231.46,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 30MM THK.38MM 30MM OFFSET FAN STERILE LATEX FREE",SUP-5400-134-279,CDM,S27200284,LOCAL,0272,RC,,,both,,,361.83,108.55,"KAISER [10500]",Kaiser,,242.43,67,,,,,0,42.08,307.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 26X10-15X10MM EXPANDABLE PARALLEL",SUP-194226,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"NOVANET [10819]",Novanet,,21600,75,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000165,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM KNEE 135MM 10MM 16MM ENDO-MODEL-M CONICAL TILASTAN",SUP-15-2952/05,CDM,C1776,HCPCS,0278,RC,,,both,,,17756.24,5326.87,"CIGNA [10200]",Cigna,,7102.5,40,,5873.17,5873.17,5873.17,"1 through 10",2065.05,15092.8,"percent of total billed charges",
"SOL IRRIGATION WATER FLEXIBLE CNTNR 3L STERILE LATEX FREE",SUP-07973-08,CDM,S27200284,LOCAL,0272,RC,,,both,,,112.06,33.62,"FIRST HEALTH [10303]","First Health",,89.65,80,,,,,0,13.03,95.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET VENTRICULAR ASSIST 2.5IN IMPELLA STERILE LATEX FREE",SUP-005042,CDM,S27800098,LOCAL,0278,RC,,,both,,,114000.00,34200,"MULTIPLAN [10600]",Multiplan,,96900,85,,,,,0,13258.2,96900,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE THK1.5MM 3-0 SH 36IN 2 ARM MONOFILAMENT FIRM",SUP-P8522H,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.29,24.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,34.23,41.1,,,,,0,9.69,70.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION TENSION BAND SYSTEM 50MM ORTHOPEDIC STAINLESS",SUP-TB-1550K,CDM,C1713,HCPCS,0278,RC,,,both,,,2962.50,888.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2014.5,68,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR RCB CURVE ANGIOGRAPHIC CORONARY 2",SUP-H749163911902,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"KAISER [10500]",Kaiser,,51.31,67,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 125MM ACCOLADE HFX 127D 4 44MM OFFSET HIP",SUP-6077-0435,CDM,C1776,HCPCS,0278,RC,,,both,,,8983.80,2695.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3692.34,41.1,,6417.48,6417.48,6417.48,"1 through 10",1044.82,7636.23,"percent of total billed charges",
"SCR BONE 5MM 25MM VIPER EXPEDIUM TITANIUM SPINE CORTICAL",SUP-186731525,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 50MM 1.6MM 7MM STOP TWIST 7MM STERILE",SUP-6016007,CDM,S27200284,LOCAL,0272,RC,,,both,,,1073.25,321.97,"AETNA [10100]","Aetna HMO/PPO",,853.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.82,912.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ORTHOPEDIC 11MM INDEPENDENCE",SUP-376.411,CDM,C1776,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4061.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3986.25,29134.26,"percent of total billed charges",
"SABER .035 3X60 40CM SL",SUP-48003006P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"NOVANET [10819]",Novanet,,736.6,75,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR VENTILATOR AVEA HOTWIRE FLOW NEONATE",SUP-16465,CDM,S27000186,LOCAL,0270,RC,,,both,,,1794.00,538.2,"CIGNA [10200]","Cigna Open Access",,1020.79,56.9,,,,,0,208.64,1524.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Assay of Transcortin",PX-301000700,CDM,84449,CPT,0301,RC,,,both,,,170.00,51,"PHCS [10601]",PHCS,,119,70,,,,,0,0.01,144.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 5MM BALLOON DILATATION STERILE LATEX",SUP-595004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"KAISER [10500]",Kaiser,,976.86,67,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY CHORDAL GUIDE DURAN ANCORE",SUP-620RG25,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UHC [10700]","United Healthcare",,8298.63,63.3,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Steth Esophageal Tapscope",PX-E27000220,CDM,E27000220,LOCAL,0270,RC,,,both,,,1003.20,300.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,682.18,68,,,,,0,116.67,852.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 56MM 13MM 5.4MM 14FR ZENITH SPIRAL-Z",SUP-G55231,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"FIRST HEALTH [10303]","First Health",,16939.44,80,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THOMASMEDICAL INTRDCR FR7 LONG - EACH",SUP-666273-001,CDM,C1894,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADAPTA IS-1 DR",SUP-ADDR01,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"MULTIPLAN [10600]",Multiplan,,35360,85,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 23MM 8MM STEP TAPER ACL PCL",SUP-AR-1380C,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"MULTIPLAN [10600]",Multiplan,,1573.04,85,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CTRL ANGIOGRAPHY HAND MULTIPATIENT SHEATH AVANTA STERILE","SUP-AVA 500 HC",CDM,S27000186,LOCAL,0270,RC,,,both,,,104.40,31.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,47.92,45.9,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Dil",PX-750000084,CDM,45340,CPT,0750,RC,,,both,,,2362.42,708.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,274.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,274.75,2362.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TIGHTROPE XP FIXATION TITANIUM SYNDESMOSIS",SUP-AR-8925T,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"CIGNA [10200]","Cigna Local Plus",,5518.79,53.5,,3978.14,359.25,3978.14,24,1199.69,8768.18,"percent of total billed charges",
"CATH TREK 145CM 25MM 2.75MM ULTRA LOW PROFILE BALLOON",SUP-1012273-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 19MM 80CM 7MM 11MM 7FR .035IN",SUP-BXA071901A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMOTE MNTR INSPIRE 2",SUP-2580,CDM,S27200284,LOCAL,0272,RC,,,both,,,9660.00,2898,"NOVANET [10819]",Novanet,,7245,75,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING ORANGE 20IN 6.5FR ENTERAL POLYURETHANE HUB END",SUP-ENFPU2065LD,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.84,17.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.84,50.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 10MM KNEE GVF POLYETHYLENE ROTATE",SUP-129405610,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6571.15,68,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 3 KNEE REVISION",SUP-5612-B-300,CDM,C1776,HCPCS,0278,RC,,,both,,,26089.56,7826.87,"MULTIPLAN [10600]",Multiplan,,22176.13,85,,,,,0,3034.22,22176.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 26CM 3CM 6FR .035IN PIGTAIL",SUP-M006180223190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]","Cigna Local Plus",,676.98,,,,,,,147.16,1075.57,"percent of total billed charges",
"SPACER ALLOGRAFT 12.5X15X6MM PARALLEL SPINE",SUP-17306,CDM,S27800098,LOCAL,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SMART 150MM 120CM 7MM LONG BILIARY NITINOL SELF EXPAND",SUP-C07150MB,CDM,C1876,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"PHCS [10601]",PHCS,,5433.75,70,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 0MM 28MM HIP MODULAR TYPE 1 CERAMIC BIOLOX",SUP-650-1158,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4051.93,41.1,,6417.48,6417.48,6417.48,"1 through 10",1146.57,8379.91,"percent of total billed charges",
"SYSTEM ACCUDRAIN DRNG CSF GRADUATE BURETTE NEEDLELESS SAMPLE",SUP-INS-8400,CDM,S27200284,LOCAL,0272,RC,,,both,,,3272.78,981.83,"NOVANET [10819]",Novanet,,2454.59,75,,,,,0,380.62,2781.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 58MM 80CM 6MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU0800658,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3040.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3040.66,22223.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STIM PROXIMATE GENITOURINARY HANDSET NONSTERILE LATEX",SUP-TH90P01,CDM,S27200284,LOCAL,0272,RC,,,both,,,12516.60,3754.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1483.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1455.68,10639.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 26CM 6FR RESONANCE URETER METAL RADIOPAQUE POS",SUP-G34111,CDM,C2625,HCPCS,0272,RC,,,both,,,7887.39,2366.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3241.72,41.1,,,,,0,917.3,6704.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 16MM STAINLESS STEEL CORTICAL HAND FOOT SELF",SUP-201.646,CDM,C1713,HCPCS,0278,RC,,,both,,,391.94,117.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,179.9,45.9,,,,,0,45.58,333.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX PDS PLUS 1 OS-6 24IN VIOLET ABSORBABLE",SUP-SXPP1A203,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.50 X 28 MM  RX FDA",SUP-1203350-28,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP CAUT 8MM ONE DA VINCI SI ENDOWRIST VESSEL SEALER",SUP-410322,CDM,S27000186,LOCAL,0270,RC,,,both,,,4105.50,1231.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,486.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,477.47,3489.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL ARTHREX UNIVERS REVERS 12 SHOULDER STERILE",SUP-AR-9501-12P,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"CIGNA [10200]","Cigna Open Access",,6006.93,56.9,,5302.19,4377.88,6578.61,27,1227.78,8973.45,"percent of total billed charges",
"CATH CORDIS SABER 90CM 20MM 2MM BALLOON DILATATION DURALYN",SUP-48002002S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"FIRST HEALTH [10303]","First Health",,1004.4,80,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM INTERSTIM 32 CONTACT PADDLE",SUP-SC-8352-50,CDM,C1778,HCPCS,0278,RC,,,both,,,31500.00,9450,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3663.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC 3D .75CM 16.2CU CM SPIRAL 4.45X6.13CM",SUP-U125,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6608.47,28.62,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM AVENIR 10 HELICAL FINISH STERILE",SUP-10HFN-03006,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"KAISER [10500]",Kaiser,,6929.88,67,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 4.50 X 20MM",SUP-H7493942820450,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1777.3,28.62,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR 24CM 3CM 8FR .035IN 2 FLOPPY PIGTAIL",SUP-M006180242090,CDM,C2617,HCPCS,0278,RC,,,both,,,1294.14,388.24,"KAISER [10500]",Kaiser,,867.07,67,,,,,0,150.51,1100.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 15MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71933735,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"NOVANET [10819]",Novanet,,9128.7,75,,,,,0,1415.56,10345.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM CLAW CHARLOTTE FOOT ANKLE LOCK HEXAGON",SUP-40133518,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE SP 39S",SUP-TENDV-SP-39S-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20263.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SPINAL XLIF NEUROVISION DIL M5 DISPOSABLE",SUP-2029950,CDM,S27200284,LOCAL,0272,RC,,,both,,,5347.50,1604.25,"NOVANET [10819]",Novanet,,4010.63,75,,,,,0,621.91,4545.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SHAMP 21X16IN SLEEK CURVE PLASTIC LOOP STRAP HIGH RIM",SUP-81565027,CDM,S27000186,LOCAL,0270,RC,,,both,,,225.33,67.6,"PHCS [10601]",PHCS,,157.73,70,,,,,0,26.21,191.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2MM 285MM KIRSCHNER STAINLESS STEEL TROCAR",SUP-292.21,CDM,C1713,HCPCS,0278,RC,,,both,,,75.76,22.73,"CIGNA [10200]","Cigna Local Plus",,40.53,53.5,,3978.14,359.25,3978.14,24,8.81,64.4,"percent of total billed charges",
"VALVE AORTIC AVALUS 21MM 400 SERIES LATEX FREE",SUP-40021,CDM,S27800098,LOCAL,0278,RC,,,both,,,33390.00,10017,"UHC [10700]","United Healthcare",,21135.87,63.3,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM PREBENT 28X16X2.5MM TITANIUM 2 LEVEL SKYLINE BONE",SUP-186802028,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,1144.80,304.56,2275.09,66,521.61,3812.25,"percent of total billed charges",
"CATH HI-FLO RENEGADE 135CM 38CM 3-2.8FR .027IN MICRO",SUP-M001183010,CDM,C1887,HCPCS,0272,RC,,,both,,,4726.50,1417.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MASK CPAP MEDIUM LEAK 1 ENTRAINMENT NEB ELBOW",SUP-73-1061734,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.58,61.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4.5MM 10MM MOUNTAINEER TITANIUM SPINE",SUP-188362010,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 12.5MM KNEE AOX STABILIZE ROTATE PLATFORM",SUP-196192142,CDM,C1776,HCPCS,0278,RC,,,both,,,13386.00,4015.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3831.07,28.62,,,,,0,1556.79,11378.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cntrst Locm 300-399mg per 1ml",PX-255000010,CDM,Q9967,HCPCS,0255,RC,,,both,,,22.00,6.6,"FIRST HEALTH [10303]","First Health",,17.6,80,,,,,0,2.56,18.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",479,MS-DRG,,,,,,,inpatient,,,74518.26,22355.48,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,11876.8,,"Case rate ($11,530.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,707.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,746.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,191.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,721.35. The transfer operating threshold is the transfer adjustment factor * $10,707.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.52. The transfer capital threshold is the transfer adjustment factor * $809.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,54272.44,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 80MM 80CM 7MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM07080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7508.97,41.1,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT EXTERNAL FIXATION 20MM SIDEKICK FREEDOM CIRCULAR FIXTR",SUP-RR2000,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,40.47,295.8,"percent of total billed charges",
"CMPNT PATELLAR 38MM ONLAY ADVANCE METAL KNEE STERILE",SUP-KPON38MB,CDM,C1776,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,5302.19,4377.88,6578.61,27,601.85,4398.75,"percent of total billed charges",
"EXERCISER HAND THERABAND XL GREEN",SUP-927807,CDM,S27000186,LOCAL,0270,RC,,,both,,,91.44,27.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.63,77.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC COBALT HF 2 CHMBR DF-1 PIN PLUG RADIOPAQUE",SUP-DTPB2D1,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"CIGNA [10200]",Cigna,,30780,40,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 18-20MM 0-34MM COREVALVE EVOLUT 23MM HEART",SUP-MCS-P4-23-AOA-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,48940.2,28.62,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BUTTON 3CM 12MM ARTHREX PASSPORT BUTTON CANN",SUP-AR-6592-12-30,CDM,S27000186,LOCAL,0270,RC,,,both,,,510.30,153.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,347,68,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TALON 160CM 2.5MM SPECIMEN RETRIEVAL STAINLESS STEEL",SUP-00711175,CDM,S27200284,LOCAL,0272,RC,,,both,,,1134.00,340.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,520.51,45.9,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG GAUZE 1.5X1.5IN QUIKCLOT HEMOSTATIC",SUP-467-Z,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"UHC [10700]","United Healthcare",,110.14,63.3,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 4CM 5.8FR 18FR BALLOON",SUP-M0062251020,CDM,C1726,HCPCS,0272,RC,,,both,,,1832.70,549.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KETOROLAC 10 MG TABLET",RX-10371,CDM,,,0250,RC,60687-0104-11,NDC,both,1,UN,27.65,8.29,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"METHYLNALTREXONE 150 MG TABLET",RX-176276,CDM,,,0637,RC,65649-0150-90,NDC,both,1,UN,139.80,41.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE AMPLATZ VASCULAR 3CM STRAIGHT TAPER 145CM 7CM .035IN",SUP-G03095,CDM,C1769,HCPCS,0272,RC,,,both,,,239.16,71.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ORTHOPEDIC 475MM 3.2MM TIBIA THREAD STERILE",SUP-09.037.010S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1001.89,300.57,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX ULTRAVERSE GEOALIGN 100CM 220MM 6MM BALLOON",SUP-LX1810062205F,CDM,C2623,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EUPHORA 142CM 15MM 3.75MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP37515X,CDM,C1725,HCPCS,0272,RC,,,both,,,546.75,164.02,"AETNA [10100]","Aetna HMO/PPO",,434.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,63.59,464.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SUBSTITUTE 45X11MM DEMINERALIZED MATRIX IN RESORB",SUP-56800060,CDM,,,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]",Cigna,,4222.8,68,,,,,0,6.21,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 26CM 3CM 8FR .038IN 2",SUP-M006192153170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CIGNA [10200]",Cigna,,948.76,68,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 24CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192122010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS [10001]","Blue Cross HMO",,470.63,39.2,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 23MM 18.6MM MASTERS 85D PYROLYTIC CARBON",SUP-23MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 8MM 10-8MM 16MM DUCT SELF EXPANDABLE",SUP-9-PDA-006,CDM,C1817,HCPCS,0278,RC,,,both,,,34398.00,10319.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14137.58,41.1,,,,,0,4000.49,29238.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 4MM AZUR .018IN",SUP-45-480415,CDM,S27800098,LOCAL,0278,RC,,,both,,,1417.50,425.25,"KAISER [10500]",Kaiser,,949.73,67,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA C KNEE LEFT 2 PEG TIVANIUM STERILE",SUP-42530006401,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5674.01,40,,,,,0,1649.72,12057.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE LEFT CRUCIATE RETAIN CEMENT ATTUNE",SUP-150400102,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"FIRST HEALTH [10303]","First Health",,17914.68,80,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1MM 1.6MM 13MM TITANIUM CORTEX HAND SELF TAPPING",SUP-400.533,CDM,C1713,HCPCS,0278,RC,,,both,,,526.18,157.85,"CIGNA [10200]","Cigna Open Access",,299.4,56.9,,1144.80,304.56,2275.09,66,61.19,447.25,"percent of total billed charges",
"BLADE SAW 29.5X7MM PRECISION THK.38MM LONG MICRO NARROW THIN",SUP-2296003115,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.00,18.6,"FIRST HEALTH [10303]","First Health",,49.6,80,,,,,0,7.21,52.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE SP 41S",SUP-TENDV-SP-41S-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"CIGNA [10200]","Cigna Local Plus",,91485,53.5,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOGRAPHIC RADIALTIGER CURVE 6FR 4.5MM 100CM CORONARY",SUP-40-6012,CDM,C1713,HCPCS,0278,RC,,,both,,,313.20,93.96,"NOVANET [10819]",Novanet,,234.9,75,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UROLOGICAL 150CM 3CM .038IN PTFE STIFF BODY STRAIGHT",SUP-M0066201010,CDM,C1769,HCPCS,0272,RC,,,both,,,100.40,30.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.68,85.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DIVERGENCE-L 15X9.4X9MM ANTERIOR OBLIQUE LUMBAR",SUP-736529,CDM,S27800098,LOCAL,0278,RC,,,both,,,9177.00,2753.1,"KAISER [10500]",Kaiser,,6148.59,67,,,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 10 12MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151621012,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7652.65,68,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SURGICAL BARIATRIC RUNNING",SUP-021021,CDM,S27200284,LOCAL,0272,RC,,,both,,,1530.90,459.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,702.68,45.9,,,,,0,178.04,1301.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HIP HYBRID AND DISP",SUP-98000100224,CDM,C1776,HCPCS,0278,RC,,,both,,,32760.00,9828,"KAISER [10500]",Kaiser,,21949.2,67,,,,,0,3809.99,27846,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HIP HYBRID AND DISP",SUP-98000100224,CDM,C1776,HCPCS,0278,RC,,,both,,,32760.00,9828,"BLUE CROSS [10001]","Blue Cross PPO",,12841.92,39.2,,3949.44,3949.44,3949.44,"1 through 10",3809.99,27846,"percent of total billed charges",
"SPLINT ORTHOPEDIC SMALL 8IN WRIST LEFT BLACK",SUP-A120105,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.29,17.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.78,49.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Orthopantogram Panoramic",PX-320000257,CDM,70355,CPT,0320,RC,,,both,,,549.00,164.7,"BLUE CROSS [10001]","Blue Cross PPO",,27.02,,"Fee schedule rate ($27.02).",,,,0,13.64,466.65,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 59CM ENDOTAK RELIANCE ENDOCARDIUM STEROID ELUTING",SUP-275,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"NOVANET [10819]",Novanet,,11385,75,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 CT-2 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8410H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 20FR SILICONE Y PORT BALLOON GASTRO KANGAROO 20ML",SUP-8884720205,CDM,S27200284,LOCAL,0272,RC,,,both,,,235.51,70.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,27.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.39,200.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Circum W/Clamp / Other Dvc",PX-361000390,CDM,54150,CPT,0361,RC,,,both,,,3893.94,1168.18,"PHCS [10601]",PHCS,,3893.94,,"Case rate ($4,710). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,452.87,3893.94,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vrtplsty Augment Perc Thor",PX-361000378,CDM,22513,CPT,0361,RC,,,both,,,15829.96,4748.99,"UHC [10700]","United Healthcare",,9679,,"Case rate ($9,679). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1841.02,15829.96,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 174MM 8MM HOFFMANN II MRI CARBON SEMI",SUP-5028-7-030,CDM,S27800098,LOCAL,0278,RC,,,both,,,3150.60,945.18,"BLUE CROSS [10001]","Blue Cross HMO",,1235.04,39.2,,,,,0,366.41,2678.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLIDESHEATH SLENDER SS KIT, 0.025 GW, 5 FR, 10CM",SUP-80-1055,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"PHCS [10601]",PHCS,,311.85,70,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH COAXIAL UMBILICAL DISPOSABLE",SUP-203CXC,CDM,S27200284,LOCAL,0272,RC,,,both,,,816.75,245.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,555.39,68,,,,,0,94.99,694.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CASSETTE INFUSION PUMP PURGE CTRL IMPELLA",SUP-0043-0003,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"KAISER [10500]",Kaiser,,1085.4,67,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 11X6MM VERTE-STACK CORNERSTONE PSR 11MM",SUP-6286611,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 3-0 CT-1 18IN CONTROL RELEASE MONOFILAMENT 8",SUP-Y738D,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.06,52.22,"MULTIPLAN [10600]",Multiplan,,147.95,85,,,,,0,20.24,147.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION CLOSED WOUND SUCTION TROCAR 4 FREE FLOW",SUP-072217,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.37,37.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.58,106.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RIST 95CM GUIDING STERILE LATEX FREE",SUP-106F-071-95,CDM,C1887,HCPCS,0272,RC,,,both,,,8093.70,2428.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5503.72,68,,,,,0,941.3,6879.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEARTRAIL III 100CM 6FR IKARI LEFT 3.5 CURVE GUIDING",SUP-40-6370,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH C315H4002 RIGHTSITE",SUP-C315H4002,CDM,C1887,HCPCS,0272,RC,,,both,,,2175.00,652.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC",345,MS-DRG,,,,,,,inpatient,,,56562.03,16968.61,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 2.63INX1.73IN LARGE THERMOPLASTIC THERMASPLINT",SUP-1529020,CDM,S27000186,LOCAL,0270,RC,,,both,,,204.45,61.33,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FUROSEMIDE 20 MG TABLET",RX-3294,CDM,,,0637,RC,00054-8297-25,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"4.0 PLY SCRW 4.0X18",SUP-102040118,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 8MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS08030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UHC [10700]","United Healthcare",,7420.72,63.3,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STOPPER EXTERNAL FIXATION TRUELOK RUBBER WIRE",SUP-54-1133,CDM,C1713,HCPCS,0278,RC,,,both,,,54.20,16.26,"MULTIPLAN [10600]",Multiplan,,46.07,85,,,,,0,6.3,46.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 50CM 11CM GWIRE PRELUDE PRO .035IN BLUE",SUP-PRO-8F-11-035,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAMINAR IMPLANT SIZE (18MM)",SUP-FG-6033,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 20MM 12MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171120270,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,136.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Assay of Pregnenolone",PX-301000371,CDM,84140,CPT,0301,RC,,,both,,,111.00,33.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.01,,,,,,,0.01,94.35,"fee schedule",
"HC Maternity Care Procedure Unlisted",PX-361000670,CDM,59899,CPT,0361,RC,,,both,,,6106.00,1831.8,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,710.13,6106,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Vag Injury",PX-450000287,CDM,57200,CPT,0361,RC,,,both,,,4627.00,1388.1,"AETNA [10100]","Aetna HMO/PPO",,3678.47,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,538.12,4627,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Transneph Stnt Bi W Si",PX-361000218,CDM,50387,CPT,0361,RC,,,both,,,6400.07,1920.02,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,744.33,5440.06,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 4IN TUNGSTEN 15X12MM NONHEX",SUP-E15604,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.49,30.15,"CIGNA [10200]","Cigna Local Plus",,53.76,53.5,,,,,0,11.69,85.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAUT OPHTHALMIC .5IN ACCU-TEMP 677C LOW TEMPERATURE FINE TIP",SUP-8441000,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.94,39.28,"AETNA [10100]","Aetna HMO/PPO",,104.1,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.23,111.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM TSRH OSTEOGRIP THINLINE TITANIUM SPINE 2",SUP-83575401,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"CIGNA [10200]",Cigna,,1750.32,68,,1831.33,1831.33,1831.33,16,299.36,2187.9,"percent of total billed charges",
"DEVICE V-LOC 90 4-0 P-12 3/8 CIRCLE 58CM CLSR SURGALLOY",SUP-VLOCM0033,CDM,S27200284,LOCAL,0272,RC,,,both,,,262.83,78.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,178.72,68,,,,,0,30.57,223.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPYRIDAMOLE 25 MG TABLET",RX-2528,CDM,,,0637,RC,00115-1070-01,NDC,both,1,UN,7.15,2.14,"NOVANET [10819]",Novanet,,5.36,75,,,,,0,0.83,6.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 45MM 10MM ZENITH ILIAC BRANCH 58MM",SUP-G60341,CDM,C1874,HCPCS,0278,RC,,,both,,,68399.94,20519.98,"BLUE CROSS [10001]","Blue Cross HMO",,26812.78,39.2,,9776.84,9776.84,9776.84,"1 through 10",7954.91,58139.95,"percent of total billed charges",
"PLATE 1.6V 20MM 1 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18006120,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,,1521.93,481.35,16760.95,30,521.61,3812.25,"percent of total billed charges",
"DIL SHEATH 20FR PEEL-AWAY ENTERAL ACCESS SYSTEM SERIAL",SUP-98704,CDM,S27200284,LOCAL,0272,RC,,,both,,,814.29,244.29,"FIRST HEALTH [10303]","First Health",,651.43,80,,,,,0,94.7,692.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 45CM 5.7FR ATRIUM VENTRICLE TRANSVENOUS BIPOLAR",SUP-407645,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"MULTIPLAN [10600]",Multiplan,,1897.63,85,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 25MM 9MM BICEPTOR BIOSURE SCR",SUP-72202359,CDM,C1713,HCPCS,0278,RC,,,both,,,2895.75,868.72,"CIGNA [10200]",Cigna,,1969.11,68,,1831.33,1831.33,1831.33,16,336.78,2461.39,"percent of total billed charges",
"STEM FEMORAL 111MM COLLAR ACTIS DUOFIX 8 12/14 STANDARD OFFS",SUP-101011080,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12190.5,40,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 22GA 5CM CHIBA STERILE DISPOSABLE",SUP-G01133,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"CIGNA [10200]","Cigna Open Access",,46.83,56.9,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUBICON 135CM 5.1FR 2.84FR 50MM SPACE GUIDING NYLON",SUP-H74939240035131,CDM,C1887,HCPCS,0272,RC,,,both,,,1449.90,434.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,171.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPYRIDAMOLE 25 MG TABLET",RX-2528,CDM,,,0637,RC,00115-1070-01,NDC,both,1,UN,7.15,2.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3.28,45.9,,,,,0,0.83,6.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CALCAR 27MM RESTORATION +30MM OFFSET HIP MODULAR",SUP-6276-4-327,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"NOVANET [10819]",Novanet,,17404.54,75,,,,,0,2698.86,19725.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 MEDIUM 36MM HIP ACETABULUM BIOLOX",SUP-00877503602,CDM,C1776,HCPCS,0278,RC,,,both,,,8526.00,2557.8,"MULTIPLAN [10600]",Multiplan,,7247.1,85,,,,,0,991.57,7247.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 190ML GEL ROUND TEXTURED MEMORYGEL SILTEX P2.",SUP-3541907MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MICROPOINT 10-0 TG160-6 12IN 2 ARM MONOFILAMENT",SUP-7756G,CDM,S27200284,LOCAL,0272,RC,,,both,,,189.70,56.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,129,68,,,,,0,22.06,161.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 10MM KNEE POSTERIOR STABILIZE IDENTITY",SUP-TPS-020-104S,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"FIRST HEALTH [10303]","First Health",,4703.04,80,,,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txcath Plc Stent Cca WO Dp",PX-360000047,CDM,37216,CPT,0361,RC,,,both,,,11808.10,3542.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5284,,"Case rate ($5,284). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,11.81,10036.89,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-607,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]","Cigna Open Access",,4397.63,33.5,,5302.19,4377.88,6578.61,27,1526.7,11158.16,"percent of total billed charges",
"SCR BONE 2.4MM 10MM TITANIUM T8 FULL THREAD CORTEX",SUP-AR-8724-10,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"NOVANET [10819]",Novanet,,668.25,75,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC IPERIA 7 VR-T DX IMPLANTABLE HOME MNTR PROMRI",SUP-393032,CDM,C1882,HCPCS,0278,RC,,,both,,,39000.00,11700,"FIRST HEALTH [10303]","First Health",,31200,80,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 STD KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508606001,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3051.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 38MM AXSOS TITANIUM CORTEX NONSTERILE",SUP-661738,CDM,C1713,HCPCS,0278,RC,,,both,,,330.25,99.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,39.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,38.41,280.71,"percent of total billed charges",
"COIL EMBOLIZATION 20CM 7MM TARGET XL 360D STD LARGE",SUP-M0036107200,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RALTEGRAVIR 400 MG TABLET",RX-88608,CDM,,,0637,RC,00006-0227-61,NDC,both,1,UN,157.49,47.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.32,133.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 FSL 30IN BRAID BLACK NONABSORBABLE",SUP-679H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PHCS [10601]",PHCS,,17.5,70,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE 5CC PRO-DENSE INJECTABLE REGENERATIVE",SUP-87SR0050,CDM,C1713,HCPCS,0278,RC,,,both,,,11150.40,3345.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4582.81,41.1,,,,,0,1296.79,9477.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP SUCTION DISPOSABLE LUCAS 2",SUP-11576-000046,CDM,S27000186,LOCAL,0270,RC,,,both,,,391.33,117.4,"AETNA [10100]","Aetna HMO/PPO",,311.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.51,332.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG 18OZ MEDIUM CNCT EXT TUBE PLEAT SIDE DRAIN VALVE",SUP-9348,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.04,13.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.24,38.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.465,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"AETNA [10100]","Aetna HMO/PPO",,3849.87,79.5,,1521.93,481.35,16760.95,30,563.19,4116.21,"percent of total billed charges",
"CNCT ROD DOMINO CL5.5 SD6.35 CURVE SPINE TITANIUM OPEN CLOSE",SUP-779146555,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"MULTIPLAN [10600]",Multiplan,,3028.13,85,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 100CM 3MM BALL NOSE DISPOSABLE VERSANAIL",SUP-281001100,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 12MM PRESS FIT FLUTED TRIATHLON KNEE",SUP-5566-S-012,CDM,C1776,HCPCS,0278,RC,,,both,,,5447.65,1634.29,"BLUE CROSS [10001]","Blue Cross PPO",,2135.48,39.2,,3949.44,3949.44,3949.44,"1 through 10",633.56,4630.5,"percent of total billed charges",
"SPACER ALLOGRAFT 23-27MMX17MM FRA 8D LORDOTIC NARROW WEDGE",SUP-10017,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE 5CC PRO-DENSE INJECTABLE REGENERATIVE",SUP-87SR0050,CDM,C1713,HCPCS,0278,RC,,,both,,,11150.40,3345.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7582.27,68,,,,,0,1296.79,9477.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AWL SURGICAL STRAIGHT FORTIFY I SELF CENTERING",SUP-676.706,CDM,S27000186,LOCAL,0270,RC,,,both,,,2010.00,603,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,826.11,41.1,,,,,0,233.76,1708.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SUPERORDERABLE",RX-40810176,CDM,J1644,HCPCS,0636,RC,63323-0540-05,NDC,both,10,ML,65.84,19.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.11,,"Fee schedule rate ($2.11). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.11,55.96,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.403,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"CIGNA [10200]","Cigna Open Access",,787.57,56.9,,1144.80,304.56,2275.09,66,160.97,1176.51,"percent of total billed charges",
"STEM HUMERAL 74MM PRESS FIT AEQUALIS ASCEND FLEX PTC 127.5D",SUP-DWF603A,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5040,40,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM SENSAR INTRAOCULAR LENS, BICONVEX, 22.5 DIOPTER",SUP-AR40E00225,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"CIGNA [10200]",Cigna,,633.42,68,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM EDWARDS INTUITY ELITE STERILE LATEX FREE",SUP-8300KITB27A,CDM,S27800098,LOCAL,0278,RC,,,both,,,68400.00,20520,"UHC [10700]","United Healthcare",,43297.2,63.3,,,,,0,7954.92,58140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STELLAREX 135CM 150MM 6MM BALLOON DILATATION OTW DRUG",SUP-AB35SX060150135,CDM,C2623,HCPCS,0272,RC,,,both,,,11557.50,3467.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) TF (-T) CRADLE ASSEMBLY INTPD-TF-C",SUP-INTPDTFCG,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOFT-VU 40CM 4FR ANGLE KUMPE CURVE ANGIOGRAPHIC",SUP-10734301,CDM,S27200284,LOCAL,0272,RC,,,both,,,86.83,26.05,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INVESTIGATIONAL DRUG PO (DOSE BY STUDY PROTOCOL)",RX-410998,CDM,,,0250,RC,99999-4109-98,NDC,both,1,UN,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 15GA 22CM CENTIMETER MARK ADJUSTABLE STOP COLOR",SUP-MSPN2206,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE OXIMETER 300CM SPO2 LNC-10",SUP-2027263-002,CDM,S27000186,LOCAL,0270,RC,,,both,,,1007.75,302.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 55X9.5MM HALL THK.6MM RECIPROCATE STERILE",SUP-505225900,CDM,S27200284,LOCAL,0272,RC,,,both,,,257.17,77.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,174.88,68,,,,,0,29.91,218.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 37MM SIMULUS C FULL FLEXIBLE STERILE",SUP-700FC37,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"AETNA [10100]","Aetna HMO/PPO",,10422.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE 1.4MM X 222MM SINGLE DIAMOND TIP",SUP-KWIR-SD-14222,CDM,S27000186,LOCAL,0270,RC,,,both,,,542.70,162.81,"AETNA [10100]","Aetna HMO/PPO",,431.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,63.12,461.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 2 RIGHT DISTAL KNEE",SUP-5542-A-202,CDM,C1776,HCPCS,0278,RC,,,both,,,5009.55,1502.86,"MULTIPLAN [10600]",Multiplan,,4258.12,85,,,,,0,582.61,4258.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM 37.6MM 30MM MITRAL TRICUSPID FLEXIBLE",SUP-460030MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"CIGNA [10200]","Cigna Local Plus",,6090.98,53.5,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION VIOLET POLYDIOXANONE BIOABSORBABLE ANCHOR 2",SUP-TR-0001-21,CDM,C1713,HCPCS,0278,RC,,,both,,,8073.00,2421.9,"CIGNA [10200]","Cigna Local Plus",,4319.06,53.5,,3978.14,359.25,3978.14,24,938.89,6862.05,"percent of total billed charges",
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT 20MM ALIF",SUP-3W3220,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"NOVANET [10819]",Novanet,,15858.99,75,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE 8X20CM 1MM CORTIVA DERMIS ALLOGRAFT",SUP-DH2820,CDM,S27800098,LOCAL,0278,RC,,,both,,,28782.68,8634.8,"MULTIPLAN [10600]",Multiplan,,24465.28,85,,,,,0,3347.43,24465.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 2.5CM 10CM DIL GWIRE KINK RESISTANT",SUP-10-2032,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"MULTIPLAN [10600]",Multiplan,,73.95,85,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE TITANIUM 5 HOLE LOW PROFILE VARIAX SMARTLOCK",SUP-40-15013,CDM,C1713,HCPCS,0278,RC,,,both,,,4614.17,1384.25,"BLUE CROSS [10001]","Blue Cross PPO",,1808.75,39.2,,957.42,570.23,957.42,28,536.63,3922.04,"percent of total billed charges",
"SHEATH TIGHTRAIL 15.9FR 18.7IN 9FR 20FR 9.2FR DIL ROTATE",SUP-545-509,CDM,C1773,HCPCS,0272,RC,,,both,,,15766.50,4729.95,"KAISER [10500]",Kaiser,,10563.56,67,,,,,0,1833.64,13401.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT ELITE VASCULAR J CURVE",SUP-1011882J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 29X3.8X.8MM TITANIUM 1.5MM SCR 6 HOLE LOW",SUP-446.031,CDM,C1713,HCPCS,0278,RC,,,both,,,2790.90,837.27,"MULTIPLAN [10600]",Multiplan,,2372.27,85,,,,,0,324.58,2372.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE 63X38X3MM POLYETHLENE MEDPOR BLOCK",SUP-6338,CDM,C1713,HCPCS,0278,RC,,,both,,,7928.10,2378.43,"MULTIPLAN [10600]",Multiplan,,6738.89,85,,,,,0,922.04,6738.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SELECT CORTICAL FIBULA WEDGE 6MM",SUP-210600,CDM,S27800098,LOCAL,0278,RC,,,both,,,3018.75,905.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,863.97,28.62,,,,,0,351.08,2565.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 140D SHORT BARREL 94X19X5.8MM STAINLESS STEEL 4.5MM",SUP-281.65,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 48MM 3 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.348,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"AETNA [10100]","Aetna HMO/PPO",,4207.14,79.5,,1521.93,481.35,16760.95,30,615.46,4498.2,"percent of total billed charges",
"CATH SABER 150CM 120MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,169.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 3 STD KNEE LEFT KEEL NONPOROUS",SUP-ETPKN3SL,CDM,C1776,HCPCS,0278,RC,,,both,,,11060.70,3318.21,"PHCS [10601]",PHCS,,7742.49,70,,,,,0,1286.36,9401.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER PATELLAR 38MM DISPOSABLE",SUP-8000-0038,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.00,675,"CIGNA [10200]","Cigna Local Plus",,1203.75,53.5,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VICI VENOUS STENT 120MM 100CM 12MM ENDOPROSTHESIS",SUP-H74912120100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"FIRST HEALTH [10303]","First Health",,10488,80,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM DCP LC-DCP STAINLESS STEEL FULL THREAD",SUP-218.025,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"CIGNA [10200]",Cigna,,305.36,68,,1831.33,1831.33,1831.33,16,52.23,381.7,"percent of total billed charges",
"CATH ARMADA 35 135CM 40MM 7MM .035IN LOW PROFILE BALLOON",SUP-B2070-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 3X200 135CM SL",SUP-48003020R,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"PHCS [10601]",PHCS,,697.98,70,,,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +19.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.195,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 RB-1 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP215H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 9IN CODMAN VERSATRU 1.5MM STD NONSTICK SLEEK",SUP-9009150ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,3198.15,959.44,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MONOCRYL MULTIPASS 3-0 PS-2 18IN MONOFILAMENT UNDYED",SUP-Y497G,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE 74MM FENESTRATE CUFFLESS DISPOSABLE INNER CANN ROUND",SUP-6DCFN,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.84,87.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAXX 15CM 10MM NEPHRSTMY VINYL RADIOPAQUE BALLOON",SUP-G57620,CDM,C1726,HCPCS,0272,RC,,,both,,,1943.25,582.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dil Biliary Duct Ampulla",PX-361000409,CDM,47542,CPT,0361,RC,,,both,,,4146.05,1243.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT ABSORB GT1 18MM 3MM CORONARY EVEROLIMUS ELUTING POLY L",SUP-1235300-18,CDM,C1874,HCPCS,0278,RC,,,both,,,8280.00,2484,"AETNA [10100]","Aetna HMO/PPO",,6582.6,79.5,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR NANO 2.5MM SWIVELOCK DISPOSABLE STERILE LATEX FREE",SUP-AR-8998DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,2323.13,696.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,275.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,270.18,1974.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 12CM 33MM MASTERS HEMASHIELD CLLGN MECHANICAL","SUP-33CAVGJ-514  00",CDM,S27800098,LOCAL,0278,RC,,,both,,,25533.90,7660.17,"CIGNA [10200]","Cigna Open Access",,8553.86,33.5,,,,,0,2969.59,21703.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 140MM 120CM 16MM .035IN VASCULAR VENOUS CATH",SUP-VENUL16140,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"NOVANET [10819]",Novanet,,17482.5,75,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 54MM SURGICAL 2MM CORTEX SCR NONSTERILE",SUP-311.19,CDM,S27000186,LOCAL,0270,RC,,,both,,,1319.00,395.7,"CIGNA [10200]","Cigna Open Access",,750.51,56.9,,,,,0,153.4,1121.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ABLATION 7.5FR J CURVE THERMOCOOL SF UNIDIRECTIONAL",SUP-D131504,CDM,C1732,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM HELIX R SPINE SELF DRILL VARIABLE ANGLE",SUP-7801115,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,117.75,860.63,"percent of total billed charges",
"LENS IOL 5 D +18.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM POST",SUP-ZA90030185,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,460.4,39.2,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 119MM STAINLESS STEEL 3.5MM SCR 6 HOLE LCP BONE LEFT",SUP-239.957,CDM,C1713,HCPCS,0278,RC,,,both,,,9506.13,2851.84,"FIRST HEALTH [10303]","First Health",,7604.9,80,,,,,0,1105.56,8080.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 14MM COLLAR CEMENTLESS LOW PROFILE NECK",SUP-3L93714,CDM,C1776,HCPCS,0278,RC,,,both,,,28658.70,8597.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3396.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3333.01,24359.9,"percent of total billed charges",
"CATH JADE 150CM 20MM 2MM BALLOON DILATATION OTW STERILE",SUP-582002022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,177.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-150440108,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"BLUE CROSS [10001]","Blue Cross PPO",,11804.69,39.2,,3949.44,3949.44,3949.44,"1 through 10",3502.26,25596.9,"percent of total billed charges",
"DTERG INSTR 12OZ BOTTLE LIQUID FOAM INTERCEPT",SUP-ML02-0139,CDM,S27000186,LOCAL,0270,RC,,,both,,,401.94,120.58,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,47.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.75,341.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYPROPYLENE 12X10CM PERMANENT GRID 1 SMOOTH",SUP-F10246-1012P,CDM,C1781,HCPCS,0278,RC,,,both,,,12966.48,3889.94,"AETNA [10100]","Aetna HMO/PPO",,10308.35,79.5,,,,,0,1508,11021.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERCI 95CM 8FR GUIDING SILICONE BALLOON STERILE LATEX",SUP-90073,CDM,C1725,HCPCS,0272,RC,,,both,,,9696.36,2908.91,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1149.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1127.69,8241.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR PULSE HFX IQ TITANIUM 16 OUTPUT CHANNEL 2 PORT",SUP-NIPG3000,CDM,C1822,HCPCS,0278,RC,,,both,,,136230.00,40869,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,38989.03,28.62,,,,,0,15843.55,115795.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (2-2.5 MCI)",RX-411873,CDM,A9520,HCPCS,0343,RC,08888-8876-07,NDC,both,1,UN,4614.97,1384.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,546.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,536.72,3922.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 6MM 2.75MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP27506X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"PHCS [10601]",PHCS,,368.55,70,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.404,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.21,68,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS TESTICULAR SALINE FILLED INFUSION LINE NDL XS STERILE",SUP-4501323,CDM,L8699,HCPCS,0278,RC,,,both,,,14973.00,4491.9,"UHC [10700]","United Healthcare",,9477.91,63.3,,,,,0,1741.36,12727.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 60MM 150CM 6MM VASCULAR NICKEL",SUP-EVD35-06-060-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4273.8,68,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 19MM HELIX-REVOLUTION ACP SPINE SELF TAPPING",SUP-7803119,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]","Cigna Local Plus",,754.35,53.5,,3978.14,359.25,3978.14,24,163.98,1198.5,"percent of total billed charges",
"TUBE TRACH 8MM PORTEX BLUSELECT UNCUFF STERILE LATEX FREE",SUP-101/816/080,CDM,S27200284,LOCAL,0272,RC,,,both,,,311.63,93.49,"AETNA [10100]","Aetna HMO/PPO",,247.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.24,264.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM 1.7-2.4FR .017IN",SUP-M003C17150J0,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"PHCS [10601]",PHCS,,5403.47,70,,,,,0,897.75,6561.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ASPIRATION ANTICOAGULATION LINE ELECTA ESSENTIAL CONCEPT",SUP-AAL,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]","Cigna Local Plus",,121.02,53.5,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 26FR CUT ACMI CLASSIC",SUP-M0068802541,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"AETNA [10100]","Aetna HMO/PPO",,380.18,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 24CM 6FR URETERAL FIRM STERILE LATEX FREE",SUP-M0061456460,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"BLUE CROSS [10001]","Blue Cross PPO",,245.09,39.2,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 70X12.5X.8MM STAINLESS STEEL 2 SIDED RECIPROCATING",SUP-0277096276,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.41,87.12,"CIGNA [10200]","Cigna Local Plus",,155.37,53.5,,,,,0,33.77,246.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF ENHANCR II 110CM 4MM 7FR 2-5-2MM SPACE 55MM MEDIUM",SUP-FND-019-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"AETNA [10100]","Aetna HMO/PPO",,1081.84,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT SHOULDER PARTIAL","SUP-CON S2",CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2426.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2381.24,17403.75,"percent of total billed charges",
"SIZER IMPL 11.5CM NATRELLE INSPIRA P4.7CM FULL PROFILE ROUND",SUP-SSZ-F335,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"AETNA [10100]","Aetna HMO/PPO",,1184.87,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVOLUTION 10CM 8MM 20MM 25MM ESOPHAGEAL SILICONE",SUP-G48031,CDM,C1876,HCPCS,0278,RC,,,both,,,14283.00,4284.9,"NOVANET [10819]",Novanet,,10712.25,75,,,,,0,1661.11,12140.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM MITRAL CARPENTIER-EDWARDS PHYSIO II",SUP-5200M26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"UHC [10700]","United Healthcare",,8735.4,63.3,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION IJS ELBOW BASE PLATE",SUP-IJS-ELB-BPA,CDM,C1776,HCPCS,0278,RC,,,both,,,33950.70,10185.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3948.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3948.47,28858.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 52MM COCR",SUP-VAL-35520-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"CIGNA [10200]","Cigna Open Access",,1194.9,56.9,,1144.80,304.56,2275.09,66,244.23,1785,"percent of total billed charges",
"CATHETER 115CM 7FR 2-12-2MM SPACING ISMUS CATH CURVE ELECTRO",SUP-D7R20P14CT,CDM,C1731,HCPCS,0272,RC,,,both,,,2100.00,630,"AETNA [10100]","Aetna HMO/PPO",,1669.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM STAINLESS STEEL 2.4MM SCR 6 HOLE HEAD 2 HOLE",SUP-02.111.621S,CDM,C1713,HCPCS,0278,RC,,,both,,,4102.05,1230.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,486.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",477.07,3486.74,"percent of total billed charges",
"SCR BONE 5.5MM 35MM CD HORIZON TITANIUM COCR SPINE",SUP-55890005535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP PARTIAL POROUS STEM WITH COCR HEAD",SUP-71701075,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1635.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1604.94,11730,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 38MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25038W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"FIRST HEALTH [10303]","First Health",,2700,80,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 28CM INTERSTIM SURESCAN MRI LEAD KIT 2.16MM",SUP-978A128,CDM,C1778,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]",Cigna,,8820,40,,6217.33,6217.33,6217.33,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"GRAFT BONE ARTHROCELL PLUS DEMINERALIZE CORTICAL CANCELLOUS",SUP-ABS-2090-05,CDM,C1734,HCPCS,0278,RC,,,both,,,22050.00,6615,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS ELECTROSURGICAL 36CM 5MM HARMONIC ACE+ TITANIUM",SUP-HAR36,CDM,S27200284,LOCAL,0272,RC,,,both,,,2369.00,710.7,"FIRST HEALTH [10303]","First Health",,1895.2,80,,,,,0,275.51,2013.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT 85CM PRESSURE RELATIVE RISK UNITIZE DISTAL CATH",SUP-NS0007,CDM,S27800098,LOCAL,0278,RC,,,both,,,11094.58,3328.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5092.41,45.9,,,,,0,1290.3,9430.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 24CM 6FR .038IN PIGTAIL CURVE TAPER URETER GLIDEX",SUP-M001245740,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,708.98,41.1,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR",RX-28824,CDM,,,0250,RC,64980-0324-30,NDC,both,30,GR,549.31,164.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,373.53,68,,,,,0,63.88,466.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 80CM 60MM 7MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV07006008P,CDM,C1725,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,938.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 65CM 5FR .046IN .038IN KA2 CURVE ANGIOGRAPHIC",SUP-56538KA2,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"CIGNA [10200]","Cigna Local Plus",,58.18,53.5,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETER 14.5FR L40CM INSERTION L23CM POLYURETHANE DOUBL",SUP-8888145040P,CDM,C1750,HCPCS,0278,RC,,,both,,,2876.79,863.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,334.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.57,2445.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEARTRAIL III 100CM 6FR IKARI LEFT 3.5 CURVE GUIDING",SUP-40-6370,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,69.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X3 HUMERAL INSERT - 32MM X 6 CONSTRAINED",SUP-5571-C-3206,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"MULTIPLAN [10600]",Multiplan,,8568,85,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IV NACL 0.9PCT 1000ML BG LF",SUP-2B1324X,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,12.39,45.9,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 8-0 TG140-8 12IN 2 ARM BRAID COATED VIOLET",SUP-J548G,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.98,46.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT NYLON ETHILON MULTIPASS 6-0 PC-3 18IN MONOFILAMENT BLACK",SUP-1866G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPN NC 20MM 1.5MM BALLOON DILATATION PLATINUM IRIDIUM",SUP-150-020-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WORKHORSE II 75CM 4CM 6FR 8MM BALLOON DILATATION",SUP-16500416,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 20MM 6FR 3.5MM",SUP-H7493926720350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PREMATURITY WITHOUT MAJOR PROBLEMS",792,MS-DRG,,,,,,,inpatient,,,10514.80,3154.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOGRAPHIC VITEK CEREBRAL CURVE 5FR 125CM BRAID",SUP-G12082,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.55,134.56,"PHCS [10601]",PHCS,,313.99,70,,,,,0,52.17,381.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 55MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840007555,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH DURAL 14X8CM DURA-GUARD CRANIAL BOVINE PERICARDIUM",SUP-DG0814SN,CDM,,,0278,RC,,,both,,,6314.67,1894.4,"NOVANET [10819]",Novanet,,4736,75,,,,,0,6.31,5367.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,J0735,HCPCS,0636,RC,00143-9724-01,NDC,both,10,ML,380.52,114.16,"CIGNA [10200]",Cigna,,46.31,,,,,,,21.18,323.44,"fee schedule",
"SHEATH FLEXOR CHECK-FLO STRAIGHT 55CM 8FR 2.9MM GUIDING",SUP-G56233,CDM,C1894,HCPCS,0272,RC,,,both,,,472.23,141.67,"PHCS [10601]",PHCS,,330.56,70,,,,,0,54.92,401.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SYMPLICITY SPYRAL CATHETER",SUP-IDEHTNRDN016,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION KAMVAC MINI CURVE STERILE LATEX FREE",SUP-5300-20-500,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SMALL INTERNAL FILSHIE SILASTIC TITANIUM SOFT LINE",SUP-AVM-851J,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,408.97,45.9,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM EDWARDS SAPIEN ASCENDRA PLUS TRANSAPICAL",SUP-9355ASP29A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"BLUE CROSS [10001]","Blue Cross PPO",,72618,39.2,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 45CM 16/8MM GELSOFT PLUS VASCUTEK 2 BRANCH",SUP-631608P,CDM,C1768,HCPCS,0278,RC,,,both,,,8383.50,2515.05,"CIGNA [10200]",Cigna,,5700.78,68,,,,,0,975,7125.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 3.5IN 1.6IN 3 WAY RADIOPAQUE MARKER TIP DIL",SUP-PSS-6F-4MT,CDM,C1894,HCPCS,0272,RC,,,both,,,148.68,44.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,61.11,41.1,,,,,0,17.29,126.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 4.5MM CORONARY STENT",SUP-H7493941820450,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 20MM 9MM KNEE FASTTHREAD",SUP-AR-4020C-09,CDM,C1713,HCPCS,0278,RC,,,both,,,2323.13,696.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1066.32,45.9,,,,,0,270.18,1974.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 8MM 144CM 3.5MM CORONARY STENT PEBAX",SUP-H7493926008350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AETNA [10100]","Aetna HMO/PPO",,4424.18,79.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hsg Si",PX-320000126,CDM,74740,CPT,0320,RC,,,both,,,1418.02,425.41,"BLUE CROSS [10001]","Blue Cross PPO",,252.77,,"Fee schedule rate ($252.77).",253.71,241.38,253.71,"1 through 10",118.57,1205.32,"fee schedule",
"SCR BONE 6.5MM 40MM SOLERA COCR SPINE MULTIAXIAL",SUP-55840006540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1110.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1110.3,8114.82,"percent of total billed charges",
"INSERT TIBIAL 4 16MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620416,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"AETNA [10100]","Aetna HMO/PPO",,8946.85,79.5,,10981.53,8986.79,12413.38,12,1308.83,9565.82,"percent of total billed charges",
"ANCHOR KT SUT MINI BIO-SUTURETAK 2 FW 2.4X5MM DISP",SUP-AR-1322DSC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"MULTIPLAN [10600]",Multiplan,,1265.12,85,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL DURAL DURAGEN 3X 3IN SQUARE CALLAGEN DURAMATRIX REPAIR",SUP-DMR33,CDM,,,0278,RC,,,both,,,7742.49,2322.75,"CIGNA [10200]","Cigna Open Access",,4405.48,56.9,,,,,0,7.74,6581.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 70MM VALOR HINDFOOT FUSION SYSTEM",SUP-4151150070,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"FIRST HEALTH [10303]","First Health",,1380,80,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 150MM 20GA 10MM",SUP-AC0012,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.91,41.1,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE MIC-KEY",SUP-0270-18-2.0-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"CIGNA [10200]","Cigna Local Plus",,1408.55,53.5,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 545CC",SUP-SMPX545,CDM,C1789,HCPCS,0278,RC,,,both,,,6382.50,1914.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1826.67,28.62,,,,,0,742.28,5425.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 3MM BALLOON DILATATION STERILE LATEX",SUP-593015022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 2CM 9MM BALLOON DILATATION ILIAC",SUP-G34372,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,MODERATE",233,APR-DRG,,,,,,,inpatient,,,82161.26,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $8,977.81. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($35,800.99) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY",SUP-F6HF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) TF (-T) SHEATH AND DILATOR LPLHR-0107",SUP-LHR-0107,CDM,C1894,HCPCS,0272,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) QUALIBREATH",SUP-QB-XS,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 20GA 15CM CHIBA COLOR CODED HUB FNA ADJUSTABLE",SUP-MCN2006,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 200CM 40MM 6MM BALLOON DILATATION STERILE",SUP-H74939031604020,CDM,C1725,HCPCS,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER AND ELBOW JOINT REPLACEMENT,MAJOR",322,APR-DRG,,,,,,,inpatient,,,232196.75,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $14,178.81. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($87,448.76) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CESAREAN SECTION WITH STERILIZATION,MODERATE",539,APR-DRG,,,,,,,inpatient,,,43943.85,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,712.21. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 30MM 2.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2530X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"NOVANET [10819]",Novanet,,425.25,75,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR ADULT LNCS ADTX-3 3FT OXIMETER ADHSV LATEX FREE",SUP-2317,CDM,S27000186,LOCAL,0270,RC,,,both,,,64.38,19.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.49,54.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR ADULT LNCS ADTX-3 3FT OXIMETER ADHSV LATEX FREE",SUP-2317,CDM,S27000186,LOCAL,0270,RC,,,both,,,64.38,19.31,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,26.46,41.1,,,,,0,7.49,54.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM STAINLESS STEEL 3.5MM SCR 3 HOLE LCP BONE",SUP-241.901,CDM,C1713,HCPCS,0278,RC,,,both,,,9928.27,2978.48,"CIGNA [10200]",Cigna,,6751.22,68,,1831.33,1831.33,1831.33,16,1154.66,8439.03,"percent of total billed charges",
"HC Ld Recovery 1st Hour",PX-710000002,CDM,9999144,LOCAL,0710,RC,,,both,,,3269.70,980.91,"UHC [10700]","United Healthcare",,2069.72,63.3,,,,,0,380.27,2779.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 SH 27IN CONTROL RELEASE BRAIDED 8 STRAND",SUP-VCP785D,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.21,38.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.03,109.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6X20X75/ 6F UNISTEP PLUS",SUP-M001711080,CDM,C1725,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1001.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC N Telopeptide Crosslinks",PX-301000155,CDM,82523,CPT,0301,RC,,,both,,,318.00,95.4,"FIRST HEALTH [10303]","First Health",,254.4,80,,,,,0,0.01,270.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 20MM TITANIUM FOOT VARIABLE ANGLE LOCK",SUP-AR-8933V-20,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"CIGNA [10200]",Cigna,,963.9,68,,1831.33,1831.33,1831.33,16,164.86,1204.88,"percent of total billed charges",
"INSRT TIBIAL 8 7MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620807,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1308.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ECLS PACK",SUP-627383402,CDM,S27200284,LOCAL,0272,RC,,,both,,,1425.60,427.68,"KAISER [10500]",Kaiser,,955.15,67,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 16CM 3CM 5FR .035IN 2",SUP-M006192114180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"CIGNA [10200]",Cigna,,1081.11,68,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"**DO NOT REUSE ITEM # - PS GO LIVE ISSUE**TROCAR LAPAROSCOPI",SUP-C0R47,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA [10200]","Cigna Open Access",,103.96,56.9,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X14X7MM ANCHOR-C 4D HOLLOW CERVICAL ANTERIOR",SUP-48323074,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"FIRST HEALTH [10303]","First Health",,14400,80,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11.9-11.7CM NATRELLE BIOCELL P5-5.9CM HIGH",SUP-SZHP68400,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"MULTIPLAN [10600]",Multiplan,,258.83,85,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"23 MM LOTUS EDGE AORTIC VALVE SYSTEM AND LARGE LOTUS INTRODU",SUP-H749LVSUS230,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"PHCS [10601]",PHCS,,129675,70,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 12X7.5-8.4CM BREAST 200ML STYLE 133LV TEXTURED",SUP-133LV-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,5460.00,1638,"CIGNA [10200]","Cigna Local Plus",,2921.1,53.5,,,,,0,635,4641,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 31MMX12MMX15CM 22FR",SUP-TAC123115A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,49248,27,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 4MM CONCERTO 3D",SUP-PV-4-12-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO 120CM 9FR ELECTROHYDRAULIC STERILE",SUP-E-9F,CDM,S27200284,LOCAL,0272,RC,,,both,,,1320.92,396.28,"CIGNA [10200]",Cigna,,898.23,68,,,,,0,153.62,1122.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH C315S1002",SUP-C315S1002,CDM,C1887,HCPCS,0272,RC,,,both,,,2175.00,652.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1479,68,,,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 555ML P5.9CM MODERATE PLUS PROFILE TALL HEIGHT",SUP-334-1409,CDM,C1789,HCPCS,0278,RC,,,both,,,8107.50,2432.25,"MULTIPLAN [10600]",Multiplan,,6891.38,85,,,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 40MM 125CM 6MM 6FR VASCULAR NITINOL",SUP-G43821,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Local Plus",,2022.3,53.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +26 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.260,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOSURGICAL 70MM SURGIFROST ABLATION",SUP-60SF7,CDM,S27200284,LOCAL,0272,RC,,,both,,,14490.00,4347,"CIGNA [10200]","Cigna Local Plus",,7752.15,53.5,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOPROSTHESIS STENT AORTOILIAC L39MM DIA6MM VIABAHN V",SUP-BXB063902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5582.27,28.62,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chest Exploration Icu Bedside",PX-361000299,CDM,361000299,LOCAL,0361,RC,,,both,,,8503.36,2551.01,"CIGNA [10200]","Cigna Open Access",,4838.41,56.9,,,,,0,988.94,7227.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 40MM 130CM 6MM LONG VASCULAR NITINOL ILIAC",SUP-SC640LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]",Cigna,,4926.6,68,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MTRL SPLINTING THK1/8IN SMALL STATURE 24X18IN OPTIPERF",SUP-550549,CDM,S27000186,LOCAL,0270,RC,,,both,,,630.50,189.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,73.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.33,535.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL TROUTMAN-BARRAQUER 45D .12MM 3IN ANGLED 2X3",SUP-60-1463,CDM,S27200284,LOCAL,0272,RC,,,both,,,1402.60,420.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,166.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,163.12,1192.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 125MM 23MM RESTORATION +10MM STD HIP MODULAR",SUP-6276-1-123,CDM,C1776,HCPCS,0278,RC,,,both,,,17360.18,5208.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7135.03,41.1,,6417.48,6417.48,6417.48,"1 through 10",2018.99,14756.15,"percent of total billed charges",
"SCREW SPINAL 8.5X40MM POLYAXIAL 4S RELINE-O",SUP-13118540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TFNT30 PANOPTIX TORIC",SUP-TFNT30,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"CIGNA [10200]",Cigna,,574.6,68,,,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL BLOCK 14X13",SUP-245341,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTNR SCR 12MM 3.5MM PRODISC-C SPINE NONSTERILE",SUP-03.820.102,CDM,S27200284,LOCAL,0272,RC,,,both,,,1239.30,371.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,509.35,41.1,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 6CM 6MM BALLOON DILATATION ILIAC",SUP-G34335,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAVVY 120CM 6CM 3.5-3FR 3.5MM .018IN LOW PROFILE",SUP-435356L,CDM,C1725,HCPCS,0272,RC,,,both,,,2137.50,641.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,253.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM 16MM DCP LC-DCP STAINLESS STEEL",SUP-216.030,CDM,C1713,HCPCS,0278,RC,,,both,,,485.43,145.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,138.93,28.62,,,,,0,56.46,412.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIVERSAL 1L POUCH WITH SHOULDER STRAP AND WAIST BELT DISP","SUP-EQPRA-T-750 DISP",CDM,S27200284,LOCAL,0272,RC,,,both,,,111.80,33.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13,95.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY CUT-AWAY 6FR GUIDING INNER",SUP-7039,CDM,C1887,HCPCS,0272,RC,,,both,,,1579.50,473.85,"KAISER [10500]",Kaiser,,1058.27,67,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +20.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.205,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR 6CM TAPER 145CM 7CM .035",SUP-M001465001,CDM,C1769,HCPCS,0272,RC,,,both,,,494.10,148.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,203.08,41.1,,,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 13MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G613,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"PHCS [10601]",PHCS,,6556.26,70,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION",RX-10224,CDM,J1171,HCPCS,0636,RC,00703-0113-01,NDC,both,5,ML,110.54,33.16,"KAISER [10500]",Kaiser,,74.06,67,,,,,0,13.1,110.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0102,CDM,S27800098,LOCAL,0278,RC,,,both,,,5451.00,1635.3,"AETNA [10100]","Aetna HMO/PPO",,4333.55,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,633.95,4633.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Angio Adrenal Uni Sel Si",PX-323000018,CDM,75731,CPT,0323,RC,,,both,,,5619.82,1685.95,"CIGNA [10200]","Cigna Open Access",,219.32,,,,,,,156.81,5619.82,"fee schedule",
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN STD",SUP-67004100,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"FIRST HEALTH [10303]","First Health",,334.08,80,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 12MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192012,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"CIGNA [10200]",Cigna,,9499.39,40,,5873.17,5873.17,5873.17,"1 through 10",2761.95,20186.21,"percent of total billed charges",
"LEAD ICD 70CM ENDOTAK RELIANCE G ENDOCARDIAL STEROID",SUP-176,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS [10001]","Blue Cross HMO",,5950.56,39.2,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI 100CM 4FR AMPLATZ RIGHT 2 MODIFY CURVE",SUP-538443,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,60.87,68,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR .5MM ULTRASHARP STRAIGHT STRAIGHT KNIFE SURGICAL",SUP-681.05,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT XL 20 CC MATRIX BIOACTIVE S",SUP-74000200,CDM,C1713,HCPCS,0278,RC,,,both,,,27720.00,8316,"CIGNA [10200]","Cigna Local Plus",,8731.8,31.5,,3978.14,359.25,3978.14,24,3223.84,23562,"percent of total billed charges",
"RESTRICT CEMENT MEDIUM UNIVERSAL DISTAL DISPOSABLE INSRT",SUP-B000-1240,CDM,S27800098,LOCAL,0278,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 36MMX8MM CAPSTONE",SUP-9440836,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4936.95,28.62,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 38MM STAINLESS STEEL T8 METAPHYSEAL SELF TAP",SUP-02.118.538,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"MULTIPLAN [10600]",Multiplan,,445.32,85,,,,,0,60.93,445.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 8MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBJR080502A,CDM,C1874,HCPCS,0278,RC,,,both,,,19895.40,5968.62,"MULTIPLAN [10600]",Multiplan,,16911.09,85,,,,,0,2313.84,16911.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 5MM COOLCUT FLUSHCUT 6 FLUTE OVAL",SUP-AR-8500FOS,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,230.71,41.1,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY SPADE SNARECOIL BONE MARROW",SUP-RBN-114S,CDM,S27200284,LOCAL,0272,RC,,,both,,,400.20,120.06,"CIGNA [10200]",Cigna,,272.14,68,,,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL DIA8CM POLYESTER MONOFILAMENT POLYLACTIC ACID",SUP-PNP8X3,CDM,C1781,HCPCS,0278,RC,,,both,,,889.54,266.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,408.3,45.9,,,,,0,103.45,756.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 165MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-410-165,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,957.42,570.23,957.42,28,2014.9,14726.25,"percent of total billed charges",
"PLATE CS1 STAINLESS STEEL 2.7MM SCR VARIABLE ANGLE LCP BONE",SUP-02.112.620,CDM,C1713,HCPCS,0278,RC,,,both,,,6189.30,1856.79,"BLUE CROSS [10001]","Blue Cross HMO",,2426.21,39.2,,957.42,156.86,7483.26,51,719.82,5260.91,"percent of total billed charges",
"HC Lyse Chest Fibrin Init Day",PX-361000427,CDM,32561,CPT,0361,RC,,,both,,,2278.07,683.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,269.95,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,264.94,2278.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 160MM 2.7MM QUICK COUPLING CANNULATED STERILE",SUP-310.67S,CDM,C1713,HCPCS,0278,RC,,,both,,,2568.60,770.58,"NOVANET [10819]",Novanet,,1926.45,75,,,,,0,298.73,2183.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEM SM 65MM KN LT GMRS",SUP-6495-2-010,CDM,C1776,HCPCS,0278,RC,,,both,,,34883.10,10464.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14336.95,41.1,,6417.48,6417.48,6417.48,"1 through 10",4056.9,29650.64,"percent of total billed charges",
"KT GSTRM 22FR BLN",SUP-6221,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TACTICATH 115CM 3.5MM 7FR 65MM CURVE 2-5-2MM SPACE","SUP-PN-004 065",CDM,C1732,HCPCS,0272,RC,,,both,,,16560.00,4968,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1962.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 33.58CM 8MM DA VINCI XI ENDOWRIST 42D",SUP-470405,CDM,S27000186,LOCAL,0270,RC,,,both,,,2115.00,634.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CENTEZE 6FR DRNG CENTESIS STERILE LATEX FREE DISPOSABLE",SUP-DRC-002-06,CDM,C1729,HCPCS,0272,RC,,,both,,,163.39,49.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RECTANGULAR SHANNON BURR 2.0MM X 20MM (STERILE)",SUP-CD-BS-4220-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,2880.00,864,"AETNA [10100]","Aetna HMO/PPO",,2289.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.94,2448,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT GLENOID UNIVERS REVERS POROUS OD30 MM MODULAR POST",SUP-AR-9582-30,CDM,C1776,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"FIRST HEALTH [10303]","First Health",,4195.2,80,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 7CM 7FR PIGTAIL CURVE TAPER PANCREATIC",SUP-G22353,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA [10200]","Cigna Local Plus",,338.01,,,,,,,73.48,537.03,"percent of total billed charges",
"HEAD FEMORAL +5MM 12/14 TAPER 36MM HIP CEMENTLESS M",SUP-136552000,CDM,C1776,HCPCS,0278,RC,,,both,,,3991.68,1197.5,"NOVANET [10819]",Novanet,,2993.76,75,,,,,0,464.23,3392.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X8MM DIVERGENCE 12MM LORDOTIC NUCLEUS PULPOSUS",SUP-G6626528,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"CIGNA [10200]",Cigna,,4968,40,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fibrinolysins Screen I&R",PX-305000082,CDM,85390,CPT,0305,RC,,,both,,,135.20,40.56,"CIGNA [10200]",Cigna,,34.06,,,,,,,0.14,114.92,"fee schedule",
"HC Cytology Body Fluid",PX-311000004,CDM,88108,CPT,0311,RC,,,both,,,202.00,60.6,"AETNA [10100]","Aetna HMO/PPO",,160.59,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,171.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONTOUR 150-250 2 VIALS BX/2",SUP-M0017600221,CDM,S27800098,LOCAL,0278,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross PPO",,571.54,39.2,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Sel Opn Add 20scm (Go)",PX-430000025,CDM,97598,CPT,0430,RC,,,both,,,1339.00,401.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,215,,"Per diem ($215).",,,,0,155.73,1138.15,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER FLEXIVA 200UM FLEXSHIELD HIGH POWER POLISH",SUP-M0068403910,CDM,S27200284,LOCAL,0272,RC,,,both,,,2752.13,825.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1131.13,41.1,,,,,0,320.07,2339.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 57MM 135CM 5MM 60MM BILIARY STAINLESS STEEL",SUP-PXB35-05-57-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"KAISER [10500]",Kaiser,,2925.89,67,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 18MM RETRACTA DETACHABLE .035IN",SUP-G34203,CDM,S27800098,LOCAL,0278,RC,,,both,,,4674.68,1402.4,"AETNA [10100]","Aetna HMO/PPO",,3716.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,543.67,3973.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY DRNG 18CM 8FR THAL-QUICK THORACIC 3 SIDEPORT RADIOPAQUE",SUP-G06791,CDM,C1729,HCPCS,0272,RC,,,both,,,1652.25,495.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1123.53,68,,,,,0,192.16,1404.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 RB-1 36IN 2 ARM MONOFILAMENT BLUE",SUP-8558H,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.79,19.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.54,55.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 5-0 C-1 30IN 2 ARM MONOFILAMENT VIOLET ABSORBABLE",SUP-Z126H,CDM,S27200284,LOCAL,0272,RC,,,both,,,193.43,58.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.5,164.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 15CM 120CM 6MM 6FR ENDOPROSTHESIS HEPARIN",SUP-VBJR061502A,CDM,C1874,HCPCS,0278,RC,,,both,,,25143.30,7542.99,"BLUE CROSS [10001]","Blue Cross PPO",,9856.17,39.2,,,,,0,2924.17,21371.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 38CM 135CM 9MM VASCULAR COVER BALLOON",SUP-LSMU1350938,CDM,C1874,HCPCS,0278,RC,,,both,,,15870.00,4761,"FIRST HEALTH [10303]","First Health",,12696,80,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 115CM 5MM 5FR ELECTROPHYSIOLOGY 4 POLE 12 PIN",SUP-D1085413,CDM,C1730,HCPCS,0272,RC,,,both,,,1425.60,427.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,165.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 9IN SPETZLER-MALIS SLIM .5MM DISPOSABLE",SUP-6780-230-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,3208.53,962.56,"CIGNA [10200]","Cigna Open Access",,1825.65,56.9,,,,,0,373.15,2727.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CRANIOTOMY 5.31MM ACCESS DRILL BIT RAZOR SYR NDL HOLDER",SUP-INS-5HND,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +15.5 DIOPTER 13MM 6MM POSTERIOR CHMBR 3 PIECE",SUP-Z900200155,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"BLUE CROSS [10001]","Blue Cross HMO",,400.08,39.2,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grad Compression Knee 40-50",PX-E27100011,CDM,A6532,HCPCS,0292,RC,,,both,,,217.80,65.34,"AETNA [10100]","Aetna HMO/PPO",,173.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.33,185.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 31CM 3MM PRUITT F3 OUTLYING PORT",SUP-E2012-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,9446.10,2833.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1119.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1098.58,8029.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 220MM 7FR 5MM 5FR BALLOON DILATATION",SUP-39032-50221,CDM,C1725,HCPCS,0272,RC,,,both,,,2137.50,641.25,"PHCS [10601]",PHCS,,1496.25,70,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 56MM 20MM 6MM 16FR ZENITH SPIRAL-Z 2",SUP-G55241,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"AETNA [10100]","Aetna HMO/PPO",,16833.57,79.5,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 5-0 RB-1 30IN 2 ARM BRAID GREEN",SUP-X550H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"MULTIPLAN [10600]",Multiplan,,21.25,85,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTRUMENT MINI-HOHMANN RETRACTOR SMALL",SUP-INST-MHR-SM,CDM,S27000186,LOCAL,0270,RC,,,both,,,1755.00,526.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 20MM 10MM BALLOON DILATATION DURALYN",SUP-48010002S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,163.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT HAND ACCESS 120MM WOUND RTRCTR LAPAROSCOPIC MARK PEN",SUP-C8XX2,CDM,S27200284,LOCAL,0272,RC,,,both,,,4312.50,1293.75,"MULTIPLAN [10600]",Multiplan,,3665.63,85,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH 3.5MM AORTIC",SUP-APU535,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"CIGNA [10200]","Cigna Open Access",,164.99,56.9,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTRA 42CM 7FR 130D GUIDING STERILE LATEX FREE",SUP-451790,CDM,C1893,HCPCS,0272,RC,,,both,,,1800.00,540,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1224,68,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +28.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.285,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,98.74,28.62,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PROFILE SOFTTOUCH SMOOTH",SUP-SSL-125,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,878.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPIC VASCULAR 6X80X75",SUP-H74939200068070,CDM,C1725,HCPCS,0272,RC,,,both,,,4140.00,1242,"UHC [10700]","United Healthcare",,2620.62,63.3,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR MEDIUM 48MM COCR",SUP-626-00-48G,CDM,C1776,HCPCS,0278,RC,,,both,,,9500.40,2850.12,"AETNA [10100]","Aetna HMO/PPO",,7552.82,79.5,,10981.53,8986.79,12413.38,12,1104.9,8075.34,"percent of total billed charges",
"ADPTR ELECTROSURGICAL HARMONIC SYNERGY HANDSWITCH DISPOSABLE",SUP-HSA08,CDM,S27000186,LOCAL,0270,RC,,,both,,,277.56,83.27,"NOVANET [10819]",Novanet,,208.17,75,,,,,0,32.28,235.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR CORTICAL LORDOTIC BLOCK 11X11X6",SUP-340611,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 102MM 2.7MM STAINLESS STEEL QUICK CONNECT 76MM",SUP-KM166-310-26,CDM,S27200284,LOCAL,0272,RC,,,both,,,198.53,59.56,"KAISER [10500]",Kaiser,,133.02,67,,,,,0,23.09,168.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 150CM 100MM 4MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013466-100,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"NOVANET [10819]",Novanet,,941.63,75,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 13.3MM 24.2MM 22.8MM ATS OPEN PIVOT AP360 24MM",SUP-505DM24,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2747.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 24MM 28.7MM 22.9MM MITRAL FLEXIBLE",SUP-4450M24,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"BLUE CROSS [10001]","Blue Cross HMO",,4462.92,39.2,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX12MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183522,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"AETNA [10100]","Aetna HMO/PPO",,6232.63,79.5,,10981.53,8986.79,12413.38,12,911.77,6663.81,"percent of total billed charges",
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC",516,MS-DRG,,,,,,,inpatient,,,107161.13,32148.34,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,13470.66,,"Case rate ($12,890.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,969.78, add-ons for qualifying new technology services are included. If operating cost exceeds $45,009.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,286.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,985.61. The transfer operating threshold is the transfer adjustment factor * $11,969.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $904.97. The transfer capital threshold is the transfer adjustment factor * $904.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,60672.21,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Access Av Grft Thromb W Pta",PX-361000438,CDM,36905,CPT,0361,RC,,,both,,,43810.07,13143.02,"PHCS [10601]",PHCS,,30667.05,70,,,,,0,5095.11,37238.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE DOUBLE TROCAR 1.6MM X 171MM",SUP-KWIR-DT-16171,CDM,S27000186,LOCAL,0270,RC,,,both,,,453.60,136.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,208.2,45.9,,,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HYBRID TOTAL KNEE SYSTEM (EITHER POROUS FEMUR OR TIBIA)",SUP-98000200313,CDM,C1776,HCPCS,0278,RC,,,both,,,26460.00,7938,"NOVANET [10819]",Novanet,,19845,75,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR FL4.5 CURVE ANGIOGRAPHIC FEMORAL 2",SUP-H74916599232,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]",Cigna,,52.07,68,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP MULTIHOLE COLOR CODED OSSEOTI G7 F",SUP-110010265,CDM,C1776,HCPCS,0278,RC,,,both,,,20755.98,6226.79,"AETNA [10100]","Aetna HMO/PPO",,16501,79.5,,10981.53,8986.79,12413.38,12,2413.92,17642.58,"percent of total billed charges",
"SOUND 14-24FR URETHRAL CURVE VAN BUREN 10.75IN",SUP-51-6350,CDM,S27200284,LOCAL,0272,RC,,,both,,,342.82,102.85,"PHCS [10601]",PHCS,,239.97,70,,,,,0,39.87,291.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP040200090 PLUS US D4L200UL900",SUP-PCP040200090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,506.02,41.1,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 2.5MM BALLOON DILATATION STERILE LATEX",SUP-592515022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"UHC [10700]","United Healthcare",,846,63.3,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 22CM 5FR .035",SUP-M006192121090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"CIGNA [10200]","Cigna Local Plus",,798.45,,,,,,,173.57,1268.57,"percent of total billed charges",
"GENRTR NEROSTIMLTR 2.63INX1.98IN PROCLAIM ELITE THK.53IN 7",SUP-3662,CDM,C1820,HCPCS,0278,RC,,,both,,,88207.50,26462.25,"PHCS [10601]",PHCS,,61745.25,70,,,,,0,10258.53,74976.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Temp Pacing Catheter/Intro Kit",PX-E27200289,CDM,E27200289,LOCAL,0278,RC,,,both,,,950.40,285.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,112.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,110.53,807.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH VASCULAR 8X.8CM VASCU-GUARD PERIPHERAL BOVINE",SUP-VG0108N,CDM,C1768,HCPCS,0278,RC,,,both,,,1897.13,569.14,"BLUE CROSS [10001]","Blue Cross HMO",,743.67,39.2,,,,,0,220.64,1612.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 80MM 3.5MM BALLOON DILATATION DURALYN",SUP-48003508S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"FIRST HEALTH [10303]","First Health",,1004.4,80,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 9CM 5FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22981,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA [10200]","Cigna Open Access",,359.49,,,,,,,73.48,537.03,"percent of total billed charges",
"STENT WALLFLEX 230CM 120CM 22-27MM 10FR COLONIC ENTERAL",SUP-M00565120,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE REGENESORB 20MM 5MM OPEN ARCHITECTURE SOLID",SUP-72204389,CDM,C1713,HCPCS,0278,RC,,,both,,,2079.00,623.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,595.01,28.62,,,,,0,241.79,1767.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 135CM 200MM 3MM .035IN BALLOON",SUP-AB35W03200135,CDM,C1725,HCPCS,0272,RC,,,both,,,1061.91,318.57,"FIRST HEALTH [10303]","First Health",,849.53,80,,,,,0,123.5,902.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 60CC FINE 1-4MM LATEX FREE",SUP-800111,CDM,S27800098,LOCAL,0278,RC,,,both,,,6399.75,1919.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,758.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,744.29,5439.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TYSHAK NUCLEUS 100CM 4CM 10FR 20MM .035IN 8FR 2 TAPER",SUP-612094,CDM,C1725,HCPCS,0272,RC,,,both,,,5345.43,1603.63,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL INTRAOSSEOUS 45MM 15GA EZ-IO STAINLESS STEEL 5GM LATEX",SUP-9078,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.80,114.84,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT ZILVER 518 80CM 125CM 8MM VASCULAR HIWIRE NITINOL",SUP-G43783,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,495.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +28 DIOPTER MODIFIED C BICONVEX 13.5MM 6.5MM",SUP-MC50BD.280,CDM,V2632,HCPCS,0276,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,231.82,28.62,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER HUMERAL INSPACE MEDIUM",SUP-131,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10206,27,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 4.5IN 9FR FRAZIER ANGLE",SUP-70-1080,CDM,S27200284,LOCAL,0272,RC,,,both,,,189.83,56.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.08,161.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +23.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.235,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR EBU4.5 CURVE GUIDING LEFT ATRIAL",SUP-LA7EBU45,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 22MM 140CM 3.5MM",SUP-RSINT35022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,644.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 24FR SILICONE TROCAR CANN ROUND EXTERNAL BOLST",SUP-M00509061,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"UHC [10700]","United Healthcare",,307.64,63.3,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 800MM 3MM STERILE LATEX FREE DISPOSABLE",SUP-99-177281,CDM,C1769,HCPCS,0272,RC,,,both,,,1339.42,401.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,910.81,68,,,,,0,155.77,1138.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLCHICINE 0.6 MG TABLET",RX-1821,CDM,,,0637,RC,50268-0187-11,NDC,both,1,UN,27.21,8.16,"UHC [10700]","United Healthcare",,17.22,63.3,,,,,0,3.16,23.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 64X43MM PFC SIGMA 2 KNEE CEMENT MODULAR PLUS FIX",SUP-860122,CDM,C1776,HCPCS,0278,RC,,,both,,,16046.64,4813.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1901.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1866.22,13639.64,"percent of total billed charges",
"SCR BONE 4MM 14MM TITANIUM SPINE CERVICAL SELF RETAINING",SUP-04.613.614,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,1144.80,304.56,2275.09,66,117.75,860.63,"percent of total billed charges",
"XIENCE SKYPOINT EVEROLIMUS ELUTING CORONARY STENT SYSTEM 5.0",SUP-1804500-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE",318,MS-DRG,,,,,,,inpatient,,,145994.79,43798.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,38618.9,,,,,,,15025.05,59796.97,"case rate",
"KIT DRNG 15.5FR 1 VALVE CAP SAFETY SCPL FRCP PERITONEAL CATH",SUP-50-9000B,CDM,C1729,HCPCS,0272,RC,,,both,,,3967.50,1190.25,"AETNA [10100]","Aetna HMO/PPO",,3154.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-08041,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 5.5MM TITANIUM",SUP-8452120,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"SLEEVE TIBIAL 37MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-1511-11-202,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,8601.07,8395.67,8601.07,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"STENT SURPASS EVOLVE 12MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDS40012,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,23761.67,28.62,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COOK-Z 5CM 35MM 16FR TRACHEOBRONCHIAL STAINLESS STEEL",SUP-G08556,CDM,C1877,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2841.72,68,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.75CM NATRELLE INSPIRA P6.4CM EXTRA FULL",SUP-MSZ-X615,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL KNEE 2A POROUS/HYBRID PROPRIETARY))/STRYKER X3 W/TRITA",SUP-CAP-K-2A,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6310.71,28.62,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 465CC",SUP-SMPX465,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"AETNA [10100]","Aetna HMO/PPO",,5924.34,79.5,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 12D 16D BAND STD 24FR PLASMABAND",SUP-WA22721S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3215.54,964.66,"NOVANET [10819]",Novanet,,2411.66,75,,,,,0,373.97,2733.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 3MM25CM 190",SUP-R51003025L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"MULTIPLAN [10600]",Multiplan,,2118.1,85,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 50MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.850,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,393.36,28.62,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR NEONATAL LNCS OXIMETER ADHESIVE CABLED TAPE MASIMO SE",SUP-1862,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.00,20.7,"KAISER [10500]",Kaiser,,46.23,67,,,,,0,0.58,58.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 14MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-714-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3444.02,28.62,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES",213,MS-DRG,,,,,,,inpatient,,,268163.70,80449.11,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PROGRESS 40 VASCULAR STRAIGHT 190CM 3CM .014",SUP-1011836,CDM,C1769,HCPCS,0272,RC,,,both,,,1036.80,311.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LATERAL LUMBAR ANCHOR 22MM",SUP-1219.0022,CDM,C1713,HCPCS,0278,RC,,,both,,,3277.50,983.25,"AETNA [10100]","Aetna HMO/PPO",,2605.61,79.5,,1521.93,481.35,16760.95,30,381.17,2785.88,"percent of total billed charges",
"STENT 24CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX TAPER TIP",SUP-M0061453610,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,181.19,28.62,,,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 4.75MM PERCUTANEOUS CCM",SUP-641000030,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"ASCOPE 4 BRONCHO REGULAR SAMPLER SET",SUP-477501000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2010.00,603,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,922.59,45.9,,,,,0,233.76,1708.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 95MM 5.5MM MATRIX 200MM RADIUS CURVE BULLET NOSE",SUP-04.651.295,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"IMMOB ORTHOPEDIC UNIVERSAL 24IN 12-24IN KNEE 3 PANEL T BAR",SUP-7091-52,CDM,L1830,HCPCS,0274,RC,,,both,,,264.57,79.37,"NOVANET [10819]",Novanet,,198.43,75,,,,,0,30.77,224.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC",432,MS-DRG,,,,,,,inpatient,,,46475.47,13942.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,31380.45,,,,,,,7561,46475.47,"case rate",
"DEFIBRILLATOR CRT-D GALLANT BIPOLAR DF1HF",SUP-CDHFA500B,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8949.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ganglioside Monosialic Acd Abs",PX-301000265,CDM,83520,CPT,0301,RC,,,both,,,354.35,106.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.48,,"Fee schedule rate ($18.48). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.35,301.2,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 54CM EPICARDIAL UNIPOLAR ACTIVE FIXATION",SUP-4047,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,652.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 40MM 130CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-EX060403CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"NOVANET [10819]",Novanet,,8797.5,75,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 20MM 5FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206060270,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"**DO NOT REUSE ITEM # - PS GO LIVE ISSUE**TROCAR ENDOSCOPIC",SUP-CTF33,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA [10200]","Cigna Open Access",,103.96,56.9,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 60MM 120CM 18MM .035IN 3MM VASCULAR ILIOFEMORAL",SUP-VENUL18060,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"BLUE CROSS [10001]","Blue Cross HMO",,9137.52,39.2,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 39MM 24MM +4MM LATERALIZE GLENOSPHERE ARTHREX",SUP-AR-9564-2439-LAT,CDM,C1776,HCPCS,0278,RC,,,both,,,9763.50,2929.05,"BLUE CROSS [10001]","Blue Cross PPO",,3827.29,39.2,,3949.44,3949.44,3949.44,"1 through 10",1135.5,8298.98,"percent of total billed charges",
"SCR BONE LIGHT GREEN 72MM 5MM NAIL-EX FEMORAL TIBIAL",SUP-04.005.562,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,530.92,45.9,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SOLITAIRE PARAMETRIC 50MM 40MM 4MM 10MM SPACE 3-1",SUP-SFR4-4-40-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,40761.00,12228.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4740.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4740.5,34646.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS ELECTROSURGICAL 14CM 5MM HARMONIC SCPL ACE TITANIUM",SUP-ACE14S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2048.86,614.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,242.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,238.28,1741.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 0 SH 30IN BRAID GREEN NONABSORBABLE",SUP-X834H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR JR4.5 CURVE GUIDING CORONARY",SUP-LA8JR45,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 27MMX13MM CAPSTONE CONTROL 6D PEEK INTERBODY",SUP-4001327,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"PHCS [10601]",PHCS,,11592,70,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIPRASIDONE 20 MG CAPSULE",RX-29778,CDM,,,0637,RC,00904-6269-45,NDC,both,1,UN,16.65,4.99,"CIGNA [10200]",Cigna,,11.32,68,,,,,0,1.94,14.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK 12X10IN THERAPEUTIC MOIST HEAT THERMAL COLOR CODED TABS",SUP-561725,CDM,S27000186,LOCAL,0270,RC,,,both,,,201.58,60.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,92.53,45.9,,,,,0,23.44,171.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 STRAIGHT OVAL 9IN BRUNS SPINE SURGICAL",SUP-29-5352,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.25,71.77,"FIRST HEALTH [10303]","First Health",,191.4,80,,,,,0,27.82,203.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 20MM AXSOS STAINLESS STEEL T20 FEMUR HUMERUS",SUP-370120,CDM,C1713,HCPCS,0278,RC,,,both,,,1219.05,365.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,828.95,68,,,,,0,141.78,1036.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE DESTINATION STRAIGHT 65CM 35CM 8FR GUIDING",SUP-54-86501,CDM,C1887,HCPCS,0272,RC,,,both,,,769.50,230.85,"AETNA [10100]","Aetna HMO/PPO",,611.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 5FR .058IN EXTRA BACKUP 3.75 LEFT CURVE",SUP-LA5EBU375,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,266.22,68,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165CM 10.5-12MM OTSC 6MM NITINOL GC",SUP-100.27,CDM,C1760,HCPCS,0278,RC,,,both,,,4547.10,1364.13,"FIRST HEALTH [10303]","First Health",,3637.68,80,,,,,0,528.83,3865.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT 137CM 6MM 2.5MM RECTANGLE HELIX TAPER",SUP-2200-2506,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"MULTIPLAN [10600]",Multiplan,,4985.25,85,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL SHOULDER ANATOMIC CAP AUGMENTED GLENOID CAP",SUP-TSA3,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 150ML GEL SMOOTH ROUND COHESIVE I SILICONE P2.8","SUP-3501501 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1051.79,28.62,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 14X13CM BREAST 600ML STYLE 133MX TEXTURED STERILE",SUP-133MX-14,CDM,C1789,HCPCS,0278,RC,,,both,,,5460.00,1638,"CIGNA [10200]","Cigna Local Plus",,2921.1,,,,,,,635,4641,"percent of total billed charges",
"GRAFT BONE PROGENIX PLUS DEMINERALIZED BONE MATRIX BOVINE",SUP-6001,CDM,C1713,HCPCS,0278,RC,,,both,,,1394.82,418.45,"CIGNA [10200]",Cigna,,948.48,68,,1831.33,1831.33,1831.33,16,162.22,1185.6,"percent of total billed charges",
"STENT ZIPWIRE 30CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175275180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"NOVANET [10819]",Novanet,,1095.08,75,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 5ML MASTERGRAFT MATRIX BLOCK EXT",SUP-7610305,CDM,C1713,HCPCS,0278,RC,,,both,,,3582.75,1074.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,424.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,416.67,3045.34,"percent of total billed charges",
"SCR BONE SELF TAPPING T8 STARDRIVE RECESS THREADED CONICAL",SUP-212.820,CDM,C1713,HCPCS,0278,RC,,,both,,,843.45,253.03,"BLUE CROSS [10001]","Blue Cross PPO",,330.63,39.2,,957.42,570.23,957.42,28,98.09,716.93,"percent of total billed charges",
"TRAY HEMODIALYSIS CATHETER 12.5FR X 24CM PASS ACUTE STRAIGHT",SUP-8888231424,CDM,C1752,HCPCS,0272,RC,,,both,,,1178.06,353.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,139.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,137.01,1001.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 3.50 X 38 MM",SUP-1212350-38,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"NOVANET [10819]",Novanet,,12937.5,75,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 360 145CM 20MM 2MM 6FR 2MM ATHERECTOMY",SUP-DBP-200CLASS145,CDM,C1724,HCPCS,0272,RC,,,both,,,21388.50,6416.55,"UHC [10700]","United Healthcare",,13538.92,63.3,,,,,0,2487.48,18180.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Fluoro Guide Spine Inj",PX-320000175,CDM,77003,CPT,0320,RC,,,both,,,1421.42,426.43,"BLUE CROSS [10001]","Blue Cross PPO",,251.72,,"Fee schedule rate ($251.72).",,,,0,165.31,1208.21,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Driveline W Closure 6x6",PX-E27200437,CDM,E27200437,LOCAL,0272,RC,,,both,,,43.97,13.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.11,37.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dil Intracranial Vspasm",PX-361000255,CDM,61640,CPT,0361,RC,,,both,,,7679.39,2303.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,7.68,7679.39,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mopath Procedure Level 9",PX-309000101,CDM,81408,CPT,0310,RC,,,both,,,1100.00,330,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1100,,"Fee schedule rate ($2,140.33). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1100,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC if Herpes Smpx Antigen",PX-306000206,CDM,87290,CPT,0306,RC,,,both,,,251.00,75.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,42.56,,,,,,,0.25,213.35,"fee schedule",
"HC MR Quan Tis Comp WO Dx MRI Mlt",PX-610000068,CDM,0697T,CPT,0610,RC,,,both,,,415.00,124.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,48.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.26,415,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hiv 2 Ab",PX-302000223,CDM,86702,CPT,0302,RC,,,both,,,385.70,115.71,"PHCS [10601]",PHCS,,269.99,70,,,,,0,0.01,327.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Scr Breast Tomosynthesis Uni",PX-403000008,CDM,77063,CPT,0403,RC,,,both,,,96.68,29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.24,96.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 0 UR-6 27IN MONOFILAMENT ABSORBABLE",SUP-N879H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,18.36,68,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +28 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.280,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Stent & Ather Cmplx Init",PX-361000735,CDM,37294,CPT,0361,RC,,,both,,,21707.51,6512.25,"PHCS [10601]",PHCS,,15195.26,70,,,,,0,21.71,18451.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Vulva Peri Abscess",PX-450000282,CDM,56405,CPT,0361,RC,,,both,,,1183.72,355.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1183.72,,"Case rate ($2,262). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,137.67,1183.72,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB TISSUE 30X20CM STRATTICE PORCINE DERMAL MATRIX MESH",SUP-2030002,CDM,Q4130,HCPCS,0636,RC,,,both,,,82957.80,24887.34,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,53922.57,65,,,,,0,9830.5,70514.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI FIELDER VASCULAR STRAIGHT 300CM 3CM .014IN",SUP-AGP140300,CDM,C1769,HCPCS,0272,RC,,,both,,,3562.50,1068.75,"UHC [10700]","United Healthcare",,2255.06,63.3,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP",RX-123703,CDM,,,0250,RC,60687-0576-40,NDC,both,5,ML,59.09,17.73,"KAISER [10500]",Kaiser,,39.59,67,,,,,0,6.87,50.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL SHOULDER RESURFACE COPELAND HA 3",SUP-11114643,CDM,C1776,HCPCS,0278,RC,,,both,,,16174.80,4852.44,"FIRST HEALTH [10303]","First Health",,12939.84,80,,,,,0,1881.13,13748.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES",213,MS-DRG,,,,,,,inpatient,,,268163.70,80449.11,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,37524.27,,"Case rate ($35,400.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $32,871.53, add-ons for qualifying new technology services are included. If operating cost exceeds $65,911.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,867.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $32,915.00. The transfer operating threshold is the transfer adjustment factor * $32,871.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,485.25. The transfer capital threshold is the transfer adjustment factor * $2,485.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,140886.53,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VENTRALIGHT ST ECHO 2 15X10CM ELLIPSE",SUP-5991015,CDM,C1781,HCPCS,0278,RC,,,both,,,4358.04,1307.41,"CIGNA [10200]","Cigna Local Plus",,2331.55,53.5,,3096.73,1.00,3096.73,"1 through 10",506.84,3704.33,"percent of total billed charges",
"CATH SUPREME 120CM 6FR 2-5-2MM SPACING JSN CURVE",SUP-401451,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"MULTIPLAN [10600]",Multiplan,,619.65,85,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIPOLAR/BIPOLAR CEMENTED",SUP-CAP-DS-PH-1,CDM,C1776,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]","Cigna Open Access",,4711.32,56.9,,5302.19,4377.88,6578.61,27,962.96,7038,"percent of total billed charges",
"CATH X-FORCE U30 4CM 6FR 4MM BALLOON DILATATION PERCUTANEOUS",SUP-997404,CDM,C1726,HCPCS,0272,RC,,,both,,,1529.38,458.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,628.58,41.1,,,,,0,177.87,1299.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL GOLD 60MM 3.5MM SYNAPSE CURVE TITANIUM PREBENT",SUP-04.614.760,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SPINAL 45MM 6.5MM CREO POLYAXIAL FENESTRATED THREAD",SUP-5192.1647,CDM,C1713,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,782.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",782.41,5718.38,"percent of total billed charges",
"CAP KIT TKR 92 CAP EXTRA",SUP-98000200196,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9828,40,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 3MM AXOGUARD NERVE CAP SIS MATRIX END TAB",SUP-AGT315,CDM,C1763,HCPCS,0278,RC,,,both,,,15304.20,4591.26,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1779.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1779.88,13008.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Pta Sf Init",PX-361000721,CDM,37280,CPT,0361,RC,,,both,,,14777.16,4433.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1751.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1718.58,12560.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP MILLER 1 STRAIGHT STAINLESS STEEL FIBER OPTIC",SUP-040-851U,CDM,S27200284,LOCAL,0272,RC,,,both,,,265.18,79.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,30.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.84,225.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 20MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540020L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY INTRO EXPRESS KYPHOPAK FIRST FRACTURE 15/2",SUP-KPE1003,CDM,C1894,HCPCS,0272,RC,,,both,,,11021.40,3306.42,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE 20CM 12FR DRNG DIL",SUP-K12-08324,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET 30CM 8FR NEPHRSTMY PERCUTANEOUS ACCESS PIGTAIL CATH",SUP-M0064201110,CDM,C1729,HCPCS,0272,RC,,,both,,,811.13,243.34,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 5.5FR 11CM GRAY HUB TUBING ROTATING SUT RING",SUP-PSI-5F-11ACT,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 45MM 6MM EGG STERILE",SUP-1607002003,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHILON 2 LR 30IN 2 ARM MONOFILAMENT BLACK NONABSORBABLE",SUP-490T,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV",RX-29805,CDM,J1806,HCPCS,0636,RC,44567-0450-01,NDC,both,250,ML,560.85,168.25,"NOVANET [10819]",Novanet,,420.64,75,,,,,0,66.46,476.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC",085,MS-DRG,,,,,,,inpatient,,,78766.18,23629.85,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 75MM TITANIUM ENDOSCOPIC LINEAR CUTTER SAFETY",SUP-TLC75,CDM,S27200284,LOCAL,0272,RC,,,both,,,2800.28,840.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) AMENDTS SYSTEM TSP38T",SUP-90-7001-138,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 7X80 40CM SL",SUP-48007008P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL IRRIGATION 0.9% SODIUM CHLORIDE 500ML PRESERVATIVE FREE",SUP-06138-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT GRAFTON SMALL DEFECT DEMINERALIZED BONE",SUP-T44145,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1979.44,45.9,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VASCBAND 29 CM",SUP-3529,CDM,S27000186,LOCAL,0270,RC,,,both,,,165.30,49.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,112.4,68,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL SHOULDER: HUMMERAL HEAD, HUMERAL STEM",SUP-SI-HEMI,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"PHCS [10601]",PHCS,,14332.5,70,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 750ML GEL SMOOTH MEMORYGEL SILICONE P5.9CM HIGH","SUP-3507504 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"PHCS [10601]",PHCS,,2646,70,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 16FR SILICONE INTERNAL RETENTION BALLOON RECESS DISTAL",SUP-8100-16LV,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"CIGNA [10200]","Cigna Local Plus",,149.74,53.5,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5CMX12MM FLAT ROUND TIP OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-6-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,169.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 95MM 25MM AFX VELA STRATA AORTIC EXT AAA STERILE",SUP-A25-25/C95V,CDM,C1874,HCPCS,0278,RC,,,both,,,35406.00,10621.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10133.2,28.62,,,,,0,4117.72,30095.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 95MM 5.5MM MATRIX 200MM RADIUS CURVE BULLET NOSE",SUP-04.651.295,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"CABLE CATH 5FT INGEVITY J ATRIAL PASSIVE FIXATION",SUP-636,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6238.98,41.1,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 1 GS-21 18IN CLSR NONABSORBABLE BLUE",SUP-VLOCN0327,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.33,69.4,"PHCS [10601]",PHCS,,161.93,70,,,,,0,26.9,196.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PATELLAR WEDGE 16-18MM",SUP-T00557,CDM,S27800098,LOCAL,0278,RC,,,both,,,6964.86,2089.46,"KAISER [10500]",Kaiser,,4666.46,67,,,,,0,810.01,5920.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT MEDIUM 11.5X3-3.5IN PLASTIC HAND LEFT ORTHOSIS REST",SUP-55460407,CDM,L3807,HCPCS,0274,RC,,,both,,,460.89,138.27,"NOVANET [10819]",Novanet,,345.67,75,,,,,0,53.6,391.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00210,CDM,C1780,HCPCS,0276,RC,,,both,,,1093.50,328.05,"FIRST HEALTH [10303]","First Health",,874.8,80,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 100CM 4FR SIDEWINDER I CURVE ANGIOGRAPHIC NEON",SUP-451430H0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"CIGNA [10200]","Cigna Open Access",,59.4,56.9,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 34MM 23MM FREESTYLE ROOT PORCINE BIOPROSTHESIS",SUP-FR995-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,38430.00,11529,"BLUE CROSS [10001]","Blue Cross PPO",,15064.56,39.2,,,,,0,4469.41,32665.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veno Renal Bil Sel Si",PX-320000134,CDM,75833,CPT,0320,RC,,,both,,,8568.35,2570.5,"CIGNA [10200]","Cigna Local Plus",,173.95,,,,,,,124.38,7592.53,"fee schedule",
"STEM FEMORAL 129MM 15MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771101500,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"CIGNA [10200]",Cigna,,8359.85,40,,5873.17,5873.17,5873.17,"1 through 10",2430.63,17764.68,"percent of total billed charges",
"BODY CONE 29MM RESTORATION +0MM STD HIP MODULAR REVISION",SUP-6276-1-029,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"CIGNA [10200]",Cigna,,8901.9,40,,5873.17,5873.17,5873.17,"1 through 10",2588.23,18916.54,"percent of total billed charges",
"GWIRE ORTHOPEDIC 150MM 1.1MM",SUP-MSG11150,CDM,C1769,HCPCS,0272,RC,,,both,,,174.00,52.2,"MULTIPLAN [10600]",Multiplan,,147.9,85,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 90CM 3.1FR .05-.063IN 50MM SPACE SPRT",SUP-518-036,CDM,C1887,HCPCS,0272,RC,,,both,,,972.00,291.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,113.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 6MM ENDOWRIST SP CADIERE NONSTERILE LATEX",SUP-431300,CDM,S27000186,LOCAL,0270,RC,,,both,,,2063.40,619.02,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,239.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.97,1753.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 SH 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8832H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.4MM 85MM TRIGEN TITANIUM FEMUR INTERNAL CAPTURE",SUP-71642385,CDM,C1713,HCPCS,0278,RC,,,both,,,3334.28,1000.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,395.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,387.78,2834.14,"percent of total billed charges",
"TRAP WATER MEMB LATEX FREE DISPOSABLE D-FEND RPO PTFE",SUP-M1182629,CDM,S27000186,LOCAL,0270,RC,,,both,,,64.47,19.34,"UHC [10700]","United Healthcare",,40.81,63.3,,,,,0,7.5,55.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CM 7MM CLLGN",SUP-AG750,CDM,C1768,HCPCS,0278,RC,,,both,,,26327.70,7898.31,"CIGNA [10200]",Cigna,,10531.08,40,,,,,0,3061.91,22378.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET .195IN 81IN SET Y GRAVITY FLOW ROLLER CLAMP CYSTOSCOPIC",SUP-2C4041,CDM,S27200284,LOCAL,0272,RC,,,both,,,151.31,45.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,102.89,68,,,,,0,17.6,128.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 6MM 3.5MM BALLOON DILATATION",SUP-H7493912406350,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 90MM VALOR",SUP-4151150090,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1173,68,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP BIOPSY MUSCLE RAYPORT",SUP-SU130-1113,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.53,58.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) STABILIZER SLIDER",SUP-25100SL,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RING ANNULOPLASTY 36MM 41.2MM 34.8MM MITRAL FLEXIBLE HOLDER",SUP-4450M36,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"AETNA [10100]","Aetna HMO/PPO",,9051.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 74MM PRESS FIT AEQUALIS ASCEND FLEX PTC 127.5D",SUP-DWF603A,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOPLASTY 5FR L130CM BALLOON L2CM DIA5MM DUAL LAY",SUP-U813052,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE STABILIT MX VERTEBRAL SATURATE MIX SYSTEM",SUP-4457,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"AETNA [10100]","Aetna HMO/PPO",,1788.75,79.5,,1521.93,481.35,16760.95,30,261.68,1912.5,"percent of total billed charges",
"DIL SURGICAL .038IN 18CM 14FR VESSEL",SUP-DIL-600-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.99,20.1,"CIGNA [10200]","Cigna Local Plus",,35.84,53.5,,,,,0,7.79,56.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2XS UNIVERSAL 12MM KNEE COCR POLYETHYLENE",SUP-198727012,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"KAISER [10500]",Kaiser,,19796.07,67,,,,,0,3436.24,25114.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Foramen Epi Lumb Sngl",PX-510000128,CDM,64483,CPT,0361,RC,,,both,,,4057.93,1217.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1550,,"Case rate ($1,550). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1550,2385,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X10MM CASCADIA 0D PARALLEL TITANIUM POROUS",SUP-6101-2184510LP-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,42048.72,12614.62,"UHC [10700]","United Healthcare",,26616.84,63.3,,,,,0,4890.27,35741.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 14CM 5FR 2 PIGTAIL CURVE",SUP-M0061921130,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"KAISER [10500]",Kaiser,,760.87,67,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SKATER 20CM 7FR .035IN PIGTAIL CURVE DRNG SLIP-COAT",SUP-756507020,CDM,C1729,HCPCS,0272,RC,,,both,,,651.24,195.37,"KAISER [10500]",Kaiser,,436.33,67,,,,,0,75.74,553.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch W Excsn Tumor",PX-750000017,CDM,31640,CPT,0750,RC,,,both,,,5006.00,1501.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2795.56,,"Case rate ($2,795.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,582.2,5006,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATHETER TURNPIKE 135CM 2.9FR 2.1FR VASCULAR GOLD MUL",SUP-5621,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850016540,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"AETNA [10100]","Aetna HMO/PPO",,5211.23,79.5,,1521.93,481.35,16760.95,30,762.35,5571.75,"percent of total billed charges",
"TREVO NXT 3X32+TRAK21 2-PACK - US",SUP-91312,CDM,S27200284,LOCAL,0272,RC,,,both,,,24624.97,7387.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2918.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2863.88,20931.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL ENDOSCOPIC SHEATH BOX BIOPSY PORT ADJUSTABLE Y ADPTR",SUP-BPS-Y,CDM,S27200284,LOCAL,0272,RC,,,both,,,186.72,56.02,"CIGNA [10200]",Cigna,,126.97,68,,,,,0,21.72,158.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 9MM KNEE CONSTRAIN LEGION",SUP-71420523,CDM,C1776,HCPCS,0278,RC,,,both,,,17832.15,5349.64,"CIGNA [10200]","Cigna Local Plus",,5617.13,31.5,,5372.07,4581.20,7242.98,23,2073.88,15157.33,"percent of total billed charges",
"CATH COYOTE 150CM 150MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939186251510,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MARVEL VASCULAR 190CM",SUP-H749393011902,CDM,C1769,HCPCS,0272,RC,,,both,,,689.78,206.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.22,586.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAXTORQUE? 1.4MM GUIDE-WIRE SLEEVE (GOLD)",SUP-CSS04114,CDM,S27200284,LOCAL,0272,RC,,,both,,,1603.80,481.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,659.16,41.1,,,,,0,186.52,1363.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 7MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620407,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1308.83,9565.82,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 18MM 140CM 3.5MM 2.1-2.7FR CORONARY",SUP-RONYX35018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"FIRST HEALTH [10303]","First Health",,2970,80,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 3 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022213,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"BLUE CROSS [10001]","Blue Cross PPO",,6515.86,39.2,,3949.44,3949.44,3949.44,"1 through 10",1933.15,14128.79,"percent of total billed charges",
"CATH NANOCROSS 150CM 100MM 5MM .014IN BALLOON DILATATION",SUP-AB14W050100150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,569.28,41.1,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 24MM 144CM 5MM CORONARY STENT",SUP-H7493941824500,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 90MM 75CM 16MM 9FR 100CM",SUP-H965403330,CDM,C1876,HCPCS,0278,RC,,,both,,,7560.00,2268,"CIGNA [10200]","Cigna Open Access",,4301.64,56.9,,,,,0,879.23,6426,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD MEDIUM TSRH TITANIUM SPINAL 3DX",SUP-8351521,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1110.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1110.3,8114.82,"percent of total billed charges",
"CORTICAL SCREW 4MM X 48MM",SUP-HTN-U-4-48,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"CIGNA [10200]",Cigna,,1057.54,68,,1831.33,1831.33,1831.33,16,180.87,1321.92,"percent of total billed charges",
"ALTIVATE REVERSE REVISION HUMERAL STEM, SZ 8X220MM",SUP-530-08-220,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UHC [10700]","United Healthcare",,7975.8,63.3,,8601.07,8395.67,8601.07,"1 through 10",1465.38,10710,"percent of total billed charges",
"BALLOON KPA25 CATHETER 25MM UNIPEDICULAR",SUP-KPA25,CDM,S27200284,LOCAL,0272,RC,,,both,,,20790.00,6237,"AETNA [10100]","Aetna HMO/PPO",,16528.05,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Presumpt ID Ea Isol Urine",PX-306000064,CDM,87088,CPT,0306,RC,,,both,,,17.00,5.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17,,,,,,,0.01,17,"fee schedule",
"PORT IMPLANTABLE INFUSION POWERPORT ISP MRI PLASTIC SILICONE",SUP-1809660,CDM,C1788,HCPCS,0278,RC,,,both,,,1905.00,571.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,874.4,45.9,,,,,0,221.55,1619.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Arthgm Elbow Si",PX-322000002,CDM,73085,CPT,0322,RC,,,both,,,1259.43,377.83,"FIRST HEALTH [10303]","First Health",,1007.54,80,,,,,0,117,1070.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLP Admit Visit",PX-441000001,CDM,G0153,HCPCS,0441,RC,,,outpatient,,,363.00,108.9,"MULTIPLAN [10600]",Multiplan,,308.55,85,,,,,0,243.21,308.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Ctrl Blood",PX-750000091,CDM,45382,CPT,0750,RC,,,both,,,3655.67,1096.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,425.15,3655.67,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ld Routine Delivery Charge",PX-722000001,CDM,9999147,LOCAL,0722,RC,,,both,,,4023.46,1207.04,"AETNA [10100]","Aetna HMO/PPO",,3198.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,467.93,3419.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 62.5MM KNEE LEFT POSTERIOR STABILIZE OPEN BOX",SUP-184526,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"NOVANET [10819]",Novanet,,18619.34,75,,,,,0,2887.24,21101.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY PRO 45CM 9FR WIDE CURVE GUIDING CORONARY SINUS",SUP-8110,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"KAISER [10500]",Kaiser,,2487.38,67,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Culture Stool",PX-306000002,CDM,87045,CPT,0306,RC,,,both,,,286.90,86.07,"BLUE CROSS [10001]","Blue Cross HMO",,12.1,,"Fee schedule rate ($12.10).",,,,0,4.26,243.87,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 3.5MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES3520CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,776.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vrtplsty Cerv/Thorac W Img",PX-361000375,CDM,22510,CPT,0361,RC,,,both,,,9476.00,2842.8,"UHC [10700]","United Healthcare",,7311,,"Case rate ($7,311). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1102.06,9476,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 137MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 10",SUP-223.601,CDM,C1713,HCPCS,0278,RC,,,both,,,2192.40,657.72,"CIGNA [10200]","Cigna Open Access",,1247.48,56.9,,1144.80,304.56,2275.09,66,254.98,1863.54,"percent of total billed charges",
"SCR BONE 3.5MM 30MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.330,CDM,C1713,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1184.87,28.62,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 20MM 6FR 8MM .018IN BALLOON",SUP-39031-80201,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Beta 2 Glycoprotein I Ab Ea",PX-302000016,CDM,86146,CPT,0302,RC,,,both,,,324.90,97.47,"CIGNA [10200]","Cigna Local Plus",,55.99,,,,,,,0.01,276.17,"fee schedule",
"COIL EMBOLIZATION 2CM 1MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR091020,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"NOVANET [10819]",Novanet,,9919.39,75,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT AORTIC 4.5CM 23MM EXCLUDER CONFORMABLE ACTIVE CONTROL",SUP-CXA230005,CDM,C1874,HCPCS,0278,RC,,,both,,,27612.90,8283.87,"FIRST HEALTH [10303]","First Health",,22090.32,80,,,,,0,3211.38,23470.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOABLATION 11IN 8MM CRYOSPHERE 180D UP BALL TIP",SUP-CRYOS,CDM,C9808,HCPCS,0272,RC,,,both,,,17250.00,5175,"CIGNA [10200]",Cigna,,11730,68,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 12X4CM GENTRIX PORCINE URINARY BLADDER",SUP-PSM0412,CDM,C1781,HCPCS,0278,RC,,,both,,,3894.91,1168.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1787.76,45.9,,,,,0,452.98,3310.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 65CM RVOT KIT MOND STAINLESS STEEL WIDE",SUP-4151/65,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"NOVANET [10819]",Novanet,,431.33,75,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revasc Acute Occl Ami Sngl Ves 1maj C Art",PX-481000087,CDM,92941,CPT,0481,RC,,,both,,,33062.33,9918.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3917.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3845.15,28102.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 23MM 145CM 2.25MM CORONARY STENT",SUP-1145225-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STAPLER TRI-STAPLE 2 MM L30 MM MEDIUM THICK TISSUE AR",SUP-SIG30AMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1098.77,329.63,"NOVANET [10819]",Novanet,,824.08,75,,,,,0,127.79,933.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH URI-CATH 3 WAY STPCOCK DRNG CLOSED SYSTEM",SUP-4195007,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.55,67.96,"CIGNA [10200]",Cigna,,154.05,68,,,,,0,26.35,192.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 4.5MM BALLOON DILATATION PEBAX",SUP-1012279-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT PERICARDIUM HYDR 1X1",SUP-10-0053,CDM,S27800098,LOCAL,0278,RC,,,both,,,2062.50,618.75,"CIGNA [10200]","Cigna Local Plus",,1103.44,53.5,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL GRAY 45MM 5.5MM CONTOUR",SUP-101-65545,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"CATHETER TORQR 110CM 6FR 2-5-2MM SPACING JSN CURVE ELECTROPH",SUP-04122JMR,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,212.98,68,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 275ML P3.5CM MODERATE PLUS PROFILE HIGH",SUP-350-2751BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"NOVANET [10819]",Novanet,,3933,75,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROUND FLUTED DRAIN FR 19",SUP-27419,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.63,38.89,"CIGNA [10200]",Cigna,,88.15,68,,,,,0,15.08,110.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 115CM 2.2FR 1CM TIPLESS STONE NCIRCLE UROLOGICAL",SUP-G18778,CDM,S27200284,LOCAL,0272,RC,,,both,,,1804.50,541.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1227.06,68,,,,,0,209.86,1533.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Declot Cannula W Baln",PX-361000127,CDM,36861,CPT,0361,RC,,,both,,,4928.23,1478.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,584,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,573.15,4928.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 1.2CM 14FR RADIOPAQUE LOW PROFILE TAPER DISTAL TIP",SUP-0120-14-1.2,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CIGNA [10200]",Cigna,,529.76,68,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE ROUND 202MM STAINLESS STEEL 12 HOLE 1 THREADED LOCKING",SUP-437112S,CDM,C1713,HCPCS,0278,RC,,,both,,,8594.64,2578.39,"CIGNA [10200]","Cigna Local Plus",,4598.13,53.5,,3978.14,359.25,3978.14,24,999.56,7305.44,"percent of total billed charges",
"STENT CONTOUR VL 22-30CM 4.8FR PIGTAIL CURVE URETERAL",SUP-M0061801550,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"MULTIPLAN [10600]",Multiplan,,766.85,85,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Stent & Ather Sf Init",PX-361000733,CDM,37292,CPT,0361,RC,,,both,,,21707.51,6512.25,"BLUE CROSS [10001]","Blue Cross PPO",,21.71,.1,,,,,0,21.71,18451.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 75CM 60MM 8MM BALLOON DILATATION DRUG COATED",SUP-LX3575860V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"KAISER [10500]",Kaiser,,5663.18,67,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC",241,MS-DRG,,,,,,,inpatient,,,58839.08,17651.72,"CIGNA [10200]","Cigna Local Plus",,14285.62,,"Fee schedule rate ($14,285.62). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,40418.94,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 118MM PRIMARY ANTHOLOGY POROUS 131D 10 HIGH",SUP-71356110,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"CIGNA [10200]",Cigna,,13256.46,40,,5873.17,5873.17,5873.17,"1 through 10",3854.32,28169.98,"percent of total billed charges",
"PLATE 145MM STAINLESS STEEL SMALL FRAGMENT SET 1/3 TUBULAR",SUP-241.42,CDM,C1713,HCPCS,0278,RC,,,both,,,1258.74,377.62,"NOVANET [10819]",Novanet,,944.06,75,,,,,0,146.39,1069.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COAG SUCTION 6IN 10FR LECTROVAC VALLEYLAB CORD HAND",SUP-E2505-10FR,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.90,17.07,"KAISER [10500]",Kaiser,,38.12,67,,,,,0,6.62,48.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 45MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-54840014545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 38MM LCP STAINLESS STEEL SMALL BONE SELF",SUP-02.211.038,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"MULTIPLAN [10600]",Multiplan,,763.41,85,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM ENDOCARDIUM 4 SITE 2 COIL ACTIVE FIXATION",SUP-0276,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6868.8,40,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 4.75MM SOLERA COCR MOLYBDENUM CURVED",SUP-1475501055,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"HEAD FEMORAL +1MM 12/14 TAPER 32MM HIP BIOLOX DELTA",SUP-136532310,CDM,C1776,HCPCS,0278,RC,,,both,,,6844.32,2053.3,"PHCS [10601]",PHCS,,4791.02,70,,,,,0,795.99,5817.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 85CM 5.7FR ATRIUM VENTRICLE TRANSVENOUS BIPOLAR",SUP-407685,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"AETNA [10100]","Aetna HMO/PPO",,1774.84,79.5,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY SHARP JAW RADIOPAQUE 104CM 7FR 2.3MM STAINLESS",SUP-504300L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"KAISER [10500]",Kaiser,,949.73,67,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM OFFSET 36MM HIP TYPE 1 COCR G7",SUP-11363661,CDM,C1776,HCPCS,0278,RC,,,both,,,5296.44,1588.93,"CIGNA [10200]","Cigna Local Plus",,2833.6,53.5,,5372.07,4581.20,7242.98,23,615.98,4501.97,"percent of total billed charges",
"STENT GORE VIABAHN 39MM 135CM 8MM 11MM 7FR .035IN",SUP-BXA083902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2311.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 60MM 2MM BALLOON DILATATION PEBAX",SUP-H74939032200610,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cta Head W/WO Cntrst",PX-351000014,CDM,70496,CPT,0351,RC,,,both,,,4058.16,1217.45,"UHC [10700]","United Healthcare",,437.65,,,,,,,405,3449.44,"fee schedule",
"BOLT SPINAL 50MM 6.5MM DECADE LARGE PLATE EXTREME LATERAL",SUP-7146550,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 20MM 120CM 4MM LONG BILIARY NITINOL SELF",SUP-SC420LV,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross PPO",,1481.76,39.2,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 8MM 1.5MM BALLOON DILATATION PEBAX",SUP-1012269-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Out of or Bedside Procedure",PX-361000431,CDM,361000431,LOCAL,0361,RC,,,both,,,5325.22,1597.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2444.28,45.9,,,,,0,619.32,4526.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Out of or Bedside Procedure",PX-361000431,CDM,361000431,LOCAL,0361,RC,,,both,,,5325.22,1597.57,"KAISER [10500]",Kaiser,,3567.9,67,,,,,0,619.32,4526.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Battery Elec/Combo Vad, Rep",PX-E27400023,CDM,Q0496,HCPCS,0274,RC,,,both,,,543.40,163.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,64.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,63.2,461.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Biopatch",PX-E27200089,CDM,E27200089,LOCAL,0272,RC,,,both,,,32.47,9.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.78,27.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 44.5MM .76MM 6MM STOP J LATCH NONSTERILE",SUP-316.306,CDM,S27000186,LOCAL,0270,RC,,,both,,,1013.80,304.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,465.33,45.9,,,,,0,117.9,861.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM QUICKFIX TITANIUM SHORT PARTIAL THREAD T15",SUP-AR-8740-26PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,382.51,28.62,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732062,CDM,C1776,HCPCS,0278,RC,,,both,,,9510.48,2853.14,"AETNA [10100]","Aetna HMO/PPO",,7560.83,79.5,,10981.53,8986.79,12413.38,12,1106.07,8083.91,"percent of total billed charges",
"OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC",093,MS-DRG,,,,,,,inpatient,,,39339.82,11801.95,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,5285.27,,"Case rate ($4,939.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,586.66, add-ons for qualifying new technology services are included. If operating cost exceeds $37,626.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,728.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,592.72. The transfer operating threshold is the transfer adjustment factor * $4,586.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $346.77. The transfer capital threshold is the transfer adjustment factor * $346.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,4939.5,19858.93,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM MULTIFIX S ULTRA KNOTLESS PEEK",SUP-72290001,CDM,C1713,HCPCS,0278,RC,,,both,,,3138.75,941.62,"FIRST HEALTH [10303]","First Health",,2511,80,,,,,0,365.04,2667.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U185,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,88.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 55MMX2.59MM TITANIUM THIN VASCULAR TISSUE 4",SUP-TVC55,CDM,S27200284,LOCAL,0272,RC,,,both,,,2010.80,603.24,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH 12IN 7MM TNLR POLYMER VASCULAR RADIOPAQUE SMOOTH",SUP-9009-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,557.28,167.18,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) QUALI BRA ADVANCED S",SUP-QADV-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE II PRO 30MM 2.5MM BALLOON DILATATION STERILE",SUP-225-303-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IMPL BREAST SMOOTH MOD + PROF XTRA 465CC",SUP-SMPX465,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"BLUE CROSS [10001]","Blue Cross HMO",,2921.18,39.2,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 120MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171081210,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AETNA [10100]","Aetna HMO/PPO",,933.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 3.5MM VERTEX SELECT PRECUT",SUP-7753790,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 14X14.5CM 535ML STYLE FF HIGHLY COHESIVE GEL",SUP-FF-410535,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Open Access",,3166.49,56.9,,5166.00,5166.00,5166.00,"1 through 10",647.21,4730.25,"percent of total billed charges",
"CAGE SPINAL 17X10MM DIVERGENCE 14MM LORDOTIC NUCLEUS",SUP-G6626740,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5104.62,41.1,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ADMIN 126IN 15 GTT/ML INTRAVENOUS STERILE LATEX FREE",SUP-490283,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.83,25.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.87,72.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT CATH FLEXIBLE KINK RESISTANT FEMALE LUER LOCK FIT DRNG",SUP-M0067401200,CDM,S27200284,LOCAL,0272,RC,,,both,,,55.85,16.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,22.95,41.1,,,,,0,6.5,47.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR MP1 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389691380,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"NOVANET [10819]",Novanet,,274.83,75,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PENCIL 15FT EDGE BUTTON SWITCH CORD",SUP-E2450HDBNSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.71,1.41,"NOVANET [10819]",Novanet,,3.53,75,,,,,0,0.55,4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS ELECTROSURGICAL 36CM 5MM HARMONIC ACE+7 CURVE 3",SUP-HARH36,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,262.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS AIM 7.62FR 90D GUIDING NONSTEERABLE",SUP-DS2N027-59,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DREAMTOME PRO RX 44 SPHINCTEROTOME 0.035 X 450CM",SUP-M00584410,CDM,C1769,HCPCS,0272,RC,,,both,,,3112.43,933.73,"NOVANET [10819]",Novanet,,2334.32,75,,,,,0,361.98,2645.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 65MM 2.1MM 1703 3 CARBIDE STERILE LATEX FREE",SUP-1030040-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.25,19.57,"MULTIPLAN [10600]",Multiplan,,55.46,85,,,,,0,7.59,55.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Reptilase Test",PX-305000060,CDM,85635,CPT,0305,RC,,,both,,,195.00,58.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,15.49,,,,,,,0.01,165.75,"fee schedule",
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA3-17-75-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,9949.80,2984.94,"FIRST HEALTH [10303]","First Health",,7959.84,80,,,,,0,1157.16,8457.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE ASP 15CM 8GA BN MRW ACC",SUP-RAN-815N,CDM,S27200284,LOCAL,0272,RC,,,both,,,993.20,297.96,"PHCS [10601]",PHCS,,695.24,70,,,,,0,115.51,844.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 25MM SPINAL",SUP-7976025,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"CIGNA [10200]","Cigna Open Access",,1672.86,56.9,,1144.80,304.56,2275.09,66,341.92,2499,"percent of total billed charges",
"CATH MUSTANG 75CM 20MM 6MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171060270,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,482.72,41.1,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 30MM 2.5MM BALLOON DILATATION DRUG COATED",SUP-H7493960830250,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"KAISER [10500]",Kaiser,,26064.68,67,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERF 9MM 6MM CODMAN HUDSON END SHARP COLOR CODED ATRAUMATIC",SUP-261223,CDM,S27200284,LOCAL,0272,RC,,,both,,,2624.25,787.27,"CIGNA [10200]","Cigna Local Plus",,1403.97,53.5,,,,,0,305.2,2230.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENROUTE STENT FLEX 20MM X 57CM X 6CM",SUP-SR-0620-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON SUPRAMID EXTRA II 4-0 BB 12IN LOOPED MONOFILAMENT",SUP-HEA-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.92,41.98,"CIGNA [10200]","Cigna Open Access",,79.61,56.9,,,,,0,16.27,118.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FUSION ZILVER 6CM 208CM 10MM 7FR .035IN BILIARY",SUP-G31560,CDM,C1876,HCPCS,0278,RC,,,both,,,9597.90,2879.37,"CIGNA [10200]",Cigna,,6526.57,68,,,,,0,1116.24,8158.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 55CM 5FR .038IN CHECK-FLO FLEXOR RAABE",SUP-G13009,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"NOVANET [10819]",Novanet,,334.13,75,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 30X10X7MM 0D EXPAND NONSTERILE",SUP-823007,CDM,S27800098,LOCAL,0278,RC,,,both,,,6094.49,1828.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2797.37,45.9,,,,,0,708.79,5180.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL 50 MCG/ML INJECTION SUPERORDERABLE",RX-4083037,CDM,J3010,HCPCS,0636,RC,00641-6029-01,NDC,both,20,ML,97.67,29.3,"BLUE CROSS [10001]","Blue Cross HMO",,12.82,,,,,,,11.57,83.02,"fee schedule",
"STENT 30CM 3CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175285110,CDM,C2617,HCPCS,0278,RC,,,both,,,1205.77,361.73,"CIGNA [10200]","Cigna Local Plus",,645.09,,,,,,,140.23,1024.9,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 24CM 3CM 5FR .038IN STRAIGHT URETERAL",SUP-M006155222170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS [10001]","Blue Cross PPO",,556.77,39.2,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Upr Ext Jnt W&WO Cntrst",PX-610000029,CDM,73223,CPT,0610,RC,,,both,,,5821.36,1746.41,"MULTIPLAN [10600]",Multiplan,,4948.16,85,,,,,0,677.02,4948.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Upr Ext Jnt W&WO Cntrst",PX-610000029,CDM,73223,CPT,0610,RC,,,both,,,5821.36,1746.41,"CIGNA [10200]","Cigna Open Access",,799,,"Per diem ($799). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,677.02,4948.16,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Vad Tunl 2 Caths 2 Sites",PX-361000114,CDM,36566,CPT,0361,RC,,,both,,,33905.50,10171.65,"FIRST HEALTH [10303]","First Health",,27124.4,80,,,,,0,33.91,28819.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Vad Tunl 2 Caths 2 Sites",PX-361000114,CDM,36566,CPT,0361,RC,,,both,,,33905.50,10171.65,"MULTIPLAN [10600]",Multiplan,,28819.68,85,,,,,0,33.91,28819.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Thorax W/WO Cntrst Dx",PX-352000006,CDM,71270,CPT,0352,RC,,,both,,,3904.65,1171.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,437.65,,,,,,,384.26,3318.95,"fee schedule",
"HC Ext Ecg>48hr<7d Recording",PX-731000005,CDM,93242,CPT,0731,RC,,,both,,,383.00,114.9,"CIGNA [10200]",Cigna,,260.44,68,,,,,0,30.87,383,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.75 X 18 MM  RX FDA",SUP-1203375-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 210CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCM-210,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,878.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH C-FLEX 70CM 4.8FR URETERAL TAPER TIP 1 LUMEN RADIOPAQUE",SUP-M0064001500,CDM,C1758,HCPCS,0272,RC,,,both,,,334.60,100.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,137.52,41.1,,,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9/64IN THREAD 9IN STEINMANN NONSTERILE",SUP-KM169-39-96,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,7.4,54.07,"percent of total billed charges",
"GRAFT SKIN 8X3CM AMNIOBAND 24SQ CM ALLOGRAFT",SUP-WC3038,CDM,Q4151,HCPCS,0636,RC,,,both,,,19348.88,5804.66,"CIGNA [10200]","Cigna Open Access",,362.66,,,,,,,362.66,16446.55,"fee schedule",
"AMVIA EDGE HF-T QP",SUP-460162,CDM,C2621,HCPCS,0275,RC,,,both,,,25200.00,7560,"BLUE CROSS [10001]","Blue Cross PPO",,9878.4,39.2,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 7CM 10FR PROXIMAL BEND BILIARY 2 LAYER STERILE",SUP-PBD-421-1007,CDM,C2625,HCPCS,0278,RC,,,both,,,1387.85,416.35,"FIRST HEALTH [10303]","First Health",,1110.28,80,,,,,0,161.41,1179.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR STRAIGHT 180CM .018IN PTFE STAINLESS STEEL",SUP-G04194,CDM,C1769,HCPCS,0272,RC,,,both,,,121.71,36.51,"UHC [10700]","United Healthcare",,77.04,63.3,,,,,0,14.15,103.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 60MM 5MM BALLOON DILATATION DURALYN",SUP-48005006X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AETNA [10100]","Aetna HMO/PPO",,998.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPYRIDAMOLE 25 MG TABLET",RX-2528,CDM,,,0637,RC,00115-1070-01,NDC,both,1,UN,7.15,2.14,"KAISER [10500]",Kaiser,,4.79,67,,,,,0,0.83,6.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE 40MM 57CM 9-7MM TAPER VASCULAR NITINOL",SUP-SR-090740-TCS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 14.2MM 27/29MM 23.4MM ON-X 36MM CONICAL HEART",SUP-ONXANE-27/29,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"MULTIPLAN [10600]",Multiplan,,32130,85,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METOPROLOL TARTRATE 50 MG TABLET",RX-5009,CDM,,,0637,RC,65862-0063-01,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 3MM TRUDI 0D STRAIGHT STERILE LATEX FREE",SUP-TSB3STR,CDM,S27200284,LOCAL,0272,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]",Cigna,,2422.5,68,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 90CM .1IN 6FR .07IN",SUP-67027090,CDM,C1887,HCPCS,0272,RC,,,both,,,304.50,91.35,"NOVANET [10819]",Novanet,,228.38,75,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMAKER CARDIAC THK6MM 59X55MM ALLURE RF IS-1 CONNECTOR CO",SUP-PM3222,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9236.16,40,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 32MM SIMUPLUS FLEXIBLE LUMEN STERILE LATEX",SUP-7700FB32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE RIGHT CONSTRAIN LEGION OXINIUM",SUP-71421174,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6853.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,6726.09,49158.9,"percent of total billed charges",
"AIRWAY LARYNGEAL MASK ADULT SIZE 5 40ML PVC CUFF STRAIGHT DI",SUP-ALAA050SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.20,15.66,"PHCS [10601]",PHCS,,36.54,70,,,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACCU-VU 70CM 20CM 5FR PIGTAIL CURVE ANGIOGRAPHIC",SUP-H787137098015,CDM,C1887,HCPCS,0272,RC,,,both,,,1099.98,329.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,452.09,41.1,,,,,0,127.93,934.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE COAGULATION PURPLE 350CM 10FR BRIGHTON",SUP-BP-10F-SP-350,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 16MM RETRACTA DETACHABLE .035IN",SUP-G34193,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"CIGNA [10200]","Cigna Local Plus",,2270.27,53.5,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 8MM 2.5MM CORONARY STENT COCR",SUP-1007823-08,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELUVIA US 7X150 130 CM",SUP-H74939294701510,CDM,C1874,HCPCS,0278,RC,,,both,,,25168.50,7550.55,"NOVANET [10819]",Novanet,,18876.38,75,,,,,0,2927.1,21393.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 45MM MATRIX TITANIUM T25 SPINE PEDICLE",SUP-04.639.645,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER QUICKPASS SUTURELASSO 25D SMALL TIGHT RIGHT CURVE",SUP-AR-6068-25TR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,624.61,45.9,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 6MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT060080A,CDM,C1768,HCPCS,0278,RC,,,both,,,17056.80,5117.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2021.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1983.71,14498.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 63MM STAINLESS STEEL 2.4MM SCREWS 6X4 HOLES 2",SUP-02.111.541,CDM,C1713,HCPCS,0278,RC,,,both,,,4041.68,1212.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,478.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,470.05,3435.43,"percent of total billed charges",
"CAGE SPINAL 32X25X10MM DIVERGENCE-L 6D SMALL ANTERIOR OLIF",SUP-2151110,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"CIGNA [10200]","Cigna Open Access",,8864.1,33.5,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE LEUKEMIA WITH MCC",834,MS-DRG,,,,,,,inpatient,,,92101.13,27630.34,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,36097.44,,"Case rate ($34,054.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $31,621.62, add-ons for qualifying new technology services are included. If operating cost exceeds $64,661.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,772.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $31,663.43. The transfer operating threshold is the transfer adjustment factor * $31,621.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,390.75. The transfer capital threshold is the transfer adjustment factor * $2,390.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,92101.13,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"FABRIC CARDIOVASCULAR 12X12CM PRECLUDE THK.1MM PERICARDIUM",SUP-1PCM102,CDM,S27800098,LOCAL,0278,RC,,,both,,,5830.50,1749.15,"CIGNA [10200]","Cigna Local Plus",,3119.32,53.5,,,,,0,678.09,4955.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.8MM SALVATION ORTHOLOC 3DI 5.5MM SCR DISPOSABLE",SUP-59250038,CDM,S27200284,LOCAL,0272,RC,,,both,,,1287.90,386.37,"AETNA [10100]","Aetna HMO/PPO",,1023.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,149.78,1094.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY 10CM 20GA BARD MAX-CORE 2 TRIGGER ULTRA SHARP",SUP-MC2010,CDM,S27200284,LOCAL,0272,RC,,,both,,,254.04,76.21,"FIRST HEALTH [10303]","First Health",,203.23,80,,,,,0,29.54,215.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 28MM 140CM 3MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927428300,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"PHCS [10601]",PHCS,,2625,70,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135MM 30MM 3.8-3.4FR 8MM LOW PROFILE",SUP-39031-80301,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR LAPAROSCOPIC ENDOWRIST DA VINCI S/SI 2 BLADE",SUP-420249,CDM,S27000186,LOCAL,0270,RC,,,both,,,2212.50,663.75,"NOVANET [10819]",Novanet,,1659.38,75,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 4-0 PS-2 SPIRAL 14CM SUT",SUP-SXMP2B407,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.59,68.58,"CIGNA [10200]","Cigna Local Plus",,122.3,53.5,,,,,0,26.59,194.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL SYMMETRY .6-1.5MM APPROXIMATOR WITHOUT FRAME",SUP-ABB-22VB,CDM,S27200284,LOCAL,0272,RC,,,both,,,1895.55,568.66,"CIGNA [10200]","Cigna Local Plus",,1014.12,53.5,,,,,0,220.45,1611.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 8.9MM 6.5MM NASAL ORAL TAPER CUFF MURPHY",SUP-18765S,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.13,22.24,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,30.47,41.1,,,,,0,8.62,63.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Proc Unlisted",PX-614000006,CDM,76498,CPT,0614,RC,,,both,,,1755.00,526.5,"PHCS [10601]",PHCS,,1228.5,70,,,,,0,204.11,1755,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL MULTIPASS 4-0 PC-5 18IN BRAID COATED UNDYED",SUP-J823G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"MULTIPLAN [10600]",Multiplan,,21.25,85,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7-3MM TORNADO PLATINUM .035IN CATH",SUP-G47522,CDM,S27800098,LOCAL,0278,RC,,,both,,,931.42,279.43,"FIRST HEALTH [10303]","First Health",,745.14,80,,,,,0,108.32,791.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC 17-27IN 30.5- IN KNEE ROM HINGE TRIMMABLE",SUP-8814,CDM,S27000186,LOCAL,0270,RC,,,both,,,611.71,183.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,280.77,45.9,,,,,0,71.14,519.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION DEB 2.75X30",SUP-SCA14U-275030D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Manual Ea 15min (Gp)",PX-420000026,CDM,97140,CPT,0420,RC,,,both,,,276.79,83.04,"CIGNA [10200]","Cigna Local Plus",,276.79,,"Per diem ($290).",145.36,145.36,145.36,"1 through 10",32.19,276.79,"per diem",
"CAGE SPINAL TLIF 10X11X26MM 20DEG TITANIUM ALLOY SELF EXPAND",SUP-5902026P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"NOVANET [10819]",Novanet,,21262.5,75,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Not Feeynolm 12.6-20cm",PX-450000022,CDM,12005,CPT,0361,RC,,,both,,,1625.00,487.5,"NOVANET [10819]",Novanet,,1218.75,75,,,,,0,188.99,1625,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC LARGE 35-39IN SHOULDER LOW PROFILE ELASTIC",SUP-ORT16100L,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.94,15.58,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.04,44.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHYLENE BLUE (ANTIDOTE) 1 % (10 MG/ML) INTRAVENOUS SOLUTION",RX-4985,CDM,Q9968,HCPCS,0636,RC,54288-0147-01,NDC,both,10,ML,1887.50,566.25,"PHCS [10601]",PHCS,,1321.25,70,,,,,0,223.67,1887.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASCOPE 5 BROCHNO 4.2/2.2 THIN",SUP-620001000US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2362.50,708.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,274.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,274.76,2008.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 9.5CM 16MM 13.5-14.5MM EXCLUDER",SUP-PLC161000,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"KAISER [10500]",Kaiser,,18758.12,67,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sars Cov-2 Antibody Qn",PX-302000239,CDM,86413,CPT,0302,RC,,,both,,,228.00,68.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,104.65,45.9,,,,,0,13.35,193.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035423040,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1672.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Cardiac Stress",PX-610000067,CDM,C9763,HCPCS,0610,RC,,,both,,,812.00,243.6,"KAISER [10500]",Kaiser,,544.04,67,,,,,0,94.44,812,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCRP OPHTHALMIC 25GA RETINA DDMS TANO",SUP-20.04.25S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1106.27,331.88,"AETNA [10100]","Aetna HMO/PPO",,879.48,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,128.66,940.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.3MM 250MM KIRSCHNER STAINLESS STEEL THREADED",SUP-44182523,CDM,C1713,HCPCS,0278,RC,,,both,,,191.40,57.42,"MULTIPLAN [10600]",Multiplan,,162.69,85,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X9MM 5D LORDOTIC OVAL SPINE CORTICAL",SUP-17209,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 3 WAY STPCOCK 3 FLUSH DEVICE TRNSDUC",SUP-PX3X3,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE NDL DUAL READY TO USE INDIVIDUALLY STERILE DISPOSABLE",SUP-UA1329-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"PHCS [10601]",PHCS,,109.62,70,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Renal Cyst Study Translumb",PX-320000123,CDM,74470,CPT,0320,RC,,,both,,,1197.00,359.1,"PHCS [10601]",PHCS,,837.9,70,,,,,0,68.87,1197,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Proc Spine Unlisted",PX-510000066,CDM,22899,CPT,0761,RC,,,both,,,6795.00,2038.5,"BLUE CROSS [10001]","Blue Cross PPO",,5500.9,,"Case rate ($5,500.90). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,790.26,5775.75,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION DEB 2.25X30",SUP-SCA14U-225030D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUCTION ENDOSCOPIC 8.6-10MM ESUCTION ESOPHAGEAL 2.8MM",SUP-ET2000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1584.90,475.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO LEAD SCOUTPRO FLEXIBLE SYSTEM CORONARY SINUS","SUP-358 735",CDM,C1893,HCPCS,0272,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AMPLATZ RENAL SHEATH SET 24-30F",SUP-M0062601500,CDM,C1894,HCPCS,0272,RC,,,both,,,830.57,249.17,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT ARTICULAR 5-6 21MM KNEE POSTERIOR STABILIZE UHMWPE",SUP-71420840,CDM,C1776,HCPCS,0278,RC,,,both,,,11416.05,3424.81,"AETNA [10100]","Aetna HMO/PPO",,9075.76,79.5,,10981.53,8986.79,12413.38,12,1327.69,9703.64,"percent of total billed charges",
"BLADE SAW 25X9MM MEDIUM OSCILLATING SAGITTAL STERILE",SUP-2296023111,CDM,S27200284,LOCAL,0272,RC,,,both,,,306.85,92.05,"PHCS [10601]",PHCS,,214.8,70,,,,,0,35.69,260.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.6MM 16MM VIP SPINE SELF TAP FIX ANGLE NONSTERILE",SUP-171.716,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acetone Serum Qual",PX-301000084,CDM,82009,CPT,0301,RC,,,both,,,252.00,75.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,214.2,"per diem",
"STENT ABSOLUTE PRO 100MM 80CM 6MM VASCULAR PERIPHERAL SELF",SUP-1012528-100,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP 195MM GREENLINE 3 STAINLESS STEEL MILLER",SUP-301-B3130EA,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.97,17.09,"CIGNA [10200]","Cigna Local Plus",,30.48,53.5,,,,,0,6.63,48.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,inpatient,,,46575.25,13972.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,17343.59,,,,,,,6747.69,27128.64,"case rate",
"DRILL SURGICAL FULL THICK CALIBRATE DEPTH MARK CANNULATED",SUP-AR-1218-85,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X60 40CM SL",SUP-48003006P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"PHCS [10601]",PHCS,,687.49,70,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP POROCOAT PINNACLE 300 SERIES",SUP-121703054,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"BLUE CROSS [10001]","Blue Cross HMO",,2630.62,39.2,,5311.50,4717.44,5388.59,31,780.46,5704.15,"percent of total billed charges",
"RING RTRCTR 11-17CM XL ALEXIS C SECTION 11-17CM",SUP-G6304,CDM,S27200284,LOCAL,0272,RC,,,both,,,558.90,167.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,66.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 60MM 130CM 7MM 6FR .035IN VASCULAR NITINOL",SUP-EX070603CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"MULTIPLAN [10600]",Multiplan,,9970.5,85,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30MM NONSTERILE LATEX FREE DISPOSABLE",SUP-470430,CDM,S27000186,LOCAL,0270,RC,,,both,,,1156.68,347,"MULTIPLAN [10600]",Multiplan,,983.18,85,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 7.9MM 5.5MM MAGILL CURVE NASAL ORAL 2 CUFF",SUP-86395,CDM,S27200284,LOCAL,0272,RC,,,both,,,8390.91,2517.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,994.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,975.86,7132.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM OFFSET 28MM HIP COCR V40 LFIT",SUP-6260-9-428,CDM,C1776,HCPCS,0278,RC,,,both,,,3753.24,1125.97,"AETNA [10100]","Aetna HMO/PPO",,2983.83,79.5,,10981.53,8986.79,12413.38,12,436.5,3190.25,"percent of total billed charges",
"TUBE NASOGASTRIC PREINSERT STYLET GWIRE CORFLO POLYURETHANE",SUP-30-9601,CDM,S27200284,LOCAL,0272,RC,,,both,,,512.00,153.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,60.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.55,435.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM SWIVELOCK PEEK STERILE LATEX FREE",SUP-AR-1665PSL,CDM,C1713,HCPCS,0278,RC,,,both,,,5614.88,1684.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1606.98,28.62,,,,,0,653.01,4772.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL +8MM 40MM STD LATERAL OFFSET 165MM 20MM 15MM",SUP-523420,CDM,C1776,HCPCS,0278,RC,,,both,,,11104.56,3331.37,"PHCS [10601]",PHCS,,7773.19,70,,,,,0,1291.46,9438.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BREAST BINDER L/L",SUP-L/L,CDM,S27000186,LOCAL,0270,RC,,,both,,,191.40,57.42,"KAISER [10500]",Kaiser,,128.24,67,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 105MM STAINLESS STEEL 2.7MM SCR 5 HOLE CONTOUR SHAFT",SUP-02.118.405,CDM,C1713,HCPCS,0278,RC,,,both,,,4378.26,1313.48,"PHCS [10601]",PHCS,,3064.78,70,,,,,0,509.19,3721.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM OSSEOTI THR E1 CUP LINER INSRT",SUP-98B00100214,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7250.04,41.1,,6417.48,6417.48,6417.48,"1 through 10",2051.53,14994,"percent of total billed charges",
"SCR BONE 4.5MM 8MM MOUNTAINEER TITANIUM SPINE",SUP-188362008,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"VALVE HEMOSTASIS 9FR MBA MERIT METAL LARGE BORE GWIRE INSRT",SUP-MAP453,CDM,S27200284,LOCAL,0272,RC,,,both,,,219.07,65.72,"NOVANET [10819]",Novanet,,164.3,75,,,,,0,25.48,186.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 40MM TITANIUM ALUMINUM VANADIUM FEMUR",SUP-00493504001,CDM,C1713,HCPCS,0278,RC,,,both,,,607.50,182.25,"MULTIPLAN [10600]",Multiplan,,516.38,85,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 73X40X14IN FORTIFY 2.5V 500OHM 60 PPM TITANIUM",SUP-CD1231-40,CDM,C1722,HCPCS,0278,RC,,,both,,,35000.00,10500,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4147.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4070.5,29750,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 101MM COLLAR ACTIS DUOFIX 3 12/14 STD OFFSET",SUP-101011030,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12190.5,40,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 16MM 4.5MM EMBOLIZATION NEUROVASCULAR",SUP-PED-450-16,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"KAISER [10500]",Kaiser,,51556.5,67,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV",RX-156003,CDM,,,0250,RC,44567-0642-01,NDC,both,250,ML,476.59,142.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,56.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.43,405.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS MULTIPASS 5-0 P-3 18IN ANTIBACTERIAL VIOLET",SUP-PDP463G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 140MM 5.5MM CREO STRAIGHT TITANIUM MIS NONSTERILE",SUP-1134.514,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"HC ED Visit B Level 3 W Proc",PX-450000330,CDM,G0382,HCPCS,0450,RC,,,both,,,1257.00,377.1,"CIGNA [10200]","Cigna Open Access",,1257,,,,,,,67.13,1257,"case rate",
"GRAFT SOFT TISSUE 3.5X3.5CM AMNIOGRAFT THK50-100UM C",SUP-AG-3535,CDM,V2790,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"FIRST HEALTH [10303]","First Health",,6762,80,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 13MM 51X74MM CLARIA MRI CRT-D SURESCAN",SUP-DTMA1Q1,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"BLUE CROSS [10001]","Blue Cross PPO",,22626.24,39.2,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM 11/13 TAPER 32MM HIP MODULAR BIOLOX DELTA",SUP-136532220,CDM,C1776,HCPCS,0278,RC,,,both,,,12385.50,3715.65,"BLUE CROSS [10001]","Blue Cross HMO",,4855.12,39.2,,5311.50,4717.44,5388.59,31,1440.43,10527.68,"percent of total billed charges",
"CATH CHRG 135CM 20MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206050210,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 3CM 10FR BILIARY POLYETHYLENE TAPERED TIP",SUP-G21464,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS [10001]","Blue Cross HMO",,247.67,39.2,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM TITANIUM 5 LEVEL ATLANTIS VISION ELITE BONE SPINE",SUP-7200090,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"DEFIB CARDIAC CURRENT DR 36J DS-1/IS-1 CNCT DUAL CHMBR",SUP-2207-36,CDM,C1721,HCPCS,0278,RC,,,both,,,70537.50,21161.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,28215,40,,,,,0,8203.51,59956.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 36MM TITANIUM 2.4MM SCREW 6 HOLE STRAIGHT BONE HAND NO",SUP-449.906,CDM,C1713,HCPCS,0278,RC,,,both,,,2591.40,777.42,"BLUE CROSS [10001]","Blue Cross PPO",,1015.83,39.2,,957.42,570.23,957.42,28,301.38,2202.69,"percent of total billed charges",
"GRAFT BONE CORNERSTONE-SR FREEZE DRIED 14X14X9MM",SUP-200944,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP SMALL ALLOGRAFT COMPRESSIBLE SPONGE 10X8",SUP-13810309,CDM,C1713,HCPCS,0278,RC,,,both,,,6017.95,1805.38,"MULTIPLAN [10600]",Multiplan,,5115.26,85,,,,,0,699.89,5115.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 110.5MM CEMENT C-STEM AMT 2 12/14 STD OFFSET",SUP-157004085,CDM,C1776,HCPCS,0278,RC,,,both,,,20320.65,6096.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5815.77,28.62,,,,,0,2363.29,17272.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 83MM 11MM COMPREHENSIVE POROUS MINI SHOULDER",SUP-113631,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]",Cigna,,5040,40,,5873.17,5873.17,5873.17,"1 through 10",1465.38,10710,"percent of total billed charges",
"HEAD FEMORAL -3MM 12/14 TAPER 36MM HIP OXINIUM ECHELON",SUP-71343603,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"MULTIPLAN [10600]",Multiplan,,13205.05,85,,,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFECROSS TRANSSEPTAL RF PUNCTURE AND INTRODUCER SYSTEM - LA",SUP-3007,CDM,C1893,HCPCS,0272,RC,,,both,,,15145.50,4543.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6224.8,41.1,,,,,0,1761.42,12873.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR AL1 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916599960,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"UHC [10700]","United Healthcare",,48.48,63.3,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCOPIC ENDOTRAC HOOK BLADE STERILE LATEX FREE",SUP-2056-6,CDM,S27200284,LOCAL,0272,RC,,,both,,,2044.35,613.3,"CIGNA [10200]","Cigna Open Access",,1163.24,56.9,,,,,0,237.76,1737.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 8MM CEREPAK FREEFORM DETACHABLE",SUP-SCR120815,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"UHC [10700]","United Healthcare",,8371.96,63.3,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 106MM STAINLESS STEEL 8 HOLE LOCK BONE ANKLE",SUP-AR-8943C-08,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 8CM 3MM GALAXY G3 MINI STRETCH",SUP-GLM930080,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"NOVANET [10819]",Novanet,,8911.35,75,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYSORB 3-0 CV-25 48IN BRAID COATED VIOLET ABSORBABLE",SUP-EL-440,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.58,36.77,"PHCS [10601]",PHCS,,85.81,70,,,,,0,14.26,104.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE OVERLAP NEW LOCK ATLANTIS VISION BONE ANTERIOR",SUP-7200172,CDM,C1713,HCPCS,0278,RC,,,both,,,4620.00,1386,"BLUE CROSS [10001]","Blue Cross PPO",,1811.04,39.2,,957.42,570.23,957.42,28,537.31,3927,"percent of total billed charges",
"COIL EMBOLIZATION 8CM 4MM DELTAXSFT MICRO 10 STRETCH",SUP-DLX100408,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6155.9,68,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 13MM LCP STAINLESS STEEL DISTAL CORTICAL",SUP-201.763,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 40CM 16/8MM 2 VELOUR KNITTED BIFURCATED",SUP-M002020851680,CDM,C1768,HCPCS,0278,RC,,,both,,,4673.51,1402.05,"NOVANET [10819]",Novanet,,3505.13,75,,,,,0,543.53,3972.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 6CM 180CM 20MM 10.5FR ESOPHAGEAL FULL",SUP-G57339,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"PHCS [10601]",PHCS,,12312.72,70,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HIP FEM P2 POROUS OFFSZ12",SUP-425-97-012,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11490.78,27,,,,,0,4949.55,36174.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM CREO CREO AMP SPINE MODULAR NONSTERILE",SUP-1067.1230,CDM,C1713,HCPCS,0278,RC,,,both,,,2812.50,843.75,"CIGNA [10200]",Cigna,,1912.5,68,,1831.33,1831.33,1831.33,16,327.09,2390.63,"percent of total billed charges",
"CABLE FIBER OPTIC 8FT RELIEVA LUMA LIGHT GUIDE",SUP-SIS-LGC08,CDM,S27200284,LOCAL,0272,RC,,,both,,,3217.50,965.25,"CIGNA [10200]","Cigna Open Access",,1830.76,56.9,,,,,0,374.2,2734.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBO ELITE 150CM 1.7MM .069IN .068IN ATHERECTOMY",SUP-417-152,CDM,C1885,HCPCS,0272,RC,,,both,,,18868.50,5660.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2194.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2194.41,16038.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 40CM RIGHT TROCHANTERIC INTRAMEDULLARY 125D LONG",SUP-456.400S,CDM,C1713,HCPCS,0278,RC,,,both,,,12838.83,3851.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5135.53,40,,,,,0,1493.16,10913.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE C TI ROD, 3.5X60MM PRE BENT",SUP-3943060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Selct Plc Cath Ica Brain",PX-361000290,CDM,36224,CPT,0361,RC,,,both,,,20746.53,6223.96,"NOVANET [10819]",Novanet,,15559.9,75,,,,,0,2412.82,17634.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR 57MM MULTIPOLAR HIP METAL STERILE",SUP-500105700,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"NOVANET [10819]",Novanet,,2805,75,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 36CM HIP LEFT FEMUR AFFIXUS INTRAMEDULLARY 130D",SUP-814609360,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"BLUE CROSS [10001]","Blue Cross PPO",,8131.16,39.2,,957.42,570.23,957.42,28,2412.38,17631.34,"percent of total billed charges",
"TRAY BIOPSY BONE MARROW STERILE DISPOSABLE",SUP-BAK4511,CDM,S27200284,LOCAL,0272,RC,,,both,,,320.07,96.02,"PHCS [10601]",PHCS,,224.05,70,,,,,0,37.22,272.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC XL SHOULDER BREATHABLE ADJUSTABLE STRAP D",SUP-VP20105-050,CDM,L3670,HCPCS,0274,RC,,,both,,,63.42,19.03,"CIGNA [10200]",Cigna,,43.13,68,,,,,0,7.38,63.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OLYMPUS 4MM 60 DEG ROTATABLE SHAVER",SUP-SB4060RC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1541.46,462.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,179.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,179.27,1310.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE LEVEL ONE SQUARE CRANIOFACIAL TITANIUM 2X 2 HOLE",SUP-25-153-22-09,CDM,C1713,HCPCS,0278,RC,,,both,,,2087.93,626.38,"MULTIPLAN [10600]",Multiplan,,1774.74,85,,,,,0,242.83,1774.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENNOSIDES 8.6 MG TABLET",RX-11349,CDM,,,0637,RC,00904-7252-61,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAMIVUDINE 10 MG/ML ORAL SOLUTION",RX-15881,CDM,,,0250,RC,08888-8887-44,NDC,both,5,ML,17.42,5.23,"CIGNA [10200]","Cigna Local Plus",,9.32,53.5,,,,,0,2.03,14.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION",RX-22560,CDM,,,0250,RC,00121-0853-20,NDC,both,20,ML,128.82,38.65,"UHC [10700]","United Healthcare",,81.54,63.3,,,,,0,14.98,109.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Lt (Gp)",PX-510000081,CDM,29581,CPT,0761,RC,,,both,,,729.00,218.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,495.72,68,,,,,0,84.78,729,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM CONCERTO 3D",SUP-PV-4-8-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VISIGLIDE 2 UROLOGICAL 4500MM 70MM .035IN HYDROPHILIC",SUP-G-260-3545A,CDM,C1769,HCPCS,0272,RC,,,both,,,1288.95,386.68,"NOVANET [10819]",Novanet,,966.71,75,,,,,0,149.9,1095.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOROOT VALSALVA 26MM",SUP-HEWROOT0026,CDM,C1768,HCPCS,0278,RC,,,both,,,13998.17,4199.45,"CIGNA [10200]","Cigna Open Access",,4689.39,33.5,,,,,0,1627.99,11898.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 95MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355095,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X6MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7306,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"AETNA [10100]","Aetna HMO/PPO",,5485.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Distl Fibula W Manip",PX-450000162,CDM,27788,CPT,0450,RC,,,both,,,1879.00,563.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1261,,,,,,,67.13,1879,"case rate",
"CAP NANO HUM/MD GLD/PLY PST/VSDL HD/INS",SUP-98000900235,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3297.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 80X6.4X.6MM LONG STAINLESS STEEL RECIPROCATE",SUP-0277-096-300,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.85,90.25,"AETNA [10100]","Aetna HMO/PPO",,239.18,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.99,255.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM 9FR 18CM SPACE ENDOCARDIUM 2 COIL",SUP-0158,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7057.69,41.1,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"7F DECA 3-3-3 PV12 110CM",SUP-901641,CDM,C1730,HCPCS,0272,RC,,,both,,,5692.50,1707.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3870.9,68,,,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 40CM 4FR 21GA MICROPUNCTURE ECHOTIP .018IN",SUP-G47944,CDM,C1894,HCPCS,0272,RC,,,both,,,291.45,87.43,"AETNA [10100]","Aetna HMO/PPO",,231.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.9,247.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EMPHASYS THR METAL ON POLYETHYLENE",SUP-OSC382186,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"PHCS [10601]",PHCS,,16317,70,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 60MM 16MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-1513-16-060,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5621.02,68,,,,,0,961.36,7026.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X3CM MATRION PLACENTAL MEMB TROPHOBLAST",SUP-PAC12M,CDM,Q4201,HCPCS,0636,RC,,,both,,,5451.00,1635.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT CHROMIC ETHILON ULTIMA 8-0 CS175-8 12IN 2 ARM",SUP-9038G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 15X10MM THK.4MM SMOOTH FINE TEETH SAGITTAL SLOTTED",SUP-532.042S,CDM,S27200284,LOCAL,0272,RC,,,both,,,605.07,181.52,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 80CM 6CM 10MM BALLOON DILATATION OTW LOW",SUP-G30929,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) INTRAVENOUS SOLUTION",RX-187204,CDM,A9562,HCPCS,0343,RC,08888-8878-33,NDC,both,1,UN,1798.82,539.65,"PHCS [10601]",PHCS,,1259.17,70,,,,,0,209.2,1546.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 75CM 1.3MM VECTRIS SURESCAN 4MM SPACE 1X8",SUP-977A275,CDM,C1778,HCPCS,0278,RC,,,both,,,13800.00,4140,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5520,40,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE CROSS-IT 100XT VASCULAR J CURVE 300CM 3CM",SUP-1003310HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX BILIARY TH UNCOVERED 10X100",SUP-M00574680,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 560CC COHESIVE NATRELLE INSPIRA STERILE LATEX",SUP-SCF-560,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR050202A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"UHC [10700]","United Healthcare",,11875.97,63.3,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 214MM 16MM CANNULATED HOLLOW LARGE QUICK COUPLING",SUP-03.037.004,CDM,S27200284,LOCAL,0272,RC,,,both,,,4712.15,1413.64,"AETNA [10100]","Aetna HMO/PPO",,3746.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,548.02,4005.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONDUIT VALVE 21MM ATS OPEN PIVOT AORTIC MECHANICAL GRAFT",SUP-502AG21,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10584,40,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 2 6MM",SUP-TPS-030-062S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 3-11 EF KNEE RIGHT VIVACIT-E",SUP-42522000510,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Local Plus",,5765.38,53.5,,5372.07,4581.20,7242.98,23,1253.3,9159.96,"percent of total billed charges",
"SPACER ALLOGRAFT 24X10X13-9.7MM LUMINARY BULLET NOSE",SUP-15813,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS [10001]","Blue Cross HMO",,7408.8,39.2,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 7 KNEE LEFT BICRUCIATE STABILIZE",SUP-74022227,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"KAISER [10500]",Kaiser,,11136.81,67,,,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERFLOW 14GA INTRAVENOUS",SUP-AIV14,CDM,C1788,HCPCS,0278,RC,,,both,,,261.00,78.3,"BLUE CROSS [10001]","Blue Cross PPO",,102.31,39.2,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 150MM 2MM BALLOON DILATATION RAPID",SUP-47520150L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Chest W Cntrst",PX-610000013,CDM,71551,CPT,0610,RC,,,both,,,3865.00,1159.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1248,,,,,,,449.5,3285.25,"per diem",
"SYSTEM EMPHASYS THR METAL ON POLYETHYLENE",SUP-OSC382186,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"UHC [10700]","United Healthcare",,14755.23,63.3,,8601.07,8395.67,8601.07,"1 through 10",2710.95,19813.5,"percent of total billed charges",
"CPLR TUBING OHMEDA MEDICAL AIR Y BLOCK",SUP-YB-CO-OHUA-OH,CDM,S27200284,LOCAL,0272,RC,,,both,,,594.30,178.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,272.78,45.9,,,,,0,69.12,505.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 SWIVELOCK PEEK 19.1MM",SUP-AR-2324KPSLC,CDM,C1713,HCPCS,0278,RC,,,both,,,3425.63,1027.69,"FIRST HEALTH [10303]","First Health",,2740.5,80,,,,,0,398.4,2911.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP",RX-6627,CDM,,,0250,RC,08888-8887-83,NDC,both,5,ML,25.19,7.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 108MM 8MM SMALL SHELL ALTIVATE REVERSE SHOULDER",SUP-533-08-108,CDM,C1776,HCPCS,0278,RC,,,both,,,43175.16,12952.55,"CIGNA [10200]","Cigna Local Plus",,13600.18,31.5,,5372.07,4581.20,7242.98,23,5021.27,36698.89,"percent of total billed charges",
"KIT SEROSAFUSE IMPLANTABLE FASTNER",SUP-R2275,CDM,S27800098,LOCAL,0278,RC,,,both,,,34618.50,10385.55,"MULTIPLAN [10600]",Multiplan,,29425.73,85,,,,,0,4026.13,29425.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 130MM 11.7MM 8MM ADJUSTABLE NECK FLANGE CLIP IN OBTR",SUP-75HA80,CDM,S27200284,LOCAL,0272,RC,,,both,,,1619.19,485.76,"UHC [10700]","United Healthcare",,1024.95,63.3,,,,,0,188.31,1376.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 RB-1 18IN 2 ARM MONOFILAMENT BLUE",SUP-8757H,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.08,18.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.22,52.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +6.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.065,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE RIGHT CEMENTED CRUCIATE",SUP-150400225,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2604.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEWIRE PACING LEAD 65CM FINISHING WIRE SUPPORTRAK LV-1",SUP-6681,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"NOVANET [10819]",Novanet,,850.5,75,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150180,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 11.5CM MEMORYGEL P2.9CM MODERATE PROFILE SILTEX",SUP-3542157MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 6.2CM 23MM ESOPHAGEAL FULL COVER CATH DIAMETER",SUP-M00517750,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"MULTIPLAN [10600]",Multiplan,,15529.5,85,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS 90CM 4MM 8FR 2-5-2MM SPACE B CURVE ABLATION 10",SUP-D8BTCBL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"KAISER [10500]",Kaiser,,3323.94,67,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 165MM 5MM FLOWPORT II STRYKER HIP POLYMER",SUP-CAT02438,CDM,S27200284,LOCAL,0272,RC,,,both,,,2467.50,740.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1132.58,45.9,,,,,0,286.97,2097.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grft T/a/L >= 100scm 1st 100sq Cm",PX-510000052,CDM,15273,CPT,0761,RC,,,both,,,2175.00,652.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,257.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,252.95,2175,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grft T/a/L >= 100scm 1st 100sq Cm",PX-510000052,CDM,15273,CPT,0761,RC,,,both,,,2175.00,652.5,"KAISER [10500]",Kaiser,,1457.25,67,,,,,0,252.95,2175,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Muscle-Specific Kinase Antb",PX-301000694,CDM,86366,CPT,0301,RC,,,both,,,1781.25,534.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,1514.06,"per diem",
"HC Muscle-Specific Kinase Antb",PX-301000694,CDM,86366,CPT,0301,RC,,,both,,,1781.25,534.37,"NOVANET [10819]",Novanet,,1335.94,75,,,,,0,0.01,1514.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 40MM 10MM 8.5FR .035IN BILIARY RAPID EXCHANGE",SUP-M00570890,CDM,C1876,HCPCS,0278,RC,,,both,,,11927.41,3578.22,"UHC [10700]","United Healthcare",,7550.05,63.3,,,,,0,1387.16,10138.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC DRN Dental Abscess",PX-450000253,CDM,41800,CPT,0450,RC,,,both,,,909.00,272.7,"CIGNA [10200]","Cigna Open Access",,909,,,,,,,67.13,909,"case rate",
"HC Selenium",PX-301000393,CDM,84255,CPT,0301,RC,,,both,,,262.60,78.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,22.98,,,,,,,0.26,223.21,"fee schedule",
"HC Selenium",PX-301000393,CDM,84255,CPT,0301,RC,,,both,,,262.60,78.78,"PHCS [10601]",PHCS,,183.82,70,,,,,0,0.26,223.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORTICAL SCREW 4MM X 58MM",SUP-HTN-4-U-58,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"NOVANET [10819]",Novanet,,1166.4,75,,,,,0,180.87,1321.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VALLEYLAB SMOKE EVAC LAPAROSCOPIC",SUP-SEL7010,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.21,44.76,"FIRST HEALTH [10303]","First Health",,119.37,80,,,,,0,17.35,126.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 12MM ANVIL CENTRIC CANN SUREFORM 60 DA VINCI",SUP-480460,CDM,S27200284,LOCAL,0272,RC,,,both,,,3839.85,1151.95,"NOVANET [10819]",Novanet,,2879.89,75,,,,,0,446.57,3263.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 7 MM HEAD SCR",SUP-P20-910-7000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1279.80,383.94,"UHC [10700]","United Healthcare",,810.11,63.3,,,,,0,148.84,1087.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER II HTD 110CM 4MM 7FR 2.5MM SPACE STD SMALL CURVE",SUP-5031TK1,CDM,C1733,HCPCS,0272,RC,,,both,,,6382.50,1914.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2623.21,41.1,,,,,0,742.28,5425.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 58CM DEFLECT STEERABLE LOCATOR PLUS ATRIAL 16MM",SUP-1292/58,CDM,S27500001,LOCAL,0275,RC,,,both,,,1972.50,591.75,"NOVANET [10819]",Novanet,,1479.38,75,,,,,0,229.4,1676.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CM 6MM 5CM HYBRID REINFORCED COATED",SUP-0650HYB0905A,CDM,C1768,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"MULTIPLAN [10600]",Multiplan,,14369.25,85,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW FREEFIX LOCKING 3.5MM X 16MM TI",SUP-FFL-35160-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1223.10,366.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,561.4,45.9,,,,,0,142.25,1039.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anoscopy Diagnostic",PX-750000178,CDM,46601,CPT,0750,RC,,,both,,,711.00,213.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,711,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,82.69,711,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 6-32MM SYNERGRAFT CRYOVALVE SG PULMONARY",SUP-SGPV00,CDM,S27800098,LOCAL,0278,RC,,,both,,,145293.00,43587.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17217.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16897.58,123499.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 115CM 7FR 2-8-2MM SPACE D CURVE MAPPING",SUP-D710DRP10RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"AETNA [10100]","Aetna HMO/PPO",,2963.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER BIPOLAR AQUAMANTYS MIS FLEX",SUP-23-321-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 24CM 6FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856130,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,503.37,45.9,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 C 32MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30103203,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"FIRST HEALTH [10303]","First Health",,8201.62,80,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 3.2MM STEINMANN SHARP",SUP-11-1109-FD16,CDM,C1713,HCPCS,0278,RC,,,both,,,3326.40,997.92,"FIRST HEALTH [10303]","First Health",,2661.12,80,,,,,0,386.86,2827.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMNIOFIX,2 CM X 6 CM AMNIFIX LINE EXT.",SUP-APS-5260,CDM,Q4433,HCPCS,0636,RC,,,both,,,4146.90,1244.07,"CIGNA [10200]",Cigna,,2819.89,68,,,,,0,247.92,3524.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE WALKING 11-13 12-13.5 LARGE STD FOOT ANKLE CLOSED HEEL",SUP-15590067,CDM,S27000186,LOCAL,0270,RC,,,both,,,223.94,67.18,"UHC [10700]","United Healthcare",,141.75,63.3,,,,,0,26.04,190.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESVR 150UM CELL SAVER 5+ ELITE SMARTSUCTION HARMONY 3L",SUP-00205-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,760.91,228.27,"UHC [10700]","United Healthcare",,481.66,63.3,,,,,0,88.49,646.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENOL 1.4 % MUCOSAL AEROSOL SPRAY",RX-27889,CDM,,,0250,RC,00904-6305-21,NDC,both,177,ML,80.00,24,"CIGNA [10200]","Cigna Open Access",,45.52,56.9,,,,,0,9.3,68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER UV ABSORBENT CLAREON AUTONOME",SUP-CCA0T0.210,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Selct Plc Cath Ica Brain",PX-361000290,CDM,36224,CPT,0361,RC,,,both,,,20746.53,6223.96,"KAISER [10500]",Kaiser,,13900.18,67,,,,,0,2412.82,17634.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.230,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 25FR BIO-MEDICUS",SUP-96880-025,CDM,S27200284,LOCAL,0272,RC,,,both,,,3476.33,1042.9,"PHCS [10601]",PHCS,,2433.43,70,,,,,0,404.3,2954.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 7CM 7FR 2 PIGTAIL CURVE THIN WALL BILIARY",SUP-M00532190,CDM,C2617,HCPCS,0278,RC,,,both,,,447.93,134.38,"BLUE CROSS [10001]","Blue Cross PPO",,175.59,39.2,,,,,0,52.09,380.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 NARROW KNEE LEFT CRUCIATE RETAIN PERSONA",SUP-42502205401,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"BLUE CROSS [10001]","Blue Cross PPO",,11327.07,39.2,,3949.44,3949.44,3949.44,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"STENT SURPASS EVOLVE 25MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45025,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9838.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE 100CM 4FR .0395IN SIDEWINDER SIMMONS",SUP-532415,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"NOVANET [10819]",Novanet,,78.3,75,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablation Perc Plexus Nerve",PX-361000543,CDM,0442T,CPT,0361,RC,,,both,,,8447.00,2534.1,"MULTIPLAN [10600]",Multiplan,,7179.95,85,,,,,0,982.39,8294,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,inpatient,,,24420.43,7326.13,"CIGNA [10200]","Cigna Open Access",,9687.85,,"Fee schedule rate ($9,687.85). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,1958,22016.15,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 154SQ CM UNMESH TISSUE",SUP-SK-S,CDM,Q4433,HCPCS,0636,RC,,,both,,,3186.23,955.87,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SEMI-FLOATING 125CM 7FR 10MM SPACING PACING BIPOLAR",SUP-006242P,CDM,S27200284,LOCAL,0272,RC,,,both,,,923.40,277.02,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NANOCROSS 150CM 20MM 3.0MM .014IN BALLOON DILATATION",SUP-AB14W030150150,CDM,C1725,HCPCS,0272,RC,,,both,,,1577.48,473.24,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR ATHERECTOMY 135CM 2.5MM ROTABLATOR ROTALINK PLUS",SUP-M0011402500,CDM,C1724,HCPCS,0272,RC,,,both,,,16525.50,4957.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"DEVICE THE MAGNET GWIRE EXCHANGE ACCEPTS 182 CM GWIRE",SUP-H74908966011,CDM,C1769,HCPCS,0272,RC,,,both,,,946.08,283.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUT 3.3MM 2 POPLOK HI-FI KNOTLESS TECHNOLOGY",SUP-GKP-3301,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 129MM 15MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771101520,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"CIGNA [10200]",Cigna,,8359.85,40,,5873.17,5873.17,5873.17,"1 through 10",2430.63,17764.68,"percent of total billed charges",
"EXTRACTOR, BROKEN SCREW, 2 MM, 6"" LONG, SINGLE USE",SUP-SXT003-BR3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,344.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR SR4 CURVE GUIDING CORONARY",SUP-LA6SR40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AETNA [10100]","Aetna HMO/PPO",,311.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT MRI GROSHONG 8FR",SUP-1878001,CDM,C1788,HCPCS,0278,RC,,,both,,,2137.50,641.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,253.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",255.04,255.04,255.04,"1 through 10",248.59,1816.88,"percent of total billed charges",
"GYNECARE TVT (SINGLE USE DEVICE)",SUP-810041B,CDM,C1771,HCPCS,0278,RC,,,both,,,7617.67,2285.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,885.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,885.94,6475.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 36MM 2 LEVEL ARCHON BONE SPINE NONSTERILE",SUP-8787236,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross PPO",,1728.72,39.2,,957.42,570.23,957.42,28,512.88,3748.5,"percent of total billed charges",
"CAP ENDOSCOPIC 7FR UROLOGICAL BIOPSY PORT WHITE SILICONE",SUP-AUR-BP,CDM,S27200284,LOCAL,0272,RC,,,both,,,152.28,45.68,"MULTIPLAN [10600]",Multiplan,,129.44,85,,,,,0,17.71,129.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETERIZATION 8IN 20GA ARTERY BIOPATH LATEX FREE",SUP-NA-04550-X1A,CDM,S27200284,LOCAL,0272,RC,,,both,,,939.60,281.88,"PHCS [10601]",PHCS,,657.72,70,,,,,0,109.28,798.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRA-THIN SDS 90CM 40MM 5.3FR 7MM STD BALLOON",SUP-M001176570,CDM,C1725,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOQUE TRICUSPID VALVE REPLACEMENT SYSTEM 52MM",SUP-EVQ1US52,CDM,S27800098,LOCAL,0278,RC,,,both,,,245100.00,73530,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,70147.62,28.62,,,,,0,28505.13,208335,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP FULL OSTEOTOM 56MM HEMISPHERE ACETABULAR",SUP-00705305620,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"PHCS [10601]",PHCS,,3168.48,70,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE FLOPPY II VASCULAR STRAIGHT 190CM 30CM .014",SUP-22339M-903,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 NARROW KNEE RIGHT CRUCIATE RETAIN CEMENTLESS",SUP-150401226,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"PHCS [10601]",PHCS,,20142.68,70,,,,,0,3346.56,24458.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X12X8MM MODULUS 7D CERVICAL STERILE LATEX FREE",SUP-67940003P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"MULTIPLAN [10600]",Multiplan,,5278.5,85,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR ANGIOGRAPHY LATEX FREE MARK 7 ARTERION","SUP-ART 700 SYR",CDM,S27200284,LOCAL,0272,RC,,,both,,,73.29,21.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,30.12,41.1,,,,,0,8.52,62.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER MELLON YELLOW 5.5MM SYNOVATOR STRAIGHT STERILE",SUP-7205311,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 2MM TPS ELITE ROUND FLUTED SOFT TOUCH STERILE",SUP-5820010120,CDM,S27000186,LOCAL,0270,RC,,,both,,,1094.96,328.49,"AETNA [10100]","Aetna HMO/PPO",,870.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 20B LARGE HIP PROXIMAL",SUP-521405,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"FIRST HEALTH [10303]","First Health",,8707.8,80,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYNCHRO .014GUIDE WIRE  35 CM TIP",SUP-M00313010,CDM,C1769,HCPCS,0272,RC,,,both,,,4568.90,1370.67,"PHCS [10601]",PHCS,,3198.23,70,,,,,0,531.36,3883.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA 30CM 8FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061921550,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 14CM 5FR 2.1FR POLARIS ULTRA NAUTILUS .035IN 2",SUP-M006192113050,CDM,C2617,HCPCS,0278,RC,,,both,,,1142.10,342.63,"CIGNA [10200]","Cigna Local Plus",,611.02,,,,,,,132.83,970.79,"percent of total billed charges",
"SUT VICRYL RAPIDE MULTIPASS 5-0 PC-3 18IN BRAID",SUP-VR844,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.27,21.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,33.17,45.9,,,,,0,8.41,61.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT PRESS FIT EMPOWR KNEE STERILE BP",SUP-353-01-104,CDM,C1776,HCPCS,0278,RC,,,both,,,15979.64,4793.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1858.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1858.43,13582.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 13X12CM BREAST 400ML STYLE 133MV TEXTURED STERILE",SUP-133MV-13,CDM,C1789,HCPCS,0278,RC,,,both,,,5460.00,1638,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,647.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",635,4641,"percent of total billed charges",
"SCR BONE 4MM 11MM HELIX R SPINE SELF TAP VARIABLE ANGLE",SUP-7803111,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 84MM TITANIUIM 7 HOLE LOCKING ACUMED BONE MEDIAL",SUP-PL-LEM7,CDM,C1713,HCPCS,0278,RC,,,both,,,6755.10,2026.53,"BLUE CROSS [10001]","Blue Cross PPO",,2648,39.2,,957.42,570.23,957.42,28,785.62,5741.84,"percent of total billed charges",
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 42MM TI",SUP-MTC-37420-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,147.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",145.07,1060.29,"percent of total billed charges",
"KIT VESSEL HARVESTING HEMPRO ENDOSCOPIC","SUP-VH - 3000",CDM,S27200284,LOCAL,0272,RC,,,both,,,7590.00,2277,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5161.2,68,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 24CM 3CM 5FR .038IN STRAIGHT URETERAL",SUP-M006155222010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS [10001]","Blue Cross HMO",,482.54,39.2,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.155 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.155,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING .48MM ATRIAL UNIPOLAR TEMPORARY STREAMLINE 3MM",SUP-6492F,CDM,C1898,HCPCS,0275,RC,,,both,,,304.50,91.35,"FIRST HEALTH [10303]","First Health",,243.6,80,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTMASTER 19MM 4MM CORONARY STENT STAINLESS STEEL",SUP-1012582-19,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"MULTIPLAN [10600]",Multiplan,,14046.68,85,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X22X12MM COROENT WIDE XL 100",SUP-6921260,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2815.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AWL ORTHOPEDIC 4.75MM ALPHA VENT OMEGA AWL",SUP-3910-947-201,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.00,513,"CIGNA [10200]","Cigna Local Plus",,914.85,53.5,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pleur Drain W/Insrt Cath W/Img",PX-361000459,CDM,32557,CPT,0361,RC,,,both,,,5724.68,1717.4,"CIGNA [10200]","Cigna Open Access",,2090,,"Case rate ($2,090). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,665.78,4937,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA MEDIAL CONGRUENT 8-11 G-H",SUP-42522100913,CDM,C1776,HCPCS,0278,RC,,,both,,,9466.80,2840.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3890.85,41.1,,6417.48,6417.48,6417.48,"1 through 10",1100.99,8046.78,"percent of total billed charges",
"PLATE T 29X13X1MM TITANIUM 2/2.3MM SCR 3X4 HOLE APTUS",SUP-A-4650.11,CDM,S27200284,LOCAL,0272,RC,,,both,,,5823.60,1747.08,"KAISER [10500]",Kaiser,,3901.81,67,,,,,0,677.28,4950.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 70MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661070,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,599.33,45.9,,,,,0,151.86,1109.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 110MM QUICK CONNECT PERIARTICULAR ZPS 3.5MM",SUP-00480611035,CDM,S27000186,LOCAL,0270,RC,,,both,,,1275.75,382.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,524.33,41.1,,,,,0,148.37,1084.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 3MM 2MM 35D 5.5IN HOUGH SERRATE SURGICAL",SUP-61-0348,CDM,S27200284,LOCAL,0272,RC,,,both,,,570.08,171.02,"CIGNA [10200]","Cigna Local Plus",,304.99,53.5,,,,,0,66.3,484.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 22.5MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962326,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4150.99,28.62,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 15.5CM 15FR PEEL-AWAY .038IN PERCUTANEOUS STERILE",SUP-G06497,CDM,C1894,HCPCS,0272,RC,,,both,,,382.71,114.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,45.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 6.5MM FASTIN RC ORTHOCORD ROTATOR CUFF NDL",SUP-222992,CDM,C1713,HCPCS,0278,RC,,,both,,,2475.00,742.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,293.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",287.84,2103.75,"percent of total billed charges",
"COIL EMBOLIZATION 7CM 10MM RETRACTA DETACHABLE GWIRE .035IN",SUP-G34190,CDM,S27800098,LOCAL,0278,RC,,,both,,,4308.98,1292.69,"CIGNA [10200]","Cigna Local Plus",,2305.3,53.5,,,,,0,501.13,3662.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 18FR SILICONE RADIOPAQUE BOLUS ENTERAL FEED INTERNAL",SUP-0110-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"FIRST HEALTH [10303]","First Health",,223.9,80,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X13X7MM ACIS STD LORDOTIC PEEK RADIOPAQUE",SUP-08.843.007S,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 8MM 4MM ELBOW TITANIUM HEAD TOTAL STERILE",SUP-TR-S0800-S,CDM,C1776,HCPCS,0278,RC,,,both,,,15145.50,4543.65,"KAISER [10500]",Kaiser,,10147.49,67,,,,,0,1761.42,12873.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 22MM GEMINUS COCR POLYAXIAL CANNULATED LOCK",SUP-PALS-25220-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1036.80,311.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,122.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,120.58,881.28,"percent of total billed charges",
"TRAY TIBIAL 67MM REGENEREX KNEE PRIMARY CRUCIATE RETAINING P",SUP-141272,CDM,C1776,HCPCS,0278,RC,,,both,,,11964.60,3589.38,"FIRST HEALTH [10303]","First Health",,9571.68,80,,,,,0,1391.48,10169.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Ulnar Styloid",PX-450000117,CDM,25650,CPT,0450,RC,,,both,,,1347.00,404.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1347,,"Per diem ($1,469).",,,,0,67.13,1347,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 65MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0298,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,434.99,45.9,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 43IN 10FR TEFLON POLYURETHANE SILICONE",SUP-30-1431,CDM,S27200284,LOCAL,0272,RC,,,both,,,626.37,187.91,"UHC [10700]","United Healthcare",,396.49,63.3,,,,,0,72.85,532.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 120MM 120CM 6MM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200061220,CDM,C1876,HCPCS,0278,RC,,,both,,,4620.00,1386,"CIGNA [10200]",Cigna,,3141.6,68,,,,,0,537.31,3927,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE EXPRT GPS 40MM 135CM 7MM 6FR STRAIGHT VASCULAR",SUP-SECX-7-40-135,CDM,C1876,HCPCS,0278,RC,,,both,,,12420.00,3726,"AETNA [10100]","Aetna HMO/PPO",,9873.9,79.5,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, ALL-POLY PEGGED GLENOID, SIZE 38, E-PLUS",SUP-521-07-238,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"KAISER [10500]",Kaiser,,6140.15,67,,,,,0,1065.82,7789.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 11X11X25MM 15",SUP-5811255,CDM,C1889,HCPCS,0278,RC,,,both,,,28800.00,8640,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3412.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 22MM 140CM 3MM CORONARY STERILE LATEX",SUP-453952,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC",741,MS-DRG,,,,,,,inpatient,,,84838.68,25451.6,"AMBETTER EXCHANGE  [11102]",Ambetter,,8846.18,,"Case rate ($8,846.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,214.28, add-ons for qualifying new technology services are included. If operating cost exceeds $41,253.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,003.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,225.15. The transfer operating threshold is the transfer adjustment factor * $8,214.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $621.04. The transfer capital threshold is the transfer adjustment factor * $621.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,41636.42,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE VARIABLE ANGLE SELF TAPPING ANTERIOR CERVICAL PLATE",SUP-876-853,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"CATH CHRG 135CM 100MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-05101,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACHIEVE 165CM 146CM 3.3FR 20MM 4MM 1MM",SUP-990063-020,CDM,C1730,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"UHC [10700]","United Healthcare",,3712.55,63.3,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 8-10 MEDIUM MALE ROCKER COMFORTABLE D",SUP-798505,CDM,S27000186,LOCAL,0270,RC,,,both,,,61.07,18.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,41.53,68,,,,,0,7.1,51.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE EASYFUSE FOOT PACK",SUP-FFSP1530,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.00,675,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,261.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 18MM 135CM 5MM 3.3-2.9FR VASCULAR COCR",SUP-1011493-18,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,732.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR EXTERNAL FIXATION 60MM 3MM 2.5-3MM XCALIBER FOOT CORTEX",SUP-M311,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"KAISER [10500]",Kaiser,,515.57,67,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25X1.19MM INTREX",SUP-507132300,CDM,S27200284,LOCAL,0272,RC,,,both,,,323.12,96.94,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,37.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.58,274.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM DVR RADIUS CORTICAL DISTAL LOCK 3 LEAD",SUP-131227112,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM EPIC SUPRA THV",SUP-ESP100-19-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,36722.70,11016.81,"FIRST HEALTH [10303]","First Health",,29378.16,80,,,,,0,4270.85,31214.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 33MM TITANIUM INTRALUMINAL ENDOSCOPIC LINEAR",SUP-CDH33,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1537.14,41.1,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM ATTUNE 5 KNEE DISTAL CEMENT REVISION STERILE",SUP-154705001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"NOVANET [10819]",Novanet,,4554,75,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE NEVOS FIBER CORTICAL BONE 5CC OSTEOCONDUCTIVE",SUP-BNEF0005,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"AETNA [10100]","Aetna HMO/PPO",,3428.44,79.5,,1521.93,481.35,16760.95,30,501.54,3665.63,"percent of total billed charges",
"HC Enteroscopy W Ileum W Ins Stnt",PX-750000231,CDM,44379,CPT,0750,RC,,,both,,,9903.00,2970.9,"CIGNA [10200]","Cigna Local Plus",,7882,,"Case rate ($7,882). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1151.72,9903,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION",RX-98312,CDM,Q0138,HCPCS,0636,RC,59338-0775-01,NDC,both,17,ML,7204.65,2161.39,"MULTIPLAN [10600]",Multiplan,,6123.95,85,,,,,0,190.21,6123.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RISPERIDONE 1 MG TABLET",RX-18313,CDM,,,0637,RC,43547-0341-06,NDC,both,1,UN,22.89,6.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10.51,45.9,,,,,0,2.66,19.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL PERSONA COCR 4 NARROW KNEE LEFT CRUCIATE R",SUP-42502005601,CDM,C1776,HCPCS,0278,RC,,,both,,,21420.00,6426,"BLUE CROSS [10001]","Blue Cross HMO",,8396.64,39.2,,5311.50,4717.44,5388.59,31,2491.15,18207,"percent of total billed charges",
"LENS IOL SY60WF.075 CLAREON",SUP-SY60WF.075,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.5MM TI CERV SELF-RETAIN SCR SLF-DRLG/VARIABLE ANGLE 14MM",SUP-04.613.564,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 82MM PRESS FIT AEQUALIS ASCEND FLEX PTC 127.5D",SUP-DWF605A,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3606.12,28.62,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 BIOKNOTLESS PLUS ORTHOCORD ROTATOR CUFF",SUP-212722,CDM,C1713,HCPCS,0278,RC,,,both,,,5664.90,1699.47,"CIGNA [10200]",Cigna,,3852.13,68,,1831.33,1831.33,1831.33,16,658.83,4815.17,"percent of total billed charges",
"SYSTEM MULTI-LINK VISION 15MM 2.75MM CORONARY STENT COCR",SUP-1007847-15,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ABLATION RHYTHMIA HDX LOCATION REFERENCE PATCH MAP",SUP-M004RAPATCH20,CDM,S27000186,LOCAL,0270,RC,,,both,,,3933.00,1179.9,"CIGNA [10200]","Cigna Open Access",,2237.88,56.9,,,,,0,457.41,3343.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 11MM 2.4FR GEMINI HELICAL",SUP-M0063303070,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"MULTIPLAN [10600]",Multiplan,,1257.62,85,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 8IN BUZZ RUGGLES REDMOND 2MM BAYONET",SUP-N22BS20,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 8.5X40MM POLYAXIAL 4S RELINE-O",SUP-13118540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"TRAY TIBIAL 67MM ASCENT MAXIM KNEE INTERLOK COCR 1 PIECE",SUP-141232,CDM,C1776,HCPCS,0278,RC,,,both,,,11379.48,3413.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1323.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1323.43,9672.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMT BRIDLE PRO- 16 FR",SUP-4-4216,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"PHCS [10601]",PHCS,,498.96,70,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Perc Bile Duct Stent New Access",PX-361000406,CDM,47539,CPT,0361,RC,,,both,,,13746.00,4123.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1598.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1598.66,11684.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 235MM 18MM MODULAR RESTORATION BOWED CONICAL",SUP-6276-7-318,CDM,C1776,HCPCS,0278,RC,,,both,,,12862.80,3858.84,"MULTIPLAN [10600]",Multiplan,,10933.38,85,,,,,0,1495.94,10933.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 18MM 22MM AMPLATZER II DELIVERY SYSTEM",SUP-9-AVP2-022,CDM,S27800098,LOCAL,0278,RC,,,both,,,6589.50,1976.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3024.58,45.9,,,,,0,766.36,5601.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR COBRA 1 CURVE ANGIOGRAPHIC VISCERAL",SUP-10709107,CDM,C1887,HCPCS,0272,RC,,,both,,,236.64,70.99,"PHCS [10601]",PHCS,,165.65,70,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 14CM 3CM 5FR .035IN 2",SUP-M006192113180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1081.11,68,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL 6MM OFFSET LAMINA LEFT",SUP-7756074L,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,1831.33,1831.33,1831.33,16,348.9,2550,"percent of total billed charges",
"HC Smn1 Gene Dos/Deletion Alys",PX-310000037,CDM,81329,CPT,0310,RC,,,both,,,1162.00,348.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,137.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,987.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Guide Cath Fluid Drain per Sft Tiss",PX-361000339,CDM,10030,CPT,0361,RC,,,both,,,5501.62,1650.49,"MULTIPLAN [10600]",Multiplan,,4676.38,85,,,,,0,639.84,5501.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE RIGHT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F202,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6856.01,40,,,,,0,1993.39,14569.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET HELICAL ULTRA 3 MM X 4 CM",SUP-M0035433040,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"CIGNA [10200]","Cigna Open Access",,5210.72,56.9,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 150MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"KAISER [10500]",Kaiser,,960.58,67,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 20MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171030270,CDM,C1726,HCPCS,0272,RC,,,both,,,1174.50,352.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,136.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-71422342,CDM,C1776,HCPCS,0278,RC,,,both,,,29720.25,8916.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3456.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3456.47,25262.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 15MM 3.3-3.6FR 4.5MM BALLOON",SUP-1008191-15,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"AETNA [10100]","Aetna HMO/PPO",,1126.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN .045IN STEINMANN ORTHOPEDIC STAINLESS STEEL",SUP-KM173-29-45,CDM,C1713,HCPCS,0278,RC,,,both,,,59.29,17.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,16.97,28.62,,,,,0,6.9,50.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X200 80CM SL",SUP-48006020N,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,118.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 12MM 144CM 2.25MM",SUP-H7493941212220,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,919.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES MONORAIL 143CM 20MM 1.5MM BALLOON DILATATION",SUP-H74939135152010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71-75X11MM VANGUARD VIVACIT-E KNEE CRUCIATE RETAIN",SUP-VE183441,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"AETNA [10100]","Aetna HMO/PPO",,10297.38,79.5,,10981.53,8986.79,12413.38,12,1506.4,11009.78,"percent of total billed charges",
"SCR BONE 4MM 6MM 16MM TITANIUM FULL THREAD CANCELLOUS SMALL",SUP-406.016,CDM,C1713,HCPCS,0278,RC,,,both,,,294.76,88.43,"KAISER [10500]",Kaiser,,197.49,67,,,,,0,34.28,250.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC PULSED LAVAGE INTERPULSE SUCTION COAXIAL HIGH FLOW TIP",SUP-0210-114-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.14,99.04,"FIRST HEALTH [10303]","First Health",,264.11,80,,,,,0,38.4,280.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 1.7CM 20FR LOW PROFILE APPLE BALLOON EXTERNAL BOLST",SUP-M1-5-2017,CDM,S27200284,LOCAL,0272,RC,,,both,,,1069.20,320.76,"AETNA [10100]","Aetna HMO/PPO",,850.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL AMPLATZ FIRM KINK RESISTANT GRADUATE TAPER 35CM",SUP-M0062601080,CDM,C1894,HCPCS,0272,RC,,,both,,,362.44,108.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,148.96,41.1,,,,,0,42.15,308.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION COMPLETE CARE BARDEX IC STATLOCK",SUP-A303318A,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.27,54.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,83.66,45.9,,,,,0,21.2,154.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 26MM AEQUALIS TITANIUM SHOULDER NONLOCKING",SUP-VDV226,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CIGNA [10200]","Cigna Open Access",,885.36,56.9,,1144.80,304.56,2275.09,66,180.96,1322.6,"percent of total billed charges",
"DRILL SURGICAL 25MM FLEXIBLE SCR",SUP-71362925,CDM,S27200284,LOCAL,0272,RC,,,both,,,1538.19,461.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,632.2,41.1,,,,,0,178.89,1307.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 7-10 C-H STD 82X51X12MM KNEE PROLONG UHMWPE",SUP-00595205012,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"CIGNA [10200]",Cigna,,5331.05,68,,5873.17,5873.17,5873.17,"1 through 10",911.77,6663.81,"percent of total billed charges",
"SHELL ACETABULAR 44MM HIP 3 HOLE POLY POROUS R3 SMALL",SUP-71335544,CDM,C1776,HCPCS,0278,RC,,,both,,,14614.20,4384.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1731.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1699.63,12422.07,"percent of total billed charges",
"SPACER SPINAL 23MM NIKO PEEK LUMBAR INTERBODY FUSION",SUP-342.823,CDM,S27800098,LOCAL,0278,RC,,,both,,,31320.00,9396,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12528,40,,,,,0,3642.52,26622,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR STD STRAIGHT TAPER 80CM 6CM .038IN STAINLESS",SUP-G00664,CDM,C1769,HCPCS,0272,RC,,,both,,,95.61,28.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.12,81.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM MITRAL VALVE BAND CG FUTURE",SUP-638RL30,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"MULTIPLAN [10600]",Multiplan,,11143.5,85,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER RIGID SHARP DELIVERY SYSTEM HYDROMARK BREAST BIOPSY",SUP-4010-02-15-T4,CDM,A4648,HCPCS,0278,RC,,,both,,,640.49,192.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,74.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.49,544.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X8MM COLONIAL 7D LORDOTIC 12MM LARGE",SUP-365.408CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 47MM STAINLESS STEEL 2.4MM SCR 4X3 HOLE LCP BONE RIGHT",SUP-242.464,CDM,C1713,HCPCS,0278,RC,,,both,,,4922.87,1476.86,"AETNA [10100]","Aetna HMO/PPO",,3913.68,79.5,,1521.93,481.35,16760.95,30,572.53,4184.44,"percent of total billed charges",
"COIL EMBOLIZATION 3.5CM 2.5MM GALAXY G3 XTRASOFT",SUP-GLX122535,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3400.57,28.62,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STOP DRILL 3.0MM X 70MM",SUP-DRLL-30070,CDM,S27000186,LOCAL,0270,RC,,,both,,,3781.20,1134.36,"UHC [10700]","United Healthcare",,2393.5,63.3,,,,,0,439.75,3214.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cryptococcal Ag Ref",PX-302000088,CDM,86403,CPT,0302,RC,,,both,,,180.75,54.22,"AETNA [10100]","Aetna HMO/PPO",,143.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.91,153.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 54MM HAND TITANIUM 2X8 HOLE T 2.4MM SCR",SUP-449.913,CDM,C1713,HCPCS,0278,RC,,,both,,,3755.81,1126.74,"CIGNA [10200]","Cigna Open Access",,2137.06,56.9,,1144.80,304.56,2275.09,66,436.8,3192.44,"percent of total billed charges",
"LINER HUMERAL 36MM EQUINOXE +0MM STERILE LATEX FREE",SUP-322-36-00,CDM,C1776,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 10IN STAINLESS STEEL 4.5MM SCREWS 9 HOLE 10",SUP-3704-3-120,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"CIGNA [10200]","Cigna Local Plus",,1203.75,53.5,,3978.14,359.25,3978.14,24,261.68,1912.5,"percent of total billed charges",
"PATCH VASCULAR 8X1CM BOVINE PERICARDIAL",SUP-DP1X6,CDM,C1768,HCPCS,0278,RC,,,both,,,1263.68,379.1,"CIGNA [10200]","Cigna Local Plus",,676.07,53.5,,,,,0,146.97,1074.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE NITREX VASCULAR 15D ANGLE 300CM 5CM .018IN NITINOL",SUP-N183002,CDM,C1769,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL MEDIUM 70X61MM KNEE RIGHT MODULAR ROTATE HINGE",SUP-64811121,CDM,C1776,HCPCS,0278,RC,,,both,,,25203.15,7560.94,"CIGNA [10200]","Cigna Open Access",,8443.06,33.5,,5302.19,4377.88,6578.61,27,2931.13,21422.68,"percent of total billed charges",
"VALVE MITRAL 31MM CARPENTIER-EDWARDS PERIMOUNT MAGNA HEART",SUP-7300TFX31MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,36508.50,10952.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9857.3,27,,,,,0,4245.94,31032.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 100MM 5FR 6MM .035IN LOW PROFILE BALLOON",SUP-B1060-100,CDM,C1725,HCPCS,0272,RC,,,both,,,891.00,267.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,605.88,68,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 12MM 135CM 4MM .018IN BILIARY STAINLESS",SUP-G56618,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1442.45,28.62,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 140MM 80CM 5MM 6FR .035IN BILIARY",SUP-G50115,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,708.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP 11MM OPEN 235CM INTERNAL RESOLUTION RADIOPAQUE USER",SUP-M00522610,CDM,S27200284,LOCAL,0272,RC,,,both,,,1347.76,404.33,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,618.62,45.9,,,,,0,156.74,1145.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION 12MM RETROBUTTON FEMUR ACL TITANIUM UHMWPE",SUP-AR-1588-25,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"BLUE CROSS [10001]","Blue Cross HMO",,725.45,39.2,,957.42,156.86,7483.26,51,215.23,1573.04,"percent of total billed charges",
"BIT DRILL 88MM 1.5MM K WIRE ATTACH THREAD HOLE NONSTERILE",SUP-03.130.300,CDM,S27200284,LOCAL,0272,RC,,,both,,,576.07,172.82,"UHC [10700]","United Healthcare",,364.65,63.3,,,,,0,67,489.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 6.5MM CONICAL STOP QUICK COUPLING STERILE",SUP-03.019.018S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2295.30,688.59,"KAISER [10500]",Kaiser,,1537.85,67,,,,,0,266.94,1951.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 250MM 190CM 6MM",SUP-R51006025L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"MULTIPLAN [10600]",Multiplan,,2118.1,85,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 15MM 6FR 2.75MM .07IN BALLOON",SUP-H7493918915270,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"KAISER [10500]",Kaiser,,379.89,67,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM SENSAR INTRAOCULAR LENS, BICONVEX, 11.5 DIOPTER",SUP-AR40E00115,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,266.6,28.62,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .62IN 5FR .056IN LONG",SUP-5560020L,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"FIRST HEALTH [10303]","First Health",,334.08,80,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE PLUS 125CM 6FR JL4 CURVE ANGIOGRAPHIC",SUP-SR3056,CDM,S27200284,LOCAL,0272,RC,,,both,,,314.24,94.27,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,129.15,41.1,,,,,0,36.55,267.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 18MM IMPL CANNULATED",SUP-200-30-018,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,520.51,45.9,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKAGED RADIAL STEM 9MM X -2MM",SUP-ALN-RST-09M2,CDM,C1776,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1653.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1653.89,12087.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPOON SURGICAL 7.25INX40MM LARGE",SUP-MG001R,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.24,63.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.8,181.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Stoma W Rmvl Snare",PX-750000074,CDM,44394,CPT,0750,RC,,,both,,,2975.83,892.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,346.09,2975.83,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 RIGHT KNEE CRUCIATE RETAINING CEMENTED",SUP-5510-F-602,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"PHCS [10601]",PHCS,,11478.5,70,,,,,0,1907.07,13938.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEOSTIGMINE METHYLSULFATE 0.5 MG/ML INTRAVENOUS SOLUTION",RX-163545,CDM,J2710,HCPCS,0636,RC,00641-6150-01,NDC,both,10,ML,72.48,21.74,"CIGNA [10200]","Cigna Local Plus",,38.78,53.5,,,,,0,1.2,61.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 24MM SPINE PEDICLE PLY NONSTERILE 4MM ROD",SUP-102055224,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC",274,MS-DRG,,,,,,,inpatient,,,173924.64,52177.39,"CIGNA [10200]","Cigna Local Plus",,33967.05,,"Fee schedule rate ($33,967.05). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,96104.47,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronchl Alveolar Lav Mini",PX-410000026,CDM,31899,CPT,0410,RC,,,both,,,1137.30,341.19,"CIGNA [10200]","Cigna Local Plus",,290,,"Per diem ($290).",,,,0,132.27,1137.3,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 122MM 10MM COMPREHENSIVE PPS SHOULDER",SUP-12-113560,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"MULTIPLAN [10600]",Multiplan,,10710,85,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Incsn/Rmvl FB Sq Cmplx",PX-450000009,CDM,10121,CPT,0361,RC,,,both,,,7667.00,2300.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,7.67,7667,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 14MM RSP SHOULDER LOCK GLENOID BASEPLT",SUP-506-03-114,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"CIGNA [10200]",Cigna,,1057.88,68,,1831.33,1831.33,1831.33,16,180.93,1322.35,"percent of total billed charges",
"STAPLE BONE 20X20MM JAWS STRAIGHT NITINOL",SUP-P71-020-2020-S,CDM,C1713,HCPCS,0278,RC,,,both,,,8952.75,2685.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1060.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1041.2,7609.84,"percent of total billed charges",
"CLAREONPANOPTIX PROTORIC(BLF)",SUP-PXYWT5,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"KAISER [10500]",Kaiser,,613.05,67,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tis W/ Stent Non-Congenital",PX-481000378,CDM,93799,CPT,0481,RC,,,both,,,28740.00,8622,"CIGNA [10200]","Cigna Local Plus",,15375.9,53.5,,,,,0,1249,24429,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FUROSEMIDE 20 MG TABLET",RX-3294,CDM,,,0637,RC,00054-8297-25,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 6MM ENDOPROSTHESIS GORE-TEX NITINOL",SUP-VBC061002,CDM,C1874,HCPCS,0278,RC,,,both,,,17646.30,5293.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5050.37,28.62,,,,,0,2052.26,14999.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK ANGIOPLSTY ACCESSPLUS HEMOSTASIS VALVE GWIRE INSRT TOOL",SUP-MAP151,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.36,34.01,"NOVANET [10819]",Novanet,,85.02,75,,,,,0,13.18,96.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Antibody ID Plt Ig",PX-302000010,CDM,86023,CPT,0302,RC,,,both,,,779.95,233.98,"KAISER [10500]",Kaiser,,522.57,67,,,,,0,0.01,662.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRACTOR SURGICAL L15.2CM BLADE W6.3CM D7.6CM Z DOANE",SUP-78-5998,CDM,S27200284,LOCAL,0272,RC,,,both,,,475.47,142.64,"CIGNA [10200]","Cigna Local Plus",,254.38,53.5,,,,,0,55.3,404.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL 18.3MM 3.2MM LONG 3.2MM HELICOIDAL",SUP-5130080030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1035.26,310.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,475.18,45.9,,,,,0,120.4,879.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pulse Ox O2 Sat Sngl",PX-460000015,CDM,94760,CPT,0460,RC,,,both,,,70.94,21.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,48.24,68,,,,,0,8.25,60.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.818,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,100.54,28.62,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 8MM X 20CM",SUP-M0035478200,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4039.61,28.62,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SPINAL 3.5IN 18GA 27GA LIDOCAINE METAL GLASS TUOHY",SUP-333192,CDM,C1755,HCPCS,0278,RC,,,both,,,251.69,75.51,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.27,213.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 18MM KNEE POSTERIOR STABILIZE GENESIS II",SUP-71420824,CDM,C1776,HCPCS,0278,RC,,,both,,,9998.10,2999.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1162.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1162.78,8498.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dna Histogram Ploidy S Phase",PX-311000019,CDM,88182,CPT,0311,RC,,,both,,,685.65,205.69,"FIRST HEALTH [10303]","First Health",,548.52,80,,,,,0,0.01,582.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 8X6CM SUSPEND TUTOPLAST FASCIA LATA",SUP-937268,CDM,C1762,HCPCS,0278,RC,,,both,,,3238.30,971.49,"MULTIPLAN [10600]",Multiplan,,2752.56,85,,,,,0,376.61,2752.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 15X12MM 12MM X-CORE 7D LORDOTIC MINI TITANIUM",SUP-5962526,CDM,S27800098,LOCAL,0278,RC,,,both,,,6345.24,1903.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,737.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,737.95,5393.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC ANGIOGRAPHY 48IN MERITRANS NONWINGE HOUSING MALE",SUP-K11-00419A,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.36,30.41,"UHC [10700]","United Healthcare",,64.16,63.3,,,,,0,11.79,86.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 60MMX4.8MM PROXIMATE TITANIUM THICK TISSUE 2",SUP-XR60G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1010.79,303.24,"AETNA [10100]","Aetna HMO/PPO",,803.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.55,859.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 35CM 26FR VENOUS 90D OPEN LIGHTHOUSE 1 STAGE",SUP-TF026L90,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.54,58.36,"PHCS [10601]",PHCS,,136.18,70,,,,,0,22.63,165.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4650,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,348.9,2550,"percent of total billed charges",
"CATH GLIDECATH GLIDE TECHNOLOGY 100CM 15CM 4FR .041IN",SUP-CG401,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER MAMMARY SILICONE 350ML BREAST RESTERILIZABLE GEL",SUP-RSZ-3504,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.91,39.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 135CM 200MM 5FR 4MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-04201,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 8FR 80CM 23CM BLUE HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-8F-23-035,CDM,C1894,HCPCS,0272,RC,,,both,,,117.45,35.23,"PHCS [10601]",PHCS,,82.22,70,,,,,0,13.66,99.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00250,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,743.58,68,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CENTERPIECE CORTICAL ALLOGRAFT FREEZE DRIED STRUT",SUP-853910,CDM,S27800098,LOCAL,0278,RC,,,both,,,3412.50,1023.75,"FIRST HEALTH [10303]","First Health",,2730,80,,,,,0,396.87,2900.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 4X120 135CM SL",SUP-48004012R,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"KAISER [10500]",Kaiser,,668.06,67,,,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 100MM 6MM BALLOON DILATATION DURALYN",SUP-48006010X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 100CM 5FR SIM2 CURVE ANGIOGRAPHIC",SUP-G47027,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"KAISER [10500]",Kaiser,,141.05,67,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.2MM 140MM STERILE",SUP-143140,CDM,C1713,HCPCS,0278,RC,,,both,,,1010.88,303.26,"CIGNA [10200]","Cigna Local Plus",,540.82,53.5,,3978.14,359.25,3978.14,24,117.57,859.25,"percent of total billed charges",
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM NARROW BLADE",SUP-7541123,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 405CC NATRELLE INSPIRA COHESIVE STERILE LATEX",SUP-SCM-405,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AETNA [10100]","Aetna HMO/PPO",,6006.62,79.5,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION",RX-9266,CDM,J0702,HCPCS,0636,RC,00517-0720-01,NDC,both,5,ML,498.60,149.58,"BLUE CROSS [10001]","Blue Cross HMO",,81.12,,,,,,,72.78,423.81,"fee schedule",
"SCR BONE 5MM 40MM AXSOS STAINLESS STEEL T20 FEMUR HUMERUS",SUP-371340,CDM,C1713,HCPCS,0278,RC,,,both,,,991.44,297.43,"NOVANET [10819]",Novanet,,743.58,75,,,,,0,115.3,842.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 30MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840005530,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Open Access",,5432.16,56.9,,1144.80,304.56,2275.09,66,1110.3,8114.82,"percent of total billed charges",
"GRAFT BONE DEMINERALIZED BONE MATRIX 1ML PUTTY STERILE",SUP-038010,CDM,C1713,HCPCS,0278,RC,,,both,,,1160.90,348.27,"CIGNA [10200]",Cigna,,789.41,68,,1831.33,1831.33,1831.33,16,135.01,986.77,"percent of total billed charges",
"SCR BONE 4.5MM 20MM PERIPHERAL",SUP-5572-4520,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"BLUE CROSS [10001]","Blue Cross PPO",,609.83,39.2,,957.42,570.23,957.42,28,180.93,1322.35,"percent of total billed charges",
"TRI-STAPLE 2.0 RELOAD 60MM VASCULAR/MEDIUM TISSUE TAN",SUP-SIG60AVM,CDM,S27200284,LOCAL,0272,RC,,,both,,,1576.18,472.85,"CIGNA [10200]",Cigna,,1071.8,68,,,,,0,183.31,1339.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR070202A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"PHCS [10601]",PHCS,,13132.98,70,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Glucose Postdose",PX-301000206,CDM,82950,CPT,0301,RC,,,both,,,125.00,37.5,"CIGNA [10200]",Cigna,,10.45,,,,,,,0.13,106.25,"fee schedule",
"CATH EAGLE EYE 150CM 5FR 20MM 20MHZ SHORT TAPER ULTRASOUND",SUP-85900PST,CDM,C1753,HCPCS,0272,RC,,,both,,,5002.50,1500.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,581.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE 17GA 10MM RADIOFREQUENCY ELECTROTHERAPY OSTEOCOOL 2MM",SUP-OCP210,CDM,S27200284,LOCAL,0272,RC,,,both,,,25389.00,7616.7,"MULTIPLAN [10600]",Multiplan,,21580.65,85,,,,,0,2952.74,21580.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON UVA VIVITY TORIC AUTONOME",SUP-CCAET5,CDM,V2787,HCPCS,0276,RC,,,both,,,880.00,264,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,102.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,102.34,748,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 1.35MM 18MM 9MM LCP STAINLESS STEEL FEMORAL",SUP-207.718,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,297.66,28.62,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC BLUE 76MM OBTR TROCAR SEAL STERILE",SUP-0124-05,CDM,S27200284,LOCAL,0272,RC,,,both,,,219.87,65.96,"CIGNA [10200]",Cigna,,149.51,68,,,,,0,25.57,186.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TRANSEND VASCULAR STRAIGHT 165CM 2CM .014IN SCITANIUM",SUP-M001468110,CDM,C1769,HCPCS,0272,RC,,,both,,,2062.50,618.75,"PHCS [10601]",PHCS,,1443.75,70,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THREADED FACET DOWEL, 5.5MM",SUP-012005,CDM,S27800098,LOCAL,0278,RC,,,both,,,10799.00,3239.7,"CIGNA [10200]","Cigna Open Access",,6144.63,56.9,,,,,0,1255.92,9179.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 8X4IN POSTOPERATIVE SILVER STERILE MEPILEX BORDER FOAM",SUP-498400,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.58,61.07,"UHC [10700]","United Healthcare",,128.87,63.3,,,,,0,23.68,173.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE (RSP) MONOBLOCK REVISION HUMERAL STEM, 220MM, 6X220M",SUP-510-06-220,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Open Access",,4221,33.5,,5302.19,4377.88,6578.61,27,1465.38,10710,"percent of total billed charges",
"INTRO SHEATH 7FR 50CM 11CM HUB SNAP FIT DIL TUBE GWIRE",SUP-PRO-7F-11-038,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDRALAZINE 25 MG TABLET",RX-3700,CDM,,,0637,RC,00904-7448-61,NDC,both,1,UN,6.27,1.88,"FIRST HEALTH [10303]","First Health",,5.02,80,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 8X 38MM CATH 120CM ENDOVASCULAR",SUP-42838,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5014.31,28.62,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 7.0 MM X 80 MM X 130 CM",SUP-IPU07008013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"KAISER [10500]",Kaiser,,5408.91,67,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Occult Blood Feces Immunoassy",PX-301000119,CDM,82274,CPT,0301,RC,,,both,,,120.00,36,"FIRST HEALTH [10303]","First Health",,96,80,,,,,0,11.68,102,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 7/8-5MM 10MM SPACEMAKER BLUNT CONVERTER",SUP-OMS-T10BT,CDM,C1727,HCPCS,0272,RC,,,both,,,1685.25,505.57,"PHCS [10601]",PHCS,,1179.68,70,,,,,0,195.99,1432.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE TIBIAL 5MM LEGION 3-4 HEMI KNEE LEFT MEDIAL RIGHT",SUP-71421142,CDM,C1776,HCPCS,0278,RC,,,both,,,15369.75,4610.92,"KAISER [10500]",Kaiser,,10297.73,67,,,,,0,1787.5,13064.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.7MM 2.6 KNOTLESS TIGERTAPE FIBERTAK LOOP SELF",SUP-AR-3653TTSP,CDM,C1713,HCPCS,0278,RC,,,both,,,3839.85,1151.95,"MULTIPLAN [10600]",Multiplan,,3263.87,85,,,,,0,446.57,3263.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 118CM 6FR MRADIAL CURVE GUIDING STERILE LATEX",SUP-LA6MRADIALY,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"PHCS [10601]",PHCS,,255.78,70,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SILVERHAWK LS-M MEC 110CM 6CM 4.5-7MM .105IN",SUP-P4052,CDM,C1714,HCPCS,0272,RC,,,both,,,18238.50,5471.55,"MULTIPLAN [10600]",Multiplan,,15502.73,85,,,,,0,2121.14,15502.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 45MM 6MM EGG STERILE",SUP-1607002003,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 32MM HEMASHIELD PLATINUM STRAIGHT TUBE",SUP-M00202175432P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3797.28,1139.18,"PHCS [10601]",PHCS,,2658.1,70,,,,,0,441.62,3227.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 170MM FEMUR PROXIMAL TFN-ADVANCED INTRAMEDULLARY",SUP-04.037.242S,CDM,C1713,HCPCS,0278,RC,,,both,,,8273.93,2482.18,"NOVANET [10819]",Novanet,,6205.45,75,,,,,0,962.26,7032.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inhaled Nitric Oxide per Hour",PX-271000001,CDM,9999968,LOCAL,0271,RC,,,both,,,990.50,297.15,"CIGNA [10200]",Cigna,,673.54,68,,,,,0,115.2,841.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 70CM PRECISION PERCUTANEOUS LINEAR 3-4",SUP-SC-2352-70,CDM,C1778,HCPCS,0278,RC,,,both,,,8914.80,2674.44,"FIRST HEALTH [10303]","First Health",,7131.84,80,,,,,0,1036.79,7577.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 4.5FR 3IN TAUT STERILE 20018-M55 18305 18400",SUP-PI-63,CDM,C1894,HCPCS,0272,RC,,,both,,,244.47,73.34,"MULTIPLAN [10600]",Multiplan,,207.8,85,,,,,0,28.43,207.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION 155CM 2.4-3FR .021IN MICRO INFUSION NITINOL",SUP-M001195310,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 22IN 5FR PORT ANTICLOG RADIOPAQUE BOW TIP",SUP-20-C1225,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.97,23.99,"CIGNA [10200]","Cigna Local Plus",,42.78,53.5,,,,,0,9.3,67.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 4MM BALLOON",SUP-U357548,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 28MM 3.5MM CORONARY STENT COCR",SUP-1007849-28,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LRNSCP 3 MCNTSH EURO PRFL GLS",SUP-4003VS,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.88,13.76,"KAISER [10500]",Kaiser,,30.74,67,,,,,0,5.34,39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO2 VASCULAR 215CM .014IN HYDROPHILIC PRESHAPE",SUP-S2SPS14215,CDM,C1769,HCPCS,0272,RC,,,both,,,4568.90,1370.67,"MULTIPLAN [10600]",Multiplan,,3883.57,85,,,,,0,531.36,3883.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 10X9X6MM ARCH PARALLEL SPINE FREEZE DRIED",SUP-15110,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 135CM 5MM 8MM 7FR .035IN",SUP-BXA052902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8016.47,41.1,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachythrpy Nonstranded I-125",PX-E27800022,CDM,C2639,HCPCS,0278,RC,,,both,,,735.90,220.77,"BLUE CROSS [10001]","Blue Cross PPO",,288.47,39.2,,,,,0,85.59,625.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP FEEDING MEDICINE GRADUATED LATEX FREE REUSABLE STAINLESS",SUP-2,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.87,23.96,"CIGNA [10200]","Cigna Local Plus",,42.73,53.5,,,,,0,9.29,67.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txcath Retrev Intrvas FB",PX-361000295,CDM,37197,CPT,0361,RC,,,both,,,10102.49,3030.75,"NOVANET [10819]",Novanet,,7576.87,75,,,,,0,1174.92,10015,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 6-2MM TORNADO MICROCOILS PLATINUM",SUP-G08259,CDM,S27800098,LOCAL,0278,RC,,,both,,,696.60,208.98,"KAISER [10500]",Kaiser,,466.72,67,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL PERCUTANEOUS 20CM 18GA NAVIGUIDE ACCESS ADJUSTABLE",SUP-M0067001330,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.70,104.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.55,296.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOTALOL 80 MG TABLET",RX-11421,CDM,,,0637,RC,50268-0724-11,NDC,both,1,UN,11.67,3.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5.36,45.9,,,,,0,1.36,9.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 25MM FLEXIBLE SURE LOCK DELIVERY SYSTEM",SUP-TARP-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"UHC [10700]","United Healthcare",,7663.35,63.3,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK VITRECTOMY 25+ GA TOTAL PLUS CONSTELLATION 5000 CPM",SUP-8065751462,CDM,S27200284,LOCAL,0272,RC,,,both,,,3742.50,1122.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1717.81,45.9,,,,,0,435.25,3181.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 5MM ENDOPATH XCEL BLADELESS",SUP-B5XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,817.99,245.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,556.23,68,,,,,0,95.13,695.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HYDROXYAPATITE TRIDENT PSL G",SUP-542-11-58G,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"CIGNA [10200]","Cigna Open Access",,3958.94,56.9,,5302.19,4377.88,6578.61,27,809.18,5914.06,"percent of total billed charges",
"SYSTEM ANGIASSIST 24IN 36IN DRUG DELIVERY 60ML GAS",SUP-AA0608,CDM,S27000186,LOCAL,0270,RC,,,both,,,769.50,230.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +13.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030135,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,460.4,39.2,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 48MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.148,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,131.73,962.8,"percent of total billed charges",
"NDL LOCALIZATION 7CM WIRE",SUP-49720,CDM,A4648,HCPCS,0278,RC,,,both,,,152.32,45.7,"CIGNA [10200]","Cigna Local Plus",,81.49,53.5,,,,,0,17.71,129.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2 X 2 COMPLEX PICO COIL",SUP-10USC02002,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"KAISER [10500]",Kaiser,,8760.59,67,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GASTROJEJUNOSTOMY TUBE 16FR STOMA L5CM JEJUNAL L45CM SIL",SUP-8270-16-5.0-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1208.46,45.9,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Iadna Ehrlicha Chafeensis Amp Prb",PX-306000250,CDM,87484,CPT,0306,RC,,,both,,,744.80,223.44,"FIRST HEALTH [10303]","First Health",,595.84,80,,,,,0,0.01,633.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 22GA 5CM CHIBA STERILE DISPOSABLE",SUP-G01133,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"UHC [10700]","United Healthcare",,52.1,63.3,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL NECK PROFEMUR GLADIATOR 6 STRAIGHT HIP",SUP-PRGLCLS6,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"AETNA [10100]","Aetna HMO/PPO",,15025.5,79.5,,10981.53,8986.79,12413.38,12,2198.07,16065,"percent of total billed charges",
"RETRIEVER ENDOSCOPIC NONSTERILE DISPOSABLE LATEX FREE ROTH",SUP-00711170,CDM,S27200284,LOCAL,0272,RC,,,both,,,834.30,250.29,"CIGNA [10200]",Cigna,,567.32,68,,,,,0,97.03,709.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE POWERTURN FLEX VASCULAR STRAIGHT 300CM 3CM",SUP-1044593,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VALVE AORTIC 26MM SAPIEN 3 EDWARDS HEART TRANSCATHETE",SUP-9750TFX26A,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,48940.2,28.62,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY PRESSURE MNTR 2.5FR 5CM .015IN STRAIGHT 1 LUMEN NDL HUB",SUP-G58413,CDM,C1887,HCPCS,0272,RC,,,both,,,891.00,267.3,"UHC [10700]","United Healthcare",,564,63.3,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC RELOAD AEON 60MMX2.5MM STERILE LATEX FREE",SUP-AESR60W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL 5.5-6MM MEDIUM WIDE BLADE",SUP-5541113,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 41MM TRUNION ARTHREX ECLIPSE SHOULDER",SUP-AR-9301-41CPC,CDM,C1776,HCPCS,0278,RC,,,both,,,9239.10,2771.73,"MULTIPLAN [10600]",Multiplan,,7853.24,85,,,,,0,1074.51,7853.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Speech Production",PX-444000016,CDM,92522,CPT,0444,RC,,,both,,,394.37,118.31,"NOVANET [10819]",Novanet,,295.78,75,,,,,0,45.87,394.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT INSUFFLATION THERMOFLATOR ADPTR PATIENT CONNECTION TUBE",SUP-20400034,CDM,S27200284,LOCAL,0272,RC,,,both,,,1224.72,367.42,"CIGNA [10200]",Cigna,,832.81,68,,,,,0,142.43,1041.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM ADVANCED CONVEX SPINE",SUP-17812,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 15MM 3.3-3.6FR 7MM BALLOON",SUP-1008201-15,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 180MM HIP TROCHANTERIC GAMMA3 INTRAMEDULLARY 120D",SUP-3120-1180S,CDM,C1713,HCPCS,0278,RC,,,both,,,8430.28,2529.08,"CIGNA [10200]",Cigna,,5732.59,68,,1831.33,1831.33,1831.33,16,980.44,7165.74,"percent of total billed charges",
"ILIVIA NEO DR-T DF1 HIGH ENERGY PROMRI TI AND CLS",SUP-429529,CDM,C1721,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"PHCS [10601]",PHCS,,40792.5,70,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cortisol Blood Total Adrenal",PX-301000159,CDM,82533,CPT,0301,RC,,,both,,,357.50,107.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14.67,,,,,,,0.01,303.88,"fee schedule",
"SCR BONE 6.5MM 45MM REVERE TITANIUM SPINE PEDICLE CANNULATED",SUP-124.365,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"IN.PACT 018 5.0 MM X 120 MM X 130 CM",SUP-IPU05012013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3318,41.1,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.9H 50MM 3 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009350,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"ALTIVATE ANATOMIC, SHORT HUMERAL STEM, 10MM",SUP-520-10-000,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"BLUE CROSS [10001]","Blue Cross PPO",,3104.64,39.2,,3949.44,3949.44,3949.44,"1 through 10",921.1,6732,"percent of total billed charges",
"SYSTEM SYNERGY 28MM 144CM 4MM CORONARY STENT PEBAX",SUP-H7493926028400,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"KAISER [10500]",Kaiser,,3728.55,67,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION FATHOM 130CM 180CM 2.4-3FR .021IN MICRO",SUP-M001195670,CDM,C1887,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"PHCS [10601]",PHCS,,5071.5,70,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER LENS B CRTDG IOL DELIVERY SYSTEM HNDPC MONARCH II",SUP-8065977758,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.03,72.01,"NOVANET [10819]",Novanet,,180.02,75,,,,,0,27.92,204.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 STD KNEE LEFT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB5SL,CDM,C1776,HCPCS,0278,RC,,,both,,,17652.60,5295.78,"PHCS [10601]",PHCS,,12356.82,70,,,,,0,2053,15004.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X4MM COROENT 20D XL PEEK-OPTIMA",SUP-6200450,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"CIGNA [10200]","Cigna Local Plus",,10796.81,31.5,,16168.95,16168.95,16168.95,"1 through 10",3986.25,29134.26,"percent of total billed charges",
"CATH ADVANCE PLIAFORM STARCAST 135CM 2CM 5MM BALLOON",SUP-G52257,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"FIRST HEALTH [10303]","First Health",,767.82,80,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM GLOBAL UNITE ARTHROPLASTY REVERSE",SUP-OSC379458,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"UHC [10700]","United Healthcare",,28712.88,63.3,,8601.07,8395.67,8601.07,"1 through 10",5275.37,38556,"percent of total billed charges",
"MATRIX TISSUE 2X2CM AMNIOBAND PLACENTAL ALLOGRAFT",SUP-WC3022,CDM,Q4151,HCPCS,0636,RC,,,both,,,6749.93,2024.98,"CIGNA [10200]","Cigna Local Plus",,362.66,,,,,,,362.66,5737.44,"fee schedule",
"STENT 26CM 6FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175263070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"CIGNA [10200]",Cigna,,678.25,68,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 118CM 6FR EBU3.5 CURVE GUIDING STERILE LATEX",SUP-LA6EBU35Y,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INJECTION GOLD PROBE 210CM 7FR 25GA .24MM 2.8MM",SUP-M00560150,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRN2PR,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 5MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035475200,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"FIRST HEALTH [10303]","First Health",,11291.71,80,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 60MM 18MM VASCULAR NITINOL VENOUS ILIOFEMORAL",SUP-AB9U18060090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"KAISER [10500]",Kaiser,,6934.5,67,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 12D 13CM 4.5MM CURVED RADENOID TONSIL SURGICAL ADULT",SUP-1884008,CDM,S27200284,LOCAL,0272,RC,,,both,,,1782.00,534.6,"PHCS [10601]",PHCS,,1247.4,70,,,,,0,207.25,1514.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 135CM 2CM 5FR 6MM 7.5MM BALLOON DILATATION",SUP-4196020X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.0 PLY SCRW 4.0X18",SUP-102040118,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"HC Glidescope Blade Disp",PX-E27200455,CDM,E27200455,LOCAL,0272,RC,,,both,,,364.53,109.36,"PHCS [10601]",PHCS,,255.17,70,,,,,0,42.39,309.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE STD 25MM BLUNT SCPL BONESCALPEL SURGICAL STERILE LATEX",SUP-MXB-25,CDM,S27200284,LOCAL,0272,RC,,,both,,,3466.88,1040.06,"UHC [10700]","United Healthcare",,2194.54,63.3,,,,,0,403.2,2946.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 58MM 80CM 8MM VASCULAR BALLOON EXPANDABLE",SUP-LSMU0800858,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"FIRST HEALTH [10303]","First Health",,20916,80,,,,,0,3040.66,22223.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL XS UNIVERSAL 23MM KNEE HINGE LPS",SUP-198727123,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"AETNA [10100]","Aetna HMO/PPO",,23489.36,79.5,,10981.53,8986.79,12413.38,12,3436.24,25114.41,"percent of total billed charges",
"CONTOUR 150-250 2 VIALS BX/2",SUP-M0017600221,CDM,S27800098,LOCAL,0278,RC,,,both,,,1458.00,437.4,"MULTIPLAN [10600]",Multiplan,,1239.3,85,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 10FT CARTO REDEL 10 PIN CNCT 4 ELECTROGRAM",SUP-C10MR10MSTKS,CDM,S27000186,LOCAL,0270,RC,,,both,,,2115.00,634.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,869.27,41.1,,,,,0,245.97,1797.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.8CM NATRELLE BIOCELL P5.7CM HIGH PROFILE ROUND",SUP-MSZ20600,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE V92 CELLULAR BONE MATRIX ALLOGRAFT 2.5ML",SUP-P01-V92-0250,CDM,C1713,HCPCS,0278,RC,,,both,,,12075.00,3622.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4962.83,41.1,,,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X10MM MODULUS 10D XL WIDE STERILE LATEX",SUP-1221050P2,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"CIGNA [10200]","Cigna Local Plus",,7484.4,31.5,,16168.95,16168.95,16168.95,"1 through 10",2763.29,20196,"percent of total billed charges",
"SYSTEM IVAS ELITE 10MM 11GA DIAGNOSTIC CATH STERILE LATEX",SUP-0808-110-800,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,11781,68,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC UNIVERSAL THUMB RIGHT ABDUCT LAMINATE",SUP-79-87100,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.42,15.43,"KAISER [10500]",Kaiser,,34.45,67,,,,,0,5.98,43.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL 50 MCG/ML INJECTION SUPERORDERABLE|DISCARDED DRUG NOT ADMINISTE",RX-4083037,CDM,J3010,HCPCS,0636,RC,00409-9094-18,NDC,both,5,ML,30.96,9.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,JW,3.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.56,26.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE ELECTROTHERAPY 130IN SENSOR TRUNK",SUP-888414,CDM,S27000186,LOCAL,0270,RC,,,both,,,2581.95,774.58,"CIGNA [10200]",Cigna,,1755.73,68,,,,,0,300.28,2194.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 40X14-18MM",SUP-400720,CDM,S27800098,LOCAL,0278,RC,,,both,,,3978.54,1193.56,"BLUE CROSS [10001]","Blue Cross HMO",,1559.59,39.2,,,,,0,462.7,3381.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 16X14X8MM SPINE CERVICAL",SUP-6940864,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .035IN 5FR 10MM 135CM 2CM PERIPHERAL",SUP-4190020X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT 17GA 75MM ACTIVE TIP COOL RADIOFREQUENCY PROBE TUBE",SUP-CRK-17-75-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mopath Procedure Level 1",PX-309000093,CDM,81400,CPT,0310,RC,,,both,,,1109.85,332.95,"BLUE CROSS [10001]","Blue Cross PPO",,81.72,,"Fee schedule rate ($81.72).",,,,0,0.01,943.37,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +28 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200280,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"BLUE CROSS [10001]","Blue Cross HMO",,400.08,39.2,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 12MM KII FIOS FIRST ENTRY ADVANCE",SUP-CFF73,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,83.86,45.9,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAVER BLADE 4MM 40DEG ROTATABLE WINDOW  CLOSED",SUP-SB4040RC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1541.46,462.44,"AETNA [10100]","Aetna HMO/PPO",,1225.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,179.27,1310.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREONPANOPTIX PRO(BLF)",SUP-PXYAT0,CDM,V2788,HCPCS,0276,RC,,,both,,,915.00,274.5,"NOVANET [10819]",Novanet,,686.25,75,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 34MM ORTHOLOC TITANIUM CORTICAL SELF TAP",SUP-59225534,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,285.14,28.62,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIPHERAL CUTTING BALLOON 50CM 20MM 6MM BALLOON",SUP-PCB602050,CDM,C1725,HCPCS,0272,RC,,,both,,,5037.00,1511.1,"AETNA [10100]","Aetna HMO/PPO",,4004.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,585.8,4281.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTILUME 5CM 18FR BALLOON DRUG COATED BALLOON INFLATION",SUP-OPTBDL7001B,CDM,C1726,HCPCS,0272,RC,,,both,,,14455.50,4336.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1712.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",379.61,375.47,414.12,"1 through 10",1681.17,12287.18,"percent of total billed charges",
"DRESSING OPTICELL 18X.75IN FORZAGEL",SUP-MSC9818EPZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"PHCS [10601]",PHCS,,57.31,70,,,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 9MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532-G-309,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"KAISER [10500]",Kaiser,,5834.1,67,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CELLULAR LIFETIME DATA PLAN",SUP-CSDL,CDM,S27000186,LOCAL,0270,RC,,,both,,,3375.00,1012.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1387.13,41.1,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PULSE GENRTR WAVEWRITER ALPHA IMPLANTABLE",SUP-SC-1432,CDM,C1820,HCPCS,0278,RC,,,both,,,99750.00,29925,"NOVANET [10819]",Novanet,,74812.5,75,,,,,0,11600.93,84787.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPERANCE CATHETER KIT, 6F, 131CM",SUP-ASP6F131KIT,CDM,C1757,HCPCS,0272,RC,,,both,,,15145.50,4543.65,"PHCS [10601]",PHCS,,10601.85,70,,,,,0,1761.42,12873.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transport Advanced One Way",PX-546000003,CDM,A0427,HCPCS,0546,RC,,,both,,,2466.12,739.84,"PHCS [10601]",PHCS,,1726.28,70,,,,,0,286.81,2096.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 325CC",SUP-RSZ-MPX-325S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"AETNA [10100]","Aetna HMO/PPO",,1287.9,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REVOLVE BREAST BIOPSY STERILE DISPOSABLE",SUP-RV0002,CDM,S27200284,LOCAL,0272,RC,,,both,,,6147.90,1844.37,"CIGNA [10200]","Cigna Open Access",,3498.16,56.9,,,,,0,715,5225.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 26MM COUNTSINK MAXIMUM TORQUE 4MM",SUP-MSD01040026S,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross PPO",,555.66,39.2,,957.42,570.23,957.42,28,164.86,1204.88,"percent of total billed charges",
"CATH LAUNCHER 5FR .058IN AMPLATZ LEFT 2 CURVE GUIDING NYLON",SUP-LA5AL20,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"FIRST HEALTH [10303]","First Health",,313.2,80,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 36MM HIP TAPER ORTHINOX V40",SUP-6364-2-236,CDM,C1776,HCPCS,0278,RC,,,both,,,4778.25,1433.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,555.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,555.71,4061.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO GREEN 23CM 6FR BRITE TIP CANN INTERVENTIONAL",SUP-401623M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 100MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.700S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,291.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,286.03,2090.49,"percent of total billed charges",
"GWIRE FATHOM VASCULAR 180CM 35CM .016IN STAINLESS STEEL",SUP-M001509110,CDM,C1769,HCPCS,0272,RC,,,both,,,1792.50,537.75,"KAISER [10500]",Kaiser,,1200.98,67,,,,,0,208.47,1523.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32MMX8MM CAPSTONE PEEK LUMBAR INTERBODY FUSION",SUP-9440832,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"MULTIPLAN [10600]",Multiplan,,14662.5,85,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X8MM DIVERGENCE 12MM LORDOTIC NUCLEUS PULPOSUS",SUP-G6626528,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3554.6,28.62,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO 1000093013 OPTISEAL GLBL11FR25CM",SUP-1000093013,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6.6CM 3.5MM MICRUSFRAME 10 COIL",SUP-MFR100356,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]",Cigna,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 160MM 3.5MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.68,CDM,S27000186,LOCAL,0270,RC,,,both,,,2271.60,681.48,"CIGNA [10200]",Cigna,,1544.69,68,,,,,0,264.19,1930.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT PL SITEMARK 58CM 54CM 9FR 7FR MULTIPURPOSE",SUP-410181,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2524.5,68,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 115MM 1.5MM TWIST J NOTCH 2MM SCR",SUP-25-469-11-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,1270.49,381.15,"AETNA [10100]","Aetna HMO/PPO",,1010.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.76,1079.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL HIP C TAPER COBALT CHROME LFIT",SUP-06-2805,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"NOVANET [10819]",Novanet,,2345.78,75,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20GA 20GA 12CM .025IN GWIRE NDL SYR DRAPE CENTRAL",SUP-AK-04550-S,CDM,C1751,HCPCS,0272,RC,,,both,,,217.50,65.25,"PHCS [10601]",PHCS,,152.25,70,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.235 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.235,CDM,V2632,HCPCS,0276,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]","Cigna Open Access",,1920.38,56.9,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYDIOXANONE QUILL SRS 2 2XT11 TAPER 1/2 CIRCLE 36X36CM",SUP-RA-1065Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.89,65.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,100.01,45.9,,,,,0,25.34,185.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC",239,MS-DRG,,,,,,,inpatient,,,141174.97,42352.49,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,32361.39,,"Case rate ($30,529.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $28,348.81, add-ons for qualifying new technology services are included. If operating cost exceeds $61,388.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,525.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $28,386.30. The transfer operating threshold is the transfer adjustment factor * $28,348.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,143.31. The transfer capital threshold is the transfer adjustment factor * $2,143.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,10994,141174.97,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPN NC 15MM 2.5MM BALLOON DILATATION CORONARY ACCEPTS 6",SUP-250-015-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,962.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT SL II SITEMARK 50.7CM 47CM 9FR 7FR 115D",SUP-DS2C002,CDM,C1887,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1545.57,41.1,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION INTERMEDIATE KIT 2 LUMEN",SUP-1829500,CDM,C1788,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,305.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA TRACHEOSTOMY DIA8MM INNER SPARE SHILEY",SUP-8SIC,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.12,18.64,"AETNA [10100]","Aetna HMO/PPO",,49.39,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.22,52.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 11 STD KNEE LEFT CRUCIATE RETAIN CEMENT",SUP-42502607001,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS [10001]","Blue Cross PPO",,8962.18,39.2,,3949.44,3949.44,3949.44,"1 through 10",2658.93,19433.3,"percent of total billed charges",
"STEM EXT 75MM 16MM UNIVERSAL FLUTE KNEE PRESS FIT",SUP-86-7416,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"CIGNA [10200]",Cigna,,5508.41,68,,5873.17,5873.17,5873.17,"1 through 10",942.1,6885.51,"percent of total billed charges",
"NAIL 10MM 390MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.458S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2379.02,28.62,,,,,0,966.74,7065.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 14CM PUMP SET NARROW",SUP-EN8814,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]",Cigna,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 3.543X.433IN THK.050IN 2 CUT HIGH PERFORMANCE KNEE",SUP-4111127090,CDM,S27200284,LOCAL,0272,RC,,,both,,,393.85,118.15,"CIGNA [10200]",Cigna,,267.82,68,,,,,0,45.8,334.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 7MMX59MM 7FR 80CMCATH HEPARIN",SUP-BXB075901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5266.3,27,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 67MM 7MM VORTX 35 COIL PUSHABLE 5.5MM",SUP-M0013733071,CDM,S27800098,LOCAL,0278,RC,,,both,,,769.50,230.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,220.23,28.62,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADHESIVE SKIN SURGISEAL",SUP-DHV12,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.04,24.91,"CIGNA [10200]","Cigna Local Plus",,44.43,53.5,,,,,0,9.66,70.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +19.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1950,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 18MM 44MM SHOULDER SOFT TISSUE BALANCE",SUP-7122881,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"BLUE CROSS [10001]","Blue Cross PPO",,3104.64,39.2,,3949.44,3949.44,3949.44,"1 through 10",921.1,6732,"percent of total billed charges",
"LINER ACETABULAR G7 C 32MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30123203,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"CIGNA [10200]",Cigna,,6971.37,68,,5873.17,5873.17,5873.17,"1 through 10",1192.31,8714.22,"percent of total billed charges",
"TRAY SPINAL 3.5IN 18GA 27GA LIDOCAINE METAL GLASS TUOHY",SUP-333192,CDM,C1755,HCPCS,0278,RC,,,both,,,251.69,75.51,"BLUE CROSS [10001]","Blue Cross HMO",,98.66,39.2,,,,,0,29.27,213.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK PERFUSION PUMP ECMO",SUP-65964,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"FIRST HEALTH [10303]","First Health",,104.4,80,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE NEVOS DEMINERALIZED BONE MATRIX 2.5CC ALLOGRAFT",SUP-BNEPP0025,CDM,C1713,HCPCS,0278,RC,,,both,,,2343.75,703.12,"CIGNA [10200]","Cigna Open Access",,1333.59,56.9,,1144.80,304.56,2275.09,66,272.58,1992.19,"percent of total billed charges",
"CATH 6FR HS2 CURVE GUIDING SIDEHOLE",SUP-LA6HS2SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -2MM 12/14 TAPER 36MM HIP CEMENTLESS M",SUP-136550000,CDM,C1776,HCPCS,0278,RC,,,both,,,3991.68,1197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,473.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,464.23,3392.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR060202A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"CIGNA [10200]",Cigna,,7504.56,40,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 10CM 45MM GORE TAG THORACIC ACTIVE CONTROL",SUP-TGM454510,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"BLUE CROSS [10001]","Blue Cross HMO",,45461.1,39.2,,9776.84,9776.84,9776.84,"1 through 10",13487.57,98576.37,"percent of total billed charges",
"SUT VICRYL 4-0 RB-1 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J214H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP ACETABULAR 54MM 48MM M2A-MAGNUM PRESS FIT HIP STERILE",SUP-US157854,CDM,C1776,HCPCS,0278,RC,,,both,,,20061.72,6018.52,"CIGNA [10200]","Cigna Local Plus",,6319.44,31.5,,5372.07,4581.20,7242.98,23,2333.18,17052.46,"percent of total billed charges",
"INSRT TIBIAL 8 19MM KNEE X3 BEARING CRUCIATE RETAIN",SUP-5530-G-819,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"AETNA [10100]","Aetna HMO/PPO",,9073.02,79.5,,10981.53,8986.79,12413.38,12,1327.29,9700.71,"percent of total billed charges",
"INSRT CLAMP EVERCLIP FOGARTY HYDRAGRIP 86MM ATRAUMATIC",SUP-EVERGRIP86,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.16,41.45,"KAISER [10500]",Kaiser,,92.57,67,,,,,0,16.07,117.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Voriconazole",PX-301000626,CDM,80285,CPT,0301,RC,,,both,,,314.93,94.48,"CIGNA [10200]",Cigna,,59.64,,,,,,,0.01,267.69,"fee schedule",
"SYSTEM XIENCE PRIME 38MM 143CM 3.5MM CORONARY STENT",SUP-1011734-38,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"AETNA [10100]","Aetna HMO/PPO",,7624.85,79.5,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM PERIPHERAL STERILE",SUP-AR-9562-40NL,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"CIGNA [10200]",Cigna,,406.22,68,,1831.33,1831.33,1831.33,16,69.48,507.77,"percent of total billed charges",
"DRIVER HEX QUICK CONNECT 3.2MM SURGICAL",SUP-8361025,CDM,S27000186,LOCAL,0270,RC,,,both,,,4930.05,1479.01,"KAISER [10500]",Kaiser,,3303.13,67,,,,,0,573.36,4190.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNCOMPLICATED PEPTIC ULCER WITH MCC",383,MS-DRG,,,,,,,inpatient,,,51769.34,15530.8,"UHC [10700]","United Healthcare",,34433.28,,"Fee schedule rate ($34,433.28). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,34433.28,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 26CM 3CM 5FR .035IN 2 PIGTAIL",SUP-M006192123050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]",Cigna,,816.39,68,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 20MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UHC [10700]","United Healthcare",,907.53,63.3,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC STD 12IN 25- IN KNEE 1 PANEL FINGER POCKET",SUP-VP40101-005,CDM,L1830,HCPCS,0274,RC,,,both,,,132.94,39.88,"CIGNA [10200]","Cigna Local Plus",,71.12,53.5,,,,,0,15.46,113,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SPINAL 14MM 3.5MM CODA ANTERIOR CERVICAL SELF DRILL",SUP-102250014,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",117.75,860.63,"percent of total billed charges",
"EGIA RADIAL MED THK RELOAD",SUP-SIGRADMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2461.50,738.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1673.82,68,,,,,0,286.27,2092.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX SAFE PERFORMAXX 80MM 80CM 10MM 6FR .035IN",SUP-ZBM10080,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"MULTIPLAN [10600]",Multiplan,,8504.25,85,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM INFINITY SPINE OCCIPITOCERVICAL UPPER",SUP-3603526,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,3978.14,359.25,3978.14,24,441.36,3225.75,"percent of total billed charges",
"STPLR INTERNAL 37CM XL CIRCULAR 2 ROW SEAL 5.2MMX1.5-2.2MM",SUP-ECS29B,CDM,S27200284,LOCAL,0272,RC,,,both,,,6267.91,1880.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4262.18,68,,,,,0,728.96,5327.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 60MM 36MM XLPE HIP STERILE",SUP-71332760,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"CIGNA [10200]","Cigna Open Access",,6330.84,56.9,,5302.19,4377.88,6578.61,27,1293.98,9457.31,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 18MM 145CM 3.25MM CORONARY STENT",SUP-1145325-18,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]",Cigna,,3969.84,68,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 8FR .088IN EXTRA",SUP-5888101,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PASSER SMARTSTITCH CNCT MAGNUM WIRE BRAIDED SUT POLYESTER",SUP-OM-8176,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.18,543.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TENDYNE MITRAL VALVE SP 35L",SUP-TENDV-SP-35L-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"VALVE AORTIC 21MM 16.7MM MASTERS SERIES 85D STD HEART",SUP-21AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8333.92,28.62,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Lig Band",PX-750000177,CDM,45398,CPT,0750,RC,,,both,,,4005.00,1201.5,"FIRST HEALTH [10303]","First Health",,3204,80,,,,,0,465.78,4005,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFT TOUCH",SUP-SSM-445,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2162.38,28.62,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM HIP ACETABULAR CANCELLOUS PRIMARY",SUP-2020-6540-1,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA [10200]","Cigna Local Plus",,407.35,53.5,,3978.14,359.25,3978.14,24,88.55,647.19,"percent of total billed charges",
"SPACER ALLOGRAFT 12X14X7MM 5D OVAL SPINE CORTICAL FREEZE DRY",SUP-017207,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SURGICAL .062IN",SUP-WS-1607ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"PHCS [10601]",PHCS,,200.97,70,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 18LP 135CM 2CM 4FR 3MM .018IN BALLOON",SUP-G50216,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X6MM SABLE 8D STERILE LATEX FREE",SUP-1172.2010S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13860,40,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 23X9X11MM CONCORDE PARALLEL BULLET NOSE",SUP-187823111,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS [10001]","Blue Cross PPO",,6491.52,39.2,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH DESTINO SURESEAL FLEXSTEER 17MM BEND STANDARD 55CM 73",SUP-PSS0855517,CDM,C1887,HCPCS,0272,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X13/10.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-4813,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"BLUE CROSS [10001]","Blue Cross PPO",,5815.32,39.2,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 20MM 135CM 10MM 160CM",SUP-M001711330,CDM,C1876,HCPCS,0278,RC,,,both,,,8728.50,2618.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4006.38,45.9,,,,,0,1015.12,7419.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 12MM 3MM BALLOON DILATATION DURATRAC",SUP-NCEUP3012X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,216.39,41.1,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.25CM NATRELLE INSPIRA P5.5CM FULL PROFILE",SUP-MSZ-F520,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"FIRST HEALTH [10303]","First Health",,126.54,80,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INVESTIGATIONAL DRUG PO (DOSE BY STUDY PROTOCOL)",RX-410998,CDM,,,0250,RC,99999-4109-98,NDC,both,1,UN,0.01,,"UHC [10700]","United Healthcare",,0.01,63.3,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +20.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030205,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANNITOL 20 % INTRAVENOUS SOLUTION",RX-4749,CDM,J2151,HCPCS,0636,RC,00990-7715-03,NDC,both,500,ML,144.67,43.4,"BLUE CROSS [10001]","Blue Cross PPO",,27.97,,,,,,,17.14,122.97,"fee schedule",
"DIL VASCULAR 12FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G00995,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"MULTIPLAN [10600]",Multiplan,,41.93,85,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UROLOGICAL 150CM 3MM .038IN PTFE J TIP MOVABLE CORE",SUP-M0066201220,CDM,C1769,HCPCS,0272,RC,,,both,,,153.29,45.99,"KAISER [10500]",Kaiser,,102.7,67,,,,,0,17.83,130.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 180MM 8MM BALLOON DILATATION OTW",SUP-H74939206081810,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSOR LOGICUT 450MM",SUP-120-7004,CDM,S27200284,LOCAL,0272,RC,,,both,,,320.70,96.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.3,272.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE IRON MAN VASCULAR J RIBBON 190CM 3CM .014IN",SUP-1001309J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 12MM CEREPAK XL UNIFORM DETACHABLE",SUP-FCX181240,CDM,S27800098,LOCAL,0278,RC,,,both,,,15872.28,4761.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6523.51,41.1,,,,,0,1845.95,13491.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +19 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030190,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 300MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030300M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR DYNASTY A-CLASS STD 36MM POLY BIOFOAM HIP",SUP-DLXPGD36,CDM,C1776,HCPCS,0278,RC,,,both,,,7507.20,2252.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2148.56,28.62,,,,,0,873.09,6381.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 7MM 11MM 7FR .035IN",SUP-BXA077901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8798.44,41.1,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHOCARBAMOL 100 MG/ML INJECTION SOLUTION",RX-4970,CDM,J2800,HCPCS,0636,RC,71288-0716-11,NDC,both,10,ML,81.54,24.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.33,,"Fee schedule rate ($5.33). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.33,69.31,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFAZOLIN 1 G VIAL|DISCARDED DRUG NOT ADMINISTE",RX-1445,CDM,J0690,HCPCS,0636,RC,44567-0707-25,NDC,both,1,UN,14.95,4.48,"CIGNA [10200]",Cigna,JW,4.45,,,,,,,1.41,12.71,"fee schedule",
"TISSUE 270120 RESERVE 12MM SRVC FEE",SUP-270120,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FELT CARDIOVASCULAR 4X.5IN THK1.65MM PTFE PATCH STERILE",SUP-007975,CDM,C1768,HCPCS,0278,RC,,,both,,,1359.43,407.83,"PHCS [10601]",PHCS,,951.6,70,,,,,0,158.1,1155.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CMX.49MM 22/12MM KNIT REVERSE LOCKNIT",SUP-HGK2412,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUVOXAMINE ER 100 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-91128,CDM,,,0637,RC,00228-2848-03,NDC,both,1,UN,38.50,11.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.48,32.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pta Baln Artery Addl",PX-361000444,CDM,37247,CPT,0361,RC,,,both,,,26786.85,8036.05,"MULTIPLAN [10600]",Multiplan,,22768.82,85,,,,,0,1249,22768.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC .99IN MINI 5.37X8.18CM DYNAGEN X4 IS-1 DF-4",SUP-G158,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA [10200]","Cigna Open Access",,19336.2,33.5,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEVELAMER CARBONATE 800 MG TABLET",RX-89201,CDM,,,0637,RC,50268-0720-11,NDC,both,1,UN,33.64,10.09,"UHC [10700]","United Healthcare",,21.29,63.3,,,,,0,3.91,28.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VASOVIEW 6 SHORT VESSEL HARVESTING 30ML BLUNT TIP",SUP-C-VH-2004,CDM,S27200284,LOCAL,0272,RC,,,both,,,880.10,264.03,"NOVANET [10819]",Novanet,,660.08,75,,,,,0,102.36,748.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 120MM 75CM 5MM VASCULAR METAL SUPERFICIAL",SUP-H74939293051270,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]","Cigna Local Plus",,2584.05,53.5,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 60MM 80CM 6MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM06060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"FIRST HEALTH [10303]","First Health",,14616,80,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL SPACER",SUP-345544,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 3 RIGHT DISTAL KNEE",SUP-5542-A-302,CDM,C1776,HCPCS,0278,RC,,,both,,,5009.55,1502.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1433.73,28.62,,,,,0,582.61,4258.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 15MM 1.50MM BALLOON DILATATION PEBAX",SUP-1400150-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cortisol Blood Total Adrenal",PX-301000159,CDM,82533,CPT,0301,RC,,,both,,,357.50,107.25,"UHC [10700]","United Healthcare",,14.67,,,,,,,0.01,303.88,"fee schedule",
"STPLR INTERNAL 37CM XL CIRCULAR 2 ROW SEAL 5.2MMX1.5-2.2MM",SUP-ECS25B,CDM,S27200284,LOCAL,0272,RC,,,both,,,6267.91,1880.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,742.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,728.96,5327.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP 2300MM LOWER OPEN CLOSE FUNCTION PRECISE",SUP-HX-202UR.B,CDM,S27200284,LOCAL,0272,RC,,,both,,,1234.23,370.27,"KAISER [10500]",Kaiser,,826.93,67,,,,,0,143.54,1049.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PERICARDIOCENTESIS 8.3FR PERIVAC STRAIGHT CATH",SUP-M00443141,CDM,C1729,HCPCS,0272,RC,,,both,,,1242.00,372.6,"KAISER [10500]",Kaiser,,832.14,67,,,,,0,144.44,1055.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 8X6CM AXIS TUTOPLAST DERMIS ALLOGRAFT",SUP-939268,CDM,C1762,HCPCS,0278,RC,,,both,,,16629.00,4988.7,"CIGNA [10200]","Cigna Local Plus",,5238.14,31.5,,,,,0,1933.95,14134.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH MICROBIOLOGY 1MM 1.8MM 110CM STERILE DISPOSABLE",SUP-130,CDM,S27200284,LOCAL,0272,RC,,,both,,,151.03,45.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.56,128.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMARTCLIP SOFT TISSUE MARKER AND DELIVERY SYSTEM, PURPLE 10C",SUP-SMARTCLIPLT-PRUP-10,CDM,A4648,HCPCS,0278,RC,,,both,,,2625.00,787.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1785,68,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Type if Ea Antiserum",PX-306000075,CDM,87140,CPT,0306,RC,,,both,,,303.05,90.91,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,257.59,"per diem",
"(EVAL) DISPOSABLE WEIGHT",SUP-5675,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL SHOULDER 36MM SMR ECCENTRICAL GLENOSPHERE STERILE",SUP-1376.09.031,CDM,C1776,HCPCS,0278,RC,,,both,,,9183.90,2755.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4215.41,45.9,,,,,0,1068.09,7806.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC",351,MS-DRG,,,,,,,inpatient,,,44461.40,13338.42,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,9882.11,,"Case rate ($9,456.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,781.06, add-ons for qualifying new technology services are included. If operating cost exceeds $41,820.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,045.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,792.68. The transfer operating threshold is the transfer adjustment factor * $8,781.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $663.89. The transfer capital threshold is the transfer adjustment factor * $663.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,44461.4,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL YELLOW 24FR USA ELITE SYSTEM USA",SUP-KE-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,838.19,251.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,569.97,68,,,,,0,97.48,712.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D MODIFIED L BICONVEX 13MM 6MM POSTERIOR CHMBR 1",SUP-SN60AT,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Pelvis WO Cntrst",PX-610000018,CDM,72195,CPT,0610,RC,,,both,,,4177.74,1253.32,"CIGNA [10200]","Cigna Local Plus",,752,,"Per diem ($752). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,436.31,3551.08,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 7 UNIVERSAL KNEE TOTAL STABILIZE",SUP-5521-B-700,CDM,C1776,HCPCS,0278,RC,,,both,,,10384.92,3115.48,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4268.2,41.1,,6417.48,6417.48,6417.48,"1 through 10",1207.77,12263.72,"percent of total billed charges",
"STENT LIFESTENT 160MM 135CM 5MM 5FR VASCULAR NITINOL LOW",SUP-5F051503CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20128.50,6038.55,"MULTIPLAN [10600]",Multiplan,,17109.23,85,,,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Lumb/Sac Sngl WO Img",PX-510000205,CDM,62322,CPT,0761,RC,,,both,,,4263.00,1278.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,495.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,495.79,3623.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE COLLAR 8 HOLE 1/3 TUBULAR DCP LC-DCP FOOT NONSTERILE",SUP-241.38,CDM,C1713,HCPCS,0278,RC,,,both,,,1158.95,347.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,788.09,68,,,,,0,134.79,985.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUE FLOW 110CM 3.5CM 24MM 14FR PERFUSION BALLOON",SUP-TF0243514,CDM,C1725,HCPCS,0272,RC,,,both,,,11730.00,3519,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1390.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 25MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G725,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"BLUE CROSS [10001]","Blue Cross HMO",,3920,39.2,,5311.50,4717.44,5388.59,31,1163,8500,"percent of total billed charges",
"GRAFT STENT 160MM 28-14MM 13FR TRIVASCULAR OVATION PRIME",SUP-TV-IL1428160-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"UHC [10700]","United Healthcare",,21135.87,63.3,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDELINER V3 150CM 25CM 5.5FR 4.8FR .051IN .012IN",SUP-5570,CDM,C1887,HCPCS,0272,RC,,,both,,,2872.50,861.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,340.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.07,2441.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 40MM TSRH OSTEOGRIP THINLINE SPINE",SUP-83585409,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1181.47,45.9,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STREAMER VASCULAR POLYMER CORONARY SINUS EXTRA DISTAL",SUP-363727,CDM,C1769,HCPCS,0272,RC,,,both,,,486.00,145.8,"FIRST HEALTH [10303]","First Health",,388.8,80,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 12CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192112010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS [10001]","Blue Cross PPO",,470.63,39.2,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 5CM 20GA GHIATAS BEADED STIFFENED SECTION",SUP-49520,CDM,A4648,HCPCS,0278,RC,,,both,,,182.79,54.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,83.9,45.9,,,,,0,21.26,155.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 59MM 31.8MM 23MM DURAN ANCORE 25.8MM 2",SUP-620BG23,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"AETNA [10100]","Aetna HMO/PPO",,10422.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Analyze 20-25 Cells",PX-312000062,CDM,88264,CPT,0311,RC,,,both,,,1835.40,550.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,227.47,,,,,,,0.01,1560.09,"fee schedule",
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 28MM COCR",SUP-VAL-25280-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,168.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,165.8,1211.76,"percent of total billed charges",
"DRSG WOUND 6X6IN AQUACEL EXTRA HYDROFIBER ABSORBENT NONWOVEN",SUP-420673,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.41,18.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,41.08,68,,,,,0,7.03,51.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESALAMINE 800 MG TABLET,DELAYED RELEASE",RX-96949,CDM,,,0637,RC,60687-0408-95,NDC,both,1,UN,61.99,18.6,"CIGNA [10200]","Cigna Open Access",,35.27,56.9,,,,,0,7.21,52.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE MC PLUS 2.5MM x 18MM BALLOON DIATATION",SUP-225-183-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 8MM 4MM 1 C0901 OVAL CARBIDE TORI REMOVAL HALL",SUP-03-C0901,CDM,S27200284,LOCAL,0272,RC,,,both,,,119.71,35.91,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.92,101.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 60MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171080670,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AETNA [10100]","Aetna HMO/PPO",,933.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 10-12 G-H KNEE RIGHT TIBIA",SUP-42522401012,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]",Cigna,,7327.97,68,,5873.17,5873.17,5873.17,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"SUPREME EP EXT. CABLE GREY  150 CM",SUP-401982,CDM,S27200284,LOCAL,0272,RC,,,both,,,248.00,74.4,"PHCS [10601]",PHCS,,173.6,70,,,,,0,28.84,210.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309015,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"KAISER [10500]",Kaiser,,25300.67,67,,,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL WEIL-BLAKESLEY PEDIATRIC 45D UP 00 6.25IN",SUP-63-7424,CDM,S27200284,LOCAL,0272,RC,,,both,,,1913.63,574.09,"PHCS [10601]",PHCS,,1339.54,70,,,,,0,222.56,1626.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 345CC SMOOTH SHELL SURFACE NATRELLE INSPIRA FULL",SUP-SRF-345,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,470.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 80MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-583508022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"AETNA [10100]","Aetna HMO/PPO",,1191.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 6.9MM 5MM NASAL ORAL TAPER CUFF MURPHY EYE",SUP-18750,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.76,19.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.53,55.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 36MM",SUP-497-36-000,CDM,C1776,HCPCS,0278,RC,,,both,,,7869.52,2360.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2252.26,28.62,,,,,0,915.23,6689.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON ENDOSCOPIC ULTRAMATRIX RADIAL NONSTERILE LATEX FREE",SUP-USBOR,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.90,44.37,"MULTIPLAN [10600]",Multiplan,,125.72,85,,,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 20MM 29MM HANCOCK II ULTRA CINCH PORCINE",SUP-T505U229,CDM,S27800098,LOCAL,0278,RC,,,both,,,21420.00,6426,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6130.4,28.62,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE SELF RETAINING SELF DRILLING FIXED ANGLE 4MM 16MM",SUP-04.613.516,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST 59MM 80CM 9MM ENDOVASCULAR STAINLESS STEEL PTFE",SUP-48959,CDM,C1874,HCPCS,0278,RC,,,both,,,18881.10,5664.33,"AETNA [10100]","Aetna HMO/PPO",,15010.47,79.5,,,,,0,2195.87,16048.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAPE 36INX2MM REVERSE CUT NDL CLSR BLUE WHITE",SUP-AR-7288,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"FIRST HEALTH [10303]","First Health",,1190.7,80,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX10MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183540,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3707.06,28.62,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC",708,MS-DRG,,,,,,,inpatient,,,101616.14,30484.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,29114.51,,"Fee schedule rate ($29,114.51). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,44792.5,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 34MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.434TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"CIGNA [10200]","Cigna Local Plus",,1081.53,53.5,,3978.14,359.25,3978.14,24,235.11,1718.32,"percent of total billed charges",
"HEATED TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION 0-30 MCI",RX-411522,CDM,A9560,HCPCS,0343,RC,08888-8878-61,NDC,both,1,UN,5851.21,1755.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,680.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.55,4973.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 4-5 E-F KNEE RIGHT TIBIA FIX",SUP-42522100611,CDM,C1776,HCPCS,0278,RC,,,both,,,9466.80,2840.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6437.42,68,,,,,0,1100.99,8046.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR MP6 NEUTRAL 36MM HXE-PLUS HIP STERILE",SUP-931-36-750,CDM,C1776,HCPCS,0278,RC,,,both,,,12087.14,3626.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4834.86,40,,,,,0,1405.73,10274.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GRIESHABER REVOLUTION 23GA END GRASPING FINE",SUP-706.43,CDM,S27200284,LOCAL,0272,RC,,,both,,,984.07,295.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,451.69,45.9,,,,,0,114.45,836.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.7MM 50MM 18MM LOW PROFILE SCREWS TITANIUM 3.5MM",SUP-AR-8967-1850,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,218.06,1593.75,"percent of total billed charges",
"SNARE HEXAGONAL 1.5CM 1CM 7FR SOFT ACUSNARE 1 PIECE BRAID",SUP-G22704,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.43,49.33,"CIGNA [10200]","Cigna Local Plus",,87.97,53.5,,,,,0,19.12,139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 14CM 5FR 3MM .035IN D BALLOON",SUP-G52250,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR EMPHASYS +4MM NEUTRAL 56-58MM 40MM AOX",SUP-472256440,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,5873.17,5873.17,5873.17,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"HC Compres Band Tubigrip per Linear Yd",PX-E27000091,CDM,A6457,HCPCS,0270,RC,,,both,,,47.30,14.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STAPLER INTERNAL 25X4.8MM TITANIUM XL CIRCLE STAPLE ENDOSCOP",SUP-EEAXL25,CDM,S27200284,LOCAL,0272,RC,,,both,,,2269.80,680.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SINGLE-USE 1000 MICRON LASER",SUP-HLFDBX1000C,CDM,S27200284,LOCAL,0272,RC,,,both,,,5276.02,1582.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CAP SYSTEM PERSONA STD TKR POLYETHYLENE KNEE FEMUR PATELLA T",SUP-98000200165,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"BLUE CROSS [10001]","Blue Cross PPO",,8890.56,39.2,,3949.44,3949.44,3949.44,"1 through 10",2637.68,19278,"percent of total billed charges",
"CATH INJECTION GOLD PROBE 201CM 10FR 25GA .24MM 3.7MM",SUP-M00560160,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC .045MM 2 ENDED",SUP-210-40-006,CDM,C1769,HCPCS,0272,RC,,,both,,,113.10,33.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,76.91,68,,,,,0,13.15,96.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 341111 LACSR 11X11X11 SRVC FEE",SUP-341111,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 26CM 8FR .035",SUP-M006192153090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,427.13,28.62,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 34MMX8MMX15CM 24FR",SUP-TAC083415A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"NOVANET [10819]",Novanet,,136800,75,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Trigger Pnt>=3 Mscl",PX-510000063,CDM,20553,CPT,0761,RC,,,both,,,3925.00,1177.5,"NOVANET [10819]",Novanet,,2943.75,75,,,,,0,456.48,3336.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 45MM 26MM UHR UNIVERSAL ACETABULAR HIP COCR",SUP-UH1-45-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"BLUE CROSS [10001]","Blue Cross PPO",,1692.57,39.2,,3949.44,3949.44,3949.44,"1 through 10",502.16,3670.1,"percent of total billed charges",
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 34MMX8MMX15CM 24FR",SUP-TAC083415A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"PHCS [10601]",PHCS,,127680,70,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC MICRO STRAIGHT TIP",SUP-58-6900,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.44,19.03,"FIRST HEALTH [10303]","First Health",,50.75,80,,,,,0,7.38,53.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR MP8 NEUTRAL 40MM HXE+ HIP STERILE NONHOOD",SUP-931-40-754,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross PPO",,2569.56,39.2,,3949.44,3949.44,3949.44,"1 through 10",762.35,5571.75,"percent of total billed charges",
"OLYMPUS 4MM 15 DEG SERRATED SHAVER",SUP-SB4015SC,CDM,S27200284,LOCAL,0272,RC,,,both,,,4205.69,1261.71,"CIGNA [10200]",Cigna,,2859.87,68,,,,,0,489.12,3574.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM PRESTIGE PLUS HELICAL EXTRA PACK",SUP-PRES0103HXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug or Sub Ql/Qn Nos 1-3",PX-301000526,CDM,80375,CPT,0301,RC,,,both,,,249.00,74.7,"MULTIPLAN [10600]",Multiplan,,211.65,85,,,,,0,0.01,249,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYPROPYLENE 20X20IN PERMANENT GRID 2 SMOOTH",SUP-F10248-2020P,CDM,C1781,HCPCS,0278,RC,,,both,,,49593.60,14878.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5876.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5767.74,42154.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X6MM HEDRON HEDRON IC 7D 10MM STERILE LATEX",SUP-1213.6076S,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross HMO",,4057.2,39.2,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 55MM 3.5MM LC-DCP CORTEX PELVIC STAINLESS STEEL",SUP-204.655,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"MULTIPLAN [10600]",Multiplan,,233.98,85,,,,,0,32.01,233.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 10MM LCP STAINLESS STEEL SMALL BONE SELF",SUP-02.211.010,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"BLUE CROSS [10001]","Blue Cross HMO",,352.07,39.2,,957.42,156.86,7483.26,51,104.45,763.41,"percent of total billed charges",
"INSRT TIBIAL 4 9MM KNEE ONLAY MULTICOMPARTMENTAL RESTORIS",SUP-180704-1,CDM,C1776,HCPCS,0278,RC,,,both,,,4046.85,1214.05,"KAISER [10500]",Kaiser,,2711.39,67,,,,,0,470.65,3439.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 31MM 26.1MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-31MECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 17MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDS32517,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA [10200]",Cigna,,33209.89,40,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINE PRESSURE MON CARDIOPLEGIA HEART TRANSPLANT",SUP-027742202,CDM,S27200284,LOCAL,0272,RC,,,both,,,400.20,120.06,"CIGNA [10200]","Cigna Local Plus",,214.11,53.5,,,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLAZER PRIME 8FR/10MM=P4790THN4",SUP-M004P4790THN4,CDM,C1733,HCPCS,0272,RC,,,both,,,12420.00,3726,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1471.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fem Art Cannula",PX-E27200298,CDM,E27200298,LOCAL,0272,RC,,,both,,,2503.60,751.08,"UHC [10700]","United Healthcare",,1584.78,63.3,,,,,0,291.17,2128.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM 1.6MM KIRSCHNER STAINLESS STEEL THREADED",SUP-292.71,CDM,C1713,HCPCS,0278,RC,,,both,,,113.03,33.91,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,13.15,96.08,"percent of total billed charges",
"CAP CONSTRUCT TOTAL KNEE JOURNEY II XR CRUCIATE RETAINING OX",SUP-71709030,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"UHC [10700]","United Healthcare",,13957.65,63.3,,8601.07,8395.67,8601.07,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"ANCHOR SUT 3.5MM MEDIUM DX SWIVELOCK FOOT ELBOW PEEK 13.5MM",SUP-AR-8979P,CDM,C1713,HCPCS,0278,RC,,,both,,,3346.88,1004.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2275.88,68,,,,,0,389.24,2844.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 124MM 20-16MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1620C124E,CDM,S27800098,LOCAL,0278,RC,,,both,,,30315.60,9094.68,"CIGNA [10200]",Cigna,,12126.24,40,,,,,0,3525.7,25768.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 55D 18MM 3.75MM EMBOLIZATION 75% COCR",SUP-PED-375-18,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"KAISER [10500]",Kaiser,,51556.5,67,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 10MM THORAX SOFT FLEXIBLE WOVEN",SUP-M00202175210P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9MM 70MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704970,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"VALVE AORTIC 19MM ON-X CONFORM-X CUFF MECHANICAL",SUP-ONXACE/19,CDM,S27800098,LOCAL,0278,RC,,,both,,,21780.00,6534,"CIGNA [10200]","Cigna Local Plus",,6860.7,31.5,,,,,0,2533.01,18513,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 20MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE45020,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9914.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 109MM 28MM 24-25MM 16FR ZENITH ALPHA",SUP-G35337,CDM,C1874,HCPCS,0278,RC,,,both,,,96672.00,29001.6,"PHCS [10601]",PHCS,,67670.4,70,,,,,0,11242.95,82171.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 20MM 80CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-G43844,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2570.4,68,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM FUSION ORTHOLOC BONE TIBIOTALAR ANTEROLATERAL",SUP-59206020,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,957.42,156.86,7483.26,51,2014.9,14726.25,"percent of total billed charges",
"TUBE 22FR REPLACEMENT STRAIGHT ANGLE BOLST GASTRO ENDOVIVE",SUP-M00509931,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.82,72.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,28.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.01,204.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 3-0 PS-2 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP427H,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.45,19.63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.61,55.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ 110CM 7FR PULMONARY ARTERY 2 LUMEN MNTR",SUP-111F7P,CDM,C1751,HCPCS,0272,RC,,,both,,,731.84,219.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,85.11,622.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT EMG STIM PATHWAY VAGINA",SUP-2949,CDM,S27200284,LOCAL,0272,RC,,,both,,,329.38,98.81,"CIGNA [10200]",Cigna,,223.98,68,,,,,0,38.31,279.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45MM LINEAR CUTTER ARTICULATION TRIGGER LOCK",SUP-PSE45A,CDM,S27200284,LOCAL,0272,RC,,,both,,,5656.21,1696.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,657.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,657.82,4807.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AUTOFIX ORTHOPEDIC 80MM .91MM STAINLESS STEEL",SUP-4511136,CDM,C1769,HCPCS,0272,RC,,,both,,,171.74,51.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,70.59,41.1,,,,,0,19.97,145.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 21GA 40CM 4CM BLUE HUB TUBING STAINLESS",SUP-PSS-8F-4-018MT,CDM,C1894,HCPCS,0272,RC,,,both,,,286.67,86,"KAISER [10500]",Kaiser,,192.07,67,,,,,0,33.34,243.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 TWINFIX ULTRA ULTRABRAID NDL COBRAID PLLA",SUP-72202612,CDM,C1713,HCPCS,0278,RC,,,both,,,2039.63,611.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1386.95,68,,,,,0,237.21,1733.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC",737,MS-DRG,,,,,,,inpatient,,,108598.58,32579.57,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,13676.76,,"Case rate ($12,782.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,868.98, add-ons for qualifying new technology services are included. If operating cost exceeds $44,908.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,279.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,884.67. The transfer operating threshold is the transfer adjustment factor * $11,868.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.35. The transfer capital threshold is the transfer adjustment factor * $897.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,60161.28,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 0 FSL 18IN BRAIDED BLACK NONABSORBABLE",SUP-678H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 6-9 G-H KNEE RIGHT TIBIA",SUP-42522400912,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4946.38,45.9,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000095,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6.6CM 3.5MM MICRUSFRAME 10 COIL",SUP-MFR100356,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6.6CM 3.5MM MICRUSFRAME 10 COIL",SUP-MFR100356,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"FIRST HEALTH [10303]","First Health",,9505.44,80,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 10MM 11FR ENDOPROSTHESIS HEPARIN",SUP-VBH101002,CDM,C1874,HCPCS,0278,RC,,,both,,,19939.50,5981.85,"BLUE CROSS [10001]","Blue Cross HMO",,7816.28,39.2,,9776.84,9776.84,9776.84,"1 through 10",2318.96,16948.58,"percent of total billed charges",
"STENT UNISTEP PLUS WALLSTENT RP 66MM 135CM 8MM 160CM",SUP-M001712230,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3473.98,41.1,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 7.5CMX1MM THK2.5CM SILICONE FLEXIBLE FIRM",SUP-400561,CDM,S27000186,LOCAL,0270,RC,,,both,,,245.34,73.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,166.83,68,,,,,0,28.53,208.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREONPANOPTIX PRO(BLF)",SUP-PXYAT6,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"CIGNA [10200]","Cigna Open Access",,520.64,56.9,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 2.25MM CORONARY STENT EVEROLIMUS",SUP-H7493926132220,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5865,68,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRAVASTATIN 40 MG TABLET",RX-11112,CDM,,,0637,RC,50268-0667-11,NDC,both,1,UN,21.60,6.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.51,18.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC",261,MS-DRG,,,,,,,inpatient,,,72451.35,21735.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,30141.62,,,,,,,7561,55195.04,"case rate",
"SUB BONE GRAFT 100X25X8MM SIGNAFUSE GLASS CLLGN TYPE 1",SUP-SGFS-020,CDM,C1713,HCPCS,0278,RC,,,both,,,25578.00,7673.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3030.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,2974.72,21741.3,"percent of total billed charges",
"TUBE 10.5IN 26FR SILICONE Y PORT GRADUATE SHAFT OPEN DISTAL",SUP-8884720265E,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.71,111.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,44.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.35,316.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 150MM 2.5MM .014IN BALLOON DILATATION",SUP-39186-25151,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST EXTERNAL FIXATION MAXFRAME 1 HIGH MOUNT MULTIPARALLEL",SUP-03.313.857,CDM,C1713,HCPCS,0278,RC,,,both,,,1280.37,384.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,148.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",148.91,1088.31,"percent of total billed charges",
"STPLR INTERNAL 40MM 45MM CURVE TIP ANVIL CENTRIC 12 FIRE CUT",SUP-480545,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 520CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-520,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"FIRST HEALTH [10303]","First Health",,6044.4,80,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 120MM 4MM .035IN BALLOON",SUP-AB35W04120135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"UHC [10700]","United Healthcare",,428.64,63.3,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM TRITIUM STD CANCELLOUS SELF DRILL",SUP-86-27-16,CDM,C1713,HCPCS,0278,RC,,,both,,,745.20,223.56,"KAISER [10500]",Kaiser,,499.28,67,,,,,0,86.67,633.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 8MM 3.25MM ULTRA LOW PROFILE BALLOON",SUP-1012275-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 60MM 28MM XLPE HIP",SUP-71334960,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"NOVANET [10819]",Novanet,,8360.21,75,,,,,0,1296.39,9474.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Upr Ext WO Cntrst",PX-359000001,CDM,73200,CPT,0352,RC,,,both,,,2018.48,605.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,261.88,,,,,,,234.75,1933,"fee schedule",
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 7 HIP",SUP-PRTLE027,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 300MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050300M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"UHC [10700]","United Healthcare",,1186.88,63.3,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 12MM 100MM KII ABDOMINAL ADVANCE",SUP-CFS22,CDM,S27200284,LOCAL,0272,RC,,,both,,,119.63,35.89,"AETNA [10100]","Aetna HMO/PPO",,95.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR BLADDER PROCEDURES WITH MCC",653,MS-DRG,,,,,,,inpatient,,,179067.25,53720.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR CHAMP1.5 CURVE GUIDING CORONARY",SUP-LA7CHAMP15SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 14 150CM 40MM 4FR 2.5MM ROUND TAPER LOW PROFILE",SUP-A2025-040,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAMP SURGICAL SYMMETRY .6-1.5MM APPROXIMATOR WITHOUT FRAME",SUP-ABB-22VB,CDM,S27200284,LOCAL,0272,RC,,,both,,,1895.55,568.66,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GATEWAY 135CM 9MM 3.5MM BALLOON DILATATION HYDROPHILIC",SUP-M0032072209350,CDM,C1725,HCPCS,0272,RC,,,both,,,9423.88,2827.16,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INFINITI THRULUMEN 100CM 6FR .057IN RIGHT CORONARY 3D",SUP-534676T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,inpatient,,,791596.38,237478.91,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT XXL PASSIVE LOOP 600LB DISPOSABLE",SUP-MFA2100-XXL-L1,CDM,S27000186,LOCAL,0270,RC,,,both,,,231.51,69.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM FEMORAL 124MM 12.5MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-00771101200,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2476.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2430.63,17764.68,"percent of total billed charges",
"STENT COTTON-LEUNG 15CM 5FR .035IN GENTLE CURVE BILIARY",SUP-G22399,CDM,C2617,HCPCS,0278,RC,,,both,,,729.00,218.7,"MULTIPLAN [10600]",Multiplan,,619.65,85,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE SCOPE 10.2X3.7X7CM RECHARGEABLE SMART UNIVERSAL CHRG",SUP-71910,CDM,S27200284,LOCAL,0272,RC,,,both,,,1123.31,336.99,"FIRST HEALTH [10303]","First Health",,898.65,80,,,,,0,130.64,954.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 11.5CM 4MM MICRUSFRAME 10 COIL",SUP-MFR100412,CDM,S27800098,LOCAL,0278,RC,,,both,,,16974.00,5092.2,"AETNA [10100]","Aetna HMO/PPO",,13494.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1974.08,14427.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL HANK 2 ENDED 19-20FR UTERINE",SUP-500-237,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.44,54.13,"UHC [10700]","United Healthcare",,114.22,63.3,,,,,0,20.99,153.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 100MM 130CM 7MM 6FR .035IN VASCULAR NITINOL",SUP-EX071003CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]","Cigna Local Plus",,4781.7,31.5,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH SURGICAL 25MM 180MM DURAPRO 5MM BRUSH",SUP-6262.4351S,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Meckel Divert",PX-341000021,CDM,78290,CPT,0341,RC,,,both,,,1730.12,519.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,201.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,201.21,1470.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 500MM 5.5MM 2 HEXAGON STRAIGHT DEFORMITY DENALI",SUP-111-B55500,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 24CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006155232170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,168.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUCICLOVINE F-18 INTRAVENOUS SOLUTION (12-13 MCI)",RX-411838,CDM,A9588,HCPCS,0343,RC,08888-8877-90,NDC,both,1,UN,755.00,226.5,"KAISER [10500]",Kaiser,,505.85,67,,,,,0,87.81,755,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Meckel Divert",PX-341000021,CDM,78290,CPT,0341,RC,,,both,,,1730.12,519.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,205.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,201.21,1470.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L52 MM OD5 MM LOW PROFILE LOCK TUBE NONSTERILE IN",SUP-04.045.352TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1271.53,68,,,,,0,217.47,1589.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC PERI 19MM (PERI)",SUP-3300TFX19MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,40887.00,12266.1,"NOVANET [10819]",Novanet,,30665.25,75,,,,,0,4755.16,34753.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 34CM FEMUR RIGHT PROXIMAL TALON DISTALFIX",SUP-SLN-125-34R,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1875.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1875.37,13706.51,"percent of total billed charges",
"DEVICE V-LOC 90 SURGALLOY 3-0 P-12 18IN CLSR ABSORBABLE",SUP-VLOCM0024,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.73,70.42,"FIRST HEALTH [10303]","First Health",,187.78,80,,,,,0,27.3,199.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 2CM 10MM BALLOON DILATATION ILIAC",SUP-G35546,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.64,68,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 33MM STD SEWING CUFF",SUP-M7-033,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"AETNA [10100]","Aetna HMO/PPO",,17529.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165CM 8.5-11MM OTSC 6MM NITINOL STERILE",SUP-100.09,CDM,C1760,HCPCS,0272,RC,,,both,,,3667.50,1100.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1507.34,41.1,,,,,0,1507.34,2321.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 20MM 80CM 5MM 6FR .035IN BILIARY NITINOL",SUP-G32001,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"AETNA [10100]","Aetna HMO/PPO",,3005.1,79.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR EXTRA BACKUP 4.5",SUP-67005800,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,49.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP SYSTEM WITH CERAMIC HEAD",SUP-55500018,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"BLUE CROSS [10001]","Blue Cross PPO",,8890.56,39.2,,3949.44,3949.44,3949.44,"1 through 10",2637.68,19278,"percent of total billed charges",
"SLEEVE CENTERING 9.5MM S-ROM ZTT 18F SMALL HIP PROXIMAL",SUP-550717,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"FIRST HEALTH [10303]","First Health",,8707.8,80,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL 15X6MM MOBI-C 13MM CERVICAL TITANIUM COCRMO UHMWPE","SUP-MB 3356",CDM,S27800098,LOCAL,0278,RC,,,both,,,33075.00,9922.5,"KAISER [10500]",Kaiser,,22160.25,67,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY BROACHED RESTORATION 5 HIP FEMUR PROXIMAL REVISION",SUP-6276-3-005,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"MULTIPLAN [10600]",Multiplan,,18916.54,85,,,,,0,2588.23,18916.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM RELINE-O 2S SPINE POLYAXIAL NONSTERILE",SUP-13015040,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOPLASTY L150CM BALLOON L40MM DIA6MM COMPATIBLE",SUP-1013470-040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1255.50,376.65,"CIGNA [10200]","Cigna Open Access",,714.38,56.9,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 10CM 5FR ZIMMON PIGTAIL CURVE PANCREATIC",SUP-G21689,CDM,C2625,HCPCS,0272,RC,,,both,,,1328.40,398.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,154.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 7CM MR8 5MM BALL DISSECTING CARBIDE",SUP-MR8-7BA50C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1089.86,326.96,"PHCS [10601]",PHCS,,762.9,70,,,,,0,126.75,926.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32MMX8MM CAPSTONE PEEK LUMBAR INTERBODY FUSION",SUP-9440832,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]",Cigna,,6900,40,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cyp2c19 Gene Com Variants",PX-309000020,CDM,81225,CPT,0310,RC,,,both,,,935.55,280.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,262.22,,,,,,,0.94,837.78,"fee schedule",
"HC Everolimus Assay",PX-301000457,CDM,80169,CPT,0301,RC,,,both,,,394.25,118.27,"BLUE CROSS [10001]","Blue Cross HMO",,0.39,.1,,,,,0,0.01,335.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 240MM 3.2MM VERTEX STD TITANIUM PRECURVED",SUP-6900240,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"BLUE CROSS [10001]","Blue Cross HMO",,552.72,39.2,,957.42,156.86,7483.26,51,163.98,1198.5,"percent of total billed charges",
"STENT HANAROSTENT 60MM 1800MM 8MM 2.33MM BILIARY NITINOL",SUP-SHS-08-060-180,CDM,C1874,HCPCS,0278,RC,,,both,,,6855.84,2056.75,"BLUE CROSS [10001]","Blue Cross HMO",,2687.49,39.2,,9776.84,9776.84,9776.84,"1 through 10",797.33,5827.46,"percent of total billed charges",
"INSRT TIBIAL 2 22.5MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962326,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3916.03,27,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Eus Fna/Bx",PX-750000086,CDM,45342,CPT,0750,RC,,,both,,,4085.00,1225.5,"AETNA [10100]","Aetna HMO/PPO",,3247.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,475.09,4085,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"Bx Bone Open Superfic",PX-450000363,CDM,20240,CPT,0361,RC,,,both,,,6136.00,1840.8,"CIGNA [10200]","Cigna Local Plus",,2587,,"Case rate ($2,587). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,6.14,6136,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Admn Sarscov2 Vac 1st/Only Cmp",PX-771000053,CDM,90480,CPT,0771,RC,,,both,,,121.05,36.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,82.31,68,,,,,0,14.08,121.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR SILICONE Y PORT FENESTRATE DRAPE SAFETY",SUP-M00566721,CDM,S27200284,LOCAL,0272,RC,,,both,,,726.49,217.95,"NOVANET [10819]",Novanet,,544.87,75,,,,,0,84.49,617.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSRT FEMORAL VENOUS CANN BIO-MEDICUS NEXTGEN 23FR",SUP-96600-123,CDM,S27200284,LOCAL,0272,RC,,,both,,,3022.88,906.86,"CIGNA [10200]","Cigna Local Plus",,1617.24,53.5,,,,,0,351.56,2569.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Rmvl Hot Bx",PX-750000093,CDM,45384,CPT,0750,RC,,,both,,,4713.82,1414.15,"BLUE CROSS [10001]","Blue Cross PPO",,3634.7,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",3634.70,3634.70,3634.70,"1 through 10",548.22,4713.82,"fee schedule",
CABLE,SUP-05001-I,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chloride Body Fluid",PX-301000143,CDM,82438,CPT,0301,RC,,,both,,,126.00,37.8,"MULTIPLAN [10600]",Multiplan,,107.1,85,,,,,0,0.13,107.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM LCP STAINLESS STEEL PEDIATRIC MEDIAL",SUP-212.107,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,582.96,68,,,,,0,99.7,728.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32MMX10MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2991032,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1883.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM CD HORIZON LEGACY TITANIUM SPINE SELF",SUP-7543535,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,441.36,3225.75,"percent of total billed charges",
"SPACER SPINAL 14X11X10MM ALEUTIAN SMALL LORDOTIC ANTERIOR",SUP-403-21410L,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS [10001]","Blue Cross PPO",,2617.94,39.2,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 56MM UNITRAX HIP FEMORAL MODULAR EXETER V40",SUP-6942-5-056,CDM,C1776,HCPCS,0278,RC,,,both,,,4291.80,1287.54,"NOVANET [10819]",Novanet,,3218.85,75,,,,,0,499.14,3648.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bag Infusor Pressure",PX-E27000046,CDM,E27000046,LOCAL,0270,RC,,,both,,,157.30,47.19,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH URETERAL 5.8FR 5MM 75CM 4CM HIGH PRESSURE BALLOON",SUP-M0062251010,CDM,C1726,HCPCS,0272,RC,,,both,,,1832.70,549.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP SURGICAL 28MM BIPOLAR RETAINING",SUP-205516000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1781.25,534.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DYNAMIC XT 110CM 6FR 2-5-2MM SPACE LARGE 4 CURVE",SUP-M0042011010,CDM,C1730,HCPCS,0272,RC,,,both,,,5002.50,1500.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD DEFIB PEDI-PADZ II PEDIATRIC AED PLUS DISPOSABLE",SUP-8900-0810-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,638.60,191.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH COYOTE ES MONORAIL 144CM 20MM 4MM BALLOON DILATATION",SUP-H74939135402010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND 6-0 C-1 18IN 2 ARM BRAID BLACK",SUP-706G,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.79,29.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MATRIX TISSUE 20X20CM STRATTICE PORCINE DERMIS",SUP-2020002,CDM,Q4130,HCPCS,0636,RC,,,both,,,61128.90,18338.67,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"NDL BIOPSY 20GA 7.95FR 8- CM ECHOTIP PROCORE RECESSE BALL",SUP-G34785,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 4CM 5.8FR 21FR BALLOON",SUP-M0062251030,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"APPL INTERNAL CLIP 20D MEDIUM HEART 8IN TITANIUM LIGATE",SUP-237081,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 4.9MM ASNIS III LARGE CANNULATED AO FIT 6.5MM SCR",SUP-702601,CDM,S27200284,LOCAL,0272,RC,,,both,,,2838.15,851.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION",RX-176571,CDM,Q9968,HCPCS,0636,RC,00517-0374-01,NDC,both,10,ML,2123.59,637.08,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCREW METAPHYSEAL LOCKING 3.7MM X 24MM TI",SUP-MTLS-37240-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 59MM 135CM 10MM 13MM 8FR .035IN",SUP-BXA105902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5266.3,27,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 80MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 10",SUP-245.220,CDM,C1713,HCPCS,0278,RC,,,both,,,3664.50,1099.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1682.01,45.9,,,,,0,426.18,3114.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 CURVE 10MM KNEE XLK FIX BEARING PFC SIGMA",SUP-158113110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]","Cigna Open Access",,6358.32,56.9,,5302.19,4377.88,6578.61,27,1299.6,9498.37,"percent of total billed charges",
"BLADE SAW 41X14X.38MM HALL MICRO STAINLESS STEEL SAGITTAL",SUP-5301025033,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.29,43.59,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,66.69,45.9,,,,,0,16.9,123.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chest Tube Tray",PX-E27200441,CDM,E27200441,LOCAL,0272,RC,,,both,,,246.40,73.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,167.55,68,,,,,0,28.66,209.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Proctoidsigmoidoscopy Diag",PX-750000145,CDM,45300,CPT,0750,RC,,,both,,,1835.00,550.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1729.39,,"Fee schedule rate ($1,729.39).",,,,0,213.41,1835,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OSCILLATING LARGE 9.5MMX71MMX0.9MM",SUP-ZO-7277,CDM,S27200284,LOCAL,0272,RC,,,both,,,255.78,76.73,"PHCS [10601]",PHCS,,179.05,70,,,,,0,29.75,217.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER BALLOON DILATATION CHOCOLATE NITINOL .014 IN L135 C",SUP-CB1413535040OTW,CDM,C2623,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"FIRST HEALTH [10303]","First Health",,4581.6,80,,,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG HEMOSTATIC 5X5IN QUIKCLOT CONTROL+ 4 PLY STERILE LATEX",SUP-4000,CDM,S27200284,LOCAL,0272,RC,,,both,,,497.06,149.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,228.15,45.9,,,,,0,57.81,422.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ERCP .025IN TAPERED TIP FLUORO TIP 210CM 5FR BILIARY",SUP-M00530980,CDM,S27200284,LOCAL,0272,RC,,,both,,,255.08,76.52,"UHC [10700]","United Healthcare",,161.47,63.3,,,,,0,29.67,216.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ekg Holter Scan/Report",PX-731000002,CDM,93226,CPT,0731,RC,,,both,,,986.00,295.8,"FIRST HEALTH [10303]","First Health",,788.8,80,,,,,0,114.67,838.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM TOMCAT SPINE SELF DRILL VARIABLE ANGLE",SUP-RT10-D3514,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC15ST-LK,CDM,S27200284,LOCAL,0272,RC,,,both,,,17640.00,5292,"CIGNA [10200]","Cigna Local Plus",,9437.4,53.5,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR WRP CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389696090,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"MULTIPLAN [10600]",Multiplan,,311.47,85,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RED 72 132CM .085IN 2.16MM REPERFUSION LARGE BORE",SUP-RED72SDKIT,CDM,C1757,HCPCS,0272,RC,,,both,,,31027.50,9308.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12752.3,41.1,,,,,0,3608.5,26373.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 230MM 2.5MM 3 FLUTED QUICK COUPLING NONSTERILE",SUP-315.92,CDM,S27000186,LOCAL,0270,RC,,,both,,,1181.63,354.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,137.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,137.42,1004.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER/DIVIDER LAPAROSCOPIC 44CM 5MM LIGASURE 180D 17.8MM 2",SUP-LF1844,CDM,S27200284,LOCAL,0272,RC,,,both,,,3386.18,1015.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2302.6,68,,,,,0,393.81,2878.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR GUIDE 27MM PERSONA KNEE STAINLESS STEEL",SUP-579104300,CDM,C1713,HCPCS,0278,RC,,,both,,,763.83,229.15,"NOVANET [10819]",Novanet,,572.87,75,,,,,0,88.83,649.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175262080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"MULTIPLAN [10600]",Multiplan,,1053.47,85,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZONISAMIDE 100 MG CAPSULE",RX-27780,CDM,,,0637,RC,60687-0230-11,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,3.57,56.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET OPHTHALMIC 155CM .051CM .081CM C-LINE .064CM ROUND",SUP-8590450,CDM,S27200284,LOCAL,0272,RC,,,both,,,797.04,239.11,"NOVANET [10819]",Novanet,,597.78,75,,,,,0,92.7,677.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Epi Bld/Clot Patch",PX-510000104,CDM,62273,CPT,0761,RC,,,both,,,3571.50,1071.45,"PHCS [10601]",PHCS,,3571.5,,"Case rate ($4,710). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,415.37,3571.5,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS COMMANDER DELIVERY SYSTEM WITH SAPIEN 3 ULTRA",SUP-9750CM29A,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +10 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1000,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 4FR 21GA 3FR MERIT PAK .018IN 40CM MINI PEDAL",SUP-PAKM5NPD7,CDM,C1894,HCPCS,0272,RC,,,both,,,389.06,116.72,"PHCS [10601]",PHCS,,272.34,70,,,,,0,45.25,330.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis Be Ab",PX-302000147,CDM,86707,CPT,0302,RC,,,both,,,196.98,59.09,"FIRST HEALTH [10303]","First Health",,157.58,80,,,,,0,0.01,167.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 5 SLOT RIGHT TI",SUP-PHPF-C5R,CDM,C1713,HCPCS,0278,RC,,,both,,,17640.00,5292,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7250.04,41.1,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 8MM 10-8MM 16MM DUCT SELF EXPANDABLE",SUP-9-PDA-006,CDM,C1817,HCPCS,0278,RC,,,both,,,34398.00,10319.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4000.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4000.49,29238.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH BRITE TIP 23CM 4FR INTRO CANN INTERVENTIONAL LATEX",SUP-401423M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"UHC [10700]","United Healthcare",,66.09,63.3,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 2MM LARGE 110MM VITALLIUM 2 CABLE GRIP RECONSTRUCTION",SUP-6704-3-091,CDM,C1713,HCPCS,0278,RC,,,both,,,6913.80,2074.14,"AETNA [10100]","Aetna HMO/PPO",,5496.47,79.5,,1521.93,481.35,16760.95,30,804.07,5876.73,"percent of total billed charges",
"SCR BONE 8.5MM 70MM CD HORIZON SPINE MULTIAXIAL CANNULATED",SUP-25840018570,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 28FR CUT OLYMPUS OES",SUP-M0068802391,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,55.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Occl Dev Arty/Vein",PX-481000066,CDM,G0269,HCPCS,0481,RC,,,both,,,1536.99,461.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,182.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,178.75,1536.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Occl Dev Arty/Vein",PX-481000066,CDM,G0269,HCPCS,0481,RC,,,both,,,1536.99,461.1,"PHCS [10601]",PHCS,,1075.89,70,,,,,0,178.75,1536.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Lt/Rt Pulm Arty",PX-361000072,CDM,36014,CPT,0361,RC,,,both,,,1340.08,402.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1340.08,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,155.85,1340.08,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY",SUP-F6QRF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"FIRST HEALTH [10303]","First Health",,725.76,80,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE KYPHON 3 GUN FILLER DEVICE",SUP-CDS3A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1814.67,544.4,"AETNA [10100]","Aetna HMO/PPO",,1442.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,211.05,1542.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 125CM 5FR MPA2 CURVE ANGIOGRAPHIC PERIPHERAL",SUP-H749163911222,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"AETNA [10100]","Aetna HMO/PPO",,60.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Upper GI Barium & Air",PX-320000101,CDM,74246,CPT,0320,RC,,,both,,,1725.88,517.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,204.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,151.98,1467,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25MMX14MM CRESCENT PEEK-OPTIMA VERTEBRAL BODY",SUP-9392514,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA [10200]","Cigna Local Plus",,5216.4,31.5,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CBL PCNG DISP",SUP-4042,CDM,S27200284,LOCAL,0272,RC,,,both,,,696.60,208.98,"FIRST HEALTH [10303]","First Health",,557.28,80,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 19MM RESTORATION +30MM HIP MODULAR",SUP-6276-1-319,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"BLUE CROSS [10001]","Blue Cross HMO",,5670.99,39.2,,5311.50,4717.44,5388.59,31,1682.49,12296.8,"percent of total billed charges",
"Y-KNOT FLEX, 1.3MM ALL-SUTURE ANCHOR, WITH ONE #2 WHITE/BLUE",SUP-Y1301,CDM,C1713,HCPCS,0278,RC,,,both,,,4513.64,1354.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,534.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,524.94,3836.59,"percent of total billed charges",
"SCR BONE 5.5MM 48MM UNIVERS REVERS POROUS GLENOID PERIPHERAL",SUP-AR-9563-48,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,69.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",69.48,507.77,"percent of total billed charges",
"CEFTRIAXONE 1 G VIAL",RX-9487,CDM,J0696,HCPCS,0636,RC,00143-9857-01,NDC,both,1,UN,18.92,5.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.16,,"Fee schedule rate ($2.16). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",2.35,2.35,7.70,"1 through 10",2,16.08,"fee schedule",
"DEVICE PIPELINE FLEX 16MM 3.75MM EMBOLIZATION NEUROVASCULAR",SUP-PED-375-16,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,20776.5,27,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 14MM DCP STAINLESS STEEL CORTICAL SELF TAPPING",SUP-201.814,CDM,C1713,HCPCS,0278,RC,,,both,,,358.09,107.43,"CIGNA [10200]","Cigna Open Access",,203.75,56.9,,1144.80,304.56,2275.09,66,41.65,304.38,"percent of total billed charges",
"STENT 22CM 3CM 4.8FR .035IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145350050,CDM,C2617,HCPCS,0278,RC,,,both,,,940.57,282.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,639.59,68,,,,,0,109.39,799.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 80CM 23CM ORANGE HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-7F-23-035,CDM,C1894,HCPCS,0272,RC,,,both,,,117.45,35.23,"KAISER [10500]",Kaiser,,78.69,67,,,,,0,13.66,99.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12.5CM 10-5MM TORNADO SMALL STD PLATINUM",SUP-G10413,CDM,S27800098,LOCAL,0278,RC,,,both,,,696.60,208.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,319.74,45.9,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 12.5CM 20GA HAWKINS III 9 STRAND CABLE",SUP-243125,CDM,A4648,HCPCS,0278,RC,,,both,,,310.59,93.18,"NOVANET [10819]",Novanet,,232.94,75,,,,,0,36.12,264,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRAMIPEXOLE 1 MG TABLET",RX-21288,CDM,,,0637,RC,60687-0592-11,NDC,both,1,UN,6.67,2,"CIGNA [10200]","Cigna Local Plus",,3.57,53.5,,,,,0,0.78,5.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X15MM 9-11MM SPINE CORTICAL FREEZE DRIED",SUP-14915,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS [10001]","Blue Cross HMO",,6491.52,39.2,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Amniotic Fluid Protein",PX-301000462,CDM,84112,CPT,0301,RC,,,both,,,401.70,120.51,"CIGNA [10200]",Cigna,,215.84,,,,,,,0.01,341.45,"fee schedule",
"HC Colonoscopy W Eus Bx/Fna",PX-750000098,CDM,45392,CPT,0750,RC,,,both,,,3751.00,1125.3,"CIGNA [10200]","Cigna Open Access",,2751,,"Case rate ($2,751). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,436.24,3751,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 20MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158100120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross HMO",,4380.42,39.2,,5311.50,4717.44,5388.59,31,1299.6,9498.37,"percent of total billed charges",
"GRAFT SOFT TISSUE 230MM 4+ MM FLEXIGRAFT GRACILIS TENDON",SUP-FGRACILIS,CDM,S27800098,LOCAL,0278,RC,,,both,,,7607.25,2282.17,"KAISER [10500]",Kaiser,,5096.86,67,,,,,0,884.72,6466.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE STD 25MM BLUNT SCPL BONESCALPEL SURGICAL STERILE LATEX",SUP-MXB-25,CDM,S27200284,LOCAL,0272,RC,,,both,,,3466.88,1040.06,"MULTIPLAN [10600]",Multiplan,,2946.85,85,,,,,0,403.2,2946.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL 22-30CM 3CM 4.8FR .035IN PIGTAIL CURVE",SUP-M006180155050,CDM,C2617,HCPCS,0278,RC,,,both,,,1047.90,314.37,"BLUE CROSS [10001]","Blue Cross HMO",,410.78,39.2,,,,,0,121.87,890.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE NONABSORBABLE TAPERCUT POLYESTER 1/2 CIRCLE TAPER L36",SUP-M0068332241,CDM,S27200284,LOCAL,0272,RC,,,both,,,546.75,164.02,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,250.96,45.9,,,,,0,63.59,464.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MILL BONE MEDIUM BIOPSY DISPOSABLE",SUP-5400-701-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2556.18,766.85,"KAISER [10500]",Kaiser,,1712.64,67,,,,,0,297.28,2172.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL VLP MINIMOD 1.5MM LG",SUP-71177196,CDM,S27200284,LOCAL,0272,RC,,,both,,,1184.63,355.39,"MULTIPLAN [10600]",Multiplan,,1006.94,85,,,,,0,137.77,1006.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP PROV 50MM CLSR TIP FIRST OPEN END CLIP LEFT",SUP-PROV50,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9355.5,27,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DEX 5    .9 SALINE 1000ML",SUP-794109,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA [10200]","Cigna Open Access",,46.09,56.9,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 22CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006155231010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,143.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM MITRAL FLEXIBLE HOLDER KNIT SEW",SUP-4450M26,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3258.39,28.62,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +9.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.095,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lrt Iad 18bct/8vir&7arg Rna",PX-310000032,CDM,0528U,CPT,0310,RC,,,both,,,1745.00,523.5,"CIGNA [10200]",Cigna,,1186.6,68,,,,,0,206.78,1483.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BONE MARROW ASPIRATION 11GAUGE 11CM NEEDLE W/SIDE HOLES-STER",SUP-710.111.99S,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.80,262.44,"UHC [10700]","United Healthcare",,553.75,63.3,,,,,0,101.74,743.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.35MM 95MM TFN-ADVANCED T-I6AL-7NB 3.5MM",SUP-04.038.195S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,,1521.93,481.35,16760.95,30,434.96,3179,"percent of total billed charges",
"3.4 X 3.0 X 14MM TWO-STEP HAMMER TOE IMPLANT",SUP-204-30-014,CDM,C1713,HCPCS,0278,RC,,,both,,,9832.50,2949.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1165.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1143.52,8357.63,"percent of total billed charges",
"ELEMENT 17 F VASCULAR ACCESS SYSTEM 45CM",SUP-ELMNT17F45,CDM,C1887,HCPCS,0272,RC,,,both,,,6210.00,1863,"NOVANET [10819]",Novanet,,4657.5,75,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 71MMX5MM VANGUARD 360 UNIVERSAL KNEE REVISION",SUP-185223,CDM,C1776,HCPCS,0278,RC,,,both,,,7577.58,2273.27,"NOVANET [10819]",Novanet,,5683.19,75,,,,,0,881.27,6440.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POUCH SURGICAL TISSUE 8X5IN LAPSAC NYLON POLYPROPYLENE",SUP-G15656,CDM,S27200284,LOCAL,0272,RC,,,both,,,512.24,153.67,"CIGNA [10200]","Cigna Open Access",,291.46,56.9,,,,,0,59.57,435.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DTECT CARBON DIOXIDE END TIDAL COLORIMETRIC CNCT PORT LATEX",SUP-EASYCAPII,CDM,S27000186,LOCAL,0270,RC,,,both,,,82.22,24.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.56,69.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIA MATRIX (4 X 6) 24 SQ CM",SUP-585-007,CDM,Q4309,HCPCS,0636,RC,,,both,,,171000.00,51300,"UHC [10700]","United Healthcare",,247.92,,,,,,,247.92,145350,"fee schedule",
"SCR BONE 2.5-2.8MM 14MM ACUTRAK 2 TITANIUM MICRO FULL THREAD",SUP-AT2-C14,CDM,C1713,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"AETNA [10100]","Aetna HMO/PPO",,2951.44,79.5,,1521.93,481.35,16760.95,30,431.76,3155.63,"percent of total billed charges",
"CATH ADVANCE PLIAFORM STARCAST 135CM 8CM 6MM BALLOON",SUP-G52267,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AETNA [10100]","Aetna HMO/PPO",,763.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 20IN 20FR STRAIGHT",SUP-8888570523,CDM,C1729,HCPCS,0272,RC,,,both,,,93.55,28.06,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,38.45,41.1,,,,,0,10.88,79.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 11MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-111-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]","Cigna Open Access",,4031.26,33.5,,5302.19,4377.88,6578.61,27,1399.51,10228.56,"percent of total billed charges",
"HC Ablt Perc Liver Tmr Rf",PX-361000179,CDM,47382,CPT,0361,RC,,,both,,,7662.58,2298.77,"PHCS [10601]",PHCS,,5363.81,70,,,,,0,891.16,7662.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 7MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640507,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 20X50X13MM ORACLE 8D SPINE LUMBAR FREEZE",SUP-15013,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 100MM 12MM 7FR BILIARY VENOUS SELF EXPAND",SUP-G57434,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5796,40,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 12MM KII FIOS FIRST ENTRY ADVANCED",SUP-CFF71,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC",917,MS-DRG,,,,,,,inpatient,,,36486.30,10945.89,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER TORQR 90CM 5FR 2-8-2MM SPACING CORONARY SINUS CURVE",SUP-041890CS,CDM,C1730,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET INTRO 13CM 14FR CHECK-FLO PERFORMER .038IN J TIP LARGE",SUP-G08024,CDM,C1894,HCPCS,0272,RC,,,both,,,378.19,113.46,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY SUPRAPUBIC 14FR 12FR FOLEY CATH NDL INTRO COLL BAG",SUP-143112,CDM,C2627,HCPCS,0272,RC,,,both,,,967.79,290.34,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"APPL INTERNAL CLIP 20D MEDIUM HEART 8IN TITANIUM LIGATE",SUP-237081,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,199.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 90CM 100MM 3MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186301090,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 18MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA [10200]","Cigna Local Plus",,1444.5,53.5,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 46CM 8FR STRAIGHT ENDOCARDIAL IS-1 BIPOLAR CNCT",SUP-LPA1200M/46,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"PHCS [10601]",PHCS,,1562.75,70,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TRACER METRO DIRECT ENDOSCOPIC STRAIGHT 600CM 5CM .035",SUP-G50660,CDM,C1769,HCPCS,0272,RC,,,both,,,2610.00,783,"PHCS [10601]",PHCS,,1827,70,,,,,0,303.54,2218.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Inters Vc for Rad Tx Guid",PX-361000266,CDM,C9728,HCPCS,0361,RC,,,both,,,4000.72,1200.22,"NOVANET [10819]",Novanet,,3000.54,75,,,,,0,465.28,4000.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840007540,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 9.5CM 16MM 13.5-14.5MM EXCLUDER",SUP-PLC161000,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7559.24,27,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BIOPSY 15CM 13GA OSTEO-SITE BONE CANN TROCAR TIP STYLET",SUP-G12500,CDM,S27200284,LOCAL,0272,RC,,,both,,,374.10,112.23,"CIGNA [10200]","Cigna Local Plus",,200.14,53.5,,,,,0,43.51,317.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 16MM 144CM 2.5MM CORONARY STENT",SUP-H7493952816250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Brain Scan Static=>4v",PX-341000036,CDM,78605,CPT,0341,RC,,,both,,,1678.47,503.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,195.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.68,1426.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 20MM 16MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044162070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"NOVANET [10819]",Novanet,,6468.75,75,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FG STERLING MR  5.0MMX20MMX80CM (4F)",SUP-H74939031502080,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BROADBAND INTERNET KIT MODEL EX1170, US",SUP-EX1170,CDM,S27000186,LOCAL,0270,RC,,,both,,,2062.50,618.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 85MM TITANIUM LOCK TRANSLATIONAL ATLANTIS BONE SPINE",SUP-6190085,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"CATH EMERGE MONORAIL 144CM 30MM 6FR 2MM .07IN BALLOON",SUP-H7493918930200,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 38MM 6.5MM CUT",SUP-E8165LSO,CDM,S27200284,LOCAL,0272,RC,,,both,,,453.28,135.98,"PHCS [10601]",PHCS,,317.3,70,,,,,0,52.72,385.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE",RX-19146,CDM,,,0637,RC,60687-0683-11,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM EDWARDS SAPIEN NOVAFLEX TRANSFEMORAL",SUP-9355NF29A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"MULTIPLAN [10600]",Multiplan,,157462.5,85,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEFIX V",SUP-ZV-181E10,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.46,25.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,38.31,45.9,,,,,0,9.71,70.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOUTHPC ENDOSCOPIC REUSABLE",SUP-MB-142,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.09,25.53,"CIGNA [10200]",Cigna,,57.86,68,,,,,0,9.9,72.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan",PX-302000263,CDM,86581,CPT,0302,RC,,,both,,,167.70,50.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,142.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOMATRIX DR DEMINERALIZED BONE MATRIX 3ML PUTTY",SUP-86DR0300,CDM,C1713,HCPCS,0278,RC,,,both,,,4229.70,1268.91,"CIGNA [10200]",Cigna,,2876.2,68,,1831.33,1831.33,1831.33,16,491.91,3595.25,"percent of total billed charges",
"KIT PERITONEAL LAVAGE 9.25IN 8FR 18GA HI-LITE ORANGE",SUP-AK-09000,CDM,C1729,HCPCS,0272,RC,,,both,,,200.10,60.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,82.24,41.1,,,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL, SIZE 2 ANTI-ROTATION NOTCH",SUP-200178002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 6FR 5.5MM .07",SUP-H7493926708550,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION",RX-77725,CDM,,,0250,RC,88880-8882-11,NDC,both,10,ML,12.54,3.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) AGENT DCB MR 3.50MM X 20MM",SUP-H74939436352010,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 9.5IN MEYERDING 3.5IN BLADE STAINLESS STEEL SURGICAL",SUP-200-192,CDM,S27000186,LOCAL,0270,RC,,,both,,,815.27,244.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PATCH SURGICAL 9.7X7.7IN SPRING OPEN BIORESORBABLE SELF",SUP-5950070,CDM,C1781,HCPCS,0278,RC,,,both,,,5880.00,1764,"CIGNA [10200]","Cigna Open Access",,3345.72,56.9,,11235.02,819.42,11235.02,"1 through 10",683.84,4998,"percent of total billed charges",
"CATH SUPER TORQUE PLUS 100CM 6FR .044IN .042IN JUDKINS LEFT",SUP-533622,CDM,S27200284,LOCAL,0272,RC,,,both,,,411.51,123.45,"CIGNA [10200]","Cigna Local Plus",,220.16,53.5,,,,,0,47.86,349.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +13 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.130,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR SILICONE RADIOPAQUE EXTERNAL RETENTION RING",SUP-8150-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,592.52,177.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,70.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.91,503.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 15ML .1-4MM CRUSH",SUP-T20020,CDM,S27800098,LOCAL,0278,RC,,,both,,,2614.50,784.35,"BLUE CROSS [10001]","Blue Cross HMO",,1024.88,39.2,,,,,0,304.07,2222.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SMART CONTROL MICROMARKER 30MM 80CM 14MM BILIARY",SUP-C14030SB,CDM,C1876,HCPCS,0278,RC,,,both,,,6037.50,1811.25,"AETNA [10100]","Aetna HMO/PPO",,4799.81,79.5,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM LOW PROFILE SCREWS TITANIUM T15 FULL",SUP-AR-8935-38,CDM,C1713,HCPCS,0278,RC,,,both,,,696.60,208.98,"MULTIPLAN [10600]",Multiplan,,592.11,85,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT DERMAL ALLOGRAFT DERMIS 1MM 10X15CM CORTIVA",SUP-DH3015,CDM,S27800098,LOCAL,0278,RC,,,both,,,26983.78,8095.13,"BLUE CROSS [10001]","Blue Cross HMO",,10577.64,39.2,,,,,0,3138.21,22936.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752640,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,106.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis B Core Igm Ab",PX-302000145,CDM,86705,CPT,0302,RC,,,both,,,412.30,123.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.97,,,,,,,0.01,350.46,"fee schedule",
"TUBE ENDOTRACHEAL 4MM CUFF MURPHY EYE RADIOPAQUE VITAL SIGNS",SUP-8040RTC,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.24,15.07,"PHCS [10601]",PHCS,,35.17,70,,,,,0,5.84,42.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WINGSPAN GATEWAY 15MM 3.5MM 3.5FR INTRACRANIAL",SUP-M003WS0350150,CDM,C1874,HCPCS,0278,RC,,,both,,,51979.47,15593.84,"CIGNA [10200]","Cigna Open Access",,17413.12,33.5,,,,,0,6045.21,44182.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 169.9MM 18GA 1.25MM VENOM CURVE 150MM",SUP-0406-860-225,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ALLOPURINOL 100 MG TABLET",RX-310,CDM,,,0637,RC,60687-0677-11,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE UROLOGICAL 150CM .038IN LUBRIGLIDE STRAIGHT TIP",SUP-M0066001000,CDM,C1769,HCPCS,0272,RC,,,both,,,247.43,74.23,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,EXTREME",890,APR-DRG,,,,,,,inpatient,,,102851.30,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $18,698.62. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($114,677.47) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 14X3MM COLOSSEUM 0D 12MM NONSTERILE LATEX",SUP-156.253,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"NOVANET [10819]",Novanet,,2581.88,75,,,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETHRAL BARDEX IC 18FR FOLEY 2 WAY COUNCIL TIP 2",SUP-0196SI18,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.25,42.67,"FIRST HEALTH [10303]","First Health",,113.8,80,,,,,0,16.54,120.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 7-0 TG140-8 18IN 2 ARM BRAID COATED VIOLET",SUP-J546G,CDM,S27200284,LOCAL,0272,RC,,,both,,,152.85,45.85,"CIGNA [10200]",Cigna,,103.94,68,,,,,0,17.78,129.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 100MM 125CM 6MM BILIARY NITINOL SELF",SUP-G50165,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"MULTIPLAN [10600]",Multiplan,,5176.5,85,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 265CC P3.2CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-265,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM WATCHMAN TRUSEAL ACCESS SHEATH DIL STERILE LATEX FREE",SUP-M635TU70010,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Open Access",,3926.1,56.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 45MM 2.5MM IJS AXIS",SUP-IJS-EAP-25450,CDM,C1713,HCPCS,0278,RC,,,both,,,2212.50,663.75,"FIRST HEALTH [10303]","First Health",,1770,80,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 24.5X9X.64MM XSHORT NARROW THIN STAINLESS STEEL",SUP-2108145000,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"CIGNA [10200]","Cigna Local Plus",,127.91,53.5,,,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR VACUUM 14MM VACRET PLASTIC ASPIR PUMP BERKELEY",SUP-003696,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.67,36.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.27,104.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY ESOPHAGEAL 5 60CM 20 LMA UNIQUE SOFT FLEXIBLE CUFF",SUP-1F8050,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.14,28.84,"PHCS [10601]",PHCS,,67.3,70,,,,,0,11.18,81.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CITATION TMZF HA 6 SHORT HIP RIGHT",SUP-6265-5216,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"AETNA [10100]","Aetna HMO/PPO",,19415.45,79.5,,10981.53,8986.79,12413.38,12,2840.27,20758.66,"percent of total billed charges",
"KIT INTRO 18FR JEJUNAL TRANSGASTRIC FEEDING TUBE MIC",SUP-98436A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1649.78,494.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR SIMMONS 2 CURVE",SUP-G08625,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 5.5MM 45MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.455,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"FIRST HEALTH [10303]","First Health",,3874.08,80,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARCADIA 36MM 30MM 20MM BALLOON DILATATION 8CC STEERABLE",SUP-ARC30SB,CDM,S27200284,LOCAL,0272,RC,,,both,,,5978.16,1793.45,"CIGNA [10200]","Cigna Open Access",,3401.57,56.9,,,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION LARGE 4 POSITION PIN MR SAFE LARGE",SUP-390.009,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1028.79,41.1,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM FIBERLOCK INTERNAL FIXATION FIBERLOCK SUSPENSION",SUP-AR-8988-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,11555.78,3466.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3307.26,28.62,,,,,0,1343.94,9822.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM HIP LIMIT HOLE COLOR CODED POROUS G7 B",SUP-010000660,CDM,C1776,HCPCS,0278,RC,,,both,,,10120.92,3036.28,"PHCS [10601]",PHCS,,7084.64,70,,,,,0,1177.06,8602.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 32CM 14.5FR 15FR STRAIGHT POLYURETHANE GLIDEPATH",SUP-5397270,CDM,C1750,HCPCS,0278,RC,,,both,,,1875.00,562.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,860.63,45.9,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUSEAL 6MM X 50CM US",SUP-ECH060050A,CDM,C1768,HCPCS,0278,RC,,,both,,,11060.70,3318.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4545.95,41.1,,,,,0,1286.36,9401.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE L150MM DIA4-5.5MM SEMITENDINOSUS FROZEN R",SUP-FROPE,CDM,S27800098,LOCAL,0278,RC,,,both,,,6128.93,1838.68,"PHCS [10601]",PHCS,,4290.25,70,,,,,0,712.79,5209.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 65MM KNEE RIGHT CRUCIATE RETAINING CEMENTED",SUP-183008,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"BLUE CROSS [10001]","Blue Cross PPO",,7873.58,39.2,,3949.44,3949.44,3949.44,"1 through 10",2335.96,17072.81,"percent of total billed charges",
"HC Bundle of His Recording",PX-481000070,CDM,93600,CPT,0481,RC,,,both,,,6134.00,1840.2,"CIGNA [10200]","Cigna Local Plus",,6134,,"Case rate ($18,569). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,713.38,6134,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PRELUDESYNC EZ SLIP-N-LOCK 29CM COMPRESSION RADIAL",SUP-EZ-REG,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.77,71.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,110.05,45.9,,,,,0,27.89,203.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 150MM 2.5MM BALLOON DILATATION PEBAX",SUP-H74939148251510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 130CM 5FR VERTEBRAL CURVE ANGIOGRAPHIC DURATION",SUP-H787117193035,CDM,C1887,HCPCS,0272,RC,,,both,,,398.81,119.64,"UHC [10700]","United Healthcare",,252.45,63.3,,,,,0,46.38,338.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD REAMER 13MM RIA 2 STERILE",SUP-03.404.022S,CDM,S27200284,LOCAL,0272,RC,,,both,,,6005.07,1801.52,"CIGNA [10200]",Cigna,,4083.45,68,,,,,0,698.39,5104.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12IN 24FR ARTERIAL ADULT 3/8IN CNCT NONVENTED",SUP-77524,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"UHC [10700]","United Healthcare",,283.58,63.3,,,,,0,52.1,380.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 10CM 12MM GORE EXCLUDER CONTRALATERAL LEG",SUP-PLC121000,CDM,C1874,HCPCS,0278,RC,,,both,,,27997.20,8399.16,"BLUE CROSS [10001]","Blue Cross HMO",,10974.9,39.2,,9776.84,9776.84,9776.84,"1 through 10",3256.07,23797.62,"percent of total billed charges",
"INSRT TIBIAL LARGE 12.5MM KNEE POLYETHYLENE STABILIZE ROTATE",SUP-129416612,CDM,C1776,HCPCS,0278,RC,,,both,,,12447.60,3734.28,"PHCS [10601]",PHCS,,8713.32,70,,,,,0,1447.66,10580.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH DRYSEAL FLEX 33CM 12FR 4.7MM 4MM INTRO HYDROPHILIC",SUP-GDSF1233,CDM,C1894,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"PHCS [10601]",PHCS,,2632.35,70,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 8X40 80CM SL",SUP-48008004N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LEVOTHYROXINE 112 MCG TABLET",RX-10404,CDM,,,0637,RC,42292-0039-01,NDC,both,1,UN,6.27,1.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT SOLITAIRE 31MM 20MM 6MM 10MM SPACE 4-1 VASCULAR",SUP-SFR4-6-20-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,40761.00,12228.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"RONGEUR 6IN CURVE MINI 3MM RUSKIN 2 ACTION SURGICAL",SUP-31-0503,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.97,301.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND 3-0 SH 18IN BRAID 8 STRAND BLACK",SUP-M13T,CDM,S27200284,LOCAL,0272,RC,,,both,,,86.41,25.92,"KAISER [10500]",Kaiser,,57.89,67,,,,,0,10.05,73.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 11CMX20MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-8-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,991.44,68,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 167MM 12MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-112,CDM,C1776,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"PHCS [10601]",PHCS,,12264.21,70,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 60X16MM DARCO FOOT HEADLESS",SUP-DC001660,CDM,C1713,HCPCS,0278,RC,,,both,,,4629.90,1388.97,"CIGNA [10200]","Cigna Open Access",,2634.41,56.9,,1144.80,304.56,2275.09,66,538.46,3935.42,"percent of total billed charges",
"ROCKET IPC DRAINAGE KIT INCLUDES 2L BAG AND DRESSING PACK",SUP-R51401H,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM VARIAX TITANIUM DISTAL RADIUS T7 DRIVE",SUP-53-27614E,CDM,C1713,HCPCS,0278,RC,,,both,,,762.05,228.61,"CIGNA [10200]","Cigna Local Plus",,407.7,53.5,,3978.14,359.25,3978.14,24,88.63,647.74,"percent of total billed charges",
"SHUNT DENVER SINGLE VALVE 15.5",SUP-42-2025,CDM,S27200284,LOCAL,0272,RC,,,both,,,15525.00,4657.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10557,68,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 8MM ZERO-P STD LORDOTIC PEEK-OPTIMA ELGILOY",SUP-04.647.128S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"PHCS [10601]",PHCS,,8694,70,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRUT EXTERNAL FIXATION MAXFRAME MEDIUM POLYAXIAL FINE GROSS",SUP-03.313.879,CDM,C1713,HCPCS,0278,RC,,,both,,,7773.68,2332.1,"MULTIPLAN [10600]",Multiplan,,6607.63,85,,,,,0,904.08,6607.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 23MM 7MM STERILE",SUP-AR-1370P,CDM,C1713,HCPCS,0278,RC,,,both,,,1968.75,590.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,228.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",228.97,1673.44,"percent of total billed charges",
"CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC",324,MS-DRG,,,,,,,inpatient,,,199894.76,59968.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,50238.69,,,,,,,19545.84,91996.6,"case rate",
"SCREW NON-LOCKING 2.0MM X 12MM TI",SUP-VAN-20120-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"FIRST HEALTH [10303]","First Health",,777.6,80,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 5X4IN DURAGEN PLUS CRANIAL DURA BOVINE",SUP-DP1045,CDM,,,0278,RC,,,both,,,6737.85,2021.35,"PHCS [10601]",PHCS,,4716.5,70,,,,,0,6.74,5727.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 8X4IN RESORBABLE REINFORCE",SUP-F10254-0408G,CDM,C1781,HCPCS,0278,RC,,,both,,,1968.00,590.4,"MULTIPLAN [10600]",Multiplan,,1672.8,85,,,,,0,228.88,1672.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 30MM 120CM 6MM 6FR VASCULAR PERIPHERAL",SUP-S-60-030-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"BLUE CROSS [10001]","Blue Cross PPO",,3944.3,39.2,,,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 500MM 6MM EVEREST CONTOUR TITANIUM 2 HEXAGONAL",SUP-2901-B660500,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mopath Procedure Level 2",PX-309000094,CDM,81401,CPT,0310,RC,,,both,,,1016.50,304.95,"KAISER [10500]",Kaiser,,681.06,67,,,,,0,0.01,864.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DIVERGENCE-L 15X9.4X5MM ANTERIOR OBLIQUE LUMBAR",SUP-736525,CDM,S27800098,LOCAL,0278,RC,,,both,,,9177.00,2753.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6240.36,68,,,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR OSSEOTI E1 XLPE CUP 2 MOBILITY AA LINER",SUP-98B00100942,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9321.48,41.1,,6417.48,6417.48,6417.48,"1 through 10",2637.68,19278,"percent of total billed charges",
"STENT POLARIS 30CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006155235010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"FIRST HEALTH [10303]","First Health",,984.77,80,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X8MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7208,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"BLUE CROSS [10001]","Blue Cross HMO",,2704.8,39.2,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 20CM 3CM 6FR .035IN",SUP-M006192130190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,165.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PRESSUREWIRE AERIS VASCULAR 30-300 MMHG 175CM",SUP-C12059,CDM,C1769,HCPCS,0272,RC,,,both,,,4954.20,1486.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,587.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.17,4211.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOWRIST STAPLER 30 GREEN RELOAD",SUP-48630G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1453.28,435.98,"FIRST HEALTH [10303]","First Health",,1162.62,80,,,,,0,169.02,1235.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER ACCUMAX 550UM HOLMIUM FLEXIBLE POLISH OUTPUT TIP",SUP-M0068404032,CDM,S27200284,LOCAL,0272,RC,,,both,,,2976.66,893,"MULTIPLAN [10600]",Multiplan,,2530.16,85,,,,,0,346.19,2530.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHEATHLESS EAUCATH 100CM 7.5FR .081IN MP1 CURVE GUIDING",SUP-G6AL07-0-L125,CDM,C1887,HCPCS,0272,RC,,,both,,,1053.00,315.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,124.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175260190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]","Cigna Open Access",,720,,,,,,,147.16,1075.57,"percent of total billed charges",
"HC Flecainide",PX-301000067,CDM,80299,CPT,0301,RC,,,both,,,219.00,65.7,"BLUE CROSS [10001]","Blue Cross PPO",,23.81,,"Fee schedule rate ($23.81).",,,,0,0.01,186.15,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,inpatient,,,30890.30,9267.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,30890.3,,"Fee schedule rate ($35,626.59). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,30890.3,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 10MM .021IN AZUR DETACHABLE .018IN",SUP-45-481010,CDM,S27800098,LOCAL,0278,RC,,,both,,,5678.70,1703.61,"CIGNA [10200]","Cigna Local Plus",,3038.1,53.5,,,,,0,660.43,4826.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 10MM .021IN AZUR DETACHABLE .018IN",SUP-45-481010,CDM,S27800098,LOCAL,0278,RC,,,both,,,5678.70,1703.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3861.52,68,,,,,0,660.43,4826.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEO IMPLANTABLE PULSE GENERATOR","SUP-MODEL 2102",CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACK PHACOEMULSIFICATION .9MM INFINITI 30D ULTRASOUND",SUP-8065741081,CDM,S27200284,LOCAL,0272,RC,,,both,,,432.39,129.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER 6 1/8IN 12FR URETHRAL FEMALE",SUP-51-7112,CDM,C1887,HCPCS,0272,RC,,,both,,,266.22,79.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT CLAMP STEALTH SMALL FIBRA SIDE BITE STERILE LATEX FREE",SUP-A0G05,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"8MM X 22MM X 9MM 5 DEGREE POROUS COATED",SUP-P10822-509,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2515.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Belt Gait 72x2in Delrin Polyur",PX-HHE27100028,CDM,HHE27100028,LOCAL,0271,RC,,,outpatient,,,195.00,58.5,"MULTIPLAN [10600]",Multiplan,,165.75,85,,,,,0,22.68,165.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 5FR 2MM SPACE A CURVE ELECTROPHYSIOLOGY",SUP-F5QA002RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"KAISER [10500]",Kaiser,,607.82,67,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 75CM 8MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200084070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"AETNA [10100]","Aetna HMO/PPO",,3291.3,79.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTILUME 5CM 24FR BALLOON PACLITAXEL",SUP-OPTBDL7003B,CDM,C1726,HCPCS,0272,RC,,,both,,,14455.50,4336.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9829.74,68,,,,,0,1681.17,12287.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATH LAUNCHER 55CM 6FR IMA CURVE GUIDING NYLON PERIPH",SUP-LA6IMAK,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,48.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL PEERS 5.75IN TOWEL NONPENETRATE",SUP-17-5800,CDM,S27200284,LOCAL,0272,RC,,,both,,,163.39,49.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,19.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19,138.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 80MM 120CM 5MM LONG BILIARY NITINOL SELF",SUP-SC580L,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"AETNA [10100]","Aetna HMO/PPO",,5759.78,79.5,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBO ELITE 150CM 1.4MM ATHERECTOMY PERIPHERAL RAPID",SUP-414-159,CDM,C1885,HCPCS,0272,RC,,,both,,,18868.50,5660.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2235.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2194.41,16038.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE STAINLESS STEEL T15 2 PART CONNECT STARDRIVE",SUP-02.120.606,CDM,C1713,HCPCS,0278,RC,,,both,,,1192.32,357.7,"KAISER [10500]",Kaiser,,798.85,67,,,,,0,138.67,1013.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM EAR FARRIOR 1 6MM ROUND OBLIQUE END",SUP-61-0924,CDM,S27200284,LOCAL,0272,RC,,,both,,,416.90,125.07,"CIGNA [10200]",Cigna,,283.49,68,,,,,0,48.49,354.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE FLOPPY II VASCULAR STRAIGHT 190CM 2CM .014IN",SUP-22339H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23MMX9MM ELEVATE STD STERILE",SUP-7770923,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"PHCS [10601]",PHCS,,20160,70,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 60MM 80CM 9MM 6FR .035IN VASCULAR NITINOL",SUP-G43862,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Open Access",,2150.82,56.9,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Tmj Bilat Open Clsd",PX-320000021,CDM,70330,CPT,0320,RC,,,both,,,904.07,271.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,94.14,,"Fee schedule rate ($94.14).",,,,0,65.33,768.46,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL PEDIATRIC O2 RESVR BAG MASK LATEX FREE",SUP-540212000,CDM,S27000186,LOCAL,0270,RC,,,both,,,59.47,17.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.92,50.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER ENDOTRAC HOOK STERILE DISPOSABLE",SUP-3055-6,CDM,S27200284,LOCAL,0272,RC,,,both,,,209.50,62.85,"UHC [10700]","United Healthcare",,132.61,63.3,,,,,0,24.36,178.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 200CM 10MM .063IN 1.5MM ATHERECTOMY",SUP-DBP-CART-150SOL200,CDM,C1724,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM 20MM 15MM STD NECK S-ROM CERAMIC 135D",SUP-523194,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"CIGNA [10200]","Cigna Local Plus",,6127.14,31.5,,5372.07,4581.20,7242.98,23,2262.18,16533.56,"percent of total billed charges",
"SCR BONE 2.7MM 20MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0330,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"FIRST HEALTH [10303]","First Health",,758.16,80,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE-O SCREW 6.5X40MM TRACTION POLY",SUP-13116540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"MULTIPLAN [10600]",Multiplan,,8114.82,85,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HIWIRE VASCULAR TAPER 145CM 7CM .018IN STAINLESS STEEL",SUP-G00587,CDM,C1769,HCPCS,0272,RC,,,both,,,178.26,53.48,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,73.26,41.1,,,,,0,20.73,151.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT WALKING AIRCAST AIRSELECT SHORT MEDIUM FOOT ANKLE LOW",SUP-01ES-M,CDM,L4360,HCPCS,0274,RC,,,both,,,372.01,111.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,215.76,,,,,,,43.26,316.21,"fee schedule",
"SYSTEM SYNERGY 20MM 144CM 2.75MM CORONARY STENT EVEROLIMUS",SUP-H7493926120270,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]","Cigna Local Plus",,4614.38,53.5,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Pelvis W&WO Cntrst",PX-352000020,CDM,72194,CPT,0352,RC,,,both,,,3749.84,1124.95,"UHC [10700]","United Healthcare",,437.65,,,,,,,377.28,3187.36,"fee schedule",
"SHEARS ELECTROSURGICAL 14CM 5MM HARMONIC SCPL ACE TITANIUM",SUP-ACE14S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2048.86,614.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,842.08,41.1,,,,,0,238.28,1741.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 19MM 52MM SHOULDER SIMPLICITI",SUP-7122875,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"NOVANET [10819]",Novanet,,7514.25,75,,,,,0,1165.21,8516.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS ELECTROSURGICAL 14CM 5MM HARMONIC SCPL ACE TITANIUM",SUP-ACE14S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2048.86,614.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,940.43,45.9,,,,,0,238.28,1741.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL CERVICAL 7X14X12MM 7DEG LORDOTIC PEEK COHERE",SUP-4071427P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"FIRST HEALTH [10303]","First Health",,4968,80,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR ROSCH INFERIOR MESENTRIC CURVE",SUP-H787107333015,CDM,C1887,HCPCS,0272,RC,,,both,,,236.64,70.99,"UHC [10700]","United Healthcare",,149.79,63.3,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG SENSATRAC OPEN ABTHERA FOAM ABDOMINAL",SUP-M8275026/5,CDM,A6550,HCPCS,0272,RC,,,both,,,3588.00,1076.4,"KAISER [10500]",Kaiser,,2403.96,67,,,,,0,26.26,3049.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 206MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT SET 8",SUP-222.658,CDM,C1713,HCPCS,0278,RC,,,both,,,9194.39,2758.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2631.43,28.62,,,,,0,1069.31,7815.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 7X8CM OMEGA3 MARIGEN FISH SKIN STERILE LATEX FREE",SUP-50200N11B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,180.89,,,,,,,180.89,14726.25,"fee schedule",
"TIP SCISSORS ENDOCUT L16.5 MM LAPAROSCOPIC STERILE DISPOSABL",SUP-85-3142,CDM,S27200284,LOCAL,0272,RC,,,both,,,232.50,69.75,"FIRST HEALTH [10303]","First Health",,186,80,,,,,0,27.04,197.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX 30MM 80CM 8MM 6FR .035IN BILIARY CATH GWIRE",SUP-ZBM08030,CDM,C1874,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1163.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Shuntogram Nonvasc Shunt Si",PX-323000028,CDM,75809,CPT,0320,RC,,,both,,,668.30,200.49,"MULTIPLAN [10600]",Multiplan,,568.06,85,,,,,0,77.72,568.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL CERVICAL 7X14X12MM 7DEG LORDOTIC PEEK COHERE",SUP-4071427P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross HMO",,2434.32,39.2,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 4-0 9IN BRUNS BONE ANGLED TIP OVAL CUP SURGICAL",SUP-240139,CDM,S27100035,LOCAL,0271,RC,,,both,,,337.21,101.16,"CIGNA [10200]",Cigna,,229.3,68,,,,,0,39.22,286.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 6CM 7FR ZIMMON PIGTAIL CURVE PANCREATIC",SUP-G22042,CDM,C2625,HCPCS,0272,RC,,,both,,,1328.40,398.52,"CIGNA [10200]","Cigna Local Plus",,710.69,53.5,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM LCS COMPLETE STANDARD+ KNEE RIGHT DISTAL",SUP-129426050,CDM,C1776,HCPCS,0278,RC,,,both,,,5583.48,1675.04,"BLUE CROSS [10001]","Blue Cross HMO",,2188.72,39.2,,5311.50,4717.44,5388.59,31,649.36,4745.96,"percent of total billed charges",
"BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION",RX-9316,CDM,J0665,HCPCS,0636,RC,00409-3613-11,NDC,both,2,ML,30.99,9.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,21.07,68,,,,,0,0.35,26.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5.5IN 2.5 FREEFORM MINI",SUP-MCR092555,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"NOVANET [10819]",Novanet,,9919.39,75,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 4X250 135CM SL",SUP-48004025R,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"KAISER [10500]",Kaiser,,697.48,67,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK PHACOEMULSIFICATION .9MM INFINITI 30D ULTRASOUND",SUP-8065741081,CDM,S27200284,LOCAL,0272,RC,,,both,,,432.39,129.72,"CIGNA [10200]",Cigna,,294.03,68,,,,,0,50.29,367.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACING 110CM 5FR BALLOON FLOW-ASSISTED HEPARIN BIPOLAR",SUP-008556P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1498.50,449.55,"CIGNA [10200]",Cigna,,1018.98,68,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR ENDOSCOPIC L100MM OD5MM DILATING TIP OBTURATOR RADIOL",SUP-D5LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"MULTIPLAN [10600]",Multiplan,,133.11,85,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTEPLASE 100 MG/100ML IV (WET SOLR VIAL)",RX-4159002,CDM,J2997,HCPCS,0636,RC,50242-0085-27,NDC,both,1,UN,53118.96,15935.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,34527.32,65,,,,,0,6294.6,45151.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR 3MM J TAPER 180CM 7CM",SUP-M001465011,CDM,C1769,HCPCS,0272,RC,,,both,,,494.10,148.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,58.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PLASMABLADE X 4S LIGHT",SUP-PS200-041S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2167.50,650.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FLEXIMA 70CM 4FR URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002001,CDM,C1758,HCPCS,0272,RC,,,both,,,82.25,24.67,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-FLO RENEGADE FATHOM VASCULAR 105CM 20CM .016IN",SUP-M001184510,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR ACCEPTS .038IN GWIRE 7FR 20CM RADIOPAQUE",SUP-G00973,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CAP NON POROUS TM REV SHLDRSTD GLEND AND INST",SUP-98000965000,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5375.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,5275.37,38556,"percent of total billed charges",
"COIL EMBOLIZATION 6CM 2MM CONCERTO DETACHABLE HELIX",SUP-NV-2-6-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOXIFLOXACIN 0.5 % EYE DROPS",RX-35699,CDM,,,0250,RC,00781-7135-93,NDC,both,3,ML,876.88,263.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,596.28,68,,,,,0,101.98,745.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 18MM 135CM 6MM 3.6-3.3FR 6FR LOW",SUP-1011499-18,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"MULTIPLAN [10600]",Multiplan,,5355,85,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC 3D .75CM 16.2CU CM SPIRAL 4.45X6.13CM",SUP-U125,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"KAISER [10500]",Kaiser,,15470.57,67,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 100MM TITANIUM SHORT THREAD CANNULATED",SUP-04.353.700S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"CIGNA [10200]","Cigna Local Plus",,1315.78,53.5,,3978.14,359.25,3978.14,24,286.03,2090.49,"percent of total billed charges",
"COIL EMBOLIZATION 47CM 14MM AVENIR 18 COIL COMPLEX FRAME",SUP-18CFR-14047,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1549.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL 17X5MM MOBI-C 13MM CERVICAL TITANIUM COCRMO UHMWPE","SUP-MB 3375",CDM,S27800098,LOCAL,0278,RC,,,both,,,33075.00,9922.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13230,40,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 5MM TITANIUM T4 HAND SELF TAP VARIABLE ANGLE",SUP-04.130.205,CDM,C1713,HCPCS,0278,RC,,,both,,,925.34,277.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,107.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",107.62,786.54,"percent of total billed charges",
"HC Ncntc Ifr Spctrsc O/T Pad 1",PX-361000655,CDM,0640T,CPT,0361,RC,,,both,,,61.00,18.3,"CIGNA [10200]",Cigna,,41.48,68,,,,,0,7.09,51.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 13MM GEMINUS TITANIUM DISTAL CORTEX VOLAR",SUP-COLS-35130-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,180.82,28.62,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM PRESTIGE PLUS HELICAL ULTRA",SUP-PRES4510CPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL KOCHER-OCHSNER CURVE 8IN ARTERY 1X2 TEETH",SUP-BH647R,CDM,S27200284,LOCAL,0272,RC,,,both,,,224.72,67.42,"AETNA [10100]","Aetna HMO/PPO",,178.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.13,191.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 20MM LCP TITANIUM DISTAL VOLAR RADIUS LOCKING",SUP-04.210.120,CDM,C1713,HCPCS,0278,RC,,,both,,,1063.69,319.11,"CIGNA [10200]",Cigna,,723.31,68,,1831.33,1831.33,1831.33,16,123.71,904.14,"percent of total billed charges",
"STEM FEMORAL 142MM 11MM PRESS FIT FULL PROFILE TAPERLOC PPS",SUP-51-101110,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2814.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 31X8-11MM MAGNIFY-S 8D 25MM EXPAND STANDALONE",SUP-1126.0108,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"BLUE CROSS [10001]","Blue Cross PPO",,16793.28,39.2,,,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DRAGONFLY OPSTAR DIAGNOSTIC IMAGING STERILE LATEX FREE",SUP-1014651,CDM,S27200284,LOCAL,0272,RC,,,both,,,6472.20,1941.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4401.1,68,,,,,0,752.72,5501.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM GALAXY G3 XTRASOFT HELICAL",SUP-GLX120206,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1072.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE L-ASCR CORTICAL 11MM LORDOTIC",SUP-340641,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.6MM 5MM CERVICAL LATERAL MASS",SUP-7650505,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"PHCS [10601]",PHCS,,935.55,70,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 2CM 24FR RADIOPAQUE LOW PROFILE PROXIMAL ANTIREFLUX",SUP-0120-24-2.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"NOVANET [10819]",Novanet,,584.3,75,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TISSUE CLSR PRIMA DUPLOJECT TISSEEL PREFILL SYR FROZEN",SUP-1506079,CDM,S27200284,LOCAL,0272,RC,,,both,,,1280.04,384.01,"PHCS [10601]",PHCS,,896.03,70,,,,,0,148.87,1088.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 2MM GALAXY G3 XTRASOFT HELICAL",SUP-GLX120208,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"BLUE CROSS [10001]","Blue Cross PPO",,3548.7,39.2,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOPROSTHESIS STENT AORTOILIAC L59MM DIA8MM VIABAHN V",SUP-BXBL085902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"PHCS [10601]",PHCS,,13653.36,70,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC SMALL MEDIUM 2.5-3.5IN LEFT THUMB SPICA",SUP-340S/ML,CDM,S27000186,LOCAL,0270,RC,,,both,,,146.68,44,"AETNA [10100]","Aetna HMO/PPO",,116.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.06,124.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COALESCE 10X28X12MM STRAIGHT LORDOT",SUP-2000-00-101208,CDM,C1889,HCPCS,0278,RC,,,both,,,21420.00,6426,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6130.4,28.62,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MANTA 8FR CLSR DEPTH LOC",SUP-188F,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"MULTIPLAN [10600]",Multiplan,,258.83,85,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X12MM 10D XL PEEK-OPTIMA PLATE FUSION",SUP-7871250,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"CIGNA [10200]",Cigna,,13710.24,40,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE WATCHMAN FLX PRO 24MM CLSR LEFT ATRIAL APPENDAGE",SUP-M635WU60240,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet Myocardial Metabolic Eval",PX-404000008,CDM,78459,CPT,0404,RC,,,both,,,6429.00,1928.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2608,,"Per diem ($2,608). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,6.43,5464.65,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.135,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 30FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0165SI30,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.82,19.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.54,55.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE L 35MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 2X3",SUP-249.686,CDM,C1713,HCPCS,0278,RC,,,both,,,2305.80,691.74,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1058.36,45.9,,,,,0,268.16,1959.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Icd Gen Sngl Lead Sys",PX-480000033,CDM,33262,CPT,0481,RC,,,both,,,19976.15,5992.84,"AETNA [10100]","Aetna HMO/PPO",,15881.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2323.23,19976.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 100MM SPINAL LOCKING POST",SUP-8461100,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1636.49,68,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL INFANT 40- CM 2O T PIECE INLINE CTRL CIRCUIT",SUP-1050814,CDM,S27000186,LOCAL,0270,RC,,,both,,,204.73,61.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,24.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.81,174.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 10FR 30CM TRANSITIONLESS RADIOPAQUE DIL DRNG",SUP-G08316,CDM,C1892,HCPCS,0272,RC,,,both,,,526.42,157.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.22,447.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 24MM 144CM 2.25MM",SUP-H7493941224220,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2221.63,28.62,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG VARIABLE ANGLE LOCKING 1.8MM X 18MM",SUP-SPLS-18180-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"NOVANET [10819]",Novanet,,1069.2,75,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 5FR 24CM WITHOUT GWIRE POLARIS ULTRA",SUP-M0061921220,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"KAISER [10500]",Kaiser,,760.87,67,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 15IN 36FR VENOUS ADULT 3/8IN 1 STAGE RIGHT",SUP-67636,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.59,90.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,35.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.07,256.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 22F LARGE HIP PROXIMAL",SUP-550738,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1265.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS HIGHFLOW 110CM 7FR 145D PIGTAIL CURVE",SUP-527752S,CDM,C1887,HCPCS,0272,RC,,,both,,,137.11,41.13,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,56.35,41.1,,,,,0,15.95,116.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC INTERVERTEBRAL 16MM 6MM PRESTIGE LP CERVICAL SPINE",SUP-6972660,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,8601.07,8395.67,8601.07,"1 through 10",3297.11,24097.5,"percent of total billed charges",
"STEM HUMERAL 83MM 5MM COMPREHENSIVE POROUS MINI SHOULDER",SUP-113625,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"PHCS [10601]",PHCS,,8820,70,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DILATOR 4FR/.035",SUP-48-149,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.00,1.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.47,3.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH 20.5IN 12MM TNLR POLYMER VASCULAR RADIOPAQUE COLOR",SUP-9009-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,557.28,167.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,255.79,45.9,,,,,0,64.81,473.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X9-6.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-4809,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"BLUE CROSS [10001]","Blue Cross HMO",,5815.32,39.2,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HYDRA JAGWIRE DREAM TIP ENDOSCOPIC 260CM .035IN",SUP-M00556001,CDM,C1769,HCPCS,0272,RC,,,both,,,1422.36,426.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,584.59,41.1,,,,,0,165.42,1209.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE PROTECTION RIGID 8-13 MM NAIL STERILE",SUP-03.043.036S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1633.13,489.94,"UHC [10700]","United Healthcare",,1033.77,63.3,,,,,0,189.93,1388.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 11CM ROTATE SUT COLLAR KINK RESISTANT CANN",SUP-504608A,CDM,C1894,HCPCS,0272,RC,,,both,,,72.65,21.79,"AETNA [10100]","Aetna HMO/PPO",,57.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.45,61.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 27-48X10IN SOLID PANEL ELASTIC VELCRO CLSR",SUP-13950000,CDM,S27000186,LOCAL,0270,RC,,,both,,,103.53,31.06,"CIGNA [10200]",Cigna,,70.4,68,,,,,0,12.04,88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 90MM TITANIUM FULL THREAD LOCK STERILE T2 NAIL",SUP-1896-5090S,CDM,C1713,HCPCS,0278,RC,,,both,,,1279.15,383.74,"NOVANET [10819]",Novanet,,959.36,75,,,,,0,148.77,1087.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS LACTATED RINGERS 1L VIAFLEX LATEX FREE",SUP-2B2324X,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"NOVANET [10819]",Novanet,,60.75,75,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 1 CT-1 6IN CLSR ABSORBABLE",SUP-SXPP1A420,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,163.4,68,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 14MM PERSONA 10-12 G-H KNEE RIGHT TIBIA",SUP-42522401014,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Local Plus",,5765.38,53.5,,5372.07,4581.20,7242.98,23,1253.3,9159.96,"percent of total billed charges",
"COMPONENT FEM POR LEFT SZ 10.5",SUP-427-01-105,CDM,C1776,HCPCS,0278,RC,,,both,,,32703.43,9811.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3803.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3803.41,27797.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT SCROTAL WHITE BAUER AND BLACK XL COTTON SUSPENSORY LEG",SUP-201352,CDM,S27000186,LOCAL,0270,RC,,,both,,,127.48,38.24,"CIGNA [10200]","Cigna Open Access",,72.54,56.9,,,,,0,14.83,108.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN APLIGRAF HUMAN FIBROBLAST BOVINE CLLGN MATRIX",SUP-APLIGRAF-COM,CDM,Q4101,HCPCS,0636,RC,,,both,,,28192.50,8457.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,247.92,,,,,,,81.28,23963.63,"fee schedule",
"SYSTEM IFUSE IMPL SYSTEM TRIANGLE 30MM 7MM SPINAL FIXATION",SUP-7030-90,CDM,C1713,HCPCS,0278,RC,,,both,,,10080.00,3024,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2884.9,28.62,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X6MM ENDOSKELETON TCS 6D 12MM SMALL TITANIUM",SUP-5346-1206-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,23310.00,6993,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2762.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 54MM 32MM MARATHON HIP",SUP-121932054,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"CIGNA [10200]","Cigna Open Access",,4116.52,56.9,,5302.19,4377.88,6578.61,27,841.39,6149.45,"percent of total billed charges",
"GWIRE HI-TORQUE PILOT 150 VASCULAR STRAIGHT 190CM 3CM .014IN",SUP-1010481-H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 266MM 16MM TFN-ADVANCED CANNULATED LARGE QUICK",SUP-03.037.002,CDM,S27200284,LOCAL,0272,RC,,,both,,,4358.59,1307.58,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1791.38,41.1,,,,,0,506.9,3704.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Assay of Transcortin",PX-301000700,CDM,84449,CPT,0301,RC,,,both,,,170.00,51,"CIGNA [10200]",Cigna,,39.6,,,,,,,0.01,144.5,"fee schedule",
"INSRT HUMERAL 39MM UNIVERS REVERS +3MM MEDIUM SHOULDER",SUP-AR-9503M-03C,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,341.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE 5CM",SUP-7509145,CDM,C1713,HCPCS,0278,RC,,,both,,,13282.50,3984.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3801.45,28.62,,,,,0,1544.75,11290.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fluoro Guide Plc Cvad",PX-320000173,CDM,77001,CPT,0320,RC,,,both,,,1546.93,464.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,179.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,179.91,1314.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,90707,HCPCS,0636,RC,00006-4681-01,NDC,both,1,UN,589.21,176.76,"NOVANET [10819]",Novanet,,441.91,75,,,,,0,11.97,500.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 235MM 17MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-317,CDM,C1776,HCPCS,0278,RC,,,both,,,18758.25,5627.47,"MULTIPLAN [10600]",Multiplan,,15944.51,85,,,,,0,2181.58,15944.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 30+ MM 14MM PERSONA TAPER KNEE TIBIA",SUP-42557000114,CDM,C1776,HCPCS,0278,RC,,,both,,,9648.96,2894.69,"FIRST HEALTH [10303]","First Health",,7719.17,80,,,,,0,1122.17,8201.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 70CM 6MM GORE PROPATEN VASCULAR GRAFT THIN",SUP-HT066070A,CDM,C1768,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 6MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBH061502,CDM,C1874,HCPCS,0278,RC,,,both,,,23102.10,6930.63,"CIGNA [10200]","Cigna Local Plus",,7277.16,31.5,,,,,0,2686.77,19636.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 75CM 2CM 10MM BALLOON DILATATION PERIPHERAL",SUP-CQ75102,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 18CM 23MM 12MM 19-21MM 10-11MM GORE",SUP-RLT231218,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"PHCS [10601]",PHCS,,43890,70,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 52MM CATHCART BALL HIP FEMORAL ORTHOCHROME",SUP-136352000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,1466.08,39.2,,3949.44,3949.44,3949.44,"1 through 10",434.96,3179,"percent of total billed charges",
"TRAY TIBIAL INBONE 5 STD ANKLE LEFT",SUP-200252905,CDM,C1776,HCPCS,0278,RC,,,both,,,11847.30,3554.19,"MULTIPLAN [10600]",Multiplan,,10070.21,85,,,,,0,1377.84,10070.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENT BUR 6.0MM FLUTED TS SHORT ANSPACH",SUP-SA-FB6,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,791.78,45.9,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 60MM STAINLESS STEEL T15 METAPHYSEAL SELF TAP",SUP-02.127.160,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"BLUE CROSS [10001]","Blue Cross HMO",,444.02,39.2,,957.42,156.86,7483.26,51,131.73,962.8,"percent of total billed charges",
"SCR BONE 3.5MM 60MM STAINLESS STEEL T15 METAPHYSEAL SELF TAP",SUP-02.127.160,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"FIRST HEALTH [10303]","First Health",,906.16,80,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +10 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1000,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER TUMARK BREAST BIOPSY VISION BREVERA PETITE STERILE",SUP-TUMARK-BREV-P-V-02,CDM,A4648,HCPCS,0278,RC,,,both,,,942.84,282.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,432.76,45.9,,,,,0,109.65,801.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH AORTIC VASCULAR 4.0MM",SUP-DP-40K,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"FIRST HEALTH [10303]","First Health",,453.6,80,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 10MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158124110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"MULTIPLAN [10600]",Multiplan,,9498.37,85,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10MM 90MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704090,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT ISP MRI AIRGUARD",SUP-1808060,CDM,C1788,HCPCS,0278,RC,,,both,,,1905.00,571.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1295.4,68,,,,,0,221.55,1619.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PARALLEL FLEXOR 45CM 12FR ENDOSCOPIC HYDROPHILIC",SUP-G56436,CDM,C1894,HCPCS,0272,RC,,,both,,,1396.44,418.93,"MULTIPLAN [10600]",Multiplan,,1186.97,85,,,,,0,162.41,1186.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 2.5IN ANKLE STERILE",SUP-351-90-22,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"NOVANET [10819]",Novanet,,637.88,75,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Stnt Ea Addl Br Maj Cor",PX-481000077,CDM,92929,CPT,0481,RC,,,both,,,26800.00,8040,"AETNA [10100]","Aetna HMO/PPO",,21306,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3116.84,25681,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Eus Fna/Bx",PX-750000031,CDM,43242,CPT,0750,RC,,,both,,,5373.23,1611.97,"CIGNA [10200]","Cigna Local Plus",,2587,,"Case rate ($2,587). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,624.91,5373.23,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"8MM TI MULTILOC PROX HUMERAL NAIL/LEFT/CANN/160MM-STER",SUP-04.016.035S,CDM,C1713,HCPCS,0278,RC,,,both,,,10722.60,3216.78,"FIRST HEALTH [10303]","First Health",,8578.08,80,,,,,0,1247.04,9114.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOSE 12FT NEONATE SLIP LUER LIGHT BLUE BLOOD PRESSURE LATEX",SUP-107368,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"KAISER [10500]",Kaiser,,192.36,67,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Ather Cmplx Ea Add",PX-361000715,CDM,37274,CPT,0361,RC,,,both,,,10249.92,3074.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1249,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,10.25,8712.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTICROSS 135CM 1.6CM 12MM 30 MHZ ULTRASOUND PERIPHERAL",SUP-H7493932800180,CDM,C1753,HCPCS,0272,RC,,,both,,,10281.00,3084.3,"KAISER [10500]",Kaiser,,6888.27,67,,,,,0,1195.68,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP 1CC 2-4MM ALLOGRAFT GRANULE",SUP-12700201,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,957.42,156.86,7483.26,51,348.9,2550,"percent of total billed charges",
"SHELL ACETABULAR 54MM HIP 5 SCR HOLE CLUSTER TRITANIUM",SUP-702-04-54E,CDM,C1776,HCPCS,0278,RC,,,both,,,12551.10,3765.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1487.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1459.69,10668.44,"percent of total billed charges",
"BRA COMPRESSION 30-32 FABRIC FIT A AND B ADJUSTABLE SHOULDER",SUP-700,CDM,S27000186,LOCAL,0270,RC,,,both,,,328.86,98.66,"PHCS [10601]",PHCS,,230.2,70,,,,,0,38.25,279.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 20MM 3.8-3.4FR 6MM TAPER",SUP-H74939031602010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ANESTHESIA 16GA 25CM MALLEABLE SHAFT INJECTION RADIESSE",SUP-9010M0,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"FIRST HEALTH [10303]","First Health",,421.2,80,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 16MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532-G-516,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"PHCS [10601]",PHCS,,6095.33,70,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 2-0 GS-21 .5 CIRCLE 9IN TAPER POINT",SUP-VLOCL0345,CDM,S27200284,LOCAL,0272,RC,,,both,,,405.94,121.78,"MULTIPLAN [10600]",Multiplan,,345.05,85,,,,,0,47.21,345.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM TRIATHLON 2 LEFT MEDIAL RIGHT LATERAL",SUP-5612-A-211,CDM,C1776,HCPCS,0278,RC,,,both,,,9878.04,2963.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2827.1,28.62,,,,,0,1148.82,8396.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 7X7CM AMNIOBAND ALLOGRAFT MEMB",SUP-WC3077,CDM,Q4151,HCPCS,0636,RC,,,both,,,57330.00,17199,"CIGNA [10200]",Cigna,,362.66,,,,,,,362.66,48730.5,"fee schedule",
"SHELL ACETABULAR 48MM HIP LIMIT HOLE MODULAR TITANIUM POROUS",SUP-PT-116048,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4684.14,45.9,,,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
FACEPLATE,SUP-06001-I,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SELUTION DEB 2.50X40",SUP-SCA14U-250040D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HYDRALAZINE 25 MG TABLET",RX-3700,CDM,,,0637,RC,00904-7448-61,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT HUMERAL H+12MM 36MM AEQUALIS SHOULDER RETENTIVE",SUP-DWD972,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"AETNA [10100]","Aetna HMO/PPO",,7177.26,79.5,,10981.53,8986.79,12413.38,12,1049.96,7673.8,"percent of total billed charges",
"MICROCATHETER CEREBROVASCULAR 150CM 2.9-2.7FR .027IN",SUP-M003XT2750820,CDM,S27200284,LOCAL,0272,RC,,,both,,,8474.58,2542.37,"KAISER [10500]",Kaiser,,5677.97,67,,,,,0,985.59,7203.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 24CM 7FR 2 PIGTAIL CURVE",SUP-M0061921420,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,325.01,28.62,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 73MM 37.7MM 29MM DURAN ANCORE 31.7MM 2",SUP-620BG29,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Local Plus",,4129.65,31.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 5.5MM TSRH-2D CONTOUR PEDICLE TITANIUM",SUP-8370065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 7/8IN BLADE 15FT 3/8IN PLUMEPEN",SUP-PLPUL2520,CDM,S27200284,LOCAL,0272,RC,,,both,,,277.08,83.12,"CIGNA [10200]","Cigna Open Access",,157.66,56.9,,,,,0,32.22,235.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX16MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183546,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"MULTIPLAN [10600]",Multiplan,,11009.78,85,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hdr Rdncl Skn Surf Brachytx > 2 Chnl",PX-342000017,CDM,77768,CPT,0333,RC,,,both,,,6814.10,2044.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,807.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,408.8,5791.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEADGEAR CPAP SMALL INFANT FLOW LATEX FREE DISPOSABLE LIGHT",SUP-139315,CDM,S27000186,LOCAL,0270,RC,,,both,,,116.53,34.96,"CIGNA [10200]","Cigna Open Access",,66.31,56.9,,,,,0,13.55,99.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULE RESUSCITATION ORANGE BROSELOW INTRAOSSEOUS PEDIATRIC",SUP-7700OIO,CDM,S27200284,LOCAL,0272,RC,,,both,,,518.40,155.52,"MULTIPLAN [10600]",Multiplan,,440.64,85,,,,,0,60.29,440.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT VENTRICULOSTOMY EUROPEAN VERSION",SUP-46154,CDM,S27200284,LOCAL,0272,RC,,,both,,,2803.43,841.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,332.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,326.04,2382.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INLAY INTERVERTEBRAL DISC PRODISC-L 10MM MEDIUM SPINE",SUP-PDL-M-PT10S,CDM,C1889,HCPCS,0278,RC,,,both,,,10022.25,3006.67,"NOVANET [10819]",Novanet,,7516.69,75,,,,,0,1165.59,8518.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUTTLE ACCU-PASS 1 MONOFILAMENT SUT STERILE",SUP-72201361,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOLDER 7.25IN RYDER NDL TUNGSTEN CARBIDE DUST STRAIGHT RING",SUP-55-2662,CDM,S27200284,LOCAL,0272,RC,,,both,,,2070.23,621.07,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CYCLOBENZAPRINE 10 MG TABLET, IMMEDIATE RELEASE",RX-2017,CDM,,,0637,RC,00904-7401-61,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RESPONSE 65CM 7FR 2-8-2MM SPACING CSL CURVE",SUP-401130,CDM,C1730,HCPCS,0272,RC,,,both,,,2677.50,803.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONCIERGE 100CM 8FR SBS4.5 MOD CURVE GUIDING STAINLESS",SUP-CGC8100SBS45SH-M,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 80MM 3.5MM BALLOON DILATATION DURALYN",SUP-48003508S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPECLM EAR 7.5MM ROUND EBONY FINISH STAINLESS STEEL",SUP-130675,CDM,S27200284,LOCAL,0272,RC,,,both,,,535.98,160.79,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,246.01,45.9,,,,,0,62.33,455.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMUR SHAFT ALLOGRAFT 100MM",SUP-800141,CDM,S27800098,LOCAL,0278,RC,,,both,,,5940.90,1782.27,"BLUE CROSS [10001]","Blue Cross PPO",,2328.83,39.2,,,,,0,690.93,5049.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM CD HORIZON LEGACY TITANIUM SPINAL",SUP-75447535,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"BLUE CROSS [10001]","Blue Cross HMO",,1898.3,39.2,,957.42,156.86,7483.26,51,563.19,4116.21,"percent of total billed charges",
"DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION",RX-27103,CDM,,,0250,RC,66794-0233-02,NDC,both,2,ML,31.71,9.51,"CIGNA [10200]","Cigna Local Plus",,16.96,53.5,,,,,0,3.69,26.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM ORTHOLOC LONG CORTEX ANKLE FOOT 3DI",SUP-58803516,CDM,C1713,HCPCS,0278,RC,,,both,,,1506.60,451.98,"CIGNA [10200]","Cigna Open Access",,857.26,56.9,,1144.80,304.56,2275.09,66,175.22,1280.61,"percent of total billed charges",
"AEQUALIS PERFORM GLENOID (PEGGED)- L40",SUP-DWE321,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"KAISER [10500]",Kaiser,,6241.72,67,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL ALL KNEE ROTATING HINGE",SUP-6481-2-140,CDM,S27000186,LOCAL,0270,RC,,,both,,,2966.25,889.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,351.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.97,2521.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 4MM LORDOSIS TITANIUM",SUP-102064060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY 290CC DIA10.8CM P4.7CM SALINE SMOOTH ROUND HIG",SUP-351-3290SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,371.79,45.9,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 135CM 8MM 11MM 8FR .035IN",SUP-BXA087902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"FIRST HEALTH [10303]","First Health",,17125.92,80,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AFTERCARE WITHOUT CC/MCC",950,MS-DRG,,,,,,,inpatient,,,49164.70,14749.41,"AETNA [10100]","Aetna HMO/PPO",,11810.18,,"Fee schedule rate ($11,810.18). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,2462,38264.95,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 18X8MM COLONIAL 7D LORDOTIC 15MM 2XL TITANIUM",SUP-365.068CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 128MM 12MM PRESS FIT REUNION SHOULDER STERILE",SUP-5569-P-2012,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5040,40,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FLEXSEGMENT PALMAZ GENESIS AVIATOR 11MM 135CM 5MM 4-6",SUP-H739PG1250BAX3,CDM,C1876,HCPCS,0278,RC,,,both,,,6554.03,1966.21,"CIGNA [10200]",Cigna,,4456.74,68,,,,,0,762.23,5570.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 140MM 120CM 10MM BILIARY VENA CAVA OTW DELIVERY",SUP-G57439,CDM,C1876,HCPCS,0278,RC,,,both,,,13109.93,3932.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3752.06,28.62,,,,,0,1524.68,11143.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER 180CM 10FR GWIRE STENT BILIARY PANCREATIC STERILE",SUP-G22205,CDM,S27200284,LOCAL,0272,RC,,,both,,,1239.30,371.79,"PHCS [10601]",PHCS,,867.51,70,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 560CC",SUP-RSZ-MPX-560S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"FIRST HEALTH [10303]","First Health",,1296,80,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X60 80CM SL",SUP-48003006N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"NOVANET [10819]",Novanet,,644.26,75,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE? NC PLUS BALLOON NON-COMPLIANT 2.0 MM X 18 MM",SUP-220-183-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO VASCULAR 300CM .014IN HYDROPHILIC PRESHAPE",SUP-SSFT300PRE,CDM,C1769,HCPCS,0272,RC,,,both,,,5686.57,1705.97,"NOVANET [10819]",Novanet,,4264.93,75,,,,,0,661.35,4833.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPIXL 4X10 CM",SUP-XL-5410,CDM,Q4186,HCPCS,0636,RC,,,both,,,22018.50,6605.55,"AETNA [10100]","Aetna HMO/PPO",,17504.71,79.5,,,,,0,406.44,18715.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X17-14.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-4817,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1757.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 340MM FEMORAL RFN-ADVANCED INTRAMEDULLARY 5D BEND",SUP-04.233.234S,CDM,C1713,HCPCS,0278,RC,,,both,,,11445.44,3433.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1331.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1331.1,9728.62,"percent of total billed charges",
"CATH APD 25CM 6FR LOOP DRNG FLEXIMA METAL HYDROPHILIC",SUP-M001271330,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PLASTIBELL 1.4CM CIRCUMCISION PLASTIC PEDIATRIC",SUP-9234,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.51,30.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46.13,45.9,,,,,0,11.69,85.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL PEDIATRIC 1.5MM 5.2MM 9 7/8INX3MM BACKBITE",SUP-3712013,CDM,S27200284,LOCAL,0272,RC,,,both,,,8618.38,2585.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5860.5,68,,,,,0,1002.32,7325.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 38MM 2.5MM CORONARY STENT EVEROLIMUS",SUP-1550250-38,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 2CM 8MM BALLOON DILATATION",SUP-DR13582,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 3CM 7FR .035IN PIGTAIL CURVE STRAIGHT LOW PROFILE",SUP-M006145374050,CDM,C2617,HCPCS,0278,RC,,,both,,,940.57,282.17,"FIRST HEALTH [10303]","First Health",,752.46,80,,,,,0,109.39,799.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 8MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBJR080502A,CDM,C1874,HCPCS,0278,RC,,,both,,,19895.40,5968.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2313.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2313.84,16911.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC",583,MS-DRG,,,,,,,inpatient,,,208387.21,62516.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32723.94,,"Fee schedule rate ($32,723.94). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,10696.56,50345.58,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E KNEE FEMUR TIBIAL PATELLA",SUP-98000200128,CDM,C1776,HCPCS,0278,RC,,,both,,,19530.00,5859,"NOVANET [10819]",Novanet,,14647.5,75,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HYDRUS MICRO OPHTHALMIC STERILE",SUP-F00022,CDM,C1783,HCPCS,0278,RC,,,both,,,14498.28,4349.48,"KAISER [10500]",Kaiser,,9713.85,67,,,,,0,1686.15,12323.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SYR TWIN PACK GEL PREFILL PREDYE 23GA ORISE INTERJECT 10",SUP-M00519211,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"CIGNA [10200]","Cigna Local Plus",,845.03,53.5,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH CPS DIRECT SL II FIX CURVE",SUP-DS2C022,CDM,C1893,HCPCS,0272,RC,,,both,,,3339.00,1001.7,"PHCS [10601]",PHCS,,2337.3,70,,,,,0,388.33,2838.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP LUBRICATH STATLOCK 16FR URINE",SUP-A902916,CDM,S27200284,LOCAL,0272,RC,,,both,,,155.90,46.77,"AETNA [10100]","Aetna HMO/PPO",,123.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.13,132.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,inpatient,,,89493.55,26848.06,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,8816.3,,"Case rate ($8,239.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,650.96, add-ons for qualifying new technology services are included. If operating cost exceeds $40,690.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,960.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $7,661.08. The transfer operating threshold is the transfer adjustment factor * $7,650.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $578.45. The transfer capital threshold is the transfer adjustment factor * $578.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,38781.05,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.75/35",SUP-404668,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP MEDIUM INTERNAL HORIZON TITANIUM ENDOSCOPIC LIGATING",SUP-002200,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.57,20.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.86,57.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC",462,MS-DRG,,,,,,,inpatient,,,233760.96,70128.29,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,35475.3,,"Case rate ($16,500.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $15,321.50, add-ons for qualifying new technology services are included. If operating cost exceeds $48,361.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,540.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $15,341.76. The transfer operating threshold is the transfer adjustment factor * $15,321.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.38. The transfer capital threshold is the transfer adjustment factor * $1,158.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 215%.",,,,0,7561,77661.36,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM PERSONA 7 7+ KNEE DISTAL STERILE LATEX FREE",SUP-42556606205,CDM,C1776,HCPCS,0278,RC,,,both,,,7236.72,2171.02,"NOVANET [10819]",Novanet,,5427.54,75,,,,,0,841.63,6151.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.50 X 23 RX US",SUP-1804350-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM VUEPOINT II SPINE FAVORED ANGLE",SUP-8975516,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"NOVANET [10819]",Novanet,,3150,75,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 11MM 8.2MM 95MM TALON HIP DISTALFIX TECHNOLOGY LAG",SUP-SLN-011-095,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3378.24,68,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL LARGE KNEE RIGHT CEMENT LCS COMPLETE COCR",SUP-129401060,CDM,C1776,HCPCS,0278,RC,,,both,,,20635.65,6190.69,"BLUE CROSS [10001]","Blue Cross PPO",,8089.17,39.2,,3949.44,3949.44,3949.44,"1 through 10",2399.93,17540.3,"percent of total billed charges",
"SCR BONE 2.3MM 20MM STAINLESS STEEL CORTEX FIX ANGLE",SUP-TRX2.3-20,CDM,C1713,HCPCS,0278,RC,,,both,,,729.00,218.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,495.72,68,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMIPRAMINE 10 MG TABLET",RX-3860,CDM,,,0637,RC,69584-0425-10,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC INJECTOR STERILE LATEX FREE DISPOSABLE",SUP-NM-610U-1826,CDM,S27200284,LOCAL,0272,RC,,,both,,,342.17,102.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,40.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.79,290.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X5MM CERVICAL ANATOMIC",SUP-6940541,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR PRO-TOE VO STD STERILE DISPOSABLE",SUP-45710500,CDM,S27200284,LOCAL,0272,RC,,,both,,,1077.30,323.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,494.48,45.9,,,,,0,125.29,915.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WISE CRT SYSTEM (INCLUDES MODEL 1000, MODEL 2000, MODEL 3100",SUP-4131SYSUS,CDM,S62400003,LOCAL,0624,RC,,,both,,,142500.00,42750,"FIRST HEALTH [10303]","First Health",,114000,80,,,,,0,16572.75,121125,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.5MM SURGICAL STERILE DISPOSABLE",SUP-703704,CDM,S27200284,LOCAL,0272,RC,,,both,,,993.38,298.01,"MULTIPLAN [10600]",Multiplan,,844.37,85,,,,,0,115.53,844.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ALIMAXX-B 60MM 192CM 8MM BILIARY NITINOL RADIOPAQUE",SUP-70129-205,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"KAISER [10500]",Kaiser,,5085.3,67,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 38MM 43.2MM 36.8MM MITRAL FLEXIBLE HOLDER",SUP-4450M38,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3258.39,28.62,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA POWERTRAC 142CM 12MM 5MM BALLOON DILATATION",SUP-NCEUP5012X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"NOVANET [10819]",Novanet,,394.88,75,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X6MM COALITION MIS 7D 14MM TITANIUM STERILE",SUP-1136.4676,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 15X6MM THK.4MM SAGITTAL FINE TEETH",SUP-532.041S,CDM,S27200284,LOCAL,0272,RC,,,both,,,605.07,181.52,"NOVANET [10819]",Novanet,,453.8,75,,,,,0,70.37,514.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADAPTA  SR  IS-1  213",SUP-ADSR01,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"UHC [10700]","United Healthcare",,15723.72,63.3,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Icd Elect Thoracotomy",PX-360000025,CDM,33243,CPT,0361,RC,,,both,,,10760.85,3228.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1275.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1251.49,10760.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENROUTE ENFLATE TRANSCAROTID RX BALLOON DILATATION CATHETER",SUP-SR-5025-BC,CDM,C1725,HCPCS,0272,RC,,,both,,,2625.00,787.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,305.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 26MM LCP STAINLESS STEEL DISTAL CORTICAL",SUP-201.776,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,170.52,39.2,,957.42,570.23,957.42,28,50.59,369.75,"percent of total billed charges",
"ON-X AORTIC PROSTHETIC HEART VALVE 27/29MM WITH CONFORM-XSEW",SUP-ONXACE-27/29,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"AETNA [10100]","Aetna HMO/PPO",,30051,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GRIFFITHS-BROWN 110MM TISSUE DELICATE TEETH 5",SUP-N5423,CDM,S27200284,LOCAL,0272,RC,,,both,,,1923.53,577.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,227.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,223.71,1635,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 200MM 6MM .014IN BALLOON DILATATION",SUP-AB14W060200150,CDM,C1725,HCPCS,0272,RC,,,both,,,1638.75,491.62,"KAISER [10500]",Kaiser,,1097.96,67,,,,,0,190.59,1392.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIRATION DIA1.9MM NOTCHED STANDARD SHORT AND TUBESET",SUP-130-35-1499,CDM,S27200284,LOCAL,0272,RC,,,both,,,5673.19,1701.96,"AETNA [10100]","Aetna HMO/PPO",,4510.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,659.79,4822.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT HUMERAL 42MM AEQUALIS SHOULDER METAPHYSIS REVERSE",SUP-DWB961,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1172.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Neck/Thorax Lesion",PX-361000036,CDM,21501,CPT,0361,RC,,,both,,,6589.00,1976.7,"KAISER [10500]",Kaiser,,4414.63,67,,,,,0,766.3,6589,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH INTRDCR FR11 LONG - EACH",SUP-668005-001,CDM,C1892,HCPCS,0272,RC,,,both,,,1174.50,352.35,"KAISER [10500]",Kaiser,,786.92,67,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 3FR 20CM PROVENA BIOPATCH 1 LUMEN MIDLINE MAXIMUM",SUP-S4153108BDP,CDM,C1751,HCPCS,0272,RC,,,both,,,1388.02,416.41,"UHC [10700]","United Healthcare",,878.62,63.3,,,,,0,161.43,1179.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER BIPOLAR AQUAMAN EDIDURAL VIEN",SUP-23-121-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXAMETHASONE 4 MG TABLET",RX-2327,CDM,J8540,HCPCS,0637,RC,00054-8175-25,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRACE ORTHOPEDIC 12.75IN COTTON FOAM XL SHOULDER HUMERAL",SUP-79-97958,CDM,S27000186,LOCAL,0270,RC,,,both,,,512.49,153.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL 3-0 CT-1 36IN BRAID COATED UNDYED ABSORBABLE",SUP-J944H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 11.75CM NATRELLE INSPIRA P3.1CM LOW PLUS PROFILE",SUP-MSZ-LP235,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AETNA [10100]","Aetna HMO/PPO",,125.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 9.5CM MEMORYGEL P2.9CM MODERATE PLUS PROFILE",SUP-RSZ-1501,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"FIRST HEALTH [10303]","First Health",,1296,80,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 65MM KNEE LEFT CRUCIATE RETAINING CEMENTED",SUP-183028,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"PHCS [10601]",PHCS,,14059.96,70,,,,,0,2335.96,17072.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 72MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.572,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,129.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,127.51,931.96,"percent of total billed charges",
"ENV TISSUE 6.9X6.5CM CANGAROO MEDIUM SOFT SUPPLE POCKET NO",SUP-CMCV-010-MED,CDM,S27800098,LOCAL,0278,RC,,,both,,,31027.50,9308.25,"BLUE CROSS [10001]","Blue Cross HMO",,12162.78,39.2,,,,,0,3608.5,26373.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR 10CM 5FR .035IN BLADDER LOOP LOW",SUP-M006155211090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"NOVANET [10819]",Novanet,,1022.06,75,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 3.5MM PRECUT",SUP-3603760,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"STENT ENDOMAXX 90CM 100CM 23MM 24FR ESOPHAGEAL SILICONE",SUP-MAXX-2310,CDM,C1874,HCPCS,0278,RC,,,both,,,17640.00,5292,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7250.04,41.1,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 28.5MM 12MM 24-26MM 10-11MM GORE",SUP-RLT281212,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]","Cigna Open Access",,21004.5,33.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +26 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.260,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 6MM BALLOON",SUP-U357568,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 59CM ENDOTAK RELIANCE G 4 SITE ENDOCARDIAL GORE",SUP-295,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6072,40,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS 135CM 60MM 6MM .035IN BALLOON DILATATION",SUP-AB35W06060135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,78.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCP ELLIPSYS S 21 GAX7 CM ECHO-TIP MICROPUNCTURE NDL",SUP-K21-00022,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"PHCS [10601]",PHCS,,447.93,70,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RAMROD CLASSIC 28CM 6FR KIDNEY BLADDER CURL URETERAL",SUP-5606028,CDM,C2617,HCPCS,0278,RC,,,both,,,910.00,273,"CIGNA [10200]","Cigna Local Plus",,486.85,,,,,,,105.83,773.5,"percent of total billed charges",
"KIT INTRO 14FR IMPELLA LONG STERILE LATEX DISPOSABLE",SUP-0052-0039,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"CIGNA [10200]",Cigna,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM 20.4MM MASTERS 85D 3.09SQ CM STD RING",SUP-25AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AETNA [10100]","Aetna HMO/PPO",,23149.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE HEMOSTATIC ERASER STRAIGHT TAPER 20-23GA BIPOLAR FINE",SUP-221265,CDM,S27200284,LOCAL,0272,RC,,,both,,,589.94,176.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,69.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.61,501.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 28.5MM 12MM 24-26MM 10-11MM GORE",SUP-RLT281212,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25769.7,41.1,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +19.5 DIOPTER +3 CYL BICONVEX 13MM 6MM",SUP-SN6AD1U195,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA [10200]","Cigna Local Plus",,398.58,53.5,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP FEM N/POROUS SIZE 4 LEFT",SUP-2153-0-0004,CDM,C1776,HCPCS,0278,RC,,,both,,,8280.00,2484,"AMERIGROUP MEDICAID [20100]",Amerigroup,,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYGNUS MATRIX (4 X 4) 16 SQ CM",SUP-585-010,CDM,Q4199,HCPCS,0636,RC,,,both,,,9832.50,2949.75,"NOVANET [10819]",Novanet,,7374.38,75,,,,,0,298.85,8357.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 6 STRAIGHT OVAL 9IN BRUNS SPINE SURGICAL",SUP-29-5356,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.25,71.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.82,203.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 40CM 140CM 2.75MM CORONARY STERILE",SUP-453975,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"CATH SUPERTORQUE 100CM 6FR .051IN .042IN JUDKINS LEFT",SUP-532624,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA [10200]","Cigna Open Access",,47.03,56.9,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 6MM 36MM STAINLESS STEEL 2.5MM FULL THREAD",SUP-206.036,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,125.59,45.9,,,,,0,31.82,232.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH DRUG DELIVERY 80 MINUTE IONTOPATCH WIRELESS SELF",SUP-A939650,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.05,14.71,"AETNA [10100]","Aetna HMO/PPO",,38.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.7,41.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 11GA 15CM 1 PORT ASPIRATION WITHOUT SIDEHOLE BONE",SUP-710.150.99S,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.80,262.44,"NOVANET [10819]",Novanet,,656.1,75,,,,,0,101.74,743.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Submuc Inj",PX-750000027,CDM,43236,CPT,0750,RC,,,both,,,3031.65,909.49,"FIRST HEALTH [10303]","First Health",,2425.32,80,,,,,0,352.58,3031.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN",RX-94576,CDM,J2404,HCPCS,0636,RC,00143-9633-01,NDC,both,200,ML,981.86,294.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,667.66,68,,,,,0,32.63,834.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 150MM 1.25MM NONTHREAD NONSTERILE",SUP-900.721,CDM,C1769,HCPCS,0272,RC,,,both,,,169.13,50.74,"MULTIPLAN [10600]",Multiplan,,143.76,85,,,,,0,19.67,143.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 12MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.512,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,1521.93,481.35,16760.95,30,441.36,3225.75,"percent of total billed charges",
"CATH VIATRAC 14 PLUS 135CM 20MM 3.6-3.5FR 6.5MM .014IN LOW",SUP-1008199-20,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"AETNA [10100]","Aetna HMO/PPO",,1126.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 60MM 80CM 8MM VASCULAR PERIPHERAL SELF",SUP-1012530-60,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE FEMORAL 30MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-151101202,CDM,C1776,HCPCS,0278,RC,,,both,,,16151.52,4845.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6460.61,40,,,,,0,1878.42,13728.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 28-14MM 13FR TRIVASCULAR OVATION PRIME",SUP-TV-IL1428100-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3956.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR 30CM 3CM 7FR .035IN 2 FLOPPY PIGTAIL",SUP-M006180235090,CDM,C2617,HCPCS,0278,RC,,,both,,,1294.14,388.24,"CIGNA [10200]","Cigna Open Access",,736.37,,,,,,,150.51,1100.02,"percent of total billed charges",
"(EVAL) CATHETER TURNPIKE 150CM 2.6-2.9FR 1.6FR VASCULAR MULT",SUP-5643,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 STD 14MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS7S14L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"BLUE CROSS [10001]","Blue Cross PPO",,4073.43,39.2,,3949.44,3949.44,3949.44,"1 through 10",1208.52,8832.69,"percent of total billed charges",
"SUT VICRYL 8-0 TG140-8 8IN 2 ARM BRAID COATED VIOLET",SUP-J547G,CDM,S27200284,LOCAL,0272,RC,,,both,,,161.34,48.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,74.06,45.9,,,,,0,18.76,137.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY THORACENTESIS 3.5IN 8FR TURKEL ARGYLE MONOJECT 11 SYR",SUP-566059,CDM,C1729,HCPCS,0272,RC,,,both,,,1908.65,572.59,"NOVANET [10819]",Novanet,,1431.49,75,,,,,0,221.98,1622.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 10IN MARS BAYONET 1MM",SUP-632.678S,CDM,S27200284,LOCAL,0272,RC,,,both,,,6810.30,2043.09,"CIGNA [10200]","Cigna Local Plus",,3643.51,53.5,,,,,0,792.04,5788.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 30MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206050370,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repo Cvc W Fluoro",PX-450000234,CDM,36597,CPT,0361,RC,,,both,,,6675.32,2002.6,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,776.34,6675.32,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTITORQUE 100CM 5FR 4MM 1.2MM .038IN 21ML/SEC RADIAL",SUP-40-5011,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"FIRST HEALTH [10303]","First Health",,250.56,80,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 50X14MM STD OSCILLATE ERGONOMIC LIGHTWEIGHT THK.6",SUP-519.150S,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"CIGNA [10200]","Cigna Open Access",,290.36,56.9,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE MEDIUM OVAL 240CM 2.4MM CAPTIFLEX LOOP FLEXIBLE BRAID",SUP-M00562401,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.84,35.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,80.13,68,,,,,0,13.7,100.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 5.5MM CORE THK.51MM 25MM LONG NARROW SAGITTAL",SUP-2296-033-414,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.84,87.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,119.54,41.1,,,,,0,33.82,247.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEMORAL PFC SIGMA 5D KNEE STERILE",SUP-96-0781,CDM,C1776,HCPCS,0278,RC,,,both,,,10187.16,3056.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2915.57,28.62,,,,,0,1184.77,8659.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 60MM 32MM MARATHON HIP",SUP-121932060,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"FIRST HEALTH [10303]","First Health",,5787.72,80,,,,,0,841.39,6149.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 75MMX12MM VANGUARD ARCOM KNEE ANTERIOR STABILIZE",SUP-189082,CDM,C1776,HCPCS,0278,RC,,,both,,,12144.00,3643.2,"MULTIPLAN [10600]",Multiplan,,10322.4,85,,,,,0,1412.35,10322.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE NITREX VASCULAR 45D 260CM 4CM .035IN NITINOL TUNGSTEN",SUP-N352603,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW STRAIGHT 90MM MINI FRAGMENT 7 HOLE COMPRESSION",SUP-629527,CDM,C1713,HCPCS,0278,RC,,,both,,,3303.30,990.99,"KAISER [10500]",Kaiser,,2213.21,67,,,,,0,384.17,2807.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SURGICAL BARIATRIC RUNNING",SUP-021021,CDM,S27200284,LOCAL,0272,RC,,,both,,,1530.90,459.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHILON MULTIPASS 4-0 PC-3 18IN MONOFILAMENT BLACK",SUP-1964G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLI KIT SS10 SAFESHEATH II 10FR 13CM",SUP-SS10,CDM,C1894,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 10CM 9FR ARROWG+ARD BLUE CATH-GARD PERCUTANEOUS",SUP-CDC-21142-XCN1A,CDM,C1894,HCPCS,0272,RC,,,both,,,1524.42,457.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP LAPAROSCOPIC 6MM ENDOWRIST SP CADIERE NONSTERILE LATEX",SUP-431300,CDM,S27000186,LOCAL,0270,RC,,,both,,,2063.40,619.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BALLOON DILATATION .035IN 5.3FR 80CM FLOW DIRECTED",SUP-G10851,CDM,C2628,HCPCS,0272,RC,,,both,,,612.85,183.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2.7MM 54MM STAINLESS STEEL T8 SELF TAP LOCK",SUP-02.211.054,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"KAISER [10500]",Kaiser,,601.75,67,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 115D 1.5MM MANDIBLE 6 HOLE BAR 2/2.3MM SCR BONE",SUP-55-15526,CDM,C1713,HCPCS,0278,RC,,,both,,,4352.59,1305.78,"MULTIPLAN [10600]",Multiplan,,3699.7,85,,,,,0,506.21,3699.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 490CC",SUP-SMPX490,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"NOVANET [10819]",Novanet,,5589,75,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.00MM X 10MM  SCOREFLEX  NC",SUP-630-104-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORD, HI FREQ, W/8MM PLUG, 300CM",SUP-277KB-HN,CDM,S27000186,LOCAL,0270,RC,,,both,,,1714.05,514.21,"CIGNA [10200]",Cigna,,1165.55,68,,,,,0,199.34,1456.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 60ML 1.7-10MM ALLOGRAFT CHIPS FREEZE",SUP-T00045,CDM,S27800098,LOCAL,0278,RC,,,both,,,5105.31,1531.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3471.61,68,,,,,0,593.75,4339.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE EMBOLIZATION GREEN EMBOZENE 700UM POLYZENE-F HYDROGEL",SUP-17020-S1,CDM,S27800098,LOCAL,0278,RC,,,both,,,1417.50,425.25,"NOVANET [10819]",Novanet,,1063.13,75,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 62.5MM KNEE RIGHT POSTERIOR STABILIZE OPEN BOX",SUP-184506,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"KAISER [10500]",Kaiser,,16633.27,67,,,,,0,2887.24,21101.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 60MM 75CM 8MM VASCULAR SELF EXPAND RADIOPAQUE",SUP-H74939293086070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"AMERIGROUP MEDICAID [20100]",Amerigroup,,572.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Needle Biopsy Lymph Node",PX-361000273,CDM,38505,CPT,0361,RC,,,both,,,3339.05,1001.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,395.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,388.33,3339.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE STC-18 130CM 20CM 2.4-3FR .021IN MICRO",SUP-M001181310,CDM,C1887,HCPCS,0272,RC,,,both,,,2287.50,686.25,"KAISER [10500]",Kaiser,,1532.63,67,,,,,0,266.04,1944.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Theophylline",PX-301000058,CDM,80198,CPT,0301,RC,,,both,,,351.25,105.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,12.59,,"Fee schedule rate ($12.59).",,,,0,9.58,298.56,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 12.5MM KNEE POLYETHYLENE STABILIZE ROTATE",SUP-129416612,CDM,C1776,HCPCS,0278,RC,,,both,,,12447.60,3734.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1475.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1447.66,10580.46,"percent of total billed charges",
"INSERT TIBIAL 6 16MM KNEE POSTERIOR STABILIZE BEARING TRIATH",SUP-5532P616,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]",Cigna,,5682.01,68,,5873.17,5873.17,5873.17,"1 through 10",971.79,7102.52,"percent of total billed charges",
"PACK CATH 45CM 14.5FR 14FR PALINDROME TAL VENATRAC 2 LUMEN 2",SUP-8888128454P,CDM,C1750,HCPCS,0278,RC,,,both,,,2649.68,794.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1216.2,45.9,,,,,0,308.16,2252.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MIDFACE BURR HOLE 1.5MM SCREWS BONE TITANIUM 18.5MM",SUP-017308,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.70,405.81,"BLUE CROSS [10001]","Blue Cross PPO",,530.26,39.2,,957.42,570.23,957.42,28,157.32,1149.8,"percent of total billed charges",
"VIVIGEN CELLULAR BONE MATRIX 10CC CRYO",SUP-BL-1500-003,CDM,C1713,HCPCS,0278,RC,,,both,,,21168.00,6350.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2508.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,2461.84,17992.8,"percent of total billed charges",
"DRILL TWIST 38MM 1.1MM LORENZ STOP 5MM 1.5MM SCR MIDAS REX",SUP-1/1/7139,CDM,S27200284,LOCAL,0272,RC,,,both,,,1008.45,302.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.28,857.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 3-5 C-D KNEE RIGHT VIVACIT-E",SUP-42522600410,CDM,C1776,HCPCS,0278,RC,,,both,,,12351.00,3705.3,"CIGNA [10200]",Cigna,,4940.4,40,,5873.17,5873.17,5873.17,"1 through 10",1436.42,10498.35,"percent of total billed charges",
"PLATE 56MM 3 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800356,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"COMPRESSION STOCKING ANTI-EMBOLISM 18MMHG KNEE HIGH MEDIUM R",SUP-4279,CDM,S27000186,LOCAL,0270,RC,,,both,,,111.19,33.36,"KAISER [10500]",Kaiser,,74.5,67,,,,,0,12.93,94.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X22X8-15MM RISE-L 6D",SUP-193.425,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"FIRST HEALTH [10303]","First Health",,27468,80,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLACK USA ELITE SYSTEM USA SERIES",SUP-VE-F,CDM,S27200284,LOCAL,0272,RC,,,both,,,1214.65,364.39,"KAISER [10500]",Kaiser,,813.82,67,,,,,0,141.26,1032.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE REVISION HYBRID PS OXI FEM CONCELOC PATEL",SUP-71704647,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6293.7,27,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 100MM 7FR 7MM .018IN SHORT BALLOON",SUP-V1870100,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,650.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 1.5MM CRANIOFACIAL TITANIUM SELF DRILLING LOW",SUP-400.836,CDM,C1713,HCPCS,0278,RC,,,both,,,708.75,212.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,325.32,45.9,,,,,0,82.43,602.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE LEFT CEMENTED CRUCIATE RETAINING",SUP-150400125,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9203.67,41.1,,6417.48,6417.48,6417.48,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"BIT DRILL 125MM 1.6MM TWIST STERILE",SUP-KM166-00-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.04,24.01,"MULTIPLAN [10600]",Multiplan,,68.03,85,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUROFORM 3 EZ 4.5 X 20MM",SUP-M003N3EZ45200,CDM,C1874,HCPCS,0278,RC,,,both,,,47878.17,14363.45,"BLUE CROSS [10001]","Blue Cross HMO",,18768.24,39.2,,9776.84,9776.84,9776.84,"1 through 10",5568.23,40696.44,"percent of total billed charges",
"5F DECA 2-2-2 MPA 120CM",SUP-901521,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"MULTIPLAN [10600]",Multiplan,,2518.13,85,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATHLETIS 135CM 40MM 6MM BALLOON DILATATION STERILE",SUP-H74939347060410,CDM,C1725,HCPCS,0272,RC,,,both,,,1449.90,434.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,168.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 5CM 2.83MM DUODENAL BEND BILIARY",SUP-M00534260,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"CIGNA [10200]","Cigna Open Access",,619.9,56.9,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8840-14,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",50.59,369.75,"percent of total billed charges",
"IMIPENEM-CILASTATIN 500 MG/10ML IV (WET SOLR VIAL)",RX-4159603,CDM,J0743,HCPCS,0636,RC,44567-0705-01,NDC,both,1,UN,226.52,67.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.68,192.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM STAINLESS STEEL ORTHOPEDIC SELF TAPPING",SUP-S35-16S-11,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"MULTIPLAN [10600]",Multiplan,,929.48,85,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUTTY THERAPY SAMMONS PRESTON RED MEDIUM SOFT RESISTANCE",SUP-50719905,CDM,S27000186,LOCAL,0270,RC,,,both,,,361.14,108.34,"MULTIPLAN [10600]",Multiplan,,306.97,85,,,,,0,42,306.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION MEDIUM COMBINATION SELF HOLDING CLIP",SUP-390.031,CDM,S27000186,LOCAL,0270,RC,,,both,,,3469.20,1040.76,"CIGNA [10200]","Cigna Local Plus",,1856.02,53.5,,,,,0,403.47,2948.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 4MM 80MM KNEE NONSTERILE",SUP-144080,CDM,C1713,HCPCS,0278,RC,,,both,,,1010.88,303.26,"BLUE CROSS [10001]","Blue Cross HMO",,396.26,39.2,,957.42,156.86,7483.26,51,117.57,859.25,"percent of total billed charges",
"CATH PACIFIC PLUS 130CM 40MM 4FR 6MM .018IN BALLOON",SUP-PCP060040130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"MULTIPLAN [10600]",Multiplan,,1046.52,85,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 20MM 3MM BALLOON DILATATION HYDROPHILIC",SUP-603002022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 2MM PRESTIGE PLUS HELICAL HELICAL XTRA",SUP-PRES0208HXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PRESSURE MNTR INTRAABDOMINAL KIT FOLEY CATH STERILE",SUP-BRDIAP001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1419.40,425.82,"AETNA [10100]","Aetna HMO/PPO",,1128.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.08,1206.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE APPROACH VASCULAR STRAIGHT TAPER 300CM .014IN",SUP-G52939,CDM,C1769,HCPCS,0272,RC,,,both,,,1389.07,416.72,"NOVANET [10819]",Novanet,,1041.8,75,,,,,0,161.55,1180.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-507,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1526.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 4.3MM XLONG CALIBRATED STERILE",SUP-03.313.702S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 15MM 2.25MM CORONARY STENT EVEROLIMUS",SUP-1550225-15,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"(EVAL) DORAYA DEVICE",SUP-40-0002,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 4-0 FS-2 18IN MONOFILAMENT BLACK NONABSORBABLE",SUP-662G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ROCHESTER-OCHSNER STRAIGHT 14IN 1X2 TEETH",SUP-16-1230,CDM,S27200284,LOCAL,0272,RC,,,both,,,702.76,210.83,"UHC [10700]","United Healthcare",,444.85,63.3,,,,,0,81.73,597.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 8X8MM FUSEFORCE 2MM FOREFOOT MIDFOOT REARFOOT",SUP-FFS0808,CDM,C1713,HCPCS,0278,RC,,,both,,,5582.10,1674.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2562.18,45.9,,,,,0,649.2,4744.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.7MM 40MM 18MM LOW PROFILE SCREWS TITANIUM 3.5MM",SUP-AR-8967-1840,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,218.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",218.06,1593.75,"percent of total billed charges",
"HEAD HUMERAL 27MM 46MM SHOULDER COMPREHENSIVE VERSA-DIAL",SUP-113048,CDM,C1776,HCPCS,0278,RC,,,both,,,9089.00,2726.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2601.27,28.62,,,,,0,1057.05,7725.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 45CM 16FR SILICONE MIC SECUR-LOK UNIVERSAL",SUP-0250-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"UHC [10700]","United Healthcare",,1109.3,63.3,,,,,0,203.81,1489.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 7 UNIVERSAL KNEE TOTAL STABILIZE",SUP-5521-B-700,CDM,C1776,HCPCS,0278,RC,,,both,,,14427.90,4328.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1709.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1207.77,12263.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR ANGLE 260CM .018IN HYDROPHILIC FIX CORE",SUP-H2OSTDA18260EX,CDM,C1769,HCPCS,0272,RC,,,both,,,408.47,122.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,48.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.51,347.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Arthrocent Jt Small W/US",PX-361000387,CDM,20604,CPT,0361,RC,,,both,,,2970.00,891,"AETNA [10100]","Aetna HMO/PPO",,2361.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,345.41,2970,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL KOCHER-OCHSNER CURVE 8IN ARTERY 1X2 TEETH",SUP-BH647R,CDM,S27200284,LOCAL,0272,RC,,,both,,,224.72,67.42,"MULTIPLAN [10600]",Multiplan,,191.01,85,,,,,0,26.13,191.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD MONOPOLAR BLACK PROBE POWER POCKET SUCTION",SUP-7209654,CDM,S27200284,LOCAL,0272,RC,,,both,,,1522.80,456.84,"CIGNA [10200]",Cigna,,1035.5,68,,,,,0,177.1,1294.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC MEDIUM 8IN WRIST RIGHT BLACK",SUP-A120206,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.29,17.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.78,49.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch Unlstd Proc",PX-750000192,CDM,31899,CPT,0750,RC,,,both,,,3924.00,1177.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,456.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,456.36,3924,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 50MM 22GA SONOPLEX II FACET S TIP INJECTION",SUP-001287-74,CDM,C9812,HCPCS,0272,RC,,,both,,,139.20,41.76,"CIGNA [10200]","Cigna Open Access",,79.2,56.9,,,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 145CC P2.6CM LOW PLUS PROFILE ROUND SMOOTH SOFT",SUP-SSLP-145,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]","Cigna Local Plus",,4042.19,,,,,,,878.7,6422.18,"percent of total billed charges",
"PLATE 30-34MM TITANIUM 5.5MM ROD LOW PROFILE LEGACY",SUP-8115530,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Open Access",,2027.06,56.9,,1144.80,304.56,2275.09,66,414.32,3028.13,"percent of total billed charges",
"CMPNT PATELLAR 32MM PERSONA ALL POLY KNEE LATEX FREE",SUP-42540000032,CDM,C1776,HCPCS,0278,RC,,,both,,,4667.16,1400.15,"MULTIPLAN [10600]",Multiplan,,3967.09,85,,,,,0,542.79,3967.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNETOS 20CC 2-4MM ALLOGRAFT GRANULE",SUP-703-026-US,CDM,C1713,HCPCS,0278,RC,,,both,,,21420.00,6426,"BLUE CROSS [10001]","Blue Cross HMO",,8396.64,39.2,,957.42,156.86,7483.26,51,2491.15,18207,"percent of total billed charges",
"ELECTRD DEFIB RESUSCITATION PACING AMBULATORY CARE ONESTEP",SUP-8900-0212-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,363.66,109.1,"MULTIPLAN [10600]",Multiplan,,309.11,85,,,,,0,42.29,309.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTERNAL FIXATION DYNACLIP L10 MM X W10 MM X H10 MM S",SUP-3000-00-101010,CDM,C1713,HCPCS,0278,RC,,,both,,,10591.50,3177.45,"BLUE CROSS [10001]","Blue Cross PPO",,4151.87,39.2,,957.42,570.23,957.42,28,1231.79,9002.78,"percent of total billed charges",
"IMMOB ORTHOPEDIC SMALL 20IN 14-16IN KNEE T BAR CONTOUR",SUP-A142005,CDM,L1830,HCPCS,0274,RC,,,both,,,117.71,35.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,79.56,,,,,,,13.69,100.05,"fee schedule",
"SCR BONE 6.5MM 150MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.425,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"FIRST HEALTH [10303]","First Health",,1107.3,80,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.2MM 6MM RELIEVE SPINE SELF DRILL NONSTERILE LATEX",SUP-136.406,CDM,C1713,HCPCS,0278,RC,,,both,,,1077.30,323.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,494.48,45.9,,,,,0,125.29,915.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE 80MM 130CM 10MM .035IN LONG BILIARY NITINOL",SUP-SC1080LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3325.46,45.9,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 22MM 140CM 2.5MM CORONARY STERILE LATEX",SUP-453950,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 42X4IN ATS CYL PORT STERILE DISPOSABLE",SUP-60707510700,CDM,S27200284,LOCAL,0272,RC,,,both,,,227.12,68.14,"KAISER [10500]",Kaiser,,152.17,67,,,,,0,26.41,193.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 73X25X.89MM MEDIUM WIDE STAINLESS STEEL SAGITTAL 2",SUP-2108-105-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"KAISER [10500]",Kaiser,,160.18,67,,,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 10X6IN RESORBABLE REINFORCE",SUP-F10254-0610G,CDM,C1781,HCPCS,0278,RC,,,both,,,3690.00,1107,"KAISER [10500]",Kaiser,,2472.3,67,,,,,0,429.15,3136.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTMASTER 16MM 4.8MM CORONARY STENT STAINLESS STEEL",SUP-1012584-16,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"FIRST HEALTH [10303]","First Health",,13220.4,80,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 80MM 120CM 7MM 6FR VASCULAR NITINOL PERIPHERAL",SUP-S-70-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 25MM 2.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2525X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AETNA [10100]","Aetna HMO/PPO",,450.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DRNG PURPLE 250CM 7FR PIGTAIL CURVE NASOBILIARY 5",SUP-G21586,CDM,C1729,HCPCS,0272,RC,,,both,,,1239.30,371.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OVERSTITCH ENDOSCOPIC SUTURE SYSTEM",SUP-M00505410,CDM,S27200284,LOCAL,0272,RC,,,both,,,8797.50,2639.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AMITRIPTYLINE 10 MG TABLET",RX-432,CDM,,,0637,RC,57664-0687-88,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMPRESS 40CM 5FR .046IN .038IN KA2 CURVE ANGIOGRAPHIC",SUP-54038KA2,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BALLOON DILATATION .018IN 4FR 6MM 135CM 4CM PTA LOW",SUP-G50247,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMERGE MONORAIL 144CM 20MM 6FR 3MM .07IN BALLOON",SUP-H7493918920300,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"NOVANET [10819]",Novanet,,425.25,75,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSRT PERCUTANEOUS KNOTLESS SUTURETAK",SUP-AR-1938PK,CDM,C1713,HCPCS,0278,RC,,,both,,,2795.63,838.69,"CIGNA [10200]",Cigna,,1901.03,68,,1831.33,1831.33,1831.33,16,325.13,2376.29,"percent of total billed charges",
"DEVICE STRATAFIX PDS PLUS 1 CTX 45CM SUT ABSORBABLE KNOTLESS",SUP-SXPP1A400,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,163.4,68,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 11MM ATLANTIS TITANIUM SPINE CERVICAL ANTERIOR",SUP-3120211,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"PHCS [10601]",PHCS,,987,70,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 24MM RIGHT STERILE",SUP-TR-H240R-S,CDM,C1776,HCPCS,0278,RC,,,both,,,13489.50,4046.85,"CIGNA [10200]","Cigna Local Plus",,4249.19,31.5,,5372.07,4581.20,7242.98,23,1568.83,11466.08,"percent of total billed charges",
"LINER ACETABULAR G7 H 50MM COCR HIP 2 MOBILITY",SUP-110024466,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3707.06,28.62,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 45D NDL SHORT 4IN COLORADO STERILE",SUP-E1134,CDM,S27200284,LOCAL,0272,RC,,,both,,,556.15,166.84,"NOVANET [10819]",Novanet,,417.11,75,,,,,0,64.68,472.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SQUARE 2.4MM SCR 4 HOLE LOW PROFILE 2 SIDE STERNALOCK",SUP-73-2622,CDM,C1713,HCPCS,0278,RC,,,both,,,2437.50,731.25,"NOVANET [10819]",Novanet,,1828.13,75,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRUGSORB ATR SHAM","SUP-DSS 202",CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR VIVACIT-E II ELEVATED 52MM 36MM HIP",SUP-00885201036,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"FIRST HEALTH [10303]","First Health",,8201.62,80,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 3 STRAIGHT OVAL 8IN SURGICAL SPINAL FUSION",SUP-29-5033,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.68,68.9,"UHC [10700]","United Healthcare",,145.39,63.3,,,,,0,26.71,195.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 8X2.75IN 2 PORT 1 BLADDER WITHOUT SLEEVE ATS",SUP-60707010100,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.40,44.22,"NOVANET [10819]",Novanet,,110.55,75,,,,,0,17.14,125.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 24FR SILICONE MIC-KEY SECUR-LOK ENFIT BOLUS",SUP-8200-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,451.93,41.1,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEIGHT EYELID THK1MM GOLD CONTOUR 1.2GM IMPL 3 DIMENSIONAL","SUP-LL 3012",CDM,L8699,HCPCS,0278,RC,,,both,,,1987.50,596.25,"BLUE CROSS [10001]","Blue Cross PPO",,779.1,39.2,,,,,0,231.15,1689.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SYSTEM 6",SUP-02.527.069,CDM,C1713,HCPCS,0278,RC,,,both,,,7813.91,2344.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,908.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",908.76,6641.82,"percent of total billed charges",
"ROD SPINAL 110MM 5.5MM LONGITUDE II STRAIGHT TITANIUM",SUP-1554006110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM ELLIPSE POSTERIOR",SUP-182.224,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2856,68,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 16MM PERSONA 6-9 G-H KNEE RIGHT TIBIA",SUP-42521400916,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"BLUE CROSS [10001]","Blue Cross HMO",,3165.7,39.2,,5311.50,4717.44,5388.59,31,939.21,6864.4,"percent of total billed charges",
"GRAFT BONE MDII ALLOGRAFT 26MMX18MM TISSUE",SUP-401318A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC",462,MS-DRG,,,,,,,inpatient,,,233760.96,70128.29,"CIGNA [10200]","Cigna Open Access",,29190.84,,"Fee schedule rate ($29,190.84). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,77661.36,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X60 40CM SL",SUP-48003006P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPO 100CM 6FR .056IN WILLIAMS RIGHT CURVE ANGIOGRAPHIC",SUP-H74908641502,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"M AC611 HFNC FEP CONNECT 20 PK",SUP-73-1134191,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.51,57.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC TREK NEO 145CM 8MM 2.50MM BALLOON DILATATION PEBAX",SUP-1400250-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT POLYPROPYLENE 2-0 NDL DIGITEX DELIVERY DEVICE",SUP-520270,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CURET ANGLE 00000 OVAL 9IN BRUNS SPINE SURGICAL",SUP-29-5360,CDM,S27200284,LOCAL,0272,RC,,,both,,,253.00,75.9,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL 14CM MR8 6MM BALL DISSECTING",SUP-MR8-14BA60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.19,388.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRANSURETHRAL PROCEDURES WITH MCC",668,MS-DRG,,,,,,,inpatient,,,88844.31,26653.29,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 40MM 3.8FR 7MM LOW PROFILE BALLOON",SUP-H749392032704010,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 40MM 5MM BALLOON DILATATION HYDROPHILIC",SUP-585004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KT PCNG VN PICK",SUP-420,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL PERCUTANEOUS 20CM 18GA NAVIGUIDE ACCESS ADJUSTABLE",SUP-M0067001330,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.70,104.61,"AETNA [10100]","Aetna HMO/PPO",,277.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.55,296.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 10D G 9.4MM 36MM X3 HIP",SUP-623-10-36G,CDM,C1776,HCPCS,0278,RC,,,both,,,6879.60,2063.88,"NOVANET [10819]",Novanet,,5159.7,75,,,,,0,800.1,5847.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL SHAFT SMALL FREEZE DRIED 100-125MM",SUP-72A002,CDM,S27800098,LOCAL,0278,RC,,,both,,,3360.00,1008,"AMERIGROUP MEDICAID [20100]",Amerigroup,,398.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,390.77,2856,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transport Advanced One Way",PX-546000003,CDM,A0427,HCPCS,0546,RC,,,both,,,2466.12,739.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1676.96,68,,,,,0,286.81,2096.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 8MM 144CM 3.5MM CORONARY STENT",SUP-H7493911408350,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross HMO",,3583.86,39.2,,9776.84,9776.84,9776.84,"1 through 10",1063.27,7771.13,"percent of total billed charges",
"TUBING SUCTION 30CM 10FR T SILICONE TRANSLUCENT STERILE LATE",SUP-SU130-1228,CDM,S27200284,LOCAL,0272,RC,,,both,,,2175.00,652.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,252.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIASSIST 24IN 36IN DRUG DELIVERY 60ML GAS",SUP-AA0608,CDM,S27000186,LOCAL,0270,RC,,,both,,,769.50,230.85,"PHCS [10601]",PHCS,,538.65,70,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 110.5MM CEMENT C-STEM AMT 2 12/14 STD OFFSET",SUP-157004085,CDM,C1776,HCPCS,0278,RC,,,both,,,20320.65,6096.19,"BLUE CROSS [10001]","Blue Cross PPO",,7965.69,39.2,,3949.44,3949.44,3949.44,"1 through 10",2363.29,17272.55,"percent of total billed charges",
"STENT ONYX FRONTIER 30MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"BLUE CROSS [10001]","Blue Cross PPO",,1058.4,39.2,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MICROPOINT 9-0 VAS100-4 6IN MONOFILAMENT BLACK",SUP-2890G,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.24,86.17,"NOVANET [10819]",Novanet,,215.43,75,,,,,0,33.41,244.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTSC TWIN GRASPER (165 CM)",SUP-200.44,CDM,S27200284,LOCAL,0272,RC,,,both,,,4823.10,1446.93,"PHCS [10601]",PHCS,,3376.17,70,,,,,0,560.93,4099.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN EXTRA BACKUP 4 LEFT CURVE",SUP-LA6EBU40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"KAISER [10500]",Kaiser,,244.82,67,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 10MM 4MM FOOT ANKLE VENT",SUP-AR-1540PS,CDM,C1713,HCPCS,0278,RC,,,both,,,2480.63,744.19,"PHCS [10601]",PHCS,,1736.44,70,,,,,0,288.5,2108.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE DEMINERALIZED BONE MATRIX 5X2.5CM",SUP-7509225,CDM,S27800098,LOCAL,0278,RC,,,both,,,13765.50,4129.65,"FIRST HEALTH [10303]","First Health",,11012.4,80,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTOURA BREAST TISSUE EXPANDER HIGH PROJECTION 300CC",SUP-TEXP110RH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"AETNA [10100]","Aetna HMO/PPO",,10943.57,79.5,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 22CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006175281180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,169.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER PILOTED HEAD 7.5MM",SUP-AR-1453,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T 5.5X1.3MM 7 HOLE ORTHOLOC BONE",SUP-52020207,CDM,C1713,HCPCS,0278,RC,,,both,,,4278.00,1283.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,497.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",497.53,3636.3,"percent of total billed charges",
"HC NM Radrx Thrpy Oral Admin",PX-342000011,CDM,79005,CPT,0342,RC,,,both,,,3245.68,973.7,"FIRST HEALTH [10303]","First Health",,2596.54,80,,,,,0,80.54,2758.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 17.8MM 31-33MM 36MM 23.4MM ON-X 31/33 STD",SUP-ONXM-31/33,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15120,40,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 1.7CM 20FR LOW PROFILE APPLE BALLOON EXTERNAL BOLST",SUP-M1-5-2017,CDM,S27200284,LOCAL,0272,RC,,,both,,,1069.20,320.76,"NOVANET [10819]",Novanet,,801.9,75,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REUNION TSA - PRESS-FIT HUMERAL STEM 8MM",SUP-5569-P-2008,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5040,40,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immuno Optical Org",PX-306000173,CDM,87899,CPT,0306,RC,,,both,,,343.90,103.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,292.32,"per diem",
"STENT 24CM 3CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175282110,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,146.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 44MM T10 FULL THREAD STARDRIVE NONSTERILE",SUP-657444,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"FIRST HEALTH [10303]","First Health",,646.96,80,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP H2D I.E. PROPRIETARY TECHNOLOGY/STRYKER - X3 W/TRI",SUP-CAP-H-2D,CDM,C1776,HCPCS,0278,RC,,,both,,,34650.00,10395,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4029.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 3INX12MM OSTEOTOM THIN MRI STERILE LATEX FREE",SUP-47998602122,CDM,S27200284,LOCAL,0272,RC,,,both,,,996.30,298.89,"KAISER [10500]",Kaiser,,667.52,67,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID LOWER LEG REDUCTION KIT- STANDARD, REGULAR",SUP-25101217,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"FIRST HEALTH [10303]","First Health",,1004.4,80,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 15MM 3MM 1.5MM 1.2MM BALLOON DILATATION RAPID",SUP-DC-RY3015UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,406.15,41.1,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 4 HIGH OFFSET HIP",SUP-71935576,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,14613.48,40,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM ULNAR SIZE 5 L115MM LEFT CEMENTED CONSTRAINED NEXEL",SUP-840001511,CDM,C1776,HCPCS,0278,RC,,,both,,,31971.49,9591.45,"NOVANET [10819]",Novanet,,23978.62,75,,,,,0,3718.28,27175.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR GUIDE 33MM 3.2MM 3.5MM NEXGEN HEXAGON",SUP-590103533,CDM,C1713,HCPCS,0278,RC,,,both,,,880.07,264.02,"NOVANET [10819]",Novanet,,660.05,75,,,,,0,102.35,748.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM INTERLOCK IDC 18 COIL SOFT 2D",SUP-M0033612020,CDM,S27800098,LOCAL,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT POSTOPERATIVE 10.5-12 LARGE WIDE MALE BLACK ETHYLENE VI",SUP-199651,CDM,S27000186,LOCAL,0270,RC,,,both,,,217.50,65.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BEHAVIORAL AND DEVELOPMENTAL DISORDERS",886,MS-DRG,,,,,,,inpatient,,,55987.78,16796.33,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DILTIAZEM 30 MG TABLET, IMMEDIATE RELEASE",RX-2475,CDM,,,0637,RC,60687-0717-11,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT CLAMP EVERCLIP FOGARTY HYDRAGRIP 61MM ATRAUMATIC",SUP-EVERGRIP61,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.16,41.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INFUSION CATH ACCESS PORT SYNCHROMED II NONSTERILE LATEX",SUP-8540,CDM,A4220,HCPCS,0272,RC,,,both,,,278.40,83.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 3MM ROUND STERILE LATEX FREE DISPOSABLE",SUP-5820110030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1164.70,349.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRACCATH, 13W",SUP-4875,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) AVALON ELITE VASCULAR ACCESS KIT",SUP-12210,CDM,C1769,HCPCS,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC",233,MS-DRG,,,,,,,inpatient,,,365237.85,109571.35,"AETNA [10100]","Aetna HMO/PPO",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $208,489. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 79.5%. Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,,,other,"IP STOP LOSS Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 5MM ZERO-P STANDARD LORDOTIC PEEK-OPTIMA TITAN",SUP-04.617.125S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"MULTIPLAN [10600]",Multiplan,,10557,85,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 12MM 80CM 6MM 3.6-3.3FR 6FR BILIARY",SUP-1011498-12,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 16MM KNEE X3 BEARING POSTERIOR STABILIZE",SUP-5532-G-316,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3578.83,41.1,,6417.48,6417.48,6417.48,"1 through 10",1012.7,7401.47,"percent of total billed charges",
"STENT ZIPWIRE 30CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006175285080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"BLUE CROSS [10001]","Blue Cross HMO",,485.84,39.2,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 9MM BALLOON",SUP-U357596,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 11 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502607002,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"CIGNA [10200]","Cigna Local Plus",,7201.75,31.5,,5372.07,4581.20,7242.98,23,2658.93,19433.3,"percent of total billed charges",
"ADPTR CATH GATEWAY ADVANTAGE TUOHY Y LEAK RESISTANT SEAL",SUP-M0067301501,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.72,41.62,"KAISER [10500]",Kaiser,,92.94,67,,,,,0,16.13,117.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 15MM CEMENTLESS MODULAR AML POROUS 52MM",SUP-155403150,CDM,C1776,HCPCS,0278,RC,,,both,,,15374.88,4612.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1821.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1788.1,13068.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR STRAIGHT 300CM 8CM .018IN",SUP-H74917541,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE MEDIUM 230CM 2.8MM 15MM SNAREMASTER WIRE LOOP INTEGRAL",SUP-SD-240U-15,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.57,23.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.25,67.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINE PRESSURE MON CARDIOPLEGIA HEART TRANSPLANT",SUP-027742202,CDM,S27200284,LOCAL,0272,RC,,,both,,,400.20,120.06,"FIRST HEALTH [10303]","First Health",,320.16,80,,,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 70MM 16MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-216.070,CDM,C1713,HCPCS,0278,RC,,,both,,,280.49,84.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,190.73,68,,,,,0,32.62,238.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL SHOULDER RESURFACE COPELAND HA 5",SUP-11-114645,CDM,C1776,HCPCS,0278,RC,,,both,,,16174.80,4852.44,"BLUE CROSS [10001]","Blue Cross PPO",,6340.52,39.2,,3949.44,3949.44,3949.44,"1 through 10",1881.13,13748.58,"percent of total billed charges",
"HC Frozen Section 1st Block",PX-312000037,CDM,88331,CPT,0312,RC,,,both,,,569.50,170.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,64.81,,,,,,,0.01,484.08,"fee schedule",
"(COMM) OCCLUDER CARDIOVASCULAR 18MM CARDIAC PLUG AMPLATZER S",SUP-9-ACP2-007-018,CDM,C1817,HCPCS,0278,RC,,,both,,,96900.00,29070,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,39825.9,41.1,,,,,0,11269.47,82365,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) 28 FR. THORAGUARD CHEST TUBE KIT (BOX OF 10)",SUP-TGCT120028,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,187.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM 24.2MM MASTERS SERIES 85D STD SUPRA",SUP-29AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]",Cigna,,11647.69,40,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00205,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"BLUE CROSS [10001]","Blue Cross PPO",,428.65,39.2,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 3CM 6FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175265050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,491.47,45.9,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 6 KNEE CEMENT REVISION ROTATE PLATFORM",SUP-1506-60-006,CDM,C1776,HCPCS,0278,RC,,,both,,,22629.60,6788.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2681.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2631.82,19235.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC 6.25MM FLEXOR HALLUCIS LONGUS",SUP-AR-1562BC-CP,CDM,S27200284,LOCAL,0272,RC,,,both,,,10831.28,3249.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7365.27,68,,,,,0,1259.68,9206.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP EASY LOAD DESIGN LOCK HANDLE SAFELY INSRT 3CM",SUP-KC-RUMI-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"CIGNA [10200]","Cigna Local Plus",,613.02,53.5,,,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SLIP-CATH BEACON TIP SHUTTLE FLEXOR 125CM 5.5FR SIMMONS",SUP-G36360,CDM,S27200284,LOCAL,0272,RC,,,both,,,708.75,212.62,"PHCS [10601]",PHCS,,496.13,70,,,,,0,82.43,602.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 140MM 3.2MM BONE STERILE LATEX FREE",SUP-213527,CDM,S27200284,LOCAL,0272,RC,,,both,,,505.44,151.63,"FIRST HEALTH [10303]","First Health",,404.35,80,,,,,0,58.78,429.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL E LEFT KNEE CEMENTED POSTERIOR STABILIZED",SUP-00596401551,CDM,C1776,HCPCS,0278,RC,,,both,,,15346.80,4604.04,"UHC [10700]","United Healthcare",,9714.52,63.3,,8601.07,8395.67,8601.07,"1 through 10",1784.83,13044.78,"percent of total billed charges",
"CMPNT PATELLAR OVAL 32MMX9MM GENESIS II UHMWPE KNEE",SUP-71421032,CDM,C1776,HCPCS,0278,RC,,,both,,,7162.20,2148.66,"CIGNA [10200]","Cigna Open Access",,4075.29,56.9,,5302.19,4377.88,6578.61,27,832.96,6087.87,"percent of total billed charges",
"LEAD NEROSTIMLTR 30CM 8 CONTACT LINEAR",SUP-SC-2366-30,CDM,C1778,HCPCS,0278,RC,,,both,,,8914.80,2674.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6062.06,68,,,,,0,1036.79,7577.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM AXIUM 3D FRAME V01",SUP-FC-14-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"UHC [10700]","United Healthcare",,10460.64,63.3,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFARI VASCULAR SMALL CURVE 300CM .035IN LUBRIGREEN",SUP-H74939272S1,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 2.5CM 1.5MM GALAXY G3 MINI STRETCH",SUP-GLM915025,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"FIRST HEALTH [10303]","First Health",,9505.44,80,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X11MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7011,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"PHCS [10601]",PHCS,,4830,70,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 105MM 3.5MM DCP LC-DCP CORTEX PELVIC STAINLESS",SUP-204.705,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"BLUE CROSS [10001]","Blue Cross HMO",,107.91,39.2,,957.42,156.86,7483.26,51,32.01,233.98,"percent of total billed charges",
"HC Herpes Simplex Dna Ampl Probe",PX-306000135,CDM,87529,CPT,0306,RC,,,both,,,443.65,133.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,377.1,"per diem",
"STENT CONTOUR 24CM 3CM 7FR .035IN STRAIGHT PIGTAIL CURVE",SUP-M006180232050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,708.27,68,,,,,0,121.14,885.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN RTRCTR 20MM MARS 3VL 3.3MM DOCK",SUP-6133.0320S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2640.00,792,"NOVANET [10819]",Novanet,,1980,75,,,,,0,307.03,2244,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 12MM 140CM 4MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927412400,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Open Access",,2133.75,56.9,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 5MM ZERO-P STANDARD LORDOTIC PEEK-OPTIMA TITAN",SUP-04.617.125S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3554.6,28.62,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLER INTERNAL 25X4.8MM TITANIUM XL CIRCLE STAPLE ENDOSCOP",SUP-EEAXL25,CDM,S27200284,LOCAL,0272,RC,,,both,,,2269.80,680.94,"PHCS [10601]",PHCS,,1588.86,70,,,,,0,263.98,1929.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCRP OPHTHALMIC .75IN 22GA KRATZ 30D CPSL SANDBLAST 1MM",SUP-60-1131,CDM,S27000186,LOCAL,0270,RC,,,both,,,216.11,64.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,99.19,45.9,,,,,0,25.13,183.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 110MM PRIMARY CEMENT DISTAL BULLET TIP SYNERGY",SUP-71316009,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"MULTIPLAN [10600]",Multiplan,,18073.13,85,,,,,0,2472.83,18073.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL E 68X61.5MM KNEE RIGHT SET SCR CEMENT REVISION",SUP-00599401592,CDM,C1776,HCPCS,0278,RC,,,both,,,41440.14,12432.04,"CIGNA [10200]","Cigna Local Plus",,13053.64,31.5,,5372.07,4581.20,7242.98,23,4819.49,35224.12,"percent of total billed charges",
"SCR BONE 10MM CREO MIS SPINE POLYAXIAL TULIP REDUCTION",SUP-1134.0110,CDM,C1713,HCPCS,0278,RC,,,both,,,3555.00,1066.5,"PHCS [10601]",PHCS,,2488.5,70,,,,,0,413.45,3021.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 100MM 4MM .014IN BALLOON DILATATION",SUP-AB14W040100150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.87,68,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE WATCHMAN FXD CURVE 15FR 12FR CLSR 2 CURVE ACCESS",SUP-M635TU80010,CDM,C1894,HCPCS,0272,RC,,,both,,,6900.00,2070,"MULTIPLAN [10600]",Multiplan,,5865,85,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 45MM MATRIX TITANIUM T25 SPINE PEDICLE",SUP-04.639.745,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"RING EXTERNAL FIXATION 150MM MAXFRAME FULL ALUMINUM",SUP-03.312.150,CDM,C1713,HCPCS,0278,RC,,,both,,,8122.27,2436.68,"CIGNA [10200]","Cigna Open Access",,4621.57,56.9,,1144.80,304.56,2275.09,66,944.62,6903.93,"percent of total billed charges",
"SPACER ALLOGRAFT 23-27X24-32X17MM FRA 8D SPINE THORACOLUMBAR",SUP-10517,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,inpatient,,,46072.65,13821.79,"PHCS [10601]",PHCS,,7561,,,,,,,5332.77,25099.8,"per diem","Estimated amount calculated based on 4 day length of stay."
"BIT DRILL 289MM 4.3MM AXSOS CALIBRATE 4MM SMALL FRAGMENT",SUP-702742,CDM,S27200284,LOCAL,0272,RC,,,both,,,1010.39,303.12,"FIRST HEALTH [10303]","First Health",,808.31,80,,,,,0,117.51,858.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 20MM KNEE LEFT MEDIAL PIVOT ADVANCE II",SUP-KIMP320L,CDM,C1776,HCPCS,0278,RC,,,both,,,6141.00,1842.3,"CIGNA [10200]",Cigna,,4175.88,68,,5873.17,5873.17,5873.17,"1 through 10",714.2,5219.85,"percent of total billed charges",
"TUBE JEJUNOSTOMY 18FR SILICONE MIC-KEY SECUR-LOK ENFIT BOLUS",SUP-8200-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"CIGNA [10200]","Cigna Local Plus",,588.28,53.5,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG TRANSPARENT 9X9IN HYDROGEL SILICONE ADHSV FLEXIBLE",SUP-MSCOV99EP,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.70,28.71,"UHC [10700]","United Healthcare",,60.58,63.3,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4.5MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN04508,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1389.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIDOVUDINE 10 MG/ML ORAL SYRUP",RX-11693,CDM,,,0250,RC,08888-8883-21,NDC,both,10,ML,14.78,4.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.72,12.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 67.5MM TITANIUM LOCK TRANSLATIONAL ATLANTIS BONE SPINE",SUP-6190067,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"TRAY BIOPSY T-LOK STD BONE MARROW",SUP-BMT1104BTL,CDM,S27200284,LOCAL,0272,RC,,,both,,,434.30,130.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.32,68,,,,,0,50.51,369.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VASOPRESSIN 40 UNIT/100 ML (0.4 UNIT/ML) IN 0.9 % SODIUM CHLORIDE IV",RX-179640,CDM,J2601,HCPCS,0636,RC,00338-9647-12,NDC,both,100,ML,905.40,271.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,107.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,93.71,769.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM .91-1.12MM 2.25MM CORONARY",SUP-RONYX22508W,CDM,C1874,HCPCS,0278,RC,,,both,,,1875.00,562.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,218.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ CCOMBO 110CM 7.5FR STD PULMONARY ARTERY",SUP-774F75,CDM,C1751,HCPCS,0272,RC,,,both,,,1782.30,534.69,"MULTIPLAN [10600]",Multiplan,,1514.96,85,,,,,0,207.28,1514.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 10 5MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151641005,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Open Access",,6403.47,56.9,,5302.19,4377.88,6578.61,27,1308.83,9565.82,"percent of total billed charges",
"HC Instant Wave Free Ratio Init",PX-481000372,CDM,93799,CPT,0481,RC,,,both,,,2425.57,727.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,282.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,282.09,2061.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,inpatient,,,42492.52,12747.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,11484.27,,,,,,,4468.07,17963.56,"case rate",
"HANDLE KNIFE 8.25IN 3LA STAINLESS STEEL SATIN FINISH",SUP-110171,CDM,S27000186,LOCAL,0270,RC,,,both,,,174.35,52.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.28,148.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Levetiracetam",PX-301000075,CDM,80177,CPT,0301,RC,,,both,,,314.93,94.48,"UHC [10700]","United Healthcare",,11.93,,,,,,,0.01,267.69,"fee schedule",
"HC Bx Ndl Liver Perc",PX-361000175,CDM,47000,CPT,0361,RC,,,both,,,4291.77,1287.53,"PHCS [10601]",PHCS,,4291.77,,"Case rate ($4,710). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,499.13,4291.77,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 1.5MM TARGET NANO HELICAL DETACHABLE",SUP-M0035431540,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3763.81,41.1,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2.5MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN02506,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3165.24,27,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOOP 7.7MM 5.2MM MEDIUM OVAL 7IN FLEXIBLE MATTE MIRROR SATIN",SUP-AU5611,CDM,S27200284,LOCAL,0272,RC,,,both,,,402.03,120.61,"KAISER [10500]",Kaiser,,269.36,67,,,,,0,46.76,341.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 3.5 MM SCREWS 1 HOLE LOW PROFILE",SUP-02.100.301S,CDM,C1713,HCPCS,0278,RC,,,both,,,2629.20,788.76,"CIGNA [10200]",Cigna,,1787.86,68,,1831.33,1831.33,1831.33,16,305.78,2234.82,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 20CM 3CM 5FR .035IN",SUP-M006192120190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"NOVANET [10819]",Novanet,,1046.42,75,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZEBRA UROLOGICAL 150CM 3CM .038IN URO-GLIDE NITINOL",SUP-M0066701151,CDM,C1769,HCPCS,0272,RC,,,both,,,447.74,134.32,"PHCS [10601]",PHCS,,313.42,70,,,,,0,52.07,380.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 15CM 31MM 14.5MM EXCLUDER C3 TRUNK",SUP-RLT311415,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"MULTIPLAN [10600]",Multiplan,,53295,85,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemoglobin Chromatography",PX-301000224,CDM,83021,CPT,0301,RC,,,both,,,118.00,35.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,28.41,,,,,,,0.01,100.3,"fee schedule",
"HC ER Amput Finger/Thumb Sgl Clsr",PX-450000365,CDM,26951,CPT,0361,RC,,,both,,,9895.00,2968.5,"NOVANET [10819]",Novanet,,7421.25,75,,,,,0,1150.79,8410.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR CEMENTLESS HIGH OFFSET Z1 TITANIUM ALLOY",SUP-611202030,CDM,C1776,HCPCS,0278,RC,,,both,,,28967.40,8690.22,"FIRST HEALTH [10303]","First Health",,23173.92,80,,,,,0,3368.91,24622.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR 45CM 12FR ACCESS URETERAL CONTINUOUS WORK",SUP-G46168,CDM,C1894,HCPCS,0272,RC,,,both,,,1244.97,373.49,"AETNA [10100]","Aetna HMO/PPO",,989.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.79,1058.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6842.16,68,,,,,0,1083.33,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 80MM 80CM 10MM .035IN 3MM VASCULAR VENOUS",SUP-VENUM10080,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS [10001]","Blue Cross HMO",,8643.6,39.2,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 42MM FEMORAL LOW PROFILE STERILE RFN-ADVANCED",SUP-04.045.342TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,221.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",217.47,1589.42,"percent of total billed charges",
"STENT SURPASS EVOLVE 12MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45012,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"FIRST HEALTH [10303]","First Health",,66419.78,80,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 10.7MM 8MM STD LOW PROFILE DEPH FREE",SUP-8229708,CDM,S27200284,LOCAL,0272,RC,,,both,,,2895.00,868.5,"UHC [10700]","United Healthcare",,1832.54,63.3,,,,,0,336.69,2460.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY 270CM 1MM .039IN SPYBITE 55D 4.1MM 1.2MM WORK",SUP-M00546270,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1537.14,41.1,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 11MM X 14MM",SUP-4W7405,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]",Cigna,,4692,68,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 9MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-809,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"NOVANET [10819]",Novanet,,10093.84,75,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC LARGE 13X3.5-3.75IN RIGHT WRIST HAND",SUP-81096080,CDM,L3807,HCPCS,0274,RC,,,both,,,460.89,138.27,"CIGNA [10200]","Cigna Open Access",,262.25,56.9,,,,,0,53.6,391.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 48MM 28MM NEUTRAL HIP CERAMIC STERILE LATEX",SUP-121889648,CDM,C1776,HCPCS,0278,RC,,,both,,,14690.10,4407.03,"UHC [10700]","United Healthcare",,9298.83,63.3,,8601.07,8395.67,8601.07,"1 through 10",1708.46,12486.59,"percent of total billed charges",
"CATH INFINITI THRULUMEN 100CM 4FR .042IN MULTIPURPOSE A 2",SUP-538442,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELEV SURGICAL 7IN MOLT 2 END SHARP/SHARP",SUP-DO543R,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.53,83.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TRANSFORM 10MM 4MM BALLOON OCCLUSION 1 LUMEN SUPER",SUP-M003SSC07100,CDM,C1725,HCPCS,0272,RC,,,both,,,11760.02,3528.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 14X12.9CM NATRELLE P6.5CM EXTRA MODERATE HEIGHT",SUP-MSZMX520,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TEMPO 65CM 5FR COBRA 2 CURVE ANGIOGRAPHIC SLX TUNGSTEN",SUP-451543V0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP BIOPSY 270CM 1MM .039IN SPYBITE 55D 4.1MM 1.2MM WORK",SUP-M00546270,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2MM 11MM QUICKFIX TITANIUM FULL THREAD FOOT HAND",SUP-AR-8930-11,CDM,C1713,HCPCS,0278,RC,,,both,,,1800.00,540,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1224,68,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Ather Cmplx Init",PX-361000731,CDM,37290,CPT,0361,RC,,,both,,,23403.71,7021.11,"CIGNA [10200]","Cigna Open Access",,6428,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,23.4,19893.15,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Presumpt ID Ea Isol Urine",PX-306000064,CDM,87088,CPT,0306,RC,,,both,,,17.00,5.1,"PHCS [10601]",PHCS,,11.9,70,,,,,0,0.01,17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE 2 MG/ML INTRAVENOUS SYRINGE",RX-166018,CDM,J2270,HCPCS,0636,RC,00409-1890-01,NDC,both,1,ML,115.79,34.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.57,,"Fee schedule rate ($3.57). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.54,98.42,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION",RX-6221,CDM,J2560,HCPCS,0636,RC,00641-0477-21,NDC,both,1,ML,372.40,111.72,"UHC [10700]","United Healthcare",,113.42,,,,,,,7.76,316.54,"fee schedule",
"SABER .035 4X100 80CM SL",SUP-48004010N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,584.13,68,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 188MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-224.601,CDM,C1713,HCPCS,0278,RC,,,both,,,3116.40,934.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,369.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,362.44,2648.94,"percent of total billed charges",
"SCR BONE 3.5MM 12MM VUEPOINT II SPINE MULTIAXIAL NONSTERILE",SUP-8975312,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR ACTIS DUOFIX 1 STD OFFSET HIP STERILE",SUP-101011010,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"BLUE CROSS [10001]","Blue Cross PPO",,11946.69,39.2,,3949.44,3949.44,3949.44,"1 through 10",3544.39,25904.81,"percent of total billed charges",
"CATH SUPREME 120CM 5FR 5MM SPACE COURNAND 2 CURVE",SUP-401860R,CDM,C1730,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION LCS SIGMA HIP QUICK DRILL STERILE",SUP-950502300,CDM,S27200284,LOCAL,0272,RC,,,both,,,2043.75,613.12,"AETNA [10100]","Aetna HMO/PPO",,1624.78,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,237.69,1737.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 45CM .013IN SFT KNOB",SUP-6047,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HYDRA JAGWIRE DREAM TIP ENDOSCOPIC 260CM .035IN",SUP-M00556001,CDM,C1769,HCPCS,0272,RC,,,both,,,1422.36,426.71,"PHCS [10601]",PHCS,,995.65,70,,,,,0,165.42,1209.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +22.5 DIOPTER MODIFIED C BICONVEX 12.5MM 7MM",SUP-CZ70BD.225,CDM,V2632,HCPCS,0276,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,170.52,39.2,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 401120 MDII 20X20 SRVC FEE",SUP-401120,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM GORILLA R3CON LOCK",SUP-P50-353-3516,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",155.43,1136.03,"percent of total billed charges",
"CAP MOP - EMPHASYS",SUP-OSC382188,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9580.41,41.1,,6417.48,6417.48,6417.48,"1 through 10",2710.95,19813.5,"percent of total billed charges",
"CAP LINER ACETABULAR XLPE HIP CUSTOM KIT CAPITATE",SUP-71701012,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 120MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206051210,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 130CM 2CM 6MM BALLOON DILATATION",SUP-U813062,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGTRACE 10 VIAL CARTON",SUP-MTVC10001,CDM,A9697,HCPCS,0255,RC,,,both,,,5416.50,1624.95,"FIRST HEALTH [10303]","First Health",,4333.2,80,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL LEGION 6 KNEE LEFT JOURNEY LOCK",SUP-71933572,CDM,C1776,HCPCS,0278,RC,,,both,,,25949.70,7784.91,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3075.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3017.95,22057.25,"percent of total billed charges",
"HC Legion Pneumophilia Ag If",PX-306000097,CDM,87278,CPT,0306,RC,,,both,,,215.00,64.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.38,,"Fee schedule rate ($16.38). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,182.75,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 31CM 3MM PRUITT F3 OUTLYING PORT",SUP-E2012-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,9446.10,2833.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6423.35,68,,,,,0,1098.58,8029.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 12MM 144CM 3MM",SUP-H7493941212300,CDM,C1874,HCPCS,0278,RC,,,both,,,8245.50,2473.65,"MULTIPLAN [10600]",Multiplan,,7008.68,85,,,,,0,958.95,7008.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) AMENDTS SYSTEM TSP40T",SUP-90-7001-140,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 30MM MESENTERY THIN TISSUE ARTICULATE CURVE TIP",SUP-SIG30CTAV,CDM,S27200284,LOCAL,0272,RC,,,both,,,1461.81,438.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,173.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,170.01,1242.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Beta 2 Microglobulin",PX-301000112,CDM,82232,CPT,0301,RC,,,both,,,230.10,69.03,"CIGNA [10200]","Cigna Open Access",,35.6,,,,,,,0.01,195.59,"fee schedule",
"TIP MANIP 6.7MM RUMI UTERUS SOFT FLEXIBLE 8CM STERILE LATEX",SUP-UMB678,CDM,S27200284,LOCAL,0272,RC,,,both,,,563.16,168.95,"KAISER [10500]",Kaiser,,377.32,67,,,,,0,65.5,478.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 60MM 10MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U10060090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"FIRST HEALTH [10303]","First Health",,8280,80,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM 22.5MM PYROLYTIC CARBON MECHANICAL",SUP-27AECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"UHC [10700]","United Healthcare",,18432.47,63.3,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0210,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MEIER VASCULAR 185CM 15CM .035IN STAINLESS STEEL PTFE",SUP-SCH-30600,CDM,C1769,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE RIGHT CEMENTED POSTERIOR",SUP-150410225,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"CIGNA [10200]","Cigna Open Access",,7501.77,33.5,,5302.19,4377.88,6578.61,27,2604.35,19034.35,"percent of total billed charges",
"CMPNT PATELLAR 35MM MEDIALIZE DOME ATTUNE",SUP-151810035,CDM,C1776,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"MULTIPLAN [10600]",Multiplan,,6099.6,85,,,,,0,834.57,6099.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP LIMIT HOLE COLOR CODED POROUS G7 C",SUP-010000661,CDM,C1776,HCPCS,0278,RC,,,both,,,10120.92,3036.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2896.61,28.62,,,,,0,1177.06,8602.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE L 35MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 2X3",SUP-249.686,CDM,C1713,HCPCS,0278,RC,,,both,,,2305.80,691.74,"CIGNA [10200]",Cigna,,1567.94,68,,1831.33,1831.33,1831.33,16,268.16,1959.93,"percent of total billed charges",
"INSRT ARTICULAR 3-4 15MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934384,CDM,C1776,HCPCS,0278,RC,,,both,,,18947.25,5684.17,"BLUE CROSS [10001]","Blue Cross HMO",,7427.32,39.2,,5311.50,4717.44,5388.59,31,2203.57,16105.16,"percent of total billed charges",
"BEARING 87/91MMX14MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183584,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"FIRST HEALTH [10303]","First Health",,6271.82,80,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 12FR 40CM LARGE VALVE ASSEMB RADIOPAQUE BAND",SUP-G32373,CDM,C1894,HCPCS,0272,RC,,,both,,,476.85,143.05,"KAISER [10500]",Kaiser,,319.49,67,,,,,0,55.46,405.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kleinhauer Betke",PX-305000049,CDM,85460,CPT,0305,RC,,,both,,,223.25,66.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,27.46,,,,,,,1.64,189.76,"fee schedule",
"BURR SHAVER 13CM 4MM COOLCUT 8 FLUTE OVAL STERILE DISPOSABLE",SUP-AR-8400OBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,59.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 42X4IN 2 PORT 1 BLADDER DURABLE CONTACT CLSR",SUP-60-7070-107,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"CIGNA [10200]","Cigna Local Plus",,39.56,53.5,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED 100CM 6CM 11FR 35MM .035IN BALLOON DILATATION",SUP-611672,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"UHC [10700]","United Healthcare",,3366.32,63.3,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 81CM HEMOSTASIS GWIRE SWARTZ .032IN SL0",SUP-406949,CDM,C1893,HCPCS,0272,RC,,,both,,,1368.90,410.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,562.62,41.1,,,,,0,159.2,1163.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 150MM 4MM BALLOON DILATATION OTW",SUP-H74939206041510,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIPERACILLIN-TAZOBACTAM 3.375 G/15 ML IV (WET SOLR VIAL)",RX-41518303,CDM,J2543,HCPCS,0636,RC,00781-3113-90,NDC,both,1,UN,139.40,41.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,94.79,68,,,,,0,3.74,118.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lrt Iad 18bct/8vir&7arg Rna",PX-310000032,CDM,0528U,CPT,0310,RC,,,both,,,1745.00,523.5,"FIRST HEALTH [10303]","First Health",,1396,80,,,,,0,206.78,1483.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA NATURAL TIBIA 5D C KNEE LEFT STEM",SUP-42532006401,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"AETNA [10100]","Aetna HMO/PPO",,8692.32,79.5,,10981.53,8986.79,12413.38,12,1271.59,9293.68,"percent of total billed charges",
"CABLE CATH 3MR CARTO 3 INTERFACE REPROCESSED",SUP-D134401,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"CIGNA [10200]","Cigna Open Access",,1916.11,56.9,,,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT BUMPER GMRS 3D KNEE PROXIMAL MODULAR ROTATE HINGE",SUP-6481-2-133,CDM,C1776,HCPCS,0278,RC,,,both,,,3543.75,1063.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1626.58,45.9,,,,,0,412.14,3012.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 2-0 CT-1 27IN MONOFILAMENT YELLOWISH TAN",SUP-843H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TRISOL DELIVERY SYSTEM KIT",SUP-DMS-14630,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROLENE 12X12IN HERNIA NONABSORBABLE SOFT",SUP-PML,CDM,C1781,HCPCS,0278,RC,,,both,,,1322.83,396.85,"BLUE CROSS [10001]","Blue Cross HMO",,518.55,39.2,,,,,0,153.85,1124.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 26CM 5FR .038IN PIGTAIL CURVE",SUP-M006155223120,CDM,C2617,HCPCS,0278,RC,,,both,,,1357.97,407.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,623.31,45.9,,,,,0,157.93,1154.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS MBA LARGE BORE",SUP-MAP400,CDM,S27200284,LOCAL,0272,RC,,,both,,,185.40,55.62,"CIGNA [10200]",Cigna,,126.07,68,,,,,0,21.56,157.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM 3.5MM 2.1-2.7FR CORONARY",SUP-RONYX35022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3112.50,933.75,"AETNA [10100]","Aetna HMO/PPO",,2474.44,79.5,,,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 15MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158125115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1299.6,9498.37,"percent of total billed charges",
"ROD SPINAL 40MM 5.5MM MATRIX CURVE TITANIUM HARD NONSTERILE",SUP-04.636.040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"SOL FORMIC ACID FORMALDEHYDE CAL-RITE 1GL DECALCIFY FIXATION",SUP-5501,CDM,S27000186,LOCAL,0270,RC,,,both,,,552.50,165.75,"KAISER [10500]",Kaiser,,370.18,67,,,,,0,64.26,469.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD 25CM 8FR DRNG FLEXIMA METAL HYDROPHILIC REGULAR",SUP-M001271290,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BENTSON 28CM 15CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175264060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,285.46,28.62,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 12MM 5.5MM REVERE SPINE WIDE BLADE PARALLEL CLAMP",SUP-124.965,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1985.13,41.1,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X9MM SABLE 8D STERILE LATEX FREE",SUP-1172.2013S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"FIRST HEALTH [10303]","First Health",,27720,80,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP 5MM TITANIUM ENDOSCOPIC LIGATING SUPER",SUP-176620,CDM,S27200284,LOCAL,0272,RC,,,both,,,1042.63,312.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,121.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.26,886.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING UNITRAX V40 +12MM HIP UNIPOLAR",SUP-6942-6-080,CDM,C1776,HCPCS,0278,RC,,,both,,,1085.40,325.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,128.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,126.23,922.59,"percent of total billed charges",
"SET RTRCTR FUKUSHIMA-DAY STAINLESS STEEL TABLE CLAMP U BAR",SUP-R9100,CDM,S27200284,LOCAL,0272,RC,,,both,,,108384.99,32515.5,"KAISER [10500]",Kaiser,,72617.94,67,,,,,0,12605.17,92127.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS SOLN DEX 2.5 % LOW CA+ 2.5 MEQ/L&MAG 0.5 MEQ/L",RX-27800,CDM,,,0250,RC,00941-0430-52,NDC,both,2000,ML,241.44,72.43,"NOVANET [10819]",Novanet,,181.08,75,,,,,0,28.08,205.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 80CM 2CM 5MM BALLOON",SUP-G52337,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"FIRST HEALTH [10303]","First Health",,767.82,80,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ctrl Nosebleed Postr Subq",PX-450000216,CDM,30906,CPT,0450,RC,,,both,,,813.00,243.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,96.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.81,813,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM SWIVELOCK FIBERLINK SUTURETAPE",SUP-AR-1665KBCSL,CDM,C1713,HCPCS,0278,RC,,,both,,,6230.70,1869.21,"CIGNA [10200]",Cigna,,4236.88,68,,1831.33,1831.33,1831.33,16,724.63,5296.1,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL LOOP BLADDER TUMOR RESECTION",SUP-M0065051641,CDM,S27200284,LOCAL,0272,RC,,,both,,,446.34,133.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.91,379.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CREO CREO AMP SPINAL MODULAR NONSTERILE",SUP-1067.1650,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3923.76,41.1,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 LEFT KNEE CRUCIATE RETAINING CEMENTED",SUP-5510-F-301,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"MULTIPLAN [10600]",Multiplan,,13938.17,85,,,,,0,1907.07,13938.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC or Add 15 Min",PX-360000005,CDM,9999157,LOCAL,0360,RC,,,both,,,2241.14,672.34,"AETNA [10100]","Aetna HMO/PPO",,1781.71,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,260.64,1904.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X7MM 7D LORDOTIC TRAPEZOID SPINE",SUP-7407,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION",RX-31432,CDM,J1162,HCPCS,0636,RC,50633-0120-11,NDC,both,1,UN,30023.06,9006.92,"MULTIPLAN [10600]",Multiplan,,25519.6,85,,,,,0,567.33,25519.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE ABSORBABLE 4X3IN HELISTAT HEMOSTATIC AGENT 5ML",SUP-3410ZX,CDM,S27200284,LOCAL,0272,RC,,,both,,,1551.97,465.59,"CIGNA [10200]","Cigna Open Access",,883.07,56.9,,,,,0,180.49,1319.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 74X50X14MM CURRENT PLUS VR 36J TITANIUM CAN",SUP-CD1211-36Q,CDM,C1722,HCPCS,0278,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X17MM 9/11MM SPINE CORTICAL FREEZE DRIED",SUP-14917,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6624,40,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE VISI-BLACK 5-0 C-1 24IN 2 ARM MONOFILAMENT BLUE",SUP-8725H,CDM,S27200284,LOCAL,0272,RC,,,both,,,150.18,45.05,"CIGNA [10200]",Cigna,,102.12,68,,,,,0,17.47,127.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHLORHEXIDINE GLUCONATE 2 % TOWELETTE",RX-88296,CDM,,,0250,RC,53462-0705-23,NDC,both,1,UN,27.62,8.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,12.68,45.9,,,,,0,3.21,23.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR 5MM STORZ 1 STEM",SUP-M0068804011,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"PHCS [10601]",PHCS,,361.54,70,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIFY ASSURA NEXT GENERATION CRT-D 40",SUP-CD3357-40C,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"BLUE CROSS [10001]","Blue Cross PPO",,22626.24,39.2,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE MONORAIL 150CM 220MM 3MM BALLOON DILATATION",SUP-H74939185302210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 5CMX18MM METRX ANGLED TUBULAR 18MM SPINAL SURGICAL",SUP-9569815,CDM,S27800098,LOCAL,0278,RC,,,both,,,1702.50,510.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1157.7,68,,,,,0,198,1447.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 8 SLOT RIGHT TI",SUP-PHPF-C8R,CDM,C1713,HCPCS,0278,RC,,,both,,,21420.00,6426,"AETNA [10100]","Aetna HMO/PPO",,17028.9,79.5,,1521.93,481.35,16760.95,30,2491.15,18207,"percent of total billed charges",
"SCREW NON-LOCKING 2.0MM X 15MM TI",SUP-VAN-20150-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",113.04,826.2,"percent of total billed charges",
"CANN ARTHROSCOPIC 8.5MM COMPLETE SYSTEM 45MM CLEAR-TRAC",SUP-72200904,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,141.98,68,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VICI VENOUS STENT 120MM 100MM 16MM ENDOPROSTHESIS",SUP-H74916120100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT FLITES MEDIUM LOOP DISPOSABLE",SUP-MFA2100-M-L1,CDM,S27000186,LOCAL,0270,RC,,,both,,,231.51,69.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,157.43,68,,,,,0,26.92,196.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPREME EXTENSION CABLE RED  150 CM",SUP-401983R,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"CIGNA [10200]","Cigna Local Plus",,153.6,53.5,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 16.1MM 23MM 29MM 21.4MM ON-X 23 STD CYLINDRICAL",SUP-ONXAE-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"CIGNA [10200]","Cigna Local Plus",,11907,31.5,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VASCURE FOR VASCULAR REPAIR FIVE PACK 1 X 10 CM",SUP-CMCV-014-609,CDM,C1768,HCPCS,0278,RC,,,both,,,3457.50,1037.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,989.54,28.62,,,,,0,402.11,2938.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL BLUE 25X32X8.4-12MM SYNFIX 10D SMALL PEEK",SUP-08.815.112S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AETNA [10100]","Aetna HMO/PPO",,22538.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 30MM 2.5MM BALLOON DILATATION DURALYN",SUP-48002503S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UHC [10700]","United Healthcare",,794.73,63.3,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"M AC611 HFNC FEP CONNECT 20 PK",SUP-73-1134191,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.51,57.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,78.71,41.1,,,,,0,22.27,162.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ILLMNTR OPHTHALMIC 25GA CONSTELLATION EDGEPLUS 106D RADIO",SUP-8065751577,CDM,S27200284,LOCAL,0272,RC,,,both,,,1079.08,323.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,127.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,125.5,917.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 5MM KII ADVANCE FIXATION RETENTION",SUP-CFR01,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR 2.4MM STEP DRILL GUIDE DISPOSABLE SMALL JOINT",SUP-AR-8934DSC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1233.23,369.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 75CM 80MM 12MM BALLOON DILATATION OTW NONCOMPLIANT",SUP-H74939206120870,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNARE MEDIUM 230CM 2.8MM 15MM SNAREMASTER WIRE LOOP INTEGRAL",SUP-SD-240U-15,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.57,23.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE LESLIE PARACHUTE 120CM 11MM 3.1FR SPECIMEN RETRIEVAL",SUP-M0063203020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1464.48,439.34,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRACKER NAVIGATION VPAD",SUP-INS-0050,CDM,S27200284,LOCAL,0272,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABERX RADIANZ 9MM8CM 190",SUP-R51009008L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT 8-0 VICRYL",SUP-J974G,CDM,S27200284,LOCAL,0272,RC,,,both,,,199.77,59.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ZIPWIRE STIFF .025IN STRAIGHT TIP BX 5",SUP-M0066802161,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 9 STD OFFSET HIP",SUP-71935569,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15015.35,41.1,,6417.48,6417.48,6417.48,"1 through 10",4248.87,31053.65,"percent of total billed charges",
"ENT BUR 6.0MMDIA FINE DIAMOND SS 70MM LONG SHORT ANSPACH",SUP-SA-DB6,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,200.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 24FR CUT STORZ 2 STEM",SUP-M0068802231,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"MULTIPLAN [10600]",Multiplan,,406.49,85,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X8MM 5D OVAL SPINE CORTICAL FREEZE",SUP-017208,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VADO 2.1 STEERABLE SHEATH ? BI-DIRECTIONAL",SUP-SS8FMB74,CDM,C1766,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3988.2,68,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 60CM 6MM STRAIGHT FUSION BIOLINE POLYESTER 2",SUP-M00201503066B0,CDM,C1768,HCPCS,0278,RC,,,both,,,10631.52,3189.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4879.87,45.9,,,,,0,1236.45,9036.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 9IN DERRICO BAYONET CURVE BLADE NERVE SURGICAL 7.9MM",SUP-NL5770,CDM,S27200284,LOCAL,0272,RC,,,both,,,823.12,246.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,97.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,95.73,699.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 26MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.526,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"CIGNA [10200]","Cigna Local Plus",,586.58,53.5,,3978.14,359.25,3978.14,24,127.51,931.96,"percent of total billed charges",
"VALVE AORTIC 26MM EDWARDS SAPIEN NOVAFLEX TRANSFEMORAL",SUP-9355NF26A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,53018.55,28.62,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ARTHROCELL PLUS DEMINERALIZE CORTICAL CANCELLOUS",SUP-ABS-2090-05,CDM,C1734,HCPCS,0278,RC,,,both,,,22050.00,6615,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8820,40,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 18FR TUNGSTEN SILICONE 2.3CM MIC-KEY",SUP-0270-18-2.3-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"AETNA [10100]","Aetna HMO/PPO",,2093.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 5X5CM CYTAL PORCINE BLADDER 6 LAYER WOUND",SUP-WSX0505,CDM,Q4166,HCPCS,0636,RC,,,both,,,9515.38,2854.61,"AETNA [10100]","Aetna HMO/PPO",,7564.73,79.5,,,,,0,53.69,8088.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 20MM 2.5MM BALLOON DILATATION PEBAX",SUP-1012272-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CEREGLIDE 71 132CM 55CM .082IN .071IN ASPIRATION",SUP-NIC71132U,CDM,C1757,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 30MM DST SERIES TA TITANIUM VASCULAR ENDOSCOPIC",SUP-TA30V3L,CDM,S27200284,LOCAL,0272,RC,,,both,,,307.89,92.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,141.32,45.9,,,,,0,35.81,261.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 CURVE PLUS 15MM KNEE XLK FIX BEARING SIGMA",SUP-970433,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross PPO",,4380.42,39.2,,3949.44,3949.44,3949.44,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"GRAFT ENDOVASCULAR 225MM 38-42MM 37-38MM ZENITH ALPHA CAPTOR",SUP-G38204,CDM,C1874,HCPCS,0278,RC,,,both,,,89876.46,26962.94,"CIGNA [10200]","Cigna Open Access",,30108.61,33.5,,,,,0,10452.63,76394.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 6MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBH061502,CDM,C1874,HCPCS,0278,RC,,,both,,,23102.10,6930.63,"KAISER [10500]",Kaiser,,15478.41,67,,,,,0,2686.77,19636.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL JANSEN-MIDDLETON 8.25IN",SUP-OK405R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1917.83,575.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,223.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,223.04,1630.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENICILLIN G POTASSIUM 10,000 UNITS/ML SKIN TEST ANTIGEN",RX-411111,CDM,J2540,HCPCS,0636,RC,08888-8877-31,NDC,both,1,UN,115.25,34.57,"CIGNA [10200]","Cigna Local Plus",,2.11,,,,,,,0.92,97.96,"fee schedule",
"CNCT ROD SMALL 5.5MM TSRH-3D OPEN OFFSET TITANIUM POSTERIOR",SUP-8379120,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"AETNA [10100]","Aetna HMO/PPO",,2832.19,79.5,,1521.93,481.35,16760.95,30,414.32,3028.13,"percent of total billed charges",
"STENT CONTOUR SENSOR 20CM 3CM 7FR .035IN 2 FLOPPY PIGTAIL",SUP-M006180230090,CDM,C2617,HCPCS,0278,RC,,,both,,,1294.14,388.24,"CIGNA [10200]",Cigna,,880.02,68,,,,,0,150.51,1100.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 9.5CM 20MM 16.5-18.5MM EXCLUDER",SUP-PLC201000,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"PHCS [10601]",PHCS,,19598.04,70,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3.5MM 24MM TITANIUM CORTEX SELF TAP CRUCIFORM",SUP-401.824,CDM,C1713,HCPCS,0278,RC,,,both,,,397.07,119.12,"CIGNA [10200]","Cigna Open Access",,225.93,56.9,,1144.80,304.56,2275.09,66,46.18,337.51,"percent of total billed charges",
"HC Outr/Ua Assay of Urine Sulfate",PX-300000030,CDM,84392,CPT,0301,RC,,,both,,,41.60,12.48,"KAISER [10500]",Kaiser,,27.87,67,,,,,0,0.01,35.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 20MM 2 VELOUR STRAIGHT TUBE",SUP-M002020952200,CDM,C1768,HCPCS,0278,RC,,,both,,,3633.53,1090.06,"PHCS [10601]",PHCS,,2543.47,70,,,,,0,422.58,3088.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT PARALLEL ALLOGRAFT 8MM TLIF",SUP-3W3308,CDM,S27800098,LOCAL,0278,RC,,,both,,,17139.60,5141.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2031.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1993.34,14568.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR .9MM DORNHOFFER MICRO TITANIUM 3 POINT",SUP-7014-3253,CDM,L8613,HCPCS,0278,RC,,,both,,,1684.73,505.42,"PHCS [10601]",PHCS,,1179.31,70,,,,,0,195.93,1432.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE D-STAT TOPICAL SILVER DRY STERILE",SUP-3000,CDM,S27200284,LOCAL,0272,RC,,,both,,,361.05,108.31,"UHC [10700]","United Healthcare",,228.54,63.3,,,,,0,41.99,306.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 44MM CERAMIC DELTA",SUP-400-03-443,CDM,S27200284,LOCAL,0272,RC,,,both,,,16953.92,5086.18,"PHCS [10601]",PHCS,,11867.74,70,,,,,0,1971.74,14410.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.2MM KIRSCHNER TEMPORARY",SUP-DC4212,CDM,C1713,HCPCS,0278,RC,,,both,,,550.80,165.24,"BLUE CROSS [10001]","Blue Cross HMO",,215.91,39.2,,957.42,156.86,7483.26,51,64.06,468.18,"percent of total billed charges",
"BIT DRILL 12MM SPINE",SUP-610.712,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"NOVANET [10819]",Novanet,,437.4,75,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION SUPERORDERABLE",RX-408818,CDM,,,0250,RC,00409-9558-10,NDC,both,10,ML,64.86,19.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.54,55.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET SPINE LOCKING XLNK MAS CNCT",SUP-7752529,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,159.73,45.9,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fecal Fat Qual",PX-301000187,CDM,82705,CPT,0301,RC,,,both,,,170.05,51.01,"NOVANET [10819]",Novanet,,127.54,75,,,,,0,0.01,144.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACEMKR 46CM 6FR TENDRIL STS ENDOCARDIUM STEROID",SUP-2088TC/46,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"MULTIPLAN [10600]",Multiplan,,1897.63,85,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pack Perfusion Custom",PX-E27200369,CDM,E27200369,LOCAL,0272,RC,,,both,,,2772.00,831.6,"CIGNA [10200]","Cigna Local Plus",,1483.02,53.5,,,,,0,322.38,2356.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY ALLIGATOR JAW STEP NDL 1550MM 1.9MM ENDOJAW",SUP-FB-221K.A,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.00,58.5,"UHC [10700]","United Healthcare",,123.44,63.3,,,,,0,22.68,165.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MICROSHEATH XL 110CM STRAIGHT GUIDING PERIPHERAL BRAID",SUP-MSXL17110,CDM,C1887,HCPCS,0272,RC,,,both,,,2062.50,618.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,847.69,41.1,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 16 X 13 X 08MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-161308-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"AMERIGROUP MEDICAID [20100]",Amerigroup,,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 5-0 P-1 18IN MONOFILAMENT GREEN NONABSORBABLE",SUP-G695G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 49MM CENTERPULSE LEGACY 12/14 TAPER HIP FEMUR",SUP-451000049,CDM,C1776,HCPCS,0278,RC,,,both,,,2398.65,719.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1631.08,68,,,,,0,278.96,2038.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 24FR NEPHRSTMY NATURAL RUBBER 4 WING DRAIN",SUP-086024,CDM,C1729,HCPCS,0272,RC,,,both,,,105.65,31.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,71.84,68,,,,,0,12.29,89.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION",RX-88011,CDM,Q2009,HCPCS,0636,RC,00069-5471-01,NDC,both,2,ML,27.69,8.31,"CIGNA [10200]","Cigna Open Access",,15.76,56.9,,,,,0,3.28,23.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 2.5CM 18FR SILICONE MIC-KEY RADIOPAQUE LOW",SUP-8230-18-2.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,170.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 1.75IN 2.1MM CARBIDE 6 FLUTED CROSS CUT",SUP-0277010221,CDM,S27000186,LOCAL,0270,RC,,,both,,,54.98,16.49,"UHC [10700]","United Healthcare",,34.8,63.3,,,,,0,6.39,46.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN DEBRIDEMENT WITH MCC",570,MS-DRG,,,,,,,inpatient,,,87589.05,26276.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,55813.25,,"Fee schedule rate ($55,813.25). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,85868.36,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"LIGASURE EXACT DISSECTOR NANO-COATED",SUP-LF2019,CDM,S27200284,LOCAL,0272,RC,,,both,,,3719.93,1115.98,"CIGNA [10200]","Cigna Open Access",,2116.64,56.9,,,,,0,432.63,3161.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 175MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309117,CDM,C1776,HCPCS,0278,RC,,,both,,,37771.65,11331.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15524.15,41.1,,6417.48,6417.48,6417.48,"1 through 10",4392.84,32105.9,"percent of total billed charges",
"SPACER SPINAL 14X12X7MM COALITION TITANIUM ANTERIOR CERVICAL",SUP-384.107,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7398,41.1,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 80CM 6MM 8FR STRAIGHT VASCULAR",SUP-AVSM06100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2124.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,inpatient,,,81965.04,24589.51,"PHCS [10601]",PHCS,,7561,,,,,,,7561,59825.52,"per diem","Estimated amount calculated based on 4 day length of stay."
"DEFIB CARDIAC 73X40X14IN FORTIFY 2.5V 500OHM 60 PPM TITANIUM",SUP-CD1231-40,CDM,C1722,HCPCS,0278,RC,,,both,,,35000.00,10500,"PHCS [10601]",PHCS,,24500,70,,,,,0,4070.5,29750,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL TRIATHLON 3 4 KNEE HINGE BEARING STERILE LATEX",SUP-5612-0-003,CDM,C1776,HCPCS,0278,RC,,,both,,,28659.96,8597.99,"CIGNA [10200]","Cigna Open Access",,9601.09,33.5,,5302.19,4377.88,6578.61,27,3333.15,24360.97,"percent of total billed charges",
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN AMPLATZ",SUP-77803600,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RIGIFLEX II 90CM 10CM 14FR 30MM BALLOON DILATATION",SUP-M00554500,CDM,C1726,HCPCS,0272,RC,,,both,,,4370.81,1311.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,508.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,508.33,3715.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 82MM PRESS FIT AEQUALIS ASCEND FLEX PTC 137.5D",SUP-DWF605C,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"KAISER [10500]",Kaiser,,8442,67,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 0 GS-21 HALF CIRCLE 6IN 37MM CLSR GLYCOLIC",SUP-VLOCL0306,CDM,S27200284,LOCAL,0272,RC,,,both,,,406.03,121.81,"AETNA [10100]","Aetna HMO/PPO",,322.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.22,345.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER 13.5MM 5.5MM SPIKE LC-DCP ORTHOPEDIC PEEK-OPTIMA 6%",SUP-219.951,CDM,C1713,HCPCS,0278,RC,,,both,,,743.90,223.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,88.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",86.52,632.32,"percent of total billed charges",
"SUT VICRYL PLUS 4-0 FS-2 27IN BRAID COATED ANTIBACTERIAL",SUP-VCP422H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)VALVE AORTIC 26MM SAPIEN RETROFLEX 3 HEART COCR BOVINE",SUP-9600TFX26,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"AETNA [10100]","Aetna HMO/PPO",,135945,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC",440,MS-DRG,,,,,,,inpatient,,,22910.11,6873.03,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,3970.22,,"Case rate ($3,854.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,579.24, add-ons for qualifying new technology services are included. If operating cost exceeds $36,618.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,652.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,583.97. The transfer operating threshold is the transfer adjustment factor * $3,579.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $270.61. The transfer capital threshold is the transfer adjustment factor * $270.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,3854.58,15497.09,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM HELIX R SPINE SELF DRILL VARIABLE ANGLE",SUP-7801115,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pregnancy Test Urine",PX-307000008,CDM,81025,CPT,0307,RC,,,both,,,383.80,115.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.21,,"Fee schedule rate ($9.21). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",9.53,9.53,9.53,56,4.29,326.23,"fee schedule",
"HC Repo Pcmkr/Lead Ra/Rv",PX-480000010,CDM,33215,CPT,0481,RC,,,both,,,8007.76,2402.33,"NOVANET [10819]",Novanet,,6005.82,75,,,,,0,931.3,8007.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repo Pcmkr/Lead Ra/Rv",PX-480000010,CDM,33215,CPT,0481,RC,,,both,,,8007.76,2402.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4752,,"Case rate ($4,752). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,931.3,8007.76,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repo Pcmkr/Lead Ra/Rv",PX-480000010,CDM,33215,CPT,0481,RC,,,both,,,8007.76,2402.33,"CIGNA [10200]",Cigna,,8007.76,,"Case rate ($37,605). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,931.3,8007.76,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tomosynthesis Breast Dgtl Dx Bi",PX-401000009,CDM,77062,CPT,0401,RC,,,both,,,621.66,186.5,"PHCS [10601]",PHCS,,435.16,70,,,,,0,72.3,528.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Epidrm Autograft a/T/L <=100scm",PX-761000021,CDM,15110,CPT,0761,RC,,,both,,,2471.00,741.3,"CIGNA [10200]","Cigna Local Plus",,2051,,"Per diem ($2,051).",,,,0,2.47,2471,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 2.5MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-02505,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3165.24,27,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM ROUND CARBIDE STERILE LATEX FREE",SUP-5820-110-030C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1910.03,573.01,"UHC [10700]","United Healthcare",,1209.05,63.3,,,,,0,222.14,1623.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 4MM .4MM GRACE BUCKET HANDLE OFFSET NITINOL",SUP-430-400,CDM,L8613,HCPCS,0278,RC,,,both,,,2371.58,711.47,"PHCS [10601]",PHCS,,1660.11,70,,,,,0,232.31,2015.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 11CM 24MM 33MM 21.4MM GELWEAVE VALSALVA ON-X",SUP-ONXAAP-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,51187.50,15356.25,"AETNA [10100]","Aetna HMO/PPO",,40694.06,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5953.11,43509.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40022W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"BLUE CROSS [10001]","Blue Cross PPO",,2132.09,39.2,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 200CM 10MM .063IN 1.5MM ATHERECTOMY",SUP-DBP-CART-150SOL200,CDM,C1724,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 85MM 5.5MM CREO LATERAL HEAD RIGHT NONSTERILE",SUP-1175.5522,CDM,C1713,HCPCS,0278,RC,,,both,,,12061.20,3618.36,"PHCS [10601]",PHCS,,8442.84,70,,,,,0,1402.72,10252.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 700MM 22GA 1.8MM 40MM TRANSBRONCHIAL",SUP-NA-201SX-4022-A,CDM,S27200284,LOCAL,0272,RC,,,both,,,682.02,204.61,"UHC [10700]","United Healthcare",,431.72,63.3,,,,,0,79.32,579.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 51MM BIO-MOORE II ENDO II HIP ACETABULAR",SUP-12-139026,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"CIGNA [10200]",Cigna,,1899.24,68,,5873.17,5873.17,5873.17,"1 through 10",324.83,2374.05,"percent of total billed charges",
"TROCAR 10CM SPLIT SURGICAL STERILE DISPOSABLE",SUP-824095,CDM,S27200284,LOCAL,0272,RC,,,both,,,2635.35,790.6,"CIGNA [10200]","Cigna Local Plus",,1409.91,53.5,,,,,0,306.49,2240.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 9 HIP",SUP-PRTLE029,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7767.9,41.1,,6417.48,6417.48,6417.48,"1 through 10",2198.07,16065,"percent of total billed charges",
"STENT GORE VIABAHN 59MM 135CM 11MM 16SQ MM 8FR .035IN",SUP-BXA115902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS [10001]","Blue Cross PPO",,7645.88,39.2,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM COLLAR SECUR-FIT TITANIUM HA 132D 13 C",SUP-S-2337-HF13,CDM,C1776,HCPCS,0278,RC,,,both,,,24037.65,7211.29,"BLUE CROSS [10001]","Blue Cross HMO",,9422.76,39.2,,5311.50,4717.44,5388.59,31,2795.58,20432,"percent of total billed charges",
"MESH SURGICAL BARD MARLEX 12X2IN GROIN MONOFILAMENT GOLD STD",SUP-0112670,CDM,C1781,HCPCS,0278,RC,,,both,,,399.33,119.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,114.29,28.62,,,,,0,46.44,339.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 75CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR061001A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"BLUE CROSS [10001]","Blue Cross PPO",,8337.37,39.2,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET TITANIUM T15 STD SPINE LOCK CAP NONSTERILE",SUP-102000000,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 5MM BALL DISSECTING DIAMOND STERILE DISPOSABLE",SUP-MR8-14BA50D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.17,412.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,934.44,68,,,,,0,159.82,1168.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 15MM KNEE GVF STABILIZE ROTATE PLATFORM PFC",SUP-962113,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4684.14,45.9,,,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 3.5MM CCM PRECUT",SUP-G7753890,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"INSRT ARTICULAR 3-7 CD 11MM KNEE RIGHT ULTRACONGRUENT",SUP-42522200411,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1253.3,9159.96,"percent of total billed charges",
"HC Aspen Pads for Cerv Coll",PX-E27400103,CDM,L0999,HCPCS,0274,RC,,,both,,,258.50,77.55,"CIGNA [10200]","Cigna Open Access",,147.09,56.9,,,,,0,30.06,219.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUADRA ALLURE MP RF CRT-P",SUP-PM3262,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"BLUE CROSS [10001]","Blue Cross PPO",,9051.44,39.2,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PICK SURGICAL 6IN STRAIGHT HOUGH MALLEABLE HEAVY SHAFT",SUP-61-0349,CDM,S27200284,LOCAL,0272,RC,,,both,,,421.34,126.4,"NOVANET [10819]",Novanet,,316.01,75,,,,,0,49,358.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 17MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50017,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"MULTIPLAN [10600]",Multiplan,,70571.01,85,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 40MX19.5MMX.4MM STERILE",SUP-KM-3231,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM TITANIUM FULL THREAD LOCK STERILE T2 NAIL",SUP-1896-4030S,CDM,C1713,HCPCS,0278,RC,,,both,,,1309.77,392.93,"MULTIPLAN [10600]",Multiplan,,1113.3,85,,,,,0,152.33,1113.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 122MM 9.5-13MM 6 SHOOTER SAEED 6 BAND STERILE",SUP-MBL-6,CDM,S27200284,LOCAL,0272,RC,,,both,,,3247.50,974.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1490.6,45.9,,,,,0,377.68,2760.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC ENDOBLADE GASTROC RECESSION SYSTEM",SUP-AR-8855DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,6484.28,1945.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,768.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,754.12,5511.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Phosphorus Urine",PX-301000360,CDM,84105,CPT,0301,RC,,,both,,,132.05,39.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,112.24,"per diem",
"DEVICE HEARTMATE GOGEAR THORATEC LARGE VENTRICULAR ASSIST",SUP-104231,CDM,Q0498,HCPCS,0274,RC,,,both,,,2883.60,865.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,341.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,335.36,2451.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTAINSTABILITY QUADPOLE LEAD",SUP-479878,CDM,C1900,HCPCS,0278,RC,,,both,,,11626.50,3487.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3139.16,27,,,,,0,1352.16,9882.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION 16FR SURESTEP BARDEX IC COMPLETE CARE",SUP-A300316A,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.29,41.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,57.25,41.1,,,,,0,16.2,118.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM HEALIX ADVANCE PERMATAPE PEEK BLUE",SUP-222363,CDM,C1713,HCPCS,0278,RC,,,both,,,2812.50,843.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1290.94,45.9,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 10MM BALLOON",SUP-U3575108,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 560CC",SUP-RSZ-SHPX-560S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"AETNA [10100]","Aetna HMO/PPO",,132.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L32 MM OD5 MM LOW PROFILE LOCK NONSTERILE RFN-ADV",SUP-04.045.332TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"MULTIPLAN [10600]",Multiplan,,1589.42,85,,,,,0,217.47,1589.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 7.6CM 3MM LEGEND CARBIDE METAL CUTTING FINAL",SUP-MC30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 34MM TI",SUP-MTLS-37340-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 65X35MM SMALL ALUMINUM DENVER SEPTUM 2 PIECE",SUP-10-1800-05KS,CDM,S27000186,LOCAL,0270,RC,,,both,,,498.96,149.69,"PHCS [10601]",PHCS,,349.27,70,,,,,0,58.03,424.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLINDAMYCIN 150 MG/ML INJECTION SOLUTION",RX-82303,CDM,J0736,HCPCS,0636,RC,00009-0870-26,NDC,both,2,ML,22.53,6.76,"BLUE CROSS [10001]","Blue Cross PPO",,2.13,,,,,,,2.13,19.15,"fee schedule",
"CATH STERLING MONORAIL 150CM 20MM 2MM BALLOON DILATATION",SUP-H74939031202010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE EXPLOR LOCK",SUP-11-210099,CDM,S27800098,LOCAL,0278,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,231.82,28.62,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 30MM 154CM 12MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200123020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 28MM 3MM CORONARY STENT EVEROLIMUS",SUP-1550300-28,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X20 80CM SL",SUP-48005002N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"PHCS [10601]",PHCS,,601.31,70,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 10MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-310,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]",Cigna,,5250.9,40,,5873.17,5873.17,5873.17,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"CATH SUPREME 120CM 6FR 2-5-2MM SPACING JSN CURVE",SUP-401451,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"FIRST HEALTH [10303]","First Health",,583.2,80,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 46MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-46-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"PHCS [10601]",PHCS,,3960.6,70,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM ATTUNE 5 KNEE POSTERIOR CEMENT REVISION",SUP-1549-05-001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,719.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Abd&Pelvis W/WO Cntrst 1+ Reg",PX-352000030,CDM,74178,CPT,0352,RC,,,both,,,6666.64,1999.99,"CIGNA [10200]","Cigna Local Plus",,446,,"Per diem ($446). Each unique revenue code and service date combination is paid its own per diem rate.",567.00,567.00,567.00,"1 through 10",405,5666.64,"per diem",
"RING ANNULOPLASTY SIZE 38 OD45MM ID37MM MITRAL VALVE SEMI RI",SUP-SARP-38,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3268.73,27,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20 DIOPTER +1.5 CYL HAPTIC C BICONVEX 13MM 6MM",SUP-ZXT150U200,CDM,V2788,HCPCS,0276,RC,,,both,,,834.00,250.2,"BLUE CROSS [10001]","Blue Cross HMO",,326.93,39.2,,,,,0,96.99,708.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 30MMX4.8MM PROXIMATE TX TITANIUM THICK TISSUE 2",SUP-XR30G,CDM,S27200284,LOCAL,0272,RC,,,both,,,938.45,281.53,"UHC [10700]","United Healthcare",,594.04,63.3,,,,,0,109.14,797.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 14MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-714-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]",Cigna,,4813.44,40,,5873.17,5873.17,5873.17,"1 through 10",1399.51,10228.56,"percent of total billed charges",
"HC Rpr Sclp/Limb 1.1-2.5cm Cmplx",PX-450000049,CDM,13120,CPT,0450,RC,,,both,,,1861.00,558.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1861,,,,,,,1.86,1861,"case rate",
"CNTRLZR STEM 12MM C-STEM HIP FEMUR PMMA CEMENT VOID STERILE",SUP-961212500,CDM,C1776,HCPCS,0278,RC,,,both,,,842.40,252.72,"CIGNA [10200]","Cigna Open Access",,479.33,56.9,,5302.19,4377.88,6578.61,27,97.97,716.04,"percent of total billed charges",
"SCR BONE CANNULATED STERILE 7MM 100MM 16MM STAINLESS STEEL",SUP-71127100,CDM,C1713,HCPCS,0278,RC,,,both,,,2479.50,743.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1686.06,68,,,,,0,288.37,2107.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY",RX-15738,CDM,,,0250,RC,60505-0823-06,NDC,both,3.7,ML,596.26,178.88,"MULTIPLAN [10600]",Multiplan,,506.82,85,,,,,0,69.35,506.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA ALLOGRAFT STRUT FROZEN 110X5MM",SUP-450655,CDM,S27800098,LOCAL,0278,RC,,,both,,,6172.74,1851.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2833.29,45.9,,,,,0,717.89,5246.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 11CM 20MM 17.4MM 27MM GELWEAVE VALSALVA ON-X",SUP-ONXAAP-19,CDM,S27800098,LOCAL,0278,RC,,,both,,,51187.50,15356.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,21038.06,41.1,,,,,0,5953.11,43509.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veno Svc W Si",PX-320000132,CDM,75827,CPT,0320,RC,,,both,,,3762.17,1128.65,"CIGNA [10200]","Cigna Open Access",,144.67,,,,,,,103.44,3762.17,"fee schedule",
"HC Rv Tib/Prneal W Ather Sf Init",PX-361000729,CDM,37288,CPT,0361,RC,,,both,,,23403.71,7021.11,"CIGNA [10200]",Cigna,,7680,,"Case rate ($7,680). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2721.85,19893.15,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 35MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840005035,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PHCS [10601]",PHCS,,6682.8,70,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Proc Cardiac Unlisted",PX-480000066,CDM,33999,CPT,0361,RC,,,both,,,16955.00,5086.5,"NOVANET [10819]",Novanet,,12716.25,75,,,,,0,1550,14411.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZEBRA UROLOGICAL 150CM 3CM .032IN URO-GLIDE NITINOL",SUP-M0066701111,CDM,C1769,HCPCS,0272,RC,,,both,,,432.13,129.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.26,367.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 57MM STAINLESS STEEL 2.4MM SCR 7 HOLE HEAD 5 HOLE",SUP-02.115.850S,CDM,C1713,HCPCS,0278,RC,,,both,,,4536.34,1360.9,"CIGNA [10200]","Cigna Open Access",,2581.18,56.9,,1144.80,304.56,2275.09,66,527.58,3855.89,"percent of total billed charges",
"BASEPLT TIBIAL RESTORIS 6 KNEE RIGHT MEDIAL LEFT LATERAL",SUP-180616,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"BLUE CROSS [10001]","Blue Cross HMO",,2597.96,39.2,,5311.50,4717.44,5388.59,31,770.77,5633.33,"percent of total billed charges",
"COIL EMBOLIZATION 4CM 1MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR091040,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"PHCS [10601]",PHCS,,9258.1,70,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25X5.5X.43MM SAGITTAL STERILE",SUP-KM33-414,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.65,24.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,37.02,45.9,,,,,0,9.38,68.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 11MM HIP DISTAL PMMA POS ANSWER IMPACT INTEGRAL",SUP-162657,CDM,C1776,HCPCS,0278,RC,,,both,,,1195.56,358.67,"BLUE CROSS [10001]","Blue Cross HMO",,468.66,39.2,,5311.50,4717.44,5388.59,31,139.04,1016.23,"percent of total billed charges",
"SCR BONE 7.5MM 50MM XIA SERRATO SPINE POLYAXIAL NONSTERILE",SUP-482617550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM OFFSET 36MM HIP TYPE 1 COCR G7",SUP-11363663,CDM,C1776,HCPCS,0278,RC,,,both,,,5296.44,1588.93,"AETNA [10100]","Aetna HMO/PPO",,4210.67,79.5,,10981.53,8986.79,12413.38,12,615.98,4501.97,"percent of total billed charges",
"HC Copper Cu-64 Dotatate Dx Inj per Mci",PX-343000040,CDM,A9592,HCPCS,0343,RC,,,both,,,6292.00,1887.6,"KAISER [10500]",Kaiser,,4215.64,67,,,,,0,731.76,5348.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, SHORT HUMERAL STEM, 8MM",SUP-520-08-000,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"AETNA [10100]","Aetna HMO/PPO",,6296.4,79.5,,10981.53,8986.79,12413.38,12,921.1,6732,"percent of total billed charges",
"SCR BONE 6.5MM 60MM TRIDENT TITANIUM HEMISPHERE CANCELLOUS",SUP-2030-6560-1,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"BLUE CROSS [10001]","Blue Cross HMO",,298.47,39.2,,957.42,156.86,7483.26,51,88.55,647.19,"percent of total billed charges",
"MESH SURGICAL 15X15CM 10MM RESORBABLE PLA POLYPROPYLENE",SUP-PP1515G,CDM,C1781,HCPCS,0278,RC,,,both,,,3217.95,965.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,381.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,374.25,2735.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC",521,MS-DRG,,,,,,,inpatient,,,110850.82,33255.25,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,19050.31,,"Case rate ($17,804.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $16,532.24, add-ons for qualifying new technology services are included. If operating cost exceeds $49,571.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,631.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,554.11. The transfer operating threshold is the transfer adjustment factor * $16,532.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.92. The transfer capital threshold is the transfer adjustment factor * $1,249.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,7561,83798.36,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR NEONATAL LNCS OXIMETER ADHESIVE CABLED TAPE MASIMO SE",SUP-1862,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.00,20.7,"CIGNA [10200]","Cigna Local Plus",,36.92,53.5,,,,,0,0.58,58.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 5MM BALL DISSECTING",SUP-MR8-9BA50,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.28,371.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,567.91,45.9,,,,,0,143.9,1051.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, SHORT HUMERAL STEM, 8MM",SUP-520-08-000,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,938.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,921.1,6732,"percent of total billed charges",
"ALTEPLASE 2 MG INTRA-CATHETER SOLUTION",RX-31310,CDM,J2997,HCPCS,0636,RC,50242-0041-64,NDC,both,1,UN,1117.67,335.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,504.56,,,,,,,132.44,950.02,"fee schedule",
"HC Proc Cardiac Unlisted",PX-480000066,CDM,33999,CPT,0361,RC,,,both,,,16955.00,5086.5,"PHCS [10601]",PHCS,,11868.5,70,,,,,0,1550,14411.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO CLEAR 10CM .018IN 21GA 3FR MERIT PAK 40CM PEDAL",SUP-PAKS5NPD7,CDM,C1894,HCPCS,0272,RC,,,both,,,497.02,149.11,"MULTIPLAN [10600]",Multiplan,,422.47,85,,,,,0,57.8,422.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 10MM 24MM EXPLOR ELBOW MODULAR",SUP-11-210041,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"MULTIPLAN [10600]",Multiplan,,12081.9,85,,,,,0,1653.09,12081.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 5MM BALL DISSECTING",SUP-MR8-9BA50,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.28,371.18,"MULTIPLAN [10600]",Multiplan,,1051.69,85,,,,,0,143.9,1051.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 7 STD OFFSET HIP",SUP-71935567,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"CIGNA [10200]","Cigna Open Access",,12238.79,33.5,,5302.19,4377.88,6578.61,27,4248.87,31053.65,"percent of total billed charges",
"CATH SABERX 200CM 20MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540020L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 40MM 28MM ACTIVE ARTICULATION E1 UHMWPE",SUP-EP-200146,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1204.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1204.51,8803.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL REVISION RSP DJO SURGICAL STERILE",SUP-510-10-175,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5178.6,41.1,,6417.48,6417.48,6417.48,"1 through 10",1465.38,10710,"percent of total billed charges",
"HC Tx Cath Clsr Vsd W Imp",PX-481000047,CDM,93581,CPT,0481,RC,,,both,,,24896.00,7468.8,"CIGNA [10200]","Cigna Local Plus",,20211,,"Case rate ($20,211). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2895.4,24896,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch Transbronch Ndl Asp Bx",PX-750000011,CDM,31629,CPT,0750,RC,,,both,,,5666.00,1699.8,"CIGNA [10200]","Cigna Local Plus",,2587,,"Case rate ($2,587). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,658.96,5666,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Difficult Xm Report",PX-312000001,CDM,86077,CPT,0312,RC,,,both,,,208.00,62.4,"BLUE CROSS [10001]","Blue Cross PPO",,62.33,,"Fee schedule rate ($62.33).",,,,0,22.82,176.8,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE VERSACORE VASCULAR 260CM .035IN STAINLESS",SUP-1012068-09,CDM,C1769,HCPCS,0272,RC,,,both,,,793.80,238.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,326.25,41.1,,,,,0,92.32,674.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM AVENIR 10 HELICAL FINISH STERILE",SUP-10HFN-04006,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4747.48,45.9,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 7.6CM 3MM LEGEND CARBIDE METAL CUTTING FINAL",SUP-MC30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE HEARTMATE GOGEAR THORATEC LARGE VENTRICULAR ASSIST",SUP-104231,CDM,Q0498,HCPCS,0274,RC,,,both,,,2883.60,865.08,"KAISER [10500]",Kaiser,,1932.01,67,,,,,0,335.36,2451.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP BIOFOAM DYNASTY",SUP-DSBFGB48,CDM,C1776,HCPCS,0278,RC,,,both,,,18918.90,5675.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7775.67,41.1,,6417.48,6417.48,6417.48,"1 through 10",2200.27,16081.07,"percent of total billed charges",
"BLADE 3 ANGLE RIGHT RTRCTR 3IN DAVIS MCGIVOR MOUTH GAG RING",SUP-45-2145,CDM,S27200284,LOCAL,0272,RC,,,both,,,453.76,136.13,"PHCS [10601]",PHCS,,317.63,70,,,,,0,52.77,385.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR CHEST TRAUMA WITHOUT CC/MCC",185,MS-DRG,,,,,,,inpatient,,,37292.38,11187.71,"PHCS [10601]",PHCS,,7561,,,,,,,4878.71,19614.52,"per diem","Estimated amount calculated based on 4 day length of stay."
"GRAFT BONE FIBULA ALLOGRAFT STRUT FROZEN 110X5MM",SUP-450655,CDM,S27800098,LOCAL,0278,RC,,,both,,,6172.74,1851.82,"CIGNA [10200]","Cigna Local Plus",,3302.42,53.5,,,,,0,717.89,5246.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X7MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7207,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"NOVANET [10819]",Novanet,,5175,75,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Sclp/Limb 1.1-2.5cm Cmplx",PX-450000049,CDM,13120,CPT,0450,RC,,,both,,,1861.00,558.3,"CIGNA [10200]","Cigna Local Plus",,1442,,,,,,,1.86,1861,"case rate",
"COIL EMBOLIZATION 6CM 2MM INTERLOCK IDC OCCLUSION SYSTEM",SUP-M001361490,CDM,S27800098,LOCAL,0278,RC,,,both,,,2400.00,720,"FIRST HEALTH [10303]","First Health",,1920,80,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORD ELECTROSURGICAL GREEN 12FT PLASTIC BIPOLAR STERILE",SUP-10-4000,CDM,S27200284,LOCAL,0272,RC,,,both,,,118.32,35.5,"CIGNA [10200]",Cigna,,80.46,68,,,,,0,13.76,100.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION 16FR SURESTEP BARDEX IC COMPLETE CARE",SUP-A300316A,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.29,41.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.2,118.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NEGATIVE PRESSURE 4X1IN PICO DRSG STERILE DISPOSABLE",SUP-66022004,CDM,S27200284,LOCAL,0272,RC,,,both,,,1995.00,598.5,"PHCS [10601]",PHCS,,1396.5,70,,,,,0,232.02,1695.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE VASCULAR J CURVE 190CM 3CM .014IN",SUP-28000J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE RIGHT CRUCIATE RETAINING PERSONA",SUP-42502806202,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"CIGNA [10200]",Cigna,,11558.23,40,,5873.17,5873.17,5873.17,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"HC Proc Cardiac Unlisted",PX-480000066,CDM,33999,CPT,0361,RC,,,both,,,16955.00,5086.5,"CIGNA [10200]","Cigna Open Access",,6428,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1550,14411.75,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Stellate Ganglion",PX-510000144,CDM,64510,CPT,0761,RC,,,both,,,4093.00,1227.9,"FIRST HEALTH [10303]","First Health",,3274.4,80,,,,,0,476.02,4093,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 8MM 144CM 4MM CORONARY STENT PEBAX EVEROLIMUS",SUP-H7493926008400,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1592.7,28.62,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 5CM 16GA ACCURIAN CURVE SHARP 10MM",SUP-AC0001,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"FIRST HEALTH [10303]","First Health",,83.52,80,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 4CM 7FR PANCREATIC POLYETHYLENE PUSH CATH DRAIN",SUP-G21373,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,290,45.9,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE RIGHT CRUCIATE RETAINING PERSONA",SUP-42502806202,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"PHCS [10601]",PHCS,,20226.91,70,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUTOINJECTOR2, PMA",SUP-TV-AI01-N,CDM,S27200284,LOCAL,0272,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROPAFENONE 150 MG TABLET, IMMEDIATE RELEASE",RX-11146,CDM,,,0250,RC,59651-0256-01,NDC,both,1,UN,8.23,2.47,"KAISER [10500]",Kaiser,,5.51,67,,,,,0,0.96,7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 401118 MDII 18X20 SRVC FEE",SUP-401118,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC SMALL KNEE OPEN BACK AIRMESH ROADRUNNER",SUP-14142,CDM,S27000186,LOCAL,0270,RC,,,both,,,614.55,184.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,417.89,68,,,,,0,71.47,522.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OXIMETER PULSE BLACK ONYX 9590 FINGERTIP LATEX FREE",SUP-P7100,CDM,S27000186,LOCAL,0270,RC,,,both,,,1820.63,546.19,"UHC [10700]","United Healthcare",,1152.46,63.3,,,,,0,211.74,1547.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC",093,MS-DRG,,,,,,,inpatient,,,39339.82,11801.95,"BLUE CROSS [10001]","Blue Cross PPO",,19658.3,,,,,,,4939.5,19858.93,"case rate",
"STENT GEENEN 4CM 7FR PANCREATIC POLYETHYLENE PUSH CATH DRAIN",SUP-G21373,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM MULTIFIX S ULTRA KNOTLESS PEEK",SUP-72290001,CDM,C1713,HCPCS,0278,RC,,,both,,,3138.75,941.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,365.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",365.04,2667.94,"percent of total billed charges",
"ALTEPLASE 2 MG INTRA-CATHETER SOLUTION",RX-31310,CDM,J2997,HCPCS,0636,RC,50242-0041-64,NDC,both,1,UN,1117.67,335.3,"NOVANET [10819]",Novanet,,838.25,75,,,,,0,132.44,950.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lampoon of Mitral Valve Leaflet",PX-361000642,CDM,33999,CPT,0361,RC,,,both,,,16913.00,5073.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2004.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1550,14376.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop Uni W Pta",PX-361000152,CDM,37224,CPT,0361,RC,,,both,,,12247.10,3674.13,"PHCS [10601]",PHCS,,8572.97,70,,,,,0,1424.34,10410.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fibrin Degradation Products",PX-305000040,CDM,85362,CPT,0305,RC,,,both,,,343.20,102.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.67,,,,,,,0.01,291.72,"fee schedule",
"PLATE BONE LEVEL ONE Y CRANIOFACIAL TITANIUM ULTRA LOW",SUP-25-153-07-09,CDM,C1713,HCPCS,0278,RC,,,both,,,2211.60,663.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,262.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,257.21,1879.86,"percent of total billed charges",
"INSRT ACETABULAR 28MM 10D D HIP X3 TRIDENT",SUP-623-10-28D,CDM,C1776,HCPCS,0278,RC,,,both,,,6242.04,1872.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,725.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,725.95,5305.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 330-360ML STYLE 68 SMOOTH ANTERIOR DIAPH VALVE",SUP-68-330,CDM,C1789,HCPCS,0278,RC,,,both,,,2250.00,675,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,266.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",261.68,1912.5,"percent of total billed charges",
"INSRT TIBIAL 6 10MM KNEE RIGHT E-PLUS EMPOWR 3D KNEE STERILE",SUP-342-10-706,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross PPO",,2569.56,39.2,,3949.44,3949.44,3949.44,"1 through 10",762.35,5571.75,"percent of total billed charges",
"COIL EMBOLIZATION 50CM 17MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181750,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2162.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 8X6CM AXIS TUTOPLAST DERMIS ALLOGRAFT",SUP-939268,CDM,C1762,HCPCS,0278,RC,,,both,,,16629.00,4988.7,"CIGNA [10200]",Cigna,,6651.6,40,,,,,0,1933.95,14134.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM CREO CREO AMP COCR SPINE POLYAXIAL TULIP",SUP-7146.0100,CDM,C1713,HCPCS,0278,RC,,,both,,,2812.50,843.75,"BLUE CROSS [10001]","Blue Cross PPO",,1102.5,39.2,,957.42,570.23,957.42,28,327.09,2390.63,"percent of total billed charges",
"SUT VICRYL PLUS 1 CT-1 36IN BRAID ANTIBACTERIAL COATED",SUP-VCP347H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"MULTIPLAN [10600]",Multiplan,,21.25,85,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN WILLIAMS RIGHT CURVE ANGIOGRAPHIC",SUP-H74908641502,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]","Cigna Local Plus",,40.97,53.5,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 110MM 4MM STRAIGHTSHOT M4 TRICUT INFERIOR",SUP-1884004HR,CDM,S27200284,LOCAL,0272,RC,,,both,,,2097.00,629.1,"CIGNA [10200]",Cigna,,1425.96,68,,,,,0,243.88,1782.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 11 FINGER INDIVIDUAL OVAL 8",SUP-92728111,CDM,S27000186,LOCAL,0270,RC,,,both,,,88.13,26.44,"MULTIPLAN [10600]",Multiplan,,74.91,85,,,,,0,10.25,74.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 150MM 4MM BALLOON DILATATION NYBAX",SUP-H74939186401510,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Abd Paracentesis WO Img",PX-361000199,CDM,49082,CPT,0361,RC,,,both,,,2966.42,889.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,344.99,2966.42,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 90MM LCP STAINLESS STEEL PROXIMAL FEMORAL",SUP-212.227,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"CIGNA [10200]","Cigna Local Plus",,467.15,53.5,,3978.14,359.25,3978.14,24,101.55,742.2,"percent of total billed charges",
"GRAFT BONE CORNERSTONE-SR FREEZE DRIED 14X14X8MM",SUP-200844,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 345MM TIBIA EXPERT INTRAMEDULLARY ROUND BARREL",SUP-04.034.349S,CDM,C1713,HCPCS,0278,RC,,,both,,,8166.56,2449.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3748.45,45.9,,,,,0,949.77,6941.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Afo Brace",PX-E27400078,CDM,L1930,HCPCS,0274,RC,,,both,,,639.10,191.73,"BLUE CROSS [10001]","Blue Cross PPO",,250.53,39.2,,,,,0,74.33,543.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 70MM KNEE RIGHT POSTERIOR STABILIZE OPEN BOX",SUP-184512,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"KAISER [10500]",Kaiser,,16633.27,67,,,,,0,2887.24,21101.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 40MM 4FR 2MM .018IN BALLOON",SUP-PCP020040130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"MULTIPLAN [10600]",Multiplan,,1046.52,85,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +11 DIOPTER MODIFIED C BICONVEX TECNIS OPTIEDGE",SUP-ZA90030110,CDM,V2632,HCPCS,0276,RC,,,both,,,955.80,286.74,"BLUE CROSS [10001]","Blue Cross HMO",,374.67,39.2,,,,,0,111.16,812.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM TITANIUM T25 SELF TAP LOCK STARDRIVE",SUP-412.214S,CDM,C1713,HCPCS,0278,RC,,,both,,,1220.18,366.05,"KAISER [10500]",Kaiser,,817.52,67,,,,,0,141.91,1037.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL WEREWOLF FASTSEAL 6 HEMOSTASIS STERILE",SUP-72290042,CDM,S27200284,LOCAL,0272,RC,,,both,,,2437.50,731.25,"AETNA [10100]","Aetna HMO/PPO",,1937.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 5-0 P-3 18IN MONOFILAMENT PLIABILIZE",SUP-698H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 1.5CM 4FR STRAIGHT ART CURVE ANGIOGRAPHIC",SUP-H787107314025,CDM,C1887,HCPCS,0272,RC,,,both,,,156.60,46.98,"UHC [10700]","United Healthcare",,99.13,63.3,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION",RX-26226,CDM,J2470,HCPCS,0636,RC,72603-0128-01,NDC,both,1,UN,52.92,15.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16.95,,,,,,,2.2,44.98,"fee schedule",
"STEM FEMORAL PROFEMUR TL CLASSIC 2 SHORT NECK EXTEND OFFSET",SUP-PRTLE022,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Open Access",,6331.5,33.5,,5302.19,4377.88,6578.61,27,2198.07,16065,"percent of total billed charges",
"HC Cyanide",PX-301000171,CDM,82600,CPT,0301,RC,,,both,,,603.25,180.97,"UHC [10700]","United Healthcare",,17.46,,,,,,,0.01,512.76,"fee schedule",
"CATH VISTA BRITE TIP TRUELUMEN 125CM 6FR .07IN JUDKINS LEFT",SUP-SM7435,CDM,C1887,HCPCS,0272,RC,,,both,,,1310.50,393.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,155.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,152.41,1113.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Genotype Hiv 1 Oth Region",PX-306000210,CDM,87906,CPT,0306,RC,,,both,,,1337.60,401.28,"MULTIPLAN [10600]",Multiplan,,1136.96,85,,,,,0,0.01,1136.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Genotype Hiv 1 Oth Region",PX-306000210,CDM,87906,CPT,0306,RC,,,both,,,1337.60,401.28,"AETNA [10100]","Aetna HMO/PPO",,1063.39,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1136.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 58MM TI",SUP-SPL-60580-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"NOVANET [10819]",Novanet,,1215,75,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 6MMX39MM 7FR 80CMCATH HEPARIN",SUP-BXB063901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5582.27,28.62,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"C2 IVL CATHETER, 4.0 X 12 MM",SUP-C2IVL4012,CDM,C1761,HCPCS,0272,RC,,,both,,,29610.00,8883,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,20134.8,68,,,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 25MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962367,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"CIGNA [10200]","Cigna Open Access",,4858.77,33.5,,5302.19,4377.88,6578.61,27,1686.79,12328.23,"percent of total billed charges",
"BRONCHOSCOPE EXAMINATION BFLEX REGULAR 5 SINGLE USE X2",SUP-0570-0449,CDM,S27200284,LOCAL,0272,RC,,,both,,,1990.50,597.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1353.54,68,,,,,0,231.5,1691.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 295CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-295,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PHCS [10601]",PHCS,,5288.85,70,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 5FR .058IN EXTRA BACKUP 3.75 LEFT CURVE",SUP-LA5EBU375,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 26MM LCP STAINLESS STEEL DISTAL RADIAL T8",SUP-212.826,CDM,C1713,HCPCS,0278,RC,,,both,,,802.87,240.86,"MULTIPLAN [10600]",Multiplan,,682.44,85,,,,,0,93.37,682.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUTTY THERAPY SAMMONS PRESTON TAN SUPER SOFT RESISTANCE",SUP-506503,CDM,S27000186,LOCAL,0270,RC,,,both,,,338.52,101.56,"NOVANET [10819]",Novanet,,253.89,75,,,,,0,39.37,287.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM STAINLESS STEEL CORTICAL SELF TAP",SUP-47483501401,CDM,C1713,HCPCS,0278,RC,,,both,,,546.75,164.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,64.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,63.59,464.74,"percent of total billed charges",
"SCR BONE 4.5MM 8MM 72MM STAINLESS STEEL CORTICAL SELF TAP",SUP-214.872,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"CIGNA [10200]",Cigna,,170.62,68,,1831.33,1831.33,1831.33,16,29.18,213.27,"percent of total billed charges",
"SYSTEM ANGIOGUARD 100UM 180CM .014IN 6MM EMBOLIC PROTECTION",SUP-601814RMC,CDM,C1884,HCPCS,0272,RC,,,both,,,6520.50,1956.15,"NOVANET [10819]",Novanet,,4890.38,75,,,,,0,758.33,5542.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Interluken 288 Polymorph Geno",PX-309000114,CDM,81400,CPT,0310,RC,,,both,,,1773.65,532.09,"UHC [10700]","United Healthcare",,57.56,,,,,,,0.01,1507.6,"fee schedule",
"SUT STRATAFIX MONOCRYL PLUS 3-0 PS-2 SPIRAL 60CM KNOTLESS",SUP-SXMP1B108,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,87.91,41.1,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 11MM STAINLESS STEEL T4 CORTEX SELF TAP",SUP-02.214.111,CDM,C1713,HCPCS,0278,RC,,,both,,,418.99,125.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,192.32,45.9,,,,,0,48.73,356.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 65MM CONDYLAR VARIABLE ANGLE CANNULATED LOCK",SUP-42.231.665,CDM,C1713,HCPCS,0278,RC,,,both,,,1693.95,508.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,200.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",197.01,1439.86,"percent of total billed charges",
"CATH GUIDEZILLA II 150CM 8FR .072IN GUIDING Z-GLIDE EXT",SUP-H7493933515080,CDM,C1769,HCPCS,0272,RC,,,both,,,2956.88,887.06,"KAISER [10500]",Kaiser,,1981.11,67,,,,,0,343.89,2513.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 9 HIP",SUP-PRTLE029,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2198.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 36MM BIOLOX",SUP-400-03-362,CDM,C1776,HCPCS,0278,RC,,,both,,,16953.92,5086.18,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4852.21,28.62,,,,,0,1971.74,14410.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS THK12MM ALLOGRAFT BLOCK FREEZE DRIED",SUP-400293,CDM,S27800098,LOCAL,0278,RC,,,both,,,5547.60,1664.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,645.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,645.19,4715.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175264090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,157.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION",RX-1224,CDM,J0665,HCPCS,0636,RC,63323-0472-37,NDC,both,30,ML,74.29,22.29,"UHC [10700]","United Healthcare",,9,,,,,,,5.24,63.15,"fee schedule",
"STENT CONTOUR SENSOR DUAL-FLEX 24CM 6FR .038IN PIGTAIL CURVE",SUP-M006180222120,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,157.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 24CM 6FR .038IN PIGTAIL CURVE",SUP-M006180222120,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"CIGNA [10200]",Cigna,,904.58,68,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 300MM 2.5MM BALLOON DILATATION RAPID",SUP-47525300S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,235.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 54MM 32MM 10D CROSSFIRE",SUP-2041C-3254,CDM,C1776,HCPCS,0278,RC,,,both,,,5140.80,1542.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3495.74,68,,,,,0,597.88,4369.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE 30IN INFLATION EXT TUBING",SUP-K05-01172,CDM,S27200284,LOCAL,0272,RC,,,both,,,256.65,76.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,174.52,68,,,,,0,29.85,218.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 10MM BALLOON",SUP-U3575108,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUROLOGICAL EYE DISORDERS",123,MS-DRG,,,,,,,inpatient,,,43843.81,13153.14,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,5251,,"Case rate ($4,953.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,599.91, add-ons for qualifying new technology services are included. If operating cost exceeds $37,639.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,729.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,605.99. The transfer operating threshold is the transfer adjustment factor * $4,599.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $347.78. The transfer capital threshold is the transfer adjustment factor * $347.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,4953.77,19916.29,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 300MM 6MM BALLOON",SUP-U3575630,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 60MM 7MM BALLOON DILATATION STERILE LATEX",SUP-597006022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"NOVANET [10819]",Novanet,,1093.5,75,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT TKR 92 CAP EXTRA",SUP-98000200196,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2911.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB TISSUE 30X20CM STRATTICE PORCINE DERMAL MATRIX MESH",SUP-2030002,CDM,Q4130,HCPCS,0636,RC,,,both,,,82957.80,24887.34,"CIGNA [10200]","Cigna Local Plus",,44382.42,53.5,,,,,0,9830.5,70514.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFOXITIN 2 G VIAL",RX-9463,CDM,J0694,HCPCS,0636,RC,44567-0246-25,NDC,both,1,UN,180.75,54.22,"CIGNA [10200]","Cigna Local Plus",,25.48,,,,,,,11.14,153.64,"fee schedule",
"CEFOXITIN 2 G VIAL",RX-9463,CDM,J0694,HCPCS,0636,RC,44567-0246-25,NDC,both,1,UN,180.75,54.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,122.91,68,,,,,0,11.14,153.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFOXITIN 2 G VIAL",RX-9463,CDM,J0694,HCPCS,0636,RC,44567-0246-25,NDC,both,1,UN,180.75,54.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,25.48,,,,,,,11.14,153.64,"fee schedule",
"SYSTEM SYNERGY 12MM 144CM 3.5MM CORONARY STENT PEBAX",SUP-H7493926012350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Open Access",,3166.49,56.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 90MM 16MM 5.4MM 14FR ZENITH SPIRAL-Z",SUP-G55239,CDM,C1874,HCPCS,0278,RC,,,both,,,19435.50,5830.65,"AETNA [10100]","Aetna HMO/PPO",,15451.22,79.5,,,,,0,2260.35,16520.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Demo/Eval Pat Use Inhale",PX-410000012,CDM,94664,CPT,0410,RC,,,both,,,351.20,105.36,"NOVANET [10819]",Novanet,,263.4,75,,,,,0,40.84,351.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE EKOSONIC MACH 4 135CM 50CM 5.4FR DRUG DELIVERY",SUP-500-56150,CDM,C1887,HCPCS,0272,RC,,,both,,,37894.50,11368.35,"UHC [10700]","United Healthcare",,23987.22,63.3,,,,,0,4407.13,32210.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 112MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 7",SUP-71357107,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"PHCS [10601]",PHCS,,23198.81,70,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 8MM NESTER 5.6 LOOP CATH END HOLE",SUP-G26995,CDM,S27800098,LOCAL,0278,RC,,,both,,,696.60,208.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,473.69,68,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 20X20MM JAWS STRAIGHT NITINOL",SUP-P71-020-2020-S,CDM,C1713,HCPCS,0278,RC,,,both,,,8952.75,2685.82,"BLUE CROSS [10001]","Blue Cross PPO",,3509.48,39.2,,957.42,570.23,957.42,28,1041.2,7609.84,"percent of total billed charges",
"CATH EXPEL TWIST-LOC APD 30CM 16FR DRNG FLEXITHANE METAL",SUP-H7493932016300,CDM,C1729,HCPCS,0272,RC,,,both,,,761.40,228.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,88.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 52CM 20FR 8FR NEPHRSTMY PERCUFLEX STENTING",SUP-M001224200,CDM,C1729,HCPCS,0272,RC,,,both,,,599.40,179.82,"NOVANET [10819]",Novanet,,449.55,75,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM AVENIR HELICAL 10 FINISH STERILE",SUP-10HFN-03004,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"UHC [10700]","United Healthcare",,6547.18,63.3,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER PACING LEAD ACUITY 9FR",SUP-667463-001,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 120MM 80CM 7MM 6FR .035IN BILIARY",SUP-G50130,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"MULTIPLAN [10600]",Multiplan,,5176.5,85,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 55MM 2.4MM STAINLESS STEEL ROUND FAST CUTTING",SUP-1608-006-147,CDM,S27000186,LOCAL,0270,RC,,,both,,,375.49,112.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,43.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.67,319.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309111,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"CIGNA [10200]",Cigna,,15104.88,40,,5873.17,5873.17,5873.17,"1 through 10",4391.74,32097.87,"percent of total billed charges",
"SET LEADWIRE 10 LEAD PLUG AHA BANANA NEONATAL CABLE",SUP-2016032-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2167.50,650.25,"KAISER [10500]",Kaiser,,1452.23,67,,,,,0,252.08,1842.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL TAPERFILL 6 STD OFFSET HIP STERILE LATEX FREE",SUP-425-96-006,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"CIGNA [10200]",Cigna,,5520,40,,5873.17,5873.17,5873.17,"1 through 10",1604.94,11730,"percent of total billed charges",
"STENT ZILVER 635 FLEXOR 40MM 80CM 7MM 6FR VASCULAR NITINOL",SUP-G43851,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Local Plus",,2022.3,53.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM SPINAL POLYAXIAL 5.5MM ROD",SUP-8457550,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA [10200]",Cigna,,3292.97,68,,1831.33,1831.33,1831.33,16,563.19,4116.21,"percent of total billed charges",
"STENT HERCULINK ELITE 12MM 135CM 5.5MM 3.3-2.9FR 6FR LOW",SUP-1011496-12,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4284,68,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 8X42X32MM 15 DEGREE",SUP-1921086P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"BLUE CROSS [10001]","Blue Cross PPO",,13582.8,39.2,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.215,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR .083IN 25CM ROBUST VALVE SPLITTABLE WITHOUT",SUP-PLSX-2506,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 15MM 6FR 3.5MM .07IN BALLOON",SUP-H7493918915350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"FIRST HEALTH [10303]","First Health",,453.6,80,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER SHORT TIP RELOAD 60MM PURPLE",SUP-ASR60PS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"AETNA [10100]","Aetna HMO/PPO",,1159.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BEND GROOVE PREBENT 66X16.5X2.5MM TITANIUM 4/4.5MM SCR",SUP-04.613.257,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOGA SURGICAL STERI-SHIELD XL HYTREL ZIPPER DISPOSABLE",SUP-400851000,CDM,S27000186,LOCAL,0270,RC,,,both,,,415.76,124.73,"PHCS [10601]",PHCS,,291.03,70,,,,,0,48.35,353.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM STD THR POROUS HIP STEM MULTIPOLAR CUP LINER BIPO",SUP-98000100600,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"PHCS [10601]",PHCS,,7245,70,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRIP CABLE 2MM DALL-MILES 2MM MEDIUM HIP TROCHANTER",SUP-6704-3-080,CDM,C1713,HCPCS,0278,RC,,,both,,,4429.15,1328.74,"PHCS [10601]",PHCS,,3100.41,70,,,,,0,515.11,3764.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS EVOQUE VALVE (EVOQUE VALVE)48 MM",SUP-9850EV48CL,CDM,S62400003,LOCAL,0624,RC,,,both,,,216600.00,64980,"MULTIPLAN [10600]",Multiplan,,184110,85,,,,,0,25190.58,184110,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 50CM 10FR URETERAL 2 LUMEN STERILE LATEX FREE",SUP-130200,CDM,C1758,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION 0.9% SODIUM CHLORIDE 500ML PRESERVATIVE FREE",SUP-06138-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SPINAL SPACER W14.5XH8XL12MM 7DEG CERVICAL LORDOSIS PR",SUP-VG1C-T68P,CDM,S27800098,LOCAL,0278,RC,,,both,,,5865.00,1759.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2692.04,45.9,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 15MM",SUP-SPL30015X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"MULTIPLAN [10600]",Multiplan,,447.53,85,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VITAL-VUE YANKAUER 12FT IRRIGATION 7 BULB TIP EXTEND",SUP-8886828006,CDM,S27200284,LOCAL,0272,RC,,,both,,,1459.38,437.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.73,1240.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 59MM 135CM 11MM 16SQ MM 8FR .035IN",SUP-BXA115902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]","Cigna Open Access",,6534.11,33.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET",RX-24559,CDM,,,0250,RC,77333-0948-25,NDC,both,1,UN,6.27,1.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 4.5CM 20FR RADIOPAQUE LOW PROFILE PROXIMAL ANTIREFLUX",SUP-0120-20-4.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"NOVANET [10819]",Novanet,,584.3,75,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 2-0 GS-21 12IN CLSR ABSORBABLE GREEN",SUP-VLOCL0315,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 28MM 144CM 2.75MM CORONARY STENT",SUP-H7493952828270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AETNA [10100]","Aetna HMO/PPO",,4424.18,79.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATFORM ACCESS 4X4CM GELPOINT GELSEAL INSUFFLATION",SUP-CNB10,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"MULTIPLAN [10600]",Multiplan,,5131.88,85,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION",RX-179659,CDM,Q5104,HCPCS,0636,RC,78206-0162-01,NDC,both,1,UN,4547.47,1364.24,"BLUE CROSS [10001]","Blue Cross HMO",,314.69,,,,,,,314.69,3865.35,"fee schedule",
"SYSTEM REGULAR 5FR INTRO NINITOL ECHOGENIC NDL FIXED CORE",SUP-70-5160,CDM,C1894,HCPCS,0272,RC,,,both,,,304.50,91.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,36.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.35MM 105MM TFN-ADVANCED TITANIUM ALUMINUM",SUP-04.038.205S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENHANCED NATUS EDS 3 EXTERNAL DRNG WIDE POLE CLAMP",SUP-821730C,CDM,C1729,HCPCS,0272,RC,,,both,,,1955.55,586.66,"AETNA [10100]","Aetna HMO/PPO",,1554.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,227.43,1662.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 25MM VIPER EXPEDIUM TITANIUM SPINE CORTICAL",SUP-186731525,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 5.00 X 32MM",SUP-H7493942832500,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"MULTIPLAN [10600]",Multiplan,,5278.5,85,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 83MM ASCENT MAXIM KNEE INTERLOK COCR 1 PIECE",SUP-141236,CDM,C1776,HCPCS,0278,RC,,,both,,,11379.48,3413.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3256.81,28.62,,,,,0,1323.43,9672.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 18FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0118L18,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.96,26.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,40.37,45.9,,,,,0,10.23,74.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"T'LIFT RETRACTOR SYSTEM",SUP-AW16280V-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,631.80,189.54,"PHCS [10601]",PHCS,,442.26,70,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL",RX-177586,CDM,,,0250,RC,48582-0512-01,NDC,both,42,GR,29.59,8.88,"AETNA [10100]","Aetna HMO/PPO",,23.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.44,25.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 8CM 6MM BALLOON",SUP-G52267,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 130MM 4.5MM STAINLESS STEEL JACOBS CHUCK COUPLING",SUP-310.45,CDM,S27200284,LOCAL,0272,RC,,,both,,,480.82,144.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER SPINAL 30X12X8-15MM RISE 10D",SUP-193.223,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3297.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 40MM 3.2MM 10MM 8.5FR .035IN BILIARY RAPID",SUP-M00570720,CDM,C1874,HCPCS,0278,RC,,,both,,,9158.00,2747.4,"FIRST HEALTH [10303]","First Health",,7326.4,80,,,,,0,1065.08,7784.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 37.5MM T2 TITANIUM FULL THREAD FEMUR HUMERUS",SUP-1896-5037S,CDM,C1713,HCPCS,0278,RC,,,both,,,1297.80,389.34,"FIRST HEALTH [10303]","First Health",,1038.24,80,,,,,0,150.93,1103.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 24CM 4.8FR URETERAL FIRM STERILE LATEX FREE",SUP-M0061456410,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,74.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH",RX-27862,CDM,,,0250,RC,00536-5895-88,NDC,both,1,UN,12.93,3.88,"UHC [10700]","United Healthcare",,8.18,63.3,,,,,0,1.5,10.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD TIGERTAIL 70CM 5FR URETERAL POLYURETHANE NONPORT",SUP-139005,CDM,C1758,HCPCS,0272,RC,,,both,,,107.53,32.26,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE TENDER TOUCH ULTRA 65MM 65MM VACUUM EXTRACTION",SUP-505TTL,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.75,58.72,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SAFARI GUIDEWIRE",SUP-H74939406XS0,CDM,C1769,HCPCS,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSTR ORTHOPEDIC AUG GUIDE SHOULDER LEFT COMPREHENSIVE",SUP-20809000401,CDM,S27000186,LOCAL,0270,RC,,,both,,,7562.40,2268.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLED SOFT MED 1/4X1/8X1/16",SUP-K-705,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT ZILVER PTX 60MM 125CM 8MM VASCULAR PERIPHERAL OTW DRUG",SUP-G38516,CDM,C1874,HCPCS,0278,RC,,,both,,,10322.33,3096.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7019.18,68,,,,,0,1200.49,8773.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK ELECTROSURGICAL 32CM 5MM HARMONIC SCPL ULTRACISION",SUP-HDH05,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.41,432.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,592.83,41.1,,,,,0,167.75,1226.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 014 150CM 15CM 2MM BALLOON DILATATION",SUP-U4150215,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Angio Ext Bil Si",PX-323000016,CDM,75716,CPT,0323,RC,,,both,,,7863.27,2358.98,"MULTIPLAN [10600]",Multiplan,,6683.78,85,,,,,0,112.89,7592.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LEVEL 1 VIP BONE SPINE CERVICAL ANTERIOR",SUP-171.115,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"MULTIPLAN [10600]",Multiplan,,3570,85,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 25MM SPINAL",SUP-7976025,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,341.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",341.92,2499,"percent of total billed charges",
"HC ER Laryngoscopy Direct Dx (Exc",PX-450000372,CDM,31525,CPT,0450,RC,,,both,,,3057.00,917.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2292.95,,"Case rate ($2,292.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,67.13,3057,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 2 VIVID LED BLADE HANDLE MERCURY FREE",SUP-301-LED-020S,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.97,29.09,"PHCS [10601]",PHCS,,67.88,70,,,,,0,11.28,82.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thaw Ffp Ea Unit",PX-302000203,CDM,86927,CPT,0302,RC,,,both,,,318.00,95.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,146.47,,,,,,,0.01,270.3,"fee schedule",
"SHELL ACETABULAR HEMI 3HL 54MM",SUP-430-98-054,CDM,C1776,HCPCS,0278,RC,,,both,,,16956.34,5086.9,"CIGNA [10200]","Cigna Local Plus",,5341.25,31.5,,5372.07,4581.20,7242.98,23,1972.02,14412.89,"percent of total billed charges",
"PENCIL SMOKE EVAC 10FT 3/8IN PLUMEPEN ULTRA 7/8IN TELESCOPIC",SUP-PLPUL2020,CDM,S27200284,LOCAL,0272,RC,,,both,,,233.41,70.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,95.93,41.1,,,,,0,27.15,198.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 10X60 80CM SL",SUP-48010006N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"MULTIPLAN [10600]",Multiplan,,730.16,85,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 4.5MM BROAD 296MM STAINLESS STEEL 4.5MM SCREWS LARGE",SUP-226.661,CDM,C1713,HCPCS,0278,RC,,,both,,,5067.64,1520.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,600.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,589.37,4307.49,"percent of total billed charges",
"LINER ACETABULAR G7 E 36MM LONGEVITY HIP STERILE LUMEN LATEX",SUP-20123605,CDM,C1776,HCPCS,0278,RC,,,both,,,8101.98,2430.59,"BLUE CROSS [10001]","Blue Cross PPO",,3175.98,39.2,,3949.44,3949.44,3949.44,"1 through 10",942.26,6886.68,"percent of total billed charges",
"CMPNT FEMORAL 7 KNEE RIGHT TOTAL STABILIZE TRIATHLON COCR",SUP-5512-F-702,CDM,C1776,HCPCS,0278,RC,,,both,,,32652.90,9795.87,"BLUE CROSS [10001]","Blue Cross PPO",,12799.94,39.2,,3949.44,3949.44,3949.44,"1 through 10",3797.53,27754.97,"percent of total billed charges",
"SPACER SPINAL 14X11X5MM CORNERSTONE PSR PEEK LUMBAR",SUP-6277541,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"MULTIPLAN [10600]",Multiplan,,5676.66,85,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 10IN FOREARM RIGHT WRIST D RING",SUP-5066-80,CDM,S27000186,LOCAL,0270,RC,,,both,,,72.91,21.87,"KAISER [10500]",Kaiser,,48.85,67,,,,,0,8.48,61.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150180,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,158.36,45.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 28CM 9MM .021-.027IN AZUR CX HYDROCOIL",SUP-45-780928,CDM,S27800098,LOCAL,0278,RC,,,both,,,5278.50,1583.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,625.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,613.89,4486.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 12MM 4MM STAINLESS STEEL SHORT THREAD HAND",SUP-02.226.212,CDM,C1713,HCPCS,0278,RC,,,both,,,1647.00,494.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,191.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",191.55,1399.95,"percent of total billed charges",
"PLATE 115MM STAINLESS STEEL 3.5MM SCR 8 HOLE PRECONTOUR",SUP-02.112.084S,CDM,C1713,HCPCS,0278,RC,,,both,,,6443.22,1932.97,"CIGNA [10200]","Cigna Open Access",,3666.19,56.9,,1144.80,304.56,2275.09,66,749.35,5476.74,"percent of total billed charges",
"SCR BONE 5.5MM 35MM CD HORIZON VOYAGER SPINE MULTIAXIAL",SUP-55850015535,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"CIGNA [10200]","Cigna Local Plus",,3506.93,53.5,,3978.14,359.25,3978.14,24,762.35,5571.75,"percent of total billed charges",
"MINOR BLADDER PROCEDURES WITHOUT CC/MCC",664,MS-DRG,,,,,,,inpatient,,,54205.43,16261.63,"CIGNA [10200]",Cigna,,13726.95,,"Fee schedule rate ($13,726.95). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,6493.99,30565.29,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URI-CATH 3.5FR URETHRAL SILICONE NEONATE DRNG STERILE",SUP-4193505,CDM,S27200284,LOCAL,0272,RC,,,both,,,112.23,33.67,"MULTIPLAN [10600]",Multiplan,,95.4,85,,,,,0,13.05,95.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPAT SURGICAL 7X7/8IN DAVIS BRAIN MALLEABLE",SUP-22-0070,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.12,43.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.88,123.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701062,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"BLUE CROSS [10001]","Blue Cross HMO",,4449.4,39.2,,5311.50,4717.44,5388.59,31,1320.06,9647.93,"percent of total billed charges",
"TOOL 9CM MIDAS REX LEGEND 10.8MM HOLE SAW DISSECTING BURR",SUP-9HS108,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 40MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.140,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"MULTIPLAN [10600]",Multiplan,,962.8,85,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER BIPOLAR AQUAMAN 9.5XL",SUP-23-313-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"NOVANET [10819]",Novanet,,2805,75,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30MM NONSTERILE LATEX FREE DISPOSABLE",SUP-470430,CDM,S27000186,LOCAL,0270,RC,,,both,,,1156.68,347,"CIGNA [10200]","Cigna Open Access",,658.15,56.9,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 439014 PG 14X26 SRVC FEE FD",SUP-439014,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75446525,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE LEAD DISP 12 LEAD SZ 7L",SUP-LS-20B,CDM,S27000186,LOCAL,0270,RC,,,both,,,8939.09,2681.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1039.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1039.62,7598.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-EXTENSIVE BURNS",935,MS-DRG,,,,,,,inpatient,,,29457.93,8837.38,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVICROSS 150CM 40MM 60MM SPACE SPRT STAINLESS STEEL",SUP-NC18151,CDM,C1887,HCPCS,0272,RC,,,both,,,1462.05,438.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 5X3CM EPICORD PURION PLUS AMNIOTIC",SUP-EC-5350,CDM,Q4187,HCPCS,0636,RC,,,both,,,20550.60,6165.18,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH ADVANCE PLIAFORM STARCAST 80CM 4CM 7MM BALLOON",SUP-G52352,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Xr Knee 1-2v",PX-320000081,CDM,73560,CPT,0320,RC,,,both,,,521.35,156.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,41.31,,,,,,,41.31,443.15,"fee schedule",
"SUT VICRYL 1 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND COATED",SUP-VCP841D,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.38,38.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,58.93,45.9,,,,,0,14.93,109.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 700-900UM 2ML MICROSPHERES PREFILLED",SUP-S820GH,CDM,S27800098,LOCAL,0278,RC,,,both,,,1860.00,558,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,532.33,28.62,,,,,0,216.32,1581,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 550-660CC P5.3-6.1CM MODERATE PLUS PROFILE ROUND",SUP-3502550,CDM,C1789,HCPCS,0278,RC,,,both,,,3487.50,1046.25,"KAISER [10500]",Kaiser,,2336.63,67,,,,,0,405.6,2964.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grft T/a/L <=100scm 1st 25 Sq Cm",PX-510000050,CDM,15271,CPT,0761,RC,,,both,,,1638.76,491.63,"KAISER [10500]",Kaiser,,1097.97,67,,,,,0,190.59,1638.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grft T/a/L <=100scm 1st 25 Sq Cm",PX-510000050,CDM,15271,CPT,0761,RC,,,both,,,1638.76,491.63,"AETNA [10100]","Aetna HMO/PPO",,1302.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,190.59,1638.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grft T/a/L <=100scm 1st 25 Sq Cm",PX-510000050,CDM,15271,CPT,0761,RC,,,both,,,1638.76,491.63,"CIGNA [10200]","Cigna Open Access",,1638.76,,"Per diem ($2,181).",,,,0,190.59,1638.76,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP 6MM ENDOWRIST SP MEDIUM LARGE NONSTERILE LATEX",SUP-430005,CDM,S27000186,LOCAL,0270,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 31MM 26.1MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-31MECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"BLUE CROSS [10001]","Blue Cross PPO",,11414.74,39.2,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 58CM .016IN KNOB CAP KT",SUP-6043,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 1 MO-4 18IN CONTROL RELEASE MONOFILAMENT 8",SUP-CC01G,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.74,110.02,"CIGNA [10200]","Cigna Open Access",,208.68,56.9,,,,,0,42.65,311.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORONARY BYPASS WITH PTCA WITHOUT MCC",232,MS-DRG,,,,,,,inpatient,,,338939.15,101681.74,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,38734.88,,"Case rate ($37,606.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $34,920.35, add-ons for qualifying new technology services are included. If operating cost exceeds $67,960.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $4,022.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $34,966.53. The transfer operating threshold is the transfer adjustment factor * $34,920.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,640.15. The transfer capital threshold is the transfer adjustment factor * $2,640.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,37606.68,177003.67,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug or Sub Ql/Qn Nos 1-3",PX-301000526,CDM,80375,CPT,0301,RC,,,both,,,249.00,74.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,249,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 28MM 140CM 2.25MM CORONARY STENT PLATINUM",SUP-H7493927428220,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 25MM FLEXIBLE SURE LOCK DELIVERY SYSTEM",SUP-TARP-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1407.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32MM TITANIUM T25 SELF TAP LOCK STARDRIVE",SUP-412.210S,CDM,C1713,HCPCS,0278,RC,,,both,,,1220.18,366.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.91,1037.15,"percent of total billed charges",
"GRAFT SOFT TISSUE 6X3CM PRO3 THICK AMNIOTIC UMBILICAL CORD",SUP-P01-AMC-0306,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 34MM SALVATION ORTHOLOC 3DI LOW PROFILE FOOT",SUP-59215534,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1008.65,45.9,,,,,0,255.57,1867.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 140MM 5MM MIDAS REX LEGEND BALL FLUTED",SUP-14BA50,CDM,S27200284,LOCAL,0272,RC,,,both,,,1326.78,398.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,902.21,68,,,,,0,154.3,1127.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) DELIVERY DEVICE GEN II (201-600MG)",SUP-P-1074,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 10MM NATURAL LARGE LORDOTIC",SUP-19410,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20CM 13FR POLYURETHANE POWER-TRIALYSIS 3 LUMEN",SUP-5613200,CDM,C1752,HCPCS,0272,RC,,,both,,,1321.11,396.33,"UHC [10700]","United Healthcare",,836.26,63.3,,,,,0,153.65,1122.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 28MM 140CM 2.25MM CORONARY STENT PLATINUM",SUP-H7493927428220,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"NOVANET [10819]",Novanet,,2812.5,75,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM ROUND DIAMOND STERILE LATEX FREE",SUP-5820-012-030D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1164.70,349.41,"UHC [10700]","United Healthcare",,737.26,63.3,,,,,0,135.45,990,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 20MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,166.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 93MM 16-10MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1610C93E,CDM,S27800098,LOCAL,0278,RC,,,both,,,17730.00,5319,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2101.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2062,15070.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 24FR 3/8IN AORTA CURVE NONVENTED STRAIGHT",SUP-EZC24A,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,199.75,41.1,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ACCESS 63CM VERSACROSS 45D CURVE 1 TRANSSEPTAL DIL",SUP-VXSK0122,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4199.34,68,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARM RTRCTR FUKUSHIMA-DAY EXT ADJUSTABLE NONSTERILE STAINLESS",SUP-R9104,CDM,S27200284,LOCAL,0272,RC,,,both,,,7709.30,2312.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5242.32,68,,,,,0,896.59,6552.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM PINNACLE DOME HIP ACETABULAR CANCELLOUS",SUP-1217-40-500,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"MULTIPLAN [10600]",Multiplan,,974.23,85,,,,,0,133.3,974.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DIVERGENCE-L 15X9.4X5MM ANTERIOR OBLIQUE LUMBAR",SUP-736525,CDM,S27800098,LOCAL,0278,RC,,,both,,,9177.00,2753.1,"CIGNA [10200]","Cigna Open Access",,5221.71,56.9,,,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANSURETHRAL PROCEDURES WITHOUT CC/MCC",670,MS-DRG,,,,,,,inpatient,,,37883.74,11365.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18546.22,,"Fee schedule rate ($18,546.22). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,6062.26,28533.25,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immunology Unlstd Proc",PX-302000225,CDM,86849,CPT,0302,RC,,,both,,,332.00,99.6,"PHCS [10601]",PHCS,,232.4,70,,,,,0,0.01,282.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIPOLAR FEMORAL HEAD ADAPTER +0MM",SUP-451010000,CDM,C1776,HCPCS,0278,RC,,,both,,,1539.00,461.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,706.4,45.9,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 18CM 28.5MM 12MM 24-26MM 10-11MM GORE",SUP-RLT281218,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Speech/Hearing Group",PX-440000003,CDM,92508,CPT,0440,RC,,,both,,,432.53,129.76,"NOVANET [10819]",Novanet,,324.4,75,,,,,0,50.3,426,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Attendance at Delivery",PX-410000018,CDM,99464,CPT,0722,RC,,,both,,,291.67,87.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,34.56,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.92,247.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM ATLANTIS TITANIUM SPINE CERVICAL ANTERIOR",SUP-3120414,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IV VIAFLEX 40 MEQ POTASSIUM CHLORIDE 5% DEXTROSE 0.45%",SUP-2B1674X,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.95,24.58,"NOVANET [10819]",Novanet,,61.46,75,,,,,0,9.53,69.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 10MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-210-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"KAISER [10500]",Kaiser,,8062.51,67,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 7MM GORE INTERING THIN WALL PTFE RADIAL",SUP-IRST07040040L,CDM,C1768,HCPCS,0278,RC,,,both,,,6348.00,1904.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,738.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,738.27,5395.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 21MM TITANIUM CIRCULAR LINEAR CUTTER SQUEEZE",SUP-EEAORVIL21,CDM,S27200284,LOCAL,0272,RC,,,both,,,692.71,207.81,"CIGNA [10200]","Cigna Open Access",,394.15,56.9,,,,,0,80.56,588.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 19MM 29MM 26.3MM EPIC TISSUE STENT REDEFINE",SUP-E200-29M,CDM,S27800098,LOCAL,0278,RC,,,both,,,26775.00,8032.5,"BLUE CROSS [10001]","Blue Cross HMO",,10495.8,39.2,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 56MM 36MM ALTRX HIP",SUP-122136456,CDM,C1776,HCPCS,0278,RC,,,both,,,6814.08,2044.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1950.19,28.62,,,,,0,792.48,5791.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN WRP CURVE ANGIOGRAPHIC TRILON",SUP-H74908641512,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.17,22.55,"MULTIPLAN [10600]",Multiplan,,63.89,85,,,,,0,8.74,63.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDELINER 150CM 25CM 5FR .056IN .046IN INTERVENTIONAL",SUP-5569,CDM,C1887,HCPCS,0272,RC,,,both,,,2872.50,861.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,340.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.07,2441.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 100CM 5FR .038IN SIM1",SUP-G08584,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CIGNA [10200]",Cigna,,161.49,68,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GALAFLEX 8X6IN SOFT TISSUE MONOFILAMENT",SUP-GP0608,CDM,C1781,HCPCS,0278,RC,,,both,,,12420.00,3726,"CIGNA [10200]",Cigna,,4968,40,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL E STD 68X61.5MM KNEE RIGHT POSTERIOR STABILIZE",SUP-599201502,CDM,C1776,HCPCS,0278,RC,,,both,,,15214.50,4564.35,"MULTIPLAN [10600]",Multiplan,,12932.33,85,,,,,0,1769.45,12932.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD TITANIUM 4 HOLE GEMINUS BONE LEFT DISTAL VOLAR",SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,0278,RC,,,both,,,5161.20,1548.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,600.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",600.25,4387.02,"percent of total billed charges",
"SPACER SPINAL 32X23X12MM CRESCENT SOVEREIGN 12D SMALL PEEK",SUP-7967212,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL 29MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-151111201,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 30MM 80CM 7MM VASCULAR NITINOL PERIPHERAL",SUP-1012529-30,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Open Access",,2355.66,56.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP GRIPTION PINNACLE STERILE LATEX",SUP-121731062,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"BLUE CROSS [10001]","Blue Cross HMO",,6357.63,39.2,,5311.50,4717.44,5388.59,31,1886.21,13785.68,"percent of total billed charges",
"ANCHOR SUT 4.75MM SWIVELOCK C CLOSED EYELET VENT",SUP-AR-2324BCC,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.00,945,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2142,68,,,,,0,366.35,2677.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 44-41MM COMPREHENSIVE STD SHOULDER E1",SUP-EP-115396,CDM,C1776,HCPCS,0278,RC,,,both,,,8854.00,2656.2,"BLUE CROSS [10001]","Blue Cross HMO",,3470.77,39.2,,5311.50,4717.44,5388.59,31,1029.72,7525.9,"percent of total billed charges",
"SCR BONE 2MM 8MM LCP STAINLESS STEEL SMALL BONE T6 STARDRIVE",SUP-201.878,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"CIGNA [10200]","Cigna Local Plus",,377.36,53.5,,3978.14,359.25,3978.14,24,82.03,599.55,"percent of total billed charges",
"PIN FIXATION TUBERCLE STERILE",SUP-351-90-20,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,100.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",98.91,722.93,"percent of total billed charges",
"SUB BONE GRAFT XEMPLIFI DEMINERALIZE BONE MATRIX GEL 5ML",SUP-8103.0105S,CDM,C1713,HCPCS,0278,RC,,,both,,,5692.50,1707.75,"PHCS [10601]",PHCS,,3984.75,70,,,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 24CM 6FR URETERAL",SUP-M0061456130,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"BLUE CROSS [10001]","Blue Cross PPO",,245.09,39.2,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCIVA VR",SUP-D400,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"AETNA [10100]","Aetna HMO/PPO",,31005,79.5,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL FIBRA STEALTH 6MM LOW PROFILE .75 FORCE",SUP-A1650,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,153.82,68,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 50CM 4CM ORANGE HUB STAINLESS STEEL GWIRE",SUP-PSS-8F-4-035MT,CDM,C1894,HCPCS,0272,RC,,,both,,,208.80,62.64,"FIRST HEALTH [10303]","First Health",,167.04,80,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 20MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDS40020,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22416.67,27,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.5MM EXTREMITIES DISTAL ANKLE FRACTURE MANAGEMENT",SUP-AR-8943-42,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER BIPOLAR AQUAMAN 9.5XL",SUP-23-313-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR SYMMETRY UNIVERSAL RING HORIZONTAL BAR SURGICAL",SUP-58-0004,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LIVEWIRE 115CM 4MM 6FR 1MM 2-5-2MM SPACE LARGE SWEEP",SUP-401606,CDM,C1730,HCPCS,0272,RC,,,both,,,2625.00,787.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 135CM 11MM 16SQ MM 8FR .035IN",SUP-BXA112902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"AETNA [10100]","Aetna HMO/PPO",,15506.32,79.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 12MM 5.5-6MM CREO SPINE 2 HEAD LATERAL NONSTERILE",SUP-1175.9933,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1203.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"STENT ZIPWIRE 24CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006175282070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,116,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cholecystotomy Perc W Si",PX-361000183,CDM,47490,CPT,0361,RC,,,both,,,8521.79,2556.54,"BLUE CROSS [10001]","Blue Cross HMO",,4025.22,,"Case rate ($4,025.22). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,991.08,7883,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"7F DECA 6-6-6 PV21 110CM",SUP-901644,CDM,C1730,HCPCS,0272,RC,,,both,,,5692.50,1707.75,"KAISER [10500]",Kaiser,,3813.98,67,,,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Tube G/C W Fl",PX-750000104,CDM,49450,CPT,0750,RC,,,both,,,5321.52,1596.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1718,,"Case rate ($1,718). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,618.89,4617,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X22X9MM TRANSCONTINENTAL 10D MEDIUM TITANIUM",SUP-375.369CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CIGNA [10200]","Cigna Open Access",,10552.5,33.5,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE DERMATOME BABY MANUAL THROW AWAY STERILE DISPOSABLE",SUP-3539-106,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"NOVANET [10819]",Novanet,,364.5,75,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 15MM CRANIOFACIAL TITANIUM 5 HOLE Y LOW PROFILE",SUP-421.515,CDM,C1713,HCPCS,0278,RC,,,both,,,1792.50,537.75,"KAISER [10500]",Kaiser,,1200.98,67,,,,,0,208.47,1523.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5MM 2 CORKSCREW FIBERWIRE ROTATOR CUFF SELF TAP",SUP-AR-1920SF,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"WAND ELECTROSURGICAL 3.3MM ARTHROWAND COVAC 2O 20D HOOK",SUP-AC434001,CDM,S27200284,LOCAL,0272,RC,,,both,,,3692.25,1107.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,429.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,429.41,3138.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 12MM EXCLUDER C3 CONTRALATERAL LEG",SUP-PXC121200,CDM,S27800098,LOCAL,0278,RC,,,both,,,27720.00,8316,"NOVANET [10819]",Novanet,,20790,75,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 5/32IN STEINMANN FULL THREAD STAINLESS",SUP-KM169-29-53,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"BLUE CROSS [10001]","Blue Cross HMO",,24.94,39.2,,957.42,156.86,7483.26,51,7.4,54.07,"percent of total billed charges",
"GWIRE SAMURAI VASCULAR 190CM",SUP-H749393021902,CDM,C1769,HCPCS,0272,RC,,,both,,,689.78,206.93,"PHCS [10601]",PHCS,,482.85,70,,,,,0,80.22,586.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM PINNACLE GRIPTION TF DOME 4 POINT CUT",SUP-121730500,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"BLUE CROSS [10001]","Blue Cross HMO",,449.29,39.2,,957.42,156.86,7483.26,51,133.3,974.23,"percent of total billed charges",
"MARKER TUMARK BREAST BIOPSY PROFESSIONAL Q BREVERA STD",SUP-TUMARK-BREV-S-Q-02,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"BLUE CROSS [10001]","Blue Cross PPO",,261.8,39.2,,,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"Bien-Air 40deg Curved Adenoid, Double Serrated, Convex, 4.0m",SUP-1600572,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752620,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]","Cigna Open Access",,513.34,,,,,,,104.92,766.85,"percent of total billed charges",
"COIL EMBOLIZATION 177CM 10MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240100200,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1951.08,28.62,,,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE RESTERILIZABLE STERILE LATEX FREE",SUP-MSZFX615,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"NOVANET [10819]",Novanet,,133.46,75,,,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 7 X 15 HELICAL FILLING COIL",SUP-10HFL-07015,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"AETNA [10100]","Aetna HMO/PPO",,7125.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE RESTERILIZABLE STERILE LATEX FREE",SUP-MSZFX615,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"MULTIPLAN [10600]",Multiplan,,151.26,85,,,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 12MM 145CM 5.5MM BALLOON DILATATION",SUP-1400550-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 20MM 5MM 4.9FR DREAMTOME DREAMWIRE BILIARY RAPID",SUP-M00584020,CDM,C1769,HCPCS,0272,RC,,,both,,,3112.43,933.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,368.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,361.98,2645.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 16MM 144CM 4MM CORONARY STENT EVEROLIMUS",SUP-H7493926116400,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"PHCS [10601]",PHCS,,6520.5,70,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM INTERLOCK FIBERED IDC 18 COIL",SUP-M001361520,CDM,S27800098,LOCAL,0278,RC,,,both,,,1984.50,595.35,"MULTIPLAN [10600]",Multiplan,,1686.83,85,,,,,0,230.8,1686.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT TRACTION MEDIUM TRIANGLE BUCKLE HOOK CLSR VENTILATION",SUP-19404,CDM,S27000186,LOCAL,0270,RC,,,both,,,140.59,42.18,"CIGNA [10200]",Cigna,,95.6,68,,,,,0,16.35,119.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE IRRIGATION 7CM STERILE LATEX FREE DISPOSABLE",SUP-5407-010-450,CDM,S27200284,LOCAL,0272,RC,,,both,,,585.74,175.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STAPLE INTERNAL EXTRA THICK STERILE GIA TRI-STAPLE LATEX",SUP-GIA80MTS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1127.12,338.14,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SENSOR FLOW CALIBRATION ADPTR CNCT 188CM 15MM 22MM",SUP-281637,CDM,S27000186,LOCAL,0270,RC,,,both,,,121.81,36.54,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 40MM 4MM NONSTERILE REUSABLE",SUP-7005-4040,CDM,S27200284,LOCAL,0272,RC,,,both,,,476.93,143.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TACTIFLEX SE BID CURVE F-J",SUP-A-TFSE-FJ,CDM,C2630,HCPCS,0272,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SLEEVE TIBIAL 53MM ATTUNE KNEE POROCOAT REVISION PARTIAL COA",SUP-151111104,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 RIGHT KNEE CEMENTED CRUCIATE RETAINING",SUP-5510-F-702,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1943.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1907.07,13938.17,"percent of total billed charges",
"SCR INTERFERENCE PEEK-OPTIMA 15MM 8MM BIOSURE BICEPTOR",SUP-72202284,CDM,C1713,HCPCS,0278,RC,,,both,,,2054.03,616.21,"MULTIPLAN [10600]",Multiplan,,1745.93,85,,,,,0,238.88,1745.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 175MM SCHANZ STAINLESS STEEL CONDYLAR HIP SELF",SUP-294.785,CDM,C1713,HCPCS,0278,RC,,,both,,,1042.88,312.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,123.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",121.29,886.45,"percent of total billed charges",
"HC Ihc 1st Antibody per Slide",PX-312000041,CDM,88342,CPT,0312,RC,,,both,,,766.65,229.99,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,651.65,"per diem",
"SYSTEM FRONTIER ONYX 30MM 3.50MM CORONARY STENT ZOTAROLIMUS",SUP-ONYXNG35030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA [10200]","Cigna Open Access",,1536.3,56.9,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERRATA PRESSURE GUIDE WIRE",SUP-10185,CDM,C1769,HCPCS,0272,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Mycobacteria Defin ID",PX-306000074,CDM,87118,CPT,0306,RC,,,both,,,335.35,100.6,"UHC [10700]","United Healthcare",,13.15,,,,,,,0.01,285.05,"fee schedule",
"EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION",RX-24513,CDM,J0885,HCPCS,0636,RC,59676-0340-01,NDC,both,1,ML,6452.48,1935.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,363.69,,"Fee schedule rate ($363.69). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,363.69,5484.61,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 17GA 2.75IN TRUGUIDE COAXIAL DISPOSABLE MONOPTY",SUP-C1810B,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.96,27.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,62.53,68,,,,,0,10.69,78.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TWISTER PLUS 230CM 26MM 2.5MM SPECIMEN RETRIEVAL",SUP-TWIST26,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"CIGNA [10200]","Cigna Open Access",,322.62,56.9,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAUT OPHTHALMIC .5IN ACCU-TEMP 677C LOW TEMPERATURE FINE TIP",SUP-8441000,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.94,39.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,53.82,41.1,,,,,0,15.23,111.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 20MM 2.5MM BALLOON DILATATION PEBAX",SUP-1012272-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 30CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155245180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURPASS EVOLVE 3.25MM X 12MM - PMA",SUP-FDS32512,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"UHC [10700]","United Healthcare",,52554.65,63.3,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 82MM 32MM 7.7MM 20FR ZENITH FLEX Z-TRAK 2",SUP-G48427,CDM,C1874,HCPCS,0278,RC,,,both,,,50122.80,15036.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,20049.12,40,,,,,0,5829.28,42604.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trcran Dplr Intrcr Complt",PX-921000003,CDM,93886,CPT,0921,RC,,,both,,,1764.05,529.21,"CIGNA [10200]","Cigna Local Plus",,943.77,53.5,,,,,0,205.16,1499.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 CTX 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J363H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 1IN 20GA 90D INFUSION 1 HAND CLAMP UNIVERSAL LUER LOCK",SUP-H787LG201005,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.74,26.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,60.34,68,,,,,0,10.32,75.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 9MM 9FR ENDOPROSTHESIS HEPARIN ILIAC",SUP-VBH090502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18566.10,5569.83,"BLUE CROSS [10001]","Blue Cross HMO",,7277.91,39.2,,9776.84,9776.84,9776.84,"1 through 10",2159.24,15781.19,"percent of total billed charges",
"BLADE LARYNSCP BRITEPRO OMNI MACINTOSH 2 COLOR CODED STD",SUP-040-04-0120U,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.42,18.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25.65,41.1,,,,,0,7.26,53.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 300MM 6MM BALLOON",SUP-LX1813063005F,CDM,C2623,HCPCS,0272,RC,,,both,,,18270.00,5481,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 9MM BALLOON",SUP-U357598,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 22MM EVOLVE 2+ MM ELBOW PROLINE MODULAR STERILE",SUP-496H222,CDM,C1776,HCPCS,0278,RC,,,both,,,12295.80,3688.74,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5053.57,41.1,,6417.48,6417.48,6417.48,"1 through 10",1430,10451.43,"percent of total billed charges",
"BEARING HIP 42MM 28MM E VIVACIT-E LUMEN STERILE LATEX FREE",SUP-110031011,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"BLUE CROSS [10001]","Blue Cross PPO",,4059.9,39.2,,3949.44,3949.44,3949.44,"1 through 10",1204.51,8803.37,"percent of total billed charges",
"SCR BONE 5MM 22MM LCP STAINLESS STEEL PROXIMAL MEDIAL TIBIAL",SUP-212.205,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,249.9,28.62,,,,,0,101.55,742.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.25 X 18 RX US",SUP-1804325-18,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOSCOPIC WATER 200X173MM 385MM 230ML/MINUTE AUXILIARY",SUP-K10016135,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.01,40.2,"CIGNA [10200]",Cigna,,91.13,68,,,,,0,15.59,113.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM 22.5MM MASTERS HP MECHANICAL ROTATABLE STD",SUP-25MHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE RIGHT PRESS FIT EMPOWR 3D KNEE STERILE",SUP-243-02-108,CDM,C1776,HCPCS,0278,RC,,,both,,,27824.45,8347.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3297.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3235.98,23650.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC 2XL 44X6IN SHOULDER VELPEAU PADDED WRIST",SUP-9008-05,CDM,S27000186,LOCAL,0270,RC,,,both,,,103.62,31.09,"PHCS [10601]",PHCS,,72.53,70,,,,,0,12.05,88.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 3-0 6IN ENDO STITCH V-LOC POLYBUTESTER LOAD",SUP-VLOCN306L,CDM,S27200284,LOCAL,0272,RC,,,both,,,381.41,114.42,"CIGNA [10200]",Cigna,,259.36,68,,,,,0,44.36,324.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM MITRAL CARPENTIER-EDWARDS PHYSIO II",SUP-520028MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,15180.00,4554,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1765.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BARR ADHESION 5X6IN BIORESORBABLE MEMB SEPRAFILM SODIUM",SUP-4301-02,CDM,C1765,HCPCS,0278,RC,,,both,,,2305.04,691.51,"KAISER [10500]",Kaiser,,1544.38,67,,,,,0,268.08,1959.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 64CM ENDOTAK RELIANCE S ENDOCARDIAL STEROID",SUP-128,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6238.98,41.1,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 18MM 2.25MM CORONARY STENT FULCRUM COCR",SUP-INT22518UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CIGNA [10200]","Cigna Open Access",,1374.14,56.9,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM TSRH OSTEOGRIP TITANIUM SPINE",SUP-83575359,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,305.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,299.36,2187.9,"percent of total billed charges",
"CMPNT FEMORAL 1 KNEE RIGHT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517-F-102,CDM,C1776,HCPCS,0278,RC,,,both,,,22765.05,6829.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9106.02,40,,,,,0,2647.58,19350.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 30CM POLYURETHANE POWER-TRIALYSIS 3 LUMEN POWER",SUP-5603300,CDM,C1752,HCPCS,0272,RC,,,both,,,1245.78,373.73,"MULTIPLAN [10600]",Multiplan,,1058.91,85,,,,,0,144.88,1058.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 4CM 8MM BALLOON DILATATION ILIAC",SUP-G34344,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 4-0 BB 36IN 2 ARM MONOFILAMENT BLUE",SUP-8581H,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.21,18.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRESSING ANTIMICROBIAL 3.5 X 12 INCH AQUACEL AG ADVANTAGE",SUP-422606,CDM,S27200284,LOCAL,0272,RC,,,both,,,325.56,97.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 150CM 2CM 7MM BALLOON DILATATION ILIAC",SUP-G34338,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GUIDING 8FR .088IN RADIOPAQUE SIDEHOLE HYBRID BRAID",SUP-588844,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 30MM SUREFORM STERILE 8MM LATEX FREE DISPOSABLE",SUP-48230W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM AXSOS TITANIUM CORTEX NONSTERILE",SUP-661740,CDM,C1713,HCPCS,0278,RC,,,both,,,330.25,99.07,"BLUE CROSS [10001]","Blue Cross PPO",,129.46,39.2,,957.42,570.23,957.42,28,38.41,280.71,"percent of total billed charges",
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 20MM 144CM 2.75MM",SUP-H7493941220270,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,919.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 50MM GORILLA R3CON LOCK",SUP-P50-353-4250,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Local Plus",,715.03,53.5,,3978.14,359.25,3978.14,24,155.43,1136.03,"percent of total billed charges",
"SUPREME EXTENSION CABLE RED  150 CM",SUP-401983,CDM,S27200284,LOCAL,0272,RC,,,both,,,248.00,74.4,"PHCS [10601]",PHCS,,173.6,70,,,,,0,28.84,210.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.5IN 8FR PHILLIPS 1/56IN HOLLOW PLASTIC 1 EYE",SUP-346108,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.46,41.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,63.09,45.9,,,,,0,15.99,116.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DICYCLOMINE 10 MG CAPSULE",RX-2418,CDM,,,0637,RC,00904-6987-61,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,3.35,53.5,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 475CC P5.4CM HIGH PROFILE ROUND TEXTURE",SUP-354-4475,CDM,C1789,HCPCS,0278,RC,,,both,,,4823.10,1446.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,560.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,560.93,4099.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit B Level 1 W Proc",PX-450000326,CDM,G0380,HCPCS,0450,RC,,,both,,,442.00,132.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,442,,,,,,,67.13,442,"case rate",
"MARKER FIDUCIAL STRAIGHT 5MM .018IN LUMICOIL PLATINUM",SUP-M00553831,CDM,A4648,HCPCS,0278,RC,,,both,,,1387.72,416.32,"KAISER [10500]",Kaiser,,929.77,67,,,,,0,161.39,1179.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM SWIVELOCK PEEK STERILE LATEX FREE",SUP-AR-1665PSL,CDM,C1713,HCPCS,0278,RC,,,both,,,5614.88,1684.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2577.23,45.9,,,,,0,653.01,4772.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS PNEUMATIC LIFEBAND CHEST COMPRESSION STRAP LATEX FREE",SUP-8700-0706-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1202.12,360.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,494.07,41.1,,,,,0,139.81,1021.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CD HORIZON SPINAL FENESTRATE MULTIAXIAL",SUP-55840026540T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"STENT 22CM 8FR LARGE REGULAR PIGTAIL CURVE URETERAL FLEXIMA",SUP-M001274010,CDM,C2617,HCPCS,0278,RC,,,both,,,1053.00,315.9,"NOVANET [10819]",Novanet,,789.75,75,,,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 210CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRM-210,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,637.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT SMALL INLINE CODMAN CERTAS PLUS SIPHONGUARD",SUP-828814PL,CDM,S27800098,LOCAL,0278,RC,,,both,,,36453.69,10936.11,"UHC [10700]","United Healthcare",,23075.19,63.3,,,,,0,4239.56,30985.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 10 6MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151621006,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3038.55,27,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CIV-FLEX BRACHYTHERAPY BALLOON LATEX FREE TRNSDUC 8848",SUP-UA0059,CDM,S27200284,LOCAL,0272,RC,,,both,,,250.56,75.17,"KAISER [10500]",Kaiser,,167.88,67,,,,,0,29.14,212.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE 20MM 8MM BIOSURE REGENESORB",SUP-72204398,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"MULTIPLAN [10600]",Multiplan,,2357.93,85,,,,,0,322.62,2357.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 20X5.5X.4MM MICROCHOICE OSCILLATING STERILE",SUP-KM-3003,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"CIGNA [10200]",Cigna,,42,68,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.250 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.250,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 75X12.5X.8MM .9MM HALL RECIPROCATE STERILE",SUP-00505217900,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.89,65.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,89.96,41.1,,,,,0,25.46,186.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 30CM 3CM 6FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155235050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]","Cigna Open Access",,700.42,,,,,,,143.16,1046.32,"percent of total billed charges",
"BURR SURGICAL 4MM ELITE OSTEON ROUND SOFT TOUCH STERILE",SUP-5820010140,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 22GA 20CM CANN SERRATED EDGE FRANSEEN LUNG",SUP-G01269,CDM,S27200284,LOCAL,0272,RC,,,both,,,190.10,57.03,"AETNA [10100]","Aetna HMO/PPO",,151.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.11,161.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CD HORIZON SOLERA COCR HA SPINE",SUP-54740106540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"HOLDER 6IN RYDER SERRATE INSRT NDL TUNGSTEN CARBIDE 1MM RING",SUP-32-466,CDM,S27200284,LOCAL,0272,RC,,,both,,,364.44,109.33,"MULTIPLAN [10600]",Multiplan,,309.77,85,,,,,0,42.38,309.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X20X8MM PIVOX 0D LATERAL OLIF25",SUP-2110145,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"KAISER [10500]",Kaiser,,17728.2,67,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH XXL QUADRA-FOLD 75CM 60MM 16MM BALLOON DILATATION",SUP-M001145540,CDM,C1725,HCPCS,0272,RC,,,both,,,1709.63,512.89,"KAISER [10500]",Kaiser,,1145.45,67,,,,,0,198.83,1453.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Afo Brace",PX-E27400078,CDM,L1930,HCPCS,0274,RC,,,both,,,639.10,191.73,"CIGNA [10200]","Cigna Local Plus",,341.92,53.5,,,,,0,74.33,543.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL ZIPWIRE 22-30CM 3CM 4.8FR .035IN PIGTAIL",SUP-M006180155180,CDM,C2617,HCPCS,0278,RC,,,both,,,1466.59,439.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,419.74,28.62,,,,,0,170.56,1246.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUTTY PROGENIX DBM 5ML",SUP-005005,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IOTHALAMATE SODIUM 0.1 % INTRAVENOUS SOLUTION 20-30 MICROCURIES",RX-411485,CDM,A9554,HCPCS,0343,RC,08888-8878-49,NDC,both,1,UN,13286.75,3986.02,"UHC [10700]","United Healthcare",,3800.4,,,,,,,131.12,11293.74,"fee schedule",
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-12098,CDM,,,0637,RC,00480-3310-01,NDC,both,1,UN,21.61,6.48,"CIGNA [10200]","Cigna Open Access",,12.3,56.9,,,,,0,2.51,18.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 18MM PERSONA 6-9 C-D KNEE RIGHT VIVACIT-E",SUP-42-5226-005-18,CDM,C1776,HCPCS,0278,RC,,,both,,,13634.40,4090.32,"CIGNA [10200]",Cigna,,5453.76,40,,5873.17,5873.17,5873.17,"1 through 10",1585.68,11589.24,"percent of total billed charges",
"SCR INTERFERENCE TITANIUM 20MM 8MM ACL PCL CANNULATED SHEATH",SUP-AR-1380E,CDM,C1713,HCPCS,0278,RC,,,both,,,978.08,293.42,"FIRST HEALTH [10303]","First Health",,782.46,80,,,,,0,113.75,831.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2728.13,818.44,"BLUE CROSS [10001]","Blue Cross HMO",,1069.43,39.2,,9776.84,9776.84,9776.84,"1 through 10",317.28,2318.91,"percent of total billed charges",
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC",718,MS-DRG,,,,,,,inpatient,,,45243.20,13572.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,21414.02,,,,,,,7561,39213.15,"case rate",
"NDL EPIDURAL 14GA 90MM TUOHY THIN WALL SNAP ON WING STERILE",SUP-990-003,CDM,S27200284,LOCAL,0272,RC,,,both,,,1077.30,323.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,442.77,41.1,,,,,0,125.29,915.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD 16FR URETHRAL NATURAL RUBBER SILICONE ELASTOMER 30",SUP-266716,CDM,S27200284,LOCAL,0272,RC,,,both,,,2.29,0.69,"NOVANET [10819]",Novanet,,1.72,75,,,,,0,0.27,1.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR BALKIN CURVE 40CM 7FR GUIDING ACCEPTS .035IN",SUP-G10405,CDM,C1894,HCPCS,0272,RC,,,both,,,1466.10,439.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,602.57,41.1,,,,,0,170.51,1246.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 50MM GORILLA R3CON LOCK",SUP-P50-353-4250,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NEURON 125CM 6FR SIMMONS CURVE THROMBECTOMY SELECT",SUP-PNS6F125SIM,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"AETNA [10100]","Aetna HMO/PPO",,804.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP CONSTRUCT 2",SUP-CAP-Z-H-2,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"BLUE CROSS [10001]","Blue Cross HMO",,9631.44,39.2,,5311.50,4717.44,5388.59,31,2857.49,20884.5,"percent of total billed charges",
"KIT INTRO 2.5IN 13FR IMPELLA",SUP-0052-0007,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"UHC [10700]","United Healthcare",,3057.39,63.3,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM ALLOGRAFT 10MM",SUP-310110,CDM,S27800098,LOCAL,0278,RC,,,both,,,3139.50,941.85,"FIRST HEALTH [10303]","First Health",,2511.6,80,,,,,0,365.12,2668.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 16MM 135CM 5MM .018IN BILIARY STAINLESS",SUP-G56623,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"NOVANET [10819]",Novanet,,3780,75,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 5MM CANNULATED",SUP-71177134,CDM,S27200284,LOCAL,0272,RC,,,both,,,4305.32,1291.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1976.14,45.9,,,,,0,500.71,3659.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STBL SURGICAL UNIVERSAL ASSISTANT CABG ABLATION THORACIC",SUP-401-210S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.00,495,"KAISER [10500]",Kaiser,,1105.5,67,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22.5 DIOPTER +3.25 CYLINDER C HAPTIC BICONVEX 13MM",SUP-ZLB00U0225,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"FIRST HEALTH [10303]","First Health",,596,80,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,,,0250,RC,00713-0268-31,NDC,both,28.4,GR,22.62,6.79,"NOVANET [10819]",Novanet,,16.97,75,,,,,0,2.63,19.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 130MM 5.5MM GATOR STRAIGHT NONSTERILE",SUP-9260A,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Test Non Stress Fetal",PX-361000246,CDM,59025,CPT,0920,RC,,,both,,,1503.45,451.03,"AETNA [10100]","Aetna HMO/PPO",,1195.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.85,1277.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUADRASPHERES EMBOCATH PLUS 135CM 2.9-3FR .028IN MICRO",SUP-ECP135,CDM,C1751,HCPCS,0272,RC,,,both,,,2022.75,606.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,239.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.25,1719.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Oasis Wnd Matrix per Scm",PX-636000013,CDM,Q4102,HCPCS,0636,RC,,,both,,,134.20,40.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,91.26,68,,,,,0,15.9,134.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 25MM 9MM BIOSURE",SUP-72202272,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"BLADE SAW 11.5X5.5MM THK.38MM THK.43MM SMALL BONE OSCILLATE",SUP-KM3-410,CDM,S27200284,LOCAL,0272,RC,,,both,,,557.28,167.18,"UHC [10700]","United Healthcare",,352.76,63.3,,,,,0,64.81,473.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBJR050502A,CDM,C1874,HCPCS,0278,RC,,,both,,,19895.40,5968.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7958.16,40,,,,,0,2313.84,16911.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 3MM BALLOON DILATATION OTW STERILE",SUP-593004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,169.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 80CM 7FR EMBOLECTOMY ARTERY THRULUMEN BALLOON",SUP-12TLW807F,CDM,C1757,HCPCS,0272,RC,,,both,,,746.58,223.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,507.67,68,,,,,0,86.83,634.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 56MM STAINLESS STEEL T8 SELF TAP LOCK",SUP-02.211.056,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"NOVANET [10819]",Novanet,,673.6,75,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 3 KNEE PRIMARY BEAD PA",SUP-5526-B-300,CDM,C1776,HCPCS,0278,RC,,,both,,,15783.75,4735.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4261.61,27,,,,,0,1835.65,13416.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 3.5MM OASYS TITANIUM OCCIPITOCERVICOTHORACIC",SUP-48552070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"CORTICAL SCREW 4MM X 46MM",SUP-HTN-U-4-46,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1057.54,68,,,,,0,180.87,1321.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MONTEREY AL STAND-ALONE ANTERIOR LUMBAR ANTERIOR LUMBAR CAGE",SUP-480114531,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA [10200]",Cigna,,13860,40,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UNI-FUSE FLOW-THRU HUB 90CM 50CM 5FR THROMBECTOMY",SUP-H787124018105,CDM,C1757,HCPCS,0272,RC,,,both,,,1641.75,492.52,"MULTIPLAN [10600]",Multiplan,,1395.49,85,,,,,0,190.94,1395.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 16MM 4MM STAINLESS STEEL SHORT THREAD HAND",SUP-02.226.216,CDM,C1713,HCPCS,0278,RC,,,both,,,1647.00,494.1,"FIRST HEALTH [10303]","First Health",,1317.6,80,,,,,0,191.55,1399.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 12MM SECUR-FIT PLUS MAX HYDROXYAPATITE 8 HIP",SUP-6054-0812S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"FIRST HEALTH [10303]","First Health",,12932.35,80,,,,,0,1880.04,13740.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Pulm Img Perfsn",PX-341000031,CDM,78580,CPT,0341,RC,,,both,,,1836.14,550.84,"UHC [10700]","United Healthcare",,982.43,,,,,,,213.54,1560.72,"fee schedule",
"HC C-Peptide",PX-301000448,CDM,84681,CPT,0301,RC,,,both,,,344.50,103.35,"CIGNA [10200]","Cigna Open Access",,45.78,,,,,,,0.34,292.83,"fee schedule",
"HC NM Tum Loc Plnr Sgl Area 1 Day",PX-341000076,CDM,78800,CPT,0341,RC,,,both,,,1257.73,377.32,"PHCS [10601]",PHCS,,880.41,70,,,,,0,146.27,1069.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Tum Loc Plnr Sgl Area 1 Day",PX-341000076,CDM,78800,CPT,0341,RC,,,both,,,1257.73,377.32,"KAISER [10500]",Kaiser,,842.68,67,,,,,0,146.27,1069.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hsg Si",PX-320000126,CDM,74740,CPT,0320,RC,,,both,,,1418.02,425.41,"MULTIPLAN [10600]",Multiplan,,1205.32,85,,,,,0,118.57,1205.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immobilizer Shoulder Uni",PX-E27400084,CDM,L3650,HCPCS,0274,RC,,,both,,,48.40,14.52,"KAISER [10500]",Kaiser,,32.43,67,,,,,0,5.63,42.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 270CC P4.7CM MODERATE PLUS PROFILE TALL HEIGHT",SUP-334-1109,CDM,C1789,HCPCS,0278,RC,,,both,,,7583.10,2274.93,"KAISER [10500]",Kaiser,,5080.68,67,,,,,0,881.91,6445.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON UVA TORIC AUTONOME",SUP-CCA0T6,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"BLUE CROSS [10001]","Blue Cross HMO",,145.04,39.2,,,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC M/Phmtrc Alys Ishquant/Semiq",PX-312000068,CDM,88374,CPT,0312,RC,,,both,,,981.00,294.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,386.9,,,,,,,0.01,875.24,"fee schedule",
"PLATE MEDIUM 82MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE",SUP-02.117.402S,CDM,C1713,HCPCS,0278,RC,,,both,,,6974.52,2092.36,"KAISER [10500]",Kaiser,,4672.93,67,,,,,0,811.14,5928.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Biofdbk Trn Ea Add 15 Min(Gp)",PX-420000177,CDM,90913,CPT,0420,RC,,,both,,,840.12,252.04,"BLUE CROSS [10001]","Blue Cross HMO",,344.92,,"Per diem ($344.92).",,,,0,97.71,714.1,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 12.1CM MEMORYGEL P3.1CM MODERATE PROFILE SILTEX",SUP-3542557MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 80MM 130MM 5MM LONG VASCULAR NITINOL",SUP-SC580LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,858.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 12MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE32512,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22589.44,27,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION INTERNALBRACE FIBERTAPE CLLGN",SUP-AR-1688-CP,CDM,S27200284,LOCAL,0272,RC,,,both,,,7788.38,2336.51,"CIGNA [10200]",Cigna,,5296.1,68,,,,,0,905.79,6620.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 12MM 5FR 2MM BALLOON DILATATION PEBAX",SUP-1012403-12,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 20CM 34MM GORE TAG THORACIC ACTIVE CONTROL",SUP-TGM343420,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13742.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENVEO R DELIVERY LOAD",SUP-LS-ENVEOR2629US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2925.00,877.5,"KAISER [10500]",Kaiser,,1959.75,67,,,,,0,340.18,2486.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 15MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158126115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]","Cigna Open Access",,6358.32,56.9,,5302.19,4377.88,6578.61,27,1299.6,9498.37,"percent of total billed charges",
"AIRWAY ESOPHAGEAL 5 8.7MM ADULT LMA FLEXIBLE LARYNGEAL MASK",SUP-115050,CDM,S27200284,LOCAL,0272,RC,,,both,,,160.95,48.28,"CIGNA [10200]",Cigna,,109.45,68,,,,,0,18.72,136.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ldl Cholesterol",PX-301000306,CDM,83721,CPT,0301,RC,,,both,,,107.90,32.37,"NOVANET [10819]",Novanet,,80.93,75,,,,,0,0.01,91.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION",RX-5886,CDM,J2360,HCPCS,0636,RC,25021-0651-02,NDC,both,2,ML,108.72,32.62,"NOVANET [10819]",Novanet,,81.54,75,,,,,0,7.51,92.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Complement Total (Ch50)",PX-302000033,CDM,86162,CPT,0302,RC,,,both,,,345.83,103.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21.34,,"Fee schedule rate ($21.34). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,293.96,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 6.35MM TSRH-2D CONTOUR PEDICLE TITANIUM",SUP-8371030,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 14MM STAINLESS STEEL ORTHOPEDIC CANNULATED LOW",SUP-S20-14S-09,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]",Cigna,,688.5,68,,1831.33,1831.33,1831.33,16,117.75,860.63,"percent of total billed charges",
"SCR BONE 3MM 2MM 28MM 6MM STAINLESS STEEL 1.1MM SHORT THREAD",SUP-02.226.028,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"CIGNA [10200]","Cigna Local Plus",,880.18,53.5,,3978.14,359.25,3978.14,24,191.34,1398.42,"percent of total billed charges",
"ROD SPINAL 120MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000120,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,188.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",188.41,1377,"percent of total billed charges",
"CATH RF MARINR 80CM 4MM 5FR 2-5-2MM SPACING SINGLE CURVE",SUP-076515,CDM,C1733,HCPCS,0272,RC,,,both,,,3562.50,1068.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 23GA 13MM 45D LUER LOCK HUB EXT TONSIL SURGICAL",SUP-72-9514,CDM,S27200284,LOCAL,0272,RC,,,both,,,367.84,110.35,"CIGNA [10200]",Cigna,,250.13,68,,,,,0,42.78,312.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G211,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"AETNA [10100]","Aetna HMO/PPO",,7446.03,79.5,,10981.53,8986.79,12413.38,12,1089.28,7961.17,"percent of total billed charges",
"GRAFT SOFT TISSUE MTF SMALL DIAMETER ANTERIOR TIBIALIS",SUP-430337,CDM,S27800098,LOCAL,0278,RC,,,both,,,10522.50,3156.75,"NOVANET [10819]",Novanet,,7891.88,75,,,,,0,1223.77,8944.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 175MM CEMENT PROXIMAL GROOVE ECHELON COCR 12",SUP-71310312,CDM,C1776,HCPCS,0278,RC,,,both,,,44689.05,13406.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5295.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,5197.34,37985.69,"percent of total billed charges",
"HC Caregiver Training 1st 30 Min (Gn)",PX-440000023,CDM,97550,CPT,0440,RC,,,both,,,90.21,27.06,"MULTIPLAN [10600]",Multiplan,,76.68,85,,,,,0,10.49,90.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH EXCLUDER 28CM 26FR 9.8MM 8.9MM INTRO EPTFE PERIPHERAL",SUP-SDV2628,CDM,C1894,HCPCS,0272,RC,,,both,,,2512.50,753.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,297.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,292.2,2135.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM 41.6MM 34MM MITRAL TRICUSPID FLEXIBLE",SUP-460034MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"NOVANET [10819]",Novanet,,8538.75,75,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IOTHALAMATE SODIUM 0.1 % INTRAVENOUS SOLUTION 20-30 MICROCURIES",RX-411485,CDM,A9554,HCPCS,0343,RC,08888-8878-49,NDC,both,1,UN,13286.75,3986.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3800.4,,,,,,,131.12,11293.74,"fee schedule",
"COIL EMBOLIZATION 177CM 14MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240140300,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"UHC [10700]","United Healthcare",,5455.26,63.3,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER CELEROMARK BREAST BIOPSY","SUP-CELERO MARK -2S",CDM,A4648,HCPCS,0278,RC,,,both,,,628.56,188.57,"CIGNA [10200]","Cigna Open Access",,357.65,56.9,,,,,0,73.1,534.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,inpatient,,,30603.42,9181.03,"CIGNA [10200]","Cigna Open Access",,10052.18,,"Fee schedule rate ($10,052.18). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,5682.01,22844.12,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE 12.5-14 XL MALE PATIENT POSTOPERATIVE RIBBED ROCKER D",SUP-798507,CDM,S27000186,LOCAL,0270,RC,,,both,,,61.07,18.32,"CIGNA [10200]",Cigna,,41.53,68,,,,,0,7.1,51.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER ENDO HOOK SH 2.0",SUP-13-201-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,715.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 4MM CORONARY STENT",SUP-1145400-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]","Cigna Open Access",,3321.82,56.9,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 16MM 2MM QUICK COUPLING STOP NONSTERILE",SUP-03.617.916,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 54MM 47MM HIP 2 MOBILITY",SUP-121854047,CDM,C1776,HCPCS,0278,RC,,,both,,,15870.00,4761,"PHCS [10601]",PHCS,,11109,70,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 10FR .131IN 25CM ROBUST VALVE SPLITTABLE",SUP-PLSX-2510,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 STD KNEE LEFT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB4SL,CDM,C1776,HCPCS,0278,RC,,,both,,,17652.60,5295.78,"BLUE CROSS [10001]","Blue Cross HMO",,6919.82,39.2,,5311.50,4717.44,5388.59,31,2053,15004.71,"percent of total billed charges",
"GWIRE ENTEER VASCULAR 28D 2.5MM FLAT 300CM .014IN",SUP-ENW-SF-014-300,CDM,C1769,HCPCS,0272,RC,,,both,,,1620.00,486,"UHC [10700]","United Healthcare",,1025.46,63.3,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 7MM GORE INTERING THIN WALL PTFE RADIAL",SUP-IRST07040040L,CDM,C1768,HCPCS,0278,RC,,,both,,,6348.00,1904.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1816.8,28.62,,,,,0,738.27,5395.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 3X3IN DURAGEN PLUS DURAL BOVINE CLLGN PATCH",SUP-DP5033,CDM,,,0278,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,3.74,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 11MM KNEE BEARING POSTERIOR STABILIZE",SUP-5532-G-311-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7760.57,68,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRACCATH, 15W",SUP-4900,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 9MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-409,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"AETNA [10100]","Aetna HMO/PPO",,7815.26,79.5,,10981.53,8986.79,12413.38,12,1143.29,8355.94,"percent of total billed charges",
"SOL DEX 5    .5 SALINE 1000ML",SUP-792609,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA [10200]","Cigna Local Plus",,43.34,53.5,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850016545,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,762.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",762.35,5571.75,"percent of total billed charges",
"HC Rv Tib/Prneal W Pta Sf Ea Add",PX-361000722,CDM,37281,CPT,0361,RC,,,both,,,6735.46,2020.64,"MULTIPLAN [10600]",Multiplan,,5725.14,85,,,,,0,6.74,6735.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 11/13 TAPER 40MM HIP M SPECIFICATION",SUP-136547500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5084.78,45.9,,,,,0,1288.37,9416.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cytomegalovirus (Cmv) Igm Ab",PX-302000112,CDM,86645,CPT,0302,RC,,,both,,,224.20,67.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.03,,"Fee schedule rate ($18.03). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,190.57,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 18.5X5.5X.38MM HALL MICRO STAINLESS STEEL",SUP-5301030062,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.29,43.59,"PHCS [10601]",PHCS,,101.7,70,,,,,0,16.9,123.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 28CM 7FR 2.1FR 2 PIGTAIL CURVE",SUP-M0061921440,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,132.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 38MM 4MM CORONARY STENT EVEROLIMUS",SUP-1550400-38,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"SET STENT 16CM 5FR 2.1FR POLARIS ULTRA NAUTILUS ZIPWIRE .038",SUP-M006192114170,CDM,C2617,HCPCS,0278,RC,,,both,,,1357.24,407.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,160.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,157.85,1153.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR TUBING HUB SIDE ARM POLYURETHANE 4FR CATH 8IN RED",SUP-VA-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.10,33.93,"KAISER [10500]",Kaiser,,75.78,67,,,,,0,13.15,96.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) CATHETER WALRUS 90CM 8FR STRAIGHT BALLOON DILATATION",SUP-BG8087-090,CDM,C1887,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"FIRST HEALTH [10303]","First Health",,9108,80,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 TWINFIX ULTRA COBRAID PEEK-OPTIMA STERILE",SUP-72202599,CDM,C1713,HCPCS,0278,RC,,,both,,,1724.63,517.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,493.59,28.62,,,,,0,200.57,1465.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD REAMER 17MM STAINLESS STEEL RIA STERILE DISPOSABLE",SUP-352.261S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2533.80,760.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1041.39,41.1,,,,,0,294.68,2153.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 65CM 5FR PIGTAIL CURVE ANGIOGRAPHIC",SUP-5653810PIG-NB,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"KAISER [10500]",Kaiser,,72.86,67,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.3MM 2.4MM 12MM TITANIUM CORTEX HAND SELF TAPPING",SUP-400.692,CDM,C1713,HCPCS,0278,RC,,,both,,,650.92,195.28,"MULTIPLAN [10600]",Multiplan,,553.28,85,,,,,0,75.7,553.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR REGULAR 30X3.5MM DST SERIES TA TITANIUM",SUP-TA3035L,CDM,S27200284,LOCAL,0272,RC,,,both,,,275.79,82.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,187.54,68,,,,,0,32.07,234.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SURGICAL MEDIUM CIRCLE 2.5IN SPRING OPEN BIORESORBABLE",SUP-5950008,CDM,C1781,HCPCS,0278,RC,,,both,,,2068.00,620.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,240.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,240.51,1757.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 48MM SHOULDER REVISION SMR COCR MOLYBDENUM",SUP-1322.09.480,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,938.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,921.1,6732,"percent of total billed charges",
"SPACER SPINAL 22MMX14MM VERTE-STACK CAPSTONE PEEK-OPTIMA END",SUP-2961422,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1848.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO2 VASCULAR 200CM 35CM .014IN NITINOL STAINLESS",SUP-M00326410,CDM,C1769,HCPCS,0272,RC,,,both,,,4186.64,1255.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,496.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.91,3558.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 110CM 6FR AP2 CURVE ANGIOGRAPHIC",SUP-G05739,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,57.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM SPINE MULTIAXIAL REDUCTION 5.5/6MM ROD",SUP-55890007545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"GWIRE VASCULAR 260CM .018IN RADIOPAQUE",SUP-0052-3005,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"KAISER [10500]",Kaiser,,2512.5,67,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 100MM 80CM 10MM 6FR .035IN BILIARY",SUP-G50138,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"BLUE CROSS [10001]","Blue Cross HMO",,2387.28,39.2,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM LCP STAINLESS STEEL CORTICAL T25 STARDRIVE",SUP-02.204.030,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"NOVANET [10819]",Novanet,,739.94,75,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 88MM 1.5MM K WIRE ATTACH THREAD HOLE NONSTERILE",SUP-03.130.300,CDM,S27200284,LOCAL,0272,RC,,,both,,,576.07,172.82,"KAISER [10500]",Kaiser,,385.97,67,,,,,0,67,489.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 20MM 14MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044142070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]","Cigna Open Access",,4907.63,56.9,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP RVS CNTRL 6.5X35MM ST/RST",SUP-115397,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"MULTIPLAN [10600]",Multiplan,,1322.6,85,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL MITRACLIP BUNDLE SGC0301 2 CDS0601 XTR",SUP-MBR0202,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68400,40,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 19MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G719,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1012.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 12MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240120300,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"MULTIPLAN [10600]",Multiplan,,7325.39,85,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 150MM 150CM 8MM VASCULAR NICKEL",SUP-EVD35-08-150-150,CDM,C1876,HCPCS,0278,RC,,,both,,,8295.00,2488.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,982.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,964.71,7050.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 23MM 20.4MM MASTERS HP MECHANICAL ROTATABLE STD",SUP-23MHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"PHCS [10601]",PHCS,,20383.46,70,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER TEAL 5.5MM DYONICS INCISOR PLUS STRAIGHT",SUP-7205459,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,143.03,41.1,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX RADIOPAQUE",SUP-M0061453530,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"BLUE CROSS [10001]","Blue Cross HMO",,248.18,39.2,,,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 25MM 25MM AEQUALIS REVERSE II",SUP-DWE725,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"NOVANET [10819]",Novanet,,7082.25,75,,,,,0,1098.22,8026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 2.25X10MM",SUP-PRV022510CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CD HORIZON MODULEX SPINE CORTICAL",SUP-55900106540,CDM,C1713,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"BLUE CROSS [10001]","Blue Cross HMO",,2299.08,39.2,,957.42,156.86,7483.26,51,682.1,4985.25,"percent of total billed charges",
"SUT SOFSILK 2 V-26 30IN CONTROL RELEASE BRAIDED COATED",SUP-CS-746,CDM,S27200284,LOCAL,0272,RC,,,both,,,55.33,16.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,22.74,41.1,,,,,0,6.43,47.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 15CM 7MM BALLOON DILATATION OTW LOW",SUP-G30968,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM ARTHREX SWIVELOCK 2 LOAD PEEK STERILE",SUP-AR-2324PSLC-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,3110.63,933.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1427.78,45.9,,,,,0,361.77,2644.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 29MM TORNIER AEQUALIS PERFORM +6MM SHOULDER",SUP-DWJ513,CDM,C1776,HCPCS,0278,RC,,,both,,,11340.00,3402,"NOVANET [10819]",Novanet,,8505,75,,,,,0,1318.84,9639,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CGUARD PRIME CAROTID STENT SYSTEM 135CM 10MM LENGTH  40MM",SUP-CND1040,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5604.8,27,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enteroscopy W Ileum W Ins Stnt",PX-750000231,CDM,44379,CPT,0750,RC,,,both,,,9903.00,2970.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4752,,"Case rate ($4,752). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1151.72,9903,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Driveline W Closure 6x6",PX-E27200437,CDM,E27200437,LOCAL,0272,RC,,,both,,,43.97,13.19,"KAISER [10500]",Kaiser,,29.46,67,,,,,0,5.11,37.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT SWIVELOCK SP KNOTLESS SELF PUNCH EYELET PEEK 24.5",SUP-AR-2324KPSP,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 80MM 125CM 8MM 6FR .035IN VASCULAR NITINOL",SUP-G43833,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross HMO",,1481.76,39.2,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUGMENT TIBIAL PERSONA SMALL CONE KNEE CENTRAL STERILE LATEX",SUP-42545000511,CDM,C1776,HCPCS,0278,RC,,,both,,,47966.69,14390.01,"FIRST HEALTH [10303]","First Health",,38373.35,80,,,,,0,5578.53,40771.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60MM MEDIUM VASCULAR ARTICULATING EXTRA THICK",SUP-SIG60CTAMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1887.83,566.35,"CIGNA [10200]","Cigna Local Plus",,1009.99,53.5,,,,,0,219.55,1604.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM 15MM ES2 SPINE CANNULATED LOW PROFILE 6",SUP-482804640,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE TRNSDUC 48IN MERITRANS MALE ROTATE LUER FEMALE FIX",SUP-K11-00392B,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.22,27.67,"PHCS [10601]",PHCS,,64.55,70,,,,,0,10.73,78.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM ACCOLADE HFX 127D 8 54MM OFFSET HIP",SUP-6077-0840,CDM,C1776,HCPCS,0278,RC,,,both,,,8983.80,2695.14,"PHCS [10601]",PHCS,,6288.66,70,,,,,0,1044.82,7636.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL O2 THERAPY HIGH FLOW NEONATE AIRLIFE OPTIFLOW",SUP-BC2435-20,CDM,S27000186,LOCAL,0270,RC,,,both,,,70.91,21.27,"FIRST HEALTH [10303]","First Health",,56.73,80,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBO ELITE 150CM 1.4MM ATHERECTOMY PERIPHERAL RAPID",SUP-414-159,CDM,C1885,HCPCS,0272,RC,,,both,,,18868.50,5660.55,"MULTIPLAN [10600]",Multiplan,,16038.23,85,,,,,0,2194.41,16038.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 60MM 2.5MM .014IN BALLOON DILATATION",SUP-AB14W025060150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"KAISER [10500]",Kaiser,,928.02,67,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR/ELEV LAPAROSCOPIC 34MM VCARE PLUS CUP CERVICAL",SUP-60-6085-201A,CDM,S27200284,LOCAL,0272,RC,,,both,,,522.45,156.73,"FIRST HEALTH [10303]","First Health",,417.96,80,,,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 15MM 3.2-2.5-2.7FR 4MM BALLOON",SUP-SPR4015W,CDM,C1725,HCPCS,0272,RC,,,both,,,546.75,164.02,"UHC [10700]","United Healthcare",,346.09,63.3,,,,,0,63.59,464.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN SUCTION UNIVERSAL PLUS STD 5MM 44CM SUMP STERILE",SUP-60-6001-205,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.75,61.12,"CIGNA [10200]","Cigna Open Access",,115.93,56.9,,,,,0,23.7,173.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vad Cable Disply Mod to Pwr Mod",PX-E27400010,CDM,Q0486,HCPCS,0274,RC,,,both,,,2025.00,607.5,"MULTIPLAN [10600]",Multiplan,,1721.25,85,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL REVERSE ALTIVATE SMALL SHELL 6MM X 220MM",SUP-533-06-220,CDM,C1776,HCPCS,0278,RC,,,both,,,45388.92,13616.68,"BLUE CROSS [10001]","Blue Cross PPO",,17792.46,39.2,,3949.44,3949.44,3949.44,"1 through 10",5278.73,38580.58,"percent of total billed charges",
"KNIFE OPHTHALMIC 2.6MM CLEARCUT ANGLED SLIT FULL HANDLE",SUP-8065992648,CDM,S27200284,LOCAL,0272,RC,,,both,,,221.68,66.5,"CIGNA [10200]","Cigna Local Plus",,118.6,53.5,,,,,0,25.78,188.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 15D 56MM 32MM MARATHON HIP STERILE",SUP-121932256,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"BLUE CROSS [10001]","Blue Cross HMO",,3179.49,39.2,,5311.50,4717.44,5388.59,31,943.3,6894.31,"percent of total billed charges",
"BLADE CORNEAL 8.5MM STAINLESS STEEL TREPHINE STERILE LATEX",SUP-K20-2160,CDM,S27200284,LOCAL,0272,RC,,,both,,,430.65,129.19,"PHCS [10601]",PHCS,,301.46,70,,,,,0,50.08,366.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 40MM TITANIUM ALUMINUM VANADIUM FEMUR",SUP-00493504001,CDM,C1713,HCPCS,0278,RC,,,both,,,607.50,182.25,"BLUE CROSS [10001]","Blue Cross HMO",,238.14,39.2,,957.42,156.86,7483.26,51,70.65,516.38,"percent of total billed charges",
"TISSUE 9441426 CPSTNE BNE 14X26 SRVC FEE",SUP-9441426,CDM,S27800098,LOCAL,0278,RC,,,both,,,20855.00,6256.5,"AETNA [10100]","Aetna HMO/PPO",,16579.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2425.44,17726.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 60MM 150CM 7MM VASCULAR NICKEL",SUP-EVD35-07-060-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2884.82,45.9,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOGUARD 100UM 180CM .014IN 5MM EMBOLIC PROTECTION",SUP-501814RMC,CDM,C1884,HCPCS,0272,RC,,,both,,,6520.50,1956.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,772.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,758.33,5542.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM TARGET TETRA DETACHABLE STERILE",SUP-TG5414010,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3810.95,27,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SHEATH GUIDE KINK RESISTANT STOPPER",SUP-K-402,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"AETNA [10100]","Aetna HMO/PPO",,1287.9,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 14MM 140CM 2.75MM",SUP-RSINT27514UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"KAISER [10500]",Kaiser,,3714.48,67,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTH CRNL TREPH MIC HNNA 8MM DISP",SUP-17171D800,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"CIGNA [10200]","Cigna Local Plus",,407.35,53.5,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA ELECTROTHERAPY L100 MM OD22 GA RADIOFREQUENCY CURVED",SUP-PMC20-100-10CS,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.04,53.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,73.59,41.1,,,,,0,20.82,152.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX PROGRIP 20X15CM SELF FIX FLAT SHEET",SUP-TEM2015G,CDM,C1781,HCPCS,0278,RC,,,both,,,2225.18,667.55,"PHCS [10601]",PHCS,,1557.63,70,,,,,0,258.79,1891.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 60MM 10MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171100610,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SPEEDSTITCH SUTURING CASSETTE NDL STERILE DISPOSABLE",SUP-OM8850,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 8CMX4CMX.2-.75MM DERMACELL DERMIS",SUP-DCELL154,CDM,Q4122,HCPCS,0636,RC,,,both,,,15278.81,4583.64,"AETNA [10100]","Aetna HMO/PPO",,12146.65,79.5,,,,,0,1810.54,12986.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13175540,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Open Access",,1707,56.9,,1144.80,304.56,2275.09,66,348.9,2550,"percent of total billed charges",
"BASKET STONE RETRIEVAL 120CM 11MM 2.4FR GEMINI HELICAL",SUP-M0063303070,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"CIGNA [10200]",Cigna,,1006.09,68,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE SCLEROTHERAPY STAR CATHETER INTERJECT L4 MM L240 CM O",SUP-M00518311,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.66,81.2,"CIGNA [10200]","Cigna Local Plus",,144.8,53.5,,,,,0,31.48,230.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 135CM 6MM 8MM 7FR .035IN",SUP-BXA062902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS [10001]","Blue Cross HMO",,7645.88,39.2,,9776.84,9776.84,9776.84,"1 through 10",2268.41,16579.08,"percent of total billed charges",
"HEAD BIPOLAR 51MM 26MM UHR UNIVERSAL ACETABULAR HIP COCR",SUP-UH1-51-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"KAISER [10500]",Kaiser,,2892.91,67,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA E KNEE RIGHT 2 PEG TIVANIUM STERILE",SUP-42530007102,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1680.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1649.72,12057.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 16MM DELTAFILL 18",SUP-DLF181650,CDM,S27800098,LOCAL,0278,RC,,,both,,,16974.00,5092.2,"CIGNA [10200]","Cigna Local Plus",,5346.81,31.5,,,,,0,1974.08,14427.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PROTECTIVE 6MM FIXATION PIN NONSTERILE BLUE",SUP-394.994,CDM,S27000186,LOCAL,0270,RC,,,both,,,48.42,14.53,"PHCS [10601]",PHCS,,33.89,70,,,,,0,5.63,41.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG SURGICAL LARGE TAPER 1.9IN 1.6IN GROIN MONOFILAMENT",SUP-0112770,CDM,C1781,HCPCS,0278,RC,,,both,,,755.43,226.63,"MULTIPLAN [10600]",Multiplan,,642.12,85,,,,,0,87.86,642.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 40MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"PHCS [10601]",PHCS,,1003.59,70,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 34CM 7FR VENTRICLE BIPOLAR PASSIVE FIXATION",SUP-1646T/34,CDM,C1898,HCPCS,0275,RC,,,both,,,1786.00,535.8,"CIGNA [10200]","Cigna Local Plus",,955.51,53.5,,,,,0,207.71,1518.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 80MM 125CM 6MM VASCULAR PERIPHERAL DRUG",SUP-G38480,CDM,C1874,HCPCS,0278,RC,,,both,,,11921.68,3576.5,"NOVANET [10819]",Novanet,,8941.26,75,,,,,0,1386.49,10133.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAMERA ENDOSCOPIC DA VINCI SP",SUP-430077,CDM,S27000186,LOCAL,0270,RC,,,both,,,6272.73,1881.82,"AETNA [10100]","Aetna HMO/PPO",,4986.82,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,729.52,5331.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 20MM 4MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012278-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE VASCULAR STRAIGHT 180CM 3CM .018IN",SUP-GR1803,CDM,C1769,HCPCS,0272,RC,,,both,,,461.70,138.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,313.96,68,,,,,0,53.7,392.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE ROUND 202MM STAINLESS STEEL 12 HOLE 1 THREADED LOCKING",SUP-437112S,CDM,C1713,HCPCS,0278,RC,,,both,,,8594.64,2578.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3532.4,41.1,,,,,0,999.56,7305.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM PERSONA CD KNEE RIGHT LATERAL HALF BLOCK",SUP-42555803210,CDM,C1776,HCPCS,0278,RC,,,both,,,7236.72,2171.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2071.15,28.62,,,,,0,841.63,6151.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GA-68-GOZETOTIDE INTRAVENOUS SOLUTION (6 MCI)",RX-411541,CDM,A9596,HCPCS,0343,RC,08888-8878-72,NDC,both,1,UN,24796.80,7439.04,"KAISER [10500]",Kaiser,,16613.86,67,,,,,0,1181,21077.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEOSTIGMINE METHYLSULFATE 5 MG/5 ML (1 MG/ML) INTRAVENOUS SYRINGE",RX-122897,CDM,J2710,HCPCS,0636,RC,69374-0902-05,NDC,both,5,ML,128.95,38.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.22,,"Fee schedule rate ($8.22). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.2,109.61,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PT2 VASCULAR STRAIGHT 185CM 2CM .014IN STAINLESS STEEL",SUP-H74938931012,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION X-PORT DUO HICKMAN SILICONE 10FR 2",SUP-607655,CDM,C1788,HCPCS,0278,RC,,,both,,,2625.00,787.5,"NOVANET [10819]",Novanet,,1968.75,75,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 10MM LCP STAINLESS STEEL DISTAL FEMUR CONDYLE",SUP-02.221.510S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"CATH DXTERITY 110CM 6FR .056IN MULTIPURPOSE A CURVE",SUP-DXT6MPASHA,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"AETNA [10100]","Aetna HMO/PPO",,65.71,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERSACROSS CONNECT LAAC 180P D0",SUP-VXAK0101,CDM,S27200284,LOCAL,0272,RC,,,both,,,6969.00,2090.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2864.26,41.1,,,,,0,810.49,5923.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 300CM 3CM",SUP-1020016,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D E KNEE LEFT OSSEOTI KEEL",SUP-42535007101,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"CIGNA [10200]",Cigna,,5506.2,40,,5873.17,5873.17,5873.17,"1 through 10",1600.93,11700.68,"percent of total billed charges",
"SET EXT 2.5CM 16FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-16-2.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"PHCS [10601]",PHCS,,545.34,70,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 30MM 8MM ALIGN FLUTE TITANIUM STERILE",SUP-ALN-RST-0800,CDM,C1776,HCPCS,0278,RC,,,both,,,14138.10,4241.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5655.24,40,,,,,0,1644.26,12017.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 16FR URETHRAL BACTI-GUARD RUBBER HYDROGEL 30",SUP-0167SI16,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.45,32.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.5,91.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 3 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022213,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1969.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1933.15,14128.79,"percent of total billed charges",
"HC Bandage Viscopaste",PX-E27000051,CDM,E27000051,LOCAL,0270,RC,,,both,,,61.43,18.43,"UHC [10700]","United Healthcare",,38.89,63.3,,,,,0,7.14,52.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Sasorb Mextra 9x13in",PX-E27200409,CDM,E27200409,LOCAL,0272,RC,,,both,,,39.81,11.94,"CIGNA [10200]","Cigna Open Access",,22.65,56.9,,,,,0,4.63,33.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pretreat RBC Ab ID Densitysep",PX-302000211,CDM,86972,CPT,0302,RC,,,both,,,289.88,86.96,"NOVANET [10819]",Novanet,,217.41,75,,,,,0,0.01,246.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL TWIST 70MM 3.5MM SCP",SUP-829032070,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION",RX-25005,CDM,J7528,HCPCS,0636,RC,66689-0307-08,NDC,both,160,ML,9116.98,2735.09,"CIGNA [10200]","Cigna Local Plus",,209.76,,,,,,,89.51,7749.43,"fee schedule",
"DRILL SURGICAL LONG 110MM SOLID AO 2MM",SUP-P99-100-2011,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"AETNA [10100]","Aetna HMO/PPO",,798.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 22MM 3.5MM CORONARY STENT FULCRUM COCR",SUP-INT35022UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,286.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP TOTAL SHOULDER ARTHROPLASTY",SUP-71701412,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"CIGNA [10200]","Cigna Open Access",,8969.63,33.5,,5302.19,4377.88,6578.61,27,3113.93,22758.75,"percent of total billed charges",
"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC",250,MS-DRG,,,,,,,inpatient,,,138658.66,41597.6,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,14350.47,,"Case rate ($13,538.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,571.12, add-ons for qualifying new technology services are included. If operating cost exceeds $45,610.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,332.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $12,587.74. The transfer operating threshold is the transfer adjustment factor * $12,571.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.44. The transfer capital threshold is the transfer adjustment factor * $950.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,13538.18,63720.27,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT MEDIAL RIGHT LATERAL RESTORIS",SUP-180504,CDM,C1776,HCPCS,0278,RC,,,both,,,12440.70,3732.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3358.99,27,,,,,0,1446.85,10574.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESTORIS MCK ONLAY TIBIAL INSERT SIZE 3 X 10MM",SUP-180703-3,CDM,C1776,HCPCS,0278,RC,,,both,,,4046.85,1214.05,"CIGNA [10200]","Cigna Open Access",,2302.66,56.9,,5302.19,4377.88,6578.61,27,470.65,3439.82,"percent of total billed charges",
"(EVAL) QUALIBREATH",SUP-QB-XS,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,96.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 440CC P3.8CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-440,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"NOVANET [10819]",Novanet,,5666.63,75,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL RESTORIS 2 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-180602,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1896.78,28.62,,,,,0,770.77,5633.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 22MM AXIUM 3D FRAME V01",SUP-FC-22-50-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6791.98,41.1,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest Cerv/Thor Facet Jnt",PX-510000151,CDM,64633,CPT,0761,RC,,,both,,,2933.00,879.9,"BLUE CROSS [10001]","Blue Cross PPO",,2933,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,341.11,2933,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 3-0 RB-1 SPIRAL 6IN KNOTLESS",SUP-SXMP1B424,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.17,68.75,"MULTIPLAN [10600]",Multiplan,,194.79,85,,,,,0,26.65,194.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BURN 8X4IN ACTICOAT FLEX 3 POLYESTER NANOCRYSTALLINE",SUP-66800417,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.50,30.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.69,85.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RAMROD CLASSIC 24CM 4.5FR KIDNEY BLADDER CURL URETERAL",SUP-5604524,CDM,C2617,HCPCS,0278,RC,,,both,,,692.15,207.64,"CIGNA [10200]","Cigna Open Access",,393.83,,,,,,,80.5,588.33,"percent of total billed charges",
"SURFACE ARTICULAR 66X42X12MM NEXGEN LCCK 3-4 C-D STD KNEE",SUP-00599403012,CDM,C1776,HCPCS,0278,RC,,,both,,,16256.40,4876.92,"CIGNA [10200]",Cigna,,6502.56,40,,5873.17,5873.17,5873.17,"1 through 10",1890.62,13817.94,"percent of total billed charges",
"SHOE POSTOPERATIVE 15D 12.5-14 XL MALE CONTACT CLSR",SUP-HS1005-16,CDM,S27000186,LOCAL,0270,RC,,,both,,,128.06,38.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,87.08,68,,,,,0,14.89,108.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WOUND DEBRIDEMENTS FOR INJURIES WITH CC",902,MS-DRG,,,,,,,inpatient,,,79923.41,23977.02,"AETNA [10100]","Aetna HMO/PPO",,36021.32,,"Fee schedule rate ($36,021.32). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,55895.74,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 54MM 47MM HIP 2 MOBILITY",SUP-121854047,CDM,C1776,HCPCS,0278,RC,,,both,,,15870.00,4761,"NOVANET [10819]",Novanet,,11902.5,75,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 STD 10MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS7S10R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"FIRST HEALTH [10303]","First Health",,8313.12,80,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 CURVE 10MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962021,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1096.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 25D LARGE AUG CORTILOC SHOULDER LEFT",SUP-DWK405LA25S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"CIGNA [10200]","Cigna Local Plus",,5617.5,53.5,,5372.07,4581.20,7242.98,23,1221.15,8925,"percent of total billed charges",
"DEVICE WATCHMAN FLX PRO 20MM CLSR LEFT ATRIAL APPENDAGE",SUP-M635WU60200,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tte W/Wwo Cntrst Complt 2d",PX-483000018,CDM,C8929,HCPCS,0480,RC,,,both,,,3690.00,1107,"FIRST HEALTH [10303]","First Health",,2952,80,,,,,0,429.15,3690,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL 6. 5IN HOUSE 20D .5MM INCUDOSTAPEDIAL BLADE",SUP-61-0396,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Unlisted Molec Path",PX-309000117,CDM,81479,CPT,0310,RC,,,both,,,2947.10,884.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1352.72,45.9,,,,,0,0.01,2505.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Analysis Electr Spine Pump",PX-510000112,CDM,62367,CPT,0761,RC,,,both,,,2899.73,869.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1729.39,,"Case rate ($1,729.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,337.24,2740.57,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Biotinidase Ea Specimen",PX-301000115,CDM,82261,CPT,0301,RC,,,both,,,229.00,68.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.05,,"Fee schedule rate ($18.05). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,194.65,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX SMALL - L 11MM X",SUP-T600412,CDM,S27800098,LOCAL,0278,RC,,,both,,,4347.00,1304.1,"CIGNA [10200]",Cigna,,2955.96,68,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET TRAUMA FIXATION OATS KIT",SUP-AR-992,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,693.56,41.1,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 40MM COMPREHENSIVE TITANIUM SHOULDER FIX",SUP-180505,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,184.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,180.93,1322.35,"percent of total billed charges",
"SOL IRRIGATION AQUALITE 0.9% SODIUM CHLORIDE 1L LATEX FREE",SUP-713809,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY DRNG 12FR FLEXIBLE RESOLVE",SUP-RLC-NV-12,CDM,C1729,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Radrx Thrpy Oral Admin",PX-342000011,CDM,79005,CPT,0342,RC,,,both,,,3245.68,973.7,"UHC [10700]","United Healthcare",,592.6,,,,,,,80.54,2758.83,"fee schedule",
"CATH REDEL 92CM 1MM 6FR 2MM SPACE D CURVE ELECTROPHYSIOLOGY",SUP-D608DR002CT,CDM,C1730,HCPCS,0272,RC,,,both,,,1997.50,599.25,"NOVANET [10819]",Novanet,,1498.13,75,,,,,0,232.31,1697.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC H Pylori Breath Test Anly C-13",PX-301000536,CDM,83013,CPT,0301,RC,,,both,,,383.80,115.14,"CIGNA [10200]","Cigna Local Plus",,148.19,,,,,,,0.01,326.23,"fee schedule",
"HC Urinalysis Auto WO Micro",PX-307000005,CDM,81003,CPT,0307,RC,,,both,,,120.65,36.19,"CIGNA [10200]","Cigna Local Plus",,4.95,,,,,,,0.12,102.55,"fee schedule",
"HC Xr Abdomen >=3",PX-320000222,CDM,74021,CPT,0320,RC,,,both,,,714.10,214.23,"BLUE CROSS [10001]","Blue Cross PPO",,98.31,,"Fee schedule rate ($98.31).",,,,0,47.57,606.99,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 7X7CM MARIGEN OMEGA3 ACELLULAR FISH SKIN",SUP-50200S04B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,11316.00,3394.8,"MULTIPLAN [10600]",Multiplan,,9618.6,85,,,,,0,180.89,9618.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE EMBOLIZATION ORANGE EMBOSPHERE 40-120UM TRISACRYL",SUP-S120GH,CDM,S27800098,LOCAL,0278,RC,,,both,,,1852.50,555.75,"CIGNA [10200]",Cigna,,1259.7,68,,,,,0,215.45,1574.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 229MM 4.8MM STEINMANN STAINLESS STEEL TROCAR",SUP-47018700759,CDM,C1713,HCPCS,0278,RC,,,both,,,247.95,74.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,168.61,68,,,,,0,28.84,210.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE POWERTURN FLEX VASCULAR STRAIGHT 300CM 3CM",SUP-1044593,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.2MM 22MM CORTICAL HEXAGONAL",SUP-HEX3.2-22,CDM,C1713,HCPCS,0278,RC,,,both,,,729.00,218.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",84.78,619.65,"percent of total billed charges",
"CATH BARD TIGERTAIL 70CM 5FR URETERAL POLYURETHANE NONPORT",SUP-139005,CDM,C1758,HCPCS,0272,RC,,,both,,,107.53,32.26,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.51,91.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 20CM 3CM 8FR .035IN STD PIGTAIL CURVE",SUP-M006180240190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 20MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"NOVANET [10819]",Novanet,,1196.78,75,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 20CM TEMNO EVOLUTION COAXIAL INTRO SOFT",SUP-CTT2020,CDM,S27200284,LOCAL,0272,RC,,,both,,,369.23,110.77,"AETNA [10100]","Aetna HMO/PPO",,293.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.94,313.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 85X10X1.27MM OSCILLATE",SUP-507118000,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.01,58.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,22.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.56,164.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Attendance at Delivery",PX-410000018,CDM,99464,CPT,0722,RC,,,both,,,291.67,87.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER ENDOCRINE DISORDERS,MODERATE",424,APR-DRG,,,,,,,inpatient,,,32045.43,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,102.10. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE MAJOR EYE INFECTIONS WITH CC/MCC",121,MS-DRG,,,,,,,inpatient,,,23450.54,7035.16,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 8FR 40D GUIDING DURAFORM PTFE",SUP-M003101440,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SHOCKWAVE M5 60MM 110CM 3.5MM 7MM BALLOON DILATATION",SUP-M5PIVL3560,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"PRESSURE INJECTABLE ARROWGARD BLUE ADVANCEONE-LUMEN MIDLINE",SUP-CDC-41541-MPKB,CDM,C1751,HCPCS,0272,RC,,,both,,,1477.44,443.23,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 70X25.4X.6MM WIDE STAINLESS STEEL SAGITTAL DUAL",SUP-2108100000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT ACETABULAR 38MM 22.2MM D HIP X3 STERILE LATEX FREE MDM",SUP-7236-2-244,CDM,C1776,HCPCS,0278,RC,,,both,,,8711.25,2613.37,"MULTIPLAN [10600]",Multiplan,,7404.56,85,,,,,0,1013.12,7404.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR STRAIGHT 145CM .014IN CORONARY TIP",SUP-TFC14145S,CDM,C1769,HCPCS,0272,RC,,,both,,,2250.00,675,"MULTIPLAN [10600]",Multiplan,,1912.5,85,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 40MM 140CM 2.5MM CORONARY STERILE LATEX",SUP-453974,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"BIT DRILL 16MM 2MM QUICK COUPLING STOP NONSTERILE",SUP-03.617.916,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.8MM ANGLED SLIT KNIFE",SUP-MSL28,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.20,24.36,"NOVANET [10819]",Novanet,,60.9,75,,,,,0,9.44,69.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X20X8MM PIVOX 6D LATERAL OLIF25",SUP-2111140,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"UHC [10700]","United Healthcare",,16749.18,63.3,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Naf-18 per Study",PX-343000031,CDM,A9580,HCPCS,0343,RC,,,both,,,624.00,187.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,73.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.57,530.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.118,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"NOVANET [10819]",Novanet,,849.53,75,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 134MM 7MM PRESS FIT FULL PROFILE TAPERLOC PPS",SUP-51-101070,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9681.34,40,,,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM DCP LC-DCP STAINLESS STEEL PROXIMAL",SUP-204.218,CDM,C1713,HCPCS,0278,RC,,,both,,,117.28,35.18,"CIGNA [10200]","Cigna Open Access",,66.73,56.9,,1144.80,304.56,2275.09,66,13.64,99.69,"percent of total billed charges",
"INSRT TIBIAL 5 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650507,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3544.36,27,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ZIPTIGHT ZIPLOOP FIXATION TITANIUM ANKLE KNOTLESS LOW",SUP-909853,CDM,S27200284,LOCAL,0272,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Local Plus",,4470.41,53.5,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 70CM NEVRO 5MM SPACING TRAIL LEAD STERILE",SUP-TLEAD1058-70B,CDM,C1897,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,1470,39.2,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 18MM LCP STAINLESS STEEL CORTICAL PERIARTICULAR",SUP-02.204.018,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"FIRST HEALTH [10303]","First Health",,789.26,80,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 36MM TIBIAL METAPHYSEAL META-NAIL INTRAMEDULLARY",SUP-71655136,CDM,C1713,HCPCS,0278,RC,,,both,,,15548.46,4664.54,"CIGNA [10200]","Cigna Local Plus",,4897.76,31.5,,3978.14,359.25,3978.14,24,1808.29,13216.19,"percent of total billed charges",
"LEAD PACING SCR IN ELECTRD ACTIVE FIXATION BIPOLAR IS 1 CNCT",SUP-1688T/58,CDM,C1898,HCPCS,0275,RC,,,both,,,3375.00,1012.5,"BLUE CROSS [10001]","Blue Cross HMO",,1323,39.2,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SPIDER POSITIONING SHOULDER KIT STABILIZATION STERILE",SUP-7210573,CDM,S27200284,LOCAL,0272,RC,,,both,,,457.97,137.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,54.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.26,389.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 20MM SEPTAL SOFT WIRE FRAME FLUOROSCOPIC",SUP-GSX0020A,CDM,C1817,HCPCS,0278,RC,,,both,,,59616.90,17885.07,"KAISER [10500]",Kaiser,,39943.32,67,,,,,0,6933.45,50674.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS SURGICAL DISPOSABLE LONG SMOOTH",SUP-NF07,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"AETNA [10100]","Aetna HMO/PPO",,159.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC LARGE 13+ IN ARM DEROTATION STRAP HOOK",SUP-11-0449-4-06000,CDM,S27000186,LOCAL,0270,RC,,,both,,,401.07,120.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,47.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.64,340.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAA - AMPLATZ CARDIAC PLUG 2-IDE-028",SUP-9-ACP2-IDE-028,CDM,S62400003,LOCAL,0624,RC,,,both,,,63452.40,19035.72,"NOVANET [10819]",Novanet,,47589.3,75,,,,,0,7379.51,53934.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 8FR PIGTAIL CURVE DRNG FLEXIMA BILIARY REGULAR",SUP-M001271560,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION COMPLETE CARE 16FR 5ML FOLEY DRNG BAG",SUP-300116A,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.80,35.34,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.7,100.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT",SUP-M006145362170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,518.65,45.9,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TIBIAL YELLOW STRIPE 66X42MM NEXGEN 3 WEDGE KNEE",SUP-598800300,CDM,C1713,HCPCS,0278,RC,,,both,,,15836.88,4751.06,"AETNA [10100]","Aetna HMO/PPO",,12590.32,79.5,,1521.93,481.35,16760.95,30,1841.83,13461.35,"percent of total billed charges",
"IMPL HIP STEM 101MM NK 36MM INSIGNIA 3 HIGH STEM HIGH OFFSET",SUP-7000-6603,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3623.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3555.74,25987.82,"percent of total billed charges",
"AVENIR 10 10 X 34 COMPLEX FRAMING COIL",SUP-10CFR-10034,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"NOVANET [10819]",Novanet,,8792.33,75,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 16MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P216,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,971.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICROINTRODUCER 45CM 4FR .018IN TUNGSTEN NITINOL GWIRE",SUP-H787065970525,CDM,C1894,HCPCS,0272,RC,,,both,,,281.01,84.3,"MULTIPLAN [10600]",Multiplan,,238.86,85,,,,,0,32.68,238.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 10CM 5MM 6FR BALLOON DILATATION",SUP-V1850100,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,650.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 140MM 125CM 8MM 6FR BILIARY",SUP-G50173,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"AMERIGROUP MEDICAID [20100]",Amerigroup,,721.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT TIBIAL PERSONA NONPOROUS E KNEE LEFT REVISION FIXA",SUP-42542007101,CDM,C1776,HCPCS,0278,RC,,,both,,,23892.50,7167.75,"PHCS [10601]",PHCS,,16724.75,70,,,,,0,2778.7,20308.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SALINE 375-450ML ROUND MODERATE PLUS PROFILE",SUP-351-2375SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"FIRST HEALTH [10303]","First Health",,680.4,80,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 70MM TI",SUP-MTC-37700-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"BLUE CROSS [10001]","Blue Cross PPO",,488.98,39.2,,957.42,570.23,957.42,28,145.07,1060.29,"percent of total billed charges",
"INTRO SHEATH 2.5MM 13CM SMALL VALVE RADIOPAQUE FLEXOR",SUP-G11211,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502605602,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2709.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP STEALTH FIBRA 3 60MM SOFT WOVEN LATEX FREE",SUP-A0G03,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]","Cigna Open Access",,128.71,56.9,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 40CM 14FR DRNG BILIARY 18 HOLE PIGTAIL TIP",SUP-RBDC-14-038,CDM,C1729,HCPCS,0272,RC,,,both,,,558.90,167.67,"MULTIPLAN [10600]",Multiplan,,475.07,85,,,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 12MM 3MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3012X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"FIRST HEALTH [10303]","First Health",,421.2,80,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.280 CLAREON",SUP-SY60WF.280,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEMORYGEL SMOOTH ROUND ULTRA HIGH BREAST IMPLANT 650 CC","SUP-3505650 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSCONN ROD 45-50MM ADJUSTABLE ARCH",SUP-8450245,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross PPO",,1893.36,39.2,,957.42,570.23,957.42,28,561.73,4105.5,"percent of total billed charges",
"BRUSH CYTOLOGY 7FR 3MM 240CM BRISTLE STERILE DISPOSABLE RED",SUP-G22108,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 63X49X.9MM HALL OSCILLATING STRAIGHT STERILE",SUP-507155000,CDM,S27200284,LOCAL,0272,RC,,,both,,,221.50,66.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE SABRELOC 10-0 STC-6 8IN 2 ARM MONOFILAMENT",SUP-1713G,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.75,65.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXERCISER HAND 5 SPRING 5 HOLE COVER GRIP 3.75IN",SUP-081520857,CDM,S27000186,LOCAL,0270,RC,,,both,,,224.55,67.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BONE CEMENT STABILIT MX POWERCURVE VERTECOR LONG",SUP-MX-2100L-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,14904.00,4471.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TROCAR LAPAROSCOPIC 150MM 12MM KII FIRST ENTRY FLAT BLADE Z",SUP-CTF71,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"3.3/4F DUO-DECA 2-5-2 S 120CM",SUP-903273,CDM,C1731,HCPCS,0272,RC,,,both,,,8970.00,2691,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 14FR IMPELLA SHORT STERILE LATEX DISPOSABLE",SUP-0052-0038,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL 2.3MM ARTHROWAND ARTHROVAC KNEE",SUP-AC282301,CDM,C2625,HCPCS,0272,RC,,,both,,,2693.25,807.97,"KAISER [10500]",Kaiser,,1804.48,67,,,,,0,313.22,2289.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 22GA ACCURIAN CURVE BLUNT 10MM",SUP-AC0020,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.91,41.1,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC",847,MS-DRG,,,,,,,inpatient,,,63157.72,18947.32,"AMBETTER EXCHANGE  [11102]",Ambetter,,8114.85,,"Case rate ($8,114.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,535.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,574.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,951.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,545.15. The transfer operating threshold is the transfer adjustment factor * $7,535.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.70. The transfer capital threshold is the transfer adjustment factor * $569.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,32625.2,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 55MM CENTERPULSE LEGACY 12/14 TAPER HIP FEMUR",SUP-451000055,CDM,C1776,HCPCS,0278,RC,,,both,,,2328.75,698.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,270.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,270.83,1979.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC",437,MS-DRG,,,,,,,inpatient,,,34098.35,10229.5,"UHC [10700]","United Healthcare",,21280.45,,"Fee schedule rate ($21,280.45). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,5293.08,21280.45,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 6MM AZUR HYDROCOIL PUSHABLE .035IN",SUP-45-250610,CDM,S27800098,LOCAL,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH MANOSHIELD MANOSCAN CATH DISPOSABLE",SUP-MSS-2155,CDM,S27000186,LOCAL,0270,RC,,,both,,,242.30,72.69,"MULTIPLAN [10600]",Multiplan,,205.96,85,,,,,0,28.18,205.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 100CM 5FR .038IN SIM1",SUP-G08584,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"PHCS [10601]",PHCS,,166.24,70,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 85MM CONDYLAR VARIABLE ANGLE CANNULATED LOCK",SUP-42.231.685,CDM,C1713,HCPCS,0278,RC,,,both,,,1693.95,508.18,"CIGNA [10200]","Cigna Open Access",,963.86,56.9,,1144.80,304.56,2275.09,66,197.01,1439.86,"percent of total billed charges",
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 6MM 3.25MM .017IN",SUP-H7493926706320,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE L-ASCR CORTICAL LORDOTIC ALLOGRAFT 14",SUP-341241,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY PRO 3CM 14FR GUIDING ENTERAL BALLOON FEED LOW",SUP-8100,CDM,C1887,HCPCS,0272,RC,,,both,,,1837.50,551.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,217.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9CM 3.5MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY123509,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"BLUE CROSS [10001]","Blue Cross HMO",,4657.67,39.2,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 3CM 170CM 7FR 2 PIGTAIL CURVE BILIARY",SUP-G22159,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,73.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOLUTION HEP 25000U 500ML D5W",SUP-776103,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"AETNA [10100]","Aetna HMO/PPO",,64.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 9MM THK.6MM 35MM SAGITTAL OSCILLATE LATEX FREE",SUP-350S90-06,CDM,S27200284,LOCAL,0272,RC,,,both,,,866.70,260.01,"FIRST HEALTH [10303]","First Health",,693.36,80,,,,,0,100.8,736.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840007540,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STELLAREX 135CM 40MM 5MM BALLOON DILATATION ENDURACOAT",SUP-AB35SX050040135,CDM,C2623,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1103.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 2 CT-1 SPIRAL 5IN ABSORBABLE",SUP-SXMP2B400,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.59,68.58,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,155.44,68,,,,,0,26.59,194.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE RD180 STD 5MM SUTURING 1 PORT AUTORELEASE STERILE",SUP-021100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"PHCS [10601]",PHCS,,1207.5,70,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LASER ABLATION SYSTEM 3MM VISUALASE 1.65MM TIP CATH STERILE",SUP-9735559,CDM,S27200284,LOCAL,0272,RC,,,both,,,62700.00,18810,"CIGNA [10200]",Cigna,,42636,68,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTITORQUE 100CM 5FR 3.5MM JACKY RADIAL CURVE",SUP-40-5021,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"KAISER [10500]",Kaiser,,209.84,67,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 3FR 20CM PROVENA BIOPATCH 1 LUMEN MIDLINE MAXIMUM",SUP-S4153108BDP,CDM,C1751,HCPCS,0272,RC,,,both,,,1388.02,416.41,"KAISER [10500]",Kaiser,,929.97,67,,,,,0,161.43,1179.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GERALD STRAIGHT NARROW 7IN TISSUE 1X2 TEETH",SUP-285125,CDM,S27000186,LOCAL,0270,RC,,,both,,,179.48,53.84,"CIGNA [10200]",Cigna,,122.05,68,,,,,0,20.87,152.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN JUDKINS LEFT",SUP-534622T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 38MM 144CM 2.25MM CORONARY STENT PEBAX",SUP-H7493926038220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NORTRIPTYLINE 25 MG CAPSULE",RX-5675,CDM,,,0637,RC,00093-0811-01,NDC,both,1,UN,7.38,2.21,"UHC [10700]","United Healthcare",,4.67,63.3,,,,,0,0.86,6.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 7FR L20CM SOFT WITHOUT GUIDEWIRE TRIA",SUP-M0061903300,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 11CM 5MM AZUR CX DETACHABLE SOFT SOLID",SUP-45-750511,CDM,S27800098,LOCAL,0278,RC,,,both,,,7672.80,2301.84,"NOVANET [10819]",Novanet,,5754.6,75,,,,,0,892.35,6521.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM SPINE MULTIAXIAL CANNULATED EXT TAB 4.75",SUP-54850017535,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"CIGNA [10200]",Cigna,,4457.4,68,,1831.33,1831.33,1831.33,16,762.35,5571.75,"percent of total billed charges",
"DEFIB CARDIAC .99CM 5.37X7.36CM DYNAGEN ENDURALIFE EASYVIEW",SUP-D150,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"CIGNA [10200]","Cigna Open Access",,13065,33.5,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X22X7MM RISE-L NONSTERILE",SUP-193.405,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9270.45,27,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP APPLR 40CM STAINLESS STEEL DUPLOSPRAY",SUP-601130,CDM,S27200284,LOCAL,0272,RC,,,both,,,970.96,291.29,"CIGNA [10200]","Cigna Open Access",,552.48,56.9,,,,,0,112.92,825.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 9MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-809-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3444.02,28.62,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PERFIX 1.9X1.6IN HERNIA LIGHT MONOFILAMENT",SUP-0117070,CDM,C1781,HCPCS,0278,RC,,,both,,,1420.74,426.22,"CIGNA [10200]","Cigna Open Access",,808.4,56.9,,11235.02,819.42,11235.02,"1 through 10",165.23,1207.63,"percent of total billed charges",
"CAP CONSTRUCT TOTAL KNEE JOURNEY II BCS OXI WITH ASMD INSERT",SUP-71709002,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"MULTIPLAN [10600]",Multiplan,,18742.5,85,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 80MM 75CM 5MM 100CM",SUP-M001711060,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"CIGNA [10200]","Cigna Local Plus",,4522.09,53.5,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL CURVE SPAT 45CM CLEANCOAT",SUP-E3771-45C,CDM,S27200284,LOCAL,0272,RC,,,both,,,316.07,94.82,"CIGNA [10200]","Cigna Open Access",,179.84,56.9,,,,,0,36.76,268.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 0D 27MM STD MEDIUM LASER CAGE BETA SHOULDER",SUP-314-23-13,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]",Cigna,,7038,68,,5873.17,5873.17,5873.17,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"CATH TORCON NB ADVANTAGE BEACON TIP 125CM 5FR ANGLE VANSCHIE",SUP-G35735,CDM,S27200284,LOCAL,0272,RC,,,both,,,538.63,161.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,63.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.64,457.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 64CM 7.8FR 9MM KT FIRM",SUP-6768,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,170.52,39.2,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pt Eval High Complex 45 Min",PX-420000155,CDM,97163,CPT,0424,RC,,,both,,,535.54,160.66,"KAISER [10500]",Kaiser,,358.81,67,,,,,0,62.28,455.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL CANNULATED 3 MM SCR",SUP-44112004,CDM,S27200284,LOCAL,0272,RC,,,both,,,1296.00,388.8,"CIGNA [10200]",Cigna,,881.28,68,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 345041FZ L-ASR 10X14X11 FZ SRVCFE",SUP-345041FZ,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Head/Brain W/WO Cntrst",PX-351000004,CDM,70470,CPT,0351,RC,,,both,,,3265.19,979.56,"KAISER [10500]",Kaiser,,2187.68,67,,,,,0,379.74,2775.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 56MM 13MM 5.4MM 14FR ZENITH SPIRAL-Z",SUP-G55231,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"NOVANET [10819]",Novanet,,15880.73,75,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 40.5CM TIBIAL NAIL-EX INTRAMEDULLARY CANNULATED",SUP-04.004.361S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"CIGNA [10200]","Cigna Open Access",,4729.77,56.9,,1144.80,304.56,2275.09,66,966.74,7065.57,"percent of total billed charges",
"STENT WALLSTENT 90MM 14MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044149070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"PHCS [10601]",PHCS,,6037.5,70,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR 30CM 3CM 7FR .035IN 2 FLOPPY PIGTAIL",SUP-M006180235090,CDM,C2617,HCPCS,0278,RC,,,both,,,1294.14,388.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.51,1100.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EPIDURAL 60CM 20GA 18GA STIMUCATH SNAPTEAR PERIPHERAL",SUP-AB-20608-KS,CDM,C1755,HCPCS,0278,RC,,,both,,,537.27,161.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,63.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.48,456.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 475MM 3.2MM TIBIA THREAD STERILE",SUP-09.037.010S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1001.89,300.57,"KAISER [10500]",Kaiser,,671.27,67,,,,,0,116.52,851.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 7.5X55MM 2C REDUCTION POLYAXIAL RELINE MAS",SUP-16027555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"CMPNT FEMORAL 4 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-71422344,CDM,C1776,HCPCS,0278,RC,,,both,,,29720.25,8916.07,"BLUE CROSS [10001]","Blue Cross HMO",,11650.34,39.2,,5311.50,4717.44,5388.59,31,3456.47,25262.21,"percent of total billed charges",
"STENT XIENCE V 28MM 143CM 2.75MM CORONARY EVEROLIMUS ELUTING",SUP-1009540-28,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"CIGNA [10200]",Cigna,,6521.88,68,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER GUIDING ACUITY PRO CS-H CURVE L45 CM OD9 FR STERILE",SUP-8115,CDM,C1887,HCPCS,0272,RC,,,both,,,1386.50,415.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.25,1178.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATROPINE 0.1 MG/ML INJECTION SYRINGE",RX-730,CDM,J0461,HCPCS,0636,RC,00409-1630-15,NDC,both,10,ML,93.02,27.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,11.66,,,,,,,11.02,79.07,"fee schedule",
"MONOFILAMENT SELF-FIXATING POLYESTER MESH WITH POLYLACTIC AC",SUP-LPG1510AL,CDM,C1781,HCPCS,0278,RC,,,both,,,3206.70,962.01,"MULTIPLAN [10600]",Multiplan,,2725.7,85,,,,,0,372.94,2725.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 4MM TRAUMAONE LORENZ TITANIUM MIDFACE SELF",SUP-916104,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,153.47,39.2,,957.42,570.23,957.42,28,45.53,332.78,"percent of total billed charges",
"BLADE SHAVER PELLO 12D 4MM",SUP-6290-112-040-12,CDM,S27200284,LOCAL,0272,RC,,,both,,,1837.50,551.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,843.41,45.9,,,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 16CM PUMP SET INFLATABLE FLUID FILL SOFT",SUP-ES8816,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]","Cigna Local Plus",,19750.5,31.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL PROCISE MAX COBLATION PLASMA FLAT",SUP-EICA889801,CDM,S27200284,LOCAL,0272,RC,,,both,,,2042.40,612.72,"CIGNA [10200]","Cigna Open Access",,1162.13,56.9,,,,,0,237.53,1736.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GASTRO 2CM 20FR SILICONE ENTERAL FEEDING TUBE RADIOPAQUE",SUP-0120-20-2.0,CDM,C1713,HCPCS,0278,RC,,,both,,,779.06,233.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,90.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",90.6,662.2,"percent of total billed charges",
"STPLR SKIN REGULAR 35 STAPLE ROTATE HEAD EXTR SPRINGLOAD",SUP-059035,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.80,36.54,"MULTIPLAN [10600]",Multiplan,,103.53,85,,,,,0,14.17,103.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN LEFT CORONARY BYPASS CURVE",SUP-DXT6LCB,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"NOVANET [10819]",Novanet,,61.99,75,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER MAROON 4MM DYONICS ELITE STONECUTTER STRAIGHT",SUP-72200728,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"CIGNA [10200]",Cigna,,212.98,68,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX TAPER TIP",SUP-M0061453720,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"BLUE CROSS [10001]","Blue Cross HMO",,248.18,39.2,,,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORCLTR SURGICAL ROTOCUT G1 CUTTER 15MM",SUP-091115-05,CDM,S27200284,LOCAL,0272,RC,,,both,,,5157.06,1547.12,"MULTIPLAN [10600]",Multiplan,,4383.5,85,,,,,0,599.77,4383.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45 REPOSABLE DA VINCI SI ENDOWRIST",SUP-410298,CDM,S27000186,LOCAL,0270,RC,,,both,,,1134.00,340.2,"KAISER [10500]",Kaiser,,759.78,67,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SURGICAL 10.1X6.1IN VENTRAL 2 LAYER MONOFILAMENT SELF",SUP-0010219,CDM,C1781,HCPCS,0278,RC,,,both,,,6453.30,1935.99,"KAISER [10500]",Kaiser,,4323.71,67,,,,,0,750.52,5485.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION MRI GROSHONG SILICONE PLASTIC 8FR",SUP-0602830,CDM,C1788,HCPCS,0278,RC,,,both,,,1762.50,528.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,204.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM INTERLOCK IDC OCCLUSION SYSTEM",SUP-M001361480,CDM,S27800098,LOCAL,0278,RC,,,both,,,2400.00,720,"AMERIGROUP MEDICAID [20100]",Amerigroup,,284.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR MEDIUM CEMENT 3 PEG LOW PROFILE LCS",SUP-129409430,CDM,C1776,HCPCS,0278,RC,,,both,,,7055.25,2116.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2019.21,28.62,,,,,0,820.53,5996.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE",RX-165066,CDM,J1447,HCPCS,0636,RC,63459-0912-18,NDC,both,.8,ML,2879.78,863.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,314.64,,,,,,,140.96,2447.81,"fee schedule",
"LENS IOL 0 D +14 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.140,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 5.5MM CREO CURVE TITANIUM MIS NONSTERILE",SUP-1134.7080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 73X25X1.24MM WIDE THICK STAINLESS STEEL SAGITTAL",SUP-2108110000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,78.74,41.1,,,,,0,22.28,162.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 140MM 80CM 6MM 6FR BILIARY",SUP-G50122,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2795.31,45.9,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SKIN W5MMXL6 1/4IN JOSEPH",SUP-20-5005,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.72,41.32,"CIGNA [10200]",Cigna,,93.65,68,,,,,0,16.02,117.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN AMPLATZ RIGHT 1 CURVE GUIDING",SUP-LA6AR10,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN READIGRAFT CRYOSKIN 232SQ CM FIBROBLAST",SUP-SK-M,CDM,Q4433,HCPCS,0636,RC,,,both,,,4809.58,1442.87,"KAISER [10500]",Kaiser,,3222.42,67,,,,,0,247.92,4088.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE 130CM 80MM 6MM BALLOON DILATATION",SUP-LX181306805F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"MULTIPLAN [10600]",Multiplan,,5718.38,85,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING EXTRACTION KIT",SUP-518-027,CDM,C1773,HCPCS,0272,RC,,,both,,,1012.50,303.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,416.14,41.1,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP INTERNAL HULKA VESSEL STERILE",SUP-4986.09,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.48,103.04,"UHC [10700]","United Healthcare",,217.42,63.3,,,,,0,39.95,291.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 2.4X2.4IN XENMATRIX AQUAPURE SQUARE ACELLULAR",SUP-1160606,CDM,C1781,HCPCS,0278,RC,,,both,,,6047.16,1814.15,"CIGNA [10200]",Cigna,,4112.07,68,,,,,0,703.28,5140.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Nacl",PX-E27200280,CDM,E27200280,LOCAL,0272,RC,,,both,,,119.90,35.97,"UHC [10700]","United Healthcare",,75.9,63.3,,,,,0,13.94,101.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 2.5MM BALLOON DILATATION STERILE LATEX",SUP-582512022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1018.98,68,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM 20MM PRESS FIT UNIVERSAL FLUTE KNEE",SUP-867433,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"MULTIPLAN [10600]",Multiplan,,6885.51,85,,,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 48MM TITANIUM CANNULATED",SUP-604648,CDM,C1713,HCPCS,0278,RC,,,both,,,1319.00,395.7,"CIGNA [10200]","Cigna Local Plus",,705.67,53.5,,3978.14,359.25,3978.14,24,153.4,1121.15,"percent of total billed charges",
"CANN ARTHROSCOPIC 110MM 8.5MM CLEAR-TRAC HIP COMPLETE",SUP-72200436,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,177.48,68,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SECUREMENT CRESCENT TRICOAT SLIDING POST PIGTAIL RETA",SUP-CV0220,CDM,S27200284,LOCAL,0272,RC,,,both,,,46.28,13.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.38,39.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 14CM 5FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552130,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"KAISER [10500]",Kaiser,,804.39,67,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esoph Capsule",PX-750000115,CDM,91111,CPT,0750,RC,,,both,,,7900.00,2370,"NOVANET [10819]",Novanet,,5925,75,,,,,0,918.77,6715,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK CATH 36CM 14.5FR PALINDROME 2 LUMEN SYMMETRIC TIP",SUP-8888119360P,CDM,C1750,HCPCS,0278,RC,,,both,,,2649.68,794.9,"BLUE CROSS [10001]","Blue Cross PPO",,1038.67,39.2,,,,,0,308.16,2252.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHORTCUT (4-PACK)",SUP-Z-A-20.003-US,CDM,S27200284,LOCAL,0272,RC,,,both,,,85500.00,25650,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,58140,68,,,,,0,9943.65,72675,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 5 X 6 HELICAL FINISHING COIL",SUP-10HFN-05006,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"BLUE CROSS [10001]","Blue Cross HMO",,4054.5,39.2,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 36MM FLEX +9MM POLYETHYLENE",SUP-DWF362B,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"BLUE CROSS [10001]","Blue Cross HMO",,3538.98,39.2,,5311.50,4717.44,5388.59,31,1049.96,7673.8,"percent of total billed charges",
"TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC",069,MS-DRG,,,,,,,inpatient,,,33623.13,10086.94,"CIGNA [10200]",Cigna,,10473.87,,"Fee schedule rate ($10,473.87). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,4955.01,19921.27,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CROSSTELLA 90CM 40MM 5FR 6MM BALLOON DILATATION RAPID",SUP-BD-F60040MR,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"UHC [10700]","United Healthcare",,948.55,63.3,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 700ML GEL SMOOTH MEMORYGEL SILICONE P5.8CM HIGH","SUP-3507004 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Open Access",,2150.82,56.9,,5166.00,5166.00,5166.00,"1 through 10",439.61,3213,"percent of total billed charges",
"PLATE 55MM TITANIUM LOCK TRANSLATIONAL ATLANTIS BONE SPINE",SUP-6190055,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"MULTIPLAN [10600]",Multiplan,,4498.2,85,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 17MM MODULAR RESTORATION BOWED CONICAL",SUP-6276-7-217,CDM,C1776,HCPCS,0278,RC,,,both,,,11695.32,3508.6,"MULTIPLAN [10600]",Multiplan,,9941.02,85,,,,,0,1360.17,9941.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACETAZOLAMIDE (25 MG/ML) ORAL SUSPENSION",RX-408541,CDM,,,0637,RC,08888-8886-40,NDC,both,1,ML,12.54,3.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5.76,45.9,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 15IN 24FR VENOUS .25-3/8IN CONNECTION SITE 1",SUP-68124,CDM,S27200284,LOCAL,0272,RC,,,both,,,340.62,102.19,"CIGNA [10200]","Cigna Open Access",,193.81,56.9,,,,,0,39.61,289.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.2MM 45MM CLICKX TITANIUM BUTTRESS SPINE PEDICLE",SUP-498.563,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"NOVANET [10819]",Novanet,,2812.5,75,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL PRECISION 3 MM SCR",SUP-P27-940-0030,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC XL LARGE SHOULDER HOOK LOOP CLSR SWATHE",SUP-ORT16020LXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.24,15.37,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH METACROSS 135CM 100MM 5.7FR 7MM BALLOON DILATATION 2",SUP-BD-L70100CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE STRATAFIX MONOCRYL PLUS 4-0 PS-2 2 SPIRAL 12IN SUT",SUP-SXMP2B409,CDM,S27200284,LOCAL,0272,RC,,,both,,,219.64,65.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN RADIOFREQUENCY 10CM 22GA ACCURIAN CURVE SHARP 10MM",SUP-AC0018,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ARTHROSCOPIC 110MM 8.5MM CLEAR-TRAC HIP COMPLETE",SUP-72200436,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EUPHORA 142CM 10MM 3.75MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP37510X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PILOT 50 VASCULAR J 300CM 3CM .014IN",SUP-1010483-HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC IV Push Init Drug",PX-260000007,CDM,96374,CPT,0260,RC,,,both,,,452.19,135.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,53.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",57.81,53.60,58.48,"1 through 10",52.59,452.19,"percent of total billed charges",
"DILATOR 4FR/.035",SUP-48-149,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.00,1.2,"NOVANET [10819]",Novanet,,3,75,,,,,0,0.47,3.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPEL TWIST-LOC 25CM 8FR NEPHRSTMY FLEXITHANE METAL",SUP-H7493934108250,CDM,C1729,HCPCS,0272,RC,,,both,,,826.20,247.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,561.82,68,,,,,0,96.09,702.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.140 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.140,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 35.5X5MM TITANIUM VASCULAR 30 HELICAL",SUP-174006,CDM,S27200284,LOCAL,0272,RC,,,both,,,2215.95,664.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FOOT AND TOE PROCEDURES,EXTREME",314,APR-DRG,,,,,,,inpatient,,,158983.19,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $14,568.22. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($97,226.61) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 4MM CORONARY STENT EVEROLIMUS",SUP-H7493926132400,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2468.48,28.62,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 16CM 2MM BALLOON DILATATION HYDROPHILIC",SUP-G50318,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,274.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 10CM 40MM GORE TAG THORACIC ACTIVE CONTROL",SUP-TGMR404010,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13742.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 1 POSTERIOR KNEE TOTAL STABILIZED",SUP-5543-A-100,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"PHCS [10601]",PHCS,,3339.69,70,,,,,0,554.87,4055.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 CURVE 17.5MM KNEE GVF UHMWPE ROTATE",SUP-962024,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"CIGNA [10200]","Cigna Local Plus",,4948.46,53.5,,5372.07,4581.20,7242.98,23,1075.71,7862.03,"percent of total billed charges",
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL BLOCK 14X11X8",SUP-245841,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 39MM 80CM 7MM 11MM 7FR .035IN",SUP-BXA073901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5266.3,27,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM 2.25MM 2.1-2.7FR CORONARY",SUP-RONYX22526UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"PHCS [10601]",PHCS,,2598.75,70,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 10MM LCP STAINLESS STEEL SMALL BONE T6",SUP-201.88,CDM,C1713,HCPCS,0278,RC,,,both,,,689.72,206.92,"CIGNA [10200]","Cigna Open Access",,392.45,56.9,,1144.80,304.56,2275.09,66,80.21,586.26,"percent of total billed charges",
"GRAFT VASCULAR 80CM 8MM GORE INTERING THIN WALL PTFE RADIAL",SUP-IRST08080080L,CDM,C1768,HCPCS,0278,RC,,,both,,,11605.80,3481.74,"BLUE CROSS [10001]","Blue Cross PPO",,4549.47,39.2,,,,,0,1349.75,9864.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SMARTSTITCH CNCT MAGNUM WIRE BRAIDED SUT POLYESTER",SUP-OM-8176,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.18,543.35,"KAISER [10500]",Kaiser,,1213.49,67,,,,,0,210.64,1539.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3.3MM 0 POPLOK HI-FI SECURE FIXATION VERSATILE",SUP-GKP-3302,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 80MM 130CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-EX060803CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"KAISER [10500]",Kaiser,,7859.1,67,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE TOTAL SHOULDER",SUP-CAP-ZB-RS1,CDM,C1776,HCPCS,0278,RC,,,both,,,51975.00,15592.5,"AETNA [10100]","Aetna HMO/PPO",,41320.13,79.5,,10981.53,8986.79,12413.38,12,6044.69,44178.75,"percent of total billed charges",
"STENT CONTOUR VL SENSOR DUAL-FLEX 22-30CM 6FR .038IN PIGTAIL",SUP-M006180156120,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"CIGNA [10200]","Cigna Open Access",,705.21,,,,,,,144.14,1053.47,"percent of total billed charges",
"INSRT TIBIAL 7 11MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G711,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"BLUE CROSS [10001]","Blue Cross HMO",,3413.38,39.2,,5311.50,4717.44,5388.59,31,1012.7,7401.47,"percent of total billed charges",
"GWIRE HI-TORQUE BALANCE HEAVYWEIGHT VASCULAR J CURVE 300CM",SUP-1000463HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Nerve Root Block",PX-E27200174,CDM,E27200174,LOCAL,0272,RC,,,both,,,85.80,25.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.98,72.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC CLLGN POWDER SACHET STIMULEN 1GM",SUP-ST9501,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.27,41.48,"KAISER [10500]",Kaiser,,92.64,67,,,,,0,16.08,117.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT VALLEYLAB ACCUVAC",SUP-E2515HS,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.47,21.14,"AETNA [10100]","Aetna HMO/PPO",,56.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.2,59.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Wnd Rmvl Tis Non-Sel (Go)",PX-430000026,CDM,97602,CPT,0430,RC,,,both,,,625.00,187.5,"AETNA [10100]","Aetna HMO/PPO",,496.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.69,625,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 20MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158123120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AETNA [10100]","Aetna HMO/PPO",,8883.77,79.5,,10981.53,8986.79,12413.38,12,1299.6,9498.37,"percent of total billed charges",
"SCREW BONE 2MM 6MM LCP STAINLESS STEEL CORTICAL SELF TAPPING",SUP-201.356.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"BLUE CROSS [10001]","Blue Cross PPO",,162.34,39.2,,957.42,570.23,957.42,28,48.16,352,"percent of total billed charges",
"HC Sigmoid Flex W Dil",PX-750000084,CDM,45340,CPT,0750,RC,,,both,,,2362.42,708.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1718,,"Case rate ($1,718). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,274.75,2362.42,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASE TIB STEM #5 RIGHT PEGLESS",SUP-2586-0-0005,CDM,C1776,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Open Access",,3533.49,56.9,,5302.19,4377.88,6578.61,27,722.22,5278.5,"percent of total billed charges",
"LENS IOL MONOFOCAL PRELOAD 1 PIECE UV BLOCK TECNIS ITEC",SUP-PCB0000260,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT 1.5 KNEE CEMENT ROTATE PLATFORM",SUP-129431115,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"BLADE SAW 6.27X32X.79MM THK.031IN STERNUM STERILE LATEX FREE",SUP-298-97-101,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.01,57.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.33,163.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM TITANIUM SPINAL SET NON BRAKE OFF NONSTERILE",SUP-5440130,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"NOVANET [10819]",Novanet,,1804.95,75,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAWSON-MUELLER 15CM 6.3FR .035IN DRNG HYDROPHILIC",SUP-G51594,CDM,C1729,HCPCS,0272,RC,,,both,,,688.42,206.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.13,68,,,,,0,80.06,585.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20CM 14.5FR 15FR STRAIGHT POLYURETHANE GLIDEPATH",SUP-5397150,CDM,C1750,HCPCS,0278,RC,,,both,,,1875.00,562.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 36MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0315,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,434.99,45.9,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 62MM 32MM MARATHON HIP",SUP-121932062,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"FIRST HEALTH [10303]","First Health",,5787.72,80,,,,,0,841.39,6149.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Perc Bile Duct Stent Exist Access",PX-361000405,CDM,47538,CPT,0361,RC,,,both,,,12296.60,3688.98,"CIGNA [10200]","Cigna Open Access",,8383,,"Case rate ($8,383). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1430.09,10452.11,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE VOYANT MARYLAND 7MM 18MM 37CM 20MM LAPAROSCOPIC 1",SUP-EB215,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,377.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +8 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR CHMBR",SUP-MTA3U0.080,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 450CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-450,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,878.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 23IN 28FR ANGLE RIGHT TAPER DRNG PVC THORAX 5 EYELET",SUP-8128,CDM,C1729,HCPCS,0272,RC,,,both,,,89.25,26.77,"MULTIPLAN [10600]",Multiplan,,75.86,85,,,,,0,10.38,75.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Screening Clo Test",PX-306000060,CDM,87081,CPT,0306,RC,,,both,,,260.00,78,"BLUE CROSS [10001]","Blue Cross PPO",,0.26,.1,,,,,0,0.01,221,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest L/S Facet Jnt Add",PX-510000157,CDM,64636,CPT,0761,RC,,,both,,,1988.00,596.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,231.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,231.2,1988,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 80CM 5FR NEFF CURVE ANGIOGRAPHIC",SUP-G47077,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,75.09,41.1,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLARED SECUR-FIT HYDROXYAPATITE 8 HIP",SUP-S-2337-HF08,CDM,C1776,HCPCS,0278,RC,,,both,,,16482.96,4944.89,"BLUE CROSS [10001]","Blue Cross PPO",,6461.32,39.2,,3949.44,3949.44,3949.44,"1 through 10",1916.97,14010.52,"percent of total billed charges",
"STENT AXIOS 8MM 8MM BILIARY ELECTROCAUTERY STERILE LATEX",SUP-M00553690,CDM,C1874,HCPCS,0278,RC,,,both,,,32412.56,9723.77,"AETNA [10100]","Aetna HMO/PPO",,25767.99,79.5,,,,,0,3769.58,27550.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Path Clin Conslt Sf",PX-310000007,CDM,80503,CPT,0310,RC,,,both,,,104.00,31.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.22,,"Fee schedule rate ($24.22). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,88.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CAPSTONE ALLOGRAFT 22MMX8MM",SUP-9440822,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6900,40,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 100MM 19GA 20GA SONOLONG SONOLONG SONO",SUP-521187-31A,CDM,C9814,HCPCS,0272,RC,,,both,,,477.90,143.37,"AETNA [10100]","Aetna HMO/PPO",,379.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.58,406.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 7 POSTERIOR TOTAL STABILIZE",SUP-5544-A-700,CDM,C1776,HCPCS,0278,RC,,,both,,,6699.90,2009.97,"CIGNA [10200]","Cigna Open Access",,3812.24,56.9,,5302.19,4377.88,6578.61,27,779.2,5694.92,"percent of total billed charges",
"IMPL BREAST NATRELLE INSPIRA EXTRA FULL PROFILE SOFT TOUCH",SUP-SSX-700,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3467.97,45.9,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 30MM STAINLESS STEEL PARTIAL THREAD FOOT",SUP-214.530,CDM,C1713,HCPCS,0278,RC,,,both,,,1597.00,479.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",185.73,1357.45,"percent of total billed charges",
"STEM EXT 150MM 14MM OSS BOW KNEE FEMUR INTRAMEDULLARY CEMENT",SUP-150368,CDM,C1776,HCPCS,0278,RC,,,both,,,13211.43,3963.43,"AETNA [10100]","Aetna HMO/PPO",,10503.09,79.5,,10981.53,8986.79,12413.38,12,1536.49,11229.72,"percent of total billed charges",
"VALVE MITRAL 23MM 18.6MM MASTERS PYROLYTIC CARBON PTFE",SUP-23MTJ-503,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AETNA [10100]","Aetna HMO/PPO",,23149.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 16X14X10MM SPINE CERVICAL",SUP-6941064,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 18.5X5.5X.4MM MICRO 100 MICROPOWER HALL THK.6MM",SUP-5023-144,CDM,S27200284,LOCAL,0272,RC,,,both,,,207.67,62.3,"MULTIPLAN [10600]",Multiplan,,176.52,85,,,,,0,24.15,176.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 16MM PERSONA 6-9 C-D KNEE RIGHT VIVACIT-E",SUP-42522600516,CDM,C1776,HCPCS,0278,RC,,,both,,,13634.40,4090.32,"UHC [10700]","United Healthcare",,8630.58,63.3,,8601.07,8395.67,8601.07,"1 through 10",1585.68,11589.24,"percent of total billed charges",
"SUT CHROMIC MICROPOINT 4-0 G-2 18IN 2 ARM MONOFILAMENT BROWN",SUP-798G,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.02,54.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE",RX-2863,CDM,,,0637,RC,50268-0297-11,NDC,both,1,UN,9.66,2.9,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FR7 OSCOR",SUP-6089,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL SURGICAL 40MM 2.7MM DISPOSABLE",SUP-DRLL-SSC-27040,CDM,S27200284,LOCAL,0272,RC,,,both,,,753.30,225.99,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL 25MMX3.5MM TITANIUM STD CIRCULAR LINEAR",SUP-EEA2535,CDM,S27200284,LOCAL,0272,RC,,,both,,,1978.05,593.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SUPER TORQUE PLUS 100CM 6FR JL6 CURVE",SUP-533624,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEPRESSIVE NEUROSES",881,MS-DRG,,,,,,,inpatient,,,20130.14,6184.05,"BLUE CROSS [10001]","Blue Cross HMO",,3142.79,,,,,,,1958,12548.37,"per diem","Estimated amount calculated based on 3 day length of stay."
"SYSTEM AGEE DIGIT WIDGET EXTERNAL FIXATION STERILE LATEX",SUP-DWD-232,CDM,S27200284,LOCAL,0272,RC,,,both,,,11385.00,3415.5,"CIGNA [10200]",Cigna,,7741.8,68,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL G KNEE LEFT CEMENT LPS-FLEX NEXGEN TIVANIUM",SUP-596801751,CDM,C1776,HCPCS,0278,RC,,,both,,,26214.30,7864.29,"MULTIPLAN [10600]",Multiplan,,22282.16,85,,,,,0,3048.72,22282.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 4-0 PS-2 18IN MONOFILAMENT VIOLET",SUP-Y513G,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.23,19.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,43.68,68,,,,,0,7.47,54.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROLAMINE SALICYLATE 10 % TOPICAL CREAM",RX-27680,CDM,,,0637,RC,41167-0057-23,NDC,both,85,GR,25.66,7.7,"NOVANET [10819]",Novanet,,19.25,75,,,,,0,2.98,21.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP SOLID BACK TRITANIUM TRIDENT II F",SUP-700-04-56F,CDM,C1776,HCPCS,0278,RC,,,both,,,12895.96,3868.79,"KAISER [10500]",Kaiser,,8640.29,67,,,,,0,1499.8,10961.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 9MM 33MM METAL BACKED SYMMETRIC RESURFACING",SUP-5556-L-339,CDM,C1776,HCPCS,0278,RC,,,both,,,4410.00,1323,"MULTIPLAN [10600]",Multiplan,,3748.5,85,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 8MM RIGHT MEDIAL LEFT LATERAL X3 PARTIAL KNEE",SUP-5630-G-428,CDM,C1776,HCPCS,0278,RC,,,both,,,5309.55,1592.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,617.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,617.5,4513.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TRUCLEAR INCISOR 357MM 2.9MM REMOVAL TISSUE WINDOW",SUP-72202536,CDM,S27000186,LOCAL,0270,RC,,,both,,,4339.76,1301.93,"AETNA [10100]","Aetna HMO/PPO",,3450.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,504.71,3688.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fluorescent Ab Screen Ea",PX-302000051,CDM,86255,CPT,0302,RC,,,both,,,115.00,34.5,"CIGNA [10200]","Cigna Open Access",,26.51,,,,,,,0.12,97.75,"fee schedule",
"SYSTEM XIENCE SIERRA 15MM 2.5MM CORONARY STENT EVEROLIMUS",SUP-1550250-15,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 20CC 50CC CALCIUM SULFATE STIMULAN RAPID",SUP-620-020,CDM,C1713,HCPCS,0278,RC,,,both,,,10080.00,3024,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6854.4,68,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT REVISION XS PIN BUSH COONRAD/MORREY STERILE TOTAL ELBOW",SUP-32810502701,CDM,C1713,HCPCS,0278,RC,,,both,,,8279.66,2483.9,"CIGNA [10200]","Cigna Local Plus",,4429.62,53.5,,3978.14,359.25,3978.14,24,962.92,7037.71,"percent of total billed charges",
"SET TRANSFER XSHORT 4IN EXTENDED TWIST CLAMP MINICAP",SUP-5C4483,CDM,S27200284,LOCAL,0272,RC,,,both,,,402.72,120.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,47.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.84,342.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 20MM 2MM BALLOON DILATATION PEBAX",SUP-1012270-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 60CM 5MM GORE STD WALL HEPARIN PROPATEN PTFE",SUP-H050060A,CDM,C1768,HCPCS,0278,RC,,,both,,,11378.10,3413.43,"FIRST HEALTH [10303]","First Health",,9102.48,80,,,,,0,1323.27,9671.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC",698,MS-DRG,,,,,,,inpatient,,,42098.63,12629.59,"CIGNA [10200]",Cigna,,21692.49,,"Fee schedule rate ($21,692.49). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,41259.08,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER SPINAL MOUNTAINEER SPINE OCCIPITOCERVICAL LATERAL",SUP-188365000,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"SCR BONE 7MM 40MM EXPEDIUM TITANIUM SPINE 1 INNIE POLYAXIAL",SUP-179712740,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"NOVANET [10819]",Novanet,,3631.95,75,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE COMPRESSION LARGE KNEE LENGTH KENDALL SCD SEQUENTIAL",SUP-74023,CDM,S27000186,LOCAL,0270,RC,,,both,,,318.59,95.58,"CIGNA [10200]","Cigna Local Plus",,170.45,53.5,,,,,0,37.05,270.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH DYNAMIC 120X120MM THK.6MM STD LARGE CRANIOMAXILLOFACIAL",SUP-56-90616,CDM,C1713,HCPCS,0278,RC,,,both,,,27222.17,8166.65,"AETNA [10100]","Aetna HMO/PPO",,21641.63,79.5,,1521.93,481.35,16760.95,30,3165.94,23138.84,"percent of total billed charges",
"SCR BONE 5MM 80MM LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.080S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,1144.80,304.56,2275.09,66,189.34,1383.8,"percent of total billed charges",
"PLATE 25MM TITANIUM 5.5MM ROD LOW PROFILE FIX LEGACY X10",SUP-8115525,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"MULTIPLAN [10600]",Multiplan,,3028.13,85,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1.5 KNEE RIGHT CRUCIATE RETAIN SIGMA STERILE",SUP-940027,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"PHCS [10601]",PHCS,,18122.9,70,,,,,0,3010.99,22006.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM PFC SIGMA TC3 4 KNEE RIGHT TITANIUM CEMENTED",SUP-960883,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"AETNA [10100]","Aetna HMO/PPO",,4079.02,79.5,,10981.53,8986.79,12413.38,12,596.72,4361.21,"percent of total billed charges",
"SCR BONE 5MM 50MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.050S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"SCR BONE 3.5MM 14MM ORTHOLOC FULL THREAD FOOT ANKLE CORTICAL",SUP-58813514,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,89.49,654.08,"percent of total billed charges",
"FELT CARDIOVASCULAR 6X1IN THK1.65MM PTFE PATCH STERILE",SUP-007976,CDM,C1768,HCPCS,0278,RC,,,both,,,790.88,237.26,"BLUE CROSS [10001]","Blue Cross PPO",,310.02,39.2,,,,,0,91.98,672.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC",393,MS-DRG,,,,,,,inpatient,,,33120.72,9936.22,"UHC [10700]","United Healthcare",,33120.72,,"Fee schedule rate ($39,884.94). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,33120.72,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 2-0 CT-1 SPIRAL 70CM SUT",SUP-SXPP1B412,CDM,S27200284,LOCAL,0272,RC,,,both,,,224.03,67.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.05,190.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COBALT VR MRI DEVICE",SUP-DVPB3D4,CDM,C1722,HCPCS,0278,RC,,,both,,,56385.00,16915.5,"MULTIPLAN [10600]",Multiplan,,47927.25,85,,,,,0,6557.58,47927.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ACETABULAR 26MM RINGLOC HIP LOCK",SUP-105426,CDM,C1776,HCPCS,0278,RC,,,both,,,1211.68,363.5,"PHCS [10601]",PHCS,,848.18,70,,,,,0,140.92,1029.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insitu Hybridization Quant Cad",PX-312000057,CDM,88367,CPT,0312,RC,,,both,,,1242.00,372.6,"NOVANET [10819]",Novanet,,931.5,75,,,,,0,0.01,1055.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN AMPLATZ",SUP-77811300,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FOGARTY THRULUMEN 80CM 5.5FR 11MM EMBOLECTOMY STAINLESS",SUP-12TLW805F35,CDM,C1757,HCPCS,0272,RC,,,both,,,746.58,223.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACING 110CM 5FR BALLOON FLOW-ASSISTED HEPARIN BIPOLAR",SUP-008556P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE DESTINATION RENAL DOUBLE CURVE 45CM 5CM 6FR",SUP-RSR13,CDM,C1887,HCPCS,0272,RC,,,both,,,672.30,201.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT UNISTEP PLUS WALLSTENT RP 24MM 135CM 6MM 160CM",SUP-M001712010,CDM,C1876,HCPCS,0278,RC,,,both,,,8728.50,2618.55,"CIGNA [10200]","Cigna Open Access",,4966.52,56.9,,,,,0,1015.12,7419.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0330,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,112.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,110.22,805.55,"percent of total billed charges",
"SCR BONE 6.5MM 35MM TSRH OSTEOGRIP THINLINE TITANIUM SHORT",SUP-83565351,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1181.47,45.9,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 45MM 10MM 13FR 10FR TRIVASCULAR OVATION PRIME",SUP-TV-EX101045-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"FIRST HEALTH [10303]","First Health",,26712,80,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 8- CM 19GA 5.2-4.2FR GASTROINTESTINAL",SUP-G52012,CDM,S27200284,LOCAL,0272,RC,,,both,,,2857.50,857.25,"PHCS [10601]",PHCS,,2000.25,70,,,,,0,332.33,2428.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 8MM 145CM 3MM CORONARY STENT EVEROLIMUS",SUP-1145300-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"NOVANET [10819]",Novanet,,4378.5,75,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK RETRACTION SHARP NONSTERILE",SUP-319.39,CDM,S27200284,LOCAL,0272,RC,,,both,,,1147.61,344.28,"FIRST HEALTH [10303]","First Health",,918.09,80,,,,,0,133.47,975.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDOSCOPIC SUBMUCOSAL INJECTION",SUP-SIS-30-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Trach Uncuffed Fen",PX-E27200238,CDM,E27200238,LOCAL,0272,RC,,,both,,,333.30,99.99,"KAISER [10500]",Kaiser,,223.31,67,,,,,0,38.76,283.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SOF-CURL 26CM 7FR URETERAL TEMPORARY INDWELL CATH",SUP-SSC7026,CDM,C2617,HCPCS,0278,RC,,,both,,,760.51,228.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,217.66,28.62,,,,,0,88.45,646.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 20MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-207.020,CDM,C1713,HCPCS,0278,RC,,,both,,,133.20,39.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,90.58,68,,,,,0,15.49,113.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN JUDKINS LEFT 5 CURVE",SUP-DXT5JL50,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"MULTIPLAN [10600]",Multiplan,,70.25,85,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 119MM STAINLESS STEEL 3.5MM SCR 6 HOLE LCP BONE LEFT",SUP-239.957,CDM,C1713,HCPCS,0278,RC,,,both,,,9506.13,2851.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1126.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1105.56,8080.21,"percent of total billed charges",
"GRAFT VASCULAR 45CM 4-7MM FLIXENE 2 SLIDER GDS GRADUATED",SUP-25135,CDM,C1768,HCPCS,0278,RC,,,both,,,8774.04,2632.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5966.35,68,,,,,0,1020.42,7457.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 45CM 4-7MM FLIXENE 2 SLIDER GDS GRADUATED",SUP-25135,CDM,C1768,HCPCS,0278,RC,,,both,,,8774.04,2632.21,"NOVANET [10819]",Novanet,,6580.53,75,,,,,0,1020.42,7457.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAV PIN ROSA 3.2 X 150MM","SUP-GS902.150.032 STE",CDM,S27200284,LOCAL,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOVAC PERFUSION CIRCUIT BUBBLE TRAP",SUP-H965251880,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"UHC [10700]","United Healthcare",,6551.55,63.3,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC .99CM 5.37X8.08CM MOMENTUM HEARTLOGIC RIGHT",SUP-G126,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"MULTIPLAN [10600]",Multiplan,,49062,85,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 4 62MM 9.4MM SHILEY UNCUFF DISPOSABLE INNER CANN",SUP-4UN65H,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.56,98.27,"FIRST HEALTH [10303]","First Health",,262.05,80,,,,,0,38.1,278.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY 10CM 16GA BARD MARQUEE CORE ENHANCE TROCAR TIP",SUP-MQ1610,CDM,S27200284,LOCAL,0272,RC,,,both,,,514.35,154.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,60.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.82,437.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 43CM 13MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181343,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"UHC [10700]","United Healthcare",,11772.28,63.3,,,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GRAFT HARVEST RIA 2",SUP-03.404.000S,CDM,S27200284,LOCAL,0272,RC,,,both,,,22413.51,6724.05,"CIGNA [10200]","Cigna Open Access",,12753.29,56.9,,,,,0,2606.69,19051.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 65MM TITANIUM ANKLE CALCANEUS THREAD HEAD",SUP-99-T775065,CDM,C1713,HCPCS,0278,RC,,,both,,,1754.10,526.23,"BLUE CROSS [10001]","Blue Cross HMO",,687.61,39.2,,957.42,156.86,7483.26,51,204,1490.99,"percent of total billed charges",
"GRAFT BONE CANCELLOUS CORTICAL 15ML 4-10MM ALLOGRAFT CHIP",SUP-T00085,CDM,S27800098,LOCAL,0278,RC,,,both,,,1632.75,489.82,"BLUE CROSS [10001]","Blue Cross HMO",,640.04,39.2,,,,,0,189.89,1387.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL PILOT SPADE 3.4MM",SUP-214-00-006,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.00,495,"CIGNA [10200]","Cigna Open Access",,938.85,56.9,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X100 80CM SL",SUP-48005010N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,353.05,41.1,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BN 3MM 4MM 1.2MM 26MM 12MM SS",SUP-202.726,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"FIRST HEALTH [10303]","First Health",,888.02,80,,,,,0,129.1,943.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS AIM SL 68CM 65CM 7FR 5FR 90D GUIDING PEBAX",SUP-DS2N022-65,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X6MM ENDOSKELETON TCS 6D 14MM MEDIUM TITANIUM",SUP-5366-1406-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,23310.00,6993,"FIRST HEALTH [10303]","First Health",,18648,80,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INLAY INTERVERTEBRAL DISC PRODISC-L 10MM MEDIUM SPINE",SUP-PDL-M-PT10S,CDM,C1889,HCPCS,0278,RC,,,both,,,10022.25,3006.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1187.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1165.59,8518.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 325CC",SUP-RSZ-MPX-325S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,665.82,41.1,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 25MM 5.5MM DECADE LARGE PLATE EXTREME LATERAL",SUP-7145525,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"NOVANET [10819]",Novanet,,1215,75,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GASTRO 2CM 20FR SILICONE ENTERAL FEEDING TUBE RADIOPAQUE",SUP-0120-20-2.0,CDM,C1713,HCPCS,0278,RC,,,both,,,779.06,233.72,"FIRST HEALTH [10303]","First Health",,623.25,80,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 RIGHT MEDIAL LEFT LATERAL PARTIAL KNEE",SUP-5610-F-202,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1163.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1163.24,8501.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +10.5 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.105,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"NOVANET [10819]",Novanet,,258.75,75,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GIRAFFE 45D 2MM 5.25IN FRONTAL SINUS 2 ACTION",SUP-63-8845,CDM,S27200284,LOCAL,0272,RC,,,both,,,3430.28,1029.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1409.85,41.1,,,,,0,398.94,2915.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP MONOPOLAR 12.5IN 5MM ULTRA BOTTLE NOSE 2 ACTION DISSECT",SUP-90-1030I,CDM,S27200284,LOCAL,0272,RC,,,both,,,2909.63,872.89,"CIGNA [10200]","Cigna Local Plus",,1556.65,53.5,,,,,0,338.39,2473.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 22CM 6FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001274110,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 19MM MODULAR RESTORATION HA CONICAL",SUP-6276-7-019,CDM,C1776,HCPCS,0278,RC,,,both,,,10468.22,3140.47,"CIGNA [10200]","Cigna Local Plus",,5600.5,53.5,,5372.07,4581.20,7242.98,23,1217.45,8897.99,"percent of total billed charges",
"HC US Fetal Echo W/W/O M F/U",PX-402000060,CDM,76826,CPT,0402,RC,,,both,,,1016.95,305.08,"FIRST HEALTH [10303]","First Health",,813.56,80,,,,,0,118.27,864.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 150MM 3.5MM BALLOON DILATATION RAPID",SUP-47535150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PHCS [10601]",PHCS,,1116.99,70,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 113MM TYPE 1 TAPERLOC MICROPLASTY TITANIUM PPS",SUP-51107140,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7407.51,27,,,,,0,3190.72,23319.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Upr Ext Nonjnt WO Cntrst",PX-610000024,CDM,73218,CPT,0610,RC,,,both,,,3640.89,1092.27,"MULTIPLAN [10600]",Multiplan,,3094.76,85,,,,,0,423.44,3094.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA EZ GLIDE AORTIC 24FR",SUP-EZF24TA,CDM,S27200284,LOCAL,0272,RC,,,both,,,385.15,115.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,158.3,41.1,,,,,0,44.79,327.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER RADIOLOGY 7.5X7IN GUIDELINES SKIN CT BIOPSY",SUP-217,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.67,19.4,"CIGNA [10200]","Cigna Open Access",,36.8,56.9,,,,,0,7.52,54.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 44MM GLENOID SCR RSP",SUP-508-44-101,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"AETNA [10100]","Aetna HMO/PPO",,9693.59,79.5,,10981.53,8986.79,12413.38,12,1418.07,10364.22,"percent of total billed charges",
"S MEGATRON US MR 5.00 X 20MM",SUP-H7493942820500,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"AETNA [10100]","Aetna HMO/PPO",,4936.95,79.5,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDELINER 150CM 25CM 7FR .078IN .062IN INTERVENTIONAL",SUP-5572,CDM,C1887,HCPCS,0272,RC,,,both,,,2872.50,861.75,"NOVANET [10819]",Novanet,,2154.38,75,,,,,0,334.07,2441.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 STD KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500606402,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS [10001]","Blue Cross HMO",,8962.18,39.2,,5311.50,4717.44,5388.59,31,2658.93,19433.3,"percent of total billed charges",
"STENT BARD INLAY 22CM 7FR 2 PIGTAIL CURVE URETERAL",SUP-778722,CDM,C2617,HCPCS,0278,RC,,,both,,,625.73,187.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,287.21,45.9,,,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X20MM COLOSSEUM 12MM MESH NONSTERILE LATEX",SUP-156.205,CDM,S27800098,LOCAL,0278,RC,,,both,,,27184.50,8155.35,"CIGNA [10200]",Cigna,,10873.8,40,,,,,0,3161.56,23106.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON SMALL TITANIUM NARROW BLADE RAMP 5.5",SUP-7541142,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,,1521.93,481.35,16760.95,30,348.9,2550,"percent of total billed charges",
"HEAD RADIAL 22MM ALIGN COCR SIDE LOAD HYBRID ADJUSTABLE LOCK",SUP-ALN-RHI-220,CDM,C1776,HCPCS,0278,RC,,,both,,,10681.20,3204.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1242.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1242.22,9079.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC 12IN 30- IN KNEE 3 PANEL TERRYCLOTH",SUP-VP40106-005,CDM,L1830,HCPCS,0274,RC,,,both,,,152.42,45.73,"MULTIPLAN [10600]",Multiplan,,129.56,85,,,,,0,17.73,129.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP SOLID BACK TRITANIUM TRIDENT II F",SUP-700-04-56F,CDM,C1776,HCPCS,0278,RC,,,both,,,12895.96,3868.79,"NOVANET [10819]",Novanet,,9671.97,75,,,,,0,1499.8,10961.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL 2MR CO2 O2 HIGH HUMIDITY SAMPLING LINE ADULT",SUP-704-3837-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,127.18,38.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.79,108.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 19.5+ CMX10-20MM ACHILLES TENDON CALCANEUS",SUP-430201,CDM,C1762,HCPCS,0278,RC,,,both,,,14314.74,4294.42,"CIGNA [10200]","Cigna Local Plus",,4509.14,31.5,,,,,0,1664.8,12167.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING SUCTION 6FT BERKELEY VACRET PLASTIC COLL SET SWIVEL",SUP-610,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.55,34.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,53.5,45.9,,,,,0,13.55,99.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 18MM 1.8MM TITANIUM BUTTRESS NONSTERILE",SUP-401.968.96,CDM,S27000186,LOCAL,0270,RC,,,both,,,446.80,134.04,"AETNA [10100]","Aetna HMO/PPO",,355.21,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.96,379.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 26CM 3CM 6FR .035IN PIGTAIL CURVE",SUP-M006180223180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"AMERIGROUP MEDICAID [20100]",Amerigroup,,173.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UNI-FUSE FLOW-THRU HUB 90CM 10CM 5FR THROMBECTOMY",SUP-H787124018065,CDM,C1757,HCPCS,0272,RC,,,both,,,1563.30,468.99,"KAISER [10500]",Kaiser,,1047.41,67,,,,,0,181.81,1328.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 20MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR182050,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2162.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE MIC-KEY",SUP-0270-18-2.0-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"KAISER [10500]",Kaiser,,1763.98,67,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO ORTHOPEDIC EXPRESS KYPHX OSTEO INTRO 10GA PERCUTANEOUS",SUP-T34A,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 15MM 44MM SHOULDER SOFT TISSUE BALANCE",SUP-7122880,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3635.28,45.9,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X20 40CM SL",SUP-48005002P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"NOVANET [10819]",Novanet,,736.6,75,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 175MM 12MM SMALL SHELL REVISION ALTIVATE",SUP-533-12-175,CDM,C1776,HCPCS,0278,RC,,,both,,,43228.40,12968.52,"PHCS [10601]",PHCS,,30259.88,70,,,,,0,5027.46,36744.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEV TRQ TIP INTRO",SUP-4071,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,67.94,41.1,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION",RX-16169,CDM,,,0250,RC,63323-0418-01,NDC,both,20,ML,1509.40,452.82,"PHCS [10601]",PHCS,,1056.58,70,,,,,0,175.54,1282.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE RX BILIARY SYSTEM LOCKING BIOPSY CAP STERILE",SUP-4527,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"FIRST HEALTH [10303]","First Health",,4485.6,80,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 265ML STYLE 15 SMOOTH NATRELLE SILICONE P3.7CM",SUP-15-265,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"CIGNA [10200]","Cigna Local Plus",,1909.95,,,,,,,415.19,3034.5,"percent of total billed charges",
"STENT GORE VIABAHN 59MM 80CM 5MM 8MM 7FR .035IN",SUP-BXA055901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS [10001]","Blue Cross HMO",,7645.88,39.2,,9776.84,9776.84,9776.84,"1 through 10",2268.41,16579.08,"percent of total billed charges",
"FARAPOINT PFA CATHETER F-F CURVE",SUP-M004PF81M310,CDM,C1733,HCPCS,0272,RC,,,both,,,24570.00,7371,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2911.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 80MM 16MM DARCO FOOT ANKLE HEAD",SUP-777758062,CDM,C1713,HCPCS,0278,RC,,,both,,,2827.50,848.25,"BLUE CROSS [10001]","Blue Cross HMO",,1108.38,39.2,,957.42,156.86,7483.26,51,328.84,2403.38,"percent of total billed charges",
"SPLINT ORTHOPEDIC MEDIUM 24IN 16-19IN KNEE CONTACT CLSR",SUP-79-80035,CDM,S27000186,LOCAL,0270,RC,,,both,,,117.10,35.13,"CIGNA [10200]",Cigna,,79.63,68,,,,,0,13.62,99.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 80MM 125CM 7MM 6FR VASCULAR NITINOL",SUP-G43828,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]",Cigna,,2570.4,68,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT 120MM SCP ACCUPORT 11GA KNEE SIDE DELIVERY",SUP-414.502,CDM,C1713,HCPCS,0278,RC,,,both,,,23486.40,7045.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9652.91,41.1,,,,,0,2731.47,19963.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CORTICAL BLOCK 14X11X7MM CERVICAL",SUP-330741,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 20MM AXSOS STAINLESS STEEL T20 FEMUR HUMERUS",SUP-370120,CDM,C1713,HCPCS,0278,RC,,,both,,,1219.05,365.71,"CIGNA [10200]","Cigna Open Access",,693.64,56.9,,1144.80,304.56,2275.09,66,141.78,1036.19,"percent of total billed charges",
"CATH FLEXTOME 142CM 6MM 3MM BALLOON DILATATION NYLON",SUP-H749CBM3300060,CDM,C1725,HCPCS,0272,RC,,,both,,,5395.80,1618.74,"AETNA [10100]","Aetna HMO/PPO",,4289.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,627.53,4586.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE WALKING 4- 5- SHORT FOOT ANKLE 2 ADJUSTABLE DISTAL",SUP-01A-P,CDM,S27000186,LOCAL,0270,RC,,,both,,,797.61,239.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,92.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,92.76,677.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT TAPERED COMPONENT",SUP-G47480,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"AETNA [10100]","Aetna HMO/PPO",,81589.66,79.5,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"NOVANET [10819]",Novanet,,9832.5,75,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP INSRT TIBIAL POROUS ROTATE PLATFORM ATTUNE",SUP-OSC367989,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"CIGNA [10200]",Cigna,,9324,40,,5873.17,5873.17,5873.17,"1 through 10",2710.95,19813.5,"percent of total billed charges",
"PROBE BREAST BIOPSY 11GA MAMMOTOME 3 COIL TITANIUM FLEXIBLE",SUP-4010-01-11-T3,CDM,A4648,HCPCS,0278,RC,,,both,,,640.49,192.15,"BLUE CROSS [10001]","Blue Cross PPO",,251.07,39.2,,,,,0,74.49,544.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTRELL MAPPING ELECTRD RECORDING D-F CURVE",SUP-D140901,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"FIRST HEALTH [10303]","First Health",,12696,80,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 13 STD OFFSET HIP",SUP-71935573,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10455.94,28.62,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00180,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 400ML GEL SMOOTH MEMORYGEL SILICONE P5CM HIGH","SUP-3504004 BC",CDM,S27200284,LOCAL,0272,RC,,,both,,,4823.10,1446.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3279.71,68,,,,,0,560.93,4099.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 300MM 3.2MM ASNIS III NONSTERILE",SUP-702626,CDM,S27200284,LOCAL,0272,RC,,,both,,,1020.60,306.18,"CIGNA [10200]",Cigna,,694.01,68,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATHETERIZATION 9IN 15FR 16FR 11 CANNON II PLUS",SUP-CS-15282-VSP,CDM,C1750,HCPCS,0278,RC,,,both,,,2400.00,720,"KAISER [10500]",Kaiser,,1608,67,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 6.5MM 2 FULL THREAD CORKSCREW FIBERWIRE TITANIUM",SUP-AR-1929SF-3,CDM,C1713,HCPCS,0278,RC,,,both,,,1929.38,578.81,"KAISER [10500]",Kaiser,,1292.68,67,,,,,0,224.39,1639.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 40MM 12MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171120470,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PHCS [10601]",PHCS,,822.15,70,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd Bx",PX-750000030,CDM,43239,CPT,0750,RC,,,both,,,3570.43,1071.13,"FIRST HEALTH [10303]","First Health",,2856.34,80,,6727.89,6727.89,6727.89,"1 through 10",415.24,3570.43,"percent of total billed charges",
"LEAD PACING 35CM 6.6FR MYOCARDIUM IS-1 UNIPOLAR FIX SCR",SUP-5071-35,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"NOVANET [10819]",Novanet,,4205.25,75,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLF TORIC AUTONOME",SUP-CNA0T6,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"MULTIPLAN [10600]",Multiplan,,314.5,85,,,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 3-0 PS-1 SIRAL 30CM SUT",SUP-SXMP2B410,CDM,S27200284,LOCAL,0272,RC,,,both,,,219.64,65.89,"NOVANET [10819]",Novanet,,164.73,75,,,,,0,25.54,186.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATHLETIS 135CM 60MM 12MM BALLOON DILATATION STERILE",SUP-H74939347120610,CDM,C1725,HCPCS,0272,RC,,,both,,,1449.90,434.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,595.91,41.1,,,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Outr/Ua Assay of Urine Sulfate",PX-300000030,CDM,84392,CPT,0301,RC,,,both,,,41.60,12.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.88,,"Fee schedule rate ($5.88). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,35.36,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 12MM 5MM EMBOLIZATION BRAID SOFT DISTAL",SUP-PED-500-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"FIRST HEALTH [10303]","First Health",,61560,80,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 80MM 159CM 8MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200088020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 36CM 18MM .021-.027IN AZUR CX HYDROCOIL",SUP-45-781836,CDM,S27800098,LOCAL,0278,RC,,,both,,,5278.50,1583.55,"KAISER [10500]",Kaiser,,3536.6,67,,,,,0,613.89,4486.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 8FR .06IN 5CM 1 LUMEN INTERMEDIATE POWER",SUP-0805810,CDM,C1751,HCPCS,0272,RC,,,both,,,2745.00,823.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1128.2,41.1,,,,,0,319.24,2333.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UROLOGICAL STD STRAIGHT 145CM 3CM .038IN STAINLESS",SUP-G14323,CDM,C1769,HCPCS,0272,RC,,,both,,,163.56,49.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,67.22,41.1,,,,,0,19.02,139.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 80MM 80CM 10MM .035IN 3MM VASCULAR VENOUS",SUP-VENUM10080,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2564.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP CORTICAL CANCELLOUS 20CC 2-4MM ALLOGRAFT",SUP-12710001,CDM,C1713,HCPCS,0278,RC,,,both,,,18160.38,5448.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7264.15,40,,,,,0,2112.05,15436.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 16MM 144CM 4MM",SUP-H7493941216400,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"PHCS [10601]",PHCS,,5433.75,70,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL 220CM 2.3MM FIAPC FLEXIBLE SIDEFIRE",SUP-20132-217,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE GT VASCULAR 45D 180CM 25CM .018IN NITINOL",SUP-RG*GA1818SA,CDM,C1887,HCPCS,0272,RC,,,both,,,1393.20,417.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,165.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.03,1184.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 40MM HIP PRIMARY COCR V40 LFIT",SUP-6260-9-240,CDM,C1776,HCPCS,0278,RC,,,both,,,7962.60,2388.78,"CIGNA [10200]","Cigna Open Access",,4530.72,56.9,,5302.19,4377.88,6578.61,27,926.05,6768.21,"percent of total billed charges",
"SET BIOPSY 15CM 11GA OSTEO-SITE 30D SIDE BEVEL DIAMOND BONE",SUP-G12374,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"KAISER [10500]",Kaiser,,313.41,67,,,,,0,54.4,397.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 75CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR071001A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"UHC [10700]","United Healthcare",,13463.15,63.3,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 55MM ASNIS III STAINLESS STEEL PARTIAL THREAD",SUP-325055,CDM,C1713,HCPCS,0278,RC,,,both,,,1929.60,578.88,"FIRST HEALTH [10303]","First Health",,1543.68,80,,,,,0,224.41,1640.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 55MM ASNIS III STAINLESS STEEL PARTIAL THREAD",SUP-325055,CDM,C1713,HCPCS,0278,RC,,,both,,,1929.60,578.88,"PHCS [10601]",PHCS,,1350.72,70,,,,,0,224.41,1640.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 42.5-67MM 6MM CREO LONG SPINE CROSS LOW PROFILE",SUP-1119.0267,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross PPO",,1396.5,39.2,,957.42,570.23,957.42,28,414.32,3187.5,"percent of total billed charges",
"IMPL BREAST 580CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRX-580,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"KAISER [10500]",Kaiser,,2659.23,67,,,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STAYFIX SMALL 5-14FR SECUREMENT DRAIN CATH FSTNR",SUP-680ME,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.43,24.43,"CIGNA [10200]","Cigna Local Plus",,43.57,53.5,,,,,0,9.47,69.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE MATRIX 5CC ALLOGRAFT",SUP-T44105,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"BLUE CROSS [10001]","Blue Cross HMO",,1690.5,39.2,,957.42,156.86,7483.26,51,501.54,3665.63,"percent of total billed charges",
"NAIL 15.5-11MM 22CM FEMUR PROXIMAL TALON DISTALFIX",SUP-SLN-130-220,CDM,C1713,HCPCS,0278,RC,,,both,,,13227.30,3968.19,"CIGNA [10200]","Cigna Local Plus",,4166.6,31.5,,3978.14,359.25,3978.14,24,1538.33,11243.21,"percent of total billed charges",
"SPACER ALLOGRAFT 26X13MM 9/11MM SPINE CORTICAL FREEZE DRY",SUP-14913,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4471.2,27,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 5MM 55MM KII ABDOMEN Z THREADED SEAL",SUP-CTS03,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"PHCS [10601]",PHCS,,48.72,70,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW PIN FIXATION L62.5MM DIA3.2MM STEEL SQUARE HUB 2.25MM",SUP-GS903.062.032STE,CDM,S27200284,LOCAL,0272,RC,,,both,,,1210.95,363.28,"PHCS [10601]",PHCS,,847.67,70,,,,,0,140.83,1029.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 4MM 32MM REUNION X3 SHOULDER STERILE LATEX",SUP-5571-S-3204-E,CDM,C1776,HCPCS,0278,RC,,,both,,,8119.92,2435.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2323.92,28.62,,,,,0,944.35,6901.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 159MM STAINLESS STEEL 4.5MM SCR 6 HOLE 4 COLUMN",SUP-02.124.407S,CDM,C1713,HCPCS,0278,RC,,,both,,,13248.28,3974.48,"KAISER [10500]",Kaiser,,8876.35,67,,,,,0,1540.77,11261.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AZATHIOPRINE 50 MG TABLET",RX-9183,CDM,J7500,HCPCS,0636,RC,60219-1076-01,NDC,both,1,UN,25.75,7.72,"UHC [10700]","United Healthcare",,0.12,,,,,,,0.07,21.89,"fee schedule",
"SET EPIDURAL 3 2/3IN 21GA 18GA SONOPLEX CORNERSTONE 20GA",SUP-211285-40E,CDM,C9812,HCPCS,0272,RC,,,both,,,321.90,96.57,"FIRST HEALTH [10303]","First Health",,257.52,80,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 40MM HIP PRIMARY COCR V40 LFIT",SUP-6260-9-240,CDM,C1776,HCPCS,0278,RC,,,both,,,7962.60,2388.78,"CIGNA [10200]","Cigna Local Plus",,4259.99,53.5,,5372.07,4581.20,7242.98,23,926.05,6768.21,"percent of total billed charges",
"LEAD NERVE STIM 74CM AVISTA PERCUTANEOUS 8 CONTACT MRI",SUP-SC-2408-74,CDM,C1778,HCPCS,0278,RC,,,both,,,13800.00,4140,"BLUE CROSS [10001]","Blue Cross HMO",,5409.6,39.2,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 11CM GREEN HUB TUBING RADIOPAQUE MARKER TIP",SUP-PRO-6F-11MT,CDM,C1894,HCPCS,0272,RC,,,both,,,161.39,48.42,"FIRST HEALTH [10303]","First Health",,129.11,80,,,,,0,18.77,137.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEIZURES WITH MCC",100,MS-DRG,,,,,,,inpatient,,,37993.84,11398.15,"AMBETTER EXCHANGE  [11102]",Ambetter,,12014.1,,"Case rate ($12,014.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,155.90, add-ons for qualifying new technology services are included. If operating cost exceeds $44,195.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,225.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,170.65. The transfer operating threshold is the transfer adjustment factor * $11,155.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $843.44. The transfer capital threshold is the transfer adjustment factor * $843.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",22213.58,22213.58,22213.58,"1 through 10",7561,37993.84,other,"INPATIENT DRG"
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR JUDKINS LEFT 4",SUP-67001400,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,48.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 550-660CC P5.3-6.1CM MODERATE PLUS PROFILE ROUND",SUP-3502550,CDM,C1789,HCPCS,0278,RC,,,both,,,3487.50,1046.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,405.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,405.6,2964.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 16X9MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2409,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3970.26,41.1,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840007535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UHC [10700]","United Healthcare",,6043.16,63.3,,5023.51,2672.93,6679.78,18,1110.3,8114.82,"percent of total billed charges",
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC",310,MS-DRG,,,,,,,inpatient,,,20255.38,6076.61,"BLUE CROSS [10001]","Blue Cross HMO",,12995.84,,,,,,,3511.56,14117.97,"case rate",
"COIL EMBOLIZATION 47CM 14MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181447,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7439.04,40,,,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 10MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036121040,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 100CM 5FR SIMMONS 3 CURVE ANGIOGRAPHIC",SUP-M001314361,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"CIGNA [10200]",Cigna,,79.27,68,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL KNIFE 24FR TUIP STORZ 1 STEM",SUP-M0068802071,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"CIGNA [10200]","Cigna Open Access",,293.88,56.9,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI CHIKAI VASCULAR STRAIGHT 200CM 30CM .36MM",SUP-WAIN-CKI-200,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"UHC [10700]","United Healthcare",,2373.75,63.3,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LEMAITRE 80CM 5FR 13MM EMBOLECTOMY 15ML STERILE LATEX",SUP-E1601-58,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"PHCS [10601]",PHCS,,419.58,70,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AIR/WATER DEFENDO BUTTON KIT SUCTION CLEAN BIOPSY",SUP-100305,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.07,15.92,"PHCS [10601]",PHCS,,37.15,70,,,,,0,6.17,45.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HARVESTER 9MM GRAFT QUADPRO",SUP-AR-2386-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,3346.88,1004.06,"CIGNA [10200]",Cigna,,2275.88,68,,,,,0,389.24,2844.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL INSRT TRANSVALVULAR 7FR",SUP-TVI-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"CIGNA [10200]","Cigna Local Plus",,88.44,53.5,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 8-0 TG160-6 12IN 2 ARM BRAID COATED VIOLET",SUP-J975G,CDM,S27200284,LOCAL,0272,RC,,,both,,,199.77,59.93,"CIGNA [10200]","Cigna Local Plus",,106.88,53.5,,,,,0,23.23,169.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HIP FEM P2 POROUS OFFSZ14",SUP-425-97-014,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"NOVANET [10819]",Novanet,,31918.84,75,,,,,0,4949.55,36174.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB ADULT 45MM ADHSV CONDUCTIVE RADIOLUCENT",SUP-8900-4005,CDM,S27000186,LOCAL,0270,RC,,,both,,,263.18,78.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,31.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.56,334.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 25CM 12FR MAC-LOC SUPRAPUBIC ULTRATHANE NDL OBTR",SUP-G30404,CDM,C2627,HCPCS,0272,RC,,,both,,,1219.86,365.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT POLARIS ULTRA NAUTILUS 20CM 3CM 8FR .038IN 2 PIGTAIL",SUP-M006192150010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]","Cigna Local Plus",,642.31,,,,,,,139.63,1020.49,"percent of total billed charges",
"IMPL BREAST SMOOTH MOD + PROF XTRA 350CC",SUP-SMPX350,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3420.47,45.9,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAWSON-MUELLER MAC-LOC INTRO-TIP 25CM 8.5FR DRNG",SUP-G09705,CDM,C1729,HCPCS,0272,RC,,,both,,,660.07,198.02,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,76.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,76.77,561.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CENTRAL VENOUS 28CM PALINDROME",SUP-8888145064,CDM,C1750,HCPCS,0278,RC,,,both,,,2487.65,746.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,294.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,289.31,2114.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY HUMERAL SMR TITANIUM LOCKING SCR FINNED REVISION",SUP-1350.15.110,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3635.28,45.9,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trach-Esoph Voice Pros Pt In",PX-E27400041,CDM,L8507,HCPCS,0274,RC,,,both,,,105.60,31.68,"NOVANET [10819]",Novanet,,79.2,75,,,,,0,12.28,89.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TFAT00 AS UVA PANOPTIX",SUP-TFAT00,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"NOVANET [10819]",Novanet,,633.75,75,,,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ivus/Oct Hrt Ea Vssl Init",PX-480000068,CDM,92978,CPT,0481,RC,,,both,,,11421.36,3426.41,"PHCS [10601]",PHCS,,7994.95,70,,,,,0,1249,9708.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESTORIS MCK ONLAY TIBIAL INSERT SIZE 3 X 10MM",SUP-180703-3,CDM,C1776,HCPCS,0278,RC,,,both,,,4046.85,1214.05,"PHCS [10601]",PHCS,,2832.8,70,,,,,0,470.65,3439.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 64MM HIP PRIMARY CLUSTER HOLE RIM X3",SUP-502-03-64G,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"PHCS [10601]",PHCS,,7326.77,70,,,,,0,1217.29,8896.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE 10CC",SUP-7509141,CDM,S27800098,LOCAL,0278,RC,,,both,,,17955.00,5386.5,"CIGNA [10200]",Cigna,,7182,40,,,,,0,2088.17,15261.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST FIXATION 30MM 4.5MM LOW PROFILE KNEE BICORTICAL",SUP-AR-1365-30,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,390.38,45.9,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PSN ASF CPS 12MM VE R 3-5 CD",SUP-42-5226-004-12,CDM,C1776,HCPCS,0278,RC,,,both,,,13634.40,4090.32,"CIGNA [10200]",Cigna,,5453.76,40,,5873.17,5873.17,5873.17,"1 through 10",1585.68,11589.24,"percent of total billed charges",
"MATRIX TISSUE 22X11.5IN OVITEX PRS CONTOUR OVINE",SUP-R20252-1122G,CDM,C1781,HCPCS,0278,RC,,,both,,,25937.10,7781.13,"FIRST HEALTH [10303]","First Health",,20749.68,80,,,,,0,3016.48,22046.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOJET ULTRA CROSS-STREAM SPIROFLEX THROMBECTOMY",SUP-106553-001,CDM,C1757,HCPCS,0272,RC,,,both,,,12891.96,3867.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1527.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1499.33,10958.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .014IN 4FR 5.5MM 142CM 1.5CM",SUP-4245515W,CDM,C1725,HCPCS,0272,RC,,,both,,,1438.80,431.64,"AETNA [10100]","Aetna HMO/PPO",,1143.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.33,1222.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUBICON 135CM 5.1FR 2.84FR 50MM SPACE GUIDING NYLON",SUP-H74939240035131,CDM,C1887,HCPCS,0272,RC,,,both,,,1449.90,434.97,"AETNA [10100]","Aetna HMO/PPO",,1152.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 200MM 120CM 7MM VASCULAR PERIPHERAL SELF",SUP-PRB35-07-200-120,CDM,C1876,HCPCS,0278,RC,,,both,,,11625.00,3487.5,"CIGNA [10200]",Cigna,,4650,40,,,,,0,1351.99,9881.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETENE DS 25X20CM COMPOSITE ABSORBABLE FILM",SUP-PPDS2520,CDM,C1781,HCPCS,0278,RC,,,both,,,6915.11,2074.53,"BLUE CROSS [10001]","Blue Cross PPO",,2710.72,39.2,,,,,0,765.93,5877.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE CORNEAL 8.5MM STAINLESS STEEL TREPHINE STERILE LATEX",SUP-K20-2160,CDM,S27200284,LOCAL,0272,RC,,,both,,,430.65,129.19,"MULTIPLAN [10600]",Multiplan,,366.05,85,,,,,0,50.08,366.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X11X9MM ALLOCRAFT 5D LORDOSIS CORTICAL",SUP-6183-7-009,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 30.5-43MM 6MM CREO LONG SPINE LOW PROFILE CROSS",SUP-1119.0243,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross PPO",,1396.5,39.2,,957.42,570.23,957.42,28,414.32,3028.13,"percent of total billed charges",
"INSRT ACETABULAR 28MM 10D D HIP X3 TRIDENT",SUP-623-10-28D,CDM,C1776,HCPCS,0278,RC,,,both,,,6242.04,1872.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1786.47,28.62,,,,,0,725.95,5305.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 12MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620412,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"UHC [10700]","United Healthcare",,7123.72,63.3,,8601.07,8395.67,8601.07,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"SURFACE ARTICULAR 17MM NEXGEN LPS-FLEX 1-2 C-D KNEE PROLONG",SUP-596202217,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,938.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,920.91,6730.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR STRAIGHT 180CM .038IN HYDROPHILIC FIX CORE",SUP-H2OSTFS38180,CDM,C1769,HCPCS,0272,RC,,,both,,,348.00,104.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,41.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CROSSER 146CM 20CM 1.3MM 1.1MM .067IN .014IN",SUP-CRU14PA,CDM,C1714,HCPCS,0272,RC,,,both,,,13282.50,3984.75,"FIRST HEALTH [10303]","First Health",,10626,80,,,,,0,1544.75,11290.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE TIBIAL 13MM PFC SIGMA 20D 2 HEMI KNEE TITANIUM MODULAR",SUP-860172,CDM,C1776,HCPCS,0278,RC,,,both,,,8260.68,2478.2,"BLUE CROSS [10001]","Blue Cross HMO",,3238.19,39.2,,5311.50,4717.44,5388.59,31,960.72,7021.58,"percent of total billed charges",
"SPACER SPINAL 8MM ZERO-P LARGE LORDOTIC PEEK-OPTIMA TITANIUM",SUP-04.617.228S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3353.4,27,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 34MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ334,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,114,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,111.88,817.7,"percent of total billed charges",
"LEAD PACING 87CM 5.4FR 18MM TIP TO RING 2 CURVE LEFT",SUP-368346,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1604.72,28.62,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 220CM 11.5-14MM OTSC 6MM NITINOL",SUP-100.14,CDM,C1760,HCPCS,0278,RC,,,both,,,4754.10,1426.23,"CIGNA [10200]","Cigna Open Access",,2705.08,56.9,,,,,0,552.9,4040.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 15CM 37MM TAG THORACIC ACTIVE CONTROL",SUP-TGMR373715,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"CIGNA [10200]","Cigna Open Access",,38850.69,33.5,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 2.5CM 10CM WITHOUT MINI GWIRE DIL PINNACLE",SUP-RSS504,CDM,C1894,HCPCS,0272,RC,,,both,,,73.95,22.18,"UHC [10700]","United Healthcare",,46.81,63.3,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MNTR CARDIAC BIOMONITOR IV INJECTABLE",SUP-471155,CDM,C1764,HCPCS,0278,RC,,,both,,,23940.00,7182,"AETNA [10100]","Aetna HMO/PPO",,19032.3,79.5,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 102MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 2",SUP-71357102,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"NOVANET [10819]",Novanet,,24855.86,75,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE 40MM 135CM 8MM VASCULAR NITINOL CAROTID ARTERY",SUP-P08040RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,12178.50,3653.55,"MULTIPLAN [10600]",Multiplan,,10351.73,85,,,,,0,1416.36,10351.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 85MM DHS/DCS STAINLESS STEEL CONDYLAR HIP",SUP-280.285,CDM,C1713,HCPCS,0278,RC,,,both,,,2043.30,612.99,"FIRST HEALTH [10303]","First Health",,1634.64,80,,,,,0,237.64,1736.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY AND URINARY TRACT NEOPLASMS WITH CC",687,MS-DRG,,,,,,,inpatient,,,44973.68,13492.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,20799.88,,"Fee schedule rate ($20,799.88). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,6499.58,26131.08,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Genculr Nrv Brn Bi",PX-510000534,CDM,64454,CPT,0361,RC,,,both,,,2521.94,756.58,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1550,,"Case rate ($1,550). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1550,2385,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-9 CD 14MM KNEE LEFT CRUCIATE RETAINING",SUP-42512000414,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4429.11,41.1,,6417.48,6417.48,6417.48,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"SCR BONE 85MM ANTIROTATE STERILE FEMORAL NECK SYSTEM",SUP-04.168.485S,CDM,C1713,HCPCS,0278,RC,,,both,,,1642.20,492.66,"CIGNA [10200]",Cigna,,1116.7,68,,1831.33,1831.33,1831.33,16,190.99,1395.87,"percent of total billed charges",
"INSRT ARTICULAR 3-9 CD 14MM KNEE LEFT CRUCIATE RETAINING",SUP-42512000414,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UHC [10700]","United Healthcare",,6821.47,63.3,,8601.07,8395.67,8601.07,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"SUB BONE GRAFT GRAFTON SMALL DEFECT DEMINERALIZED BONE",SUP-T44145,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"CIGNA [10200]","Cigna Local Plus",,2307.19,53.5,,3978.14,359.25,3978.14,24,501.54,3665.63,"percent of total billed charges",
"BAND ANNULOPLASTY 25MM SJM TAILOR SILICONE FLEXIBLE SURE",SUP-TAB-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"KAISER [10500]",Kaiser,,8111.29,67,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DSRCTOR 100MM 2.5MM LATEX FREE",SUP-MPX25100,CDM,S27000186,LOCAL,0270,RC,,,both,,,445.50,133.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 15CM 45D TURNER BEVELED CANN TUMOR STERILE",SUP-G01087,CDM,S27200284,LOCAL,0272,RC,,,both,,,235.42,70.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,108.06,45.9,,,,,0,27.38,200.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET MICRO BAYONET 7.25IN YASARGIL SYMMETRY OVAL CUP SHARP",SUP-58-3309,CDM,S27200284,LOCAL,0272,RC,,,both,,,740.26,222.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,86.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.09,629.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 26CM 3CM 5FR .038IN STRAIGHT URETERAL",SUP-M006155223170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CIGNA [10200]","Cigna Local Plus",,759.88,,,,,,,165.19,1207.29,"percent of total billed charges",
"LINER ACETABULAR TRILOGY 9.8MM 60MM 36MM LONGEVITY HIP",SUP-00633406036,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"CIGNA [10200]",Cigna,,9681.34,40,,5873.17,5873.17,5873.17,"1 through 10",2814.85,20572.84,"percent of total billed charges",
"SUT POLYPROPYLENE PROLENE 0 CT-1 18IN CONTROL RELEASE",SUP-C821G,CDM,S27200284,LOCAL,0272,RC,,,both,,,168.03,50.41,"NOVANET [10819]",Novanet,,126.02,75,,,,,0,19.54,142.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION LAPIPLASTY SPEEDPLATE RAPID COMPRESSION",SUP-SK53,CDM,C1713,HCPCS,0278,RC,,,both,,,22465.80,6739.74,"CIGNA [10200]",Cigna,,8986.32,40,,1831.33,1831.33,1831.33,16,2612.77,19095.93,"percent of total billed charges",
"DEVICE WATCHMAN FXD CURVE 15FR 12FR CLSR 2 CURVE ACCESS",SUP-M635TU80010,CDM,C1894,HCPCS,0272,RC,,,both,,,6900.00,2070,"FIRST HEALTH [10303]","First Health",,5520,80,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH PEDIATRIC 6FR 5.5CM HEXCUSPID VALVE KINK",SUP-504606P,CDM,C1894,HCPCS,0272,RC,,,both,,,200.54,60.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) CATHETER GUIDELINER V3 150CM 25CM 7FR INTERVENTIONAL",SUP-5572,CDM,C1887,HCPCS,0272,RC,,,both,,,0.01,,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,,41.1,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AIRWAY ESOPHAGEAL 4 STD 6MM 5MM ADULT LMA UNIQUE LARYNGEAL",SUP-125040,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.20,15.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,inpatient,,,99343.25,29802.97,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DRILL 4MM RETROBUTTON TIGHTROPE KNEE ACL CLOSED EYELET",SUP-AR-1595TC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1063.13,318.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN NASAL O2 LOW FLOW PEDIATRIC SMALL VAPOTHERM .073-.11IN",SUP-MPS1500,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.76,14.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXP TISSUE 800ML STYLE 7200 MEDIUM HEIGHT CENTERSCOPE",SUP-354-7216,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH QUICK-CROSS 135CM 3.1FR 50MM SPACE SPRT RADIOPAQUE",SUP-518-037,CDM,C1887,HCPCS,0272,RC,,,both,,,972.00,291.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Neu Prksn Msfl Î±-Syncln Prtn",PX-310000034,CDM,0393U,CPT,0310,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHILON MULTIPASS 5-0 P-3 18IN MONOFILAMENT UNDYED",SUP-690G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58-81MM TITANIUM 5.5MM ROD LOW PROFILE LEGACY X10 XLNK",SUP-8115558,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",414.32,3028.13,"percent of total billed charges",
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT ELITE VASCULAR J CURVE",SUP-1011882J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE MEDIUM OVAL 240CMX20MM 2.4MM TRU-TORQUE ROTATABLE STAR",SUP-M00561831,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.26,51.08,"KAISER [10500]",Kaiser,,114.07,67,,,,,0,19.8,144.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.8MM",SUP-58850028,CDM,S27000186,LOCAL,0270,RC,,,both,,,1069.20,320.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,490.76,45.9,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 2-0 CT-2 27IN MONOFILAMENT ABSORBABLE",SUP-883H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15.3CM 9MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR180915,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3208.09,27,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.6V 34MM 2 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18006234,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND MULTIPASS 2-0 PS-2 18IN BRAID BLACK",SUP-583H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT WOODING SCOTT COMPLETE",SUP-66800212,CDM,S27000186,LOCAL,0270,RC,,,both,,,523.58,157.07,"KAISER [10500]",Kaiser,,350.8,67,,,,,0,60.89,445.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 V5 ETHIBOND GII QUICKANCHOR PLUS ROTATOR CUFF",SUP-212035,CDM,C1713,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"CIGNA [10200]",Cigna,,4574.7,68,,1831.33,1831.33,1831.33,16,782.41,5718.38,"percent of total billed charges",
"KIT HIPEC HANG AND GO HT PAC PRE-ASSEMBLED",SUP-R9900117,CDM,S27200284,LOCAL,0272,RC,,,both,,,25200.00,7560,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2930.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355070,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"SYSTEM SYNERGY 12MM 144CM 2.5MM CORONARY STENT PEBAX",SUP-H7493926012250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER PROBE ULTRACOVER 244X12CM FOLD INTRAOPERATIVE TAPE",SUP-PC3787,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.73,15.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.9,43.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 45D HH 50MM 28MM LONGEVITY HIP STERILE",SUP-875800928,CDM,C1776,HCPCS,0278,RC,,,both,,,18074.70,5422.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2102.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2102.09,15363.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 80MM 190CM 2MM",SUP-R51002008L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"NOVANET [10819]",Novanet,,1478.81,75,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 13MM KNEE POSTERIOR STABILIZE HIGH",SUP-71421510,CDM,C1776,HCPCS,0278,RC,,,both,,,10774.35,3232.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4428.26,41.1,,6417.48,6417.48,6417.48,"1 through 10",1253.06,9158.2,"percent of total billed charges",
"BIT DRILL 3.2MM QUICK RELEASE",SUP-201-78-89,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL SHALLCROSS S 7.13IN CYSTIC DUCT",SUP-51-3510,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTNR DRSG 25YDX41IN 10 SMALL CHEST TUBULAR SPANDEX POLYESTER",SUP-NONSTNDNET10,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.55,40.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,55.71,41.1,,,,,0,15.76,115.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CLEANERXT 65CM 6FR THROMBECTOMY ROTATIONAL 2 POWER CELL",SUP-700009XT,CDM,C1757,HCPCS,0272,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 150CM 6FR .035IN 3CM STD STRAIGHT URETERAL",SUP-M006175265190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"PHCS [10601]",PHCS,,885.77,70,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 14CM TOUCH NARROW BASE",SUP-EN2814,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"KAISER [10500]",Kaiser,,42009,67,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY FIXATION GOLD 85MM 11MM HELIX",SUP-456.302,CDM,C1713,HCPCS,0278,RC,,,both,,,3964.33,1189.3,"CIGNA [10200]","Cigna Open Access",,2255.7,56.9,,1144.80,304.56,2275.09,66,461.05,3369.68,"percent of total billed charges",
"SYSTEM WATCHMAN TRUSTEER 2 CURVE 17FR 12FR ACCESS PEBAX PTFE",SUP-M635TU90050,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"PHCS [10601]",PHCS,,7245,70,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBJR051002A,CDM,C1874,HCPCS,0278,RC,,,both,,,22163.40,6649.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2626.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2577.6,18838.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPOON SURGICAL 7.25INX40MM LARGE",SUP-MG001R,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.24,63.97,"NOVANET [10819]",Novanet,,159.93,75,,,,,0,24.8,181.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 12MM 140CM 5MM 2.1-2.7FR CORONARY STENT",SUP-RONYX50012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"BLUE CROSS [10001]","Blue Cross PPO",,1440.6,39.2,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 10MM LCP TITANIUM DISTAL VOLAR RADIUS LOCKING",SUP-04.210.110,CDM,C1713,HCPCS,0278,RC,,,both,,,1063.69,319.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,304.43,28.62,,,,,0,123.71,904.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17CM 5MM AVENIR 10 COIL COMPLEX FINISH",SUP-10CFN05017,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"FIRST HEALTH [10303]","First Health",,9378.48,80,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 30MM 80CM 9MM 8FR STRAIGHT VASCULAR",SUP-AVSM09030,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"FIRST HEALTH [10303]","First Health",,14616,80,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Sciatic Sngl",PX-510000121,CDM,64445,CPT,0761,RC,,,both,,,3769.65,1130.89,"PHCS [10601]",PHCS,,2638.76,70,,,,,0,438.41,3204.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Iabp Perc",PX-360000032,CDM,33968,CPT,0361,RC,,,both,,,1436.37,430.91,"PHCS [10601]",PHCS,,1005.46,70,,,,,0,167.05,1436.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 STD SHORT LENGTH 18IN BRAID 12 STRAND",SUP-VCP110G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"MULTIPLAN [10600]",Multiplan,,21.25,85,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 2.50 X 18 MM",SUP-1212250-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"NOVANET [10819]",Novanet,,12937.5,75,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 24MM STAINLESS STEEL T6 SELF TAP LOCK VARIABLE",SUP-02.130.324,CDM,C1713,HCPCS,0278,RC,,,both,,,841.43,252.43,"NOVANET [10819]",Novanet,,631.07,75,,,,,0,97.86,715.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOCKWAVE C2+ IVL CATHETER 3.5X12 MM",SUP-C2PIVL3512,CDM,C1761,HCPCS,0272,RC,,,both,,,29610.00,8883,"FIRST HEALTH [10303]","First Health",,23688,80,,,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 36MM LCP STAINLESS STEEL CORTIEX PERIARTICULAR",SUP-02.204.036,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,452.84,45.9,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BLUE 54MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103554000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"CIGNA [10200]",Cigna,,2083.74,68,,5873.17,5873.17,5873.17,"1 through 10",356.38,2604.67,"percent of total billed charges",
"CATH EVERCROSS BEVEL 360 80CM 60MM 9MM .035IN BALLOON",SUP-AB35W09060080,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 16IN 36FR VENOUS RETURN LIGHTHOUSE STRAIGHT 1",SUP-RV-40036,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET INTRO 65CM 5.5FR PEEL-AWAY MICROPUNCTURE ECHOTIP",SUP-G11567,CDM,C1892,HCPCS,0272,RC,,,both,,,629.53,188.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP SURGICAL STEALTH LATIS 6MM LOW PROFILE 30MM .5 SPRING",SUP-A1601,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC",354,MS-DRG,,,,,,,inpatient,,,45036.03,13510.81,"BLUE CROSS [10001]","Blue Cross HMO",,,100,,38622.50,38622.50,38622.50,"1 through 10",,,"percent of total billed charges",
"EXTR STONE 115CM 2.2FR 11MM MULTIWIRE BASKET KINK RESISTANT",SUP-G48296,CDM,S27200284,LOCAL,0272,RC,,,both,,,2063.25,618.97,"UHC [10700]","United Healthcare",,1306.04,63.3,,,,,0,239.96,1753.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP GRIPTION PINNACLE STERILE LATEX",SUP-121731060,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"KAISER [10500]",Kaiser,,10866.36,67,,,,,0,1886.21,13785.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 125CM 5FR .038IN BERN CURVE ANGIOGRAPHIC",SUP-512538BER-H,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"FIRST HEALTH [10303]","First Health",,271.44,80,,,,,0,39.46,288.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 5MM 1MM BALLOON DILATATION PERCUTANEOUS",SUP-210-053-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PHCS [10601]",PHCS,,878.85,70,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM VARIAX TITANIUM T7 FULL THREAD RADIUS",SUP-53-27218E,CDM,C1713,HCPCS,0278,RC,,,both,,,571.54,171.46,"CIGNA [10200]",Cigna,,388.65,68,,1831.33,1831.33,1831.33,16,66.47,485.81,"percent of total billed charges",
"STENT AGILE 102MM 14MM ESOPHAGEAL FULL COVER STERILE LATEX",SUP-M00517410,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PHCS [10601]",PHCS,,12789,70,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM ULNAR SIZE 5 L115MM LEFT CEMENTED CONSTRAINED NEXEL",SUP-840001511,CDM,C1776,HCPCS,0278,RC,,,both,,,31971.49,9591.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3788.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3718.28,27175.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG SECUREMENT 6X6IN TAPE STRIP",SUP-LVAD66UXT,CDM,S27200284,LOCAL,0272,RC,,,both,,,51.17,15.35,"CIGNA [10200]",Cigna,,34.8,68,,,,,0,5.95,43.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAWSON-MUELLER 25CM 7FR .035IN DRNG HYDROPHILIC",SUP-G11020,CDM,C1729,HCPCS,0272,RC,,,both,,,660.07,198.02,"AMERIGROUP MEDICAID [20100]",Amerigroup,,78.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,76.77,561.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL 50 MCG/ML INJECTION SUPERORDERABLE",RX-4083037,CDM,J3010,HCPCS,0636,RC,00409-9094-18,NDC,both,5,ML,56.15,16.84,"BLUE CROSS [10001]","Blue Cross HMO",,3.85,,,,,,,3.85,47.73,"fee schedule",
"MITRACLIP G4 CDS XTW REPAIR-MR CLINICAL",SUP-CDS0704-XTW,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS [10001]","Blue Cross HMO",,67032,39.2,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pulmonary Stress Testing",PX-482000006,CDM,94618,CPT,0460,RC,,,both,,,270.62,81.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,124.21,45.9,,,,,0,31.47,230.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES 145CM 40MM 4MM .014IN BALLOON DILATATION OTW",SUP-39134-40401,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,881.28,68,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +13 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.130,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 114MM STAINLESS STEEL 3.5MM SCR 5 HOLE LCP BONE",SUP-241.903,CDM,C1713,HCPCS,0278,RC,,,both,,,10239.32,3071.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4699.85,45.9,,,,,0,1190.83,8703.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 270MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.334S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"FIRST HEALTH [10303]","First Health",,6649.94,80,,,,,0,966.74,7065.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CREO SPINE PREASSEMBLE 5.5MM ROD",SUP-5119.165,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"KAISER [10500]",Kaiser,,3236.1,67,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 13MM 15D MEDIUM",SUP-376.513,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"BLUE CROSS [10001]","Blue Cross HMO",,13436.04,39.2,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETER 23CM 14FR 22GA BLUE FLEXTIP .035IN STRAIGHT PER",SUP-AK-01601,CDM,C1729,HCPCS,0272,RC,,,both,,,1085.40,325.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,446.1,41.1,,,,,0,126.23,922.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC .99CM 5.37X7.79CM MOMENTUM HEARTLOGIC RIGHT",SUP-D121,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"FIRST HEALTH [10303]","First Health",,32448,80,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL HIP 2",SUP-CAP-S-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross HMO",,4057.2,39.2,,5311.50,4717.44,5388.59,31,1203.71,8797.5,"percent of total billed charges",
"BURR SURGICAL ORANGE 1MM OTO-FLEX SKEETER CARBIDE",SUP-3155631,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17CM 5MM CEREPAK MICRO UNIFORM DETACHABLE",SUP-FCX100517,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS [10001]","Blue Cross PPO",,5184.53,39.2,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXERCISER HAND ROLYAN BLACK RUBBER ERGONOMIC LATEX FREE",SUP-A3481,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.33,13.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,20.81,45.9,,,,,0,5.27,38.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 24MM 144CM 4MM CORONARY STENT EVEROLIMUS",SUP-H7493926124400,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myelography Lumb Inj Lumbsac Si",PX-361000373,CDM,62304,CPT,0361,RC,,,both,,,4612.82,1383.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3311,,"Case rate ($3,311). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,536.47,4612.82,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 30MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.030,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,94.72,45.9,,,,,0,24,175.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X60 80CM SL",SUP-48006006N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"AETNA [10100]","Aetna HMO/PPO",,682.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 75MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355075,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"STENT COTTON-LEUNG 10CM 7FR .035IN GENTLE CURVE BILIARY",SUP-G21979,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,290,45.9,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 8IN SPETZLER-MALIS 1.5MM 2 IRRIGATE DISPOSABLE",SUP-6770-200-015,CDM,S27200284,LOCAL,0272,RC,,,both,,,3282.98,984.89,"NOVANET [10819]",Novanet,,2462.24,75,,,,,0,381.81,2790.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,inpatient,,,34737.02,10421.11,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,6167.45,,"Case rate ($5,987.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,560.09, add-ons for qualifying new technology services are included. If operating cost exceeds $38,599.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,802.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,567.44. The transfer operating threshold is the transfer adjustment factor * $5,560.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.37. The transfer capital threshold is the transfer adjustment factor * $420.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,5987.82,24073.62,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE PREBENT 94MM TITANIUM RIBFIX TITAN BONE EXTRATHORACIC",SUP-323.4094,CDM,C1713,HCPCS,0278,RC,,,both,,,23398.20,7019.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2772.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2721.21,19888.47,"percent of total billed charges",
"HC Cytp Urne 3-5 Probes Ea Spec",PX-311000037,CDM,88120,CPT,0311,RC,,,both,,,3075.00,922.5,"PHCS [10601]",PHCS,,2152.5,70,,,,,0,0.01,2613.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 11MM KNEE LEFT BICRUCIATE STABILIZE XLPE",SUP-74027263,CDM,C1776,HCPCS,0278,RC,,,both,,,20478.15,6143.44,"BLUE CROSS [10001]","Blue Cross PPO",,8027.43,39.2,,3949.44,3949.44,3949.44,"1 through 10",2381.61,17406.43,"percent of total billed charges",
"SPACER SPINAL 45X22X10MM COROENT XL WIDE PEEK LUMBAR",SUP-6910245,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6800.11,28.62,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SMARTSTITCH CNCT MAGNUM WIRE BRAIDED SUT POLYESTER",SUP-OM-8176,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.18,543.35,"NOVANET [10819]",Novanet,,1358.39,75,,,,,0,210.64,1539.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 80CM 5FR ANGLE",SUP-G09312,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"MULTIPLAN [10600]",Multiplan,,201.87,85,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIVAV FLX INFUSION SYSTEM 021X150CM",SUP-FLX-21150-35,CDM,C1982,HCPCS,0272,RC,,,both,,,50292.90,15087.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5959.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5849.06,42748.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE PENCIL STD 2.75IN 3/32IN EDGE",SUP-E1455B,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.24,14.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.73,41.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION 11MM TIGHTROPE ROUND CONCAVE ATTACHABLE",SUP-AR-1588TB-3,CDM,C1713,HCPCS,0278,RC,,,both,,,1764.00,529.2,"NOVANET [10819]",Novanet,,1323,75,,,,,0,205.15,1499.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006175284180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"KAISER [10500]",Kaiser,,978.27,67,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 4MM VAPR 90D PROBE INTEGRATED CABLE",SUP-225370,CDM,S27200284,LOCAL,0272,RC,,,both,,,1353.60,406.08,"PHCS [10601]",PHCS,,947.52,70,,,,,0,157.42,1150.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1MM TARGET NANO 360D DETACHABLE",SUP-M0035421020,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]",Cigna,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 4MM RETRACTA 5.6 LOOP DETACHABLE",SUP-G34187,CDM,S27800098,LOCAL,0278,RC,,,both,,,4308.98,1292.69,"FIRST HEALTH [10303]","First Health",,3447.18,80,,,,,0,501.13,3662.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 5.5IN WEITLANER 3X4 PRONG BLUNT SELF RETAIN SURGICAL",SUP-24-2214,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.68,68.9,"UHC [10700]","United Healthcare",,145.39,63.3,,,,,0,26.71,195.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 122MM 13MM 5.4MM 4.7MM ZENITH SPIRAL-Z",SUP-G55235,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5717.06,27,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 20MM 7MM STAINLESS STEEL LONG THREAD FOOT HAND",SUP-02.226.120,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"MULTIPLAN [10600]",Multiplan,,1398.42,85,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 STD KNEE LEFT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB5SL,CDM,C1776,HCPCS,0278,RC,,,both,,,17652.60,5295.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2091.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2053,15004.71,"percent of total billed charges",
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.215,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Open Access",,196.31,56.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTNR SCR 14MM 3.5MM PRODISC-C SPINE NONSTERILE",SUP-03.820.103,CDM,C1713,HCPCS,0278,RC,,,both,,,1239.30,371.79,"CIGNA [10200]","Cigna Local Plus",,663.03,53.5,,3978.14,359.25,3978.14,24,144.13,1053.41,"percent of total billed charges",
"STENT RX BILIARY SYSTEM 15CM 7FR BILIARY PLASTIC TEMPORARY",SUP-M00545590,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"BLUE CROSS [10001]","Blue Cross HMO",,334.29,39.2,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 46-48MM 28MM 10D HIP SERIES II CROSSFIRE",SUP-2041C-2846,CDM,C1776,HCPCS,0278,RC,,,both,,,5140.80,1542.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,597.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,597.88,4369.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM EVEREST SPINE POLYAXIAL",SUP-2911-06535,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2222.75,45.9,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS",029,MS-DRG,,,,,,,inpatient,,,151883.42,45565.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,54393.63,,,,,,,7561,99605.07,"case rate",
"AVENIR 10 2 X 1 HELICAL FINISHING COIL",SUP-10HFN-02001,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4747.48,45.9,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION 10MM INBONE 3 ANKLE EVERLAST",SUP-22023310,CDM,C1776,HCPCS,0278,RC,,,both,,,13530.90,4059.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3653.34,27,,,,,0,1573.64,11501.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000195,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JADA SYSTEM 2.0 VACUUM INDUCED HEMORRHAGE CONTROL SYSTEM",SUP-1047196,CDM,S27200284,LOCAL,0272,RC,,,both,,,8935.50,2680.65,"AETNA [10100]","Aetna HMO/PPO",,7103.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 13MM ECHO FX COCR STD OFFSET HIP STERILE",SUP-12151313,CDM,C1776,HCPCS,0278,RC,,,both,,,8941.02,2682.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1059.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1039.84,7599.87,"percent of total billed charges",
"DEVICE PRESET 30MM 48MM 6MM THROMBECTOMY CLOSED RING HELICAL",SUP-PRE-6-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,34650.00,10395,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14241.15,41.1,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD PLEXA PROMRI RIGHT VENTRICULAR DF-1 S DX 65/15",SUP-414005,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1997.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SUPERORDERABLE",RX-408844,CDM,J1171,HCPCS,0636,RC,76045-0009-05,NDC,both,.5,ML,44.00,13.2,"FIRST HEALTH [10303]","First Health",,35.2,80,,,,,0,0.58,37.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZIPWIRE VASCULAR STRAIGHT 260CM .035IN NITINOL POLYMER",SUP-M00146317B1,CDM,C1769,HCPCS,0272,RC,,,both,,,339.13,101.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,230.61,68,,,,,0,39.44,288.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 12MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDS40012,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,34123.16,41.1,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 114MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 8",SUP-71357008,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"CIGNA [10200]","Cigna Local Plus",,10439.46,31.5,,5372.07,4581.20,7242.98,23,3854.32,28169.98,"percent of total billed charges",
"REAMER SURGICAL 14.5MM HEAD SIDE CUT MEDULLARY NONSTERILE",SUP-352.145,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE PREP QUIK-USE FEMUR POLYETHYLENE BARIUM SULFATE",SUP-00504905500,CDM,S27200284,LOCAL,0272,RC,,,both,,,1061.10,318.33,"AETNA [10100]","Aetna HMO/PPO",,843.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,123.41,901.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 13.5X12.5CM 445ML STYLE 410 GEL TEXTURED",SUP-MX-410445,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"FIRST HEALTH [10303]","First Health",,4452,80,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM LOCK STERILE",SUP-2361-5040S,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.05,506.11,"FIRST HEALTH [10303]","First Health",,1349.64,80,,,,,0,196.2,1433.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET TITANIUM 5.5-6MM SOLERA SEXTANT CD HORIZON",SUP-5540430,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"KAISER [10500]",Kaiser,,1612.42,67,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM 10-12MM POD",SUP-RBYPOD12,CDM,S27800098,LOCAL,0278,RC,,,both,,,11661.00,3498.3,"UHC [10700]","United Healthcare",,7381.41,63.3,,,,,0,1356.17,9911.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.190,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,197.05,28.62,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ZUMA 100CM 6FR EBV4.5 CURVE GUIDING CORONARY SIDEHOLE",SUP-Z26EBU45,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Set Rad Ther Field Int",PX-333000005,CDM,77285,CPT,0333,RC,,,both,,,1628.16,488.45,"AETNA [10100]","Aetna HMO/PPO",,1294.39,,"Per diem ($1,294.39). Each quantity on the visit service is paid its own per diem rate. Each eligible service on a given day will be paid its own per diem rate. Maximum number of claim lines to pay is 3.",,,,0,189.36,1628.16,other,"OP RAD THER SERVICE LIMIT 3 Zero final payments for the item or service in the 15 months prior to posting the file."
".035 INTERLOCK 2D 18MM X 40CM",SUP-M001363670,CDM,C1725,HCPCS,0272,RC,,,both,,,5181.90,1554.57,"KAISER [10500]",Kaiser,,3471.87,67,,,,,0,602.65,4404.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 26CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155243180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,,,,,,,189.34,1383.8,"percent of total billed charges",
"BIT DRILL LAG META-TAN",SUP-7163-1432,CDM,S27200284,LOCAL,0272,RC,,,both,,,3289.50,986.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1351.98,41.1,,,,,0,382.57,2796.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK 4.5CM ANTERIOR SINUS NASAL RAPID RHINO 6MM",SUP-RR450,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 80CM 40MM 7MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV07004008P,CDM,C1725,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5489.64,68,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 5MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630305,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]","Cigna Open Access",,4397.63,33.5,,5302.19,4377.88,6578.61,27,1526.7,11158.16,"percent of total billed charges",
"5.5X80MM MIS BULLETED LORDOSED ROD",SUP-62210-080,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross HMO",,1728.72,39.2,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 60CM HEMOSTASIS GWIRE SWARTZ .032IN SL1",SUP-406849,CDM,C1893,HCPCS,0272,RC,,,both,,,1178.55,353.56,"PHCS [10601]",PHCS,,824.99,70,,,,,0,137.07,1001.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 5MM XLONG 50MM 7.3MM SHILEY PEDIATRIC CUFF TAPE",SUP-5.0PLCF,CDM,S27200284,LOCAL,0272,RC,,,both,,,475.23,142.57,"AETNA [10100]","Aetna HMO/PPO",,377.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.27,403.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL LUMBAR ALIF ANTERIOR CONVEX 12 DEGRE",SUP-12421,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"KAISER [10500]",Kaiser,,12663,67,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR ENDOSCOPIC DIA12MM 100MM NON BLADED STABILITY SLEEVE",SUP-B12LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"PHCS [10601]",PHCS,,109.62,70,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14.3CM 7MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR180714,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"AETNA [10100]","Aetna HMO/PPO",,9446.03,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM SOLERA CD HORIZON SPINE MULTIAXIAL",SUP-54850017550,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,776.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,762.35,5571.75,"percent of total billed charges",
"HC Instant Wave Free Ratio Add",PX-481000373,CDM,93799,CPT,0481,RC,,,both,,,1734.36,520.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,205.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,201.71,1734.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM CD HORIZON VOYAGER SPINE NONSTERILE",SUP-55850047545,CDM,C1713,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2122.89,28.62,,,,,0,862.66,6304.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS MULTIPASS 3-0 PS-2 27IN BRAID COATED UNDYED",SUP-VCP427H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM LCP STAINLESS STEEL T14 CORTEX SELF TAP",SUP-02.206.232,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"CIGNA [10200]","Cigna Local Plus",,173.33,53.5,,3978.14,359.25,3978.14,24,37.68,275.39,"percent of total billed charges",
"KIT VENTRICULOSTOMY EUROPEAN VERSION",SUP-46154,CDM,S27200284,LOCAL,0272,RC,,,both,,,2803.43,841.03,"PHCS [10601]",PHCS,,1962.4,70,,,,,0,326.04,2382.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET",RX-7555,CDM,,,0637,RC,60687-0614-11,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FIRMAP 153CM 8.5FR 50MM 50MM MAPPING 64 ELECTRD TOPERA",SUP-USAR064050,CDM,C1732,HCPCS,0272,RC,,,both,,,30870.00,9261,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"METER DRNG BARD EZ-LOK URETERAL URINE ADPTR 400ML ACCEPTS",SUP-001531,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.43,20.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) DORAYA DEVICE",SUP-40-0002,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY NERVE BLOCK 3.25IN 18GA 20GA PAJUNK E-CATH 21GA",SUP-TDL112,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL NERVE BLOCK 100MM 18GA 20GA SONOLONG SONOLONG SONO",SUP-521187-31C,CDM,C9814,HCPCS,0272,RC,,,both,,,510.30,153.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRNQT SURGICAL 42IN ATS",SUP-60-7075-157R,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 3.5MM 16MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0259,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,110.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",110.22,805.55,"percent of total billed charges",
"SUT FIBERTAPE FIBERWIRE 2 TAPER 54IN BRAID BLUE 36INX2MM",SUP-AR-7237,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.03,267.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,607.26,68,,,,,0,103.86,759.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP FOGARTY HYDRAGRIP 61MM SOFTJAW SET ATRAUMATIC",SUP-SOFT61,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.35,28,"NOVANET [10819]",Novanet,,70.01,75,,,,,0,10.86,79.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8.5MM 12/14 TAPER 36MM HIP CEMENTLESS BIOLOX",SUP-136536330,CDM,C1776,HCPCS,0278,RC,,,both,,,7222.32,2166.7,"CIGNA [10200]","Cigna Open Access",,4109.5,56.9,,5302.19,4377.88,6578.61,27,839.96,6138.97,"percent of total billed charges",
"SCR BONE 5MM 30MM NAIL-EX TITANIUM TIBIAL 2 CORE LOCKING",SUP-04.015.520,CDM,C1713,HCPCS,0278,RC,,,both,,,1313.17,393.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,152.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",152.72,1116.19,"percent of total billed charges",
"TRIATHLON PS X3 TIBIAL INSERT",SUP-5532-G-811-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"KAISER [10500]",Kaiser,,7646.44,67,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX SEPRA 10X5IN MONOFILAMENT RESORBABLE",SUP-1201325,CDM,C1781,HCPCS,0278,RC,,,both,,,39253.41,11776.02,"MULTIPLAN [10600]",Multiplan,,33365.4,85,,,,,0,4565.17,33365.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 14X3MM COLOSSEUM 0D 12MM NONSTERILE LATEX",SUP-156.253,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"KAISER [10500]",Kaiser,,2306.48,67,,,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 4.0/13",SUP-401740,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,9776.84,9776.84,9776.84,"1 through 10",521.61,3812.25,"percent of total billed charges",
"SCR BONE 3MM 38MM 16MM STAINLESS STEEL CANCELLOUS FOOT HAND",SUP-02.226.138,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"NOVANET [10819]",Novanet,,1233.9,75,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Homocysteine",PX-301000234,CDM,83090,CPT,0301,RC,,,both,,,343.90,103.17,"BLUE CROSS [10001]","Blue Cross PPO",,22.89,,"Fee schedule rate ($22.89).",,,,0,0.01,292.32,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE ENDOSCOPIC LARGE HEXAGONAL L230 CM OD25 MM ODSEC7 FR H",SUP-PS52041,CDM,S27200284,LOCAL,0272,RC,,,both,,,57.42,17.23,"NOVANET [10819]",Novanet,,43.07,75,,,,,0,43.07,43.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II MULTIPASS 4-0 PS-2 18IN MONOFILAMENT VIOLET",SUP-Z513G,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.55,19.96,"CIGNA [10200]",Cigna,,45.25,68,,,,,0,7.74,56.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +21 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.210,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR JUDKINS LEFT 4.5",SUP-67000600,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"MULTIPLAN [10600]",Multiplan,,354.96,85,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 560CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCX-560,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2162.38,28.62,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE ULTRA THIN 76X50X.85MM POLYETHYLENE",SUP-7212,CDM,C1763,HCPCS,0278,RC,,,both,,,4104.53,1231.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,486.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,477.36,3488.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 90CM 40MM 6MM .014IN BALLOON DILATATION",SUP-AB14W060040090,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,164.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 18MM 4MM CORONARY STENT COCR RAPID",SUP-1007850-18,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 76MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.076TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"SPACER ALLOGRAFT 30X17MM LUMINARY 10-11MM SPINE",SUP-14717,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"NOVANET [10819]",Novanet,,23625,75,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 2 9MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530-P-209,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"MULTIPLAN [10600]",Multiplan,,7102.52,85,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23MMX11MM ELEVATE STD PEEK TITANIUM STERILE",SUP-7771123,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8113.77,28.62,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 235MM 16MM MODULAR RESTORATION BOWED CONICAL",SUP-6276-7-316,CDM,C1776,HCPCS,0278,RC,,,both,,,12862.80,3858.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5286.61,41.1,,6417.48,6417.48,6417.48,"1 through 10",1495.94,10933.38,"percent of total billed charges",
"COIL EMBOLIZATION 30CM 7MM AXIUM 3D FRAME V01",SUP-FC-7-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,13765.50,4129.65,"BLUE CROSS [10001]","Blue Cross PPO",,5396.08,39.2,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN ADULT DORO STRONG PROTECTIVE CAP FURROWED GRIP UNIQUE",SUP-3006-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.04,27.91,"CIGNA [10200]","Cigna Local Plus",,49.78,53.5,,,,,0,10.82,79.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RECONNAISSANCE VASCULAR PV .018 IN OTW",SUP-018OTW,CDM,C1753,HCPCS,0272,RC,,,both,,,5002.50,1500.75,"AETNA [10100]","Aetna HMO/PPO",,3976.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN LOCK-OUT PUMP SET INFLAT SELF CONTAIN",SUP-ES2920,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7429.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 9MM 9FR ENDOPROSTHESIS HEPARIN",SUP-VBH091002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21142.80,6342.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6051.07,28.62,,,,,0,2458.91,17971.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXIMA 70CM 5FR URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002361,CDM,C1758,HCPCS,0272,RC,,,both,,,80.01,24,"AETNA [10100]","Aetna HMO/PPO",,63.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.31,68.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal Uni W Pta Init",PX-361000156,CDM,37228,CPT,0361,RC,,,both,,,14777.16,4433.15,"CIGNA [10200]","Cigna Local Plus",,6044,,"Case rate ($6,044). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1718.58,12560.59,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-105634,CDM,,,0250,RC,00409-9045-16,NDC,both,30,ML,36.01,10.8,"MULTIPLAN [10600]",Multiplan,,30.61,85,,,,,0,4.19,30.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.0MM PHALANX LNTRAMEDULLARY NAIL 3MM X 27.5MM TI",SUP-IHFN-PHX-30027,CDM,C1713,HCPCS,0278,RC,,,both,,,8052.30,2415.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5475.56,68,,,,,0,936.48,6844.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 FS-1 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8684G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PERFORM STEM RSA-PERF REV STD",SUP-CAP1188,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"BLUE CROSS [10001]","Blue Cross HMO",,17781.12,39.2,,5311.50,4717.44,5388.59,31,5275.37,38556,"percent of total billed charges",
"HEAD UNIPOLAR 60MM CATHCART BALL HIP FEMORAL ORTHOCHROME",SUP-136360000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 100CM 6.7FR GPC CURVE ANGIOGRAPHIC POLYETHYLENE",SUP-G00174,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.19,73.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,167.41,68,,,,,0,28.63,209.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 5-0 P-3 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J493H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW OXFORD CEMENTED",SUP-506298,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 17MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-017,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,561.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,550.92,4026.54,"percent of total billed charges",
"SN6AT3.8 SP AS TORIC IQ REFERENCE",SUP-SN6AT3.8,CDM,V2632,HCPCS,0276,RC,,,both,,,3712.50,1113.75,"BLUE CROSS [10001]","Blue Cross HMO",,1455.3,39.2,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE EXPRT GPS 40MM 135CM 7MM 6FR STRAIGHT VASCULAR",SUP-SECX-7-40-135,CDM,C1876,HCPCS,0278,RC,,,both,,,12420.00,3726,"CIGNA [10200]",Cigna,,4968,40,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 15X18MM DYNANITE SUPERMX NITINOL COMPRESSION LOW",SUP-AR-8719MXDS-1815,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,1831.33,1831.33,1831.33,16,2014.9,14726.25,"percent of total billed charges",
"BASKET STONE RETRIEVAL 90CM 20MM 4.5FR SEGURA HEMISPHERE",SUP-M0063801180,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"NOVANET [10819]",Novanet,,1109.66,75,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 520CC 12.3CM 6CM PROJECTION HIGH PROFILE SMOO",SUP-SHPB520,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5184.66,68,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL BABCOCK STRAIGHT 9 3/8IN INTESTINAL SERRATE",SUP-50-1123,CDM,S27200284,LOCAL,0272,RC,,,both,,,1023.19,306.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,119,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,119,869.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 4CM 9MM BALLOON DILATATION OTW LOW",SUP-G30978,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL KNEE 2 POROUS/HYBRID DEPUY - ATTUNE FIXED BEARING",SUP-CAP-K-2,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"KAISER [10500]",Kaiser,,12663,67,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X11X6MM COROENT 5D SMALL PEEK NONSTERILE LATEX",SUP-6806714,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 1 XLH 30IN 2 ARM BRAID GREEN",SUP-X190G,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.89,23.67,"AETNA [10100]","Aetna HMO/PPO",,62.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.17,67.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS",029,MS-DRG,,,,,,,inpatient,,,151883.42,45565.03,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,22432.11,,"Case rate ($21,162.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $19,650.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,690.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,867.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $19,676.67. The transfer operating threshold is the transfer adjustment factor * $19,650.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,485.69. The transfer capital threshold is the transfer adjustment factor * $1,485.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,99605.07,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 20MM 3MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012407-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thyroxine Bind Globulin (Tbg)",PX-301000413,CDM,84442,CPT,0301,RC,,,both,,,209.00,62.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.82,,"Fee schedule rate ($15.82). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,177.65,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"5FR SILICONE DUEL LUMEN UMBILICAL CATHETER",SUP-S2UVC-536,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.19,90.06,"CIGNA [10200]",Cigna,,204.13,68,,,,,0,34.91,255.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 BUCK EAR ANGLED SHARP SURGICAL",SUP-380213,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.07,40.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,61.54,45.9,,,,,0,15.59,113.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ON-Q I-FLOW 4ML/HOUR DRUG DELIVERY DEHP 270ML CUSTOM",SUP-P270X4D,CDM,C9804,HCPCS,0272,RC,,,both,,,1066.53,319.96,"PHCS [10601]",PHCS,,746.57,70,,,,,0,124.04,906.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRA-THIN SDS 75CM 40MM 5.8FR 10MM STD BALLOON",SUP-M001177360,CDM,C1725,HCPCS,0272,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL MODULUS 7 D L17 MM X W14 MM X H8 MM CERVICAL STE",SUP-67940038P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2850.39,45.9,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 12X3IN WRIST PRECUT IMMOB ROLL WRINKLE",SUP-OG-3PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,44.25,13.27,"CIGNA [10200]","Cigna Local Plus",,23.67,53.5,,,,,0,5.15,37.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 30MM 7MM STAINLESS STEEL 1.1MM SHORT THREAD",SUP-02.226.030,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,194.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,191.34,1398.42,"percent of total billed charges",
"INSRT SURGICAL 97.5MM 1.2MM RICHARDS T STAINLESS STEEL TUBE",SUP-130549,CDM,S27200284,LOCAL,0272,RC,,,both,,,2084.55,625.36,"FIRST HEALTH [10303]","First Health",,1667.64,80,,,,,0,242.43,1771.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.106,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"BLUE CROSS [10001]","Blue Cross HMO",,336.06,39.2,,957.42,156.86,7483.26,51,99.7,728.71,"percent of total billed charges",
"CATH ADMIRAL XTREME 130CM 80MM 7MM BALLOON DILATATION",SUP-ADM070080130,CDM,C1725,HCPCS,0272,RC,,,both,,,1134.00,340.2,"MULTIPLAN [10600]",Multiplan,,963.9,85,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIDENT X3 ELEVATED RIM 36MM ID",SUP-743-00-36E,CDM,C1776,HCPCS,0278,RC,,,both,,,9915.30,2974.59,"KAISER [10500]",Kaiser,,6643.25,67,,,,,0,1153.15,8428.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE AXON TITANIUM SPINE LOCK STARDRIVE NONSTERILE",SUP-406.104,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,1144.80,304.56,2275.09,66,50.59,369.75,"percent of total billed charges",
"SUT STAINLESS STEEL TAPERCUT 6 V-40 18IN MONOFILAMENT 4",SUP-M649G,CDM,S27200284,LOCAL,0272,RC,,,both,,,152.96,45.89,"CIGNA [10200]",Cigna,,104.01,68,,,,,0,17.79,130.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 200MM 6MM BALLOON",SUP-U3575620,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT GREEN 44X4IN EXPRESSAIRE XLONG LEG 1 FILL LINE 1",SUP-A70107012,CDM,S27200284,LOCAL,0272,RC,,,both,,,473.57,142.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,56.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.08,402.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 0 CT-2 9IN CLSR UNIDIRECTIONAL",SUP-SXPP1A446,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"CIGNA [10200]","Cigna Open Access",,136.73,56.9,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE 100CM 6FR AMPLATZ RIGHT MODIFIED CURVE",SUP-532648,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Methotrexate",PX-301000077,CDM,80299,CPT,0301,RC,,,both,,,425.60,127.68,"FIRST HEALTH [10303]","First Health",,340.48,80,,,,,0,0.01,361.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMB FIXATION MAXFRAME RETENTION BAND",SUP-03.313.886,CDM,C1713,HCPCS,0278,RC,,,both,,,459.76,137.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,53.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",53.47,390.8,"percent of total billed charges",
"(EVAL) EDWARDS PASCAL TRANSCATHETER VALVE REPAIR SYSTEM -IMP",SUP-10000ISMCL,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"AETNA [10100]","Aetna HMO/PPO",,135945,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12MM NATURAL LARGE LORDOTIC",SUP-19412,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM PRIMARY HEMISPHERICAL CLUSTER HOLE",SUP-502-03-48C,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"UHC [10700]","United Healthcare",,6625.5,63.3,,8601.07,8395.67,8601.07,"1 through 10",1217.29,8896.8,"percent of total billed charges",
"SCR BONE 6.5MM 35MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850016535,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"KAISER [10500]",Kaiser,,4391.85,67,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 7MMX79MM 7FR 80CMCATH HEPARIN",SUP-BXB077901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"BLUE CROSS [10001]","Blue Cross PPO",,8391.7,39.2,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS AIM 59MM 2.46MM 8FR UNIVERSAL GUIDE II SLITTABLE",SUP-DS2N101-59,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT SARA PLUS LIFT",SUP-MFA4000,CDM,S27000186,LOCAL,0270,RC,,,both,,,139.90,41.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,64.21,45.9,,,,,0,16.27,118.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 100MM 4MM BALLOON DILATATION RAPID",SUP-47540100L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X20MM COLOSSEUM 14MM MESH NONSTERILE LATEX",SUP-156.505,CDM,S27800098,LOCAL,0278,RC,,,both,,,28343.70,8503.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3358.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3296.37,24092.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP LATIS STEALTH 5 90MM MESH LATEX FREE",SUP-A0C04,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036122030,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 8FR 19CM LATEX FREE VESSEL ACCEPTS .038IN GWIRE",SUP-504508X,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.26,26.18,"CIGNA [10200]",Cigna,,59.34,68,,,,,0,10.15,74.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC",700,MS-DRG,,,,,,,inpatient,,,32478.87,9743.66,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,4407.87,,"Case rate ($4,279.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,973.80, add-ons for qualifying new technology services are included. If operating cost exceeds $37,013.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,682.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,979.05. The transfer operating threshold is the transfer adjustment factor * $3,973.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $300.44. The transfer capital threshold is the transfer adjustment factor * $300.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4279.49,17205.42,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.5CM NATRELLE INSPIRA P2.5CM LOW PROFILE ROUND",SUP-MSZ-L260,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.69,42.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CAMERA ENDOSCOPIC DA VINCI SP",SUP-430077,CDM,S27000186,LOCAL,0270,RC,,,both,,,6272.73,1881.82,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DRNG 23CM 4FR STD VENTRICULAR BARIUM IMPREGNATED SHUNT",SUP-41101,CDM,C1729,HCPCS,0272,RC,,,both,,,1143.07,342.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BONE BIOPSY IVAS 10GA",SUP-0306-104-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,855.37,256.61,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INFECTIONS OF UPPER RESPIRATORY TRACT,MODERATE",113,APR-DRG,,,,,,,inpatient,,,23085.50,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $3,032.66. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%.",,,,0,,,other,"SOI-2 Shortstay; Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),EXTREME",009,APR-DRG,,,,,,,inpatient,,,770351.26,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $161,663.03. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($730,431.36) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"MALFUNCTION, REACTION, COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE,EXTREME",206,APR-DRG,,,,,,,inpatient,,,229939.99,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $10,779.27. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($88,645.91) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA,MAJOR",691,APR-DRG,,,,,,,inpatient,,,72525.60,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $10,147.20. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($95,787.49) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 16MM 144CM 2.5MM CORONARY STENT",SUP-H7493941816250,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRAUMA FIXATION 85MM META-TAN INTEGRATE LAG COMPRESSION",SUP-71642685,CDM,C1713,HCPCS,0278,RC,,,both,,,4950.06,1485.02,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2272.08,45.9,,,,,0,575.69,4207.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 85MM 6MM CURVE TITANIUM SOFT NORMALIZE NONSTERILE",SUP-498.143,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML INJECTABLE SUPERORDERABLE",RX-1171150,CDM,J2919,HCPCS,0636,RC,00009-0047-25,NDC,both,1,UN,94.38,28.31,"FIRST HEALTH [10303]","First Health",,75.5,80,,,,,0,6.12,80.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127D 5 30MM CONDYLAR STABILIZED NECK OMNIFIT",SUP-6097-0530,CDM,C1776,HCPCS,0278,RC,,,both,,,10292.40,3087.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2945.68,28.62,,,,,0,1197.01,8748.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 08.5",SUP-DIB00U0085,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 12.5X13CM 375ML STYLE FF HIGHLY COHESIVE GEL",SUP-FF-410375,CDM,C1789,HCPCS,0278,RC,,,both,,,8280.00,2484,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2369.74,28.62,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRIMARY KNEE/PARTIAL KNEES (KNEE CONSTRUCT)",SUP-CAP-OI-K-1,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,5311.50,4717.44,5388.59,31,2014.9,14726.25,"percent of total billed charges",
"STENT VIABAHN 5CM 75CM 6MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR060501A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4838.21,28.62,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (OTW)  2.00MM X 6MM",SUP-H74939402062000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"FIRST HEALTH [10303]","First Health",,4333.2,80,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ileoscopy W Polypectomy",PX-750000243,CDM,44799,CPT,0750,RC,,,both,,,3746.37,1123.91,"UHC [10700]","United Healthcare",,3746.37,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,435.7,3746.37,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT LARGE SOLO HIGHBACK 25",SUP-P3525916-2,CDM,S27000186,LOCAL,0270,RC,,,both,,,308.50,92.55,"KAISER [10500]",Kaiser,,206.7,67,,,,,0,35.88,262.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP LIMIT HOLE FIN RINGLOC+ 24 STERILE",SUP-16-104156,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"NOVANET [10819]",Novanet,,5278.5,75,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 5-0 C-1 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-K895H,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.31,23.19,"FIRST HEALTH [10303]","First Health",,61.85,80,,,,,0,8.99,65.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 40MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PHCS [10601]",PHCS,,1116.99,70,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Ctrl Bld",PX-750000079,CDM,45334,CPT,0750,RC,,,both,,,3094.10,928.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2292.95,,"Case rate ($2,292.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,359.84,3094.1,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAMADOL 50 MG TABLET, IMMEDIATE RELEASE",RX-14632,CDM,,,0637,RC,60687-0795-11,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,3.57,56.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 48IN 8FR ANTICLOG BOW TIP BOLUS WITHOUT",SUP-40-1368,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.72,17.02,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,26.03,45.9,,,,,0,6.6,48.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL LUMBAR BUTTRESS 6MM X 27.5MM SELF DRILLING VARI",SUP-1236.3127,CDM,C1713,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,392.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",392.51,2868.75,"percent of total billed charges",
"SCR INTERFERENCE BIOCOMPOSITE 30MM 7MM FASTTHREAD",SUP-AR-4030C-07,CDM,C1713,HCPCS,0278,RC,,,both,,,2323.13,696.94,"AETNA [10100]","Aetna HMO/PPO",,1846.89,79.5,,1521.93,481.35,16760.95,30,270.18,1974.66,"percent of total billed charges",
"FRCP BIOPSY SHORT TOOTH",SUP-NF03,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.32,22.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,34.57,45.9,,,,,0,8.76,64.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 6FR POWERLINE 2 LUMEN POWER INJECTABLE",SUP-0700615,CDM,C1751,HCPCS,0272,RC,,,both,,,1860.00,558,"AMERIGROUP MEDICAID [20100]",Amerigroup,,220.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,216.32,1581,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C1 Esterase Inh",PX-302000020,CDM,86160,CPT,0302,RC,,,both,,,303.50,91.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.3,.1,,,,,0,0.3,257.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 36MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR36,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5388.21,41.1,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP 55.9CM 8MM DA VINCI S/SI ENDOWRIST 45- D LARGE",SUP-420230,CDM,S27000186,LOCAL,0270,RC,,,both,,,700.41,210.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,321.49,45.9,,,,,0,81.46,595.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION",RX-1649,CDM,J3230,HCPCS,0636,RC,00641-1397-31,NDC,both,1,ML,226.52,67.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,29.45,,,,,,,9.53,192.54,"fee schedule",
"SENSOR EMG PATHWAY STIM VAGINAL RECTAL",SUP-2959,CDM,S27200284,LOCAL,0272,RC,,,both,,,333.47,100.04,"MULTIPLAN [10600]",Multiplan,,283.45,85,,,,,0,38.78,283.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 110MM 7 HOLE LOW PROFILE BONE RIGHT OLECRANON",SUP-70-0307,CDM,C1713,HCPCS,0278,RC,,,both,,,7051.80,2115.54,"CIGNA [10200]","Cigna Local Plus",,3772.71,53.5,,3978.14,359.25,3978.14,24,820.12,5994.03,"percent of total billed charges",
"(EVAL) PREVAIL DCB 2.50X30MM",SUP-PRV025030CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 26MM MODULAR RESTORATION HA STRAIGHT CONE",SUP-6276-7-026,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,5873.17,5873.17,5873.17,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"HC Porphobilinogen Urine Qual",PX-301000613,CDM,84106,CPT,0301,RC,,,both,,,55.00,16.5,"KAISER [10500]",Kaiser,,36.85,67,,,,,0,0.01,46.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Porphobilinogen Urine Qual",PX-301000613,CDM,84106,CPT,0301,RC,,,both,,,55.00,16.5,"UHC [10700]","United Healthcare",,5.24,,,,,,,0.01,46.75,"fee schedule",
"HC Porphobilinogen Urine Qual",PX-301000613,CDM,84106,CPT,0301,RC,,,both,,,55.00,16.5,"FIRST HEALTH [10303]","First Health",,44,80,,,,,0,0.01,46.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 10CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061751950,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]","Cigna Open Access",,513.34,,,,,,,104.92,766.85,"percent of total billed charges",
"LENS IOL 23.5 DIOPTER",SUP-SV25T0,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"KAISER [10500]",Kaiser,,499.15,67,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 9X20 135CM SL",SUP-48009002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,101.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL XS UNIVERSAL 23MM KNEE HINGE LPS",SUP-198727123,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"FIRST HEALTH [10303]","First Health",,23637.1,80,,,,,0,3436.24,25114.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ugt1a1 Gene",PX-309000077,CDM,81350,CPT,0310,RC,,,both,,,322.40,96.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,115.59,,"Fee schedule rate ($115.59). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,322.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UNI-FUSE FLOW-THRU HUB 135CM 40CM 5FR THROMBECTOMY",SUP-12401815,CDM,C1757,HCPCS,0272,RC,,,both,,,3112.50,933.75,"UHC [10700]","United Healthcare",,1970.21,63.3,,,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR/ELEV LAPAROSCOPIC 34MM VCARE PLUS CUP CERVICAL",SUP-60-6085-201A,CDM,S27200284,LOCAL,0272,RC,,,both,,,522.45,156.73,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC",574,MS-DRG,,,,,,,inpatient,,,85510.30,25653.09,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Hemodialysis Temp",PX-E27200058,CDM,C1752,HCPCS,0272,RC,,,both,,,941.16,282.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MALECOT 52CM 20FR 8FR NEPHRSTMY PERCUFLEX STENTING",SUP-M001224200,CDM,C1729,HCPCS,0272,RC,,,both,,,599.40,179.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET INTRO 23CM 6FR CHECK-FLO FLEXOR .018IN RADIAL ARTERY",SUP-G11605,CDM,C1894,HCPCS,0272,RC,,,both,,,312.33,93.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 87.5MM 4.2MM STAINLESS STEEL STERILE",SUP-180023000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 200CM 150MM 3MM BALLOON DILATATION RAPID",SUP-47530150L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE V-LOC 2-0 GS-21 6IN CLSR NONABSORBABLE BLUE",SUP-VLOCN0305,CDM,S27200284,LOCAL,0272,RC,,,both,,,211.85,63.55,"UHC [10700]","United Healthcare",,134.1,63.3,,,,,0,24.64,180.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 5.5MM CURVE TITANIUM NONSTERILE",SUP-1553201090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT VITOSS BIOACTIVE",SUP-2102-2101,CDM,C1713,HCPCS,0278,RC,,,both,,,4865.60,1459.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1392.53,28.62,,,,,0,565.87,4135.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 19MM 52MM SHOULDER AEQUALIS ASCEND FLEX COCR 4",SUP-DWF152,CDM,C1776,HCPCS,0278,RC,,,both,,,10004.00,3001.2,"BLUE CROSS [10001]","Blue Cross PPO",,3921.57,39.2,,3949.44,3949.44,3949.44,"1 through 10",1163.47,8503.4,"percent of total billed charges",
"PLATE BROAD 8IN STAINLESS STEEL 4.5MM SCREWS 7 HOLE 8 GROOVE",SUP-3704-3-110,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"CIGNA [10200]","Cigna Local Plus",,1203.75,53.5,,3978.14,359.25,3978.14,24,261.68,1912.5,"percent of total billed charges",
"TUBE CHEST INSERTION TRAY",SUP-23-9608C,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.11,67.83,"FIRST HEALTH [10303]","First Health",,180.89,80,,,,,0,26.3,192.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 24MM 52MM 50MM SHOULDER COMPREHENSIVE",SUP-113055,CDM,C1776,HCPCS,0278,RC,,,both,,,9089.00,2726.7,"PHCS [10601]",PHCS,,6362.3,70,,,,,0,1057.05,7725.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEIGHT EYELID THK1MM GOLD CONTOUR 12.3X5MM 1GM SPHERICAL","SUP-LL 3010",CDM,L8699,HCPCS,0278,RC,,,both,,,1987.50,596.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,912.26,45.9,,,,,0,231.15,1689.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 18MM ACUTRAK 2 TITANIUM MINI ORTHOPEDIC STERILE",SUP-AT2-M18-S,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"NOVANET [10819]",Novanet,,2390.63,75,,,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC LARGE 24IN 19-22IN KNEE CONTACT CLSR",SUP-79-80037,CDM,S27000186,LOCAL,0270,RC,,,both,,,117.10,35.13,"NOVANET [10819]",Novanet,,87.83,75,,,,,0,13.62,99.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 200MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040200S,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"MULTIPLAN [10600]",Multiplan,,1593.75,85,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 10CM CHIBA ASPIRATION STERILE DISPOSABLE",SUP-G01559,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.31,31.29,"FIRST HEALTH [10303]","First Health",,83.45,80,,,,,0,12.13,88.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR HD 36CM 11-13FR ACCESS STAINLESS STEEL",SUP-M0062502220,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR EXTRA BACKUP LAD 4",SUP-67006300,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH INTRO GREEN 23CM 6FR BRITE TIP CANN INTERVENTIONAL",SUP-401623M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE PLIAFORM STARCAST 135CM 12CM 8MM BALLOON",SUP-G52283,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STALIF L FLX 18MM 65CM THROMBECTOMY INTRILL",SUP-43-102,CDM,C1757,HCPCS,0272,RC,,,both,,,15180.00,4554,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH TREK 145CM 15MM 3MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012274-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) WISE PULSE GENERATOR BATTERY","SUP-MODEL 3100",CDM,S62400003,LOCAL,0624,RC,,,both,,,31500.00,9450,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 4CM 5.8FR 30FR BALLOON",SUP-M0062251050,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WAX BONE 2CC MONTAGE STERILE LATEX FREE DISPOSABLE",SUP-OS-MON-1604,CDM,S27200284,LOCAL,0272,RC,,,both,,,20840.40,6252.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"7F DECA 4-4-4 PV15 110CM",SUP-901642,CDM,C1730,HCPCS,0272,RC,,,both,,,5692.50,1707.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,674.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D MODIFIED L BICONVEX 13MM 6MM POSTERIOR CHMBR 1",SUP-SN60AT,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 7-8 18MM KNEE POSTERIOR STABILIZE HIGH",SUP-71421526,CDM,C1776,HCPCS,0278,RC,,,both,,,10774.35,3232.3,"CIGNA [10200]",Cigna,,7326.56,68,,5873.17,5873.17,5873.17,"1 through 10",1253.06,9158.2,"percent of total billed charges",
"LENS IOL +19 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0190,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Local Plus",,715.03,53.5,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prolactin",PX-301000375,CDM,84146,CPT,0301,RC,,,both,,,394.00,118.2,"MULTIPLAN [10600]",Multiplan,,334.9,85,,,,,0,0.01,334.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 80MM 6FR 12MM .035IN LOW PROFILE BALLOON",SUP-B1120-080,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"PHCS [10601]",PHCS,,538.65,70,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thyroxine Bind Globulin (Tbg)",PX-301000413,CDM,84442,CPT,0301,RC,,,both,,,209.00,62.7,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,177.65,"per diem",
"HC Tube Feeding Ng",PX-E27200223,CDM,E27200223,LOCAL,0272,RC,,,both,,,225.50,67.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,92.68,41.1,,,,,0,26.23,191.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RECTANGULAR SHANNON BURR 2.0MM X 20MM (STERILE)",SUP-CD-BS-4220-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,2880.00,864,"CIGNA [10200]",Cigna,,1958.4,68,,,,,0,334.94,2448,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 SH 27IN CONTROL RELEASE BRAIDED 8 STRAND",SUP-VCP785D,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.21,38.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.03,109.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER KIT FOR IMPELLA 2.5",SUP-0052-0007,CDM,S27800098,LOCAL,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross HMO",,1893.36,39.2,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 130MM 11.7MM 8MM ADJUSTABLE NECK FLANGE CLIP IN OBTR",SUP-75HA80,CDM,S27200284,LOCAL,0272,RC,,,both,,,1619.19,485.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1101.05,68,,,,,0,188.31,1376.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 300MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.640S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"BLUE CROSS [10001]","Blue Cross PPO",,3258.47,39.2,,957.42,570.23,957.42,28,966.74,7065.57,"percent of total billed charges",
"SIZER IMPL 14.5CM NATRELLE INSPIRA P6.7CM EXTRA FULL PROFILE",SUP-MSZ-X750,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"FIRST HEALTH [10303]","First Health",,126.54,80,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 50MM AXSOS STAINLESS STEEL T15 FEMUR HUMERUS",SUP-371550,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,408.97,45.9,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 56MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.556,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"BLUE CROSS [10001]","Blue Cross HMO",,429.8,39.2,,957.42,156.86,7483.26,51,127.51,931.96,"percent of total billed charges",
"DEVICE OLCOTT .014-.045IN TORQUE HYDROPHILIC 1 HAND GWIRE",SUP-G13811,CDM,C1769,HCPCS,0272,RC,,,both,,,132.59,39.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,54.49,41.1,,,,,0,15.42,112.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALIPER SURGICAL 4IN 3MM NARROW FLAT JAMESON",SUP-60-1934,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.92,161.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,365.79,68,,,,,0,62.56,457.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X16MM COLOSSEUM 12MM MESH NONSTERILE LATEX",SUP-156.204,CDM,S27800098,LOCAL,0278,RC,,,both,,,27184.50,8155.35,"UHC [10700]","United Healthcare",,17207.79,63.3,,,,,0,3161.56,23106.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 4-0 STD ANGLE MICRO 9IN HOLLOW HANDLE SURGICAL 3X2.1MM",SUP-RN0987,CDM,S27200284,LOCAL,0272,RC,,,both,,,842.56,252.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,346.29,41.1,,,,,0,97.99,716.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 2-0 STP-10 27IN 2 ARM MONOFILAMENT VIOLET",SUP-Z997G,CDM,S27200284,LOCAL,0272,RC,,,both,,,202.71,60.81,"FIRST HEALTH [10303]","First Health",,162.17,80,,,,,0,23.58,172.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE CRESCENT 165CM 2MM 25MM SNAREMASTER 2 WIRE ENDOSCOPIC",SUP-SD-221L-25,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.82,51.85,"CIGNA [10200]","Cigna Local Plus",,92.46,53.5,,,,,0,20.1,146.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Glomerular Filtration",PX-340000002,CDM,78725,CPT,0340,RC,,,both,,,966.87,290.06,"BLUE CROSS [10001]","Blue Cross HMO",,0.97,.1,,,,,0,0.97,966.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE CRESCENT 165CM 2MM 25MM SNAREMASTER 2 WIRE ENDOSCOPIC",SUP-SD-221L-25,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.82,51.85,"CIGNA [10200]","Cigna Open Access",,98.33,56.9,,,,,0,20.1,146.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 90CM ENDOTAK RELIANCE G HELIX ENDOCARDIUM STEROID",SUP-187,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]","Cigna Local Plus",,4781.7,31.5,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM TSRH OSTEOGRIP TITANIUM SHORT SPINE",SUP-83555508,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.10,1106.73,"FIRST HEALTH [10303]","First Health",,2951.28,80,,,,,0,429.04,3135.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X3 HUMERAL INSERT - 36MM X 6MM STANDARD",SUP-5571-S-3606,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1194.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.125 CLAREON",SUP-SY60WF.125,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 8MMX8MMX6CM",SUP-TSB080806A,CDM,C1874,HCPCS,0278,RC,,,both,,,49140.00,14742,"AETNA [10100]","Aetna HMO/PPO",,39066.3,79.5,,,,,0,5714.98,41769,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cysto W/Rmvl FB/Stent Smpl",PX-510000101,CDM,52310,CPT,0761,RC,,,both,,,6622.89,1986.87,"KAISER [10500]",Kaiser,,4437.34,67,,,,,0,770.24,6277,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 86MM STAINLESS STEEL 2.7/3.5MM SCR 4 HOLE LCP",SUP-02.112.139S,CDM,C1713,HCPCS,0278,RC,,,both,,,3486.00,1045.8,"NOVANET [10819]",Novanet,,2614.5,75,,,,,0,405.42,2963.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE LESLIE PARACHUTE 120CM 11MM 3.1FR SPECIMEN RETRIEVAL",SUP-M0063203020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1464.48,439.34,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,601.9,41.1,,,,,0,170.32,1244.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE WHISPER LS VASCULAR J CURVE 190CM 3CM .014IN",SUP-1005351HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9FR 30CM NONVASCULAR DRNG CATH SILHOUETTE",SUP-G08315,CDM,C1892,HCPCS,0272,RC,,,both,,,526.42,157.93,"MULTIPLAN [10600]",Multiplan,,447.46,85,,,,,0,61.22,447.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 16MM 3.5MM EMBOLIZATION",SUP-PED2-350-16,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9574.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 20MM 2 HOLE CASCADIA CAYMAN BONE SPINE NONSTERILE",SUP-7908-42F203,CDM,C1713,HCPCS,0278,RC,,,both,,,31594.50,9478.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3674.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",3674.44,26855.33,"percent of total billed charges",
"CATH BERMAN 110CM 7FR 11MM .038IN ANGIOGRAPHIC 1.25ML 2",SUP-AI-07137,CDM,S27200284,LOCAL,0272,RC,,,both,,,2332.50,699.75,"NOVANET [10819]",Novanet,,1749.38,75,,,,,0,271.27,1982.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH VIZIGO INTRO STERILE LATEX FREE DISPOSABLE",SUP-D138502,CDM,C1766,HCPCS,0272,RC,,,both,,,6824.10,2047.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,793.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,793.64,5800.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 55MM 3.5MM LC-DCP CORTEX PELVIC STAINLESS STEEL",SUP-204.655,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"CIGNA [10200]","Cigna Open Access",,156.63,56.9,,1144.80,304.56,2275.09,66,32.01,233.98,"percent of total billed charges",
"BLADE SAW 29.5X7MM STRYKER THK.38MM MICRO OSCILLATE SAGITTAL",SUP-SM-3115,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 18IN ATS 1 PORT 1 BLADDER LUER LOCK CNCT STERILE",SUP-60707505300,CDM,S27200284,LOCAL,0272,RC,,,both,,,215.08,64.52,"UHC [10700]","United Healthcare",,136.15,63.3,,,,,0,25.01,182.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK 143CM 6MM 2.75MM ROUND BALLOON DILATATION",SUP-1012448-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JAGWIRE DREAM TIP ENDOSCOPIC 450CM 5CM .025IN",SUP-M00556561,CDM,C1769,HCPCS,0272,RC,,,both,,,932.72,279.82,"KAISER [10500]",Kaiser,,624.92,67,,,,,0,108.48,792.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SCR VERTEX M6 POSTERIOR SPINE TITANIUM",SUP-6950315,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"FIRST HEALTH [10303]","First Health",,1925.28,80,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE MEDIUM 230CM 2.8MM 15MM SNAREMASTER WIRE LOOP INTEGRAL",SUP-SD-240U-15,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.57,23.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,36.52,45.9,,,,,0,9.25,67.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STATSEAL POWDER",SUP-LP636,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"MULTIPLAN [10600]",Multiplan,,221.85,85,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PARALLEL FLEXOR 55CM 14FR ENDOSCOPIC HYDROPHILIC",SUP-G56443,CDM,C1894,HCPCS,0272,RC,,,both,,,1396.44,418.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,573.94,41.1,,,,,0,162.41,1186.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 31.5CM 8MM SUTURECUT ENDOWRIST DA VINCI XI 38D",SUP-470296,CDM,S27000186,LOCAL,0270,RC,,,both,,,16560.00,4968,"PHCS [10601]",PHCS,,11592,70,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MX523 ETHBOND 2-0",SUP-MX523,CDM,S27200284,LOCAL,0272,RC,,,both,,,175.94,52.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,80.76,45.9,,,,,0,20.46,149.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 12MM 2.5MM BALLOON DILATATION STERILE",SUP-225-123-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM PRESTIGE PLUS HELICAL COMPLEX XTRA",SUP-PRES0101CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MERSILENE 5-0 BP 12IN 2 ARM WHITE NONABSORBABLE",SUP-RS20,CDM,S27200284,LOCAL,0272,RC,,,both,,,360.77,108.23,"MULTIPLAN [10600]",Multiplan,,306.65,85,,,,,0,41.96,306.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +23 DIOPTER +3 CYL BICONVEX 13MM 6MM POSTERIOR",SUP-SN6AD1U230,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"MULTIPLAN [10600]",Multiplan,,633.25,85,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemdnrv 1-4 Musc Ea Add Ext",PX-361000331,CDM,64643,CPT,0761,RC,,,both,,,2598.27,779.48,"AETNA [10100]","Aetna HMO/PPO",,2065.62,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,302.18,2598.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Anaero Defin ID Ea Isol",PX-306000053,CDM,87076,CPT,0306,RC,,,both,,,162.45,48.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.47,,,,,,,0.01,138.08,"fee schedule",
"HC Cult Anaero Defin ID Ea Isol",PX-306000053,CDM,87076,CPT,0306,RC,,,both,,,162.45,48.73,"NOVANET [10819]",Novanet,,121.84,75,,,,,0,0.01,138.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TOTAL ABSCESSION BLUE SILK 40CM 10FR PIGTAIL CURVE DRNG",SUP-H787140009025,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,92.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE OTOMIMIX CALCIUM PHOSPHATE 2GM FILLER STERILE",SUP-7014-3266,CDM,C1713,HCPCS,0278,RC,,,both,,,2866.35,859.9,"BLUE CROSS [10001]","Blue Cross HMO",,1123.61,39.2,,957.42,156.86,7483.26,51,333.36,2436.4,"percent of total billed charges",
"STENT PROTEGE GPS EXPRT 30MM 80CM 9MM .079IN LARGE DIAMETER",SUP-SERB65-09-30-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"KAISER [10500]",Kaiser,,3728.55,67,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 80MM AXSOS STAINLESS STEEL 3.5MM FULL THREAD",SUP-343080,CDM,C1713,HCPCS,0278,RC,,,both,,,299.63,89.89,"BLUE CROSS [10001]","Blue Cross HMO",,117.45,39.2,,957.42,156.86,7483.26,51,34.85,254.69,"percent of total billed charges",
"TRICLIP G4 XTW CLIP DELIVERY SYSTEM CLIN",SUP-TCDS0303-XTW,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"PIN DRILL 75MM 3.2MM 2.5MM NEXGEN TROCAR HEXAGON TROCAR TIP",SUP-00-5901-020-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,797.04,239.11,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TAKERU 15MM 2MM BALLOON DILATATION RAPID EXCHANGE LOW",SUP-DC-RY2015UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 4X60 135CM SL",SUP-48004006R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 150CM 40MM 8MM BALLOON DILATATION DURALYN",SUP-48008004X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ARTHROSCOPIC 7CM 8.25MM TWIST-IN 3 DAM TRANSLUCENT",SUP-AR-6530TD,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOURNIQUET CUFF,SINGLE HOSE SINGLE BLADDER34 (BROWN) LUER CO",SUP-60-7075-006,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.84,63.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Guide DRN Perc Plc Cath Si",PX-402000003,CDM,75989,CPT,0402,RC,,,both,,,2467.97,740.39,"AETNA [10100]","Aetna HMO/PPO",,1962.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,277,2097.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3.5MM SWIVELOCK VENT PEEK-OPTIMA 15.8MM",SUP-AR-2325PSLC,CDM,C1713,HCPCS,0278,RC,,,both,,,2953.13,885.94,"BLUE CROSS [10001]","Blue Cross PPO",,1157.63,39.2,,957.42,570.23,957.42,28,343.45,2510.16,"percent of total billed charges",
"SCR BONE 2.4MM 14MM LCP TITANIUM DISTAL HUMERAL CORTICAL",SUP-401.764,CDM,C1713,HCPCS,0278,RC,,,both,,,455.87,136.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,53.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",53.02,387.49,"percent of total billed charges",
"LENS IOL +21 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.210,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT BLACK 22CM 6FR 2 PIGTAIL CURVE STRAIGHT URETERAL",SUP-G46438,CDM,C2617,HCPCS,0278,RC,,,both,,,1194.75,358.42,"CIGNA [10200]","Cigna Open Access",,679.81,,,,,,,138.95,1015.54,"percent of total billed charges",
"HC Hpv Types 16 & 18 Only",PX-306000193,CDM,87625,CPT,0306,RC,,,both,,,249.85,74.95,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,212.37,"per diem",
"INSRT TIBIAL STD 20MM KNEE GVF ROTATE PLATFORM LCS COMPLETE",SUP-129405420,CDM,C1776,HCPCS,0278,RC,,,both,,,31317.30,9395.19,"NOVANET [10819]",Novanet,,23487.98,75,,,,,0,3642.2,26619.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 26MM QUARTEX SPINE POLYAXIAL NONSTERILE LATEX",SUP-1149.4526,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,1521.93,481.35,16760.95,30,441.36,3225.75,"percent of total billed charges",
"SCR BONE 4MM 40MM QUICKFIX TITANIUM SHORT PARTIAL THREAD T15",SUP-AR-8740-40PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,1144.80,304.56,2275.09,66,155.43,1136.03,"percent of total billed charges",
"ASSEMB BLADE SMARTRELEASE STERILE DISPOSABLE ECTR",SUP-81010-6,CDM,S27200284,LOCAL,0272,RC,,,both,,,1900.00,570,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE CATH 3MR CARTO 3 INTERFACE REPROCESSED",SUP-D134401,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP IRRIGATION XMAX MICROMAX EMAX 2 PLUS SHORT ATTACH",SUP-IRR-CLIP-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FIBER LASER FLEXIVA TRAC TIP 200UM FLEXSHIELD HOLMIUM",SUP-M0068403960,CDM,S27200284,LOCAL,0272,RC,,,both,,,3351.98,1005.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD SUT ASSISTANT 3-0 ES-9 7IN 1 STITCH ENDO STITCH",SUP-170072,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND 0 FSL 18IN BRAID BLACK NONABSORBABLE",SUP-678G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL 5MM LEGION 3-4 LONG KNEE POSTERIOR",SUP-71421803,CDM,C1776,HCPCS,0278,RC,,,both,,,11043.45,3313.03,"CIGNA [10200]","Cigna Open Access",,6283.72,56.9,,5302.19,4377.88,6578.61,27,1284.35,9386.93,"percent of total billed charges",
"CNCT ROD 45-65MM 5MM RELINE-O SPINE LOW PROFILE ADJUSTABLE",SUP-10050445,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1019.59,28.62,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PRUITT 23CM 9FR 18MM C4ML BALLOON OCCLUSION 5ML 2 LUMEN",SUP-E2102-09,CDM,C2628,HCPCS,0272,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 46CM 6.8FR 10MM SPACING J ATRIUM BIPOLAR ACTIVE",SUP-1782TC/46,CDM,C1898,HCPCS,0275,RC,,,both,,,1786.00,535.8,"PHCS [10601]",PHCS,,1250.2,70,,,,,0,207.71,1518.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEM POR RT SZ 8",SUP-427-02-080,CDM,C1776,HCPCS,0278,RC,,,both,,,32703.43,9811.03,"FIRST HEALTH [10303]","First Health",,26162.74,80,,,,,0,3803.41,27797.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 4CM 2MM BALLOON DILATATION OTW LOW",SUP-G30933,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER EMBOLIZATION VENA CAVA FEMORAL DELIVERY KIT STERILE",SUP-DL900F,CDM,C1880,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"FIRST HEALTH [10303]","First Health",,6900,80,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID BEAST 100 DEMINERALIZED BONE MATRIX",SUP-P01-DBM-1010,CDM,C1713,HCPCS,0278,RC,,,both,,,12713.25,3813.97,"AETNA [10100]","Aetna HMO/PPO",,10107.03,79.5,,1521.93,481.35,16760.95,30,1478.55,10806.26,"percent of total billed charges",
"CNTNR TRANSPEC DEVICE PERFORATED COMPRESSION PLATE SPECIMEN",SUP-600101,CDM,S27000186,LOCAL,0270,RC,,,both,,,171.52,51.46,"FIRST HEALTH [10303]","First Health",,137.22,80,,,,,0,19.95,145.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 26X9X11MM ENDOSKELETON TO 4D LORDOTIC LARGE",SUP-3114-2611-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,20475.00,6142.5,"BLUE CROSS [10001]","Blue Cross HMO",,8026.2,39.2,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING EXTRACTION KIT",SUP-518-027,CDM,C1773,HCPCS,0272,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 6MM CANNULATED HEAD TUNNEL ACL STD STERILE",SUP-AR-1406,CDM,S27200284,LOCAL,0272,RC,,,both,,,1693.13,507.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,200.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,196.91,1439.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 30MM 8MM BALLOON DILATATION DURALYN",SUP-48008003X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG HYDROCOLLOID 35X9CM AQUACEL AG COVER ANTIMICROBIAL",SUP-412012,CDM,S27200284,LOCAL,0272,RC,,,both,,,325.79,97.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM SYNERGY 12MM 144CM 2.5MM CORONARY STENT EVEROLIMUS",SUP-H7493926112250,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5865,68,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 38MM 144CM 2.5MM",SUP-H7493941238250,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"BLUE CROSS [10001]","Blue Cross PPO",,3042.9,39.2,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 75MM PROXIMATE TITANIUM THICK TISSUE ENDOSCOPIC",SUP-TRT75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM REDUCED",SUP-R5-025,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Open Access",,7386.75,33.5,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER ORANGE 5.5MM STRAIGHT FULL RADIUS STERILE",SUP-7205307,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,143.03,41.1,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 8 HOLE STRAIGHT LOW PROFILE BONE CLAVICLE",SUP-70-0286,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,783.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,768.77,5618.67,"percent of total billed charges",
"LINER ACETABULAR G7 G 40MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30104007,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"NOVANET [10819]",Novanet,,7689.02,75,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TITANIUM UHMWPE XBRAID 1.2MM BLUE NONSTERILE LATEX FREE",SUP-3910900017,CDM,S27800098,LOCAL,0278,RC,,,both,,,729.00,218.7,"CIGNA [10200]",Cigna,,495.72,68,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY 10CM 18GA BARD MAX-CORE 2 TRIGGER ULTRA SHARP",SUP-MC1810,CDM,S27200284,LOCAL,0272,RC,,,both,,,254.04,76.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,29.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.54,215.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Massage Ea 15min (Gp)",PX-420000025,CDM,97124,CPT,0420,RC,,,both,,,163.34,49,"CIGNA [10200]","Cigna Open Access",,163.34,,"Per diem ($309).",,,,0,19,163.34,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Powder Arglaes",PX-E27200099,CDM,E27200099,LOCAL,0272,RC,,,both,,,72.60,21.78,"CIGNA [10200]","Cigna Open Access",,41.31,56.9,,,,,0,8.44,61.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 10MM 13MM 8FR .035IN",SUP-BXA107901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"AETNA [10100]","Aetna HMO/PPO",,17018.88,79.5,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752700,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,106.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.3/4F DUO-DECA 2-2-2 S 120CM",SUP-903269,CDM,C1731,HCPCS,0272,RC,,,both,,,8970.00,2691,"FIRST HEALTH [10303]","First Health",,7176,80,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE UNICORTICAL DOWEL ALLOGRAFT FREEZE DRIED 22-40MM",SUP-400209,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"BLUE CROSS [10001]","Blue Cross HMO",,1663.45,39.2,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 12 STD 36MM 17MM 13.5MM PROVOX LIFE LARYTUBE",SUP-7419,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"MULTIPLAN [10600]",Multiplan,,1015.67,85,,,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 65MM 9.4MM 15MM 5MM CUFFLESS REUSABLE INNER CANN",SUP-4CFN,CDM,S27200284,LOCAL,0272,RC,,,both,,,312.85,93.85,"CIGNA [10200]","Cigna Local Plus",,167.37,53.5,,,,,0,36.38,265.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Needle Brachythrpy Morgansten",PX-E27200194,CDM,C1715,HCPCS,0272,RC,,,both,,,478.50,143.55,"KAISER [10500]",Kaiser,,320.6,67,,,,,0,55.65,406.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lso Ortholine",PX-E27400064,CDM,L0631,HCPCS,0274,RC,,,both,,,3290.10,987.03,"CIGNA [10200]","Cigna Open Access",,1872.07,56.9,,,,,0,382.64,2796.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.25CM NATRELLE INSPIRA P4.4CM MODERATE PROFILE",SUP-MSZ-M405,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA [10200]","Cigna Local Plus",,84.63,53.5,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.3MM 8MM TITANIUM CORTICAL CRANIOFACIAL SELF",SUP-400.688,CDM,C1713,HCPCS,0278,RC,,,both,,,650.92,195.28,"CIGNA [10200]",Cigna,,442.63,68,,1831.33,1831.33,1831.33,16,75.7,553.28,"percent of total billed charges",
"SHELL ACETABULAR 50MM HIP GRIPTION PINNACLE STERILE LATEX",SUP-121731050,CDM,C1776,HCPCS,0278,RC,,,both,,,8971.20,2691.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4117.78,45.9,,,,,0,1043.35,7625.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Txcath Art Inf Init Day",PX-361000276,CDM,37211,CPT,0361,RC,,,both,,,4940.57,1482.17,"FIRST HEALTH [10303]","First Health",,3952.46,80,,,,,0,574.59,4940.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT CLEARVUE AIRGUARD",SUP-1608062,CDM,C1788,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA [10200]",Cigna,,1836,68,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.220,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM LOW PROFILE STRAIGHT BONE 14MM SPINAL",SUP-853-014,CDM,C1713,HCPCS,0278,RC,,,both,,,2624.40,787.32,"KAISER [10500]",Kaiser,,1758.35,67,,,,,0,305.22,2230.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg WO Vid Ea 12-26hr Intmt",PX-740000044,CDM,95709,CPT,0740,RC,,,both,,,5038.00,1511.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5.04,.1,,,,,0,5.04,4282.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg WO Vid Ea 12-26hr Intmt",PX-740000044,CDM,95709,CPT,0740,RC,,,both,,,5038.00,1511.4,"CIGNA [10200]",Cigna,,3425.84,68,,,,,0,5.04,4282.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg WO Vid Ea 12-26hr Intmt",PX-740000044,CDM,95709,CPT,0740,RC,,,both,,,5038.00,1511.4,"FIRST HEALTH [10303]","First Health",,4030.4,80,,,,,0,5.04,4282.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE OXYGEN SAMPLE BODY BOX SAMPLE LINE ASSEMBLY FOR V62J AN",SUP-769525,CDM,S27200284,LOCAL,0272,RC,,,both,,,792.02,237.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,93.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,92.11,673.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET HOUSING REAMER",SUP-AR-1204AF-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"NOVANET [10819]",Novanet,,1919.54,75,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 9CM 7FR .035IN GENTLE CURVE BILIARY",SUP-G21685,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LASSOSTAR NAV 15MM DIAGNOSTIC CIRCULAR MAPPING CATH",SUP-D140401,CDM,C1732,HCPCS,0272,RC,,,both,,,7286.40,2185.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,863.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,847.41,6193.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 59MM 80CM 10MM THIN VASCULAR COCR",SUP-1012626-59,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"KAISER [10500]",Kaiser,,5628,67,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE POLY L LACTIC ACID 12MM 8MM ACL PCL",SUP-AR-1680B,CDM,C1713,HCPCS,0272,RC,,,both,,,2480.63,744.19,"UHC [10700]","United Healthcare",,1570.24,63.3,,5023.51,2672.93,6679.78,18,1019.54,1570.24,"percent of total billed charges",
"PLEDGET MED-FIRM 1/4X1/8X1/16",SUP-Q-705,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +14.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000145,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Test Prsmv Dir Opt Obs",PX-301000547,CDM,80305,CPT,0301,RC,,,both,,,240.00,72,"BLUE CROSS [10001]","Blue Cross PPO",,16.1,,"Fee schedule rate ($16.10).",,,,0,0.01,204,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 25CM 8.5FR PIGTAIL CURVE DRNG POLYURETHANE",SUP-RLC-8-038,CDM,C1729,HCPCS,0272,RC,,,both,,,531.36,159.41,"KAISER [10500]",Kaiser,,356.01,67,,,,,0,61.8,451.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT CURVE MINITAPE COBRAID NDL",SUP-72205433,CDM,S27200284,LOCAL,0272,RC,,,both,,,484.79,145.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,57.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.38,412.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUROFORM ATLAS STENT SYSTEM 3.0 X 21MM WITHOUT TIP ZERO (PM",SUP-M003UZAS30210,CDM,C1874,HCPCS,0278,RC,,,both,,,49397.73,14819.32,"NOVANET [10819]",Novanet,,37048.3,75,,,,,0,5744.96,41988.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK-83/2,5M STERILE",SUP-115489,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.80,114.84,"KAISER [10500]",Kaiser,,256.48,67,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENCORE 26 12FR INFLATION 20ML PRESSURE GAUGE",SUP-M001151062,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"NOVANET [10819]",Novanet,,313.2,75,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SUPIRA INTRODUCER",SUP-FG-04436,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO 1000093001 OPTISEAL GLBL6FR13CM",SUP-1000093001,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENYLEPHRINE 25 MG/250 ML (0.1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV",RX-124469,CDM,J2371,HCPCS,0636,RC,70004-0807-40,NDC,both,250,ML,173.54,52.06,"MULTIPLAN [10600]",Multiplan,,147.51,85,,,,,0,14.57,147.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Impl Drug Deliv Non-Biodeg",PX-361000531,CDM,11981,CPT,0361,RC,,,both,,,770.23,231.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,91.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.58,770.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +15 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE 13",SUP-PCB0000150,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 10MM ENDOPROSTHESIS GORE-TEX",SUP-VBC101002A,CDM,C1874,HCPCS,0278,RC,,,both,,,19435.50,5830.65,"AETNA [10100]","Aetna HMO/PPO",,15451.22,79.5,,,,,0,2260.35,16520.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN CHAMP 1.5 CURVE GUIDING NYLON",SUP-LA7CHAMP15,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"FIRST HEALTH [10303]","First Health",,313.2,80,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 2 POSTERIOR KNEE TOTAL STABILIZED",SUP-5543-A-200,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,554.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,554.87,4055.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 5X5CM GRAFIX PRIME PLACENTAL MEMBRANE ALLO",SUP-PS13055,CDM,Q4133,HCPCS,0636,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,373.04,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH SUPER SHEATH SHORT 25CM 6FR INTRO SILICONE TWIST LOCK",SUP-H7491603706B1,CDM,C1894,HCPCS,0272,RC,,,both,,,108.05,32.41,"AETNA [10100]","Aetna HMO/PPO",,85.9,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.57,91.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ICD-VR VISIA MRI AF S US/OUS DF4",SUP-DVFC3D4,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"KAISER [10500]",Kaiser,,26130,67,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL L35MM DIA5.5MM TITANIUM OSTEOGRIP TSRH",SUP-83555351,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"BLUE CROSS [10001]","Blue Cross PPO",,1009.01,39.2,,957.42,570.23,957.42,28,299.36,2187.9,"percent of total billed charges",
"SUT STRATAFIX PDS PLUS 1 CT-2 6IN UNIDIRECTIONAL SYMMETRIC",SUP-SXPP1A419,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,98.76,41.1,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E KNEE FEMUR TIBIA CEMENT",SUP-98000600010,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL SHORT HINDFOOT VALOR 4.3MM SCR IMPL KIT",SUP-415S002351,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"MULTIPLAN [10600]",Multiplan,,1466.25,85,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EDM 80CM EXTERNAL DRNG SILICONE LUMBAR CLOSED TIP",SUP-46419,CDM,C1729,HCPCS,0272,RC,,,both,,,1989.60,596.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1352.93,68,,,,,0,231.39,1691.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 40CM 5FR ANGLE KUMPE CURVE ANGIOGRAPHIC",SUP-H787107327025,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rabies Vaccine Titer",PX-302000086,CDM,86382,CPT,0302,RC,,,both,,,387.00,116.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,328.95,"per diem",
"COIL EMBOLIZATION 2CM .02IN 2MM PENUMBRA COIL 400 RUBY",SUP-RBY4C0202,CDM,S27800098,LOCAL,0278,RC,,,both,,,4158.00,1247.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,492.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,483.58,3534.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 66MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701066,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4665.06,41.1,,6417.48,6417.48,6417.48,"1 through 10",1320.06,9647.93,"percent of total billed charges",
"BIT DRILL GOLD 180MM 2.5MM STAINLESS STEEL QUICK COUPLING",SUP-310.23,CDM,S27200284,LOCAL,0272,RC,,,both,,,519.37,155.81,"UHC [10700]","United Healthcare",,328.76,63.3,,,,,0,60.4,441.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CAPIO VICRYL W/NEEDLE",SUP-M0068332451,CDM,S27200284,LOCAL,0272,RC,,,both,,,492.27,147.68,"CIGNA [10200]",Cigna,,334.74,68,,,,,0,57.25,418.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 108MM RADIUS CURVE 104X10.2X2.7MM STAINLESS STEEL 3.5",SUP-245.878,CDM,C1713,HCPCS,0278,RC,,,both,,,4488.04,1346.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1284.48,28.62,,,,,0,521.96,3814.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3MM 2 BIO-SUTURETAK FIBERWIRE ROTATOR CUFF",SUP-AR-1934BF,CDM,C1713,HCPCS,0278,RC,,,both,,,1929.38,578.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,224.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",224.39,1639.97,"percent of total billed charges",
"THREADED CAP",SUP-32500-000,CDM,S27800098,LOCAL,0278,RC,,,both,,,2406.60,721.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,285.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insert Cervical Dilator",PX-721000003,CDM,59200,CPT,0721,RC,,,both,,,1079.01,323.7,"MULTIPLAN [10600]",Multiplan,,917.16,85,,,,,0,125.49,1079.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 24MM PRESS FIT TRIATHLON TITANIUM KNEE",SUP-5566-S-024,CDM,C1776,HCPCS,0278,RC,,,both,,,7345.05,2203.51,"CIGNA [10200]","Cigna Local Plus",,3929.6,53.5,,5372.07,4581.20,7242.98,23,854.23,6243.29,"percent of total billed charges",
"HC Drug Assay Posaconazole",PX-301000622,CDM,80187,CPT,0301,RC,,,both,,,382.00,114.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,42.64,,,,,,,0.01,324.7,"fee schedule",
"HC Creatine Kinase Mb Fraction",PX-301000165,CDM,82553,CPT,0301,RC,,,both,,,306.80,92.04,"MULTIPLAN [10600]",Multiplan,,260.78,85,,,,,0,0.01,260.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROXYUREA 500 MG CAPSULE",RX-10236,CDM,,,0637,RC,00904-6939-61,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]",Cigna,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE C SCREW, 3.5X16MM FA",SUP-3913516,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",521.61,3812.25,"percent of total billed charges",
"TUBE JEJUNOSTOMY 57.9CM 26FR TUNGSTEN SILICONE MIC SECUR-LOK",SUP-8210-26,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"KAISER [10500]",Kaiser,,966.71,67,,,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK RTRCTR LONE STAR 5MM STAINLESS STEEL SHARP ELASTIC STAY",SUP-3311-8G,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.91,23.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,52.3,68,,,,,0,8.94,65.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cpap Init & Mgmt Rpeat",PX-410000010,CDM,94660,CPT,0410,RC,,,both,,,1484.41,445.32,"MULTIPLAN [10600]",Multiplan,,1261.75,85,,,,,0,172.64,1261.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Attendance at Delivery",PX-410000018,CDM,99464,CPT,0722,RC,,,both,,,291.67,87.5,"NOVANET [10819]",Novanet,,218.75,75,,,,,0,33.92,247.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32MM TITANIUM CORTICAL 2 LEAD THREAD SELF TAP",SUP-14-405032,CDM,C1713,HCPCS,0278,RC,,,both,,,2475.00,742.5,"PHCS [10601]",PHCS,,1732.5,70,,,,,0,287.84,2103.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM AZUR HYDROCOIL DETACHABLE 18D .018",SUP-45-480202,CDM,S27800098,LOCAL,0278,RC,,,both,,,5361.30,1608.39,"AETNA [10100]","Aetna HMO/PPO",,4262.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,623.52,4557.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 560CC MODERATE PROFILE SMOOTH SHELL SURFACE",SUP-SSM-560,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]",Cigna,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL SMALL 12-14.4INX3IN ACTIMOVE MEDIUM DENSITY",SUP-72819-00026-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,48.20,14.46,"UHC [10700]","United Healthcare",,30.51,63.3,,,,,0,5.61,40.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAP TISSUE BERKELEY SAFETOUCH SPECIMEN ASPIRATION SYSTEM",SUP-003853-902,CDM,S27000186,LOCAL,0270,RC,,,both,,,74.12,22.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.62,63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 2.8MM 36MM ORTHOLOC FULL THREAD MIDFOOT",SUP-58803536,CDM,S27200284,LOCAL,0272,RC,,,both,,,1506.60,451.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,619.21,41.1,,,,,0,175.22,1280.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HIP FEM POROUS OFFSET SZ7",SUP-425-96-007,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"BLUE CROSS [10001]","Blue Cross HMO",,16682.91,39.2,,5311.50,4717.44,5388.59,31,4949.55,36174.68,"percent of total billed charges",
"SYSTEM PROMUS PREMIER 24MM 144CM 2.25MM CORONARY STENT",SUP-H7493952824220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"KAISER [10500]",Kaiser,,3728.55,67,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 100CM 8FR AL.75 CURVE GUIDING STAINLESS",SUP-588890,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA 3-7 C-D KNEE RIGHT TIBIA",SUP-42521200413,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"CIGNA [10200]","Cigna Local Plus",,4320.53,53.5,,5372.07,4581.20,7242.98,23,939.21,6864.4,"percent of total billed charges",
"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC",871,MS-DRG,,,,,,,inpatient,,,47206.78,14162.03,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,12772.41,,"Case rate ($12,049.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,188.73, add-ons for qualifying new technology services are included. If operating cost exceeds $44,228.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,227.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,203.52. The transfer operating threshold is the transfer adjustment factor * $11,188.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.92. The transfer capital threshold is the transfer adjustment factor * $845.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",7914.81,7914.81,7914.81,"1 through 10",7561,47206.78,other,"INPATIENT DRG"
"DEVICE 30IN INFLATION EXT TUBING",SUP-K05-01172,CDM,S27200284,LOCAL,0272,RC,,,both,,,256.65,76.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,29.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.85,218.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 10MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-310,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"BLUE CROSS [10001]","Blue Cross PPO",,5145.88,39.2,,3949.44,3949.44,3949.44,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"ROD SPINAL 80MM 3.5MM RELINE-C PRE BENT TITANIUM NONSTERILE",SUP-3943080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20 DIOPTER +1.5 CYL HAPTIC C BICONVEX 13MM 6MM",SUP-ZXT150U200,CDM,V2788,HCPCS,0276,RC,,,both,,,834.00,250.2,"CIGNA [10200]",Cigna,,567.12,68,,,,,0,96.99,708.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY DRSG 115CM 3FR S URETEROSCOPIC",SUP-M0065051600,CDM,S27200284,LOCAL,0272,RC,,,both,,,2373.38,712.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1089.38,45.9,,,,,0,276.02,2017.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX13MM FRA 8D 30D NARROW SPINE LUMBAR",SUP-213,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END 0MM TIBIA T40 STARDRIVE RECESS EXT CANNULATED",SUP-04.004.000,CDM,C1713,HCPCS,0278,RC,,,both,,,1086.37,325.91,"BLUE CROSS [10001]","Blue Cross HMO",,425.86,39.2,,957.42,156.86,7483.26,51,126.34,923.41,"percent of total billed charges",
"HC Ins Artery Line Perc",PX-450000236,CDM,36620,CPT,0361,RC,,,both,,,773.31,231.99,"NOVANET [10819]",Novanet,,579.98,75,,,,,0,89.94,773.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL XS KNEE LEFT TAPER FEMALE ANTIROTATION TAB LPS",SUP-198713105,CDM,C1776,HCPCS,0278,RC,,,both,,,77842.62,23352.79,"KAISER [10500]",Kaiser,,52154.56,67,,,,,0,9053.1,66166.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM ENDOSKELETON TCS SPINE LOCK NONSTERILE",SUP-5302-3514,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"BLUE CROSS [10001]","Blue Cross HMO",,368.48,39.2,,957.42,156.86,7483.26,51,109.32,799,"percent of total billed charges",
"OCCL CARDIOVASCULAR 17MM SEPTAL 2 DISK NITINOL MESH SELF",SUP-9-ASD-017,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2471.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 560CC",SUP-RSZ-SHPX-560S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"UHC [10700]","United Healthcare",,105.13,63.3,,,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC or OP Cmplx 1st Hr",PX-360000017,CDM,9999169,LOCAL,0360,RC,,,both,,,17381.36,5214.41,"AETNA [10100]","Aetna HMO/PPO",,13818.18,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2021.45,14774.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL LARGE 4IN MEDIUM DENSITY",SUP-72819-00028-00,CDM,L0120,HCPCS,0274,RC,,,both,,,59.07,17.72,"CIGNA [10200]",Cigna,,40.17,68,,,,,0,6.87,50.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR SHUTTLE 80CM 6FR 2.2MM GUIDING HYDROPHILIC",SUP-G13539,CDM,C1894,HCPCS,0272,RC,,,both,,,1109.62,332.89,"UHC [10700]","United Healthcare",,702.39,63.3,,,,,0,129.05,943.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PICK SURGICAL 6IN STRAIGHT HOUGH MALLEABLE HEAVY SHAFT",SUP-61-0349,CDM,S27200284,LOCAL,0272,RC,,,both,,,421.34,126.4,"AETNA [10100]","Aetna HMO/PPO",,334.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,49,358.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 30CM 6FR 2.1FR POLARIS ULTRA NAUTILUS .035IN 2",SUP-M006192135050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]","Cigna Open Access",,683.13,,,,,,,139.63,1020.49,"percent of total billed charges",
"STENT 22CM 8FR LARGE REGULAR PIGTAIL CURVE URETERAL GLIDEX",SUP-M001245500,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,605.88,68,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 65X35MM SMALL ALUMINUM DENVER SEPTUM 2 PIECE",SUP-10-1800-05KS,CDM,S27000186,LOCAL,0270,RC,,,both,,,498.96,149.69,"CIGNA [10200]","Cigna Open Access",,283.91,56.9,,,,,0,58.03,424.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP",RX-123703,CDM,,,0250,RC,60687-0576-40,NDC,both,5,ML,59.09,17.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,27.12,45.9,,,,,0,6.87,50.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +31 DIOPTER MODIFIED C BICONVEX 13MM 6MM POSTERIOR",SUP-PCB0000310,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 65X35MM SMALL ALUMINUM DENVER SEPTUM 2 PIECE",SUP-10-1800-05KS,CDM,S27000186,LOCAL,0270,RC,,,both,,,498.96,149.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,59.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.03,424.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X22X7MM RISE-L NONSTERILE",SUP-193.403,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"PHCS [10601]",PHCS,,24034.5,70,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 195MM STAINLESS STEEL 4.5MM SCR 8 HOLE 4 COLUMN",SUP-02.124.409S,CDM,C1713,HCPCS,0278,RC,,,both,,,13302.23,3990.67,"CIGNA [10200]","Cigna Local Plus",,4190.2,31.5,,3978.14,359.25,3978.14,24,1547.05,11306.9,"percent of total billed charges",
"NAPROXEN 250 MG TABLET, IMMEDIATE RELEASE",RX-5391,CDM,,,0637,RC,65162-0188-10,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 24CM 6FR .038IN PIGTAIL CURVE",SUP-M006180222120,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"FIRST HEALTH [10303]","First Health",,1064.21,80,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 46MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-46-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"NOVANET [10819]",Novanet,,4243.5,75,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL SHOULDER RESURFACE COPELAND HA 3",SUP-11114643,CDM,C1776,HCPCS,0278,RC,,,both,,,16174.80,4852.44,"AETNA [10100]","Aetna HMO/PPO",,12858.97,79.5,,10981.53,8986.79,12413.38,12,1881.13,13748.58,"percent of total billed charges",
"ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES",213,MS-DRG,,,,,,,inpatient,,,268163.70,80449.11,"CIGNA [10200]","Cigna Open Access",,62627.52,,"Fee schedule rate ($62,627.52). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,140886.53,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA 3-7 C-D KNEE RIGHT TIBIA",SUP-42521200413,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,956.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 54MM 32MM 10D CROSSFIRE",SUP-2041C-3254,CDM,C1776,HCPCS,0278,RC,,,both,,,5140.80,1542.24,"KAISER [10500]",Kaiser,,3444.34,67,,,,,0,597.88,4369.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREONPANOPTIX PRO(BLF)",SUP-PXYWT0,CDM,V2788,HCPCS,0276,RC,,,both,,,915.00,274.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,622.2,68,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ELUVIA 40MM 130CM 6MM VASCULAR DELIVERY SYSTEM",SUP-H74939294600410,CDM,C1874,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"PHCS [10601]",PHCS,,9635.85,70,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD ONFLEX SORBAFLEX 5.6X3.4IN SELF EXPAND",SUP-0115410,CDM,C1781,HCPCS,0278,RC,,,both,,,1845.75,553.72,"BLUE CROSS [10001]","Blue Cross PPO",,723.53,39.2,,,,,0,214.66,1568.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIV WITH MAJOR RELATED CONDITION WITH CC",975,MS-DRG,,,,,,,inpatient,,,47370.52,14211.16,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,8394.45,,"Case rate ($8,032.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,459.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,498.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,945.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,469.02. The transfer operating threshold is the transfer adjustment factor * $7,459.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.95. The transfer capital threshold is the transfer adjustment factor * $563.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,32296.01,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY 2MM SPACING 6FR 115CM 2MM DECAPOLAR",SUP-401923R,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRECEPT TI ROD, 95MM PREBENT LORDOTIC",SUP-8847095,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"FIRST HEALTH [10303]","First Health",,3528,80,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER 1000UM FLEXIVA FLEXSHIELD HIGH POWER POLISH",SUP-M006R8403941,CDM,S27200284,LOCAL,0272,RC,,,both,,,4603.54,1381.06,"NOVANET [10819]",Novanet,,3452.66,75,,,,,0,535.39,3913.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO CLEAR 10CM .018IN 21GA 3FR MERIT PAK 40CM PEDAL",SUP-PAKS5NPD7,CDM,C1894,HCPCS,0272,RC,,,both,,,497.02,149.11,"PHCS [10601]",PHCS,,347.91,70,,,,,0,57.8,422.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309011,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"CIGNA [10200]","Cigna Local Plus",,11895.09,31.5,,5372.07,4581.20,7242.98,23,4391.74,32097.87,"percent of total billed charges",
"HC C5",PX-302000029,CDM,86160,CPT,0302,RC,,,both,,,354.35,106.3,"NOVANET [10819]",Novanet,,265.76,75,,,,,0,0.35,301.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER SHEATH 5FR 10CM MICRO ACCESS TEAR AWAY SET PEEL-A",SUP-INT-106-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC",521,MS-DRG,,,,,,,inpatient,,,110850.82,33255.25,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,18338.15,,"Case rate ($17,804.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $16,532.24, add-ons for qualifying new technology services are included. If operating cost exceeds $49,571.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,631.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,554.11. The transfer operating threshold is the transfer adjustment factor * $16,532.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,249.92. The transfer capital threshold is the transfer adjustment factor * $1,249.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.",,,,0,7561,83798.36,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"OXIMETER PULSE BLACK ONYX 9590 FINGERTIP LATEX FREE",SUP-P7100,CDM,S27000186,LOCAL,0270,RC,,,both,,,1820.63,546.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,835.67,45.9,,,,,0,211.74,1547.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 40MM 4MM .014IN LOW PROFILE",SUP-1008189-40,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 3-0 SH 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z316H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL RESTORIS 6 KNEE RIGHT MEDIAL LEFT LATERAL",SUP-180616,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"MULTIPLAN [10600]",Multiplan,,5633.33,85,,,,,0,770.77,5633.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 V-7 36IN 2 ARM BRAID 10 STRAND GREEN",SUP-10X66,CDM,S27200284,LOCAL,0272,RC,,,both,,,535.35,160.6,"AETNA [10100]","Aetna HMO/PPO",,425.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.26,455.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE RIGHT CRUCIATE RETAINING PERSONA",SUP-42502806202,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"FIRST HEALTH [10303]","First Health",,23116.46,80,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COPE MAC-LOC 28CM 8.5FR PIGTAIL CURVE",SUP-G48183,CDM,C2617,HCPCS,0278,RC,,,both,,,980.02,294.01,"KAISER [10500]",Kaiser,,656.61,67,,,,,0,113.98,833.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 5MM BALL DISSECTING",SUP-MR8-9BA50,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.28,371.18,"AETNA [10100]","Aetna HMO/PPO",,983.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.9,1051.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 50MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.850,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CIGNA [10200]","Cigna Open Access",,782.04,56.9,,1144.80,304.56,2275.09,66,159.84,1168.25,"percent of total billed charges",
"OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC",093,MS-DRG,,,,,,,inpatient,,,39339.82,11801.95,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL SHALLCROSS FULL CURVE 8IN CYSTIC DUCT",SUP-SU10510,CDM,S27200284,LOCAL,0272,RC,,,both,,,466.97,140.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH Z-MED II 100CM 6CM 25MM .035IN BALLOON DILATATION",SUP-611479,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 9.5IN MEYERDING 3IN 2 MEDIUM TEETH EDGE SURGICAL 1IN",SUP-23-6302,CDM,S27200284,LOCAL,0272,RC,,,both,,,311.98,93.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES",213,MS-DRG,,,,,,,inpatient,,,268163.70,80449.11,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"1.1MM X 425MM TRILOGY PROBE KIT",SUP-M0068403470,CDM,S27200284,LOCAL,0272,RC,,,both,,,5531.45,1659.43,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH INTRO GREEN 90CM 6FR BRITE TIP CANN INTERVENTIONAL",SUP-401690M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 90CM 300MM 2.5MM BALLOON DILATATION RAPID",SUP-47525300S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP 100CM 8FR AL.75 CURVE GUIDING STAINLESS",SUP-588890,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Prolact Rtf26 Qtr Btl",PX-E27000213,CDM,E27000213,LOCAL,0270,RC,,,both,,,300.30,90.09,"FIRST HEALTH [10303]","First Health",,240.24,80,,,,,0,34.92,255.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prolact Rtf26 Qtr Btl",PX-E27000213,CDM,E27000213,LOCAL,0270,RC,,,both,,,300.30,90.09,"CIGNA [10200]",Cigna,,204.2,68,,,,,0,34.92,255.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Natural Killer Total Count",PX-302000079,CDM,86357,CPT,0302,RC,,,both,,,333.45,100.03,"KAISER [10500]",Kaiser,,223.41,67,,,,,0,0.01,283.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAFT 2.5MM SMALL HEXAGONAL SCRDRVR",SUP-314.03,CDM,S27000186,LOCAL,0270,RC,,,both,,,730.30,219.09,"KAISER [10500]",Kaiser,,489.3,67,,,,,0,84.93,620.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 22MM DART-FIRE TITANIUM SMALL PARTIAL THREAD",SUP-D2N30022,CDM,C1713,HCPCS,0278,RC,,,both,,,1657.50,497.25,"CIGNA [10200]","Cigna Local Plus",,886.76,53.5,,3978.14,359.25,3978.14,24,192.77,1408.88,"percent of total billed charges",
"SCR BONE CANNULATED STERILE 7MM 100MM 16MM STAINLESS STEEL",SUP-71127100,CDM,C1713,HCPCS,0278,RC,,,both,,,2479.50,743.85,"NOVANET [10819]",Novanet,,1859.63,75,,,,,0,288.37,2107.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +19.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.195,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 54MM 32MM 10D CROSSFIRE",SUP-2041C-3254,CDM,C1776,HCPCS,0278,RC,,,both,,,5140.80,1542.24,"MULTIPLAN [10600]",Multiplan,,4369.68,85,,,,,0,597.88,4369.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 1 22MM KNEE X3 POSTERIOR STABILIZED BEARING TR",SUP-5532-G-122,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"MULTIPLAN [10600]",Multiplan,,9700.71,85,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 35 SMALL KEEL AEQUALIS PERFORM SHOULDER",SUP-DWE502,CDM,C1776,HCPCS,0278,RC,,,both,,,9315.60,2794.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1103.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1083.4,7918.26,"percent of total billed charges",
"STENT ELUVIA 40MM 130CM 6MM VASCULAR DELIVERY SYSTEM",SUP-H74939294600410,CDM,C1874,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"UHC [10700]","United Healthcare",,8713.56,63.3,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER EMBOLIZATION 49MM 65CM VENA CAVA RADIOPAQUE PRELOAD",SUP-G34502,CDM,C1880,HCPCS,0278,RC,,,both,,,7621.05,2286.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3498.06,45.9,,,,,0,886.33,6477.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX13MM FRA 8D 30D NARROW SPINE LUMBAR",SUP-213,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC THK1/8IN MEDIUM WRIST THUMB SPICA 2%",SUP-550407,CDM,S27000186,LOCAL,0270,RC,,,both,,,110.84,33.25,"CIGNA [10200]",Cigna,,75.37,68,,,,,0,12.89,94.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 31.50CM 8MM DA VINCI XI ENDOWRIST 30D LARGE 1CM",SUP-471006,CDM,S27000186,LOCAL,0270,RC,,,both,,,1446.12,433.84,"PHCS [10601]",PHCS,,1012.28,70,,,,,0,168.18,1229.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDEZILLA II 150CM 8FR .072IN GUIDING Z-GLIDE EXT",SUP-H7493933515080,CDM,C1769,HCPCS,0272,RC,,,both,,,2956.88,887.06,"MULTIPLAN [10600]",Multiplan,,2513.35,85,,,,,0,343.89,2513.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 4FR ANGLE KUMPE CURVE ANGIOGRAPHIC",SUP-H787107140215,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"UHC [10700]","United Healthcare",,640.91,63.3,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 30MM 2.5MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012405-30,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 3.5MM RELINE-C PRE BENT TITANIUM NONSTERILE",SUP-3943080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Parvovirus Ab",PX-302000156,CDM,86747,CPT,0302,RC,,,both,,,414.20,124.26,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.41,.1,,,,,0,0.01,352.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 9 HIP",SUP-PRTLE029,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"PHCS [10601]",PHCS,,13230,70,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI FIELDER VASCULAR STRAIGHT 300CM 3CM .014IN",SUP-AGP140300,CDM,C1769,HCPCS,0272,RC,,,both,,,3562.50,1068.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2422.5,68,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLASH 8MM 4MM MINI BALLOON DILATATION ACCEPTS .035IN",SUP-OCB3508BA,CDM,C1725,HCPCS,0272,RC,,,both,,,6762.00,2028.6,"KAISER [10500]",Kaiser,,4530.54,67,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR CHEST TRAUMA WITHOUT CC/MCC",185,MS-DRG,,,,,,,inpatient,,,37292.38,11187.71,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,5025.07,,"Case rate ($4,878.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,530.21, add-ons for qualifying new technology services are included. If operating cost exceeds $37,569.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,724.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,536.20. The transfer operating threshold is the transfer adjustment factor * $4,530.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.51. The transfer capital threshold is the transfer adjustment factor * $342.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4878.71,19614.52,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 28MM 10MM STAINLESS STEEL 1.1MM LONG THREAD",SUP-02.226.128,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"PHCS [10601]",PHCS,,1151.64,70,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 1 22MM KNEE X3 POSTERIOR STABILIZED BEARING TR",SUP-5532-G-122,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"BLUE CROSS [10001]","Blue Cross PPO",,4473.74,39.2,,3949.44,3949.44,3949.44,"1 through 10",1327.29,9700.71,"percent of total billed charges",
"INSRT TIBIAL 3 10MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-310,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3544.36,27,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM HELIX R SPINE SELF DRILL FIX ANGLE",SUP-7802215,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 300MM 2.5MM BALLOON DILATATION RAPID",SUP-47525300S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,832.28,41.1,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 32MM HEMASHIELD PLATINUM STRAIGHT TUBE",SUP-M00202175432P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3797.28,1139.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.62,3227.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THOMASMEDICAL INTRDCR FR7 - EACH",SUP-666264-001,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CLEANING ALWAYS-ON TIP TRACKED 3 NDL",SUP-INS-5300,CDM,S27200284,LOCAL,0272,RC,,,both,,,5868.45,1760.53,"CIGNA [10200]",Cigna,,3990.55,68,,,,,0,682.5,4988.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 54MM HAND TITANIUM 2X8 HOLE T 2.4MM SCR",SUP-449.913,CDM,C1713,HCPCS,0278,RC,,,both,,,3755.81,1126.74,"MULTIPLAN [10600]",Multiplan,,3192.44,85,,,,,0,436.8,3192.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 5MM 50MM NAIL-EX TITANIUM FULL THREAD FEMORAL TIB",SUP-04.005.540,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,134.52,983.18,"percent of total billed charges",
"HC Ileoscopy Stoma W Stent",PX-750000160,CDM,44384,CPT,0750,RC,,,both,,,7444.00,2233.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,865.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,865.74,6327.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 2-0 UR-5 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-U245H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.5MM 85MM GAMMA3 TITANIUM TROCHANTER HIP LAG",SUP-3060-0085S,CDM,C1713,HCPCS,0278,RC,,,both,,,3471.30,1041.39,"BLUE CROSS [10001]","Blue Cross HMO",,1360.75,39.2,,957.42,156.86,7483.26,51,403.71,2950.61,"percent of total billed charges",
"SUT ETHIBOND EXCEL 2-0 V-7 36IN 2 ARM BRAID 10 STRAND GREEN",SUP-10X66,CDM,S27200284,LOCAL,0272,RC,,,both,,,535.35,160.6,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC",093,MS-DRG,,,,,,,inpatient,,,39339.82,11801.95,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Total Tau",PX-301000702,CDM,84394,CPT,0301,RC,,,both,,,630.00,189,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TREK 145CM 8MM 3MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012407-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CURET 000 8IN EPSTEIN SPINE SURGICAL",SUP-57-4620,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.74,104.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 110CM 7FR .081IN RIGHT BACKUP 4 CURVE GUIDING",SUP-LA7RBU40,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT POLARIS 20CM 8FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552500,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"KAISER [10500]",Kaiser,,804.39,67,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE CONNECTING DRNG BAG",SUP-M001229101,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.10,33.93,"CIGNA [10200]","Cigna Local Plus",,60.51,53.5,,,,,0,13.15,96.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 75MM 25MM AFX VELA SUPRARENAL STRATA AORTIC EXT",SUP-A25-25/C75-O20V,CDM,C1874,HCPCS,0278,RC,,,both,,,35406.00,10621.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9559.62,27,,,,,0,4117.72,30095.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 57MM 2MM MINI QUICK COUPLING GLIDE HOLE NONSTERILE",SUP-03.130.312,CDM,S27200284,LOCAL,0272,RC,,,both,,,576.07,172.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DISECT ENDOSCOPIC AGGRESSIVE 13CM 5MM COOLCUT STERILE",SUP-AR-8500DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEO IMPLANTABLE PULSE GENERATOR","SUP-MODEL 2102",CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4.5MM 45MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-54840014545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Incsn/Rmvl FB Sq Cmplx",PX-450000009,CDM,10121,CPT,0361,RC,,,both,,,7667.00,2300.1,"MULTIPLAN [10600]",Multiplan,,6516.95,85,,,,,0,7.67,7667,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHYTONADIONE 1 MG/ML ORAL SOLUTION",RX-408176,CDM,J3430,HCPCS,0636,RC,,,both,5,ML,182.07,54.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,15.91,,,,,,,15.91,154.76,"fee schedule",
"CMPNT FEMORAL 6 STD KNEE RIGHT CRUCIATE RETAINING PERSONA",SUP-42502806002,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"CIGNA [10200]","Cigna Open Access",,9680.02,33.5,,5302.19,4377.88,6578.61,27,3360.56,24561.24,"percent of total billed charges",
"PK PAPYRUS 4.5/26",SUP-434902,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"PHCS [10601]",PHCS,,13825.35,70,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 15MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158121115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"FIRST HEALTH [10303]","First Health",,8939.64,80,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 FSL 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8675H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN GLAUCOMA THK.9MM BLUNT TAPER AHMED FLEXIBLE PLATE",SUP-FP7,CDM,C1783,HCPCS,0278,RC,,,both,,,6900.00,2070,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,802.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE REGENESORB 20MM 10MM BIOSURE",SUP-72204407,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"BLUE CROSS [10001]","Blue Cross PPO",,1087.42,39.2,,957.42,570.23,957.42,28,322.62,2357.93,"percent of total billed charges",
"SHELL ACETABULAR 48MM HIP SOLID BACK METAL HA TRIDENT D",SUP-500-11-48D,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.85,2973.55,"UHC [10700]","United Healthcare",,6274.2,63.3,,8601.07,8395.67,8601.07,"1 through 10",1152.75,8425.07,"percent of total billed charges",
"TAP 3.5MM SURGICAL 3.5MM SCR ELLIPSE",SUP-682.106,CDM,C1713,HCPCS,0278,RC,,,both,,,534.60,160.38,"KAISER [10500]",Kaiser,,358.18,67,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 55MM NCB TITANIUM ALUMINUM VANADIUM DEEP THREAD",SUP-0203154055,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X15MM LUMINARY 10/11MM SPINE",SUP-4715,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"AETNA [10100]","Aetna HMO/PPO",,25042.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 5.5MM CURVE NONSTERILE",SUP-1555501120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"SCR BONE 7.5MM 45MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1",SUP-179712045,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",441.36,3225.75,"percent of total billed charges",
"STENT CONTOUR ZIPWIRE 26CM 3CM 6FR .035IN PIGTAIL CURVE",SUP-M006180223170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"KAISER [10500]",Kaiser,,847.8,67,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL SMALL 13MM KNEE DURATION POSTERIOR STABILIZE",SUP-6742-1-113,CDM,C1776,HCPCS,0278,RC,,,both,,,5709.75,1712.92,"MULTIPLAN [10600]",Multiplan,,4853.29,85,,,,,0,664.04,4853.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.050S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DORZOLAMIDE 2 % EYE DROPS",RX-14471,CDM,,,0250,RC,42571-0141-26,NDC,both,10,ML,420.17,126.05,"UHC [10700]","United Healthcare",,265.97,63.3,,,,,0,48.87,357.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR ENDOSCOPIC L100MM OD5MM DILATING TIP OBTURATOR RADIOL",SUP-D5LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,71.88,45.9,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CASTING 4IN 10: BOOT TCC-EZ XL",SUP-TCC24024,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.43,23.23,"UHC [10700]","United Healthcare",,49.01,63.3,,,,,0,9.01,65.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION",RX-24916,CDM,,,0250,RC,76204-0900-11,NDC,both,3,ML,12.59,3.78,"CIGNA [10200]","Cigna Local Plus",,6.74,53.5,,,,,0,1.46,10.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOPLASTY L150CM BALLOON L22CM DIA3.5MM SHEATH DI",SUP-U41503H22,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR HOCKEY STICK CURVE",SUP-67027900,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"AETNA [10100]","Aetna HMO/PPO",,331.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 1.80IN .10IN .08IN CUSA CLARITY 36KHZ STD EXTEND",SUP-C7412S,CDM,S27200284,LOCAL,0272,RC,,,both,,,5971.96,1791.59,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET LEADWIRE 10 LEAD PLUG AHA BANANA NEONATAL CABLE",SUP-2016032-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2167.50,650.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SENSOR ADULT DURASENSOR NELLCOR 24IN FINGER OXIMETER O2",SUP-DS100A-1,CDM,S27000186,LOCAL,0270,RC,,,both,,,1179.77,353.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 300CM 3CM",SUP-1020015,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 150CM 150MM 7FR 6MM 5FR BALLOON DILATATION",SUP-39032-60151,CDM,C1725,HCPCS,0272,RC,,,both,,,1762.50,528.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATH 8FR .06IN 5CM 1 LUMEN INTERMEDIATE POWER",SUP-0805810,CDM,C1751,HCPCS,0272,RC,,,both,,,2745.00,823.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPECLM OPHTHALMIC SOLID BLADE CLOSED EYE LIEBERMAN 15MM",SUP-60-2005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1330.91,399.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,154.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.78,1131.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 4MM 4.5MM 5MM XTHICK TISSUE SLOPE CRTDG FACE",SUP-TRIEEA25XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2219.25,665.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,912.11,41.1,,,,,0,258.1,1886.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 35MM VIVACIT-E ALL POLY KNEE LATEX FREE",SUP-42540200035,CDM,C1776,HCPCS,0278,RC,,,both,,,5322.66,1596.8,"MULTIPLAN [10600]",Multiplan,,4524.26,85,,,,,0,619.03,4524.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEV TRQ TIP INTRO",SUP-4071,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"CIGNA [10200]","Cigna Local Plus",,88.44,53.5,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM .02IN 6MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0630,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.00,2003.4,"PHCS [10601]",PHCS,,4674.6,70,,,,,0,776.65,5676.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vitamin E",PX-301000416,CDM,84446,CPT,0301,RC,,,both,,,96.20,28.86,"NOVANET [10819]",Novanet,,72.15,75,,,,,0,0.1,81.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +10MM OFFSET C TAPER 36MM HIP COCR LFIT",SUP-06-3610,CDM,C1776,HCPCS,0278,RC,,,both,,,7962.60,2388.78,"MULTIPLAN [10600]",Multiplan,,6768.21,85,,,,,0,926.05,6768.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO SD 45D LEFT CURVE 1.8MM 3.8MM THUMB PAD",SUP-AR-4068-45L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1190.70,357.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,141.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) REPRIEVE SYSTEM SALINE INFUSION SINGLE USE SET / STER",SUP-AC00001,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARR GRAFT 8IN SKIN PVC BOARD CARR STERILE LATEX FREE",SUP-00-7708-000-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145362010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,443.81,45.9,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 90CM .035IN STRAIGHT SPRT",SUP-518-078,CDM,C1887,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 6MM 2.75MM .017IN",SUP-H7493926706270,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 54.4CM 8MM DA VINCI S/SI ENDOWRIST 30- D LARGE",SUP-420006,CDM,S27000186,LOCAL,0270,RC,,,both,,,1732.50,519.75,"CIGNA [10200]",Cigna,,1178.1,68,,,,,0,201.49,1472.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Orbit/Face/Nck WO Cntrst",PX-610000003,CDM,70540,CPT,0610,RC,,,both,,,3801.18,1140.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,450.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,430.45,3231,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.3/4F DUO-DECA 5-5-5 S 120CM",SUP-903271,CDM,C1731,HCPCS,0272,RC,,,both,,,8970.00,2691,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6099.6,68,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 9 SLOT RIGHT TI",SUP-PHPF-C9R,CDM,C1713,HCPCS,0278,RC,,,both,,,21924.00,6577.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2597.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2549.76,18635.4,"percent of total billed charges",
"PLATE UNIVERSAL 42X6.5X1.3MM 5TH METATARSAL FRACTURE 3 HOLE",SUP-52020400,CDM,C1713,HCPCS,0278,RC,,,both,,,7700.40,2310.12,"CIGNA [10200]",Cigna,,5236.27,68,,1831.33,1831.33,1831.33,16,895.56,6545.34,"percent of total billed charges",
"SUT ETHILON 8-0 BV130-3 5IN MONOFILAMENT BLACK NONABSORBABLE",SUP-2822G,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.37,52.31,"NOVANET [10819]",Novanet,,130.78,75,,,,,0,20.28,148.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 12.5MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962322,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"FIRST HEALTH [10303]","First Health",,11603.04,80,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 54MM HAND TITANIUM 2X8 HOLE T 2.4MM SCR",SUP-449.913,CDM,C1713,HCPCS,0278,RC,,,both,,,3755.81,1126.74,"BLUE CROSS [10001]","Blue Cross PPO",,1472.28,39.2,,957.42,570.23,957.42,28,436.8,3192.44,"percent of total billed charges",
"LENS IOL 0 D +11.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.115,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,98.74,28.62,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Distl Fibula W Manip",PX-450000162,CDM,27788,CPT,0450,RC,,,both,,,1879.00,563.7,"MULTIPLAN [10600]",Multiplan,,1597.15,85,,,,,0,67.13,1879,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 135CM 60MM 6MM BALLOON DILATATION PACLITAXEL OTW",SUP-H74939419600610,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5865,68,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RAMROD QUADRA-COIL 22-28CM 6FR KIDNEY BLADDER CURL",SUP-5001960,CDM,C2617,HCPCS,0278,RC,,,both,,,721.79,216.54,"CIGNA [10200]",Cigna,,490.82,68,,,,,0,83.94,613.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 43CM 13MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181343,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"BLUE CROSS [10001]","Blue Cross PPO",,7290.26,39.2,,,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 SURGALLOY 4-0 V-20 18IN CLSR ABSORBABLE",SUP-VLOCM0623,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.73,70.42,"AETNA [10100]","Aetna HMO/PPO",,186.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.3,199.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 32MM MEDLINE UNITE HEAD BRONZE",SUP-MSL04032,CDM,C1713,HCPCS,0278,RC,,,both,,,1987.50,596.25,"PHCS [10601]",PHCS,,1391.25,70,,,,,0,231.15,1689.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDDICK 50CM 4FR CHOLANGIOGRAM CYSTIC DUCT SCOOP TIP",SUP-E2400-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,897.97,269.39,"PHCS [10601]",PHCS,,628.58,70,,,,,0,104.43,763.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 12/14 TAPER 36MM HIP CEMENTLESS BIOLOX",SUP-136536340,CDM,C1776,HCPCS,0278,RC,,,both,,,7222.32,2166.7,"BLUE CROSS [10001]","Blue Cross PPO",,2831.15,39.2,,3949.44,3949.44,3949.44,"1 through 10",839.96,6138.97,"percent of total billed charges",
"SYSTEM MULTI-LINK VISION 28MM 4MM CORONARY STENT COCR RAPID",SUP-1007850-28,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTDG HEPCON HMS PLUS CRTDG SYR BLUNT TIP NDL PORCINE",SUP-304-20POR,CDM,S27200284,LOCAL,0272,RC,,,both,,,157.04,47.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,72.08,45.9,,,,,0,18.26,133.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lo Flexible",PX-E27400070,CDM,L0625,HCPCS,0274,RC,,,both,,,227.63,68.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.47,193.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 545CC",SUP-SMPX545,CDM,C1789,HCPCS,0278,RC,,,both,,,6382.50,1914.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,756.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",742.28,5425.13,"percent of total billed charges",
"SCR INTERFERENCE POLY L LACTIC ACID 28MM 8.5MM 10MM DELTA",SUP-AR-5028B-10,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE UNICORTICAL DOWEL ALLOGRAFT FREEZE DRIED 14-40MM",SUP-400239,CDM,S27800098,LOCAL,0278,RC,,,both,,,4719.60,1415.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2166.3,45.9,,,,,0,548.89,4011.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CARTIFORM 25X20MM",SUP-ABS-1102-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"AETNA [10100]","Aetna HMO/PPO",,49846.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 HEALIX ADVANCE BR ORTHOCORD STERILE LATEX",SUP-222297,CDM,C1713,HCPCS,0278,RC,,,both,,,3270.00,981,"BLUE CROSS [10001]","Blue Cross PPO",,1281.84,39.2,,957.42,570.23,957.42,28,380.3,2779.5,"percent of total billed charges",
"STEM FEMORAL 14MM PRESS FIT ECHO PF TITANIUM STD OFFSET HIP",SUP-12-150314,CDM,C1776,HCPCS,0278,RC,,,both,,,8336.51,2500.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,969.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,969.54,7086.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT EXTERNAL FIXATION SCHANZ CANNULATED RING MOUNT",SUP-03.311.058,CDM,C1713,HCPCS,0278,RC,,,both,,,1681.43,504.43,"KAISER [10500]",Kaiser,,1126.56,67,,,,,0,195.55,1429.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Speech Dev 1st Hr",PX-444000004,CDM,92607,CPT,0444,RC,,,both,,,1042.00,312.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,254,,"Per diem ($254).",,,,0,121.18,885.7,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL JANSEN-MIDDLETON 6.75IN SEPTUM THROUGH CUT JAW",SUP-66-2565,CDM,S27200284,LOCAL,0272,RC,,,both,,,1788.90,536.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,211.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,208.05,1520.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 47MM 135CM 8MM 160CM",SUP-M001712210,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"FIRST HEALTH [10303]","First Health",,6762,80,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 330MM 5MM 3 FLUTE QUICK COUPLING CALIBRATED 100MM",SUP-03.010.062,CDM,S27200284,LOCAL,0272,RC,,,both,,,1617.08,485.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1099.61,68,,,,,0,188.07,1374.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT CONGR SZ.5X12MM RT",SUP-2042-0-1212,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,414.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TYSHAK II 100CM 6CM 8FR 18MM BALLOON DILATATION DEHP",SUP-611930,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"NOVANET [10819]",Novanet,,2850.91,75,,,,,0,442.08,3231.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM SWIVELOCK C CLOSED EYELET VENT BIOCOMPOSITE",SUP-AR-2323BCC,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.00,945,"CIGNA [10200]","Cigna Open Access",,1792.35,56.9,,1144.80,304.56,2275.09,66,366.35,2677.5,"percent of total billed charges",
"ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION",RX-184423,CDM,J0122,HCPCS,0636,RC,71773-0050-05,NDC,both,1,UN,400.04,120.01,"UHC [10700]","United Healthcare",,126,,,,,,,47.4,340.03,"fee schedule",
"SUT PROLENE 5-0 C-1 18IN 2 ARM MONOFILAMENT BLUE",SUP-8717H,CDM,S27200284,LOCAL,0272,RC,,,both,,,150.18,45.05,"AETNA [10100]","Aetna HMO/PPO",,119.39,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.47,127.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE RIGHT CEMENTED CRUCIATE RETAINING",SUP-150400208,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9203.67,41.1,,6417.48,6417.48,6417.48,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"SCR BONE 6.5MM 40MM CD HORIZON TITANIUM COCR SPINE",SUP-55890006540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRN6PR,CDM,C1776,HCPCS,0278,RC,,,both,,,13075.50,3922.65,"AETNA [10100]","Aetna HMO/PPO",,10395.02,79.5,,10981.53,8986.79,12413.38,12,1520.68,11114.18,"percent of total billed charges",
"PLATE 47MM STAINLESS STEEL 2.4MM SCR 4X3 HOLE LCP BONE RIGHT",SUP-242.464,CDM,C1713,HCPCS,0278,RC,,,both,,,4922.87,1476.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,583.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",572.53,4184.44,"percent of total billed charges",
"PLATE MINI STRAIGHT 8MMX1MM MANDIBLE 4 HOLE 2MM SCR BONE",SUP-55-10503,CDM,C1713,HCPCS,0278,RC,,,both,,,1085.16,325.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,126.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",126.2,922.39,"percent of total billed charges",
"WIRE FIXATION 2.8MM 200MM 15MM LCP ANKLE COMPRESSION THREAD",SUP-03.118.015,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 38MM 2 MARKER SEMIRIGID WIRE STIFFENER",SUP-800SR38,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Local Plus",,4129.65,31.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 30CC CRUSH 1-10MM LATEX FREE",SUP-800104,CDM,S27800098,LOCAL,0278,RC,,,both,,,2940.00,882,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,341.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL LEGION 5 L 5D 10P KNEE SCR ON",SUP-71421742,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,5311.50,4717.44,5388.59,31,2014.9,14726.25,"percent of total billed charges",
"COIL EMBOLIZATION 10CM 4MM CEREPAK XTRASOFT FREEFORM",SUP-XCR120410,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3570.98,27,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM 9FR ENDOCARDIUM 1 COIL 2 COIL IS-1 DF-1",SUP-0181,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]",Cigna,,6868.8,40,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE? II PRO SZ PTCA BALLOON SEMI-COMPLIANT 1.25 MM X 15",SUP-212-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.7MM 45MM 18MM LOW PROFILE SCREWS TITANIUM 3.5MM",SUP-AR-8967-1845,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"PHCS [10601]",PHCS,,1312.5,70,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.050TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSELECT DEMINERALIZED BONE MATRIX 10CC",SUP-309100,CDM,C1713,HCPCS,0278,RC,,,both,,,5602.80,1680.84,"CIGNA [10200]",Cigna,,3809.9,68,,1831.33,1831.33,1831.33,16,651.61,4762.38,"percent of total billed charges",
"SPACER SPINAL 14X16MM VERTE-STACK CORNERSTONE PSR 6MM",SUP-6240064,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXCISOR BIOPSY .472X.354IN FISCHER 74D 12MM SMALL CONE",SUP-900-150,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.28,60.98,"KAISER [10500]",Kaiser,,136.2,67,,,,,0,23.64,172.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIC PEG REPLACEMENT FEEDING ADAPTER  20FR",SUP-0135-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.86,20.36,"UHC [10700]","United Healthcare",,42.96,63.3,,,,,0,7.89,57.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X22X7MM RISE-L 3D LORDOTIC NONSTERILE",SUP-193.603,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"UHC [10700]","United Healthcare",,21734.06,63.3,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 16MM STD SHELL DJO SURGICAL ALTIVATE",SUP-530-16-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5523.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5523.6,40370.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 88MM RADIUS CURVE 104MM STAINLESS STEEL 3.5MM SCR 8",SUP-245.908,CDM,C1713,HCPCS,0278,RC,,,both,,,4488.04,1346.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",521.96,3814.83,"percent of total billed charges",
"CATH CORDIS SABER 90CM 150MM 2.5MM BALLOON DILATATION",SUP-48002515S,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,881.28,68,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 5MM CARBIDE ROUND STERILE",SUP-0277010250,CDM,S27200284,LOCAL,0272,RC,,,both,,,262.31,78.69,"MULTIPLAN [10600]",Multiplan,,222.96,85,,,,,0,30.51,222.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701062,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7718.34,68,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3.5MM 18MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.818.96,CDM,C1713,HCPCS,0278,RC,,,both,,,319.12,95.74,"MULTIPLAN [10600]",Multiplan,,271.25,85,,,,,0,37.11,271.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING CAPSULAR FIXATION THK.17MM REFORM PMMA 11-13MM STERILE",SUP-ACTR11,CDM,S27800098,LOCAL,0278,RC,,,both,,,575.10,172.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,68.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 7 KNEE CEMENTED FIX BEARING STERILE",SUP-150600007,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"CIGNA [10200]","Cigna Local Plus",,4726.28,31.5,,5372.07,4581.20,7242.98,23,1744.97,12753.44,"percent of total billed charges",
"STENT FRMLA 418 16MM 135CM 7MM .018IN BILIARY STAINLESS",SUP-G56629,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"BLUE CROSS [10001]","Blue Cross HMO",,1975.68,39.2,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE LEFT CEMENTED POSTERIOR",SUP-150410125,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2653.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2604.35,19034.35,"percent of total billed charges",
"NEUROFORM ATLAS STENT SYSTEM 3.0 X 24MM WITHOUT TIP ZERO (PM",SUP-M003UZAS30240,CDM,C1874,HCPCS,0278,RC,,,both,,,52885.22,15865.57,"CIGNA [10200]","Cigna Open Access",,17716.55,33.5,,,,,0,6150.55,44952.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LACRIMAL SIZE 0000 000 L5.9IN MALLEABLE STERLING SILVE",SUP-E4200,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.79,105.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,145,41.1,,,,,0,41.03,299.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPIDERFX .014IN 190CM 3.2-4.2FR 6MM EMBOLIC",SUP-SPD2-US-060-190,CDM,C1884,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"MULTIPLAN [10600]",Multiplan,,6158.25,85,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.3MM 230MM KIRSCHNER 1 END TROCAR TIP SMOOTH",SUP-P99-192-2323,CDM,C1713,HCPCS,0278,RC,,,both,,,146.16,43.85,"KAISER [10500]",Kaiser,,97.93,67,,,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 190MM 12MM REVISION DISTAL FILL BEAD FULLCOAT",SUP-784301218,CDM,C1776,HCPCS,0278,RC,,,both,,,40748.53,12224.56,"BLUE CROSS [10001]","Blue Cross HMO",,15973.42,39.2,,5311.50,4717.44,5388.59,31,4739.05,34636.25,"percent of total billed charges",
"CABLE CATH BLUE 10FT ELECTROPHYSIOLOGY HYPERTONICS 34 PIN TO",SUP-CB3434CT,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"UHC [10700]","United Healthcare",,2131.63,63.3,,,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 22MM LOW PROFILE SCREWS TITANIUM VARIABLE",SUP-AR-8724V-22,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross HMO",,635.04,39.2,,957.42,156.86,7483.26,51,188.41,1377,"percent of total billed charges",
"HC Rmvl Perq Right Heart Vad",PX-360000064,CDM,33997,CPT,0360,RC,,,both,,,2344.58,703.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,277.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,272.67,2344.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nfct Ds Chrnc Hcv 6 Assays",PX-309000126,CDM,81596,CPT,0310,RC,,,both,,,710.60,213.18,"MULTIPLAN [10600]",Multiplan,,604.01,85,,,,,0,0.01,604.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nfct Ds Chrnc Hcv 6 Assays",PX-309000126,CDM,81596,CPT,0310,RC,,,both,,,710.60,213.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,69.14,,"Fee schedule rate ($69.14). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,604.01,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc De Ea Addl Br Maj Cor",PX-481000078,CDM,C9601,HCPCS,0481,RC,,,both,,,24225.13,7267.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2870.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2817.38,24225.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 30CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175275190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,580.81,45.9,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HALYARD BALLARD 3MM 2.5MM 12IN 6FR 2.5MM SUCTION",SUP-196,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.21,33.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,74.94,68,,,,,0,12.82,93.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 4-0 PS-2 2 SPIRAL 12IN SUT",SUP-SXMP2B409,CDM,S27200284,LOCAL,0272,RC,,,both,,,219.64,65.89,"AETNA [10100]","Aetna HMO/PPO",,174.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.54,186.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 20 MEQ POTASSIUM CHLORIDE .45% SODIUM",SUP-925739,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA [10200]",Cigna,,55.08,68,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 80MM 34MM VELA ENDOVASCULAR ABDOMEN AORTA 20MM",SUP-A34-34/C80-O20V,CDM,C1874,HCPCS,0278,RC,,,both,,,35406.00,10621.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4195.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4117.72,30095.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC",728,MS-DRG,,,,,,,inpatient,,,23237.50,6971.25,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,5182.88,,"Case rate ($5,031.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,672.48, add-ons for qualifying new technology services are included. If operating cost exceeds $37,712.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,735.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,678.66. The transfer operating threshold is the transfer adjustment factor * $4,672.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $353.26. The transfer capital threshold is the transfer adjustment factor * $353.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,5031.92,20230.52,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP INSRT TIBIAL KNEE ROTATE PLATFORM HYBRID ATTUNE",SUP-OSC370780,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8820,40,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT STEM 155MM 13MM NEXGEN STRAIGHT KNEE TIBIA ROTATE HINGE",SUP-00598801113,CDM,C1776,HCPCS,0278,RC,,,both,,,8049.54,2414.86,"PHCS [10601]",PHCS,,5634.68,70,,,,,0,936.16,6842.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE SINGLE DIAMOND 2.0MM X 152MM",SUP-KWIR-SD-20152,CDM,S27000186,LOCAL,0270,RC,,,both,,,391.50,117.45,"KAISER [10500]",Kaiser,,262.31,67,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL GOLD 36MM EXPERT SPIRAL HUMERAL",SUP-462.636S,CDM,C1713,HCPCS,0278,RC,,,both,,,3518.55,1055.56,"PHCS [10601]",PHCS,,2462.99,70,,,,,0,409.21,2990.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BTTRY PRODUCT SPECIFIC 14V CLIP SET LITHIUM ION",SUP-2865,CDM,Q0497,HCPCS,0274,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,1466.08,39.2,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Screen Mrsa",PX-306000059,CDM,87081,CPT,0306,RC,,,both,,,290.70,87.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.96,,"Fee schedule rate ($6.96). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,247.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 135D STD BARREL DHS/DCP HIP STERILE 46MM STAINLESS",SUP-281.102S,CDM,C1713,HCPCS,0278,RC,,,both,,,3765.33,1129.6,"BLUE CROSS [10001]","Blue Cross PPO",,1476.01,39.2,,957.42,570.23,957.42,28,437.91,3200.53,"percent of total billed charges",
"HC Factor VIII 1 Stage",PX-305000018,CDM,85240,CPT,0305,RC,,,both,,,563.11,168.93,"CIGNA [10200]",Cigna,,39.38,,,,,,,0.01,478.64,"fee schedule",
"VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION",RX-185505,CDM,J3373,HCPCS,0636,RC,00409-3515-11,NDC,both,1,UN,220.64,66.19,"MULTIPLAN [10600]",Multiplan,,187.54,85,,,,,0,5.24,187.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 80MM 3MM BALLOON DILATATION STERILE LATEX",SUP-583008022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 1 TP-1 27IN MONOFILAMENT 2 STRAND VIOLET",SUP-Z690G,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.58,33.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.98,94.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC",136,MS-DRG,,,,,,,inpatient,,,66879.74,20063.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,20154.72,,"Fee schedule rate ($20,154.72). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,6297.96,29642.7,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 NARROW KNEE LEFT CRUCIATE RETAINING PERSONA",SUP-42502206201,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"BLUE CROSS [10001]","Blue Cross PPO",,11327.07,39.2,,3949.44,3949.44,3949.44,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"HC Comp Ep Eval Tx V Tach/V Ectop",PX-481000094,CDM,93654,CPT,0481,RC,,,both,,,32036.13,9610.84,"CIGNA [10200]","Cigna Open Access",,23021,,"Case rate ($23,021). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3725.8,27504,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER PACING LEAD ACUITY 10FR",SUP-667465-001,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 33MM MITRAL TRICUSPID FULL FLEXIBLE BAND O",SUP-700FF33,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENTUS OTW QP S-85/49",SUP-406079,CDM,C1725,HCPCS,0624,RC,,,both,,,7797.00,2339.1,"AETNA [10100]","Aetna HMO/PPO",,6198.62,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,906.79,6627.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 SH-1 30IN MONOFILAMENT DOUBLE ARM BLUE",SUP-8762H,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.06,18.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,28.94,45.9,,,,,0,7.33,53.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 535CC STERILE ARTOURA ULTRA HIGH PROFILE ROUND",SUP-TEXP120RUH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"MULTIPLAN [10600]",Multiplan,,11700.68,85,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,inpatient,,,40449.45,12134.83,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,4422.58,,"Case rate ($4,293.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,987.05, add-ons for qualifying new technology services are included. If operating cost exceeds $37,026.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,683.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $3,992.32. The transfer operating threshold is the transfer adjustment factor * $3,987.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.44. The transfer capital threshold is the transfer adjustment factor * $301.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4293.77,17262.78,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.4MM KIRSCHNER",SUP-24872018,CDM,C1713,HCPCS,0278,RC,,,both,,,243.60,73.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,28.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",28.33,207.06,"percent of total billed charges",
"SCREW BONE FUZEFIX TITANIUM T8 MINI L14 MM OD2.5 MM COMPRESS",SUP-FX-HL-2514,CDM,C1713,HCPCS,0278,RC,,,both,,,2287.50,686.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,271.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",266.04,1944.38,"percent of total billed charges",
"STENT 120CM 7.5CM 7MM VASCULAR CATH 7.5CM",SUP-VBJR070702A,CDM,C1874,HCPCS,0278,RC,,,both,,,22163.40,6649.02,"CIGNA [10200]","Cigna Open Access",,7424.74,33.5,,,,,0,2577.6,18838.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE PIN ORTHOPEDIC 30CM 2.4MM ACL PREDRILL STERILE",SUP-AR-1250L,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"CIGNA [10200]",Cigna,,198.78,68,,,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 5 % IV BOLUS",RX-400293,CDM,,,0258,RC,00338-0017-04,NDC,both,1000,ML,100.65,30.19,"CIGNA [10200]",Cigna,,68.44,68,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 850CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP140RUH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"AETNA [10100]","Aetna HMO/PPO",,9462.49,79.5,,,,,0,1384.26,10117.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL RAPIDE MULTIPASS 4-0 PS-2 18IN BRAID COATED",SUP-VR496,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.87,20.06,"PHCS [10601]",PHCS,,46.81,70,,,,,0,7.78,56.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT FIBERTAK 2 TAPE SELF PUNCH SOFT 1.3MM",SUP-AR-3632SP,CDM,C1713,HCPCS,0278,RC,,,both,,,3110.63,933.19,"MULTIPLAN [10600]",Multiplan,,2644.04,85,,,,,0,361.77,2644.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM OSTEOLOCK HIP CANCELLOUS",SUP-5260-5-040,CDM,C1713,HCPCS,0278,RC,,,both,,,580.01,174,"MULTIPLAN [10600]",Multiplan,,493.01,85,,,,,0,67.46,493.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM EVEREST SPINE POLYAXIAL EXTEND TAB",SUP-E5111-07550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"ROD RTRCTR LEYLA 2 PIECE RIGID HOLD SELF RETAIN BRAIN",SUP-R2381,CDM,S27200284,LOCAL,0272,RC,,,both,,,3105.53,931.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,368.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,361.17,2639.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ATTUNE FB HYBRID",SUP-OSC371227,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 32MM 2MM LCP CORTICAL STAINLESS STEEL SELF TAPPING",SUP-201.378.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,49.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",48.16,352,"percent of total billed charges",
"HEAD FEMORAL +5MM OFFSET TAPER 36MM HIP ALUMINA CERAMIC V40",SUP-6565-0-236,CDM,C1776,HCPCS,0278,RC,,,both,,,7383.00,2214.9,"CIGNA [10200]","Cigna Open Access",,4200.93,56.9,,5302.19,4377.88,6578.61,27,858.64,6275.55,"percent of total billed charges",
"HC Xr Skull>=4v",PX-320000018,CDM,70260,CPT,0320,RC,,,both,,,768.38,230.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,81.63,,,,,,,49.14,653.12,"fee schedule",
"CATH LAUNCHER 100CM 7FR CHAMP1.5 CURVE GUIDING CORONARY",SUP-LA7CHAMP15SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,150.18,41.1,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SPINAL BLACK 5IN 22GA BD QUINCKE LONG LENGTH BEVEL FIT",SUP-405148,CDM,S27200284,LOCAL,0272,RC,,,both,,,55.12,16.54,"AETNA [10100]","Aetna HMO/PPO",,43.82,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.41,46.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 13MM SPINE CERVICAL ANTERIOR SELF DRILL",SUP-18008113,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,117.75,860.63,"percent of total billed charges",
"BRUSH CYTOLOGY 1.9MM 150CM BRONCHOSCOPE BULLET TIP WIRE",SUP-M00516151,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.01,40.5,"MULTIPLAN [10600]",Multiplan,,114.76,85,,,,,0,15.7,114.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Ish Ea Mult",PX-312000083,CDM,0850T,CPT,0312,RC,,,both,,,104.00,31.2,"KAISER [10500]",Kaiser,,69.68,67,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THREAD PILOT DRILL",SUP-214-00-013,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"CIGNA [10200]",Cigna,,1275,68,,1831.33,1831.33,1831.33,16,218.06,1593.75,"percent of total billed charges",
"COIL EMBOLIZATION 4CM 2MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-02004,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA [10200]","Cigna Open Access",,5885.22,56.9,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECTRUM DVM S3",SUP-0270-0932,CDM,S27200284,LOCAL,0272,RC,,,both,,,328.86,98.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.25,279.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK CROSSFLEX SLIM SEAL 15MM 4.5MM BALLOON DILATATION",SUP-1012412-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fmr1 Gene Detection",PX-309000028,CDM,81243,CPT,0310,RC,,,both,,,2368.35,710.5,"CIGNA [10200]","Cigna Local Plus",,125.49,,,,,,,0.01,2013.1,"fee schedule",
"FILLER BONE VOID 10CC 1-2MM GRANULE MAGNETOS EASYPACK PUTTY",SUP-703-053-US,CDM,C1713,HCPCS,0278,RC,,,both,,,20317.50,6095.25,"CIGNA [10200]",Cigna,,8127,40,,1831.33,1831.33,1831.33,16,2362.93,17269.88,"percent of total billed charges",
"CATH TREK 145CM 6MM 2.25MM ULTRA LOW PROFILE BALLOON",SUP-1012404-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL SMALL UNIVERSAL 12MM KNEE COCR POLYETHYLENE",SUP-198727212,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8456.17,28.62,,,,,0,3436.24,25114.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL STD 200MM SERRATE",SUP-BD051R,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.35,26.2,"PHCS [10601]",PHCS,,61.15,70,,,,,0,10.16,74.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION",RX-39477,CDM,J0153,HCPCS,0636,RC,67457-0855-00,NDC,both,2,ML,56.63,16.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6.18,,,,,,,3.74,48.14,"fee schedule",
"CMPNT FEMORAL 8 NARROW KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508006401,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3051.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 2-0 SH 30IN BRAID GREEN NONABSORBABLE",SUP-X833H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PREVAIL DCB 2.50X20MM",SUP-PRV025020CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 1.2MM 14MM APTUS TITANIUM HAND ELBOW HEXADRIVE 4",SUP-A-5100.14/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 54.5MM 2.4MM ROUND STAINLESS STEEL 8 FLUTE",SUP-1608-002-009,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT RAINS 52MM 39MM 5.2MM 3.7MM LARGE NASAL FRONTAL SINUS",SUP-7089-0931,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.04,111.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HYPERTENSION,MODERATE",199,APR-DRG,,,,,,,inpatient,,,27322.24,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,230.94. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,423.62) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE,MAJOR",384,APR-DRG,,,,,,,inpatient,,,79462.21,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $6,157.19. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($52,062.25) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER SIGNIFICANT HIP AND FEMUR SURGERY,EXTREME",309,APR-DRG,,,,,,,inpatient,,,298957.05,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $25,118.12. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($162,467.82) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUSTAIN",SUP-EFSRN3PL,CDM,C1776,HCPCS,0278,RC,,,both,,,13075.50,3922.65,"BLUE CROSS [10001]","Blue Cross HMO",,5125.6,39.2,,5311.50,4717.44,5388.59,31,1520.68,11114.18,"percent of total billed charges",
"KIT MICROINTRODUCER 4FR 21GA 40CM .018IN GALT GOLD X-SHARP",SUP-KIT-039-03,CDM,C1894,HCPCS,0272,RC,,,both,,,281.88,84.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,32.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.78,239.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 50MM 28MM ALTRX HIP STERI",SUP-122128150,CDM,C1776,HCPCS,0278,RC,,,both,,,9128.70,2738.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2612.63,28.62,,,,,0,1061.67,7759.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 15MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-103150,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2814.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 8MM .0135IN AXIUM PRIME 3D FRAME",SUP-FC-8-15-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"NOVANET [10819]",Novanet,,12394.13,75,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 4MM PRESTIGE PLUS HELICAL COMPLEX PACK",SUP-PRES0407CPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL MEDIUM 16MM KNEE DURATION POSTERIOR STABILIZE",SUP-6742-1-216,CDM,C1776,HCPCS,0278,RC,,,both,,,5709.75,1712.92,"PHCS [10601]",PHCS,,3996.83,70,,,,,0,664.04,4853.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 41MM 4.5MM AEQUALIS SHOULDER TITANIUM LOCK",SUP-DWD041,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"BLUE CROSS [10001]","Blue Cross PPO",,609.95,39.2,,3949.44,3949.44,3949.44,"1 through 10",180.96,1322.6,"percent of total billed charges",
"HC Alcohols",PX-301000490,CDM,80320,CPT,0301,RC,,,both,,,562.90,168.87,"FIRST HEALTH [10303]","First Health",,450.32,80,,,,,0,0.01,478.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 50CM 5FR 21GA MICROPUNCTURE .018IN LONG NDL WIRE",SUP-G49471,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 150CM 200MM 3.5MM BALLOON DILATATION",SUP-48003520X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL SURGICAL AMPLATZ SHEATH 10FR RENAL",SUP-G01688,CDM,C1894,HCPCS,0272,RC,,,both,,,510.30,153.09,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RUBICON 14 150CM .035IN GUIDING HYDROPHILIC RADIOPAQUE",SUP-H74939240035151,CDM,C1887,HCPCS,0272,RC,,,both,,,1449.90,434.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTTER SUT REMOVAL NOVOCUT MANAGER",SUP-CTXC001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1093.50,328.05,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT ARTICULAR 3-4 9MM KNEE LEFT BICRUCIATE STABILIZE XLPE",SUP-74027241,CDM,C1776,HCPCS,0278,RC,,,both,,,20478.15,6143.44,"CIGNA [10200]","Cigna Open Access",,6860.18,33.5,,5302.19,4377.88,6578.61,27,2381.61,17406.43,"percent of total billed charges",
"WEDGE 814000 FIB STRUT 40MM SRVC FEE",SUP-814000,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 28MM T8 FULL THREAD STARDRIVE NONSTERILE",SUP-656428,CDM,C1713,HCPCS,0278,RC,,,both,,,1107.59,332.28,"BLUE CROSS [10001]","Blue Cross HMO",,434.18,39.2,,957.42,156.86,7483.26,51,128.81,941.45,"percent of total billed charges",
"GWIRE ORTHOPEDIC 100CM 3MM BALL NOSE DISPOSABLE VERSANAIL",SUP-281001100,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 5IN 2MM QUICK RELEASE STERILE",SUP-MS-DC5020,CDM,S27200284,LOCAL,0272,RC,,,both,,,696.60,208.98,"FIRST HEALTH [10303]","First Health",,557.28,80,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60MM 3MM 3.5MM 4MM MEDIUM GIA PURPLE",SUP-GIA60MTS,CDM,S27200284,LOCAL,0272,RC,,,both,,,756.78,227.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,347.36,45.9,,,,,0,88.01,643.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE TITANIUM 25MM 8MM ACL PCL CANNULATED",SUP-AR-1381,CDM,C1713,HCPCS,0278,RC,,,both,,,807.98,242.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",93.97,686.78,"percent of total billed charges",
"STENT ONYX FRONTIER 15MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1239.3,45.9,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 26CM 3CM 5FR .035IN STRAIGHT URETERAL",SUP-M006155223050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS [10001]","Blue Cross HMO",,482.54,39.2,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 7MM KNEE POSTERIOR STABILIZE IDENTITY IMPRINT",SUP-TPS-020-073S,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"PHCS [10601]",PHCS,,4115.16,70,,,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 80MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-02.207.480,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"NOVANET [10819]",Novanet,,1166.89,75,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CXI 150CM 4FR DAVIS CURVE SPRT STAINLESS STEEL",SUP-G52545,CDM,C1887,HCPCS,0272,RC,,,both,,,1522.72,456.82,"FIRST HEALTH [10303]","First Health",,1218.18,80,,,,,0,177.09,1294.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT PROSERIES 150MM 80MM 5MM 5FR .014-.035IN",SUP-5F051501CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20128.50,6038.55,"CIGNA [10200]",Cigna,,8051.4,40,,,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)GWIRE R350 VASCULAR 200CM STRAIGHT 350CM 5CM .013IN NI",SUP-7390,CDM,C1769,HCPCS,0272,RC,,,both,,,1611.90,483.57,"MULTIPLAN [10600]",Multiplan,,1370.12,85,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SQUARE MIDFACE 1.5MM SCREWS BONE LORENZ TITANIUM",SUP-1/1/7131,CDM,C1713,HCPCS,0278,RC,,,both,,,2055.00,616.5,"AETNA [10100]","Aetna HMO/PPO",,1633.73,79.5,,1521.93,481.35,16760.95,30,239,1746.75,"percent of total billed charges",
"HC Immuno Optical Org",PX-306000173,CDM,87899,CPT,0306,RC,,,both,,,343.90,103.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,25.28,,,,,,,0.01,292.32,"fee schedule",
"HEAD BIPOLAR 58MM 26MM UHR UNIVERSAL ACETABULAR HIP COCR",SUP-UH1-58-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1235.75,28.62,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LACTULOSE 10 GRAM/15 ML ORAL SOLUTION",RX-38245,CDM,,,0250,RC,45963-0439-65,NDC,both,946,ML,422.48,126.74,"PHCS [10601]",PHCS,,295.74,70,,,,,0,49.13,359.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Eus Fna/Bx",PX-750000086,CDM,45342,CPT,0750,RC,,,both,,,4085.00,1225.5,"NOVANET [10819]",Novanet,,3063.75,75,,,,,0,475.09,4085,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701062,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"CIGNA [10200]","Cigna Local Plus",,6072.52,53.5,,5372.07,4581.20,7242.98,23,1320.06,9647.93,"percent of total billed charges",
"SHEATH PINNACLE 25CM 2.5CM 7FR INTRO STAINLESS STEEL",SUP-RSS706,CDM,C1894,HCPCS,0272,RC,,,both,,,156.60,46.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,106.49,68,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 28MM 145CM 3MM CORONARY STENT",SUP-1125300-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM OFFSET TAPER 32MM HIP ALUMINA CERAMIC V40",SUP-6565-0-132,CDM,C1776,HCPCS,0278,RC,,,both,,,7383.00,2214.9,"CIGNA [10200]",Cigna,,5020.44,68,,5873.17,5873.17,5873.17,"1 through 10",858.64,6275.55,"percent of total billed charges",
"MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY",RX-114231,CDM,,,0250,RC,00472-1738-03,NDC,both,1,UN,59.59,17.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.93,50.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDPLATE SPINAL 16MM SECURE-C 6D 14MM SPHERICAL CYLINDRICAL",SUP-714.306S,CDM,C1713,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Local Plus",,6945.75,31.5,,3978.14,359.25,3978.14,24,2564.42,18742.5,"percent of total billed charges",
"VALVE MITRAL 29MM BOVINE PERICARDIUM LEAFLET COBALT CHROMIUM",SUP-11400M29,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"CIGNA [10200]",Cigna,,18144,40,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN MICROPOINT 5-0 G-3 18IN 2 ARM MONOFILAMENT",SUP-772G,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.58,54.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21,153.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VG2 PRESERVON VERTIGRAFT CORTICAL CANCELLOUS",SUP-VG2C-T810P,CDM,S27800098,LOCAL,0278,RC,,,both,,,5865.00,1759.5,"BLUE CROSS [10001]","Blue Cross HMO",,2299.08,39.2,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 TAPER 36MM HIP OXINIUM ECHELON",SUP-71343600,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"CIGNA [10200]",Cigna,,6214.14,40,,5873.17,5873.17,5873.17,"1 through 10",1806.76,13205.05,"percent of total billed charges",
"ANCHOR SUT 2 5.5MM HEALICOIL ULTRABRAID PRELOAD OPEN",SUP-72203379,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"CIGNA [10200]",Cigna,,1526.18,68,,1831.33,1831.33,1831.33,16,261.02,1907.72,"percent of total billed charges",
"SPACER ALLOGRAFT 12.5X15X5MM ADVANCED PARALLEL TRAPEZOIDAL",SUP-7605,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3800.52,45.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT XEMPLIFI DEMINERALIZE BONE MATRIX PUTTY 5ML",SUP-8103.0005S,CDM,S27800098,LOCAL,0278,RC,,,both,,,3750.00,1125,"MULTIPLAN [10600]",Multiplan,,3187.5,85,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ext Ecg>7d<15d Recording",PX-731000007,CDM,93246,CPT,0731,RC,,,both,,,383.00,114.9,"BLUE CROSS [10001]","Blue Cross HMO",,44.45,,"Fee schedule rate ($44.45).",,,,0,30.87,383,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RX BILIARY SYSTEM 15CM 11.5FR BILIARY PLASTIC RAPID",SUP-M00545740,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"KAISER [10500]",Kaiser,,571.36,67,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 140MM 125CM 8MM 6FR BILIARY",SUP-G50173,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"FIRST HEALTH [10303]","First Health",,4872,80,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 11MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-611,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"KAISER [10500]",Kaiser,,6586.45,67,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PLLA HA 25MM 10MM 1.5MM ACL PCL CANNULATED",SUP-7209016,CDM,C1713,HCPCS,0278,RC,,,both,,,1882.13,564.64,"BLUE CROSS [10001]","Blue Cross PPO",,737.79,39.2,,957.42,570.23,957.42,28,218.89,1599.81,"percent of total billed charges",
"UNIT ELECTROSURGICAL PROC SET GENESYS HTA",SUP-58021,CDM,S27200284,LOCAL,0272,RC,,,both,,,12385.50,3715.65,"NOVANET [10819]",Novanet,,9289.13,75,,,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tlpa Renal Arty",PX-481000002,CDM,0234T,CPT,0481,RC,,,both,,,18540.00,5562,"NOVANET [10819]",Novanet,,13905,75,,,,,0,18.54,15759,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 150MM 2300MM 20MM ESOPHAGEAL METAL NITINOL",SUP-ECBA-20-150-230,CDM,C1874,HCPCS,0278,RC,,,both,,,16425.45,4927.63,"AETNA [10100]","Aetna HMO/PPO",,13058.23,79.5,,,,,0,1910.28,13961.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 TWINFIX ULTRA ULTRABRAID NDL COBRAID",SUP-72202616,CDM,C1713,HCPCS,0278,RC,,,both,,,2039.63,611.89,"CIGNA [10200]","Cigna Open Access",,1160.55,56.9,,1144.80,304.56,2275.09,66,237.21,1733.69,"percent of total billed charges",
"TISSUE SYNTHETIC 4.8MM OSTEOSET CALCIUM SULFATE PELLET 10ML",SUP-84000102,CDM,C1713,HCPCS,0278,RC,,,both,,,3339.00,1001.7,"MULTIPLAN [10600]",Multiplan,,2838.15,85,,,,,0,388.33,2838.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 7MM ENDOPROSTHESIS HEPARIN",SUP-VBJR070502A,CDM,C1874,HCPCS,0278,RC,,,both,,,19895.40,5968.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2357.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2313.84,16911.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 50MM 26MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-50-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"FIRST HEALTH [10303]","First Health",,3454.22,80,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCALE SPRING C5KG 8X2X1IN .01ML",SUP-5K3582Z,CDM,S27000186,LOCAL,0270,RC,,,both,,,241.43,72.43,"CIGNA [10200]","Cigna Local Plus",,129.17,53.5,,,,,0,28.08,205.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN RIGHT",SUP-77808300,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER C304S5906 SELECTSITE GLOBAL",SUP-C304S5906,CDM,C1887,HCPCS,0272,RC,,,both,,,5520.00,1656,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2268.72,41.1,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 4MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG40008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA [10200]",Cigna,,1836,68,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT GREEN 44X4IN EXPRESSAIRE XLONG LEG 1 FILL LINE 1",SUP-A70107012,CDM,S27200284,LOCAL,0272,RC,,,both,,,473.57,142.07,"CIGNA [10200]","Cigna Local Plus",,253.36,53.5,,,,,0,55.08,402.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 3-0 FS-1 18IN MONOFILAMENT BLACK",SUP-663G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET .241IN 77IN NONVENT PIERCE PIN LARGE BORE TUBE SIGHT",SUP-06544-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.20,15.66,"PHCS [10601]",PHCS,,36.54,70,,,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 SH 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J317H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP REVERSE SHOULDER: SHORT STEM RSA W/ AUGMENTS",SUP-71701432,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"FIRST HEALTH [10303]","First Health",,38808,80,,,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1MM 7MM STAINLESS STEEL CORTICAL HAND SELF TAPPING",SUP-200.527,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"CIGNA [10200]",Cigna,,323.87,68,,1831.33,1831.33,1831.33,16,55.39,404.84,"percent of total billed charges",
"STEM FEMORAL INSIGNIA 3 35.5 STANDARD OFFSET L101 MM L32.5 M",SUP-7000-5503,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"AETNA [10100]","Aetna HMO/PPO",,24306.25,79.5,,10981.53,8986.79,12413.38,12,3555.74,25987.82,"percent of total billed charges",
"HC Sol Irr Nacl 9% 250ml",PX-E27200204,CDM,E27200204,LOCAL,0272,RC,,,both,,,37.40,11.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,17.17,45.9,,,,,0,4.35,31.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM ATTUNE .75 UNIVERSAL KNEE REVISION",SUP-152303001,CDM,C1776,HCPCS,0278,RC,,,both,,,6900.00,2070,"NOVANET [10819]",Novanet,,5175,75,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ANGLE 8.75IN MISKIMON CEREBELLAR",SUP-24-2810,CDM,S27200284,LOCAL,0272,RC,,,both,,,536.63,160.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,364.91,68,,,,,0,62.41,456.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC",437,MS-DRG,,,,,,,inpatient,,,34098.35,10229.5,"AMBETTER EXCHANGE  [11102]",Ambetter,,5293.08,,"Case rate ($5,293.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,914.98, add-ons for qualifying new technology services are included. If operating cost exceeds $37,954.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,753.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,921.48. The transfer operating threshold is the transfer adjustment factor * $4,914.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $371.60. The transfer capital threshold is the transfer adjustment factor * $371.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,5293.08,21280.45,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CAPSTONE CORTICAL IMPACTED 26MMX12MM",SUP-9441226,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4657.5,27,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2 X 3 HELICAL PICO COIL",SUP-10USH02003,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"NOVANET [10819]",Novanet,,8792.33,75,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT CAST NYLON 3-5 XS ROCKER BOTTOM STRETCHABLE UPPER",SUP-79-98432,CDM,S27000186,LOCAL,0270,RC,,,both,,,94.83,28.45,"FIRST HEALTH [10303]","First Health",,75.86,80,,,,,0,11.03,80.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, ALL-POLY PEGGED GLENOID, SIZE 38, E-PLUS",SUP-521-07-238,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2622.85,28.62,,,,,0,1065.82,7789.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLARED SECUR-FIT HYDROXYAPATITE 11 HIP",SUP-S-2337-HF11,CDM,C1776,HCPCS,0278,RC,,,both,,,16482.96,4944.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1953.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1916.97,14010.52,"percent of total billed charges",
"CANNULA BONE CEMENT GPS L200 MM PUTTY BIOACTIVE STERILE FIBE",SUP-75000200,CDM,S27200284,LOCAL,0272,RC,,,both,,,1296.00,388.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 11MM CATALYFT PL40 SHORT",SUP-6069113,CDM,S27800098,LOCAL,0278,RC,,,both,,,39060.00,11718,"PHCS [10601]",PHCS,,27342,70,,,,,0,4542.68,33201,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Pulse Gen W Exst Dual Lead",PX-480000024,CDM,33230,CPT,0481,RC,,,both,,,6640.00,1992,"BLUE CROSS [10001]","Blue Cross HMO",,6640,,"Case rate ($25,005.81). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,772.23,6640,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ALEXIS 360D MEDIUM FLEXIBLE RING ATRAUMATIC SELF",SUP-C8302,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"NOVANET [10819]",Novanet,,234.9,75,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 300MM 11MM CARBON FIBER MR CONDITIONAL",SUP-394.85,CDM,C1713,HCPCS,0278,RC,,,both,,,1441.80,432.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,412.64,28.62,,,,,0,167.68,1225.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 120MM 5FR 4MM BALLOON DILATATION OTW 2",SUP-BD-L40120CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.7,68,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 147MM CEMENT AVENIR PROTASUL-S30 4 40.22MM STD",SUP-01.06010.204,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 5-0 P-1 18IN MONOFILAMENT GREEN NONABSORBABLE",SUP-G695G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.28,41.1,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myelography Lumb Inj Cerv Si",PX-361000371,CDM,62302,CPT,0361,RC,,,both,,,4612.82,1383.85,"UHC [10700]","United Healthcare",,2385,,"Case rate ($2,385). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,536.47,4612.82,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 25MM 2.50MM BALLOON DILATATION PEBAX",SUP-1400250-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 100MM 18GA 20GA SONOLONG SONOLONG SONO",SUP-521187-31C,CDM,C9814,HCPCS,0272,RC,,,both,,,510.30,153.09,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,59.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 NARROW KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-42500006001,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2709.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2658.93,19433.3,"percent of total billed charges",
"COIL EMBOLIZATION 7CM 8MM NESTER MICROCOIL PLATINUM .018IN",SUP-G47342,CDM,S27800098,LOCAL,0278,RC,,,both,,,890.92,267.28,"BLUE CROSS [10001]","Blue Cross PPO",,349.24,39.2,,,,,0,103.61,757.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Removal Tooth Root Residual",PX-450000362,CDM,D7250,HCPCS,0450,RC,,,both,,,706.00,211.8,"CIGNA [10200]","Cigna Open Access",,706,,,,,,,67.13,706,"case rate",
"RTRCTR 4IN ALM BLUNT SELF RETAINING SURGICAL",SUP-BV011R,CDM,S27200284,LOCAL,0272,RC,,,both,,,393.24,117.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.73,334.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD 24X16IN FOAM ROLYAN OPEN CELL SELF ADHSV MEDIUM DENSITY",SUP-A4881,CDM,S27000186,LOCAL,0270,RC,,,both,,,107.88,32.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OCTREOTIDE ACETATE 500 MCG/ML INJECTION SUPERORDERABLE",RX-409441,CDM,J2354,HCPCS,0637,RC,00641-6176-01,NDC,both,1,ML,264.18,79.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CEREGLIDE 71 132CM 55CM .082IN .071IN ASPIRATION",SUP-NIC71132U,CDM,C1757,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"(EVAL) TF (-T) SHEATH AND DILATOR LPLHR-0107",SUP-LHR-0107,CDM,C1894,HCPCS,0272,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES,MODERATE",347,APR-DRG,,,,,,,inpatient,,,41553.84,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $5,404.37. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 7FR 19CM VESSEL ACCEPTS .035IN GWIRE",SUP-504407X,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.86,31.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,47.67,45.9,,,,,0,12.08,88.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.25 X 33 RX US",SUP-1804225-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 0 127D",SUP-6721-0027,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6857.94,28.62,,,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL LONG TEETH",SUP-NF02,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.32,23.5,"KAISER [10500]",Kaiser,,52.47,67,,,,,0,9.11,66.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MONTEREY AL STAND-ALONE ANTERIOR LUMBAR ANTERIOR LUMBAR CAGE",SUP-480114535,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4106.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 5-0 P-3 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J493H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP M ADULT FULL FACE WITH HEADGEAR BIPAP PERFORMATRAK",SUP-989805610641,CDM,S27000186,LOCAL,0270,RC,,,both,,,218.12,65.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,89.65,41.1,,,,,0,25.37,185.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"24FR X 3CM OPTILUME DCB, 18FR X 3CM BASIC BALLOON AND INFLAT",SUP-OPTBDL7008B,CDM,C1726,HCPCS,0272,RC,,,both,,,16525.50,4957.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1921.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 250MM SCHANZ STAINLESS STEEL CONDYLAR HIP SELF",SUP-294.788,CDM,C1713,HCPCS,0278,RC,,,both,,,1042.88,312.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,709.16,68,,,,,0,121.29,886.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 55CM 100CM PROGUIDE SIDEHOLE COMPLETE HUB CUFF 50CM",SUP-DC21455550,CDM,C1894,HCPCS,0272,RC,,,both,,,1296.00,388.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE BASIXCOMPAK PHD INFLATION METAL VALVE SPRING INSRT",SUP-IN4802,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUMMIT FEMORAL STEM",SUP-157003090,CDM,C1776,HCPCS,0278,RC,,,both,,,18219.60,5465.88,"MULTIPLAN [10600]",Multiplan,,15486.66,85,,,,,0,2118.94,15486.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUMMIT FEMORAL STEM",SUP-157003090,CDM,C1776,HCPCS,0278,RC,,,both,,,18219.60,5465.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7488.26,41.1,,6417.48,6417.48,6417.48,"1 through 10",2118.94,15486.66,"percent of total billed charges",
"RESTRICT CEMENT 25MM BUCK 16-21MM HIP FEMUR PLUG STERILE",SUP-129419,CDM,S27800098,LOCAL,0278,RC,,,both,,,2820.38,846.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1917.86,68,,,,,0,328.01,2397.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X10MM CLYDESDALE PTC 0D PEEK TITANIUM",SUP-4980055,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD REAMER 19MM STAINLESS STEEL RIA STERILE DISPOSABLE",SUP-352.265S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2533.80,760.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,294.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,294.68,2153.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTW TAKERU PTCA BALLOON 2.00MM X 20MM",SUP-DC-PY2020UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"NOVANET [10819]",Novanet,,741.15,75,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ARTHROSCOPIC MEASUREMENT 60D 220MM",SUP-AR-4070-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 65CM .4MM FIRM TPR",SUP-333413,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"CIGNA [10200]","Cigna Local Plus",,204.8,53.5,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 80MM TITANIUM FULL THREAD LOCK STERILE T2 NAIL",SUP-1896-5080S,CDM,C1713,HCPCS,0278,RC,,,both,,,1279.15,383.74,"NOVANET [10819]",Novanet,,959.36,75,,,,,0,148.77,1087.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE HI-FLO 105CM 10CM 20.8-30FR .027IN STRAIGHT",SUP-18-284,CDM,C1876,HCPCS,0278,RC,,,both,,,2162.10,648.63,"PHCS [10601]",PHCS,,1513.47,70,,,,,0,251.45,1837.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM .91-1.12MM 2.25MM CORONARY",SUP-RONYX22508W,CDM,C1874,HCPCS,0278,RC,,,both,,,1875.00,562.5,"MULTIPLAN [10600]",Multiplan,,1593.75,85,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 8- CM 19GA 1.83MM COCR SILICONE 137.5-147.5CM",SUP-M00555500,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 65X35MM SMALL VELCRO ALUMINUM DENVER SEPTUM 2",SUP-10-1500-05KS,CDM,S27000186,LOCAL,0270,RC,,,both,,,546.02,163.81,"MULTIPLAN [10600]",Multiplan,,464.12,85,,,,,0,63.5,464.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 2MM 12MM DCP STAINLESS STEEL SMALL BONE SELF TAPP",SUP-201.882,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"MULTIPLAN [10600]",Multiplan,,599.55,85,,,,,0,82.03,599.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 16FR SILICONE MIC RADIOPAQUE FEED TUBE",SUP-8250-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"NOVANET [10819]",Novanet,,1314.34,75,,,,,0,203.81,1489.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 115CM 3FR 2CM TIPLESS MODIFIED BASKET MEMORY WIRE",SUP-G17872,CDM,S27200284,LOCAL,0272,RC,,,both,,,1804.50,541.35,"CIGNA [10200]","Cigna Local Plus",,965.41,53.5,,,,,0,209.86,1533.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 55MM AXSOS STAINLESS STEEL T15 FEMUR HUMERUS",SUP-371555,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"NOVANET [10819]",Novanet,,668.25,75,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TWISTER WIRE 7.25IN BERRY DUROGRIP ROUND STERNUM TUNGSTEN",SUP-MD456R,CDM,S27000186,LOCAL,0270,RC,,,both,,,667.44,200.23,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH FLEXOR CHECK-FLO MULTIPURPOSE CURVE 45CM 6FR 2.2MM",SUP-G29982,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FLEXIMA 70CM 5FR .035IN URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002510,CDM,C1758,HCPCS,0272,RC,,,both,,,237.25,71.17,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL INJECTION 1000ML 5% DEXTROSE USP LIFE FLEXIBLE CNTNR",SUP-792209,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ENDCAP SPINAL 16MM CORE DIA14MM ROUND PARALLEL MINI VBR SYST",SUP-5960400,CDM,S27800098,LOCAL,0278,RC,,,both,,,6345.24,1903.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4314.76,68,,,,,0,737.95,5393.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION",RX-10010,CDM,,,0250,RC,68180-0150-01,NDC,both,50,ML,1113.02,333.91,"MULTIPLAN [10600]",Multiplan,,946.07,85,,,,,0,129.44,946.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 30MM 3.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3530X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 20MM 125CM 10MM 6FR .035IN VASCULAR NITINOL",SUP-G43839,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1081.84,28.62,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 70MM TRIGEN FEMUR LOW PROFILE",SUP-71645070,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1407.29,68,,,,,0,240.69,1759.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMEDY SPECTRUM GV FEMORAL HEAD - 54MM",SUP-GVHDMD,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS [10001]","Blue Cross HMO",,7408.8,39.2,,5311.50,4717.44,5388.59,31,2198.07,16065,"percent of total billed charges",
"CATH STERLING MONORAIL 150CM 60MM 2.5MM BALLOON DILATATION",SUP-H74939031256010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 52MM STAINLESS STEEL 3.5MM SCR 3 HOLE T OBLIQUE RIGHT",SUP-241.931,CDM,C1713,HCPCS,0278,RC,,,both,,,2081.10,624.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,595.61,28.62,,,,,0,242.03,1768.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT CONSTRAIN LEGION OXINIUM",SUP-71421164,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6853.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6726.09,49158.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL SHOULDER 40MM ECLIPSE LARGE GLENOID CAGE SCR",SUP-AR-9301-03,CDM,C1776,HCPCS,0278,RC,,,both,,,9080.40,2724.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1056.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1056.05,7718.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTERIAL LINE 12CM 20GA",SUP-ASK-04510-HF,CDM,S27200284,LOCAL,0272,RC,,,both,,,260.13,78.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,30.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.25,221.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 150CM .035IN STRAIGH SPRT",SUP-518-082,CDM,C1887,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2 38IN BRAID 2 STRAND LOWER KNOT PROFILE BLACK",SUP-AR-7240,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.73,95.92,"NOVANET [10819]",Novanet,,239.8,75,,,,,0,37.18,271.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 18MM 48MM OFFSET 4MM TOTAL SHOULDER REPLACEMENT",SUP-5552-E-4818,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"BLUE CROSS [10001]","Blue Cross PPO",,3562.81,39.2,,3949.44,3949.44,3949.44,"1 through 10",1057.03,7725.48,"percent of total billed charges",
"SCR BONE 2MM 30MM LCP STAINLESS STEEL CORTEX WRIST HAND FOOT",SUP-201.377.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"KAISER [10500]",Kaiser,,277.46,67,,,,,0,48.16,352,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]",Cigna,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR LARGE+ CEMENT 3 PEG LOW PROFILE LCS",SUP-129409470,CDM,C1776,HCPCS,0278,RC,,,both,,,7055.25,2116.57,"BLUE CROSS [10001]","Blue Cross HMO",,2765.66,39.2,,5311.50,4717.44,5388.59,31,820.53,5996.96,"percent of total billed charges",
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 26MM COCR",SUP-VAL-35260-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"CIGNA [10200]","Cigna Open Access",,1194.9,56.9,,1144.80,304.56,2275.09,66,244.23,1785,"percent of total billed charges",
"STENT ZIMMON 5CM 7FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G24588,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,180.82,28.62,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL HOOK PENCIL 90D RIGHT ANGLE 10FT",SUP-E2510H,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.27,56.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,128.02,68,,,,,0,21.9,160.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 100MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,974.92,68,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP VESOLOCK LARGE",SUP-61114V,CDM,S27200284,LOCAL,0272,RC,,,both,,,273.43,82.03,"MULTIPLAN [10600]",Multiplan,,232.42,85,,,,,0,31.8,232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 5.5IN HOKE SPINE SURGICAL CURVE 1/8IN",SUP-28-4953,CDM,S27200284,LOCAL,0272,RC,,,both,,,197.40,59.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.96,167.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 6-9 G-H KNEE RIGHT VIVACIT-E",SUP-42522600910,CDM,C1776,HCPCS,0278,RC,,,both,,,13634.40,4090.32,"CIGNA [10200]","Cigna Open Access",,4567.52,33.5,,5302.19,4377.88,6578.61,27,1585.68,11589.24,"percent of total billed charges",
"LENS IOL 0 D +19 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.190,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 30MM LCP STAINLESS STEEL DISTAL CORTICAL",SUP-201.780,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,50.59,369.75,"percent of total billed charges",
"GWIRE PT2 VASCULAR 185CM 2CM .014IN STAINLESS STEEL NITINOL",SUP-H74938931030,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 26CM 3CM 5FR .038IN 2",SUP-M006192123170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"FIRST HEALTH [10303]","First Health",,1116.18,80,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 30MM LCP STAINLESS STEEL CORTEX WRIST HAND FOOT",SUP-201.377.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"BLUE CROSS [10001]","Blue Cross HMO",,162.34,39.2,,957.42,156.86,7483.26,51,48.16,352,"percent of total billed charges",
"CATH LAUNCHER 100CM 7FR EBU3 CURVE GUIDING LEFT CORONARY",SUP-LA7EBU30SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"KAISER [10500]",Kaiser,,262.31,67,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 13CM 14FR CHECK-FLO PERFORMER .038IN J TIP LARGE",SUP-G08024,CDM,C1894,HCPCS,0272,RC,,,both,,,378.19,113.46,"PHCS [10601]",PHCS,,264.73,70,,,,,0,43.98,321.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 16FR 42CM 30CM RADIOPAQUE BAND NONTAPERED END",SUP-G09691,CDM,C1894,HCPCS,0272,RC,,,both,,,813.24,243.97,"PHCS [10601]",PHCS,,569.27,70,,,,,0,94.58,691.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 CURVE PLUS 17.5MM KNEE XLK FIX BEARING",SUP-970444,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3017.13,27,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 29MM TORNIER AEQUALIS PERFORM +6MM SHOULDER",SUP-DWJ513,CDM,C1776,HCPCS,0278,RC,,,both,,,11340.00,3402,"BLUE CROSS [10001]","Blue Cross HMO",,4445.28,39.2,,5311.50,4717.44,5388.59,31,1318.84,9639,"percent of total billed charges",
"(EVAL) MOTIV SCAFFOLD 3.0MMX18MM","SUP-930030-18 (115)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX18MM VANGUARD ARCOM KNEE POSTERIOR STABILIZE",SUP-183648,CDM,C1776,HCPCS,0278,RC,,,both,,,8259.30,2477.79,"CIGNA [10200]","Cigna Local Plus",,4418.73,53.5,,5372.07,4581.20,7242.98,23,960.56,7020.41,"percent of total billed charges",
"SCR BONE 8.5MM 50MM SOLERA COCR SPINAL MULTIAXIAL CANNULATED",SUP-54840008550,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"FIRST HEALTH [10303]","First Health",,7637.48,80,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC",025,MS-DRG,,,,,,,inpatient,,,200885.48,60265.64,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,30177.69,,"Case rate ($28,203.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $26,188.82, add-ons for qualifying new technology services are included. If operating cost exceeds $59,228.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,362.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $26,223.45. The transfer operating threshold is the transfer adjustment factor * $26,188.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,980.00. The transfer capital threshold is the transfer adjustment factor * $1,980.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,28203.45,132745.45,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd Dx",PX-750000026,CDM,43235,CPT,0750,RC,,,both,,,3963.66,1189.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,460.97,3963.66,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 75CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR071501A,CDM,C1874,HCPCS,0278,RC,,,both,,,24374.70,7312.41,"AETNA [10100]","Aetna HMO/PPO",,19377.89,79.5,,,,,0,2834.78,20718.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 STD KNEE RIGHT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB7SR,CDM,C1776,HCPCS,0278,RC,,,both,,,17652.60,5295.78,"KAISER [10500]",Kaiser,,11827.24,67,,,,,0,2053,15004.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Smn1 Gene Dos/Deletion Alys",PX-310000037,CDM,81329,CPT,0310,RC,,,both,,,1162.00,348.6,"KAISER [10500]",Kaiser,,778.54,67,,,,,0,0.01,987.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X22X12MM MODULUS 10D XL WIDE STERILE LATEX",SUP-1221245P2,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"CIGNA [10200]",Cigna,,9504,40,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immunoassay Non Infect Ab/Ag",PX-301000243,CDM,83516,CPT,0301,RC,,,both,,,146.90,44.07,"CIGNA [10200]","Cigna Open Access",,25.37,,,,,,,0.01,124.87,"fee schedule",
"ROD REAMER 950MM 2.5MM BALL TIP STERILE DISPOSABLE",SUP-351.706S,CDM,S27200284,LOCAL,0272,RC,,,both,,,910.85,273.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,107.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.93,774.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X10MM SABLE 15D STERILE LATEX FREE",SUP-1172.2024S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"UHC [10700]","United Healthcare",,21933.45,63.3,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X10MM SABLE 15D STERILE LATEX FREE",SUP-1172.2024S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14241.15,41.1,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 8CM 4MM 5FR BALLOON DILATATION",SUP-V184080,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"PHCS [10601]",PHCS,,3839.85,70,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 5MM TRAUMAONE MANDIBLE SELF DRILL CROSS DRIVE",SUP-41-2205,CDM,C1713,HCPCS,0278,RC,,,both,,,664.20,199.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,78.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",77.25,564.57,"percent of total billed charges",
"STEM HUMERAL 86MM PRESS FIT AEQUALIS ASCEND FLEX PTC 137.5D",SUP-DWF606C,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS [10001]","Blue Cross PPO",,4939.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",1465.38,10710,"percent of total billed charges",
"STENT 22CM 3CM 4.8FR .035IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145350050,CDM,C2617,HCPCS,0278,RC,,,both,,,940.57,282.17,"CIGNA [10200]","Cigna Open Access",,535.18,,,,,,,109.39,799.48,"percent of total billed charges",
"CEMENT BONE SIMPLEX P RADIOPAQUE HALF DOSE",SUP-6188-1-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,460.73,138.22,"CIGNA [10200]",Cigna,,313.3,68,,,,,0,53.58,391.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM 2.6-2FR .019IN EXCELSIOR",SUP-M0031441910,CDM,S27200284,LOCAL,0272,RC,,,both,,,7801.42,2340.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,907.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,907.31,6631.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL SF 8FR F-J CURVE ABLATION",SUP-D134804,CDM,C1732,HCPCS,0272,RC,,,both,,,21312.90,6393.87,"NOVANET [10819]",Novanet,,15984.68,75,,,,,0,2478.69,18115.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM SPINE",SUP-8805540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4382,45.9,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM ATTUNE 7 KNEE POSTERIOR CEMENT REVISION",SUP-1549-07-002,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"PHCS [10601]",PHCS,,4250.4,70,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 210MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-410-210,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 70MM HIP MULTIHOLE RIM TRITANIUM X3 MDM",SUP-509-02-70I,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"NOVANET [10819]",Novanet,,8424,75,,,,,0,1306.28,9547.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 8MM 144CM 2.75MM",SUP-H7493941208270,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5278.5,68,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION DEB 2.25X30",SUP-SCA14U-225030D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +8 DIOPTER +1.5 CYL BICONVEX 13MM 6MM POSTERIOR",SUP-SN6AT3.080,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NUCLEUS-X 110CM 5CM 28MM BALLOON DILATATION POLYAMIDE",SUP-612033,CDM,C1725,HCPCS,0272,RC,,,both,,,6566.52,1969.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,763.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,763.69,5581.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 2-0 CT-1 27IN MONOFILAMENT YELLOWISH TAN",SUP-843H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 6MM ENDOWRIST SP CADIERE NONSTERILE LATEX",SUP-431300,CDM,S27000186,LOCAL,0270,RC,,,both,,,2063.40,619.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,848.06,41.1,,,,,0,239.97,1753.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 70CM POWERPICC 2 LUMEN GWIRE INTRO NDL CUFF",SUP-3386355,CDM,C1751,HCPCS,0272,RC,,,both,,,929.88,278.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,632.32,68,,,,,0,108.15,790.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT LARGE 11 CC PUTTY BIOACTIVE",SUP-78000110,CDM,C1713,HCPCS,0278,RC,,,both,,,13662.00,4098.6,"PHCS [10601]",PHCS,,9563.4,70,,,,,0,1588.89,11612.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 3.5IN 17GA 19GA PERIFIX TUOHY BPA DEHP PVC",SUP-332097,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.47,61.94,"AETNA [10100]","Aetna HMO/PPO",,164.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.01,175.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 69MM 3 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-43F69V,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"(EVAL) INSERTABLE CARDIAC MONITOR SYSTEM","SUP-M301 - LUX-DX",CDM,C1764,HCPCS,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 100CM 5FR SIMMONS 2 CURVE STRAIGHT",SUP-M001314351,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"MULTIPLAN [10600]",Multiplan,,99.09,85,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE WITH OLIVE - DIA 2.0 X 450 MM",SUP-4933-8-040,CDM,C1713,HCPCS,0278,RC,,,both,,,756.70,227.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,216.57,28.62,,,,,0,88,643.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 24MM 144CM 3.5MM CORONARY STENT",SUP-H7493952824350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross HMO",,2181.48,39.2,,9776.84,9776.84,9776.84,"1 through 10",647.21,4730.25,"percent of total billed charges",
"GWIRE HI-TORQUE EXTRA S-PORT VASCULAR J 190CM 3CM .014IN",SUP-22225MJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30MM 4MM VORTX 35 COIL PUSHABLE 4MM",SUP-M0013732041,CDM,S27800098,LOCAL,0278,RC,,,both,,,769.50,230.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 2 KNEE DISTAL HINGE",SUP-5612-D-205,CDM,C1776,HCPCS,0278,RC,,,both,,,10143.00,3042.9,"BLUE CROSS [10001]","Blue Cross HMO",,3976.06,39.2,,5311.50,4717.44,5388.59,31,1179.63,8621.55,"percent of total billed charges",
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET HOUSING REAMER",SUP-AR-1204AF-75,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1740.38,68,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOLUTION POROUS KEEL PRIMARY 15MM X SIZE 5/6",SUP-ETPK1556,CDM,C1776,HCPCS,0278,RC,,,both,,,4326.30,1297.89,"AETNA [10100]","Aetna HMO/PPO",,3439.41,79.5,,10981.53,8986.79,12413.38,12,503.15,3677.36,"percent of total billed charges",
"PIN FIXATION 1/8IN HEADLESS SQUARE END 3.5IN STAINLESS STEEL",SUP-7650-2038,CDM,S27200284,LOCAL,0272,RC,,,both,,,2947.50,884.25,"PHCS [10601]",PHCS,,2063.25,70,,,,,0,342.79,2505.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 5.5MM CREO CURVE TITANIUM NONSTERILE",SUP-1119.7050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID STIMUBLAST DEMINERALIZED BONE MATRIX GEL",SUP-ABS-2002-10,CDM,C1713,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]","Cigna Local Plus",,4429.8,53.5,,3978.14,359.25,3978.14,24,962.96,7038,"percent of total billed charges",
"SUT POLYPROPYLENE PROLENE HS 5-0 RB-2 30IN 2 ARM",SUP-EPH8710H,CDM,S27200284,LOCAL,0272,RC,,,both,,,168.43,50.53,"PHCS [10601]",PHCS,,117.9,70,,,,,0,19.59,143.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETENE DS 25X20CM COMPOSITE ABSORBABLE FILM",SUP-PPDS2520,CDM,C1781,HCPCS,0278,RC,,,both,,,6915.11,2074.53,"MULTIPLAN [10600]",Multiplan,,5877.84,85,,,,,0,765.93,5877.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABLE, 12X26MM, 10-17MM, 15%C2%B0",SUP-1172.4124S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"MULTIPLAN [10600]",Multiplan,,29452.5,85,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL SHAFT SMALL FREEZE DRIED 100-125MM",SUP-72A002,CDM,S27800098,LOCAL,0278,RC,,,both,,,3360.00,1008,"CIGNA [10200]","Cigna Local Plus",,1797.6,53.5,,,,,0,390.77,2856,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP UNISTEP PLUS 20MM 100CM 8MM 6FR",SUP-M001711240,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1001.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR SL4ST CURVE GUIDING CORONARY",SUP-LA7SL40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"AETNA [10100]","Aetna HMO/PPO",,290.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 6MM BALL DISSECTING",SUP-MR8-14BA60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.19,388.56,"FIRST HEALTH [10303]","First Health",,1036.15,80,,,,,0,150.63,1100.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Paravrt Jt L/S 1 Lvl",PX-510000138,CDM,64493,CPT,0761,RC,,,both,,,6149.00,1844.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4181.32,68,,,,,0,715.13,5226.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LACTASE 9,000 UNIT CHEWABLE TABLET",RX-114495,CDM,,,0637,RC,00450-0930-32,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 12.4X1.4MM TITANIUM 2/2.3MM SCR 6 HOLE STT FUSION",SUP-A-4660.15,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,9857.93,56.9,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 575CC P4.6CM MODERATE PLUS PROFILE MODERATE BASE",SUP-350-5751BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",601.85,4398.75,"percent of total billed charges",
"SCR BONE 7MM 30MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712730,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,1521.93,481.35,16760.95,30,441.36,3225.75,"percent of total billed charges",
"HC I&D Abscess Nasal Septum",PX-450000210,CDM,30020,CPT,0450,RC,,,both,,,1347.00,404.1,"FIRST HEALTH [10303]","First Health",,1077.6,80,,,,,0,1.35,1347,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemo Extend IV Infus W/Pump",PX-335000006,CDM,G0498,HCPCS,0335,RC,,,both,,,1831.05,549.31,"CIGNA [10200]","Cigna Local Plus",,449,,"Per diem ($449).",,,,0,212.95,1556.39,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Short Somatosensory Test Tr/Hd",PX-922000010,CDM,95927,CPT,0922,RC,,,both,,,888.00,266.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,103.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.27,754.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 150MM 4MM BALLOON DILATATION RAPID",SUP-47540150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"NOVANET [10819]",Novanet,,1196.78,75,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE INFILTRAC PLUS VASCULAR 190CM TIP .014IN",SUP-1030003J,CDM,C1769,HCPCS,0272,RC,,,both,,,1036.80,311.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,705.02,68,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repair Ortho Dev 15 Min",PX-E27400089,CDM,L4205,HCPCS,0274,RC,,,both,,,56.10,16.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.52,47.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 20MM DEGENERATIVE DISC 1 LEVEL ARCHON BONE SPINE",SUP-8787120,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1927.8,45.9,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1.5MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-1.5-2-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4806.85,41.1,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 60MM 130CM 5MM OFFSET CROWN VASCULAR ILIAC",SUP-SC560LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]","Cigna Local Plus",,3876.08,53.5,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER SMOKE EVAC 7/8IN VIROSAFE 1 PORT FEMALE PORT TUBE",SUP-VS06004,CDM,S27000186,LOCAL,0270,RC,,,both,,,1008.45,302.53,"KAISER [10500]",Kaiser,,675.66,67,,,,,0,117.28,857.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 7FR 40D GUIDING DURAFORM PTFE",SUP-M003101430,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,296.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13175540,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",348.9,2550,"percent of total billed charges",
"SCR BONE 2.7MM 12MM STERNALOCK BLU STERNAL CANCELLOUS LOCK",SUP-73-2712,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,153.47,39.2,,957.42,570.23,957.42,28,45.53,332.78,"percent of total billed charges",
"STEM HUMERAL 83MM 19MM COMPREHENSIVE POROUS MINI SHOULDER",SUP-113639,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"FIRST HEALTH [10303]","First Health",,10080,80,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 75CM 6MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200064070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,481.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850016550,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"KAISER [10500]",Kaiser,,4391.85,67,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HIP FEM P2 POROUS OFFSZ12",SUP-425-97-012,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"PHCS [10601]",PHCS,,29790.92,70,,,,,0,4949.55,36174.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR",RX-27181,CDM,,,0637,RC,59651-0018-90,NDC,both,1,UN,21.31,6.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.48,18.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701056,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"MULTIPLAN [10600]",Multiplan,,9647.93,85,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 24CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006155242010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]","Cigna Local Plus",,658.56,,,,,,,143.16,1046.32,"percent of total billed charges",
"BINDER ABDOMINAL 9IN 3 PANEL ELASTIC HOOK LOOP CLSR 30-45IN",SUP-13661056,CDM,S27000186,LOCAL,0270,RC,,,both,,,71.08,21.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,29.21,41.1,,,,,0,8.27,60.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 13X11CM BREAST 400ML STYLE 133SV TEXTURED SUT TAB",SUP-133SX-13-T,CDM,C1789,HCPCS,0278,RC,,,both,,,6510.00,1953,"NOVANET [10819]",Novanet,,4882.5,75,,,,,0,757.11,5533.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINIARC PRECISE",SUP-720191-01,CDM,C1771,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Open Access",,5889.15,56.9,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 80MM 120CM 10MM 159CM VASCULAR NITINOL ILIAC",SUP-H74939200108020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYOSURE REACH TISSUE REMOVAL 3 DEVICES PER BOX",SUP-10-403FC-NMS,CDM,S27200284,LOCAL,0272,RC,,,both,,,5692.50,1707.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,662.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 6FR 15CM RADIOPAQUE GWIRE STERILE DISPOSABLE",SUP-G00944,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"PHCS [10601]",PHCS,,34.53,70,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOLUTPRO TRANSCATHETER AORTIC VALVE-26MM - THE 26MM EVOLTR",SUP-EVOLUTPRO-26-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS [10001]","Blue Cross HMO",,67032,39.2,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 25MM 9.5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ225,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"AETNA [10100]","Aetna HMO/PPO",,7177.04,79.5,,10981.53,8986.79,12413.38,12,1049.92,7673.56,"percent of total billed charges",
"PLATE 43MM TITANIUM LEVEL 2 ZEVO BONE SPINE CERVICAL",SUP-3002043,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,957.42,156.86,7483.26,51,521.61,3812.25,"percent of total billed charges",
"BLADE INTRAMEDULLARY NAIL TAN 85MM 10.35MM TFN-ADVANCED",SUP-04.038.385,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DESFLURANE 100 % INHALATION LIQUID",RX-9747,CDM,,,0250,RC,10019-0641-64,NDC,both,240,ML,1209.19,362.76,"AETNA [10100]","Aetna HMO/PPO",,961.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.63,1027.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SURGICAL CLP XWIDE RECHARGEABLE PIVOT HEAD LIGHTWEIGHT",SUP-9690,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.34,19.6,"UHC [10700]","United Healthcare",,41.36,63.3,,,,,0,7.6,55.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 4.0/40",SUP-404677,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -6MM OFFSET 28MM HIP TYPE 1 COCR G7",SUP-163660,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"AETNA [10100]","Aetna HMO/PPO",,3856.31,79.5,,10981.53,8986.79,12413.38,12,564.14,4123.1,"percent of total billed charges",
"CATH LAUNCHER 6FR .071IN EXTRA BACKUP 5 LEFT CURVE GUIDING",SUP-LA6EBU50,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON SMALL TITANIUM WIDE BLADE TRANSVERSE",SUP-7541112,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL DEXTILE 16X12CM LEFT ANATOMICAL 3D",SUP-DXT1612AL,CDM,C1781,HCPCS,0278,RC,,,both,,,1616.68,485,"PHCS [10601]",PHCS,,1131.68,70,,,,,0,188.02,1374.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 40CM 36FR VENOUS THIN WALL STRAIGHT 1 STAGE",SUP-TF036L,CDM,S27200284,LOCAL,0272,RC,,,both,,,187.62,56.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEMODIALYSIS DRESSING CHANGE KIT",SUP-78539,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.20,68.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SEEKER 150CM 4FR .018IN GUIDING CROSSING SPRT",SUP-SK15018,CDM,C1887,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT ORTHOPEDIC LARGE 8IN WRIST RIGHT 4 WAY STRETCH",SUP-351LR,CDM,S27000186,LOCAL,0270,RC,,,both,,,121.28,36.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Hood Oxygen",PX-E27000193,CDM,E27000193,LOCAL,0270,RC,,,both,,,89.10,26.73,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.5MM X 22.0MM",SUP-492502212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.4 X 3.0 X 12MM TWO-STEP HAMMER TOE IMPLANT",SUP-204-30-012,CDM,C1713,HCPCS,0278,RC,,,both,,,6141.00,1842.3,"MULTIPLAN [10600]",Multiplan,,5219.85,85,,,,,0,714.2,5219.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 42MM 28MM E HIP X3 ADM STERILE LATEX FREE",SUP-7236-2-848,CDM,C1776,HCPCS,0278,RC,,,both,,,8711.25,2613.37,"PHCS [10601]",PHCS,,6097.88,70,,,,,0,1013.12,7404.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GA-68-GOZETOTIDE INTRAVENOUS SOLUTION (9 MCI)",RX-411559,CDM,A9596,HCPCS,0343,RC,08888-8878-84,NDC,both,1,UN,24796.80,7439.04,"KAISER [10500]",Kaiser,,16613.86,67,,,,,0,1181,21077.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTELLISYSTEM25 13IN INFLATION POLYCARBONATE 20ML",SUP-IN1525,CDM,S27200284,LOCAL,0272,RC,,,both,,,464.13,139.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,315.61,68,,,,,0,53.98,394.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 122MM 12MM COMPREHENSIVE PPS SHOULDER",SUP-12-113562,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS [10001]","Blue Cross HMO",,4939.2,39.2,,5311.50,4717.44,5388.59,31,1465.38,10710,"percent of total billed charges",
"ROD SPINAL 50MM 5.5MM VIPER 2 PREBENT TITANIUM NONSTERILE",SUP-186788050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 110CM 1MM 5FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY FIX",SUP-F5QF005CT,CDM,C1730,HCPCS,0272,RC,,,both,,,551.20,165.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,64.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.1,468.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RELIANCE XK AIRGUARD DUALATOR 24CM 19CM 16FR 16.5FR",SUP-5323190,CDM,C1750,HCPCS,0278,RC,,,both,,,1498.50,449.55,"PHCS [10601]",PHCS,,1048.95,70,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 8MM 3.75MM BALLOON DILATATION DURATRAC",SUP-NCEUP37508X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"KAISER [10500]",Kaiser,,379.89,67,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 20MM GORE-TEX STD WALL STD WALLED RING",SUP-R20030030,CDM,C1768,HCPCS,0278,RC,,,both,,,6141.00,1842.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,727.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,714.2,5219.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTUNE KNEE SYSTEM REVISION CRS TOTATIN PLATFORM INSERT  SIZ",SUP-151710522,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"MULTIPLAN [10600]",Multiplan,,12574.56,85,,,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER BURR HOLE .4MM 14MM UNIVERSAL NEURO III",SUP-53-34514,CDM,C1713,HCPCS,0278,RC,,,both,,,1858.37,557.51,"NOVANET [10819]",Novanet,,1393.78,75,,,,,0,216.13,1579.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PULSE GENRTR WAVEWRITER ALPHA IMPLANTABLE",SUP-SC-1432,CDM,C1820,HCPCS,0278,RC,,,both,,,99750.00,29925,"CIGNA [10200]","Cigna Local Plus",,31421.25,31.5,,,,,0,11600.93,84787.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +29 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.290,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 46MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-46,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross HMO",,119.36,39.2,,957.42,156.86,7483.26,51,35.41,258.83,"percent of total billed charges",
"SLING GYNECOLOGICAL SPARC SYSTEM FEMALE",SUP-72403656,CDM,C1771,HCPCS,0278,RC,,,both,,,8280.00,2484,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 12CM 7FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22356,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS [10001]","Blue Cross HMO",,247.67,39.2,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM 2 MARKER SEMIRIGID WIRE STIFFENER",SUP-800SR26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"NOVANET [10819]",Novanet,,9832.5,75,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE V-18 CONTROLWIRE VASCULAR STRAIGHT 150CM 12CM .018IN",SUP-M001468560,CDM,C1769,HCPCS,0272,RC,,,both,,,602.64,180.79,"MULTIPLAN [10600]",Multiplan,,512.24,85,,,,,0,70.09,512.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 83MMX12MM VANGUARD ARCOM KNEE ANTERIOR STABILIZE",SUP-189122,CDM,C1776,HCPCS,0278,RC,,,both,,,8154.42,2446.33,"BLUE CROSS [10001]","Blue Cross HMO",,3196.53,39.2,,5311.50,4717.44,5388.59,31,948.36,6931.26,"percent of total billed charges",
"HC Maskset Brainlab",PX-E27000192,CDM,9999119,LOCAL,0270,RC,,,both,,,1400.30,420.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,165.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.85,1190.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Maskset Brainlab",PX-E27000192,CDM,9999119,LOCAL,0270,RC,,,both,,,1400.30,420.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,952.2,68,,,,,0,162.85,1190.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC",240,MS-DRG,,,,,,,inpatient,,,87360.93,26208.28,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,18212.27,,"Case rate ($17,681.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $16,418.77, add-ons for qualifying new technology services are included. If operating cost exceeds $49,458.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,623.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $16,440.49. The transfer operating threshold is the transfer adjustment factor * $16,418.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,241.34. The transfer capital threshold is the transfer adjustment factor * $1,241.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,83223.2,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC",240,MS-DRG,,,,,,,inpatient,,,87360.93,26208.28,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,18742.73,,"Case rate ($17,681.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $16,418.77, add-ons for qualifying new technology services are included. If operating cost exceeds $49,458.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,623.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $16,440.49. The transfer operating threshold is the transfer adjustment factor * $16,418.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,241.34. The transfer capital threshold is the transfer adjustment factor * $1,241.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,83223.2,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ATTAIN HYBRID VASCULAR STRAIGHT 108CM .018IN STABILITY",SUP-GWR419688,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRACTOR SURGICAL L6 1/4IN SHARP PREMIUM GRADE SENN",SUP-20-0508,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.99,22.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.72,63.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 7FR L22CM FIRM TRI LAYER DESIGN RAW COLORANT",SUP-M0061902310,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SEEKER 150CM SPRT HYDROPHILIC PERIPHERAL RADIOPAQUE",SUP-SK15035M,CDM,C1887,HCPCS,0272,RC,,,both,,,1498.50,449.55,"NOVANET [10819]",Novanet,,1123.88,75,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE/SLEEVE ORTHOPEDIC 2MM DALL-MILES HIP STAINLESS STEEL",SUP-3704-0-510,CDM,C1713,HCPCS,0278,RC,,,both,,,2205.00,661.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,261.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,256.44,1874.25,"percent of total billed charges",
"KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) INTRAVENOUS SOLUTION",RX-187204,CDM,A9562,HCPCS,0343,RC,08888-8878-33,NDC,both,1,UN,1798.82,539.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1223.2,68,,,,,0,209.2,1546.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17CM 5MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-05017,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"FIRST HEALTH [10303]","First Health",,9378.48,80,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 57MM 135CM 8MM 60MM BILIARY TANTALUM",SUP-PXB35-08-57-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"PHCS [10601]",PHCS,,3056.9,70,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.00 X 12 RX US",SUP-1804300-12,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOLD FEMORAL STEM 56MM STAGEONE HIP STAINLESS STEEL SILICONE",SUP-431183,CDM,S27200284,LOCAL,0272,RC,,,both,,,7955.01,2386.5,"NOVANET [10819]",Novanet,,5966.26,75,,,,,0,925.17,6761.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 12MM SMALL SHELL DJO SURGICAL ALTIVATE",SUP-533-12-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"PHCS [10601]",PHCS,,33246.11,70,,,,,0,5523.6,40370.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT 7IN PENFIELD 1 BROAD CURVE 2 END SHARP ROUND SPOON",SUP-57-3651,CDM,S27200284,LOCAL,0272,RC,,,both,,,258.48,77.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,30.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.06,219.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY IV SFT STRG 59CM .014IN",SUP-6601,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC OP Surgery Center or Time Half Hour",PX-360000055,CDM,360000055,LOCAL,0360,RC,,,both,,,410.94,123.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,48.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.79,349.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 80MM 2.5MM BALLOON DILATATION RAPID",SUP-47525080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"FIRST HEALTH [10303]","First Health",,1276.56,80,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 9MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140914,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1407.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED 100CM 4CM 11FR 35MM BALLOON DILATATION RADIOPAQUE",SUP-611671,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"NOVANET [10819]",Novanet,,3988.53,75,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 115CM 1MM 6FR 10MM SPACING FIX CURVE",SUP-F6QF010RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"FIRST HEALTH [10303]","First Health",,725.76,80,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 47CM 14MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181447,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2162.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 24MM 8MM STAINLESS STEEL LONG THREAD HAND",SUP-02.226.324,CDM,C1713,HCPCS,0278,RC,,,both,,,1647.00,494.1,"PHCS [10601]",PHCS,,1152.9,70,,,,,0,191.55,1399.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5-6 11MM KNEE XLPE POSTERIOR STABILIZED HIGH",SUP-71453222,CDM,C1776,HCPCS,0278,RC,,,both,,,13420.50,4026.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5515.83,41.1,,6417.48,6417.48,6417.48,"1 through 10",1560.8,11407.43,"percent of total billed charges",
"BLADE BEAVER 376984",SUP-376984,CDM,S27200284,LOCAL,0272,RC,,,both,,,105.85,31.75,"FIRST HEALTH [10303]","First Health",,84.68,80,,,,,0,12.31,89.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHAMFERED SCREW CALIBRATED DRILL CANNULATED 4.0MM (3.2MM)",SUP-CD-CS-1040,CDM,S27000186,LOCAL,0270,RC,,,both,,,2130.00,639,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,247.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 11MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-111,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"NOVANET [10819]",Novanet,,7372.89,75,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 6MMX59MM 7FR 80CMCATH HEPARIN",SUP-BXB065901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2268.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM MEDIUM BARREL",SUP-5120017040,CDM,S27200284,LOCAL,0272,RC,,,both,,,765.94,229.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.08,651.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 9MM KNEE ONLAY MULTICOMPARTMENTAL RESTORIS",SUP-180705-2,CDM,C1776,HCPCS,0278,RC,,,both,,,4046.85,1214.05,"CIGNA [10200]","Cigna Local Plus",,2165.06,53.5,,5372.07,4581.20,7242.98,23,470.65,3439.82,"percent of total billed charges",
"HC Dressing Burn Triact",PX-E27200090,CDM,E27200090,LOCAL,0272,RC,,,both,,,73.70,22.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,50.12,68,,,,,0,8.57,62.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 12MM 144CM 2.5MM CORONARY STENT PEBAX",SUP-H7493926012250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"KAISER [10500]",Kaiser,,3728.55,67,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 46-62X9IN 3 PANEL ELASTIC HOOK LOOP CLSR",SUP-13992000,CDM,S27000186,LOCAL,0270,RC,,,both,,,121.71,36.51,"CIGNA [10200]",Cigna,,82.76,68,,,,,0,14.15,103.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,inpatient,,,84889.64,25466.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,40434.89,,,,,,,7561,74043.98,"case rate",
"CLAREONPANOPTIX PROTORIC",SUP-PXCAT6,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,622.2,68,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP MULTIHOLE TRITANIUM TRIDENT II E",SUP-709-04-54E,CDM,C1776,HCPCS,0278,RC,,,both,,,17958.91,5387.67,"PHCS [10601]",PHCS,,12571.24,70,,,,,0,2088.62,15265.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 64MM 3 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800364,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"SYSTEM PINNACLE PRECISION ACCESS SYSTEM 45CM 10CM 5FR 21-19",SUP-70-5165,CDM,C1894,HCPCS,0272,RC,,,both,,,304.50,91.35,"PHCS [10601]",PHCS,,213.15,70,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 10MM 120CM 6FR 2-10-2MM SPACING ELECTROPHYSIOLOGY 10",SUP-D1086784,CDM,C1730,HCPCS,0272,RC,,,both,,,2040.00,612,"AETNA [10100]","Aetna HMO/PPO",,1621.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,237.25,1734,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC XL 41X6IN SHOULDER ELASTIC CONTOURED RIB",SUP-9008-04,CDM,S27000186,LOCAL,0270,RC,,,both,,,103.62,31.09,"NOVANET [10819]",Novanet,,77.72,75,,,,,0,12.05,88.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +28.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030285,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR WHITE 57MM 28MM RINGLOC ECCENTRIC HIP",SUP-11-165238,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"CIGNA [10200]",Cigna,,4528.72,68,,5873.17,5873.17,5873.17,"1 through 10",774.54,5660.9,"percent of total billed charges",
"CAP SYSTEM MULTIPOLAR THR CERAMIC CEMENTED STEM CUP LINER HE",SUP-98000100701,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"AETNA [10100]","Aetna HMO/PPO",,7679.7,79.5,,10981.53,8986.79,12413.38,12,1123.46,8211,"percent of total billed charges",
"SHELL ACETABULAR 54MM HIP MULTIHOLE TRITANIUM TRIDENT II E",SUP-709-04-54E,CDM,C1776,HCPCS,0278,RC,,,both,,,17958.91,5387.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7183.56,40,,,,,0,2088.62,15265.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MOTIV SCAFFOLD 2.5MMX18MM","SUP-930025-18 (105)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 6MM 3.25MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP32506X,CDM,C1725,HCPCS,0272,RC,,,both,,,536.63,160.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,220.55,41.1,,,,,0,62.41,456.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.9H 56MM 3 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009356,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"INSRT TIBIAL 2 10MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962321,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"AETNA [10100]","Aetna HMO/PPO",,11530.52,79.5,,10981.53,8986.79,12413.38,12,1686.79,12328.23,"percent of total billed charges",
"HC Nrv Condct 1-2 Studies",PX-922000019,CDM,95907,CPT,0922,RC,,,both,,,1022.50,306.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,118.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.92,869.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.6MM 480MM KIRSCHNER STAINLESS STEEL TROCAR",SUP-02.606.001,CDM,C1713,HCPCS,0278,RC,,,both,,,413.25,123.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,189.68,45.9,,,,,0,48.06,351.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insulin Total Berkeley",PX-301000285,CDM,83525,CPT,0301,RC,,,both,,,244.00,73.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,207.4,"per diem",
"HC Prevnt Indv Counsel 15 Min",PX-510000181,CDM,99401,CPT,0510,RC,,,both,,,39.00,11.7,"KAISER [10500]",Kaiser,,26.13,67,,,,,0,4.54,39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBTR SHEATH 13.5CM 5FR INFUSION PRESSURE MNTR KINK RESISTANT",SUP-502190,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.83,25.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,57.68,68,,,,,0,9.87,72.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 32MM 144CM 4MM CORONARY STENT",SUP-H7493911432400,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA [10200]",Cigna,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ihc 1st Antibody per Slide",PX-312000041,CDM,88342,CPT,0312,RC,,,both,,,766.65,229.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,113.35,,,,,,,0.01,651.65,"fee schedule",
"TLX IMPLANT, 11X11X30MM 15",SUP-5811305,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3412.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CORONARY 2.5MM 14MM DRUG ELUDING ENDEAVOR SPRINT",SUP-ENSP25014UX,CDM,C1874,HCPCS,0278,RC,,,both,,,9108.00,2732.4,"CIGNA [10200]","Cigna Local Plus",,4872.78,53.5,,,,,0,1059.26,7741.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AERO DV 60MM 18MM TRACHEOBRONCHIAL NITINOL FULLY",SUP-90129-202,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7089.75,41.1,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 5.6MM 30MM NCB TITANIUM ALUMINUM VANADIUM",SUP-00236903035,CDM,C1713,HCPCS,0278,RC,,,both,,,1275.75,382.72,"CIGNA [10200]","Cigna Local Plus",,682.53,53.5,,3978.14,359.25,3978.14,24,148.37,1084.39,"percent of total billed charges",
"WIRE FIXATION 285MM 3MM KIRSCHNER T2 RETROGRADE FEMUR",SUP-1806-0050S,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"MULTIPLAN [10600]",Multiplan,,722.93,85,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 12MM 145CM 5.5MM BALLOON DILATATION",SUP-1400550-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 18MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ318,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"CIGNA [10200]",Cigna,,654.16,68,,5873.17,5873.17,5873.17,"1 through 10",111.88,817.7,"percent of total billed charges",
"GRAFT SOFT TISSUE 30X10MM COSTAL CARTILAGE FROZEN",SUP-70B001,CDM,C1713,HCPCS,0278,RC,,,both,,,2088.75,626.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,247.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,242.92,1775.44,"percent of total billed charges",
"COIL EMBOLIZATION 6CM 2.5MM TARGET NANO HELICAL DETACHABLE",SUP-M0035452560,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"CIGNA [10200]",Cigna,,6227.22,68,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM 9FR ENDOCARDIAL DF4-LLHO CNCT 1 COIL TINE",SUP-263,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"PHCS [10601]",PHCS,,10626,70,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 15X18MM DYNANITE SUPERMX NITINOL COMPRESSION LOW",SUP-AR-8719MX-1815,CDM,C1713,HCPCS,0278,RC,,,both,,,14455.50,4336.65,"KAISER [10500]",Kaiser,,9685.19,67,,,,,0,1681.17,12287.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSAN4PR,CDM,C1776,HCPCS,0278,RC,,,both,,,22610.70,6783.21,"BLUE CROSS [10001]","Blue Cross PPO",,8863.39,39.2,,3949.44,3949.44,3949.44,"1 through 10",2629.62,19219.1,"percent of total billed charges",
"STEM FEMORAL COLLAR ACTIS DUOFIX 1 STD OFFSET HIP STERILE",SUP-101011010,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"AETNA [10100]","Aetna HMO/PPO",,24228.62,79.5,,10981.53,8986.79,12413.38,12,3544.39,25904.81,"percent of total billed charges",
"CATH MARINER 100CM 5FR SIDEWINDER SIMMONS TECHNIQUE 1 CURVE",SUP-11709009,CDM,C1887,HCPCS,0272,RC,,,both,,,344.52,103.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.07,292.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 2.6MM CLEARCUT ANGLED SLIT FULL HANDLE",SUP-8065992648,CDM,S27200284,LOCAL,0272,RC,,,both,,,221.68,66.5,"PHCS [10601]",PHCS,,155.18,70,,,,,0,25.78,188.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 4.1MM ECHELON ENDOPATH THICK TISSUE 2MM GREEN",SUP-GST45G,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) JAVELIN CORONARY IVL CATHETER",SUP-FG72651,CDM,C1761,HCPCS,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH FLEXCATH ADVANCE 135D 65CM 81CM 15FR 12FR INTRO PEBAX",SUP-4FC12,CDM,C1766,HCPCS,0272,RC,,,both,,,7590.00,2277,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATHETERIZATION SURESTEP LUBRICATH STATLOCK 18FR 5ML",SUP-A899918,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.36,32.21,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) OSCOR GUIDESTAR 10F SHEATH 50MM","SUP-D-1433-03-SI (50MM)",CDM,C1887,HCPCS,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 100MM 6MM BALLOON",SUP-LX1813061005F,CDM,C2623,HCPCS,0272,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT VASCULAR 80CM 6MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT060080A,CDM,C1768,HCPCS,0278,RC,,,both,,,17056.80,5117.04,"BLUE CROSS [10001]","Blue Cross PPO",,6686.27,39.2,,,,,0,1983.71,14498.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT 2 KNEE CEMENT ROTATE PLATFORM",SUP-129431120,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Epstein Barr Virus Dna CSF",PX-306000159,CDM,87799,CPT,0306,RC,,,both,,,979.00,293.7,"CIGNA [10200]",Cigna,,94.25,,,,,,,0.98,832.15,"fee schedule",
"STENT GEENEN 7CM 7FR PANCREATIC POLYETHYLENE PUSH CATH DRAIN",SUP-G21377,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"NOVANET [10819]",Novanet,,473.85,75,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X3 HUMERAL INSERT - 32MM X 10MM STANDARD",SUP-5571-S-3210,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"KAISER [10500]",Kaiser,,6753.6,67,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trnscth Rnl Symp Dnrv Perc Uni",PX-481000146,CDM,0338T,CPT,0481,RC,,,both,,,9752.00,2925.6,"BLUE CROSS [10001]","Blue Cross PPO",,7889.77,,"Case rate ($7,889.77). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1134.16,9752,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Breast Local Dev MR",PX-361000318,CDM,19287,CPT,0361,RC,,,both,,,1856.18,556.85,"CIGNA [10200]",Cigna,,1856.18,,"Case rate ($2,497). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,215.87,1856.18,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII ALLOGRAFT 16MM 23MM",SUP-401216A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM CARBO-SEAL ASCENDING AORTA VALSALVA",SUP-CP-029,CDM,S27800098,LOCAL,0278,RC,,,both,,,29408.40,8822.52,"AETNA [10100]","Aetna HMO/PPO",,23379.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3420.2,24997.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SECURE EVIVA BREAST BIOPSY",SUP-SMARKEVIVA2S10,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,454.14,68,,,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 180CM 150MM 4FR 2.5MM .018IN BALLOON",SUP-PCP025150180,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,143.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hep C Genotype Dna Reverse",PX-306000174,CDM,87902,CPT,0306,RC,,,both,,,1412.65,423.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,59.08,,,,,,,0.01,1200.75,"fee schedule",
"CATH SOFT-VU 80CM 5FR MIKAELSSON CURVE ANGIOGRAPHIC VISCERAL",SUP-10732101,CDM,C1887,HCPCS,0272,RC,,,both,,,118.84,35.65,"PHCS [10601]",PHCS,,83.19,70,,,,,0,13.82,101.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 46MM LCP STAINLESS STEEL SHORT THREAD",SUP-207.646,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"CIGNA [10200]",Cigna,,707.23,68,,1831.33,1831.33,1831.33,16,120.96,884.03,"percent of total billed charges",
"PORT IMPLANTABLE INFUSION MRI GROSHONG SILICONE PLASTIC 8FR",SUP-0602830,CDM,C1788,HCPCS,0278,RC,,,both,,,1762.50,528.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,208.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",255.04,255.04,255.04,"1 through 10",204.98,1498.13,"percent of total billed charges",
"GWIRE ORTHOPEDIC GREEN 1.9MM MAXTORQUE STAINLESS STEEL",SUP-CSS04019,CDM,C1769,HCPCS,0272,RC,,,both,,,139.20,41.76,"NOVANET [10819]",Novanet,,104.4,75,,,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Medihoney",PX-E27200098,CDM,E27200098,LOCAL,0272,RC,,,both,,,68.95,20.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.02,58.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 6MM BALL DISSECTING",SUP-MR8-9BA60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.28,371.18,"MULTIPLAN [10600]",Multiplan,,1051.69,85,,,,,0,143.9,1051.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 100CM 8FR AL1.5 CURVE GUIDING PTFE FEMORAL",SUP-H74934358850,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE TRUWAVE 1 WAY SHUTOFF 3 WAY VENT STPCOCK",SUP-PX600I,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.31,27.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,62.77,68,,,,,0,10.74,78.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 11.5CM 4MM MICRUSFRAME 10 COIL",SUP-MFR100412,CDM,S27800098,LOCAL,0278,RC,,,both,,,16974.00,5092.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2011.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1974.08,14427.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X20X8MM PIVOX 6D LATERAL OLIF25",SUP-2111140,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"BLUE CROSS [10001]","Blue Cross HMO",,10372.32,39.2,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 40MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712640,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",441.36,3225.75,"percent of total billed charges",
"FILTER EMBOLIZATION 49MM 65CM VENA CAVA JUGULAR RADIOPAQUE",SUP-G34309,CDM,C1880,HCPCS,0278,RC,,,both,,,7621.05,2286.31,"PHCS [10601]",PHCS,,5334.74,70,,,,,0,886.33,6477.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 80CM 40MM 9MM .035IN BALLOON",SUP-AB35W09040080,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,80.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT TKR 85 CAP EXTRA",SUP-98000200189,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9072,40,,,,,0,2637.68,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 18MM INTERLOCK FIBERED IDC 18 COIL",SUP-M001361940,CDM,S27800098,LOCAL,0278,RC,,,both,,,4843.80,1453.14,"MULTIPLAN [10600]",Multiplan,,4117.23,85,,,,,0,563.33,4117.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 60MM 9MM 9FR FLUENCY PLUS ENDOVASCULAR",SUP-FEM09060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]","Cigna Open Access",,6120.45,33.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Stent & Ather Cmplx Init",PX-361000718,CDM,37277,CPT,0361,RC,,,both,,,28914.88,8674.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3426.41,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.91,24577.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 80MM 120CM 4.5MM 6FR VASCULAR NITINOL",SUP-S-45-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1083.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GALASHAPE 3D 21X7.5CM SOFT TISSUE SCAFFOLD",SUP-SH3D05,CDM,C1781,HCPCS,0278,RC,,,both,,,8280.00,2484,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5630.4,68,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 12D-30D LONG SMALL LOOP 24FR",SUP-WA22742S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3181.82,954.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FORMULA BARREL BUR 12-FLUTE,(TAN/TAN)5.5MM ARTHROSCOPIC SHAV",SUP-0375951012,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PDS II 3-0 SH 36IN 2 ARM MONOFILAMENT VIOLET ABSORBABLE",SUP-D6264,CDM,S27200284,LOCAL,0272,RC,,,both,,,404.88,121.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FENOFIBRATE 54 MG TABLET",RX-31336,CDM,,,0637,RC,50268-0312-11,NDC,both,1,UN,8.57,2.57,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE NASOGASTRIC 45IN 8FR SIDEPORT WEIGHTED STYLET FLEXIFLO",SUP-00473,CDM,S27000186,LOCAL,0270,RC,,,both,,,73.95,22.18,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 12-15IN 32FR VENOUS ADULT 3/8IN 1 STAGE RIGHT",SUP-67532,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.59,90.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ROD SPINAL 70MM PERCUTANEOUS LORDOTIC",SUP-11-4070*,CDM,S27800098,LOCAL,0278,RC,,,both,,,1498.50,449.55,"KAISER [10500]",Kaiser,,1004,67,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE PALACOS R+G 40GM GENTAMICIN SINGLE",SUP-00111314001,CDM,C1713,HCPCS,0278,RC,,,both,,,1444.80,433.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,171.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,168.03,1228.08,"percent of total billed charges",
"CATH ACCU-VU 100CM 20CM 4FR PIGTAIL CURVE ANGIOGRAPHIC",SUP-H787137098055,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.98,329.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,452.09,41.1,,,,,0,127.93,934.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM NAIL-EX TITANIUM FULL THREAD HUMERAL",SUP-04.005.416,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,134.52,983.18,"percent of total billed charges",
"INSOLE SHOE 8.5-10 LARGE FEMALE DARCO PEG-ASSIST REMOVABLE",SUP-PTQW3,CDM,S27000186,LOCAL,0270,RC,,,both,,,100.92,30.28,"PHCS [10601]",PHCS,,70.64,70,,,,,0,11.74,85.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +18 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.180,CDM,V2632,HCPCS,0276,RC,,,both,,,3292.50,987.75,"CIGNA [10200]","Cigna Open Access",,1873.43,56.9,,,,,0,382.92,2798.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL 50 MCG/ML INJECTION SUPERORDERABLE",RX-4083037,CDM,J3010,HCPCS,0636,RC,00641-6029-01,NDC,both,20,ML,97.67,29.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.98,,"Fee schedule rate ($13.98). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.57,83.02,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 14MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036121450,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 2-0 V-20 TAPER POINT 18IN CLSR ABSORBABLE",SUP-VLOCL0625,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.81,131.34,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.92,372.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +10.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000105,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON MONORAIL 6MM 3.75MM BALLOON",SUP-H74939401063750,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"KAISER [10500]",Kaiser,,3629.06,67,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL IUNI TIBIAL IPOLY STERILE",SUP-UKA1111111,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"NOVANET [10819]",Novanet,,16537.5,75,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 325ML GEL ROUND SMOOTH SILTEX SILICONE P4.6CM","SUP-3503254 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1735.02,45.9,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE SOLERA COCR L40 MM OD5.5 MM SPINE MULTIAXIAL 5.5",SUP-55840005540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4382,45.9,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Stent & Ather Cmplx Ea Add",PX-361000719,CDM,37278,CPT,0361,RC,,,both,,,17348.93,5204.68,"PHCS [10601]",PHCS,,12144.25,70,,,,,0,17.35,14746.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING RTRCTR 11-17CM XL ALEXIS C SECTION 11-17CM",SUP-G6304,CDM,S27200284,LOCAL,0272,RC,,,both,,,558.90,167.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,380.05,68,,,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR ACCENT SR 52X52MM 12.8ML 23GM 1 CHMBR STORED EGMS",SUP-PM1210,CDM,C1786,HCPCS,0275,RC,,,both,,,9576.00,2872.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6511.68,68,,,,,0,1113.69,8139.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8.5MM 12/14 TAPER 36MM HIP CEMENTLESS BIOLOX",SUP-136536330,CDM,C1776,HCPCS,0278,RC,,,both,,,7222.32,2166.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4911.18,68,,,,,0,839.96,6138.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) DORAYA DEVICE",SUP-40-0002,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 16X8CM ALLODERM SELECT THK.4-2.4MM THICK",SUP-1519128,CDM,Q4116,HCPCS,0636,RC,,,both,,,23391.90,7017.57,"PHCS [10601]",PHCS,,16374.33,70,,,,,0,247.92,19883.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 105MM STAINLESS STEEL FULL THREAD FEMUR",SUP-208.477,CDM,C1713,HCPCS,0278,RC,,,both,,,1519.48,455.84,"MULTIPLAN [10600]",Multiplan,,1291.56,85,,,,,0,176.72,1291.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 230CM 120CM 22-27MM 10FR COLONIC ENTERAL",SUP-M00565120,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 8MM KNEE XLK POSTERIOR LIPPED FIX BEARING PFC",SUP-158106108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]",Cigna,,7598.69,68,,5873.17,5873.17,5873.17,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"STENT ICAST STENT DIAMETER 7X 16MM CATH 120CM ENDOVASCULAR",SUP-42716,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE R/O II 6CM 2.5CM 7FR GUIDING RADIOPAQUE DIL",SUP-RSB701,CDM,C1894,HCPCS,0272,RC,,,both,,,174.00,52.2,"MULTIPLAN [10600]",Multiplan,,147.9,85,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS03010,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1389.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STELLAREX 135CM 120MM 6MM BALLOON DILATATION ENDURACOAT",SUP-AB35SX060120135,CDM,C2623,HCPCS,0272,RC,,,both,,,11005.50,3301.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7483.74,68,,,,,0,1279.94,9354.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 29X5X1MM STAINLESS STEEL 2MM SCR MINI",SUP-243.15,CDM,C1713,HCPCS,0278,RC,,,both,,,1845.60,553.68,"NOVANET [10819]",Novanet,,1384.2,75,,,,,0,214.64,1568.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 12MM 145CM 4MM CORONARY STENT",SUP-1145400-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"MULTIPLAN [10600]",Multiplan,,4962.3,85,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL 13INX6.9MM STRAIGHT CUT LARGE TEAR SMALL BONE",SUP-KM-81,CDM,S27200284,LOCAL,0272,RC,,,both,,,457.81,137.34,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,311.31,68,,,,,0,53.24,389.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Albumin",PX-301000088,CDM,82040,CPT,0301,RC,,,both,,,119.70,35.91,"BLUE CROSS [10001]","Blue Cross HMO",,0.12,.1,,,,,0,0.12,101.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 18MM TARGET XL 360D STD LARGE",SUP-M0036101850,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CS1 STAINLESS STEEL 2.7MM SCR VARIABLE ANGLE LCP BONE",SUP-02.112.620S,CDM,C1713,HCPCS,0278,RC,,,both,,,6808.23,2042.47,"CIGNA [10200]",Cigna,,4629.6,68,,1831.33,1831.33,1831.33,16,791.8,5787,"percent of total billed charges",
"ANCHOR SUT ALPHAVENT 3 STRAND HARD BODY PLATFORM PEEK 1.4 MM",SUP-3910-947-031,CDM,C1713,HCPCS,0278,RC,,,both,,,2737.50,821.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,783.47,28.62,,,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E FEMUR PATELLA TIBIA CEMENT",SUP-98000244715,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"CIGNA [10200]",Cigna,,9324,40,,5873.17,5873.17,5873.17,"1 through 10",2710.95,19813.5,"percent of total billed charges",
"HEAD UNIPOLAR 47MM CENTERPULSE LEGACY 12/14 TAPER HIP FEMUR",SUP-451000047,CDM,C1776,HCPCS,0278,RC,,,both,,,2398.65,719.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,284.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,278.96,2038.85,"percent of total billed charges",
"LIGASURE ATLAS SEAL DIV 20CM",SUP-LS1020,CDM,S27200284,LOCAL,0272,RC,,,both,,,2537.18,761.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1725.28,68,,,,,0,295.07,2156.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 58.5MM 1.6MM LONG CROSS CUT TAPER CARBIDE",SUP-2296101216,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.64,16.99,"NOVANET [10819]",Novanet,,42.48,75,,,,,0,6.59,48.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 42MM 28MM 0D F HIP CONSTRAIN UHMWPE TRIDENT",SUP-690-00-28F,CDM,C1776,HCPCS,0278,RC,,,both,,,17046.45,5113.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4878.69,28.62,,,,,0,1982.5,14489.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +10.5 DIOPTER .5 MM 12.5MM 5.5MM ANTERIOR CHMBR",SUP-MTA3U0.105,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 54MM 36MM MARATHON",SUP-121936454,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"MULTIPLAN [10600]",Multiplan,,8366.42,85,,,,,0,1144.72,8366.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 26CM 6MM CEREPAK MICRO UNIFORM DETACHABLE",SUP-FCX100626,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1538.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,inpatient,,,55820.68,16746.2,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,6274.75,,"Case rate ($5,919.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,496.73, add-ons for qualifying new technology services are included. If operating cost exceeds $38,536.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,797.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,504.00. The transfer operating threshold is the transfer adjustment factor * $5,496.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $415.58. The transfer capital threshold is the transfer adjustment factor * $415.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,5919.58,23799.29,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 12MM OSS UHMWPE KNEE TIBIAL STD STERILE",SUP-150410,CDM,C1776,HCPCS,0278,RC,,,both,,,8317.26,2495.18,"BLUE CROSS [10001]","Blue Cross PPO",,3260.37,39.2,,3949.44,3949.44,3949.44,"1 through 10",967.3,7069.67,"percent of total billed charges",
"CMPNT FEMORAL E KNEE LEFT LPS-FLEX GENDER SOLUTIONS NEXGEN",SUP-00576201551,CDM,C1776,HCPCS,0278,RC,,,both,,,22113.00,6633.9,"MULTIPLAN [10600]",Multiplan,,18796.05,85,,,,,0,2571.74,18796.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL 6MM LAMINA RIGHT OFFSET",SUP-7756074R,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ZEPHYR 2.8MM 4 DELIVERY SYSTEM FLEXIBLE EMPHASYS",SUP-EDC-TS-4.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,3898.50,1169.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2650.98,68,,,,,0,453.4,3313.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 650ML GEL SMOOTH MEMORYGEL SILICONE P5.7CM HIGH","SUP-3506504 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"KAISER [10500]",Kaiser,,2532.6,67,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METRONIDAZOLE 500 MG TABLET",RX-5016,CDM,,,0637,RC,50268-0535-11,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOBILIZER KNEE WRAP EZ",SUP-01259B22OP,CDM,L1830,HCPCS,0274,RC,,,both,,,232.81,69.84,"CIGNA [10200]","Cigna Open Access",,132.47,56.9,,,,,0,27.08,197.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPIDCROSS 170CM 210MM 2MM .014IN BALLOON DILATATION",SUP-A14BX020210170,CDM,C1725,HCPCS,0272,RC,,,both,,,1638.75,491.62,"KAISER [10500]",Kaiser,,1097.96,67,,,,,0,190.59,1392.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +8.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.085,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II VASCULAR",SUP-1009665,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC",716,MS-DRG,,,,,,,inpatient,,,80981.54,24294.46,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,9672.17,,"Case rate ($9,124.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,472.90, add-ons for qualifying new technology services are included. If operating cost exceeds $41,512.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,022.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $8,484.11. The transfer operating threshold is the transfer adjustment factor * $8,472.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.59. The transfer capital threshold is the transfer adjustment factor * $640.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,42947.32,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 8CM 5FR 3MM .035IN BALLOON DILATATION",SUP-G52327,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.47,41.1,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 35MM REDAPT LOCK",SUP-71354506,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Treponema Pallidum Ab",PX-302000167,CDM,86780,CPT,0302,RC,,,both,,,222.30,66.69,"KAISER [10500]",Kaiser,,148.94,67,,,,,0,0.01,188.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 74X46X14MM NEXGEN LCCK 5-6 C-D STD KNEE",SUP-00599404114,CDM,C1776,HCPCS,0278,RC,,,both,,,16256.40,4876.92,"FIRST HEALTH [10303]","First Health",,13005.12,80,,,,,0,1890.62,13817.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 550ML P5.5CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-5504BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTRIAXONE 1 G VIAL IV PUSH",RX-408304,CDM,J0696,HCPCS,0636,RC,00409-7332-21,NDC,both,1,UN,18.92,5.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3.6,,,,,,,2,16.08,"fee schedule",
"PROGREAT LAMBDA 1.9FR 130CM TRIPLE ANGLE",SUP-CC-MC913DN,CDM,C1725,HCPCS,0272,RC,,,both,,,5375.10,1612.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3655.07,68,,,,,0,625.12,4568.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SKIN 4FT NEONATE TEMPERATURE SENSOR DISPOSABLE",SUP-HNICU-37,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.42,14.53,"MULTIPLAN [10600]",Multiplan,,41.16,85,,,,,0,5.63,41.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 80MM 75CM 6MM VASCULAR METAL SUPERFICIAL",SUP-H74939293068070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"NOVANET [10819]",Novanet,,3622.5,75,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 11X11.5CM 300CC STYLE 133S SMOOTH SUT TAB",SUP-133S-FV-11-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3828.47,41.1,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM 20.4MM MASTERS-SERIES 85D STD PYROLYTIC",SUP-25MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]",Cigna,,11647.69,40,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH R2P DESTINATION SLENDER 105CM 6FR GUIDING STERILE",SUP-GS-R6ST1C10W,CDM,C1894,HCPCS,0272,RC,,,both,,,2216.25,664.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1507.05,68,,,,,0,257.75,1883.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 16.1CM 8MM CEREPAK MICRO UNIFORM",SUP-FCX100816,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3570.98,27,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO SMALL STYLET SURESIGHT",SUP-321900010,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.00,26.1,"CIGNA [10200]",Cigna,,59.16,68,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6D XS 66X58MM KNEE LEFT ROTATE HINGE PIN",SUP-623421L,CDM,C1776,HCPCS,0278,RC,,,both,,,30350.88,9105.26,"CIGNA [10200]",Cigna,,12140.35,40,,5873.17,5873.17,5873.17,"1 through 10",3529.81,25798.25,"percent of total billed charges",
"CAGE SPINAL 50X20X7.8MM TITAN NANOLOCK 12D 12MM ANTERALIGN",SUP-46221250,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"BLUE CROSS [10001]","Blue Cross HMO",,16793.28,39.2,,,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR INFINION CX",SUP-SC-2317-50,CDM,C1897,HCPCS,0278,RC,,,both,,,17640.00,5292,"BLUE CROSS [10001]","Blue Cross PPO",,6914.88,39.2,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 74CM 23-25FR FEMORAL VEIN .035IN .5IN 2 STAGE",SUP-200-150,CDM,S27200284,LOCAL,0272,RC,,,both,,,3600.00,1080,"PHCS [10601]",PHCS,,2520,70,,,,,0,418.68,3060,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 3.6IN VENTRAL HERNIA ROUND RESORBABLE",SUP-PCO9,CDM,C1781,HCPCS,0278,RC,,,both,,,2038.88,611.66,"AETNA [10100]","Aetna HMO/PPO",,1620.91,79.5,,,,,0,237.12,1733.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 9MM CATALYFT PL LONG",SUP-6068096,CDM,S27800098,LOCAL,0278,RC,,,both,,,39060.00,11718,"UHC [10700]","United Healthcare",,24724.98,63.3,,,,,0,4542.68,33201,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL MEMORYSHAPE MEDIUM HEIGHT MODERATE PLUS PROFILE",SUP-RSZ-1155S,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.55,69.16,"PHCS [10601]",PHCS,,161.39,70,,,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANGIOGRAPHIC 100CM 6FR SUPERTORQUE JR4 POLYURETHANE SOFTER",SUP-532621,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA [10200]",Cigna,,56.2,68,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 22MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-022,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"CIGNA [10200]","Cigna Local Plus",,6694,31.5,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 4CM 8MM BALLOON DILATATION ILIAC",SUP-G34344,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO GWIRE 10CM 4FR 21GA MERIT S-MAK .018IN STAINLESS STEEL",SUP-S-MAK401,CDM,C1894,HCPCS,0272,RC,,,both,,,295.80,88.74,"MULTIPLAN [10600]",Multiplan,,251.43,85,,,,,0,34.4,251.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM PRELOAD DISTAL WIREGUIDE STERILE DISPOSABLE",SUP-KD-VC631Q-07203S,CDM,C1769,HCPCS,0272,RC,,,both,,,2817.75,845.32,"KAISER [10500]",Kaiser,,1887.89,67,,,,,0,327.7,2395.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 24MM 144CM 3MM CORONARY STENT",SUP-H7493952824300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross HMO",,2181.48,39.2,,9776.84,9776.84,9776.84,"1 through 10",647.21,4730.25,"percent of total billed charges",
"INTRO SHEATH 6FR 40CM CONTRALATERAL RADIOPAQUE BAND MAXIMUM",SUP-G10406,CDM,C1894,HCPCS,0272,RC,,,both,,,1547.10,464.13,"FIRST HEALTH [10303]","First Health",,1237.68,80,,,,,0,179.93,1315.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30X4.8MM TITANIUM LARGE THICK TISSUE LINEAR",SUP-4901T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1346.54,403.96,"MULTIPLAN [10600]",Multiplan,,1144.56,85,,,,,0,156.6,1144.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE INSTAFILL SIGNIFY 5CC ALLOGRAFT CRTDG GEL STERILE",SUP-8112.5105S,CDM,C1713,HCPCS,0278,RC,,,both,,,7852.20,2355.66,"CIGNA [10200]","Cigna Local Plus",,4200.93,53.5,,3978.14,359.25,3978.14,24,913.21,6674.37,"percent of total billed charges",
"ACUTE LEUKEMIA WITH MCC",834,MS-DRG,,,,,,,inpatient,,,92101.13,27630.34,"BLUE CROSS [10001]","Blue Cross PPO",,92101.13,,,,,,,7561,92101.13,"case rate",
"CATH SABERX RADIANZ 190CM 80MM 6MM .018IN BALLOON DILATATION",SUP-R51006008L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"PHCS [10601]",PHCS,,1380.23,70,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 4 KNEE RIGHT CRUCIATE RETAINING PFC SIGMA",SUP-940024,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"KAISER [10500]",Kaiser,,17346.2,67,,,,,0,3010.99,22006.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 20MM 135CM 6MM .018IN BILIARY STAINLESS",SUP-G56627,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2313.36,45.9,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HEMODIALYSIS 28CM 12.5FR PRECURVE SILICONE HEMO-CATH 2",SUP-MCDLTSL28PC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1966.50,589.95,"MULTIPLAN [10600]",Multiplan,,1671.53,85,,,,,0,228.7,1671.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FLOWSTASIS SUTURING RETENTION STERILE LATEX FREE",SUP-70-101,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE E CURVE",SUP-D7BTCEL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"FIRST HEALTH [10303]","First Health",,3968.88,80,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3.5MM 18MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.818.96,CDM,C1713,HCPCS,0278,RC,,,both,,,319.12,95.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,37.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",37.11,271.25,"percent of total billed charges",
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 8MM 144CM 4MM",SUP-H7493941208400,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2221.63,28.62,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STBL SURGICAL OCTOPUS NONSTERNOTOMY TISSUE",SUP-TS102,CDM,S27000186,LOCAL,0270,RC,,,both,,,9625.50,2887.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1140.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1119.45,8181.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN DEBRIDEMENT WITH CC",571,MS-DRG,,,,,,,inpatient,,,68950.84,20685.25,"PHCS [10601]",PHCS,,7561,,,,,,,7561,49326.64,"per diem","Estimated amount calculated based on 5 day length of stay."
"DIL URETERAL HYDROPLUS 70CM 12FR STERILE",SUP-M0062401130,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.52,130.06,"MULTIPLAN [10600]",Multiplan,,368.49,85,,,,,0,50.42,368.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IRBESARTAN 150 MG TABLET",RX-21848,CDM,,,0637,RC,00024-5851-30,NDC,both,1,UN,34.72,10.42,"CIGNA [10200]",Cigna,,23.61,68,,,,,0,4.04,29.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 13.9CM 7MM CEREPAK MICRO UNIFORM",SUP-FCX100713,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1567.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 4 X 6 COMPLEX PICO COIL",SUP-10USC04006,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"BLUE CROSS [10001]","Blue Cross HMO",,5125.6,39.2,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 3.2MM 3CM 1.5CM RAPID EXCHANGE",SUP-M00510860,CDM,S27200284,LOCAL,0272,RC,,,both,,,2036.93,611.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,241.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,236.89,1731.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUARD PIN STD WHITE 3/8IN JURGAN PIN BALL 6 BALL REFILL",SUP-W062,CDM,C1713,HCPCS,0278,RC,,,both,,,417.60,125.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,191.68,45.9,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 15MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45015,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,33209.89,40,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANASTROZOLE 1 MG TABLET",RX-16205,CDM,,,0250,RC,60687-0112-11,NDC,both,1,UN,10.42,3.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.21,8.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +11MM 14/16 OFFSET TAPER 36MM HIP M",SUP-101836511,CDM,C1776,HCPCS,0278,RC,,,both,,,5239.08,1571.72,"MULTIPLAN [10600]",Multiplan,,4453.22,85,,,,,0,609.31,4453.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 20MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDS40020,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"MULTIPLAN [10600]",Multiplan,,70571.01,85,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 8X22X55MM 5DEG LORDOTIC TITANIUM ALLOY MODULUS X",SUP-1223855P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXAMETHASONE 4 MG TABLET",RX-2327,CDM,J8540,HCPCS,0637,RC,00054-8175-25,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.46,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Cysto/Vcg",PX-361000233,CDM,51600,CPT,0361,RC,,,both,,,1146.63,343.99,"AETNA [10100]","Aetna HMO/PPO",,911.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,133.35,1146.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL SYMBOTEX 2 SIDE COMPOSITE 3D BIOABSORBABLE",SUP-SYM20,CDM,C1781,HCPCS,0278,RC,,,both,,,5719.69,1715.91,"FIRST HEALTH [10303]","First Health",,4575.75,80,,,,,0,665.2,4861.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ammonia",PX-301000104,CDM,82140,CPT,0301,RC,,,both,,,293.80,88.14,"NOVANET [10819]",Novanet,,220.35,75,,,,,0,0.29,249.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VANSONNENBERG SUMP 35CM 14FR LOOP DRNG FLEXIMA",SUP-M001273040,CDM,C1729,HCPCS,0272,RC,,,both,,,1053.00,315.9,"MULTIPLAN [10600]",Multiplan,,895.05,85,,,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TWIN-PASS 135CM 20MM 3.4-2.7FR 2FR 0D GUIDING STAINLESS",SUP-5200,CDM,C1887,HCPCS,0272,RC,,,both,,,2362.50,708.75,"MULTIPLAN [10600]",Multiplan,,2008.13,85,,,,,0,274.76,2008.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 30MM 80CM 7MM VASCULAR NITINOL PERIPHERAL",SUP-1012529-30,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,481.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 5MM UROWIRE KII FIOS 2 PACK",SUP-CTR14,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,89.39,41.1,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MTRL SPLINTING HAND THERMOPLASTIC THK3/32IN 24X18IN EDGE",SUP-A297007,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 22MM 2 VELOUR KNITTED STRAIGHT",SUP-M002020952220,CDM,C1768,HCPCS,0278,RC,,,both,,,3633.53,1090.06,"CIGNA [10200]",Cigna,,2470.8,68,,,,,0,422.58,3088.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP IDENTITY STEM/COMPREHENSIVE GLENOID/VITAMIN E/AUGMENTED",SUP-98000900280,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,13883.56,28.62,,,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC In111 Dtpa per 0.5mci",PX-343000017,CDM,A9548,HCPCS,0343,RC,,,both,,,4510.00,1353,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,534.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,524.51,3833.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SELECT CORTICAL FIBULA WEDGE 8MM",SUP-210800,CDM,S27800098,LOCAL,0278,RC,,,both,,,3018.75,905.62,"BLUE CROSS [10001]","Blue Cross HMO",,1183.35,39.2,,,,,0,351.08,2565.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC RELOAD AEON 45MMX3.25MM STERILE LATEX FREE",SUP-AESR45R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 20MM 6MM BALLOON DILATATION STERILE LATEX",SUP-596002022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC",315,MS-DRG,,,,,,,inpatient,,,28495.90,8548.77,"CIGNA [10200]","Cigna Open Access",,10571.25,,"Fee schedule rate ($10,571.25). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,5975.41,24023.74,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC DF-1 CNCT 2 CHMBR CARDIOVERTER PULSE GENRTR",SUP-E163,CDM,C1721,HCPCS,0278,RC,,,both,,,63000.00,18900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25200,40,,,,,0,7326.9,53550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL CEMENT HEAD POROUS STD SHOULDER GLENOID",SUP-98000900025,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3113.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR .09IN JUDKINS RIGHT 4 CURVE GUIDING",SUP-LA8JR40SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 28CM 3CM 7FR .038IN 2 PIGTAIL",SUP-M006192144010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"FIRST HEALTH [10303]","First Health",,960.46,80,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.9H 56MM 3 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009356,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 2MM .064MM 10MM COVERED SHEATH THICKER",SUP-BC-202D-2010,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.76,38.63,"UHC [10700]","United Healthcare",,81.51,63.3,,,,,0,14.97,109.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710512,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4233.93,28.62,,,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 135CM 100MM 6MM BALLOON DILATATION PACLITAXEL",SUP-H74939419601010,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1022.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Dil Schatzki Ring W Bx Forceps",PX-750000241,CDM,43499,CPT,0750,RC,,,both,,,5311.00,1593.3,"MULTIPLAN [10600]",Multiplan,,4514.35,85,,,,,0,617.67,5311,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR RUST 41MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103541000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,363.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,356.38,2604.67,"percent of total billed charges",
"PLATE 37.5MM TITANIUM LOCKING ATLANTIS VISION BONE ANTERIOR",SUP-976-137,CDM,C1713,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"BLUE CROSS [10001]","Blue Cross HMO",,2299.08,39.2,,957.42,156.86,7483.26,51,682.1,4985.25,"percent of total billed charges",
"STENT ZIMMON 4CM 170CM 7FR 2 PIGTAIL CURVE BILIARY",SUP-G22161,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD GLENOID 36MM RSP -4MM OFFSET RETAIN SCR",SUP-508-36-103,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1444.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1418.07,10364.22,"percent of total billed charges",
"IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION",RX-172574,CDM,,,0250,RC,00597-0197-05,NDC,both,50,ML,16795.87,5038.76,"NOVANET [10819]",Novanet,,12596.9,75,,,,,0,1953.36,14276.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT AORTIC 4.5CM 28.5MM EXCLUDER CONFORMABLE ACTIVE CONTROL",SUP-CXA280005,CDM,C1874,HCPCS,0278,RC,,,both,,,27612.90,8283.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11348.9,41.1,,,,,0,3211.38,23470.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 20MM CLEVERCUT3V PRELOAD DISTAL TIP STERILE",SUP-KD-VC411Q-0720,CDM,S27200284,LOCAL,0272,RC,,,both,,,1500.61,450.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1020.41,68,,,,,0,174.52,1275.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 58MM 28MM 7.1MM 20FR ZENITH FLEX Z-TRAK",SUP-G55214,CDM,C1874,HCPCS,0278,RC,,,both,,,14138.10,4241.43,"NOVANET [10819]",Novanet,,10603.58,75,,,,,0,1644.26,12017.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 28MM 145CM 3MM CORONARY STENT",SUP-1145300-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 550ML P5.5CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-5504BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 40MM 10MM AXOGUARD EXTRACELLULAR MATRIX",SUP-AG1040,CDM,C1763,HCPCS,0278,RC,,,both,,,20002.50,6000.75,"UHC [10700]","United Healthcare",,12661.58,63.3,,,,,0,2326.29,17002.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABIL 40MM 200CM 10MM ENDOPROSTHESIS METAL NO",SUP-VSWVN1004,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 20CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155240180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,190.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STBL SURGICAL ASSISTANT STABLESOFT",SUP-401-212S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.00,495,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,195.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-3-4-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3157.79,27,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR HEMI 3HL 56MM",SUP-430-98-056,CDM,C1776,HCPCS,0278,RC,,,both,,,16956.34,5086.9,"AETNA [10100]","Aetna HMO/PPO",,13480.29,79.5,,10981.53,8986.79,12413.38,12,1972.02,14412.89,"percent of total billed charges",
"PLATE 86MM STAINLESS STEEL 2.7/3.5MM SCR 4 HOLE LCP BONE",SUP-02.112.139,CDM,C1713,HCPCS,0278,RC,,,both,,,3031.88,909.56,"NOVANET [10819]",Novanet,,2273.91,75,,,,,0,352.61,2577.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 4MM TWIST STERILE",SUP-KM166-10-06,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"MULTIPLAN [10600]",Multiplan,,87.7,85,,,,,0,12,87.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM 37.6MM 30MM MITRAL TRICUSPID FLEXIBLE",SUP-460030MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"BLUE CROSS [10001]","Blue Cross PPO",,4462.92,39.2,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 22CM 3CM 7FR .035IN PIGTAIL",SUP-M006180231190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]",Cigna,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 300MM 3.5MM BALLOON DILATATION RAPID",SUP-47535300L,CDM,C1725,HCPCS,0272,RC,,,both,,,1890.00,567,"PHCS [10601]",PHCS,,1323,70,,,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AZITHROMYCIN 600 MG TABLET",RX-17387,CDM,,,0637,RC,69452-0173-13,NDC,both,1,UN,70.62,21.19,"NOVANET [10819]",Novanet,,52.97,75,,,,,0,8.21,60.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM TITANIUM DOME HIP ACETABULAR CANCELLOUS",SUP-103532,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"CIGNA [10200]","Cigna Open Access",,566.89,56.9,,1144.80,304.56,2275.09,66,115.87,846.86,"percent of total billed charges",
"QUARTET, WIDE SPACING - 1458QL/86",SUP-1458QL/86,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,652.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 100CM 5FR HEADHUNTER 1 CURVE ANGIOGRAPHIC",SUP-11719501,CDM,C1887,HCPCS,0272,RC,,,both,,,344.52,103.36,"AETNA [10100]","Aetna HMO/PPO",,273.89,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.07,292.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -2.5MM 32MM HIP C TAPER NECK COCR LFIT",SUP-S-1400-HH31,CDM,C1776,HCPCS,0278,RC,,,both,,,4188.30,1256.49,"MULTIPLAN [10600]",Multiplan,,3560.06,85,,,,,0,487.1,3560.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.5MM 80MM GAMMA3 TITANIUM HIP TROCHANTER LAG",SUP-3060-0080S,CDM,C1713,HCPCS,0278,RC,,,both,,,3471.30,1041.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,411.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",403.71,2950.61,"percent of total billed charges",
"CATH SUPER TORQUE PLUS 100CM 6FR MULTIPURPOSE B 2 CURVE",SUP-533642,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"CIGNA [10200]","Cigna Open Access",,46.83,56.9,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 38MM TI",SUP-SPL-60380-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,188.41,1377,"percent of total billed charges",
"SCR BONE 6.5MM 50MM PINNACLE GRIPTION TF DOME 4 POINT CUT",SUP-121750500,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,133.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",133.3,974.23,"percent of total billed charges",
"AMPICILLIN 2 G IV VIAL",RX-27281,CDM,J0290,HCPCS,0636,RC,00781-3413-15,NDC,both,1,UN,226.52,67.96,"BLUE CROSS [10001]","Blue Cross HMO",,2.56,,,,,,,2.56,192.54,"fee schedule",
"MOMENTUM IS1 DF1",SUP-3501,CDM,C1896,HCPCS,0278,RC,,,both,,,28350.00,8505,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 76MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.876,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 15MM",SUP-SPL35015X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"PHCS [10601]",PHCS,,368.55,70,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS 5-0 RB-2 30IN 2 ARM ANTIBACTERIAL VIOLET",SUP-PDP148H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.09,19.83,"FIRST HEALTH [10303]","First Health",,52.87,80,,,,,0,7.69,56.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 20MM TRIDENT SECUR-FIT TITANIUM CANCELLOUS",SUP-2030-6520-1,CDM,C1713,HCPCS,0278,RC,,,both,,,571.90,171.57,"KAISER [10500]",Kaiser,,383.17,67,,,,,0,66.51,486.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FUSION 200CM 6FR ENDOSCOPIC STERILE DISPOSABLE ACCEPTS",SUP-G31528,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"MULTIPLAN [10600]",Multiplan,,654.08,85,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 CTX 36IN BRAID COATED UNDYED ABSORBABLE",SUP-J980H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 55MM CD HORIZON LEGACY TITANIUM ANGLE REVERSE",SUP-75448555,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +24 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2400,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 30MM ORTHOLOC STAINLESS STEEL FULL THREAD",SUP-58812730,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,578.34,68,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PERIPHERAL L60MM DIA14MM CATHETER L120CM GUIDEWIRE 0.0",SUP-VENUL14060,CDM,C1725,HCPCS,0272,RC,,,both,,,22050.00,6615,"KAISER [10500]",Kaiser,,14773.5,67,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 28MM 3.5MM CORONARY STENT EVEROLIMUS",SUP-1550350-28,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 80CM 5FR SOS OMNI 1 CURVE ANGIOGRAPHIC VISCERAL",SUP-10720401,CDM,C1887,HCPCS,0272,RC,,,both,,,209.32,62.8,"PHCS [10601]",PHCS,,146.52,70,,,,,0,24.34,177.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE XL MALE",SUP-100611-050,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.99,17.7,"CIGNA [10200]","Cigna Local Plus",,31.56,53.5,,,,,0,6.86,50.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE KURTIS MSD 3MM SUCTION NEONATE ENDOTRACHEAL TUBE",SUP-4530,CDM,S27000186,LOCAL,0270,RC,,,both,,,74.05,22.21,"FIRST HEALTH [10303]","First Health",,59.24,80,,,,,0,8.61,62.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL UTERINE HANK 2 END 10.75IN 25/26FR",SUP-52-3725,CDM,S27000186,LOCAL,0270,RC,,,both,,,184.96,55.49,"PHCS [10601]",PHCS,,129.47,70,,,,,0,21.51,157.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AMPLATZ 17CM 14FR ACCESS PTFE RENAL FIRM TAPER TIP",SUP-M0062601450,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"FIRST HEALTH [10303]","First Health",,267.68,80,,,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 26MM 3.5MM CORONARY STENT FULCRUM COCR",SUP-INT35026UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CIGNA [10200]","Cigna Local Plus",,1292.03,53.5,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL TWIST 5IN 3/16IN STAINLESS STEEL TWIST NONSTERILE",SUP-KM166-00-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.04,24.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rem Impl Drug Deliv Non-Biodeg",PX-361000515,CDM,11982,CPT,0361,RC,,,both,,,4282.83,1284.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1729.39,,"Case rate ($1,729.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,498.09,4282.83,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM TITANIUM 4/5.5MM SCR LOW PROFILE BRIDGE FUSION",SUP-SP02003L,CDM,C1713,HCPCS,0278,RC,,,both,,,17677.80,5303.34,"UHC [10700]","United Healthcare",,11190.05,63.3,,5023.51,2672.93,6679.78,18,2055.93,15026.13,"percent of total billed charges",
"CATH DORADO CHECKER 80CM 2CM 6MM BALLOON DILATATION",SUP-DR8062,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC AVALUS 25MM 400 SERIES LATEX FREE",SUP-40025,CDM,S27800098,LOCAL,0278,RC,,,both,,,33390.00,10017,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3956.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 12MM KII OPTICAL ACCESS SYSTEM",SUP-CFR74,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBRANT 15CC 12MM OPEN ALLOGRAFT 2 LEVEL PAK",SUP-IFLX-FBG-LG-DC,CDM,S27800098,LOCAL,0278,RC,,,both,,,39690.00,11907,"CIGNA [10200]",Cigna,,15876,40,,,,,0,4615.95,33736.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Selct Plc Cath Cca/Innom Brain",PX-361000289,CDM,36223,CPT,0361,RC,,,both,,,23564.37,7069.31,"PHCS [10601]",PHCS,,16495.06,70,,,,,0,2740.54,20029.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IOTHALAMATE SODIUM 0.1 % INTRAVENOUS SOLUTION 20-30 MICROCURIES",RX-411485,CDM,A9554,HCPCS,0343,RC,08888-8878-49,NDC,both,1,UN,13286.75,3986.02,"AETNA [10100]","Aetna HMO/PPO",,10562.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.12,11293.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 G 46MM COCR HIP 2 MOBILITY",SUP-110024465,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5323.55,41.1,,6417.48,6417.48,6417.48,"1 through 10",1506.4,11009.78,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 15MM 140CM .91-1.12MM 2.75MM CORONARY",SUP-RONYX27515W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,399.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 25CM 120CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBJR062502A,CDM,C1874,HCPCS,0278,RC,,,both,,,41491.80,12447.54,"UHC [10700]","United Healthcare",,26264.31,63.3,,,,,0,4825.5,35268.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 CT-1 36IN BRAID COATED UNDYED ABSORBABLE",SUP-J944H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD OR TABLE 72X20X2IN DEVON FOAM CONVOLUTE LATEX FREE",SUP-FP-ORTBL2,CDM,S27000186,LOCAL,0270,RC,,,both,,,62.15,18.64,"AETNA [10100]","Aetna HMO/PPO",,49.41,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.23,52.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640306,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1308.83,9565.82,"percent of total billed charges",
"BRA 34-36IN B-D MEDIUM FRONT HOOK LOOP CLSR SOFT SPRT",SUP-702,CDM,S27000186,LOCAL,0270,RC,,,both,,,353.83,106.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.27,300.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC XS 8IN WRIST RIGHT BLACK",SUP-A120204,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.29,17.49,"PHCS [10601]",PHCS,,40.8,70,,,,,0,6.78,49.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 52MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.452TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"CIGNA [10200]",Cigna,,1374.65,68,,1831.33,1831.33,1831.33,16,235.11,1718.32,"percent of total billed charges",
"HC Pneumatic Walking Boot",PX-E27400092,CDM,L4360,HCPCS,0274,RC,,,both,,,902.00,270.6,"MULTIPLAN [10600]",Multiplan,,766.7,85,,,,,0,104.9,766.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD THERAPEUTIC 23X14X12.5IN COLD WRAP ON REGULAR HOSE",SUP-11-1334-9-00000,CDM,S27000187,LOCAL,0270,RC,,,both,,,224.20,67.26,"AETNA [10100]","Aetna HMO/PPO",,178.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.07,190.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 405CC NATRELLE INSPIRA COHESIVE STERILE LATEX",SUP-SCM-405,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"MULTIPLAN [10600]",Multiplan,,6422.18,85,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRESTIGE PLUS HELICAL PACK",SUP-PRES0412HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1876.04,28.62,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ATTAIN HYBRID THUNDER VASCULAR STRAIGHT 190CM 3CM .014",SUP-THNDR190S,CDM,C1769,HCPCS,0272,RC,,,both,,,502.20,150.66,"UHC [10700]","United Healthcare",,317.89,63.3,,,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 108MM ALTIVATE DJO SURGICAL 10 STD SHOULDER",SUP-530-10-108,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UHC [10700]","United Healthcare",,7975.8,63.3,,8601.07,8395.67,8601.07,"1 through 10",1465.38,10710,"percent of total billed charges",
"STENT CONTOUR 30CM 3CM 6FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006180225050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,478.09,45.9,,,,,0,121.14,885.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM ALPHAVENT NONABSORBABLE STERILE",SUP-3911956547,CDM,C1713,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"MULTIPLAN [10600]",Multiplan,,3155.63,85,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM VARIAX LOCK NONSTERILE",SUP-657312,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"FIRST HEALTH [10303]","First Health",,1189.47,80,,,,,0,172.92,1263.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 15MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158105115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]",Cigna,,7598.69,68,,5873.17,5873.17,5873.17,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"SCR BONE 4MM 38MM MINI-MONSTER SHORT THREAD CANNULATED",SUP-P20-540-038S,CDM,C1713,HCPCS,0278,RC,,,both,,,1876.88,563.06,"PHCS [10601]",PHCS,,1313.82,70,,,,,0,218.28,1595.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 100MM 18MM 3MM VASCULAR VENOUS ILIOFEMORAL VEIN",SUP-VENUM18100,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2762.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 30MM 140CM 2.25MM",SUP-RSINT22530UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]",Cigna,,3769.92,68,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Tum Loc Planar Wb Sngl",PX-341000049,CDM,78802,CPT,0341,RC,,,both,,,2226.26,667.88,"MULTIPLAN [10600]",Multiplan,,1892.32,85,,,,,0,258.91,2226.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 TAPER 22MM HIP OXINIUM ECHELON",SUP-71342200,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"CIGNA [10200]","Cigna Open Access",,5204.34,33.5,,5302.19,4377.88,6578.61,27,1806.76,13205.05,"percent of total billed charges",
"PLATE 38MM 2 LEVEL ARCHON BONE SPINE NONSTERILE",SUP-8787238,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross PPO",,1728.72,39.2,,957.42,570.23,957.42,28,512.88,3748.5,"percent of total billed charges",
"SET DRNG 15CM 6FR 18GA FUHRMAN PLEURAL PNEUMOPERICARDIAL",SUP-G55714,CDM,C1729,HCPCS,0272,RC,,,both,,,1278.99,383.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,869.71,68,,,,,0,148.75,1087.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR BENTSON 28CM 15CM 6FR .035IN STRAIGHT URETERAL",SUP-M006180224060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"BLUE CROSS [10001]","Blue Cross HMO",,390.99,39.2,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 110CM 4FR 145D PIGTAIL CURVE",SUP-538453S,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"PHCS [10601]",PHCS,,62.66,70,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAC 136CM 3.9FR .038IN GUIDING DISTAL ACCESS STERILE",SUP-90721,CDM,S27200284,LOCAL,0272,RC,,,both,,,9626.67,2888,"AETNA [10100]","Aetna HMO/PPO",,7653.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1119.58,8182.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 10 127D",SUP-6721-1040,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9584.82,40,,,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DOVER 18FR URETHRAL ULTRAMER HYDROGEL 5ML 2 WAY FOLEY",SUP-1618C,CDM,S27200284,LOCAL,0272,RC,,,both,,,155.93,46.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.13,132.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 35MM SOLERA CD HORIZON OSTEOGRIP TITANIUM COCR",SUP-54840004035,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1110.3,8114.82,"percent of total billed charges",
"CMPNT FEMORAL F 72X65.4MM KNEE LEFT CEMENT NEXGEN CR-FLEX",SUP-595601601,CDM,C1776,HCPCS,0278,RC,,,both,,,19845.00,5953.5,"AETNA [10100]","Aetna HMO/PPO",,15776.78,79.5,,10981.53,8986.79,12413.38,12,2307.97,16868.25,"percent of total billed charges",
"PACK VITRECTOMY 20GA CONSTELLATION PROBE FRAGMENTATION HNDPC",SUP-8065750958,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.76,160.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,245.45,45.9,,,,,0,62.19,454.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 7CM 8.5FR DUODENAL BEND BILIARY",SUP-M00534270,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"CIGNA [10200]","Cigna Open Access",,619.9,56.9,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 10MM TI",SUP-VAN-25100-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Open Access",,553.07,56.9,,1144.80,304.56,2275.09,66,113.04,826.2,"percent of total billed charges",
"CATH EXPO 100CM 5FR .045IN FULL LENGTH MULTIPURPOSE A 2",SUP-8526121,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,29.14,41.1,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE RIGHT POSTERIOR STABILIZE GENESIS II",SUP-71421205,CDM,C1776,HCPCS,0278,RC,,,both,,,29077.65,8723.29,"BLUE CROSS [10001]","Blue Cross PPO",,11398.44,39.2,,3949.44,3949.44,3949.44,"1 through 10",3381.73,24716,"percent of total billed charges",
"CANN LAPAROSCOPIC 12MM 100MM KII THREAD",SUP-C0R73,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.85,40.45,"MULTIPLAN [10600]",Multiplan,,114.62,85,,,,,0,15.68,114.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 24MM 5MM CORONARY STENT PLATINUM",SUP-H7493926024500,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"PHCS [10601]",PHCS,,6520.5,70,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN JUDKINS RIGHT 4 CURVE",SUP-DXT6JR40,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.97,41.1,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 CT-2 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP726D,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.24,37.57,"FIRST HEALTH [10303]","First Health",,100.19,80,,,,,0,14.57,106.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP OPHTHALMIC 25+ GA GRIESHABER MAXGRIP MICRO TEXTURE",SUP-705.13P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.84,388.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.59,41.1,,,,,0,150.71,1101.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 4-0 SH-1 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP218H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.48,45.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM EAR 5.5MM ROUND EBONY FINISH STAINLESS STEEL",SUP-130655,CDM,S27200284,LOCAL,0272,RC,,,both,,,535.98,160.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,220.29,41.1,,,,,0,62.33,455.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM T15 LOW PROFILE NONLOCK NONSTERILE",SUP-110017720,CDM,C1713,HCPCS,0278,RC,,,both,,,729.00,218.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",84.78,619.65,"percent of total billed charges",
"TOOL 12CM MR8 2MM BALL DISSECTING",SUP-MR8-12BA20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1416.29,424.89,"UHC [10700]","United Healthcare",,896.51,63.3,,,,,0,164.71,1203.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM TRIDENT II LOW PROFILE HEXAGONAL STERILE",SUP-7030-6525,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"MULTIPLAN [10600]",Multiplan,,647.19,85,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTRUMENT MINI-HOHMANN RETRACTOR SMALL",SUP-INST-MHR-SM,CDM,S27000186,LOCAL,0270,RC,,,both,,,1755.00,526.5,"KAISER [10500]",Kaiser,,1175.85,67,,,,,0,204.11,1491.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 40MM 80CM 10MM VASCULAR PERIPHERAL SELF",SUP-1012532-40,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross HMO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 62MM LCP STAINLESS STEEL CORTICAL PERIARTICULAR",SUP-02.204.062,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"FIRST HEALTH [10303]","First Health",,789.26,80,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +6 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200060,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,118.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Test Presumptive Instrmnt",PX-301000581,CDM,80306,CPT,0301,RC,,,both,,,66.30,19.89,"CIGNA [10200]","Cigna Open Access",,37.71,,,,,,,0.07,56.36,"fee schedule",
"HC Tomosynthesis Breast Dgtl Dx Uni",PX-401000008,CDM,77061,CPT,0401,RC,,,both,,,310.40,93.12,"CIGNA [10200]",Cigna,,252,,"Per diem ($252).",,,,0,36.1,275,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 35MM 5.5MM CD HORIZON CURVE COCRMO NONSTERILE",SUP-1555501035,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Iadna Mtb Rifampin Resistance Amp Prb Tq",PX-306000256,CDM,87564,CPT,0306,RC,,,both,,,360.00,108,"AETNA [10100]","Aetna HMO/PPO",,286.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,306,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Compres Band Profore >16<= 48 Sq In",PX-E27000089,CDM,A6207,HCPCS,0270,RC,,,both,,,203.50,61.05,"NOVANET [10819]",Novanet,,152.63,75,,,,,0,7.03,172.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPLR FEMORAL LEGION 2MM OFFSET KNEE",SUP-71424223,CDM,C1776,HCPCS,0278,RC,,,both,,,12161.25,3648.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3480.55,28.62,,,,,0,1414.35,10337.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE OVAL 230CM 2.8MM 15MM SNAREMASTER WIRE LOOP INTEGRAL",SUP-SD-210U-15,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.57,23.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.25,67.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45X4.8MM TITANIUM THICK TISSUE ENDOSCOPIC",SUP-TA4548S,CDM,S27200284,LOCAL,0272,RC,,,both,,,860.30,258.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,353.58,41.1,,,,,0,100.05,731.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Bone Multiple",PX-341000078,CDM,78305,CPT,0341,RC,,,both,,,2646.92,794.08,"BLUE CROSS [10001]","Blue Cross HMO",,711.33,,"Fee schedule rate ($711.33).",,,,0,307.84,2249.88,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 0D 4.8MM MULTIFIRE ENDO HERNIA TITANIUM STERILE",SUP-174007,CDM,S27200284,LOCAL,0272,RC,,,both,,,388.11,116.43,"MULTIPLAN [10600]",Multiplan,,329.89,85,,,,,0,45.14,329.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 20MM 1.5MM BALLOON DILATATION RAPID",SUP-47515020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 8MM 2.75MM BALLOON DILATATION DURATRAC",SUP-NCEUP27508X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"NOVANET [10819]",Novanet,,425.25,75,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL BLUE GOLD 330MM 3.2MM EXPERT 3 FLUTE QUICK",SUP-03.010.060S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1808.10,542.43,"CIGNA [10200]","Cigna Local Plus",,967.33,53.5,,,,,0,210.28,1536.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 5MMX15MM 7FR 80CMCATH HEPARIN",SUP-BXB051501A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45X4.8MM TITANIUM THICK TISSUE ENDOSCOPIC",SUP-TA4548S,CDM,S27200284,LOCAL,0272,RC,,,both,,,860.30,258.09,"UHC [10700]","United Healthcare",,544.57,63.3,,,,,0,100.05,731.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 10CM MR8 3MM MATCH HEAD DISSECTING STERILE DISPOSABLE",SUP-MR8-10MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1047.74,314.32,"FIRST HEALTH [10303]","First Health",,838.19,80,,,,,0,121.85,890.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS MULTIPASS 3-0 PS-1 18IN BRAID ANTIBACTERIAL",SUP-VCP683G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Open Access",,14.23,56.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 12IN 1/8IN PVC 3 SPRING EVAC TROCAR Y CNCT TUBE",SUP-0043610,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.08,20.12,"UHC [10700]","United Healthcare",,42.46,63.3,,,,,0,7.8,57.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 90MM STAINLESS STEEL 2.7/3.5MM SCR 4 HOLE LCP",SUP-02.112.108,CDM,C1713,HCPCS,0278,RC,,,both,,,3131.63,939.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,371.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,364.21,2661.89,"percent of total billed charges",
"CATH IMPRESS 65CM 5FR STRAIGHT ANGIOGRAPHIC POLYURETHANE",SUP-5653510STF-NB,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"MULTIPLAN [10600]",Multiplan,,92.44,85,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 65CM 4FR PIGTAIL CURVE ANGIOGRAPHIC PEBAX",SUP-7742-2M65SH,CDM,S27200284,LOCAL,0272,RC,,,both,,,235.94,70.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,96.97,41.1,,,,,0,27.44,200.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH CLEARPETRA 15CM 20FR 18FR ACCESS NEPHRSTMY",SUP-90121815,CDM,C1894,HCPCS,0272,RC,,,both,,,3157.50,947.25,"PHCS [10601]",PHCS,,2210.25,70,,,,,0,367.22,2683.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 80MM 10MM BILIARY STERILE LATEX FREE DISPOSABLE",SUP-M00572330,CDM,C1876,HCPCS,0278,RC,,,both,,,10624.97,3187.49,"KAISER [10500]",Kaiser,,7118.73,67,,,,,0,1235.68,9031.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 32MM TITANIUM 1.3MM SCREW 11HOLE EXTENDED T BONE HAND",SUP-421.333,CDM,C1713,HCPCS,0278,RC,,,both,,,2385.60,715.68,"AETNA [10100]","Aetna HMO/PPO",,1896.55,79.5,,1521.93,481.35,16760.95,30,277.45,2027.76,"percent of total billed charges",
"NEROSTIMLTR 50CM LINEAR PERCUTANEOUS 3-6 LEAD TRIAL SUT",SUP-SC-2366-50E,CDM,C1778,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 5MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-05010,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"FIRST HEALTH [10303]","First Health",,7170.48,80,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 5MM BALLOON DILATATION STERILE LATEX",SUP-585012022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CIRCUIT BREATHING PEDIATRIC ULTRA FLEX",SUP-2703Y-80,CDM,S27000186,LOCAL,0270,RC,,,both,,,73.08,21.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"REVISION OF HIP OR KNEE REPLACEMENT WITH MCC",466,MS-DRG,,,,,,,inpatient,,,153376.94,46013.08,"PHCS [10601]",PHCS,,,70,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERTORQUE 100CM 5FR VERTEBRAL CURVE ANGIOGRAPHIC",SUP-532549H0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BLAZER II HTD 110CM 4MM 7FR 2.5MM SPACE ASYMMETRIC 4",SUP-M0045031THN40,CDM,C1733,HCPCS,0272,RC,,,both,,,8107.50,2432.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 135CM 40MM 4MM BALLOON DILATATION PEBAX",SUP-H74939032404010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 135CM 80MM 3.8FR 7MM BALLOON DILATATION PEBAX",SUP-H74939032708010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SWAN-GANZ 90CM 5FR PULMONARY ARTERY 3 LUMEN BIPOLAR",SUP-D97120F5,CDM,C1730,HCPCS,0272,RC,,,both,,,953.86,286.16,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR MEDIUM RING SOFT COMPLIANT 7.5CM SOFT TISSUE SURGICAL",SUP-TRM,CDM,S27200284,LOCAL,0272,RC,,,both,,,2453.70,736.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER 105MM 4.2MM RHINOTEC GATOR 30D BENDABLE",SUP-E9360,CDM,S27200284,LOCAL,0272,RC,,,both,,,741.96,222.59,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEAD FEMORAL +6MM 11/13 32MM HIP ALUMINA S-ROM",SUP-528330,CDM,C1776,HCPCS,0278,RC,,,both,,,8956.20,2686.86,"BLUE CROSS [10001]","Blue Cross PPO",,3510.83,39.2,,3949.44,3949.44,3949.44,"1 through 10",1041.61,7612.77,"percent of total billed charges",
"KIT JEJUNOSTOMY 45CM 18FR TUNGSTEN SILICONE 2.5CM MIC-KEY",SUP-8270-18-2.5-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,311.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 30MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206080370,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 19CM 10MM AZUR CX DETACHABLE SOFT SOLID",SUP-45-751019,CDM,S27800098,LOCAL,0278,RC,,,both,,,7672.80,2301.84,"CIGNA [10200]","Cigna Local Plus",,4104.95,53.5,,,,,0,892.35,6521.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SCR HUMERUS",SUP-00840009000,CDM,C1713,HCPCS,0278,RC,,,both,,,2703.75,811.12,"PHCS [10601]",PHCS,,1892.63,70,,,,,0,314.45,2298.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 6X4IN RIGHT HERNIA 3D LIGHTWEIGHT",SUP-TECT1510ADPR,CDM,C1781,HCPCS,0278,RC,,,both,,,1047.00,314.1,"MULTIPLAN [10600]",Multiplan,,889.95,85,,,,,0,121.77,889.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 19CM 10MM AZUR CX DETACHABLE SOFT SOLID",SUP-45-751019,CDM,S27800098,LOCAL,0278,RC,,,both,,,7672.80,2301.84,"BLUE CROSS [10001]","Blue Cross PPO",,3007.74,39.2,,,,,0,892.35,6521.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL CANCELLOUS 90ML .5-3MM ALLOGRAFT CRUSH",SUP-T20080,CDM,S27800098,LOCAL,0278,RC,,,both,,,6365.94,1909.78,"PHCS [10601]",PHCS,,4456.16,70,,,,,0,740.36,5411.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION MRI PLASTIC SILICONE 12FR 2 LUMEN",SUP-0603500,CDM,C1788,HCPCS,0278,RC,,,both,,,1547.10,464.13,"MULTIPLAN [10600]",Multiplan,,1315.04,85,,,,,0,179.93,1315.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE COAGULATION PURPLE 350CM 7FR BRIGHTON GASTROINTESTINAL",SUP-BP-7F-DP-350,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE 15IN 5FR 18GA 21GA UMBILICAL POLYURETHANE",SUP-8888160556,CDM,S27200284,LOCAL,0272,RC,,,both,,,305.39,91.62,"FIRST HEALTH [10303]","First Health",,244.31,80,,,,,0,35.52,259.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 18GA 50CM 11CM GRAY HUB DIL GWIRE",SUP-PSI-5F-11-038-18G,CDM,C1894,HCPCS,0272,RC,,,both,,,102.23,30.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.89,86.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 383074 BIPOLAR CATH DELIV 4FR",SUP-383074,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"BLUE CROSS [10001]","Blue Cross HMO",,875.14,39.2,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 3.5MM VERTEX SELECT PRECUT",SUP-7753760,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"HC Set Rad Ther Field Cmplx",PX-333000006,CDM,77290,CPT,0333,RC,,,both,,,3279.64,983.89,"BLUE CROSS [10001]","Blue Cross PPO",,617.85,,"Per diem ($617.85).",,,,0,381.42,3279.64,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM FILTERWIRE EZ .014IN 110UM 3.2FR 300CM 6FR 3.5-5.5MM",SUP-H749201003000,CDM,S27200284,LOCAL,0272,RC,,,both,,,9844.09,2953.23,"CIGNA [10200]","Cigna Local Plus",,5266.59,53.5,,,,,0,1144.87,8367.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHASIX UMBILICAL SMALL CIRCLE W/ STRAP (4.3CM)",SUP-1230007,CDM,C1781,HCPCS,0278,RC,,,both,,,9453.00,2835.9,"UHC [10700]","United Healthcare",,5983.75,63.3,,,,,0,1099.38,8035.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Post OP Limbguard Bk",PX-E27400095,CDM,L5450,HCPCS,0274,RC,,,both,,,2143.90,643.17,"KAISER [10500]",Kaiser,,1436.41,67,,,,,0,249.34,1822.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 100MM 6MM BALLOON",SUP-LX1813061005F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 9FR 2.5CM 25CM WITHOUT MINI GWIRE DIL PINNACLE",SUP-RSS906,CDM,C1894,HCPCS,0272,RC,,,both,,,156.60,46.98,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 150CM 2CM 6MM BALLOON DILATATION ILIAC",SUP-G34333,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHIELD CONTAMINATION BLUE CATH-GARD 7-7.5FR CATH",SUP-ST-09880,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.14,31.84,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL SURGICAL 5.3MM TAPER STOP EXT KIT STPLR A1 STERILE",SUP-5.30K,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET THROMBECTOMY 135CM 4FR 2MM ANGIOJET ULTRA XMI LOW",SUP-105041-001,CDM,C1757,HCPCS,0272,RC,,,both,,,12213.00,3663.9,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHOCOLATE 135CM 120MM 4MM 5FR BALLOON DILATATION",SUP-CB1413540120OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,666.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Breast Local Dev MR",PX-361000318,CDM,19287,CPT,0361,RC,,,both,,,1856.18,556.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1856.18,,"Case rate ($15,303). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,215.87,1856.18,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 65CM 12MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1265CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,940.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aorto Abd Lwr Ext W Si",PX-323000004,CDM,75630,CPT,0323,RC,,,both,,,8577.30,2573.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,997.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,101.41,7592.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 135CM 2.7FR DRAGONFLY OPTIS 20MM HYDROPHILIC",SUP-C408646,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 57MM 75CM 9MM 60MM",SUP-H74938046960750,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"AMERIGROUP MEDICAID [20100]",Amerigroup,,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RED 72 132CM THROMBECTOMY REPERFUSION CATH PENUMBRA",SUP-RED72KIT,CDM,C1757,HCPCS,0272,RC,,,both,,,17608.50,5282.55,"KAISER [10500]",Kaiser,,11797.7,67,,,,,0,2047.87,14967.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 10.8MM 19MM 17.4MM ON-X 27MM CYLINDRICAL HEART",SUP-ONXANE-19,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"PHCS [10601]",PHCS,,26460,70,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 17MM SEPTAL 2 DISK NITINOL MESH SELF",SUP-9-ASD-017,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"CIGNA [10200]","Cigna Local Plus",,6694,31.5,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION",RX-4904,CDM,J2175,HCPCS,0636,RC,00641-6053-01,NDC,both,1,ML,49.12,14.74,"FIRST HEALTH [10303]","First Health",,39.3,80,,,,,0,1.7,41.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHIELD CONTAMINATION BLUE CATH-GARD 7-7.5FR CATH",SUP-ST-09880,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.14,31.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,43.62,41.1,,,,,0,12.34,90.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 18MM OSTEOLOCK TITANIUM HIP ACETABULAR",SUP-5260-5-018,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"MULTIPLAN [10600]",Multiplan,,647.19,85,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD 37MM 135CM 10MM 7FR BILIARY METAL BALLOON",SUP-H74938047140130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"CIGNA [10200]",Cigna,,3394.56,68,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rad Tx Del Lvl 2",PX-333000069,CDM,77407,CPT,0333,RC,,,both,,,2868.12,860.44,"CIGNA [10200]","Cigna Local Plus",,1534.44,53.5,,,,,0,333.56,2868.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,,,0637,RC,68462-0292-01,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC INTERVERTEBRAL 5MM PRESTIGE LP 14MM SPINE STERILE LATEX",SUP-6972450,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 28MM STAINLESS STEEL FULL THREAD ORTHOPEDIC",SUP-214.728,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,130.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",130.68,955.09,"percent of total billed charges",
"COIL EMBOLIZATION 19CM 10MM AZUR CX DETACHABLE SOFT SOLID",SUP-45-751019,CDM,S27800098,LOCAL,0278,RC,,,both,,,7672.80,2301.84,"PHCS [10601]",PHCS,,5370.96,70,,,,,0,892.35,6521.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tlso Flex Thoracic Pf",PX-E27400069,CDM,L0456,HCPCS,0274,RC,,,both,,,3278.00,983.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,938.16,28.62,,,,,0,381.23,2786.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 15MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-015,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8500.32,40,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 7CM 7FR 2 PIGTAIL CURVE THIN WALL BILIARY",SUP-M00532190,CDM,C2617,HCPCS,0278,RC,,,both,,,447.93,134.38,"MULTIPLAN [10600]",Multiplan,,380.74,85,,,,,0,52.09,380.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE PULMONARY 27MM CRYOVALVE SG HEART WITHOUT CONDUIT",SUP-SGPV10-27-99,CDM,S27800098,LOCAL,0278,RC,,,both,,,145293.00,43587.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16897.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16897.58,123499.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VALVE AORTIC 15MM 27MM AVALUS ULTRA 27MM BOVINE PERIC",SUP-400U27,CDM,S27800098,LOCAL,0278,RC,,,both,,,36225.00,10867.5,"FIRST HEALTH [10303]","First Health",,28980,80,,,,,0,4212.97,30791.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 3.0X10MM",SUP-PRV030010CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drsg Picc Cvc Securement",PX-E27200313,CDM,E27200313,LOCAL,0272,RC,,,both,,,36.33,10.9,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP 11MM OPEN 235CM INTERNAL RESOLUTION RADIOPAQUE USER",SUP-M00522610,CDM,S27200284,LOCAL,0272,RC,,,both,,,1347.76,404.33,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH HYPERGLIDE X-PEDION 150CM 15MM 2.8-2.2FR 5MM .01IN 4MM",SUP-104-4515,CDM,C1725,HCPCS,0272,RC,,,both,,,9273.60,2782.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 5FR 22GA 45CM 11CM JACKET WIRE ANGLE FLOPPY TIP",SUP-PID5F11021PW,CDM,C1894,HCPCS,0272,RC,,,both,,,850.50,255.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) BACKING PLATE LBL-0094",SUP-LBL-0094,CDM,S27000186,LOCAL,0270,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 135CM 20MM 12MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171120210,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOLUTION ANTI COAG CITRATE 500",SUP-4B7898Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.04,23.41,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND SUTUPAK 3-0 30IN BRAID TIES 10 STRAND",SUP-SA84H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PIN PASSING 15IN 2.4MM ACL PCL DRILL TIP STERILE DISPOSABLE",SUP-7208678,CDM,S27200284,LOCAL,0272,RC,,,both,,,942.35,282.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIBUCAINE 1 % TOPICAL OINTMENT",RX-2412,CDM,,,0637,RC,00536-1211-95,NDC,both,28,GR,36.99,11.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.3,31.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCOPIC INSTR MASTER 1.5MM 14GA GWIRE KNIFE BLADE",SUP-AR-6526S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3543.75,1063.12,"MULTIPLAN [10600]",Multiplan,,3012.19,85,,,,,0,412.14,3012.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHADONE 10 MG/ML ORAL CONCENTRATE",RX-15996,CDM,,,0637,RC,08888-8878-67,NDC,both,5,ML,39.12,11.74,"KAISER [10500]",Kaiser,,26.21,67,,,,,0,4.55,33.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Propoxyphene",PX-301000571,CDM,80367,CPT,0301,RC,,,both,,,83.00,24.9,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,83,"per diem",
"STENT CONTOUR 24CM 150CM 6FR .038IN STD STRAIGHT LOW PROFILE",SUP-M006180522170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"MULTIPLAN [10600]",Multiplan,,1046.32,85,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Analysis Abl1 Variants Kinase",PX-309000125,CDM,81170,CPT,0310,RC,,,both,,,1344.25,403.27,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,1142.61,"per diem",
"SHEATH TOURGUIDE 55CM 9MM 7FR CATH",SUP-TG0705509,CDM,C1766,HCPCS,0272,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 12FR URETHRAL BACTI-GUARD HYDROGEL 5CC 1 EYE",SUP-0168SI12,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.14,33.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,45.27,41.1,,,,,0,12.81,93.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DIEGO ELITE TUBING DECLOC",SUP-TS101DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1764.53,529.36,"FIRST HEALTH [10303]","First Health",,1411.62,80,,,,,0,205.21,1499.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICROINTRODUCER 7CM 5FR 21GA MINI STICK MAX TUNGSTEN",SUP-H965457591,CDM,C1894,HCPCS,0272,RC,,,both,,,220.98,66.29,"MULTIPLAN [10600]",Multiplan,,187.83,85,,,,,0,25.7,187.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBERFUSE CANCELLOUS DEMINERALIZE CORTICAL BONE",SUP-420710,CDM,C1713,HCPCS,0278,RC,,,both,,,25755.98,7726.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3052.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,2995.42,21892.58,"percent of total billed charges",
"COIL EMBOLIZATION 3CM 1MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN01003,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS [10001]","Blue Cross PPO",,4595.46,39.2,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 26MMX3.8MMX4CM 20FR",SUP-TE2638A,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"UHC [10700]","United Healthcare",,39689.1,63.3,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE REGENESORB 20MM 6MM SOLID OPEN ARCHITECTURE",SUP-72204391,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,328.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",322.62,2357.93,"percent of total billed charges",
"IMPL BREAST 600ML P4.6CM MODERATE PLUS PROFILE HIGH",SUP-350-6001BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 260CM .035IN STRAIGHT TIP FIXED CORE EXCHANGE",SUP-008633,CDM,C1769,HCPCS,0272,RC,,,both,,,87.00,26.1,"PHCS [10601]",PHCS,,60.9,70,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23.5 DIOPTER +4 CYL HAPTIC C BICONVEX 13MM 6MM",SUP-ZMB00U0235,CDM,V2632,HCPCS,0276,RC,,,both,,,6175.50,1852.65,"AETNA [10100]","Aetna HMO/PPO",,4909.52,79.5,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL IDENTITY IMPRINT 3 NARROW KNEE POSTERIOR",SUP-TPS-301-T03N,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5982.3,68,,,,,0,1023.15,7477.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 67MM 135CM 7MM 160CM",SUP-M001712150,CDM,C1876,HCPCS,0278,RC,,,both,,,13323.90,3997.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1549.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1549.57,11325.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X21MM ENDOSKELETON TAS 7D 16MM STD TITANIUM",SUP-2307-0116,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PHCS [10601]",PHCS,,19845,70,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.9MM 2 JUGGERKNOT MAXBRAID 2 LOAD BLUE",SUP-912029,CDM,C1713,HCPCS,0278,RC,,,both,,,2782.50,834.75,"MULTIPLAN [10600]",Multiplan,,2365.13,85,,,,,0,323.6,2365.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL THUMB CUSTOM FIT UNIQUE",SUP-79-82710,CDM,S27000186,LOCAL,0270,RC,,,both,,,83.43,25.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,38.29,45.9,,,,,0,9.7,70.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Connector Straight 1/2x1/2",PX-E27200361,CDM,E27200361,LOCAL,0272,RC,,,both,,,59.40,17.82,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Spec Handling",PX-309000112,CDM,99001,CPT,0309,RC,,,both,,,57.00,17.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Transport Mileage per Mi",PX-546000002,CDM,A0425,HCPCS,0546,RC,,,both,,,23.38,7.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ACURATE NE02TM AORTIC VALVE M - CLINICAL",SUP-SYM-SV25-006-C,CDM,S62400003,LOCAL,0624,RC,,,both,,,159600.00,47880,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"DIL SURGICAL DILATARIA STRING THICK ROUND 5MM CERVICAL LATEX",SUP-MX230,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.45,35.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,79.87,68,,,,,0,13.66,99.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR NEROSTIMLTR PRECISION MONTAGE 16 CONTACT MRI",SUP-SC-1200,CDM,C1820,HCPCS,0278,RC,,,both,,,95760.00,28728,"FIRST HEALTH [10303]","First Health",,76608,80,,,,,0,11136.89,81396,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 3CM 7FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006180231050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,478.09,45.9,,,,,0,121.14,885.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORMULA BARREL BUR 12-FLUTE,(TAN/TAN)5.5MM ARTHROSCOPIC SHAV",SUP-0375951012,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 20MM .021-.027IN AZUR CX HYDROCOIL",SUP-45-782040,CDM,S27800098,LOCAL,0278,RC,,,both,,,5278.50,1583.55,"CIGNA [10200]","Cigna Local Plus",,2824,53.5,,,,,0,613.89,4486.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT MASTERGRAFT MINI GRANULES VOID FILLER 3ML",SUP-8600103,CDM,C1713,HCPCS,0278,RC,,,both,,,2251.50,675.45,"BLUE CROSS [10001]","Blue Cross PPO",,882.59,39.2,,957.42,570.23,957.42,28,261.85,1913.78,"percent of total billed charges",
"ANCHOR SUT 4.75MM SWIVELOCK C CLOSED EYELET VENT",SUP-AR-2324BCC,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.00,945,"CIGNA [10200]","Cigna Open Access",,1792.35,56.9,,1144.80,304.56,2275.09,66,366.35,2677.5,"percent of total billed charges",
"HC Transport Mileage per Mi",PX-546000002,CDM,A0425,HCPCS,0546,RC,,,both,,,23.38,7.01,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,23.38,,,,,,,2.72,23.38,"case rate",
"HC Transport Mileage per Mi",PX-546000002,CDM,A0425,HCPCS,0546,RC,,,both,,,23.38,7.01,"PHCS [10601]",PHCS,,16.37,70,,,,,0,2.72,23.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prep Wnd Hd/Ext >100scm",PX-510000049,CDM,15005,CPT,0761,RC,,,both,,,1731.00,519.3,"CIGNA [10200]","Cigna Open Access",,1731,,"Per diem ($2,181).",,,,0,201.32,1731,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prep Wnd Hd/Ext >100scm",PX-510000049,CDM,15005,CPT,0761,RC,,,both,,,1731.00,519.3,"PHCS [10601]",PHCS,,1731,,"Case rate ($4,710). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,201.32,1731,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE BONE SAGITTAL L 90X25MM",SUP-BR4125-127-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,225.50,67.65,"CIGNA [10200]","Cigna Open Access",,128.31,56.9,,,,,0,26.23,191.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL TRIATHLON E CONE KNEE TRITANIUM SYMMETRIC",SUP-5549-A-150,CDM,C1776,HCPCS,0278,RC,,,both,,,22087.80,6626.34,"MULTIPLAN [10600]",Multiplan,,18774.63,85,,,,,0,2568.81,18774.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 6MM 11MM 5MM DUCT TYPE II SELF EXPANDING",SUP-9-PDA2-05-06,CDM,C1817,HCPCS,0278,RC,,,both,,,15444.00,4633.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1796.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1796.14,13127.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 5FR 21GA MERIT MAK .018IN STAINLESS STEEL",SUP-MAK505-PED,CDM,C1894,HCPCS,0272,RC,,,both,,,230.55,69.16,"PHCS [10601]",PHCS,,161.39,70,,,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 36MM REDUCT TITANIUM ARTHRODESIS",SUP-HCSD-20036,CDM,C1713,HCPCS,0278,RC,,,both,,,3277.50,983.25,"KAISER [10500]",Kaiser,,2195.93,67,,,,,0,381.17,2785.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 28MM TI",SUP-VAN-25280-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"BLUE CROSS [10001]","Blue Cross PPO",,381.02,39.2,,957.42,570.23,957.42,28,113.04,826.2,"percent of total billed charges",
"VIABAHN BX BALLOON EXP ENDO 5MMX19MM 7FR 135CMCATH HEPARIN",SUP-BXB051902A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH SURGICAL 140MM 22MM DURAPRO 5MM BALL REMOVAL",SUP-6262.2351S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR RLG CURVE",SUP-G09371,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dressing Aquacel 6x6",PX-E27200088,CDM,E27200088,LOCAL,0272,RC,,,both,,,293.70,88.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRAIN INCISION 3/16IN 3/16IN BARD SILICONE 4 FREE FLOW",SUP-072223,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.71,37.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,inpatient,,,154147.97,46244.39,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOGRAPHY 6FR L100CM 0.038IN CORONARY POLYURETHAN",SUP-532649,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.83,25.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 40CM 5.5FR .035IN ROUND INTRAUTERINE SOFT OPEN END",SUP-660005040,CDM,S27200284,LOCAL,0272,RC,,,both,,,316.68,95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE CATH IMPELLA CTRL CNCT IMPELLA 2.5 IMPELLA CP IMPELLA",SUP-0042-0002,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC CT Abd&Pelvis W Cntrst",PX-352000029,CDM,74177,CPT,0352,RC,,,both,,,5824.71,1747.41,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($536.40). Procedures 2 - 999, Per diem ($268.20).",268.20,258.70,517.40,"1 through 10",,,"per diem",
"(EVAL) LAA - AMPLATZ CARDIAC PLUG 2-IDE-028",SUP-9-ACP2-IDE-028,CDM,S62400003,LOCAL,0624,RC,,,both,,,63452.40,19035.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SOLUTION ANTI COAG CITRATE 500",SUP-4B7898Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.04,23.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ENROUTE ENFLATE TRANSCAROTID RX BALLOON DILATATION CATHETER",SUP-SR-4025-BC,CDM,C1725,HCPCS,0272,RC,,,both,,,2625.00,787.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 58MM COCR",SUP-VAL-35580-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"AMERIGROUP MEDICAID [20100]",Amerigroup,,248.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",244.23,1785,"percent of total billed charges",
"SUT NYLON 6 6 NUROLON 4-0 TF 18IN CONTROL RELEASE BRAID 8",SUP-C584D,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.10,51.03,"FIRST HEALTH [10303]","First Health",,136.08,80,,,,,0,19.78,144.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 20MM NESTER MICROCOIL PLATINUM .035IN",SUP-G47361,CDM,S27800098,LOCAL,0278,RC,,,both,,,1113.67,334.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,511.17,45.9,,,,,0,129.52,946.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 800107 CANC CRSHD 1-10MM 15CC FZN",SUP-800107,CDM,S27800098,LOCAL,0278,RC,,,both,,,1632.75,489.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,749.43,45.9,,,,,0,189.89,1387.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM CD HORIZON SPINAL FENESTRATE MULTIAXIAL",SUP-55840025545T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 15CM 5MM BALLOON DILATATION",SUP-DR135515,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"FIRST HEALTH [10303]","First Health",,1101.6,80,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 80MM 80CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-G43848,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,439.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X12X8MM ENDOSKELETON TC 6D LORDOTIC SMALL",SUP-5146-1208-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"NOVANET [10819]",Novanet,,7762.5,75,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALIF SPACER, ANTERIOR: 9MM (H) X 22-24MM (L) X 27-32MM (W):",SUP-10609,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"NOVANET [10819]",Novanet,,23625,75,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENZONATATE 100 MG CAPSULE",RX-988,CDM,,,0637,RC,68084-0214-11,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC COMPIA MRI SURESCAN QUAD CRT D",SUP-DTMC1QQ,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"KAISER [10500]",Kaiser,,38672.4,67,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 15CM 4MM BALLOON DILATATION OTW LOW",SUP-G30950,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID KINEX BIOACTIVE PUTTY 2CC",SUP-8115.0302S,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]",Cigna,,2422.5,68,,1831.33,1831.33,1831.33,16,414.32,3028.13,"percent of total billed charges",
"TISSUE SERVICES",SUP-9441026,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"MULTIPLAN [10600]",Multiplan,,14662.5,85,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 120MM 6MM 8FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEM06120,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7308,40,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC De Revasc Cto Cor Art/Br/Grf",PX-481000090,CDM,C9607,HCPCS,0481,RC,,,both,,,27922.64,8376.79,"KAISER [10500]",Kaiser,,18708.17,67,,,,,0,3247.4,25681,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 30MM 6FR 3.75MM",SUP-H7493926730370,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION KIRSCHNER BLUNT",SUP-48230231,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL ULTRAPRO 11X6CM PARTIAL ABSORBABLE LIGHTWEIGHT",SUP-UMS3,CDM,C1781,HCPCS,0278,RC,,,both,,,826.66,248,"NOVANET [10819]",Novanet,,620,75,,,,,0,96.14,702.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 8IN 12MM MODULAR SOL SYSTEM POROUS 12/14 LARGE",SUP-157202121,CDM,C1776,HCPCS,0278,RC,,,both,,,38107.44,11432.23,"CIGNA [10200]","Cigna Open Access",,12765.99,33.5,,5302.19,4377.88,6578.61,27,4431.9,32391.32,"percent of total billed charges",
"(EVAL) BRIOVAD IMPLANT KIT",SUP-490022,CDM,S62400003,LOCAL,0624,RC,,,both,,,523630.50,157089.15,"FIRST HEALTH [10303]","First Health",,418904.4,80,,,,,0,60898.23,445085.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ATHLETIC 3X2.5IN 33-38IN MEDIUM ELASTIC WAISTBAND KNIT",SUP-202549,CDM,S27000186,LOCAL,0270,RC,,,both,,,78.63,23.59,"AETNA [10100]","Aetna HMO/PPO",,62.51,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.14,66.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL MONOFILAMENT ABSORBABLE LOW PROFILE",SUP-5954113,CDM,C1781,HCPCS,0278,RC,,,both,,,6720.00,2016,"FIRST HEALTH [10303]","First Health",,5376,80,,,,,0,781.54,5712,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 32MM HIP PRIMARY TAPER OFFSET COCR LFIT V",SUP-6260-9-432,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,370.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,363.75,2658.55,"percent of total billed charges",
"SPRT SCROTAL BLACK BAUER AND BLACK LARGE COTTON SUSPENSORY LEG",SUP-201255,CDM,S27000186,LOCAL,0270,RC,,,both,,,135.81,40.74,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,55.82,41.1,,,,,0,15.79,115.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUPLER 4.0MM",SUP-GEM2756,CDM,S27200284,LOCAL,0272,RC,,,both,,,2962.50,888.75,"MULTIPLAN [10600]",Multiplan,,2518.13,85,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BARICITINIB 2 MG TABLET",RX-183410,CDM,,,0637,RC,00002-4182-30,NDC,both,1,UN,414.29,124.29,"CIGNA [10200]","Cigna Local Plus",,221.65,53.5,,,,,0,48.18,352.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA POWERTRAC 142CM 12MM 2MM BALLOON DILATATION",SUP-NCEUP2012X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,358.02,68,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTED TOTAL KNEE SYSTEM INCLUDING CONSTRAINED",SUP-98000200262,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"MULTIPLAN [10600]",Multiplan,,16065,85,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORTHOLOC 3DI FOOT RECONSTRUCTION SYSTEM HALLUX PLATES - LAP",SUP-58510000,CDM,C1713,HCPCS,0278,RC,,,both,,,12420.00,3726,"BLUE CROSS [10001]","Blue Cross HMO",,4868.64,39.2,,957.42,156.86,7483.26,51,1444.45,10557,"percent of total billed charges",
"DISC INTERVERTEBRAL 5MM PRESTIGE LP 14MM SPINE STERILE LATEX",SUP-6972450,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8113.77,28.62,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHIELD CONTAMINATION BLUE CATH-GARD 7-7.5FR CATH",SUP-ST-09880,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.14,31.84,"FIRST HEALTH [10303]","First Health",,84.91,80,,,,,0,12.34,90.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS ALLOGRAFT BLOCK 30X13X13MM",SUP-T00150,CDM,S27800098,LOCAL,0278,RC,,,both,,,4805.85,1441.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,569.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,558.92,4084.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUTURING OVERSTITCH HELIX TISSUE STERILE DISPOSABLE",SUP-THX-165-028,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIPOLAR HIP WITH PRESS FIT STEM",SUP-55500031,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"KAISER [10500]",Kaiser,,6472.2,67,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SQUARE EDGE 1 PIECE ANTERIOR ASPHERIC UV BLOCK",SUP-ZCB0000110,CDM,C1780,HCPCS,0276,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 39MM 80CM 10MM THIN VASCULAR COCR",SUP-1012626-39,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"CIGNA [10200]",Cigna,,5712,68,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BENTSON 26CM 15CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175273060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"BLUE CROSS [10001]","Blue Cross PPO",,390.99,39.2,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUPLER 4.0MM",SUP-GEM2756,CDM,S27200284,LOCAL,0272,RC,,,both,,,2962.50,888.75,"CIGNA [10200]","Cigna Open Access",,1685.66,56.9,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM TRIATHLON 5 LEFT MEDIAL RIGHT LATERAL",SUP-5546-A-501,CDM,C1776,HCPCS,0278,RC,,,both,,,4252.25,1275.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1951.78,45.9,,,,,0,494.54,3614.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 6CM 180CM 20MM 10.5FR ESOPHAGEAL FULL",SUP-G57339,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"BLUE CROSS [10001]","Blue Cross PPO",,6895.12,39.2,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 10.8MM HOLE SAW DISSECTING",SUP-MR8-9HS108,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LIOTHYRONINE 5 MCG TABLET",RX-10443,CDM,,,0637,RC,42794-0018-12,NDC,both,1,UN,6.27,1.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNARE SPIRAL 230CM 2.8MM 20MM SNAREMASTER RIDGE WIRE",SUP-SD-230U-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.14,56.44,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPHERE EMBOLIZATION BLUE EMBOGOLD 300-500UM GELATIN 2% GOLD",SUP-S420EG,CDM,S27800098,LOCAL,0278,RC,,,both,,,2175.00,652.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,257.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM FILTERWIRE EZ .014IN 110UM 3.2FR 300CM 6FR 3.5-5.5MM",SUP-H749201003000,CDM,S27200284,LOCAL,0272,RC,,,both,,,9844.09,2953.23,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEEDLE SPINAL FENESTRATED RELINE MAS",SUP-10001117,CDM,S27000186,LOCAL,0270,RC,,,both,,,1008.45,302.53,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOE POSTOPERATIVE 6-8 SMALL MALE NYLON MESH ROCKER",SUP-798504,CDM,S27000186,LOCAL,0270,RC,,,both,,,61.07,18.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH QUICK-CROSS 150CM 3.1FR .05-.063IN 50MM SPACE SPRT",SUP-518-038,CDM,C1887,HCPCS,0272,RC,,,both,,,972.00,291.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 12IN 12.3-13CM MEMORYGEL P3.8-4.5CM STD MODERATE",SUP-351-325SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) CHAMPIONIR DES SYSTEM US 6-100",SUP-412601000USRD,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ENROUTE ENFLATE TRANSCAROTID RX BALLOON DILATATION CATHETER",SUP-SR-4525-BC,CDM,C1725,HCPCS,0272,RC,,,both,,,2625.00,787.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1785,68,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SILICONE 475ML BREAST RESTERILIZABLE GEL",SUP-RSZ-4754,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"FIRST HEALTH [10303]","First Health",,123.38,80,,,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR REGULAR 30MM PROXIMATE TX TITANIUM ENDOSCOPIC",SUP-XR30B,CDM,S27200284,LOCAL,0272,RC,,,both,,,938.45,281.53,"UHC [10700]","United Healthcare",,594.04,63.3,,,,,0,109.14,797.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 105MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.443,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"KAISER [10500]",Kaiser,,927.37,67,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PASSPORT 75CM 73CM 9MM CURVE 70CM 55CM 7FR 3.3MM 2.4",SUP-PSS0705509,CDM,C1887,HCPCS,0272,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PASSPORT 75CM 73CM 9MM CURVE 70CM 55CM 7FR 3.3MM 2.4",SUP-PSS0705509,CDM,C1887,HCPCS,0272,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC STD 24IN 25- IN KNEE ADJUSTABLE 3 PANEL",SUP-VP40105-070,CDM,L1830,HCPCS,0274,RC,,,both,,,160.08,48.02,"NOVANET [10819]",Novanet,,120.06,75,,,,,0,18.62,136.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 73X25X.89MM MEDIUM WIDE STAINLESS STEEL 2 CUT",SUP-2108-105,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,98.26,41.1,,,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM TSRH-3D TITANIUM POSTERIOR PEDICLE",SUP-837-655,CDM,C1713,HCPCS,0278,RC,,,both,,,2361.60,708.48,"PHCS [10601]",PHCS,,1653.12,70,,,,,0,274.65,2007.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.1MM 140MM KIRSCHNER STAINLESS STEEL 1 END",SUP-NO2228012,CDM,C1713,HCPCS,0278,RC,,,both,,,243.60,73.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,28.33,207.06,"percent of total billed charges",
"BLADE EXPLANT HIP FULL OSTEOTOM 64MM HEMISPHERE ACETABULAR",SUP-705306420,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3077.95,68,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR MINI INCISION TENSION SIDE PLANTAR POWER BONE",SUP-SD20,CDM,C1713,HCPCS,0278,RC,,,both,,,11385.00,3415.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3073.95,27,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 190CM 3CM",SUP-1020013,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 25MM ATLANTIS VISION ELITE BONE ANTERIOR CERVICAL",SUP-7200025,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PHCS [10601]",PHCS,,2940,70,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR BI-MENTUM 45MM 22MM POLYETHYLENE FEMUR",SUP-DS10014522,CDM,C1776,HCPCS,0278,RC,,,both,,,12406.20,3721.86,"CIGNA [10200]","Cigna Local Plus",,3907.95,31.5,,5372.07,4581.20,7242.98,23,1442.84,10545.27,"percent of total billed charges",
"HC Sodium Body Fluid",PX-301000525,CDM,84302,CPT,0301,RC,,,both,,,266.95,80.08,"KAISER [10500]",Kaiser,,178.86,67,,,,,0,0.01,226.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC",855,MS-DRG,,,,,,,inpatient,,,58107.80,17432.34,"CIGNA [10200]","Cigna Open Access",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.5 X 28MM ESPRIT BTK IDE",SUP-1202250-28,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SPECIMEN RETRIEVAL 120CM 2.6FR 8MM URETERAL STONE 2",SUP-M0063204010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BAKRI 54CM 180CM 24FR INTRAUTERINE SILICONE 500ML 60ML",SUP-G24237,CDM,S27200284,LOCAL,0272,RC,,,both,,,2965.28,889.58,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1218.73,41.1,,,,,0,344.86,2520.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 42MM LCP STAINLESS STEEL CORTEX FOREFOOT",SUP-202.962,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,220.31,68,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 80MM LCP STAINLESS STEEL PERIARTICULAR FEMORAL",SUP-02.205.280,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1057.98,68,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT225180,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 80MM NAIL-EX TITANIUM FEMORAL TIBIAL LOCKING",SUP-04.005.570,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,134.52,983.18,"percent of total billed charges",
"PROBE THRMOMTR 12FR TEMPERATURE STETH ESOPHAGEAL VITAL SIGNS",SUP-M1024212,CDM,S27200284,LOCAL,0272,RC,,,both,,,46.05,13.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,21.14,45.9,,,,,0,5.36,39.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATRIX-C UNION CERVICAL ALLOGRAFT SPACER 13 X 16 X 8MM 7",SUP-X094-3011,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM PERIPHERAL",SUP-5572-4540,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1057.88,68,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 6 KNEE CEMENTED FIX BEARING STERILE",SUP-150600006,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"KAISER [10500]",Kaiser,,10052.71,67,,,,,0,1744.97,12753.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT225180,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Local Plus",,184.58,53.5,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP MANIP SMALL CONTOUR TAPER POLYCARBONATE THIMBLE LIKE",SUP-LH-SCOLPO-SML,CDM,S27200284,LOCAL,0272,RC,,,both,,,1352.70,405.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,555.96,41.1,,,,,0,157.32,1149.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Phenytoin Free",PX-301000050,CDM,80186,CPT,0301,RC,,,both,,,211.90,63.57,"UHC [10700]","United Healthcare",,12.38,,,,,,,0.01,180.12,"fee schedule",
"GWIRE VICTORY VASCULAR STRAIGHT 300CM .014IN PERIPHERAL",SUP-H74939471300300,CDM,C1769,HCPCS,0272,RC,,,both,,,2835.00,850.5,"NOVANET [10819]",Novanet,,2126.25,75,,,,,0,329.71,2409.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Orbits>=4v",PX-320000013,CDM,70200,CPT,0320,RC,,,both,,,641.16,192.35,"AETNA [10100]","Aetna HMO/PPO",,509.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.36,544.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 8MM 6FR 1.2MM .07IN ULTRA LOW",SUP-H7493918908120,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC",785,MS-DRG,,,,,,,inpatient,,,39001.45,11700.43,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DIEGO ELITE TUBING DECLOC",SUP-TS101DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1764.53,529.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW CORE INTRAORAL",SUP-5400031053,CDM,S27200284,LOCAL,0272,RC,,,both,,,857.06,257.12,"UHC [10700]","United Healthcare",,542.52,63.3,,,,,0,99.68,728.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 2-0 P-12 6IN CLSR ABSORBABLE PREMIUM REVERSE",SUP-VLOCM0005,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.00,51,"KAISER [10500]",Kaiser,,113.9,67,,,,,0,19.77,144.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 4CM 16FR MIC-KEY SECUR-LOK ENFIT SILICONE RADIOPAQUE",SUP-8140-16-4.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,90.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 20IN 29- IN KNEE CONTACT CLSR",SUP-79-80020,CDM,L1830,HCPCS,0274,RC,,,both,,,122.76,36.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,56.35,45.9,,,,,0,14.28,104.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aqmbf Spect Xers/Strs & Rest",PX-341000093,CDM,0742T,HCPCS,0341,RC,,,both,,,720.11,216.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,330.53,45.9,,,,,0,83.75,612.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 1.5MM ROSEN CURVE 220CM .035IN STAINLESS",SUP-G01623,CDM,C1769,HCPCS,0272,RC,,,both,,,125.54,37.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,51.6,41.1,,,,,0,14.6,106.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 150MM 130CM 6MM 6FR .035IN HELICAL VASCULAR",SUP-EX061503CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20128.50,6038.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5434.7,27,,,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 10.0",SUP-DIB00U0100,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Choa Shared Svcs -",PX-990000033,CDM,,,0990,RC,,,both,,,391.65,117.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.39,332.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 6-8 SMALL MALE BEIGE CANVAS RUBBER RIGID",SUP-2041-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.42,14.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.51,40.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL SMALL 65MM DISTAL RIGHT GMRS",SUP-64952020,CDM,C1776,HCPCS,0278,RC,,,both,,,34883.10,10464.93,"UHC [10700]","United Healthcare",,22081,63.3,,8601.07,8395.67,8601.07,"1 through 10",4056.9,29650.64,"percent of total billed charges",
"LENS IOL 10 D +10.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.105,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,396.9,39.2,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175252080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,568.88,45.9,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 18MM TITANIUM LEVEL 1 ASSURE BONE SPINE CERVICAL",SUP-110.118,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PHCS [10601]",PHCS,,2940,70,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 105MM TRI-LOCK BPS GRIPTION 5 HIGH OFFSET HIP",SUP-101214050,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"BLUE CROSS [10001]","Blue Cross HMO",,6313.99,39.2,,5311.50,4717.44,5388.59,31,1873.26,13691.05,"percent of total billed charges",
"AUG TIBIAL 10MM TRIATHLON 2 LEFT MEDIAL RIGHT LATERAL TOTAL",SUP-5546-A-201,CDM,C1776,HCPCS,0278,RC,,,both,,,5971.95,1791.58,"MULTIPLAN [10600]",Multiplan,,5076.16,85,,,,,0,694.54,5076.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS PASCAL PRECISION TRANSCATHETER VALVE REPAIR S",SUP-20000ISCL,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,78489,45.9,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SPACER ANTERIOR CERVICAL SPINE FREEZE DRIED BLOCK",SUP-245841,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING UNITRAX V40 EXETER +8MM TAPER HIP UNIPOLAR",SUP-6942-6-075,CDM,C1776,HCPCS,0278,RC,,,both,,,1085.40,325.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,310.64,28.62,,,,,0,126.23,922.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175252080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"BLUE CROSS [10001]","Blue Cross PPO",,485.84,39.2,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175252080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"MULTIPLAN [10600]",Multiplan,,1053.47,85,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Circumcision",PX-E27200157,CDM,E27200157,LOCAL,0272,RC,,,both,,,71.50,21.45,"CIGNA [10200]","Cigna Open Access",,40.68,56.9,,,,,0,8.32,60.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERLINK FIBERWIRE 2 26IN CLOSED LOOP BLACK WHITE",SUP-AR-7235T,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,55.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.4,397.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 120MM 75CM 6MM VASCULAR RADIOPAQUE SELF EXPAND",SUP-H74939293061270,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Carbamazepine Free",PX-301000037,CDM,80157,CPT,0301,RC,,,both,,,337.00,101.1,"MULTIPLAN [10600]",Multiplan,,286.45,85,,,,,0,0.01,286.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 40 75CM 2CM 12MM BALLOON DILATATION PERIPHERAL",SUP-CQF75122,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RENEGADE 150CM 20CM 3-2.5FR .021IN MICRO GUIDING HYDRO",SUP-M001182530,CDM,C1887,HCPCS,0272,RC,,,both,,,2100.00,630,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC",421,MS-DRG,,,,,,,inpatient,,,84505.46,25351.64,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER PACING LEAD ACUITY 11FR",SUP-667467-001,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER MAMMARY SALINE 225-250ML 2 WAY CHECK VALVE SMOOTH",SUP-351-225SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 14.1CM MEMORYGEL COHESIVE I P4.3CM MODERATE PLUS",SUP-RSZ-5001S,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL 24FR POWERBALL OLYMPUS OES PRO",SUP-M0068802661,CDM,S27200284,LOCAL,0272,RC,,,both,,,956.45,286.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Misc Research Device",PX-E62400001,CDM,E62400001,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FLECAINIDE 100 MG TABLET",RX-10041,CDM,,,0637,RC,00054-0011-20,NDC,both,1,UN,18.01,5.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRIVER NDL 25.4IN 6MM DA VINCI SP 9.8MM",SUP-430200,CDM,S27000186,LOCAL,0270,RC,,,both,,,2324.70,697.41,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CORPLEX 3X5 CM",SUP-CX-3050,CDM,Q4232,HCPCS,0636,RC,,,both,,,14966.10,4489.83,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 90CM 80MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY TIBIAL MBT LCS COMPLETE 3 KNEE POROUS CEMENTED KEEL",SUP-129434130,CDM,C1776,HCPCS,0278,RC,,,both,,,17561.25,5268.37,"KAISER [10500]",Kaiser,,11766.04,67,,,,,0,2042.37,14927.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 100MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-100-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA [10200]","Cigna Local Plus",,4891.24,53.5,,,,,0,1063.27,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 100MM 8 HOLE MIDSHAFT LOCKING ACUMED BONE ULNAR",SUP-70-0071,CDM,S27800098,LOCAL,0278,RC,,,both,,,5754.60,1726.38,"CIGNA [10200]",Cigna,,3913.13,68,,,,,0,669.26,4891.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 10MM KNEE RIGHT E-PLUS EMPOWR 3D KNEE STERILE",SUP-342-10-707,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"KAISER [10500]",Kaiser,,4391.85,67,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 2CM 10MM BALLOON DILATATION ILIAC",SUP-G35546,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MONOFOCAL PRELOAD 1 PIECE UV BLOCK TECNIS ITEC",SUP-PCB0000120,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 20MM 31MM 29MM BIOCOR FLEXFIT PORCINE",SUP-B100-31M-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,30744.00,9223.2,"FIRST HEALTH [10303]","First Health",,24595.2,80,,,,,0,3575.53,26132.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 0D SHORT 1.3MM DORSIFLEXION PRIMARY GORILLA PRECISION",SUP-P53-103-L001,CDM,C1713,HCPCS,0278,RC,,,both,,,8159.25,2447.77,"KAISER [10500]",Kaiser,,5466.7,67,,,,,0,948.92,6935.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 13MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G213,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"BLUE CROSS [10001]","Blue Cross PPO",,3671.5,39.2,,3949.44,3949.44,3949.44,"1 through 10",1089.28,7961.17,"percent of total billed charges",
"KIT INTRO 10CM 4FR 21GA MERIT MAK .018IN STD STAINLESS STEEL",SUP-MAK405,CDM,C1894,HCPCS,0272,RC,,,both,,,225.77,67.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.26,191.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENICILLIN G DESENSITIZATION (0.1 MG/ML)",RX-410811,CDM,,,0636,RC,09999-9997-06,NDC,both,250,ML,100.65,30.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.93,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW PHTHALATE FREE",SUP-CG-14-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"UHC [10700]","United Healthcare",,333.27,63.3,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 7MM TI",SUP-VAN-25070-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]",Cigna,,660.96,68,,1831.33,1831.33,1831.33,16,113.04,826.2,"percent of total billed charges",
"SCR BONE 5.5MM 60MM TSRH OSTEOGRIP TITANIUM THIN SPINE",SUP-83555609,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"FIRST HEALTH [10303]","First Health",,2059.2,80,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 66MM PRESS FIT AEQUALIS ASCEND FLEX PTC 137.5D",SUP-DWF601C,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5178.6,41.1,,6417.48,6417.48,6417.48,"1 through 10",1465.38,10710,"percent of total billed charges",
"CATH COYOTE MONORAIL 150CM 220MM 2MM BALLOON DILATATION",SUP-H74939185202210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 10 10MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151621010,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PHCS [10601]",PHCS,,7877.73,70,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 4.0/22",SUP-401758,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR POROUS UNIPOLAR PRIMARY INSRT",SUP-98B00100117,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"MULTIPLAN [10600]",Multiplan,,8797.5,85,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL PRONG O2 TUBE ADPTR DEHP FREE NEOTECH RAM CANN",SUP-N4904,CDM,S27000186,LOCAL,0270,RC,,,both,,,107.88,32.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,44.34,41.1,,,,,0,12.55,91.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VICI VENOUS STENT 60MM 100CM 12MM ENDOPROSTHESIS CATH",SUP-H74912060100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BANDAGE ISOBAND 5MRX15CM STERILE WHITE COMPRESSION LATEX FRE",SUP-01958,CDM,S27200284,LOCAL,0272,RC,,,both,,,3096.60,928.98,"FIRST HEALTH [10303]","First Health",,2477.28,80,,,,,0,360.13,2632.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION BARDEX LUBRICATH 18FR 350ML URINE METER",SUP-304918,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.92,54.58,"CIGNA [10200]",Cigna,,123.71,68,,,,,0,21.16,154.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 30CM 150CM 8FR .035IN 3CM BLADDER LOOP",SUP-M006155255190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"KAISER [10500]",Kaiser,,951.63,67,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE SURGICAL KNIFE CHUCK",SUP-1352321,CDM,S27200284,LOCAL,0272,RC,,,both,,,1134.00,340.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,520.51,45.9,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 20MM 135CM 10MM VASCULAR NITINOL",SUP-1012538-20,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,481.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE FOR VPROBE KIT-CRYO 2.4M",SUP-CRYO-207V,CDM,C2618,HCPCS,0272,RC,,,both,,,34020.00,10206,"PHCS [10601]",PHCS,,23814,70,,,,,0,3956.53,28917,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC",451,MS-DRG,,,,,,,inpatient,,,153195.27,45958.58,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,21441.06,,"Case rate ($20,038.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $18,606.98, add-ons for qualifying new technology services are included. If operating cost exceeds $51,646.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,788.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $18,631.59. The transfer operating threshold is the transfer adjustment factor * $18,606.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,406.78. The transfer capital threshold is the transfer adjustment factor * $1,406.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,94314.76,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT COMPREHENSIVE TRABECULAR METAL XLPE REVE",SUP-98000900077,CDM,C1776,HCPCS,0278,RC,,,both,,,51660.00,15498,"PHCS [10601]",PHCS,,36162,70,,,,,0,6008.06,43911,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION",RX-4452,CDM,J2003,HCPCS,0636,RC,63323-0201-10,NDC,both,10,ML,24.09,7.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",4.48,4.46,6.13,39,1.17,20.48,"percent of total billed charges",
"BLADE 11MM SURGICAL PARALLEL GRAFT KNIFE STERILE",SUP-AR-2285-11,CDM,S27200284,LOCAL,0272,RC,,,both,,,429.35,128.8,"UHC [10700]","United Healthcare",,271.78,63.3,,,,,0,49.93,364.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM STAINLESS STEEL T15 CORTEX SELF TAP LOW",SUP-02.206.230S,CDM,C1713,HCPCS,0278,RC,,,both,,,725.76,217.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,84.41,616.9,"percent of total billed charges",
"SUCRALFATE 1 GRAM TABLET",RX-11442,CDM,,,0637,RC,00093-2210-01,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 82X50X17MM NEXGEN LCCK 7-10 G-H STD KNEE",SUP-00599405017,CDM,C1776,HCPCS,0278,RC,,,both,,,16256.40,4876.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6681.38,41.1,,6417.48,6417.48,6417.48,"1 through 10",1890.62,13817.94,"percent of total billed charges",
"SCR BONE 5.5MM 50MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840005550,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,1521.93,481.35,16760.95,30,441.36,3225.75,"percent of total billed charges",
"PROTG MRI PATIENT PROGRAMMER",SUP-3853,CDM,C1787,HCPCS,0270,RC,,,both,,,4830.00,1449,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,561.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XACT 40MM 8-10MM TAPER VASCULAR NITINOL CAROTID ARTERY",SUP-82096-01,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"AETNA [10100]","Aetna HMO/PPO",,7441.2,79.5,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER SLIMLINE 200UM SMART ID SYSTEM",SUP-M0068409230,CDM,S27200284,LOCAL,0272,RC,,,both,,,8334.51,2500.35,"CIGNA [10200]","Cigna Open Access",,4742.34,56.9,,,,,0,969.3,7084.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE HEARTMATE II VENTRICULAR ASSIST STABILIZATION BELT",SUP-100760,CDM,Q0508,HCPCS,0274,RC,,,both,,,787.32,236.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,93.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,91.57,669.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE LEFT CRUCIATE RETAIN ATTUNE POROCOAT",SUP-150401108,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8235.48,28.62,,,,,0,3346.56,24458.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD HEEL FOOTPEDAL",SUP-401320,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 19MM 80CM 7MM THIN VASCULAR COCR",SUP-1012623-19,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"UHC [10700]","United Healthcare",,5317.2,63.3,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS FIRSTCHOICE 20 MEQ POTASSIUM CHLORIDE 0.9%",SUP-711509,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA [10200]",Cigna,,55.08,68,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 62MM 3MM SWANSON SHORT PILOT POINT STERILE",SUP-1608-002-133,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135CM 100MM 5MM .035IN LOW PROFILE BALLOON",SUP-B2050-100,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"MULTIPLAN [10600]",Multiplan,,654.08,85,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 LEFT MEDIAL RIGHT LATERAL PARTIAL KNEE",SUP-5610-F-201,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"AETNA [10100]","Aetna HMO/PPO",,7951.67,79.5,,10981.53,8986.79,12413.38,12,1163.24,8501.79,"percent of total billed charges",
"VALVE AORTIC 29MM CARBO-SEAL ASCENDING AORTA VALSALVA",SUP-CP-029,CDM,S27800098,LOCAL,0278,RC,,,both,,,29408.40,8822.52,"FIRST HEALTH [10303]","First Health",,23526.72,80,,,,,0,3420.2,24997.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veno Adrenal Uni Sel Si",PX-320000135,CDM,75840,CPT,0320,RC,,,both,,,3504.97,1051.49,"KAISER [10500]",Kaiser,,2348.33,67,,,,,0,117.6,3504.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 5.5IN .028IN KIRSCHNER STAINLESS STEEL GUIDE",SUP-1600-020,CDM,C1713,HCPCS,0278,RC,,,both,,,63.19,18.96,"KAISER [10500]",Kaiser,,42.34,67,,,,,0,7.35,53.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mnt Reassess Indv Ea 15min",PX-942000005,CDM,97803,CPT,0942,RC,,,both,,,81.19,24.36,"CIGNA [10200]",Cigna,,55.21,68,,,,,0,9.44,81.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE DRILL 2.8MM LCP THREADED SMALL FRAGMENT SET NONSTERILE",SUP-323.061,CDM,S27000186,LOCAL,0270,RC,,,both,,,4189.68,1256.9,"PHCS [10601]",PHCS,,2932.78,70,,,,,0,487.26,3561.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175272190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,580.81,45.9,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SUPRAPUBIC 16FR 20- FR 17CM 20CM 1 STEP DIL TROCAR",SUP-G26655,CDM,S27200284,LOCAL,0272,RC,,,both,,,734.67,220.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,85.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,85.44,624.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT WALKING 17.4IN AIRSELECT 10-13 11-15 LARGE STD",SUP-01EF-L,CDM,L4360,HCPCS,0274,RC,,,both,,,409.16,122.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,47.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.59,347.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CARTO XP THERMOCOOL SF 115CM 8FR 3.5MM DD CURVE",SUP-BNI35DDH,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"KAISER [10500]",Kaiser,,12101.61,67,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 90CM 8FR JL4 CURVE GUIDING PTFE FEMORAL",SUP-H749343582010,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,249.18,68,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 56MM 40MM XLPE HIP STERILE",SUP-71338679,CDM,C1776,HCPCS,0278,RC,,,both,,,13589.55,4076.86,"CIGNA [10200]","Cigna Open Access",,4552.5,33.5,,5302.19,4377.88,6578.61,27,1580.46,11551.12,"percent of total billed charges",
"SCR BONE 3.5MM 30MM STAINLESS STEEL T15 CORTEX SELF TAP LOW",SUP-02.206.230S,CDM,C1713,HCPCS,0278,RC,,,both,,,725.76,217.73,"MULTIPLAN [10600]",Multiplan,,616.9,85,,,,,0,84.41,616.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 360D 25KHZ LONG SUPER PAYNER ULTRASONIC SONOPET",SUP-5450800302,CDM,S27200284,LOCAL,0272,RC,,,both,,,5827.74,1748.32,"KAISER [10500]",Kaiser,,3904.59,67,,,,,0,677.77,4953.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 40MM AEQUALIS FLEX REVIVE SHOULDER",SUP-ARS655104,CDM,C1713,HCPCS,0278,RC,,,both,,,4330.00,1299,"NOVANET [10819]",Novanet,,3247.5,75,,,,,0,503.58,3680.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ICD-VR DVFC3D1 VISIA AF MRI S OUS/US DF1",SUP-DVFC3D1,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"AETNA [10100]","Aetna HMO/PPO",,31005,79.5,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-5 THC-13 30IN 2 ARM MONOFILAMENT WHITE",SUP-5M12A,CDM,S27200284,LOCAL,0272,RC,,,both,,,303.78,91.13,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TRANSFORM 10MM 3MM BALLOON OCCLUSION 1 LUMEN COMPLIANT",SUP-M003SRC03100,CDM,C1725,HCPCS,0272,RC,,,both,,,11760.02,3528.01,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"APPENDIX PROCEDURES WITH CC",398,MS-DRG,,,,,,,inpatient,,,60476.49,18142.95,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SPRAY 100MM COSEAL SEAL 2 SPRAY HEAD 2 LUMEN CNCT HOSE",SUP-0600021,CDM,S25000001,LOCAL,0250,RC,,,both,,,540.38,162.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRIVER UNIVERSAL STAR QC T 20 CONNECT QUICK SURGICAL WRIST",SUP-DRVR-UQC-T20,CDM,S27000186,LOCAL,0270,RC,,,both,,,583.20,174.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 40CM 40MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171080440,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMPRESS 80CM 5FR .046IN .038IN MIK CURVE ANGIOGRAPHIC",SUP-58038MIK,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 18GA 17GA 11CM 5CM ADJUSTABLE COAXIAL TEMNO",SUP-ACT1811,CDM,S27200284,LOCAL,0272,RC,,,both,,,423.60,127.08,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL 90X4.8MM TITANIUM THICK TISSUE ENDOSCOPIC",SUP-TA9048S,CDM,S27200284,LOCAL,0272,RC,,,both,,,621.27,186.38,"AETNA [10100]","Aetna HMO/PPO",,493.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.25,528.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM SPINE POLYAXIAL STERILE 4MM ROD",SUP-102035114S,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",441.36,3225.75,"percent of total billed charges",
"PICK SURGICAL 6.5IN 90D .50MM MEDIUM HOUSE MALLEABLE SHAFT",SUP-61-0374,CDM,S27200284,LOCAL,0272,RC,,,both,,,367.84,110.35,"PHCS [10601]",PHCS,,257.49,70,,,,,0,42.78,312.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 109MM TRI-LOCK BPS GRIPTION 7 STD OFFSET HIP",SUP-101204070,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4609.86,28.62,,,,,0,1873.26,13691.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 80MM 6MM BALLOON DILATATION DURALYN",SUP-48006008X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,853.74,68,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ARTHROSCOPIC SUT RETRIEVAL",SUP-16.1018,CDM,S27200284,LOCAL,0272,RC,,,both,,,6652.15,1995.64,"AETNA [10100]","Aetna HMO/PPO",,5288.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,773.65,5654.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM STERNALOCK BLU STERNAL CANCELLOUS LOCK",SUP-73-2718,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",45.53,332.78,"percent of total billed charges",
"PLATE 194MM STAINLESS STEEL 3.5MM SCREWS 8 HOLE LCP BONE",SUP-02.104.028S,CDM,C1713,HCPCS,0278,RC,,,both,,,9177.00,2753.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1087.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1067.29,7800.45,"percent of total billed charges",
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 32MM TI",SUP-MTC-37320-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,848.23,68,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 2-0 SH SPIRAL 30CM SUT ABSORBABLE",SUP-SXPP1B416,CDM,S27200284,LOCAL,0272,RC,,,both,,,224.03,67.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.05,190.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM TRITIUM STD CANCELLOUS SELF DRILL",SUP-86-27-16,CDM,C1713,HCPCS,0278,RC,,,both,,,745.20,223.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,88.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",86.67,633.42,"percent of total billed charges",
"HOLDER IMPL SPINE TEMPORARY FIXATION SCR",SUP-650.012,CDM,S27800098,LOCAL,0278,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 400CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCX-400,CDM,C1789,HCPCS,0278,RC,,,both,,,8004.00,2401.2,"CIGNA [10200]",Cigna,,5442.72,68,,,,,0,930.87,6803.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 48MM T10 FULL THREAD STARDRIVE NONSTERILE",SUP-657448,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"MULTIPLAN [10600]",Multiplan,,687.4,85,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 133MM CEMENT BASIC SUMMIT 7 12/14 TAPER HIP",SUP-157006135,CDM,C1776,HCPCS,0278,RC,,,both,,,8135.10,2440.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3734.01,45.9,,,,,0,946.11,6914.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 20MM 130CM 6MM .035IN VASCULAR SELF",SUP-EX060203CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"AETNA [10100]","Aetna HMO/PPO",,9325.35,79.5,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 3-0 PS-1 24IN ANTIBACTERIAL",SUP-SXMP1B103,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,87.91,41.1,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 13MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-813,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"FIRST HEALTH [10303]","First Health",,10766.76,80,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXENATIDE 10 MCG/DOSE(250 MCG/ML)2.4 ML SUBCUTANEOUS PEN INJECTOR",RX-105629,CDM,,,0637,RC,70121-1686-01,NDC,both,2.4,ML,4873.77,1462.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,577.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,566.82,4142.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 41-49MM 5.5MM EXPEDIUM SFX A5 SPINE MEDIAL TITANIUM",SUP-189401405,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"FIRST HEALTH [10303]","First Health",,2850,80,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE-9 CATHETER",SUP-AFR-00001,CDM,C1733,HCPCS,0272,RC,,,both,,,53550.00,16065,"MULTIPLAN [10600]",Multiplan,,45517.5,85,,,,,0,6227.87,45517.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 9MM LEFT MEDIAL RIGHT LATERAL X3 PARTIAL KNEE",SUP-5630-G-309,CDM,C1776,HCPCS,0278,RC,,,both,,,5309.55,1592.86,"BLUE CROSS [10001]","Blue Cross PPO",,2081.34,39.2,,3949.44,3949.44,3949.44,"1 through 10",617.5,4513.12,"percent of total billed charges",
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 22MM COCR",SUP-VAL-25220-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"KAISER [10500]",Kaiser,,955.15,67,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 415CC COHESIVE GEL NATRELLE INSPIRA SILICONE",SUP-SCF-415,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",555,MS-DRG,,,,,,,inpatient,,,48597.28,14579.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11922.64,,"Fee schedule rate ($11,922.64). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,7561,32964.37,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM NAIL-EX TITANIUM FULL THREAD HUMERAL",SUP-04.005.420S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"PHCS [10601]",PHCS,,1047.82,70,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE NOVAGOLD ENDOSCOPIC STRAIGHT 480CM .018IN BILIARY",SUP-M00552011,CDM,C1769,HCPCS,0272,RC,,,both,,,1460.03,438.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,992.82,68,,,,,0,169.8,1241.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR E 42MM HIP MODULAR DUAL MOBILITY",SUP-626-00-42E,CDM,C1776,HCPCS,0278,RC,,,both,,,8517.60,2555.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3500.73,41.1,,6417.48,6417.48,6417.48,"1 through 10",990.6,7239.96,"percent of total billed charges",
"STENT SUPERA 100MM 120CM 6MM 6FR VASCULAR PERIPHERAL",SUP-S-60-100-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1192.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 20CM 6MM BALLOON DILATATION OTW LOW",SUP-G30909,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,inpatient,,,32919.14,9875.74,"BLUE CROSS [10001]","Blue Cross PPO",,11235.08,,,,,,,2823.02,11349.74,"case rate",
"LENS IOL +20.5 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE",SUP-PCB0000205,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET RTRCTR REDDICK-SAYE SCR KIT NDL",SUP-E2504-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,2617.22,785.17,"CIGNA [10200]","Cigna Local Plus",,1400.21,53.5,,,,,0,304.38,2224.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .067IN .047IN AMPLATZ",SUP-534541T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 13CM 8FR CHECK-FLO PERFORMER RADIOPAQUE TIP",SUP-G07856,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 23MM 7MM ACL TENODESIS STERILE",SUP-AR-1570BC,CDM,C1713,HCPCS,0278,RC,,,both,,,2716.88,815.06,"KAISER [10500]",Kaiser,,1820.31,67,,,,,0,315.97,2309.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 25MM ATLANTIS VISION ELITE BONE ANTERIOR CERVICAL",SUP-7200025,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CIGNA [10200]","Cigna Open Access",,2389.8,56.9,,1144.80,304.56,2275.09,66,488.46,3570,"percent of total billed charges",
"CAP END 10MM TALON DISTALFIX 15.5MM",SUP-SLN-155-010,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC VIVA S CRT-D PHYSIOCURVE CARDIOSYNC SMARTSHOCK",SUP-DTBB1D4,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA [10200]",Cigna,,23088,40,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 20MM 154CM 6MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200062020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 12MM ANVIL CENTRIC CANN SUREFORM 60 DA VINCI",SUP-480460,CDM,S27200284,LOCAL,0272,RC,,,both,,,3839.85,1151.95,"CIGNA [10200]","Cigna Local Plus",,2054.32,53.5,,,,,0,446.57,3263.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23X9X8MM COALESCE LORDOTIC STRAIGHT STERILE",SUP-2000-00-090808,CDM,C1889,HCPCS,0278,RC,,,both,,,21420.00,6426,"BLUE CROSS [10001]","Blue Cross HMO",,8396.64,39.2,,8555.87,8555.87,8996.26,"1 through 10",2491.15,18207,"percent of total billed charges",
"BIT DRILL L270MM DIA12MM NONSTERILE 3 FLUTED CANNULATED LARG",SUP-03.010.439,CDM,S27200284,LOCAL,0272,RC,,,both,,,2926.35,877.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOBRONCHIAL 35FR ANGLE 2 RIGHT",SUP-M126135,CDM,S27200284,LOCAL,0272,RC,,,both,,,520.51,156.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Aep Thrshld Est Mlt Freq I&R",PX-471000014,CDM,92652,CPT,0471,RC,,,both,,,1504.00,451.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OCCL CARDIOVASCULAR 27MM DELIVERY SYSTEM WATCHMAN FLX",SUP-M635WU50270,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE LITHO 330MM 3.3MM SWISS LITHOCLAST ULTRASOUND FLEXIBLE",SUP-M0068407140,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASEPLT GLENOID 15MM AEQUALIS 6 SHOULDER HA REVERSED STD",SUP-DWD003,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"CIGNA [10200]","Cigna Open Access",,5373.07,56.9,,5302.19,4377.88,6578.61,27,1098.22,8026.55,"percent of total billed charges",
"HC Mpl Gene Common Variants",PX-310000012,CDM,81338,HCPCS,0310,RC,,,both,,,836.00,250.8,"MULTIPLAN [10600]",Multiplan,,710.6,85,,,,,0,0.01,710.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE CARDIOFORM ASD OCCLUDER 37MM 11FR",SUP-00733132636501,CDM,C1817,HCPCS,0278,RC,,,both,,,52321.50,15696.45,"KAISER [10500]",Kaiser,,35055.41,67,,,,,0,6084.99,44473.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 60MM TRI-STAPLE 2 MEDIUM THICK TISSUE",SUP-SIGTRSB60AMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2693.03,807.91,"FIRST HEALTH [10303]","First Health",,2154.42,80,,,,,0,313.2,2289.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esophagosc Rem Lesion by Snare",PX-750000203,CDM,43217,CPT,0750,RC,,,both,,,2075.00,622.5,"CIGNA [10200]",Cigna,,2075,,"Case rate ($2,497). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,241.32,2075,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION",RX-36576,CDM,,,0250,RC,43598-0326-75,NDC,both,7.5,ML,1353.16,405.95,"CIGNA [10200]","Cigna Open Access",,769.95,56.9,,,,,0,157.37,1150.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 0 GS-22 12IN CLSR ABSORBABLE GREEN",SUP-VLOCL2216,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.67,61.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,94.4,45.9,,,,,0,23.92,174.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASC AORT EXT CUF 28MM",SUP-PLA280300,CDM,C1713,HCPCS,0278,RC,,,both,,,19725.30,5917.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8107.1,41.1,,,,,0,2294.05,16766.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXCELSIOR SL-10 PRE-SHAPED 90 150CM",SUP-M0031681910,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"UHC [10700]","United Healthcare",,4886.28,63.3,,,,,0,897.75,6561.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTNR 8.875X5.625IN SMALL VISCUS STERILE LATEX FREE",SUP-3202,CDM,S27200284,LOCAL,0272,RC,,,both,,,404.55,121.36,"FIRST HEALTH [10303]","First Health",,323.64,80,,,,,0,47.05,343.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 16MM ORTHOLOC TITANIUM NITRIDE FOREFOOT ANKLE",SUP-5201024016,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,200.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",200.62,1466.25,"percent of total billed charges",
"RELOAD STPLR 0 6IN ENDO STITCH V-LOC POLYBUTESTER LOAD UNIT",SUP-VLOCN006L,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.01,84.3,"NOVANET [10819]",Novanet,,210.76,75,,,,,0,32.68,238.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 5MM 18MM LCP TITANIUM FULL THREAD DISTAL",SUP-402.818,CDM,C1713,HCPCS,0278,RC,,,both,,,380.02,114.01,"BLUE CROSS [10001]","Blue Cross HMO",,148.97,39.2,,957.42,156.86,7483.26,51,44.2,323.02,"percent of total billed charges",
"HC Drug Assay Salicylate",PX-301000673,CDM,80179,CPT,0301,RC,,,both,,,220.40,66.12,"KAISER [10500]",Kaiser,,147.67,67,,,,,0,0.01,187.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE 1%-EPI 1:100,000 BUFFERED W/SOD BICARB 8.4% SYRINGE 10 ML",RX-411235,CDM,,,0250,RC,08888-8879-61,NDC,both,10,ML,18.92,5.68,"PHCS [10601]",PHCS,,13.24,70,,,,,0,2.2,16.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Caregiver Training Each Adl 15 Min (Go)",PX-430000065,CDM,97551,CPT,0430,RC,,,both,,,48.11,14.43,"CIGNA [10200]",Cigna,,48.11,,"Per diem ($369).",,,,0,5.6,48.11,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 30CM 150CM 7FR .038IN 3CM BLADDER LOOP",SUP-M006155255170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS [10001]","Blue Cross HMO",,556.77,39.2,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 6.5MM MICRO100 MICROPOWER 10MM FLUTE ROUND",SUP-509123200,CDM,S27200284,LOCAL,0272,RC,,,both,,,388.11,116.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,263.91,68,,,,,0,45.14,329.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 121MM 11MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771101100,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5981.47,28.62,,,,,0,2430.63,17764.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VXSK-180P RF WIRE 63CM/55DEG/D1 SHEATH",SUP-VXSK0124,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"PHCS [10601]",PHCS,,4322.85,70,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Microbe Suscept Macrobroth",PX-306000217,CDM,87188,CPT,0306,RC,,,both,,,199.00,59.7,"CIGNA [10200]",Cigna,,14.61,,,,,,,0.01,169.15,"fee schedule",
"PLATE 87MM STAINLESS STEEL 3.5MM SCR 4 HOLE VARIABLE ANGLE",SUP-02.127.211S,CDM,C1713,HCPCS,0278,RC,,,both,,,9729.00,2918.7,"BLUE CROSS [10001]","Blue Cross HMO",,3813.77,39.2,,957.42,156.86,7483.26,51,1131.48,8269.65,"percent of total billed charges",
"KIT PACING NEURX DPS",SUP-22-0035,CDM,C1767,HCPCS,0278,RC,,,both,,,197505.00,59251.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,53326.35,27,,,,,0,22969.83,167879.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE NDL 9GA DISPOSABLE EVIVA","SUP-EVIVA NG09L",CDM,S27200284,LOCAL,0272,RC,,,both,,,90.31,27.09,"CIGNA [10200]",Cigna,,61.41,68,,,,,0,10.5,76.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 20MM CANCELLOUS",SUP-117220000,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"BLUE CROSS [10001]","Blue Cross HMO",,449.29,39.2,,957.42,156.86,7483.26,51,133.3,974.23,"percent of total billed charges",
"CAGE SPINAL 50X18X12MM CLYDESDALE PTC 6D PEEK TITANIUM",SUP-4986250,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH CRANIAL 85X53X.3MM LORENZ NEURO PANEL 1.5MM SCR",SUP-1/1/7185,CDM,C1713,HCPCS,0278,RC,,,both,,,5934.00,1780.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,690.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",690.12,5043.9,"percent of total billed charges",
"VALVE SHUNT HAKIM CSF 120CM 14CM UNITIZED DISTAL CATH",SUP-823834,CDM,S27800098,LOCAL,0278,RC,,,both,,,34085.02,10225.51,"CIGNA [10200]","Cigna Local Plus",,10736.78,31.5,,,,,0,3964.09,28972.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ALEXIS KII 14CM EXTRACTION SPECIMEN CONTAINMENT BAG",SUP-GTK14,CDM,S27200284,LOCAL,0272,RC,,,both,,,2812.50,843.75,"NOVANET [10819]",Novanet,,2109.38,75,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 20MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-02008,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1225.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 28CM 3CM 6FR .038IN 2 PIGTAIL",SUP-M006192134010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS [10001]","Blue Cross HMO",,470.63,39.2,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CRYOSURGICAL TRUFREEZE PASSIVE VENT CATH",SUP-CO8407030501,CDM,C2618,HCPCS,0272,RC,,,both,,,13765.50,4129.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5657.62,41.1,,,,,0,1520.68,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Caregiver Training Each Adl 15 Min (Go)",PX-430000065,CDM,97551,CPT,0430,RC,,,both,,,48.11,14.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,48.11,,"Per diem ($215).",,,,0,5.6,48.11,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 12X19MM FORTIFY 12MM NONSTERILE LATEX FREE",SUP-151.051,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"PHCS [10601]",PHCS,,22468.95,70,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 80MM 12MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U12080090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4750.65,45.9,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Proc Dirct Ea 15min (Gp)",PX-420000021,CDM,97110,CPT,0420,RC,,,both,,,194.83,58.45,"KAISER [10500]",Kaiser,,130.54,67,,,,,0,22.66,194.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 100MM 130CM 7MM 6FR .035IN VASCULAR NITINOL",SUP-EX071003CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]","Cigna Open Access",,5085.3,33.5,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Iron",PX-301000287,CDM,83540,CPT,0301,RC,,,both,,,169.00,50.7,"UHC [10700]","United Healthcare",,5.82,,,,,,,0.17,143.65,"fee schedule",
"HC Excsn Skin Lesn Tr/Ext >4cm",PX-510000031,CDM,11406,CPT,0761,RC,,,both,,,4908.96,1472.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,581.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,570.91,4908.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION",RX-109034,CDM,J0706,HCPCS,0636,RC,25021-0601-03,NDC,both,3,ML,181.20,54.36,"NOVANET [10819]",Novanet,,135.9,75,,,,,0,16.92,154.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD THK14MM 40J 40X71MM","SUP-CD1357-40Q CELL",CDM,C1722,HCPCS,0278,RC,,,both,,,35964.00,10789.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4261.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4182.61,30569.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLCHICINE 0.6 MG TABLET",RX-1821,CDM,,,0637,RC,50268-0187-11,NDC,both,1,UN,27.21,8.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.16,23.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH THREADER MONORAIL POWERCOIL 150CM 12MM 1.2MM MICRO",SUP-H7493926912120,CDM,C1725,HCPCS,0272,RC,,,both,,,3300.00,990,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,391.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,383.79,2805,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grad Compression Gauntlet",PX-E27100007,CDM,S8428,HCPCS,0292,RC,,,both,,,210.00,63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,24.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.42,178.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 20FTX3IN ROLL 15 LAYER REINFORCE OPEN CELL",SUP-SR315,CDM,S27000186,LOCAL,0270,RC,,,both,,,449.15,134.74,"CIGNA [10200]","Cigna Local Plus",,240.3,53.5,,,,,0,52.24,381.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET NDL 45MM 15GA ARROW EZ-IO EZ-CONNECT NDL VISE WRIST BAND",SUP-9079P-VC-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1138.86,341.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,468.07,41.1,,,,,0,132.45,968.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX11MM FRA 8D 30D NARROW SPINE LUMBAR",SUP-10211,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5409.18,28.62,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETENE 30X30CM MONOFILAMENT STERILE",SUP-PPM3030,CDM,C1781,HCPCS,0278,RC,,,both,,,882.58,264.77,"MULTIPLAN [10600]",Multiplan,,750.19,85,,,,,0,102.64,750.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 132D 10 HIP",SUP-6720-1040,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"KAISER [10500]",Kaiser,,16054.57,67,,,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH SAFE 9FR",SUP-CLS-1009,CDM,C1894,HCPCS,0272,RC,,,both,,,255.78,76.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.75,217.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dilatation Ureter",PX-361000237,CDM,53899,CPT,0361,RC,,,both,,,3053.01,915.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3053.01,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,355.07,3053.01,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"270 SINGLE USE FLAT TIP HOLMIUM FIBER",SUP-HOL270SBX,CDM,S27200284,LOCAL,0272,RC,,,both,,,1677.50,503.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 3MM PRECISION MATCH HEAD LATEX FREE",SUP-8470107530,CDM,S27200284,LOCAL,0272,RC,,,both,,,2033.10,609.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DISECT 9.5INX2MM OLIVECRONA DURA 2 END SURGICAL 3MM",SUP-57-3602,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STYLET PACEMAKER SOFT STRAIGHT 52CM LENGTH",SUP-6522,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT SYR STELLANT 2 SPIKE DUAL T CNCT LOW PRESSURE TUBING 200",SUP-SDS-CTP-SCS,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.53,35.26,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MIXER BONE CEMENT REVOLUTION FEMUR STERILE LATEX FREE",SUP-0606-565-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,783.88,235.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) GUIDEWIRE RAIDER VASCULAR STRAIGHT 300CM .014IN STAIN",SUP-7449,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,,41.1,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 70.8X12.5MM THK1MM THK1.12MM LARGE BONE",SUP-KM-277R,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.18,55.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUT GII QUICKANCHOR PLUS ORTHOCORD SHOULDER WITHOUT",SUP-222983,CDM,C1713,HCPCS,0278,RC,,,both,,,6127.20,1838.16,"KAISER [10500]",Kaiser,,4105.22,67,,,,,0,712.59,5208.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC MRI SURESCAN VENTRICULAR 1 CHMBR EV4 LATEX",SUP-DVEA3E4,CDM,C1722,HCPCS,0278,RC,,,both,,,118275.00,35482.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14015.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13755.38,100533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0180,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.75MM X 10.0MM",SUP-492751012,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 55CM 14FR STRAIGHT TRINIFLEX SPLIT CATH III BASIC",SUP-ASPC55-3,CDM,C1750,HCPCS,0278,RC,,,both,,,2437.50,731.25,"NOVANET [10819]",Novanet,,1828.13,75,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 16MM 144CM 5MM CORONARY STENT",SUP-H7493926016500,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"UHC [10700]","United Healthcare",,5896.4,63.3,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 28MM 1 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800128,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF CONDUCTR 110CM 7FR MULTICURVE ABLATION STEERABLE",SUP-786044,CDM,C1733,HCPCS,0272,RC,,,both,,,3967.50,1190.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,470.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDIUM IN-111 OXYQUINOLINE INTRAVENOUS SOLUTION 0.5-1 MCI",RX-411588,CDM,A9547,HCPCS,0343,RC,08888-8877-01,NDC,both,1,UN,11022.18,3306.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7164.42,65,,,,,0,1281.88,9368.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MITRACLIP XTR CDS (CLIP DELIVERY SYSTEM) PRIMARY MR CLINICAL",SUP-CDS0604-XTR,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68400,40,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 3.2MM STEINMANN COMPREHENSIVE STAINLESS",SUP-405800,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CIGNA [10200]","Cigna Open Access",,885.36,56.9,,1144.80,304.56,2275.09,66,180.96,1322.6,"percent of total billed charges",
"VANCOMYCIN HCL 500 MG/10ML IV (WET SOLR VIAL)",RX-4158443,CDM,J3373,HCPCS,0636,RC,00409-4332-11,NDC,both,1,UN,73.94,22.18,"BLUE CROSS [10001]","Blue Cross HMO",,1.75,,,,,,,1.75,62.85,"fee schedule",
"SPACER SPINAL 22MMX7MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2990722,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"BLUE CROSS [10001]","Blue Cross HMO",,6231.86,39.2,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 22CM 11FR SHORT LENGTH URETERAL",SUP-H7493936110220,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,146.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIPHERAL CUTTING BALLOON 90CM 20MM 6MM BALLOON",SUP-M001PCB6020900,CDM,C1725,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"MULTIPLAN [10600]",Multiplan,,3958.88,85,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mech Thromb Venous Add",PX-361000135,CDM,37188,CPT,0361,RC,,,both,,,8693.76,2608.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1011.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1011.08,8693.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 22-30CM 3CM 6FR .035IN",SUP-M006180156190,CDM,C2617,HCPCS,0278,RC,,,both,,,1271.86,381.56,"BLUE CROSS [10001]","Blue Cross PPO",,498.57,39.2,,,,,0,147.92,1081.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM SEMIRIGID OPEN ANTERIOR SEG SEWING",SUP-5300M28,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3726,27,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 8FR LARGE REGULAR PIGTAIL CURVE URETERAL",SUP-M001245530,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,408.97,45.9,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR S ENDOSCOPIC TISSUE",SUP-26031SO,CDM,S27200284,LOCAL,0272,RC,,,both,,,1445.53,433.66,"CIGNA [10200]","Cigna Local Plus",,773.36,53.5,,,,,0,168.12,1228.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO 1000093009 OPTISEAL GLBL 7FR25CM",SUP-1000093009,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 42MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.042TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIBRILLATOR 65CM 8FR OPTISURE ENDOCARDIUM 2 COIL DF1",SUP-LDA220-65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1997.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE NARROW SAGITTAL MICS SURGICAL DISPOSABLE",SUP-116171,CDM,S27200284,LOCAL,0272,RC,,,both,,,2287.50,686.25,"CIGNA [10200]",Cigna,,1555.5,68,,,,,0,266.04,1944.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X3IN DURAGEN CRANIAL DURA BOVINE CLLGN",SUP-ID-3305,CDM,,,0278,RC,,,both,,,5821.01,1746.3,"KAISER [10500]",Kaiser,,3900.08,67,,,,,0,5.82,4947.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +6 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR 1",SUP-MTA4U0.060,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 18MM 3MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT30018UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CIGNA [10200]","Cigna Local Plus",,1292.03,53.5,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 10X6.8IN MEPITEL ONE NONADHERENT LATEX FREE",SUP-081532332,CDM,S27200284,LOCAL,0272,RC,,,both,,,363.03,108.91,"PHCS [10601]",PHCS,,254.12,70,,,,,0,42.22,308.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1.5 X 4 COMPLEX PICO COIL",SUP-10USC01504,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"AETNA [10100]","Aetna HMO/PPO",,10395.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pulm Rhb W Cont Oximetry Mntr",PX-948000003,CDM,94626,CPT,0948,RC,,,both,,,301.15,90.34,"KAISER [10500]",Kaiser,,201.77,67,,,,,0,35.02,301.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 STD 12MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS6S12L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"KAISER [10500]",Kaiser,,6962.24,67,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 12MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-012,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"CIGNA [10200]","Cigna Open Access",,2695.41,56.9,,5302.19,4377.88,6578.61,27,550.92,4026.54,"percent of total billed charges",
"CW005, 5MMX42CM EPIX ES SMK EVAC STR LHK",SUP-CW005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC MATRIX RECOTHROM FLOSEAL",SUP-ADS202110,CDM,S27200284,LOCAL,0272,RC,,,both,,,1994.35,598.3,"NOVANET [10819]",Novanet,,1495.76,75,,,,,0,231.94,1695.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 19MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-219,CDM,C1776,HCPCS,0278,RC,,,both,,,17822.70,5346.81,"CIGNA [10200]",Cigna,,7129.08,40,,5873.17,5873.17,5873.17,"1 through 10",2072.78,15149.3,"percent of total billed charges",
"SUT TIGERLINK FIBERWIRE 2 26IN CLOSED LOOP BLACK WHITE",SUP-AR-7235T,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,55.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.4,397.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN HCL 500 MG/10ML IV (WET SOLR VIAL)",RX-4158443,CDM,J3373,HCPCS,0636,RC,00409-4332-11,NDC,both,1,UN,73.94,22.18,"CIGNA [10200]","Cigna Open Access",,4.28,,,,,,,1.75,62.85,"fee schedule",
"TRIATHLON PS X3 TIBIAL INSERT",SUP-5532-G-222,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"PHCS [10601]",PHCS,,7988.82,70,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE EVERPOINT 8-0 BV175-6 24IN 2 ARM MONOFILAMENT",SUP-EP8741H,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.23,104.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,237.48,68,,,,,0,40.62,296.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 19CM 14.5FR 360D STD 2 BRANCH STRAIGHT POLYURETHANE",SUP-5733690,CDM,S27200284,LOCAL,0272,RC,,,both,,,1897.50,569.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,224.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,220.68,1612.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 16MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0101600,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,591.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,591.02,4319.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MITRACLIP XTR CDS (CLIP DELIVERY SYSTEM) PRIMARY MR CLINICAL",SUP-CDS0604-XTR,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"FIRST HEALTH [10303]","First Health",,136800,80,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL CRYOABLATION 17.5CM 14GA ICEFORCE 2.1CX 90D DISTAL SHAFT",SUP-FPRPR3602,CDM,C2618,HCPCS,0272,RC,,,both,,,13110.00,3933,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 156MM 18MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-104180,CDM,C1776,HCPCS,0278,RC,,,both,,,27004.32,8101.3,"CIGNA [10200]",Cigna,,10801.73,40,,5873.17,5873.17,5873.17,"1 through 10",3140.6,22953.67,"percent of total billed charges",
"DEVICE BIOPINCE ULTRA 20CM 18GA BIOPSY FULL CORE INDCTR",SUP-360-2080-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"UHC [10700]","United Healthcare",,258.83,63.3,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 3MM X 10CM",SUP-M0035473100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"UHC [10700]","United Healthcare",,8934.57,63.3,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ABSORBATACK 5MM FIXATION POLYESTER 15 TACK ABSORBABLE",SUP-ABSTACK15,CDM,S27200284,LOCAL,0272,RC,,,both,,,2795.85,838.75,"CIGNA [10200]",Cigna,,1901.18,68,,,,,0,325.16,2376.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 8.75IN BUZZ RUGGLES REDMOND 1MM BAYONET",SUP-N24BS10,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM CORTICAL LOW PROFILE NONSTERILE ALPS",SUP-131218022,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,226.03,28.62,,,,,0,91.85,671.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK 4.5CM STD SEPTUM NASAL AIRWAY DRAWSTRING MEROCEL STERILE",SUP-440409,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.70,41.61,"CIGNA [10200]",Cigna,,94.32,68,,,,,0,16.13,117.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL STD 12CM 5MM STERILE BRASS",SUP-B0512,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.17,46.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.16,132.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMT BRIDLE PRO- 08 FR",SUP-4-4208,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"KAISER [10500]",Kaiser,,477.58,67,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL OD22 MM CONCAVE",SUP-6200-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,2625.00,787.5,"PHCS [10601]",PHCS,,1837.5,70,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 12CM OCCL GLDEWIRE NEPHRSTMY INTRO PERCUTANEOUS",SUP-M0067001210,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.79,81.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,111.71,41.1,,,,,0,31.61,231.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET HOUSING REAMER",SUP-AR-1204AF-75,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"KAISER [10500]",Kaiser,,1714.78,67,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX25MM NARROW FEMORAL RING ALIF",SUP-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]",Cigna,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POWER DRIVER BATTERIES",SUP-PDBP-001-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,811.62,243.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.39,689.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 3.5MM CASPIAN MEDIUM SPINE TRANSVERSE NONSTERILE",SUP-1101-73038M,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"MULTIPLAN [10600]",Multiplan,,3028.13,85,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER FACTORS INFLUENCING HEALTH STATUS",951,MS-DRG,,,,,,,inpatient,,,31435.44,9430.63,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,10547.35,,"Case rate ($9,950.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,239.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,279.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,080.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,251.77. The transfer operating threshold is the transfer adjustment factor * $9,239.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $698.56. The transfer capital threshold is the transfer adjustment factor * $698.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,31435.44,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 4MM CANNULATED",SUP-AR-8943-05,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 22MM 52MM SHOULDER ANATOMIC RESTORATION",SUP-AR-9152-22P,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"AMERIGROUP MEDICAID [20100]",Amerigroup,,938.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DEBAKEY CARDIO-GRIP STRAIGHT 14.25IN VASCULAR",SUP-320108,CDM,S27200284,LOCAL,0272,RC,,,both,,,1211.84,363.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,824.05,68,,,,,0,140.94,1030.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SERTRALINE 50 MG TABLET",RX-11351,CDM,,,0637,RC,16714-0612-06,NDC,both,1,UN,14.02,4.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.63,11.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.7MM 20MM THREAD NONLOCK TITANIUM NONSTERILE",SUP-PANL-27200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.60,379.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,361.64,28.62,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIR STPLR TRIEEA33XT BLK EXTHK",SUP-TRIEEA33XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2254.95,676.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1533.37,68,,,,,0,262.25,1916.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 0 CT 45CM SUT ABSORBABLE KNOTLESS",SUP-SXPP1A406,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"MULTIPLAN [10600]",Multiplan,,204.26,85,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"174015 MF ENDO HERNIA DLU 4.0MM X6",SUP-174015,CDM,S27200284,LOCAL,0272,RC,,,both,,,388.11,116.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,159.51,41.1,,,,,0,45.14,329.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR BENTSON 22CM 15CM 6FR .035IN STRAIGHT URETERAL",SUP-M006180221060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"FIRST HEALTH [10303]","First Health",,797.94,80,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 8X.25IN RIBBON 2 END MALLEABLE STAINLESS STEEL SPINE",SUP-22-0006,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.21,22.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.63,63.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR FR4 CURVE ANGIOGRAPHIC VENTRICULAR 2",SUP-H74916391022,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"MULTIPLAN [10600]",Multiplan,,65.09,85,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX9MM CAPSTONE PEEK PTC LUMBAR INTERBODY",SUP-3992209,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM SOLERA COCR SPINE MULTIAXIAL",SUP-54840007540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6491.86,68,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 54MM LCP STAINLESS STEEL LONG THREAD SMALL BONE",SUP-207.654,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,477.38,45.9,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Cervical Balloon Dilatation",PX-E27200255,CDM,C1726,HCPCS,0272,RC,,,both,,,309.10,92.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,36.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.95,262.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 36MM SALVATION ORTHOLOC TITANIUM ANKLE",SUP-59215536,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"NOVANET [10819]",Novanet,,1648.13,75,,,,,0,255.57,1867.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 150CM 6FR .038IN 3CM STD STRAIGHT URETERAL",SUP-M006145359170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,323.39,28.62,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 14CM 6MM BALLOON",SUP-G52270,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.47,41.1,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 BACKWARD STRAIGHT OFFSET 9.5IN KARLIN LUMBAR HANDLE",SUP-46-3132,CDM,S27200284,LOCAL,0272,RC,,,both,,,1195.16,358.55,"NOVANET [10819]",Novanet,,896.37,75,,,,,0,139,1015.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 98CM 22-19GA RADIOFREQUENCY ENERGY PUNCTURE STEERABLE",SUP-NRG-E-HF-98-C0,CDM,S27200284,LOCAL,0272,RC,,,both,,,3562.50,1068.75,"AETNA [10100]","Aetna HMO/PPO",,2832.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 3X32+TRAK21+CAT7 3-PACK - US",SUP-SFP913120,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,11781,68,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIPHERAL CUTTING BALLOON 135CM 20MM 6MM BALLOON",SUP-M001PCB60201350,CDM,C1725,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,551.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN HALF 70MM 5MM JET-X LONG ORTHOPEDIC TITANIUM NITRIDE",SUP-71065709,CDM,C1887,HCPCS,0272,RC,,,both,,,2085.00,625.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,247.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,242.49,1772.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 7.75MM BARRON 360D STAINLESS STEEL TREPHINE",SUP-K20-2057,CDM,S27200284,LOCAL,0272,RC,,,both,,,599.40,179.82,"AETNA [10100]","Aetna HMO/PPO",,476.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 4FR 3.17MM CAMINO INTRACRANIAL SUBDURAL",SUP-1104G,CDM,S27200284,LOCAL,0272,RC,,,both,,,6614.06,1984.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3035.85,45.9,,,,,0,769.22,5621.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 18GA MAGSEED BREAST BIOPSY 12CM",SUP-SM18112001,CDM,A4648,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"PHCS [10601]",PHCS,,2598.75,70,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502606202,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9145.08,40,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 23.5 DIOPTER",SUP-SV25T0,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"NOVANET [10819]",Novanet,,558.75,75,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 3CM 170CM 7FR 2 PIGTAIL CURVE BILIARY",SUP-G22159,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"KAISER [10500]",Kaiser,,423.31,67,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.5CM NATRELLE INSPIRA P6.7CM EXTRA FULL PROFILE",SUP-MSZ-X750,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA [10200]","Cigna Local Plus",,84.63,53.5,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPEEDBRIDGE 3.9MM FIXATION ACHILLES",SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,0278,RC,,,both,,,19150.43,5745.13,"AETNA [10100]","Aetna HMO/PPO",,15224.59,79.5,,1521.93,481.35,16760.95,30,2227.2,16277.87,"percent of total billed charges",
"SUT PROLENE 2-0 V-5 36IN 2 ARM MONOFILAMENT BLUE",SUP-8937H,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.29,24.69,"PHCS [10601]",PHCS,,57.6,70,,,,,0,9.57,69.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 10X22X55MM 10DEG LORDOTIC WIDE MODULUS XL-W",SUP-1221055P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE SPARTACORE VASCULAR STRAIGHT 190CM 5CM .014",SUP-1005202,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE REDUCTION 150MM 1.25MM STAINLESS STEEL THREAD TIP SMALL",SUP-02.111.500.01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,384.98,115.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,176.71,45.9,,,,,0,44.77,327.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 50CM 45CM 9.2FR .102IN MULTIPURPOSE CURVE GUIDING LEAD",SUP-8113,CDM,C1887,HCPCS,0272,RC,,,both,,,1386.50,415.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,164.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.25,1178.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX 20MM 135CM 7MM VASCULAR NITINOL CAROTID",SUP-PC0720RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,9418.50,2825.55,"CIGNA [10200]","Cigna Local Plus",,5038.9,53.5,,,,,0,1095.37,8005.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD LUBRI-SIL IC 12FR URETHRAL BACTI-GUARD SILICONE",SUP-1758SI12,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.35,24.4,"KAISER [10500]",Kaiser,,54.5,67,,,,,0,9.46,69.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 132 MEQ SODIUM 2.5 MEQ CALCIUM 0.5 MEQ MAGNESIUM 96 MEQ",SUP-L5B9772,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 26CM 6FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49906,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"NOVANET [10819]",Novanet,,564.98,75,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERIT MAESTRO 150CM 2.8FR .024IN .038IN .021IN MICRO",SUP-28MC28150ST,CDM,C1887,HCPCS,0272,RC,,,both,,,2301.00,690.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,267.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,267.61,1955.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 110CM 5FR PIGTAIL 155 CURVE ANGIOGRAPHIC",SUP-08526-42,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"KAISER [10500]",Kaiser,,51.31,67,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE DRILL EXTREMITIES UNIVERSAL STERILE LATEX FREE",SUP-72205699,CDM,S27200284,LOCAL,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 4-0 P-11 3/8 CIRCLE 12IN 16MM CLSR SURGALLOY",SUP-VLOCM1413,CDM,S27200284,LOCAL,0272,RC,,,both,,,412.21,123.66,"MULTIPLAN [10600]",Multiplan,,350.38,85,,,,,0,47.94,350.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 8MM KII OPTICAL ACCESS SYSTEM Z",SUP-C0Q19,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"NOVANET [10819]",Novanet,,117.45,75,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 16FR SILICONE INTERNAL RETENTION BALLOON RECESS DISTAL",SUP-8100-16LV,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"CIGNA [10200]",Cigna,,190.32,68,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL CENTERING PIN 4.5 MM SCREWS NONSTERILE",SUP-309.470,CDM,S27000186,LOCAL,0270,RC,,,both,,,961.31,288.39,"KAISER [10500]",Kaiser,,644.08,67,,,,,0,111.8,817.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CORONARY 3MM 16MM .014IN OTW BALLOON EXPANDING",SUP-12744-16,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"PHCS [10601]",PHCS,,11567.85,70,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.145 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.145,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT 17GA 50MM ELECTROTHERAPY COOLIEF STERILE LATEX FREE",SUP-CRK-17-50-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT 17GA 50MM ELECTROTHERAPY COOLIEF STERILE LATEX FREE",SUP-CRK-17-50-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER 3992612 26MM X 12MM",SUP-3992612,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5730.91,27,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 6MM 18MM STAINLESS STEEL T15 FULL THREAD",SUP-02.200.018,CDM,C1713,HCPCS,0278,RC,,,both,,,240.38,72.11,"CIGNA [10200]","Cigna Local Plus",,128.6,53.5,,3978.14,359.25,3978.14,24,27.96,204.32,"percent of total billed charges",
"LARYNSCP VIDEO S2.5 HYPERANGULATE LOW PROFILE BLADE GLIDESCO",SUP-0270-1091,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.40,131.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 7IN STRAIGHT 1.5MM CUSHING DELICATE SURGICAL",SUP-57-2001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2266.43,679.93,"NOVANET [10819]",Novanet,,1699.82,75,,,,,0,263.59,1926.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOLOIST 110CM 6FR 5MM SPACING JSN CURVE",SUP-44516J,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"UHC [10700]","United Healthcare",,461.46,63.3,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER ETHIBOND 2-0 SH 30IN 2 ARM BRAID GREEN",SUP-X563H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND SUTUPAK 0 18IN BRAID TIES 17 STRAND",SUP-SA66G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 11MM 8.2MM 100MM TALON HIP DISTALFIX TECHNOLOGY LAG",SUP-SLN-011-100,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"PHCS [10601]",PHCS,,3477.6,70,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM FIBERTAG TIGHTROPE II FLIPCUTTER III FIBERSNARE",SUP-AR-1288RTT2-FC3,CDM,C1713,HCPCS,0278,RC,,,both,,,7353.68,2206.1,"NOVANET [10819]",Novanet,,5515.26,75,,,,,0,855.23,6250.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 45CM .013IN SFT KNOB",SUP-6047,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR ENDOSCOPIC SURGICEL 73.6OZ",SUP-3123SPEA,CDM,S27200284,LOCAL,0272,RC,,,both,,,353.29,105.99,"CIGNA [10200]",Cigna,,240.24,68,,,,,0,41.09,300.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 90MM 9.6MM 5MM CUFF PROXIMAL EXT EXTEND LENGTH SOFT",SUP-50XLTCP,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,329.98,68,,,,,0,56.44,412.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 1MM 1MM ANGLED SIDEPORT CLEARCUT SURGICAL STERILE",SUP-8065921540,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.62,32.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.75,93.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 401322 MDII 22X26 SRVC FEE",SUP-401322,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X8MM COROENT 10D XL+ PEEK NONSTERILE LATEX",SUP-6308845,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2784.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 56MM 16MM 5.4MM 14FR ZENITH SPIRAL-Z",SUP-G55237,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6060.08,28.62,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X5MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7005,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]",Cigna,,4692,68,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SUTURETAPE 2 .5 CIRCLE 36.6MM TAPER NDL BLACK WHITE 1.3",SUP-AR-7506T,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN INTERNAL MAMMARY CURVE",SUP-H74908641201,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"UHC [10700]","United Healthcare",,44.89,63.3,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SURGICAL 38CM ON-Q PAINBUSTER CATH SYCHROMED",SUP-8591-38,CDM,S27200284,LOCAL,0272,RC,,,both,,,980.10,294.03,"AMERIGROUP MEDICAID [20100]",Amerigroup,,116.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.99,833.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 30MM 5MM E9000 ROUND 10 FLUTE CARBIDE CUT LOW",SUP-E8050LSO,CDM,S27200284,LOCAL,0272,RC,,,both,,,453.28,135.98,"KAISER [10500]",Kaiser,,303.7,67,,,,,0,52.72,385.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET PACEMAKER SOFT STRAIGHT 59CM LENGTH",SUP-6521,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 110CM 5FR PIGTAIL 155 CURVE ANGIOGRAPHIC",SUP-08526-42,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC MICROPOINT 4-0 G-2 18IN 2 ARM MONOFILAMENT BROWN",SUP-798G,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.02,54.01,"CIGNA [10200]","Cigna Open Access",,102.43,56.9,,,,,0,20.94,153.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 4.5MM CORONARY STENT",SUP-H7493941820450,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM CONCERTO DETACHABLE HELIX PERIPHER",SUP-NV-2-4-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY L85MM DIA10.35MM GOLD TITANIUM CANNULAT",SUP-04.038.385S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"CIGNA [10200]","Cigna Local Plus",,2130.29,53.5,,3978.14,359.25,3978.14,24,463.09,3384.57,"percent of total billed charges",
"STENT ZILVER FLEX 35 100MM 80CM 9MM 6FR .035IN BILIARY",SUP-G50135,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CIGNA [10200]","Cigna Open Access",,3465.21,56.9,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 20MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036122050,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 12FR FEEDING REPLACEMENT STRAIGHT BOLST GASTRO ENDOVIVE",SUP-M00509881,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.82,72.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.01,204.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILFRM URETHRAL 18IN 3FR DILATION CATH WOVEN STRAIGHT TIP",SUP-021803,CDM,S27200284,LOCAL,0272,RC,,,both,,,1126.22,337.87,"MULTIPLAN [10600]",Multiplan,,957.29,85,,,,,0,130.98,957.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL 17MM 3.2MM MEDIUM TPS HELIOCOIDAL STERILE",SUP-5120-080-030,CDM,S27200284,LOCAL,0272,RC,,,both,,,965.20,289.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,114.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.25,820.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE INQWIRE AMPLATZ VASCULAR 3MM RADIUS J CURVE 145CM .035",SUP-IQA500,CDM,S27200284,LOCAL,0272,RC,,,both,,,298.58,89.57,"PHCS [10601]",PHCS,,209.01,70,,,,,0,34.72,253.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 25MM 5MM 4.4FR AUTOTOME PRO RX 44 CANNULATED",SUP-M00584380,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLER INTERNAL 31X4.8MM TITANIUM XL CIRCLE STAPLE ENDOSCOP",SUP-EEAXL31,CDM,S27200284,LOCAL,0272,RC,,,both,,,2269.80,680.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1041.84,45.9,,,,,0,263.98,1929.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 90CM 5FR MHK CURVE ANGIOGRAPHIC POLYURETHANE",SUP-590386MHK-NB,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"KAISER [10500]",Kaiser,,72.86,67,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD BIPOLAR 24FR BALL COAGULATION STERILE LATEX FREE",SUP-26040NB-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3144.38,943.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2138.18,68,,,,,0,365.69,2672.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETERIZATION .035IN 9IN GWIRE NDL SYR DRAPE ARROW",SUP-AK-01600,CDM,C1729,HCPCS,0272,RC,,,both,,,1030.32,309.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,423.46,41.1,,,,,0,119.83,875.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120MM 8MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR080502A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2003.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 15MM 4MM CORONARY STENT EVEROLIMUS",SUP-1550400-15,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 14MM PERSONA MEDIAL CONGRUENT 4-5 C-D KNEE",SUP-42512100314,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AETNA [10100]","Aetna HMO/PPO",,8567.25,79.5,,10981.53,8986.79,12413.38,12,1253.3,9159.96,"percent of total billed charges",
"DEVICE RAPTOR 230CM 2.4MM SPECIMEN RETRIEVAL HYBRID JAW",SUP-00711177,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER ANGIOGRAPHY L100CM OD4FR 0.038IN NYLON JR4 JL4 PIG1",SUP-538493,CDM,S27200284,LOCAL,0272,RC,,,both,,,227.51,68.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 9MM BALLOON",SUP-U357598,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC",841,MS-DRG,,,,,,,inpatient,,,60638.75,18191.62,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC",788,MS-DRG,,,,,,,inpatient,,,42726.41,12817.92,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 150CM 20MM 6MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013470-020,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH AMPHIRION DEEP 150CM 40MM 2MM BROAD TAPER BALLOON",SUP-AMP020040152,CDM,C1725,HCPCS,0272,RC,,,both,,,2422.50,726.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 135CM 200MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171032010,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.0MM X 26.0MM",SUP-493002612,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 35 135CM 80MM 6FR 10MM .035IN LOW PROFILE",SUP-B2100-080,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 150CM 80MM 6MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013470-080,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WEBSTER 110CM 5FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY",SUP-F5CQF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTTER ARTHROSCOPIC ANATOMIC SOCKET FLIPCUTTER II SHORT KNEE",SUP-AR-1204AS-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE FLOPPY II VASCULAR 190CM 2CM .014IN",SUP-22299M,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LUTONIX 035 130CM4X100MM 1/EACH",SUP-LX351304100,CDM,C1725,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL LONG TEETH",SUP-NF02,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.32,23.5,"CIGNA [10200]","Cigna Open Access",,44.56,56.9,,,,,0,9.11,66.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 4CM 10MM BALLOON",SUP-G52293,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UHC [10700]","United Healthcare",,607.53,63.3,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 25MM SIMULUS FULLY FLEXIBLE",SUP-700FC25,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"PHCS [10601]",PHCS,,9177,70,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC",177,MS-DRG,,,,,,,inpatient,,,39693.19,11907.96,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,10275.13,,"Case rate ($9,693.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,001.09, add-ons for qualifying new technology services are included. If operating cost exceeds $42,040.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,062.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,013.00. The transfer operating threshold is the transfer adjustment factor * $9,001.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $680.53. The transfer capital threshold is the transfer adjustment factor * $680.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,38972.18,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD MONOPOLAR LINA ENDOSCOPIC LOOP",SUP-EL-200-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,2756.25,826.87,"CIGNA [10200]","Cigna Local Plus",,1474.59,53.5,,,,,0,320.55,2342.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE BLUE DIAMOND 30 ATM 13IN INFLATION SYR EXT TUBING 3",SUP-IN7130,CDM,S27200284,LOCAL,0272,RC,,,both,,,399.59,119.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,46.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.47,339.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 22IN 24FR STRAIGHT TAPER DRNG HYDRAGLIDE XL PVC",SUP-8024,CDM,C1729,HCPCS,0272,RC,,,both,,,59.23,17.77,"NOVANET [10819]",Novanet,,44.42,75,,,,,0,6.89,50.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 CT-2 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J333H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"AETNA [10100]","Aetna HMO/PPO",,21.47,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM 12MM MODULAR RESTORATION HA POROUS PLASMA",SUP-6276-5-012,CDM,C1776,HCPCS,0278,RC,,,both,,,12929.16,3878.75,"BLUE CROSS [10001]","Blue Cross HMO",,5068.23,39.2,,5311.50,4717.44,5388.59,31,1503.66,10989.79,"percent of total billed charges",
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000105,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CITATION TMZF HA 6 SHORT HIP LEFT",SUP-6265-5206,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9768.78,40,,,,,0,2840.27,20758.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR TRILOGY STD NEUTRAL 6.8MM 50/52/54MM 36MM",SUP-00630505036,CDM,C1776,HCPCS,0278,RC,,,both,,,6497.40,1949.22,"FIRST HEALTH [10303]","First Health",,5197.92,80,,,,,0,755.65,5522.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM 3 HOLE BIOFOAM DYNASTY",SUP-DBFPGE54,CDM,C1776,HCPCS,0278,RC,,,both,,,18194.40,5458.32,"MULTIPLAN [10600]",Multiplan,,15465.24,85,,,,,0,2116.01,15465.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM 12MM MODULAR RESTORATION HA POROUS PLASMA",SUP-6276-5-012,CDM,C1776,HCPCS,0278,RC,,,both,,,12929.16,3878.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5171.66,40,,,,,0,1503.66,10989.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 80MM CEMENT KINEMAX COCR KNEE",SUP-6476-8-260,CDM,C1776,HCPCS,0278,RC,,,both,,,4905.90,1471.77,"BLUE CROSS [10001]","Blue Cross HMO",,1923.11,39.2,,5311.50,4717.44,5388.59,31,570.56,4170.02,"percent of total billed charges",
"INSRT TIBIAL 2 25MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-225,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5383.38,40,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 12/14 TAPER 36MM HIP SLEEVE TOTAL",SUP-136536720,CDM,C1776,HCPCS,0278,RC,,,both,,,13002.36,3900.71,"FIRST HEALTH [10303]","First Health",,10401.89,80,,,,,0,1512.17,11052.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echovirus Abs",PX-302000124,CDM,86658,CPT,0302,RC,,,both,,,77.00,23.1,"PHCS [10601]",PHCS,,53.9,70,,,,,0,0.01,65.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45X3.5MM TITANIUM REGULAR ENDOSCOPIC LINEAR",SUP-TA4535S,CDM,S27200284,LOCAL,0272,RC,,,both,,,860.30,258.09,"CIGNA [10200]","Cigna Local Plus",,460.26,53.5,,,,,0,100.05,731.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ONE1STEP CENTESIS CATHETER 5F 10CM19GA INTRODUCER NEEDLE4",SUP-OSC-5F-10LT,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.35,53.5,"PHCS [10601]",PHCS,,124.85,70,,,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL 2-0 TE SKS-3 24IN 2 ARM BRAID DARK BLUE",SUP-TPW80,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.87,53.96,"AETNA [10100]","Aetna HMO/PPO",,143,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.92,152.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14.8IN 24FR AORTA 3/8IN CURVE AUTO DILATE TIP",SUP-EZC24TA,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"NOVANET [10819]",Novanet,,364.5,75,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 14FR SILICONE PULL RADIOPAQUE MED PORT MIC SECUR-LOK",SUP-7180-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.81,228.54,"UHC [10700]","United Healthcare",,482.23,63.3,,,,,0,88.6,647.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA CARDIOPLEGIA ANTEGRADE W/VENT",SUP-ANT-2012S,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.72,41.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 15.1CM MEMORYGEL BOOST P5CM MODERATE PLUS PROFILE",SUP-RSZMPB675S,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL 28MMX3.5MM TITANIUM XL CIRCULAR LINEAR CUTTER",SUP-EEAXL2835,CDM,S27200284,LOCAL,0272,RC,,,both,,,2399.55,719.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC",964,MS-DRG,,,,,,,inpatient,,,59010.67,17703.2,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACCU-TRACE KENDALL SMALL FLAT ROUND PRESSURE",SUP-56300,CDM,S27200284,LOCAL,0272,RC,,,both,,,295.97,88.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE V-LOC 90 4-0 P-12 12IN CLSR ABSORBABLE UNDYED",SUP-VLOCM0013,CDM,S27200284,LOCAL,0272,RC,,,both,,,381.15,114.34,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE 22FR SILICONE INTERNAL RETENTION BALLOON RECESS DISTAL",SUP-8100-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMPULSE 125CM 5FR FL3.5 CURVE ANGIOGRAPHIC FEMORAL 2",SUP-H749163912412,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND MICROPOINT 4-0 G-3 18IN 2 ARM BRAID",SUP-783G,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.02,40.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPO 100CM 6FR .056IN WRP CURVE ANGIOGRAPHIC TRILON",SUP-H74908641512,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.17,22.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTTER SUT REMOVAL MENISCAL CINCH KNOT PUSHER 2-0 FIBERWIRE",SUP-AR-4515,CDM,S27200284,LOCAL,0272,RC,,,both,,,1063.13,318.94,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 1.5MM 8MM APTUS TITANIUM HEXADRIVE 4 HAND CORTICAL",SUP-A-5200.08/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE 17GA 10MM RADIOFREQUENCY ELECTROTHERAPY OSTEOCOOL 2MM",SUP-OCP210,CDM,S27200284,LOCAL,0272,RC,,,both,,,25389.00,7616.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"(EVAL) ZEBRA 6F 95CM ACCESS SYSTEM BER",SUP-AC6074-095-20,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CRTDG UTERINE DEVICE NOVASURE ENDOMETRIUM CO2 MEDICAL GAS",SUP-ASY-02742,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.61,26.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE WECK EFX SHIELD CLSR FASCIAL UNIFORM SUT RETRIEVAL",SUP-EFX002,CDM,S27200284,LOCAL,0272,RC,,,both,,,944.46,283.34,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT EPIC 60MM 112CM 9MM 75CM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200096070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 28MM 140CM 4.5MM CORONARY STENT PLATINUM",SUP-H7493927428450,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Open Access",,2133.75,56.9,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 20MM 75CM 5MM 100CM",SUP-M001711000,CDM,C1876,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"KAISER [10500]",Kaiser,,4969.73,67,,,,,0,862.66,6304.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PERIPHERAL L60MM DIA8MM CATHETER L80CM ILIAC LIFESTAR",SUP-VIUS08060,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 150CM 150MM 7MM BALLOON DILATATION PACLITAXEL",SUP-H74939419701510,CDM,C2623,HCPCS,0272,RC,,,both,,,10695.00,3208.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTREPID MITRAL PRE-CRIMP TOOL CLINICAL",SUP-ASM-0039,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"Rn Infusion",PX-551000014,CDM,G0299,HCPCS,0551,RC,,,outpatient,,,236.00,70.8,"KAISER [10500]",Kaiser,,158.12,67,,,,,0,158.12,200.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MITRL VAL INTPDMVL42C INTREPID 42MM CLIN",SUP-INTPDMVL42C,CDM,S62400003,LOCAL,0624,RC,,,both,,,256500.00,76950,"CIGNA [10200]",Cigna,,174420,68,,,,,0,29830.95,218025,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 60MM 100CM 12MM 75CM",SUP-H965402120,CDM,C1876,HCPCS,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 90MM 75CM 7MM 100CM",SUP-M001711220,CDM,C1876,HCPCS,0278,RC,,,both,,,12592.50,3777.75,"UHC [10700]","United Healthcare",,7971.05,63.3,,,,,0,1464.51,10703.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 120MM 75CM 5MM VASCULAR METAL SUPERFICIAL",SUP-H74939293051270,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"AETNA [10100]","Aetna HMO/PPO",,3839.85,79.5,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 18MM 135CM 5.5MM 3.3-2.9FR 6FR LOW",SUP-1011496-18,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,746.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP UNISTEP PLUS 80MM 194CM 10MM 7.5FR",SUP-H965430600,CDM,C1876,HCPCS,0278,RC,,,both,,,9068.53,2720.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1054.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1054.67,7708.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 100MM 75CM 10MM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200101070,CDM,C1876,HCPCS,0278,RC,,,both,,,4515.00,1354.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,535.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,525.09,3837.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX 40MM 135CM 9MM VASCULAR NITINOL CAROTID",SUP-PC0940RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"KAISER [10500]",Kaiser,,5085.3,67,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS THERMOCOOL REDEL 115CM 3.5MM 7FR 2-5-2MM SPACE",SUP-DI7TCBLRT,CDM,C2630,HCPCS,0272,RC,,,both,,,9142.50,2742.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP UNISTEP PLUS 20MM 100CM 8MM 6FR",SUP-M001711240,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"PHCS [10601]",PHCS,,5916.75,70,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Brain Complt Vasc Flow>=4v",PX-341000037,CDM,78606,CPT,0341,RC,,,both,,,2244.92,673.48,"UHC [10700]","United Healthcare",,1287.48,,,,,,,2.24,1908.18,"fee schedule",
"INTRO SHEATH 6FR .083IN 25CM ROBUST VALVE SPLITTABLE",SUP-PLS-2506,CDM,C1892,HCPCS,0272,RC,,,both,,,319.73,95.92,"UHC [10700]","United Healthcare",,202.39,63.3,,,,,0,37.18,271.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 30MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE50030,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9730.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 69MM 75CM 10MM 100CM",SUP-M001712380,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"CIGNA [10200]","Cigna Local Plus",,4522.09,53.5,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 40MM 40CM 8MM BILIARY SELF EXPAND",SUP-G31494,CDM,C1876,HCPCS,0278,RC,,,both,,,4653.98,1396.19,"PHCS [10601]",PHCS,,3257.79,70,,,,,0,541.26,3955.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENROUTE TRANSCAROTID STENT SYSTEM 10 X 30",SUP-SR-1030-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 135CM 8MM 30MM",SUP-38047-83013,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2216.97,45.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 100MM 80CM 9MM 6FR .035IN BILIARY",SUP-G50135,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CIGNA [10200]","Cigna Local Plus",,3258.15,53.5,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 135CM 6MM 20MM",SUP-H74938047620130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"FIRST HEALTH [10303]","First Health",,3993.6,80,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE EVERFLEX 100MM 120CM 5MM .079IN BILIARY",SUP-PRB35-05-100-120,CDM,C1876,HCPCS,0278,RC,,,both,,,7098.00,2129.4,"AETNA [10100]","Aetna HMO/PPO",,5642.91,79.5,,,,,0,825.5,6033.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 60MM 80CM 14MM .079IN LARGE DIAMETER",SUP-SERB65-14-60-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AETNA [10100]","Aetna HMO/PPO",,4424.18,79.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 20MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE45020,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,23944.81,28.62,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PALMAZ BLUE SLALOM FLEXSEGMENT 17MM 80CM 6MM 20MM",SUP-PB1860BSS,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]",Cigna,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 80MM 130CM 5MM VASCULAR SELF EXPAND RADIOPAQUE",SUP-H74939293058030,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross HMO",,1893.36,39.2,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 40MM 80CM 9MM 6FR VASCULAR NITINOL",SUP-G43861,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"MULTIPLAN [10600]",Multiplan,,3213,85,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE EVERFLEX 30MM 120CM 5MM .079IN BILIARY NITINOL",SUP-PRB35-05-030-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2554.34,45.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLOBAZAM 10 MG TABLET",RX-155225,CDM,,,0637,RC,60687-0423-11,NDC,both,1,UN,15.69,4.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6.45,41.1,,,,,0,1.82,13.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myeloperoxidase",PX-301000706,CDM,83876,CPT,0301,RC,,,both,,,88.00,26.4,"FIRST HEALTH [10303]","First Health",,70.4,80,,,,,0,0.01,88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC 8IN MEDIUM 15IN SHOULDER SLING SOFT CONTACT",SUP-79-84165,CDM,L3660,HCPCS,0274,RC,,,both,,,44.20,13.26,"CIGNA [10200]",Cigna,,30.06,68,,,,,0,5.14,44.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP 39MM 100CM 10MM 75CM ENDOPROSTHESIS METAL",SUP-M001712340,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"AETNA [10100]","Aetna HMO/PPO",,6719.74,79.5,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 150MM 130CM 6MM BILIARY SELF EXPANDING",SUP-SC6150L,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"MULTIPLAN [10600]",Multiplan,,7624.5,85,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 60MM 135CM 8MM VASCULAR NITINOL",SUP-1012536-60,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg Extend Monitor 41-60min",PX-740000008,CDM,95812,CPT,0740,RC,,,both,,,1762.04,528.61,"KAISER [10500]",Kaiser,,1180.57,67,,,,,0,204.93,1762.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 60MM 125CM 8MM 5FR .018IN VASCULAR NITINOL",SUP-G43782,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,495.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 60MM 125CM 8MM 5FR .018IN VASCULAR NITINOL",SUP-G43782,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2841.72,68,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 5X5CM NATURALLY POROUS NON-SIDED THIN DURABLE",SUP-DP-25,CDM,Q4122,HCPCS,0636,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Open Access",,3926.1,56.9,,,,,0,817.65,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 5X5CM NATURALLY POROUS NON-SIDED THIN DURABLE",SUP-DP-25,CDM,Q4122,HCPCS,0636,RC,,,both,,,6900.00,2070,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4485,65,,,,,0,817.65,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EQUALIZER 100CM 33MM 7FR BALLOON OCCLUSION PERIPHERAL",SUP-M001171100,CDM,C2628,HCPCS,0272,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla Class II Semi-Quan Panel",PX-302000240,CDM,86835,CPT,0302,RC,,,both,,,650.00,195,"AMERIGROUP MEDICAID [20100]",Amerigroup,,77.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.03,650,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO PEEL-AWAY SAFE-T-J PERCUTANEOUS STAINLESS STEEL 2",SUP-G04502,CDM,C1892,HCPCS,0272,RC,,,both,,,818.10,245.43,"AETNA [10100]","Aetna HMO/PPO",,650.39,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,95.15,695.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 12MM 2.25MM CORONARY STENT",SUP-1007822-12,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Open Access",,1707,56.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 150MM 130CM 6MM VASCULAR METAL SUPERFICIAL",SUP-H74939293061530,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins/Rplc Pcmkr Gen Only Dual",PX-480000008,CDM,33213,CPT,0481,RC,,,both,,,7475.15,2242.54,"AETNA [10100]","Aetna HMO/PPO",,5942.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,869.36,7475.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 30MM 125CM 4MM 5FR .018IN BILIARY NITINOL",SUP-G31438,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"AETNA [10100]","Aetna HMO/PPO",,3322.31,79.5,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAFIRE BLU DUO COMFORTGRIP 110CM 4MM 7FR 2-5-2MM SPACE",SUP-A088109,CDM,C2630,HCPCS,0272,RC,,,both,,,11040.00,3312,"KAISER [10500]",Kaiser,,7396.8,67,,,,,0,1283.95,9384,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SAPIEN M3 VALVE 29MM",SUP-9680TFX29M,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"CIGNA [10200]","Cigna Local Plus",,106732.5,53.5,,,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 20MM 10MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044102070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"KAISER [10500]",Kaiser,,5778.75,67,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 10X4CM AMNIOFIX PURION AMNIOTIC MEMB",SUP-APS-5410,CDM,Q4433,HCPCS,0636,RC,,,both,,,17980.20,5394.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"HC Tube Trach Uncuffed",PX-E27200237,CDM,E27200237,LOCAL,0272,RC,,,both,,,373.07,111.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PCMKR CRD THK6MM SM 50X47MM","SUP-PM1240 CELL",CDM,C1786,HCPCS,0275,RC,,,both,,,9324.00,2797.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1104.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1084.38,7925.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 11FR .144IN 25CM ROBUST VALVE SPLITTABLE",SUP-PLSX-2511,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Aqmbf Spect Xers/Strs & Rest",PX-341000093,CDM,0742T,HCPCS,0341,RC,,,both,,,720.11,216.03,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET INTRO PEEL-AWAY SAFE-T-J PERCUTANEOUS STAINLESS STEEL 2",SUP-G04502,CDM,C1892,HCPCS,0272,RC,,,both,,,818.10,245.43,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH THERMOCOOL SF D-D CURVE ABLATION BIDIRECTIONAL",SUP-BDI35DDRT,CDM,C2630,HCPCS,0272,RC,,,both,,,11350.50,3405.15,"AETNA [10100]","Aetna HMO/PPO",,9023.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 6CM 230CM 25-30MM 10FR 270CM COLONIC NITINOL",SUP-M00565040,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 75CM 5MM 20MM",SUP-38046-52075,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]",Cigna,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 20MM 120CM 9MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200092020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH HEMOSTASIS VALVE TEAR AWAY SIDEPORT SAFESHEATH",SUP-HLS2507,CDM,C1892,HCPCS,0272,RC,,,both,,,319.73,95.92,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,37.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.18,271.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 30MM 125CM 5MM 5FR SLOT BILIARY NITINOL OTW",SUP-G31351,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"CIGNA [10200]","Cigna Open Access",,2377.85,56.9,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VICI VENOUS STENT 120MM 100CM 12MM ENDOPROSTHESIS",SUP-H74912120100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 145MM 23/16MM 18FR ENDURANT II ABDOMINAL",SUP-ETBF2316C145E,CDM,C1876,HCPCS,0278,RC,,,both,,,58443.53,17533.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,23377.41,40,,,,,0,6796.98,49677,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 80CM 125CM 9MM VASCULAR HIWIRE NITINOL",SUP-G43788,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1196.03,28.62,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 120MM 130CM 7MM LONG VASCULAR NITINOL",SUP-SC7120LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"NOVANET [10819]",Novanet,,6727.5,75,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dihydrotestosterone (Dht)",PX-301000572,CDM,82642,CPT,0301,RC,,,both,,,71.50,21.45,"PHCS [10601]",PHCS,,50.05,70,,,,,0,0.01,64.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 18MM 135CM 6MM 3.6-3.3FR 6FR LOW",SUP-1011499-18,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"PHCS [10601]",PHCS,,4410,70,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 18MM 135CM 6MM 3.6-3.3FR 6FR LOW",SUP-1011499-18,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"CIGNA [10200]","Cigna Local Plus",,3370.5,53.5,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ACCULINK 30MM 132CM 5MM STRAIGHT VASCULAR NITINOL",SUP-1011337-30,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]","Cigna Open Access",,5085.3,33.5,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 25MM 75CM 9MM 30MM",SUP-H74938046920750,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"KAISER [10500]",Kaiser,,2773.8,67,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ACCULINK 40MM 132CM 6-8MM TAPER VASCULAR NITINOL",SUP-1011343-40,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"CIGNA [10200]","Cigna Open Access",,5325.84,56.9,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 30MM 109CM 9MM 75CM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200093070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Whole Blood L/R Irr Ea",PX-390000018,CDM,P9056,HCPCS,0390,RC,,,both,,,853.00,255.9,"NOVANET [10819]",Novanet,,639.75,75,,,,,0,99.2,725.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 20IN 36FR STRAIGHT DRNG PVC THORACIC 6 EYELET FIRM",SUP-15036,CDM,C1729,HCPCS,0272,RC,,,both,,,60.26,18.08,"UHC [10700]","United Healthcare",,38.14,63.3,,,,,0,7.01,51.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +7.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.075,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Factor VIII Vw Multimetric",PX-305000022,CDM,85247,CPT,0305,RC,,,both,,,246.00,73.8,"UHC [10700]","United Healthcare",,20.65,,,,,,,0.01,209.1,"fee schedule",
"PLUG CARDIOVASCULAR 100CM 5FR 8MM AMPLATZER .056IN TYPE II",SUP-9-AVP2-008,CDM,S27800098,LOCAL,0278,RC,,,both,,,6589.50,1976.85,"FIRST HEALTH [10303]","First Health",,5271.6,80,,,,,0,766.36,5601.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXS VECTA 71 132CM .082-.085IN .071IN ASPIRATION SCOUT",SUP-INC-11129-132,CDM,S27200284,LOCAL,0272,RC,,,both,,,16943.99,5083.2,"NOVANET [10819]",Novanet,,12707.99,75,,,,,0,1970.59,14402.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INSTR 27MM 3.5MM PERSONA HEX HEAD STERILE LATEX FREE",SUP-00590103527,CDM,S27200284,LOCAL,0272,RC,,,both,,,531.36,159.41,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 18GA 1.25MM ACCUCATH ACE DOT",SUP-AC1181252,CDM,S27200284,LOCAL,0272,RC,,,both,,,323.03,96.91,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CROWN FISTULA WOUND",SUP-00860013000301.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET DRNG INSRT ROCKET MINI STERILE LATEX FREE DISPOSABLE",SUP-R51400-MI-PL,CDM,C1729,HCPCS,0272,RC,,,both,,,2550.00,765,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PTS 80CM 3CM 8FR 20MM 2 TAPER SUPER THIN BALLOON",SUP-613700,CDM,C1725,HCPCS,0272,RC,,,both,,,2251.50,675.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TREK 145CM 20MM 3.75MM ULTRA LOW PROFILE BALLOON",SUP-1012277-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOTRACHEAL 7.9MM 5.5MM MAGILL CURVE NASAL ORAL 2 CUFF",SUP-86395,CDM,S27200284,LOCAL,0272,RC,,,both,,,8390.91,2517.27,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 18LP 135CM 6CM 4FR 6MM .018IN BALLOON",SUP-G50249,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMERGE MONORAIL 40MM 2MM BALLOON DILATATION ZGLIDE PTFE",SUP-H7493918940200,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 130CM 20MM 6MM BALLOON",SUP-U3513062,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SYNTHETIC ETHIBOND EXCEL 2-0 V-5 30IN 2 ARM BRAID FIRM",SUP-PXX50N,CDM,S27200284,LOCAL,0272,RC,,,both,,,632.96,189.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,73.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.61,538.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADMIRAL XTREME 130CM 150MM 5MM BALLOON DILATATION",SUP-ADM050150130,CDM,C1725,HCPCS,0272,RC,,,both,,,1638.75,491.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1114.35,68,,,,,0,190.59,1392.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PTS 80CM 3CM 8FR 20MM 2 TAPER SUPER THIN BALLOON",SUP-613700,CDM,C1725,HCPCS,0272,RC,,,both,,,2251.50,675.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,261.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.85,1913.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 220MM 3.5MM BALLOON DILATATION NYBAX",SUP-H74939186352210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.50MM X 20MM  SCOREFLEX  NC",SUP-625-204-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"UHC [10700]","United Healthcare",,3275.78,63.3,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 135CM 4CM 5FR 9MM 7.5MM BALLOON DILATATION",SUP-4209040X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 100MM 4MM BALLOON DILATATION HYDROPHILIC",SUP-604010022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"UHC [10700]","United Healthcare",,461.46,63.3,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 135CM 4CM 5FR 9MM 7.5MM BALLOON DILATATION",SUP-4209040X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 5MM BALLOON DILATATION STERILE LATEX",SUP-595004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Sclerosant Mult Vein",PX-361000099,CDM,36471,CPT,0361,RC,,,both,,,2784.62,835.39,"FIRST HEALTH [10303]","First Health",,2227.7,80,,,,,0,323.85,2784.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 15MM 3.3-3.6FR 7MM BALLOON",SUP-1008201-15,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (6.5-7 MCI)",RX-411882,CDM,A9520,HCPCS,0343,RC,08888-8876-16,NDC,both,1,UN,4614.97,1384.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2307.49,50,,,,,0,536.72,4614.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 2.5IN 13FR IMPELLA",SUP-0052-0007,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2216.97,45.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL RAPIDE MULTIPASS 4-0 P-3 18IN BRAID COATED UNDYED",SUP-VR494,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.44,20.83,"AETNA [10100]","Aetna HMO/PPO",,55.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.08,59.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS POWERFLEX P3 80CM 20MM 6MM 7.5MM BALLOON",SUP-4206020S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X60 80CM SL",SUP-48003006N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,353.05,41.1,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plt Ea Unit",PX-390000006,CDM,P9019,HCPCS,0390,RC,,,both,,,506.00,151.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,232.25,45.9,,,,,0,58.85,430.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 135CM 2CM 5FR 6MM 7.5MM BALLOON DILATATION",SUP-4206020X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 18LP 135CM 6CM 4FR 6MM .018IN BALLOON",SUP-G50249,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 40MM 2MM BALLOON DILATATION ZGLIDE PTFE",SUP-H7493918940200,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 40MM 2MM BALLOON DILATATION DURALYN",SUP-48002004X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fluoro Guide Plc Cvad",PX-320000173,CDM,77001,CPT,0320,RC,,,both,,,1546.93,464.08,"CIGNA [10200]","Cigna Open Access",,880.2,56.9,,,,,0,179.91,1314.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tte W/Wwo Cntrst Complt 2d",PX-483000018,CDM,C8929,HCPCS,0480,RC,,,both,,,3690.00,1107,"AMERIGROUP MEDICAID [20100]",Amerigroup,,437.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,429.15,3690,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Ganglion Sphenopalat",PX-361000423,CDM,64505,CPT,0361,RC,,,both,,,2996.00,898.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3,2996,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM 7.8FR 11MM TIP TO RING STRAIGHT TRIPOLAR","SUP-369 818",CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]","Cigna Local Plus",,5409.18,31.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO ELEC HYDRLC 3FRX120CM STRL DISP",SUP-E-3F,CDM,S27200284,LOCAL,0272,RC,,,both,,,1941.55,582.46,"NOVANET [10819]",Novanet,,1456.16,75,,,,,0,225.8,1650.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 44MM LCP STAINLESS STEEL LONG THREAD FEMORAL",SUP-207.744,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"NOVANET [10819]",Novanet,,780.03,75,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 35MM 35CM KINK RESISTANT CANN RADIOPAQUE 6",SUP-401835M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE HYDROSET INJECTABLE 5CC",SUP-79-43905,CDM,C1713,HCPCS,0278,RC,,,both,,,10257.26,3077.18,"AETNA [10100]","Aetna HMO/PPO",,8154.52,79.5,,1521.93,481.35,16760.95,30,1192.92,8718.67,"percent of total billed charges",
"LENS IOL +9 DIOPTER +4 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT400090,CDM,V2787,HCPCS,0276,RC,,,both,,,495.00,148.5,"NOVANET [10819]",Novanet,,371.25,75,,,,,0,57.57,420.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 5MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBH050502,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 12IN ATS 1 PORT 1 BLADDER LUER LOCK CNCT STERILE",SUP-60707505200,CDM,S27200284,LOCAL,0272,RC,,,both,,,198.36,59.51,"AETNA [10100]","Aetna HMO/PPO",,157.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.07,168.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 3MM ANKLE VALOR INTRAMEDULLARY ENTRY GWIRE SCR KIT",SUP-4150004025,CDM,C1713,HCPCS,0278,RC,,,both,,,1672.50,501.75,"PHCS [10601]",PHCS,,1170.75,70,,,,,0,194.51,1421.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 STD 14MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS7S14L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"CIGNA [10200]",Cigna,,7066.15,68,,5873.17,5873.17,5873.17,"1 through 10",1208.52,8832.69,"percent of total billed charges",
"GRAFT STENT 100MM 22-14MM 15MM 12FR TRIVASCULAR OVATION",SUP-TV-IL1422100-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13723.29,41.1,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 12X8CM XENFORM PELVIC FLOOR FETAL BOVINE",SUP-M0068302470,CDM,C1763,HCPCS,0278,RC,,,both,,,2379.85,713.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,681.11,28.62,,,,,0,276.78,2022.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ANTIBIOTIC TIBIAL",SUP-RKTBMD,CDM,C1776,HCPCS,0278,RC,,,both,,,20613.60,6184.08,"PHCS [10601]",PHCS,,14429.52,70,,,,,0,2397.36,17521.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 150MM 5.4FR 5MM BALLOON DILATATION 2",SUP-BD-L50150CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32MM NCB PROTASUL-64 3.5MM SELF TAP 2 LEAD",SUP-0203150032,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,219.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",215.88,1577.81,"percent of total billed charges",
"CATH SABERX 150CM 120MM 3.5MM BALLOON DILATATION RAPID",SUP-47535120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 8-11 E-F",SUP-42512100812,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PHCS [10601]",PHCS,,7543.49,70,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR BLUE 12MM TROCAR 60MM ECHELON LINEAR CUTTER",SUP-GST60B,CDM,S27200284,LOCAL,0272,RC,,,both,,,3907.19,1172.16,"FIRST HEALTH [10303]","First Health",,3125.75,80,,,,,0,454.41,3321.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.25 X 23 RX US",SUP-1804325-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 24MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.824,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"NOVANET [10819]",Novanet,,263.48,75,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 700CC",SUP-RSZ-SHPX-700S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"KAISER [10500]",Kaiser,,111.28,67,,,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP POLAR CUP CEMENTED STEM DELTA HEAD",SUP-71703510,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6851.63,28.62,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 RB-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP713D,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.99,39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,88.39,68,,,,,0,15.12,110.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC PULSED LAVAGE INTERPULSE SUCTION COAXIAL HIGH FLOW TIP",SUP-0210-114-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.14,99.04,"KAISER [10500]",Kaiser,,221.19,67,,,,,0,38.4,280.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X250 80CM SL",SUP-48005025N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT LIFESTENT 100MM 135CM 6MM 5FR VASCULAR NITINOL LOW",SUP-5F061003CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4344.52,28.62,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRESTIGE PLUS HELICAL PACK",SUP-PRES0615HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3008.75,45.9,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEADLESS COMPRESSION SCREW  4.0MM / L36MM",SUP-658036,CDM,C1713,HCPCS,0278,RC,,,both,,,2394.30,718.29,"BLUE CROSS [10001]","Blue Cross HMO",,938.57,39.2,,957.42,156.86,7483.26,51,278.46,2035.16,"percent of total billed charges",
"HC Adenosine Deaminase Fluid",PX-301000404,CDM,84311,CPT,0301,RC,,,both,,,337.25,101.17,"CIGNA [10200]","Cigna Open Access",,17.82,,,,,,,0.01,286.66,"fee schedule",
"SINGLE USE INSTRUMENTS - FEMORAL KIT (PS) - SIZE 6",SUP-5555-2256,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"MULTIPLAN [10600]",Multiplan,,1204.88,85,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE -90D RIGHT 41MM STAINLESS STEEL 2.4MM SCR 2 HOLE HEAD",SUP-02.115.631S,CDM,C1713,HCPCS,0278,RC,,,both,,,4045.61,1213.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,470.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",470.5,3438.77,"percent of total billed charges",
"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC",026,MS-DRG,,,,,,,inpatient,,,150443.61,45133.08,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,20443.76,,"Case rate ($19,286.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $17,908.88, add-ons for qualifying new technology services are included. If operating cost exceeds $50,948.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,736.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $17,932.56. The transfer operating threshold is the transfer adjustment factor * $17,908.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,354.00. The transfer capital threshold is the transfer adjustment factor * $1,354.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 106%.",,,,0,7561,90776.2,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"MOUTH PROCEDURES WITHOUT CC/MCC",138,MS-DRG,,,,,,,inpatient,,,46644.69,13993.41,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,5826.98,,"Case rate ($5,497.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,104.48, add-ons for qualifying new technology services are included. If operating cost exceeds $38,144.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,767.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $5,111.23. The transfer operating threshold is the transfer adjustment factor * $5,104.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $385.92. The transfer capital threshold is the transfer adjustment factor * $385.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,5497.15,25873.5,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY",RX-3738,CDM,,,0250,RC,00713-0503-06,NDC,both,1,UN,113.92,34.18,"KAISER [10500]",Kaiser,,76.33,67,,,,,0,13.25,96.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 12D ALLOGRAFT 24MM ALIF",SUP-3W4224,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2505.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHAIT TRAPDOOR 20CM 6- CM 10.2FR SHORT CECOSTOMY",SUP-G11632,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ASPIRATION 1400MM 2.2MM 22GA WITHOUT SIDEHOLE 80MM",SUP-NA-U200H-8022,CDM,S27200284,LOCAL,0272,RC,,,both,,,2173.50,652.05,"FIRST HEALTH [10303]","First Health",,1738.8,80,,,,,0,252.78,1847.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL COMPLETE OPEN REAMER ASSEMB",SUP-03.168.004,CDM,S27200284,LOCAL,0272,RC,,,both,,,9341.08,2802.32,"UHC [10700]","United Healthcare",,5912.9,63.3,,,,,0,1086.37,7939.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL CO2 O2 SAMPLE HUMD ADULT LOFLO NAFION LATEX FREE",SUP-989805628041,CDM,S27000186,LOCAL,0270,RC,,,both,,,152.50,45.75,"CIGNA [10200]",Cigna,,103.7,68,,,,,0,17.74,129.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC ANATOMIC SOCKET FLIPCUTTER II SHORT KNEE",SUP-AR-1204AS-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,303.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL INSUFFLATION 120MM 14GA ENDOPATH ULTRA VERESS STPCOCK",SUP-PN120,CDM,S27200284,LOCAL,0272,RC,,,both,,,264.41,79.32,"NOVANET [10819]",Novanet,,198.31,75,,,,,0,30.75,224.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE LEFT CRUCIATE RETAIN CEMENT PERSONA",SUP-42502606201,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2709.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2658.93,19433.3,"percent of total billed charges",
"SCR BONE 4.5MM 32MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.532,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"CIGNA [10200]",Cigna,,745.57,68,,1831.33,1831.33,1831.33,16,127.51,931.96,"percent of total billed charges",
"CMPNT TIBIAL PERSONA E KNEE RIGHT NONPOROUS REVISION",SUP-42-5420-071-02,CDM,C1776,HCPCS,0278,RC,,,both,,,16335.06,4900.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6713.71,41.1,,6417.48,6417.48,6417.48,"1 through 10",1899.77,13884.8,"percent of total billed charges",
"HC Sjogrens Abs",PX-302000045,CDM,86235,CPT,0302,RC,,,both,,,411.35,123.4,"KAISER [10500]",Kaiser,,275.6,67,,,,,0,0.41,349.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE LEFT CRUCIATE RETAIN ATTUNE POROCOAT",SUP-150401108,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11510.1,40,,,,,0,3346.56,24458.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR THK.6MM MICRO 15X10CM 2 SIDED MYCROMESH",SUP-1710015006,CDM,C1781,HCPCS,0278,RC,,,both,,,10170.60,3051.18,"NOVANET [10819]",Novanet,,7627.95,75,,,,,0,1182.84,8645.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 40MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75448540,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC",578,MS-DRG,,,,,,,inpatient,,,197441.45,59232.43,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,10662.12,,"Case rate ($9,964.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,252.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,292.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,081.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,265.04. The transfer operating threshold is the transfer adjustment factor * $9,252.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $699.56. The transfer capital threshold is the transfer adjustment factor * $699.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,9964.6,46900.45,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD .99CM 5.37X8.08CM",SUP-G138,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA [10200]",Cigna,,23088,40,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL H+9MM 42MM AEQUALIS ASCEND FLEX 12.5D SHOULDER",SUP-DWF422B,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"CIGNA [10200]",Cigna,,6139.04,68,,5873.17,5873.17,5873.17,"1 through 10",1049.96,7673.8,"percent of total billed charges",
"PRAVASTATIN 40 MG TABLET",RX-11112,CDM,,,0637,RC,50268-0667-11,NDC,both,1,UN,21.60,6.48,"CIGNA [10200]",Cigna,,14.69,68,,,,,0,2.51,18.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 80MM 7MM BALLOON DILATATION OTW NONCOMPLIANT",SUP-H74939206070870,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 FORCE FIBER NDL STRAND 38IN",SUP-3910900020,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"NOVANET [10819]",Novanet,,130.5,75,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 240MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-409-240,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT WOODING SCOTT COMPLETE",SUP-66800212,CDM,S27000186,LOCAL,0270,RC,,,both,,,523.58,157.07,"CIGNA [10200]","Cigna Open Access",,297.92,56.9,,,,,0,60.89,445.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 8MM 7FR 1-7-4MM SPACE LARGE F CURVE",SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"UHC [10700]","United Healthcare",,10045.71,63.3,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 E 36MM LONGEVITY HIP STERILE LUMEN LATEX",SUP-20103605,CDM,C1776,HCPCS,0278,RC,,,both,,,8101.98,2430.59,"CIGNA [10200]","Cigna Local Plus",,4334.56,53.5,,5372.07,4581.20,7242.98,23,942.26,6886.68,"percent of total billed charges",
"INBORN AND OTHER DISORDERS OF METABOLISM",642,MS-DRG,,,,,,,inpatient,,,39926.25,11977.87,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR 35CM 10.7FR ACCESS URETER DILATION CONTINUOUS",SUP-G34879,CDM,C1725,HCPCS,0272,RC,,,both,,,1253.88,376.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ADPTR CATH GATEWAY PLUS Y",SUP-M001153223,CDM,S27200284,LOCAL,0272,RC,,,both,,,346.83,104.05,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL HARTMANN BABY MOSQUITO CURVE 4IN ARTERY",SUP-15-3309,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.61,24.48,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RELIEVA SPIN 16MM 6MM M-110 GUIDING MAXILLARY SINUS",SUP-RSM110,CDM,C1726,HCPCS,0272,RC,,,both,,,2400.00,720,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE SAFARI2 VASCULAR XS CURVE 275X2.9X3.2CM .035IN LUB",SUP-H74939406XS1,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY PROC CUSTOM SPINAL",SUP-530068,CDM,S27200284,LOCAL,0272,RC,,,both,,,474.95,142.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,56.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.24,403.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHOLECYSTECTOMY WITH C.D.E. WITH CC",412,MS-DRG,,,,,,,inpatient,,,106611.91,31983.57,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,26556,,"Case rate ($13,041.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,110.32, add-ons for qualifying new technology services are included. If operating cost exceeds $45,150.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,297.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $12,126.34. The transfer operating threshold is the transfer adjustment factor * $12,110.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $915.60. The transfer capital threshold is the transfer adjustment factor * $915.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,61384.59,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE CONFLOW 40GM",SUP-110043025,CDM,C1713,HCPCS,0278,RC,,,both,,,580.93,174.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,67.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",67.56,493.79,"percent of total billed charges",
"PIN FIXATION 5MM CENTRAL THREAD 300MM STEINMANN STAINLESS",SUP-293.940,CDM,C1713,HCPCS,0278,RC,,,both,,,791.78,237.53,"CIGNA [10200]","Cigna Local Plus",,423.6,53.5,,3978.14,359.25,3978.14,24,92.08,673.01,"percent of total billed charges",
"SCR BONE 4MM 40MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840004040,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"PLATE NEW LOCK OVERLAP ATLANTIS VISION BONE SPINAL",SUP-7200170,CDM,C1713,HCPCS,0278,RC,,,both,,,4620.00,1386,"CIGNA [10200]","Cigna Local Plus",,2471.7,53.5,,3978.14,359.25,3978.14,24,537.31,3927,"percent of total billed charges",
"GRAFT BONE ALLOMATRIX DR DEMINERALIZED BONE MATRIX 3ML PUTTY",SUP-86DR0300,CDM,C1713,HCPCS,0278,RC,,,both,,,4229.70,1268.91,"BLUE CROSS [10001]","Blue Cross PPO",,1658.04,39.2,,957.42,570.23,957.42,28,491.91,3595.25,"percent of total billed charges",
"SCR BONE 3.5MM 14MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835L-14,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"PHCS [10601]",PHCS,,935.55,70,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 15CC ALLOGRAFT CUBE 6-10MM",SUP-100315,CDM,S27800098,LOCAL,0278,RC,,,both,,,2483.25,744.97,"CIGNA [10200]","Cigna Open Access",,1412.97,56.9,,,,,0,288.8,2110.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 80MM RELINE 2C SPINE ILIAC POLYAXIAL",SUP-16018580,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL LEGION 3 L 10DX5P KNEE SCR",SUP-71421723,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,957.42,156.86,7483.26,51,2014.9,14726.25,"percent of total billed charges",
"ANCHOR SUT 3.5MM MEDIUM DX SWIVELOCK FOOT ELBOW PEEK 13.5MM",SUP-AR-8979P,CDM,C1713,HCPCS,0278,RC,,,both,,,3346.88,1004.06,"FIRST HEALTH [10303]","First Health",,2677.5,80,,,,,0,389.24,2844.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP FEM N/POROUS SIZE 3 RIGHT",SUP-2154-0-0003,CDM,C1776,HCPCS,0278,RC,,,both,,,8280.00,2484,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5630.4,68,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 128MM 13MM REUNION STERILE REVERSIBLE FRACTURE",SUP-5568-0013,CDM,C1776,HCPCS,0278,RC,,,both,,,25615.80,7684.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10246.32,40,,,,,0,2979.12,21773.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 120MM 130CM 7MM LONG VASCULAR NITINOL",SUP-SC7120LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"BLUE CROSS [10001]","Blue Cross HMO",,3516.24,39.2,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WALKER PATIENT MEDIUM STD PLASTIC FOAM ROCKER BOTTOM",SUP-15500033,CDM,S27000186,LOCAL,0270,RC,,,both,,,249.86,74.96,"AETNA [10100]","Aetna HMO/PPO",,198.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.06,212.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEADWEAR 12 LEADSIZE 7L",SUP-LS-208B,CDM,S27000186,LOCAL,0270,RC,,,both,,,234.81,70.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.31,199.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 4.5MM 16MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.516.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"KAISER [10500]",Kaiser,,399.64,67,,,,,0,69.37,507.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE 40X40X2.5MM POLYETHYLENE MEDPOR TSI",SUP-82007,CDM,C1713,HCPCS,0278,RC,,,both,,,4347.97,1304.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,515.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,505.67,3695.77,"percent of total billed charges",
"PLATE 8 HOLE STRAIGHT BONE LEFT CLAVICLE",SUP-70-0298,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3034.08,45.9,,,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 5.5MM CURVE TITANIUM NONSTERILE",SUP-1553201050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 3.5MM TRAUMAONE LORENZ TITANIUM MIDFACE SELF",SUP-916103,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",45.53,332.78,"percent of total billed charges",
"PIN FIXATION ODYSSEY STERILE",SUP-K0001298,CDM,C1713,HCPCS,0278,RC,,,both,,,2355.00,706.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,674,28.62,,,,,0,273.89,2001.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 15FTX6IN WRIST IMMOB ROLL INTERLOCK",SUP-OG-6L2,CDM,S27000186,LOCAL,0270,RC,,,both,,,738.07,221.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,87.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,85.84,627.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 25MM COMPREHENSIVE 3.5MM SHOULDER FIX ANGLE",SUP-180552,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1058.08,68,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM HELIX SPINE REVOLUTION",SUP-7803115,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"BLUE CROSS [10001]","Blue Cross HMO",,552.72,39.2,,957.42,156.86,7483.26,51,163.98,1198.5,"percent of total billed charges",
"WIRE FIXATION 9IN .045IN KIRSCHNER 2 END TROCAR POINT THREAD",SUP-163836000,CDM,C1713,HCPCS,0278,RC,,,both,,,185.60,55.68,"BLUE CROSS [10001]","Blue Cross PPO",,72.76,39.2,,957.42,570.23,957.42,28,21.59,157.76,"percent of total billed charges",
"WIRE FIXATION 9IN .035IN KIRSCHNER 2 END TROCAR SMOOTH",SUP-164710000,CDM,C1713,HCPCS,0278,RC,,,both,,,455.63,136.69,"BLUE CROSS [10001]","Blue Cross PPO",,178.61,39.2,,957.42,570.23,957.42,28,52.99,387.29,"percent of total billed charges",
"CRTDG NOVOSTITCH 0 SUT",SUP-CTXR002,CDM,C1713,HCPCS,0278,RC,,,both,,,3570.75,1071.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1638.97,45.9,,,,,0,415.28,3035.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DEMINERALIZED BONE MATRIX 2.5ML PUTTY NONSTERILE",SUP-038025,CDM,C1713,HCPCS,0278,RC,,,both,,,2310.00,693,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,661.12,28.62,,,,,0,268.65,1963.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS MULTIPASS 5-0 PS-2 18IN BRAID ANTIBACTERIAL",SUP-VCP495G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 30.0",SUP-DIB00U0300,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Local Plus",,715.03,53.5,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 24/26FR STERILE DISPOSABLE YELLOW",SUP-27040BL1-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3100.64,930.19,"UHC [10700]","United Healthcare",,1962.71,63.3,,,,,0,360.6,2635.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 36MM 24 BASEPLT TAPER",SUP-AR-9564-2436,CDM,C1776,HCPCS,0278,RC,,,both,,,9763.50,2929.05,"BLUE CROSS [10001]","Blue Cross HMO",,3827.29,39.2,,5311.50,4717.44,5388.59,31,1135.5,8298.98,"percent of total billed charges",
"KIT NEUROSURGICAL INTERSTIM PROC SUPPLIES DISPOSABLE",SUP-3560031,CDM,S27200284,LOCAL,0272,RC,,,both,,,2662.50,798.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1810.5,68,,,,,0,309.65,2263.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC STRAIGHT 130MM 2.75MM SHUTT MINI-AGGRESSOR",SUP-32.10034,CDM,S27200284,LOCAL,0272,RC,,,both,,,7971.71,2391.51,"KAISER [10500]",Kaiser,,5341.05,67,,,,,0,927.11,6775.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 85MM STAINLESS STEEL LARGE FRAGMENT SET 4 HOLE ANGLED",SUP-240.54,CDM,C1713,HCPCS,0278,RC,,,both,,,9574.16,2872.25,"BLUE CROSS [10001]","Blue Cross HMO",,3753.07,39.2,,957.42,156.86,7483.26,51,1113.47,8138.04,"percent of total billed charges",
"CAP KIT REPLACEMENT SHOULDER HUMERAL GLENOID TRABECULAR META",SUP-98000972001,CDM,C1776,HCPCS,0278,RC,,,both,,,33075.00,9922.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9466.07,28.62,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 12CM 4FR STRAIGHT PANCREATIC POLYMER DRNG HOLE",SUP-M00536220,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,182.95,28.62,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.2MM 16MM CORTICAL HEXAGONAL HEAD",SUP-HEX3.2-16,CDM,C1713,HCPCS,0278,RC,,,both,,,729.00,218.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,334.61,45.9,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 15.5CM NATRELLE INSPIRA P6.7CM EXTRA FULL PROFILE",SUP-MSZ-X800,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"NOVANET [10819]",Novanet,,118.64,75,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 4.5MM 65MM T7 CORTEX SELF RETAINING SCRDRVR",SUP-72402765,CDM,C1713,HCPCS,0278,RC,,,both,,,456.52,136.96,"BLUE CROSS [10001]","Blue Cross HMO",,178.96,39.2,,957.42,156.86,7483.26,51,53.09,388.04,"percent of total billed charges",
"KIT THROMBECTOMY 145CM 1.5MM 3-4FR ANGIOJET ULTRA ULTRA",SUP-104834-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"CIGNA [10200]","Cigna Open Access",,163.36,56.9,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 8FR 19CM VESSEL ACCEPTS .035IN GWIRE",SUP-504408X,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.26,26.18,"CIGNA [10200]",Cigna,,59.34,68,,,,,0,10.15,74.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2MM CLAW II ANKLE FOOT 2.7MM SCR POLYAXIAL",SUP-40250020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1069.20,320.76,"CIGNA [10200]","Cigna Open Access",,608.37,56.9,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCALPEL SURGICAL TIP 25MM MONOPOLAR CANADY HYBRID PLASMA",SUP-AW-422552,CDM,S27200284,LOCAL,0272,RC,,,both,,,2812.50,843.75,"FIRST HEALTH [10303]","First Health",,2250,80,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 30MM 80CM 9MM 8FR STRAIGHT VASCULAR",SUP-AVSM09030,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"MULTIPLAN [10600]",Multiplan,,15529.5,85,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 73X40X14IN FORTIFY 2.5V 500OHM 60 PPM TITANIUM",SUP-CD1231-40,CDM,C1722,HCPCS,0278,RC,,,both,,,35000.00,10500,"AETNA [10100]","Aetna HMO/PPO",,27825,79.5,,,,,0,4070.5,29750,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION",RX-23063,CDM,,,0637,RC,00536-1268-12,NDC,both,222,ML,41.89,12.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.87,35.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 40MM 190CM 3MM",SUP-R51003004L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,233.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 500-710UM 2 VIAL CONTOUR PVA",SUP-M0017600621,CDM,S27800098,LOCAL,0278,RC,,,both,,,1458.00,437.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,669.22,45.9,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 5 X 10 COMPLEX FINISHING COIL",SUP-10CFN-05010,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PHCS [10601]",PHCS,,8206.17,70,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.6MM 16MM VIP SPINE SELF TAP FIX ANGLE NONSTERILE",SUP-171.716,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 1.3FR 6-11MM OPTIFLEX SMALL",SUP-M0063903000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1652.33,495.7,"MULTIPLAN [10600]",Multiplan,,1404.48,85,,,,,0,192.17,1404.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM DVR TITANIUM RADIUS CORTICAL DISTAL",SUP-CS14000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1093.50,328.05,"PHCS [10601]",PHCS,,765.45,70,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 31MM TITANIUM 4.8MM ENDOSCOPIC LINEAR CUTTER",SUP-EEA31,CDM,S27200284,LOCAL,0272,RC,,,both,,,1880.70,564.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,863.24,45.9,,,,,0,218.73,1598.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 9MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-009,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"FIRST HEALTH [10303]","First Health",,17000.64,80,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 2MM BALLOON DILATATION OTW STERILE",SUP-582004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"AETNA [10100]","Aetna HMO/PPO",,1191.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 12MM 140CM .91-1.12MM 2.25MM CORONARY",SUP-RONYX22512W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"PHCS [10601]",PHCS,,2362.5,70,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 4X4IN CUTIMED EPIONA TISSUE 90% NATIVE CLLGN 10%",SUP-7322701,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.04,63.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.43,178.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 22MM 2.5MM CORONARY STENT FULCRUM COCR",SUP-INT25022UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,691.17,28.62,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 17MM 20 GRIT BLAST SURFACE FINISH RECLAIM",SUP-197617140,CDM,C1776,HCPCS,0278,RC,,,both,,,11104.56,3331.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3178.13,28.62,,,,,0,1291.46,9438.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL TWIST 115MM 1.9MM LEVEL ONE 3MM STOP NOTCH",SUP-50-519-16-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,1270.49,381.15,"NOVANET [10819]",Novanet,,952.87,75,,,,,0,147.76,1079.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Androstenedione",PX-301000106,CDM,82157,CPT,0301,RC,,,both,,,217.65,65.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,30.74,,"Fee schedule rate ($30.74). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",53.45,53.45,53.45,"1 through 10",0.01,185,"fee schedule",
"SCR BONE 1.5MM 10MM TITANIUM CRANIOFACIAL CORTICAL SELF",SUP-400360,CDM,S27800098,LOCAL,0278,RC,,,both,,,3937.14,1181.14,"BLUE CROSS [10001]","Blue Cross PPO",,1543.36,39.2,,,,,0,457.89,3346.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 8MM 4MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012278-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL BIT ASSY, CARBIDE, HUDSON END, 4 MM, SINGLE USE",SUP-SBT003,CDM,S27000186,LOCAL,0270,RC,,,both,,,2212.50,663.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,262.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 5MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640505,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]",Cigna,,7652.65,68,,5873.17,5873.17,5873.17,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"SUT STAINLESS STEEL TFE POLYMER 3-0 FS-1 18IN MONOFILAMENT",SUP-631G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 130MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.930,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,159.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",159.84,1168.25,"percent of total billed charges",
"SHOE LARGE MALE PATIENT POSTOPERATIVE SHORT WEDGE HEELWEDGE",SUP-92732604,CDM,S27000186,LOCAL,0270,RC,,,both,,,256.65,76.99,"MULTIPLAN [10600]",Multiplan,,218.15,85,,,,,0,29.85,218.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VG2 PRESERVON VERTIGRAFT CORTICAL CANCELLOUS",SUP-VG2C-T79P,CDM,S27800098,LOCAL,0278,RC,,,both,,,5865.00,1759.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,695,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INLAY OPTIMA 26CM 7FR URETERAL PHREECOAT POLYMER",SUP-788726,CDM,C2617,HCPCS,0278,RC,,,both,,,834.30,250.29,"CIGNA [10200]",Cigna,,567.32,68,,,,,0,97.03,709.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,inpatient,,,111735.95,33520.78,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,13285.61,,"Case rate ($12,898.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,977.27, add-ons for qualifying new technology services are included. If operating cost exceeds $45,016.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,287.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $11,993.10. The transfer operating threshold is the transfer adjustment factor * $11,977.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.54. The transfer capital threshold is the transfer adjustment factor * $905.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,60710.16,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM GORILLA NONSTERILE R3CON NON LOCK PLATE",SUP-P50-453-3520,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",113.04,826.2,"percent of total billed charges",
"SET EPIDURAL 2IN 18GA 20GA CONTIPLEX TUOHY NYLON PVC",SUP-331691,CDM,S27200284,LOCAL,0272,RC,,,both,,,167.12,50.14,"PHCS [10601]",PHCS,,116.98,70,,,,,0,19.44,142.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING 14FR BALLOON 7-10ML L45CM JEJUNAL SILICONE INFL",SUP-0200-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"AETNA [10100]","Aetna HMO/PPO",,874.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESTRICT CEMENT 18.5MM SMALL UNIVERSAL HIP REVISION PLUG",SUP-B000-0185,CDM,S27800098,LOCAL,0278,RC,,,both,,,810.00,243,"CIGNA [10200]",Cigna,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALARM WC POSEY SELF RELEASE BELT DISPOSABLE",SUP-8399L,CDM,S27100035,LOCAL,0271,RC,,,both,,,219.68,65.9,"PHCS [10601]",PHCS,,153.78,70,,,,,0,25.55,186.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 70MM KNEE LEFT CRUCIATE RETAINING CEMENTED",SUP-183032,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"BLUE CROSS [10001]","Blue Cross PPO",,7873.58,39.2,,3949.44,3949.44,3949.44,"1 through 10",2335.96,17072.81,"percent of total billed charges",
"CATH ROYAL FLUSH PLUS 100CM 5FR PIGTAIL CURVE ANGIOGRAPHIC",SUP-G58543,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.17,61.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,23.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.98,175.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STIM SPRINT EXTENSA XT NERVE NONSTERILE LATEX FREE DISPOSABL",SUP-9288-6003,CDM,C1778,HCPCS,0278,RC,,,both,,,54180.00,16254,"BLUE CROSS [10001]","Blue Cross PPO",,21238.56,39.2,,,,,0,6301.13,46053,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,J1644,HCPCS,0636,RC,63323-0540-07,NDC,both,10,ML,19.40,5.82,"BLUE CROSS [10001]","Blue Cross HMO",,2.45,,,,,,,2.11,16.49,"fee schedule",
"SCR BONE 6.5MM 70MM REFLECTION ACETABULAR SPHERICAL HEAD",SUP-71332570,CDM,C1713,HCPCS,0278,RC,,,both,,,1287.90,386.37,"BLUE CROSS [10001]","Blue Cross HMO",,504.86,39.2,,957.42,156.86,7483.26,51,149.78,1094.72,"percent of total billed charges",
"KIT CATH 8FR 18GA 20CM .032IN 2 LUMEN INDWELL CATH GWIRE NDL",SUP-CDC-45802-XP1A,CDM,C1752,HCPCS,0272,RC,,,both,,,1028.70,308.61,"NOVANET [10819]",Novanet,,771.53,75,,,,,0,119.64,874.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 60MM STAINLESS STEEL T8 SELF TAP LOCK",SUP-02.211.060,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,412.24,45.9,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF ENHANCR II 110CM 4MM 7FR 2-5-2MM SPACE 55MM MEDIUM",SUP-FND-019-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,158.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 14MM COLLAR CEMENTLESS LOW PROFILE NECK",SUP-3L93714,CDM,C1776,HCPCS,0278,RC,,,both,,,28658.70,8597.61,"PHCS [10601]",PHCS,,20061.09,70,,,,,0,3333.01,24359.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2 T-8 38IN 2 ARM BRAID MULTISTRAND LOWER KNOT",SUP-AR-7206,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"CIGNA [10200]","Cigna Local Plus",,107.52,53.5,,,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIAGON FLEXTUBE 4MM","SUP-FFT-E 01 2106",CDM,S27000186,LOCAL,0270,RC,,,both,,,1629.00,488.7,"FIRST HEALTH [10303]","First Health",,1303.2,80,,,,,0,189.45,1384.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB PEDIATRIC 4.25X3IN MULTIFUNCTION",SUP-22770P,CDM,S27200284,LOCAL,0272,RC,,,both,,,159.68,47.9,"AETNA [10100]","Aetna HMO/PPO",,126.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.57,135.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X11X6MM COROENT 5D SMALL PEEK NONSTERILE LATEX",SUP-6806714,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,inpatient,,,126140.57,37842.17,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,38150.96,,"Case rate ($18,736.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $17,397.97, add-ons for qualifying new technology services are included. If operating cost exceeds $50,437.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,697.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $17,420.97. The transfer operating threshold is the transfer adjustment factor * $17,397.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,315.37. The transfer capital threshold is the transfer adjustment factor * $1,315.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,10994,88186.52,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"CGUARD PRIME CAROTID STENT SYSTEM 135CM 9MM LENGTH  40MM",SUP-CND0940,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5941.08,28.62,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE BIODRESTORE CRYOPRIME MEDIUM HUMAN AMNIOTIC",SUP-AM-010050,CDM,V2790,HCPCS,0278,RC,,,both,,,7590.00,2277,"BLUE CROSS [10001]","Blue Cross HMO",,2975.28,39.2,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 5MM OPTICAL ACCESS SYSTEM 150MM KII",SUP-CFR10,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"KAISER [10500]",Kaiser,,145.73,67,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR BROAD LORDOTIC 12 DEGREE",SUP-012411,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"PHCS [10601]",PHCS,,13230,70,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit Level 5",PX-450000319,CDM,99285,CPT,0450,RC,,,both,,,2982.77,894.83,"PHCS [10601]",PHCS,,2087.94,70,,,,,0,419.55,2535.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 65CM 10MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1065CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"PHCS [10601]",PHCS,,5554.5,70,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.5MM X 8.0MM",SUP-493500812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 16X4MM COLOSSEUM 3.5D 14MM NONSTERILE LATEX",SUP-156.564,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"FIRST HEALTH [10303]","First Health",,2754,80,,,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +12.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00125,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross PPO",,460.4,39.2,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 110MM PRIMARY ANTHOLOGY POROUS 131D 6 STD",SUP-71356006,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"NOVANET [10819]",Novanet,,24855.86,75,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X8MM 10D LORDOTIC",SUP-6980850,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"CIGNA [10200]","Cigna Local Plus",,7484.4,31.5,,16168.95,16168.95,16168.95,"1 through 10",2763.29,20196,"percent of total billed charges",
"S MEGATRON US MR 5.00 X 16MM",SUP-H7493942816500,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"AMERIGROUP MEDICAID [20100]",Amerigroup,,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PRELUDESYNC 24CM COMPRESSION 20ML RADIAL BAND SOFT",SUP-SRB24MED,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"FIRST HEALTH [10303]","First Health",,174,80,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ILLMNTR OPHTHALMIC 23GA CONSTELLATION SAPPHIRE WIDE ANGLE",SUP-8065751184,CDM,S27200284,LOCAL,0272,RC,,,both,,,1033.32,310,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PCP050250090 PLUS US D5L250UL900",SUP-PCP050250090,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MACH1 55CM 8FR .091IN LIMA CURVE GUIDING PTFE",SUP-M001198620,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE WHISPER MS VASCULAR J 300CM 3CM .014IN",SUP-1005359HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH C315S402",SUP-C315S402,CDM,C1887,HCPCS,0272,RC,,,both,,,2175.00,652.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 69.9MM 4MM LONG CARBIDE ROUND 8 FLUTED 5092228",SUP-5300020511,CDM,S27000186,LOCAL,0270,RC,,,both,,,271.18,81.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ENROUTE ENFLATE TRANSCAROTID RX BALLOON DILATATION CATHETER",SUP-SR-5035-BC,CDM,C1725,HCPCS,0272,RC,,,both,,,2625.00,787.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRIVER SURGICAL DIA4.5MM STANDARD CANNULATED HEX",SUP-3142-MICROLINER,CDM,S27200284,LOCAL,0272,RC,,,both,,,2651.93,795.58,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,308.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,308.42,2254.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 4CM 7MM BALLOON DILATATION",SUP-DR13574,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"NOVANET [10819]",Novanet,,1032.75,75,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM LOW PROFILE NONSTERILE LATEX FREE",SUP-131227214,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"FIRST HEALTH [10303]","First Health",,680.4,80,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 2.5 KNEE RIGHT CRUCIATE RETAIN SIGMA POROC",SUP-940028,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6990.26,27,,,,,0,3010.99,22006.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 70MM KNEE RIGHT CRUCIATE RETAINING CEMENTED",SUP-183012,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"MULTIPLAN [10600]",Multiplan,,17072.81,85,,,,,0,2335.96,17072.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 3.2FR 115CM BIOPSY SET STRAIGHT TIP OCCLUSIVE",SUP-G14919,CDM,S27200284,LOCAL,0272,RC,,,both,,,721.71,216.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,490.76,68,,,,,0,83.93,613.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Innovamatrix Ac, per Sq Cm",PX-E63600050,CDM,A2001,HCPCS,0636,RC,,,both,,,767.80,230.34,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,522.1,68,,,,,0,90.98,652.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 18FR DELIVERY SYSTEM",SUP-ENVPRO-14-US,CDM,S27200284,LOCAL,0272,RC,,,both,,,14559.00,4367.7,"MULTIPLAN [10600]",Multiplan,,12375.15,85,,,,,0,1693.21,12375.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM ARSENAL ANKLE",SUP-307-27-016,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"PHCS [10601]",PHCS,,765.45,70,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 48MM 28MM NEUTRAL HIP CERAMIC STERILE LATEX",SUP-121889650,CDM,C1776,HCPCS,0278,RC,,,both,,,14690.10,4407.03,"BLUE CROSS [10001]","Blue Cross PPO",,5758.52,39.2,,3949.44,3949.44,3949.44,"1 through 10",1708.46,12486.59,"percent of total billed charges",
"INSERT TIBIAL TRIATHLON X3 4 H12 MM KNEE CONDYLAR STABILIZE",SUP-5531-G-412-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]","Cigna Local Plus",,3790.58,31.5,,5372.07,4581.20,7242.98,23,1399.51,10228.56,"percent of total billed charges",
"PLATE 45-58MM TITANIUM 5.5MM ROD LOW PROFILE LEGACY",SUP-8115545,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross PPO",,1396.5,39.2,,957.42,570.23,957.42,28,414.32,3028.13,"percent of total billed charges",
"L AC611 HFNC FEP CONNECT 20 PK",SUP-73-1134192,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.51,57.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TREK 6MM 3.25MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012408-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 12D 13CM 4.5MM CURVED RADENOID TONSIL SURGICAL ADULT",SUP-1884008,CDM,S27200284,LOCAL,0272,RC,,,both,,,1782.00,534.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 2MM AO CONNECTION LOCK 3MM SCR",SUP-AR-8944-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE IRON MAN VASCULAR 300CM .014IN STAINLESS",SUP-1001311J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RENAL FAILURE WITHOUT CC/MCC",684,MS-DRG,,,,,,,inpatient,,,23649.13,7094.74,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,3947.13,,"Case rate ($3,723.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,457.71, add-ons for qualifying new technology services are included. If operating cost exceeds $36,497.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,643.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,462.28. The transfer operating threshold is the transfer adjustment factor * $3,457.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $261.42. The transfer capital threshold is the transfer adjustment factor * $261.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,3723.71,14970.88,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CPS DIRECT« UPSIZED, RIGHT SIDE 47CM-DS2C023",SUP-DS2C023,CDM,C1893,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"FIRST HEALTH [10303]","First Health",,3008.4,80,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM TRIGEN FEMUR LOW PROFILE",SUP-71645435,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"AETNA [10100]","Aetna HMO/PPO",,1645.29,79.5,,1521.93,481.35,16760.95,30,240.69,1759.12,"percent of total billed charges",
"NAIL 12MM 360MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.257S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"AETNA [10100]","Aetna HMO/PPO",,9872.58,79.5,,1521.93,481.35,16760.95,30,1444.25,10555.59,"percent of total billed charges",
"SYSTEM DYONICS 25 FLUID MANAGEMENT SUCTION INFLOW OUTFLOW",SUP-7211005,CDM,S27000186,LOCAL,0270,RC,,,both,,,451.98,135.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,185.76,41.1,,,,,0,52.57,384.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 360MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.257S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"FIRST HEALTH [10303]","First Health",,9934.67,80,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 22GA BINKHORST SMALL BLUNT IRR SMOOTH FRONT",SUP-60-1230,CDM,S27200284,LOCAL,0272,RC,,,both,,,190.88,57.26,"AETNA [10100]","Aetna HMO/PPO",,151.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.2,162.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM INSET SHOULDER LOCK REVERSE",SUP-2R1PT45035,CDM,C1713,HCPCS,0278,RC,,,both,,,865.08,259.52,"CIGNA [10200]","Cigna Open Access",,492.23,56.9,,1144.80,304.56,2275.09,66,100.61,735.32,"percent of total billed charges",
"TISSUE 345841FZ L-ASR 8X14X11 FZ SRVCFEE",SUP-345841FZ,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 9IN .035IN KIRSCHNER 2 END TROCAR SMOOTH",SUP-164710000,CDM,C1713,HCPCS,0278,RC,,,both,,,455.63,136.69,"CIGNA [10200]","Cigna Local Plus",,243.76,53.5,,3978.14,359.25,3978.14,24,52.99,387.29,"percent of total billed charges",
"SCR BONE 2.4MM 24MM 8MM STAINLESS STEEL LONG THREAD HAND",SUP-02.226.324,CDM,C1713,HCPCS,0278,RC,,,both,,,1647.00,494.1,"FIRST HEALTH [10303]","First Health",,1317.6,80,,,,,0,191.55,1399.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM 47.8MM HIP 3 SCR HOLE CLUSTER HA",SUP-542-11-46D,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,809.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,809.18,5914.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 710-1000UM 2 VIAL CONTOUR PVA",SUP-M0017600821,CDM,S27800098,LOCAL,0278,RC,,,both,,,1458.00,437.4,"PHCS [10601]",PHCS,,1020.6,70,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE CARDIOXYL MITRAL RING",SUP-73P30E,CDM,S27200284,LOCAL,0272,RC,,,both,,,667.58,200.27,"CIGNA [10200]",Cigna,,453.95,68,,,,,0,77.64,567.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH CBDE SUPER SHEATH SILICONE SPYGLASS DISCOVER",SUP-M00542961,CDM,C1894,HCPCS,0272,RC,,,both,,,349.48,104.84,"AETNA [10100]","Aetna HMO/PPO",,277.84,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.64,297.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC .75CM 4.45X5.02CM ACCOLADE LATITUDE NXT",SUP-L301,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"CIGNA [10200]",Cigna,,16640,40,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROGESTERONE MICRONIZED 100 MG CAPSULE",RX-23122,CDM,,,0637,RC,70700-0162-01,NDC,both,1,UN,25.19,7.56,"NOVANET [10819]",Novanet,,18.89,75,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM BONE CEMENT 1 2 MIX",SUP-414701,CDM,S27200284,LOCAL,0272,RC,,,both,,,963.90,289.17,"NOVANET [10819]",Novanet,,722.93,75,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING ORANGE 40CM 8FR NUTRIO TWISTLOK ENTERAL",SUP-ENSI6080,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.36,32.21,"CIGNA [10200]",Cigna,,73,68,,,,,0,12.49,91.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 20CM 12FR MAHURKAR 3 LUMEN STRAIGHT EXT",SUP-8888104003HP,CDM,C1752,HCPCS,0272,RC,,,both,,,1178.06,353.42,"CIGNA [10200]",Cigna,,801.08,68,,,,,0,137.01,1001.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP 5CC ALLOGRAFT PUTTY",SUP-14100401,CDM,C1713,HCPCS,0278,RC,,,both,,,7458.76,2237.63,"BLUE CROSS [10001]","Blue Cross HMO",,2923.83,39.2,,957.42,156.86,7483.26,51,867.45,6339.95,"percent of total billed charges",
"HOOK 12MM 12MM RETRACTION BLUNT ELASTIC STAY LONE STAR",SUP-3350-8G,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.91,23.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.94,65.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION",RX-112896,CDM,,,0250,RC,00409-4092-11,NDC,both,10,ML,287.35,86.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,34.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.42,244.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BRACHYTHERAPY 20CM 17GA APPLR SEED ULTRA SHARP TIP",SUP-917201,CDM,C1715,HCPCS,0272,RC,,,both,,,61.68,18.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOLDER TUBE STABILOCK DALE ADHESIVE BASE CONTACT CLOSURE LAT",SUP-344536,CDM,S27000186,LOCAL,0270,RC,,,both,,,85.23,25.57,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COCAINE 4 % SOLUTION SUPERORDERABLE",RX-409212,CDM,,,0250,RC,70839-0362-04,NDC,both,4,ML,1962.17,588.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,900.64,45.9,,,,,0,228.2,1667.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENV ABSORBABLE MEDIUM 2.7X2.5IN POLYARYLATE MINOCYCLINE",SUP-NMRM6122,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,718.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELUPRO ANTIBIOTIC-ELUTING BIOENVELOPE, L, SINGLE PACK",SUP-CMCV-124-LRG,CDM,S27800098,LOCAL,0278,RC,,,both,,,6520.50,1956.15,"BLUE CROSS [10001]","Blue Cross PPO",,2556.04,39.2,,,,,0,758.33,5542.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X9MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7009,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"MULTIPLAN [10600]",Multiplan,,5865,85,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? BONE SCREW, 2.7MM X 14MM, 4 PACK",SUP-94-27-14-4S,CDM,C1713,HCPCS,0278,RC,,,both,,,2947.50,884.25,"AETNA [10100]","Aetna HMO/PPO",,2343.26,79.5,,1521.93,481.35,16760.95,30,342.79,2505.38,"percent of total billed charges",
"TUBE ENDOTRACHEAL 7MM CUFFED MURPHY TIP RADIOPAQUE PILOT",SUP-86204,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.69,1.41,"PHCS [10601]",PHCS,,3.28,70,,,,,0,0.55,3.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 20MM CHESAPEAKE SPINE SELF TAPPING",SUP-2001-15520,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1999.2,68,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FAST-FIX 360D CURVE FIXATION 2 ANCHOR PRETIE SUT",SUP-72202468,CDM,C1713,HCPCS,0278,RC,,,both,,,3300.75,990.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,391.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,383.88,2805.64,"percent of total billed charges",
"PIN FIXATION 457MM 3.2MM STEINMANN LONG BLUNT",SUP-11-1109-FD21,CDM,C1713,HCPCS,0278,RC,,,both,,,3326.40,997.92,"BLUE CROSS [10001]","Blue Cross HMO",,1303.95,39.2,,957.42,156.86,7483.26,51,386.86,2827.44,"percent of total billed charges",
"SCR BONE 6.5MM 55MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850016555,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4457.4,68,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENDO STITCH V-LOC 180 2-0 4IN CLSR ABSORBABLE RELOAD",SUP-VLOCA204L,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.84,83.65,"MULTIPLAN [10600]",Multiplan,,237.01,85,,,,,0,32.43,237.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL X-PAC LORDOTIC TALL L28 MM X H10 MM",SUP-EI2507LT,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"MULTIPLAN [10600]",Multiplan,,24097.5,85,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION",RX-2357,CDM,,,0250,RC,00990-7930-09,NDC,both,1000,ML,100.65,30.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68.44,68,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 35MM 35CM KINK RESISTANT CANN RADIOPAQUE 6",SUP-401735M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"MULTIPLAN [10600]",Multiplan,,88.74,85,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL 50 MCG/ML INJECTION SUPERORDERABLE|DISCARDED DRUG NOT ADMINISTE",RX-4083037,CDM,J3010,HCPCS,0636,RC,00641-6027-01,NDC,both,2,ML,19.24,5.77,"NOVANET [10819]",Novanet,JW,14.43,75,,,,,0,1.28,16.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 80MM 2.5MM BALLOON DILATATION",SUP-48002508X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175270180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"KAISER [10500]",Kaiser,,978.27,67,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC",430,MS-DRG,,,,,,,inpatient,,,227459.69,68237.91,"BLUE CROSS [10001]","Blue Cross HMO",,132394.1,,"Fee schedule rate ($132,394.10). The outlier threshold amount is ($224,410.00),  the outlier percentage is (63.7%).  The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1). Includes an add-on of $3,230.48 when RC 0681-0684 total amount is above $1.",,,,0,7561,168376.25,other,"IP STOPLOSS Zero final payments for the item or service in the 15 months prior to posting the file."
"COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC",430,MS-DRG,,,,,,,inpatient,,,227459.69,68237.91,"UHC [10700]","United Healthcare",,168376.25,,"Fee schedule rate ($168,376.25). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,168376.25,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"PRIMARY DELIVERY CATHETER",SUP-4840-03,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMODIALYSIS DRESSING CHANGE KIT",SUP-78539,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.20,68.46,"NOVANET [10819]",Novanet,,171.15,75,,,,,0,26.54,193.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM .91-1.12MM 3.5MM CORONARY",SUP-RONYX35022W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"BLUE CROSS [10001]","Blue Cross PPO",,2132.09,39.2,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) GOMCO ASPIRATOR PUMP",SUP-01-12-4005,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 38MM 3MM CORONARY STENT EVEROLIMUS",SUP-1550300-38,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 60MM 2MM TAPER BALLOON DILATATION JET",SUP-A2020-060,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 200MM 6FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-06201,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X20 135CM SL",SUP-48007002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"AETNA [10100]","Aetna HMO/PPO",,682.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 6MM 2.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP2506X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,233.04,41.1,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 10CM 3MM BALLOON DILATATION HYDROPHILIC",SUP-V1430100,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2254.54,41.1,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lso Flex Surg Support",PX-E27400071,CDM,L0628,HCPCS,0274,RC,,,both,,,575.30,172.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,164.65,28.62,,,,,0,52.83,489.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Intro Sheath",PX-E27200169,CDM,E27200169,LOCAL,0272,RC,,,both,,,221.10,66.33,"CIGNA [10200]","Cigna Local Plus",,118.29,53.5,,,,,0,25.71,187.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATHLETIS 135CM 40MM 7MM BALLOON DILATATION STERILE",SUP-H74939347070410,CDM,C1725,HCPCS,0272,RC,,,both,,,1449.90,434.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,171.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP EASY LOAD DESIGN LOCK HANDLE SAFELY INSRT 3CM",SUP-KC-RUMI-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"NOVANET [10819]",Novanet,,859.38,75,,,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE VITRECTOMY 23GA ALCON CENTURION ULTRAVIT ANTERIOR",SUP-8065752134,CDM,S27200284,LOCAL,0272,RC,,,both,,,1764.90,529.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,810.09,45.9,,,,,0,205.26,1500.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL ORANGE 125MM 2MM QUICK COUPLE 2.7MM LOCKING SCR",SUP-03.119.014,CDM,S27200284,LOCAL,0272,RC,,,both,,,629.69,188.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,289.03,45.9,,,,,0,73.23,535.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 28MM 145CM 4MM CORONARY STENT",SUP-1125400-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross HMO",,2288.5,39.2,,9776.84,9776.84,9776.84,"1 through 10",678.96,4962.3,"percent of total billed charges",
"CATH LAUNCHER 100CM 6FR .071IN AMPLATZ LEFT 1 CURVE GUIDING",SUP-LA6AL10SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM 16MM PRESS FIT LEGION KNEE",SUP-71424029,CDM,C1776,HCPCS,0278,RC,,,both,,,11747.25,3524.17,"NOVANET [10819]",Novanet,,8810.44,75,,,,,0,1366.21,9985.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EMPHASYS THR CERAMIC ON POLYETHYLENE",SUP-OSC382182,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2762.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2710.95,19813.5,"percent of total billed charges",
"INSRT TIBIAL 3 12.5MM KNEE AOX STABILIZE ROTATE PLATFORM",SUP-196192132,CDM,C1776,HCPCS,0278,RC,,,both,,,13386.00,4015.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1556.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1556.79,11378.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE 22MM HELI-FX 16FR",SUP-SA-64,CDM,S27200284,LOCAL,0272,RC,,,both,,,9775.02,2932.51,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1158.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1136.83,8308.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES 145CM 40MM 3MM .014IN BALLOON DILATATION OTW",SUP-39134-30401,CDM,C1725,HCPCS,0272,RC,,,both,,,2175.00,652.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,252.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICROINTRODUCER 45CM 5FR 21GA .018IN 10CM PERCUTANEOUS",SUP-06597016,CDM,C1894,HCPCS,0272,RC,,,both,,,238.38,71.51,"MULTIPLAN [10600]",Multiplan,,202.62,85,,,,,0,27.72,202.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 8CM 18MM 10.5MM ESOPHAGEAL DELIVERY",SUP-G57314,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7229.33,41.1,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 28MM 144CM 2.5MM CORONARY STENT EVEROLIMUS",SUP-H7493926128250,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"NOVANET [10819]",Novanet,,6468.75,75,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE OSTEOCONDUCTIVE MATRIX PLUS 10CC",SUP-OCMP10,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HURRICANE 180CM 2CM 5.8FR 4MM 12 ATM BALLOON DILATATION",SUP-M00545890,CDM,C1726,HCPCS,0272,RC,,,both,,,1849.50,554.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,219.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",379.61,375.47,414.12,"1 through 10",215.1,1572.08,"percent of total billed charges",
"MICROCATHETER INFUSION 155IN .021IN DIREXION FATHOM-16",SUP-M001195980,CDM,C1887,HCPCS,0272,RC,,,both,,,6734.40,2020.32,"FIRST HEALTH [10303]","First Health",,5387.52,80,,,,,0,783.21,5724.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X12MM ENDOSKELETON TAS 7D 21MM STD TITANIUM",SUP-2307-0112-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,43942.50,13182.75,"KAISER [10500]",Kaiser,,29441.48,67,,,,,0,5110.51,37351.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 135CM 8MM 16SQ MM 8FR .035IN",SUP-BXAL087902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"CIGNA [10200]","Cigna Local Plus",,6743.33,31.5,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ORTHOPEDIC 3 LONG 2 COLLAR PIN ADVANCE EVOLUTION STERILE",SUP-K0001288,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA [10200]","Cigna Open Access",,1493.63,56.9,,1144.80,304.56,2275.09,66,305.29,2231.25,"percent of total billed charges",
"CONNECTIVE TISSUE DISORDERS WITH MCC",545,MS-DRG,,,,,,,inpatient,,,74257.79,22277.34,"CIGNA [10200]","Cigna Local Plus",,25608.66,,"Fee schedule rate ($25,608.66). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,61891.12,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIBRILLATOR 65CM 8FR OPTISURE ENDOCARDIUM 2 COIL DF4",SUP-LDA230Q-65,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"FIRST HEALTH [10303]","First Health",,12144,80,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA SOFT TOUCH 545CC STERILE LATEX",SUP-SSX-545,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"KAISER [10500]",Kaiser,,5062.19,67,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 1CM 12FR RADIOPAQUE LOW PROFILE TAPER DISTAL TIP",SUP-0120-12-1.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CIGNA [10200]","Cigna Local Plus",,416.8,53.5,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL SIZE 5-6 THK9MM STANDARD KNEE POLYETHYLENE POS",SUP-71420537,CDM,C1776,HCPCS,0278,RC,,,both,,,18474.75,5542.42,"KAISER [10500]",Kaiser,,12378.08,67,,,,,0,2148.61,15703.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS 2-0 UCL 27IN ANTIBACTERIAL VIOLET ABSORBABLE",SUP-PDP114H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 12MM 140CM 4.5MM CORONARY STENT PLATINUM",SUP-H7493927412450,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1073.25,28.62,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ACCESS 72CM 8.5FR VERSACROSS 1 SMALL TRANSSEPTAL PIGTAIL",SUP-VSTK0118,CDM,C1766,HCPCS,0272,RC,,,both,,,11212.50,3363.75,"MULTIPLAN [10600]",Multiplan,,9530.63,85,,,,,0,1304.01,9530.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY 7FR 25-15MM LASSO D CURVE 22 POLE",SUP-LN222515CT,CDM,C1732,HCPCS,0272,RC,,,both,,,14055.30,4216.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1665.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1634.63,11947.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 28CM 7FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856210,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"CIGNA [10200]",Cigna,,745.73,68,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0264,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]",Cigna,,644.44,68,,1831.33,1831.33,1831.33,16,110.22,805.55,"percent of total billed charges",
"CATH WOLVERINE CUTTING BALLOON (OTW)  2.00MM X 10MM",SUP-H74939402102000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"PHCS [10601]",PHCS,,3791.55,70,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 18CM 3CM 5FR .035IN 2 PIGTAIL",SUP-M006192115050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS [10001]","Blue Cross HMO",,470.63,39.2,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL CANNULATED 6.5/7.5 MM SCR STERILE",SUP-03.333.204S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2718.60,815.58,"CIGNA [10200]","Cigna Open Access",,1546.88,56.9,,,,,0,316.17,2310.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 70MM LCP",SUP-212.326,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.25,337.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,130.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",130.87,956.46,"percent of total billed charges",
"CATH CORDIS SABER 90CM 200MM 6MM BALLOON DILATATION DURALYN",SUP-48006020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,936.36,68,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 40MM 10MM AXOGUARD EXTRACELLULAR MATRIX",SUP-AG1040,CDM,C1763,HCPCS,0278,RC,,,both,,,20002.50,6000.75,"BLUE CROSS [10001]","Blue Cross HMO",,7840.98,39.2,,,,,0,2326.29,17002.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 15MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDS40015,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"BLUE CROSS [10001]","Blue Cross PPO",,32545.69,39.2,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3.5MM TARGET TETRA DETACHABLE STERILE",SUP-TG5413580,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1672.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENICILLIN VK DESENSITIZATION ORAL (0.5 MG/ML)",RX-411686,CDM,,,0250,RC,08888-8877-42,NDC,both,20,ML,12.54,3.76,"AETNA [10100]","Aetna HMO/PPO",,9.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 280MM 11MM LARGE QUICK COUPLING CANNULATED TAPERED",SUP-357.404,CDM,S27200284,LOCAL,0272,RC,,,both,,,2883.30,864.99,"MULTIPLAN [10600]",Multiplan,,2450.81,85,,,,,0,335.33,2450.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
1457Q/86,SUP-1457Q/86,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"MULTIPLAN [10600]",Multiplan,,4765.95,85,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Cath Drain Thoracic",PX-E27200150,CDM,C1729,HCPCS,0272,RC,,,both,,,448.80,134.64,"UHC [10700]","United Healthcare",,284.09,63.3,,,,,0,52.2,381.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL KNEE 12.5MM PFC TC3 SIGMA 4 TIBIAL FIX BEARING INSERT",SUP-961541,CDM,C1776,HCPCS,0278,RC,,,both,,,676.35,202.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,80.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,78.66,574.9,"percent of total billed charges",
"STENT ZIMMON 7CM 5FR PIGTAIL CURVE TAPER SPIRAL PANCREATIC",SUP-G22360,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 80MM DHS/DCS STAINLESS STEEL CONDYLAR HIP",SUP-280.280,CDM,C1713,HCPCS,0278,RC,,,both,,,2043.30,612.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,584.79,28.62,,,,,0,237.64,1736.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POD XL 4MMX30CM",SUP-RBYPODXL0430,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR DOME 10MM 29MM 3 PEG APEX KNEE ALL POLY KNEE",SUP-KC-40290,CDM,C1776,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TACTIFLEX SE BID CURVE D-F",SUP-A-TFSE-DF,CDM,C2630,HCPCS,0272,RC,,,both,,,23940.00,7182,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16279.2,68,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 3D .6MM MID FACE 6X2 HOLE 1.7MM SCR BONE TITANIUM",SUP-55-06733,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.98,945.29,"FIRST HEALTH [10303]","First Health",,2520.78,80,,,,,0,366.46,2678.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 80CM 40MM 4MM BALLOON DILATATION",SUP-H74939031404080,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING FIXATION 13MM THORNTON TITANIUM OPEN SWIVEL HANDLE",SUP-ET9020,CDM,S27200284,LOCAL,0272,RC,,,both,,,2650.73,795.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,308.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,308.28,2253.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RITONAVIR 100 MG TABLET",RX-100995,CDM,,,0637,RC,00054-0407-13,NDC,both,1,UN,35.00,10.5,"CIGNA [10200]","Cigna Local Plus",,18.73,53.5,,,,,0,4.07,29.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 11/13 TAPER 32MM HIP COCR S-ROM STERILE",SUP-522032,CDM,S27800098,LOCAL,0278,RC,,,both,,,2882.88,864.86,"PHCS [10601]",PHCS,,2018.02,70,,,,,0,335.28,2450.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIMETHYL FUMARATE 240 MG CAPSULE,DELAYED RELEASE",RX-162311,CDM,,,0250,RC,16729-0417-12,NDC,both,1,UN,561.20,168.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,66.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.27,477.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 4-0 RB-1 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J304H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Calcitonin",PX-301000122,CDM,82308,CPT,0301,RC,,,both,,,328.70,98.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,42.14,,,,,,,0.01,279.4,"fee schedule",
"COIL EMBOLIZATION 6CM 3MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-03006,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3683.83,41.1,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG HYDROCOLLOID 15X9CM AQUACEL AG COVER ANTIMICROBIAL",SUP-412010,CDM,S27200284,LOCAL,0272,RC,,,both,,,233.90,70.17,"NOVANET [10819]",Novanet,,175.43,75,,,,,0,27.2,198.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 12MM CEREPAK FREEFORM DETACHABLE",SUP-SCR121230,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5290.34,40,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8.5FR 180CM 81CM GWIRE BRAID HEMOSTASIS VALVE",SUP-407456,CDM,C1893,HCPCS,0272,RC,,,both,,,1409.40,422.82,"MULTIPLAN [10600]",Multiplan,,1197.99,85,,,,,0,163.91,1197.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDPN ORTHOPEDIC 140MM 1.3MM BAYONET POINT 4MM AND 5MM SCR",SUP-128039,CDM,S27200284,LOCAL,0272,RC,,,both,,,45.18,13.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18.57,41.1,,,,,0,5.25,38.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL 12.7X7MM LARGE TPS STAINLESS STEEL TEAR",SUP-5100-037-116,CDM,S27200284,LOCAL,0272,RC,,,both,,,928.26,278.48,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,426.07,45.9,,,,,0,107.96,789.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE CONNECT FLEX VASCULAR 195CM .018IN DURASTEEL",SUP-1012591,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"MULTIPLAN [10600]",Multiplan,,819.32,85,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION 0.9% SODIUM CHLORIDE LIFECARE 3L LATEX FREE",SUP-07972-08,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.92,32.68,"AETNA [10100]","Aetna HMO/PPO",,86.59,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.67,92.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE SURGICEL NU-KNIT LATEX FREE STERILE",SUP-1943S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1487.17,446.15,"UHC [10700]","United Healthcare",,941.38,63.3,,,,,0,172.96,1264.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE SURGICEL NU-KNIT LATEX FREE STERILE",SUP-1943S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1487.17,446.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1011.28,68,,,,,0,172.96,1264.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SYNTHETIC ETHIBOND EXCEL 2-0 V-7 30IN 2 ARM BRAID FIRM",SUP-PXX77N,CDM,S27200284,LOCAL,0272,RC,,,both,,,676.31,202.89,"KAISER [10500]",Kaiser,,453.13,67,,,,,0,78.65,574.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE PIN ORTHOPEDIC 2.4MM FEMUR BREAK AWAY OSTEOTOMY",SUP-AR-13303-2.4,CDM,S27200284,LOCAL,0272,RC,,,both,,,338.00,101.4,"FIRST HEALTH [10303]","First Health",,270.4,80,,,,,0,39.31,287.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COTTON 200CM 4CM 8.5FR 7-5FR .035IN BALLOON DILATATION",SUP-G22061,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD REAMER 650MM 2.5MM BALL TIP STERILE",SUP-351.709S,CDM,S27200284,LOCAL,0272,RC,,,both,,,968.76,290.63,"CIGNA [10200]","Cigna Open Access",,551.22,56.9,,,,,0,112.67,823.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM EGG",SUP-5820-015-040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"CIGNA [10200]","Cigna Local Plus",,585.8,53.5,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER FLEXIVA TRAC TIP 200UM FLEXSHIELD HOLMIUM",SUP-M0068403961,CDM,S27200284,LOCAL,0272,RC,,,both,,,3284.22,985.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1507.46,45.9,,,,,0,381.95,2791.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 6.5MM CYL XCOARSE GRIT DISSECTING DIAMOND",SUP-MR8-14CY65DX,CDM,S27200284,LOCAL,0272,RC,,,both,,,1345.17,403.55,"CIGNA [10200]","Cigna Open Access",,765.4,56.9,,,,,0,156.44,1143.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BRACHYTHERAPY 10CM 18GA 1 LOOSE SOURCE IODINE 125",SUP-10172-2,CDM,C1715,HCPCS,0272,RC,,,both,,,963.90,289.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,396.16,41.1,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 6.44IN 8FR 22GA PNEUMOTHORAX CATH RADIOPAQUE NDL",SUP-AK-01500,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,103.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ALLIS 6IN INTESTINAL 4X5 TEETH GRASPING",SUP-EA015R,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"AETNA [10100]","Aetna HMO/PPO",,71.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ZEPHYR 5.5-8.5MM AIRWAY EXCHANGE NICKEL TITANIUM",SUP-EDC-TS-5.5-DM,CDM,S27200284,LOCAL,0272,RC,,,both,,,3898.50,1169.55,"CIGNA [10200]","Cigna Open Access",,2218.25,56.9,,,,,0,453.4,3313.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ENDOSCOPIC MICRO SICKLE",SUP-28164MS-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1500.85,450.25,"CIGNA [10200]","Cigna Open Access",,853.98,56.9,,,,,0,174.55,1275.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLITTER CATH CPS UNIVERSAL II STERILE LATEX FREE DISPOSABLE",SUP-DS2A006,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
PROTEKDUO-31FR,SUP-5820-3118,CDM,S27200284,LOCAL,0272,RC,,,both,,,105450.00,31635,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,43339.95,41.1,,,,,0,12263.84,89632.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 5MM KII LOW PROFILE Z THREADED",SUP-CTR22,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.90,44.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,60.79,41.1,,,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 2 VIVID LED BLADE HANDLE MERCURY FREE",SUP-301-LED-102S,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.97,29.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,65.94,68,,,,,0,11.28,82.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM CORTICAL RAYHACK GENERATION II",SUP-40100914,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,517.75,68,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEWIRE VASCULAR ADX PTFE BENTSON STRAIGHT L150 CM OD.035",SUP-H7878141351501,CDM,C1769,HCPCS,0272,RC,,,both,,,110.58,33.17,"NOVANET [10819]",Novanet,,82.94,75,,,,,0,12.86,93.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 15D 6-8 7.5-10 SMALL CONTACT CLSR",SUP-HS1005-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,128.06,38.42,"CIGNA [10200]","Cigna Local Plus",,68.51,53.5,,,,,0,14.89,108.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK EMBOLECTOMY STROKE FAST PACK STROKE STERILE LATEX FREE",SUP-M0033PK62523001,CDM,S27200284,LOCAL,0272,RC,,,both,,,20045.55,6013.66,"FIRST HEALTH [10303]","First Health",,16036.44,80,,,,,0,2331.3,17038.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 9MM APTUS TRILOCK TITANIUM PHALANGEAL HAND",SUP-A-5250.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,662.49,41.1,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POS STENT 45CM 8FR URETERAL RADIOPAQUE",SUP-M0061802031,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.15,26.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,59.94,68,,,,,0,10.25,74.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 15CM ADJUSTABLE STOP CM MARKING FRANSEEN",SUP-MFN2006,CDM,S27200284,LOCAL,0272,RC,,,both,,,153.82,46.15,"CIGNA [10200]","Cigna Local Plus",,82.29,53.5,,,,,0,17.89,130.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 14FR IMPELLA SHORT STERILE LATEX DISPOSABLE",SUP-0052-0038,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"KAISER [10500]",Kaiser,,3236.1,67,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SERFAS 90-S CRUISE ENERGY ENDOSCOPIC",SUP-0279401200,CDM,S27200284,LOCAL,0272,RC,,,both,,,1174.50,352.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,482.72,41.1,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 4 PREASSEMBLE BLADE STD HANDLE LED LIGHT",SUP-040-04-0140U,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.42,18.73,"CIGNA [10200]","Cigna Local Plus",,33.39,53.5,,,,,0,7.26,53.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 12FR URETHRAL BACTI-GUARD HYDROGEL 5CC 1 EYE",SUP-0168SI12,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.14,33.04,"KAISER [10500]",Kaiser,,73.79,67,,,,,0,12.81,93.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP 11MM OPEN 235CM INTERNAL RESOLUTION RADIOPAQUE USER",SUP-M00522610,CDM,S27200284,LOCAL,0272,RC,,,both,,,1347.76,404.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,159.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,156.74,1145.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 120MM 4MM CANNULATED 6.7MM SCR",SUP-AR-8967-40C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"CIGNA [10200]","Cigna Local Plus",,845.03,53.5,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 110CM 6FR .056IN MULTIPURPOSE A CURVE",SUP-DXT6MPASHA,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"NOVANET [10819]",Novanet,,61.99,75,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL INSUFFLATION 15CM 14GA VERRES PNEUMOPERITONEAL",SUP-600-481,CDM,S27200284,LOCAL,0272,RC,,,both,,,642.17,192.65,"MULTIPLAN [10600]",Multiplan,,545.84,85,,,,,0,74.68,545.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUTURING OVERSTITCH HELIX TISSUE STERILE DISPOSABLE",SUP-THX-165-028,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYOSURE 1.8MM 54MM 140ML/MIN 300 MMHG 14MM 32CM 3MM",SUP-10-401,CDM,S27200284,LOCAL,0272,RC,,,both,,,5692.50,1707.75,"AETNA [10100]","Aetna HMO/PPO",,4525.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN 1,000 MG VIAL",RX-8442,CDM,J3373,HCPCS,0636,RC,00409-6533-11,NDC,both,1,UN,147.51,44.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8.55,,,,,,,3.5,125.38,"fee schedule",
"LEAD ICD 58CM 7FR DURATA ENDOCARDIUM OPTIM TRUE BIPOLAR",SUP-7121Q/58,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2034.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.2MM OCCIPITAL CERVICAL FUSION SYSTEM NONSTERILE",SUP-03.161.024,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RUBY XL COIL 20MMX55CM",SUP-RBYXL2055,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7742.01,41.1,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE WIDE LOCK VARIAX BONE LEFT DISTAL DORSAL RADIAL",SUP-54-25293,CDM,C1713,HCPCS,0278,RC,,,both,,,6505.04,1951.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2985.81,45.9,,,,,0,756.54,5529.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT WALLFLEX 75MM 28MM 10MM",SUP-7472,CDM,C1894,HCPCS,0272,RC,,,both,,,261.00,78.3,"MULTIPLAN [10600]",Multiplan,,221.85,85,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON PANOPTIX TORIC",SUP-CNWTT6,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,588.2,68,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 30CM 6FR 2MM CHECK-FLO PERFORMER RADIOPAQUE BAND",SUP-G08550,CDM,C1894,HCPCS,0272,RC,,,both,,,225.24,67.57,"FIRST HEALTH [10303]","First Health",,180.19,80,,,,,0,26.2,191.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 15CM 5FR MERIT S-MAK STIFFENED DIL COAXIAL PAIR",SUP-S-MAK5F-15,CDM,C1894,HCPCS,0272,RC,,,both,,,224.81,67.44,"NOVANET [10819]",Novanet,,168.61,75,,,,,0,26.15,191.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE WATCHMAN FXD CURVE 15FR 12FR CLSR 2 CURVE ACCESS",SUP-M635TU80010,CDM,C1894,HCPCS,0272,RC,,,both,,,6900.00,2070,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH THERMOCOOL SF 115CM 8FR D-J CURVE ABLATION",SUP-BDI35DJRT,CDM,C2630,HCPCS,0272,RC,,,both,,,11350.50,3405.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7718.34,68,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 190MM 12MM LARGE QUICK COUPLING 3 FLUTED",SUP-03.010.036,CDM,S27200284,LOCAL,0272,RC,,,both,,,3080.70,924.21,"FIRST HEALTH [10303]","First Health",,2464.56,80,,,,,0,358.29,2618.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 280016 UNCRT DWL 16MM SRVC FEE",SUP-280016,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCKER SPINAL OASYS OCCIPITO CERVICO THORACIC",SUP-48551000,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"KAISER [10500]",Kaiser,,1612.42,67,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 135+ MM 10MM PERSONA 6MM OFFSET KNEE STERILE LATEX",SUP-42560613510,CDM,C1776,HCPCS,0278,RC,,,both,,,16990.56,5097.17,"NOVANET [10819]",Novanet,,12742.92,75,,,,,0,1976,14441.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIR STPLR TRIEEAXL33XT BLK EXT",SUP-TRIEEAXL33XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,3083.78,925.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2096.97,68,,,,,0,358.64,2621.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURETTE UTERINE 11IN SIMS",SUP-52-8154,CDM,S27200284,LOCAL,0272,RC,,,both,,,187.31,56.19,"MULTIPLAN [10600]",Multiplan,,159.21,85,,,,,0,21.78,159.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 129MM STAINLESS STEEL 2.7/3.5MM SCR 7 HOLE LCP",SUP-02.112.115S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,,1521.93,481.35,16760.95,30,434.96,3179,"percent of total billed charges",
"WIRE FIXATION 1.1MM 140MM KIRSCHNER STAINLESS STEEL 1 END",SUP-NO2228012,CDM,C1713,HCPCS,0278,RC,,,both,,,243.60,73.08,"FIRST HEALTH [10303]","First Health",,194.88,80,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDO 1 CT-1 SPIRAL 14CM SUT ABSORBABLE",SUP-SXPD2B401,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.87,63.26,"NOVANET [10819]",Novanet,,158.15,75,,,,,0,24.52,179.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL KNEE 2A POROUS/HYBRID PROPRIETARY DEPUY - ATTUNE ROTAT",SUP-CAP-K-2A,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"CIGNA [10200]","Cigna Local Plus",,7342.65,31.5,,5372.07,4581.20,7242.98,23,2710.95,19813.5,"percent of total billed charges",
"PLATE STD CONTOUR TITANIUM 2.3MM CORTICAL SCR 5 HOLE LOCK 7",SUP-VLBPL-5-7,CDM,C1713,HCPCS,0278,RC,,,both,,,8176.50,2452.95,"NOVANET [10819]",Novanet,,6132.38,75,,,,,0,950.93,6950.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 11/13 TAPER 36MM HIP M SPECIFICATION",SUP-136536000,CDM,C1776,HCPCS,0278,RC,,,both,,,6875.85,2062.75,"PHCS [10601]",PHCS,,4813.1,70,,,,,0,799.66,5844.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT NEUROSURGICAL INNERVISION 2.8IN CSF VENTRICULAR CATH",SUP-27165,CDM,S27800098,LOCAL,0278,RC,,,both,,,1948.95,584.68,"BLUE CROSS [10001]","Blue Cross PPO",,763.99,39.2,,,,,0,226.66,1656.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK LAPAROSCOPIC 8MM ENDOWRIST PERMANENT CAUT GRASPING",SUP-470183,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"NOVANET [10819]",Novanet,,765.45,75,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 42.5-67MM 6MM CREO LONG SPINE CROSS LOW PROFILE",SUP-1119.0267,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"MULTIPLAN [10600]",Multiplan,,3187.5,85,,,,,0,414.32,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 101MM TRI-LOCK BPS GRIPTION 3 STD OFFSET HIP",SUP-101204030,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4348.92,27,,,,,0,1873.26,13691.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 415CC",SUP-SSZ-F415,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CIGNA [10200]","Cigna Local Plus",,797.36,53.5,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 7MM THIN WALL PERIPHERAL GORE-TEX",SUP-ST0708,CDM,C1768,HCPCS,0278,RC,,,both,,,8535.30,2560.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5804,68,,,,,0,992.66,7255.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100/110CM 6FR PIGTAIL FL4 FR4 CURVE",SUP-H749165993002,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 100MM 80CM 8MM VASCULAR NITINOL",SUP-1012530-100,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 17MM 42MM SHOULDER ANATOMIC RESTORATION",SUP-AR-9142-17P,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5385.6,68,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 116MM PRIMARY ANTHOLOGY POROUS 131D 9 STD",SUP-71356009,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"BLUE CROSS [10001]","Blue Cross HMO",,12991.33,39.2,,5311.50,4717.44,5388.59,31,3854.32,28169.98,"percent of total billed charges",
"SYSTEM GRAFTMASTER 19MM 2.8MM CORONARY STENT STAINLESS STEEL",SUP-1012580-19,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4729.6,28.62,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX11MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2991122,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"BLUE CROSS [10001]","Blue Cross HMO",,6231.86,39.2,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PERFORM STEM HEMI",SUP-CAP1179,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS [10001]","Blue Cross PPO",,8643.6,39.2,,3949.44,3949.44,3949.44,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"DEVICE ULTRA FAST-FIX STRAIGHT FIXATION MENISCAL REPAIR",SUP-72201490,CDM,C1713,HCPCS,0278,RC,,,both,,,2338.88,701.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1590.44,68,,,,,0,272.01,1988.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL ERGO REVERSE DRILL DISPOSABLE",SUP-531-55-88,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 6MM 7CM TWIST-IN 3 DAM SIDEPORT LUER LOCK",SUP-AR-6535TD,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"KAISER [10500]",Kaiser,,195.85,67,,,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 2-0 CT 27IN MONOFILAMENT ABSORBABLE",SUP-801H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"CIGNA [10200]","Cigna Open Access",,15.36,56.9,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bordetella Ab",PX-302000100,CDM,86615,CPT,0302,RC,,,both,,,175.00,52.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,20.75,,,,,,,0.01,148.75,"fee schedule",
"LINER BIPOLAR 50/51/52MM 28MM LEGACY HIP UHMWPE MULTIPOLAR S",SUP-00500105028,CDM,C1776,HCPCS,0278,RC,,,both,,,2365.50,709.65,"CIGNA [10200]","Cigna Open Access",,1345.97,56.9,,5302.19,4377.88,6578.61,27,275.11,2010.68,"percent of total billed charges",
"SCR BONE 4MM 42MM ALPS TIMAX T15 TIBIA CANCELLOUS PROXIMAL",SUP-816140042,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,189.34,1383.8,"percent of total billed charges",
"SHEATH 22.5FR ENDOSCOPIC OBTR CYSTOURETHROSCOPE",SUP-A20914A,CDM,S27200284,LOCAL,0272,RC,,,both,,,7184.69,2155.41,"MULTIPLAN [10600]",Multiplan,,6106.99,85,,,,,0,835.58,6106.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE AUGMENTATION 16MM CORTICAL INTERSPINOUS PROCESS",SUP-4578116,CDM,S27800098,LOCAL,0278,RC,,,both,,,19921.48,5976.44,"BLUE CROSS [10001]","Blue Cross HMO",,7809.22,39.2,,,,,0,2316.87,16933.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE RETINAL ROUND SILICONE STYLE 270",SUP-92-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.70,28.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL TRIATHLON E CONE KNEE TRITANIUM SYMMETRIC",SUP-5549-A-150,CDM,C1776,HCPCS,0278,RC,,,both,,,22087.80,6626.34,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8835.12,40,,,,,0,2568.81,18774.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE 0.9MM X 102MM PHALINX HAMMERTOE NON CE",SUP-5306,CDM,C1713,HCPCS,0278,RC,,,both,,,95.70,28.71,"BLUE CROSS [10001]","Blue Cross HMO",,37.51,39.2,,957.42,156.86,7483.26,51,11.13,81.35,"percent of total billed charges",
"SET INTRO 17.75IN 7FR 8FR SUPER ARROW-FLEX PERCUTANEOUS 3",SUP-CL-07745,CDM,C1894,HCPCS,0272,RC,,,both,,,547.56,164.27,"UHC [10700]","United Healthcare",,346.61,63.3,,,,,0,63.68,465.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOWL BONE CEMENT QUICK-VAC LARGE CAPACITY VACUUM MIX ADPTR",SUP-00-5049-001-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,656.10,196.83,"UHC [10700]","United Healthcare",,415.31,63.3,,,,,0,76.3,557.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT CONSTRAIN LEGION OXINIUM",SUP-71421167,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"AETNA [10100]","Aetna HMO/PPO",,45978.03,79.5,,10981.53,8986.79,12413.38,12,6726.09,49158.9,"percent of total billed charges",
"(EVAL) PREVAIL DCB 2.50X30MM",SUP-PRV025030CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PACKAGED DELIVERY SYSTEM",SUP-ES0200,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ISOLATOR SYNERGY ENCOMPASS CLAMP - MODEL OSH",SUP-A001144-9,CDM,S62400003,LOCAL,0624,RC,,,both,,,34020.00,10206,"CIGNA [10200]",Cigna,,23133.6,68,,,,,0,3956.53,28917,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS INTRALIPID 20% FAT EMULSION PLASTIC BAG 250",SUP-2B6022,CDM,S27200284,LOCAL,0272,RC,,,both,,,389.43,116.83,"MULTIPLAN [10600]",Multiplan,,331.02,85,,,,,0,45.29,331.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) DISPOSABLE COLLECTION CANISTER",SUP-01-90-3696,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER SURGICAL DIA4.5MM STANDARD CANNULATED HEX",SUP-3142-MICROLINER,CDM,S27200284,LOCAL,0272,RC,,,both,,,2651.93,795.58,"CIGNA [10200]","Cigna Open Access",,1508.95,56.9,,,,,0,308.42,2254.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.2MM QUICK RELEASE",SUP-201-78-89,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL STD 5 1/8IN TISSUE 1X2 TEETH",SUP-BD555R,CDM,S27200284,LOCAL,0272,RC,,,both,,,105.36,31.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,48.36,45.9,,,,,0,12.25,89.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 12MM ENDOPATH XCEL STABILITY",SUP-D12LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"MULTIPLAN [10600]",Multiplan,,133.11,85,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN FULL LENGTH WILLIAMS RIGHT CURVE",SUP-H74908641501,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.56,22.97,"UHC [10700]","United Healthcare",,48.46,63.3,,,,,0,8.9,65.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 3-0 CV-23 12IN CLSR ABSORBABLE VIOLET",SUP-VLOCM0814,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"CIGNA [10200]",Cigna,,133.17,68,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 8MM SALVATION STEP MIDFOOT NAIL",SUP-SMN10018,CDM,S27200284,LOCAL,0272,RC,,,both,,,3292.50,987.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,390.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,382.92,2798.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ERCP .035IN SHORT SWING TIP STAR TIP V 1950MM 2.5FR 2.1",SUP-PR-233Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,1249.34,374.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,145.3,1061.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 6-0 PS-3 18IN MONOFILAMENT PLIABILIZE",SUP-1665G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH FEMORAL CANAL SUCTION IRRIGATION",SUP-0210-004-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.99,28.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,43.14,45.9,,,,,0,10.93,79.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 4-0 PC-3 18IN MONOFILAMENT BLUE",SUP-8634G,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.79,20.34,"CIGNA [10200]","Cigna Local Plus",,36.27,53.5,,,,,0,7.88,57.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 2.9 MM PUSHLOCK",SUP-AR-1923DL,CDM,S27200284,LOCAL,0272,RC,,,both,,,807.98,242.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,549.43,68,,,,,0,93.97,686.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK BUTTON DRESSING AID WIRE HOOK WITH ZIPPER PULL BUILT UP",SUP-2038,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.37,14.51,"CIGNA [10200]",Cigna,,32.89,68,,,,,0,5.63,41.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 3FT THERMISTOR",SUP-M0046510,CDM,S27200284,LOCAL,0272,RC,,,both,,,2537.63,761.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,295.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,295.13,2156.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 19FR JACKSON-PRATT SILICONE ROUND HUBLESS",SUP-JP-2230,CDM,S27200284,LOCAL,0272,RC,,,both,,,207.54,62.26,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,85.3,41.1,,,,,0,24.14,176.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LACRIMAL SIZE 0000 000 L5.9IN MALLEABLE STERLING SILVE",SUP-E4200,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.79,105.84,"KAISER [10500]",Kaiser,,236.37,67,,,,,0,41.03,299.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 6.5IN LOVE-ADSON PERIOSTEUM",SUP-26-4810,CDM,S27200284,LOCAL,0272,RC,,,both,,,221.50,66.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,150.62,68,,,,,0,25.76,188.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 2CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE RADIOPAQUE",SUP-8140-24-2.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"FIRST HEALTH [10303]","First Health",,623.25,80,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 4CM 22MM METRX TUBULAR MICRODISCECTOMY STERILE",SUP-9560704,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM ELITE OSTEON ROUND SOFT TOUCH STERILE",SUP-5820010140,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"MULTIPLAN [10600]",Multiplan,,930.72,85,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 4X3IN MEPITEL ONE SAFETAC NONADHERENT LATEX FREE",SUP-565991,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.33,19,"KAISER [10500]",Kaiser,,42.43,67,,,,,0,7.37,53.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STBL SURGICAL SHORT ASSISTANT HEART-LIFT STABLESOFT 2 FINGER",SUP-T401212S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4036.50,1210.95,"MULTIPLAN [10600]",Multiplan,,3431.03,85,,,,,0,469.44,3431.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 14FR SILICONE MEDICATION PORT RADIOPAQUE STRIPE",SUP-0100-14LV,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"NOVANET [10819]",Novanet,,209.91,75,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR GUIDE AUG REAM",SUP-110040300,CDM,S27200284,LOCAL,0272,RC,,,both,,,650.75,195.22,"MULTIPLAN [10600]",Multiplan,,553.14,85,,,,,0,75.68,553.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE ARISTA MPH PLANT STARCH BIONERT 1GM",SUP-SM0005USA,CDM,S27200284,LOCAL,0272,RC,,,both,,,634.04,190.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,291.02,45.9,,,,,0,73.74,538.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 52CM .014IN SOFT STIFFNESS KNOB CAP INGEVITY",SUP-5013,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 22GA 15CM FRANSEEN LUER LOCK HUB CROWN POINT TIP",SUP-FRA2215,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.66,17.6,"AETNA [10100]","Aetna HMO/PPO",,46.63,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.82,49.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 52CM .014IN SOFT STIFFNESS KNOB CAP INGEVITY",SUP-5013,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 STD 12MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS6S12R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"MULTIPLAN [10600]",Multiplan,,8832.69,85,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 216MM 3.2MM AXSOS 3 SHORT TITANIUM NONLOCK",SUP-705032,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION",RX-15797,CDM,Q0144,HCPCS,0250,RC,59762-3140-01,NDC,both,30,ML,219.46,65.84,"MULTIPLAN [10600]",Multiplan,,186.54,85,,,,,0,25.52,186.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM VARIAX T10 FULL THREAD FOOT ANKLE",SUP-657428,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,94.05,687.4,"percent of total billed charges",
"CATH ADVANCE 35LP 80CM 10CM 5FR 3MM .035IN BALLOON",SUP-G52328,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"MULTIPLAN [10600]",Multiplan,,815.8,85,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE MYRINGOTOMY SPEAR SPEAR STERILE DISPOSABLE",SUP-1458276,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.95,20.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,32.11,45.9,,,,,0,8.14,59.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 34MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25034UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"AETNA [10100]","Aetna HMO/PPO",,2086.88,79.5,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 15.7IN 5FR .018IN MERIT MAK STD COAXIAL STAINLESS",SUP-MAK501,CDM,C1894,HCPCS,0272,RC,,,both,,,197.06,59.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,80.99,41.1,,,,,0,22.92,167.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC",331,MS-DRG,,,,,,,inpatient,,,60802.64,18240.79,"BLUE CROSS [10001]","Blue Cross PPO",,41545.84,,,,,,,7561,49133.95,"case rate",
"STEINMANN PIN SINGLE DIAMOND 2.4 MM X 229 MM",SUP-SPIN-SD-24229,CDM,S27000186,LOCAL,0270,RC,,,both,,,891.00,267.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,105.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRI-SIL IC 60IN 14FR URETHRAL BACTI-GUARD SILICONE",SUP-0170SI14,CDM,S27200284,LOCAL,0272,RC,,,both,,,193.66,58.1,"AETNA [10100]","Aetna HMO/PPO",,153.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.52,164.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 20MM HEMASHIELD PLATINUM STRAIGHT 2",SUP-M00202175420P0,CDM,L8670,HCPCS,0278,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,427.53,,,,,,,427.53,3179,"fee schedule",
"BIT DRILL 12.7CM 3.5MM STAINLESS STEEL STRAIGHT SHANK",SUP-231803506,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 200MM 5.5MM VIPER 2 STRAIGHT TITANIUM MIS",SUP-186789200,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC",371,MS-DRG,,,,,,,inpatient,,,34126.49,10237.95,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 1.7CM 14FR ENTERAL FEEDING TUBE RADIOPAQUE LOW",SUP-0120-14-1.7,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"UHC [10700]","United Healthcare",,493.14,63.3,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT FLOWABLE 2.5CC OSTEOAMP SELECT",SUP-OAFL-025,CDM,C1713,HCPCS,0278,RC,,,both,,,7427.64,2228.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2125.79,28.62,,,,,0,863.83,6313.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDON ANCHOR",SUP-2504-1,CDM,C1713,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"CIGNA [10200]",Cigna,,3988.2,68,,1831.33,1831.33,1831.33,16,682.1,4985.25,"percent of total billed charges",
"GRAFT VASCULAR 30CM 38MM HEMASHIELD PLATINUM STRAIGHT 2",SUP-M00202175438P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3797.28,1139.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.62,3227.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 35CM .02IN 10MM PENUMBRA COIL 400 RUBY",SUP-RBY2C1035,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.00,2003.4,"NOVANET [10819]",Novanet,,5008.5,75,,,,,0,776.65,5676.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PALMAZ GENESIS OPTA PRO FLEXSEGMENT 24MM 80CM 10MM 6-7",SUP-PG2910BPS,CDM,C1876,HCPCS,0278,RC,,,both,,,6210.00,1863,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 345CC",SUP-SSZ-M345,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CIGNA [10200]","Cigna Local Plus",,797.36,53.5,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 9MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530-G-609,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1031.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1012.7,7401.47,"percent of total billed charges",
"CMPNT FEMORAL 3 KNEE RIGHT CEMENTED CRUCIATE RETAINING",SUP-150400203,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"PHCS [10601]",PHCS,,15675.35,70,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 2.3 MM SCR 13 HOLE LOCKING BONE RIGHT DISTAL",SUP-70-0125,CDM,C1713,HCPCS,0278,RC,,,both,,,6651.60,1995.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4523.09,68,,,,,0,773.58,5653.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 100CM 25CM 5FR .047IN ANGLE",SUP-CG508,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL DECOMPRESSION 3.25IN 14GA RUG TUBE OPEN HEX CAP SHOCK",SUP-TM-303,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.43,20.23,"CIGNA [10200]","Cigna Open Access",,38.37,56.9,,,,,0,7.84,57.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 12MM TITANIUM UNIVERSAL VASCULAR HANDLE INSTR",SUP-030403,CDM,S27200284,LOCAL,0272,RC,,,both,,,604.10,181.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,70.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.26,513.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 300MM 2.8MM THREAD",SUP-03.333.015.04,CDM,S27200284,LOCAL,0272,RC,,,both,,,1123.33,337,"MULTIPLAN [10600]",Multiplan,,954.83,85,,,,,0,130.64,954.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T OFFSET 35X10X.6MM TITANIUM 1.2/1.5MM SCR 3X8 HOLE 2",SUP-A-4340.11,CDM,S27200284,LOCAL,0272,RC,,,both,,,6161.70,1848.51,"NOVANET [10819]",Novanet,,4621.28,75,,,,,0,716.61,5237.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 4-0 P-3 18IN MONOFILAMENT BLACK",SUP-699G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (PS) - SIZE 3",SUP-5555-2253,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"CIGNA [10200]","Cigna Local Plus",,758.36,53.5,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 300MM 2.8MM THREAD",SUP-03.333.015.04,CDM,S27200284,LOCAL,0272,RC,,,both,,,1123.33,337,"PHCS [10601]",PHCS,,786.33,70,,,,,0,130.64,954.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ACCESS 63CM VERSACROSS 45D CURVE 1 TRANSSEPTAL DIL",SUP-VXSK0122,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"CIGNA [10200]","Cigna Local Plus",,3303.89,53.5,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 11MM",SUP-7080510,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"AETNA [10100]","Aetna HMO/PPO",,3145.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP 8IN OPEN LIGATE SMALL CURVE WIDE HORIZON",SUP-137082,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,199.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP740D,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.09,38.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,53.06,41.1,,,,,0,15.01,109.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 7.25IN 4.5MM STAINLESS STEEL FREER 2 END SHARP",SUP-656620,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.01,32.7,"CIGNA [10200]","Cigna Local Plus",,58.32,53.5,,,,,0,12.68,92.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEK 17 FEMORAL ARTERIAL CANNULA 17FR",SUP-5130-1717,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"NOVANET [10819]",Novanet,,668.25,75,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 80CM 15MM 6FR 5MM .018IN BALLOON",SUP-H74939031501580,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP STEALTH FIBRA 3 60MM SOFT WOVEN LATEX FREE",SUP-A0G03,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]","Cigna Local Plus",,121.02,53.5,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CONCISE BONE CEMENT SCULP KIT",SUP-111000,CDM,S27200284,LOCAL,0272,RC,,,both,,,336.69,101.01,"AETNA [10100]","Aetna HMO/PPO",,267.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.16,286.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 3 WAY STPCOCK 3 FLUSH DEVICE TRNSDUC",SUP-PX3X3,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 0 18IN BRAID TIE 12 STRAND COATED UNDYED",SUP-J912G,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.83,26.95,"AETNA [10100]","Aetna HMO/PPO",,71.41,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.45,76.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25MM STRYKER PERFORMANCE SERIES THK.89MM",SUP-6125-089-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 4-0 TF 27IN BRAID COATED UNDYED ABSORBABLE",SUP-VCP434H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR 75CM 7CM .035IN STAINLESS",SUP-46-563,CDM,C1769,HCPCS,0272,RC,,,both,,,192.13,57.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.34,163.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 13MM SYNERGY TITANIUM POROUS PLUS STD",SUP-71309013,CDM,C1776,HCPCS,0278,RC,,,both,,,32476.50,9742.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3848.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3777.02,27605.03,"percent of total billed charges",
"PORT IMPLANTABLE INFUSION VORTEX PEELPRO TITANIUM SILICONE",SUP-P5355K,CDM,C1788,HCPCS,0278,RC,,,both,,,2482.50,744.75,"AETNA [10100]","Aetna HMO/PPO",,1973.59,79.5,,1729.13,1729.13,1729.13,"1 through 10",288.71,2110.13,"percent of total billed charges",
"AVENIR 10, 4 X 8 HELICAL PICO COIL",SUP-10USH04008,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]",Cigna,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 3MM CORONARY STENT PEBAX",SUP-H7493926032300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Open Access",,3166.49,56.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 16CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155214180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"FIRST HEALTH [10303]","First Health",,1287.77,80,,,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14FR CORONARY SINUS RETROGRADE MANUAL INFLATE",SUP-PLD014MIBH,CDM,S27200284,LOCAL,0272,RC,,,both,,,653.75,196.12,"MULTIPLAN [10600]",Multiplan,,555.69,85,,,,,0,76.03,555.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 5MM DA VINCI SI SINGLE-SITE CADIERE",SUP-428055,CDM,S27000186,LOCAL,0270,RC,,,both,,,963.90,289.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,655.45,68,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 694758  LEAD-QUADRIPOLAR RV/SVC 58C",SUP-6947-58,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]","Cigna Open Access",,5752.62,33.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 32MM 0D C HIP X3 TRIDENT",SUP-723-00-32C,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5811.04,68,,,,,0,993.86,7263.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR WHITE 49MM 28MM RINGLOC ECCENTRIC HIP",SUP-11-165222,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"CIGNA [10200]","Cigna Local Plus",,3563.04,53.5,,5372.07,4581.20,7242.98,23,774.54,5660.9,"percent of total billed charges",
"MESALAMINE ER 250 MG CAPSULE,EXTENDED RELEASE",RX-10533,CDM,,,0637,RC,54092-0189-81,NDC,both,1,UN,18.33,5.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8.41,45.9,,,,,0,2.13,15.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID UPPER LEG REDUCTION KIT- SHORT, WIDE",SUP-25302117,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"NOVANET [10819]",Novanet,,941.63,75,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 4.75MM CD HORIZON SOLERA COCRMO CAP",SUP-641003055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC",495,MS-DRG,,,,,,,inpatient,,,141821.79,42546.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,68804.91,,"Fee schedule rate ($68,804.91). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,105855.94,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 15CM 5FR 2 PIGTAIL CURVE BILIARY POLYETHYLENE",SUP-G22128,CDM,C2625,HCPCS,0278,RC,,,both,,,1328.40,398.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,157.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PATCH KIT",SUP-900-00031,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIDOVUDINE 10 MG/ML ORAL SYRUP",RX-11693,CDM,,,0250,RC,65862-0048-24,NDC,both,240,ML,354.76,106.43,"KAISER [10500]",Kaiser,,237.69,67,,,,,0,41.26,301.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 310115 ILBL TRCT 15X15 SRVC FEE",SUP-310115,CDM,S27800098,LOCAL,0278,RC,,,both,,,4858.98,1457.69,"CIGNA [10200]",Cigna,,3304.11,68,,,,,0,565.1,4130.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X22X12MM COROENT WIDE XL",SUP-6912255,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"KAISER [10500]",Kaiser,,15919.2,67,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL IN 0.9 % NACL 10 MCG/ML IV SUPERORDERABLE|DISCARDED DRUG NOT ADMINISTE",RX-40830807,CDM,J3010,HCPCS,0636,RC,70004-0202-40,NDC,both,250,ML,151.00,45.3,"MULTIPLAN [10600]",Multiplan,JW,128.35,85,,,,,0,17.89,128.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 3.5MM CEREPAK XTRASOFT FREEFORM",SUP-XCR123505,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA [10200]","Cigna Local Plus",,4166.14,31.5,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 150MM 130CM 6MM OFFSET CROWN VASCULAR",SUP-SC6150LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1043.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 18MM 27MM 32MM 26MM CARPENTIER-EDWARDS",SUP-3000TFX27MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"CIGNA [10200]",Cigna,,12839.4,40,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 6MM 4MM BALLOON DILATATION DURATRAC",SUP-NCEUP4006X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 150MM 11 HOLE LOW PROFILE BONE RIGHT OLECRANON",SUP-70-0309,CDM,C1713,HCPCS,0278,RC,,,both,,,7051.80,2115.54,"NOVANET [10819]",Novanet,,5288.85,75,,,,,0,820.12,5994.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 80MM 8MM BALLOON",SUP-U3513088,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 15CM 5FR 4 SIDEPORTS HOLLOW STYLET NDL CATH CAVITIES",SUP-G09492,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.61,54.78,"PHCS [10601]",PHCS,,127.83,70,,,,,0,21.24,155.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 SWIVELOCK SUTURETAPE KNOTLESS PEEK 19.1MM",SUP-AR-2323KPSLC,CDM,C1713,HCPCS,0278,RC,,,both,,,3425.63,1027.69,"FIRST HEALTH [10303]","First Health",,2740.5,80,,,,,0,398.4,2911.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP 68MM 100CM 10MM 75CM ENDOPROSTHESIS METAL",SUP-M001711360,CDM,C1876,HCPCS,0278,RC,,,both,,,4410.00,1323,"FIRST HEALTH [10303]","First Health",,3528,80,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 11FR 45MM 23CM RADIOPAQUE HEMOSTASIS VALVE",SUP-401123M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"PHCS [10601]",PHCS,,73.08,70,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FARAWAVE NAV 115CM 12FR 35MM ABLATION OTW 20 ELECTRD",SUP-M004PF41M412,CDM,C1733,HCPCS,0272,RC,,,both,,,53235.00,15970.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6308.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6191.23,45249.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Serotonin",PX-301000394,CDM,84260,CPT,0301,RC,,,both,,,565.50,169.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,48.73,,,,,,,0.01,480.68,"fee schedule",
"FORTIFY ASSURA NEXT GENERATION VR 40 DF4 CONNECTOR",SUP-CD1357-40Q,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"MULTIPLAN [10600]",Multiplan,,33150,85,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS 115CM 4MM 7FR 2-5-2MM SPACE F CURVE ABLATION",SUP-D7TCFL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,587.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla Class I or II Ab Qual",PX-302000217,CDM,86829,CPT,0302,RC,,,both,,,507.00,152.1,"CIGNA [10200]",Cigna,,141.22,,,,,,,57.17,430.95,"fee schedule",
"INTRO SHEATH 6FR 13CM SPLITTABLE SIDEPORT ROBUST VALVE",SUP-PLSH-1006,CDM,C1892,HCPCS,0272,RC,,,both,,,505.44,151.63,"FIRST HEALTH [10303]","First Health",,404.35,80,,,,,0,58.78,429.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO BLUE 45CM 8FR BRITE TIP CANN INTERVENTIONAL",SUP-401845M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"MULTIPLAN [10600]",Multiplan,,88.74,85,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPR LD 5MM UNPLR",SUP-501203,CDM,C1883,HCPCS,0278,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OLSEN 43CM 12CM 4FR 16GA CHOLANGIOGRAM BILE DUCT TROCAR",SUP-C-OECS-400,CDM,C1894,HCPCS,0272,RC,,,both,,,704.70,211.41,"KAISER [10500]",Kaiser,,472.15,67,,,,,0,81.96,599,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER REDEL 115CM 4MM 7FR 1-7-4MM SPACE D-F CURVE",SUP-BD7TCDF4L,CDM,C1733,HCPCS,0272,RC,,,both,,,6113.40,1834.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4157.11,68,,,,,0,710.99,5196.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER PRIME XP 110CM 8MM 7FR 8FR 2.5MM SPACE STRAIGHT",SUP-M004P4790THK20,CDM,C1733,HCPCS,0272,RC,,,both,,,12916.80,3875.04,"NOVANET [10819]",Novanet,,9687.6,75,,,,,0,1502.22,10979.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Dist Rad W Manip",PX-450000112,CDM,25605,CPT,0361,RC,,,both,,,2393.00,717.9,"FIRST HEALTH [10303]","First Health",,1914.4,80,,,,,0,278.31,2393,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 100CM 40MM 9MM BALLOON DILATATION DRUG COATED",SUP-LX35100940V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"PHCS [10601]",PHCS,,5916.75,70,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH SUPER SHEATH 11CM 7FR INTRO ACCEPTS .038IN GWIRE",SUP-H7491603607B1,CDM,C1894,HCPCS,0272,RC,,,both,,,79.31,23.79,"UHC [10700]","United Healthcare",,50.2,63.3,,,,,0,9.22,67.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHIELD CONTAMINATION YELLOW 80CM TWISTLOCK CATH-GARD",SUP-ST-09875,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.71,33.51,"MULTIPLAN [10600]",Multiplan,,94.95,85,,,,,0,12.99,94.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RX BILIARY SYSTEM 10CM 8.5FR DUODENAL BEND BILIARY",SUP-M00545670,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"BLUE CROSS [10001]","Blue Cross PPO",,334.29,39.2,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SYSTEM TRUFILL EMBOLIC 1GM KIT LIQUID",SUP-631500,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 62MM 36MM ALTRX HIP",SUP-122136062,CDM,C1776,HCPCS,0278,RC,,,both,,,6186.60,1855.98,"CIGNA [10200]",Cigna,,4206.89,68,,5873.17,5873.17,5873.17,"1 through 10",719.5,5258.61,"percent of total billed charges",
"CATH STERLING 150CM 220MM 7FR 5MM 5FR BALLOON DILATATION",SUP-H74939032502210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM TIBIA CORTICAL DISTAL NONLOCK NONSTERILE",SUP-815037016,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,93.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",91.85,671.29,"percent of total billed charges",
"STBL SURGICAL ACROBAT-I DISPOSABLE STERILE LATEX FREE",SUP-OM-10000Z,CDM,S27200284,LOCAL,0272,RC,,,both,,,9781.99,2934.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE,EXTREME",711,APR-DRG,,,,,,,inpatient,,,215080.17,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $48,531.84. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($274,830.46) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 15GA 24-48MM ILLINOIS ADJUSTABLE DEPTH STOP T",SUP-DIN1515X,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.20,24.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EVERCROSS CROSSTEC 135CM 30MM 5MM .035IN BALLOON",SUP-AB35W05030135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 3.5MM 14MM LOW PROFILE SCREWS TITANIUM T15 FULL",SUP-AR-8935-14,CDM,C1713,HCPCS,0278,RC,,,both,,,486.00,145.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,56.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",56.52,413.1,"percent of total billed charges",
"CMPNT FEMORAL 5 62X56MM KNEE LEFT POSTERIOR STABILIZE",SUP-81-4405L,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"BLUE CROSS [10001]","Blue Cross HMO",,6357.63,39.2,,5311.50,4717.44,5388.59,31,1886.21,13785.68,"percent of total billed charges",
"COIL EMBOLIZATION 6CM 2MM EMBOLD NITINOL FIBER DETACHABLE",SUP-M001394240020060,CDM,S27800098,LOCAL,0278,RC,,,both,,,6127.20,1838.16,"AETNA [10100]","Aetna HMO/PPO",,4871.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,712.59,5208.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE CORNEAL 8.5MM STAINLESS STEEL TREPHINE STERILE LATEX",SUP-K20-2160,CDM,S27200284,LOCAL,0272,RC,,,both,,,430.65,129.19,"CIGNA [10200]","Cigna Local Plus",,230.4,53.5,,,,,0,50.08,366.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 8CM 8MM BALLOON DILATATION PERIPHERAL",SUP-G50272,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVETIRACETAM 500 MG TABLET, IMMEDIATE RELEASE",RX-26817,CDM,,,0637,RC,51079-0821-01,NDC,both,1,UN,17.68,5.3,"CIGNA [10200]","Cigna Open Access",,10.06,56.9,,,,,0,2.06,15.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 30CM MIC-KEY SECUR-LOK ENFIT CNCT GASTRO",SUP-0144-12,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.91,20.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,32.09,45.9,,,,,0,8.13,59.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE ORTHOFLO AMNIOTIC FLUID .50 - LYOPHILIZED",SUP-LQ-0050,CDM,S25000001,LOCAL,0250,RC,,,both,,,6555.00,1966.5,"CIGNA [10200]","Cigna Local Plus",,3506.93,53.5,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 22MM STAINLESS STEEL T8 LOCK VARIABLE ANGLE",SUP-02.210.122TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1011.53,303.46,"BLUE CROSS [10001]","Blue Cross PPO",,396.52,39.2,,957.42,570.23,957.42,28,117.64,859.8,"percent of total billed charges",
"SPACER ALLOGRAFT 12.5X15X12MM PARALLEL SPINE",SUP-17312,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PACKAGED DELIVERY SYSTEM",SUP-ES0200,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 52CM .013IN ATR J SFT",SUP-6051,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 13MM PRIMARY SECUR-FIT PLUS HA 7 30MM HIP",SUP-6054-0713S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1915.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1880.04,13740.62,"percent of total billed charges",
"SCR BONE 2.3MM 8MM VARIAX TITANIUM SMALL BONE LOCK SELF TAP",SUP-53-23008E,CDM,C1713,HCPCS,0278,RC,,,both,,,738.23,221.47,"CIGNA [10200]",Cigna,,502,68,,1831.33,1831.33,1831.33,16,85.86,627.5,"percent of total billed charges",
"STENT TRIA 30CM 6FR URETERAL SOFT",SUP-M0061903250,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vasc Embol Occl Organ Trinav",PX-361000638,CDM,C9797,HCPCS,0361,RC,,,both,,,26377.00,7913.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17936.36,68,,,,,0,3067.65,22420.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STBL SURGICAL OCTOPUS EVOLUTION TISSUE",SUP-TS2000,CDM,S27000186,LOCAL,0270,RC,,,both,,,9240.48,2772.14,"CIGNA [10200]","Cigna Open Access",,5257.83,56.9,,,,,0,1074.67,7854.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,inpatient,,,33328.69,9998.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,14612.43,,,,,,,5685.11,22856.59,"case rate",
"DIL URETERAL HYDROPLUS 70CM 10FR STERILE",SUP-M0062401120,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.52,130.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.42,368.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 10MM .0135IN AXIUM PRIME 3D FRAME",SUP-FC-10-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"BLUE CROSS [10001]","Blue Cross HMO",,6478,39.2,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.828,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,27.52,201.14,"percent of total billed charges",
"COIL EMBOLIZATION 25CM 15MM INTERLOCK FIBERED IDC 35 COIL",SUP-M001363810,CDM,S27800098,LOCAL,0278,RC,,,both,,,3891.60,1167.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,452.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,452.59,3307.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 300MM 3.2MM PERCUTANEOUS QUICK COUPLING CALIBRATED",SUP-324.212,CDM,S27000186,LOCAL,0270,RC,,,both,,,1272.35,381.7,"CIGNA [10200]",Cigna,,865.2,68,,,,,0,147.97,1081.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mlh1 Gene",PX-309000128,CDM,81288,CPT,0310,RC,,,both,,,1210.75,363.22,"AETNA [10100]","Aetna HMO/PPO",,962.55,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1029.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .018IN 5FR 3MM 150CM 10CM PTA OTW",SUP-435300X,CDM,C1725,HCPCS,0272,RC,,,both,,,2137.50,641.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,878.51,41.1,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER 3992208 22MM X 8MM",SUP-3992208,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8723.72,41.1,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 12MM 2MM BALLOON DILATATION STERILE",SUP-220-123-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS LOC LARGE CARDIAC PERCUTANEOUS 3D STERILE",SUP-DS2C300-42,CDM,C1893,HCPCS,0272,RC,,,both,,,2250.00,675,"FIRST HEALTH [10303]","First Health",,1800,80,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH XXL QUADRA-FOLD 75CM 60MM 18MM BALLOON DILATATION",SUP-M001145590,CDM,C1725,HCPCS,0272,RC,,,both,,,1709.63,512.89,"KAISER [10500]",Kaiser,,1145.45,67,,,,,0,198.83,1453.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X300 135CM SL",SUP-48007030R,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"AETNA [10100]","Aetna HMO/PPO",,827.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 4-0 PC-3 18IN MONOFILAMENT BLACK",SUP-1964G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"MULTIPLAN [10600]",Multiplan,,21.25,85,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 30CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175265180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"PHCS [10601]",PHCS,,1022.08,70,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-150440105,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3568.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3502.26,25596.9,"percent of total billed charges",
"SCR BONE 5.5MM 40MM CD HORIZON VOYAGER SPINE NONSTERILE",SUP-55850045540,CDM,C1713,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"NOVANET [10819]",Novanet,,5563.13,75,,,,,0,862.66,6304.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE RIGHT CRUCIATE RETAIN CEMENTED",SUP-5510-F-802,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"CIGNA [10200]","Cigna Open Access",,5493.28,33.5,,5302.19,4377.88,6578.61,27,1907.07,13938.17,"percent of total billed charges",
"BLADE SHAVER 4.8MM PK DIEGO STRAIGHT SINUS HEMOSTATIC",SUP-70139002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1418.42,425.53,"KAISER [10500]",Kaiser,,950.34,67,,,,,0,164.96,1205.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 4 STD OFFSET HIP",SUP-71935564,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,14613.48,40,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T 53MM STAINLESS STEEL 2MM SCR MINI FRAGMENT SET 7",SUP-247.615,CDM,C1713,HCPCS,0278,RC,,,both,,,2541.00,762.3,"BLUE CROSS [10001]","Blue Cross PPO",,996.07,39.2,,957.42,570.23,957.42,28,295.52,2159.85,"percent of total billed charges",
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 64MM 36MM MARATHON",SUP-121936464,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"MULTIPLAN [10600]",Multiplan,,8366.42,85,,,,,0,1144.72,8366.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 70CM 11FR CHECK-FLO RB DESIGN RADIOPAQUE TIP SIDE",SUP-G11240,CDM,C1894,HCPCS,0272,RC,,,both,,,753.22,225.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,89.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.6,640.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Culture Bone Marrow.",PX-306000034,CDM,87070,CPT,0306,RC,,,both,,,500.00,150,"CIGNA [10200]","Cigna Local Plus",,18.96,,,,,,,0.01,425,"fee schedule",
"CATH DXTERITY 100CM 6FR .056IN MULTIPURPOSE A CURVE",SUP-DXT6MPA,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA [10200]","Cigna Open Access",,47.03,56.9,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM ROUND FLUTE",SUP-5540010040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1288.63,386.59,"CIGNA [10200]","Cigna Open Access",,733.23,56.9,,,,,0,149.87,1095.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET RECON ORBIT FLR MIC MEDPOR THN 50X30X0.4MM POLYETH",SUP-8438,CDM,S27800098,LOCAL,0278,RC,,,both,,,3382.50,1014.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,968.07,28.62,,,,,0,393.38,2875.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP 39MM 160CM 10MM 135CM ENDOPROSTHESIS",SUP-M001712350,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,983.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 30CM FEMUR RIGHT PROXIMAL TALON DISTALFIX",SUP-SLN-125-30R,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1910.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1875.37,13706.51,"percent of total billed charges",
"STPLR INTERNAL 25X3.5MM TITANIUM ENDOSCOPIC LINEAR CUTTER",SUP-EEAXL2535,CDM,S27200284,LOCAL,0272,RC,,,both,,,2399.55,719.86,"MULTIPLAN [10600]",Multiplan,,2039.62,85,,,,,0,279.07,2039.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 8CM 6MM BALLOON",SUP-G52267,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.64,68,,,,,0,111.62,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE POWERTURN VASCULAR J CURVE 300CM .014IN",SUP-1044593J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14CM NATRELLE INSPIRA P4.6CM MODERATE PROFILE",SUP-MSZ-M485,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA [10200]","Cigna Local Plus",,84.63,53.5,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY TRANSPLANT",652,MS-DRG,,,,,,,inpatient,,,91630.23,27489.07,"AMBETTER EXCHANGE  [11102]",Ambetter,,8198.58,,"Case rate ($8,198.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,612.94, add-ons for qualifying new technology services are included. If operating cost exceeds $40,652.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,957.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,623.01. The transfer operating threshold is the transfer adjustment factor * $7,612.94 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.58. The transfer capital threshold is the transfer adjustment factor * $575.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,38588.35,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE CREO AMP QUAD SPINE RIGHT 2 HEAD THREAD NONSTERILE",SUP-1119.0165,CDM,C1713,HCPCS,0278,RC,,,both,,,18314.10,5494.23,"BLUE CROSS [10001]","Blue Cross PPO",,7179.13,39.2,,957.42,570.23,957.42,28,2129.93,15566.99,"percent of total billed charges",
"STENT ADVANIX NAVIFLEX 15CM 7FR DUODENAL BEND BILIARY",SUP-M00534240,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,129.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG GAUZE 1.5X1.5IN QUIKCLOT HEMOSTATIC",SUP-467-Z,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"MULTIPLAN [10600]",Multiplan,,147.9,85,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT FIBERTAK HYBRID 1 KNOTLESS 1 KNOT",SUP-AR-3770SP,CDM,C1713,HCPCS,0278,RC,,,both,,,3803.63,1141.09,"MULTIPLAN [10600]",Multiplan,,3233.09,85,,,,,0,442.36,3233.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIAFILL DEMINERAILIZED BONE FIBERS 12CC",SUP-VFB012,CDM,C1713,HCPCS,0278,RC,,,both,,,8280.00,2484,"AMERIGROUP MEDICAID [20100]",Amerigroup,,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",962.96,7038,"percent of total billed charges",
"STEM HUMERAL ARTHREX UNIVERS REVERS 10 SHOULDER STERILE",SUP-AR-9501-10S,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4338.93,41.1,,6417.48,6417.48,6417.48,"1 through 10",1227.78,8973.45,"percent of total billed charges",
"SURFACE ARTICULAR PERSONA 6-7 C-D KNEE RIGHT TIBIA FIX",SUP-42522100413,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1253.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 15MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158126115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross HMO",,4380.42,39.2,,5311.50,4717.44,5388.59,31,1299.6,9498.37,"percent of total billed charges",
"(EVAL) MOTIV SCAFFOLD 2.5MMX24MM","SUP-930025-24 (140)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM SPINE PLY NONSTERILE 4MM ROD",SUP-102035122,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"CAGE SPINAL 22X10X11MM CASCADIA CONVEX ANATOMICALLY NARROW",SUP-6101-2102211NC-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"FIRST HEALTH [10303]","First Health",,16980.48,80,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NERVE STIM RESPIRATORY",SUP-4340,CDM,C1778,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8738.89,41.1,,,,,0,2472.83,18073.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 60MM 5MM .035IN BALLOON DILATATION NYBAX",SUP-39171-05064,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AETNA [10100]","Aetna HMO/PPO",,933.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 3.3MM 46MM TITANIUM T25 FULL THREAD HUMERAL",SUP-04.005.436S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"CIGNA [10200]",Cigna,,1017.88,68,,1831.33,1831.33,1831.33,16,174.09,1272.35,"percent of total billed charges",
"SUT VICRYL PLUS 3-0 CT-1 27IN BRAID COATED UNDYED ABSORBABLE",SUP-VCP258H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"NOVANET [10819]",Novanet,,18.75,75,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER RADIOLOGY 4MM 17GA ULTRACLIP II 3MM TISSUE COIL",SUP-864017,CDM,A4648,HCPCS,0278,RC,,,both,,,640.63,192.19,"BLUE CROSS [10001]","Blue Cross PPO",,251.13,39.2,,,,,0,74.51,544.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 18X8MM HEDRON C 7D 15MM STERILE LATEX FREE",SUP-1211.5818S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Shave Ext Lesn <=0.5cm",PX-510000018,CDM,11300,CPT,0761,RC,,,both,,,347.00,104.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,142.62,41.1,,,,,0,40.36,347,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INJECTION 1000ML 5% DEXTROSE USP LIFE FLEXIBLE CNTNR",SUP-792209,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,37.18,45.9,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 80MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"MULTIPLAN [10600]",Multiplan,,1218.65,85,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 10-12 G-H KNEE RIGHT TIBIA",SUP-42522401010,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Open Access",,6131.78,56.9,,5302.19,4377.88,6578.61,27,1253.3,9159.96,"percent of total billed charges",
"PLATE 118MM STAINLESS STEEL 3.5MM SCREWS SMALL FRAGMENT SET",SUP-245.00,CDM,C1713,HCPCS,0278,RC,,,both,,,3503.10,1050.93,"BLUE CROSS [10001]","Blue Cross PPO",,1373.22,39.2,,957.42,570.23,957.42,28,407.41,2977.64,"percent of total billed charges",
"COMPONENT GLENOID 44 REUNION X3",SUP-5542-P-0044,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"KAISER [10500]",Kaiser,,6048.57,67,,,,,0,1049.92,7673.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE RIGHT CEMENTED POSTERIOR",SUP-150410225,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2653.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2604.35,19034.35,"percent of total billed charges",
"GRASPER BULLETNOSE DISSECTING FORCEPS  ROTATING 5MM 32CM WIT",SUP-625117,CDM,S27000186,LOCAL,0270,RC,,,both,,,4108.33,1232.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1688.52,41.1,,,,,0,477.8,3492.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH II SS9.5",SUP-398347,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 16FR SILICONE MEDICATION PORT RADIOPAQUE RETENTION",SUP-0100-16LV,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"CIGNA [10200]","Cigna Open Access",,159.25,56.9,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATHETERIZATION ASCEND BALLOON DILATATION INFLATION",SUP-G32840,CDM,C1758,HCPCS,0272,RC,,,both,,,1745.63,523.69,"UHC [10700]","United Healthcare",,1104.98,63.3,,,,,0,203.02,1483.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 5.5MM CREO CURVE TITANIUM MIS NONSTERILE",SUP-1134.7055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CEREBROVASCULAR DISORDERS WITH MCC",070,MS-DRG,,,,,,,inpatient,,,37516.25,11254.87,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,10636.67,,"Case rate ($10,326.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,589.19, add-ons for qualifying new technology services are included. If operating cost exceeds $42,628.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,107.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $9,601.87. The transfer operating threshold is the transfer adjustment factor * $9,589.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $724.99. The transfer capital threshold is the transfer adjustment factor * $724.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,37516.25,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STEERABLE GUIDEWIRE TRITON NITINOL ALLOY .018"""" DIAMETER 260",SUP-CM2010,CDM,C1769,HCPCS,0272,RC,,,both,,,1875.00,562.5,"MULTIPLAN [10600]",Multiplan,,1593.75,85,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 22MM 140CM 2.5MM CORONARY STERILE LATEX",SUP-453950,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"GRAFT ENDOVASCULAR 91MM 16FR ZENITH ABDOMINAL AORTIC",SUP-G32555,CDM,C1874,HCPCS,0278,RC,,,both,,,23565.28,7069.58,"FIRST HEALTH [10303]","First Health",,18852.22,80,,,,,0,2740.64,20030.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT",SUP-M006145362170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CIGNA [10200]","Cigna Local Plus",,604.52,,,,,,,131.41,960.46,"percent of total billed charges",
"INSRT ARTICULAR 3-4 10MM RIGHT BICRUCIATE STABILIZED XLPE",SUP-74027232,CDM,C1776,HCPCS,0278,RC,,,both,,,20478.15,6143.44,"BLUE CROSS [10001]","Blue Cross HMO",,8027.43,39.2,,5311.50,4717.44,5388.59,31,2381.61,17406.43,"percent of total billed charges",
"CANN ARTHROSCOPIC BLUE 76MM THREADED OBTR SEAL CLEAR-TRAC",SUP-014719,CDM,S27200284,LOCAL,0272,RC,,,both,,,215.33,64.6,"PHCS [10601]",PHCS,,150.73,70,,,,,0,25.04,183.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC THK6MM 57X59MM SYNCRA ATRIUM VENTRICLE 2",SUP-C2TR01,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9490.15,41.1,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR TRILOGY 7.4MM 58MM 32MM LONGEVITY HIP",SUP-00633405832,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"BLUE CROSS [10001]","Blue Cross PPO",,9487.71,39.2,,3949.44,3949.44,3949.44,"1 through 10",2814.85,20572.84,"percent of total billed charges",
"HYDROMORPHONE 2 MG/ML INJECTION SUPERORDERABLE",RX-408121050,CDM,J1171,HCPCS,0636,RC,00409-1312-03,NDC,both,1,ML,55.69,16.71,"CIGNA [10200]","Cigna Local Plus",,7.41,,,,,,,2.33,47.34,"fee schedule",
"KNIFE OPHTHALMIC 14.6X2.65MM LASEREDGE 2.65MM ANGLE SLIT",SUP-LP7551A,CDM,S27200284,LOCAL,0272,RC,,,both,,,114.69,34.41,"KAISER [10500]",Kaiser,,76.84,67,,,,,0,13.34,97.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 20X15CM VENTRAL HERNIA OPTIMIZED",SUP-PCO2015X,CDM,C1781,HCPCS,0278,RC,,,both,,,4231.00,1269.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,501.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,492.07,3596.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD REAMER 19MM STAINLESS STEEL RIA STERILE DISPOSABLE",SUP-352.265S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2533.80,760.14,"UHC [10700]","United Healthcare",,1603.9,63.3,,,,,0,294.68,2153.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 7.5MM CANNULATED SURGICAL",SUP-6134.0075,CDM,C1713,HCPCS,0278,RC,,,both,,,583.20,174.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,396.58,68,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 13.5CM 16MM 13.5-14.5MM EXCLUDER",SUP-PLC161400,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3317.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 10MM TITANIUM CORTICAL LOW PROFILE",SUP-AR-8933-10,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,605.88,68,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS SUTUPAK 4-0 18IN BRAID 12 STRAND",SUP-VCP103G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"MULTIPLAN [10600]",Multiplan,,21.25,85,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 10MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650510,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"KAISER [10500]",Kaiser,,8795.26,67,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOMET FINNED PRI STEM 40MM",SUP-141314,CDM,C1776,HCPCS,0278,RC,,,both,,,4719.60,1415.88,"CIGNA [10200]","Cigna Open Access",,2685.45,56.9,,5302.19,4377.88,6578.61,27,548.89,4011.66,"percent of total billed charges",
"STEM FEMORAL 109MM COLLAR ACTIS DUOFIX 7 12/14 STD OFFSET",SUP-101011070,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"CIGNA [10200]","Cigna Local Plus",,9600.02,31.5,,5372.07,4581.20,7242.98,23,3544.39,25904.81,"percent of total billed charges",
"SYSTEM CRYO/CUFF IC UNIVERSAL 45- IN COMPRESSION THERAPY",SUP-51A14A,CDM,S27000186,LOCAL,0270,RC,,,both,,,649.78,194.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.57,552.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +28.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000285,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2.5 X 2 HELICAL PICO COIL",SUP-10USH02502,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"FIRST HEALTH [10303]","First Health",,9378.48,80,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000280,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 12MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-1517-10-412,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"AETNA [10100]","Aetna HMO/PPO",,11760.91,79.5,,10981.53,8986.79,12413.38,12,1720.5,12574.56,"percent of total billed charges",
"ROD SPINAL 70MM XIA MAX",SUP-48239070,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADAPTA IS-1 DR",SUP-ADDR01,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"BLUE CROSS [10001]","Blue Cross PPO",,16307.2,39.2,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 14MM BABY GORILLA LOCK",SUP-P50-053-2514,CDM,C1713,HCPCS,0278,RC,,,both,,,1316.25,394.87,"PHCS [10601]",PHCS,,921.38,70,,,,,0,153.08,1118.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 5CM 4FR PIGTAIL CURVE PANCREATIC POLYMER",SUP-M00537370,CDM,C2625,HCPCS,0278,RC,,,both,,,1411.18,423.35,"NOVANET [10819]",Novanet,,1058.39,75,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM .91-1.12MM 4MM CORONARY STENT",SUP-RONYX40008W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"CIGNA [10200]",Cigna,,3698.52,68,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP 55.6CM 8MM DA VINCI S/SI ENDOWRIST 35- D MEDIUM",SUP-420327,CDM,S27000186,LOCAL,0270,RC,,,both,,,700.41,210.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.46,595.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROSUVASTATIN 5 MG TABLET",RX-36612,CDM,,,0637,RC,60687-0234-11,NDC,both,1,UN,27.01,8.1,"KAISER [10500]",Kaiser,,18.1,67,,,,,0,3.14,22.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X9MM SABLE 8D STERILE LATEX FREE",SUP-1172.2013S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"NOVANET [10819]",Novanet,,25987.5,75,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL IO-FLEX MICROBLADE SHAVER SPINE TIGHT DISTAL",SUP-IO-IP-TR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1599.75,479.92,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,186.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,186.05,1359.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD GLENOID 42MM UNIVERS REVERS +2.5MM MEDIUM UNIVERSAL",SUP-AR-9504M-02,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"NOVANET [10819]",Novanet,,9144.9,75,,,,,0,1418.07,10364.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 59CM 4.1FR ATRIUM VENTRICLE TRANSVENOUS BIPOLAR",SUP-383059,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,264.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUSELECT 175CM 2-2.8FR .021IN MICRO EMBOLIZATION",SUP-M001394101750,CDM,C1887,HCPCS,0272,RC,,,both,,,5402.70,1620.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 135CM 20MM 7FR 12MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206120210,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXTRACTOR, STRIPPED SCREW, 3 MM, 6"" LONG, SINGLE USE",SUP-SXT010-ST3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DIAMONDBACK 360 60CM 10MM 1.25MM ATHERECTOMY PERIPHERAL",SUP-DBP-125SOLID60,CDM,C1724,HCPCS,0272,RC,,,both,,,21388.50,6416.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"ELECTRD ELECTROSURGICAL L HOOK STD 32CM 5MM STERILE",SUP-60-5163-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,251.69,75.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE DERMATOME INTEGRA PADGETT STERILE DISPOSABLE",SUP-3539252,CDM,S27200284,LOCAL,0272,RC,,,both,,,855.36,256.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT POLYDIOXANONE QUILL SRS 2 2XT11 TAPER 1/2 CIRCLE 36X36CM",SUP-RA-1065Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.89,65.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 100MM 6MM BALLOON DILATATION DURALYN",SUP-48006010S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMPULSE 100CM 6FR FR3.5 CURVE ANGIOGRAPHIC FEMORAL 2",SUP-H74916599012,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Afp Tumor Marker CSF",PX-302000059,CDM,86316,CPT,0302,RC,,,both,,,218.75,65.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18.73,,,,,,,0.01,185.94,"fee schedule",
"STEM FEMORAL 107.5MM TYPE 1 TAPERLOC MICROPLASTY PPS 133D 11",SUP-51106110,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"CIGNA [10200]","Cigna Open Access",,9190.81,33.5,,5302.19,4377.88,6578.61,27,3190.72,23319.95,"percent of total billed charges",
"INSRT CLAMP 33MM FOGARTY FIBRA ATRAUMATIC OCCLUSION STERILE",SUP-G-3355,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,103.83,45.9,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 12MM INTERLOCK FIBERED IDC 35 COIL",SUP-M001363620,CDM,S27800098,LOCAL,0278,RC,,,both,,,3891.60,1167.48,"CIGNA [10200]","Cigna Local Plus",,2082.01,53.5,,,,,0,452.59,3307.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE READIGRAFT CANCELLOUS 30CC 1-4MM ALLOGRAFT CHIP",SUP-CAN3014BP,CDM,S27800098,LOCAL,0278,RC,,,both,,,3144.38,943.31,"CIGNA [10200]","Cigna Local Plus",,1682.24,53.5,,,,,0,365.69,2672.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,inpatient,,,162263.37,48679.01,"UHC [10700]","United Healthcare",,84674.24,,"Fee schedule rate ($84,674.24). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,84674.24,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.35IN 14FR HEYMAN PLASTIC DILATION CATH",SUP-021114,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.13,65.14,"CIGNA [10200]",Cigna,,147.65,68,,,,,0,25.25,184.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 38MM 5MM E9000 FINE ROUND DIAMOND STERILE",SUP-E6150,CDM,S27200284,LOCAL,0272,RC,,,both,,,463.08,138.92,"CIGNA [10200]",Cigna,,314.89,68,,,,,0,53.86,393.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 2-0 CP-1 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z466H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM CEMENTLESS SUMMIT POROCOAT 4 12/14 STD",SUP-157001100,CDM,C1776,HCPCS,0278,RC,,,both,,,14221.44,4266.43,"BLUE CROSS [10001]","Blue Cross HMO",,5574.8,39.2,,5311.50,4717.44,5388.59,31,1653.95,12088.22,"percent of total billed charges",
"SPACER SPINAL 50X22X9MM TRANSCONTINENTAL 10D MEDIUM TITANIUM",SUP-375.369CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"FIRST HEALTH [10303]","First Health",,25200,80,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 90CM CORONARY VENOUS LEFT VENTRICLE 2 ELECTRD",SUP-4525,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross HMO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE OTOMIMIX CALCIUM PHOSPHATE 2GM FILLER STERILE",SUP-7014-3266,CDM,C1713,HCPCS,0278,RC,,,both,,,2866.35,859.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,333.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",333.36,2436.4,"percent of total billed charges",
"CATH BARDEX IC 18FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0166SI18,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.21,20.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.93,57.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL AMPLATZ FIRM KINK RESISTANT GRADUATE TAPER 35CM",SUP-M0062601050,CDM,C1894,HCPCS,0272,RC,,,both,,,362.44,108.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,148.96,41.1,,,,,0,42.15,308.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 145MM 32/16MM 20FR ENDURANT II ABDOMINAL",SUP-ETBF3216C145E,CDM,S27800098,LOCAL,0278,RC,,,both,,,35910.00,10773,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4176.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4176.33,30523.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR THK.6MM 15X2.5CM GORE-TEX",SUP-1702515006,CDM,C1768,HCPCS,0278,RC,,,both,,,1353.60,406.08,"CIGNA [10200]","Cigna Open Access",,770.2,56.9,,,,,0,157.42,1150.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BILIARY 8MM 8.5FR 60MM FULLY COVERED TRANSHEPATIC WALL",SUP-M00574750,CDM,C1874,HCPCS,0278,RC,,,both,,,22050.00,6615,"MULTIPLAN [10600]",Multiplan,,18742.5,85,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 60MM COCR",SUP-VAL-35600-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"BLUE CROSS [10001]","Blue Cross HMO",,823.2,39.2,,957.42,156.86,7483.26,51,244.23,1785,"percent of total billed charges",
"HC NM Indium III Wbc",PX-343000032,CDM,A9547,HCPCS,0343,RC,,,both,,,9098.00,2729.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1058.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1058.1,7733.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28MMX12MM X-PAC PARALLEL",SUP-EI2448P,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 18MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25018W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"MULTIPLAN [10600]",Multiplan,,2868.75,85,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL VASCULAR J",SUP-1009662J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT PRO+ 23MM",SUP-EVPROPLUS-23US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"MULTIPLAN [10600]",Multiplan,,145350,85,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM 11/13 STD TAPER 28MM HIP MODULAR ULTAMET",SUP-875953,CDM,C1776,HCPCS,0278,RC,,,both,,,4754.10,1426.23,"MULTIPLAN [10600]",Multiplan,,4040.99,85,,,,,0,552.9,4040.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 5MM MEDIUM CARBIDE ROUND ZIMMER RSC",SUP-5300-10-513,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.08,49.82,"MULTIPLAN [10600]",Multiplan,,141.17,85,,,,,0,19.32,141.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 5MM KII FIOS FIRST ENTRY Z THREAD",SUP-CTF01,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"PHCS [10601]",PHCS,,100.49,70,,,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP HEMOSTATIC 30 CRTDG SUPERFINE BLUE GEM TITANIUM",SUP-GEM1521,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.50,30.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.8,86.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Volatiles",PX-301000560,CDM,84600,CPT,0301,RC,,,both,,,150.00,45,"CIGNA [10200]","Cigna Local Plus",,37.64,,,,,,,0.01,127.5,"fee schedule",
"SCR BONE 5MM 55MM TRIGEN FEMUR LOW PROFILE",SUP-71645055,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"PHCS [10601]",PHCS,,1448.69,70,,,,,0,240.69,1759.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 7MM BALLOON DILATATION STERILE LATEX",SUP-597004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"KAISER [10500]",Kaiser,,976.86,67,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 8MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR081502A,CDM,C1874,HCPCS,0278,RC,,,both,,,24374.70,7312.41,"KAISER [10500]",Kaiser,,16331.05,67,,,,,0,2834.78,20718.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +24 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-ZA90030240,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY 25CM 18GA 17GA BARD MISSION TRUGUIDE 10MM CORE",SUP-1825MSK,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,187.69,45.9,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 36MM AEQUALIS CENTERED COCR CENTER REVERSE II",SUP-DWD190,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"KAISER [10500]",Kaiser,,8169.31,67,,,,,0,1418.05,10364.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC",413,MS-DRG,,,,,,,inpatient,,,155737.30,46721.19,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,10609.19,,"Case rate ($10,300.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,564.42, add-ons for qualifying new technology services are included. If operating cost exceeds $42,604.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,105.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $9,577.07. The transfer operating threshold is the transfer adjustment factor * $9,564.42 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.12. The transfer capital threshold is the transfer adjustment factor * $723.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,48479.96,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 6MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620906,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]",Cigna,,7652.65,68,,5873.17,5873.17,5873.17,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"MATRIX TISSUE 6X4CM PLACENTAL ALLOGRAFT",SUP-WC4046,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 90CM OCTRODE 8 ELECTRD LEAD",SUP-3189,CDM,C1778,HCPCS,0278,RC,,,both,,,1134.00,340.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25.5X9.5MM MICRO 100 MICROPOWER HALL THK.4MM",SUP-00502313800,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.02,36.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.31,104.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM STAINLESS STEEL T15 METAPHYSEAL SELF TAP",SUP-02.127.126,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,519.91,45.9,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIRE RETINAL 2.5MM GROOVE CONCAVE SILICONE 7MM ASYMMETRICAL",SUP-9218,CDM,S27800098,LOCAL,0278,RC,,,both,,,207.06,62.12,"MULTIPLAN [10600]",Multiplan,,176,85,,,,,0,24.08,176,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY ESOPHAGEAL 37FR ADULT SHILEY COMBITUBE 2 LUMEN",SUP-5-18537,CDM,S27200284,LOCAL,0272,RC,,,both,,,390.46,117.14,"MULTIPLAN [10600]",Multiplan,,331.89,85,,,,,0,45.41,331.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BALL 37CM 6FR NONSTERILE REUSABLE",SUP-257F6,CDM,S27000186,LOCAL,0270,RC,,,both,,,868.40,260.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,100.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,100.99,738.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BEACON TIP 65CM 5FR .035IN VANSCHIE4 CURVE ANGIOGRAPHIC",SUP-G13792,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.56,87.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,33.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.79,246.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X8MM COUGAR LS PARALLEL",SUP-189145408,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]",Cigna,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAPE FIBERWIRE 0 8INX1.7MM TAPER END BLUE 30IN",SUP-AR-7273-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG SURGICAL 1.6X1.3IN MONOFILAMENT FULL RESORBABLE PATCH",SUP-1190601,CDM,C1781,HCPCS,0278,RC,,,both,,,3563.25,1068.97,"BLUE CROSS [10001]","Blue Cross PPO",,1396.79,39.2,,,,,0,414.41,3028.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTNR DRSG 25YD 7 SMALL TUBULAR MT SPANDAGE ELASTIC NET LATEX",SUP-MT07,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.17,23.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.97,65.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPANDER BREAST TISSUE SMOOTH SURFACE WITH SUTURE TABS MEDIU",SUP-SCPX146MH,CDM,C1789,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"CIGNA [10200]",Cigna,,5911.92,68,,,,,0,1011.11,7389.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 15IN LARGE",SUP-D-497-LRG,CDM,S27000186,LOCAL,0270,RC,,,both,,,178.35,53.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA 2XL VELCRO POST SURGICAL",SUP-958-V/XXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,408.55,122.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,187.52,45.9,,,,,0,47.51,347.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOOP SPLINT 25YDX2IN ELASTICIZE HTH HOOK BLACK R-STRETCH THK",SUP-550385,CDM,S27000186,LOCAL,0270,RC,,,both,,,798.42,239.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,92.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,92.86,678.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 15.7X7.9IN XENMATRIX AB RECTANGLE DERMAL CLLGN",SUP-1152040,CDM,C1781,HCPCS,0278,RC,,,both,,,116480.64,34944.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13546.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13546.7,99008.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 17.7X11.8IN XENMATRIX AB RECTANGLE DERMAL",SUP-1153045,CDM,C1781,HCPCS,0278,RC,,,both,,,201492.72,60447.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,80597.09,40,,,,,0,23433.6,171268.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE GRAFT 9CC DEMINERALIZED CORTICAL FIBER ACCELERATE",SUP-T50209,CDM,C1713,HCPCS,0278,RC,,,both,,,14283.00,4284.9,"CIGNA [10200]","Cigna Open Access",,4784.81,33.5,,1144.80,304.56,2275.09,66,1661.11,12140.55,"percent of total billed charges",
"SCR BONE 6.5MM 70MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.770S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1672.39,68,,,,,0,286.03,2090.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 6MM 2.75MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012406-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 42X41X.85MM ORBITAL FLOOR MEDIAL WALL MESH EMBED EXT",SUP-81034,CDM,C1713,HCPCS,0278,RC,,,both,,,7073.05,2121.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,822.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",822.6,6012.09,"percent of total billed charges",
"INSERT TIB PCL SUBS 1-2X10MM L",SUP-2141-1-1210,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross HMO",,1396.5,39.2,,5311.50,4717.44,5388.59,31,414.32,3028.13,"percent of total billed charges",
"IMPL BREAST NATRELLE INSPIRA LOW PROFILE SILICONE SMOOTH",SUP-SCL-290,CDM,C1789,HCPCS,0278,RC,,,both,,,8004.00,2401.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5442.72,68,,,,,0,930.87,6803.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY HUMERAL SMR +9MM SHOULDER TITANIUM REVERSE LOCKING SCR",SUP-1352.15.001,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"PHCS [10601]",PHCS,,2058,70,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP050060150 PLUS US D5L60UL1500",SUP-PCP050060150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PHCS [10601]",PHCS,,861.84,70,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 20X25MM ARTHREX DYNANITE NITINOL TITANIUM",SUP-AR-8719DS-2520,CDM,C1713,HCPCS,0278,RC,,,both,,,15835.50,4750.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1876.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1841.67,13460.18,"percent of total billed charges",
"CATH ADVANCE 150CM 12CM 2MM BALLOON DILATATION OTW LOW",SUP-G30937,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 46MM 2 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800246,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,957.42,156.86,7483.26,51,521.61,3812.25,"percent of total billed charges",
"FENESTROMETER EAR 6.5IN 4MM PAPARELLA",SUP-61-0438,CDM,S27000186,LOCAL,0270,RC,,,both,,,776.47,232.94,"AETNA [10100]","Aetna HMO/PPO",,617.29,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.3,660,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 55X4.8MM TITANIUM REGULAR THICK TISSUE",SUP-017614,CDM,S27200284,LOCAL,0272,RC,,,both,,,1516.48,454.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,696.06,45.9,,,,,0,176.37,1289.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 29MM RESTORATION +20MM HIP PROXIMAL MODULAR",SUP-6276-1-229,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"FIRST HEALTH [10303]","First Health",,17803.8,80,,,,,0,2588.23,18916.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 HEALICOIL PK ULTRATAPE ULTRABRAID COBRAID",SUP-72203984,CDM,C1713,HCPCS,0278,RC,,,both,,,2559.38,767.81,"CIGNA [10200]","Cigna Local Plus",,1369.27,53.5,,3978.14,359.25,3978.14,24,297.66,2175.47,"percent of total billed charges",
"OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC",166,MS-DRG,,,,,,,inpatient,,,100065.18,30019.55,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,23880.74,,"Case rate ($23,185.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $21,529.01, add-ons for qualifying new technology services are included. If operating cost exceeds $54,568.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,009.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $21,557.48. The transfer operating threshold is the transfer adjustment factor * $21,529.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,627.70. The transfer capital threshold is the transfer adjustment factor * $1,627.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,100065.18,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 22MM 3.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG35022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1239.3,45.9,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC LARGE LEFT WRIST FOREARM PREFORM PAD",SUP-9101-06,CDM,S27000186,LOCAL,0270,RC,,,both,,,72.38,21.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,29.75,41.1,,,,,0,8.42,61.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 13MM KNEE X3 POSTERIOR STABILIZED TRIATHLON",SUP-5532G713,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"KAISER [10500]",Kaiser,,5834.1,67,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE ORTHOFLO AMNIOTIC FLUID 2 ML- LYOPHILIZED",SUP-LQ-0200,CDM,S25000001,LOCAL,0250,RC,,,both,,,18868.50,5660.55,"MULTIPLAN [10600]",Multiplan,,16038.23,85,,,,,0,2194.41,16038.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC MEDIUM 3-3.5IN HAND RIGHT REST FINGER",SUP-81096148,CDM,L3807,HCPCS,0274,RC,,,both,,,499.85,149.95,"CIGNA [10200]","Cigna Local Plus",,267.42,53.5,,,,,0,58.13,424.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 1 TP-1 54IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z879G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT COMPREHENSIVE GLENOID SHOULDER TRABECULA",SUP-98000900027,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"CIGNA [10200]",Cigna,,19404,40,,5873.17,5873.17,5873.17,"1 through 10",5641.71,41233.5,"percent of total billed charges",
"STEM FEMORAL 113MM COLLAR ACTIS DUOFIX 9 12/14 HIGH OFFSET",SUP-101012090,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"CIGNA [10200]","Cigna Open Access",,10209.54,33.5,,5302.19,4377.88,6578.61,27,3544.39,25904.81,"percent of total billed charges",
"SUT PROLENE 5-0 RB-1 36IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8556,CDM,S27200284,LOCAL,0272,RC,,,both,,,255.14,76.54,"FIRST HEALTH [10303]","First Health",,204.11,80,,,,,0,29.67,216.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Swan Ganz Alsius",PX-E27200073,CDM,C1751,HCPCS,0272,RC,,,both,,,2820.40,846.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,328.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,328.01,2397.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 5MM KII ADVANCE FIXATION RETENTION",SUP-CFR01,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"AETNA [10100]","Aetna HMO/PPO",,114.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 6X 22MM CATH 120CM ENDOVASCULAR",SUP-42622,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOOP SPLINT 25YDX1IN ELASTICIZE HTH HOOK BLACK R-STRETCH THK",SUP-550384,CDM,S27000186,LOCAL,0270,RC,,,both,,,420.21,126.06,"CIGNA [10200]","Cigna Open Access",,239.1,56.9,,,,,0,48.87,357.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP 35CM AUTOMATIC 5MM LATEX FREE STERILE WECK AUTO",SUP-AE05ML,CDM,S27200284,LOCAL,0272,RC,,,both,,,1117.80,335.34,"PHCS [10601]",PHCS,,782.46,70,,,,,0,130,950.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 55MM TSRH-3D TITANIUM SPINE PEDICLE POSTERIOR",SUP-837-755,CDM,C1713,HCPCS,0278,RC,,,both,,,2361.60,708.48,"BLUE CROSS [10001]","Blue Cross HMO",,925.75,39.2,,957.42,156.86,7483.26,51,274.65,2007.36,"percent of total billed charges",
"INSRT ARTICULAR 1-2 15MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934381,CDM,C1776,HCPCS,0278,RC,,,both,,,19429.20,5828.76,"BLUE CROSS [10001]","Blue Cross PPO",,7616.25,39.2,,3949.44,3949.44,3949.44,"1 through 10",2259.62,16514.82,"percent of total billed charges",
"RING ANNULOPLASTY 26MM 30.7MM 24.9MM MITRAL FLEXIBLE HOLDER",SUP-4450M26,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"CIGNA [10200]","Cigna Local Plus",,6090.98,53.5,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE LIGHT MAXCESS LIGHT GUIDE STERILE DISPOSABLE",SUP-3200220,CDM,S27000186,LOCAL,0270,RC,,,both,,,2973.75,892.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,352.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,345.85,2527.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM G7 THR XLPE CERAMIC HIP CEMENT STEM CUP LINER HEA",SUP-98000700040,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"FIRST HEALTH [10303]","First Health",,19152,80,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL ULTRAPRO 5CM HERNIA PLUG THERMOFORMED ONLAY",SUP-UPPL2,CDM,C1781,HCPCS,0278,RC,,,both,,,1554.31,466.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,180.77,1321.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODAFINIL 100 MG TABLET",RX-24702,CDM,,,0637,RC,00904-6791-04,NDC,both,1,UN,48.67,14.6,"NOVANET [10819]",Novanet,,36.5,75,,,,,0,5.66,41.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 55MM 6.5MM MODULEX OSTEOGRIP SPINE",SUP-55900506555,CDM,C1713,HCPCS,0278,RC,,,both,,,4519.50,1355.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1293.48,28.62,,,,,0,525.62,3841.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESTRICT CEMENT 12MM",SUP-415-00-120,CDM,S27800098,LOCAL,0278,RC,,,both,,,1555.70,466.71,"CIGNA [10200]","Cigna Open Access",,885.19,56.9,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Culture Respiratory",PX-306000042,CDM,87070,CPT,0306,RC,,,both,,,479.75,143.92,"KAISER [10500]",Kaiser,,321.43,67,,,,,0,0.01,407.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 12 STD KNEE RIGHT CRUCIATE RETAIN PERSONA COCR",SUP-42502807402,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"MULTIPLAN [10600]",Multiplan,,24561.24,85,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 60MM 112CM 12MM 75CM VASCULAR NITINOL ILIAC",SUP-H74939200126070,CDM,C1725,HCPCS,0272,RC,,,both,,,4140.00,1242,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,481.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,inpatient,,,31163.00,9348.9,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,10248.84,,"Case rate ($9,950.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,239.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,279.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,080.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,251.77. The transfer operating threshold is the transfer adjustment factor * $9,239.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $698.56. The transfer capital threshold is the transfer adjustment factor * $698.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",10509.25,10509.25,10509.25,"1 through 10",7561,31163,other,"IP DRGs"
"RTRCTR ALEXIS LARGE RING C SECTION 9-14CM SURGICAL STERILE",SUP-G6303,CDM,S27200284,LOCAL,0272,RC,,,both,,,445.50,133.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 5FR SIDEWINDER 1 CURVE ANGIOGRAPHIC",SUP-H787107090065,CDM,C1887,HCPCS,0272,RC,,,both,,,182.70,54.81,"MULTIPLAN [10600]",Multiplan,,155.3,85,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 9IN LAMBOTTE SPINE SURGICAL STRAIGHT .5IN",SUP-28-9412,CDM,S27200284,LOCAL,0272,RC,,,both,,,225.16,67.55,"MULTIPLAN [10600]",Multiplan,,191.39,85,,,,,0,26.19,191.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 320108 TRICORT BLK 8MM SRVC FEE",SUP-320108,CDM,S27800098,LOCAL,0278,RC,,,both,,,3412.50,1023.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,404.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,396.87,2900.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UROLOGICAL STRAIGHT 150CM 3CM .025IN PTFE FLEXIBLE TIP",SUP-M0066201070,CDM,C1769,HCPCS,0272,RC,,,both,,,93.35,28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,63.48,68,,,,,0,10.86,79.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.464,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA [10200]",Cigna,,3292.97,68,,1831.33,1831.33,1831.33,16,563.19,4116.21,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 30CM 12MM 2 VELOUR STRAIGHT TUBE",SUP-M002020954120,CDM,C1768,HCPCS,0278,RC,,,both,,,3431.40,1029.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,399.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,399.07,2916.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 7MM BALLOON DILATATION STERILE LATEX",SUP-597004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"MULTIPLAN [10600]",Multiplan,,1239.3,85,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTALINK 135CM 2.15MM ATHERECTOMY BURR",SUP-H749393002150,CDM,C1724,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 90MM 14MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044149070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"FIRST HEALTH [10303]","First Health",,6900,80,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT SWIVE TENDON 7X19.1",SUP-AR-1662BCC-7,CDM,C1713,HCPCS,0278,RC,,,both,,,3425.63,1027.69,"PHCS [10601]",PHCS,,2397.94,70,,,,,0,398.4,2911.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOUNDSTAR 90CM 8FR ULTRASOUND GREEN SIEMENS SEQUOIA",SUP-10439011R,CDM,C1759,HCPCS,0272,RC,,,both,,,7590.00,2277,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5161.2,68,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MITRACLIP DELIVERY KIT SGC0101 CDS0201",SUP-MSK0101,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS [10001]","Blue Cross HMO",,67032,39.2,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL ACUTRAK REGULAR CANNULATED TAPERED STERILE",SUP-AT-7032,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUANFACINE 1 MG TABLET, IMMEDIATE RELEASE",RX-10149,CDM,,,0637,RC,00591-0444-01,NDC,both,1,UN,6.27,1.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 16MM DJO SURGICAL ALTIVATE SHORT SHOULDER",SUP-520-16-000,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"AETNA [10100]","Aetna HMO/PPO",,6296.4,79.5,,10981.53,8986.79,12413.38,12,921.1,6732,"percent of total billed charges",
"INTRO SHEATH 8FR 11CM AVANTI+ MID LENGTH ENDOVASCULAR",SUP-402608A,CDM,C1894,HCPCS,0272,RC,,,both,,,50.03,15.01,"MULTIPLAN [10600]",Multiplan,,42.53,85,,,,,0,5.82,42.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX LARGE C6 9.5MM X",SUP-T600306,CDM,S27800098,LOCAL,0278,RC,,,both,,,3150.00,945,"AETNA [10100]","Aetna HMO/PPO",,2504.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,366.35,2677.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175250080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,354.71,28.62,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT PARALLEL ALLOGRAFT 16MM TLIF",SUP-3W3316,CDM,S27800098,LOCAL,0278,RC,,,both,,,17139.60,5141.88,"CIGNA [10200]","Cigna Open Access",,5741.77,33.5,,,,,0,1993.34,14568.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC THK1/8IN SMALL 2.5-3.5IN HAND LEFT WRIST",SUP-A311301,CDM,S27000186,LOCAL,0270,RC,,,both,,,260.13,78.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,30.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.25,221.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 11CM 7FR DUODENAL PIGTAIL CURVE PANCREATIC",SUP-G27195,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"KAISER [10500]",Kaiser,,423.31,67,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL 60MM ACETABULAR HEMI 3HL",SUP-430-98-060,CDM,C1776,HCPCS,0278,RC,,,both,,,3200.74,960.22,"BLUE CROSS [10001]","Blue Cross PPO",,1254.69,39.2,,3949.44,3949.44,3949.44,"1 through 10",372.25,2720.63,"percent of total billed charges",
"SUT ETHILON MULTIPASS 3-0 FS-1 18IN MONOFILAMENT BLACK",SUP-663G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nerve Teasing Preparations",PX-312000070,CDM,88362,CPT,0312,RC,,,both,,,1001.00,300.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,737.36,,,,,,,0.01,850.85,"fee schedule",
"FLUOXETINE 10 MG CAPSULE",RX-10069,CDM,,,0637,RC,16714-0720-02,NDC,both,1,UN,13.07,3.92,"FIRST HEALTH [10303]","First Health",,10.46,80,,,,,0,1.52,11.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPANDER BREAST TISSUE SUTURE TABS SMOOTH MEDIUM HEIGHT 800C",SUP-SCPX156MH,CDM,C1789,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"FIRST HEALTH [10303]","First Health",,6955.2,80,,,,,0,1011.11,7389.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORPAC 90CM STD PERITONEAL BARIUM CARDIAC IMPREGNATE",SUP-43103,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 51MM UNITRAX HIP MODULAR ENDOPROSTHESIS",SUP-6942-5-051,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"PHCS [10601]",PHCS,,2189.39,70,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE STIM SONOPLEX CANN TIP ULTRASOUND WAVE ECHOGENIC",SUP-001187-74,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.62,34.09,"PHCS [10601]",PHCS,,79.53,70,,,,,0,13.21,96.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSOR LOGICUT 450MM",SUP-120-7004,CDM,S27200284,LOCAL,0272,RC,,,both,,,320.70,96.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,37.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.3,272.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 100CM 6FR AR MOD CURVE ANGIOGRAPHIC PEBAX",SUP-7506-11,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.74,23.62,"PHCS [10601]",PHCS,,55.12,70,,,,,0,9.16,66.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 12MM TITANIUM UNIVERSAL VASCULAR HANDLE INSTR",SUP-030403,CDM,S27200284,LOCAL,0272,RC,,,both,,,604.10,181.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,277.28,45.9,,,,,0,70.26,513.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL PACEMKR WRENCH TORQUE",SUP-108984,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.80,114.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,157.33,41.1,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 30MM 6FR 2.5MM",SUP-H7493926730250,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AETNA [10100]","Aetna HMO/PPO",,450.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SILICONE 500ML BREAST GEL SMOOTH",SUP-RSZ-5004,CDM,S27200284,LOCAL,0272,RC,,,both,,,127.64,38.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.84,108.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 15MM 24MM 19MM TRIFECTA GLIDE LINX BOVINE",SUP-TFGT-19A,CDM,S27800098,LOCAL,0278,RC,,,both,,,38367.00,11510.1,"NOVANET [10819]",Novanet,,28775.25,75,,,,,0,4462.08,32611.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METER STATSTRIP BTTRY QUICK REFERENCE GUIDE GLUCOSE",SUP-54790,CDM,S27000186,LOCAL,0270,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC",820,MS-DRG,,,,,,,inpatient,,,189628.67,56888.6,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,37471.11,,"Case rate ($36,379.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $33,781.03, add-ons for qualifying new technology services are included. If operating cost exceeds $66,820.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,936.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $33,825.70. The transfer operating threshold is the transfer adjustment factor * $33,781.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,554.01. The transfer capital threshold is the transfer adjustment factor * $2,554.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,36379.72,171228.7,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 8MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR081002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5742.58,27,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM TARGET HELICAL PLATINUM DETACHABLE",SUP-M0035434080,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"CIGNA [10200]","Cigna Open Access",,5210.72,56.9,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X80 40CM SL",SUP-48007008P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,116.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC LARGE HUB STERLING GATOR 2500-6000 RPM 13",SUP-C9266,CDM,S27200284,LOCAL,0272,RC,,,both,,,564.25,169.27,"MULTIPLAN [10600]",Multiplan,,479.61,85,,,,,0,65.62,479.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 28MM MULTILOC TITANIUM NIOBIUM ALUMINUM 3.8MM",SUP-04.019.028S,CDM,C1713,HCPCS,0278,RC,,,both,,,1747.20,524.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,500.05,28.62,,,,,0,203.2,1485.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR JCR3.5 CURVE GUIDING NYLON CORONARY",SUP-LA6JCR35,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 22MM LOW PROFILE SCREWS STAINLESS STEEL T10",SUP-AR-8827-22,CDM,C1713,HCPCS,0278,RC,,,both,,,522.45,156.73,"CIGNA [10200]","Cigna Open Access",,297.27,56.9,,1144.80,304.56,2275.09,66,60.76,444.08,"percent of total billed charges",
"VALVE CATH REPLACEMENT RADIOPAQUE ROCKET INDWELL PLEURAL",SUP-R54410-00-VV,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"CIGNA [10200]",Cigna,,218.89,68,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 12MM OSS UHMWPE KNEE TIBIAL STD STERILE",SUP-150410,CDM,C1776,HCPCS,0278,RC,,,both,,,8317.26,2495.18,"MULTIPLAN [10600]",Multiplan,,7069.67,85,,,,,0,967.3,7069.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pretreat Serum Ab ID Dilution",PX-302000213,CDM,86976,CPT,0302,RC,,,both,,,75.40,22.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,51.27,68,,,,,0,0.01,73.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 60MM 32MM XLPE HIP STERILE",SUP-71339560,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"PHCS [10601]",PHCS,,7788.38,70,,,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 18CM 3.5MM SKIMMER 15D 2 CURVED ANGLED TIP LOW",SUP-1883525,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM 2.25MM 2.1-2.7FR CORONARY",SUP-RONYX22526UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"AETNA [10100]","Aetna HMO/PPO",,2951.44,79.5,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 28CM 3CM 6FR .035IN PIGTAIL CURVE",SUP-M006180224170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETER MIDLINE MAX BARRIER PLUS 4FR SINGLE LUMEN WITH",SUP-PP4154108DCP,CDM,C1751,HCPCS,0272,RC,,,both,,,1304.59,391.38,"KAISER [10500]",Kaiser,,874.08,67,,,,,0,151.72,1108.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN AMPLATZ",SUP-77804200,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 STD 12MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS5S12R,CDM,C1776,HCPCS,0278,RC,,,both,,,7569.30,2270.79,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3474.31,45.9,,,,,0,880.31,6433.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cr Thiopurine Methyl Transfera",PX-300000026,CDM,82657,CPT,0301,RC,,,both,,,276.00,82.8,"CIGNA [10200]","Cigna Open Access",,48.77,,,,,,,0.28,234.6,"fee schedule",
"INTRO SHEATH 6FR 2.5CM 10CM DIL GWIRE KINK RESISTANT",SUP-10-2032,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING UNITRAX V40 +0MM HIP UNIPOLAR",SUP-6942-6-065,CDM,C1776,HCPCS,0278,RC,,,both,,,855.82,256.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,101.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,99.53,727.45,"percent of total billed charges",
"ROD SPINAL 240MM 4MM STRAIGHT TITANIUM",SUP-102014240,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"PROBE CRYOABLATION 18IN 8MM CRYOSPHERE 180D UP BALL TIP",SUP-CRYOS-L,CDM,C9808,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 5 LEFT DISTAL KNEE",SUP-5540-A-501,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,538.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,528.45,3862.24,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 30CM 3CM 6FR .035IN 2",SUP-M006192135180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1081.11,68,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 1 KNEE PARTIAL KNEE RESURFACING 10",SUP-5620-B-102,CDM,C1776,HCPCS,0278,RC,,,both,,,6899.26,2069.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,817.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.38,5864.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK",RX-116499,CDM,J2020,HCPCS,0636,RC,63323-0713-03,NDC,both,300,ML,274.64,82.39,"BLUE CROSS [10001]","Blue Cross PPO",,12.48,,,,,,,9.66,233.44,"fee schedule",
"CATH SABERX 200CM 150MM 6MM BALLOON DILATATION RAPID",SUP-47560150L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 8MM 6FR 1.5MM .07IN BALLOON",SUP-H7493918908150,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AETNA [10100]","Aetna HMO/PPO",,450.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN AMPLATZ LEFT 1 CURVE ANGIOGRAPHIC",SUP-H74908526962,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"AETNA [10100]","Aetna HMO/PPO",,60.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 80MM 125CM 14MM 6FR .035IN BILIARY NITINOL",SUP-G36246,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1735.02,45.9,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +14.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-SY60WF.145,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 120MM 120CM 6MM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200061220,CDM,C1876,HCPCS,0278,RC,,,both,,,4620.00,1386,"NOVANET [10819]",Novanet,,3465,75,,,,,0,537.31,3927,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 7FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856200,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"BLUE CROSS [10001]","Blue Cross HMO",,429.89,39.2,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM CREO SPINE POLYAXIAL PREASSEMBLE",SUP-5119.1242,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 15MM ECHO FX COCR STD OFFSET HIP STERILE",SUP-12-151315,CDM,C1776,HCPCS,0278,RC,,,both,,,8941.02,2682.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1039.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1039.84,7599.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID .7CC 9MM DEMINERALIZED CANCELLOUS CONFORM",SUP-0W1009,CDM,S27800098,LOCAL,0278,RC,,,both,,,3600.00,1080,"KAISER [10500]",Kaiser,,2412,67,,,,,0,418.68,3060,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOTTLE DRNG SET UNIQUE FLOW CONTROL EMPTY OUT PORT",SUP-R514110000,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"AETNA [10100]","Aetna HMO/PPO",,269.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.46,288.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 35CM 4MM ARTEGRAFT BOVINE CAROTID",SUP-AG535,CDM,C1768,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 100MM 130CM 6MM 6FR .035IN HELICAL VASCULAR",SUP-EX061003CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"PHCS [10601]",PHCS,,10626,70,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 25MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE32525,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"CIGNA [10200]","Cigna Open Access",,28027.64,33.5,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 2.5 MEQ/L LOW CALCIUM 2.5% DEXTROSE 2000ML 3000ML BAG",SUP-L5B9727,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.02,40.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.82,115.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I125 Glofil per Study Up to 10mci",PX-343000020,CDM,A9554,HCPCS,0343,RC,,,both,,,10967.00,3290.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1275.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.71,9321.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 60CM HEMOSTASIS GWIRE FAST-CATH .038IN RAMP",SUP-406898,CDM,C1893,HCPCS,0272,RC,,,both,,,1197.34,359.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,141.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.25,1017.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE (PF) 20 MG/ML (2%) INJECTION AMP/VIAL SUPERORDERABLE",RX-408650,CDM,J2003,HCPCS,0636,RC,63323-0208-01,NDC,both,5,ML,33.98,10.19,"MULTIPLAN [10600]",Multiplan,,28.88,85,,,,,0,1.17,28.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 2 X 1 HELICAL FINISHING COIL",SUP-10HFN-02001,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"AETNA [10100]","Aetna HMO/PPO",,8222.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 2-0 SH 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP417H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 3.1X2.4IN XENMATRIX AB RECTANGLE PORCINE",SUP-1150608,CDM,C1781,HCPCS,0278,RC,,,both,,,8599.47,2579.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3534.38,41.1,,,,,0,1000.12,7309.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 20MM 4MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP4020X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"UHC [10700]","United Healthcare",,333.27,63.3,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 20MM 2MM BALLOON DILATATION HYDROPHILIC",SUP-2200-2020-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"MULTIPLAN [10600]",Multiplan,,4985.25,85,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.0 X 30MM MA SCREWS",SUP-8975430,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYPERTENSION WITHOUT MCC",305,MS-DRG,,,,,,,inpatient,,,26912.14,8073.64,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,4824.45,,"Case rate ($4,683.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,349.35, add-ons for qualifying new technology services are included. If operating cost exceeds $37,389.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,710.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,355.10. The transfer operating threshold is the transfer adjustment factor * $4,349.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $328.83. The transfer capital threshold is the transfer adjustment factor * $328.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",4806.44,4806.44,4806.44,"1 through 10",4683.93,18831.44,other,"IP DRGs"
"MIXER BONE CEMENT OSSEOFLEX CD-H",SUP-OP-0005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1587.60,476.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1079.57,68,,,,,0,184.64,1349.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHOCKWAVE C2 AERO 138CM 12MM 3MM .045IN LITHOTRIPSY",SUP-C2AIVL3012,CDM,C1761,HCPCS,0272,RC,,,both,,,29610.00,8883,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,20134.8,68,,,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALL TIPPED GUIDE ROD 3.0 X 550MM PHANTOM? HINDFOOT NAIL",SUP-P31-955-1550,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"KAISER [10500]",Kaiser,,976.86,67,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 300MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025300M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,770.63,41.1,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit B Level 3",PX-450000329,CDM,G0382,HCPCS,0450,RC,,,both,,,1257.00,377.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1208.84,,,,,,,67.13,1257,"case rate",
"TUBE ESOPHAGEAL 20FR ADULT SENGSTAKEN BALLOON RADIOPAQUE",SUP-0092030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1167.94,350.38,"NOVANET [10819]",Novanet,,875.96,75,,,,,0,135.83,992.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE MEDIUM OVAL 240CM 2.4MM CAPTIVATOR LOOP STIFF",SUP-M00562321,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.33,36.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,55.69,45.9,,,,,0,14.11,103.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR MALE PELVIC PROCEDURES WITH CC/MCC",707,MS-DRG,,,,,,,inpatient,,,123733.47,37120.04,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,12780.22,,"Case rate ($12,407.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,521.65, add-ons for qualifying new technology services are included. If operating cost exceeds $44,561.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,253.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $11,536.89. The transfer operating threshold is the transfer adjustment factor * $11,521.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $871.09. The transfer capital threshold is the transfer adjustment factor * $871.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,58400.76,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 14/16 BALL TAPER 28MM HIP COCR STERILE",SUP-101813000,CDM,C1776,HCPCS,0278,RC,,,both,,,4783.08,1434.92,"CIGNA [10200]","Cigna Local Plus",,2558.95,53.5,,5372.07,4581.20,7242.98,23,556.27,4065.62,"percent of total billed charges",
"APPLR SURGICAL 26CM 20GA SNAP LOCK FIBRIN SEAL LATEX FREE",SUP-0601137,CDM,S27200284,LOCAL,0272,RC,,,both,,,535.91,160.77,"KAISER [10500]",Kaiser,,359.06,67,,,,,0,62.33,455.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 11MM 2.4FR GEMINI HELICAL",SUP-M0063303040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,679.11,45.9,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 58MM 135CM 8MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU1350858,CDM,C1874,HCPCS,0278,RC,,,both,,,15870.00,4761,"PHCS [10601]",PHCS,,11109,70,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 48MM 32MM ALTRX HIP",SUP-122132148,CDM,C1776,HCPCS,0278,RC,,,both,,,5531.40,1659.42,"FIRST HEALTH [10303]","First Health",,4425.12,80,,,,,0,643.3,4701.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 6 KNEE CEMENTED ROTATE PLATFORM",SUP-150610006,CDM,C1776,HCPCS,0278,RC,,,both,,,16694.55,5008.36,"BLUE CROSS [10001]","Blue Cross PPO",,6544.26,39.2,,3949.44,3949.44,3949.44,"1 through 10",1941.58,14190.37,"percent of total billed charges",
"HC Tube Connecting Drainage Bag",PX-E27200220,CDM,E27200220,LOCAL,0272,RC,,,both,,,79.20,23.76,"FIRST HEALTH [10303]","First Health",,63.36,80,,,,,0,9.21,67.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 300CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP110RH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1410.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1384.26,10117.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tbs Techl Calculation Only",PX-320000273,CDM,77091,CPT,0320,RC,,,both,,,404.00,121.2,"CIGNA [10200]",Cigna,,274.72,68,,,,,0,46.99,343.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 605CC",SUP-SMPX605,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,866.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPPORT ARTHRITIS SM LEFT WRIST SOFT FOAM PADDED FLANNEL FLE",SUP-A918-LS,CDM,S27000186,LOCAL,0270,RC,,,both,,,272.31,81.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,111.92,41.1,,,,,0,31.67,231.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 28MM 2.5MM CORONARY STENT COCR",SUP-1007823-28,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TIBIAL SHAFT THK10+ MM ALLOGRAFT FROZEN 50MMX10+",SUP-450500,CDM,S27800098,LOCAL,0278,RC,,,both,,,4719.60,1415.88,"NOVANET [10819]",Novanet,,3539.7,75,,,,,0,548.89,4011.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 80CM 8MM 9FR STRAIGHT VASCULAR",SUP-AVSM08100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"FIRST HEALTH [10303]","First Health",,14616,80,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 3-0 CV-23 .5 CIRCLE 12IN 17MM CLSR TAPER",SUP-VLOCL0814,CDM,S27200284,LOCAL,0272,RC,,,both,,,426.30,127.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,175.21,41.1,,,,,0,49.58,362.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOGRAPHIC .038IN RIM CURVE 5FR 65CM VISCERAL",SUP-G11995,CDM,S27200284,LOCAL,0272,RC,,,both,,,468.16,140.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,54.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.45,397.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 28CM 3CM 7FR .038IN PIGTAIL CURVE",SUP-M006180534170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"MULTIPLAN [10600]",Multiplan,,1046.32,85,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X11MM SABLE 22D STERILE LATEX FREE",SUP-1172.2035S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13860,40,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE RIGHT TOTAL STABILIZE TRIATHLON COCR",SUP-5512-F-802,CDM,C1776,HCPCS,0278,RC,,,both,,,32652.90,9795.87,"PHCS [10601]",PHCS,,22857.03,70,,,,,0,3797.53,27754.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SAPPHIRE 3 CORONARY DILATATION CATHETER 1.25 X 10MM",SUP-54125-100-02,CDM,C1725,HCPCS,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE GLADIUS MONGO 0.014 190CM",SUP-AP14R023S,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE VERSATURN VASCULAR STRAIGHT 190CM 3CM .014IN",SUP-1013319,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL JACOBSON MICRO STRAIGHT 7 1/8IN ARTERY EXTRA",SUP-16-4088,CDM,S27200284,LOCAL,0272,RC,,,both,,,494.51,148.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) LAPLACE TTVR DELIVERY SYSTEM",SUP-TTVR-DS-2673,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL LOOP 28FR CUT OLYMPUS OES PRO",SUP-M0068802631,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT E-LUMINEXX SAFE PERFORMAXX 80MM 80CM 10MM 6FR .035IN",SUP-ZBM10080,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6803.4,68,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 10MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158104110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"NOVANET [10819]",Novanet,,8380.91,75,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 4CM 5FR 3MM .035IN BALLOON",SUP-G52246,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"NOVANET [10819]",Novanet,,719.83,75,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 65MM 9.4MM 5MM CUFF INNER CANN LOW PROFILE FENESTRATE",SUP-4FEN,CDM,S27200284,LOCAL,0272,RC,,,both,,,399.33,119.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,47.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.44,339.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ext Ecg>48hr<7d Recording",PX-731000005,CDM,93242,CPT,0731,RC,,,both,,,383.00,114.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,45.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.87,383,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALPRAZOLAM 0.25 MG TABLET SUPERORDERABLE, IMMEDIATE RELEASE",RX-409585,CDM,,,0637,RC,59762-3719-01,NDC,both,1,UN,12.54,3.76,"MULTIPLAN [10600]",Multiplan,,10.66,85,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 70CMX.49MM 10MM KNIT REVERSE LOCKNIT",SUP-HGK0010-70,CDM,C1768,HCPCS,0278,RC,,,both,,,2765.70,829.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1880.68,68,,,,,0,321.65,2350.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN 1,000 MG VIAL",RX-8442,CDM,J3373,HCPCS,0636,RC,00409-6533-11,NDC,both,1,UN,147.51,44.25,"CIGNA [10200]","Cigna Local Plus",,8.55,,,,,,,3.5,125.38,"fee schedule",
".035 INTERLOCK 2D 10MM X 20CM",SUP-M001363600,CDM,C1725,HCPCS,0272,RC,,,both,,,3891.60,1167.48,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MALFUNCTION, REACTION, COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE,MAJOR",206,APR-DRG,,,,,,,inpatient,,,50010.39,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $9,843.30. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($75,009.48) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 BB 24IN 2 ARM MONOFILAMENT BLUE",SUP-8862H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT DRSG BLACK 18X12.5CM GRANUFOAM SILVER SENSATRAC VAC",SUP-M8275096/10,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 6-14FR TITANIUM GREENFIELD SET INTRO VENA CAVA",SUP-M001503350,CDM,S27200284,LOCAL,0272,RC,,,both,,,303.80,91.14,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PREVAIL DCB 3.0X25MM",SUP-PRV030025CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CAGE SPINAL 13MM CENTERPIECE C",SUP-436013C,CDM,S27800098,LOCAL,0278,RC,,,both,,,39060.00,11718,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15624,40,,,,,0,4542.68,33201,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 90CM 3.1FR .05-.063IN 50MM SPACE SPRT",SUP-518-036,CDM,C1887,HCPCS,0272,RC,,,both,,,972.00,291.6,"FIRST HEALTH [10303]","First Health",,777.6,80,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 34CM FEMUR LEFT PROXIMAL TALON DISTALFIX",SUP-SLN-125-34L,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"MULTIPLAN [10600]",Multiplan,,13706.51,85,,,,,0,1875.37,13706.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID BIOCARTILAGE 1CC",SUP-ABS-1010-BC,CDM,C1713,HCPCS,0278,RC,,,both,,,6762.00,2028.6,"CIGNA [10200]","Cigna Open Access",,3847.58,56.9,,1144.80,304.56,2275.09,66,786.42,5747.7,"percent of total billed charges",
"CATH LUTONIX 035 130CM 80MM 5MM BALLOON DILATATION",SUP-LX351305805F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,782.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM SPINAL POLYAXIAL 5.5MM ROD",SUP-8457540,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,573.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,563.19,4116.21,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL NDL 4IN 3/32IN EDGE SAFETY SLEEVE",SUP-E1465B-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,54.81,16.44,"UHC [10700]","United Healthcare",,34.69,63.3,,,,,0,6.37,46.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +25 DIOPTER +1.5 CYL 13MM 6MM POSTERIOR CHMBR 1",SUP-SN6AT3.250,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY SOFT TISSUE",SUP-4382SP,CDM,S27200284,LOCAL,0272,RC,,,both,,,238.73,71.62,"KAISER [10500]",Kaiser,,159.95,67,,,,,0,27.76,202.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ST CLAIR 7.25IN ADENOID RING JAW 10X5MM",SUP-71-5018,CDM,S27200284,LOCAL,0272,RC,,,both,,,1750.20,525.06,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,719.33,41.1,,,,,0,203.55,1487.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26MMX8MM VERTE-STACK CAPSTONE PEEK-OPTIMA END",SUP-2960826,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"CIGNA [10200]",Cigna,,6359.04,40,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 9.5-11.5MM 6 SHOOTER SAEED OPTI-VU 6 BAND NONSTERILE",SUP-G24654,CDM,S27200284,LOCAL,0272,RC,,,both,,,2107.50,632.25,"KAISER [10500]",Kaiser,,1412.03,67,,,,,0,245.1,1791.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Albumin",PX-301000088,CDM,82040,CPT,0301,RC,,,both,,,119.70,35.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.57,,,,,,,0.12,101.75,"fee schedule",
"CATH FOGARTY 80CM 4FR 9MM ROUND EMBOLECTOMY STAINLESS STEEL",SUP-120804FP,CDM,C1757,HCPCS,0272,RC,,,both,,,310.76,93.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,36.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.14,264.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 3MM BALLOON",SUP-U357538,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV",RX-9801,CDM,J3480,HCPCS,0258,RC,00264-7635-00,NDC,both,1000,ML,100.65,30.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68.44,68,,,,,0,0.02,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER RIGID SHARP DELIVERY SYSTEM HYDROMARK BREAST BIOPSY",SUP-4010-02-15-T4,CDM,A4648,HCPCS,0278,RC,,,both,,,640.49,192.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,293.98,45.9,,,,,0,74.49,544.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC AGILIS HISPRO SLITTER",SUP-DS3A001,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"NOVANET [10819]",Novanet,,455.63,75,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2 T-5 38IN BRAID TIES MULTISTRAND LOWER KNOT",SUP-AR-7200,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.35,53.5,"MULTIPLAN [10600]",Multiplan,,151.6,85,,,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 26CM 8FR .038IN LARGE REGULAR PIGTAIL CURVE",SUP-M001245650,CDM,C2617,HCPCS,0278,RC,,,both,,,1725.00,517.5,"BLUE CROSS [10001]","Blue Cross HMO",,676.2,39.2,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 13.5MM CEMENTLESS MODULAR AML POROUS 43MM",SUP-155401135,CDM,C1776,HCPCS,0278,RC,,,both,,,15374.88,4612.46,"CIGNA [10200]","Cigna Open Access",,5150.58,33.5,,5302.19,4377.88,6578.61,27,1788.1,13068.65,"percent of total billed charges",
"PATCH DURAL 4X4CM DURA-GUARD BOVINE PERICARDIAL RESORBABLE",SUP-DG0404SN,CDM,,,0278,RC,,,both,,,3132.45,939.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,371.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.13,2662.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 255CC",SUP-SSZ-M255,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CIGNA [10200]","Cigna Local Plus",,797.36,53.5,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Selct Plc Cath Cca/Innom Brain",PX-361000289,CDM,36223,CPT,0361,RC,,,both,,,23564.37,7069.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2740.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2740.54,20029.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 90CM 8FR AL1 CURVE GUIDING PTFE FEMORAL",SUP-H749343583980,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 100MM 3.5MM BALLOON DILATATION",SUP-48003510X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER SHORT TIP RELOAD 60MM PURPLE",SUP-ASR60PS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"PHCS [10601]",PHCS,,1020.6,70,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 8IN STAINLESS STEEL 4.5MM SCREWS 7 HOLE 8 GROOVE",SUP-3704-3-110,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,261.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",261.68,1912.5,"percent of total billed charges",
"MARKER BREAST BIOPSY CELERO SYSTEM",SUP-SMARK-CELERO,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"BLUE CROSS [10001]","Blue Cross HMO",,261.8,39.2,,,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN SMALL JUDKINS RIGHT",SUP-534619T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"AETNA [10100]","Aetna HMO/PPO",,69.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 7X5IN DURAGEN PLUS CRANIUM ULTRA PURE",SUP-DP-1057,CDM,,,0278,RC,,,both,,,10860.26,3258.08,"BLUE CROSS [10001]","Blue Cross PPO",,10.86,.1,,,,,0,10.86,9231.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FLOSWITCH 1050 PSI FLOW CONTROL 1 WAY HIGH PRESSURE",SUP-M00144200,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.22,18.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25.98,41.1,,,,,0,7.35,53.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR ANGLE ROSCH",SUP-G08444,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CIGNA [10200]","Cigna Local Plus",,127.06,53.5,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHOCKWAVE M5 60MM 110CM 8MM 7MM BALLOON DILATATION",SUP-M5PIVL8060,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"FIRST HEALTH [10303]","First Health",,17388,80,,,,,0,2527.78,18474.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21.5 DIOPTER MODIFY C BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB0000215,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CIGNA [10200]",Cigna,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE PASSER WITH GUIDE SUTURE PASSING PUNCTURE CLOSURE DEV",SUP-RSG-14F,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.80,52.44,"AETNA [10100]","Aetna HMO/PPO",,138.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.33,148.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 115MM DHS/DCS STAINLESS STEEL CONDYLAR HIP",SUP-280.315,CDM,C1713,HCPCS,0278,RC,,,both,,,2043.30,612.99,"MULTIPLAN [10600]",Multiplan,,1736.81,85,,,,,0,237.64,1736.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X9MM COLONIAL 7D LORDOTIC 12MM LARGE",SUP-365.409CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT AORTIC VALVE 18FR CERTITUDE SAPIEN 3 ATRION 20MM",SUP-9600CT20A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,53018.55,28.62,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BENTSON 28CM 15CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175264060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,457.82,45.9,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 37MM 135CM 7MM VASCULAR BALLOON EXPANDABLE",SUP-LSMU1350737,CDM,C1874,HCPCS,0278,RC,,,both,,,15870.00,4761,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1845.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 8CM 5FR PIGTAIL CURVE PANCREATIC",SUP-M00537040,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,75.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 331011 ACSR 10X11X11 SRVC FEE",SUP-331011,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 16MM PERSONA MEDIAL CONGRUENT 6-7 E-F KNEE",SUP-42522100716,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"MULTIPLAN [10600]",Multiplan,,9159.96,85,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 12MM TITANIUM T10 FULL THREAD CORTEX SELF TAP",SUP-AR-8933-12,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"FIRST HEALTH [10303]","First Health",,712.8,80,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 83MM 11MM COMPREHENSIVE POROUS MINI SHOULDER",SUP-113631,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Open Access",,4221,33.5,,5302.19,4377.88,6578.61,27,1465.38,10710,"percent of total billed charges",
"STEM HUMERAL ARTHREX UNIVERS REVERS 9 SHOULDER STERILE",SUP-AR-9501-09P,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"PHCS [10601]",PHCS,,7389.9,70,,,,,0,1227.78,8973.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 27MM REVERE TITANIUM SPINE MONOAXIAL",SUP-124131,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONCIERGE GUIDE CATHETER 7F 100CM 2 SIDE HOLES SUPER BACK UP",SUP-CGC7100SBS45SH-M,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 20MM 6FR 9MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-09027,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2.5MM TARGET NANO HELICAL DETACHABLE",SUP-M0035452560,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1065.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LANTERN 135CM .025IN 45D MICRO DELIVERY SYSTEM HIGH",SUP-PXSLIMLAN135T45,CDM,S27200284,LOCAL,0272,RC,,,both,,,4071.00,1221.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,473.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309114,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"BLUE CROSS [10001]","Blue Cross PPO",,14802.78,39.2,,3949.44,3949.44,3949.44,"1 through 10",4391.74,32097.87,"percent of total billed charges",
"SCR BONE 6.5MM 30MM LC-DCP LCP STAINLESS STEEL FULL THREAD",SUP-218.030,CDM,C1713,HCPCS,0278,RC,,,both,,,485.43,145.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,57.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,56.46,412.62,"percent of total billed charges",
"SUT SUTURETAPE .5 CIRCLE 38IN CONVENTIONAL CUT NDL BLUE",SUP-AR-7511,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 4MM FRMLA 8 FLUTE LONG PEAR STERILE",SUP-0385943000,CDM,S27200284,LOCAL,0272,RC,,,both,,,494.10,148.23,"CIGNA [10200]","Cigna Open Access",,281.14,56.9,,,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Wnd Surgical Secndry",PX-510000045,CDM,13160,CPT,0761,RC,,,both,,,14163.00,4248.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5820.99,41.1,,,,,0,1647.16,12038.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 90MMX1.5-2.5MM TITANIUM THICK TISSUE 2 ROW",SUP-TLH90,CDM,S27200284,LOCAL,0272,RC,,,both,,,2160.20,648.06,"AETNA [10100]","Aetna HMO/PPO",,1717.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,251.23,1836.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 5MM CHARLOTTE STAINLESS STEEL CANNULATED STERILE",SUP-44180010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC PRIMO MRI PHYSIOCURVE SURESCAN SPRINT QUATTRO",SUP-DDMD3D1,CDM,C1721,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"UHC [10700]","United Healthcare",,36888.08,63.3,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC15ST-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,19530.00,5859,"KAISER [10500]",Kaiser,,13085.1,67,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 18CM 7FR 2 PIGTAIL CURVE BILIARY POLYETHYLENE",SUP-G21530,CDM,C2617,HCPCS,0278,RC,,,both,,,1328.40,398.52,"CIGNA [10200]",Cigna,,903.31,68,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 4 X 6 HELICAL PICO COIL",SUP-10USH04006,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4818.19,41.1,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 24MM LCP STAINLESS STEEL DISTAL RADIUS T8",SUP-02.210.124,CDM,C1713,HCPCS,0278,RC,,,both,,,959.36,287.81,"CIGNA [10200]",Cigna,,652.36,68,,1831.33,1831.33,1831.33,16,111.57,815.46,"percent of total billed charges",
"BIT DRILL 1/8IN PFC STEINMANN PRESERVATION KNEE KIT TWIST",SUP-864192,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 40MM 29MM AEQUALIS 2MM LATERAL OFFSET",SUP-DWE840,CDM,C1776,HCPCS,0278,RC,,,both,,,9442.80,2832.84,"KAISER [10500]",Kaiser,,6326.68,67,,,,,0,1098.2,8026.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 30CM SPECIFY 5-6-5 LEAD 16 CONTACT PADDLE",SUP-39565-30,CDM,C1778,HCPCS,0278,RC,,,both,,,30240.00,9072,"MULTIPLAN [10600]",Multiplan,,25704,85,,,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 33MM CHORDAL GUIDE DURAN ANCORE",SUP-620RG33,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UHC [10700]","United Healthcare",,8298.63,63.3,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 16MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-316,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"FIRST HEALTH [10303]","First Health",,7864.42,80,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET ANGLE 00000 OVAL 9IN BRUNS SPINE SURGICAL",SUP-29-5360,CDM,S27200284,LOCAL,0272,RC,,,both,,,253.00,75.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.42,215.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT VITOSS B-TCP CLLGN VOID FILLER FOAM PACK 5ML",SUP-2102-1405,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"KAISER [10500]",Kaiser,,2889.38,67,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP ACETABULAR 56MM PINNACLE HIP GRIPTION SECTOR SERIES",SUP-1217-32-056,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1921.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1886.21,13785.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5.5MM TI CURVED ROD 55MM",SUP-04.636.055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 3MM15CM 190",SUP-R51003015L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"MULTIPLAN [10600]",Multiplan,,1735.28,85,,,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 72.5MM KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-183113,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2519.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2519.72,18415.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 195MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-409-195,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CRE RX 9MM 10MM 8MM BALLOON DILATATION BILIARY LATEX",SUP-M00558920,CDM,C1726,HCPCS,0272,RC,,,both,,,2085.75,625.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,247.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",379.61,375.47,414.12,"1 through 10",242.57,1772.89,"percent of total billed charges",
"TRICLIP G5 SYSTEM- ONE (1) STEERABLE GUIDE CATHETER AND ANY",SUP-TCG50100,CDM,S27800098,LOCAL,0278,RC,,,both,,,205200.00,61560,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,58728.24,28.62,,,,,0,23864.76,174420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 107.5MM 11MM PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51-107110,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3251.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3190.72,23319.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 75X25MM 3 TONGUE DAVIS",SUP-45-5113,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.96,81.59,"CIGNA [10200]","Cigna Open Access",,154.75,56.9,,,,,0,31.63,231.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 30CM 3CM 5FR .035IN 2 PIGTAIL",SUP-M006192125050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS [10001]","Blue Cross PPO",,470.63,39.2,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUITY WHISPER VIEW ES CS-J - EACH",SUP-664641-001,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"UHC [10700]","United Healthcare",,717.82,63.3,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 118MM CEMENTLESS NECK ACCOLADE TMZF 127D 2.5 40",SUP-6021-2530,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2654.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2654.17,19398.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM AXSOS STAINLESS STEEL 2.5MM FULL THREAD",SUP-345438,CDM,C1713,HCPCS,0278,RC,,,both,,,211.93,63.58,"FIRST HEALTH [10303]","First Health",,169.54,80,,,,,0,24.65,180.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2 PACK OF DRIVERS ONLY",SUP-NCAAX2U,CDM,S27800098,LOCAL,0278,RC,,,both,,,430.65,129.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,123.25,28.62,,,,,0,50.08,366.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 2.5CM 10CM DIL GWIRE KINK RESISTANT",SUP-10-2032,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"UHC [10700]","United Healthcare",,55.07,63.3,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 32MM 5MM CORONARY STENT PLATINUM",SUP-H7493926032500,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1103.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT BTCP CLLGN 1.2ML VITOSS FOAM PACK BIOACTIVE",SUP-2102-1601,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 TWINFIX ULTRA ULTRABRAID NDL COBRAID",SUP-72202616,CDM,C1713,HCPCS,0278,RC,,,both,,,2039.63,611.89,"BLUE CROSS [10001]","Blue Cross HMO",,799.53,39.2,,957.42,156.86,7483.26,51,237.21,1733.69,"percent of total billed charges",
"COIL EMBOLIZATION 13.9CM 7MM CEREPAK MICRO UNIFORM",SUP-FCX100713,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3785.24,28.62,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KETOROLAC 0.5 % EYE DROPS",RX-19733,CDM,,,0250,RC,61314-0126-05,NDC,both,5,ML,530.67,159.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,243.58,45.9,,,,,0,61.72,451.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12-15IN 28FR VENOUS ADULT 3/8IN CNCT 1 STAGE",SUP-68128,CDM,S27200284,LOCAL,0272,RC,,,both,,,340.62,102.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,231.62,68,,,,,0,39.61,289.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM X25 LOCK LOW PROFILE STERILE",SUP-04.045.334S,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"KAISER [10500]",Kaiser,,1252.83,67,,,,,0,217.47,1589.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 20CM 5FR .035",SUP-M006192120090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"KAISER [10500]",Kaiser,,999.93,67,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GALLIUM-67 CITRATE INTRAVENOUS SOLUTION (2-3 MCI)",RX-411842,CDM,A9556,HCPCS,0343,RC,08888-8877-93,NDC,both,1,UN,404.00,121.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,274.72,68,,,,,0,0.03,343.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 10MM RIGHT BICRUCIATE STABILIZED XLPE",SUP-74027232,CDM,C1776,HCPCS,0278,RC,,,both,,,20478.15,6143.44,"UHC [10700]","United Healthcare",,12962.67,63.3,,8601.07,8395.67,8601.07,"1 through 10",2381.61,17406.43,"percent of total billed charges",
"GWIRE SENSOR UROLOGICAL 150CM 3CM .038IN NITINOL STAINLESS",SUP-M0066703101,CDM,C1769,HCPCS,0272,RC,,,both,,,355.45,106.63,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TYSHAK NUCLEUS 100CM 4CM 9FR 25MM BALLOON DILATATION",SUP-612114,CDM,C1725,HCPCS,0272,RC,,,both,,,5345.43,1603.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 14IN 22FR VENOUS 3/8IN RIGHT ANGLE 1 STAGE",SUP-69322,CDM,S27200284,LOCAL,0272,RC,,,both,,,369.61,110.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP ELECTROSURGICAL 8.25INX1.5MM OLSEN BIPOLAR BAYONET",SUP-20-0431R,CDM,S27200284,LOCAL,0272,RC,,,both,,,843.15,252.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,387.01,45.9,,,,,0,98.06,716.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 24MM 47MM 46MM SHOULDER COMPREHENSIVE",SUP-113046,CDM,C1776,HCPCS,0278,RC,,,both,,,9089.00,2726.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3735.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",1057.05,7725.65,"percent of total billed charges",
"SHELL ACETABULAR 58MM HIP 5 SCR HOLE CLUSTER METAL HA",SUP-502-11-58F,CDM,C1776,HCPCS,0278,RC,,,both,,,9525.45,2857.63,"MULTIPLAN [10600]",Multiplan,,8096.63,85,,,,,0,1107.81,8096.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION|DISCARDED DRUG NOT ADMINISTE",RX-123700,CDM,J3010,HCPCS,0636,RC,08888-8879-66,NDC,both,100,ML,422.80,126.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,JW,50.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.1,359.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 142MM 30MM 25-27MM 20FR ZENITH TX2",SUP-G47445,CDM,C1874,HCPCS,0278,RC,,,both,,,98041.65,29412.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11617.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11402.24,83335.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +23 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.230,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC MEDIUM 7IN 6.75-7.5IN LEFT WRIST D RING",SUP-A611LM,CDM,S27000186,LOCAL,0270,RC,,,both,,,136.16,40.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,92.59,68,,,,,0,15.84,115.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLIER INTERNAL CLIP 5MM ENDOSCOPIC HEM-O-LOK 5MM",SUP-544965,CDM,S27200284,LOCAL,0272,RC,,,both,,,16387.50,4916.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1941.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1905.87,13929.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +29 DIOPTER BICONVEX 13MM 6MM POSTERIOR CHMBR",SUP-MA60AC.290,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 220CM 10.5-12MM OTSC 6MM NITINOL",SUP-100.3,CDM,C1760,HCPCS,0272,RC,,,both,,,4133.10,1239.93,"UHC [10700]","United Healthcare",,2616.25,63.3,,,,,0,1698.7,2616.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 110MM 4MM STRAIGHTSHOT M4 TRICUT INFERIOR",SUP-1884004HR,CDM,S27200284,LOCAL,0272,RC,,,both,,,2097.00,629.1,"PHCS [10601]",PHCS,,1467.9,70,,,,,0,243.88,1782.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION 130CM 2.4FR .035IN MICRO SWAN INFUSION NITINOL",SUP-M001195300,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.3MM ICONIX XBRAID 2 STRAND INTELLIBRAID TAPE",SUP-3910500322,CDM,C1713,HCPCS,0278,RC,,,both,,,2797.50,839.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1284.05,45.9,,,,,0,325.35,2377.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 30MM RSP P2 STERILE",SUP-508-32-204,CDM,C1776,HCPCS,0278,RC,,,both,,,9442.80,2832.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1118.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1098.2,8026.38,"percent of total billed charges",
"HC Cardiac Rehab WO Ecg Ea Sesn",PX-943000002,CDM,93797,CPT,0943,RC,,,both,,,389.00,116.7,"KAISER [10500]",Kaiser,,260.63,67,,,,,0,45.24,356,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 24FR CUT OLYMPUS OES",SUP-M0068802331,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,55.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR EXTRICATION PURPLE 1.75IN PROCARE LOW FLAT CONTOUR",SUP-79-83028,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.12,17.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,26.68,45.9,,,,,0,6.76,49.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 44-41MM COMPREHENSIVE +3MM STD SHOULDER E1",SUP-EP-115397,CDM,C1776,HCPCS,0278,RC,,,both,,,8854.00,2656.2,"MULTIPLAN [10600]",Multiplan,,7525.9,85,,,,,0,1029.72,7525.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PS MEDICAL C14-24CM 2O 84CM 20GA 14GA CATH BARIUM",SUP-44410,CDM,S27800098,LOCAL,0278,RC,,,both,,,6045.57,1813.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,703.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,703.1,5138.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1.5MM .0108IN AXIUM PRIME HELICAL",SUP-APB-1.5-1-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"FIRST HEALTH [10303]","First Health",,7148.4,80,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP UNIPOLAR HEAD AND ADAPTER",SUP-OSC365963,CDM,C1776,HCPCS,0278,RC,,,both,,,3750.00,1125,"NOVANET [10819]",Novanet,,2812.5,75,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5N KNEE LEFT POSTERIOR STABILIZE LEGION",SUP-71421265,CDM,C1776,HCPCS,0278,RC,,,both,,,32536.35,9760.9,"CIGNA [10200]","Cigna Open Access",,10899.68,33.5,,5302.19,4377.88,6578.61,27,3783.98,27655.9,"percent of total billed charges",
"COIL EMBOLIZATION 8IN 3IN FREEFORM MINI",SUP-MCR093080,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"KAISER [10500]",Kaiser,,8861.32,67,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 46MM LCP STAINLESS STEEL T25 CONDYLAR",SUP-02.231.246,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"CIGNA [10200]","Cigna Open Access",,744.16,56.9,,1144.80,304.56,2275.09,66,152.1,1111.66,"percent of total billed charges",
"HC NM Lymph Node Img",PX-341000010,CDM,78195,CPT,0341,RC,,,both,,,2177.92,653.38,"BLUE CROSS [10001]","Blue Cross HMO",,891.3,,"Fee schedule rate ($891.30).",,,,0,253.29,1851.23,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13175540,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.2MM IFUSE IMPL SYSTEM SACROILIAC PUSH",SUP-500090,CDM,S27000186,LOCAL,0270,RC,,,both,,,3326.40,997.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,394.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,386.86,2827.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GUIDERIGHT VASCULAR J 180CM 3CM .032IN SUPER STIFF",SUP-404560,CDM,C1769,HCPCS,0272,RC,,,both,,,174.00,52.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 8MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710408,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"AETNA [10100]","Aetna HMO/PPO",,11760.91,79.5,,10981.53,8986.79,12413.38,12,1720.5,12574.56,"percent of total billed charges",
"KIT CATH BIOFLO DURAMAX VASCPAK ENDEXO 2 VALVE ADULT 28CM",SUP-H787103028195,CDM,C1750,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,396.9,39.2,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CARTO 3 THERMOCOOL SF 7.5FR J-J CURVE ELECTROPHYSIOLOGY",SUP-BNI35JJCT,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"AETNA [10100]","Aetna HMO/PPO",,14359.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR .071IN JUDKINS RIGHT 4.5 CURVE GUIDING",SUP-LA6JR45SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUTTLE ACCU-PASS CRESCENT 1 HANDED DESIGN 1 MONOFILAMENT",SUP-7210427,CDM,S27200284,LOCAL,0272,RC,,,both,,,1129.95,338.98,"CIGNA [10200]","Cigna Local Plus",,604.52,53.5,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 46MM CATHCART BALL HIP FEMUR ORTHOCHROME",SUP-136346000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,5311.50,4717.44,5388.59,31,434.96,3179,"percent of total billed charges",
"CATH TRUE DILATATION 110CM 4.5CM 12FR 24MM BALLOON",SUP-0244512,CDM,C1725,HCPCS,0272,RC,,,both,,,7590.00,2277,"KAISER [10500]",Kaiser,,5085.3,67,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE KORE FIBER CORTICAL BONE FIBER 10CC ALLOGRAFT",SUP-423210,CDM,C1713,HCPCS,0278,RC,,,both,,,14296.80,4289.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3860.14,27,,,,,0,1662.72,12152.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 25MM 7MM BIOSURE",SUP-72202263,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 33MMX1MM TITANIUM 2/2.3MM SCR 6 HOLE APTUS",SUP-A-4650.03,CDM,S27200284,LOCAL,0272,RC,,,both,,,5313.00,1593.9,"MULTIPLAN [10600]",Multiplan,,4516.05,85,,,,,0,617.9,4516.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 15MM KNEE POSTERIOR STABILIZE HIGH",SUP-71421518,CDM,C1776,HCPCS,0278,RC,,,both,,,10774.35,3232.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7326.56,68,,,,,0,1253.06,9158.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 155CM 8MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200084020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALVIMOPAN 12 MG CAPSULE",RX-91870,CDM,,,0637,RC,00591-2312-45,NDC,both,1,UN,783.59,235.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,359.67,45.9,,,,,0,91.13,666.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM VARIAX TORX TITANIUM FULL THREAD T10",SUP-40-35012,CDM,C1713,HCPCS,0278,RC,,,both,,,612.36,183.71,"BLUE CROSS [10001]","Blue Cross PPO",,240.05,39.2,,957.42,570.23,957.42,28,71.22,520.51,"percent of total billed charges",
"BAND ANNULOPLASTY 77MM 39.8MM 31MM DURAN ANCORE 33.8MM 2",SUP-620BG31,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3752.08,28.62,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 16MM TARGET 360D 2XL DETACHABLE",SUP-M0036181650,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 20MM 8MM KNEE FASTTHREAD",SUP-AR-4020C-08,CDM,C1713,HCPCS,0278,RC,,,both,,,2323.13,696.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1066.32,45.9,,,,,0,270.18,1974.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 9MM APTUS TITANIUM 6MM HEAD HAND CORTICAL LOCK",SUP-A-5400.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"NOVANET [10819]",Novanet,,947.7,75,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 19MM 29MM 26.3MM EPIC TISSUE STENT REDEFINE",SUP-E200-29M,CDM,S27800098,LOCAL,0278,RC,,,both,,,26775.00,8032.5,"UHC [10700]","United Healthcare",,16948.58,63.3,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH HEARTSPAN MR0 CURVE 81CM 8.5FR GUIDING PEBAX STEEL",SUP-FCB8581MR0,CDM,C1894,HCPCS,0272,RC,,,both,,,1432.08,429.62,"FIRST HEALTH [10303]","First Health",,1145.66,80,,,,,0,166.55,1217.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC",269,MS-DRG,,,,,,,inpatient,,,220739.83,66221.95,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC",825,MS-DRG,,,,,,,inpatient,,,94664.25,28399.27,"AETNA [10100]","Aetna HMO/PPO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER UNIVERSAL QC T6",SUP-DRVR-UQC-T6,CDM,S27000186,LOCAL,0270,RC,,,both,,,907.20,272.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,372.86,41.1,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL LARGE KNEE RIGHT LCS COMPLETE POROCOAT",SUP-129403060,CDM,C1776,HCPCS,0278,RC,,,both,,,28683.90,8605.17,"BLUE CROSS [10001]","Blue Cross PPO",,11244.09,39.2,,3949.44,3949.44,3949.44,"1 through 10",3335.94,24381.32,"percent of total billed charges",
"HC Cath Infusion Dual Luman Elite",PX-E27200291,CDM,C1751,HCPCS,0272,RC,,,both,,,12888.70,3866.61,"FIRST HEALTH [10303]","First Health",,10310.96,80,,,,,0,1498.96,10955.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOR SKIN DISORDERS WITH MCC",606,MS-DRG,,,,,,,inpatient,,,37704.84,11311.45,"CIGNA [10200]","Cigna Local Plus",,15614.71,,"Fee schedule rate ($15,614.71). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,37704.84,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 CP-2 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP762D,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.96,47.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.25,133.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 92CM 1MM 6FR 2MM SPACE D CURVE",SUP-D610DR002RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"MULTIPLAN [10600]",Multiplan,,3168.38,85,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II MULTIPASS 3-0 PS-1 18IN MONOFILAMENT UNDYED",SUP-Z683G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE CAST PEDIATRIC CANVAS RUBBER ROCKER SOLE HOOK LOOP CLSR",SUP-2035-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.41,13.62,"AETNA [10100]","Aetna HMO/PPO",,36.1,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.28,38.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOQUE TRICUSPID VALVE REPLACEMENT SYSTEM (52 MM VALVE)",SUP-EVQ1A2US52,CDM,S27800098,LOCAL,0278,RC,,,both,,,245100.00,73530,"PHCS [10601]",PHCS,,171570,70,,,,,0,28505.13,208335,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 2 OFFSET DOME 8.5MM CEMENT UNITY KNEE",SUP-112.018.46,CDM,C1776,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHASIX UMBILICAL LARGE CIRCLE W/ STRAP (8.0CM)",SUP-1230009,CDM,C1781,HCPCS,0278,RC,,,both,,,12144.00,3643.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4991.18,41.1,,,,,0,1412.35,10322.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 20MM 2.25MM BALLOON DILATATION PACLITAXEL",SUP-H7493960820220,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,17856.25,45.9,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1-2 11MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71934432,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"UHC [10700]","United Healthcare",,7704.62,63.3,,8601.07,8395.67,8601.07,"1 through 10",1415.56,10345.86,"percent of total billed charges",
"NAIL INTRAMEDULLARY L400MM DIA12MM LEFT FEMORAL GREATER TROC",SUP-04.033.271S,CDM,C1713,HCPCS,0278,RC,,,both,,,12217.14,3665.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3298.63,27,,,,,0,1420.85,10384.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC",918,MS-DRG,,,,,,,inpatient,,,19632.20,5889.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,13665.37,,,,,,,5316.64,19632.2,"case rate",
"6.0MM X 13MM TECNIS EYHANCE TORIC II INTRAOCULAR LENS, 1-PIE",SUP-DIU150U205,CDM,V2787,HCPCS,0276,RC,,,both,,,445.00,133.5,"KAISER [10500]",Kaiser,,298.15,67,,,,,0,51.75,378.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAA - AMPLATZ CARDIAC PLUG 2-IDE-034",SUP-9-ACP2-IDE-034,CDM,S62400003,LOCAL,0624,RC,,,both,,,63452.40,19035.72,"CIGNA [10200]","Cigna Local Plus",,33947.03,53.5,,,,,0,7379.51,53934.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 20CM 7FR .035IN URETERAL",SUP-M006155240090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,625.5,45.9,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 2-0 GS-22 9IN CLSR ABSORBABLE VIOLET",SUP-VLOCM2145,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"UHC [10700]","United Healthcare",,123.97,63.3,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE MONOPOLAR L7MM WORKING L1.8MM STANDARD TYPE SB KNIFE",SUP-MD-47706,CDM,S27200284,LOCAL,0272,RC,,,both,,,5706.02,1711.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2345.17,41.1,,,,,0,663.61,4850.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM 7MM S-ROM ZTT 16F LARGE HIP POROUS",SUP-550516,CDM,C1776,HCPCS,0278,RC,,,both,,,6466.32,1939.9,"NOVANET [10819]",Novanet,,4849.74,75,,,,,0,752.03,5496.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM TARGET 3D DETACHABLE CONSISTENT",SUP-M0036153060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MANTA 18FR CLSR VASCULAR",SUP-2115,CDM,C1760,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"MULTIPLAN [10600]",Multiplan,,3155.63,85,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM PRIMARY CEMENT DISTAL BULLET TIP SYNERGY",SUP-71316217,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5740.88,27,,,,,0,2472.83,18073.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lymphocyte Transformation",PX-302000077,CDM,86353,CPT,0302,RC,,,both,,,1470.60,441.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,52.47,,"Fee schedule rate ($52.47). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1250.01,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 40CM 140CM 4MM CORONARY STERILE LATEX",SUP-453978,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X20X8MM PIVOX 0D LATERAL OLIF25",SUP-2110150,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"AETNA [10100]","Aetna HMO/PPO",,21035.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 95MM 28MM AFX VELA ENDOVASCULAR STRATA AORTIC",SUP-A28-28/C95-O20V,CDM,C1874,HCPCS,0278,RC,,,both,,,35406.00,10621.8,"PHCS [10601]",PHCS,,24784.2,70,,,,,0,4117.72,30095.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRAVASTATIN 40 MG TABLET",RX-11112,CDM,,,0637,RC,50268-0667-11,NDC,both,1,UN,21.60,6.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.51,18.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX13MM FRA 8D LORDOTIC NARROW WEDGE",SUP-10013,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Oxydronate Up to 30mci",PX-343000037,CDM,A9561,HCPCS,0343,RC,,,both,,,180.00,54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,153,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X11MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7011,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1974.78,28.62,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP EASY LOAD DESIGN LOCK HANDLE SAFELY INSRT 3CM",SUP-KC-RUMI-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,133.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 45CM 14MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1445CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"BLUE CROSS [10001]","Blue Cross PPO",,2840.04,39.2,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 18MM LCP STAINLESS STEEL SMALL BONE T6",SUP-201.888,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"CIGNA [10200]","Cigna Open Access",,401.34,56.9,,1144.80,304.56,2275.09,66,82.03,599.55,"percent of total billed charges",
"CATHETER URETERAL LASER 3 FR 115CM",SUP-G15020,CDM,C1758,HCPCS,0272,RC,,,both,,,119.19,35.76,"UHC [10700]","United Healthcare",,75.45,63.3,,,,,0,13.86,101.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 95MM 25MM AFX VELA STRATA AORTIC EXT AAA STERILE",SUP-A25-25/C95V,CDM,C1874,HCPCS,0278,RC,,,both,,,35406.00,10621.8,"AETNA [10100]","Aetna HMO/PPO",,28147.77,79.5,,,,,0,4117.72,30095.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOBILIZER KNEE WRAP EZ",SUP-01259B22OP,CDM,L1830,HCPCS,0274,RC,,,both,,,232.81,69.84,"BLUE CROSS [10001]","Blue Cross PPO",,91.26,39.2,,,,,0,27.08,197.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 10MM ACUMED TITANIUM CORTICAL CLAVICLE",SUP-CO-2710,CDM,C1713,HCPCS,0278,RC,,,both,,,696.60,208.98,"KAISER [10500]",Kaiser,,466.72,67,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,inpatient,,,24404.56,7321.37,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,5290.57,,"Case rate ($4,944.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,591.27, add-ons for qualifying new technology services are included. If operating cost exceeds $37,630.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,729.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,597.34. The transfer operating threshold is the transfer adjustment factor * $4,591.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $347.12. The transfer capital threshold is the transfer adjustment factor * $347.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,4944.46,19878.88,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +28 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.280,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXS CATALYST 7 132CM .082-.0825IN .068IN ASPIRATION",SUP-IC068132,CDM,S27200284,LOCAL,0272,RC,,,both,,,13688.22,4106.47,"CIGNA [10200]",Cigna,,9307.99,68,,,,,0,1591.94,11634.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Graftjacket per Sq Cm",PX-E63600020,CDM,Q4107,HCPCS,0636,RC,,,both,,,445.50,133.65,"KAISER [10500]",Kaiser,,298.49,67,,,,,0,52.79,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM",RX-5754,CDM,,,0250,RC,45802-0880-14,NDC,both,15,GR,158.13,47.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.39,134.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 85MM 16MM STAINLESS STEEL ORTHOPEDIC CANNULATED",SUP-71127085,CDM,C1713,HCPCS,0278,RC,,,both,,,2479.50,743.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,293.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",288.37,2107.58,"percent of total billed charges",
"FRACTURES OF HIP AND PELVIS WITHOUT MCC",536,MS-DRG,,,,,,,inpatient,,,30392.55,9117.76,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,5360.26,,"Case rate ($5,009.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,651.75, add-ons for qualifying new technology services are included. If operating cost exceeds $37,691.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,733.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,657.90. The transfer operating threshold is the transfer adjustment factor * $4,651.75 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $351.69. The transfer capital threshold is the transfer adjustment factor * $351.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,5009.59,20140.74,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CM 6MM HEMODIALYSIS ACCESS VECTRA THK",SUP-T6050001,CDM,C1768,HCPCS,0278,RC,,,both,,,4684.26,1405.28,"MULTIPLAN [10600]",Multiplan,,3981.62,85,,,,,0,544.78,3981.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 167MM 16MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-116,CDM,C1776,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"FIRST HEALTH [10303]","First Health",,14016.24,80,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SPINAL 1.5IN 22GA STD SAFETY LUMBAR PUNCTURE PEDIATRIC",SUP-26-LP2SF,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.57,62.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.26,177.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR 45CM 14FR ACCESS URETERAL CONTINUOUS WORK",SUP-G46169,CDM,C1894,HCPCS,0272,RC,,,both,,,1244.97,373.49,"FIRST HEALTH [10303]","First Health",,995.98,80,,,,,0,144.79,1058.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE PIGTAIL CATHETER",SUP-4418,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enteroscopy W Tattoo(Ing) Submuc Inj",PX-750000248,CDM,44799,CPT,0750,RC,,,both,,,2809.93,842.98,"FIRST HEALTH [10303]","First Health",,2247.94,80,,,,,0,326.79,2809.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 60MM VIPER EXPEDIUM TITANIUM SPINE CORTICAL",SUP-186727660,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Cslt Cyt Ea",PX-312000077,CDM,0844T,CPT,0312,RC,,,both,,,104.00,31.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,47.74,45.9,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 ANGLE OVAL 9IN BRUNS SPINE SURGICAL",SUP-29-5392,CDM,S27200284,LOCAL,0272,RC,,,both,,,253.00,75.9,"KAISER [10500]",Kaiser,,169.51,67,,,,,0,29.42,215.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM .02IN 4MM PENUMBRA COIL 400 RUBY",SUP-RBY4C0406,CDM,S27800098,LOCAL,0278,RC,,,both,,,4158.00,1247.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,492.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,483.58,3534.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DTECT CARBON DIOXIDE END TIDAL COLORIMETRIC CNCT PORT LATEX",SUP-EASYCAPII,CDM,S27000186,LOCAL,0270,RC,,,both,,,82.22,24.67,"NOVANET [10819]",Novanet,,61.67,75,,,,,0,9.56,69.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTAZIDIME-AVIBACTAM 2.5 G/10ML IV (WET SOLR VIAL)",RX-415170282,CDM,J0714,HCPCS,0636,RC,00456-2700-01,NDC,both,1,UN,2507.14,752.14,"CIGNA [10200]","Cigna Open Access",,1126.09,,,,,,,297.1,2131.07,"fee schedule",
"HC Dilate Urethra Stricture Male",PX-450000379,CDM,53600,CPT,0450,RC,,,both,,,1173.46,352.04,"PHCS [10601]",PHCS,,821.42,70,,,,,0,1.17,1173.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ther Speech-Generating Device",PX-440000006,CDM,92609,CPT,0440,RC,,,both,,,330.99,99.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,330.99,,"Per diem ($426).",,,,0,38.49,330.99,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"PALIPERIDONE PALMITATE 117 MG/0.75 ML INTRAMUSCULAR SYRINGE",RX-108108,CDM,J2426,HCPCS,0636,RC,50458-0562-01,NDC,both,.75,ML,10771.54,3231.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2076.72,,"Fee schedule rate ($2,076.72). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1276.43,9155.81,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veno Ivc W Si",PX-320000131,CDM,75825,CPT,0320,RC,,,both,,,4758.69,1427.61,"CIGNA [10200]","Cigna Local Plus",,135.17,,,,,,,96.65,4758.69,"fee schedule",
"CATH INPACT ADMIRAL 130CM 40MM 5MM BALLOON DILATATION",SUP-ADM05004013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,956.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 5.00 X 16MM",SUP-H7493942816500,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Local Plus",,3322.35,53.5,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POLYETHYLENE GLYCOL 400  1 % EYE DROPS",RX-230680,CDM,,,0637,RC,74300-0010-67,NDC,both,15,ML,47.84,14.35,"MULTIPLAN [10600]",Multiplan,,40.66,85,,,,,0,5.56,40.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X13X1.19MM THK1.04MM STAINLESS STEEL SAGITTAL 2",SUP-4113-119-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,393.85,118.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.8,334.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatobiliary Sys Img",PX-341000017,CDM,78226,CPT,0341,RC,,,both,,,3290.63,987.19,"CIGNA [10200]",Cigna,,575.08,,,,,,,382.7,2797.04,"fee schedule",
"CATH DAWSON-MUELLER MAC-LOC INTRO-TIP 25CM 8.5FR DRNG",SUP-G09705,CDM,C1729,HCPCS,0272,RC,,,both,,,660.07,198.02,"UHC [10700]","United Healthcare",,417.82,63.3,,,,,0,76.77,561.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest Benign Skin Lesn >=15",PX-761000007,CDM,17111,CPT,0761,RC,,,both,,,2862.00,858.6,"CIGNA [10200]",Cigna,,2606,,"Per diem ($2,606).",,,,0,2.86,2606,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 50X27MM STD OSCILLATE ERGONOMIC LIGHTWEIGHT THK.6",SUP-519.100S,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"AETNA [10100]","Aetna HMO/PPO",,405.69,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC MICROFIBRILLAR CLLGN SPONGE AVITENE",SUP-1050030,CDM,S27200284,LOCAL,0272,RC,,,both,,,272.40,81.72,"UHC [10700]","United Healthcare",,172.43,63.3,,,,,0,31.68,231.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X6MM VERTE-STACK CORNERSTONE PSR 14MM",SUP-6278006,CDM,S27800098,LOCAL,0278,RC,,,both,,,5299.20,1589.76,"BLUE CROSS [10001]","Blue Cross HMO",,2077.29,39.2,,,,,0,616.3,4504.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 14MM 2 VELOUR STRAIGHT TUBE",SUP-M002020952140,CDM,C1768,HCPCS,0278,RC,,,both,,,3553.58,1066.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,413.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,413.28,3020.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veno Ext Bil Si",PX-320000130,CDM,75822,CPT,0320,RC,,,both,,,2582.46,774.74,"UHC [10700]","United Healthcare",,2582.46,,,,,,,102.91,2582.46,"fee schedule",
"HC Antithrombin III Ag",PX-305000031,CDM,85301,CPT,0305,RC,,,both,,,516.75,155.02,"CIGNA [10200]","Cigna Open Access",,23.78,,,,,,,0.01,439.24,"fee schedule",
"PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SUPERORDERABLE",RX-408803,CDM,J3430,HCPCS,0636,RC,76329-1240-01,NDC,both,.5,ML,226.52,67.96,"BLUE CROSS [10001]","Blue Cross HMO",,3.18,,,,,,,3.18,192.54,"fee schedule",
"STPLR INTERNAL CURVE TIP NONSTERILE LATEX FREE REUSABLE 12MM",SUP-470530,CDM,S27000186,LOCAL,0270,RC,,,both,,,1224.72,367.42,"AETNA [10100]","Aetna HMO/PPO",,973.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,142.43,1041.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 4 KNEE LEFT TOTAL STABILIZE",SUP-5542-A-401,CDM,C1776,HCPCS,0278,RC,,,both,,,5009.55,1502.86,"CIGNA [10200]","Cigna Open Access",,2850.43,56.9,,5302.19,4377.88,6578.61,27,582.61,4258.12,"percent of total billed charges",
"REFERENCE TOE 1ST MTP IMPLANT WITH GROMMETS  SIZE 2","SUP-M30 SE020",CDM,C1776,HCPCS,0278,RC,,,both,,,11937.00,3581.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3222.99,27,,,,,0,1388.27,10146.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grft a/T/L Add 25scm",PX-510000051,CDM,15272,CPT,0761,RC,,,both,,,344.00,103.2,"AETNA [10100]","Aetna HMO/PPO",,273.48,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.01,344,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 4MM MICRO CARBIDE OVAL STERILE",SUP-00509123600,CDM,S27200284,LOCAL,0272,RC,,,both,,,207.76,62.33,"CIGNA [10200]","Cigna Open Access",,118.22,56.9,,,,,0,24.16,176.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X21.1X1.1MM SAGITTAL",SUP-6221119090,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC CT Head/Brain WO Cntrst",PX-351000002,CDM,70450,CPT,0351,RC,,,both,,,2782.72,834.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($536.40). Procedures 2 - 999, Per diem ($268.20).",517.40,96.64,517.40,"1 through 10",,,"per diem",
"DISECT 7.5IN RHOTON LARGE STRAIGHT SPAT SURGICAL",SUP-58-6022,CDM,S27200284,LOCAL,0272,RC,,,both,,,524.07,157.22,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STEALTH 145CM 10MM .07IN 1.25MM .014IN ATHERECTOMY",SUP-PRD-SC30-125,CDM,C1724,HCPCS,0272,RC,,,both,,,21388.50,6416.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL VASCULAR",SUP-1009663,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT DRILL 2MM",SUP-DK-200C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1660.50,498.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT COVERA 30MM 80CM 8MM 8FR STRAIGHT VASCULAR",SUP-AVSM08030,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"FIRST HEALTH [10303]","First Health",,14616,80,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25MM THK1.27MM STAINLESS STEEL SAGITTAL 2 CUT",SUP-4125127090,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.02,114.61,"NOVANET [10819]",Novanet,,286.52,75,,,,,0,44.43,324.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM 12-14MM POD",SUP-RBYPOD14,CDM,S27800098,LOCAL,0278,RC,,,both,,,11661.00,3498.3,"AETNA [10100]","Aetna HMO/PPO",,9270.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1356.17,9911.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mgmt Diabetes Indv per 30min",PX-942000007,CDM,G0108,HCPCS,0942,RC,,,both,,,131.07,39.32,"AETNA [10100]","Aetna HMO/PPO",,104.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.24,131.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 26MMX8MMX15CM 20FR",SUP-TAC082615A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"CIGNA [10200]","Cigna Local Plus",,57456,31.5,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE -90D RIGHT 41MM STAINLESS STEEL 2.4MM SCR 2 HOLE HEAD",SUP-02.115.631S,CDM,C1713,HCPCS,0278,RC,,,both,,,4045.61,1213.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1856.93,45.9,,,,,0,470.5,3438.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26MM 8MM CAPSTONE PEEK INTERBODY",SUP-2990826,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"NOVANET [10819]",Novanet,,15919.2,75,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE LUNDERQUIST VASCULAR 5CM CURVE 300CM 4CM .035IN",SUP-G45408,CDM,C1769,HCPCS,0272,RC,,,both,,,874.80,262.44,"KAISER [10500]",Kaiser,,586.12,67,,,,,0,101.74,743.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 3MM SEPTAL SMOOTH TAPER NOSE PRELOAD FLAP",SUP-601-00100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1518.10,455.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,623.94,41.1,,,,,0,176.56,1290.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txcath Occl/Embl Cns",PX-361000251,CDM,61624,CPT,0361,RC,,,both,,,7574.38,2272.31,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6657,,"Case rate ($6,657). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,880.9,7574.38,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thyroid Stim Immunoglobin",PX-301000415,CDM,84445,CPT,0301,RC,,,both,,,275.60,82.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,234.26,"per diem",
"GRAFT SKIN READIGRAFT CRYOSKIN 154SQ CM FIBROBLAST",SUP-SK-F,CDM,Q4433,HCPCS,0636,RC,,,both,,,3360.30,1008.09,"AETNA [10100]","Aetna HMO/PPO",,2671.44,79.5,,,,,0,247.92,2856.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nonselct Plc Cath Thorac Aorta",PX-361000287,CDM,36221,CPT,0361,RC,,,both,,,7132.17,2139.65,"AETNA [10100]","Aetna HMO/PPO",,5670.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,829.47,7132.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 28MM LCP STAINLESS STEEL SHORT THREAD",SUP-207.628,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"MULTIPLAN [10600]",Multiplan,,884.03,85,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 27MM 22.5MM MASTERS 85D STD RING ANNULUS",SUP-27MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AETNA [10100]","Aetna HMO/PPO",,23149.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2.5 63X59MM KNEE LEFT CRUCIATE STABILIZE",SUP-96-0086,CDM,C1776,HCPCS,0278,RC,,,both,,,27588.96,8276.69,"MULTIPLAN [10600]",Multiplan,,23450.62,85,,,,,0,3208.6,23450.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 5MM KII FIOS FIRST ENTRY ADVANCE",SUP-CFF03,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 64MM 32MM MARATHON HIP",SUP-121932064,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"CIGNA [10200]",Cigna,,4919.56,68,,5873.17,5873.17,5873.17,"1 through 10",841.39,6149.45,"percent of total billed charges",
"AUG FEMORAL 12MM ATTUNE 5 KNEE DISTAL CEMENT REVISION",SUP-1547-05-003,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"KAISER [10500]",Kaiser,,4068.24,67,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 40MM 125CM 6MM 6FR VASCULAR PACLITAXEL",SUP-G24888,CDM,C1874,HCPCS,0278,RC,,,both,,,8107.50,2432.25,"NOVANET [10819]",Novanet,,6080.63,75,,,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP TOTAL SHOULDER ARTHROPLASTY",SUP-71701412,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"KAISER [10500]",Kaiser,,17939.25,67,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 18LP 15CM 8MM BALLOON DILATATION LOW PROFILE",SUP-G30974,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY HUMERAL SMR SHORT TITANIUM LOCKING SCR REVERSE REVISION",SUP-1352.15.005,CDM,C1776,HCPCS,0278,RC,,,both,,,7980.00,2394,"KAISER [10500]",Kaiser,,5346.6,67,,,,,0,928.07,6783,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEK 17 FEMORAL ARTERIAL CANNULA 17FR",SUP-5130-1717,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"KAISER [10500]",Kaiser,,596.97,67,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Gel Wound Normlgel Ag",PX-HHE27200408,CDM,HHE27200408,LOCAL,0272,RC,,,outpatient,,,41.00,12.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,18.82,45.9,,,,,0,4.77,34.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHORD-X 2-0 .5 CIRCLE 18MM 2 ARM LOOP PLEDG 3 CHORDAL 24",SUP-CXL-20-1812-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"UHC [10700]","United Healthcare",,2367.42,63.3,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,J1644,HCPCS,0636,RC,63323-0540-07,NDC,both,10,ML,19.40,5.82,"BLUE CROSS [10001]","Blue Cross PPO",,2.45,,,,,,,2.11,16.49,"fee schedule",
"ESPRIT BTK OTW 3.75 X 18 MM",SUP-1212375-18,CDM,C1874,HCPCS,0272,RC,,,both,,,17250.00,5175,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7089.75,41.1,,,,,0,7089.75,10919.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 30CM 13FR POWER-TRIALYSIS STRAIGHT 3 LUMEN SHORT",SUP-5605300,CDM,C1752,HCPCS,0272,RC,,,both,,,1614.33,484.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1097.74,68,,,,,0,187.75,1372.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 3D .6MM MID FACE 6X2 HOLE 1.7MM SCR BONE TITANIUM",SUP-55-06733,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.98,945.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,366.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",366.46,2678.33,"percent of total billed charges",
"GWIRE GLDEWIRE UROLOGICAL STRAIGHT 150CM 5CM .035IN NITINOL",SUP-UWS2035,CDM,C1769,HCPCS,0272,RC,,,both,,,436.70,131.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.79,371.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHOHEXITAL SODIUM 0.5 G/15ML IV (WET SOLR VIAL)",RX-41570545,CDM,,,0250,RC,42023-0105-01,NDC,both,1,UN,698.41,209.52,"AETNA [10100]","Aetna HMO/PPO",,555.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.23,593.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD 16FR URETHRAL NATURAL RUBBER SILICONE ELASTOMER 5",SUP-265716,CDM,S27200284,LOCAL,0272,RC,,,both,,,1.84,0.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1.25,68,,,,,0,0.21,1.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD SAFIO S 45 K",SUP-113588,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,260.3,68,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Biatain",PX-E27200106,CDM,E27200106,LOCAL,0272,RC,,,both,,,85.80,25.74,"CIGNA [10200]","Cigna Open Access",,48.82,56.9,,,,,0,9.98,72.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEMMED ANATOMIC PSI KIT (HUMERAL ONLY)",SUP-1235-7153-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"CIGNA [10200]","Cigna Local Plus",,3230.06,53.5,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 260MM 8MM",SUP-81B002,CDM,C1762,HCPCS,0278,RC,,,both,,,8852.70,2655.81,"KAISER [10500]",Kaiser,,5931.31,67,,,,,0,1029.57,7524.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 60MM 6FR 10MM .035IN LOW PROFILE BALLOON",SUP-B1100-060,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC STRAIGHT ROUND TIP MENISCECTOMY ACUFEX",SUP-010620,CDM,S27200284,LOCAL,0272,RC,,,both,,,381.83,114.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,259.64,68,,,,,0,44.41,324.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.5MM KIRSCHNER DARCO HEADED",SUP-NK112527,CDM,C1713,HCPCS,0278,RC,,,both,,,191.40,57.42,"KAISER [10500]",Kaiser,,128.24,67,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 65MM 1.2MM KIRSCHNER SMOOTH TROCAR TIP",SUP-XBR001002,CDM,C1713,HCPCS,0278,RC,,,both,,,918.54,275.56,"FIRST HEALTH [10303]","First Health",,734.83,80,,,,,0,106.83,780.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOTION SKIN COCOA BUTTER 7.25OZ MOISTURIZER PALMERS",SUP-69003,CDM,S27000186,LOCAL,0270,RC,,,both,,,94.57,28.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,64.31,68,,,,,0,11,80.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 12MM 2.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP2512X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X19MM 8D CONVEX LORDOTIC WEDGE",SUP-10619,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CIGNA [10200]",Cigna,,12600,40,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADMIRAL XTREME 130CM 200MM 6MM BALLOON DILATATION",SUP-ADM060200130,CDM,C1725,HCPCS,0272,RC,,,both,,,1781.25,534.37,"PHCS [10601]",PHCS,,1246.88,70,,,,,0,207.16,1514.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 3.5MM OASYS TITANIUM OCCIPITOCERVICOTHORACIC",SUP-48552070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MTRL STRAPPING PILE LOOP FABRIC NYLON TRICOT THK1/8IN STD 10",SUP-A8097,CDM,S27000186,LOCAL,0270,RC,,,both,,,168.61,50.58,"UHC [10700]","United Healthcare",,106.73,63.3,,,,,0,19.61,143.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 38MM SIMULUS ANNULUS POSTERIOR POLYESTER",SUP-800SC38,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Local Plus",,4129.65,31.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 170CM 7FR .035IN PUSHING GWIRE STERILE DISPOSABLE",SUP-G21774,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 59X53MM RIGHT KNEE TOTAL STABILIZED",SUP-5512-F-302,CDM,C1776,HCPCS,0278,RC,,,both,,,20599.49,6179.85,"UHC [10700]","United Healthcare",,13039.48,63.3,,8601.07,8395.67,8601.07,"1 through 10",2395.72,17509.57,"percent of total billed charges",
"STENT ONYX FRONTIER 26MM 2.25MM CORONARY RAPID EXCHANGE",SUP-ONYXNG22526UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1785,68,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM TAPER 28MM HIP COCR V40",SUP-6260-5-228,CDM,C1776,HCPCS,0278,RC,,,both,,,3461.25,1038.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,402.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,402.54,2942.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP 36X4IN THERAPEUTIC HOLDS THERAPEUTIC PACKS OR",SUP-294505,CDM,S27000186,LOCAL,0270,RC,,,both,,,117.22,35.17,"KAISER [10500]",Kaiser,,78.54,67,,,,,0,13.63,99.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG 26.2X21.2CM GRANUFOAM SENSATRAC TEGADERM SIMPLACE",SUP-M8275041/10.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,280.08,84.02,"NOVANET [10819]",Novanet,,210.06,75,,,,,0,32.57,238.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE FATHOM VASCULAR STRAIGHT 200CM 10CM .014IN PERIPHERAL",SUP-M001508100,CDM,C1769,HCPCS,0272,RC,,,both,,,1815.00,544.5,"PHCS [10601]",PHCS,,1270.5,70,,,,,0,211.08,1542.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 13MM KNEE POSTERIOR STABILIZED PRIMARY",SUP-5532P313,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"KAISER [10500]",Kaiser,,5598.45,67,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SIEGEL TAVR DELIVERY SYSTEM - HANDLE BALLOON CATHETER",SUP-30-1-0223,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN SL4 CURVE GUIDING CORONARY",SUP-LA7SL40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM TRIATHLON 7 RIGHT MEDIAL LEFT LATERAL TOTAL",SUP-5545-A-702,CDM,C1776,HCPCS,0278,RC,,,both,,,4327.60,1298.28,"NOVANET [10819]",Novanet,,3245.7,75,,,,,0,503.3,3678.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE SYNTHETIC CALCIUM SULFATE 25ML OSTEOSET RESORBABLE",SUP-84000311,CDM,C1713,HCPCS,0278,RC,,,both,,,9924.93,2977.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1176.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1154.27,8436.19,"percent of total billed charges",
"CAGE SPINAL 28X10X11MM COALESCE LORDOTIC STRAIGHT STERILE",SUP-2000-00-101108,CDM,C1889,HCPCS,0278,RC,,,both,,,21420.00,6426,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5783.4,27,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 64MM 40MM ALTRX HIP",SUP-122140164,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3950.55,28.62,,,,,0,1605.34,11732.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM LOW PROFILE SCREWS TITANIUM T15 FULL",SUP-AR-8935-24,CDM,C1713,HCPCS,0278,RC,,,both,,,486.00,145.8,"NOVANET [10819]",Novanet,,364.5,75,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 158MM STAINLESS STEEL 3.5MM SCR 6 HOLE LCP BONE LEFT",SUP-02.104.026,CDM,C1713,HCPCS,0278,RC,,,both,,,8557.10,2567.13,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2449.04,28.62,,,,,0,995.19,7273.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 150MM 5.4FR 4MM BALLOON DILATATION 2",SUP-BD-L40150CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.7,68,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN SL4 CURVE GUIDING CORONARY",SUP-LA7SL40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Influenza a/B/Ag Eia",PX-306000108,CDM,87400,CPT,0306,RC,,,both,,,279.00,83.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.28,.1,,,,,0,0.28,237.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 25MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE32525,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9914.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 RIGHT MEDIAL LEFT LATERAL PARTIAL KNEE",SUP-5610-F-202,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"PHCS [10601]",PHCS,,7001.47,70,,,,,0,1163.24,8501.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM PRESTIGE PLUS HELICAL HELICAL XTRA",SUP-PRES0204HXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Non-Indwelling Cath Strt",PX-450000271,CDM,51701,CPT,0361,RC,,,both,,,1404.45,421.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,166.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,163.34,1404.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 5FR HEADHUNTER 1 CURVE ANGIOGRAPHIC",SUP-H787107195035,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"PHCS [10601]",PHCS,,152.25,70,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN AMPLATZ RIGHT 2 CURVE",SUP-DXT5AR20,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,37.94,45.9,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Factor XII",PX-305000026,CDM,85280,CPT,0305,RC,,,both,,,529.00,158.7,"PHCS [10601]",PHCS,,370.3,70,,,,,0,0.01,449.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC25ST-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,19530.00,5859,"AETNA [10100]","Aetna HMO/PPO",,15526.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLODERM (RTU) 12CM X 16CM - THICK",SUP-15201216,CDM,Q4116,HCPCS,0636,RC,,,both,,,34731.90,10419.57,"CIGNA [10200]","Cigna Local Plus",,18581.57,53.5,,,,,0,247.92,29522.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 24CM 4.8FR URETERAL",SUP-M0061456070,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"CIGNA [10200]","Cigna Local Plus",,334.5,,,,,,,72.72,531.45,"percent of total billed charges",
"TRIAL KNEE 12.5MM PFC TC3 SIGMA 4 TIBIAL FIX BEARING INSERT",SUP-961541,CDM,C1776,HCPCS,0278,RC,,,both,,,676.35,202.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,193.57,28.62,,,,,0,78.66,574.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOPROSTHESIS STENT AORTOILIAC L39MM DIA6MM VIABAHN V",SUP-BXB063902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2268.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 12/14 OFFSET TAPER 44MM HIP M",SUP-136562000,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"CIGNA [10200]","Cigna Local Plus",,5926.7,53.5,,5372.07,4581.20,7242.98,23,1288.37,9416.26,"percent of total billed charges",
"CAGE SPINAL 34X24X14IN 12D BRIGADE",SUP-6951434,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"AETNA [10100]","Aetna HMO/PPO",,27249.1,79.5,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 22CM 7FR POLARIS ULTRA NAUTILUS ZIPWIRE .035IN 2",SUP-M006192141190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,640.41,45.9,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 52MM 32MM XLPE HIP STERILE",SUP-71339552,CDM,C1776,HCPCS,0278,RC,,,both,,,11457.45,3437.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3093.51,27,,,,,0,1332.5,9738.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 320MM VASCULAR TISSUE POWER ADVANCE PLACEMENT",SUP-PVE35A,CDM,S27200284,LOCAL,0272,RC,,,both,,,6740.84,2022.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,798.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,783.96,5729.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 21MM 54MM SOFT TISSUE BALANCE AEQUALIS ASCEND",SUP-DWG055,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"FIRST HEALTH [10303]","First Health",,6336,80,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VERTESSA LITE 22X10CM LIGHTWEIGHT",SUP-CAL-VL1022,CDM,C1781,HCPCS,0278,RC,,,both,,,5444.10,1633.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,645.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,633.15,4627.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP XLONG 125MM SURGICAL 2.7MM CORTEX AND 3.5MM TI SHAFT SCR",SUP-311.28,CDM,S27000186,LOCAL,0270,RC,,,both,,,1550.02,465.01,"KAISER [10500]",Kaiser,,1038.51,67,,,,,0,180.27,1317.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 100MM TITANIUM SHORT THREAD CANNULATED",SUP-04.353.700,CDM,C1713,HCPCS,0278,RC,,,both,,,2240.85,672.25,"PHCS [10601]",PHCS,,1568.6,70,,,,,0,260.61,1904.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 11MM 8.2MM 100MM TALON HIP DISTALFIX TECHNOLOGY LAG",SUP-SLN-011-100,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3378.24,68,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 28MM HIP BIOLOX DELTA V40",SUP-6570-0-128,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"NOVANET [10819]",Novanet,,7500,75,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 14MM APTUS TITANIUM 6MM HEAD HAND CORTICAL LOCK",SUP-A-5450.14/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA MEDIAL CONGRUENT 4-5 C-D KNEE",SUP-42522100310,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Local Plus",,5765.38,53.5,,5372.07,4581.20,7242.98,23,1253.3,9159.96,"percent of total billed charges",
"MEROPENEM 1 G VIAL",RX-17380,CDM,J2185,HCPCS,0636,RC,63323-0508-30,NDC,both,1,UN,53.45,16.03,"MULTIPLAN [10600]",Multiplan,,45.43,85,,,,,0,4.46,45.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esoph Flex Trnsoral Dil<30mm",PX-750000150,CDM,43220,CPT,0750,RC,,,both,,,4531.00,1359.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,536.92,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,526.96,4531,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Creatine Kinase Mb Fraction",PX-301000165,CDM,82553,CPT,0301,RC,,,both,,,306.80,92.04,"NOVANET [10819]",Novanet,,230.1,75,,,,,0,0.01,260.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 11MM 1 LEVEL SAPPHIRE BONE SPINE CERVICAL ANTERIOR",SUP-26001-011,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,488.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",488.46,3570,"percent of total billed charges",
"NDL BIOPSY 16GA 15GA 15CM TEMNO EVOLUTION 2 NOTCH COAXIAL",SUP-CTT1615,CDM,S27200284,LOCAL,0272,RC,,,both,,,439.91,131.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,180.8,41.1,,,,,0,51.16,373.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X12MM MODULUS 10D XL WIDE STERILE LATEX",SUP-1221250P2,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6415.2,27,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PLLA HA 25MM 10MM 1.5MM ACL PCL CANNULATED",SUP-7209016,CDM,C1713,HCPCS,0278,RC,,,both,,,1882.13,564.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,218.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",218.89,1599.81,"percent of total billed charges",
"SCR BONE 4.5MM 6.5MM 1.75MM 14MM TITANIUM FULL THREAD",SUP-414.814,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"BLUE CROSS [10001]","Blue Cross PPO",,107.91,39.2,,957.42,570.23,957.42,28,32.01,233.98,"percent of total billed charges",
"PICK SURGICAL 45D 4MM POWERPICK DRILL",SUP-AR-9100PP-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.01,257.7,"FIRST HEALTH [10303]","First Health",,687.21,80,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 1MM STAINLESS STEEL 1.5MM SCR 6 HOLE LOCK",SUP-02.130.250S,CDM,C1713,HCPCS,0278,RC,,,both,,,2862.30,858.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1313.8,45.9,,,,,0,332.89,2432.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 2.5MM CEREPAK FREEFORM DETACHABLE",SUP-SCR122505,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"MULTIPLAN [10600]",Multiplan,,11241.97,85,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW MARK SPRING TIP",SUP-CG-10-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"CIGNA [10200]",Cigna,,358.02,68,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 1 CT-1 45CM SUT ABSORBABLE",SUP-SXPP1A404,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"CIGNA [10200]","Cigna Open Access",,136.73,56.9,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE XL FEMALE SUEDE RUBBER BOTTOM WOOD SOLE",SUP-2007-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.43,23.23,"CIGNA [10200]","Cigna Open Access",,44.06,56.9,,,,,0,9.01,65.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 180CM 5CM 2.5CM RAPID EXCHANGE",SUP-M00510880,CDM,S27200284,LOCAL,0272,RC,,,both,,,2036.93,611.08,"KAISER [10500]",Kaiser,,1364.74,67,,,,,0,236.89,1731.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM CD HORIZON SPINAL FENESTRATE MULTIAXIAL",SUP-55840026545T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL STRAIGHT BIPOLAR TAPERED BLUNT POINT",SUP-221266,CDM,S27200284,LOCAL,0272,RC,,,both,,,566.25,169.87,"CIGNA [10200]","Cigna Local Plus",,302.94,53.5,,,,,0,65.85,481.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 28MM 10D C HIP X3 TRIDENT 6.9MM",SUP-623-10-28C,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,993.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,993.86,7263.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 3.9MM 32MM MULTILOC TITANIUM NIOBIUM ALUMINUM",SUP-04.019.032S,CDM,C1713,HCPCS,0278,RC,,,both,,,1747.20,524.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,207.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",203.2,1485.12,"percent of total billed charges",
"CANN PERFUSION 12-15IN 26FR 3/8IN VENOUS TAPER 1 STAGE 1",SUP-66126,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.63,85.69,"PHCS [10601]",PHCS,,199.94,70,,,,,0,33.22,242.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 64MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.064S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fo W/O Joints Cf",PX-E27400037,CDM,L3933,HCPCS,0274,RC,,,both,,,493.00,147.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,58.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.34,419.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION",RX-9748,CDM,J2597,HCPCS,0636,RC,43598-0931-11,NDC,both,1,ML,286.82,86.05,"MULTIPLAN [10600]",Multiplan,,243.8,85,,,,,0,16.41,243.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIVERSAL PIN 3.2MM 89MM 70.0MM","SUP-GP001.089.032 STE",CDM,S27200284,LOCAL,0272,RC,,,both,,,2242.50,672.75,"CIGNA [10200]",Cigna,,1524.9,68,,,,,0,260.8,1906.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VORICONAZOLE 200 MG VIAL",RX-33010,CDM,J3465,HCPCS,0636,RC,00049-3190-28,NDC,both,1,UN,455.15,136.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,29.2,,,,,,,17.95,386.88,"fee schedule",
"HC Admin Vacc Sngl",PX-771000001,CDM,90471,CPT,0771,RC,,,both,,,112.41,33.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,76.44,68,,,,,0,13.07,112.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 109MM 30MM 26-27MM 16FR ZENITH ALPHA",SUP-G35341,CDM,C1874,HCPCS,0278,RC,,,both,,,89041.07,26712.32,"BLUE CROSS [10001]","Blue Cross HMO",,34904.1,39.2,,9776.84,9776.84,9776.84,"1 through 10",10355.48,75684.91,"percent of total billed charges",
"SPACER SPINAL 55X18X8-15MM RISE-L 6D",SUP-193.325,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"AETNA [10100]","Aetna HMO/PPO",,27296.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TPAK 10 GAUGE DECOMPRESSION NEEDLE",SUP-TM-310,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.12,20.44,"PHCS [10601]",PHCS,,47.68,70,,,,,0,7.92,57.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 95MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.895,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,934.6,68,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT HUMERAL XSM L6IN UNIVERSAL DISTAL ELBOW TIVANIUM P",SUP-32810502706,CDM,C1776,HCPCS,0278,RC,,,both,,,34391.70,10317.51,"PHCS [10601]",PHCS,,24074.19,70,,,,,0,3999.75,29232.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 22CM 2MM BALLOON DILATATION",SUP-U8150222,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE LIGHT GREEN 66MM 5MM NAIL-EX FEMORAL TIBIAL",SUP-04.005.556,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"FIRST HEALTH [10303]","First Health",,925.34,80,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +28 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000280,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTEPLASE BOLUS FROM VIAL (100 MG VIAL)",RX-409108,CDM,J2997,HCPCS,0636,RC,50242-0085-25,NDC,both,1,UN,53118.96,15935.69,"MULTIPLAN [10600]",Multiplan,,45151.12,85,,,,,0,6294.6,45151.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URETEROSCOPE FLEXIBLE ASCOPE 5 URETERO REVERSE DEFLECTION",SUP-605101000,CDM,C1747,HCPCS,0272,RC,,,both,,,8581.88,2574.56,"CIGNA [10200]","Cigna Open Access",,4883.09,56.9,,,,,0,998.07,7294.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VERTESSA LITE 26X5CM 4CM LIGHTWEIGHT FLEXIBLE",SUP-CAL-VLY2654,CDM,C1781,HCPCS,0278,RC,,,both,,,6285.90,1885.77,"BLUE CROSS [10001]","Blue Cross PPO",,2464.07,39.2,,,,,0,731.05,5343.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 50MM TRANSITION HA SPINE PEDICLE POLYAXIAL",SUP-152.786S,CDM,C1713,HCPCS,0278,RC,,,both,,,10791.60,3237.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1255.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1255.06,9172.86,"percent of total billed charges",
"SCR BONE 3.5MM 22MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-22,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 15MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-104150,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"CIGNA [10200]",Cigna,,9681.34,40,,5873.17,5873.17,5873.17,"1 through 10",2814.85,20572.84,"percent of total billed charges",
"FRCP GRASPING 3 NAIL 3.25MM",SUP-WA63819A,CDM,S27200284,LOCAL,0272,RC,,,both,,,4657.91,1397.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,541.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,541.71,3959.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 NARROW KNEE LEFT CRUCIATE RETAINING PERSONA",SUP-42502206201,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3360.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE LP 29S",SUP-TENDV-LP-29S-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20263.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY 550CC HP SILCONE",SUP-RSZ-5504,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM LCP STAINLESS STEEL CORTICAL FOREFOOT",SUP-202.878,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"CIGNA [10200]",Cigna,,220.31,68,,1831.33,1831.33,1831.33,16,37.68,275.39,"percent of total billed charges",
"FREEFIX PROXIMAL HUMERUS PLATE 1 SLOT RIGHT TI",SUP-PHPF-1R,CDM,C1713,HCPCS,0278,RC,,,both,,,15732.00,4719.6,"NOVANET [10819]",Novanet,,11799,75,,,,,0,1829.63,13372.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONCIERGE 100CM 8FR AL.75 CURVE GUIDING STAINLESS STEEL",SUP-CGC8100AL75,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"UHC [10700]","United Healthcare",,282,63.3,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 2 TP-1 60IN MONOFILAMENT BROWN ABSORBABLE",SUP-GL31G,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.72,24.82,"KAISER [10500]",Kaiser,,55.42,67,,,,,0,9.62,70.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 20CM PUMP SET",SUP-ES2820,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"NOVANET [10819]",Novanet,,47025,75,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 18MM CORE THK.51MM 30MM INTRAORAL CRESCENTIC",SUP-5400-031-417,CDM,S27200284,LOCAL,0272,RC,,,both,,,865.57,259.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,102.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,100.67,735.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZENITH 120MM 36MM 20-30MM 16MM 6FR VASCULAR AORTIC",SUP-G47492,CDM,C1876,HCPCS,0278,RC,,,both,,,87438.00,26231.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,35937.02,41.1,,,,,0,10169.04,74322.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 4.5MM BROAD 296MM STAINLESS STEEL 4.5MM SCREWS LARGE",SUP-226.661,CDM,C1713,HCPCS,0278,RC,,,both,,,5067.64,1520.29,"BLUE CROSS [10001]","Blue Cross PPO",,1986.51,39.2,,957.42,570.23,957.42,28,589.37,4307.49,"percent of total billed charges",
"BEARING 79/83MMX12MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183662,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"CIGNA [10200]",Cigna,,5275.46,40,,5873.17,5873.17,5873.17,"1 through 10",1533.84,11210.36,"percent of total billed charges",
"NUT EXTERNAL FIXATION HEX MRI SAFE NONSTERILE",SUP-03.311.061.10,CDM,S27800098,LOCAL,0278,RC,,,both,,,66.83,20.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,19.13,28.62,,,,,0,7.77,56.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cognitive Trn 1st 15 Min (Go)",PX-430000052,CDM,97129,CPT,0430,RC,,,both,,,173.48,52.04,"CIGNA [10200]","Cigna Open Access",,173.48,,"Per diem ($309).",,,,0,20.18,173.48,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR OPTISEAL",SUP-7441,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ATLAS 75CM 2CM 7FR 14MM BALLOON DILATATION SHAFT",SUP-AT75142,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CPS DIRECT SL II SITEMARK 50.7CM 47CM 9FR 7FR XWIDE",SUP-DS2C005,CDM,C1887,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ERCP TAPER TANDEM RX 195CM 7-5.5FR BILIARY STERILE",SUP-M00545820,CDM,S27200284,LOCAL,0272,RC,,,both,,,483.89,145.17,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MAJOR CRANIAL OR FACIAL BONE PROCEDURES,MINOR",089,APR-DRG,,,,,,,inpatient,,,127894.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $13,093.77. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($54,244.64) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 35MM DELIVERY SYSTEM WATCHMAN FLX",SUP-M635WU50350,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRUSH CYTOLOGY 3MM 1.8MM 160CM 3 RING HANDLE BRISTLE CATH",SUP-60314,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.41,38.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ALCOHOLIC LIVER DISEASE,MAJOR",280,APR-DRG,,,,,,,inpatient,,,33269.71,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 250MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020250S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 9.5IN RICHARDSON 1.5IN STD HANDLE SURGICAL 1.5IN",SUP-23-4503,CDM,S27200284,LOCAL,0272,RC,,,both,,,115.71,34.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COVER BURR HOLE 13.5MM SPINE BENT",SUP-19-1019,CDM,C1713,HCPCS,0278,RC,,,both,,,1987.50,596.25,"NOVANET [10819]",Novanet,,1490.63,75,,,,,0,231.15,1689.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM 3.5MM 2.1-2.7FR CORONARY",SUP-RONYX35026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"NOVANET [10819]",Novanet,,2531.25,75,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 20MM 135CM 7MM .018IN BILIARY STAINLESS",SUP-G56630,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"PHCS [10601]",PHCS,,3528,70,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mopath Procedure Level 7",PX-309000099,CDM,81406,CPT,0310,RC,,,both,,,6574.95,1972.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,779.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,5588.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 8MM MREYE 2 LOOP PLATINUM ARTERIAL",SUP-G42423,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"CIGNA [10200]","Cigna Open Access",,474.67,56.9,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 8-11 G-H KNEE RIGHT TIBIA FIX",SUP-42522100911,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UHC [10700]","United Healthcare",,6821.47,63.3,,8601.07,8395.67,8601.07,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"HC App Intracav Rad Smpl",PX-333000048,CDM,77761,CPT,0333,RC,,,both,,,3441.55,1032.46,"UHC [10700]","United Healthcare",,3441.55,,"Per diem ($4,991).",,,,0,400.25,3441.55,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla Class I High Def Qual",PX-302000218,CDM,86832,CPT,0302,RC,,,both,,,1024.40,307.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,509.26,,,,,,,1.02,930.91,"fee schedule",
"HC Mopath Procedure Level 1",PX-309000093,CDM,81400,CPT,0310,RC,,,both,,,1109.85,332.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,68.45,,"Fee schedule rate ($68.45). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,943.37,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Td Vaccine No Prsrv >/= 7 Im",PX-771000017,CDM,90714,CPT,0636,RC,,,both,,,99.03,29.71,"FIRST HEALTH [10303]","First Health",,79.22,80,,,,,0,11.97,99.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 7MMX79MM 7FR 80CMCATH HEPARIN",SUP-BXB077901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"BLUE CROSS [10001]","Blue Cross HMO",,8391.7,39.2,,9776.84,9776.84,9776.84,"1 through 10",2489.68,18196.29,"percent of total billed charges",
"GRAFT HUMAN TISSUE L150MM DIA4-5.5MM SEMITENDINOSUS FROZEN R",SUP-FROPE,CDM,S27800098,LOCAL,0278,RC,,,both,,,6128.93,1838.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4167.67,68,,,,,0,712.79,5209.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ADAPTER SYRINGE PURASTAT",SUP-001-099,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 80CM 8MM 9FR STRAIGHT VASCULAR",SUP-AVSM08100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UHC [10700]","United Healthcare",,11564.91,63.3,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIPHERAL CUTTING BALLOON 90CM 20MM 8MM BALLOON",SUP-PCB802090,CDM,C1725,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"FIRST HEALTH [10303]","First Health",,3726,80,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 50X40X.25MM RECTANGLE POLYDIOXANONE PDS FACE",SUP-ZFP5,CDM,S27800098,LOCAL,0278,RC,,,both,,,2242.50,672.75,"CIGNA [10200]","Cigna Local Plus",,1199.74,53.5,,,,,0,260.8,1906.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 9.8X8.7IN SELF ADHERENT WATERPROOF STERILE MEPILEX",SUP-282455,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.95,22.48,"FIRST HEALTH [10303]","First Health",,59.96,80,,,,,0,8.72,63.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM EVEREST SPINE CANNULATED POLYAXIAL MIS",SUP-M5111-05535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 9MM THK.43MM 10MM MICRO SMALL BONE SAGITTAL",SUP-KM3-101,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.65,24.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.38,68.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Tum Loc Plnr 2areas 1 Day",PX-341000077,CDM,78801,CPT,0341,RC,,,both,,,1657.19,497.16,"BLUE CROSS [10001]","Blue Cross PPO",,717.34,,"Fee schedule rate ($717.34).",,,,0,192.73,1408.61,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMB LINER 53/54/55MM 26MM MULTIPOLAR HIP UHMWPE STERILE",SUP-500105326,CDM,C1776,HCPCS,0278,RC,,,both,,,2365.50,709.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,280.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,275.11,2010.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 28MM 145CM 2.5MM CORONARY STENT",SUP-1145250-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAVER BLADES STRAIGHT SHAFT 3MM SINGLE SERRATED STERILE",SUP-1600541-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP 2 - SPECIALTY",SUP-CAP-DJO-H-2,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"NOVANET [10819]",Novanet,,18427.5,75,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4.3MM QUADCUT STRAIGHTSHOT M4",SUP-1884380EM,CDM,S27200284,LOCAL,0272,RC,,,both,,,3510.00,1053,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2386.8,68,,,,,0,408.21,2983.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +10 DIOPTER MODIFIED C CONVEXOPLANO 13.5MM 5.5MM",SUP-MTA5U0.100,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER 13.5MM 4MM SPIKE LC-DCP ORTHOPEDIC STAINLESS STEEL",SUP-219.941,CDM,C1713,HCPCS,0278,RC,,,both,,,752.98,225.89,"KAISER [10500]",Kaiser,,504.5,67,,,,,0,87.57,640.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 47MM 28MM TANDEM ACETABULUM UHMWPE COCR",SUP-71322047,CDM,C1776,HCPCS,0278,RC,,,both,,,7003.50,2101.05,"BLUE CROSS [10001]","Blue Cross HMO",,2745.37,39.2,,5311.50,4717.44,5388.59,31,814.51,5952.98,"percent of total billed charges",
"IMMOB ORTHOPEDIC STD 16IN 25- IN KNEE ADJUSTABLE 3 PANEL",SUP-VP40105-010,CDM,L1830,HCPCS,0274,RC,,,both,,,160.08,48.02,"KAISER [10500]",Kaiser,,107.25,67,,,,,0,18.62,136.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 130MM 5MM STERLING OVAL LARGE HUB BURR REDUCED",SUP-H9103RH,CDM,S27200284,LOCAL,0272,RC,,,both,,,564.25,169.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,258.99,45.9,,,,,0,65.62,479.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 17.5MM 5MM BASE TITANIUM VARIABLE ANGLE",SUP-6955172,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,463.64,28.62,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULE ANALZR BD VERITOR PLUS",SUP-256066,CDM,S27000186,LOCAL,0270,RC,,,both,,,1846.28,553.88,"NOVANET [10819]",Novanet,,1384.71,75,,,,,0,214.72,1569.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION 9.6FR 10FR 1.6MM TITANIUM SILICONE",SUP-CT96STSD,CDM,C1788,HCPCS,0278,RC,,,both,,,2505.00,751.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,291.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,291.33,2129.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.185 CLAREON",SUP-SY60WF.185,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULE ANALZR BD VERITOR PLUS",SUP-256066,CDM,S27000186,LOCAL,0270,RC,,,both,,,1846.28,553.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,218.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,214.72,1569.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intro GI Tube Long",PX-361000173,CDM,44500,CPT,0361,RC,,,both,,,2973.36,892.01,"CIGNA [10200]",Cigna,,2497,,"Case rate ($2,497). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,345.8,2973.36,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis a Ab",PX-302000148,CDM,86708,CPT,0302,RC,,,both,,,228.00,68.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.23,.1,,,,,0,0.23,193.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 20MM 75CM 5MM VASCULAR METAL SUPERFICIAL",SUP-H74939293050270,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,572.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SURGICAL 10.7X8.7IN SPRING OPEN BIORESORBABLE SELF",SUP-5950080,CDM,C1781,HCPCS,0278,RC,,,both,,,6930.00,2079,"KAISER [10500]",Kaiser,,4643.1,67,,,,,0,805.96,5890.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM 12/14 TAPER 32MM HIP OXINIUM ECHELON",SUP-71343203,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"BLUE CROSS [10001]","Blue Cross PPO",,6089.86,39.2,,3949.44,3949.44,3949.44,"1 through 10",1806.76,13205.05,"percent of total billed charges",
"KIT TKR 14MM ITOTAL IPOLY XE POSTERIOR STABILIZE INSRT",SUP-RPS0201400,CDM,C1776,HCPCS,0278,RC,,,both,,,6254.85,1876.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,727.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,727.44,5316.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 5FR FEMORAL LEFT 4 CURVE ANGIOGRAPHIC",SUP-H74908526222,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 7MM MICRUSFRAME 10 COIL",SUP-MFR100730,CDM,S27800098,LOCAL,0278,RC,,,both,,,16974.00,5092.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4857.96,28.62,,,,,0,1974.08,14427.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUINTON CURL CATH 57CM DIALYSIS PERITONEAL 1 CUFF",SUP-8811313014,CDM,C1750,HCPCS,0278,RC,,,both,,,550.15,165.04,"KAISER [10500]",Kaiser,,368.6,67,,,,,0,63.98,467.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Flecainide",PX-301000067,CDM,80299,CPT,0301,RC,,,both,,,219.00,65.7,"NOVANET [10819]",Novanet,,164.25,75,,,,,0,0.01,186.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 20MM 3.0MM .014IN BALLOON DILATATION",SUP-AB14W030150150,CDM,C1725,HCPCS,0272,RC,,,both,,,1577.48,473.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,186.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.46,1340.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMP ST/CNV GLD/STD HD/INS",SUP-98B00900121,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"NOVANET [10819]",Novanet,,20081.25,75,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 170MM FEMORAL PROXIMAL TFN-ADVANCED LATERAL RELIEF",SUP-04.037.112S,CDM,C1713,HCPCS,0278,RC,,,both,,,8273.93,2482.18,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2368,28.62,,,,,0,962.26,7032.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER C304S5906 SELECTSITE GLOBAL",SUP-C304S5906,CDM,C1887,HCPCS,0272,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR NEVRO IMPLANATABLE PULSE GENRTR STERILE",SUP-ACCK7100,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"KAISER [10500]",Kaiser,,407.03,67,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enteroscopy Retro Through Rectum",PX-750000245,CDM,44799,CPT,0750,RC,,,both,,,3746.37,1123.91,"MULTIPLAN [10600]",Multiplan,,3184.41,85,,,,,0,435.7,3746.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 4-0 P-2 18IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Z504G,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.37,23.51,"FIRST HEALTH [10303]","First Health",,62.7,80,,,,,0,9.11,66.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEMOSTAR XK AIRGUARD 28CM 23CM 16FR STRAIGHT",SUP-5883730,CDM,C1750,HCPCS,0278,RC,,,both,,,1563.30,468.99,"CIGNA [10200]","Cigna Local Plus",,836.37,53.5,,,,,0,181.81,1328.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRD SURGICAL 5MM 5MM ROTO-CAM",SUP-625129,CDM,S27000186,LOCAL,0270,RC,,,both,,,4716.50,1414.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2164.87,45.9,,,,,0,548.53,4009.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grad Compression Waist 18-20",PX-E27100015,CDM,A6539,HCPCS,0292,RC,,,both,,,336.60,100.98,"PHCS [10601]",PHCS,,235.62,70,,,,,0,39.15,286.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM POLYSTYRENE SULFONATE 15 GRAM ORAL POWDER",RX-7356,CDM,,,0250,RC,10702-0036-15,NDC,both,15,GR,85.01,25.5,"FIRST HEALTH [10303]","First Health",,68.01,80,,,,,0,9.89,72.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 24CM 14.5FR STD POLYURETHANE PTFE HEMOSTAR AIRGUARD",SUP-5835190,CDM,C1750,HCPCS,0278,RC,,,both,,,1563.30,468.99,"BLUE CROSS [10001]","Blue Cross PPO",,612.81,39.2,,,,,0,181.81,1328.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAPE 2MM 17IN BRAID STRAIGHT NDL BLUE NONABSORBABLE",SUP-AR-7237-17LN,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYOSURE LITE REMOVAL TISSUE BLADE HYSTEROSCOPIC",SUP-30-401LITE,CDM,S27200284,LOCAL,0272,RC,,,both,,,3852.50,1155.75,"NOVANET [10819]",Novanet,,2889.38,75,,,,,0,448.05,3274.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 30CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175255180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA [10200]",Cigna,,992.87,68,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR .09IN JUDKINS LEFT 3.5 CURVE GUIDING",SUP-LA8JL35SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 120MM 20MM VASCULAR NITINOL VENOUS ILIOFEMORAL",SUP-AB9U20120090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2962.17,28.62,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 330944 ACSR 9X14X14 SRVC FEE",SUP-330944,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 0D 4.8MM MULTIFIRE ENDO HERNIA TITANIUM STERILE",SUP-174007,CDM,S27200284,LOCAL,0272,RC,,,both,,,388.11,116.43,"PHCS [10601]",PHCS,,271.68,70,,,,,0,45.14,329.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE 12MM SPINE TISSUE",SUP-331241,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 2.75X15MM",SUP-PRV027515CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 7CM 8.5FR DUODENAL BEND BILIARY",SUP-M00534270,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"NOVANET [10819]",Novanet,,817.09,75,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ELECTROSURGICAL 1.5MM ORISE",SUP-M00519351,CDM,S27200284,LOCAL,0272,RC,,,both,,,5863.28,1758.98,"PHCS [10601]",PHCS,,4104.3,70,,,,,0,681.9,4983.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM TITANIUM T15 FULL THREAD HEXALOBE",SUP-AR-8935-32,CDM,C1713,HCPCS,0278,RC,,,both,,,486.00,145.8,"BLUE CROSS [10001]","Blue Cross PPO",,190.51,39.2,,957.42,570.23,957.42,28,56.52,413.1,"percent of total billed charges",
"TISSUE 330944 ACSR 9X14X14 SRVC FEE",SUP-330944,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AIR/WATER DEFENDO BUTTON KIT SUCTION CLEAN BIOPSY",SUP-100305,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.07,15.92,"UHC [10700]","United Healthcare",,33.59,63.3,,,,,0,6.17,45.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 3.5MM LORDOSIS TITANIUM",SUP-102063070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"DEVICE V-LOC 90 SURGALLOY 3-0 P-14 18IN CLSR ABSORBABLE",SUP-VLOCM0124,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.73,70.42,"UHC [10700]","United Healthcare",,148.58,63.3,,,,,0,27.3,199.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 6 KNEE LEFT BICRUCIATE STABILIZE",SUP-74022226,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"CIGNA [10200]",Cigna,,6648.84,40,,5873.17,5873.17,5873.17,"1 through 10",1933.15,14128.79,"percent of total billed charges",
"GRAFT BONE CORNERSTONE 12MM SPINE TISSUE",SUP-331241,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tubing Press Monitor Sep",PX-E27200272,CDM,E27200272,LOCAL,0272,RC,,,both,,,414.70,124.41,"CIGNA [10200]",Cigna,,282,68,,,,,0,48.23,352.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 330944 ACSR 9X14X14 SRVC FEE",SUP-330944,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 13GA 3IN BONE MARROW",SUP-RBN-133,CDM,S27200284,LOCAL,0272,RC,,,both,,,400.20,120.06,"UHC [10700]","United Healthcare",,253.33,63.3,,,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BD NEXIVA MAXZERO 1IN 20GA IV NDL FREE CNCT 1 PORT",SUP-383556,CDM,S27200284,LOCAL,0272,RC,,,both,,,45.15,13.54,"CIGNA [10200]","Cigna Local Plus",,24.16,53.5,,,,,0,5.25,38.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE 20CM 8FR DRNG DIL",SUP-K12-08322,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 4X60 40CM SL",SUP-48004006P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EVERCROSS CROSSTEC 135CM 60MM 4MM .035IN BALLOON",SUP-AB35W04060135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 7FR .081IN AL1 CURVE GUIDING CORONARY",SUP-LA7AL10SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 3.3MM SUT GUIDE STERILE",SUP-8757,CDM,S27200284,LOCAL,0272,RC,,,both,,,1058.02,317.41,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,125.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,123.05,899.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 4 HIP",SUP-PRTLE024,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE SELF DRILLING RIGID 4MM 14MM ASSURE TITANIUM",SUP-110.014,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"BLUE CROSS [10001]","Blue Cross PPO",,552.72,39.2,,957.42,570.23,957.42,28,163.98,1198.5,"percent of total billed charges",
"STENT WALLSTENT RX 80MM 194CM 10MM 8FR TAPER ENDOPROSTHESIS",SUP-M00569720,CDM,S27500001,LOCAL,0275,RC,,,both,,,11537.01,3461.1,"MULTIPLAN [10600]",Multiplan,,9806.46,85,,,,,0,1341.75,9806.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO2 VASCULAR 215CM .014IN HYDROPHILIC SELECT SPRT",SUP-SSUP215PRE,CDM,C1769,HCPCS,0272,RC,,,both,,,4186.64,1255.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1720.71,41.1,,,,,0,486.91,3558.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 5 % AND 0.45 % NACL IV BOLUS",RX-400295,CDM,,,0258,RC,00338-0085-04,NDC,both,1000,ML,100.65,30.19,"CIGNA [10200]",Cigna,,68.44,68,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 350CC",SUP-SMPX350,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"KAISER [10500]",Kaiser,,4992.84,67,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 201MM 32MM 28-29MM ZENITH ALPHA FLEXOR",SUP-G35348,CDM,C1874,HCPCS,0278,RC,,,both,,,96672.00,29001.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11455.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11242.95,82171.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Hypogastric Plexus",PX-761000051,CDM,64517,CPT,0761,RC,,,both,,,5968.00,1790.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,707.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,694.08,5968,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN 20GA 10CM CURVE MONOPOLAR ACTIVE TIP ELECTROTHERAPY",SUP-0406630125,CDM,S27200284,LOCAL,0272,RC,,,both,,,1914.23,574.27,"NOVANET [10819]",Novanet,,1435.67,75,,,,,0,222.62,1627.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABIL 8CM 200CM 10MM ENDOPROSTHESIS NO HOLE",SUP-VSWVN1008,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"BLUE CROSS [10001]","Blue Cross PPO",,3944.3,39.2,,,,,0,1083.33,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 45CM .013IN SFT KNOB",SUP-6047,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,170.52,39.2,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 8MM 3.75MM BALLOON DILATATION DURATRAC",SUP-NCEUP37508X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 90CM 150MM 3MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186301590,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 8FR .038IN LARGE REGULAR PIGTAIL CURVE URETERAL",SUP-M001274030,CDM,C2617,HCPCS,0278,RC,,,both,,,1053.00,315.9,"CIGNA [10200]","Cigna Local Plus",,563.36,,,,,,,122.46,895.05,"percent of total billed charges",
"HC Insertion Perm Ccm-D System Pulse Generator Only",PX-481000411,CDM,0916T,CPT,0481,RC,,,both,,,34567.00,10370.1,"BLUE CROSS [10001]","Blue Cross PPO",,11835.63,,"Case rate ($11,835.63). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,4020.14,34567,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Leukocyte Histamine Release",PX-302000234,CDM,86343,CPT,0302,RC,,,both,,,227.05,68.11,"NOVANET [10819]",Novanet,,170.29,75,,,,,0,0.01,192.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1170.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1083.33,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cystine Quant Urine",PX-301000101,CDM,82131,CPT,0301,RC,,,both,,,379.48,113.84,"BLUE CROSS [10001]","Blue Cross PPO",,29.36,,"Fee schedule rate ($29.36).",,,,0,0.01,322.56,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE RIB FREEZE DRIED WHOLE",SUP-51A001,CDM,S27800098,LOCAL,0278,RC,,,both,,,2092.50,627.75,"PHCS [10601]",PHCS,,1464.75,70,,,,,0,243.36,1778.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFARI2 EXTRA SPRT VASCULAR LARGE CURVE 275X4.9X5CM",SUP-H74939598ESL0,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,,,0637,RC,68084-0313-11,NDC,both,1,UN,7.14,2.14,"FIRST HEALTH [10303]","First Health",,5.71,80,,,,,0,0.83,6.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 18CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175199190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]","Cigna Open Access",,720,,,,,,,147.16,1075.57,"percent of total billed charges",
"PLATE NARROW 160MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-224.59,CDM,C1713,HCPCS,0278,RC,,,both,,,3324.60,997.38,"KAISER [10500]",Kaiser,,2227.48,67,,,,,0,386.65,2825.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW 7975525 SOVEREIGN FA 5.5 X 25MM",SUP-7975525,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"CIGNA [10200]","Cigna Local Plus",,1572.9,53.5,,3978.14,359.25,3978.14,24,341.92,2499,"percent of total billed charges",
"STENT CONTOUR ZIPWIRE 20CM 150CM 8FR .038IN STD PIGTAIL",SUP-M006180240170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR EXTRICATION PURPLE 1.75IN PROCARE LOW FLAT CONTOUR",SUP-79-83028,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.12,17.44,"PHCS [10601]",PHCS,,40.68,70,,,,,0,6.76,49.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 24FR CUT OLYMPUS OES",SUP-M0068802331,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,56.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 30MM 140CM 2.25MM CORONARY STERILE",SUP-453961,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 10CM 6FR 7MM .035IN BALLOON",SUP-G52355,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2MM 26MM FOSSA RADIUS DISTAL VOLAR SMOOTH LOCK",SUP-SPLS-20260-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,639.90,191.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,74.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",74.42,543.92,"percent of total billed charges",
"CATH LAUNCHER 100CM 6FR SL4 CURVE GUIDING CORONARY SIDEHOLE",SUP-LA6SL40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE SP 37L",SUP-TENDV-SP-37L-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20263.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TANDEM II DUO ANCHOR SYSTEM",SUP-PN0610,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,inpatient,,,114760.44,34428.13,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,14047.82,,"Case rate ($13,638.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,664.43, add-ons for qualifying new technology services are included. If operating cost exceeds $45,704.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,339.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,681.18. The transfer operating threshold is the transfer adjustment factor * $12,664.43 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.49. The transfer capital threshold is the transfer adjustment factor * $957.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.",,,,0,7561,64193.25,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR KNEE FEMUR PATELLA TIBIA CEMENT STD",SUP-98000200168,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"NOVANET [10819]",Novanet,,16537.5,75,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT WALLFLEX 40MM 194CM 10MM",SUP-7089,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"KAISER [10500]",Kaiser,,298.49,67,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 45CM 11MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1145CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"BLUE CROSS [10001]","Blue Cross PPO",,2840.04,39.2,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 75MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355075,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 100MM 4MM BALLOON",SUP-LX1813041004F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"FIRST HEALTH [10303]","First Health",,5382,80,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 300MM 150MM 2.8MM STAINLESS STEEL CALIBRATE",SUP-292.81,CDM,C1769,HCPCS,0272,RC,,,both,,,552.10,165.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,64.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.21,469.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 49MM 28MM 18FR ENDURANT II ABDOMINAL",SUP-ETCF2828C49E,CDM,C1876,HCPCS,0278,RC,,,both,,,26932.50,8079.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3191.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3132.25,22892.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC",330,MS-DRG,,,,,,,inpatient,,,92120.58,27636.17,"PHCS [10601]",PHCS,,7561,,,,,,,7561,69988.65,"per diem","Estimated amount calculated based on 8 day length of stay."
"CAGE SPINAL 25X9X15MM CONCORDE 10D THORACOLUMBAR CFRP INLINE",SUP-187855215,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA [10200]","Cigna Open Access",,5547.6,33.5,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMINO ACID 4.25 % NO.1 IN DEXTROSE 5 % INTRAVENOUS SOLUTION",RX-27927,CDM,J3490,HCPCS,0258,RC,00338-1133-03,NDC,both,1000,ML,231.38,69.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,112.45,48.6,,,,,0,26.91,196.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 7MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0720CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"NOVANET [10819]",Novanet,,4916.25,75,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR STD 34MM 3 PEG KNEE SERIES A",SUP-184766,CDM,C1776,HCPCS,0278,RC,,,both,,,4824.48,1447.34,"AETNA [10100]","Aetna HMO/PPO",,3835.46,79.5,,10981.53,8986.79,12413.38,12,561.09,4100.81,"percent of total billed charges",
"ANCHOR SUT 3.5MM PUSHLOCK BIOCOMPOSITE 19.5MM STERILE",SUP-AR-1926BC,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.00,945,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,901.53,28.62,,,,,0,366.35,2677.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Voriconazole",PX-301000626,CDM,80285,CPT,0301,RC,,,both,,,314.93,94.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.48,,"Fee schedule rate ($25.48). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,267.69,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75446560,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 80MM 130CM 7MM VASCULAR METAL SUPERFICIAL",SUP-H74939293078030,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"PHCS [10601]",PHCS,,3381,70,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 31MM MASTER-SERIES PYROLYTIC CARBON PTFE",SUP-31AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"FIRST HEALTH [10303]","First Health",,23295.38,80,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X20MM BENGAL 12MM STD LORDOTIC THORACOLUMBAR",SUP-177306120,CDM,S27800098,LOCAL,0278,RC,,,both,,,15950.04,4785.01,"BLUE CROSS [10001]","Blue Cross HMO",,6252.42,39.2,,,,,0,1854.99,13557.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL FOERSTER CURVE 7IN SERRATE SPONGE",SUP-19-5118,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.19,36.96,"AETNA [10100]","Aetna HMO/PPO",,97.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.33,104.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 11X11X7MM CORNERSTONE PSR PEEK LUMBAR",SUP-6276711,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA [10200]","Cigna Local Plus",,3572.95,53.5,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 6MM 18MM TITANIUM FULL THREAD CANCELLOUS SMALL",SUP-406.018,CDM,C1713,HCPCS,0278,RC,,,both,,,294.76,88.43,"CIGNA [10200]",Cigna,,200.44,68,,1831.33,1831.33,1831.33,16,34.28,250.55,"percent of total billed charges",
"CATH EXPO 100CM 5FR .045IN FULL LENGTH MULTIPURPOSE A 2",SUP-8526121,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"MULTIPLAN [10600]",Multiplan,,60.27,85,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 6FT THERMOCOOL SF 3.5MM POROUS TIP",SUP-C5MHNAVMHS,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"CIGNA [10200]","Cigna Local Plus",,1801.61,53.5,,,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REDUC LAPAROSCOPIC ENDOPATH ONESEAL 5-12MM UNIVERSAL STERILE",SUP-1SEAL,CDM,S27200284,LOCAL,0272,RC,,,both,,,540.45,162.13,"KAISER [10500]",Kaiser,,362.1,67,,,,,0,62.85,459.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE COMPRESSION MEDIUM KNEE LENGTH KENDALL SCD EXPRESS",SUP-9529,CDM,S27000186,LOCAL,0270,RC,,,both,,,100.00,30,"CIGNA [10200]","Cigna Open Access",,56.9,56.9,,,,,0,11.63,85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 240MM 4MM 110D PREBENT TITANIUM",SUP-04.615.632,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 28CM 6FR URETERAL",SUP-M0061456150,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,178.94,28.62,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txcath Plc Stent Init Vein",PX-361000325,CDM,37238,CPT,0361,RC,,,both,,,16222.38,4866.71,"NOVANET [10819]",Novanet,,12166.79,75,,,,,0,1886.66,13789.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309113,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15104.88,40,,,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 15MM 21MM BIOCOR FLEXFIT LOW PROFILE SUPRA",SUP-BSP100-21,CDM,S27800098,LOCAL,0278,RC,,,both,,,32715.90,9814.77,"CIGNA [10200]","Cigna Open Access",,10959.83,33.5,,,,,0,3804.86,27808.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 340MM FEMORAL EXPERT INTRAMEDULLARY CANNULATED",SUP-04.013.448S,CDM,C1713,HCPCS,0278,RC,,,both,,,8319.74,2495.92,"CIGNA [10200]","Cigna Local Plus",,4451.06,53.5,,3978.14,359.25,3978.14,24,967.59,7071.78,"percent of total billed charges",
"CATH NC TREK NEO 145CM 15MM 3MM BALLOON DILATATION PEBAX",SUP-1400300-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ather/De Stnt Sngl Cor Art/Br",PX-481000080,CDM,C9602,HCPCS,0481,RC,,,both,,,27922.64,8376.79,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,17669,,"Case rate ($17,669). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3247.4,25681,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION DEB 2.75X40",SUP-SCA14U-275040D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLOTRIMAZOLE 1 % TOPICAL CREAM",RX-1767,CDM,,,0250,RC,45802-0434-11,NDC,both,30,GR,53.97,16.19,"MULTIPLAN [10600]",Multiplan,,45.87,85,,,,,0,6.28,45.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183562,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5323.55,41.1,,6417.48,6417.48,6417.48,"1 through 10",1506.4,11009.78,"percent of total billed charges",
"TENDYNE MITRAL VALVE SP 39S",SUP-TENDV-SP-39S-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"FIRST HEALTH [10303]","First Health",,136800,80,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rotavirus Ag Eia",PX-306000110,CDM,87425,CPT,0306,RC,,,both,,,247.00,74.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,42.56,,,,,,,0.01,209.95,"fee schedule",
"SET INTRO 13CM 8FR CHECK-FLO PERFORMER SIDEARM FITTING SIDE",SUP-G07432,CDM,C1894,HCPCS,0272,RC,,,both,,,139.90,41.97,"NOVANET [10819]",Novanet,,104.93,75,,,,,0,16.27,118.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 65MM 9.4MM 5MM CUFF INNER CANN SMOOTH OBTR INTEGRAL",SUP-4LPC,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 420MM HIP RIGHT FEMUR AFFIXUS INTRAMEDULLARY 125D",SUP-814311420,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"BLUE CROSS [10001]","Blue Cross HMO",,8131.16,39.2,,957.42,156.86,7483.26,51,2412.38,17631.34,"percent of total billed charges",
"FRCP SURGICAL PETIT-POINT MIXTER ANGLE RIGHT 5.25IN GALL",SUP-140218,CDM,S27000186,LOCAL,0270,RC,,,both,,,265.00,79.5,"AETNA [10100]","Aetna HMO/PPO",,210.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.82,225.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.75MM X 15.0MM",SUP-492751512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 15.5FR 1 VALVE CAP SAFETY SCPL FRCP PERITONEAL CATH",SUP-50-9000C,CDM,C1729,HCPCS,0272,RC,,,both,,,5085.30,1525.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2090.06,41.1,,,,,0,591.42,4322.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM VARIAX NONSTERILE",SUP-657412,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,371.19,45.9,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 10.25IN CARB-BITE RYDER INSRT NDL STAINLESS STEEL",SUP-121165,CDM,S27200284,LOCAL,0272,RC,,,both,,,626.45,187.93,"MULTIPLAN [10600]",Multiplan,,532.48,85,,,,,0,72.86,532.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL STRAIGHT SELF CENTERING FORTIFY I",SUP-676.704,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"UHC [10700]","United Healthcare",,2504.4,63.3,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METER DRNG BARD EZ-LOK URETERAL URINE ADPTR 400ML ACCEPTS",SUP-001531,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.43,20.83,"NOVANET [10819]",Novanet,,52.07,75,,,,,0,8.07,59.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 90X3.5MM DST SERIES TA TITANIUM ENDOSCOPIC",SUP-TA9035L,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.47,98.24,"CIGNA [10200]","Cigna Local Plus",,175.2,53.5,,,,,0,38.08,278.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC SMOOTH CUTTER BITE STRYKER STERILE LATEX",SUP-475333000,CDM,S27200284,LOCAL,0272,RC,,,both,,,752.77,225.83,"AETNA [10100]","Aetna HMO/PPO",,598.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.55,639.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE CONNECT FLEX VASCULAR 300CM .018IN DURASTEEL",SUP-1012592,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"NOVANET [10819]",Novanet,,722.93,75,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL",RX-230392,CDM,,,0250,RC,10310-0283-13,NDC,both,11.9,GR,32.94,9.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.83,28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cpk Isoenzymes",PX-301000164,CDM,82552,CPT,0301,RC,,,both,,,80.75,24.22,"AETNA [10100]","Aetna HMO/PPO",,64.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,68.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MEIER VASCULAR 185CM 15CM .035IN STAINLESS STEEL PTFE",SUP-SCH-30600,CDM,C1769,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3.5MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN03506,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4818.19,41.1,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AMPLATZ 17CM 16FR ACCESS PTFE RENAL FIRM TAPER TIP",SUP-M0062601460,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,38.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 19MM HELIX R SPINE SELF TAP FIX ANGLE",SUP-7804219,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,117.75,860.63,"percent of total billed charges",
"SUT SILK PERMA-HAND 2 MH 30IN BRAID BLACK NONABSORBABLE",SUP-K846H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 90D 5.5MM TSRH-3D OPEN OFFSET TITANIUM POSTERIOR",SUP-8379124,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]",Cigna,,2422.5,68,,1831.33,1831.33,1831.33,16,414.32,3028.13,"percent of total billed charges",
"F/G WINGSPAN STENT SYSTEM  4.0 X 20MM",SUP-M003WS0400200,CDM,C1874,HCPCS,0278,RC,,,both,,,51979.47,15593.84,"CIGNA [10200]",Cigna,,20791.79,40,,,,,0,6045.21,44182.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE STC-18 105CM 20CM 3-2.4FR .021IN MICRO GUIDING",SUP-M001181250,CDM,C1887,HCPCS,0272,RC,,,both,,,2287.50,686.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,271.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,266.04,1944.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 10MM 4MM STERILE",SUP-TR-S1004-S,CDM,C1776,HCPCS,0278,RC,,,both,,,15145.50,4543.65,"CIGNA [10200]","Cigna Local Plus",,4770.83,31.5,,5372.07,4581.20,7242.98,23,1761.42,12873.68,"percent of total billed charges",
"ROD SPINAL 480MM 6MM XIA 3 TITANIUM NONSTERILE",SUP-48233480,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"HOLDER 8.75IN RYDER RING HANDLE NDL TUNGSTEN CARBIDE",SUP-55-2664,CDM,S27200284,LOCAL,0272,RC,,,both,,,2123.25,636.97,"NOVANET [10819]",Novanet,,1592.44,75,,,,,0,246.93,1804.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 23MM 4.5MM AEQUALIS REVERSED GLENOID TITANIUM",SUP-VDV223,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 480MM 6MM XIA 3 TITANIUM NONSTERILE",SUP-48233480,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UROLOGICAL STRAIGHT 150CM 3CM .035IN PTFE STIFF BODY",SUP-M0066201100,CDM,C1769,HCPCS,0272,RC,,,both,,,100.40,30.12,"FIRST HEALTH [10303]","First Health",,80.32,80,,,,,0,11.68,85.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E XLPE FEMUR PATELLA TIBIA CE",SUP-98000200090,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"BLUE CROSS [10001]","Blue Cross PPO",,8890.56,39.2,,3949.44,3949.44,3949.44,"1 through 10",2637.68,19278,"percent of total billed charges",
"COIL EMBOLIZATION 1CM 1MM TARGET NANO HELICAL DETACHABLE",SUP-M0035431010,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1085.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 40 SMALL PEG AEQUALIS PERFORM CORTILOC",SUP-DWE403,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2666.24,28.62,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Chest W Cntrst",PX-610000013,CDM,71551,CPT,0610,RC,,,both,,,3865.00,1159.5,"CIGNA [10200]",Cigna,,955,,"Per diem ($955). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,449.5,3285.25,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Elec Dual",PX-480000012,CDM,33217,CPT,0481,RC,,,both,,,8966.11,2689.83,"PHCS [10601]",PHCS,,6276.28,70,,,,,0,1042.76,8966.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"22MM X 45MM X 15MM 12 LLIF CAGE POROUS COATED",SUP-P12245-215,CDM,S27800098,LOCAL,0278,RC,,,both,,,25200.00,7560,"MULTIPLAN [10600]",Multiplan,,21420,85,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST FIXATION 40MM 4.5MM LOW PROFILE KNEE BICORTICAL",SUP-AR-1365-40,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,98.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",98.91,722.93,"percent of total billed charges",
"GRAFT VASC AXLLBFMRL KNIT HEMSHLD MICROVEL 8MMX100X60CM",SUP-95589,CDM,C1768,HCPCS,0278,RC,,,both,,,4159.80,1247.94,"BLUE CROSS [10001]","Blue Cross HMO",,1630.64,39.2,,,,,0,483.78,3535.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPANDER TISSUE CPX4TABS 800ML",SUP-3549216,CDM,C1789,HCPCS,0278,RC,,,both,,,9694.50,2908.35,"BLUE CROSS [10001]","Blue Cross PPO",,3800.24,39.2,,16595.83,16595.83,16595.83,"1 through 10",1127.47,8240.33,"percent of total billed charges",
"STENT VIABAHN 10CM 120CM 6MM 6FR ENDOPROSTHESIS HEPARIN",SUP-VBJ061002,CDM,C1874,HCPCS,0278,RC,,,both,,,21218.40,6365.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2514.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2467.7,18035.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 90MM 230CM 22MM 10FR",SUP-M00565590,CDM,C1876,HCPCS,0278,RC,,,both,,,12152.97,3645.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1440.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1413.39,10330.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT THR VERSA-FX HIP VIVACIT-E CERAMIC POROUS CEMENT STE",SUP-98000100109,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6804,27,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 4MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG40008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"PHCS [10601]",PHCS,,1890,70,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Sel Opn Wnd<=20scm (Gp)",PX-420000032,CDM,97597,CPT,0420,RC,,,both,,,1190.27,357.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,141.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,138.43,1190.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC",614,MS-DRG,,,,,,,inpatient,,,119151.48,35745.44,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,29231.14,,"Case rate ($13,595.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,624.69, add-ons for qualifying new technology services are included. If operating cost exceeds $45,664.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,336.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $12,641.38. The transfer operating threshold is the transfer adjustment factor * $12,624.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $954.49. The transfer capital threshold is the transfer adjustment factor * $954.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,63991.79,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 150MM 3MM 4FR .014IN 6FR BALLOON",SUP-39186-30151,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 160MM 18-14MM 13FR 11FR TRIVASCULAR OVATION",SUP-TV-IL1418160-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CIGNA [10200]","Cigna Open Access",,11185.65,33.5,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DEBAKEY-DIETHRICH 7.75INX1.5MM CORONARY ARTERY",SUP-320-114,CDM,S27000186,LOCAL,0270,RC,,,both,,,447.36,134.21,"CIGNA [10200]","Cigna Open Access",,254.55,56.9,,,,,0,52.03,380.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM 51X16X2.5MM TITANIUM 3 LEVEL PREBENT SKYLINE BONE",SUP-186803051,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"AETNA [10100]","Aetna HMO/PPO",,4207.14,79.5,,1521.93,481.35,16760.95,30,615.46,4498.2,"percent of total billed charges",
"SYSTEM SYNERGY XD MONORAIL 38MM 144CM 4MM CORONARY STENT",SUP-H7493941838400,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,9776.84,9776.84,9776.84,"1 through 10",348.9,2550,"percent of total billed charges",
"TRAY CATH GREEN 24CM 12.5FR MAHURKAR ELITE DOUBLE-D LARGE",SUP-8888233324,CDM,C1752,HCPCS,0272,RC,,,both,,,995.43,298.63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,117.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,115.77,846.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 55MM 5MM KII Z THREAD SLEEVE LOW PROFILE",SUP-CTR23,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"PHCS [10601]",PHCS,,152.25,70,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH HIGH PROFILE XTRA 790CC",SUP-SHPX790,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,866.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL V MUELLER GERALD 7IN 1X2 TEETH DELICATE SATIN",SUP-NL1440,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.94,67.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.04,190.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTERIAL LINE 12CM 20GA",SUP-ASK-04510-HF,CDM,S27200284,LOCAL,0272,RC,,,both,,,260.13,78.04,"CIGNA [10200]","Cigna Open Access",,148.01,56.9,,,,,0,30.25,221.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 11.7X10CM BREAST 350ML SUT TAB STYLE 8200 9200",SUP-3548212,CDM,C1789,HCPCS,0278,RC,,,both,,,9694.50,2908.35,"MULTIPLAN [10600]",Multiplan,,8240.33,85,,,,,0,1127.47,8240.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOOP ENDOSCOPIC MONOPOLAR CABLE ESU CNCT LINA GOLD LOOP 240",SUP-EL-240-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,2981.25,894.37,"UHC [10700]","United Healthcare",,1887.13,63.3,,,,,0,346.72,2534.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY 10CM 10GA TREK BONE MARROW AUTOMATIC BRAKE",SUP-TKM1110,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"PHCS [10601]",PHCS,,1181.25,70,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 10MM INTERLOCK FIBERED IDC 18 COIL",SUP-M001361920,CDM,S27800098,LOCAL,0278,RC,,,both,,,4843.80,1453.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,563.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,563.33,4117.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM COROENT SMALL INTERLOCK SPINE SELF TAP",SUP-6791715,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]",Cigna,,688.5,68,,1831.33,1831.33,1831.33,16,117.75,860.63,"percent of total billed charges",
"SCR BONE 6.5MM 35MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16026535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 60MM LCP STAINLESS STEEL T25 MEDIAL PROXIMAL",SUP-212.221,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,101.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",101.55,742.2,"percent of total billed charges",
"PLATE BONE GOLD .6MM 4.1CM UNIVERSAL NEURO III SMALL ROUND",SUP-92-00692,CDM,C1713,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"CIGNA [10200]","Cigna Local Plus",,5540.94,53.5,,3978.14,359.25,3978.14,24,1204.51,8803.37,"percent of total billed charges",
"KIT CIRCUIT 480CM SET COAXIAL NONHEAT ELBOW ADPTR HAMILTON-C",SUP-260168,CDM,S27000186,LOCAL,0270,RC,,,both,,,522.98,156.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,61.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.82,444.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 330744 ACSR 7X14X14 SRVC FEE",SUP-330744,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 4FR 12FR CAMINO MICRO INTRACRANIAL",SUP-1104HM,CDM,C1751,HCPCS,0272,RC,,,both,,,5777.09,1733.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,671.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,671.88,4910.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE MARKER 4 X 4 BIOZORB",SUP-F0404,CDM,A4648,HCPCS,0278,RC,,,both,,,7935.00,2380.5,"PHCS [10601]",PHCS,,5554.5,70,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE RTRCTR 7 1/8INX60MM AUFRICHT NASAL",SUP-67-2136,CDM,S27200284,LOCAL,0272,RC,,,both,,,653.43,196.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,268.56,41.1,,,,,0,75.99,555.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 28FR CUT OLYMPUS OES PRO",SUP-M0068802631,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"PHCS [10601]",PHCS,,334.75,70,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661038,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,154.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,151.86,1109.86,"percent of total billed charges",
"INSTR BIOPSY 16CM 20GA BARD MAX-CORE 2 TRIGGER ULTRA SHARP",SUP-MC2016,CDM,S27200284,LOCAL,0272,RC,,,both,,,254.04,76.21,"CIGNA [10200]",Cigna,,172.75,68,,,,,0,29.54,215.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C1 Complement Esterase Inhib",PX-302000031,CDM,86161,CPT,0302,RC,,,both,,,237.90,71.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,18.88,,,,,,,0.01,202.22,"fee schedule",
"FRCP LAPAROSCOPIC 32.77CM 8MM DA VINCI XI ENDOWRIST 75D",SUP-470207,CDM,S27000186,LOCAL,0270,RC,,,both,,,1732.50,519.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"7F DUO-DECA 2.5-2.5-2.5 PV21 110CM",SUP-903953,CDM,C1731,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHAFT T8 STARDRIVE SELF RETAINING QUICK COUPLING SCRDRVR",SUP-314.467,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CELOS OXIDIZED 4X4IN ABSORBABLE HEMOSTAT SURGICEL SNOW",SUP-2083,CDM,S27200284,LOCAL,0272,RC,,,both,,,1865.48,559.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE 2.5CM MIC-KEY",SUP-0270-18-2.5-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAP TRAC MED FNGR STRL DISP",SUP-AR-1616-M,CDM,S27000186,LOCAL,0270,RC,,,both,,,237.51,71.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 135CM 60MM 7MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171070610,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET JEJUNOSTOMY 100CM 10.2FR 16FR CAREY-ALZATE-COONS .038IN",SUP-G02956,CDM,S27200284,LOCAL,0272,RC,,,both,,,1832.85,549.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,217.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,213.16,1557.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOOP SMALL 6.5IN BILLEAU EAR SURGICAL",SUP-62-1401,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"CIGNA [10200]",Cigna,,59.16,68,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 9MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530P509,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3434.27,41.1,,6417.48,6417.48,6417.48,"1 through 10",971.79,7102.52,"percent of total billed charges",
"BODY HUMERAL 13MM AEQUALIS FLEX REVIVE SHOULDER",SUP-ARS741703,CDM,C1776,HCPCS,0278,RC,,,both,,,18558.00,5567.4,"MULTIPLAN [10600]",Multiplan,,15774.3,85,,,,,0,2158.3,15774.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 0 8IN EPSTEIN SPINE SURGICAL",SUP-57-4622,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.74,104.92,"MULTIPLAN [10600]",Multiplan,,297.28,85,,,,,0,40.67,297.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALL POLY PAT VE 32 MM DIA",SUP-42-5402-000-32,CDM,C1776,HCPCS,0278,RC,,,both,,,5322.66,1596.8,"CIGNA [10200]","Cigna Local Plus",,2847.62,53.5,,5372.07,4581.20,7242.98,23,619.03,4524.26,"percent of total billed charges",
"RTRCTR 7IN FREEMAN 7 PRONG CORONAL BROW LIFT SURGICAL",SUP-22-2008,CDM,S27200284,LOCAL,0272,RC,,,both,,,1679.10,503.73,"KAISER [10500]",Kaiser,,1125,67,,,,,0,195.28,1427.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 90CM 5FR MP CURVE GUIDING DURAFORM",SUP-M003100630,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,296.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY BIOSEAL BONE FLAP AUTOLOGOUS SKULL STERILE LATEX",SUP-BIEBBF00710,CDM,S27200284,LOCAL,0272,RC,,,both,,,356.10,106.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,163.45,45.9,,,,,0,41.41,302.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (OTW)  3.50MM X 6MM",SUP-H74939402063500,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,641.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM TITANIUM T8 SELF TAP LOCK VARIABLE ANGLE",SUP-04.211.012,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"MULTIPLAN [10600]",Multiplan,,838.59,85,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JAGWIRE ENDOSCOPIC 200CM .035IN BILIARY EXTEND HIGH",SUP-M00556902,CDM,C1769,HCPCS,0272,RC,,,both,,,3339.38,1001.81,"KAISER [10500]",Kaiser,,2237.38,67,,,,,0,388.37,2838.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR ROSCH INFERIOR MESENTRIC CURVE",SUP-10733401,CDM,C1887,HCPCS,0272,RC,,,both,,,108.75,32.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,73.95,68,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLUX PUTTY 10CC",SUP-IFLX-PT-10,CDM,S27800098,LOCAL,0278,RC,,,both,,,11281.50,3384.45,"NOVANET [10819]",Novanet,,8461.13,75,,,,,0,1312.04,9589.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ESR CONTROL HEMATOLOGY 8.5ML NORMAL/ABNORMAL VIAL ACCU-S",SUP-DS-71005A,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.87,58.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,132.51,68,,,,,0,22.66,165.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 LEFT KNEE CRUCIATE RETAINING CEMENTED",SUP-5510-F-401,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"CIGNA [10200]",Cigna,,6559.14,40,,5873.17,5873.17,5873.17,"1 through 10",1907.07,13938.17,"percent of total billed charges",
"ATOMOXETINE 10 MG CAPSULE",RX-34444,CDM,,,0637,RC,42291-0064-30,NDC,both,1,UN,77.98,23.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,53.03,68,,,,,0,9.07,66.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +26 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT225260,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 35CM 5.7FR ATRIUM VENTRICLE TRANSVENOUS BIPOLAR",SUP-407635,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,264.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTDG BONE CEMENT PRISM II BREAKOFF NOZZLE LATEX FREE",SUP-5401-33-500,CDM,S27200284,LOCAL,0272,RC,,,both,,,3592.50,1077.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2442.9,68,,,,,0,417.81,3053.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT CONTRACTURE XL ANKLE ANTIROTATION BAR PAD TOE PIECE",SUP-4301E,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.35MM 35MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1",SUP-179712435,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"IMPL BREAST 650ML GEL SMOOTH MEMORYGEL SILICONE P5.7CM HIGH","SUP-3506504 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"MULTIPLAN [10600]",Multiplan,,3213,85,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 55MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4855,CDM,C1713,HCPCS,0278,RC,,,both,,,3112.50,933.75,"PHCS [10601]",PHCS,,2178.75,70,,,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Driveline W Closure 6x6",PX-E27200437,CDM,E27200437,LOCAL,0272,RC,,,both,,,43.97,13.19,"PHCS [10601]",PHCS,,30.78,70,,,,,0,5.11,37.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 8MM 70MM 22MM DHS/DCS STAINLESS STEEL",SUP-280.270,CDM,C1713,HCPCS,0278,RC,,,both,,,2576.10,772.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1182.43,45.9,,,,,0,299.6,2189.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Aerobic Other Pres ID",PX-306000028,CDM,87070,CPT,0306,RC,,,both,,,351.50,105.45,"NOVANET [10819]",Novanet,,263.63,75,,,,,0,0.01,298.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR ZEPHYR SR 44X41MM 8ML 17GM IMPLANTABLE 1 CHMBR RATE",SUP-5620,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"AETNA [10100]","Aetna HMO/PPO",,19747.8,79.5,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 30MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE50030,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"MULTIPLAN [10600]",Multiplan,,71114.91,85,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 2.4X2.4IN XENMATRIX AQUAPURE SQUARE ACELLULAR",SUP-1160606,CDM,C1781,HCPCS,0278,RC,,,both,,,6047.16,1814.15,"MULTIPLAN [10600]",Multiplan,,5140.09,85,,,,,0,703.28,5140.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA SURG VELC STRP ZIP SM 30-32IN",SUP-958-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,333.99,100.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,38.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.84,283.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 44MM 2 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800244,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 27.5MM TITANIUM LOCK TRANSLATIONAL ATLANTIS BONE SPINE",SUP-6190027,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,497.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,488.46,3570,"percent of total billed charges",
"DEVICE NANOPASS CRESCENT 1.5MM SUTURING ACETABULAR LABRUM",SUP-CAT02298,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,213.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMEDY SPECTRUM GV FEMORAL HEAD - 54MM",SUP-GVHDMD,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"UHC [10700]","United Healthcare",,11963.7,63.3,,8601.07,8395.67,8601.07,"1 through 10",2198.07,16065,"percent of total billed charges",
"STENT SET BANDER URETER  LF 7F",SUP-25707,CDM,S27200284,LOCAL,0272,RC,,,both,,,523.26,156.98,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,inpatient,,,250756.63,75226.99,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,MINOR",323,APR-DRG,,,,,,,inpatient,,,132875.24,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $9,708.10. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,922.63) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC",217,MS-DRG,,,,,,,inpatient,,,412543.49,123763.05,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER RESPIRATORY AND CHEST PROCEDURES,MAJOR",121,APR-DRG,,,,,,,inpatient,,,166977.02,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $18,385.48. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($111,146.69) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,MINOR",323,APR-DRG,,,,,,,inpatient,,,132875.24,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $9,708.10. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,922.63) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"FRACTURE OF PELVIS OR DISLOCATION OF HIP,MAJOR",341,APR-DRG,,,,,,,inpatient,,,36158.25,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $5,137.44. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($32,359.08) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 50CMX.49MM 22/11MM HEMAGARD 2 BRANCH",SUP-HGK2211,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,1466.08,39.2,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL E 68X61.5MM KNEE RIGHT SET SCR CEMENT REVISION",SUP-00599401592,CDM,C1776,HCPCS,0278,RC,,,both,,,41440.14,12432.04,"PHCS [10601]",PHCS,,29008.1,70,,,,,0,4819.49,35224.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 8 STD OFFSET HIP",SUP-71935568,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4329.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 12MM 144CM 3MM",SUP-H7493941212300,CDM,C1874,HCPCS,0278,RC,,,both,,,8245.50,2473.65,"CIGNA [10200]","Cigna Local Plus",,4411.34,53.5,,,,,0,958.95,7008.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL HIP 28MM ARTIC/EZE +1.5MM BALL GROOVE",SUP-253081000,CDM,C1776,HCPCS,0278,RC,,,both,,,3371.25,1011.37,"PHCS [10601]",PHCS,,2359.88,70,,,,,0,392.08,2865.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION",RX-9892,CDM,J1250,HCPCS,0636,RC,00409-2344-01,NDC,both,20,ML,53.45,16.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.42,,"Fee schedule rate ($9.42). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.7,45.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 20MM REVISION 20 GRIT BLAST SURFACE",SUP-197620140,CDM,C1776,HCPCS,0278,RC,,,both,,,17952.48,5385.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7180.99,40,,,,,0,2087.87,15259.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 13CM 5.5MM STERLING 12000 RPM SPHERE LARGE HUB",SUP-H9112,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SURGICAL MEDIUM CIRCLE 2.5IN SPRING OPEN BIORESORBABLE",SUP-5950008,CDM,C1781,HCPCS,0278,RC,,,both,,,2068.00,620.4,"KAISER [10500]",Kaiser,,1385.56,67,,,,,0,240.51,1757.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TACK 6MM 150CM 4FR VASCULAR NITINOL RADIOPAQUE OTW 4",SUP-154150041,CDM,C1876,HCPCS,0278,RC,,,both,,,18238.50,5471.55,"PHCS [10601]",PHCS,,12766.95,70,,,,,0,2121.14,15502.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM TITANIUM CORTICAL LOCKING NONSTERILE",SUP-CO-2720,CDM,C1713,HCPCS,0278,RC,,,both,,,696.60,208.98,"CIGNA [10200]","Cigna Local Plus",,372.68,53.5,,3978.14,359.25,3978.14,24,81.01,592.11,"percent of total billed charges",
"DEVICE SYNETURE V-LOC 1 GS-22 12IN CLSR ABSORBABLE BLUE",SUP-VLOCN2117,CDM,S27200284,LOCAL,0272,RC,,,both,,,242.99,72.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,111.53,45.9,,,,,0,28.26,206.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 210CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRM-210,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3730.14,68,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 13CM 5.5MM STERLING 12000 RPM SPHERE LARGE HUB",SUP-H9112,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 18MM 1MM FLO-THRU INTRALUMINAL",SUP-FT12100,CDM,S27200284,LOCAL,0272,RC,,,both,,,741.67,222.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,87.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.26,630.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG LAPAROSCOPIC TROCAR R-MED DISPOSABLE 12MM",SUP-10154,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.20,15.66,"CIGNA [10200]","Cigna Local Plus",,27.93,53.5,,,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 22.5 % IN WATER(IV)",RX-410565,CDM,,,0258,RC,08888-8879-96,NDC,both,250,ML,100.65,30.19,"AETNA [10100]","Aetna HMO/PPO",,80.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 4FR 11CM RED HUB HEMOSTASIS VALVE PRELUDE",SUP-PSI-4F-11,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"KAISER [10500]",Kaiser,,50.71,67,,,,,0,8.8,64.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 235MM 27MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-327,CDM,C1776,HCPCS,0278,RC,,,both,,,18758.25,5627.47,"FIRST HEALTH [10303]","First Health",,15006.6,80,,,,,0,2181.58,15944.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE CORTICAL VARIABLE ANGLE STERILE",SUP-111655,CDM,C1713,HCPCS,0278,RC,,,both,,,2052.00,615.6,"CIGNA [10200]","Cigna Open Access",,1167.59,56.9,,1144.80,304.56,2275.09,66,238.65,1744.2,"percent of total billed charges",
"FRCP LAPAROSCOPIC 6MM CADIERE DA VINCI SP",SUP-430009,CDM,S27000186,LOCAL,0270,RC,,,both,,,2063.40,619.02,"NOVANET [10819]",Novanet,,1547.55,75,,,,,0,239.97,1753.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 10CM 3CM 5FR .035IN",SUP-M006192111190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"BLUE CROSS [10001]","Blue Cross HMO",,546.93,39.2,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3.5MM 12/14 TAPER 28MM HIP COCR VERSYS STERILE",SUP-801802801,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"MULTIPLAN [10600]",Multiplan,,4123.1,85,,,,,0,564.14,4123.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 140MM 16MM 3MM VASCULAR VENOUS ILIOFEMORAL VEIN",SUP-VENUM16140,CDM,C1876,HCPCS,0278,RC,,,both,,,23940.00,7182,"UHC [10700]","United Healthcare",,15154.02,63.3,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXIMA 70CM 5FR URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002311,CDM,C1758,HCPCS,0272,RC,,,both,,,80.01,24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH COYOTE 90CM 220MM 3MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186302290,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"2.5MM X 40MM S4 CATHETER",SUP-FG63091-2540,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RED 43 REPERFUSION CATHETER 138 CM",SUP-RED43138,CDM,C1757,HCPCS,0272,RC,,,both,,,16767.00,5030.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"GWIRE BENTSON VASCULAR 145CM 15CM .035IN STAINLESS STEEL",SUP-G14590,CDM,C1769,HCPCS,0272,RC,,,both,,,246.21,73.86,"PHCS [10601]",PHCS,,172.35,70,,,,,0,28.63,209.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 9MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-809,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"FIRST HEALTH [10303]","First Health",,10766.76,80,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"25 MM LOTUS EDGE AORTIC VALVE SYSTEM AND LARGE LOTUS INTRODU",SUP-H749LVSUS250,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"CIGNA [10200]","Cigna Local Plus",,58353.75,31.5,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 10CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192111010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]","Cigna Open Access",,683.13,,,,,,,139.63,1020.49,"percent of total billed charges",
"STENT WALLSTENT RX 80MM 194CM 10MM 8FR TAPER ENDOPROSTHESIS",SUP-M00569720,CDM,S27500001,LOCAL,0275,RC,,,both,,,11537.01,3461.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7845.17,68,,,,,0,1341.75,9806.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 200ML GEL ROUND SMOOTH SILTEX SILICONE P3.2CM","SUP-3502001 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"KAISER [10500]",Kaiser,,2462.25,67,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUINTON CURL CATH 57CM DIALYSIS PERITONEAL 1 CUFF",SUP-8811313014,CDM,C1750,HCPCS,0278,RC,,,both,,,550.15,165.04,"FIRST HEALTH [10303]","First Health",,440.12,80,,,,,0,63.98,467.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 70CM INFINION 16 CONTACT LEAD CX",SUP-SC-2317-70,CDM,C1897,HCPCS,0278,RC,,,both,,,17640.00,5292,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7250.04,41.1,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 10CM 3CM 5FR .035IN 2",SUP-M006192111180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"CIGNA [10200]",Cigna,,1081.11,68,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 1.1MM TIGHTROPE KIRSCHNER MINI",SUP-AR-8919DS,CDM,C1713,HCPCS,0278,RC,,,both,,,6484.28,1945.28,"KAISER [10500]",Kaiser,,4344.47,67,,,,,0,754.12,5511.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM ORTHOLOC LONG CORTICAL ANKLE FOOT 3DI",SUP-58802716,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,189.34,1383.8,"percent of total billed charges",
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 15MM 140CM 4MM CORONARY",SUP-RSINT40015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"MULTIPLAN [10600]",Multiplan,,4712.4,85,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 70CM INFINION 16 CONTACT LEAD CX",SUP-SC-2317-70,CDM,C1897,HCPCS,0278,RC,,,both,,,17640.00,5292,"CIGNA [10200]","Cigna Local Plus",,5556.6,31.5,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SNARE AMPLATZ GOOSENECK 90D 200CM 2.3-3FR 7MM",SUP-SK701,CDM,C1773,HCPCS,0272,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAFIRE COMFORTGRIP 115CM 5MM 7FR 2-5-2MM SPACING 1MM",SUP-402817,CDM,C1733,HCPCS,0272,RC,,,both,,,4129.65,1238.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,480.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,480.28,3510.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCORTISONE (PF) 100 MG SOLUTION FOR INJECTION SUPERORDERABLE",RX-408113689,CDM,J1720,HCPCS,0636,RC,00009-0011-03,NDC,both,1,UN,226.52,67.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,154.03,68,,,,,0,24.84,192.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCORTISONE (PF) 100 MG SOLUTION FOR INJECTION SUPERORDERABLE",RX-408113689,CDM,J1720,HCPCS,0636,RC,00009-0011-03,NDC,both,1,UN,226.52,67.96,"UHC [10700]","United Healthcare",,43.02,,,,,,,24.84,192.54,"fee schedule",
"DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID",RX-12556,CDM,,,0637,RC,69339-0152-01,NDC,both,10,ML,18.37,5.51,"PHCS [10601]",PHCS,,12.86,70,,,,,0,2.14,15.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL OSS LONG KNEE NONMODULAR 71MM STERILE",SUP-161043,CDM,C1776,HCPCS,0278,RC,,,both,,,23169.51,6950.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9522.67,41.1,,6417.48,6417.48,6417.48,"1 through 10",2694.61,19694.08,"percent of total billed charges",
"KNIFE ENDOSCOPIC LANCET BLADE ROUND HANDLE STAINLESS STEEL",SUP-130916,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.63,31.09,"AETNA [10100]","Aetna HMO/PPO",,82.39,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.05,88.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 12MM 140CM 3MM 2.1-2.7FR CORONARY STENT",SUP-RONYX30012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,inpatient,,,250756.63,75226.99,"AMBETTER EXCHANGE  [11102]",Ambetter,,26152.11,,"Case rate ($26,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $24,284, add-ons for qualifying new technology services are included. If operating cost exceeds $57,323.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,218.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $24,316.12. The transfer operating threshold is the transfer adjustment factor * $24,284.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,835.99. The transfer capital threshold is the transfer adjustment factor * $1,835.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,10994,123090.34,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FAST-FIX 360D REVERSE CURVE FIXATION 2 ANCHOR PRETIE",SUP-72202469,CDM,C1713,HCPCS,0278,RC,,,both,,,3300.75,990.22,"AETNA [10100]","Aetna HMO/PPO",,2624.1,79.5,,1521.93,481.35,16760.95,30,383.88,2805.64,"percent of total billed charges",
"STENT CONTOUR SENSOR DUAL-FLEX 22CM 3CM 6FR .035IN PIGTAIL",SUP-M006180221190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"NOVANET [10819]",Novanet,,949.04,75,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO ORTHOPEDIC KYPHX 1 STEP BEVEL OSTEO SYSTEM",SUP-T15K,CDM,C1894,HCPCS,0272,RC,,,both,,,2355.98,706.79,"NOVANET [10819]",Novanet,,1766.99,75,,,,,0,274,2002.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Glucose Postdose",PX-301000206,CDM,82950,CPT,0301,RC,,,both,,,125.00,37.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.13,.1,,,,,0,0.13,106.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 11FR NONHEMOSTASIS GUIDING ELECTROPHYSIOLOGICAL",SUP-7097,CDM,C1894,HCPCS,0272,RC,,,both,,,3339.00,1001.7,"FIRST HEALTH [10303]","First Health",,2671.2,80,,,,,0,388.33,2838.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rem/Reins Impl Drug Deliv",PX-761000066,CDM,11983,CPT,0761,RC,,,both,,,4213.65,1264.09,"UHC [10700]","United Healthcare",,2667.24,63.3,,,,,0,490.05,3581.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 5N 7MM",SUP-TPS-030-075N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT FEMORAL KNEE PATELLA TIBIA POSTERIOR STABILIZE CEM",SUP-98000641521,CDM,C1776,HCPCS,0278,RC,,,both,,,20790.00,6237,"FIRST HEALTH [10303]","First Health",,16632,80,,,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 44MM X25 LOCK INTRAMEDULLARY NAIL",SUP-04.045.044S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 18FR SILICONE UNIVERSAL FEEDING PORT CNCT MEDICATION",SUP-0100-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"NOVANET [10819]",Novanet,,209.91,75,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9.5MM 100MM CD HORIZON SPINE MULTIAXIAL CANNULATED",SUP-25630019510,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"INSRT TIBIAL 3 11MM KNEE HINGE REVISION TRIATHLON",SUP-5612-P-311,CDM,C1776,HCPCS,0278,RC,,,both,,,16199.82,4859.95,"AETNA [10100]","Aetna HMO/PPO",,12878.86,79.5,,10981.53,8986.79,12413.38,12,1884.04,13769.85,"percent of total billed charges",
"CNCT CATH 3FT PKG SOURCING4",SUP-0653,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]",Cigna,,6072,40,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL SHAVER 2.6MM FIBERTAK",SUP-AR-3657SD,CDM,S27200284,LOCAL,0272,RC,,,both,,,1063.13,318.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,436.95,41.1,,,,,0,123.64,903.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE GASTRIC LAVAGE 40FR TUM-E-VAC 1 LUMEN MULTIPLE EYELET",SUP-2140,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.69,14.91,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,20.42,41.1,,,,,0,5.78,42.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOLOIST 110CM 6FR 5MM SPACING JSN CURVE",SUP-307F1,CDM,C1733,HCPCS,0272,RC,,,both,,,10005.00,3001.5,"FIRST HEALTH [10303]","First Health",,8004,80,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 176MM STAINLESS STEEL 2.7MM SCREWS 22 HOLE",SUP-245.28,CDM,C1713,HCPCS,0278,RC,,,both,,,3749.46,1124.84,"CIGNA [10200]","Cigna Open Access",,2133.44,56.9,,1144.80,304.56,2275.09,66,436.06,3187.04,"percent of total billed charges",
"CATH ADVANCE 35LP 135CM 8CM 5FR 7MM .035IN BALLOON",SUP-G52274,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"FIRST HEALTH [10303]","First Health",,767.82,80,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +27 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-AR40E00270,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"NOVANET [10819]",Novanet,,698.63,75,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER BRAID GREEN NONABSORBABLE",SUP-SXP52N,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.74,206.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,316.13,45.9,,,,,0,80.1,585.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING SUCTION 30CM 8FR T SILICONE TRANSLUCENT STERILE LATEX",SUP-SU130-1224,CDM,S27200284,LOCAL,0272,RC,,,both,,,2175.00,652.5,"PHCS [10601]",PHCS,,1522.5,70,,,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L14MM DIA3.5MM CORTICAL STAINLESS STEEL SELF TAPP",SUP-02.206.014,CDM,C1713,HCPCS,0278,RC,,,both,,,321.55,96.46,"KAISER [10500]",Kaiser,,215.44,67,,,,,0,37.4,273.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 13 HIGH OFFSET HIP",SUP-71935585,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"KAISER [10500]",Kaiser,,24477.58,67,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL SHALLCROSS FULL CURVE 8IN CYSTIC DUCT",SUP-SU10510,CDM,S27200284,LOCAL,0272,RC,,,both,,,466.97,140.09,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT LEAD SPLICE 6.1FR 8.3FR CAPSURE 10.7FR TRANSVENOUS",SUP-5867-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,174.00,52.2,"FIRST HEALTH [10303]","First Health",,139.2,80,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 5N 8MM",SUP-TPS-030-085N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LRNSCP 3 MCNTSH EURO PRFL GLS",SUP-4003VS,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.88,13.76,"MULTIPLAN [10600]",Multiplan,,39,85,,,,,0,5.34,39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insert Tunneled Pleural Cath",PX-361000055,CDM,32550,CPT,0361,RC,,,both,,,11344.57,3403.37,"BLUE CROSS [10001]","Blue Cross PPO",,4431.65,,"Case rate ($4,431.65). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1319.37,10015,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSORB GT1 18MM 3MM CORONARY EVEROLIMUS ELUTING POLY L",SUP-1235300-18,CDM,C1874,HCPCS,0278,RC,,,both,,,8280.00,2484,"PHCS [10601]",PHCS,,5796,70,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING FULL CARBON FIBER 180MM",SUP-4933-5-180,CDM,S27800098,LOCAL,0278,RC,,,both,,,11248.79,3374.64,"CIGNA [10200]","Cigna Local Plus",,6018.1,53.5,,,,,0,1308.23,9561.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM THIN WALL HYPERINFLATION .5L NO MASK BAG O2 TUBE",SUP-87-HS4051EA,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.24,25.27,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.8,71.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +8.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.085,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 45CM 61CM SMOOTH TRANSITION STEERABLE",SUP-MAP645,CDM,S27200284,LOCAL,0272,RC,,,both,,,4071.00,1221.3,"FIRST HEALTH [10303]","First Health",,3256.8,80,,,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 79MM 36MM 31-32MM 22FR ZENITH TX2",SUP-G47456,CDM,C1874,HCPCS,0278,RC,,,both,,,98041.65,29412.49,"PHCS [10601]",PHCS,,68629.16,70,,,,,0,11402.24,83335.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REFERENCE TOE IMPLANT SIZER","SUP-M03 S0001",CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"FIRST HEALTH [10303]","First Health",,1350,80,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 48MM TITANIUM T25 SELF TAP LOCK STARDRIVE",SUP-412.218S,CDM,C1713,HCPCS,0278,RC,,,both,,,1220.18,366.05,"BLUE CROSS [10001]","Blue Cross HMO",,478.31,39.2,,957.42,156.86,7483.26,51,141.91,1037.15,"percent of total billed charges",
"SABER .035 9X40 40CM SL",SUP-48009004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"KAISER [10500]",Kaiser,,658.03,67,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 15CM 4MM BALLOON DILATATION",SUP-U8150415,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DRNG INSRT ROCKET MINI STERILE LATEX FREE DISPOSABLE",SUP-R51400-MI-PL,CDM,C1729,HCPCS,0272,RC,,,both,,,2550.00,765,"UHC [10700]","United Healthcare",,1614.15,63.3,,,,,0,296.57,2167.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 150MM 38MM 24FR VALIANT CAPTIVIA FREEFLO",SUP-VAMF3838C150TU,CDM,C1874,HCPCS,0278,RC,,,both,,,96987.78,29096.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,39861.98,41.1,,,,,0,11279.68,82439.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PROGRESS 40 VASCULAR STRAIGHT 190CM 3CM .014",SUP-1011836,CDM,C1769,HCPCS,0272,RC,,,both,,,1036.80,311.04,"UHC [10700]","United Healthcare",,656.29,63.3,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 445CC P5.5CM MODERATE PLUS PROJECTION TALL",SUP-334-1309,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA [10200]",Cigna,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 4FR 65CM TRIFORCE FLEXOR PEEL-AWAY CURVE TAPER DOWN",SUP-G56419,CDM,S27200284,LOCAL,0272,RC,,,both,,,2711.18,813.35,"MULTIPLAN [10600]",Multiplan,,2304.5,85,,,,,0,315.31,2304.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLAMMATORY BOWEL DISEASE WITH CC",386,MS-DRG,,,,,,,inpatient,,,34543.87,10363.16,"CIGNA [10200]","Cigna Open Access",,10713.92,,"Fee schedule rate ($10,713.92). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,6056.05,24347.95,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT 85CM PRESSURE RELATIVE RISK UNITIZE DISTAL CATH",SUP-NS0005,CDM,S27800098,LOCAL,0278,RC,,,both,,,13732.38,4119.71,"CIGNA [10200]",Cigna,,5492.95,40,,,,,0,1597.08,11672.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 14MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650614,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"AETNA [10100]","Aetna HMO/PPO",,10436.16,79.5,,10981.53,8986.79,12413.38,12,1526.7,11158.16,"percent of total billed charges",
"RECTAL RESECTION WITHOUT CC/MCC",334,MS-DRG,,,,,,,inpatient,,,90693.67,27208.1,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE ORTHOPEDIC THK1/8IN 2XL 13IN NEOPRENE KNEE EXTRA",SUP-79-82009,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.72,17.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRANSURETHRAL PROCEDURES WITHOUT CC/MCC",670,MS-DRG,,,,,,,inpatient,,,37883.74,11365.12,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 115CM 2.4FR 1CM TIPLESS BASKET NCIRCLE DELTA WIRE",SUP-G19110,CDM,S27200284,LOCAL,0272,RC,,,both,,,2063.25,618.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE VASCULAR .035IN 115CM LOCKING EXT LOC+ STERILE LATEX",SUP-52260,CDM,C1769,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER 8CM 2.9MM STERLING GATOR 6000 RPM SMALL JOINT",SUP-C9961A,CDM,S27200284,LOCAL,0272,RC,,,both,,,638.28,191.48,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STPLR 80X3.8MM GIA TITANIUM LINEAR CUTTER",SUP-GIA8038L,CDM,S27200284,LOCAL,0272,RC,,,both,,,489.73,146.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BODY CALCAR 29MM RESTORATION +10MM OFFSET HIP MODULAR",SUP-6276-4-129,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"CIGNA [10200]",Cigna,,9282.42,40,,5873.17,5873.17,5873.17,"1 through 10",2698.86,19725.14,"percent of total billed charges",
"SUT PROLENE 2-0 CT-2 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8411H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 23MM 3MM CORONARY STENT COCR RAPID",SUP-1007848-23,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 1 STRAIGHT OVAL 9IN BRUNS SPINE SURGICAL",SUP-29-5351,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.25,71.77,"AETNA [10100]","Aetna HMO/PPO",,190.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.82,203.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR HD 36CM 13-15FR ACCESS STAINLESS STEEL",SUP-M0062502280,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.05,833.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY THRULUMEN 40CM 5.5FR 11MM EMBOLECTOMY STAINLESS",SUP-12TLW405F35,CDM,C1757,HCPCS,0272,RC,,,both,,,746.58,223.97,"MULTIPLAN [10600]",Multiplan,,634.59,85,,,,,0,86.83,634.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 60MM 125CM 5MM 6FR BILIARY NITINOL",SUP-G32033,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,447.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 8MM 144CM 2.25MM",SUP-H7493941208220,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"AETNA [10100]","Aetna HMO/PPO",,6171.19,79.5,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM PRIMARY CEMENT DISTAL BULLET TIP SYNERGY",SUP-71316010,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"NOVANET [10819]",Novanet,,15946.88,75,,,,,0,2472.83,18073.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RADSTAT STD COMPRESSION WRIST RADIAL ARTERY 3 BAND",SUP-RADSTD,CDM,S27200284,LOCAL,0272,RC,,,both,,,204.45,61.33,"CIGNA [10200]","Cigna Local Plus",,109.38,53.5,,,,,0,23.78,173.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 300MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520300S,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 80X3.8MM GIA TITANIUM LINEAR CUTTER",SUP-GIA8038L,CDM,S27200284,LOCAL,0272,RC,,,both,,,489.73,146.92,"PHCS [10601]",PHCS,,342.81,70,,,,,0,56.96,416.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 60 LARGE KEEL AEQUALIS PERFORM SHOULDER",SUP-DWE523,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"KAISER [10500]",Kaiser,,6241.72,67,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 15MM 2.75MM BALLOON DILATATION",SUP-NCEUP27515X,CDM,C1725,HCPCS,0272,RC,,,both,,,562.95,168.88,"UHC [10700]","United Healthcare",,356.35,63.3,,,,,0,65.47,478.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 44MM MEDLINE UNITE HEAD BRONZE",SUP-MSL04044,CDM,C1713,HCPCS,0278,RC,,,both,,,1987.50,596.25,"PHCS [10601]",PHCS,,1391.25,70,,,,,0,231.15,1689.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL WAND WEREWOLF COBLATION FLOW 50",SUP-72290037,CDM,S27200284,LOCAL,0272,RC,,,both,,,1788.75,536.62,"PHCS [10601]",PHCS,,1252.13,70,,,,,0,208.03,1520.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 2.5MM 8.25IN STAINLESS STEEL GARRETT MALLEABLE",SUP-25-8019,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.43,22.03,"KAISER [10500]",Kaiser,,49.2,67,,,,,0,8.54,62.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 12MM CEMENTLESS MODULAR AML POROUS 40MM",SUP-155401121,CDM,C1776,HCPCS,0278,RC,,,both,,,15374.88,4612.46,"MULTIPLAN [10600]",Multiplan,,13068.65,85,,,,,0,1788.1,13068.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 6 RIGHT DISTAL KNEE",SUP-5542-A-602,CDM,C1776,HCPCS,0278,RC,,,both,,,6011.46,1803.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1720.48,28.62,,,,,0,699.13,5109.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2-0 CT-2 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8411H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 108MM RADIUS CURVE 104X10.2X2.7MM STAINLESS STEEL 3.5",SUP-245.878,CDM,C1713,HCPCS,0278,RC,,,both,,,4488.04,1346.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",521.96,3814.83,"percent of total billed charges",
"SUT VICRYL PLUS 5-0 PS-5 18IN BRAID ANTIBACTERIAL COATED",SUP-VCP593G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.48,45.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 8MM 144CM 2.25MM",SUP-H7493941208220,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,919.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS ELECTROSURGICAL 45CM 5MM HARMONIC ACE +7 CURVE",SUP-HARH45,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 45CM 10MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1045CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,842.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 15X10CM SELF GRIP RESORBING",SUP-TSB1510,CDM,C1781,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]",Cigna,,6900,40,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 12MM 2MM MICA STERILE",SUP-57SR0212,CDM,S27200284,LOCAL,0272,RC,,,both,,,2580.00,774,"NOVANET [10819]",Novanet,,1935,75,,,,,0,300.05,2193,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 0MM 36MM HIP C TAPER OFFSET COBALT CHROME LFIT",SUP-06-3600,CDM,C1776,HCPCS,0278,RC,,,both,,,6224.40,1867.32,"CIGNA [10200]","Cigna Open Access",,3541.68,56.9,,5302.19,4377.88,6578.61,27,723.9,5290.74,"percent of total billed charges",
"PRESSURE INJECTABLE ARROWGARD BLUE ADVANCEONE-LUMEN MIDLINE",SUP-CDC-41541-MPKB,CDM,C1751,HCPCS,0272,RC,,,both,,,1477.44,443.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1004.66,68,,,,,0,171.83,1255.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE XL FEMALE SUEDE RUBBER BOTTOM WOOD SOLE",SUP-2007-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.43,23.23,"FIRST HEALTH [10303]","First Health",,61.94,80,,,,,0,9.01,65.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL HIP 44MM +1.5 44MM FEMORAL HEAD",SUP-136561000,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1312.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1288.37,9416.26,"percent of total billed charges",
"SCR BONE 3.5MM 34MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0268,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"NOVANET [10819]",Novanet,,710.78,75,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERPICC SOLO 2 SHERLOCK 3CG 55CM 5FR CENTRAL VENOUS",SUP-1395108QD,CDM,C1751,HCPCS,0272,RC,,,both,,,2090.55,627.16,"PHCS [10601]",PHCS,,1463.39,70,,,,,0,243.13,1776.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NUVISION 10FR ULTRASOUND ICE NAV",SUP-FG12081,CDM,C1759,HCPCS,0272,RC,,,both,,,21369.60,6410.88,"AETNA [10100]","Aetna HMO/PPO",,16988.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2485.28,18164.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 2.5MM 3MM 1MM MICRON PORP EAR TITANIUM",SUP-70142028,CDM,S27000186,LOCAL,0270,RC,,,both,,,2235.00,670.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1025.87,45.9,,,,,0,259.93,1899.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45 REPOSABLE NONSTERILE LATEX FREE DA VINCI",SUP-470298,CDM,S27000186,LOCAL,0270,RC,,,both,,,1134.00,340.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,520.51,45.9,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR OSSEOTI E1 XLPE CUP 2 MOBILITY AA LINER",SUP-98B00100942,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9072,40,,,,,0,2637.68,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUSHG TIBIAL OSS KNEE POLYETHYLENE LOW FRICTION INTERFACE",SUP-150476,CDM,C1770,HCPCS,0278,RC,,,both,,,2460.00,738,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,704.05,28.62,,,,,0,286.1,2091,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY THRULUMEN 40CM 5.5FR 11MM EMBOLECTOMY STAINLESS",SUP-12TLW405F35,CDM,C1757,HCPCS,0272,RC,,,both,,,746.58,223.97,"KAISER [10500]",Kaiser,,500.21,67,,,,,0,86.83,634.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 166MM 32-16MM 20FR ENDURANT II ABDOMEN",SUP-ETBF3216C166E,CDM,C1876,HCPCS,0278,RC,,,both,,,62842.50,18852.75,"NOVANET [10819]",Novanet,,47131.88,75,,,,,0,7308.58,53416.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE LEGACY DBM 1CC ALLOGRAFT NONSTERILE LATEX FREE",SUP-420801,CDM,C1713,HCPCS,0278,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,317.52,39.2,,957.42,156.86,7483.26,51,94.2,688.5,"percent of total billed charges",
"HC Hdr Ntrstl Icav Brachytx 2-12 Chnl Sd",PX-342000022,CDM,77771,CPT,0342,RC,,,both,,,6027.68,1808.3,"CIGNA [10200]","Cigna Open Access",,3429.75,56.9,,,,,0,408.8,5123.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 60X4.8MM GIA TITANIUM THICK TISSUE ENDOSCOPIC",SUP-GIA6048L,CDM,S27200284,LOCAL,0272,RC,,,both,,,354.61,106.38,"NOVANET [10819]",Novanet,,265.96,75,,,,,0,41.24,301.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DIVERGENCE-L 15X9.4X5MM ANTERIOR OBLIQUE LUMBAR",SUP-736525,CDM,S27800098,LOCAL,0278,RC,,,both,,,9177.00,2753.1,"UHC [10700]","United Healthcare",,5809.04,63.3,,,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X7MM COLONIAL 7D LORDOTIC 12MM LARGE",SUP-365.407CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK15MM 51X69MM PROTECTA XT CRT-D VENTRICLE 2",SUP-D334TRG,CDM,C1882,HCPCS,0278,RC,,,both,,,85500.00,25650,"MULTIPLAN [10600]",Multiplan,,72675,85,,,,,0,9943.65,72675,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOOP SPLINT 25YDX2IN ELASTICIZE HTH HOOK BLACK R-STRETCH THK",SUP-550385,CDM,S27000186,LOCAL,0270,RC,,,both,,,798.42,239.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,94.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,92.86,678.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL ORBITAL MEDPOR POLYETHYLENE 20MM CRANIOMAXILLOFACIAL",SUP-6317,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3.5MM PUSHLOCK SELFPUNCH BIOCOMPOSITE STERILE",SUP-AR-1926BCSP,CDM,C1713,HCPCS,0278,RC,,,both,,,3543.75,1063.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1626.58,45.9,,,,,0,412.14,3012.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 10MM FLEXIGRAFT DOWEL ACHILLES TENDON",SUP-FATB10,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 24CM 7MM .021-.027IN AZUR CX DETACHABLE",SUP-45-780724,CDM,S27800098,LOCAL,0278,RC,,,both,,,5278.50,1583.55,"NOVANET [10819]",Novanet,,3958.88,75,,,,,0,613.89,4486.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 65CM 5FR PIGTAIL CURVE ANGIOGRAPHIC",SUP-5653510PIG-NB,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"AETNA [10100]","Aetna HMO/PPO",,83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC IRRIGATION 1.8MM CPSL GUARD SURELOCK 2.2MM-2.85MM",SUP-85910ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,87.85,45.9,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 6 RIGHT DISTAL KNEE",SUP-5542-A-602,CDM,C1776,HCPCS,0278,RC,,,both,,,6011.46,1803.44,"PHCS [10601]",PHCS,,4208.02,70,,,,,0,699.13,5109.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 28CM 3CM 7FR .038IN 2 PIGTAIL",SUP-M006192144010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,139.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC App Splint Short Leg",PX-450000203,CDM,29515,CPT,0361,RC,,,both,,,1281.63,384.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1281.63,,"Fee schedule rate ($1,729.39).",,,,0,149.05,1281.63,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 28MM 20MM AFX2 2 BRANCH 40MM",SUP-BEA28-100/I20-40,CDM,C1874,HCPCS,0278,RC,,,both,,,84559.50,25367.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10020.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9834.27,71875.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIPOLAR FEMORAL HEAD ADAPTER +0MM",SUP-451010000,CDM,C1776,HCPCS,0278,RC,,,both,,,1539.00,461.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,440.46,28.62,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL WAND WEREWOLF COBLATION FLOW 50",SUP-72290037,CDM,S27200284,LOCAL,0272,RC,,,both,,,1788.75,536.62,"UHC [10700]","United Healthcare",,1132.28,63.3,,,,,0,208.03,1520.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR .035IN 115CM LOCKING EXT LOC+ STERILE LATEX",SUP-52260,CDM,C1769,HCPCS,0272,RC,,,both,,,445.50,133.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X6MM COALITION AGX 7D 10MM NONSTERILE LATEX",SUP-3128.1476,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 230CM 120CM 22-27MM 10FR COLONIC ENTERAL",SUP-M00565120,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 12MM 140CM 2.25MM 2.1-2.7FR CORONARY",SUP-RONYX22512UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"KAISER [10500]",Kaiser,,2487.38,67,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SPINAL 28MM 4MM VUEPOINT II MULTIAXIAL",SUP-8975428,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,3978.14,359.25,3978.14,24,441.36,3225.75,"percent of total billed charges",
"CATH ADVANCE 18LP 80CM 4CM 4FR 6MM .018IN BALLOON DILATATION",SUP-G50246,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45 REPOSABLE NONSTERILE LATEX FREE DA VINCI",SUP-470298,CDM,S27000186,LOCAL,0270,RC,,,both,,,1134.00,340.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 10MM FLEXIGRAFT DOWEL ACHILLES TENDON",SUP-FATB10,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CALCAR 29MM RESTORATION +10MM OFFSET HIP MODULAR",SUP-6276-4-129,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6265.63,27,,,,,0,2698.86,19725.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SKATER CHOICE LOCK 25CM 8FR PIGTAIL CURVE DRNG",SUP-756608025,CDM,C1729,HCPCS,0272,RC,,,both,,,651.24,195.37,"FIRST HEALTH [10303]","First Health",,520.99,80,,,,,0,75.74,553.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ZEBRA 6F 95CM ACCESS SYSTEM SIM2",SUP-AC6074-095-30,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"UHC [10700]","United Healthcare",,5656.17,63.3,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 128MM 12MM REUNION SHOULDER STERILE REVERSIBLE",SUP-5568-0012,CDM,C1776,HCPCS,0278,RC,,,both,,,25615.80,7684.74,"PHCS [10601]",PHCS,,17931.06,70,,,,,0,2979.12,21773.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 10MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-610-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1425.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 12 STD KNEE LEFT CRUCIATE RETAIN PERSONA COCR",SUP-42502807401,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11558.23,40,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG GERMICIDAL DISK .75IN 1.5MM BIOPATCH CHG ANTIMICROBIAL",SUP-4151,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.49,14.85,"UHC [10700]","United Healthcare",,31.33,63.3,,,,,0,5.76,42.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE C SCREW, 3.5X16MM FA",SUP-3913516,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,1144.80,304.56,2275.09,66,521.61,3812.25,"percent of total billed charges",
"BAND ANNULOPLASTY 81MM 41.8MM 33MM DURAN ANCORE 35.8MM 2",SUP-620BG33,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STAYFIX SMALL 5-14FR SECUREMENT DRAIN CATH FSTNR",SUP-680ME,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.43,24.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.47,41.1,,,,,0,9.47,69.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM PINNACLE ACETABULAR CANCELLOUS STERILE",SUP-1217-25-500,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"KAISER [10500]",Kaiser,,767.92,67,,,,,0,133.3,974.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN AMPLATZ",SUP-67011300,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,49.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 40MM 7MM .035IN BALLOON DILATATION NYBAX",SUP-H74939171070440,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC",414,MS-DRG,,,,,,,inpatient,,,138816.43,41644.93,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,23645.96,,"Case rate ($22,099.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,520.44, add-ons for qualifying new technology services are included. If operating cost exceeds $53,560.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,933.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $20,547.58. The transfer operating threshold is the transfer adjustment factor * $20,520.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,551.45. The transfer capital threshold is the transfer adjustment factor * $1,551.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,104013.67,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 190MM 11MM SHORT CARBON FIBER BRIDGE",SUP-394.796,CDM,S27800098,LOCAL,0278,RC,,,both,,,4945.09,1483.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2269.8,45.9,,,,,0,575.11,4203.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1 KNEE LEFT TOTAL STABILIZE TRIATHLON COCR",SUP-5512-F-101,CDM,C1776,HCPCS,0278,RC,,,both,,,32652.90,9795.87,"KAISER [10500]",Kaiser,,21877.44,67,,,,,0,3797.53,27754.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1.5MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-01502,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"AETNA [10100]","Aetna HMO/PPO",,8222.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 8FR 3DRC CURVE GUIDING CORONARY",SUP-LA83DRC,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IFUSE IMPL SYSTEM TRIANGLE 35MM 7MM SPINAL FIXATION",SUP-7035-90,CDM,S27800098,LOCAL,0278,RC,,,both,,,10080.00,3024,"BLUE CROSS [10001]","Blue Cross HMO",,3951.36,39.2,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ercp Cath Pancreatic Si",PX-320000111,CDM,74329,CPT,0320,RC,,,both,,,1592.00,477.6,"CIGNA [10200]","Cigna Open Access",,905.85,56.9,,,,,0,96.47,1353.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 6MM CEREPAK XTRASOFT FREEFORM",SUP-XCR120610,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"AETNA [10100]","Aetna HMO/PPO",,10514.55,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION",RX-11634,CDM,,,0250,RC,25021-0685-10,NDC,both,1,UN,39.86,11.96,"PHCS [10601]",PHCS,,27.9,70,,,,,0,4.64,33.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION LCS SIGMA HIP THREAD HEADLESS STERILE",SUP-950502302,CDM,S27200284,LOCAL,0272,RC,,,both,,,1698.75,509.62,"CIGNA [10200]",Cigna,,1155.15,68,,,,,0,197.56,1443.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEDICAL BACK PROBLEMS WITH MCC",551,MS-DRG,,,,,,,inpatient,,,45439.03,13631.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,33272.26,,"Fee schedule rate ($33,272.26). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,10396.95,41800.26,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 15MM KNEE GVF STABILIZE ROTATE PLATFORM PFC",SUP-962163,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"CIGNA [10200]","Cigna Local Plus",,5459.73,53.5,,5372.07,4581.20,7242.98,23,1186.85,8674.34,"percent of total billed charges",
"WEDGE TIBIAL 5MM LEGION 1-2 HEMI KNEE LEFT MEDIAL RIGHT",SUP-71421141,CDM,C1776,HCPCS,0278,RC,,,both,,,15369.75,4610.92,"NOVANET [10819]",Novanet,,11527.31,75,,,,,0,1787.5,13064.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 20MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405620,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"PHCS [10601]",PHCS,,6764.42,70,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW DISTRACTION CASPAR L12 MM CERVICAL PIN STERILE",SUP-0022-LDR,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,436.13,3187.5,"percent of total billed charges",
"STENT VIABAHN 15CM 120CM 9MM 9FR ENDOPROSTHESIS HEPARIN",SUP-VBH091502,CDM,C1874,HCPCS,0278,RC,,,both,,,22428.00,6728.4,"CIGNA [10200]","Cigna Open Access",,7513.38,33.5,,,,,0,2608.38,19063.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 20MM 7FR 12MM BALLOON DILATATION NONCOMPLIANT",SUP-H74939206120270,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE ROUND SILICONE",SUP-SRF-325,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,637.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 300MM 3.2MM ASNIS III NONSTERILE",SUP-702626,CDM,S27200284,LOCAL,0272,RC,,,both,,,1020.60,306.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,694.01,68,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT 2:1 SILICONE CARDIAC DRNG 4 CHANNEL RADIOPAQUE SOLID",SUP-BCC2,CDM,S27200284,LOCAL,0272,RC,,,both,,,252.07,75.62,"PHCS [10601]",PHCS,,176.45,70,,,,,0,29.32,214.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TESTES PROCEDURES WITH CC/MCC",711,MS-DRG,,,,,,,inpatient,,,54422.83,16326.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,18795.88,,"Fee schedule rate ($18,795.88). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,7561,54422.83,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH BIOFLO DURAMAX ENDEXO BASIC 2 VALVE ADULT 28CM 15.5",SUP-H787103028045,CDM,C1750,HCPCS,0278,RC,,,both,,,1212.60,363.78,"MULTIPLAN [10600]",Multiplan,,1030.71,85,,,,,0,141.03,1030.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT STRAIGHT RETRACTION 40MM MARS 26MM",SUP-632.464S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2880.00,864,"UHC [10700]","United Healthcare",,1823.04,63.3,,,,,0,334.94,2448,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ACHILLES TENDON STRUT",SUP-02B002,CDM,S27800098,LOCAL,0278,RC,,,both,,,8073.00,2421.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,938.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD BIPOLAR 100MM 1.1MM CELONPROBREATH 25-W CONE NASAL",SUP-WB990210,CDM,S27200284,LOCAL,0272,RC,,,both,,,5992.44,1797.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL SURGICAL FULL THICK CALIBRATE DEPTH MARK CANNULATED",SUP-AR-1218-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE 10.5IN 24FR SILICONE Y PORT GRADUATE SHAFT OPEN DISTAL",SUP-8884720247E,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.71,111.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OCCL CARDIOVASCULAR 14MM SEPTAL SELF EXPANDING DELIVERY",SUP-9-ASD-014,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2471.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 38MM 140CM 3MM 2.1-2.7FR CORONARY STENT",SUP-RONYX30038UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"AETNA [10100]","Aetna HMO/PPO",,2951.44,79.5,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSORB GT1 23MM 2.5MM CORONARY EVEROLIMUS ELUTING POLY",SUP-1235250-23,CDM,C1874,HCPCS,0278,RC,,,both,,,8280.00,2484,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,962.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM CREO AMP HA SPINE CANNULATED MODULAR",SUP-1067.4541S,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Local Plus",,2006.25,53.5,,3978.14,359.25,3978.14,24,436.13,3187.5,"percent of total billed charges",
"SABER .035 5X120 40CM SL",SUP-48005012P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"PHCS [10601]",PHCS,,687.49,70,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CROSSER 146CM 20CM 1.3MM 1.1MM .067IN .014IN",SUP-CRU14PA,CDM,C1714,HCPCS,0272,RC,,,both,,,13282.50,3984.75,"KAISER [10500]",Kaiser,,8899.28,67,,,,,0,1544.75,11290.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 2.8MM 9.5-13MM 5FR DUETTE ESOPHAGEAL GASTRIC COLONIC 6",SUP-G35129,CDM,S27200284,LOCAL,0272,RC,,,both,,,2625.00,787.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,305.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE OZARK L12 MM OD4 MM SPINE CERVICAL SELF START VAR",SUP-8801-04012DA,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",117.75,860.63,"percent of total billed charges",
"VALVE AORTIC 23-26MM 0-43MM COREVALVE 29MM HEART PORCINE",SUP-MCS-P3-29-AOA-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]","Cigna Local Plus",,53865,31.5,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 100MM 120CM 10MM BILIARY VENA CAVA OTW DELIVERY",SUP-G57438,CDM,C1876,HCPCS,0278,RC,,,both,,,13109.93,3932.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5243.97,40,,,,,0,1524.68,11143.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 19GA 5.4CM TRU-CORE II COAXIAL INTRO ECHOGENIC",SUP-MCXS2010TY,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.00,28.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,39.05,41.1,,,,,0,11.05,80.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABACAVIR 600 MG-DOLUTEGRAVIR 50 MG-LAMIVUDINE 300 MG TABLET",RX-167929,CDM,,,0637,RC,49702-0231-13,NDC,both,1,UN,606.97,182.09,"AETNA [10100]","Aetna HMO/PPO",,482.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.59,515.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.75/13",SUP-401737,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12CM NATRELLE INSPIRA P6CM EXTRA FULL PROFILE",SUP-MSZ-X445,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA [10200]","Cigna Open Access",,90,56.9,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.468,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2222.75,45.9,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE KURTIS MSD 3.5MM SUCTION NEONATE ENDOTRACHEAL TUBE",SUP-4535,CDM,S27000186,LOCAL,0270,RC,,,both,,,74.05,22.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.61,62.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR BLUE 12MM TROCAR 60MM ECHELON LINEAR CUTTER",SUP-GST60B,CDM,S27200284,LOCAL,0272,RC,,,both,,,3907.19,1172.16,"UHC [10700]","United Healthcare",,2473.25,63.3,,,,,0,454.41,3321.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR ZEPHYR DR DUAL CHMBR BEAT BY BEAT AUTOCAPTURE RATE",SUP-5820,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,11905.92,28.62,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RETENTION PANNUS WITH ADHESIVE PAD MEDICAL GRADE HOOK",SUP-CZ-PRS-04,CDM,S27200284,LOCAL,0272,RC,,,both,,,571.05,171.31,"UHC [10700]","United Healthcare",,361.47,63.3,,,,,0,66.41,485.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ASCEND FLEX REV W PERF REV AUG BASEPLATE",SUP-CAP1133,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"KAISER [10500]",Kaiser,,32501.7,67,,,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONDUIT VALVE 23MM ATS OPEN PIVOT MECHANICAL GRAFT STERILE",SUP-502AG23,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"CIGNA [10200]",Cigna,,10584,40,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 240MM 6MM BALLOON DILATATION STERILE LATEX",SUP-586024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT AMNIOTIC 6.0 X 3.0 CM",SUP-NX-10-6030,CDM,Q4148,HCPCS,0636,RC,,,both,,,18144.00,5443.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2150.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,332.85,15422.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Excsn Skin Lesn Tr/Ext 1.1-2cm",PX-510000028,CDM,11402,CPT,0761,RC,,,both,,,4138.00,1241.4,"AETNA [10100]","Aetna HMO/PPO",,3289.71,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.25,3517.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fna Bx W/Fluor Gdn 1st Les",PX-361000479,CDM,10007,CPT,0361,RC,,,both,,,3171.00,951.3,"CIGNA [10200]",Cigna,,2497,,"Case rate ($2,497). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,368.79,2740.57,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PRELUDESYNC 24CM COMPRESSION BAND STERILE LATEX FREE",SUP-SDRB-REG-LT,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"CIGNA [10200]","Cigna Open Access",,173.26,56.9,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DESFLURANE 100 % INHALATION LIQUID",RX-9747,CDM,,,0250,RC,10019-0641-64,NDC,both,240,ML,1209.19,362.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,555.02,45.9,,,,,0,140.63,1027.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 401120 MDII 20X20 SRVC FEE",SUP-401120,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 CURVE PLUS 17.5MM KNEE XLK FIX BEARING SIGMA",SUP-970434,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1299.6,9498.37,"percent of total billed charges",
"LINER ACETABULAR G7 D 36MM LONGEVITY HIP STERILE LUMEN LATEX",SUP-20123604,CDM,C1776,HCPCS,0278,RC,,,both,,,8101.98,2430.59,"BLUE CROSS [10001]","Blue Cross PPO",,3175.98,39.2,,3949.44,3949.44,3949.44,"1 through 10",942.26,6886.68,"percent of total billed charges",
"KIT DRNG THORACIC 1 WAY VALVE CNCT OPTION STRAP MOBILE",SUP-16400,CDM,S27200284,LOCAL,0272,RC,,,both,,,731.20,219.36,"CIGNA [10200]","Cigna Local Plus",,391.19,53.5,,,,,0,85.04,621.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 15CM SUPERCORE COAXIAL ECHOGENIC TIP INTRO",SUP-701118150,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.65,103.09,"KAISER [10500]",Kaiser,,230.25,67,,,,,0,39.97,292.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT CYL 30X4IN 1 BLADDER 2 PORT QUICK COLOR CUFF 40IN",SUP-5921-030-235,CDM,S27200284,LOCAL,0272,RC,,,both,,,201.14,60.34,"AETNA [10100]","Aetna HMO/PPO",,159.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.39,170.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVERSTITCH ENDOSCOPIC SUTURE SYSTEM",SUP-M00505410,CDM,S27200284,LOCAL,0272,RC,,,both,,,8797.50,2639.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4038.05,45.9,,,,,0,1023.15,7477.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 150MM 2MM BALLOON DILATATION DURALYN",SUP-48002015X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MICROPOINT 9-0 VAS100-4 6IN MONOFILAMENT BLACK",SUP-2890G,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.24,86.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,118.06,41.1,,,,,0,33.41,244.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM LOCK STERILE",SUP-2361-5040S,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.05,506.11,"NOVANET [10819]",Novanet,,1265.29,75,,,,,0,196.2,1433.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 60MM 14MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-1513-14-060,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,979.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,961.36,7026.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE 40MM 57CM 10-8MM TAPER VASCULAR NITINOL",SUP-SR-100840-TCS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11.9-11.8CM NATRELLE BIOCELL P4.1-4.4CM MODERATE",SUP-SZ68300,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,207.06,68,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE AMNIOBAND PLACENTAL ALLOGRAFT DEHYDRATE",SUP-WC3160,CDM,S27800098,LOCAL,0278,RC,,,both,,,16086.04,4825.81,"BLUE CROSS [10001]","Blue Cross PPO",,6305.73,39.2,,,,,0,1870.81,13673.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 3.5MM VUEPOINT II TITANIUM NONSTERILE LATEX",SUP-8976104,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"INSRT TIBIAL 4 16MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-416,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2813.49,28.62,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB SKIN 21.4X7.65CM STRATTICE PORCINE DERMAL MATRIX",SUP-CON3006,CDM,Q4130,HCPCS,0636,RC,,,both,,,14096.70,4229.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1670.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1670.46,11982.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH OTOLOGIC 2.5X2.5CM EPIFILM EAR LAMINA FILM RESORBABLE",SUP-1417000,CDM,C1763,HCPCS,0278,RC,,,both,,,1581.53,474.46,"MULTIPLAN [10600]",Multiplan,,1344.3,85,,,,,0,183.93,1344.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 11MM 3FR GEMINI HELICAL URETERAL",SUP-M0063301140,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"AETNA [10100]","Aetna HMO/PPO",,1176.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP ENDOSCOPIC MANTIS TRUGRIP 235CM 2.8MM 3 STEP ANCHOR",SUP-M00521420,CDM,S27200284,LOCAL,0272,RC,,,both,,,3037.50,911.25,"CIGNA [10200]",Cigna,,2065.5,68,,,,,0,353.26,2581.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32X27X14MM SOVEREIGN 8D MEDIUM",SUP-7968814,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"AETNA [10100]","Aetna HMO/PPO",,27249.1,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 13MM ATLANTIS TITANIUM ANTERIOR CERVICAL",SUP-3125213,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"NOVANET [10819]",Novanet,,1057.5,75,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE",RX-27644,CDM,,,0637,RC,68462-0405-60,NDC,both,1,UN,31.58,9.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,14.5,45.9,,,,,0,3.67,26.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 9MM ECHO FX COCR LATERAL OFFSET HIP STERILE",SUP-12-151409,CDM,C1776,HCPCS,0278,RC,,,both,,,8941.02,2682.31,"MULTIPLAN [10600]",Multiplan,,7599.87,85,,,,,0,1039.84,7599.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE LARGE MALE",SUP-100611-040,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.99,17.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.86,50.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DRNG 28FR 16IN 2 EYELET TROCAR TAPERED STYLET",SUP-8428,CDM,C1729,HCPCS,0272,RC,,,both,,,86.30,25.89,"FIRST HEALTH [10303]","First Health",,69.04,80,,,,,0,10.04,73.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 4.5IN VOLKMAN 6 PRONG FENESTRATED HANDLE SHARP",SUP-22-2606,CDM,S27200284,LOCAL,0272,RC,,,both,,,453.28,135.98,"PHCS [10601]",PHCS,,317.3,70,,,,,0,52.72,385.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 18MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71933736,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"NOVANET [10819]",Novanet,,9128.7,75,,,,,0,1415.56,10345.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT RETRIEVER 20MM 3MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0032PK32010001,CDM,S27200284,LOCAL,0272,RC,,,both,,,29495.34,8848.6,"CIGNA [10200]","Cigna Local Plus",,15780.01,53.5,,,,,0,3430.31,25071.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM OPHTHALMIC SOLID BLADE CLOSED EYE LIEBERMAN 15MM",SUP-60-2005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1330.91,399.27,"CIGNA [10200]","Cigna Local Plus",,712.04,53.5,,,,,0,154.78,1131.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH AORTIC ROTATING 2.8MM X 20CM CLEANCUT STERILE",SUP-RCL28,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PICK SURGICAL 6.5IN 3MM CURVE HOUSE-ROSEN MALLEABLE",SUP-3722117,CDM,S27200284,LOCAL,0272,RC,,,both,,,653.51,196.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,444.39,68,,,,,0,76,555.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 6-0 BV-1 30IN 2 ARM MONOFILAMENT VIOLET",SUP-Z117H,CDM,S27200284,LOCAL,0272,RC,,,both,,,197.00,59.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,133.96,68,,,,,0,22.91,167.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4.2MM STERLING 6000 RPM END CUTTER",SUP-C9284,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45MM STAINLESS STEEL INSTR SURGIDAC SUT",SUP-020730,CDM,S27200284,LOCAL,0272,RC,,,both,,,544.40,163.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,63.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,63.31,462.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Compres Band Medigrip per Linear Yd",PX-E27000194,CDM,A6457,HCPCS,0270,RC,,,both,,,10.43,3.13,"KAISER [10500]",Kaiser,,6.99,67,,,,,0,1.09,8.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR LOW DOME 7MM 28MM RECESS ADVANCE ALL POLY",SUP-KPRC28LO,CDM,C1776,HCPCS,0278,RC,,,both,,,4195.20,1258.56,"MULTIPLAN [10600]",Multiplan,,3565.92,85,,,,,0,487.9,3565.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 130CM 2CM 6MM BALLOON DILATATION",SUP-U813062,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 2-0 GS-22 6IN CLSR ABSORBABLE GREEN",SUP-VLOCL2105,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"UHC [10700]","United Healthcare",,123.97,63.3,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO HALYARD STERILE LATEX FREE DISPOSABLE MIC/MIC-KEY",SUP-10237,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.93,543.58,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1232.11,68,,,,,0,210.73,1540.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 3X2.5MM APPLEBAUM INCUS HA PARTIAL CANNULATED",SUP-140973,CDM,L8613,HCPCS,0278,RC,,,both,,,2680.88,804.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,232.31,,,,,,,232.31,2278.75,"fee schedule",
"HC Dressing Wound Iodoflex",PX-E27200113,CDM,E27200113,LOCAL,0272,RC,,,both,,,61.60,18.48,"NOVANET [10819]",Novanet,,46.2,75,,,,,0,7.16,52.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MICROPOINT 9-0 TG160-6 12IN 2 ARM MONOFILAMENT",SUP-7760G,CDM,S27200284,LOCAL,0272,RC,,,both,,,185.16,55.55,"CIGNA [10200]","Cigna Local Plus",,99.06,53.5,,,,,0,21.53,157.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SALINE 175-200ML 2 WAY CHECK VALVE SMOOTH",SUP-351-175SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"KAISER [10500]",Kaiser,,569.84,67,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LEAD 75CM 5FR .046IN WORLEY ERGONOMIC WING HUB BRAID",SUP-57538CSV-WOR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1010.88,303.26,"UHC [10700]","United Healthcare",,639.89,63.3,,,,,0,117.57,859.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 12X6CM REPLIFORM PELVIC FLOOR ACELLULAR DERMAL",SUP-M0068202460,CDM,C1762,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL ADULT 5 MASK O2 RESVR BAG PATIENT VALVE LATEX",SUP-520211000A,CDM,S27000186,LOCAL,0270,RC,,,both,,,59.60,17.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.93,50.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 83MMX12MM VANGUARD ARCOM KNEE ANTERIOR STABILIZE",SUP-189122,CDM,C1776,HCPCS,0278,RC,,,both,,,8154.42,2446.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2333.8,28.62,,,,,0,948.36,6931.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 50MM 2 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800250,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LINER BIPOLAR TANDEM HIP ACETABULAR HIGH DEMAND",SUP-71701450,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]",Cigna,,7038,68,,5873.17,5873.17,5873.17,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"STPLR INTERNAL 37CM XL CIRCULAR 2 ROW SEAL 5.2MMX1.5-2.2MM",SUP-ECS29B,CDM,S27200284,LOCAL,0272,RC,,,both,,,6267.91,1880.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2876.97,45.9,,,,,0,728.96,5327.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK VITRECTOMY INFINITI ANTERIOR STERILE DISPOSABLE",SUP-8065750157,CDM,S27200284,LOCAL,0272,RC,,,both,,,1232.09,369.63,"UHC [10700]","United Healthcare",,779.91,63.3,,,,,0,143.29,1047.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP LIMIT HOLE COLOR CODED POROUS G7 G",SUP-010000667,CDM,C1776,HCPCS,0278,RC,,,both,,,10120.92,3036.28,"NOVANET [10819]",Novanet,,7590.69,75,,,,,0,1177.06,8602.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 2.75X10MM",SUP-PRV027510CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM STERILE LATEX FREE DISPOSABLE",SUP-G3606010,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +12.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00125,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"KAISER [10500]",Kaiser,,786.92,67,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +12.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00125,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,336.14,28.62,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 300MM 5.5MM EXPEDIUM Z TITANIUM NONSTERILE",SUP-179798300,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",414.32,3028.13,"percent of total billed charges",
"BASEPLT TIBIAL EVOLUTION MP 6 STD KNEE RIGHT KEEL NONPOROUS",SUP-ETPKN6SR,CDM,C1776,HCPCS,0278,RC,,,both,,,11060.70,3318.21,"MULTIPLAN [10600]",Multiplan,,9401.6,85,,,,,0,1286.36,9401.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 40CM 4FR 21GA MICROPUNCTURE .018IN",SUP-G47949,CDM,C1894,HCPCS,0272,RC,,,both,,,242.82,72.85,"KAISER [10500]",Kaiser,,162.69,67,,,,,0,28.24,206.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 10 1/8IN C W MAYO ANGLED ABDOMINAL",SUP-SU3450,CDM,S27200284,LOCAL,0272,RC,,,both,,,1314.63,394.39,"PHCS [10601]",PHCS,,920.24,70,,,,,0,152.89,1117.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 235MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.115S,CDM,C1713,HCPCS,0278,RC,,,both,,,9346.95,2804.08,"NOVANET [10819]",Novanet,,7010.21,75,,,,,0,1087.05,7944.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 90MM 3.5MM BALLOON DILATATION RAPID",SUP-47535150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"NOVANET [10819]",Novanet,,1196.78,75,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 7MM CUFFED MURPHY TIP RADIOPAQUE PILOT",SUP-86204,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.69,1.41,"NOVANET [10819]",Novanet,,3.52,75,,,,,0,0.55,3.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.3MM 18MM DISTAL RADIAL WRIST HAND LOCKING",SUP-CO-S2318,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"NOVANET [10819]",Novanet,,571.05,75,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM VARIAX T8 FULL THREAD NONSTERILE",SUP-656414,CDM,C1713,HCPCS,0278,RC,,,both,,,779.22,233.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,529.87,68,,,,,0,90.62,662.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL STEEL 6 CCS 18IN MONOFILAMENT 4 STRAND",SUP-M654G,CDM,S27200284,LOCAL,0272,RC,,,both,,,175.08,52.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.36,148.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Islet Cell Ab",PX-302000075,CDM,86341,CPT,0302,RC,,,both,,,240.50,72.15,"KAISER [10500]",Kaiser,,161.14,67,,,,,0,0.01,204.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN JUDKINS RIGHT 4 CURVE",SUP-DXT5JR40,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA [10200]","Cigna Open Access",,47.03,56.9,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 100MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540100S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"FIRST HEALTH [10303]","First Health",,1276.56,80,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 75CM 8CM 7MM BALLOON DILATATION PERIPHERAL",SUP-CQF7578,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 20MM 4MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP4020X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"NOVANET [10819]",Novanet,,394.88,75,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAVVY 150CM 4CM 3.5-3FR 2MM BALLOON DILATATION DURALYN",SUP-435204X,CDM,C1725,HCPCS,0272,RC,,,both,,,2137.50,641.25,"KAISER [10500]",Kaiser,,1432.13,67,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK 143CM 15MM 4.5MM ROUND BALLOON DILATATION",SUP-1012454-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 120MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,166.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 80MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"KAISER [10500]",Kaiser,,960.58,67,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 80CM 8CM 6MM BALLOON",SUP-G52347,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"NOVANET [10819]",Novanet,,719.83,75,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS RX 135CM 20MM 5.7-3.9FR 6MM BALLOON",SUP-BD-L60020CR,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 150MM 6MM BALLOON DILATATION OTW",SUP-H74939206061510,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 150MM 5.4FR 3MM BALLOON DILATATION 2",SUP-BD-L30150CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"PHCS [10601]",PHCS,,671.9,70,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Brain Perfusion",PX-610000081,CDM,76498,CPT,0610,RC,,,both,,,1755.00,526.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,207.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,204.11,1755,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 4CM 7MM BALLOON DILATATION",SUP-DR8074,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,163.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nephelometry",PX-301000321,CDM,83883,CPT,0301,RC,,,both,,,393.30,117.99,"CIGNA [10200]","Cigna Open Access",,29.92,,,,,,,0.01,334.31,"fee schedule",
"SABERX RADIANZ 3MM20CM 190",SUP-R51003020L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"PHCS [10601]",PHCS,,1744.32,70,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 3MM20CM 190",SUP-R51003020L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"UHC [10700]","United Healthcare",,1577.36,63.3,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 4.5MM X 8.0MM",SUP-494500812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Free Kappa Lambda",PX-301000320,CDM,83883,CPT,0301,RC,,,both,,,393.30,117.99,"UHC [10700]","United Healthcare",,12.24,,,,,,,0.01,334.31,"fee schedule",
"CATH EVERCROSS CROSSTEC 135CM 20MM 4MM .035IN BALLOON",SUP-AB35W04020135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"KAISER [10500]",Kaiser,,453.7,67,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP060200150 PLUS US D6L200UL1500",SUP-PCP060200150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"KAISER [10500]",Kaiser,,824.9,67,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plt Pheresis Lr Cmvneg Irrad",PX-390000017,CDM,P9053,HCPCS,0390,RC,,,both,,,1645.00,493.5,"CIGNA [10200]",Cigna,,1118.6,68,,,,,0,191.31,1398.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Consult Slide W Prep",PX-312000031,CDM,88323,CPT,0312,RC,,,both,,,920.40,276.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46.53,,,,,,,0.01,782.34,"fee schedule",
"CATH SABERX 90CM 150MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"UHC [10700]","United Healthcare",,1010.08,63.3,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTW TAKERU PTCA BALLOON 2.25MM X 15MM",SUP-DC-PY2215UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"UHC [10700]","United Healthcare",,625.53,63.3,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS GOLD 80CM 4CM 12MM LARGE DIAMETER BALLOON",SUP-ATG80124,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,239.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis Be Ab",PX-302000147,CDM,86707,CPT,0302,RC,,,both,,,196.98,59.09,"BLUE CROSS [10001]","Blue Cross PPO",,14.78,,"Fee schedule rate ($14.78).",,,,0,0.01,167.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-593512022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVOCATE 1500MM 200MM 2MM BALLOON DILATATION SERENE OTW",SUP-A18020200150,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 40CM 40MM 9MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV09004004P,CDM,C1725,HCPCS,0272,RC,,,both,,,10281.00,3084.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4225.49,41.1,,,,,0,1195.68,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVOCATE 1500MM 200MM 2MM BALLOON DILATATION SERENE OTW",SUP-A18020200150,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X60 135CM SL",SUP-48006006R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"FIRST HEALTH [10303]","First Health",,687.21,80,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 6MM 3.5MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012276-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHOCKWAVE M5 60MM 110CM 8MM 7MM BALLOON DILATATION",SUP-M5PIVL5560,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"PHCS [10601]",PHCS,,15214.5,70,,,,,0,2527.78,18474.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 27MM 2.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP2527X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HYPERFORM 150CM 7MM 2.8-2.2FR 3MM .01IN 2MM BALLOON",SUP-104-4370,CDM,C1725,HCPCS,0272,RC,,,both,,,10425.90,3127.77,"UHC [10700]","United Healthcare",,6599.59,63.3,,,,,0,1212.53,8862.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 20MM 5MM BALLOON DILATATION STERILE LATEX",SUP-595002022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 16X4MM COLOSSEUM 3.5D 14MM NONSTERILE LATEX",SUP-156.564,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2340.9,68,,,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 4MM 170MM KNEE STERILE",SUP-111640,CDM,C1713,HCPCS,0278,RC,,,both,,,1010.88,303.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",117.57,859.25,"percent of total billed charges",
"DRILL SURGICAL PROFILE MICRO COMPRESSION FT SCR",SUP-AR-8737-46,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 110CM 8CM 5FR 6MM 7.5MM BALLOON DILATATION",SUP-4196080L,CDM,C1725,HCPCS,0272,RC,,,both,,,931.50,279.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,110.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SELECT CORTICAL FIBULA WEDGE 8MM",SUP-210800,CDM,S27800098,LOCAL,0278,RC,,,both,,,3018.75,905.62,"NOVANET [10819]",Novanet,,2264.06,75,,,,,0,351.08,2565.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 200MM 5.5MM RELINE STRAIGHT TITANIUM MULTIAXIAL",SUP-12355200,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"CATH ARMADA 35 135CM 40MM 10MM .035IN LOW PROFILE BALLOON",SUP-B2100-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"PHCS [10601]",PHCS,,538.65,70,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER SUT ACUFEX ISOMETRY ROTATOR CUFF STERILE LATEX",SUP-013593,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.46,94.04,"PHCS [10601]",PHCS,,219.42,70,,,,,0,36.46,266.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 8MM 3MM BALLOON DILATATION PTCA",SUP-DC-RZ3008UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"FIRST HEALTH [10303]","First Health",,790.56,80,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENDOMAXX 100MM 90CM 19MM 24FR ESOPHAGEAL SILICONE",SUP-MAXX-1910,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"KAISER [10500]",Kaiser,,11557.5,67,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 9MM KNEE ONLAY MULTICOMPARTMENTAL RESTORIS",SUP-180704-2,CDM,C1776,HCPCS,0278,RC,,,both,,,4046.85,1214.05,"KAISER [10500]",Kaiser,,2711.39,67,,,,,0,470.65,3439.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GASTROJEJUNOSTOMY TUBE 18FR STOMA L2.7CM JEJUNAL L30CM S",SUP-8270-18-2.7-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"UHC [10700]","United Healthcare",,1666.56,63.3,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX23MM FRA 8D NARROW SPINE ANTERIOR",SUP-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"KAISER [10500]",Kaiser,,12663,67,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 60MM 1800MM 18MM ESOPHAGEAL METAL NITINOL",SUP-ECBA-18-060-180,CDM,C1874,HCPCS,0278,RC,,,both,,,16425.45,4927.63,"UHC [10700]","United Healthcare",,10397.31,63.3,,,,,0,1910.28,13961.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.0MM X 7MM TI",SUP-VAN-20070-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"MULTIPLAN [10600]",Multiplan,,826.2,85,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 34MM LCP STAINLESS STEEL METATARSAL LOCKING",SUP-02.211.034,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"KAISER [10500]",Kaiser,,601.75,67,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC LARGE HUB STERLING GATOR 2500-6000 RPM 13",SUP-C9266,CDM,S27200284,LOCAL,0272,RC,,,both,,,564.25,169.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,258.99,45.9,,,,,0,65.62,479.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPERIENCE NO RINSE ANTIMOCROBIAL SOLUTION 500 ML",SUP-MC-SL-0005-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEPTIC ARTHRITIS WITH CC",549,MS-DRG,,,,,,,inpatient,,,35913.08,10773.92,"PHCS [10601]",PHCS,,7561,,,,,,,7488.34,30106.36,"per diem","Estimated amount calculated based on 2 day length of stay."
"BLADE LARYNSCP SURESIGHT 1 HYPERANGULATED NONSTERILE",SUP-390211000,CDM,S27000186,LOCAL,0270,RC,,,both,,,445.50,133.65,"PHCS [10601]",PHCS,,311.85,70,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 5.5MM CD HORIZON LEGACY TITANIUM PREBENT",SUP-8690060,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Open Access",,2509.29,56.9,,1144.80,304.56,2275.09,66,512.88,3748.5,"percent of total billed charges",
"LENS IOL 10 D +14.5 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z900200145,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"FIRST HEALTH [10303]","First Health",,816.48,80,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 2.4MM INTREPID ANGLE BEVEL STAB MICRO",SUP-8065992445,CDM,S27200284,LOCAL,0272,RC,,,both,,,288.75,86.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,34.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.58,245.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA VENOUS RT ANGLE 38FR",SUP-67638,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.72,87.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,34.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.04,248.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEMMED ANATOMIC PSI KIT (HUMERAL AND GLENOID)",SUP-1235-7153-003,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,802.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 4-0 SH-1 36IN 2 ARM BRAID GREEN",SUP-X761H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL 6.25IN SMILLIE RIGHT CURVE MENISCUS",SUP-77-5002,CDM,S27200284,LOCAL,0272,RC,,,both,,,541.65,162.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,62.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.99,460.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX8MM CAPSTONE PEEK INTERBODY",SUP-2990822,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"CIGNA [10200]","Cigna Local Plus",,6686.06,31.5,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 28MM ABDOMEN THORAX SUT RETENTION",SUP-733028,CDM,C1768,HCPCS,0278,RC,,,both,,,6831.00,2049.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,794.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,794.45,5806.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INDIGO LIGHTNING CAT12 HTORQ 115CM THROMBECTOMY",SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,0272,RC,,,both,,,42147.00,12644.1,"KAISER [10500]",Kaiser,,28238.49,67,,,,,0,4901.7,35824.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 6X4IN VENTRAL HERNIA COMPOSITE",SUP-PCO1510X,CDM,C1781,HCPCS,0278,RC,,,both,,,2638.00,791.4,"CIGNA [10200]",Cigna,,1793.84,68,,,,,0,306.8,2242.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE SMR TITANIUM L35 MM OD6.5 MM SHOULDER REVISION",SUP-8420.15.040,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1057.88,68,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CLLGN FIBERTAPE FIBERWIRE 2 TAPER 7INX2MM BRAID BLUE",SUP-AR-7237-7B,CDM,S27200284,LOCAL,0272,RC,,,both,,,637.88,191.36,"PHCS [10601]",PHCS,,446.52,70,,,,,0,74.19,542.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR VIVACIT-E LL 58MM 36MM HIP NEUTRAL",SUP-00885101336,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"BLUE CROSS [10001]","Blue Cross HMO",,4018.79,39.2,,5311.50,4717.44,5388.59,31,1192.31,8714.22,"percent of total billed charges",
"CAP IDENTITY STEM/COMPREHENSIVE GLENOID/VITAMIN E/AUGMENTED",SUP-98000900280,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"BLUE CROSS [10001]","Blue Cross HMO",,19015.92,39.2,,5311.50,4717.44,5388.59,31,5641.71,41233.5,"percent of total billed charges",
"SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET",RX-171286,CDM,,,0637,RC,00078-0659-20,NDC,both,1,UN,53.31,15.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.2,45.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4F MICRO-INTRODUCER KIT",SUP-KIT-002-30,CDM,C1894,HCPCS,0272,RC,,,both,,,182.70,54.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BONE FENESTRATION PERFORATOR",SUP-P99-100-2010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 12MM STAINLESS STEEL T25 CONDYLAR SELF TAP LOCK",SUP-02.231.012,CDM,C1713,HCPCS,0278,RC,,,both,,,1738.80,521.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1182.38,68,,,,,0,202.22,1477.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-507,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]","Cigna Open Access",,4397.63,33.5,,5302.19,4377.88,6578.61,27,1526.7,11158.16,"percent of total billed charges",
"BLADE SAW 24.5X9X.64MM XSHORT NARROW THIN STAINLESS STEEL",SUP-2108145000,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"CIGNA [10200]","Cigna Open Access",,136.04,56.9,,,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR FR3.5 CURVE ANGIOGRAPHIC FEMORAL 2",SUP-H74916391012,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE 12.4X1.4MM TITANIUM 2/2.3MM SCR 6 HOLE STT FUSION",SUP-A-4660.15,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CELECOXIB 200 MG CAPSULE",RX-24501,CDM,,,0637,RC,50268-0169-11,NDC,both,1,UN,12.21,3.66,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TYSHAK II 100CM 6CM 8FR 20MM BALLOON DILATATION DEHP",SUP-611934,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE CATH 10FT 2 SENSOR EXT REDEL 10 PIN CNCT MALE TO MALE",SUP-C10MRMSTKDTCS,CDM,S27000186,LOCAL,0270,RC,,,both,,,2115.00,634.5,"AETNA [10100]","Aetna HMO/PPO",,1681.43,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,245.97,1797.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 20MM 10MM KNEE FASTTHREAD",SUP-AR-4020C-10,CDM,C1713,HCPCS,0278,RC,,,both,,,2323.13,696.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,275.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,270.18,1974.66,"percent of total billed charges",
"CANN ARTHROSCOPIC 5.2MM 120MM DRAGONWING LARGE AUTOGRAFT",SUP-AD5CH52120,CDM,S27200284,LOCAL,0272,RC,,,both,,,8273.10,2481.93,"PHCS [10601]",PHCS,,5791.17,70,,,,,0,962.16,7032.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 6FR 15CM RADIOPAQUE GWIRE STERILE DISPOSABLE",SUP-G00944,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"CIGNA [10200]",Cigna,,33.54,68,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA MEDIAL CONGRUENT 4-5 E-F KNEE",SUP-42512100613,CDM,C1776,HCPCS,0278,RC,,,both,,,9466.80,2840.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3890.85,41.1,,6417.48,6417.48,6417.48,"1 through 10",1100.99,8046.78,"percent of total billed charges",
"BOLT EXTERNAL FIXATION 1.5-2MM HOFFMANN LRF SHORT WIRE",SUP-4933-1-001,CDM,C1713,HCPCS,0278,RC,,,both,,,638.60,191.58,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,75.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,74.27,542.81,"percent of total billed charges",
"SUT VICRYL PLUS 2-0 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP839D,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.94,37.78,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN RIGHT",SUP-67018300,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC",356,MS-DRG,,,,,,,inpatient,,,161549.45,48464.83,"CIGNA [10200]","Cigna Local Plus",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 44%. Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BALL 3MM 24/26FR 3MM STERILE YELLOW",SUP-27050N,CDM,S27200284,LOCAL,0272,RC,,,both,,,1113.89,334.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 20MM 6MM BALLOON DILATATION DURALYN",SUP-48006002S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"NOVANET [10819]",Novanet,,941.63,75,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 20CM 3CM 6FR .035IN",SUP-M006192130190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"MULTIPLAN [10600]",Multiplan,,1185.95,85,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,inpatient,,,30890.30,9267.09,"UHC [10700]","United Healthcare",,30890.3,,"Fee schedule rate ($44,758.02). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,30890.3,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 29MM ONLAY ADVANCE METAL KNEE STERILE",SUP-KPON29MB,CDM,C1776,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,5302.19,4377.88,6578.61,27,601.85,4398.75,"percent of total billed charges",
"CATH DORADO CHECKER 135CM 2CM 5MM BALLOON DILATATION",SUP-DR13552,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"AETNA [10100]","Aetna HMO/PPO",,1094.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 CURVE 17.5MM KNEE GVF ROTATE PLATFORM PFC",SUP-972004,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1096.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM .0108IN AXIUM PRIME HELICAL",SUP-APB-2-4-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"BLUE CROSS [10001]","Blue Cross PPO",,3502.72,39.2,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT ACCESS DA VINCI SP 2.7-4CM SMALL KIT INCISION",SUP-430073,CDM,S27200284,LOCAL,0272,RC,,,both,,,3741.25,1122.37,"NOVANET [10819]",Novanet,,2805.94,75,,,,,0,435.11,3180.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IBUPROFEN 400 MG TABLET",RX-3843,CDM,,,0637,RC,00904-5853-61,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM VUEPOINT II SPINE MULTIAXIAL NONSTERILE",SUP-8975324,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 LEFT KNEE POSTERIOR STABILIZED CEMENTED",SUP-5515-F-501,CDM,C1776,HCPCS,0278,RC,,,both,,,16566.90,4970.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4473.06,27,,,,,0,1926.73,14081.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLITTER CATH CPS UNIVERSAL II STERILE LATEX FREE DISPOSABLE",SUP-DS2A006,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 5-0 V-5 36IN 2 ARM MONOFILAMENT BLUE",SUP-8934H,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.98,25.49,"KAISER [10500]",Kaiser,,56.94,67,,,,,0,9.88,72.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 1 9MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530-P-109,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS [10001]","Blue Cross HMO",,3275.51,39.2,,5311.50,4717.44,5388.59,31,971.79,7102.52,"percent of total billed charges",
"STEM FEMORAL COLLAR AVENIR COMPLETE 4 STD HIP STERILE LATEX",SUP-574201040,CDM,C1776,HCPCS,0278,RC,,,both,,,23461.20,7038.36,"CIGNA [10200]","Cigna Open Access",,7859.5,33.5,,5302.19,4377.88,6578.61,27,2728.54,19942.02,"percent of total billed charges",
"NDL BIOPSY 19GA 10.2CM SUPERCORE COAXIAL INTRO ECHOGENIC TIP",SUP-MCXS2015LY,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.64,44.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.4,127.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 480MM 6MM XIA 3 TITANIUM NONSTERILE",SUP-48233480,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"ANCHOR SUT 4.75MM SWIVELOCK KNOTLESS PEEK STERILE LATEX FREE",SUP-AR-1665KPSL,CDM,C1713,HCPCS,0278,RC,,,both,,,6049.58,1814.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4113.71,68,,,,,0,703.57,5142.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 12MM OLIF51 DIVERGENCE-L BONE SPINE",SUP-2150012,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Open Access",,5889.15,56.9,,1144.80,304.56,2275.09,66,1203.71,8797.5,"percent of total billed charges",
"CMPNT TIBIAL XS-XL LEFT KNEE MODULAR ROTATING HINGE",SUP-6481-2-100,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2995.6,28.62,,,,,0,1217.29,8896.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 4 127D",SUP-6721-0435,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2786.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 3INX12MM OSTEOTOM THIN MRI STERILE LATEX FREE",SUP-47998602122,CDM,S27200284,LOCAL,0272,RC,,,both,,,996.30,298.89,"NOVANET [10819]",Novanet,,747.23,75,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 125MM STAINLESS STEEL 2.7/3.5MM SCR 7 HOLE LCP BONE",SUP-02.112.145,CDM,C1713,HCPCS,0278,RC,,,both,,,3194.63,958.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,378.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,371.54,2715.44,"percent of total billed charges",
"SPACER SPINAL 45X18X10-17MM RISE-L 10D",SUP-193.333,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"NOVANET [10819]",Novanet,,25751.25,75,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAPHAZOLINE 0.025 %-PHENIRAMINE 0.3 % EYE DROPS",RX-5384,CDM,,,0637,RC,00065-0085-15,NDC,both,15,ML,59.16,17.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.88,50.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID COMPREHENSIVE MEDIUM SHOULDER AUG TAPER",SUP-110032420,CDM,C1776,HCPCS,0278,RC,,,both,,,10764.00,3229.2,"UHC [10700]","United Healthcare",,6813.61,63.3,,8601.07,8395.67,8601.07,"1 through 10",1251.85,9149.4,"percent of total billed charges",
"INSRT TIBIAL 4+ 10MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS4P10R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"CIGNA [10200]","Cigna Open Access",,5912.71,56.9,,5302.19,4377.88,6578.61,27,1208.52,8832.69,"percent of total billed charges",
"STEM FEMORAL 125MM CEMENTLESS OFFSET ACCOLADE TMZF 132D 4 +0",SUP-6020-0435,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"UHC [10700]","United Healthcare",,9905.94,63.3,,8601.07,8395.67,8601.07,"1 through 10",1820,13301.82,"percent of total billed charges",
"SCREW METAPHYSEAL LOCKING 3.7MM X 38MM TI",SUP-MTLS-37380-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",155.43,1136.03,"percent of total billed charges",
"VALVE AORTIC 25MM 20.4MM MASTERS 85D 3.09SQ CM STD RING",SUP-25AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"NOVANET [10819]",Novanet,,21839.42,75,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.5 2-0 CURVE FIBERSTITCH FIBERWIRE IMPL",SUP-AR-4580,CDM,C1713,HCPCS,0278,RC,,,both,,,3984.75,1195.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1829,45.9,,,,,0,463.43,3387.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 135D STD BARREL 78MM STAINLESS STEEL 1 STEP SYSTEM 4",SUP-281.140,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",434.96,3179,"percent of total billed charges",
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 38MM 144CM 4MM",SUP-H7493941238400,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"BLUE CROSS [10001]","Blue Cross HMO",,3042.9,39.2,,9776.84,9776.84,9776.84,"1 through 10",902.78,6598.13,"percent of total billed charges",
"STEM HUMERAL 116MM 10.5MM MODULAR REMEDY STAINLESS STEEL",SUP-RSHSMD,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"FIRST HEALTH [10303]","First Health",,16380,80,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 16GA 15GA 15CM TEMNO EVOLUTION 2 NOTCH COAXIAL",SUP-CTT1615,CDM,S27200284,LOCAL,0272,RC,,,both,,,439.91,131.97,"PHCS [10601]",PHCS,,307.94,70,,,,,0,51.16,373.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemosiderin Qual",PX-301000231,CDM,83070,CPT,0301,RC,,,both,,,229.00,68.7,"KAISER [10500]",Kaiser,,153.43,67,,,,,0,0.01,194.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 7CM 12MM GORE EXCLUDER ILIAC INTERNAL",SUP-HGB161207A,CDM,S27800098,LOCAL,0278,RC,,,both,,,19089.00,5726.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2262.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2220.05,16225.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE XLONG TITANIUM 14 HOLE BONE RIGHT LATERAL EPICONDYLAR",SUP-PL-LEL14R,CDM,C1713,HCPCS,0278,RC,,,both,,,6755.10,2026.53,"PHCS [10601]",PHCS,,4728.57,70,,,,,0,785.62,5741.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE DEMINERALIZED BONE MATRIX 5X2.5CM",SUP-7509225,CDM,S27800098,LOCAL,0278,RC,,,both,,,13765.50,4129.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5657.62,41.1,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR .071IN MULTIPURPOSE 2 CURVE GUIDING NYLON",SUP-LA6MP2,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X18X10-17MM RISE-L 10D",SUP-193.333,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4068.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG ACETABULAR 25MM 62MM RESTORATION WEDGE",SUP-5096-6225,CDM,C1776,HCPCS,0278,RC,,,both,,,12461.40,3738.42,"MULTIPLAN [10600]",Multiplan,,10592.19,85,,,,,0,1449.26,10592.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB TISSUE 13X6CM STRATTICE PORCINE DERMAL MATRIX MESH",SUP-0613009,CDM,Q4130,HCPCS,0636,RC,,,both,,,9487.50,2846.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1124.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1124.27,8064.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLORBETABEN F-18 INTRAVENOUS SOLUTION (0-8.1 MCI)",RX-229540,CDM,Q9983,HCPCS,0343,RC,08888-8878-55,NDC,both,1,UN,15094.80,4528.44,"BLUE CROSS [10001]","Blue Cross PPO",,3962.7,,,,,,,1755.53,12830.58,"fee schedule",
"KIT INTRO HALYARD STERILE LATEX FREE DISPOSABLE MIC/MIC-KEY",SUP-10237,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.93,543.58,"CIGNA [10200]",Cigna,,1232.11,68,,,,,0,210.73,1540.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM G7 THR E1 POROUS HIP CUP AA LINER",SUP-98B00100939,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL 33MM INSET 0MM SHOULDER TITANIUM REVERSE",SUP-2R1M380001,CDM,C1776,HCPCS,0278,RC,,,both,,,6423.90,1927.17,"FIRST HEALTH [10303]","First Health",,5139.12,80,,,,,0,747.1,5460.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X17MM LUMINARY 10-11MM SPINE",SUP-14717,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8505,27,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROLENE 6X6IN KNIT NONABSORBABLE 2 DIRECTIONAL",SUP-SPMH,CDM,C1781,HCPCS,0278,RC,,,both,,,1873.59,562.08,"CIGNA [10200]",Cigna,,1274.04,68,,,,,0,217.9,1592.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 85MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.412,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"CIGNA [10200]","Cigna Open Access",,787.57,56.9,,1144.80,304.56,2275.09,66,160.97,1176.51,"percent of total billed charges",
"HEAD UNIPOLAR 52MM CENTERPULSE LEGACY 12/14 TAPER HIP FEMUR",SUP-451000052,CDM,C1776,HCPCS,0278,RC,,,both,,,2398.65,719.59,"PHCS [10601]",PHCS,,1679.06,70,,,,,0,278.96,2038.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR STRAIGHT 260CM 7CM .035IN",SUP-M001465261,CDM,C1769,HCPCS,0272,RC,,,both,,,494.10,148.23,"PHCS [10601]",PHCS,,345.87,70,,,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS MULTIPASS 3-0 PS-2 27IN BRAID COATED UNDYED",SUP-VCP427H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 12MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-112-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4813.44,40,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 115CM 6FR 2-5-2MM SPACE F CURVE MAPPING STERILE",SUP-F6QF252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,107.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +14 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1400,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 22CM FEMUR PROXIMAL TALON DISTALFIX",SUP-SLN-130-220,CDM,C1713,HCPCS,0278,RC,,,both,,,13227.30,3968.19,"AETNA [10100]","Aetna HMO/PPO",,10515.7,79.5,,1521.93,481.35,16760.95,30,1538.33,11243.21,"percent of total billed charges",
"STENT ZILVER 635 8CM 200CM 10MM 6FR .035IN BILIARY NITINOL",SUP-G50624,CDM,C1876,HCPCS,0278,RC,,,both,,,13275.60,3982.68,"CIGNA [10200]","Cigna Open Access",,4447.33,33.5,,,,,0,1543.95,11284.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0270,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,110.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",110.22,805.55,"percent of total billed charges",
"BLADE INTRAMEDULLARY NAIL GOLD 95MM 10.35MM TFN-ADVANCED",SUP-04.038.295S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"CIGNA [10200]",Cigna,,2707.66,68,,1831.33,1831.33,1831.33,16,463.09,3384.57,"percent of total billed charges",
"INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION",RX-10289,CDM,J1815,HCPCS,0637,RC,00002-8215-01,NDC,both,10,ML,404.15,121.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.22,,,,,,,47,343.53,"fee schedule",
"STEM FEMORAL 150MM 16MM PRESSFIT TRIATHLON TITANIUM FLUTE",SUP-5566-S-016,CDM,C1776,HCPCS,0278,RC,,,both,,,5447.65,1634.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,645.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,633.56,4630.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG MIDFACE 6 HOLE 2Y 1.5MM SCREWS BONE TITANIUM",SUP-01-7112,CDM,C1713,HCPCS,0278,RC,,,both,,,1441.80,432.54,"CIGNA [10200]",Cigna,,980.42,68,,1831.33,1831.33,1831.33,16,167.68,1225.53,"percent of total billed charges",
"LINER ACETABULAR RINGLOC 25 36MM E-POLY HIP STERILE HIGH",SUP-EP-105915,CDM,C1776,HCPCS,0278,RC,,,both,,,14076.00,4222.8,"CIGNA [10200]",Cigna,,5630.4,40,,5873.17,5873.17,5873.17,"1 through 10",1637.04,11964.6,"percent of total billed charges",
"FRCP SURGICAL VIRTUS 6IN SPLINTER STAINLESS STEEL",SUP-30-4258,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.38,72.11,"AETNA [10100]","Aetna HMO/PPO",,191.1,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.96,204.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE L-ACSR 6D ALLOGRAFT FREEZE DRIED 11",SUP-340511,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT ARTICULAR 3-4 C-D 17MM KNEE FIX BEARING PROLONG NEXGE",SUP-596203017,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2266.26,28.62,,,,,0,920.91,6730.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY 400ML GEL P5.1CM HIGH PROFILE ROUND 12.3CM",SUP-RSZ-4004,CDM,S27200284,LOCAL,0272,RC,,,both,,,127.64,38.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.84,108.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 36MM REVISION MEDIUM LONG SHOULDER",SUP-520003036,CDM,C1776,HCPCS,0278,RC,,,both,,,29116.08,8734.82,"NOVANET [10819]",Novanet,,21837.06,75,,,,,0,3386.2,24748.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC MEDIUM 16IN 16-19IN KNEE CONTACT CLSR",SUP-79-80015,CDM,S27000186,LOCAL,0270,RC,,,both,,,98.92,29.68,"MULTIPLAN [10600]",Multiplan,,84.08,85,,,,,0,11.5,84.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 16MM 23MM BIOCOR FLEXFIT LOW PROFILE SUPRA",SUP-BSP100-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,32715.90,9814.77,"BLUE CROSS [10001]","Blue Cross PPO",,12824.63,39.2,,,,,0,3804.86,27808.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 11MM KII Z THREADED HANDLED",SUP-CTR34,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"UHC [10700]","United Healthcare",,154.2,63.3,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN JUDKINS RIGHT 5",SUP-534623T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,39.93,45.9,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 3003059 ZEVO 59MM 3 LVL",SUP-3003059,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"CIGNA [10200]","Cigna Local Plus",,2831.22,53.5,,3978.14,359.25,3978.14,24,615.46,4498.2,"percent of total billed charges",
"CAP SYSTEM TKR POROUS FEMUR PATELLA TIBIA CEMENT HYBRID",SUP-98000670511,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6310.71,28.62,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL DIA11.5MM HOLLOW FOR 9.5MM MULTILOC PROXIMAL HUMER",SUP-03.019.004,CDM,S27200284,LOCAL,0272,RC,,,both,,,2383.50,715.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,282.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,277.2,2025.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 8CM 6FR 10MM .035IN BALLOON",SUP-G52375,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.47,41.1,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SUCTION CONNECTING TUBE",SUP-16-66302,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 12MM 3MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3012X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MAXFIRE FIXATION MENISCUS REPAIR ZIPLOOP TECHNOLOGY",SUP-900339,CDM,C1713,HCPCS,0278,RC,,,both,,,3307.50,992.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,391.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,384.66,2811.38,"percent of total billed charges",
"PSEUDOEPHEDRINE 30 MG TABLET",RX-6714,CDM,,,0637,RC,00904-6990-61,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOZORB MARKER LP, 3CM X 3CM X 1CM",SUP-F0331,CDM,A4648,HCPCS,0278,RC,,,both,,,5250.00,1575,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,610.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,610.58,4462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20GA 8CM POWERGLIDE PRO BIOPATCH BASIC INSRT",SUP-F320087T,CDM,S27200284,LOCAL,0272,RC,,,both,,,575.67,172.7,"KAISER [10500]",Kaiser,,385.7,67,,,,,0,66.95,489.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE NORIAN CALCIUM PHOSPHATE FIBER 10CC DRILLABLE",SUP-07.704.110S,CDM,C1713,HCPCS,0278,RC,,,both,,,15870.00,4761,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6522.57,41.1,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 4-0 PSL 30IN MONOFILAMENT BLACK NONABSORBABLE",SUP-562H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 4-11 E-F KNEE RIGHT TIBIA",SUP-42522200510,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7327.97,68,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR CHEST TRAUMA WITH CC",184,MS-DRG,,,,,,,inpatient,,,32048.25,9614.47,"CIGNA [10200]",Cigna,,13952.48,,"Fee schedule rate ($13,952.48). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,6600.69,26537.59,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 36MM QUICKFIX TITANIUM SHORT PARTIAL THREAD T15",SUP-AR-8740-36PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-150440106,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"CIGNA [10200]",Cigna,,12045.6,40,,5873.17,5873.17,5873.17,"1 through 10",3502.26,25596.9,"percent of total billed charges",
"NDL INTRO 14.9CM 17GA SUPERCORE COAXIAL ECHOGENIC",SUP-MCXS1820LX,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.64,44.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.4,127.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 60MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.860,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,159.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",159.84,1168.25,"percent of total billed charges",
"INSTRUMENT SURGICAL RELINE FENESTRATE REPLACEABLE TIP NONSTE",SUP-1729023,CDM,S27000186,LOCAL,0270,RC,,,both,,,1395.23,418.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,162.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORTHOLOC 3DI FOOT RECONSTRUCTION SYSTEM HALLUX PLATES - MTP",SUP-587220RT,CDM,C1713,HCPCS,0278,RC,,,both,,,12420.00,3726,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5104.62,41.1,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP5PL,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2547.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2500.67,18276.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS02006,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]",Cigna,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 35MM 4.5MM AEQUALIS REVERSED GLENOID TITANIUM",SUP-VDV235,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1058.08,68,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 11MM KNEE CONSTRAIN UHMWPE GENESIS II",SUP-71420538,CDM,C1776,HCPCS,0278,RC,,,both,,,18474.75,5542.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7593.12,41.1,,6417.48,6417.48,6417.48,"1 through 10",2148.61,15703.54,"percent of total billed charges",
"SYSTEM PUSHLOCK SHORT 2.9MM FIXATION BIOCOMPOSITE",SUP-AR-2923BCS,CDM,C1713,HCPCS,0278,RC,,,both,,,5107.73,1532.32,"PHCS [10601]",PHCS,,3575.41,70,,,,,0,594.03,4341.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC BREAST BIOPSY 14CM 9GA ATEC 20MM STD MRI DISPOSABLE","SUP-ATEC 0914-20MR",CDM,S27200284,LOCAL,0272,RC,,,both,,,2619.00,785.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,304.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,304.59,2226.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHISEL SURGICAL 6.25IN 4MM V BALLENGER",SUP-63-0089,CDM,S27200284,LOCAL,0272,RC,,,both,,,415.43,124.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,48.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.31,353.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.285,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM 16.7MM MASTERS HP 85D SUPRA ANNULAR",SUP-19AEHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"NOVANET [10819]",Novanet,,21839.42,75,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.3MM 19MM THREAD LOCK TITANIUM NONSTERILE",SUP-TPLS-23190-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,680.40,204.12,"CIGNA [10200]","Cigna Open Access",,387.15,56.9,,1144.80,304.56,2275.09,66,79.13,578.34,"percent of total billed charges",
"TUBE JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE MIC-KEY",SUP-0270-18-2.7-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"KAISER [10500]",Kaiser,,1763.98,67,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM CD HORIZON SPINAL FENESTRATE MULTIAXIAL",SUP-55840025545T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 4 62MM 9.4MM SHILEY CUFF DISPOSABLE INNER CANN",SUP-4CN65H,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.97,110.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.68,311.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 120CM 6MM 8FR STRAIGHT VASCULAR",SUP-AVSL06100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"KAISER [10500]",Kaiser,,12240.9,67,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SMALL INTERNAL HORIZON TITANIUM ENDOSCOPIC LIGATING",SUP-001201,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.48,18.44,"CIGNA [10200]","Cigna Local Plus",,32.89,53.5,,,,,0,7.15,52.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXERCISER REHABILITATION FITBALL SEATING 15IN",SUP-561735,CDM,S27000186,LOCAL,0270,RC,,,both,,,306.41,91.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,125.93,41.1,,,,,0,35.64,260.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 5.0 MM X 100 MM X 130 CM",SUP-IPU05010013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"UHC [10700]","United Healthcare",,5110.21,63.3,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 50MM MATRIX TITANIUM SPINE THORACOLUMBAR",SUP-04.606.650,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 38MM 144CM 4MM CORONARY STENT",SUP-H7493941838400,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 80MM 120CM 10MM .079IN LARGE",SUP-SERB65-10-80-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION .062IN 9IN KIRSCHNER DUAL TROCAR POINT BOTH",SUP-1600-1962T,CDM,C1713,HCPCS,0278,RC,,,both,,,200.22,60.07,"BLUE CROSS [10001]","Blue Cross HMO",,78.49,39.2,,957.42,156.86,7483.26,51,23.29,170.19,"percent of total billed charges",
"SCR BONE 3.5MM 40MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.140,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,770.24,68,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DISTRACTION 14MM CASPAR STERILE",SUP-73-2592-S5,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE XS OVAL 240CM 1.9MM PROFILE LOOP FLEXIBLE ENDOSCOPIC",SUP-M00562531,CDM,S27200284,LOCAL,0272,RC,,,both,,,176.10,52.83,"PHCS [10601]",PHCS,,123.27,70,,,,,0,20.48,149.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 5.5MM CD HORIZON LEGACY TITANIUM PREBENT",SUP-8690070,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,512.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",512.88,3748.5,"percent of total billed charges",
"INSRT ACETABULAR 56MM 32MM 10D HIP CROSSFIRE OMNIFIT STERILE",SUP-2041C-3256,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"KAISER [10500]",Kaiser,,4715.46,67,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 105MM 16MM DCP LC-DCP STAINLESS STEEL",SUP-216.105,CDM,C1713,HCPCS,0278,RC,,,both,,,485.35,145.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,138.91,28.62,,,,,0,56.45,412.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 42.5MM TRIGEN FEMUR LOW PROFILE",SUP-71645042,CDM,C1713,HCPCS,0278,RC,,,both,,,2314.95,694.48,"CIGNA [10200]",Cigna,,1574.17,68,,1831.33,1831.33,1831.33,16,269.23,1967.71,"percent of total billed charges",
"SCR BONE 3.5MM 2.7MM 16MM STAINLESS STEEL PERIARTICULAR",SUP-00235901638,CDM,C1713,HCPCS,0278,RC,,,both,,,1275.75,382.72,"KAISER [10500]",Kaiser,,854.75,67,,,,,0,148.37,1084.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL CANNULATED LARGE QUICK COUPLING 6.5 MM 7.5",SUP-03.333.214,CDM,S27000186,LOCAL,0270,RC,,,both,,,2965.05,889.51,"MULTIPLAN [10600]",Multiplan,,2520.29,85,,,,,0,344.84,2520.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 6FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006145361190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CIGNA [10200]","Cigna Open Access",,642.94,,,,,,,131.41,960.46,"percent of total billed charges",
"SCR BONE 4.5MM 85MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.885,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,50.59,369.75,"percent of total billed charges",
"VALVE AORTIC 14.2MM 25MM 23.4MM ON-X 34MM CYLINDRICAL HEART",SUP-ONXANE-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"AETNA [10100]","Aetna HMO/PPO",,30051,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TFAT50 UVA PANOPTIX TORIC",SUP-TFAT50,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"NOVANET [10819]",Novanet,,633.75,75,,,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 22MM 10D E HIP CONSTRAIN TRIDENT",SUP-690-10-22E,CDM,C1776,HCPCS,0278,RC,,,both,,,17046.45,5113.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4878.69,28.62,,,,,0,1982.5,14489.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 4FR 11CM HEXACUSPID VALVE KINK RESISTANT CANN",SUP-504604X,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID",RX-28188,CDM,,,0637,RC,00116-1061-04,NDC,both,118,ML,28.21,8.46,"FIRST HEALTH [10303]","First Health",,22.57,80,,,,,0,3.28,23.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM GALAXY G3 XTRASOFT NEUROVASCULAR",SUP-GLX120410,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1381.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 20MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962325,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"AETNA [10100]","Aetna HMO/PPO",,11530.52,79.5,,10981.53,8986.79,12413.38,12,1686.79,12328.23,"percent of total billed charges",
"SYSTEM HALYARD BALLARD 3.5MM 3MM 12IN 7FR 4MM SUCTION",SUP-197,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.21,33.06,"MULTIPLAN [10600]",Multiplan,,93.68,85,,,,,0,12.82,93.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 10X4IN ANTIMICROBIAL BACK FILM MULTILAYER ABSORBENT",SUP-498450,CDM,S27200284,LOCAL,0272,RC,,,both,,,219.24,65.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.5,186.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 44MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-44-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,670.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,658.03,4809.3,"percent of total billed charges",
"KIT STENT 7CM 5FR ADVANIX NAVIFLEX STRAIGHT PANCREATIC",SUP-M00537530,CDM,C2625,HCPCS,0278,RC,,,both,,,1411.18,423.35,"BLUE CROSS [10001]","Blue Cross PPO",,553.18,39.2,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Thorac Spine W/WO Cntrst",PX-612000008,CDM,72157,CPT,0612,RC,,,both,,,5553.36,1666.01,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,916.05,,,,,,,645.86,4720.36,"fee schedule",
"CATH SABERX 150CM 150MM 5MM BALLOON DILATATION RAPID",SUP-47550150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP SECTOR POROCOAT PINNACLE STERILE",SUP-121722058,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"CIGNA [10200]","Cigna Open Access",,3818.42,56.9,,5302.19,4377.88,6578.61,27,780.46,5704.15,"percent of total billed charges",
"SET THORACENTESIS 30IN 15GA PORTEX MALE ADPTR SLIDE CLAMP",SUP-PTX465348,CDM,C1729,HCPCS,0272,RC,,,both,,,48.66,14.6,"NOVANET [10819]",Novanet,,36.5,75,,,,,0,5.66,41.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 41X14X.38MM HALL MICRO STAINLESS STEEL SAGITTAL",SUP-5301025033,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.29,43.59,"CIGNA [10200]","Cigna Local Plus",,77.73,53.5,,,,,0,16.9,123.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 5.5MM TSRH-3D LARGE SPINE TITANIUM OFFSET",SUP-8379122,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Local Plus",,1905.94,53.5,,3978.14,359.25,3978.14,24,414.32,3028.13,"percent of total billed charges",
"SCR INTERFERENCE TITANIUM 25MM 9MM ORTHOPEDIC CANNULATED",SUP-C8610,CDM,C1713,HCPCS,0278,RC,,,both,,,1016.15,304.84,"BLUE CROSS [10001]","Blue Cross PPO",,398.33,39.2,,957.42,570.23,957.42,28,118.18,863.73,"percent of total billed charges",
"CAGE SPINAL 8X22X55MM 10DEG LORDOTIC WIDE MODULUS XL-W",SUP-1221855P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION SWIVELOCK MENISCAL BIOCOMPOSITE",SUP-AR-4550BC,CDM,C1713,HCPCS,0278,RC,,,both,,,12316.50,3694.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3524.98,28.62,,,,,0,1432.41,10469.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 C-1 30IN 2 ARM MONOFILAMENT BLUE",SUP-8706H,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.57,52.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,79.67,45.9,,,,,0,20.19,147.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 2 KNEE RIGHT CRUCIATE RETAINING PFC SIGMA",SUP-940022,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3067.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3010.99,22006.37,"percent of total billed charges",
"PLATE BROAD 135MM STAINLESS STEEL 4.5MM SCREWS LARGE",SUP-226.08,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,1831.33,1831.33,1831.33,16,434.96,3179,"percent of total billed charges",
"SCR BONE 5MM 58MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.058TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"STIM SPRINT EXTENSA NERVE NONSTERILE LATEX FREE DISPOSABLE",SUP-9288-6002,CDM,C1778,HCPCS,0278,RC,,,both,,,51030.00,15309,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6047.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5934.79,43375.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.75MM X 18.0MM",SUP-493751812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 57MM 135CM 9MM 60MM BILIARY STAINLESS STEEL",SUP-PXB35-09-57-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1249.84,28.62,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPLR ANASTOMOSIS 2MM GEM MICROVASCULAR STERILE DISPOSABLE",SUP-GEM2752,CDM,S27200284,LOCAL,0272,RC,,,both,,,2962.50,888.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1217.59,41.1,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PRELUDE ROADSTAR 65CM 75CM 6FR .088IN GUIDING",SUP-PG6F65S,CDM,C1894,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM RADIUS DISTAL VOLAR LOCK 3 LEAD TAPER",SUP-131227118,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"PHCS [10601]",PHCS,,935.55,70,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 31CM 14.5FR STD STRAIGHT POLYURETHANE GLIDEPATH",SUP-5393310R,CDM,C1750,HCPCS,0278,RC,,,both,,,2062.50,618.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1402.5,68,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GALLIUM-67 CITRATE INTRAVENOUS SOLUTION (4-5 MCI)",RX-411844,CDM,A9556,HCPCS,0343,RC,08888-8877-95,NDC,both,1,UN,404.00,121.2,"FIRST HEALTH [10303]","First Health",,323.2,80,,,,,0,0.06,343.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 5FR MP CURVE GUIDING DURAFORM",SUP-M003101630,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,296.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG GERMICIDAL 4X5IN AQUACEL AG",SUP-422299,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.99,21,"CIGNA [10200]",Cigna,,47.59,68,,,,,0,8.14,59.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,inpatient,,,44667.96,13400.39,"AETNA [10100]","Aetna HMO/PPO",,23554.5,,"Fee schedule rate ($23,554.50). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,36550.47,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS MULTIPASS 3-0 PS-1 18IN MONOFILAMENT",SUP-PDP683G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Open Access",,14.23,56.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HTC VITRECTOMY CORRECTION LENS THUMBSCREW COVER FULL",SUP-40211,CDM,S27200284,LOCAL,0272,RC,,,both,,,1731.38,519.41,"CIGNA [10200]",Cigna,,1177.34,68,,,,,0,201.36,1471.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 RIGHT KNEE POSTERIOR STABILIZED CEMENTED",SUP-5515-F-602,CDM,C1776,HCPCS,0278,RC,,,both,,,16566.90,4970.07,"CIGNA [10200]","Cigna Local Plus",,5218.57,31.5,,5372.07,4581.20,7242.98,23,1926.73,14081.87,"percent of total billed charges",
"TARGET 360 SOFT 3MM X 10CM",SUP-M0035473100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]","Cigna Open Access",,4728.4,33.5,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 STD KNEE LEFT CRUCIATE RETAIN CEMENT PERSONA",SUP-42572606401,CDM,C1776,HCPCS,0278,RC,,,both,,,26429.76,7928.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3131.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3073.78,22465.3,"percent of total billed charges",
"CAP HYBRID TOTAL KNEE SYSTEM (EITHER POROUS FEMUR OR TIBIA)",SUP-98000600208,CDM,C1776,HCPCS,0278,RC,,,both,,,26460.00,7938,"FIRST HEALTH [10303]","First Health",,21168,80,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE EVERPOINT 6-0 BV 24IN 2 ARM MONOFILAMENT BLUE",SUP-8610H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM MITRAL SEMIRIGID MEMO 3D",SUP-SMD34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13455.00,4036.5,"AETNA [10100]","Aetna HMO/PPO",,10696.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD SUT ASSISTANT 2-0 EEN 6IN UNIT ETHIBOND EXCEL STERILE",SUP-SW112,CDM,S27200284,LOCAL,0272,RC,,,both,,,500.19,150.06,"UHC [10700]","United Healthcare",,316.62,63.3,,,,,0,58.17,425.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 10-0 BVH100-3 5IN MONOFILAMENT BLACK",SUP-2860G,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.30,72.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.3,206.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM LOCKING",SUP-58803514,CDM,C1713,HCPCS,0278,RC,,,both,,,1506.60,451.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,175.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",175.22,1280.61,"percent of total billed charges",
"FRCP BIPOLAR 9IN SPETZLER-MALIS SLIM 1MM DISPOSABLE",SUP-6780-230-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,3208.53,962.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,380.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,373.15,2727.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH XP 100CM 5FR STRAIGHT ANGIOGRAPHIC STAINLESS",SUP-ZM75110M,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONDUIT VALVE 21MM KONECT AORTIC RESILIA",SUP-11060A21,CDM,S27800098,LOCAL,0278,RC,,,both,,,79800.00,23940,"CIGNA [10200]",Cigna,,31920,40,,,,,0,9280.74,67830,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 6.3IN SEWALL HANDHELD SURGICAL",SUP-N3323,CDM,S27200284,LOCAL,0272,RC,,,both,,,1320.30,396.09,"KAISER [10500]",Kaiser,,884.6,67,,,,,0,153.55,1122.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 20X10.5IN OVITEX PRS CONTOUR OVINE",SUP-R20252-1020G,CDM,C1781,HCPCS,0278,RC,,,both,,,20981.27,6294.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6004.84,28.62,,,,,0,2440.12,17834.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7.5CM 4MM CEREPAK MICRO UNIFORM DETACHABLE",SUP-FCX100407,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS [10001]","Blue Cross HMO",,5184.53,39.2,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 28MMX1.5MM MANDIBLE 4 HOLE LOCK 2/2.3MM SCR BONE LEVEL",SUP-50-712-04-09,CDM,C1713,HCPCS,0278,RC,,,both,,,3513.83,1054.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2389.4,68,,,,,0,408.66,2986.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONCIERGE 100CM 8FR AL.75 CURVE GUIDING STAINLESS STEEL",SUP-CGC8100AL75,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 48MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.548,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"CIGNA [10200]","Cigna Local Plus",,586.58,53.5,,3978.14,359.25,3978.14,24,127.51,931.96,"percent of total billed charges",
"STENT ORSIRO 3.5/26",SUP-401763,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL HOOK TAB HEADSTRAP QUICK RELEASE BUCKLE UNIVERSAL",SUP-OPT1046,CDM,S27000186,LOCAL,0270,RC,,,both,,,264.70,79.41,"UHC [10700]","United Healthcare",,167.56,63.3,,,,,0,30.78,225,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 60ML .1-4MM ALLOGRAFT CRUSH FREEZE",SUP-T20027,CDM,S27800098,LOCAL,0278,RC,,,both,,,6399.75,1919.92,"KAISER [10500]",Kaiser,,4287.83,67,,,,,0,744.29,5439.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE TUTOPLAST PERICARDIUM ALLOGRAFT",SUP-938227,CDM,C1762,HCPCS,0278,RC,,,both,,,6720.60,2016.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,796.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,781.61,5712.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 22MM AO QUICK 1.2MM SCREWS",SUP-60-10322,CDM,S27200284,LOCAL,0272,RC,,,both,,,724.63,217.39,"NOVANET [10819]",Novanet,,543.47,75,,,,,0,84.27,615.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4.2MM ULTRAGATOR LARGE HUB ERGO ADVANTAGE TURBO",SUP-DPS-C002,CDM,S27200284,LOCAL,0272,RC,,,both,,,960.98,288.29,"CIGNA [10200]","Cigna Open Access",,546.8,56.9,,,,,0,111.76,816.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 90CC 1.7-10MM CANCELLOUS ALLOGRAFT FREEZE",SUP-400160,CDM,C1713,HCPCS,0278,RC,,,both,,,7182.90,2154.87,"PHCS [10601]",PHCS,,5028.03,70,,,,,0,835.37,6105.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOLUTION 5  DEX 50ML FILL",SUP-07923-36,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,55.08,68,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 0D4.5MM 34MM STAINLESS STEEL PARTIAL THREAD LONG",SUP-214.534,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"KAISER [10500]",Kaiser,,734.6,67,,,,,0,127.51,931.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 2.75MM 1.5MM 1.27MM COLLAR BUTTON LUMEN",SUP-510-131C,CDM,S27800098,LOCAL,0278,RC,,,both,,,178.18,53.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.72,151.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 12IN CRILE-WOOD SERRATE INSRT NDL TUNGSTEN CARBIDE",SUP-32-310,CDM,S27200284,LOCAL,0272,RC,,,both,,,734.10,220.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,499.19,68,,,,,0,85.38,623.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 25MMX10MM X-PAC LORDOTIC SPINE",SUP-EI2511L,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7654.5,27,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG VIAL",RX-10577,CDM,J2919,HCPCS,0636,RC,00143-9851-01,NDC,both,1,UN,316.20,94.86,"NOVANET [10819]",Novanet,,237.15,75,,,,,0,37.47,268.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 10CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175195180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"MULTIPLAN [10600]",Multiplan,,1241.09,85,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nongyn Cyto Prep",PX-311000003,CDM,88104,CPT,0311,RC,,,both,,,422.75,126.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,127.04,,,,,,,0.01,359.34,"fee schedule",
"JADE OTW .018 150CM PTA BALLOONAND#59; 2.0X20MM",SUP-592002022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 CURVE PLUS 12.5MM KNEE XLK FIX BEARING",SUP-970442,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3017.13,27,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL MEDIUM PARTIAL KNEE UNICOMPARTMENTAL PHASE 3",SUP-161469,CDM,C1776,HCPCS,0278,RC,,,both,,,16754.58,5026.37,"CIGNA [10200]","Cigna Local Plus",,5277.69,31.5,,5372.07,4581.20,7242.98,23,1948.56,14241.39,"percent of total billed charges",
"SURFACE ARTICULAR 12MM PERSONA 3-11 E-F KNEE RIGHT TIBIA",SUP-42522000512,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS [10001]","Blue Cross PPO",,4224.36,39.2,,3949.44,3949.44,3949.44,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"KIT BIOPSY PINK 20CM 18GA 17GA BARD MISSION TRUGUIDE 10MM 20",SUP-1820MSK,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PUNCH ARTHROSCOPIC STD KNOTLESS DISPOSABLE CROSSFT 4.75/5.5",SUP-CFK-DBP4755,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TRIA 26CM 6FR URETERAL SOFT",SUP-M0061903230,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,,,,,,,189.34,1383.8,"percent of total billed charges",
"HC Pulse Ox O2 Sat Sngl",PX-460000015,CDM,94760,CPT,0460,RC,,,both,,,70.94,21.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.25,60.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ORTHOPEDIC 15MM INDEPENDENCE 8D INDEPENDENT GS",SUP-376.415,CDM,C1776,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"BLUE CROSS [10001]","Blue Cross HMO",,13436.04,39.2,,5311.50,4717.44,5388.59,31,3986.25,29134.26,"percent of total billed charges",
"4.0 PLY SCRW CFX 5.0X22",SUP-102050222,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER TISSUE 45CM 5MM ENSEAL G2 CURVE ARTICULATE ETHICON",SUP-NSLG2C45A,CDM,S27200284,LOCAL,0272,RC,,,both,,,3679.46,1103.84,"CIGNA [10200]","Cigna Local Plus",,1968.51,53.5,,,,,0,427.92,3127.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM 16MM NECK SECUR-FIT MAX HA 127D 13 53MM",SUP-6052-1340S,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"MULTIPLAN [10600]",Multiplan,,19398.49,85,,,,,0,2654.17,19398.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 20-30MM SPINE CROSS HEAD TO HEAD NONSTERILE",SUP-102023101,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PHCS [10601]",PHCS,,2493.75,70,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTERIAL LINE 16CM 18GA 20GA CUSTOM INDWELL CATH",SUP-ASK-04018-UPM,CDM,S27200284,LOCAL,0272,RC,,,both,,,441.45,132.43,"CIGNA [10200]","Cigna Open Access",,251.19,56.9,,,,,0,51.34,375.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 10MM 4MM DISPOSABLE DRIVER",SUP-AR-1540CDS,CDM,C1713,HCPCS,0278,RC,,,both,,,3189.38,956.81,"BLUE CROSS [10001]","Blue Cross PPO",,1250.24,39.2,,957.42,570.23,957.42,28,370.92,2710.97,"percent of total billed charges",
"CATH DRNG 28FR 21IN PLEUR-EVAC STRAIGHT SOFT THERMOSENSITIVE",SUP-DSTC-28S,CDM,C1729,HCPCS,0272,RC,,,both,,,53.94,16.18,"NOVANET [10819]",Novanet,,40.46,75,,,,,0,6.27,45.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM EVEREST SPINE CANNULATED POLYAXIAL MIS",SUP-M5111-05540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR CANCELLOUS CORTICAL LORDOTIC",SUP-345811,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 15.5CM 9FR PEEL-AWAY PERCUTANEOUS STERILE",SUP-G01697,CDM,C1894,HCPCS,0272,RC,,,both,,,382.71,114.81,"UHC [10700]","United Healthcare",,242.26,63.3,,,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 3.1X3.1IN XENMATRIX AB SQUARE DERMAL CLLGN",SUP-1150808,CDM,C1781,HCPCS,0278,RC,,,both,,,10482.48,3144.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7128.09,68,,,,,0,1219.11,8910.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 365CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-365,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2162.38,28.62,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TLS FLAT 4MM DRNG SILICONE 15ML EVACUATE TUBE",SUP-6660,CDM,S27200284,LOCAL,0272,RC,,,both,,,274.05,82.21,"CIGNA [10200]","Cigna Open Access",,155.93,56.9,,,,,0,31.87,232.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 30CM 3CM 7FR .038IN BLADDER LOOP STRAIGHT LOW",SUP-M006155245010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]","Cigna Local Plus",,658.56,,,,,,,143.16,1046.32,"percent of total billed charges",
"SUT PDS II 0 CTX 36IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z370T,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 23MM 3MM CORONARY STENT EVEROLIMUS",SUP-1550300-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG ACETABULAR 10MM 66MM HIP TRABECULAR METAL",SUP-489406610,CDM,C1776,HCPCS,0278,RC,,,both,,,18002.88,5400.86,"NOVANET [10819]",Novanet,,13502.16,75,,,,,0,2093.73,15302.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR CHAMP5 CURVE GUIDING",SUP-LA6CHAMP05,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 35MM ARTHREX SHOULDER CENTRAL MODULAR STERILE",SUP-AR-9561-35S,CDM,C1713,HCPCS,0278,RC,,,both,,,4029.60,1208.88,"KAISER [10500]",Kaiser,,2699.83,67,,,,,0,468.64,3425.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR STD JL2 CURVE GUIDING NYLON CORONARY",SUP-LA6JL20,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AXIOS 10MM 146MM 10MM 21MM 138MM 10.8FR PANCREATIC",SUP-M00553640,CDM,C1874,HCPCS,0278,RC,,,both,,,28551.60,8565.48,"CIGNA [10200]","Cigna Open Access",,9564.79,33.5,,,,,0,3320.55,24268.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.7MM CANNULATED",SUP-CSS07237,CDM,S27200284,LOCAL,0272,RC,,,both,,,1506.60,451.98,"FIRST HEALTH [10303]","First Health",,1205.28,80,,,,,0,175.22,1280.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION NUMBER 2 1.14MM BLUE ULTRASIL GROMMET BEVEL",SUP-70245755,CDM,S27800098,LOCAL,0278,RC,,,both,,,104.91,31.47,"FIRST HEALTH [10303]","First Health",,83.93,80,,,,,0,12.2,89.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SHUNT STRATA LUMBOPERITONEAL CSF CATH STEPDOWN STERILE",SUP-21066,CDM,S27800098,LOCAL,0278,RC,,,both,,,578.66,173.6,"FIRST HEALTH [10303]","First Health",,462.93,80,,,,,0,67.3,491.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 3-0 PS-2 SPIRAL 70CM SUT",SUP-SXMP1B109,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,145.45,68,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 28MM COCR",SUP-VAL-35280-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"CIGNA [10200]","Cigna Open Access",,1194.9,56.9,,1144.80,304.56,2275.09,66,244.23,1785,"percent of total billed charges",
"STYLET KIT W/UNIV CLIP-ON TOOL AND IMPLANT TOOL, 58CM-DS0600",SUP-DS06002/58,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,299.62,41.1,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 6MM AVENIR 10 HELICAL FINISH STERILE",SUP-10HFN-06008,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"BLUE CROSS [10001]","Blue Cross PPO",,4054.5,39.2,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC T Strap Add to Lower Ext",PX-E27400081,CDM,L2270,HCPCS,0274,RC,,,both,,,269.50,80.85,"MULTIPLAN [10600]",Multiplan,,229.08,85,,,,,0,31.34,229.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DRILL PATHWAY PACK QUICK",SUP-217842010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1526.85,458.05,"UHC [10700]","United Healthcare",,966.5,63.3,,,,,0,177.57,1297.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 224MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-224.621,CDM,C1713,HCPCS,0278,RC,,,both,,,3612.00,1083.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,420.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",420.08,3070.2,"percent of total billed charges",
"VALVE AORTIC 23MM EPIC SUPRA THV",SUP-ESP100-23-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,36722.70,11016.81,"CIGNA [10200]","Cigna Local Plus",,11567.65,31.5,,,,,0,4270.85,31214.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL MEDIUM 10MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405310,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1123.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 0 CT-1 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-812H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 21MM 48MM SHOULDER SOFT TISSUE BALANCE",SUP-7122885,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4117.81,41.1,,6417.48,6417.48,6417.48,"1 through 10",1165.21,8516.15,"percent of total billed charges",
"CUFF TRNQT 24IN 2 PORT 1 BLADDER WITHOUT SLEEVE ATS STERILE",SUP-60707010400,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"AETNA [10100]","Aetna HMO/PPO",,58.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 4-0 SH 18IN CONTROL RELEASE BRAID 8",SUP-C014D,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.40,29.82,"KAISER [10500]",Kaiser,,66.6,67,,,,,0,11.56,84.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBTR SHEATH 13.5CM 6FR INFUSION PRESSURE MNTR KINK RESISTANT",SUP-502191,CDM,S27000186,LOCAL,0270,RC,,,both,,,84.83,25.45,"UHC [10700]","United Healthcare",,53.7,63.3,,,,,0,9.87,72.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR CHEST TRAUMA WITH CC",184,MS-DRG,,,,,,,inpatient,,,32048.25,9614.47,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,6996.73,,"Case rate ($6,600.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,129.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,168.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,845.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,137.28. The transfer operating threshold is the transfer adjustment factor * $6,129.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.40. The transfer capital threshold is the transfer adjustment factor * $463.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,6600.69,26537.59,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL F KNEE LEFT LPS-FLEX GENDER SOLUTIONS NEXG",SUP-00576201651,CDM,C1776,HCPCS,0278,RC,,,both,,,20412.00,6123.6,"CIGNA [10200]","Cigna Open Access",,6838.02,33.5,,5302.19,4377.88,6578.61,27,2373.92,17350.2,"percent of total billed charges",
"CLIP 11MM OPEN 235CM INTERNAL RESOLUTION RADIOPAQUE USER",SUP-M00522611,CDM,S27200284,LOCAL,0272,RC,,,both,,,1277.40,383.22,"CIGNA [10200]","Cigna Open Access",,726.84,56.9,,,,,0,148.56,1085.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D F KNEE RIGHT OSSEOTI KEEL",SUP-42535007502,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"UHC [10700]","United Healthcare",,8713.56,63.3,,8601.07,8395.67,8601.07,"1 through 10",1600.93,11700.68,"percent of total billed charges",
"SCR BONE 5MM 80MM NAIL-EX TITANIUM FEMORAL TIBIAL LOCKING",SUP-04.005.570,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,134.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",134.52,983.18,"percent of total billed charges",
"SCR BONE 7.3MM 30MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.830,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,159.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",159.84,1168.25,"percent of total billed charges",
"CATH RENEGADE HI-FLO 135CM 10CM 2.8-3FR .027IN MICRO",SUP-M001182880,CDM,C1887,HCPCS,0272,RC,,,both,,,2100.00,630,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,248.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 150CM 40MM 5MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013468-040,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVISOR FL SENSOR ENABLED 105CM 7.5FR 20MM 2MM 3-3-3MM",SUP-D-AVSE-DF10-F20,CDM,C1732,HCPCS,0272,RC,,,both,,,10315.50,3094.65,"PHCS [10601]",PHCS,,7220.85,70,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ATHERECTOMY DIAMONDBACK L145 CM OD2 MM MAX CROWN CA",SUP-DBP-CART-200MAX145,CDM,C1724,HCPCS,0272,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,inpatient,,,222121.71,66636.51,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT LAPAROSCOPIC 56.1CM 5MM DA VINCI S/SI ENDOWRIST",SUP-420143,CDM,S27200284,LOCAL,0272,RC,,,both,,,27090.00,8127,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"PASSER GABBAY-FRATER GUIDE ORG SUT VALVE IMPLANTATION",SUP-GFS-10A,CDM,S27000186,LOCAL,0270,RC,,,both,,,591.30,177.39,"AETNA [10100]","Aetna HMO/PPO",,470.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.77,502.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONCUSSION WITHOUT CC/MCC",090,MS-DRG,,,,,,,inpatient,,,49755.35,14329.13,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,10978.67,,"Case rate ($5,106.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,741.60, add-ons for qualifying new technology services are included. If operating cost exceeds $37,781.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,740.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,747.87. The transfer operating threshold is the transfer adjustment factor * $4,741.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $358.49. The transfer capital threshold is the transfer adjustment factor * $358.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,5106.36,20529.78,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X12MM LUMINARY 10-11MM SPINE",SUP-14712,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9015.3,28.62,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC LOW PROFILE 55MM 5MM KII 2 PACK ACCESS",SUP-CTB23,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"KAISER [10500]",Kaiser,,145.73,67,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 56MM 40MM ALTRX HIP",SUP-122140456,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"NOVANET [10819]",Novanet,,10352.59,75,,,,,0,1605.34,11732.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 12FR .158IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1012,CDM,C1894,HCPCS,0272,RC,,,both,,,304.50,91.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,36.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 275CC P3CM MODERATE CLASSIC PROFILE STD",SUP-350-7275MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL SILICONE DOYLE II SEPTUM COMPRESSED HOLE IN",SUP-1524055,CDM,S27000186,LOCAL,0270,RC,,,both,,,469.80,140.94,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,inpatient,,,151155.63,45346.69,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE CHECKER 130CM 22CM 3MM BALLOON DILATATION",SUP-U8130322,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"METHADONE 10 MG/ML ORAL CONCENTRATE",RX-15996,CDM,,,0637,RC,08888-8878-67,NDC,both,5,ML,39.12,11.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.55,33.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TGS GUIDEWIRE",SUP-8000-060-009,CDM,C1769,HCPCS,0272,RC,,,both,,,1762.50,528.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1198.5,68,,,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TGS GUIDEWIRE",SUP-8000-060-009,CDM,C1769,HCPCS,0272,RC,,,both,,,1762.50,528.75,"KAISER [10500]",Kaiser,,1180.88,67,,,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0328,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,644.44,68,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 13.6CM 8MM CEREPAK XL UNIFORM DETACHABLE",SUP-FCX180813,CDM,S27800098,LOCAL,0278,RC,,,both,,,15872.28,4761.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1880.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1845.95,13491.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR SYMMETRIC TOTAL REVISION TRIATHLON X3 KNEE",SUP-5550-G-391,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"PHCS [10601]",PHCS,,3022.44,70,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 200MM 4MM BALLOON DILATATION",SUP-PCU040200130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,506.02,41.1,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 3MM .017IN",SUP-H7493926708300,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GUIDER SOFTIP XF 100CM 6FR 40D GUIDING DURAFORM PTFE",SUP-M003101420,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 1.9MM STD TWIST",SUP-MFT-072-19,CDM,S27200284,LOCAL,0272,RC,,,both,,,1409.40,422.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 90CM 8FR .09IN EXTRA BACKUP 3.5 LEFT CURVE",SUP-LA8EBU35D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DISORDERS OF GALLBLADDER AND BILIARY TRACT,MINOR",284,APR-DRG,,,,,,,inpatient,,,33317.46,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488.00. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.20. DRG Reimbursement is equal to $3,643.35. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%.",,,,0,,,other,"SOI-1 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER RESPIRATORY AND CHEST PROCEDURES,MODERATE",121,APR-DRG,,,,,,,inpatient,,,98195.77,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $11,274.99. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($59,461.30) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC",601,MS-DRG,,,,,,,inpatient,,,23833.60,7150.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 110MM 9.2MM 6MM ADJUSTABLE NECK FLANGE CLIP IN OBTR",SUP-75HA60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1619.19,485.76,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE JL 2.4MM SCR 8 HOLE STERNALOCK BLU BONE STERNAL",SUP-73-2645,CDM,C1713,HCPCS,0278,RC,,,both,,,3870.90,1161.27,"MULTIPLAN [10600]",Multiplan,,3290.27,85,,,,,0,450.19,3290.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TNLR SURGICAL SHEATH ON-Q 12IN 11GA DISPOSABLE",SUP-T11X12,CDM,S27200305,LOCAL,0272,RC,,,both,,,250.93,75.28,"KAISER [10500]",Kaiser,,168.12,67,,,,,0,29.18,213.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD LINER XLT MP9 40MM",SUP-932-40-256,CDM,C1776,HCPCS,0278,RC,,,both,,,12462.02,3738.61,"BLUE CROSS [10001]","Blue Cross HMO",,4885.11,39.2,,5311.50,4717.44,5388.59,31,1449.33,10592.72,"percent of total billed charges",
"(EVAL) EFS SIEGEL TAVR TRANSCATHETER AORTIC VALVE - 29 MM","SUP-30-1-0129 -EFS",CDM,S62400003,LOCAL,0624,RC,,,both,,,182400.00,54720,"NOVANET [10819]",Novanet,,136800,75,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 7FR L30CM SOFT WITHOUT GUIDEWIRE TRIA",SUP-M0061903350,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 110CM 5FR 145D PIGTAIL CURVE",SUP-534552S,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"AETNA [10100]","Aetna HMO/PPO",,74.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ortho/Pros Mgmt Sub 15min (Go)",PX-430000040,CDM,97763,CPT,0430,RC,,,both,,,173.40,52.02,"BLUE CROSS [10001]","Blue Cross PPO",,173.4,,"Per diem ($371.22).",,,,0,20.17,173.4,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +17.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030175,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,460.4,39.2,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.5MM X 28MM TI",SUP-VAN-15280-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",113.04,826.2,"percent of total billed charges",
"STAPLE INTERNAL EXTRA THICK STERILE GIA TRI-STAPLE LATEX",SUP-GIA80XTS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.91,343.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,133.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,133.27,974.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Myoview per Study",PX-343000003,CDM,A9502,HCPCS,0343,RC,,,both,,,206.95,62.08,"FIRST HEALTH [10303]","First Health",,165.56,80,,,,,0,24.07,206.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD BIPOLAR HEMISPHERICAL VAPOR ENUCLEATION STERILE",SUP-27040VE-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3439.15,1031.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2338.62,68,,,,,0,399.97,2923.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 8MM 145CM 3.25MM CORONARY STENT",SUP-1145325-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 14MM COCR",SUP-VAL-25140-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"MULTIPLAN [10600]",Multiplan,,1211.76,85,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 80CM 60MM 6MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV06006008P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3318,41.1,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM CREO SPINE PREASSEMBLE THREAD",SUP-5119.1647,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 110CM 5FR 5MM SPACE ELECTROPHYSIOLOGY 4 PIN FIX",SUP-F5QF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"UHC [10700]","United Healthcare",,574.26,63.3,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 16MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620216,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7652.65,68,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6",SUP-ZCT225205,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH CHECK-FLO FLEXOR .018/.038IN ANL3 CURVE 45CM 6FR .087",SUP-G29984,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BNDG TG FIX 25MR WHITE COMPRESSION LATEX WIDE MESH HIGHLY",SUP-568261,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.98,15.89,"CIGNA [10200]",Cigna,,36.03,68,,,,,0,6.16,45.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION",RX-5751,CDM,,,0250,RC,00904-7276-41,NDC,both,5,ML,12.54,3.76,"MULTIPLAN [10600]",Multiplan,,10.66,85,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRAMEDULLARY NAIL 420MM 11MM GAMMA 125D LONG R1.5",SUP-3425-1420S,CDM,C1713,HCPCS,0278,RC,,,both,,,13435.13,4030.54,"BLUE CROSS [10001]","Blue Cross PPO",,5266.57,39.2,,957.42,570.23,957.42,28,1562.51,11419.86,"percent of total billed charges",
"HC G6pd Quant",PX-301000210,CDM,82955,CPT,0301,RC,,,both,,,196.30,58.89,"NOVANET [10819]",Novanet,,147.23,75,,,,,0,0.01,166.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT VALEO 18MM 120CM 6MM LOW PROFILE TAPER",SUP-EV06182CD,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6099.6,68,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 360MM FEMORAL EXPERT INTRAMEDULLARY ROUND",SUP-04.013.452S,CDM,C1713,HCPCS,0278,RC,,,both,,,8319.74,2495.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2381.11,28.62,,,,,0,967.59,7071.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT SWIVELOCK SPEEDBRIDGE 5.5 KNOTLESS",SUP-AR-2600FSB-4,CDM,C1713,HCPCS,0278,RC,,,both,,,18356.63,5506.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2134.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",2134.88,15603.14,"percent of total billed charges",
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 28MM 144CM 2.75MM",SUP-H7493941228270,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,919.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL INBONE 5 STD ANKLE RIGHT",SUP-200222905,CDM,C1776,HCPCS,0278,RC,,,both,,,11847.30,3554.19,"BLUE CROSS [10001]","Blue Cross HMO",,4644.14,39.2,,5311.50,4717.44,5388.59,31,1377.84,10070.21,"percent of total billed charges",
"EXP TISSUE BREAST 600CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP140RH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1410.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",1384.26,10117.13,"percent of total billed charges",
"CATH CHRG 135CM 100MM 8MM BALLOON DILATATION OTW",SUP-H74939206081010,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 80MM 6MM .014IN BALLOON DILATATION",SUP-AB14W060080150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"AETNA [10100]","Aetna HMO/PPO",,1101.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 40MM 6MM .018IN BALLOON DILATATION",SUP-R51006004L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"UHC [10700]","United Healthcare",,1248.12,63.3,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM LOW PROFILE NECK VERTICAL GROOVE CORAIL2",SUP-L20309,CDM,C1776,HCPCS,0278,RC,,,both,,,28658.70,8597.61,"MULTIPLAN [10600]",Multiplan,,24359.9,85,,,,,0,3333.01,24359.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 4X6CM AMNIOBAND PLACENTAL MEMB ALLOGRAFT",SUP-WC3046,CDM,Q4151,HCPCS,0636,RC,,,both,,,19778.85,5933.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH TREK 20MM 2.5MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012405-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TENDYNE MITRAL VALVE LP 35S",SUP-TENDV-LP-35S-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,93.18,27.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 100MM 4MM BALLOON",SUP-U3575410,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOOK SPINAL CD HORIZON TITANIUM LEFT OFFSET 5.5 MM ROD",SUP-7541199,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,3978.14,359.25,3978.14,24,348.9,2550,"percent of total billed charges",
"CUTTER SURGICAL 28MM 28MM PATELLA DISPOSABLE",SUP-8000-0028,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.00,675,"CIGNA [10200]","Cigna Open Access",,1280.25,56.9,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 31MM RESTORATION +30MM HIP PROXIMAL MODULAR",SUP-6276-1-331,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"AETNA [10100]","Aetna HMO/PPO",,17692.53,79.5,,10981.53,8986.79,12413.38,12,2588.23,18916.54,"percent of total billed charges",
"SNAP(R) CARTRIDGE - 75 MM HG - 10 IN A CASE",SUP-SNPA075,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"PHCS [10601]",PHCS,,714.42,70,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SKATER 35CM 12FR .038IN NEPHRSTMY RADIOPACITY METAL",SUP-756612035,CDM,C1729,HCPCS,0272,RC,,,both,,,651.24,195.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,267.66,41.1,,,,,0,75.74,553.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIATHLON PS X3 TIBIAL INSERT",SUP-5532-G-222,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"NOVANET [10819]",Novanet,,8559.45,75,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE HA 20MM 10MM ACL BIOSURE",SUP-72201784,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CITATION TMZF HA 2 SHORT HIP RIGHT",SUP-6265-5212,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"BLUE CROSS [10001]","Blue Cross PPO",,9573.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",2840.27,20758.66,"percent of total billed charges",
"SHEATH NAVIGATOR 28CM 11-13FR ACCESS STAINLESS STEEL",SUP-M0062502000,CDM,C1894,HCPCS,0272,RC,,,both,,,895.54,268.66,"NOVANET [10819]",Novanet,,671.66,75,,,,,0,104.15,761.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 20MM 6FR 5.5MM",SUP-H7493926720550,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 8X40 80CM SL",SUP-48008004N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"MULTIPLAN [10600]",Multiplan,,730.16,85,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 8FR 20CM 15.5CM RADIOPAQUE STERILE DISPOSABLE",SUP-G00980,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"UHC [10700]","United Healthcare",,31.23,63.3,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPIFIX MESH 4X4.5 CM",SUP-ES-4400,CDM,Q4186,HCPCS,0636,RC,,,both,,,9515.10,2854.53,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LANTERN 135CM .025IN MICRO DELIVERY SYSTEM HIGH FLOW",SUP-PXSLIMLAN135STR,CDM,S27200284,LOCAL,0272,RC,,,both,,,4071.00,1221.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"METHYLPHENIDATE 5 MG TABLET, IMMEDIATE RELEASE",RX-4988,CDM,,,0637,RC,68084-0805-11,NDC,both,1,UN,20.50,6.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,MODERATE",313,APR-DRG,,,,,,,inpatient,,,112980.06,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,MINOR",248,APR-DRG,,,,,,,inpatient,,,25418.14,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $3,732.91. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT-S CERVICAL 5D ALLOGRAFT 7MM",SUP-3W5007,CDM,S27800098,LOCAL,0278,RC,,,both,,,6216.90,1865.07,"CIGNA [10200]","Cigna Local Plus",,3326.04,53.5,,,,,0,723.03,5284.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NICARDIPINE 30 MG CAPSULE",RX-10713,CDM,,,0637,RC,42806-0502-09,NDC,both,1,UN,83.88,25.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.76,71.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850014535,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross PPO",,2569.56,39.2,,957.42,570.23,957.42,28,762.35,5571.75,"percent of total billed charges",
"SCR BONE 3.5MM 12MM VARIAX LOCK NONSTERILE",SUP-657312,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"NOVANET [10819]",Novanet,,1115.13,75,,,,,0,172.92,1263.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acetylcholn Rcptr Bndng Antb",PX-301000691,CDM,86041,CPT,0301,RC,,,both,,,398.05,119.41,"MULTIPLAN [10600]",Multiplan,,338.34,85,,,,,0,0.01,338.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 80MM 80CM 10MM 9FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM10080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]","Cigna Open Access",,6120.45,33.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL XS UNIVERSAL 18MM KNEE COCR POLYETHYLENE",SUP-198727118,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"CIGNA [10200]",Cigna,,11818.55,40,,5873.17,5873.17,5873.17,"1 through 10",3436.24,25114.41,"percent of total billed charges",
"SUT ETHILON 4-0 PS-2 18IN MONOFILAMENT GREEN NONABSORBABLE",SUP-G667G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 49MM 28MM TANDEM HIP ACETABULAR COCR",SUP-71322049,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"FIRST HEALTH [10303]","First Health",,6681.96,80,,,,,0,971.39,7099.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 8FR .088IN AMPLATZ",SUP-588847,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 55MM AXSOS STAINLESS STEEL T15 FEMUR HUMERUS",SUP-371555,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,105.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,103.62,757.35,"percent of total billed charges",
"STENT GEENEN 7CM 7FR PANCREATIC POLYETHYLENE POSITION SLEEVE",SUP-G21479,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"KAISER [10500]",Kaiser,,824.9,67,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CREAM SOFT TISSUE MASSAGE PROTECTIVE 8OZ FREE-UP SOFT TISSUE",SUP-8319,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.70,26.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.2,74.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ARTHROSCOPIC GRAFT 9MM ACL",SUP-232109,CDM,S27200284,LOCAL,0272,RC,,,both,,,2318.25,695.47,"PHCS [10601]",PHCS,,1622.78,70,,,,,0,269.61,1970.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALPHAGRAFT, BONE MATRIX GEL, DEMINERALIZED, 5CC",SUP-1001-050,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,1470,39.2,,957.42,156.86,7483.26,51,436.13,3187.5,"percent of total billed charges",
"CYCLOPENTOLATE 2 % EYE DROPS",RX-9700,CDM,,,0637,RC,00065-0397-02,NDC,both,2,ML,210.31,63.09,"PHCS [10601]",PHCS,,147.22,70,,,,,0,24.46,178.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 8MM 145CM 2.25MM CORONARY STENT",SUP-1125225-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Liver & Spleen Img Static",PX-341000015,CDM,78215,CPT,0341,RC,,,both,,,1815.78,544.73,"FIRST HEALTH [10303]","First Health",,1452.62,80,,,,,0,211.18,1543.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE (RSP) MONOBLOCK REVISION HUMERAL STEM, 220MM, 10X220",SUP-510-10-220,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"MULTIPLAN [10600]",Multiplan,,10710,85,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.6MM 14MM COALITION SPINE SELF TAP VARIABLE ANGLE",SUP-184.114,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,269.03,28.62,,,,,0,109.32,799,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER GEMINUS T10 UNIVERSAL QUICK CONNECT 2MM SURGICAL",SUP-DRVR-UQC-T10,CDM,S27200284,LOCAL,0272,RC,,,both,,,753.30,225.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,89.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATH NUVISION ICE 10FR ULTRASOUND",SUP-FG10593,CDM,C1759,HCPCS,0272,RC,,,both,,,0.01,,"UHC [10700]","United Healthcare",,0.01,63.3,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ISTO CORTICAL FIBERS - 5CC",SUP-ISTO-CF-05,CDM,S27800098,LOCAL,0278,RC,,,both,,,4657.50,1397.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,541.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Laser Capsulotomy",PX-761000008,CDM,66821,CPT,0761,RC,,,both,,,1088.00,326.4,"NOVANET [10819]",Novanet,,816,75,,,,,0,1.09,1088,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HYPERGLIDE X-PEDION 150CM 20MM 2.2-2.8FR 4MM .01IN 4MM",SUP-104-4127,CDM,C1725,HCPCS,0272,RC,,,both,,,8790.60,2637.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1041.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1022.35,7472.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD THERAPEUTIC 23X14X12.5IN COLD WRAP ON REGULAR HOSE",SUP-11-1334-9-00000,CDM,S27000187,LOCAL,0270,RC,,,both,,,224.20,67.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,102.91,45.9,,,,,0,26.07,190.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE PLUS 100CM 6FR .044IN .042IN JUDKINS LEFT",SUP-533622,CDM,S27200284,LOCAL,0272,RC,,,both,,,411.51,123.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,188.88,45.9,,,,,0,47.86,349.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZINC SULFATE 1 MG/ML ORAL LIQUID",RX-408890,CDM,,,0637,RC,08888-8884-07,NDC,both,100,ML,12.54,3.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 26CM 3CM 7FR .035IN PIGTAIL",SUP-M006180233090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,904.58,68,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHOCOLATE 120CM 120MM 5MM 6FR BALLOON DILATATION",SUP-CB1812050120OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"NOVANET [10819]",Novanet,,4295.25,75,,,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL L HOOK STD 32CM 5MM STERILE",SUP-60-5163-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,251.69,75.51,"CIGNA [10200]","Cigna Local Plus",,134.65,53.5,,,,,0,29.27,213.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LANTERN 150CM .025IN MICRO DELIVERY SYSTEM HIGH FLOW",SUP-PXSLIMLAN150STR,CDM,S27200284,LOCAL,0272,RC,,,both,,,4071.00,1221.3,"FIRST HEALTH [10303]","First Health",,3256.8,80,,,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII POSTERIOR STABILIZED POR",SUP-71704555,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"PHCS [10601]",PHCS,,16317,70,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM PROFILE 3D",SUP-680R34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 8MM 145CM 3.5MM CORONARY STENT",SUP-1125350-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1670.84,28.62,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PURPLE 11CM LETZ UTAHLOOP LOOP 5X5MM",SUP-DLP-T11,CDM,S27200284,LOCAL,0272,RC,,,both,,,140.07,42.02,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.29,119.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE COALITION AGX 7D ALLOGRAFT 8X14X7MM",SUP-8128.1277S,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 52CM .013IN BRADY SFT",SUP-6048,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ELECTROSURGICAL 8.25IN OLSEN BAYONET BIPOLAR FRCP SMOOTH",SUP-20-1440KI,CDM,S27200284,LOCAL,0272,RC,,,both,,,388.65,116.59,"PHCS [10601]",PHCS,,272.06,70,,,,,0,45.2,330.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 90ML .1-4MM ALLOGRAFT CRUSH FREEZE",SUP-T20029,CDM,S27800098,LOCAL,0278,RC,,,both,,,9307.41,2792.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1102.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1082.45,7911.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 160MM 15MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424048,CDM,C1776,HCPCS,0278,RC,,,both,,,12181.95,3654.58,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5006.78,41.1,,6417.48,6417.48,6417.48,"1 through 10",1416.76,10354.66,"percent of total billed charges",
"**DO NOT REUSE ITEM # - PS GO LIVE ISSUE**SLEEVE COMPRESSION",SUP-5897,CDM,S27000186,LOCAL,0270,RC,,,both,,,232.62,69.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,27.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.05,197.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOURNIQUET DSP CUF SPSB STL34",SUP-60707510600,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.84,63.25,"FIRST HEALTH [10303]","First Health",,168.67,80,,,,,0,24.52,179.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 57MM 135CM 9MM 60MM",SUP-38047-96013,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL 5.5IN TISSUE 1X2 TEETH FLUTED HANDLE MATTE",SUP-130-161,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.69,23.31,"CIGNA [10200]",Cigna,,52.83,68,,,,,0,9.04,66.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MECLIZINE 12.5 MG TABLET",RX-12024,CDM,,,0637,RC,50268-0522-11,NDC,both,1,UN,6.27,1.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING RTRCTR AMS 700 SKW DEEP SCROTAL",SUP-72403867,CDM,S27200284,LOCAL,0272,RC,,,both,,,3864.00,1159.2,"PHCS [10601]",PHCS,,2704.8,70,,,,,0,449.38,3284.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH .038IN SR0 CURVE 8FR 63CM HEMOSTASIS GWIRE",SUP-406844,CDM,C1893,HCPCS,0272,RC,,,both,,,1174.50,352.35,"KAISER [10500]",Kaiser,,786.92,67,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 28MM SIMUPLUS FLEXIBLE LUMEN STERILE LATEX",SUP-7700FB28,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Open Access",,4391.85,33.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-2 THX-36 36IN MONOFILAMENT WHITE",SUP-2N07B,CDM,S27200284,LOCAL,0272,RC,,,both,,,227.65,68.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,104.49,45.9,,,,,0,26.48,193.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END 0MM RFN-ADVANCED STERILE",SUP-04.233.000S,CDM,C1713,HCPCS,0278,RC,,,both,,,1531.39,459.42,"MULTIPLAN [10600]",Multiplan,,1301.68,85,,,,,0,178.1,1301.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL 45D PERFORATE BLADE",SUP-3722086,CDM,S27200284,LOCAL,0272,RC,,,both,,,809.84,242.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ATHLETIS 135CM 20MM 8MM BALLOON DILATATION STERILE",SUP-H74939347080210,CDM,C1725,HCPCS,0272,RC,,,both,,,1449.90,434.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH GLIDELIGHT 25-80HZ 50CM 14FR 9.5FR 10.2FR 14.7FR",SUP-500-302,CDM,C2629,HCPCS,0272,RC,,,both,,,19624.50,5887.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"FOL URETHRAL 13.35IN 18FR HEYMAN PLASTIC COUDE TIP DILATION",SUP-021318,CDM,S27200284,LOCAL,0272,RC,,,both,,,242.30,72.69,"CIGNA [10200]","Cigna Local Plus",,129.63,53.5,,,,,0,28.18,205.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 0MM 28MM HIP MODULAR TYPE 1 CERAMIC BIOLOX",SUP-650-1158,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"FIRST HEALTH [10303]","First Health",,7886.98,80,,,,,0,1146.57,8379.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 34IN ATS 1 PORT 1 BLADDER LUER LOCK CNCT STERILE",SUP-60707505600,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.02,90.31,"UHC [10700]","United Healthcare",,190.55,63.3,,,,,0,35.01,255.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 11MM KNEE BEARING POSTERIOR STABILIZE",SUP-5532-G-511-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"AETNA [10100]","Aetna HMO/PPO",,9073.02,79.5,,10981.53,8986.79,12413.38,12,1327.29,9700.71,"percent of total billed charges",
"PLATE STD 54MM TITANIUM 2.4MM SCR 6 HOLE HEAD 3 HOLE SHAFT 2",SUP-04.111.630S,CDM,C1713,HCPCS,0278,RC,,,both,,,4602.30,1380.69,"MULTIPLAN [10600]",Multiplan,,3911.96,85,,,,,0,535.25,3911.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +6 DIOPTER MODIFY L BICONVEX 13MM 6MM POSTERIOR",SUP-CCA0T0.060,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,345.41,28.62,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRS TRANSFER 34IN DISPOSABLE",SUP-MAS014000-US,CDM,S27000186,LOCAL,0270,RC,,,both,,,589.68,176.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,69.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.58,501.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 5.5MM COOLCUT FLUSHCUT 8 FLUTE OVAL STERILE",SUP-AR-8550FOE,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"FIRST HEALTH [10303]","First Health",,449.06,80,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transplant Eval Liver Day 1 New Pt",PX-761000010,CDM,99205,CPT,0761,RC,,,both,,,1263.00,378.9,"NOVANET [10819]",Novanet,,947.25,75,,,,,0,1.26,1263,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 8MM 144CM 4MM CORONARY STENT",SUP-H7493952808400,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Open Access",,3166.49,56.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE SOFTTOUCH SMOOTH",SUP-SSF-265,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",878.7,6422.18,"percent of total billed charges",
"HEAD FEMORAL +10MM 28MM HIP COCR UHMWPE PCA",SUP-6280-0-328,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA [10200]","Cigna Local Plus",,1673.32,53.5,,5372.07,4581.20,7242.98,23,363.75,2658.55,"percent of total billed charges",
"SUT SILK PERMA-HAND MICROPOINT 4-0 G-3 18IN 2 ARM BRAID",SUP-783G,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.02,40.21,"AETNA [10100]","Aetna HMO/PPO",,106.55,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.59,113.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Collar Cervical Hard",PX-E27400066,CDM,L0150,HCPCS,0274,RC,,,both,,,44.00,13.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,20.2,45.9,,,,,0,5.12,44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Airway Exchange",PX-E27200051,CDM,E27200051,LOCAL,0272,RC,,,both,,,270.60,81.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,124.21,45.9,,,,,0,31.47,230.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plt Ea Unit",PX-390000006,CDM,P9019,HCPCS,0390,RC,,,both,,,506.00,151.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,59.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.85,430.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Factor VII Stable",PX-305000017,CDM,85230,CPT,0305,RC,,,both,,,663.67,199.1,"UHC [10700]","United Healthcare",,16.11,,,,,,,0.01,564.12,"fee schedule",
"DILTIAZEM 100 MG INTRAVENOUS SOLUTION",RX-22156,CDM,J1163,HCPCS,0636,RC,00409-4350-13,NDC,both,1,UN,103.38,31.01,"CIGNA [10200]",Cigna,,17.1,,,,,,,6.99,87.87,"fee schedule",
"HC Tavi/Tavr Open Fem Approach",PX-361000344,CDM,33362,CPT,0361,RC,,,both,,,45298.00,13589.4,"BLUE CROSS [10001]","Blue Cross HMO",,8667.44,,"Case rate ($8,667.44). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2491,38503.3,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Compression Bandage Coban",PX-E27000086,CDM,E27000086,LOCAL,0270,RC,,,both,,,81.72,24.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.5,69.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Screen Collection",PX-300000001,CDM,99000,CPT,0300,RC,,,both,,,57.00,17.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.06,48.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Proctoidsigmoidoscopy W Bx",PX-750000144,CDM,45305,CPT,0750,RC,,,both,,,2377.00,713.1,"BLUE CROSS [10001]","Blue Cross HMO",,2377,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,276.45,2377,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aspirator Meconium",PX-E27000042,CDM,E27000042,LOCAL,0270,RC,,,both,,,74.36,22.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,34.13,45.9,,,,,0,8.65,63.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Iliac W Pta Cmplx Init",PX-361000697,CDM,37256,CPT,0361,RC,,,both,,,10816.36,3244.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1257.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.82,9679,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Iliac W Pta Cmplx Init",PX-361000697,CDM,37256,CPT,0361,RC,,,both,,,10816.36,3244.91,"FIRST HEALTH [10303]","First Health",,8653.09,80,,,,,0,10.82,9679,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Outr Maternal Quad Sreen Serum",PX-300000024,CDM,81511,CPT,0310,RC,,,both,,,302.00,90.6,"CIGNA [10200]",Cigna,,302,,,,,,,0.01,302,"fee schedule",
"HC Outr Maternal Quad Sreen Serum",PX-300000024,CDM,81511,CPT,0310,RC,,,both,,,302.00,90.6,"MULTIPLAN [10600]",Multiplan,,256.7,85,,,,,0,0.01,302,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Skin & Sq Tiss<=20scm",PX-510000007,CDM,11042,CPT,0761,RC,,,both,,,4376.70,1313.01,"UHC [10700]","United Healthcare",,2770.45,63.3,,,,,0,509.01,4376.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC IV Inf Ther Concurr (Max 1)",PX-260000006,CDM,96368,CPT,0260,RC,,,both,,,393.60,118.08,"PHCS [10601]",PHCS,,275.52,70,,,,,0,45.78,393.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Weighted Prosthesis",PX-E27000249,CDM,L8030,HCPCS,0270,RC,,,both,,,1096.70,329.01,"MULTIPLAN [10600]",Multiplan,,932.2,85,,,,,0,127.55,932.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Phase III/Cr/per Visit",PX-943000001,CDM,9999179,LOCAL,0943,RC,,,both,,,23.00,6.9,"CIGNA [10200]","Cigna Local Plus",,12.31,53.5,,,,,0,2.67,23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg Coma/Sleep",PX-740000012,CDM,95822,CPT,0740,RC,,,both,,,1681.40,504.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,199.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,195.55,1681.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg Coma/Sleep",PX-740000012,CDM,95822,CPT,0740,RC,,,both,,,1681.40,504.42,"CIGNA [10200]",Cigna,,1143.35,68,,,,,0,195.55,1681.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH GREEN 16CM 12.5FR MAHURKAR ELITE DOUBLE-D LARGE",SUP-8888233316,CDM,C1752,HCPCS,0272,RC,,,both,,,995.43,298.63,"PHCS [10601]",PHCS,,696.8,70,,,,,0,115.77,846.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.8MM 200MM 10MM LCP ANKLE COMPRESSION THREAD",SUP-03.118.010,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 745CC",SUP-SSZ-F745,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"MULTIPLAN [10600]",Multiplan,,1266.84,85,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOLOIST 110CM 6FR 2-5-2MM SPACING CRD2 LONG CURVE",SUP-44216U,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"KAISER [10500]",Kaiser,,488.43,67,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 58MM TI",SUP-MTC-37580-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"BLUE CROSS [10001]","Blue Cross PPO",,488.98,39.2,,957.42,570.23,957.42,28,145.07,1060.29,"percent of total billed charges",
"COIL EMBOLIZATION PRESTIGE PLUS 1 DETACTMENT CTRL",SUP-ULTRA,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"KAISER [10500]",Kaiser,,949.73,67,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SALINE 425ML ROUND MODERATE PLUS PROFILE",SUP-351-2425SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENSIONER SURGICAL CERCLAGE STERILE LATEX FREE DISPOSABLE",SUP-AR-7820,CDM,S27200284,LOCAL,0272,RC,,,both,,,2165.63,649.69,"CIGNA [10200]","Cigna Local Plus",,1158.61,53.5,,,,,0,251.86,1840.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APREPITANT 32 MG/4.4 ML (7.2 MG/ML) INTRAVENOUS EMULSION",RX-240358,CDM,C9145,HCPCS,0636,RC,47426-0401-01,NDC,both,4.4,ML,565.90,169.77,"BLUE CROSS [10001]","Blue Cross HMO",,70.86,,,,,,,67.06,481.02,"fee schedule",
"ROCKET IPC DRAINAGE KIT INCLUDES BOTTLE AND DRESSING PACK 10",SUP-R51411H,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL BLOCK",SUP-345744,CDM,S27800098,LOCAL,0278,RC,,,both,,,4975.00,1492.5,"CIGNA [10200]","Cigna Local Plus",,2661.63,53.5,,,,,0,578.59,4228.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 120CM 7MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200074020,CDM,C1725,HCPCS,0272,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HIP FEM P2 POROUS OFFSZ10",SUP-425-97-010,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"BLUE CROSS [10001]","Blue Cross HMO",,16682.91,39.2,,5311.50,4717.44,5388.59,31,4949.55,36174.68,"percent of total billed charges",
"INSRT TIBIAL 2 29MM KNEE RIGHT MEDIAL X3 PARTIAL RESURFACE",SUP-5630-G-229,CDM,C1776,HCPCS,0278,RC,,,both,,,4514.33,1354.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3069.74,68,,,,,0,525.02,3837.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM AXSOS STAINLESS STEEL 2.5MM FULL THREAD",SUP-345438,CDM,C1713,HCPCS,0278,RC,,,both,,,211.93,63.58,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,144.11,68,,,,,0,24.65,180.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lgh Vari Regional Mutation",PX-309000039,CDM,81263,CPT,0310,RC,,,both,,,1512.00,453.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,115.59,,"Fee schedule rate ($115.59). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1285.2,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING INSUFFLATION PNEUMOSURE THERMOPLASTIC SET HIGH FLOW",SUP-0620040660,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.90,32.67,"FIRST HEALTH [10303]","First Health",,87.12,80,,,,,0,12.67,92.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Cerv Spine W Cntrst",PX-612000002,CDM,72142,CPT,0612,RC,,,both,,,4812.12,1443.64,"MULTIPLAN [10600]",Multiplan,,4090.3,85,,,,,0,536.99,4090.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Clavicle Complt",PX-320000060,CDM,73000,CPT,0320,RC,,,both,,,619.96,185.99,"FIRST HEALTH [10303]","First Health",,495.97,80,,,,,0,38.7,526.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vitamin D 25 Hydroxy",PX-301000121,CDM,82306,CPT,0301,RC,,,both,,,262.50,78.75,"FIRST HEALTH [10303]","First Health",,210,80,,,,,0,0.26,223.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 100MM 10MM 7FR BILIARY VENOUS SELF EXPAND",SUP-G57430,CDM,C1876,HCPCS,0278,RC,,,both,,,13109.93,3932.98,"UHC [10700]","United Healthcare",,8298.59,63.3,,,,,0,1524.68,11143.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 3 WAY STPCOCK TRNSDUC 3 FLUSH DEVICE",SUP-PX3X3272,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Feeynolm 2.6-5.0cm",PX-450000026,CDM,12013,CPT,0361,RC,,,both,,,909.00,272.7,"MULTIPLAN [10600]",Multiplan,,772.65,85,,,,,0,105.72,909,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE SYNTHETIC MATRIX INJECTION STEM CELL NUCLEAR FIELD",SUP-NC-1000,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"BLUE CROSS [10001]","Blue Cross PPO",,2420.8,39.2,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 18CM TITANIUM CURVE CIRCLE INTRALUMINAL",SUP-CDH21A,CDM,S27200284,LOCAL,0272,RC,,,both,,,5683.28,1704.98,"CIGNA [10200]","Cigna Local Plus",,3040.55,53.5,,,,,0,660.97,4830.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 TAPER 32MM HIP OXINIUM ECHELON",SUP-71343200,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"UHC [10700]","United Healthcare",,9833.88,63.3,,8601.07,8395.67,8601.07,"1 through 10",1806.76,13205.05,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 20CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155230190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,165.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 60MM 3 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800360,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,inpatient,,,56836.00,17050.8,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTDG HEPCON HMS PLUS 4 CHANNEL SYR NDL HEPARIN BLUE",SUP-304-05POR,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.04,37.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP CAUT 5MM DA VINCI 1 SITE HOOK MONOPOLAR RESPOSABLE",SUP-428090,CDM,S27000186,LOCAL,0270,RC,,,both,,,1154.25,346.27,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC QUANTUM APEX 143CM 15MM 3.25MM BALLOON DILATATION",SUP-H7493912415320,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WOUND DEBRIDEMENTS FOR INJURIES WITH CC",902,MS-DRG,,,,,,,inpatient,,,79923.41,23977.02,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONFIRM MART-1/MELAN A (A103) PRIMARY AN",SUP-790-2990,CDM,S27000186,LOCAL,0270,RC,,,both,,,66.58,19.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE VIPERWIRE ADVANCE VASCULAR 335CM .014IN PERIPHERAL",SUP-VPR-GW-14,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 7FR 20CM AQ DECREASE FRICTION RADIOPAQUE",SUP-G10208,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE PROTECTION RIGID 8-13 MM NAIL STERILE",SUP-03.043.036S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1633.13,489.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL 4 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-407,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1526.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL 17X8.8MM LARGE COTTLE DISPOSABLE STERILE LATEX",SUP-5100-037-125,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.38,176.51,"UHC [10700]","United Healthcare",,372.44,63.3,,,,,0,68.43,500.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 70MM 1800MM 10MM 2.33MM BILIARY NITINOL",SUP-SHS-10-070-180,CDM,C1874,HCPCS,0278,RC,,,both,,,6855.84,2056.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,812.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,797.33,5827.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER BREAST BIOPSY TUMARK ECONOMY Q CLIP 18G X 12CM",SUP-271500,CDM,A4648,HCPCS,0278,RC,,,both,,,391.50,117.45,"CIGNA [10200]","Cigna Open Access",,222.76,56.9,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 270090 RESERVE 9MM SRVC FEE",SUP-270090,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 120MM 1.5MM BALLOON DILATATION RAPID",SUP-47515120L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR IMPLANTABLE 55CM PRECISION M-1 CNCT",SUP-SC-9004-55,CDM,C1883,HCPCS,0278,RC,,,both,,,3525.00,1057.5,"PHCS [10601]",PHCS,,2467.5,70,,,,,0,409.96,2996.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Oasis Wnd Matrix per Scm",PX-636000013,CDM,Q4102,HCPCS,0636,RC,,,both,,,134.20,40.26,"NOVANET [10819]",Novanet,,100.65,75,,,,,0,15.9,134.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER ENDOSCOPIC 25MM 6MM TREVO XP PROVUE MICROCATHETER",SUP-93068,CDM,C1757,HCPCS,0272,RC,,,both,,,49249.94,14774.98,"NOVANET [10819]",Novanet,,36937.46,75,,,,,0,5727.77,41862.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL TAPERFILL 12 STD OFFSET HIP STERILE LATEX FREE",SUP-425-96-012,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"PHCS [10601]",PHCS,,9660,70,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 26CM 5FR URETERAL AQ FIRM POS NO GWIRE",SUP-G23398,CDM,C2617,HCPCS,0278,RC,,,both,,,535.41,160.62,"CIGNA [10200]",Cigna,,364.08,68,,,,,0,62.27,455.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 50MM LCP STAINLESS STEEL CORTICAL PERIARTICULAR",SUP-02.204.050,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"BLUE CROSS [10001]","Blue Cross HMO",,386.74,39.2,,957.42,156.86,7483.26,51,114.74,838.59,"percent of total billed charges",
"SCR BONE 4MM 40MM ASNIS III TITANIUM 1/3 THREAD REVERSE CUT",SUP-604640S,CDM,C1713,HCPCS,0278,RC,,,both,,,1929.60,578.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,228.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,224.41,1640.16,"percent of total billed charges",
"KIT INTRO 10CM 6FR 22GA GLIDESHEATH SLENDER .021IN 25MM",SUP-RM*ES6F10HAU,CDM,C1894,HCPCS,0272,RC,,,both,,,761.40,228.42,"MULTIPLAN [10600]",Multiplan,,647.19,85,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 80MM 2.5MM QUICK CONNECT STERILE",SUP-03.133.103S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1025.14,307.54,"MULTIPLAN [10600]",Multiplan,,871.37,85,,,,,0,119.22,871.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX12MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183522,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5331.05,68,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 15MM AEQUALIS HA REVERSED 25MM STD POST",SUP-DWD170,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1119,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1098.22,8026.55,"percent of total billed charges",
"SPACER SPINAL 26X12X15MM SUSTAIN OBLIQUE PEEK RADIOLUCENT",SUP-304.975,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"MULTIPLAN [10600]",Multiplan,,14076,85,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 5-0 PS-2 18IN MONOFILAMENT PLIABILIZE",SUP-1666H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EDGE ROCKER SWITCH PENCIL W/HO",SUP-E2350H-DBNSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.42,14.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.75,42.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD + VE",SUP-98000500308,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"BLUE CROSS [10001]","Blue Cross HMO",,9878.4,39.2,,5311.50,4717.44,5388.59,31,2930.76,21420,"percent of total billed charges",
"STENT URETERAL 4.8FR L10CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902050,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 5FR .058IN JUDKINS LEFT 3 CURVE GUIDING NYLON",SUP-LA5JL30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AETNA [10100]","Aetna HMO/PPO",,311.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 46MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.046TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FUSION TITAN 190CM 4CM 12FR 4MM .035IN BALLOON",SUP-G49219,CDM,C1726,HCPCS,0272,RC,,,both,,,2452.50,735.75,"UHC [10700]","United Healthcare",,1552.43,63.3,,,,,0,285.23,2084.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) QUALI BRA ADVANCED S",SUP-QADV-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC 112-137CM SMARTVEST XL HIGH FREQUENCY CHEST",SUP-SW-44/54-1,CDM,S27000186,LOCAL,0270,RC,,,both,,,437.40,131.22,"CIGNA [10200]","Cigna Local Plus",,234.01,53.5,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 39MM 135CM 8MM 11MM 7FR .035IN",SUP-BXA083902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"PHCS [10601]",PHCS,,13653.36,70,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 14MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-014,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"CIGNA [10200]",Cigna,,3221.23,68,,5873.17,5873.17,5873.17,"1 through 10",550.92,4026.54,"percent of total billed charges",
"SUT VICRYL RAPIDE MULTIPASS 4-0 PS-2 18IN BRAID COATED",SUP-VR496,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.87,20.06,"MULTIPLAN [10600]",Multiplan,,56.84,85,,,,,0,7.78,56.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ELECTROPHYSIOLOGY BLACK 110CM 5FR 5MM SPACE F CURVE",SUP-F5QF005CTR,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +26 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0260,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Local Plus",,715.03,53.5,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 5FR SIDEWINDER 2 CURVE ANGIOGRAPHIC",SUP-10719607,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLUX SPARC 10CC",SUP-IFLX-CM-10,CDM,S27800098,LOCAL,0278,RC,,,both,,,22995.00,6898.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9450.95,41.1,,,,,0,2674.32,19545.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 17MM 46MM SHOULDER SIMPLICITI",SUP-7122871,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1187.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1165.21,8516.15,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL 4MM VAPR 90D PROBE INTEGRATED CABLE",SUP-225370,CDM,S27200284,LOCAL,0272,RC,,,both,,,1353.60,406.08,"FIRST HEALTH [10303]","First Health",,1082.88,80,,,,,0,157.42,1150.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 65CM 5FR BERN CURVE ANGIOGRAPHIC SLX CEREBRAL",SUP-451513V0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"MULTIPLAN [10600]",Multiplan,,88.74,85,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACETAZOLAMIDE 250 MG TABLET, IMMEDIATE RELEASE",RX-113,CDM,,,0637,RC,50268-0054-11,NDC,both,1,UN,21.07,6.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9.67,45.9,,,,,0,2.45,17.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNLIMITED PIECE ENDURANT II BUNDLE",SUP-ENDURANTIIUNL,CDM,S27800098,LOCAL,0278,RC,,,both,,,108300.00,32490,"BLUE CROSS [10001]","Blue Cross HMO",,42453.6,39.2,,,,,0,12595.29,92055,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCIVA VR DF4",SUP-D412,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"PHCS [10601]",PHCS,,27300,70,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT PARALLEL ALLOGRAFT 8MM TLIF",SUP-3W3308,CDM,S27800098,LOCAL,0278,RC,,,both,,,17139.60,5141.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4905.35,28.62,,,,,0,1993.34,14568.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 4MM .4MM GRACE BUCKET HANDLE OFFSET NITINOL",SUP-430-400,CDM,L8613,HCPCS,0278,RC,,,both,,,2371.58,711.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1612.67,68,,,,,0,232.31,2015.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TI CERVICAL SPINE LOCKING",SUP-450.351,CDM,S27200284,LOCAL,0272,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 14MM PERSONA MEDIAL CONGRUENT 4-5 C-D KNEE",SUP-42512100314,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"NOVANET [10819]",Novanet,,8082.32,75,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17MM MASTERS HEMODYNAMIC PLUS STD MECHANICAL",SUP-17AHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 24MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.424,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1927.8,45.9,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 CT-2 30IN BRAID GREEN NONABSORBABLE",SUP-X411H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY PRO 54CM 9FR GUIDING STERILE LATEX FREE",SUP-8104,CDM,C1887,HCPCS,0272,RC,,,both,,,1386.50,415.95,"NOVANET [10819]",Novanet,,1039.88,75,,,,,0,161.25,1178.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 150CM 20MM 2MM BALLOON DILATATION",SUP-H74939031202010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENICILLIN G POTASSIUM 5 MILLION UNIT VIAL",RX-6086,CDM,J2540,HCPCS,0636,RC,00049-0520-84,NDC,both,1,UN,115.25,34.57,"CIGNA [10200]",Cigna,,18.98,,,,,,,8.25,97.96,"fee schedule",
"HC Revasc Lithotr-Ather Tib/Per",PX-481000131,CDM,C9774,HCPCS,0481,RC,,,both,,,28404.41,8521.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7461.64,,"Fee schedule rate ($7,461.64).",,,,0,3303.43,24143.75,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vitamin Nos",PX-301000439,CDM,84591,CPT,0301,RC,,,both,,,255.55,76.66,"FIRST HEALTH [10303]","First Health",,204.44,80,,,,,0,0.01,217.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vitamin Nos",PX-301000439,CDM,84591,CPT,0301,RC,,,both,,,255.55,76.66,"AETNA [10100]","Aetna HMO/PPO",,203.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,217.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pretreat Serum Ab ID Absorp",PX-302000215,CDM,86978,CPT,0302,RC,,,both,,,334.10,100.23,"MULTIPLAN [10600]",Multiplan,,283.99,85,,,,,0,0.01,283.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 60MM 2.5MM BALLOON DILATATION PEBAX",SUP-H74939032250610,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Flortaucipir F18 Dx IV 1 Mci",PX-343000048,CDM,A9601,HCPCS,0343,RC,,,both,,,2756.60,826.98,"KAISER [10500]",Kaiser,,1846.92,67,,,,,0,320.59,2343.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 5.5MM VIPER 2 PREBENT TITANIUM NONSTERILE",SUP-186788050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"HC Legionella Ab",PX-302000151,CDM,86713,CPT,0302,RC,,,both,,,365.75,109.72,"MULTIPLAN [10600]",Multiplan,,310.89,85,,,,,0,0.01,310.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Spectroscopy",PX-610000056,CDM,76390,CPT,0610,RC,,,both,,,1247.00,374.1,"UHC [10700]","United Healthcare",,216.45,,,,,,,145.03,1247,"fee schedule",
"CATH SYMPLICITY SPYRAL RENAL",SUP-RDN016,CDM,C1735,HCPCS,0272,RC,,,both,,,91200.00,27360,"AETNA [10100]","Aetna HMO/PPO",,72504,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10606.56,77520,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Njx Cth Slct P-Art Angrp Bi",PX-481000375,CDM,93573,CPT,0481,RC,,,both,,,6091.00,1827.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4141.88,68,,,,,0,708.38,6091,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Stent Cmplx Init",PX-361000710,CDM,37269,CPT,0361,RC,,,both,,,23212.16,6963.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2699.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.21,19730.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Eps Icd Lead",PX-481000059,CDM,93640,CPT,0481,RC,,,both,,,1194.00,358.2,"UHC [10700]","United Healthcare",,1194,,"Case rate ($16,259). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,138.86,1194,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Eps Icd Lead",PX-481000059,CDM,93640,CPT,0481,RC,,,both,,,1194.00,358.2,"CIGNA [10200]",Cigna,,1194,,"Case rate ($23,595). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,138.86,1194,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM SPINE MULTIAXIAL",SUP-8806550A,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1110.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1110.3,8114.82,"percent of total billed charges",
"HC Long Chain Fatty Acids",PX-301000628,CDM,82726,CPT,0301,RC,,,both,,,451.25,135.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,64.09,,,,,,,0.45,383.56,"fee schedule",
"HC Long Chain Fatty Acids",PX-301000628,CDM,82726,CPT,0301,RC,,,both,,,451.25,135.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.87,,"Fee schedule rate ($8.87). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.45,383.56,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Respiratory Flow Vol Loop",PX-460000007,CDM,94375,CPT,0460,RC,,,both,,,223.59,67.08,"PHCS [10601]",PHCS,,156.51,70,,,,,0,26,190.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Short Somatosensory Test Upr",PX-922000008,CDM,95925,CPT,0922,RC,,,both,,,1542.00,462.6,"AETNA [10100]","Aetna HMO/PPO",,1225.89,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,179.33,1310.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revasc Bypass Grft Sngl Maj Cor Art/Br",PX-481000083,CDM,92937,CPT,0481,RC,,,both,,,30344.63,9103.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3529.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3529.08,25792.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revasc Bypass Grft Sngl Maj Cor Art/Br",PX-481000083,CDM,92937,CPT,0481,RC,,,both,,,30344.63,9103.39,"KAISER [10500]",Kaiser,,20330.9,67,,,,,0,3529.08,25792.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revasc Bypass Grft Sngl Maj Cor Art/Br",PX-481000083,CDM,92937,CPT,0481,RC,,,both,,,30344.63,9103.39,"CIGNA [10200]","Cigna Open Access",,21495,,"Case rate ($21,495). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3529.08,25792.94,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MR Quan Tis Comp WO Dx MRI Mlt",PX-610000068,CDM,0697T,CPT,0610,RC,,,both,,,415.00,124.5,"CIGNA [10200]","Cigna Local Plus",,415,,"Per diem ($752). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,48.26,415,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MR Quan Tis Comp WO Dx MRI Mlt",PX-610000068,CDM,0697T,CPT,0610,RC,,,both,,,415.00,124.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,415,,,,,,,48.26,415,"fee schedule",
"HC Incisional Biopsy Skin Sgl",PX-761000063,CDM,11106,CPT,0761,RC,,,both,,,2168.00,650.4,"CIGNA [10200]","Cigna Open Access",,2168,,"Per diem ($2,181).",,,,0,252.14,2168,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Incisional Biopsy Skin Sgl",PX-761000063,CDM,11106,CPT,0761,RC,,,both,,,2168.00,650.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,256.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,252.14,2168,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg Cont Rec W/Vid Eeg Tech",PX-740000039,CDM,95700,CPT,0740,RC,,,both,,,6997.00,2099.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1169,,"Per diem ($1,169).",,,,0,813.75,5947.45,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Ankle >=3v Complt",PX-320000088,CDM,73610,CPT,0320,RC,,,both,,,696.21,208.86,"KAISER [10500]",Kaiser,,466.46,67,,,,,0,44.44,591.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Ankle >=3v Complt",PX-320000088,CDM,73610,CPT,0320,RC,,,both,,,696.21,208.86,"CIGNA [10200]","Cigna Local Plus",,62.15,,,,,,,44.44,591.78,"fee schedule",
"HC Gtt 3 Specimens",PX-301000207,CDM,82951,CPT,0301,RC,,,both,,,235.60,70.68,"PHCS [10601]",PHCS,,164.92,70,,,,,0,0.01,200.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Gtt 3 Specimens",PX-301000207,CDM,82951,CPT,0301,RC,,,both,,,235.60,70.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.72,,,,,,,0.01,200.26,"fee schedule",
"HC Ndl Emg Ea Extremity Ltd",PX-922000011,CDM,95885,CPT,0922,RC,,,both,,,434.84,130.45,"UHC [10700]","United Healthcare",,275.25,63.3,,,,,0,50.57,369.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ndl Emg Ea Extremity Ltd",PX-922000011,CDM,95885,CPT,0922,RC,,,both,,,434.84,130.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.72,41.1,,,,,0,50.57,369.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ndl Emg Ea Extremity Ltd",PX-922000011,CDM,95885,CPT,0922,RC,,,both,,,434.84,130.45,"CIGNA [10200]","Cigna Local Plus",,232.64,53.5,,,,,0,50.57,369.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Noninvas Ffr Analysis Cta",PX-480000105,CDM,75580,CPT,0350,RC,,,both,,,2831.81,849.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1896.22,,"Fee schedule rate ($1,896.22).",,,,0,329.34,2730.34,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Inhal Aero Sputum",PX-410000004,CDM,94640,CPT,0410,RC,,,both,,,298.34,89.5,"KAISER [10500]",Kaiser,,199.89,67,,,,,0,34.7,298.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Feeynolm 20.1-30cm",PX-450000030,CDM,12017,CPT,0450,RC,,,both,,,1347.00,404.1,"MULTIPLAN [10600]",Multiplan,,1144.95,85,,,,,0,67.13,1347,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Excsn Skin Lesn Tr/Ext .6-1cm",PX-510000027,CDM,11401,CPT,0761,RC,,,both,,,4138.00,1241.4,"CIGNA [10200]",Cigna,,2606,,"Per diem ($2,606).",,,,0,481.25,3517.3,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Sclp/Ax/Tr/Ext <=2.5 Int",PX-450000031,CDM,12031,CPT,0450,RC,,,both,,,920.57,276.17,"BLUE CROSS [10001]","Blue Cross PPO",,920.57,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,67.13,920.57,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC RBC Ea Unit",PX-390000021,CDM,P9021,HCPCS,0390,RC,,,both,,,335.00,100.5,"CIGNA [10200]","Cigna Open Access",,190.62,56.9,,,,,0,38.96,284.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC RBC Ea Unit",PX-390000021,CDM,P9021,HCPCS,0390,RC,,,both,,,335.00,100.5,"AETNA [10100]","Aetna HMO/PPO",,266.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.96,284.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Extracranial Vert Stent Init",PX-361000005,CDM,0075T,CPT,0361,RC,,,both,,,18245.72,5473.72,"MULTIPLAN [10600]",Multiplan,,15508.86,85,,,,,0,2121.98,15508.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Estradiol",PX-301000181,CDM,82670,CPT,0301,RC,,,both,,,399.95,119.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.4,.1,,,,,0,0.4,339.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet Myocard Perf Dual W CT",PX-404000017,CDM,78433,CPT,0404,RC,,,both,,,7080.79,2124.24,"MULTIPLAN [10600]",Multiplan,,6018.67,85,,,,,0,823.5,7080.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP 5 SCR HOLE CLUSTER TRITANIUM",SUP-702-04-62G,CDM,C1776,HCPCS,0278,RC,,,both,,,12551.10,3765.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5158.5,41.1,,6417.48,6417.48,6417.48,"1 through 10",1459.69,10668.44,"percent of total billed charges",
"BRACE ORTHOPEDIC SHORT UNIVERSAL OFFSET 18IN 30IN KNEE 2",SUP-11-0523-2-06060,CDM,S27000186,LOCAL,0270,RC,,,both,,,402.46,120.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,47.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.81,342.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 48MM 28MM 10D HIP CROSSFIRE OMNIFIT STERILE",SUP-2041C-2848,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2014.28,28.62,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR ENDOSCOPIC BALLOON FIBER OPTIC BF-UC160F",SUP-MAJ-1352,CDM,S27200284,LOCAL,0272,RC,,,both,,,801.33,240.4,"KAISER [10500]",Kaiser,,536.89,67,,,,,0,93.19,681.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT SWIVELOCK ANCHOR FIBERLINK SUTURETAPE PUNCH LOOP",SUP-AR-1665BCSL,CDM,C1713,HCPCS,0272,RC,,,both,,,5796.00,1738.8,"UHC [10700]","United Healthcare",,3668.87,63.3,,5023.51,2672.93,6679.78,18,2382.16,3668.87,"percent of total billed charges",
"(EVAL) VALVE AORTIC 26MM SAPIEN 3 BOVINE TRANSCATHETER STERI",SUP-9600TFX26A,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,70281,41.1,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 8MM 4MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012278-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veno Ext Uni Si",PX-320000129,CDM,75820,CPT,0320,RC,,,both,,,1743.69,523.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1743.69,,,,,,,93,1743.69,"fee schedule",
"WRAP THERAPEUTIC MEDI-THERM SMALL MEDIUM",SUP-8001061550,CDM,S27000186,LOCAL,0270,RC,,,both,,,1140.48,342.14,"CIGNA [10200]","Cigna Open Access",,648.93,56.9,,,,,0,132.64,969.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 100MM 5.7FR 7MM BALLOON DILATATION 2",SUP-BD-L70100CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"UHC [10700]","United Healthcare",,607.59,63.3,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT OSSEOPERM MENDEC PMMA INJECTOR MIX CNTNR",SUP-OP-0001,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,957.42,156.86,7483.26,51,434.96,3179,"percent of total billed charges",
"BASEPLT TIBIAL TRIATHLON 5 PRIMARY",SUP-5520-B-500,CDM,C1776,HCPCS,0278,RC,,,both,,,7151.76,2145.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3282.66,45.9,,,,,0,831.75,6079,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LASMIDITAN 50 MG TABLET",RX-189200,CDM,,,0637,RC,00002-4312-01,NDC,both,1,UN,400.08,120.02,"CIGNA [10200]",Cigna,,272.05,68,,,,,0,46.53,340.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X4CM VIASHIELD AMNION 2 LAYER PATCH",SUP-8155.2004S,CDM,V2790,HCPCS,0278,RC,,,both,,,15180.00,4554,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 95MM TRI-LOCK BPS GRIPTION 0 STD OFFSET HIP",SUP-101204005,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1908.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1873.26,13691.05,"percent of total billed charges",
"INSRT TIBIAL 7 22MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532-P-722,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"MULTIPLAN [10600]",Multiplan,,7102.52,85,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FULL THICK CALIBRATE DEPTH MARK CANNULATED",SUP-AR-1218-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +19.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030195,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,136.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOMATRIX+ POROUS ALLOGRAFT STERILE",SUP-OMP-09,CDM,C1713,HCPCS,0278,RC,,,both,,,9522.00,2856.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1107.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1107.41,8093.7,"percent of total billed charges",
"SPACER SPINAL 23MMX11MM ELEVATE STD PEEK TITANIUM STERILE",SUP-7771123,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.75MM X 15.0MM",SUP-492751512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X2CM VIASHIELD AMNION 2 LAYER PATCH",SUP-8155.2002S,CDM,V2790,HCPCS,0278,RC,,,both,,,8970.00,2691,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1062.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 2MM BALLOON DILATATION STERILE LATEX",SUP-582015022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORQR 90CM 5FR 2-5-2MM SPACING CORONARY SINUS CURVE",SUP-041590CS,CDM,C1730,HCPCS,0272,RC,,,both,,,2250.00,675,"FIRST HEALTH [10303]","First Health",,1800,80,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INFLOW OUTFLOW IRRIGATION STERILE LATEX FREE DISPOSABLE",SUP-AR-6436,CDM,S27200284,LOCAL,0272,RC,,,both,,,799.47,239.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,92.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,92.98,679.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GEOALIGN 130CM 220MM 7MM 6FR .035IN BALLOON DILATATION",SUP-LX351307220,CDM,C2623,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U220,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"KAISER [10500]",Kaiser,,499.15,67,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 110CM 10CM 5FR 6MM 7.5MM BALLOON",SUP-4206000L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 36CM 13.5FR 12FR .038IN STAINLESS STEEL SILICONE",SUP-8833074001,CDM,C1752,HCPCS,0272,RC,,,both,,,1698.35,509.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,201.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,197.52,1443.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTMASTER 26MM 2.8MM CORONARY STENT STAINLESS STEEL",SUP-1012580-26,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"FIRST HEALTH [10303]","First Health",,13220.4,80,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 5.0/26",SUP-434903,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8117.46,41.1,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PREFACE MULTIPURPOSE CURVE 77CM 8FR .11IN GUIDING",SUP-301805M,CDM,C1893,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FLEXIMA 70CM 6FR .035IN URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002520,CDM,C1758,HCPCS,0272,RC,,,both,,,237.25,71.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,97.51,41.1,,,,,0,27.59,201.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 40MM 0D I HIP X3 TRIDENT 10.6MM",SUP-623-00-40I,CDM,C1776,HCPCS,0278,RC,,,both,,,9332.25,2799.67,"UHC [10700]","United Healthcare",,5907.31,63.3,,8601.07,8395.67,8601.07,"1 through 10",1085.34,7932.41,"percent of total billed charges",
"AEQ FRACTURE (INCLUSIVE OF STD FX STEM, HUMERAL HEAD AND CEMEN",SUP-CAP1003,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8820,40,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 30CM 18FR SILICONE MIC RADIOPAQUE FEED TUBE",SUP-8250-18-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,720.26,41.1,,,,,0,203.81,1489.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET LEADWIRE L51IN 5 LEAD MULTI LINK GRABBER INDIVIDUALLY RE",SUP-414556-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,807.98,242.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,370.86,45.9,,,,,0,93.97,686.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 24FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0118L24,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.96,26.39,"PHCS [10601]",PHCS,,61.57,70,,,,,0,10.23,74.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 92CM 4MM 6FR 2-5-2MM SPACE D CURVE",SUP-D6TDL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3373.55,68,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 15CM 180CM 20MM 10.5FR ESOPHAGEAL",SUP-G57355,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"CIGNA [10200]","Cigna Local Plus",,5540.72,31.5,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WATCHMAN FLX PROCEDURE  TRUSEAL ACCESS SYSTEM",SUP-WMFLXTRUACCPERPROC,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4692,68,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 200MM 5MM BALLOON DILATATION RAPID",SUP-47550200M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,235.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 75MMX10MM VANGUARD E1 KNEE ANTERIOR STABILIZE TIBIAL",SUP-EP189080,CDM,C1776,HCPCS,0278,RC,,,both,,,13372.20,4011.66,"CIGNA [10200]",Cigna,,5348.88,40,,5873.17,5873.17,5873.17,"1 through 10",1555.19,11366.37,"percent of total billed charges",
"TUBE NASOGASTRIC SALEM SUMP 14FR RADIOPAQUE LINE 14FR 48IN",SUP-8888265124,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.37,32.21,"AETNA [10100]","Aetna HMO/PPO",,85.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.49,91.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Spectroscopy",PX-610000056,CDM,76390,CPT,0610,RC,,,both,,,1247.00,374.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($683.51). Procedures 2 - 999, Per diem ($341.76).",,,,0,,,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC",319,MS-DRG,,,,,,,inpatient,,,109934.38,32980.31,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Splint Forearm",PX-E27000166,CDM,E27000166,LOCAL,0270,RC,,,both,,,71.50,21.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Anes Spec Proc Fee Endo Clinic",PX-E27200014,CDM,E27200014,LOCAL,0272,RC,,,both,,,1043.90,313.17,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE ALL STAR VASCULAR J 190CM .014IN STAINLESS",SUP-1001740J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII ALLOGRAFT 20MM 26MM",SUP-401320A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ewho W/Joint(S) Cf",PX-E27400028,CDM,L3764,HCPCS,0274,RC,,,both,,,1790.80,537.24,"CIGNA [10200]","Cigna Open Access",,1018.97,56.9,,,,,0,208.27,1522.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ewho W/Joint(S) Cf",PX-E27400028,CDM,L3764,HCPCS,0274,RC,,,both,,,1790.80,537.24,"CIGNA [10200]",Cigna,,1217.74,68,,,,,0,208.27,1522.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28X10X12MM CASCADIA CONVEX TITANIUM POROUS",SUP-6101-2102812NC-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS [10001]","Blue Cross HMO",,8643.6,39.2,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,inpatient,,,44667.96,13400.39,"AMBETTER EXCHANGE  [11102]",Ambetter,,7765.62,,"Case rate ($7,765.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,210.90, add-ons for qualifying new technology services are included. If operating cost exceeds $40,250.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,927.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,220.43. The transfer operating threshold is the transfer adjustment factor * $7,210.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $545.18. The transfer capital threshold is the transfer adjustment factor * $545.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,36550.47,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"DETOUR SYSTEM CAP FOR ANY NUMBER OF TORUS STENT GRAFTS AND E","SUP-CASE PRICE-DETOUR",CDM,C1604,HCPCS,0278,RC,,,both,,,142500.00,42750,"PHCS [10601]",PHCS,,99750,70,,,,,0,16572.75,121125,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 40CM 3FR EMBOLECTOMY 1 LUMEN BALLOON",SUP-E1601-34,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"PHCS [10601]",PHCS,,419.58,70,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Euglobulin Lysis",PX-305000039,CDM,85360,CPT,0305,RC,,,both,,,584.00,175.2,"MULTIPLAN [10600]",Multiplan,,496.4,85,,,,,0,0.01,496.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 14MM SKYLINE TITANIUM SPINE SELF DRILL VARIABLE",SUP-186850014,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",117.75,860.63,"percent of total billed charges",
"HC Colonoscopy Stoma W Abln",PX-750000161,CDM,44401,CPT,0750,RC,,,both,,,2610.00,783,"CIGNA [10200]","Cigna Open Access",,2610,,"Case rate ($4,028). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,303.54,2610,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Calcaneus >=2v",PX-320000091,CDM,73650,CPT,0320,RC,,,both,,,511.40,153.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,32.95,,,,,,,32.95,434.69,"fee schedule",
"HC Sling Flites",PX-E27000160,CDM,E27000160,LOCAL,0270,RC,,,both,,,188.10,56.43,"UHC [10700]","United Healthcare",,119.07,63.3,,,,,0,21.88,159.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Not Feeynolm 12.6-20cm",PX-450000022,CDM,12005,CPT,0361,RC,,,both,,,1625.00,487.5,"MULTIPLAN [10600]",Multiplan,,1381.25,85,,,,,0,188.99,1625,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 3CM 7FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175271110,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"KAISER [10500]",Kaiser,,830.38,67,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATHETER GUIDELINER V3 150CM 25CM 6FR 5.1FR .056IN IN",SUP-5571,CDM,C1887,HCPCS,0272,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Labor Room Add Hour",PX-721000002,CDM,9999139,LOCAL,0721,RC,,,both,,,277.64,83.29,"AETNA [10100]","Aetna HMO/PPO",,220.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.29,235.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE COMPRESSION 20X20MM STAINLESS STEEL FOOT ANKLE",SUP-43110007,CDM,C1713,HCPCS,0278,RC,,,both,,,3682.50,1104.75,"MULTIPLAN [10600]",Multiplan,,3130.13,85,,,,,0,428.27,3130.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION|DISCARDED DRUG NOT ADMINISTE",RX-3037,CDM,J3010,HCPCS,0636,RC,63323-0806-12,NDC,both,2,ML,20.75,6.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",JW,3.19,,,,,,,1.28,17.64,"fee schedule",
"SPHERE GLENOID 36MM +8 ECCENTRIC",SUP-550536108,CDM,C1776,HCPCS,0278,RC,,,both,,,12450.36,3735.11,"UHC [10700]","United Healthcare",,7881.08,63.3,,8601.07,8395.67,8601.07,"1 through 10",1447.98,10582.81,"percent of total billed charges",
"HC Colonoscopy W Rmvl Snare",PX-750000094,CDM,45385,CPT,0750,RC,,,both,,,3930.04,1179.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,457.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,457.06,3930.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 40MM 75CM 14MM 100CM",SUP-40311,CDM,C1876,HCPCS,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross HMO",,2434.32,39.2,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X13MM 9/11MM SPINE CORTICAL FREEZE DRY",SUP-14913,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4739.47,28.62,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER BREAST IMPLANT RESTERILIZABLE GEL SMOOTH ROUND MODERAT",SUP-RSZMPB265,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"CIGNA [10200]","Cigna Local Plus",,95.2,53.5,,,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 5FR 4MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-04041,CDM,C1725,HCPCS,0272,RC,,,both,,,972.00,291.6,"AETNA [10100]","Aetna HMO/PPO",,772.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 0.9% SODIUM CHLORIDE 250ML VIAFLEX LATEX",SUP-2B1322Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"UHC [10700]","United Healthcare",,51.27,63.3,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Ather Cmplx Init",PX-361000731,CDM,37290,CPT,0361,RC,,,both,,,23403.71,7021.11,"NOVANET [10819]",Novanet,,17552.78,75,,,,,0,23.4,19893.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 32MM 144CM 3MM",SUP-H7493941232300,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CIGNA [10200]","Cigna Open Access",,4416.86,56.9,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE RADIUS DISTAL VOLAR TWO COLUMN RIGHT 6X4 HOLE STE",SUP-02.111.540S,CDM,C1713,HCPCS,0278,RC,,,both,,,4447.05,1334.11,"CIGNA [10200]",Cigna,,3023.99,68,,1831.33,1831.33,1831.33,16,517.19,3779.99,"percent of total billed charges",
"SLEEVE CENTERING 13.5MM S-ROM ZTT 22F LARGE HIP PROXIMAL",SUP-550738,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3115.22,28.62,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4.5MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN04508,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1389.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JAGWIRE ENDOSCOPIC STD STRAIGHT ROUND 260CM .025IN",SUP-M00556461,CDM,C1769,HCPCS,0272,RC,,,both,,,811.01,243.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,96.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.32,689.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH SENTRANT .035IN 64CM 16FR INTRO HYDROPHILIC",SUP-SENSH1664W,CDM,C1894,HCPCS,0272,RC,,,both,,,3180.00,954,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,376.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,369.83,2703,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 8 STD OFFSET HIP",SUP-71935568,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"CIGNA [10200]","Cigna Open Access",,12238.79,33.5,,5302.19,4377.88,6578.61,27,4248.87,31053.65,"percent of total billed charges",
"GWIRE SAMURAI VASCULAR 300CM",SUP-H749393023002,CDM,C1769,HCPCS,0272,RC,,,both,,,689.78,206.93,"NOVANET [10819]",Novanet,,517.34,75,,,,,0,80.22,586.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Compatibility Test Imm Spin",PX-302000198,CDM,86920,CPT,0302,RC,,,both,,,441.50,132.45,"NOVANET [10819]",Novanet,,331.13,75,,,,,0,10.86,375.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 9 HIGH OFFSET HIP",SUP-71935581,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"CIGNA [10200]","Cigna Open Access",,12238.79,33.5,,5302.19,4377.88,6578.61,27,4248.87,31053.65,"percent of total billed charges",
"SPHERE EYE 14MM STERILE PMMA LIGHTWEIGHT",SUP-L1414,CDM,S27800098,LOCAL,0278,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross PPO",,40.92,39.2,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO HALYARD STERILE LATEX FREE DISPOSABLE MIC/MIC-KEY",SUP-10237,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.93,543.58,"PHCS [10601]",PHCS,,1268.35,70,,,,,0,210.73,1540.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 20MM 3.8-3.4FR 5MM TAPER",SUP-H74939031502010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAFT T8 STARDRIVE SELF RETAINING QUICK COUPLING SCRDRVR",SUP-314.467,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAFT T8 STARDRIVE SELF RETAINING QUICK COUPLING SCRDRVR",SUP-314.467,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE LIGHT KIT STERILE DISPOSABLE",SUP-10-1520,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"MULTIPLAN [10600]",Multiplan,,5131.88,85,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 110CM 2FR .019IN PROGREAT",SUP-MC*PC2011Y,CDM,C1887,HCPCS,0272,RC,,,both,,,4754.10,1426.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,563.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,552.9,4040.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 122MM 14MM COMPREHENSIVE POROUS STD SHOULDER",SUP-113654,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"AETNA [10100]","Aetna HMO/PPO",,10017,79.5,,10981.53,8986.79,12413.38,12,1465.38,10710,"percent of total billed charges",
"HC DRN Lesion Ear Extrnl Cmplx",PX-450000301,CDM,69005,CPT,0450,RC,,,both,,,5935.00,1780.5,"PHCS [10601]",PHCS,,4154.5,70,,,,,0,5.94,5044.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 208CM 6CM 3CM MONOFILAMENT GWIRE",SUP-G48278,CDM,S27200284,LOCAL,0272,RC,,,both,,,3060.00,918,"AMERIGROUP MEDICAID [20100]",Amerigroup,,362.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,355.88,2601,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 8CM 1.5MM LEGEND TAPERED STERILE",SUP-F1/8TA15,CDM,S27200284,LOCAL,0272,RC,,,both,,,974.03,292.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,113.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.28,827.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP 4 UNIPOLAR/BIPOLAR -  PRIMARY/REVISION STEM/DEPUY",SUP-CAP-H-4,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross PPO",,4057.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"TUBE NASOGASTRIC 36IN 8FR RADIOPAQUE STRIPE STYLET ENTRIFLEX",SUP-8884720825E,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.01,31.8,"KAISER [10500]",Kaiser,,71.03,67,,,,,0,12.33,90.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROXYZINE HCL 25 MG TABLET",RX-3774,CDM,,,0637,RC,63739-0486-10,NDC,both,1,UN,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 170MM 2.4MM SCR LCP BONE WRIST STERILE",SUP-242.003S,CDM,C1713,HCPCS,0278,RC,,,both,,,17470.72,5241.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6988.29,40,,,,,0,2031.84,14850.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE JAWS STAPLE SYSTEM 12MM 12X12 STRAIGHT",SUP-P71-012-1212-S,CDM,C1713,HCPCS,0278,RC,,,both,,,8330.03,2499.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3823.48,45.9,,,,,0,968.78,7080.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 110MM 20MM ASNIS III TITANIUM HIP FEMUR",SUP-602710,CDM,C1713,HCPCS,0278,RC,,,both,,,1866.45,559.93,"FIRST HEALTH [10303]","First Health",,1493.16,80,,,,,0,217.07,1586.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERTAPE TIGERWIRE 2 2MM 8IN BLUE 24IN NONABSORBABLE",SUP-AR-7275T,CDM,S27200284,LOCAL,0272,RC,,,both,,,595.35,178.6,"PHCS [10601]",PHCS,,416.75,70,,,,,0,69.24,506.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TOURNIQUET W4.125XL24IN SINGLE PORT SINGLE BLADDER CYLI",SUP-60-7075-104R,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.73,54.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.02,153.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR 5MM STORZ 1 STEM",SUP-M0068804011,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"CIGNA [10200]","Cigna Local Plus",,276.32,53.5,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 12MM 6FR 3.75MM",SUP-H7493926712370,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 8MM 6FR 2.25MM .07IN BALLOON",SUP-H7493918908220,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 800CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRX-800,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,470.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",461.59,3373.65,"percent of total billed charges",
"GRAFT BONE CANCELLOUS THK15MM ALLOGRAFT BLOCK FREEZE DRIED",SUP-400280,CDM,S27800098,LOCAL,0278,RC,,,both,,,6371.46,1911.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4332.59,68,,,,,0,741,5415.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 20MM PRECISION CANNULATED CHAMFER MIS BUNION",SUP-P27-130-0020,CDM,C1713,HCPCS,0278,RC,,,both,,,5492.40,1647.72,"NOVANET [10819]",Novanet,,4119.3,75,,,,,0,638.77,4668.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM ATTUNE 5 KNEE POSTERIOR CEMENT REVISION",SUP-154905002,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4128.96,68,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemoglobin Chromatography",PX-301000224,CDM,83021,CPT,0301,RC,,,both,,,118.00,35.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,64.09,,,,,,,0.01,100.3,"fee schedule",
"HC Bx Tissue Pelvis/Hip Superfic",PX-361000503,CDM,27040,CPT,0361,RC,,,both,,,3583.00,1074.9,"FIRST HEALTH [10303]","First Health",,2866.4,80,,,,,0,416.7,3583,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE 62CM 15FR CURL DIALYSIS SILICONE PERITONEAL 2",SUP-8811313010,CDM,C1750,HCPCS,0278,RC,,,both,,,632.63,189.79,"BLUE CROSS [10001]","Blue Cross PPO",,247.99,39.2,,,,,0,73.57,537.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION SORBITOL MANNITOL FLEXIBLE CNTNR 3L LATEX",SUP-07981-08,CDM,S27200284,LOCAL,0272,RC,,,both,,,112.93,33.88,"NOVANET [10819]",Novanet,,84.7,75,,,,,0,13.13,95.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 30MM COMPREHENSIVE 3.5MM SHOULDER FIX ANGLE",SUP-180553,CDM,C1713,HCPCS,0278,RC,,,both,,,1557.00,467.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,714.66,45.9,,,,,0,181.08,1323.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL OSS LONG KNEE NONMODULAR 71MM STERILE",SUP-161043,CDM,C1776,HCPCS,0278,RC,,,both,,,23169.51,6950.85,"PHCS [10601]",PHCS,,16218.66,70,,,,,0,2694.61,19694.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL SHOULDER RESURFACE COPELAND HA 6",SUP-11114646,CDM,C1776,HCPCS,0278,RC,,,both,,,16174.80,4852.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1916.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1881.13,13748.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 10MM 32MM ASYMMETRIC TRITANIUM",SUP-5552-L-320,CDM,C1776,HCPCS,0278,RC,,,both,,,6037.50,1811.25,"CIGNA [10200]","Cigna Local Plus",,3230.06,53.5,,5372.07,4581.20,7242.98,23,702.16,5131.88,"percent of total billed charges",
"TUBE JEJUNOSTOMY 18FR SILICONE MIC-KEY SECUR-LOK ENFIT BOLUS",SUP-8200-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,130.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG LEAD IMAGEREADY IS4 DS4 PORT",SUP-7148,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG LEAD IMAGEREADY IS4 DS4 PORT",SUP-7148,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRD SURGICAL 5MM 5MM ROTO-CAM",SUP-625129,CDM,S27000186,LOCAL,0270,RC,,,both,,,4716.50,1414.95,"UHC [10700]","United Healthcare",,2985.54,63.3,,,,,0,548.53,4009.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28X10X12MM CASCADIA CONVEX TITANIUM POROUS",SUP-6101-2102812NC-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Open Access",,7386.75,33.5,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 16MM MICRO FUSHIA",SUP-AT2-C16-S,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"MULTIPLAN [10600]",Multiplan,,2709.38,85,,,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 40MM 6MM .035IN BALLOON",SUP-AB35W06040135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,278.31,41.1,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drsg Wound 4x4in Thk .25in Rtd",PX-HHE27200406,CDM,HHE27200406,LOCAL,0272,RC,,,outpatient,,,92.00,27.6,"PHCS [10601]",PHCS,,64.4,70,,,,,0,10.7,78.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PNEUMOTHORAX WITHOUT CC/MCC",201,MS-DRG,,,,,,,inpatient,,,26856.90,8057.07,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,9536.97,,"Case rate ($4,435.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,118.95, add-ons for qualifying new technology services are included. If operating cost exceeds $37,158.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,693.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,124.40. The transfer operating threshold is the transfer adjustment factor * $4,118.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.41. The transfer capital threshold is the transfer adjustment factor * $311.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,4435.8,17833.88,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20GA 10CM POWERGLIDE PRO FULL COVER INSRT",SUP-F220108PT,CDM,C1751,HCPCS,0272,RC,,,both,,,909.39,272.82,"NOVANET [10819]",Novanet,,682.04,75,,,,,0,105.76,772.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Resp Virus 6-11 Targets",PX-306000231,CDM,87632,CPT,0306,RC,,,both,,,4400.40,1320.12,"FIRST HEALTH [10303]","First Health",,3520.32,80,,,,,0,0.01,3740.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET STD SPINE INFINITY NONSTERILE LATEX FREE",SUP-3600315,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"CIGNA [10200]",Cigna,,236.64,68,,1831.33,1831.33,1831.33,16,40.47,295.8,"percent of total billed charges",
"PLATE 206MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT SET 8",SUP-222.658,CDM,C1713,HCPCS,0278,RC,,,both,,,9194.39,2758.32,"NOVANET [10819]",Novanet,,6895.79,75,,,,,0,1069.31,7815.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHISEL SURGICAL 16MM LONG BLADE OSTEOTOMY",SUP-399.56,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 40MM 8MM 8FR BILIARY PLATINOL METAL RAPID",SUP-M00570600,CDM,C1876,HCPCS,0278,RC,,,both,,,11927.41,3578.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1413.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1387.16,10138.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 520CC",SUP-SSZ-F520,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"AETNA [10100]","Aetna HMO/PPO",,1184.87,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 6MM XIA 3 TITANIUM RADIOLUCENT",SUP-48238060,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 55MM 12MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113612,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS [10001]","Blue Cross PPO",,4939.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",1465.38,10710,"percent of total billed charges",
"SCR BONE 3MM 50MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0319,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"MULTIPLAN [10600]",Multiplan,,805.55,85,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO2 VASCULAR 300CM .014IN HYDROPHILIC PRESHAPE",SUP-S2SPS14300,CDM,C1769,HCPCS,0272,RC,,,both,,,5686.57,1705.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,673.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,661.35,4833.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 20MM 8MM .035IN BALLOON DILATATION NYBAX",SUP-39171-08024,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT LARGE 11 CC PUTTY BIOACTIVE",SUP-78000110,CDM,C1713,HCPCS,0278,RC,,,both,,,13662.00,4098.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1588.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1588.89,11612.7,"percent of total billed charges",
"BURR SURGICAL 12.5CM 4MM IBUR DISTAL BEND ROUND INTEGRATE",SUP-8431-009-040,CDM,S27200284,LOCAL,0272,RC,,,both,,,3128.93,938.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1285.99,41.1,,,,,0,363.89,2659.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC 91-112CM 36-44IN SMARTVEST LARGE",SUP-SW-36/44-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM ELITE ROUND COARSE DIAMOND 5 STEP NOTCH",SUP-5820-013-030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"CIGNA [10200]",Cigna,,744.57,68,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Pulm Angio Si",PX-481000043,CDM,93568,CPT,0481,RC,,,both,,,2252.00,675.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2252,,"Case rate ($6,002). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,261.91,2252,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 7FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175270010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"MULTIPLAN [10600]",Multiplan,,910.13,85,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION 18FR SURESTEP BARDEX IC COMPLETE CARE",SUP-A300318A,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.29,41.79,"CIGNA [10200]","Cigna Local Plus",,74.52,53.5,,,,,0,16.2,118.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 80MM 3MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186300810,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHALLOY NYLON ETHILON 5-0 PC-5 18IN MONOFILAMENT BLACK",SUP-1895G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 20MM KNEE LEFT MEDIAL PIVOT ADVANCE II",SUP-KIMP320L,CDM,C1776,HCPCS,0278,RC,,,both,,,6141.00,1842.3,"BLUE CROSS [10001]","Blue Cross PPO",,2407.27,39.2,,3949.44,3949.44,3949.44,"1 through 10",714.2,5219.85,"percent of total billed charges",
"GRAFT SOFT TISSUE 50CMX.49MM 16/8MM HEMAGARD VASCULAR BOVINE",SUP-HGK1608,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNETOS 15CC 1-2MM ALLOGRAFT PUTTY",SUP-703-054-US,CDM,C1713,HCPCS,0278,RC,,,both,,,30334.50,9100.35,"NOVANET [10819]",Novanet,,22750.88,75,,,,,0,3527.9,25784.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL SQUARE LOOP 10X8MM 3/32IN COVIDIEN",SUP-E1567,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.35,27.4,"FIRST HEALTH [10303]","First Health",,73.08,80,,,,,0,10.62,77.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Stoma W US",PX-750000166,CDM,44406,CPT,0750,RC,,,both,,,4135.00,1240.5,"BLUE CROSS [10001]","Blue Cross PPO",,3634.7,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,480.9,4135,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 4FR MERIT S-MAK STIFFENED DIL COAXIAL PAIR",SUP-S-MAK4F-10,CDM,C1894,HCPCS,0272,RC,,,both,,,197.66,59.3,"NOVANET [10819]",Novanet,,148.25,75,,,,,0,22.99,168.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grad Compression Waist 18-20",PX-E27100015,CDM,A6539,HCPCS,0292,RC,,,both,,,336.60,100.98,"CIGNA [10200]","Cigna Local Plus",,180.08,53.5,,,,,0,39.15,286.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG TRANSPARENT 9X9IN HYDROGEL SILICONE ADHSV FLEXIBLE",SUP-MSCOV99EP,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.70,28.71,"CIGNA [10200]",Cigna,,65.08,68,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Desensitization Rapid Ea Hr",PX-510000211,CDM,95180,CPT,0510,RC,,,both,,,310.00,93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,310,,"Per diem ($361).",,,,0,0.31,310,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 5.5MM ARMADA TITANIUM PREBENT",SUP-8052045,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"SCR BONE 85MM ANTIROTATE STERILE FEMORAL NECK SYSTEM",SUP-04.168.485S,CDM,C1713,HCPCS,0278,RC,,,both,,,1642.20,492.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,194.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",190.99,1395.87,"percent of total billed charges",
"HC US OB >1st Trimst Txabd Add",PX-402000017,CDM,76810,CPT,0402,RC,,,both,,,1266.00,379.8,"UHC [10700]","United Healthcare",,426,,"Per diem ($426).",,,,0,126.95,1076.1,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET FEEDING 18FR L2.7CM TUBE JEJUNAL EXTENSION MIC-KEY ENFIT",SUP-8230-18-2.7,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"KAISER [10500]",Kaiser,,966.71,67,,,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REVEAL LINQ MYCARELINK CARDIAC MNTR LOOP RCRD MNTR",SUP-LINQSYS,CDM,S27200284,LOCAL,0272,RC,,,both,,,19062.00,5718.6,"KAISER [10500]",Kaiser,,12771.54,67,,,,,0,2216.91,16202.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X7MM HEDRON C 7D 14MM STERILE LATEX FREE",SUP-1211.4617S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"PHCS [10601]",PHCS,,4347,70,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER STANDOFF 120MM MAXFRAME",SUP-03.313.866,CDM,C1713,HCPCS,0278,RC,,,both,,,975.65,292.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,279.23,28.62,,,,,0,113.47,829.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 41CM INTERSTIM MICRO TINE SSMRI",SUP-978A141,CDM,C1778,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Local Plus",,6945.75,31.5,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR ACTIS DUOFIX 1 STD OFFSET HIP STERILE",SUP-101011010,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8228.59,27,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L50MM DIA5MM CARBURIZED VARIABLE ANGLE LOCKING SE",SUP-42.231.250,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"FIRST HEALTH [10303]","First Health",,1082.03,80,,,,,0,157.3,1149.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Malaria Ab Plasmodium",PX-302000221,CDM,86750,CPT,0302,RC,,,both,,,380.00,114,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.94,,,,,,,0.01,323,"fee schedule",
"STEM FEMORAL 175MM 24MM 19MM STD NECK S-ROM CERAMIC 135D",SUP-523396,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"BLUE CROSS [10001]","Blue Cross PPO",,7624.89,39.2,,3949.44,3949.44,3949.44,"1 through 10",2262.18,16533.56,"percent of total billed charges",
"BURR SURGICAL 13CM 5.5MM STERLING 12000 RPM SPHERE LARGE HUB",SUP-H9112,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 4MM 170MM KNEE STERILE",SUP-144170,CDM,S27200284,LOCAL,0272,RC,,,both,,,1010.88,303.26,"MULTIPLAN [10600]",Multiplan,,859.25,85,,,,,0,117.57,859.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 8MM GORE-TEX THIN WALL PTFE THIN WALLED",SUP-SRRT08070080L,CDM,C1768,HCPCS,0278,RC,,,both,,,11267.70,3380.31,"KAISER [10500]",Kaiser,,7549.36,67,,,,,0,1310.43,9577.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 11.5X5.5MM THK.38MM THK.43MM SMALL BONE OSCILLATE",SUP-KM3-410,CDM,S27200284,LOCAL,0272,RC,,,both,,,557.28,167.18,"PHCS [10601]",PHCS,,390.1,70,,,,,0,64.81,473.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR SSSA-09 SEALING ADAPTOR - SHORT WI",SUP-SSSA-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,239.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL SMALL 4.25IN CALIFORNIA PROCARE 2 PIECE",SUP-79-83143,CDM,S27000186,LOCAL,0270,RC,,,both,,,82.74,24.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.62,70.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM REVISION TRITANIUM E",SUP-509-02-56E,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"NOVANET [10819]",Novanet,,8424,75,,,,,0,1306.28,9547.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE INTERNAL EXTRA THICK STERILE GIA TRI-STAPLE LATEX",SUP-GIA80MTS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1127.12,338.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,766.44,68,,,,,0,131.08,958.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Neck/Soft Tiss W/WO Cntrst",PX-351000013,CDM,70492,CPT,0351,RC,,,both,,,3189.70,956.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($377.70). Procedures 2 - 999, Per diem ($188.85).",,,,0,,,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,MINOR",315,APR-DRG,,,,,,,inpatient,,,99314.30,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $5,103.35. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"DIABETES,MAJOR",420,APR-DRG,,,,,,,inpatient,,,36230.81,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $6,087.86. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($31,266.17) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CELLULITIS AND OTHER SKIN INFECTIONS,MODERATE",383,APR-DRG,,,,,,,inpatient,,,29319.35,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT CHPV CSF 14CM 120CM 1 INTEGRAL CNCT PROGRAMMABLE",SUP-823842,CDM,S27800098,LOCAL,0278,RC,,,both,,,44384.89,13315.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17753.96,40,,,,,0,5161.96,37727.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 20CM 6FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552300,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]","Cigna Open Access",,683.13,,,,,,,139.63,1020.49,"percent of total billed charges",
"HC NM Salivary Gland",PX-341000081,CDM,78230,CPT,0341,RC,,,both,,,1730.90,519.27,"BLUE CROSS [10001]","Blue Cross PPO",,469.97,,"Fee schedule rate ($469.97).",,,,0,201.3,1471.27,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE 15X12CM PREPERITONEAL KNIT WEB SYNECOR",SUP-GKWR1215,CDM,C1781,HCPCS,0278,RC,,,both,,,6423.90,1927.17,"FIRST HEALTH [10303]","First Health",,5139.12,80,,,,,0,747.1,5460.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0267,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"MULTIPLAN [10600]",Multiplan,,805.55,85,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE DESTINATION STRAIGHT 45CM 35CM 5FR GUIDING",SUP-54-54501,CDM,C1887,HCPCS,0272,RC,,,both,,,672.30,201.69,"NOVANET [10819]",Novanet,,504.23,75,,,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP SECTOR POROCOAT PINNACLE STERILE",SUP-121722060,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"PHCS [10601]",PHCS,,4697.53,70,,,,,0,780.46,5704.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (PS) - SIZE 5",SUP-5555-2255,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL HIP CONSTRUCT 2",SUP-CAP-MI-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"BLUE CROSS [10001]","Blue Cross PPO",,3786.72,39.2,,3949.44,3949.44,3949.44,"1 through 10",1123.46,8211,"percent of total billed charges",
"ADPTR ELECTROSURGICAL HARMONIC SYNERGY HANDSWITCH DISPOSABLE",SUP-HSA08,CDM,S27000186,LOCAL,0270,RC,,,both,,,277.56,83.27,"CIGNA [10200]","Cigna Local Plus",,148.49,53.5,,,,,0,32.28,235.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 12CM 10FR SHORT LENGTH URETERAL",SUP-H7493936110120,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"BLUE CROSS [10001]","Blue Cross HMO",,485.81,39.2,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM ATTUNE 5 KNEE POSTERIOR CEMENT REVISION",SUP-1549-05-001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2787.05,45.9,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 23MM PRESS FIT TRIATHLON TITANIUM KNEE",SUP-5566-S-023,CDM,C1776,HCPCS,0278,RC,,,both,,,7345.05,2203.51,"AMERIGROUP MEDICAID [20100]",Amerigroup,,870.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,854.23,6243.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 17MM 46MM SHOULDER AEQUALIS ASCEND FLEX COCR",SUP-DWF046,CDM,C1776,HCPCS,0278,RC,,,both,,,9475.00,2842.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1122.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1101.94,8053.75,"percent of total billed charges",
"NAIL 11MM 380MM FEMUR RIGHT GAMMA INTRAMEDULLARY 125D LONG",SUP-3425-1380S,CDM,C1713,HCPCS,0278,RC,,,both,,,13435.13,4030.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5374.05,40,,,,,0,1562.51,11419.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL DUALMESH 15X10CM SOFT TISSUE BIOMATERIAL",SUP-1DLMC200,CDM,C1781,HCPCS,0278,RC,,,both,,,6423.90,1927.17,"CIGNA [10200]",Cigna,,4368.25,68,,,,,0,747.1,5460.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8.5FR 145CM 63CM GUIDE HEMOSTASIS VALVE",SUP-406853,CDM,C1893,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AETNA [10100]","Aetna HMO/PPO",,933.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP LARGE 6.2MM INTERNAL LIGACLIP TITANIUM ENDOSCOPIC",SUP-LT400,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.42,32.53,"MULTIPLAN [10600]",Multiplan,,92.16,85,,,,,0,12.61,92.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 75CM 7FR 2 DUST CAP O2 ADPTR EZ-BLOCKER",SUP-MG-02770-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1441.80,432.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,592.58,41.1,,,,,0,167.68,1225.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Asp/Inj Renal Cyst",PX-361000220,CDM,50390,CPT,0361,RC,,,both,,,4068.18,1220.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4068.18,,"Case rate ($4,617). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,473.13,4068.18,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Surg Tx Abort Missed 1st Tr",PX-450000361,CDM,59820,CPT,0361,RC,,,both,,,8037.00,2411.1,"FIRST HEALTH [10303]","First Health",,6429.6,80,,,,,0,934.7,6831.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 10MM RETRACTA DETACHABLE .035IN",SUP-G34199,CDM,S27800098,LOCAL,0278,RC,,,both,,,4674.68,1402.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3178.78,68,,,,,0,543.67,3973.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mthfr Gene",PX-309000051,CDM,81291,CPT,0310,RC,,,both,,,1599.80,479.94,"AETNA [10100]","Aetna HMO/PPO",,1271.84,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1359.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEIGHT REHABILITATION SOFT GREEN THERABAND 4.5IN",SUP-929253,CDM,S27000186,LOCAL,0270,RC,,,both,,,152.25,45.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,62.57,41.1,,,,,0,17.71,129.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 120CM 15CM 4FR .041IN ANGLE",SUP-CG417,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 30MM 2.75MM BALLOON DILATATION PACLITAXEL",SUP-H7493960830270,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"CIGNA [10200]","Cigna Open Access",,22135.52,56.9,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL MODULUS 7 D L17 MM X W14 MM X H7 MM CERVICAL STE",SUP-67940037P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross PPO",,2434.32,39.2,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TI 4.0X110 LOR ROD",SUP-102064110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"INTRO SHEATH 10FR .134IN 45CM ANL0 CURVE STRAIGHT TIP ANSEL",SUP-G56278,CDM,C1894,HCPCS,0272,RC,,,both,,,472.23,141.67,"AETNA [10100]","Aetna HMO/PPO",,375.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.92,401.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 1 CP 36IN BRAID ANTIBACTERIAL COATED VIOLET",SUP-VCP486H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 120CM 15CM 4FR .041IN ANGLE",SUP-CG417,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 44MM 28MM XLPE HIP",SUP-71934404,CDM,C1776,HCPCS,0278,RC,,,both,,,11974.95,3592.48,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4921.7,41.1,,6417.48,6417.48,6417.48,"1 through 10",1392.69,10178.71,"percent of total billed charges",
"CURET 6 10IN SIMS UTERINE SHARP MALLEABLE SURGICAL",SUP-ER416R,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 275ML GEL TEXTURED SILTEX SILICONE P4.6CM HIGH",SUP-3544275,CDM,C1789,HCPCS,0278,RC,,,both,,,3885.00,1165.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1783.22,45.9,,,,,0,451.83,3302.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,inpatient,,,250756.63,75226.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,83691.82,,"Fee schedule rate ($83,691.82). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,10994,123090.34,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 80MM 80CM 18MM .035IN 3MM VASCULAR CATH GWIRE",SUP-VENUM18080,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9580.41,41.1,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 11.5X5.5MM THK.38MM THK.43MM SMALL BONE OSCILLATE",SUP-KM3-410,CDM,S27200284,LOCAL,0272,RC,,,both,,,557.28,167.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,255.79,45.9,,,,,0,64.81,473.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TACK 6MM 150CM 4FR VASCULAR NITINOL RADIOPAQUE OTW 4",SUP-154150041,CDM,C1876,HCPCS,0278,RC,,,both,,,18238.50,5471.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2121.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2121.14,15502.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 11MM QUICKFIX TITANIUM FULL THREAD FOOT HAND",SUP-AR-8930-11,CDM,C1713,HCPCS,0278,RC,,,both,,,1800.00,540,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,515.16,28.62,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TI 4.0X110 LOR ROD",SUP-102064110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Tissue Pelvis/Hip Superfic",PX-361000503,CDM,27040,CPT,0361,RC,,,both,,,3583.00,1074.9,"CIGNA [10200]","Cigna Open Access",,2090,,"Case rate ($2,090). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,416.7,3583,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 12CM 5FR .035",SUP-M006192112090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"CIGNA [10200]",Cigna,,1014.85,68,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII POSTERIOR STABILIZED OXI",SUP-71704570,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Local Plus",,6945.75,31.5,,5372.07,4581.20,7242.98,23,2564.42,18742.5,"percent of total billed charges",
"LEAD PACING 60CM 6.8FR 11MM SPACING ENDOCARDIUM INTEGRATED",SUP-7130/60,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4636.44,27,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +14.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.145,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 9-0 BV100-4 5IN MONOFILAMENT BLACK NONABSORBABLE",SUP-2829G,CDM,S27200284,LOCAL,0272,RC,,,both,,,253.80,76.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,104.31,41.1,,,,,0,29.52,215.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM ATTUNE 5 KNEE POSTERIOR CEMENT REVISION",SUP-154905002,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1737.81,28.62,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 120MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-120-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10782.00,3234.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4948.94,45.9,,,,,0,1253.95,9164.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS AIM SL 68CM 65CM 7FR 5FR CORONARY SINUS LEFT CURVE",SUP-DS2N024-65,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM PRECISION PERCUTANEOUS LINEAR 3-4",SUP-SC-2352-50,CDM,C1778,HCPCS,0278,RC,,,both,,,8914.80,2674.44,"MULTIPLAN [10600]",Multiplan,,7577.58,85,,,,,0,1036.79,7577.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 30CM 3CM 7FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006180235050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"BLUE CROSS [10001]","Blue Cross HMO",,408.3,39.2,,,,,0,121.14,885.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 150MM 75CM 5MM VASCULAR METAL SUPERFICIAL",SUP-H74939293051570,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 14MM BABY GORILLA LOCK",SUP-P50-053-2014,CDM,C1713,HCPCS,0278,RC,,,both,,,1316.25,394.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,155.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,153.08,1118.81,"percent of total billed charges",
"SUB BONE GRAFT GRAFTON SMALL DEFECT DEMINERALIZED BONE",SUP-T44145,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"CIGNA [10200]",Cigna,,2932.5,68,,1831.33,1831.33,1831.33,16,501.54,3665.63,"percent of total billed charges",
"OSTEOTOM 5.5IN HOKE SPINE SURGICAL CURVE .25IN",SUP-28-4956,CDM,S27200284,LOCAL,0272,RC,,,both,,,197.40,59.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,134.23,68,,,,,0,22.96,167.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet Initial Diag Breast Cx",PX-404000010,CDM,G0252,HCPCS,0404,RC,,,both,,,7151.00,2145.3,"PHCS [10601]",PHCS,,5005.7,70,,,,,0,7.15,6078.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 16CM PUMP SET",SUP-ES2916,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16929,27,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1 KNEE LEFT POSTERIOR STABILIZE BEAD TRIATHLON",SUP-5516-F-101,CDM,C1776,HCPCS,0278,RC,,,both,,,23001.30,6900.39,"NOVANET [10819]",Novanet,,17250.98,75,,,,,0,2675.05,19551.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM TARGET 3D DETACHABLE CONSISTENT",SUP-M0036154080,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]",Cigna,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 40MM 3.8FR 8MM LOW PROFILE BALLOON",SUP-39032-80408,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 10.2X18MM THK.3MM SMALL SAGITTAL STERILE",SUP-1200-018,CDM,S27200284,LOCAL,0272,RC,,,both,,,146.16,43.85,"FIRST HEALTH [10303]","First Health",,116.93,80,,,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TALAR INBONE 3 DOME ANKLE SULCUS",SUP-220220903,CDM,C1776,HCPCS,0278,RC,,,both,,,23719.50,7115.85,"BLUE CROSS [10001]","Blue Cross HMO",,9298.04,39.2,,5311.50,4717.44,5388.59,31,2758.58,20161.58,"percent of total billed charges",
"SHELL ACETABULAR 60MM HIP MULTIHOLE R3 STD STERILE",SUP-71338669,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4289.56,27,,,,,0,1847.69,13504.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 2MM SPS TWIST CALIBRATED AO FITTING",SUP-700346,CDM,S27200284,LOCAL,0272,RC,,,both,,,962.77,288.83,"CIGNA [10200]","Cigna Local Plus",,515.08,53.5,,,,,0,111.97,818.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDRALAZINE 20 MG/ML INJECTION SOLUTION",RX-3697,CDM,J0360,HCPCS,0636,RC,63323-0614-00,NDC,both,1,ML,154.38,46.31,"UHC [10700]","United Healthcare",,8.56,,,,,,,5.16,131.22,"fee schedule",
"SET FEEDING 18FR L2.7CM TUBE JEJUNAL EXTENSION MIC-KEY ENFIT",SUP-8230-18-2.7,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"AETNA [10100]","Aetna HMO/PPO",,1147.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 5MM 5MM LUER LOCK SPRING LOAD HANDLE",SUP-BX00711812,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"MULTIPLAN [10600]",Multiplan,,281.01,85,,,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 12MM 145CM 2.25MM CORONARY STENT",SUP-1145225-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross PPO",,2288.5,39.2,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC LARGE SHOULDER ELASTIC FOAM",SUP-A111007,CDM,L3670,HCPCS,0274,RC,,,both,,,58.03,17.41,"MULTIPLAN [10600]",Multiplan,,49.33,85,,,,,0,6.75,58.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 67MMX10MM VANGUARD E1 KNEE ANTERIOR STABILIZE TIBIAL",SUP-EP189040,CDM,C1776,HCPCS,0278,RC,,,both,,,13372.20,4011.66,"BLUE CROSS [10001]","Blue Cross HMO",,5241.9,39.2,,5311.50,4717.44,5388.59,31,1555.19,11366.37,"percent of total billed charges",
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U165,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA [10200]","Cigna Open Access",,423.91,56.9,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 24MM ARTHREX +2MM SHOULDER MODULAR",SUP-AR-9560-24-2,CDM,C1776,HCPCS,0278,RC,,,both,,,9335.70,2800.71,"UHC [10700]","United Healthcare",,5909.5,63.3,,8601.07,8395.67,8601.07,"1 through 10",1085.74,7935.35,"percent of total billed charges",
"STEM FEMORAL 235MM 27MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-327,CDM,C1776,HCPCS,0278,RC,,,both,,,18758.25,5627.47,"UHC [10700]","United Healthcare",,11873.97,63.3,,8601.07,8395.67,8601.07,"1 through 10",2181.58,15944.51,"percent of total billed charges",
"SLEEVE LAPAROSCOPIC 5MM 150MM KII FIOS ABDOMEN 2 PACK FIRST",SUP-CFF10,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,89.39,41.1,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2.5MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN02506,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Local Plus",,3692.78,31.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 24MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-124,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2.5MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN02506,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1389.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE ENFORM 10X10CM PREPERITONEAL 2 SIDE",SUP-GBWR1010,CDM,C1781,HCPCS,0278,RC,,,both,,,8970.00,2691,"CIGNA [10200]","Cigna Open Access",,5103.93,56.9,,11235.02,819.42,11235.02,"1 through 10",1043.21,7624.5,"percent of total billed charges",
"NAIL 15.5-11MM 38CM FEMUR RIGHT PROXIMAL TALON DISTALFIX",SUP-SLN-125-38R,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"KAISER [10500]",Kaiser,,10803.95,67,,,,,0,1875.37,13706.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM AZUR CX HYDROCOIL DETACHABLE LOOP",SUP-45-780204,CDM,S27800098,LOCAL,0278,RC,,,both,,,5275.05,1582.51,"CIGNA [10200]",Cigna,,3587.03,68,,,,,0,613.49,4483.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 60MM 7MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171070610,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UHC [10700]","United Healthcare",,743.46,63.3,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 100MM 8MM .035IN BALLOON DILATATION NYBAX",SUP-39171-08107,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"NOVANET [10819]",Novanet,,941.63,75,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60MM 3MM 3.5MM 4MM MEDIUM GIA PURPLE",SUP-GIA60MTS,CDM,S27200284,LOCAL,0272,RC,,,both,,,756.78,227.03,"MULTIPLAN [10600]",Multiplan,,643.26,85,,,,,0,88.01,643.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GA-68-GOZETOTIDE INTRAVENOUS SOLUTION (4 MCI)",RX-411539,CDM,A9596,HCPCS,0343,RC,08888-8878-70,NDC,both,1,UN,24796.80,7439.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4816.78,,,,,,,1181,21077.28,"fee schedule",
"CATH MUSTANG 135CM 20MM 5MM .035IN BALLOON DILATATION NYBAX",SUP-H74939171050210,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UHC [10700]","United Healthcare",,743.46,63.3,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT BTCP CLLGN 5ML VITOSS VOID FILLER FOAM PACK",SUP-2102-1605,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"CIGNA [10200]",Cigna,,2932.5,68,,1831.33,1831.33,1831.33,16,501.54,3665.63,"percent of total billed charges",
"GWIRE AMPLATZ VASCULAR J CURVE 260CM 3MM .032IN STAINLESS",SUP-G03750,CDM,C1769,HCPCS,0272,RC,,,both,,,200.01,60,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,136.01,68,,,,,0,23.26,170.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM TKR POROUS MIS",SUP-98000225521,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 1.5MM 10MM TITANIUM CORTICAL HAND SELF TAPPING NO",SUP-400.810.96,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",37.68,275.39,"percent of total billed charges",
"INTRO SHEATH 10FR 2.5CM 10CM WITHOUT MINI GWIRE DIL PINNACLE",SUP-RSS004,CDM,C1894,HCPCS,0272,RC,,,both,,,73.95,22.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 5.5MM UNID COCR 4UP LEVEL EXPAND NONSTERILE LATEX",SUP-B33225599-02,CDM,C1713,HCPCS,0278,RC,,,both,,,13800.00,4140,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3726,27,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 10.7MM 8MM STD LOW PROFILE DEPH FREE",SUP-8229708,CDM,S27200284,LOCAL,0272,RC,,,both,,,2895.00,868.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1189.85,41.1,,,,,0,336.69,2460.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 4.25% DEXTROSE 2000ML 1 BAG LUER CNTNR AMBU-FLEX II",SUP-L5B5187,CDM,S27200284,LOCAL,0272,RC,,,both,,,260.30,78.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,119.48,45.9,,,,,0,30.27,221.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plt Pheresis Lr Irrad Ea Unit",PX-390000011,CDM,P9037,HCPCS,0390,RC,,,both,,,3851.50,1155.45,"CIGNA [10200]",Cigna,,2619.02,68,,,,,0,447.93,3273.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM ATTUNE 5 KNEE POSTERIOR CEMENT REVISION",SUP-154905002,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"FIRST HEALTH [10303]","First Health",,4857.6,80,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE DRILL 4.8MM INFINITY INBONE TIBIA BICORTICAL PROXIMAL",SUP-33600048,CDM,S27200284,LOCAL,0272,RC,,,both,,,1603.80,481.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,186.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,186.52,1363.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 9IN SPETZLER MALIS 2 IRRIGATE 1.5MM DISPOSABLE",SUP-6770-230-015,CDM,S27200284,LOCAL,0272,RC,,,both,,,3282.98,984.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOE POSTOPERATIVE XL BREATHABLE SQUARE TOE OFFLOAD 11.6FT",SUP-VP50201-050,CDM,S27000186,LOCAL,0270,RC,,,both,,,126.15,37.84,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"5F X 30CM TEARAWAY INTRODUCER",SUP-INT-106-31,CDM,C1894,HCPCS,0272,RC,,,both,,,216.49,64.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 135CM 20MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206050210,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL SQUARE LOOP 10X8MM 3/32IN COVIDIEN",SUP-E1567,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.35,27.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 75MM 1.5MM J LATCH NONSTERILE",SUP-310.143,CDM,S27000186,LOCAL,0270,RC,,,both,,,503.50,151.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXTR PRO 200CM 7-6FR 9-12MM SPECIMEN RETRIEVAL NATURAL",SUP-M00547000,CDM,C1726,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CIRCAID LOWER LEG REDUCTION KIT- STANDARD, WIDE",SUP-25102217,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE CENTERING 13.5MM S-ROM ZTT 22F LARGE HIP PROXIMAL",SUP-550738,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"FIRST HEALTH [10303]","First Health",,8707.8,80,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP ACETABULAR 58MM 52MM BHR HYBRID FIXATION HIP",SUP-74122158,CDM,C1776,HCPCS,0278,RC,,,both,,,36977.85,11093.35,"BLUE CROSS [10001]","Blue Cross HMO",,14495.32,39.2,,5311.50,4717.44,5388.59,31,4300.52,31431.17,"percent of total billed charges",
"VASOPRESSIN 40 UNIT/100 ML (0.4 UNIT/ML) IN 0.9 % SODIUM CHLORIDE IV",RX-179640,CDM,J2601,HCPCS,0636,RC,00338-9647-12,NDC,both,100,ML,905.40,271.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,615.67,68,,,,,0,93.71,769.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM PRECISION PERCUTANEOUS LINEAR 3-4",SUP-SC-2352-50,CDM,C1778,HCPCS,0278,RC,,,both,,,8914.80,2674.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3663.98,41.1,,,,,0,1036.79,7577.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAPE 2MM 17IN BRAID STRAIGHT NDL BLUE NONABSORBABLE",SUP-AR-7237-17LN,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THREADED CAP",SUP-32500-000,CDM,S27800098,LOCAL,0278,RC,,,both,,,2406.60,721.98,"NOVANET [10819]",Novanet,,1804.95,75,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8MM 285MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.237S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"NOVANET [10819]",Novanet,,6234.32,75,,,,,0,966.74,7065.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTICA NEO HF-T DF1 HIGH ENERGY PROMRI TI AND CLS",SUP-429553,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"UHC [10700]","United Healthcare",,48709.35,63.3,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7608,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 60MM 2.5MM BALLOON DILATATION PEBAX",SUP-H74939032250610,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE LOADING SYSTEM",SUP-TENDV-LS-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TENDYNE MITRAL VALVE LP 37M",SUP-TENDV-LP-37M-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"INSRT TIBIAL MEDIUM 15MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405315,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1123.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 170MM PERFORM 14 LONG SHOULDER STERILE LATEX",SUP-PFX14170,CDM,C1776,HCPCS,0278,RC,,,both,,,42493.50,12748.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4941.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4941.99,36119.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1MM TARGET NANO 360D DETACHABLE",SUP-M0035421020,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS [10001]","Blue Cross PPO",,5532.94,39.2,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PREVENA PLUS NEGATIVE PRESSURE STANDALONE EXTEND",SUP-PRE4010.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1387.13,41.1,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FRACTURE STABILIT LONG COMPLETE",SUP-3506,CDM,S27200284,LOCAL,0272,RC,,,both,,,16905.00,5071.5,"NOVANET [10819]",Novanet,,12678.75,75,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 14MM MINI-MONSTER SHORT THREAD CANNULATED",SUP-P20-120-014S,CDM,C1713,HCPCS,0278,RC,,,both,,,1559.25,467.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,446.26,28.62,,,,,0,181.34,1325.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE AUGMENTATION THK10MM BIOIMPLANT PREHYDRATE EVANS",SUP-MWEV0010,CDM,C1713,HCPCS,0278,RC,,,both,,,12075.00,3622.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3260.25,27,,,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 3MM DOG BONE SUTURELASSO KNOTLESS",SUP-AR-2371BL,CDM,C1713,HCPCS,0278,RC,,,both,,,13584.38,4075.31,"CIGNA [10200]","Cigna Open Access",,4550.77,33.5,,1144.80,304.56,2275.09,66,1579.86,11546.72,"percent of total billed charges",
"PEG FIXATION 2MM 16MM SMOOTH LOCKING DVR NONSTERILE ANATOMIC",SUP-P16000,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"CIGNA [10200]","Cigna Open Access",,622.2,56.9,,1144.80,304.56,2275.09,66,127.17,929.48,"percent of total billed charges",
"TRAY TIBIAL IDENTITY IMPRINT 5 KNEE POSTERIOR STABILIZE",SUP-TPS-301-T05S,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"MULTIPLAN [10600]",Multiplan,,7477.88,85,,,,,0,1023.15,7477.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM TITANIUM T8 LOCK VARIABLE ANGLE TUBE",SUP-04.210.118TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1056.89,317.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,122.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",122.92,898.36,"percent of total billed charges",
"ASCEND FLEX REVERSE",SUP-CAP-T-FLEXREV,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"NOVANET [10819]",Novanet,,34020,75,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.406,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,160.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",160.97,1176.51,"percent of total billed charges",
"FRCP LAPAROSCOPIC 55.8CM 8MM DA VINCI S/SI ENDOWRIST",SUP-420172,CDM,S27000186,LOCAL,0270,RC,,,both,,,2126.25,637.87,"CIGNA [10200]","Cigna Local Plus",,1137.54,53.5,,,,,0,247.28,1807.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SURGICAL 4MM HOFFER BAYONET",SUP-1564-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.60,562.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,218.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.13,1594.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM TSRH OSTEOGRIP THINLINE TITANIUM SPINE",SUP-83545359,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"CIGNA [10200]",Cigna,,1750.32,68,,1831.33,1831.33,1831.33,16,299.36,2187.9,"percent of total billed charges",
"SCR BONE 12.7MM 8.2MM 125MM 22MM DHS/DCS STAINLESS STEEL",SUP-280.25,CDM,C1713,HCPCS,0278,RC,,,both,,,2264.18,679.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,268.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",263.32,1924.55,"percent of total billed charges",
"GUIDEROD ORTHOPEDIC 1000MM 3MM TRIGEN STAINLESS STEEL BALL",SUP-71631626,CDM,S27200284,LOCAL,0272,RC,,,both,,,2214.30,664.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,262.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,257.52,1882.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 6.5X50MM MIDLINE SYSTEM POLYAXIAL CORTICAL 4S R",SUP-14616550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"CATH PROGREAT 130CM 2.4-2.9FR .022IN .021IN MICRO",SUP-MC*PB2413Y,CDM,C1887,HCPCS,0272,RC,,,both,,,2463.75,739.12,"PHCS [10601]",PHCS,,1724.63,70,,,,,0,286.53,2094.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 6 STD KNEE LEFT KEEL NONPOROUS",SUP-ETPKN6SL,CDM,C1776,HCPCS,0278,RC,,,both,,,11060.70,3318.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4545.95,41.1,,6417.48,6417.48,6417.48,"1 through 10",1286.36,9401.6,"percent of total billed charges",
"DIL ENDOSCOPIC CRE 180CM 5.5CM 7.5FR 12-15MM ESOPHAGUS",SUP-M00558420,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"FIRST HEALTH [10303]","First Health",,1319.22,80,,,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -4 40MM HIP BIOLOX DELTA FMP STERILE LATEX FREE",SUP-400-03-401,CDM,C1776,HCPCS,0278,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER HUMERAL SMR SMALL SHOULDER UHMWPE REVISION METAL BACK",SUP-1377.50.005,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"FIRST HEALTH [10303]","First Health",,2352,80,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 6MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620806,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"NOVANET [10819]",Novanet,,8440.43,75,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 25MM 3.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3525X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"AETNA [10100]","Aetna HMO/PPO",,418.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 32MM 4MM LCP CORTICAL PERIARTICULAR TIBIAL",SUP-02.204.032,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"BLUE CROSS [10001]","Blue Cross PPO",,386.74,39.2,,957.42,570.23,957.42,28,114.74,838.59,"percent of total billed charges",
"DEVICE STRATAFIX MONOCRYL PLUS 3-0 CT-1 SPIRAL 45CM SUT",SUP-SXMP1B429,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"UHC [10700]","United Healthcare",,135.4,63.3,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 23MM STAINLESS STEEL 2MM SCR MINI FRAGMENT SET 4 HOLE",SUP-243.14,CDM,C1713,HCPCS,0278,RC,,,both,,,1845.60,553.68,"PHCS [10601]",PHCS,,1291.92,70,,,,,0,214.64,1568.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 13MM 140CM 2.75MM CORONARY STERILE",SUP-453933,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"KAISER [10500]",Kaiser,,3004.95,67,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE MEDIUM BREATHABLE SQUARE TOE OFFLOAD 10FT",SUP-VP50201-030,CDM,S27000186,LOCAL,0270,RC,,,both,,,114.67,34.4,"CIGNA [10200]","Cigna Local Plus",,61.35,53.5,,,,,0,13.34,97.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM AVENIR 10 HELICAL FINISH STERILE",SUP-10HFN-04010,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA [10200]",Cigna,,7033.31,68,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 100MM 5MM RECTANGLE HELIX BALLOON",SUP-2237-50100,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3403.08,41.1,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 16MM MODULAR REVISION RESTORATION BOW",SUP-6276-7-216,CDM,C1776,HCPCS,0278,RC,,,both,,,11695.32,3508.6,"CIGNA [10200]","Cigna Local Plus",,3684.03,31.5,,5372.07,4581.20,7242.98,23,1360.17,9941.02,"percent of total billed charges",
"VALVE AORTIC 14MM 21MM 19MM EPIC LINX SUPRA BIOPROSTHESIS",SUP-E100-21A-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,36722.70,11016.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4270.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4270.85,31214.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 20CMX10MM SILICONE FULL PERFORATED HUBLESS EVAC",SUP-0072440,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.40,30.72,"UHC [10700]","United Healthcare",,64.82,63.3,,,,,0,11.91,87.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 18CM 3CM 5FR .038IN 2",SUP-M006192115170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"BLUE CROSS [10001]","Blue Cross HMO",,546.93,39.2,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM LCP STAINLESS STEEL LONG FEMORAL",SUP-207.716,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,123.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,120.96,884.03,"percent of total billed charges",
"6215  BALLOON CATHETER-80CM X 10MM BALL",SUP-6215,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,299.62,41.1,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 22GA ACCURIAN CURVE SHARP 10MM",SUP-AC0018,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UHC [10700]","United Healthcare",,66.09,63.3,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM MEDLINE UNITE FOOT ANKLE NONLOCK",SUP-MPSN3520,CDM,C1713,HCPCS,0278,RC,,,both,,,1174.50,352.35,"PHCS [10601]",PHCS,,822.15,70,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 25MM PINNACLE GRIPTION TF HIP ACETABULAR",SUP-125725000,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,324.55,28.62,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 140MM 125CM 8MM 6FR BILIARY",SUP-G50173,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2795.31,45.9,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X12X7MM COALITION TITANIUM ANTERIOR CERVICAL",SUP-384.107,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"UHC [10700]","United Healthcare",,11394,63.3,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE SPINE MODULAR TULIP NONSTERILE MAS PLIF",SUP-7070000,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",348.9,2550,"percent of total billed charges",
"SPLINT ORTHOPEDIC XL 8.75IN RIGHT WRIST THUMB SPICA SLIP ON",SUP-A61510,CDM,S27000186,LOCAL,0270,RC,,,both,,,224.55,67.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL HOOK 90D COOLCUT STERILE",SUP-AR-9801,CDM,S27200284,LOCAL,0272,RC,,,both,,,978.08,293.42,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 150CM 200MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030200M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC",027,MS-DRG,,,,,,,inpatient,,,164317.86,49295.36,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM COLLAR SECUR-FIT TITANIUM HA 132D 14 C",SUP-S-2337-HF14,CDM,C1776,HCPCS,0278,RC,,,both,,,24037.65,7211.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2795.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2795.58,20432,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 8MM MREYE 2 LOOP PLATINUM ARTERIAL",SUP-G42423,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,567.27,68,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM VERTEX MAX TITANIUM SPINAL MULTIAXIAL GOLD",SUP-6958826,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1927.8,45.9,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC SHORT 17IN KNEE DUAL AXIS POLYCENTRIC HINGE",SUP-A402550,CDM,S27000186,LOCAL,0270,RC,,,both,,,551.37,165.41,"CIGNA [10200]","Cigna Local Plus",,294.98,53.5,,,,,0,64.12,468.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP415H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Muscle Biopsy",PX-312000008,CDM,88305,CPT,0312,RC,,,both,,,413.40,124.02,"CIGNA [10200]","Cigna Local Plus",,78.21,,,,,,,0.01,351.39,"fee schedule",
"STENT POLARIS SENSOR DUAL-FLEX 24CM 7FR .035IN URETERAL",SUP-M006155242090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"BLUE CROSS [10001]","Blue Cross HMO",,534.19,39.2,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PERFIX LIGHT 1.5IN 2IN GROIN PLUG MONOFILAMENT",SUP-0117080,CDM,C1781,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG ROUND DRAPE SENSATRAC PAD CNCT POLYURETHANE VAC",SUP-M8275075/10.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,337.70,101.31,"UHC [10700]","United Healthcare",,213.76,63.3,,,,,0,39.27,287.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Neutralization Test Viral",PX-302000085,CDM,86382,CPT,0302,RC,,,both,,,526.00,157.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,60.04,,,,,,,0.01,447.1,"fee schedule",
"TUBE NASOGASTRIC 55IN 8FR ENTERAL RADIOPAQUE WEIGHT TIP",SUP-8884710826E,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.39,32.82,"AETNA [10100]","Aetna HMO/PPO",,86.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.72,92.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 26CM 3CM 7FR .035IN 2",SUP-M006192143180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"KAISER [10500]",Kaiser,,1065.21,67,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 10MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158105110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AETNA [10100]","Aetna HMO/PPO",,8883.77,79.5,,10981.53,8986.79,12413.38,12,1299.6,9498.37,"percent of total billed charges",
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 9MM BALLOON",SUP-U357598,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 40 MEQ POTASSIUM CHLORIDE 5% DEXTROSE .9%",SUP-710909,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXCISOR BIOPSY FISCHER SMALL WIDE CONE",SUP-900-157,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.28,60.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR HSII CURVE GUIDING NYLON CORONARY",SUP-LA6HSII,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SUPER TORQUE 100CM 4FR .0395IN SIDEWINDER SIMMONS",SUP-532415,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MERSILENE 5MM BP-1 12IN 2 ARM WOVEN WHITE NONABSORBABLE",SUP-RS21XN,CDM,S27200284,LOCAL,0272,RC,,,both,,,363.82,109.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL INTUITIVE DA VINCI XI BLUE GREEN 60",SUP-1BSGXI60GB,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS 3-0 FS-2 18IN BRAID ANTIBACTERIAL COATED",SUP-VCP393H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) CATH NUVISION ICE 10FR ULTRASOUND",SUP-FG10593,CDM,C1759,HCPCS,0272,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUCTION FEN 9FR",SUP-S001,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) CHAMPIONIR DES SYSTEM US 5-100",SUP-412501000USRD,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"JOINT TOE LPT 1 ANGLE GREAT TOE",SUP-487A001,CDM,C1776,HCPCS,0278,RC,,,both,,,11585.10,3475.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1372.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1347.35,9847.34,"percent of total billed charges",
"SCR BONE 6.5MM 40MM CD HORIZON SPINAL FENESTRATE MULTIAXIAL",SUP-55840026540T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.6MM VIP SPINE VARIABLE ANGLE",SUP-171.318,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]",Cigna,,958.8,68,,1831.33,1831.33,1831.33,16,163.98,1198.5,"percent of total billed charges",
"CATH TURBO-ELITE 150CM 2MM .08IN .081IN ATHERECTOMY",SUP-420-006,CDM,C1885,HCPCS,0272,RC,,,both,,,18868.50,5660.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12830.58,68,,,,,0,2194.41,16038.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +22 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2200,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 76MM 10.8MM 6.4MM CUFF LOW PRESSURE FENESTRATE INNER",SUP-6FEN,CDM,S27200284,LOCAL,0272,RC,,,both,,,399.33,119.8,"NOVANET [10819]",Novanet,,299.5,75,,,,,0,46.44,339.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIMETHICONE 80 MG CHEWABLE TABLET",RX-7227,CDM,,,0637,RC,77333-0812-25,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 15.5X14X.6MM MICROPOWER MICRO100 90D SAGITTAL",SUP-502313600,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.00,27.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,42.69,45.9,,,,,0,10.82,79.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 7MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630507,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"MULTIPLAN [10600]",Multiplan,,11158.16,85,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 30MM 4MM .035IN BALLOON DILATATION NYBAX",SUP-39171-04034,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 8MM 4MM BALLOON DILATATION DURATRAC",SUP-NCEUP4008X,CDM,C1725,HCPCS,0272,RC,,,both,,,550.80,165.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,65.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.06,468.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL .25IN TRIATHLON PEG",SUP-6541-4-525,CDM,S27000186,LOCAL,0270,RC,,,both,,,1672.50,501.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,198.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,194.51,1421.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH GORE DRYSEAL FLEX 65CM 8.8MM 24FR INTRO HYDROPHILIC",SUP-GDSF2465,CDM,C1894,HCPCS,0272,RC,,,both,,,6858.60,2057.58,"MULTIPLAN [10600]",Multiplan,,5829.81,85,,,,,0,797.66,5829.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR ENDOSCOPIC 34CM SURGIFLO STERILE LATEX FREE DISPOSABLE",SUP-MS1995,CDM,S27000186,LOCAL,0270,RC,,,both,,,589.48,176.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,68.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.56,501.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 200MM 4MM BALLOON DILATATION DURALYN",SUP-48004020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,565.95,41.1,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 25MM TITANIUM LOCK TRANSLATIONAL ATLANTIS BONE SPINE",SUP-6190025,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 22CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175271180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,992.87,68,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT HUMERAL GLOBAL AP POROUS CEMENT",SUP-OSC11795,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5859.95,28.62,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM 4 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800490,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"COIL EMBOLIZATION 20CM 8MM AZUR HYDROCOIL 18 COILS",SUP-45-480820,CDM,S27800098,LOCAL,0278,RC,,,both,,,6406.65,1921.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,759.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,745.09,5445.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 4MM 8MM ELBOW TITANIUM HEAD STERILE",SUP-TR-S0804-S,CDM,C1776,HCPCS,0278,RC,,,both,,,15145.50,4543.65,"AETNA [10100]","Aetna HMO/PPO",,12040.67,79.5,,10981.53,8986.79,12413.38,12,1761.42,12873.68,"percent of total billed charges",
"STENT INNOVA 120MM 130CM 7MM VASCULAR METAL SUPERFICIAL",SUP-H74939293071230,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]","Cigna Local Plus",,2584.05,53.5,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 6FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856120,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,503.37,45.9,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASNIS III ORTHOPEDIC 300MM 3.2MM FEMUR HIP THREAD",SUP-702462S,CDM,C1769,HCPCS,0272,RC,,,both,,,918.54,275.56,"MULTIPLAN [10600]",Multiplan,,780.76,85,,,,,0,106.83,780.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 64MM 36MM MARATHON",SUP-121936464,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"KAISER [10500]",Kaiser,,6594.71,67,,,,,0,1144.72,8366.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 18GA 2.25MM ACCUCATH ACE DOT",SUP-AC1182252,CDM,S27200284,LOCAL,0272,RC,,,both,,,446.88,134.06,"CIGNA [10200]",Cigna,,303.88,68,,,,,0,51.97,379.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE RIGHT MEDIAL LEFT LATERAL RESTORIS",SUP-180516,CDM,C1776,HCPCS,0278,RC,,,both,,,12440.70,3732.21,"NOVANET [10819]",Novanet,,9330.53,75,,,,,0,1446.85,10574.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INJECTION 5% DEXTROSE LACTATED RINGERS USP LIFE 1000ML",SUP-792909,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mopath Procedure Level 1",PX-309000093,CDM,81400,CPT,0310,RC,,,both,,,1109.85,332.95,"CIGNA [10200]","Cigna Local Plus",,140.71,,,,,,,0.01,943.37,"fee schedule",
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 48MM 32MM MARATHON",SUP-121932448,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"CIGNA [10200]","Cigna Local Plus",,4339.36,53.5,,5372.07,4581.20,7242.98,23,943.3,6894.31,"percent of total billed charges",
"HEAD GLENOID 36MM UNIVERS REVERS SMALL UNIVERSAL SHOULDER",SUP-AR-9504S,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"FIRST HEALTH [10303]","First Health",,9754.56,80,,,,,0,1418.07,10364.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENDOMAXX 90CM 100CM 23MM 24FR ESOPHAGEAL SILICONE",SUP-MAXX-2310,CDM,C1874,HCPCS,0278,RC,,,both,,,17640.00,5292,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5048.57,28.62,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 10D F HIP X3 TRIDENT",SUP-623-10-36F,CDM,C1776,HCPCS,0278,RC,,,both,,,6879.60,2063.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,800.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,800.1,5847.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Absc Fgr Smpl",PX-450000119,CDM,26010,CPT,0450,RC,,,both,,,909.00,272.7,"CIGNA [10200]","Cigna Local Plus",,909,,,,,,,0.91,909,"case rate",
"SCR BONE 4.75MM 20MM COMPREHENSIVE 3.5MM HEXAGON SHOULDER",SUP-180558,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",180.96,1322.6,"percent of total billed charges",
"STENT POLARIS 20CM 5FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552200,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,142.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 3.5CM 18FR GUIDING BALLOON LOW PROFILE",SUP-8117,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"MULTIPLAN [10600]",Multiplan,,3155.63,85,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN SX ENDO HEPARIN 35 RO 13MMX5CM 10FR 120CMCATH",SUP-VBHR130502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"UHC [10700]","United Healthcare",,11875.97,63.3,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 8-9 C-D KNEE RIGHT TIBIA FIX",SUP-42522100516,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"FIRST HEALTH [10303]","First Health",,8621.14,80,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.3MM 300MM KIRSCHNER 1 END TROCAR TIP SMOOTH",SUP-P99-192-2330,CDM,C1713,HCPCS,0278,RC,,,both,,,146.16,43.85,"MULTIPLAN [10600]",Multiplan,,124.24,85,,,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SUBSTITUTE DEMINERALIZED CANCELLOUS ALLOGRAFT BLO",SUP-PBB12,CDM,S27800098,LOCAL,0278,RC,,,both,,,4944.71,1483.41,"AETNA [10100]","Aetna HMO/PPO",,3931.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,575.07,4203,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT TIBIAL PERSONA NONPOROUS E KNEE LEFT REVISION FIXA",SUP-42542007101,CDM,C1776,HCPCS,0278,RC,,,both,,,23892.50,7167.75,"CIGNA [10200]","Cigna Open Access",,8003.99,33.5,,5302.19,4377.88,6578.61,27,2778.7,20308.63,"percent of total billed charges",
"MICROCATHETER CEREBROVASCULAR 150CM 2.9-2.7FR .027IN",SUP-M003XT2750820,CDM,S27200284,LOCAL,0272,RC,,,both,,,8474.58,2542.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3483.05,41.1,,,,,0,985.59,7203.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTERSINK 3.0MM HEADED",SUP-P20-910-3000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"MULTIPLAN [10600]",Multiplan,,853.74,85,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 7MM SEALGUARD EVAC STERILE",SUP-110870,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.91,99.27,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,136,41.1,,,,,0,38.48,281.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Candida Ag Detection",PX-306000112,CDM,87449,CPT,0306,RC,,,both,,,97.00,29.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.12,,,,,,,0.01,82.45,"fee schedule",
"HC Coxsackie a Antibodies CSF",PX-302000118,CDM,86658,CPT,0302,RC,,,both,,,313.00,93.9,"BLUE CROSS [10001]","Blue Cross PPO",,16.65,,"Fee schedule rate ($16.65).",,,,0,0.01,266.05,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +29.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2950,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL INTRAMEDULLARY FEMORAL BENT 11 MM DIA 420 MM LENGTH 130",SUP-04.037.163S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CIGNA [10200]",Cigna,,4967.34,40,,1831.33,1831.33,1831.33,16,1444.25,10555.59,"percent of total billed charges",
"VIABAHN BX BALLOON EXP ENDO 7MMX15MM 7FR 80CMCATH HEPARIN",SUP-BXB071501A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL BREATHE-EASY STERILE",SUP-20-10500,CDM,S27200284,LOCAL,0272,RC,,,both,,,305.63,91.69,"NOVANET [10819]",Novanet,,229.22,75,,,,,0,35.54,259.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plasminogen Not Ag",PX-305000046,CDM,85420,CPT,0305,RC,,,both,,,255.00,76.5,"CIGNA [10200]","Cigna Local Plus",,14.37,,,,,,,0.01,216.75,"fee schedule",
"SYSTEM RESOLUTE ONYX 34MM 140CM .91-1.12MM 3.5MM CORONARY",SUP-RONYX35034W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"KAISER [10500]",Kaiser,,3644.13,67,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL TRANSSEPTAL 98CM 50D",SUP-FND01905,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT TRACTION UNIVERSAL FOOT TOE 4 CLSR ADJUSTABLE STRAP",SUP-79-99890,CDM,S27000186,LOCAL,0270,RC,,,both,,,99.79,29.94,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.61,84.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP050300090 PLUS US D5L300UL900",SUP-PCP050300090,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR SET TITANIUM T15 STD SPINE LOCK CAP NONSTERILE",SUP-102000000,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 7.75MM BARRON 360D STAINLESS STEEL TREPHINE",SUP-K20-2057,CDM,S27200284,LOCAL,0272,RC,,,both,,,599.40,179.82,"CIGNA [10200]","Cigna Local Plus",,320.68,53.5,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET ARTHROSCOPIC OPEN OSTEOPREP ACL PCL 8MM NOTCHPLASTIES",SUP-8211,CDM,S27200284,LOCAL,0272,RC,,,both,,,3876.56,1162.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,450.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,450.84,3295.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 13MM KNEE CRUCIATE RETAIN TRIATHLON",SUP-5530P713,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5682.01,68,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 9CM 23MM 18.5FR ESOPHAGEAL PERMALUME",SUP-M00516940,CDM,C1874,HCPCS,0278,RC,,,both,,,10022.00,3006.6,"KAISER [10500]",Kaiser,,6714.74,67,,,,,0,1165.56,8518.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 750CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP150RH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"BLUE CROSS [10001]","Blue Cross PPO",,4665.78,39.2,,16595.83,16595.83,16595.83,"1 through 10",1384.26,10117.13,"percent of total billed charges",
"HC Ca Urine Quant Timed Specimen",PX-301000126,CDM,82340,CPT,0301,RC,,,both,,,110.74,33.22,"NOVANET [10819]",Novanet,,83.06,75,,,,,0,0.01,94.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 14FR SILICONE PULL RADIOPAQUE MED PORT MIC SECUR-LOK",SUP-7180-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.81,228.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,313.1,41.1,,,,,0,88.6,647.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL ICONIX 1.4MM STERILE DISPOSABLE",SUP-3910500568,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"AETNA [10100]","Aetna HMO/PPO",,1004.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR ENDOSCOPIC DIA12MM 100MM NON BLADED STABILITY SLEEVE",SUP-B12LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"UHC [10700]","United Healthcare",,99.13,63.3,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM GRAY FLEXIBLE BLADE SURGICAL 6MMX67MM STERILE",SUP-6210-0-720,CDM,S27200284,LOCAL,0272,RC,,,both,,,1377.10,413.13,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,565.99,41.1,,,,,0,160.16,1170.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS BLOCK ALLOGRAFT 8MM",SUP-290841,CDM,S27800098,LOCAL,0278,RC,,,both,,,3839.85,1151.95,"CIGNA [10200]","Cigna Open Access",,2184.87,56.9,,,,,0,446.57,3263.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.5MM X 15.0MM",SUP-492501512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 12MM 2.75MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012406-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 22MM TARGET XL 360D STD LARGE",SUP-M0036102250,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Head&Neck Soft Tiss",PX-402000005,CDM,76536,CPT,0402,RC,,,both,,,1579.16,473.75,"MULTIPLAN [10600]",Multiplan,,1342.29,85,,,,,0,131.63,1342.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR SENZA CHRG NONSTERILE LATEX FREE REUSABLE",SUP-CHGR1000,CDM,C1822,HCPCS,0278,RC,,,both,,,6900.00,2070,"NOVANET [10819]",Novanet,,5175,75,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 16MM 144CM 2.25MM CORONARY STENT",SUP-H7493952816220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT LARGE 12.5 CC MATRIX BIOACT",SUP-74000125,CDM,C1713,HCPCS,0278,RC,,,both,,,18113.76,5434.13,"BLUE CROSS [10001]","Blue Cross PPO",,7100.59,39.2,,957.42,570.23,957.42,28,2106.63,15396.7,"percent of total billed charges",
"EXERCISER HAND ROLYAN BLACK RUBBER ERGONOMIC LATEX FREE",SUP-A3481,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.33,13.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18.63,41.1,,,,,0,5.27,38.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 40MM 6FR 9MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206090470,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X17-14.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-4817,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1725.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 340MM FEMORAL RFN-ADVANCED INTRAMEDULLARY 5D BEND",SUP-04.233.234S,CDM,C1713,HCPCS,0278,RC,,,both,,,11445.44,3433.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7782.9,68,,,,,0,1331.1,9728.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (PS) - SIZE 7",SUP-5555-2257,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM KII ROUND 100MM 12MM BALLOON DILATATION INTEGRATE",SUP-COK14,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,860.63,45.9,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 7CM 170CM 10FR 2 PIGTAIL CURVE TAPER BILIARY",SUP-G21787,CDM,C2625,HCPCS,0278,RC,,,both,,,1231.20,369.36,"NOVANET [10819]",Novanet,,923.4,75,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 60MM 130CM 6MM LONG VASCULAR NITINOL ILIAC",SUP-SC660LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3325.46,45.9,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl FB Peritoneal",PX-361000202,CDM,49402,CPT,0361,RC,,,both,,,2339.99,702,"KAISER [10500]",Kaiser,,1567.79,67,,,,,0,2.34,2339.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST TAPER 32MM 12MM HEMICAP CONTOUR OVOID SHOULDER TITANIUM",SUP-8156-0032-A,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,,10981.53,8986.79,12413.38,12,348.9,2550,"percent of total billed charges",
"(EVAL) MOTIV SCAFFOLD 3.5MMX12MM","SUP-930035-12 (72)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myelography Lumb Inj Lumbsac Si",PX-361000373,CDM,62304,CPT,0361,RC,,,both,,,4612.82,1383.85,"MULTIPLAN [10600]",Multiplan,,3920.9,85,,,,,0,536.47,4612.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 24CM 3CM 8FR .035IN",SUP-M006192152190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,948.76,68,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 5MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBH050502,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM TKR CEMENT FLEX",SUP-98000670100,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]",Cigna,,7560,40,,5873.17,5873.17,5873.17,"1 through 10",2198.07,16065,"percent of total billed charges",
"CATH DORADO CHECKER 80CM 2CM 6MM BALLOON DILATATION",SUP-DR8062,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"KAISER [10500]",Kaiser,,922.59,67,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 4MM 1.2MM 26MM 6MM STAINLESS STEEL SHORT THREAD",SUP-202.626,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"KAISER [10500]",Kaiser,,743.71,67,,,,,0,129.1,943.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING EXTERNAL FIXATION 150MM MAXFRAME 5/8 ALUMINUM",SUP-03.312.650,CDM,C1713,HCPCS,0278,RC,,,both,,,7754.08,2326.22,"NOVANET [10819]",Novanet,,5815.56,75,,,,,0,901.8,6590.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aqaprn-4 Antb Flo Cytmtry Ea",PX-302000252,CDM,86053,CPT,0302,RC,,,both,,,751.45,225.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,89.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,638.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 55.4CM 8MM DA VINCI S/SI ENDOWRIST PK 70-",SUP-420227,CDM,S27000186,LOCAL,0270,RC,,,both,,,2175.00,652.5,"KAISER [10500]",Kaiser,,1457.25,67,,,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2 X 4 HELICAL PICO COIL",SUP-10USH02004,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Local Plus",,3692.78,31.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3N CURVE 10MM KNEE GVF FIX BEARING CRUCIATE",SUP-984391,CDM,C1776,HCPCS,0278,RC,,,both,,,7509.96,2252.99,"BLUE CROSS [10001]","Blue Cross PPO",,2943.9,39.2,,3949.44,3949.44,3949.44,"1 through 10",873.41,6383.47,"percent of total billed charges",
"KIT INTRO 10CM 5FR 19-21GA GLIDESHEATH SLENDER .021IN 7CM",SUP-51-1050,CDM,C1894,HCPCS,0272,RC,,,both,,,607.50,182.25,"FIRST HEALTH [10303]","First Health",,486,80,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC",717,MS-DRG,,,,,,,inpatient,,,89366.82,26810.05,"UHC [10700]","United Healthcare",,55195.04,,"Fee schedule rate ($55,195.04). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,55195.04,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.160,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 5.00 X 8MM",SUP-H7493942808500,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"AETNA [10100]","Aetna HMO/PPO",,4936.95,79.5,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Shoe Off Load",PX-E27400083,CDM,L3260,HCPCS,0274,RC,,,both,,,206.80,62.04,"BLUE CROSS [10001]","Blue Cross PPO",,81.07,39.2,,,,,0,24.05,175.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC DRN Lesion Ear Extrnl Smpl",PX-450000300,CDM,69000,CPT,0450,RC,,,both,,,1347.00,404.1,"CIGNA [10200]","Cigna Open Access",,1347,,,,,,,1.35,1347,"case rate",
"PLATE NARROW STRAIGHT 90MM MINI FRAGMENT 7 HOLE COMPRESSION",SUP-629527,CDM,C1713,HCPCS,0278,RC,,,both,,,3303.30,990.99,"CIGNA [10200]",Cigna,,2246.24,68,,1831.33,1831.33,1831.33,16,384.17,2807.81,"percent of total billed charges",
"SCR BONE 4.5MM 45MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75444545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,1831.33,1831.33,1831.33,16,441.36,3225.75,"percent of total billed charges",
"SCR BONE 5MM 55MM TRIGEN FEMUR LOW PROFILE",SUP-71645055,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"CIGNA [10200]","Cigna Local Plus",,1107.21,53.5,,3978.14,359.25,3978.14,24,240.69,1759.12,"percent of total billed charges",
"SCR BONE 5MM 85MM 32MM NCB TITANIUM ALUMINUM VANADIUM",SUP-203152085,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,1831.33,1831.33,1831.33,16,189.34,1383.8,"percent of total billed charges",
"ROD SPINAL 80MM 6MM DIAPASON TITANIUM UNION THORACOLUMBAR",SUP-665080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"DEVICE STATLOCK UNIVERSAL PLUS LARGE 12-14FR SECUREMENT FOAM",SUP-VUPD1214,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.96,25.79,"FIRST HEALTH [10303]","First Health",,68.77,80,,,,,0,10,73.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ACQUIRE S FRANSEEN 22GA BIOPSY ULTRASOUND FINE NDL",SUP-M00555640,CDM,S27200284,LOCAL,0272,RC,,,both,,,3051.38,915.41,"CIGNA [10200]","Cigna Local Plus",,1632.49,53.5,,,,,0,354.88,2593.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING .5MM MYOCARDIUM TEMPORARY UNIPOLAR COIL FIXATION",SUP-6491F,CDM,S27500001,LOCAL,0275,RC,,,both,,,304.50,91.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,139.77,45.9,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endovasc Intracran Adm Rx 1st",PX-361000499,CDM,61650,CPT,0361,RC,,,both,,,4922.46,1476.74,"NOVANET [10819]",Novanet,,3691.85,75,,,,,0,4.92,4922.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT STRAIGHT RETRACTION 50MM MARS 26MM",SUP-632.465S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2880.00,864,"AETNA [10100]","Aetna HMO/PPO",,2289.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.94,2448,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 100MM 9MM BALLOON",SUP-U3575910,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 36MM TORNIER AEQUALIS PERFORM +3MM SHOULDER",SUP-DWJ022,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"CIGNA [10200]","Cigna Open Access",,4084.66,33.5,,5302.19,4377.88,6578.61,27,1418.05,10364.05,"percent of total billed charges",
"KIT CATH ADULT 28CM 15.5FR DURATHANE DURAFLOW EMBOSAFE BASIC",SUP-H787103012025,CDM,C1750,HCPCS,0278,RC,,,both,,,1175.00,352.5,"PHCS [10601]",PHCS,,822.5,70,,,,,0,136.65,998.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 50MM VIPER EXPEDIUM TITANIUM SPINE CORTICAL",SUP-186731650,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 28CM 10FR URETERAL FLEXITHANE",SUP-H7493936110280,CDM,C2617,HCPCS,0278,RC,,,both,,,1142.10,342.63,"KAISER [10500]",Kaiser,,765.21,67,,,,,0,132.83,970.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2MM 150MM KIRSCHNER STAINLESS STEEL TROCAR",SUP-292.20,CDM,C1713,HCPCS,0278,RC,,,both,,,61.14,18.34,"BLUE CROSS [10001]","Blue Cross PPO",,23.97,39.2,,957.42,570.23,957.42,28,7.11,51.97,"percent of total billed charges",
"HC Nfct Ds Chrnc Hcv 6 Assays",PX-309000126,CDM,81596,CPT,0310,RC,,,both,,,710.60,213.18,"PHCS [10601]",PHCS,,497.42,70,,,,,0,0.01,604.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 50MM CD HORIZON SPINAL MULTIAXIAL CANNULATED",SUP-54850014550,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4457.4,68,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.440TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"CIGNA [10200]",Cigna,,1374.65,68,,1831.33,1831.33,1831.33,16,235.11,1718.32,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 24CM 7FR .038",SUP-M006192142120,CDM,C2617,HCPCS,0278,RC,,,both,,,1498.34,449.5,"FIRST HEALTH [10303]","First Health",,1198.67,80,,,,,0,174.26,1273.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD REAMER 13MM IRR ASPIR STERILE DISPOSABLE",SUP-352.252S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2560.05,768.01,"MULTIPLAN [10600]",Multiplan,,2176.04,85,,,,,0,297.73,2176.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VICI VENOUS STENT 90MM 100CM 12MM ENDOPROSTHESIS",SUP-H74912090100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immunoassy Tumor Ca 125",PX-302000057,CDM,86304,CPT,0302,RC,,,both,,,511.10,153.33,"KAISER [10500]",Kaiser,,342.44,67,,,,,0,0.01,434.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 10IN 13.5MM REDUCE NECK SOL SYSTEM POROUS 12/14",SUP-157211136,CDM,C1776,HCPCS,0278,RC,,,both,,,39412.80,11823.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10641.46,27,,,,,0,4583.71,33500.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-207.026,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"KAISER [10500]",Kaiser,,183.33,67,,,,,0,31.82,232.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cementoplasty Femur or Knee",PX-361000667,CDM,27599,CPT,0361,RC,,,both,,,668.00,200.4,"BLUE CROSS [10001]","Blue Cross HMO",,0.67,.1,,,,,0,0.67,668,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL VASCULAR J",SUP-1009662J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X8MM ADVANCED LORDOTIC SPINE",SUP-017708,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]","Cigna Open Access",,4711.32,56.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 4.8FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175250050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CIGNA [10200]",Cigna,,728.1,68,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 100MM 5.5MM CD HORIZON CURVE TITANIUM CP4",SUP-1553201100,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"CATH SABERX 150CM 200MM 2.5MM BALLOON DILATATION RAPID",SUP-47525200M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,239.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 6MM AVENIR 10 HELICAL FINISH STERILE",SUP-10HFN-06008,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA [10200]","Cigna Local Plus",,5533.56,53.5,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX EXTREME 80CM 4CM 5FR 5MM 7MM BALLOON",SUP-4156040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 475ML GEL ROUND SMOOTH MEMORYGEL SILICONE P4.2CM",SUP-3504751BC,CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,427.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP TRUNCATE OSTEOTOM 54MM HEMISPHERE",SUP-00705305410,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3077.95,68,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X10MM COROENT 10 XL PEEK",SUP-6981050,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2815.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAFT SCRDRVR 100MM 3.5MM LARGE HEXAGONAL QUICK COUPLING",SUP-314.15,CDM,S27000186,LOCAL,0270,RC,,,both,,,726.57,217.97,"CIGNA [10200]","Cigna Local Plus",,388.71,53.5,,,,,0,84.5,617.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 12CM 11.5FR DUODENAL BEND BILIARY PLASTIC RAPID",SUP-M00545730,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"NOVANET [10819]",Novanet,,639.58,75,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 115MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.418,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,635.32,45.9,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMB LINER 53/54/55MM 28MM MULTIPOLAR HIP UHMWPE STERILE",SUP-500105328,CDM,C1776,HCPCS,0278,RC,,,both,,,2365.50,709.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,275.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,275.11,2010.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 650ML GEL ROUND SMOOTH MEMORYGEL SILICONE P4.7CM","SUP-3506501 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"BLUE CROSS [10001]","Blue Cross PPO",,1440.6,39.2,,16595.83,16595.83,16595.83,"1 through 10",427.4,3123.75,"percent of total billed charges",
"HC Dest Benign Skin Lesn <=14",PX-761000006,CDM,17110,CPT,0761,RC,,,both,,,2862.00,858.6,"CIGNA [10200]",Cigna,,2606,,"Per diem ($2,606).",,,,0,332.85,2740.57,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 5CMX12MMX8MM VIEWSITE INTRO WORK CHANNEL SURGICAL",SUP-TC120805,CDM,S27200284,LOCAL,0272,RC,,,both,,,4795.50,1438.65,"FIRST HEALTH [10303]","First Health",,3836.4,80,,,,,0,557.72,4076.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT PROSERIES GEOALIGN 120MM 80CM 5MM 5FR",SUP-5F051201CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6238.98,41.1,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +30 DIOPTER POSTERIOR CHMBR 1 PIECE FOLDABLE UV",SUP-ACU0T0,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 36MM VOLT STAINLESS STEEL T8 CORTEX",SUP-02.527.136,CDM,C1713,HCPCS,0278,RC,,,both,,,1033.56,310.07,"CIGNA [10200]",Cigna,,702.82,68,,1831.33,1831.33,1831.33,16,120.2,878.53,"percent of total billed charges",
"COIL EMBOLIZATION 30CM 9MM AVENIR 10 COMPLEX FRAME STERILE",SUP-10CFR-09030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]",Cigna,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 125MM 12MM PRIMARY CEMENT SATIN FINISH VERSYS",SUP-785001200,CDM,C1776,HCPCS,0278,RC,,,both,,,18721.08,5616.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2177.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2177.26,15912.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 4MM ROUND RESURFACE DISSECTING STERILE LATEX FREE",SUP-1900-010-040,CDM,S27200284,LOCAL,0272,RC,,,both,,,921.86,276.56,"CIGNA [10200]","Cigna Local Plus",,493.2,53.5,,,,,0,107.21,783.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ASAHI CORSAIR PRO 150CM .42MM .87-.93MM .38MM .45MM",SUP-CSR150-26P,CDM,C1887,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,695,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insj Perm Ccm-D Sys Pg&Dual Transvns Eltrds/Lds",PX-481000410,CDM,0915T,CPT,0481,RC,,,both,,,49376.00,14812.8,"FIRST HEALTH [10303]","First Health",,39500.8,80,,,,,0,5742.43,41969.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +31 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-LI61AOR3100,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO AQUA 125CM 4FR 135D VERTEBRAL CURVE ANGIOGRAPHIC",SUP-SRD6108,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"UHC [10700]","United Healthcare",,121.16,63.3,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 23MM 143CM 2.5MM CORONARY EVEROLIMUS ELUTING",SUP-1009539-23,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2744.94,28.62,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 22.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962336,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"BLUE CROSS [10001]","Blue Cross HMO",,5685.49,39.2,,5311.50,4717.44,5388.59,31,1686.79,12328.23,"percent of total billed charges",
"NAIL 9MM 340MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.955S,CDM,C1713,HCPCS,0278,RC,,,both,,,13031.06,3909.32,"PHCS [10601]",PHCS,,9121.74,70,,,,,0,1515.51,11076.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 64MM STAINLESS STEEL T8 METAPHYSEAL SELF TAP",SUP-02.118.564,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"MULTIPLAN [10600]",Multiplan,,445.32,85,,,,,0,60.93,445.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 13MM HELIX R SPINE SELF DRILL FIX ANGLE",SUP-7802213,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 5-0 P-3 18IN MONOFILAMENT UNDYED",SUP-690G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE MYRINGOTOMY SPEAR SPEAR STERILE DISPOSABLE",SUP-1458276,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.95,20.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.14,59.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH MICROBIOLOGY 1MM 1.8MM 110CM STERILE DISPOSABLE",SUP-130,CDM,S27200284,LOCAL,0272,RC,,,both,,,151.03,45.31,"AETNA [10100]","Aetna HMO/PPO",,120.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.56,128.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERLOOP FIBERTAG SWAGE STRAIGHT NDL NONABSORBABLE",SUP-AR-7266,CDM,S27200284,LOCAL,0272,RC,,,both,,,1063.13,318.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,436.95,41.1,,,,,0,123.64,903.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALSARTAN 320 MG TABLET",RX-31211,CDM,,,0637,RC,62332-0047-90,NDC,both,1,UN,25.19,7.56,"MULTIPLAN [10600]",Multiplan,,21.41,85,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 9MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G309,CDM,C1776,HCPCS,0278,RC,,,both,,,15387.14,4616.14,"AETNA [10100]","Aetna HMO/PPO",,12232.78,79.5,,10981.53,8986.79,12413.38,12,1089.28,13079.07,"percent of total billed charges",
"CMPNT HUMERAL SIMPLICITI 3 NUCLEUS",SUP-DWG403,CDM,C1776,HCPCS,0278,RC,,,both,,,15840.00,4752,"NOVANET [10819]",Novanet,,11880,75,,,,,0,1842.19,13464,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 20MM 144CM 2.25MM CORONARY STENT PEBAX",SUP-H7493926020220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 2-0 P-14 12IN CLSR ABSORBABLE UNDYED",SUP-VLOCM0115,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"MULTIPLAN [10600]",Multiplan,,166.46,85,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla I& II Typing Lr",PX-309000079,CDM,81370,CPT,0310,RC,,,both,,,3069.00,920.7,"FIRST HEALTH [10303]","First Health",,2455.2,80,,,,,0,115.59,2608.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 13MM DIVERGENCE TITANIUM SPINAL CERVICAL",SUP-G7733513,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"FIRST HEALTH [10303]","First Health",,1500,80,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 116MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 9",SUP-71357109,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"AETNA [10100]","Aetna HMO/PPO",,26347.21,79.5,,10981.53,8986.79,12413.38,12,3854.32,28169.98,"percent of total billed charges",
"CATH SABERX 90CM 120MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520120S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIPHERAL CUTTING BALLOON 50CM 20MM 6MM BALLOON",SUP-PCB602050,CDM,C1725,HCPCS,0272,RC,,,both,,,5037.00,1511.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,596.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,585.8,4281.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SHEPHERD ANGIOGRAPHIC STRAIGHT .014IN 6GM PERIPHERAL",SUP-PSP14S-30006,CDM,C1769,HCPCS,0272,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC",330,MS-DRG,,,,,,,inpatient,,,92120.58,27636.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,45491.66,,"Fee schedule rate ($45,491.66). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,69988.65,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 11GA 6IN SNARECOIL BONE MARROW",SUP-RBN-116,CDM,S27200284,LOCAL,0272,RC,,,both,,,400.20,120.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,47.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 20CM 5FR .035IN URETERAL",SUP-M006155220090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,161.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RUBY XL COIL 28MMX55CM",SUP-RBYXL2855,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"CIGNA [10200]","Cigna Local Plus",,5933.66,31.5,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 35CM 5.7FR ATRIUM VENTRICLE TRANSVENOUS BIPOLAR",SUP-407635,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1518.1,68,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 26MM STAINLESS STEEL ORTHOPEDIC SELF TAPPING",SUP-S30-26S-11,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 130MM WEBSTER DUROGRIP SMOOTH NDL TUNGSTEN CARBIDE",SUP-BM014R,CDM,S27000186,LOCAL,0270,RC,,,both,,,323.21,96.96,"NOVANET [10819]",Novanet,,242.41,75,,,,,0,37.59,274.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 10MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0101000,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"CIGNA [10200]",Cigna,,3455.66,68,,5873.17,5873.17,5873.17,"1 through 10",591.02,4319.57,"percent of total billed charges",
"TROCAR LAPAROSCOPIC 100MM 5MM ENDOPATH XCEL BLADELESS",SUP-2B5LT,CDM,S27200284,LOCAL,0272,RC,,,both,,,919.46,275.84,"MULTIPLAN [10600]",Multiplan,,781.54,85,,,,,0,106.93,781.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN SMOOTH TIP GUIDE 2.5MM x 200MM",SUP-DWD168,CDM,S27200284,LOCAL,0272,RC,,,both,,,1556.00,466.8,"CIGNA [10200]",Cigna,,1058.08,68,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTERNAL FIXATION DYNACLIP L10 MM X W10 MM X H10 MM S",SUP-3000-00-101010,CDM,C1713,HCPCS,0278,RC,,,both,,,10591.50,3177.45,"AETNA [10100]","Aetna HMO/PPO",,8420.24,79.5,,1521.93,481.35,16760.95,30,1231.79,9002.78,"percent of total billed charges",
"2.50MM X 15MM  SCOREFLEX  NC",SUP-625-154-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revasc Cto Cor Art/Br/Grf Sngl Ant&Rtrgr",PX-481000430,CDM,92945,CPT,0481,RC,,,both,,,29518.12,8855.44,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"BLADE OPHTHALMIC 15.8MM 7MM BEAVER CORNEAL STAINLESS STEEL",SUP-0009709,CDM,S27200284,LOCAL,0272,RC,,,both,,,456.35,136.9,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LAMOTRIGINE 100 MG TABLET",RX-13982,CDM,,,0637,RC,68084-0319-11,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET INTRO 7CM 7FR 21GA .018IN STRAIGHT MICRO 1 END GWIRE",SUP-MIS-7F07,CDM,C1894,HCPCS,0272,RC,,,both,,,174.00,52.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AWL SURGICAL 3.8MM TAPER DISPOSABLE",SUP-72202621,CDM,S27200284,LOCAL,0272,RC,,,both,,,546.75,164.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FLEXIMA 70CM 4FR URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002001,CDM,C1758,HCPCS,0272,RC,,,both,,,82.25,24.67,"PHCS [10601]",PHCS,,57.58,70,,,,,0,9.57,69.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 200ML P3.2CM MODERATE PLUS PROFILE HIGH",SUP-350-2001BC,CDM,C1789,HCPCS,0278,RC,,,both,,,4823.10,1446.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,560.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,560.93,4099.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN REGULAR",SUP-67018100,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"FIRST HEALTH [10303]","First Health",,334.08,80,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 10MM TARGET XL 360D STD LARGE",SUP-M0036101040,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Calculi Infrared Spect",PX-301000129,CDM,82365,CPT,0301,RC,,,both,,,330.20,99.06,"AETNA [10100]","Aetna HMO/PPO",,262.51,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,280.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX PERMALUME 80MM 194CM 8MM 8.5FR .035IN BILIARY",SUP-M00570350,CDM,C1874,HCPCS,0278,RC,,,both,,,9360.00,2808,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4296.24,45.9,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 18IN ENDOLOOP MONOFILAMENT TIE LOOP SUT ENDOSCOPIC PDS",SUP-EZ10G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1325.14,397.54,"FIRST HEALTH [10303]","First Health",,1060.11,80,,,,,0,154.11,1126.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL SF D CURVE ABLATION UNIDIRECTION",SUP-D134701,CDM,C1732,HCPCS,0272,RC,,,both,,,20304.90,6091.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13807.33,68,,,,,0,2361.46,17259.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 27MM THK.25MM STERILE",SUP-GC906R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1834.50,550.35,"AETNA [10100]","Aetna HMO/PPO",,1458.43,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,213.35,1559.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH RED 150CM RESPONSE ELECTROPHYSIOLOGY HEXAPOLAR",SUP-401977R,CDM,S27000186,LOCAL,0270,RC,,,both,,,729.00,218.7,"AETNA [10100]","Aetna HMO/PPO",,579.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID",RX-42219,CDM,,,0250,RC,70677-1107-01,NDC,both,120,ML,25.66,7.7,"CIGNA [10200]","Cigna Open Access",,14.6,56.9,,,,,0,2.98,21.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXFIT SEAMLESS BRA FRONT CLOSURE-40 D/E-BLACK","SUP-B01G-40 D/E-B",CDM,S27000186,LOCAL,0270,RC,,,both,,,200.45,60.13,"NOVANET [10819]",Novanet,,150.34,75,,,,,0,23.31,170.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPISTAXIS WITH MCC",150,MS-DRG,,,,,,,inpatient,,,48475.86,14542.76,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,8754.93,,"Case rate ($8,259.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,669.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,709.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,961.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,679.53. The transfer operating threshold is the transfer adjustment factor * $7,669.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.84. The transfer capital threshold is the transfer adjustment factor * $579.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,33206.28,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO BALKIN CURVE 40CM 7FR 2.5MM GUIDING",SUP-G10384,CDM,C1894,HCPCS,0272,RC,,,both,,,405.25,121.57,"MULTIPLAN [10600]",Multiplan,,344.46,85,,,,,0,47.13,344.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 26CM 8FR .038",SUP-M006192153120,CDM,C2617,HCPCS,0278,RC,,,both,,,1528.96,458.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1039.69,68,,,,,0,177.82,1299.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 12CM 33MM MASTERS HEMASHIELD CLLGN MECHANICAL","SUP-33CAVGJ-514  00",CDM,S27800098,LOCAL,0278,RC,,,both,,,25533.90,7660.17,"AETNA [10100]","Aetna HMO/PPO",,20299.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2969.59,21703.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 25MM X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-325,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1594.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 4-0 SH-1 27IN MONOFILAMENT ABSORBABLE",SUP-G181H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 20MM 80CM 8MM 6FR .035IN VASCULAR NITINOL",SUP-G43854,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"KAISER [10500]",Kaiser,,2532.6,67,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 8MMX39MM 7FR 135CMCATH HEPARIN",SUP-BXBL083902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"PHCS [10601]",PHCS,,13653.36,70,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 50MM 5.5MM SPINE TITANIUM FIXED CROSS",SUP-8450150,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,414.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",414.32,3028.13,"percent of total billed charges",
"TUBE FEEDING 18FR STOMA L4CM JEJUNAL L45CM BALLOON 7-10ML GA",SUP-8270-18-4.0-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,306.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 19MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-219,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4040.34,41.1,,6417.48,6417.48,6417.48,"1 through 10",1143.29,8355.94,"percent of total billed charges",
"FRCP SURGICAL MEEKER 90D 7IN",SUP-54-5005,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.18,53.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPEL APD TWIST-LOC 20CM 8FR J DRNG FLEXITHANE METAL",SUP-H7493931008200,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BUTTON 1CM 16FR RADIOPAQUE LOW PROFILE TAPER DISTAL TIP",SUP-0120-16-1.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SEEKER 135CM SPRT HYDROPHILIC PERIPHERAL RADIOPAQUE",SUP-SK13514,CDM,C1887,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INSTR INFERIOR GLENOID HEMICAP DISPOSABLE STERILE HEMI",SUP-G000-0100,CDM,S27200284,LOCAL,0272,RC,,,both,,,3300.00,990,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL 31MM TITANIUM 4.8MM ENDOSCOPIC LINEAR CUTTER",SUP-EEA31,CDM,S27200284,LOCAL,0272,RC,,,both,,,1880.70,564.21,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ANGIOSCULPT 137CM 15MM 3.5MM RECTANGLE HELIX TAPER",SUP-2200-3515,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER 110MM 2.9MM TRICUT 360D 5000 RPM SINUS M4",SUP-1882904HRE,CDM,S27200284,LOCAL,0272,RC,,,both,,,2025.00,607.5,"KAISER [10500]",Kaiser,,1356.75,67,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH R2P DESTINATION SLENDER 149CM 6FR GUIDING STERILE",SUP-GS-R6ST1C15W,CDM,C1894,HCPCS,0272,RC,,,both,,,2216.25,664.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,910.88,41.1,,,,,0,257.75,1883.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE V-18 CONTROLWIRE VASCULAR STRAIGHT 300CM 12CM .018IN",SUP-M001468600,CDM,C1769,HCPCS,0272,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR WHITE 4.3MM 30MM ENDOWRIST STERILE LATEX FREE",SUP-48630W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1453.28,435.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.02,1235.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 110MM 4MM SKIMMER 40D SINUS CURVED STERILE",SUP-1884006,CDM,S27200284,LOCAL,0272,RC,,,both,,,1914.00,574.2,"UHC [10700]","United Healthcare",,1211.56,63.3,,,,,0,222.6,1626.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR KK NEUTRAL 56MM 36MM VIVACIT-E HIP",SUP-00885101236,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2934.13,28.62,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ACCULINK 40MM 132CM 7-10MM TAPER VASCULAR NITINOL",SUP-1011344-40,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6364.8,68,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL PERCUFLEX PLUS HYDROPLUS",SUP-M006175197080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"FIRST HEALTH [10303]","First Health",,991.5,80,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL MASK NEONATE PROSOFT NONSTERILE LATEX FREE",SUP-PROSOFT-PRE,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.06,33.62,"AETNA [10100]","Aetna HMO/PPO",,89.09,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.03,95.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET VENTRICULAR ASSIST IMPELLA RP FLEX ASSIST",SUP-1000323,CDM,S27800098,LOCAL,0278,RC,,,both,,,153900.00,46170,"KAISER [10500]",Kaiser,,103113,67,,,,,0,17898.57,130815,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE TAPER TIP",SUP-02.107.302,CDM,C1713,HCPCS,0278,RC,,,both,,,5840.44,1752.13,"CIGNA [10200]",Cigna,,3971.5,68,,1831.33,1831.33,1831.33,16,679.24,4964.37,"percent of total billed charges",
"LENS IOL 0 D +12.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.125,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 24MMX9MM WAVE D 6D PEEK STERILE",SUP-2660924,CDM,S27800098,LOCAL,0278,RC,,,both,,,24192.00,7257.6,"PHCS [10601]",PHCS,,16934.4,70,,,,,0,2813.53,20563.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 8FR STRAIGHT ENDOCARDIAL IS-1 BIPOLAR CNCT",SUP-LPA1200M/52,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1518.1,68,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 7 KNEE CEMENTED PRIMARY",SUP-5520B700,CDM,C1776,HCPCS,0278,RC,,,both,,,7151.76,2145.53,"BLUE CROSS [10001]","Blue Cross PPO",,2803.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",831.75,6079,"percent of total billed charges",
"STENT UNISTEP PLUS WALLSTENT RP 60MM 135CM 8MM 160CM",SUP-M001711290,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1001.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MTRL SPLINTING THK1/8IN 24X18IN PERFORATE OPTIPERF",SUP-A96321,CDM,S27000186,LOCAL,0270,RC,,,both,,,707.05,212.11,"UHC [10700]","United Healthcare",,447.56,63.3,,,,,0,82.23,600.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD INSULATION CARDIAC ADULT",SUP-ACIP,CDM,S27200284,LOCAL,0272,RC,,,both,,,148.38,44.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.26,126.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TIGHTROPE II TIGHTROPE FIBERLINK 2 4MM FIXATION PIN",SUP-AR-1588RT2-IBS,CDM,C1713,HCPCS,0278,RC,,,both,,,5614.88,1684.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3818.12,68,,,,,0,653.01,4772.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PLIAFORM STARCAST ADVANCE 35LP 135CM 10CM 5FR 4MM 15",SUP-G52254,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"FIRST HEALTH [10303]","First Health",,767.82,80,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM LOW PROFILE NONSTERILE LATEX FREE",SUP-131227214,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"BLUE CROSS [10001]","Blue Cross PPO",,333.4,39.2,,957.42,570.23,957.42,28,98.91,722.93,"percent of total billed charges",
"SHEATH PINNACLE DESTINATION TUOHY-BORST STRAIGHT 90CM 15CM 7",SUP-RSC02,CDM,C1887,HCPCS,0272,RC,,,both,,,785.70,235.71,"KAISER [10500]",Kaiser,,526.42,67,,,,,0,91.38,667.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FIRMAP 153CM 8.5FR 50MM 50MM MAPPING 64 ELECTRD TOPERA",SUP-USAR064050,CDM,C1732,HCPCS,0272,RC,,,both,,,30870.00,9261,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3658.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3590.18,26239.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 36MM COMPRESSION FT TITANIUM STD FULL THREAD",SUP-AR-8740-36H,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"BLUE CROSS [10001]","Blue Cross HMO",,1029,39.2,,957.42,156.86,7483.26,51,305.29,2231.25,"percent of total billed charges",
"HEAD BIPOLAR 51MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-51-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"MULTIPLAN [10600]",Multiplan,,4809.3,85,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE PALACOS R 40GM 1 DOSE STERILE",SUP-00111214001,CDM,C1713,HCPCS,0278,RC,,,both,,,607.50,182.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,173.87,28.62,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rp Quan Meas Single Area",PX-341000075,CDM,78835,CPT,0341,RC,,,both,,,973.00,291.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,446.61,45.9,,,,,0,0.97,827.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 3MM ANKLE VALOR INTRAMEDULLARY BEADED TIP GWIRE SCR KIT",SUP-4150004030,CDM,C1769,HCPCS,0272,RC,,,both,,,1672.50,501.75,"UHC [10700]","United Healthcare",,1058.69,63.3,,,,,0,194.51,1421.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG AUTOTRANSFUSION 400ML CARDIOPAT ORTHOPAT REPLACEMENT RBC",SUP-01200-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.68,40.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,55.35,41.1,,,,,0,15.66,114.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 50MM 1.5MM SMARTPIN PLLA SELF REINFORCE STERILE",SUP-121550,CDM,S27200284,LOCAL,0272,RC,,,both,,,1160.08,348.02,"AMERIGROUP MEDICAID [20100]",Amerigroup,,137.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,134.92,986.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 146MM TYPE 1 PRESS FIT REDUCE TAPERLOC PPS 133D",SUP-51103130,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"CIGNA [10200]",Cigna,,9681.34,40,,5873.17,5873.17,5873.17,"1 through 10",2814.85,20572.84,"percent of total billed charges",
"HEAD RADIAL 14MM 22MM EXPLOR ELBOW MODULAR",SUP-11-210033,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1684.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1653.09,12081.9,"percent of total billed charges",
"APPROXIMATOR SURGICAL 5.75IN BAILEY RIB SHARP TEETH",SUP-54-2530,CDM,S27200284,LOCAL,0272,RC,,,both,,,1265.71,379.71,"FIRST HEALTH [10303]","First Health",,1012.57,80,,,,,0,147.2,1075.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIGHTNING FLASH CATHETER, 100CM",SUP-LITNGFHT100H1,CDM,C1757,HCPCS,0272,RC,,,both,,,60795.00,18238.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7204.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7070.46,51675.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 1IN 27GA HYDRODISSECTION NUCLEUS VERTICAL",SUP-118-27S,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.85,17.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.96,50.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACTOR, STRIPPED SCREW, 5 MM, 6"" LONG, SINGLE USE",SUP-SXT012-ST3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1359.79,45.9,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALL TIPPED GUIDE ROD 3.0 X 550MM PHANTOM? HINDFOOT NAIL",SUP-P31-955-1550,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Inj Paravrt Jt C/T 2 Lvl Bi",PX-510000135,CDM,64491,CPT,0761,RC,,,both,,,3365.42,1009.63,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPECLM EAR FARRIOR 4 REGULAR 9X7.5MM",SUP-61-0920,CDM,S27200284,LOCAL,0272,RC,,,both,,,406.46,121.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL 25X3.5MM TITANIUM ENDOSCOPIC LINEAR CUTTER",SUP-EEAXL2535,CDM,S27200284,LOCAL,0272,RC,,,both,,,2399.55,719.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 135CM 40MM 3MM .035IN BALLOON DILATATION NYBAX",SUP-H74939171030410,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE RUNTHROUGH NS VASCULAR STRAIGHT 150CM .014IN STAINLESS",SUP-25-9092,CDM,C1769,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT WALLFLEX 60MM 10MM 8FR BILIARY METAL UNCOVER RAPID",SUP-7064,CDM,C1887,HCPCS,0272,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) LAPLACE TTVR DELIVERY SYSTEM",SUP-TTVR-DS-2673,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC TREK NEO 145CM 8MM 1.50MM BALLOON DILATATION PEBAX",SUP-1400150-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT FIBERSNARE FIBERWIRE 2 26IN CLOSED LOOP STIFFEN GREEN 12",SUP-AR-7209SN,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.03,267.91,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"UNIT ELECTROSURGICAL 36X3.3-4.7MM 18CM INSTR DISPOSABLE",SUP-LF4200,CDM,S27200284,LOCAL,0272,RC,,,both,,,4350.11,1305.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 14 150CM 40MM 1.5MM TAPER BALLOON DILATATION JET",SUP-A2015-040,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ELUNIR THK90UM 20MM 140CM 2.5MM CORONARY STENT",SUP-LUN250R20US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 20MM PRESS FIT LEGION KNEE",SUP-71424053,CDM,C1776,HCPCS,0278,RC,,,both,,,12181.95,3654.58,"CIGNA [10200]","Cigna Open Access",,4080.95,33.5,,5302.19,4377.88,6578.61,27,1416.76,10354.66,"percent of total billed charges",
"VALVE EXHALATION ASSEMBLY AND RESPIRATORY FLOW SENSOR DISPOS",SUP-1505-3848-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX22MM VANGUARD POROUS KNEE POSTERIOR",SUP-183772,CDM,C1776,HCPCS,0278,RC,,,both,,,8757.48,2627.24,"BLUE CROSS [10001]","Blue Cross HMO",,3432.93,39.2,,5311.50,4717.44,5388.59,31,1018.49,7443.86,"percent of total billed charges",
"MESH SURGICAL VERSATEX 15X15CM MONOFILAMENT POLYESTER",SUP-VTX1515X3,CDM,C1781,HCPCS,0278,RC,,,both,,,964.06,289.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,114.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.12,819.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 39MM CEMENTLESS OFFSET SECUR-FIT MAX 127D",SUP-6052-0730S,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4225.28,27,,,,,0,1820,13301.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +17 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1700,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR EXTERNAL FIXATION 70MM 3MM 2.5-3MM XCALIBER FOOT CORTEX",SUP-M314,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"CIGNA [10200]","Cigna Local Plus",,411.68,53.5,,3978.14,359.25,3978.14,24,89.49,654.08,"percent of total billed charges",
"HC Dup Scan Lwr Ext Arty Uni",PX-921000007,CDM,93926,CPT,0921,RC,,,both,,,1226.47,367.94,"AETNA [10100]","Aetna HMO/PPO",,975.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,142.64,1042.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Lwr Ext Arty Uni",PX-921000007,CDM,93926,CPT,0921,RC,,,both,,,1226.47,367.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,834,68,,,,,0,142.64,1042.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Pelvis Complt>=3v",PX-320000049,CDM,72190,CPT,0320,RC,,,both,,,535.15,160.54,"FIRST HEALTH [10303]","First Health",,428.12,80,,,,,0,47.57,454.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LACTOBACILLUS RHAMNOSUS GG 10 BILLION CELL CAPSULE",RX-27974,CDM,,,0637,RC,49100-0381-64,NDC,both,1,UN,7.76,2.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.9,6.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL XLIF 0-15 DEGREE 8MM X 18MM X 50MM MOD-EX",SUP-5088500P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,45076.50,13522.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,12900.89,28.62,,,,,0,5242.4,38315.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 35CM 16FR STRAIGHT STD POLYURETHANE PTFE HEMOSPLIT",SUP-5683350,CDM,S27200284,LOCAL,0272,RC,,,both,,,1897.50,569.25,"PHCS [10601]",PHCS,,1328.25,70,,,,,0,220.68,1612.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DIVERGENCE-L 15X9.4X8MM ANTERIOR OBLIQUE LUMBAR",SUP-736528,CDM,S27800098,LOCAL,0278,RC,,,both,,,9177.00,2753.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3771.75,41.1,,,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE CAST CUTTER 2.5IN NITRIDE CAST SAW LATEX FREE",SUP-31-0168,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"AETNA [10100]","Aetna HMO/PPO",,159.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES 145CM 40MM 3MM .014IN BALLOON DILATATION OTW",SUP-39134-30401,CDM,C1725,HCPCS,0272,RC,,,both,,,2175.00,652.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1479,68,,,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM G7 DOME HIP ACETABULAR LOW PROFILE",SUP-010000998,CDM,C1713,HCPCS,0278,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Cisternography",PX-341000040,CDM,78630,CPT,0341,RC,,,both,,,1846.31,553.89,"AETNA [10100]","Aetna HMO/PPO",,1467.82,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,214.73,1569.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH HIGH PROFILE XTRA 560CC",SUP-SHPX560,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,883.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",866.67,6334.2,"percent of total billed charges",
"KIT CRICOTHYROTOMY 22MM 13FR CD18FR 8 SET DILATION DISPOSABL",SUP-10-1530,CDM,S27200284,LOCAL,0272,RC,,,both,,,15007.50,4502.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6888.44,45.9,,,,,0,1745.37,12756.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC 5MM ENDOWRIST CROCODILE",SUP-428059,CDM,S27000186,LOCAL,0270,RC,,,both,,,963.90,289.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,112.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URETHRAL PROCEDURES WITH CC/MCC",671,MS-DRG,,,,,,,inpatient,,,55333.71,16600.11,"CIGNA [10200]",Cigna,,23536.04,,"Fee schedule rate ($23,536.04). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,52406.82,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 56MM TI",SUP-SPL-35560-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,155.43,1136.03,"percent of total billed charges",
"PEG FIXATION 2.7MM 20MM DISTAL VOLAR RADIUS FOSSA HIGH",SUP-HCLP-27200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",80.07,585.23,"percent of total billed charges",
"PLATE 34MM 1 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800134,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 43MM CENTERPULSE LEGACY 12/14 TAPER HIP FEMUR",SUP-451000043,CDM,C1776,HCPCS,0278,RC,,,both,,,2398.65,719.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,686.49,28.62,,,,,0,278.96,2038.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 0-8CM 19GA 4.8FR PROCORE ECHOTIP ULTRASOUND HIGH",SUP-G53585,CDM,S27200284,LOCAL,0272,RC,,,both,,,3195.00,958.5,"CIGNA [10200]",Cigna,,2172.6,68,,,,,0,371.58,2715.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 12X4IN ABSORBENT SELF ADHERENT SHOWER PROOF",SUP-395990,CDM,S27200284,LOCAL,0272,RC,,,both,,,225.59,67.68,"MULTIPLAN [10600]",Multiplan,,191.75,85,,,,,0,26.24,191.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, NEUTRAL HUMERAL HEAD, 54X18",SUP-520-54-218,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"BLUE CROSS [10001]","Blue Cross PPO",,3562.81,39.2,,3949.44,3949.44,3949.44,"1 through 10",1057.03,7725.48,"percent of total billed charges",
"ROD SPINAL 100MM 5.5MM EXPEDIUM TITANIUM LINE PREBENT",SUP-179771100,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 83MM 6MM COMPREHENSIVE POROUS MINI SHOULDER",SUP-113626,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS [10001]","Blue Cross HMO",,4939.2,39.2,,5311.50,4717.44,5388.59,31,1465.38,10710,"percent of total billed charges",
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 4.5MM X 22.0MM",SUP-494502212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT THORACENTESIS 7.5IN 8FR 18GA ARROW-CLARKE PLEURA-SEAL",SUP-AK-01000,CDM,C1729,HCPCS,0272,RC,,,both,,,385.41,115.62,"UHC [10700]","United Healthcare",,243.96,63.3,,,,,0,34.59,327.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 8IN 1.5MM BAYONET KIT",SUP-20-1410KI,CDM,S27200284,LOCAL,0272,RC,,,both,,,324.74,97.42,"CIGNA [10200]",Cigna,,220.82,68,,,,,0,37.77,276.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET SPINE MULTIAXIAL CNCT RECONSTRUCTION VERTEX",SUP-7753500,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"CIGNA [10200]","Cigna Open Access",,198.01,56.9,,1144.80,304.56,2275.09,66,40.47,295.8,"percent of total billed charges",
"HC Aerovent",PX-E27000034,CDM,E27000034,LOCAL,0270,RC,,,both,,,35.18,10.55,"NOVANET [10819]",Novanet,,26.39,75,,,,,0,4.09,29.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Bi (Go)",PX-510000545,CDM,29581,CPT,0430,RC,,,both,,,729.00,218.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,426,,"Per diem ($426).",,,,0,84.78,729,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESPONSE 65CM 6FR 2MM 1MM 2-8-2MM SPACE CSL CURVE",SUP-401353,CDM,C1730,HCPCS,0272,RC,,,both,,,2437.50,731.25,"MULTIPLAN [10600]",Multiplan,,2071.88,85,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LASER G-PROBE ILLUMINATE BOX STERILE LATEX FREE",SUP-16200,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"KAISER [10500]",Kaiser,,1381.88,67,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URI-CATH 3.5FR URETHRAL SILICONE NEONATE DRNG STERILE",SUP-4193505,CDM,S27200284,LOCAL,0272,RC,,,both,,,112.23,33.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,46.13,41.1,,,,,0,13.05,95.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 4.5MM STAINLESS STEEL 3.5MM SCR 4 HOLE LOCK ATTACH LCP",SUP-02.120.601S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR HD 46CM 13-15FR ACCESS STAINLESS STEEL",SUP-M0062502290,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"MULTIPLAN [10600]",Multiplan,,833.57,85,,,,,0,114.05,833.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 5MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620405,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"KAISER [10500]",Kaiser,,7540.11,67,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUNAV 9FR ULTRASOUND CRYSTAL GE",SUP-11657484,CDM,C1759,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION",RX-89570,CDM,,,0250,RC,00338-0322-01,NDC,both,1,UN,519.10,155.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,352.99,68,,,,,0,60.37,441.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 3MM BALLOON DILATATION STERILE LATEX",SUP-593012022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"PHCS [10601]",PHCS,,935.55,70,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 10MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640510,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3038.55,27,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,inpatient,,,55820.68,16746.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,15215.1,,,,,,,5919.58,23799.29,"case rate",
"BEARING 12MM OSS UHMWPE KNEE TIBIAL STD STERILE",SUP-150410,CDM,C1776,HCPCS,0278,RC,,,both,,,8317.26,2495.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,985.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,967.3,7069.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOLTERODINE 2 MG TABLET, IMMEDIATE RELEASE",RX-22783,CDM,,,0637,RC,59762-0800-02,NDC,both,1,UN,17.09,5.13,"AETNA [10100]","Aetna HMO/PPO",,13.59,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.99,14.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION T 5MM 1.14MM 5MM TOUMA EAR GROMMET C-FLEX",SUP-1066012,CDM,S27800098,LOCAL,0278,RC,,,both,,,103.40,31.02,"MULTIPLAN [10600]",Multiplan,,87.89,85,,,,,0,12.03,87.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT PL SITEMARK 51CM 47CM 9FR 7FR 135D GUIDING",SUP-410173,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"MULTIPLAN [10600]",Multiplan,,3155.63,85,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pouchoscopy With Dil Stenosis",PX-750000244,CDM,44799,CPT,0750,RC,,,both,,,4157.00,1247.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4157,,"Case rate ($4,617). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,483.46,4157,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALPRAZOLAM 1 MG TABLET, IMMEDIATE RELEASE",RX-326,CDM,,,0637,RC,00781-1079-01,NDC,both,1,UN,12.54,3.76,"CIGNA [10200]","Cigna Local Plus",,6.71,53.5,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 6CM SHORT UNIVERSAL VASCULAR ARTICULATING",SUP-EGIAUSHORT,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"CIGNA [10200]",Cigna,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT",SUP-M006145362170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"BLUE CROSS [10001]","Blue Cross HMO",,442.94,39.2,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 38MM 145CM 3MM CORONARY STENT",SUP-1145300-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PHCS [10601]",PHCS,,4086.6,70,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER TUMARK BREAST BIOPSY VISION EVIVA PETITE",SUP-TUMARK-E13-P-V-02,CDM,A4648,HCPCS,0278,RC,,,both,,,942.84,282.85,"BLUE CROSS [10001]","Blue Cross PPO",,369.59,39.2,,,,,0,109.65,801.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 28CM 8FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001274190,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,,,,,,,189.34,1383.8,"percent of total billed charges",
"LINER ACETABULAR PINNACLE 49MM 28MM ALTRX HIP",SUP-122128049,CDM,C1776,HCPCS,0278,RC,,,both,,,12578.70,3773.61,"UHC [10700]","United Healthcare",,7962.32,63.3,,8601.07,8395.67,8601.07,"1 through 10",1462.9,10691.9,"percent of total billed charges",
"CMPNT GLENOID MEDIUM 4MM BASE MODULAR COMPREHENSIVE HYBRID",SUP-113954,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.00,2749.2,"NOVANET [10819]",Novanet,,6873,75,,,,,0,1065.77,7789.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END 5MM TIBIA STARDRIVE",SUP-04.004.001S,CDM,C1713,HCPCS,0278,RC,,,both,,,1688.40,506.52,"PHCS [10601]",PHCS,,1181.88,70,,,,,0,196.36,1435.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 2.6MM 3MM SUTURETAK",SUP-AR-1938D,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.03,267.91,"FIRST HEALTH [10303]","First Health",,714.42,80,,,,,0,103.86,759.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 57MM 135CM 9MM 60MM",SUP-38047-96013,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"AETNA [10100]","Aetna HMO/PPO",,3291.3,79.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 1MM BEAVER EDGEAHEAD ANGLE SIDEPORT",SUP-373710,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.58,41.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16,116.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 200ML GEL TEXTURED SILTEX SILICONE P4.1CM HIG",SUP-3544200,CDM,C1789,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION DEB 2.00X40",SUP-SCA14U-200040D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO SELECT VASCULAR 300CM .014IN HYDROPHILIC SPRT",SUP-SSUP300PRE,CDM,C1769,HCPCS,0272,RC,,,both,,,5686.57,1705.97,"PHCS [10601]",PHCS,,3980.6,70,,,,,0,661.35,4833.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.5/35",SUP-404670,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTIGRAFT CERVICAL LARGE PARALLEL 14X14.5X8MM",SUP-VG2C-DR8P,CDM,S27800098,LOCAL,0278,RC,,,both,,,6077.73,1823.32,"CIGNA [10200]","Cigna Local Plus",,3251.59,53.5,,,,,0,706.84,5166.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI FIELDER XT-R 300CM",SUP-APW14R305S,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS TESTICULAR 3.5CMX2.5MM TOROSA SMALL SALINE FILL",SUP-4501325,CDM,L8699,HCPCS,0278,RC,,,both,,,14973.00,4491.9,"FIRST HEALTH [10303]","First Health",,11978.4,80,,,,,0,1741.36,12727.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 80MM 120CM 5.5MM 6FR BILIARY NITINOL PERIPHERAL",SUP-S-55-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4135.48,41.1,,,,,0,1063.27,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER STENT 115CM 2.4FR NSNARE NITINOL UNIDEX HANDLE",SUP-G46191,CDM,C1773,HCPCS,0272,RC,,,both,,,1201.23,360.37,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD SUT ASSISTANT 0 ES-9 7IN 1 STITCH ENDO STITCH",SUP-170054,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOLDER 9.25IN JACOBSON INSRT LOCK HEAVY ROUND HANDLE NDL",SUP-32-471,CDM,S27200284,LOCAL,0272,RC,,,both,,,2245.28,673.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 8FR .088IN EXTRA",SUP-588894,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 250MM 6MM BALLOON DILATATION RAPID",SUP-47560250M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNARE VASCULAR 120CM 27-45MM 7FR EN SNARE STD PLATINUM",SUP-EN2007045,CDM,C1773,HCPCS,0272,RC,,,both,,,2520.00,756,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL BABCOCK STRAIGHT 9 3/8IN INTESTINAL SERRATE",SUP-50-1123,CDM,S27200284,LOCAL,0272,RC,,,both,,,1023.19,306.96,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 150CM 4CM 9MM BALLOON DILATATION OTW LOW",SUP-G30978,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ROTABLATOR ROTALINK 135CM .58IN 2MM ATHERECTOMY PTFE",SUP-H802227680050,CDM,C1724,HCPCS,0272,RC,,,both,,,6641.25,1992.37,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MONOCRYL ETHIGUARD 1 CTB-1 36IN MONOFILAMENT UNDYED",SUP-YB947,CDM,S27200284,LOCAL,0272,RC,,,both,,,427.61,128.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MERIT MAESTRO 130CM 2.8FR .024IN .038IN .021IN STRAIGHT",SUP-28MC28130ST,CDM,C1887,HCPCS,0272,RC,,,both,,,2301.00,690.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR IRIS GRIESHABER FLEXIBLE SURGICAL STERILE LATEX FREE",SUP-611.75,CDM,S27200284,LOCAL,0272,RC,,,both,,,746.66,224,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 135CM 6CM 5MM BALLOON DILATATION PERIPHERAL",SUP-G50239,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC RBC Deglycerolized Ea Unit",PX-390000012,CDM,P9039,HCPCS,0390,RC,,,both,,,1922.00,576.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC",233,MS-DRG,,,,,,,inpatient,,,365237.85,109571.35,"CIGNA [10200]",Cigna,,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 55.9%. Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Protek Solo",PX-E27200440,CDM,E27200440,LOCAL,0272,RC,,,both,,,38695.80,11608.74,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"HC Hood Oxygen",PX-E27000193,CDM,E27000193,LOCAL,0270,RC,,,both,,,89.10,26.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.36,75.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM 2.25MM 2.1-2.7FR CORONARY",SUP-RONYX22530UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ENDARTERECTOMY 5MM 7MM 2 COAXIAL METAL RING",SUP-4500-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,18893.70,5668.11,"MULTIPLAN [10600]",Multiplan,,16059.65,85,,,,,0,2197.34,16059.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.35MM 110MM TFN-ADVANCED TI-6AL-7NB CANNULATED",SUP-04.038.210S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",434.96,3179,"percent of total billed charges",
"CELLULAR LIFETIME DATA PLAN",SUP-CSDL,CDM,S27000186,LOCAL,0270,RC,,,both,,,3375.00,1012.5,"AETNA [10100]","Aetna HMO/PPO",,2683.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIPHERAL CUTTING BALLOON 50CM 20MM 6MM BALLOON",SUP-PCB602050,CDM,C1725,HCPCS,0272,RC,,,both,,,5037.00,1511.1,"UHC [10700]","United Healthcare",,3188.42,63.3,,,,,0,585.8,4281.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 6FR L30CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902250,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,,,,,,,189.34,1383.8,"percent of total billed charges",
"SCREW FREEFIX COMPRESSION 3.5MM X 24MM TI",SUP-FFC-35240-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1061.10,318.33,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,487.04,45.9,,,,,0,123.41,901.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN GUIDE 9IN 2.4MM STAINLESS STEEL HIGH STRENGTH",SUP-9742D,CDM,S27200284,LOCAL,0272,RC,,,both,,,196.36,58.91,"PHCS [10601]",PHCS,,137.45,70,,,,,0,22.84,166.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 100MM 130CM 8MM LONG VASCULAR NITINOL",SUP-SC8100LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"MULTIPLAN [10600]",Multiplan,,7624.5,85,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC STD 16IN 25- IN KNEE ADJUSTABLE 3 PANEL",SUP-VP40105-010,CDM,L1830,HCPCS,0274,RC,,,both,,,160.08,48.02,"FIRST HEALTH [10303]","First Health",,128.06,80,,,,,0,18.62,136.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD GLENOID 42MM UNIVERS REVERS LARGE UNIVERSAL SHOULDER",SUP-AR-9504L,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"BLUE CROSS [10001]","Blue Cross PPO",,4779.73,39.2,,3949.44,3949.44,3949.44,"1 through 10",1418.07,10364.22,"percent of total billed charges",
"SCR BONE 2.7MM 16MM STAINLESS STEEL FULL THREAD CORTICAL",SUP-349616,CDM,C1713,HCPCS,0278,RC,,,both,,,233.86,70.16,"KAISER [10500]",Kaiser,,156.69,67,,,,,0,27.2,198.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT",RX-122493,CDM,,,0637,RC,41100-0811-63,NDC,both,42.5,GR,14.17,4.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.65,12.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TWISTER PLUS 230CM 26MM 2.5MM SPECIMEN RETRIEVAL",SUP-TWIST26,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,260.25,45.9,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 8-0 BV130-5 5IN MONOFILAMENT BLACK",SUP-2808G,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.96,51.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.12,147.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 2.5MM BALLOON DILATATION PEBAX",SUP-1012272-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 16MM 144CM 2.5MM CORONARY STENT",SUP-H7493941816250,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BRIDGE 90CM 80CM 4MM 20MM .9MM BALLOON OCCLUSION 60CC",SUP-590-001,CDM,C1725,HCPCS,0272,RC,,,both,,,6244.50,1873.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,726.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,726.24,5307.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX11MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2991122,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"MULTIPLAN [10600]",Multiplan,,13512.96,85,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 37MM 75CM 8MM 40MM",SUP-H74938046840750,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,481.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Stool Culture",PX-300000402,CDM,300000402,LOCAL,0300,RC,,,both,,,173.25,51.97,"UHC [10700]","United Healthcare",,86.63,50,,,,,0,20.53,147.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.7MM STD STAINLESS STEEL TRA",SUP-MFT07227,CDM,S27200284,LOCAL,0272,RC,,,both,,,1409.40,422.82,"FIRST HEALTH [10303]","First Health",,1127.52,80,,,,,0,163.91,1197.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 3 12MM",SUP-TPS-030-123S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"CIGNA [10200]","Cigna Local Plus",,433.35,53.5,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 3002037 ZEVO 37MM 2 LVL",SUP-3002037,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",512.88,3748.5,"percent of total billed charges",
"HC Kit Transducer Single",PX-E27200188,CDM,E27200188,LOCAL,0272,RC,,,both,,,113.17,33.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,46.51,41.1,,,,,0,13.16,96.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION",RX-164538,CDM,J2250,HCPCS,0636,RC,00409-2308-22,NDC,both,2,ML,44.00,13.2,"CIGNA [10200]","Cigna Local Plus",,3.71,,,,,,,1.64,37.4,"fee schedule",
"BARR ADHESION 3X5IN PROC PACK BIORESORBABLE MEMB SEPRAFILM",SUP-5086-02,CDM,C1765,HCPCS,0278,RC,,,both,,,5187.63,1556.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,614.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,603.32,4409.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752510,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,613.48,68,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC T4 Free",PX-301000412,CDM,84439,CPT,0301,RC,,,both,,,200.20,60.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.65,,"Fee schedule rate ($9.65). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",13.57,13.57,13.57,"1 through 10",0.2,170.17,"fee schedule",
"SUT PROLENE 6-0 BV-1 18IN 2 ARM MONOFILAMENT BLUE",SUP-8806H,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.57,52.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.19,147.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dvc Heart Assist Impella 5.5",PX-E27800027,CDM,E27800027,LOCAL,0278,RC,,,both,,,16531.26,4959.38,"CIGNA [10200]","Cigna Open Access",,5537.97,33.5,,,,,0,1922.59,14051.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 100MM 18MM 3MM VASCULAR VENOUS ILIOFEMORAL VEIN",SUP-VENUM18100,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"BLUE CROSS [10001]","Blue Cross PPO",,9137.52,39.2,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis B Core Igm Ab",PX-302000145,CDM,86705,CPT,0302,RC,,,both,,,412.30,123.69,"KAISER [10500]",Kaiser,,276.24,67,,,,,0,0.01,350.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Urea Nitrogen Urine",PX-301000431,CDM,84540,CPT,0301,RC,,,both,,,176.00,52.8,"AETNA [10100]","Aetna HMO/PPO",,139.92,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.18,149.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL LORDOTIC",SUP-345741,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Gastric Emptying Sb Colon Multi",PX-341000069,CDM,78266,CPT,0341,RC,,,both,,,2794.10,838.23,"BLUE CROSS [10001]","Blue Cross HMO",,1188.43,,"Fee schedule rate ($1,188.43).",,,,0,324.95,2374.99,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE STC-18 105CM 20CM 2.4-3FR .021IN MICRO GUIDING",SUP-M001181270,CDM,C1887,HCPCS,0272,RC,,,both,,,2325.00,697.5,"FIRST HEALTH [10303]","First Health",,1860,80,,,,,0,270.4,1976.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SWIVELOCK 19.1MM 4.75MM FIXATION BIOCOMPOSITE",SUP-AR-1593-BC,CDM,C1713,HCPCS,0278,RC,,,both,,,5002.50,1500.75,"FIRST HEALTH [10303]","First Health",,4002,80,,,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000230,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS ETHIGUARD 0 CTB-1 18IN CONTROL RELEASE BRAID",SUP-VCPB840D,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Open Access",,14.23,56.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD REAMER 12.5MM DEEP FLUTE STAINLESS STEEL CONICAL TIP",SUP-352.251S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2560.05,768.01,"FIRST HEALTH [10303]","First Health",,2048.04,80,,,,,0,297.73,2176.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ACROBAT ENDOSCOPIC 450CM 4CM .035IN HYDROPHILIC",SUP-G34266,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE PRIME 33MM 143CM 4MM CORONARY STENT EVEROLIMUS",SUP-1011735-33,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"MULTIPLAN [10600]",Multiplan,,8152.35,85,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Split Blood Ea Unit",PX-302000216,CDM,86985,CPT,0302,RC,,,both,,,226.20,67.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,146.47,,,,,,,0.23,192.27,"fee schedule",
"GWIRE VISIGLIDE ENDOSCOPIC ANGLE 2700MM .025IN FLUORINE",SUP-G-240-2527A,CDM,C1769,HCPCS,0272,RC,,,both,,,1288.95,386.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LIGHTED SIGMOIDOSCOPE KIT 10 KITS/CS 1 LIGHTED SCOPE RECTO M",SUP-ADKI610,CDM,S27200284,LOCAL,0272,RC,,,both,,,731.43,219.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BONE CEMENT KYPHON 15/2 FIRST FRACTURE",SUP-KPE1003-CDS,CDM,S27200284,LOCAL,0272,RC,,,both,,,13098.00,3929.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8906.64,68,,,,,0,1523.3,11133.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 50MM 28MM TANDEM HIP ACETABULAR COCR",SUP-71322050,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5679.67,68,,,,,0,971.39,7099.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN STD JUDKINS RIGHT",SUP-534621T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"KAISER [10500]",Kaiser,,58.29,67,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM LOW PROFILE SCREWS STAINLESS STEEL FULL",SUP-AR-8827L-12,CDM,C1713,HCPCS,0278,RC,,,both,,,931.50,279.45,"NOVANET [10819]",Novanet,,698.63,75,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC or OP Robotics 1st Hr",PX-360000019,CDM,9999171,LOCAL,0360,RC,,,both,,,17562.00,5268.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2042.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2042.46,14927.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM CONCERTO DETACHABLE HELIX",SUP-NV-2-6-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"KAISER [10500]",Kaiser,,3004.95,67,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 24CM 7MM AVENIR 10 COIL COMPLEX FINISH",SUP-10CFN07024,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"NOVANET [10819]",Novanet,,8792.33,75,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM MITRAL VALVE PROFILE 3D",SUP-680R26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3752.08,28.62,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE 12.5-14 XL MALE PATIENT 2 PADDED POSTOPERATIVE SQUARE",SUP-MQM4B,CDM,S27000186,LOCAL,0270,RC,,,both,,,78.91,23.67,"CIGNA [10200]","Cigna Open Access",,44.9,56.9,,,,,0,9.18,67.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTUNE FB",SUP-CAP-DS-K-1A,CDM,C1776,HCPCS,0278,RC,,,both,,,20160.00,6048,"CIGNA [10200]",Cigna,,8064,40,,5873.17,5873.17,5873.17,"1 through 10",2344.61,17136,"percent of total billed charges",
"HC Arthcs Asp/Inj Int Jt",PX-361000031,CDM,20605,CPT,0361,RC,,,both,,,2316.24,694.87,"CIGNA [10200]","Cigna Local Plus",,1965,,"Case rate ($1,965). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,269.38,2316.24,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC or OP Int 1st Hr",PX-360000018,CDM,9999170,LOCAL,0360,RC,,,both,,,13639.30,4091.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9274.72,68,,,,,0,1586.25,11593.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 5MM 2MM 90D SMALL STRAIGHT OBLONG 7.5IN FRONTAL SINUS",SUP-63-8815,CDM,S27200284,LOCAL,0272,RC,,,both,,,660.07,198.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,271.29,41.1,,,,,0,76.77,561.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 28CM 8FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001245660,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"MULTIPLAN [10600]",Multiplan,,1466.25,85,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM HIP MULTIHOLE R3 STD STERILE",SUP-71338662,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1882.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1847.69,13504.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X14MM COROENT PEEK THORACOLUMBAR INTERBODY",SUP-6981455,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6800.11,28.62,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mycobacteria TB Dna Ampl Prob",PX-306000140,CDM,87556,CPT,0306,RC,,,both,,,990.85,297.25,"CIGNA [10200]","Cigna Local Plus",,91.7,,,,,,,0.01,842.22,"fee schedule",
"HC Mycobacteria TB Dna Ampl Prob",PX-306000140,CDM,87556,CPT,0306,RC,,,both,,,990.85,297.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.86,,,,,,,0.01,842.22,"fee schedule",
"CATH TAKERU 15MM 3.5MM 1.5MM 1.2MM BALLOON DILATATION RAPID",SUP-DC-RY3515UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"MULTIPLAN [10600]",Multiplan,,839.97,85,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR THK2MM 30X20CM SOFT TISSUE GORE-TEX",SUP-1320030020,CDM,C1781,HCPCS,0278,RC,,,both,,,25294.50,7588.35,"CIGNA [10200]",Cigna,,10117.8,40,,,,,0,2941.75,21500.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 12MM 145CM 4MM CORONARY STENT",SUP-1125400-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"NOVANET [10819]",Novanet,,4378.5,75,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM 2 FULL THREAD CORKSCREW TIGERTAIL",SUP-AR-1927BCF-475,CDM,C1713,HCPCS,0278,RC,,,both,,,2795.63,838.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,325.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",325.13,2376.29,"percent of total billed charges",
"SMOOTH PEG LOCKING 3.5MM X 34MM TI",SUP-SPL-35340-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Local Plus",,715.03,53.5,,3978.14,359.25,3978.14,24,155.43,1136.03,"percent of total billed charges",
"CATH FOX SV 150CM 80MM 4FR 2.5MM .018IN BALLOON DILATATION",SUP-83967-02,CDM,C1725,HCPCS,0272,RC,,,both,,,3037.50,911.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,353.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,353.26,2581.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE GRAFT 12CC DEMINERALIZED CORTICAL FIBER ACCELERATE",SUP-T50212,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,957.42,570.23,957.42,28,2014.9,14726.25,"percent of total billed charges",
"SCR BONE 2.4MM 40MM STAINLESS STEEL LONG THREAD FOOT HAND",SUP-02.226.340,CDM,C1713,HCPCS,0278,RC,,,both,,,1647.00,494.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,471.37,28.62,,,,,0,191.55,1399.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CD HORIZON TITANIUM COCR SPINE",SUP-55890006540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC END COOLCUT 13CM STERILE DISPOSABLE 3.8",SUP-AR-8380EC,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,30.39,41.1,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 15MM AEQUALIS HA REVERSED 25MM STD POST",SUP-DWD170,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4334.34,45.9,,,,,0,1098.22,8026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC STRAIGHT 9IN .078IN STAINLESS STEEL 1",SUP-WS-2009ST,CDM,C1769,HCPCS,0272,RC,,,both,,,287.10,86.13,"MULTIPLAN [10600]",Multiplan,,244.04,85,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE CR OXI FEMUR ALL POLY TIBIA LEGION GENESI",SUP-71701265,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Open Access",,7386.75,33.5,,5302.19,4377.88,6578.61,27,2564.42,18742.5,"percent of total billed charges",
"CATH NEURON 125CM 6FR SIMMONS CURVE THROMBECTOMY SELECT",SUP-PNS6F125SIM,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 3.5MM PRECUT",SUP-3603760,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"BASEPLT TIBIAL TRIATHLON 5 UNIVERSAL KNEE TOTAL STABILIZED",SUP-5521-B-500,CDM,C1776,HCPCS,0278,RC,,,both,,,10384.92,3115.48,"CIGNA [10200]",Cigna,,7061.75,68,,5873.17,5873.17,5873.17,"1 through 10",1207.77,8827.18,"percent of total billed charges",
"EPILONG SOFT 19G X 35 (90CM) SPRINGWOUND CATHETER WITH CLOSE",SUP-041151-37P,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RADIUM RA-223 DICHLOR INTRAVENOUS SOLN",RX-162677,CDM,A9606,HCPCS,0344,RC,08888-8877-03,NDC,both,1,UN,10.00,3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6.8,68,,,,,0,1.16,10,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM PK COIL LP STERILE LATEX FREE",SUP-RBYPCLP10,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"CIGNA [10200]","Cigna Open Access",,3847.58,56.9,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 6FR L20CM FIRM TRI LAYER DESIGN RAW COLORANT",SUP-M0061902200,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 3.5MM 35MM TITANIUM HEXAGON CANCELLOUS KNEE",SUP-C2612,CDM,C1713,HCPCS,0278,RC,,,both,,,634.88,190.46,"CIGNA [10200]",Cigna,,431.72,68,,1831.33,1831.33,1831.33,16,73.84,539.65,"percent of total billed charges",
"HEAD BIPOLAR GRAY 45MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103545000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,356.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERCROSS 130CM 80CM 2.4-3.2FR .017-.018IN 120D MICRO",SUP-5306,CDM,C1887,HCPCS,0272,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X5MM OVAL PARALLEL SPINE CORTICAL",SUP-17105,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM SYNAPSE TITANIUM 50D T15 SPINE CANCELLOUS",SUP-04.614.116,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE+ 10MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405710,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6571.15,68,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC",970,MS-DRG,,,,,,,inpatient,,,65720.68,18440.2,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,17341.55,,"Case rate ($16,359.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $15,191.32, add-ons for qualifying new technology services are included. If operating cost exceeds $48,231.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,530.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $15,211.41. The transfer operating threshold is the transfer adjustment factor * $15,191.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,148.54. The transfer capital threshold is the transfer adjustment factor * $1,148.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,65720.68,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 36MM MITRAL HOLDER CARPENTIER-EDWARDS",SUP-5200M36,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"FIRST HEALTH [10303]","First Health",,11040,80,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 2IN 18GA 20GA PAJUNK SONOLONG TUOHY",SUP-TDL108,CDM,S27200284,LOCAL,0272,RC,,,both,,,591.30,177.39,"CIGNA [10200]",Cigna,,402.08,68,,,,,0,68.77,502.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 150CM 120MM 5MM BALLOON DILATATION PACLITAXEL",SUP-H74939419501210,CDM,C2623,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"MULTIPLAN [10600]",Multiplan,,7917.75,85,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +6MM 40MM HIP MODULAR TYPE 1 COCR SELEX",SUP-S661140,CDM,C1776,HCPCS,0278,RC,,,both,,,4574.70,1372.41,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,542.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,532.04,3888.5,"percent of total billed charges",
"SCR BONE 1.5MM 9MM TITANIUM T4 CORTICAL SELF TAP STARDRIVE",SUP-04.214.109,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",50.59,369.75,"percent of total billed charges",
"STENT ASCERTA 26CM 6FR URETERAL",SUP-M0061456140,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"NOVANET [10819]",Novanet,,468.93,75,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER ACCU-PASS XL DIRECT CRESCENT SUT HIP ARTHROSCOPY",SUP-23-2005,CDM,S27200284,LOCAL,0272,RC,,,both,,,2261.25,678.37,"CIGNA [10200]",Cigna,,1537.65,68,,,,,0,262.98,1922.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE HEARTMATE 3 VENTRICULAR ASSIST SEAL OUTFLOW GRAFT",SUP-105581US,CDM,L8670,HCPCS,0278,RC,,,both,,,32659.20,9797.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8817.98,27,,,,,0,427.53,27760.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD MEDIUM 5.5MM TSRH-3D OPEN OFFSET TITANIUM POSTERIOR",SUP-8379121,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Open Access",,2027.06,56.9,,1144.80,304.56,2275.09,66,414.32,3028.13,"percent of total billed charges",
"GUIDPN ORTHOPEDIC 300MM 3.2MM THREADED",SUP-71177201,CDM,S27200284,LOCAL,0272,RC,,,both,,,1624.32,487.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.91,1380.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SHORT CONTOUR TITANIUM FUSION MODULE LOW PROFILE MTP",SUP-AR-8944CL-P,CDM,C1713,HCPCS,0278,RC,,,both,,,6175.50,1852.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2834.55,45.9,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 2MM BALLOON DILATATION STERILE LATEX",SUP-582012022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +6 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200060,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CIGNA [10200]",Cigna,,694.01,68,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 20MM 7FR 3 ELECTROPHYSIOLOGY 20 POLE DEFLECTABLE CARTO",SUP-D7L2020CT,CDM,C1731,HCPCS,0272,RC,,,both,,,10950.30,3285.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4500.57,41.1,,,,,0,1273.52,9307.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTP W4TR02 SERENA QUAD CRTP MRI US",SUP-W4TR02,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"FIRST HEALTH [10303]","First Health",,18472.32,80,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RIFAMPIN 150 MG CAPSULE",RX-11292,CDM,,,0637,RC,68180-0658-06,NDC,both,1,UN,16.31,4.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11.09,68,,,,,0,1.9,13.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE KIRSCHNER ORTHOPEDIC 5.75IN .035IN SMALL BONE 1 TROCAR",SUP-WS-0906ST,CDM,C1769,HCPCS,0272,RC,,,both,,,287.10,86.13,"NOVANET [10819]",Novanet,,215.33,75,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FLEXIGRAFT PRESERVON XLONG ALLOGRAFT REVISION",SUP-PRDXL10,CDM,S27800098,LOCAL,0278,RC,,,both,,,7917.75,2375.32,"BLUE CROSS [10001]","Blue Cross HMO",,3103.76,39.2,,,,,0,920.83,6730.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 23MM 8MM STEP TAPER ACL PCL",SUP-AR-1380C,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1258.43,68,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 300MM 6MM .018IN BALLOON",SUP-R51006030L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"AETNA [10100]","Aetna HMO/PPO",,1981.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT",RX-164210,CDM,,,0250,RC,45802-0188-16,NDC,both,57,GR,31.55,9.46,"UHC [10700]","United Healthcare",,19.97,63.3,,,,,0,3.67,26.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC 57.3MM 5MM DA VINCI S/SI ENDOWRIST 30- D",SUP-420343,CDM,S27000186,LOCAL,0270,RC,,,both,,,1800.00,540,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1224,68,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 10MM STAINLESS STEEL CORTICAL LOCK TRIMED",SUP-LCBS2.7-10,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"KAISER [10500]",Kaiser,,569.84,67,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR PIGTAIL CURVE ANGIOGRAPHIC BRAID",SUP-31-519,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.04,22.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.84,64.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 10X 38MM CATH 80CM ENDOVASCULAR",SUP-48038,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"CIGNA [10200]","Cigna Open Access",,5869.3,33.5,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH XP 100CM 5FR ANGLE ANGIOGRAPHIC STAINLESS",SUP-RF*ZV95110M,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP COMPLETE CARE STATLOCK FOLEY",SUP-A319414AM,CDM,S27200284,LOCAL,0272,RC,,,both,,,268.66,80.6,"PHCS [10601]",PHCS,,188.06,70,,,,,0,31.25,228.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Spray Skin 28ml No Sting",PX-HHE27000223,CDM,HHE27000223,LOCAL,0270,RC,,,outpatient,,,39.00,11.7,"CIGNA [10200]","Cigna Local Plus",,20.87,53.5,,,,,0,4.54,33.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 4.5MM 11MM EVOS MINI STAINLESS STEEL T8",SUP-72412711,CDM,C1713,HCPCS,0278,RC,,,both,,,1050.98,315.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,300.79,28.62,,,,,0,122.23,893.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 6MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710806,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"NOVANET [10819]",Novanet,,11095.2,75,,,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 13MM RADIUS DISTAL VOLAR NONLOCK 3 LEAD TAPER",SUP-131227213,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"CIGNA [10200]","Cigna Local Plus",,455.02,53.5,,3978.14,359.25,3978.14,24,98.91,722.93,"percent of total billed charges",
"AMPLATZ RENAL SHEATH 26FX17CM",SUP-M0062601520,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,227.53,68,,,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +24.5 DIOPTER MODIFIED C BICONVEX 13.5MM 6.5MM",SUP-MC50BD.245,CDM,V2632,HCPCS,0276,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 8FR L24CM SOFT WITHOUT GUIDEWIRE TRIA",SUP-M0061903420,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ENDOSCP SEALING .1MM",SUP-A0298,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.79,14.34,"UHC [10700]","United Healthcare",,30.25,63.3,,,,,0,5.56,40.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cyp2c19 Gene Com Variants",PX-309000020,CDM,81225,CPT,0310,RC,,,both,,,935.55,280.66,"BLUE CROSS [10001]","Blue Cross PPO",,0.94,.1,,,,,0,0.94,837.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 2 KNEE CEMENT ROTATE PLATFORM STERILE",SUP-150680002,CDM,C1776,HCPCS,0278,RC,,,both,,,17225.85,5167.75,"CIGNA [10200]",Cigna,,6890.34,40,,5873.17,5873.17,5873.17,"1 through 10",2003.37,14641.97,"percent of total billed charges",
"CANNULA TRACHEOSTOMY DIA8MM INNER SPARE SHILEY",SUP-8SIC,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.12,18.64,"NOVANET [10819]",Novanet,,46.59,75,,,,,0,7.22,52.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE B CURVE",SUP-D7BTCBL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3373.55,68,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB ADULT MULTIFUNCTION STAT PADZ HIGH VISCOSITY",SUP-8900-4004,CDM,S27000186,LOCAL,0270,RC,,,both,,,155.30,46.59,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Selct Plc Cath Extrnl Cartd",PX-361000293,CDM,36227,CPT,0361,RC,,,both,,,3629.33,1088.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SAPPHIRE 3 CORONARY DILATATION CATHETER 1.0 X 10MM",SUP-54100-100-02,CDM,C1725,HCPCS,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ESOMEPRAZOLE MAGNESIUM DR 40 MG GRANULES DELAYED RELEASE FOR SUSP",RX-78616,CDM,,,0250,RC,68382-0849-93,NDC,both,1,UN,61.37,18.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Tube Trach Sealguard",PX-E27200236,CDM,E27200236,LOCAL,0272,RC,,,both,,,240.83,72.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RF ENHANCR II 110CM 4MM 7FR 2-5-2MM SPACE 45MM SINGLE",SUP-31744523,CDM,C1733,HCPCS,0272,RC,,,both,,,3375.00,1012.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM FEMORAL 127D 5 30MM CONDYLAR STABILIZED NECK OMNIFIT",SUP-6097-0530,CDM,C1776,HCPCS,0278,RC,,,both,,,10292.40,3087.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6998.83,68,,,,,0,1197.01,8748.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +9.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.095,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 42MM LCP STAINLESS STEEL T25 CONDYLAR VARIABLE",SUP-02.231.242,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"CIGNA [10200]","Cigna Local Plus",,699.69,53.5,,3978.14,359.25,3978.14,24,152.1,1111.66,"percent of total billed charges",
"GARM COMPRESSION STD UNIVERSAL THIGH FABRIC FLOWTRON 10.6X9",SUP-DVT30,CDM,S27000186,LOCAL,0270,RC,,,both,,,130.85,39.25,"KAISER [10500]",Kaiser,,87.67,67,,,,,0,15.22,111.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 60MM 10MM BILIARY STERILE LATEX FREE DISPOSABLE",SUP-M00572320,CDM,C1876,HCPCS,0278,RC,,,both,,,10624.97,3187.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4876.86,45.9,,,,,0,1235.68,9031.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AXS INFINITY LS LONG 70CM 8FR .088IN INTRO STERILE",SUP-GEN-10800-70,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 110MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BUTTON 3CM 12MM ARTHREX PASSPORT BUTTON CANN",SUP-AR-6592-12-30,CDM,S27000186,LOCAL,0270,RC,,,both,,,510.30,153.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,209.73,41.1,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LD SCOUTPRO TL SLTR","SUP-383 119",CDM,S27200284,LOCAL,0272,RC,,,both,,,801.90,240.57,"NOVANET [10819]",Novanet,,601.43,75,,,,,0,93.26,681.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 80MM 5MM BALLOON DILATATION RAPID EXCHANGE",SUP-47550080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KNEE: CMTLS OXFORD UNI FM/CM/TB UNIBLD",SUP-98-0002-005-46,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2762.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 52MM 32MM MARATHON",SUP-121932452,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"AETNA [10100]","Aetna HMO/PPO",,6448.21,79.5,,10981.53,8986.79,12413.38,12,943.3,6894.31,"percent of total billed charges",
"SCR BONE 4.5MM 45MM MAS SPINE CANNULATED EXT TAB 4.75MM ROD",SUP-54850014545,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"FIRST HEALTH [10303]","First Health",,5244,80,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT225220,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,98.74,28.62,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END 5MM TIBIA STARDRIVE",SUP-04.004.001S,CDM,C1713,HCPCS,0278,RC,,,both,,,1688.40,506.52,"NOVANET [10819]",Novanet,,1266.3,75,,,,,0,196.36,1435.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 33MM 3.25MM CORONARY STENT EVEROLIMUS",SUP-1550325-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REINFORCEMENT STAPLE LINE UNIVERSAL 6 FIRING 3 GEL TUBE","SUP-PSD 4506-UN",CDM,S27200284,LOCAL,0272,RC,,,both,,,1256.85,377.05,"CIGNA [10200]",Cigna,,854.66,68,,,,,0,146.17,1068.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 160MM 10MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424043,CDM,C1776,HCPCS,0278,RC,,,both,,,12181.95,3654.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3289.13,27,,,,,0,1416.76,10354.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 43IN 10FR ANTICLOG RADIOPAQUE SMOOTH BOLUS",SUP-40-4431,CDM,S27200284,LOCAL,0272,RC,,,both,,,127.29,38.19,"UHC [10700]","United Healthcare",,80.57,63.3,,,,,0,14.8,108.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 125MM 5.5MM REVERE STRAIGHT TITANIUM NONSTERILE",SUP-124.512,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mlh1 Gene Dup/Delete Variants",PX-309000054,CDM,81294,CPT,0310,RC,,,both,,,2420.00,726,"MULTIPLAN [10600]",Multiplan,,2057,85,,,,,0,2.42,2057,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 32MM 144CM 2.5MM CORONARY STENT",SUP-H7493911432250,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross PPO",,3583.86,39.2,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 34MM TI",SUP-SPL-60340-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross PPO",,635.04,39.2,,957.42,570.23,957.42,28,188.41,1377,"percent of total billed charges",
"STENT 20CM 10FR LARGE REGULAR PIGTAIL CURVE URETERAL GLIDEX",SUP-M001245570,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,408.97,45.9,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bk Virus Qpcr CSF 2500",PX-306000154,CDM,87799,CPT,0306,RC,,,both,,,986.10,295.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,116.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.99,838.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HIP FEM P2 POROUS OFFSZ10",SUP-425-97-010,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"CIGNA [10200]","Cigna Open Access",,14257.08,33.5,,5302.19,4377.88,6578.61,27,4949.55,36174.68,"percent of total billed charges",
"TROCAR LAPAROSCOPIC LOW PROFILE 55MM 5MM KII 2 PACK ACCESS",SUP-CTB23,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT VITRECTOMY PERFLUORO-N-OCTANE PROCEDURAL LIQUID PURIFY",SUP-8065900164,CDM,C1784,HCPCS,0278,RC,,,both,,,3845.92,1153.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1100.7,28.62,,,,,0,447.28,3269.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 100CM 5FR 1 CURVE ANGIOGRAPHIC",SUP-G47001,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"CIGNA [10200]","Cigna Local Plus",,112.63,53.5,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL RIGID 1.8MM DISPOSABLE FIBERTAK",SUP-AR-3600D-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.03,267.91,"CIGNA [10200]","Cigna Open Access",,508.13,56.9,,,,,0,103.86,759.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP ELECTROSURGICAL ISOLATOR SYNERGY SHORT JAW LEFT CURVE",SUP-OSL2,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH INFINITI THRULUMEN 110CM 5FR .047IN .047IN PIGTAIL",SUP-534550S,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL 26CMX4MM UNIVERSAL VASCULAR XTHICK TISSUE",SUP-EGIAUXL,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE 20MM 8MM BIOSURE REGENESORB",SUP-72204398,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"AETNA [10100]","Aetna HMO/PPO",,2205.35,79.5,,1521.93,481.35,16760.95,30,322.62,2357.93,"percent of total billed charges",
"CNCT ROD XLNK BAR",SUP-6902530,CDM,C1713,HCPCS,0278,RC,,,both,,,745.20,223.56,"CIGNA [10200]","Cigna Local Plus",,398.68,53.5,,3978.14,359.25,3978.14,24,86.67,633.42,"percent of total billed charges",
"AVENIR 10, 4 X 6 HELICAL PICO COIL",SUP-10USH04006,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS [10001]","Blue Cross PPO",,4595.46,39.2,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +32.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000325,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 110CM 1MM 5FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY FIX",SUP-F5QF005CT,CDM,C1730,HCPCS,0272,RC,,,both,,,551.20,165.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,65.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.1,468.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 2.7/3.5/4 MM SCR FUSION MEDLINE UNITE BONE FOOT LEFT",SUP-MPP8201L,CDM,C1713,HCPCS,0278,RC,,,both,,,11005.50,3301.65,"BLUE CROSS [10001]","Blue Cross HMO",,4314.16,39.2,,957.42,156.86,7483.26,51,1279.94,9354.68,"percent of total billed charges",
"STENT 28CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145363010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"CIGNA [10200]","Cigna Local Plus",,517.29,,,,,,,112.45,821.87,"percent of total billed charges",
"CATH LAUNCHER 8FR .09IN JUDKINS RIGHT 3.5 CURVE GUIDING",SUP-LA8JR35SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL LIGAPAK 4-0 54IN BRAID REEL COATED UNDYED",SUP-J284G,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DARUNAVIR 800 MG TABLET",RX-160155,CDM,,,0250,RC,59651-0086-30,NDC,both,1,UN,285.13,85.54,"UHC [10700]","United Healthcare",,180.49,63.3,,,,,0,33.16,242.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER 5.5MM CONTOUR ORTHOPEDIC",SUP-CSS50055A,CDM,C1713,HCPCS,0278,RC,,,both,,,858.60,257.58,"KAISER [10500]",Kaiser,,575.26,67,,,,,0,99.86,729.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLINICAL TRIAL OF VENAPAX EVH SYSTEM",SUP-VPX3000,CDM,S27200284,LOCAL,0272,RC,,,both,,,4795.50,1438.65,"MULTIPLAN [10600]",Multiplan,,4076.18,85,,,,,0,557.72,4076.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest Rectal Tmr Trnsanal",PX-750000157,CDM,45190,CPT,0750,RC,,,both,,,12954.00,3886.2,"BLUE CROSS [10001]","Blue Cross PPO",,3634.7,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1506.55,11010.9,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM SEMIRIGID OPEN ANTERIOR SEG SEWING",SUP-5300M26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"FIRST HEALTH [10303]","First Health",,11040,80,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 80CM 6MM FLEX DISTAFLO SMALL 2 BRANCH",SUP-DFM8006SC,CDM,C1768,HCPCS,0278,RC,,,both,,,9401.24,2820.37,"BLUE CROSS [10001]","Blue Cross PPO",,3685.29,39.2,,,,,0,1093.36,7991.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT LARGE EXTREMITY HEELBO ELBOW HEEL DISPOSABLE WHITE",SUP-D12039,CDM,S27000186,LOCAL,0270,RC,,,both,,,102.98,30.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.98,87.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X3CM DERMACELL THK.2-1MM DERMIS ALLOGRAFT",SUP-DCELL111,CDM,Q4122,HCPCS,0636,RC,,,both,,,6334.96,1900.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4117.72,65,,,,,0,750.69,5384.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIATHLON CR TIBIAL INSERT",SUP-5530-P-519,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,971.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CRYO/CUFF IC UNIVERSAL 45- IN COMPRESSION THERAPY",SUP-51A14A,CDM,S27000186,LOCAL,0270,RC,,,both,,,649.78,194.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.57,552.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON SABRELOC 5-0 RD-1 18IN 2 ARM MONOFILAMENT BLACK",SUP-749G,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.65,34.99,"NOVANET [10819]",Novanet,,87.49,75,,,,,0,13.57,124.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 10X22X50MM 5DEG LORDOTIC MODULUS XLW",SUP-1223050P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"MULTIPLAN [10600]",Multiplan,,24097.5,85,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 157MM STAINLESS STEEL 2.7MM SCR 9 HOLE CONTOUR SHAFT",SUP-02.118.410,CDM,C1713,HCPCS,0278,RC,,,both,,,5093.79,1528.14,"PHCS [10601]",PHCS,,3565.65,70,,,,,0,592.41,4329.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR HEAD AND NECK PROCEDURES WITH MCC",140,MS-DRG,,,,,,,inpatient,,,172534.24,51760.27,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,80942.6,,"Fee schedule rate ($80,942.60). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,124529.7,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY ESOPHAGEAL 3 PEDIATRIC LMA FASTRACH CUFF REINFORCE",SUP-135130,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"KAISER [10500]",Kaiser,,279.79,67,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR MICRO SHOULDER 1.8MM BIT DRILL GUIDE PUNCH",SUP-AR-1320DSC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,683.17,45.9,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR ITOTAL IDENTITY IPOLY XE CRUCIATE RETAIN INSRT 1",SUP-ITCR-XE-1PC,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"KAISER [10500]",Kaiser,,17939.25,67,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 17MM ATLANTIS TITANIUM SPINE CERVICAL",SUP-3125217,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,1144.80,304.56,2275.09,66,117.75,860.63,"percent of total billed charges",
"CATH LAUNCHER 110CM 5FR .058IN JL4 CURVE GUIDING CORONARY",SUP-LA5JL40A,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"FIRST HEALTH [10303]","First Health",,292.32,80,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM DCP LC-DCP STAINLESS STEEL PROXIMAL",SUP-204.234,CDM,C1713,HCPCS,0278,RC,,,both,,,177.48,53.24,"MULTIPLAN [10600]",Multiplan,,150.86,85,,,,,0,20.64,150.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 200MM 2.5MM BALLOON DILATATION RAPID",SUP-47525200M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"UHC [10700]","United Healthcare",,1281.83,63.3,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR KL4H CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389696150,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 42X6X.4MM CRANIOFACIAL TITANIUM 22 HOLE STRUT 1MM",SUP-42004,CDM,C1713,HCPCS,0278,RC,,,both,,,3082.50,924.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,358.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",358.49,2620.13,"percent of total billed charges",
"STENT ABRE 60MM 16MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U16060090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross PPO",,4057.2,39.2,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM NEXGEN D KNEE DISTAL",SUP-00549003410,CDM,C1776,HCPCS,0278,RC,,,both,,,14525.88,4357.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5810.35,40,,,,,0,1689.36,12347,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON SEPTAL 3CM NASAL 2 PART ADJUSTABLE CRUSTING EPISTAXIS",SUP-1524110,CDM,S27200284,LOCAL,0272,RC,,,both,,,2685.00,805.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,318.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,312.27,2282.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INNATE IMPLANT 3.6MM X 50MM",SUP-EXINN923650,CDM,C1713,HCPCS,0278,RC,,,both,,,5347.50,1604.25,"PHCS [10601]",PHCS,,3743.25,70,,,,,0,621.91,4545.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYNXGRIP GRIP 5FR CLSR 10ML VASCULAR BALLOON CATH",SUP-MX5021,CDM,C1760,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 2-0 SH 30IN BRAID GREEN NONABSORBABLE",SUP-X833H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT ELITE VASCULAR STRAIGHT",SUP-1011880,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6D XS 66X58MM KNEE RIGHT ROTATE HINGE PIN",SUP-623421R,CDM,C1776,HCPCS,0278,RC,,,both,,,30350.88,9105.26,"AETNA [10100]","Aetna HMO/PPO",,24128.95,79.5,,10981.53,8986.79,12413.38,12,3529.81,25798.25,"percent of total billed charges",
"KIT DRNG 6.44IN 8FR 22GA PNEUMOTHORAX CATH RADIOPAQUE NDL",SUP-AK-01500,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,408.97,45.9,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 39X5X1.2MM TITANIUM 2MM SCR MINI FRAGMENT 7 HOLE BONE",SUP-443.62,CDM,C1713,HCPCS,0278,RC,,,both,,,3965.71,1189.71,"BLUE CROSS [10001]","Blue Cross PPO",,1554.56,39.2,,957.42,570.23,957.42,28,461.21,3370.85,"percent of total billed charges",
"STENT WINGSPAN 15MM 4MM INTRACRANIAL HYDROPHILIC SELF EXPAND",SUP-M003WS0400150,CDM,C1874,HCPCS,0278,RC,,,both,,,51979.47,15593.84,"AETNA [10100]","Aetna HMO/PPO",,41323.68,79.5,,,,,0,6045.21,44182.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM RECONSTRUCTION VALVULAR RETRACTION",SUP-680R32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Local Plus",,4129.65,31.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENDO STITCH V-LOC 180 2-0 4IN CLSR ABSORBABLE RELOAD",SUP-VLOCA204L,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.84,83.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,33.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.43,237.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION 17MM TIGHTROPE ROUND CONCAVE",SUP-AR-1588TB-17,CDM,C1713,HCPCS,0278,RC,,,both,,,2165.63,649.69,"BLUE CROSS [10001]","Blue Cross HMO",,848.93,39.2,,957.42,156.86,7483.26,51,251.86,1840.79,"percent of total billed charges",
"SLEEVE CENTERING 9.5MM S-ROM ZTT 20D SMALL HIP PROXIMAL",SUP-550533,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"MULTIPLAN [10600]",Multiplan,,9252.04,85,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARCTIC FRONT ADVANCE 95CM 23MM 10.5FR 28MM CRYOABLATION",SUP-2AF284,CDM,C2630,HCPCS,0272,RC,,,both,,,26460.00,7938,"NOVANET [10819]",Novanet,,19845,75,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 105CM 3FR BUGBEE SINGLE SHORT TIP",SUP-BE-302,CDM,S27200284,LOCAL,0272,RC,,,both,,,680.33,204.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,462.62,68,,,,,0,79.12,578.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 53CM SOLIA JT STERILE LATEX FREE DISPOSABLE",SUP-395134,CDM,C1898,HCPCS,0275,RC,,,both,,,2250.00,675,"CIGNA [10200]","Cigna Open Access",,1280.25,56.9,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETENE DS 25X20CM COMPOSITE ABSORBABLE FILM",SUP-PPDS2520,CDM,C1781,HCPCS,0278,RC,,,both,,,6585.84,1975.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3022.9,45.9,,,,,0,765.93,5877.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 82MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 7",SUP-245.17,CDM,C1713,HCPCS,0278,RC,,,both,,,2990.40,897.12,"BLUE CROSS [10001]","Blue Cross HMO",,1172.24,39.2,,957.42,156.86,7483.26,51,347.78,2541.84,"percent of total billed charges",
"CATH JADE 135CM 100MM 4MM BALLOON DILATATION HYDROPHILIC",SUP-604015022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"NOVANET [10819]",Novanet,,546.75,75,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X7MM DIVERGENCE 12MM LORDOTIC NUCLEUS PULPOSUS",SUP-G6626527,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4968,40,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 131MM STAINLESS STEEL 3.5MM SCR 6 HOLE LOW PROFILE",SUP-02.120.706,CDM,C1713,HCPCS,0278,RC,,,both,,,5347.50,1604.25,"PHCS [10601]",PHCS,,3743.25,70,,,,,0,621.91,4545.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PERIPHERAL L150MM DIA5MM CATHETER L130CM VASCULAR LIFE",SUP-EX051503CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20128.50,6038.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2340.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 4MM 1.2MM 25MM 10MM STAINLESS STEEL LONG THREAD",SUP-202.725,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"MULTIPLAN [10600]",Multiplan,,943.52,85,,,,,0,129.1,943.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 80CM 4FR RDC1 CURVE ANGIOGRAPHIC NYLON NEON SLX",SUP-451446S0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"CIGNA [10200]","Cigna Local Plus",,55.85,53.5,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-150440105,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8130.78,27,,,,,0,3502.26,25596.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TIGHTRAIL MINI 11FR 6.1IN 23FR 18FR 11.2FR DIL",SUP-540-011,CDM,C1773,HCPCS,0272,RC,,,both,,,12385.50,3715.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5090.44,41.1,,,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 6CM 180CM 18MM 10.5FR ESOPHAGEAL FULL",SUP-G57306,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2084.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 100MM 3MM BALLOON DILATATION RAPID",SUP-47530100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP DA VINCI S/SI ENDOWRIST HEMOCLIP 8MM SMALL",SUP-420003,CDM,S27000186,LOCAL,0270,RC,,,both,,,1000.59,300.18,"PHCS [10601]",PHCS,,700.41,70,,,,,0,116.37,850.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-207.016,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,32.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,31.82,232.58,"percent of total billed charges",
"SUT PDS PLUS 0 CTX 60IN MONOFILAMENT ANTIBACTERIAL VIOLET",SUP-PDP990G,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.31,19.29,"MULTIPLAN [10600]",Multiplan,,54.66,85,,,,,0,7.48,54.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 70CM 6MM GORE PROPATEN VASCULAR GRAFT THIN",SUP-HT066070A,CDM,C1768,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SIDE RAIL CLAMP 1.25IN MARKED",SUP-50235-001ES,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH UMBILICAL VESSEL ARGYLE NEO-SERT MAGELLAN 2 TIER",SUP-8888160408,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 4-0 RB-1 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP304H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 13MM 2MM LCP CORTICAL STAINLESS STEEL SELF TAPPING",SUP-201.363.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"MULTIPLAN [10600]",Multiplan,,352,85,,,,,0,48.16,352,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 21MM 16.7MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-21MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]","Cigna Open Access",,9754.94,33.5,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 40MM 6FR 12MM .035IN LOW PROFILE BALLOON",SUP-B1120-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROMETHAZINE 25 MG TABLET",RX-6622,CDM,Q0169,HCPCS,0250,RC,68084-0155-11,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PRIME HD DBM .5CC ALLOGRAFT LATEX FREE",SUP-421005,CDM,C1713,HCPCS,0278,RC,,,both,,,506.25,151.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,59.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,58.88,430.31,"percent of total billed charges",
"STEM FEMORAL 115MM TRI-LOCK BPS GRIPTION 10 STANDARD OFFSET",SUP-101204100,CDM,C1776,HCPCS,0278,RC,,,both,,,29153.25,8745.97,"PHCS [10601]",PHCS,,20407.28,70,,,,,0,3390.52,24780.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) AUDIBLE FLOW INDICATOR (AFI) SYSTEM FOR HELO PE",SUP-30001,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet Myocardial Metabolic Eval",PX-404000008,CDM,78459,CPT,0404,RC,,,both,,,6429.00,1928.7,"KAISER [10500]",Kaiser,,4307.43,67,,,,,0,6.43,5464.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESPONSE 120CM 5FR 5MM SPACE JOSEPHSON CURVE",SUP-401223,CDM,C1730,HCPCS,0272,RC,,,both,,,746.09,223.83,"AETNA [10100]","Aetna HMO/PPO",,593.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.77,634.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER II XP 110CM 8MM 7FR 8FR 2.5MM SPACE LARGE CURVE",SUP-M0044500THK20,CDM,C1733,HCPCS,0272,RC,,,both,,,11840.40,3552.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1403.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1377.04,10064.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 3SQ CM THERASKIN ALLOGRAFT CRYOPRESERVE",SUP-3TS,CDM,Q4121,HCPCS,0636,RC,,,both,,,4761.00,1428.3,"KAISER [10500]",Kaiser,,3189.87,67,,,,,0,141.84,4046.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GYNECARE EXACT",SUP-TVTRL,CDM,C1771,HCPCS,0278,RC,,,both,,,8784.80,2635.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2514.21,28.62,,,,,0,1021.67,7467.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTP W4TR03 SOLARA QUAD CRTP MRI US",SUP-W4TR03,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"UHC [10700]","United Healthcare",,14616.22,63.3,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 7IN .062IN",SUP-AR-8941-7,CDM,C1769,HCPCS,0272,RC,,,both,,,365.40,109.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,150.18,41.1,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW FEATHERRASP SM STERILE LATEX FREE DISPOSABLE",SUP-SN31,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"NOVANET [10819]",Novanet,,2784.38,75,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 93MM STAINLESS STEEL 3.5MM SCR 4 HOLE LIMIT",SUP-239.954S,CDM,C1713,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"FIRST HEALTH [10303]","First Health",,6955.2,80,,,,,0,1011.11,7389.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP SMF WITH OXINIUM HEAD R3 HIGHLY CROS",SUP-71705530,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,9384.48,39.2,,3949.44,3949.44,3949.44,"1 through 10",2784.22,20349,"percent of total billed charges",
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC",715,MS-DRG,,,,,,,inpatient,,,132254.08,39676.22,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,14710.8,,"Case rate ($13,878.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,886.76, add-ons for qualifying new technology services are included. If operating cost exceeds $45,926.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,356.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $12,903.81. The transfer operating threshold is the transfer adjustment factor * $12,886.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $974.30. The transfer capital threshold is the transfer adjustment factor * $974.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,65320.21,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"5.5MM TI CURVED ROD 65MM",SUP-04.636.065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 60X16MM DARCO FOOT HEADLESS",SUP-DC001660,CDM,C1713,HCPCS,0278,RC,,,both,,,4629.90,1388.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,538.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",538.46,3935.42,"percent of total billed charges",
"WIRE FIXATION 1.4MM KIRSCHNER VARIAX OLIVE DISTAL RADIUS",SUP-56-40281,CDM,C1713,HCPCS,0278,RC,,,both,,,237.51,71.25,"CIGNA [10200]","Cigna Open Access",,135.14,56.9,,1144.80,304.56,2275.09,66,27.62,201.88,"percent of total billed charges",
"SHAVER BLADE 4MM 40DEG ROTATABLE WINDOW  CLOSED",SUP-SB4040RC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1541.46,462.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,633.54,41.1,,,,,0,179.27,1310.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BUTTON 8MM 6CM PASSPORT BUTTON SILICONE CURVE HIP 1",SUP-AR-6592-08-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"MULTIPLAN [10600]",Multiplan,,248.47,85,,,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM 1.4MM KIRSCHNER HOFFMANN II MICRO",SUP-390162,CDM,C1713,HCPCS,0278,RC,,,both,,,65.77,19.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,44.72,68,,,,,0,7.65,55.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 1 BACKWARD DOWN OFFSET 9.5IN KARLIN LUMBAR HANDLE",SUP-46-3138,CDM,S27200284,LOCAL,0272,RC,,,both,,,1195.16,358.55,"NOVANET [10819]",Novanet,,896.37,75,,,,,0,139,1015.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Scr Mammo Uni Incl Cad",PX-403000007,CDM,77067,CPT,0403,RC,,,both,,,722.12,216.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,179,,"Per diem ($179). Each quantity on the visit service is paid its own per diem rate. Each eligible service on a given day will be paid its own per diem rate.",,,,0,83.98,613.8,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON MONORAIL 6MM 3.75MM BALLOON",SUP-H74939401063750,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,641.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,,,0250,RC,45802-0059-35,NDC,both,15,GR,110.11,33.03,"CIGNA [10200]",Cigna,,74.87,68,,,,,0,12.81,93.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL FIXATION 1.5IN TRIATHLON HEAD",SUP-6541-4-515,CDM,C1713,HCPCS,0278,RC,,,both,,,595.35,178.6,"CIGNA [10200]",Cigna,,404.84,68,,1831.33,1831.33,1831.33,16,69.24,506.05,"percent of total billed charges",
"GWIRE HI-TORQUE POWERTURN VASCULAR J CURVE 190CM .014IN",SUP-1044594J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 3CM 5FR STRAIGHT PANCREATIC PLASTIC",SUP-M00537540,CDM,C2617,HCPCS,0278,RC,,,both,,,1411.18,423.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,403.88,28.62,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL INTRAOSSEOUS 45MM 15GA EZ-IO EZ-CONNECT NDL VISE",SUP-9079,CDM,S27200284,LOCAL,0272,RC,,,both,,,1106.46,331.94,"CIGNA [10200]","Cigna Local Plus",,591.96,53.5,,,,,0,128.68,940.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 39MM 80CM 6MM 8MM 7FR .035IN",SUP-BXA063901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"KAISER [10500]",Kaiser,,13068.22,67,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH-PROFILE BOOST, 700CC",SUP-SMHB700,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"MULTIPLAN [10600]",Multiplan,,6480.83,85,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID MODULAR HYBRID POST COMPREHENSIVE REGENEREX",SUP-PT113950,CDM,C1776,HCPCS,0278,RC,,,both,,,3150.00,945,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,373.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,366.35,2677.5,"percent of total billed charges",
"SUT CLLGN FIBERTAPE FIBERWIRE 2 TAPER 7INX2MM BRAID BLUE",SUP-AR-7237-7B,CDM,S27200284,LOCAL,0272,RC,,,both,,,637.88,191.36,"CIGNA [10200]","Cigna Open Access",,362.95,56.9,,,,,0,74.19,542.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 4-0 PS-2 18IN BRAID COATED UNDYED ABSORBABLE",SUP-VCP496G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]",Cigna,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 26CM 8FR POLARIS ULTRA .035IN STRAIGHT URETERAL",SUP-M006192153190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,162.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 235CC P3.1CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-235,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 18CM 3CM 4.8FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175199050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,728.1,68,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 37.5MM TRIGEN FEMUR LOW PROFILE",SUP-71645037,CDM,C1713,HCPCS,0278,RC,,,both,,,2846.25,853.87,"FIRST HEALTH [10303]","First Health",,2277,80,,,,,0,331.02,2419.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,inpatient,,,145350.75,43605.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,73273.99,,"Fee schedule rate ($73,273.99). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,112731.6,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT STRETCH VL SENSOR 22-30CM 5CM 7FR .035IN PIGTAIL CURVE",SUP-M006185157080,CDM,C2617,HCPCS,0278,RC,,,both,,,1271.86,381.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,150.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.92,1081.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710512,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"FIRST HEALTH [10303]","First Health",,11834.88,80,,,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR COMMUNICATOR HANDSET NONSTERILE LATEX FREE",SUP-TH91SCSR,CDM,C1787,HCPCS,0270,RC,,,both,,,7348.50,2204.55,"MULTIPLAN [10600]",Multiplan,,6246.23,85,,,,,0,854.63,6246.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE 100CM 150MM 7MM BALLOON DILATATION",SUP-LX1810071505F,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"UHC [10700]","United Healthcare",,5350.43,63.3,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY PRESSURE MNTR 4FR .021IN 12CM 1 LUMEN CATH GWIRE NDL",SUP-G58419,CDM,C1887,HCPCS,0272,RC,,,both,,,850.50,255.15,"UHC [10700]","United Healthcare",,538.37,63.3,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 105MM CEMENT EXT PROSTALAC 1 HIGH OFFSET HIP",SUP-1541-06-000,CDM,C1776,HCPCS,0278,RC,,,both,,,18814.32,5644.3,"CIGNA [10200]","Cigna Local Plus",,5926.51,31.5,,5372.07,4581.20,7242.98,23,2188.11,15992.17,"percent of total billed charges",
"FRCP ELECTROSURGICAL 8.5INX.5MM HARDY BIPOLAR INSULATE",SUP-US410SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,2487.93,746.38,"UHC [10700]","United Healthcare",,1574.86,63.3,,,,,0,289.35,2114.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drsg Interdry 3ft",PX-E27200318,CDM,E27200318,LOCAL,0272,RC,,,both,,,294.25,88.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,135.06,45.9,,,,,0,34.22,250.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTAINSTABILITY QUADPOLE LEAD LV",SUP-479888,CDM,C1900,HCPCS,0278,RC,,,both,,,11626.50,3487.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4778.49,41.1,,,,,0,1352.16,9882.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Periph Ins Impl Vad",PX-361000120,CDM,36585,CPT,0361,RC,,,both,,,7533.44,2260.03,"BLUE CROSS [10001]","Blue Cross PPO",,4431.65,,"Case rate ($4,431.65). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,876.14,7533.44,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 605CC",SUP-RSZ-MPX-605S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"NOVANET [10819]",Novanet,,1215,75,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Incsn Toe Tendon Mult",PX-510000072,CDM,28011,CPT,0761,RC,,,both,,,8374.00,2512.2,"NOVANET [10819]",Novanet,,6280.5,75,,,,,0,973.9,8239,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 66MM 36MM MARATHON",SUP-121936466,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"BLUE CROSS [10001]","Blue Cross PPO",,3858.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",1144.72,8366.42,"percent of total billed charges",
"COIL EMBOLIZATION 24CM 7MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-07024,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS [10001]","Blue Cross HMO",,4595.46,39.2,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rubella Ab",PX-302000161,CDM,86762,CPT,0302,RC,,,both,,,230.50,69.15,"UHC [10700]","United Healthcare",,12.95,,,,,,,0.01,195.93,"fee schedule",
"FIBEROS 5CC",SUP-FB050,CDM,C1713,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER IMPL SPINE TEMPORARY FIXATION SCR",SUP-650.012,CDM,S27800098,LOCAL,0278,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION SLR PTCA DEB 4.5X30MM",SUP-SCA14U-450030D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 100MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171081010,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,482.72,41.1,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 80MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,169.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Umbilical Arty",PX-450000238,CDM,36660,CPT,0361,RC,,,both,,,272.01,81.6,"BLUE CROSS [10001]","Blue Cross PPO",,272.01,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,31.63,272.01,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 19MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G419,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1109.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1089.28,7961.17,"percent of total billed charges",
"HC Prolact+6 Qtr Btl",PX-E27000208,CDM,E27000208,LOCAL,0270,RC,,,both,,,268.40,80.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,110.31,41.1,,,,,0,31.21,228.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORITAVANCIN 400 MG INTRAVENOUS SOLUTION",RX-168175,CDM,J2407,HCPCS,0636,RC,70842-0140-01,NDC,both,1,UN,7006.66,2102,"AETNA [10100]","Aetna HMO/PPO",,5570.29,79.5,,,,,0,830.29,5955.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3510,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1018.98,68,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Arm/Hnd Rt",PX-510000099,CDM,29584,CPT,0761,RC,,,both,,,891.00,267.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,891,,"Case rate ($1,729.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,103.62,891,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pt Eval High Complex 45 Min",PX-420000155,CDM,97163,CPT,0424,RC,,,both,,,535.54,160.66,"BLUE CROSS [10001]","Blue Cross PPO",,371.22,,"Per diem ($371.22).",,,,0,62.28,455.21,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE RADIUS ULNA SHAFT ALLOGRAFT FREEZE DRIED 60X15-18",SUP-400810,CDM,S27800098,LOCAL,0278,RC,,,both,,,4694.76,1408.43,"KAISER [10500]",Kaiser,,3145.49,67,,,,,0,546,3990.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 150MM 130CM 6MM OFFSET CROWN VASCULAR",SUP-SC6150LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4117.23,45.9,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 30CM 7FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856220,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"KAISER [10500]",Kaiser,,734.76,67,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC",438,MS-DRG,,,,,,,inpatient,,,40794.08,12238.22,"UHC [10700]","United Healthcare",,40655.56,,"Fee schedule rate ($40,655.56). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,40655.56,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 38MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.528S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"NOVANET [10819]",Novanet,,1122.66,75,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ahg Test Direct",PX-302000188,CDM,86880,CPT,0302,RC,,,both,,,248.90,74.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,19.12,,,,,,,3.64,211.57,"fee schedule",
"PLATE 32MM 2 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.232,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLP Routine Visit",PX-441000003,CDM,G0153,HCPCS,0441,RC,,,outpatient,,,261.00,78.3,"NOVANET [10819]",Novanet,,195.75,75,,,,,0,174.87,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 4FR 11CM RED HUB HEMOSTASIS VALVE PRELUDE",SUP-PSI-4F-11,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"MULTIPLAN [10600]",Multiplan,,64.34,85,,,,,0,8.8,64.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plt Pheresis Lr Irrad Ea Unit",PX-390000011,CDM,P9037,HCPCS,0390,RC,,,both,,,3851.50,1155.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1582.97,41.1,,,,,0,447.93,3273.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 16GA ACCURIAN CURVE SHARP 10MM",SUP-AC0002,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis B Core Ab Total",PX-302000144,CDM,86704,CPT,0302,RC,,,both,,,301.15,90.34,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.9,,"Fee schedule rate ($12.90). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.3,255.98,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"POD XL 14MMX55CM",SUP-RBYPODXL1455,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5085.99,27,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 74MM 9MM 5.4MM 4.7MM ZENITH SPIRAL-Z",SUP-G55220,CDM,C1874,HCPCS,0278,RC,,,both,,,20160.00,6048,"KAISER [10500]",Kaiser,,13507.2,67,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENZTROPINE 1 MG/ML INJECTION SOLUTION",RX-9259,CDM,J0515,HCPCS,0636,RC,00143-9233-01,NDC,both,2,ML,407.70,122.31,"FIRST HEALTH [10303]","First Health",,326.16,80,,,,,0,32.47,346.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAVARY-GILLIARD ENDOSCOPIC 250CM",SUP-G57281,CDM,C1769,HCPCS,0272,RC,,,both,,,1206.90,362.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,496.04,41.1,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Capsule Bravo",PX-E27200247,CDM,9999114,LOCAL,0272,RC,,,both,,,2234.10,670.23,"UHC [10700]","United Healthcare",,1414.19,63.3,,,,,0,259.83,1898.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER ENDOSCOPIC 20MM 4MM TREVO XP PROVUE STERILE LATEX",SUP-90182,CDM,S27200284,LOCAL,0272,RC,,,both,,,47273.94,14182.18,"FIRST HEALTH [10303]","First Health",,37819.15,80,,,,,0,5497.96,40182.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP060100090 PLUS US D6L100UL900",SUP-PCP060100090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET CATH 3IN ON-Q QUIKBLOC DEHP OVER THE NDL STERILE",SUP-QB10016SGC,CDM,S27200305,LOCAL,0272,RC,,,both,,,328.86,98.66,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC QUANTUM APEX MONORAIL 143CM 20MM 3MM BALLOON",SUP-H7493912420300,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ANTEPARTUM WITH O.R. PROCEDURE,MAJOR",547,APR-DRG,,,,,,,inpatient,,,101137.53,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $7,489.50. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($44,685.46) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 70X40MM ARTHROFLEX THK1.76-2.25MM",SUP-AFLEX201,CDM,Q4125,HCPCS,0636,RC,,,both,,,17520.30,5256.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH REDEL 115CM 1MM 6FR 2-5-2MM SPACE G CURVE",SUP-F6DG252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2040.00,612,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 6FR 21GA 40CM 4CM GREEN HUB TUBING STAINLESS",SUP-PSS-6F-4-018MT,CDM,C1894,HCPCS,0272,RC,,,both,,,286.67,86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,194.94,68,,,,,0,33.34,243.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACCU-TRACE KENDALL SMALL FLAT ROUND PRESSURE",SUP-56300,CDM,S27200284,LOCAL,0272,RC,,,both,,,295.97,88.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT AXIOS 10MM 146MM 15MM 24MM 138MM 10.8FR PANCREATIC",SUP-M00553650,CDM,C1874,HCPCS,0278,RC,,,both,,,28551.60,8565.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8171.47,28.62,,,,,0,3320.55,24268.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ULTRAFLEX 40MM 25MM 18MM 27FR 95CM 5.1MM",SUP-M00576640,CDM,C1874,HCPCS,0278,RC,,,both,,,19467.00,5840.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5256.09,27,,,,,0,2264.01,16546.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 14CM 14FR 18GA PEEL-AWAY 3MM .038IN TRANSSEPTAL",SUP-405144,CDM,C1892,HCPCS,0272,RC,,,both,,,261.00,78.3,"NOVANET [10819]",Novanet,,195.75,75,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 0 FSL 30IN BRAID BLACK NONABSORBABLE",SUP-680H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 80MM 159CM 6MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200068020,CDM,C1876,HCPCS,0278,RC,,,both,,,4515.00,1354.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,535.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,525.09,3837.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 KNEE RIGHT CEMENTED POSTERIOR STABILIZE",SUP-150410209,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"CIGNA [10200]","Cigna Local Plus",,7053.91,31.5,,5372.07,4581.20,7242.98,23,2604.35,19034.35,"percent of total billed charges",
"CMPNT FEMORAL 7 STD KNEE CONDYLAR CEMENT CONSTRAIN PERSONA",SUP-42-5046-062-02,CDM,C1776,HCPCS,0278,RC,,,both,,,42373.80,12712.14,"BLUE CROSS [10001]","Blue Cross PPO",,16610.53,39.2,,3949.44,3949.44,3949.44,"1 through 10",4928.07,36017.73,"percent of total billed charges",
"ROD SPINAL 55MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000055,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Open Access",,921.78,56.9,,1144.80,304.56,2275.09,66,188.41,1377,"percent of total billed charges",
"8MM AMPLATZER MUSCULAR VSD OCCLUDER",SUP-9-VSD-MUSC-008,CDM,C1817,HCPCS,0278,RC,,,both,,,62700.00,18810,"AETNA [10100]","Aetna HMO/PPO",,49846.5,79.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X12MM VERTE-STACK CORNERSTONE PSR 11MM",SUP-6287241,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIPASE-PROTEASE-AMYLASE (PORK) 3,000-9,500-15,000 UNIT CAPSULE,DEL REL",RX-111147,CDM,,,0637,RC,00032-0045-70,NDC,both,1,UN,10.94,3.28,"UHC [10700]","United Healthcare",,6.93,63.3,,,,,0,1.27,9.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX 10X6IN MONOFILAMENT SCAFFOLD FULL",SUP-1191525,CDM,C1781,HCPCS,0272,RC,,,both,,,37341.99,11202.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15347.56,41.1,,,,,0,15347.56,23637.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +16.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.165,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Local Plus",,184.58,53.5,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 11",SUP-71357011,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"CIGNA [10200]","Cigna Open Access",,11102.29,33.5,,5302.19,4377.88,6578.61,27,3854.32,28169.98,"percent of total billed charges",
"CATH DORADO CHECKER 135CM 17CM 5MM BALLOON DILATATION",SUP-DR135517,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 180MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309118,CDM,C1776,HCPCS,0278,RC,,,both,,,37771.65,11331.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10198.35,27,,,,,0,4392.84,32105.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Skull<4v",PX-320000017,CDM,70250,CPT,0320,RC,,,both,,,546.18,163.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,42.88,,,,,,,42.88,464.25,"fee schedule",
"HEALING CAP WITH PLUG 30 MM",SUP-95084,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.90,44.37,"MULTIPLAN [10600]",Multiplan,,125.72,85,,,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 5MM 1.35MM TRIUNE EAR SILICONE BLUE",SUP-510-121,CDM,S27800098,LOCAL,0278,RC,,,both,,,245.41,73.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,112.64,45.9,,,,,0,28.54,208.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 24MM TI",SUP-MTLS-37240-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]",Cigna,,908.82,68,,1831.33,1831.33,1831.33,16,155.43,1136.03,"percent of total billed charges",
"STENT ZILVER 635 30MM 125CM 12MM 6FR .035IN BILIARY NITINOL",SUP-G36238,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,439.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 32MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.622,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"CIGNA [10200]","Cigna Open Access",,658.15,56.9,,1144.80,304.56,2275.09,66,134.52,983.18,"percent of total billed charges",
"CAP SYSTEM PREMIER ACTIVE ARTICULATION THR OSSEOTI XLPE CERA",SUP-98000100192,CDM,C1776,HCPCS,0278,RC,,,both,,,31500.00,9450,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9015.3,28.62,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 6MM LEIBINGER UNIVERSAL TITANIUM MAXILLOFACIAL",SUP-50-20506,CDM,C1713,HCPCS,0278,RC,,,both,,,788.29,236.49,"CIGNA [10200]","Cigna Local Plus",,421.74,53.5,,3978.14,359.25,3978.14,24,91.68,670.05,"percent of total billed charges",
"GRAFT SKIN 4X6CM AMNIOBAND PLACENTAL MEMB ALLOGRAFT",SUP-WC3046,CDM,Q4151,HCPCS,0636,RC,,,both,,,19778.85,5933.65,"AETNA [10100]","Aetna HMO/PPO",,15724.19,79.5,,,,,0,362.66,16812.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE STEM/WEDGE/AUGMENT",SUP-CAP-U-SWA,CDM,C1776,HCPCS,0278,RC,,,both,,,2250.00,675,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,643.95,28.62,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 15MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-55840014515,CDM,C1713,HCPCS,0278,RC,,,both,,,6900.00,2070,"PHCS [10601]",PHCS,,4830,70,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX 1S REINFORCED TISSUE MATRIX, LONG-TERM RESORBABLE REI",SUP-F10266-1020G,CDM,C1781,HCPCS,0278,RC,,,both,,,19731.60,5919.48,"CIGNA [10200]","Cigna Open Access",,6610.09,33.5,,11235.02,819.42,11235.02,"1 through 10",2294.79,16771.86,"percent of total billed charges",
"3.0MM PHALANX LNTRAMEDULLARY NAIL 3MM X 32.5MM TI",SUP-IHFN-PHX-30032,CDM,C1713,HCPCS,0278,RC,,,both,,,8052.30,2415.69,"NOVANET [10819]",Novanet,,6039.23,75,,,,,0,936.48,6844.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM SWIVELOCK CLOSED EYELET VENT PEEK 19.1MM",SUP-AR-2324PSLC,CDM,C1713,HCPCS,0278,RC,,,both,,,2953.13,885.94,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,343.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",343.45,2510.16,"percent of total billed charges",
"BLADE SHAVER FOREST GREEN 17MM 4.5MM SYNOVATOR CURVED",SUP-7205334,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"PHCS [10601]",PHCS,,243.6,70,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CELECOXIB 200 MG CAPSULE",RX-24501,CDM,,,0637,RC,50268-0169-11,NDC,both,1,UN,12.21,3.66,"CIGNA [10200]",Cigna,,8.3,68,,,,,0,1.42,10.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC IV Inf Ther Add Hr",PX-260000004,CDM,96366,CPT,0260,RC,,,both,,,293.52,88.06,"BLUE CROSS [10001]","Blue Cross HMO",,201.35,68.6,,,,,0,34.14,293.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE 2CM MIC-KEY",SUP-8270-18-2.0-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"FIRST HEALTH [10303]","First Health",,2106.24,80,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DRNG PURPLE 250CM 7FR PIGTAIL CURVE NASOBILIARY 5",SUP-G21586,CDM,C1729,HCPCS,0272,RC,,,both,,,1239.30,371.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,146.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 280016 UNCRT DWL 16MM SRVC FEE",SUP-280016,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZIPWIRE VASCULAR STRAIGHT 180CM .035IN NITINOL POLYMER",SUP-M00146309B1,CDM,C1769,HCPCS,0272,RC,,,both,,,339.13,101.74,"FIRST HEALTH [10303]","First Health",,271.3,80,,,,,0,39.44,288.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DIVERGENCE-L 15X9.4X8MM ANTERIOR OBLIQUE LUMBAR",SUP-736528,CDM,S27800098,LOCAL,0278,RC,,,both,,,9177.00,2753.1,"CIGNA [10200]","Cigna Local Plus",,4909.7,53.5,,,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPIDCROSS 170CM 80MM 2MM .014IN BALLOON DILATATION",SUP-A14BX020080170,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.87,68,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION HI-FLO FATHOM 130CM 180CM 2.4FR .027IN MICRO",SUP-M001195740,CDM,C1887,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2977.7,41.1,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X10MM COROENT XL+ NONSTERILE LATEX FREE",SUP-6010845,CDM,C1889,HCPCS,0278,RC,,,both,,,23940.00,7182,"FIRST HEALTH [10303]","First Health",,19152,80,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT AUTOPLEX VERTAPLEX HV M4 MIXER STERILE LATEX",SUP-0707-000-000,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross PPO",,2569.56,39.2,,957.42,570.23,957.42,28,762.35,5571.75,"percent of total billed charges",
"SYSTEM INTEGRITY 18MM 3.5MM CORONARY STENT FULCRUM COCR",SUP-INT35018UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"BLUE CROSS [10001]","Blue Cross PPO",,946.68,39.2,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VOLT, AGILIS 13F SMALL CURVE, ICE SE",SUP-K-VOLT-I-S,CDM,C1732,HCPCS,0272,RC,,,both,,,62700.00,18810,"MULTIPLAN [10600]",Multiplan,,53295,85,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 12MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240120500,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"KAISER [10500]",Kaiser,,5774.13,67,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM PRESTIGE PLUS HELICAL COMPLEX XTRA",SUP-PRES0202CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 24MM COCR",SUP-VAL-25240-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,969.41,68,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC",435,MS-DRG,,,,,,,inpatient,,,74505.71,22351.71,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,24495.29,,"Case rate ($11,393.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,579.32, add-ons for qualifying new technology services are included. If operating cost exceeds $43,619.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,181.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,593.31. The transfer operating threshold is the transfer adjustment factor * $10,579.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.85. The transfer capital threshold is the transfer adjustment factor * $799.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,45805.46,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT HAKIM CSF 120CM RIGHT ANGLE SIPHONGUARD UNITIZED",SUP-823146,CDM,S27800098,LOCAL,0278,RC,,,both,,,44384.89,13315.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11983.92,27,,,,,0,5161.96,37727.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18.5 DIOPTER +3 CYL MODIFIED C BICONVEX 13MM 6MM","SUP-ZCT300 18.5",CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross HMO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM EXCELSIOR XT-27 1 TIP",SUP-M003XT2750910,CDM,S27200284,LOCAL,0272,RC,,,both,,,8474.58,2542.37,"CIGNA [10200]","Cigna Open Access",,4822.04,56.9,,,,,0,985.59,7203.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT225220,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"MULTIPLAN [10600]",Multiplan,,293.25,85,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 4CM RADIOPAQUE LARGE BORE STPCOCK PINCH",SUP-PSS-5F-4MT,CDM,C1894,HCPCS,0272,RC,,,both,,,165.30,49.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,67.94,41.1,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 31MM FLEXIBLE SURE LOCK DELIVERY SYSTEM",SUP-TARP-31,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"CIGNA [10200]","Cigna Open Access",,4055.64,33.5,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 15MM ECHO FX COCR STD OFFSET HIP STERILE",SUP-12-151315,CDM,C1776,HCPCS,0278,RC,,,both,,,8941.02,2682.31,"CIGNA [10200]",Cigna,,6079.89,68,,5873.17,5873.17,5873.17,"1 through 10",1039.84,7599.87,"percent of total billed charges",
"STEM FEMORAL TAPERFILL 6 STD OFFSET HIP STERILE LATEX FREE",SUP-425-96-006,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1604.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X12X7MM MODULUS 7D CERVICAL STERILE LATEX FREE",SUP-67940002P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"KAISER [10500]",Kaiser,,4160.7,67,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTITORQUE 110CM 5FR SARAH RADIAL 4 CURVE ANGIOGRAPHIC",SUP-40-5024,CDM,C1887,HCPCS,0272,RC,,,both,,,313.20,93.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,212.98,68,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 3.5CM 16FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-16-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BAG RESUS SPUR II PEDIATRIC",SUP-530213030,CDM,S27000186,LOCAL,0270,RC,,,both,,,74.61,22.38,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COLLAR CERVICAL VISTA TX HEIGHT ADJUSTMENT TECHNOLOGY",SUP-100084-000,CDM,S27000186,LOCAL,0270,RC,,,both,,,413.34,124,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATH 20CM 11.5FR PRECURVE POLYURETHANE DUO-FLOW",SUP-MCDLT118IJ-2,CDM,C1752,HCPCS,0272,RC,,,both,,,701.46,210.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMPRESS 65CM 5FR MHK CURVE ANGIOGRAPHIC POLYURETHANE",SUP-565386MHK-NB,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GUIDE CATHETER, SHAPE 20",SUP-4679-01,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARDEX LUBRICATH 18FR MEDIUM URETHRAL HYDROPHILIC",SUP-0174L18,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.47,22.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE A CURVE",SUP-D7TAL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 4MM ROUND STERILE LATEX FREE DISPOSABLE",SUP-5820-110-040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1164.70,349.41,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HIV WITH OR WITHOUT OTHER RELATED CONDITION",977,MS-DRG,,,,,,,inpatient,,,44546.33,13363.9,"BLUE CROSS [10001]","Blue Cross PPO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 V-5 36IN 2 ARM BRAID 1 STRAND FIRM",SUP-PX17H,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.67,73.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MICROCATHETER CEREBROVASCULAR 150CM .0165IN PROWLER SELECT",SUP-MC1755M2U,CDM,C1887,HCPCS,0272,RC,,,both,,,7390.38,2217.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 135CM 10CM 7MM BALLOON DILATATION PERIPHERAL",SUP-G50264,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VASCURE FOR VASCULAR REPAIR SINGLE PACK 1 X 10 CM",SUP-CMCV-013-609,CDM,C1768,HCPCS,0278,RC,,,both,,,12040.50,3612.15,"PHCS [10601]",PHCS,,8428.35,70,,,,,0,1400.31,10234.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION RUBY DETACHMENT HANDLE PERIPHERAL",SUP-RH1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"UHC [10700]","United Healthcare",,1068.19,63.3,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE DRILL 3.2MM THREADED 4MM LOCKING SCR SELF TAPPING",SUP-312.445,CDM,S27200284,LOCAL,0272,RC,,,both,,,1773.30,531.99,"KAISER [10500]",Kaiser,,1188.11,67,,,,,0,206.23,1507.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Umbilical Neonate",PX-E27200076,CDM,E27200076,LOCAL,0272,RC,,,both,,,359.70,107.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,165.1,45.9,,,,,0,41.83,305.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY FIXATION GOLD 42MMX3.9MM 13MM HUMERUS",SUP-462.642S,CDM,C1713,HCPCS,0278,RC,,,both,,,3288.60,986.58,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2236.25,68,,,,,0,382.46,2795.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5F DECA 5-5-5-20-3-3-3-3-3 MPA 120CM",SUP-901583,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"MULTIPLAN [10600]",Multiplan,,2518.13,85,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET",RX-165121,CDM,,,0637,RC,00310-6210-39,NDC,both,1,UN,90.68,27.2,"KAISER [10500]",Kaiser,,60.76,67,,,,,0,10.55,77.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH HEARTSPAN MUL CURVE 61CM 8.5FR GUIDING TRANSSEPTAL",SUP-FCB8561MUL,CDM,C1894,HCPCS,0272,RC,,,both,,,1432.08,429.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,973.81,68,,,,,0,166.55,1217.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC",797,MS-DRG,,,,,,,inpatient,,,50780.54,15234.16,"PHCS [10601]",PHCS,,5018,,,,,,,5018,13341.95,"per diem","Estimated amount calculated based on 4 day length of stay."
"CAP HEAD UNIPOLAR UNIPOLAR",SUP-71701030,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4433.94,45.9,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 31X14-17MM MAGNIFY-S 15D LORDOTIC 25MM EXPAND",SUP-1126.0214,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"BLUE CROSS [10001]","Blue Cross HMO",,16793.28,39.2,,,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VAC VERATRAC DUO NEGATIVE PRESSURE TUBE SET REMOVAL",SUP-ULTDUO0500.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,577.13,173.14,"UHC [10700]","United Healthcare",,365.32,63.3,,,,,0,67.12,490.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 E 36MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30103605,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"FIRST HEALTH [10303]","First Health",,8201.62,80,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 85MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 6",SUP-223.561,CDM,C1713,HCPCS,0278,RC,,,both,,,1837.50,551.25,"FIRST HEALTH [10303]","First Health",,1470,80,,,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG 600ML DRNG DEPOT TWIST VALVE ADJUSTABLE TUBING KIT",SUP-MDD600,CDM,S27000186,LOCAL,0270,RC,,,both,,,85.00,25.5,"CIGNA [10200]",Cigna,,57.8,68,,,,,0,9.89,72.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VISIGLIDE ENDOSCOPIC STRAIGHT 4500MM .035IN .025IN",SUP-G-240-3545S,CDM,C1769,HCPCS,0272,RC,,,both,,,1288.95,386.68,"NOVANET [10819]",Novanet,,966.71,75,,,,,0,149.9,1095.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SYNERGY XD 8MM 2.25MM CORONARY EVEROLIMUS",SUP-H7493941808220,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION 30-60 MCI",RX-411503,CDM,A9560,HCPCS,0343,RC,08888-8878-57,NDC,both,1,UN,882.80,264.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,233.1,,,,,,,102.67,750.38,"fee schedule",
"SCR BONE 35MM REDAPT LOCK",SUP-71354506,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"TISSUE 341211 LACSR 12X11X11 SRVC FEE",SUP-341211,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET FEEDING 18FR L4CM JEJUNAL TUBE EXTENSION MIC-KEY",SUP-8230-18-4.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"MULTIPLAN [10600]",Multiplan,,1226.42,85,,,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE ORTHOTIC 9-11 11.5-12.5 LARGE PROCARE OFF LOAD DIABETIC",SUP-79-81517,CDM,S27000186,LOCAL,0270,RC,,,both,,,237.16,71.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,108.86,45.9,,,,,0,27.58,201.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 60MM 6FR 6MM 4FR BALLOON",SUP-H74939031606010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 4-0 PS-1 18IN MONOFILAMENT UNDYED",SUP-Y682H,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.63,20.59,"FIRST HEALTH [10303]","First Health",,54.9,80,,,,,0,7.98,58.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE HI-FLO 150CM 10CM 3-2.8FR .027IN MICRO",SUP-M001182900,CDM,C1887,HCPCS,0272,RC,,,both,,,2100.00,630,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,244.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRAMEDULLARY NAIL 420MM 11MM GAMMA 125D LONG R1.5",SUP-3525-1420S,CDM,C1713,HCPCS,0278,RC,,,both,,,13435.13,4030.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5521.84,41.1,,,,,0,1562.51,11419.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EDWARDS INTUITY ELITE VALVE SYSTEM",SUP-8300KITB,CDM,S27800098,LOCAL,0278,RC,,,both,,,68400.00,20520,"CIGNA [10200]",Cigna,,27360,40,,,,,0,7954.92,58140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TACTIFLEX ABLATION CATHETER SENSOR ENABLED",SUP-A-TFSE-FJ-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 8MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630308,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UHC [10700]","United Healthcare",,8309.55,63.3,,8601.07,8395.67,8601.07,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"INTRO SHEATH 12FR 40CM LARGE VALVE ASSEMB RADIOPAQUE BAND",SUP-G32373,CDM,C1894,HCPCS,0272,RC,,,both,,,476.85,143.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,195.99,41.1,,,,,0,55.46,405.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 36MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0246,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,271.23,28.62,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM QUICKFIX TITANIUM T15 SHORT THREAD",SUP-AR-8740-30PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM ROUND DIAMOND STERILE LATEX FREE",SUP-5820-012-030D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1164.70,349.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,534.6,45.9,,,,,0,135.45,990,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 5MM CORONARY STENT",SUP-H7493941820500,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,858.6,28.62,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 23MM 7MM STERILE",SUP-AR-1370P,CDM,C1713,HCPCS,0278,RC,,,both,,,1968.75,590.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1338.75,68,,,,,0,228.97,1673.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP HUMERAL 33MM UNIVERS REVERS +2 RIGHT SUT",SUP-AR-9502F-33LCPC,CDM,C1776,HCPCS,0278,RC,,,both,,,7576.20,2272.86,"AETNA [10100]","Aetna HMO/PPO",,6023.08,79.5,,10981.53,8986.79,12413.38,12,881.11,6439.77,"percent of total billed charges",
"CLIP MEDIUM INTERNAL HEMOCLIP TITANIUM ENDOSCOPIC LIGATING",SUP-523100,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4.5CM 4MM .0135IN MICRUSFRAME MICRO",SUP-MFR140445,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 25MM 7FR FUSION OMNI-TOME BILIARY PANCREATIC",SUP-G31911,CDM,C1769,HCPCS,0272,RC,,,both,,,3082.50,924.75,"UHC [10700]","United Healthcare",,1951.22,63.3,,,,,0,358.49,2620.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM TRUDI 15D CURVE STERILE LATEX FREE",SUP-TSB415,CDM,S27200284,LOCAL,0272,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Open Access",,2027.06,56.9,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 113MM 30-12MM 7.7MM 20FR ZENITH RENU",SUP-G55382,CDM,C1874,HCPCS,0278,RC,,,both,,,43501.50,13050.45,"KAISER [10500]",Kaiser,,29146.01,67,,,,,0,5059.22,36976.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +25 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030250,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TRANSEND VASCULAR 205CM 2CM .014IN SCITANIUM ICE",SUP-M001468080,CDM,C1769,HCPCS,0272,RC,,,both,,,3942.52,1182.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,458.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,458.52,3351.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR",SUP-SSR10-01,CDM,A4648,HCPCS,0278,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 14.5MM 28.5MM EXCLUDER TRUNK",SUP-CXT281412,CDM,C1874,HCPCS,0278,RC,,,both,,,71175.90,21352.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8434.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8277.76,60499.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR XLPE POROUS CUP LINER INSRT",SUP-98B00100190,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"CIGNA [10200]","Cigna Open Access",,4623,33.5,,5302.19,4377.88,6578.61,27,1604.94,11730,"percent of total billed charges",
"NAIL 15.5-11MM 22CM FEMUR PROXIMAL TALON DISTALFIX",SUP-SLN-120-220,CDM,C1713,HCPCS,0278,RC,,,both,,,13227.30,3968.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1567.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1538.33,11243.21,"percent of total billed charges",
"KIT AIRWAY ACCESS 11008211 11008208",SUP-WW8214,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.14,23.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.2,67.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER SURGICAL 42MM KNEE PATELLA DISPOSABLE",SUP-8000-0042,CDM,S27200284,LOCAL,0272,RC,,,both,,,1567.92,470.38,"FIRST HEALTH [10303]","First Health",,1254.34,80,,,,,0,182.35,1332.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP ADD-A-FOLEY COMPLETE CARE",SUP-A399400A,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.70,27.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.66,77.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH XP 135CM 5FR RAVI MG2 CURVE ANGIOGRAPHIC",SUP-RF*ZUF511DJM,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 131MM 36MM 22FR ZENITH FLEX Z-TRAK 2",SUP-G48434,CDM,C1874,HCPCS,0278,RC,,,both,,,50122.80,15036.84,"AETNA [10100]","Aetna HMO/PPO",,39847.63,79.5,,,,,0,5829.28,42604.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP MONOPOLAR 12.5IN 5MM ULTRA BOTTLE NOSE 2 ACTION DISSECT",SUP-90-1030I,CDM,S27200284,LOCAL,0272,RC,,,both,,,2909.63,872.89,"FIRST HEALTH [10303]","First Health",,2327.7,80,,,,,0,338.39,2473.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ADMIN 120IN 60 GTT/ML 25ML INTRAVENOUS ULTRASITE SPIN",SUP-375040,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.36,18.11,"KAISER [10500]",Kaiser,,40.44,67,,,,,0,7.02,51.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.8MM CLAW II ORTHOLOC 3DSI",SUP-40250028,CDM,S27200284,LOCAL,0272,RC,,,both,,,1069.20,320.76,"PHCS [10601]",PHCS,,748.44,70,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Antiannexin V-Igg",PX-301000261,CDM,83520,CPT,0301,RC,,,both,,,373.00,111.9,"FIRST HEALTH [10303]","First Health",,298.4,80,,,,,0,0.37,317.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH GREEN 20CM 12.5FR MAHURKAR ELITE DOUBLE-D LARGE",SUP-8888231420,CDM,C1752,HCPCS,0272,RC,,,both,,,1178.06,353.42,"UHC [10700]","United Healthcare",,745.71,63.3,,,,,0,137.01,1001.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 52MM 28MM 10D HIP CROSSFIRE OMNIFIT STERILE",SUP-2041C-2852,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"FIRST HEALTH [10303]","First Health",,5630.4,80,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW HEADED THREAD 3.2MM L 27.0MM","SUP-GS909.027.032 STE",CDM,C1713,HCPCS,0278,RC,,,both,,,1579.50,473.85,"PHCS [10601]",PHCS,,1105.65,70,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MERSILENE 2 MO-7 30IN BRAID D SPECIAL GREEN LIGHT GREEN",SUP-D8649,CDM,S27200284,LOCAL,0272,RC,,,both,,,776.02,232.81,"AETNA [10100]","Aetna HMO/PPO",,616.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.25,659.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 15MM 6.5MM G7 DOME HIP ACETABULAR LOW PROFILE",SUP-010000996,CDM,C1713,HCPCS,0278,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 20MM 144CM 2.5MM CORONARY STENT EVEROLIMUS",SUP-H7493926120250,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1003.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 10.5IN 26FR SILICONE Y PORT GRADUATE SHAFT OPEN DISTAL",SUP-8884720265E,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.71,111.81,"KAISER [10500]",Kaiser,,249.72,67,,,,,0,43.35,316.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X9MM ADVANCED LORDOTIC TRAPEZOIDAL",SUP-7709,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,962.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 2.7MM STAINLESS STEEL QUICK COUPLING",SUP-310.28,CDM,S27000186,LOCAL,0270,RC,,,both,,,553.39,166.02,"KAISER [10500]",Kaiser,,370.77,67,,,,,0,64.36,470.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 2.50X15MM",SUP-PRV025015CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI STRAIGHT 8MMX1MM MANDIBLE 4 HOLE 2MM SCR BONE",SUP-55-10503,CDM,C1713,HCPCS,0278,RC,,,both,,,1085.16,325.55,"PHCS [10601]",PHCS,,759.61,70,,,,,0,126.2,922.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PASSPORT 150CM 2CM 3FR 12FR BALLOON DILATATION",SUP-M0062181000,CDM,C1726,HCPCS,0272,RC,,,both,,,1928.85,578.65,"PHCS [10601]",PHCS,,1350.2,70,,,,,0,224.33,1639.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 26CM 3CM 7FR .038IN 2 PIGTAIL",SUP-M006192143010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,142.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM REVOLVE PREBENT",SUP-132.165,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"STYLET LEAD 52CM 16MM STEERABLE TOOL SMOOTH EXTEND LOCATOR P",SUP-1292/52,CDM,S27500001,LOCAL,0275,RC,,,both,,,1972.50,591.75,"PHCS [10601]",PHCS,,1380.75,70,,,,,0,229.4,1676.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HEAD UNIPOLAR UNIPOLAR",SUP-71701030,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3970.26,41.1,,6417.48,6417.48,6417.48,"1 through 10",1123.46,8211,"percent of total billed charges",
"PLATE 52MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 6",SUP-244.06,CDM,C1713,HCPCS,0278,RC,,,both,,,3031.80,909.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,359.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",352.6,2577.03,"percent of total billed charges",
"KIT CATH 12FR 18GA 20CM .035IN 3 LUMEN CATH GWIRE NDL DRAPE",SUP-AK-25123-F,CDM,C1751,HCPCS,0272,RC,,,both,,,944.46,283.34,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,388.17,41.1,,,,,0,109.84,802.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 575CC P4.6CM MODERATE PLUS PROFILE MODERATE BASE",SUP-350-5751BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) SYSTEM AVEIR 19.5F PACEMKR LEADLESS PACEMKR 38.5MM RV",SUP-LSP112V,CDM,C1786,HCPCS,0275,RC,,,both,,,44100.00,13230,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5128.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5128.83,37485,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC LARGE 7.75-8.5IN LEFT WRIST THUMB SPICA",SUP-A6157,CDM,S27000186,LOCAL,0270,RC,,,both,,,224.55,67.36,"PHCS [10601]",PHCS,,157.19,70,,,,,0,26.12,190.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANSTR VACUUM REPLACEMENT 800CC MAMMOTOME REVOLVE SYSTEM",SUP-MCANISTER1,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.68,19.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,43.3,68,,,,,0,7.41,54.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 20CM 150CM 6FR .038IN STD STRAIGHT LOW PROFILE",SUP-M006180520170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,565.01,45.9,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 6 SLOT PLUS LEFT TI",SUP-PHPF-C6PL,CDM,C1713,HCPCS,0278,RC,,,both,,,19152.00,5745.6,"CIGNA [10200]",Cigna,,7660.8,40,,1831.33,1831.33,1831.33,16,2227.38,16279.2,"percent of total billed charges",
"TRIAL KNEE 8MM IDENTITY IMPRINT 3 TIBIAL INSRT POSTERIOR",SUP-TPS-030-083S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SPINAL LUMBAR ANTERIOR 3 HOLE 21MM VICTORY",SUP-1236.5021,CDM,C1713,HCPCS,0278,RC,,,both,,,28350.00,8505,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXERCISER HAND ROLYAN BLACK RUBBER ERGONOMIC LATEX FREE",SUP-A3481,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.33,13.6,"UHC [10700]","United Healthcare",,28.69,63.3,,,,,0,5.27,38.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.3/4F DUO-DECA 5-5-5 S 120CM",SUP-903271,CDM,C1731,HCPCS,0272,RC,,,both,,,8970.00,2691,"MULTIPLAN [10600]",Multiplan,,7624.5,85,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 4-11 E-F KNEE LEFT",SUP-42511200510,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3706.77,45.9,,,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP MULTIHOLE R3 STD STERILE",SUP-71338668,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1882.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1847.69,13504.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC",073,MS-DRG,,,,,,,inpatient,,,54588.84,16376.65,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,10548.66,,"Case rate ($9,951.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,240.71, add-ons for qualifying new technology services are included. If operating cost exceeds $42,280.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,080.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,252.93. The transfer operating threshold is the transfer adjustment factor * $9,240.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $698.64. The transfer capital threshold is the transfer adjustment factor * $698.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,40009.64,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 18MM 140CM 3.5MM 2.1-2.7FR CORONARY",SUP-RONYX35018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"PHCS [10601]",PHCS,,2598.75,70,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAROTID ARTERY STENT PROCEDURES WITH CC",035,MS-DRG,,,,,,,inpatient,,,125170.43,37551.13,"AMBETTER EXCHANGE  [11102]",Ambetter,,14828.42,,"Case rate ($14,828.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,769.19, add-ons for qualifying new technology services are included. If operating cost exceeds $46,808.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,423.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $13,787.40. The transfer operating threshold is the transfer adjustment factor * $13,769.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,041.02. The transfer capital threshold is the transfer adjustment factor * $1,041.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,8593,69793.04,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"WORLEY RIGHT-SIDED SSR9",SUP-416574,CDM,S27200284,LOCAL,0272,RC,,,both,,,2325.00,697.5,"MULTIPLAN [10600]",Multiplan,,1976.25,85,,,,,0,270.4,1976.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 20CM 7FR POLARIS ULTRA NAUTILUS ZIPWIRE .035IN 2",SUP-M006192140190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CIGNA [10200]","Cigna Local Plus",,746.45,,,,,,,162.27,1185.95,"percent of total billed charges",
"COIL EMBOLIZATION 5CM 5MM MREYE 3.1 LOOP PLATINUM ARTERIAL",SUP-G36405,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"KAISER [10500]",Kaiser,,558.93,67,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 20MM THORAX KNIT SOFT FLEXIBLE",SUP-M002020951200,CDM,C1768,HCPCS,0278,RC,,,both,,,2698.73,809.62,"CIGNA [10200]","Cigna Open Access",,1535.58,56.9,,,,,0,313.86,2293.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP SECTOR POROCOAT PINNACLE STERILE",SUP-121722048,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"MULTIPLAN [10600]",Multiplan,,5704.15,85,,,,,0,780.46,5704.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER QUICKPASS SUTURELASSO 30D SMALL STRAIGHT 7MM CANN",SUP-AR-6068-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,925.34,68,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NUCEL LG",SUP-NC-1002,CDM,S27800098,LOCAL,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]","Cigna Open Access",,6120.45,33.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +14 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.140,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SALINE 275-300ML 2 WAY CHECK VALVE SMOOTH",SUP-351-275SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL THK20MM S1 S2 PROXIMAL MODULAR ROTATE HINGE",SUP-64813220,CDM,C1776,HCPCS,0278,RC,,,both,,,6061.65,1818.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2782.3,45.9,,,,,0,704.97,5152.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TIGHTROPE II FLIPCUTTER III FIBERSTICK FIXATION",SUP-AR-1288RTIB-FC3,CDM,C1713,HCPCS,0278,RC,,,both,,,7643.48,2293.04,"AETNA [10100]","Aetna HMO/PPO",,6076.57,79.5,,1521.93,481.35,16760.95,30,888.94,6496.96,"percent of total billed charges",
"SCR BONE 3.5MM 11MM GEMINUS TITANIUM DISTAL VOLAR RADIUS",SUP-PANL-35110-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,623.70,187.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,73.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",72.54,530.15,"percent of total billed charges",
"STENT SURPASS ELITE 12MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE50012,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"PHCS [10601]",PHCS,,58565.22,70,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 40MM 2MM .018IN BALLOON DILATATION",SUP-R51002004L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,241.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRAMEDULLARY NAIL 360MM 11MM GAMMA 125D LONG R1.5",SUP-3525-1360S,CDM,C1713,HCPCS,0278,RC,,,both,,,13435.13,4030.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1592.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1562.51,11419.86,"percent of total billed charges",
"OBTR LAPAROSCOPIC 8MM DA VINCI S/SI ENDOWRIST SHORT STERILE",SUP-420023,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"PHCS [10601]",PHCS,,159.87,70,,,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 9CM 8.5FR BILIARY POLYETHYLENE TAPERED",SUP-G21621,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS [10001]","Blue Cross HMO",,247.67,39.2,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 105X19.5MM PRECISION THK1.33MM FALCON CRTDG LATEX",SUP-6725127105,CDM,S27200284,LOCAL,0272,RC,,,both,,,2580.23,774.07,"CIGNA [10200]",Cigna,,1754.56,68,,,,,0,300.08,2193.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 15MM 140CM .91-1.12MM 3MM CORONARY",SUP-RONYX30015W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"KAISER [10500]",Kaiser,,3644.13,67,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONE IRRIGATION VISI-FLOW STOMA",SUP-022736,CDM,S27000186,LOCAL,0270,RC,,,both,,,44.02,13.21,"PHCS [10601]",PHCS,,30.81,70,,,,,0,5.12,37.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 20MM 75CM 8MM VASCULAR METAL SUPERFICIAL",SUP-H74939293080270,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"AMERIGROUP MEDICAID [20100]",Amerigroup,,572.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 1MM 5FR 120CM SHEATH STERILE DISPOSABLE BLUE",SUP-G22124,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.98,40.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.58,113.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 5.5IN 12GA AORTIC ROOT ADULT ANTEGRADE INTRO",SUP-20012,CDM,S27200284,LOCAL,0272,RC,,,both,,,196.65,58.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,90.26,45.9,,,,,0,22.87,167.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR VIVACIT-E HH ELEVATED 50MM 32MM HIP",SUP-00885200932,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1192.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 5-0 P-1 18IN MONOFILAMENT UNDYED",SUP-Y490G,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.59,20.88,"CIGNA [10200]","Cigna Open Access",,39.6,56.9,,,,,0,8.09,59.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 7FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856200,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,745.73,68,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +24.5 DIOPTER MODIFIED C BICONVEX 13.5MM 6.5MM",SUP-MC50BD.245,CDM,V2632,HCPCS,0276,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,231.82,28.62,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM 12-14MM POD",SUP-RBYPOD14,CDM,S27800098,LOCAL,0278,RC,,,both,,,11661.00,3498.3,"CIGNA [10200]","Cigna Local Plus",,3673.22,31.5,,,,,0,1356.17,9911.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VASCADE MVP XL CLSR VASCULAR VENOUS",SUP-800-1012XL-10U,CDM,C1760,HCPCS,0278,RC,,,both,,,1800.00,540,"MULTIPLAN [10600]",Multiplan,,1530,85,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 235MM 15MM MODULAR RESTORATION BOW CONICAL HIP",SUP-6276-7-315,CDM,C1776,HCPCS,0278,RC,,,both,,,18758.25,5627.47,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7709.64,41.1,,6417.48,6417.48,6417.48,"1 through 10",2181.58,15944.51,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS 28CM 3CM 6FR .038IN 2 PIGTAIL",SUP-M006192134010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,551.07,45.9,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +12.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.125,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SHORT 72MM STAINLESS STEEL 2.7/3.5MM SCR 1 HOLE",SUP-02.117.601,CDM,C1713,HCPCS,0278,RC,,,both,,,6541.75,1962.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4448.39,68,,,,,0,760.81,5560.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 12MM 150MM KII ABDOMINAL ACCESS SYSTEM",SUP-CFS21,CDM,S27200284,LOCAL,0272,RC,,,both,,,119.63,35.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,81.35,68,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 SUPER REVO HI-FI",SUP-C6140HB,CDM,C1713,HCPCS,0278,RC,,,both,,,1568.48,470.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,185.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",182.41,1333.21,"percent of total billed charges",
"SUT MONOCRYL PLUS 5-0 PS-2 18IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP495G,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.40,19.62,"CIGNA [10200]","Cigna Open Access",,37.21,56.9,,,,,0,7.61,55.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14.8IN 24FR AORTA 3/8IN CURVE AUTO DILATE TIP",SUP-EZC24TA,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"KAISER [10500]",Kaiser,,325.62,67,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL SURGICAL 32MM LFIT C-TAPER -5MM HIP COCR HEAD",SUP-06-3299,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA [10200]",Cigna,,2126.84,68,,5873.17,5873.17,5873.17,"1 through 10",363.75,2658.55,"percent of total billed charges",
"AVENIR 10, 1.5 X 3 COMPLEX PICO COIL",SUP-10USC01503,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"PHCS [10601]",PHCS,,9152.85,70,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR NARROW LORDOTIC 12 DEGRE",SUP-12315,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7767.9,41.1,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +7 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200070,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CIGNA [10200]","Cigna Open Access",,580.72,56.9,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2.5MM DELTAXSFT 10 COIL",SUP-DLX100254,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"UHC [10700]","United Healthcare",,5730.42,63.3,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMUR HEAD FREEZE DRIED PROXIMAL",SUP-24A001,CDM,S27800098,LOCAL,0278,RC,,,both,,,5733.90,1720.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3899.05,68,,,,,0,666.85,4873.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 1MM 5FR 120CM SHEATH STERILE DISPOSABLE BLUE",SUP-G22124,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.98,40.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,91.11,68,,,,,0,15.58,113.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON DISECT LAPAROSCOPIC KII OVAL",SUP-C0K11,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"PHCS [10601]",PHCS,,1312.5,70,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VANSONNENBERG SUMP 30CM 14FR DRNG FLEXIMA POLYURETHANE",SUP-M001273010,CDM,C1729,HCPCS,0272,RC,,,both,,,1053.00,315.9,"KAISER [10500]",Kaiser,,705.51,67,,,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BN 1.2MM 4MM LEIBINGER UNV 2",SUP-50-12904,CDM,C1713,HCPCS,0278,RC,,,both,,,610.82,183.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,174.82,28.62,,,,,0,71.04,519.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 135X30MM EIKON LT LOW PROFILE NONCONDUCTIVE SURGICAL",SUP-C135,CDM,S27200284,LOCAL,0272,RC,,,both,,,7832.88,2349.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,928.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,910.96,6657.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 80CM 5FR CHG-B CURVE",SUP-G13560,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"AETNA [10100]","Aetna HMO/PPO",,188.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR .035IN 115CM LOCKING EXT LOC+ STERILE LATEX",SUP-52260,CDM,C1769,HCPCS,0272,RC,,,both,,,445.50,133.65,"FIRST HEALTH [10303]","First Health",,356.4,80,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LASER 25-27GA ILLUMINATION",SUP-14560,CDM,S27200284,LOCAL,0272,RC,,,both,,,2060.00,618,"CIGNA [10200]","Cigna Open Access",,1172.14,56.9,,,,,0,239.58,1751,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 72MM TAN X25 LOCK STERILE LIGHT GREEN 4.2MM",SUP-04.045.072TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"CATH PTS 80CM 3CM 8FR 25MM .035IN BALLOON DILATATION 2",SUP-PTS253,CDM,C1725,HCPCS,0272,RC,,,both,,,2259.00,677.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,262.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,262.72,1920.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 46MM TI",SUP-SPL-60460-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Local Plus",,866.7,53.5,,3978.14,359.25,3978.14,24,188.41,1377,"percent of total billed charges",
"FIBER LASER 365UM FLEXIVA HIGH POWER STERILE LATEX FREE",SUP-M006R8403920,CDM,S27200284,LOCAL,0272,RC,,,both,,,2303.10,690.93,"MULTIPLAN [10600]",Multiplan,,1957.64,85,,,,,0,267.85,1957.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY ESOPHAGEAL 5 60CM 20 LMA UNIQUE SOFT FLEXIBLE CUFF",SUP-1F8050,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.14,28.84,"CIGNA [10200]","Cigna Open Access",,54.7,56.9,,,,,0,11.18,81.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM ROUND SMALL HUB 10 FLUTE",SUP-AR-9300RBT,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,66.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSELECT DEMINERALIZED BONE MATRIX 1CC",SUP-309010,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",131.88,963.9,"percent of total billed charges",
"STENT VENOVO 100MM 120CM 20MM .035IN 3MM VASCULAR VENOUS",SUP-VENUL20100,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2762.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 7IN ANGLE UP INTERVERTEBRAL DISC 10X2MM CUSHING",SUP-280406,CDM,S27200284,LOCAL,0272,RC,,,both,,,1564.60,469.38,"AETNA [10100]","Aetna HMO/PPO",,1243.86,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,181.96,1329.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X22X12MM MODULUS 10D XL WIDE STERILE LATEX",SUP-1221245P2,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"NOVANET [10819]",Novanet,,17820,75,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 4MM AZUR .018IN",SUP-45-480405,CDM,S27800098,LOCAL,0278,RC,,,both,,,5361.30,1608.39,"MULTIPLAN [10600]",Multiplan,,4557.11,85,,,,,0,623.52,4557.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 9MM HIP DISTAL PMMA POS ANSWER IMPACT INTEGRAL",SUP-162656,CDM,C1713,HCPCS,0278,RC,,,both,,,1195.56,358.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,342.17,28.62,,,,,0,139.04,1016.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 11MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-011,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,561.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,550.92,4026.54,"percent of total billed charges",
"FREEFIX PROXIMAL HUMERUS PLATE 1 SLOT RIGHT TI",SUP-PHPF-1R,CDM,C1713,HCPCS,0278,RC,,,both,,,15732.00,4719.6,"BLUE CROSS [10001]","Blue Cross HMO",,6166.94,39.2,,957.42,156.86,7483.26,51,1829.63,13372.2,"percent of total billed charges",
"SPACER ALLOGRAFT 12.5X15X6MM PRECISION 7D TRAPEZOID SPINE",SUP-7406,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 12CM 5FR 2.1FR POLARIS ULTRA NAUTILUS ZIPWIRE .035",SUP-M006192112180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"NOVANET [10819]",Novanet,,1192.4,75,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 7MM GORE INTERING THIN WALL PTFE RADIAL",SUP-IRST07040040L,CDM,C1768,HCPCS,0278,RC,,,both,,,6348.00,1904.4,"CIGNA [10200]","Cigna Local Plus",,3396.18,53.5,,,,,0,738.27,5395.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.6MM 14MM VIP SPINE SELF DRILL VARIABLE ANGLE",SUP-171.014,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"AMERIGROUP MEDICAID [20100]",Amerigroup,,167.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",163.98,1198.5,"percent of total billed charges",
"BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC",519,MS-DRG,,,,,,,inpatient,,,112416.67,33725,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,13275.88,,"Case rate ($12,407.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,521.08, add-ons for qualifying new technology services are included. If operating cost exceeds $44,560.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,253.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,536.31. The transfer operating threshold is the transfer adjustment factor * $11,521.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $871.05. The transfer capital threshold is the transfer adjustment factor * $871.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,58397.84,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"RESVR PROS 75ML TITAN COLOPLAST LOCK-OUT INFLATABLE SELF",SUP-ER8075,CDM,C1813,HCPCS,0278,RC,,,both,,,15166.20,4549.86,"PHCS [10601]",PHCS,,10616.34,70,,,,,0,1763.83,12891.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 24CM 3CM 8FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155252050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS [10001]","Blue Cross HMO",,482.54,39.2,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 4 MM HEADLESS SCR",SUP-P20-915-4000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"KAISER [10500]",Kaiser,,672.95,67,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 70CM 15MM 4FR 6 WIRE STONE UROLOGY",SUP-GU6359,CDM,S27200284,LOCAL,0272,RC,,,both,,,479.36,143.81,"AETNA [10100]","Aetna HMO/PPO",,381.09,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.75,407.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RELIEVA SPIN 16MM 6MM 0D S-0 GUIDING SPHENOID SINUS",SUP-RSS0,CDM,S27200284,LOCAL,0272,RC,,,both,,,2400.00,720,"CIGNA [10200]",Cigna,,1632,68,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 15MM ENDO GIA TITANIUM EXTRA THICK TISSUE",SUP-SIGRADXT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2947.73,884.32,"PHCS [10601]",PHCS,,2063.41,70,,,,,0,342.82,2505.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 52MM 36MM ALTRX HIP",SUP-1221-36-052,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4750.65,45.9,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.7MM 5 2 STRAIGHT SUTUREFIX ULTRA SHOULDER 1",SUP-72203853,CDM,C1713,HCPCS,0278,RC,,,both,,,1607.45,482.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,737.82,45.9,,,,,0,186.95,1366.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONDUIT VALVE 29MM ATS OPEN PIVOT AORTIC PYROLYTIC CARBON",SUP-502AG29,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"PHCS [10601]",PHCS,,18522,70,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 615CC NATRELLE INSPIRA COHESIVE STERILE",SUP-SCX-615,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,878.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 240CM 5.5CM 7.5FR 12-13.5-15MM ESOPHAGUS",SUP-M00558690,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"KAISER [10500]",Kaiser,,1104.85,67,,,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9MM 100MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704999,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC",738,MS-DRG,,,,,,,inpatient,,,68404.17,20521.25,"UHC [10700]","United Healthcare",,42874.33,,"Fee schedule rate ($42,874.33). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,42874.33,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 110CM 6CM 5FR 8MM 7.5MM BALLOON DILATATION",SUP-4198060L,CDM,C1725,HCPCS,0272,RC,,,both,,,931.50,279.45,"UHC [10700]","United Healthcare",,589.64,63.3,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO S4 HYPERANGULATE LOW PROFILE BLADE GLIDESCOPE",SUP-0270-1084,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SOFSILK 0 C-16 30IN BRAIDED COATED BLACK NONABSORBABLE",SUP-SS-680,CDM,S27200284,LOCAL,0272,RC,,,both,,,3134.70,940.41,"AETNA [10100]","Aetna HMO/PPO",,2492.09,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,364.57,2664.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 800ML P6CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-8004BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5347.50,1604.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1530.45,28.62,,,,,0,621.91,4545.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DAT515. AS UVA VIVITY",SUP-DAT515,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"BLUE CROSS [10001]","Blue Cross HMO",,331.24,39.2,,,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Convert Nephrostomy Cath Exist",PX-361000415,CDM,50434,CPT,0361,RC,,,both,,,2658.10,797.43,"CIGNA [10200]","Cigna Open Access",,2658.1,,"Case rate ($3,307). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,309.14,2658.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 20X20CM SELF GRIP RESORBING",SUP-TSB2020,CDM,C1781,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"AETNA [10100]","Aetna HMO/PPO",,23790.38,79.5,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION",RX-365,CDM,,,0250,RC,00121-0646-16,NDC,both,473,ML,458.18,137.45,"UHC [10700]","United Healthcare",,290.03,63.3,,,,,0,53.29,389.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 34CM RIGHT TROCHANTERIC INTRAMEDULLARY 125D LONG",SUP-456.394S,CDM,C1713,HCPCS,0278,RC,,,both,,,12838.83,3851.65,"FIRST HEALTH [10303]","First Health",,10271.06,80,,,,,0,1493.16,10913.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 2MM 2.5MM 3MM 45MM ENDO GIA TITANIUM MEDIUM",SUP-SIG45AVM,CDM,S27200284,LOCAL,0272,RC,,,both,,,1308.72,392.62,"FIRST HEALTH [10303]","First Health",,1046.98,80,,,,,0,152.2,1112.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE SUCTION/IRRIGATION 10FT UNIVERSAL PLUS STRAIGHT",SUP-60-6010-003,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.14,58.54,"PHCS [10601]",PHCS,,136.6,70,,,,,0,22.69,165.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL GOLD 30MM 3.5MM SYNAPSE CURVE TITANIUM PREBENT",SUP-04.614.730,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"INSERT TIBIAL 3 28MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-328,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3633.78,27,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 1 SMALL HYPERINFLATION PEDIATRIC .5L 2 PLEAT BAG 1",SUP-HS4151,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.88,30.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.85,86.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC",099,MS-DRG,,,,,,,inpatient,,,46755.41,14026.62,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,9042.62,,"Case rate ($8,451.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,847.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,887.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,975.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,857.75. The transfer operating threshold is the transfer adjustment factor * $7,847.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.30. The transfer capital threshold is the transfer adjustment factor * $593.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,33976.89,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM QUICKFIX TITANIUM T8 PARTIAL THREAD",SUP-AR-8724-18,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"MULTIPLAN [10600]",Multiplan,,757.35,85,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 75MM 5.5MM EXPEDIUM PREBENT TITANIUM LINE",SUP-179771075,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY 2-5-2MM SPACING 7FR 95CM 2MM DUO",SUP-401914R,CDM,C1731,HCPCS,0272,RC,,,both,,,2100.00,630,"PHCS [10601]",PHCS,,1470,70,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 60MM 14MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-1513-14-060,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,979.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,961.36,7026.27,"percent of total billed charges",
"PIN HOLDING 1/8IN KNEE .75IN",SUP-201-78-15,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",50.59,369.75,"percent of total billed charges",
"GENRTR PULSE ATTESTA DR MRI IMPLANTABLE",SUP-ATDR01,CDM,C1785,HCPCS,0275,RC,,,both,,,15525.00,4657.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1805.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 12MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630312,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"AETNA [10100]","Aetna HMO/PPO",,10436.16,79.5,,10981.53,8986.79,12413.38,12,1526.7,11158.16,"percent of total billed charges",
"GWIRE ZIPWIRE VASCULAR STD STRAIGHT 150CM 3CM .035IN NITINOL",SUP-M00146155B1,CDM,C1769,HCPCS,0272,RC,,,both,,,486.00,145.8,"FIRST HEALTH [10303]","First Health",,388.8,80,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PUBOVAGINAL MONARC FEMALE",SUP-72403830,CDM,C1771,HCPCS,0278,RC,,,both,,,8280.00,2484,"FIRST HEALTH [10303]","First Health",,6624,80,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 32MM 144CM 2.5MM CORONARY STENT",SUP-H7493911632250,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"MULTIPLAN [10600]",Multiplan,,7771.13,85,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOFLOXACIN 500 MG TABLET",RX-18919,CDM,,,0250,RC,65862-0537-50,NDC,both,1,UN,72.83,21.85,"KAISER [10500]",Kaiser,,48.8,67,,,,,0,8.47,61.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 220MM 2MM BALLOON DILATATION NYBAX",SUP-H74939186202210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 17.5MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158126117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross PPO",,4380.42,39.2,,3949.44,3949.44,3949.44,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"GRAFT SKIN GRAFTJACKET XPRESS ACELLULAR DERMAL MATRIX SOFT",SUP-GJX,CDM,Q4113,HCPCS,0636,RC,,,both,,,12447.60,3734.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3895.13,,,,,,,1475.04,10580.46,"fee schedule",
"SCR BONE 8-6.5MM 35MM CREO SPINE 2 OUTER DIAMETER",SUP-5119.2237,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",601.85,4398.75,"percent of total billed charges",
"(EVAL) CATHETER TURNPIKE 150CM 2.2-2.9FR 1.6FR GUIDING LOW P",SUP-5639,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TENDYNE MITRAL VALVE SP 33M",SUP-TENDV-SP-33M-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"36FR X 3CM OPTILUME DCB AND INFLATION DEVICE",SUP-OPTBDL7006B,CDM,C1726,HCPCS,0272,RC,,,both,,,14455.50,4336.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT POLYFLEX 50MM 9MM 12MM AIRWAY POLYESTER SILICONE SELF",SUP-7009,CDM,C1887,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR",RX-113068,CDM,,,0637,RC,42858-0701-01,NDC,both,1,UN,6.83,2.05,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANNULA PERFUSION BIO-MEDICUS OD19 FR",SUP-96570-019,CDM,S27200284,LOCAL,0272,RC,,,both,,,2120.63,636.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 170CM 12CM 2.5MM BALLOON DILATATION HYDROPHILIC",SUP-G50324,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BEARING 71/75MMX14MM VANGUARD ARCOM KNEE POSTERIOR STABILIZE",SUP-183644,CDM,C1776,HCPCS,0278,RC,,,both,,,8259.30,2477.79,"FIRST HEALTH [10303]","First Health",,6607.44,80,,,,,0,960.56,7020.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 37MM 80CM 8MM 40MM BILIARY STAINLESS STEEL",SUP-PXB35-08-37-080,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"BLUE CROSS [10001]","Blue Cross PPO",,1711.86,39.2,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN FULL LENGTH MULTIPURPOSE A 2",SUP-8526121,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"UHC [10700]","United Healthcare",,44.89,63.3,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAVIGO STEERABLE INTRACARDIAC CATHETER INTRODUCER KIT, LARGE",SUP-S08574LL,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"AETNA [10100]","Aetna HMO/PPO",,3839.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 42X30X16MM 8D LARGE",SUP-7969816,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"CIGNA [10200]","Cigna Open Access",,11482.33,33.5,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW .37IN MICROCHOICE .79IN THK.03IN OSCILLATING",SUP-KM-3005,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"CIGNA [10200]","Cigna Open Access",,35.15,56.9,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECT 125CM 90CM 6FR BERENSTEIN CURVE DELIVERY SYSTEM",SUP-BMX9690BER125,CDM,S27200284,LOCAL,0272,RC,,,both,,,6727.50,2018.25,"FIRST HEALTH [10303]","First Health",,5382,80,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 200MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530200S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"UHC [10700]","United Healthcare",,1281.83,63.3,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLI KIT SS10 SAFESHEATH II 10FR 13CM",SUP-SS10,CDM,C1894,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEMORYGEL SMOOTH ROUND ULTRA HIGH BREAST IMPLANT 750 CC","SUP-3505750 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COLONIC L12CM DIA25MM CATHETER 10.2FR L230CM HOOK CROS",SUP-CNJF-25-120-230,CDM,C1876,HCPCS,0278,RC,,,both,,,15104.24,4531.27,"BLUE CROSS [10001]","Blue Cross HMO",,5920.86,39.2,,,,,0,1756.62,12838.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER QUICKPASS SUTURELASSO 25D 1.5MM CURVE RIGHT PRELOAD",SUP-AR-6068-25R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1445.85,433.75,"AETNA [10100]","Aetna HMO/PPO",,1149.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.15,1228.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR ERADLLT CURVE GUIDING NYLON CORONARY",SUP-LA6ERADLLT,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"FIRST HEALTH [10303]","First Health",,292.32,80,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Aerobic Presump ID Eye",PX-306000032,CDM,87070,CPT,0306,RC,,,both,,,335.35,100.6,"UHC [10700]","United Healthcare",,7.76,,,,,,,0.01,285.05,"fee schedule",
"SPLINT ORTHOPEDIC LARGE 7.75-8.5IN RIGHT WRIST THUMB SPICA",SUP-A6158,CDM,S27000186,LOCAL,0270,RC,,,both,,,224.55,67.36,"PHCS [10601]",PHCS,,157.19,70,,,,,0,26.12,190.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 2MM 14MM DCP STAINLESS STEEL SMALL BONE SELF TAPP",SUP-201.884,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"FIRST HEALTH [10303]","First Health",,564.28,80,,,,,0,82.03,599.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM OFFSET TAPER 32MM HIP PRIMARY COCR V40",SUP-6260-9-132,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"FIRST HEALTH [10303]","First Health",,2502.16,80,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 75MM 5MM KII FIOS 2 PACK ACCESS SYSTEM",SUP-CFF14,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,147.9,68,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 74X46X12MM NEXGEN LCCK 5-6 C-D STD KNEE",SUP-599404112,CDM,C1776,HCPCS,0278,RC,,,both,,,16256.40,4876.92,"UHC [10700]","United Healthcare",,10290.3,63.3,,8601.07,8395.67,8601.07,"1 through 10",1890.62,13817.94,"percent of total billed charges",
"(EVAL) LAMINAR IMPLANT SIZE (18MM)",SUP-FG-6033,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 150MM 150CM 7MM VASCULAR NICKEL",SUP-EVD35-07-150-150,CDM,C1876,HCPCS,0278,RC,,,both,,,8295.00,2488.5,"CIGNA [10200]","Cigna Local Plus",,4437.83,53.5,,,,,0,964.71,7050.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 34MM ORTHOLOC TITANIUM CORTICAL SELF TAP",SUP-59225534,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"MULTIPLAN [10600]",Multiplan,,846.86,85,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HUMERAL CUP - 36MM DIA X 10MM THK",SUP-5570-3610,CDM,C1776,HCPCS,0278,RC,,,both,,,7980.00,2394,"FIRST HEALTH [10303]","First Health",,6384,80,,,,,0,928.07,6783,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI FIELDER XT-A 190CM",SUP-APW14R009S,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"FIRST HEALTH [10303]","First Health",,907.2,80,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AIR/WATER BUTTON FLEXIBLE GI ENDOSCP OES-10/20/30",SUP-MB-196,CDM,S27200284,LOCAL,0272,RC,,,both,,,723.33,217,"PHCS [10601]",PHCS,,506.33,70,,,,,0,84.12,614.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 15MM 80CM 5MM 3.3-2.9FR 6FR LOW",SUP-1011492-15,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"NOVANET [10819]",Novanet,,4725,75,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOEHENDRA 200CM 3CM 6-4FR BALLOON DILATATION BILIARY",SUP-G21571,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"CIGNA [10200]",Cigna,,484.7,68,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Quadratus Lumborum (Ql) Block",PX-361000650,CDM,64999,CPT,0361,RC,,,both,,,2896.00,868.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2896,,"Case rate ($3,471.70). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,336.8,2896,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-55840016535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 58MM 135CM 8MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU1350858,CDM,C1874,HCPCS,0278,RC,,,both,,,15870.00,4761,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1880.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PLATE 6 74X50MM CEMENTED STEMMED MODULAR NEXGEN",SUP-00598004702,CDM,C1776,HCPCS,0278,RC,,,both,,,8643.60,2593.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2473.8,28.62,,,,,0,1005.25,7347.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 3CM 5FR STRAIGHT PANCREATIC POLYMER RADIOPAQUE",SUP-M00536250,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"BLUE CROSS [10001]","Blue Cross PPO",,250.59,39.2,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 40MM 80CM 8MM VASCULAR NITINOL PERIPHERAL",SUP-1012530-40,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 2.7MM RIGIDFIX BONE TISSUE BONE",SUP-256868,CDM,C1713,HCPCS,0278,RC,,,both,,,4533.30,1359.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3082.64,68,,,,,0,527.22,3853.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM SPINE REVOLVING",SUP-185.466,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"KAISER [10500]",Kaiser,,6396.39,67,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 54.7CM 8MM MEGA DA VINCI S/SI ENDOWRIST 30- D 1.3",SUP-420194,CDM,S27000186,LOCAL,0270,RC,,,both,,,1732.50,519.75,"CIGNA [10200]",Cigna,,1178.1,68,,,,,0,201.49,1472.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM LOW PROFILE SCREWS TITANIUM T15 FULL",SUP-AR-8935-18,CDM,C1713,HCPCS,0278,RC,,,both,,,486.00,145.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,57.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,56.52,413.1,"percent of total billed charges",
"HC So Gsap Cll Fr Mcrstl Ins",PX-310000022,CDM,81464,CPT,0310,RC,,,both,,,5525.00,1657.5,"CIGNA [10200]","Cigna Open Access",,3143.73,56.9,,,,,0,0.01,4696.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 135CM 40MM 6MM BALLOON DILATATION PACLITAXEL OTW",SUP-H74939419600410,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1022.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT FLOWABLE 2.5CC OSTEOAMP SELECT",SUP-OAFL-025,CDM,C1713,HCPCS,0278,RC,,,both,,,7427.64,2228.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,880.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,863.83,6313.49,"percent of total billed charges",
"CATH ULTRAVERSE 018 150CM 6CM 3MM BALLOON DILATATION",SUP-U815036,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +25 DIOPTER 13MM 6MM POSTERIOR CHMBR 3 PIECE","SUP-Z9002 25.0",CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"FIRST HEALTH [10303]","First Health",,874.8,80,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 CURVE PLUS 12.5MM KNEE XLK FIX BEARING",SUP-970422,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AETNA [10100]","Aetna HMO/PPO",,8883.77,79.5,,10981.53,8986.79,12413.38,12,1299.6,9498.37,"percent of total billed charges",
"SCR BONE 4.2MM 14MM XTEND SPINE FIX ANGLE SELF TAP",SUP-161.714,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]",Cigna,,688.5,68,,1831.33,1831.33,1831.33,16,117.75,860.63,"percent of total billed charges",
"GRAFT BONE CORTICAL CANCELLOUS ALLOGRAFT RING 6MM",SUP-270060,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,inpatient,,,56693.48,17008.04,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,26110.66,,"of the excess amount. Final payment is multiplied by 106%.",,,,0,2462,52960.31,"case rate","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PALMPUMP KIWI OMNICUP VACUUM EXTRACTION NEONATE",SUP-VAC-6000MT,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"CIGNA [10200]","Cigna Open Access",,173.26,56.9,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 26CM 6FR URETERAL",SUP-M0061456140,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,178.94,28.62,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 4FR JUDKINS RIGHT 4 CURVE",SUP-538421,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"CIGNA [10200]",Cigna,,60.87,68,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIG GLEN CT GD/BONE MODEL SET",SUP-110004347,CDM,C1776,HCPCS,0278,RC,,,both,,,4200.00,1260,"BLUE CROSS [10001]","Blue Cross PPO",,1646.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",488.46,3570,"percent of total billed charges",
"STENT ADVANIX 3CM 5FR STRAIGHT PANCREATIC PLASTIC TEMPORARY",SUP-M00536370,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"NOVANET [10819]",Novanet,,479.44,75,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 61MM STEALTH FOGARTY ATRAUMAX 3 SOFT STERILE",SUP-G-6150,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"MULTIPLAN [10600]",Multiplan,,192.27,85,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 10 MICRO RIGHT ANGLE 7.5IN RETRACTION BLUNT 3MM",SUP-RN6210,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 26MM STAINLESS STEEL T8 CORTEX TUBE STARDRIVE",SUP-201.776TS,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"CIGNA [10200]","Cigna Open Access",,271,56.9,,1144.80,304.56,2275.09,66,55.39,404.84,"percent of total billed charges",
"SCR BONE 3.5MM 17MM SPINE CERVICAL ANTERIOR SELF DRILL",SUP-18008117,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,396.9,39.2,,957.42,570.23,957.42,28,117.75,860.63,"percent of total billed charges",
"VALVE AORTIC 26MM SAPIEN HEART TRANSCATHETER RETROFLEX 3",SUP-9100RF326A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,76137.75,41.1,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.040,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"BLUE CROSS [10001]","Blue Cross PPO",,80.89,39.2,,957.42,570.23,957.42,28,24,175.41,"percent of total billed charges",
"STEM FEMORAL 10IN 18MM REDUCE NECK SOL SYSTEM POROUS 12/14",SUP-157210180,CDM,C1776,HCPCS,0278,RC,,,both,,,39412.80,11823.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10641.46,27,,,,,0,4583.71,33500.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH ARTHROSCOPIC STD KNOTLESS DISPOSABLE CROSSFT 4.75/5.5",SUP-CFK-DBP4755,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 30MM 4.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG45030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1785,68,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 120MM 12-14MM 13FR 10FR TRIVASCULAR OVATION",SUP-TV-IL1412120-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3956.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET GRAVITY FLOW LEVEL 1 IRRIGATION 300 MMHG DISPOSABLE",SUP-IR-600,CDM,S27200284,LOCAL,0272,RC,,,both,,,400.40,120.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,164.56,41.1,,,,,0,46.57,340.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 8 X 20 HELICAL FILLING COIL",SUP-10HFL-08020,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"CIGNA [10200]","Cigna Local Plus",,4795.26,53.5,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD LITHO 5FR ELECTROHYDRAULIC",SUP-21371505,CDM,S27200284,LOCAL,0272,RC,,,both,,,1391.18,417.35,"UHC [10700]","United Healthcare",,880.62,63.3,,,,,0,161.79,1182.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FG GATEWAY OTW  US 3.00MM X 9MM",SUP-M0032072209300,CDM,C1725,HCPCS,0272,RC,,,both,,,9423.88,2827.16,"AETNA [10100]","Aetna HMO/PPO",,7491.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1096,8010.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER PIN 7.5IN 1.6MM CANNULATED END CUT",SUP-14-3030,CDM,S27200284,LOCAL,0272,RC,,,both,,,966.01,289.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,114.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.35,821.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 100MM 125CM 7MM 6FR BILIARY NITINOL",SUP-G50168,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,721.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT CRUCIATE RETAIN GENESIS II LEGION",SUP-71421227,CDM,C1776,HCPCS,0278,RC,,,both,,,28831.95,8649.58,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11532.78,40,,,,,0,3353.16,24507.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U235,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,341.96,45.9,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 65MM 9.4MM 15MM 5MM CUFFLESS REUSABLE INNER CANN",SUP-4CFN,CDM,S27200284,LOCAL,0272,RC,,,both,,,312.85,93.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,36.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.38,265.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL CURVE 9IN BONE REDUCTION SPEED LOCK",SUP-35-1147,CDM,S27200284,LOCAL,0272,RC,,,both,,,1974.30,592.29,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 170CM 8CM 3MM BALLOON DILATATION HYDROPHILIC",SUP-G50330,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,MODERATE",613,APR-DRG,,,,,,,inpatient,,,91511.91,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $15,255.75. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to (Final Base Payment plus Newborn Screen Add-on Amount $63.00) multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($82,426.58) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 Newborn; Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL 2 18IN MONOFILAMENT TIE 12 STRAND SILVER",SUP-DS24,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.11,21.03,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER GUIDING 6FR DIA0.07IN MULTIPURPOSE 2 CURVE PTFE LIN",SUP-H74938969390,CDM,C1725,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SMOOTH PEG LOCKING 6.0MM X 40MM TI",SUP-SPL-60400-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1101.6,68,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 36MM TIBIAL METAPHYSEAL META-NAIL INTRAMEDULLARY",SUP-71655136,CDM,C1713,HCPCS,0278,RC,,,both,,,15548.46,4664.54,"FIRST HEALTH [10303]","First Health",,12438.77,80,,,,,0,1808.29,13216.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM MITRAL SEMIRIGID MEMO 3D",SUP-SMD26,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"MULTIPLAN [10600]",Multiplan,,10850.25,85,,,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL 1-2.25MM ARTERY BLACK",SUP-B-3AB,CDM,S27200284,LOCAL,0272,RC,,,both,,,547.11,164.13,"CIGNA [10200]","Cigna Open Access",,311.31,56.9,,,,,0,63.63,465.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 36MM TIBIAL METAPHYSEAL META-NAIL INTRAMEDULLARY",SUP-71655136,CDM,C1713,HCPCS,0278,RC,,,both,,,15548.46,4664.54,"AETNA [10100]","Aetna HMO/PPO",,12361.03,79.5,,1521.93,481.35,16760.95,30,1808.29,13216.19,"percent of total billed charges",
"INSRT TIBIAL 5 13MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P513,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"NOVANET [10819]",Novanet,,6266.93,75,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE CORNEAL 8.5MM STAINLESS STEEL TREPHINE STERILE LATEX",SUP-K20-2160,CDM,S27200284,LOCAL,0272,RC,,,both,,,430.65,129.19,"UHC [10700]","United Healthcare",,272.6,63.3,,,,,0,50.08,366.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS 9FR MBA MERIT METAL LARGE BORE GWIRE INSRT",SUP-MAP453,CDM,S27200284,LOCAL,0272,RC,,,both,,,219.07,65.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.48,186.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM MAS SPINE CANNULATED EXT TAB 4.75MM ROD",SUP-54850014540,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"PHCS [10601]",PHCS,,4588.5,70,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 65MM VALOR HINDFOOT FUSION SYSTEM",SUP-4151150065,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,200.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",200.62,1466.25,"percent of total billed charges",
"LINER ACETABULAR G7 H 50MM COCR HIP 2 MOBILITY",SUP-110024466,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"CIGNA [10200]",Cigna,,5181.07,40,,5873.17,5873.17,5873.17,"1 through 10",1506.4,11009.78,"percent of total billed charges",
"CNTRLZR STEM 9MM INVIS HIP FEMUR PMMA RECONSTRUCTION",SUP-71313209,CDM,C1776,HCPCS,0278,RC,,,both,,,972.00,291.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO 1000093001 OPTISEAL GLBL6FR13CM",SUP-1000093001,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY NDL GASTROSCOPIC YELLOW CHANNEL 160CM 1.8MM 2MM",SUP-M00513453,CDM,S27200284,LOCAL,0272,RC,,,both,,,297.96,89.39,"MULTIPLAN [10600]",Multiplan,,253.27,85,,,,,0,34.65,253.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 80MM 135CM 6MM 5FR VASCULAR NITINOL LOW",SUP-5F060803CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4821.03,41.1,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 80CM 4FR SOS OMNI 2 CURVE ANGIOGRAPHIC DURATION",SUP-H787117140255,CDM,C1887,HCPCS,0272,RC,,,both,,,466.56,139.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,317.26,68,,,,,0,54.26,396.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 200MM 3MM STERILE DISPOSABLE",SUP-7020140,CDM,C1713,HCPCS,0278,RC,,,both,,,955.80,286.74,"CIGNA [10200]",Cigna,,649.94,68,,1831.33,1831.33,1831.33,16,111.16,812.43,"percent of total billed charges",
"TACK ORTHOPEDIC CLAW II 3DSI FOOT ANKLE PLATE POLYAXIAL",SUP-40250010,CDM,C1713,HCPCS,0278,RC,,,both,,,696.60,208.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,199.37,28.62,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Splint Leg Full Pneu Prefb Ots",PX-E27400061,CDM,L4370,HCPCS,0274,RC,,,both,,,1683.00,504.9,"CIGNA [10200]","Cigna Local Plus",,900.41,53.5,,,,,0,138.46,1430.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL L HOOK LATEX 33CM 5MM DAVOL",SUP-5600160,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"CIGNA [10200]","Cigna Open Access",,193.06,56.9,,,,,0,39.46,288.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC LARGE 8IN RIGHT WRIST BLACK",SUP-A120207,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.29,17.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.78,49.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VOLT, AGILIS 13F MED CURVE, ICE",SUP-K-VOLT-V-M,CDM,C1732,HCPCS,0272,RC,,,both,,,62700.00,18810,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"GRAFT SKIN OMEGA3 MARIGEN 16MM CIRCULAR FISH SKIN STERILE",SUP-50200S16B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 5X5CM SOLID SHEET NONSTERILE LATEX FREE",SUP-PAC25,CDM,Q4201,HCPCS,0636,RC,,,both,,,7521.00,2256.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET THORACENTESIS 30IN 15GA PORTEX MALE ADPTR SLIDE CLAMP",SUP-PTX465348,CDM,C1729,HCPCS,0272,RC,,,both,,,48.66,14.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 26CM 6FR .038",SUP-M006192133120,CDM,C2617,HCPCS,0278,RC,,,both,,,1528.96,458.69,"FIRST HEALTH [10303]","First Health",,1223.17,80,,,,,0,177.82,1299.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FS 40MM UTERINE DISTAL CUP TEXTURE HANDLE SOUND LATCH",SUP-110040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1539.00,461.7,"NOVANET [10819]",Novanet,,1154.25,75,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 116MM PRIMARY ANTHOLOGY POROUS 131D 9 STD",SUP-71356009,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"FIRST HEALTH [10303]","First Health",,26512.92,80,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE WALKING LARGE STD FOOT ANKLE 1 PIECE 2 LAYER MEMORY",SUP-SL8001-07,CDM,S27000186,LOCAL,0270,RC,,,both,,,228.03,68.41,"UHC [10700]","United Healthcare",,144.34,63.3,,,,,0,26.52,193.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SALINE 275-300ML 2 WAY CHECK VALVE SMOOTH",SUP-351-275SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 23MM 143CM 2.5MM CORONARY EVEROLIMUS ELUTING",SUP-1009539-23,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"CIGNA [10200]","Cigna Open Access",,5457.28,56.9,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 12/14 TITANIUM MODULAR HEAD TPR 4",SUP-71344245,CDM,C1776,HCPCS,0278,RC,,,both,,,1885.50,565.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,223.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,219.28,1602.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN AL.75 CURVE GUIDING CORONARY",SUP-LA7AL75SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 9MM 33MM SYMMETRIC TRIATHLON X3 KNEE",SUP-5550-G-339,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"MULTIPLAN [10600]",Multiplan,,3670.1,85,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC",390,MS-DRG,,,,,,,inpatient,,,19097.53,5729.26,"UHC [10700]","United Healthcare",,13566.82,,"Fee schedule rate ($13,566.82). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,3374.47,13566.82,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 80MM 80CM 7MM VASCULAR NITINOL PERIPHERAL",SUP-1012529-80,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"MULTIPLAN [10600]",Multiplan,,3519,85,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 82MM 16-10MM 14FR ENDURANT II ABDOMINAL",SUP-ETLW1610C82E,CDM,C1876,HCPCS,0278,RC,,,both,,,28416.15,8524.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3304.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3304.8,24153.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 80MM 80CM 7MM VASCULAR NITINOL PERIPHERAL",SUP-1012529-80,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross PPO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 5X5CM SOLID SHEET NONSTERILE LATEX FREE",SUP-PAC25,CDM,Q4201,HCPCS,0636,RC,,,both,,,7521.00,2256.3,"FIRST HEALTH [10303]","First Health",,6016.8,80,,,,,0,204.57,6392.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 30MM 4MM MAXTORQUE",SUP-MSD01040030S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"CIGNA [10200]","Cigna Local Plus",,758.36,53.5,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG 232X12X3.7MM STAINLESS STEEL 3.5MM SCR SMALL",SUP-241.923S,CDM,C1713,HCPCS,0278,RC,,,both,,,10695.00,3208.5,"PHCS [10601]",PHCS,,7486.5,70,,,,,0,1243.83,9090.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 75CM 6MM 20MM",SUP-H74938046620750,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"CIGNA [10200]","Cigna Open Access",,2840.45,56.9,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PG PRO 2.8FR/140CM/STRAIGHT",SUP-PGP28140STR,CDM,C1887,HCPCS,0272,RC,,,both,,,3697.50,1109.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1519.67,41.1,,,,,0,430.02,3142.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 1 KNEE PRIMARY CEMENT",SUP-5520B100,CDM,C1776,HCPCS,0278,RC,,,both,,,7151.76,2145.53,"CIGNA [10200]","Cigna Open Access",,4069.35,56.9,,5302.19,4377.88,6578.61,27,831.75,6079,"percent of total billed charges",
"GRAFT BONE DIVERGENCE-L 15X9.4X10MM ANTERIOR OBLIQUE LUMBAR",SUP-736520,CDM,S27800098,LOCAL,0278,RC,,,both,,,9177.00,2753.1,"AETNA [10100]","Aetna HMO/PPO",,7295.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL AMPLATZ PTFE POLYETHYLENE SET RADIOPAQUE 20-30",SUP-G57460,CDM,C1726,HCPCS,0272,RC,,,both,,,2029.50,608.85,"FIRST HEALTH [10303]","First Health",,1623.6,80,,,,,0,236.03,1725.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 17MM 42MM SHOULDER ANATOMIC RESTORATION",SUP-AR-9142-17P,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"NOVANET [10819]",Novanet,,5940,75,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 695CC",SUP-SSZ-F695,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,176.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 70MM KNEE LEFT POSTERIOR STABILIZE OPEN BOX",SUP-183326,CDM,C1776,HCPCS,0278,RC,,,both,,,40793.76,12238.13,"CIGNA [10200]",Cigna,,16317.5,40,,5873.17,5873.17,5873.17,"1 through 10",4744.31,34674.7,"percent of total billed charges",
"MONTEREY AL STAND-ALONE ANTERIOR LUMBAR ANTERIOR LUMBAR CAGE",SUP-480110531,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14241.15,41.1,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION LIFECARE 0.9% SODIUM CHLORIDE 2L LATEX FREE",SUP-07972-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN LEFT CORONARY BYPASS CURVE",SUP-DXT5LCB,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"MULTIPLAN [10600]",Multiplan,,59.16,85,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 93MM 3.5MM SCR 4 HOLE LCP BONE TIBIA LEFT PROXIMAL",SUP-239.955S,CDM,C1713,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"BLUE CROSS [10001]","Blue Cross PPO",,3408.05,39.2,,957.42,570.23,957.42,28,1011.11,7389.9,"percent of total billed charges",
"TROCAR LAPAROSCOPIC Z THREAD 100MM 12MM KII FIOS FIRST ENTRY",SUP-CTF74,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA [10200]",Cigna,,124.24,68,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U235,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA [10200]","Cigna Open Access",,423.91,56.9,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING EXTERNAL FIXATION 150MM MAXFRAME 5/8 ALUMINUM",SUP-03.312.650,CDM,C1713,HCPCS,0278,RC,,,both,,,7754.08,2326.22,"CIGNA [10200]","Cigna Local Plus",,4148.43,53.5,,3978.14,359.25,3978.14,24,901.8,6590.97,"percent of total billed charges",
"GWIRE CORDIS EMERALD VASCULAR STRAIGHT 150CM 7CM .025IN PTFE",SUP-502549,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL SPIN GUARD FEMORAL METATARSOPHALANGEAL",SUP-P01-900-1902,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"CIGNA [10200]",Cigna,,1326,68,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ULTRAFLEX 30MM 14MM 18FR 4.1MM TRACHEOBRONCHIAL DISTAL",SUP-M00576320,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X10X10-17MM RISE 15D",SUP-193.142,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PHCS [10601]",PHCS,,19845,70,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 014 150CM 8CM 3MM BALLOON DILATATION",SUP-U415038,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 80CM 23CM BLUE HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-8F-23-035,CDM,C1894,HCPCS,0272,RC,,,both,,,117.45,35.23,"NOVANET [10819]",Novanet,,88.09,75,,,,,0,13.66,99.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 118MM PRIMARY ANTHOLOGY POROUS 131D 10 HIGH",SUP-71356110,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3927.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 20MM 4MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012411-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 9IN ULTRA MICROVASCULAR NDL STAINLESS STEEL TUNGSTEN",SUP-55-2522,CDM,S27200284,LOCAL,0272,RC,,,both,,,2167.80,650.34,"KAISER [10500]",Kaiser,,1452.43,67,,,,,0,252.12,1842.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transcath Intraop Microinf",PX-361000641,CDM,C9759,HCPCS,0361,RC,,,both,,,5464.00,1639.2,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,635.46,4644.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 100MM TITANIUM 1.5MM SCREWS MINI FRAGMENT SET 20 HOLE",SUP-446.19,CDM,C1713,HCPCS,0278,RC,,,both,,,2865.60,859.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1948.61,68,,,,,0,333.27,2435.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC .062IN TROCAR TIP DISPOSABLE 5MM SCR",SUP-AR-8750K,CDM,C1713,HCPCS,0278,RC,,,both,,,130.50,39.15,"CIGNA [10200]",Cigna,,88.74,68,,1831.33,1831.33,1831.33,16,15.18,110.93,"percent of total billed charges",
"ALLOGRAFT FLOWABLE 10CC OSTEOAMP SELECT",SUP-OAFL-10,CDM,C1713,HCPCS,0278,RC,,,both,,,18909.45,5672.83,"FIRST HEALTH [10303]","First Health",,15127.56,80,,,,,0,2199.17,16073.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Quest Yeast Susceptibility",PX-306000245,CDM,87186,CPT,0306,RC,,,both,,,1074.00,322.2,"CIGNA [10200]","Cigna Open Access",,19.03,,,,,,,0.01,912.9,"fee schedule",
"STENT CONTOUR VL 22-30CM 3CM 6FR .035IN PIGTAIL CURVE",SUP-M006180156050,CDM,C2617,HCPCS,0278,RC,,,both,,,1077.22,323.17,"CIGNA [10200]","Cigna Local Plus",,576.31,,,,,,,125.28,915.64,"percent of total billed charges",
"CATH RANGER 150CM 120MM 7MM BALLOON DILATATION PACLITAXEL",SUP-H74939419701210,CDM,C2623,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"NOVANET [10819]",Novanet,,6986.25,75,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +19 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.190,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .047IN JUDKINS LEFT 4.5",SUP-534517T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,63.6,68,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X9-6.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-14809,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4005.45,27,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM NCB PROTASUL-64 3.5MM SELF TAP 2 LEAD",SUP-0203150034,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,852.02,45.9,,,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 50MM MATRIX TITANIUM SPINE THORACOLUMBAR",SUP-04.606.650,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,3978.14,359.25,3978.14,24,641.98,4692,"percent of total billed charges",
"CUFF TRNQT 34IN ATS 1 PORT 1 BLADDER LUER LOCK CNCT STERILE",SUP-60707505600,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.02,90.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,35.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.01,255.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BALL 37CM 8FR NONSTERILE REUSABLE",SUP-257F8,CDM,S27000186,LOCAL,0270,RC,,,both,,,833.98,250.19,"CIGNA [10200]",Cigna,,567.11,68,,,,,0,96.99,708.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Vad Tunl W Port Age 5 Yr/>",PX-361000111,CDM,36561,CPT,0361,RC,,,both,,,8433.66,2530.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4752,,"Case rate ($4,752). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,980.83,8239,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 26MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"BLUE CROSS [10001]","Blue Cross HMO",,1029,39.2,,9776.84,9776.84,9776.84,"1 through 10",305.29,2231.25,"percent of total billed charges",
"BAG DRNG 9.5IN NATURAL RUBBER BILE 2 ADJUSTABLE BELT ADPTR",SUP-0015850,CDM,S27000186,LOCAL,0270,RC,,,both,,,46.46,13.94,"PHCS [10601]",PHCS,,32.52,70,,,,,0,5.4,39.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 16MM 140CM 3MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927416300,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit Level 5 W Proc",PX-450000320,CDM,99285,CPT,0450,RC,,,both,,,2982.77,894.83,"MULTIPLAN [10600]",Multiplan,,2535.35,85,,,,,0,419.55,2535.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING MYOCARDIAL 2 DISCRETE ELECTRD BIPOLAR CURVE NDL",SUP-6495,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTIGRAFT CERVICAL LARGE PARALLEL 14X14.5X8MM",SUP-VG2C-DR8P,CDM,S27800098,LOCAL,0278,RC,,,both,,,6077.73,1823.32,"CIGNA [10200]","Cigna Open Access",,3458.23,56.9,,,,,0,706.84,5166.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL OXFORD C KNEE LEFT MEDIAL COCRMO",SUP-154722,CDM,C1776,HCPCS,0278,RC,,,both,,,11195.94,3358.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1326.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1302.09,9516.55,"percent of total billed charges",
"PLATE SMALL OLIF25 2 HOLE BONE SPINE STERILE",SUP-2140001,CDM,C1713,HCPCS,0278,RC,,,both,,,17250.00,5175,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6900,40,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY SHARP JAW RADIOPAQUE 104CM 7FR 2.3MM STAINLESS",SUP-504300L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"PHCS [10601]",PHCS,,992.25,70,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE RIB SEG THK1-20MM ALLOGRAFT FROZEN 50-300X5-30MM",SUP-450010,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 4 6MM KNEE AOX CRUCIATE RETAIN ROTATE PLATFORM",SUP-151630406,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5250.9,40,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIPRASIDONE 20 MG CAPSULE",RX-29778,CDM,,,0637,RC,00904-6269-45,NDC,both,1,UN,16.65,4.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7.64,45.9,,,,,0,1.94,14.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS ENDOSCOPIC L230CM DIA2.4MM OPENING 8MM GRASPING ALLI",SUP-M00527451,CDM,S27200284,LOCAL,0272,RC,,,both,,,625.73,187.72,"PHCS [10601]",PHCS,,438.01,70,,,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOGRAPHIC VITEK CEREBRAL CURVE 5FR 125CM BRAID",SUP-G12082,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.55,134.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,205.88,45.9,,,,,0,52.17,381.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 5MM COOLCUT FLUSHCUT 8 FLUTE ROUND STERILE",SUP-AR-8500RBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"MULTIPLAN [10600]",Multiplan,,426.53,85,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 27MM 10MM STAINLESS STEEL 1.1MM LONG THREAD",SUP-02.226.127,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,194.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,191.34,1398.42,"percent of total billed charges",
"GS 90, 95 CM, STRAIGHT, DISTAL",SUP-GS9095SD,CDM,C1887,HCPCS,0272,RC,,,both,,,3573.98,1072.19,"UHC [10700]","United Healthcare",,2262.33,63.3,,,,,0,415.65,3037.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM MULTILOC TITANIUM NIOBIUM ALUMINUM 3.8MM",SUP-04.019.040S,CDM,C1713,HCPCS,0278,RC,,,both,,,1747.20,524.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,500.05,28.62,,,,,0,203.2,1485.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 7.0 MM X 80 MM X 130 CM",SUP-IPU07008013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"PHCS [10601]",PHCS,,5651.1,70,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 55MM 4MM STAINLESS STEEL ROUND 8 FLUTED",SUP-1608006137,CDM,S27000186,LOCAL,0270,RC,,,both,,,375.49,112.65,"UHC [10700]","United Healthcare",,237.69,63.3,,,,,0,43.67,319.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX12MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183542,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"CIGNA [10200]",Cigna,,5181.07,40,,5873.17,5873.17,5873.17,"1 through 10",1506.4,11009.78,"percent of total billed charges",
"SUT VICRYL PLUS MULTIPASS 5-0 PC-1 18IN BRAID ANTIBACTERIAL",SUP-VCP834G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.48,45.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET",RX-10491,CDM,,,0637,RC,10006-0700-28,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 30CM 3CM 7FR .038IN PIGTAIL CURVE STRAIGHT LOW",SUP-M006180235010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"KAISER [10500]",Kaiser,,717.4,67,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO S2.5 HYPERANGULATE LOW PROFILE BLADE GLIDESCO",SUP-0270-1091,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.40,131.22,"KAISER [10500]",Kaiser,,293.06,67,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO ORTHOPEDIC ONE-STEP XPANDER 15 3 SYSTEM II",SUP-KPX153PB,CDM,S27200284,LOCAL,0272,RC,,,both,,,12130.56,3639.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1410.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1410.78,10310.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 22GA 9IN CHIBA CENTIMETER MARKING STOP",SUP-MCN2203,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"AETNA [10100]","Aetna HMO/PPO",,98.21,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR PULSE WAVEWRITER ALPHA 32",SUP-SC-1232,CDM,C1820,HCPCS,0278,RC,,,both,,,99750.00,29925,"UHC [10700]","United Healthcare",,63141.75,63.3,,,,,0,11600.93,84787.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 10MM 3.5MM EMBOLIZATION BRAID SOFT",SUP-PED-350-10,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"UHC [10700]","United Healthcare",,48709.35,63.3,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 90MM 16MM 5.4MM 14FR ZENITH SPIRAL-Z",SUP-G55239,CDM,C1874,HCPCS,0278,RC,,,both,,,19435.50,5830.65,"MULTIPLAN [10600]",Multiplan,,16520.18,85,,,,,0,2260.35,16520.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 60MM 130CM 5MM 6FR .035IN VASCULAR NITINOL",SUP-EX050603CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"BLUE CROSS [10001]","Blue Cross PPO",,4598.16,39.2,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.180 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.180,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 25GA SILICONE DISPOSABLE",SUP-8065149525,CDM,S27200284,LOCAL,0272,RC,,,both,,,201.93,60.58,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.48,171.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VENTURA INTERATRIAL SHUNT",SUP-VIS-01-5.0-14F,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 5-0 18IN BRAID TIE 12 STRAND PRECUT",SUP-A182H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM 12MM PRESS FIT UNIVERSAL FLUTE KNEE",SUP-867426,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5508.41,68,,,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Progesterone",PX-301000373,CDM,84144,CPT,0301,RC,,,both,,,181.45,54.43,"BLUE CROSS [10001]","Blue Cross PPO",,26.65,,"Fee schedule rate ($26.65).",,,,0,0.18,154.23,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Upr Ext Nonjnt WO Cntrst",PX-610000024,CDM,73218,CPT,0610,RC,,,both,,,3640.89,1092.27,"KAISER [10500]",Kaiser,,2439.4,67,,,,,0,423.44,3094.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN AMPLATZ RIGHT",SUP-534648T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"PHCS [10601]",PHCS,,60.9,70,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE VITAMIN E POLY LINERS INSERTS",SUP-CAP-U-VE,CDM,C1776,HCPCS,0278,RC,,,both,,,1875.00,562.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 10.5MM CEMENTLESS MODULAR AML POROUS 40MM",SUP-155402106,CDM,C1776,HCPCS,0278,RC,,,both,,,15374.88,4612.46,"FIRST HEALTH [10303]","First Health",,12299.9,80,,,,,0,1788.1,13068.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +10 DIOPTER MODIFIED C CONVEXOPLANO 13.5MM 5.5MM",SUP-MTA5U0.100,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY IV SFT STRG 59CM .014IN",SUP-6601,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.8MM 310MM KIRSCHNER K WIRE INTRAMEDULLARY",SUP-0152-0218S,CDM,C1713,HCPCS,0278,RC,,,both,,,836.89,251.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,97.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",97.33,711.36,"percent of total billed charges",
"CATH SABERX 200CM 80MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520080L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORTIVA SILHOUETTE 16X20 CM",SUP-UTD1620,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]","Cigna Open Access",,21004.5,33.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 180MM 4.2MM T2 AO",SUP-18064270S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1319.98,395.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,897.59,68,,,,,0,153.51,1121.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2MM TARGET NANO 360D DETACHABLE",SUP-M0035442030,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4039.61,28.62,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 130MM 5MM STERLING OVAL LARGE HUB BURR REDUCED",SUP-H9103RH,CDM,S27200284,LOCAL,0272,RC,,,both,,,564.25,169.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,383.69,68,,,,,0,65.62,479.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ASPIRA PLEURAL DRSG LATEX FREE DISPOSABLE",SUP-4991503,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"UHC [10700]","United Healthcare",,126.66,63.3,,,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG HYDROCOLLOID PLUROGEL WATER SOLUBLE NONIONIC PRIMARY",SUP-PGL050TUBEH,CDM,S27000186,LOCAL,0270,RC,,,both,,,777.52,233.26,"CIGNA [10200]","Cigna Local Plus",,415.97,53.5,,,,,0,90.43,660.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION 10MM ENDOBUTTON CL ULTRA PRELOAD BRAID SUT",SUP-72203331,CDM,C1713,HCPCS,0278,RC,,,both,,,2362.50,708.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1084.39,45.9,,,,,0,274.76,2008.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 MEDIUM 36MM HIP ACETABULUM BIOLOX",SUP-00877503602,CDM,C1776,HCPCS,0278,RC,,,both,,,8526.00,2557.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3504.19,41.1,,6417.48,6417.48,6417.48,"1 through 10",991.57,7247.1,"percent of total billed charges",
"PORT IMPLANTABLE INFUSION MRI GROSHONG SILICONE PLASTIC 8FR",SUP-0602830,CDM,C1788,HCPCS,0278,RC,,,both,,,1762.50,528.75,"NOVANET [10819]",Novanet,,1321.88,75,,,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL CONTOUR 12IN 32- IN KNEE PATELLA",SUP-79-80410,CDM,S27000186,LOCAL,0270,RC,,,both,,,96.22,28.87,"CIGNA [10200]",Cigna,,65.43,68,,,,,0,11.19,81.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC LARGE HUB STERLING GATOR 2500-6000 RPM 13",SUP-C9266,CDM,S27200284,LOCAL,0272,RC,,,both,,,564.25,169.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,383.69,68,,,,,0,65.62,479.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN AMPLATZ LEFT .75 CURVE",SUP-LA7AL75,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 8MM 75MM 32MM LCP STAINLESS STEEL PARTIAL",SUP-217.075,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"NOVANET [10819]",Novanet,,336.8,75,,,,,0,52.23,381.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Test Sleep Attnd",PX-740000002,CDM,95807,CPT,0920,RC,,,both,,,6574.00,1972.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1732,,,,,,,764.56,5587.9,"case rate",
"CATHETER 6248V-90SP ATTAIN SELECT II",SUP-6248V-90SP,CDM,C1887,HCPCS,0272,RC,,,both,,,2272.50,681.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,269.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,264.29,1931.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP 20CC 2MM ALLOGRAFT GRANULE",SUP-12610101,CDM,C1713,HCPCS,0278,RC,,,both,,,4588.50,1376.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1313.23,28.62,,,,,0,533.64,3900.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FLOSWITCH 1050 PSI FLOW CONTROL 1 WAY HIGH PRESSURE",SUP-M00144200,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.22,18.97,"CIGNA [10200]",Cigna,,42.99,68,,,,,0,7.35,53.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cholinesterase RBC",PX-301000147,CDM,82482,CPT,0301,RC,,,both,,,273.00,81.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,28.21,,,,,,,0.27,232.05,"fee schedule",
"CABLE CATH 10FT CARTO REDEL 10 PIN CNCT 4 ELECTROGRAM",SUP-C10MR10MSTKS,CDM,S27000186,LOCAL,0270,RC,,,both,,,2115.00,634.5,"UHC [10700]","United Healthcare",,1338.8,63.3,,,,,0,245.97,1797.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLASSIC COLD THERAPY SYSTEM",SUP-11-0494,CDM,C9810,HCPCS,0270,RC,,,both,,,515.89,154.77,"KAISER [10500]",Kaiser,,345.65,67,,,,,0,60,438.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE EPI-SENSE 3CM COAGULATION GUIDE ELECTRD IRRIGATION",SUP-CDP-4330-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,66690.00,20007,"NOVANET [10819]",Novanet,,50017.5,75,,,,,0,7756.05,56686.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE APPROACH VASCULAR TAPER 300CM .014IN STAINLESS STEEL",SUP-G50792,CDM,C1769,HCPCS,0272,RC,,,both,,,1251.37,375.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,145.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,145.53,1063.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOCYCLINE 100 MG INTRAVENOUS SOLUTION",RX-10612,CDM,,,0250,RC,70842-0160-01,NDC,both,1,UN,1560.31,468.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,184.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,181.46,1326.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT OSTEOSET CALCIUM SULFATE PELLET INJECTOR 5ML",SUP-87004805,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2932.5,68,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135CM 80MM 6FR 10MM .035IN LOW PROFILE",SUP-B2100-080,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"KAISER [10500]",Kaiser,,515.57,67,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON SABRELOC 5-0 RD-1 18IN 2 ARM MONOFILAMENT BLACK",SUP-749G,CDM,S27200284,LOCAL,0272,RC,,,both,,,146.68,44,"FIRST HEALTH [10303]","First Health",,117.34,80,,,,,0,13.57,124.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE 10CM 2.5CM 11FR INTRO STAINLESS STEEL",SUP-RSS101,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"MULTIPLAN [10600]",Multiplan,,66.56,85,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA",955,MS-DRG,,,,,,,inpatient,,,419460.64,125838.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR",RX-37648,CDM,,,0637,RC,60687-0768-11,NDC,both,1,UN,9.63,2.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PERMA-HAND SUTUPAK 2 60IN BRAID TIES 2 STRAND PRECUT",SUP-SA8H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOLNAFTATE 1 % TOPICAL CREAM",RX-8020,CDM,,,0250,RC,10939-0563-33,NDC,both,15,GR,29.53,8.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE PLIAFORM STARCAST 80CM 6CM 5MM BALLOON",SUP-G52339,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CURET 2 11IN COBB OVAL CUP ANGLE TIP HOLLOW KNURL HANDLE",SUP-240189,CDM,S27200284,LOCAL,0272,RC,,,both,,,834.95,250.48,"KAISER [10500]",Kaiser,,559.42,67,,,,,0,97.1,709.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 21MM 2 STAGGERED TITANIUM STAPLE CIRCULAR ROW",SUP-EEAORVIL21A,CDM,S27200284,LOCAL,0272,RC,,,both,,,685.83,205.75,"FIRST HEALTH [10303]","First Health",,548.66,80,,,,,0,79.76,582.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MILL BONE MEDIUM BIOPSY DISPOSABLE",SUP-5400-701-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2556.18,766.85,"CIGNA [10200]",Cigna,,1738.2,68,,,,,0,297.28,2172.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"**DO NOT REUSE ITEM # - PS GO LIVE ISSUE**DRAIN INCISION EXP",SUP-4000-100N,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.40,83.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,32.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 30MM ATS SPINE MULTIAXIAL 4.75MM ROD",SUP-54840044530,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2732.31,28.62,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 194MM STAINLESS STEEL 3.5MM SCR 8 HOLE LCP BONE RIGHT",SUP-02.104.008S,CDM,C1713,HCPCS,0278,RC,,,both,,,9988.58,2996.57,"PHCS [10601]",PHCS,,6992.01,70,,,,,0,1161.67,8490.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SIZE 5 HIGH OFFSET CEMENTLESS HA TITANIUM ALLOY",SUP-611202050,CDM,C1776,HCPCS,0278,RC,,,both,,,28967.40,8690.22,"UHC [10700]","United Healthcare",,18336.36,63.3,,8601.07,8395.67,8601.07,"1 through 10",3368.91,24622.29,"percent of total billed charges",
"STENT SURPASS ELITE 15MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE32515,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9730.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 6 KNEE CEMENT ROTATE PLATFORM STERILE",SUP-150680006,CDM,C1776,HCPCS,0278,RC,,,both,,,17225.85,5167.75,"NOVANET [10819]",Novanet,,12919.39,75,,,,,0,2003.37,14641.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 20MM 135CM 8MM 160CM",SUP-M001712170,CDM,C1876,HCPCS,0278,RC,,,both,,,8728.50,2618.55,"UHC [10700]","United Healthcare",,5525.14,63.3,,,,,0,1015.12,7419.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 480-575ML TEXTURED LOW POLE PLUS LATERAL EXT",SUP-LPP-FH14,CDM,C1789,HCPCS,0278,RC,,,both,,,8349.00,2504.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2389.48,28.62,,,,,0,970.99,7096.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 11MM TITANIUM CORTICAL HAND SELF TAPPING",SUP-400.811,CDM,C1713,HCPCS,0278,RC,,,both,,,421.52,126.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,286.63,68,,,,,0,49.02,358.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 77.5MM TITANIUM LOCK ATLANTIS TRANSLATIONAL BONE SPINE",SUP-6190077,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,3978.14,359.25,3978.14,24,641.98,4692,"percent of total billed charges",
"CMPNT FEMORAL 7 KNEE RIGHT MEDIAL LEFT LATERAL",SUP-71422357,CDM,C1776,HCPCS,0278,RC,,,both,,,29030.40,8709.12,"PHCS [10601]",PHCS,,20321.28,70,,,,,0,3376.24,24675.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IOL LENS 80 DIOPTER",SUP-SA60WF.080,CDM,V2632,HCPCS,0276,RC,,,both,,,1085.40,325.62,"CIGNA [10200]","Cigna Local Plus",,580.69,53.5,,,,,0,126.23,922.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GOLD PROBE 300CM 2.8MM 7FR ELECTROHEMOSTASIS HEMOGLIDE",SUP-M00560070,CDM,S27200284,LOCAL,0272,RC,,,both,,,1300.70,390.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,884.48,68,,,,,0,151.27,1105.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 10MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158106110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7598.69,68,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 8CM 6FR 10MM .035IN BALLOON",SUP-G52375,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"KAISER [10500]",Kaiser,,643.05,67,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 50MM 1.5MM TWIST NOTCH STERILE",SUP-25-449-16,CDM,S27000186,LOCAL,0270,RC,,,both,,,1200.26,360.08,"CIGNA [10200]","Cigna Open Access",,682.95,56.9,,,,,0,139.59,1020.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 13CM 5.5MM STERLING 10000 RPM SPHERE LARGE HUB",SUP-H9112RH,CDM,S27200284,LOCAL,0272,RC,,,both,,,564.25,169.27,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAREON VIVITY TORIC UVA",SUP-CCWET6,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"BLUE CROSS [10001]","Blue Cross PPO",,339.08,39.2,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP MEDICAL L235CM L2.8MM 11MM OPENING HEMOSTATIC FIXING RE",SUP-M00522612,CDM,S27200284,LOCAL,0272,RC,,,both,,,1239.81,371.94,"CIGNA [10200]","Cigna Local Plus",,663.3,53.5,,,,,0,144.19,1053.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5INX8MM OSTEOTOM LONG MRI STERILE LATEX FREE",SUP-47998602127,CDM,S27200284,LOCAL,0272,RC,,,both,,,996.30,298.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,118.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TENOR VASCULAR ANGLE MICRO 65IN .014IN STAINLESS STEEL",SUP-TNR2411,CDM,C1769,HCPCS,0272,RC,,,both,,,1705.20,511.56,"MULTIPLAN [10600]",Multiplan,,1449.42,85,,,,,0,198.31,1449.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL VASCUCHEK",SUP-VC-SP-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 32MM 10D G HIP PRIMARY X3 TRIDENT",SUP-623-10-32G,CDM,C1776,HCPCS,0278,RC,,,both,,,6242.04,1872.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,739.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,725.95,5305.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG 35CM PREVENA PLUS PEEL AND PLACE STERILE LATEX FREE",SUP-PRE3201US,CDM,S27200284,LOCAL,0272,RC,,,both,,,4255.58,1276.67,"MULTIPLAN [10600]",Multiplan,,3617.24,85,,,,,0,494.92,3617.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 100MM 5.5MM REVOLVE",SUP-185.300,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2998.8,68,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 2.5/20",SUP-434893,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5332.64,27,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colposcopy W/Bx&Curettage",PX-361000521,CDM,57454,CPT,0361,RC,,,both,,,1459.50,437.85,"BLUE CROSS [10001]","Blue Cross PPO",,1.46,.1,,,,,0,1.46,1459.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOTTLE DRNG EVACUATE LUER LOCK NDL FREE DEHP FREE ACCEL 2000",SUP-622298,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.22,43.27,"PHCS [10601]",PHCS,,100.95,70,,,,,0,16.77,122.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK 12MM 1.5MM ROUND BALLOON DILATATION CROSSFLEX2",SUP-1012432-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 122MM 12MM COMPREHENSIVE POROUS STD SHOULDER",SUP-113652,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS [10001]","Blue Cross PPO",,4939.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",1465.38,10710,"percent of total billed charges",
"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION",RX-1222,CDM,J0665,HCPCS,0636,RC,00409-1559-19,NDC,both,30,ML,46.21,13.86,"BLUE CROSS [10001]","Blue Cross HMO",,1.75,,,,,,,1.75,39.28,"fee schedule",
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 41CM 5FR ROSCH",SUP-G10082,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"AETNA [10100]","Aetna HMO/PPO",,188.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 20CM SONOPET IQ BONE APEX 360 2.5X3.15MM STERILE",SUP-5500-25B-302,CDM,S27200284,LOCAL,0272,RC,,,both,,,8950.21,2685.06,"CIGNA [10200]","Cigna Local Plus",,4788.36,53.5,,,,,0,1040.91,7607.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 20CM 8FR .038",SUP-M006192150120,CDM,C2617,HCPCS,0278,RC,,,both,,,1487.32,446.2,"CIGNA [10200]",Cigna,,1011.38,68,,,,,0,172.98,1264.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 15.75IN 20FR DRNG",SUP-8888561043,CDM,C1729,HCPCS,0272,RC,,,both,,,221.42,66.43,"KAISER [10500]",Kaiser,,148.35,67,,,,,0,25.75,188.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN EXTRA",SUP-67005300,CDM,C1769,HCPCS,0272,RC,,,both,,,417.60,125.28,"MULTIPLAN [10600]",Multiplan,,354.96,85,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA SURG VELC STRP ZIP MED 34-36IN",SUP-958-V/M,CDM,S27000186,LOCAL,0270,RC,,,both,,,333.99,100.2,"KAISER [10500]",Kaiser,,223.77,67,,,,,0,38.84,283.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 14/16 BALL TAPER 28MM HIP COCR STERILE",SUP-101813000,CDM,C1776,HCPCS,0278,RC,,,both,,,4783.08,1434.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,566.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,556.27,4065.62,"percent of total billed charges",
"LINER ACETABULAR R3 20D 48MM 32MM XLPE HIP",SUP-71337648,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3004.09,27,,,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 12.9CM MEMORYGEL P3.3CM MODERATE PROFILE SILTEX",SUP-3543207MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 360MM RIGHT TROCHANTERIC INTRAMEDULLARY 130D LONG",SUP-456.356S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"CIGNA [10200]",Cigna,,5468.17,40,,1831.33,1831.33,1831.33,16,1589.87,11619.86,"percent of total billed charges",
"INSRT TIBIAL 2 13MM KNEE X3 BEARING CRUCIATE RETAIN",SUP-5530-G-213-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7760.57,68,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 27.5CM 3.5MM SKIMMER 15D SUBGLOTTIC 2 CURVED",SUP-1883523,CDM,S27200284,LOCAL,0272,RC,,,both,,,4429.80,1328.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1820.65,41.1,,,,,0,515.19,3765.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45X4.8MM TITANIUM THICK TISSUE ENDOSCOPIC",SUP-TA4548S,CDM,S27200284,LOCAL,0272,RC,,,both,,,860.30,258.09,"NOVANET [10819]",Novanet,,645.23,75,,,,,0,100.05,731.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ULTRAFLEX 40MM 25MM 18MM 27FR 95CM 5.1MM",SUP-M00576640,CDM,C1874,HCPCS,0278,RC,,,both,,,19467.00,5840.1,"PHCS [10601]",PHCS,,13626.9,70,,,,,0,2264.01,16546.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 100MM KNEE STEM EXT REMEDY STERILE",SUP-RSK100,CDM,C1776,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Open Access",,3533.49,56.9,,5302.19,4377.88,6578.61,27,722.22,5278.5,"percent of total billed charges",
"SHEATH AMPLATZ 17CM 20FR ACCESS PTFE RENAL FIRM TAPER TIP",SUP-M0062601480,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"AETNA [10100]","Aetna HMO/PPO",,266.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"Q-FIX KNTLS ASA 1.8MM W/1 MT SUT CB-BL",SUP-72205885,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1635.19,45.9,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA 5D D KNEE RIGHT CEMENT STEM TIVANIUM",SUP-42532006702,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5018.59,45.9,,,,,0,1271.59,9293.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC IV Push Add Seq Drug",PX-260000009,CDM,96376,CPT,0260,RC,,,both,,,315.72,94.72,"NOVANET [10819]",Novanet,,236.79,75,,,,,0,36.72,315.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG 13CM VAC PREVENA PEEL AND PLACE PATCH STRIPS PRESSURE",SUP-PRE1155US.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2091.15,627.34,"PHCS [10601]",PHCS,,1463.81,70,,,,,0,243.2,1777.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 129MM 15MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771101500,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2430.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2430.63,17764.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)CORONARY IVL CATHETER, 2.5MM X 12MM, RX IDE",SUP-501050-001,CDM,C1761,HCPCS,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 5MM ENDOPATH XCEL BLADELESS",SUP-2B5LT,CDM,S27200284,LOCAL,0272,RC,,,both,,,919.46,275.84,"NOVANET [10819]",Novanet,,689.6,75,,,,,0,106.93,781.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER QUICKPASS SUTURELASSO 25D 1.5MM CURVE RIGHT PRELOAD",SUP-AR-6068-25R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1445.85,433.75,"KAISER [10500]",Kaiser,,968.72,67,,,,,0,168.15,1228.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 12.5X11.8CM 315ML STYLE CPG 312 MEMORYSHAPE",SUP-3541258,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"KAISER [10500]",Kaiser,,6125.48,67,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 21MM 64MM 54MM SHOULDER COMPREHENSIVE",SUP-113063,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"CIGNA [10200]","Cigna Open Access",,5171.53,56.9,,5302.19,4377.88,6578.61,27,1057.03,7725.48,"percent of total billed charges",
"CAP CONSTRUCT KNEE CR CEMENTED HIGH DEMAND INSERT LEGION GEN",SUP-71704505,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 13MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P513,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"FIRST HEALTH [10303]","First Health",,6684.72,80,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 40MMX12MMX20CM 26FR",SUP-TAC124020A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,52202.88,28.62,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 21GA 40CM 1.6IN HUB TUBE RADIOPAQUE GWIRE",SUP-PSS-8F-4-038MT,CDM,C1894,HCPCS,0272,RC,,,both,,,208.80,62.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM CEMENT SUMMIT 6 12/14 STD OFFSET TAPER",SUP-157003120,CDM,C1776,HCPCS,0278,RC,,,both,,,18219.60,5465.88,"CIGNA [10200]","Cigna Open Access",,6103.57,33.5,,5302.19,4377.88,6578.61,27,2118.94,15486.66,"percent of total billed charges",
"GWIRE ZIPWIRE UROLOGICAL 150CM 3CM .025IN NITINOL",SUP-630-216B,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE",RX-29746,CDM,,,0637,RC,31722-0665-30,NDC,both,1,UN,32.22,9.67,"PHCS [10601]",PHCS,,22.55,70,,,,,0,3.75,27.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 17GA 15CM 9CM ADJUSTABLE COAXIAL TEMNO",SUP-ACT1815,CDM,S27200284,LOCAL,0272,RC,,,both,,,815.44,244.63,"UHC [10700]","United Healthcare",,516.17,63.3,,,,,0,94.84,693.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 330841 ACSR 8X14X11 SRVC FEE",SUP-330841,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 100MM 4MM .014IN BALLOON DILATATION NYBAX",SUP-39186-40101,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"START UP KIT, STD TUBING (6FT), CG-500D",SUP-8700-0784-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 6X 38MM CATH 80CM ENDOVASCULAR",SUP-48638,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2076.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 48MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.548,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,313.8,28.62,,,,,0,127.51,931.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 3.5MM ELLIPSE STERILE",SUP-182.804,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,647.19,45.9,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM DYNACLIP 20X22X22MM INTERNAL FIXATION",SUP-3000-00-202222,CDM,C1713,HCPCS,0278,RC,,,both,,,13662.00,4098.6,"FIRST HEALTH [10303]","First Health",,10929.6,80,,,,,0,1588.89,11612.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 4MM BALLOON DILATATION STERILE LATEX",SUP-594012022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT KINEX PLUS BIOACTIVE PUTTY 2CC",SUP-8115.5302S,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1635.19,45.9,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SKATER 25CM 14FR PIGTAIL NEPHRSTMY LOCK ACCEPTS .038IN",SUP-756614025,CDM,C1729,HCPCS,0272,RC,,,both,,,651.24,195.37,"KAISER [10500]",Kaiser,,436.33,67,,,,,0,75.74,553.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 37MM TITANIUM 4.75MM SCR FIX SOLERA X10 XLNK CD",SUP-5442037,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"MULTIPLAN [10600]",Multiplan,,3028.13,85,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3MM 2 SUTURETAK FIBERWIRE BIOCOMPOSITE 14.5MM",SUP-AR-1934BCF,CDM,C1713,HCPCS,0272,RC,,,both,,,2401.88,720.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,987.17,41.1,,,,,0,987.17,1520.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 8.5FR 18GA 16CM .032IN 4 LUMEN INDWELL CATH GWIRE",SUP-CDC-42854-1A,CDM,C1751,HCPCS,0272,RC,,,both,,,831.24,249.37,"NOVANET [10819]",Novanet,,623.43,75,,,,,0,96.67,706.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO 1000093002 OPTISEAL GLBL7FR13CM",SUP-1000093002,CDM,C1894,HCPCS,0272,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR RINGLOC +3MM 23 36MM E-POLY HIP STERILE",SUP-EP-108223,CDM,C1776,HCPCS,0278,RC,,,both,,,14076.00,4222.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3800.52,27,,,,,0,1637.04,11964.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOTHYROXINE 100 MCG TABLET",RX-4423,CDM,,,0637,RC,00904-6953-61,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADHSV SKIN CLSR 2 OCTYL CYANOACRYLATE DERMABOND MINI LIQUID",SUP-DHVM12,CDM,S27200284,LOCAL,0272,RC,,,both,,,308.17,92.45,"NOVANET [10819]",Novanet,,231.13,75,,,,,0,35.84,261.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 100MM 7FR 7MM .018IN SHORT BALLOON",SUP-V1870100,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"FIRST HEALTH [10303]","First Health",,4388.4,80,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL CANCELLOUS THK8MM ALLOGRAFT STRUT FREEZE",SUP-400605,CDM,S27800098,LOCAL,0278,RC,,,both,,,6412.86,1923.86,"BLUE CROSS [10001]","Blue Cross PPO",,2513.84,39.2,,,,,0,745.82,5450.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE THRUWAY VASCULAR 190CM 3CM .018IN PERIPHERAL SHAPEABLE",SUP-M001492791,CDM,C1769,HCPCS,0272,RC,,,both,,,564.08,169.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,66.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.6,479.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 100CM 5FR HEADHUNTER 3 CURVE ANGIOGRAPHIC",SUP-M001314171,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.52,25.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.71,70.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 4FR 5MM SPACE REGULAR D CURVE",SUP-D4S04DR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,274.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 RIGHT KNEE CRUCIATE RETAINING CEMENTED",SUP-5510-F-502,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"MULTIPLAN [10600]",Multiplan,,13938.17,85,,,,,0,1907.07,13938.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 15MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158100115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross HMO",,4380.42,39.2,,5311.50,4717.44,5388.59,31,1299.6,9498.37,"percent of total billed charges",
"ABACAVIR 300 MG TABLET",RX-24438,CDM,,,0637,RC,50268-0049-11,NDC,both,1,UN,37.95,11.38,"UHC [10700]","United Healthcare",,24.02,63.3,,,,,0,4.41,32.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 63MM REGENEREX KNEE PRIMARY CRUCIATE RETAINING P",SUP-141271,CDM,C1776,HCPCS,0278,RC,,,both,,,11964.60,3589.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3230.44,27,,,,,0,1391.48,10169.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT CEMENT REVISION CONSTRAIN ATTUNE",SUP-150440207,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3568.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3502.26,25596.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I131 Therapy Capsl per Mci",PX-344000001,CDM,A9517,HCPCS,0344,RC,,,both,,,103.36,31.01,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,46.94,,,,,,,12.02,87.86,"fee schedule",
"COLLAR CERVICAL SMALL 12-14.4INX3IN ACTIMOVE MEDIUM DENSITY",SUP-72819-00026-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,48.20,14.46,"MULTIPLAN [10600]",Multiplan,,40.97,85,,,,,0,5.61,40.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 120MM 80CM 10MM 6FR .035IN BILIARY",SUP-G50139,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CIGNA [10200]","Cigna Open Access",,3465.21,56.9,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 100MM 5MM BALLOON DILATATION STERILE LATEX",SUP-595010022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC in Situ Hybridization (Fish)",PX-312000048,CDM,88365,CPT,0312,RC,,,both,,,916.50,274.95,"NOVANET [10819]",Novanet,,687.38,75,,,,,0,0.01,779.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HI-FLO RENEGADE 115CM 20CM 3-2.8FR .027IN MICRO",SUP-M001182870,CDM,C1887,HCPCS,0272,RC,,,both,,,2100.00,630,"MULTIPLAN [10600]",Multiplan,,1785,85,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 2.5MM BALLOON DILATATION STERILE LATEX",SUP-592512022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE ORTHOPEDIC COCR 1.8MM 635CM TROCHANTER CERCLAGE CRIMP",SUP-00223200418,CDM,C1713,HCPCS,0278,RC,,,both,,,3829.50,1148.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,453.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,445.37,3255.08,"percent of total billed charges",
"GWIRE 2O VASCULAR ANGLE 260CM .035IN HYDROPHILIC FIX CORE",SUP-H2OSTFA35260EX,CDM,C1769,HCPCS,0272,RC,,,both,,,348.00,104.4,"MULTIPLAN [10600]",Multiplan,,295.8,85,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.0MM X 9MM TI",SUP-VAN-20090-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Local Plus",,520.02,53.5,,3978.14,359.25,3978.14,24,113.04,826.2,"percent of total billed charges",
"INSRT CLAMP 86MM STEALTH FIBRA SOFT LATEX FREE",SUP-G-8655,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,153.82,68,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHIELD SPIRAL, 30 MM DIAMETER",SUP-50215K52B0D,CDM,A2019,HCPCS,0636,RC,,,both,,,37195.20,11158.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,24176.88,65,,,,,0,247.92,31615.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR",SUP-SSR75-01,CDM,A4648,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 20MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE40020,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"CIGNA [10200]",Cigna,,33465.84,40,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXCISOR BIOPSY FISCHER LARGE CERVICAL CONE SHALLOW STERILE",SUP-900-155,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.28,60.98,"UHC [10700]","United Healthcare",,128.68,63.3,,,,,0,23.64,172.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL PRONG O2 TUBE ADPTR DEHP FREE NEOTECH RAM CANN",SUP-N4906,CDM,S27000186,LOCAL,0270,RC,,,both,,,107.88,32.36,"CIGNA [10200]",Cigna,,73.36,68,,,,,0,12.55,91.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 80MM 125CM 7MM 6FR VASCULAR NITINOL",SUP-G43828,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"AETNA [10100]","Aetna HMO/PPO",,3005.1,79.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 6MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR060502A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"AETNA [10100]","Aetna HMO/PPO",,13439.48,79.5,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 50MM DCP STAINLESS STEEL SHORT THREAD DISTAL",SUP-202.850,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CIGNA [10200]","Cigna Local Plus",,187.95,53.5,,3978.14,359.25,3978.14,24,40.86,298.61,"percent of total billed charges",
"POD XL 6MMX55CM",SUP-RBYPODXL0655,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"BLUE CROSS [10001]","Blue Cross PPO",,7384.1,39.2,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOLD CEMENT 70MM STAGEONE UNIVERSAL KNEE FEMORAL SILICONE",SUP-432170,CDM,S27200284,LOCAL,0272,RC,,,both,,,12867.12,3860.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8749.64,68,,,,,0,1496.45,10937.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR",SUP-SSR75-01,CDM,A4648,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SYMPLICITY SPYRAL CATHETER",SUP-IDEHTNRDN016,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 270CC P4.7CM MODERATE PLUS PROFILE TALL HEIGHT",SUP-334-1109,CDM,C1789,HCPCS,0278,RC,,,both,,,7583.10,2274.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,898.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",881.91,6445.64,"percent of total billed charges",
"SPLINT ORTHOPEDIC LARGE 13X3.5-3.75IN HAND LEFT ORTHOSIS",SUP-81096072,CDM,L3807,HCPCS,0274,RC,,,both,,,460.89,138.27,"BLUE CROSS [10001]","Blue Cross PPO",,180.67,39.2,,,,,0,53.6,391.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT CRUCIATE RETAIN GENESIS II LEGION",SUP-71421236,CDM,C1776,HCPCS,0278,RC,,,both,,,28831.95,8649.58,"CIGNA [10200]","Cigna Local Plus",,9082.06,31.5,,5372.07,4581.20,7242.98,23,3353.16,24507.16,"percent of total billed charges",
"GRAFT STENT 20CM 40MM GORE TAG THORACIC ACTIVE CONTROL",SUP-TGMR404020,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"AETNA [10100]","Aetna HMO/PPO",,92197.9,79.5,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FERROUS SULFATE 325 MG (65 MG IRON) TABLET",RX-3074,CDM,,,0637,RC,00904-7591-61,NDC,both,1,UN,6.27,1.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT CLAMP WHITE 61MM STEALTH FIBRA 2 SOFT STERILE",SUP-G-6155,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 12X40 40CM SL",SUP-48012004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,inpatient,,,32209.95,9662.98,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECTRUM DVM S4",SUP-0270-0933,CDM,S27200284,LOCAL,0272,RC,,,both,,,328.86,98.66,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,MAJOR",810,APR-DRG,,,,,,,inpatient,,,39010.19,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $5,894.89. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($39,841.12) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE BGK0/2.5 POLYOLEFIN 5000ML NONPVC 2",SUP-110240,CDM,S27200284,LOCAL,0272,RC,,,both,,,332.60,99.78,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR",RX-113068,CDM,,,0637,RC,42858-0701-01,NDC,both,1,UN,6.83,2.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) CATHETER TRAPLINER 150CM 13CM 6.5FR INTERVENTIONAL HY",SUP-5568,CDM,C1887,HCPCS,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"**DO NOT REUSE ITEM # - PS GO LIVE ISSUE**POUCH OSTOMY TRANS",SUP-18103,CDM,S27000186,LOCAL,0270,RC,,,both,,,0.72,0.22,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL INTRAVENOUS 0.9% SODIUM CHLORIDE 500ML VIAFLEX LATEX",SUP-2B1323Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONVEY 5FR .058IN CONTRALATERAL SPRT 4 CURVE GUIDING",SUP-H749392285750,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE TRACH 12.7MM 9MM SHILEY CUFF DISPOSABLE INNER CANN",SUP-9CN90A,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.97,110.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNARE 47IN .98IN ONE SNARE 1 LOOP GOLD PLATED TUNGSTEN",SUP-ONE2500,CDM,C1773,HCPCS,0272,RC,,,both,,,2175.00,652.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES,MINOR",098,APR-DRG,,,,,,,inpatient,,,55133.71,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,972.20. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($33,421.74) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET OBLONG 7.5IN ANTRUM SURGICAL STAINLESS STEEL 5X2MM",SUP-440400,CDM,S27200284,LOCAL,0272,RC,,,both,,,642.65,192.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SENSOR NEONATE LNCS NEO-3 3FT OXIMETER ADHSV SPO2 STERILE",SUP-2604,CDM,S27000186,LOCAL,0270,RC,,,both,,,148.77,44.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC NM Bone Marrow Wb",PX-341000071,CDM,78104,CPT,0341,RC,,,both,,,1531.98,459.59,"MULTIPLAN [10600]",Multiplan,,1302.18,85,,,,,0,178.17,1302.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM SENSAR INTRAOCULAR LENS, BICONVEX, 20.0 DIOPTER",SUP-AR40E00200,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"CIGNA [10200]",Cigna,,633.42,68,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X3IN DURAMATRIX BOVINE CLLGN DURA MEMB",SUP-DMS33,CDM,S27800098,LOCAL,0278,RC,,,both,,,6758.90,2027.67,"BLUE CROSS [10001]","Blue Cross PPO",,2649.49,39.2,,,,,0,786.06,5745.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vasc Embol Occl Organ Trinav",PX-361000638,CDM,C9797,HCPCS,0361,RC,,,both,,,26377.00,7913.1,"MULTIPLAN [10600]",Multiplan,,22420.45,85,,,,,0,3067.65,22420.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL SOFT/FIBRA 6MM .25 FORCE SPRING ATRAUMATIC",SUP-G-6054,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]","Cigna Local Plus",,121.02,53.5,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS ZIPWIRE 26CM 3CM 6FR .035IN PIGTAIL CURVE",SUP-M0061265730,CDM,C2617,HCPCS,0278,RC,,,both,,,1483.43,445.03,"CIGNA [10200]",Cigna,,1008.73,68,,,,,0,172.52,1260.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X21MM ENDOSKELETON TAS 7D 13MM STD TITANIUM",SUP-2307-0113,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 20MM PERSONA 3-5+ C-D KNEE RIGHT CONDYLAR",SUP-42522800420,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,5372.07,4581.20,7242.98,23,2014.9,14726.25,"percent of total billed charges",
"GUIDEWIRE L145CM .014IN IMAGING STRAIGHT TIP OCCLUDING HYDRO",SUP-4583,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"MULTIPLAN [10600]",Multiplan,,963.9,85,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HABIB 180CM 8FR ABLATION BIPOLAR RADIOFREQUENCY",SUP-M00500070,CDM,S27200284,LOCAL,0272,RC,,,both,,,11335.67,3400.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5203.07,45.9,,,,,0,1318.34,9635.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOTTLE DRNG VACUUM DRAIN LINE PLEURX 500ML",SUP-50-7205B,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"CIGNA [10200]",Cigna,,283.97,68,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 8IN 1.5MM BAYONET KIT",SUP-20-1410KI,CDM,S27200284,LOCAL,0272,RC,,,both,,,324.74,97.42,"UHC [10700]","United Healthcare",,205.56,63.3,,,,,0,37.77,276.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DURASEAL EXACT SPINE SEALANT SYSTEM 3ML US BOX OF 5",SUP-206320,CDM,S27200284,LOCAL,0272,RC,,,both,,,6092.29,1827.69,"NOVANET [10819]",Novanet,,4569.22,75,,,,,0,708.53,5178.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 17MM ATLANTIS TITANIUM SPINE CERVICAL ANTERIOR",SUP-3120217,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM ACTIVE ARTICULATION THR POROUS CUP 2 MOBILITY LIN",SUP-98B00100194,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"MULTIPLAN [10600]",Multiplan,,16065,85,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 84MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 6",SUP-245.061,CDM,C1713,HCPCS,0278,RC,,,both,,,2927.40,878.22,"AETNA [10100]","Aetna HMO/PPO",,2327.28,79.5,,1521.93,481.35,16760.95,30,340.46,2488.29,"percent of total billed charges",
"IMPL BREAST 11.5X12CM 290ML STYLE FF HIGHLY COHESIVE GEL",SUP-FF-410290,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MERSILENE 2 MO-7 30IN BRAID D SPECIAL GREEN LIGHT GREEN",SUP-D8649,CDM,S27200284,LOCAL,0272,RC,,,both,,,776.02,232.81,"CIGNA [10200]",Cigna,,527.69,68,,,,,0,90.25,659.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM PK COIL LP STERILE LATEX FREE",SUP-RBYPCLP15,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"MULTIPLAN [10600]",Multiplan,,5747.7,85,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER PERFUSION PALL .2UM DISPOSABLE",SUP-ELD96LL,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.99,22.5,"FIRST HEALTH [10303]","First Health",,59.99,80,,,,,0,8.72,63.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HIP FEM P2 POROUS OFFSZ7",SUP-425-97-007,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,12180.23,28.62,,,,,0,4949.55,36174.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 19MM HELIX-REVOLUTION ACP SPINE SELF TAPPING",SUP-7803119,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]","Cigna Open Access",,802.29,56.9,,1144.80,304.56,2275.09,66,163.98,1198.5,"percent of total billed charges",
"CAP CONSTRUCT HIP CEMENTED OR3O WITH COCR HEAD",SUP-71703480,CDM,C1776,HCPCS,0278,RC,,,both,,,30240.00,9072,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8654.69,28.62,,,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CXI 90CM 4FR SPRT STAINLESS STEEL HYDROPHILIC LOW",SUP-G52547,CDM,C1887,HCPCS,0272,RC,,,both,,,1522.72,456.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,180.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,177.09,1294.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM SPINE PLY NONSTERILE 4MM ROD",SUP-102035120,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 2 KNEE LOW PROFILE",SUP-5520-M-200,CDM,C1776,HCPCS,0278,RC,,,both,,,7998.48,2399.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,930.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,930.22,6798.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 9MM 33MM METAL BACKED SYMMETRIC RESURFACING",SUP-5556-L-339,CDM,C1776,HCPCS,0278,RC,,,both,,,4410.00,1323,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2998.8,68,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 130MM 7MM REVERSE FRACTURE AEQUALIS SHOULDER",SUP-DWD901,CDM,C1776,HCPCS,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS [10001]","Blue Cross PPO",,6491.52,39.2,,3949.44,3949.44,3949.44,"1 through 10",1925.93,14076,"percent of total billed charges",
"PLATE 80MM TITANIUM LOCK ATLANTIS TRANSLATIONAL BONE SPINE",SUP-6190080,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAVVY 150CM 10CM 3.5-3FR 2MM BALLOON DILATATION DURALYN",SUP-435200X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"MULTIPLAN [10600]",Multiplan,,1067.18,85,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 11X3.9IN XENMATRIX AQUAPURE RECTANGLE",SUP-1161028,CDM,C1781,HCPCS,0278,RC,,,both,,,42696.99,12809.1,"KAISER [10500]",Kaiser,,28606.98,67,,,,,0,4965.66,36292.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUCICLOVINE F-18 INTRAVENOUS SOLUTION (13-14 MCI)|DISCARDED DRUG NOT ADMINISTE",RX-411839,CDM,A9588,HCPCS,0343,RC,08888-8877-91,NDC,both,1,UN,638.44,191.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",JW,638.44,,,,,,,74.25,638.44,"fee schedule",
"CAP CONSTRUCT HIP CERAMIC R3 DELTA POROUS R3 XLPE LINER",SUP-71703415,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6463.8,27,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER OPHTHALMIC 19GA PACKER/CHANG COAXIAL LOW PROFILE",SUP-DFH-1012,CDM,S27200284,LOCAL,0272,RC,,,both,,,1167.75,350.32,"NOVANET [10819]",Novanet,,875.81,75,,,,,0,135.81,992.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 110CM 6FR 145D PIGTAIL CURVE ANGIOGRAPHIC",SUP-H74916599412,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"UHC [10700]","United Healthcare",,48.48,63.3,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 18MM 9MM STD WALL THIN WALL 2 BRANCH",SUP-SBT1802D,CDM,C1768,HCPCS,0278,RC,,,both,,,8611.20,2583.36,"MULTIPLAN [10600]",Multiplan,,7319.52,85,,,,,0,1001.48,7319.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 55.9CM 8MM DA VINCI S/SI ENDOWRIST 45- D",SUP-420205,CDM,S27000186,LOCAL,0270,RC,,,both,,,2126.25,637.87,"MULTIPLAN [10600]",Multiplan,,1807.31,85,,,,,0,247.28,1807.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 310-375CC P4.8-6CM HIGH PROFILE ROUND STYLE 3000",SUP-350-3310,CDM,C1789,HCPCS,0278,RC,,,both,,,2475.00,742.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1683,68,,,,,0,287.84,2103.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VESUVIUS PUTTY DBM PUTTY 100 5CC",SUP-4104-K5050DP,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"BLUE CROSS [10001]","Blue Cross PPO",,1690.5,39.2,,957.42,570.23,957.42,28,501.54,3665.63,"percent of total billed charges",
"OTHER VASCULAR PROCEDURES WITH MCC",252,MS-DRG,,,,,,,inpatient,,,142770.90,42831.27,"CIGNA [10200]","Cigna Open Access",,38280.6,,"Fee schedule rate ($38,280.60). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,101844.41,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 62MM 9.4MM 5MM CUFFLESS DISPOSABLE INNER CANN",SUP-4DCFN,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.84,87.85,"UHC [10700]","United Healthcare",,185.37,63.3,,,,,0,34.06,248.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12CM NATRELLE INSPIRA P4.9CM FULL PROFILE ROUND",SUP-MSZ-F365,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,72.6,45.9,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 100MM 80CM 7MM 6FR .035IN BILIARY",SUP-G50123,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,721.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PARALLEL FLEXOR 45CM 12FR ENDOSCOPIC HYDROPHILIC",SUP-G56436,CDM,C1894,HCPCS,0272,RC,,,both,,,1396.44,418.93,"NOVANET [10819]",Novanet,,1047.33,75,,,,,0,162.41,1186.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 180MM 5MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171051810,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACIFIC PLUS 180CM 120MM 5MM BALLOON DILATATION",SUP-PCP050120180,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE",RX-38224,CDM,,,0637,RC,60687-0215-11,NDC,both,1,UN,10.97,3.29,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC",715,MS-DRG,,,,,,,inpatient,,,132254.08,39676.22,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT RED 18X4IN 10.5-16.5IN ATS 750/1200 CYL 1 PORT 1",SUP-60707515300,CDM,S27200284,LOCAL,0272,RC,,,both,,,211.85,63.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER 6250V-AM ATTAIN COMMAND",SUP-6250V-AM,CDM,C1887,HCPCS,0272,RC,,,both,,,2602.50,780.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) TF(-T) SHEATH AND DILATOR LHR-0104",SUP-LHR-0104,CDM,C1894,HCPCS,0272,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 1.3 MM SCREWS 3 HOLE HEAD 8 HOLE SHAFT",SUP-221.333,CDM,C1713,HCPCS,0278,RC,,,both,,,2202.90,660.87,"CIGNA [10200]",Cigna,,1497.97,68,,1831.33,1831.33,1831.33,16,256.2,1872.47,"percent of total billed charges",
"TRAY CATH GREEN 20CM 12FR MAHURKAR ELITE DOUBLE-D LARGE",SUP-8888222320,CDM,C1752,HCPCS,0272,RC,,,both,,,860.01,258,"CIGNA [10200]","Cigna Open Access",,489.35,56.9,,,,,0,100.02,731.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN EXTRA",SUP-67005300,CDM,C1769,HCPCS,0272,RC,,,both,,,417.60,125.28,"KAISER [10500]",Kaiser,,279.79,67,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 4-5 E-F KNEE RIGHT TIBIA FIX",SUP-42522100611,CDM,C1776,HCPCS,0278,RC,,,both,,,9466.80,2840.04,"BLUE CROSS [10001]","Blue Cross HMO",,3710.99,39.2,,5311.50,4717.44,5388.59,31,1100.99,8046.78,"percent of total billed charges",
"BLADE SAW 34.5X9X.64MM SHORT NARROW THIN STAINLESS STEEL",SUP-2108148000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"NOVANET [10819]",Novanet,,143.69,75,,,,,0,22.28,162.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 10MM 3.5MM BALLOON DILATATION",SUP-2200-3510-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"AETNA [10100]","Aetna HMO/PPO",,4662.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 65MM KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-183108,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"KAISER [10500]",Kaiser,,14516.02,67,,,,,0,2519.72,18415.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM FRMLA TOMCAT LONG HIP STERILE",SUP-385545000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2287.50,686.25,"CIGNA [10200]",Cigna,,1555.5,68,,,,,0,266.04,1944.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 PC-5 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J824G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 28CM 150CM 6FR .038IN STD STRAIGHT URETERAL",SUP-M006180524170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,352.3,28.62,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Foramen Epi Lumb Add",PX-510000130,CDM,64484,CPT,0761,RC,,,both,,,3392.48,1017.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,402.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,394.55,3392.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 16MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-016,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"NOVANET [10819]",Novanet,,15938.1,75,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL 2.4MM HELIOCOID DISPOSABLE STERILE LATEX FREE",SUP-1608-002-103,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"APPL INTERNAL CLIP 5MM 11IN TITANIUM ENDOSCOPIC PISTOL GRIP",SUP-176630,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEXAMETHASONE 4 MG TABLET",RX-2327,CDM,J8540,HCPCS,0637,RC,00054-8175-25,NDC,both,1,UN,6.27,1.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DIAMONDBACK 145CM 20MM .079IN 2MM ATHERECTOMY",SUP-DBP-EX-200CLA145,CDM,C1724,HCPCS,0272,RC,,,both,,,23278.50,6983.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"STPLR ENDOSCOPIC CURVE TIP RELOAD AEON 45MMX2.5MM STERILE",SUP-AESC45W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) MOTIV SCAFFOLD 2.5MMX48MM","SUP-930025-48 (280)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ADPR LD 6MM",SUP-501204,CDM,C1883,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1.5 X 1 HELICAL PICO COIL",SUP-10USH01501,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1363.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 90CM 5MM 8FR 2-5-2MM SPACE D CURVE",SUP-D8BTD5L252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,576.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN READIGRAFT CRYOSKIN 500SQ CM FIBROBLAST",SUP-SK-H,CDM,Q4433,HCPCS,0636,RC,,,both,,,8843.25,2652.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3957.35,44.75,,,,,0,247.92,7516.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30X2.5MM TITANIUM VASCULAR ENDOSCOPIC LINEAR",SUP-TX30V,CDM,S27200284,LOCAL,0272,RC,,,both,,,2001.38,600.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,232.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,232.76,1701.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM 11MM PRIMARY VERSYS TIVANIUM FIBER METAL",SUP-786201100,CDM,C1776,HCPCS,0278,RC,,,both,,,26645.22,7993.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3157.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3098.84,22648.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 36MM REVERSE SHELL MEDIUM +8MM",SUP-550000368,CDM,C1776,HCPCS,0278,RC,,,both,,,23826.60,7147.98,"CIGNA [10200]","Cigna Open Access",,7981.91,33.5,,5302.19,4377.88,6578.61,27,2771.03,20252.61,"percent of total billed charges",
"IMPL BREAST 220CC FULL PROFILE SMOOTH NATRELLE INSPIRA",SUP-SSF-220,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AETNA [10100]","Aetna HMO/PPO",,6006.62,79.5,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 12MM 3.5MM BALLOON DILATATION STERILE",SUP-235-123-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UHC [10700]","United Healthcare",,512.73,63.3,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 24CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192122010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]",Cigna,,816.39,68,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revasc Cto Ea Addl Art/Br/Grft",PX-481000091,CDM,92944,CPT,0481,RC,,,both,,,26800.00,8040,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12474,,"Case rate ($12,474). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,3116.84,25681,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revasc Cto Ea Addl Art/Br/Grft",PX-481000091,CDM,92944,CPT,0481,RC,,,both,,,26800.00,8040,"BLUE CROSS [10001]","Blue Cross HMO",,19285.75,,"Case rate ($19,285.75). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3116.84,25681,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL KNEE RIGHT 2.5 63X59MM CEMENTED CRUCIATE",SUP-960092,CDM,C1776,HCPCS,0278,RC,,,both,,,27588.96,8276.69,"CIGNA [10200]","Cigna Open Access",,9242.3,33.5,,5302.19,4377.88,6578.61,27,3208.6,23450.62,"percent of total billed charges",
"FRCP LAPAROSCOPIC CADIERE 6MM ENDOWRIST SP NONSTERILE",SUP-430300,CDM,S27000186,LOCAL,0270,RC,,,both,,,2063.40,619.02,"CIGNA [10200]","Cigna Local Plus",,1103.92,53.5,,,,,0,239.97,1753.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X11X5MM ALLOCRAFT 5D LORDOSIS CORTICAL",SUP-6183-7-005,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPS QUARTET INNER- CN-CSL 65CM-DS2N029-65",SUP-DS2N029-65,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRAMEDULLARY NAIL 360MM 11MM GAMMA 125D LONG R1.5",SUP-3425-1360S,CDM,C1713,HCPCS,0278,RC,,,both,,,13435.13,4030.54,"MULTIPLAN [10600]",Multiplan,,11419.86,85,,,,,0,1562.51,11419.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE TRANSPAC IV SAFESET RESVR",SUP-46115-39,CDM,S27200284,LOCAL,0272,RC,,,both,,,120.93,36.28,"UHC [10700]","United Healthcare",,76.55,63.3,,,,,0,14.06,102.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT EPTFE GORE-TEX CV-2 TF-25 36IN MONOFILAMENT DOUBLE ARM",SUP-2N19A,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.15,90.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,34.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.91,255.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM TITANIUM T15 FULL THREAD SELF TAP LOCK",SUP-412.104,CDM,C1713,HCPCS,0278,RC,,,both,,,954.83,286.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",111.05,811.61,"percent of total billed charges",
"BASKET STONE RETRIEVAL 120CM 1.3FR 6-11MM OPTIFLEX SMALL",SUP-M0063903010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1652.33,495.7,"AETNA [10100]","Aetna HMO/PPO",,1313.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,192.17,1404.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 21-23MM 3.5MM ELLIPSE STRAIGHT TITANIUM SPINE",SUP-182.923,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]",Cigna,,3284.4,68,,1831.33,1831.33,1831.33,16,561.73,4105.5,"percent of total billed charges",
"KIT SURGICAL OSTEOCOOL BONE ACCESS 10GA",SUP-OCN002,CDM,C1886,HCPCS,0272,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM OFFSET TAPER 28MM HIP ALUMINA CERAMIC V40",SUP-6565-0-128,CDM,C1776,HCPCS,0278,RC,,,both,,,7383.00,2214.9,"CIGNA [10200]","Cigna Open Access",,4200.93,56.9,,5302.19,4377.88,6578.61,27,858.64,6275.55,"percent of total billed charges",
"PK PAPYRUS 4.5/26",SUP-434902,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5332.64,27,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONCUSSION WITH MCC",088,MS-DRG,,,,,,,inpatient,,,56617.48,19990.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,26834.58,,"Fee schedule rate ($26,834.58). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,8385.3,33712.54,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL ATTUNE STERILE 4 KNEE RIGHT CEMENTED POSTERIOR",SUP-150410204,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6408.98,28.62,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL PREP SCRUB CARE EXIDINE 2% CHG 30OZ BOTTLE ANTIMICROBIAL",SUP-4CHG2-FM,CDM,S27000186,LOCAL,0270,RC,,,both,,,56.84,17.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23.36,41.1,,,,,0,6.61,48.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 30MM TITANIUM ALUMINUM NIOBIUM X25 MEDULLARY",SUP-04.045.030S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"ROD SPINAL 80MM 5.5MM CURVE NONSTERILE",SUP-1555501080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 9IN LAMBOTTE SPINE SURGICAL CURVE .25IN",SUP-28-9456,CDM,S27200284,LOCAL,0272,RC,,,both,,,225.16,67.55,"CIGNA [10200]","Cigna Open Access",,128.12,56.9,,,,,0,26.19,191.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .047IN MULTIPURPOSE A 2",SUP-534542T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"NOVANET [10819]",Novanet,,70.15,75,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 38MM 3MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG30038UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2643.75,793.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,313.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,307.47,2247.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 45MM SPINE POLYAXIAL 1 INNIE NONSTERILE",SUP-179712545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SOLITAIRE 180CM 40MM 4MM THROMBECTOMY SCAFFOLD",SUP-SFR3-4-40-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,40761.00,12228.3,"UHC [10700]","United Healthcare",,25801.71,63.3,,,,,0,4740.5,34646.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Stoma W Inj",PX-750000164,CDM,44404,CPT,0750,RC,,,both,,,2630.79,789.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,311.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.96,2630.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CREO CREO AMP SPINE MODULAR",SUP-1067.1640,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2732.31,28.62,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP CLUSTER HOLE HA TRIDENT II PSL D",SUP-742-11-48D,CDM,C1776,HCPCS,0278,RC,,,both,,,9502.96,2850.89,"CIGNA [10200]","Cigna Open Access",,5407.18,56.9,,5302.19,4377.88,6578.61,27,1105.19,8077.52,"percent of total billed charges",
"CATH MINI TREK 145CM 8MM 1.5MM BALLOON DILATATION PEBAX",SUP-1012269-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20 DIOPTER +5.25 CYLINDER MODIFIED C BICONVEX 13MM",SUP-ZCT525U200,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +25 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030250,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"PHCS [10601]",PHCS,,822.15,70,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEEDING SET MIC FEED ACCESS",SUP-0301-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.69,24.51,"CIGNA [10200]","Cigna Local Plus",,43.7,53.5,,,,,0,9.5,69.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ABLATION 7.5FR J CURVE THERMOCOOL SF UNIDIRECTIONAL",SUP-D131504,CDM,C1732,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL SEPRAMESH IP SEPRA 8X6IN VENTRAL MONOFILAMENT",SUP-5959680,CDM,C1781,HCPCS,0278,RC,,,both,,,5140.50,1542.15,"MULTIPLAN [10600]",Multiplan,,4369.43,85,,,,,0,597.84,4369.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.2MM 9MM APTUS TITANIUM HAND CORTICAL HEXADRIVE 4",SUP-A-5100.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,859.25,68,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 40MM 8MM 8FR BILIARY PLATINOL METAL RAPID",SUP-M00570600,CDM,C1876,HCPCS,0278,RC,,,both,,,11927.41,3578.22,"AETNA [10100]","Aetna HMO/PPO",,9482.29,79.5,,,,,0,1387.16,10138.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INLAY OPTIMA 30CM 4.7FR TAPER URETERAL POLYMER",SUP-788430,CDM,C2617,HCPCS,0278,RC,,,both,,,834.30,250.29,"MULTIPLAN [10600]",Multiplan,,709.16,85,,,,,0,97.03,709.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 8FR 19CM VESSEL ACCEPTS .035IN GWIRE",SUP-504408X,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.26,26.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,40.05,45.9,,,,,0,10.15,74.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 80MM 2MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186200810,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTILUME 5CM 30FR BALLOON PACLITAXEL",SUP-OPTBDL7005B,CDM,C1726,HCPCS,0272,RC,,,both,,,21577.50,6473.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,14672.7,68,,,,,0,2509.46,18340.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 135CM 40MM 4MM BALLOON DILATATION PACLITAXEL OTW",SUP-H74939419400410,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"FIRST HEALTH [10303]","First Health",,6900,80,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL SHOULDER WITH NECK ANATOMIC ALTIVATE CS SIZE 1",SUP-520-08-018,CDM,C1776,HCPCS,0278,RC,,,both,,,34907.04,10472.11,"FIRST HEALTH [10303]","First Health",,27925.63,80,,,,,0,4059.69,29670.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 19MM HELIX-REVOLUTION ACP SPINE SELF TAPPING",SUP-7803119,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"KAISER [10500]",Kaiser,,944.7,67,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET TITANIUM 17.5MM 8MM HIP GAMMA3 STERILE LONG NAIL",SUP-3003-0822S,CDM,C1713,HCPCS,0278,RC,,,both,,,1343.79,403.14,"CIGNA [10200]",Cigna,,913.78,68,,1831.33,1831.33,1831.33,16,156.28,1142.22,"percent of total billed charges",
"HC Prgrmg Evl Ldls Pm 1chmbr IP",PX-481000393,CDM,0826T,CPT,0481,RC,,,both,,,58.00,17.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP BIOPSY ALLIGATOR JAW STEP NDL 1550MM 1.9MM ENDOJAW",SUP-FB-221K.A,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.00,58.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE CORDIS EMERALD AMPLATZ VASCULAR STRAIGHT 150CM 4CM",SUP-502581A,CDM,C1769,HCPCS,0272,RC,,,both,,,107.53,32.26,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER 7969812 L 42 X 30 X 12MM 8 DEG",SUP-7969812,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"BLUE CROSS [10001]","Blue Cross HMO",,13436.04,39.2,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 12IN GIGLI SPIRAL",SUP-210482,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.41,37.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,58.02,45.9,,,,,0,14.7,107.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLYFLEX 40MM 11MM 18MM TRACHEOBRONCHIAL SILICONE SELF",SUP-7021,CDM,C1887,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2269.5,68,,,,,0,388.15,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXCATH CONTOUR 12FR STEERABLE SHEATH - 13MM TIP LENGTH",SUP-12FCC13,CDM,C1766,HCPCS,0272,RC,,,both,,,7590.00,2277,"MULTIPLAN [10600]",Multiplan,,6451.5,85,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EPIDURAL 60CM 19GA STIMUCATH PERIPHERAL",SUP-AB-19608-K,CDM,C1755,HCPCS,0278,RC,,,both,,,740.34,222.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,87.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.1,629.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T 5.5X1.3MM 7 HOLE ORTHOLOC BONE",SUP-52020207,CDM,C1713,HCPCS,0278,RC,,,both,,,4278.00,1283.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1963.6,45.9,,,,,0,497.53,3636.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2.5MM TARGET NANO HELICAL DETACHABLE",SUP-M0035452540,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"PHCS [10601]",PHCS,,6410.38,70,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 3CM 4.8FR .035IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145352050,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"FIRST HEALTH [10303]","First Health",,773.52,80,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET",RX-28384,CDM,,,0250,RC,27808-0037-01,NDC,both,1,UN,12.54,3.76,"UHC [10700]","United Healthcare",,7.94,63.3,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 12MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE40012,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"PHCS [10601]",PHCS,,58565.22,70,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X4CM VIASHIELD AMNION 2 LAYER PATCH",SUP-8155.2004S,CDM,V2790,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]","Cigna Local Plus",,4781.7,31.5,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 4MM XCOARSE BALL DISSECTING DIAMOND",SUP-MR8-14BA40DX,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.17,412.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,934.44,68,,,,,0,159.82,1168.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL PRE BENT TITANIUM 35MM X 110MM RELINE-C",SUP-3943110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR VIVACIT-E OSSEOTI CERAMIC CEMENT STEM HEAD",SUP-98000100232,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"CIGNA [10200]","Cigna Local Plus",,8731.8,31.5,,5372.07,4581.20,7242.98,23,3223.84,23562,"percent of total billed charges",
"SCR BONE 3.5MM 38MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0247,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross PPO",,371.5,39.2,,957.42,570.23,957.42,28,110.22,805.55,"percent of total billed charges",
"CATH DXTERITY 100CM 6FR .056IN JUDKINS LEFT 4 CURVE",SUP-DXT6JL40,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"KAISER [10500]",Kaiser,,55.38,67,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 8MM SMALL SHELL DJO SURGICAL ALTIVATE",SUP-533-08-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"BLUE CROSS [10001]","Blue Cross PPO",,18617.82,39.2,,3949.44,3949.44,3949.44,"1 through 10",5523.6,40370.27,"percent of total billed charges",
"GWIRE ZIPWIRE VASCULAR 180CM 3CM .035IN NITINOL POLYMER",SUP-M00146152B1,CDM,C1769,HCPCS,0272,RC,,,both,,,486.00,145.8,"KAISER [10500]",Kaiser,,325.62,67,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT",SUP-M006145362170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,768.37,68,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SKATER 40CM 12FR PIGTAIL CURVE DRNG BILIARY LOCK",SUP-755312040,CDM,C1729,HCPCS,0272,RC,,,both,,,651.24,195.37,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SELUTION DEB 2.00X35",SUP-SCA14U-200035D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL LOOP 6.5IN TUNGSTEN 20X12MM NONHEX",SUP-E15616,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.49,30.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT ELITE VASCULAR STRAIGHT",SUP-1011883,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT 22CM 3CM 6FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175261110,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"CIGNA [10200]","Cigna Local Plus",,663.07,,,,,,,144.14,1053.47,"percent of total billed charges",
"HOLDER 9.25IN JACOBSON INSRT LOCK HEAVY ROUND HANDLE NDL",SUP-32-471,CDM,S27200284,LOCAL,0272,RC,,,both,,,2245.28,673.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,266.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.13,1908.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VENACORE THROMBECTOMY STERILE LATEX FREE",SUP-46-101,CDM,C1757,HCPCS,0272,RC,,,both,,,40950.00,12285,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,27846,68,,,,,0,4762.49,34807.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOTUS VALVE SYSTEM: 21MM REPRISE III",SUP-H749LTVR3CL210,CDM,S62400003,LOCAL,0624,RC,,,both,,,142500.00,42750,"PHCS [10601]",PHCS,,99750,70,,,,,0,16572.75,121125,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM DCP LC-DCP STAINLESS STEEL PROXIMAL",SUP-204.218,CDM,C1713,HCPCS,0278,RC,,,both,,,117.28,35.18,"NOVANET [10819]",Novanet,,87.96,75,,,,,0,13.64,99.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD 25CM 8FR LOOP DRNG FLEXIMA METAL HYDROPHILIC",SUP-M001271320,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 65CM 4FR UNIVERSAL ANGIOGRAPHIC NEON SLX NYLON 5",SUP-451404V5,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"NOVANET [10819]",Novanet,,78.3,75,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Stoma",PX-750000068,CDM,44388,CPT,0750,RC,,,both,,,2592.95,777.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,307.26,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,301.56,2592.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 6.0 MM X 80 MM X 130 CM",SUP-IPU06008013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5489.64,68,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 45IN 8FR SIDEPORT WEIGHTED STYLET FLEXIFLO",SUP-00473,CDM,S27000186,LOCAL,0270,RC,,,both,,,73.95,22.18,"AETNA [10100]","Aetna HMO/PPO",,58.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) DEVICE CELT ACD 5FR CLSR VASCULAR STERILE LATEX FREE",SUP-KCLT-05,CDM,C1760,HCPCS,0278,RC,,,both,,,1539.00,461.7,"PHCS [10601]",PHCS,,1077.3,70,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.4MM OLIVE THREAD",SUP-P99.201.1406,CDM,C1713,HCPCS,0278,RC,,,both,,,550.80,165.24,"BLUE CROSS [10001]","Blue Cross HMO",,215.91,39.2,,957.42,156.86,7483.26,51,64.06,468.18,"percent of total billed charges",
"CATH MALECOT 35CM 24FR SUPRAPUBIC STENT LARGE OPEN NEPHRSTMY",SUP-M001224130,CDM,C1729,HCPCS,0272,RC,,,both,,,599.40,179.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,69.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Ctrl Bld",PX-750000079,CDM,45334,CPT,0750,RC,,,both,,,3094.10,928.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,366.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,359.84,3094.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 RB-1 36IN 2 ARM MONOFILAMENT BLUE",SUP-8557H,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.81,17.94,"KAISER [10500]",Kaiser,,40.07,67,,,,,0,6.96,50.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 4.8FR L18CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902090,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 5.5MM TITANIUM PREBENT",SUP-8052120,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"FIRST HEALTH [10303]","First Health",,3528,80,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 2 140CM 8CM 7FR 7MM .018IN BALLOON DILATATION",SUP-V187080,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,650.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM LCP TITANIUM DISTAL CORTICAL RADIAL SELF",SUP-402.874,CDM,C1713,HCPCS,0278,RC,,,both,,,358.70,107.61,"KAISER [10500]",Kaiser,,240.33,67,,,,,0,41.72,304.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 8MM 4MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012278-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG SILVER CELOS ETHYL SULPHONATE FIBER ANTIMICROBIAL",SUP-66800571,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.97,20.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,28.76,41.1,,,,,0,8.14,59.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URINARY STONES WITH MCC",693,MS-DRG,,,,,,,inpatient,,,47078.46,14123.54,"UHC [10700]","United Healthcare",,33530.49,,"Fee schedule rate ($33,530.49). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,33530.49,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH REFERENCE CARTO 3 EXTERNAL",SUP-CREFP6,CDM,S27000186,LOCAL,0270,RC,,,both,,,3142.50,942.75,"AETNA [10100]","Aetna HMO/PPO",,2498.29,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,365.47,2671.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPRESS ULTRA 6MMX20MM",SUP-ULF-106,CDM,C1726,HCPCS,0272,RC,,,both,,,11364.30,3409.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1321.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1321.67,9659.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Aero Presump ID Drainage",PX-306000014,CDM,87070,CPT,0306,RC,,,both,,,397.00,119.1,"CIGNA [10200]","Cigna Local Plus",,18.96,,,,,,,0.01,337.45,"fee schedule",
"HC ED Visit Level 2 W Proc",PX-450000314,CDM,99282,CPT,0450,RC,,,both,,,1194.97,358.49,"CIGNA [10200]","Cigna Open Access",,1194.97,,,,,,,67.13,1194.97,"case rate",
"GABAPENTIN 300 MG CAPSULE, IMMEDIATE RELEASE",RX-18308,CDM,,,0637,RC,00904-6666-61,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 70MM HIP MULTIHOLE RIM TRITANIUM X3 MDM",SUP-509-02-70I,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1330.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1306.28,9547.2,"percent of total billed charges",
"SCR BONE 6MM 50MM VIPER PRIME SPINE CORTEX POLYAXIAL FIX",SUP-186760450,CDM,C1713,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3325.46,45.9,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 121MM 11MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-00771101140,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2476.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2430.63,17764.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 21GA .087IN 45CM 10CM SPRING STRAIGHT WIRE",SUP-20-1060,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"FIRST HEALTH [10303]","First Health",,356.4,80,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X21MM ENDOSKELETON TAS 7D 11MM STD TITANIUM",SUP-2307-0111,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AETNA [10100]","Aetna HMO/PPO",,22538.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tte W/Wwo Cntrst Complt 2d",PX-483000018,CDM,C8929,HCPCS,0480,RC,,,both,,,3690.00,1107,"CIGNA [10200]","Cigna Open Access",,3690,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,429.15,3690,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 3MM TRUDI 0D STRAIGHT STERILE LATEX FREE",SUP-TSB3STR,CDM,S27200284,LOCAL,0272,RC,,,both,,,3562.50,1068.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ENDARTERECTOMY 9MM 11MM 2 COAXIAL METAL RING",SUP-4500-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,18893.70,5668.11,"KAISER [10500]",Kaiser,,12658.78,67,,,,,0,2197.34,16059.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG VARIABLE ANGLE LOCKING 1.8MM X 16MM",SUP-SPLS-18160-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,654.35,45.9,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH 45MM LAPAROSCOPIC STPLR",SUP-410370,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,83.86,45.9,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORMULA RESECTOR CUTTER,(BLACK/TAN)5.5MM ARTHROSCOPIC SHAVER",SUP-0375562000,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.94,39.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.23,111.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORD ELECTROSURGICAL UNIVERSAL ACTIVE ADPTR NONSTERILE",SUP-G22092,CDM,S27200284,LOCAL,0272,RC,,,both,,,777.60,233.28,"UHC [10700]","United Healthcare",,492.22,63.3,,,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR MEDIUM 30MM AVON KNEE",SUP-64300030,CDM,C1776,HCPCS,0278,RC,,,both,,,5561.40,1668.42,"AETNA [10100]","Aetna HMO/PPO",,4421.31,79.5,,10981.53,8986.79,12413.38,12,646.79,4727.19,"percent of total billed charges",
"CLIP INTERNAL HULKA VESSEL STERILE",SUP-4986.09,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.48,103.04,"PHCS [10601]",PHCS,,240.44,70,,,,,0,39.95,291.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION HI-FLO 155CM 2.8FR .027IN MICRO STRAIGHT",SUP-M001195420,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 41MM STD GLENOSPHERE COLOR CODED COMPREHENSIVE",SUP-115320,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3489.64,28.62,,,,,0,1418.05,10364.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esophagosc W/Sclero Inject",PX-750000199,CDM,43204,CPT,0750,RC,,,both,,,2075.00,622.5,"NOVANET [10819]",Novanet,,1556.25,75,,,,,0,241.32,2075,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PERIPHERAL L150MM DIA5MM CATHETER L130CM VASCULAR LIFE",SUP-EX051503CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20128.50,6038.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8051.4,40,,,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 16MM TITANIUM LOCK VARIABLE ANGLE",SUP-AR-8933V-16,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,164.86,1204.88,"percent of total billed charges",
"PUNCH STD HANDLE 3MM AORTIC PX6",SUP-APU430,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"MULTIPLAN [10600]",Multiplan,,246.47,85,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VERSACROSS VASCULAR 1 CURVE 93CM 180CM 24MM",SUP-VXAK0045,CDM,S27200284,LOCAL,0272,RC,,,both,,,6969.00,2090.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3198.77,45.9,,,,,0,810.49,5923.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM PRIMARY HEMISPHERICAL CLUSTER HOLE",SUP-502-03-52D,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"NOVANET [10819]",Novanet,,7850.12,75,,,,,0,1217.29,8896.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 17X10MM DIVERGENCE 14MM LORDOTIC NUCLEUS",SUP-G6626740,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"KAISER [10500]",Kaiser,,8321.4,67,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOJET ULTRA SOLENT OMNI THROMBECTOMY PERIPHERAL",SUP-109681-001,CDM,C1757,HCPCS,0272,RC,,,both,,,26365.50,7909.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH NC TREK 143CM 12MM 4.5MM ROUND BALLOON DILATATION",SUP-1012454-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC CT Hrt Morphology",PX-352000033,CDM,75572,CPT,0352,RC,,,both,,,1739.45,521.83,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($536.40). Procedures 2 - 999, Per diem ($268.20).",,,,0,,,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 79MM 12.2MM 7.6MM CUFFLESS NONFENESTRATE DISPOSABLE",SUP-8DCFS,CDM,S27200284,LOCAL,0272,RC,,,both,,,308.24,92.47,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOOK BONE 230MM BLUNT",SUP-MB418R,CDM,S27200284,LOCAL,0272,RC,,,both,,,357.57,107.27,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 8FR 15.5CM PEEL-AWAY PERCUTANEOUS STERILE",SUP-G00930,CDM,C1894,HCPCS,0272,RC,,,both,,,382.71,114.81,"PHCS [10601]",PHCS,,267.9,70,,,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE 30ML THORACIC DRNG 1 WAY STEPPED CNCT AIR LEAK WELL",SUP-16100,CDM,S27200284,LOCAL,0272,RC,,,both,,,613.59,184.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,252.19,41.1,,,,,0,71.36,521.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 100CM 5FR 8MM AMPLATZER .056IN TYPE II",SUP-9-AVP2-008,CDM,S27800098,LOCAL,0278,RC,,,both,,,6589.50,1976.85,"NOVANET [10819]",Novanet,,4942.13,75,,,,,0,766.36,5601.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE UBER FLEX 30MM 57CM 6MM .065IN VASCULAR",SUP-SR-0630-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE EYE 14MM NONSTERILE PMMA",SUP-14152-1,CDM,S27800098,LOCAL,0278,RC,,,both,,,147.90,44.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA D KNEE RIGHT 2 PEG TIVANIUM STERILE",SUP-42530006702,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"BLUE CROSS [10001]","Blue Cross PPO",,5560.53,39.2,,3949.44,3949.44,3949.44,"1 through 10",1649.72,12057.27,"percent of total billed charges",
"HC Influenza a/B/Ag Eia",PX-306000108,CDM,87400,CPT,0306,RC,,,both,,,279.00,83.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,42.56,,,,,,,0.28,237.15,"fee schedule",
"SCR BONE 2MM 14MM CHARLOTTE TITANIUM ORTHOPEDIC SELF TAPPING",SUP-45110003,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,1144.80,304.56,2275.09,66,189.34,1383.8,"percent of total billed charges",
"CATH 40CM 7.1FR URETERAL LASER",SUP-G17797,CDM,C1758,HCPCS,0272,RC,,,both,,,192.27,57.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,130.74,68,,,,,0,22.36,163.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION 4MM 8MM CORONARY OSTIUM NONPYROGENIC",SUP-OCB4008BA,CDM,C1725,HCPCS,0272,RC,,,both,,,6900.00,2070,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 20CM 3CM 8FR .035IN",SUP-M006192150190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CIGNA [10200]","Cigna Local Plus",,746.45,,,,,,,162.27,1185.95,"percent of total billed charges",
"SPLINT ORTHOPEDIC 6 2 3/16IN FINGER ADJUSTABLE WATERPROOF",SUP-92728106,CDM,S27000186,LOCAL,0270,RC,,,both,,,88.13,26.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,59.93,68,,,,,0,10.25,74.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X9MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7309,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"AMERIGROUP MEDICAID [20100]",Amerigroup,,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IV VIAFLEX 10 MEQ POTASSIUM CHLORIDE 5% DEXTROSE 0.45%",SUP-2B1644X,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC PULSED LAVAGE INTERPULSE SUCTION COAXIAL HIGH FLOW TIP",SUP-0210-114-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.14,99.04,"PHCS [10601]",PHCS,,231.1,70,,,,,0,38.4,280.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 6FR 4.5MM .07",SUP-H7493926708450,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.7MM 80MM 18MM LOW PROFILE SCREWS TITANIUM 3.5MM",SUP-AR-8967-1880,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"CIGNA [10200]","Cigna Open Access",,1066.88,56.9,,1144.80,304.56,2275.09,66,218.06,1593.75,"percent of total billed charges",
"SCR BASEPLT 29MM 4.5MM AEQUALIS REVERSED GLENOID TITANIUM",SUP-VDV229,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"MULTIPLAN [10600]",Multiplan,,1322.6,85,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 7FR 5MM SPACE D CURVE ELECTROPHYSIOLOGY",SUP-D7DR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"KAISER [10500]",Kaiser,,1552.73,67,,,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON CABLE BLUE 2.5MM FEMUR TITANIUM ALUMINUM VANADIUM",SUP-47223206001,CDM,C1713,HCPCS,0278,RC,,,both,,,1912.50,573.75,"KAISER [10500]",Kaiser,,1281.38,67,,,,,0,222.42,1625.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 40MM 150CM 6MM VASCULAR NICKEL",SUP-EVD35-06-040-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"MULTIPLAN [10600]",Multiplan,,5342.25,85,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 15MM 3.2-2.4-2.6FR 2.5MM BALLOON",SUP-SPR2515W,CDM,C1725,HCPCS,0272,RC,,,both,,,607.50,182.25,"FIRST HEALTH [10303]","First Health",,486,80,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT SL II SITEMARK 50.7CM 47CM 9FR 7FR RIGHT",SUP-DS2C006,CDM,C1887,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,437.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINIARC PRECISE",SUP-720191-01,CDM,C1771,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross HMO",,4057.2,39.2,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUADRA ALLURE MP RF CRT-P MRI, MERLIN PKG",SUP-PM3562CELL,CDM,C2621,HCPCS,0275,RC,,,both,,,25200.00,7560,"MULTIPLAN [10600]",Multiplan,,21420,85,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SEALING 35CM 5MM ENSEAL G2 CURVED JAW VESSEL SEAL",SUP-NSLG2C35,CDM,S27200284,LOCAL,0272,RC,,,both,,,3520.22,1056.07,"AETNA [10100]","Aetna HMO/PPO",,2798.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,409.4,2992.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPEEDAKIN ANATOMIC RAPID COMPRESSION IMPLANT - 9MM X 9MM",SUP-SK63,CDM,C1713,HCPCS,0278,RC,,,both,,,12937.50,3881.25,"FIRST HEALTH [10303]","First Health",,10350,80,,,,,0,1504.63,10996.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TIGHTRAIL 18FR 18.7IN 11FR 23FR 11.2FR DIL ROTATE",SUP-545-511,CDM,C1773,HCPCS,0272,RC,,,both,,,15766.50,4729.95,"UHC [10700]","United Healthcare",,9980.19,63.3,,,,,0,1833.64,13401.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640706,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Open Access",,6403.47,56.9,,5302.19,4377.88,6578.61,27,1308.83,9565.82,"percent of total billed charges",
"MATRIX TISSUE 10X7CM CYTAL PORCINE BLADDER 3 LAYER",SUP-WSR0710,CDM,Q4166,HCPCS,0636,RC,,,both,,,14096.70,4229.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9162.86,65,,,,,0,53.69,11982.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS ANTIBACTERIAL UNIDIRECTIONAL",SUP-SXMP1B411,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.17,68.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,155.84,68,,,,,0,26.65,194.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 7MM 0MM ELBOW",SUP-TR-S0700-S,CDM,C1776,HCPCS,0278,RC,,,both,,,15145.50,4543.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1761.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1761.42,12873.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 16MM COCR",SUP-VAL-20160-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]","Cigna Local Plus",,762.7,53.5,,3978.14,359.25,3978.14,24,165.8,1211.76,"percent of total billed charges",
"GUIDE PIN ORTHOPEDIC 100MM DECADE SPINE XLIF",SUP-7141112,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 4MM 7FR 1-7-4MM SPACE J CURVE ABLATION",SUP-118432S,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9337.08,68,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSPONGE CANCELLOUS DEMINERALIZED BONE MATRIX",SUP-109530,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"PHCS [10601]",PHCS,,7245,70,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE SURGICEL OXIDIZED REGENERATED CELOS",SUP-3013SP,CDM,S27200284,LOCAL,0272,RC,,,both,,,2581.88,774.56,"AETNA [10100]","Aetna HMO/PPO",,2052.59,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,300.27,2194.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F702,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"KAISER [10500]",Kaiser,,11483.82,67,,,,,0,1993.39,14569.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 33MM BOVINE PERICARDIUM LEAFLET COBALT CHROMIUM",SUP-11400M33,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18642.96,41.1,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 20GA 25GA 3.5IN 1.5IN 5ML 20ML LOR 1 DOSE WING",SUP-332254,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.92,34.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,77.47,68,,,,,0,13.25,96.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH-PROFILE BOOST, 280CC",SUP-SMHB280,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2182.13,28.62,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR EVAC ELLIK LATEX",SUP-03664,CDM,S27200284,LOCAL,0272,RC,,,both,,,726.08,217.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.44,617.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SOLUS 7CM 210CM 10FR 5FR .035IN 2 PIGTAIL CURVE",SUP-G25673,CDM,C2625,HCPCS,0278,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross PPO",,482.63,39.2,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEPTIC ARTHRITIS WITHOUT CC/MCC",550,MS-DRG,,,,,,,inpatient,,,22873.73,6862.12,"UHC [10700]","United Healthcare",,21799.18,,"Fee schedule rate ($21,799.18). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,5422.09,21799.18,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY JNS CURVE 5MM SPACING 5FR 120CM",SUP-401443,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"AETNA [10100]","Aetna HMO/PPO",,248.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE WIDE ACU-LOC 2 BONE RIGHT VOLAR DISTAL RADIAL",SUP-70-0361,CDM,C1713,HCPCS,0278,RC,,,both,,,5019.00,1505.7,"BLUE CROSS [10001]","Blue Cross HMO",,1967.45,39.2,,957.42,156.86,7483.26,51,583.71,4266.15,"percent of total billed charges",
"SABER .035 4X250 135CM SL",SUP-48004025R,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"PHCS [10601]",PHCS,,728.71,70,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 39MM TORNIER AEQUALIS PERFORM +3MM SHOULDER",SUP-DWJ023,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"FIRST HEALTH [10303]","First Health",,9754.4,80,,,,,0,1418.05,10364.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT 120MM SCP ACCUPORT 11GA KNEE SIDE DELIVERY",SUP-414.502,CDM,C1713,HCPCS,0278,RC,,,both,,,23486.40,7045.92,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2731.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",2731.47,19963.44,"percent of total billed charges",
"INSRT TIBIAL 4 CURVE PLUS 20MM KNEE XLK FIX BEARING SIGMA",SUP-970465,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AETNA [10100]","Aetna HMO/PPO",,8883.77,79.5,,10981.53,8986.79,12413.38,12,1299.6,9498.37,"percent of total billed charges",
"CATH 20CM CENTRAL VENOUS 3 LUMEN OXIMETRY CONTINUOUS SCVO2",SUP-XA3820SAFKT,CDM,C1751,HCPCS,0272,RC,,,both,,,2887.50,866.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,342.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR TRABECULAR METAL CERAMIC XLPE POROUS STEM CUP",SUP-98000570005,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"UHC [10700]","United Healthcare",,15154.02,63.3,,8601.07,8395.67,8601.07,"1 through 10",2784.22,20349,"percent of total billed charges",
"SCR BONE 3.5MM 26MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.826,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,160.92,68,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Initial Care Training 30 M (Gp)",PX-420000188,CDM,G0539,HCPCS,0420,RC,,,both,,,70.00,21,"NOVANET [10819]",Novanet,,52.5,75,,,,,0,0.07,70,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON THORACIC RIGHT TITANIUM ANGLE BLADE",SUP-7541188,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VEST, CUP X-LARGE","SUP-STYLE 16V X-LRG",CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 5.5MM CURVE TITANIUM NONSTERILE",SUP-1553201090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X16MM COLOSSEUM 12MM MESH NONSTERILE LATEX",SUP-156.204,CDM,S27800098,LOCAL,0278,RC,,,both,,,27184.50,8155.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3221.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3161.56,23106.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTRA 45CM 8.7FR 7.3FR AL6 CURVE GUIDING PEBAX","SUP-375 519",CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA ARTHROSCOPIC L90 MM OD5.5 MM THREAD STERILE CLEAR",SUP-214110,CDM,S27200284,LOCAL,0272,RC,,,both,,,759.78,227.93,"FIRST HEALTH [10303]","First Health",,607.82,80,,,,,0,88.36,645.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 15MM 140CM 2.5MM 2.1-2.7FR CORONARY",SUP-RONYX25015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1704.04,45.9,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SET EXPEDIUM VERSE SPINE UNITIZE 5.5 MM ROD",SUP-199721001S,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,170.52,39.2,,957.42,570.23,957.42,28,50.59,369.75,"percent of total billed charges",
"REMOVAL KIT",SUP-R540000RK,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.80,114.84,"NOVANET [10819]",Novanet,,287.1,75,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN AMPLATZ RIGHT 1 CURVE",SUP-H74908641842,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"FIRST HEALTH [10303]","First Health",,61.26,80,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AMULET 75CM 14FR CATH STEERABLE DELIVERY STERILE",SUP-STRBL-14F-075,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"AETNA [10100]","Aetna HMO/PPO",,5485.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 80CM 80MM 8MM .035IN BALLOON",SUP-AB35W08080080,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,460.47,68,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 520CC SMOOTH SHELL SURFACE COHESIVE GEL 1 LUMEN",SUP-SRF-520,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"KAISER [10500]",Kaiser,,3675.29,67,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 24CM 20FR AXILLARY AORTA SUBCLAVIAN 3/8IN",SUP-OPTI20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1902.83,570.85,"CIGNA [10200]","Cigna Local Plus",,1018.01,53.5,,,,,0,221.3,1617.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemdnrv 1-4 Musc Ea Add Ext",PX-361000331,CDM,64643,CPT,0761,RC,,,both,,,2598.27,779.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 115CM 1MM 7FR 2-8-2MM SPACE D CURVE ELECTROPHYSIOLOGY",SUP-D710DRP10CT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE L145CM .014IN IMAGING STRAIGHT TIP OCCLUDING HYDRO",SUP-4583,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Ekg Holter Scan/Report",PX-731000002,CDM,93226,CPT,0731,RC,,,both,,,986.00,295.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Bx Endometrial",PX-361000465,CDM,58100,CPT,0361,RC,,,both,,,567.46,170.24,"NOVANET [10819]",Novanet,,425.6,75,,,,,0,66,567.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX12MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183522,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1506.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM MAXIM ARCOM KNEE POSTERIOR STABILIZE",SUP-11-146572,CDM,C1776,HCPCS,0278,RC,,,both,,,7472.70,2241.81,"MULTIPLAN [10600]",Multiplan,,6351.8,85,,,,,0,869.08,6351.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endoscopic Revision Gastrojejunostomy Anastomosis, Using Overstitch Device",PX-750000263,CDM,43999,CPT,0750,RC,,,both,,,1428.00,428.4,"BLUE CROSS [10001]","Blue Cross PPO",,1428,,"Case rate ($5,500.90). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,166.08,1428,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HALOPERIDOL LACTATE 5 MG/ML INJECTION SUPERORDERABLE",RX-409467,CDM,J1630,HCPCS,0636,RC,63323-0474-00,NDC,both,1,ML,54.27,16.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1.97,,,,,,,0.86,46.13,"fee schedule",
"CATH TORCON NB ADVANTAGE BEACON TIP 100CM 5FR .038IN VERT",SUP-G11484,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CIGNA [10200]",Cigna,,161.49,68,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTIGRAFT VG1 7D ALLOGRAFT PRESERVON 12X14.5X9MM",SUP-VG1C-T79P,CDM,C1713,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1678.56,28.62,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Tunl IP Cath W Img Guid",PX-361000203,CDM,49418,CPT,0361,RC,,,both,,,12941.24,3882.37,"FIRST HEALTH [10303]","First Health",,10352.99,80,,,,,0,1505.07,11000.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 17.5MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962344,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1718.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US OB 1st Trimst Txabd Add",PX-402000015,CDM,76802,CPT,0402,RC,,,both,,,953.00,285.9,"CIGNA [10200]","Cigna Open Access",,542.26,56.9,,,,,0,66.05,810.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 165CM TRIANGLETIP KNIFE J STERILE",SUP-KD-645L,CDM,S27200284,LOCAL,0272,RC,,,both,,,6099.60,1829.88,"AETNA [10100]","Aetna HMO/PPO",,4849.18,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,709.38,5184.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR DYNASTY A-CLASS 15D 36MM POLY BIOFOAM HIP",SUP-DLXPLD36,CDM,C1776,HCPCS,0278,RC,,,both,,,7507.20,2252.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3445.8,45.9,,,,,0,873.09,6381.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 7MM LONG ROUND HEAD DIAMOND POINT STERILE",SUP-5130012070,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.07,262.22,"NOVANET [10819]",Novanet,,655.55,75,,,,,0,101.65,742.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRAUMA SHEATH GWIRE NDL SYR ARROW-FLEX 3.5IN .035IN",SUP-AK-05801,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.27,57.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,130.74,68,,,,,0,22.36,163.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORTICAL SCREW 4MM X 48MM",SUP-HTN-U-4-48,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"KAISER [10500]",Kaiser,,1041.98,67,,,,,0,180.87,1321.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 22MM LCP STAINLESS STEEL FULL THREAD CORTEX",SUP-02.204.022,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"CIGNA [10200]","Cigna Open Access",,561.36,56.9,,1144.80,304.56,2275.09,66,114.74,838.59,"percent of total billed charges",
"STENT PROTEGE GPS EXPRT 40MM 80CM 14MM .079IN LARGE DIAMETER",SUP-SERB65-14-40-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Open Access",,3166.49,56.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA HAND SUTUPAK 1 24IN BRAID TIES 13 STRAND",SUP-SA77G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,inpatient,,,561084.65,168325.39,"CIGNA [10200]","Cigna Local Plus",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 44%. Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STARTER BENTSON VASCULAR STD TAPER 260CM 15CM .035IN",SUP-M001491481,CDM,C1769,HCPCS,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYNCHRO .014GUIDE WIRE  300 CM LENGTH",SUP-M00313310,CDM,C1769,HCPCS,0272,RC,,,both,,,5686.57,1705.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT SHEATH 10CM 5FR 21GA .074IN .068IN GLIDESHEATH SURFLO",SUP-20-1050,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL 3 STD 10MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS3S10L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"UHC [10700]","United Healthcare",,6577.76,63.3,,8601.07,8395.67,8601.07,"1 through 10",1208.52,8832.69,"percent of total billed charges",
"DISC ARTIFICIAL 15X7MM M6-C 12.5MM MEDIUM SPINE CERVICAL",SUP-CDM-725,CDM,C1776,HCPCS,0278,RC,,,both,,,37800.00,11340,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15120,40,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR",SUP-SSR10-01,CDM,A4648,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM 5MM S-ROM ZTT 18D LARGE HIP POROUS",SUP-550524,CDM,C1776,HCPCS,0278,RC,,,both,,,6466.32,1939.9,"AETNA [10100]","Aetna HMO/PPO",,5140.72,79.5,,10981.53,8986.79,12413.38,12,752.03,5496.37,"percent of total billed charges",
"KIT INTRO 10CM 4FR 21GA 3FR MERIT PAK .018IN 40CM PEDAL",SUP-PAKS4NPD7,CDM,C1894,HCPCS,0272,RC,,,both,,,497.02,149.11,"UHC [10700]","United Healthcare",,314.61,63.3,,,,,0,57.8,422.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISSECTOR ENDOSCOPIC KITTNER STAINLESS STEEL L38 CM OD5 MM 2",SUP-KT-9105,CDM,S27200284,LOCAL,0272,RC,,,both,,,115.60,34.68,"UHC [10700]","United Healthcare",,73.17,63.3,,,,,0,13.44,98.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 150MM 4MM BALLOON DILATATION",SUP-H74939147401510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY PRESSURE MNTR 4FR .021IN 12CM 1 LUMEN CATH GWIRE NDL",SUP-G58419,CDM,C1887,HCPCS,0272,RC,,,both,,,850.50,255.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,100.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE PSR CORTICAL BLOCK 14X11X8MM CERVICAL",SUP-200841,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 195MM STAINLESS STEEL 4.5MM SCR 8 HOLE 4 COLUMN",SUP-02.124.408,CDM,C1713,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"NOVANET [10819]",Novanet,,7503.75,75,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 10X22X55MM 5DEG LORDOTIC WIDE MODULUS XL-W",SUP-1223055P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 100CM 40MM 7MM BALLOON",SUP-LX181007405F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4574.7,68,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 38MM 2 LEVEL ARCHON BONE SPINE NONSTERILE",SUP-8787238,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"KAISER [10500]",Kaiser,,2954.7,67,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD ILINK 2X IMPLANTABLE UNIPOLAR BIPOLAR IS-1",SUP-347481,CDM,S27200284,LOCAL,0272,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lyme Western Blot",PX-302000101,CDM,86617,CPT,0302,RC,,,both,,,486.40,145.92,"AETNA [10100]","Aetna HMO/PPO",,386.69,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,413.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 6.3X3.1IN XENMATRIX AB RECTANGLE DERMAL CLLGN",SUP-1150816,CDM,C1781,HCPCS,0278,RC,,,both,,,20829.69,6248.91,"NOVANET [10819]",Novanet,,15622.27,75,,,,,0,2422.49,17705.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"Y-KNOT RC ALL-SUTURE ANCHOR, WITH TWO #2 ( 5 METRIC) HI-FI S",SUP-YRC02,CDM,C1713,HCPCS,0278,RC,,,both,,,4552.69,1365.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1302.98,28.62,,,,,0,529.48,3869.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 RB-1 30IN 2 ARM BRAID 10 STRAND GREEN",SUP-10X42,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.10,84.33,"NOVANET [10819]",Novanet,,210.83,75,,,,,0,32.69,238.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 150MM NEXEL 4",SUP-00840004415,CDM,C1776,HCPCS,0278,RC,,,both,,,36662.85,10998.85,"AETNA [10100]","Aetna HMO/PPO",,29146.97,79.5,,10981.53,8986.79,12413.38,12,4263.89,31163.42,"percent of total billed charges",
"IMPACT TISSUE FUSION OPEN INSTRUMENT",SUP-LF4418,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM TITANIUM NIOBIUM ALUMINUM X25 FEMORAL",SUP-04.045.040TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 6947100  LEAD-QUADRIPOLAR RV/SVC 10",SUP-6947-100,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6868.8,40,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DIL GARRETT 8.25IN",SUP-25-8015,CDM,S27200284,LOCAL,0272,RC,,,both,,,1366.71,410.01,"PHCS [10601]",PHCS,,956.7,70,,,,,0,158.95,1161.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 16CM 6FR SHORT LENGTH URETERAL",SUP-H7493936106160,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"CIGNA [10200]",Cigna,,842.72,68,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 19MM 135CM 6MM THIN VASCULAR COCR",SUP-1012629-19,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"BLUE CROSS [10001]","Blue Cross HMO",,3292.8,39.2,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 81MM 12.2MM 7.6MM CUFF INNER CANN LOW PRESSURE",SUP-8FEN,CDM,S27200284,LOCAL,0272,RC,,,both,,,399.33,119.8,"PHCS [10601]",PHCS,,279.53,70,,,,,0,46.44,339.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TEGADERM ANITBDY FILM HEMATOLOGY TEST",SUP-HPAD22,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"CIGNA [10200]","Cigna Local Plus",,153.6,53.5,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X10MM CLYDESDALE PTC 0D PEEK TITANIUM",SUP-4980050,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3297.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR TRABECULAR METAL STEM STD HEAD",SUP-98786410000,CDM,C1776,HCPCS,0278,RC,,,both,,,15180.00,4554,"MULTIPLAN [10600]",Multiplan,,12903,85,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR GREEN 46MM 28MM RINGLOC BIO-MOORE II HIP",SUP-11165216,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"NOVANET [10819]",Novanet,,4994.91,75,,,,,0,774.54,5660.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRODUCER 30CM 6.5FR TEARAWAY SMOOTH TRANSITION ACCEPTS",SUP-INT-106-09,CDM,C1894,HCPCS,0272,RC,,,both,,,369.75,110.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43,314.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPRESSION STOCKING ANTI-EMBOLISM 18MMHG KNEE HIGH MEDIUM R",SUP-4279,CDM,S27000186,LOCAL,0270,RC,,,both,,,111.19,33.36,"UHC [10700]","United Healthcare",,70.38,63.3,,,,,0,12.93,94.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 12/14 TAPER 28MM HIP OXINIUM ECHELON",SUP-71342804,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"FIRST HEALTH [10303]","First Health",,12428.28,80,,,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nfct Ds 22 Trgt Sars-Cov-2",PX-300000414,CDM,0202U,CPT,0300,RC,,,both,,,1106.30,331.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1.11,.1,,,,,0,1.11,940.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 150MM 1.4MM",SUP-MSG14150,CDM,C1769,HCPCS,0272,RC,,,both,,,174.00,52.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD REAMER 950MM 3MM TITANIUM SMOOTH TIP DISTAL FEMORAL NAIL",SUP-355.041S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1183.90,355.17,"CIGNA [10200]",Cigna,,805.05,68,,,,,0,137.69,1006.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 2-0 CT-2 SPIRAL 15CM CLSR",SUP-SXPP1B413,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.96,69.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,157.73,68,,,,,0,26.98,197.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM CD HORIZON SPINAL FENESTRATE MULTIAXIAL",SUP-55840025540T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"CMPNT FEMORAL 6 NARROW KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-71933655,CDM,C1776,HCPCS,0278,RC,,,both,,,22273.65,6682.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9154.47,41.1,,6417.48,6417.48,6417.48,"1 through 10",2590.43,18932.6,"percent of total billed charges",
"ROD SPINAL 300MM 5.5MM RELINE STRAIGHT TITANIUM MAS",SUP-12355300,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE WALKING SMALL STD FOOT ANKLE 1 PIECE 2 LAYER MEMORY",SUP-SL8001-03,CDM,S27000186,LOCAL,0270,RC,,,both,,,228.03,68.41,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.52,193.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 7CM 7FR DUODENAL BEND BILIARY FLEXIMA PLASTIC",SUP-M00539210,CDM,C2625,HCPCS,0278,RC,,,both,,,755.24,226.57,"CIGNA [10200]",Cigna,,513.56,68,,,,,0,87.83,641.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 5-0 C-1 30IN BRAID BLACK NONABSORBABLE",SUP-K890H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"NOVANET [10819]",Novanet,,18.75,75,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 445CC P5.5CM MODERATE PLUS PROJECTION TALL",SUP-334-1309,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4196.41,45.9,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 20MM 6FR 4.5MM 4FR BALLOON",SUP-39031-45201,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP CUP ENDOSCOPIC VCARE PLUS XL 40MM CERVICAL UTERINE",SUP-60-6085-203A,CDM,S27200284,LOCAL,0272,RC,,,both,,,522.45,156.73,"CIGNA [10200]","Cigna Open Access",,297.27,56.9,,,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 11MM KII ABDOMEN ADVANCE FIXATION",SUP-CFR33,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE RELINE C SPINE OPEN LOCK NONSTERILE LATEX FREE",SUP-3900240,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"CIGNA [10200]",Cigna,,236.64,68,,1831.33,1831.33,1831.33,16,40.47,295.8,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 38MM 140CM 2.25MM 2.1-2.7FR CORONARY",SUP-RONYX22538UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1062.52,28.62,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.2MM 150MM KIRSCHNER 1 END TROCAR TIP SMOOTH",SUP-P99-192-1215,CDM,C1713,HCPCS,0278,RC,,,both,,,146.16,43.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,41.83,28.62,,,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL AMPLATZ FIRM KINK RESISTANT GRADUATE TAPER 35CM",SUP-M0062601090,CDM,C1894,HCPCS,0272,RC,,,both,,,362.44,108.73,"NOVANET [10819]",Novanet,,271.83,75,,,,,0,42.15,308.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 50MM FIXOS COMPRESSION HEADLESS NONSTERILE",SUP-658350,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,957.42,156.86,7483.26,51,434.96,3179,"percent of total billed charges",
"BASEPLT TIBIAL TRIATHLON 4 LEFT MEDIAL RIGHT LATERAL PARTIAL",SUP-5620-B-401,CDM,C1776,HCPCS,0278,RC,,,both,,,6899.26,2069.78,"KAISER [10500]",Kaiser,,4622.5,67,,,,,0,802.38,5864.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR070502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5369.51,28.62,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AFX2 BIFURCATED STENT GRAFT 25MM X 16MM X 135MM - BEA25-80/I",SUP-BEA25-80/I16-55,CDM,S27800098,LOCAL,0278,RC,,,both,,,84559.50,25367.85,"AETNA [10100]","Aetna HMO/PPO",,67224.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9834.27,71875.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 70MM LCP STAINLESS STEEL PROXIMAL FEMORAL",SUP-02.205.070,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"CIGNA [10200]","Cigna Local Plus",,675.85,53.5,,3978.14,359.25,3978.14,24,146.92,1073.79,"percent of total billed charges",
"CATH SABERX 200CM 120MM 3MM BALLOON DILATATION RAPID",SUP-47530120L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EDWARDS SAPIEN M3 MITRAL VALVE REPLACEMENT SYSTEM (29 MM VAL",SUP-SM329US1,CDM,S27800098,LOCAL,0278,RC,,,both,,,307800.00,92340,"UHC [10700]","United Healthcare",,194837.4,63.3,,,,,0,35797.14,261630,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERSACROSS CONNECT LAAC 180J D0",SUP-VXAK0109,CDM,S27200284,LOCAL,0272,RC,,,both,,,6969.00,2090.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4738.92,68,,,,,0,810.49,5923.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 2X133MM GOLDENBERG EAR HA FOOTPLATE SHOE",SUP-140914,CDM,L8613,HCPCS,0278,RC,,,both,,,1710.08,513.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,489.42,28.62,,,,,0,198.88,1453.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 4 LEFT MEDIAL RIGHT LATERAL PARTIAL",SUP-5620-B-401,CDM,C1776,HCPCS,0278,RC,,,both,,,6899.26,2069.78,"CIGNA [10200]","Cigna Open Access",,3925.68,56.9,,5302.19,4377.88,6578.61,27,802.38,5864.37,"percent of total billed charges",
"CATHETER ANGIOPLASTY L150CM BALLOON L22CM DIA3.5MM SHEATH DI",SUP-U41503H22,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.00 X 33 RX US",SUP-1804300-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"LENS IOL +24 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.240,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Transducer Triple",PX-E27200279,CDM,E27200279,LOCAL,0272,RC,,,both,,,314.61,94.38,"CIGNA [10200]","Cigna Open Access",,179.01,56.9,,,,,0,36.59,267.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X8X7MM RISE NONSTERILE",SUP-193.001,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOUTH PROCEDURES WITHOUT CC/MCC",138,MS-DRG,,,,,,,inpatient,,,46644.69,13993.41,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,5881.95,,"Case rate ($5,497.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,104.48, add-ons for qualifying new technology services are included. If operating cost exceeds $38,144.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,767.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $5,111.23. The transfer operating threshold is the transfer adjustment factor * $5,104.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $385.92. The transfer capital threshold is the transfer adjustment factor * $385.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,5497.15,25873.5,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"ISTENT INJECT",SUP-G2W-US,CDM,C1783,HCPCS,0278,RC,,,both,,,11212.50,3363.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1328.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1304.01,9530.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 2-0 GS-21 .5 CIRCLE 6IN 37MM CLSR TAPER",SUP-VLOCL0305,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"CIGNA [10200]",Cigna,,133.17,68,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE ENFORM 25X40CM INTRAPERITONEAL",SUP-GBFR2540,CDM,C1781,HCPCS,0272,RC,,,both,,,103084.50,30925.35,"UHC [10700]","United Healthcare",,65252.49,63.3,,,,,0,42367.73,65252.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatobiliary Sys Img",PX-341000017,CDM,78226,CPT,0341,RC,,,both,,,3290.63,987.19,"BLUE CROSS [10001]","Blue Cross HMO",,871.78,,"Fee schedule rate ($871.78).",,,,0,382.7,2797.04,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Del Vag Only",PX-450000288,CDM,59409,CPT,0450,RC,,,both,,,4627.00,1388.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.13,,,,,,,67.13,3932.95,"case rate",
"AVENIR 10, 1.5 X 3 HELICAL PICO COIL",SUP-10USH01503,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"KAISER [10500]",Kaiser,,7854.48,67,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM CREO SPINE POLYAXIAL FENESTRATE THREAD",SUP-5192.1547,CDM,C1713,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,797.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,782.41,5718.38,"percent of total billed charges",
"FILTER VASCULAR 46MM 12FR VENA CAVA GREENFIELD JUGULAR",SUP-M001504000,CDM,C1880,HCPCS,0278,RC,,,both,,,4195.00,1258.5,"PHCS [10601]",PHCS,,2936.5,70,,,,,0,487.88,3565.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9 % IV BOLUS 1000 ML",RX-410707,CDM,,,0258,RC,00990-7983-09,NDC,both,1000,ML,100.65,30.19,"CIGNA [10200]",Cigna,,68.44,68,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM LCP",SUP-02.211.020,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,257.04,28.62,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE REGENERATION",SUP-345111,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER PACING LEAD ACUITY 8FR",SUP-7442,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE LEFT POSTERIOR STABILIZE BEAD TRIATHLON",SUP-5516F801,CDM,C1776,HCPCS,0278,RC,,,both,,,23001.30,6900.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2675.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2675.05,19551.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 3MM 27FR STERILE DISPOSABLE BROWN 1",SUP-27050M/6,CDM,S27200284,LOCAL,0272,RC,,,both,,,1050.84,315.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,482.34,45.9,,,,,0,122.21,893.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TELESCOPING SMOKE EVACUATION R",SUP-SEP6000NSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.47,70.34,"UHC [10700]","United Healthcare",,148.42,63.3,,,,,0,27.27,199.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SIGNAFUSE BIPHASIC CALCIUM PHOSPHATE BIOACTIVE",SUP-SGF-150,CDM,C1713,HCPCS,0278,RC,,,both,,,12972.00,3891.6,"UHC [10700]","United Healthcare",,8211.28,63.3,,5023.51,2672.93,6679.78,18,1508.64,11026.2,"percent of total billed charges",
"SCR BONE 5MM 12MM LCP STAINLESS STEEL DISTAL FEMUR CONDYLE",SUP-02.221.512S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL 15X5MM MOBI-C 13MM CERVICAL TITANIUM COCRMO UHMWPE","SUP-MB 3355",CDM,S27800098,LOCAL,0278,RC,,,both,,,33075.00,9922.5,"KAISER [10500]",Kaiser,,22160.25,67,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C1 Inhibitor Protein",PX-302000021,CDM,86160,CPT,0302,RC,,,both,,,373.00,111.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.84,,"Fee schedule rate ($12.84). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.37,317.05,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX EXTREME 80CM 4CM 5FR 4MM LOW PROFILE TAPER",SUP-4154040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM TITANIUM T15 FULL THREAD HEXALOBE",SUP-AR-8935-32,CDM,C1713,HCPCS,0278,RC,,,both,,,486.00,145.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,56.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",56.52,413.1,"percent of total billed charges",
"CATH INFINITI THRULUMEN 110CM 4FR 145D PIGTAIL CURVE",SUP-538453S,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"FIRST HEALTH [10303]","First Health",,71.62,80,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM TITANIUM SELF TAP LOCK NONSTERILE AXSOS 3",SUP-661134,CDM,C1713,HCPCS,0278,RC,,,both,,,1377.32,413.2,"BLUE CROSS [10001]","Blue Cross HMO",,539.91,39.2,,957.42,156.86,7483.26,51,160.18,1170.72,"percent of total billed charges",
"BIT DRILL 4.3MM LONG CALIBRATED STERILE",SUP-03.313.701S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22-24X27-32X9MM LUMINARY CC BICONVEX SPINE",SUP-16809,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3868.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 60MM 2.5MM .014IN BALLOON DILATATION",SUP-AB14W025060150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 16CM NARROW BASE INFRAPUBIC NARROW CORPORA",SUP-EN8816,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"FIRST HEALTH [10303]","First Health",,50160,80,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 380MM FEMUR RIGHT GAMMA INTRAMEDULLARY 125D LONG",SUP-3425-1380S,CDM,C1713,HCPCS,0278,RC,,,both,,,13435.13,4030.54,"PHCS [10601]",PHCS,,9404.59,70,,,,,0,1562.51,11419.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Progesterone",PX-301000373,CDM,84144,CPT,0301,RC,,,both,,,181.45,54.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,32.81,,,,,,,0.18,154.23,"fee schedule",
"CATH JADE 150CM 240MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-583524022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 3CM 7FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175274050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,126.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 6-9 E-F KNEE LEFT",SUP-42511400710,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"CIGNA [10200]","Cigna Open Access",,4595.11,56.9,,5302.19,4377.88,6578.61,27,939.21,6864.4,"percent of total billed charges",
"LANOLIN-MINERAL OIL LOTION",RX-2787,CDM,,,0637,RC,00904-4299-09,NDC,both,236,ML,14.85,4.45,"MULTIPLAN [10600]",Multiplan,,12.62,85,,,,,0,1.73,12.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE GENESIS 23CM 9.5MM TAIL CAP TRIMMABLE",SUP-919509SC,CDM,C2622,HCPCS,0278,RC,,,both,,,55704.60,16711.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6601,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6478.44,47348.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 54MM ALPS T15 TIBIA CORTICAL DISTAL LOCK SELF",SUP-816135054,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDPLATE SPINAL 14X6MM SECURE-C 6D 13MM SPHERICAL",SUP-714.266S,CDM,C1713,HCPCS,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8113.77,28.62,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23MMX11MM ELEVATE XLORDOTIC PEEK TITANIUM",SUP-8881123,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross HMO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL CHARLOTTE STAINLESS STEEL CANNULATED 4.3 MM SCR",SUP-44112003,CDM,S27200284,LOCAL,0272,RC,,,both,,,1296.00,388.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,594.86,45.9,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ER Amput Finger/Thumb Sgl Clsr",PX-450000365,CDM,26951,CPT,0361,RC,,,both,,,9895.00,2968.5,"BLUE CROSS [10001]","Blue Cross PPO",,4431.65,,"Case rate ($4,431.65). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1150.79,8410.75,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 80MM 80CM 12MM 3MM VASCULAR ILIOFEMORAL VEIN",SUP-VENUM12080,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"KAISER [10500]",Kaiser,,14773.5,67,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 10D E HIP X3 TRIDENT",SUP-623-10-36E,CDM,C1776,HCPCS,0278,RC,,,both,,,6879.60,2063.88,"NOVANET [10819]",Novanet,,5159.7,75,,,,,0,800.1,5847.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 14MM 90CM 6MM BILIARY STAINLESS",SUP-H74937911614900,CDM,C1876,HCPCS,0278,RC,,,both,,,3967.50,1190.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1135.5,28.62,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTHROSCOPE RIGID QUICKLATCH 1 STPCOCK SHEATH 4 MM SCOPE",SUP-T5801,CDM,S27200284,LOCAL,0272,RC,,,both,,,1600.56,480.17,"PHCS [10601]",PHCS,,1120.39,70,,,,,0,186.15,1360.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X9MM HEDRON C 7D 12MM STERILE LATEX FREE",SUP-1211.2419S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross PPO",,2434.32,39.2,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +17.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1750,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 45CM 7FR ATRIAL ENDOCARDIAL IMPLANTABLE BIPOLAR",SUP-4479,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross HMO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.5IN 10FR PHILLIPS 1/56IN HOLLOW PLASTIC MALE",SUP-346110,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.46,41.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,63.09,45.9,,,,,0,15.99,116.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM 5 HOLE LOW PROFILE EXTENDED BONE RIGHT OLECRANON",SUP-70-0313,CDM,C1713,HCPCS,0278,RC,,,both,,,7051.80,2115.54,"FIRST HEALTH [10303]","First Health",,5641.44,80,,,,,0,820.12,5994.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 2.75MM BALLOON DILATATION PEBAX",SUP-1012406-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MULTIPIECE FOLDABLE ASYMMETRIC BICONVEX ACRYSOF",SUP-MA60AC.210,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT NEROSTIMLTR 35CM SPINAL CORD PHASE III",SUP-SC-3138-35,CDM,C1883,HCPCS,0278,RC,,,both,,,3525.00,1057.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,417.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,409.96,2996.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 3MM PRESTIGE PLUS HELICAL HELICAL PACK",SUP-PRES0303CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM PERSONA CD KNEE RIGHT MEDIAL HALF BLOCK",SUP-42555803410,CDM,C1776,HCPCS,0278,RC,,,both,,,7236.72,2171.02,"NOVANET [10819]",Novanet,,5427.54,75,,,,,0,841.63,6151.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL 50 MCG/ML INJECTION SUPERORDERABLE|DISCARDED DRUG NOT ADMINISTE",RX-4083037,CDM,J3010,HCPCS,0636,RC,00641-6029-01,NDC,both,20,ML,72.48,21.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,JW,49.29,68,,,,,0,8.59,61.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE PRO3 AMNIOTIC PLACENTAL MEMBRANE THIN L8 C",SUP-P01-AMP-0408,CDM,S27800098,LOCAL,0278,RC,,,both,,,13886.25,4165.87,"CIGNA [10200]","Cigna Open Access",,4651.89,33.5,,,,,0,1614.97,11803.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 14MM 9MM STD NECK S-ROM CERAMIC 135D",SUP-523251,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"BLUE CROSS [10001]","Blue Cross PPO",,7624.89,39.2,,3949.44,3949.44,3949.44,"1 through 10",2262.18,16533.56,"percent of total billed charges",
"SET BREAST BIOPSY 7CM LOCALIZER TAG NDL",SUP-09-0028S,CDM,A4648,HCPCS,0278,RC,,,both,,,2055.00,616.5,"CIGNA [10200]","Cigna Open Access",,1169.3,56.9,,,,,0,239,1746.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR RINGLOC +3MM 22 32MM E-POLY HIP STERILE",SUP-EP-108322,CDM,C1776,HCPCS,0278,RC,,,both,,,14076.00,4222.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5630.4,40,,,,,0,1637.04,11964.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-71422344,CDM,C1776,HCPCS,0278,RC,,,both,,,29720.25,8916.07,"AETNA [10100]","Aetna HMO/PPO",,23627.6,79.5,,10981.53,8986.79,12413.38,12,3456.47,25262.21,"percent of total billed charges",
"CLIP SHORT 25MM INTERNAL STRAIGHT",SUP-PL544S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 67.5MM ATLANTIS VISION ELITE BONE SPINAL",SUP-7200067,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,627.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,615.46,4498.2,"percent of total billed charges",
"PTCA CATHETER 2.0 X 10MM (620-104-1U) SCOREFLEX NC SCORING",SUP-SD36003-04,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 60MM 130CM 8MM VASCULAR METAL SUPERFICIAL",SUP-H74939293086030,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,572.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE 2.8CM XL ROUND 240CM 2.4MM CAPTIVATOR II LOOP STIFF",SUP-M00561291,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.70,40.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.78,115.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVISOR FL SENSOR ENABLED 105CM 7.5FR 20MM 2MM 3-3-3MM",SUP-D-AVSE-DF10-F20,CDM,C1732,HCPCS,0272,RC,,,both,,,10315.50,3094.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4239.67,41.1,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM DVR TITANIUM RADIUS CORTICAL DISTAL",SUP-CS10,CDM,C1713,HCPCS,0278,RC,,,both,,,777.60,233.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,528.77,68,,,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 20CM 14FR PEEL-AWAY SAFE-T-J .038IN STD",SUP-G04499,CDM,C1892,HCPCS,0272,RC,,,both,,,417.51,125.25,"KAISER [10500]",Kaiser,,279.73,67,,,,,0,48.56,354.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 45MM 4.5MM AEQUALIS REVERSED GLENOID TITANIUM",SUP-VDV245,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CIGNA [10200]","Cigna Local Plus",,832.46,53.5,,5372.07,4581.20,7242.98,23,180.96,1322.6,"percent of total billed charges",
"STEM HUMERAL NECK KIT ALTIVATE ANATOMIC CS 3 STERILE",SUP-520-08-024,CDM,C1776,HCPCS,0278,RC,,,both,,,34907.04,10472.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4136.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,4059.69,29670.98,"percent of total billed charges",
"KIT BRACE UNIVERSE AIR-STIRRUP UNIVERSAL ANKLE COLD PACK",SUP-02EK,CDM,S27000186,LOCAL,0270,RC,,,both,,,159.12,47.74,"CIGNA [10200]","Cigna Local Plus",,85.13,53.5,,,,,0,18.51,135.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Lung Ventil&Perfsn Diff",PX-341000034,CDM,78598,CPT,0341,RC,,,both,,,2819.08,845.72,"CIGNA [10200]","Cigna Local Plus",,520.32,,,,,,,327.86,2396.22,"fee schedule",
"HC Rv Tib/Prneal W Stent Cmplx Init",PX-361000727,CDM,37286,CPT,0361,RC,,,both,,,18849.10,5654.73,"MULTIPLAN [10600]",Multiplan,,16021.74,85,,,,,0,18.85,16021.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS LAPAROSCOPIC 54.5CM 8MM DA VINCI S/SI ENDOWRIST",SUP-420007,CDM,S27200284,LOCAL,0272,RC,,,both,,,13455.00,4036.5,"KAISER [10500]",Kaiser,,9014.85,67,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 100MM 8MM BALLOON DILATATION OTW",SUP-H74939206081010,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTROLYTES-DEXTROSE ORAL SOLUTION",RX-10784,CDM,,,0637,RC,10939-0959-05,NDC,both,1000,ML,31.45,9.43,"PHCS [10601]",PHCS,,22.02,70,,,,,0,3.66,26.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 180MM HIP RIGHT FEMORAL AFFIXUS GOAL POST",SUP-814311180,CDM,C1713,HCPCS,0278,RC,,,both,,,16042.50,4812.75,"KAISER [10500]",Kaiser,,10748.48,67,,,,,0,1865.74,13636.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 9CM 10FR GENTLE CURVE BILIARY",SUP-G21474,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS [10001]","Blue Cross PPO",,247.67,39.2,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 15MM 2.5MM BALLOON DILATATION RAPID EXCHANGE",SUP-DC-RY2515UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,117.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 12FR 30CM STRAIGHT KELLER-TIMMERMANS STERILE",SUP-G09346,CDM,C1894,HCPCS,0272,RC,,,both,,,522.45,156.73,"AETNA [10100]","Aetna HMO/PPO",,415.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICROINTRODUCER 5FR 50CM GWIRE BEVEL A NDL SMOOTH DIL",SUP-0228950,CDM,C1894,HCPCS,0272,RC,,,both,,,438.05,131.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.95,387.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X10X10MM SABLE 15D STERILE LATEX FREE",SUP-1172.2124S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"NOVANET [10819]",Novanet,,25987.5,75,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ALEXIS 12X100MM EXTRACTION 6500ML BALLOON BLUNT TIP",SUP-GTK17,CDM,S27200284,LOCAL,0272,RC,,,both,,,2812.50,843.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1155.94,41.1,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 5MM PRECEPT PREBENT LORDOTIC",SUP-8847085,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"FIRST HEALTH [10303]","First Health",,3528,80,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION",RX-89570,CDM,,,0250,RC,00338-0322-01,NDC,both,1,UN,519.10,155.73,"PHCS [10601]",PHCS,,363.37,70,,,,,0,60.37,441.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEIGHT EYELID THK1MM ROUND SPHERE TAPER GOLD CONTOUR 18.8X5",SUP-LL3016,CDM,L8699,HCPCS,0278,RC,,,both,,,2662.50,798.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,309.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,309.65,2263.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RCRD CARDIAC LUX-DX-II+ LITHIUM-MANGANESE DIOXIDE MOBILE",SUP-M312,CDM,C1764,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Local Plus",,7541.1,31.5,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM LC-DCP LCP STAINLESS STEEL FULL THREAD",SUP-218.040,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"CIGNA [10200]","Cigna Local Plus",,240.25,53.5,,3978.14,359.25,3978.14,24,52.23,381.7,"percent of total billed charges",
"UPCHARGE STEM/WEDGE/AUGMENT",SUP-CAP-U-SWA,CDM,C1776,HCPCS,0278,RC,,,both,,,2250.00,675,"BLUE CROSS [10001]","Blue Cross PPO",,882,39.2,,3949.44,3949.44,3949.44,"1 through 10",261.68,1912.5,"percent of total billed charges",
"AIRWAY SIZING KIT",SUP-REF-PIV-SK,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE HEXAGONAL 230CM 2.4MM TRAXTION OLYMPUS ACTIVE CORD",SUP-00711113,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"KAISER [10500]",Kaiser,,145.73,67,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 320MM FEMORAL PROXIMAL TFN-ADVANCED INTRAMEDULLARY",SUP-04.037.253S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1471.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1444.25,10555.59,"percent of total billed charges",
"BIT DRILL 3MM AEQUALIS REVERSED DISPOSABLE",SUP-DWD055,CDM,S27200284,LOCAL,0272,RC,,,both,,,1556.00,466.8,"AETNA [10100]","Aetna HMO/PPO",,1237.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 137MM CEMENT ACCOLADE C 127D 4 46MM OFFSET HIP",SUP-6057-0435D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4704.91,28.62,,,,,0,1911.88,13973.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CALCANEUS ALLOGRAFT FREEZE DRIED CROSS SECTION",SUP-400480,CDM,S27800098,LOCAL,0278,RC,,,both,,,4545.72,1363.72,"MULTIPLAN [10600]",Multiplan,,3863.86,85,,,,,0,528.67,3863.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32MM AFFIXUS 3.5MM HIP FEMUR CORTICAL HEXAGONAL",SUP-814550032,CDM,C1713,HCPCS,0278,RC,,,both,,,2081.25,624.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,246.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,242.05,1769.06,"percent of total billed charges",
"KIT DRSG GRANUFOAM SIMPLACE VAC 2 SPIRALCUT XS FOAM 1 SENSA",SUP-M8275046/5.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,309.38,92.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,127.16,41.1,,,,,0,35.98,262.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 26CM 6FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49906,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"KAISER [10500]",Kaiser,,504.71,67,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM AGEE DIGIT WIDGET EXTERNAL FIXATION STERILE LATEX",SUP-DWD-232,CDM,S27200284,LOCAL,0272,RC,,,both,,,11385.00,3415.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1324.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VXSK-230J RF WIRE 63CM/45DEG/D1 SHEATH",SUP-VXSK0112,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"CIGNA [10200]",Cigna,,4199.34,68,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP .8CM UNIVERSAL LARGE 12X2CM",SUP-R2008,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.67,49.7,"KAISER [10500]",Kaiser,,111,67,,,,,0,19.27,140.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 15MM PRIMARY PRESSFIT TRABECULAR METAL TI",SUP-00786401500,CDM,C1776,HCPCS,0278,RC,,,both,,,30164.40,9049.32,"KAISER [10500]",Kaiser,,20210.15,67,,,,,0,3508.12,25639.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 8MM 144CM 2.5MM CORONARY STENT PEBAX",SUP-H7493926008250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross HMO",,2181.48,39.2,,9776.84,9776.84,9776.84,"1 through 10",647.21,4730.25,"percent of total billed charges",
"HC Dil Exist Tract Endurlgc Px",PX-361000487,CDM,50436,CPT,0361,RC,,,both,,,3352.00,1005.6,"PHCS [10601]",PHCS,,2346.4,70,,,,,0,389.84,3352,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLIDESHEATH SLENDER SS KIT, 0.021 GW, 7 FR, 16CM",SUP-80-1670,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,183.1,41.1,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 15CM 120CM 10MM ENDOPROSTHESIS LUMEN CATH",SUP-VBCR101502A,CDM,C1874,HCPCS,0278,RC,,,both,,,21577.50,6473.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6175.48,28.62,,,,,0,2509.46,18340.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 50CMX.49MM 22/11MM HEMAGARD 2 BRANCH",SUP-HGK2211,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3524,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,177.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",174.28,1273.73,"percent of total billed charges",
"BRUSH CYTOLOGY 3MM 8FR 2.5CM 2 LUMEN GWIRE FILFRM TIP FUSION",SUP-G31525,CDM,S27200284,LOCAL,0272,RC,,,both,,,1239.30,371.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FOL URETHRAL 13.35IN 22FR HEYMAN PLASTIC DILATION CATH",SUP-021122,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.13,65.14,"CIGNA [10200]",Cigna,,147.65,68,,,,,0,25.25,184.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL TRANSEPTAL 81CM ACQCROSS SL1",SUP-900309,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE EXTRA SPORT VASCULAR STRAIGHT 300CM 3CM .014",SUP-22235M,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Amino Acids 2-5 Acids Qn",PX-301000580,CDM,82136,CPT,0301,RC,,,both,,,590.00,177,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,59.89,,,,,,,0.01,501.5,"fee schedule",
"INSRT TIBIAL 9 5MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640905,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3220.87,28.62,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.155 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.155,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross PPO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Removal Perm Ccm-D System Pulse Generator Only",PX-481000414,CDM,0919T,CPT,0481,RC,,,both,,,5605.00,1681.5,"KAISER [10500]",Kaiser,,3755.35,67,,,,,0,651.86,5605,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION COMPLETE CARE LUBRI-SIL IC STATLOCK",SUP-A300414A,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.07,41.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,56.75,41.1,,,,,0,16.06,117.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD 25CM 12FR DRNG FLEXIMA METAL HYDROPHILIC REGULAR",SUP-M001271360,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 8FR PIGTAIL NEPHROURETERAL PERCUFLEX METAL",SUP-M001221370,CDM,C2617,HCPCS,0278,RC,,,both,,,811.20,243.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,372.34,45.9,,,,,0,94.34,689.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CRYO/CUFF IC LARGE 20-31IN COMPRESSION THERAPY KNEE",SUP-51A11B,CDM,S27000186,LOCAL,0270,RC,,,both,,,649.78,194.93,"AETNA [10100]","Aetna HMO/PPO",,516.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.57,552.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM TRANSNASAL ROUND FLUTED STERILE",SUP-TN40RFL,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"MULTIPLAN [10600]",Multiplan,,2345.36,85,,,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VTC 25CM 12FR PIGTAIL CURVE NEPHRSTMY POLYURETHANE",SUP-24-528,CDM,C1729,HCPCS,0272,RC,,,both,,,656.10,196.83,"MULTIPLAN [10600]",Multiplan,,557.69,85,,,,,0,76.3,557.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 53CM KT MED",SUP-107235,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"BLUE CROSS [10001]","Blue Cross PPO",,150.06,39.2,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 39MM 80CM 9MM 13MM 8FR .035IN",SUP-BXA093901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]","Cigna Open Access",,6534.11,33.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00230,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CIGNA [10200]","Cigna Local Plus",,628.36,53.5,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cea",PX-301000132,CDM,82378,CPT,0301,RC,,,both,,,331.01,99.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,67.31,,,,,,,0.01,281.36,"fee schedule",
"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC",739,MS-DRG,,,,,,,inpatient,,,103309.50,30992.85,"CIGNA [10200]","Cigna Local Plus",,36970.91,,"Fee schedule rate ($36,970.91). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,103309.5,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO S4 GLIDESCOPE SPECTRUM MACINTOSH DISPOSABLE",SUP-0270-1086,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"AETNA [10100]","Aetna HMO/PPO",,276.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 ANGLE FORWARD OFFSET 9.5IN KARLIN LUMBAR HANDLE",SUP-46-3126,CDM,S27200284,LOCAL,0272,RC,,,both,,,1195.16,358.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 25X6MM STD TOOTH AGGRESSIVE CALIBRATE THK.6MM CUT",SUP-532.061S,CDM,S27200284,LOCAL,0272,RC,,,both,,,605.07,181.52,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH SAFESHEATH 6FR",SUP-7460,CDM,C1894,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET EXT 1.7CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-24-1.7,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Rubidium Rb82 Up to 60mci",PX-343000029,CDM,A9555,HCPCS,0343,RC,,,both,,,5032.00,1509.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,585.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,585.22,4277.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ENDOSCOPIC MICRO SICKLE",SUP-28164MS-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1500.85,450.25,"UHC [10700]","United Healthcare",,950.04,63.3,,,,,0,174.55,1275.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 5 RIGHT DISTAL KNEE",SUP-5541-A-502,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"NOVANET [10819]",Novanet,,3578.24,75,,,,,0,554.87,4055.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 5.5MM COOLCUT 12 FLUTE OVAL STERILE",SUP-AR-8550OBT,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,58.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 20MM 140CM 2.5MM CORONARY STENT PLATINUM",SUP-H7493927420250,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Local Plus",,2006.25,53.5,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL STAND OFFSET SZ9",SUP-425-98-009,CDM,C1776,HCPCS,0278,RC,,,both,,,38695.80,11608.74,"MULTIPLAN [10600]",Multiplan,,32891.43,85,,,,,0,4500.32,32891.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) BELT SPRT LARGE STERNUM",SUP-QB-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,564.02,68,,,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 6 UNIVERSAL KNEE CEMENTED TOTAL",SUP-5521-B-600,CDM,C1776,HCPCS,0278,RC,,,both,,,10384.92,3115.48,"CIGNA [10200]",Cigna,,7061.75,68,,5873.17,5873.17,5873.17,"1 through 10",1207.77,8827.18,"percent of total billed charges",
"BASEPLT TIBIAL ATTUNE 4 KNEE CEMENTED ROTATE PLATFORM",SUP-150610004,CDM,C1776,HCPCS,0278,RC,,,both,,,16694.55,5008.36,"FIRST HEALTH [10303]","First Health",,13355.64,80,,,,,0,1941.58,14190.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 1 7MM",SUP-TPS-030-071S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"CIGNA [10200]",Cigna,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 90CM 20MM 4MM BALLOON DILATATION",SUP-PCP040020090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UHC [10700]","United Healthcare",,779.35,63.3,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL PURPLE 17MM SYNFIX 14D MEDIUM EVOLUTION 10.9MM",SUP-08.815.225S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"NOVANET [10819]",Novanet,,21262.5,75,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 20MM 10MM STD WALL THIN WALL 2 BRANCH",SUP-SBT2002D,CDM,C1768,HCPCS,0278,RC,,,both,,,8611.20,2583.36,"CIGNA [10200]",Cigna,,5855.62,68,,,,,0,1001.48,7319.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 17.5MM 5MM BASE TITANIUM VARIABLE ANGLE",SUP-6955172,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,743.58,45.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 60MM 10MM PRESS FIT REMOVABLE TRUNION SUT HOLE",SUP-AR-9100-10S,CDM,C1776,HCPCS,0278,RC,,,both,,,10713.60,3214.08,"BLUE CROSS [10001]","Blue Cross PPO",,4199.73,39.2,,3949.44,3949.44,3949.44,"1 through 10",1245.99,9106.56,"percent of total billed charges",
"BIT DRILL 2.4MM 65MM STOP QUICK COUPLING NONSTERILE",SUP-388.394,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 8MM STERNALOCK BLU STERNAL CANCELLOUS LOCK",SUP-73-2708,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",45.53,332.78,"percent of total billed charges",
"HC Bronch Transbronchial Lung Bx",PX-750000010,CDM,31628,CPT,0750,RC,,,both,,,5731.61,1719.48,"UHC [10700]","United Healthcare",,3833,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,666.59,5731.61,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TOURGUIDE 180D 45CM 9MM 7FR CATH HYDROPHILIC",SUP-TG0704509,CDM,C1887,HCPCS,0272,RC,,,both,,,4209.00,1262.7,"MULTIPLAN [10600]",Multiplan,,3577.65,85,,,,,0,489.51,3577.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pyruvate",PX-301000387,CDM,84210,CPT,0301,RC,,,both,,,452.20,135.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,41.64,,,,,,,0.01,384.37,"fee schedule",
"HC Pyruvate",PX-301000387,CDM,84210,CPT,0301,RC,,,both,,,452.20,135.66,"FIRST HEALTH [10303]","First Health",,361.76,80,,,,,0,0.01,384.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 60MM 190CM 2.5",SUP-R51002506L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"AETNA [10100]","Aetna HMO/PPO",,1567.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER PRIME HTD 110CM 11CM 7FR 4MM 2.5MM SPACE LARGE",SUP-M004P5031THK20,CDM,C1733,HCPCS,0272,RC,,,both,,,8797.50,2639.25,"FIRST HEALTH [10303]","First Health",,7038,80,,,,,0,1023.15,7477.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 33MM 2.25MM CORONARY STENT EVEROLIMUS",SUP-1550225-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY DRNG 10FR FLEXIBLE STAYFIX SMALL SECUREMENT DEVICE",SUP-RLC-NV-10-SFX,CDM,C1729,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 640CC",SUP-SSZ-M640,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"AETNA [10100]","Aetna HMO/PPO",,1184.87,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION",RX-169057,CDM,,,0637,RC,00173-0873-10,NDC,both,1,UN,89.09,26.73,"MULTIPLAN [10600]",Multiplan,,75.73,85,,,,,0,10.36,75.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 200MM 135CM 6MM 6FR .035IN HELICAL VASCULAR",SUP-EX062003CL,CDM,C1876,HCPCS,0278,RC,,,both,,,22018.50,6605.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8807.4,40,,,,,0,2560.75,18715.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE EVERPOINT 6-0 C-1 30IN 2 ARM MONOFILAMENT 4",SUP-EPM8706,CDM,S27200284,LOCAL,0272,RC,,,both,,,734.16,220.25,"UHC [10700]","United Healthcare",,464.72,63.3,,,,,0,85.38,624.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 320MM FEMORAL PROXIMAL TFN-ADVANCED INTRAMEDULLARY",SUP-04.037.253S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"UHC [10700]","United Healthcare",,7860.81,63.3,,5023.51,2672.93,6679.78,18,1444.25,10555.59,"percent of total billed charges",
"STPLR ENDOSCOPIC RELOAD AEON 45MMX4MM STERILE LATEX FREE",SUP-AESR45P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET ANGLE 2 OVAL 8IN SURGICAL SPINAL FUSION",SUP-29-4942,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.68,68.9,"CIGNA [10200]","Cigna Open Access",,130.69,56.9,,,,,0,26.71,195.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Arm/Hnd Bi (Go)",PX-510000547,CDM,29584,CPT,0430,RC,,,both,,,891.00,267.3,"BLUE CROSS [10001]","Blue Cross PPO",,891,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,103.62,891,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +16.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.165,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 4.50 X 32MM",SUP-H7493942832450,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,722.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 6FR L30CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902250,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH ADULT 28CM 15.5FR POLYURETHANE BIOFLO DURAMAX",SUP-H965103028191,CDM,C1750,HCPCS,0278,RC,,,both,,,1781.25,534.37,"MULTIPLAN [10600]",Multiplan,,1514.06,85,,,,,0,207.16,1514.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 36MM +3MM GLENOSPHERE COLOR CODED",SUP-115313,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"NOVANET [10819]",Novanet,,9144.75,75,,,,,0,1418.05,10364.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 90CM 20GA EPILONG TUOHYSONO STAINLESS STEEL",SUP-0431187-51,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,34.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 60X2.5MM DST SERIES GIA TITANIUM VASCULAR",SUP-GIA6025L,CDM,S27200284,LOCAL,0272,RC,,,both,,,383.41,115.02,"MULTIPLAN [10600]",Multiplan,,325.9,85,,,,,0,44.59,325.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 11CM GREEN HUB TUBING RADIOPAQUE MARKER TIP",SUP-PRO-6F-11MT,CDM,C1894,HCPCS,0272,RC,,,both,,,161.39,48.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 45MM 1.2MM TAPER CARBIDE SIDE CUT STERILE",SUP-1607-002-105,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.18,26.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX RADIANZ 190CM 80MM 6MM .018IN BALLOON DILATATION",SUP-R51006008L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PORT ACCESS 100MM 5MM AIRSEAL 2 WALL CANN LOW PROFILE OBTR",SUP-IAS5-100LP,CDM,S27200284,LOCAL,0272,RC,,,both,,,705.48,211.64,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATH 20CM 13.5FR STRAIGHT POLYURETHANE NIAGARA 2 LUMEN",SUP-5575200,CDM,C1752,HCPCS,0272,RC,,,both,,,1031.94,309.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH AMPHIRION DEEP 150CM 120MM 2.8-3.9FR 3MM TAPER BALLOON",SUP-AMP030120152,CDM,C1725,HCPCS,0272,RC,,,both,,,2422.50,726.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOE CAST 11IN 4.75IN MEDIUM NONSKID SOLE",SUP-SA901005,CDM,S27000186,LOCAL,0270,RC,,,both,,,55.59,16.68,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT COVERA 100MM 80CM 9MM 9FR STRAIGHT VASCULAR",SUP-AVSM09100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4932.9,27,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML IV SUPERORDERABLE",RX-408117332,CDM,J1642,HCPCS,0636,RC,64253-0333-35,NDC,both,5,ML,28.01,8.4,"KAISER [10500]",Kaiser,,18.77,67,,,,,0,1.17,23.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL TRIATHLON B CONE KNEE LEFT MEDIAL RIGHT LATERAL",SUP-5549-A-221,CDM,C1776,HCPCS,0278,RC,,,both,,,23621.85,7086.55,"CIGNA [10200]",Cigna,,9448.74,40,,5873.17,5873.17,5873.17,"1 through 10",2747.22,20078.57,"percent of total billed charges",
"CATH SABERX 150CM 300MM 3MM BALLOON DILATATION RAPID",SUP-47530300M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,832.28,41.1,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR SKIN 4.1X6.5MM 35 WIDE STAPLE CRTDG LATEX FREE APPOSE",SUP-8886803712,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.55,1.36,"CIGNA [10200]","Cigna Local Plus",,2.43,53.5,,,,,0,0.53,3.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM AVENIR FITMORE MULTIPOLAR STD THR CERAMIC BIPOLAR",SUP-98000100016,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4253.85,41.1,,6417.48,6417.48,6417.48,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"CAP CONSTRUCT TOTAL HIP POROUS FEMUR BIOLOX DELTA HEAD R3 HI",SUP-71703613,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"NOVANET [10819]",Novanet,,17955,75,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BILIARY 10MM 8.5FR 40MM FULLY COVERED TRANSHEPATIC WAL",SUP-M00574770,CDM,C1874,HCPCS,0278,RC,,,both,,,22050.00,6615,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 14.5MM EXCLUDER GORE CONTRALATERAL",SUP-PLC141200,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"FIRST HEALTH [10303]","First Health",,22397.76,80,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 65MM STERILE",SUP-74013480,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.02,64.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.89,181.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,J7507,HCPCS,0636,RC,51079-0818-01,NDC,both,1,UN,22.43,6.73,"KAISER [10500]",Kaiser,,15.03,67,,,,,0,0.2,19.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 65CM 25CM 5FR .047IN",SUP-CG505,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING SMOKE EVAC 4IN VALLEYLAB EDGE EXT ELECTRD STERILE",SUP-SEA54506,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.03,20.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,27.96,41.1,,,,,0,7.91,57.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM PINNACLE GRIPTION TF DOME 4 POINT CUT",SUP-121750500,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,135.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,133.3,974.23,"percent of total billed charges",
"SHELL ACETABULAR 44MM HIP 3 HOLE POLY POROUS R3 SMALL",SUP-71335544,CDM,C1776,HCPCS,0278,RC,,,both,,,14614.20,4384.26,"PHCS [10601]",PHCS,,10229.94,70,,,,,0,1699.63,12422.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 3.50 X 20MM",SUP-H7493942820350,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2850.39,45.9,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM FRMLA ANGLED AGGRESSIVE PLUS ARTHROSCOPIC",SUP-0380544100,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"CIGNA [10200]",Cigna,,224.81,68,,,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.5IN 14FR PHILLIPS PLASTIC DILATION CATH",SUP-021514,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROTIGOTINE 4 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH",RX-82101,CDM,,,0637,RC,50474-0804-03,NDC,both,1,UN,173.83,52.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,79.79,45.9,,,,,0,20.22,147.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 55MM OPTILINK SELF TAP VARIABLE ANGLE STARDRIVE",SUP-42.231.255,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,157.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",157.3,1149.66,"percent of total billed charges",
"HC Mecp2 Gene Full Sequence",PX-309000062,CDM,81302,CPT,0310,RC,,,both,,,5251.00,1575.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,117.81,,"Fee schedule rate ($117.81). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.25,4463.35,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mecp2 Gene Full Sequence",PX-309000062,CDM,81302,CPT,0310,RC,,,both,,,5251.00,1575.3,"MULTIPLAN [10600]",Multiplan,,4463.35,85,,,,,0,5.25,4463.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 230MM STAINLESS STEEL 3.5MM SCR 10 HOLE LCP BONE LEFT",SUP-02.104.030,CDM,C1713,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"BLUE CROSS [10001]","Blue Cross PPO",,3408.05,39.2,,957.42,570.23,957.42,28,1011.11,7389.9,"percent of total billed charges",
"SYSTEM LAVA-34 EMBOLIC 6ML LIQUID",SUP-SLLES346,CDM,S27800098,LOCAL,0278,RC,,,both,,,36540.00,10962,"KAISER [10500]",Kaiser,,24481.8,67,,,,,0,4249.6,31059,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 30MM 3.8-3.4FR 6.5MM LOW",SUP-39031-65301,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OCCL 65CM 5FR 26FR BALLOON OCCLUSION 1 INFLATION PORT",SUP-M0062201070,CDM,C2628,HCPCS,0272,RC,,,both,,,1155.14,346.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,136.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,134.34,981.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 1 KNEE PRIMARY CEMENT",SUP-5520B100,CDM,C1776,HCPCS,0278,RC,,,both,,,7151.76,2145.53,"CIGNA [10200]",Cigna,,4863.2,68,,5873.17,5873.17,5873.17,"1 through 10",831.75,6079,"percent of total billed charges",
"SCR BONE 2.7MM 70MM STAINLESS STEEL T8 METAPHYSEAL SELF TAP",SUP-02.118.570,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,60.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",60.93,445.32,"percent of total billed charges",
"STENT MARDIS 30CM 6FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251350,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 20MM SEPTAL SELF EXPANDING DELIVERY",SUP-9-ASD-020,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"KAISER [10500]",Kaiser,,14238.04,67,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE RIGHT REVISION CEMENT CONSTRAIN LEGION",SUP-71421176,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,15615.18,27,,,,,0,6726.09,49158.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZIPWIRE BENTSON UROLOGICAL STRAIGHT 150CM 8CM .035IN",SUP-M0066802241,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11.5MM 200MM VALOR",SUP-415101120L,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,1521.93,481.35,16760.95,30,2014.9,14726.25,"percent of total billed charges",
"SYSTEM TLS FLAT 4MM DRNG SILICONE 15ML EVACUATE TUBE",SUP-6660,CDM,S27200284,LOCAL,0272,RC,,,both,,,274.05,82.21,"KAISER [10500]",Kaiser,,183.61,67,,,,,0,31.87,232.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STIM 3 OUTPUT SETTING LOC LED NEURO PULSE NERVE LATEX RED",SUP-0003EA,CDM,S27200284,LOCAL,0272,RC,,,both,,,409.51,122.85,"PHCS [10601]",PHCS,,286.66,70,,,,,0,47.63,348.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DSRCTOR EXTERNAL FIXATION 70MM TRUELOK LINEAR TELESCOPIC",SUP-50-11010,CDM,C1713,HCPCS,0278,RC,,,both,,,2973.08,891.92,"NOVANET [10819]",Novanet,,2229.81,75,,,,,0,345.77,2527.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X19MM LUMINARY CC 30D BICONVEX",SUP-6919,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3868.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 5CM 5FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22980,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STRLZTN 16INX10INX2.75IN STAINLESS STEEL 3 INSTR RACK",SUP-JC253R,CDM,S27200284,LOCAL,0272,RC,,,both,,,829.85,248.95,"CIGNA [10200]","Cigna Local Plus",,443.97,53.5,,,,,0,96.51,705.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 12IN .062IN",SUP-AR-8941-12,CDM,S27000186,LOCAL,0270,RC,,,both,,,411.08,123.32,"FIRST HEALTH [10303]","First Health",,328.86,80,,,,,0,47.81,349.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Candida Species Direct Probe",PX-306000120,CDM,87480,CPT,0306,RC,,,both,,,607.05,182.11,"CIGNA [10200]","Cigna Local Plus",,44.11,,,,,,,0.61,515.99,"fee schedule",
"SHEET SILASTIC 2X2X.05IN THK.005IN SILICONE BIOCOMPATIBLE",SUP-1532505,CDM,S27800098,LOCAL,0278,RC,,,both,,,237.51,71.25,"KAISER [10500]",Kaiser,,159.13,67,,,,,0,27.62,201.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 12CM 3.3MM DUODENAL BEND BILIARY PLASTIC",SUP-M00533020,CDM,C2617,HCPCS,0278,RC,,,both,,,447.93,134.38,"CIGNA [10200]",Cigna,,304.59,68,,,,,0,52.09,380.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 7MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650407,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1555.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1526.7,11158.16,"percent of total billed charges",
"VALVE SHUNT SMALL INLINE CODMAN CERTAS PLUS SIPHONGUARD",SUP-828814PL,CDM,S27800098,LOCAL,0278,RC,,,both,,,36453.69,10936.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4239.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4239.56,30985.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL PIN JOINT FENESTRATION 2.0MM",SUP-MPDP0020,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"NOVANET [10819]",Novanet,,1123.88,75,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIPWIRE .038IN STRAIGHT BENTSON TIP BX 5",SUP-M0066802151,CDM,C1769,HCPCS,0272,RC,,,both,,,362.42,108.73,"KAISER [10500]",Kaiser,,242.82,67,,,,,0,42.15,308.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X10MM ADVANCED LORDOTIC TRAPEZOIDAL",SUP-7710,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"AMERIGROUP MEDICAID [20100]",Amerigroup,,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM LEGACY TITANIUM SPINAL MAS CANNULATED",SUP-7576550,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS [10001]","Blue Cross HMO",,3742.37,39.2,,957.42,156.86,7483.26,51,1110.3,8114.82,"percent of total billed charges",
"SET ACCESS 40CM 5FR 21GA MICROPUNCTURE TRANSITIONLESS-TIP",SUP-G43869,CDM,C1894,HCPCS,0272,RC,,,both,,,242.82,72.85,"UHC [10700]","United Healthcare",,153.71,63.3,,,,,0,28.24,206.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 7CM MR8 6MM BALL DISSECTING CARBIDE",SUP-MR8-7BA60C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1089.86,326.96,"MULTIPLAN [10600]",Multiplan,,926.38,85,,,,,0,126.75,926.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 54MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.544,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"BLUE CROSS [10001]","Blue Cross HMO",,453.42,39.2,,957.42,156.86,7483.26,51,134.52,983.18,"percent of total billed charges",
"23 MM EDWARDS SAPIEN 3 ULTRA TRANSCATHETER HEART VALVE (THV)",SUP-S3UCM23A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"CIGNA [10200]","Cigna Local Plus",,58353.75,31.5,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X9MM ADVANCED LORDOTIC TRAPEZOIDAL",SUP-7709,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"KAISER [10500]",Kaiser,,5547.6,67,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0257,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,434.99,45.9,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET",RX-99694,CDM,,,0250,RC,00115-1365-30,NDC,both,1,UN,96.85,29.05,"PHCS [10601]",PHCS,,67.8,70,,,,,0,11.26,82.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 30MM 80CM 9MM VASCULAR NITINOL PERIPHERAL",SUP-1012531-30,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"MULTIPLAN [10600]",Multiplan,,3519,85,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 26CM 6FR .038IN PIGTAIL CURVE",SUP-M006180223120,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"BLUE CROSS [10001]","Blue Cross PPO",,521.46,39.2,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NERVOUS SYSTEM NEOPLASMS WITH MCC",054,MS-DRG,,,,,,,inpatient,,,48364.08,14509.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,24751.05,,"Fee schedule rate ($24,751.05). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,38079.36,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA2-17-150-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,9177.00,2753.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1067.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE TAG 10CM 37MM ENDOPROSTHESIS EPTFE FEP NITINOL",SUP-TGU373710,CDM,C1874,HCPCS,0278,RC,,,both,,,97310.40,29193.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11531.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11317.2,82713.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 10MM 4MM OFFSET KNEE HEMICAPWAVE 36/35MM",SUP-PX02-1004-W,CDM,C1776,HCPCS,0278,RC,,,both,,,27216.00,8164.8,"BLUE CROSS [10001]","Blue Cross PPO",,10668.67,39.2,,3949.44,3949.44,3949.44,"1 through 10",3165.22,23133.6,"percent of total billed charges",
"PENIS PROCEDURES WITH CC/MCC",709,MS-DRG,,,,,,,inpatient,,,78096.88,23429.06,"CIGNA [10200]","Cigna Local Plus",,24013.34,,"Fee schedule rate ($24,013.34). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,67942.01,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH 22.5FR ENDOSCOPIC OBTR CYSTOURETHROSCOPE",SUP-A20914A,CDM,S27200284,LOCAL,0272,RC,,,both,,,7184.69,2155.41,"CIGNA [10200]","Cigna Local Plus",,3843.81,53.5,,,,,0,835.58,6106.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 31MM TITANIUM CURVE CIRCLE 2 STAGGER LOW",SUP-111989,CDM,S27200284,LOCAL,0272,RC,,,both,,,2138.85,641.65,"KAISER [10500]",Kaiser,,1433.03,67,,,,,0,248.75,1818.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE",RX-38315,CDM,,,0250,RC,00597-0075-75,NDC,both,1,UN,459.99,138,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,312.79,68,,,,,0,53.5,390.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 20MM 6MM .035IN BALLOON DILATATION NYBAX",SUP-H74939171060210,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"MULTIPLAN [10600]",Multiplan,,998.33,85,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MENISCAL CINCH CURVE SUTURING STERILE DISPOSABLE",SUP-AR-4500,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,265.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,261.02,1907.72,"percent of total billed charges",
"TUBE ENDOTRACHEAL 5MM REINFORCE CUFF MURPHY EYE LOW PRESSURE",SUP-DYNJAARC50,CDM,S27200284,LOCAL,0272,RC,,,both,,,201.46,60.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,136.99,68,,,,,0,23.43,171.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER FLEXIVA 200UM FLEXSHIELD HIGH POWER POLISH",SUP-M0068403911,CDM,S27200284,LOCAL,0272,RC,,,both,,,2720.04,816.01,"FIRST HEALTH [10303]","First Health",,2176.03,80,,,,,0,316.34,2312.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT TOTAL STBL TRIATHLON COCR",SUP-5512-F-301,CDM,C1776,HCPCS,0278,RC,,,both,,,20599.49,6179.85,"KAISER [10500]",Kaiser,,13801.66,67,,,,,0,2395.72,17509.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL ADULT L H2.25IN FOR 16-19IN NONTOXIC HYPOALL",SUP-A9918-13,CDM,S27000186,LOCAL,0270,RC,,,both,,,97.27,29.18,"PHCS [10601]",PHCS,,68.09,70,,,,,0,11.31,82.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SHUNT ACCU-FLO CSF CATH 3 WAY PLASTIC STERILE",SUP-45105,CDM,S27800098,LOCAL,0278,RC,,,both,,,2171.03,651.31,"PHCS [10601]",PHCS,,1519.72,70,,,,,0,252.49,1845.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 22MM 140CM 2.25MM",SUP-RSINT22522UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"MULTIPLAN [10600]",Multiplan,,4712.4,85,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP SMALL ALLOGRAFT COMPRESSIBLE SPONGE",SUP-13810809,CDM,C1713,HCPCS,0278,RC,,,both,,,7197.47,2159.24,"CIGNA [10200]","Cigna Open Access",,4095.36,56.9,,1144.80,304.56,2275.09,66,837.07,6117.85,"percent of total billed charges",
"CANN ARTHROSCOPIC 7CM 8.25MM TWIST-IN 3 DAM TRANSLUCENT",SUP-AR-6530TD,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"NOVANET [10819]",Novanet,,219.24,75,,,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 20MM 140CM 2.5MM CORONARY STENT PLATINUM",SUP-H7493927420250,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]",Cigna,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE HUMERAL 9MM COMPREHENSIVE SHOULDER POSITIONING",SUP-113577,CDM,C1776,HCPCS,0278,RC,,,both,,,1518.10,455.43,"PHCS [10601]",PHCS,,1062.67,70,,,,,0,176.56,1290.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ONE STEP CENTESIS 10CM 5FR DRNG TEFLON PERCUTANEOUS 4",SUP-OSC-5F-10S,CDM,C1729,HCPCS,0272,RC,,,both,,,160.95,48.28,"FIRST HEALTH [10303]","First Health",,128.76,80,,,,,0,18.72,136.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 250MM 3.5MM BALLOON DILATATION RAPID",SUP-47535250S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"NOVANET [10819]",Novanet,,1518.75,75,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 6MM 3.25MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP32506X,CDM,C1725,HCPCS,0272,RC,,,both,,,536.63,160.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,364.91,68,,,,,0,62.41,456.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 16X3MM COLOSSEUM 0D 14MM NONSTERILE LATEX",SUP-156.553,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,407.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Compres Band Comprilan W>=3""<5""/Yd",PX-E27000280,CDM,A6443,HCPCS,0270,RC,,,both,,,118.00,35.4,"NOVANET [10819]",Novanet,,88.5,75,,,,,0,0.28,100.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 12X26MM CAPSTONE VERTEBRAL TEMPORARY GHX",SUP-2991226,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"NOVANET [10819]",Novanet,,11923.2,75,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acute Hepatitis Panel",PX-301000012,CDM,80074,CPT,0301,RC,,,both,,,928.15,278.44,"NOVANET [10819]",Novanet,,696.11,75,,,,,0,0.93,788.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 13MM MONSTER SHORT THREAD BITE NONSTERILE",SUP-P24-020-013S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 26FR WOLF RESECTOSCOPE",SUP-M0068802461,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,61.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 32.77CM 8MM DA VINCI XI ENDOWRIST 45D",SUP-470205,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11781,68,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 16MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620316,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"FIRST HEALTH [10303]","First Health",,9003.12,80,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC",542,MS-DRG,,,,,,,inpatient,,,49552.32,14865.7,"AETNA [10100]","Aetna HMO/PPO",,33236.7,,"Fee schedule rate ($33,236.70). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,44054.74,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Colon",PX-320000104,CDM,74270,CPT,0320,RC,,,both,,,1386.64,415.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,164.5,,,,,,,161.27,1178.64,"fee schedule",
"STENT XACT 30MM 7-9MM TAPER VASCULAR NITINOL CAROTID ARTERY",SUP-82087-01,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"MULTIPLAN [10600]",Multiplan,,7956,85,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 220CM 11.5-14MM OTSC 3MM NITINOL",SUP-100.07,CDM,C1760,HCPCS,0278,RC,,,both,,,4754.10,1426.23,"CIGNA [10200]","Cigna Open Access",,2705.08,56.9,,,,,0,552.9,4040.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 3-0 CV-23 6IN CLSR ABSORBABLE TAPER POINT",SUP-VLOCL0804,CDM,S27200284,LOCAL,0272,RC,,,both,,,406.03,121.81,"CIGNA [10200]",Cigna,,276.1,68,,,,,0,47.22,345.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 18MM 3MM CORONARY STENT COCR RAPID",SUP-1007848-18,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM INSPIRIS RESILIA BOVINE PERICARDIUM",SUP-11500A29,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"BLUE CROSS [10001]","Blue Cross PPO",,17781.12,39.2,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 1.35MM 18MM 9MM LCP STAINLESS STEEL FEMORAL",SUP-207.718,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"BLUE CROSS [10001]","Blue Cross HMO",,407.7,39.2,,957.42,156.86,7483.26,51,120.96,884.03,"percent of total billed charges",
"GRAFT BONE BICORTICAL ILIUM THK8-16MM ALLOGRAFT FREEZE DRIED",SUP-400371,CDM,S27800098,LOCAL,0278,RC,,,both,,,4806.54,1441.96,"CIGNA [10200]","Cigna Local Plus",,2571.5,53.5,,,,,0,559,4085.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 44MM ASNIS III TITANIUM PARTIAL THREAD REVERSE",SUP-604644,CDM,C1713,HCPCS,0278,RC,,,both,,,1319.00,395.7,"CIGNA [10200]",Cigna,,896.92,68,,1831.33,1831.33,1831.33,16,153.4,1121.15,"percent of total billed charges",
"LENS IOL +14.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000145,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hematocrit (Fluid)",PX-305000079,CDM,85013,CPT,0305,RC,,,both,,,89.00,26.7,"MULTIPLAN [10600]",Multiplan,,75.65,85,,,,,0,1.61,75.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 1.4MM ORTHOLOC TEMPORARY",SUP-5882000014,CDM,C1713,HCPCS,0278,RC,,,both,,,785.70,235.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,93.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,91.38,667.85,"percent of total billed charges",
"DEXTROSE 5 % AND 0.45 % NACL IV BOLUS",RX-400295,CDM,,,0258,RC,00338-0085-04,NDC,both,1000,ML,100.65,30.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4.5MM AVENIR COMPLEX 10 COIL FRAME",SUP-10CFR04508,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Open Access",,3927.24,33.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER/DIVIDER LAPAROSCOPIC 37CM 5MM LIGASURE XP MARYLAND",SUP-LXMJ37S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SIGNAFUSE BIPHASIC CALCIUM PHOSPHATE BIOACTIVE",SUP-SGF-150,CDM,C1713,HCPCS,0278,RC,,,both,,,12972.00,3891.6,"AETNA [10100]","Aetna HMO/PPO",,10312.74,79.5,,1521.93,481.35,16760.95,30,1508.64,11026.2,"percent of total billed charges",
"BURR SURGICAL 1.8MM MEDIUM MICRO CARBIDE ROUND 8 FLUTED",SUP-5091-221,CDM,S27000186,LOCAL,0270,RC,,,both,,,118.06,35.42,"PHCS [10601]",PHCS,,82.64,70,,,,,0,13.73,100.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AUROUS BEACON TIP 70CM 5FR .035IN VCF CURVE",SUP-G31220,CDM,S27200284,LOCAL,0272,RC,,,both,,,1137.22,341.17,"FIRST HEALTH [10303]","First Health",,909.78,80,,,,,0,132.26,966.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 31MMX12MMX20CM 22FR",SUP-TAC123120A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,72960,40,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDEAVOR SPRINT 12MM 142CM 2.5MM CORONARY STENT",SUP-ENSP25012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"BLUE CROSS [10001]","Blue Cross PPO",,2173.25,39.2,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ICD-DR DDBB1D1 EVERA XT IS1/DF1 US",SUP-DDBB1D1,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"FIRST HEALTH [10303]","First Health",,32448,80,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 100CM 5FR .038IN SIM1",SUP-G08584,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CIGNA [10200]","Cigna Open Access",,135.13,56.9,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 30CM 8FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552550,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"NOVANET [10819]",Novanet,,900.44,75,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC",437,MS-DRG,,,,,,,inpatient,,,34098.35,10229.5,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,5451.87,,"Case rate ($5,293.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,914.98, add-ons for qualifying new technology services are included. If operating cost exceeds $37,954.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,753.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,921.48. The transfer operating threshold is the transfer adjustment factor * $4,914.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $371.60. The transfer capital threshold is the transfer adjustment factor * $371.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,5293.08,21280.45,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 4MM 140MM KNEE STERILE",SUP-144140-,CDM,S27200284,LOCAL,0272,RC,,,both,,,1010.88,303.26,"PHCS [10601]",PHCS,,707.62,70,,,,,0,117.57,859.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM ULNAR 4 L115MM RIGHT NEXEL",SUP-840002411,CDM,C1776,HCPCS,0278,RC,,,both,,,31971.49,9591.45,"BLUE CROSS [10001]","Blue Cross HMO",,12532.82,39.2,,5311.50,4717.44,5388.59,31,3718.28,27175.77,"percent of total billed charges",
"(EVAL) STABILIZER RAIL",SUP-25100RL,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH COYOTE 150CM 80MM 3MM .014IN BALLOON DILATATION NYBAX",SUP-39186-30081,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNIFE URETHROTOME CHANNEL SEMICIRCLE 4FR",SUP-A3556,CDM,S27200284,LOCAL,0272,RC,,,both,,,2166.45,649.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAFESHEATH INTRDCR FR10 LONG - EACH",SUP-668003-001,CDM,C1892,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DENTAL AND ORAL DISEASES WITHOUT CC/MCC",159,MS-DRG,,,,,,,inpatient,,,19512.79,5853.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE ORTHOFLO AMNIOTIC FLUID 2 ML- LYOPHILIZED",SUP-LQ-0200,CDM,S25000001,LOCAL,0250,RC,,,both,,,18868.50,5660.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SCR BONE 3.5MM 52MM T15 TIBIA CORTICAL DISTAL SELF TAP LOCK",SUP-816135052,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"GRAFT SOFT TISSUE 15MM 2-3MM AVANCE NERVE ALLOGRAFT",SUP-211215,CDM,C1762,HCPCS,0278,RC,,,both,,,17734.50,5320.35,"BLUE CROSS [10001]","Blue Cross HMO",,6951.92,39.2,,,,,0,2062.52,15074.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 38MM 16MM STAINLESS STEEL CANCELLOUS FOOT HAND",SUP-02.226.138,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"KAISER [10500]",Kaiser,,1102.28,67,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 7FR 2-8-2MM SPACE ELECTROPHYSIOLOGY DEFLECT",SUP-D728260RT,CDM,C1731,HCPCS,0272,RC,,,both,,,7086.30,2125.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,824.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,824.14,6023.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 28MM 20MM AFX2 2 BRANCH 40MM",SUP-BEA28-100/I20-40,CDM,C1874,HCPCS,0278,RC,,,both,,,84559.50,25367.85,"MULTIPLAN [10600]",Multiplan,,71875.58,85,,,,,0,9834.27,71875.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 155IN .021IN DIREXION FATHOM-16",SUP-M001195980,CDM,C1887,HCPCS,0272,RC,,,both,,,6734.40,2020.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE 2CM MIC-KEY",SUP-8270-18-2.0-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 150CM 10CM 6MM BALLOON DILATATION ILIAC",SUP-G34337,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) WARRIOR GUIDEWIRE (200 CM)",SUP-7388,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 110MM 3.5MM STAINLESS STEEL QUICK COUPLING STERILE",SUP-310.35S,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.57,257.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OSSEOFLEX CONVENIENCE PACKS OSSEOFLEX SB 10GA/2ML STRAIGHT S",SUP-OCP-0012,CDM,S27200284,LOCAL,0272,RC,,,both,,,12054.30,3616.29,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 11.75CM NATRELLE INSPIRA P4.8CM FULL PROFILE",SUP-MSZ-F345,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BLOOD PUMP 15FR 24FR TANDEMLIFE TANDEMHEART TANDEMLUNG",SUP-5740-2415,CDM,S27200284,LOCAL,0272,RC,,,both,,,88350.00,26505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"GRAFT VASC STR KNIT HEMSHLD GLD MICROVEL 24MMX30CM DBL VEL",SUP-M002020952240,CDM,C1768,HCPCS,0278,RC,,,both,,,3553.58,1066.07,"BLUE CROSS [10001]","Blue Cross HMO",,1393,39.2,,,,,0,413.28,3020.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 3MM A-OK SATINSLIT ANGLE FULL HANDLE",SUP-8065992961,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.32,36.7,"PHCS [10601]",PHCS,,85.62,70,,,,,0,14.23,103.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO 403MM 3.3MM SWISS LITHOCLAST ULTRASOUND FLEXIBLE",SUP-M0068407160,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL XL MEDIUM THICK CIRCLE EEA TRI-STAPLE PURPLE",SUP-TRIEEAXL28MT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2610.30,783.09,"AETNA [10100]","Aetna HMO/PPO",,2075.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,303.58,2218.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BIOEXPAND DEMINERALIZED CANCELLOUS ALLOGRAFT",SUP-77101013,CDM,S27800098,LOCAL,0278,RC,,,both,,,7911.54,2373.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3631.4,45.9,,,,,0,920.11,6724.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 11GA 6IN SPADE SNARECOIL BONE MARROW",SUP-RBN-116S,CDM,S27200284,LOCAL,0272,RC,,,both,,,364.53,109.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,247.88,68,,,,,0,42.39,309.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +21.5 DIOPTER MODIFIED C BICONVEX 3 PIECE",SUP-Z900200215,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,118.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 20X50X17-14.2MM ORACLE 8D SPINE FREEZE",SUP-15017,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 20MM 135CM 12MM 9FR 160CM",SUP-H965412000,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1001.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN SURGICAL FENESTRATE OPEN STERILE",SUP-279726500,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.00,675,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1032.75,45.9,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 13MM COCR",SUP-VAL-20130-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,168.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,165.8,1211.76,"percent of total billed charges",
"SOL INTRAVENOUS 10% DEXTROSE EXCEL 500ML LATEX FREE",SUP-L5201,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA [10200]","Cigna Local Plus",,43.34,53.5,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC",198,MS-DRG,,,,,,,inpatient,,,43483.37,13045.01,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,4575.92,,"Case rate ($4,442.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,125.29, add-ons for qualifying new technology services are included. If operating cost exceeds $37,164.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,693.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,130.74. The transfer operating threshold is the transfer adjustment factor * $4,125.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $311.89. The transfer capital threshold is the transfer adjustment factor * $311.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4442.64,17861.31,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL XS UNIVERSAL 18MM KNEE COCR POLYETHYLENE",SUP-198727118,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"FIRST HEALTH [10303]","First Health",,23637.1,80,,,,,0,3436.24,25114.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC",350,MS-DRG,,,,,,,inpatient,,,102768.93,30830.68,"BLUE CROSS [10001]","Blue Cross PPO",,61517.66,,,,,,,7561,72753.51,"case rate",
"EDWARDS CAVAL PRESTENT LOADER",SUP-9600CP26L,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ORTHOPEDIC WRIST WRISTWIDGET LATEX FREE",SUP-564743,CDM,S27000186,LOCAL,0270,RC,,,both,,,340.78,102.23,"MULTIPLAN [10600]",Multiplan,,289.66,85,,,,,0,39.63,289.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 24MM 12/10/8/8MM HEMASHIELD PLATINUM",SUP-M00202175724AP0,CDM,L8670,HCPCS,0278,RC,,,both,,,12405.37,3721.61,"UHC [10700]","United Healthcare",,7852.6,63.3,,,,,0,427.53,10544.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI STRAIGHT 4MMX1MM MANDIBLE 4 HOLE 2MM SCR BONE",SUP-55-10505,CDM,C1713,HCPCS,0278,RC,,,both,,,825.55,247.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,97.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",96.01,701.72,"percent of total billed charges",
"DIL ENDOSCOPIC CRE 180CM 8CM 6FR 6-8MM ESOPHAGEAL FIX WIRE",SUP-M00558330,CDM,C1726,HCPCS,0272,RC,,,both,,,1562.98,468.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,185.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,181.77,1328.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 46MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-46,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,139.77,45.9,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URETHRAL PROCEDURES WITH CC/MCC",671,MS-DRG,,,,,,,inpatient,,,55333.71,16600.11,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 5MM KII ADVANCE FIXATION RETENTION",SUP-CFR01,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIDNEY AND URINARY TRACT INFECTIONS,MODERATE",463,APR-DRG,,,,,,,inpatient,,,21482.00,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,423.33. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTERIAL 20FR 12IN 1 PIECE BLUNT TIP INTRO ELONGATED",SUP-77420,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE CHOICE VASCULAR 182CM 3CM .014IN STAINLESS STEEL",SUP-H74912132012,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 5-0 V-5 36IN 2 ARM MONOFILAMENT BLUE",SUP-8934H,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.98,25.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CMPNT FEMORAL 3 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP3PL,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"BLUE CROSS [10001]","Blue Cross PPO",,8428.74,39.2,,3949.44,3949.44,3949.44,"1 through 10",2500.67,18276.62,"percent of total billed charges",
"CATH DIAMONDBACK 180CM 30MM 1.75MM ATHERECTOMY PERIPHERAL",SUP-DBP-175SOLID180,CDM,C1724,HCPCS,0272,RC,,,both,,,22648.50,6794.55,"PHCS [10601]",PHCS,,15853.95,70,,,,,0,2634.02,19251.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET KIT W/UNIV CLIP-ON TOOL AND IMPLANT TOOL, 65CM-DS0600",SUP-DS06002/65,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"FIRST HEALTH [10303]","First Health",,583.2,80,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG HYDROCOLLOID 15X9CM AQUACEL AG COVER ANTIMICROBIAL",SUP-412010,CDM,S27200284,LOCAL,0272,RC,,,both,,,233.90,70.17,"CIGNA [10200]",Cigna,,159.05,68,,,,,0,27.2,198.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 3MM CORONARY STENT PEBAX",SUP-H7493926032300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 65X61MM KNEE RIGHT CEMENTED CRUCIATE",SUP-960088,CDM,C1776,HCPCS,0278,RC,,,both,,,27588.96,8276.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7449.02,27,,,,,0,3208.6,23450.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repositioning Prev Impl Ccm-D Transvns Eltrd/Ld",PX-481000419,CDM,0924T,CPT,0481,RC,,,both,,,953.00,285.9,"MULTIPLAN [10600]",Multiplan,,810.05,85,,,,,0,110.83,953,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR AR2 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916391862,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 22-38CMX6-12MM 6-12MM PERONEUS LONGUS",SUP-430345,CDM,C1762,HCPCS,0278,RC,,,both,,,9735.90,2920.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6620.41,68,,,,,0,1132.29,8275.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.25CM NATRELLE INSPIRA P6.6CM EXTRA FULL",SUP-MSZ-X700,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"KAISER [10500]",Kaiser,,105.98,67,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI MIRACLEBROS 6 PTCA GUIDE WIRE 180 CM",SUP-AG14M060,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,771.12,68,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER CURVED TIP RELOAD 30MM PURPLE",SUP-ASR30PC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Stent & Ather Sf Ea Add",PX-361000734,CDM,37293,CPT,0361,RC,,,both,,,12161.75,3648.52,"NOVANET [10819]",Novanet,,9121.31,75,,,,,0,12.16,10337.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT HUMERAL 6IN COONRAD/MORREY SMALL ELBOW TIVANIUM",SUP-32810502506,CDM,C1776,HCPCS,0278,RC,,,both,,,34391.70,10317.51,"CIGNA [10200]",Cigna,,13756.68,40,,5873.17,5873.17,5873.17,"1 through 10",3999.75,29232.95,"percent of total billed charges",
"CATH ULTRAVERSE 035 GEOALIGN 75CM 20MM 3MM BALLOON",SUP-U357532,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL SOFT/FIBRA 6MM .25 FORCE SUPERIOR TRACTION",SUP-A1654,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"UHC [10700]","United Healthcare",,143.18,63.3,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM 41.6MM 34MM MITRAL TRICUSPID FLEXIBLE",SUP-460034MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3258.39,28.62,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X1.5CM GRAFIX PRIME 3SQ CM PLACENTAL MEMB",SUP-PS11015,CDM,Q4133,HCPCS,0636,RC,,,both,,,5768.40,1730.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3749.46,65,,,,,0,373.04,4903.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 130MM 4.2MM T2 AO COUPLING CENTER TIPPED",SUP-18064280S,CDM,S27000186,LOCAL,0270,RC,,,both,,,147.00,44.1,"PHCS [10601]",PHCS,,102.9,70,,,,,0,17.1,124.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC MEDIUM 16IN 16-19IN KNEE SUPER STURDY",SUP-80015,CDM,S27000186,LOCAL,0270,RC,,,both,,,117.89,35.37,"CIGNA [10200]",Cigna,,80.17,68,,,,,0,13.71,100.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID REUNION SHOULDER STERILE LATEX FREE",SUP-5572-2802,CDM,C1776,HCPCS,0278,RC,,,both,,,11169.72,3350.92,"KAISER [10500]",Kaiser,,7483.71,67,,,,,0,1299.04,9494.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dpyd Gene Common Variants",PX-309000132,CDM,81232,CPT,0310,RC,,,both,,,942.40,282.72,"AETNA [10100]","Aetna HMO/PPO",,749.21,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,801.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 12MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-412-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"MULTIPLAN [10600]",Multiplan,,9700.71,85,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 9 3/8IN 6FR 8FR SUPER ARROW-FLEX PERCUTANEOUS 3",SUP-CL-07624,CDM,C1894,HCPCS,0272,RC,,,both,,,534.60,160.38,"KAISER [10500]",Kaiser,,358.18,67,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SIEGEL TRANSCATHETER AORTIC VALVE - 23MM",SUP-30-1-0123,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"MULTIPLAN [10600]",Multiplan,,169575,85,,,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 30MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-030,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2518.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 32MM 0D C HIP X3 TRIDENT",SUP-723-00-32C,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,993.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,993.86,7263.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 600MM 5.5MM HEXAGONAL RADIUS",SUP-486613600,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"CATH CHRG 75CM 60MM 5FR 3MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-03067,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.25MM X 10MM  SCOREFLEX  NC",SUP-622-104-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ESURG 195MM 3MM MULTIVAC 50D",SUP-72290004,CDM,S27200284,LOCAL,0272,RC,,,both,,,3476.25,1042.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,404.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,404.29,2954.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Incisional Biopsy Skin Sgl",PX-761000063,CDM,11106,CPT,0761,RC,,,both,,,2168.00,650.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,256.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,252.14,2168,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Extcr Arty Bi",PX-921000002,CDM,93880,CPT,0921,RC,,,both,,,2272.06,681.62,"CIGNA [10200]","Cigna Open Access",,1292.8,56.9,,,,,0,264.24,1931.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 45MM VIPER PRIME SPINE POLYAXIAL EXTEND TAB",SUP-186770245,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"LENS IOL 0 D +28 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.280,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,345.41,28.62,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 16IN 32FR VENOUS RETURN LIGHTHOUSE STRAIGHT 1",SUP-RV-40032,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,128.73,41.1,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP FEM N/POROUS SIZE 6 RIGHT",SUP-2154-0-0006,CDM,C1776,HCPCS,0278,RC,,,both,,,10151.40,3045.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1202.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1180.61,8628.69,"percent of total billed charges",
"INSRT TIBIAL 4 16MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-416-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4690.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",1327.29,9700.71,"percent of total billed charges",
"CMPNT FEMORAL 8 NARROW KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500006402,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"PHCS [10601]",PHCS,,16003.89,70,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 3-0 CV-23 12IN CLSR ABSORBABLE VIOLET",SUP-VLOCM0814,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,80.49,41.1,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPARIN LOCK FLUSH (PORCINE) 10 UNIT/ML IV SUPERORDERABLE",RX-4083626,CDM,J1642,HCPCS,0636,RC,64253-0222-35,NDC,both,5,ML,18.92,5.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,0.29,,,,,,,0.12,16.08,"fee schedule",
"ELECTRD ELECTROSURGICAL BLACK USA ELITE SYSTEM USA SERIES",SUP-VE-F,CDM,S27200284,LOCAL,0272,RC,,,both,,,1214.65,364.39,"CIGNA [10200]","Cigna Open Access",,691.14,56.9,,,,,0,141.26,1032.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rom Measurement Hnd (Gp)",PX-420000011,CDM,95852,CPT,0420,RC,,,both,,,252.89,75.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,252.89,,"Per diem ($254).",,,,0,29.41,252.89,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X5MM OVAL PARALLEL SPINE CORTICAL",SUP-17105,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Bn Length Study",PX-320000180,CDM,77073,CPT,0320,RC,,,both,,,383.34,115,"AMERIGROUP MEDICAID [20100]",Amerigroup,,45.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.58,325.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Proc Dirct Ea 15min (Go)",PX-430000014,CDM,97110,CPT,0430,RC,,,both,,,194.83,58.45,"BLUE CROSS [10001]","Blue Cross HMO",,194.83,,"Per diem ($344.92).",,,,0,22.66,194.83,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Ureter Stnt Perc Si",PX-361000211,CDM,50382,CPT,0361,RC,,,both,,,8063.12,2418.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,955.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,937.74,6853.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC IV Inf Ther Init 1st Hr",PX-260000003,CDM,96365,CPT,0260,RC,,,both,,,424.22,127.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,212.45,50.08,,,,,0,49.34,424.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DRAGONFLY OPSTAR DIAGNOSTIC IMAGING STERILE LATEX FREE",SUP-1014651,CDM,S27200284,LOCAL,0272,RC,,,both,,,6472.20,1941.66,"CIGNA [10200]",Cigna,,4401.1,68,,,,,0,752.72,5501.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC DF-4 CNCT 2 CHMBR CARDIOVERTER PULSE GENRTR",SUP-E162,CDM,C1721,HCPCS,0278,RC,,,both,,,63000.00,18900,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25893,41.1,,,,,0,7326.9,53550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTMASTER 19MM 3.5MM CORONARY STENT STAINLESS STEEL",SUP-1012581-19,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1958.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 36MM 22MM DHS/DCS STAINLESS STEEL CONDYLAR",SUP-280.990,CDM,C1713,HCPCS,0278,RC,,,both,,,332.78,99.83,"CIGNA [10200]","Cigna Local Plus",,178.04,53.5,,3978.14,359.25,3978.14,24,38.7,282.86,"percent of total billed charges",
"NAIL 9MM 195MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-409-195,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ASAHI SASUKE 145CM 3.3FR INFUSION STERILE LATEX FREE",SUP-SA145-33N,CDM,C1887,HCPCS,0272,RC,,,both,,,3262.50,978.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1340.89,41.1,,,,,0,379.43,2773.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 39MM TITANIUM 2 LEVEL VECTRA BONE 30MM ANTERIOR",SUP-04.613.130,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,1831.33,1831.33,1831.33,16,521.61,3812.25,"percent of total billed charges",
"CATH BD NEXIVA DIFFUSICS 1.25IN 20GA IV BD VIALON CLOSED",SUP-383593,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.16,17.75,"CIGNA [10200]",Cigna,,40.23,68,,,,,0,6.88,50.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SELEGILINE 5 MG TABLET",RX-11340,CDM,,,0637,RC,60505-3438-03,NDC,both,1,UN,10.57,3.17,"PHCS [10601]",PHCS,,7.4,70,,,,,0,1.23,8.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 19FR JACKSON-PRATT SILICONE ROUND HUBLESS",SUP-JP-2230,CDM,S27200284,LOCAL,0272,RC,,,both,,,207.54,62.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,95.26,45.9,,,,,0,24.14,176.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION HELIX TEMPORARY",SUP-7807110,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM OFFSET TAPER 40MM HIP PRIMARY ANATOMIC",SUP-6260-9-440,CDM,C1776,HCPCS,0278,RC,,,both,,,7469.28,2240.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3428.4,45.9,,,,,0,868.68,6348.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 22CM 150CM 8FR .035IN PIGTAIL CURVE",SUP-M006180241180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"AMERIGROUP MEDICAID [20100]",Amerigroup,,173.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR MM ELEVATE 60MM 36MM VIVACIT-E HIP STERILE",SUP-00885201436,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"AETNA [10100]","Aetna HMO/PPO",,8150.36,79.5,,10981.53,8986.79,12413.38,12,1192.31,8714.22,"percent of total billed charges",
"LINER ACETABULAR F 46MM COCR HIP MODULAR DUAL MOBILITY",SUP-626-00-46F,CDM,C1776,HCPCS,0278,RC,,,both,,,8517.60,2555.28,"CIGNA [10200]","Cigna Open Access",,4846.51,56.9,,5302.19,4377.88,6578.61,27,990.6,7239.96,"percent of total billed charges",
"BLADE SAW 18X5.5X.38MM PRECISION MEDIUM NARROW STAINLESS",SUP-2296-003-412,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,31.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 20MM COMPREHENSIVE 3.5MM HEXAGON SHOULDER",SUP-180558,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1058.08,68,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET THROMBECTOMY 38CM 20FR PROTRIEVE SHEATH STERILE LATEX",SUP-60-101,CDM,C1894,HCPCS,0272,RC,,,both,,,25200.00,7560,"PHCS [10601]",PHCS,,17640,70,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 60MM 9MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171090670,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"KAISER [10500]",Kaiser,,786.92,67,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 40MM 2MM BALLOON DILATATION DURALYN",SUP-48002004X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,853.74,68,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM OSSEOTI THR E1 CUP LINER INSRT",SUP-98B00100214,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"NOVANET [10819]",Novanet,,13230,75,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Orbits>=4v",PX-320000013,CDM,70200,CPT,0320,RC,,,both,,,641.16,192.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,75.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.36,544.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 20MM 125CM 10MM 6FR .035IN VASCULAR NITINOL",SUP-G43839,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,439.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING ORANGE 40CM 5FR NUTRIO TWISTLOK ENTERAL",SUP-ENSI4050,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.36,32.21,"PHCS [10601]",PHCS,,75.15,70,,,,,0,12.49,91.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 195MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-409-195,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 13 STD OFFSET HIP",SUP-71935573,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"MULTIPLAN [10600]",Multiplan,,31053.65,85,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP ADD-A-FOLEY COMPLETE CARE",SUP-A304400A,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.19,33.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,46.52,41.1,,,,,0,13.16,96.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER SUT REMOVAL FIBERTAPE ARTHROSCOPY",SUP-AR-13250,CDM,S27200284,LOCAL,0272,RC,,,both,,,7607.25,2282.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5172.93,68,,,,,0,884.72,6466.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 10MM ORTHOLOC TITANIUM NITRIDE FOREFOOT",SUP-5201124010,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,90.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",88.55,647.19,"percent of total billed charges",
"HC Emg Anal/Urethral Not Ndl",PX-750000108,CDM,51784,CPT,0750,RC,,,both,,,3331.00,999.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,394.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,387.4,3331,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.00MM X 20MM  SCOREFLEX  NC",SUP-630-204-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NANOCROSS 150CM 80MM 3MM .014IN BALLOON DILATATION",SUP-AB14W030080150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 40MM 6MM BALLOON DILATATION DURALYN",SUP-48006004S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ROSEN VASCULAR J CURVE 260CM 1.5CM .035IN STAINLESS",SUP-G01253,CDM,C1769,HCPCS,0272,RC,,,both,,,232.73,69.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PDS II 0 CT-1 36IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z346H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 7FR .081IN INTERNAL MAMMARY ARTERY CURVE",SUP-LA7IMA,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP SUT LAPRA-TY POLYMER POLY ABSORBABLE LAPAROSCOPIC",SUP-XC200,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPN NC 20MM 1.5MM BALLOON DILATATION PLATINUM IRIDIUM",SUP-150-020-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 4CM 2.5MM .0108IN AXIUM PRIME 3D",SUP-APB-2.5-4-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3157.79,27,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.0MM X 22MM TI",SUP-VAN-20220-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",113.04,826.2,"percent of total billed charges",
"CATH LUTONIX 035 130CM 100MM 5MM BALLOON DILATATION",SUP-LX3513051005F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4574.7,68,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,inpatient,,,162263.37,48679.01,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,18529.81,,"Case rate ($17,990.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $16,705.04, add-ons for qualifying new technology services are included. If operating cost exceeds $49,744.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,644.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $16,727.13. The transfer operating threshold is the transfer adjustment factor * $16,705.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,262.98. The transfer capital threshold is the transfer adjustment factor * $1,262.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,84674.24,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"PIPERACILLIN-TAZOBACTAM 2.25 G/10ML IV (WET SOLR VIAL)",RX-41518304,CDM,J2543,HCPCS,0636,RC,00781-3110-90,NDC,both,1,UN,92.93,27.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.34,,,,,,,2.49,78.99,"fee schedule",
"LENS IOL +18 DIOPTER +3 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT300180,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 4-5 C-D KNEE",SUP-42-5121-003-11,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS [10001]","Blue Cross HMO",,4224.36,39.2,,5311.50,4717.44,5388.59,31,1253.3,9159.96,"percent of total billed charges",
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 2 6MM",SUP-TPS-030-062S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mycoplasma Ab",PX-302000155,CDM,86738,CPT,0302,RC,,,both,,,481.65,144.49,"MULTIPLAN [10600]",Multiplan,,409.4,85,,,,,0,0.01,409.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VENTRALIGHT ST ECHO 2 6IN CIRCLE",SUP-5990015,CDM,C1781,HCPCS,0278,RC,,,both,,,6787.53,2036.26,"BLUE CROSS [10001]","Blue Cross HMO",,2660.71,39.2,,,,,0,789.39,5769.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 118MM STAINLESS STEEL 2.7MM SCR 6 HOLE CONTOUR SHAFT",SUP-02.118.407S,CDM,C1713,HCPCS,0278,RC,,,both,,,5079.09,1523.73,"CIGNA [10200]","Cigna Open Access",,2890,56.9,,1144.80,304.56,2275.09,66,590.7,4317.23,"percent of total billed charges",
"SYSTEM AUDION INFLATION EUSTACHIAN TUBE CARTILAGE LATEX FREE",SUP-AET-100,CDM,C1726,HCPCS,0272,RC,,,both,,,11074.50,3322.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1287.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1287.96,9413.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM ULNAR 90MM NEXEL 6 RIGHT",SUP-00840002609,CDM,C1776,HCPCS,0278,RC,,,both,,,31971.49,9591.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12788.6,40,,,,,0,3718.28,27175.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PATELLAR THK13-15MM WEDGE ALLOGRAFT FREEZE DRIED",SUP-400580,CDM,S27800098,LOCAL,0278,RC,,,both,,,5870.52,1761.16,"CIGNA [10200]","Cigna Open Access",,3340.33,56.9,,,,,0,682.74,4989.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 62MM 40MM ALTRX HIP",SUP-122140162,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1635.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1605.34,11732.93,"percent of total billed charges",
"MARKER DEPLOYMENT DEVICE TRIMARK BREAST BIOPSY HOURGLASS",SUP-TRIMARK-EVIVA-2S-13,CDM,A4648,HCPCS,0278,RC,,,both,,,628.56,188.57,"FIRST HEALTH [10303]","First Health",,502.85,80,,,,,0,73.1,534.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDOMETHACIN 100 MG RECTAL SUPPOSITORY",RX-233460,CDM,,,0637,RC,73702-0140-71,NDC,both,1,UN,1134.00,340.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM 3MM 2.1-2.7FR CORONARY STENT",SUP-RONYX30026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CIGNA [10200]",Cigna,,2524.5,68,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ENDOSCOPIC COLD BLADE URETHROTOME USA ELITE SYSTEM",SUP-K-SB,CDM,S27200284,LOCAL,0272,RC,,,both,,,1214.41,364.32,"AETNA [10100]","Aetna HMO/PPO",,965.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.24,1032.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +18.5 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z900200185,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,694.01,68,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 60MM 36MM MARATHON",SUP-121936460,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"NOVANET [10819]",Novanet,,7382.14,75,,,,,0,1144.72,8366.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC 64-76CM SMARTVEST SMALL",SUP-SW-25/30-1,CDM,S27000186,LOCAL,0270,RC,,,both,,,437.40,131.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE HEMOSTASIS 9FR MBA MERIT METAL LARGE BORE GWIRE INSRT",SUP-MAP453,CDM,S27200284,LOCAL,0272,RC,,,both,,,219.07,65.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNIFE OPHTHALMIC 2.3MM A-OK SATINCRESCENT STRAIGHT BEVEL UP",SUP-8065990001,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.01,57.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE 100MM 12.3MM 7MM CUFF DISTAL EXT DISPOSABLE INNER CANN",SUP-70XLTCD,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) EDWARDS EVOQUE DILATOR KIT",SUP-9850DKCL,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 20MM 3MM BALLOON",SUP-U357532,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HNDPC ELECTROSURGICAL 9IN ABC BEND-A-BEAM 1 FUNCTION",SUP-134009,CDM,S27200284,LOCAL,0272,RC,,,both,,,921.80,276.54,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 35 135CM 120MM 5MM .035IN LOW PROFILE BALLOON",SUP-B2050-120,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"KAISER [10500]",Kaiser,,515.57,67,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 5MM TRAUMAONE MANDIBLE SELF DRILL CROSS DRIVE",SUP-41-2205,CDM,C1713,HCPCS,0278,RC,,,both,,,664.20,199.26,"FIRST HEALTH [10303]","First Health",,531.36,80,,,,,0,77.25,564.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AVALON ELITE 12.2IN 31FR 3/8IN INFUSION POLYURETHANE",SUP-10031,CDM,C1751,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LARGE 116MM TITANIUM 4 HOLE SHAFT 2 COMPRESSION SLOT",SUP-59202030,CDM,C1713,HCPCS,0278,RC,,,both,,,14993.70,4498.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4048.3,27,,,,,0,1743.77,12744.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 110CM 1MM 5FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY FIX",SUP-F5QF005CT,CDM,C1730,HCPCS,0272,RC,,,both,,,551.20,165.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,226.54,41.1,,,,,0,64.1,468.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ATTAIN HYBRID THUNDER VASCULAR STRAIGHT 190CM 3CM .014",SUP-THNDR190S,CDM,C1769,HCPCS,0272,RC,,,both,,,502.20,150.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,59.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Swallow Func Incomplt",PX-444000007,CDM,92610,CPT,0444,RC,,,both,,,536.62,160.99,"CIGNA [10200]","Cigna Local Plus",,290,,"Per diem ($290).",,,,0,62.41,456.13,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM CD HORIZON MODULEX SPINE CORTICAL SHANK",SUP-55900106555,CDM,C1713,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"BLUE CROSS [10001]","Blue Cross PPO",,2299.08,39.2,,957.42,570.23,957.42,28,682.1,4985.25,"percent of total billed charges",
"SPACER SPINAL 35X15MM CONTINENTAL 15D 24MM MEDIUM PEEK",SUP-364.615CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOFETILIDE 125 MCG CAPSULE",RX-26965,CDM,,,0637,RC,00069-5800-60,NDC,both,1,UN,50.77,15.23,"FIRST HEALTH [10303]","First Health",,40.62,80,,,,,0,5.9,43.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD BARDEX 16FR URETHRAL SILICONE ELASTOMER NATURAL",SUP-0166V16S,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.59,28.08,"CIGNA [10200]",Cigna,,63.64,68,,,,,0,10.88,79.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC",099,MS-DRG,,,,,,,inpatient,,,46755.41,14026.62,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,8958.11,,"Case rate ($8,451.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,847.37, add-ons for qualifying new technology services are included. If operating cost exceeds $40,887.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,975.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,857.75. The transfer operating threshold is the transfer adjustment factor * $7,847.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.30. The transfer capital threshold is the transfer adjustment factor * $593.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,33976.89,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 11CM MINI GWIRE AVANTI+ STAINLESS STEEL",SUP-504658X,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"AETNA [10100]","Aetna HMO/PPO",,62.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INBORN AND OTHER DISORDERS OF METABOLISM",642,MS-DRG,,,,,,,inpatient,,,39926.25,11977.87,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,9438.87,,"Case rate ($8,821.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,191.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,230.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,001.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,202.07. The transfer operating threshold is the transfer adjustment factor * $8,191.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.30. The transfer capital threshold is the transfer adjustment factor * $619.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,35465.75,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PERIPHERAL L12MM DIA5MM CATHETER L80CM GUIDE 6FR BILIA",SUP-1011492-12,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE VASCULAR 1.5MM STD 180CM 3CM .035IN NITINOL",SUP-GR3525,CDM,C1769,HCPCS,0272,RC,,,both,,,361.05,108.31,"UHC [10700]","United Healthcare",,228.54,63.3,,,,,0,41.99,306.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER ORTHOPEDIC 4 MM CANNULATED SCR STERILE",SUP-04.353.904S,CDM,C1713,HCPCS,0278,RC,,,both,,,258.56,77.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,74,28.62,,,,,0,30.07,219.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SECONDARY ANCHOR DELIVERY CATHETER, SHAPE 03",SUP-4740-03,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 5MM MREYE ARTERIAL VENOUS PLATINUM 3.2",SUP-G42460,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"NOVANET [10819]",Novanet,,625.67,75,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER BURR HOLE .4MM 10MM UNIVERSAL NEURO III",SUP-53-34510,CDM,C1713,HCPCS,0278,RC,,,both,,,1858.37,557.51,"BLUE CROSS [10001]","Blue Cross HMO",,728.48,39.2,,957.42,156.86,7483.26,51,216.13,1579.61,"percent of total billed charges",
"HC Bx Prostate Transrectal US Guided",PX-361000741,CDM,55707,CPT,0361,RC,,,both,,,4814.28,1444.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3279,,"Case rate ($3,279). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,559.9,4814.28,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOMATRIX C DEMINERALIZED BONE MATRIX CANCELLOUS",SUP-86XC1000,CDM,C1713,HCPCS,0278,RC,,,both,,,9239.10,2771.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1074.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1074.51,7853.24,"percent of total billed charges",
"OCCL CARDIOVASCULAR 2 DISK NITINOL MESH SELF EXPANDING 18MM",SUP-9-ASD-018,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5737.72,27,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 6-9 C-D KNEE RIGHT VIVACIT-E",SUP-42522400510,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4429.11,41.1,,6417.48,6417.48,6417.48,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"KNIFE OPHTHALMIC 2.3MM A-OK SATINCRESCENT STRAIGHT BEVEL UP",SUP-8065990001,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.01,57.6,"PHCS [10601]",PHCS,,134.41,70,,,,,0,22.33,163.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 30MM 4MM .035IN BALLOON DILATATION NYBAX",SUP-39171-04034,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIRE RETINAL 3.5MM GROOVE CONVEX SILICONE 7MM STERILE STYLE",SUP-9223,CDM,S27800098,LOCAL,0278,RC,,,both,,,229.68,68.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,105.42,45.9,,,,,0,26.71,195.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 4-0 SH 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J415H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.35IN 18FR HEYMAN PLASTIC DILATION CATH",SUP-021118,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.15,65.14,"UHC [10700]","United Healthcare",,137.46,63.3,,,,,0,25.25,184.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 8MM 3.5MM CORONARY STENT COCR RAPID",SUP-1007849-08,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"MULTIPLAN [10600]",Multiplan,,2550,85,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BIOLOGICAL 3.5X3CM OASIS PORCINE SMALL INTESTINE",SUP-8213-1000-33,CDM,Q4102,HCPCS,0636,RC,,,both,,,894.24,268.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,31.95,,,,,,,31.95,760.1,"fee schedule",
"RTRCTR 7.25X1.25IN TAYLOR 4IN LARGE SPINE SURGICAL",SUP-57-5410,CDM,S27200284,LOCAL,0272,RC,,,both,,,347.39,104.22,"AETNA [10100]","Aetna HMO/PPO",,276.18,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.4,295.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 13MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G313,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"KAISER [10500]",Kaiser,,6275.27,67,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SHEATH 60CM 5FR MICROPUNCTURE STAINLESS STEEL",SUP-G07324,CDM,C1894,HCPCS,0272,RC,,,both,,,251.26,75.38,"PHCS [10601]",PHCS,,175.88,70,,,,,0,29.22,213.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM ATRIAL VENTRICULAR BIPOLAR SCR IN ELECTRD",SUP-407665,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"MULTIPLAN [10600]",Multiplan,,1897.63,85,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850017540,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,776.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,762.35,5571.75,"percent of total billed charges",
"CAP NAIL 10MM 25CM HINDFOOT TRIGEN INTRAMEDULLARY FUSION",SUP-71701025,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4433.94,45.9,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM TITANIUM 2.4MM SCR 6X3 HOLE 2 COLUMN VARIABLE",SUP-04.111.630,CDM,C1713,HCPCS,0278,RC,,,both,,,4217.63,1265.29,"CIGNA [10200]","Cigna Open Access",,2399.83,56.9,,1144.80,304.56,2275.09,66,490.51,3584.99,"percent of total billed charges",
"HC CT Brain Perfsn W Cntrst W CT/Cta Add-On",PX-351000019,CDM,70472,CPT,0351,RC,,,both,,,1352.72,405.82,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TREVO NXT 6X37+TRAK21+CAT7 3-PACK - US",SUP-SFP913150,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"NDL 98CM 18GA STYLET PROC TRANSSEPTAL BRK ADULT",SUP-407206,CDM,S27200284,LOCAL,0272,RC,,,both,,,1539.00,461.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HNDPC PULSED LAVAGE 14MM VERSAJET II 15D EXACT SET NARROWER",SUP-66800040,CDM,S27200284,LOCAL,0272,RC,,,both,,,4278.00,1283.4,"CIGNA [10200]","Cigna Local Plus",,2288.73,53.5,,,,,0,497.53,3636.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Guide Ndl Plc",PX-610000046,CDM,77021,CPT,0610,RC,,,both,,,1073.00,321.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1073,,,,,,,124.79,1073,"per diem",
"SCR BONE 6.5MM 40MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840016545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UHC [10700]","United Healthcare",,6043.16,63.3,,5023.51,2672.93,6679.78,18,1110.3,8114.82,"percent of total billed charges",
"CATH STERLING MONORAIL 135CM 30MM 6FR 6MM 4FR BALLOON",SUP-H74939031603010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 5MM COOLCUT FLUSHCUT 8 FLUTE ROUND STERILE",SUP-AR-8500RBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,206.24,41.1,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC XL 20IN KNEE OPEN PATELLA CONTOURED STAY",SUP-7062-04,CDM,L1830,HCPCS,0274,RC,,,both,,,125.37,37.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,57.54,45.9,,,,,0,14.58,106.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 70X12.5X.8MM STAINLESS STEEL 2 SIDED RECIPROCATING",SUP-0277096276,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.41,87.12,"UHC [10700]","United Healthcare",,183.83,63.3,,,,,0,33.77,246.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 10.6-10.5CM NATRELLE P4.7-5.2CM HIGH PROFILE",SUP-SZHP68280,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"CIGNA [10200]","Cigna Open Access",,173.26,56.9,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 50MM 22MM TURON STD",SUP-520-50-022,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"CIGNA [10200]","Cigna Open Access",,5171.53,56.9,,5302.19,4377.88,6578.61,27,1057.03,7725.48,"percent of total billed charges",
"CATH EXPEL ADP TWIST-LOC 25CM 8FR LOOP PIGTAIL CURVE DRNG",SUP-H7493931108250,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"NOVANET [10819]",Novanet,,583.2,75,,,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840007545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,3978.14,359.25,3978.14,24,441.36,3225.75,"percent of total billed charges",
"STENT LIFESTENT 200MM 135CM 6MM 6FR .035IN HELICAL VASCULAR",SUP-EX062003CL,CDM,C1876,HCPCS,0278,RC,,,both,,,22018.50,6605.55,"UHC [10700]","United Healthcare",,13937.71,63.3,,,,,0,2560.75,18715.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATHLETIS 135CM 40MM 7MM BALLOON DILATATION STERILE",SUP-H74939347070410,CDM,C1725,HCPCS,0272,RC,,,both,,,1449.90,434.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,168.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Func Study Laryngeal",PX-440000004,CDM,92520,CPT,0440,RC,,,both,,,836.00,250.8,"MULTIPLAN [10600]",Multiplan,,710.6,85,,,,,0,97.23,710.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7610,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"FIRST HEALTH [10303]","First Health",,5520,80,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 2 KNEE DISTAL HINGE",SUP-5612-D-205,CDM,C1776,HCPCS,0278,RC,,,both,,,10143.00,3042.9,"MULTIPLAN [10600]",Multiplan,,8621.55,85,,,,,0,1179.63,8621.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 25X9X8MM COROENT 8D LARGE CONTOUR PEEK LUMBAR",SUP-6608925,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6806.16,41.1,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Head/Brain W/WO Cntrst",PX-351000004,CDM,70470,CPT,0351,RC,,,both,,,3265.19,979.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,386.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,379.74,2775.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Barrier Cream",PX-E27000052,CDM,E27000052,LOCAL,0270,RC,,,both,,,28.60,8.58,"KAISER [10500]",Kaiser,,19.16,67,,,,,0,3.33,24.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 60MM SOLERA CD HORIZON TITANIUM COCR SPINE 2",SUP-54840008560,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT LEAD CAP STERILE LATEX FREE DISPOSABLE",SUP-7007,CDM,S27800098,LOCAL,0278,RC,,,both,,,1174.50,352.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,136.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 75MM 8MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR081001A,CDM,C1874,HCPCS,0278,RC,,,both,,,17545.50,5263.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2040.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2040.54,14913.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ahg Indirct Titer",PX-302000190,CDM,86886,CPT,0302,RC,,,both,,,440.00,132,"CIGNA [10200]","Cigna Local Plus",,11.4,,,,,,,0.01,374,"fee schedule",
"SCR BONE 2MM 14MM ORTHOLOC TITANIUM NITRIDE FOREFOOT LOCKING",SUP-5201020014,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,204.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",200.62,1466.25,"percent of total billed charges",
"BIT DRILL 10MM",SUP-7812025,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"KAISER [10500]",Kaiser,,2650.79,67,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LEMAITRE 80CM 4FR 10.5MM EMBOLECTOMY 75ML STERILE LATEX",SUP-E1601-48,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 3X2CM MATRION PLACENTAL MEMB TROPHOBLAST",SUP-PAC06,CDM,Q4201,HCPCS,0636,RC,,,both,,,3300.00,990,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BLAZER II HTD 110CM 5MM 7FR 8FR 2.5MM SPACE STD CURVE",SUP-M0045086TH0,CDM,C1733,HCPCS,0272,RC,,,both,,,8107.50,2432.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 45MMX4.6MMX6.5CM 26F",SUP-TE4546A,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7429.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARR GRAFT 8X3IN 1.5:1 DERMACARRIER II SKIN PLATEAU GROOVES",SUP-00219501200,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"CIGNA [10200]","Cigna Local Plus",,223.42,53.5,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 3MR CARTO 3 INTERFACE REPROCESSED",SUP-D134401,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,399.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +12 DIOPTER +3 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT300120,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"KAISER [10500]",Kaiser,,231.15,67,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +24.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0245,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,523.91,39.2,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR061002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"CIGNA [10200]","Cigna Open Access",,7125.05,33.5,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH UHP-L BREAST IMPLANTS 1240 CC",SUP-350-51240L,CDM,A4648,HCPCS,0278,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 13MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-513,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"NOVANET [10819]",Novanet,,7372.89,75,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 8CMX4CMX.2-1MM DERMACELL DERMIS",SUP-DCELL104,CDM,Q4122,HCPCS,0636,RC,,,both,,,15132.53,4539.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1793.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1793.2,12862.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPLATZER PFO OCCLUDER 18MM",SUP-9-PFO-018,CDM,C1817,HCPCS,0278,RC,,,both,,,56668.50,17000.55,"CIGNA [10200]","Cigna Local Plus",,17850.58,31.5,,,,,0,6590.55,48168.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM XIA SERRATO SPINE POLYAXIAL NONSTERILE 3",SUP-482616535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"CAGE SPINAL 28X10X10MM COALESCE LORDOTIC STRAIGHT STERILE",SUP-2000-00-101008,CDM,C1889,HCPCS,0278,RC,,,both,,,21420.00,6426,"AETNA [10100]","Aetna HMO/PPO",,17028.9,79.5,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 18MM 140CM 3.5MM",SUP-RSINT35018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]",Cigna,,3769.92,68,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL NUT",SUP-03.168.007,CDM,S27200284,LOCAL,0272,RC,,,both,,,1315.28,394.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE 10.5IN 26FR SILICONE Y PORT GRADUATE SHAFT OPEN DISTAL",SUP-8884720265E,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.71,111.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Grad Compression Knee 30-40",PX-E27100010,CDM,A6531,HCPCS,0292,RC,,,both,,,122.10,36.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANSTR WOUND DRNG PREVENA PLUS 150ML",SUP-PRE4095.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.63,64.39,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"REAMER SURGICAL 20MM CANNULATED PROXIMAL 1.6MM KWIRE",SUP-03.211.120,CDM,S27200284,LOCAL,0272,RC,,,both,,,2436.00,730.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Sol Lactated Ringer",PX-E27200281,CDM,E27200281,LOCAL,0272,RC,,,both,,,122.10,36.63,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER ALLOGRAFT 12X14X7MM FORGE CERVICAL",SUP-865.307S,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 12MM 6FR 1.5MM .07IN BALLOON",SUP-H7493919012150,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2MM 12MM STOP QUICK COUPLING NONSTERILE",SUP-03.617.912,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP: BIPOLAR HIP Z1 STEM/ METAL HEAD",SUP-98000100278,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1203.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79MMX12MM VANGUARD E1 KNEE ANTERIOR STABILIZE TIBIAL",SUP-EP189102,CDM,C1776,HCPCS,0278,RC,,,both,,,13372.20,4011.66,"PHCS [10601]",PHCS,,9360.54,70,,,,,0,1555.19,11366.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACURATE PRIME AORTIC VALVE XL",SUP-SYM-SV29-009-C,CDM,S62400003,LOCAL,0624,RC,,,both,,,127680.00,38304,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15130.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14849.18,108528,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMINO ACID 4.25 % NO.1 IN DEXTROSE 5 % INTRAVENOUS SOLUTION",RX-27927,CDM,J3490,HCPCS,0258,RC,00338-1089-04,NDC,both,2000,ML,452.70,135.81,"KAISER [10500]",Kaiser,,303.31,67,,,,,0,52.65,384.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cystine Quant Urine",PX-301000101,CDM,82131,CPT,0301,RC,,,both,,,379.48,113.84,"CIGNA [10200]","Cigna Local Plus",,50.56,,,,,,,0.01,322.56,"fee schedule",
"BRACE WALKING SMALL WIDE FOOT ANKLE 2 ADJUSTABLE DISTAL",SUP-01F-S,CDM,L4360,HCPCS,0274,RC,,,both,,,955.64,286.69,"MULTIPLAN [10600]",Multiplan,,812.29,85,,,,,0,111.14,812.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 39MM TITANIUM 2 LEVEL VECTRA BONE 30MM ANTERIOR",SUP-04.613.130,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,3978.14,359.25,3978.14,24,521.61,3812.25,"percent of total billed charges",
"CATH ULTRAVERSE 035 GEOALIGN 75CM 40MM 9MM BALLOON",SUP-U357594,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 65CM PAMIRA S DX 17CM",SUP-428776,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS [10001]","Blue Cross HMO",,5950.56,39.2,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUNAV 90CM 8FR ULTRASOUND INTRACARDIAC 4 WAY STEER",SUP-10135910,CDM,C1759,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Surg Path Gross Micro Level 6",PX-312000018,CDM,88309,CPT,0312,RC,,,both,,,1129.70,338.91,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,960.25,"per diem",
"SUCTION FEN 12FR",SUP-S042,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.44,26.83,"FIRST HEALTH [10303]","First Health",,71.55,80,,,,,0,10.4,76.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 15MM SPINE CERVICAL ANTERIOR SELF DRILL",SUP-18008115,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 5MM KII ADVANCED FIXATION SLEEVE",SUP-CFB01,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"MULTIPLAN [10600]",Multiplan,,122.02,85,,,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 90CM 4.1-2.6FR SPIRAL LEFT VENTRICLE CORONARY",SUP-4592,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,664.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 10MM THORAX SOFT FLEXIBLE WOVEN",SUP-M00202175210P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"NOVANET [10819]",Novanet,,2805,75,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT 13CM 5.5MM AGGRESSIVE SURGICAL STERILE DISPOSABLE",SUP-AR-8550DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,59.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL 25CM END GRASPING TIP POSITIVE",SUP-705.43P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1279.31,383.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,525.8,41.1,,,,,0,148.78,1087.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYPROPYLENE 20X16IN PERMANENT REINFORCE LOCK",SUP-F10244-1620P,CDM,C1781,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 40MM 130CM 7MM 6FR .035IN HELICAL VASCULAR",SUP-EX070403CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"BLUE CROSS [10001]","Blue Cross PPO",,4598.16,39.2,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ewhfo Rigid W/O Jnts Cf",PX-E27400029,CDM,L3765,HCPCS,0274,RC,,,both,,,2900.70,870.21,"KAISER [10500]",Kaiser,,1943.47,67,,,,,0,337.35,2465.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Proc Unlisted",PX-614000006,CDM,76498,CPT,0614,RC,,,both,,,1755.00,526.5,"CIGNA [10200]","Cigna Local Plus",,752,,"Per diem ($752). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,204.11,1755,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 35MM TITANIUM LEVEL 2 ZEVO BONE SPINE CERVICAL",SUP-3002035,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",512.88,3748.5,"percent of total billed charges",
"CMPNT FEMORAL 65MM KNEE LEFT POSTERIOR STABILIZE CEMENT OPEN",SUP-183128,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"CIGNA [10200]","Cigna Local Plus",,6824.7,31.5,,5372.07,4581.20,7242.98,23,2519.72,18415.85,"percent of total billed charges",
"PASSER SUTURELASSO 45D 1 RIGHT CURVE 10YD 1.5MM ERGONOMIC",SUP-AR-6069-45R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,158.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 60MM 4MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171040670,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT EXTREMITY GREEN 23IN HEELBO XL HEEL ELBOW FABRIC FOAM",SUP-D12040,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.80,26.34,"NOVANET [10819]",Novanet,,65.85,75,,,,,0,10.21,74.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP CEMENTED OR3O WITH OXINIUM HEAD",SUP-71703485,CDM,C1776,HCPCS,0278,RC,,,both,,,30240.00,9072,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8164.8,27,,,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ostomy Wafer",PX-E27000141,CDM,E27000141,LOCAL,0270,RC,,,both,,,80.30,24.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,54.6,68,,,,,0,9.34,68.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C02 Membrane Diffuse Capacity",PX-460000013,CDM,94729,CPT,0460,RC,,,both,,,849.77,254.93,"NOVANET [10819]",Novanet,,637.33,75,,,,,0,98.83,722.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Disco Cerv/Thorac Ea",PX-510000107,CDM,62291,CPT,0761,RC,,,both,,,1524.00,457.2,"CIGNA [10200]",Cigna,,1524,,"Per diem ($2,606).",,,,0,1.52,1524,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Binder Abdominal",PX-E27000058,CDM,E27000058,LOCAL,0270,RC,,,both,,,332.20,99.66,"CIGNA [10200]",Cigna,,225.9,68,,,,,0,38.63,282.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM STAINLESS STEEL T25 SELF TAP LOCK VARIABLE",SUP-02.231.234,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,152.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",152.1,1111.66,"percent of total billed charges",
"MESH SURGICAL DURASORB 25X10CM MONOFILAMENT STERILE LATEX",SUP-PTM1025,CDM,C1781,HCPCS,0278,RC,,,both,,,14490.00,4347,"MULTIPLAN [10600]",Multiplan,,12316.5,85,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 60MM 135CM 7MM VASCULAR OTW SELF EXPAND",SUP-1012535-60,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"MULTIPLAN [10600]",Multiplan,,3519,85,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE SHOULDER STANDARD CAP",SUP-RSA1,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5375.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 10.2CM SILTEX P4.3CM HIGH PROFILE ROUND SILICONE",SUP-3544225,CDM,C1789,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 12MM 1.5MM BALLOON DILATATION STERILE",SUP-215-123-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BIO DBM PUTTY PLUS DEMINERALIZED BONE MATRIX 10CC",SUP-7777010,CDM,C1713,HCPCS,0278,RC,,,both,,,6900.00,2070,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,802.47,5865,"percent of total billed charges",
"CMPNT TIBIAL PERSONA 0D E KNEE RIGHT OSSEOTI KEEL",SUP-42535007102,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1600.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 38MM 144CM 2.5MM",SUP-H7493941238250,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3562.99,45.9,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Screen Bordetella",PX-306000055,CDM,87081,CPT,0306,RC,,,both,,,208.00,62.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,23.52,,,,,,,0.01,176.8,"fee schedule",
"KNIFE SURGICAL STRAIGHT SICKLE",SUP-3722110,CDM,S27200284,LOCAL,0272,RC,,,both,,,922.10,276.63,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 6-0 C-1 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8889H,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.95,32.08,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC",868,MS-DRG,,,,,,,inpatient,,,32172.67,9651.8,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 33CM 5MM E-Z CLEAN STERILE PTFE",SUP-0021,CDM,S27200284,LOCAL,0272,RC,,,both,,,331.98,99.59,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 40MM 3MM BALLOON DILATATION OTW STERILE",SUP-593004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 100CM 6.7FR GPC CURVE ANGIOGRAPHIC POLYETHYLENE",SUP-G00174,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.19,73.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Lamotrigine",PX-301000074,CDM,80175,CPT,0301,RC,,,both,,,219.70,65.91,"PHCS [10601]",PHCS,,153.79,70,,,,,0,0.01,186.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OMNICURVE 15MM G11 BALLOON VERTEBRAL FRACTURE KIT",SUP-1032-015-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,17883.68,5365.1,"UHC [10700]","United Healthcare",,11320.37,63.3,,,,,0,2079.87,15201.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK LARGE BALL 7.25IN NERVE VESSEL RETRACTION KRAYENBUEHL 3",SUP-58-3032,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 12MM 2MM BALLOON DILATATION PACLITAXEL RADIOPAQUE",SUP-H7493960812200,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"MULTIPLAN [10600]",Multiplan,,33067.13,85,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EX 139CM 15MM 2MM LONG RECTANGLE HELIX",SUP-2034-2015,CDM,C1725,HCPCS,0272,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 5.75IN DAVIS 2 END STAINLESS STEEL SURGICAL",SUP-410230,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.33,38.5,"KAISER [10500]",Kaiser,,85.98,67,,,,,0,14.92,109.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .067IN .047IN AMPLATZ",SUP-534541T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"UHC [10700]","United Healthcare",,59.2,63.3,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3MM CONCERTO 3D",SUP-PV-3-8-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM PRECISION .014IN LINEAR TRIAL PRELOAD",SUP-SC-2158-50E,CDM,C1778,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,6217.33,6217.33,6217.33,"1 through 10",641.98,4692,"percent of total billed charges",
"SCR BONE 4MM 32MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661032,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"FIRST HEALTH [10303]","First Health",,1044.58,80,,,,,0,151.86,1109.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 100MM 80CM 7MM VASCULAR PERIPHERAL SELF",SUP-1012529-100,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1184.87,28.62,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW FREEFIX COMPRESSION 3.5MM X 24MM TI",SUP-FFC-35240-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1061.10,318.33,"BLUE CROSS [10001]","Blue Cross PPO",,415.95,39.2,,957.42,570.23,957.42,28,123.41,901.94,"percent of total billed charges",
"LARYNSCP INTUB 3 PREASSEMBLE BLADE STD HANDLE LED LIGHT",SUP-040-04-0130U,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.42,18.73,"MULTIPLAN [10600]",Multiplan,,53.06,85,,,,,0,7.26,53.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 30MM TI",SUP-SPL-35300-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Iridot/Iredect Ls per Sess",PX-761000058,CDM,66761,CPT,0761,RC,,,both,,,1266.35,379.9,"MULTIPLAN [10600]",Multiplan,,1076.4,85,,,,,0,147.28,1266.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 48MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661048,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"BLUE CROSS [10001]","Blue Cross PPO",,511.84,39.2,,957.42,570.23,957.42,28,151.86,1109.86,"percent of total billed charges",
"CATH SEEKER 150CM 4FR .018IN GUIDING CROSSING SPRT",SUP-SK15018,CDM,C1887,HCPCS,0272,RC,,,both,,,1498.50,449.55,"UHC [10700]","United Healthcare",,948.55,63.3,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TOURNIQUET W4XL24IN DUAL PORT SINGLE BLADDER CYLINDRICA",SUP-60-7070-104R,CDM,S27200284,LOCAL,0272,RC,,,both,,,193.76,58.13,"PHCS [10601]",PHCS,,135.63,70,,,,,0,22.53,164.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 100CM 1.9CM 6FR .038IN JR4 CURVE ANGIOGRAPHIC",SUP-7503-21,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE PRIME 38MM 143CM 2.5MM CORONARY STENT",SUP-1011731-38,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"CIGNA [10200]","Cigna Open Access",,5457.28,56.9,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 90CM 6FR LCB CURVE GUIDING PTFE FEMORAL LARGE",SUP-H74938969250,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"KAISER [10500]",Kaiser,,245.51,67,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 80MM 80CM 7MM 8FR STRAIGHT VASCULAR",SUP-AVSM07080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bonnet Infant Flow",PX-E27000063,CDM,E27000063,LOCAL,0270,RC,,,both,,,70.40,21.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.19,59.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 24CM 7FR 2 PIGTAIL CURVE",SUP-M0061921420,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"FIRST HEALTH [10303]","First Health",,908.5,80,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER CURVED TIP RELOAD 30MM GRAY",SUP-ASR30GC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"NOVANET [10819]",Novanet,,1063.13,75,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE? NC PLUS BALLOON NON-COMPLIANT 3.5 MM X 18 MM",SUP-235-183-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 100MM",SUP-8847100,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1262.14,28.62,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Shunt Eval",PX-320000002,CDM,49427,CPT,0320,RC,,,both,,,437.00,131.1,"BLUE CROSS [10001]","Blue Cross HMO",,0.44,.1,,,,,0,0.44,371.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis C Ab",PX-302000172,CDM,86803,CPT,0302,RC,,,both,,,401.85,120.55,"BLUE CROSS [10001]","Blue Cross HMO",,0.4,.1,,,,,0,0.4,341.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Njx Cth Slct Pulm Vn Angrph",PX-481000376,CDM,93574,CPT,0481,RC,,,both,,,3045.00,913.5,"PHCS [10601]",PHCS,,2131.5,70,,,,,0,354.13,3045,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE U - UPCHARGE FOR E1 POLY","SUP-CAP-U-E1 POLY",CDM,C1776,HCPCS,0278,RC,,,both,,,2250.00,675,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,266.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,261.68,1912.5,"percent of total billed charges",
"TOOL DISSECTING 12CM 3MM MIDAS REX MR8 MATCH HEAD SD STERILE",SUP-MR8-SD12MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"CIGNA [10200]","Cigna Open Access",,1570.01,56.9,,,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY 10CM 18GA BIOPINCE FULL CORE CENTIMETER MARK",SUP-360-1080-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,342.78,102.83,"AETNA [10100]","Aetna HMO/PPO",,272.51,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.87,291.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER SUT BLUE 3/8IN SMALL MINI OPEN STRESS RISER",SUP-9893,CDM,S27200284,LOCAL,0272,RC,,,both,,,376.36,112.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,172.75,45.9,,,,,0,43.77,319.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 NARROW KNEE LEFT CEMENTED CRUCIATE RETAINING",SUP-150400124,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2653.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2604.35,19034.35,"percent of total billed charges",
"SHEATH TIGHTRAIL SUB-C .145IN DIL ROTATE STERILE LATEX FREE",SUP-560-011,CDM,C1773,HCPCS,0272,RC,,,both,,,12385.50,3715.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1467.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 40MM 3.2MM 10MM 8.5FR .035IN BILIARY RAPID",SUP-M00570720,CDM,C1874,HCPCS,0278,RC,,,both,,,9158.00,2747.4,"BLUE CROSS [10001]","Blue Cross PPO",,3589.94,39.2,,,,,0,1065.08,7784.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIMPLE PNEUMONIA AND PLEURISY WITH MCC",193,MS-DRG,,,,,,,inpatient,,,36986.35,11095.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,21306.42,,"Fee schedule rate ($21,306.42). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,32779.82,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 8MM 2MM BALLOON DILATATION PEBAX",SUP-1012270-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 45MM MATRIX TITANIUM SPINE THORACOLUMBAR",SUP-04.606.645,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE SMOOTH SHELL",SUP-SRF-180,CDM,C1789,HCPCS,0278,RC,,,both,,,5892.60,1767.78,"BLUE CROSS [10001]","Blue Cross HMO",,2309.9,39.2,,,,,0,685.31,5008.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 125CM 5FR ULT4 CURVE ANGIOGRAPHIC PEBAX",SUP-PV512538U4SH,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,234.23,45.9,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X13MM 9/11MM SPINE CORTICAL FREEZE DRY",SUP-14913,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1962.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 6MM TITANIUM SPINE CORTEX SELF TAP STARDRIVE",SUP-401.356.99,CDM,C1713,HCPCS,0278,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",61.23,447.53,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL BALL 3MM 24/26FR 3MM STERILE YELLOW",SUP-27050N,CDM,S27200284,LOCAL,0272,RC,,,both,,,1113.89,334.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,511.28,45.9,,,,,0,129.55,946.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 2.3MM A-OK SATINCRESCENT STRAIGHT BEVEL UP",SUP-8065990001,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.01,57.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,130.57,68,,,,,0,22.33,163.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 25CM 120CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBJR062502A,CDM,C1874,HCPCS,0278,RC,,,both,,,41491.80,12447.54,"NOVANET [10819]",Novanet,,31118.85,75,,,,,0,4825.5,35268.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION FIBERTAG TIGHTROPE II ATTACHABLE BUTTON SYSTEM",SUP-AR-1588TNT2,CDM,C1713,HCPCS,0278,RC,,,both,,,3189.38,956.81,"PHCS [10601]",PHCS,,2232.57,70,,,,,0,370.92,2710.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROPARACAINE 0.5 % EYE DROPS",RX-6644,CDM,,,0250,RC,70069-0601-01,NDC,both,15,ML,275.22,82.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,187.15,68,,,,,0,32.01,233.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE MARKER 4 X 4 BIOZORB",SUP-F0404,CDM,A4648,HCPCS,0278,RC,,,both,,,7935.00,2380.5,"BLUE CROSS [10001]","Blue Cross HMO",,3110.52,39.2,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Thorac Ea 1st Ord",PX-361000083,CDM,36215,CPT,0361,RC,,,both,,,3218.39,965.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,374.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,374.3,3218.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC DF-1 CNCT HIGH ENERGY IS-1 TAPER LEAD TIP 72.8",SUP-G151,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6839.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 109MM TYPE 1 TAPERLOC MICROPLASTY PPS 133D 12",SUP-51106120,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"MULTIPLAN [10600]",Multiplan,,23319.95,85,,,,,0,3190.72,23319.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER 19CM 4.2MM HIP LENGTH ADAPTEUR POWER SYSTEM RESECTOR",SUP-AR-6420BC,CDM,S27200284,LOCAL,0272,RC,,,both,,,654.89,196.47,"PHCS [10601]",PHCS,,458.42,70,,,,,0,76.16,556.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 25MM 3MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3025X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"UHC [10700]","United Healthcare",,333.27,63.3,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X8MM CLYDESDALE PTC 0D PEEK TITANIUM",SUP-4980855,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULUS ALIF BOLT, 5.0X25MM FIXATION",SUP-1450250,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"KAISER [10500]",Kaiser,,1085.4,67,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE TITANIUM 25MM 8MM 3.5MM 2 HELIX HEXAGON",SUP-C8810,CDM,C1713,HCPCS,0278,RC,,,both,,,1016.15,304.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,690.98,68,,,,,0,118.18,863.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INQUIRY 110CM 1MM 5FR 2-5-2MM SPACE LARGE CURVE",SUP-81174,CDM,C1730,HCPCS,0272,RC,,,both,,,2250.00,675,"PHCS [10601]",PHCS,,1575,70,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET",RX-2516,CDM,,,0637,RC,00406-1236-01,NDC,both,1,UN,12.54,3.76,"CIGNA [10200]","Cigna Open Access",,7.14,56.9,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL KNEE ATTUNE FB - CEMENTED",SUP-009504191,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]",Cigna,,11340,40,,5873.17,5873.17,5873.17,"1 through 10",3297.11,24097.5,"percent of total billed charges",
"SCR BONE 4.5MM 3.9MM 50MM MULTILOC TITANIUM NIOBIUM ALUMINUM",SUP-04.019.050S,CDM,C1713,HCPCS,0278,RC,,,both,,,1747.20,524.16,"CIGNA [10200]","Cigna Open Access",,994.16,56.9,,1144.80,304.56,2275.09,66,203.2,1485.12,"percent of total billed charges",
"HC Thrombin Time",PX-305000063,CDM,85670,CPT,0305,RC,,,both,,,137.75,41.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.17,,"Fee schedule rate ($6.17). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,117.09,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP LONG 45MM INTERNAL CURVED",SUP-PL549S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 180MM 4.5MM BONECUTTER LONG ARTHROSCOPIC",SUP-7210979,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"UHC [10700]","United Healthcare",,369.17,63.3,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX29MM 8FR 80CMCATH HEPARIN",SUP-BXB092901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7801.92,40,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 52MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 3",SUP-241.031,CDM,C1713,HCPCS,0278,RC,,,both,,,2076.90,623.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1412.29,68,,,,,0,241.54,1765.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 14MM OZARK SPINE CERVICAL SELF TAP VARIABLE",SUP-8801-04514CA,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,396.9,39.2,,957.42,156.86,7483.26,51,117.75,860.63,"percent of total billed charges",
"CMPNT TOE 13.6MM HEMICAP DF-P STERILE LATEX FREE",SUP-9P15-S180-W,CDM,C1776,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]",Cigna,,3284.4,68,,5873.17,5873.17,5873.17,"1 through 10",561.73,4105.5,"percent of total billed charges",
"SABER .035 3X80 40CM SL",SUP-48003008P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"AETNA [10100]","Aetna HMO/PPO",,780.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CS1 STAINLESS STEEL 2.7MM SCR VARIABLE ANGLE LCP BONE",SUP-02.112.620,CDM,C1713,HCPCS,0278,RC,,,both,,,6189.30,1856.79,"KAISER [10500]",Kaiser,,4146.83,67,,,,,0,719.82,5260.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE MATRIX PLIF 5X2.5CM",SUP-42210,CDM,C1713,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4275.59,45.9,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMNIOEFFECT 6 CM X 8 CM",SUP-LS-5680,CDM,Q4433,HCPCS,0636,RC,,,both,,,28847.70,8654.31,"CIGNA [10200]","Cigna Open Access",,16414.34,56.9,,,,,0,247.92,24520.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4-2MM TORNADO MICROCOIL PLATINUM FIBER",SUP-G47417,CDM,S27800098,LOCAL,0278,RC,,,both,,,931.42,279.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,108.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.32,791.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTRUMENT AIRSEAL 2 BRANCH FILTER TUBE SET ACTIVATED CH",SUP-ASM-EVAC1-BI,CDM,S27200284,LOCAL,0272,RC,,,both,,,871.16,261.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,101.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,101.32,740.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 11MM 8.2MM 90MM TALON HIP DISTALFIX TECHNOLOGY LAG",SUP-SLN-011-090,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1421.84,28.62,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 33.58CM 8MM ENDOWRIST 42D BIPOLAR 2.8CM",SUP-471405,CDM,S27000186,LOCAL,0270,RC,,,both,,,1850.63,555.19,"MULTIPLAN [10600]",Multiplan,,1573.04,85,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 FULL THREAD CORKSCREW FIBERWIRE TIGERWIRE",SUP-AR-1927BCF,CDM,C1713,HCPCS,0278,RC,,,both,,,2559.38,767.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,297.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",297.66,2175.47,"percent of total billed charges",
"COIL EMBOLIZATION 40CM 12MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181240,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"FIRST HEALTH [10303]","First Health",,14878.08,80,,,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL GENESIS II 3 KNEE LEFT CEMENTED TITANIUM",SUP-71420164,CDM,C1776,HCPCS,0278,RC,,,both,,,14593.50,4378.05,"AETNA [10100]","Aetna HMO/PPO",,11601.83,79.5,,10981.53,8986.79,12413.38,12,1697.22,12404.48,"percent of total billed charges",
"SCR BIOABSORBABLE PEEK-OPTIMA 15MM 5MM RADIOLUCENT G-FORCE",SUP-86PS0515,CDM,C1713,HCPCS,0278,RC,,,both,,,3037.50,911.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,353.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",353.26,2581.88,"percent of total billed charges",
"SUT GORE-TEX CV-3 TH-26 36IN MONOFILAMENT WHITE",SUP-3N07A,CDM,S27200284,LOCAL,0272,RC,,,both,,,255.93,76.78,"CIGNA [10200]",Cigna,,174.03,68,,,,,0,29.76,217.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 77.5MM TITANIUM LOCK ATLANTIS TRANSLATIONAL BONE SPINE",SUP-6190077,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"GRAFT BONE FIBULA WEDGE ALLOGRAFT STRUT 70MM",SUP-817000,CDM,S27800098,LOCAL,0278,RC,,,both,,,3864.00,1159.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2627.52,68,,,,,0,449.38,3284.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MYCOPHENOLATE MOFETIL 250 MG CAPSULE",RX-15113,CDM,J7517,HCPCS,0636,RC,60687-0885-11,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]",Cigna,,0.4,,,,,,,0.19,5.33,"fee schedule",
"GRAFT BONE MAGNIFUSE SD 20X1CM",SUP-7509212,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEERABLE GUIDEWIRE TRITON NITINOL ALLOY .018"""" DIAMETER 260",SUP-CM2010,CDM,C1769,HCPCS,0272,RC,,,both,,,1875.00,562.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 10MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158122110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AETNA [10100]","Aetna HMO/PPO",,8883.77,79.5,,10981.53,8986.79,12413.38,12,1299.6,9498.37,"percent of total billed charges",
"STENT EXPEL TWIST-LOC 28CM 10FR URETERAL FLEXITHANE",SUP-H7493936110280,CDM,C2617,HCPCS,0278,RC,,,both,,,1142.10,342.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,326.87,28.62,,,,,0,132.83,970.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SHORT 75MM STAINLESS STEEL 2.7/3.5MM SCR 3 HOLE TAPER",SUP-02.117.303S,CDM,C1713,HCPCS,0278,RC,,,both,,,6974.52,2092.36,"NOVANET [10819]",Novanet,,5230.89,75,,,,,0,811.14,5928.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD REAMING 950MM 2.5MM BALL TIP EXT STERILE",SUP-351.707S,CDM,S27200284,LOCAL,0272,RC,,,both,,,910.85,273.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,107.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.93,774.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRODE ELECTROSURGICAL 24FR ANGLED NEEDLE 12-30DEG HF RES",SUP-WA22755S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3215.54,964.66,"CIGNA [10200]","Cigna Open Access",,1829.64,56.9,,,,,0,373.97,2733.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.25CM NATRELLE INSPIRA P3.5CM LOW PLUS PROFILE",SUP-MSZ-LP340,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PHCS [10601]",PHCS,,110.73,70,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ALEXIS 360D MEDIUM FLEXIBLE RING ATRAUMATIC SELF",SUP-C8302,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"CIGNA [10200]","Cigna Open Access",,178.21,56.9,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 12MM 3.25MM INTRACRANIAL BARE METAL",SUP-FDS32512,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"BLUE CROSS [10001]","Blue Cross PPO",,32545.69,39.2,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 29MM STD HEART MECHANICAL",SUP-500DM29,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"NOVANET [10819]",Novanet,,17718.75,75,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC MEDIUM 14.5-17IN ARM COMFORT LIGHTWEIGHT",SUP-72819-00062-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,76.21,22.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,34.98,45.9,,,,,0,8.86,64.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 38MM 28MM C VIVACIT-E LUMEN STERILE LATEX FREE",SUP-110031009,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1227.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1204.51,8803.37,"percent of total billed charges",
"RED BLOOD CELL DISORDERS WITHOUT MCC",812,MS-DRG,,,,,,,inpatient,,,22995.81,6898.74,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,5866.52,,"Case rate ($5,695.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,288.80, add-ons for qualifying new technology services are included. If operating cost exceeds $38,328.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,781.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,295.79. The transfer operating threshold is the transfer adjustment factor * $5,288.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.86. The transfer capital threshold is the transfer adjustment factor * $399.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,5695.65,22898.99,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PYRIDOSTIGMINE BROMIDE 60 MG TABLET, IMMEDIATE RELEASE",RX-11239,CDM,,,0637,RC,00904-6622-61,NDC,both,1,UN,8.11,2.43,"PHCS [10601]",PHCS,,5.68,70,,,,,0,0.94,6.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMODIALYSIS DRESSING CHANGE KIT",SUP-78539,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.20,68.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.54,193.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM 32.9MM 26.9MM MITRAL FLEXIBLE HOLDER",SUP-4450M28,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1349.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 24MM OSTEOLOCK TITANIUM HIP ACETABULAR",SUP-5260-5-024,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,349.48,45.9,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 80MM 12MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171120870,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 11MM PRESS FIT ECHO PF TITANIUM STD OFFSET HIP",SUP-12-150311,CDM,C1776,HCPCS,0278,RC,,,both,,,8336.51,2500.95,"MULTIPLAN [10600]",Multiplan,,7086.03,85,,,,,0,969.54,7086.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 5MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR051502A,CDM,C1874,HCPCS,0278,RC,,,both,,,21577.50,6473.25,"NOVANET [10819]",Novanet,,16183.13,75,,,,,0,2509.46,18340.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 16MM 144CM 3MM CORONARY STENT PEBAX",SUP-H7493926016300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"FIRST HEALTH [10303]","First Health",,4452,80,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 4MM RELINE-C PRE BENT TITANIUM NONSTERILE",SUP-3944120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X2CM VIASHIELD AMNION 2 LAYER PATCH",SUP-8155.2002S,CDM,V2790,HCPCS,0278,RC,,,both,,,8970.00,2691,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3686.67,41.1,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC",854,MS-DRG,,,,,,,inpatient,,,64962.71,19488.81,"BLUE CROSS [10001]","Blue Cross HMO",,45869.96,,,,,,,7561,58336.53,"case rate",
"CMPNT FEMORAL ATTUNE STERILE 3 KNEE LEFT CEMENTED POSTERIOR",SUP-150410103,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"BLUE CROSS [10001]","Blue Cross HMO",,8778.19,39.2,,5311.50,4717.44,5388.59,31,2604.35,19034.35,"percent of total billed charges",
"DEVICE MYOSURE REACH TISSUE REMOVAL REPROCESSED",SUP-10-401FC,CDM,S27200284,LOCAL,0272,RC,,,both,,,5002.50,1500.75,"UHC [10700]","United Healthcare",,3166.58,63.3,,,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 20CM 5FR 2.1FR POLARIS ULTRA NAUTILUS ZIPWIRE .035",SUP-M006192120180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"NOVANET [10819]",Novanet,,1192.4,75,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL LARGE KNEE RIGHT LCS COMPLETE POROCOAT",SUP-129403060,CDM,C1776,HCPCS,0278,RC,,,both,,,28683.90,8605.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11473.56,40,,,,,0,3335.94,24381.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE FEEDING TUBE ENFIT FARRELL ENTERAL GASTRIC PRESSURE",SUP-43-4100,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.63,16.99,"KAISER [10500]",Kaiser,,37.94,67,,,,,0,6.59,48.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 19MM REVISION 20 GRIT BLAST SURFACE",SUP-197619140,CDM,C1776,HCPCS,0278,RC,,,both,,,17952.48,5385.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5138,28.62,,,,,0,2087.87,15259.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 75MM 20MM ASNIS III TITANIUM PARTIAL THREAD",SUP-602675,CDM,C1713,HCPCS,0278,RC,,,both,,,1866.45,559.93,"MULTIPLAN [10600]",Multiplan,,1586.48,85,,,,,0,217.07,1586.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 5.5MM TWINFIX ULTRA TITANIUM STERILE COBRAID",SUP-72202897,CDM,C1713,HCPCS,0278,RC,,,both,,,2155.13,646.54,"AETNA [10100]","Aetna HMO/PPO",,1713.33,79.5,,1521.93,481.35,16760.95,30,250.64,1831.86,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 14CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155213180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"AMERIGROUP MEDICAID [20100]",Amerigroup,,190.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC SHORT TIP RELOAD AEON 60MMX3.25MM STERILE",SUP-ASR60RS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"FIRST HEALTH [10303]","First Health",,1166.4,80,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 9CM 7FR PIGTAIL CURVE PANCREATIC POLYMER",SUP-M00537280,CDM,C2617,HCPCS,0278,RC,,,both,,,722.28,216.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,331.53,45.9,,,,,0,84,613.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 75MM 20MM ASNIS III TITANIUM PARTIAL THREAD",SUP-602675,CDM,C1713,HCPCS,0278,RC,,,both,,,1866.45,559.93,"CIGNA [10200]","Cigna Open Access",,1062.01,56.9,,1144.80,304.56,2275.09,66,217.07,1586.48,"percent of total billed charges",
"STEMMED ANATOMIC PSI KIT (HUMERAL ONLY)",SUP-1235-7153-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"FIRST HEALTH [10303]","First Health",,4830,80,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM RAYHACK CORTICAL ULNAR LOW PROFILE",SUP-40100956,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"CIGNA [10200]","Cigna Local Plus",,407.35,53.5,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Virus Culture",PX-306000091,CDM,87252,CPT,0306,RC,,,both,,,584.25,175.27,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,496.61,"per diem",
"LENS IOL 0 D +10 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SA60AT.100,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,EXTREME",443,APR-DRG,,,,,,,inpatient,,,211279.03,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 5.0 MM X 40 MM X 130 CM",SUP-IPU05004013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SENSOR DUAL-FLEX UROLOGICAL 10CM 150CM 3CM .038IN",SUP-M0066703121,CDM,C1769,HCPCS,0272,RC,,,both,,,372.19,111.66,"KAISER [10500]",Kaiser,,249.37,67,,,,,0,43.29,316.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (0.5-1 MCI)",RX-411870,CDM,A9520,HCPCS,0343,RC,08888-8876-04,NDC,both,1,UN,4614.97,1384.49,"UHC [10700]","United Healthcare",,2307.49,50,,,,,0,536.72,3922.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN EXTRA BACKUP 3.5 LEFT CURVE",SUP-LA6EBU35SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,266.22,68,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUCTION FEN 9FR",SUP-S001,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 95MM 5.5MM TSRH-2D CONTOUR PEDICLE TITANIUM",SUP-8370095,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 51MM STAINLESS STEEL 2.4MM SCR 6 HOLE HEAD 3",SUP-02.111.530S,CDM,C1713,HCPCS,0278,RC,,,both,,,4217.63,1265.29,"CIGNA [10200]",Cigna,,2867.99,68,,1831.33,1831.33,1831.33,16,490.51,3584.99,"percent of total billed charges",
"BLADE RTRCTR 20MM MARS 3V SYSTEM DOCK PIN",SUP-698.315S,CDM,C1713,HCPCS,0278,RC,,,both,,,2640.00,792,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,755.57,28.62,,,,,0,307.03,2244,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 24FR SILICONE STD J MIC SECUR-LOK TRIMMABLE",SUP-0200-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"PHCS [10601]",PHCS,,769.71,70,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16MMX8MM ANATOMIC 14MM PTC RADIOPAQUE CERVICAL",SUP-5030864,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 156MM 16-16MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1616C156E,CDM,S27800098,LOCAL,0278,RC,,,both,,,38997.00,11699.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4535.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4535.35,33147.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC BREAST BIOPSY 14CM 3.7MM ATEC 12MM PETITE MRI",SUP-0914-12MR,CDM,S27200284,LOCAL,0272,RC,,,both,,,2619.00,785.7,"PHCS [10601]",PHCS,,1833.3,70,,,,,0,304.59,2226.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 41CM 5FR ROSCH",SUP-G10082,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"PHCS [10601]",PHCS,,166.24,70,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 7MM 8FR ENDOPROSTHESIS HEPARIN",SUP-VBH070502,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL ORANGE 115MM 2MM VOLT 2 BAND AO QUICK COUPLING",SUP-03.527.201,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 32MM 144CM 3.5MM CORONARY STENT",SUP-H7493952832350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross HMO",,2181.48,39.2,,9776.84,9776.84,9776.84,"1 through 10",647.21,4730.25,"percent of total billed charges",
"SET INTRO BLUE RHINO G2 PERCUTANEOUS MULTI",SUP-G57682,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP CLUSTER HOLE SNAP FIT INTEGRATED",SUP-00875705401,CDM,C1776,HCPCS,0278,RC,,,both,,,9319.80,2795.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6337.46,68,,,,,0,1083.89,7921.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP CLUSTER HOLE SNAP FIT INTEGRATED",SUP-00875705401,CDM,C1776,HCPCS,0278,RC,,,both,,,9319.80,2795.94,"CIGNA [10200]","Cigna Local Plus",,4986.09,53.5,,5372.07,4581.20,7242.98,23,1083.89,7921.83,"percent of total billed charges",
"CLAREONPANOPTIX PROTORIC",SUP-PXCAT5,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"BLUE CROSS [10001]","Blue Cross HMO",,358.68,39.2,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LASSO NAVISTAR 7FR 20MM D CURVE ELECTROPHYSIOLOGY 22",SUP-D134904,CDM,C1732,HCPCS,0272,RC,,,both,,,12889.20,3866.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8764.66,68,,,,,0,1499.01,10955.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insert Wcs Lv Complt Sys",PX-480000072,CDM,0515T,CPT,0480,RC,,,both,,,51039.00,15311.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7461.64,,"Fee schedule rate ($7,461.64).",,,,0,2041,43383.15,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 110MM 3.5MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.35,CDM,S27000186,LOCAL,0270,RC,,,both,,,329.00,98.7,"CIGNA [10200]",Cigna,,223.72,68,,,,,0,38.26,279.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 75CM 8MM 8FR ENDOPROSTHESIS HEPARIN",SUP-VBH080501,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 2.5MM20CM 190",SUP-R51002520L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"MULTIPLAN [10600]",Multiplan,,2118.1,85,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 46MM LCP STAINLESS STEEL LONG THREAD FEMORAL",SUP-207.746,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"NOVANET [10819]",Novanet,,780.03,75,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETAB HXL 44MM",SUP-932-44-260,CDM,C1776,HCPCS,0278,RC,,,both,,,12462.02,3738.61,"AETNA [10100]","Aetna HMO/PPO",,9907.31,79.5,,10981.53,8986.79,12413.38,12,1449.33,10592.72,"percent of total billed charges",
"CAP SYSTEM PERSONA TKR VIVACIT-E KNEE FEMUR TIBIA CEMENT",SUP-98000600010,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Open Access",,8019.9,33.5,,5302.19,4377.88,6578.61,27,2784.22,20349,"percent of total billed charges",
"INSRT TIBIAL 6 11MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P611,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3434.27,41.1,,6417.48,6417.48,6417.48,"1 through 10",971.79,7102.52,"percent of total billed charges",
"LENS IOL +17 DIOPTER UV ABSORBENT CLAREON AUTONOME",SUP-CCA0T0.170,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 74MM 4 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800474,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE CONDYLAR CEMENT CONSTRAIN PERSONA",SUP-42-5046-062-02,CDM,C1776,HCPCS,0278,RC,,,both,,,42373.80,12712.14,"CIGNA [10200]","Cigna Local Plus",,13347.75,31.5,,5372.07,4581.20,7242.98,23,4928.07,36017.73,"percent of total billed charges",
"SCR BONE 12.7MM 95MM DHS/DCS STAINLESS STEEL CONDYLAR HIP",SUP-280.295,CDM,C1713,HCPCS,0278,RC,,,both,,,2043.30,612.99,"MULTIPLAN [10600]",Multiplan,,1736.81,85,,,,,0,237.64,1736.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 8IN 15MM MODULAR SOL SYSTEM POROUS 12/14 LARGE",SUP-157202150,CDM,C1776,HCPCS,0278,RC,,,both,,,38107.44,11432.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4515.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4431.9,32391.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 80MM 12MM BALLOON",SUP-U35130128,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 14MM WRIST VOLAR THREAD LOCK TORX",SUP-TPEG-14,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"CIGNA [10200]",Cigna,,578.34,68,,1831.33,1831.33,1831.33,16,98.91,722.93,"percent of total billed charges",
"LC BEAD LUMI SIZE 40 - 90 MICRON",SUP-RO2L000,CDM,S27800098,LOCAL,0278,RC,,,both,,,20475.00,6142.5,"BLUE CROSS [10001]","Blue Cross HMO",,8026.2,39.2,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FUSION 200CM 6FR ENDOSCOPIC STERILE DISPOSABLE ACCEPTS",SUP-G31528,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE FEEDING ORANGE 60CM 5FR NUTRIO TWISTLOK ENTERAL",SUP-ENSI6050,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.36,32.21,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FUROSEMIDE 40 MG TABLET",RX-3295,CDM,,,0637,RC,00904-7178-61,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC",853,MS-DRG,,,,,,,inpatient,,,95089.08,28526.72,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 3.5X15MM",SUP-PRV035015CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR CHAMP5 CURVE GUIDING",SUP-LA6CHAMP05,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE CATH HYPERTONICS 34 PIN TO 25 PIN CNCT",SUP-CR3425CT,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE ELECTROSURGICAL INTRACEPT RADIOFREQUENCY STERILE LATEX","SUP-FG 0043",CDM,S27200284,LOCAL,0272,RC,,,both,,,26460.00,7938,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"PLATE TRIANGLE 25X25X.5MM CRANIOMAXILLOFACIAL 1.7MM SCR BONE",SUP-70-92013,CDM,C1713,HCPCS,0278,RC,,,both,,,5315.83,1594.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,629.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,618.23,4518.46,"percent of total billed charges",
"CUP ACETABULAR 62MM 56MM BHR HEAD",SUP-74122162,CDM,C1776,HCPCS,0278,RC,,,both,,,30051.00,9015.3,"CIGNA [10200]","Cigna Local Plus",,9466.07,31.5,,5372.07,4581.20,7242.98,23,3494.93,25543.35,"percent of total billed charges",
"STENT VIABAHN 10CM 120CM 5MM 6FR ENDOPROSTHESIS HEPARIN",SUP-VBJ051002,CDM,C1874,HCPCS,0278,RC,,,both,,,21218.40,6365.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6072.71,28.62,,,,,0,2467.7,18035.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.3MM 6MM STAINLESS STEEL CORTICAL HAND SELF",SUP-200.686,CDM,C1713,HCPCS,0278,RC,,,both,,,594.22,178.27,"MULTIPLAN [10600]",Multiplan,,505.09,85,,,,,0,69.11,505.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Vedolizumab",PX-301000625,CDM,80280,CPT,0301,RC,,,both,,,277.85,83.35,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,236.17,"per diem",
"LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC",820,MS-DRG,,,,,,,inpatient,,,189628.67,56888.6,"AMBETTER EXCHANGE  [11102]",Ambetter,,36379.72,,"Case rate ($36,379.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $33,781.03, add-ons for qualifying new technology services are included. If operating cost exceeds $66,820.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,936.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $33,825.70. The transfer operating threshold is the transfer adjustment factor * $33,781.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,554.01. The transfer capital threshold is the transfer adjustment factor * $2,554.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,36379.72,171228.7,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 40MM 5.5MM MODULEX OSTEOGRIP SPINE",SUP-55900505540,CDM,C1713,HCPCS,0278,RC,,,both,,,4519.50,1355.85,"NOVANET [10819]",Novanet,,3389.63,75,,,,,0,525.62,3841.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP3PR,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"PHCS [10601]",PHCS,,15051.33,70,,,,,0,2500.67,18276.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYSORB SURGIWIP 0 SK 48IN BRAID COATED VIOLET",SUP-ELW-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.04,51.91,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.12,147.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP3PR,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2547.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2500.67,18276.62,"percent of total billed charges",
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,P9047,HCPCS,0636,RC,44206-0251-10,NDC,both,100,ML,1358.64,407.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,607.99,44.75,,,,,0,122.58,1154.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ERCP .025IN TAPERED TIP FLUORO TIP 210CM 5FR BILIARY",SUP-M00530980,CDM,S27200284,LOCAL,0272,RC,,,both,,,255.08,76.52,"CIGNA [10200]","Cigna Local Plus",,136.47,53.5,,,,,0,29.67,216.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LANGSTON 110CM 6FR .038IN PIGTAIL 145D CURVE",SUP-5540,CDM,S27200284,LOCAL,0272,RC,,,both,,,1304.10,391.23,"KAISER [10500]",Kaiser,,873.75,67,,,,,0,151.67,1108.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL CORTICAL THK3-12MM HALVED ALLOGRAFT STRUT",SUP-450485,CDM,S27800098,LOCAL,0278,RC,,,both,,,5576.58,1672.97,"MULTIPLAN [10600]",Multiplan,,4740.09,85,,,,,0,648.56,4740.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FEEDING SNS SUPPLEMENTAL NURSING SYSTEM CNTNR COVER",SUP-00901S,CDM,S27200284,LOCAL,0272,RC,,,both,,,175.65,52.69,"NOVANET [10819]",Novanet,,131.74,75,,,,,0,20.43,149.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PICK SURGICAL 13CM 1.5MM 45D XL POWERPICK POWER TROCAR",SUP-AR-8150PX-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.01,257.7,"MULTIPLAN [10600]",Multiplan,,730.16,85,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 10CM 21MM 22MM 18.6MM ANNULUS EXPAND",SUP-21VAVGJ-515,CDM,S27800098,LOCAL,0278,RC,,,both,,,36805.86,11041.76,"CIGNA [10200]",Cigna,,14722.34,40,,,,,0,4280.52,31284.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 71CM 21GA 18GA PROC CURVE STERILE BROCKENBROUGH ADULT",SUP-EP003994S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX CORE PERMANENT, 25X40 CM",SUP-F10244-2540P,CDM,C1781,HCPCS,0278,RC,,,both,,,49266.00,14779.8,"BLUE CROSS [10001]","Blue Cross PPO",,19312.27,39.2,,,,,0,5729.64,41876.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHYTONADIONE (VITAMIN K1) 5 MG TABLET",RX-11024,CDM,,,0637,RC,60687-0381-11,NDC,both,1,UN,305.61,91.68,"CIGNA [10200]","Cigna Open Access",,173.89,56.9,,,,,0,35.54,259.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM VARIAX TITANIUM T10 FULL THREAD FOOT",SUP-40-35034,CDM,C1713,HCPCS,0278,RC,,,both,,,612.36,183.71,"MULTIPLAN [10600]",Multiplan,,520.51,85,,,,,0,71.22,520.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GW VISIONWIRE VASC 175CM 0.014",SUP-352023,CDM,C1883,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Open Access",,553.07,56.9,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 60MM 24MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-151324060,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"NOVANET [10819]",Novanet,,6199.65,75,,,,,0,961.36,7026.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE WEB 1.5",SUP-PRT-WEB-015,CDM,C1713,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"KAISER [10500]",Kaiser,,4807.92,67,,,,,0,834.57,6099.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 58MM 40MM ALTRX HIP",SUP-122140058,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5673.22,41.1,,6417.48,6417.48,6417.48,"1 through 10",1605.34,11732.93,"percent of total billed charges",
"INSRT TIBIAL 8 10MM KNEE RIGHT E-PLUS EMPOWR 3D KNEE STERILE",SUP-342-10-708,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross PPO",,2569.56,39.2,,3949.44,3949.44,3949.44,"1 through 10",762.35,5571.75,"percent of total billed charges",
"HC Cont Monitor Glucose >=72hrs",PX-510000163,CDM,95250,CPT,0761,RC,,,both,,,1136.00,340.8,"MULTIPLAN [10600]",Multiplan,,965.6,85,,,,,0,1.14,1136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 325ML GEL ROUND SMOOTH SILTEX SILICONE P4.6CM","SUP-3503254 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross PPO",,1481.76,39.2,,16595.83,16595.83,16595.83,"1 through 10",439.61,3213,"percent of total billed charges",
"PLATE 36-39MM TITANIUM 5.5MM ROD LOW PROFILE LEGACY",SUP-8115536,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Open Access",,2027.06,56.9,,1144.80,304.56,2275.09,66,414.32,3028.13,"percent of total billed charges",
"STENT VIABAHN 15CM 120CM 10MM 11FR ENDOPROSTHESIS HEPARIN",SUP-VBH101502A,CDM,C1874,HCPCS,0278,RC,,,both,,,23102.10,6930.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2737.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2686.77,19636.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 20MM 31IN 29IN EPIC 31IN 3 SEPARATE PORCINE",SUP-E100-31M-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,24570.00,7371,"NOVANET [10819]",Novanet,,18427.5,75,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK ULTRA 28MM 4.5MM CORONARY STENT XCELON",SUP-1003381-28,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE SKYPOINT CORONARY EVEROLIMUS ELUTING CORONARY",SUP-1804275-48,CDM,C1874,HCPCS,0278,RC,,,both,,,4554.00,1366.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1303.35,28.62,,,,,0,529.63,3870.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK ULTRA 28MM 4.5MM CORONARY STENT XCELON",SUP-1003381-28,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 24MM 144CM 3.5MM CORONARY STENT",SUP-H7493941824350,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,858.6,28.62,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUNAV 9FR ULTRASOUND CRYSTAL GE",SUP-11657484,CDM,C1759,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 CURVE PLUS 20MM KNEE XLK FIX BEARING SIGMA",SUP-970485,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3198.16,28.62,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METRONIDAZOLE 0.75 % TOPICAL GEL",RX-19741,CDM,,,0250,RC,21922-0070-06,NDC,both,45,GR,2010.79,603.24,"PHCS [10601]",PHCS,,1407.55,70,,,,,0,233.85,1709.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.2MM IFUSE IMPL SYSTEM SACROILIAC PUSH",SUP-500090,CDM,S27000186,LOCAL,0270,RC,,,both,,,3326.40,997.92,"CIGNA [10200]",Cigna,,2261.95,68,,,,,0,386.86,2827.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 22MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532-P-522,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS [10001]","Blue Cross PPO",,3275.51,39.2,,3949.44,3949.44,3949.44,"1 through 10",971.79,7102.52,"percent of total billed charges",
"NAIL 11MM 180MM HIP RIGHT FEMORAL AFFIXUS GOAL POST",SUP-814311180,CDM,C1713,HCPCS,0278,RC,,,both,,,16042.50,4812.75,"CIGNA [10200]","Cigna Local Plus",,5053.39,31.5,,3978.14,359.25,3978.14,24,1865.74,13636.13,"percent of total billed charges",
"HC Fo Pip Dip Jnt/Sprng Pre Ots",PX-E27400036,CDM,L3925,HCPCS,0274,RC,,,both,,,119.90,35.97,"KAISER [10500]",Kaiser,,80.33,67,,,,,0,13.94,101.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 54MM 36MM ALTRX HIP",SUP-122136454,CDM,C1776,HCPCS,0278,RC,,,both,,,6814.08,2044.22,"BLUE CROSS [10001]","Blue Cross PPO",,2671.12,39.2,,3949.44,3949.44,3949.44,"1 through 10",792.48,5791.97,"percent of total billed charges",
"APPL INTERNAL CLIP 5MM ENDOSCOPIC LIGAMAX 5MM STERILE LATEX",SUP-EL5ML,CDM,S27200284,LOCAL,0272,RC,,,both,,,2116.45,634.93,"AETNA [10100]","Aetna HMO/PPO",,1682.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,246.14,1798.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 36FR NEPHRSTMY NATURAL RUBBER 4 WING DRAIN",SUP-086036,CDM,C1729,HCPCS,0272,RC,,,both,,,105.62,31.69,"NOVANET [10819]",Novanet,,79.22,75,,,,,0,12.28,89.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON 10-O CU-8",SUP-8065202001,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.98,94.19,"CIGNA [10200]","Cigna Local Plus",,167.98,53.5,,,,,0,36.52,266.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST TAPER 18MM 9.5MM HEMICAP FOOT METATARSOPHALANGEAL INLAY",SUP-9095-0018-W,CDM,C1776,HCPCS,0278,RC,,,both,,,2250.00,675,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1530,68,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - TIBIAL KIT (CR) - SIZE 4",SUP-5555-2324,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAVIGATOR CATHETER",SUP-3696,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Coccidioides Ab",PX-302000108,CDM,86635,CPT,0302,RC,,,both,,,518.70,155.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.32,,,,,,,0.01,440.9,"fee schedule",
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 8 SLOT LEFT TI",SUP-PHPF-C8L,CDM,C1713,HCPCS,0278,RC,,,both,,,21420.00,6426,"CIGNA [10200]","Cigna Open Access",,7175.7,33.5,,1144.80,304.56,2275.09,66,2491.15,18207,"percent of total billed charges",
"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC",816,MS-DRG,,,,,,,inpatient,,,21595.68,6478.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5700.64,,"Fee schedule rate ($5,700.64). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,3920.33,15761.45,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 54MM TI",SUP-SPL-35540-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I123 Iodide Dx per 100 Uci",PX-343000007,CDM,A9516,HCPCS,0343,RC,,,both,,,324.00,97.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,123.82,,,,,,,37.68,275.4,"fee schedule",
"HC App Splint Short Arm Static",PX-450000192,CDM,29125,CPT,0361,RC,,,both,,,1115.10,334.53,"BLUE CROSS [10001]","Blue Cross HMO",,1115.1,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,129.69,1115.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BMA NEEDLE 74285-02M 11 GAUGE X 15CM",SUP-7428502M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.00,513,"UHC [10700]","United Healthcare",,1082.43,63.3,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 20FR DELIVERY SYSTEM",SUP-ENVPRO-16-US,CDM,S27200284,LOCAL,0272,RC,,,both,,,14559.00,4367.7,"CIGNA [10200]","Cigna Local Plus",,7789.07,53.5,,,,,0,1693.21,12375.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM 2 MARKER SEMIRIGID WIRE STIFFENER",SUP-800SR34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"KAISER [10500]",Kaiser,,8783.7,67,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MERSILENE 2 MO-7 30IN BRAID D SPECIAL GREEN LIGHT GREEN",SUP-D8649,CDM,S27200284,LOCAL,0272,RC,,,both,,,776.02,232.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EVERCROSS BEVEL 360 CROSSTEC 80CM 40MM 8MM .035IN",SUP-AB35W08040080,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 13.5CM NATRELLE INSPIRA P4.5CM MODERATE PROFILE",SUP-MSZ-M445,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ABLATION 3FR THERMOCOOL SF J CURVE DEFLECTABLE",SUP-D131804,CDM,C1732,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH DIAMONDBACK 360 145CM 30MM .079IN 2MM .014IN",SUP-DBP-CART-200SOL145,CDM,C1724,HCPCS,0272,RC,,,both,,,17250.00,5175,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"PLATE CONTOUR LOW BEND 206MM STAINLESS STEEL 3.5MM SCR 14",SUP-02.124.220,CDM,C1713,HCPCS,0278,RC,,,both,,,9182.80,2754.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1088.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1067.96,7805.38,"percent of total billed charges",
"COIL EMBOLIZATION 25CM .02IN 7MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0725,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.00,2003.4,"BLUE CROSS [10001]","Blue Cross HMO",,2617.78,39.2,,,,,0,776.65,5676.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 63CM EPSILA EV SUBSTERNAL QUADRIPOLAR PASSIVE",SUP-EV240163,CDM,C1896,HCPCS,0278,RC,,,both,,,33957.00,10187.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13582.8,40,,,,,0,3949.2,28863.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 12MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192012,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"BLUE CROSS [10001]","Blue Cross HMO",,9309.4,39.2,,5311.50,4717.44,5388.59,31,2761.95,20186.21,"percent of total billed charges",
"STENT EVERFLEX ENTRUST 80MM 150CM 8MM VASCULAR NICKEL",SUP-EVD35-08-080-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"FIRST HEALTH [10303]","First Health",,5028,80,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +22.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2250,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 19MM KNEE X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G619,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"CIGNA [10200]","Cigna Local Plus",,5010.85,53.5,,5372.07,4581.20,7242.98,23,1089.28,7961.17,"percent of total billed charges",
"CATH LAUNCHER 5FR .058IN AMPLATZ LEFT 1 CURVE GUIDING NYLON",SUP-LA5AL10,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 37MM SIMULUS C FULL FLEXIBLE STERILE",SUP-700FC37,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"PHCS [10601]",PHCS,,9177,70,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cardiolipin Ab Ea Ig Class",PX-302000017,CDM,86147,CPT,0302,RC,,,both,,,313.50,94.05,"UHC [10700]","United Healthcare",,22.91,,,,,,,0.01,266.48,"fee schedule",
"INTRODUCER PACING LEAD ACUITY 7FR LONG",SUP-667470-001,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT MONOLITHIC 8MM PLIF",SUP-3W3108,CDM,S27800098,LOCAL,0278,RC,,,both,,,12487.62,3746.29,"AETNA [10100]","Aetna HMO/PPO",,9927.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1452.31,10614.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEARTMATE 3 SKIN CORING PUNCH",SUP-106528US,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.40,131.22,"KAISER [10500]",Kaiser,,293.06,67,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOMATRIX C CANCELLOUS 5ML PUTTY MOLDABLE",SUP-860C0500,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"PHCS [10601]",PHCS,,3477.6,70,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X9MM VERTE-STACK CORNERSTONE PSR 11MM",SUP-6287941,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION COMPLETE CARE LUBRI-SIL IC STATLOCK",SUP-A319516AM,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.71,86.91,"AETNA [10100]","Aetna HMO/PPO",,230.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.69,246.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.5MM 110MM GAMMA3 TITANIUM HIP TROCHANTERIC LAG",SUP-3060-0110S,CDM,C1713,HCPCS,0278,RC,,,both,,,3471.30,1041.39,"CIGNA [10200]",Cigna,,2360.48,68,,1831.33,1831.33,1831.33,16,403.71,2950.61,"percent of total billed charges",
"SCR BONE 2.7MM 36MM VOLT STAINLESS STEEL T8 CORTEX",SUP-02.527.136,CDM,C1713,HCPCS,0278,RC,,,both,,,1033.56,310.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,702.82,68,,,,,0,120.2,878.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER GUIDING ADULT 8FR L100CM CORONARY BLUE NYLON PTFE X",SUP-5888100,CDM,C1725,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Pelvis W Cntrst",PX-352000019,CDM,72193,CPT,0352,RC,,,both,,,3422.78,1026.83,"PHCS [10601]",PHCS,,2395.95,70,,,,,0,398.07,2909.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 1.5MM X 16MM COCR",SUP-VAL-15160-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]",Cigna,,969.41,68,,1831.33,1831.33,1831.33,16,165.8,1211.76,"percent of total billed charges",
"RING ANNULOPLASTY 28MM 35.6MM 28MM MITRAL TRICUSPID FLEXIBLE",SUP-460028MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1324.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE CARDIOXYL MITRAL RING",SUP-73P30E,CDM,S27200284,LOCAL,0272,RC,,,both,,,667.58,200.27,"PHCS [10601]",PHCS,,467.31,70,,,,,0,77.64,567.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE CARDIOXYL MITRAL RING",SUP-73P30E,CDM,S27200284,LOCAL,0272,RC,,,both,,,667.58,200.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,453.95,68,,,,,0,77.64,567.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 0 GS-21 12IN CLSR ABSORBABLE TAPER POINT",SUP-VLOCL0316,CDM,S27200284,LOCAL,0272,RC,,,both,,,426.39,127.92,"CIGNA [10200]","Cigna Open Access",,242.62,56.9,,,,,0,49.59,362.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 0 GS-21 12IN CLSR ABSORBABLE TAPER POINT",SUP-VLOCL0316,CDM,S27200284,LOCAL,0272,RC,,,both,,,426.39,127.92,"PHCS [10601]",PHCS,,298.47,70,,,,,0,49.59,362.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 130CM 100MM 6MM BALLOON DILATATION",SUP-LX3513061005F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4574.7,68,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.75MM X 10.0MM",SUP-493751012,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 32MM 140CM 3.5MM CORONARY STENT PLATINUM",SUP-H7493927432350,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"KAISER [10500]",Kaiser,,2512.5,67,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.165,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 140MM 120CM 14MM .035IN VASCULAR VENOUS CATH",SUP-VENUL14140,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"AETNA [10100]","Aetna HMO/PPO",,18531.45,79.5,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC F5 Gene",PX-309000026,CDM,81241,CPT,0310,RC,,,both,,,769.60,230.88,"MULTIPLAN [10600]",Multiplan,,654.16,85,,,,,0,0.01,654.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT PL SITEMARK 51CM 47CM 9FR 7FR RIGHT SIDE",SUP-410176,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,439.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE 30X20CM KNIT FILM SYNECOR RECTANGLE",SUP-GKFR2030,CDM,C1781,HCPCS,0278,RC,,,both,,,27442.80,8232.84,"KAISER [10500]",Kaiser,,18386.68,67,,,,,0,3191.6,23326.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEPHRSTMY 10FR 21GA INTRO CATH CUFF GWIRE CONNECT TUBE",SUP-M001281660,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSURITY PACEMAKER RF SR",SUP-PM1240,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"AETNA [10100]","Aetna HMO/PPO",,19747.8,79.5,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 2.5CM 10CM GWIRE DIL RADIOPAQUE KINK",SUP-RSB812,CDM,C1894,HCPCS,0272,RC,,,both,,,217.50,65.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 90MM 22MM 16MM AFX2 2 BRANCH 30MM AAA STERILE",SUP-BEA22-90/I16-30,CDM,C1874,HCPCS,0278,RC,,,both,,,84559.50,25367.85,"AETNA [10100]","Aetna HMO/PPO",,67224.8,79.5,,,,,0,9834.27,71875.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP 12 SCALLOP CLUSTER HOLE SNAP FIT",SUP-00875705801,CDM,C1776,HCPCS,0278,RC,,,both,,,11012.40,3303.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1304.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1280.74,9360.54,"percent of total billed charges",
"STENT WALLSTENT UNISTEP PLUS 60MM 75CM 16MM 9FR 100CM",SUP-40332,CDM,C1876,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"BLUE CROSS [10001]","Blue Cross HMO",,2637.18,39.2,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PLA HA 20MM 7MM ACL TAPERED BIOCOMPATIBLE",SUP-72201771,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest Rectal Tmr Trnsanal",PX-750000157,CDM,45190,CPT,0750,RC,,,both,,,12954.00,3886.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1535.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1506.55,11010.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK PHACOEMULSIFICATION .9MM 45D ABS TIP FLUID MANAGEMENT",SUP-8065752201,CDM,S27200284,LOCAL,0272,RC,,,both,,,833.00,249.9,"CIGNA [10200]","Cigna Open Access",,473.98,56.9,,,,,0,96.88,708.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MONITOR CARDIAC LUX DX INSERTABLE",SUP-M301,CDM,C1764,HCPCS,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 75CM 80MM 5FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206060870,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FLUOXETINE 20 MG CAPSULE",RX-10070,CDM,,,0637,RC,00904-7346-61,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ARTHROSCOPIC 8IN .092IN TROCAR DISPOSABLE",SUP-AR-8967K,CDM,C1769,HCPCS,0272,RC,,,both,,,130.50,39.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BENCH TRANSFER ALUMINUM PLASTIC BATHTUB NONPAD SEAT SIDE",SUP-A8303,CDM,S27000186,LOCAL,0270,RC,,,both,,,679.35,203.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE OPHTHALMIC 8.5MM HANNA",SUP-17171D850,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 150CM 250MM 6MM BALLOON DILATATION DURALYN",SUP-48006025X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHELL ACETABULAR 48MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732048,CDM,C1776,HCPCS,0278,RC,,,both,,,9510.48,2853.14,"MULTIPLAN [10600]",Multiplan,,8083.91,85,,,,,0,1106.07,8083.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE RIGHT CRUCIATE RETAIN CEMENT ATTUNE",SUP-1504-00-208,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"CIGNA [10200]",Cigna,,8957.34,40,,5873.17,5873.17,5873.17,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"FILLER BONE VOID 90CC 1.7-10MM CANCELLOUS ALLOGRAFT FREEZE",SUP-400160,CDM,C1713,HCPCS,0278,RC,,,both,,,7182.90,2154.87,"CIGNA [10200]",Cigna,,4884.37,68,,1831.33,1831.33,1831.33,16,835.37,6105.47,"percent of total billed charges",
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.5MM X 15.0MM",SUP-493501512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 20MM COMPREHENSIVE 3.5MM HEXAGON SHOULDER",SUP-180558,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"BLUE CROSS [10001]","Blue Cross HMO",,609.95,39.2,,957.42,156.86,7483.26,51,180.96,1322.6,"percent of total billed charges",
"CATH GUIDER SOFTIP XF 100CM 6FR STRAIGHT GUIDING DURAFORM",SUP-M003101500,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"KAISER [10500]",Kaiser,,1677.1,67,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION HOFFMANN II MICRO PERIARTICULAR",SUP-4960-3-030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1183.90,355.17,"NOVANET [10819]",Novanet,,887.93,75,,,,,0,137.69,1006.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE BTTRY SMART AA THERMAL PISTON HEAT DEVICE",SUP-70131012,CDM,S27000186,LOCAL,0270,RC,,,both,,,671.33,201.4,"PHCS [10601]",PHCS,,469.93,70,,,,,0,78.08,570.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.2MM 18MM ACUTRAK 2 MINI HINDFOOT ANKLE STD",SUP-AT2-L2515,CDM,C1713,HCPCS,0278,RC,,,both,,,1702.50,510.75,"KAISER [10500]",Kaiser,,1140.68,67,,,,,0,198,1447.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TRUCLEAR ULTRA 10MM MINI REMOVAL CUT WINDOW BLADE",SUP-72204064,CDM,C1782,HCPCS,0272,RC,,,both,,,7062.29,2118.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,821.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,821.34,6002.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM AVENIR 10 HELICAL FINISH STERILE",SUP-10HFN-04010,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"UHC [10700]","United Healthcare",,6547.18,63.3,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE INFLATION DEFLATION",SUP-OF-0008,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"CIGNA [10200]",Cigna,,605.88,68,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 63CM SUPERSTIFF GWIRE GUIDING HEMOSTASIS",SUP-407436,CDM,C1893,HCPCS,0272,RC,,,both,,,1012.50,303.75,"AETNA [10100]","Aetna HMO/PPO",,804.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PROC 1 TRIATHLON PS DISPOSABLE FEMORAL",SUP-5555-2251,CDM,C1776,HCPCS,0278,RC,,,both,,,1417.50,425.25,"FIRST HEALTH [10303]","First Health",,1134,80,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 116MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 9",SUP-71357009,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"KAISER [10500]",Kaiser,,22204.57,67,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE REVISION HYBRID CONCELOC HYBRID WITH NON",SUP-71704638,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2762.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 20MM 2.5MM BALLOON DILATATION",SUP-2200-2520-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"FIRST HEALTH [10303]","First Health",,4692,80,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK 8CM STD SINUS NASAL NASOPORE FOAM",SUP-5400010008,CDM,S27200284,LOCAL,0272,RC,,,both,,,1550.25,465.07,"KAISER [10500]",Kaiser,,1038.67,67,,,,,0,180.29,1317.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 3-0 PSL 30IN MONOFILAMENT BLACK NONABSORBABLE",SUP-1691H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UHC [10700]","United Healthcare",,15.83,63.3,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 1 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND COATED",SUP-J741D,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.33,40,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.51,113.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0247,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,434.99,45.9,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXS CATALYST 5 115CM 5.3-5.6FR GUIDING DISTAL ACCESS",SUP-M003IC0581150,CDM,S27200284,LOCAL,0272,RC,,,both,,,12417.10,3725.13,"FIRST HEALTH [10303]","First Health",,9933.68,80,,,,,0,1444.11,10554.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA RAM  MICRO PREEMIE",SUP-N4900,CDM,S27000186,LOCAL,0270,RC,,,both,,,97.44,29.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.33,82.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.35IN 22FR HEYMAN PLASTIC COUDE TIP DILATION",SUP-021322,CDM,S27200284,LOCAL,0272,RC,,,both,,,242.30,72.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.18,205.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 16MM 144CM 3MM",SUP-H7493941216300,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2221.63,28.62,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 80MM AXSOS STAINLESS STEEL 3.5MM FULL THREAD",SUP-343080,CDM,C1713,HCPCS,0278,RC,,,both,,,299.63,89.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,34.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",34.85,254.69,"percent of total billed charges",
"TOOL 14CM MR8 4MM BALL DISSECTING STERILE DISPOSABLE",SUP-MR8-14BA40,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.19,388.56,"FIRST HEALTH [10303]","First Health",,1036.15,80,,,,,0,150.63,1100.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE RADIUS ULNA SHAFT ALLOGRAFT FREEZE DRIED 60X15-18",SUP-400810,CDM,S27800098,LOCAL,0278,RC,,,both,,,4694.76,1408.43,"CIGNA [10200]","Cigna Open Access",,2671.32,56.9,,,,,0,546,3990.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840004040,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 10 X 34 COMPLEX FRAMING COIL",SUP-10CFR-10034,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"KAISER [10500]",Kaiser,,7854.48,67,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC 5MM ENDOWRIST CROCODILE",SUP-428059,CDM,S27000186,LOCAL,0270,RC,,,both,,,963.90,289.17,"CIGNA [10200]",Cigna,,655.45,68,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 40MM 80CM 10MM 6FR VASCULAR NITINOL",SUP-G43866,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross HMO",,1481.76,39.2,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE 100CM 6FR AMPLATZ RIGHT MODIFIED CURVE",SUP-532648,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +7 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000070,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sars Cov-2 Antibody Qn",PX-302000239,CDM,86413,CPT,0302,RC,,,both,,,228.00,68.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,55.04,,"Fee schedule rate ($55.04). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.35,193.8,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 STANDARD 9MM X 30CM",SUP-M0035469300,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"NOVANET [10819]",Novanet,,10585.98,75,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2/0 CARDIOXYL W/ PLEDGET 3 X 7MM 25MM",SUP-73P30CM,CDM,S27200284,LOCAL,0272,RC,,,both,,,645.98,193.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,265.5,41.1,,,,,0,75.13,549.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PRELUDE ROADSTAR 65CM 75CM 6FR .088IN GUIDING",SUP-PG6F65S,CDM,C1894,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"5X14X16X4DEG AVS AS SPACER",SUP-48324054,CDM,C1776,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,5873.17,5873.17,5873.17,"1 through 10",521.61,3812.25,"percent of total billed charges",
"LEAD PACING 90CM 4.1-2.6FR SPIRAL LEFT VENTRICLE CORONARY",SUP-4592,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"NOVANET [10819]",Novanet,,4205.25,75,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Perc Bile Duct Stent New Int or Ext",PX-361000407,CDM,47540,CPT,0361,RC,,,both,,,13847.00,4154.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6891,,"Case rate ($6,891). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1610.41,11769.95,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT STABILIT VP LONG VERTEBROPLASTY",SUP-VP-1110L,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"AETNA [10100]","Aetna HMO/PPO",,3839.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X4MM VERTE-STACK CORNERSTONE PSR 14MM",SUP-6278444,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT/GRAFT ENDOPROSTHESIS 15CM 31MM 14.5MM EXCLUDER",SUP-PXT311415,CDM,C1874,HCPCS,0278,RC,,,both,,,51439.50,15431.85,"CIGNA [10200]",Cigna,,20575.8,40,,,,,0,5982.41,43723.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL VASCU-STATT II 75-80GM CLAMPING PRESSURE MIDI",SUP-1001-532,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.36,32.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.72,92.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC SMALL 8IN 6.25-7.25IN WRIST LEFT",SUP-92722002,CDM,L3908,HCPCS,0274,RC,,,both,,,148.86,44.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.31,126.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 7.5FR 10.5FR SUBCUTANEOUS DF-1 CNCT",SUP-6996SQ58,CDM,C1896,HCPCS,0278,RC,,,both,,,12420.00,3726,"MULTIPLAN [10600]",Multiplan,,10557,85,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 50MM TITANIUM ATLANTIS VISION ELITE BONE ANTERIOR",SUP-7200050,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",512.88,3748.5,"percent of total billed charges",
"SYSTEM INTERNALBRACE FIXATION ULNAR COLLATERAL LIGAMENT",SUP-AR-7715,CDM,C1713,HCPCS,0278,RC,,,both,,,8541.86,2562.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1012.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",993.42,7260.58,"percent of total billed charges",
"RING ANNULOPLASTY 24MM RECONSTRUCTION VALVULAR RETRACTION",SUP-680R24,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]",Cigna,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRACTOR ABDOMINAL RIBBON TISSUE HAND HELD MALLEABLE 8IN LE",SUP-22-0017,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.04,24.61,"CIGNA [10200]",Cigna,,55.79,68,,,,,0,9.54,69.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.7MM ALPS CALIBRATED SMALL FRAGMENT SYSTEM",SUP-214227070,CDM,S27200284,LOCAL,0272,RC,,,both,,,1275.75,382.72,"NOVANET [10819]",Novanet,,956.81,75,,,,,0,148.37,1084.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG LINGEMAN 8MM ADPTR CYSTOSCOPY UROLOGY SUCTION HOSE",SUP-LG3000N-A,CDM,S27000186,LOCAL,0270,RC,,,both,,,69.34,20.8,"FIRST HEALTH [10303]","First Health",,55.47,80,,,,,0,8.06,58.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM 22MM EMBOLD NITINOL FIBER DETACHABLE",SUP-M001394240220600,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"UHC [10700]","United Healthcare",,5455.26,63.3,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FREEZE DRY 26MMX20MM",SUP-439020,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Below Knee Sleeve",PX-E27400097,CDM,L5685,HCPCS,0274,RC,,,both,,,323.40,97.02,"NOVANET [10819]",Novanet,,242.55,75,,,,,0,37.61,274.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 40MMX8MM CLYDESDALE 6D PEEK-OPTIMA RADIOPAQUE",SUP-2968840,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2784.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 50MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.550,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,129.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",127.51,931.96,"percent of total billed charges",
"COIL EMBOLIZATION 40CM 20MM .021-.027IN AZUR CX HYDROCOIL",SUP-45-782040,CDM,S27800098,LOCAL,0278,RC,,,both,,,5278.50,1583.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2422.83,45.9,,,,,0,613.89,4486.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT VALEO 56MM 120CM 8MM LOW PROFILE TAPER",SUP-EV08562CD,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"UHC [10700]","United Healthcare",,5678.01,63.3,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MITRACIP SGC (STEERABLE GUIDE CATHETER) PRIMARY MR CLINICAL",SUP-SGC0304,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.5MM 18MM PARTIAL THREAD DISTAL VOLAR RADIUS",SUP-TP18000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1093.50,328.05,"UHC [10700]","United Healthcare",,692.19,63.3,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCSSR PNEUMATIC ADULT 33-43IN WRAP AIRWAY CLEARANCE SYSTEM",SUP-P300631005,CDM,S27000186,LOCAL,0270,RC,,,both,,,548.99,164.7,"NOVANET [10819]",Novanet,,411.74,75,,,,,0,63.85,466.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT SHOULDER HEMI",SUP-98000972500,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5859.95,28.62,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 28MM 145CM 2.75MM CORONARY STENT",SUP-1145275-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AETNA [10100]","Aetna HMO/PPO",,4641.21,79.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NUROLON 0 MO-6 18IN CONTROL RELEASE BRAID 8 STRAND BLACK",SUP-C545D,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.68,41.6,"MULTIPLAN [10600]",Multiplan,,117.88,85,,,,,0,16.13,117.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 24MM 10D OBLIQUE FULL AUG STERILE LATEX FREE",SUP-AR-9580-2410,CDM,C1776,HCPCS,0278,RC,,,both,,,11571.30,3471.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3311.71,28.62,,,,,0,1345.74,9835.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 16MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656016,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"CIGNA [10200]","Cigna Open Access",,759.73,56.9,,1144.80,304.56,2275.09,66,155.28,1134.92,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 28MM 145CM 2.5MM CORONARY STENT",SUP-1125250-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"NOVANET [10819]",Novanet,,4378.5,75,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 90CM 150MM 2MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186201590,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 100MM 135CM 9MM VASCULAR NITINOL",SUP-1012537-100,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM CD HORIZON VOYAGER SPINE NONSTERILE",SUP-55850044535,CDM,C1713,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3404.63,45.9,,,,,0,862.66,6304.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805310,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,258.2,28.62,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9.5MM 35MM SOLERA CD HORIZON TITANIUM COCR SPINE 2",SUP-54840009535,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 16X3MM COLOSSEUM 3.5D 14MM NONSTERILE LATEX",SUP-156.563,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"CIGNA [10200]",Cigna,,2340.9,68,,,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X8MM COROENT XL+ PEEK NONSTERILE LATEX FREE",SUP-6008850,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,9384.48,39.2,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bilirubin Total",PX-301000113,CDM,82247,CPT,0301,RC,,,both,,,141.55,42.46,"KAISER [10500]",Kaiser,,94.84,67,,,,,0,0.14,120.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PALIPERIDONE PALMITATE 117 MG/0.75 ML INTRAMUSCULAR SYRINGE",RX-108108,CDM,J2426,HCPCS,0636,RC,50458-0562-01,NDC,both,.75,ML,10771.54,3231.46,"PHCS [10601]",PHCS,,7540.08,70,,,,,0,1276.43,9155.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .018IN 4FR 3MM 150CM 100MM SMALL",SUP-83971-02,CDM,C1725,HCPCS,0272,RC,,,both,,,3037.50,911.25,"KAISER [10500]",Kaiser,,2035.13,67,,,,,0,353.26,2581.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X18X10MM MODULUS 10D XL STERILE LATEX FREE",SUP-1181060P2,CDM,C1889,HCPCS,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8113.77,28.62,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +14 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE 13",SUP-PCB0000140,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X12MM OVAL PARALLEL SPINE CORTICAL",SUP-17112,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PICO 7 30X10CM NEGATIVE PRESSURE STERILE LATEX FREE",SUP-66022003,CDM,S27200284,LOCAL,0272,RC,,,both,,,1995.00,598.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL BLUE 110MM 1.5MM QUICK COUPLE 2MM CORTICAL SCR",SUP-03.119.000,CDM,S27200284,LOCAL,0272,RC,,,both,,,558.90,167.67,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH INTRO ORANGE 90CM 7FR BRITE TIP CANN INTERVENTIONAL",SUP-401790M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 20GA 10CM POWERGLIDE MIDLINE STERILE LATEX FREE",SUP-M120100,CDM,C1751,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PUMP SUCTION MAX PENUMBRA SYSTEM ASPIRATION COMPATIBLE",SUP-PMX110,CDM,C1884,HCPCS,0272,RC,,,both,,,28350.00,8505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"4MM AMPLATZER MUSCULAR VSD OCCLUDER",SUP-9-VSD-MUSC-004,CDM,C1817,HCPCS,0278,RC,,,both,,,62700.00,18810,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7429.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 1CM 1CM GALAXY G3 MINI STRETCH",SUP-GLM910010,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3208.09,27,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HYBRID TOTAL KNEE SYSTEM (EITHER POROUS FEMUR OR TIBIA)",SUP-98000200382,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"CIGNA [10200]","Cigna Open Access",,7808.85,33.5,,5302.19,4377.88,6578.61,27,2710.95,19813.5,"percent of total billed charges",
"COIL EMBOLIZATION 7CM 18MM RETRACTA DETACHABLE .035IN",SUP-G34194,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"PHCS [10601]",PHCS,,2970.45,70,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL TAN 105MM 10.35MM TFN-ADVANCED",SUP-04.038.405S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"PHCS [10601]",PHCS,,2787.3,70,,,,,0,463.09,3384.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Trach Uncuffed",PX-E27200237,CDM,E27200237,LOCAL,0272,RC,,,both,,,373.07,111.92,"CIGNA [10200]","Cigna Local Plus",,199.59,53.5,,,,,0,43.39,317.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 34MM SIMUPLUS FLEXIBLE LUMEN STERILE LATEX",SUP-7700FB34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 86MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.086S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,957.42,570.23,957.42,28,189.34,1383.8,"percent of total billed charges",
"LENS IOL +21 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000210,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X8MM ALEUTIAN LORDOTIC",SUP-403-21408L,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1911.36,28.62,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LATERAL LUMBAR ANCHOR 30MM",SUP-1219.0030,CDM,C1713,HCPCS,0278,RC,,,both,,,3277.50,983.25,"CIGNA [10200]","Cigna Open Access",,1864.9,56.9,,1144.80,304.56,2275.09,66,381.17,2785.88,"percent of total billed charges",
"CATH RAPI-FIT 83CM 14FR 3MM AIRWAY EXCHANGE ADPTR LUER LOCK",SUP-G57622,CDM,S27200284,LOCAL,0272,RC,,,both,,,672.30,201.69,"CIGNA [10200]",Cigna,,457.16,68,,,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 135CM 5MM 30MM",SUP-H74938047530130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"NOVANET [10819]",Novanet,,3744,75,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET SILASTIC 2X2X.04IN TRIMMABLE STERILE LATEX FREE",SUP-1532520,CDM,S27800098,LOCAL,0278,RC,,,both,,,237.51,71.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.62,201.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 135CM 1.5FR .026-.039IN 15MM SPACE SPRT",SUP-518-032,CDM,C1887,HCPCS,0272,RC,,,both,,,972.00,291.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,113.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL FLAT L HOOK 45CM CLEANCOAT",SUP-E3774-45C,CDM,S27200284,LOCAL,0272,RC,,,both,,,316.07,94.82,"CIGNA [10200]",Cigna,,214.93,68,,,,,0,36.76,268.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE BOOKWALTER RTRCTR TILT RATCHET MECHANISM",SUP-50-4580,CDM,S27200284,LOCAL,0272,RC,,,both,,,4696.28,1408.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1930.17,41.1,,,,,0,546.18,3991.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TIGHTRAIL SUB-C .171IN DIL ROTATE STERILE LATEX FREE",SUP-560-013,CDM,C1773,HCPCS,0272,RC,,,both,,,12385.50,3715.65,"KAISER [10500]",Kaiser,,8298.29,67,,,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,,,0250,RC,24208-0295-25,NDC,both,2.5,ML,305.22,91.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET VENTRICULAR ASSIST IMPELLA AXILLARY LATEX FREE",SUP-0052-0011,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ASNIS III ORTHOPEDIC 300MM 3.2MM NONTHREADED STERILE",SUP-702463S,CDM,C1769,HCPCS,0272,RC,,,both,,,932.15,279.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SURGITIE 0 21IN LIGATE LOOP ABSORBABLE",SUP-SGL-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP SURGICAL STEALTH FIBRA 12MM VASCULAR .5 FORCE SPRING",SUP-G-1252,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE NERVE STIM STIMUPLEX NEUROMUSCULAR CABLE HNS11",SUP-333576,CDM,S27200284,LOCAL,0272,RC,,,both,,,400.46,120.14,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EUPHORA 142CM 30MM 2MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2030X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cush WC 28x22x2in Waffle C700lb Bariatric",PX-E27000271,CDM,E27000271,LOCAL,0270,RC,,,both,,,467.50,140.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,inpatient,,,128797.44,38639.23,"CIGNA [10200]","Cigna Local Plus",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 44%. Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 4FR 20CM PROVENA 2 LUMEN MIDLINE FULL STERILE LATEX",SUP-S4254108,CDM,C1751,HCPCS,0272,RC,,,both,,,1206.25,361.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SAMURAI VASCULAR 190CM J TIP",SUP-H74939302190J2,CDM,C1769,HCPCS,0272,RC,,,both,,,689.78,206.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Ndl Insrt WO Inj 3+ Musc",PX-510000524,CDM,20561,CPT,0420,RC,,,both,,,202.62,60.79,"UHC [10700]","United Healthcare",,202.62,,"Per diem ($331).",,,,0,23.56,202.62,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ndl Insrt WO Inj 3+ Musc",PX-510000524,CDM,20561,CPT,0420,RC,,,both,,,202.62,60.79,"MULTIPLAN [10600]",Multiplan,,172.23,85,,,,,0,23.56,202.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +24 DIOPTER +3 CYL BICONVEX 13MM 6MM POSTERIOR",SUP-SN6AT5.240,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 15CM SUPERCORE COAXIAL INTRO ADJUSTABLE",SUP-701120150,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.65,103.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,157.74,45.9,,,,,0,39.97,292.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17 DIOPTER +1.5 CYL MODIFY C BICONVEX 13MM 6MM",SUP-ZCT150U170,CDM,V2632,HCPCS,0276,RC,,,both,,,3712.50,1113.75,"CIGNA [10200]","Cigna Local Plus",,1986.19,53.5,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 UR-6 27IN BRAID COATED VIOLET ABSORBABLE",SUP-VCP602H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UHC [10700]","United Healthcare",,15.83,63.3,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXIMA 70CM 5FR 14FR URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002411,CDM,C1758,HCPCS,0272,RC,,,both,,,80.01,24,"FIRST HEALTH [10303]","First Health",,64.01,80,,,,,0,9.31,68.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHORD-X 2-0 .5 CIRCLE 18MM 32MM 2 ARM LOOP PLEDG 3",SUP-CXL-20-1812-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Open Access",,2133.75,56.9,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 45CM PK COIL LP STERILE LATEX FREE",SUP-RBYPCLP45,CDM,S27800098,LOCAL,0278,RC,,,both,,,8832.00,2649.6,"CIGNA [10200]","Cigna Local Plus",,4725.12,53.5,,,,,0,1027.16,7507.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 12MM 1.5MM BALLOON DILATATION STERILE",SUP-215-123-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Oxymizer",PX-E27000142,CDM,E27000142,LOCAL,0270,RC,,,both,,,110.00,33,"NOVANET [10819]",Novanet,,82.5,75,,,,,0,12.79,93.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 5-0 P-1 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J490G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER BUCKLE MRI GUIDED RIGID DEPLOYMENT DEVICE SECURMARK",SUP-SMARK-M-SS1,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"KAISER [10500]",Kaiser,,447.46,67,,,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 17.5MM KNEE GVF STABILIZE ROTATE PLATFORM PFC",SUP-962114,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6939.47,68,,,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM CEREPAK FREEFORM DETACHABLE",SUP-SCR120620,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5290.34,40,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 180CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-180,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]",Cigna,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM ULNAR SIZE 4 L75MM RIGHT CEMENTED CONSTRAINED NEXEL",SUP-840002407,CDM,C1776,HCPCS,0278,RC,,,both,,,31971.49,9591.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9150.24,28.62,,,,,0,3718.28,27175.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AXS INFINITY LS LONG 90CM 8FR .088IN INTRO STERILE",SUP-GEN-10800-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1537.14,41.1,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SHORT 51.3X24.4MM TITANIUM 3 HOLE 2 TIER DVR FAST",SUP-DVRASR,CDM,C1713,HCPCS,0278,RC,,,both,,,7607.25,2282.17,"KAISER [10500]",Kaiser,,5096.86,67,,,,,0,884.72,6466.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM SPINAL POLYAXIAL",SUP-8806540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4382,45.9,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X18X12MM COROENT POLYETHERETHERKETONE",SUP-6981260,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS [10001]","Blue Cross PPO",,9313.92,39.2,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 15MM 145CM 3.75MM BALLOON DILATATION",SUP-1400375-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 134MM 7MM PRESS FIT FULL PROFILE TAPERLOC PPS",SUP-51-100070,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6534.9,27,,,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TI 4.0-4.0X220 ADJ ROD",SUP-102074220,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Open Access",,2133.75,56.9,,1144.80,304.56,2275.09,66,436.13,3187.5,"percent of total billed charges",
"ANCHOR SUT 5.5MM 2 .5 CIRCLE FULL THREAD DIAMOND CORKSCREW",SUP-AR-1928SNF-2,CDM,C1713,HCPCS,0278,RC,,,both,,,2008.13,602.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1365.53,68,,,,,0,233.55,1706.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM PREBENT LINE",SUP-179771120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"SPACER SPINAL 10MM ZERO-P PEEK CERVICAL INTERBODY FUSION",SUP-04.617.120S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"UHC [10700]","United Healthcare",,7861.86,63.3,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TIGHTROPE II RT FIXATION FLIP SUT",SUP-AR-1588RT-2J,CDM,C1713,HCPCS,0278,RC,,,both,,,3661.88,1098.56,"BLUE CROSS [10001]","Blue Cross PPO",,1435.46,39.2,,957.42,570.23,957.42,28,425.88,3112.6,"percent of total billed charges",
"IMPL FIXATION 10MM GRAFTBOLT TIBIA RECONSTRUCTION SCR",SUP-AR-5100-10,CDM,C1713,HCPCS,0278,RC,,,both,,,3110.63,933.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,368.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",361.77,2644.04,"percent of total billed charges",
"STENT VIABAHN 15CM 120CM 8MM 8FR ENDOPROSTHESIS HEPARIN",SUP-VBH081502,CDM,C1874,HCPCS,0278,RC,,,both,,,23102.10,6930.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6237.57,27,,,,,0,2686.77,19636.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CLEANGUIDE ENDOSCOPIC 19MM ESOPHAGEAL OTW MARK SPRING",SUP-CG-19-3,CDM,C1769,HCPCS,0272,RC,,,both,,,526.50,157.95,"KAISER [10500]",Kaiser,,352.76,67,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT RIBFIX TITAN INTRATHORACIC BUTTON WASHER TITANIUM",SUP-323.5001,CDM,C1713,HCPCS,0278,RC,,,both,,,12385.50,3715.65,"MULTIPLAN [10600]",Multiplan,,10527.68,85,,,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 66MM STAINLESS STEEL 2.4MM SCR 6 HOLE HEAD 4 HOLE",SUP-02.111.641S,CDM,C1713,HCPCS,0278,RC,,,both,,,4447.05,1334.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,526.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,517.19,3779.99,"percent of total billed charges",
"2.0MM TI CORTEX SCRW SLF-TPNG WITH STARDRIVE RECESS 10MM",SUP-401.360.97,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,50.59,369.75,"percent of total billed charges",
"HEAD FEMORAL -3.5MM BIG SLIGHT TAPER 28MM HIP SUPER FINISH",SUP-26000025,CDM,C1776,HCPCS,0278,RC,,,both,,,6472.20,1941.66,"KAISER [10500]",Kaiser,,4336.37,67,,,,,0,752.72,5501.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM CD HORIZON VOYAGER SPINE NONSTERILE",SUP-55850044535,CDM,C1713,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"CIGNA [10200]","Cigna Open Access",,4220.56,56.9,,1144.80,304.56,2275.09,66,862.66,6304.88,"percent of total billed charges",
"PROBE COAGULATION PURPLE 350CM 7FR BRIGHTON GASTROINTESTINAL",SUP-BP-7F-SP-350,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NUROLON 0 MO-6 18IN CONTROL RELEASE BRAID 8 STRAND BLACK",SUP-C545D,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.68,41.6,"AETNA [10100]","Aetna HMO/PPO",,110.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.13,117.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM SOLERA COCR TITANIUM SPINE MULTIAXIAL",SUP-54840007550,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS [10001]","Blue Cross PPO",,3742.37,39.2,,957.42,570.23,957.42,28,1110.3,8114.82,"percent of total billed charges",
"DEVICE CAPIO 35CM 12MM SUTURING TRANSVAGINAL SLING OPEN",SUP-M0068321010,CDM,C2631,HCPCS,0278,RC,,,both,,,1841.18,552.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,526.95,28.62,,,,,0,214.13,1565,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-1504-40-107,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"CIGNA [10200]","Cigna Local Plus",,9485.91,31.5,,5372.07,4581.20,7242.98,23,3502.26,25596.9,"percent of total billed charges",
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 8MM BALLOON",SUP-U357586,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SAFE-T-J VASCULAR STD CURVE TAPER 50CM 3CM .035IN",SUP-G00524,CDM,C1769,HCPCS,0272,RC,,,both,,,113.01,33.9,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dvc Accupap Airway Mouthpc",PX-E27000218,CDM,E27000218,LOCAL,0270,RC,,,both,,,133.10,39.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRACE WALKING 11-13 12-13.5 LARGE STD FOOT ANKLE CLOSED HEEL",SUP-15590067,CDM,S27000186,LOCAL,0270,RC,,,both,,,223.94,67.18,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Immun Admin Vacc Thru 18yr Adl",PX-771000008,CDM,90461,CPT,0771,RC,,,both,,,80.96,24.29,"UHC [10700]","United Healthcare",,80.96,,"Per diem ($647).",,,,0,9.42,80.96,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immun Admin Vacc Thru 18yr Adl",PX-771000008,CDM,90461,CPT,0771,RC,,,both,,,80.96,24.29,"NOVANET [10819]",Novanet,,60.72,75,,,,,0,9.42,80.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Foot >=3v Complt",PX-320000090,CDM,73630,CPT,0320,RC,,,both,,,583.49,175.05,"MULTIPLAN [10600]",Multiplan,,495.97,85,,,,,0,41.31,495.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 41MM TRUNION ARTHREX ECLIPSE SHOULDER",SUP-AR-9301-41CPC,CDM,C1776,HCPCS,0278,RC,,,both,,,9239.10,2771.73,"CIGNA [10200]","Cigna Open Access",,5257.05,56.9,,5302.19,4377.88,6578.61,27,1074.51,7853.24,"percent of total billed charges",
"TOTAL KNEE - KNEE CONSTRUCT 2A SPECIALTY METALS - CEMENTED P",SUP-CAP-K-2A,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2857.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP BLOCK CUTTING TRUMATCH",SUP-OSC366405,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Not Feeynolm 20.1-30.0cm",PX-450000023,CDM,12006,CPT,0450,RC,,,both,,,2098.00,629.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,694.48,,,,,,,67.13,2098,"case rate",
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 8CM 5.8FR 24FR BALLOON",SUP-M0062251100,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,199.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,199.16,1455.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP MULTIHOLE TRITANIUM TRIDENT II D",SUP-709-04-48D,CDM,C1776,HCPCS,0278,RC,,,both,,,17958.91,5387.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2128.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2088.62,15265.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 7MM CR VERTEBRAL LORDOTIC NONSTERILE",SUP-889.923,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP HUMERAL 33MM UNIVERS REVERS NEUTRAL SUT",SUP-AR-9502F-33CPC,CDM,C1776,HCPCS,0278,RC,,,both,,,7576.20,2272.86,"FIRST HEALTH [10303]","First Health",,6060.96,80,,,,,0,881.11,6439.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE RIGHT CEMENT REVISION CONSTRAIN ATTUNE",SUP-150440205,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"BLUE CROSS [10001]","Blue Cross HMO",,11804.69,39.2,,5311.50,4717.44,5388.59,31,3502.26,25596.9,"percent of total billed charges",
"VALVE AORTIC 13.5MM 19MM MOSAIC ULTRA CINCH PORCINE",SUP-305U219,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"PHCS [10601]",PHCS,,19183.5,70,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 10X7CM MATRIX",SUP-SMRS0710,CDM,S27800098,LOCAL,0278,RC,,,both,,,6665.40,1999.62,"CIGNA [10200]","Cigna Open Access",,3792.61,56.9,,,,,0,775.19,5665.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 40MM 2.5MM BALLOON DILATATION ZGLIDE",SUP-H7493918940250,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 92MM STAINLESS STEEL 2.7MM SCR 4 HOLE VARIABLE ANGLE",SUP-02.118.402S,CDM,C1713,HCPCS,0278,RC,,,both,,,4562.97,1368.89,"CIGNA [10200]","Cigna Local Plus",,2441.19,53.5,,3978.14,359.25,3978.14,24,530.67,3878.52,"percent of total billed charges",
"COIL EMBOLIZATION 8CM 4MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036124080,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 16MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-416-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"UHC [10700]","United Healthcare",,7617.27,63.3,,8601.07,8395.67,8601.07,"1 through 10",1399.51,10228.56,"percent of total billed charges",
"CATH LUTONIX 100CM 60MM 9MM BALLOON DILATATION DRUG COATED",SUP-LX35100960V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"NOVANET [10819]",Novanet,,6339.38,75,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rp Loc Tum Spect 2 Areas",PX-341000073,CDM,78831,CPT,0341,RC,,,both,,,6854.96,2056.49,"BLUE CROSS [10001]","Blue Cross PPO",,1867.85,,"Fee schedule rate ($1,867.85).",,,,0,797.23,5826.72,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEROPENEM 1 G/20ML IV (WET SOLR VIAL)",RX-41517380,CDM,J2185,HCPCS,0636,RC,63323-0508-30,NDC,both,1,UN,53.45,16.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7.4,,,,,,,4.46,45.43,"fee schedule",
"SCR BONE 3.5MM 30MM T15 NONLOCK LOW PROFILE NONSTERILE",SUP-110017730,CDM,C1713,HCPCS,0278,RC,,,both,,,729.00,218.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,334.61,45.9,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 360MM TIBIAL TN ADVANCED INTRAMEDULLARY MR",SUP-04.043.340S,CDM,C1713,HCPCS,0278,RC,,,both,,,9579.13,2873.74,"FIRST HEALTH [10303]","First Health",,7663.3,80,,,,,0,1114.05,8142.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION",RX-14868,CDM,J2002,HCPCS,0636,RC,00264-9594-10,NDC,both,500,ML,83.05,24.91,"BLUE CROSS [10001]","Blue Cross HMO",,23.31,,,,,,,9.84,70.59,"fee schedule",
"JOINT TOE LPT 0 REGULAR GREAT TOE",SUP-487S000,CDM,C1776,HCPCS,0278,RC,,,both,,,11585.10,3475.53,"CIGNA [10200]","Cigna Local Plus",,3649.31,31.5,,5372.07,4581.20,7242.98,23,1347.35,9847.34,"percent of total billed charges",
"DRSG WOUND 2X4CM PURAPLY 8SQ CM ANTIMICROBIAL","SUP-PURAPLYAM-COM 2X4",CDM,Q4196,HCPCS,0636,RC,,,both,,,6210.00,1863,"AETNA [10100]","Aetna HMO/PPO",,4936.95,79.5,,,,,0,271.63,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEPHRSTMY 8.3FR LOCK 25CM JINRO PIGTAIL CURVE",SUP-M0064202020,CDM,C1729,HCPCS,0272,RC,,,both,,,300.06,90.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC",564,MS-DRG,,,,,,,inpatient,,,61272.78,18381.83,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ 75CM 5FR PULMONARY ARTERY RIGHT 4 LUMEN",SUP-132F5,CDM,C1751,HCPCS,0272,RC,,,both,,,1117.80,335.34,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC",480,MS-DRG,,,,,,,inpatient,,,107563.30,32268.99,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXERCISER HAND ROLYAN BLACK PLASTIC RUBBER LIGHTWEIGHT FRAME",SUP-A3488,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.81,15.84,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BAND RETINAL 125X2X.75MM SILICONE CIRCLING",SUP-92-01,CDM,S27800098,LOCAL,0278,RC,,,both,,,125.45,37.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.59,106.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 40 75CM 4CM 4MM BALLOON DILATATION PERIPHERAL",SUP-CQF7544,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 15MM 2.5MM BALLOON DILATATION",SUP-2200-2515-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2410.52,41.1,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 NARROW KNEE RIGHT POSTERIOR STABILIZE",SUP-42500206402,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3424.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3360.56,24561.24,"percent of total billed charges",
"GRAFT BONE ILIAC CREST TRICORTICAL THK8MM WEDGE ALLOGRAFT",SUP-450913,CDM,S27800098,LOCAL,0278,RC,,,both,,,4674.06,1402.22,"PHCS [10601]",PHCS,,3271.84,70,,,,,0,543.59,3972.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM VARIAX TORX TITANIUM FULL THREAD T10",SUP-40-35614,CDM,C1713,HCPCS,0278,RC,,,both,,,1211.11,363.33,"KAISER [10500]",Kaiser,,811.44,67,,,,,0,140.85,1029.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT LAPAROSCOPIC 56.1CM 5MM DA VINCI S/SI ENDOWRIST",SUP-420143,CDM,S27200284,LOCAL,0272,RC,,,both,,,27090.00,8127,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11133.99,41.1,,,,,0,3150.57,23026.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32MMX8MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2990832,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6533.91,41.1,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Selct Plc Cath Ica Brain",PX-361000290,CDM,36224,CPT,0361,RC,,,both,,,20746.53,6223.96,"CIGNA [10200]","Cigna Local Plus",,6044,,"Case rate ($6,044). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2412.82,17634.55,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 45MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.119,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"KAISER [10500]",Kaiser,,574.39,67,,,,,0,99.7,728.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 32MM LCP STAINLESS STEEL SMALL BONE SELF",SUP-02.211.032,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,106.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,104.45,763.41,"percent of total billed charges",
"KIT INTRO 10CM 5FR GLIDESHEATH .021IN HYDROPHILIC SPRING",SUP-RM*BF5F10PA,CDM,C1894,HCPCS,0272,RC,,,both,,,368.01,110.4,"MULTIPLAN [10600]",Multiplan,,312.81,85,,,,,0,42.8,312.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL SURGICAL 132MM 30MM C TAPER NECK",SUP-1100-1330,CDM,C1776,HCPCS,0278,RC,,,both,,,1195.68,358.7,"NOVANET [10819]",Novanet,,896.76,75,,,,,0,139.06,1016.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X12MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7012,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"AMERIGROUP MEDICAID [20100]",Amerigroup,,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 1.5MM X 9MM COCR",SUP-VAL-15090-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"BLUE CROSS [10001]","Blue Cross PPO",,558.84,39.2,,957.42,570.23,957.42,28,165.8,1211.76,"percent of total billed charges",
"SYSTEM FRONTIER ONYX 12MM 4.5MM CORONARY STENT RAPID",SUP-ONYXNG45012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Meter Negative Inspiratory",PX-E27000135,CDM,E27000135,LOCAL,0270,RC,,,both,,,69.30,20.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,47.12,68,,,,,0,8.06,58.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000110,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.5MM 15MM FULL THREAD LOCK SCR TIMAX ALPS",SUP-FP15,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"BLUE CROSS [10001]","Blue Cross PPO",,428.65,39.2,,957.42,570.23,957.42,28,127.17,929.48,"percent of total billed charges",
"CMPNT PATELLAR STANDARD+ CEMENT 3 PEG ROTATE PLATFORM MOBILE",SUP-129409750,CDM,C1776,HCPCS,0278,RC,,,both,,,8811.30,2643.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4044.39,45.9,,,,,0,1024.75,7489.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 2 RIGHT MEDIAL LEFT LATERAL PARTIAL",SUP-5620-B-202,CDM,C1776,HCPCS,0278,RC,,,both,,,6899.21,2069.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4691.46,68,,,,,0,802.38,5864.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL CPAP 2 CANNULAIDE LATEX FREE DISPOSABLE NONSTERILE",SUP-CA102-0-25,CDM,S27000186,LOCAL,0270,RC,,,both,,,88.81,26.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.33,75.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nucleic Acid Amp Mycobact Ai",PX-306000252,CDM,87561,CPT,0306,RC,,,both,,,392.00,117.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,333.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nucleic Acid Amp Mycobact Ai",PX-306000252,CDM,87561,CPT,0306,RC,,,both,,,392.00,117.6,"BLUE CROSS [10001]","Blue Cross PPO",,44.83,,"Fee schedule rate ($44.83).",,,,0,0.01,333.2,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Absc Cmplx/Mult",PX-450000005,CDM,10061,CPT,0361,RC,,,both,,,3501.42,1050.43,"BLUE CROSS [10001]","Blue Cross HMO",,2490.09,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,407.22,3501.42,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Absc Cmplx/Mult",PX-450000005,CDM,10061,CPT,0361,RC,,,both,,,3501.42,1050.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,407.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,407.22,3501.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fasciotomy Foot/Toe",PX-761000071,CDM,28008,CPT,0761,RC,,,both,,,2925.00,877.5,"PHCS [10601]",PHCS,,2925,,"Case rate ($8,239). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,340.18,2925,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Protein Total Other",PX-301000380,CDM,84157,CPT,0301,RC,,,both,,,182.00,54.6,"FIRST HEALTH [10303]","First Health",,145.6,80,,,,,0,2.48,154.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vasc Embol Occl Hemmorhage",PX-361000323,CDM,37244,CPT,0361,RC,,,both,,,18043.40,5413.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2138.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2098.45,15336.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Et Tube Laser",PX-E27200243,CDM,9999116,LOCAL,0272,RC,,,both,,,682.00,204.6,"CIGNA [10200]",Cigna,,463.76,68,,,,,0,79.32,579.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Perc Ather Sngl Maj Cor Art/Br",PX-481000073,CDM,92924,CPT,0481,RC,,,both,,,34204.29,10261.29,"AETNA [10100]","Aetna HMO/PPO",,27192.41,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3977.96,29073.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Perc Ather Sngl Maj Cor Art/Br",PX-481000073,CDM,92924,CPT,0481,RC,,,both,,,34204.29,10261.29,"CIGNA [10200]","Cigna Open Access",,21495,,"Case rate ($21,495). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3977.96,29073.65,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 20MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDS40020,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22416.67,27,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 5X 38MM CATH 80CM ENDOVASCULAR",SUP-48538,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2076.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 18GA ACCURIAN STRAIGHT SHARP 10MM",SUP-AC0006,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"CIGNA [10200]","Cigna Local Plus",,55.85,53.5,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 8X3CM THICK AMNION ALLOGRAFT CORD",SUP-ABS-4200-038,CDM,S27800098,LOCAL,0278,RC,,,both,,,27720.00,8316,"CIGNA [10200]",Cigna,,11088,40,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 95MM 36MM 8.5MM 22FR ZENITH FLEX Z-TRAK",SUP-G48432,CDM,C1874,HCPCS,0278,RC,,,both,,,53285.40,15985.62,"CIGNA [10200]",Cigna,,21314.16,40,,,,,0,6197.09,45292.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 24FR 3/8IN AORTA CURVE NONVENTED STRAIGHT",SUP-EZC24A,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,56.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 7.5IN RYDER IMPREGNATE NDL TITANIUM TUNGSTEN CARBIDE",SUP-55-0468T,CDM,S27200284,LOCAL,0272,RC,,,both,,,3385.13,1015.54,"CIGNA [10200]",Cigna,,2301.89,68,,,,,0,393.69,2877.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR RENAL DOUBLE CURVE ANGIOGRAPHIC",SUP-M001314881,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"CIGNA [10200]","Cigna Local Plus",,62.37,53.5,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SCEPTER XC 150CM 11MM 2.1-2.8FR 4MM 5MM BALLOON",SUP-BC0411XC,CDM,C2628,HCPCS,0272,RC,,,both,,,11730.00,3519,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1390.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 120MM 2MM .014IN BALLOON DILATATION",SUP-AB14W020120150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"MULTIPLAN [10600]",Multiplan,,1177.34,85,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 58MM COCR",SUP-VAL-35580-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,963.9,45.9,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 52CM 16MM STEERABLE TOOL SMOOTH EXTEND LOCATOR P",SUP-1292/52,CDM,S27500001,LOCAL,0275,RC,,,both,,,1972.50,591.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,564.53,28.62,,,,,0,229.4,1676.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE RIGHT PRESS FIT EMPOWR KNEE STERILE BP",SUP-353-02-106,CDM,C1776,HCPCS,0278,RC,,,both,,,15979.64,4793.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4314.5,27,,,,,0,1858.43,13582.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) INNOVALVE TRANSSEPTAL DELIVERY SYSTEM FOR TMVR TRANSC",SUP-PRO-17320,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 100CM 5FR ANGLE KMP CURVE",SUP-G47164,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 20MM 10MM KNEE FASTTHREAD",SUP-AR-4020C-10,CDM,C1713,HCPCS,0272,RC,,,both,,,2323.13,696.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,954.81,41.1,,,,,0,954.81,1470.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM COCR SPINE MULTIAXIAL CANNULATED 5.5 ROD",SUP-55840016555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"COROENT XL-XW, 12X26X55MM 10",SUP-6212155,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6851.63,28.62,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROGRIP 16X12CM INGUINAL LEFT SELF FIXATION",SUP-LPG1612AL,CDM,C1781,HCPCS,0278,RC,,,both,,,3591.45,1077.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,425.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,417.69,3052.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CYPHER 13MM 137CM 2.25MM CORONARY SIROLIMUS ELUTING",SUP-CXS13225,CDM,C1874,HCPCS,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]",Cigna,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23.5 DIOPTER +4 CYL HAPTIC C BICONVEX 13MM 6MM",SUP-ZMB00U0235,CDM,V2632,HCPCS,0276,RC,,,both,,,6175.50,1852.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,718.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT FIXATION 6MM 3.4MM 3MM TOE 2 STEP HAMMER",SUP-204-30-006,CDM,C1713,HCPCS,0278,RC,,,both,,,6141.00,1842.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2818.72,45.9,,,,,0,714.2,5219.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 16MM COCR",SUP-VAL-25160-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"BLUE CROSS [10001]","Blue Cross PPO",,558.84,39.2,,957.42,570.23,957.42,28,165.8,1211.76,"percent of total billed charges",
"HEAD FEMORAL +5MM OFFSET C TAPER 28MM HIP HIGH PERFORMANCE",SUP-18-2805,CDM,C1776,HCPCS,0278,RC,,,both,,,9121.80,2736.54,"BLUE CROSS [10001]","Blue Cross HMO",,3575.75,39.2,,5311.50,4717.44,5388.59,31,1060.87,7753.53,"percent of total billed charges",
"HC Analysis Abl1 Variants Kinase",PX-309000125,CDM,81170,CPT,0310,RC,,,both,,,1344.25,403.27,"CIGNA [10200]","Cigna Local Plus",,660,,,,,,,0.01,1142.61,"fee schedule",
"PARTICLES EMBOLIZATION 500-700UM 2ML VIAL LC BEAD RED",SUP-VE620GS,CDM,S27800098,LOCAL,0278,RC,,,both,,,10812.30,3243.69,"CIGNA [10200]","Cigna Open Access",,6152.2,56.9,,,,,0,1257.47,9190.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 20MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,974.92,68,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY FIXATION HELICAL STERILE GOLD 100MM 11",SUP-456.305S,CDM,C1713,HCPCS,0278,RC,,,both,,,4361.08,1308.32,"AETNA [10100]","Aetna HMO/PPO",,3467.06,79.5,,1521.93,481.35,16760.95,30,507.19,3706.92,"percent of total billed charges",
"BAND SCLERAL 125X2.5X.6MM SILICONE CIRCLING STERILE",SUP-92-02,CDM,S27800098,LOCAL,0278,RC,,,both,,,151.38,45.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.61,128.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE URETHROTOME MACRO PREPARATION KNIVE 10IN",SUP-5010,CDM,S27200284,LOCAL,0272,RC,,,both,,,114.67,34.4,"NOVANET [10819]",Novanet,,86,75,,,,,0,13.34,97.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 18MM INTERLOCK FIBERED IDC 18 COIL",SUP-M001361940,CDM,S27800098,LOCAL,0278,RC,,,both,,,4843.80,1453.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,573.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,563.33,4117.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 0 26MM HIP C TAPER COCR LFIT",SUP-6/1/2600,CDM,C1776,HCPCS,0278,RC,,,both,,,4619.55,1385.86,"CIGNA [10200]","Cigna Open Access",,2628.52,56.9,,5302.19,4377.88,6578.61,27,537.25,3926.62,"percent of total billed charges",
"PACEMKR CARDIAC CROME DR 2 CHMBR DF4 INLINE CNCT RADIOPAQUE",SUP-DDPC3D4,CDM,C1882,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"AETNA [10100]","Aetna HMO/PPO",,46328.63,79.5,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rickettsia Ab",PX-302000159,CDM,86757,CPT,0302,RC,,,both,,,428.45,128.53,"AETNA [10100]","Aetna HMO/PPO",,340.62,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,364.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 22MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-822,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"BLUE CROSS [10001]","Blue Cross HMO",,4717.17,39.2,,5311.50,4717.44,5388.59,31,1399.51,10228.56,"percent of total billed charges",
"CUP ACETABULAR 52MM 46MM M2A-MAGNUM PRESS FIT HIP STERILE",SUP-US157852,CDM,C1776,HCPCS,0278,RC,,,both,,,20061.72,6018.52,"AETNA [10100]","Aetna HMO/PPO",,15949.07,79.5,,10981.53,8986.79,12413.38,12,2333.18,17052.46,"percent of total billed charges",
"TUBE TRACH 12 STD 27MM PROVOX LIFE LARYTUBE SOFT SILICONE",SUP-7418,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"CIGNA [10200]","Cigna Local Plus",,639.28,53.5,,,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SCOUTPRO 55CM 7.3FR 8.7FR HOOK CURVE GUIDING","SUP-375 528",CDM,C1887,HCPCS,0272,RC,,,both,,,1800.00,540,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,209.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 20CM 3CM 7FR .038IN PIGTAIL CURVE STRAIGHT LOW",SUP-M006180230010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"BLUE CROSS [10001]","Blue Cross PPO",,419.73,39.2,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2/0 CARDIOXYL NO PLEDGET 25MM",SUP-73P30AH,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHUNT CAROTID BARD JAVID TAPER 27.5CM TYPE 1852 KINK",SUP-007714,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE MAXTACK FIXATION 30 TACK ABSORBABLE MOTORIZE",SUP-MAXTACK30,CDM,S27200284,LOCAL,0272,RC,,,both,,,3907.88,1172.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRI 2.0 SUL 30 CT ART VSCLR ME",SUP-SIG30CTAVM,CDM,S27200284,LOCAL,0272,RC,,,both,,,1268.54,380.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACIFIC XTREME 130CM 150MM 5MM BALLOON DILATATION",SUP-PCU050150130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OSELTAMIVIR 30 MG CAPSULE",RX-88704,CDM,,,0637,RC,64380-0797-01,NDC,both,1,UN,53.60,16.08,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TROCAR ENDOSCOPIC L100MM OD5MM DILATING TIP OBTURATOR RADIOL",SUP-D5LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 5FR JCR4 CURVE GUIDING CORONARY",SUP-LA5JCR40,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE STEELCORE VASCULAR STRAIGHT 300CM 3CM .018IN",SUP-1007710,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) TANDEM 2 DUO ANCHOR SYSTEM XXL",SUP-PN0610-624,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MARINER 65CM 4FR BERENSTEIN CURVE ANGIOGRAPHIC DURATION",SUP-H787117140095,CDM,C1887,HCPCS,0272,RC,,,both,,,526.50,157.95,"PHCS [10601]",PHCS,,368.55,70,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROXIMAL HUMERUS BUTTRESS PLATE SCREW COCR",SUP-PHP-BPS,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,508.03,39.2,,957.42,570.23,957.42,28,150.72,1101.6,"percent of total billed charges",
"ROD SPINAL 6MM PRECEPT PREBENT LORDOTIC",SUP-8847160,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM MITRAL RIGID GEOFORM TITANIUM","SUP-4200 M32",CDM,S27800098,LOCAL,0278,RC,,,both,,,18818.10,5645.43,"BLUE CROSS [10001]","Blue Cross PPO",,7376.7,39.2,,,,,0,2188.55,15995.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIXTR EXTERNAL FIXATION MINIRAIL HORIZONTAL AXIS ARTICULATE",SUP-M111,CDM,C1713,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"CIGNA [10200]","Cigna Open Access",,4004.62,56.9,,1144.80,304.56,2275.09,66,818.52,5982.3,"percent of total billed charges",
"BLADE RTRCTR 3.5X1.5IN SIMS",SUP-MB761R,CDM,S27200284,LOCAL,0272,RC,,,both,,,390.02,117.01,"MULTIPLAN [10600]",Multiplan,,331.52,85,,,,,0,45.36,331.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 5D MEDIUM 52MM STAINLESS STEEL 2.4/2.7MM SCR LOW",SUP-02.211.238S,CDM,C1713,HCPCS,0278,RC,,,both,,,6404.58,1921.37,"CIGNA [10200]","Cigna Open Access",,3644.21,56.9,,1144.80,304.56,2275.09,66,744.85,5443.89,"percent of total billed charges",
"DULOXETINE 30 MG CAPSULE,DELAYED RELEASE",RX-39276,CDM,,,0637,RC,51991-0747-90,NDC,both,1,UN,28.51,8.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.32,24.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805210,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]",Cigna,,613.48,68,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 12MM 3.2-2.4-2.6FR 2.25MM",SUP-SPR22512W,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL FIXATION .75IN TRIATHLON",SUP-6541-4-575,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 16MM 144CM 3MM CORONARY STENT",SUP-H7493911416300,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3757.57,41.1,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 37FR LEFT SIDE 2 LUMEN 2 THICK TRACHEAL",SUP-5-16037,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 36MM TITANIUM SHORT THREAD CANNULATED",SUP-04.353.436,CDM,C1713,HCPCS,0278,RC,,,both,,,1972.50,591.75,"CIGNA [10200]",Cigna,,1341.3,68,,1831.33,1831.33,1831.33,16,229.4,1676.63,"percent of total billed charges",
"MESH SURGICAL BARD MARLEX 4X1.8IN GROIN MONOFILAMENT GOLD",SUP-0112710,CDM,C1781,HCPCS,0278,RC,,,both,,,300.00,90,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,35.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.89,255,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEMLESS SHOULDER",SUP-PHC-CONV,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",3297.11,24097.5,"percent of total billed charges",
"SCR BONE 3.5MM 34MM EVOLVE STAINLESS STEEL CORTICAL ELBOW",SUP-4973534L,CDM,C1713,HCPCS,0278,RC,,,both,,,1710.00,513,"PHCS [10601]",PHCS,,1197,70,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP SMALL 9IN TITANIUM ENDOSCOPIC LIGATING",SUP-133650,CDM,S27200284,LOCAL,0272,RC,,,both,,,379.23,113.77,"CIGNA [10200]","Cigna Local Plus",,202.89,53.5,,,,,0,44.1,322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB CONGR SZ3/4X10MM RT",SUP-2042-0-3410,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Local Plus",,1905.94,53.5,,5372.07,4581.20,7242.98,23,414.32,3028.13,"percent of total billed charges",
"STEM FEMORAL 120MM CEMENTLESS OFFSET ACCOLADE TMZF 127D 3 43",SUP-6021-0335,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"NOVANET [10819]",Novanet,,11736.9,75,,,,,0,1820,13301.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +9MM OFFSET 28MM HIP TYPE 1 SKIRT COCR G7",SUP-163665,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"CIGNA [10200]",Cigna,,3298.48,68,,5873.17,5873.17,5873.17,"1 through 10",564.14,4123.1,"percent of total billed charges",
"SNARE 15MM 7FR ACUSNARE DUCKBILL TEFLON SHEATH ENDOSCOPIC",SUP-G22647,CDM,S27200284,LOCAL,0272,RC,,,both,,,282.75,84.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,129.78,45.9,,,,,0,32.88,240.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 5.0MM X 15.0MM",SUP-495001512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 42MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.042TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 485CC NATRELLE INSPIRA COHESIVE STERILE",SUP-TCM-485,CDM,C1789,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3800.52,45.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPS DIRECT UPSIZED 135 54CM-DS2C027",SUP-DS2C027,CDM,C1893,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"KAISER [10500]",Kaiser,,2519.54,67,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR COBRA 1 CURVE ANGIOGRAPHIC VISCERAL",SUP-10709107,CDM,C1887,HCPCS,0272,RC,,,both,,,236.64,70.99,"UHC [10700]","United Healthcare",,149.79,63.3,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 22MM 140CM 3.5MM",SUP-RSINT35022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3769.92,68,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION .5CM HILAL EMBOLIZATION MICROCOILS",SUP-G04524,CDM,S27800098,LOCAL,0278,RC,,,both,,,675.14,202.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,78.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.52,573.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 61MM FOGARTY STERILE DISPOSABLE",SUP-G-6100,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]",Cigna,,153.82,68,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE SOFTTOUCH SMOOTH",SUP-SSF-650,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]",Cigna,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8 36MM HIP BIOLOX DELTA FMP STERILE LATEX FREE",SUP-400-03-364,CDM,C1776,HCPCS,0278,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,481.48,3519,"percent of total billed charges",
"SEALER TISSUE 8MM SYNCHROSEAL DA VINCI",SUP-480440,CDM,S27200284,LOCAL,0272,RC,,,both,,,4999.05,1499.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,592.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,581.39,4249.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16027545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"SCR BONE 9MM 50MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712950,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,1831.33,1831.33,1831.33,16,441.36,3225.75,"percent of total billed charges",
"CATH SENSATION PLUS STATLOCK 6IN 8FR IAB 50ML 2 INSRT KIT",SUP-0684-00-0576-01U,CDM,C1725,HCPCS,0272,RC,,,both,,,6478.27,1943.48,"KAISER [10500]",Kaiser,,4340.44,67,,,,,0,753.42,5506.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE MNTR 27FT SDI",SUP-MAJ-1912,CDM,S27000186,LOCAL,0270,RC,,,both,,,1081.27,324.38,"AETNA [10100]","Aetna HMO/PPO",,859.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,125.75,919.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 4-0 P-3 18IN MONOFILAMENT VIOLET",SUP-Y464G,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.62,20.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEARS SURGICAL 26.84CM 8MM DA VINCI XI HARMONIC ACE CURVE",SUP-480275,CDM,S27200284,LOCAL,0272,RC,,,both,,,3949.10,1184.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE GLDEWIRE VASCULAR ANGLE 180CM 3CM .025IN NITINOL",SUP-GR2505,CDM,C1769,HCPCS,0272,RC,,,both,,,457.65,137.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RAPIDCROSS 170CM 210MM 3MM .014IN BALLOON DILATATION",SUP-A14BX030210170,CDM,C1725,HCPCS,0272,RC,,,both,,,1638.75,491.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PRAMIPEXOLE 0.125 MG TABLET",RX-21287,CDM,,,0637,RC,57237-0180-90,NDC,both,1,UN,14.84,4.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARDEX LUBRICATH 22FR STD URETHRAL NATURAL RUBBER",SUP-0119L22,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.52,23.26,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STPLR 0 8IN ENDO STITCH V-LOC POLYBUTESTER LOAD UNIT",SUP-VLOCN008L,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.99,98.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SWAN-GANZ 110CM 7.5FR ARTERIAL LINE AMC THROMBOSHIELD",SUP-931HF75,CDM,C1751,HCPCS,0272,RC,,,both,,,418.21,125.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMPRESS 65CM 4FR BERN CURVE ANGIOGRAPHIC STAINLESS",SUP-46535BER,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSTR ORTHOPEDIC PORTAL SKID",SUP-AR-4505,CDM,S27200284,LOCAL,0272,RC,,,both,,,411.08,123.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"6F DECA 4-4-4-29-5-5-5-5-5 MPA 120CM",SUP-901826,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP APPLR 4CM EVICEL CONTROL",SUP-3920,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.97,57.59,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LIGTR ORTHOPEDIC 15YDX3IN SYNTHETIC TERRYCLOTH DELTA",SUP-55145903,CDM,S27000186,LOCAL,0270,RC,,,both,,,198.88,59.66,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE HEMOSTASIS 20CM HONOR METAL GWIRE INSRT TOOL BONDED",SUP-MAP352,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.63,63.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX 100CM 60MM 8FR 10MM BALLOON DILATATION DRUG",SUP-LX351001060V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TADALAFIL 5 MG TABLET",RX-37400,CDM,,,0637,RC,43547-0049-03,NDC,both,1,UN,46.54,13.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SELUTION SLR PTCA DEB 3.0X20MM",SUP-SCA14U-300020D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ISOSORBIDE DINITRATE 10 MG TABLET, IMMEDIATE RELEASE",RX-4064,CDM,,,0637,RC,63739-0569-10,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNARE HEXAGONAL 4.5CM 3CM 7FR ACUSNARE 1 PIECE GRADUATED",SUP-G22700,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.43,49.33,"KAISER [10500]",Kaiser,,110.17,67,,,,,0,19.12,139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5-6 9MM KNEE XLPE CRUCIATE RETAINING HIGH",SUP-71453121,CDM,C1776,HCPCS,0278,RC,,,both,,,15556.05,4666.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6222.42,40,,,,,0,1809.17,13222.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 4MM 1.5MM 1.2MM BALLOON DILATATION RAPID",SUP-DC-RY4012UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"FIRST HEALTH [10303]","First Health",,790.56,80,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERCROSS 130CM 80CM 2.4-3.2FR .017-.018IN 90D MICRO",SUP-5304,CDM,C1887,HCPCS,0272,RC,,,both,,,3740.00,1122,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1537.14,41.1,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 20MM CLEVERCUT3V PRELOAD DISTAL TIP STERILE",SUP-KD-VC631Q-07201A,CDM,C1769,HCPCS,0272,RC,,,both,,,2817.75,845.32,"NOVANET [10819]",Novanet,,2113.31,75,,,,,0,327.7,2395.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Proc Dx Unlisted",PX-320000172,CDM,76499,CPT,0320,RC,,,both,,,1329.98,398.99,"NOVANET [10819]",Novanet,,997.49,75,,,,,0,154.68,1130.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TADALAFIL 5 MG TABLET",RX-37400,CDM,,,0637,RC,43547-0049-03,NDC,both,1,UN,46.54,13.96,"AETNA [10100]","Aetna HMO/PPO",,37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.41,39.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 3-0 RB-1 SPIRAL 17MM SUT",SUP-SXPP1B422,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.96,69.59,"FIRST HEALTH [10303]","First Health",,185.57,80,,,,,0,26.98,197.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUARDWIRE 200CM 2.5CM .014IN 3-6IN .070IN .036IN",SUP-GEZ6200US,CDM,C1884,HCPCS,0272,RC,,,both,,,10488.00,3146.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1219.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1219.75,8914.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT ORTHOPEDIC J2 UNI FEMORAL KNEE",SUP-71701830,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 14CM 5FR 3MM .035IN BALLOON",SUP-G52330,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.47,41.1,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 3MM CEREPAK XL HELIFORM DETACHABLE",SUP-SHD180312,CDM,S27800098,LOCAL,0278,RC,,,both,,,13884.25,4165.27,"AETNA [10100]","Aetna HMO/PPO",,11037.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1614.74,11801.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 12.5CM 4MM IBUR DISTAL BEND ROUND DIAMOND",SUP-8431-013-040DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,2737.50,821.25,"PHCS [10601]",PHCS,,1916.25,70,,,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ercp Biliary&Pancreas Si",PX-320000112,CDM,74330,CPT,0320,RC,,,both,,,2002.00,600.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,167.32,,"Fee schedule rate ($167.32).",,,,0,167.32,1701.7,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISPOSABLE CLIP LIMB SLING",SUP-VIG22000-L1,CDM,S27000186,LOCAL,0270,RC,,,both,,,145.43,43.63,"NOVANET [10819]",Novanet,,109.07,75,,,,,0,16.91,123.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND 3.2X2.4IN SILICONE PORCINE THERAGENESIS 2 LAYER",SUP-TG-M8260,CDM,A2008,HCPCS,0636,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,9857.93,56.9,,,,,0,247.92,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IMPL GLUTEUS MEDIUS",SUP-AR-2941GM-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,9201.15,2760.34,"CIGNA [10200]","Cigna Open Access",,5235.45,56.9,,1144.80,304.56,2275.09,66,1070.09,7820.98,"percent of total billed charges",
"SHELL ACETABULAR 54MM HIP SECTOR POROCOAT PINNACLE STERILE",SUP-121722054,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"CIGNA [10200]","Cigna Local Plus",,3590.26,53.5,,5372.07,4581.20,7242.98,23,780.46,5704.15,"percent of total billed charges",
"STENT ZILVER 518 80CM 125CM 8MM VASCULAR HIWIRE NITINOL",SUP-G43783,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1918.16,45.9,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 4.5 X 10 COMPLEX PICO COIL",SUP-10USC04510,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5230.2,40,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC",615,MS-DRG,,,,,,,inpatient,,,86871.33,26061.4,"CIGNA [10200]","Cigna Local Plus",,14439.38,,"Fee schedule rate ($14,439.38). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,40853.96,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 83CM 11FR AIRWAY EXCHANGE",SUP-G57621,CDM,S27200284,LOCAL,0272,RC,,,both,,,672.30,201.69,"CIGNA [10200]",Cigna,,457.16,68,,,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAP POSITIONING DIGIT TRAP SMALL FINGER ATRAUMATIC HOOK",SUP-9906,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.72,38.92,"MULTIPLAN [10600]",Multiplan,,110.26,85,,,,,0,15.09,110.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND 3.2X2.4IN SILICONE PORCINE THERAGENESIS 2 LAYER",SUP-TG-M8260,CDM,A2008,HCPCS,0636,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.92,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP SECTOR POROCOAT PINNACLE STERILE",SUP-121722054,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1920.62,28.62,,,,,0,780.46,5704.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 55D 10MM 2.5MM EMBOLIZATION 75% COCR 25",SUP-PED-250-10,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,22023.09,28.62,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 16CM 4.8FR .035IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251180,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,837.05,68,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 014 150CM 8CM 5MM BALLOON DILATATION",SUP-U415058,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT THROMBECTOMY REPERFUSION CATHETER 0.06INX160CM LUMEN 0.0",SUP-RED43KIT160,CDM,C1757,HCPCS,0272,RC,,,both,,,17608.50,5282.55,"MULTIPLAN [10600]",Multiplan,,14967.23,85,,,,,0,2047.87,14967.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PALMAZ GENESIS AVIATOR FLEXSEGMENT 14MM 135CM 4MM 17MM",SUP-PG1540BAX,CDM,C1876,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"NOVANET [10819]",Novanet,,5563.13,75,,,,,0,862.66,6304.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN HCL 500 MG/10ML IV (WET SOLR VIAL)",RX-4158443,CDM,J3373,HCPCS,0636,RC,00409-4332-11,NDC,both,1,UN,73.94,22.18,"FIRST HEALTH [10303]","First Health",,59.15,80,,,,,0,1.75,62.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-707,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]","Cigna Local Plus",,4135.08,31.5,,5372.07,4581.20,7242.98,23,1526.7,11158.16,"percent of total billed charges",
"STEM FEMORAL 140MM 10MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-104100,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"FIRST HEALTH [10303]","First Health",,19362.67,80,,,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 8.2MM 6MM STD LOW PROFILE DEPH FREE",SUP-8229706,CDM,S27200284,LOCAL,0272,RC,,,both,,,3007.50,902.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,349.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,349.77,2556.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 8MMX29MM 7FR 80CMCATH HEPARIN",SUP-BXBL082901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"PHCS [10601]",PHCS,,13653.36,70,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 42MM TI",SUP-SPL-35420-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH VIZIGO 50MM LARGE CURVE 71CM 11.5FR 8.5FR INTRO",SUP-D138503,CDM,C1892,HCPCS,0272,RC,,,both,,,6824.10,2047.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2804.71,41.1,,,,,0,793.64,5800.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 38MM 140CM 4MM 2.1-2.7FR CORONARY STENT",SUP-RONYX40038UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3487.50,1046.25,"CIGNA [10200]","Cigna Local Plus",,1865.81,53.5,,,,,0,405.6,2964.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RIFAXIMIN 550 MG TABLET",RX-104604,CDM,,,0637,RC,65649-0303-03,NDC,both,1,UN,277.53,83.26,"FIRST HEALTH [10303]","First Health",,222.02,80,,,,,0,32.28,235.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 49MM TITANIUM 2.4MM SCREWS 7X2 HOLES VARIABLE ANGLE 2",SUP-04.111.720,CDM,C1713,HCPCS,0278,RC,,,both,,,4126.20,1237.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,479.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",479.88,3507.27,"percent of total billed charges",
"GWIRE VASCULAR 60CM .018IN NITINOL STAINLESS STEEL MANDREL",SUP-SGW-019-32,CDM,C1769,HCPCS,0272,RC,,,both,,,165.30,49.59,"PHCS [10601]",PHCS,,115.71,70,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH FEMORAL CANAL 32CM 14MM INTRAMEDULLARY STERILE",SUP-6198001514,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.45,22.63,"CIGNA [10200]",Cigna,,51.31,68,,,,,0,8.77,64.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 38MM 140CM 4MM 2.1-2.7FR CORONARY STENT",SUP-RONYX40038UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3487.50,1046.25,"MULTIPLAN [10600]",Multiplan,,2964.38,85,,,,,0,405.6,2964.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 50MM 32MM ALTRX HIP",SUP-122132150,CDM,C1776,HCPCS,0278,RC,,,both,,,5531.40,1659.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,655.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,643.3,4701.69,"percent of total billed charges",
"PROBE SURGICAL 45CM 5MM PALPATION GRADUATED",SUP-600-496,CDM,S27200284,LOCAL,0272,RC,,,both,,,518.89,155.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,238.17,45.9,,,,,0,60.35,441.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD INTICA 7 VR-T DX",SUP-404633,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"FIRST HEALTH [10303]","First Health",,31200,80,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP POROCOAT PINNACLE 300 SERIES",SUP-121703052,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,795.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,780.46,5704.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 31MM RESTORATION +20MM HIP PROXIMAL MODULAR",SUP-6276-1-231,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"MULTIPLAN [10600]",Multiplan,,18916.54,85,,,,,0,2588.23,18916.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 12MM 1.14MM 9.5MM GOODE EAR SILICONE",SUP-1016035,CDM,S27800098,LOCAL,0278,RC,,,both,,,241.86,72.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,111.01,45.9,,,,,0,28.13,205.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP MEDIUM 4 POINT HEADGEAR LEAK 1 ENTRAINMENT ELBOW",SUP-989805628681,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.49,61.95,"NOVANET [10819]",Novanet,,154.87,75,,,,,0,24.01,175.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 17GA 11CM 5CM ADJUSTABLE COAXIAL TEMNO",SUP-ACT1811,CDM,S27200284,LOCAL,0272,RC,,,both,,,423.60,127.08,"AETNA [10100]","Aetna HMO/PPO",,336.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,49.26,360.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 5MM CEREPAK XTRASOFT FREEFORM",SUP-XCR120510,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3570.98,27,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ADMIN 250UM UNIVERSAL INTRAVENOUS THE BELMONT 3 BAG",SUP-903-00006,CDM,S27200284,LOCAL,0272,RC,,,both,,,1507.27,452.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1024.94,68,,,,,0,175.3,1281.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC",824,MS-DRG,,,,,,,inpatient,,,95382.67,28614.8,"CIGNA [10200]",Cigna,,29706.55,,"Fee schedule rate ($29,706.55). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,66146.46,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AXS INFINITY LS LONG 80CM 8FR .088IN INTRO STERILE",SUP-GEN-10800-80,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 28MM 1 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800128,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,3978.14,359.25,3978.14,24,521.61,3812.25,"percent of total billed charges",
"MAGSEED PRO 7CM",SUP-MS2-17-1-07,CDM,A4648,HCPCS,0278,RC,,,both,,,3829.50,1148.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,445.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,445.37,3255.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Massage Ea 15min (Go)",PX-430000016,CDM,97124,CPT,0430,RC,,,both,,,163.34,49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19,163.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135MM 60MM 5FR 5MM LOW PROFILE TAPER BALLOON",SUP-39206-05061,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC MATRIX RECOTHROM FLOSEAL",SUP-ADS202110,CDM,S27200284,LOCAL,0272,RC,,,both,,,1994.35,598.3,"KAISER [10500]",Kaiser,,1336.21,67,,,,,0,231.94,1695.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 13MM HELIX R SPINE SELF TAP FIX ANGLE",SUP-7804213,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mech Thromb Venous Add",PX-361000135,CDM,37188,CPT,0361,RC,,,both,,,8693.76,2608.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1030.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1011.08,8693.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING URETHRAL VIRTUE ALEXIS MALE",SUP-50020,CDM,C1771,HCPCS,0278,RC,,,both,,,33604.20,10081.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13441.68,40,,,,,0,3908.17,28563.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETENE 30X30CM MONOFILAMENT STERILE",SUP-PPM3030,CDM,C1781,HCPCS,0278,RC,,,both,,,882.58,264.77,"CIGNA [10200]","Cigna Open Access",,502.19,56.9,,11235.02,819.42,11235.02,"1 through 10",102.64,750.19,"percent of total billed charges",
"NAIL 8MM 240MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-408-240,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,1831.33,1831.33,1831.33,16,2014.9,14726.25,"percent of total billed charges",
"ELECTRODE DEFIBRILLATOR PRO-PADZ TIN ADULT L6.5 IN X W5 IN B",SUP-8900-2303-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,260.46,78.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,30.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.29,221.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPR LD BFUR BP CNCT TO BP",SUP-501205,CDM,C1883,HCPCS,0278,RC,,,both,,,1830.00,549,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,839.97,45.9,,,,,0,212.83,1555.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS 9FR DOUBLEPLAY POLYCARBONATE SILICONE 2",SUP-MAP220,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.63,38.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNIFE AMPUTATION 8.5IN LISTON STAINLESS STEEL BLADE",SUP-225413,CDM,S27200284,LOCAL,0272,RC,,,both,,,602.64,180.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Legionalla Pneumophila Ag UR",PX-306000114,CDM,87449,CPT,0306,RC,,,both,,,224.90,67.47,"MULTIPLAN [10600]",Multiplan,,191.17,85,,,,,0,0.01,191.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 22FR 20CM RADIOPAQUE STD ACCEPTS .038IN GWIRE",SUP-G01472,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.44,31.03,"MULTIPLAN [10600]",Multiplan,,87.92,85,,,,,0,12.03,87.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPEEDBRIDGE FIBERTAPE SWIVELOCK 24MM 5.5MM FIXATION",SUP-AR-2600SBS-5,CDM,C1713,HCPCS,0278,RC,,,both,,,12896.10,3868.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3690.86,28.62,,,,,0,1499.82,10961.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 135CM 2CM 5FR 9MM 7.5MM BALLOON DILATATION",SUP-4209020X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL 17X8.8MM LARGE COTTLE DISPOSABLE STERILE LATEX",SUP-5100-037-125,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.38,176.51,"NOVANET [10819]",Novanet,,441.29,75,,,,,0,68.43,500.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Path Clin Conslt Sf",PX-310000007,CDM,80503,CPT,0310,RC,,,both,,,104.00,31.2,"CIGNA [10200]",Cigna,,47.74,,,,,,,0.01,88.4,"fee schedule",
"CATH EZ STEER DS REDEL 115CM 8MM 7FR 1-7-4MM SPACE D-D CURVE",SUP-BD7TCDD8L,CDM,C1733,HCPCS,0272,RC,,,both,,,8700.90,2610.27,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3576.07,41.1,,,,,0,1011.91,7395.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 120MM 20GA SONOPLEX II FACET TIP INJECTION",SUP-001287-72,CDM,C9812,HCPCS,0272,RC,,,both,,,153.12,45.94,"CIGNA [10200]","Cigna Open Access",,87.13,56.9,,,,,0,17.81,130.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X13MM LUMINARY CC BICONVEX SPINE",SUP-16813,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"AETNA [10100]","Aetna HMO/PPO",,26444.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 60MM 125CM 10MM 5FR VASCULAR NITINOL ILIAC",SUP-G43792,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,486.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 P-1 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8697G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 14MM 24MM EXPLOR ELBOW MODULAR",SUP-11-210043,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"CIGNA [10200]","Cigna Local Plus",,4477.41,31.5,,5372.07,4581.20,7242.98,23,1653.09,12081.9,"percent of total billed charges",
"STEM HUMERAL 82MM PRESS FIT AEQUALIS ASCEND FLEX PTC 127.5D",SUP-DWF605A,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1465.38,10710,"percent of total billed charges",
"GWIRE AMPLATZ SUPER STIFF UROLOGICAL J 145CM 3CM .038IN PTFE",SUP-M0066401071,CDM,C1769,HCPCS,0272,RC,,,both,,,250.91,75.27,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR AMPLATZ RIGHT 2",SUP-67011200,CDM,C1887,HCPCS,0272,RC,,,both,,,83.52,25.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 89X12.5X1.5MM HALL MICROPOWER MICRO100 RECIPROCATE",SUP-5052-261,CDM,S27200284,LOCAL,0272,RC,,,both,,,98.66,29.6,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 90CM 150MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT NEPHRSTMY PERCUTANEOUS ACCESS",SUP-M0064201100,CDM,C1726,HCPCS,0272,RC,,,both,,,1103.14,330.94,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH APD 25CM 8FR DRNG FLEXIMA METAL HYDROPHILIC REGULAR",SUP-M001271290,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,inpatient,,,78138.17,23441.45,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CABLE WEIGHT AND BAR SET (1 CABLE WEIGHT AND BAR SET)",SUP-5109,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 30CM 8MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036128300,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5-6 18MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71933740,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3483.51,28.62,,,,,0,1415.56,10345.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 7IN FREEMAN 4 SHARP OFFSET PRONG SURGICAL 38MM FACE",SUP-P509,CDM,S27200284,LOCAL,0272,RC,,,both,,,419.78,125.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,285.45,68,,,,,0,48.82,356.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MITRACLIP G4 CDS NTW REPAIR-MR CLINICAL",SUP-CDS0704-NTW,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68400,40,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC SHIELD BLADE ADVANCE FIXATION SLEEVE",SUP-CFB73,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,83.86,45.9,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR 14X14X11MM",SUP-345144,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE ALLODERM ALLOGRAFT PERFORATE",SUP-1518320P,CDM,Q4116,HCPCS,0636,RC,,,both,,,60228.00,18068.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,29270.81,48.6,,,,,0,247.92,51193.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 3X3IN DURAGEN DURAL BOVINE CLLGN PATCH",SUP-ID3301,CDM,,,0278,RC,,,both,,,6468.89,1940.67,"CIGNA [10200]",Cigna,,4398.85,68,,,,,0,6.47,5498.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FIBERTAG FIXATION ACL ABS DISPOSABLE",SUP-AR-1588TNT,CDM,C1713,HCPCS,0278,RC,,,both,,,2638.13,791.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,755.03,28.62,,,,,0,306.81,2242.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 190CM 22MM 3.7MM 4 WIRE C HOOK",SUP-FGV432P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1089.29,326.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,740.72,68,,,,,0,126.68,925.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE VASCULAR 120CM 18-30MM .055IN .074IN EN SNARE NITINOL",SUP-EN2007030,CDM,C1773,HCPCS,0272,RC,,,both,,,2482.50,744.75,"FIRST HEALTH [10303]","First Health",,1986,80,,,,,0,288.71,2110.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL XS UNIVERSAL 18MM KNEE COCR POLYETHYLENE",SUP-198727118,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"MULTIPLAN [10600]",Multiplan,,25114.41,85,,,,,0,3436.24,25114.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 SH 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP774D,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.88,38.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.76,107.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA COMPRESSION 30-32 FABRIC FIT A AND B ADJUSTABLE SHOULDER",SUP-700,CDM,S27000186,LOCAL,0270,RC,,,both,,,328.86,98.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,150.95,45.9,,,,,0,38.25,279.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC IPERIA 7 PROMRI DF-1 IMPLANTABLE",SUP-393007,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"MULTIPLAN [10600]",Multiplan,,49062,85,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 4MM DELTAFILL 18 COIL",SUP-DLF180415,CDM,S27800098,LOCAL,0278,RC,,,both,,,14145.00,4243.5,"BLUE CROSS [10001]","Blue Cross HMO",,5544.84,39.2,,,,,0,1645.06,12023.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE FLOPPY II EXTRA SPORT VASCULAR STRAIGHT 190",SUP-22299H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 30MM 7MM .035IN BALLOON DILATATION NYBAX",SUP-39171-07034,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"MULTIPLAN [10600]",Multiplan,,998.33,85,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM 2MM CANNULATED TIGER",SUP-210-24-001,CDM,C1713,HCPCS,0278,RC,,,both,,,1650.00,495,"FIRST HEALTH [10303]","First Health",,1320,80,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD 7753900 PRE-CUT 3.5MM X 100 CCM+",SUP-7753900,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,167.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,163.98,1198.5,"percent of total billed charges",
"NDL BIOPSY 20GA 7.95FR 8- CM ECHOTIP PROCORE RECESSE BALL",SUP-G34785,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]","Cigna Local Plus",,1805.63,53.5,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 5 X 8 HELICAL PICO COIL",SUP-10USH05008,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"KAISER [10500]",Kaiser,,7854.48,67,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 3-0 CTX 27IN MONOFILAMENT ABSORBABLE",SUP-873H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"UHC [10700]","United Healthcare",,17.09,63.3,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AMPLATZER TORQVUE 2 120CM 5FR INTRO POLYMER PTFE",SUP-9-TV2-05F120,CDM,S27200284,LOCAL,0272,RC,,,both,,,5754.60,1726.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,669.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,669.26,4891.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOARD TRANSFER 35X8X5/8IN BIRCH THK5/8IN C600LB BARIATRIC 2",SUP-6126,CDM,S27000186,LOCAL,0270,RC,,,both,,,436.75,131.02,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.79,371.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TF (-T) SHEATH AND DILATOR LPINTPD-TF-ISDLP",SUP-INTPD-TF-ISDLP,CDM,C1894,HCPCS,0272,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII 16MM 20MM",SUP-401116,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 2 HOLE STERILE 130DEG TITANIUM FEMORAL NECK SYSTE",SUP-04.268.000S,CDM,C1713,HCPCS,0278,RC,,,both,,,4532.47,1359.74,"BLUE CROSS [10001]","Blue Cross PPO",,1776.73,39.2,,957.42,570.23,957.42,28,527.13,3852.6,"percent of total billed charges",
"SPACER ALLOGRAFT 23-27MMX13MM 12D BROAD LORDOTIC SPINE",SUP-2413,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET IMPL 68MM KNEE RIGHT FUSION NAIL MODULAR STERILE",SUP-15-0028/08,CDM,C1713,HCPCS,0278,RC,,,both,,,43703.48,13111.04,"PHCS [10601]",PHCS,,30592.44,70,,,,,0,5082.71,37147.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS FIRSTCHOICE 5% DEXTROSE 40 MEQ POTASSIUM",SUP-07904-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,37.18,45.9,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM CONCERTO DETACHABLE HELIX PERIPHE",SUP-NV-9-30-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 8MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0830CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"AETNA [10100]","Aetna HMO/PPO",,5211.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTROLYTE POTASSIUM CHLORIDE/NACL 0.9% 20MEQ/L 1000ML IV",SUP-2B1764X,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 125CM 6FR .054IN .038IN PIGTAIL 145",SUP-7509-53,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"NOVANET [10819]",Novanet,,61.4,75,,,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LORAZEPAM 1 MG TABLET",RX-4573,CDM,,,0250,RC,00093-3426-01,NDC,both,1,UN,12.54,3.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8.53,68,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIFIX 40IN 20GA EPIDURAL POLYAMIDE CNCT THREAD ASSIST",SUP-333520,CDM,S27200284,LOCAL,0272,RC,,,both,,,44.68,13.4,"FIRST HEALTH [10303]","First Health",,35.74,80,,,,,0,5.2,37.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION",RX-123154,CDM,J2919,HCPCS,0636,RC,00009-0047-27,NDC,both,1,UN,77.41,23.22,"KAISER [10500]",Kaiser,,51.86,67,,,,,0,6.12,65.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET VACUUM 14MM PLASTIC CANN CURVED ROUND TIP SEMIRIGID",SUP-21593A,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.38,21.71,"UHC [10700]","United Healthcare",,45.82,63.3,,,,,0,8.42,61.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 53MM TITANIUM 3 LEVEL ZEVO BONE SPINE CERVICAL",SUP-3003053,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,3978.14,359.25,3978.14,24,641.98,4692,"percent of total billed charges",
"NDL BIOPSY 18GA 10CM CHIBA ASPIRATION STERILE DISPOSABLE",SUP-G01559,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.31,31.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.13,88.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 13.5CM 16MM 13.5-14.5MM EXCLUDER",SUP-PLC161400,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"UHC [10700]","United Healthcare",,17722.23,63.3,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM VARIAX T10 FULL THREAD FOOT ANKLE LOCK",SUP-657326,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,682.46,45.9,,,,,0,172.92,1263.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 9MM KNEE X3 POSTERIOR STABILIZED TRIATHLON",SUP-5532-G-409,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CIGNA [10200]",Cigna,,5921.17,68,,5873.17,5873.17,5873.17,"1 through 10",1012.7,7401.47,"percent of total billed charges",
"LINER ACETABULAR PINNACLE 10D +4MM 60MM 36MM MARATHON HIP",SUP-121936160,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"AETNA [10100]","Aetna HMO/PPO",,7825.07,79.5,,10981.53,8986.79,12413.38,12,1144.72,8366.42,"percent of total billed charges",
"CUP HUMERAL 39MM UNIVERS REVERS NEUTRAL SHOULDER SUT STERILE",SUP-AR-9502F-39CPC,CDM,C1776,HCPCS,0278,RC,,,both,,,7980.00,2394,"BLUE CROSS [10001]","Blue Cross HMO",,3128.16,39.2,,5311.50,4717.44,5388.59,31,928.07,6783,"percent of total billed charges",
"STENT SURPASS ELITE 25MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE32525,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"FIRST HEALTH [10303]","First Health",,66931.68,80,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE RIGHT CONSTRAIN LEGION OXINIUM",SUP-71421174,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6853.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6726.09,49158.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 10.5X3IN WRIST RIGHT DELUXE BETA PILE II",SUP-2970017617,CDM,S27000186,LOCAL,0270,RC,,,both,,,133.88,40.16,"UHC [10700]","United Healthcare",,84.75,63.3,,,,,0,15.57,113.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,inpatient,,,40079.48,12023.84,"BLUE CROSS [10001]","Blue Cross PPO",,35349.39,,,,,,,7561,35710.15,"case rate",
"INSERT CONGR SZ.5X10MM RT",SUP-2042-0-1210,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1635.19,45.9,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 86CM 3.9-5.2FR 2.6FR 6CM 20.5-7.5-7.5MM SPACE",SUP-4674,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"NOVANET [10819]",Novanet,,4205.25,75,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED 100CM 6CM 11FR 33MM .035IN BALLOON DILATATION",SUP-611670,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3616.27,68,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 24CM 3CM 8FR .038IN 2 PIGTAIL",SUP-M006192152010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,139.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X5MM HEDRON C 7D 12MM STERILE LATEX FREE",SUP-1211.2415S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,762.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 7FR CWV SILICONE CLOT STOP ATRAUMATIC CLOSED",SUP-3640AT,CDM,S27000186,LOCAL,0270,RC,,,both,,,265.76,79.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,30.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.91,225.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC LARGE HUB STERLING ULTRACUT 2500-6000 RPM",SUP-C9405A,CDM,S27200284,LOCAL,0272,RC,,,both,,,786.35,235.9,"UHC [10700]","United Healthcare",,497.76,63.3,,,,,0,91.45,668.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 27MM SJM TAILOR SILICONE FLEXIBLE SURE",SUP-TAB-27,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1434.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) QUALIBREATH SIZE XXXL",SUP-QB-XXXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"PHCS [10601]",PHCS,,580.61,70,,,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 24CM 20FR AXILLARY AORTA SUBCLAVIAN 3/8IN",SUP-OPTI20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1902.83,570.85,"CIGNA [10200]","Cigna Open Access",,1082.71,56.9,,,,,0,221.3,1617.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 3MM PRESTIGE PLUS HELICAL HELICAL PACK",SUP-PRES0303CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 13MM SPINE CERVICAL ANTERIOR SELF TAP",SUP-18008313,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",117.75,860.63,"percent of total billed charges",
"SCR BONE 10MM 35MM SI-LOK SPINE WASHER STERILE LATEX FREE",SUP-1202.6035S,CDM,C1713,HCPCS,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross HMO",,6762,39.2,,957.42,156.86,7483.26,51,2006.18,14662.5,"percent of total billed charges",
"SCR BONE 5MM 34MM X25 LOCK LOW PROFILE STERILE",SUP-04.045.334S,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"BLUE CROSS [10001]","Blue Cross PPO",,733,39.2,,957.42,570.23,957.42,28,217.47,1589.42,"percent of total billed charges",
"SCR BONE 100MM SPINAL LOCKING POST",SUP-8461100,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"CIGNA [10200]","Cigna Open Access",,1369.36,56.9,,1144.80,304.56,2275.09,66,279.89,2045.61,"percent of total billed charges",
"STENT WALLFLEX PERMALUME 80MM 194CM 10MM 8.5FR .035IN",SUP-M00570380,CDM,C1874,HCPCS,0278,RC,,,both,,,9360.00,2808,"KAISER [10500]",Kaiser,,6271.2,67,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Critical Care 30-74min W Proc",PX-450000322,CDM,99291,CPT,0450,RC,,,both,,,4692.00,1407.6,"FIRST HEALTH [10303]","First Health",,3753.6,80,,,,,0,559.4,3988.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 2.25MM CORONARY RAPID EXCHANGE",SUP-ONYXNG22508UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1785,68,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 32MM 144CM 4MM CORONARY STENT",SUP-H7493911432400,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4196.41,45.9,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 6X9X6MM ARCH 7.5D SPINE FREEZE DRY NOTCH",SUP-015206,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 65MM LCP STAINLESS STEEL FULL THREAD CONDYLAR",SUP-02.207.065,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",189.34,1383.8,"percent of total billed charges",
"SCR INTERFERENCE PEEK-OPTIMA 28MM 9MM DELTA TAPER ROUND ACL",SUP-AR-5028P-09,CDM,C1713,HCPCS,0278,RC,,,both,,,1968.75,590.62,"CIGNA [10200]",Cigna,,1338.75,68,,1831.33,1831.33,1831.33,16,228.97,1673.44,"percent of total billed charges",
"SCR BONE 4.5MM 68MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.568,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"FIRST HEALTH [10303]","First Health",,877.14,80,,,,,0,127.51,931.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 50MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0273,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"NOVANET [10819]",Novanet,,710.78,75,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 16MM MINI-MONSTER SHORT THREAD CANNULATED",SUP-P20-125-016S,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",164.86,1204.88,"percent of total billed charges",
"SCR BONE 4.5MM 64MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.564,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,745.57,68,,,,,0,127.51,931.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LARGE 121X11MM TITANIUM 10 HOLE LOW PROFILE LOCKING",SUP-70-0294,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"CIGNA [10200]","Cigna Open Access",,3761.2,56.9,,1144.80,304.56,2275.09,66,768.77,5618.67,"percent of total billed charges",
"STENT EXPRESS SD MONORAIL 19MM 90CM 7MM SMALL BILIARY METAL",SUP-H74937912719900,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"CIGNA [10200]",Cigna,,3394.56,68,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 X-1 18IN CONTROL RELEASE 8 STRAND",SUP-VCP790D,CDM,S27200284,LOCAL,0272,RC,,,both,,,190.01,57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.1,161.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,inpatient,,,106182.45,31854.73,"CIGNA [10200]",Cigna,,26309.23,,"Fee schedule rate ($26,309.23). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,58581.77,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PLASMABLADE X ELECTROSURGICAL STERILE LATEX FREE",SUP-PS210-030S-LIGHT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2242.50,672.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,921.67,41.1,,,,,0,260.8,1906.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 44MM GORILLA R3CON LOCK",SUP-P50-353-4244,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,523.91,39.2,,957.42,570.23,957.42,28,155.43,1136.03,"percent of total billed charges",
"SCR INTERFERENCE BIOCOMPOSITE 10MM 4MM DISPOSABLE DRIVER",SUP-AR-1540CDS,CDM,C1713,HCPCS,0278,RC,,,both,,,3189.38,956.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,377.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,370.92,2710.97,"percent of total billed charges",
"TI LOW PROFILE TRANSCONNECTOR 42MM-55MM FOR 6.0MM RODS",SUP-497.798,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"PHCS [10601]",PHCS,,2625,70,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 20MM TITANIUM DISTAL RADIAL WRIST HAND",SUP-CO-N2320,CDM,C1713,HCPCS,0278,RC,,,both,,,720.90,216.27,"CIGNA [10200]","Cigna Local Plus",,385.68,53.5,,3978.14,359.25,3978.14,24,83.84,612.77,"percent of total billed charges",
"BNDG 10YDX4IN CALAMINE DOME PASTE TENDERWRAP UNNA BOOT",SUP-8036-,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.38,16.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.21,45.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE TIGRIS 40MM 120CM 7MM VASCULAR CBAS NITINOL",SUP-PHA070402A,CDM,C1874,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"KAISER [10500]",Kaiser,,6911.39,67,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8-6.5MM 80MM CREO SPINE PREASSEMBLE 2 OUTER",SUP-5119.2282,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,957.42,570.23,957.42,28,601.85,4398.75,"percent of total billed charges",
"ANCHOR SUT 1.45MM 1 SHORT JUGGERKNOT DRILL BIT SOFT RIGID",SUP-110005315,CDM,C1713,HCPCS,0278,RC,,,both,,,3884.70,1165.41,"CIGNA [10200]","Cigna Open Access",,2210.39,56.9,,1144.80,304.56,2275.09,66,451.79,3302,"percent of total billed charges",
"KIT SCR SHOULDER REVERSE TORQUE DEFINE",SUP-320-20-00,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 20MM 4.5FR SEGURA HEMISPHERE",SUP-M0063801180,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"CIGNA [10200]","Cigna Local Plus",,791.56,53.5,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 30MM ORTHOLOC ANKLE 3DI TECHNOLOGY LOCKING",SUP-59215530,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"PHCS [10601]",PHCS,,1538.25,70,,,,,0,255.57,1867.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG STD ACU-LOC 2 BONE LEFT DISTAL VOLAR RADIAL",SUP-70-0368,CDM,C1713,HCPCS,0278,RC,,,both,,,6654.91,1996.47,"CIGNA [10200]",Cigna,,4525.34,68,,1831.33,1831.33,1831.33,16,773.97,5656.67,"percent of total billed charges",
"SCR BONE 3.5MM 24MM ORTHOLOC FULL THREAD FOOT ANKLE CORTICAL",SUP-58813524,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross HMO",,301.64,39.2,,957.42,156.86,7483.26,51,89.49,654.08,"percent of total billed charges",
"SCR BONE 3.5MM 50MM STAINLESS STEEL PELVIS CORTEX SELF TAP",SUP-204.65,CDM,C1713,HCPCS,0278,RC,,,both,,,288.41,86.52,"BLUE CROSS [10001]","Blue Cross PPO",,113.06,39.2,,957.42,570.23,957.42,28,33.54,245.15,"percent of total billed charges",
"STENT VIABAHN 10CM 120CM 8MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR081002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2520.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +15 DIOPTER MODIFY C BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB0000150,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 34FR VENOUS STAINLESS STEEL",SUP-66134,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.63,85.69,"UHC [10700]","United Healthcare",,180.8,63.3,,,,,0,33.22,242.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 142MM STAINLESS STEEL 2.7/3.5MM SCR 8 HOLE VARIABLE",SUP-02.118.207S,CDM,C1713,HCPCS,0278,RC,,,both,,,10281.00,3084.3,"KAISER [10500]",Kaiser,,6888.27,67,,,,,0,1195.68,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 36CM HIP LEFT FEMUR AFFIXUS INTRAMEDULLARY 130D",SUP-814609360,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"NOVANET [10819]",Novanet,,15557.06,75,,,,,0,2412.38,17631.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.1MM 140MM KIRSCHNER STAINLESS STEEL 1 END",SUP-NO2228012,CDM,C1713,HCPCS,0278,RC,,,both,,,243.60,73.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,28.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",28.33,207.06,"percent of total billed charges",
"HC Biofire Bcid Panel",PX-306000240,CDM,87150,CPT,0306,RC,,,both,,,83.00,24.9,"AETNA [10100]","Aetna HMO/PPO",,65.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Biofire Bcid Panel",PX-306000240,CDM,87150,CPT,0306,RC,,,both,,,83.00,24.9,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,83,"per diem",
"SPACER ALLOGRAFT 14X16X6MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7006,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APOLLO MP50 PROBE ASPIRATING",SUP-AR-9815,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY FIXATION GOLD 44MM HUMERUS NAIL",SUP-462.644S,CDM,C1713,HCPCS,0278,RC,,,both,,,3288.60,986.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1509.47,45.9,,,,,0,382.46,2795.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 100CM 5FR 1 CURVE ANGIOGRAPHIC",SUP-G47001,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXCELSIOR SL-10 150CM 2 TIP",SUP-M0031681890,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"REINFORCEMENT STAPLE LINE BIOABSORBABLE STERILE SEAMGUARD",SUP-12BSGTRI45P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1242.00,372.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT SURGICAL LIPOGRAFTER STERILE DISPOSABLE AUTOLOGUS FAT",SUP-913000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2725.50,817.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT NEROSTIMLTR 30CM SPECIFY 5-6-5 LEAD 16 CONTACT PADDLE",SUP-39565-30,CDM,C1778,HCPCS,0278,RC,,,both,,,30240.00,9072,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8164.8,27,,,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 46CM 6.8FR 10MM SPACING J ATRIUM BIPOLAR ACTIVE",SUP-1782TC/46,CDM,C1898,HCPCS,0275,RC,,,both,,,1786.00,535.8,"MULTIPLAN [10600]",Multiplan,,1518.1,85,,,,,0,207.71,1518.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transplant Eval Liver Day 1 New Pt",PX-761000010,CDM,99205,CPT,0761,RC,,,both,,,1263.00,378.9,"FIRST HEALTH [10303]","First Health",,1010.4,80,,,,,0,1.26,1263,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR 180CM 3CM .018IN MEDIGLIDE",SUP-M001466040,CDM,C1769,HCPCS,0272,RC,,,both,,,1539.00,461.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,182.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355030,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"SCR BONE 3.5MM 42MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.342TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"MULTIPLAN [10600]",Multiplan,,1718.32,85,,,,,0,235.11,1718.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 2 UNIVERSAL KNEE CEMENTED TOTAL",SUP-5521-B-200,CDM,C1776,HCPCS,0278,RC,,,both,,,10384.92,3115.48,"CIGNA [10200]",Cigna,,7061.75,68,,5873.17,5873.17,5873.17,"1 through 10",1207.77,8827.18,"percent of total billed charges",
"MICROCATHETER CEREBROVASCULAR 135CM EXCELSIOR XT-27 1 TIP",SUP-M003XT2735910,CDM,S27200284,LOCAL,0272,RC,,,both,,,8474.58,2542.37,"MULTIPLAN [10600]",Multiplan,,7203.39,85,,,,,0,985.59,7203.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 62MM 36MM XLPE HIP STERILE",SUP-71332762,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"UHC [10700]","United Healthcare",,7042.92,63.3,,8601.07,8395.67,8601.07,"1 through 10",1293.98,9457.31,"percent of total billed charges",
"LENS IOL 10 D +16 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z9002160,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"BLUE CROSS [10001]","Blue Cross PPO",,400.08,39.2,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 5IN 2.8MM QUICK RELEASE STERILE",SUP-MS-DC28,CDM,S27200284,LOCAL,0272,RC,,,both,,,696.60,208.98,"CIGNA [10200]",Cigna,,473.69,68,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 8CM 7FR TAPER PANCREATIC POLYETHYLENE SPIRAL",SUP-G22354,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"NOVANET [10819]",Novanet,,473.85,75,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG LEAD DF-1 PORT",SUP-6996,CDM,S27800098,LOCAL,0278,RC,,,both,,,304.50,91.35,"CIGNA [10200]","Cigna Local Plus",,162.91,53.5,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK 143CM 8MM 1.5MM ROUND BALLOON DILATATION",SUP-1012444-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ISOLATOR SYNERGY ENCOMPASS CLAMP - MODEL OSH",SUP-A001144-9,CDM,S62400003,LOCAL,0624,RC,,,both,,,34020.00,10206,"AETNA [10100]","Aetna HMO/PPO",,27045.9,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3956.53,28917,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 18MM 13MM STD NECK S-ROM CERAMIC 135D",SUP-523393,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"PHCS [10601]",PHCS,,13615.88,70,,,,,0,2262.18,16533.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII ALLOGRAFT 18MM 26MM",SUP-401318,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 8X 38MM CATH 120CM ENDOVASCULAR",SUP-42838,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7200.84,41.1,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEMOSTAR 35CM 14.5FR STD HEMODIALYSIS BIOBLOC STRAIGHT",SUP-5833353,CDM,C1750,HCPCS,0278,RC,,,both,,,1860.00,558,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,853.74,45.9,,,,,0,216.32,1581,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL BLOCK",SUP-245241,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 80MM 3.5MM BALLOON",SUP-H74939147358010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 24MM 140CM 4MM CORONARY STENT CARBOSIL",SUP-LUN400R24US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SURGITIE 0 21IN LIGATE LOOP ABSORBABLE",SUP-SGL-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"CIGNA [10200]",Cigna,,98.03,68,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SHORT NARROW 48.9X21.6MM TITANIUM 3 HOLE LOW PROFILE",SUP-DVRANSL,CDM,C1713,HCPCS,0278,RC,,,both,,,7607.25,2282.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3491.73,45.9,,,,,0,884.72,6466.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCITRIOL 0.25 MCG CAPSULE",RX-9350,CDM,,,0637,RC,60687-0345-11,NDC,both,1,UN,6.27,1.88,"FIRST HEALTH [10303]","First Health",,5.02,80,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE SEMITENDINOSUS TENDON",SUP-FST,CDM,C1762,HCPCS,0278,RC,,,both,,,10439.70,3131.91,"CIGNA [10200]","Cigna Local Plus",,5585.24,53.5,,,,,0,1214.14,8873.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SPINAL T15 TALL TITANIUM LOCK",SUP-102023001,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 9CM 10FR PROXIMAL BEND BILIARY 2 LAYER STERILE",SUP-PBD-421-1009,CDM,C1876,HCPCS,0278,RC,,,both,,,1387.85,416.35,"KAISER [10500]",Kaiser,,929.86,67,,,,,0,161.41,1179.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 112MM PRIMARY ANTHOLOGY POROUS 131D 7 HIGH",SUP-71356107,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"CIGNA [10200]",Cigna,,13256.46,40,,5873.17,5873.17,5873.17,"1 through 10",3854.32,28169.98,"percent of total billed charges",
"FOL URETHRAL 13.35IN 16FR HEYMAN PLASTIC DILATION CATH",SUP-021116,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.13,65.14,"NOVANET [10819]",Novanet,,162.85,75,,,,,0,25.25,184.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY SIZE 26 OD31MM ID24MM MITRAL VALVE SEMI RI",SUP-SARP-26,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"UHC [10700]","United Healthcare",,7663.35,63.3,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 3.5IN 18GA 20GA PERIFIX TUOHY METAL GLASS LOR",SUP-332236,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.73,44.32,"CIGNA [10200]","Cigna Local Plus",,79.04,53.5,,,,,0,17.18,125.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.7MM 5 2 STRAIGHT SUTUREFIX ULTRA SHOULDER 1",SUP-72203853,CDM,C1713,HCPCS,0278,RC,,,both,,,1607.45,482.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,186.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",186.95,1366.33,"percent of total billed charges",
"CATH INPACT ADMIRAL 80CM 200MM 5MM BALLOON DILATATION","SUP-ADM 050 200 08P",CDM,C2623,HCPCS,0272,RC,,,both,,,12730.50,3819.15,"PHCS [10601]",PHCS,,8911.35,70,,,,,0,1480.56,10820.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 99MM TRI-LOCK BPS GRIPTION 2 HIGH OFFSET HIP",SUP-101214020,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6442.85,40,,,,,0,1873.26,13691.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE READIGRAFT PRESERVON CANCELLOUS 15ML 4-10MM CHIP","SUP-PCAN15 410",CDM,S27800098,LOCAL,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 5 1/8IN LAMBOTTE SWISS PATTERN SURGICAL MINI",SUP-27-5714,CDM,S27200284,LOCAL,0272,RC,,,both,,,148.51,44.55,"CIGNA [10200]","Cigna Open Access",,84.5,56.9,,,,,0,17.27,126.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 7 KNEE LEFT DISTAL TOTAL",SUP-5542-A-701,CDM,C1776,HCPCS,0278,RC,,,both,,,7027.65,2108.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,817.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,817.32,5973.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE REGENESORB 20MM 5MM OPEN ARCHITECTURE SOLID",SUP-72204389,CDM,C1713,HCPCS,0278,RC,,,both,,,2079.00,623.7,"CIGNA [10200]",Cigna,,1413.72,68,,1831.33,1831.33,1831.33,16,241.79,1767.15,"percent of total billed charges",
"KIT BONE GRAFT 9CC DEMINERALIZED CORTICAL FIBER ACCELERATE",SUP-T50209,CDM,C1713,HCPCS,0278,RC,,,both,,,14283.00,4284.9,"CIGNA [10200]","Cigna Local Plus",,4499.15,31.5,,3978.14,359.25,3978.14,24,1661.11,12140.55,"percent of total billed charges",
"SCR BONE 1.5MM 7MM APTUS TRILOCK TITANIUM PHALANGEAL HAND",SUP-A-5250.07/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1096.09,68,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE RIGHT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F202,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1993.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1993.39,14569.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE READIGRAFT PRESERVON CANCELLOUS 15ML 4-10MM CHIP","SUP-PCAN15 410",CDM,S27800098,LOCAL,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Feeynolm<=2.5cm",PX-450000025,CDM,12011,CPT,0361,RC,,,both,,,910.55,273.16,"BLUE CROSS [10001]","Blue Cross HMO",,910.55,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,105.9,910.55,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 6.3IN SEWALL HANDHELD SURGICAL",SUP-N3323,CDM,S27200284,LOCAL,0272,RC,,,both,,,1320.30,396.09,"CIGNA [10200]","Cigna Open Access",,751.25,56.9,,,,,0,153.55,1122.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 10-0 CS160-6 12IN 2 ARM MONOFILAMENT BLACK",SUP-9000G,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.29,68.79,"AETNA [10100]","Aetna HMO/PPO",,182.29,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.67,194.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO TRAK 21 MICROCATHETER 162CM",SUP-90338,CDM,S27200284,LOCAL,0272,RC,,,both,,,6781.32,2034.4,"UHC [10700]","United Healthcare",,4292.58,63.3,,,,,0,788.67,5764.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 4CM 5FR 3MM .035IN BALLOON DILATATION",SUP-G52326,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.64,68,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM 11/13 TAPER 40MM HIP M SPECIFICATION METAL",SUP-136541500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"NOVANET [10819]",Novanet,,8308.46,75,,,,,0,1288.37,9416.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 200MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171032010,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5-6 15MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71933739,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"CIGNA [10200]","Cigna Local Plus",,3834.05,31.5,,5372.07,4581.20,7242.98,23,1415.56,10345.86,"percent of total billed charges",
"CATH HALO90 BARRX 160CM 40X13",SUP-90-9200,CDM,C1886,HCPCS,0272,RC,,,both,,,16532.40,4959.72,"PHCS [10601]",PHCS,,11572.68,70,,,,,0,1922.72,14052.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 5MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640605,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"UHC [10700]","United Healthcare",,7123.72,63.3,,8601.07,8395.67,8601.07,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"MARKER SKIN PURPLE 5CM SOFT TISSUE DELIVERY SYSTEM STERILE",SUP-SMARTCLIPLT-PURP-5,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"MULTIPLAN [10600]",Multiplan,,2295,85,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 13MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G213,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CIGNA [10200]","Cigna Local Plus",,4658.57,53.5,,5372.07,4581.20,7242.98,23,1012.7,7401.47,"percent of total billed charges",
"SUT PLAIN 3-0 CTX 27IN MONOFILAMENT ABSORBABLE",SUP-873H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"CIGNA [10200]","Cigna Open Access",,15.36,56.9,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL CATALYFT SM 6MM ANT EXPANDABLE STERILE",SUP-981023322,CDM,S27800098,LOCAL,0278,RC,,,both,,,49770.00,14931,"PHCS [10601]",PHCS,,34839,70,,,,,0,5788.25,42304.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17.8MM 25MM 32MM 23.4MM ON-X 25 STD CYLINDRICAL",SUP-ONXAE-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"CIGNA [10200]","Cigna Local Plus",,11907,31.5,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 22F LARGE HIP PROXIMAL",SUP-550546,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"FIRST HEALTH [10303]","First Health",,8707.8,80,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 320MM FEMORAL PROXIMAL TFN-ADVANCED INTRAMEDULLARY",SUP-04.037.253S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3554.13,28.62,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 11/13 TAPER 28MM HIP BIOLOX DELTA CERAMIC",SUP-136528210,CDM,C1776,HCPCS,0278,RC,,,both,,,12385.50,3715.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1440.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 4-0 PS-4 18IN MONOFILAMENT UNDYED",SUP-1603G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 18MM 145CM 2.5MM CORONARY STENT",SUP-1145250-18,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross HMO",,2288.5,39.2,,9776.84,9776.84,9776.84,"1 through 10",678.96,4962.3,"percent of total billed charges",
"SCR BONE 4MM 46MM ASNIS III TITANIUM PARTIAL THREAD REVERSE",SUP-604646,CDM,C1713,HCPCS,0278,RC,,,both,,,1319.00,395.7,"CIGNA [10200]","Cigna Open Access",,750.51,56.9,,1144.80,304.56,2275.09,66,153.4,1121.15,"percent of total billed charges",
"CATHETER DELIVERY RIGHT SIDED SSPC",SUP-9184,CDM,C1887,HCPCS,0272,RC,,,both,,,3375.00,1012.5,"KAISER [10500]",Kaiser,,2261.25,67,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR STD .035IN 50CM J TIP FIXED CORE GUIDERIGHT",SUP-404559,CDM,C1769,HCPCS,0272,RC,,,both,,,45.68,13.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.31,38.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL OXFORD C KNEE LEFT MEDIAL COCRMO",SUP-154722,CDM,C1776,HCPCS,0278,RC,,,both,,,11195.94,3358.78,"BLUE CROSS [10001]","Blue Cross HMO",,4388.81,39.2,,5311.50,4717.44,5388.59,31,1302.09,9516.55,"percent of total billed charges",
"SCR BONE 8.5MM 50MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4850,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Splint Ankle",PX-E27000162,CDM,E27000162,LOCAL,0270,RC,,,both,,,756.80,227.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VASCUTRAK 140CM 10CM 4MM 5FR BALLOON DILATATION",SUP-V1840100,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP SURGICAL STEALTH 6MM 6MM VASCULAR .75 FORCE SPRING",SUP-A1604,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ENDOWRIST STAPLER 30 GRAY RELOAD",SUP-48630M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1453.28,435.98,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SELUTION SLR PTCA DEB 4.5X25MM",SUP-SCA14U-450025D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 11CM NATRELLE INSPIRA P4.4CM FULL PROFILE ROUND",SUP-MSZ-F265,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL JACOBSON MICRO SLIGHT CURVE 7IN ARTERY EXTRA",SUP-16-4188,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.98,64.49,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SYNCHRO SELECT VASCULAR STRAIGHT STD 300CM .014IN",SUP-SSTD300STR,CDM,C1769,HCPCS,0272,RC,,,both,,,5686.57,1705.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 45MM 19GA 23GA CLOSE TIP 3 LATERAL OPEN",SUP-0131153-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.70,80.91,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH FLEXOR CHECK-FLO ANL1 CURVE 90CM 6FR 2.2MM GUIDING",SUP-G29989,CDM,C1894,HCPCS,0272,RC,,,both,,,842.40,252.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 170CM 20CM 3MM BALLOON DILATATION HYDROPHILIC",SUP-G50333,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 74MM 1.5MM MINI QUICK COUPLING THREAD HOLE",SUP-03.130.302,CDM,S27200284,LOCAL,0272,RC,,,both,,,576.07,172.82,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Crystal Exam Fluid/Tiss",PX-309000105,CDM,89060,CPT,0309,RC,,,both,,,143.44,43.03,"CIGNA [10200]","Cigna Open Access",,16.13,,,,,,,0.14,121.92,"fee schedule",
"STENT ZIPWIRE 24CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175262180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA [10200]",Cigna,,992.87,68,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ndl Intraosseous 45mm 15ga Bar",PX-E27200301,CDM,E27200301,LOCAL,0272,RC,,,both,,,808.50,242.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.03,687.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ndl Intraosseous 45mm 15ga Bar",PX-E27200301,CDM,E27200301,LOCAL,0272,RC,,,both,,,808.50,242.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.03,687.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11CM NATRELLE INSPIRA P4.4CM FULL PROFILE ROUND",SUP-MSZ-F265,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inhibin A",PX-302000072,CDM,86336,CPT,0302,RC,,,both,,,155.00,46.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,131.75,"per diem",
"SABERX RADIANZ 2MM10CM 190",SUP-R51002010L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,241.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR EMPHASYS 50MM 36MM AOX NEUTRAL",SUP-472250036,CDM,C1776,HCPCS,0278,RC,,,both,,,14038.05,4211.41,"FIRST HEALTH [10303]","First Health",,11230.44,80,,,,,0,1632.63,11932.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 10IN WRIST 2 PIECE PERFORATE",SUP-79-87020,CDM,S27000186,LOCAL,0270,RC,,,both,,,163.04,48.91,"AETNA [10100]","Aetna HMO/PPO",,129.62,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.96,138.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.235,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 75CM MULLINS DESIGN RADIOPAQUE BAND",SUP-G08759,CDM,C1894,HCPCS,0272,RC,,,both,,,680.32,204.1,"AETNA [10100]","Aetna HMO/PPO",,540.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,79.12,578.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 6.8FR 11MM SPACING ENDOCARDIUM TRUE BIPOLAR",SUP-7122Q/58,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4636.44,27,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BONE CORT CANC BLK PARA CRNRSTN ASR 9X14X11MM",SUP-245941,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nitric Oxide Exp Gas Dterm",PX-460000018,CDM,95012,CPT,0460,RC,,,both,,,297.00,89.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,201.96,68,,,,,0,34.54,252.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 60MM 2.5MM BALLOON DILATATION DURALYN",SUP-48002506S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR070202A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2181.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC LARGE HUB 2 SERRATE STERLING CUDA",SUP-C9254,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 0 CTX 18IN CONTROL RELEASE MONOFILAMENT 8 STRAND",SUP-Z776D,CDM,S27200284,LOCAL,0272,RC,,,both,,,221.68,66.5,"AETNA [10100]","Aetna HMO/PPO",,176.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.78,188.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 180CM 5.5CM 7.5FR 8-10MM ESOPHAGEAL",SUP-M00558400,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"UHC [10700]","United Healthcare",,1043.84,63.3,,,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Column Chromotography",PX-301000162,CDM,82542,CPT,0301,RC,,,both,,,402.80,120.84,"AETNA [10100]","Aetna HMO/PPO",,320.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,342.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICROINTRODUCER 7CM 5FR MICROEZ STAINLESS STEEL GWIRE",SUP-0828950,CDM,C1894,HCPCS,0272,RC,,,both,,,455.54,136.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,309.77,68,,,,,0,52.98,387.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 16FR SILICONE MIC RADIOPAQUE FEED TUBE",SUP-8250-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"KAISER [10500]",Kaiser,,1174.14,67,,,,,0,203.81,1489.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL XL MEDIUM THICK CIRCLE EEA TRI-STAPLE PURPLE",SUP-TRIEEAXL28MT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2610.30,783.09,"PHCS [10601]",PHCS,,1827.21,70,,,,,0,303.58,2218.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Npwt >50 Sq Cm W/Dme",PX-510000170,CDM,97606,CPT,0761,RC,,,both,,,817.41,245.22,"CIGNA [10200]",Cigna,,817.41,,"Per diem ($2,606).",,,,0,95.06,817.41,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Canalith Repositioning Proc (Ot)",PX-430000066,CDM,95992,CPT,0430,RC,,,both,,,356.00,106.8,"BLUE CROSS [10001]","Blue Cross PPO",,356,,"Per diem ($371.22).",,,,0,41.4,356,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Canalith Repositioning Proc (Ot)",PX-430000066,CDM,95992,CPT,0430,RC,,,both,,,356.00,106.8,"CIGNA [10200]","Cigna Open Access",,309,,"Per diem ($309).",,,,0,41.4,356,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2XS UNIVERSAL 14MM KNEE COCR POLYETHYLENE",SUP-198727014,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8456.17,28.62,,,,,0,3436.24,25114.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE TITANIUM 25MM 7MM ACL PCL CANNULATED SHEATH",SUP-AR-1371E,CDM,C1713,HCPCS,0278,RC,,,both,,,978.08,293.42,"BLUE CROSS [10001]","Blue Cross PPO",,383.41,39.2,,957.42,570.23,957.42,28,113.75,831.37,"percent of total billed charges",
"HC Valve Trach Passay-Muir",PX-E27000182,CDM,L8501,HCPCS,0274,RC,,,both,,,535.79,160.74,"MULTIPLAN [10600]",Multiplan,,455.42,85,,,,,0,62.31,455.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Valve Trach Passay-Muir",PX-E27000182,CDM,L8501,HCPCS,0274,RC,,,both,,,535.79,160.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,63.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.31,455.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Valve Trach Passay-Muir",PX-E27000182,CDM,L8501,HCPCS,0274,RC,,,both,,,535.79,160.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,364.34,68,,,,,0,62.31,455.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH GREEN 16CM 12FR MAHURKAR ELITE POLYURETHANE 2",SUP-8888222316,CDM,C1752,HCPCS,0272,RC,,,both,,,860.01,258,"PHCS [10601]",PHCS,,602.01,70,,,,,0,100.02,731.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TRACH 8.5FR SHILEY BLUE RHINO PERCUTANEOUS FLEXIBLE",SUP-G57717,CDM,S27200284,LOCAL,0272,RC,,,both,,,4398.75,1319.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,521.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,511.57,3738.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 11MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530G811,CDM,C1776,HCPCS,0278,RC,,,both,,,8868.13,2660.44,"FIRST HEALTH [10303]","First Health",,7094.5,80,,,,,0,1031.36,7537.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 106MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 4",SUP-71357104,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"CIGNA [10200]","Cigna Open Access",,11102.29,33.5,,5302.19,4377.88,6578.61,27,3854.32,28169.98,"percent of total billed charges",
"LEAD PACING 52CM 7FR ENDOCARDIUM BIPOLAR ACTIVE FIXATION",SUP-1999/52,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,638.94,28.62,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 58-71MM REVERE TRANSVERSE ADJUSTABLE TITANIUM SPINE",SUP-124.916,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"AETNA [10100]","Aetna HMO/PPO",,3839.85,79.5,,1521.93,481.35,16760.95,30,561.73,4105.5,"percent of total billed charges",
"SYSTEM INTEGRITY 30MM 4MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT40030UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CIGNA [10200]","Cigna Local Plus",,1292.03,53.5,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IFUSE IMPL SYSTEM 35MM 7MM SPINAL FIXATION SACROILIAC",SUP-7035M-90,CDM,C1713,HCPCS,0278,RC,,,both,,,21082.95,6324.88,"PHCS [10601]",PHCS,,14758.07,70,,,,,0,2451.95,17920.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM ARTHREX TITANIUM MINI FULL THREAD",SUP-AR-8730-38H,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1785,68,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 60MM SOLERA CD HORIZON TITANIUM COCR SPINE 2",SUP-54840008560,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,1831.33,1831.33,1831.33,16,441.36,3225.75,"percent of total billed charges",
"PIN FIXATION 9IN 5/32IN STEINMANN FULL THREAD STAINLESS",SUP-KM169-29-53,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"FIRST HEALTH [10303]","First Health",,50.89,80,,,,,0,7.4,54.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 60ML .1-2MM 80% CORTICAL 20% CANCELLOUS",SUP-400064,CDM,C1713,HCPCS,0278,RC,,,both,,,4621.28,1386.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1322.61,28.62,,,,,0,537.45,3928.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 4MM NESTER MICROCOIL PLATINUM ACCEPTS",SUP-G47352,CDM,S27800098,LOCAL,0278,RC,,,both,,,890.92,267.28,"BLUE CROSS [10001]","Blue Cross PPO",,349.24,39.2,,,,,0,103.61,757.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX 1S REINFORCED TISSUE MATRIX, LONG-TERM RESORBABLE REI",SUP-F10266-1012G,CDM,C1781,HCPCS,0278,RC,,,both,,,12966.48,3889.94,"PHCS [10601]",PHCS,,9076.54,70,,,,,0,1508,11021.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 8MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR081002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"CIGNA [10200]",Cigna,,8507.52,40,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOABLATION 17IN 8MM CRYOICE CRYOSPHERE STERILE LATEX",SUP-CRYOSP-L,CDM,C9808,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT 18MM ALIF",SUP-3W3218,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"FIRST HEALTH [10303]","First Health",,16916.26,80,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE 12CM KNIT FILM SYNECOR CIRCLE",SUP-GKFC12,CDM,C1781,HCPCS,0278,RC,,,both,,,4057.20,1217.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1862.25,45.9,,,,,0,471.85,3448.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT Q-FIX MINITAPE NDL STERILE LATEX FREE",SUP-72205695,CDM,C1713,HCPCS,0278,RC,,,both,,,3003.75,901.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,349.34,2553.19,"percent of total billed charges",
"KIT ADVANCE COOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-CRKA-17-100-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX14MM VERTE-STACK CAPSTONE PEEK-OPTIMA END",SUP-2961422,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"PHCS [10601]",PHCS,,11128.32,70,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT C-FLEX 5CM 10FR 2 PIGTAIL CURVE BILIARY PLASTIC",SUP-M00532040,CDM,C2617,HCPCS,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1 KNEE LEFT CEMENTED POSTERIOR STABILIZE",SUP-5515F101,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"UHC [10700]","United Healthcare",,6330,63.3,,8601.07,8395.67,8601.07,"1 through 10",1163,8500,"percent of total billed charges",
"FRCP SURGICAL DEBAKEY ANGLE 7.75IN VASCULAR TISSUE 2MM",SUP-55-2015,CDM,S27200284,LOCAL,0272,RC,,,both,,,523.18,156.95,"UHC [10700]","United Healthcare",,331.17,63.3,,,,,0,60.85,444.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 35MM 35CM KINK RESISTANT CANN RADIOPAQUE 6",SUP-401735M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,70.99,68,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 37MM 135CM 6MM 40MM",SUP-38047-64013,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross PPO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL MEMORYSHAPE MEDIUM HEIGHT MODERATE PLUS PROFILE",SUP-RSZ-1205S,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.90,70.47,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,96.54,41.1,,,,,0,27.32,199.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL VASCULAR 30MM 2.5MM FLO-RESTER VESSEL SILICONE",SUP-60250,CDM,S27200284,LOCAL,0272,RC,,,both,,,634.52,190.36,"AETNA [10100]","Aetna HMO/PPO",,504.44,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.79,539.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Specific Gravity Non Urine",PX-301000527,CDM,84315,CPT,0301,RC,,,both,,,77.90,23.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.51,,"Fee schedule rate ($3.51). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.08,66.22,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCOPIC INSTR DISPOSABLE DX SWIVELOCK",SUP-AR-8979DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,2165.63,649.69,"NOVANET [10819]",Novanet,,1624.22,75,,,,,0,251.86,1840.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revasc Acute Occl Ami Sngl Ves 1maj C Art",PX-481000087,CDM,92941,CPT,0481,RC,,,both,,,33062.33,9918.7,"BLUE CROSS [10001]","Blue Cross PPO",,21224.89,,"Case rate ($21,224.89). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3845.15,28102.98,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ctrl Nosebleed Postr Init",PX-450000215,CDM,30905,CPT,0361,RC,,,both,,,813.00,243.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,813,,"Case rate ($4,656). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,0.81,813,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ctrl Nosebleed Postr Init",PX-450000215,CDM,30905,CPT,0361,RC,,,both,,,813.00,243.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.81,813,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 10MM ORTHOLOC TITANIUM NITRIDE FOREFOOT",SUP-5201124010,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA [10200]","Cigna Open Access",,433.24,56.9,,1144.80,304.56,2275.09,66,88.55,647.19,"percent of total billed charges",
"GRAFT BONE FEMORAL CORTICAL THK3MM-12MM THIRDS ALLOGRAFT",SUP-450488,CDM,S27800098,LOCAL,0278,RC,,,both,,,9112.14,2733.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1059.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1059.74,7745.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOOT PROCEDURES WITH MCC",503,MS-DRG,,,,,,,inpatient,,,88813.68,26644.1,"PHCS [10601]",PHCS,,7561,,,,,,,7561,7561,"per diem","Estimated amount calculated based on 5 day length of stay."
"INSERT TIBIAL 8 5MM KNEE CRUCIATE RETAINING ROTATE PLATFORM",SUP-151630805,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5395.3,41.1,,6417.48,6417.48,6417.48,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"INDCTR CLEANING VERIFY BASKET",SUP-U505,CDM,S27000186,LOCAL,0270,RC,,,both,,,203.86,61.16,"CIGNA [10200]","Cigna Open Access",,116,56.9,,,,,0,23.71,173.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 32MM AEQUALIS TITANIUM SHOULDER NONLOCKING",SUP-VDV232,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",180.96,1322.6,"percent of total billed charges",
"SCR BONE 3.5MM 38MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0270,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross PPO",,371.5,39.2,,957.42,570.23,957.42,28,110.22,805.55,"percent of total billed charges",
"LINER ACETABULAR RINGLOC +3MM 26 40MM E-POLY HIP STERILE",SUP-EP-108426,CDM,C1776,HCPCS,0278,RC,,,both,,,14076.00,4222.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3800.52,27,,,,,0,1637.04,11964.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 40MM 4MM BALLOON DILATATION HYDROPHILIC",SUP-604004022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"NOVANET [10819]",Novanet,,546.75,75,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 2.5 MEQ/L LOW CALCIUM 2.5% DEXTROSE 2000ML 3000ML BAG",SUP-L5B9727,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.02,40.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,92.49,68,,,,,0,15.82,115.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 150MM 150CM 6MM VASCULAR NICKEL",SUP-EVD35-06-150-150,CDM,C1876,HCPCS,0278,RC,,,both,,,8295.00,2488.5,"NOVANET [10819]",Novanet,,6221.25,75,,,,,0,964.71,7050.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 35D MEDIUM AUG CORTILOC SHOULDER RIGHT",SUP-DWK404RA35S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"AETNA [10100]","Aetna HMO/PPO",,8347.5,79.5,,10981.53,8986.79,12413.38,12,1221.15,8925,"percent of total billed charges",
"HC Circum W/Clamp / Other Dvc",PX-361000390,CDM,54150,CPT,0361,RC,,,both,,,3893.94,1168.18,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3279,,"Case rate ($3,279). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,452.87,3893.94,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS INTRAOCULAR +09.00 DIOPTER L13MM D5MM OPTIC BODY 6MM A",SUP-LI61AOR0900,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,,,0637,RC,68084-0313-11,NDC,both,1,UN,7.14,2.14,"CIGNA [10200]","Cigna Open Access",,4.06,56.9,,,,,0,0.83,6.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 16MM QUICKFIX TITANIUM T8 PARTIAL THREAD",SUP-AR-8724-16,CDM,C1713,HCPCS,0278,RC,,,both,,,1028.70,308.61,"BLUE CROSS [10001]","Blue Cross HMO",,403.25,39.2,,957.42,156.86,7483.26,51,119.64,874.4,"percent of total billed charges",
"SCR BONE 4MM 16MM ATLANTIS TITANIUM ANTERIOR CERVICAL SPINE",SUP-3120216,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]","Cigna Local Plus",,754.35,53.5,,3978.14,359.25,3978.14,24,163.98,1198.5,"percent of total billed charges",
"ELECTRD DEFIB ADULT 6.25X4.5IN MULTIFUNCTION",SUP-22770R,CDM,S27200284,LOCAL,0272,RC,,,both,,,153.53,46.06,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,63.1,41.1,,,,,0,17.86,130.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTELLISYSTEM25 13IN INFLATION POLYCARBONATE 20ML",SUP-IN1525,CDM,S27200284,LOCAL,0272,RC,,,both,,,464.13,139.24,"NOVANET [10819]",Novanet,,348.1,75,,,,,0,53.98,394.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 4.5CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-24-4.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,92.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 4CM 5FR 3MM .035IN BALLOON DILATATION",SUP-G52326,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 5FR 50CM 11CM GRAY HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-5F-11-035,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL IV 20 MEQ POTASSIUM CHLORIDE 5% DEXTROSE 0.45% SODIUM",SUP-L6350,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPEL APD TWIST-LOC 15CM 6FR J SHORT LENGTH DRNG",SUP-H7493931106150,CDM,C1729,HCPCS,0272,RC,,,both,,,712.80,213.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 15IN 20FR .75IN 2.75IN BULLET DRNG PVC VENTRICLE GUIDE",SUP-VT-89420,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.36,85.61,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BLOOD SAMPLING 72IN VAMP SAMPLE SITE POLE MOUNT RESVR",SUP-48VMP272,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.10,33.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 17GA 16.8CM BIOPINCE OPTIONAL COAXIAL FULL CORE",SUP-MCXS1820BP,CDM,S27200284,LOCAL,0272,RC,,,both,,,168.78,50.63,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FARAWAVE 12FR 35MM ABLATION PULSE FIELD STERILE LATEX",SUP-M004PF41M432,CDM,C1733,HCPCS,0272,RC,,,both,,,53235.00,15970.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH EMERGE MONORAIL 144CM 8MM 6FR 1.5MM .07IN BALLOON",SUP-H7493918908150,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUBICON 150CM SPRT CONTROL STERILE DISPOSABLE ACCEPTS",SUP-H749394321415A0,CDM,C1887,HCPCS,0272,RC,,,both,,,1987.50,596.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,235.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,231.15,1689.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURPASS EVOLVE 3.25MM X 12MM - PMA",SUP-FDS32512,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"FIRST HEALTH [10303]","First Health",,66419.78,80,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM 9FR ATRIUM VENTRICLE QUADRIPOLAR CAPSURE",SUP-5038L-65,CDM,C1779,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]",Cigna,,3812.76,68,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM 3.5MM 2.1-2.7FR CORONARY",SUP-RONYX35030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"BLUE CROSS [10001]","Blue Cross PPO",,1455.3,39.2,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 24CM 3CM 7FR .038IN 2",SUP-M006192142170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,640.41,45.9,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 2MM BALLOON DILATATION OTW STERILE",SUP-592004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"PHCS [10601]",PHCS,,935.55,70,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC",446,MS-DRG,,,,,,,inpatient,,,35958.41,10787.52,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,10449.35,,"Case rate ($5,131.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,765.22, add-ons for qualifying new technology services are included. If operating cost exceeds $37,804.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,742.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,771.52. The transfer operating threshold is the transfer adjustment factor * $4,765.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.27. The transfer capital threshold is the transfer adjustment factor * $360.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,5131.79,20632.03,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERPICC SHERLOCK 3CG 5FR CENTRAL VENOUS 3 LUMEN",SUP-1385108QD,CDM,C1751,HCPCS,0272,RC,,,both,,,1872.23,561.67,"PHCS [10601]",PHCS,,1310.56,70,,,,,0,217.74,1591.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L14MM DIA3.5MM CORTICAL STAINLESS STEEL SELF TAPP",SUP-02.206.014,CDM,C1713,HCPCS,0278,RC,,,both,,,321.55,96.46,"CIGNA [10200]",Cigna,,218.65,68,,1831.33,1831.33,1831.33,16,37.4,273.32,"percent of total billed charges",
"SHEATH SUPER SHEATH SHORT 11CM 9FR INTRO SILICONE TWIST LOCK",SUP-H7491603509B1,CDM,C1894,HCPCS,0272,RC,,,both,,,79.31,23.79,"PHCS [10601]",PHCS,,55.52,70,,,,,0,9.22,67.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LOW PROFILE 22MM TITANIUM 5.5MM ROD FIX LEGACY X10",SUP-8115522,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"FIRST HEALTH [10303]","First Health",,2850,80,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X11MM PRECISION CONVEX SPINE",SUP-17511,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 13CM 3MM 15D ROUND TRANSNASAL FLUTE STERILE",SUP-TN30RFL,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1266.5,45.9,,,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X8MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7108,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]",Cigna,,4692,68,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 190MM 16MM REVISION MODULAR ARCOS STS TITANIUM",SUP-11-300916,CDM,C1776,HCPCS,0278,RC,,,both,,,20372.94,6111.88,"MULTIPLAN [10600]",Multiplan,,17317,85,,,,,0,2369.37,17317,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Trach Sealguard",PX-E27200236,CDM,E27200236,LOCAL,0272,RC,,,both,,,240.83,72.25,"PHCS [10601]",PHCS,,168.58,70,,,,,0,28.01,204.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE Y 1MM STAINLESS STEEL 1.5MM SCR 3 HOLE HEAD 7 HOLE",SUP-02.130.253S,CDM,C1713,HCPCS,0278,RC,,,both,,,3078.60,923.58,"MULTIPLAN [10600]",Multiplan,,2616.81,85,,,,,0,358.04,2616.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Sclp/Limb Add 5cm Cmplx",PX-450000051,CDM,13122,CPT,0361,RC,,,both,,,1058.43,317.53,"FIRST HEALTH [10303]","First Health",,846.74,80,,,,,0,123.1,1058.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP BIOPSY MUSCLE RAYPORT",SUP-SU130-1113,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.53,58.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,79.95,41.1,,,,,0,22.62,165.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 25CM 14FR PIGTAIL CURVE NEPHRSTMY FLEXIMA POLYURETHANE",SUP-M001271820,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CD HORIZON VOYAGER SPINE NONSTERILE",SUP-55850046550,CDM,C1713,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"FIRST HEALTH [10303]","First Health",,5934,80,,,,,0,862.66,6304.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 14MM AMNIOBAND PLACENTAL ALLOGRAFT",SUP-WC3014,CDM,Q4151,HCPCS,0636,RC,,,both,,,1667.10,500.13,"FIRST HEALTH [10303]","First Health",,1333.68,80,,,,,0,197.55,1417.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET HEMODIALYSIS M100 PRISMAFLEX EXTRACORPOREAL CIRCUIT",SUP-106697,CDM,S27200284,LOCAL,0272,RC,,,both,,,2042.85,612.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,937.67,45.9,,,,,0,237.58,1736.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM .02IN 5MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0520,CDM,S27800098,LOCAL,0278,RC,,,both,,,6258.00,1877.4,"FIRST HEALTH [10303]","First Health",,5006.4,80,,,,,0,727.81,5319.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COAG SUCTION 6IN 8FR 3/8IN VALLEYLAB PLASTIC POLYOLEFIN",SUP-E2608-6,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.69,20.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,31.99,45.9,,,,,0,8.1,59.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR RETRIEVAL CATHETER",SUP-2689,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 112MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 8",SUP-245.081,CDM,C1713,HCPCS,0278,RC,,,both,,,3204.60,961.38,"PHCS [10601]",PHCS,,2243.22,70,,,,,0,372.69,2723.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUTONOME W/SY60WF",SUP-CNA0T0,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Prisma",PX-E27200118,CDM,E27200118,LOCAL,0272,RC,,,both,,,94.57,28.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,64.31,68,,,,,0,11,80.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 4IN 18GA 20GA PAJUNK SONOLONG TUOHY",SUP-TDL105,CDM,C9814,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCREW METAPHYSEAL LOCKING 3.7MM X 52MM TI",SUP-MTLS-37520-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,523.91,39.2,,957.42,570.23,957.42,28,155.43,1136.03,"percent of total billed charges",
"SPRT ORTHOPEDIC LARGE CONTOUR ALUMINUM COTTON SUEDE WRIST",SUP-79-87017,CDM,S27000186,LOCAL,0270,RC,,,both,,,50.37,15.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.86,42.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE REGENESORB 20MM 10MM BIOSURE",SUP-72204407,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"AETNA [10100]","Aetna HMO/PPO",,2205.35,79.5,,1521.93,481.35,16760.95,30,322.62,2357.93,"percent of total billed charges",
"1.9MM X 341MM TRILOGY PROBE KIT",SUP-M0068403510,CDM,S27200284,LOCAL,0272,RC,,,both,,,5531.45,1659.43,"CIGNA [10200]","Cigna Open Access",,3147.4,56.9,,,,,0,643.31,4701.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 7 STD OFFSET HIP",SUP-71935567,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"CIGNA [10200]",Cigna,,14613.48,40,,5873.17,5873.17,5873.17,"1 through 10",4248.87,31053.65,"percent of total billed charges",
"SYSTEM SYNERGY MONORAIL 12MM 144CM 4.5MM CORONARY STENT",SUP-H7493926012450,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4275.59,45.9,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 30MM TITANIUM ALUMINUM NIOBIUM X25 MEDULLARY",SUP-04.045.030S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",189.34,1383.8,"percent of total billed charges",
"GRAFT BONE VERTIGRAFT CERVICAL LARGE PARALLEL 14X14.5X9MM",SUP-VG2C-DR9P,CDM,S27800098,LOCAL,0278,RC,,,both,,,6077.73,1823.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4132.86,68,,,,,0,706.84,5166.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR TRIAL LINEAR 3-4",SUP-SC-2352-50E,CDM,C1778,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +28 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.280,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,197.05,28.62,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM 2FR .019IN PROGREAT",SUP-MC*PC2015Y,CDM,C1887,HCPCS,0272,RC,,,both,,,4754.10,1426.23,"NOVANET [10819]",Novanet,,3565.58,75,,,,,0,552.9,4040.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS",870,MS-DRG,,,,,,,inpatient,,,172930.99,51879.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,112040.28,,"Fee schedule rate ($112,040.28). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,10994,172373.38,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"TREPHINE OPHTHALMIC TRABECULAR STERILE LATEX DISPOSABLE",SUP-AX1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ortho Mgmt/Train Ea 15min (Go)",PX-430000030,CDM,97760,CPT,0430,RC,,,both,,,205.82,61.75,"UHC [10700]","United Healthcare",,205.82,,"Per diem ($331).",,,,0,23.94,205.82,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM EXCELSIOR XT-27 1 TIP",SUP-M003XT2750910,CDM,S27200284,LOCAL,0272,RC,,,both,,,8474.58,2542.37,"MULTIPLAN [10600]",Multiplan,,7203.39,85,,,,,0,985.59,7203.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM ALPS TITANIUM T15 TIBIA CORTICAL DISTAL",SUP-131218014,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"KAISER [10500]",Kaiser,,529.13,67,,,,,0,91.85,671.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARKSMAN 150CM 10CM 2.8-3.2FR .027IN MICRO INFUSION",SUP-FA-55150-1030,CDM,S27200284,LOCAL,0272,RC,,,both,,,7976.40,2392.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3661.17,45.9,,,,,0,927.66,6779.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 11X11X30MM 15",SUP-5811305,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11836.8,41.1,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOTUS VALVE SYSTEM 27MM REPRISE III",SUP-H749LTVR3CL270,CDM,S62400003,LOCAL,0624,RC,,,both,,,142500.00,42750,"CIGNA [10200]","Cigna Open Access",,81082.5,56.9,,,,,0,16572.75,121125,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Total Tau",PX-301000702,CDM,84394,CPT,0301,RC,,,both,,,630.00,189,"AETNA [10100]","Aetna HMO/PPO",,500.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,535.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 4FR 50CM 11CM RED HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-4F-11-035,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 10CM 7FR 10MM .035IN BALLOON",SUP-G52376,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.64,68,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PCMKR CRD THK6MM SM 50X47MM","SUP-PM1240 CELL",CDM,C1786,HCPCS,0275,RC,,,both,,,9324.00,2797.2,"AETNA [10100]","Aetna HMO/PPO",,7412.58,79.5,,,,,0,1084.38,7925.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Impacted Cerumen",PX-450000304,CDM,69210,CPT,0361,RC,,,both,,,1527.04,458.11,"MULTIPLAN [10600]",Multiplan,,1297.98,85,,,,,0,177.59,1527.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 16X6CM ALLODERM",SUP-1516616,CDM,Q4116,HCPCS,0636,RC,,,both,,,17835.30,5350.59,"AETNA [10100]","Aetna HMO/PPO",,14179.06,79.5,,,,,0,247.92,15160.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Copper Cu-64 Dotatate Dx Inj per Mci",PX-343000040,CDM,A9592,HCPCS,0343,RC,,,both,,,6292.00,1887.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,731.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,731.76,5348.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 3CM 18FR MIC-KEY SECUR-LOK ENFIT SILICONE RADIOPAQUE",SUP-8140-18-3.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"AETNA [10100]","Aetna HMO/PPO",,619.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 20MM 120CM 7MM 6FR VASCULAR NITINOL PERIPHERAL",SUP-S-70-020-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Ven Thin-Flex 30f",PX-E27200390,CDM,E27200390,LOCAL,0272,RC,,,both,,,168.30,50.49,"NOVANET [10819]",Novanet,,126.23,75,,,,,0,19.57,143.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM PRESTIGE PLUS HELICAL ULTRA",SUP-PRES4510CPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH C315S502",SUP-C315S502,CDM,C1887,HCPCS,0272,RC,,,both,,,2175.00,652.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1479,68,,,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL KNEE IDENTITY IMPRINT THK8MM 4 TIBIAL INSRT POSTERIOR",SUP-TPS-030-084S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9FR 11CM MINI GWIRE NO OBTR HEXCUSPID VALVE",SUP-504609X,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"UHC [10700]","United Healthcare",,49.56,63.3,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE SOFT TOUCH SMOOTH",SUP-SSF-295,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2162.38,28.62,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Trigger Pnt<=2 Mscl",PX-510000062,CDM,20552,CPT,0761,RC,,,both,,,3291.17,987.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,390,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,382.76,2797.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insj Perm Ccm-D Sys 1 Transvns Lead Only",PX-481000412,CDM,0917T,CPT,0481,RC,,,both,,,12746.00,3823.8,"BLUE CROSS [10001]","Blue Cross HMO",,8667.44,,"Case rate ($8,667.44). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1482.36,12746,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBERFUSE ALLOGRAFT",SUP-420605,CDM,C1713,HCPCS,0278,RC,,,both,,,9018.30,2705.49,"FIRST HEALTH [10303]","First Health",,7214.64,80,,,,,0,1048.83,7665.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 13X13.5CM 500CC STYLE 133S SMOOTH SUT TAB",SUP-133S-FV-13-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2665.95,28.62,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTRIAXONE SODIUM 1 G/10ML IJ (WET SOLR VIAL)",RX-4159487,CDM,J0696,HCPCS,0636,RC,00143-9857-01,NDC,both,1,UN,18.92,5.68,"UHC [10700]","United Healthcare",,3.6,,,,,,,2,16.08,"fee schedule",
"SCR BONE 4.5MM 30MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.030,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"CIGNA [10200]",Cigna,,140.32,68,,1831.33,1831.33,1831.33,16,24,175.41,"percent of total billed charges",
"FENTANYL 50 MCG/ML INJECTION SUPERORDERABLE|DISCARDED DRUG NOT ADMINISTE",RX-4083037,CDM,J3010,HCPCS,0636,RC,00641-6029-01,NDC,both,20,ML,72.48,21.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",JW,12.82,,,,,,,8.59,61.61,"fee schedule",
"HC Blood Smear WO Diff Wbc",PX-305000004,CDM,85008,CPT,0305,RC,,,both,,,73.88,22.16,"CIGNA [10200]","Cigna Open Access",,7.55,,,,,,,2.33,62.8,"fee schedule",
"PLATE 81MM 4 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-44F81V,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,3978.14,359.25,3978.14,24,641.98,4692,"percent of total billed charges",
"INSOLE SHOE 12.5-14 XL MALE PEGASSIST DARCO PRESSURE REDUCE",SUP-262825,CDM,S27000186,LOCAL,0270,RC,,,both,,,134.85,40.45,"CIGNA [10200]","Cigna Open Access",,76.73,56.9,,,,,0,15.68,114.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE RIGHT POSTERIOR STABILIZE BEAD",SUP-5516F802,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"BLUE CROSS [10001]","Blue Cross HMO",,6788.24,39.2,,5311.50,4717.44,5388.59,31,2013.96,14719.4,"percent of total billed charges",
"VALVE AORTIC 34MM 25MM FREESTYLE ROOT PORCINE BIOPROSTHESIS",SUP-FR995-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,38430.00,11529,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4553.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4469.41,32665.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cryopreserve/Store Cells",PX-311000030,CDM,88240,CPT,0311,RC,,,both,,,271.00,81.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.52,,,,,,,0.01,230.35,"fee schedule",
"DEFIB CARDIAC THK12MM 51X74MM GALLANT HF IS-1 IS-4 DF-4 CNCT",SUP-CDHFA500Q,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"PHCS [10601]",PHCS,,53865,70,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RELIEVA VORTEX IRRIGATION SINUS ENDOSCOPY",SUP-LC7065,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 35D MEDIUM AUG CORTILOC SHOULDER RIGHT",SUP-DWK404RA35S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"CIGNA [10200]","Cigna Open Access",,5974.5,56.9,,5302.19,4377.88,6578.61,27,1221.15,8925,"percent of total billed charges",
"HC Txcath Plc Stent Cca W Dp",PX-360000046,CDM,37215,CPT,0361,RC,,,both,,,11807.09,3542.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1399.14,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1373.16,10036.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE DREAMWIRE ENDOSCOPIC ANGLE STD 260CM .035IN ENDOGLIDE",SUP-M00556111,CDM,C1769,HCPCS,0272,RC,,,both,,,1422.36,426.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,584.59,41.1,,,,,0,165.42,1209.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ PACEPORT 110CM 7.5FR PULMONARY ARTERY",SUP-780F75M,CDM,C1751,HCPCS,0272,RC,,,both,,,1649.93,494.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1121.95,68,,,,,0,191.89,1402.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET IMPL INTERNALBRACE SWIVELOCK FIBERTAPE 3.5MM 2 2 NDL",SUP-AR-1678-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,7063.88,2119.16,"CIGNA [10200]","Cigna Local Plus",,3779.18,53.5,,3978.14,359.25,3978.14,24,821.53,6004.3,"percent of total billed charges",
"FRCP ELECTROSURGICAL ENDOWRIST SP BIPOLAR FENESTRATE",SUP-430011,CDM,S27000186,LOCAL,0270,RC,,,both,,,2583.00,774.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1061.61,41.1,,,,,0,300.4,2195.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txcath Plc Stent Cca W Dp",PX-360000046,CDM,37215,CPT,0361,RC,,,both,,,11807.09,3542.13,"NOVANET [10819]",Novanet,,8855.32,75,,,,,0,1373.16,10036.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 8MM CR VERTEBRAL LORDOTIC CRESCENT NONSTERILE",SUP-889.924,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LOCK BRIDGE LOCKING PLATES BONE STERILE",SUP-BRGP,CDM,C1713,HCPCS,0278,RC,,,both,,,10039.50,3011.85,"CIGNA [10200]",Cigna,,6826.86,68,,1831.33,1831.33,1831.33,16,1167.59,8533.58,"percent of total billed charges",
"SPACER SPINAL 11MM CATALYFT PL40 SHORT",SUP-6069113,CDM,S27800098,LOCAL,0278,RC,,,both,,,39060.00,11718,"MULTIPLAN [10600]",Multiplan,,33201,85,,,,,0,4542.68,33201,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TANDEM 2 DUO ANCHOR SYSTEM LARGE",SUP-PN0610-618,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI SUOH3 300 STRAIGHT",SUP-AHW14R313S,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,466.07,41.1,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 70X27MM STD OSCILLATING ERGONOMIC LIGHTWEIGHT",SUP-519.170S,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"CIGNA [10200]","Cigna Local Plus",,273.01,53.5,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 5592-53  LEAD CAP SP BI SIL DWNSIZE",SUP-5592-53,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1604.72,28.62,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lymphocyte Transformation",PX-302000077,CDM,86353,CPT,0302,RC,,,both,,,1470.60,441.18,"CIGNA [10200]","Cigna Open Access",,107.87,,,,,,,0.01,1250.01,"fee schedule",
"HC Bx Salivary Gland Ndl",PX-361000170,CDM,42400,CPT,0361,RC,,,both,,,2874.83,862.45,"CIGNA [10200]","Cigna Local Plus",,1965,,"Case rate ($1,965). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,334.34,2874.83,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 14CM TOUCH NARROW BASE",SUP-EN2914,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAUT 18IN 4.5FR 7.5FR CHOLANGIOGRAM SPRT TUBE MAXIMUM",SUP-20018-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,455.22,136.57,"CIGNA [10200]","Cigna Open Access",,259.02,56.9,,,,,0,52.94,386.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SYR TWIN PACK GEL PREFILL PREDYE 23GA ORISE INTERJECT 10",SUP-M00519211,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,187.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM 16MM NECK SECUR-FIT MAX HA 127D 13 53MM",SUP-6052-1340S,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9128.7,40,,,,,0,2654.17,19398.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X14MM CASCADIA 8D TITANIUM POROUS LATERAL",SUP-6101-2185514LL8-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LEAD 50CM 9FR 18GA WORLEY CSG BRAID CORE SHEATH GWIRE",SUP-WOR-CSG-B2-09,CDM,C1892,HCPCS,0272,RC,,,both,,,2730.00,819,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,323.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,317.5,2320.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Admin Hepatitis B Vacc",PX-771000006,CDM,G0010,HCPCS,0771,RC,,,both,,,159.60,47.88,"CIGNA [10200]","Cigna Local Plus",,85.39,53.5,,,,,0,18.56,159.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.6CM NATRELLE BIOCELL P3.5CM MODERATE PROFILE",SUP-MSZ10300,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,65.01,41.1,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 13.5X12.7CM 475CC MEMORYGEL COHESIVE III CPG 322",SUP-3341355,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"PHCS [10601]",PHCS,,6399.75,70,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ELECTROPHYSIOLOGY BLUE 92CM 6FR 10MM SPACE REGULAR",SUP-D6DR252CTR,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH BLUE 10FT CARTO 3 HYPERTONICS 34 PIN TO LEMO 10",SUP-CB3410CT,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"KAISER [10500]",Kaiser,,2256.23,67,,,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-207.016,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"BLUE CROSS [10001]","Blue Cross HMO",,107.26,39.2,,957.42,156.86,7483.26,51,31.82,232.58,"percent of total billed charges",
"SCR BONE 5MM 4.4MM 18MM TITANIUM T25 FULL THREAD SELF TAP",SUP-412.203,CDM,C1713,HCPCS,0278,RC,,,both,,,959.36,287.81,"CIGNA [10200]","Cigna Open Access",,545.88,56.9,,1144.80,304.56,2275.09,66,111.57,815.46,"percent of total billed charges",
"NDL INTRAOSSEOUS 45MM 15GA EZ-IO EZ-CONNECT NDL VISE",SUP-9079,CDM,S27200284,LOCAL,0272,RC,,,both,,,1106.46,331.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,454.76,41.1,,,,,0,128.68,940.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD REAMER 13.5MM RIA 2 STERILE",SUP-03.404.023S,CDM,S27200284,LOCAL,0272,RC,,,both,,,6005.07,1801.52,"CIGNA [10200]","Cigna Local Plus",,3212.71,53.5,,,,,0,698.39,5104.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE BIOPSY IVAS 10GA",SUP-0306-104-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,855.37,256.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,392.61,45.9,,,,,0,99.48,727.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPELLA RP PUMP SET",SUP-004334,CDM,S27800098,LOCAL,0278,RC,,,both,,,142500.00,42750,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,58567.5,41.1,,,,,0,16572.75,121125,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTABLATOR ROTALINK PLUS 135CM .58IN 1.75MM ATHERECTOMY",SUP-H749236310040,CDM,C1724,HCPCS,0272,RC,,,both,,,8534.13,2560.24,"NOVANET [10819]",Novanet,,6400.6,75,,,,,0,992.52,7254.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alignment Wedge Body",PX-E27000039,CDM,E27000039,LOCAL,0270,RC,,,both,,,56.10,16.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,25.75,45.9,,,,,0,6.52,47.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +15.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1550,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER MENDER II MENISCAL REPAIR SET SUT STERILE DISPOSABLE",SUP-7209485,CDM,S27200284,LOCAL,0272,RC,,,both,,,1148.18,344.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,136.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,133.53,975.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 4-0 RB-1 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J214H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CURET 3MM 2MM 35D 5.5IN HOUGH SERRATE SURGICAL",SUP-61-0348,CDM,S27200284,LOCAL,0272,RC,,,both,,,570.08,171.02,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH FLOWGUARD 14CM 14FR HEMODIALYSIS PEEL AWAY VALVE",SUP-DCVP1400,CDM,C1892,HCPCS,0272,RC,,,both,,,261.00,78.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.25MM X 18.0MM",SUP-492251812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TORCON NB ADVANTAGE BEACON TIP 100CM 5FR .035IN C1",SUP-G08623,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL IRRIG WATER STRL 1000-MSO",SUP-2F7114,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ENROUTE TRANSCAROTID NEUROPROTECTION SYSTEM PLUS",SUP-SR-250-NPS,CDM,C1884,HCPCS,0272,RC,,,both,,,23530.50,7059.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"COVATOR 20",SUP-AC4340-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1764.00,529.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Rv Fem/Pop W Pta Cmplx Ea Add",PX-361000707,CDM,37266,CPT,0361,RC,,,both,,,7348.26,2204.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7348.26,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,7.35,7348.26,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tavi/Tavr Transapical Exposure",PX-361000348,CDM,33366,CPT,0361,RC,,,both,,,45298.00,13589.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5367.81,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2491,38503.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION WATER 250ML PLASTIC POUR BOTTLE STERILE",SUP-2F7112,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5INX8MM OSTEOTOM LONG MRI STERILE LATEX FREE",SUP-47998602127,CDM,S27200284,LOCAL,0272,RC,,,both,,,996.30,298.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,677.48,68,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 35MM 25MM AEQUALIS 2MM LATERAL OFFSET STD",SUP-DWE735,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"CIGNA [10200]",Cigna,,6421.24,68,,5873.17,5873.17,5873.17,"1 through 10",1098.22,8026.55,"percent of total billed charges",
"BIT DRILL 130MM 4.2MM T2 AO COUPLING CENTER TIPPED",SUP-18064280S,CDM,S27000186,LOCAL,0270,RC,,,both,,,147.00,44.1,"CIGNA [10200]",Cigna,,99.96,68,,,,,0,17.1,124.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 4.75MM SOLERA COCR MOLYBDENUM CURVED",SUP-1475501120,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"GRAFT SOFT TISSUE 2X3CM GRAFIX PRIME ALLOGRAFT",SUP-PS11023,CDM,Q4133,HCPCS,0636,RC,,,both,,,6865.50,2059.65,"CIGNA [10200]","Cigna Open Access",,373.04,,,,,,,373.04,5835.68,"fee schedule",
"DRSG WOUND 2X2IN CUTIMED EPIONA 90% NATIVE CLLGN 10%",SUP-7322700,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.60,26.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.42,76.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 15MM 140CM 2.75MM 2.1-2.7FR CORONARY",SUP-RONYX27515UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,9776.84,9776.84,9776.84,"1 through 10",434.96,3179,"percent of total billed charges",
"CATH EVERCROSS BEVEL 360 80CM 60MM 10MM .035IN BALLOON",SUP-AB35W10060080,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,460.47,68,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 75MM KNEE LEFT CRUCIATE RETAIN CEMENT PRIMARY",SUP-183034,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5423.13,27,,,,,0,2335.96,17072.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 260X17.5X5.2MM STAINLESS STEEL 4.5MM CORTICAL",SUP-226.641,CDM,C1713,HCPCS,0278,RC,,,both,,,4175.05,1252.51,"CIGNA [10200]","Cigna Open Access",,2375.6,56.9,,1144.80,304.56,2275.09,66,485.56,3548.79,"percent of total billed charges",
"INTRODUCER FR9 OSCOR",SUP-6092,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 20MM SAPIEN 3 COMMANDER EDWARDS TRANSCATHETER",SUP-S3UCM220A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"AETNA [10100]","Aetna HMO/PPO",,147273.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 6 X 10 HELICAL FILLING COIL",SUP-10HFL-06010,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"CIGNA [10200]","Cigna Open Access",,5100,56.9,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECTRUM LOPRO S4 DISPOSABLE BLADES",SUP-0270-1079,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,143.03,41.1,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 49MM 28MM TANDEM HIP ACETABULAR COCR",SUP-71322049,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"KAISER [10500]",Kaiser,,5596.14,67,,,,,0,971.39,7099.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 280CC P3.3CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-280,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PHCS [10601]",PHCS,,5288.85,70,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CROSSTELLA 90CM 60MM 4-3.4FR 5MM BALLOON DILATATION",SUP-BD-F50060MR,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1018.98,68,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 11CM GWIRE AVANTI+ .035IN",SUP-402608X,CDM,C1894,HCPCS,0272,RC,,,both,,,50.03,15.01,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,20.56,41.1,,,,,0,5.82,42.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 66MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732066,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"PHCS [10601]",PHCS,,11352.92,70,,,,,0,1886.21,13785.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 9MM 9FR ENDOPROSTHESIS HEPARIN ILIAC",SUP-VBH090502,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 8MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-008,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"MULTIPLAN [10600]",Multiplan,,18063.18,85,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC LARGE LONG 21-23.5IN KNEE WRAP AROUND FLEX",SUP-14012007,CDM,S27000186,LOCAL,0270,RC,,,both,,,737.59,221.28,"UHC [10700]","United Healthcare",,466.89,63.3,,,,,0,85.78,626.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 240MM 17MM REVISION MONOLITHIC REDAPT ROCKTITE",SUP-71354706,CDM,C1776,HCPCS,0278,RC,,,both,,,51237.90,15371.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13834.23,27,,,,,0,5958.97,43552.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 8MM 2.25MM BALLOON DILATATION STERILE",SUP-222-083-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UHC [10700]","United Healthcare",,512.73,63.3,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 4.8MM TITANIUM LINEAR CUTTER DLU HELICAL",SUP-174023,CDM,S27200284,LOCAL,0272,RC,,,both,,,1154.09,346.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,136.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,134.22,980.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM IODIDE-131 (I-131) THERAPEUTIC CAPSULE",RX-411534,CDM,A9517,HCPCS,0344,RC,08888-8878-66,NDC,both,1,UN,103.36,31.01,"FIRST HEALTH [10303]","First Health",,82.69,80,,,,,0,12.02,87.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 2MM FACET SHIM",SUP-609002,CDM,S27800098,LOCAL,0278,RC,,,both,,,2887.50,866.25,"FIRST HEALTH [10303]","First Health",,2310,80,,,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X10MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7110,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"BLUE CROSS [10001]","Blue Cross HMO",,2704.8,39.2,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 10 10MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151621010,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Local Plus",,6020.84,53.5,,5372.07,4581.20,7242.98,23,1308.83,9565.82,"percent of total billed charges",
"HC Microbe Suscept Macrobroth",PX-306000217,CDM,87188,CPT,0306,RC,,,both,,,199.00,59.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5.98,,,,,,,0.01,169.15,"fee schedule",
"HC Microbe Suscept Macrobroth",PX-306000217,CDM,87188,CPT,0306,RC,,,both,,,199.00,59.7,"BLUE CROSS [10001]","Blue Cross PPO",,8.48,,"Fee schedule rate ($8.48).",,,,0,0.01,169.15,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUMP INFUSION 34MM INTERA 3000 HEPATIC ARTERY HIGH FLOW 30ML",SUP-AP03000H,CDM,C1891,HCPCS,0278,RC,,,both,,,82023.00,24606.9,"CIGNA [10200]","Cigna Open Access",,27477.71,33.5,,,,,0,9539.27,69719.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION",RX-97343,CDM,J3030,HCPCS,0637,RC,55150-0173-01,NDC,both,.5,ML,99.66,29.9,"AETNA [10100]","Aetna HMO/PPO",,79.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.59,89.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM SUMMIT POROCOAT 10 12/14 STD OFFSET TAPER",SUP-157001180,CDM,C1776,HCPCS,0278,RC,,,both,,,25247.25,7574.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10376.62,41.1,,6417.48,6417.48,6417.48,"1 through 10",2936.26,21460.16,"percent of total billed charges",
"STENT ZIPWIRE 24CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175272190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"MULTIPLAN [10600]",Multiplan,,1075.57,85,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 34CM HIP LEFT FEMUR AFFIXUS INTRAMEDULLARY 130D",SUP-814611340,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"CIGNA [10200]","Cigna Open Access",,6948.82,33.5,,1144.80,304.56,2275.09,66,2412.38,17631.34,"percent of total billed charges",
"SYSTEM FIBERTAK SPEEDBRIDGE SWIVELOCK SUTURETAPE IMPL SELF",SUP-AR-2600FSB-1,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"LENS IOL +18 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0180,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,523.91,39.2,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8MM 40MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712840,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,3978.14,359.25,3978.14,24,441.36,3225.75,"percent of total billed charges",
"STENT INNOVA 150MM 130CM 8MM VASCULAR SELF EXPAND RADIOPAQUE",SUP-H74939293081530,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ORTHOPEDIC 11MM",SUP-AR-1288QAI-110,CDM,C1713,HCPCS,0278,RC,,,both,,,19785.15,5935.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2344.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,2301.01,16817.38,"percent of total billed charges",
"HC Tte Cong W Contr Cmplt",PX-483000019,CDM,C8923,HCPCS,0480,RC,,,both,,,2274.00,682.2,"NOVANET [10819]",Novanet,,1705.5,75,,,,,0,264.47,2274,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.165 CLAREON",SUP-SY60WF.165,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Gtt Add Specimens",PX-301000209,CDM,82952,CPT,0301,RC,,,both,,,89.30,26.79,"KAISER [10500]",Kaiser,,59.83,67,,,,,0,0.01,75.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AXLE TIBIAL OSS KNEE LOW FRICTION INTERFACE",SUP-150480,CDM,C1776,HCPCS,0278,RC,,,both,,,3690.00,1107,"CIGNA [10200]",Cigna,,2509.2,68,,5873.17,5873.17,5873.17,"1 through 10",429.15,3136.5,"percent of total billed charges",
"LENS IOL 0 D +14.5 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SND1T4,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA [10200]",Cigna,,506.6,68,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAX BONE 2.5GM ABSORBABLE HEMOSTATIC AGENT",SUP-W31G,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.22,15.97,"CIGNA [10200]","Cigna Open Access",,30.28,56.9,,,,,0,6.19,45.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 62MM LCP STAINLESS STEEL CORTICAL PERIARTICULAR",SUP-02.204.062,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,452.84,45.9,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X80 135CM SL",SUP-48006008R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,584.13,68,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR HD 46CM 11-13FR ACCESS STAINLESS STEEL",SUP-M0062502230,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"MULTIPLAN [10600]",Multiplan,,833.57,85,,,,,0,114.05,833.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 62MM NAIL-EX TITANIUM FEMORAL TIBIAL LOCKING",SUP-04.005.552,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,134.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",134.52,983.18,"percent of total billed charges",
"DISPOSABLE POLYPECTOMY COLD SNARES OUTER DIAMETER 2.4MM WORK",SUP-G61204,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,85.82,41.1,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 25CM 5FR ANGLE KUMPE CURVE ANGIOGRAPHIC",SUP-H787107327075,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,147.9,68,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR AR2 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916391862,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"AETNA [10100]","Aetna HMO/PPO",,60.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 12MM LOCKING",SUP-5201024012,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,204.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",200.62,1466.25,"percent of total billed charges",
"PORT IMPLANTABLE INFUSION MRI GROSHONG SEPTUM-FINDER",SUP-0605920,CDM,C1788,HCPCS,0278,RC,,,both,,,2250.00,675,"CIGNA [10200]","Cigna Local Plus",,1203.75,53.5,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 4-11 E-F KNEE RIGHT TIBIA",SUP-42522200510,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"MULTIPLAN [10600]",Multiplan,,9159.96,85,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 24MM TARGET XL 360D STD LARGE",SUP-M0036102450,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50MM 32MM 10MM THORAX WOVEN HEMOSTASIS",SUP-M00202175832P0,CDM,C1768,HCPCS,0278,RC,,,both,,,9138.43,2741.53,"AETNA [10100]","Aetna HMO/PPO",,7265.05,79.5,,,,,0,1062.8,7767.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 10MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710710,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"BLUE CROSS [10001]","Blue Cross HMO",,5799.09,39.2,,5311.50,4717.44,5388.59,31,1720.5,12574.56,"percent of total billed charges",
"PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION",RX-186564,CDM,,,0250,RC,00264-4500-00,NDC,both,1000,ML,241.44,72.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,164.18,68,,,,,0,28.08,205.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Candida Species Direct Probe",PX-306000120,CDM,87480,CPT,0306,RC,,,both,,,607.05,182.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.61,.1,,,,,0,0.61,515.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 5MMX39MM 7FR 80CMCATH HEPARIN",SUP-BXB053901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"MULTIPLAN [10600]",Multiplan,,16579.08,85,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175272190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,362.15,28.62,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM",SUP-AR-4160-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,187.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR AVENIR COMPLETE 3 HIP STERILE LATEX FREE",SUP-574203030,CDM,C1776,HCPCS,0278,RC,,,both,,,23461.20,7038.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2780.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2728.54,19942.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLCHICINE 0.6 MG TABLET",RX-1821,CDM,,,0637,RC,50268-0187-11,NDC,both,1,UN,27.21,8.16,"MULTIPLAN [10600]",Multiplan,,23.13,85,,,,,0,3.16,23.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRENCH SURGICAL HEXAGON",SUP-SC-4275,CDM,S27000186,LOCAL,0270,RC,,,both,,,217.50,65.25,"CIGNA [10200]","Cigna Open Access",,123.76,56.9,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH XXL 75CM 60MM 5.8FR 14MM .035IN BALLOON DILATATION",SUP-M001145320,CDM,C1725,HCPCS,0272,RC,,,both,,,1709.63,512.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1162.55,68,,,,,0,198.83,1453.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Trach Cuffed Fenestrated",PX-E27200229,CDM,E27200229,LOCAL,0272,RC,,,both,,,311.43,93.43,"NOVANET [10819]",Novanet,,233.57,75,,,,,0,36.22,264.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.9MM X 350MM TRILOGY PROBE KIT",SUP-M0068403540,CDM,S27200284,LOCAL,0272,RC,,,both,,,5531.45,1659.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,655.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,643.31,4701.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 110MM PRIMARY CEMENT DISTAL BULLET TIP SYNERGY",SUP-71316209,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8738.89,41.1,,6417.48,6417.48,6417.48,"1 through 10",2472.83,18073.13,"percent of total billed charges",
"PLATE STRAIGHT FUSION ORTHOLOC 3DI BONE MIDFOOT",SUP-58180000,CDM,C1713,HCPCS,0278,RC,,,both,,,8618.10,2585.43,"FIRST HEALTH [10303]","First Health",,6894.48,80,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -2.5 28MM HIP C TAPER COCR LFIT ION TREATMENT",SUP-06-2898,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"MULTIPLAN [10600]",Multiplan,,2658.55,85,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.5MM X 15.0MM",SUP-493501512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 5CM 7FR .035IN GENTLE CURVE BILIARY",SUP-G21681,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,180.82,28.62,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (MR) 15MM X 2.50",SUP-H74939401152500,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MARKER OPHTHALMIC 4MM 4.5MM OSHER-NEUMANN CORNEAL 8 LINE",SUP-E9022,CDM,S27200284,LOCAL,0272,RC,,,both,,,1767.08,530.12,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OBTR ENDOSCOPIC 24FR RESECTOSCOPY DEFLECTABLE TIP",SUP-A22085A,CDM,S27200284,LOCAL,0272,RC,,,both,,,4234.67,1270.4,"FIRST HEALTH [10303]","First Health",,3387.74,80,,,,,0,492.49,3599.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805210,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"KAISER [10500]",Kaiser,,604.46,67,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 320MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.153S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"UHC [10700]","United Healthcare",,7860.81,63.3,,5023.51,2672.93,6679.78,18,1444.25,10555.59,"percent of total billed charges",
"SYSTEM ELUNIR THK90UM 15MM 140CM 3.5MM CORONARY STENT",SUP-LUN350R15US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 152MM 16MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-104160,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2868.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2814.85,20572.84,"percent of total billed charges",
"SPACER ALLOGRAFT 26X7MM 9/11MM SPINE CORTICAL FREEZE DRIED",SUP-14907,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"NOVANET [10819]",Novanet,,12420,75,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 12CM 180CM 20MM 10.5FR ESOPHAGEAL FULL",SUP-G57349,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2084.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +1.5MM 12/14 TAPER 40MM HIP TOTAL STABILIZE",SUP-136540710,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"CIGNA [10200]",Cigna,,6001.62,40,,5873.17,5873.17,5873.17,"1 through 10",1744.97,12753.44,"percent of total billed charges",
"LENS IOL +20.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.205,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE/SLEEVE ORTHOPEDIC 1.6MM DALL-MILES VITALLIUM SET",SUP-6704-0-410,CDM,C1713,HCPCS,0278,RC,,,both,,,1497.42,449.23,"BLUE CROSS [10001]","Blue Cross HMO",,586.99,39.2,,957.42,156.86,7483.26,51,174.15,1272.81,"percent of total billed charges",
"FLUDROCORTISONE 0.1 MG TABLET",RX-10054,CDM,,,0637,RC,50268-0330-11,NDC,both,1,UN,8.04,2.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3.3,41.1,,,,,0,0.94,6.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +16 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.160,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR STD AMPLATZ LEFT CORONARY",SUP-534545T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"MULTIPLAN [10600]",Multiplan,,79.5,85,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE BURR HOLE .5MM 18.5MM LORENZ CRANIOMAXILLOFACIAL",SUP-017306,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.70,405.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,387.14,28.62,,,,,0,157.32,1149.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 7FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145371010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"FIRST HEALTH [10303]","First Health",,773.52,80,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE HA 25MM 8MM ACL BIOSURE",SUP-72201776,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"CUFF TRNQT CYL 34X4IN 2 PORT TUBING LIMB PROTECTION SLEEVE",SUP-5921-034-235,CDM,S27200284,LOCAL,0272,RC,,,both,,,215.15,64.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.02,182.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 115MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.445,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.21,68,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 10 KNEE RIGHT CRUCIATE RETAIN CEMENT ATTUNE",SUP-150400209,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"BLUE CROSS [10001]","Blue Cross HMO",,8778.19,39.2,,5311.50,4717.44,5388.59,31,2604.35,19034.35,"percent of total billed charges",
"CATH SABER 150CM 40MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020040M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"FIRST HEALTH [10303]","First Health",,1146.96,80,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 300MM 6MM BALLOON DILATATION DURALYN",SUP-48006030S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -4MM 40MM HIP PRIMARY COCR V40 LFIT",SUP-6260-9-040,CDM,C1776,HCPCS,0278,RC,,,both,,,6224.40,1867.32,"MULTIPLAN [10600]",Multiplan,,5290.74,85,,,,,0,723.9,5290.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT GPS SMALL 4 CC PUTTY BIOACT",SUP-76000040,CDM,C1713,HCPCS,0278,RC,,,both,,,6624.00,1987.2,"BLUE CROSS [10001]","Blue Cross HMO",,2596.61,39.2,,957.42,156.86,7483.26,51,770.37,5630.4,"percent of total billed charges",
"INSRT TIBIAL LARGE 12.5MM KNEE POLYETHYLENE STABILIZE ROTATE",SUP-129416612,CDM,C1776,HCPCS,0278,RC,,,both,,,12447.60,3734.28,"UHC [10700]","United Healthcare",,7879.33,63.3,,8601.07,8395.67,8601.07,"1 through 10",1447.66,10580.46,"percent of total billed charges",
"DEVICE SPEEDSTITCH SUTURING CASSETTE NDL STERILE DISPOSABLE",SUP-OM8850,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 34MM REGENEREX KNEE STERILE LATEX FREE",SUP-141357,CDM,C1776,HCPCS,0278,RC,,,both,,,7410.60,2223.18,"PHCS [10601]",PHCS,,5187.42,70,,,,,0,861.85,6299.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 92CM 1MM 6FR 2MM SPACE D CURVE",SUP-D610DR002RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"NOVANET [10819]",Novanet,,2795.63,75,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) INNOVALVE TRANSSEPTAL DELIVERY SYSTEM FOR TMVR TRANSC",SUP-PRO-17320,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 15MM AVENIR 10 COIL STERILE LATEX",SUP-10CFR15030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PHCS [10601]",PHCS,,8206.17,70,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL EQUINOXE +0MM ADPTR +0MM STERILE LATEX FREE",SUP-322-10-00,CDM,C1776,HCPCS,0278,RC,,,both,,,10695.00,3208.5,"PHCS [10601]",PHCS,,7486.5,70,,,,,0,1243.83,9090.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM MEDIUM NECK 32MM BIOLOX DELTA",SUP-PHA04410,CDM,C1776,HCPCS,0278,RC,,,both,,,14234.70,4270.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5850.46,41.1,,6417.48,6417.48,6417.48,"1 through 10",1655.5,12099.5,"percent of total billed charges",
"CATH SAPPHIRE NC PLUS 15MM 2.5MM BALLOON DILATATION STERILE",SUP-225-153-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 90CM 4MM 8FR 2-5-2MM SPACE D CURVE",SUP-D8BRDL252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,5326.80,1598.04,"KAISER [10500]",Kaiser,,3568.96,67,,,,,0,619.51,4527.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC",064,MS-DRG,,,,,,,inpatient,,,42920.19,12876.06,"CIGNA [10200]","Cigna Local Plus",,20751.51,,"Fee schedule rate ($20,751.51). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,42920.19,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 23MM CEMENTLESS TOTAL STABILIZE PRESSFIT",SUP-5565-S-023,CDM,C1776,HCPCS,0278,RC,,,both,,,7048.35,2114.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,835.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,819.72,5991.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Spirometry Breathing Capacity",PX-460000001,CDM,94010,CPT,0460,RC,,,both,,,630.76,189.23,"MULTIPLAN [10600]",Multiplan,,536.15,85,,,,,0,73.36,536.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit Level 4 W Proc",PX-450000318,CDM,99284,CPT,0450,RC,,,both,,,2129.58,638.87,"NOVANET [10819]",Novanet,,1597.19,75,,,,,0,419.55,2129.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 94MM 20FR ZENITH ABDOMINAL AORTIC",SUP-G32532,CDM,C1874,HCPCS,0278,RC,,,both,,,62551.57,18765.47,"NOVANET [10819]",Novanet,,46913.68,75,,,,,0,7274.75,53168.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 17MM 14.8MM MASTERS HP MECHANICAL ROTATABLE STD",SUP-17MHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"NOVANET [10819]",Novanet,,21839.42,75,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL SMALL+ KNEE RIGHT CEMENT LCS COMPLETE COCR",SUP-129401020,CDM,C1776,HCPCS,0278,RC,,,both,,,20635.65,6190.69,"FIRST HEALTH [10303]","First Health",,16508.52,80,,,,,0,2399.93,17540.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM LCP STAINLESS STEEL CORTICAL FOREFOOT",SUP-202.876,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"CIGNA [10200]","Cigna Open Access",,184.35,56.9,,1144.80,304.56,2275.09,66,37.68,275.39,"percent of total billed charges",
"CATH MUSTANG 135CM 20MM 7MM .035IN BALLOON DILATATION NYBAX",SUP-39171-07021,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 36IN 12FR ANTICLOG BOW TIP BOLUS NONWEIGHT",SUP-40-1362,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.74,20.02,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,30.63,45.9,,,,,0,7.76,56.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 8X4CM ACTISHIELD AMNIOTIC BARR MEMB",SUP-AM204X08,CDM,V2790,HCPCS,0278,RC,,,both,,,18729.90,5618.97,"FIRST HEALTH [10303]","First Health",,14983.92,80,,,,,0,2178.29,15920.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDAPAMIDE 2.5 MG TABLET",RX-3879,CDM,,,0637,RC,62559-0511-01,NDC,both,1,UN,7.79,2.34,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3.2,41.1,,,,,0,0.91,6.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 26CM 3CM 5FR .038IN STRAIGHT URETERAL",SUP-M006155223010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM STAINLESS STEEL T15 CORTEX SELF TAP LOW",SUP-02.206.228S,CDM,C1713,HCPCS,0278,RC,,,both,,,725.76,217.73,"MULTIPLAN [10600]",Multiplan,,616.9,85,,,,,0,84.41,616.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL LOCK HOLE COMPRESSION SLOT PRECONTOUR",SUP-AR-2652CR,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION .5CM HILAL EMBOLIZATION MICROCOILS",SUP-G04524,CDM,S27800098,LOCAL,0278,RC,,,both,,,675.14,202.54,"BLUE CROSS [10001]","Blue Cross PPO",,264.65,39.2,,,,,0,78.52,573.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT PRO+ 34MM",SUP-EVPROPLUS-34US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS [10001]","Blue Cross PPO",,67032,39.2,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Lwr Ext WO Cntrst",PX-359000004,CDM,73700,CPT,0352,RC,,,both,,,2107.53,632.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,249.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,245.11,1933,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egfr Mutation by Pcr",PX-309000113,CDM,81235,CPT,0310,RC,,,both,,,5614.70,1684.41,"KAISER [10500]",Kaiser,,3761.85,67,,,,,0,0.01,4772.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 5MM FRMLA AUGER STRAIGHT SERIES F REPROCESSED",SUP-0375450500,CDM,S27200284,LOCAL,0272,RC,,,both,,,633.66,190.1,"MULTIPLAN [10600]",Multiplan,,538.61,85,,,,,0,73.69,538.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SHORT 72MM STAINLESS STEEL 2.7/3.5MM SCR 1 HOLE",SUP-02.117.601,CDM,C1713,HCPCS,0278,RC,,,both,,,6541.75,1962.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,760.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",760.81,5560.49,"percent of total billed charges",
"ANCHOR SUT 4.5MM POPLOK SUBCORTICAL WING",SUP-CKP-4500,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"NOVANET [10819]",Novanet,,2805,75,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN AL1 CURVE ANGIOGRAPHIC",SUP-H74908641962,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,35.15,45.9,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KETOCONAZOLE 2 % TOPICAL CREAM",RX-10368,CDM,,,0250,RC,00168-0099-15,NDC,both,15,GR,194.36,58.31,"FIRST HEALTH [10303]","First Health",,155.49,80,,,,,0,22.6,165.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL GOLD 13.5MM SYNFIX 18D MEDIUM EVOLUTION 5.4MM",SUP-08.815.263S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]",Cigna,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ULTRABUTTON FIXATION ADJUSTABLE LOOP REDUCTION",SUP-72290003,CDM,C1713,HCPCS,0278,RC,,,both,,,3543.75,1063.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,419.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,412.14,3012.19,"percent of total billed charges",
"SHELL ACETABULAR 64MM HIP 5 SCR HOLE CLUSTER METAL HA",SUP-502-11-64H,CDM,C1776,HCPCS,0278,RC,,,both,,,9525.45,2857.63,"CIGNA [10200]","Cigna Local Plus",,5096.12,53.5,,5372.07,4581.20,7242.98,23,1107.81,8096.63,"percent of total billed charges",
"STPLR INTERNAL 26CMX4MM UNIVERSAL VASCULAR XTHICK TISSUE",SUP-EGIAUXL,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 FS-1 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8684G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR ACCEPTS .035IN GWIRE 7FR 20CM RADIOPAQUE",SUP-G00892,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22.64,45.9,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOUNDSTAR 10FR ULTRASOUND INTRACARDIAC STEERING HANDLE",SUP-10439072R,CDM,C1759,HCPCS,0272,RC,,,both,,,7590.00,2277,"UHC [10700]","United Healthcare",,4804.47,63.3,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X-CORE MINI CORE, %C3%9812MM 17-24MM",SUP-5962172,CDM,S27800098,LOCAL,0278,RC,,,both,,,27720.00,8316,"CIGNA [10200]","Cigna Open Access",,9286.2,33.5,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 310CC",SUP-SSZ-M310,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"KAISER [10500]",Kaiser,,998.57,67,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DROXIDOPA 100 MG CAPSULE",RX-167748,CDM,,,0250,RC,31722-0014-90,NDC,both,1,UN,139.02,41.71,"NOVANET [10819]",Novanet,,104.27,75,,,,,0,16.17,118.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE AMS 700 LGX MS PUMP 18CM INFLATABLE PRECONNECT",SUP-72404252,CDM,C1813,HCPCS,0278,RC,,,both,,,78517.50,23555.25,"UHC [10700]","United Healthcare",,49701.58,63.3,,,,,0,9131.59,66739.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nerve Teasing Preparations",PX-312000070,CDM,88362,CPT,0312,RC,,,both,,,1001.00,300.3,"CIGNA [10200]","Cigna Open Access",,266.79,,,,,,,0.01,850.85,"fee schedule",
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET HOUSING POS",SUP-AR-1204AF-70,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"PHCS [10601]",PHCS,,1791.57,70,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 8MM KIT EMG",SUP-2010480,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,204.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 30MM 5MM DECADE SMALL THREAD PLATE EXTREME",SUP-7145030,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"NOVANET [10819]",Novanet,,1215,75,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET",RX-39255,CDM,J0750,HCPCS,0636,RC,00904-7172-07,NDC,both,1,UN,11.75,3.52,"MULTIPLAN [10600]",Multiplan,,9.99,85,,,,,0,1.39,9.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRAOCULAR PROCEDURES EXCEPT ORBIT",115,MS-DRG,,,,,,,inpatient,,,74074.89,22222.47,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 3-0 RB-1 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-U204H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MODERATE",165,APR-DRG,,,,,,,inpatient,,,300154.20,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $25,285.09. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($91,028.23) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IV VIAFLEX 20 MEQ POTASSIUM CHLORIDE 5% DEXTROSE 0.2%",SUP-2B1614X,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.24,23.47,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CXI 150CM 2.3FR SPRT STAINLESS STEEL HYDROPHILIC",SUP-G18373,CDM,S27200284,LOCAL,0272,RC,,,both,,,1522.72,456.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND 4-0 18IN BRAID TIE 12 STRAND PRECUT",SUP-A183H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PIN FIXATION 1.4MM ORTHOLOC TEMPORARY",SUP-5882000014,CDM,C1713,HCPCS,0278,RC,,,both,,,785.70,235.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,224.87,28.62,,,,,0,91.38,667.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEDICAL BACK PROBLEMS WITHOUT MCC",552,MS-DRG,,,,,,,inpatient,,,28175.88,8452.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,15326.71,,,,,,,5963.01,23973.86,"case rate",
"TRAY TIBIAL 87MM ASCENT MAXIM KNEE INTERLOK COCR 1 PIECE",SUP-141237,CDM,C1776,HCPCS,0278,RC,,,both,,,11379.48,3413.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3256.81,28.62,,,,,0,1323.43,9672.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 75CM 8.6FR CARDIAC 2 DEFIBRILLATION COIL ACTIVE",SUP-6947-75,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"MULTIPLAN [10600]",Multiplan,,14596.2,85,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 60MM STEALTH 3 LATIS STERILE LATEX FREE",SUP-A0C03,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"UHC [10700]","United Healthcare",,143.18,63.3,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE MEDIUM FEMALE",SUP-100612-030,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.99,17.7,"KAISER [10500]",Kaiser,,39.52,67,,,,,0,6.86,50.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,inpatient,,,29665.36,8899.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6233.72,,"Fee schedule rate ($6,233.72). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,4286.94,17235.34,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM ATTUNE 7 KNEE POSTERIOR CEMENT REVISION",SUP-1549-07-002,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4128.96,68,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 4MM 8 FLUTE HIP LENGTH ROUND RETRACTABLE",SUP-AR-6400RRBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.01,257.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,101.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD ONFLEX SORBAFLEX 6.2X4IN INGUINAL POCKET",SUP-0115611,CDM,C1781,HCPCS,0278,RC,,,both,,,2212.50,663.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,262.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 32MM HIP BIOLOX DELTA BIOLOX OPTION G7",SUP-6501056,CDM,C1776,HCPCS,0278,RC,,,both,,,13896.60,4168.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1646.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1616.17,11812.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 12CM 5FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552120,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS [10001]","Blue Cross PPO",,470.63,39.2,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 3MM X 8CM",SUP-M0035473080,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"UHC [10700]","United Healthcare",,8934.57,63.3,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 3.5CM 14FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-14-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,90.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G211,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"BLUE CROSS [10001]","Blue Cross PPO",,3671.5,39.2,,3949.44,3949.44,3949.44,"1 through 10",1089.28,7961.17,"percent of total billed charges",
"HC Rpr Wnd Surgical Secndry",PX-510000045,CDM,13160,CPT,0761,RC,,,both,,,14163.00,4248.9,"UHC [10700]","United Healthcare",,8965.18,63.3,,,,,0,1647.16,12038.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vrtplsty Augment Perc Thor Lumb Add",PX-361000380,CDM,22515,CPT,0361,RC,,,both,,,12753.00,3825.9,"FIRST HEALTH [10303]","First Health",,10202.4,80,,,,,0,1249,12753,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE MONORAIL 150CM 100MM 3MM BALLOON DILATATION",SUP-H74939185301010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 25CM 8.5FR PIGTAIL CURVE DRNG POLYURETHANE",SUP-RLC-8-038MB,CDM,C1729,HCPCS,0272,RC,,,both,,,537.19,161.16,"UHC [10700]","United Healthcare",,340.04,63.3,,,,,0,62.48,456.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Nephrostomy Tube W Fl",PX-361000219,CDM,50389,CPT,0361,RC,,,both,,,1947.47,584.24,"BLUE CROSS [10001]","Blue Cross PPO",,1947.47,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,226.49,1947.47,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mech Thromb Prim Artl Add",PX-361000132,CDM,37185,CPT,0361,RC,,,both,,,5304.87,1591.46,"FIRST HEALTH [10303]","First Health",,4243.9,80,,,,,0,616.96,5304.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 6FR .07IN KIESZ RIGHT 4 HORIZONTAL CURVE GUIDING",SUP-H749389696520,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 54MM 28MM XLPE HIP",SUP-71337554,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"CIGNA [10200]","Cigna Local Plus",,5963.62,53.5,,5372.07,4581.20,7242.98,23,1296.39,9474.91,"percent of total billed charges",
"HC Chromium Serum",PX-301000151,CDM,82495,CPT,0301,RC,,,both,,,379.05,113.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18.25,,,,,,,0.38,322.19,"fee schedule",
"CATH LAUNCHER 100CM 7FR SL5ST CURVE GUIDING CORONARY",SUP-LA7SL50,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 5.5MM CD HORIZON LEGACY TITANIUM PREBENT",SUP-8690030,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",512.88,3748.5,"percent of total billed charges",
"HC Francisella Tularensis Ab",PX-302000131,CDM,86668,CPT,0302,RC,,,both,,,499.00,149.7,"MULTIPLAN [10600]",Multiplan,,424.15,85,,,,,0,0.5,424.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM MASTER-SERIES PYROLYTIC CARBON PTFE",SUP-27AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"UHC [10700]","United Healthcare",,18432.47,63.3,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM 88MM STAINLESS STEEL 2.7/3.5MM SCR 4 HOLE TAPER",SUP-02.117.204S,CDM,C1713,HCPCS,0278,RC,,,both,,,6974.52,2092.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3201.3,45.9,,,,,0,811.14,5928.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 26FR CUT OLYMPUS OES",SUP-M0068802341,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,55.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 12MM 6FR 3.5MM .07IN BALLOON",SUP-H7493918912350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 36MM X25 LOCK INTRAMEDULLARY NAIL",SUP-04.045.036S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUARD BURR LONG",SUP-137501100,CDM,S27000186,LOCAL,0270,RC,,,both,,,770.96,231.29,"NOVANET [10819]",Novanet,,578.22,75,,,,,0,89.66,655.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE L OBLIQUE LEFT 34MM STAINLESS STEEL 7MM SCR MINI",SUP-242.33,CDM,C1713,HCPCS,0278,RC,,,both,,,2072.70,621.81,"CIGNA [10200]","Cigna Local Plus",,1108.89,53.5,,3978.14,359.25,3978.14,24,241.06,1761.8,"percent of total billed charges",
"DRILL BIT ASSY, CARBIDE, HUDSON END, 5 MM, SINGLE USE",SUP-SBT004,CDM,S27000186,LOCAL,0270,RC,,,both,,,2212.50,663.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,262.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL HIP HEMIARTHROPLASTY (PARTIAL HIP CONSTRUCT)",SUP-CAP-LB-PH-1,CDM,C1776,HCPCS,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Local Plus",,3691.5,53.5,,5372.07,4581.20,7242.98,23,802.47,5865,"percent of total billed charges",
"INSRT TIBIAL 8 6MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710806,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1720.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 12MM PYRENESS SPINAL",SUP-201-90104,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2690.35,68,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1-2 9MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71934431,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"UHC [10700]","United Healthcare",,7704.62,63.3,,8601.07,8395.67,8601.07,"1 through 10",1415.56,10345.86,"percent of total billed charges",
"INSRT CLAMP 75MM FOGARTY",SUP-G-7555,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,103.83,45.9,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL MINI 2.75MM CANNULATED OPEN REPAIR .066IN",SUP-AR-7000-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,2756.25,826.87,"FIRST HEALTH [10303]","First Health",,2205,80,,,,,0,320.55,2342.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Dipyridamole 10 Mg",PX-636000007,CDM,J1245,HCPCS,0636,RC,,,both,,,73.70,22.11,"FIRST HEALTH [10303]","First Health",,58.96,80,,,,,0,1.15,62.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 150MM 4FR 2.5MM .018IN BALLOON",SUP-PCP025150130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT MASTERGRAFT MATRIX EXT BLOCK 10CC",SUP-7610310,CDM,C1713,HCPCS,0278,RC,,,both,,,7734.90,2320.47,"NOVANET [10819]",Novanet,,5801.18,75,,,,,0,899.57,6574.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET .330IN 102IN SET Y GRAVITY FLOW LARGE BORE 4 LEAD",SUP-2C4031,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.89,27.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,63.17,68,,,,,0,10.8,78.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-71422344,CDM,C1776,HCPCS,0278,RC,,,both,,,29720.25,8916.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12215.02,41.1,,6417.48,6417.48,6417.48,"1 through 10",3456.47,25262.21,"percent of total billed charges",
"HC Tmvi W/Pros Vlv Perc Approach",PX-480000070,CDM,0483T,CPT,0481,RC,,,both,,,48360.36,14508.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5624.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2491,41106.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tee Plc Only",PX-483000010,CDM,93313,CPT,0483,RC,,,both,,,2122.00,636.6,"CIGNA [10200]","Cigna Local Plus",,1135.27,53.5,,,,,0,246.79,1803.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ATLANTIS TITANIUM SPINAL SELF TAPPING",SUP-876-710,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC",828,MS-DRG,,,,,,,inpatient,,,97237.62,29171.29,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,10885.82,,"Case rate ($10,568.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,813.82, add-ons for qualifying new technology services are included. If operating cost exceeds $42,853.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,123.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,826.80. The transfer operating threshold is the transfer adjustment factor * $9,813.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $741.97. The transfer capital threshold is the transfer adjustment factor * $741.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,49744.14,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHOCKWAVE M5 60MM 110CM 4.5MM 7MM BALLOON DILATATION",SUP-M5PIVL4560,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"VANCOMYCIN 50 MG/ML ORAL SOLUTION",RX-11630,CDM,,,0250,RC,65628-0206-05,NDC,both,150,ML,1384.12,415.24,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRUGSORB ATR SHAM","SUP-DSS 202",CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT SURGICAL MINI ACCESS INTRO NDL TROCAR DIL STIFFENING",SUP-MAK-NV-004,CDM,C1894,HCPCS,0272,RC,,,both,,,592.84,177.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ARTHROSCOPIC 8MM TRANSPORT 4 5 6 POLYMER PROXIMAL",SUP-CAT00223,CDM,S27200284,LOCAL,0272,RC,,,both,,,743.90,223.17,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 5MM 40MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.530S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,428.41,28.62,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 43IN 10FR ANTICLOG RADIOPAQUE SMOOTH BOLUS",SUP-20-7431,CDM,S27200284,LOCAL,0272,RC,,,both,,,118.20,35.46,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP BIPOLAR 8IN SPETZLER-MALIS 1.5MM SLIM DISPOSABLE",SUP-6780-200-015,CDM,S27200284,LOCAL,0272,RC,,,both,,,3208.53,962.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT ENDOVASCULAR 58MM 32MM ZENITH LOW PROFILE MAIN BODY",SUP-G50993,CDM,C1874,HCPCS,0624,RC,,,both,,,6510.15,1953.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,757.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,757.13,5533.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 250MM 3.5MM BALLOON DILATATION",SUP-48003525S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,565.95,41.1,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK 4.5CM STD SEPTUM NASAL AIRWAY DRAWSTRING MEROCEL STERILE",SUP-440409,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.70,41.61,"CIGNA [10200]","Cigna Open Access",,78.92,56.9,,,,,0,16.13,117.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICROINTRODUCER 7CM 5FR MICROEZ STAINLESS STEEL GWIRE",SUP-0828950,CDM,C1894,HCPCS,0272,RC,,,both,,,455.54,136.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,53.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.98,387.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 10 SLOT RIGHT TI",SUP-PHPF-S10R,CDM,C1713,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Local Plus",,5953.5,31.5,,3978.14,359.25,3978.14,24,2198.07,16065,"percent of total billed charges",
"CATH SABER 150CM 200MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040200M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"PHCS [10601]",PHCS,,1312.5,70,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER SHEATH 10CM 6FR 22GA",SUP-506610P22G,CDM,C1894,HCPCS,0272,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Tube Obstruction W Fl",PX-750000107,CDM,49460,CPT,0750,RC,,,both,,,3168.00,950.4,"BLUE CROSS [10001]","Blue Cross PPO",,2740.57,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,368.44,3168,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PILLOW ABDUCTION 20.5X7.5IN FOAM XL SHOULDER WAIST STRAP",SUP-11640008,CDM,S27000186,LOCAL,0270,RC,,,both,,,307.28,92.18,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,126.29,41.1,,,,,0,35.74,261.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RAMROD CLASSIC 22CM 6FR KIDNEY BLADDER CURL URETERAL",SUP-5606022,CDM,C2617,HCPCS,0278,RC,,,both,,,692.15,207.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,470.66,68,,,,,0,80.5,588.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR ACETABULAR X3 TRITANIUM 40MM 6.5MM HIP CANCELLOUS DRIVE",SUP-2080-0040,CDM,C1713,HCPCS,0278,RC,,,both,,,632.74,189.82,"FIRST HEALTH [10303]","First Health",,506.19,80,,,,,0,73.59,537.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHOCKWAVE M5 60MM 110CM 3.5MM 7MM BALLOON DILATATION",SUP-M5PIVL3560,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"UHC [10700]","United Healthcare",,13758.26,63.3,,,,,0,2527.78,18474.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Chest 1v",PX-324000009,CDM,71045,CPT,0324,RC,,,both,,,318.27,95.48,"CIGNA [10200]",Cigna,,38.06,,,,,,,27.21,270.53,"fee schedule",
"HC Colonoscopy W Rmvl Hot Bx",PX-750000093,CDM,45384,CPT,0750,RC,,,both,,,4713.82,1414.15,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",3301.54,3301.54,3301.54,"1 through 10",548.22,4713.82,"fee schedule",
"SCR BONE 4MM 28MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.428,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 6FR STD JL4.5 CURVE GUIDING NYLON",SUP-LA6JL45A,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"UHC [10700]","United Healthcare",,231.3,63.3,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 45CM 4-7MM FLIXENE 2 SLIDER GDS TAPERED",SUP-25138,CDM,C1768,HCPCS,0278,RC,,,both,,,10206.27,3061.88,"PHCS [10601]",PHCS,,7144.39,70,,,,,0,1186.99,8675.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL IHF 1.4MM",SUP-DRLL-IHF-14,CDM,S27000186,LOCAL,0270,RC,,,both,,,996.30,298.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL SUT FIRST PASS STERILE",SUP-224036,CDM,S27200284,LOCAL,0272,RC,,,both,,,1523.61,457.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT STENT 20CM 8FR .038IN PIGTAIL CURVE TAPER URETER GLIDEX",SUP-M001245620,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEV TRQ TIP INTRO",SUP-4071,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RN Admit Visit",PX-551000001,CDM,G0299,HCPCS,0551,RC,,,outpatient,,,363.00,108.9,"MULTIPLAN [10600]",Multiplan,,308.55,85,,,,,0,243.21,308.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM TRIDENT TITANIUM HEMISPHERE CANCELLOUS",SUP-2030-6560-1,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,90.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,88.55,647.19,"percent of total billed charges",
"HC Trans Removal Perm Ldles Pace",PX-481000119,CDM,33275,CPT,0481,RC,,,both,,,6081.65,1824.49,"PHCS [10601]",PHCS,,4257.16,70,,,,,0,707.3,6081.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Sclp/Ax/Tr/Ext 12.6-20 Int",PX-450000034,CDM,12035,CPT,0450,RC,,,both,,,1979.00,593.7,"CIGNA [10200]","Cigna Open Access",,1534,,,,,,,1.98,1979,"case rate",
"HC Rpr Sclp/Ax/Tr/Ext 12.6-20 Int",PX-450000034,CDM,12035,CPT,0450,RC,,,both,,,1979.00,593.7,"BLUE CROSS [10001]","Blue Cross HMO",,1.98,.1,,,,,0,1.98,1979,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-166772,CDM,J7168,HCPCS,0636,RC,63833-0386-02,NDC,both,1,UN,7897.10,2369.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3837.99,48.6,,,,,0,7.9,6712.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Exome Sequence Analysis",PX-310000033,CDM,81415,CPT,0310,RC,,,both,,,5050.00,1515,"MULTIPLAN [10600]",Multiplan,,4292.5,85,,,,,0,5.05,5050,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Exome Sequence Analysis",PX-310000033,CDM,81415,CPT,0310,RC,,,both,,,5050.00,1515,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5050,,,,,,,5.05,5050,"fee schedule",
"BRACE ORTHOPEDIC SHORT UNIVERSAL 17IN 36- IN KNEE 2 AXIS",SUP-79-94230,CDM,S27000186,LOCAL,0270,RC,,,both,,,363.57,109.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,166.88,45.9,,,,,0,42.28,309.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER FEMORAL 10MM OMNIFIT UNIVERSAL DISTAL HIP CEMENTED",SUP-1067-0010,CDM,C1776,HCPCS,0278,RC,,,both,,,620.57,186.17,"CIGNA [10200]","Cigna Local Plus",,332,53.5,,5372.07,4581.20,7242.98,23,72.17,527.48,"percent of total billed charges",
"SPACER SPINAL 25MMX7MM CRESCENT PEEK-OPTIMA VERTEBRAL BODY",SUP-9392507,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6624,40,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 26MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1204.88,45.9,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 14MM 1MM CLEARVIEW INTRACORONARY BULB",SUP-31100,CDM,S27800098,LOCAL,0278,RC,,,both,,,632.53,189.76,"BLUE CROSS [10001]","Blue Cross HMO",,247.95,39.2,,,,,0,73.56,537.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTAPRO 135CM .58IN 2.5MM ATHERECTOMY PRECONNECT BURR",SUP-H749394672500,CDM,C1724,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"AETNA [10100]","Aetna HMO/PPO",,10696.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 48MM LOW PROFILE SCREWS STAINLESS STEEL FOOT",SUP-AR-8827-48,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",45.53,332.78,"percent of total billed charges",
"CATH DORADO CHECKER 120CM 4CM 5MM BALLOON DILATATION",SUP-DR12054,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"FIRST HEALTH [10303]","First Health",,1101.6,80,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablt Pulm Tumor Perc Cryo",PX-361000470,CDM,32994,CPT,0361,RC,,,both,,,9566.00,2869.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1112.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1112.53,9566,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR SKIN 4.1X6.5MM 35 WIDE STAPLE CRTDG LATEX FREE APPOSE",SUP-8886803712,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.55,1.36,"FIRST HEALTH [10303]","First Health",,3.64,80,,,,,0,0.53,3.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD BIPOLAR CELONPROBREATH STERILE LATEX FREE DISPOSABLE",SUP-WB990310,CDM,S27200284,LOCAL,0272,RC,,,both,,,1406.44,421.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,645.56,45.9,,,,,0,163.57,1195.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 9MM KNEE BEARING POSTERIOR STABILIZE",SUP-5532-G-409-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"PHCS [10601]",PHCS,,7988.82,70,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 24MM 2 MARKER SEMIRIGID WIRE STIFFENER",SUP-800SR24,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION 2 LUMEN OTW LOW PROFILE OPTA PRO",SUP-4196040X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 22CM 3.33MM LARGE PROXIMAL PIGTAIL CURVE",SUP-M001231400,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"FIRST HEALTH [10303]","First Health",,712.8,80,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 110MM 3.5MM TRICUT ETHMOID STRAIGHT ENDOSCOPIC",SUP-1883504,CDM,S27200284,LOCAL,0272,RC,,,both,,,1834.50,550.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,217.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,213.35,1559.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2 T-5 38IN BRAID TIES MULTISTRAND LOWER KNOT",SUP-AR-7200,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.35,53.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,121.28,68,,,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE NDL 9GA DISPOSABLE EVIVA","SUP-EVIVA NG09L",CDM,S27200284,LOCAL,0272,RC,,,both,,,90.31,27.09,"KAISER [10500]",Kaiser,,60.51,67,,,,,0,10.5,76.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL UTERINE HEGAR 2 END 9/10MM",SUP-52-3509,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNGOSCOPE LOPRO 3 GLIDESCOPE",SUP-0270-0938,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"KAISER [10500]",Kaiser,,233.16,67,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"Q-FIX KNTLS ASA 1.8MM W/1 MT SUT BL",SUP-72205884,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross PPO",,1396.5,39.2,,957.42,570.23,957.42,28,414.32,3028.13,"percent of total billed charges",
"INSERT TIBIAL 4 20MM KNEE POSTERIOR STABILIZE ROTATE PLATFOR",SUP-151650420,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"FIRST HEALTH [10303]","First Health",,10501.8,80,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 415CC COHESIVE GEL NATRELLE INSPIRA SILICONE",SUP-SCF-415,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,878.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 17.7X.8IN EXUFIBER FIBER FLUID RETENTION HIGH",SUP-603420,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.86,19.46,"NOVANET [10819]",Novanet,,48.65,75,,,,,0,7.54,55.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR DYNASTY A-CLASS STD 36MM POLY BIOFOAM",SUP-DLXPGF36,CDM,C1776,HCPCS,0278,RC,,,both,,,12771.90,3831.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3448.41,27,,,,,0,1485.37,10856.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE 6-8 SMALL MALE PATIENT 2 PADDED POSTOPERATIVE SQUARE",SUP-MQM1B,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.43,23.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MEMANTINE 10 MG TABLET, IMMEDIATE RELEASE",RX-36966,CDM,,,0637,RC,00591-3875-45,NDC,both,1,UN,25.19,7.56,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GORE CARDIOFORM ASD OCCLUDER 32MM 10FR",SUP-00733132636495,CDM,C1817,HCPCS,0278,RC,,,both,,,52321.50,15696.45,"FIRST HEALTH [10303]","First Health",,41857.2,80,,,,,0,6084.99,44473.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"C2 IVL CATHETER, 3.5 X 12 MM",SUP-C2IVL3512,CDM,C1761,HCPCS,0272,RC,,,both,,,29610.00,8883,"CIGNA [10200]",Cigna,,20134.8,68,,,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Lwr Ext W Cntrst",PX-359000005,CDM,73701,CPT,0352,RC,,,both,,,2213.54,664.06,"AETNA [10100]","Aetna HMO/PPO",,1933,,"Per diem ($1,933). Each eligible service on a given day will be paid its own per diem rate.",,,,0,257.43,1933,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"12MM AMPLATZER MUSCULAR VSD OCCLUDER",SUP-9-VSD-MUSC-012,CDM,C1817,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]","Cigna Local Plus",,19750.5,31.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 40MM 150CM 8MM VASCULAR NICKEL",SUP-EVD35-08-040-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"CIGNA [10200]","Cigna Local Plus",,3362.48,53.5,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 23MM 143CM 2.5MM CORONARY EVEROLIMUS ELUTING",SUP-1009539-23,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"MULTIPLAN [10600]",Multiplan,,8152.35,85,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840006530,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2732.31,28.62,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ROADRUNNER PC THE FIRM VASCULAR ANGLE LONG TAPER 145CM",SUP-G06866,CDM,C1769,HCPCS,0272,RC,,,both,,,313.11,93.93,"FIRST HEALTH [10303]","First Health",,250.49,80,,,,,0,36.41,266.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 240MM 4MM BALLOON DILATATION STERILE LATEX",SUP-594024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,991.44,68,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 4MM SURGICAL REVERE 6.35MM ROD",SUP-634.213,CDM,C1713,HCPCS,0278,RC,,,both,,,583.20,174.96,"CIGNA [10200]","Cigna Open Access",,331.84,56.9,,1144.80,304.56,2275.09,66,67.83,495.72,"percent of total billed charges",
"SCR BONE 4MM 12MM ATLANTIS TITANIUM SPINE CERVICAL ANTERIOR",SUP-3120512,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",117.75,860.63,"percent of total billed charges",
"CATH TAKERU 21MM 3.25MM BALLOON DILATATION PTCA",SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"PHCS [10601]",PHCS,,691.74,70,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI MIRACLEBROS 12 PTCA GUIDE WIRE 180 CM",SUP-AG14M070,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"MULTIPLAN [10600]",Multiplan,,963.9,85,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 30MM SOLERA COCR SPINAL MULTIAXIAL CANNULATED",SUP-54840005030,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6491.86,68,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG CHEST TUBE FENESTRATED DRAPE NDL DRIVER SCISSORS",SUP-17100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1144.80,343.44,"CIGNA [10200]",Cigna,,778.46,68,,,,,0,133.14,973.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 105X18X1.2MM 18MM THK1.2MM 105MM XLONG STAINLESS",SUP-2108185000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"MULTIPLAN [10600]",Multiplan,,162.84,85,,,,,0,22.28,162.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 30MM 10MM .035IN BALLOON",SUP-AB35W10030135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,460.47,68,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 34X11MM HEDRON IA 8D 26MM STERILE LATEX FREE",SUP-1212.0611S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9916.83,28.62,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAPTURE NDL SUT STERILE LATEX FREE DISPOSABLE",SUP-22-4036EA,CDM,S27200284,LOCAL,0272,RC,,,both,,,1063.13,318.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,436.95,41.1,,,,,0,123.64,903.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X11-8.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-14811,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"KAISER [10500]",Kaiser,,9939.45,67,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET HOUSING POS",SUP-AR-1204AF-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"UHC [10700]","United Healthcare",,1620.09,63.3,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR MP1 CURVE SIDEHOLE GUIDING CORONARY",SUP-LA7MP1SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH CHECK-FLO FLEXOR .018/.035IN ANL0 CURVE 90CM 4FR .059",SUP-G48188,CDM,C1894,HCPCS,0272,RC,,,both,,,842.40,252.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,572.83,68,,,,,0,97.97,716.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE CRANIOFACIAL TITANIUM 6 HOLE STRUT LOW PROFILE",SUP-421.522,CDM,C1713,HCPCS,0278,RC,,,both,,,3127.50,938.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1435.52,45.9,,,,,0,363.73,2658.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM VANGUARD E1 KNEE CRUCIATE RETAINING",SUP-EP183462,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"PHCS [10601]",PHCS,,9066.88,70,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST TRICORTICAL THK19-21MM WEDGE",SUP-400413,CDM,S27800098,LOCAL,0278,RC,,,both,,,6305.22,1891.57,"CIGNA [10200]","Cigna Open Access",,3587.67,56.9,,,,,0,733.3,5359.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 22MM DCP STAINLESS STEEL CORTICAL HAND/FOOT",SUP-201.822,CDM,C1713,HCPCS,0278,RC,,,both,,,358.09,107.43,"NOVANET [10819]",Novanet,,268.57,75,,,,,0,41.65,304.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 STD KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500606602,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"NOVANET [10819]",Novanet,,17147.03,75,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 10CM 4FR PIGTAIL CURVE PANCREATIC POLYMER",SUP-M00536940,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"CIGNA [10200]","Cigna Open Access",,363.73,,,,,,,74.34,543.36,"percent of total billed charges",
"TOOL DISSECTING 5CM 5MM BALL FLUTE BURR SHORT STRAIGHT",SUP-S-5B,CDM,S27200284,LOCAL,0272,RC,,,both,,,1474.20,442.26,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,605.9,41.1,,,,,0,171.45,1253.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 80MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206080870,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BROVIAC/HICKMAN/LEONARD CATHETERS HICKMAN TRIPLE LUMEN CATHE",SUP-0606564,CDM,C1751,HCPCS,0272,RC,,,both,,,1611.90,483.57,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 018 130CM 2CM 4MM BALLOON DILATATION",SUP-U813042,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LARGE VAULTLOCK GLENOID",SUP-AR-9106-03,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"UHC [10700]","United Healthcare",,5801.07,63.3,,8601.07,8395.67,8601.07,"1 through 10",1065.82,7789.74,"percent of total billed charges",
"CATH ANGIOSCULPT XL 137CM 40MM 6FR 5MM .018IN BALLOON",SUP-2076-5040,CDM,C1725,HCPCS,0272,RC,,,both,,,6865.50,2059.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 12.5FR .164IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLSX-1012.5,CDM,C1892,HCPCS,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) EDWARDS COMMANDER DELIVERY SYSTEM WITH SAPIEN 3 ULTRA",SUP-9750CM29A,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET INTRO 63CM VERSACROSS 45D TRANSSEPTAL PIGTAIL RF WIRE 1",SUP-VXSK0022,CDM,C1893,HCPCS,0272,RC,,,both,,,6175.50,1852.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 100MM 7MM BALLOON DILATATION DURALYN",SUP-48007010S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,936.36,68,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM 14MM PRIMARY VERSYS TIVANIUM FIBER METAL",SUP-786201400,CDM,C1776,HCPCS,0278,RC,,,both,,,26645.22,7993.57,"PHCS [10601]",PHCS,,18651.65,70,,,,,0,3098.84,22648.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG VARIABLE ANGLE LOCKING 1.8MM X 7MM",SUP-SPLS-18070-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]","Cigna Open Access",,811.17,56.9,,1144.80,304.56,2275.09,66,165.8,1211.76,"percent of total billed charges",
"STENT ABRE 60MM 20MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U20060090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1226.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREONPANOPTIX PROTORIC(BLF)",SUP-PXYWT3,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"CIGNA [10200]",Cigna,,622.2,68,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL ADHESIOLYSIS WITH CC",336,MS-DRG,,,,,,,inpatient,,,57144.78,17143.43,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,13996.02,,"Case rate ($13,080.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,146.03, add-ons for qualifying new technology services are included. If operating cost exceeds $45,185.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,300.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,162.09. The transfer operating threshold is the transfer adjustment factor * $12,146.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.30. The transfer capital threshold is the transfer adjustment factor * $918.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,57144.78,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"PIRANHA CERVICAL VARIABLE SCREW 4.0 MM X 16 MM",SUP-SK-CSV-40-16,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 20CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192120010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,139.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CRYOTHERAPY 122CM ELECTRICAL UMBILICAL DISPOSABLE",SUP-2035UC,CDM,S27000186,LOCAL,0270,RC,,,both,,,1447.88,434.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC US Hysterography W Color Flow",PX-402000026,CDM,76831,CPT,0402,RC,,,both,,,1077.00,323.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure count. Procedure 1, Fee schedule rate ($267.91). Procedures 2 - 999, Fee schedule rate ($133.96).",,,,0,,,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Pilonidal Cyst Cmplx",PX-450000007,CDM,10081,CPT,0450,RC,,,both,,,12300.00,3690,"AETNA [10100]","Aetna HMO/PPO",,9778.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.13,10455,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH SHORT 5.5MM ENDOSCOPIC OBTR HANDLE STERILE OLIVE",SUP-7205470,CDM,S27000186,LOCAL,0270,RC,,,both,,,348.00,104.4,"UHC [10700]","United Healthcare",,220.28,63.3,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 80MM LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.080S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,957.42,570.23,957.42,28,189.34,1383.8,"percent of total billed charges",
"STAPLER INTERNAL 31X4.8MM TITANIUM XL CIRCLE STAPLE ENDOSCOP",SUP-EEAXL31,CDM,S27200284,LOCAL,0272,RC,,,both,,,2269.80,680.94,"MULTIPLAN [10600]",Multiplan,,1929.33,85,,,,,0,263.98,1929.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 50MM LOW PROFILE SCREWS TITANIUM FULL THREAD",SUP-AR-8945-50FT,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross PPO",,555.66,39.2,,957.42,570.23,957.42,28,164.86,1204.88,"percent of total billed charges",
"LENS IOL +12 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0120,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR PRESSURE NIFOMETER 60- CM 2O SMALL NEGATIVE",SUP-1034002,CDM,S27000186,LOCAL,0270,RC,,,both,,,125.57,37.67,"AETNA [10100]","Aetna HMO/PPO",,99.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.6,106.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 89MM 10.9MM 8MM 1 CANN CUFF SMOOTH ROUND TIP OBTR",SUP-8SCT,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.54,64.36,"MULTIPLAN [10600]",Multiplan,,182.36,85,,,,,0,24.95,182.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (PS) - SIZE 5",SUP-5555-2255,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,650.63,45.9,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEADGEAR CPAP SMALL INFANT FLOW LATEX FREE DISPOSABLE LIGHT",SUP-139315,CDM,S27000186,LOCAL,0270,RC,,,both,,,116.53,34.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,47.89,41.1,,,,,0,13.55,99.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK II 145CM 15MM 2MM BALLOON DILATATION PEBAX",SUP-1012403-15A,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE WIRE GWR419578 ATTAIN HYBRID 98CM",SUP-GWR419578,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ENDOSCOPIC 75MM 8MM DRI-LOK THREAD STERILE",SUP-3910075800,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"KAISER [10500]",Kaiser,,116.58,67,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CRE 5.5CM 8-9-10MM BALLOON DILATATION PEBAX ADULT RAPID",SUP-M00558870,CDM,C1726,HCPCS,0272,RC,,,both,,,2085.75,625.72,"PHCS [10601]",PHCS,,1460.03,70,,,,,0,242.57,1772.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON ENDOSCOPIC MAXFORCE 3CM 2.8MM 8MM 5FR BILIARY",SUP-6742,CDM,C1726,HCPCS,0272,RC,,,both,,,217.50,65.25,"AETNA [10100]","Aetna HMO/PPO",,172.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Homovanillic Acid",PX-301000236,CDM,83150,CPT,0301,RC,,,both,,,253.00,75.9,"PHCS [10601]",PHCS,,177.1,70,,,,,0,0.01,215.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 122MM 9.5-13MM 6 SHOOTER SAEED 6 BAND STERILE",SUP-MBL-6,CDM,S27200284,LOCAL,0272,RC,,,both,,,3247.50,974.25,"CIGNA [10200]","Cigna Open Access",,1847.83,56.9,,,,,0,377.68,2760.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELIANCE 4 FRONT PASSIVE FIXATION SINGLE COIL 59CM",SUP-0662,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"PHCS [10601]",PHCS,,10626,70,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 40CM 5FR 11MM EMBOLECTOMY STAINLESS STEEL SILICONE .75",SUP-NL5EMB40T,CDM,C1757,HCPCS,0272,RC,,,both,,,413.60,124.08,"KAISER [10500]",Kaiser,,277.11,67,,,,,0,48.1,351.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 20X20MM DYNANITE SUPERMX NITINOL COMPRESSION LOW",SUP-AR-8719MXDS-2020,CDM,C1713,HCPCS,0278,RC,,,both,,,17215.50,5164.65,"PHCS [10601]",PHCS,,12050.85,70,,,,,0,2002.16,14633.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM CONCERTO DETACHABLE HELIX PERIPHER",SUP-NV-2-4-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 100MM TITANIUM SHORT THREAD CANNULATED",SUP-04.353.700S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"CIGNA [10200]","Cigna Open Access",,1399.4,56.9,,1144.80,304.56,2275.09,66,286.03,2090.49,"percent of total billed charges",
"INTRO SHEATH 28GA SPLITTABLE NDL BREAKAWAY MIDLINE CATH PICC",SUP-384061,CDM,C1892,HCPCS,0272,RC,,,both,,,327.38,98.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,38.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.07,278.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 130CM 200MM 6MM BALLOON DILATATION",SUP-ADM06020013P,CDM,C2623,HCPCS,0272,RC,,,both,,,12730.50,3819.15,"FIRST HEALTH [10303]","First Health",,10184.4,80,,,,,0,1480.56,10820.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR .092IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1007,CDM,C1892,HCPCS,0272,RC,,,both,,,298.32,89.5,"FIRST HEALTH [10303]","First Health",,238.66,80,,,,,0,34.69,253.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CSGWORBC19M SAFESHTH GDE",SUP-CSGWORBC19M,CDM,C1892,HCPCS,0272,RC,,,both,,,2887.50,866.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,342.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 10 STD OFFSET HIP",SUP-71935570,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"NOVANET [10819]",Novanet,,27400.28,75,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE HA 30MM 8MM 1.5MM ACL/PCL CANNULATION",SUP-7207679,CDM,C1713,HCPCS,0278,RC,,,both,,,1882.13,564.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,538.67,28.62,,,,,0,218.89,1599.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 7FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175272050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"BLUE CROSS [10001]","Blue Cross HMO",,419.73,39.2,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 13MM ZEVO TITANIUM SPINE CERVICAL ANTERIOR",SUP-7723513,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",117.75,860.63,"percent of total billed charges",
"HC NM Cisternography",PX-341000040,CDM,78630,CPT,0341,RC,,,both,,,1846.31,553.89,"MULTIPLAN [10600]",Multiplan,,1569.36,85,,,,,0,214.73,1569.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 TWINFIX ULTRA SHOULDER LOW PROFILE",SUP-72202595,CDM,C1713,HCPCS,0278,RC,,,both,,,1724.63,517.39,"MULTIPLAN [10600]",Multiplan,,1465.94,85,,,,,0,200.57,1465.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR 28CM 3CM 7FR .035IN 2 FLOPPY PIGTAIL",SUP-M006180234090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"BLUE CROSS [10001]","Blue Cross PPO",,521.46,39.2,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 15.5CM 78CM 23MM 28MM 12CM 18.5FR ESOPHAGEAL",SUP-M00516950,CDM,C1874,HCPCS,0278,RC,,,both,,,16701.45,5010.43,"MULTIPLAN [10600]",Multiplan,,14196.23,85,,,,,0,1942.38,14196.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 80MM 3.5MM BALLOON DILATATION RAPID",SUP-47535080L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) GUIDEWIRE VASCULAR .024INX200CM ARISTOTLE 24 SOFT",SUP-A24-200-001,CDM,C1769,HCPCS,0272,RC,,,both,,,5692.50,1707.75,"KAISER [10500]",Kaiser,,3813.98,67,,,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP LIMIT HOLE COLOR CODED OSSEOTI G7",SUP-110010248,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUE FLOW 110CM 3.5CM 20MM 11FR PERFUSION VALVULOPLASTY",SUP-TF0203511,CDM,C1725,HCPCS,0272,RC,,,both,,,11730.00,3519,"FIRST HEALTH [10303]","First Health",,9384,80,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 325CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-325,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,878.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 42MM NAIL-EX TITANIUM FULL THREAD HUMERAL",SUP-04.005.432S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"FIRST HEALTH [10303]","First Health",,1197.5,80,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUADRA ALLURE MP RF CRT-P MRI, MERLIN PKG",SUP-PM3562CELL,CDM,C2621,HCPCS,0275,RC,,,both,,,25200.00,7560,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6804,27,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Strap Toes",PX-450000206,CDM,29550,CPT,0361,RC,,,both,,,748.02,224.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,86.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.99,748.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE PIN ORTHOPEDIC 355MM 3.2MM THREAD STERILE",SUP-471133,CDM,C1713,HCPCS,0278,RC,,,both,,,911.25,273.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,260.8,28.62,,,,,0,105.98,774.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T 72MM STAINLESS STEEL 2.7MM SCR 4 HOLE VARIABLE ANGLE",SUP-02.118.306S,CDM,C1713,HCPCS,0278,RC,,,both,,,6122.65,1836.79,"CIGNA [10200]","Cigna Open Access",,3483.79,56.9,,1144.80,304.56,2275.09,66,712.06,5204.25,"percent of total billed charges",
"GORE VIABIL BILIARY ENDOPROSTHESIS, 10MMX10CM 10FR",SUP-VH1010040,CDM,C1874,HCPCS,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS [10001]","Blue Cross PPO",,8643.6,39.2,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 12MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630312,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"NOVANET [10819]",Novanet,,9845.44,75,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC SMOOTH CUTTER BITE STRYKER STERILE LATEX",SUP-475333000,CDM,S27200284,LOCAL,0272,RC,,,both,,,752.77,225.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,89.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.55,639.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 24MM 140CM 3MM CORONARY STENT CARBOSIL",SUP-LUN300R24US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 22GA 10CM CHIBA ASPIRATION STERILE DISPOSABLE",SUP-G00852,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.01,33.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,76.85,68,,,,,0,13.14,96.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 5.0/26",SUP-434903,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"KAISER [10500]",Kaiser,,13232.84,67,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE WHISPER LS VASCULAR J CURVE 190CM 3CM .014IN",SUP-1005351HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 28MM 144CM 3.5MM CORONARY STENT EVEROLIMUS",SUP-H7493926128350,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"FIRST HEALTH [10303]","First Health",,6900,80,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 64MM 36MM XLPE HIP STERILE",SUP-71332764,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"AETNA [10100]","Aetna HMO/PPO",,8845.37,79.5,,10981.53,8986.79,12413.38,12,1293.98,9457.31,"percent of total billed charges",
"HC Dx Bone Marrow Bx & Aspir",PX-361000471,CDM,38222,CPT,0361,RC,,,both,,,5202.30,1560.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,605.03,4421.96,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 75MM AXSOS 3 TITANIUM CORTEX SELF TAP LOCK",SUP-661475,CDM,C1713,HCPCS,0278,RC,,,both,,,289.54,86.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,34.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,33.67,246.11,"percent of total billed charges",
"(EVAL) QUALIBREATH SIZE XXL",SUP-QB-XXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"MULTIPLAN [10600]",Multiplan,,705.02,85,,,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DILTIAZEM 30 MG TABLET, IMMEDIATE RELEASE",RX-2475,CDM,,,0637,RC,60687-0717-11,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X18X8-15MM RISE-L 6D",SUP-193.324,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"PHCS [10601]",PHCS,,24034.5,70,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 90MM 22MM 16MM AFX2 2 BRANCH 30MM AAA STERILE",SUP-BEA22-90/I16-30,CDM,C1874,HCPCS,0278,RC,,,both,,,84559.50,25367.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10020.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9834.27,71875.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION OXI FEMUR LEGION INSERT JOUR",SUP-71704630,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5953.5,27,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Stent & Ather Add",PX-361000163,CDM,37235,CPT,0361,RC,,,both,,,12161.75,3648.52,"BLUE CROSS [10001]","Blue Cross PPO",,12.16,.1,,,,,0,12.16,10337.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACHEOSTOMY ADULT L88MM OD11MM ID8MM SILICONE CUFFED S",SUP-750180,CDM,S27200284,LOCAL,0272,RC,,,both,,,693.36,208.01,"MULTIPLAN [10600]",Multiplan,,589.36,85,,,,,0,80.64,589.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOXYCYCLINE MONOHYDRATE 100 MG TABLET",RX-21818,CDM,,,0637,RC,60687-0344-95,NDC,both,1,UN,13.28,3.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.54,11.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 180CM 30MM 1.75MM ATHERECTOMY PERIPHERAL",SUP-DBP-175SOLID180,CDM,C1724,HCPCS,0272,RC,,,both,,,22648.50,6794.55,"MULTIPLAN [10600]",Multiplan,,19251.23,85,,,,,0,2634.02,19251.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-10,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,35.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",35.41,258.83,"percent of total billed charges",
"SUT PROLENE 3-0 V-7 36IN 2 ARM MONOFILAMENT BLUE",SUP-8976H,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.23,24.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,56.6,68,,,,,0,9.68,70.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS .096IN DUOSTAT ROTATE",SUP-23242,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"AETNA [10100]","Aetna HMO/PPO",,131.41,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +14.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000145,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 20MM 52MM OFFSET 4MM TOTAL SHOULDER REPLACEMENT",SUP-5552-E-5220,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"UHC [10700]","United Healthcare",,5753.21,63.3,,8601.07,8395.67,8601.07,"1 through 10",1057.03,7725.48,"percent of total billed charges",
"STENT WALLSTENT 40MM 16MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044164070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]","Cigna Local Plus",,4614.38,53.5,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 3CM 170CM 5FR CONTOUR PANCREATIC POLYETHYLENE",SUP-G22206,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"CIGNA [10200]","Cigna Local Plus",,658.69,53.5,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (CR) - SIZE 5",SUP-5555-2205,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"PHCS [10601]",PHCS,,992.25,70,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 12X11X30MM 15",SUP-5821305,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"FIRST HEALTH [10303]","First Health",,23040,80,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,inpatient,,,34412.37,10323.71,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 RB-2 18IN 2 ARM MONOFILAMENT BLUE",SUP-8714H,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.97,19.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PERIVIEW FLEX 21G",SUP-NA-403D-2021,CDM,S27200284,LOCAL,0272,RC,,,both,,,6575.70,1972.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CROSSWALK 90CM 4.2FR 3.2FR .039FR .037FR MICRO SPRT",SUP-PSC35090A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXCELSIOR SL-10 PRE-SHAPED 90 150CM",SUP-M0031681910,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TROCAR LAPAROSCOPIC 5MM SPACEMAKER PRO ENDO-LUBE BLUNT TIP",SUP-SMBTTRNDX,CDM,C1727,HCPCS,0272,RC,,,both,,,3323.48,997.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,393.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,386.52,2824.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA 36-39IN MEDIUM HOOK LOOP CLSR WIDE ADJUSTABLE SHOULDER",SUP-M5001-M,CDM,S27000186,LOCAL,0270,RC,,,both,,,161.39,48.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.77,137.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE (RSP) MONOBLOCK REVISION HUMERAL STEM, 220MM, 6X220M",SUP-510-06-220,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"KAISER [10500]",Kaiser,,8442,67,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFTON PUTTY 1CC",SUP-T43102,CDM,C1713,HCPCS,0278,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",94.2,688.5,"percent of total billed charges",
"FORCEPS TYING L83MM PLATFORM 4MM STAINLESS STEEL STRAIGHT SE","SUP-E1815 S",CDM,S27200284,LOCAL,0272,RC,,,both,,,1307.50,392.25,"FIRST HEALTH [10303]","First Health",,1046,80,,,,,0,152.06,1111.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 28CM 7FR .038IN PIGTAIL CURVE",SUP-M006180234120,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,154.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 RB-2 18IN 2 ARM MONOFILAMENT BLUE",SUP-8714H,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.97,19.49,"FIRST HEALTH [10303]","First Health",,51.98,80,,,,,0,7.56,55.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERSACROSS CONNECT LAAC 230P D0",SUP-VXAK0105,CDM,S27200284,LOCAL,0272,RC,,,both,,,6969.00,2090.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4738.92,68,,,,,0,810.49,5923.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 80CM 7MM 8FR STRAIGHT VASCULAR",SUP-AVSM07100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7508.97,41.1,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 18MM RSP SHOULDER LOCK GLENOID BASEPLT",SUP-506-03-118,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"CIGNA [10200]","Cigna Open Access",,885.19,56.9,,1144.80,304.56,2275.09,66,180.93,1322.35,"percent of total billed charges",
"SUT VICRYL PLUS MULTIPASS 5-0 P-1 18IN BRAID ANTIBACTERIAL",SUP-VCP490G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 3 KNEE CEMENTED FIX BEARING STERILE",SUP-150600003,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6166.66,41.1,,6417.48,6417.48,6417.48,"1 through 10",1744.97,12753.44,"percent of total billed charges",
"CATH JET THROMBECTOMY STERILE LATEX FREE",SUP-5MAXJETD,CDM,C1757,HCPCS,0272,RC,,,both,,,16767.00,5030.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6891.24,41.1,,,,,0,1950,14251.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 200MM 5MM BALLOON DILATATION",SUP-PCU050200130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,143.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Slp Stdy Unatnd W Hrt/O2/Pat/Time",PX-740000066,CDM,95800,CPT,0920,RC,,,both,,,2079.00,623.7,"KAISER [10500]",Kaiser,,1392.93,67,,,,,0,241.79,2079,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST EXTERNAL FIXATION TRUELOK 1 HOLE NONSTERILE LATEX FREE",SUP-54-11600,CDM,C1713,HCPCS,0278,RC,,,both,,,1064.18,319.25,"NOVANET [10819]",Novanet,,798.14,75,,,,,0,123.76,904.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 5 LR 20IN BRAID GREEN NONABSORBABLE",SUP-B409T,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 57.9CM 26FR SILICONE Y MIC SECUR-LOK",SUP-0210-26,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,170.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 38MM TI",SUP-SPL-35380-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,382.51,28.62,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 12MM CHARLOTTE SNAP OFF",SUP-45110002,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"SCREW NON-LOCKING 2.5MM X 15MM TI",SUP-VAN-25150-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,278.19,28.62,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM PUSHLOCK SELF PUNCH BIOCOMPOSITE 28MM",SUP-AR-1922BCM,CDM,C1713,HCPCS,0278,RC,,,both,,,3268.13,980.44,"CIGNA [10200]","Cigna Open Access",,1859.57,56.9,,1144.80,304.56,2275.09,66,380.08,2777.91,"percent of total billed charges",
"KIT NEROSTIMLTR AXONICS TINE LEAD STERILE LATEX FREE",SUP-1201,CDM,C1778,HCPCS,0278,RC,,,both,,,20512.80,6153.84,"AETNA [10100]","Aetna HMO/PPO",,16307.68,79.5,,,,,0,2385.64,17435.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL MITRACLIP BUNDLE SGC0301 2 CDS0601 XTR",SUP-MBR0202,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"PHCS [10601]",PHCS,,119700,70,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE METRX ORTHOPEDIC MEDIUM 30CM .062IN REUSABLE",SUP-955-519,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12IN 12.3-13CM MEMORYGEL P3.8-4.5CM STD MODERATE",SUP-351-325SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"CIGNA [10200]","Cigna Local Plus",,455.02,53.5,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 60MM 7MM PRESS FIT REMOVABLE TRUNION SUT HOLE",SUP-AR-9100-07S,CDM,C1776,HCPCS,0278,RC,,,both,,,10713.60,3214.08,"AETNA [10100]","Aetna HMO/PPO",,8517.31,79.5,,10981.53,8986.79,12413.38,12,1245.99,9106.56,"percent of total billed charges",
"COROENT XL-XW, 1026X55MM 10",SUP-6210155,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Open Access",,8019.9,33.5,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 10.8MM 19MM 17.4MM ON-X 27MM CYLINDRICAL HEART",SUP-ONXANE-19,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4396.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 7CM 10FR DUODENAL BEND BILIARY",SUP-M00534330,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"BLUE CROSS [10001]","Blue Cross PPO",,427.06,39.2,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DAIG SUPREME CABLE BLACK  150 CM",SUP-401980R,CDM,S27200284,LOCAL,0272,RC,,,both,,,248.00,74.4,"MULTIPLAN [10600]",Multiplan,,210.8,85,,,,,0,28.84,210.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 48MM STAINLESS STEEL FULL THREAD FOOT",SUP-214.748,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"NOVANET [10819]",Novanet,,842.72,75,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM QUADLINK 9MM IMPL",SUP-AR-1288QIS-90,CDM,C1713,HCPCS,0278,RC,,,both,,,15757.88,4727.36,"AETNA [10100]","Aetna HMO/PPO",,12527.51,79.5,,1521.93,481.35,16760.95,30,1832.64,13394.2,"percent of total billed charges",
"CAP PARTIAL SHOULDER",SUP-CP-UNIVERS-APEX-CA,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"CIGNA [10200]",Cigna,,8190,40,,5873.17,5873.17,5873.17,"1 through 10",2381.24,17403.75,"percent of total billed charges",
"CATH ACUNAV 90CM 10FR ULTRASOUND INTRACARDIAC 4 WAY STEERING",SUP-10043342,CDM,C1759,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 124MM CEMENTED NECK ACCOLADE 127D 2 39MM OFFSET",SUP-6057-0230D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1948.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1911.88,13973.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP MULTIHOLE TRITANIUM TRIDENT G",SUP-509-02-62G,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"PHCS [10601]",PHCS,,7862.4,70,,,,,0,1306.28,9547.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLADIUS MONGO ES 0.014 190CM",SUP-AP14R024S,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,131.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI CORSAIR MICROCATHETER 135CM - CSW150-26N-5",SUP-CSW150-26N-5,CDM,C1887,HCPCS,0272,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 90MM 6MM DISTAFLO SMALL BEAD MINI CUFF",SUP-DFX9006SC,CDM,C1768,HCPCS,0278,RC,,,both,,,10339.63,3101.89,"CIGNA [10200]","Cigna Local Plus",,5531.7,53.5,,,,,0,1202.5,8788.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 3.5IN 17GA 19GA PERIFIX TUOHY BPA DEHP PVC",SUP-332087,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.01,54.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,123.09,68,,,,,0,21.05,153.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 10MM NATURAL LORDOTIC CORTICOCANCELLOUS",SUP-18410,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PACKAGED ACCESSORIES",SUP-ES0542,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIRE RETINAL 2.5MM GROOVE CONCAVE SILICONE 9MM STERILE STYLE",SUP-9216,CDM,S27800098,LOCAL,0278,RC,,,both,,,175.64,52.69,"NOVANET [10819]",Novanet,,131.73,75,,,,,0,20.43,149.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 48MM STAINLESS STEEL FULL THREAD FOOT",SUP-214.748,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,133.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,130.68,955.09,"percent of total billed charges",
"ANCHOR SUT 0 Q-FIX NEEDLES SUT STERILE LATEX FREE DISPOSABLE",SUP-72205691,CDM,C1713,HCPCS,0278,RC,,,both,,,3003.75,901.12,"BLUE CROSS [10001]","Blue Cross PPO",,1177.47,39.2,,957.42,570.23,957.42,28,349.34,2553.19,"percent of total billed charges",
"LINE GAS SUPPLY 2.1MR 10MM NEOPUFF LONG UNIQUE CNCT RESUS T",SUP-900RD009,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.42,14.23,"AETNA [10100]","Aetna HMO/PPO",,37.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.51,40.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Erector Spinae Plane (Esp) Block",PX-361000647,CDM,64999,CPT,0361,RC,,,both,,,2899.73,869.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,343.62,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,337.24,2899.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Erector Spinae Plane (Esp) Block",PX-361000647,CDM,64999,CPT,0361,RC,,,both,,,2899.73,869.92,"CIGNA [10200]","Cigna Open Access",,2899.73,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,337.24,2899.73,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ROCHESTER-PEAN CURVE 6.25IN STD LINE STAINLESS",SUP-32-4071,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.29,16.89,"CIGNA [10200]","Cigna Open Access",,32.03,56.9,,,,,0,6.55,47.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER 19CM 4.2MM HIP LENGTH ADAPTEUR POWER SYSTEM RESECTOR",SUP-AR-6420BC,CDM,S27200284,LOCAL,0272,RC,,,both,,,654.89,196.47,"MULTIPLAN [10600]",Multiplan,,556.66,85,,,,,0,76.16,556.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 4.0/26",SUP-434901,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"CIGNA [10200]",Cigna,,7900.2,40,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 11MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G611,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"PHCS [10601]",PHCS,,6556.26,70,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER 200UM BALL TIP DISPOSABLE",SUP-TFL-FBX200BS,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 16MM STAINLESS STEEL T6 SELF TAP LOCK VARIABLE",SUP-02.130.316,CDM,C1713,HCPCS,0278,RC,,,both,,,841.43,252.43,"BLUE CROSS [10001]","Blue Cross HMO",,329.84,39.2,,957.42,156.86,7483.26,51,97.86,715.22,"percent of total billed charges",
"TENDYNE MITRAL VALVE LP 35S",SUP-TENDV-LP-35S-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,93.18,27.95,"CIGNA [10200]","Cigna Open Access",,53.02,56.9,,,,,0,10.84,79.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM HEMICAP ARTHROPLASTY SHOULDER",SUP-8HEM-CC,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"UHC [10700]","United Healthcare",,12960.68,63.3,,8601.07,8395.67,8601.07,"1 through 10",2381.24,17403.75,"percent of total billed charges",
"SCR BONE 3.5MM 22MM VARIAX NONSTERILE",SUP-657422,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,231.45,28.62,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM COCR SPINAL MULTIAXIAL CANNULATED",SUP-54840014540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1110.3,8114.82,"percent of total billed charges",
"LATITUDE CONNECTIVITY COMMITMENT",SUP-CFRE,CDM,S27000186,LOCAL,0270,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Local Plus",,2022.3,53.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 45MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-45,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",50.59,369.75,"percent of total billed charges",
"PROS OSSICULAR 3.5X2.5MM APPLEBAUM INCUS HA PARTIAL",SUP-140974,CDM,L8613,HCPCS,0278,RC,,,both,,,2680.88,804.26,"BLUE CROSS [10001]","Blue Cross PPO",,1050.9,39.2,,,,,0,232.31,2278.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC SHORT TIP RELOAD AEON 60MMX2.5MM STERILE",SUP-ASR60WS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,599.24,41.1,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX23MM FRA 8D NARROW SPINE ANTERIOR",SUP-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"MULTIPLAN [10600]",Multiplan,,16065,85,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 81MM 12.2MM 7.6MM FENESTRATE CUFFLESS INNER CANN SHILEY",SUP-8CFN,CDM,S27200284,LOCAL,0272,RC,,,both,,,312.85,93.85,"FIRST HEALTH [10303]","First Health",,250.28,80,,,,,0,36.38,265.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 4.5IN OLSEN-HEGAR DELICATE NDL TUNGSTEN CARBIDE",SUP-32-159,CDM,S27200284,LOCAL,0272,RC,,,both,,,684.69,205.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,79.63,581.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 32MM HIP C TAPER COBALT CHROME LFIT",SUP-06-3200,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"BLUE CROSS [10001]","Blue Cross HMO",,1226.06,39.2,,5311.50,4717.44,5388.59,31,363.75,2658.55,"percent of total billed charges",
"PIN FIXATION 4MM 110MM STERILE",SUP-144110,CDM,S27200284,LOCAL,0272,RC,,,both,,,505.44,151.63,"CIGNA [10200]","Cigna Local Plus",,270.41,53.5,,,,,0,58.78,429.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW LOWPROFILE 6.5X20MM",SUP-010-55-020,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"MULTIPLAN [10600]",Multiplan,,258.83,85,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 16MM CONCERTO DETACHABLE",SUP-PV-16-40-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTNR 8.875X5.625IN SMALL VISCUS STERILE LATEX FREE",SUP-3202,CDM,S27200284,LOCAL,0272,RC,,,both,,,404.55,121.36,"KAISER [10500]",Kaiser,,271.05,67,,,,,0,47.05,343.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 18GA 50CM 11CM GRAY HUB DIL GWIRE",SUP-PSI-5F-11-038-18G,CDM,C1894,HCPCS,0272,RC,,,both,,,102.23,30.67,"MULTIPLAN [10600]",Multiplan,,86.9,85,,,,,0,11.89,86.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 20MM 2.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP2520X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"NOVANET [10819]",Novanet,,394.88,75,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drain Absc Peritoneal Open",PX-361000506,CDM,49020,CPT,0361,RC,,,both,,,1769.00,530.7,"BLUE CROSS [10001]","Blue Cross PPO",,1769,,"Case rate ($4,431.65). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,205.73,1769,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR PREPARATION OF TC-99M-BICISATE INTRAVENOUS SOLUTION (0-25 MCI)",RX-184736,CDM,A9557,HCPCS,0343,RC,08888-8877-14,NDC,both,1,UN,9455.04,2836.51,"MULTIPLAN [10600]",Multiplan,,8036.78,85,,,,,0,1099.62,8036.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLYFLEX 40MM 12MM 20MM TRACHEOBRONCHIAL SILICONE SELF",SUP-7026,CDM,C1887,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"UHC [10700]","United Healthcare",,2112.64,63.3,,,,,0,388.15,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER O.R. PROCEDURES FOR INJURIES WITH CC",908,MS-DRG,,,,,,,inpatient,,,54365.85,16309.75,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,13242.68,,"Case rate ($12,376.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,492.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,531.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,250.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,507.47. The transfer operating threshold is the transfer adjustment factor * $11,492.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $868.87. The transfer capital threshold is the transfer adjustment factor * $868.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,54365.85,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Oligoclonal Bands",PX-301000342,CDM,83916,CPT,0301,RC,,,both,,,499.20,149.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,28.76,,"Fee schedule rate ($28.76). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,424.32,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 103MM 14-23MM 18FR ENDURANT IIS 2 BRANCH",SUP-ESBF2314C103E,CDM,S27800098,LOCAL,0278,RC,,,both,,,60782.40,18234.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16411.25,27,,,,,0,7068.99,51665.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 4-0 P-3 18IN BRAID COATED VIOLET ABSORBABLE",SUP-J464G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Band Ligat",PX-750000172,CDM,45350,CPT,0750,RC,,,both,,,4085.00,1225.5,"CIGNA [10200]","Cigna Local Plus",,3787,,"Case rate ($3,787). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,475.09,4085,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER REDEL 115CM 4MM 7FR 1-7-4MM SPACE F-F CURVE",SUP-BD7TCFF4L,CDM,C1733,HCPCS,0272,RC,,,both,,,6113.40,1834.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2512.61,41.1,,,,,0,710.99,5196.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,inpatient,,,151155.63,45346.69,"CIGNA [10200]","Cigna Open Access",,40292.14,,"Fee schedule rate ($40,292.14). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,8593,107196.03,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 11MM KII FIOS FIRST ENTRY Z THREAD",SUP-CTF33,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 71CM TRANSSEPTAL CARTO VIZIGO ACQCROSS",SUP-900303,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBTR ENDOSCOPIC 24FR RESECTOSCOPY DEFLECTABLE TIP",SUP-A22085A,CDM,S27200284,LOCAL,0272,RC,,,both,,,4234.67,1270.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1943.71,45.9,,,,,0,492.49,3599.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM 12MM MODULAR RESTORATION HA POROUS PLASMA",SUP-6276-5-012,CDM,C1776,HCPCS,0278,RC,,,both,,,12929.16,3878.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5313.88,41.1,,6417.48,6417.48,6417.48,"1 through 10",1503.66,10989.79,"percent of total billed charges",
"TENSIONER SURGICAL CUTTER",SUP-AR-1938TC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,173.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAP SPECIMEN REMOVAL TISSUE FLUENT FLUID",SUP-FLT-010,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.00,26.1,"PHCS [10601]",PHCS,,60.9,70,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC STD 24IN 25- IN KNEE ADJUSTABLE 3 PANEL",SUP-VP40105-070,CDM,L1830,HCPCS,0274,RC,,,both,,,160.08,48.02,"FIRST HEALTH [10303]","First Health",,128.06,80,,,,,0,18.62,136.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH HIGH PROFILE XTRA 700CC",SUP-SHPX700,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"CIGNA [10200]","Cigna Open Access",,4240.19,56.9,,5166.00,5166.00,5166.00,"1 through 10",866.67,6334.2,"percent of total billed charges",
"HC Rmvl Benign Skin Lesn Sngl",PX-510000013,CDM,11055,CPT,0761,RC,,,both,,,525.21,157.56,"BLUE CROSS [10001]","Blue Cross PPO",,525.21,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,61.08,525.21,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 95MM 32MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-217.095,CDM,C1713,HCPCS,0278,RC,,,both,,,485.35,145.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,330.04,68,,,,,0,56.45,412.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SLIP-CATH BEACON TIP 80CM 5FR .038IN C2 CURVE",SUP-G12006,CDM,S27200284,LOCAL,0272,RC,,,both,,,468.18,140.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,318.36,68,,,,,0,54.45,397.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT BLUE 9CM 5FR COTTON-LEUNG BILIARY POLYETHYLENE",SUP-G22403,CDM,C2625,HCPCS,0278,RC,,,both,,,1328.40,398.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,380.19,28.62,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION HIP DRILL GUIDE OBTR Q-FIX 1.8MM",SUP-251811,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OLMESARTAN 40 MG TABLET",RX-32763,CDM,,,0637,RC,62332-0133-90,NDC,both,1,UN,32.99,9.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,22.43,68,,,,,0,3.84,28.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 0 CT-2 30IN BRAID GREEN NONABSORBABLE",SUP-X412H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM ASNIS III STAINLESS STEEL HIP SELF TAPPING",SUP-325038S,CDM,C1713,HCPCS,0278,RC,,,both,,,1315.28,394.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,603.71,45.9,,,,,0,152.97,1117.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 135CM 100MM 7MM BALLOON DILATATION PACLITAXEL",SUP-H74939419701010,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1022.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 45MM CATHCART BALL HIP FEMUR MODULAR STERILE",SUP-136345000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,5873.17,5873.17,5873.17,"1 through 10",434.96,3179,"percent of total billed charges",
"NDL SCLEROTHERAPY 25GA INJECTION PROJECTION STERILE",SUP-00711811,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,39.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 10MM SEPTAL SELF EXPANDING DELIVERY",SUP-9-ASD-010,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"CIGNA [10200]","Cigna Open Access",,7119.02,33.5,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC PROMRI 2 CHMBR ELUNA DR-T",SUP-394969,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"MULTIPLAN [10600]",Multiplan,,35360,85,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 430CC 12.9CM 4.4CM PROJECTION MODERATE PLUS P",SUP-SMPB430,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"PHCS [10601]",PHCS,,5337.15,70,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE HUMERAL 10MM COMPREHENSIVE SHOULDER POSITIONING",SUP-113578,CDM,C1776,HCPCS,0278,RC,,,both,,,1518.10,455.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,696.81,45.9,,,,,0,176.56,1290.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 1.1MM 24MM STAINLESS STEEL PARTIAL THREAD LOW",SUP-S30-24S-11,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,396.9,39.2,,957.42,570.23,957.42,28,117.75,860.63,"percent of total billed charges",
"STENT CONTOUR ZIPWIRE 24CM 3CM 8FR .038IN PIGTAIL CURVE",SUP-M006180542170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL LARGE FREEZE DRIED SHAFT 126MM",SUP-72A003,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,1466.08,39.2,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM VARIAX NONSTERILE",SUP-657422,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"KAISER [10500]",Kaiser,,541.83,67,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 6MM XIA 3 TITANIUM RADIOLUCENT",SUP-48238040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"STEM FEMORAL 16CM 12.7MM SECUR-FIT MAX HA 132D 10 41.7MM 35",SUP-6051-1035S,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"MULTIPLAN [10600]",Multiplan,,13301.82,85,,,,,0,1820,13301.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR HIP RIGHT TOTAL",SUP-98000700017,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"CIGNA [10200]",Cigna,,10080,40,,5873.17,5873.17,5873.17,"1 through 10",2930.76,21420,"percent of total billed charges",
"DRSG OTOPORE CYL FIRM BIORESORBABLE SOL WOUND EAR",SUP-5400020000,CDM,S27000186,LOCAL,0270,RC,,,both,,,759.38,227.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,348.56,45.9,,,,,0,88.32,645.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 6IN WATSON SURGICAL SKIN GRAFT STERILE",SUP-BA718R,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.08,20.72,"UHC [10700]","United Healthcare",,43.73,63.3,,,,,0,8.03,58.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL LONG MONOPOLAR STIMULATE",SUP-2701-90026,CDM,S27200284,LOCAL,0272,RC,,,both,,,2587.50,776.25,"MULTIPLAN [10600]",Multiplan,,2199.38,85,,,,,0,300.93,2199.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 15FTX2IN WRIST WRINKLE FREE STRETCH PAD",SUP-OG-2L2,CDM,S27000186,LOCAL,0270,RC,,,both,,,317.20,95.16,"PHCS [10601]",PHCS,,222.04,70,,,,,0,36.89,269.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 10CM 34MM TAG THORACIC ACTIVE CONTROL",SUP-TGM343410,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,31312.49,27,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOABLATION 10CM CRYOICE ALUMINUM STERILE LATEX FREE",SUP-CRYO3,CDM,C9808,HCPCS,0272,RC,,,both,,,15870.00,4761,"AETNA [10100]","Aetna HMO/PPO",,12616.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE 40MM 57CM 8-6MM TAPER VASCULAR NITINOL",SUP-SR-080640-TCS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SENTAI FIGHTER VASCULAR 190CM 18CM .009IN STAINLESS",SUP-H749393031902,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"MULTIPLAN [10600]",Multiplan,,826.2,85,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS HIGHFLOW 100CM 7FR JL5 CURVE ANGIOGRAPHIC DUCOR",SUP-527722,CDM,C1887,HCPCS,0272,RC,,,both,,,137.11,41.13,"MULTIPLAN [10600]",Multiplan,,116.54,85,,,,,0,15.95,116.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEADACHES WITHOUT MCC",103,MS-DRG,,,,,,,inpatient,,,30826.86,9248.06,"AMBETTER EXCHANGE  [11102]",Ambetter,,5187.62,,"Case rate ($5,187.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,817.06, add-ons for qualifying new technology services are included. If operating cost exceeds $37,856.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,746.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,823.43. The transfer operating threshold is the transfer adjustment factor * $4,817.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $364.19. The transfer capital threshold is the transfer adjustment factor * $364.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",9315.65,9315.65,9315.65,"1 through 10",5187.62,20856.49,other,"INPATIENT DRG"
"STENT ORSIRO 2.5/18",SUP-401748,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXERCISER HAND ROLYAN BLACK PLASTIC RUBBER LIGHTWEIGHT FRAME",SUP-A3488,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.81,15.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,24.24,45.9,,,,,0,6.14,44.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 10MMX8MMX6CM",SUP-TSB081006A,CDM,C1874,HCPCS,0278,RC,,,both,,,49140.00,14742,"BLUE CROSS [10001]","Blue Cross HMO",,19262.88,39.2,,9776.84,9776.84,9776.84,"1 through 10",5714.98,41769,"percent of total billed charges",
"TUBE JEJUNOSTOMY 45CM 22FR SILICONE MIC SECUR-LOK 1 PORT",SUP-0200-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"CIGNA [10200]",Cigna,,747.71,68,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION",RX-9859,CDM,J1110,HCPCS,0636,RC,81284-0411-00,NDC,both,1,ML,471.91,141.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,111.31,,,,,,,27.16,401.12,"fee schedule",
"SCR BONE 4.5MM 32MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.732,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,515.75,45.9,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 39FR 5.51MM LEFT ANGLE 2 LUMEN COLOR",SUP-5-16039,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID H+3MM 36MM INSET 0MM STD SHOULDER REVERSE",SUP-2R1GLC0336,CDM,C1776,HCPCS,0278,RC,,,both,,,12816.75,3845.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5126.7,40,,,,,0,1490.59,10894.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL 45X27X40MM MBT KNEE METAPHYSEAL POROUS",SUP-129454110,CDM,C1776,HCPCS,0278,RC,,,both,,,15133.08,4539.92,"BLUE CROSS [10001]","Blue Cross PPO",,5932.17,39.2,,3949.44,3949.44,3949.44,"1 through 10",1759.98,12863.12,"percent of total billed charges",
"DIL SURGICAL SET STIMULATED NIM",SUP-945NSD2750,CDM,S27200284,LOCAL,0272,RC,,,both,,,3245.00,973.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,377.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,377.39,2758.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"22MM X 45MM X 15MM 12 LLIF CAGE POROUS COATED",SUP-P12245-215,CDM,S27800098,LOCAL,0278,RC,,,both,,,25200.00,7560,"CIGNA [10200]","Cigna Local Plus",,7938,31.5,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TALAR INBONE 4 DOME ANKLE SULCUS",SUP-220220904,CDM,C1776,HCPCS,0278,RC,,,both,,,23719.50,7115.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9748.71,41.1,,6417.48,6417.48,6417.48,"1 through 10",2758.58,20161.58,"percent of total billed charges",
"SET VENTRICULAR ASSIST IMPELLA AXILLARY LATEX FREE",SUP-0052-0011,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,860.63,45.9,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM TRIATHLON 5 LEFT MEDIAL RIGHT LATERAL",SUP-5546-A-501,CDM,C1776,HCPCS,0278,RC,,,both,,,4252.25,1275.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,503.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,494.54,3614.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ORTHOPEDIC XL 23-25.5IN KNEE NEOPRENE SLEEVE OPEN",SUP-NE7702-05,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.70,30.51,"UHC [10700]","United Healthcare",,64.38,63.3,,,,,0,11.83,86.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 10MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650610,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]",Cigna,,5250.9,40,,5873.17,5873.17,5873.17,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"AUG TIBIAL TRIATHLON E CONE KNEE TRITANIUM SYMMETRIC",SUP-5549-A-150,CDM,C1776,HCPCS,0278,RC,,,both,,,22087.80,6626.34,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5963.71,27,,,,,0,2568.81,18774.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE GENESIS 27CM 13MM 3 PAIR TAIL CAP TRIMMABLE",SUP-919513SC,CDM,C2622,HCPCS,0278,RC,,,both,,,55704.60,16711.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,22281.84,40,,,,,0,6478.44,47348.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLERGIC REACTIONS WITHOUT MCC",916,MS-DRG,,,,,,,inpatient,,,22697.28,6809.18,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,8415.8,,"Case rate ($4,133.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,837.86, add-ons for qualifying new technology services are included. If operating cost exceeds $36,877.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,672.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,842.94. The transfer operating threshold is the transfer adjustment factor * $3,837.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $290.16. The transfer capital threshold is the transfer adjustment factor * $290.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,4133.09,16616.86,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Sl Imm Ea 1 / Add on 88341",PX-312000098,CDM,0761T,CPT,0312,RC,,,both,,,100.00,30,"CIGNA [10200]",Cigna,,68,68,,,,,0,11.85,85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355070,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",512.88,3748.5,"percent of total billed charges",
"SIZER IMPL 12IN 12.3-13CM MEMORYGEL P3.8-4.5CM STD MODERATE",SUP-351-325SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"KAISER [10500]",Kaiser,,569.84,67,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS MULTIPASS 5-0 P-1 18IN BRAID ANTIBACTERIAL",SUP-VCP490G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"NOVANET [10819]",Novanet,,18.75,75,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 40MM 120CM 8MM VASCULAR PERIPHERAL SELF",SUP-PRB35-08-040-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE LCP ORTHOPEDIC 200MM 2.5MM STAINLESS STEEL DRILL TIP",SUP-310.243,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 20X20MM FORTIFY 0D 20MM FOOTPRINT UPPER",SUP-151.401,CDM,S27800098,LOCAL,0278,RC,,,both,,,3172.50,951.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1456.18,45.9,,,,,0,368.96,2696.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC 7.5MM 52.3X45.4MM ADAPTA DR MVP ATRIUM",SUP-ADDRL1,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"MULTIPLAN [10600]",Multiplan,,35360,85,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE ENDOSCOPIC BNX SHARKCORE",SUP-DSC-25-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,2865.00,859.5,"CIGNA [10200]",Cigna,,1948.2,68,,,,,0,333.2,2435.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 30MM DART-FIRE SMALL HEADLESS",SUP-D2N30030,CDM,C1713,HCPCS,0278,RC,,,both,,,1657.50,497.25,"BLUE CROSS [10001]","Blue Cross PPO",,649.74,39.2,,957.42,570.23,957.42,28,192.77,1408.88,"percent of total billed charges",
"CAUT OPHTHALMIC 2IN ACCU-TEMP 1205C FINE TIP HIGH",SUP-8445000,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.14,53.74,"PHCS [10601]",PHCS,,125.4,70,,,,,0,20.83,152.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 32MM 144CM 2.5MM CORONARY STENT",SUP-H7493941832250,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14X7MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2207,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1123.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1123.46,8211,"percent of total billed charges",
"SYSTEM SYNERGY 38MM 144CM 4MM CORONARY STENT EVEROLIMUS",SUP-H7493926138400,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]","Cigna Open Access",,4907.63,56.9,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 D NEUTRAL 36MM E1 HIP",SUP-010000856,CDM,C1776,HCPCS,0278,RC,,,both,,,12282.00,3684.6,"NOVANET [10819]",Novanet,,9211.5,75,,,,,0,1428.4,10439.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 NARROW 7MM KNEE POSTERIOR STABILIZE IDENTITY",SUP-TPS-020-076N,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"PHCS [10601]",PHCS,,4115.16,70,,,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC",976,MS-DRG,,,,,,,inpatient,,,38188.64,11456.59,"BLUE CROSS [10001]","Blue Cross PPO",,3131.13,,,,,,,1958,3142.79,"per diem","Estimated amount calculated based on 4 day length of stay."
"SCR BONE 2.7MM 10MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0325,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,434.99,45.9,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERTORQUE 100CM 5FR VERTEBRAL CURVE ANGIOGRAPHIC",SUP-532549H0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UHC [10700]","United Healthcare",,66.09,63.3,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LEFT FOOT 19MM STAINLESS STEEL 2MM SCR MINI FRAGMENT",SUP-243.33,CDM,C1713,HCPCS,0278,RC,,,both,,,1053.41,316.02,"AMERIGROUP MEDICAID [20100]",Amerigroup,,124.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",122.51,895.4,"percent of total billed charges",
"SCR BONE 3MM 14MM TITANIUM CERVICAL SPINE LOCKING NONSTERILE",SUP-04.617.814,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,396.9,39.2,,957.42,570.23,957.42,28,117.75,860.63,"percent of total billed charges",
"SYSTEM INTEGRITY 18MM 4MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT40018UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,286.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 60MM 80CM 9MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM09060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PHCS [10601]",PHCS,,12789,70,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA H KNEE RIGHT 2 PEG TIVANIUM STERILE",SUP-42530008302,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5830.04,41.1,,6417.48,6417.48,6417.48,"1 through 10",1649.72,12057.27,"percent of total billed charges",
"SHEATH TIGHTRAIL SUB-C .171IN DIL ROTATE STERILE LATEX FREE",SUP-560-013,CDM,C1773,HCPCS,0272,RC,,,both,,,12385.50,3715.65,"FIRST HEALTH [10303]","First Health",,9908.4,80,,,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP 3 HOLE POLY POROUS R3 STD STERILE",SUP-71335556,CDM,C1776,HCPCS,0278,RC,,,both,,,14386.50,4315.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3884.36,27,,,,,0,1673.15,12228.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SENSOR 22CM 6FR .035IN URETERAL PERCUFLEX PLUS",SUP-M006175261090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,157.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA2-17-75-5.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,9177.00,2753.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1067.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 8MM 22MM EXPERT TITANIUM FULL THREAD TIBIA 2",SUP-04.005.412S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,177.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",174.09,1272.35,"percent of total billed charges",
"PLATE TIBIAL 82X54MM NEXGEN 8 KNEE TIVANIUM PMMA UHMWPE",SUP-598005702,CDM,C1713,HCPCS,0278,RC,,,both,,,11772.78,3531.83,"KAISER [10500]",Kaiser,,7887.76,67,,,,,0,1369.17,10006.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) REPRIEVE SYSTEM SALINE INFUSION SINGLE USE SET / STER",SUP-AC00001,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DXTERITY 100CM 5FR .047IN MULTIPURPOSE B CURVE",SUP-DXT5MPB,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL LOOP .015IN ANGLE RIGHT 26FR USA",SUP-MLE-26-015,CDM,S27200284,LOCAL,0272,RC,,,both,,,450.30,135.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HYDROXYUREA 100 MG/ML ORAL SUSPENSION",RX-408879,CDM,,,0637,RC,08888-8885-95,NDC,both,50,ML,107.03,32.11,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"REAMER SURGICAL 25MM INSRT DRILL BIT PATELLA PFC SIGMA",SUP-966676,CDM,S27200284,LOCAL,0272,RC,,,both,,,996.79,299.04,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PREVAIL DCB 2.25X20MM",SUP-PRV022520CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OCCL CARDIOVASCULAR 8MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-008,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8734.08,41.1,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR EMPHASYS 48MM 36MM AOX NEUTRAL",SUP-472248036,CDM,C1776,HCPCS,0278,RC,,,both,,,14038.05,4211.41,"MULTIPLAN [10600]",Multiplan,,11932.34,85,,,,,0,1632.63,11932.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS GWIRE INSRT TOOL TORQUE DEVICE",SUP-MAP403,CDM,S27200284,LOCAL,0272,RC,,,both,,,202.19,60.66,"UHC [10700]","United Healthcare",,127.99,63.3,,,,,0,23.51,171.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 80CM 11MM 16SQ MM 8FR .035IN",SUP-BXA112901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2311.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC",614,MS-DRG,,,,,,,inpatient,,,119151.48,35745.44,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,14411.63,,"Case rate ($13,595.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,624.69, add-ons for qualifying new technology services are included. If operating cost exceeds $45,664.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,336.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $12,641.38. The transfer operating threshold is the transfer adjustment factor * $12,624.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $954.49. The transfer capital threshold is the transfer adjustment factor * $954.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,63991.79,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 45CM 22FR SILICONE MIC SECUR-LOK UNIVERSAL",SUP-0260-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,2567.55,770.26,"CIGNA [10200]",Cigna,,1745.93,68,,,,,0,298.61,2182.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT NEUROSURGICAL DENVER ASCITES 2 VALVE PACK STERILE",SUP-42-2050,CDM,S27200284,LOCAL,0272,RC,,,both,,,12889.20,3866.76,"NOVANET [10819]",Novanet,,9666.9,75,,,,,0,1499.01,10955.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enteroscopy Retro Through Rectum",PX-750000245,CDM,44799,CPT,0750,RC,,,both,,,3746.37,1123.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3471.7,,"Case rate ($3,471.70). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,435.7,3746.37,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 4MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG40008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"AMERIGROUP MEDICAID [20100]",Amerigroup,,319.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 4FR 2.7MM CAMINO INTRACRANIAL TRNSDUC TIP",SUP-1104B,CDM,S27200284,LOCAL,0272,RC,,,both,,,5510.75,1653.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,653.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,640.9,4684.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLENOSPHERE - 36MM DIA X 2MM THK 2MM ECCENTRIC",SUP-5573-2E-3602,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"UHC [10700]","United Healthcare",,7718.3,63.3,,8601.07,8395.67,8601.07,"1 through 10",1418.07,10364.22,"percent of total billed charges",
"KIT NEROSTIMLTR NEVRO IMPLANATABLE PULSE GENRTR STERILE",SUP-ACCK7100,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,70.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTAPRO 135CM .58IN 2.5MM ATHERECTOMY PRECONNECT BURR",SUP-H749394672500,CDM,C1724,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1594.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10-5MM TORNADO PLATINUM .018IN CATH",SUP-G47518,CDM,S27800098,LOCAL,0278,RC,,,both,,,931.42,279.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,110.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.32,791.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 9MM LCP STAINLESS STEEL DISTAL RADIUS T8",SUP-212.809,CDM,C1713,HCPCS,0278,RC,,,both,,,802.87,240.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,368.52,45.9,,,,,0,93.37,682.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 6MM 2.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP2506X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 7.5X50MM POLYAXIAL 4S RELINE-O",SUP-13117550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"SCREW SPINAL PEDICLE POLYAXIAL 2FC TITANIUM 4.5MM X 40MM REL",SUP-16214540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"COMPONENT FEMORAL 3 KNEE RIGHT CRUCIATE RETAINING PFC SIGMA",SUP-940023,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"BLUE CROSS [10001]","Blue Cross PPO",,10148.82,39.2,,3949.44,3949.44,3949.44,"1 through 10",3010.99,22006.37,"percent of total billed charges",
"ANCHOR SUT 4.75MM CORKSCREW FT 3 PLAY PEEK STERILE LATEX",SUP-AR-1927PSF-475,CDM,C1713,HCPCS,0278,RC,,,both,,,2480.63,744.19,"AETNA [10100]","Aetna HMO/PPO",,1972.1,79.5,,1521.93,481.35,16760.95,30,288.5,2108.54,"percent of total billed charges",
"CATH ZOOM 158CM .051IN .035IN THROMBECTOMY REPERFUSION",SUP-ICRC035158,CDM,S27200284,LOCAL,0272,RC,,,both,,,11626.50,3487.95,"CIGNA [10200]","Cigna Local Plus",,6220.18,53.5,,,,,0,1352.16,9882.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 8MM NATURAL LORDOTIC CORTICOCANCELLOUS",SUP-018408,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035423100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"PHCS [10601]",PHCS,,9880.25,70,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cntrl Mtr Evoked Pot Upr/Lwr",PX-922000018,CDM,95939,CPT,0922,RC,,,both,,,812.00,243.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,372.71,45.9,,,,,0,94.44,690.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 4-5 C-D KNEE RIGHT TIBIA FIX",SUP-42522100316,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Open Access",,6131.78,56.9,,5302.19,4377.88,6578.61,27,1253.3,9159.96,"percent of total billed charges",
"CMPNT FEMORAL 11+ KNEE CONDYLAR CEMENT CONSTRAIN PERSONA",SUP-42504607012,CDM,C1776,HCPCS,0278,RC,,,both,,,49172.76,14751.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5718.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5718.79,41796.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ISONIAZID 300 MG TABLET",RX-4027,CDM,,,0637,RC,51079-0083-01,NDC,both,1,UN,6.48,1.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.75,5.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 57MM 36MM GLADIATOR HIP COCR XLPE UHMWPE",SUP-GLBP3657,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"MULTIPLAN [10600]",Multiplan,,12081.9,85,,,,,0,1653.09,12081.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC PROMRI 2 CHMBR ELUNA DR-T",SUP-394969,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"CIGNA [10200]","Cigna Local Plus",,13104,31.5,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 6X4IN VENTRAL HERNIA RESORBABLE",SUP-PCO1510OSX,CDM,C1781,HCPCS,0278,RC,,,both,,,3352.00,1005.6,"FIRST HEALTH [10303]","First Health",,2681.6,80,,,,,0,389.84,2849.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETERIZATION FOLEY URINE METER 16FR",SUP-81-080516,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.45,69.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,106.24,45.9,,,,,0,26.92,196.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Pelvis W Cntrst",PX-610000019,CDM,72196,CPT,0610,RC,,,both,,,3996.00,1198.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1248,,,,,,,464.73,3396.6,"per diem",
"HC Pump Bld Centrif Revol",PX-E27200275,CDM,E27200275,LOCAL,0272,RC,,,both,,,570.97,171.29,"AETNA [10100]","Aetna HMO/PPO",,453.92,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,66.4,485.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plasma Hemoglobin",PX-301000458,CDM,83051,CPT,0301,RC,,,both,,,189.05,56.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.68,,"Fee schedule rate ($7.68). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,160.69,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 7 HIP",SUP-PRTLE027,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2198.07,16065,"percent of total billed charges",
"CANN NASAL O2 DELIVERY TUBE MINIMIZE RESISTANCE INFANT",SUP-BC2745-20,CDM,S27000186,LOCAL,0270,RC,,,both,,,70.91,21.27,"NOVANET [10819]",Novanet,,53.18,75,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 11FR .144IN 25CM ROBUST VALVE SPLITTABLE",SUP-PLSX-2511,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 14 3 3/16IN FINGER ADJUSTABLE WATERPROOF",SUP-92728114,CDM,S27000186,LOCAL,0270,RC,,,both,,,88.13,26.44,"MULTIPLAN [10600]",Multiplan,,74.91,85,,,,,0,10.25,74.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 8MMX79MM 8FR 80CMCATH HEPARIN",SUP-BXB087901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8562.96,40,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL STANDARD+ KNEE LEFT CEMENT REVISION LCS",SUP-129429050,CDM,C1776,HCPCS,0278,RC,,,both,,,25958.52,7787.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3076.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3018.98,22064.74,"percent of total billed charges",
"CATH URETHRAL BARDEX IC 22FR FOLEY 2 WAY SILVER HYDROGEL 5ML",SUP-0165SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.82,19.45,"CIGNA [10200]",Cigna,,44.08,68,,,,,0,7.54,55.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM TRICUSPID 3 RADIAL MARKER POLISH WIRE",SUP-900SFC30,CDM,S27800098,LOCAL,0278,RC,,,both,,,14490.00,4347,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4147.04,28.62,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 28MM TI",SUP-VAN-25280-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"BLUE CROSS [10001]","Blue Cross HMO",,381.02,39.2,,957.42,156.86,7483.26,51,113.04,826.2,"percent of total billed charges",
"SHANK SCR 45MM 6.5MM MODULEX OSTEOGRIP SPINE",SUP-55900506545,CDM,C1713,HCPCS,0278,RC,,,both,,,4519.50,1355.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1293.48,28.62,,,,,0,525.62,3841.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Stent & Ather",PX-361000155,CDM,37227,CPT,0361,RC,,,both,,,28914.88,8674.46,"CIGNA [10200]",Cigna,,7680,,"Case rate ($7,680). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3362.8,24577.65,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 53CM 6.6FR MYOCARDIUM UNIPOLAR FIXED SCR IS-1",SUP-5071-53,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1604.72,28.62,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 80MM 12MM LEGION SHORT KNEE TITANIUM",SUP-71424163,CDM,C1776,HCPCS,0278,RC,,,both,,,8642.25,2592.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3966.79,45.9,,,,,0,1005.09,7345.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC",068,MS-DRG,,,,,,,inpatient,,,41748.27,12524.48,"BLUE CROSS [10001]","Blue Cross PPO",,21339.49,,,,,,,5361.93,21557.27,"case rate",
"PLATE SMALL 92MM TITANIUM 2 HOLE SHAFT 2 COMPRESSION SLOT",SUP-59202010,CDM,C1713,HCPCS,0278,RC,,,both,,,14993.70,4498.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6162.41,41.1,,,,,0,1743.77,12744.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Psg W Cpap/Bipap",PX-740000006,CDM,95811,CPT,0920,RC,,,both,,,7507.61,2252.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1520.44,,"Per diem ($1,520.44).",,,,0,873.14,6381.47,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC No Pt Prsnt Train Initial 30 (Go)",PX-430000070,CDM,G0541,HCPCS,0430,RC,,,both,,,70.00,21,"CIGNA [10200]",Cigna,,70,,"Per diem ($369).",,,,0,0.07,70,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM LOW PROFILE NECK VERTICAL GROOVE CORAIL2",SUP-L20315,CDM,C1776,HCPCS,0278,RC,,,both,,,28658.70,8597.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3396.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3333.01,24359.9,"percent of total billed charges",
"SCR BONE 4.5MM 14MM OZARK SPINE CERVICAL SELF START VARIABLE",SUP-8801-04514DA,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,1144.80,304.56,2275.09,66,117.75,860.63,"percent of total billed charges",
"SCR BONE 3.5MM 16MM ENDOSKELETON TCS TITANIUM STD SPINE",SUP-5301-3516,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,3978.14,359.25,3978.14,24,117.75,860.63,"percent of total billed charges",
"SUT STRATAFIX PDS PLUS 1 MO-4 SPIRAL 14IN ABSORBABLE",SUP-SXPP2B400,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PHCS [10601]",PHCS,,17.5,70,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM G7 STD THR E1 HIP STEM CUP LINER HEAD PREM",SUP-98000100155,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6804,27,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 15X10MM THK.4MM SMOOTH FINE TEETH SAGITTAL SLOTTED",SUP-532.042S,CDM,S27200284,LOCAL,0272,RC,,,both,,,605.07,181.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,71.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.37,514.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET AUTOMATIC GAS VENT LEVEL 1 IRRIGATION 300- MMHG STERILE",SUP-IR-500,CDM,S27200284,LOCAL,0272,RC,,,both,,,273.35,82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,112.35,41.1,,,,,0,31.79,232.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN MULTIPURPOSE B CURVE",SUP-DXT5MPB,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.97,41.1,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANSTR SUCTION 800CC HIGH FLOW HI-FLOW TRUFREEZE SPRAY",SUP-8002055,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.71,14.91,"CIGNA [10200]","Cigna Open Access",,28.28,56.9,,,,,0,5.78,42.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE/SLEEVE ORTHOPEDIC 2MM DALL-MILES LOW PROFILE HIP",SUP-37040050,CDM,C1713,HCPCS,0278,RC,,,both,,,2133.75,640.12,"MULTIPLAN [10600]",Multiplan,,1813.69,85,,,,,0,248.16,1813.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Rmvl Hot Bx",PX-750000078,CDM,45333,CPT,0750,RC,,,both,,,2142.07,642.62,"MULTIPLAN [10600]",Multiplan,,1820.76,85,,,,,0,249.12,2142.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 12MM 2.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2512X,CDM,C1725,HCPCS,0272,RC,,,both,,,560.93,168.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,381.43,68,,,,,0,65.24,476.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROLL STRLZTN 228FTX4IN STERRAD HEAT SEAL CHEM INDCTR TYVEK",SUP-12410,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM 21.4MM REGENT PYROLYTIC CARBON PTFE",SUP-23AGN-751,CDM,S27800098,LOCAL,0278,RC,,,both,,,31229.42,9368.83,"BLUE CROSS [10001]","Blue Cross PPO",,12241.93,39.2,,,,,0,3631.98,26545.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 10MM REUSABLE HANDLE ACL PCL SURGICAL PARALLEL GRAFT",SUP-AR-2285-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,429.35,128.8,"KAISER [10500]",Kaiser,,287.66,67,,,,,0,49.93,364.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE CORTICAL BLOCK FREEZE DRIED 14X11X6MM",SUP-200641,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cr Mycoplasma Pneumoniae by Pc",PX-306000203,CDM,87581,CPT,0306,RC,,,both,,,460.75,138.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,55.2,,,,,,,0.01,391.64,"fee schedule",
"HC Sol Irr Nacl 9 500ml",PX-E27200251,CDM,E27200251,LOCAL,0272,RC,,,both,,,37.40,11.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.35,31.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR FMP 10DEGX36",SUP-932-36-754,CDM,C1776,HCPCS,0278,RC,,,both,,,16186.99,4856.1,"PHCS [10601]",PHCS,,11330.89,70,,,,,0,1882.55,13758.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 9MM 14IN SUMP-N-SHEATH SILICONE WITHOUT CLOT",SUP-111155,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIFLUFOLASTAT F-18 IV SYRINGE (10-11 MCI)",RX-411827,CDM,A9595,HCPCS,0343,RC,08888-8877-81,NDC,both,1,UN,16868.88,5060.66,"BLUE CROSS [10001]","Blue Cross HMO",,7885.38,,,,,,,696,14338.55,"fee schedule",
"TOTAL KNEE 2A POROUS/HYBRID PROPRIETARY DEPUY - ATTUNE ROTAT",SUP-CAP-K-2A,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"PHCS [10601]",PHCS,,16317,70,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTAREX 110CM 8FR ATHERECTOMY SET GWIRE STERILE",SUP-80239,CDM,C1724,HCPCS,0272,RC,,,both,,,23625.00,7087.5,"FIRST HEALTH [10303]","First Health",,18900,80,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 36MM SYNAPSE TITANIUM 40D T15 SPINE",SUP-04.614.236,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"XIENCE SKYPOINT DES 3.25 X 28 RX US",SUP-1804325-28,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insj Perm Ccm-D Sys 1 Transvns Lead Only",PX-481000412,CDM,0917T,CPT,0481,RC,,,both,,,12746.00,3823.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1510.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1482.36,12746,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SYSTEM TRUFILL EMBOLIC 1GM KIT LIQUID",SUP-631500,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"**DO NOT REUSE ITEM # - PS GO LIVE ISSUE**WAFER OSTOMY STD 1",SUP-14202,CDM,S27000186,LOCAL,0270,RC,,,both,,,0.65,0.19,"NOVANET [10819]",Novanet,,0.49,75,,,,,0,0.08,0.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW 7713515 ZEVO VAR SD 3.5MM X 15MM",SUP-7713515,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]",Cigna,,958.8,68,,1831.33,1831.33,1831.33,16,163.98,1198.5,"percent of total billed charges",
"TRNSDUC PRESSURE 12IN MERITRANS 3 WAY STPCOCK FEMALE LUER",SUP-K11-00280,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,53.64,41.1,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 26MM 2.25MM CORONARY RAPID EXCHANGE",SUP-ONYXNG22526UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"MULTIPLAN [10600]",Multiplan,,2231.25,85,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +10MM 36MM HIP C TAPER OFFSET COBALT CHROME",SUP-624718,CDM,C1776,HCPCS,0278,RC,,,both,,,4140.00,1242,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL INBONE II 4 LONG ANKLE RIGHT",SUP-220222904,CDM,C1776,HCPCS,0278,RC,,,both,,,7211.00,2163.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,854.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,838.64,6129.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 15MM 2MM BALLOON DILATATION",SUP-H7493912415200,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25X1.35MM STAINLESS STEEL DUAL CUT SAGITTAL",SUP-4125-135-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,302.00,90.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,35.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.12,256.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVRTB ENDOSCOPIC 50CM 19.5MM 8.6-10MM 16.7MM TAPER TIP",SUP-BX00711148,CDM,S27000186,LOCAL,0270,RC,,,both,,,1687.50,506.25,"KAISER [10500]",Kaiser,,1130.63,67,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 7CM MR8 1.5MM BALL FINE GRIT DISSECTING DIAMOND",SUP-MR8-7BA15DF,CDM,S27200284,LOCAL,0272,RC,,,both,,,1142.51,342.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,132.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,132.87,971.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)J VALVE BIOPROSTHESIS 28",SUP-ETF-28,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,91570.5,45.9,,,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAPE DRSG MEPITAC 118X.75IN WATERPROOF FILM BACK BREATHABLE",SUP-298300,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.58,23.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,36.53,45.9,,,,,0,9.26,67.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 2MM AXIUM PRIME HELIX DETACHABLE EXTRA",SUP-APB-2-1-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"KAISER [10500]",Kaiser,,5986.79,67,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
PROTEKDUO-31FR,SUP-5820-3118,CDM,S27200284,LOCAL,0272,RC,,,both,,,105450.00,31635,"KAISER [10500]",Kaiser,,70651.5,67,,,,,0,12263.84,89632.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM 3.8MM NEURO STERILE",SUP-5820107430,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,502.59,45.9,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT ENDOSCOPIC 2 ACTION MONOPOLAR SERRATE JAW WIDE SPREAD",SUP-625124,CDM,S27200284,LOCAL,0272,RC,,,both,,,3935.42,1180.63,"UHC [10700]","United Healthcare",,2491.12,63.3,,,,,0,457.69,3345.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MFLD ANGIOGRAPHY 1 VALVE AUTODESK SHAPE MANAGER RIGHT OFF",SUP-H965700381071,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.86,43.46,"NOVANET [10819]",Novanet,,108.65,75,,,,,0,16.85,123.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENCORE 26 INFLATION 20ML GATEWAY Y ADPTR TORQUE GWIRE",SUP-H74904527052,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.88,84.56,"MULTIPLAN [10600]",Multiplan,,239.6,85,,,,,0,32.78,239.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SPINAL SPINEJACK 4.2MM EXPANSION",SUP-0909-200-042,CDM,S27200284,LOCAL,0272,RC,,,both,,,8966.41,2689.92,"UHC [10700]","United Healthcare",,5675.74,63.3,,,,,0,1042.79,7621.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POS OR DE MAYO LEG BOOT STERILE",SUP-110550,CDM,S27200284,LOCAL,0272,RC,,,both,,,302.76,90.83,"CIGNA [10200]","Cigna Open Access",,172.27,56.9,,,,,0,35.21,257.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUPLER ANSTM 4MM RNG PIN ULTSNC",SUP-GEM2756-FC,CDM,S27200284,LOCAL,0272,RC,,,both,,,7569.30,2270.79,"CIGNA [10200]","Cigna Local Plus",,4049.58,53.5,,,,,0,880.31,6433.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 80MM 130CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-EX060803CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3167.1,27,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"**DO NOT REUSE ITEM # - PS GO LIVE ISSUE**SLEEVE COMPRESSION",SUP-5897,CDM,S27000186,LOCAL,0270,RC,,,both,,,232.62,69.79,"CIGNA [10200]","Cigna Open Access",,132.36,56.9,,,,,0,27.05,197.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS INTRAOCULAR ADULT +21.0 DIOPTER L13MM DIA6MM AC D5.4MM",SUP-ZCB0000210,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"PHCS [10601]",PHCS,,822.15,70,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE VASCULAR 1.5MM J CURVE STD TAPER 260CM 3CM",SUP-GR3526,CDM,C1769,HCPCS,0272,RC,,,both,,,408.90,122.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,278.05,68,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR HEMI 3HL 62MM",SUP-430-98-062,CDM,C1776,HCPCS,0278,RC,,,both,,,16956.34,5086.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6969.06,41.1,,6417.48,6417.48,6417.48,"1 through 10",1972.02,14412.89,"percent of total billed charges",
"SCR BONE 1.5MM 3MM 24MM TITANIUM CORTEX HAND SELF TAPPING",SUP-400.824.96,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"FIRST HEALTH [10303]","First Health",,259.19,80,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 4CM 1.5MM GALAXY G3 MINI STRETCH",SUP-GLM915040,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]",Cigna,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 45MM FREEMAN AREOLA BREAST BIOPSY STAINLESS STEEL",SUP-P467,CDM,S27200284,LOCAL,0272,RC,,,both,,,507.79,152.34,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,59.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.06,431.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR TRNSDUC POLE MOUNT RESVR TRUWAVE VAMP 72IN",SUP-PXVMP272,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.09,54.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.94,153.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP: BIPOLAR HIP Z1 STEM / CERAMIC HEAD",SUP-98000100276,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"AETNA [10100]","Aetna HMO/PPO",,8228.25,79.5,,10981.53,8986.79,12413.38,12,1203.71,8797.5,"percent of total billed charges",
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 135CM 8MM 30MM",SUP-38047-83013,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"AETNA [10100]","Aetna HMO/PPO",,3839.85,79.5,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SHUNT ACCU-FLO CSF CATH 3 WAY PLASTIC STERILE",SUP-45105,CDM,S27800098,LOCAL,0278,RC,,,both,,,2171.03,651.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,257.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,252.49,1845.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 60MM 5MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171050610,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UHC [10700]","United Healthcare",,743.46,63.3,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIGNS AND SYMPTOMS WITHOUT MCC",948,MS-DRG,,,,,,,inpatient,,,29162.51,8748.75,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,10675.93,,"Case rate ($4,965.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,610.85, add-ons for qualifying new technology services are included. If operating cost exceeds $37,650.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,730.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,616.95. The transfer operating threshold is the transfer adjustment factor * $4,610.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $348.60. The transfer capital threshold is the transfer adjustment factor * $348.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,4965.55,19963.67,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR LONG 145CM 10CM .018IN",SUP-M001466000,CDM,C1769,HCPCS,0272,RC,,,both,,,486.32,145.9,"PHCS [10601]",PHCS,,340.42,70,,,,,0,56.56,413.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 2.25X1.25IN SMALL FOAM RUBBER DOYLE II EXTERNAL",SUP-1528110,CDM,S27000186,LOCAL,0270,RC,,,both,,,357.40,107.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,243.03,68,,,,,0,41.57,303.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SURGICAL CATARACT",SUP-SA60WF.245,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross PPO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AMPLATZ 17CM 18FR ACCESS PTFE RENAL FIRM TAPER TIP",SUP-M0062601470,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,39.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PROSTREAM VASCULAR 175CM 9CM .035IN TEFLON STAINLESS",SUP-41277-01,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 12MM 2.5MM CORONARY STENT EVEROLIMUS",SUP-1550250-12,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"SUT PROLENE 2-0 V-5 36IN 2 ARM MONOFILAMENT BLUE",SUP-8937H,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.29,24.69,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OSCOR SHEATH 13.5 FR",SUP-DCT1357125NM,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE ELECTROSURGICAL 20MM OPTABLATE 1 KIT STERILE LATEX",SUP-9700-020-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,23706.90,7112.07,"UHC [10700]","United Healthcare",,15006.47,63.3,,,,,0,2757.11,20150.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL ADULT 5 MASK O2 RESVR BAG PATIENT VALVE LATEX",SUP-520211000A,CDM,S27000186,LOCAL,0270,RC,,,both,,,59.60,17.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,40.53,68,,,,,0,6.93,50.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5.5MM CROSSBLADE BURSECTOR",SUP-0475561000,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,278.84,45.9,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 14CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155213180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"PHCS [10601]",PHCS,,1126.8,70,,,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 3-0 PS-1 27IN MONOFILAMENT UNDYED",SUP-Y936H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"CIGNA [10200]","Cigna Open Access",,15.36,56.9,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 120MM 130CM 7MM 6FR .035IN VASCULAR NITINOL",SUP-EX071203CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"FIRST HEALTH [10303]","First Health",,12144,80,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NEW LOCK OVERLAP ATLANTIS VISION BONE SPINAL",SUP-7200170,CDM,C1713,HCPCS,0278,RC,,,both,,,4620.00,1386,"AETNA [10100]","Aetna HMO/PPO",,3672.9,79.5,,1521.93,481.35,16760.95,30,537.31,3927,"percent of total billed charges",
"HC Estrone",PX-301000185,CDM,82679,CPT,0301,RC,,,both,,,331.55,99.46,"NOVANET [10819]",Novanet,,248.66,75,,,,,0,0.01,281.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"CMPNT FEMORAL 3 RIGHT MEDIAL LEFT LATERAL PARTIAL KNEE",SUP-5610-F-302,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2862.6,28.62,,,,,0,1163.24,8501.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cdisloc Shldr WO Anes",PX-450000085,CDM,23650,CPT,0361,RC,,,both,,,1314.00,394.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,155.71,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,152.82,1314,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR FR4 CURVE ANGIOGRAPHIC VENTRICULAR 2",SUP-H74916391021,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]","Cigna Local Plus",,40.97,53.5,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 2-0 GS-21 .5 CIRCLE 9IN TAPER POINT",SUP-VLOCL0345,CDM,S27200284,LOCAL,0272,RC,,,both,,,405.94,121.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,47.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.21,345.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 240MM 17MM REVISION MONOLITHIC REDAPT ROCKTITE",SUP-71354706,CDM,C1776,HCPCS,0278,RC,,,both,,,51237.90,15371.37,"NOVANET [10819]",Novanet,,38428.43,75,,,,,0,5958.97,43552.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 37MM 135CM 8MM 40MM BILIARY STAINLESS STEEL",SUP-PXB35-08-37-135,CDM,C1876,HCPCS,0278,RC,,,both,,,4347.00,1304.1,"AETNA [10100]","Aetna HMO/PPO",,3455.87,79.5,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STATLOCK ARTERIAL SELECT 8IN SECUREMENT TRICOT ADULT",SUP-ART0421,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.59,14.28,"MULTIPLAN [10600]",Multiplan,,40.45,85,,,,,0,5.53,40.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 4 HIP",SUP-PRTLE024,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2198.07,16065,"percent of total billed charges",
"STENT INNOVA 20MM 130CM 6MM VASCULAR SELF EXPAND RADIOPAQUE",SUP-H74939293060230,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,572.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DSRCTOR 14MM CERVICAL PIN SCR CASPAR SURGICAL STERILE",SUP-R6398A,CDM,S27200284,LOCAL,0272,RC,,,both,,,515.73,154.72,"KAISER [10500]",Kaiser,,345.54,67,,,,,0,59.98,438.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 150CM 7FR .038IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145372170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"FIRST HEALTH [10303]","First Health",,903.96,80,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PYROCARBON HEMI SHOULDER",SUP-CAP1109,CDM,C1776,HCPCS,0278,RC,,,both,,,50400.00,15120,"PHCS [10601]",PHCS,,35280,70,,,,,0,5861.52,42840,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 331311 ACSR 13X11X11 SRVC FEE",SUP-331311,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 115CM 5MM 5FR ELECTROPHYSIOLOGY 4 POLE 12 PIN",SUP-D1085413,CDM,C1730,HCPCS,0272,RC,,,both,,,1425.60,427.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 8CM 5FR 7MM .035IN BALLOON",SUP-G52274,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PHCS [10601]",PHCS,,671.84,70,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17MM 11MM COMPLEX .018IN HELICAL PLATINUM",SUP-M0013120771,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO IMAGER D BLADE C-MAC DISPOSABLE",SUP-051116-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,22.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC",379,MS-DRG,,,,,,,inpatient,,,23864.19,7159.26,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,4027.72,,"Case rate ($3,910.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,631.08, add-ons for qualifying new technology services are included. If operating cost exceeds $36,670.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,656.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,635.88. The transfer operating threshold is the transfer adjustment factor * $3,631.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $274.53. The transfer capital threshold is the transfer adjustment factor * $274.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,3910.41,15721.55,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL SIZE 6 L150MM CEMENTED CONSTRAINED NEXEL",SUP-840004615,CDM,C1776,HCPCS,0278,RC,,,both,,,36662.85,10998.85,"BLUE CROSS [10001]","Blue Cross HMO",,14371.84,39.2,,5311.50,4717.44,5388.59,31,4263.89,31163.42,"percent of total billed charges",
"PLATE SMALL STATURE NARROW WIDTH 22X16X2MM TITANIUM 1 LEVEL",SUP-487.213,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",521.61,3812.25,"percent of total billed charges",
"5MM ACCESS PORT WITH BLADELESS OPTICAL TIP, 100 MM",SUP-IAS5-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,705.48,211.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,289.95,41.1,,,,,0,82.05,599.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 165CM 1.9-2.8FR .019IN PROGREAT",SUP-CC*M1916DN,CDM,C1725,HCPCS,0272,RC,,,both,,,5375.10,1612.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,625.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,625.12,4568.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.0MM X 12.0MM",SUP-492001212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC",205,MS-DRG,,,,,,,inpatient,,,28308.90,8492.67,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,11698.54,,"Case rate ($11,357.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,546.49, add-ons for qualifying new technology services are included. If operating cost exceeds $43,586.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,179.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,560.44. The transfer operating threshold is the transfer adjustment factor * $10,546.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $797.37. The transfer capital threshold is the transfer adjustment factor * $797.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,8593,28308.9,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TENDYNE TMVR SYSTEM LP35M","SUP-TENDYNE TENDYNE 35M SYSTEM",CDM,S27800098,LOCAL,0278,RC,,,both,,,319200.00,95760,"CIGNA [10200]",Cigna,,127680,40,,,,,0,37122.96,271320,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +16 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.160,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEWIRE VASCULAR CORDIS EMERALD HEPARIN PTFE 3 MM RADIUS J",SUP-502587,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,39.33,41.1,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SET BANDER URETER  LF 7F",SUP-25707,CDM,S27200284,LOCAL,0272,RC,,,both,,,523.26,156.98,"PHCS [10601]",PHCS,,366.28,70,,,,,0,60.86,444.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 16IN 36-46FR VENOUS OPEN LIGHTHOUSE 3 STAGE",SUP-TF3646O2,CDM,S27200284,LOCAL,0272,RC,,,both,,,388.19,116.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,159.55,41.1,,,,,0,45.15,329.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 24CM 20FR AXILLARY AORTA SUBCLAVIAN 3/8IN",SUP-OPTI20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1902.83,570.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,873.4,45.9,,,,,0,221.3,1617.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOR SKIN DISORDERS WITHOUT MCC",607,MS-DRG,,,,,,,inpatient,,,26723.16,8016.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8175.73,,"Fee schedule rate ($8,175.73). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,5622.45,22604.71,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Occipital Bi",PX-510000116,CDM,64405,CPT,0361,RC,,,both,,,3761.00,1128.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1249,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1249,1922,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 8MM THORACIC KNIT HEMASHIELD GOLD",SUP-M002020951080,CDM,C1768,HCPCS,0278,RC,,,both,,,2540.03,762.01,"CIGNA [10200]","Cigna Local Plus",,1358.92,53.5,,,,,0,295.41,2159.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 SWIVELOCK C KNOTLESS CLOSED EYELET TWIST IN",SUP-AR-2323KBCC,CDM,C1713,HCPCS,0278,RC,,,both,,,3622.50,1086.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,429.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",421.3,3079.13,"percent of total billed charges",
"(EVAL) AGENT DCB CATHETER 3.5MM X 40MM",SUP-H7493960840350,CDM,C9610,HCPCS,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 440MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.265S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CIGNA [10200]","Cigna Local Plus",,3911.78,31.5,,3978.14,359.25,3978.14,24,1444.25,10555.59,"percent of total billed charges",
"ANCHOR SUT 5.5MM 2 .5 CIRCLE FULL THREAD BIO-CORKSCREW",SUP-AR-1927BNF,CDM,C1713,HCPCS,0278,RC,,,both,,,2212.50,663.75,"BLUE CROSS [10001]","Blue Cross HMO",,867.3,39.2,,957.42,156.86,7483.26,51,257.31,1880.63,"percent of total billed charges",
"GWIRE HI-TORQUE PROGRESS 200T VASCULAR STRAIGHT 190CM 3CM",SUP-1011842,CDM,C1769,HCPCS,0272,RC,,,both,,,1036.80,311.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,120.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 14MM 4MM STAINLESS STEEL SHORT THREAD HAND",SUP-02.226.214,CDM,C1713,HCPCS,0278,RC,,,both,,,1647.00,494.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,755.97,45.9,,,,,0,191.55,1399.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INLAY OPTIMA 28CM 8FR URETERAL PHREECOAT POLYMER",SUP-788828,CDM,C2625,HCPCS,0278,RC,,,both,,,834.30,250.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,98.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.03,709.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL VOCAL CORD PROLARYN GEL WATER BASE INJECTABLE TEMPORARY",SUP-8602M0K5,CDM,C1878,HCPCS,0278,RC,,,both,,,4933.50,1480.05,"BLUE CROSS [10001]","Blue Cross HMO",,1933.93,39.2,,,,,0,573.77,4193.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ADMIN 750ML/MIN INTRAVENOUS LEVEL 1 NORMOTHERMIC",SUP-D-70,CDM,S27200284,LOCAL,0272,RC,,,both,,,332.98,99.89,"CIGNA [10200]","Cigna Open Access",,189.47,56.9,,,,,0,38.73,283.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 98MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-224.551,CDM,C1713,HCPCS,0278,RC,,,both,,,2116.80,635.04,"BLUE CROSS [10001]","Blue Cross HMO",,829.79,39.2,,957.42,156.86,7483.26,51,246.18,1799.28,"percent of total billed charges",
"IMPL BREAST 770CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-770,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AETNA [10100]","Aetna HMO/PPO",,6006.62,79.5,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DANTROLENE 25 MG CAPSULE",RX-9718,CDM,,,0637,RC,50268-0217-11,NDC,both,1,UN,11.96,3.59,"AETNA [10100]","Aetna HMO/PPO",,9.51,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.39,10.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM CREO SPINE PREASSEMBLE THREAD",SUP-5119.1747,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPIDERFX .014IN LOOP 3MM 190CM 3.2-4.2FR .066IN",SUP-SPD2-US-030-190,CDM,C1884,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]",Cigna,,4926.6,68,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ULTRA FAST-FIX STRAIGHT FIXATION MENISCAL REPAIR",SUP-72201490,CDM,C1713,HCPCS,0278,RC,,,both,,,2338.88,701.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,277.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,272.01,1988.05,"percent of total billed charges",
"PATCH SURGICAL LARGE CIRCLE 3.2IN UMBILICAL HERNIA REPAIR",SUP-0010303,CDM,C1781,HCPCS,0278,RC,,,both,,,2370.82,711.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,280.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,275.73,2015.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 6-0 C-2 18IN MONOFILAMENT BLACK NONABSORBABLE",SUP-667G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AETNA [10100]","Aetna HMO/PPO",,19.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 4FR .042IN 1200 PSI AMPLATZ",SUP-538447,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"PHCS [10601]",PHCS,,62.66,70,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG 5L EFFULENT FEMALE LUER LOCK CNCT STERILE",SUP-114423,CDM,S27000186,LOCAL,0270,RC,,,both,,,63.87,19.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,29.32,45.9,,,,,0,7.43,54.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSELTAMIVIR 30 MG CAPSULE",RX-88704,CDM,,,0637,RC,64380-0797-01,NDC,both,1,UN,53.60,16.08,"PHCS [10601]",PHCS,,37.52,70,,,,,0,6.23,45.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 24CM 8FR .035",SUP-M006192152090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"CIGNA [10200]","Cigna Open Access",,849.19,,,,,,,173.57,1268.57,"percent of total billed charges",
"HC Angio Intrnl Mammary Si",PX-323000024,CDM,75756,CPT,0323,RC,,,both,,,4905.87,1471.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,581.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.57,4905.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENDO STITCH V-LOC 180 0 6IN CLSR ABSORBABLE RELOAD",SUP-VLOCA006L,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.01,84.3,"KAISER [10500]",Kaiser,,188.28,67,,,,,0,32.68,238.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 5FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G00983,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"AETNA [10100]","Aetna HMO/PPO",,39.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0225,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 60MM 157CM 8MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200086020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"KAISER [10500]",Kaiser,,2773.8,67,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BMA NEEDLE 74285-02M 11 GAUGE X 15CM",SUP-7428502M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.00,513,"NOVANET [10819]",Novanet,,1282.5,75,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 36MM NCB PROTASUL-64 3.5MM SELF TAP 2 LEAD",SUP-0203150036,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"MULTIPLAN [10600]",Multiplan,,1577.81,85,,,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT 3 KNEE CEMENT ROTATE PLATFORM",SUP-129431130,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH 6MM LONG HANDLE AORTIC",SUP-APU560,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"PHCS [10601]",PHCS,,202.98,70,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Interrog Dev Eval in Person",PX-480000078,CDM,0521T,CPT,0480,RC,,,both,,,579.79,173.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,68.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.43,579.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo Intestine Sm Ilium Dx",PX-750000063,CDM,44376,CPT,0750,RC,,,both,,,4078.00,1223.4,"BLUE CROSS [10001]","Blue Cross PPO",,3634.7,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,474.27,4078,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,inpatient,,,34737.02,10421.11,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,12873.81,,"Case rate ($5,987.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,560.09, add-ons for qualifying new technology services are included. If operating cost exceeds $38,599.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,802.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $5,567.44. The transfer operating threshold is the transfer adjustment factor * $5,560.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.37. The transfer capital threshold is the transfer adjustment factor * $420.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,5987.82,24073.62,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC BREAST BIOPSY 12CM 12GA ATEC 20MM ULTRASOUND FAST","SUP-ATEC 1212-20",CDM,S27200284,LOCAL,0272,RC,,,both,,,1696.50,508.95,"MULTIPLAN [10600]",Multiplan,,1442.03,85,,,,,0,197.3,1442.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA H KNEE RIGHT 2 PEG TIVANIUM STERILE",SUP-42530008302,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"KAISER [10500]",Kaiser,,9503.96,67,,,,,0,1649.72,12057.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ENDARTERECTOMY 11MM 13MM 2 COAXIAL METAL RING",SUP-E4500-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,17633.70,5290.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2050.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2050.8,14988.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC",661,MS-DRG,,,,,,,inpatient,,,39926.03,11977.81,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,6615.33,,"Case rate ($6,422.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,963.87, add-ons for qualifying new technology services are included. If operating cost exceeds $39,003.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,832.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $5,971.75. The transfer operating threshold is the transfer adjustment factor * $5,963.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.90. The transfer capital threshold is the transfer adjustment factor * $450.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,6422.65,30229.54,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPN NC 20MM 1.5MM BALLOON DILATATION PLATINUM IRIDIUM",SUP-150-020-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"NOVANET [10819]",Novanet,,6210,75,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN HALF 180MM 5MM APEX HOFFMANN II CANCELLOUS STAINLESS",SUP-5018-6-180,CDM,C1713,HCPCS,0278,RC,,,both,,,1041.01,312.3,"MULTIPLAN [10600]",Multiplan,,884.86,85,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SCIS LAPSCP LOGI-CUT SH 330MM",SUP-120-7000,CDM,S27200284,LOCAL,0272,RC,,,both,,,320.70,96.21,"AETNA [10100]","Aetna HMO/PPO",,254.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.3,272.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet Not Otherwise Specified",PX-404000011,CDM,G0235,HCPCS,0404,RC,,,both,,,9966.87,2990.06,"FIRST HEALTH [10303]","First Health",,7973.5,80,,,,,0,982.43,8808,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 150CM 8FR .038IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145380170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"MULTIPLAN [10600]",Multiplan,,960.46,85,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 59CM .013IN EXTRA SOFT STRAIGHT STERILE LATEX",SUP-5005,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 45MM BIO-MOORE II ENDO II HIP ACETABULAR",SUP-12-139014,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"CIGNA [10200]",Cigna,,1899.24,68,,5873.17,5873.17,5873.17,"1 through 10",324.83,2374.05,"percent of total billed charges",
"BEARING 4MM OXFORD ARCOM KNEE LEFT MENISCAL PHASE 3",SUP-159541,CDM,C1776,HCPCS,0278,RC,,,both,,,5270.22,1581.07,"PHCS [10601]",PHCS,,3689.15,70,,,,,0,612.93,4479.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 8.5FR 18GA 16CM .032IN 4 LUMEN INDWELL CATH GWIRE",SUP-CDC-42854-1A,CDM,C1751,HCPCS,0272,RC,,,both,,,831.24,249.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,98.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,96.67,706.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB ADULT 45MM ADHSV CONDUCTIVE RADIOLUCENT",SUP-8900-4005,CDM,S27000186,LOCAL,0270,RC,,,both,,,392.95,117.88,"MULTIPLAN [10600]",Multiplan,,334.01,85,,,,,0,26.56,334.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 0D G 11.4MM 32MM X3 HIP",SUP-623-00-32G,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"UHC [10700]","United Healthcare",,5409.4,63.3,,8601.07,8395.67,8601.07,"1 through 10",993.86,7263.8,"percent of total billed charges",
"HEAD FEMORAL -2MM 36MM CERAMIC ARTICUL/EZE",SUP-473436920,CDM,C1776,HCPCS,0278,RC,,,both,,,14072.55,4221.76,"BLUE CROSS [10001]","Blue Cross PPO",,5516.44,39.2,,3949.44,3949.44,3949.44,"1 through 10",1636.64,11961.67,"percent of total billed charges",
"SCR BONE 1.5MM 8MM APTUS TITANIUM HEXADRIVE 4 HAND CORTICAL",SUP-A-5200.08/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"CIGNA [10200]","Cigna Local Plus",,676.03,53.5,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HYPERGLIDE 150CM 10MM 2.2-2.8FR 3MM .01IN 4MM BALLOON",SUP-104-4310,CDM,C1725,HCPCS,0272,RC,,,both,,,8790.60,2637.18,"AETNA [10100]","Aetna HMO/PPO",,6988.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1022.35,7472.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 640CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRM-640,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"FIRST HEALTH [10303]","First Health",,3175.2,80,,,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 10MM LCP STAINLESS STEEL SHORT THREAD FIBULA",SUP-207.610,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"MULTIPLAN [10600]",Multiplan,,884.03,85,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT 137CM 10MM 3.5MM RECTANGLE HELIX TAPER",SUP-2200-3510,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"KAISER [10500]",Kaiser,,3929.55,67,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.5MM 16MM FULL THREAD FOOT LOCKING SCR TIMAX F",SUP-FP16,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"PHCS [10601]",PHCS,,765.45,70,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW ACU-LOC 2 BONE LEFT DISTAL VOLAR RADIAL STERILE",SUP-70-0358,CDM,C1713,HCPCS,0278,RC,,,both,,,6654.91,1996.47,"CIGNA [10200]","Cigna Open Access",,3786.64,56.9,,1144.80,304.56,2275.09,66,773.97,5656.67,"percent of total billed charges",
"HC Ptca Sngl Maj Cor Arty/Br",PX-481000071,CDM,92920,CPT,0481,RC,,,both,,,19091.70,5727.51,"KAISER [10500]",Kaiser,,12791.44,67,,,,,0,2220.36,19091.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 5-0 C-1 30IN 2 ARM MONOFILAMENT VIOLET ABSORBABLE",SUP-Z126H,CDM,S27200284,LOCAL,0272,RC,,,both,,,193.43,58.03,"KAISER [10500]",Kaiser,,129.6,67,,,,,0,22.5,164.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 42MM ANTERIOR LUMBAR FUSION LEVEL 2 CONSTRAIN PYRENEES",SUP-208-42F42,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X250 80CM SL",SUP-48005025N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,121.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN LONG",SUP-77800400,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG 8 HOLE LOW PROFILE BONE LEFT CLAVICLE",SUP-70-0288,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3034.08,45.9,,,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SUCTION FLEXIBLE INTUB SCOPE DISPOSABLE",SUP-11301CE1/20,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.02,42.61,"FIRST HEALTH [10303]","First Health",,113.62,80,,,,,0,16.52,120.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 100MM SPINAL LOCKING POST",SUP-8461100,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"MULTIPLAN [10600]",Multiplan,,2045.61,85,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 4X3IN MEPITEL ONE SAFETAC NONADHERENT LATEX FREE",SUP-565991,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.33,19,"FIRST HEALTH [10303]","First Health",,50.66,80,,,,,0,7.37,53.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VENTRALIGHT ST ECHO 2 20CM CIRCLE",SUP-5990020,CDM,C1781,HCPCS,0278,RC,,,both,,,11011.02,3303.31,"AETNA [10100]","Aetna HMO/PPO",,8753.76,79.5,,,,,0,1280.58,9359.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE MIC-KEY",SUP-0270-18-2.7-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MENTAL DISORDER DIAGNOSES",887,MS-DRG,,,,,,,inpatient,,,41043.36,12313.01,"PHCS [10601]",PHCS,,2061,,,,,,,1958,26707.18,"per diem","Estimated amount calculated based on 3 day length of stay."
"SYSTEM IMAGING STEALTHSTATION SPHERE",SUP-8801075,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"CIGNA [10200]","Cigna Local Plus",,260.01,53.5,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM TRIATHLON 5 LEFT MEDIAL RIGHT LATERAL TOTAL",SUP-5545-A-501,CDM,C1776,HCPCS,0278,RC,,,both,,,6068.55,1820.56,"PHCS [10601]",PHCS,,4247.99,70,,,,,0,705.77,5158.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BURN 48X4IN ACTICOAT FLEX 3 POLYESTER NANOCRYSTALLINE",SUP-66800434,CDM,S27200284,LOCAL,0272,RC,,,both,,,580.61,174.18,"PHCS [10601]",PHCS,,406.43,70,,,,,0,67.52,493.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 64MM HIP MULTIHOLE RIM TRITANIUM X3 MDM",SUP-509-02-64G,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"UHC [10700]","United Healthcare",,7109.86,63.3,,8601.07,8395.67,8601.07,"1 through 10",1306.28,9547.2,"percent of total billed charges",
"GWIRE STARTER VASCULAR 1.5MM STD ROSEN CURVE TAPER 260CM 4CM",SUP-M001491571,CDM,C1769,HCPCS,0272,RC,,,both,,,132.78,39.83,"KAISER [10500]",Kaiser,,88.96,67,,,,,0,15.44,112.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INSTR GMK SPHERE DISPOSABLE MIS",SUP-11.01002,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX12MM MAXIM KNEE PRIMARY CRUCIATE RETAIN",SUP-11-146352,CDM,C1776,HCPCS,0278,RC,,,both,,,7472.70,2241.81,"BLUE CROSS [10001]","Blue Cross PPO",,2929.3,39.2,,3949.44,3949.44,3949.44,"1 through 10",869.08,6351.8,"percent of total billed charges",
"SYSTEM XIENCE SIERRA 33MM 3MM CORONARY STENT EVEROLIMUS",SUP-1550300-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 116MM PRIMARY ANTHOLOGY POROUS 131D 9 STD",SUP-71356009,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"UHC [10700]","United Healthcare",,20978.35,63.3,,8601.07,8395.67,8601.07,"1 through 10",3854.32,28169.98,"percent of total billed charges",
"CATH CONQUEST 75CM 2CM 6MM 6FR BALLOON DILATATION PERIPHERAL",SUP-CQ7562,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATHETER TURNPIKE LP 135CM 2.2-2.9FR 1.6FR INTERVENTI",SUP-5638,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X8MM COLONIAL 7D LORDOTIC 12MM LARGE",SUP-365.408CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 16MM CORE ALLOGRAFT CM2",SUP-PS60014,CDM,C1713,HCPCS,0278,RC,,,both,,,3341.25,1002.37,"PHCS [10601]",PHCS,,2338.88,70,,,,,0,388.59,2840.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VOYAGER NC 8MM 2.5MM SHORT ROUND TAPER BALLOON",SUP-1011752-08,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"AETNA [10100]","Aetna HMO/PPO",,579.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 41MM UNITRAX FEMORAL HIP MODULAR",SUP-6942-5-041,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"MULTIPLAN [10600]",Multiplan,,2658.55,85,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE REVISION HYBRID OXI FEM CONCELOC PATELLA",SUP-71704643,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"BLUE CROSS [10001]","Blue Cross PPO",,9137.52,39.2,,3949.44,3949.44,3949.44,"1 through 10",2710.95,19813.5,"percent of total billed charges",
"BURR SHAVER 13CM 5MM COOLCUT FLUSHCUT 8 FLUTE ROUND STERILE",SUP-AR-8500RBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,59.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,inpatient,,,55488.36,16646.51,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,9235.84,,"Case rate ($8,838.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,206.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,246.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,002.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,217.65. The transfer operating threshold is the transfer adjustment factor * $8,206.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.47. The transfer capital threshold is the transfer adjustment factor * $620.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",9506.68,9506.68,9506.68,"1 through 10",7561,35533.09,other,"IP DRG"
"SUT VICRYL RAPIDE MULTIPASS 4-0 PS-2 27IN BRAID COATED",SUP-VR426,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.27,20.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,46.42,68,,,,,0,7.94,58.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 2-0 SH SPIRAL 30CM KNOTLESS",SUP-SXMP1B410,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.03,65.41,"NOVANET [10819]",Novanet,,163.52,75,,,,,0,25.36,185.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 4.3MM SUREFORM 45 STERILE LATEX FREE DISPOSABLE",SUP-48345G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW TITANIUM ALUMINUM VANADIUM PERIPROSTHETIC NCB",SUP-0202263301,CDM,C1713,HCPCS,0278,RC,,,both,,,9729.00,2918.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4465.61,45.9,,,,,0,1131.48,8269.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OBRIEN PEEL-AWAY 12CM 16FR SUPRAPUBIC ACCESS INTRO SET",SUP-G15089,CDM,C1725,HCPCS,0272,RC,,,both,,,792.18,237.65,"AETNA [10100]","Aetna HMO/PPO",,629.78,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,92.13,673.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 5.5MM HEALICOIL ULTRABRAID PRELOAD OPEN",SUP-72203379,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,265.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,261.02,1907.72,"percent of total billed charges",
"SPACER ALLOGRAFT 8MM NATURAL LORDOTIC CORTICOCANCELLOUS",SUP-018408,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 17MM TITANIUM SPINAL SELF TAPPING VARIABLE",SUP-3120317,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"KAISER [10500]",Kaiser,,944.7,67,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 11CM 7FR DUODENAL PIGTAIL CURVE PANCREATIC",SUP-G27195,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL SHOULDER",SUP-CAP-ZB-TS1,CDM,C1776,HCPCS,0278,RC,,,both,,,30240.00,9072,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8164.8,27,,,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 145MM 3.5MM SCR 8 HOLE LCP BONE TIBIA LEFT PROXIMAL",SUP-239.959S,CDM,C1713,HCPCS,0278,RC,,,both,,,10791.60,3237.48,"AETNA [10100]","Aetna HMO/PPO",,8579.32,79.5,,1521.93,481.35,16760.95,30,1255.06,9172.86,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 12MM 140CM 3MM 2.1-2.7FR CORONARY STENT",SUP-RONYX30012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 120MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-120-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10782.00,3234.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7331.76,68,,,,,0,1253.95,9164.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 40MM 135CM 8MM VASCULAR OTW SELF EXPAND",SUP-1012536-40,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross PPO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION HELIX TEMPORARY",SUP-7807110,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER PROBE ULTRACOVER 244X12CM FOLD INTRAOPERATIVE TAPE",SUP-PC3787,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.73,15.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,20.85,41.1,,,,,0,5.9,43.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MULTIPAC INFINITI THRULUMEN 6FR 145D JL4 JR4 PIGTAIL",SUP-534692T,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.98,63.29,"AETNA [10100]","Aetna HMO/PPO",,167.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.54,179.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 30MM LCP STAINLESS STEEL CORTICAL FOREFOOT",SUP-202.890,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"NOVANET [10819]",Novanet,,242.99,75,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-2-2-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"MULTIPLAN [10600]",Multiplan,,9941.18,85,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 20MM 2.5MM .014IN BALLOON DILATATION",SUP-AB14W030020150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"MULTIPLAN [10600]",Multiplan,,1177.34,85,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HT COMMAND 14 ST 6G X 10CM 210CM ANG",SUP-1060001A,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"PHCS [10601]",PHCS,,674.73,70,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MULTIPAC INFINITI THRULUMEN 6FR 145D JL4 JR4 PIGTAIL",SUP-534692T,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.98,63.29,"CIGNA [10200]",Cigna,,143.47,68,,,,,0,24.54,179.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TENDYNE TMVR SYSTEM LP33S","SUP-TENDYNE TENDYNE 33S SYSTEM",CDM,S27800098,LOCAL,0278,RC,,,both,,,319200.00,95760,"BLUE CROSS [10001]","Blue Cross PPO",,125126.4,39.2,,,,,0,37122.96,271320,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 90MM 24MM 6MM 16FR ZENITH SPIRAL-Z",SUP-G55247,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"AETNA [10100]","Aetna HMO/PPO",,16833.57,79.5,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 3.5 MM SCREWS 1 HOLE LOW PROFILE",SUP-02.100.301S,CDM,C1713,HCPCS,0278,RC,,,both,,,2629.20,788.76,"NOVANET [10819]",Novanet,,1971.9,75,,,,,0,305.78,2234.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX 1S PERMANENT, 25X30 CM",SUP-F10246-2530P,CDM,C1781,HCPCS,0278,RC,,,both,,,60858.00,18257.4,"BLUE CROSS [10001]","Blue Cross HMO",,23856.34,39.2,,,,,0,7077.79,51729.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIFLUFOLASTAT F-18 IV SYRINGE (11-12 MCI)",RX-411828,CDM,A9595,HCPCS,0343,RC,08888-8877-82,NDC,both,1,UN,16868.88,5060.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8107.92,,,,,,,696,14338.55,"fee schedule",
"SHELL ACETABULAR 52MM HIP 3 HOLE POLY POROUS R3 STD STERILE",SUP-71335552,CDM,C1776,HCPCS,0278,RC,,,both,,,14365.80,4309.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5746.32,40,,,,,0,1670.74,12210.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL LMD 10  IN N S 500ML",SUP-07419-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,244.21,73.26,"AETNA [10100]","Aetna HMO/PPO",,194.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.4,207.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg WO Vid 2-12 Hr Unmntr",PX-740000040,CDM,95705,CPT,0740,RC,,,both,,,4168.00,1250.4,"FIRST HEALTH [10303]","First Health",,3334.4,80,,,,,0,4.17,3542.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Screen Alcohols Etoh",PX-301000505,CDM,80320,CPT,0301,RC,,,both,,,362.70,108.81,"FIRST HEALTH [10303]","First Health",,290.16,80,,,,,0,0.01,308.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Comp Ep Eval Txsept Cath a Fib",PX-481000096,CDM,93656,CPT,0481,RC,,,both,,,32036.13,9610.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5469,,"Case rate ($5,469). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3725.8,27504,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 22CM 6FR URETERAL FIRM STERILE LATEX FREE",SUP-M0061456450,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,286.99,45.9,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GABAPENTIN 250 MG/5 ML ORAL SOLUTION SUPERORDERABLE",RX-408898,CDM,,,0250,RC,42192-0608-05,NDC,both,5,ML,45.38,13.61,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HYPERTENSION,MINOR",199,APR-DRG,,,,,,,inpatient,,,27838.38,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $3,780.86. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%.",,,,0,,,other,"SOI-1 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"FLECAINIDE 100 MG TABLET",RX-10041,CDM,,,0637,RC,00054-0011-20,NDC,both,1,UN,18.01,5.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH REDEL 110CM 1MM 5FR 2-5-2MM SPACE A CURVE",SUP-F5QRA252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"3.5MM X 60MM M5+ CATHETER",SUP-FG63502-3560,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS 2-0 18IN BRAID 12 STRAND COATED VIOLET",SUP-VCP105G,CDM,S27200284,LOCAL,0272,RC,,,both,,,97.02,29.11,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BODY CONE 25MM RESTORATION +0MM STD HIP MODULAR REVISION",SUP-6276-1-025,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"KAISER [10500]",Kaiser,,9692.77,67,,,,,0,1682.49,12296.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL MBT LCS COMPLETE 3 KNEE POROUS CEMENTED KEEL",SUP-129434130,CDM,C1776,HCPCS,0278,RC,,,both,,,17561.25,5268.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2042.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2042.37,14927.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL LUMBAR ALIF ANTERIOR CONVEX 12 DEGRE",SUP-12421,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSOR LOGICUT 450MM",SUP-120-7004,CDM,S27200284,LOCAL,0272,RC,,,both,,,320.70,96.21,"CIGNA [10200]","Cigna Local Plus",,171.57,53.5,,,,,0,37.3,272.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 6MM 3MM BALLOON DILATATION PEBAX",SUP-1400300-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 4-0 PS-2 18IN MONOFILAMENT UNDYED",SUP-Y496G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27480,CDM,,,0637,RC,60687-0195-11,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,3.57,56.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM ORTHOLOC 3DSI STAINLESS STEEL FOOT ANKLE",SUP-40233516,CDM,C1713,HCPCS,0278,RC,,,both,,,1474.20,442.26,"CIGNA [10200]",Cigna,,1002.46,68,,1831.33,1831.33,1831.33,16,171.45,1253.07,"percent of total billed charges",
"CATH 70CM 5FR 20D .035IN URETERAL FLEXIBLE ANGLED TIP",SUP-23105,CDM,C1758,HCPCS,0272,RC,,,both,,,272.75,81.82,"MULTIPLAN [10600]",Multiplan,,231.84,85,,,,,0,31.72,231.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 150MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171031510,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RCRD CARDIAC REVEAL DX INSERTABLE AUTOMATICALLY ACTIVATED",SUP-9529,CDM,C1764,HCPCS,0278,RC,,,both,,,20884.50,6265.35,"AETNA [10100]","Aetna HMO/PPO",,16603.18,79.5,,,,,0,2428.87,17751.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) DISPOSABLE WEIGHT",SUP-5675,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.7MM CANNULATED",SUP-CSS07237,CDM,S27200284,LOCAL,0272,RC,,,both,,,1506.60,451.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,619.21,41.1,,,,,0,175.22,1280.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 2.5MM BALLOON DILATATION PEBAX",SUP-1012405-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.00MM X 10MM  SCOREFLEX  NC",SUP-620-104-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ercp Dx",PX-750000045,CDM,43260,CPT,0750,RC,,,both,,,4699.78,1409.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2262,,"Case rate ($2,262). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,546.58,4699.78,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 90CM .1IN 6FR .07IN XB3.5",SUP-67005490,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,171.63,41.1,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY 100CM 1.8MM RADIAL JAW 3 2MM PULMONARY",SUP-M00515231,CDM,S27200284,LOCAL,0272,RC,,,both,,,258.62,77.59,"CIGNA [10200]","Cigna Open Access",,147.15,56.9,,,,,0,30.08,219.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULE SENSOR VALVE REDUCTION STERILE",SUP-53-000032,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,262.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 14MM 140CM 2.25MM",SUP-RSINT22514UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"PHCS [10601]",PHCS,,3880.8,70,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 28MM 144CM 2.5MM CORONARY STENT",SUP-H7493911428250,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA [10200]","Cigna Open Access",,5202.08,56.9,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 20MM TI",SUP-SPL-35200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT REPAIR MESH UPSYLON Y",SUP-M0068318220,CDM,C1763,HCPCS,0278,RC,,,both,,,11217.61,3365.28,"KAISER [10500]",Kaiser,,7515.8,67,,,,,0,1304.61,9534.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRESSING FOAM ANTIMICROBIAL WITH SILVER MEPILEX BORDER POST-",SUP-498100,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.20,18.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VISE TORQUE ACCEPTS .025-.038 IN GWIRE",SUP-M001465501,CDM,S27200284,LOCAL,0272,RC,,,both,,,44.95,13.48,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 8FR .09IN EXTRA BACKUP LEFT 4.5 CURVE",SUP-LA8EBU45,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL CNCT ACUITY X4 GWIRE FLUSH LEAD",SUP-4604,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT STENT 28CM 8FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001245660,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"NOVANET [10819]",Novanet,,1293.75,75,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM FRMLA RESECTOR SERIES F LATEX FREE",SUP-0375542000,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,132.3,41.1,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE 30X20CM PREPERITONEAL KNIT WEB SYNECOR",SUP-GKWR2030,CDM,C1781,HCPCS,0278,RC,,,both,,,27442.80,8232.84,"KAISER [10500]",Kaiser,,18386.68,67,,,,,0,3191.6,23326.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE? NC PLUS BALLOON NON-COMPLIANT 2.0 MM X 18 MM",SUP-220-183-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM 2.6-2FR .019IN EXCELSIOR",SUP-M0031441920,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"PHCS [10601]",PHCS,,5403.47,70,,,,,0,897.75,6561.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM AVENIR 10 COIL FINISH COMPLEX",SUP-10CFN-02004,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3355.15,28.62,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3MM SPINE ODLP",SUP-8532063,CDM,C1713,HCPCS,0278,RC,,,both,,,443.23,132.97,"CIGNA [10200]","Cigna Local Plus",,237.13,53.5,,3978.14,359.25,3978.14,24,51.55,376.75,"percent of total billed charges",
"STENT ZILVER 635 FLEXOR 40MM 125CM 7MM 6FR VASCULAR NITINOL",SUP-G43826,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,439.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP 42MM 160CM 10MM 135CM ENDOPROSTHESIS",SUP-M001711350,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3879.7,45.9,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM EVOLVE STAINLESS STEEL CORTICAL ELBOW",SUP-4973530L,CDM,C1713,HCPCS,0278,RC,,,both,,,1710.00,513,"AMERIGROUP MEDICAID [20100]",Amerigroup,,202.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",198.87,1453.5,"percent of total billed charges",
"SCR BONE 2MM 3.5MM 26MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.826.96,CDM,C1713,HCPCS,0278,RC,,,both,,,319.12,95.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,91.33,28.62,,,,,0,37.11,271.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAVVY 150CM 4CM 3.5-3FR 4MM BALLOON DILATATION DURALYN",SUP-435404X,CDM,C1725,HCPCS,0272,RC,,,both,,,2137.50,641.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,248.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 85MM 20MM ASNIS III STAINLESS STEEL",SUP-326085,CDM,C1713,HCPCS,0278,RC,,,both,,,1904.40,571.32,"FIRST HEALTH [10303]","First Health",,1523.52,80,,,,,0,221.48,1618.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE MONOPOLAR L7MM WORKING L1.8MM STANDARD TYPE SB KNIFE",SUP-MD-47706,CDM,S27200284,LOCAL,0272,RC,,,both,,,5706.02,1711.81,"NOVANET [10819]",Novanet,,4279.52,75,,,,,0,663.61,4850.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 30MM 5.5MM .014IN LOW PROFILE",SUP-1008195-30,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"MULTIPLAN [10600]",Multiplan,,1204.88,85,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Prox Fib/Shaft WO Manip",PX-450000160,CDM,27780,CPT,0450,RC,,,both,,,1347.00,404.1,"MULTIPLAN [10600]",Multiplan,,1144.95,85,,,,,0,67.13,1347,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 26MM 4.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG45026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2887.50,866.25,"CIGNA [10200]","Cigna Open Access",,1642.99,56.9,,,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 18MM MINI-MONSTER SHORT THREAD CANNULATED",SUP-P20-125-018S,CDM,C1713,HCPCS,0278,RC,,,both,,,1559.25,467.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,184.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,181.34,1325.36,"percent of total billed charges",
"CEFTRIAXONE 2 G VIAL IV PUSH (2 G VIAL)",RX-408305,CDM,J0696,HCPCS,0636,RC,00781-3209-90,NDC,both,1,UN,471.91,141.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4.01,,,,,,,4.01,401.12,"fee schedule",
"CMPNT FEMORAL 4 64.5X59.7MM KNEE LEFT BICRUCIATE STABILIZE",SUP-74022124,CDM,C1776,HCPCS,0278,RC,,,both,,,37771.65,11331.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4475.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4392.84,32105.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 15MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158122115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PHCS [10601]",PHCS,,7822.19,70,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DAICOFF 7.75IN VASCULAR NDL PULL",SUP-30-8015,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Surg Path Gross Micro Level 3",PX-312000006,CDM,88304,CPT,0312,RC,,,both,,,495.21,148.56,"MULTIPLAN [10600]",Multiplan,,420.93,85,,,,,0,0.01,420.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM T10 FULL THREAD LOCK NONSTERILE",SUP-657018,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1011.05,68,,,,,0,172.92,1263.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYCLOSPORINE MODIFIED 25 MG CAPSULE",RX-28842,CDM,J7515,HCPCS,0636,RC,23155-0837-11,NDC,both,1,UN,6.27,1.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.93,,,,,,,0.74,5.33,"fee schedule",
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,P9041,HCPCS,0636,RC,44206-0310-50,NDC,both,500,ML,1358.64,407.59,"MULTIPLAN [10600]",Multiplan,,1154.84,85,,,,,0,123.78,1154.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC AVALUS 25MM 400 SERIES LATEX FREE",SUP-40025,CDM,S27800098,LOCAL,0278,RC,,,both,,,33390.00,10017,"BLUE CROSS [10001]","Blue Cross HMO",,13088.88,39.2,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SWARTZ LAMP 90 CURVE 90CM 8.5FR INTRO TRANSSEPTAL",SUP-407358,CDM,C1893,HCPCS,0272,RC,,,both,,,1291.06,387.32,"KAISER [10500]",Kaiser,,865.01,67,,,,,0,150.15,1097.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 75CM .38MM TPR MED",SUP-124301,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"BLUE CROSS [10001]","Blue Cross HMO",,150.06,39.2,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP LIMIT HOLE POROUS RANAWAT/BURSTEIN",SUP-11-106048,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4785.84,68,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 62.5MM KNEE LEFT POSTERIOR STABILIZE OPEN BOX",SUP-184526,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"KAISER [10500]",Kaiser,,16633.27,67,,,,,0,2887.24,21101.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET .241IN 77IN GRAVITY FLOW LARGE BORE NONVENT PIERCING PIN",SUP-654401,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.09,1.23,"PHCS [10601]",PHCS,,2.86,70,,,,,0,0.48,3.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GARM COMPRESSION 2XL CHEST 50-52IN VEST VELCRO SHOULDER",SUP-2-8003-XXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 22MM RSP SHOULDER LOCK GLENOID BASEPLT",SUP-506-03-122,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,184.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,180.93,1322.35,"percent of total billed charges",
"SUT FIBERWIRE 4-0 T-12 18IN BRAID TIES MULTISTRAND LOWER",SUP-AR-7230-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"MULTIPLAN [10600]",Multiplan,,170.82,85,,,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 20MM 10MM .035IN BALLOON DILATATION NYBAX",SUP-39171-10024,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER WECK EFX CONE 9.82IN SUT STERILE LATEX FREE",SUP-EFXCT1,CDM,S27200284,LOCAL,0272,RC,,,both,,,644.76,193.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,265,41.1,,,,,0,74.99,548.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE B CURVE",SUP-D7TCBL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"PHCS [10601]",PHCS,,3472.77,70,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 2X1CM AXOGUARD HA+ NERVE PROTCT EXTRACELLULAR",SUP-AGHA12,CDM,C1763,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GALLIUM-67 CITRATE INTRAVENOUS SOLUTION (4-5 MCI)",RX-411844,CDM,A9556,HCPCS,0343,RC,08888-8877-95,NDC,both,1,UN,404.00,121.2,"PHCS [10601]",PHCS,,282.8,70,,,,,0,0.06,343.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 6MM CLICKX CURVE TITANIUM NORMALIZE SOFT",SUP-498.139,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 5MM PRESS FIT FULL PROFILE TAPERLOC PPS",SUP-51-101050,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"UHC [10700]","United Healthcare",,15320.71,63.3,,8601.07,8395.67,8601.07,"1 through 10",2814.85,20572.84,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 45CM 16X8MM PERIPHERAL ABDOMINAL",SUP-631608,CDM,C1768,HCPCS,0278,RC,,,both,,,7521.00,2256.3,"FIRST HEALTH [10303]","First Health",,6016.8,80,,,,,0,874.69,6392.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 60MM 2.5MM BALLOON DILATATION",SUP-48002506X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP MICRO CURVE 6IN ENDOSCOPIC LIGATE HORIZON",SUP-537061,CDM,S27200284,LOCAL,0272,RC,,,both,,,2955.00,886.5,"CIGNA [10200]","Cigna Local Plus",,1580.93,53.5,,,,,0,343.67,2511.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Histone-Dna Cmplx Igg Autoabs",PX-301000268,CDM,83520,CPT,0301,RC,,,both,,,208.00,62.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,27.17,,,,,,,0.21,176.8,"fee schedule",
"PLATE 94MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 10",SUP-247.374,CDM,C1713,HCPCS,0278,RC,,,both,,,2429.70,728.91,"BLUE CROSS [10001]","Blue Cross PPO",,952.44,39.2,,957.42,570.23,957.42,28,282.57,2065.25,"percent of total billed charges",
"STENT 28CM 150CM 4.8FR .035IN 3CM STD STRAIGHT URETERAL",SUP-M006145353190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"NOVANET [10819]",Novanet,,847.46,75,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 100MM 2.5MM BALLOON DILATATION RAPID",SUP-47525100L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 25MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50025,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,34123.16,41.1,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 59CM 9FR 18CM SPACE HELIX ENDOCARDIUM 2 COIL",SUP-0184,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"MULTIPLAN [10600]",Multiplan,,14596.2,85,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 20CM 11FR SHORT LENGTH URETERAL",SUP-H7493936110200,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"CIGNA [10200]","Cigna Open Access",,705.16,,,,,,,144.13,1053.41,"percent of total billed charges",
"ANCHOR SUT 2 SWIVELOCK PEEK 19.1MM",SUP-AR-2324KPSLC,CDM,C1713,HCPCS,0278,RC,,,both,,,3425.63,1027.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1572.36,45.9,,,,,0,398.4,2911.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Similac Probiotic Tri-Blend",PX-E27000265,CDM,E27000265,LOCAL,0270,RC,,,both,,,63.40,19.02,"MULTIPLAN [10600]",Multiplan,,53.89,85,,,,,0,7.37,53.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEMORAL TRIATHLON 4MM KNEE OFFSET TOTAL STABILIZED",SUP-5570-S-040,CDM,C1776,HCPCS,0278,RC,,,both,,,5487.96,1646.39,"BLUE CROSS [10001]","Blue Cross HMO",,2151.28,39.2,,5311.50,4717.44,5388.59,31,638.25,4664.77,"percent of total billed charges",
"HC Bronch Lung Bx Add",PX-750000014,CDM,31632,CPT,0750,RC,,,both,,,3774.12,1132.24,"CIGNA [10200]","Cigna Open Access",,2751,,"Case rate ($2,751). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,438.93,3774.12,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Non-Indwelling Cath Strt",PX-450000271,CDM,51701,CPT,0361,RC,,,both,,,1404.45,421.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,163.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,163.34,1404.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ca Total",PX-301000123,CDM,82310,CPT,0301,RC,,,both,,,98.86,29.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4.64,,,,,,,0.01,84.03,"fee schedule",
"HC Trb Gene Rearrange Amplify",PX-309000074,CDM,81340,CPT,0310,RC,,,both,,,1573.20,471.96,"UHC [10700]","United Healthcare",,188.03,,,,,,,0.01,1337.22,"fee schedule",
"HC Trb Gene Rearrange Amplify",PX-309000074,CDM,81340,CPT,0310,RC,,,both,,,1573.20,471.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,188.03,,,,,,,0.01,1337.22,"fee schedule",
"CATH UNI-FUSE FLOW-THRU HUB 90CM 30CM 5FR THROMBECTOMY",SUP-H787124018085,CDM,C1757,HCPCS,0272,RC,,,both,,,3112.50,933.75,"FIRST HEALTH [10303]","First Health",,2490,80,,,,,0,189.34,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SURGICAL 4.7X3.1IN SPRING OPEN BIORESORBABLE SELF",SUP-5950030,CDM,C1781,HCPCS,0278,RC,,,both,,,2250.00,675,"BLUE CROSS [10001]","Blue Cross PPO",,882,39.2,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Maxfac W Cntrst",PX-351000009,CDM,70487,CPT,0351,RC,,,both,,,3184.62,955.39,"NOVANET [10819]",Novanet,,2388.47,75,,,,,0,370.37,2706.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 109MM COLLAR ACTIS DUOFIX 7 12/14 STD OFFSET",SUP-101011070,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"PHCS [10601]",PHCS,,21333.38,70,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR .071IN SHORT AMPLATZ LEFT 1 CURVE GUIDING",SUP-LA6SAL10,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 80MM 80CM 7MM VASCULAR NITINOL PERIPHERAL",SUP-1012529-80,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 13MM KNEE TOTAL STBL PLUS TRIATHLON STERILE",SUP-5537-G-313-E,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"BLUE CROSS [10001]","Blue Cross PPO",,5275.71,39.2,,3949.44,3949.44,3949.44,"1 through 10",1565.22,11439.68,"percent of total billed charges",
"CATH LAUNCHER 100CM 6FR .071IN MULTIAORTIC CURVE 3 GUIDING",SUP-LA6MAC30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 7IN 11MM C-REAMER 15-70MM ACL PCL SHORT HEAD TAPER",SUP-8774A,CDM,S27200284,LOCAL,0272,RC,,,both,,,625.73,187.72,"CIGNA [10200]",Cigna,,425.5,68,,,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 9MM 33MM SYMMETRIC TRIATHLON X3 KNEE",SUP-5550-G-339,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"CIGNA [10200]",Cigna,,2936.08,68,,5873.17,5873.17,5873.17,"1 through 10",502.16,3670.1,"percent of total billed charges",
"SHELL BIPOLAR 58MM MULTIPOLAR HIP METAL STERILE",SUP-500105800,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 FREEDOM H 36MM E1 HIP CONSTRAIN",SUP-010000986,CDM,C1776,HCPCS,0278,RC,,,both,,,19199.88,5759.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5495.01,28.62,,,,,0,2232.95,16319.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 80CM 4FR 6MM EMBOLECTOMY ADHERENT CLOT",SUP-140806,CDM,C1757,HCPCS,0272,RC,,,both,,,1763.85,529.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,209.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,205.14,1499.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY 1 BITE COLL BACKLOAD 115CM 2.4FR BIGOPSY STERILE",SUP-G48240,CDM,S27200284,LOCAL,0272,RC,,,both,,,3040.50,912.15,"FIRST HEALTH [10303]","First Health",,2432.4,80,,,,,0,353.61,2584.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR SAL.75 CURVE GUIDING NYLON",SUP-LA6SAL75,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER MRI GUIDED RIGID DEPLOYMENT DEVICE TRIMARK BREAST","SUP-TRIMARK TD 13MR",CDM,A4648,HCPCS,0278,RC,,,both,,,628.56,188.57,"CIGNA [10200]","Cigna Local Plus",,336.28,53.5,,,,,0,73.1,534.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 30MM 4MM MAXTORQUE",SUP-MSD01040030S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"CIGNA [10200]","Cigna Open Access",,806.56,56.9,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 16MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-516,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4512.21,45.9,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 12MM 144CM 3MM CORONARY STENT EVEROLIMUS",SUP-H7493926112300,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"AETNA [10100]","Aetna HMO/PPO",,6856.88,79.5,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE ORTHOPEDIC THK1/8IN SMALL 13IN NEOPRENE KNEE EXTRA",SUP-79-82003,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.72,17.02,"FIRST HEALTH [10303]","First Health",,45.38,80,,,,,0,6.6,48.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM LCP STAINLESS STEEL DISTAL RADIAL",SUP-212.818,CDM,C1713,HCPCS,0278,RC,,,both,,,802.87,240.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,545.95,68,,,,,0,93.37,682.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EVOLUT R 26MM 29MM INTRO AORTIC VALVE LOAD",SUP-LS-MDT2-2629-US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2925.00,877.5,"AETNA [10100]","Aetna HMO/PPO",,2325.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,340.18,2486.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG BONE CEMENT 22MM LARGE INTRAMEDULLARY CANAL STERILE",SUP-130613,CDM,C1713,HCPCS,0278,RC,,,both,,,1029.51,308.85,"BLUE CROSS [10001]","Blue Cross HMO",,403.57,39.2,,957.42,156.86,7483.26,51,119.73,875.08,"percent of total billed charges",
"HC Pre-Pooled Cryoprecipitate, Each Unit",PX-390000025,CDM,P9012,HCPCS,0390,RC,,,both,,,399.85,119.95,"MULTIPLAN [10600]",Multiplan,,339.87,85,,,,,0,46.5,339.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 10MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630610,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"BLUE CROSS [10001]","Blue Cross PPO",,5145.88,39.2,,3949.44,3949.44,3949.44,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"PRIMIDONE 50 MG TABLET",RX-11129,CDM,,,0637,RC,50268-0686-11,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INFUSION PORT WITHOUT Y SITE ACCESS 19GA POWERLOC 1IN",SUP-2651910,CDM,C1788,HCPCS,0278,RC,,,both,,,102.14,30.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,69.46,68,,,,,0,11.88,86.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 24MM RELINE C SPINE FAVOR ANGLE NONSTERILE",SUP-3914024,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,957.42,570.23,957.42,28,521.61,3812.25,"percent of total billed charges",
"STEM FEMORAL 115MM TRI-LOCK BPS GRIPTION 10 12/14 HIGH",SUP-101214100,CDM,C1776,HCPCS,0278,RC,,,both,,,29153.25,8745.97,"AETNA [10100]","Aetna HMO/PPO",,23176.83,79.5,,10981.53,8986.79,12413.38,12,3390.52,24780.26,"percent of total billed charges",
"CATH ROYAL FLUSH PLUS 110CM 5FR 26ML/SEC PIGTAIL CURVE",SUP-G11269,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,71.88,45.9,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sporanox",PX-301000080,CDM,80299,CPT,0301,RC,,,both,,,373.00,111.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.16,,,,,,,0.01,317.05,"fee schedule",
"STENT ELUVIA 100MM 130CM 7MM VASCULAR DRUG ELUTE DELIVERY",SUP-H74939294701010,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,9776.84,9776.84,9776.84,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",478,MS-DRG,,,,,,,inpatient,,,106769.94,32030.98,"CIGNA [10200]","Cigna Local Plus",,25376.48,,"Fee schedule rate ($25,376.48). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,71798.8,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR STD STRAIGHT TAPER 145CM 6CM .038IN STAINLESS",SUP-G00671,CDM,C1769,HCPCS,0272,RC,,,both,,,133.81,40.14,"KAISER [10500]",Kaiser,,89.65,67,,,,,0,15.56,113.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOMET FINNED PRI STEM 40MM",SUP-141314,CDM,C1776,HCPCS,0278,RC,,,both,,,4719.60,1415.88,"CIGNA [10200]","Cigna Local Plus",,2524.99,53.5,,5372.07,4581.20,7242.98,23,548.89,4011.66,"percent of total billed charges",
"STENT HERCULINK ELITE 25MM 80CM 6MM 3.6-3.3FR 6FR LOW",SUP-1011498-15,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1803.06,28.62,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYMER 10X17CM PERMANENT REINFORCE OVITEX IHR",SUP-F10244-1017I,CDM,C1781,HCPCS,0278,RC,,,both,,,4526.40,1357.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2077.62,45.9,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Breast W/WO Cntrst Bi",PX-610000063,CDM,77049,CPT,0610,RC,,,both,,,5537.24,1661.17,"PHCS [10601]",PHCS,,3876.07,70,,,,,0,643.98,4706.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD MARLEX 12X2IN GROIN MONOFILAMENT GOLD STD",SUP-0112670,CDM,C1781,HCPCS,0278,RC,,,both,,,399.33,119.8,"CIGNA [10200]","Cigna Open Access",,227.22,56.9,,11235.02,819.42,11235.02,"1 through 10",46.44,339.43,"percent of total billed charges",
"CMPNT FEMORAL 7 KNEE LEFT POSTERIOR STABILIZE CEMENT LEGION",SUP-71423227,CDM,C1776,HCPCS,0278,RC,,,both,,,21886.20,6565.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8995.23,41.1,,6417.48,6417.48,6417.48,"1 through 10",2545.37,18603.27,"percent of total billed charges",
"HC Chemo Cns",PX-331000006,CDM,96450,CPT,0331,RC,,,both,,,872.12,261.64,"NOVANET [10819]",Novanet,,654.09,75,,,,,0,101.43,872.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 5D SMALL FUSION MEDLINE UNITE BONE METATARSOPHALANGEAL",SUP-MPP1002L,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"FIRST HEALTH [10303]","First Health",,8252.4,80,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC CAP FIX STRAIGHT HIP CPSL",SUP-72205318,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 10.2MM 7MM EMG REINFORCED 2 CHANNEL LOW",SUP-8229307,CDM,S27200284,LOCAL,0272,RC,,,both,,,3435.00,1030.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,407.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,399.49,2919.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM TOP HAT SUPRA ANNULAR",SUP-S5-027,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9062.55,41.1,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 3CM 10MM BALLOON DILATATION 2 LUMEN",SUP-G52292,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBEROS 10CC",SUP-FB100,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"STENT OMNILINK ELITE 29MM 80CM 9MM THIN VASCULAR COCR",SUP-1012625-29,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"FIRST HEALTH [10303]","First Health",,6720,80,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X6MM COALITION MIS 7D 12MM TITANIUM STERILE",SUP-1136.2476,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Local Plus",,5433.75,31.5,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 20MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158123120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross PPO",,4380.42,39.2,,3949.44,3949.44,3949.44,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"FLUDEOXYGLUCOSE F-18 INTRAVENOUS SOLUTION",RX-184498,CDM,A9552,HCPCS,0343,RC,08888-8878-24,NDC,both,1,UN,755.00,226.5,"FIRST HEALTH [10303]","First Health",,604,80,,,,,0,87.81,755,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol D5",PX-E27200284,CDM,E27200284,LOCAL,0272,RC,,,both,,,121.00,36.3,"KAISER [10500]",Kaiser,,81.07,67,,,,,0,14.07,102.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 3CMX6MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-9-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"CIGNA [10200]",Cigna,,991.44,68,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 13MM 2MM SHANNON RECTA STERILE LATEX FREE",SUP-TM12013,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,909.34,41.1,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE MULTIAXIAL STERILE 7.5MM 50MM CD HORIZON LEGACY",SUP-75447550,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"NOVANET [10819]",Novanet,,3631.95,75,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 9MM APTUS TITANIUM 6MM WRIST CORTICAL 2",SUP-A-5450.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"UHC [10700]","United Healthcare",,1020.33,63.3,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 37CM XL CIRCULAR 2 ROW SEAL 5.2MMX1.5-2.2MM",SUP-ECS25B,CDM,S27200284,LOCAL,0272,RC,,,both,,,6267.91,1880.37,"CIGNA [10200]",Cigna,,4262.18,68,,,,,0,728.96,5327.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Splint Finger",PX-E27000165,CDM,E27000165,LOCAL,0270,RC,,,both,,,28.60,8.58,"MULTIPLAN [10600]",Multiplan,,24.31,85,,,,,0,3.33,24.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL TEMP PACING WIRE 2-0 SH SKS-3 24IN 2 ARM",SUP-TPW30,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.32,37.9,"CIGNA [10200]",Cigna,,85.9,68,,,,,0,14.69,107.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-593512022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP GRASPING ALLIGATOR JAW AUTOCLAVABLE RETRIEVAL BASKET",SUP-FG-49L-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3433.88,1030.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1576.15,45.9,,,,,0,399.36,2918.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM LCP STAINLESS STEEL SUPERIOR ANTERIOR",SUP-02.211.016,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"CIGNA [10200]","Cigna Local Plus",,480.5,53.5,,3978.14,359.25,3978.14,24,104.45,763.41,"percent of total billed charges",
"LENS IOL +14 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.140,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 8MM 3.5MM CORONARY STENT EVEROLIMUS",SUP-1550350-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 60MM 36MM MARATHON HIP",SUP-121936060,CDM,C1776,HCPCS,0278,RC,,,both,,,8942.40,2682.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1059.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1040,7601.04,"percent of total billed charges",
"PUNCH AORTIC ROTATING 2.8MM X 20CM CLEANCUT STERILE",SUP-RCL28,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"CIGNA [10200]",Cigna,,155.3,68,,,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 21GA 45CM 11CM SPRING COIL WIRE STRAIGHT",SUP-PID5F11021SSC,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL UROLOGICAL AMS 800 CONTROL PUMP INHIBIZONE SILICONE",SUP-72404127,CDM,C1815,HCPCS,0278,RC,,,both,,,49392.00,14817.6,"AETNA [10100]","Aetna HMO/PPO",,39266.64,79.5,,,,,0,5744.29,41983.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL RAPIDE MULTIPASS 5-0 P-3 18IN BRAID COATED UNDYED",SUP-VR493,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.98,20.99,"CIGNA [10200]",Cigna,,47.59,68,,,,,0,8.14,59.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PS MEDICAL C14-24CM 2O 84CM 20GA 14GA CATH BARIUM",SUP-44410,CDM,S27800098,LOCAL,0278,RC,,,both,,,6045.57,1813.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4110.99,68,,,,,0,703.1,5138.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRAVASTATIN 10 MG TABLET",RX-11110,CDM,,,0637,RC,00904-5891-61,NDC,both,1,UN,14.55,4.36,"CIGNA [10200]",Cigna,,9.89,68,,,,,0,1.69,12.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 6 KNEE LEFT DISTAL TOTAL",SUP-5542-A-601,CDM,C1776,HCPCS,0278,RC,,,both,,,7027.65,2108.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4778.8,68,,,,,0,817.32,5973.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 85X10X1.27MM OSCILLATE",SUP-507118000,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.01,58.2,"NOVANET [10819]",Novanet,,145.51,75,,,,,0,22.56,164.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPIDERFX .014IN 190CM 5MM EMBOLIC PROTECTION NITINOL",SUP-SPDRX-US-050,CDM,C1884,HCPCS,0272,RC,,,both,,,5859.00,1757.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2408.05,41.1,,,,,0,681.4,4980.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDPLATE SPINAL 14X6MM SECURE-C 6D 13MM SPHERICAL",SUP-714.266S,CDM,C1713,HCPCS,0278,RC,,,both,,,28350.00,8505,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7654.5,27,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 55CM 6FR .07IN REGULAR",SUP-67019055,CDM,C1887,HCPCS,0272,RC,,,both,,,304.50,91.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,125.15,41.1,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL ATTUNE CEMENTED POSTERIOR STABILIZE STERILE 5",SUP-150410105,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"BLUE CROSS [10001]","Blue Cross PPO",,8778.19,39.2,,3949.44,3949.44,3949.44,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"INSRT TIBIAL STD+ 15MM KNEE GVF POLYETHYLENE ROTATE PLATFORM",SUP-129405515,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"UHC [10700]","United Healthcare",,6116.96,63.3,,8601.07,8395.67,8601.07,"1 through 10",1123.86,8213.93,"percent of total billed charges",
"CATH CELSIUS REDEL 90CM 4MM 8FR 2-5-2MM SPACE F CURVE",SUP-D8BTFL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"KAISER [10500]",Kaiser,,3323.94,67,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH INSRT 6IN 7.5FR SENSATION PLUS REINFORCED SHEATH",SUP-0884-00-0019-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,1217.27,365.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,827.74,68,,,,,0,141.57,1034.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET SUPERORDERABLE",RX-409435,CDM,,,0637,RC,37000-0024-10,NDC,both,1,UN,12.54,3.76,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SHOCKWAVE C2 AERO 138CM 12MM 2.5MM .044IN LITHOTRIPSY",SUP-C2AIVL2512,CDM,C1761,HCPCS,0272,RC,,,both,,,29610.00,8883,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"TRAY TIBIAL 63MM VANGUARD 360 KNEE POROUS PRIMARY REVISION",SUP-185201,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"SCR INTERFERENCE 70% PLDLA 30% BETA TRI-CALCIUM PHOSPHATE 25",SUP-110004595,CDM,C1713,HCPCS,0278,RC,,,both,,,2835.00,850.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,335.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,329.71,2409.75,"percent of total billed charges",
"SYSTEM ACCUSTICK II 6FR INTRO STERILE DISPOSABLE",SUP-M001207050,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,358.02,68,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 7X11X35MM 12",SUP-5871352,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"FIRST HEALTH [10303]","First Health",,23040,80,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL JACOBSON MICRO STRAIGHT 7 1/8IN ARTERY EXTRA",SUP-16-4088,CDM,S27200284,LOCAL,0272,RC,,,both,,,494.51,148.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,226.98,45.9,,,,,0,57.51,420.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 4MM 1.2MM 32MM 14MM STAINLESS STEEL LONG THREAD",SUP-202.732,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"BLUE CROSS [10001]","Blue Cross PPO",,435.13,39.2,,957.42,570.23,957.42,28,129.1,943.52,"percent of total billed charges",
"NAIL 10MM 44CM LEFT TROCHANTERIC INTRAMEDULLARY 130D LONG",SUP-456.365S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3691.01,27,,,,,0,1589.87,11619.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 28CM 3CM 6FR .035IN 2",SUP-M006192134180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"KAISER [10500]",Kaiser,,1065.21,67,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR 54.5MM STAINLESS STEEL 3.2MM ROUND 6 FLUTE DENTAL",SUP-16-S0107,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.36,33.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.95,94.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO 90D 2.3MM ELBOW SHOULDER SUT NITINOL",SUP-AR-4065-90S,CDM,S27200284,LOCAL,0272,RC,,,both,,,978.08,293.42,"PHCS [10601]",PHCS,,684.66,70,,,,,0,113.75,831.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR STD CEMENT 3 PEG ROTATE PLATFORM MOBILE",SUP-129409840,CDM,C1776,HCPCS,0278,RC,,,both,,,4131.72,1239.52,"CIGNA [10200]","Cigna Open Access",,2350.95,56.9,,5302.19,4377.88,6578.61,27,480.52,3511.96,"percent of total billed charges",
"HC Evasc Plc Occl Dev Iliac Arty",PX-360000039,CDM,34808,CPT,0361,RC,,,both,,,6145.87,1843.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,728.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,714.76,6145.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8IN 3IN FREEFORM MINI",SUP-MCR093080,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS [10001]","Blue Cross PPO",,5184.53,39.2,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET TUBING Y INFLOW OUTFLOW",SUP-AQL-112,CDM,S27000186,LOCAL,0270,RC,,,both,,,668.25,200.47,"PHCS [10601]",PHCS,,467.78,70,,,,,0,77.72,568.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 6MM AZUR HYDROCOIL PUSHABLE .035IN",SUP-45-250610,CDM,S27800098,LOCAL,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEP LAWRENCE CURVED 11IN",SUP-54-5007,CDM,S27200284,LOCAL,0272,RC,,,both,,,589.28,176.78,"FIRST HEALTH [10303]","First Health",,471.42,80,,,,,0,68.53,500.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX19MM FRA 8D 30D LORDOTIC NARROW",SUP-10219,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2198.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183562,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,911.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM .91-1.12MM 3.5MM CORONARY",SUP-RONYX35030W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1556.64,28.62,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL LARGE KNEE STEM REMEDY STERILE",SUP-RSKFLG,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross HMO",,6762,39.2,,5311.50,4717.44,5388.59,31,2006.18,14662.5,"percent of total billed charges",
"SURFACE ARTICULAR 12MM PERSONA 4-11 E-F KNEE RIGHT TIBIA",SUP-42521200512,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"AETNA [10100]","Aetna HMO/PPO",,6420.23,79.5,,10981.53,8986.79,12413.38,12,939.21,6864.4,"percent of total billed charges",
"GRAFT ENDOVASCULAR 14CM 14.5MM 36MM EXCLUDER TRUNK",SUP-CXT361414,CDM,C1874,HCPCS,0278,RC,,,both,,,71175.90,21352.77,"CIGNA [10200]",Cigna,,28470.36,40,,,,,0,8277.76,60499.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 34X12-16MM MAGNIFY-S 8D LORDOTIC 26MM EXPAND",SUP-1126.1112,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,17607.24,41.1,,,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER 6227DEF04 ATTAIN GLOBAL",SUP-6227DEF04,CDM,C1887,HCPCS,0272,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ERYTHROMYCIN 250 MG TABLET, IMMEDIATE RELEASE",RX-2889,CDM,,,0637,RC,75834-0242-30,NDC,both,1,UN,50.01,15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE LITHO 668MM .8MM SWISS LITHOCLAST PNEUMATIC LATEX FREE",SUP-M0068407310,CDM,S27200284,LOCAL,0272,RC,,,both,,,1680.60,504.18,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 135CM 80MM 12MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171120810,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT SUT 2 MAXBRAID",SUP-CM0222N,CDM,S27200284,LOCAL,0272,RC,,,both,,,631.80,189.54,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 150CM 100MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NERVOUS SYSTEM MALIGNANCY,EXTREME",041,APR-DRG,,,,,,,inpatient,,,59718.58,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $11,310.81. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($77,112.87) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION DEB 2.75X15",SUP-SCA14U-275015D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH APD 20CM 6FR REGULAR DRNG FLEXIMA METAL HYDROPHILIC",SUP-M001271260,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE VASCULAR 185CM PRESSURE VERRATA PLUS STERILE LATEX",SUP-10185P,CDM,C1769,HCPCS,0272,RC,,,both,,,4140.00,1242,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 9FR .118IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1009,CDM,C1894,HCPCS,0272,RC,,,both,,,298.32,89.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,202.86,68,,,,,0,34.69,253.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +10 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1000,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH CRANIAL 76X50X.85MM MTM CRANIOMAXILLOFACIAL TITANIUM",SUP-81020,CDM,C1713,HCPCS,0278,RC,,,both,,,8837.93,2651.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1047.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1027.85,7512.24,"percent of total billed charges",
"GRAFT SKIN 5X5CM ALLOPATCH HD THK.8-1.7MM THICK ACELLULAR",SUP-371505,CDM,Q4128,HCPCS,0636,RC,,,both,,,9894.26,2968.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1172.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.43,8410.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 6MM 5.5MM EVEREST XWIDE SPINE NONSTERILE",SUP-2901-86055Y,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"AETNA [10100]","Aetna HMO/PPO",,2832.19,79.5,,1521.93,481.35,16760.95,30,414.32,3028.13,"percent of total billed charges",
"HC Chng Tube Nephro/Pyelostomy",PX-361000225,CDM,50435,CPT,0361,RC,,,both,,,3817.84,1145.35,"PHCS [10601]",PHCS,,2672.49,70,,,,,0,444.01,3817.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chng Tube Nephro/Pyelostomy",PX-361000225,CDM,50435,CPT,0361,RC,,,both,,,3817.84,1145.35,"NOVANET [10819]",Novanet,,2863.38,75,,,,,0,444.01,3817.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE XLONG CRANIOMAXILLOFACIAL TITANIUM 2Y 1.5MM SCR",SUP-017114,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.60,379.08,"PHCS [10601]",PHCS,,884.52,70,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 70MM 32MM NCB TITANIUM ALUMINUM VANADIUM",SUP-0203152070,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",189.34,1383.8,"percent of total billed charges",
"CTRL NEROSTIMLTR INTELLIS PTM PAPER NONSTERILE LATEX FREE",SUP-97745NT,CDM,C1787,HCPCS,0270,RC,,,both,,,5865.00,1759.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2692.04,45.9,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Socket Insrt WO Lock Mec",PX-E27400096,CDM,L5679,HCPCS,0274,RC,,,both,,,1477.30,443.19,"NOVANET [10819]",Novanet,,1107.98,75,,,,,0,171.81,1255.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM TSRH OSTEOGRIP TITANIUM SHORT SPINE",SUP-83565558,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.10,1106.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2508.59,68,,,,,0,429.04,3135.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC",718,MS-DRG,,,,,,,inpatient,,,45243.20,13572.96,"UHC [10700]","United Healthcare",,39213.15,,"Fee schedule rate ($39,213.15). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,39213.15,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.6V 32MM 2 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18006232,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cardiac Rehab WO Ecg Ea Sesn",PX-943000002,CDM,93797,CPT,0943,RC,,,both,,,389.00,116.7,"UHC [10700]","United Healthcare",,356,,"Per diem ($356).",,,,0,45.24,356,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL HELICAL FIBER.PLAT.4MX30M",SUP-312043,CDM,S27800098,LOCAL,0278,RC,,,both,,,664.23,199.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,77.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.25,564.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETERIZATION 8FR 18GA 6IN .032IN 2 LUMEN SPRING GWIRE",SUP-CDC-42802-1A,CDM,C1751,HCPCS,0272,RC,,,both,,,648.19,194.46,"NOVANET [10819]",Novanet,,486.14,75,,,,,0,75.38,550.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 100MM 130CM 8MM LONG VASCULAR NITINOL",SUP-SC8100LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"NOVANET [10819]",Novanet,,6727.5,75,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADAPTA  SR  IS-1  213",SUP-ADSR01,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7109.21,28.62,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXAMETHASONE 4 MG TABLET",RX-2327,CDM,J8540,HCPCS,0637,RC,00054-8175-25,NDC,both,1,UN,6.27,1.88,"PHCS [10601]",PHCS,,4.39,70,,,,,0,0.46,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 34CM FEMUR LEFT PROXIMAL TALON DISTALFIX",SUP-SLN-125-34L,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"BLUE CROSS [10001]","Blue Cross HMO",,6321.12,39.2,,957.42,156.86,7483.26,51,1875.37,13706.51,"percent of total billed charges",
"CATH SABER 90CM 300MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020300S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1085.08,68,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esophagosc W/Band Varices",PX-750000200,CDM,43205,CPT,0750,RC,,,both,,,2075.00,622.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1718,,"Case rate ($1,718). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,241.32,2075,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER SUTURE HOFFEE LASSO LOOP STERILE LATEX FREE DISPOS",SUP-710000,CDM,S27200284,LOCAL,0272,RC,,,both,,,507.90,152.37,"UHC [10700]","United Healthcare",,321.5,63.3,,,,,0,59.07,431.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 15GA 24-48MM ILLINOIS ADJUSTABLE DEPTH STOP T",SUP-DIN1515X,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.20,24.36,"KAISER [10500]",Kaiser,,54.4,67,,,,,0,9.44,69.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 42MM 28MM E VIVACIT-E LUMEN STERILE LATEX FREE",SUP-110031011,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"KAISER [10500]",Kaiser,,6939.12,67,,,,,0,1204.51,8803.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR092020,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5290.34,40,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR SILICONE RADIOPAQUE EXTERNAL RETENTION RING",SUP-8180-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.81,228.54,"NOVANET [10819]",Novanet,,571.36,75,,,,,0,88.6,647.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL TITAN LOCK-OUT STD BIOFLEX SILICONE HYDROPHILIC",SUP-91-9480SC,CDM,S27200284,LOCAL,0272,RC,,,both,,,5154.30,1546.29,"NOVANET [10819]",Novanet,,3865.73,75,,,,,0,599.45,4381.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2.5CM 2.5MM GALAXY G3 XTRASOFT",SUP-GLX122525,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"KAISER [10500]",Kaiser,,7960.81,67,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK 20MM 6MM FASTTHREAD",SUP-AR-4020P-06,CDM,C1713,HCPCS,0278,RC,,,both,,,2323.13,696.94,"KAISER [10500]",Kaiser,,1556.5,67,,,,,0,270.18,1974.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL SUTUPAK 2-0 75CM BRAID 12 STRAND PRECUT",SUP-X305H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 7 X 20 HELICAL FILLING COIL",SUP-10HFL-07020,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2565.24,28.62,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PILOT 150 VASCULAR STRAIGHT 300CM 3CM .014IN",SUP-1010484-H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 42MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.842,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"CIGNA [10200]",Cigna,,170.62,68,,1831.33,1831.33,1831.33,16,29.18,213.27,"percent of total billed charges",
"BURR SURGICAL 48MM 5.5MM CARBIDE OVAL",SUP-03-C0905,CDM,S27200284,LOCAL,0272,RC,,,both,,,105.88,31.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.31,90,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL KNEE IDENTITY IMPRINT THK10MM 6 NARROW TIBIAL INSRT",SUP-TPS-030-106N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PLUS PROFILE SOFTTOUCH",SUP-SSLP-360,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN FEMORAL RIGHT 4 CURVE",SUP-H74908526022,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"UHC [10700]","United Healthcare",,48.48,63.3,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH LONGER LUKE LAPAROSCOPIC PLACEMENT PERITONEAL",SUP-VP-411,CDM,S27200284,LOCAL,0272,RC,,,both,,,1522.80,456.84,"PHCS [10601]",PHCS,,1065.96,70,,,,,0,177.1,1294.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYSORB SURGITIE 2-0 21IN BRAID LOOP COATED VIOLET",SUP-EL-22-LN,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.68,42.8,"NOVANET [10819]",Novanet,,107.01,75,,,,,0,16.59,121.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SPINAL NONSTERILE FOR 5/6MM ROD VERSATIE",SUP-8610260,CDM,C1713,HCPCS,0278,RC,,,both,,,6827.62,2048.29,"PHCS [10601]",PHCS,,4779.33,70,,,,,0,794.05,5803.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71-75X11MM VANGUARD VIVACIT-E KNEE CRUCIATE RETAIN",SUP-VE183441,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5181.07,40,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Feeynolm 12.6-20cm",PX-450000029,CDM,12016,CPT,0450,RC,,,both,,,1347.00,404.1,"AETNA [10100]","Aetna HMO/PPO",,1070.87,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.13,1347,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 45MM 1.2MM SHORT CARBIDE CROSS CUT FISSURE",SUP-0277010212,CDM,S27000186,LOCAL,0270,RC,,,both,,,54.98,16.49,"NOVANET [10819]",Novanet,,41.24,75,,,,,0,6.39,46.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM SECUR-FIT TRIDENT TITANIUM HIP",SUP-2029-5540-1,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"KAISER [10500]",Kaiser,,510.14,67,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP FEM N/POROUS SIZE 5 RIGHT",SUP-2154-0-0005,CDM,C1776,HCPCS,0278,RC,,,both,,,8280.00,2484,"MULTIPLAN [10600]",Multiplan,,7038,85,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 6MM STRAIGHT FUSION BIOLINE POLYESTER 2",SUP-M00201503046B0,CDM,L8670,HCPCS,0278,RC,,,both,,,8859.60,2657.88,"NOVANET [10819]",Novanet,,6644.7,75,,,,,0,427.53,7530.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL +8MM 40MM STD LATERAL OFFSET 165MM 20MM 15MM",SUP-523420,CDM,C1776,HCPCS,0278,RC,,,both,,,11104.56,3331.37,"CIGNA [10200]",Cigna,,7551.1,68,,5873.17,5873.17,5873.17,"1 through 10",1291.46,9438.88,"percent of total billed charges",
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 15MM 4MM",SUP-SPL40015X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 2MM BALL DISSECTING DIAMOND",SUP-MR8-14BA20D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1468.94,440.68,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC",862,MS-DRG,,,,,,,inpatient,,,43300.62,12990.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,,,"Fee schedule rate ($0). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,,,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 445CC",SUP-SSZ-M445,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 160MM 3.5MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.68,CDM,S27000186,LOCAL,0270,RC,,,both,,,2271.60,681.48,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES,EXTREME",220,APR-DRG,,,,,,,inpatient,,,474572.97,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $41,270.55. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($190,723.41) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 41MM 22MM TANDEM HIP ACETABULAR COCR",SUP-71322041,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"MULTIPLAN [10600]",Multiplan,,7099.58,85,,,,,0,971.39,7099.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cysto Uret/Pyelosc W/Litho",PX-361000511,CDM,52353,CPT,0361,RC,,,both,,,10398.48,3119.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4617,,"Case rate ($4,617). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1209.34,10398.48,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCOUT 7.5CM DELIVERY NEEDLE ULTRASOUND",SUP-SSR75S-01,CDM,A4648,HCPCS,0278,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP 3 HOLE QUADRANT GROUP F BIOFOAM",SUP-DBFPGF56,CDM,C1776,HCPCS,0278,RC,,,both,,,18194.40,5458.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2156.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2116.01,15465.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 85MM 1.5MM QUICK COUPLING WITHOUT STOP NONSTERILE",SUP-310.15,CDM,S27000186,LOCAL,0270,RC,,,both,,,496.69,149.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,58.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.77,422.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 12 G-H KNEE",SUP-42512101011,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4429.11,41.1,,6417.48,6417.48,6417.48,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"REPROCESSED CATHETER EAGLE EYE 150CM 5FR 20MM 20MHZ SHORT TA",SUP-85900PSTR,CDM,C1753,HCPCS,0272,RC,,,both,,,3341.25,1002.37,"PHCS [10601]",PHCS,,2338.88,70,,,,,0,388.59,2840.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 15MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE45015,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"PHCS [10601]",PHCS,,58565.22,70,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPLATZ RENAL SHEATH 26FX17CM",SUP-M0062601520,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"NOVANET [10819]",Novanet,,250.95,75,,,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 18MM LCP STAINLESS STEEL SMALL BONE T6",SUP-201.888,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"CIGNA [10200]","Cigna Local Plus",,377.36,53.5,,3978.14,359.25,3978.14,24,82.03,599.55,"percent of total billed charges",
"SCREW BONE L15 MM OD3.5 MM SPINE CERVICAL ANTERIOR SELF TAP",SUP-18008415,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 15.75IN 32FR DRNG",SUP-8888561076,CDM,C1729,HCPCS,0272,RC,,,both,,,231.01,69.3,"AETNA [10100]","Aetna HMO/PPO",,183.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.87,196.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL DARK BLUE 15MM SYNFIX 18D LARGE EVOLUTION 6MM",SUP-08.815.364S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC FLEXIBLE OVAL BIOPSY CUP 115CM 3.3FR TISSUE",SUP-G15054,CDM,S27200284,LOCAL,0272,RC,,,both,,,2733.75,820.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1254.79,45.9,,,,,0,317.94,2323.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM PRESS FIT REDUCE TAPERLOC PPS 133D 10 STD",SUP-51103100,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"UHC [10700]","United Healthcare",,15320.71,63.3,,8601.07,8395.67,8601.07,"1 through 10",2814.85,20572.84,"percent of total billed charges",
"KNIFE NEUROSURGICAL 8IN APEX ARACHNOID KNIVES ULTEM",SUP-AM-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 4-0 RB-1 24IN 2 ARM BRAID BLACK",SUP-K571H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20GA 8CM POWERGLIDE PRO BIOPATCH FULL RADIOPAQUE",SUP-F320088PT,CDM,C1751,HCPCS,0272,RC,,,both,,,942.76,282.83,"FIRST HEALTH [10303]","First Health",,754.21,80,,,,,0,109.64,801.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BOX 5 HOLE CABLE TRITIUM BONE STERNAL NONSTERILE",SUP-86-400,CDM,C1713,HCPCS,0278,RC,,,both,,,4926.60,1477.98,"AETNA [10100]","Aetna HMO/PPO",,3916.65,79.5,,1521.93,481.35,16760.95,30,572.96,4187.61,"percent of total billed charges",
"VEST SPU 23-33- IN SMALL CHEST WRAP DISPOSABLE",SUP-P300630005,CDM,S27000186,LOCAL,0270,RC,,,both,,,548.99,164.7,"CIGNA [10200]","Cigna Open Access",,312.38,56.9,,,,,0,63.85,466.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 50MM 32MM MARATHON",SUP-121932450,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"CIGNA [10200]","Cigna Local Plus",,4339.36,53.5,,5372.07,4581.20,7242.98,23,943.3,6894.31,"percent of total billed charges",
"CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC",262,MS-DRG,,,,,,,inpatient,,,57910.24,17373.07,"CIGNA [10200]","Cigna Open Access",,17886.52,,"Fee schedule rate ($17,886.52). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,47586.56,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 3 TAPER SELF LOCK NARROW DISTAL TIP CEMENT",SUP-75002112,CDM,C1776,HCPCS,0278,RC,,,both,,,23558.85,7067.65,"FIRST HEALTH [10303]","First Health",,18847.08,80,,,,,0,2739.89,20025.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Infect Agent Nos Ampl Probe",PX-306000147,CDM,87798,CPT,0306,RC,,,both,,,744.80,223.44,"AETNA [10100]","Aetna HMO/PPO",,592.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,633.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE POWERTURN VASCULAR J CURVE 300CM .014IN",SUP-1044595J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60MM 4MM 4.5MM 5MM XTHICK PURPLE",SUP-GIA60XTS,CDM,S27200284,LOCAL,0272,RC,,,both,,,769.42,230.83,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL 30X2.5MM TITANIUM 12MM VASCULAR ENDOSCOPIC",SUP-010901,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 150MM 4MM BALLOON DILATATION DURALYN",SUP-48004015S,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE RETRIEVE CUT 30CM 10MM",SUP-691.003S,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.50,506.25,"BLUE CROSS [10001]","Blue Cross HMO",,661.5,39.2,,957.42,156.86,7483.26,51,196.26,1434.38,"percent of total billed charges",
"ANAKINRA 100 MG/0.67 ML SUBCUTANEOUS SYRINGE",RX-31784,CDM,,,0637,RC,66658-0234-01,NDC,both,.67,ML,935.63,280.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,384.54,41.1,,,,,0,108.81,795.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Pacing Elect Lv Lead Add",PX-480000019,CDM,33225,CPT,0481,RC,,,both,,,7637.14,2291.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7637.14,,"Case rate ($25,873). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,888.2,7637.14,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Breast Uni Complete",PX-402000048,CDM,76641,CPT,0402,RC,,,both,,,1193.28,357.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,138.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,107.09,1014.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127D 6 30MM CONDYLAR STABILIZED NECK OMNIFIT",SUP-6097-0630,CDM,C1776,HCPCS,0278,RC,,,both,,,10292.40,3087.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1219.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1197.01,8748.54,"percent of total billed charges",
"TUBE ENDOTRACHEAL 11.8MM 8MM TAPER CUFF MAGILL CURVE MURPHY",SUP-110880,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.65,86.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,33.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.69,246.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 28CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155234180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 220MM 13MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424066,CDM,C1776,HCPCS,0278,RC,,,both,,,13703.40,4111.02,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3699.92,27,,,,,0,1593.71,11647.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Bone Density Axial 1or More",PX-320000218,CDM,77085,CPT,0320,RC,,,both,,,233.00,69.9,"BLUE CROSS [10001]","Blue Cross PPO",,120.99,,"Fee schedule rate ($120.99).",,,,0,27.1,233,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Pacing Elect Lv Lead Add",PX-480000019,CDM,33225,CPT,0481,RC,,,both,,,7637.14,2291.14,"NOVANET [10819]",Novanet,,5727.86,75,,,,,0,888.2,7637.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 9MM 31MM SYMMETRIC TRIATHLON X3 KNEE SUPERIOR",SUP-5550L319,CDM,C1776,HCPCS,0278,RC,,,both,,,4478.10,1343.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3045.11,68,,,,,0,520.8,3806.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 11.8MM 8MM TAPER CUFF MAGILL CURVE MURPHY",SUP-110880,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.65,86.89,"CIGNA [10200]","Cigna Open Access",,164.81,56.9,,,,,0,33.69,246.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 18X.75IN FINGER 4 PRONG XRAY LUCENT STRIP",SUP-9115-03,CDM,S27000186,LOCAL,0270,RC,,,both,,,75.73,22.72,"KAISER [10500]",Kaiser,,50.74,67,,,,,0,8.81,64.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 7MM THIN WALL PERIPHERAL GORE-TEX",SUP-ST0708,CDM,C1768,HCPCS,0278,RC,,,both,,,8535.30,2560.59,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3917.7,45.9,,,,,0,992.66,7255.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM 34.9MM 28.9MM MITRAL FLEXIBLE HOLDER",SUP-4450M30,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"UHC [10700]","United Healthcare",,7206.71,63.3,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 75CM 7FR ENDOCARDIAL TRUE BIPOLAR ACTIVE",SUP-7121/75,CDM,C1895,HCPCS,0278,RC,,,both,,,21892.50,6567.75,"NOVANET [10819]",Novanet,,16419.38,75,,,,,0,2546.1,18608.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 95CM 3.9-5.2FR 2.6FR 75CM SPACE LEFT VENTRICULAR",SUP-4678,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2573.61,45.9,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 CURVE 15MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-96-2033,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"PHCS [10601]",PHCS,,6474.62,70,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 5X5CM ALLOPATCH HD THK.4-.7MM THIN ACELLULAR",SUP-470505,CDM,Q4128,HCPCS,0636,RC,,,both,,,10101.60,3030.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6566.04,65,,,,,0,80.43,8586.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 26MM LCP DCP STAINLESS STEEL CORTICAL FOOT/HAND",SUP-201.826,CDM,C1713,HCPCS,0278,RC,,,both,,,358.09,107.43,"CIGNA [10200]","Cigna Open Access",,203.75,56.9,,1144.80,304.56,2275.09,66,41.65,304.38,"percent of total billed charges",
"GRAFT BONE RETRIEVE CUT 30CM 10MM",SUP-691.003S,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.50,506.25,"CIGNA [10200]","Cigna Open Access",,960.19,56.9,,1144.80,304.56,2275.09,66,196.26,1434.38,"percent of total billed charges",
"HC Whfo W/Joint(S) Custom Fab",PX-E27400030,CDM,L3806,HCPCS,0274,RC,,,both,,,1027.40,308.22,"FIRST HEALTH [10303]","First Health",,821.92,80,,,,,0,119.49,873.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 92CM 1MM 6FR 5MM SPACING D CURVE ELECTROPHYSIOLOGY",SUP-D610DR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"MULTIPLAN [10600]",Multiplan,,3168.38,85,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIAFILL DEMINERAILIZED BONE FIBERS 6CC",SUP-VFB006,CDM,C1713,HCPCS,0278,RC,,,both,,,4140.00,1242,"MULTIPLAN [10600]",Multiplan,,3519,85,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC",826,MS-DRG,,,,,,,inpatient,,,278940.49,83682.15,"BLUE CROSS [10001]","Blue Cross HMO",,107387.27,,"Fee schedule rate ($107,387.27). The outlier threshold amount is ($224,410.00),  the outlier percentage is (63.7%).  The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1). Includes an add-on of $3,230.48 when RC 0681-0684 total amount is above $1.",,,,0,29016.67,136573.05,other,"IP STOPLOSS Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM 40DEG BIPOLAR CONVEX SERRATED",SUP-BB4040XC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1434.01,430.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,169.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.78,1218.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Whfo W/Joint(S) Custom Fab",PX-E27400030,CDM,L3806,HCPCS,0274,RC,,,both,,,1027.40,308.22,"CIGNA [10200]",Cigna,,698.63,68,,,,,0,119.49,873.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 60MM 80CM 10MM BILIARY VENOUS DELIVERY",SUP-G57429,CDM,C1876,HCPCS,0278,RC,,,both,,,12771.83,3831.55,"NOVANET [10819]",Novanet,,9578.87,75,,,,,0,1485.36,10856.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL CARDIOBLATE BP2 STERILE DISPOSABLE",SUP-60831,CDM,S27200284,LOCAL,0272,RC,,,both,,,17250.00,5175,"PHCS [10601]",PHCS,,12075,70,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Asp/Inj Renal Cyst",PX-361000220,CDM,50390,CPT,0361,RC,,,both,,,4068.18,1220.45,"CIGNA [10200]","Cigna Open Access",,2090,,"Case rate ($2,090). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,473.13,4068.18,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TMPLT BENDING PELVIC 16 HOLE 3.5 MM LOW PROFILE",SUP-03.100.035,CDM,S27000186,LOCAL,0270,RC,,,both,,,855.04,256.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,392.46,45.9,,,,,0,99.44,726.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT MONORAIL 29MM 135CM 8MM ENDOPROSTHESIS METAL",SUP-M001719020,CDM,C1876,HCPCS,0278,RC,,,both,,,16615.20,4984.56,"BLUE CROSS [10001]","Blue Cross PPO",,6513.16,39.2,,,,,0,1932.35,14122.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 6MM THORACIC KNIT HEMASHIELD GOLD",SUP-M002020951060,CDM,C1768,HCPCS,0278,RC,,,both,,,2540.03,762.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,300.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,295.41,2159.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 40MM 2MM .018IN BALLOON DILATATION",SUP-R51002004L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"FIRST HEALTH [10303]","First Health",,1633.2,80,,,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30X4.8MM TITANIUM LARGE THICK TISSUE LINEAR",SUP-4901T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1346.54,403.96,"AETNA [10100]","Aetna HMO/PPO",,1070.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,156.6,1144.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 46MM 15MM STAINLESS STEEL CANNULATED STERILE",SUP-121846,CDM,C1713,HCPCS,0278,RC,,,both,,,2006.40,601.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,574.23,28.62,,,,,0,233.34,1705.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 2.5CM 1.8CM 8.5FR WITTICH BILIARY",SUP-G07313,CDM,S27200284,LOCAL,0272,RC,,,both,,,3682.43,1104.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2504.05,68,,,,,0,428.27,3130.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-3 TH-26 36IN MONOFILAMENT WHITE",SUP-3N07A,CDM,S27200284,LOCAL,0272,RC,,,both,,,255.93,76.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.76,217.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 2.5MM BALLOON DILATATION STERILE LATEX",SUP-582515022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOPLASTY 5FR L130CM BALLOON L2CM DIA5MM DUAL LAY",SUP-U813052,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS ANTIBACTERIAL UNIDIRECTIONAL",SUP-SXMP1B411,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.17,68.75,"NOVANET [10819]",Novanet,,171.88,75,,,,,0,26.65,194.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TWISTER WIRE 7.25IN BERRY DUROGRIP ROUND STERNUM TUNGSTEN",SUP-MD456R,CDM,S27000186,LOCAL,0270,RC,,,both,,,667.44,200.23,"CIGNA [10200]","Cigna Open Access",,379.77,56.9,,,,,0,77.62,567.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR",RX-9773,CDM,,,0637,RC,08888-8887-37,NDC,both,5,ML,80.00,24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.3,68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 6 KNEE 4 CRUCIFORM PEG KEEL",SUP-5536-B-600,CDM,C1776,HCPCS,0278,RC,,,both,,,10139.04,3041.71,"UHC [10700]","United Healthcare",,6418.01,63.3,,8601.07,8395.67,8601.07,"1 through 10",1179.17,8618.18,"percent of total billed charges",
"PLATE NEW LOCK OVERLAP ATLANTIS VISION BONE SPINAL",SUP-7200180,CDM,C1713,HCPCS,0278,RC,,,both,,,4620.00,1386,"PHCS [10601]",PHCS,,3234,70,,,,,0,537.31,3927,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UNI-FUSE FLOW-THRU HUB 90CM 50CM 5FR THROMBECTOMY",SUP-H787124018105,CDM,C1757,HCPCS,0272,RC,,,both,,,1641.75,492.52,"FIRST HEALTH [10303]","First Health",,1313.4,80,,,,,0,190.94,1395.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEEDING SET 20FR PONSKY-GAUDERER SILICONE 2 PORT PEG",SUP-000333,CDM,S27000186,LOCAL,0270,RC,,,both,,,208.80,62.64,"CIGNA [10200]","Cigna Open Access",,118.81,56.9,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 6IN RYDER SERRATE INSRT NDL TUNGSTEN CARBIDE 1MM RING",SUP-32-466,CDM,S27200284,LOCAL,0272,RC,,,both,,,364.44,109.33,"CIGNA [10200]",Cigna,,247.82,68,,,,,0,42.38,309.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 35CM 24FR NEPHRSTMY DRNG STERILE LATEX FREE",SUP-M0064101030,CDM,C1729,HCPCS,0272,RC,,,both,,,551.53,165.46,"NOVANET [10819]",Novanet,,413.65,75,,,,,0,64.14,468.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 20MM TRIDENT II LOW PROFILE HEXAGONAL STERILE",SUP-7030-6520,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"NOVANET [10819]",Novanet,,571.05,75,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR RINGLOC +3MM 22 32MM E-POLY HIP STERILE",SUP-EP-108322,CDM,C1776,HCPCS,0278,RC,,,both,,,14076.00,4222.8,"NOVANET [10819]",Novanet,,10557,75,,,,,0,1637.04,11964.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIBRILLATOR 58CM 8FR OPTISURE ENDOCARDIUM OPTIM 1 COI",SUP-LDA210Q/58,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"FIRST HEALTH [10303]","First Health",,13737.6,80,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 CURVE 12.5MM KNEE GVF UHMWPE ROTATE",SUP-962022,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"PHCS [10601]",PHCS,,6474.62,70,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.00MM X 15MM  SCOREFLEX  NC",SUP-640-154-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"UHC [10700]","United Healthcare",,3275.78,63.3,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -2.5 28MM HIP C TAPER COCR LFIT ION TREATMENT",SUP-06-2898,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA [10200]","Cigna Local Plus",,1673.32,53.5,,5372.07,4581.20,7242.98,23,363.75,2658.55,"percent of total billed charges",
"SCR BONE 12.7MM 75MM DHS/DCS STAINLESS STEEL CONDYLAR HIP",SUP-280.275,CDM,C1713,HCPCS,0278,RC,,,both,,,2043.30,612.99,"KAISER [10500]",Kaiser,,1369.01,67,,,,,0,237.64,1736.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 45D COOLCUT STERILE ABLATOR",SUP-AR-9802M-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,931.50,279.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH FLEXOR SHUTTLE 80CM 7FR 2.5MM GUIDING ACCEPTS .038IN",SUP-G13338,CDM,C1894,HCPCS,0272,RC,,,both,,,1109.62,332.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SKIN GRAFT FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES,MINOR",312,APR-DRG,,,,,,,inpatient,,,33568.76,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $7,271.11. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($44,959.66) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ARTHROSCOPIC 125MM 2MM NANO SCOPE",SUP-AR-3210-0070,CDM,S27200284,LOCAL,0272,RC,,,both,,,4036.50,1210.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE 2O VASCULAR ANGLE 180CM .018IN HYDROPHILIC FIX CORE",SUP-H2OSTDA18180,CDM,C1769,HCPCS,0272,RC,,,both,,,408.47,122.54,"KAISER [10500]",Kaiser,,273.67,67,,,,,0,47.51,347.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PSN FEM CR CMT CCR STD SZ 7 L",SUP-42-5026-062-01,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"CIGNA [10200]",Cigna,,9145.08,40,,5873.17,5873.17,5873.17,"1 through 10",2658.93,19433.3,"percent of total billed charges",
"PLATE NARROW 206X13.5X4.2MM TITANIUM 4.5MM SCR LARGE",SUP-424.611,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.70,1106.91,"BLUE CROSS [10001]","Blue Cross HMO",,1446.36,39.2,,957.42,156.86,7483.26,51,429.11,3136.25,"percent of total billed charges",
"COMPONENT FEMORAL F KNEE RIGHT LPS-FLEX NEXGEN POROUS",SUP-00596201652,CDM,C1776,HCPCS,0278,RC,,,both,,,28570.50,8571.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11428.2,40,,,,,0,3322.75,24284.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.3MM 30MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.520,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,786.54,68,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 90CM 6FR LCB CURVE GUIDING PTFE FEMORAL LARGE",SUP-H74938969250,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"FIRST HEALTH [10303]","First Health",,293.15,80,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURVED SUTURE GUIDE, 3-PACK",SUP-SUT-013,CDM,S27200284,LOCAL,0272,RC,,,both,,,506.05,151.81,"MULTIPLAN [10600]",Multiplan,,430.14,85,,,,,0,58.85,430.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 10MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-310-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"FIRST HEALTH [10303]","First Health",,9626.88,80,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG ACETABULAR 15MM 46MM RESTORATION WEDGE HIP",SUP-5096-4615,CDM,C1776,HCPCS,0278,RC,,,both,,,12461.40,3738.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1449.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1449.26,10592.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS 5-0 RB-2 30IN 2 ARM ANTIBACTERIAL VIOLET",SUP-PDP148H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.09,19.83,"CIGNA [10200]","Cigna Open Access",,37.61,56.9,,,,,0,7.69,56.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKING COILS XL 15CM",SUP-RBYPCXL15,CDM,S27800098,LOCAL,0278,RC,,,both,,,13731.00,4119.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5643.44,41.1,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.0 X 18MM ESPRIT BTK IDE",SUP-1202300-18,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 15.5CM 9FR PEEL-AWAY PERCUTANEOUS STERILE",SUP-G01697,CDM,C1894,HCPCS,0272,RC,,,both,,,382.71,114.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,44.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT RED 18X4IN STD ARM 2 FILL LINE POSITIVE LOCK CNCT",SUP-ASP-564007,CDM,S27200284,LOCAL,0272,RC,,,both,,,151.15,45.34,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,62.12,41.1,,,,,0,17.58,128.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 14CM 7FR 12MM .035IN BALLOON",SUP-G52303,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"NOVANET [10819]",Novanet,,719.83,75,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 28CM 3CM 6FR .038IN 2",SUP-M006192134170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"MULTIPLAN [10600]",Multiplan,,1185.95,85,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONVEY 100CM 5FR CLS3 CURVE GUIDING HYDROPHILIC FEMORAL",SUP-H749392285730,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"MULTIPLAN [10600]",Multiplan,,311.47,85,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 19MM KNEE X3 BEARING CRUCIATE RETAIN",SUP-5530-G-219,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"MULTIPLAN [10600]",Multiplan,,9700.71,85,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM MAS SPINE CANNULATED EXT TAB 4.75MM ROD",SUP-54850017540,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4457.4,68,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CW004, 5MMX42CM EPIX ES SMK EVAC STR SPT",SUP-CW004,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 20MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50020,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA [10200]","Cigna Local Plus",,26152.79,31.5,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 20MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50020,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"UHC [10700]","United Healthcare",,52554.65,63.3,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ICD-DR DDBB1D4 EVERA XT IS1/DF4 US",SUP-DDBB1D4,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4717.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 26CM 8FR 2 PIGTAIL CURVE",SUP-M0061921530,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"NOVANET [10819]",Novanet,,851.72,75,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 CTX 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J369H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CPR MINI SCORPION DX FIXATION",SUP-AR-8690DS,CDM,C1713,HCPCS,0278,RC,,,both,,,7933.28,2379.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,940.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,922.64,6743.29,"percent of total billed charges",
"STEM FEMORAL 115MM 17MM MODULAR RESTORATION HIP DISTAL",SUP-6276-7-417,CDM,C1776,HCPCS,0278,RC,,,both,,,20188.35,6056.5,"FIRST HEALTH [10303]","First Health",,16150.68,80,,,,,0,2347.91,17160.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM EVEREST SPINE CANNULATED POLYAXIAL MIS",SUP-M5111-05540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X6MM DIVERGENCE 12MM LORDOTIC NUCLEUS PULPOSUS",SUP-G6626526,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3353.4,27,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM ELITE ROUND DIAMOND ROUND DIAMOND STERILE",SUP-5820012040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC MRI Lwr Ext Nonjnt WO Cntrst",PX-610000031,CDM,73718,CPT,0610,RC,,,both,,,4076.82,1223.05,"KAISER [10500]",Kaiser,,2731.47,67,,,,,0,430.75,3465.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 90CM 40MM 2MM .014IN BALLOON DILATATION",SUP-AB14W020040090,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 22X11.5IN OVITEX PRS CONTOUR OVINE",SUP-R20252-1122G,CDM,C1781,HCPCS,0278,RC,,,both,,,25937.10,7781.13,"MULTIPLAN [10600]",Multiplan,,22046.54,85,,,,,0,3016.48,22046.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 15MM 40MM SHOULDER OFFSET MODULAR BIGLIANI",SUP-00430204015,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"KAISER [10500]",Kaiser,,6089.5,67,,,,,0,1057.03,7725.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SENSOR DUAL-FLEX 24CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175262120,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"KAISER [10500]",Kaiser,,891.27,67,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP LIMIT HOLE COLOR CODED POROUS G7 C",SUP-010000661,CDM,C1776,HCPCS,0278,RC,,,both,,,10120.92,3036.28,"BLUE CROSS [10001]","Blue Cross HMO",,3967.4,39.2,,5311.50,4717.44,5388.59,31,1177.06,8602.78,"percent of total billed charges",
"BLADE SHAVER 13CM 4.3MM QUADCUT",SUP-1884380HR,CDM,S27200284,LOCAL,0272,RC,,,both,,,2190.00,657,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1489.2,68,,,,,0,254.7,1861.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM TKR PATELLOFEMORAL",SUP-98000661000,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"PHCS [10601]",PHCS,,13230,70,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.235 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.235,CDM,V2632,HCPCS,0276,RC,,,both,,,3375.00,1012.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1549.13,45.9,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL GOLD 95MM 10.35MM TFN-ADVANCED",SUP-04.038.295S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"MULTIPLAN [10600]",Multiplan,,3384.57,85,,,,,0,463.09,3384.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X150 80CM SL",SUP-48005015N,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"MULTIPLAN [10600]",Multiplan,,847.54,85,,,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 90MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.440,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,635.32,45.9,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 14MM LEGION STRAIGHT KNEE TITANIUM CEMENT",SUP-71424186,CDM,C1776,HCPCS,0278,RC,,,both,,,12357.90,3707.37,"KAISER [10500]",Kaiser,,8279.79,67,,,,,0,1437.22,10504.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE L-ACSR CORTICAL LORDOTIC ALLOGRAFT",SUP-341041,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 65MM 2.4MM SCR 8 HOLE LOCK VARIAX BONE",SUP-629708,CDM,C1713,HCPCS,0278,RC,,,both,,,4951.44,1485.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2272.71,45.9,,,,,0,575.85,4208.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 2IN 18GA 20GA PAJUNK E-CATH 21GA CONTINUOUS",SUP-TDL103,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"NOVANET [10819]",Novanet,,394.88,75,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM DCP LC-DCP STAINLESS STEEL PROXIMAL",SUP-204.230,CDM,C1713,HCPCS,0278,RC,,,both,,,177.48,53.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,50.79,28.62,,,,,0,20.64,150.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM LAVA 18 EMBOLIC 2ML LIQUID",SUP-SLLES182,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"UHC [10700]","United Healthcare",,10482.48,63.3,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL SQUARE LOOP 10X8MM 3/32IN COVIDIEN",SUP-E1567,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.35,27.4,"CIGNA [10200]","Cigna Local Plus",,48.87,53.5,,,,,0,10.62,77.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BRACHYTHERAPY 20CM 18GA MICK APPLR ULTRA SHARP TIP",SUP-918205,CDM,C1715,HCPCS,0272,RC,,,both,,,80.13,24.04,"AETNA [10100]","Aetna HMO/PPO",,63.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.32,68.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 9 HIGH OFFSET HIP",SUP-71935581,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"BLUE CROSS [10001]","Blue Cross HMO",,14321.21,39.2,,5311.50,4717.44,5388.59,31,4248.87,31053.65,"percent of total billed charges",
"EPILONG SOFT TRAY 17G X 3.5     (90MM) NEEDLE WITH 1CM GRADU",SUP-TAL151,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"PHCS [10601]",PHCS,,231.42,70,,,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22-24X27-32X9MM 8D LORDOTIC RING WEDGE",SUP-609,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"BLUE CROSS [10001]","Blue Cross PPO",,12348,39.2,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ot Eval High Complex 60 Min",PX-430000037,CDM,97167,CPT,0434,RC,,,both,,,531.81,159.54,"CIGNA [10200]","Cigna Open Access",,309,,"Per diem ($309).",,,,0,61.85,452.04,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM LCP STAINLESS STEEL CORTICAL PERIARTICULAR",SUP-02.204.026,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"FIRST HEALTH [10303]","First Health",,789.26,80,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORTIFY ASSURA NEXT GENERATION DR 40 DF4 CONNECTOR",SUP-CD2357-40Q,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4806.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPILONG SOFT TRAY 17G X 3.5     (90MM) NEEDLE WITH 1CM GRADU",SUP-TAL151,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,39.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Compatibility Test Imm Spin",PX-302000198,CDM,86920,CPT,0302,RC,,,both,,,441.50,132.45,"UHC [10700]","United Healthcare",,146.47,,,,,,,10.86,375.28,"fee schedule",
"HEAD FEMORAL +4MM 12/14 STD TAPER 22.225MM HIP COCR",SUP-136529000,CDM,C1776,HCPCS,0278,RC,,,both,,,4457.40,1337.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,518.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,518.4,3788.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIDOVUDINE 10 MG/ML ORAL SYRUP",RX-11693,CDM,,,0250,RC,08888-8883-21,NDC,both,10,ML,14.78,4.43,"NOVANET [10819]",Novanet,,11.09,75,,,,,0,1.72,12.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE? II PRO SZ PTCA BALLOON SEMI-COMPLIANT 3.0 MM X 30",SUP-230-303-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLS-1009.5 CLASSICSHEATH STANDARD",SUP-398717,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +10 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200100,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,694.01,68,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 160MM 12-14MM 12FR 10FR TRIVASCULAR OVATION",SUP-TV-IL1412160-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CIGNA [10200]","Cigna Local Plus",,10517.85,31.5,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E FEMUR PATELLA TIBIA CEMENT",SUP-98000241100,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"BLUE CROSS [10001]","Blue Cross PPO",,9137.52,39.2,,3949.44,3949.44,3949.44,"1 through 10",2710.95,19813.5,"percent of total billed charges",
"STENT SUPERA 30MM 120CM 4.5MM 6FR VASCULAR NITINOL",SUP-S-45-030-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2879.74,28.62,,,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE FLEXIBLE 600MM 3.8MM 1.2MM AMBU ASCOPE 4 AVIEW",SUP-476101000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"MULTIPLAN [10600]",Multiplan,,1657.5,85,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 6MM PRECISION ACORN STERILE LATEX FREE",SUP-5820-030-560,CDM,S27200284,LOCAL,0272,RC,,,both,,,3040.88,912.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,360.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,353.65,2584.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.5/30",SUP-401766,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 30CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061802450,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,258.2,28.62,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR DURALOC +4MM NEUTRAL 50MM 28MM MARATHON HIP",SUP-122028450,CDM,C1776,HCPCS,0278,RC,,,both,,,8961.72,2688.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1061.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1042.25,7617.46,"percent of total billed charges",
"SUT CHROMIC MICROPOINT 4-0 G-2 18IN 2 ARM MONOFILAMENT BROWN",SUP-798G,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.02,54.01,"CIGNA [10200]","Cigna Local Plus",,96.31,53.5,,,,,0,20.94,153.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION REUNION NITINOL PILOT STERILE LATEX FREE",SUP-5901-6072,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"FIRST HEALTH [10303]","First Health",,609.12,80,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST GEL , TEXTURED, SHAPED, OVAL BASE, HIGH, 550C",SUP-20645-550HP,CDM,C1789,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3008.75,45.9,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 6FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175260010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,306.45,28.62,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 16MM 21MM 29MM 22.6MM EPIC MAX 13MM TISSUE",SUP-EMAX-21,CDM,S27800098,LOCAL,0278,RC,,,both,,,27990.90,8397.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3255.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3255.34,23792.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 13MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-513,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"CIGNA [10200]","Cigna Open Access",,5593.57,56.9,,5302.19,4377.88,6578.61,27,1143.29,8355.94,"percent of total billed charges",
"CATH ADVANCE 170CM 4CM 4MM BALLOON DILATATION HYDROPHILIC",SUP-G50335,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"KAISER [10500]",Kaiser,,1582.83,67,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 32MM 2MM LCP CORTICAL STAINLESS STEEL SELF TAPPING",SUP-201.378.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"FIRST HEALTH [10303]","First Health",,331.3,80,,,,,0,48.16,352,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC RBC Auto",PX-305000009,CDM,85041,CPT,0305,RC,,,both,,,102.60,30.78,"FIRST HEALTH [10303]","First Health",,82.08,80,,,,,0,2.04,87.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 82MM PRESS FIT AEQUALIS ASCEND FLEX PTC 127.5D",SUP-DWF605A,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 28CM 5FR .035IN URETERAL",SUP-M006155224090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"NOVANET [10819]",Novanet,,1022.06,75,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM 4X1.75IN STEINER-AUVARD VAGINAL STAINLESS STEEL",SUP-500-147,CDM,S27200284,LOCAL,0272,RC,,,both,,,1355.37,406.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,157.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,157.63,1152.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +10.5 DIOPTER MODIFIED C BICONVEX 12.5MM 7MM",SUP-CZ70BD.105,CDM,V2632,HCPCS,0276,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL PEDIATRIC O2 RESVR BAG MASK LATEX FREE",SUP-540212000,CDM,S27000186,LOCAL,0270,RC,,,both,,,59.47,17.84,"MULTIPLAN [10600]",Multiplan,,50.55,85,,,,,0,6.92,50.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LPT ANGLED GREAT TOE SIZE 2",SUP-487A002,CDM,C1776,HCPCS,0278,RC,,,both,,,11585.10,3475.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1347.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1347.35,9847.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER SURGICAL ACUITY UNIVERSAL SPIRAL",SUP-7060,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS03008,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1389.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Mark Abd/Pel for Rt Perc",PX-333000002,CDM,49411,CPT,0333,RC,,,both,,,10661.77,3198.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1263.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1239.96,9062.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CEMENTED EXETER V40 3 37.5MM OFFSET HIP",SUP-0580-1-373,CDM,C1776,HCPCS,0278,RC,,,both,,,17001.60,5100.48,"CIGNA [10200]","Cigna Open Access",,5695.54,33.5,,5302.19,4377.88,6578.61,27,1977.29,14451.36,"percent of total billed charges",
"STENT ZILVER FLEX 35 140MM 125CM 7MM 6FR BILIARY NITINOL",SUP-G50170,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CIGNA [10200]","Cigna Local Plus",,3258.15,53.5,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 12MM 143CM 2.25MM CORONARY EVEROLIMUS ELUTING",SUP-1009544-12,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"UHC [10700]","United Healthcare",,6071.1,63.3,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE SMARTSET 40GM MEDIUM VISCOSITY STERILE",SUP-3122040,CDM,C1713,HCPCS,0278,RC,,,both,,,469.80,140.94,"CIGNA [10200]","Cigna Local Plus",,251.34,53.5,,3978.14,359.25,3978.14,24,54.64,399.33,"percent of total billed charges",
"INSRT ARTICULAR 5-6 11MM KNEE POSTERIOR STABILIZE HIGH",SUP-71421516,CDM,C1776,HCPCS,0278,RC,,,both,,,10774.35,3232.3,"NOVANET [10819]",Novanet,,8080.76,75,,,,,0,1253.06,9158.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 15MM 135CM 4.5MM 3.3-2.9FR 6FR BILIARY",SUP-1011490-15,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"NOVANET [10819]",Novanet,,4725,75,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X14X7MM ENDOSKELETON TCS 6D MEDIUM LORDOTIC",SUP-5366-1407,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7398,41.1,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 63MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 4",SUP-241.041,CDM,C1713,HCPCS,0278,RC,,,both,,,2169.30,650.79,"NOVANET [10819]",Novanet,,1626.98,75,,,,,0,252.29,1843.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X9MM PARALLEL SPINE CERVICAL",SUP-17909,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.175 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.175,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.8MM 200MM 15MM LCP ANKLE COMPRESSION THREAD",SUP-03.118.015S,CDM,C1769,HCPCS,0272,RC,,,both,,,793.64,238.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,326.19,41.1,,,,,0,92.3,674.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 0 GS-22 23CM CLSR ABSORBABLE GREEN",SUP-VLOCL2246,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.67,61.7,"FIRST HEALTH [10303]","First Health",,164.54,80,,,,,0,23.92,174.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165CM 8.5-11MM OTSC 3MM NITINOL STERILE",SUP-100.04,CDM,C1760,HCPCS,0278,RC,,,both,,,3667.50,1100.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1049.64,28.62,,,,,0,426.53,3117.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER CS L 115CM 7FR 2-8-2MM SPACE FJ CURVE MAPPING",SUP-BD710FJ282RTS,CDM,C1730,HCPCS,0272,RC,,,both,,,2142.00,642.6,"AETNA [10100]","Aetna HMO/PPO",,1702.89,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,249.11,1820.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 5CM 8.5FR CENTER BEND THIN WALL",SUP-M00534620,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"CIGNA [10200]","Cigna Open Access",,619.9,56.9,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145361010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,443.81,45.9,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 7 5MM KNEE AOX CRUCIATE RETAIN ROTATE PLATFORM",SUP-151630705,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]","Cigna Open Access",,4397.63,33.5,,5302.19,4377.88,6578.61,27,1526.7,11158.16,"percent of total billed charges",
"INSRT TIBIAL 7 10MM KNEE LEFT E-PLUS EMPOWR 3D KNEE STERILE",SUP-341-10-707,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"CIGNA [10200]","Cigna Open Access",,3729.8,56.9,,5302.19,4377.88,6578.61,27,762.35,5571.75,"percent of total billed charges",
"OCCL CARDIOVASCULAR 12MM SEPTAL SELF EXPANDING DELIVERY",SUP-9-ASD-012,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"PHCS [10601]",PHCS,,14875.56,70,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER PELLO 4MM STRAIGHT",SUP-6290-112-040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1837.50,551.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,217.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL RAPIDE 5-0 P-1 18IN BRAID COATED UNDYED",SUP-VR490,CDM,S27200284,LOCAL,0272,RC,,,both,,,71.48,21.44,"CIGNA [10200]",Cigna,,48.61,68,,,,,0,8.31,60.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 0.9% SODIUM CHLORIDE 500ML LIFECARE LATEX",SUP-798303,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA [10200]","Cigna Open Access",,46.09,56.9,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL BIOVER LARGE VEIN 2 POLYCARBONATE STERILE","SUP-GEM TKLV-2",CDM,S27200284,LOCAL,0272,RC,,,both,,,616.41,184.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,282.93,45.9,,,,,0,71.69,523.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED DUAL MOBILITY HIP SYSTEM + CER HD + VE",SUP-98000500324,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3370.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3370.37,24633,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM 11/13 TAPER 40MM HIP M SPECIFICATION METAL",SUP-136541500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"CIGNA [10200]","Cigna Open Access",,6303.35,56.9,,5302.19,4377.88,6578.61,27,1288.37,9416.26,"percent of total billed charges",
"OCCL CARDIOVASCULAR 12MM SEPTAL SELF EXPANDING DELIVERY",SUP-9-ASD-012,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"MULTIPLAN [10600]",Multiplan,,18063.18,85,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 8.5FR 18GA 16CM .032IN 4 LUMEN INDWELL GWIRE NDL",SUP-CDC-42854-XP1A,CDM,C1751,HCPCS,0272,RC,,,both,,,1229.58,368.87,"PHCS [10601]",PHCS,,860.71,70,,,,,0,143,1045.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 200MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171032010,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"KAISER [10500]",Kaiser,,786.92,67,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 13MM ATLANTIS TITANIUM ANTERIOR CERVICAL",SUP-3125513,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"KAISER [10500]",Kaiser,,944.7,67,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL STARTER SCREW METTAN",SUP-71631448,CDM,S27200284,LOCAL,0272,RC,,,both,,,1647.30,494.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,195.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,191.58,1400.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED II 100CM 6CM 8FR 20MM .035IN BALLOON DILATATION",SUP-611759,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"FIRST HEALTH [10303]","First Health",,4254.43,80,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY FORMABLE SHAFT UNIQUE CUTTING EDGE SUPERIOR",SUP-190051,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,774.56,45.9,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 12MM SEPTAL SELF EXPANDING DELIVERY",SUP-9-ASD-012,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"AETNA [10100]","Aetna HMO/PPO",,16894.39,79.5,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 8MM 8FR ENDOPROSTHESIS HEPARIN",SUP-VBH081002,CDM,C1874,HCPCS,0278,RC,,,both,,,19939.50,5981.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5706.68,28.62,,,,,0,2318.96,16948.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 20FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0196L20,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.32,32.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.6,92.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL STEEL 6 CCS 18IN MONOFILAMENT 4 STRAND",SUP-M654G,CDM,S27200284,LOCAL,0272,RC,,,both,,,175.08,52.52,"PHCS [10601]",PHCS,,122.56,70,,,,,0,20.36,148.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 14FR 30CM RADIOPAQUE DRNG SILHOUETTE PEEL-AWAY",SUP-G08321,CDM,C1892,HCPCS,0272,RC,,,both,,,526.42,157.93,"PHCS [10601]",PHCS,,368.49,70,,,,,0,61.22,447.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +9.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.095,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SPECTRUM II SMALL CRESCENT 15MM 3MM HOOK ERGONOMIC",SUP-C6385,CDM,S27200284,LOCAL,0272,RC,,,both,,,685.50,205.65,"UHC [10700]","United Healthcare",,433.92,63.3,,,,,0,79.72,582.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23X9X10MM COALESCE LORDOTIC STRAIGHT STERILE",SUP-2000-00-091008,CDM,C1889,HCPCS,0278,RC,,,both,,,21420.00,6426,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2491.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM ENDOCARDIAL BIPOLAR SINGLE COIL ACTIVE",SUP-1582,CDM,C1777,HCPCS,0278,RC,,,both,,,20538.00,6161.4,"CIGNA [10200]",Cigna,,8215.2,40,,,,,0,2388.57,17457.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Islet Cell Ab",PX-302000075,CDM,86341,CPT,0302,RC,,,both,,,240.50,72.15,"FIRST HEALTH [10303]","First Health",,192.4,80,,,,,0,0.01,204.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 3DMAX 6.7X4.8IN ABDOMINAL RIGHT LIGHTWEIGHT",SUP-0117322,CDM,C1781,HCPCS,0278,RC,,,both,,,1005.80,301.74,"NOVANET [10819]",Novanet,,754.35,75,,,,,0,116.97,854.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 12MM BALLOON",SUP-U3575126,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CORDELLA SYSTEM (CHFS) KIT",SUP-100171-00,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 150CM 4CM 3MM BALLOON DILATATION ILIAC",SUP-G34319,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Arthcs Asp/Inj Mjr Jt Bi",PX-361000033,CDM,20610,CPT,0361,RC,,,both,,,2944.45,883.33,"KAISER [10500]",Kaiser,,1972.78,67,,,,,0,342.44,2944.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HETASTARCH 6 % IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION",RX-25174,CDM,,,0250,RC,00409-7248-13,NDC,both,500,ML,382.28,114.68,"AETNA [10100]","Aetna HMO/PPO",,303.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.46,324.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RAPR ROUND LARGE VEST AND LEG WRAPS",SUP-8001061560,CDM,S27000186,LOCAL,0270,RC,,,both,,,2400.15,720.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1101.67,45.9,,,,,0,279.14,2040.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR 28CM 13-15FR ACCESS STAINLESS STEEL",SUP-M0062502071,CDM,C1894,HCPCS,0272,RC,,,both,,,815.04,244.51,"AMERIGROUP MEDICAID [20100]",Amerigroup,,96.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.79,692.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 15CM 120CM 10MM ENDOPROSTHESIS HEPARIN",SUP-VBHR101502A,CDM,C1874,HCPCS,0278,RC,,,both,,,24374.70,7312.41,"CIGNA [10200]","Cigna Local Plus",,7678.03,31.5,,,,,0,2834.78,20718.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 110MM QUICK CONNECT PERIARTICULAR ZPS 2.5MM",SUP-00480611025,CDM,S27000186,LOCAL,0270,RC,,,both,,,1275.75,382.72,"UHC [10700]","United Healthcare",,807.55,63.3,,,,,0,148.37,1084.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 100MM 130CM 7MM VASCULAR METAL SUPERFICIAL",SUP-H74939293071030,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"FIRST HEALTH [10303]","First Health",,3864,80,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM ACTIVE ARTICULATION THR POROUS CUP 2 MOBILITY LIN",SUP-98B00100194,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 84MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 6",SUP-245.061,CDM,C1713,HCPCS,0278,RC,,,both,,,2927.40,878.22,"BLUE CROSS [10001]","Blue Cross HMO",,1147.54,39.2,,957.42,156.86,7483.26,51,340.46,2488.29,"percent of total billed charges",
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 28MM 144CM 3.5MM",SUP-H7493941228350,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CIGNA [10200]",Cigna,,5278.5,68,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIKING 110CM 6FR 5MM SPACE JOSEPHSON CURVE",SUP-M0044005040,CDM,C1730,HCPCS,0272,RC,,,both,,,1558.44,467.53,"KAISER [10500]",Kaiser,,1044.15,67,,,,,0,181.25,1324.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 80MM 5MM .035IN BALLOON DILATATION NYBAX",SUP-H74939171050870,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PHCS [10601]",PHCS,,822.15,70,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP050250150 PLUS US D5L250UL1500",SUP-PCP050250150,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"AETNA [10100]","Aetna HMO/PPO",,1009.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 9MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P409,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3835.36,45.9,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP PULSED LAVAGE 11IN INTERPULSE FEMORAL CANAL IRRIGATION",SUP-210005000,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.35,28.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.21,81.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 12MM 2.25MM CORONARY RAPID EXCHANGE",SUP-ONYXNG22512UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA [10200]",Cigna,,1785,68,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-150440105,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"NOVANET [10819]",Novanet,,22585.5,75,,,,,0,3502.26,25596.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONTROL REMOTE AXONICS NONSTERILE LATEX FREE",SUP-2301,CDM,C1787,HCPCS,0270,RC,,,both,,,5692.50,1707.75,"NOVANET [10819]",Novanet,,4269.38,75,,,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 22-30CM 7FR URETERAL",SUP-M0061456310,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"FIRST HEALTH [10303]","First Health",,500.19,80,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,J0131,HCPCS,0636,RC,31722-0205-31,NDC,both,100,ML,98.15,29.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6.99,,,,,,,6.99,83.43,"fee schedule",
"PATCH DURAL 9X2CM DURA-GUARD BOVINE PERICARDIUM",SUP-DG0209SN,CDM,S27800098,LOCAL,0278,RC,,,both,,,2948.48,884.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1353.35,45.9,,,,,0,342.91,2506.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z2 100CM 6FR JL4 CURVE GUIDING CORONARY STERILE LATEX",SUP-Z26JL40,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE IRON MAN VASCULAR 190CM STAINLESS STEEL",SUP-7081,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,MINOR",793,APR-DRG,,,,,,,inpatient,,,118953.84,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $6,241.54. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($42,179.60) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER SLATE 4.5MM DYONICS INCISOR PLUS ELITE CURVE",SUP-72200036,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(COMM) CATH LITHOPLASTY 110CM 60MM 3.5MM .064IN ULTRASOUND",SUP-M732LPBC3560DX1,CDM,C1725,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"TUBE TRACH 5.5MM 46MM 7.9MM SHILEY PEDIATRIC UNCUFF TAPE TIE",SUP-5.5PEF,CDM,S27200284,LOCAL,0272,RC,,,both,,,395.85,118.75,"MULTIPLAN [10600]",Multiplan,,336.47,85,,,,,0,46.04,336.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 14MM PCM SPINE DISTRACTION NONSTERILE",SUP-7670214,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 70MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.770S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,291.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,286.03,2090.49,"percent of total billed charges",
"MATRIX TISSUE 3X3IN DURAGEN PLUS DURAL BOVINE CLLGN PATCH",SUP-DP5033,CDM,,,0278,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,3.74,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 27CM 15FR 18GA .038IN POLYURETHANE CANNON II PLUS",SUP-CS-15322-VSP,CDM,C1750,HCPCS,0278,RC,,,both,,,2400.00,720,"AETNA [10100]","Aetna HMO/PPO",,1908,79.5,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 175MM 24MM 19MM STD NECK S-ROM CERAMIC 135D",SUP-523196,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"UHC [10700]","United Healthcare",,12312.64,63.3,,8601.07,8395.67,8601.07,"1 through 10",2262.18,16533.56,"percent of total billed charges",
"CATH 5.75IN 16FR URETHRAL STAINLESS STEEL FEMALE NONSTERILE",SUP-475-636,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.39,103.02,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,157.62,45.9,,,,,0,39.94,291.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Stnt 2+ Maj Cor Arty",PX-481000429,CDM,92930,CPT,0481,RC,,,both,,,46067.25,13820.17,"AETNA [10100]","Aetna HMO/PPO",,36623.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4937,39157.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Ren Arty 1st Ord Bi",PX-361000092,CDM,36252,CPT,0361,RC,,,both,,,14951.46,4485.44,"CIGNA [10200]","Cigna Local Plus",,6044,,"Case rate ($6,044). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1738.85,12708.74,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Breast Uni Complete",PX-402000048,CDM,76641,CPT,0402,RC,,,both,,,1193.28,357.98,"CIGNA [10200]",Cigna,,149.78,,,,,,,107.09,1014.29,"fee schedule",
"HC Ins Pacing Elect Lv Lead Add",PX-480000019,CDM,33225,CPT,0481,RC,,,both,,,7637.14,2291.14,"FIRST HEALTH [10303]","First Health",,6109.71,80,,,,,0,888.2,7637.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 CURVE 15MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-96-2033,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2647.19,28.62,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 7FR JR4 CURVE GUIDING CORONARY SIDEHOLE",SUP-LA7JR40SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL CEMENT DELTA XTEND SHOULDER",SUP-OSC368289,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5275.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 15MM MBT 2.5 KNEE REVISION STEP WEDGE STERILE",SUP-129456127,CDM,C1776,HCPCS,0278,RC,,,both,,,9889.08,2966.72,"PHCS [10601]",PHCS,,6922.36,70,,,,,0,1150.1,8405.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR AEROSOL VAPOTHERM PRECISION FLOW AEROGEN LATEX FREE",SUP-AAA-1,CDM,S27000186,LOCAL,0270,RC,,,both,,,83.52,25.06,"KAISER [10500]",Kaiser,,55.96,67,,,,,0,9.71,70.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 110MM 2.5MM STAINLESS STEEL QUICK COUPLING",SUP-310.25,CDM,S27000186,LOCAL,0270,RC,,,both,,,310.00,93,"MULTIPLAN [10600]",Multiplan,,263.5,85,,,,,0,36.05,263.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 275X2.9X3.2CM .035IN STREAMLINE DEVICE",SUP-H74939407XS0,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RANGER 150CM 200MM 7MM BALLOON DILATATION PACLITAXEL",SUP-H74939419702010,CDM,C2623,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AGENT HEMOSTATIC MATRIX RECOTHROM FLOSEAL",SUP-ADS202105,CDM,S27200284,LOCAL,0272,RC,,,both,,,1126.09,337.83,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE VIPERWIRE ADVANCE VASCULAR 335CM .014IN PERIPHERAL",SUP-VPR-GW-14,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNIFE ELECTROSURGICAL 1650MM 2.8MM HOOKKNIFE DISTAL L HOOK",SUP-KD-620LR,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 300MM 3MM BALLOON DILATATION RAPID",SUP-47530300M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH GLIDELIGHT 25-80HZ 50CM 16FR 11.5FR 12.5FR 17.2FR",SUP-500-303,CDM,C2629,HCPCS,0272,RC,,,both,,,19624.50,5887.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"DEVICE BASIXCOMPAK 30 ATM 13IN INFLATION POLYCARBONATE 20ML",SUP-IN4330,CDM,S27200284,LOCAL,0272,RC,,,both,,,332.51,99.75,"AETNA [10100]","Aetna HMO/PPO",,264.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.67,282.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR ACTIS DUOFIX 11 HIGH OFFSET HIP STERILE",SUP-101012110,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"MULTIPLAN [10600]",Multiplan,,25904.81,85,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ACHIEVE 20MM 10CM 9CM 15CM 14GA 13.5GA BIOPSY SOFT",SUP-CA1415,CDM,S27200284,LOCAL,0272,RC,,,both,,,446.96,134.09,"FIRST HEALTH [10303]","First Health",,357.57,80,,,,,0,51.98,379.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL 6MM STD VASCULAR 2 TRACTION SPRING STEALTH",SUP-AVD-6025,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"KAISER [10500]",Kaiser,,104.92,67,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE STD 240CM 2.4MM 27MM SENSATION POLYPECTOMY OVAL LOOP",SUP-M00562671,CDM,S27200284,LOCAL,0272,RC,,,both,,,161.30,48.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.76,137.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 4FR 6MM LOW PROFILE",SUP-39031-60401,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 6-0 P-3 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J492H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,18.36,68,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL S-ROM +3MM 11/13 TAPER 36MM HIP M SPECIFICATION",SUP-136532000,CDM,C1776,HCPCS,0278,RC,,,both,,,6875.85,2062.75,"CIGNA [10200]","Cigna Open Access",,3912.36,56.9,,5302.19,4377.88,6578.61,27,799.66,5844.47,"percent of total billed charges",
"4.0 PLY SCRW 4.0X16",SUP-102040116,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NUROLON 2-0 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-C522D,CDM,S27200284,LOCAL,0272,RC,,,both,,,127.14,38.14,"CIGNA [10200]","Cigna Local Plus",,68.02,53.5,,,,,0,14.79,108.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET",RX-99694,CDM,,,0250,RC,00115-1365-30,NDC,both,1,UN,96.85,29.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.26,82.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 7CM 7FR DUODENAL BEND BILIARY PLASTIC",SUP-M00534210,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,740.83,68,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING HME FILTER MASK BAG SAMPLE ELBOW PORT 70IN",SUP-NCF375-6121Z,CDM,S27000186,LOCAL,0270,RC,,,both,,,88.04,26.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,36.18,41.1,,,,,0,10.24,74.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD GLENOID 42MM UNIVERS REVERS +2.5MM MEDIUM UNIVERSAL",SUP-AR-9504M-02,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4877.28,40,,,,,0,1418.07,10364.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE 11IN VALLEYLAB STERILE ARGON",SUP-E3580-28,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.15,88.24,"CIGNA [10200]","Cigna Open Access",,167.37,56.9,,,,,0,34.21,250.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 1-2 15MM KNEE POSTERIOR STABILIZE HIGH",SUP-71421504,CDM,C1776,HCPCS,0278,RC,,,both,,,10774.35,3232.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3083.62,28.62,,,,,0,1253.06,9158.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GALLANT HF CRT-D DF1 CONNECTOR",SUP-CDHFA500T,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9118.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 30MM 7MM STAINLESS STEEL 1.1MM SHORT THREAD",SUP-02.226.030,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"BLUE CROSS [10001]","Blue Cross PPO",,644.92,39.2,,957.42,570.23,957.42,28,191.34,1398.42,"percent of total billed charges",
"SCR BONE 4.5MM 36MM STAINLESS STEEL FULL THREAD FOOT",SUP-214.736,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,130.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",130.68,955.09,"percent of total billed charges",
"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC",482,MS-DRG,,,,,,,inpatient,,,74822.22,22446.67,"AMBETTER EXCHANGE  [11102]",Ambetter,,10117.19,,"Case rate ($10,117.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,394.50, add-ons for qualifying new technology services are included. If operating cost exceeds $42,434.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,092.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,406.92. The transfer operating threshold is the transfer adjustment factor * $9,394.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.27. The transfer capital threshold is the transfer adjustment factor * $710.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,47618.68,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch W Guid Navigation",PX-750000009,CDM,31627,CPT,0750,RC,,,both,,,4188.00,1256.4,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,487.06,4188,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC",239,MS-DRG,,,,,,,inpatient,,,141174.97,42352.49,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,32666.68,,"Case rate ($30,529.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $28,348.81, add-ons for qualifying new technology services are included. If operating cost exceeds $61,388.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,525.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $28,386.30. The transfer operating threshold is the transfer adjustment factor * $28,348.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,143.31. The transfer capital threshold is the transfer adjustment factor * $2,143.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,10994,141174.97,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4MM EXCALIBUR COOLCUT STERILE DISPOSABLE",SUP-AR-8400EX,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"UHC [10700]","United Healthcare",,317.64,63.3,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 150MM 3MM BALLOON DILATATION RAPID",SUP-47530150L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 50MM SPINE POLYAXIAL REVOLVE",SUP-185.486,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"KAISER [10500]",Kaiser,,6396.39,67,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC 4X3IN BICOL CLLGN ABSORBABLE MICROFIBRILLAR",SUP-801460,CDM,S27200284,LOCAL,0272,RC,,,both,,,1033.59,310.08,"CIGNA [10200]","Cigna Local Plus",,552.97,53.5,,,,,0,120.21,878.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING URETHRAL ARIS THK.3MM POLYPROPYLENE MACROPOROUS HEAT",SUP-934400,CDM,C1763,HCPCS,0278,RC,,,both,,,7431.30,2229.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2126.84,28.62,,,,,0,864.26,6316.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 70MM LCP STAINLESS STEEL FULL THREAD PROXIMAL",SUP-02.207.070,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,1831.33,1831.33,1831.33,16,189.34,1383.8,"percent of total billed charges",
"LEAD DEFIB 65CM PLEXA PROMRI CARDIAC DF4 17CM S DX STERILE",SUP-436910,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]","Cigna Local Plus",,4781.7,31.5,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sars-Cov-2/2019-Ncov (Covid-19)",PX-300000409,CDM,U0002,HCPCS,0300,RC,,,both,,,315.90,94.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,46.18,,,,,,,27.64,268.52,"fee schedule",
"IMPL ORBITAL HA 22MM I O I",SUP-I00022S,CDM,S27800098,LOCAL,0278,RC,,,both,,,5865.00,1759.5,"BLUE CROSS [10001]","Blue Cross PPO",,2299.08,39.2,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Gentamicin",PX-301000044,CDM,80170,CPT,0301,RC,,,both,,,416.10,124.83,"PHCS [10601]",PHCS,,291.27,70,,,,,0,11.1,353.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UNI-FUSE FLOW-THRU HUB 135CM 40CM 5FR THROMBECTOMY",SUP-12401815,CDM,C1757,HCPCS,0272,RC,,,both,,,3112.50,933.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,368.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OPEN HEART ADULT PACK (OAUHJ)166",SUP-PV21OAUHB,CDM,S27200284,LOCAL,0272,RC,,,both,,,2381.18,714.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,276.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,276.93,2024,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TIBIAL VANTAGE 2 ANKLE LEFT STERILE LATEX FREE",SUP-350-11-02,CDM,C1713,HCPCS,0278,RC,,,both,,,29389.50,8816.85,"PHCS [10601]",PHCS,,20572.65,70,,,,,0,3418,24981.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 100CM 8FR AL1 CURVE GUIDING PTFE FEMORAL",SUP-H74934358680,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 2.50 X 38 MM RX FDA",SUP-1203250-38,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Local Plus",,5433.75,31.5,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER BACTERIAL/VIRAL EXPIRATORY PURITAN BENNETT SERIES 980",SUP-10043551,CDM,S27000186,LOCAL,0270,RC,,,both,,,139.83,41.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.26,118.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT MONOLITHIC 16MM PLIF",SUP-3W3116,CDM,S27800098,LOCAL,0278,RC,,,both,,,12487.62,3746.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4995.05,40,,,,,0,1452.31,10614.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 20MM 190CM 4MM",SUP-R51004002L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"AETNA [10100]","Aetna HMO/PPO",,1567.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE STANDARD TIP HPS PLS 1.1 MM X 152 MM",SUP-KWIR-HPS-PLS,CDM,S27000186,LOCAL,0270,RC,,,both,,,356.70,107.01,"AETNA [10100]","Aetna HMO/PPO",,283.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.48,303.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA CARDIOPLEGIA ANTEGRADE W/VENT",SUP-ANT-2012S,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.72,41.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.25,118.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC ANATOMIC SOCKET FLIPCUTTER II SHORT KNEE",SUP-AR-1204AS-80,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,303.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Benzodiazepines 1-12",PX-301000498,CDM,80346,CPT,0301,RC,,,both,,,189.00,56.7,"PHCS [10601]",PHCS,,132.3,70,,,,,0,0.01,189,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.25 X 15 RX US",SUP-1804325-15,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Benzodiazepines 1-12",PX-301000498,CDM,80346,CPT,0301,RC,,,both,,,189.00,56.7,"UHC [10700]","United Healthcare",,102.99,,,,,,,0.01,189,"fee schedule",
"SCR BONE 4MM 40MM 14MM STAINLESS STEEL CANNULATED STERILE",SUP-121840,CDM,C1713,HCPCS,0278,RC,,,both,,,2006.40,601.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1364.35,68,,,,,0,233.34,1705.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BIOLOGICAL 4.5X4.25IN PURACOL PLUS SQUARE CLLGN",SUP-MSC8644EP,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.49,36.75,"UHC [10700]","United Healthcare",,77.54,63.3,,,,,0,14.25,104.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X12MM COROENT PEEK THORACOLUMBAR INTERBODY",SUP-6981255,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS [10001]","Blue Cross PPO",,9313.92,39.2,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 35CM 7.5FR VENTRICLE TRANSVENE SILICONE",SUP-6937A-35,CDM,C1883,HCPCS,0278,RC,,,both,,,6900.00,2070,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3167.1,45.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOLD FEMORAL STEM 145MM 13MM STAGEONE HIP STAINLESS STEEL",SUP-431192,CDM,C1776,HCPCS,0278,RC,,,both,,,9954.63,2986.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4091.35,41.1,,6417.48,6417.48,6417.48,"1 through 10",1157.72,8461.44,"percent of total billed charges",
"LENS IOL +21.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.215,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DIL GARRETT 8.25IN",SUP-25-8015,CDM,S27200284,LOCAL,0272,RC,,,both,,,1366.71,410.01,"CIGNA [10200]","Cigna Open Access",,777.66,56.9,,,,,0,158.95,1161.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 5CM 120CM 13MM ENDOPROSTHESIS LUMEN CATH",SUP-VBCR130502A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"AETNA [10100]","Aetna HMO/PPO",,13439.48,79.5,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MISOPROSTOL 100 MCG TABLET",RX-10628,CDM,,,0637,RC,60687-0735-11,NDC,both,1,UN,12.47,3.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.45,10.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GIRAFFE 45D 2MM 5.25IN FRONTAL SINUS 2 ACTION",SUP-63-8840,CDM,S27200284,LOCAL,0272,RC,,,both,,,3430.28,1029.08,"AETNA [10100]","Aetna HMO/PPO",,2727.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,398.94,2915.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 100CM 5FR LCB CURVE ANGIOGRAPHIC PEBAX",SUP-7534-13,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X13MM LUMINARY 10/11MM SPINE",SUP-4713,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"FIRST HEALTH [10303]","First Health",,25200,80,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 24IN 2 PORT 1 BLADDER WITHOUT SLEEVE ATS STERILE",SUP-60707010400,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"PHCS [10601]",PHCS,,51.77,70,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 119MM TRI-LOCK BPS GRIPTION 12 STANDARD OFFSET",SUP-101204120,CDM,C1776,HCPCS,0278,RC,,,both,,,29153.25,8745.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11981.99,41.1,,6417.48,6417.48,6417.48,"1 through 10",3390.52,24780.26,"percent of total billed charges",
"ROD SPINAL 70MM 5.5MM CREO CURVE TITANIUM NONSTERILE",SUP-1119.7070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENV TISSUE 6.9X8CM CORMATRIX CANGAROO ECM LARGE PORCINE SOFT",SUP-CMCV-009-LRG,CDM,S27800098,LOCAL,0278,RC,,,both,,,6796.50,2038.95,"CIGNA [10200]","Cigna Local Plus",,3636.13,53.5,,,,,0,790.43,5777.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5.5MM TI CURVED ROD 65MM",SUP-04.636.065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"GRAFT SKIN 22X19CM FLEXHD PLIABLE PRE THK.7-1.4MM THIN SMALL",SUP-PP1500,CDM,Q4128,HCPCS,0636,RC,,,both,,,71820.00,21546,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,247.92,,,,,,,80.43,61047,"fee schedule",
"STENT WALLSTENT UNISTEP PLUS 35MM 75CM 22MM 100CM",SUP-H965404500,CDM,C1876,HCPCS,0278,RC,,,both,,,14331.30,4299.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5890.16,41.1,,,,,0,1666.73,12181.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TIGHTRAIL 18FR 18.7IN 11FR 23FR 11.2FR DIL ROTATE",SUP-545-511,CDM,C1773,HCPCS,0272,RC,,,both,,,15766.50,4729.95,"AETNA [10100]","Aetna HMO/PPO",,12534.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1833.64,13401.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 38MM 140CM .91-1.12MM 3.5MM CORONARY",SUP-RONYX35038W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"KAISER [10500]",Kaiser,,3644.13,67,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Porphobilinogen Urine Quant",PX-301000361,CDM,84110,CPT,0301,RC,,,both,,,456.00,136.8,"AETNA [10100]","Aetna HMO/PPO",,362.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,387.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 35MM 35CM KINK RESISTANT CANN RADIOPAQUE 6",SUP-401835M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"AETNA [10100]","Aetna HMO/PPO",,83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION 155CM 2.4FR MICRO STRAIGHT INFUSION NITINOL 1",SUP-M001195220,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"KAISER [10500]",Kaiser,,2512.5,67,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 6MM 2.25MM .017IN",SUP-H7493926706220,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 100MM 11MM NEXGEN OFFSET KNEE FEMUR 145MM STERILE",SUP-00598802011,CDM,C1776,HCPCS,0278,RC,,,both,,,10435.56,3130.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1213.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1213.66,8870.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 22CM 3CM 7FR .038IN PIGTAIL CURVE",SUP-M006180531170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"MULTIPLAN [10600]",Multiplan,,1046.32,85,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tumor Immunohistochem Cad",PX-312000046,CDM,88361,CPT,0312,RC,,,both,,,615.33,184.6,"FIRST HEALTH [10303]","First Health",,492.26,80,,,,,0,0.01,523.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 40MMX12MMX20CM 26FR",SUP-TAC124020A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"UHC [10700]","United Healthcare",,115459.2,63.3,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 24CM 3CM 5FR .035IN STRAIGHT URETERAL",SUP-M006155222190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPPORTER ATHLETIC XLG",SUP-SA1503-WH-XL,CDM,S27000186,LOCAL,0270,RC,,,both,,,128.24,38.47,"AETNA [10100]","Aetna HMO/PPO",,101.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.91,109,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP DA VINCI S/SI ENDOWRIST HEMOCLIP 8MM SMALL",SUP-420003,CDM,S27000186,LOCAL,0270,RC,,,both,,,1000.59,300.18,"FIRST HEALTH [10303]","First Health",,800.47,80,,,,,0,116.37,850.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 36CM FEMUR RIGHT PROXIMAL TALON DISTALFIX",SUP-SLN-125-36R,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"CIGNA [10200]",Cigna,,6450.12,40,,1831.33,1831.33,1831.33,16,1875.37,13706.51,"percent of total billed charges",
"LENS IOL +27 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.270,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 34CM FEMUR LEFT PROXIMAL TALON DISTALFIX",SUP-SLN-125-34L,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"BLUE CROSS [10001]","Blue Cross PPO",,6321.12,39.2,,957.42,570.23,957.42,28,1875.37,13706.51,"percent of total billed charges",
"HOOK SKIN W5MMXL6 1/4IN JOSEPH",SUP-20-5005,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.72,41.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,63.21,45.9,,,,,0,16.02,117.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 650CC SUT TAB INTEGRAL INJECTION DOME",SUP-SDC130UH,CDM,C1789,HCPCS,0278,RC,,,both,,,12730.50,3819.15,"PHCS [10601]",PHCS,,8911.35,70,,,,,0,1480.56,10820.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR RUST 58MM 28MM RINGLOC ECCENTRIC HIP",SUP-11-165240,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"PHCS [10601]",PHCS,,4661.92,70,,,,,0,774.54,5660.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 485CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-485,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]",Cigna,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Volatiles",PX-301000560,CDM,84600,CPT,0301,RC,,,both,,,150.00,45,"UHC [10700]","United Healthcare",,15.4,,,,,,,0.01,127.5,"fee schedule",
"STENT COTTON-HUIBREGTSE 7CM 10FR BILIARY POLYETHYLENE DRAIN",SUP-G21656,CDM,C1877,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA [10200]","Cigna Local Plus",,338.01,53.5,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERSACROSS SHEATH 63CM 45DEG D0",SUP-VXS0201,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"AETNA [10100]","Aetna HMO/PPO",,1287.9,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 7MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120715,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]","Cigna Open Access",,3980.4,33.5,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 SH 27IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP784D,CDM,S27200284,LOCAL,0272,RC,,,both,,,127.77,38.33,"KAISER [10500]",Kaiser,,85.61,67,,,,,0,14.86,108.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE AND SUBACUTE ENDOCARDITIS WITH CC",289,MS-DRG,,,,,,,inpatient,,,67175.13,20152.54,"BLUE CROSS [10001]","Blue Cross PPO",,42138.33,,,,,,,7561,42568.38,"case rate",
"SIZER IMPL 13.25CM NATRELLE INSPIRA P5.5CM FULL PROFILE",SUP-MSZ-F520,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA [10200]","Cigna Local Plus",,84.63,53.5,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2MM TARGET NANO HELICAL DETACHABLE",SUP-M0035452030,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"PHCS [10601]",PHCS,,6410.38,70,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS ILM 25GA",SUP-705.44,CDM,S27200284,LOCAL,0272,RC,,,both,,,984.07,295.22,"KAISER [10500]",Kaiser,,659.33,67,,,,,0,114.45,836.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 4MM EMBOLD PLATINUM TUNGSTUN NITINOL",SUP-M001394240040150,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"BLUE CROSS [10001]","Blue Cross HMO",,2672.34,39.2,,,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 20MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158102120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3198.16,28.62,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 7CM 170CM 10FR 2 PIGTAIL CURVE TAPER BILIARY",SUP-G21787,CDM,C2625,HCPCS,0278,RC,,,both,,,1231.20,369.36,"CIGNA [10200]","Cigna Local Plus",,658.69,53.5,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM VUEPOINT II SPINE FAVORED ANGLE",SUP-8975526,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"FIRST HEALTH [10303]","First Health",,3360,80,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502605802,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"PHCS [10601]",PHCS,,16003.89,70,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hba1/Hba2 Full Gene Sequence Alpha Globins",PX-309000134,CDM,81259,CPT,0310,RC,,,both,,,554.00,166.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,554,,,,,,,0.01,554,"fee schedule",
"HC Cann Eopa Blunt Nonvent 22f",PX-E27200343,CDM,E27200343,LOCAL,0272,RC,,,both,,,342.10,102.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Ureteral Embolization/Occl",PX-361000420,CDM,50705,CPT,0361,RC,,,both,,,1796.00,538.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Prolact Cr Qtr Btl",PX-E27000211,CDM,E27000211,LOCAL,0270,RC,,,both,,,57.20,17.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,EXTREME",952,APR-DRG,,,,,,,inpatient,,,186705.18,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $20,174.22. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($152,765.10) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR LARGE BOWEL PROCEDURES,MINOR",231,APR-DRG,,,,,,,inpatient,,,105478.15,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP MACINTOSH 4 STAINLESS STEEL FIBER OPTIC",SUP-040-914U,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 15CM 45D TURNER BEVELED CANN TUMOR STERILE",SUP-G01087,CDM,S27200284,LOCAL,0272,RC,,,both,,,235.42,70.63,"FIRST HEALTH [10303]","First Health",,188.34,80,,,,,0,27.38,200.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 40MM 6MM .035IN BALLOON",SUP-AB35W06040135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,80.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Pcmkr Elect Dual",PX-480000028,CDM,33235,CPT,0481,RC,,,both,,,10033.02,3009.91,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1188.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1166.84,8528.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Resp Virus 12-25 Targets",PX-306000225,CDM,87633,CPT,0306,RC,,,both,,,1656.80,497.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,227.77,,"Fee schedule rate ($227.77). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1479.54,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET",RX-9285,CDM,,,0637,RC,00904-7205-46,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MERIT LAUREATE VASCULAR ANGLE 260CM 3CM .035IN NITINOL",SUP-LWSTDA35260EX,CDM,C1769,HCPCS,0272,RC,,,both,,,295.80,88.74,"MULTIPLAN [10600]",Multiplan,,251.43,85,,,,,0,34.4,251.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROLENE 6X6IN HERNIA NONABSORBABLE SOFT",SUP-PMH,CDM,C1781,HCPCS,0278,RC,,,both,,,644.72,193.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,438.41,68,,,,,0,74.98,548.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 8X38X28MM 10DEG",SUP-1921042P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"UHC [10700]","United Healthcare",,21933.45,63.3,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP PROV 45MM CLSR TIP FIRST OPEN END CLIP LEFT",SUP-PROV45,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4029.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 30MM CLEVERCUT3V PRELOAD DISTAL TIP STERILE",SUP-KD-VC631Q-07301S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2817.75,845.32,"CIGNA [10200]","Cigna Local Plus",,1507.5,53.5,,,,,0,327.7,2395.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW INBONE NARROW",SUP-200138105S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1150.20,345.06,"CIGNA [10200]",Cigna,,782.14,68,,,,,0,133.77,977.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14.8IN 24FR AORTA 3/8IN CURVE AUTO DILATE TIP",SUP-EZC24TA,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"UHC [10700]","United Healthcare",,307.64,63.3,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 24MM TI",SUP-SPL-35240-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,523.91,39.2,,957.42,156.86,7483.26,51,155.43,1136.03,"percent of total billed charges",
"SPACER SPINAL 14X11X12MM ALEUTIAN 7D SMALL PEEK ACDF",SUP-403-21412L,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 20MM DCP STAINLESS STEEL CORTICAL SELF TAPPING",SUP-201.820,CDM,C1713,HCPCS,0278,RC,,,both,,,377.15,113.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,256.46,68,,,,,0,43.86,320.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL INBONE 5 STD ANKLE LEFT",SUP-200252905,CDM,C1776,HCPCS,0278,RC,,,both,,,11847.30,3554.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1403.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1377.84,10070.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 28.5MM 12MM 24-26MM 10-11MM GORE",SUP-RLT281212,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"MULTIPLAN [10600]",Multiplan,,53295,85,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SURGICAL .062IN",SUP-WS-1607ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"NOVANET [10819]",Novanet,,215.33,75,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ASPIRATION 4CM 21GA SPIN XTEND ALWAYS-ON TIP TRACKED",SUP-INS-5450,CDM,S27200284,LOCAL,0272,RC,,,both,,,5868.45,1760.53,"UHC [10700]","United Healthcare",,3714.73,63.3,,,,,0,682.5,4988.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL RFN-ADVANCED INTRAMEDULLARY POLYMER INLAY STERILE LATEX",SUP-08.233.001S,CDM,C1713,HCPCS,0278,RC,,,both,,,2409.00,722.7,"CIGNA [10200]",Cigna,,1638.12,68,,1831.33,1831.33,1831.33,16,280.17,2047.65,"percent of total billed charges",
"IMMOB ORTHOPEDIC UNIVERSAL 18.5X9.5IN SHOULDER ULTRASOFT",SUP-VP20106-000,CDM,L3670,HCPCS,0274,RC,,,both,,,63.51,19.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",7.04,7.04,7.04,"1 through 10",7.39,63.51,"percent of total billed charges",
"SCR BONE 2.7MM 28MM VOLT STAINLESS STEEL T8 CORTEX",SUP-02.527.128,CDM,C1713,HCPCS,0278,RC,,,both,,,1033.56,310.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,122.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",120.2,878.53,"percent of total billed charges",
"PLI KIT SSL6 SAFESHEATH II 6FR 23CM",SUP-SSL6,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RUBY XL COIL 28MMX55CM",SUP-RBYXL2855,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5085.99,27,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 25MM SHOULDER CENTRAL",SUP-550025600,CDM,C1713,HCPCS,0278,RC,,,both,,,2796.00,838.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1901.28,68,,,,,0,325.17,2376.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 36FR NEPHRSTMY NATURAL RUBBER 4 WING DRAIN",SUP-086036,CDM,C1729,HCPCS,0272,RC,,,both,,,105.62,31.69,"UHC [10700]","United Healthcare",,66.86,63.3,,,,,0,12.28,89.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 110MM 4MM RAD 60X-TREME STRAIGHTSHOT M4 FRONTAL",SUP-1884016HR,CDM,S27200284,LOCAL,0272,RC,,,both,,,2092.50,627.75,"KAISER [10500]",Kaiser,,1401.98,67,,,,,0,243.36,1778.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBTALAR DISTRACTION ARTHRODESIS WEDGE, 12 MM",SUP-PSBT-1206,CDM,S27800098,LOCAL,0278,RC,,,both,,,12851.25,3855.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3469.84,27,,,,,0,1494.6,10923.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 5MM CUFF MURPHY EYE RADIOPAQUE VITAL SIGNS",SUP-8050RTC,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.28,14.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.5,40.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 25D LARGE AUG CORTILOC SHOULDER LEFT",SUP-DWK405LA25S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"KAISER [10500]",Kaiser,,7035,67,,,,,0,1221.15,8925,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 9MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-109,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"CIGNA [10200]","Cigna Open Access",,5593.57,56.9,,5302.19,4377.88,6578.61,27,1143.29,8355.94,"percent of total billed charges",
"LENS 17.0 DIOPTER",SUP-MTA3UO170,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 12MM ROUND 11.8CMX20MM STERILE",SUP-0470,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.20,28.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.19,81.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 6MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650706,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1555.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1526.7,11158.16,"percent of total billed charges",
"FORK TUNING 9.5IN HARDY 3 PRONG 3.5IN",SUP-58-3519,CDM,S27000186,LOCAL,0270,RC,,,both,,,1098.36,329.51,"CIGNA [10200]",Cigna,,746.88,68,,,,,0,127.74,933.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL BALLENTINE CURVE 8.25IN 1 TEETH LONGITUDINAL",SUP-52-5511,CDM,S27200284,LOCAL,0272,RC,,,both,,,363.14,108.94,"CIGNA [10200]","Cigna Local Plus",,194.28,53.5,,,,,0,42.23,308.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Pilonidal Cyst Cmplx",PX-450000007,CDM,10081,CPT,0450,RC,,,both,,,12300.00,3690,"CIGNA [10200]",Cigna,,1833,,,,,,,67.13,10455,"case rate",
"MAS 54850015550 4.75 EXT TAB CANN 5.5X50",SUP-54850015550,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"MULTIPLAN [10600]",Multiplan,,8114.82,85,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12-15IN 28FR VENOUS ADULT 3/8IN CNCT 1 STAGE",SUP-68128,CDM,S27200284,LOCAL,0272,RC,,,both,,,340.62,102.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.61,289.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 35MM FLEXIBLE REFLECTION STERILE LATEX FREE",SUP-71362935,CDM,S27200284,LOCAL,0272,RC,,,both,,,1538.19,461.46,"FIRST HEALTH [10303]","First Health",,1230.55,80,,,,,0,178.89,1307.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.35MM 45MM VIPER EXPEDIUM TITANIUM SPINE CORTICAL",SUP-186731445,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL ROLLER BALL 27FR 1 STEM RESECTOSCOPE",SUP-M0068802061,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"PHCS [10601]",PHCS,,361.54,70,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 29MM STD HEART MECHANICAL",SUP-500DM29,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2799.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM VERTEX MAX TITANIUM SPINE MULTIAXIAL",SUP-6958732,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1202.04,28.62,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL JANSEN-MIDDLETON 6.75IN SEPTUM THROUGH CUT JAW",SUP-66-2565,CDM,S27200284,LOCAL,0272,RC,,,both,,,1788.90,536.67,"KAISER [10500]",Kaiser,,1198.56,67,,,,,0,208.05,1520.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 24FR SILICONE PULL RADIOPAQUE MED PORT MIC SECUR-LOK",SUP-7180-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.81,228.54,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 20MM 3MM 35 COIL PUSHABLE 2D HELICAL",SUP-M0013723021,CDM,S27800098,LOCAL,0278,RC,,,both,,,769.50,230.85,"CIGNA [10200]",Cigna,,523.26,68,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 8MM 4MM XLONG CARBIDE OVAL 8 FLUTED STERILE",SUP-00509323600,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.27,56.48,"PHCS [10601]",PHCS,,131.79,70,,,,,0,21.9,160.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 24MM LOW PROFILE SCREWS TITANIUM VARIABLE",SUP-AR-8724V-24,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,463.64,28.62,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 20MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158123120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"MULTIPLAN [10600]",Multiplan,,9498.37,85,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR HIGH DOME 9MM 28MM ADVANCE ALL POLY KNEE",SUP-KPRC28HI,CDM,C1776,HCPCS,0278,RC,,,both,,,3322.50,996.75,"NOVANET [10819]",Novanet,,2491.88,75,,,,,0,386.41,2824.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mcg Dna Probe",PX-311000071,CDM,88271,CPT,0311,RC,,,both,,,705.90,211.77,"CIGNA [10200]","Cigna Local Plus",,47.12,,,,,,,0.01,600.02,"fee schedule",
"TOOL 12CM MR8 2.5MM MATCH HEAD TELESCOPE DISSECTING",SUP-MR8-T12MH25,CDM,S27200284,LOCAL,0272,RC,,,both,,,1134.41,340.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,134.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.93,964.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INQUIRY 110CM 1MM 5FR 2-5-2MM SPACE LARGE CURVE",SUP-81174,CDM,C1730,HCPCS,0272,RC,,,both,,,2250.00,675,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1530,68,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) STABILIZATION SYSTEM",SUP-TTVR-SS,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 39X10.2X2.7MM STAINLESS STEEL 3.5MM SCR LOW PROFILE",SUP-245.023,CDM,C1713,HCPCS,0278,RC,,,both,,,2446.50,733.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,284.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",284.53,2079.53,"percent of total billed charges",
"BIT DRILL 2.5MM CALIBRATE GRADUATE 3.5MM LOCK CORTICAL SCR",SUP-AR-8916-06,CDM,S27200284,LOCAL,0272,RC,,,both,,,550.80,165.24,"UHC [10700]","United Healthcare",,348.66,63.3,,,,,0,64.06,468.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX15MM FRA 12D LORDOTIC NARROW SPINE",SUP-2315,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR KNEE FEMUR PATELLA TIBIA CEMENT STD",SUP-98000200168,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"FIRST HEALTH [10303]","First Health",,17640,80,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 40MM 80CM 9MM 8FR STRAIGHT VASCULAR COVER",SUP-AVSM09040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross PPO",,7161.84,39.2,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 40MM 80CM 9MM 8FR STRAIGHT VASCULAR COVER",SUP-AVSM09040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2124.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTERED TC 99M-SODIUM THIOSULFATE SOLUTION (0-20 MCI)",RX-411525,CDM,A9541,HCPCS,0343,RC,08888-8878-63,NDC,both,1,UN,746.77,224.03,"KAISER [10500]",Kaiser,,500.34,67,,,,,0,86.85,746.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE REVERSE REVISION HUMERAL STEM, SZ 16X175MM",SUP-530-16-175,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"PHCS [10601]",PHCS,,8820,70,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 22CM 10.2FR RB AMPLATZ PIGTAIL CURVE URETER",SUP-G09712,CDM,C2625,HCPCS,0278,RC,,,both,,,1227.07,368.12,"CIGNA [10200]","Cigna Open Access",,698.2,56.9,,,,,0,142.71,1043.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATH NUVISION ICE 10FR ULTRASOUND",SUP-FG10593,CDM,C1759,HCPCS,0272,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL MICROBIAL OMNEX SURGICAL",SUP-4901,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.28,371.18,"UHC [10700]","United Healthcare",,783.2,63.3,,,,,0,143.9,1051.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 2-0 SH-2 30IN 2 ARM BRAID 10 STRAND GREEN WHITE",SUP-PXX82N,CDM,S27200284,LOCAL,0272,RC,,,both,,,571.48,171.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,66.46,485.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 115CM 1.5FR 1CM 4 WIRE TIPLESS BASKET SPECIMEN",SUP-G46206,CDM,S27200284,LOCAL,0272,RC,,,both,,,2063.25,618.97,"AETNA [10100]","Aetna HMO/PPO",,1640.28,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.96,1753.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 100MM 5MM RECTANGLE HELIX BALLOON",SUP-2237-50100,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"MULTIPLAN [10600]",Multiplan,,7038,85,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Sclp/Ax/Tr/Ext 2.6-7.5 Int",PX-450000032,CDM,12032,CPT,0361,RC,,,both,,,1180.00,354,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1180,,"Case rate ($7,363). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,137.23,1180,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX39MM 8FR 135CMCATH HEPARIN",SUP-BXB093902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"KAISER [10500]",Kaiser,,13068.22,67,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 20CM 37MM TAG THORACIC ACTIVE CONTROL",SUP-TGMR373720,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"BLUE CROSS [10001]","Blue Cross PPO",,45461.1,39.2,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 71CM 18GA CURVE PROC TRANSSEPTAL BRK-1 ADULT",SUP-G407209,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"CIGNA [10200]",Cigna,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 80CM 4FR IRRIGATION ARTERY CLOT MANAGEMENT",SUP-220804F,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.79,54.84,"AETNA [10100]","Aetna HMO/PPO",,145.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.26,155.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM AUDION INFLATION EUSTACHIAN TUBE CARTILAGE LATEX FREE",SUP-AET-100,CDM,C1726,HCPCS,0272,RC,,,both,,,11074.50,3322.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4551.62,41.1,,,,,0,1287.96,9413.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X18X10-17MM RISE-L 10D",SUP-193.335,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9270.45,27,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT MONORAIL 31MM 135CM 10MM ENDOPROSTHESIS",SUP-M001719050,CDM,C1876,HCPCS,0278,RC,,,both,,,16615.20,4984.56,"AETNA [10100]","Aetna HMO/PPO",,13209.08,79.5,,,,,0,1932.35,14122.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X18X8MM COROENT 10D PEEK THORACOLUMBAR",SUP-6980855,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"FIRST HEALTH [10303]","First Health",,19008,80,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 14X12CM BREAST 500ML STYLE 133SV TEXTURED SUT TAB",SUP-133SX-14-T,CDM,C1789,HCPCS,0278,RC,,,both,,,6510.00,1953,"CIGNA [10200]",Cigna,,4426.8,68,,,,,0,757.11,5533.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 3.5MM AXON CURVE TITANIUM PREBENT NONSTERILE",SUP-498.137,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 SH-1 30IN 2 ARM MONOFILAMENT BLUE",SUP-8526H,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.76,19.13,"MULTIPLAN [10600]",Multiplan,,54.2,85,,,,,0,7.42,54.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH BLUE 10FT ELECTROPHYSIOLOGY HYPERTONICS 34 PIN TO",SUP-CB3434CT,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"FIRST HEALTH [10303]","First Health",,2694,80,,,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER 10MM LCP ORTHOPEDIC STAINLESS STEEL 4.5MM CANNULATED",SUP-219.91,CDM,C1713,HCPCS,0278,RC,,,both,,,158.69,47.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",18.46,134.89,"percent of total billed charges",
"CAGE SPINAL 32X21MM ENDOSKELETON TAS 7D 13MM STD TITANIUM",SUP-2307-0113,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AETNA [10100]","Aetna HMO/PPO",,22538.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL 5MM LEGION 4 KNEE SCR",SUP-71421661,CDM,C1776,HCPCS,0278,RC,,,both,,,11995.65,3598.69,"BLUE CROSS [10001]","Blue Cross HMO",,4702.29,39.2,,5311.50,4717.44,5388.59,31,1395.09,10196.3,"percent of total billed charges",
"CUBE DEMINERALIZED BONE 11MM Q-PACK CONFORM",SUP-4W0011,CDM,S27800098,LOCAL,0278,RC,,,both,,,4462.92,1338.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3034.79,68,,,,,0,519.04,3793.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 85MM TITANIUM FULL THREAD CANNULATED STERILE",SUP-04.355.785S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,291.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,286.03,2090.49,"percent of total billed charges",
"CATH URETHRAL BARDEX IC 22FR FOLEY 2 WAY COUNCIL TIP 2",SUP-0196SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.25,42.67,"PHCS [10601]",PHCS,,99.58,70,,,,,0,16.54,120.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 9MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530G109,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"PHCS [10601]",PHCS,,6095.33,70,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 22MM EVOLVE 2+ MM ELBOW PROLINE MODULAR STERILE",SUP-496H222,CDM,C1776,HCPCS,0278,RC,,,both,,,12295.80,3688.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4918.32,40,,,,,0,1430,10451.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 8FR PIGTAIL NEPHROURETERAL PERCUFLEX METAL",SUP-M001221390,CDM,C2617,HCPCS,0278,RC,,,both,,,811.20,243.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,372.34,45.9,,,,,0,94.34,689.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII CRUCIATE RETAINING CEMEN",SUP-71704500,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS [10001]","Blue Cross HMO",,7408.8,39.2,,5311.50,4717.44,5388.59,31,2198.07,16065,"percent of total billed charges",
"COIL EMBOLIZATION 8CM 2MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES0208CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST OP BRA 42C BLACK","SUP-B01G-42 B/C-B",CDM,S27000186,LOCAL,0270,RC,,,both,,,407.16,122.15,"FIRST HEALTH [10303]","First Health",,325.73,80,,,,,0,47.35,346.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 20MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171030270,CDM,C1726,HCPCS,0272,RC,,,both,,,1174.50,352.35,"MULTIPLAN [10600]",Multiplan,,998.33,85,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL RETINAL 12MM SILICONE MERIDIONAL 112 STYLE",SUP-92-27,CDM,S27800098,LOCAL,0278,RC,,,both,,,215.06,64.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,61.55,28.62,,,,,0,25.01,182.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Strep B (V/R) by Pcr",PX-306000186,CDM,87653,CPT,0306,RC,,,both,,,581.00,174.3,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,493.85,"per diem",
"CATH METACROSS RX 135CM 120MM 5.7-3.9FR 6MM BALLOON",SUP-BD-L60120CR,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC",749,MS-DRG,,,,,,,inpatient,,,134433.84,40330.15,"AETNA [10100]","Aetna HMO/PPO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 20MM INTERLOCK FIBERED IDC 35 COIL",SUP-M001363830,CDM,S27800098,LOCAL,0278,RC,,,both,,,5181.90,1554.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1483.06,28.62,,,,,0,602.65,4404.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL ROCHESTER-PEAN 8IN STRAIGHT",SUP-BH446R,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.10,57.63,"FIRST HEALTH [10303]","First Health",,153.68,80,,,,,0,22.34,163.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SURGICAL BIOSEAL CUSTOM BONE FLAP STERILE DISPOSABLE",SUP-BBF001/10,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.09,51.03,"UHC [10700]","United Healthcare",,107.67,63.3,,,,,0,19.78,144.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION",RX-41787,CDM,,,0250,RC,67457-0162-00,NDC,both,2,ML,589.70,176.91,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,242.37,41.1,,,,,0,68.58,501.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 300MM 5MM BALLOON DILATATION DURALYN",SUP-48005030X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 4-0 T-12 18IN BRAID TIES MULTISTRAND LOWER",SUP-AR-7230-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM 2.75MM 2.1-2.7FR CORONARY",SUP-RONYX27530UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]",Cigna,,2295,68,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2MM 1MM 14 MICRO ANGLE 7.5IN SURGICAL NONSTERILE",SUP-RN6214,CDM,S27200284,LOCAL,0272,RC,,,both,,,686.88,206.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,79.88,583.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATRIX-C UNION CERVICAL ALLOGRAFT SPACER 13 X 16 X 7MM 7",SUP-X094-3010,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1 X 2 COMPLEX PICO COIL",SUP-10USC01002,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"BLUE CROSS [10001]","Blue Cross HMO",,5125.6,39.2,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC",309,MS-DRG,,,,,,,inpatient,,,25811.57,7743.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,11729.8,,,,,,,4563.58,18347.62,"case rate",
"CATH RESOLVE 15CM 7.5FR .038IN PIGTAIL CURVE DRNG",SUP-RLC15-7-038MB,CDM,C1729,HCPCS,0272,RC,,,both,,,537.19,161.16,"AETNA [10100]","Aetna HMO/PPO",,427.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.48,456.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 200CM 10MM .063IN 1.25MM ATHERECTOMY",SUP-DBP-EX-125SOL200,CDM,C1724,HCPCS,0272,RC,,,both,,,24538.50,7361.55,"PHCS [10601]",PHCS,,17176.95,70,,,,,0,2853.83,20857.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER +4 CYL HAPTIC C BICONVEX 13MM 6MM",SUP-ZMB00U0165,CDM,V2632,HCPCS,0276,RC,,,both,,,6175.50,1852.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,731.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KWIRE, HSC, 1.1MM X 127MM, DOUBLE TROCAR",SUP-KWIR-DT-11127,CDM,S27000186,LOCAL,0270,RC,,,both,,,234.90,70.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,27.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.32,199.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PILOT 150 VASCULAR STRAIGHT 190CM 3CM .014IN",SUP-1010481-H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP C-MAC S D HYPERANGULATE VIDEO DISPOSABLE",SUP-051216-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,191.40,57.42,"CIGNA [10200]","Cigna Open Access",,108.91,56.9,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 8-9 C-D KNEE",SUP-42512100512,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTCLAW 145CM 5FR .035IN 32MM THROMBECTOMY TACTILE",SUP-FD0660-02,CDM,C1757,HCPCS,0272,RC,,,both,,,25168.50,7550.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10344.25,41.1,,,,,0,2927.1,21393.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5MM 2MM 8-18 COIL FIBERED PLATINUM 10MM",SUP-M0013120211,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,316.02,45.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 8MM 90MM STAINLESS STEEL FULL THREAD",SUP-218.09,CDM,C1713,HCPCS,0278,RC,,,both,,,228.98,68.69,"FIRST HEALTH [10303]","First Health",,183.18,80,,,,,0,26.63,194.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 57MM 75CM 10MM 60MM",SUP-H74938046106070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 110MM 5.5MM STRAIGHT PERCUTANEOUS CCM",SUP-1555006110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"HC Muscle Test Cran Nrv Unil",PX-922000026,CDM,95867,CPT,0922,RC,,,both,,,842.00,252.6,"NOVANET [10819]",Novanet,,631.5,75,,,,,0,97.92,715.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Clavicle Complt",PX-320000060,CDM,73000,CPT,0320,RC,,,both,,,619.96,185.99,"PHCS [10601]",PHCS,,433.97,70,,,,,0,38.7,526.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 10MM KNEE LEFT E-PLUS EMPOWR 3D KNEE STERILE",SUP-341-10-707,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"AETNA [10100]","Aetna HMO/PPO",,5211.23,79.5,,10981.53,8986.79,12413.38,12,762.35,5571.75,"percent of total billed charges",
"NAIL 10MM 360MM FEMORAL EXPERT INTRAMEDULLARY ROUND",SUP-04.013.452S,CDM,C1713,HCPCS,0278,RC,,,both,,,8319.74,2495.92,"MULTIPLAN [10600]",Multiplan,,7071.78,85,,,,,0,967.59,7071.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 5CM 8.5FR CENTER BEND THIN WALL",SUP-M00534620,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"FIRST HEALTH [10303]","First Health",,871.56,80,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 105MM 13.3MM 8MM CUFF PROXIMAL EXT EXTEND LENGTH",SUP-80XLTCP,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"KAISER [10500]",Kaiser,,325.13,67,,,,,0,56.44,412.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 22MM DCP STAINLESS STEEL CORTICAL HAND/FOOT",SUP-201.822,CDM,C1713,HCPCS,0278,RC,,,both,,,358.09,107.43,"BLUE CROSS [10001]","Blue Cross HMO",,140.37,39.2,,957.42,156.86,7483.26,51,41.65,304.38,"percent of total billed charges",
"DEVICE V-LOC 180 0 GS-21 9IN CLSR ABSORBABLE TAPER POINT",SUP-VLOCL0346,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"CIGNA [10200]","Cigna Open Access",,111.43,56.9,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 80MM DHS/DCS STAINLESS STEEL CONDYLAR HIP",SUP-280.8,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"CIGNA [10200]",Cigna,,1236.5,68,,1831.33,1831.33,1831.33,16,211.48,1545.62,"percent of total billed charges",
"SCREW NON-LOCKING 2.0MM X 30MM TI",SUP-VAN-20300-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"KAISER [10500]",Kaiser,,651.24,67,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE JUMBO 240CM 30MM CAPTIVATOR POLYPECTOMY OVAL",SUP-6131,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.33,36.4,"KAISER [10500]",Kaiser,,81.29,67,,,,,0,14.11,103.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 72CM 21FR TANDEMHEART VENOUS DIL INTRO",SUP-5140-6217,CDM,S27200284,LOCAL,0272,RC,,,both,,,62700.00,18810,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,28779.3,45.9,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION TRANSSEPTAL",SUP-5140-6217,CDM,S27200284,LOCAL,0272,RC,,,both,,,13455.00,4036.5,"FIRST HEALTH [10303]","First Health",,10764,80,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 405CC 11.2CM 5.6CM PROJECTION HIGH PROFILE SM",SUP-SHPB405,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"FIRST HEALTH [10303]","First Health",,6099.6,80,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPR LD 17CM LV IS-1 CNCT",SUP-4402,CDM,C1883,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSCONN ROD 45-50MM ADJUSTABLE ARCH",SUP-8450245,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"PHCS [10601]",PHCS,,3381,70,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM TRIATHLON 3 RIGHT MEDIAL LEFT LATERAL TOAL",SUP-5546-A-302,CDM,C1776,HCPCS,0278,RC,,,both,,,4766.58,1429.97,"CIGNA [10200]",Cigna,,3241.27,68,,5873.17,5873.17,5873.17,"1 through 10",554.35,4051.59,"percent of total billed charges",
"ALTIVATE REVERSE REVISION HUMERAL STEM, SZ 12X175MM",SUP-530-12-175,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS [10001]","Blue Cross PPO",,4939.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",1465.38,10710,"percent of total billed charges",
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 20MM 6FR 3.75MM",SUP-H7493926720370,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 60MM 120CM 8MM VASCULAR PERIPHERAL SELF",SUP-PRB35-08-060-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]",Cigna,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 10.5MM CEMENTLESS MODULAR AML POROUS 40MM",SUP-155401106,CDM,C1776,HCPCS,0278,RC,,,both,,,15374.88,4612.46,"FIRST HEALTH [10303]","First Health",,12299.9,80,,,,,0,1788.1,13068.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 SH-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP772D,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL RAPIDE MULTIPASS 4-0 P-3 18IN BRAID COATED UNDYED",SUP-VR494,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.44,20.83,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 90CM 7FR .081IN GUIDING",SUP-LA7EBU375D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER 110MM 3.5MM TRICUT ETHMOID STRAIGHT ENDOSCOPIC",SUP-1883504,CDM,S27200284,LOCAL,0272,RC,,,both,,,1834.50,550.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC",656,MS-DRG,,,,,,,inpatient,,,133265.07,39979.52,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 39MM 30MM 7.7MM 20FR ZENITH FLEX Z-TRAK",SUP-G55208,CDM,C1874,HCPCS,0278,RC,,,both,,,14138.10,4241.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3817.29,27,,,,,0,1644.26,12017.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 0-8CM ULTRASOUND CONE TIP SIDEHOLE DISPOSABLE",SUP-G49257,CDM,S27200284,LOCAL,0272,RC,,,both,,,2302.50,690.75,"AETNA [10100]","Aetna HMO/PPO",,1830.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,267.78,1957.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 15CM 5MM BALLOON DILATATION OTW LOW",SUP-G30956,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.270 CLAREON",SUP-SY60WF.270,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 6.75IN 9FR FRAZIER ANGLE 5-9CM CALIBRATED",SUP-63-7559,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING ORANGE 16IN 5FR NUTRIO TWISTLOK ENTERAL",SUP-ENPU1650,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.84,17.65,"KAISER [10500]",Kaiser,,39.42,67,,,,,0,6.84,50.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL TEMP PACING WIRE 2-0 SH SKS-3 24IN 2 ARM",SUP-TPW30,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.32,37.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,51.92,41.1,,,,,0,14.69,107.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 145CM 7MM .052- MM 1.25MM .014IN",SUP-DBP-CART-125SOL145,CDM,C1724,HCPCS,0272,RC,,,both,,,17250.00,5175,"FIRST HEALTH [10303]","First Health",,13800,80,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 6 STD KNEE LEFT KEEL NONPOROUS",SUP-ETPKN6SL,CDM,C1776,HCPCS,0278,RC,,,both,,,11060.70,3318.21,"BLUE CROSS [10001]","Blue Cross PPO",,4335.79,39.2,,3949.44,3949.44,3949.44,"1 through 10",1286.36,9401.6,"percent of total billed charges",
"STENT 22CM 10FR PIGTAIL CURVE TAPER URETERAL GLIDEX",SUP-M001245580,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"BLUE CROSS [10001]","Blue Cross HMO",,349.27,39.2,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 90CM 150MM 3.5MM BALLOON DILATATION NYBAX",SUP-H74939186351590,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 26MM 140CM 2.5MM",SUP-RSINT25026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]","Cigna Open Access",,3154.54,56.9,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP STEALTH MEDIUM LATIS SIDE BITE STERILE LATEX",SUP-A0C06,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM PRECISION ROUND",SUP-5820009040,CDM,S27200284,LOCAL,0272,RC,,,both,,,3587.85,1076.35,"CIGNA [10200]","Cigna Open Access",,2041.49,56.9,,,,,0,417.27,3049.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 8MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140812,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"MULTIPLAN [10600]",Multiplan,,10099.53,85,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX13MM CAPSTONE PEEK PTC LUMBAR INTERBODY",SUP-3992213,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"MULTIPLAN [10600]",Multiplan,,18742.5,85,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC",830,MS-DRG,,,,,,,inpatient,,,108153.52,32446.06,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,19009.15,,"Case rate ($9,335.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,668.74, add-ons for qualifying new technology services are included. If operating cost exceeds $41,708.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,037.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,680.21. The transfer operating threshold is the transfer adjustment factor * $8,668.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.40. The transfer capital threshold is the transfer adjustment factor * $655.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,43939.98,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP4PL,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5805.51,27,,,,,0,2500.67,18276.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.50MM X 20MM  SCOREFLEX  NC",SUP-625-204-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 3.5CM 18FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-18-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,92.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETENE DS 25X20CM COMPOSITE ABSORBABLE FILM",SUP-PPDS2520,CDM,C1781,HCPCS,0278,RC,,,both,,,6585.84,1975.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1884.87,28.62,,,,,0,765.93,5877.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 260MM 8MM ANTERIOR TIBIALIS TENDON FROZEN",SUP-81B001,CDM,S27800098,LOCAL,0278,RC,,,both,,,8852.70,2655.81,"BLUE CROSS [10001]","Blue Cross PPO",,3470.26,39.2,,,,,0,1029.57,7524.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STBL SURGICAL UNIVERSAL ASSISTANT CABG ABLATION THORACIC",SUP-401-210S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.00,495,"CIGNA [10200]","Cigna Local Plus",,882.75,53.5,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Fungi Defin ID Mold",PX-306000069,CDM,87107,CPT,0306,RC,,,both,,,206.15,61.84,"CIGNA [10200]","Cigna Local Plus",,22.7,,,,,,,0.01,175.23,"fee schedule",
"ROD SPINAL 65MM 4.75MM PERCUTANEOUS CCM",SUP-641000065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE BALLOON DILATATION 6FR RADIOPAQUE FOGARTY BILIARY 1.24",SUP-410236F,CDM,S27200284,LOCAL,0272,RC,,,both,,,617.30,185.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,283.34,45.9,,,,,0,71.79,524.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD SENTUS PROMRI LEFT VENTRICULAR OTW QUADRIPOLAR",SUP-406081,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]","Cigna Open Access",,3190.38,56.9,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 42MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.342TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"CIGNA [10200]","Cigna Open Access",,1150.26,56.9,,1144.80,304.56,2275.09,66,235.11,1718.32,"percent of total billed charges",
"HC Cult Screen Mrsa",PX-306000059,CDM,87081,CPT,0306,RC,,,both,,,290.70,87.21,"PHCS [10601]",PHCS,,203.49,70,,,,,0,0.01,247.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 13.4CM MEMORYGEL P3.4CM MODERATE PROFILE SILTEX",SUP-3543607MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD XLNK SMALL SPINE MULTIAXIAL SCR",SUP-7752525,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1019.59,28.62,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 65MM LCP STAINLESS STEEL T25 CONDYLAR VARIABLE",SUP-02.231.265,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"NOVANET [10819]",Novanet,,980.87,75,,,,,0,152.1,1111.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Retroperitoneal Ltd",PX-402000011,CDM,76775,CPT,0402,RC,,,both,,,1265.37,379.61,"NOVANET [10819]",Novanet,,949.03,75,,,,,0,51.23,1075.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 26MM 4MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT40026UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CIGNA [10200]",Cigna,,1642.2,68,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 100MM TITANIUM 1.5MM SCREWS MINI FRAGMENT SET 20 HOLE",SUP-446.19,CDM,C1713,HCPCS,0278,RC,,,both,,,2865.60,859.68,"NOVANET [10819]",Novanet,,2149.2,75,,,,,0,333.27,2435.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.032S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,189.34,1383.8,"percent of total billed charges",
"SYSTEM ELUNIR THK90UM 28MM 140CM 2.75MM CORONARY STENT",SUP-LUN275R28US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL BALLENTINE STRAIGHT 8.25IN 1 TEETH",SUP-52-5510,CDM,S27200284,LOCAL,0272,RC,,,both,,,443.72,133.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,182.37,41.1,,,,,0,51.6,377.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 64CM ENDOTAK RELIANCE 4 SITE ENDOCARDIAL STEROID",SUP-276,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]",Cigna,,6072,40,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT STRETCH VL 22-30CM 3CM 4.8FR .035IN PIGTAIL CURVE",SUP-M006185155050,CDM,C2617,HCPCS,0278,RC,,,both,,,1038.34,311.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,120.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,120.76,882.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 14.7MM 21MM 26MM 19.4MM ON-X 21 STD CYLINDRICAL",SUP-ONXAE-21,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4396.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRAMEDULLARY NAIL .062IN SLOTTED AWL LOCKING DEVICE",SUP-SBFS062,CDM,C1713,HCPCS,0278,RC,,,both,,,4347.00,1304.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1995.27,45.9,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 40MM 4.8FR 9MM LOW PROFILE BALLOON",SUP-39032-90408,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE ENFORM 8X16CM INTRAPERITONEAL BIOMATERIAL",SUP-GBFR0816,CDM,C1781,HCPCS,0278,RC,,,both,,,15952.80,4785.84,"BLUE CROSS [10001]","Blue Cross PPO",,6253.5,39.2,,,,,0,1855.31,13559.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP LIMIT HOLE COLOR CODED OSSEOTI G7",SUP-110010248,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 200MM 3MM TAPER BALLOON DILATATION JET",SUP-A2030-200,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS RX 135CM 60MM 5.7-3.9FR 5MM BALLOON",SUP-BD-L50060CR,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.7,68,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 56MM CATHCART BALL HIP FEMORAL ORTHOCHROME",SUP-136356000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,5873.17,5873.17,5873.17,"1 through 10",434.96,3179,"percent of total billed charges",
"STENT ADVANIX NAVIFLEX 12CM 10FR CENTER BEND THIN WALL",SUP-M00534710,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"KAISER [10500]",Kaiser,,729.93,67,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 85MM STAINLESS STEEL T25 SELF TAP LOCK VARIABLE",SUP-02.231.285,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"CIGNA [10200]","Cigna Open Access",,744.16,56.9,,1144.80,304.56,2275.09,66,152.1,1111.66,"percent of total billed charges",
"CATH TRAPLINER 150CM 13CM 5.7FR INTERVENTIONAL HYDROPHILIC",SUP-5567,CDM,S27200284,LOCAL,0272,RC,,,both,,,4291.80,1287.54,"AETNA [10100]","Aetna HMO/PPO",,3411.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,499.14,3648.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL EZ-IO ARROW VASCULAR ACCESS",SUP-9058,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE L-ASCR CORTICAL 11MM LORDOTIC",SUP-340641,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TIBIAL 18MM INBONE ANKLE PLASMA BASE",SUP-200009902,CDM,C1776,HCPCS,0278,RC,,,both,,,2743.00,822.9,"NOVANET [10819]",Novanet,,2057.25,75,,,,,0,319.01,2331.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO VASCULAR STRAIGHT 300CM .014IN HYDROPHILIC",SUP-SSFT300STR,CDM,C1769,HCPCS,0272,RC,,,both,,,5686.57,1705.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET BRACHYTHERAPY INTERFACE CONTROL SYSTEM BRACHYBALLOON",SUP-610-898,CDM,S27200284,LOCAL,0272,RC,,,both,,,584.62,175.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 35LL 135CM 150MM 5FR 4MM .035IN LOW PROFILE",SUP-B2040-150,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 12IN 22FR ARTERIAL 3/8IN RADIOPAQUE 1 PIECE",SUP-77422,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 190CM 3CM",SUP-1020014,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INVESTIGATIONAL DRUG PO (DOSE BY STUDY PROTOCOL)",RX-410998,CDM,,,0250,RC,99999-4109-98,NDC,both,1,UN,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MASK CPAP LARGE LEAK 1 ENTRAINMENT ELBOW CAPSTRAP HEADGEAR",SUP-989805628751,CDM,S27000186,LOCAL,0270,RC,,,both,,,224.74,67.42,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POUCH SURGICAL TISSUE 8X5IN LAPSAC DRAWSTRING COLOR CODED",SUP-G16496,CDM,S27200284,LOCAL,0272,RC,,,both,,,877.54,263.26,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE CLSR 14GA 15CM SUT 1 HND",SUP-RSG-14F-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.80,52.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR .071IN MULTIAORTIC CURVE 3 GUIDING",SUP-LA6MAC30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 5X5CM SOLID SHEET NONSTERILE LATEX FREE",SUP-PAC25,CDM,Q4201,HCPCS,0636,RC,,,both,,,7521.00,2256.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 7IN 11MM C-REAMER 15-70MM ACL PCL SHORT HEAD TAPER",SUP-8774A,CDM,S27200284,LOCAL,0272,RC,,,both,,,625.73,187.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GYNECOLOGIC PROCEDURES WITHOUT MALIGNANCY,MINOR",513,APR-DRG,,,,,,,inpatient,,,74185.57,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,623.24. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cftr Gene Com Variants",PX-309000015,CDM,81220,CPT,0310,RC,,,both,,,692.00,207.6,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,692,"per diem",
"CATH ADVOCATE 1500MM 200MM 2MM BALLOON DILATATION SERENE OTW",SUP-A18020200150,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE ORTHOFLO AMNIOTIC FLUID 2 ML- LYOPHILIZED",SUP-LQ-0200,CDM,S25000001,LOCAL,0250,RC,,,both,,,18868.50,5660.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2235.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2194.41,16038.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 40MM 80CM 12MM .079IN LARGE DIAMETER",SUP-SERB65-12-40-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]",Cigna,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP OCCL BALLOON AUDIO INDCTR ALERT ELECTROSURGERY DEVICE",SUP-KC-ARCH-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"CIGNA [10200]",Cigna,,779.17,68,,,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR HEMI 3HL 64MM",SUP-430-98-064,CDM,C1776,HCPCS,0278,RC,,,both,,,16956.34,5086.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6969.06,41.1,,6417.48,6417.48,6417.48,"1 through 10",1972.02,14412.89,"percent of total billed charges",
"BIT DRILL 7IN 11MM C-REAMER 15-70MM ACL PCL SHORT HEAD TAPER",SUP-8774A,CDM,S27200284,LOCAL,0272,RC,,,both,,,625.73,187.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG 232X12X3.7MM STAINLESS STEEL 3.5MM SCR SMALL",SUP-241.923S,CDM,C1713,HCPCS,0278,RC,,,both,,,10695.00,3208.5,"BLUE CROSS [10001]","Blue Cross HMO",,4192.44,39.2,,957.42,156.86,7483.26,51,1243.83,9090.75,"percent of total billed charges",
"SYSTEM LAVA-34 EMBOLIC 6ML LIQUID",SUP-SLLES346,CDM,S27800098,LOCAL,0278,RC,,,both,,,36540.00,10962,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4329.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4249.6,31059,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE PIN ORTHOPEDIC PERSONA FEMUR TIBIA CRUCIATE RETAIN",SUP-00-5970-000-25,CDM,S27200284,LOCAL,0272,RC,,,both,,,7044.21,2113.26,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,819.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,819.24,5987.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DIVERGENCE-L 15X9.4X10MM ANTERIOR OBLIQUE LUMBAR",SUP-736520,CDM,S27800098,LOCAL,0278,RC,,,both,,,9177.00,2753.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1087.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 11MM TITANIUM CORTEX SELF TAP STARDRIVE",SUP-401.361.97,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EVOLUT R 26MM 29MM INTRO AORTIC VALVE LOAD",SUP-LS-MDT2-2629-US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2925.00,877.5,"NOVANET [10819]",Novanet,,2193.75,75,,,,,0,340.18,2486.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 24CM 6FR .035",SUP-M006192132090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"FIRST HEALTH [10303]","First Health",,1193.94,80,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXTOME 142CM 10MM 4MM BALLOON DILATATION NYLON",SUP-H749CBM3400100,CDM,C1725,HCPCS,0272,RC,,,both,,,5395.80,1618.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,639.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,627.53,4586.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT VITOSS B-TCP CLLGN VOID FILLER FOAM PACK 5ML",SUP-2102-1405,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"MULTIPLAN [10600]",Multiplan,,3665.63,85,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 230MM STAINLESS STEEL 3.5MM SCR 10 HOLE LCP BONE LEFT",SUP-02.104.030,CDM,C1713,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"MULTIPLAN [10600]",Multiplan,,7389.9,85,,,,,0,1011.11,7389.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR MEDIALIZE ANATOMIC 29MM CEMENT ATTUNE AOX",SUP-151810029,CDM,C1776,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"BLUE CROSS [10001]","Blue Cross HMO",,2812.99,39.2,,5311.50,4717.44,5388.59,31,834.57,6099.6,"percent of total billed charges",
"STEM FEMORAL COLLAR CEMENTLESS HIGH OFFSET Z1 TITANIUM ALLOY",SUP-611202040,CDM,C1776,HCPCS,0278,RC,,,both,,,28967.40,8690.22,"AETNA [10100]","Aetna HMO/PPO",,23029.08,79.5,,10981.53,8986.79,12413.38,12,3368.91,24622.29,"percent of total billed charges",
"VALVE AORTIC EVOLUT FX 23MM",SUP-EVOLUTFX-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,48940.2,28.62,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X22X10MM COROENT 10D XL+ WIDE PEEK NONSTERILE",SUP-6310260,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,9384.48,39.2,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 20MM",SUP-SPL20020X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Instill Anticarcinogen Blad",PX-510000100,CDM,51720,CPT,0761,RC,,,both,,,2014.00,604.2,"BLUE CROSS [10001]","Blue Cross PPO",,2014,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,234.23,2014,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 52MM 32MM MARATHON HIP",SUP-121932152,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"CIGNA [10200]","Cigna Local Plus",,4339.36,53.5,,5372.07,4581.20,7242.98,23,943.3,6894.31,"percent of total billed charges",
"SHELL ACETABULAR 66MM HIP MULTIHOLE RIM TRITANIUM X3 MDM",SUP-509-02-66H,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1330.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1306.28,9547.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 76.2CM 27FR 3/8IN VENOUS INTRO HEMOSTASIS CAP",SUP-96670-127,CDM,S27200284,LOCAL,0272,RC,,,both,,,3073.95,922.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,364.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,357.5,2612.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM 27MM BIOCOR FLEXFIT LOW PROFILE SUPRA",SUP-BSP100-27,CDM,S27800098,LOCAL,0278,RC,,,both,,,32715.90,9814.77,"KAISER [10500]",Kaiser,,21919.65,67,,,,,0,3804.86,27808.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DSRCTOR 12MM CERVICAL SCR CASPAR SURGICAL STERILE",SUP-R6367A,CDM,S27200284,LOCAL,0272,RC,,,both,,,429.35,128.8,"AETNA [10100]","Aetna HMO/PPO",,341.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,49.93,364.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ 100CM 24CM 5FR ARTERIAL LINE PULMONARY ARTERY",SUP-TS105F5,CDM,C1751,HCPCS,0272,RC,,,both,,,1225.45,367.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,833.31,68,,,,,0,142.52,1041.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AGILITY ENDOSCOPIC STD XL 350CM 42CM .014IN",SUP-614491,CDM,C1769,HCPCS,0272,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE 2.8MM MEDIUM OVAL 240CM 2.4MM SENSATION FLEXIBLE SHORT",SUP-M00562673,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.43,23.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.01,65.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 45D JJ 54MM 28MM LONGEVITY HIP CONSTRAINED",SUP-00875801128,CDM,C1776,HCPCS,0278,RC,,,both,,,18074.70,5422.41,"FIRST HEALTH [10303]","First Health",,14459.76,80,,,,,0,2102.09,15363.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR 30CM 7FR .035IN BLADDER LOOP LOW",SUP-M006155245090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"PHCS [10601]",PHCS,,953.92,70,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 80MM 80CM 7MM VASCULAR NITINOL PERIPHERAL",SUP-1012529-80,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]",Cigna,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 25MM SYNFIX EVOLUTION STERILE",SUP-04.835.225.02S,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 2CM 8MM BALLOON DILATATION PERIPHERAL",SUP-G50265,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 C 38MM COCR HIP 2 MOBILITY",SUP-110024461,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5323.55,41.1,,6417.48,6417.48,6417.48,"1 through 10",1506.4,11009.78,"percent of total billed charges",
"HEAD HUMERAL 20MM 46MM SHOULDER ANATOMIC RESTORATION",SUP-AR-9146-20P,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"BLUE CROSS [10001]","Blue Cross HMO",,3104.64,39.2,,5311.50,4717.44,5388.59,31,921.1,6732,"percent of total billed charges",
"SUB BONE GRAFT VITOSS B-TCP CLLGN VOID FILLER FOAM PACK 5ML",SUP-2102-1405,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1234.24,28.62,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION",RX-250,CDM,,,0250,RC,00378-8270-31,NDC,both,3,ML,12.54,3.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8.53,68,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MITRACLIP NTR CDS (CLIP DELIVERY SYSTEM) PRIMARY MR CLINICAL",SUP-CDS0604-NTR,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,70281,41.1,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 156MM 18MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-103180,CDM,C1776,HCPCS,0278,RC,,,both,,,27004.32,8101.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3140.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3140.6,22953.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 18MM 90CM 6MM SMALL BILIARY METAL",SUP-H74937912618900,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"CIGNA [10200]","Cigna Local Plus",,2670.72,53.5,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FEVER AND INFLAMMATORY CONDITIONS",864,MS-DRG,,,,,,,inpatient,,,36826.81,11048.04,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,11212.25,,"Case rate ($5,506.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,113.12, add-ons for qualifying new technology services are included. If operating cost exceeds $38,152.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,768.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,119.88. The transfer operating threshold is the transfer adjustment factor * $5,113.12 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $386.58. The transfer capital threshold is the transfer adjustment factor * $386.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,5506.46,22138.35,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145362010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"FIRST HEALTH [10303]","First Health",,773.52,80,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 16CM TOUCH NARROW BASE PENOSCROTAL NARROW",SUP-EN2916,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS [10001]","Blue Cross HMO",,24578.4,39.2,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTRELL MAPPING ELECTRD RECORDING D-F CURVE",SUP-D140901,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"UHC [10700]","United Healthcare",,10045.71,63.3,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR STRAIGHT 145CM .014IN CORONARY TIP",SUP-TFC14145S,CDM,C1769,HCPCS,0272,RC,,,both,,,2250.00,675,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,266.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.9MM ULTRAFIX RC SHOULDER ARTHROSCOPIC STAINLESS",SUP-10139,CDM,C1713,HCPCS,0278,RC,,,both,,,1535.11,460.53,"BLUE CROSS [10001]","Blue Cross PPO",,601.76,39.2,,957.42,570.23,957.42,28,178.53,1304.84,"percent of total billed charges",
"ROD EXTERNAL FIXATION 450MM 11MM HOFFMANN 3 VECTRAN CARBON",SUP-4922-8-450,CDM,C1713,HCPCS,0278,RC,,,both,,,3401.70,1020.51,"FIRST HEALTH [10303]","First Health",,2721.36,80,,,,,0,395.62,2891.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERLOOP 2 .5 CIRCLE CURVE 20IN BRAID MULTISTRAND NDL",SUP-AR-7234C,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETHRAL BARDEX IC 16FR FOLEY 2 WAY SILVER HYDROGEL 5ML",SUP-0165SI16,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.82,19.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,29.75,45.9,,,,,0,7.54,55.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 4.00 X 23 RX US",SUP-1804400-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 9MM KNEE BEARING POSTERIOR STABILIZE",SUP-5532-G-409-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]",Cigna,,7760.57,68,,5873.17,5873.17,5873.17,"1 through 10",1327.29,9700.71,"percent of total billed charges",
"TUBE FEEDING 14FR STOMA L2.7CM TAIL L30CM GASTRIC JEJUNAL LO",SUP-8270-14-2.7-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,3027.60,908.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2058.77,68,,,,,0,352.11,2573.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM S-ROM NOILES KNEE ROTATE HINGE",SUP-623805,CDM,C1776,HCPCS,0278,RC,,,both,,,2736.30,820.89,"BLUE CROSS [10001]","Blue Cross PPO",,1072.63,39.2,,3949.44,3949.44,3949.44,"1 through 10",318.23,2325.86,"percent of total billed charges",
"HC Heparin Assay",PX-305000051,CDM,85520,CPT,0305,RC,,,both,,,511.46,153.44,"UHC [10700]","United Healthcare",,11.78,,,,,,,0.01,434.74,"fee schedule",
"SPACER ALLOGRAFT 21-26X27-32X11MM LUMINARY CC SPINE LUMBAR",SUP-16811,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"UHC [10700]","United Healthcare",,21056.11,63.3,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 36MM AXSOS STAINLESS STEEL 2.5MM FULL THREAD",SUP-338636,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"BLUE CROSS [10001]","Blue Cross HMO",,90.24,39.2,,957.42,156.86,7483.26,51,26.77,195.67,"percent of total billed charges",
"AVENIR 10 1.5 X 4 HELICAL FINISHING COIL",SUP-10HFN-01504,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2960.2,28.62,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 60MM 15MM STAINLESS STEEL PARTIAL THREAD",SUP-121860,CDM,C1713,HCPCS,0278,RC,,,both,,,2006.40,601.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,237.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",233.34,1705.44,"percent of total billed charges",
"PEG FIXATION 2MM 16MM FOSSA RADIUS DISTAL VOLAR SMOOTH LOCK",SUP-SPLS-20160-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,639.90,191.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,75.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",74.42,543.92,"percent of total billed charges",
"SLING PATIENT FLITES MEDIUM LOOP DISPOSABLE",SUP-MFA2100-M-L1,CDM,S27000186,LOCAL,0270,RC,,,both,,,231.51,69.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,27.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.92,196.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 24FR URETHRAL BACTI-GUARD RUBBER HYDROGEL 30",SUP-1857SI24,CDM,S27200284,LOCAL,0272,RC,,,both,,,163.13,48.94,"CIGNA [10200]","Cigna Local Plus",,87.27,53.5,,,,,0,18.97,138.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM DCP LC-DCP STAINLESS STEEL FULL THREAD",SUP-218.060,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"CIGNA [10200]","Cigna Open Access",,255.52,56.9,,1144.80,304.56,2275.09,66,52.23,381.7,"percent of total billed charges",
"SET 25CM 8FR PIGTAIL CURVE NEPHRSTMY LOCK REGULAR DUROMETER",SUP-M001271860,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 40MM 150CM 7MM VASCULAR NICKEL",SUP-EVD35-07-040-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"CIGNA [10200]",Cigna,,4273.8,68,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS GUARDIAN II GWIRE INSRT TOOL",SUP-8210,CDM,S27200284,LOCAL,0272,RC,,,both,,,477.90,143.37,"AETNA [10100]","Aetna HMO/PPO",,379.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.58,406.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 70MM 1-2MM AVANCE NERVE",SUP-111270,CDM,C1762,HCPCS,0278,RC,,,both,,,56586.60,16975.98,"BLUE CROSS [10001]","Blue Cross PPO",,22181.95,39.2,,,,,0,6581.02,48098.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT DOUBLE-J 22CM 100CM 7FR .028IN URETERAL SILICONE PTFE",SUP-5204700,CDM,C2625,HCPCS,0278,RC,,,both,,,1202.28,360.68,"PHCS [10601]",PHCS,,841.6,70,,,,,0,139.83,1021.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM 6 HOLE LOCKING BONE STERNAL NONSTERILE",SUP-460.038,CDM,C1713,HCPCS,0278,RC,,,both,,,3769.95,1130.98,"BLUE CROSS [10001]","Blue Cross HMO",,1477.82,39.2,,957.42,156.86,7483.26,51,438.45,3204.46,"percent of total billed charges",
"LENS IOL 0 D +19 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.190,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 60MM 15MM STAINLESS STEEL PARTIAL THREAD",SUP-121860,CDM,C1713,HCPCS,0278,RC,,,both,,,2006.40,601.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,574.23,28.62,,,,,0,233.34,1705.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM LOW PROFILE NECK VERTICAL GROOVE CORAIL2",SUP-3L92510,CDM,C1776,HCPCS,0278,RC,,,both,,,28658.70,8597.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11778.73,41.1,,6417.48,6417.48,6417.48,"1 through 10",3333.01,24359.9,"percent of total billed charges",
"MESH SURGICAL GORE ENFORM 25X40CM INTRAPERITONEAL",SUP-GBFR2540,CDM,C1781,HCPCS,0278,RC,,,both,,,103084.50,30925.35,"CIGNA [10200]",Cigna,,41233.8,40,,,,,0,11988.73,87621.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 15MM HELIX R SPINE SELF TAP VARIABLE ANGLE",SUP-7805115,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 120MM 14MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U14120090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"KAISER [10500]",Kaiser,,6934.5,67,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 60MM 15MM STAINLESS STEEL PARTIAL THREAD",SUP-121860,CDM,C1713,HCPCS,0278,RC,,,both,,,2006.40,601.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,237.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,233.34,1705.44,"percent of total billed charges",
"SUB BONE GRAFT 20CM MASTERGRAFT SPINE STRIP",SUP-7800320,CDM,C1713,HCPCS,0278,RC,,,both,,,17643.78,5293.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7057.51,40,,,,,0,2051.97,14997.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPLANT 14.5CM NATRELLE INSPIRA P4.8CM MODERATE PROFIL",SUP-MSZ-M520,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PHCS [10601]",PHCS,,110.73,70,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER PEACH 7CM 2.9MM DYONICS POWERMINI INCISOR PLUS",SUP-72201513,CDM,S27200284,LOCAL,0272,RC,,,both,,,461.70,138.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,54.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.7,392.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MECLIZINE 12.5 MG TABLET",RX-12024,CDM,,,0637,RC,50268-0522-11,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]",Cigna,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX OTW CORONARY STENT   2.00 X 08MM",SUP-RONYX20008W,CDM,C1874,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]",Cigna,,2422.5,68,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH DURAL 5X4IN DUREPAIR CRANIAL BOVINE CLLGN MATRIX",SUP-62110,CDM,,,0278,RC,,,both,,,12983.32,3895,"MULTIPLAN [10600]",Multiplan,,11035.82,85,,,,,0,12.98,11035.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL FEMORAL THK3MM HALVE FROZEN TRADITIONAL",SUP-T20675,CDM,S27800098,LOCAL,0278,RC,,,both,,,6109.95,1832.98,"BLUE CROSS [10001]","Blue Cross PPO",,2395.1,39.2,,,,,0,710.59,5193.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 14MM NEXGEN LPS-FLEX 5-6 G-H KNEE PROLONG",SUP-596204214,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"PHCS [10601]",PHCS,,5542.91,70,,,,,0,920.91,6730.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ECHOTIP CLEARCORE EUS BIOPSY NEEDLE 22 GA NEEDLE GAGE 5.3 FR",SUP-G60992,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,399.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA3-17-75-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,9949.80,2984.94,"CIGNA [10200]","Cigna Local Plus",,5323.14,53.5,,,,,0,1157.16,8457.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 5IN 2.8MM QUICK RELEASE STERILE",SUP-MS-DC28,CDM,S27200284,LOCAL,0272,RC,,,both,,,696.60,208.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,82.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 30X27X14MM ROI-A 14D PEEK-OPTIMA ALIF","SUP-IR 2543 P",CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"UHC [10700]","United Healthcare",,21696.45,63.3,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEDICAL BACK PROBLEMS WITHOUT MCC",552,MS-DRG,,,,,,,inpatient,,,28175.88,8452.76,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,6380.42,,"Case rate ($5,963.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,537.05, add-ons for qualifying new technology services are included. If operating cost exceeds $38,576.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,800.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,544.37. The transfer operating threshold is the transfer adjustment factor * $5,537.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.63. The transfer capital threshold is the transfer adjustment factor * $418.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,5963.01,23973.86,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CYPHER 23MM 137CM 2.25MM CORONARY SIROLIMUS ELUTING",SUP-CXS23225,CDM,C1874,HCPCS,0278,RC,,,both,,,13110.00,3933,"NOVANET [10819]",Novanet,,9832.5,75,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2 X 4 HELICAL PICO COIL",SUP-10USH02004,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS [10001]","Blue Cross PPO",,4595.46,39.2,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sleeve Knee Neoprene",PX-E27400102,CDM,L1820,HCPCS,0274,RC,,,both,,,196.90,59.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,133.89,68,,,,,0,22.9,167.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEMENT 17 F VASCULAR ACCESS SYSTEM 13CM",SUP-ELMNT17F13,CDM,C1887,HCPCS,0272,RC,,,both,,,6210.00,1863,"PHCS [10601]",PHCS,,4347,70,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION",RX-89570,CDM,,,0250,RC,00338-0322-01,NDC,both,1,UN,519.10,155.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,61.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.37,441.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 16MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532-G-616,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1031.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 15MM ATLANTIS TITANIUM SPINE CERVICAL",SUP-3125215,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE 100 MEQ SODIUM 2 MEQ POTASSIUM 3.5 MEQ CALCIUM",SUP-08-2351-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.29,15.99,"PHCS [10601]",PHCS,,37.3,70,,,,,0,6.2,45.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY AND URINARY TRACT NEOPLASMS WITH CC",687,MS-DRG,,,,,,,inpatient,,,44973.68,13492.1,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 5CM 5FR TAPER CONTOUR SPIRAL OFFSET PANCREATIC",SUP-G21803,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHOCOLATE 135CM 80MM 4MM .014IN BALLOON DILATATION",SUP-CB1413540080OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) MICROCATHETER PLATO .017X127 CM 45 ANGLE",SUP-PL17-160-045,CDM,C1887,HCPCS,0272,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ARTHROSCOPIC FLOWPORT II OBTR STERILE LATEX FREE",SUP-CAT02439,CDM,S27200284,LOCAL,0272,RC,,,both,,,2655.00,796.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 135CM 20CM 6MM BALLOON DILATATION ILIAC",SUP-G35536,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 110CM 7FR .081IN JUDKINS RIGHT 4 CURVE GUIDING",SUP-LA7JR40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 36CM 18MM .021-.027IN AZUR CX HYDROCOIL",SUP-45-781836,CDM,S27800098,LOCAL,0278,RC,,,both,,,5278.50,1583.55,"PHCS [10601]",PHCS,,3694.95,70,,,,,0,613.89,4486.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CORDIS EMERALD VASCULAR STRAIGHT 150CM 7CM .025IN PTFE",SUP-502549,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"MULTIPLAN [10600]",Multiplan,,81.35,85,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bartonella Dna Ampl Probe",PX-306000117,CDM,87471,CPT,0306,RC,,,both,,,769.65,230.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,124.59,,,,,,,0.01,654.2,"fee schedule",
"CATH PACIFIC PLUS 130CM 20MM 4FR 6MM .018IN BALLOON",SUP-PCP060020130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"KAISER [10500]",Kaiser,,824.9,67,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 24FR SILICONE RADIOPAQUE BOLUS ENTERAL FEED INTERNAL",SUP-0110-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"PHCS [10601]",PHCS,,195.92,70,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT COMPRESSION 4IN THREEFLEX 3 LAYER PAD MEDI STRIP",SUP-MSC4300,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.88,23.96,"KAISER [10500]",Kaiser,,53.52,67,,,,,0,9.29,67.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SHUNT ACCU-FLO CSF CATH 3 WAY PLASTIC STERILE",SUP-45105,CDM,S27800098,LOCAL,0278,RC,,,both,,,2171.03,651.31,"NOVANET [10819]",Novanet,,1628.27,75,,,,,0,252.49,1845.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 20MM 130CM 9MM 6FR VASCULAR NITINOL 2",SUP-SC920LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]","Cigna Local Plus",,3876.08,53.5,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Consult Compr Data Review",PX-312000032,CDM,88325,CPT,0312,RC,,,both,,,1419.60,425.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.19,,,,,,,0.01,1206.66,"fee schedule",
"PLATE 1.9H 44MM 2 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009244,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,957.42,156.86,7483.26,51,521.61,3812.25,"percent of total billed charges",
"LENS IOL 0D +2.25 CYL BICONVEX TORIC 13MM 6MM ASPHERIC",SUP-SN6AT4,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"FIRST HEALTH [10303]","First Health",,276,80,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC 2 POUCH PACK 1 POWDER STD APPLR TIP PVC",SUP-PCUS003,CDM,A6250,HCPCS,0272,RC,,,both,,,1348.71,404.61,"PHCS [10601]",PHCS,,944.1,70,,,,,0,156.85,1146.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT VALEO 18MM 120CM 8MM LOW PROFILE TAPER",SUP-EV08182CD,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"FIRST HEALTH [10303]","First Health",,7176,80,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 6CM 5.8FR 18FR BALLOON",SUP-M0062251080,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"MULTIPLAN [10600]",Multiplan,,1455.61,85,,,,,0,199.16,1455.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 26MM TI",SUP-VAN-25260-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"MULTIPLAN [10600]",Multiplan,,826.2,85,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.0MM X 26.0MM",SUP-492002612,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BD NEXIVA DIFFUSICS 1.25IN 20GA IV BD VIALON CLOSED",SUP-383593,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.16,17.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NEURON MAX 100CM .088IN STRAIGHT DELIVERY SYSTEM DIL",SUP-PNML6F0881004,CDM,C1887,HCPCS,0272,RC,,,both,,,3675.00,1102.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 9.5MM 4MM MICRO EGG STERILE",SUP-1607235,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 5FR 55CM BIOFLO ENDEXO PICC 2 LUMEN MAXIMAL BARR",SUP-H965750335,CDM,C1751,HCPCS,0272,RC,,,both,,,1725.00,517.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) TF (-T) CRADLE ASSEMBLY INTPD-TF-C",SUP-INTPDTFCG,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 150CM 17CM 6MM BALLOON DILATATION OTW LOW",SUP-G30963,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE PIPELINE 12MM 4.5MM EMBOLIZATION",SUP-PED2-450-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"FIRST HEALTH [10303]","First Health",,64638,80,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION",RX-7322,CDM,J3490,HCPCS,0258,RC,63323-0093-01,NDC,both,30,ML,69.31,20.79,"MULTIPLAN [10600]",Multiplan,,58.91,85,,,,,0,8.06,58.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM COLLAR SECUR-FIT TITANIUM HA 132D 14 C",SUP-S-2337-HF14,CDM,C1776,HCPCS,0278,RC,,,both,,,24037.65,7211.29,"CIGNA [10200]",Cigna,,9615.06,40,,5873.17,5873.17,5873.17,"1 through 10",2795.58,20432,"percent of total billed charges",
"STENT GORE VIABAHN 15MM 80CM 6MM 8MM 7FR .035IN",SUP-BXA061501A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYOSURE REACH TISSUE REMOVAL REPROCESSED",SUP-10-401FC,CDM,S27200284,LOCAL,0272,RC,,,both,,,5002.50,1500.75,"MULTIPLAN [10600]",Multiplan,,4252.13,85,,,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION 0.9% SODIUM CHLORIDE PLASTIC POUR BOTTLE 1L",SUP-2F7124,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 12.5CM STAINLESS STEEL 2.7/3.5MM SCR 7 HOLE LCP BONE",SUP-02.112.144,CDM,C1713,HCPCS,0278,RC,,,both,,,3194.63,958.39,"CIGNA [10200]","Cigna Open Access",,1817.74,56.9,,1144.80,304.56,2275.09,66,371.54,2715.44,"percent of total billed charges",
"KIT 17GA 150MM COOL RADIOFREQUENCY PROBE ELECTROTHERAPY",SUP-CRK-17-150-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 20MM 144CM 3.5MM CORONARY STENT PEBAX",SUP-H7493926020350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I123 Datscan per Dose Up to 5mci",PX-343000027,CDM,A9584,HCPCS,0343,RC,,,both,,,11340.00,3402,"KAISER [10500]",Kaiser,,7597.8,67,,,,,0,1318.84,9639,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR STRAIGHT SPRING COIL 180CM 5CM",SUP-H74917511,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT DIALYSIS 2 PART FLEX-NECK CATH TITANIUM STERILE",SUP-CC-2300,CDM,S27200284,LOCAL,0272,RC,,,both,,,1223.10,366.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,144.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,142.25,1039.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP PULSED LAVAGE INTERPULSE IRRIGATION PUMP SUCTION FEMORAL",SUP-210008000,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.44,28.93,"MULTIPLAN [10600]",Multiplan,,81.97,85,,,,,0,11.22,81.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 135MM DHS/DCS STAINLESS STEEL CONDYLAR HIP",SUP-280.335,CDM,C1713,HCPCS,0278,RC,,,both,,,2043.30,612.99,"AETNA [10100]","Aetna HMO/PPO",,1624.42,79.5,,1521.93,481.35,16760.95,30,237.64,1736.81,"percent of total billed charges",
"LEAD DEFIB 59CM 7.3FR RELIANCE 4-FRONT RIGHT VENTRICLE MP35N",SUP-675,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"PHCS [10601]",PHCS,,10626,70,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QDOT MICRO F CURVE ABLATION UNIDIRECTIONAL",SUP-D139402,CDM,C1732,HCPCS,0272,RC,,,both,,,22560.30,6768.09,"MULTIPLAN [10600]",Multiplan,,19176.26,85,,,,,0,2623.76,19176.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MULTIFLEX PENTALUMEN TORQUE-LINE 110CM 7FR STD",SUP-41223-02,CDM,C1751,HCPCS,0272,RC,,,both,,,343.22,102.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) TRISOL DELIVERY SYSTEM KIT",SUP-DMS-14630,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONQUEST 75CM 2CM 12MM 8FR BALLOON DILATATION",SUP-CQ75122,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEALER TISSUE 25CM ENSEAL X1 CURVE JAW SHAFT STERILE LATEX",SUP-NSLX125C,CDM,S27200284,LOCAL,0272,RC,,,both,,,3109.07,932.72,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SUTURETAPE .5 CIRCLE 40INX1.3MM TAPER END REVERSE CUT",SUP-AR-7502,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.73,95.92,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 40CM 20MM 10MM .035IN BALLOON DILATATION NYBAX",SUP-39171-10024,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SHEPHERD ANGIOGRAPHIC STRAIGHT .014IN 6GM PERIPHERAL",SUP-PSP14S-30006,CDM,C1769,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLING ORTHOPEDIC PROCARE FOAM LARGE XL UNIVERSAL L55 IN X W1",SUP-79-92471,CDM,S27000186,LOCAL,0270,RC,,,both,,,53.42,16.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 7FR 2.5MM 45CM RADIOPAQUE SMALL VALVE FLEXOR",SUP-G09810,CDM,C1894,HCPCS,0272,RC,,,both,,,468.67,140.6,"FIRST HEALTH [10303]","First Health",,374.94,80,,,,,0,54.51,398.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 21MM 19.6MM REGENT PYROLYTIC CARBON PTFE",SUP-21AGN-751,CDM,S27800098,LOCAL,0278,RC,,,both,,,31229.42,9368.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3700.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3631.98,26545.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL 4IN ETCO2 O2 NONINTUBATE SIDESTREAM ADULT LOFLO",SUP-989803206641,CDM,S27000186,LOCAL,0270,RC,,,both,,,134.87,40.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.69,114.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX OI BLOCK- 10MM",SUP-441010,CDM,S27800098,LOCAL,0278,RC,,,both,,,8383.50,2515.05,"KAISER [10500]",Kaiser,,5616.95,67,,,,,0,975,7125.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM 34X16X2.5MM TITANIUM 2 LEVEL PREBENT SKYLINE BONE",SUP-186802034,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross HMO",,1728.72,39.2,,957.42,156.86,7483.26,51,512.88,3748.5,"percent of total billed charges",
"HEAD UNIPOLAR 52MM BIO-MOORE II ENDO II HIP ACETABULAR",SUP-12-139028,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,324.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,324.83,2374.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"15.0 DIOPTER, TECNIS SIMPLICITY EYHANCE IOL PRELOADED DELIVE",SUP-DIB00U0150,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH INTRDCR FR10 - EACH",SUP-667117-002,CDM,C1892,HCPCS,0272,RC,,,both,,,607.50,182.25,"MULTIPLAN [10600]",Multiplan,,516.38,85,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE LP 37M",SUP-TENDV-LP-37M-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"FIRST HEALTH [10303]","First Health",,136800,80,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION",RX-6462,CDM,J2730,HCPCS,0636,RC,60977-0141-01,NDC,both,1,UN,523.32,157,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.01,444.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ORTHOPEDIC 3 LONG 2 COLLAR PIN ADVANCE EVOLUTION STERILE",SUP-K0001288,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA [10200]","Cigna Local Plus",,1404.38,53.5,,3978.14,359.25,3978.14,24,305.29,2231.25,"percent of total billed charges",
"DRIVER MINI QC T4",SUP-DRVR-MQC-T4,CDM,S27000186,LOCAL,0270,RC,,,both,,,907.20,272.16,"AETNA [10100]","Aetna HMO/PPO",,721.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 4-5 C-D KNEE",SUP-42522100311,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4946.38,45.9,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS MONOPOLAR 31CM 5MM ENDO SHEARS STD RATCHET HANDLE",SUP-176643,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.82,91.45,"UHC [10700]","United Healthcare",,192.95,63.3,,,,,0,35.45,259.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 16MM 144CM 3MM",SUP-H7493941216300,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CIGNA [10200]","Cigna Open Access",,4416.86,56.9,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620512,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"MULTIPLAN [10600]",Multiplan,,9565.82,85,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SMART 150MM 120CM 8MM LONG BILIARY NITINOL SELF",SUP-C08150MB,CDM,C1876,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"FIRST HEALTH [10303]","First Health",,6210,80,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SR LORDOTIC ALLOGRAFT",SUP-400941,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POLYMER INTREPID TRANSFORMER I/A HANDPIECE (SINGLE USE)",SUP-8065752885,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.64,69.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,94.79,41.1,,,,,0,26.82,196.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 2.50 X 38 MM RX FDA",SUP-1203250-38,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Open Access",,5778.75,33.5,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +24.5 DIOPTER MODIFIED C BICONVEX 13.5MM 6.5MM",SUP-MC50BD.245,CDM,V2632,HCPCS,0276,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - TIBIAL KIT (PS) - SIZE 5",SUP-5555-2365,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 30CM 3CM 5FR .038IN 2",SUP-M006192125170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,165.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM STABILIT SHORT BONE CEMENT DELIVERY",SUP-DF-4011S,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 12CMX11MM HIP MEDIAL OSTEOTOM CURVE NONSTERILE",SUP-SBLDCURVE-3-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"FIRST HEALTH [10303]","First Health",,1166.4,80,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 32MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.432TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"NOVANET [10819]",Novanet,,1516.16,75,,,,,0,235.11,1718.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORTHOSIS SMALL 11IN THERMOPLASTIC FOAM HAND RIGHT BREATHABLE",SUP-55460406,CDM,L3807,HCPCS,0274,RC,,,both,,,460.89,138.27,"BLUE CROSS [10001]","Blue Cross PPO",,180.67,39.2,,,,,0,53.6,391.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 300MM 4MM BALLOON",SUP-LX1813043005F,CDM,C2623,HCPCS,0272,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH WOLVERINE CUTTING BALLOON (OTW)  4.00MM X 15MM",SUP-H74939402154000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SAMURAI VASCULAR 300CM J TIP",SUP-H74939302300J2,CDM,C1769,HCPCS,0272,RC,,,both,,,689.78,206.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CPLR TUBING OHMEDA O2 Y BLOCK",SUP-YB-CO-OHUO-OH,CDM,S27200284,LOCAL,0272,RC,,,both,,,594.30,178.29,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL 36CM CLEANCOAT PTFE STAINLESS STEEL",SUP-E3771-36C,CDM,S27200284,LOCAL,0272,RC,,,both,,,251.00,75.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC15ST-LK,CDM,S27200284,LOCAL,0272,RC,,,both,,,17640.00,5292,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"KIT INTRO 16CM 10FR SHEATH PEEL AWAY SPLIT",SUP-491115A,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BAG DRNG 700ML ACCUDRAIN CSF ANTIREFLUX VALVE FEMALE LUER",SUP-INS8700,CDM,S27200284,LOCAL,0272,RC,,,both,,,867.22,260.17,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BEARING 87/91MMX12MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183582,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"BLUE CROSS [10001]","Blue Cross PPO",,3073.19,39.2,,3949.44,3949.44,3949.44,"1 through 10",911.77,6663.81,"percent of total billed charges",
"TUBE VENTILATION 1MM 1.27MM 2.6MM REUTER BOBBIN EAR TITANIUM",SUP-1027070,CDM,S27800098,LOCAL,0278,RC,,,both,,,412.38,123.71,"FIRST HEALTH [10303]","First Health",,329.9,80,,,,,0,47.96,350.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 0 18IN BRAID 12 STRAND COATED VIOLET ABSORBABLE",SUP-J906G,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.08,26.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,40.89,45.9,,,,,0,10.36,75.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 4 STD OFFSET HIP",SUP-71935564,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9864.1,27,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alpha-Fetoprotein Serum",PX-301000097,CDM,82105,CPT,0301,RC,,,both,,,293.00,87.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,26.38,,,,,,,0.01,249.05,"fee schedule",
"SUT PROLENE 5-0 C-1 36IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8720,CDM,S27200284,LOCAL,0272,RC,,,both,,,530.50,159.15,"CIGNA [10200]","Cigna Local Plus",,283.82,53.5,,,,,0,61.7,450.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CV-5 PT-13 36IN 2 ARM NONABSORBABLE",SUP-5N08A,CDM,S27200284,LOCAL,0272,RC,,,both,,,350.90,105.27,"UHC [10700]","United Healthcare",,222.12,63.3,,,,,0,40.81,298.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC XL 20IN 20-22IN KNEE OPEN PATELLA CONTOUR",SUP-4462-05,CDM,L1830,HCPCS,0274,RC,,,both,,,140.77,42.23,"CIGNA [10200]","Cigna Open Access",,80.1,56.9,,,,,0,16.37,119.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,inpatient,,,83097.72,24929.32,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,33102.75,,"Case rate ($30,937.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $28,727.24, add-ons for qualifying new technology services are included. If operating cost exceeds $61,766.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,553.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $28,765.23. The transfer operating threshold is the transfer adjustment factor * $28,727.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,171.92. The transfer capital threshold is the transfer adjustment factor * $2,171.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,83097.72,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEURAL EFFUSION WITH MCC",186,MS-DRG,,,,,,,inpatient,,,52193.67,15658.1,"CIGNA [10200]","Cigna Open Access",,17102.98,,"Fee schedule rate ($17,102.98). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,38867.43,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 45CM 7FR ATRIAL ENDOCARDIAL IMPLANTABLE BIPOLAR",SUP-4479,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1604.72,28.62,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 2.66MM LARGE REGULAR PIGTAIL CURVE URETERAL",SUP-M001274040,CDM,C2617,HCPCS,0278,RC,,,both,,,1053.00,315.9,"FIRST HEALTH [10303]","First Health",,842.4,80,,,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 14CM 14FR 18GA PEEL-AWAY 3MM .038IN TRANSSEPTAL",SUP-405136,CDM,C1892,HCPCS,0272,RC,,,both,,,261.00,78.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,107.27,41.1,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 8CM 5.5MM TSRH SILO STD PEDICLE TITANIUM PREBENT",SUP-8370080,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Local Plus",,2359.35,53.5,,3978.14,359.25,3978.14,24,512.88,3748.5,"percent of total billed charges",
"SCR BONE 5.5MM 55MM TSRH OSTEOGRIP TITANIUM SHORT SPINE",SUP-83555558,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.10,1106.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2508.59,68,,,,,0,429.04,3135.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 40 75CM 2CM 4MM BALLOON DILATATION TAPER TIP",SUP-CQF7542,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"AETNA [10100]","Aetna HMO/PPO",,1062.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVERSTITCH ENDOSCOPIC SUTURE SYSTEM",SUP-M00505410,CDM,S27200284,LOCAL,0272,RC,,,both,,,8797.50,2639.25,"FIRST HEALTH [10303]","First Health",,7038,80,,,,,0,1023.15,7477.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 4CMX2CMX.2-.4MM DERMAMATRIX ACELLULAR DERMAL",SUP-19407,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOCKWAVE C2+ IVL CATHETER 2.5X12 MM",SUP-C2PIVL2512,CDM,C1761,HCPCS,0272,RC,,,both,,,29610.00,8883,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"KIT 1.9FR CATH 2 LUMEN RADIOPAQUE PICC COMPLETE POLYURETHANE",SUP-P2PIC1.9-S,CDM,C1751,HCPCS,0272,RC,,,both,,,1304.10,391.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER DISORDERS OF NERVOUS SYSTEM,MAJOR",058,APR-DRG,,,,,,,inpatient,,,42338.71,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $10,145.47. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($60,816.70) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETHRAL LUBRI-SIL IC 18FR FOLEY 3 WAY ROUND TIP 2",SUP-73018SI,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.23,33.07,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 58.5MM 1.2MM CARBIDE CROSS CUT FISSURE STERILE",SUP-2296101212,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.77,16.13,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"400 SINGLE USE FLAT TIP HOLMIUM FIBER",SUP-HOL400SBX,CDM,S27200284,LOCAL,0272,RC,,,both,,,1677.50,503.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Mra Upr Ext W/WO Cntrst",PX-610000030,CDM,73225,CPT,0610,RC,,,both,,,3072.00,921.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,357.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,357.27,2816,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 57MM 80CM 8MM 60MM BILIARY STAINLESS STEEL",SUP-PXB35-08-57-080,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2969.56,68,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SPINAL SPINEJACK 4.2MM EXPANSION",SUP-0909-200-042,CDM,S27200284,LOCAL,0272,RC,,,both,,,8966.41,2689.92,"NOVANET [10819]",Novanet,,6724.81,75,,,,,0,1042.79,7621.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 7.5MM ACORN DISSECTING",SUP-MR8-14AC75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1184.63,355.39,"CIGNA [10200]","Cigna Local Plus",,633.78,53.5,,,,,0,137.77,1006.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYSTOSCOPE FLEXIBLE ASCOPE 4 REVERSE DEFLECTION LEVER",SUP-600101000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1498.50,449.55,"CIGNA [10200]","Cigna Open Access",,852.65,56.9,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 12CM 2.5MM BALLOON DILATATION HYDROPHILIC",SUP-G50324,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,970.96,41.1,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 4FR 20CM PROVENA BIOPATCH 2 LUMEN MIDLINE MAX BARR",SUP-S4254108BDP,CDM,C1751,HCPCS,0272,RC,,,both,,,1586.30,475.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,184.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,184.49,1348.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 26CM 150CM 7FR .035IN 3CM BLADDER LOOP",SUP-M006155243190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CIGNA [10200]","Cigna Open Access",,808.17,,,,,,,165.19,1207.29,"percent of total billed charges",
"CMPNT TIBIAL TRAY 3 LEFT CEMENTED FIXED PRIMARY GMK",SUP-02.07.1203L,CDM,C1776,HCPCS,0278,RC,,,both,,,6136.20,1840.86,"AETNA [10100]","Aetna HMO/PPO",,4878.28,79.5,,10981.53,8986.79,12413.38,12,713.64,5215.77,"percent of total billed charges",
"3.5 X 14MM SELF-DRILLING LOCKING SCREW (BLUE)",SUP-100.035.14,CDM,C1713,HCPCS,0278,RC,,,both,,,426.30,127.89,"CIGNA [10200]","Cigna Open Access",,242.56,56.9,,1144.80,304.56,2275.09,66,49.58,362.36,"percent of total billed charges",
"CATHETER ELECTROPHYSIOLOGY BLUE 92CM 6FR 2MM SPACING D CURVE",SUP-D608DR002CTR,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 5MM COOLCUT FLUSHCUT 6 FLUTE OVAL",SUP-AR-8500FOS,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"AETNA [10100]","Aetna HMO/PPO",,446.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEPTIC ARTHRITIS WITH MCC",548,MS-DRG,,,,,,,inpatient,,,44990.58,13497.17,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,12336.81,,"Case rate ($11,977.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,121.91, add-ons for qualifying new technology services are included. If operating cost exceeds $44,161.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,222.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $11,136.62. The transfer operating threshold is the transfer adjustment factor * $11,121.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $840.87. The transfer capital threshold is the transfer adjustment factor * $840.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,44990.58,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SURGICAL 38CM SUBCUTANEOUS CATHETER DISPOSABLE",SUP-48407,CDM,S27200284,LOCAL,0272,RC,,,both,,,1459.70,437.91,"CIGNA [10200]",Cigna,,992.6,68,,,,,0,169.76,1240.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP XL ALLOGRAFT COMPRESSIBLE SPONGE 50X20X7",SUP-13812509,CDM,C1713,HCPCS,0278,RC,,,both,,,18721.06,5616.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5357.97,28.62,,,,,0,2177.26,15912.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 18MM 1.3MM CORTEX TITANIUM SELF TAPPING NONSTERILE",SUP-400.698,CDM,C1713,HCPCS,0278,RC,,,both,,,650.92,195.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,298.77,45.9,,,,,0,75.7,553.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +21.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SA60WF.215,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 6MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710606,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"BLUE CROSS [10001]","Blue Cross HMO",,5799.09,39.2,,5311.50,4717.44,5388.59,31,1720.5,12574.56,"percent of total billed charges",
"CATH RAPIDCROSS 170CM 40MM 2.5MM .014IN BALLOON DILATATION",SUP-A14BX025040170,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,161.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14.8IN 21FR AORTA 3/8IN CURVE TIP SUT FLANGE",SUP-EZF21TA,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,330.48,68,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Parathyroid Planar Img",PX-341000007,CDM,78070,CPT,0341,RC,,,both,,,2241.53,672.46,"AETNA [10100]","Aetna HMO/PPO",,1782.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,260.69,1905.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 22.5MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962356,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"CIGNA [10200]","Cigna Open Access",,4858.77,33.5,,5302.19,4377.88,6578.61,27,1686.79,12328.23,"percent of total billed charges",
"TUBE NASOGASTRIC 43IN 8FR NASOINTESTINAL RADIOPAQUE ANTICLOG",SUP-40-5438,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.88,26.66,"KAISER [10500]",Kaiser,,59.55,67,,,,,0,10.34,75.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 60MM 125CM 6MM 5FR VASCULAR NITINOL ILIAC",SUP-G43772,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2841.72,68,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 52MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 3",SUP-241.031,CDM,C1713,HCPCS,0278,RC,,,both,,,2076.90,623.07,"BLUE CROSS [10001]","Blue Cross HMO",,814.14,39.2,,957.42,156.86,7483.26,51,241.54,1765.37,"percent of total billed charges",
"GWIRE SYNCHRO2 VASCULAR 300CM .014IN HYDROPHILIC PRESHAPE",SUP-S2SPP14300,CDM,C1769,HCPCS,0272,RC,,,both,,,5686.57,1705.97,"FIRST HEALTH [10303]","First Health",,4549.26,80,,,,,0,661.35,4833.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 2.5MM 32MM AXSOS STAINLESS STEEL FULL THREAD",SUP-338632,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"MULTIPLAN [10600]",Multiplan,,195.67,85,,,,,0,26.77,195.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 300MM 5.5MM EXPEDIUM TITANIUM PRECUT HEXAGONAL",SUP-179762300,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"SURFACE ARTICULAR 10MM PERSONA 10-12 G-H KNEE RIGHT TIBIA",SUP-42522401010,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"KAISER [10500]",Kaiser,,7220.2,67,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 40CMX.49MM 22MM KNIT REVERSE LOCKNIT",SUP-HGK0022-40,CDM,C1768,HCPCS,0278,RC,,,both,,,2588.55,776.56,"FIRST HEALTH [10303]","First Health",,2070.84,80,,,,,0,301.05,2200.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE LCP ANKLE FOOT STAINLESS STEEL 2X7 HOLE MODULAR T",SUP-247.351,CDM,C1713,HCPCS,0278,RC,,,both,,,2541.00,762.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1166.32,45.9,,,,,0,295.52,2159.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 58MM 135CM 6MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU1350658,CDM,C1874,HCPCS,0278,RC,,,both,,,15870.00,4761,"MULTIPLAN [10600]",Multiplan,,13489.5,85,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHTH 7FR HMSTS CLS LNG",SUP-6273,CDM,C1894,HCPCS,0272,RC,,,both,,,139.20,41.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL YASARGIL RUGGLES REDMOND .3MM BAYONET 8.25IN",SUP-RN8030,CDM,S27200284,LOCAL,0272,RC,,,both,,,2174.10,652.23,"FIRST HEALTH [10303]","First Health",,1739.28,80,,,,,0,252.85,1847.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEPIN NON-THREADED 2.5 X 200MM",SUP-MSG25200,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,36.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA ARTERIAL SOFT-FLOW 3/8 IN L14 IN OD18 FR ANGLE TIP N",SUP-6392,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"UHC [10700]","United Healthcare",,355.32,63.3,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.035,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,24.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,24,175.41,"percent of total billed charges",
"CATH TORCON NB ADVANTAGE BEACON TIP 100CM 5FR ANGLE",SUP-G08419,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,27.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 5MM LEIBINGER UNIVERSAL 2 TITANIUM",SUP-5020405,CDM,C1713,HCPCS,0278,RC,,,both,,,458.02,137.41,"MULTIPLAN [10600]",Multiplan,,389.32,85,,,,,0,53.27,389.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TENDYNE TMVR SYSTEM LP29S","SUP-TENDYNE TENDYNE 29S SYSTEM",CDM,S27800098,LOCAL,0278,RC,,,both,,,319200.00,95760,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,91355.04,28.62,,,,,0,37122.96,271320,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 80MM 20MM 75CM ENDOPROSTHESIS VENOUS CATH",SUP-H74912044208070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]","Cigna Local Plus",,4614.38,53.5,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Graft Epifix per Sq Cm",PX-E63600024,CDM,Q4186,HCPCS,0636,RC,,,both,,,918.25,275.47,"NOVANET [10819]",Novanet,,688.69,75,,,,,0,108.81,780.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309115,CDM,C1776,HCPCS,0278,RC,,,both,,,37771.65,11331.49,"CIGNA [10200]","Cigna Open Access",,12653.5,33.5,,5302.19,4377.88,6578.61,27,4392.84,32105.9,"percent of total billed charges",
"CMPNT FEMORAL 4 NARROW KNEE LEFT CRUCIATE RETAIN CEMENTLESS",SUP-150401124,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"KAISER [10500]",Kaiser,,19279.42,67,,,,,0,3346.56,24458.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR AMPLATZ LEFT 1.5",SUP-67003800,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,49.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERTION KIT SENSATION  50CC",SUP-D884-00-0019-23,CDM,S27200284,LOCAL,0272,RC,,,both,,,1159.27,347.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,788.3,68,,,,,0,134.82,985.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTNR DRSG 25YD 7 SMALL TUBULAR MT SPANDAGE ELASTIC NET LATEX",SUP-MT07,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.17,23.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.97,65.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 3 KNEE RIGHT CRUCIATE RETAIN CEMENTLESS AT",SUP-150401203,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11826.63,41.1,,6417.48,6417.48,6417.48,"1 through 10",3346.56,24458.96,"percent of total billed charges",
"HC Nasal Smear for Eosinophils",PX-309000106,CDM,89190,CPT,0309,RC,,,both,,,108.00,32.4,"MULTIPLAN [10600]",Multiplan,,91.8,85,,,,,0,0.01,91.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG SURGICAL 1.6X1.3IN MONOFILAMENT FULL RESORBABLE PATCH",SUP-1190601,CDM,C1781,HCPCS,0278,RC,,,both,,,3563.25,1068.97,"NOVANET [10819]",Novanet,,2672.44,75,,,,,0,414.41,3028.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL REVERSE GLOBAL UNITE",SUP-OSC379347,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"FIRST HEALTH [10303]","First Health",,36288,80,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 150MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"NOVANET [10819]",Novanet,,1075.28,75,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLF TORIC AUTONOME",SUP-CNA0T3,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"CIGNA [10200]","Cigna Local Plus",,197.95,53.5,,,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 58MM 40MM ALTRX HIP",SUP-122140458,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"BLUE CROSS [10001]","Blue Cross HMO",,5410.95,39.2,,5311.50,4717.44,5388.59,31,1605.34,11732.93,"percent of total billed charges",
"SCR BONE 5.5MM 40MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16025540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"BEARING HIP 38MM 28MM C VIVACIT-E LUMEN STERILE LATEX FREE",SUP-110031009,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"MULTIPLAN [10600]",Multiplan,,8803.37,85,,,,,0,1204.51,8803.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 17X14X5MM COROENT SMALL INTERLOCK 7D PEEK",SUP-6790225,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5104.62,41.1,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 14CM 3MM MR8 MATCH HEAD DIAMOND",SUP-MR8-14MH30D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1358.37,407.51,"MULTIPLAN [10600]",Multiplan,,1154.61,85,,,,,0,157.98,1154.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC So Neo Gsap Dna/Dna&Rna",PX-310000019,CDM,81459,CPT,0310,RC,,,both,,,5525.00,1657.5,"BLUE CROSS [10001]","Blue Cross HMO",,5.53,.1,,,,,0,5.53,4696.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 10-14MM 13FR 10FR TRIVASCULAR OVATION",SUP-TV-IL1410100-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3883.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +10.5 DIOPTER .5 MM 12.5MM 5.5MM ANTERIOR CHMBR",SUP-MTA3U0.105,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175280010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,124.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X2CM ACTISHIELD AMNIOTIC BARR MEMB",SUP-AM202X04,CDM,V2790,HCPCS,0278,RC,,,both,,,9577.20,2873.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2740.99,28.62,,,,,0,1113.83,8140.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 90CM 8MM 8MM STD WALL AXILLOBIFEMORAL",SUP-SAX02,CDM,C1768,HCPCS,0278,RC,,,both,,,17098.20,5129.46,"AETNA [10100]","Aetna HMO/PPO",,13593.07,79.5,,,,,0,1988.52,14533.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 9.5CM NATRELLE INSPIRA P4CM FULL PROFILE ROUND",SUP-MSZ-F180,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"MULTIPLAN [10600]",Multiplan,,134.45,85,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE 10 MG/ML INJECTION SOLUTION",RX-5168,CDM,J2272,HCPCS,0636,RC,63323-0451-00,NDC,both,1,ML,52.82,15.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.26,44.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 22FR TUNGSTEN SILICONE 2.5CM MIC-KEY",SUP-0270-22-2.5-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1790.3,68,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SPECIMEN RETRIEVAL 90CM 10MM 3.3FR 2 PRONG KINK",SUP-M0063204020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD QD ASR MP MRLN CLLR","SUP-CD3369-40Q CELL",CDM,C1882,HCPCS,0278,RC,,,both,,,44764.00,13429.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17905.6,40,,,,,0,5206.05,38049.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 20CM 3CM 7FR .038IN 2 PIGTAIL",SUP-M006192140010,CDM,C2617,HCPCS,0278,RC,,,both,,,1167.78,350.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,794.09,68,,,,,0,135.81,992.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURESTEP(TM) FOLEY TRAY SYSTEM, TEMPERATURE SENSING WITH BAR",SUP-B319416AM,CDM,S27200284,LOCAL,0272,RC,,,both,,,1812.00,543.6,"MULTIPLAN [10600]",Multiplan,,1540.2,85,,,,,0,210.74,1540.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FAMOTIDINE 20 MG TABLET",RX-10011,CDM,,,0637,RC,50268-0299-11,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 12 STD KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508607401,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"NOVANET [10819]",Novanet,,19678.68,75,,,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8-6.5MM 90MM CREO SPINE 2 OUTER DIAMETER",SUP-5119.2292,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,957.42,156.86,7483.26,51,601.85,4398.75,"percent of total billed charges",
"SYSTEM PREVENA PLUS -125 MMHG NEGATIVE PRESSURE 0.019% IONIC",SUP-PRE4001US.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4255.57,1276.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1953.31,45.9,,,,,0,494.92,3617.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APOLLO ONYX 165CM 3CM 1.5-2.7FR .013IN MICRO INFUSION",SUP-105-5096-000,CDM,C1887,HCPCS,0272,RC,,,both,,,11667.90,3500.37,"MULTIPLAN [10600]",Multiplan,,9917.72,85,,,,,0,1356.98,9917.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656018,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"CIGNA [10200]","Cigna Local Plus",,714.33,53.5,,3978.14,359.25,3978.14,24,155.28,1134.92,"percent of total billed charges",
"SYSTEM PROMUS PREMIER 16MM 144CM 2.5MM CORONARY STENT",SUP-H7493952816250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"MULTIPLAN [10600]",Multiplan,,4730.25,85,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FELT CARDIOVASCULAR 4X.5IN THK1.65MM PTFE PATCH STERILE",SUP-007975,CDM,C1768,HCPCS,0278,RC,,,both,,,1359.43,407.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,924.41,68,,,,,0,158.1,1155.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) DILATOR KIT LHR-0105",SUP-LHR-0105,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR ANGLE 260CM .018IN HYDROPHILIC FIX CORE",SUP-H2OSTDA18260EX,CDM,C1769,HCPCS,0272,RC,,,both,,,408.47,122.54,"KAISER [10500]",Kaiser,,273.67,67,,,,,0,47.51,347.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, ALL-POLY PEGGED GLENOID, SIZE 46, E-PLUS",SUP-521-07-246,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"AETNA [10100]","Aetna HMO/PPO",,7285.7,79.5,,10981.53,8986.79,12413.38,12,1065.82,7789.74,"percent of total billed charges",
"CATH DAC 136CM 3.9FR .038IN GUIDING DISTAL ACCESS STERILE",SUP-90721,CDM,S27200284,LOCAL,0272,RC,,,both,,,9626.67,2888,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1140.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1119.58,8182.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOUNDSTAR 8FR ANGIOGRAPHIC",SUP-10439236R,CDM,C1759,HCPCS,0272,RC,,,both,,,7590.00,2277,"UHC [10700]","United Healthcare",,4804.47,63.3,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVED 278MM STAINLESS STEEL 4.5MM SCR 12 HOLE LOCKING",SUP-02.001.322,CDM,C1713,HCPCS,0278,RC,,,both,,,9833.88,2950.16,"CIGNA [10200]",Cigna,,6687.04,68,,1831.33,1831.33,1831.33,16,1143.68,8358.8,"percent of total billed charges",
"SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION",RX-27838,CDM,J3490,HCPCS,0258,RC,00264-5802-00,NDC,both,1000,ML,100.65,30.19,"AETNA [10100]","Aetna HMO/PPO",,80.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hzv Vacc Recombinant Im Njx",PX-771000022,CDM,90750,CPT,0636,RC,,,both,,,583.00,174.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,291.5,50,,,,,0,69.09,495.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 2-0 CT-1 18IN CONTROL RELEASE MONOFILAMENT 8",SUP-Z739D,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.94,65.68,"PHCS [10601]",PHCS,,153.26,70,,,,,0,25.46,186.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM TRILOGY HIP SELF TAP STERILE",SUP-625006560,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,118.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",115.87,846.86,"percent of total billed charges",
"SCR BONE 5MM 32MM X25 LOCK LOW PROFILE STERILE",SUP-04.045.332S,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"BLUE CROSS [10001]","Blue Cross PPO",,733,39.2,,957.42,570.23,957.42,28,217.47,1589.42,"percent of total billed charges",
"DIL ENDOSCOPIC ELATION 100CM 3CM 24-27-30FR PULMONARY CATH",SUP-P8L30,CDM,C1726,HCPCS,0272,RC,,,both,,,2137.50,641.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,253.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",379.61,375.47,414.12,"1 through 10",248.59,1816.88,"percent of total billed charges",
"ROD SPINAL 85MM 5.5MM CREO CURVE TITANIUM NONSTERILE",SUP-1119.7085,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 15IN 24FR VENOUS .25-3/8IN CONNECTION SITE 1",SUP-68124,CDM,S27200284,LOCAL,0272,RC,,,both,,,340.62,102.19,"UHC [10700]","United Healthcare",,215.61,63.3,,,,,0,39.61,289.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) 20F DRYSEAL FLEX INTRODUCER SHEATH (GORE)",SUP-DSF2033,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT AORTIC 4.5CM 28.5MM EXCLUDER CONFORMABLE ACTIVE CONTROL",SUP-CXA280005,CDM,C1874,HCPCS,0278,RC,,,both,,,27612.90,8283.87,"FIRST HEALTH [10303]","First Health",,22090.32,80,,,,,0,3211.38,23470.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 20MM 125CM 8MM 5FR .018IN VASCULAR NITINOL",SUP-G43779,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"AETNA [10100]","Aetna HMO/PPO",,3322.31,79.5,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 8FR .09IN MULTIPURPOSE 1 CURVE GUIDING NYLON",SUP-LA8MP1,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT STRETCH VL ZIPWIRE 22-30CM 3CM 4.8FR .035IN PIGTAIL",SUP-M006185155190,CDM,C2617,HCPCS,0278,RC,,,both,,,1199.37,359.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,142.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.49,1019.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 5MM ACCESS SYSTEM 55MM KII Z THREAD LOW",SUP-CTS28,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,47.33,68,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO BIOPSY 6CM 17GA 18GA ACHIEVE UNIVERSAL COAXIAL",SUP-PP176,CDM,S27200284,LOCAL,0272,RC,,,both,,,114.41,34.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.31,97.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 NARROW KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-42500006601,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"CIGNA [10200]","Cigna Local Plus",,7201.75,31.5,,5372.07,4581.20,7242.98,23,2658.93,19433.3,"percent of total billed charges",
"KIT MICROINTRODUCER 45CM 5FR 21GA .018IN 10CM PERCUTANEOUS",SUP-06597016,CDM,C1894,HCPCS,0272,RC,,,both,,,238.38,71.51,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.72,202.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB ADULT MULTIFUNCTION STAT-PADZ MODEL PD 2200",SUP-8900-4003,CDM,S27000186,LOCAL,0270,RC,,,both,,,270.42,81.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,124.12,45.9,,,,,0,31.45,281.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CERTUS XT PR ABLATION PROBE 20",SUP-PR20XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,14524.50,4357.35,"CIGNA [10200]","Cigna Local Plus",,7770.61,53.5,,,,,0,1689.2,12345.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD PACING 100CM 6FR BARD NBIH 1CM PROXIMAL BIPOLAR",SUP-007152P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1822.50,546.75,"KAISER [10500]",Kaiser,,1221.08,67,,,,,0,211.96,1549.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX TAPER TIP",SUP-M0061453630,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"CIGNA [10200]","Cigna Open Access",,360.23,,,,,,,73.63,538.14,"percent of total billed charges",
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT 16MM ALIF",SUP-3W3216,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"MULTIPLAN [10600]",Multiplan,,17973.52,85,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 148MM 14MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-104140,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"FIRST HEALTH [10303]","First Health",,19362.67,80,,,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 14CM 6FR 8MM .035IN BALLOON",SUP-G52364,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 44MM STAINLESS STEEL T25 CONDYLAR VARIABLE",SUP-02.231.244,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,154.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",152.1,1111.66,"percent of total billed charges",
"SCR BONE 5MM 12MM STAINLESS STEEL T25 SELF TAP VARIABLE",SUP-02.231.012S,CDM,C1713,HCPCS,0278,RC,,,both,,,2073.45,622.03,"PHCS [10601]",PHCS,,1451.42,70,,,,,0,241.14,1762.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 CURVE 12.5MM KNEE GVF ROTATE PLATFORM PFC",SUP-972002,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"AETNA [10100]","Aetna HMO/PPO",,7353.31,79.5,,10981.53,8986.79,12413.38,12,1075.71,7862.03,"percent of total billed charges",
"CATH LUBRI-SIL IC 60IN 14FR URETHRAL BACTI-GUARD SILICONE",SUP-0170SI14,CDM,S27200284,LOCAL,0272,RC,,,both,,,193.66,58.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.52,164.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM AZUR DETACHABLE HYDROGEL",SUP-45-450410,CDM,S27800098,LOCAL,0278,RC,,,both,,,1702.50,510.75,"NOVANET [10819]",Novanet,,1276.88,75,,,,,0,198,1447.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 1.5MM TARGET NANO HELICAL DETACHABLE",SUP-M0035431530,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3763.81,41.1,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 8MM 3.25MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012408-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM TSRH OSTEOGRIP TITANIUM SHORT SPINE",SUP-83565558,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.10,1106.73,"MULTIPLAN [10600]",Multiplan,,3135.74,85,,,,,0,429.04,3135.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM MINI-MONSTER SHORT THREAD HEAD NONSTERILE",SUP-P20-140-038S,CDM,C1713,HCPCS,0278,RC,,,both,,,1599.75,479.92,"MULTIPLAN [10600]",Multiplan,,1359.79,85,,,,,0,186.05,1359.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC No Pt Prsnt Train Add 15 (Gp)",PX-420000191,CDM,G0542,HCPCS,0420,RC,,,both,,,37.00,11.1,"CIGNA [10200]","Cigna Local Plus",,37,,"Per diem ($290).",,,,0,0.04,37,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mra Chest W Cntrst",PX-610000015,CDM,71555,CPT,0610,RC,,,both,,,3987.00,1196.1,"PHCS [10601]",PHCS,,2790.9,70,,,,,0,463.69,3388.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 90CM 3FR ODEC16MM 4 WIRE STONE",SUP-M0063901020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1416.61,424.98,"MULTIPLAN [10600]",Multiplan,,1204.12,85,,,,,0,164.75,1204.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP LARGE 4 POINT HEADGEAR LEAK 1",SUP-73-1061735,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.58,61.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.03,175.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 2.4MM TEMPORARY",SUP-58820024,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 SH 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J316H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FINISHING WIRE UNIVERSAL 80CM",SUP-6004,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,771.12,68,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSET CALCIUM SULFATE 20ML 4.8MM PELLETS",SUP-84000101,CDM,C1713,HCPCS,0278,RC,,,both,,,4788.00,1436.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,567.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,556.84,4069.8,"percent of total billed charges",
"LINE ANGIOGRAPHY 76.2CM 3.6MM 1.8MM 1200 PSI FEMALE TO MALE",SUP-91051302,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.77,17.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.83,49.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM 4.5MM 2.1-2.7FR CORONARY",SUP-RONYX45026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5754.00,1726.2,"PHCS [10601]",PHCS,,4027.8,70,,,,,0,669.19,4890.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 21MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-021,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"PHCS [10601]",PHCS,,3315.97,70,,,,,0,550.92,4026.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Jo-1 Igg Muscle Ab",PX-302000041,CDM,86235,CPT,0302,RC,,,both,,,424.00,127.2,"FIRST HEALTH [10303]","First Health",,339.2,80,,,,,0,0.42,360.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 4 10MM KNEE AOX CRUCIATE RETAIN ROTATE PLATFOR",SUP-151630410,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UHC [10700]","United Healthcare",,8309.55,63.3,,8601.07,8395.67,8601.07,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"SCR BONE 2MM 13MM APTUS TITANIUM TAPER HAND WRIST CORTICAL 2",SUP-A-5400.13/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ATLANTIS TITANIUM SPINE CERVICAL ANTERIOR",SUP-3120412,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTP W4TR03 SOLARA QUAD CRTP MRI US",SUP-W4TR03,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2736.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 7FR .038IN STRAIGHT URETERAL PERCUFLEX",SUP-M006180231010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"BLUE CROSS [10001]","Blue Cross PPO",,419.73,39.2,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOPERAMIDE 2 MG CAPSULE",RX-4560,CDM,,,0637,RC,51079-0690-01,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL DURAL ADHERUS AUTOSPRAY LOW SWELL",SUP-NUS-106,CDM,S27200284,LOCAL,0272,RC,,,both,,,7604.35,2281.3,"CIGNA [10200]",Cigna,,5170.96,68,,,,,0,884.39,6463.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE 815000 FIB STRUT 50MM SRVC FEE",SUP-815000,CDM,S27800098,LOCAL,0278,RC,,,both,,,3743.25,1122.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2545.41,68,,,,,0,435.34,3181.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 25MM 4MM STERILE DISPOSABLE",SUP-7005-4025S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 76.2CM 25FR 3/8IN VENOUS INTRO HEMOSTASIS CAP",SUP-96670-125,CDM,S27200284,LOCAL,0272,RC,,,both,,,3073.95,922.18,"MULTIPLAN [10600]",Multiplan,,2612.86,85,,,,,0,357.5,2612.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RX NC TAKERU PTCA BALLOON 2.25MM X 21MM",SUP-DC-RZ2221UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 52MM 36MM XLPE HIP STERILE",SUP-71335752,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"PHCS [10601]",PHCS,,7788.38,70,,,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STYLET 100CM SJ4",SUP-DS06003/75,CDM,S27500001,LOCAL,0275,RC,,,both,,,453.60,136.08,"BLUE CROSS [10001]","Blue Cross PPO",,177.81,39.2,,,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 57SQ CM 13MM 51X66MM COBALT XT VENTRICULAR",SUP-DVPA2D1,CDM,C1722,HCPCS,0278,RC,,,both,,,56385.00,16915.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23174.24,41.1,,,,,0,6557.58,47927.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ATHLETIC 3IN BAUER AND BLACK LARGE ELASTIC WAISTBAND",SUP-M202636,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.69,23.31,"CIGNA [10200]","Cigna Open Access",,44.21,56.9,,,,,0,9.04,66.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 12.5FR .164IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1012.5,CDM,C1892,HCPCS,0272,RC,,,both,,,304.50,91.35,"PHCS [10601]",PHCS,,213.15,70,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE 5CC PRO-DENSE INJECTABLE REGENERATIVE",SUP-87SR0050,CDM,C1713,HCPCS,0278,RC,,,both,,,11150.40,3345.12,"AETNA [10100]","Aetna HMO/PPO",,8864.57,79.5,,1521.93,481.35,16760.95,30,1296.79,9477.84,"percent of total billed charges",
"SURFACE ARTICULAR PERSONA 8-9 C-D KNEE RIGHT TIBIA FIX",SUP-42522100516,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Local Plus",,5765.38,53.5,,5372.07,4581.20,7242.98,23,1253.3,9159.96,"percent of total billed charges",
"KIT STYLET 100CM SJ4",SUP-DS06003/75,CDM,S27500001,LOCAL,0275,RC,,,both,,,453.60,136.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,308.45,68,,,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC ITREVIA 7 HF-T",SUP-393014,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"PHCS [10601]",PHCS,,40404,70,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 67MMX14MM VANGUARD ARCOM KNEE ANTERIOR STABILIZE",SUP-189044,CDM,C1776,HCPCS,0278,RC,,,both,,,8154.42,2446.33,"MULTIPLAN [10600]",Multiplan,,6931.26,85,,,,,0,948.36,6931.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 20MM 140CM 2.5MM CORONARY STENT",SUP-LUN250R20US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 6MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620706,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 65CM 8MM PRESTIGE PLUS HELICAL PACK ULTRA",SUP-PRES0865HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"AETNA [10100]","Aetna HMO/PPO",,6308.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 70MM CD HORIZON SPINE MULTIAXIAL CANNULATED",SUP-25840018570,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"STENT ADVANIX 9CM 5FR STRAIGHT PANCREATIC POLYMER RADIOPAQUE",SUP-M00536310,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,293.42,45.9,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 10.2MM 7.5MM NASAL ORAL TAPER CUFF MURPHY",SUP-18775S,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.56,19.97,"CIGNA [10200]","Cigna Local Plus",,35.61,53.5,,,,,0,7.74,56.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 40MM 13.5MM 10FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEL14040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5228.87,28.62,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.3MM 34MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.524,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"BLUE CROSS [10001]","Blue Cross PPO",,453.42,39.2,,957.42,570.23,957.42,28,134.52,983.18,"percent of total billed charges",
"GWIRE SAVION FLX ICE VASCULAR J 300CM .014IN .37MM",SUP-H749394223001J0,CDM,C1769,HCPCS,0272,RC,,,both,,,1446.34,433.9,"PHCS [10601]",PHCS,,1012.44,70,,,,,0,168.21,1229.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 18CM 3CM 5FR .038IN 2",SUP-M006192115170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"BLUE CROSS [10001]","Blue Cross PPO",,546.93,39.2,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION 155CM 2.4-3FR .021IN MICRO INFUSION NITINOL",SUP-M001195330,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309015,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"CIGNA [10200]",Cigna,,15104.88,40,,5873.17,5873.17,5873.17,"1 through 10",4391.74,32097.87,"percent of total billed charges",
"CANN ARTHROSCOPIC ZONENAVIGATOR LEFT POSTERIOR MIDDLE",SUP-AR-7910L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1275.75,382.72,"PHCS [10601]",PHCS,,893.03,70,,,,,0,148.37,1084.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK.39IN SMALL 2.43X3.13IN INCEPTA CRT-D DF-1",SUP-N164,CDM,C1882,HCPCS,0278,RC,,,both,,,45926.50,13777.95,"CIGNA [10200]",Cigna,,18370.6,40,,,,,0,5341.25,39037.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IRON BENDING 150MM 2.7/3.5MM PLATE",SUP-329.05,CDM,S27200284,LOCAL,0272,RC,,,both,,,2188.20,656.46,"NOVANET [10819]",Novanet,,1641.15,75,,,,,0,254.49,1859.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATHETERIZATION 1.75IN 20GA 23GA .015IN RADIAL ARTERY",SUP-RA-04122,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.00,28.5,"KAISER [10500]",Kaiser,,63.65,67,,,,,0,11.05,80.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM PFC SIGMA 5 KNEE LEFT TITANIUM STERILE LATEX",SUP-960900,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"CIGNA [10200]","Cigna Local Plus",,2745,53.5,,5372.07,4581.20,7242.98,23,596.72,4361.21,"percent of total billed charges",
"DIL UTERINE HANK 2 END 10.75IN 23/24FR",SUP-52-3723,CDM,S27000186,LOCAL,0270,RC,,,both,,,184.96,55.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,84.9,45.9,,,,,0,21.51,157.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 15MM 3MM BALLOON DILATATION STERILE",SUP-230-153-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PTS 80CM 3CM 8FR 20MM 2 TAPER SUPER THIN BALLOON",SUP-613700,CDM,C1725,HCPCS,0272,RC,,,both,,,2251.50,675.45,"FIRST HEALTH [10303]","First Health",,1801.2,80,,,,,0,261.85,1913.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM MEDLINE UNITE FOOT ANKLE NONLOCK",SUP-MPSN3518,CDM,C1713,HCPCS,0278,RC,,,both,,,1174.50,352.35,"CIGNA [10200]",Cigna,,798.66,68,,1831.33,1831.33,1831.33,16,136.59,998.33,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 16CM 3CM 5FR .035IN",SUP-M006192114190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CIGNA [10200]",Cigna,,948.76,68,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 21MM HANCOCK II CINCH STERILE LATEX FREE",SUP-T505C221,CDM,S27800098,LOCAL,0278,RC,,,both,,,21420.00,6426,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2491.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE DREAMWIRE ENDOSCOPIC ANGLE 260CM .035IN ENDOGLIDE",SUP-M00556131,CDM,C1769,HCPCS,0272,RC,,,both,,,1422.36,426.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,584.59,41.1,,,,,0,165.42,1209.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM SPINAL SELF TAPPING VARIABLE ANGLE",SUP-3120312,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"KAISER [10500]",Kaiser,,944.7,67,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 90CC ALLOGRAFT FINE FROZEN 1-4MM",SUP-800116,CDM,S27800098,LOCAL,0278,RC,,,both,,,9307.41,2792.22,"CIGNA [10200]",Cigna,,6329.04,68,,,,,0,1082.45,7911.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 18MM 135CM 5MM 3.3-2.9FR VASCULAR COCR",SUP-1011493-18,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4284,68,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA POWERTRAC 142CM 12MM 5MM BALLOON DILATATION",SUP-NCEUP5012X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"AETNA [10100]","Aetna HMO/PPO",,418.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 8MM STRAIGHT FUSION BIOLINE POLYESTER 2",SUP-M00201503088B0,CDM,C1768,HCPCS,0278,RC,,,both,,,16537.92,4961.38,"CIGNA [10200]","Cigna Local Plus",,5209.44,31.5,,,,,0,1923.36,14057.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 75CM OTW SFT G",SUP-346977,CDM,C1893,HCPCS,0272,RC,,,both,,,486.00,145.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VIATRAC 14 PLUS 135CM 15MM 3.3-3.6FR 5.5MM BALLOON",SUP-1008195-15,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ACARBOSE 25 MG TABLET",RX-22148,CDM,,,0637,RC,64380-0758-06,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT LABRALTAPE 1.5MM 36IN WHITE NONABSORBABLE",SUP-AR-7276,CDM,S27200284,LOCAL,0272,RC,,,both,,,595.35,178.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FEVER AND INFLAMMATORY CONDITIONS,MODERATE",722,APR-DRG,,,,,,,inpatient,,,30405.58,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $3,391.45. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%.",,,,0,,,other,"SOI-2 Shortstay; Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 33CM 5MM LYONS CORD",SUP-942005PK,CDM,S27200284,LOCAL,0272,RC,,,both,,,2466.60,739.98,"KAISER [10500]",Kaiser,,1652.62,67,,,,,0,286.87,2096.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GS 90, 80 CM, STRAIGHT, DISTAL",SUP-GS9080SD,CDM,C1887,HCPCS,0272,RC,,,both,,,3573.98,1072.19,"PHCS [10601]",PHCS,,2501.79,70,,,,,0,415.65,3037.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT VITRECTOMY PERFLUORO-N-OCTANE PROCEDURAL LIQUID PURIFY",SUP-8065900164,CDM,C1784,HCPCS,0278,RC,,,both,,,3845.92,1153.78,"NOVANET [10819]",Novanet,,2884.44,75,,,,,0,447.28,3269.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 4-0 RB-1 30IN BRAID BLACK NONABSORBABLE",SUP-K871H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIBRILLATOR CRT-D GALLANT BIPOLAR DF4 HF",SUP-CDHFA500D,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,30780,40,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 20FR 20CM COONS TAPER STERILE DISPOSABLE",SUP-G04264,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.61,54.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.24,155.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FABRIC CARDIOVASCULAR 3X2IN HEMASHIELD THK.46IN 2 VELOUR",SUP-M002000196240,CDM,C1768,HCPCS,0278,RC,,,both,,,1147.37,344.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,133.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,133.44,975.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AMPLATZER TORQVUE 2 120CM 6FR INTRO POLYMER PTFE",SUP-9-TV2-06F120,CDM,S27200284,LOCAL,0272,RC,,,both,,,5754.60,1726.38,"PHCS [10601]",PHCS,,4028.22,70,,,,,0,669.26,4891.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 3-0 SH-1 36IN 2 ARM BRAID GREEN",SUP-X762H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 40MM 2.5MM BALLOON DILATATION RAPID",SUP-47525040L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 22X9X9MM CONDUIT 8D STRAIGHT BULLET EIT ROUGH",SUP-PUI80902,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Esophagus Dbl Contrast",PX-320000227,CDM,74221,CPT,0320,RC,,,both,,,1725.88,517.76,"CIGNA [10200]","Cigna Open Access",,168.76,,,,,,,120.66,1467,"fee schedule",
"KIT DECOMPRESSION MICROBLADE IO-FLEX L5.5 MM SPINAL PROBE",SUP-IO-MBS5.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,9918.75,2975.62,"KAISER [10500]",Kaiser,,6645.56,67,,,,,0,1153.55,8430.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 11CM GWIRE PRELUDE PRO .035IN STERILE GREEN",SUP-PRO-6F-11,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"NOVANET [10819]",Novanet,,56.77,75,,,,,0,8.8,64.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIATHLON PS X3 TIBIAL INSERT",SUP-5532-G-811-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1352.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11.9-11.8CM NATRELLE BIOCELL P4.1-4.4CM MODERATE",SUP-SZ68300,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"CIGNA [10200]","Cigna Local Plus",,162.91,53.5,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM TRICUSPID 1 SEAM 2 WRAP ANATOMIC",SUP-4900T28,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1512.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD 40J UNIFY ASR VNTRC","SUP-CD3357-40Q CELL",CDM,C1882,HCPCS,0278,RC,,,both,,,44764.00,13429.2,"BLUE CROSS [10001]","Blue Cross PPO",,17547.49,39.2,,,,,0,5206.05,38049.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM VANGUARD E1 KNEE CRUCIATE RETAINING",SUP-EP183462,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"BLUE CROSS [10001]","Blue Cross PPO",,5077.45,39.2,,3949.44,3949.44,3949.44,"1 through 10",1506.4,11009.78,"percent of total billed charges",
"CATH CXI 150CM 2.3FR ANGLE SPRT STAINLESS STEEL HYDROPHILIC",SUP-G23861,CDM,C1887,HCPCS,0272,RC,,,both,,,1522.72,456.82,"UHC [10700]","United Healthcare",,963.88,63.3,,,,,0,177.09,1294.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 4-0 RB-1 30IN BRAID BLACK NONABSORBABLE",SUP-K871H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATH GUIDING RDND 1 CURVE 6FR .07IN 55CM CORONARY SOF",SUP-SA6RDND1K,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"KAISER [10500]",Kaiser,,244.82,67,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM MULTIPOLAR THR CERAMIC CEMENTED STEM CUP LINER HE",SUP-98000100701,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"BLUE CROSS [10001]","Blue Cross PPO",,3786.72,39.2,,3949.44,3949.44,3949.44,"1 through 10",1123.46,8211,"percent of total billed charges",
"GWIRE HI-TORQUE SPARTACORE VASCULAR STRAIGHT 300CM 10CM .014",SUP-1005206,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 6.5MM 1.75MM 14MM TITANIUM FULL THREAD",SUP-414.814,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,126.35,45.9,,,,,0,32.01,233.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ASCENDA 114CM 86CM 4FR .5MM INTRATHECAL SILICONE",SUP-8780,CDM,C1755,HCPCS,0278,RC,,,both,,,8769.90,2630.97,"FIRST HEALTH [10303]","First Health",,7015.92,80,,,,,0,1019.94,7454.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 100MM 18GA 20GA SONOLONG SONOLONG SONO",SUP-521187-31C,CDM,C9814,HCPCS,0272,RC,,,both,,,510.30,153.09,"MULTIPLAN [10600]",Multiplan,,433.76,85,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 67.5MM KNEE LEFT POSTERIOR STABILIZE OPEN BOX",SUP-184530,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"CIGNA [10200]","Cigna Open Access",,8316.64,33.5,,5302.19,4377.88,6578.61,27,2887.24,21101.91,"percent of total billed charges",
"INTICA NEO HF-T QP DF1 HIGH ENERGY PROMRI TI AND CLS",SUP-429552,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"FIRST HEALTH [10303]","First Health",,61560,80,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE HA PLLA 35MM 12MM ACL PCL ABSORBABLE",SUP-72201791,CDM,C1713,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,669.11,1030.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STAR SLEEVE POSITIONING VELCRO FOAM ARM FOREARM WRIST",SUP-AR-1606V,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"CIGNA [10200]","Cigna Open Access",,483.93,56.9,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CORTICAL LORDOTIC BLOCK 14X11X9MM",SUP-340941,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Hemo Cmpl Bi Std",PX-320000229,CDM,93985,CPT,0320,RC,,,both,,,2305.00,691.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING SL MONORAIL 150CM 150MM 4MM 4FR .018IN BALLOON",SUP-39147-40151,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRACE WALKING 5-7 6-8 SMALL 15IN AIR BRACE DYNAMIC",SUP-15500032,CDM,S27000186,LOCAL,0270,RC,,,both,,,249.86,74.96,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STRIP ISOLATOR STRIP",SUP-00860013000318.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD SUT ASSISTANT 3-0 ES-9 7IN 1 STITCH ENDO STITCH",SUP-170072,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 3.5MM 14MM DVR TITANIUM RADIUS CORTICAL DISTAL",SUP-CS14000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1093.50,328.05,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 4-0 RB-1 36IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8557,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.06,68.72,"CIGNA [10200]","Cigna Local Plus",,122.55,53.5,,,,,0,26.64,194.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 7-0 BV175-8 24IN 2 ARM MONOFILAMENT",SUP-8747H,CDM,S27200284,LOCAL,0272,RC,,,both,,,258.69,77.61,"MULTIPLAN [10600]",Multiplan,,219.89,85,,,,,0,30.09,219.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENDO STITCH V LOC 180 3-0 6IN CLSR ABSORBABLE RELOAD",SUP-VLOCA306L,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.01,84.3,"AETNA [10100]","Aetna HMO/PPO",,223.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.68,238.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 6CM FOR SURGICAL WOUND BIOABSORBABLE",SUP-50205N18D0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,19252.80,5775.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12514.32,65,,,,,0,180.89,16364.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL MEDIUM 17.5MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405317,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"CIGNA [10200]","Cigna Local Plus",,5169.95,53.5,,5372.07,4581.20,7242.98,23,1123.86,8213.93,"percent of total billed charges",
"CATH TORCON NB ADVANTAGE 80CM 5FR NEFF CURVE ANGIOGRAPHIC",SUP-G47078,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"FIRST HEALTH [10303]","First Health",,168.42,80,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 83MM 15MM COMPREHENSIVE POROUS MINI SHOULDER",SUP-113635,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]",Cigna,,5040,40,,5873.17,5873.17,5873.17,"1 through 10",1465.38,10710,"percent of total billed charges",
"KIT BIOPSY 12CM 10GA AVAMAX LOW PROFILE UNIVERSAL HANDLE",SUP-VPH0010,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAXI LD 80CM 4CM 7FR 25MM LARGE DIAMETER BALLOON",SUP-4172540S,CDM,C1725,HCPCS,0272,RC,,,both,,,1620.00,486,"PHCS [10601]",PHCS,,1134,70,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 5.5MM CURVE NONSTERILE",SUP-1555501120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 35CM 12FR 22GA FLEXIMA POLYURETHANE 3 WAY STPCOCK",SUP-M001273090,CDM,C1729,HCPCS,0272,RC,,,both,,,1950.00,585,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1326,68,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Antithrombin III Activity",PX-305000030,CDM,85300,CPT,0305,RC,,,both,,,438.55,131.56,"CIGNA [10200]",Cigna,,26.07,,,,,,,0.01,372.77,"fee schedule",
"HC Dressing Wound Triad Hydrophilic",PX-E27200468,CDM,E27200468,LOCAL,0272,RC,,,both,,,78.00,23.4,"FIRST HEALTH [10303]","First Health",,62.4,80,,,,,0,9.07,66.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTIX-PPP ARTIX PRICE PER PROCEDURE",SUP-ARTIX-PPP,CDM,C1757,HCPCS,0272,RC,,,both,,,47250.00,14175,"AETNA [10100]","Aetna HMO/PPO",,37563.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5495.18,40162.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM LARGE ALLOGRAFT BLOCK FREEZE",SUP-T00220,CDM,S27800098,LOCAL,0278,RC,,,both,,,6109.95,1832.98,"CIGNA [10200]",Cigna,,4154.77,68,,,,,0,710.59,5193.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colposcopy W/Curettage",PX-361000529,CDM,57456,CPT,0361,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross PPO",,1458,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,169.57,1458,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV",RX-9807,CDM,J3480,HCPCS,0258,RC,00990-7904-09,NDC,both,1000,ML,100.65,30.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68.44,68,,,,,0,0.02,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tavi/Tavr Bypassperc per Art",PX-361000349,CDM,33367,CPT,0361,RC,,,both,,,45298.00,13589.4,"PHCS [10601]",PHCS,,31708.6,70,,,,,0,2491,38503.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 135CM 7MM 30MM",SUP-38047-73013,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross PPO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CHAMPIONIR DES SYSTEM US 6-150",SUP-412601500USRD,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT TAPERED COMPONENT",SUP-G47480,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"CIGNA [10200]","Cigna Local Plus",,32327.98,31.5,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +29 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.290,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 8MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158125108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3017.13,27,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 167MM 18MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-218,CDM,C1776,HCPCS,0278,RC,,,both,,,19885.95,5965.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8173.13,41.1,,6417.48,6417.48,6417.48,"1 through 10",2312.74,16903.06,"percent of total billed charges",
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD + VE",SUP-98000700015,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"CIGNA [10200]","Cigna Local Plus",,7938,31.5,,5372.07,4581.20,7242.98,23,2930.76,21420,"percent of total billed charges",
"GRAFT BONE TRICORTICAL TISSUE ALLOGRAFT BLOCK 60MM",SUP-800129,CDM,S27800098,LOCAL,0278,RC,,,both,,,15794.10,4738.23,"FIRST HEALTH [10303]","First Health",,12635.28,80,,,,,0,1836.85,13424.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW MINI 22MM",SUP-AT2-M22,CDM,C1713,HCPCS,0278,RC,,,both,,,2511.60,753.48,"CIGNA [10200]",Cigna,,1707.89,68,,1831.33,1831.33,1831.33,16,292.1,2134.86,"percent of total billed charges",
"GRAFT BONE OSTEOAMP 5CC ALLOGRAFT PUTTY",SUP-14100401,CDM,C1713,HCPCS,0278,RC,,,both,,,7458.76,2237.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3423.57,45.9,,,,,0,867.45,6339.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY OSSEOFLEX SN NDL ONLY STEERABLE ACTUATION CURVE",SUP-OF-0231,CDM,S27200284,LOCAL,0272,RC,,,both,,,4560.90,1368.27,"AETNA [10100]","Aetna HMO/PPO",,3625.92,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,530.43,3876.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER HEX QUICK CONNECT 3.2MM SURGICAL",SUP-8361025,CDM,S27000186,LOCAL,0270,RC,,,both,,,4930.05,1479.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3352.43,68,,,,,0,573.36,4190.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 12MM CONCERTO DETACHABLE",SUP-PV-12-30-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 7MM 9.5MM 225MM HUMERAL RIGHT MULTILOC INTRAMEDULLARY",SUP-04.016.225S,CDM,C1713,HCPCS,0278,RC,,,both,,,11172.76,3351.83,"UHC [10700]","United Healthcare",,7072.36,63.3,,5023.51,2672.93,6679.78,18,1299.39,9496.85,"percent of total billed charges",
"CATH CORDIS SABER 90CM 80MM 8MM BALLOON DILATATION DURALYN",SUP-48008008S,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAWSON-MUELLER 25CM 12FR DRNG ULTRATHANE HYDROPHILIC",SUP-G10435,CDM,C1729,HCPCS,0272,RC,,,both,,,660.07,198.02,"KAISER [10500]",Kaiser,,442.25,67,,,,,0,76.77,561.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM LCP STAINLESS STEEL LONG FEMORAL",SUP-207.716,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"BLUE CROSS [10001]","Blue Cross PPO",,407.7,39.2,,957.42,570.23,957.42,28,120.96,884.03,"percent of total billed charges",
"INSRT TIBIAL 7 16MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532G716,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2492.12,28.62,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF ENHANCR II 110CM 4MM 7FR 2-5-2MM SPACE 45MM SINGLE",SUP-31744523,CDM,C1733,HCPCS,0272,RC,,,both,,,3375.00,1012.5,"AETNA [10100]","Aetna HMO/PPO",,2683.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPS EXT CABLE B/T/Q GRY 150 US",SUP-401982R,CDM,S27000186,LOCAL,0270,RC,,,both,,,567.00,170.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,260.25,45.9,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FECAL MICROBIOTA 250ML COLONOSCOPY TRANSPLANT",SUP-FMP250,CDM,S25000001,LOCAL,0250,RC,,,both,,,11005.50,3301.65,"CIGNA [10200]","Cigna Local Plus",,5887.94,53.5,,,,,0,1279.94,9354.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 130MM 12MM NEXGEN FLUTE KNEE FEMUR TIVANIUM",SUP-598801612,CDM,C1776,HCPCS,0278,RC,,,both,,,7446.48,2233.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2131.18,28.62,,,,,0,866.03,6329.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR WILSON XL SURGICAL",SUP-TLC5042M,CDM,S27200284,LOCAL,0272,RC,,,both,,,2865.00,859.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,339.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,333.2,2435.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 12FR DRNG FLEXIMA HYDROPHILIC BILIARY RADIOPAQUE",SUP-M001272670,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 7MM CANNULATED REAMER STERILE",SUP-AR-1218-70,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BENCHMARK 105CM .07IN MULTIPURPOSE CURVE PRESSURE MNTR",SUP-BMK6F105M,CDM,S27200284,LOCAL,0272,RC,,,both,,,6727.50,2018.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,797.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR AR2 CURVE GUIDING CORONARY SIDEHOLE",SUP-LA7AR20SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"FIRST HEALTH [10303]","First Health",,313.2,80,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 20MM 140CM 3MM CORONARY STENT CARBOSIL",SUP-LUN300R20US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23 DIOPTER HAPTIC C BICONVEX 13MM 6MM POSTERIOR",SUP-ZXR00U0230,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,341.96,45.9,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 NARROW KNEE RIGHT CRUCIATE RETAINING PERSONA",SUP-42502206202,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11876.08,41.1,,6417.48,6417.48,6417.48,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"COIL EMBOLIZATION 4CM 2MM PRESTIGE PLUS HELICAL COMPLEX XTRA",SUP-PRES0204CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 52MM TI",SUP-MTLS-37520-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Local Plus",,715.03,53.5,,3978.14,359.25,3978.14,24,155.43,1136.03,"percent of total billed charges",
"SCR BONE 4MM 14MM VUEPOINT II SPINE FAVOR ANGLE NONSTERILE",SUP-8975614,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,1521.93,481.35,16760.95,30,441.36,3225.75,"percent of total billed charges",
"PASSER SURGICAL 38CM ON-Q PAINBUSTER CATH SYCHROMED",SUP-8591-38,CDM,S27200284,LOCAL,0272,RC,,,both,,,980.10,294.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,113.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.99,833.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 30MM 2 VELOUR WOVEN STRAIGHT TUBE",SUP-M00202175130P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3046.80,914.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1398.48,45.9,,,,,0,354.34,2589.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL TISSUE ALLOGRAFT BLOCK 60MM",SUP-800129,CDM,S27800098,LOCAL,0278,RC,,,both,,,15794.10,4738.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4264.41,27,,,,,0,1836.85,13424.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 10MM 3MM BALLOON DILATATION HYDROPHILIC",SUP-2200-3010-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"AETNA [10100]","Aetna HMO/PPO",,4662.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXS CATALYST 7 132CM .082-.0825IN .068IN ASPIRATION",SUP-IC068132,CDM,S27200284,LOCAL,0272,RC,,,both,,,13688.22,4106.47,"PHCS [10601]",PHCS,,9581.75,70,,,,,0,1591.94,11634.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 5MM KII LOW PROFILE Z THREADED",SUP-CTR22,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.90,44.37,"NOVANET [10819]",Novanet,,110.93,75,,,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL MEDIUM KNEE RIGHT LCS COMPLETE POROCOAT",SUP-129403030,CDM,C1776,HCPCS,0278,RC,,,both,,,28683.90,8605.17,"CIGNA [10200]","Cigna Open Access",,9609.11,33.5,,5302.19,4377.88,6578.61,27,3335.94,24381.32,"percent of total billed charges",
"BALL THERAPEUTIC SMALL SPHERE HAND FOREARM WRIST METAL",SUP-A83720,CDM,S27000186,LOCAL,0270,RC,,,both,,,151.90,45.57,"CIGNA [10200]","Cigna Open Access",,86.43,56.9,,,,,0,17.67,129.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM CROSSFT KNOTLESS BIOCOMPOSITE STERILE",SUP-CFKB-475S,CDM,C1713,HCPCS,0278,RC,,,both,,,4385.23,1315.57,"CIGNA [10200]",Cigna,,2981.96,68,,1831.33,1831.33,1831.33,16,510,3727.45,"percent of total billed charges",
"WEDGE TIBIAL 10MM LEGION 3-4 HEMI KNEE LEFT MEDIAL RIGHT",SUP-71423034,CDM,C1776,HCPCS,0278,RC,,,both,,,15245.55,4573.66,"NOVANET [10819]",Novanet,,11434.16,75,,,,,0,1773.06,12958.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 42MM LEVEL 2 TRANSLATIONAL BONE SPINE",SUP-201-42D42,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"MANIP EASY LOAD DESIGN LOCK HANDLE SAFELY INSRT 3.5CM",SUP-KC-RUMI-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,133.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
FACEPLATE,SUP-06001-I,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 26CM 3CM 7FR .038IN PIGTAIL CURVE",SUP-M006180533170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS [10001]","Blue Cross PPO",,482.54,39.2,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 2 VIVID LED BLADE HANDLE MERCURY FREE",SUP-301-LED-102S,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.97,29.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,44.51,45.9,,,,,0,11.28,82.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 7FR SL3.5 CURVE GUIDING CORONARY",SUP-LA7SL350,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"UHC [10700]","United Healthcare",,231.3,63.3,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 75CM 8MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200084070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,481.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 28CM 8FR POLARIS ULTRA .038IN STRAIGHT URETERAL",SUP-M006192154010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"PHCS [10601]",PHCS,,840.41,70,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENCORE 26 12FR INFLATION 20ML PRESSURE GAUGE",SUP-M001151062,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"UHC [10700]","United Healthcare",,264.34,63.3,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI: REGULAR Y 1MM CRANIOMAXILLOFACIAL 5 HOLE 2MM SCR",SUP-55-08250,CDM,C1713,HCPCS,0278,RC,,,both,,,1552.45,465.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,183.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",180.55,1319.58,"percent of total billed charges",
"GWIRE MAXXWIRE ENDOSCOPIC 180CM .035IN STIFF",SUP-80129-404,CDM,C1769,HCPCS,0272,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X18X10-17MM RISE-L 10D",SUP-193.334,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CIGNA [10200]","Cigna Local Plus",,10815.53,31.5,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 4N KNEE LEFT CRUCIATE RETAINING PFC SIGMA",SUP-940019,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3067.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3010.99,22006.37,"percent of total billed charges",
"PLATE CONTOUR 129MM STAINLESS STEEL 2.7/3.5MM SCR 7 HOLE LCP",SUP-02.112.114S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,1466.08,39.2,,957.42,570.23,957.42,28,434.96,3179,"percent of total billed charges",
"HC Ather/De Stnt Addl Br Cor Arty",PX-481000082,CDM,C9603,HCPCS,0481,RC,,,both,,,25789.00,7736.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12474,,"Case rate ($12,474). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,2999.26,25681,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 90MM 16MM 5.4MM 14FR ZENITH SPIRAL-Z",SUP-G55239,CDM,C1874,HCPCS,0278,RC,,,both,,,19435.50,5830.65,"CIGNA [10200]","Cigna Local Plus",,6122.18,31.5,,,,,0,2260.35,16520.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUPERCORE ECHOGENIC 9CM 3.9CM 18GA 17GA BIOPSY",SUP-701218090,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.53,140.26,"MULTIPLAN [10600]",Multiplan,,397.4,85,,,,,0,54.37,397.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23 DIOPTER HAPTIC C BICONVEX 13MM 6MM POSTERIOR",SUP-ZXR00U0230,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,213.22,28.62,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DULOXETINE 20 MG CAPSULE,DELAYED RELEASE",RX-39275,CDM,,,0637,RC,68180-0294-07,NDC,both,1,UN,26.45,7.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.08,22.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 8MM KNEE UNICONDYLAR RIGHT MEDIAL LEFT",SUP-102408600,CDM,C1776,HCPCS,0278,RC,,,both,,,15980.40,4794.12,"AETNA [10100]","Aetna HMO/PPO",,12704.42,79.5,,10981.53,8986.79,12413.38,12,1858.52,13583.34,"percent of total billed charges",
"SUT STRATAFIX PDS PLUS 1 CTX SPIRAL 14IN ABSORBABLE",SUP-SXPP2B405,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.66,64.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.96,182.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 6FR 20CM HYDROPHILIC RADIOPAQUE STERILE",SUP-G10285,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"MULTIPLAN [10600]",Multiplan,,56.87,85,,,,,0,7.78,56.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SUTURETAPE TIGERLINK 1.3MM BLACK WHITE LATEX FREE",SUP-AR-7535T,CDM,S27200284,LOCAL,0272,RC,,,both,,,722.93,216.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,491.59,68,,,,,0,84.08,614.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENUCLEATOR MICROSURGERY 9.5IN HARDY SYMMETRY 3.4MM STD ANGLE",SUP-58-7558,CDM,S27000186,LOCAL,0270,RC,,,both,,,680.72,204.22,"CIGNA [10200]","Cigna Local Plus",,364.19,53.5,,,,,0,79.17,578.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAVITOR WITH RADIOPAQUE MARKERS 25MM",SUP-NVRO-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"FIRST HEALTH [10303]","First Health",,109440,80,,,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X6MM 5D OVAL SPINE CORTICAL FREEZE DRY",SUP-17206,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE BEARING POSTERIOR STABILIZE",SUP-5532-G-211-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"NOVANET [10819]",Novanet,,8559.45,75,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 8FR 19CM VESSEL ACCEPTS .035IN GWIRE",SUP-504408X,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.26,26.18,"CIGNA [10200]","Cigna Local Plus",,46.68,53.5,,,,,0,10.15,74.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8.5MM 31CM TIBIA META-NAIL INTRAMEDULLARY TITANIUM",SUP-71655031,CDM,C1713,HCPCS,0278,RC,,,both,,,15548.46,4664.54,"UHC [10700]","United Healthcare",,9842.18,63.3,,5023.51,2672.93,6679.78,18,1808.29,13216.19,"percent of total billed charges",
"SABLE, 12X30MM, 7-14MM, 15%C2%B0",SUP-1172.4221S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4106.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL COCHLEAR 14MM 4MM BAHA ABUTMENT BIA400 NONSTERILE LATEX",SUP-93338,CDM,L8690,HCPCS,0278,RC,,,both,,,21042.00,6312.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2493.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2447.18,17885.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 73X40X14IN UNIFY CRT-D 2.5V 500OHM 60 PPM",SUP-CD3231-40Q,CDM,C1882,HCPCS,0278,RC,,,both,,,45926.50,13777.95,"NOVANET [10819]",Novanet,,34444.88,75,,,,,0,5341.25,39037.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"1.9MM X 341MM TRILOGY PROBE KIT",SUP-M0068403510,CDM,S27200284,LOCAL,0272,RC,,,both,,,5531.45,1659.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2538.94,45.9,,,,,0,643.31,4701.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM LEGEND 9MM BALL DIAMOND DISSECTING",SUP-14BA90D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1468.94,440.68,"CIGNA [10200]",Cigna,,998.88,68,,,,,0,170.84,1248.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 20FR 20CM 13CM PEEL-AWAY LARGE STERILE",SUP-G06445,CDM,C1892,HCPCS,0272,RC,,,both,,,382.71,114.81,"AETNA [10100]","Aetna HMO/PPO",,304.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890005540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 545CC",SUP-SMPX545,CDM,C1789,HCPCS,0278,RC,,,both,,,6382.50,1914.75,"CIGNA [10200]","Cigna Local Plus",,3414.64,,,,,,,742.28,5425.13,"percent of total billed charges",
"CEMENT BONE SMARTSET 40GM HIGH VISCOSITY STERILE",SUP-3092040,CDM,C1713,HCPCS,0278,RC,,,both,,,946.40,283.92,"BLUE CROSS [10001]","Blue Cross PPO",,370.99,39.2,,957.42,570.23,957.42,28,110.07,804.44,"percent of total billed charges",
"TUBE TRACH 9MM PORTEX BLUSELECT UNCUFF STERILE LATEX FREE",SUP-101/816/090,CDM,S27200284,LOCAL,0272,RC,,,both,,,311.63,93.49,"CIGNA [10200]","Cigna Local Plus",,166.72,53.5,,,,,0,36.24,264.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 GEOALIGN 130CM 100MM 7MM BALLOON DILATATION",SUP-LX3513071005F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"KAISER [10500]",Kaiser,,4507.43,67,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +7 DIOPTER +1.5 CYL BICONVEX 13MM 6MM POSTERIOR",SUP-SN6AT3.070,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TACTIFLEX SE BID CURVE F UNIFIED",SUP-A-TFSE-F-X,CDM,C2630,HCPCS,0272,RC,,,both,,,25061.40,7518.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17041.75,68,,,,,0,2914.64,21302.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS MULTIPASS 5-0 PC-1 18IN BRAID ANTIBACTERIAL",SUP-VCP834G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"KAISER [10500]",Kaiser,,16.75,67,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL PERSONA XS CONE KNEE CENTRAL STERILE LATEX FREE",SUP-42545000510,CDM,C1776,HCPCS,0278,RC,,,both,,,29901.06,8970.32,"AETNA [10100]","Aetna HMO/PPO",,23771.34,79.5,,10981.53,8986.79,12413.38,12,3477.49,25415.9,"percent of total billed charges",
"LEAD NEROSTIMLTR TRIAL LINEAR 3-4",SUP-SC-2352-50E,CDM,C1778,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX24MM VANGUARD POROUS KNEE POSTERIOR",SUP-183754,CDM,C1776,HCPCS,0278,RC,,,both,,,8757.48,2627.24,"BLUE CROSS [10001]","Blue Cross PPO",,3432.93,39.2,,3949.44,3949.44,3949.44,"1 through 10",1018.49,7443.86,"percent of total billed charges",
"CEMENTED KNEE SYSTEM",SUP-55500009,CDM,C1776,HCPCS,0278,RC,,,both,,,18270.00,5481,"UHC [10700]","United Healthcare",,11564.91,63.3,,8601.07,8395.67,8601.07,"1 through 10",2124.8,15529.5,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 8MM 145CM 2.5MM CORONARY STENT",SUP-1125250-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"FIRST HEALTH [10303]","First Health",,4670.4,80,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDOMETHACIN 50 MG RECTAL SUPPOSITORY",RX-3901,CDM,,,0637,RC,69344-0102-33,NDC,both,1,UN,1641.60,492.48,"KAISER [10500]",Kaiser,,1099.87,67,,,,,0,190.92,1395.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TORQVUE SHEATH 12F 080CM 45X45 PKG STER",SUP-9-TV45X45-12F-080-CLINICAL,CDM,S62400003,LOCAL,0624,RC,,,both,,,5989.20,1796.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,709.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,696.54,5090.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3.5MM 12/14 TAPER UNIVERSAL 28MM HIP COCR",SUP-802202801,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2226.47,45.9,,,,,0,564.14,4123.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET 5.5/6MM CD HORIZON SOLERAL VOYAGER NONSTERILE LATEX",SUP-6540530,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"FIRST HEALTH [10303]","First Health",,278.4,80,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 20MM 1.5MM .014IN BALLOON DILATATION",SUP-AB14W015020150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.87,68,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 170MM PERFORM 12 LONG SHOULDER STERILE LATEX",SUP-PFX12170,CDM,C1776,HCPCS,0278,RC,,,both,,,42493.50,12748.05,"FIRST HEALTH [10303]","First Health",,33994.8,80,,,,,0,4941.99,36119.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 10.5IN 18FR SILICONE Y PORT GRADUATE SHAFT OPEN DISTAL",SUP-8884720189E,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREPARATION OF TC-99M-TETROFOSMIN 1.38 MG IV SOLUTION",RX-169822,CDM,A9502,HCPCS,0343,RC,08888-8878-17,NDC,both,1,UN,206.95,62.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,99.38,,,,,,,24.07,206.95,"fee schedule",
"PLATE BONE 116MM LCP BROAD METAPHYSEAL STAINLESS STEEL 6",SUP-226.561,CDM,C1713,HCPCS,0278,RC,,,both,,,2391.90,717.57,"CIGNA [10200]","Cigna Open Access",,1360.99,56.9,,1144.80,304.56,2275.09,66,278.18,2033.12,"percent of total billed charges",
"CATH CORDIS SABER 150CM 40MM 8MM BALLOON DILATATION DURALYN",SUP-48008004X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK15MM 37ML 51X64MM PROTECTA XT VR SMARTSHOCK",SUP-D314VRM,CDM,C1722,HCPCS,0278,RC,,,both,,,59850.00,17955,"AETNA [10100]","Aetna HMO/PPO",,47580.75,79.5,,,,,0,6960.56,50872.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MAILMAN VASCULAR J SPRING COIL FLOPPY 182CM 3CM .014IN",SUP-H7491213601J2,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,233.04,41.1,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) GUIDEWIRE VASCULAR .014INX200CM ZOOM WIRE 14 X-SUPPOR",SUP-Z14-200-004,CDM,C1769,HCPCS,0272,RC,,,both,,,4140.00,1242,"AMERIGROUP MEDICAID [20100]",Amerigroup,,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 18GA MAGSEED BREAST BIOPSY 12CM",SUP-SM18112001,CDM,A4648,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CIGNA [10200]",Cigna,,2524.5,68,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840006550,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 4FR 17.8CM VESSEL ACCEPTS .035IN GWIRE",SUP-504404X,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.26,26.18,"CIGNA [10200]","Cigna Open Access",,49.65,56.9,,,,,0,10.15,74.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROCKET IPC LOCKABLE DRAIN LINE WITH WIDE-BORE CONNECTOR",SUP-R54410-WB-DLH,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"MULTIPLAN [10600]",Multiplan,,155.3,85,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ENDOSCOPIC 6.5MM 90MM DRI-LOK DISTAL THREAD STERILE",SUP-3910090800,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"PHCS [10601]",PHCS,,121.8,70,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 8MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158124108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AETNA [10100]","Aetna HMO/PPO",,8883.77,79.5,,10981.53,8986.79,12413.38,12,1299.6,9498.37,"percent of total billed charges",
"LINER ACETABULAR PINNACLE 52MM 45MM HIP 2 MOBILITY",SUP-121852045,CDM,C1776,HCPCS,0278,RC,,,both,,,15870.00,4761,"CIGNA [10200]","Cigna Open Access",,5316.45,33.5,,5302.19,4377.88,6578.61,27,1845.68,13489.5,"percent of total billed charges",
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 26MM 140CM 4MM CORONARY",SUP-RSINT40026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"AETNA [10100]","Aetna HMO/PPO",,4407.48,79.5,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TIBIAL CORTICAL THK3-15MM THIRD ALLOGRAFT FROZEN",SUP-450571,CDM,S27800098,LOCAL,0278,RC,,,both,,,4765.14,1429.54,"BLUE CROSS [10001]","Blue Cross HMO",,1867.93,39.2,,,,,0,554.19,4050.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 20MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1085.08,68,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH 5.6MM STD HANDLE AORTIC",SUP-APU456,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,34.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROCKET IPC DRAINAGE KIT INCLUDES 2L BAG AND DRESSING PACK",SUP-R51401H,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 36MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR36,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1524.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 10X60 135CM SL",SUP-48010006R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,353.05,41.1,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERCI 95CM 8FR GUIDING SILICONE BALLOON STERILE LATEX",SUP-90073,CDM,C1725,HCPCS,0272,RC,,,both,,,9696.36,2908.91,"UHC [10700]","United Healthcare",,6137.8,63.3,,,,,0,1127.69,8241.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 18FR NEPHRSTMY NATURAL RUBBER 4 WING DRAIN",SUP-086018,CDM,C1729,HCPCS,0272,RC,,,both,,,105.62,31.69,"UHC [10700]","United Healthcare",,66.86,63.3,,,,,0,12.28,89.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD TITANIUM 3 HOLE GEMINUS BONE LEFT DISTAL VOLAR",SUP-GMN-LTS-3HL,CDM,C1713,HCPCS,0278,RC,,,both,,,5023.20,1506.96,"CIGNA [10200]","Cigna Local Plus",,2687.41,53.5,,3978.14,359.25,3978.14,24,584.2,4269.72,"percent of total billed charges",
"CATH CROSSTELLA 90CM 40MM 4-3.4FR 5MM BALLOON DILATATION",SUP-BD-F50040MR,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,174.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X150 80CM SL",SUP-48005015N,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"PHCS [10601]",PHCS,,697.98,70,,,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY SHORT TOOTH",SUP-NF03,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.32,22.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.76,64.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 120MM 2.5MM BALLOON DILATATION RAPID",SUP-47525120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"MULTIPLAN [10600]",Multiplan,,1356.35,85,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM SUMMIT POROCOAT 3 12/14 STD OFFSET TAPER",SUP-157001090,CDM,C1776,HCPCS,0278,RC,,,both,,,14221.44,4266.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1685.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1653.95,12088.22,"percent of total billed charges",
"CMPNT TIBIAL PERSONA 0D G KNEE RIGHT OSSEOTI KEEL",SUP-42535007902,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"AETNA [10100]","Aetna HMO/PPO",,10943.57,79.5,,10981.53,8986.79,12413.38,12,1600.93,11700.68,"percent of total billed charges",
"PACKAGED RADIAL STEM 9MM X -2MM",SUP-ALN-RST-09M2,CDM,C1776,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1685.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1653.89,12087.77,"percent of total billed charges",
"SYSTEM SPIDERFX 320CM 190CM 3.2-4.2FR 6MM EMBOLIC PROTECTION",SUP-SPD2-US-060-320,CDM,C1884,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]","Cigna Local Plus",,3876.08,53.5,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 100MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.700S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,291.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",286.03,2090.49,"percent of total billed charges",
"FECAL MICROBIOTA 250ML COLONOSCOPY TRANSPLANT",SUP-FMP250,CDM,S25000001,LOCAL,0250,RC,,,both,,,11005.50,3301.65,"CIGNA [10200]",Cigna,,7483.74,68,,,,,0,1279.94,9354.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LASSOSTARNAV,10P,25MM DIA LOOP",SUP-D140403,CDM,C1732,HCPCS,0272,RC,,,both,,,7286.40,2185.92,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,847.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,847.41,6193.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE 10CM 2.5CM 5FR INTRO STAINLESS STEEL",SUP-RSS503,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"PHCS [10601]",PHCS,,54.81,70,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4335,CDM,C1713,HCPCS,0278,RC,,,both,,,3112.50,933.75,"CIGNA [10200]","Cigna Open Access",,1771.01,56.9,,1144.80,304.56,2275.09,66,361.98,2645.63,"percent of total billed charges",
"SUT CHROMIC 3-0 SH 36IN 2 ARM MONOFILAMENT BROWN ABSORBABLE",SUP-G172H,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.78,20.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.88,57.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 45MM MAS SPINE CANNULATED EXT TAB 4.75MM ROD",SUP-54850014545,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross HMO",,2569.56,39.2,,957.42,156.86,7483.26,51,762.35,5571.75,"percent of total billed charges",
"CATH SOFTOUCH 65CM 5FR .044IN .035IN MOTARJEME CURVE",SUP-5572-13,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"PHCS [10601]",PHCS,,72.23,70,,,,,0,12,87.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 80MM 150CM 7MM VASCULAR NICKEL",SUP-EVD35-07-080-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,730.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 4.5MM 75MM EVOS MINI T8 LONG BONE SMALL BONE",SUP-72402775,CDM,C1713,HCPCS,0278,RC,,,both,,,456.52,136.96,"KAISER [10500]",Kaiser,,305.87,67,,,,,0,53.09,388.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 5FR 67CM DEFLECTABLE REMOVABLE NO HANDLE",SUP-G14179,CDM,S27200284,LOCAL,0272,RC,,,both,,,750.06,225.02,"UHC [10700]","United Healthcare",,474.79,63.3,,,,,0,87.23,637.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYPROPYLENE CAPIO TAPERCUT 0 36IN 2 ARM MONOFILAMENT",SUP-M0068331241,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CINCH AND LOCK CATHETER",SUP-4885,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TROCAR LAPAROSCOPIC 100MM 12MM KII Z THREAD NONBLADE SWITCH",SUP-CTR73,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DAILY (INPATIENT) DRIVELINE KIT",SUP-EBSI1564B,CDM,S27200284,LOCAL,0272,RC,,,both,,,112.00,33.6,"AETNA [10100]","Aetna HMO/PPO",,89.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.03,95.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC XL 23.5-26.5IN KNEE WRAP AROUND LONG FLEX",SUP-14012008,CDM,S27000186,LOCAL,0270,RC,,,both,,,737.59,221.28,"CIGNA [10200]","Cigna Open Access",,419.69,56.9,,,,,0,85.78,626.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E FEMUR PATELLA TIBIA INSRT B",SUP-98000800029,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"MULTIPLAN [10600]",Multiplan,,20884.5,85,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 6 5MM KNEE AOX CRUCIATE RETAINING ROTATE PLATF",SUP-151630605,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"KAISER [10500]",Kaiser,,8795.26,67,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X20 40CM SL",SUP-48006002P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"MULTIPLAN [10600]",Multiplan,,834.81,85,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 6MM 2.75MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP27506X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 10CM 5MM BALLOON DILATATION",SUP-DR80510,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 200MM 3.5MM BALLOON DILATATION",SUP-48003520S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 60CM 7FR ENDOCARDIAL TRUE BIPOLAR ACTIVE",SUP-7120/60,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7057.69,41.1,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 90CM 5FR STRAIGHT GUIDING DURAFORM",SUP-M003100640,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,296.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 25MM 5MM 4.4FR AUTOTOME PRO RX 44 CANNULATED",SUP-M00584380,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 40MM 120CM 9MM BILIARY NITINOL OTW",SUP-SERB65-09-40-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1592.7,28.62,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 14.5IN 22FR PHILLIPS 1/56IN HOLLOW PLASTIC 1",SUP-346122,CDM,S27200284,LOCAL,0272,RC,,,both,,,141.81,42.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.49,120.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 60X18X8-15MM RISE-L 6D",SUP-193.326,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"KAISER [10500]",Kaiser,,23004.45,67,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4MM 4MM INTRO BALLWELD END .018IN HELIX",SUP-M0013120221,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL HEMOSTATIC FLOSEAL MATRIX 10ML",SUP-1505291,CDM,S27200284,LOCAL,0272,RC,,,both,,,3367.41,1010.22,"AETNA [10100]","Aetna HMO/PPO",,2677.09,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,391.63,2862.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL CATALYFT SM 6MM ANT EXPANDABLE STERILE",SUP-981023322,CDM,S27800098,LOCAL,0278,RC,,,both,,,49770.00,14931,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13437.9,27,,,,,0,5788.25,42304.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH XP 135CM 5FR RAVI MG2 CURVE ANGIOGRAPHIC",SUP-RF*ZUF511DJM,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 70MM ATLANTIS VISION ELITE BONE SPINAL",SUP-7200070,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"KAISER [10500]",Kaiser,,3545.64,67,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD CURVE .6MM MIDFACE 10 HOLE 1.7MM SCR BONE",SUP-55-06750,CDM,C1713,HCPCS,0278,RC,,,both,,,2007.98,602.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,233.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",233.53,1706.78,"percent of total billed charges",
"GWIRE HI-FLO RENEGADE FATHOM VASCULAR 105CM 20CM .016IN",SUP-M001184510,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"PHCS [10601]",PHCS,,2625,70,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) INTRAVENOUS SYRINGE",RX-123489,CDM,J0330,HCPCS,0636,RC,70004-0908-12,NDC,both,10,ML,263.87,79.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,128.24,48.6,,,,,0,10.49,224.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE RIGHT POSTERIOR STABILIZE GENESIS II",SUP-71421204,CDM,C1776,HCPCS,0278,RC,,,both,,,24507.00,7352.1,"FIRST HEALTH [10303]","First Health",,19605.6,80,,,,,0,2850.16,20830.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 8MM 90MM 22MM DHS/DCS STAINLESS STEEL",SUP-280.9,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"KAISER [10500]",Kaiser,,1218.31,67,,,,,0,211.48,1545.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FUSION TITAN 190CM 4CM 12FR 4MM .035IN BALLOON",SUP-G49219,CDM,C1726,HCPCS,0272,RC,,,both,,,2452.50,735.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1007.98,41.1,,,,,0,285.23,2084.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 60MM 120CM 6MM VASCULAR PERIPHERAL SELF",SUP-PRB35-06-060-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2554.34,45.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 7MM 8D LARGE EIT CERVICAL INTERBODY FUSION",SUP-CUI8070L,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 TF 36IN BRAID MONOFILAMENT BLUE",SUP-D4295,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.68,18.8,"MULTIPLAN [10600]",Multiplan,,53.28,85,,,,,0,7.29,53.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 5.5MM CURVE NONSTERILE",SUP-1555501080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 5 3/8IN .018IN SPRING TUBE POSITIVE PLACEMENT",SUP-RW-04018,CDM,C1769,HCPCS,0272,RC,,,both,,,62.29,18.69,"PHCS [10601]",PHCS,,43.6,70,,,,,0,7.24,52.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT WALLFLEX 90CM 135CM 25-30",SUP-6508,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COAG SUCTION 6IN 10FR LECTROVAC VALLEYLAB CORD HAND",SUP-E2505-10FR,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.90,17.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,38.69,68,,,,,0,6.62,48.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC BALLOON NONBLADE SUPERIOR RETENTION",SUP-CFR73,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,83.86,45.9,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN SCREW SPECIALTY 3.1MMX62MM NAVI",SUP-GS903.062.032-2P,CDM,C1713,HCPCS,0278,RC,,,both,,,605.48,181.64,"CIGNA [10200]","Cigna Open Access",,344.52,56.9,,1144.80,304.56,2275.09,66,70.42,514.66,"percent of total billed charges",
"SIZER IMPL 11CM NATRELLE INSPIRA P4.4CM FULL PROFILE ROUND",SUP-SSZ-F265,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,612.55,41.1,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Western Blot Test",PX-301000383,CDM,84181,CPT,0301,RC,,,both,,,1074.45,322.33,"CIGNA [10200]","Cigna Open Access",,37.47,,,,,,,0.01,913.28,"fee schedule",
"MATRIX TISSUE MEDIUM THICK LARGE ALLOGRAFT PERFORATE",SUP-RL1518P,CDM,Q4116,HCPCS,0636,RC,,,both,,,65390.40,19617.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,42503.76,65,,,,,0,247.92,55581.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM ALLOGRAFT STRIP 55X22MM",SUP-T00247,CDM,S27800098,LOCAL,0278,RC,,,both,,,14161.56,4248.47,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5820.4,41.1,,,,,0,1646.99,12037.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 4CM WITHOUT GWIRE DIL RADIOPAQUE MARKER",SUP-RSB605H,CDM,C1894,HCPCS,0272,RC,,,both,,,217.50,65.25,"AETNA [10100]","Aetna HMO/PPO",,172.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tangntl Bx Skin Single Les",PX-761000059,CDM,11102,CPT,0761,RC,,,both,,,1954.02,586.21,"UHC [10700]","United Healthcare",,1236.89,63.3,,,,,0,227.25,1954.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE GRAFT LITE BIO DELIVERY PKG CANN STERILE",SUP-48288214,CDM,S27200284,LOCAL,0272,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GEMFIBROZIL 600 MG TABLET",RX-3378,CDM,,,0637,RC,60687-0224-11,NDC,both,1,UN,11.65,3.49,"NOVANET [10819]",Novanet,,8.74,75,,,,,0,1.35,9.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 17MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE50017,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,33465.84,40,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CD HORIZON LEGACY TITANIUM PEDICLE",SUP-75446550,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"MULTIPLAN [10600]",Multiplan,,4116.21,85,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 52MM TI",SUP-MTLS-37520-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,1144.80,304.56,2275.09,66,155.43,1136.03,"percent of total billed charges",
"GRAFT BONE CANCELLOUS 30CC CRUSH FROZEN 1-10MM",SUP-800108,CDM,S27800098,LOCAL,0278,RC,,,both,,,2777.25,833.17,"CIGNA [10200]","Cigna Local Plus",,1485.83,53.5,,,,,0,322.99,2360.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION DEB 2.00X40",SUP-SCA14U-200040D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 20MM 7FR 14MM .035IN LOW PROFILE BALLOON",SUP-B1140-020,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"NOVANET [10819]",Novanet,,577.13,75,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHORD-X 2-0 .5 CIRCLE 18MM 2 ARM LOOP PLEDG 3 CHORDAL 20",SUP-CXL-20-1812-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 40MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015040M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"KAISER [10500]",Kaiser,,960.58,67,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 24MM MITRAL SEMIRIGID MEMO 3D",SUP-SMD24,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3653.34,28.62,,,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch W Excsn Tumor",PX-750000017,CDM,31640,CPT,0750,RC,,,both,,,5006.00,1501.8,"BLUE CROSS [10001]","Blue Cross HMO",,4025.22,,"Case rate ($4,025.22). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,582.2,5006,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aep Scr Auditory Potential",PX-471000012,CDM,92650,CPT,0471,RC,,,both,,,426.36,127.91,"FIRST HEALTH [10303]","First Health",,341.09,80,,,,,0,49.59,362.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alpha1 Antitrypsin",PX-301000095,CDM,82103,CPT,0301,RC,,,both,,,247.00,74.1,"FIRST HEALTH [10303]","First Health",,197.6,80,,,,,0,0.25,209.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 7.5MM SURGICAL CREO BEACON NONSTERILE REUSABLE",SUP-655.217,CDM,S27000186,LOCAL,0270,RC,,,both,,,534.60,160.38,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC10ST-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,19530.00,5859,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"FRCP BIPOLAR 6MM ENDOWRIST SP NONSTERILE LATEX FREE REUSABLE",SUP-431150,CDM,S27000186,LOCAL,0270,RC,,,both,,,3228.75,968.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ENALAPRIL MALEATE 5 MG TABLET",RX-9927,CDM,,,0637,RC,43547-0546-10,NDC,both,1,UN,9.31,2.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT GORE-TEX CV-3 TH-35 36IN 2 ARM MONOFILAMENT WHITE",SUP-3N06A,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.85,83.95,"FIRST HEALTH [10303]","First Health",,223.88,80,,,,,0,32.55,237.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO PERCUTANEOUS 7.5-8 FR CATH LATEX FREE",SUP-CDC-29903-X1A,CDM,C1894,HCPCS,0272,RC,,,both,,,1051.38,315.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,124.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,122.28,893.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID MEDIUM 4MM BASE MODULAR COMPREHENSIVE HYBRID",SUP-113954,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"NOVANET [10819]",Novanet,,6873.3,75,,,,,0,1065.77,7789.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP 55.9CM 8MM DA VINCI S/SI ENDOWRIST 45- D LARGE",SUP-420230,CDM,S27000186,LOCAL,0270,RC,,,both,,,700.41,210.12,"NOVANET [10819]",Novanet,,525.31,75,,,,,0,81.46,595.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CAP AEQ RVS FX (INC RVS FX STM,RVS FX INSERT,RVS I OR II",SUP-CAP10102,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"MULTIPLAN [10600]",Multiplan,,38556,85,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PICO 7 20X10CM NEGATIVE PRESSURE STERILE LATEX FREE",SUP-66022002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1995.00,598.5,"CIGNA [10200]",Cigna,,1356.6,68,,,,,0,232.02,1695.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE DEMINERALIZED BONE MATRIX 10X1CM",SUP-7509111,CDM,S27800098,LOCAL,0278,RC,,,both,,,7728.00,2318.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5255.04,68,,,,,0,898.77,6568.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ENDOSCOPIC 6.5MM 90MM DRI-LOK DISTAL THREAD STERILE",SUP-3910090800,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,79.87,45.9,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Jo-1 Igg Muscle Ab",PX-302000041,CDM,86235,CPT,0302,RC,,,both,,,424.00,127.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,19.19,,"Fee schedule rate ($19.19). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.42,360.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 36MM LCP STAINLESS STEEL FOREFOOT MIDFOOT T8",SUP-02.211.036,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"FIRST HEALTH [10303]","First Health",,718.5,80,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR ORTHOPEDIC 90D ROTATION SUTURELASSO DISPOSABLE STERILE",SUP-AR-6065-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"KAISER [10500]",Kaiser,,997.21,67,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM",SUP-8847060,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1262.14,28.62,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 0 .5 CIRCLE 4 DIAMOND SUTURETAK FIBERWIRE SMALL",SUP-AR-8934BCNF-00,CDM,C1713,HCPCS,0278,RC,,,both,,,2559.38,767.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,303.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,297.66,2175.47,"percent of total billed charges",
"CUFF TRNQT 24IN 2 PORT 1 BLADDER WITHOUT SLEEVE ATS STERILE",SUP-60707010400,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,50.29,68,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 RIGHT MEDIAL LEFT LATERAL PARTIAL KNEE",SUP-5610-F-202,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"BLUE CROSS [10001]","Blue Cross HMO",,3920.82,39.2,,5311.50,4717.44,5388.59,31,1163.24,8501.79,"percent of total billed charges",
"SCR BONE 3.5MM 14MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3514,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"FIRST HEALTH [10303]","First Health",,1198.8,80,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 22CM 8FR NEPHROURETERAL FLEXITHANE",SUP-H7493935108220,CDM,C2617,HCPCS,0278,RC,,,both,,,1069.20,320.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,727.06,68,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCHON SCREW, 4.0X14MM SELF-DRILL VAR",SUP-8780214,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,647.19,45.9,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL ATTUNE STERILE 5 KNEE RIGHT CEMENTED POSTERIOR",SUP-150410205,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"AETNA [10100]","Aetna HMO/PPO",,17802.71,79.5,,10981.53,8986.79,12413.38,12,2604.35,19034.35,"percent of total billed charges",
"CATH TOTAL ABSCESSION BLUE SILK 40CM 12FR PIGTAIL CURVE DRNG",SUP-H787140009035,CDM,C1729,HCPCS,0272,RC,,,both,,,987.88,296.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,671.76,68,,,,,0,114.89,839.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.235,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 33MM 3.25MM CORONARY STENT EVEROLIMUS",SUP-1550325-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"DEVICE CARDIVA CATALYST II 5-7FR CLSR PROTAMINE SULFATE",SUP-500-580C-10U,CDM,C1760,HCPCS,0278,RC,,,both,,,1539.00,461.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,440.46,28.62,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CPR VIPER FIXATION",SUP-AR-8692DS,CDM,C1713,HCPCS,0278,RC,,,both,,,7933.28,2379.98,"NOVANET [10819]",Novanet,,5949.96,75,,,,,0,922.64,6743.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X12MM 10D XL PEEK-OPTIMA PLATE FUSION",SUP-7871250,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"UHC [10700]","United Healthcare",,21696.45,63.3,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 10D X3 TRIDENT",SUP-623-10-36H,CDM,C1776,HCPCS,0278,RC,,,both,,,6879.60,2063.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1968.94,28.62,,,,,0,800.1,5847.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 90CM 135CM 25-30MM 10FR COLONIC NITINOL",SUP-M00565080,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREONPANOPTIX PROTORIC (UVA)",SUP-PXCWT3,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"FIRST HEALTH [10303]","First Health",,732,80,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAVVY 150CM 4CM 3.5-3FR 2.5MM BALLOON DILATATION",SUP-435254X,CDM,C1725,HCPCS,0272,RC,,,both,,,2137.50,641.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,878.51,41.1,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 20FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0166SI20,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.21,20.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Selenium",PX-301000393,CDM,84255,CPT,0301,RC,,,both,,,262.60,78.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,90.63,,,,,,,0.26,223.21,"fee schedule",
"BLADE SAW 25X9MM COMMAND II SAGITTAL STERILE",SUP-KM3.111,CDM,S27200284,LOCAL,0272,RC,,,both,,,380.63,114.19,"CIGNA [10200]",Cigna,,258.83,68,,,,,0,44.27,323.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 32MM 144CM 3MM CORONARY STENT",SUP-H7493952832300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross PPO",,2181.48,39.2,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER GD 6FR .07IN RWY AL 1 CRV",SUP-H74938969680,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,249.18,68,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TYMPANOSTOMY BLUE 1.14MM ARMSTRONG 2 SILICONE BEVEL",SUP-240050,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.77,38.03,"NOVANET [10819]",Novanet,,95.08,75,,,,,0,14.74,107.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT MICRO NONSTERILE DISPOSABLE",SUP-AR-1320BCNF,CDM,C1713,HCPCS,0278,RC,,,both,,,2559.38,767.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,297.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",297.66,2175.47,"percent of total billed charges",
"(COMM) CATH GUIDELINER 150CM 25CM 8FR .088IN .071IN INTERVEN",SUP-5573,CDM,C1887,HCPCS,0272,RC,,,both,,,2872.50,861.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1953.3,68,,,,,0,334.07,2441.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 40.5CM TIBIAL NAIL-EX INTRAMEDULLARY CANNULATED",SUP-04.004.361S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,985.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",966.74,7065.57,"percent of total billed charges",
"ASCOPE 4 BRONCHO REGULAR SAMPLER SET",SUP-477501000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2010.00,603,"AETNA [10100]","Aetna HMO/PPO",,1597.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,233.76,1708.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RELIEVA SOLO PRO 16MM 5MM BALLOON DILATATION SINUS",SUP-BC0516SP,CDM,C1726,HCPCS,0272,RC,,,both,,,4719.60,1415.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3209.33,68,,,,,0,548.89,4011.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 15MM 3.5MM BALLOON DILATATION STERILE",SUP-235-153-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000050,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X7MM CONVEX SPINE CORTICOCANCELLOUS",SUP-17507,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablation Renal Tumors Uni Rf",PX-361000226,CDM,50592,CPT,0361,RC,,,both,,,14501.12,4350.34,"FIRST HEALTH [10303]","First Health",,11600.9,80,,,,,0,1686.48,12325.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG BODY SHROUD",SUP-SP3160,CDM,S27000186,LOCAL,0270,RC,,,both,,,168.22,50.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,114.39,68,,,,,0,19.56,142.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5CMX12MM FLAT ROUND TIP OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-6-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"AETNA [10100]","Aetna HMO/PPO",,1159.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 58MM 135CM 7MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU1350758,CDM,C1874,HCPCS,0278,RC,,,both,,,15870.00,4761,"PHCS [10601]",PHCS,,11109,70,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 63MM STAINLESS STEEL 2.4MM SCR 6X4 HOLES 2",SUP-02.111.540,CDM,C1713,HCPCS,0278,RC,,,both,,,4041.68,1212.5,"MULTIPLAN [10600]",Multiplan,,3435.43,85,,,,,0,470.05,3435.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 135CM 7MM 30MM",SUP-38047-73013,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]",Cigna,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENCORE 26 12FR INFLATION 20ML PRESSURE GAUGE",SUP-M001151062,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"KAISER [10500]",Kaiser,,279.79,67,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOKE FLTR SYS SWVL M LL CONN 18IN TUBE W BACT-VIR-SMK FLTR",SUP-301-S400,CDM,S27000186,LOCAL,0270,RC,,,both,,,227.64,68.29,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,93.56,41.1,,,,,0,26.47,193.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC",521,MS-DRG,,,,,,,inpatient,,,110850.82,33255.25,"BLUE CROSS [10001]","Blue Cross PPO",,70856.77,,,,,,,7561,83798.36,"case rate",
"GRAFT SOFT TISSUE 6CM FOR SURGICAL WOUND BIOABSORBABLE",SUP-50205N18D0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,19252.80,5775.84,"CIGNA [10200]",Cigna,,180.89,,,,,,,180.89,16364.88,"fee schedule",
"CATH OPN NC 20MM 4MM 35 ATM BALLOON DILATATION THIN WALL LOW",SUP-400-020-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMPULSE 100CM 5FR FR3.5 CURVE ANGIOGRAPHIC FEMORAL 2",SUP-H74916391012,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION VENOUS RETURN 1 PIECE 3 STAGE TUBING CNCT",SUP-RTS-13029,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STPLR 60X2.5MM DST SERIES GIA TITANIUM VASCULAR",SUP-GIA6025L,CDM,S27200284,LOCAL,0272,RC,,,both,,,383.41,115.02,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSTR BIOPSY 20CM 18GA BARD MONOPTY ANGLE 22MM ERGONOMIC",SUP-121820,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.02,64.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT STIMULATOR PROXIMATE GENITOURINARY HANDSET NONSTERILE LA",SUP-TH90Q01,CDM,C1787,HCPCS,0270,RC,,,both,,,12420.00,3726,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 4X3CM MATRION PLACENTAL MEMB TROPHOBLAST",SUP-PAC12,CDM,Q4201,HCPCS,0636,RC,,,both,,,5451.00,1635.3,"PHCS [10601]",PHCS,,3815.7,70,,,,,0,204.57,4633.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 BIOKNOTLESS PLUS ORTHOCORD ROTATOR CUFF",SUP-212722,CDM,C1713,HCPCS,0278,RC,,,both,,,5664.90,1699.47,"AETNA [10100]","Aetna HMO/PPO",,4503.6,79.5,,1521.93,481.35,16760.95,30,658.83,4815.17,"percent of total billed charges",
"SCR BONE 32MM 2MM LCP CORTICAL STAINLESS STEEL SELF TAPPING",SUP-201.378.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,281.6,68,,,,,0,48.16,352,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 5-0 P-3 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J493H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 17GA 11.1CM TRU-CORE II LIGHTWEIGHT AUTOMATIC",SUP-MCXS1816TX,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.64,44.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.4,127.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 30MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45030,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA [10200]",Cigna,,33209.89,40,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AZITHROMYCIN 600 MG TABLET",RX-17387,CDM,,,0637,RC,69452-0173-13,NDC,both,1,UN,70.62,21.19,"FIRST HEALTH [10303]","First Health",,56.5,80,,,,,0,8.21,60.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 42MM STAINLESS STEEL 2.4MM SCR 6 HEAD 2 SHAFT HOLES 2",SUP-02.111.521,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"NOVANET [10819]",Novanet,,2805,75,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 STD KNEE RIGHT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB4SR,CDM,C1776,HCPCS,0278,RC,,,both,,,17652.60,5295.78,"NOVANET [10819]",Novanet,,13239.45,75,,,,,0,2053,15004.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 15MM 3.25MM BALLOON DILATATION STERILE",SUP-232-153-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETENE 15X15CM POLYPROPYLENE MACROPOROUS",SUP-PPM1515,CDM,C1781,HCPCS,0278,RC,,,both,,,635.20,190.56,"BLUE CROSS [10001]","Blue Cross PPO",,249,39.2,,,,,0,73.87,539.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3.5MM 12/14 TAPER 26MM HIP COCR VERSYS STERILE",SUP-801802603,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"KAISER [10500]",Kaiser,,3249.97,67,,,,,0,564.14,4123.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM ATS SPINE MULTIAXIAL 4.75MM ROD",SUP-54840046545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Local Plus",,5107.56,53.5,,3978.14,359.25,3978.14,24,1110.3,8114.82,"percent of total billed charges",
"AVENIR 18 9 X 30 COMPLEX FRAMING COIL",SUP-18CFR-09030,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"MULTIPLAN [10600]",Multiplan,,11114.18,85,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 58MM 40MM ALTRX LD HIP",SUP-122140158,CDM,C1776,HCPCS,0278,RC,,,both,,,8094.24,2428.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5504.08,68,,,,,0,941.36,6880.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 10X4IN ADHSV ANTIMICROBIAL BARR PAD POSTOPERATIVE IONIC",SUP-MSC97410,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.65,58.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.75,166.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 450CC SMOOTH SHELL SURFACE NATRELLE INSPIRA FULL",SUP-SRF-450,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"KAISER [10500]",Kaiser,,3675.29,67,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO-14 VASCULAR 200CM 45CM .014IN NITINOL",SUP-M00313020,CDM,C1769,HCPCS,0272,RC,,,both,,,4568.90,1370.67,"PHCS [10601]",PHCS,,3198.23,70,,,,,0,531.36,3883.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECTRUM GV BONE CEMENT",SUP-SPECTRUM40,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC New Eval Visit Level 5",PX-510000175,CDM,99205,CPT,0761,RC,,,both,,,553.58,166.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.58,,"Per diem ($1,793).",,,,0,0.55,553.58,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 14X26X55MM",SUP-6214055,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"PHCS [10601]",PHCS,,16758,70,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL 29X26X40MM MBT KNEE METAPHYSEAL POROUS",SUP-129454000,CDM,C1776,HCPCS,0278,RC,,,both,,,15133.08,4539.92,"KAISER [10500]",Kaiser,,10139.16,67,,,,,0,1759.98,12863.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 15MM 44MM SHOULDER SOFT TISSUE BALANCE",SUP-7122880,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5385.6,68,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REINFORCEMENT STAPLE LINE BIOABSORBABLE STERILE SEAMGUARD",SUP-12BSGTRI45P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1242.00,372.6,"NOVANET [10819]",Novanet,,931.5,75,,,,,0,144.44,1055.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LPT ANGLED GREAT TOE SIZE 2",SUP-487A002,CDM,C1776,HCPCS,0278,RC,,,both,,,11585.10,3475.53,"MULTIPLAN [10600]",Multiplan,,9847.34,85,,,,,0,1347.35,9847.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 50CM 11CM GWIRE KINK RESISTANT FLEXIBLE",SUP-PSI-5F-11-038ACT,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-55840015545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6491.86,68,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALPRAZOLAM 1 MG TABLET, IMMEDIATE RELEASE",RX-326,CDM,,,0637,RC,00781-1079-01,NDC,both,1,UN,12.54,3.76,"UHC [10700]","United Healthcare",,7.94,63.3,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 340MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED",SUP-04.037.254S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CIGNA [10200]","Cigna Open Access",,4160.14,33.5,,1144.80,304.56,2275.09,66,1444.25,10555.59,"percent of total billed charges",
"SET .195IN 81IN SET Y GRAVITY FLOW ROLLER CLAMP CYSTOSCOPIC",SUP-2C4041,CDM,S27200284,LOCAL,0272,RC,,,both,,,151.31,45.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.6,128.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 33MM BOVINE PERICARDIUM LEAFLET COBALT CHROMIUM",SUP-11400M33,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"FIRST HEALTH [10303]","First Health",,36288,80,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIALIZE 2X12 CM",SUP-VL-0212,CDM,S27800098,LOCAL,0278,RC,,,both,,,11040.00,3312,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1308.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1283.95,9384,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR PULSE WAVEWRITER ALPHA 32",SUP-SC-1232,CDM,C1820,HCPCS,0278,RC,,,both,,,99750.00,29925,"KAISER [10500]",Kaiser,,66832.5,67,,,,,0,11600.93,84787.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 10 127D",SUP-6721-1040,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6469.75,27,,,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL IHF 1.4MM",SUP-DRLL-IHF-14,CDM,S27000186,LOCAL,0270,RC,,,both,,,996.30,298.89,"FIRST HEALTH [10303]","First Health",,797.04,80,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT ACETABULAR SIZE E DIA36MM 10DEG CLUSTERHOLE HYDROXYAP",SUP-723-10-36E,CDM,C1776,HCPCS,0278,RC,,,both,,,9332.25,2799.67,"MULTIPLAN [10600]",Multiplan,,7932.41,85,,,,,0,1085.34,7932.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12CM NATRELLE INSPIRA P4.9CM FULL PROFILE ROUND",SUP-MSZ-F365,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"MULTIPLAN [10600]",Multiplan,,134.45,85,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 120MM 120CM 4.5MM 6FR VASCULAR NITINOL",SUP-S-45-120-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"FIRST HEALTH [10303]","First Health",,7314,80,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION",RX-32700,CDM,J0585,HCPCS,0636,RC,00023-1145-01,NDC,both,1,UN,3929.44,1178.83,"PHCS [10601]",PHCS,,2750.61,70,,,,,0,654.82,3340.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 15MM 140CM 2.75MM CORONARY STENT",SUP-LUN275R15US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 60MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939186250610,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 3CM 7FR BILIARY POLYETHYLENE TAPERED TIP",SUP-G21679,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TEMPO TEMPORARY PACING LEAD",SUP-T1106,CDM,S27200284,LOCAL,0272,RC,,,both,,,3112.50,933.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,368.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP 32.77CM 8MM DA VINCI XI ENDOWRIST 33D MEDIUM LARGE",SUP-470327,CDM,S27000186,LOCAL,0270,RC,,,both,,,500.29,150.09,"KAISER [10500]",Kaiser,,335.19,67,,,,,0,58.18,425.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 5MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS05020,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Open Access",,3927.24,33.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 8MM .8MM GOLDENBERG TORP EAR HEAD PLASTIPORE",SUP-14-0917,CDM,C1713,HCPCS,0278,RC,,,both,,,2968.65,890.59,"NOVANET [10819]",Novanet,,2226.49,75,,,,,0,345.25,2523.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOXYCYCLINE MONOHYDRATE 100 MG TABLET",RX-21818,CDM,,,0637,RC,60687-0344-95,NDC,both,1,UN,13.28,3.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6.1,45.9,,,,,0,1.54,11.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X22X10MM COROENT XL WIDE 100",SUP-6921060,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2815.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM GORILLA NONSTERILE R3CON NON LOCK PLATE",SUP-P50-453-3512,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Open Access",,553.07,56.9,,1144.80,304.56,2275.09,66,113.04,826.2,"percent of total billed charges",
"HEAD FEMORAL +3.5MM 12/14 LARGE 28MM HIP ACETABULAR BIOLOX",SUP-00-8775-028-03,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"CIGNA [10200]","Cigna Open Access",,5609.61,56.9,,5302.19,4377.88,6578.61,27,1146.57,8379.91,"percent of total billed charges",
"CATH NAVISTAR THERMOCOOL 115CM 3.5MM 7.5FR 2-5-2MM SPACE J",SUP-NI75TCJH,CDM,C1732,HCPCS,0272,RC,,,both,,,16256.40,4876.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11054.35,68,,,,,0,1890.62,13817.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 80CM 5MM 8MM 7FR .035IN",SUP-BXA052901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]","Cigna Local Plus",,6144.01,31.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RX 60MM 194CM 10MM 8FR .035IN BILIARY METAL",SUP-M00569710,CDM,S27500001,LOCAL,0275,RC,,,both,,,11537.01,3461.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4741.71,41.1,,,,,0,1341.75,9806.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 8MM 140CM 2.5MM CORONARY STENT PLATINUM",SUP-H7493927408250,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]",Cigna,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM MITRAL 3D REDUCED CURVATURE SEWING","SUP-4100 M34",CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross PPO",,6762,39.2,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CARTO XP LASSO 115CM 7FR 25MM 6MM SPACING D CURVE",SUP-DLN2225CT,CDM,C1732,HCPCS,0272,RC,,,both,,,12889.20,3866.76,"KAISER [10500]",Kaiser,,8635.76,67,,,,,0,1499.01,10955.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE EYE 22MM STERILE POROUS MEDPOR OMNI DIRECTIONAL PORE",SUP-6322,CDM,S27800098,LOCAL,0278,RC,,,both,,,5016.30,1504.89,"CIGNA [10200]","Cigna Local Plus",,2683.72,53.5,,,,,0,583.4,4263.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NAVITOR LARGE LOADING STENT GUIDE LEAFLET LOADING",SUP-NVTR-LS-LG,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +10MM 36MM HIP MODULAR PCA",SUP-6280-0-336,CDM,C1776,HCPCS,0278,RC,,,both,,,7414.05,2224.21,"CIGNA [10200]","Cigna Open Access",,4218.59,56.9,,5302.19,4377.88,6578.61,27,862.25,6301.94,"percent of total billed charges",
"ZINC OXIDE 20 % TOPICAL OINTMENT",RX-8874,CDM,,,0250,RC,75834-0170-01,NDC,both,28.4,GR,41.27,12.38,"AETNA [10100]","Aetna HMO/PPO",,32.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.8,35.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE CAST PEDIATRIC CANVAS RUBBER ROCKER SOLE HOOK LOOP CLSR",SUP-2035-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.41,13.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.28,38.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY",RX-16071,CDM,,,0250,RC,60505-0827-01,NDC,both,15,ML,602.05,180.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,247.44,41.1,,,,,0,70.02,511.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER SMOKE EVAC VIROSAFE .1UM 4 STAGE INLINE ULPA MULTIUSE",SUP-BILF150,CDM,S27000186,LOCAL,0270,RC,,,both,,,132.21,39.66,"CIGNA [10200]","Cigna Open Access",,75.23,56.9,,,,,0,15.38,112.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR30,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3752.08,28.62,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 45MM T2 TITANIUM FULL THREAD FEMUR HUMERUS",SUP-1896-4045S,CDM,C1713,HCPCS,0278,RC,,,both,,,1299.56,389.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,154,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",151.14,1104.63,"percent of total billed charges",
"SYSTEM  RESOLUTE ONYX OTW CORONARY   2.00 X 26MM",SUP-RONYX20026W,CDM,C1874,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]",Cigna,,2422.5,68,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 13MM THK.64MM 50MM MICRO OFFSET SAGITTAL STERILE",SUP-2296-003-108S5,CDM,S27200284,LOCAL,0272,RC,,,both,,,659.10,197.73,"CIGNA [10200]","Cigna Local Plus",,352.62,53.5,,,,,0,76.65,560.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE CAST PEDIATRIC CANVAS RUBBER ROCKER SOLE HOOK LOOP CLSR",SUP-2035-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.41,13.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18.66,41.1,,,,,0,5.28,38.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 85MM TITANIUM SELF TAP LOCK NONSTERILE AXSOS 3",SUP-661185,CDM,C1713,HCPCS,0278,RC,,,both,,,1377.32,413.2,"NOVANET [10819]",Novanet,,1032.99,75,,,,,0,160.18,1170.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW STD 57.2X21.6MM TITANIUM 4 HOLE LOW PROFILE FIX",SUP-DVRANL,CDM,C1713,HCPCS,0278,RC,,,both,,,7607.25,2282.17,"FIRST HEALTH [10303]","First Health",,6085.8,80,,,,,0,884.72,6466.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Occipital Bi",PX-510000116,CDM,64405,CPT,0761,RC,,,both,,,3761.00,1128.3,"KAISER [10500]",Kaiser,,2519.87,67,,,,,0,437.4,3196.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.2MM GUIDE",SUP-500373,CDM,C1713,HCPCS,0278,RC,,,both,,,607.50,182.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,173.87,28.62,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 13FR 24CM TRIALYSIS DIALYSIS STERILE SHORT TERM",SUP-5605240,CDM,C1752,HCPCS,0272,RC,,,both,,,1614.33,484.3,"CIGNA [10200]","Cigna Local Plus",,863.67,53.5,,,,,0,187.75,1372.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 475CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP130RH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4761,40,,,,,0,1384.26,10117.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT MONOLITHIC 14MM PLIF",SUP-3W3114,CDM,S27800098,LOCAL,0278,RC,,,both,,,12487.62,3746.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3573.96,28.62,,,,,0,1452.31,10614.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNOT PUSHER",SUP-MI-KP-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2231.25,669.37,"FIRST HEALTH [10303]","First Health",,1785,80,,,,,0,259.49,1896.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POUCH SURGICAL TISSUE 8X5IN LAPSAC NYLON POLYPROPYLENE",SUP-G15656,CDM,S27200284,LOCAL,0272,RC,,,both,,,512.24,153.67,"AETNA [10100]","Aetna HMO/PPO",,407.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.57,435.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR RINGLOC 25 +3MM 40MM ARCOMXL HIP STERILE",SUP-XL-108525,CDM,C1776,HCPCS,0278,RC,,,both,,,7249.14,2174.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,859.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,843.07,6161.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYOSURE TISSUE REMOVAL MANUAL",SUP-20-403ML,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATH 9.5FR .036IN 5CM CENTRAL VENOUS POWERHICKMAN",SUP-805915,CDM,C1751,HCPCS,0272,RC,,,both,,,2685.00,805.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 3.5MM SURGICAL STERILE DISPOSABLE",SUP-703704,CDM,S27200284,LOCAL,0272,RC,,,both,,,993.38,298.01,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WEBSTER 115CM 6FR 5MM SPACE ELECTROPHYSIOLOGY FIX 4",SUP-F6QD005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 13.3-13.1CM NATRELLE P5.8-6.4CM HIGH PROFILE",SUP-SZHP68550,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT POLARIS ULTRA NAUTILUS 20CM 6FR 2 PIGTAIL CURVE",SUP-M0061921300,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"CIGNA [10200]","Cigna Local Plus",,607.56,,,,,,,132.07,965.28,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 35CM 4MM ARTEGRAFT BOVINE CAROTID",SUP-AG535,CDM,C1768,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Up Ext Fx Orthos Humeral Nos",PX-E27400038,CDM,L3980,HCPCS,0274,RC,,,both,,,699.60,209.88,"NOVANET [10819]",Novanet,,524.7,75,,,,,0,81.36,594.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +13.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.135,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION HOFFMANN 3 5 HOLE PIN",SUP-4922-2-020,CDM,S27200284,LOCAL,0272,RC,,,both,,,5390.69,1617.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3665.67,68,,,,,0,626.94,4582.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 THK17MM FIXED ULTRACONGRUENT PRIMARY GMK",SUP-02.07.0317FUC,CDM,C1776,HCPCS,0278,RC,,,both,,,4271.40,1281.42,"BLUE CROSS [10001]","Blue Cross PPO",,1674.39,39.2,,3949.44,3949.44,3949.44,"1 through 10",496.76,3630.69,"percent of total billed charges",
"LINER ACETABULAR R3 0D 62MM 36MM XLPE HIP STERILE",SUP-71332762,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1318.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1293.98,9457.31,"percent of total billed charges",
"HC US Infant Hips Static",PX-402000035,CDM,76886,CPT,0402,RC,,,both,,,741.24,222.37,"CIGNA [10200]","Cigna Local Plus",,154.88,,,,,,,86.21,630.05,"fee schedule",
"STENT VISI-PRO 17MM 135CM 8MM 20MM BILIARY STAINLESS STEEL",SUP-PXB35-08-17-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,517.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRACKER NAVIGATION FUSION ENT INSTR",SUP-9733533XOM,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 15MM 2.75MM BALLOON DILATATION RAPID EXCHANGE",SUP-DC-RZ2715UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,117.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 50MM TITANIUM SPINE CORTICAL POLYAXIAL FIX",SUP-186727750,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUE FLOW 110CM 3.5CM 20MM 11FR PERFUSION VALVULOPLASTY",SUP-TF0203511,CDM,C1725,HCPCS,0272,RC,,,both,,,11730.00,3519,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4821.03,41.1,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HETASTARCH 6 % IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION",RX-25174,CDM,,,0250,RC,00409-7248-13,NDC,both,500,ML,382.28,114.68,"NOVANET [10819]",Novanet,,286.71,75,,,,,0,44.46,324.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 10MM 2.25MM BALLOON DILATATION STERILE",SUP-222-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 9MM 140CM 3MM CORONARY",SUP-RSINT30009UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"NOVANET [10819]",Novanet,,4158,75,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 110CM 6CM 5FR 5MM .035IN LOW PROFILE TAPER",SUP-4195060X,CDM,C1725,HCPCS,0272,RC,,,both,,,1052.92,315.88,"PHCS [10601]",PHCS,,737.04,70,,,,,0,122.45,894.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXCISOR BIOPSY .472X.354IN FISCHER 74D 12MM SMALL CONE",SUP-900-150,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.28,60.98,"CIGNA [10200]","Cigna Local Plus",,108.75,53.5,,,,,0,23.64,172.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION",RX-121811,CDM,J3475,HCPCS,0636,RC,63323-0106-15,NDC,both,500,ML,100.65,30.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,43.32,,,,,,,2.39,85.55,"fee schedule",
"PLATE UNIVERSAL 42X6.5X1.3MM 5TH METATARSAL FRACTURE 3 HOLE",SUP-52020400,CDM,C1713,HCPCS,0278,RC,,,both,,,7700.40,2310.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,895.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",895.56,6545.34,"percent of total billed charges",
"STENT ZILVER 635 FLEXOR 30MM 80CM 12MM 6FR BILIARY NITINOL",SUP-G36228,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,439.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY ARROW ONCONTROL BONE LESION",SUP-9462-VC-006,CDM,C1830,HCPCS,0272,RC,,,both,,,3237.50,971.25,"AETNA [10100]","Aetna HMO/PPO",,2573.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,376.52,2751.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE REVERSE HYBRID WITH CEMENTED PATELLA CONC",SUP-71704620,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"KAISER [10500]",Kaiser,,15617.7,67,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BIOLOGICAL 2.22X2IN PURACOL PLUS SQUARE SILVER CLLGN",SUP-MSC8722EP,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.94,19.18,"MULTIPLAN [10600]",Multiplan,,54.35,85,,,,,0,7.44,54.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONTROL WIRE V-14 0.014 X 300CM",SUP-H74939216730010,CDM,C1769,HCPCS,0272,RC,,,both,,,2295.00,688.5,"PHCS [10601]",PHCS,,1606.5,70,,,,,0,266.91,1950.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 92CM 4MM 6FR 2-5-2MM SPACE D CURVE",SUP-D6DL252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,5326.80,1598.04,"KAISER [10500]",Kaiser,,3568.96,67,,,,,0,619.51,4527.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOCKPULSE LITHOTRIPSY PROBE STERIL",SUP-SPL-PDBX340,CDM,S27200284,LOCAL,0272,RC,,,both,,,4583.67,1375.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1883.89,41.1,,,,,0,533.08,3896.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 12MM ATTUNE 5 KNEE DISTAL CEMENT REVISION",SUP-154705003,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,706.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 6FR .07IN GUIDING",SUP-H749389696490,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 50MM 28MM XLPE HIP",SUP-71334950,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"KAISER [10500]",Kaiser,,7468.46,67,,,,,0,1296.39,9474.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK 30MM 9MM ARTHREX",SUP-AR-4030P-09,CDM,C1713,HCPCS,0278,RC,,,both,,,2323.13,696.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,664.88,28.62,,,,,0,270.18,1974.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 PS-2 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J497H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 230MM STAINLESS STEEL 4.5MM SCR 10 HOLE 4 COLUMN",SUP-02.124.411S,CDM,C1713,HCPCS,0278,RC,,,both,,,13765.64,4129.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1631.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1600.94,11700.79,"percent of total billed charges",
"HC Drsg Foam Nonadhesive Rl 4x24",PX-E27200126,CDM,E27200126,LOCAL,0272,RC,,,both,,,144.10,43.23,"NOVANET [10819]",Novanet,,108.08,75,,,,,0,16.76,122.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOCKPULSE LITHOTRIPSY PROBE STERIL",SUP-SPL-PDBX340,CDM,S27200284,LOCAL,0272,RC,,,both,,,4583.67,1375.1,"UHC [10700]","United Healthcare",,2901.46,63.3,,,,,0,533.08,3896.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 12.5MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158106112,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3017.13,27,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 40CM 5FR BERENSTEIN CURVE URETERAL STAINLESS",SUP-M0064005031,CDM,C1758,HCPCS,0272,RC,,,both,,,153.35,46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.83,130.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LABETALOL 200 MG TABLET",RX-10374,CDM,,,0637,RC,00904-7452-61,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]",Cigna,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 125CM 6FR MP1 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H74938969380,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"NOVANET [10819]",Novanet,,274.83,75,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 52MM 28MM XLPE HIP",SUP-71337552,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3190.26,28.62,,,,,0,1296.39,9474.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARRX 135CM 15.7X7.5MM",SUP-TTS-1100,CDM,C1886,HCPCS,0272,RC,,,both,,,14959.20,4487.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1772.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1739.75,12715.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 18FR TUNGSTEN SILICONE 3.5CM MIC-KEY",SUP-8270-18-3.5-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE SURGICAL VASCUCHEK",SUP-VC-SP-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VIATRAC 14 PLUS 135CM 15MM 3.3-3.6FR 5.5MM BALLOON",SUP-1008195-15,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC US Fetal Doplr Velocimerty",PX-402000063,CDM,76821,CPT,0402,RC,,,both,,,349.26,104.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure count. Procedure 1, Fee schedule rate ($125.75). Procedures 2 - 999, Fee schedule rate ($62.88).",,,,0,,,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z2 100CM 6FR MP1 CURVE GUIDING PERIPHERAL STERILE LATEX",SUP-Z26MP1,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"FIRST HEALTH [10303]","First Health",,292.32,80,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DELIVERY CABLE TUBE SPIKE ADPTR ELECTROTHERAPY REZUM 50",SUP-M006D2201-003,CDM,S27200284,LOCAL,0272,RC,,,both,,,18900.00,5670,"UHC [10700]","United Healthcare",,11963.7,63.3,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 8X.25IN RIBBON 2 END MALLEABLE STAINLESS STEEL SPINE",SUP-22-0006,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.21,22.26,"CIGNA [10200]","Cigna Open Access",,42.23,56.9,,,,,0,8.63,63.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 12MM SKYLINE TITANIUM 5- D OVERSIZE LARGE",SUP-186864012,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48.3MM 4MM MEDIUM CARBIDE ROUND STERILE",SUP-5300010511,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.08,49.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.32,141.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW MARK SPRING TIP",SUP-CG-06-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"UHC [10700]","United Healthcare",,333.27,63.3,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 100CM 1MM 4FR 5MM SPACE STD F CURVE ELECTROPHYSIOLOGY",SUP-F4QF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"UHC [10700]","United Healthcare",,574.26,63.3,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 14MM T8 FULL THREAD LOCK STARDRIVE NONSTERILE",SUP-656014,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"CIGNA [10200]",Cigna,,907.94,68,,1831.33,1831.33,1831.33,16,155.28,1134.92,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 33MM 145CM 3.25MM CORONARY STENT",SUP-1145325-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"KAISER [10500]",Kaiser,,3911.46,67,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veno Svc W Si",PX-320000132,CDM,75827,CPT,0320,RC,,,both,,,3762.17,1128.65,"CIGNA [10200]","Cigna Local Plus",,144.67,,,,,,,103.44,3762.17,"fee schedule",
"SYSTEM ACCUSTICK II 15CM 21GA INTRO NDL STYLET RADIOPAQUE",SUP-M001206041,CDM,C1894,HCPCS,0272,RC,,,both,,,100.05,30.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68.03,68,,,,,0,11.64,85.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA 3-7 C-D KNEE RIGHT TIBIA",SUP-42521200413,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"PHCS [10601]",PHCS,,5653.03,70,,,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17CM 5MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0517CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"KAISER [10500]",Kaiser,,4391.85,67,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER ETHIBOND 2-0 SH 30IN 2 ARM BRAID GREEN",SUP-X563H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8.5MM 9.5MM 225MM HUMERAL RIGHT MULTILOC INTRAMEDULLARY",SUP-04.018.225S,CDM,C1713,HCPCS,0278,RC,,,both,,,11172.76,3351.83,"CIGNA [10200]","Cigna Local Plus",,5977.43,53.5,,3978.14,359.25,3978.14,24,1299.39,9496.85,"percent of total billed charges",
"TRAY CATHETERIZATION 16FR SURESTEP BARDEX IC COMPLETE CARE",SUP-A300316A,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.29,41.79,"CIGNA [10200]","Cigna Open Access",,79.26,56.9,,,,,0,16.2,118.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 180CM 8CM 6FR 18-20MM ESOPHAGEAL PYLORIC",SUP-M00558381,CDM,C1726,HCPCS,0272,RC,,,both,,,1391.47,417.44,"UHC [10700]","United Healthcare",,880.8,63.3,,,,,0,161.83,1182.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE LOCALIZATION 20CM 20GA GHIATAS BREAST BEADED BARBED NDL",SUP-477201,CDM,A4648,HCPCS,0278,RC,,,both,,,419.34,125.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,120.02,28.62,,,,,0,48.77,356.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC THK1/8IN MEDIUM WRIST THUMB SPICA 2%",SUP-550407,CDM,S27000186,LOCAL,0270,RC,,,both,,,110.84,33.25,"KAISER [10500]",Kaiser,,74.26,67,,,,,0,12.89,94.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8.5MM 9.5MM 225MM HUMERAL RIGHT MULTILOC INTRAMEDULLARY",SUP-04.018.225S,CDM,C1713,HCPCS,0278,RC,,,both,,,11172.76,3351.83,"KAISER [10500]",Kaiser,,7485.75,67,,,,,0,1299.39,9496.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 20MM 135CM 7MM VASCULAR PERIPHERAL SELF",SUP-1012535-20,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 58MM 26MM UHR UNIVERSAL ACETABULAR HIP COCR",SUP-UH1-58-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2936.08,68,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM LOW PROFILE NECK VERTICAL GROOVE CORAIL2",SUP-L20309,CDM,C1776,HCPCS,0278,RC,,,both,,,28658.70,8597.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11778.73,41.1,,6417.48,6417.48,6417.48,"1 through 10",3333.01,24359.9,"percent of total billed charges",
"CATH EXPO 100CM 6FR .056IN WRP CURVE ANGIOGRAPHIC TRILON",SUP-H74908641512,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.17,22.55,"FIRST HEALTH [10303]","First Health",,60.14,80,,,,,0,8.74,63.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE",RX-2848,CDM,J0165,HCPCS,0636,RC,06937-4925-10,NDC,both,10,ML,69.46,20.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5.59,,,,,,,5.05,59.04,"fee schedule",
"SLING TRANSVAGINAL DESARA TV POLYPROPYLENE WARP KNIT FEMALE",SUP-CAL-DS01TV,CDM,C1771,HCPCS,0278,RC,,,both,,,6134.10,1840.23,"NOVANET [10819]",Novanet,,4600.58,75,,,,,0,713.4,5213.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL GAMMA3 CLOSED TUBE STERILE",SUP-13200125S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1041.01,312.3,"UHC [10700]","United Healthcare",,658.96,63.3,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 50MM 36MM XLPE HIP STERILE LATEX FREE",SUP-71935848,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.90,3024.27,"CIGNA [10200]","Cigna Local Plus",,5393.28,53.5,,5372.07,4581.20,7242.98,23,1172.41,8568.77,"percent of total billed charges",
"COIL EMBOLIZATION 2CM 1MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR091020,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA [10200]","Cigna Open Access",,4430.66,33.5,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X22X8MM RISE-L 6D NONSTERILE",SUP-193.422,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"AETNA [10100]","Aetna HMO/PPO",,27296.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA MIV 110CM 6FR PIGTAIL ST CURVE ANGIOGRAPHIC",SUP-6RPS110,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.84,61.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,94.48,45.9,,,,,0,23.94,174.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) INNOVALVE VALVE PROTHESIS FOR TMVR (TRANSCATHETER MIT",SUP-PRO-5813,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR 260CM 8CM .018IN GLIDEX",SUP-M001466020,CDM,C1769,HCPCS,0272,RC,,,both,,,1539.00,461.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,178.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 15D 10.5-12 13.5+ LARGE CONTACT CLSR",SUP-HS1005-14,CDM,S27000186,LOCAL,0270,RC,,,both,,,128.06,38.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.89,108.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM TITANIUM STERNAL SELF DRILLING",SUP-04.501.110.01,CDM,C1713,HCPCS,0278,RC,,,both,,,854.96,256.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,99.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",99.43,726.72,"percent of total billed charges",
"STEM FEMORAL 93MM PRESS FIT ACCOLADE II V40 PUREFIX TITANIUM",SUP-6720-0027,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"BLUE CROSS [10001]","Blue Cross HMO",,9393.12,39.2,,5311.50,4717.44,5388.59,31,2786.79,20367.74,"percent of total billed charges",
"AIRWAY ESOPHAGEAL 3 PEDIATRIC LMA FASTRACH CUFF REINFORCE",SUP-135130,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GUIDEZILLA II 150CM 40CM 6FR .067IN .057IN LONG GUIDING",SUP-H74939335150610,CDM,C1769,HCPCS,0272,RC,,,both,,,2956.88,887.06,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAFESHEATH II SS8",SUP-398343,CDM,C1894,HCPCS,0272,RC,,,both,,,3339.00,1001.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR ROUND 9.5CM GELPOINT TRANSVAGINAL ACCESS PLATFORM",SUP-C2A12,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE NASOGASTRIC 60IN 12FR 10FR .035IN 300CM NASOINTESTINAL",SUP-50-4602,CDM,S27200284,LOCAL,0272,RC,,,both,,,54.99,16.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP 100CM 8FR XB4 CURVE GUIDING STAINLESS",SUP-588896,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MALECOT 32FR NEPHRSTMY DRAIN 4 WING STERILE LATEX",SUP-086032,CDM,C1729,HCPCS,0272,RC,,,both,,,105.62,31.69,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM VASOVIEW 6 SHORT VESSEL HARVESTING 30ML BLUNT TIP",SUP-C-VH-2004,CDM,S27200284,LOCAL,0272,RC,,,both,,,880.10,264.03,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE CRYOABLATION L 17IN CRYOICE CRYOSPHERE MAX EXTENDED",SUP-CRYOSMAX-L,CDM,C9808,HCPCS,0272,RC,,,both,,,18270.00,5481,"KAISER [10500]",Kaiser,,12240.9,67,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NAVIFLEX 202.5CM 8.5FR DELIVERY BILIARY STENT",SUP-M00533570,CDM,C1887,HCPCS,0272,RC,,,both,,,667.20,200.16,"FIRST HEALTH [10303]","First Health",,533.76,80,,,,,0,77.6,567.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE  VIATORR TIPS ENDOPROSTHESIS WITH CONTROLLED EXPANSION,",SUP-PTB6106275,CDM,C1874,HCPCS,0278,RC,,,both,,,33364.80,10009.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9549.01,28.62,,,,,0,3880.33,28360.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM 3 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800358,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL REFLEX ULTRA TURBINATE PLASMA WAND",SUP-EICA4835-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,2166.38,649.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1473.14,68,,,,,0,251.95,1841.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP 2A PRESS - FIT - POLY SURFACE, METAL HEADS/DEPUY -",SUP-CAP-H-2A,CDM,C1776,HCPCS,0278,RC,,,both,,,16200.00,4860,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1884.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1884.06,13770,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL 10.5IN 18MM FLAT TAPER PUTTI 2 END STRAIGHT",SUP-26-1501,CDM,S27200284,LOCAL,0272,RC,,,both,,,449.31,134.79,"MULTIPLAN [10600]",Multiplan,,381.91,85,,,,,0,52.25,381.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 20CM 6MM BALLOON DILATATION ILIAC",SUP-G35536,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"FIRST HEALTH [10303]","First Health",,767.82,80,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X6MM SABLE 8D STERILE LATEX FREE",SUP-1172.2010S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14241.15,41.1,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +26 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-SY60WF.260,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SILICONE 225ML BREAST GEL ROUND SMOOTH",SUP-RSZ-2251,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"NOVANET [10819]",Novanet,,115.67,75,,,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL ATTUNE CEMENTED POSTERIOR STABILIZE STERILE 5",SUP-150410105,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"BLUE CROSS [10001]","Blue Cross HMO",,8778.19,39.2,,5311.50,4717.44,5388.59,31,2604.35,19034.35,"percent of total billed charges",
"GWIRE ZIPWIRE BENTSON UROLOGICAL ANGLE 150CM 8CM .038IN",SUP-M0066802071,CDM,C1769,HCPCS,0272,RC,,,both,,,362.42,108.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,42.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.15,308.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 2.5CM 10CM WITHOUT MINI GWIRE DIL PINNACLE",SUP-RSS504,CDM,C1894,HCPCS,0272,RC,,,both,,,73.95,22.18,"FIRST HEALTH [10303]","First Health",,59.16,80,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -2MM 12/14 OFFSET TAPER 40MM HIP M",SUP-136504000,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1312.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1288.37,9416.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 40MM 190CM 2.5",SUP-R51002504L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"UHC [10700]","United Healthcare",,1248.12,63.3,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT SL II SITEMARK 57.7CM 54CM 9FR 7FR WIDE",SUP-DS2C014,CDM,C1887,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,445.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,inpatient,,,62559.48,18767.84,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,6837.04,,"Case rate ($6,637.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,163.74, add-ons for qualifying new technology services are included. If operating cost exceeds $39,203.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,848.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,171.89. The transfer operating threshold is the transfer adjustment factor * $6,163.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.01. The transfer capital threshold is the transfer adjustment factor * $466.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,6637.9,26687.22,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 44MM GORILLA R3CON LOCK",SUP-P50-353-3544,CDM,C1713,HCPCS,0278,RC,,,both,,,1470.15,441.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,420.76,28.62,,,,,0,170.98,1249.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX OTW CORONARY STENT  2.00 X 22MM",SUP-RONYX20022W,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) OCCL CARDIOVASCULAR 10X19-22MM 25MM 32MM HEMOSTASIS",SUP-9-ACP2-010-025,CDM,C1817,HCPCS,0278,RC,,,both,,,102600.00,30780,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12158.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11932.38,87210,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ION CATHETER 8 LIVES",SUP-490305,CDM,C1887,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"KAISER [10500]",Kaiser,,4507.43,67,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 25MM 50MM SHOULDER MODULAR REMEDY PMMA",SUP-RSHHLG,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"CIGNA [10200]","Cigna Open Access",,6859.13,33.5,,5302.19,4377.88,6578.61,27,2381.24,17403.75,"percent of total billed charges",
"HC Drug Screen Collection",PX-300000001,CDM,99000,CPT,0300,RC,,,both,,,57.00,17.1,"KAISER [10500]",Kaiser,,38.19,67,,,,,0,0.06,48.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDPLATE SPINAL 20X26MM FORTIFY-R 14MM NONSTERILE LATEX FREE",SUP-351.15,CDM,C1713,HCPCS,0278,RC,,,both,,,47111.40,14133.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19362.79,41.1,,,,,0,5479.06,40044.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890006535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"PLATE NARROW 8 HOLE LOW PROFILE STRAIGHT BONE RIGHT CLAVICLE",SUP-70-0299,CDM,S27800098,LOCAL,0278,RC,,,both,,,6610.20,1983.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3034.08,45.9,,,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 55D 10MM 2.5MM EMBOLIZATION 75% COCR 25",SUP-PED-250-10,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,20776.5,27,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 9MM COCR",SUP-VAL-25090-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,969.41,68,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 40MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530040M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"AETNA [10100]","Aetna HMO/PPO",,1268.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 18MM KNEE CONSTRAIN UHMWPE GENESIS II",SUP-71420530,CDM,C1776,HCPCS,0278,RC,,,both,,,17832.15,5349.64,"CIGNA [10200]","Cigna Local Plus",,5617.13,31.5,,5372.07,4581.20,7242.98,23,2073.88,15157.33,"percent of total billed charges",
"SUT CHROMIC 3-0 SH-1 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-G182H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]",Cigna,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERPICC SHERLOCK 3CG 5FR CENTRAL VENOUS POLYPROPYLENE",SUP-1275108D,CDM,C1751,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 10MM SPACE F CURVE",SUP-F6QRF010RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,107.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135D 42MM STD OFFSET 38.5MM STERILE 160MM 14MM",SUP-3L92514,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"PHCS [10601]",PHCS,,11085.98,70,,,,,0,1841.86,13461.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 57SQ CM 13MM 51X66MM COBALT XT VENTRICULAR",SUP-DVPA2D1,CDM,C1722,HCPCS,0278,RC,,,both,,,56385.00,16915.5,"CIGNA [10200]",Cigna,,22554,40,,,,,0,6557.58,47927.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE LP 33M",SUP-TENDV-LP-33M-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"NOVANET [10819]",Novanet,,128250,75,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH URI-CATH 3 WAY STPCOCK DRNG CLOSED SYSTEM",SUP-4195007,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.55,67.96,"AETNA [10100]","Aetna HMO/PPO",,180.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.35,192.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 65CM RVOT KIT MOND STAINLESS STEEL WIDE",SUP-4151/65,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,391.07,68,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN JUDKINS RIGHT 6 CURVE",SUP-DXT6JR60,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 30IN 2 PORT 1 BLADDER PUMP LINE CNCT ATS STERILE",SUP-60707010500,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Open Access",,391.76,56.9,,,,,0,24.05,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-583504022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"UHC [10700]","United Healthcare",,948.55,63.3,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X3 HUMERAL INSERT - 40MM X 4 CONSTRAINED",SUP-5571-C-4004,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"BLUE CROSS [10001]","Blue Cross HMO",,3951.36,39.2,,5311.50,4717.44,5388.59,31,1172.3,8568,"percent of total billed charges",
"SPACER SPINAL 23X9X11MM COALESCE LORDOTIC STRAIGHT STERILE",SUP-2000-00-091108,CDM,C1889,HCPCS,0278,RC,,,both,,,21420.00,6426,"FIRST HEALTH [10303]","First Health",,17136,80,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH URI-CATH 3 WAY STPCOCK DRNG CLOSED SYSTEM",SUP-4195007,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.55,67.96,"NOVANET [10819]",Novanet,,169.91,75,,,,,0,26.35,192.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN JUDKINS RIGHT 6 CURVE",SUP-DXT6JR60,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"FIRST HEALTH [10303]","First Health",,66.12,80,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP SYSTEM WITH CERAMIC HEAD",SUP-55500018,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"UHC [10700]","United Healthcare",,14356.44,63.3,,8601.07,8395.67,8601.07,"1 through 10",2637.68,19278,"percent of total billed charges",
"LEAD PACING 52CM HELIX ENDOCARDIUM ATRIUM VENTRICLE BIPOLAR",SUP-4087,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"NOVANET [10819]",Novanet,,4205.25,75,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 54.5X40X.8MM HALL STERNOTOMY REPEAT STERILE",SUP-00507122900,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.37,40.01,"CIGNA [10200]","Cigna Open Access",,75.89,56.9,,,,,0,15.51,113.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET, IMMEDIATE RELEASE",RX-9406,CDM,,,0637,RC,72888-0106-01,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TWIN-PASS 135CM 3.5FR 10D INTERVENTIONAL STAINLESS",SUP-5201,CDM,C1887,HCPCS,0272,RC,,,both,,,3262.50,978.75,"MULTIPLAN [10600]",Multiplan,,2773.13,85,,,,,0,379.43,2773.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 8IN SPETZLER-MALIS 1.5MM SLIM DISPOSABLE",SUP-6780-200-015,CDM,S27200284,LOCAL,0272,RC,,,both,,,3208.53,962.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,380.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,373.15,2727.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM TSRH OSTEOGRIP TITANIUM SHORT SPINE",SUP-83575358,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.10,1106.73,"BLUE CROSS [10001]","Blue Cross PPO",,1446.13,39.2,,957.42,570.23,957.42,28,429.04,3135.74,"percent of total billed charges",
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FROZEN 120MMX5+ MM",SUP-450633,CDM,S27800098,LOCAL,0278,RC,,,both,,,5547.60,1664.28,"AETNA [10100]","Aetna HMO/PPO",,4410.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,645.19,4715.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 20CM 4MM BALLOON DILATATION ILIAC",SUP-G35527,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"NOVANET [10819]",Novanet,,719.83,75,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 48MM STAINLESS STEEL T8 ELBOW METAPHYSEAL",SUP-02.118.548,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,356.26,68,,,,,0,60.93,445.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 22MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.422,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"MULTIPLAN [10600]",Multiplan,,3570,85,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 12X4IN SILVERLON ISLAND PAD 10X2IN",SUP-ID-412,CDM,S27200284,LOCAL,0272,RC,,,both,,,295.37,88.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.35,251.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN VACUUM ASPIRATION CURVED SEMI RIGID ROUNDED TIP TAPERED",SUP-20317,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.12,19.84,"KAISER [10500]",Kaiser,,44.3,67,,,,,0,7.69,56.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 18MM EMBOLD NITINOL FIBER DETACHABLE",SUP-M001394240180500,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"MULTIPLAN [10600]",Multiplan,,7325.39,85,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 100CM 5FR SIM1 CURVE ANGIOGRAPHIC STAINLESS",SUP-510035SIM1,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"FIRST HEALTH [10303]","First Health",,87,80,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 28CM 8FR SHORT LENGTH URETERAL",SUP-H7493936108280,CDM,C2617,HCPCS,0278,RC,,,both,,,1142.10,342.63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,135.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,132.83,970.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 4.5MM 32MM EVOS MINI CORTEX T8 DRIVER SELF",SUP-72402732,CDM,C1713,HCPCS,0278,RC,,,both,,,363.14,108.94,"BLUE CROSS [10001]","Blue Cross HMO",,142.35,39.2,,957.42,156.86,7483.26,51,42.23,308.67,"percent of total billed charges",
"PLATE 80MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 10",SUP-245.220,CDM,C1713,HCPCS,0278,RC,,,both,,,3664.50,1099.35,"BLUE CROSS [10001]","Blue Cross PPO",,1436.48,39.2,,957.42,570.23,957.42,28,426.18,3114.83,"percent of total billed charges",
"ENALAPRIL MALEATE 5 MG TABLET",RX-9927,CDM,,,0637,RC,43547-0546-10,NDC,both,1,UN,9.31,2.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.08,7.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 30CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175275080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,146.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 350MM 5.5MM REVERE PEDICLE TITANIUM STRAIGHT",SUP-124.519,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"FIRST HEALTH [10303]","First Health",,3528,80,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.476,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"PHCS [10601]",PHCS,,3389.82,70,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 60MM 40CM 10MM 6FR BILIARY SELF EXPAND",SUP-G32006,CDM,C1876,HCPCS,0278,RC,,,both,,,4653.98,1396.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,551.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,541.26,3955.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 35CM INJECTION PROTECTIVE CAP RIGID",SUP-NBI035,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"CIGNA [10200]","Cigna Local Plus",,325.01,53.5,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION BARDEX 16FR 350ML COUDE TIP FOLEY URINE",SUP-A304716A,CDM,S27200284,LOCAL,0272,RC,,,both,,,241.60,72.48,"KAISER [10500]",Kaiser,,161.87,67,,,,,0,28.1,205.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 18GA 22GA 6.35CM .035IN 2 LUMEN CATH GWIRE NDL",SUP-AK-21142-SK,CDM,C1894,HCPCS,0272,RC,,,both,,,1037.61,311.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,120.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,120.67,881.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BUTTON 8MM 3CM PASSPORT SILICONE CURVE LOW PROFILE HIP",SUP-AR-6592-08-30,CDM,S27000186,LOCAL,0270,RC,,,both,,,292.32,87.7,"CIGNA [10200]","Cigna Open Access",,166.33,56.9,,,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 27MM THK.25MM STERILE",SUP-GC906R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1834.50,550.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1247.46,68,,,,,0,213.35,1559.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 54MM 26MM TURON OFFSET",SUP-520-54-126,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"MULTIPLAN [10600]",Multiplan,,7725.48,85,,,,,0,1057.03,7725.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 7FR L22CM SOFT WITHOUT GUIDEWIRE TRIA",SUP-M0061903310,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X15MM 9/11MM SPINE CORTICAL FROZEN DISTAL",SUP-4915,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6806.16,41.1,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP060150090 PLUS US D6L150UL900",SUP-PCP060150090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cr Mycoplasma Pneumoniae by Pc",PX-306000203,CDM,87581,CPT,0306,RC,,,both,,,460.75,138.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.29,,,,,,,0.01,391.64,"fee schedule",
"STENT UNISTEP PLUS WALLSTENT RP 20MM 75CM 10MM 100CM",SUP-M001711320,CDM,C1876,HCPCS,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 125MM 5.5MM REVERE TITANIUM CURVED",SUP-124.612,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"MULTIPLAN [10600]",Multiplan,,3748.5,85,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC SMALL KNEE OPEN BACK AIRMESH ROADRUNNER",SUP-14142,CDM,S27000186,LOCAL,0270,RC,,,both,,,614.55,184.36,"NOVANET [10819]",Novanet,,460.91,75,,,,,0,71.47,522.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 49CM 8.6FR TENSI-LOCK SPRINT QUATTRO HELIX STD",SUP-6947M49,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]","Cigna Open Access",,5752.62,33.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 401118 MDII 18X20 SRVC FEE",SUP-401118,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, SHORT HUMERAL STEM, 8MM",SUP-520-08-000,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"MULTIPLAN [10600]",Multiplan,,6732,85,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 8MM 2MM BALLOON DILATATION PEBAX",SUP-1400200-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 24IN 8FR SUCTION",SUP-8888256529,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.16,19.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.69,56.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CERVICAL SPINAL FUSION WITHOUT CC/MCC",473,MS-DRG,,,,,,,inpatient,,,100396.23,30118.87,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,32558.61,,"Case rate ($15,143.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,061.80, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,445.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $14,080.39. The transfer operating threshold is the transfer adjustment factor * $14,061.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,063.14. The transfer capital threshold is the transfer adjustment factor * $1,063.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,71276.19,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 60MM 3.8-3.4FR 5MM LOW PROFILE",SUP-H74939031506010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER BREAST BIOPSY MAMMOMARK CORMARK TITANIUM COLLAGEN U T",SUP-MAM3015,CDM,A4648,HCPCS,0278,RC,,,both,,,606.69,182.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,412.55,68,,,,,0,70.56,515.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9.5MM 80MM RELINE-O 2S SPINE ILIAC POLYAXIAL",SUP-13019580,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,1521.93,481.35,16760.95,30,441.36,3225.75,"percent of total billed charges",
"POTASSIUM CHLORIDE 40 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS",RX-9796,CDM,,,0250,RC,65219-0119-01,NDC,both,1000,ML,100.65,30.19,"MULTIPLAN [10600]",Multiplan,,85.55,85,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL WEIL-BLAKESLEY 45D UP 1 4MM 7.5IN NASAL",SUP-66-2812,CDM,S27200284,LOCAL,0272,RC,,,both,,,2043.00,612.9,"CIGNA [10200]","Cigna Open Access",,1162.47,56.9,,,,,0,237.6,1736.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 30MM 109CM 6MM 75CM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200063070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]",Cigna,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135D 41.5MM STD OFFSET 38.5MM STERILE 155MM 13",SUP-3L92513,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"CIGNA [10200]","Cigna Local Plus",,4988.69,31.5,,5372.07,4581.20,7242.98,23,1841.86,13461.55,"percent of total billed charges",
"CATH NEURON 130CM 9CM 5FR .04IN .018IN 1 CURVE DELIVERY",SUP-PNS5F130H1,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 63MM 33.8MM 25MM DURAN ANCORE 27.8MM 2",SUP-620BG25,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"FIRST HEALTH [10303]","First Health",,10488,80,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 22D LARGE HIP PROXIMAL",SUP-550544,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"NOVANET [10819]",Novanet,,8163.56,75,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-5 TH-26 36IN 2 ARM MONOFILAMENT WHITE",SUP-5N20B,CDM,S27200284,LOCAL,0272,RC,,,both,,,233.69,70.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,158.91,68,,,,,0,27.18,198.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8MM 240MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-408-240,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STINGRAY BALLOON",SUP-H7499393120SR0,CDM,C1725,HCPCS,0272,RC,,,both,,,11396.59,3418.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1325.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1325.42,9687.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.2MM 45MM CLICKX TITANIUM BUTTRESS SPINE PEDICLE",SUP-498.563,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,,1521.93,481.35,16760.95,30,436.13,3187.5,"percent of total billed charges",
"SHELL ACETABULAR 48MM HIP LIMIT 3 HOLE OSSEOTI G7 C",SUP-110010242,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,8601.07,8395.67,8601.07,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"SCR SET TITANIUM SPINE BREAK OFF NONSTERILE 5.5 MM ROD",SUP-5540030,CDM,S27200284,LOCAL,0272,RC,,,both,,,2406.60,721.98,"FIRST HEALTH [10303]","First Health",,1925.28,80,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 15MM INTERLOCK FIBERED IDC 35 COIL",SUP-M001363820,CDM,S27800098,LOCAL,0278,RC,,,both,,,5181.90,1554.57,"KAISER [10500]",Kaiser,,3471.87,67,,,,,0,602.65,4404.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 6MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650706,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1526.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 11 NARROW KNEE RIGHT CRUCIATE RETAIN PERSONA",SUP-42502207002,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"CIGNA [10200]","Cigna Open Access",,9680.02,33.5,,5302.19,4377.88,6578.61,27,3360.56,24561.24,"percent of total billed charges",
"SET BIOPSY 15CM 13GA OSTEO-SITE BONE CANN TROCAR TIP STYLET",SUP-G12500,CDM,S27200284,LOCAL,0272,RC,,,both,,,374.10,112.23,"NOVANET [10819]",Novanet,,280.58,75,,,,,0,43.51,317.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLATE TIBIAL ATTUNE 8 KNEE REVISION CEMENT ROTATE PLATFO",SUP-150660008,CDM,C1776,HCPCS,0278,RC,,,both,,,22629.60,6788.88,"CIGNA [10200]","Cigna Open Access",,7580.92,33.5,,5302.19,4377.88,6578.61,27,2631.82,19235.16,"percent of total billed charges",
"STENT BILIARY 8MM 6FR 24MM 135CM .035IN MEDIUM BALLOON",SUP-H739PG2480BPX3,CDM,C1876,HCPCS,0278,RC,,,both,,,6553.97,1966.19,"AETNA [10100]","Aetna HMO/PPO",,5210.41,79.5,,,,,0,762.23,5570.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 4FR 5MM SPACE STD A CURVE ELECTROPHYSIOLOGY 10 PIN CNCT",SUP-112434RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,274.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Lwr Leg Bi",PX-510000075,CDM,29581,CPT,0761,RC,,,both,,,730.14,219.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,496.5,68,,,,,0,84.92,730.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC UNIVERSAL 17-23IN KNEE TRANSITION",SUP-KB5000-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,760.27,228.08,"MULTIPLAN [10600]",Multiplan,,646.23,85,,,,,0,88.42,646.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AUROUS 100CM 5FR PIGTAIL ANGIOGRAPHIC 10 SIDEPORT",SUP-G47308,CDM,S27200284,LOCAL,0272,RC,,,both,,,1025.44,307.63,"CIGNA [10200]","Cigna Local Plus",,548.61,53.5,,,,,0,119.26,871.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JET THROMBECTOMY STERILE LATEX FREE",SUP-5MAXJETD,CDM,C1757,HCPCS,0272,RC,,,both,,,16767.00,5030.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1986.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1950,14251.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Estrogens Total",PX-301000183,CDM,82672,CPT,0301,RC,,,both,,,416.10,124.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.78,,"Fee schedule rate ($22.78). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,353.69,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Asy Hydroxychloroquine",PX-301000682,CDM,80220,CPT,0301,RC,,,both,,,163.00,48.9,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,138.55,"per diem",
"HC Peri-Proc Dev Eval & Prog Pm",PX-480000094,CDM,93286,CPT,0480,RC,,,both,,,334.61,100.38,"FIRST HEALTH [10303]","First Health",,267.69,80,,,,,0,38.92,334.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Peri-Proc Dev Eval & Prog Pm",PX-480000094,CDM,93286,CPT,0480,RC,,,both,,,334.61,100.38,"AETNA [10100]","Aetna HMO/PPO",,266.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.92,334.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO CLEAR 10CM .018IN 21GA 3FR MERIT PAK 40CM PEDAL",SUP-PAKS5NPD7,CDM,C1894,HCPCS,0272,RC,,,both,,,497.02,149.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,337.97,68,,,,,0,57.8,422.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ENDOSCP SEALING WHITE RUBBER 3.9MM SMALL TROCAR HOLE",SUP-6127590/10,CDM,S27000186,LOCAL,0270,RC,,,both,,,83.92,25.18,"MULTIPLAN [10600]",Multiplan,,71.33,85,,,,,0,9.76,71.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR .09IN EXTRA BACKUP LEFT 3.75 CURVE",SUP-LA8EBU375SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revasc Bypass Grft Ea Addl Br",PX-481000085,CDM,92938,CPT,0481,RC,,,both,,,26800.00,8040,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3175.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3116.84,25681,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cftr Gene Full Sequence",PX-309000018,CDM,81223,CPT,0310,RC,,,both,,,5423.00,1626.9,"CIGNA [10200]","Cigna Open Access",,1097.8,,,,,,,0.01,4609.55,"fee schedule",
"HC Ins Small Bowel Feed Tube W Fl",PX-750000101,CDM,49441,CPT,0750,RC,,,both,,,8277.00,2483.1,"CIGNA [10200]","Cigna Local Plus",,1965,,"Case rate ($1,965). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,962.62,7035.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Small Bowel Feed Tube W Fl",PX-750000101,CDM,49441,CPT,0750,RC,,,both,,,8277.00,2483.1,"UHC [10700]","United Healthcare",,3833,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,962.62,7035.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Breast Ultrasonic Clip Plc Add",PX-361000309,CDM,19084,CPT,0361,RC,,,both,,,4669.25,1400.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,543.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,543.03,4669.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 PS-2 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8682G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH UNI-FUSE FLOW-THRU HUB 90CM 10CM 5FR THROMBECTOMY",SUP-H787124018065,CDM,C1757,HCPCS,0272,RC,,,both,,,1563.30,468.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT DRSG VAC PEEL AND PLACE MEDIUM",SUP-EZ5MED,CDM,S27200284,LOCAL,0272,RC,,,both,,,1005.29,301.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 275CC",SUP-SSZ-M275,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE PACING BEIGE 8FT SMALL LARGE ATRIAL VENTRICULAR SMALL",SUP-S-101-97,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.45,51.13,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER ALLOGRAFT 12.5X15X7MM CONVEX SPINE CORTICOCANCELLOUS",SUP-17507,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOLOIST 110CM 6FR 5MM SPACING JSN FLEX1 CURVE",SUP-307F3,CDM,C1733,HCPCS,0272,RC,,,both,,,10005.00,3001.5,"FIRST HEALTH [10303]","First Health",,8004,80,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .035IN 5FR 5MM 80CM 6CM PTA 2 LUMEN",SUP-4205060S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 1 CP 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J196H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 15MM 1.25MM BALLOON DILATATION OTW STERILE",SUP-47012015S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"KAISER [10500]",Kaiser,,960.58,67,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 5 EXTEND LENGTH 90MM 9.6MM SHILEY XLT UNCUFF SOFT",SUP-50XLTUD,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"NOVANET [10819]",Novanet,,363.95,75,,,,,0,56.44,412.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 24CM 3CM 5FR .035IN 2 PIGTAIL",SUP-M006192122050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,343.61,28.62,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS 90CM 4MM 8FR 2-5-2MM SPACE G CURVE ABLATION 10",SUP-D8BTCGL,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"PHCS [10601]",PHCS,,3472.77,70,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 450ML STYLE 7200 MEDIUM HEIGHT CENTERSCOPE",SUP-3549213,CDM,C1789,HCPCS,0278,RC,,,both,,,9694.50,2908.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6592.26,68,,,,,0,1127.47,8240.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 10CM 5MM 6FR BALLOON DILATATION",SUP-V1850100,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"PHCS [10601]",PHCS,,3839.85,70,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 8.5MM TANNE UNIVERSAL TREPHINE UNIQUE HUB","SUP-E3050 8.50",CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"CIGNA [10200]","Cigna Local Plus",,295.76,53.5,,,,,0,64.29,469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 4CM 20FR MIC-KEY SECUR-LOK ENFIT SILICONE RADIOPAQUE",SUP-8140-20-4.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,92.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST EXTERNAL FIXATION 11MM 11MM 30D OUTRIGGER NONSTERILE",SUP-390.012,CDM,S27800098,LOCAL,0278,RC,,,both,,,737.10,221.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,501.23,68,,,,,0,85.72,626.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT LEAD SPLICE 6.1FR 8.3FR CAPSURE 10.7FR TRANSVENOUS",SUP-5867-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,174.00,52.2,"KAISER [10500]",Kaiser,,116.58,67,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOGLIDE 0 53IN MONOFILAMENT PURPLE ABSORBABLE",SUP-021506,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,34.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 340CC P3.5CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-340,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PHCS [10601]",PHCS,,5288.85,70,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE EXTERNAL FIXATION 400MM 1.8MM TRUELOK STAINLESS STEEL",SUP-54-1215,CDM,C1713,HCPCS,0278,RC,,,both,,,1254.93,376.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,145.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",145.95,1066.69,"percent of total billed charges",
"VERSACROSS SHEATH 63CM 55DEG D0",SUP-VXS0203,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"KAISER [10500]",Kaiser,,1085.4,67,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEP BONE CUTTING 5 1/2IN LISTON",SUP-33-2014,CDM,S27200284,LOCAL,0272,RC,,,both,,,694.82,208.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,82.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.81,590.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32X27X14MM SOVEREIGN 8D MEDIUM",SUP-7968814,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"MULTIPLAN [10600]",Multiplan,,29134.26,85,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 CT-1 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J338H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 58MM 32MM XLPE HIP",SUP-71337658,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"CIGNA [10200]",Cigna,,7565.85,68,,5873.17,5873.17,5873.17,"1 through 10",1293.98,9457.31,"percent of total billed charges",
"SCR BONE 4MM 40MM ASNIS III TITANIUM 1/3 THREAD REVERSE CUT",SUP-604640S,CDM,C1713,HCPCS,0278,RC,,,both,,,1929.60,578.88,"BLUE CROSS [10001]","Blue Cross HMO",,756.4,39.2,,957.42,156.86,7483.26,51,224.41,1640.16,"percent of total billed charges",
"CATH SABERX 200CM 80MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530080L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIOFLON 2/0 1/2KL 25MM DA 75CM PLEDGET TD3X7",SUP-19P30Y,CDM,S27200284,LOCAL,0272,RC,,,both,,,865.35,259.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,397.2,45.9,,,,,0,100.64,735.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 40MM 4MM BALLOON",SUP-LX181304404F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"PHCS [10601]",PHCS,,4709.25,70,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 56MM 28MM XLPE HIP",SUP-71334956,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"CIGNA [10200]",Cigna,,7579.93,68,,5873.17,5873.17,5873.17,"1 through 10",1296.39,9474.91,"percent of total billed charges",
"ANCHOR SUT 4.5MM PUSHLOCK SELF PUNCH BIOCOMPOSITE 28MM",SUP-AR-1922BCM,CDM,C1713,HCPCS,0278,RC,,,both,,,3268.13,980.44,"NOVANET [10819]",Novanet,,2451.1,75,,,,,0,380.08,2777.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WATCHDOG ACCESSORY KIT (20-PACK)",SUP-H74939343A021,CDM,C1725,HCPCS,0272,RC,,,both,,,437.40,131.22,"NOVANET [10819]",Novanet,,328.05,75,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SR LORDOTIC ALLOGRAFT",SUP-400541,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 20MM 2.5MM BALLOON DILATATION",SUP-2200-2520-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"PHCS [10601]",PHCS,,4105.5,70,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD MARLEX 12X2IN GROIN MONOFILAMENT GOLD STD",SUP-0112670,CDM,C1781,HCPCS,0278,RC,,,both,,,399.33,119.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,271.54,68,,,,,0,46.44,339.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 20MM 3MM",SUP-SPL30020X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 9.5MM 7MM NASAL ORAL TAPER CUFF MURPHY TIP",SUP-18770S,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.13,22.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.62,63.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE C2 CRYOBALLOON ENDOGRIP CRYOSURGICAL NONSTERILE LATEX",SUP-FG-1040,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 55MM 5MM KII Z THREAD SLEEVE SHIELD",SUP-CTB05,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 25MM 1.7MM ROUTER TAPERED STERILE",SUP-5120071059,CDM,S27200284,LOCAL,0272,RC,,,both,,,667.12,200.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,77.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.59,567.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 6.5MM BARREL DIAMOND EXTRA COURSE",SUP-5130-020-160,CDM,S27200284,LOCAL,0272,RC,,,both,,,955.23,286.57,"MULTIPLAN [10600]",Multiplan,,811.95,85,,,,,0,111.09,811.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.6MM CHARLOTTE",SUP-43512600,CDM,S27200284,LOCAL,0272,RC,,,both,,,1635.00,490.5,"KAISER [10500]",Kaiser,,1095.45,67,,,,,0,190.15,1389.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL OXFORD A LEFT MEDIAL RIGHT LATERAL",SUP-154718,CDM,C1776,HCPCS,0278,RC,,,both,,,11195.94,3358.78,"FIRST HEALTH [10303]","First Health",,8956.75,80,,,,,0,1302.09,9516.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75445050,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,1831.33,1831.33,1831.33,16,441.36,3225.75,"percent of total billed charges",
"SUT FIBERWIRE 2 .5 CIRCLE STRAIGHT DIAMOND POINT 38IN BRAID",SUP-AR-7201,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.73,95.92,"FIRST HEALTH [10303]","First Health",,255.78,80,,,,,0,37.18,271.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL THK.5MM STD THIN FLUOROPLASTIC REUTER SEPTUM",SUP-1527005,CDM,S27000186,LOCAL,0270,RC,,,both,,,269.70,80.91,"KAISER [10500]",Kaiser,,180.7,67,,,,,0,31.37,229.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HYBRID TOTAL KNEE SYSTEM (EITHER POROUS FEMUR OR TIBIA)",SUP-98000600208,CDM,C1776,HCPCS,0278,RC,,,both,,,26460.00,7938,"UHC [10700]","United Healthcare",,16749.18,63.3,,8601.07,8395.67,8601.07,"1 through 10",3077.3,22491,"percent of total billed charges",
"SHELL BIPOLAR WHITE 54MM 28MM RINGLOC ECCENTRIC HIP",SUP-11-165232,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"AETNA [10100]","Aetna HMO/PPO",,5294.6,79.5,,10981.53,8986.79,12413.38,12,774.54,5660.9,"percent of total billed charges",
"SCR BONE 6MM 40MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890006040,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Foley W/O Catheter",PX-E27000125,CDM,E27000125,LOCAL,0270,RC,,,both,,,58.30,17.49,"KAISER [10500]",Kaiser,,39.06,67,,,,,0,6.78,49.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 6MMX79MM 7FR 135CMCATH HEPARIN",SUP-BXB067902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"PHCS [10601]",PHCS,,14985.18,70,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.5MM X 20MM TI",SUP-VAN-15200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"BLUE CROSS [10001]","Blue Cross PPO",,381.02,39.2,,957.42,570.23,957.42,28,113.04,826.2,"percent of total billed charges",
"CUFF TRNQT PLUM 12X3.5IN EXPRESSAIRE BROADCLOTH 1 FILL LINE",SUP-A70107002,CDM,S27200284,LOCAL,0272,RC,,,both,,,387.98,116.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.12,329.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 11CM GWIRE PRELUDE .035IN STERILE BLUE",SUP-PRO-8F-11,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"PHCS [10601]",PHCS,,52.98,70,,,,,0,8.8,64.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION LARGE 4 POSITION PIN MR SAFE LARGE",SUP-390.009,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 48MM 1MM E9000 ROUND STAINLESS STEEL 6 FLUTE",SUP-E8210,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE STRATAFIX MONOCRYL PLUS 4-0 PS-2 2 SPIRAL 12IN SUT",SUP-SXMP2B409,CDM,S27200284,LOCAL,0272,RC,,,both,,,219.64,65.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4.3MM 46MM CHARLOTTE STAINLESS STEEL SHORT FIRST",SUP-44110030,CDM,S27200284,LOCAL,0272,RC,,,both,,,2055.00,616.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 150CM 60MM 7MM BALLOON DILATATION DURALYN",SUP-48007006X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Kit Infusion Powerloc",PX-E27200168,CDM,E27200168,LOCAL,0272,RC,,,both,,,44.84,13.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Sol Dialysate 106meq/Cl 100meq/L Na 3meq",PX-E25000001,CDM,E25000001,LOCAL,0250,RC,,,both,,,55.24,16.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CYGNUS MATRIX (4 X 4) 16 SQ CM",SUP-585-010,CDM,Q4199,HCPCS,0636,RC,,,both,,,9832.50,2949.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 200CM 120MM 1.5MM BALLOON DILATATION RAPID",SUP-47515120L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 130CM 20MM 7MM BALLOON",SUP-U3513072,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH SUPER SHEATH 11CM 6FR INTRO ACCEPTS .038IN GWIRE",SUP-H7491603606B1,CDM,C1894,HCPCS,0272,RC,,,both,,,79.31,23.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUFF TRNQT BLUE 30X4IN 21-28IN ATS 750/1200 CYL 1 PORT 1",SUP-60707515500,CDM,S27200284,LOCAL,0272,RC,,,both,,,260.06,78.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STY LD 90CM KT DLV SYS",SUP-6691,CDM,S27500001,LOCAL,0275,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC HERCULES PET FLEX 5.5CM 240CM 8-9-10MM 8FR",SUP-G51799,CDM,C1726,HCPCS,0272,RC,,,both,,,1965.00,589.5,"UHC [10700]","United Healthcare",,1243.85,63.3,,,,,0,228.53,1670.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ANTERIOR ASPHERIC SURFACE ABERRATION FREE ADVANCED",SUP-LI61AOR2850,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 10FR PIGTAIL URETERAL PERCUFLEX METAL",SUP-M001221420,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,105.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ACUITY VASCULAR STRAIGHT HYDRO-TRACK",SUP-7082,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,466.07,41.1,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI 100CM 6FR MPB2 CURVE ANGIOGRAPHIC VESTAN",SUP-534649T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRESSING ANTIMICROBIAL 3.5 X 6 INCH AQUACEL AG ADVANTAGE",SUP-422604,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.29,69.09,"FIRST HEALTH [10303]","First Health",,184.23,80,,,,,0,26.78,195.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM LOCK STERILE",SUP-2361-5050S,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.05,506.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,199.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",196.2,1433.99,"percent of total billed charges",
"STEM EXT 60MM 20MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-151320060,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"NOVANET [10819]",Novanet,,6199.65,75,,,,,0,961.36,7026.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 46MM 32MM XLPE HIP STERILE LATEX FREE",SUP-71935847,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"AETNA [10100]","Aetna HMO/PPO",,8845.37,79.5,,10981.53,8986.79,12413.38,12,1293.98,9457.31,"percent of total billed charges",
"SCR BONE 6.5MM 55MM TITANIUM TIBIA CANCELLOUS OPENING WEDGE",SUP-AR-13280-55,CDM,C1713,HCPCS,0278,RC,,,both,,,1968.75,590.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,563.46,28.62,,,,,0,228.97,1673.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET RETRIEVAL 80CM 6.3FR 11FR GUNTHER TULIP VENA CAVA 3 WAY",SUP-G13287,CDM,C1773,HCPCS,0272,RC,,,both,,,2194.50,658.35,"KAISER [10500]",Kaiser,,1470.32,67,,,,,0,255.22,1865.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CABLE 121X23MM CABLE-READY LONG 4 INTEGRAL GREATER",SUP-00223200205,CDM,C1713,HCPCS,0278,RC,,,both,,,22018.50,6605.55,"UHC [10700]","United Healthcare",,13937.71,63.3,,5023.51,2672.93,6679.78,18,2560.75,18715.73,"percent of total billed charges",
"BODY HUMERAL SMR TITANIUM LOCKING SCR FINNED REVISION",SUP-1350.15.110,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CIGNA [10200]","Cigna Local Plus",,4237.2,53.5,,5372.07,4581.20,7242.98,23,921.1,6732,"percent of total billed charges",
"ROPINIROLE 0.25 MG TABLET, IMMEDIATE RELEASE",RX-21688,CDM,,,0637,RC,00904-6373-61,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HALOPERIDOL 5 MG TABLET",RX-3583,CDM,,,0637,RC,70756-0004-11,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 50X76X.6MM TITANIUM POLYETHYLENE NONPOROUS MESH EMBED",SUP-81025,CDM,C1713,HCPCS,0278,RC,,,both,,,10082.14,3024.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2885.51,28.62,,,,,0,1172.55,8569.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.55-1.75IN TITANIUM 5.5MM ROD LOW PROFILE BAR FIX",SUP-811-321,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross PPO",,1396.5,39.2,,957.42,570.23,957.42,28,414.32,3028.13,"percent of total billed charges",
"INSRT HUMERAL H+0MM 36MM PERFORM .75 SHOULDER REVERSE",SUP-DWP4360,CDM,C1776,HCPCS,0278,RC,,,both,,,17388.00,5216.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7146.47,41.1,,6417.48,6417.48,6417.48,"1 through 10",2022.22,14779.8,"percent of total billed charges",
"SCR BONE 9MM 85MM REVERE SPINE PEDICLE NONSTERILE",SUP-124.224,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL CANNULATED POLYAXIAL LOCKING SCREW 2.0MM",SUP-DRLL-PLS-20,CDM,C1713,HCPCS,0278,RC,,,both,,,753.30,225.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,89.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,87.61,640.31,"percent of total billed charges",
"STEM FEMORAL 180MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309018,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"KAISER [10500]",Kaiser,,25300.67,67,,,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELIANCE 4 FRONT PASSIVE FIXATION SINGLE COIL 64CM",SUP-0663,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6238.98,41.1,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA ROUND ALLOGRAFT STRUT FROZEN 60X10MM",SUP-450660,CDM,S27800098,LOCAL,0278,RC,,,both,,,7443.72,2233.12,"CIGNA [10200]","Cigna Open Access",,4235.48,56.9,,,,,0,865.7,6327.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036123060,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 120MM 125CM 7MM 6FR BILIARY NITINOL",SUP-G50169,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CIGNA [10200]",Cigna,,4141.2,68,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE COUGAR XT VASCULAR STRAIGHT 190CM .014IN HYDRO-TRACK",SUP-CGRXT190HS,CDM,C1769,HCPCS,0272,RC,,,both,,,486.00,145.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,330.48,68,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 100MM 7MM BALLOON DILATATION STERILE LATEX",SUP-597010022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"AETNA [10100]","Aetna HMO/PPO",,1159.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X10MM COHERE XLW 15D STERILE LATEX FREE",SUP-8151050P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,29925.00,8977.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12299.18,41.1,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 65MM KNEE RIGHT POSTERIOR STABILIZE OPEN BOX",SUP-184508,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"FIRST HEALTH [10303]","First Health",,19860.62,80,,,,,0,2887.24,21101.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE ARISTA MPH PLANT STARCH 5GM",SUP-SM0007USA,CDM,S27200284,LOCAL,0272,RC,,,both,,,2550.00,765,"CIGNA [10200]","Cigna Open Access",,1450.95,56.9,,,,,0,296.57,2167.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYNX CONTROL 6-12FR CLSR HYDROPHILIC PEG VASCULAR",SUP-MX61260,CDM,C1760,HCPCS,0278,RC,,,both,,,1650.00,495,"AMERIGROUP MEDICAID [20100]",Amerigroup,,195.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOTTLE DRNG DISCHARGE PACK ROCKET IPC 1000ML NONSTERILE",SUP-R51411-DP,CDM,S27200284,LOCAL,0272,RC,,,both,,,556.88,167.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,65.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.77,473.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 90X25.4X1.27MM PRIMECUT OSCILLATING",SUP-5271-561,CDM,S27200284,LOCAL,0272,RC,,,both,,,536.38,160.91,"CIGNA [10200]",Cigna,,364.74,68,,,,,0,62.38,455.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE SURGIPRO CV-15 48",SUP-VP583X-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.74,49.72,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ORTHOPEDIC GOLD 1.4MM MAXTORQUE THREADED",SUP-CSS04014T,CDM,C1769,HCPCS,0272,RC,,,both,,,113.10,33.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPRT ORTHOPEDIC ADULT TENSOWRAP-NU THERMOPLASTIC FABRIFOAM",SUP-A952701,CDM,S27000186,LOCAL,0270,RC,,,both,,,172.78,51.83,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE HEMOSTASIS FLUORESCENT PINK GREEN DOUBLEPLAY 2Y METAL",SUP-MAP222,CDM,S27200284,LOCAL,0272,RC,,,both,,,185.40,55.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXTR SURGICAL CONICAL 2.7 MM 3.5 MM 4 MM CORTICAL CONICAL",SUP-309.520,CDM,S27000186,LOCAL,0270,RC,,,both,,,901.69,270.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE KANGAROO ENDOSCOPIC BULB NONSTERILE LATEX FREE",SUP-388105E,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 12MM BIOMET STAINLESS STEEL QUICK RELEASE COUPLING",SUP-430054,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) HELO BLOOD RETURN SYSTEM (HELO BRS)",SUP-5001,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VLVTOM 1.8MM 110CM EXPANDABLE ANGIOSCOPIC",SUP-1000-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,12965.10,3889.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PILOCARPINE 2 % EYE DROPS",RX-6280,CDM,,,0250,RC,61314-0204-15,NDC,both,15,ML,634.13,190.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PIN FIXATION LCS SIGMA HIP THREAD HEAD STERILE",SUP-950502303,CDM,S27200284,LOCAL,0272,RC,,,both,,,1938.75,581.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Adapter Perfusion Multiple",PX-E27200357,CDM,E27200357,LOCAL,0272,RC,,,both,,,151.80,45.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EPIFIX MESH 3.5X3.5 CM",SUP-ES-3300,CDM,Q4186,HCPCS,0636,RC,,,both,,,8618.10,2585.43,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PCP050300090 PLUS US D5L300UL900",SUP-PCP050300090,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DISECT 13CM 5.5MM AGGRESSIVE SURGICAL STERILE DISPOSABLE",SUP-AR-8550DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 20GA 10CM POWERGLIDE PRO BIOPATCH FULL INSRT",SUP-F320108T,CDM,C1751,HCPCS,0272,RC,,,both,,,884.36,265.31,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC",250,MS-DRG,,,,,,,inpatient,,,138658.66,41597.6,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP GLOBAL UNITE REVER",SUP-OSC379179,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"BLUE CROSS [10001]","Blue Cross PPO",,17781.12,39.2,,3949.44,3949.44,3949.44,"1 through 10",5275.37,38556,"percent of total billed charges",
"HC Semen Analysis",PX-301000452,CDM,G0027,HCPCS,0301,RC,,,both,,,257.00,77.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,218.45,"per diem",
"PACEMKR CARDIAC .75CM 13.7CU CM 4.45X5.02CM ESSENTIO",SUP-L101,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"PHCS [10601]",PHCS,,29120,70,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH SURGICAL 8.5MM BARRON CORNEA VACCUM DONOR CORNEA",SUP-K20-2080,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,63.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REFERENCE TOE 1ST MTP IMPLANT WITH GROMMETS  SIZE 2","SUP-M30 SE020",CDM,C1776,HCPCS,0278,RC,,,both,,,11937.00,3581.1,"CIGNA [10200]","Cigna Open Access",,3998.9,33.5,,5302.19,4377.88,6578.61,27,1388.27,10146.45,"percent of total billed charges",
"SCR BASEPLT 30MM 9.5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ230,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"BLUE CROSS [10001]","Blue Cross HMO",,3538.98,39.2,,5311.50,4717.44,5388.59,31,1049.96,7673.8,"percent of total billed charges",
"CLIP INTERNAL LAPRO-CLIP KIT 2 HANDLE",SUP-2LCH8812,CDM,S27200284,LOCAL,0272,RC,,,both,,,18345.60,5503.68,"NOVANET [10819]",Novanet,,13759.2,75,,,,,0,2133.59,15593.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Breast Local Dev Mammo",PX-361000312,CDM,19281,CPT,0361,RC,,,both,,,1681.32,504.4,"BLUE CROSS [10001]","Blue Cross PPO",,1681.32,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,195.54,1681.32,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA 36-39IN MEDIUM HOOK LOOP CLSR WIDE ADJUSTABLE SHOULDER",SUP-M5001-M,CDM,S27000186,LOCAL,0270,RC,,,both,,,161.39,48.42,"NOVANET [10819]",Novanet,,121.04,75,,,,,0,18.77,137.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM VERTEX MAX TITANIUM SPINE MULTIAXIAL",SUP-6958732,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"BLUE CROSS [10001]","Blue Cross PPO",,1646.4,39.2,,957.42,570.23,957.42,28,488.46,3570,"percent of total billed charges",
"STENT CONTOUR 26CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805330,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"FIRST HEALTH [10303]","First Health",,721.74,80,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME PATELLAR 38MM PFC SIGMA OVAL KNEE UHMWPE CEMENTED 3 PEG",SUP-960102,CDM,C1776,HCPCS,0278,RC,,,both,,,4723.05,1416.91,"AMERIGROUP MEDICAID [20100]",Amerigroup,,559.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,549.29,4014.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 49CM 8.6FR TENSI-LOCK SPRINT QUATTRO HELIX STD",SUP-6947M49,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2034.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 50MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 3X3",SUP-241.13,CDM,C1713,HCPCS,0278,RC,,,both,,,2315.70,694.71,"KAISER [10500]",Kaiser,,1551.52,67,,,,,0,269.32,1968.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 43IN 12FR 2 PORT CNCT RADIOPAQUE RIGID",SUP-8884711246E,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.69,20.61,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SUPERORDERABLE",RX-40814984,CDM,,,0250,RC,06332-3462-04,NDC,both,10,ML,26.12,7.84,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Bx Breast Ultrasonic Clip Plc Add",PX-361000309,CDM,19084,CPT,0361,RC,,,both,,,4669.25,1400.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN RADIOFREQUENCY 5CM 20GA ACCURIAN CURVE SHARP 10MM",SUP-AC0008,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIPOLAR HIP 2:  FX OR CEMENTED STEM",SUP-CAP-STY-BP2,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Local Plus",,5537.25,53.5,,5372.07,4581.20,7242.98,23,1203.71,8797.5,"percent of total billed charges",
"GRSP ENDOSCOPIC FLEXIBLE STERILE LATEX FREE DISPOSABLE",SUP-FG-253SX,CDM,S27200284,LOCAL,0272,RC,,,both,,,575.34,172.6,"NOVANET [10819]",Novanet,,431.51,75,,,,,0,66.91,489.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RED BLOOD CELL DISORDERS WITH MCC",811,MS-DRG,,,,,,,inpatient,,,34848.88,10454.66,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,9320.73,,"Case rate ($8,710.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,088.72, add-ons for qualifying new technology services are included. If operating cost exceeds $41,128.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,993.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,099.41. The transfer operating threshold is the transfer adjustment factor * $8,088.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.55. The transfer capital threshold is the transfer adjustment factor * $611.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,34848.88,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"UNITY - TIBIAL INSERT MC #4 Th9 R",SUP-1127409,CDM,C1776,HCPCS,0278,RC,,,both,,,4140.00,1242,"KAISER [10500]",Kaiser,,2773.8,67,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit B Level 5 W Proc",PX-450000334,CDM,G0384,HCPCS,0450,RC,,,both,,,2793.00,837.9,"BLUE CROSS [10001]","Blue Cross HMO",,1740.57,,,,,,,67.13,2374.05,"case rate",
"HC Ins Cath Cv Tunlw/O Port<5yrs",PX-361000498,CDM,36557,CPT,0361,RC,,,both,,,8549.00,2564.7,"AETNA [10100]","Aetna HMO/PPO",,6796.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,994.25,8549,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.4MM 90MM LCP STAINLESS STEEL 4MM PARTIAL",SUP-02.205.290,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1057.98,68,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 70CM PRECISION STRAIGHT PERCUTANEOUS LINEAR",SUP-SC-2218-70,CDM,C1778,HCPCS,0278,RC,,,both,,,8914.80,2674.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4091.89,45.9,,,,,0,1036.79,7577.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 12MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0280,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross HMO",,371.5,39.2,,957.42,156.86,7483.26,51,110.22,805.55,"percent of total billed charges",
"GRAFT BONE ALLOQUENT CORTICAL 5D ALLOGRAFT 8MM LATEX FREE",SUP-3W3008,CDM,S27800098,LOCAL,0278,RC,,,both,,,5896.74,1769.02,"KAISER [10500]",Kaiser,,3950.82,67,,,,,0,685.79,5012.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X17-14.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-4817,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4245.78,28.62,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARCADIA 10MM BALLOON DILATATION 3CC ROBUST DURABLE HIGH",SUP-ARC10ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,5978.16,1793.45,"KAISER [10500]",Kaiser,,4005.37,67,,,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X8MM CLYDESDALE PTC 6D PEEK TANTALUM",SUP-4986845,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"CIGNA [10200]","Cigna Local Plus",,7484.4,31.5,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF ENHANCR II 90CM 4MM 7FR 2-5-2MM SPACE 65MM SINGLE",SUP-FND-019-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CIGNA [10200]",Cigna,,925.34,68,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640406,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Open Access",,6403.47,56.9,,5302.19,4377.88,6578.61,27,1308.83,9565.82,"percent of total billed charges",
"NAIL 10MM 270MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-410-270,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,957.42,570.23,957.42,28,2014.9,14726.25,"percent of total billed charges",
"GRAFT ENDOVASCULAR 124MM 28-16MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1628C124E,CDM,C1876,HCPCS,0278,RC,,,both,,,31342.50,9402.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8970.22,28.62,,,,,0,3645.13,26641.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FUROSEMIDE 40 MG TABLET",RX-3295,CDM,,,0637,RC,00904-7178-61,NDC,both,1,UN,6.27,1.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLYFLEX 50MM 10MM 16MM AIRWAY POLYESTER SILICONE SELF",SUP-7017,CDM,C1887,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"NOVANET [10819]",Novanet,,2503.13,75,,,,,0,388.15,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS ZIPWIRE 22CM 3CM 6FR .038IN PIGTAIL CURVE",SUP-M0061265310,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CIGNA [10200]","Cigna Local Plus",,759.88,,,,,,,165.19,1207.29,"percent of total billed charges",
"STENT ENDOMAXX 150MM 90CM 19MM 24FR ESOPHAGEAL SILICONE OTW",SUP-MAXX-1915,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"MULTIPLAN [10600]",Multiplan,,14662.5,85,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIZACT OPEN SEALER DIVIDER",SUP-BZ4212A,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,909.34,41.1,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X13X9MM ACIS STD LORDOTIC PEEK RADIOPAQUE",SUP-08.843.009S,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4.2MM LANZA 6000 RPM 2500 RPM STRAIGHT",SUP-9391A,CDM,S27200284,LOCAL,0272,RC,,,both,,,622.32,186.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM NOVII FETAL MNTR PATCH",SUP-107-PT-004-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,395.66,118.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT GORE VIABAHN 29MM 135CM 11MM 16SQ MM 8FR .035IN",SUP-BXA112902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8016.47,41.1,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SPECIMEN RETRIEVAL ROTH NET 2.5MM 160CM 5.5X4CM FOOD",SUP-00711155,CDM,S27000186,LOCAL,0270,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 BIOKNOTLESS PLUS ORTHOCORD ROTATOR CUFF",SUP-212722,CDM,C1713,HCPCS,0278,RC,,,both,,,5664.90,1699.47,"CIGNA [10200]","Cigna Open Access",,3223.33,56.9,,1144.80,304.56,2275.09,66,658.83,4815.17,"percent of total billed charges",
"INSRT TIBIAL 9 5MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650905,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1526.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT EXTERNAL FIXATION TRUELOK UNIVERSAL WIRE",SUP-54-1152,CDM,C1713,HCPCS,0278,RC,,,both,,,683.48,205.04,"KAISER [10500]",Kaiser,,457.93,67,,,,,0,79.49,580.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MA60AC.9 AS MP FOLDABLE 6 REFERENCE",SUP-MA60AC.9,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,345.41,28.62,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET TITANIUM SPINE BLOCKER XIA 3",SUP-48230000,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"BLUE CROSS [10001]","Blue Cross PPO",,136.42,39.2,,957.42,570.23,957.42,28,40.47,295.8,"percent of total billed charges",
"SCR BONE 6MM 40MM TITANIUM SPINE CORTICAL POLYAXIAL FIX",SUP-186727640,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 LEFT KNEE CRUCIATE RETAINING CEMENTED",SUP-5510-F-401,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4693.06,28.62,,,,,0,1907.07,13938.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER TORQR 110CM 5FR 2MM SPACING DAMATO CURVE ELECTROPHY",SUP-04130DS,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"AETNA [10100]","Aetna HMO/PPO",,248.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY DRNG 12FR FLEXIBLE STAYFIX SMALL SECUREMENT DEVICE",SUP-RLC-NV-12-SFX,CDM,C1729,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UHC [10700]","United Healthcare",,794.73,63.3,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION",RX-33175,CDM,J3486,HCPCS,0636,RC,72266-0160-01,NDC,both,1,UN,247.50,74.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,168.3,68,,,,,0,15.92,210.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LOCKING 7 HOLE DISTAL MEDIAL TIBIAL 98MM STAINLESS",SUP-223.571,CDM,C1713,HCPCS,0278,RC,,,both,,,1913.10,573.93,"CIGNA [10200]","Cigna Open Access",,1088.55,56.9,,1144.80,304.56,2275.09,66,222.49,1626.14,"percent of total billed charges",
"SHELL ACETABULAR 66MM HIP MULTIHOLE TRIDENT H HEMISPHERE",SUP-508-11-66H,CDM,C1776,HCPCS,0278,RC,,,both,,,11233.20,3369.96,"CIGNA [10200]","Cigna Local Plus",,6009.76,53.5,,5372.07,4581.20,7242.98,23,1306.42,9548.22,"percent of total billed charges",
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (1-1.5 MCI)",RX-411871,CDM,A9520,HCPCS,0343,RC,08888-8876-05,NDC,both,1,UN,4614.97,1384.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3138.18,68,,,,,0,536.72,3922.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT HUMERAL SIMPLICITI 3 NUCLEUS",SUP-DWG403,CDM,C1776,HCPCS,0278,RC,,,both,,,15840.00,4752,"MULTIPLAN [10600]",Multiplan,,13464,85,,,,,0,1842.19,13464,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 7CM 5FR 21GA MICROPUNCTURE .18IN HEMOSTASIS VALVE",SUP-G02988,CDM,C1894,HCPCS,0272,RC,,,both,,,394.28,118.28,"KAISER [10500]",Kaiser,,264.17,67,,,,,0,45.85,335.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 35MM TITANIUM LEVEL 2 ZEVO BONE SPINE CERVICAL",SUP-3002035,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross HMO",,1728.72,39.2,,957.42,156.86,7483.26,51,512.88,3748.5,"percent of total billed charges",
"SLEEVE LAPAROSCOPIC 12MM ACCESS SYSTEM 150MM KII ABDOMEN Z",SUP-CTS21,CDM,S27200284,LOCAL,0272,RC,,,both,,,119.63,35.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 57MM TITANIUM LEVEL 3 ASSURE BONE SPINE CERVICAL",SUP-110.357,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"CIGNA [10200]",Cigna,,3598.56,68,,1831.33,1831.33,1831.33,16,615.46,4498.2,"percent of total billed charges",
"SAFESHEATH INTRDCR FR12",SUP-7119,CDM,C1892,HCPCS,0272,RC,,,both,,,130.50,39.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL 29MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-151111201,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 4MM CORONARY STENT",SUP-H7493941820400,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Open Access",,1707,56.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 20MM 3MM BALLOON DILATATION DURALYN",SUP-48003002S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UHC [10700]","United Healthcare",,794.73,63.3,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENV TISSUE 6.9X6.5CM CORMATRIX CANGAROO ECM MEDIUM PORCINE",SUP-CMCV-009-MED,CDM,S27800098,LOCAL,0278,RC,,,both,,,6796.50,2038.95,"AETNA [10100]","Aetna HMO/PPO",,5403.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,790.43,5777.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BLUE 54MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103554000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"BLUE CROSS [10001]","Blue Cross HMO",,1201.21,39.2,,5311.50,4717.44,5388.59,31,356.38,2604.67,"percent of total billed charges",
"BLADE SAW 90X12.7X1.19MM OSCILLATING",SUP-6113-119-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 11X14MM VERTE-STACK CORNERSTONE PSR 25MM",SUP-6277025,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"PHCS [10601]",PHCS,,4674.89,70,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 12MM 3.5MM ULTRA LOW PROFILE BALLOON",SUP-1012276-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MORPHINE ER 15 MG TABLET,EXTENDED RELEASE",RX-20920,CDM,,,0250,RC,00406-8315-23,NDC,both,1,UN,16.65,4.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP SURGICAL STEALTH 12MM 12MM ATRAUMATIC OCCLUSION FULL",SUP-G-1250,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BINDER ABDOMINAL 15IN LARGE",SUP-D-497-LRG,CDM,S27000186,LOCAL,0270,RC,,,both,,,178.35,53.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 7.25X1.25IN TAYLOR 4IN LARGE SPINE SURGICAL",SUP-57-5410,CDM,S27200284,LOCAL,0272,RC,,,both,,,347.39,104.22,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO GLIDESHEATH SLENDER STAINLESS STEEL",SUP-RM*RS6F10PA,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2.7MM 16MM LOW PROFILE NONSTERILE LATEX FREE",SUP-131227216,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"KAISER [10500]",Kaiser,,569.84,67,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN HOLDING MG II KNEE HEXAGON STAINLESS STEEL NONSTERILE",SUP-506106300,CDM,C1713,HCPCS,0278,RC,,,both,,,205.10,61.53,"KAISER [10500]",Kaiser,,137.42,67,,,,,0,23.85,174.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 165MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-410-165,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN AMPLATZ RIGHT",SUP-534648T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) DEVICE CELT ACD 6FR CLSR VASCULAR STERILE LATEX FREE",SUP-KCLT-06,CDM,C1760,HCPCS,0278,RC,,,both,,,1539.00,461.7,"CIGNA [10200]","Cigna Open Access",,875.69,56.9,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL IDENTITY IMPRINT 4 NARROW KNEE POSTERIOR",SUP-TPS-301-T04N,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"BLUE CROSS [10001]","Blue Cross PPO",,3448.62,39.2,,3949.44,3949.44,3949.44,"1 through 10",1023.15,7477.88,"percent of total billed charges",
"CEFTRIAXONE 2 G VIAL - INTRAMUSCULAR",RX-408316,CDM,J0696,HCPCS,0636,RC,00409-7335-21,NDC,both,1,UN,26.21,7.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7.2,,,,,,,4.01,22.28,"fee schedule",
"PLATE TIBIAL 20MM S-ROM NOILES SMALL KNEE NONPOROUS CEMENT",SUP-622166,CDM,C1713,HCPCS,0278,RC,,,both,,,9635.16,2890.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4422.54,45.9,,,,,0,1120.57,8189.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 30IN BRAID TIES 10 STRAND PRECUT",SUP-SA85H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NIMODIPINE 30 MG CAPSULE",RX-10722,CDM,,,0637,RC,69452-0209-07,NDC,both,1,UN,72.70,21.81,"PHCS [10601]",PHCS,,50.89,70,,,,,0,8.46,61.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850016535,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross PPO",,2569.56,39.2,,957.42,570.23,957.42,28,762.35,5571.75,"percent of total billed charges",
"CATH IMPULSE 110CM 6FR 145D PIGTAIL CURVE ANGIOGRAPHIC",SUP-H74916599410,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"FIRST HEALTH [10303]","First Health",,61.26,80,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U215,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"FIRST HEALTH [10303]","First Health",,596,80,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL GREEN 11CM SAFE-T-GAUGE ROUND LOOP",SUP-DLP-M11,CDM,S27200284,LOCAL,0272,RC,,,both,,,140.07,42.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY PERICARDIOCENTESIS 40CM 8.3FR 18GA PIGTAIL CURVE",SUP-G10210,CDM,C1729,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) OSCOR GUIDESTAR 10F SHEATH 22MM","SUP-D-1433-02-SI (22MM)",CDM,C1887,HCPCS,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC",086,MS-DRG,,,,,,,inpatient,,,43405.93,13021.78,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH VISISHEATH 33CM 12FR DIL",SUP-501-112,CDM,C1893,HCPCS,0272,RC,,,both,,,1987.50,596.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND 2-0 30IN BRAID TIES 10 STRAND PRECUT",SUP-SA85H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC",837,MS-DRG,,,,,,,inpatient,,,86556.24,25966.87,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 14MM TIMESH CENTERPIECE CRANIAL TITANIUM OPEN",SUP-853014WM,CDM,C1713,HCPCS,0278,RC,,,both,,,2624.40,787.32,"AETNA [10100]","Aetna HMO/PPO",,2086.4,79.5,,1521.93,481.35,16760.95,30,305.22,2230.74,"percent of total billed charges",
"SHEATH TOURGUIDE 180D 45CM 9MM 7FR CATH HYDROPHILIC",SUP-TG0704509,CDM,C1887,HCPCS,0272,RC,,,both,,,4209.00,1262.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,489.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,489.51,3577.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Psg >4 Param",PX-740000004,CDM,95810,CPT,0920,RC,,,both,,,6504.89,1951.47,"CIGNA [10200]",Cigna,,1733,,"Per diem ($1,733).",,,,0,756.52,5529.16,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +28 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.280,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,197.05,28.62,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insulin Free",PX-301000286,CDM,83527,CPT,0301,RC,,,both,,,283.00,84.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,240.55,"per diem",
"HC Sol D10",PX-E27200283,CDM,E27200283,LOCAL,0272,RC,,,both,,,121.00,36.3,"CIGNA [10200]",Cigna,,82.28,68,,,,,0,14.07,102.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 11CM MINI GWIRE AVANTI+ STAINLESS STEEL",SUP-504655X,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,53.24,68,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 40MM 80CM 10MM VASCULAR PERIPHERAL SELF",SUP-1012532-40,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 24X10X17-13.7MM LUMINARY BULLET NOSE",SUP-15817,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"UHC [10700]","United Healthcare",,11963.7,63.3,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 CURVE PLUS 10MM KNEE XLK FIX BEARING SIGMA",SUP-970441,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]",Cigna,,7598.69,68,,5873.17,5873.17,5873.17,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"MATRIX TISSUE 20X16CM ALLODERM SELECT THK.4-2.4MM THICK",SUP-1519320P,CDM,Q4116,HCPCS,0636,RC,,,both,,,60228.00,18068.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7137.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.92,51193.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR 3 DIMENSIONAL RIGHT",SUP-67013000,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"AETNA [10100]","Aetna HMO/PPO",,331.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARCTIC FRONT ADVANCE 95CM 23MM 10.5FR 28MM CRYOABLATION",SUP-2AF234,CDM,C2630,HCPCS,0272,RC,,,both,,,26460.00,7938,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10875.06,41.1,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPLATZER TALISMAN PFO OCCLUDER 35-25MM",SUP-9-PFO-3525,CDM,C1817,HCPCS,0278,RC,,,both,,,56668.50,17000.55,"PHCS [10601]",PHCS,,39667.95,70,,,,,0,6590.55,48168.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +11 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.110,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 45MM 135CM 6MM 160CM",SUP-M001711110,CDM,C1876,HCPCS,0278,RC,,,both,,,8728.50,2618.55,"CIGNA [10200]",Cigna,,5935.38,68,,,,,0,1015.12,7419.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 22MM 2.25MM CORONARY RAPID EXCHANGE",SUP-ONYXNG22522UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2662.50,798.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,762.01,28.62,,,,,0,309.65,2263.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 3.2MM 8MM TITANIUM T15 SPINE OCCIPITOCERVICAL",SUP-04.601.108,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR PRESSURE NIFOMETER 60- CM 2O SMALL NEGATIVE",SUP-1034002,CDM,S27000186,LOCAL,0270,RC,,,both,,,125.57,37.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,85.39,68,,,,,0,14.6,106.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 19MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G719,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2492.12,28.62,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ileoscopy Stoma W Stent",PX-750000160,CDM,44384,CPT,0750,RC,,,both,,,7444.00,2233.2,"AETNA [10100]","Aetna HMO/PPO",,5917.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,865.74,6327.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXTOME 142CM 10MM 3.75MM BALLOON DILATATION NYLON",SUP-H749CBM3375100,CDM,C1725,HCPCS,0272,RC,,,both,,,5395.80,1618.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3669.14,68,,,,,0,627.53,4586.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 26MM HIP C TAPER COCR LFIT",SUP-06-2605,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1435.61,45.9,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCRYL RAPIDE 30MM 7MM ACL BIOABSORBABLE",SUP-231805,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,957.42,156.86,7483.26,51,434.96,3179,"percent of total billed charges",
"SUT VICRYL PLUS 3-0 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP838D,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Open Access",,14.23,56.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SITESEER 100CM 5FR BR3.5 CURVE ANGIOGRAPHIC 1 SIDEHOLE",SUP-5A0034,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 5 KNEE CEMENT REVISION FIX BEARING",SUP-150640005,CDM,C1776,HCPCS,0278,RC,,,both,,,16284.00,4885.2,"NOVANET [10819]",Novanet,,12213,75,,,,,0,1893.83,13841.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 14MM 2.25MM CLEARVIEW INTRACORONARY",SUP-31225,CDM,S27800098,LOCAL,0278,RC,,,both,,,632.53,189.76,"BLUE CROSS [10001]","Blue Cross PPO",,247.95,39.2,,,,,0,73.56,537.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRI-SIL 60IN 22FR URETHRAL BACTI-GUARD SILICONE",SUP-0172SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.66,57.5,"CIGNA [10200]","Cigna Open Access",,109.05,56.9,,,,,0,22.29,162.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM ATLANTIS TITANIUM SPINAL CANCELLOUS",SUP-876-814,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"CATH LAUNCHER 100CM 6FR .071IN SHORT LEFT 4 CURVE GUIDING",SUP-LA6SL40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TALON ORTHOPEDIC 600MM 3MM TROCAR TIP",SUP-SLN-T35,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATTAIN COMMAND SUREVALVE 50CM 9FR 7.2FR STRAIGHT",SUP-6250V-50S,CDM,C1887,HCPCS,0272,RC,,,both,,,2602.50,780.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,308.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,302.67,2212.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X20 80CM SL",SUP-48005002N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"MULTIPLAN [10600]",Multiplan,,730.16,85,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP BASEPLT TIBIAL ATTUNE FIX BEARING CEMENTLESS",SUP-OSC381865,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2762.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2710.95,19813.5,"percent of total billed charges",
"TUBE TRACH 7.5MM PORTEX BLUSELECT CUFF STERILE LATEX FREE",SUP-101/815/075,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.48,103.04,"NOVANET [10819]",Novanet,,257.61,75,,,,,0,39.95,291.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET TRANSFER 1960X760MM 480MM MAXITUBE FLITES PREMIUM TUBE",SUP-NPA0700,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.89,30.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.85,86.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 300MM HIP RIGHT FEMUR AFFIXUS INTRAMEDULLARY 130D",SUP-814511300,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"PHCS [10601]",PHCS,,14519.93,70,,,,,0,2412.38,17631.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 3.25MM CORONARY STENT",SUP-1145325-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AETNA [10100]","Aetna HMO/PPO",,4641.21,79.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5.5FR 11CM GRAY HUB TUBING ROTATING SUT RING",SUP-PSI-5F-11ACT,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,51.47,68,,,,,0,8.8,64.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 5.5MM IMPL FLEXOR DIGITORUM LONGUS",SUP-AR-1555BC-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10831.28,3249.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4451.66,41.1,,,,,0,1259.68,9206.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 30MM LCP STAINLESS STEEL PROXIMAL FEMORAL",SUP-02.205.030,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"FIRST HEALTH [10303]","First Health",,1010.62,80,,,,,0,146.92,1073.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 75CM 7MM 30MM",SUP-H74938046730750,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1428.71,28.62,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OCTARAY 3-3-3-3-3MM SPCAE F CURVE ELECTROPHYSIOLOGY",SUP-D160906,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"AETNA [10100]","Aetna HMO/PPO",,12616.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inhibin A",PX-302000072,CDM,86336,CPT,0302,RC,,,both,,,155.00,46.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.68,,"Fee schedule rate ($16.68). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,131.75,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tavi/Tavr Open Axil Approach",PX-361000345,CDM,33363,CPT,0361,RC,,,both,,,45298.00,13589.4,"MULTIPLAN [10600]",Multiplan,,38503.3,85,,,,,0,2491,38503.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG BONE CEMENT 30MM LARGE INTRAMEDULLARY CANAL STERILE",SUP-6215-5-021,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,90.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",88.55,647.19,"percent of total billed charges",
"HC Tcat Ins 1chmbr Ldls Pm Ra",PX-481000390,CDM,0823T,CPT,0481,RC,,,both,,,29836.00,8950.8,"FIRST HEALTH [10303]","First Health",,23868.8,80,,,,,0,3469.93,25360.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 110CM ATRIUM VENTRICLE BIPOLAR FIXED SCR IN",SUP-3830110,CDM,C1898,HCPCS,0275,RC,,,both,,,2850.00,855,"NOVANET [10819]",Novanet,,2137.5,75,,,,,0,331.46,2422.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 42MM NAIL-EX TITANIUM FULL THREAD HUMERAL",SUP-04.005.432S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,177.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",174.09,1272.35,"percent of total billed charges",
"GRAFT SKIN 22X19CM FLEXHD PLIABLE PRE THK.7-1.4MM THIN SMALL",SUP-PP1500,CDM,Q4128,HCPCS,0636,RC,,,both,,,71820.00,21546,"UHC [10700]","United Healthcare",,247.92,,,,,,,80.43,61047,"fee schedule",
"CLLGN 5IN .6IN SHORTSHOT SAEED TRIVIEW 4 BAND HEMORRHOIDAL",SUP-G34063,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE CURL CATH 57CM 15FR DIALYSIS SILICONE FELT",SUP-8811313015,CDM,C1750,HCPCS,0278,RC,,,both,,,550.15,165.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,157.45,28.62,,,,,0,63.98,467.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 67MMX15MM VANGUARD 360 KNEE RIGHT MEDIAL LEFT",SUP-185252,CDM,C1776,HCPCS,0278,RC,,,both,,,7577.58,2273.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5152.75,68,,,,,0,881.27,6440.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Methotrexate",PX-301000077,CDM,80299,CPT,0301,RC,,,both,,,425.60,127.68,"KAISER [10500]",Kaiser,,285.15,67,,,,,0,0.01,361.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 8MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158122108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UHC [10700]","United Healthcare",,7073.49,63.3,,8601.07,8395.67,8601.07,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"COIL EMBOLIZATION 3CM 2MM TARGET NANO 360D DETACHABLE",SUP-M0035442030,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"UHC [10700]","United Healthcare",,8934.57,63.3,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 100CM 6.7FR GPC CURVE ANGIOGRAPHIC POLYETHYLENE",SUP-G00174,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.19,73.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.63,209.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 3-0 PS-1 SPIRAL 45CM KNOTLESS",SUP-SXMP1B102,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,98.18,45.9,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 17MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-017,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"AETNA [10100]","Aetna HMO/PPO",,3765.99,79.5,,10981.53,8986.79,12413.38,12,550.92,4026.54,"percent of total billed charges",
"NAIL 11MM 400MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.160S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CIGNA [10200]",Cigna,,4967.34,40,,1831.33,1831.33,1831.33,16,1444.25,10555.59,"percent of total billed charges",
"BLADE 12MM BIOMET STAINLESS STEEL QUICK RELEASE COUPLING",SUP-430054,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUBICON 90CM 5.1FR 2.84FR 50MM SPACE GUIDING NYLON",SUP-H74939240035091,CDM,C1887,HCPCS,0272,RC,,,both,,,1449.90,434.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,171.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 40MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"MULTIPLAN [10600]",Multiplan,,1218.65,85,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,inpatient,,,29665.36,8899.61,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,4544.16,,"Case rate ($4,286.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,980.71, add-ons for qualifying new technology services are included. If operating cost exceeds $37,020.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,682.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,985.97. The transfer operating threshold is the transfer adjustment factor * $3,980.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $300.96. The transfer capital threshold is the transfer adjustment factor * $300.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,4286.94,17235.34,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 40MM 80CM 6MM VASCULAR PERIPHERAL SELF",SUP-1012528-40,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross HMO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT BIORAPTOR SHOULDER KNOTLESS INNER LOCK PLUG",SUP-72202403,CDM,C1713,HCPCS,0278,RC,,,both,,,2212.88,663.86,"NOVANET [10819]",Novanet,,1659.66,75,,,,,0,257.36,1880.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BULKING AGNT DEXTRNMR GLS SYR VESCURTRL REFLX DEFLUX 1ML",SUP-365649922039,CDM,L8603,HCPCS,0278,RC,,,both,,,20018.00,6005.4,"PHCS [10601]",PHCS,,14012.6,70,,,,,0,336.83,17015.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS PRIMOPAC 4FR STRAIGHT PIGTAIL JR4 JL4 CURVE",SUP-538499P,CDM,S27200284,LOCAL,0272,RC,,,both,,,232.73,69.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,158.26,68,,,,,0,27.07,197.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 5 X 10 COMPLEX FINISHING COIL",SUP-10CFN-05010,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Open Access",,3927.24,33.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 140MM 22MM DHS/DCS STAINLESS STEEL CONDYLAR",SUP-280.4,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"AMERIGROUP MEDICAID [20100]",Amerigroup,,215.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",211.48,1545.62,"percent of total billed charges",
"TROCAR LAPAROSCOPIC 100MM 5MM KII FIOS FIRST ENTRY Z THREAD",SUP-CTF03,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.00,40.2,"MULTIPLAN [10600]",Multiplan,,113.9,85,,,,,0,15.58,113.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50MMX8MM CLYDESDALE 0D PEEK-OPTIMA RADIOPAQUE",SUP-2969850,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"MULTIPLAN [10600]",Multiplan,,20349,85,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT PL SITEMARK 58CM 54CM 9FR 7FR 115D GUIDING",SUP-410182,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2524.5,68,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD MONOPOLAR 12.5IN 5MM OLSEN J HOOK REUSABLE",SUP-90-9525,CDM,S27000186,LOCAL,0270,RC,,,both,,,965.03,289.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,114.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.23,820.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM MULTIPOLAR THR CERAMIC CEMENTED STEM CUP LINER HE",SUP-98000100701,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6568.8,68,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISIONS PV 90CM 100CM 8.5FR .035IN ULTRASOUND GLYDX",SUP-88901,CDM,C1753,HCPCS,0272,RC,,,both,,,6900.00,2070,"PHCS [10601]",PHCS,,4830,70,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X10MM COLONIAL 7D LORDOTIC 14MM XL TITANIUM",SUP-365.710CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) KIT INTRO 50CM 8.9MM 25FR AVEIR HYDROPHILIC COATED IN",SUP-LSN25501,CDM,C1894,HCPCS,0272,RC,,,both,,,4140.00,1242,"MULTIPLAN [10600]",Multiplan,,3519,85,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 38MM 144CM 3.5MM",SUP-H7493941238350,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CIGNA [10200]","Cigna Local Plus",,4152.94,53.5,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 6-0 PS-3 18IN MONOFILAMENT PLIABILIZE",SUP-1665G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X12MM LUMINARY 10-11MM SPINE",SUP-14712,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"MULTIPLAN [10600]",Multiplan,,26775,85,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR COBRA 1 CURVE ANGIOGRAPHIC BRAID",SUP-M001314641,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.04,22.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 75X12X.8MM LONG STAINLESS STEEL RECIPROCATING 2",SUP-0277096325,CDM,S27200284,LOCAL,0272,RC,,,both,,,303.46,91.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MICROCATHETER CEREBROVASCULAR 150CM 2.6-2FR .019IN EXCELSIOR",SUP-M0031441940,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAMP SURGICAL CLASSIC REUL 5/8IN 10IN AORTA VASCULAR 1X2",SUP-37-1026,CDM,S27200284,LOCAL,0272,RC,,,both,,,627.02,188.11,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LARYNSCP VIDEO 3 BLADE 8402ZX 8402XS S IMAGER BERCI-KAPLAN",SUP-051113-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LACTATED RINGERS IV BOLUS",RX-400296,CDM,J3490,HCPCS,0258,RC,00338-0117-04,NDC,both,1000,ML,100.65,30.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE SURGICAL ERBELIFT 260CM 1.3MM FLEXIBLE CONNECT HUB",SUP-20350-220,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.60,145.68,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL 4.25% DEXTROSE 3L LOW CALCIUM ULTRABAG DIANEAL DIALYSIS",SUP-5B9759,CDM,S27200284,LOCAL,0272,RC,,,both,,,355.14,106.54,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT VASCULAR 70CM 8MM GORE PROPATEN STD WALL",SUP-HAX01A,CDM,C1768,HCPCS,0278,RC,,,both,,,24412.50,7323.75,"MULTIPLAN [10600]",Multiplan,,20750.63,85,,,,,0,2839.17,20750.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC 64-76CM SMARTVEST SMALL",SUP-SW-25/30-1,CDM,S27000186,LOCAL,0270,RC,,,both,,,437.40,131.22,"FIRST HEALTH [10303]","First Health",,349.92,80,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 2-0 FSLX 75CM MONOFILAMENT BLACK NONABSORBABLE",SUP-1674BH,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AETNA [10100]","Aetna HMO/PPO",,19.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X9MM ENDOSKELETON TC 6D 12MM SMALL CERVICAL",SUP-5146-1209-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"UHC [10700]","United Healthcare",,6551.55,63.3,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT MONORAIL 31MM 135CM 10MM ENDOPROSTHESIS",SUP-M001719050,CDM,C1876,HCPCS,0278,RC,,,both,,,16615.20,4984.56,"KAISER [10500]",Kaiser,,11132.18,67,,,,,0,1932.35,14122.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 14FR SILICONE INTERNAL RETENTION BALLOON RECESS DISTAL",SUP-8100-14LV,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"CIGNA [10200]","Cigna Local Plus",,149.74,53.5,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD TIGERTAIL 70CM 6FR URETERAL POLYURETHANE NONPORT",SUP-139006,CDM,C1758,HCPCS,0272,RC,,,both,,,107.53,32.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",11.23,7.03,11.23,"1 through 10",12.51,91.4,"percent of total billed charges",
"IMPL FIXATION SWIVELOCK PEEK MENISCAL ROOT REPAIR",SUP-AR-4550P,CDM,C1713,HCPCS,0278,RC,,,both,,,10106.78,3032.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4639.01,45.9,,,,,0,1175.42,8590.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronchosc Sample 3/> Node",PX-750000182,CDM,31653,CPT,0750,RC,,,both,,,6145.87,1843.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,714.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,714.76,6145.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Complement Total (Ch50)",PX-302000033,CDM,86162,CPT,0302,RC,,,both,,,345.83,103.75,"AETNA [10100]","Aetna HMO/PPO",,274.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,293.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ARTHROSCOPIC 8IN .092IN TROCAR DISPOSABLE",SUP-AR-8967K,CDM,C1769,HCPCS,0272,RC,,,both,,,130.50,39.15,"MULTIPLAN [10600]",Multiplan,,110.93,85,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 4-0 PSL 30IN MONOFILAMENT BLACK NONABSORBABLE",SUP-562H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]",Cigna,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM AXSOS STAINLESS STEEL 2.5MM FULL THREAD",SUP-338618,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"CIGNA [10200]","Cigna Open Access",,130.98,56.9,,1144.80,304.56,2275.09,66,26.77,195.67,"percent of total billed charges",
"IMPL BREAST 14X14.5CM 535ML STYLE FF HIGHLY COHESIVE GEL",SUP-FF-410535,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross PPO",,2181.48,39.2,,16595.83,16595.83,16595.83,"1 through 10",647.21,4730.25,"percent of total billed charges",
"HC Repl Trach Puncture Dilator",PX-E27400047,CDM,L8514,HCPCS,0274,RC,,,both,,,234.30,70.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,107.54,45.9,,,,,0,27.25,199.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colposcopy W/Bx&Curettage",PX-361000521,CDM,57454,CPT,0361,RC,,,both,,,1459.50,437.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,1459.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Abdomen W&WO Cntrst",PX-352000026,CDM,74170,CPT,0352,RC,,,both,,,3942.51,1182.75,"KAISER [10500]",Kaiser,,2641.48,67,,,,,0,405,3351.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Selct Plc Cath Cca/Innom Brain",PX-361000289,CDM,36223,CPT,0361,RC,,,both,,,23564.37,7069.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2792.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2740.54,20029.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Consult Slide W Prep",PX-312000031,CDM,88323,CPT,0312,RC,,,both,,,920.40,276.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,39.83,,"Fee schedule rate ($39.83). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,782.34,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myelin Basic Protein",PX-301000316,CDM,83873,CPT,0301,RC,,,both,,,283.40,85.02,"MULTIPLAN [10600]",Multiplan,,240.89,85,,,,,0,0.01,240.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Respirat Syncytial Virus Ab",PX-302000158,CDM,86756,CPT,0302,RC,,,both,,,695.00,208.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,45.75,,,,,,,0.7,590.75,"fee schedule",
"HC Bronch W Valve Rmvl Ea Add",PX-750000147,CDM,31649,CPT,0750,RC,,,both,,,5006.00,1501.8,"PHCS [10601]",PHCS,,3504.2,70,,,,,0,5.01,4617,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Extcr Arty Bi",PX-921000002,CDM,93880,CPT,0921,RC,,,both,,,2272.06,681.62,"NOVANET [10819]",Novanet,,1704.05,75,,,,,0,264.24,1931.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 24MM DCP STAINLESS STEEL CORTICAL HAND SELF",SUP-200.824,CDM,C1713,HCPCS,0278,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT LAPAROSCOPIC STRAIGHT JAW ULTRASONIC CORDLESS 1",SUP-SCD13,CDM,S27200284,LOCAL,0272,RC,,,both,,,2437.50,731.25,"UHC [10700]","United Healthcare",,1542.94,63.3,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMNIOFIX 6X16 CM",SUP-APS-5616,CDM,Q4433,HCPCS,0636,RC,,,both,,,25023.60,7507.08,"AETNA [10100]","Aetna HMO/PPO",,19893.76,79.5,,,,,0,247.92,21270.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5-6MM 35MM CREO CREO AMP SPINE CORTICAL MODULAR",SUP-1119.1435,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Sclp/Ax/Tr/Ext 7.6-12.5int",PX-450000033,CDM,12034,CPT,0450,RC,,,both,,,1661.00,498.3,"CIGNA [10200]",Cigna,,1661,,,,,,,67.13,1661,"case rate",
"HC Chrom Add Cell Count",PX-311000074,CDM,88285,CPT,0311,RC,,,both,,,128.70,38.61,"MULTIPLAN [10600]",Multiplan,,109.4,85,,,,,0,0.01,109.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT EXTERNAL FIXATION TRUELOK UNIVERSAL WIRE",SUP-54-1152,CDM,C1713,HCPCS,0278,RC,,,both,,,683.48,205.04,"BLUE CROSS [10001]","Blue Cross PPO",,267.92,39.2,,957.42,570.23,957.42,28,79.49,580.96,"percent of total billed charges",
"SINGLE USE INSTRUMENTS - FEMORAL KIT (CR) - SIZE 2",SUP-5555-2202,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,582.59,41.1,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING INGEVITY+ STEROID STAINLESS STEEL SILICONE RUBBE",SUP-7840,CDM,C1898,HCPCS,0275,RC,,,both,,,2250.00,675,"PHCS [10601]",PHCS,,1575,70,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US OB 1st Trimst Txabd Sngl",PX-402000014,CDM,76801,CPT,0402,RC,,,both,,,1106.77,332.03,"KAISER [10500]",Kaiser,,741.54,67,,,,,0,111.26,940.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 27MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-027,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,8601.07,8395.67,8601.07,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"HC Needle Cath Yueh",PX-E27200195,CDM,E27200195,LOCAL,0272,RC,,,both,,,166.10,49.83,"KAISER [10500]",Kaiser,,111.29,67,,,,,0,19.32,141.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC RBC Ab Identification",PX-302000187,CDM,86870,CPT,0302,RC,,,both,,,176.00,52.8,"CIGNA [10200]","Cigna Open Access",,91.26,,,,,,,0.01,176,"fee schedule",
"INSERT ACETABULAR SIZE F DIA36MM 10DEG CLUSTERHOLE HYDROXYAP",SUP-723-10-36F,CDM,C1776,HCPCS,0278,RC,,,both,,,9332.25,2799.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1085.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1085.34,7932.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM 3DX TSRH OSTEOGRIP THINLINE TITANIUM",SUP-83555401,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,305.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,299.36,2187.9,"percent of total billed charges",
"CATH ARMADA 35 135CM 40MM 5MM .035IN LOW PROFILE BALLOON",SUP-B2050-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE XPRESS LOPROFILE 8MM 6MM BALLOON INFLATION PATHASSIST",SUP-LPLF-206,CDM,C1726,HCPCS,0272,RC,,,both,,,11074.50,3322.35,"MULTIPLAN [10600]",Multiplan,,9413.33,85,,,,,0,1287.96,9413.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 12 G-H KNEE RIGHT TIBIA FIX",SUP-42522101012,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UHC [10700]","United Healthcare",,6821.47,63.3,,8601.07,8395.67,8601.07,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"GRAFT ENDOVASCULAR 124MM 23-13MM 18FR ENDURANT II ABDOMEN",SUP-ETBF2313C124E,CDM,S27800098,LOCAL,0278,RC,,,both,,,60782.40,18234.72,"BLUE CROSS [10001]","Blue Cross PPO",,23826.7,39.2,,,,,0,7068.99,51665.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 33MM EPIC THV",SUP-E100-33M-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,24570.00,7371,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2911.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RCRD CARDIAC CONFIRM RX SMALL SLIM 1 TOUCH PROGRAM DATA",SUP-DM3500,CDM,C1764,HCPCS,0278,RC,,,both,,,23940.00,7182,"AETNA [10100]","Aetna HMO/PPO",,19032.3,79.5,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM STAINLESS STEEL PARTIAL THREAD",SUP-214.540,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,313.8,28.62,,,,,0,127.51,931.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM 24.2MM MASTERS SERIES 85D STD SUPRA",SUP-29AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"BLUE CROSS [10001]","Blue Cross PPO",,11414.74,39.2,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 86MM DEGENERATIVE DISC 4 LEVEL ARCHON BONE SPINE",SUP-8787486,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUSELECT 175CM 2-2.8FR .021IN MICRO EMBOLIZATION",SUP-M001394101750,CDM,C1887,HCPCS,0272,RC,,,both,,,5402.70,1620.81,"KAISER [10500]",Kaiser,,3619.81,67,,,,,0,628.33,4592.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Abdomen W&WO Cntrst",PX-610000042,CDM,74183,CPT,0610,RC,,,both,,,5374.41,1612.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,669.42,,,,,,,625.04,4568.25,"fee schedule",
"TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION",RX-108062,CDM,J3262,HCPCS,0636,RC,50242-0136-01,NDC,both,10,ML,8015.26,2404.58,"PHCS [10601]",PHCS,,5610.68,70,,,,,0,949.81,6812.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 3-0 CT 54IN 2 ARM MONOFILAMENT BROWN ABSORBABLE",SUP-990H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.11,19.83,"MULTIPLAN [10600]",Multiplan,,56.19,85,,,,,0,7.69,56.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT 60MM 230CM 22MM 10FR",SUP-M00565580,CDM,C1876,HCPCS,0278,RC,,,both,,,12152.97,3645.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1440.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1413.39,10330.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 4X80 80CM SL",SUP-48004008N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"KAISER [10500]",Kaiser,,575.54,67,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 70CM TRANSSEPTAL FLEXCATH ADVANCE",SUP-900305,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOEHENDRA 200CM 3CM 8.5-5FR .035IN BALLOON DILATATION",SUP-G22062,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"MULTIPLAN [10600]",Multiplan,,605.88,85,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CRICO CUFF QUICKTRACH II 4MM DISPOSABLE STERILE ADULT",SUP-30-10-004-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1669.50,500.85,"KAISER [10500]",Kaiser,,1118.57,67,,,,,0,194.16,1419.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER GD 100CM 6FR RWY AL1.5 CRV",SUP-H74938969850,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 90MM 6MM MIDAS REX LEGEND ACORN STERILE",SUP-9AC60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,135.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,135.93,993.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLUX FIBERS 2.5CC",SUP-IFLX-CF-02,CDM,S27800098,LOCAL,0278,RC,,,both,,,3815.70,1144.71,"CIGNA [10200]",Cigna,,2594.68,68,,,,,0,443.77,3243.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL TRIATHLON 3 CONE KNEE LEFT TRITANIUM REVISION",SUP-5549-A-331,CDM,C1776,HCPCS,0278,RC,,,both,,,25155.90,7546.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2980.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2925.63,21382.52,"percent of total billed charges",
"HC Vitamin A",PX-301000438,CDM,84590,CPT,0301,RC,,,both,,,163.80,49.14,"CIGNA [10200]","Cigna Open Access",,25.54,,,,,,,0.16,139.23,"fee schedule",
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,inpatient,,,109432.42,32829.73,"AETNA [10100]","Aetna HMO/PPO",,28211.21,,"Fee schedule rate ($28,211.21). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,43776.48,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AXIOS 8MM 6MM BILIARY ELECTROCAUTERY STERILE LATEX",SUP-M00553680,CDM,C1874,HCPCS,0278,RC,,,both,,,32412.56,9723.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3840.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3769.58,27550.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 7FR .081IN LARGE EBU4 CURVE FULL WALL",SUP-LA7EBU35SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 3 STD KNEE LEFT KEEL NONPOROUS",SUP-ETPKN3SL,CDM,C1776,HCPCS,0278,RC,,,both,,,11060.70,3318.21,"AETNA [10100]","Aetna HMO/PPO",,8793.26,79.5,,10981.53,8986.79,12413.38,12,1286.36,9401.6,"percent of total billed charges",
"SUT VICRYL 7-0 TG140-8 12IN 2 ARM BRAID COATED VIOLET",SUP-J566G,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.98,46.49,"NOVANET [10819]",Novanet,,116.24,75,,,,,0,18.02,131.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE DOUBLE TROCAR 1.6MM X 171MM",SUP-KWIR-DT-16171,CDM,S27000186,LOCAL,0270,RC,,,both,,,453.60,136.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,52.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 60MM 1.1MM STAINLESS STEEL QUICK COUPLING MINI",SUP-310.11,CDM,S27000186,LOCAL,0270,RC,,,both,,,496.69,149.01,"CIGNA [10200]",Cigna,,337.75,68,,,,,0,57.77,422.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE ESC +4MM NEUTRAL 50MM 28MM",SUP-121828650,CDM,C1776,HCPCS,0278,RC,,,both,,,20986.56,6295.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2486.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2440.74,17838.58,"percent of total billed charges",
"VALVE SHUNT DELTA SMALL PERFORMANCE LEVEL .5 CSF BIOGLIDE",SUP-24147,CDM,S27800098,LOCAL,0278,RC,,,both,,,12039.81,3611.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4948.36,41.1,,,,,0,1400.23,10233.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 16MM MEDLINE UNITE FOOT ANKLE CANNULATED",SUP-MSL02516,CDM,C1713,HCPCS,0278,RC,,,both,,,1762.50,528.75,"FIRST HEALTH [10303]","First Health",,1410,80,,,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR GREEN 12MM TROCAR 60MM ECHELON LINEAR CUTTER",SUP-ECR60G,CDM,S27200284,LOCAL,0272,RC,,,both,,,4076.34,1222.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,474.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,474.08,3464.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C2 Complement Component",PX-302000024,CDM,86160,CPT,0302,RC,,,both,,,271.00,81.3,"UHC [10700]","United Healthcare",,10.8,,,,,,,0.27,230.35,"fee schedule",
"COIL EMBOLIZATION 50CM 22MM TARGET 360D 2XL DETACHABLE",SUP-M0036182250,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rem Impl Drug Deliv Non-Biodeg",PX-361000515,CDM,11982,CPT,0361,RC,,,both,,,4282.83,1284.85,"BLUE CROSS [10001]","Blue Cross PPO",,2740.57,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,498.09,4282.83,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER II XP 110CM 10MM 7FR 8FR 2.5MM SPACE STD CURVE",SUP-M0044790TH0,CDM,C1733,HCPCS,0272,RC,,,both,,,12199.20,3659.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1445.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1418.77,10369.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +25.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-CC60WF.255,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VICRYL 12X12IN KNIT WOVEN",SUP-VKML,CDM,C1781,HCPCS,0278,RC,,,both,,,5261.49,1578.45,"BLUE CROSS [10001]","Blue Cross PPO",,2062.5,39.2,,,,,0,611.91,4472.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +33.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000335,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 98CM 18GA STYLET PROC TRANSSEPTAL BRK ADULT",SUP-407206,CDM,S27200284,LOCAL,0272,RC,,,both,,,1539.00,461.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 135CM 20MM 6FR 6MM BALLOON DILATATION PEBAX",SUP-39032-60201,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG 6X6IN HIGH ABSORBENT CORE NONADHERENT WATERPROOF",SUP-MSC1200EP,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.56,19.37,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"REVERSE PSI KIT (HUMERAL ONLY)",SUP-1235-7152-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 4MM TRANSNASAL DIAMOND COARSE ROUND STERILE",SUP-TN40RCD,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1134.05,41.1,,,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Gene Analys D816 Variant",PX-310000041,CDM,81273,CPT,0310,RC,,,both,,,918.00,275.4,"CIGNA [10200]",Cigna,,274.71,,,,,,,0.01,780.3,"fee schedule",
"HC Ld or Time Add 15 Min",PX-360000001,CDM,9999140,LOCAL,0360,RC,,,both,,,1311.81,393.54,"AETNA [10100]","Aetna HMO/PPO",,1042.89,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,152.56,1115.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 82MM 22MM 18FR Z-TRAK ZENITH FLEX 2",SUP-G48402,CDM,C1874,HCPCS,0278,RC,,,both,,,6141.00,1842.3,"CIGNA [10200]",Cigna,,4175.88,68,,,,,0,714.2,5219.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Fetal Echo W/W/O M",PX-402000064,CDM,76825,CPT,0402,RC,,,both,,,1275.85,382.75,"MULTIPLAN [10600]",Multiplan,,1084.47,85,,,,,0,148.38,1084.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 24FR STERILE YELLOW UROLOGICAL LOOP",SUP-27050G.30/6,CDM,S27200284,LOCAL,0272,RC,,,both,,,5370.96,1611.29,"CIGNA [10200]","Cigna Local Plus",,2873.46,53.5,,,,,0,624.64,4565.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 8IN DUROGRIP HEGAR SERRATED HEAVY NDL TUNGSTEN",SUP-BM077R,CDM,S27200284,LOCAL,0272,RC,,,both,,,410.99,123.3,"CIGNA [10200]","Cigna Local Plus",,219.88,53.5,,,,,0,47.8,349.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROLENE 10X10IN KNIT NONABSORBABLE 2",SUP-SPMLI,CDM,C1781,HCPCS,0278,RC,,,both,,,3503.55,1051.06,"KAISER [10500]",Kaiser,,2347.38,67,,,,,0,407.46,2978.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 74MM 24MM 16FR ZENITH SPIRAL-Z Z-TRAK",SUP-G55246,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"FIRST HEALTH [10303]","First Health",,16939.44,80,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM 9FR ENDOCARDIAL DF4-LLHO CNCT 1 COIL TINE",SUP-263,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"UHC [10700]","United Healthcare",,9608.94,63.3,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 5.5MM TITANIUM",SUP-101-65580,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"KAISER [10500]",Kaiser,,2954.7,67,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 10CM 6MM BALLOON DILATATION 2 LUMEN",SUP-G52348,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lymphang Pelvis/Abd Bi Si",PX-323000027,CDM,75807,CPT,0320,RC,,,both,,,6091.05,1827.31,"AETNA [10100]","Aetna HMO/PPO",,4842.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,325.8,6091.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2MM 21MM FOSSA RADIUS DISTAL VOLAR SMOOTH LOCK",SUP-SPLS-20210-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,639.90,191.97,"CIGNA [10200]","Cigna Local Plus",,342.35,53.5,,3978.14,359.25,3978.14,24,74.42,543.92,"percent of total billed charges",
"DRYSEAL FLEX INTRODUCER SHEATH 65CM 16FR HYDROPHILIC COATIN",SUP-GDSF1665,CDM,C1894,HCPCS,0272,RC,,,both,,,6858.60,2057.58,"AETNA [10100]","Aetna HMO/PPO",,5452.59,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,797.66,5829.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC",435,MS-DRG,,,,,,,inpatient,,,74505.71,22351.71,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,12190.68,,"Case rate ($11,393.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,579.32, add-ons for qualifying new technology services are included. If operating cost exceeds $43,619.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,181.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,593.31. The transfer operating threshold is the transfer adjustment factor * $10,579.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.85. The transfer capital threshold is the transfer adjustment factor * $799.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,45805.46,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CEREBROVASCULAR DISORDERS WITH CC",071,MS-DRG,,,,,,,inpatient,,,34850.13,10455.04,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,13683.33,,"Case rate ($6,364.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,909.72, add-ons for qualifying new technology services are included. If operating cost exceeds $38,949.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,828.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,917.54. The transfer operating threshold is the transfer adjustment factor * $5,909.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $446.80. The transfer capital threshold is the transfer adjustment factor * $446.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,6364.34,25587.41,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 22F LARGE HIP PROXIMAL",SUP-550738,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"BLUE CROSS [10001]","Blue Cross PPO",,4266.82,39.2,,3949.44,3949.44,3949.44,"1 through 10",1265.9,9252.04,"percent of total billed charges",
"CATH FOGARTY 80CM 5FR 11MM ROUND EMBOLECTOMY STAINLESS STEEL",SUP-120805FR,CDM,C1757,HCPCS,0272,RC,,,both,,,62.15,18.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25.54,41.1,,,,,0,7.23,52.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 119MM TRI-LOCK BPS GRIPTION 12 STANDARD OFFSET",SUP-101204120,CDM,C1776,HCPCS,0278,RC,,,both,,,29153.25,8745.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3454.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3390.52,24780.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BARD INLAY 22CM 6FR 2 PIGTAIL CURVE URETERAL",SUP-778622,CDM,C2625,HCPCS,0278,RC,,,both,,,625.73,187.72,"CIGNA [10200]","Cigna Local Plus",,334.77,53.5,,,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Volatiles",PX-301000560,CDM,84600,CPT,0301,RC,,,both,,,150.00,45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,26.91,,,,,,,0.01,127.5,"fee schedule",
"CATH HI-FLO RENEGADE 105CM 20CM 3-2.8FR .027IN MICRO",SUP-M001182850,CDM,C1887,HCPCS,0272,RC,,,both,,,2100.00,630,"NOVANET [10819]",Novanet,,1575,75,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 11MM SECUR-FIT PLUS 5 HIP STERILE",SUP-6054-0511S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"FIRST HEALTH [10303]","First Health",,12932.35,80,,,,,0,1880.04,13740.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL H+9MM 42MM AEQUALIS ASCEND FLEX 12.5D SHOULDER",SUP-DWF425B,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"CIGNA [10200]","Cigna Local Plus",,4829.83,53.5,,5372.07,4581.20,7242.98,23,1049.92,7673.56,"percent of total billed charges",
"AUG FEMORAL 12MM ATTUNE 4 KNEE DISTAL CEMENT REVISION",SUP-154704003,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"PHCS [10601]",PHCS,,4250.4,70,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 155CM 8MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200084020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 34X12-16MM MAGNIFY-S 8D LORDOTIC 26MM EXPAND",SUP-1126.1112,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"KAISER [10500]",Kaiser,,28702.8,67,,,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARCADIA 20MM 10GA BALLOON DILATATION HIGH PRESSURE",SUP-ARC20ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,5978.16,1793.45,"MULTIPLAN [10600]",Multiplan,,5081.44,85,,,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 11.4MM 8MM SHILEY TAPERGUARD FLEXIBLE CUFFLESS",SUP-7UN80A,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.56,98.27,"FIRST HEALTH [10303]","First Health",,262.05,80,,,,,0,38.1,278.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 8MM RIGHT MEDIAL LEFT LATERAL X3 PARTIAL KNEE",SUP-5630-G-528,CDM,C1776,HCPCS,0278,RC,,,both,,,5309.55,1592.86,"CIGNA [10200]","Cigna Local Plus",,2840.61,53.5,,5372.07,4581.20,7242.98,23,617.5,4513.12,"percent of total billed charges",
"CLAREONPANOPTIX PROTORIC (UVA)",SUP-PXCWT3,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"CIGNA [10200]","Cigna Open Access",,520.64,56.9,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER FASTPASS SCORPION SIDE LOAD SUT ARTHROSCOPY",SUP-AR-13999MF,CDM,S27200284,LOCAL,0272,RC,,,both,,,26426.93,7928.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,12129.96,45.9,,,,,0,3073.45,22462.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 75MM KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-183114,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"KAISER [10500]",Kaiser,,14516.02,67,,,,,0,2519.72,18415.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 75MM FOGARTY",SUP-G-7555,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]",Cigna,,153.82,68,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRAMEDULLARY NAIL 360MM 11MM GAMMA 125D LONG R1.5",SUP-3525-1360S,CDM,C1713,HCPCS,0278,RC,,,both,,,13435.13,4030.54,"UHC [10700]","United Healthcare",,8504.44,63.3,,5023.51,2672.93,6679.78,18,1562.51,11419.86,"percent of total billed charges",
"ROD SPINAL 50MM 5.5MM CURVE CHROMALOY PLUS",SUP-1556001050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"KIT BD MACRO-VUE RPR CARD AMPULE NDL DISPENSTIRS SEROLOGY",SUP-275005,CDM,S27200284,LOCAL,0272,RC,,,both,,,698.79,209.64,"UHC [10700]","United Healthcare",,442.33,63.3,,,,,0,81.27,593.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135MM 40MM 14MM .035IN LOW PROFILE BALLOON",SUP-B2140-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"UHC [10700]","United Healthcare",,487.09,63.3,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SMARTSTITCH CNCT MAGNUM WIRE BRAIDED SUT POLYESTER",SUP-OM-8176,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.18,543.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,214.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,210.64,1539.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 120MM 4MM .014IN BALLOON DILATATION",SUP-AB14W040120150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"FIRST HEALTH [10303]","First Health",,1108.08,80,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GASTROENTEROLOGYALIMAXX-B METAL BILIARY STENT 10 X 60",SUP-70129-209,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"AMERIGROUP MEDICAID [20100]",Amerigroup,,899.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 6+ MM 39MM FLEX 12.5D SHOULDER STERILE",SUP-DWF391B,CDM,C1776,HCPCS,0278,RC,,,both,,,8224.00,2467.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5592.32,68,,,,,0,956.45,6990.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 92CM 4MM 6FR 2-5-2MM SPACE D CURVE",SUP-D6DL252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,5326.80,1598.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,619.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,619.51,4527.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LD SCOUTPRO TL SLTR","SUP-383 119",CDM,S27200284,LOCAL,0272,RC,,,both,,,801.90,240.57,"MULTIPLAN [10600]",Multiplan,,681.62,85,,,,,0,93.26,681.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 CT-1 27IN BRAID COATED UNDYED ABSORBABLE",SUP-VCP258H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"MULTIPLAN [10600]",Multiplan,,21.25,85,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 19MM KNEE X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G619,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2680.57,28.62,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 0 CT-1 36IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z346H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIPERACILLIN-TAZOBACTAM 2.25 G/10ML IV (WET SOLR VIAL)",RX-41518304,CDM,J2543,HCPCS,0636,RC,00781-3110-90,NDC,both,1,UN,92.93,27.88,"UHC [10700]","United Healthcare",,4.26,,,,,,,2.49,78.99,"fee schedule",
"INSRT TIBIAL 8 19MM KNEE X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G819,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA [10200]","Cigna Local Plus",,5350,53.5,,5372.07,4581.20,7242.98,23,1163,8500,"percent of total billed charges",
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 15.75IN 20FR DRNG",SUP-8888561043,CDM,C1729,HCPCS,0272,RC,,,both,,,221.42,66.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,91,41.1,,,,,0,25.75,188.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 24MM 140CM 3.5MM CORONARY STENT",SUP-LUN350R24US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 71X40X14IN FORTIFY 2.5V 500OHM 60 PPM TITANIUM",SUP-CD1231-40Q,CDM,C1722,HCPCS,0278,RC,,,both,,,35000.00,10500,"KAISER [10500]",Kaiser,,23450,67,,,,,0,4070.5,29750,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK 8X1.5X2CM LARGE NASAL 2 COMPRESS BACTERIOSTATIC AIRWAY",SUP-7089-0837,CDM,S27200284,LOCAL,0272,RC,,,both,,,869.54,260.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,399.12,45.9,,,,,0,101.13,739.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 9IN MAYO-HEGAR INSRT NDL TUNGSTEN CARBIDE",SUP-32-145,CDM,S27200284,LOCAL,0272,RC,,,both,,,364.44,109.33,"AETNA [10100]","Aetna HMO/PPO",,289.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.38,309.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE FLOPPY II EXTRA SPORT VASCULAR STRAIGHT 190",SUP-22299H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE REVERSE HYBRID WITH CEMENTED PATELLA CONC",SUP-71704620,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"BLUE CROSS [10001]","Blue Cross PPO",,9137.52,39.2,,3949.44,3949.44,3949.44,"1 through 10",2710.95,19813.5,"percent of total billed charges",
"HC Tiss Cult Bone Marrow",PX-311000028,CDM,88237,CPT,0311,RC,,,both,,,1202.00,360.6,"BLUE CROSS [10001]","Blue Cross PPO",,183.66,,"Fee schedule rate ($183.66).",,,,0,0.01,1021.7,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE Y 60MM STAINLESS STEEL 2.4MM SCR MODULAR MINI FRAGMENT",SUP-249.669,CDM,C1713,HCPCS,0278,RC,,,both,,,3883.32,1165,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2640.66,68,,,,,0,451.63,3300.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RX BILIARY SYSTEM 15CM 11.5FR BILIARY PLASTIC RAPID",SUP-M00545740,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"CIGNA [10200]","Cigna Open Access",,485.23,56.9,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X6MM COALITION MIS 7D 12MM TITANIUM STERILE",SUP-1136.2476,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7089.75,41.1,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR GUIDE AUG REAM",SUP-110040300,CDM,S27200284,LOCAL,0272,RC,,,both,,,650.75,195.22,"CIGNA [10200]",Cigna,,442.51,68,,,,,0,75.68,553.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 194MM STAINLESS STEEL 3.5MM SCR 8 HOLE LCP BONE RIGHT",SUP-02.104.008S,CDM,C1713,HCPCS,0278,RC,,,both,,,9988.58,2996.57,"CIGNA [10200]",Cigna,,6792.23,68,,1831.33,1831.33,1831.33,16,1161.67,8490.29,"percent of total billed charges",
"HC Dbrd Wnd Rmvl Tis Non-Sel (Go)",PX-430000026,CDM,97602,CPT,0430,RC,,,both,,,625.00,187.5,"CIGNA [10200]",Cigna,,369,,"Per diem ($369).",,,,0,72.69,625,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 14MM COCR",SUP-VAL-20140-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,168.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,165.8,1211.76,"percent of total billed charges",
"LENS IOL +21.5 DIOPTER MODIFY C BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB0000215,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"MULTIPLAN [10600]",Multiplan,,998.33,85,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD LOOP WHITE 22FR ANGLED CUT NONSTERILE",SUP-26055G,CDM,S27000186,LOCAL,0270,RC,,,both,,,1050.84,315.25,"PHCS [10601]",PHCS,,735.59,70,,,,,0,122.21,893.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADAPTA IS-1 DR",SUP-ADDR01,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"KAISER [10500]",Kaiser,,27872,67,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY FEMORAL 75MM 20MM RECLAIM 40MM 12/14 OFFSET MINI TAPER",SUP-1975-20-075,CDM,C1776,HCPCS,0278,RC,,,both,,,22082.76,6624.83,"UHC [10700]","United Healthcare",,13978.39,63.3,,8601.07,8395.67,8601.07,"1 through 10",2568.22,18770.35,"percent of total billed charges",
"CATH CHRG 135CM 120MM 8MM BALLOON DILATATION OTW",SUP-H74939206081210,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11.75CM NATRELLE INSPIRA P3.9CM MODERATE PROFILE",SUP-MSZ-M295,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"NOVANET [10819]",Novanet,,118.64,75,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 15MM 90CM 7MM BILIARY STAINLESS",SUP-H74937911715900,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"BLUE CROSS [10001]","Blue Cross PPO",,1956.86,39.2,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT PERICARDIUM HYDR 1X1",SUP-10-0053,CDM,S27800098,LOCAL,0278,RC,,,both,,,2062.50,618.75,"MULTIPLAN [10600]",Multiplan,,1753.13,85,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT ELECTROSURGICAL 36X3.3-4.7MM 18CM INSTR DISPOSABLE",SUP-LF4200,CDM,S27200284,LOCAL,0272,RC,,,both,,,4350.11,1305.03,"AETNA [10100]","Aetna HMO/PPO",,3458.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,505.92,3697.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSELECT DEMINERALIZED BONE MATRIX 10CC",SUP-309100,CDM,C1713,HCPCS,0278,RC,,,both,,,5602.80,1680.84,"AETNA [10100]","Aetna HMO/PPO",,4454.23,79.5,,1521.93,481.35,16760.95,30,651.61,4762.38,"percent of total billed charges",
"VEST, CUP XXX-LARGE STYLE 16V","SUP-STYLE 16V XXX-LG",CDM,S27000186,LOCAL,0270,RC,,,both,,,461.70,138.51,"KAISER [10500]",Kaiser,,309.34,67,,,,,0,53.7,392.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAPE 36INX2MM REVERSE CUT NDL CLSR BLUE WHITE",SUP-AR-7288,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"CIGNA [10200]",Cigna,,1012.1,68,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTICROSS 135CM 1.6CM 12MM 30 MHZ ULTRASOUND PERIPHERAL",SUP-H7493932800180,CDM,C1753,HCPCS,0272,RC,,,both,,,10281.00,3084.3,"NOVANET [10819]",Novanet,,7710.75,75,,,,,0,1195.68,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Oxalate",PX-301000351,CDM,83945,CPT,0301,RC,,,both,,,270.40,81.12,"UHC [10700]","United Healthcare",,13.01,,,,,,,0.01,229.84,"fee schedule",
"HC Pt Eval Mod Complex 30 Min",PX-420000154,CDM,97162,CPT,0424,RC,,,both,,,454.45,136.33,"PHCS [10601]",PHCS,,318.12,70,,,,,0,52.85,426,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB PCL SUBST SZ 1-2X10",SUP-2142-1-1210,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"FIRST HEALTH [10303]","First Health",,2850,80,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL RESTORIS 8 KNEE RIGHT MEDIAL ONLAY",SUP-180618,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,785.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,770.77,5633.33,"percent of total billed charges",
"COLLAR EXTRICATION GREEN 3.75IN PROCARE TALL FLAT CONTOUR",SUP-79-83027,CDM,S27000186,LOCAL,0270,RC,,,both,,,61.25,18.37,"PHCS [10601]",PHCS,,42.88,70,,,,,0,7.12,52.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCH - TRUMATCH GL",SUP-OSC371062,CDM,C1776,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,3949.44,3949.44,3949.44,"1 through 10",441.36,3225.75,"percent of total billed charges",
"SCR BONE 2MM 13MM APTUS TITANIUM 6MM HEAD HAND FOOT WRIST",SUP-A-5450.13/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,662.49,41.1,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 30MM GORILLA R3CON LOCK",SUP-P50-353-4230,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Local Plus",,715.03,53.5,,3978.14,359.25,3978.14,24,155.43,1136.03,"percent of total billed charges",
"LINER ACETABULAR PINNACLE 10D +4MM 48MM 28MM ALTRX HIP STERI",SUP-122128148,CDM,C1776,HCPCS,0278,RC,,,both,,,9128.70,2738.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4190.07,45.9,,,,,0,1061.67,7759.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8.5FR 60CM HEMOSTASIS GWIRE END HOLE FAST-CATH",SUP-406804,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SUCTION/IRRIGATION INTREPID 35D POLYMER BENT IA",SUP-8065751511,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.79,32.34,"UHC [10700]","United Healthcare",,68.23,63.3,,,,,0,12.54,91.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM SUMMIT POROCOAT 5 12/14 HIGH OFFSET TAPER",SUP-157011110,CDM,C1776,HCPCS,0278,RC,,,both,,,25247.25,7574.17,"BLUE CROSS [10001]","Blue Cross PPO",,9896.92,39.2,,3949.44,3949.44,3949.44,"1 through 10",2936.26,21460.16,"percent of total billed charges",
"HC Set 10ft Mps Delivery",PX-E27200387,CDM,E27200387,LOCAL,0272,RC,,,both,,,960.30,288.09,"CIGNA [10200]","Cigna Open Access",,546.41,56.9,,,,,0,111.68,816.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X13MM LUMINARY 10/11MM SPINE",SUP-4713,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"KAISER [10500]",Kaiser,,21105,67,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ercp Papillotomy/Sphincterotmy",PX-750000047,CDM,43262,CPT,0750,RC,,,both,,,4972.95,1491.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4972.95,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,578.35,4972.95,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 5MM KII 2 PACK ACCESS SYSTEM Z",SUP-CTB12,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 114MM 15MM FULL PROXIMAL PROFILE ECHO BI-METRIC",SUP-19-3115,CDM,C1776,HCPCS,0278,RC,,,both,,,27578.88,8273.66,"UHC [10700]","United Healthcare",,17457.43,63.3,,8601.07,8395.67,8601.07,"1 through 10",3207.42,23442.05,"percent of total billed charges",
"HOOK SPINAL 4.5MM LAMINA LEFT OFFSET",SUP-7756073L,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,348.9,2550,"percent of total billed charges",
"LENS IOL +18.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000185,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Amniotic Fluid Protein",PX-301000462,CDM,84112,CPT,0301,RC,,,both,,,401.70,120.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86.82,,"Fee schedule rate ($86.82). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,341.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pyruvate Kinase",PX-301000577,CDM,84220,CPT,0301,RC,,,both,,,204.00,61.2,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,173.4,"per diem",
"HC Toxoplasma Igm Ab",PX-302000166,CDM,86778,CPT,0302,RC,,,both,,,313.50,94.05,"FIRST HEALTH [10303]","First Health",,250.8,80,,,,,0,0.01,266.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 4 10MM KNEE AOX CRUCIATE RETAIN ROTATE PLATFOR",SUP-151630410,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5250.9,40,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT AUTOPLEX VERTAPLEX HV M4 MIXER STERILE LATEX",SUP-0707-000-000,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"MULTIPLAN [10600]",Multiplan,,5571.75,85,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM 49.8MM HIP 3 SCR HOLE CLUSTER RIM",SUP-542-11-48D,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"NOVANET [10819]",Novanet,,5218.29,75,,,,,0,809.18,5914.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 35CM 24FR NEPHRSTMY DRNG STERILE LATEX FREE",SUP-M0064101030,CDM,C1729,HCPCS,0272,RC,,,both,,,551.53,165.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,64.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.14,468.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 80MM 10MM BALLOON DILATATION OTW NONCOMPLIANT",SUP-H74939206100870,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 11IN COBB OVAL CUP ANGLE TIP HOLLOW KNURL HANDLE",SUP-240189,CDM,S27200284,LOCAL,0272,RC,,,both,,,834.95,250.48,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,343.16,41.1,,,,,0,97.1,709.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 20CM 31MM GORE TAG THORACIC ACTIVE CONTROL",SUP-TGMR313120,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,31312.49,27,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 14.5MM 23MM EXCLUDER TRUNK",SUP-CXT231412,CDM,S27800098,LOCAL,0278,RC,,,both,,,71175.90,21352.77,"CIGNA [10200]","Cigna Open Access",,23843.93,33.5,,,,,0,8277.76,60499.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 20MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206080210,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 11.8X5.9IN XENMATRIX AB RECTANGLE PORCINE",SUP-1151530,CDM,C1781,HCPCS,0278,RC,,,both,,,65285.52,19585.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,26114.21,40,,,,,0,7592.71,55492.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT ALPHAVENT 3 STRAND HARD BODY PLATFORM PEEK 1.4 MM",SUP-3910-947-031,CDM,C1713,HCPCS,0278,RC,,,both,,,2737.50,821.25,"NOVANET [10819]",Novanet,,2053.13,75,,,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DECA 2-2-2 MPA 120CM",SUP-901537,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2014.5,68,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1",SUP-179712050,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,1521.93,481.35,16760.95,30,441.36,3225.75,"percent of total billed charges",
"KIT TKR 10MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0101000,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1454.43,28.62,,,,,0,591.02,4319.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UROLIFT 2 IMPLANT CARTRIDGE HANDLE BOX",SUP-UL2-C,CDM,L8699,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"PHCS [10601]",PHCS,,5071.5,70,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO 80CM 10CM 6FR 8MM .035IN 20 ATM BALLOON",SUP-DR80810,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,160.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORD ELECTROSURGICAL MONOPOLAR ACTIVE BOVIE STERILE REUSABLE",SUP-C650-129A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1273.89,382.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,523.57,41.1,,,,,0,148.15,1082.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ld Recovery Add 30 Min",PX-710000003,CDM,9999145,LOCAL,0710,RC,,,both,,,993.30,297.99,"CIGNA [10200]","Cigna Local Plus",,531.42,53.5,,,,,0,115.52,844.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LIVEWIRE 115CM 2MM 6FR 2MM SPACE XL ELECTROPHYSIOLOGY",SUP-401923,CDM,C1730,HCPCS,0272,RC,,,both,,,2606.25,781.87,"MULTIPLAN [10600]",Multiplan,,2215.31,85,,,,,0,303.11,2215.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 5FR .058IN RADIAL SPECIALTY CURVE",SUP-LA5MRADIALA,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"KAISER [10500]",Kaiser,,244.82,67,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM 1.1MM LATERAL WALL GORILLA BONE CALCANEUS LEFT",SUP-P53-102-L002,CDM,C1713,HCPCS,0278,RC,,,both,,,8254.13,2476.24,"AETNA [10100]","Aetna HMO/PPO",,6562.03,79.5,,1521.93,481.35,16760.95,30,959.96,7016.01,"percent of total billed charges",
"LINER ACETABULAR RINGLOC 10D 24 36MM ARCOMXL HIP",SUP-XL105894,CDM,C1776,HCPCS,0278,RC,,,both,,,9937.38,2981.21,"KAISER [10500]",Kaiser,,6658.04,67,,,,,0,1155.72,8446.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE LEGACY DBM 5CC ALLOGRAFT NONSTERILE LATEX FREE",SUP-420805,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]",Cigna,,2550,68,,1831.33,1831.33,1831.33,16,436.13,3187.5,"percent of total billed charges",
"CATH IMAGER II 100CM 5FR HEADHUNTER 3 CURVE ANGIOGRAPHIC",SUP-M001314171,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.52,25.06,"FIRST HEALTH [10303]","First Health",,66.82,80,,,,,0,9.71,70.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TIGHTROPE II TIGHTROPE FIBERLINK 2 4MM FIXATION PIN",SUP-AR-1588RT2-IBS,CDM,C1713,HCPCS,0278,RC,,,both,,,5614.88,1684.46,"KAISER [10500]",Kaiser,,3761.97,67,,,,,0,653.01,4772.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION .062IN 9IN KIRSCHNER STAINLESS STEEL 1 END",SUP-KM173-39-62,CDM,C1713,HCPCS,0278,RC,,,both,,,59.29,17.79,"MULTIPLAN [10600]",Multiplan,,50.4,85,,,,,0,6.9,50.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 5FR JCL4 CURVE GUIDING NYLON CORONARY",SUP-LA5JCL40,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Nephrostomy Tube W Fl",PX-361000219,CDM,50389,CPT,0361,RC,,,both,,,1947.47,584.24,"PHCS [10601]",PHCS,,1363.23,70,,,,,0,226.49,1947.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Maskset Brainlab",PX-E27000192,CDM,9999119,LOCAL,0270,RC,,,both,,,1400.30,420.09,"AETNA [10100]","Aetna HMO/PPO",,1113.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.85,1190.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Homocysteine",PX-301000234,CDM,83090,CPT,0301,RC,,,both,,,343.90,103.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,28.19,,,,,,,0.01,292.32,"fee schedule",
"BIT DRILL 4.3MM XLONG CALIBRATED STERILE",SUP-03.313.702S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 7.9MM 2.9MM 90MM 16MM TITANIUM PARTIAL THREAD",SUP-408.413,CDM,C1713,HCPCS,0278,RC,,,both,,,1520.21,456.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1033.74,68,,,,,0,176.8,1292.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE 20X15CM PREPERITONEAL KNIT WEB SYNECOR",SUP-GKWV1520,CDM,C1781,HCPCS,0278,RC,,,both,,,10108.50,3032.55,"MULTIPLAN [10600]",Multiplan,,8592.23,85,,,,,0,1175.62,8592.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest Neurlytc Agt Gnclr Nrv",PX-510000535,CDM,64624,CPT,0761,RC,,,both,,,5347.00,1604.1,"CIGNA [10200]","Cigna Open Access",,2181,,"Per diem ($2,181).",,,,0,621.86,4544.95,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chromosome Analysis 45",PX-310000044,CDM,88263,CPT,0310,RC,,,both,,,200.00,60,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,135.26,,,,,,,0.01,200,"fee schedule",
"HC Dgtz Gls Mcrscp Sl Spc Grpii / Add on 88313",PX-312000092,CDM,0755T,CPT,0312,RC,,,both,,,100.00,30,"CIGNA [10200]",Cigna,,68,68,,,,,0,11.85,85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FABRIC CARDIOVASCULAR 3X2IN HEMASHIELD THK.46IN 2 VELOUR",SUP-M002000196240,CDM,C1768,HCPCS,0278,RC,,,both,,,1147.37,344.21,"KAISER [10500]",Kaiser,,768.74,67,,,,,0,133.44,975.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE FLOPPY II VASCULAR STRAIGHT 50CM 2CM .014IN",SUP-22339M-901,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 300MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.440S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"BLUE CROSS [10001]","Blue Cross PPO",,3258.47,39.2,,957.42,570.23,957.42,28,966.74,7065.57,"percent of total billed charges",
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,inpatient,,,59170.02,17751.01,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,24943.42,,"Case rate ($11,601.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,772.86, add-ons for qualifying new technology services are included. If operating cost exceeds $43,812.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,196.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $10,787.10. The transfer operating threshold is the transfer adjustment factor * $10,772.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $814.48. The transfer capital threshold is the transfer adjustment factor * $814.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,54605.28,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 8.6FR HELIX VENTRICLE 1 COIL ACTIVE",SUP-693552,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS [10001]","Blue Cross PPO",,6731.42,39.2,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRAZOSIN 5 MG CAPSULE",RX-6470,CDM,,,0637,RC,60687-0572-33,NDC,both,1,UN,20.70,6.21,"MULTIPLAN [10600]",Multiplan,,17.6,85,,,,,0,2.41,17.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYCLOPENTOLATE 2 % EYE DROPS",RX-9700,CDM,,,0637,RC,00065-0397-02,NDC,both,2,ML,210.31,63.09,"UHC [10700]","United Healthcare",,133.13,63.3,,,,,0,24.46,178.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVED 278MM STAINLESS STEEL 4.5MM SCR 12 HOLE LOCKING",SUP-02.001.322,CDM,C1713,HCPCS,0278,RC,,,both,,,9833.88,2950.16,"BLUE CROSS [10001]","Blue Cross PPO",,3854.88,39.2,,957.42,570.23,957.42,28,1143.68,8358.8,"percent of total billed charges",
"SUT VICRYL 4-0 12-18IN BRAIDED UNDYED ABSORBABLE",SUP-J109T,CDM,S27200284,LOCAL,0272,RC,,,both,,,90.61,27.18,"CIGNA [10200]","Cigna Local Plus",,48.48,53.5,,,,,0,10.54,77.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 80MM 3.2MM 10MM 8.5FR .035IN BILIARY RAPID",SUP-M00570740,CDM,C1876,HCPCS,0278,RC,,,both,,,9158.00,2747.4,"BLUE CROSS [10001]","Blue Cross PPO",,3589.94,39.2,,,,,0,1065.08,7784.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II MULTIPASS 5-0 P-3 18IN MONOFILAMENT UNDYED",SUP-Z493G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12IN 22FR ARTERIAL ADULT 3/8IN CNCT BLUNT TIP",SUP-77522,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"MULTIPLAN [10600]",Multiplan,,380.8,85,,,,,0,52.1,380.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM REELX STT KNOTLESS SHARP TIP PROXIMAL",SUP-3910600062,CDM,C1713,HCPCS,0278,RC,,,both,,,2482.50,744.75,"AETNA [10100]","Aetna HMO/PPO",,1973.59,79.5,,1521.93,481.35,16760.95,30,288.71,2110.13,"percent of total billed charges",
"SCR BONE 6.5MM 40MM REFLECTION FULL THREAD HIP ACETABULAR",SUP-71336540,CDM,C1713,HCPCS,0278,RC,,,both,,,1341.36,402.41,"KAISER [10500]",Kaiser,,898.71,67,,,,,0,156,1140.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 10X 38MM CATH 80CM ENDOVASCULAR",SUP-48038,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2076.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Angio Visc Sel Si",PX-323000017,CDM,75726,CPT,0323,RC,,,both,,,8240.91,2472.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,958.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.77,8240.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER SUT REMOVAL MENISCAL CINCH KNOT PUSHER 2-0 FIBERWIRE",SUP-AR-4515,CDM,S27200284,LOCAL,0272,RC,,,both,,,1063.13,318.94,"KAISER [10500]",Kaiser,,712.3,67,,,,,0,123.64,903.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 15.8X7.9IN XENMATRIX AQUAPURE RECTANGLE",SUP-1162540,CDM,C1781,HCPCS,0278,RC,,,both,,,133708.32,40112.5,"AETNA [10100]","Aetna HMO/PPO",,106298.11,79.5,,,,,0,15550.28,113652.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 12.4X1.4MM TITANIUM 2/2.3MM SCR 6 HOLE STT FUSION",SUP-A-4660.15,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,9268.88,53.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAWSON-MUELLER 25CM 7FR .035IN DRNG HYDROPHILIC",SUP-G11020,CDM,C1729,HCPCS,0272,RC,,,both,,,660.07,198.02,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,76.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,76.77,561.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 20MM 2.5MM BALLOON DILATATION DURALYN",SUP-48002502S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PHCS [10601]",PHCS,,878.85,70,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE LLD 65CM .015-.023IN LEAD LOCKING PLATINUM IRIDIUM 19",SUP-518-062,CDM,C1773,HCPCS,0272,RC,,,both,,,4071.00,1221.3,"UHC [10700]","United Healthcare",,2576.94,63.3,,,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 42IN CYLINDRICAL SLEEVE ATS 1500 STERILE",SUP-60800004200,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.99,20.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.79,56.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 5.5MM CORE THK.51MM 25MM LONG NARROW SAGITTAL",SUP-2296-033-414,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.84,87.25,"CIGNA [10200]","Cigna Open Access",,165.49,56.9,,,,,0,33.82,247.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SPINAL 12MM COALITION MIS",SUP-1136.2012,CDM,C1713,HCPCS,0278,RC,,,both,,,18000.00,5400,"CIGNA [10200]","Cigna Open Access",,6030,33.5,,1144.80,304.56,2275.09,66,2093.4,15300,"percent of total billed charges",
"BIT DRILL 3MM LONG STEALTH SYSTEM",SUP-960-524,CDM,S27200284,LOCAL,0272,RC,,,both,,,1466.10,439.83,"KAISER [10500]",Kaiser,,982.29,67,,,,,0,170.51,1246.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE MEDIUM OVAL 240CM 2.4MM CAPTIFLEX LOOP FLEXIBLE BRAID",SUP-M00562401,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.84,35.35,"CIGNA [10200]","Cigna Local Plus",,63.04,53.5,,,,,0,13.7,100.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 LEFT KNEE POSTERIOR STABILIZED CEMENTED",SUP-5515-F-601,CDM,C1776,HCPCS,0278,RC,,,both,,,16566.90,4970.07,"NOVANET [10819]",Novanet,,12425.18,75,,,,,0,1926.73,14081.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 10.5IN OLSEN 1.5MM IRRIGATE SMOOTH INSULATE",SUP-20-0491,CDM,S27200284,LOCAL,0272,RC,,,both,,,325.19,97.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,37.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.82,276.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM T2 TITANIUM FULL THREAD PROXIMAL FEMUR",SUP-1896-5040S,CDM,C1713,HCPCS,0278,RC,,,both,,,1297.80,389.34,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,150.93,1103.13,"percent of total billed charges",
"STEM FEMORAL 100MM 13MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-013,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"AETNA [10100]","Aetna HMO/PPO",,3765.99,79.5,,10981.53,8986.79,12413.38,12,550.92,4026.54,"percent of total billed charges",
"SCR BONE 6MM 45MM TITANIUM SPINE CORTICAL POLYAXIAL FIX",SUP-186727645,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 13.5MM CEMENTLESS MODULAR AML POROUS 43MM",SUP-155401135,CDM,C1776,HCPCS,0278,RC,,,both,,,15374.88,4612.46,"FIRST HEALTH [10303]","First Health",,12299.9,80,,,,,0,1788.1,13068.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 60MM 100CM 12MM 75CM",SUP-H965402120,CDM,C1876,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 2CM 5MM BALLOON",SUP-G52257,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AETNA [10100]","Aetna HMO/PPO",,763.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTICROSS 135CM 1.6CM 12MM 30 MHZ ULTRASOUND PERIPHERAL",SUP-H7493932800180,CDM,C1753,HCPCS,0272,RC,,,both,,,10281.00,3084.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1218.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1195.68,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 14CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175197190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"KAISER [10500]",Kaiser,,847.8,67,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.0MM X 14MM TI",SUP-VAN-20140-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Open Access",,553.07,56.9,,1144.80,304.56,2275.09,66,113.04,826.2,"percent of total billed charges",
"SCR BONE 7.5MM 50MM TSRH OSTEOGRIP TITANIUM SPINE NONSTERILE",SUP-83575501,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"BLUE CROSS [10001]","Blue Cross HMO",,1009.01,39.2,,957.42,156.86,7483.26,51,299.36,2187.9,"percent of total billed charges",
"CATH NEURON 125CM 9CM 6FR 5.6FR .04IN 1 CURVE THROMBECTOMY",SUP-PNS6F125H1,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM LOW PROFILE SCREWS STAINLESS STEEL T10",SUP-AR-8827-20,CDM,C1713,HCPCS,0278,RC,,,both,,,522.45,156.73,"KAISER [10500]",Kaiser,,350.04,67,,,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 4CM 9MM BALLOON DILATATION OTW LOW",SUP-G30978,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH 7.5IN 4.8MM DISPOSABLE AORTIC",SUP-APU548,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"PHCS [10601]",PHCS,,202.98,70,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK HEATING 24X15IN THERMAL-PAK OVER COTTON CANVAS NYLON",SUP-561728,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SHEPHERD ANGIOGRAPHIC 3CM TAPER 300CM 44CM .018IN",SUP-PSP18S-30012,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM DYNACLIP 20X22X22MM INTERNAL FIXATION",SUP-3000-00-202222,CDM,C1713,HCPCS,0278,RC,,,both,,,13662.00,4098.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1618.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1588.89,11612.7,"percent of total billed charges",
"SYSTEM PROMUS PREMIER 20MM 144CM 2.5MM CORONARY STENT",SUP-H7493952820250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"MULTIPLAN [10600]",Multiplan,,4730.25,85,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TIBIAL 62X41MM NEXGEN 2 KNEE ZIMALOY PMMA UHMWPE",SUP-588000202,CDM,C1776,HCPCS,0278,RC,,,both,,,27069.84,8120.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3207.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3148.22,23009.36,"percent of total billed charges",
"INTRO LEAD 16CM 11FR PEEL AWAY",SUP-6095,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK CROSSFLEX SLIM SEAL 12MM 4.5MM BALLOON DILATATION",SUP-1012412-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COLPO-PNEUMO OCCL 6FR SURGICAL SILICONE",SUP-CPO-6,CDM,S27200284,LOCAL,0272,RC,,,both,,,1186.51,355.95,"KAISER [10500]",Kaiser,,794.96,67,,,,,0,137.99,1008.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 20CMX.49MM 20MM HEMAGARD STRAIGHT POLYESTER",SUP-HGK0020-20,CDM,C1768,HCPCS,0278,RC,,,both,,,1926.00,577.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,223.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,223.99,1637.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE S+ 5 KNEE CEMENT FIX BEARING",SUP-150670005,CDM,C1776,HCPCS,0278,RC,,,both,,,15487.05,4646.11,"AETNA [10100]","Aetna HMO/PPO",,12312.2,79.5,,10981.53,8986.79,12413.38,12,1801.14,13163.99,"percent of total billed charges",
"HC Ins/Plc Flow Dir Cath",PX-481000033,CDM,93503,CPT,0481,RC,,,both,,,2448.46,734.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1123.84,45.9,,,,,0,284.76,2448.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEMLESS ANATOMIC PSI KIT (HUMERAL ONLY)",SUP-1235-7151-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2771.21,45.9,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMDESIVIR 100 MG/20ML IV (WET SOLR VIAL)",RX-415225383,CDM,J0248,HCPCS,0636,RC,61958-2901-02,NDC,both,1,UN,2615.60,784.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1346,,,,,,,622.5,2223.26,"fee schedule",
"SUT VICRYL 6-0 P-3 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J492G,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11.1,41.1,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +6.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 47CM 30MM ABDOMEN THORAX WOVEN SOFT",SUP-M00202175430T0,CDM,L8670,HCPCS,0278,RC,,,both,,,13481.36,4044.41,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1597.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,427.53,11459.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Est Eval Visit Level 2",PX-510000177,CDM,99212,CPT,0761,RC,,,both,,,323.05,96.91,"KAISER [10500]",Kaiser,,216.44,67,,,,,0,0.32,323.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X13/10.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-4813,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"FIRST HEALTH [10303]","First Health",,11868,80,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cortisol Blood Total Adrenal",PX-301000159,CDM,82533,CPT,0301,RC,,,both,,,357.50,107.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,303.88,"per diem",
"NEEDLE CHIBA 18 GA X 9 CM",SUP-MCN1803,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,56.7,45.9,,,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,inpatient,,,561084.65,168325.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,220842.98,,"Fee schedule rate ($220,842.98). The outlier threshold amount is ($224,410.00),  the outlier percentage is (46.51%).  The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1). Includes an add-on of $2,243.60 when RC 0681-0684 total amount is above $1.",,,,0,85921.07,341950.2,other,"IP STOPLOSS Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 20MM 7MM BALLOON DILATATION DURALYN",SUP-48007002S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LUTONIX 035 130CM 5X40MM1/EACH",SUP-LX35130540,CDM,C1725,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1324.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAXX 15CM 10MM NEPHRSTMY PTFE SET",SUP-G47649,CDM,C1726,HCPCS,0272,RC,,,both,,,2279.25,683.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,265.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,265.08,1937.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VASOVIEW 6 SHORT VESSEL HARVESTING 30ML BLUNT TIP",SUP-C-VH-2004,CDM,S27200284,LOCAL,0272,RC,,,both,,,880.10,264.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,403.97,45.9,,,,,0,102.36,748.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 90CM 4MM 8FR 2-5-2MM SPACE D CURVE",SUP-D8BTCDL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"FIRST HEALTH [10303]","First Health",,3968.88,80,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 200MM 5MM BALLOON DILATATION OTW",SUP-H74939206052010,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 8MM 6MM SMALL CEMENT SURGICAL PLASTIC 2LB STERILE",SUP-OR1201,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.75,41.02,"CIGNA [10200]",Cigna,,92.99,68,,,,,0,15.9,116.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.6MM KIRSCHNER STAINLESS STEEL NONSTERILE",SUP-KW062SS,CDM,C1713,HCPCS,0278,RC,,,both,,,486.00,145.8,"CIGNA [10200]","Cigna Open Access",,276.53,56.9,,1144.80,304.56,2275.09,66,56.52,413.1,"percent of total billed charges",
"CANN PERFUSION 33.02CM 22FR AORTIC DIFFUSION TIP ELONGATED",SUP-78322,CDM,S27200284,LOCAL,0272,RC,,,both,,,560.00,168,"PHCS [10601]",PHCS,,392,70,,,,,0,65.13,476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT STABILIT MX POWERCURVE VERTECOR LONG",SUP-MX-2100L-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,14904.00,4471.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10134.72,68,,,,,0,1733.34,12668.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN AMPLATZ LEFT 2 CURVE ANGIOGRAPHIC",SUP-H74908526982,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 13MM 57SQ CM 51X71MM COBALT SURESCAN TITANIUM",SUP-DTPA2D1,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"CIGNA [10200]","Cigna Local Plus",,24239.25,31.5,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 4-0 PS-2 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP426H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.17,19.85,"CIGNA [10200]","Cigna Local Plus",,35.4,53.5,,,,,0,7.7,56.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM REVOLVE SPINE PEDICLE POLYAXIAL",SUP-185.453,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"NOVANET [10819]",Novanet,,7160.14,75,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ACCUDRAIN EXTERNAL DRNG CSF GRADUATE BURETTE",SUP-INS8401,CDM,C1729,HCPCS,0272,RC,,,both,,,3587.18,1076.15,"FIRST HEALTH [10303]","First Health",,2869.74,80,,,,,0,417.19,3049.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUTTLE ACCU-PASS 1 MONOFILAMENT SUT STERILE",SUP-72201361,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL PROCISE MAX COBLATION PLASMA FLAT",SUP-EICA889801,CDM,S27200284,LOCAL,0272,RC,,,both,,,2042.40,612.72,"MULTIPLAN [10600]",Multiplan,,1736.04,85,,,,,0,237.53,1736.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IDENTITY IMPRINT TKR KNEE CRUCIATE RETAIN JIG STERILE",SUP-TCR-000-D002,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,370.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX9MM FRA 8D LORDOTIC NARROW WEDGE",SUP-10009,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"PHCS [10601]",PHCS,,13230,70,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 75CM 4CM 5MM 6FR BALLOON DILATATION PERIPHERAL",SUP-CQ7554,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT EDGE STERILE PVC",SUP-E2250HNSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.80,1.44,"AETNA [10100]","Aetna HMO/PPO",,3.82,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.56,4.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG LEAD BLIND BS IS4",SUP-403724,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 26MM MODULAR RESTORATION HA STRAIGHT CONE",SUP-6276-7-026,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,5311.50,4717.44,5388.59,31,2014.9,14726.25,"percent of total billed charges",
"AXLE FEMORAL GMRS SMALL KNEE",SUP-6495-2-115,CDM,C1776,HCPCS,0278,RC,,,both,,,3698.60,1109.58,"BLUE CROSS [10001]","Blue Cross PPO",,1449.85,39.2,,3949.44,3949.44,3949.44,"1 through 10",430.15,3143.81,"percent of total billed charges",
"INTRO SHEATH 5FR 18GA 50CM 11CM GRAY HUB DIL TUBING GWIRE",SUP-PRO-5F-11-038-18G,CDM,C1894,HCPCS,0272,RC,,,both,,,102.23,30.67,"MULTIPLAN [10600]",Multiplan,,86.9,85,,,,,0,11.89,86.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CIRCULATORY SYSTEM O.R. PROCEDURES",264,MS-DRG,,,,,,,inpatient,,,113503.96,34051.19,"AETNA [10100]","Aetna HMO/PPO",,62853.39,,"Fee schedule rate ($62,853.39). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,97532.16,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BD ANGIOCATH 1.88IN 18GA STD INTRAVENOUS FEP PERIPHERAL",SUP-381147,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.83,15.85,"CIGNA [10200]",Cigna,,35.92,68,,,,,0,6.14,44.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR EXTERNAL FIXATION 120MM 4MM SCHANZ SPADE POINT 25MM",SUP-294.46,CDM,C1713,HCPCS,0278,RC,,,both,,,571.54,171.46,"FIRST HEALTH [10303]","First Health",,457.23,80,,,,,0,66.47,485.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 4.75MM SOLERA COCR MOLYBDENUM CURVED",SUP-1475501120,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross HMO",,1728.72,39.2,,957.42,156.86,7483.26,51,512.88,3748.5,"percent of total billed charges",
"ALTIVATE ANATOMIC, ALL-POLY PEGGED GLENOID, SIZE 50, E-PLUS",SUP-521-07-250,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"BLUE CROSS [10001]","Blue Cross HMO",,3592.44,39.2,,5311.50,4717.44,5388.59,31,1065.82,7789.74,"percent of total billed charges",
"CATH SOFT-VU 80CM 4FR SOS OMNI 2 CURVE ANGIOGRAPHIC VISCERAL",SUP-10711402,CDM,C1887,HCPCS,0272,RC,,,both,,,236.64,70.99,"PHCS [10601]",PHCS,,165.65,70,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM DELTAXSFT 10 COIL",SUP-DLX100202,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"BLUE CROSS [10001]","Blue Cross PPO",,3548.7,39.2,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 5MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650405,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3757.02,28.62,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TIGHTROPE XP FIXATION STAINLESS STEEL SYNDESMOSIS",SUP-AR-8925SS,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"BLUE CROSS [10001]","Blue Cross HMO",,4043.68,39.2,,957.42,156.86,7483.26,51,1199.69,8768.18,"percent of total billed charges",
"REAMER SURGICAL 14.5MM HEAD SIDE CUT MEDULLARY NONSTERILE",SUP-352.145,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM SEMIRIGID OPEN ANTERIOR SEG SEWING",SUP-5300M28,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"CIGNA [10200]","Cigna Open Access",,4623,33.5,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 3-5 C-D KNEE RIGHT TIBIA",SUP-42521400412,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"CIGNA [10200]","Cigna Open Access",,4595.11,56.9,,5302.19,4377.88,6578.61,27,939.21,6864.4,"percent of total billed charges",
"DOXEPIN 10 MG CAPSULE",RX-2608,CDM,,,0637,RC,00904-7052-61,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 11 STD KNEE RIGHT POSTERIOR STABILIZE PERSONA",SUP-42500807002,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"BLUE CROSS [10001]","Blue Cross HMO",,11327.07,39.2,,5311.50,4717.44,5388.59,31,3360.56,24561.24,"percent of total billed charges",
"HC Hbb Full Gene Sequence",PX-309000140,CDM,81364,CPT,0310,RC,,,both,,,1536.00,460.8,"BLUE CROSS [10001]","Blue Cross PPO",,414.68,,"Fee schedule rate ($414.68).",,,,0,0.01,1305.6,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 20FTX3IN ROLL 15 LAYER REINFORCE OPEN CELL",SUP-SR315,CDM,S27000186,LOCAL,0270,RC,,,both,,,449.15,134.74,"CIGNA [10200]",Cigna,,305.42,68,,,,,0,52.24,381.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Carbamazepine Free",PX-301000037,CDM,80157,CPT,0301,RC,,,both,,,337.00,101.1,"CIGNA [10200]","Cigna Open Access",,29.15,,,,,,,0.01,286.45,"fee schedule",
"STEM EXT 110MM 14MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-1513-14-110,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"BLUE CROSS [10001]","Blue Cross PPO",,3240.35,39.2,,3949.44,3949.44,3949.44,"1 through 10",961.36,7026.27,"percent of total billed charges",
"HC Specific Gravity, Urine",PX-301000459,CDM,84311,CPT,0301,RC,,,both,,,142.00,42.6,"MULTIPLAN [10600]",Multiplan,,120.7,85,,,,,0,0.01,120.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intrathecal Inj Ommaya Resevior",PX-761000033,CDM,61026,CPT,0761,RC,,,both,,,2003.00,600.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1793,,"Per diem ($1,793).",,,,0,2,2003,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"10GA 20MM BILATERAL KYPHOPLASTY KIT",SUP-VBRX-20-A-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,15352.50,4605.75,"CIGNA [10200]","Cigna Local Plus",,8213.59,53.5,,,,,0,1785.5,13049.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19 DIOPTER +4.5 ADD MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT450U190,CDM,V2632,HCPCS,0276,RC,,,both,,,3712.50,1113.75,"BLUE CROSS [10001]","Blue Cross PPO",,1455.3,39.2,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM STAINLESS STEEL 2.4MM SCR 7X3 HOLE 2 COLUMN",SUP-02.111.731,CDM,C1713,HCPCS,0278,RC,,,both,,,3884.70,1165.41,"KAISER [10500]",Kaiser,,2602.75,67,,,,,0,451.79,3302,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP BASEPLT TIBIAL ATTUNE CEMENT ROTATE PLATFORM",SUP-OSC372206,CDM,C1776,HCPCS,0278,RC,,,both,,,20790.00,6237,"KAISER [10500]",Kaiser,,13929.3,67,,,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X8MM CLYDESDALE PTC 0D PEEK TITANIUM",SUP-4980850,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AETNA [10100]","Aetna HMO/PPO",,22538.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 8MM 144CM 3MM CORONARY STENT",SUP-H7493941808300,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 100CM 5FR ANGLE",SUP-G08421,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"KAISER [10500]",Kaiser,,159.12,67,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 16FR 5CM 30CM MULTIPURPOSE PEEL-AWAY",SUP-G02950,CDM,C1894,HCPCS,0272,RC,,,both,,,530.47,159.14,"MULTIPLAN [10600]",Multiplan,,450.9,85,,,,,0,61.69,450.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KT ASCP FX 25MM 8MM BICEPTOR",SUP-72202358,CDM,C1713,HCPCS,0278,RC,,,both,,,2895.75,868.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1329.15,45.9,,,,,0,336.78,2461.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 29X12.7X.3MM SMALL SAGITTAL STERILE",SUP-1200-013,CDM,S27200284,LOCAL,0272,RC,,,both,,,146.16,43.85,"CIGNA [10200]","Cigna Open Access",,83.17,56.9,,,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Arc Panel",PX-302000185,CDM,86870,CPT,0302,RC,,,both,,,228.80,68.64,"CIGNA [10200]","Cigna Local Plus",,91.26,,,,,,,0.01,228.8,"fee schedule",
"PIN FIXATION 9IN 7/64IN STEINMANN THREAD 2 TROCAR POINT",SUP-KM169-29-76,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"KAISER [10500]",Kaiser,,42.62,67,,,,,0,7.4,54.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SHUTTLE RELAY SPECTRUM 2-0 1 MONOFILAMENT SUT STERILE",SUP-C6004,CDM,S27200284,LOCAL,0272,RC,,,both,,,277.79,83.34,"CIGNA [10200]",Cigna,,188.9,68,,,,,0,32.31,236.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (MR) 10MM X 2.25",SUP-H74939401102250,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"NOVANET [10819]",Novanet,,4062.38,75,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 4.5MM 65MM T7 CORTEX SELF RETAINING SCRDRVR",SUP-72402765,CDM,C1713,HCPCS,0278,RC,,,both,,,456.52,136.96,"NOVANET [10819]",Novanet,,342.39,75,,,,,0,53.09,388.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIBRILLATOR CARDIAC MOMENTUM HEARTLOGIC D.99 CM W5.37 CM X",SUP-G125,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"BLUE CROSS [10001]","Blue Cross HMO",,22626.24,39.2,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 6X34X24MM 20 DEGREE",SUP-1921009P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA [10200]","Cigna Local Plus",,10914.75,31.5,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC",069,MS-DRG,,,,,,,inpatient,,,33623.13,10086.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15856.98,,"Fee schedule rate ($15,856.98). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,4955.01,19921.27,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mod Sed Oth Phys Add 15min",PX-371000012,CDM,99157,CPT,0371,RC,,,both,,,151.32,45.4,"UHC [10700]","United Healthcare",,95.79,63.3,,,,,0,17.6,128.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DUMBBELL EXERCISE CAST IRON NEOPRENE 1-10LB",SUP-81513878,CDM,S27000186,LOCAL,0270,RC,,,both,,,725.19,217.56,"CIGNA [10200]","Cigna Local Plus",,387.98,53.5,,,,,0,84.34,616.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR STRAIGHT 180CM .035IN HYDROPHILIC FIX CORE",SUP-H2OSTFS35180,CDM,C1769,HCPCS,0272,RC,,,both,,,348.00,104.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 42MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ342,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,654.16,68,,,,,0,111.88,817.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN RIGHT CORONARY 3D",SUP-534676T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRICATH 22FR URETHRAL NATURAL RUBBER HYDROGEL 5ML 2",SUP-0168L22,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.78,22.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.81,64.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LINER BIPOLAR TANDEM HIP",SUP-71701455,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"KAISER [10500]",Kaiser,,6934.5,67,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 2.5CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-24-2.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"PHCS [10601]",PHCS,,545.34,70,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 22MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-322,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6684.75,68,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X12MM PARALLEL SPINE CERVICAL",SUP-17912,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9 % IV BOLUS 250 ML",RX-410649,CDM,,,0258,RC,00990-7983-02,NDC,both,250,ML,100.65,30.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 7 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022217,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"BLUE CROSS [10001]","Blue Cross HMO",,6515.86,39.2,,5311.50,4717.44,5388.59,31,1933.15,14128.79,"percent of total billed charges",
"TRAY CATHETERIZATION COMPLETE CARE ADD-A-FOLEY STATLOCK 350",SUP-304400A,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.83,29.05,"AETNA [10100]","Aetna HMO/PPO",,76.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.26,82.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK15MM 51X66MM CONSULTA CRT-D ATRIUM",SUP-D204TRM,CDM,C1882,HCPCS,0278,RC,,,both,,,84445.50,25333.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9821.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9821.01,71778.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW LOWPROFILE 6.5X25MM",SUP-010-55-025,CDM,C1713,HCPCS,0278,RC,,,both,,,2799.97,839.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1285.19,45.9,,,,,0,325.64,2379.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEMORAL PFC SIGMA +2/-2 OFFSET KNEE BOLT STERILE",SUP-960784,CDM,C1776,HCPCS,0278,RC,,,both,,,1671.00,501.3,"PHCS [10601]",PHCS,,1169.7,70,,,,,0,194.34,1420.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 26MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710626,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3994.27,27,,,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLADIUS, PERIPHERAL GUIDE WIRE,300CM 0.014''",SUP-PPW14R300S,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 10MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-510-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"FIRST HEALTH [10303]","First Health",,9626.88,80,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 20MM 144CM 3.5MM CORONARY STENT",SUP-H7493911420350,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1063.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM COCR SPINAL MULTIAXIAL CANNULATED",SUP-54840014540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2732.31,28.62,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 30MM 12MM .035IN BALLOON DILATATION NYBAX",SUP-39171-12034,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"KAISER [10500]",Kaiser,,841.19,67,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 30MM STEALTH 1 SOFT FIBRA STERILE LATEX FREE",SUP-A0G01,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]","Cigna Local Plus",,121.02,53.5,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 42CM 14.5FR STD STRAIGHT POLYURETHANE GLIDEPATH",SUP-5393420R,CDM,C1750,HCPCS,0278,RC,,,both,,,2062.50,618.75,"FIRST HEALTH [10303]","First Health",,1650,80,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Unit Suction Karmen",PX-E27000180,CDM,E27000180,LOCAL,0270,RC,,,both,,,107.80,32.34,"MULTIPLAN [10600]",Multiplan,,91.63,85,,,,,0,12.54,91.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 12MM 145CM 2.75MM CORONARY STENT",SUP-1145275-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]","Cigna Open Access",,3321.82,56.9,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH X-FLOW 22FR URETHRAL SILICONE 50ML 3 WAY DUFOUR TIP",SUP-AB6322,CDM,C1729,HCPCS,0272,RC,,,both,,,169.65,50.89,"MULTIPLAN [10600]",Multiplan,,144.2,85,,,,,0,19.73,144.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 14MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240140300,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"CIGNA [10200]","Cigna Local Plus",,4610.68,53.5,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 5 38IN BRAID TIES MULTISTRAND LOWER KNOT",SUP-AR-7210,CDM,S27200284,LOCAL,0272,RC,,,both,,,347.13,104.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,142.67,41.1,,,,,0,40.37,295.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 2X2CM AXOGUARD HA+ NERVE PROTCT EXTRACELLULAR",SUP-AGHA22,CDM,C1763,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SCR SHOULDER REVERSE TORQUE DEFINE",SUP-320-20-00,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"FIRST HEALTH [10303]","First Health",,1296,80,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONDUIT VALVE 21MM KONECT AORTIC RESILIA",SUP-11060A21,CDM,S27800098,LOCAL,0278,RC,,,both,,,79800.00,23940,"MULTIPLAN [10600]",Multiplan,,67830,85,,,,,0,9280.74,67830,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 3.75 X 18 MM",SUP-1212375-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 7FR .081IN AR1 CURVE GUIDING CORONARY",SUP-LA7AR10D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM MEDLINE UNITE FOOT ANKLE NONLOCK",SUP-MPSN3516,CDM,C1713,HCPCS,0278,RC,,,both,,,1174.50,352.35,"KAISER [10500]",Kaiser,,786.92,67,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pneumcysts Jirovecii Amp Prb",PX-306000257,CDM,87594,CPT,0306,RC,,,both,,,210.00,63,"MULTIPLAN [10600]",Multiplan,,178.5,85,,,,,0,0.21,178.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH FEMORAL CANAL 32CM 14MM INTRAMEDULLARY STERILE",SUP-6198001514,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.45,22.63,"CIGNA [10200]","Cigna Local Plus",,40.37,53.5,,,,,0,8.77,64.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +11 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.110,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROXYCHLOROQUINE 200 MG TABLET",RX-10235,CDM,,,0637,RC,50268-0412-11,NDC,both,1,UN,21.88,6.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.54,18.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM OSSEOTI THR E1 CUP LINER INSRT",SUP-98B00100214,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"AETNA [10100]","Aetna HMO/PPO",,14023.8,79.5,,10981.53,8986.79,12413.38,12,2051.53,14994,"percent of total billed charges",
"SHEATH INTRO GREEN 45CM 6FR BRITE TIP CANN INTERVENTIONAL",SUP-401645M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX10MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183540,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5331.05,68,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR MULTIAORTIC 3 CURVE GUIDING STERILE",SUP-LA6MAC3030,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"PHCS [10601]",PHCS,,255.78,70,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 3.2MM 450MM KIRSCHNER STAINLESS STEEL STERILE",SUP-1210-6450S,CDM,C1713,HCPCS,0278,RC,,,both,,,966.00,289.8,"BLUE CROSS [10001]","Blue Cross HMO",,378.67,39.2,,957.42,156.86,7483.26,51,112.35,821.1,"percent of total billed charges",
"SCR BONE 4.5MM 6MM INFINITY SPINE OCCIPITOCERVICAL",SUP-3600406,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"BEARING HUMERAL 44-41MM COMPREHENSIVE STD SHOULDER E1",SUP-EP-115396,CDM,C1776,HCPCS,0278,RC,,,both,,,8854.00,2656.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6020.72,68,,,,,0,1029.72,7525.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 20MM 120CM 8MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200082020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"KAISER [10500]",Kaiser,,2773.8,67,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Picc Double Lumen",PX-E27200064,CDM,C1751,HCPCS,0272,RC,,,both,,,905.61,271.68,"FIRST HEALTH [10303]","First Health",,724.49,80,,,,,0,105.32,769.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Picc Double Lumen",PX-E27200064,CDM,C1751,HCPCS,0272,RC,,,both,,,905.61,271.68,"MULTIPLAN [10600]",Multiplan,,769.77,85,,,,,0,105.32,769.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX10MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183540,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"CIGNA [10200]","Cigna Open Access",,4460.83,56.9,,5302.19,4377.88,6578.61,27,911.77,6663.81,"percent of total billed charges",
"ANCHOR SUTURE SUPER QUICKANCHOR PLUS ORTHOCORD 2 CP-2 DUAL S",SUP-222984,CDM,C1713,HCPCS,0278,RC,,,both,,,3405.00,1021.5,"CIGNA [10200]",Cigna,,2315.4,68,,1831.33,1831.33,1831.33,16,396,2894.25,"percent of total billed charges",
"BAND ANNULOPLASTY 32MM SIMUPLUS FLEXIBLE LUMEN STERILE LATEX",SUP-7700FB32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"NOVANET [10819]",Novanet,,9832.5,75,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TRIDENT SECUR-FIT TITANIUM CANCELLOUS",SUP-2030-6540-1,CDM,C1713,HCPCS,0278,RC,,,both,,,571.90,171.57,"CIGNA [10200]","Cigna Open Access",,325.41,56.9,,1144.80,304.56,2275.09,66,66.51,486.12,"percent of total billed charges",
"SCR BONE 4.5MM 56MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.756,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"PHCS [10601]",PHCS,,786.54,70,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 3MM BALLOON DILATATION OTW STERILE",SUP-593004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,599.24,41.1,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 22CM 3CM 7FR .035IN PIGTAIL CURVE",SUP-M006180231170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]",Cigna,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA STD TKR VIVACIT-E CERAMIC FEMUR PATELLA T",SUP-98000644700,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6293.7,27,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL MULTIPASS 4-0 PC-5 18IN BRAID COATED UNDYED",SUP-J823G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PHCS [10601]",PHCS,,17.5,70,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 90X20MM ONETRAC LX 2 SMOKE EVACUATION CHANNEL",SUP-C100240,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,218.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMEDY SPECTRUM GV FEMORAL HEAD - 54MM",SUP-GVHDMD,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 25CM 6.6FR MYOCARDIUM UNIPOLAR FIXED SCR IS-1",SUP-5071-25,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross PPO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16015545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Local Plus",,5107.56,53.5,,3978.14,359.25,3978.14,24,1110.3,8114.82,"percent of total billed charges",
"SCR BONE 5.5MM 45MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16015545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Open Access",,5432.16,56.9,,1144.80,304.56,2275.09,66,1110.3,8114.82,"percent of total billed charges",
"LINER ACETABULAR R3 20D 48MM 28MM XLPE HIP",SUP-71334948,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"CIGNA [10200]","Cigna Open Access",,6330.84,56.9,,5302.19,4377.88,6578.61,27,1293.98,9457.31,"percent of total billed charges",
"PIPERACILLIN-TAZOBACTAM 3.375 G VIAL",RX-18303,CDM,J2543,HCPCS,0636,RC,55150-0120-30,NDC,both,1,UN,49.83,14.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,33.88,68,,,,,0,3.74,42.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 27MM 21.5-25MM EXCLUDER",SUP-PLC271200,CDM,C1874,HCPCS,0278,RC,,,both,,,27997.20,8399.16,"CIGNA [10200]","Cigna Open Access",,9379.06,33.5,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR LOW BEND 154MM STAINLESS STEEL 3.5MM SCR 10",SUP-02.124.213,CDM,C1713,HCPCS,0278,RC,,,both,,,8543.30,2562.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,993.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",993.59,7261.81,"percent of total billed charges",
"SCR BONE 2MM 10MM DCP STAINLESS STEEL CORTICAL SELF TAPPING",SUP-201.810,CDM,C1713,HCPCS,0278,RC,,,both,,,358.09,107.43,"CIGNA [10200]","Cigna Local Plus",,191.58,53.5,,3978.14,359.25,3978.14,24,41.65,304.38,"percent of total billed charges",
"CAP STEM HUMERAL CEMENT HEAD TRABECULAR METAL SHOULDER GLENO",SUP-98000900024,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11970,40,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER SUT REMOVAL NOVOCUT MANAGER",SUP-CTXC001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1093.50,328.05,"UHC [10700]","United Healthcare",,692.19,63.3,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nrv Condct 1-2 Studies",PX-922000019,CDM,95907,CPT,0922,RC,,,both,,,1022.50,306.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,420.25,41.1,,,,,0,118.92,869.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER DS NAV 115CM 8MM 7FR 1-7-4MM SPACING F-J CURVE",SUP-BN7TCFJ8L,CDM,C1732,HCPCS,0272,RC,,,both,,,16477.20,4943.16,"PHCS [10601]",PHCS,,11534.04,70,,,,,0,1916.3,14005.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DISORDERS OF NERVOUS SYSTEM WITH CC",092,MS-DRG,,,,,,,inpatient,,,32975.05,9892.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9227.46,,"Fee schedule rate ($9,227.46). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,6345.73,25512.6,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 3.2MM 450MM KIRSCHNER STAINLESS STEEL STERILE",SUP-1210-6450S,CDM,C1713,HCPCS,0278,RC,,,both,,,966.00,289.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,114.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,112.35,821.1,"percent of total billed charges",
"PLATE 116MM STAINLESS STEEL 3.5MM SCREWS SMALL FRAGMENT SET",SUP-223.59,CDM,C1713,HCPCS,0278,RC,,,both,,,2230.20,669.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1023.66,45.9,,,,,0,259.37,1895.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 12MM LEGION STRAIGHT KNEE TITANIUM CEMENT",SUP-71424184,CDM,C1776,HCPCS,0278,RC,,,both,,,12357.90,3707.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4943.16,40,,,,,0,1437.22,10504.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 20MM 120CM 8MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200082020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LACTATED RINGERS IV BOLUS",RX-400296,CDM,J3490,HCPCS,0258,RC,00338-0117-04,NDC,both,1000,ML,100.65,30.19,"CIGNA [10200]","Cigna Open Access",,57.27,56.9,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Proc Unlisted",PX-614000006,CDM,76498,CPT,0614,RC,,,both,,,1755.00,526.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,204.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,204.11,1755,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 35MM MATRIX TITANIUM T25 SPINE PEDICLE",SUP-04.639.635,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 113MM 34MM 30MM 18FR ZENITH ALPHA FLEXOR",SUP-G35349,CDM,C1874,HCPCS,0278,RC,,,both,,,96672.00,29001.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,39732.19,41.1,,,,,0,11242.95,82171.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 10MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962321,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"CIGNA [10200]",Cigna,,5801.52,40,,5873.17,5873.17,5873.17,"1 through 10",1686.79,12328.23,"percent of total billed charges",
"SHUNT DENVER SINGLE VALVE 15.5",SUP-42-2025,CDM,S27200284,LOCAL,0272,RC,,,both,,,15525.00,4657.5,"KAISER [10500]",Kaiser,,10401.75,67,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT DENVER SINGLE VALVE 15.5",SUP-42-2025,CDM,S27200284,LOCAL,0272,RC,,,both,,,15525.00,4657.5,"CIGNA [10200]","Cigna Local Plus",,8305.88,53.5,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 10MM 11FR ENDOPROSTHESIS HEPARIN",SUP-VBH100502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7504.56,40,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH ARTHROSCOPIC STRAIGHT 130MM NANO BITER",SUP-AR-10911D-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,2086.88,626.06,"FIRST HEALTH [10303]","First Health",,1669.5,80,,,,,0,242.7,1773.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PALMAZ GENESIS AVIATOR FLEXSEGMENT 17MM 135CM 5MM 20MM",SUP-H739PG1850BAX3,CDM,C1876,HCPCS,0278,RC,,,both,,,6554.03,1966.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,762.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.23,5570.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Quantitative Assay Drug",PX-301000562,CDM,80299,CPT,0301,RC,,,both,,,284.70,85.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,242,"per diem",
"CATH AGENT 30MM 2MM BALLOON DILATATION PACLITAXEL RADIOPAQUE",SUP-H7493960830200,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"KAISER [10500]",Kaiser,,26064.68,67,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BIOLOGICAL TISSUE 40X30MM TAPESTRY BIOINTEGRATIVE",SUP-TP-4030-01,CDM,C1781,HCPCS,0278,RC,,,both,,,17633.70,5290.11,"NOVANET [10819]",Novanet,,13225.28,75,,,,,0,2050.8,14988.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UROLIFT 2 IMPLANT CARTRIDGE HANDLE KIT",SUP-UL2-CHK,CDM,L8699,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,858.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +6MM 11/13 TAPER 40MM HIP M SPECIFICATION METAL",SUP-136544500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"NOVANET [10819]",Novanet,,8308.46,75,,,,,0,1288.37,9416.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE REFICIO 100 DEMINERALIZED BONE MATRIX .5CC",SUP-27803518,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 4 1/8IN 8.5FR 18GA ARROW-FLEX .035IN PERCUTANEOUS",SUP-CDC-09803-1A,CDM,C1894,HCPCS,0272,RC,,,both,,,638.28,191.48,"MULTIPLAN [10600]",Multiplan,,542.54,85,,,,,0,74.23,542.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 20FTX3IN ROLL 15 LAYER REINFORCE OPEN CELL",SUP-SR315,CDM,S27000186,LOCAL,0270,RC,,,both,,,449.15,134.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,52.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.24,381.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.25 X 12 RX US",SUP-1804325-12,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 58MM 36MM ALTRX HIP",SUP-122136158,CDM,C1776,HCPCS,0278,RC,,,both,,,6814.08,2044.22,"MULTIPLAN [10600]",Multiplan,,5791.97,85,,,,,0,792.48,5791.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 51MM TITANIUM 3 LEVEL ZEVO BONE SPINE CERVICAL",SUP-3003051,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"CATH SPYSCOPE CHOLANGIOGRAM ACCESS DELIVERY DIRECT",SUP-M00546600,CDM,S27200284,LOCAL,0272,RC,,,both,,,16905.00,5071.5,"CIGNA [10200]","Cigna Local Plus",,9044.18,53.5,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 4MM OXFORD ARCOM KNEE RIGHT MENISCAL PHASE 3",SUP-159576,CDM,C1776,HCPCS,0278,RC,,,both,,,8698.97,2609.69,"BLUE CROSS [10001]","Blue Cross PPO",,3410,39.2,,3949.44,3949.44,3949.44,"1 through 10",1011.69,7394.12,"percent of total billed charges",
"SPACER SPINAL 26X10X9-13MM ALTERA 15D",SUP-1124.1032,CDM,S27800098,LOCAL,0278,RC,,,both,,,29925.00,8977.5,"MULTIPLAN [10600]",Multiplan,,25436.25,85,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXTOME CUTTING BALLOON MONORAIL 142CM 10MM 2.7-2FR",SUP-H749CBM3350100,CDM,C1725,HCPCS,0272,RC,,,both,,,5395.80,1618.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3669.14,68,,,,,0,627.53,4586.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASSURANT COBALT 60MM 80CM 8MM BILIARY COCR ILIAC 2",SUP-ASC860SV,CDM,C1876,HCPCS,0278,RC,,,both,,,6444.60,1933.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1844.44,28.62,,,,,0,749.51,5477.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC",988,MS-DRG,,,,,,,inpatient,,,78216.37,23464.91,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,31190.6,,"Fee schedule rate ($31,190.60). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,47986.55,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 12MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDS40012,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA [10200]","Cigna Open Access",,27813.28,33.5,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR MYOSURE SEAL HYSTEROSCOPE OUTFLOW",SUP-40-902,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL CARMALT CURVE 9IN ARTERY CROSS SERRATE",SUP-16-3723,CDM,S27200284,LOCAL,0272,RC,,,both,,,643.06,192.92,"CIGNA [10200]","Cigna Local Plus",,344.04,53.5,,,,,0,74.79,546.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 150CM 200MM 5MM BALLOON DILATATION PACLITAXEL",SUP-H74939419502010,CDM,C2623,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5530.01,41.1,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 40MM COMPREHENSIVE 3.5MM SHOULDER FIX ANGLE",SUP-180555,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"FIRST HEALTH [10303]","First Health",,1244.8,80,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 22MM THORAX KNIT SOFT FLEXIBLE",SUP-M002020951220,CDM,C1768,HCPCS,0278,RC,,,both,,,2698.73,809.62,"BLUE CROSS [10001]","Blue Cross HMO",,1057.9,39.2,,,,,0,313.86,2293.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC",421,MS-DRG,,,,,,,inpatient,,,84505.46,25351.64,"CIGNA [10200]","Cigna Open Access",,19067.33,,"Fee schedule rate ($19,067.33). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,50728.05,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EMBOLIC PROTECTION 70CM INFERIOR VENA CAVA FEMUR",SUP-352506070E,CDM,C1880,HCPCS,0278,RC,,,both,,,7935.00,2380.5,"NOVANET [10819]",Novanet,,5951.25,75,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 80MM 120MM 12MM .035IN 3MM VASCULAR VENOUS",SUP-VENUL12080,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"PHCS [10601]",PHCS,,15435,70,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN INNER SHILEY 6 SPARE LPC FEN PVR CFS LATEX FREE",SUP-6SIC,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.12,18.64,"UHC [10700]","United Healthcare",,39.32,63.3,,,,,0,7.22,52.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER SPINAL MOUNTAINEER SPINE OCCIPITOCERVICAL LATERAL",SUP-188365000,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"CAP CUP ACETABULAR BI-MENTUM PRESS FIT HIP CERAMIC ON",SUP-OSC371182,CDM,C1776,HCPCS,0278,RC,,,both,,,26460.00,7938,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3135.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3077.3,22491,"percent of total billed charges",
"INSRT TIBIAL 8 13MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G813,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6800,68,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 36MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.836,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,100.54,28.62,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER EMBOLIZATION NAVALIGN DELIVERY UNISET STERILE",SUP-G34505,CDM,C1880,HCPCS,0278,RC,,,both,,,7621.05,2286.31,"AETNA [10100]","Aetna HMO/PPO",,6058.73,79.5,,,,,0,886.33,6477.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR FR3.5 CURVE ANGIOGRAPHIC FEMORAL 2",SUP-H74916391012,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"MULTIPLAN [10600]",Multiplan,,65.09,85,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X11MM LUMINARY 10/11MM SPINE",SUP-4711,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12600,40,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET, IMMEDIATE RELEASE",RX-33227,CDM,,,0250,RC,42571-0161-01,NDC,both,1,UN,19.04,5.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.21,16.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO 330MM 3.3MM SWISS LITHOCLAST ULTRASOUND FLEXIBLE",SUP-M0068407140,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG GERMICIDAL 4.75X4IN MAXORB EXTRA CALCIUM ALGINATE IONIC",SUP-MSC9445EP,CDM,S27200284,LOCAL,0272,RC,,,both,,,51.36,15.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE 3.5MM SERFAS CONTOUR ENDOSCOPIC",SUP-279350301,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT COVERA 80MM 120CM 7MM 8FR STRAIGHT VASCULAR",SUP-AVSL07080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]","Cigna Open Access",,6120.45,33.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.35MM 40MM VIPER EXPEDIUM TITANIUM SPINE CORTICAL",SUP-186731440,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ULTRA STRAIGHT 7.25IN COUNT BALANCE HANDLE",SUP-55-9067,CDM,S27200284,LOCAL,0272,RC,,,both,,,1230.07,369.02,"CIGNA [10200]","Cigna Open Access",,699.91,56.9,,,,,0,143.06,1045.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 27MM 135CM 7MM 30MM BILIARY STAINLESS STEEL",SUP-PXB35-07-27-135,CDM,C1876,HCPCS,0278,RC,,,both,,,4347.00,1304.1,"KAISER [10500]",Kaiser,,2912.49,67,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORTICAL SCREW 4MM X 58MM",SUP-HTN-4-U-58,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"CIGNA [10200]","Cigna Local Plus",,832.03,53.5,,3978.14,359.25,3978.14,24,180.87,1321.92,"percent of total billed charges",
"CATH BARDEX LUBRICATH 26FR STD URETHRAL NATURAL RUBBER",SUP-0167L26,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.13,23.44,"AETNA [10100]","Aetna HMO/PPO",,62.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.09,66.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3 CROSSFT BC",SUP-CFBC-4503,CDM,C1713,HCPCS,0278,RC,,,both,,,3471.30,1041.39,"MULTIPLAN [10600]",Multiplan,,2950.61,85,,,,,0,403.71,2950.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 5.5MM EXPEDIUM PREBENT TITANIUM LINE",SUP-179771065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 12MM 144CM 3MM CORONARY STENT PEBAX",SUP-H7493926012300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 125MM 5.5MM CREO STRAIGHT TITANIUM NONSTERILE",SUP-1119.5125,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135MM 100MM 8FR 7MM .018IN BALLOON DILATATION",SUP-39032-70101,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1018.98,68,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 4MM BALL DISSECTING DIAMOND",SUP-MR8-14BA40D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.17,412.25,"MULTIPLAN [10600]",Multiplan,,1168.04,85,,,,,0,159.82,1168.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 20MM 130CM 7MM VASCULAR SELF EXPAND RADIOPAQUE",SUP-H74939293070230,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross HMO",,1893.36,39.2,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP SMF WITH OXINIUM HEAD HIGHLY CROSSLI",SUP-71705520,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLACK 11CM 3MM UTAHBALL SHAFT",SUP-DBL-311,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"NOVANET [10819]",Novanet,,97.88,75,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT 10-0 CU-1 12IN 2 ARM MONOFILAMENT BLACK NONABSORBABLE",SUP-8065198001,CDM,S27200284,LOCAL,0272,RC,,,both,,,280.40,84.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,32.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.61,238.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTP W4TR01 PERCEPTA QUAD CRTP MRI US",SUP-W4TR01,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"CIGNA [10200]",Cigna,,9236.16,40,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 27MM 80CM 8MM 30MM BILIARY STAINLESS STEEL",SUP-PXB35-08-27-080,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"FIRST HEALTH [10303]","First Health",,3493.6,80,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insert Picc With S&I >= 5yr",PX-361000486,CDM,36573,CPT,0361,RC,,,both,,,4198.10,1259.43,"AETNA [10100]","Aetna HMO/PPO",,3337.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,488.24,4198.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SLIP-CATH 40CM 5FR ANGLE KMP CURVE ANGIOGRAPHIC NYLON",SUP-G11993,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METOCLOPRAMIDE 10 MG TABLET",RX-5005,CDM,,,0637,RC,60687-0631-11,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 5FR AR1 CURVE GUIDING NYLON CORONARY",SUP-LA5AR10,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AETNA [10100]","Aetna HMO/PPO",,311.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5MM 2 3/8 CIRCLE BIO-CORKSCREW FIBERWIRE ROTATOR",SUP-AR-1920BNF,CDM,C1713,HCPCS,0278,RC,,,both,,,2126.25,637.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,975.95,45.9,,,,,0,247.28,1807.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIVIGEN CELLULAR BONE MATRIX 5CC CRYO",SUP-BL-1500-002,CDM,C1713,HCPCS,0278,RC,,,both,,,13110.00,3933,"FIRST HEALTH [10303]","First Health",,10488,80,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM COMPREHENSIVE 3.5MM SHOULDER CENTRAL",SUP-115398,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"FIRST HEALTH [10303]","First Health",,1244.8,80,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE REFICIO CORTICAL DEMINERALIZED BONE MATRIX",SUP-27812318,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,218.06,1593.75,"percent of total billed charges",
"CATH NAVIEN 115CM 8CM 6FR .072IN STRAIGHT SPRT NITINOL",SUP-RFX072-115-08,CDM,S27200284,LOCAL,0272,RC,,,both,,,6865.50,2059.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,798.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,798.46,5835.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X8MM COLONIAL 7D LORDOTIC 14MM XL TITANIUM",SUP-365.808CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD AICD QUARTET 1458Q-86",SUP-1458Q/86,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]","Cigna Local Plus",,2999.75,53.5,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 8IN DURAL RETRACTION BLUNT ADSON",SUP-285227,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.41,61.02,"KAISER [10500]",Kaiser,,136.28,67,,,,,0,23.66,172.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 8MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS08020,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS [10001]","Blue Cross PPO",,4595.46,39.2,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC ATLAS+ DR THK14MM IMPLANTABLE 38ML 78GM",SUP-V-243,CDM,C1721,HCPCS,0278,RC,,,both,,,70537.50,21161.25,"FIRST HEALTH [10303]","First Health",,56430,80,,,,,0,8203.51,59956.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BONE BIOPSY REVOLVE ACCESS BEVEL TIP 11GA",SUP-685.031S,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 38MM 145CM 3.5MM CORONARY STENT",SUP-1145350-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"NOVANET [10819]",Novanet,,4378.5,75,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.0MM X 22.0MM",SUP-492002212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +6 DIOPTER MODIFIED C CONVEXOPLANO 13.5MM 5.5MM",SUP-MTA5U0.060,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OFFSET 45D NARROW SHAFT SPEAR TIP BEAVER SURGICAL",SUP-377120,CDM,S27200284,LOCAL,0272,RC,,,both,,,338.76,101.63,"AETNA [10100]","Aetna HMO/PPO",,269.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.4,287.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS ELECTROSURGICAL 36CM 5MM HARMONIC ACE +7 CURVE",SUP-HARH36,CDM,S27200284,LOCAL,0272,RC,,,both,,,3631.45,1089.43,"UHC [10700]","United Healthcare",,2298.71,63.3,,,,,0,422.34,3086.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE AUGMENTATION 12MM CORTICAL INTERSPINOUS PROCESS",SUP-4578112,CDM,S27800098,LOCAL,0278,RC,,,both,,,19921.48,5976.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2360.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2316.87,16933.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL TRIATHLON X3 4 H12 MM KNEE CONDYLAR STABILIZE",SUP-5531-G-412-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"KAISER [10500]",Kaiser,,8062.51,67,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC",905,MS-DRG,,,,,,,inpatient,,,68959.00,20687.7,"BLUE CROSS [10001]","Blue Cross PPO",,36620.77,,,,,,,7561,43309.35,"case rate",
"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC",659,MS-DRG,,,,,,,inpatient,,,58724.78,17617.43,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 150MM 3.5MM BALLOON DILATATION RAPID",SUP-47535150L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET SHEATH 13FR LEAD EXTRACTION EVOLUTION RL DIL CONTROLLED",SUP-G23747,CDM,C1773,HCPCS,0272,RC,,,both,,,10315.50,3094.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET PERICARDIOCENTESIS 40CM 8.3FR 18GA PERICARDIAL SAC",SUP-G02433,CDM,C1729,HCPCS,0272,RC,,,both,,,1096.74,329.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER ANGIOPLASTY 9FR L80CM BALLOON L40MM DIA12MM PERIPHE",SUP-IAV12004008P,CDM,C1725,HCPCS,0272,RC,,,both,,,10281.00,3084.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SURFACE ARTICULAR 12MM PERSONA 6-9 G-H KNEE RIGHT TIBIA",SUP-42522400912,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]",Cigna,,7327.97,68,,5873.17,5873.17,5873.17,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"INTRO SHEATH 10.5FR .138IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1010.5,CDM,C1892,HCPCS,0272,RC,,,both,,,321.03,96.31,"UHC [10700]","United Healthcare",,203.21,63.3,,,,,0,37.34,272.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX 0 CT-3 SPIRAL 28CM SUT NONABSORBABLE",SUP-SXPL2B401,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.56,73.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,165.62,68,,,,,0,28.33,207.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 335CC FULL PROFILE SMOOTH SHELL SURFACE NATRELLE",SUP-SSF-335,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"KAISER [10500]",Kaiser,,5062.19,67,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACCESSORY 6216A003 DLVY SYS LEFT VENTRI",SUP-6216A003,CDM,C1887,HCPCS,0272,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH VIZIGO 17MM SMALL CURVE 71CM 11.5FR 8.5FR INTRO",SUP-D138501,CDM,C1892,HCPCS,0272,RC,,,both,,,6824.10,2047.23,"KAISER [10500]",Kaiser,,4572.15,67,,,,,0,793.64,5800.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM ATLANTIS TITANIUM ANTERIOR CERVICAL SPINE",SUP-876-715,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"LENS IOL 10 D +24 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.240,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Complement Functional Activity",PX-302000032,CDM,86161,CPT,0302,RC,,,both,,,380.00,114,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.6,,"Fee schedule rate ($12.60). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,323,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE RIGHT CRUCIATE RETAIN SIGMA STERILE",SUP-940026,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3010.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3010.99,22006.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 10X8X4MM FACET",SUP-609404,CDM,S27800098,LOCAL,0278,RC,,,both,,,3675.00,1102.5,"CIGNA [10200]","Cigna Open Access",,2091.08,56.9,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 4.5CM 32MM 27-29MM EXCLUDER GORE-TEX",SUP-PLA320400,CDM,S27800098,LOCAL,0278,RC,,,both,,,19725.30,5917.59,"UHC [10700]","United Healthcare",,12486.11,63.3,,,,,0,2294.05,16766.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 17MM PRESS FIT ECHO PF TITANIUM STD OFFSET HIP",SUP-12-150317,CDM,C1776,HCPCS,0278,RC,,,both,,,8336.51,2500.95,"AETNA [10100]","Aetna HMO/PPO",,6627.53,79.5,,10981.53,8986.79,12413.38,12,969.54,7086.03,"percent of total billed charges",
"REAMER SURGICAL 5MM CANNULATED GS",SUP-86PS1005,CDM,C1713,HCPCS,0278,RC,,,both,,,2535.00,760.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,725.52,28.62,,,,,0,294.82,2154.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DYNABRIDGE LAPILOCK KIT",SUP-DB-LL-7000,CDM,C1713,HCPCS,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,1144.80,304.56,2275.09,66,3297.11,24097.5,"percent of total billed charges",
"CATH SABERX 150CM 100MM 6MM BALLOON DILATATION RAPID",SUP-47560100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"UHC [10700]","United Healthcare",,1010.08,63.3,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (MR) 10MM X 2.25",SUP-H74939401102250,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"AETNA [10100]","Aetna HMO/PPO",,4306.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 7.5CM 2MM LEGEND FLUTE LONG BALL HEAD",SUP-75BA20L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1047.74,314.32,"CIGNA [10200]","Cigna Open Access",,596.16,56.9,,,,,0,121.85,890.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2 LR 20IN MONOFILAMENT 3 STRAND BLUE",SUP-3846T,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.63,32.89,"MULTIPLAN [10600]",Multiplan,,93.19,85,,,,,0,12.75,93.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 7MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620807,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7652.65,68,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR SL4 CURVE GUIDING CORONARY LATEX",SUP-LA8SL40,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"UHC [10700]","United Healthcare",,231.3,63.3,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X10MM PRECISION 7D TRAPEZOID SPINE",SUP-7410,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3.8MM 2.9MM MATCH HEAD",SUP-KM-AM8U,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR IMC CURVE ANGIOGRAPHIC TRILON BRACHIAL",SUP-H749085262032,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]","Cigna Local Plus",,40.97,53.5,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL FINE 7IN DRSG STD PATTERN SERRATE HANDLE",SUP-06-0018,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.94,16.18,"FIRST HEALTH [10303]","First Health",,43.15,80,,,,,0,6.27,45.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8MM 50MM MATRIX TITANIUM SPINE CANNULATED POLYAXIAL",SUP-04.606.850,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 12MM 140CM 2.5MM CORONARY STENT",SUP-LUN250R12US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE DESTINATION STRAIGHT 90CM 60CM 8FR GUIDING",SUP-54-89001,CDM,C1894,HCPCS,0272,RC,,,both,,,785.70,235.71,"KAISER [10500]",Kaiser,,526.42,67,,,,,0,91.38,667.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR IMC CURVE ANGIOGRAPHIC TRILON BRACHIAL",SUP-H749085262032,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,31.47,41.1,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM UNIVERSAL 25MM STAINLESS STEEL 2.7/3.5MM SCR 4",SUP-40240425,CDM,C1713,HCPCS,0278,RC,,,both,,,15000.60,4500.18,"FIRST HEALTH [10303]","First Health",,12000.48,80,,,,,0,1744.57,12750.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOPLASTY 9FR L80CM BALLOON L40MM DIA12MM PERIPHE",SUP-IAV12004008P,CDM,C1725,HCPCS,0272,RC,,,both,,,10281.00,3084.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1218.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1195.68,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH PORTEX PERCUTANEOUS STERILE LATEX FREE DISPOSABLE",SUP-101/595/080,CDM,S27200284,LOCAL,0272,RC,,,both,,,3080.70,924.21,"MULTIPLAN [10600]",Multiplan,,2618.6,85,,,,,0,358.29,2618.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLINDAMYCIN 900 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK",RX-178949,CDM,J0737,HCPCS,0636,RC,00338-9553-50,NDC,both,50,ML,100.65,30.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,18.9,,,,,,,7.73,85.55,"fee schedule",
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 20MM 144CM 4MM",SUP-H7493941220400,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2221.63,28.62,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fatty Acids, Free",PX-301000561,CDM,82725,CPT,0301,RC,,,both,,,97.00,29.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.02,,,,,,,0.1,82.45,"fee schedule",
"HC Fatty Acids, Free",PX-301000561,CDM,82725,CPT,0301,RC,,,both,,,97.00,29.1,"UHC [10700]","United Healthcare",,16.89,,,,,,,0.1,82.45,"fee schedule",
"BASKET SPECIMEN RETRIEVAL 115CMX10MM 1.2MM MINI HELIX 3 WIRE",SUP-FG-52D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE 40X40X2.5MM POLYETHYLENE MEDPOR TSI",SUP-82007,CDM,C1713,HCPCS,0278,RC,,,both,,,4347.97,1304.39,"CIGNA [10200]","Cigna Local Plus",,2326.16,53.5,,3978.14,359.25,3978.14,24,505.67,3695.77,"percent of total billed charges",
"TRAY CATHETERIZATION SURESTEP LUBRI-SIL STATLOCK 16FR 350ML",SUP-A942216,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.27,56.48,"PHCS [10601]",PHCS,,131.79,70,,,,,0,21.9,160.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CESAREAN SECTION WITHOUT STERILIZATION WITH MCC",786,MS-DRG,,,,,,,inpatient,,,52281.03,15684.31,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,10538.91,,"Case rate ($10,231.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,501.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,540.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,100.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,513.62. The transfer operating threshold is the transfer adjustment factor * $9,501.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.33. The transfer capital threshold is the transfer adjustment factor * $718.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,5464,21998.69,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 35CM ENDOCARDIUM MYOCARDIUM RIGHT VENTRICLE IS-1",SUP-4046,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross HMO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA SURG VELC CLSR XL 42-44IN LYCR SPANDX",SUP-958-V/XL,CDM,S27000186,LOCAL,0270,RC,,,both,,,388.54,116.56,"PHCS [10601]",PHCS,,271.98,70,,,,,0,45.19,330.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDPN ORTHOPEDIC 140MM 1.3MM BAYONET POINT 4MM AND 5MM SCR",SUP-128039,CDM,S27200284,LOCAL,0272,RC,,,both,,,45.18,13.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.25,38.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22-24X27-32X9MM LUMINARY CC BICONVEX SPINE",SUP-6809,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8981.28,27,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 27FR CUT STORZ 1 STEM",SUP-M0068802041,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM DUET EXTERNAL DRNG CSF VENTRICULAR LUMBAR DISPOSABLE",SUP-46914,CDM,S27200284,LOCAL,0272,RC,,,both,,,2017.88,605.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH AMPLATZ 17CM 30FR ACCESS RENAL RADIOPAQUE STRIPE",SUP-G57469,CDM,C1894,HCPCS,0272,RC,,,both,,,494.10,148.23,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPN NC 20MM 3.5MM BALLOON DILATATION CORONARY ACCEPTS 6",SUP-350-020-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 100MM 6MM BALLOON DILATATION RAPID",SUP-47560100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP ELECTROSURGICAL 8.5INX1MM HARDY BIPOLAR INSULATE",SUP-US411SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,2487.93,746.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1022.54,41.1,,,,,0,289.35,2114.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Specific Gravity, Urine",PX-301000459,CDM,84311,CPT,0301,RC,,,both,,,142.00,42.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,120.7,"per diem",
"1.1MM X 625MM TRILOGY PROBE KIT",SUP-M0068403490,CDM,S27200284,LOCAL,0272,RC,,,both,,,5531.45,1659.43,"NOVANET [10819]",Novanet,,4148.59,75,,,,,0,643.31,4701.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8-6.5MM 40MM CREO SPINE 2 OUTER DIAMETER",SUP-5119.2242,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,957.42,570.23,957.42,28,601.85,4398.75,"percent of total billed charges",
"SCR BONE 4MM 42MM LCP STAINLESS STEEL SHORT THREAD",SUP-207.642,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"CIGNA [10200]",Cigna,,707.23,68,,1831.33,1831.33,1831.33,16,120.96,884.03,"percent of total billed charges",
"BOLT SPINAL 35MM 5.5MM DECADE LARGE PLATE EXTREME LATERAL",SUP-7145535,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]",Cigna,,1101.6,68,,1831.33,1831.33,1831.33,16,188.41,1377,"percent of total billed charges",
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 12MM 144CM 3.5MM",SUP-H7493941212350,CDM,C1874,HCPCS,0278,RC,,,both,,,8245.50,2473.65,"KAISER [10500]",Kaiser,,5524.49,67,,,,,0,958.95,7008.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMT BRIDLE PRO- 12 FR",SUP-4-4212,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"PHCS [10601]",PHCS,,498.96,70,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 96MM STAINLESS STEEL 3.5MM SCR 7X3 HOLE T OBLIQUE LEFT",SUP-241.971,CDM,S27800098,LOCAL,0278,RC,,,both,,,2465.40,739.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1131.62,45.9,,,,,0,286.73,2095.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIRAL MENINGITIS WITH CC/MCC",075,MS-DRG,,,,,,,inpatient,,,43110.68,12933.2,"CIGNA [10200]","Cigna Open Access",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRANSFORM 10MM 3MM BALLOON OCCLUSION 1 LUMEN COMPLIANT",SUP-M003SRC03100,CDM,C1725,HCPCS,0272,RC,,,both,,,11760.02,3528.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT PEG 20FR Y ADPTR IRRIGATION DECOMPRESSION CORLOCK",SUP-50-6120,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.55,40.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOBRONCHIAL 35FR ANGLE 2 RIGHT",SUP-M126135,CDM,S27200284,LOCAL,0272,RC,,,both,,,520.51,156.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPN NC 20MM 3.5MM BALLOON DILATATION CORONARY ACCEPTS 6",SUP-350-020-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL SPINAL 6IN 20GA BD QUINCKE ANESTHESIA STERILE LATEX FREE",SUP-405211,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.24,15.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE 3D LOCK VARIAX BONE RIGHT FOOT",SUP-40-15062,CDM,C1713,HCPCS,0278,RC,,,both,,,5435.82,1630.75,"CIGNA [10200]",Cigna,,3696.36,68,,1831.33,1831.33,1831.33,16,632.19,4620.45,"percent of total billed charges",
"STEM FEMORAL 170MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309116,CDM,C1776,HCPCS,0278,RC,,,both,,,37771.65,11331.49,"BLUE CROSS [10001]","Blue Cross HMO",,14806.49,39.2,,5311.50,4717.44,5388.59,31,4392.84,32105.9,"percent of total billed charges",
"TI 4.0X085 LOR ROD",SUP-102064085,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"NDL ENDOSCOPIC 5MM 25GA INJECTOR NM600/610 STERILE LATEX",SUP-NM-610U-0525,CDM,S27200284,LOCAL,0272,RC,,,both,,,342.17,102.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.79,290.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LACRIMAL 5IN BOWMAN STAINLESS STEEL 2 ENDED SET",SUP-360-270,CDM,S27000186,LOCAL,0270,RC,,,both,,,751.52,225.46,"KAISER [10500]",Kaiser,,503.52,67,,,,,0,87.4,638.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 23MM 7MM STERILE",SUP-AR-1370P,CDM,C1713,HCPCS,0278,RC,,,both,,,1968.75,590.62,"CIGNA [10200]","Cigna Open Access",,1120.22,56.9,,1144.80,304.56,2275.09,66,228.97,1673.44,"percent of total billed charges",
"SET ADMIN 250UM UNIVERSAL INTRAVENOUS THE BELMONT 3 BAG",SUP-903-00006,CDM,S27200284,LOCAL,0272,RC,,,both,,,1507.27,452.18,"FIRST HEALTH [10303]","First Health",,1205.82,80,,,,,0,175.3,1281.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +15.5 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150155,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"NOVANET [10819]",Novanet,,258.75,75,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MELOXICAM 7.5 MG TABLET",RX-20566,CDM,,,0637,RC,50268-0525-11,NDC,both,1,UN,15.58,4.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10.59,68,,,,,0,1.81,13.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 51MM TITANIUM 3 LEVEL ZEVO BONE SPINE CERVICAL",SUP-3003051,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X15MM LUMINARY 10-11MM SPINE",SUP-14715,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CIGNA [10200]","Cigna Local Plus",,9922.5,31.5,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPYSCOPE CHOLANGIOGRAM ACCESS DELIVERY DIRECT",SUP-M00546600,CDM,S27200284,LOCAL,0272,RC,,,both,,,16905.00,5071.5,"FIRST HEALTH [10303]","First Health",,13524,80,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 3D SMALL 1MM 1.7MM SCR 4X2 HOLE LOCKING VARIAX BONE",SUP-57-10392,CDM,C1713,HCPCS,0278,RC,,,both,,,3878.63,1163.59,"CIGNA [10200]",Cigna,,2637.47,68,,1831.33,1831.33,1831.33,16,451.08,3296.84,"percent of total billed charges",
"STENT ZILVER 518 80CM 125CM 8MM VASCULAR HIWIRE NITINOL",SUP-G43783,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2841.72,68,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ISOSORBIDE DINITRATE 10 MG TABLET, IMMEDIATE RELEASE",RX-4064,CDM,,,0637,RC,63739-0569-10,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]",Cigna,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 FULL THREAD CORKSCREW II FIBERWIRE",SUP-AR-1928SF-2,CDM,C1713,HCPCS,0278,RC,,,both,,,1811.25,543.37,"FIRST HEALTH [10303]","First Health",,1449,80,,,,,0,210.65,1539.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lyme Disease Ab",PX-302000102,CDM,86618,CPT,0302,RC,,,both,,,412.30,123.69,"CIGNA [10200]","Cigna Local Plus",,37.47,,,,,,,0.01,350.46,"fee schedule",
"HC Hv Pvb Thoracic Single Inj Site",PX-510000199,CDM,64461,CPT,0761,RC,,,both,,,2882.00,864.6,"PHCS [10601]",PHCS,,2017.4,70,,,,,0,335.18,2740.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,inpatient,,,109432.42,32829.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,23906.03,,,,,,,7561,43776.48,"case rate",
"IMPL BREAST 640CC P4.3CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-640,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,878.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER QUEEN ZIPPER BRA RECOVERY MAMMARY",SUP-958-QUEEN,CDM,S27000186,LOCAL,0270,RC,,,both,,,449.39,134.82,"PHCS [10601]",PHCS,,314.57,70,,,,,0,52.26,381.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.25MM X 10MM  SCOREFLEX  NC",SUP-622-104-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRT-D DTBA1D4 VIVA XT IS1/DF4 US",SUP-DTBA1D4,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA [10200]","Cigna Open Access",,19336.2,33.5,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 E 36MM E1 HIP HIGH WALL",SUP-010000935,CDM,C1776,HCPCS,0278,RC,,,both,,,12282.00,3684.6,"AETNA [10100]","Aetna HMO/PPO",,9764.19,79.5,,10981.53,8986.79,12413.38,12,1428.4,10439.7,"percent of total billed charges",
"NDL SPINAL 6IN 20GA BD QUINCKE ANESTHESIA STERILE LATEX FREE",SUP-405211,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.24,15.97,"UHC [10700]","United Healthcare",,33.7,63.3,,,,,0,6.19,45.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUCICLOVINE F-18 INTRAVENOUS SOLUTION (12-13 MCI)",RX-411838,CDM,A9588,HCPCS,0343,RC,08888-8877-90,NDC,both,1,UN,755.00,226.5,"BLUE CROSS [10001]","Blue Cross PPO",,755,,,,,,,87.81,755,"fee schedule",
"CATH NANOCROSS 150CM 60MM 3MM .014IN BALLOON DILATATION",SUP-AB14W030060150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"FIRST HEALTH [10303]","First Health",,1108.08,80,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 38MMX1.3MM TITANIUM 2/2.3MM SCREWS 6 HOLE",SUP-A-4655.03,CDM,S27200284,LOCAL,0272,RC,,,both,,,7728.00,2318.4,"UHC [10700]","United Healthcare",,4891.82,63.3,,,,,0,898.77,6568.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 285MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.437S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"AETNA [10100]","Aetna HMO/PPO",,6608.38,79.5,,1521.93,481.35,16760.95,30,966.74,7065.57,"percent of total billed charges",
"PLUG CARDIOVASCULAR 11MM 6MM 4FR AMPLATZER .038IN NITINOL 2",SUP-9-AVP038-006,CDM,S27800098,LOCAL,0278,RC,,,both,,,7141.50,2142.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,846.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,830.56,6070.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXTOME 142CM 6MM 2.75MM BALLOON DILATATION NYLON",SUP-H749CBM3275060,CDM,C1725,HCPCS,0272,RC,,,both,,,5395.80,1618.74,"PHCS [10601]",PHCS,,3777.06,70,,,,,0,627.53,4586.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TENFUSE PIP ANGLED ALLOGRAFT 15X2MM STERILE",SUP-TFF2015A,CDM,C1762,HCPCS,0278,RC,,,both,,,8763.00,2628.9,"FIRST HEALTH [10303]","First Health",,7010.4,80,,,,,0,1019.14,7448.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 CT-1 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J338H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 24CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006155232170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"NOVANET [10819]",Novanet,,1065.26,75,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 20MM 135CM 6MM .018IN BILIARY STAINLESS",SUP-G56627,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"CIGNA [10200]","Cigna Open Access",,2867.76,56.9,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 CT-1 27IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCPP42D,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Local Plus",,13.38,53.5,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1-2 18MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71934435,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1442.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1415.56,10345.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LOW PROFILE 35MM TITANIUM INTEGRATE LOCK MECHANISM",SUP-9790035,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,521.61,3812.25,"percent of total billed charges",
"CANN INNER SHILEY 6 SPARE LPC FEN PVR CFS LATEX FREE",SUP-6SIC,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.12,18.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.22,52.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL SHOULDER ANATOMIC CAP INCLUDING CAGED GLENOID CAP",SUP-TSA2,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"NOVANET [10819]",Novanet,,20081.25,75,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET SPINE OCCIPITOCERVICOTHORACIC YUKON NONSTERILE LATEX",SUP-7601-10001,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,236.64,68,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 33MM STD SEWING CUFF",SUP-M7-033,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Open Access",,7386.75,33.5,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 2X2IN DURAGEN PLUS DURAL BOVINE CLLGN PATCH",SUP-DP5022,CDM,,,0278,RC,,,both,,,2208.65,662.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,261.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.21,1877.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURGISLEEVE LG RETRACTION RING",SUP-WPLGR914,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.97,86.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,195.82,68,,,,,0,33.49,244.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Igh@/Bcl2 Translocation Alys",PX-310000050,CDM,81278,CPT,0310,RC,,,both,,,336.00,100.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,186.58,,,,,,,0.01,336,"fee schedule",
"SYSTEM ELUNIR THK90UM 15MM 140CM 4MM CORONARY STENT CARBOSIL",SUP-LUN400R15US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 16MM HOLLOW CANNULATED PERCUTANEOUS STERILE",SUP-03.037.104S,CDM,S27000186,LOCAL,0270,RC,,,both,,,5415.40,1624.62,"CIGNA [10200]",Cigna,,3682.47,68,,,,,0,629.81,4603.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 13MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P513,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS [10001]","Blue Cross PPO",,3275.51,39.2,,3949.44,3949.44,3949.44,"1 through 10",971.79,7102.52,"percent of total billed charges",
"FIBER VENA CURE EVLT NEVERTOUCH LASER",SUP-H78711403002,CDM,C1888,HCPCS,0272,RC,,,both,,,8024.70,2407.41,"FIRST HEALTH [10303]","First Health",,6419.76,80,,,,,0,933.27,6821,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3 RING SUTURE PASSER KIT",SUP-OS3CDK,CDM,S27200284,LOCAL,0272,RC,,,both,,,421.95,126.58,"AETNA [10100]","Aetna HMO/PPO",,335.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,49.07,358.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pretreat RBC Ab ID Drug",PX-302000209,CDM,86970,CPT,0302,RC,,,both,,,159.90,47.97,"BLUE CROSS [10001]","Blue Cross PPO",,36.3,,"Fee schedule rate ($36.30).",,,,0,0.01,135.92,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 45MM TITANIUM EXTRA THICK TISSUE ARTICULATE",SUP-SIGTRSB45AXT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2521.35,756.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MICROCATHETER CEREBROVASCULAR 150CM 1.7-2.4FR .017IN",SUP-M003C1715900,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEAD FEMORAL +8MM 12/14 TAPER 36MM HIP COCR SPECTRON EF",SUP-71303608,CDM,C1776,HCPCS,0278,RC,,,both,,,10236.15,3070.84,"UHC [10700]","United Healthcare",,6479.48,63.3,,8601.07,8395.67,8601.07,"1 through 10",1190.46,8700.73,"percent of total billed charges",
"HEAD HUMERAL 19MM 51MM SHOULDER ECLIPSE STERILE ARTHROPLASTY",SUP-AR-9351-19,CDM,C1776,HCPCS,0278,RC,,,both,,,4105.50,1231.65,"BLUE CROSS [10001]","Blue Cross PPO",,1609.36,39.2,,3949.44,3949.44,3949.44,"1 through 10",477.47,3489.68,"percent of total billed charges",
"CATH SHOCKWAVE E8 150CM 80MM 3MM LITHOTRIPSY PERIPHERAL",SUP-E8IVL030080,CDM,C1725,HCPCS,0272,RC,,,both,,,29610.00,8883,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3508.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9.7CM 5MM MICRUSFRAME 10 COIL",SUP-MFR100509,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"AETNA [10100]","Aetna HMO/PPO",,9446.03,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR REGULAR 60X3.5MM DST SERIES TA TITANIUM LOADING",SUP-TA6035L,CDM,S27200284,LOCAL,0272,RC,,,both,,,310.07,93.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,127.44,41.1,,,,,0,36.06,263.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"E-CATH PLUS CATHETER-OVER-NEEDLE PNB CATHETER SYSTEM 18G X 3",SUP-241285-41E,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.80,114.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,44.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL TOE JOINT 2.75MM HAMMERTUBE 0D PEEK CANNULATED",SUP-P40-001-0275-S,CDM,C1713,HCPCS,0278,RC,,,both,,,6537.75,1961.32,"KAISER [10500]",Kaiser,,4380.29,67,,,,,0,760.34,5557.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X6MM ADVANCED LORDOTIC SPINE",SUP-017706,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"MULTIPLAN [10600]",Multiplan,,7038,85,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINE MNTR ADULT 2 PURPOSE CIRCUIT ETCO2 INTERMEDIATE FILTER",SUP-989803129751,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.32,40.6,"CIGNA [10200]",Cigna,,92.02,68,,,,,0,15.74,115.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUSPIRONE 5 MG TABLET",RX-9324,CDM,,,0637,RC,00904-7122-61,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE PLUS 100CM 6FR .051IN .042IN SMALL JUDKINS",SUP-533618,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"CIGNA [10200]","Cigna Open Access",,46.83,56.9,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000290,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 55X9.5MM HALL THK.6MM RECIPROCATE STERILE",SUP-505225900,CDM,S27200284,LOCAL,0272,RC,,,both,,,257.17,77.15,"KAISER [10500]",Kaiser,,172.3,67,,,,,0,29.91,218.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA 44 AUGMENTATION HEAVIER ADJUSTABLE STRAP FRONT ZIPPER",SUP-2-8124C-44,CDM,S27000186,LOCAL,0270,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROMORPHONE 2 MG TABLET",RX-3760,CDM,,,0250,RC,60687-0579-11,NDC,both,1,UN,12.54,3.76,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE,MINOR",593,APR-DRG,,,,,,,inpatient,,,20456.79,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE,MODERATE",770,APR-DRG,,,,,,,inpatient,,,24778.89,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $2,180.47. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR SKIN DISORDERS,MAJOR",381,APR-DRG,,,,,,,inpatient,,,20018.25,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $7,250.31. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($43,514.28) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"PRESSURE INJECTABLE ARROWGARD BLUE ADVANCEONE-LUMEN MIDLINE",SUP-CDC-41541-MPKB,CDM,C1751,HCPCS,0272,RC,,,both,,,1477.44,443.23,"AETNA [10100]","Aetna HMO/PPO",,1174.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,171.83,1255.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM DYNATRAN REFLEX HYBRID TITANIUM ANGLE FIX",SUP-48674012,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION X-PORT ISP MRI POLYURETHANE 8FR 1",SUP-607540,CDM,C1788,HCPCS,0278,RC,,,both,,,1687.50,506.25,"PHCS [10601]",PHCS,,1181.25,70,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 50CM 4CM ORANGE HUB STAINLESS STEEL GWIRE",SUP-PSS-8F-4-035MT,CDM,C1894,HCPCS,0272,RC,,,both,,,208.80,62.64,"UHC [10700]","United Healthcare",,132.17,63.3,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 18MM HEMASHIELD GOLD STRAIGHT 2 VELOUR",SUP-M002020952180,CDM,C1768,HCPCS,0278,RC,,,both,,,3553.58,1066.07,"CIGNA [10200]","Cigna Local Plus",,1901.17,53.5,,,,,0,413.28,3020.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP OPHTHALMIC 25+ GA GRIESHABER MAXGRIP MICRO TEXTURE",SUP-705.13P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.84,388.75,"MULTIPLAN [10600]",Multiplan,,1101.46,85,,,,,0,150.71,1101.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 18FR 5.9MM 42CM 30CM RADIOPAQUE DIL NONTAPER",SUP-G11672,CDM,C1894,HCPCS,0272,RC,,,both,,,813.24,243.97,"AETNA [10100]","Aetna HMO/PPO",,646.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.58,691.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP MEDIUM 2.3MM TITANIUM 35 CLIP BKLT",SUP-4010-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,6893.10,2067.93,"UHC [10700]","United Healthcare",,4363.33,63.3,,,,,0,801.67,5859.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC",314,MS-DRG,,,,,,,inpatient,,,53260.64,15978.19,"CIGNA [10200]",Cigna,,27341.14,,"Fee schedule rate ($27,341.14). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,8593,52002.8,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STIM PROXIMATE GENITOURINARY HANDSET NONSTERILE LATEX",SUP-TH90G01,CDM,C1787,HCPCS,0270,RC,,,both,,,12516.60,3754.98,"AETNA [10100]","Aetna HMO/PPO",,9950.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1455.68,10639.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE LOCALIZATION 20CM 20GA GHIATAS BREAST BEADED NDL 7CM",SUP-47720,CDM,A4648,HCPCS,0278,RC,,,both,,,182.79,54.84,"MULTIPLAN [10600]",Multiplan,,155.37,85,,,,,0,21.26,155.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ CCO VIP 110CM 7.5FR ARTERIAL LINE AMC",SUP-139HF75P,CDM,C1751,HCPCS,0272,RC,,,both,,,973.54,292.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,662.01,68,,,,,0,113.22,827.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRESSURE INJECTABLE ARROWGARD BLUE ADVANCEONE-LUMEN MIDLINE",SUP-CDC-41541-MPKB,CDM,C1751,HCPCS,0272,RC,,,both,,,1477.44,443.23,"FIRST HEALTH [10303]","First Health",,1181.95,80,,,,,0,171.83,1255.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET G4 SPINAL HEXAGONAL INTERNAL SEXTANT",SUP-7570955,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"BLUE CROSS [10001]","Blue Cross HMO",,943.39,39.2,,957.42,156.86,7483.26,51,279.89,2045.61,"percent of total billed charges",
"HC Candida Ab",PX-302000105,CDM,86628,CPT,0302,RC,,,both,,,58.49,17.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.81,,,,,,,0.01,49.72,"fee schedule",
"HC Fluorescent Ab Titer Ea",PX-302000054,CDM,86256,CPT,0302,RC,,,both,,,340.10,102.03,"MULTIPLAN [10600]",Multiplan,,289.09,85,,,,,0,0.01,289.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 60CM 8MM 2 VELOUR KNITTED STRAIGHT TUBE",SUP-M002020952080,CDM,C1768,HCPCS,0278,RC,,,both,,,3748.95,1124.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436,3186.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTAPRO ATHERECTOMY PRECONNECT EXCHANGEABLE BURR",SUP-H749394671750,CDM,C1724,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR FLOW L160CM INFANT NEONATE",SUP-260177,CDM,S27000186,LOCAL,0270,RC,,,both,,,184.94,55.48,"NOVANET [10819]",Novanet,,138.71,75,,,,,0,21.51,157.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 F 44MM COCR HIP 2 MOBILITY",SUP-110024464,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"NOVANET [10819]",Novanet,,9714.51,75,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 77MMX2.6MM STAINLESS STEEL 2.7MM SCR 8 HOLE LC-DCP",SUP-242.208,CDM,C1713,HCPCS,0278,RC,,,both,,,2429.70,728.91,"BLUE CROSS [10001]","Blue Cross HMO",,952.44,39.2,,957.42,156.86,7483.26,51,282.57,2065.25,"percent of total billed charges",
"TRAY CATH UMBILICAL VESSEL ARGYLE NEO-SERT MAGELLAN 2 TIER",SUP-8888160408,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 22FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0167SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.45,32.23,"AETNA [10100]","Aetna HMO/PPO",,85.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.5,91.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT THR PREP-IM HIP PLUG BRUSH SPONGE SUCTION LATEX FREE",SUP-121010,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"HC Bx Spinal Cord",PX-361000259,CDM,62269,CPT,0361,RC,,,both,,,1892.03,567.61,"CIGNA [10200]",Cigna,,1892.03,,"Case rate ($2,497). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1.89,1892.03,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X18X12MM COROENT 10D XL",SUP-6981250,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2815.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS HIGHFLOW 100CM 7FR IM CURVE ANGIOGRAPHIC DUCOR",SUP-527760,CDM,C1887,HCPCS,0272,RC,,,both,,,137.11,41.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.95,116.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 80MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-02.207.480,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"CIGNA [10200]","Cigna Local Plus",,832.38,53.5,,3978.14,359.25,3978.14,24,180.95,1322.47,"percent of total billed charges",
"EXTRACTOR, BROKEN SCREW, 3 MM, 6"" LONG, SINGLE USE",SUP-SXT004-BR3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"AETNA [10100]","Aetna HMO/PPO",,2355.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Genetic Tstg Severe Inh Cond",PX-310000024,CDM,81443,CPT,0310,RC,,,both,,,6000.00,1800,"MULTIPLAN [10600]",Multiplan,,5100,85,,,,,0,0.01,5386.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 7MM 7CM TWIST-IN SHOULDER OBTR STERILE",SUP-AR-6570,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE DISSECTOR ENDOSCOPIC FLAP DOUBLE END ANGLE 25/45 DEG 1",SUP-3722085,CDM,S27200284,LOCAL,0272,RC,,,both,,,915.95,274.78,"KAISER [10500]",Kaiser,,613.69,67,,,,,0,106.52,778.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASTECTOMY FOR MALIGNANCY WITH CC/MCC",582,MS-DRG,,,,,,,inpatient,,,163503.95,49051.18,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,24334.24,,"Case rate ($11,950.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,097.14, add-ons for qualifying new technology services are included. If operating cost exceeds $44,136.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,221.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $11,111.82. The transfer operating threshold is the transfer adjustment factor * $11,097.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $839.00. The transfer capital threshold is the transfer adjustment factor * $839.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,56249.01,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,J1265,HCPCS,0636,RC,00409-7809-11,NDC,both,250,ML,119.51,35.85,"NOVANET [10819]",Novanet,,89.63,75,,,,,0,7.78,101.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.25MM X 12.0MM",SUP-492251212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON DISECT LAPAROSCOPIC SPACEMAKER EXTRA VIEW",SUP-OMSXB2,CDM,C1727,HCPCS,0272,RC,,,both,,,2092.05,627.61,"KAISER [10500]",Kaiser,,1401.67,67,,,,,0,243.31,1778.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER REDEL 115CM 4MM 7FR 1-7-4MM SPACE F-J CURVE",SUP-BD7TFJ4L,CDM,C1733,HCPCS,0272,RC,,,both,,,6113.40,1834.02,"AETNA [10100]","Aetna HMO/PPO",,4860.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,710.99,5196.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 120MM 3.5MM BALLOON DILATATION RAPID",SUP-47535120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"NOVANET [10819]",Novanet,,1196.78,75,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUTTY 2.5CMX10CM DBM MATRIX PL",SUP-42200,CDM,C1713,HCPCS,0278,RC,,,both,,,14707.35,4412.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4209.24,28.62,,,,,0,1710.46,12501.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL MEDIUM NEUTRAL 65MM KNEE COCRMO UHMWPE MODULAR",SUP-16-2817/35,CDM,C1776,HCPCS,0278,RC,,,both,,,28346.09,8503.83,"FIRST HEALTH [10303]","First Health",,22676.87,80,,,,,0,3296.65,24094.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HIP FEM P2 POROUS OFFSZ13",SUP-425-97-013,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"FIRST HEALTH [10303]","First Health",,34046.76,80,,,,,0,4949.55,36174.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESTRICT CEMENT 12MM",SUP-415-00-120,CDM,S27800098,LOCAL,0278,RC,,,both,,,1555.70,466.71,"MULTIPLAN [10600]",Multiplan,,1322.35,85,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM ALPS TIMAX FULL THREAD ELBOW CORTICAL",SUP-815037028,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"CIGNA [10200]",Cigna,,537.03,68,,1831.33,1831.33,1831.33,16,91.85,671.29,"percent of total billed charges",
"STENT UNISTEP PLUS WALLSTENT RP 55MM 135CM 5MM 160CM",SUP-M001711050,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"KAISER [10500]",Kaiser,,5663.18,67,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD 641003040 40MM CAPPED ROD 4.75MM CCM",SUP-641003040,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"FIRST HEALTH [10303]","First Health",,3528,80,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 90.2X6.8X1.65MM TIMAX 2.5MM SCR LOCK LOW",SUP-131220251,CDM,C1713,HCPCS,0278,RC,,,both,,,4243.50,1273.05,"AETNA [10100]","Aetna HMO/PPO",,3373.58,79.5,,1521.93,481.35,16760.95,30,493.52,3606.98,"percent of total billed charges",
"SPACER ALLOGRAFT 20X50X15-12.2MM ORACLE 8D SPINE FREEZE",SUP-15015,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"AETNA [10100]","Aetna HMO/PPO",,19032.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,inpatient,,,106136.80,31841.04,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,40904.45,,"Case rate ($20,088.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $18,653.64, add-ons for qualifying new technology services are included. If operating cost exceeds $51,693.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,792.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $18,678.31. The transfer operating threshold is the transfer adjustment factor * $18,653.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.31. The transfer capital threshold is the transfer adjustment factor * $1,410.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,94551.25,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Rt Dvc/Marker Pros",PX-333000003,CDM,55876,CPT,0333,RC,,,both,,,1780.05,534.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1210.43,68,,,,,0,207.02,1780.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION",RX-10284,CDM,J1815,HCPCS,0637,RC,00002-8315-01,NDC,both,10,ML,404.15,121.24,"PHCS [10601]",PHCS,,282.91,70,,,,,0,47,343.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 39MM 24MM +4MM LATERALIZE GLENOSPHERE ARTHREX",SUP-AR-9564-2439-LAT,CDM,C1776,HCPCS,0278,RC,,,both,,,9763.50,2929.05,"FIRST HEALTH [10303]","First Health",,7810.8,80,,,,,0,1135.5,8298.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CESAREAN SECTION WITHOUT STERILIZATION WITH MCC",786,MS-DRG,,,,,,,inpatient,,,52281.03,15684.31,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,10538.91,,"Case rate ($10,231.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,501.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,540.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,100.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,513.62. The transfer operating threshold is the transfer adjustment factor * $9,501.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.33. The transfer capital threshold is the transfer adjustment factor * $718.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,5464,21998.69,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY JAMSHIDI SAFE-T PLUS BONE MARROW STERILE",SUP-BCAT4511SP,CDM,S27200284,LOCAL,0272,RC,,,both,,,404.65,121.39,"UHC [10700]","United Healthcare",,256.14,63.3,,,,,0,47.06,343.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transplant Eval Liver Day 1 New Pt",PX-761000010,CDM,99205,CPT,0761,RC,,,both,,,1263.00,378.9,"PHCS [10601]",PHCS,,884.1,70,,,,,0,1.26,1263,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fetal Fibronectin",PX-301000190,CDM,82731,CPT,0301,RC,,,both,,,729.60,218.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,57.36,,"Fee schedule rate ($57.36).",,,,0,0.73,620.16,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lipid Panel",PX-301000010,CDM,80061,CPT,0301,RC,,,both,,,327.75,98.32,"PHCS [10601]",PHCS,,229.43,70,,,,,0,0.33,278.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN LEFT CORONARY BYPASS CURVE",SUP-DXT6LCB,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA [10200]",Cigna,,56.2,68,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ION ENDOSCOPIC NONSTERILE LATEX FREE REUSABLE",SUP-490105,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"AMERIGROUP MEDICAID [20100]",Amerigroup,,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE VITRECTOMY 25GA GRIESHABER 30D DSP POINTED TIP",SUP-339.21,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 36MM TITANIUM FULL THREAD CANNULATED",SUP-04.355.436,CDM,C1713,HCPCS,0278,RC,,,both,,,1848.23,554.47,"CIGNA [10200]","Cigna Open Access",,1051.64,56.9,,1144.80,304.56,2275.09,66,214.95,1571,"percent of total billed charges",
"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC",240,MS-DRG,,,,,,,inpatient,,,87360.93,26208.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,25711.51,,"Fee schedule rate ($25,711.51). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,7561,83223.2,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC",240,MS-DRG,,,,,,,inpatient,,,87360.93,26208.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,54093.94,,"Fee schedule rate ($54,093.94). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,83223.2,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3MM CONCERTO DETACHABLE HELIX PERIPHER",SUP-NV-3-8-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 55MM 1.3MM MINI QUICK COUPLING NONSTERILE",SUP-316.402,CDM,S27000186,LOCAL,0270,RC,,,both,,,503.50,151.05,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TREK 20MM 2.75MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012406-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL 6 FIRING 3 GEL TUBE OPEN LINEAR STERILE LATEX",SUP-PSD7506EN,CDM,S27200284,LOCAL,0272,RC,,,both,,,1301.40,390.42,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE ESOPHAGUS RECTUM 3MR PEDIATRIC SENSOR CABLE",SUP-M1024251,CDM,S27200284,LOCAL,0272,RC,,,both,,,796.07,238.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EVERCROSS CROSSTEC 135CM 40MM 5MM .035IN BALLOON",SUP-AB35W05040135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VIABAHN BX BALLOON EXP ENDO 8MMX79MM 8FR 80CMCATH HEPARIN",SUP-BXBL087901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2536.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACE E-PLUS NEUT 10D HD40",SUP-932-40-756,CDM,C1776,HCPCS,0278,RC,,,both,,,16186.99,4856.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1918.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1882.55,13758.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER ETHIBOND 2-0 CT-2 18IN CONTROL RELEASE BRAID 8",SUP-CX26D,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.37,37.91,"FIRST HEALTH [10303]","First Health",,101.1,80,,,,,0,14.7,107.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 12CM LEGEND 3MM 2 FLUTE MATCH HEAD DISSECTING BURR",SUP-T12MH30M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"NOVANET [10819]",Novanet,,876.62,75,,,,,0,135.93,993.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 24MM VARIAX T8 FULL THREAD NONSTERILE",SUP-656424,CDM,C1713,HCPCS,0278,RC,,,both,,,779.22,233.77,"CIGNA [10200]",Cigna,,529.87,68,,1831.33,1831.33,1831.33,16,90.62,662.34,"percent of total billed charges",
"ROD SPINAL 70MM 4.75MM STRAIGHT PERCUTANEOUS CCM PLUS",SUP-1476006070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC25ST-LK,CDM,S27200284,LOCAL,0272,RC,,,both,,,17640.00,5292,"FIRST HEALTH [10303]","First Health",,14112,80,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SMART CONTROL MICROMARKER 30MM 120CM 6MM VASCULAR",SUP-C06030ML,CDM,C1876,HCPCS,0278,RC,,,both,,,4657.50,1397.25,"NOVANET [10819]",Novanet,,3493.13,75,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ENDOFLIP 16CM BALLOON DILATATION NONSTERILE LATEX FREE",SUP-EF-322N,CDM,S27200284,LOCAL,0272,RC,,,both,,,3202.50,960.75,"PHCS [10601]",PHCS,,2241.75,70,,,,,0,372.45,2722.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ENDOFLIP 16CM BALLOON DILATATION NONSTERILE LATEX FREE",SUP-EF-322N,CDM,S27200284,LOCAL,0272,RC,,,both,,,3202.50,960.75,"CIGNA [10200]","Cigna Open Access",,1822.22,56.9,,,,,0,372.45,2722.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 55MM 4MM STAINLESS STEEL ROUND 8 FLUTED",SUP-1608006137,CDM,S27000186,LOCAL,0270,RC,,,both,,,375.49,112.65,"FIRST HEALTH [10303]","First Health",,300.39,80,,,,,0,43.67,319.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 8MM GORE-TEX STD WALL PERIPHERAL STRETCH",SUP-S0808,CDM,C1768,HCPCS,0278,RC,,,both,,,7438.20,2231.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,881.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,865.06,6322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT FLITES LARGE LOOP DISPOSABLE",SUP-MFA2100-L-L1,CDM,S27000186,LOCAL,0270,RC,,,both,,,231.51,69.45,"CIGNA [10200]","Cigna Open Access",,131.73,56.9,,,,,0,26.92,196.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 180MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-05181,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 10MM 29MM PRIMARY NEXGEN POLYETHYLENE POROUS",SUP-587806529,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.16,2973.35,"NOVANET [10819]",Novanet,,7433.37,75,,,,,0,1152.67,8424.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 45D BALL COOLCUT STERILE SMALL JOINT",SUP-AR-9808SJ-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,978.08,293.42,"CIGNA [10200]","Cigna Local Plus",,523.27,53.5,,,,,0,113.75,831.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPS EXT CABLE B/T/Q BLK 150 US",SUP-401980R,CDM,S27000186,LOCAL,0270,RC,,,both,,,518.40,155.52,"CIGNA [10200]",Cigna,,352.51,68,,,,,0,60.29,440.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LASSO NAVISTAR 7FR 15MM FIXED D CURVE ELECTROPHYSIOLOGY",SUP-D134901,CDM,C1732,HCPCS,0272,RC,,,both,,,11350.50,3405.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1345.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 65MM 16MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-216.065,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,53.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",52.23,381.7,"percent of total billed charges",
"GRAFT BONE FEMORAL CORTICAL THK3-12MM ALLOGRAFT FROZEN STRUT",SUP-450498,CDM,S27800098,LOCAL,0278,RC,,,both,,,4152.42,1245.73,"NOVANET [10819]",Novanet,,3114.32,75,,,,,0,482.93,3529.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT EXTERNAL FIXATION 2MM SALVATION WIRE",SUP-SEF10001,CDM,C1713,HCPCS,0278,RC,,,both,,,1717.50,515.25,"NOVANET [10819]",Novanet,,1288.13,75,,,,,0,199.75,1459.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DEMINERALIZED BONE MATRIX 5ML PUTTY STERILE",SUP-038050,CDM,C1713,HCPCS,0278,RC,,,both,,,4263.00,1278.9,"KAISER [10500]",Kaiser,,2856.21,67,,,,,0,495.79,3623.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2 PIECE ENDURANT II BUNDLE",SUP-ENDURANTII2,CDM,S27800098,LOCAL,0278,RC,,,both,,,108300.00,32490,"PHCS [10601]",PHCS,,75810,70,,,,,0,12595.29,92055,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135D 49MM MINI TAPER HIGH OFFSET 43.2MM 160MM",SUP-L20314,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"CIGNA [10200]","Cigna Local Plus",,4988.69,31.5,,5372.07,4581.20,7242.98,23,1841.86,13461.55,"percent of total billed charges",
"CATH DIREXION HI-FLO 130CM 2.8FR .027IN MICRO J INFUSION",SUP-M001195470,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"NOVANET [10819]",Novanet,,2812.5,75,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE HEARTMATE GOGEAR THORATEC LARGE VENTRICULAR ASSIST",SUP-104231,CDM,Q0498,HCPCS,0274,RC,,,both,,,2883.60,865.08,"NOVANET [10819]",Novanet,,2162.7,75,,,,,0,335.36,2451.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 1 22MM KNEE X3 POSTERIOR STABILIZED BEARING TR",SUP-5532-G-122,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3081.4,27,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Trigger Pnt<=2 Mscl",PX-510000062,CDM,20552,CPT,0361,RC,,,both,,,3291.17,987.35,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1249,1922,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1MM 7MM STAINLESS STEEL CORTICAL HAND SELF TAPPING",SUP-200.527,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"KAISER [10500]",Kaiser,,319.11,67,,,,,0,55.39,404.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Teeth 1v",PX-320000276,CDM,70300,CPT,0320,RC,,,both,,,137.00,41.1,"BLUE CROSS [10001]","Blue Cross HMO",,26.03,,"Fee schedule rate ($26.03).",,,,0,12.6,137,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) CATHETER WALRUS 90CM 8FR STRAIGHT BALLOON DILATATION",SUP-BG8087-090,CDM,C1887,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"KAISER [10500]",Kaiser,,7627.95,67,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER FIBERTAPE STRAIGHT CERCLAGE TROCHANTERIC SUT",SUP-AR-7823,CDM,S27200284,LOCAL,0272,RC,,,both,,,1771.88,531.56,"PHCS [10601]",PHCS,,1240.32,70,,,,,0,206.07,1506.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR 51MM CARBIDE 2.3MM ROUND 8 FLUTE DENTAL",SUP-04-C0106,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.59,14.88,"MULTIPLAN [10600]",Multiplan,,42.15,85,,,,,0,5.77,42.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 5.5MM STRAIGHT SHAFT SURGICAL INTERCONTINENTAL FORTIFY I",SUP-687.526,CDM,S27000186,LOCAL,0270,RC,,,both,,,3120.00,936,"KAISER [10500]",Kaiser,,2090.4,67,,,,,0,362.86,2652,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 300MM 5.5MM CREO TITANIUM HEXAGON END",SUP-1119.6300,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 120MM 6MM .014IN BALLOON DILATATION",SUP-AB14W060120150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,161.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-04006,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"FIRST HEALTH [10303]","First Health",,7170.48,80,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASSURANT COBALT 60MM 80CM 9MM 6FR .035IN BILIARY COCR",SUP-ASC960SV,CDM,C1876,HCPCS,0278,RC,,,both,,,6444.60,1933.38,"CIGNA [10200]","Cigna Local Plus",,3447.86,53.5,,,,,0,749.51,5477.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 295CC",SUP-SSZ-M295,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CIGNA [10200]","Cigna Local Plus",,797.36,53.5,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.75 X 38 MM  RX FDA",SUP-1203375-38,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4657.5,27,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 13MM KNEE X3 BEARING CRUCIATE RETAIN",SUP-5530-G-213-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1352.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 100MM 12.3MM 7MM CUFF DISTAL EXT DISPOSABLE INNER CANN",SUP-70XLTCD,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"FIRST HEALTH [10303]","First Health",,388.22,80,,,,,0,56.44,412.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Ather",PX-361000157,CDM,37229,CPT,0361,RC,,,both,,,23403.71,7021.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2773.34,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2721.85,19893.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED + VE/",SUP-98000800203,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"CIGNA [10200]","Cigna Local Plus",,9128.7,31.5,,5372.07,4581.20,7242.98,23,3370.37,24633,"percent of total billed charges",
"HC Veeg 2-12 Hr Intmt Mntr",PX-740000047,CDM,95712,CPT,0740,RC,,,both,,,5043.88,1513.16,"NOVANET [10819]",Novanet,,3782.91,75,,,,,0,5.04,4287.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Angio Adrenal Uni Sel Si",PX-323000018,CDM,75731,CPT,0323,RC,,,both,,,5619.82,1685.95,"CIGNA [10200]",Cigna,,219.32,,,,,,,156.81,5619.82,"fee schedule",
"CALCIUM GLUCONATE 100 MG/ML (10 %) IV VIAL",RX-1312,CDM,J0612,HCPCS,0636,RC,63323-0360-01,NDC,both,10,ML,90.75,27.22,"FIRST HEALTH [10303]","First Health",,72.6,80,,,,,0,3.52,77.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 80MM 7MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171070840,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT NYLON 6 6 NUROLON 3-0 SH 18IN CONTROL RELEASE BRAID 8",SUP-C513D,CDM,S27200284,LOCAL,0272,RC,,,both,,,120.76,36.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ROD GUIDING L230MM DIA2.5MM STAINLESS STEEL TROCAR TIP WITH",SUP-03.019.026,CDM,S27200284,LOCAL,0272,RC,,,both,,,257.87,77.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOFT-VU 65CM 4FR ROSCH INFERIOR MESENTRIC CURVE",SUP-10733201,CDM,C1887,HCPCS,0272,RC,,,both,,,236.64,70.99,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET .28IN 81IN GRAVITY FLOW Y TYPE LARGE BORE TUBE TUR",SUP-2C4005,CDM,S27200284,LOCAL,0272,RC,,,both,,,140.56,42.17,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Unit Suction Karmen",PX-E27000180,CDM,E27000180,LOCAL,0270,RC,,,both,,,107.80,32.34,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AGENT HEMOSTATIC THROMBIN STERILE KIT MATRIX SURGIFLO 8ML",SUP-2994,CDM,S27200284,LOCAL,0272,RC,,,both,,,2168.14,650.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STEERABLEBALLOON CA",SUP-ARC10SB-LK,CDM,S27200284,LOCAL,0272,RC,,,both,,,17640.00,5292,"AETNA [10100]","Aetna HMO/PPO",,14023.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP5PR,CDM,C1776,HCPCS,0278,RC,,,both,,,17146.50,5143.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4907.33,28.62,,,,,0,1994.14,14574.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 11MM KNEE BEARING CRUCIATE RETAIN TRIATHLON",SUP-5530-G-311-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]",Cigna,,7760.57,68,,5873.17,5873.17,5873.17,"1 through 10",1327.29,9700.71,"percent of total billed charges",
"STEM HUMERAL 210MM PERFORM 14 XLONG SHOULDER STERILE LATEX",SUP-PFX14210,CDM,C1776,HCPCS,0278,RC,,,both,,,51351.30,15405.39,"CIGNA [10200]","Cigna Local Plus",,16175.66,31.5,,5372.07,4581.20,7242.98,23,5972.16,43648.61,"percent of total billed charges",
"GWIRE AMPLATZ EXTRA STIFF VASCULAR CURVE 260CM 3MM .035IN",SUP-THSCF-35-260-3-AES-BH,CDM,C1769,HCPCS,0272,RC,,,both,,,154.43,46.33,"UHC [10700]","United Healthcare",,97.75,63.3,,,,,0,17.96,131.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIANCE TRUELUMEN 150CM .0175IN .038IN BALLOON",SUP-VNC-FX-150,CDM,C1887,HCPCS,0272,RC,,,both,,,9219.00,2765.7,"KAISER [10500]",Kaiser,,6176.73,67,,,,,0,1072.17,7836.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE RIGHT PRESS FIT EMPOWR 3D KNEE STERILE",SUP-243-02-108,CDM,C1776,HCPCS,0278,RC,,,both,,,27824.45,8347.33,"BLUE CROSS [10001]","Blue Cross HMO",,10907.18,39.2,,5311.50,4717.44,5388.59,31,3235.98,23650.78,"percent of total billed charges",
"SHELL/LINER BIPOLAR 47MM 28MM TANDEM ACETABULUM UHMWPE COCR",SUP-71322047,CDM,C1776,HCPCS,0278,RC,,,both,,,7003.50,2101.05,"MULTIPLAN [10600]",Multiplan,,5952.98,85,,,,,0,814.51,5952.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 39MM UNIVERS REVERS +3MM MEDIUM SHOULDER",SUP-AR-9503M-03C,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"KAISER [10500]",Kaiser,,1969.8,67,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 32CM RIGHT TROCHANTERIC INTRAMEDULLARY 125D LONG",SUP-456.392S,CDM,C1713,HCPCS,0278,RC,,,both,,,12838.83,3851.65,"KAISER [10500]",Kaiser,,8602.02,67,,,,,0,1493.16,10913.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 7MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBJR071502A,CDM,C1874,HCPCS,0278,RC,,,both,,,25143.30,7542.99,"UHC [10700]","United Healthcare",,15915.71,63.3,,,,,0,2924.17,21371.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC SMALL 7.5IN 5.5-6.5IN WRIST LEFT LOOP LOCK",SUP-79-87293,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.33,14.8,"UHC [10700]","United Healthcare",,31.23,63.3,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS MULTIPASS 3-0 PS-2 18IN MONOFILAMENT",SUP-PDP497G,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.16,18.65,"PHCS [10601]",PHCS,,43.51,70,,,,,0,7.23,52.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 67.1X44.2X4.8MM MBT 2.5MM KNEE CEMENTED REVISION",SUP-129435125,CDM,C1776,HCPCS,0278,RC,,,both,,,22385.16,6715.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2603.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2603.39,19027.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 42MM AEQUALIS CENTERED REVERSED II 29MM",SUP-DWD193,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5011.32,41.1,,6417.48,6417.48,6417.48,"1 through 10",1418.05,10364.05,"percent of total billed charges",
"MESH SURGICAL MARLEX 6X6IN GROIN HERNIA PATCH KNITTED FLAT",SUP-0117011,CDM,C1781,HCPCS,0278,RC,,,both,,,1134.00,340.2,"CIGNA [10200]",Cigna,,771.12,68,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000105,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lactoferrin Stool",PX-301000295,CDM,83630,CPT,0301,RC,,,both,,,657.40,197.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,17.73,,,,,,,0.01,558.79,"fee schedule",
"PRIMARY HIP 2",SUP-CAP-S-H-2,CDM,C1776,HCPCS,0278,RC,,,both,,,25830.00,7749,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10616.13,41.1,,6417.48,6417.48,6417.48,"1 through 10",3004.03,21955.5,"percent of total billed charges",
"SURFACE ARTICULAR 74X46X14MM NEXGEN LCCK 5-6 E-F STD KNEE",SUP-00599404014,CDM,C1776,HCPCS,0278,RC,,,both,,,16256.40,4876.92,"UHC [10700]","United Healthcare",,10290.3,63.3,,8601.07,8395.67,8601.07,"1 through 10",1890.62,13817.94,"percent of total billed charges",
"HEAD BIPOLAR 57MM 36MM GLADIATOR HIP COCR XLPE UHMWPE",SUP-GLBP3657,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3837.78,27,,,,,0,1653.09,12081.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 20MM 4D RIGHT ELBOW",SUP-TR-H200R-S,CDM,C1776,HCPCS,0278,RC,,,both,,,13489.50,4046.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3860.69,28.62,,,,,0,1568.83,11466.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 10MM 0MM STERILE",SUP-TR-S1000-S,CDM,C1776,HCPCS,0278,RC,,,both,,,15145.50,4543.65,"BLUE CROSS [10001]","Blue Cross PPO",,5937.04,39.2,,3949.44,3949.44,3949.44,"1 through 10",1761.42,12873.68,"percent of total billed charges",
"INSRT TIBIAL 6 CURVE 17.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962064,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"AETNA [10100]","Aetna HMO/PPO",,7353.31,79.5,,10981.53,8986.79,12413.38,12,1075.71,7862.03,"percent of total billed charges",
"IMPL BREAST 325-375ML P3.8-4.5CM MODERATE PROFILE ROUND",SUP-350-1650,CDM,C1789,HCPCS,0278,RC,,,both,,,2475.00,742.5,"CIGNA [10200]",Cigna,,1683,68,,,,,0,287.84,2103.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX10MM VANGUARD E1 KNEE CRUCIATE RETAINING",SUP-EP183460,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3707.06,28.62,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 105MM 16MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-016,CDM,C1776,HCPCS,0278,RC,,,both,,,5684.52,1705.36,"CIGNA [10200]","Cigna Local Plus",,3041.22,53.5,,5372.07,4581.20,7242.98,23,661.11,4831.84,"percent of total billed charges",
"SCR BONE 2.2MM 6MM RELIEVE SPINE SELF DRILL NONSTERILE LATEX",SUP-136.406,CDM,C1713,HCPCS,0278,RC,,,both,,,1077.30,323.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,308.32,28.62,,,,,0,125.29,915.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UCSS ORTHOPEDIC 24IN THREAD",SUP-873-004,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 130MM 5.5MM GATOR STRAIGHT NONSTERILE",SUP-9260A,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -4MM 40MM HIP PRIMARY COCR V40 LFIT",SUP-6260-9-040,CDM,C1776,HCPCS,0278,RC,,,both,,,6224.40,1867.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1781.42,28.62,,,,,0,723.9,5290.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D C KNEE LEFT OSSEOTI KEEL",SUP-42535006401,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1631.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 10MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962331,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1718.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR HEMI 3HL 52MM",SUP-430-98-052,CDM,C1776,HCPCS,0278,RC,,,both,,,16956.34,5086.9,"CIGNA [10200]",Cigna,,6782.54,40,,5873.17,5873.17,5873.17,"1 through 10",1972.02,14412.89,"percent of total billed charges",
"SCR BONE 7MM 50MM EXPEDIUM TITANIUM SPINE 1 INNIE POLYAXIAL",SUP-179712750,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,563.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",563.19,4116.21,"percent of total billed charges",
"INSRT ACETABULAR 36MM 0D E HIP CROSSFIRE TRIDENT",SUP-621-10-36E,CDM,C1776,HCPCS,0278,RC,,,both,,,5690.16,1707.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3869.31,68,,,,,0,661.77,4836.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 58MM 32MM XLPE HIP STERILE",SUP-71339558,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3004.09,27,,,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM LCS COMPLETE STANDARD+ KNEE POSTERIOR",SUP-129427050,CDM,C1776,HCPCS,0278,RC,,,both,,,5583.48,1675.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,661.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,649.36,4745.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 101MM COLLAR ACTIS DUOFIX 3 12/14 STD OFFSET",SUP-101011030,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"CIGNA [10200]",Cigna,,12190.5,40,,5873.17,5873.17,5873.17,"1 through 10",3544.39,25904.81,"percent of total billed charges",
"BEARING HUMERAL 36MM INSET 0D 0MM SHOULDER LATERAL REVERSE",SUP-2R1P100036,CDM,C1776,HCPCS,0278,RC,,,both,,,4728.23,1418.47,"KAISER [10500]",Kaiser,,3167.91,67,,,,,0,549.89,4019,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +23.5 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z9002235,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"KAISER [10500]",Kaiser,,683.8,67,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 26MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ326,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"BLUE CROSS [10001]","Blue Cross PPO",,377.1,39.2,,3949.44,3949.44,3949.44,"1 through 10",111.88,817.7,"percent of total billed charges",
"CMPNT FEMORAL E LEFT OPTION LPS-FLEX GSF STERILE",SUP-00576401551,CDM,C1776,HCPCS,0278,RC,,,both,,,16934.40,5080.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6773.76,40,,,,,0,1969.47,14394.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (3.5-4 MCI)",RX-411876,CDM,A9520,HCPCS,0343,RC,08888-8876-10,NDC,both,1,UN,4614.97,1384.49,"KAISER [10500]",Kaiser,,3092.03,67,,,,,0,536.72,4614.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR CEMENT BIPOLAR",SUP-98000577500,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"BLUE CROSS [10001]","Blue Cross PPO",,3786.72,39.2,,3949.44,3949.44,3949.44,"1 through 10",1123.46,8211,"percent of total billed charges",
"SCR BASEPLT 29MM 4.5MM AEQUALIS SHOULDER TITANIUM LOCK",SUP-DWD029,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CIGNA [10200]",Cigna,,1058.08,68,,5873.17,5873.17,5873.17,"1 through 10",180.96,1322.6,"percent of total billed charges",
"CMPNT FEMORAL G KNEE LEFT CEMENT NEXGEN LPS-FLEX OPTION",SUP-596401751,CDM,C1776,HCPCS,0278,RC,,,both,,,19439.28,5831.78,"BLUE CROSS [10001]","Blue Cross PPO",,7620.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",2260.79,16523.39,"percent of total billed charges",
"MESH SURGICAL PARIETEX 6X4IN VENTRAL HERNIA COMPOSITE",SUP-PCO1510X,CDM,C1781,HCPCS,0278,RC,,,both,,,2638.00,791.4,"MULTIPLAN [10600]",Multiplan,,2242.3,85,,,,,0,306.8,2242.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +20 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.200,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 15MM NONCOLLAR REDUCE PROXIMAL PROFILE",SUP-192415,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"MULTIPLAN [10600]",Multiplan,,20186.21,85,,,,,0,2761.95,20186.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD MARLEX 6X3IN GROIN MONOFILAMENT GOLD STD",SUP-0112680,CDM,C1781,HCPCS,0278,RC,,,both,,,329.73,98.92,"MULTIPLAN [10600]",Multiplan,,280.27,85,,,,,0,38.35,280.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL COMPOSIX L/P 10.2X8.2IN ELLIPSE ECHO",SUP-0144810,CDM,C1781,HCPCS,0278,RC,,,both,,,7203.84,2161.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3306.56,45.9,,,,,0,837.81,6123.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE TOTAL POROUS HA CONCELOC",SUP-71704614,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"CIGNA [10200]","Cigna Open Access",,7808.85,33.5,,5302.19,4377.88,6578.61,27,2710.95,19813.5,"percent of total billed charges",
"BODY CALCAR 27MM RESTORATION +10MM OFFSET HIP MODULAR",SUP-6276-4-127,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"MULTIPLAN [10600]",Multiplan,,19725.14,85,,,,,0,2698.86,19725.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 7-8 13MM KNEE POSTERIOR STABILIZE HIGH",SUP-71453233,CDM,C1776,HCPCS,0278,RC,,,both,,,14665.95,4399.78,"AETNA [10100]","Aetna HMO/PPO",,11659.43,79.5,,10981.53,8986.79,12413.38,12,1705.65,12466.06,"percent of total billed charges",
"INSRT TIBIAL 6 19MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P619,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS [10001]","Blue Cross HMO",,3275.51,39.2,,5311.50,4717.44,5388.59,31,971.79,7102.52,"percent of total billed charges",
"STEM HUMERAL 55MM 17MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113617,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Local Plus",,3969,31.5,,5372.07,4581.20,7242.98,23,1465.38,10710,"percent of total billed charges",
"X3 HUMERAL INSERT - 32MM X 6MM STANDARD",SUP-5571-S-3206,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6854.4,68,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 108MM 8MM SMALL SHELL ALTIVATE REVERSE SHOULDER",SUP-533-08-108,CDM,C1776,HCPCS,0278,RC,,,both,,,43175.16,12952.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,17744.99,41.1,,6417.48,6417.48,6417.48,"1 through 10",5021.27,36698.89,"percent of total billed charges",
"STEM HUMERAL 55MM 17MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113617,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]",Cigna,,5040,40,,5873.17,5873.17,5873.17,"1 through 10",1465.38,10710,"percent of total billed charges",
"CANN OPHTHALMIC 22GA BINKHORST SMALL BLUNT IRR SMOOTH FRONT",SUP-60-1230,CDM,S27200284,LOCAL,0272,RC,,,both,,,190.88,57.26,"NOVANET [10819]",Novanet,,143.16,75,,,,,0,22.2,162.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 32MM TRI-AD 2 ADAM TRICUSPID VALVE MODEL",SUP-900SFC232,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Local Plus",,4129.65,31.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 NARROW KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-42-5000-064-01,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"CIGNA [10200]","Cigna Local Plus",,7201.75,31.5,,5372.07,4581.20,7242.98,23,2658.93,19433.3,"percent of total billed charges",
"SHELL BIPOLAR GREEN 44MM 28MM RINGLOC ECCENTRIC HIP",SUP-11-165212,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3056.88,45.9,,,,,0,774.54,5660.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 CURVE 17.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962044,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1096.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1075.71,7862.03,"percent of total billed charges",
"GRAFT ENDOVASCULAR 14CM 23MM 14.5MM 19-21MM 12-13.5MM GORE",SUP-RLT231414,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"FIRST HEALTH [10303]","First Health",,50160,80,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 13MM 57SQ CM 51X73MM COBALT TITANIUM",SUP-DTPA2D4,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9118.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 60MM 14MM REVISION PRESS FIT ATTUNE KNEE STERIL",SUP-151314060,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"MULTIPLAN [10600]",Multiplan,,7026.27,85,,,,,0,961.36,7026.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 13MM KNEE BEARING POSTERIOR STABILIZE",SUP-5532-G-513-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"MULTIPLAN [10600]",Multiplan,,9700.71,85,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 28MM 10D C HIP X3 TRIDENT 6.9MM",SUP-623-10-28C,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2445.77,28.62,,,,,0,993.86,7263.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXIMA 70CM 5FR .035IN URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002510,CDM,C1758,HCPCS,0272,RC,,,both,,,237.25,71.17,"KAISER [10500]",Kaiser,,158.96,67,,,,,0,27.59,201.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I131 Therapy Capsl per Mci",PX-344000001,CDM,A9517,HCPCS,0636,RC,,,both,,,103.36,31.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,70.28,"fee schedule",
"SPLINT ORTHOPEDIC MEDIUM 8IN THUMB LEFT WRIST D RING CLSR",SUP-350ML,CDM,S27000186,LOCAL,0270,RC,,,both,,,158.34,47.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.41,134.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 4 PREASSEMBLE BLADE STD HANDLE LED LIGHT",SUP-040-04-0140U,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.42,18.73,"CIGNA [10200]","Cigna Open Access",,35.52,56.9,,,,,0,7.26,53.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SENSATION 258MM 723MM 7FR 15MM .018IN IAB 40ML INSRT",SUP-0684-00-0470-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,6932.09,2079.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,806.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,806.2,5892.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC",437,MS-DRG,,,,,,,inpatient,,,34098.35,10229.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7696.77,,"Fee schedule rate ($7,696.77). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,5293.08,21280.45,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"URINARY STONES WITHOUT MCC",694,MS-DRG,,,,,,,inpatient,,,41657.92,12497.38,"BLUE CROSS [10001]","Blue Cross HMO",,17945.32,,,,,,,4848.94,19494.82,"case rate",
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,inpatient,,,24404.56,7321.37,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,5241.13,,"Case rate ($4,944.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,591.27, add-ons for qualifying new technology services are included. If operating cost exceeds $37,630.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,729.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,597.34. The transfer operating threshold is the transfer adjustment factor * $4,591.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $347.12. The transfer capital threshold is the transfer adjustment factor * $347.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,4944.46,19878.88,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC",074,MS-DRG,,,,,,,inpatient,,,32654.93,9796.48,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,6585.94,,"Case rate ($6,394.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,937.37, add-ons for qualifying new technology services are included. If operating cost exceeds $38,977.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,830.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,945.22. The transfer operating threshold is the transfer adjustment factor * $5,937.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.89. The transfer capital threshold is the transfer adjustment factor * $448.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,6394.12,25707.12,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC",074,MS-DRG,,,,,,,inpatient,,,32654.93,9796.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,16434.8,,,,,,,6394.12,25707.12,"case rate",
"HC Bx Spinal Cord",PX-361000259,CDM,62269,CPT,0361,RC,,,both,,,1892.03,567.61,"BLUE CROSS [10001]","Blue Cross HMO",,1.89,.1,,,,,0,1.89,1892.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTEMIS NEURO EVACUATION DEVICE 2.1",SUP-AP21,CDM,S27200284,LOCAL,0272,RC,,,both,,,45328.50,13598.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5271.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5271.7,38529.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plasminogen Not Ag",PX-305000046,CDM,85420,CPT,0305,RC,,,both,,,255.00,76.5,"PHCS [10601]",PHCS,,178.5,70,,,,,0,0.01,216.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hpv Types 16 & 18 Only",PX-306000193,CDM,87625,CPT,0306,RC,,,both,,,249.85,74.95,"KAISER [10500]",Kaiser,,167.4,67,,,,,0,0.01,212.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 12MM BALLOON",SUP-U3575128,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4F QUAD 2-2-2 MPA 120CM",SUP-901485,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,416.14,41.1,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC",309,MS-DRG,,,,,,,inpatient,,,25811.57,7743.47,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,4700.49,,"Case rate ($4,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,237.60, add-ons for qualifying new technology services are included. If operating cost exceeds $37,277.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,702.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.21. The transfer operating threshold is the transfer adjustment factor * $4,237.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $320.38. The transfer capital threshold is the transfer adjustment factor * $320.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4563.58,18347.62,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PLLA HA 35MM 8MM 1.5MM ACL PCL CANNULATED",SUP-7207680,CDM,C1713,HCPCS,0278,RC,,,both,,,1882.13,564.64,"NOVANET [10819]",Novanet,,1411.6,75,,,,,0,218.89,1599.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Spinal Punct Lum Dx W/Fluor/CT",PX-320000231,CDM,62328,CPT,0320,RC,,,both,,,2987.01,896.1,"PHCS [10601]",PHCS,,2090.91,70,,,,,0,347.39,2740.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Graftjacket Xpress per 1cc",PX-E63600021,CDM,Q4113,HCPCS,0636,RC,,,both,,,3105.30,931.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2111.6,68,,,,,0,367.98,3105.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Graftjacket Xpress per 1cc",PX-E63600021,CDM,Q4113,HCPCS,0636,RC,,,both,,,3105.30,931.59,"AETNA [10100]","Aetna HMO/PPO",,2468.71,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,367.98,3105.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X12X6MM ROI-C","SUP-MC 1342 P",CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7398,41.1,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC",842,MS-DRG,,,,,,,inpatient,,,52367.36,15710.21,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,13475.28,,"Case rate ($6,267.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,819.87, add-ons for qualifying new technology services are included. If operating cost exceeds $38,859.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,822.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,827.56. The transfer operating threshold is the transfer adjustment factor * $5,819.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $440.01. The transfer capital threshold is the transfer adjustment factor * $440.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,6267.57,25198.37,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Breast Ultrasonic Clip Plc",PX-361000308,CDM,19083,CPT,0361,RC,,,both,,,5626.76,1688.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,654.39,5626.76,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Inframlr W Pta Cmplx Ea Add",PX-361000740,CDM,37299,CPT,0361,RC,,,both,,,9101.85,2730.55,"CIGNA [10200]",Cigna,,7680,,"Case rate ($7,680). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,9.1,7883,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 150MM 8MM BALLOON DILATATION OTW",SUP-H74939206081510,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brain Mapping 1st Hr",PX-740000024,CDM,95961,CPT,0740,RC,,,both,,,1167.00,350.1,"NOVANET [10819]",Novanet,,875.25,75,,,,,0,135.72,1167,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC App Cast Short Leg Walk",PX-450000201,CDM,29425,CPT,0450,RC,,,both,,,1347.00,404.1,"BLUE CROSS [10001]","Blue Cross PPO",,1347,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,67.13,1347,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPTIP APD 25CM 12FR DRNG FLEXIMA METAL POLYURETHANE",SUP-M001281380,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 140MM 4.75MM STRAIGHT PERCUTANEOUS CCM PLUS",SUP-1476006140,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Tilmanocept Diag 0.5mci",PX-343000030,CDM,A9520,HCPCS,0343,RC,,,both,,,4614.97,1384.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,546.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,536.72,3922.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEPHALEXIN 250 MG CAPSULE",RX-9499,CDM,,,0637,RC,00904-7336-61,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE WEDGE ALLOGRAFT FRESH FROZEN IMPACT 20MMX6MM",SUP-160820,CDM,S27800098,LOCAL,0278,RC,,,both,,,12572.49,3771.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1462.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1462.18,10686.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805210,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,106.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prcrd Drg 0-5yr or W Anomly",PX-450000388,CDM,33018,CPT,0450,RC,,,both,,,5785.00,1735.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1261,,,,,,,67.13,4917.25,"case rate",
"KIT IMPL 15X6MM MOBI-C 13MM CERVICAL TITANIUM COCRMO UHMWPE","SUP-MB 3356",CDM,S27800098,LOCAL,0278,RC,,,both,,,33075.00,9922.5,"PHCS [10601]",PHCS,,23152.5,70,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 60MM STEALTH 3 FIBRA STERILE LATEX FREE",SUP-A0G13,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"AETNA [10100]","Aetna HMO/PPO",,179.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 78MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.078S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revasc Lith-Sten-Ath Tib/Per",PX-481000132,CDM,C9775,HCPCS,0481,RC,,,both,,,28367.00,8510.1,"CIGNA [10200]","Cigna Open Access",,16140.82,56.9,,,,,0,3299.08,24111.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION",RX-169198,CDM,J0695,HCPCS,0636,RC,67919-0030-01,NDC,both,1,UN,1052.44,315.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,124.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.71,894.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC",657,MS-DRG,,,,,,,inpatient,,,102067.89,30620.37,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,12032.7,,"Case rate ($11,351.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,540.73, add-ons for qualifying new technology services are included. If operating cost exceeds $43,580.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,178.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $10,554.67. The transfer operating threshold is the transfer adjustment factor * $10,540.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.93. The transfer capital threshold is the transfer adjustment factor * $796.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,53428.68,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ncntc Ifr Spctrsc O/T Pad 1",PX-361000655,CDM,0640T,CPT,0361,RC,,,both,,,61.00,18.3,"CIGNA [10200]","Cigna Open Access",,34.71,56.9,,,,,0,7.09,51.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 54MM 32MM ALTRX HIP",SUP-122132054,CDM,C1776,HCPCS,0278,RC,,,both,,,9128.70,2738.61,"UHC [10700]","United Healthcare",,5778.47,63.3,,8601.07,8395.67,8601.07,"1 through 10",1061.67,7759.4,"percent of total billed charges",
"URETEROSCOPE FLEXIBLE ASCOPE 5 URETERO STD DEFLECTION",SUP-604101000,CDM,C1747,HCPCS,0272,RC,,,both,,,8581.88,2574.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5835.68,68,,,,,0,998.07,7294.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE LP 37M",SUP-TENDV-LP-37M-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"NOVANET [10819]",Novanet,,128250,75,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Proc Spine Unlisted",PX-510000066,CDM,22899,CPT,0761,RC,,,both,,,6795.00,2038.5,"MULTIPLAN [10600]",Multiplan,,5775.75,85,,,,,0,790.26,5775.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Tunl IP Cath W Port",PX-361000204,CDM,49419,CPT,0361,RC,,,both,,,14379.15,4313.74,"UHC [10700]","United Healthcare",,9679,,"Case rate ($9,679). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,14.38,12222.28,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENVERSE 15 MM",SUP-EN-0015,CDM,Q4258,HCPCS,0636,RC,,,both,,,2962.50,888.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,351.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,241.31,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION",RX-166772,CDM,J7168,HCPCS,0636,RC,63833-0386-02,NDC,both,1,UN,7897.10,2369.13,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2040,,,,,,,7.9,6712.54,"fee schedule",
"MIDAZOLAM 5 MG/ML INTRANASAL",RX-408787,CDM,J2250,HCPCS,0636,RC,08888-8884-74,NDC,both,2,ML,31.35,9.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2.7,,,,,,,1.64,26.65,"fee schedule",
"HC I123 Mibg per Dose Up to 15mci",PX-343000026,CDM,A9582,HCPCS,0343,RC,,,both,,,15830.00,4749,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1875.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1841.03,13455.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 2CM 3MM NEURAWRAP PERIPHERAL CLLGN MATRIX 2",SUP-NW320,CDM,C9353,HCPCS,0278,RC,,,both,,,8652.60,2595.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2476.37,28.62,,,,,0,1006.3,7354.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.8MM 200MM 15MM LCP ANKLE COMPRESSION THREAD",SUP-03.118.015,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,3978.14,359.25,3978.14,24,50.59,369.75,"percent of total billed charges",
"BILIARY CATH 8FR FLEXIMA 27-156 FLEXIMA",SUP-27-156,CDM,C1729,HCPCS,0272,RC,,,both,,,615.60,184.68,"PHCS [10601]",PHCS,,430.92,70,,,,,0,71.59,523.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BIOLOGICAL TISSUE REGENETEN MEDIUM ROTATOR CUFF BOVINE",SUP-4565,CDM,S27800098,LOCAL,0278,RC,,,both,,,14490.00,4347,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5796,40,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 400ML P4CM MODERATE PLUS PROFILE HIGH PROJECTION",SUP-350-4001BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5347.50,1604.25,"AETNA [10100]","Aetna HMO/PPO",,4251.26,79.5,,,,,0,621.91,4545.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER GD 90CM 6FR RWY AL2 CRV",SUP-H74938969200,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"NOVANET [10819]",Novanet,,274.83,75,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ga-68 Gozetotide Illuccix 1mci",PX-343000046,CDM,A9596,HCPCS,0343,RC,,,both,,,24796.80,7439.04,"NOVANET [10819]",Novanet,,18597.6,75,,,,,0,933.11,21077.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTOLOZANE-TAZOBACTAM 1.5 G/11.4ML IV (WET SOLR VIAL)",RX-415169198,CDM,J0695,HCPCS,0636,RC,67919-0030-01,NDC,both,1,UN,1052.44,315.73,"CIGNA [10200]","Cigna Open Access",,481.08,,,,,,,124.71,894.57,"fee schedule",
"SCR BONE 7.5MM 110MM TITANIUM LONG THREAD CANNULATED",SUP-04.354.802,CDM,C1713,HCPCS,0278,RC,,,both,,,2240.85,672.25,"CIGNA [10200]","Cigna Open Access",,1275.04,56.9,,1144.80,304.56,2275.09,66,260.61,1904.72,"percent of total billed charges",
"HC Vitamin B12 Binding Capacity",PX-301000173,CDM,82608,CPT,0301,RC,,,both,,,164.00,49.2,"CIGNA [10200]",Cigna,,31.5,,,,,,,0.16,139.4,"fee schedule",
"HC Pulm Func Test Lung Vol",PX-460000011,CDM,94727,CPT,0460,RC,,,both,,,591.36,177.41,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,70.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.78,502.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Feeynolm 5.1-7.5cm Int",PX-450000043,CDM,12053,CPT,0450,RC,,,both,,,2140.00,642,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.13,,,,,,,67.13,2140,"case rate",
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR ANGLE KMP CURVE",SUP-G09469,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"NOVANET [10819]",Novanet,,178.12,75,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC",027,MS-DRG,,,,,,,inpatient,,,164317.86,49295.36,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,16745.19,,"Case rate ($15,649.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,531.81, add-ons for qualifying new technology services are included. If operating cost exceeds $47,571.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,480.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $14,551.03. The transfer operating threshold is the transfer adjustment factor * $14,531.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,098.68. The transfer capital threshold is the transfer adjustment factor * $1,098.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,15649.71,73658.59,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.214,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,400.79,45.9,,,,,0,101.55,742.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Debrisoft",PX-E27200435,CDM,E27200435,LOCAL,0272,RC,,,both,,,73.70,22.11,"PHCS [10601]",PHCS,,51.59,70,,,,,0,8.57,62.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pretreat Serum Ab ID Dilution",PX-302000213,CDM,86976,CPT,0302,RC,,,both,,,75.40,22.62,"MULTIPLAN [10600]",Multiplan,,64.09,85,,,,,0,0.01,73.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Carotene",PX-301000134,CDM,82380,CPT,0301,RC,,,both,,,190.00,57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8.3,,,,,,,0.01,161.5,"fee schedule",
"KIT DRNG 25CM 10FR 21GA FLEXIMA PLATINUM HYDROPHILIC",SUP-M001271970,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 22CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175261180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA [10200]","Cigna Open Access",,830.8,,,,,,,169.81,1241.09,"percent of total billed charges",
"FILLER BONE VOID 60ML .5-5MM 80% CORTICAL 20% CANCELLOUS",SUP-400058,CDM,C1713,HCPCS,0278,RC,,,both,,,4621.28,1386.38,"CIGNA [10200]",Cigna,,3142.47,68,,1831.33,1831.33,1831.33,16,537.45,3928.09,"percent of total billed charges",
"SET IRRIGATION PVC STERILE LATEX FREE DISPOSABLE",SUP-9350,CDM,S27200284,LOCAL,0272,RC,,,both,,,627.67,188.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73,533.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.040S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"CATH EXPO 6FR FEMORAL LEFT 4.5 CURVE ANGIOGRAPHIC",SUP-08641-23,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]","Cigna Local Plus",,40.97,53.5,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TWISTER PLUS 230CM 32MM 2.5MM SPECIMEN RETRIEVAL",SUP-TWIST32,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"CIGNA [10200]",Cigna,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 91MM STAINLESS STEEL 5 HOLE LOCK MODULAR LOW PROFILE",SUP-AR-8943BR-05,CDM,C1713,HCPCS,0278,RC,,,both,,,6410.10,1923.03,"CIGNA [10200]","Cigna Open Access",,3647.35,56.9,,1144.80,304.56,2275.09,66,745.49,5448.59,"percent of total billed charges",
"KIT JEJUNOSTOMY 45CM 18FR TUNGSTEN SILICONE 3.5CM MIC-KEY",SUP-0270-18-3.5-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1082.08,41.1,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 9IN DERRICO BAYONET CURVE BLADE NERVE SURGICAL 7.9MM",SUP-NL5770,CDM,S27200284,LOCAL,0272,RC,,,both,,,823.12,246.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,559.72,68,,,,,0,95.73,699.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION MR.I SILICONE PLASTIC 6.6FR 1",SUP-0603880,CDM,C1788,HCPCS,0278,RC,,,both,,,1547.10,464.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,179.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,179.93,1315.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG 13CM VAC PREVENA PEEL AND PLACE PATCH STRIPS PRESSURE",SUP-PRE1155US.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2091.15,627.34,"NOVANET [10819]",Novanet,,1568.36,75,,,,,0,243.2,1777.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM MITROFLOW BOVINE PERICARDIUM",SUP-LXA25,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Local Plus",,8930.25,31.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45MM STAINLESS STEEL INSTR SURGIDAC SUT",SUP-020730,CDM,S27200284,LOCAL,0272,RC,,,both,,,544.40,163.32,"NOVANET [10819]",Novanet,,408.3,75,,,,,0,63.31,462.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG BLACK 26X15CM GRANUFOAM VAC THK1.6CM THIN PRECUT",SUP-M8275081/5.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,441.46,132.44,"MULTIPLAN [10600]",Multiplan,,375.24,85,,,,,0,51.34,375.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 SH 18IN CONTROL RELEASE BRAID 8 STRAND COATED",SUP-J775D,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.90,37.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,84.25,68,,,,,0,14.41,105.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR PULSE ATTESTA DR MRI IMPLANTABLE LONGEVITY",SUP-ATDRL1,CDM,C1785,HCPCS,0275,RC,,,both,,,15525.00,4657.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6210,40,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC .99IN MINI 5.37X8.18CM DYNAGEN X4 IS-1 DF-4",SUP-G158,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6839.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ELECTROSURGICAL 230CM 4.5CM DOME CERAMIC KNOB NDL",SUP-KD-650U,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOBRONCHIAL ARNDT PEDIATRIC 65CM 7FR STD 1 LUMEN CATH",SUP-G44114,CDM,S27200284,LOCAL,0272,RC,,,both,,,1942.50,582.75,"UHC [10700]","United Healthcare",,1229.6,63.3,,,,,0,225.91,1651.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Adhesive Cement Ostomy",PX-E27000032,CDM,E27000032,LOCAL,0270,RC,,,both,,,59.40,17.82,"NOVANET [10819]",Novanet,,44.55,75,,,,,0,6.91,50.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alkaloids Nos Nicotine",PX-301000487,CDM,80323,CPT,0301,RC,,,both,,,213.75,64.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.21,213.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.7-13.6CM NATRELLE BIOCELL P4.6-4.7CM MODERATE",SUP-SZ68450,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"CIGNA [10200]","Cigna Local Plus",,162.91,53.5,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 90CM 106CM SMOOTH TRANSITION STEERABLE",SUP-MAP690,CDM,S27200284,LOCAL,0272,RC,,,both,,,4071.00,1221.3,"CIGNA [10200]","Cigna Local Plus",,2177.99,53.5,,,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT ENDOSCOPIC AGGRESSIVE 13CM 5MM COOLCUT STERILE",SUP-AR-8500DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"UHC [10700]","United Healthcare",,317.64,63.3,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE LARYNSCP BRITEPRO SOLO MILLER 4 METAL BLADE OVERMOULD",SUP-040-344U,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.63,21.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.45,61.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 150MM 1.4MM TROCAR TIP STERILE",SUP-03.333.002.01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,577.37,173.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,68.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.15,490.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL INSUFFLATION 120MM 14GA ENDOPATH ULTRA VERESS STPCOCK",SUP-PN120,CDM,S27200284,LOCAL,0272,RC,,,both,,,264.41,79.32,"KAISER [10500]",Kaiser,,177.15,67,,,,,0,30.75,224.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 19GA 11CM 5CM ADJUSTABLE COAXIAL TEMNO",SUP-ACT2011,CDM,S27200284,LOCAL,0272,RC,,,both,,,473.85,142.15,"AETNA [10100]","Aetna HMO/PPO",,376.71,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.11,402.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN INNER SHILEY XLT 6 95MM 11MM 6MM ADULT EXTEND LENGTH",SUP-60XLTIN,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.83,1.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.56,4.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25X1.47MM SAGITTAL SYSTEM 6",SUP-6125147090,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP TRUNCATE OSTEOTOM 52MM HEMISPHERE",SUP-00705305210,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"CIGNA [10200]","Cigna Open Access",,2575.52,56.9,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 13MM 51X73MM CLARIA MRI CRT-D SURESCAN",SUP-DTMA1D4,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA [10200]",Cigna,,23088,40,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG HYDROCOLLOID 10X3.5IN AQUACEL AG SURGICAL COVER",SUP-412011,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.85,86.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,132.12,45.9,,,,,0,33.48,244.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER ETHIBOND 5 MO-6 75CM 2 ARM BRAID",SUP-D7372,CDM,S27200284,LOCAL,0272,RC,,,both,,,509.07,152.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,209.23,41.1,,,,,0,59.2,432.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINE ANGIOGRAPHY 121.92CM 3.6MM 1.8MM 1200 PSI FEMALE LUER",SUP-91051483,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.70,26.91,"PHCS [10601]",PHCS,,62.79,70,,,,,0,10.43,76.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND MICROPOINT 6-0 G-6 18IN 2 ARM BRAID",SUP-769G,CDM,S27200284,LOCAL,0272,RC,,,both,,,140.84,42.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,57.89,41.1,,,,,0,16.38,119.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 215MM 3.2MM 3 FLUTED CALIBRATED QUICK COUPLING 80",SUP-356.97,CDM,S27200284,LOCAL,0272,RC,,,both,,,1428.84,428.65,"CIGNA [10200]","Cigna Open Access",,813.01,56.9,,,,,0,166.17,1214.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK STRAIGHT 9IN NERVE RETRACTION BLUNT HOEN STAINLESS",SUP-285235,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.01,84.9,"PHCS [10601]",PHCS,,198.11,70,,,,,0,32.91,240.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 43IN 10FR ENTERAL RADIOPAQUE WEIGHT TIP",SUP-8884721088E,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.69,20.61,"PHCS [10601]",PHCS,,48.08,70,,,,,0,7.99,58.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POS STENT 45CM 7FR URETERAL RADIOPAQUE",SUP-M0061802021,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.15,26.44,"FIRST HEALTH [10303]","First Health",,70.52,80,,,,,0,10.25,74.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 5.5MM 72MM CLEAR-TRAC SHOULDER OBTR",SUP-72200429,CDM,S27200284,LOCAL,0272,RC,,,both,,,317.90,95.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,37.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.97,270.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK LARGE BALL 7.25IN NERVE VESSEL RETRACTION KRAYENBUEHL 3",SUP-58-3032,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE SCOPE RECHARGEABLE UNIVERSAL DESK CHRG NICAD 3.5V",SUP-71670,CDM,S27200284,LOCAL,0272,RC,,,both,,,542.30,162.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,248.92,45.9,,,,,0,63.07,460.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 5 LR 20IN BRAID GREEN NONABSORBABLE",SUP-B409T,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT 8 REGULAR STRAIGHT 2.008IN .03IN TEMPER STRENGTH",SUP-213408,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.75,39.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,60.01,45.9,,,,,0,15.21,111.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRICATH 24FR URETHRAL NATURAL RUBBER NYLON 30CC 3 WAY",SUP-2551H24,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.57,57.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.28,162.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL BLACK EFLEX MONOPOLAR ABLATOR SHAFT",SUP-72200683,CDM,S27200284,LOCAL,0272,RC,,,both,,,3465.00,1039.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,410.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,402.98,2945.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS LIGAPAK 0 54IN BRAID ANTIBACTERIAL COATED",SUP-VCP287G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Local Plus",,13.38,53.5,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 27FR CUT STORZ 1 STEM",SUP-M0068802041,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,56.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER IMPL FOREFOOT MIDFOOT TEMPORARY FIXATION TACK PLATE",SUP-PL-PTACK,CDM,S27200284,LOCAL,0272,RC,,,both,,,696.60,208.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,82.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER SLIMLINE EZ 365UM 1 INCISION SLING",SUP-M0068409211,CDM,S27200284,LOCAL,0272,RC,,,both,,,2338.15,701.44,"AETNA [10100]","Aetna HMO/PPO",,1858.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,271.93,1987.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTAFILL CARTRIDGE 5CC",SUP-6132.6005S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3030.00,909,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1390.77,45.9,,,,,0,352.39,2575.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLINISOL 15% SOLUTION",SUP-2B6189,CDM,S27200284,LOCAL,0272,RC,,,both,,,1023.49,307.05,"CIGNA [10200]",Cigna,,695.97,68,,,,,0,119.03,869.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE LARYNSCP BRITEPRO SOLO MILLER 1 METAL BLADE OVERMOULD",SUP-040-341U,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.63,21.79,"PHCS [10601]",PHCS,,50.84,70,,,,,0,8.45,61.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTERIAL 12IN 20FR 3/8IN EOPA BLUNT TIP INTRO NONVENT",SUP-77520,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"FIRST HEALTH [10303]","First Health",,358.4,80,,,,,0,52.1,380.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIB 2.4MM SCREW CALIBRATED PILOT DRILL BIT",SUP-317-24-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,196.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 0 CT-1 36IN MONOFILAMENT ABSORBABLE",SUP-924H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SILICONE 475ML BREAST RESTERILIZABLE GEL",SUP-RSZ-4754,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"CIGNA [10200]","Cigna Local Plus",,82.51,53.5,,,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SILICONE 475ML BREAST RESTERILIZABLE GEL",SUP-RSZ-4754,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"MULTIPLAN [10600]",Multiplan,,131.1,85,,,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC BONE COOLCUT CURVE 13CM STERILE 4MM",SUP-AR-8400BC,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,66.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR AL1 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916599962,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,52.07,68,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEK DUO",SUP-5190-0020,CDM,S27200284,LOCAL,0272,RC,,,both,,,111150.00,33345,"CIGNA [10200]","Cigna Local Plus",,59465.25,53.5,,,,,0,12926.75,94477.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC IPERIA 7 VR-T DX IMPLANTABLE HOME MNTR PROMRI",SUP-393032,CDM,C1882,HCPCS,0278,RC,,,both,,,39000.00,11700,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4621.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 6-0 PC-3 18IN MONOFILAMENT BLUE",SUP-8636G,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.14,21.04,"AETNA [10100]","Aetna HMO/PPO",,55.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.16,59.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 5FR 25CM RADIOPAQUE GWIRE STERILE DISPOSABLE",SUP-G06587,CDM,S27200284,LOCAL,0272,RC,,,both,,,169.65,50.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,69.73,41.1,,,,,0,19.73,144.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DILATOR 4FR/.035",SUP-48-149,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.00,1.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.47,3.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTITORQUE 110CM 5FR JACKY RADIAL 3.5 CURVE",SUP-40-5023,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"CIGNA [10200]","Cigna Local Plus",,167.56,53.5,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 10X4IN SILVERLON ISLAND TAPE PAD ANTIMICROBIAL",SUP-ID-410,CDM,S27200284,LOCAL,0272,RC,,,both,,,253.17,75.95,"MULTIPLAN [10600]",Multiplan,,215.19,85,,,,,0,29.44,215.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR SYMMETRY UNIVERSAL RING HORIZONTAL BAR SURGICAL",SUP-58-0004,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTELLISYSTEM25 13IN INFLATION POLYCARBONATE 20ML",SUP-IN1525,CDM,S27200284,LOCAL,0272,RC,,,both,,,464.13,139.24,"FIRST HEALTH [10303]","First Health",,371.3,80,,,,,0,53.98,394.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SUCTION 25MM MACRO HOOK SHAVER TUBE NEXUS BONE SCPL",SUP-110-31-1220,CDM,S27200284,LOCAL,0272,RC,,,both,,,4127.77,1238.33,"UHC [10700]","United Healthcare",,2612.88,63.3,,,,,0,480.06,3508.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE THK1.5MM 3-0 SH 36IN 2 ARM MONOFILAMENT FIRM",SUP-P8522H,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.29,24.99,"CIGNA [10200]","Cigna Local Plus",,44.56,53.5,,,,,0,9.69,70.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SUTURETAPE .5 CIRCLE 38IN CONVENTIONAL CUT NDL BLUE",SUP-AR-7511,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL V MUELLER GERALD 7IN 1X2 TEETH DELICATE SATIN",SUP-NL1440,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.94,67.18,"PHCS [10601]",PHCS,,156.76,70,,,,,0,26.04,190.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE MORCELLATION 12MM STERILE",SUP-53-000012,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 10.1MM 7MM 6MM SHILEY UNCUFF FLEXIBLE INNER CANN",SUP-5UN70A,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.56,98.27,"KAISER [10500]",Kaiser,,219.47,67,,,,,0,38.1,278.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 3.7MM 11-14MM 7FR DUETTE GASTROINTESTINAL 6 BAND",SUP-G34054,CDM,S27200284,LOCAL,0272,RC,,,both,,,2625.00,787.5,"FIRST HEALTH [10303]","First Health",,2100,80,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 43IN 8FR ANTICLOG RADIOPAQUE SMOOTH BOLUS",SUP-40-4438,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.71,37.41,"UHC [10700]","United Healthcare",,78.94,63.3,,,,,0,14.5,106,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AERVIA NEONATAL SUPRAGLOTTIC AIRWAY DEVICE, X-LARGE, 3500-50",SUP-AVXL,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.47,70.34,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.27,199.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING ORANGE 60CM 5FR NUTRIO TWISTLOK ENTERAL",SUP-ENSI6050,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.36,32.21,"CIGNA [10200]","Cigna Local Plus",,57.44,53.5,,,,,0,12.49,91.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS FIRSTCHOICE 10 MEQ POTASSIUM CHLORIDE 5%",SUP-07993-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA [10200]","Cigna Open Access",,46.09,56.9,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 8.9MM 6.5MM NASAL ORAL TAPER CUFF MURPHY",SUP-18765S,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.13,22.24,"CIGNA [10200]",Cigna,,50.41,68,,,,,0,8.62,63.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION BARD URO-PREP LUBRI-SIL CRITICORE 16FR",SUP-909516M,CDM,S27200284,LOCAL,0272,RC,,,both,,,190.18,57.05,"PHCS [10601]",PHCS,,133.13,70,,,,,0,22.12,161.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE NDL BRKT KIT COVER STERILE INFINITI PLUS",SUP-610-1230,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.19,25.56,"UHC [10700]","United Healthcare",,53.93,63.3,,,,,0,9.91,72.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE VOYANT 180D 7MM 38MM 20CM 40MM LAPAROSCOPIC 2 ACTION",SUP-EB240,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"CIGNA [10200]","Cigna Open Access",,1813.69,56.9,,,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEV TRQ TIP INTRO",SUP-4071,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPL 7F DEC 2/5 2M 115 MEDSWP",SUP-401582R,CDM,S27200284,LOCAL,0272,RC,,,both,,,2625.00,787.5,"MULTIPLAN [10600]",Multiplan,,2231.25,85,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE EXAMINATION BFLEX REGULAR 5 SINGLE USE X2",SUP-0570-0449,CDM,S27200284,LOCAL,0272,RC,,,both,,,1990.50,597.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,235.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,231.5,1691.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 1 12MM",SUP-TPS-030-121S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION UROMATIC 3% SORBITOL PLASTIC CNTNR 3000ML",SUP-2B7357,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.61,63.18,"AETNA [10100]","Aetna HMO/PPO",,167.43,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.49,179.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER BIPOLAR AQUAMANTYS 2 ELECTRD TIP ELECTRICAL CABLE",SUP-23-320-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,4416.00,1324.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,523.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,513.58,3753.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 57.9CM 18FR TUNGSTEN SILICONE MIC SECUR-LOK",SUP-8210-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"CIGNA [10200]",Cigna,,981.14,68,,,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN AMPLATZ RIGHT 1 CURVE",SUP-DXT6AR10,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"FIRST HEALTH [10303]","First Health",,66.12,80,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT QUILL MONODERM 0 T9 36X36CM BRB CLR",SUP-YA1029Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,212.21,63.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,97.4,45.9,,,,,0,24.68,180.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 3-0 PS-1 18IN MONOFILAMENT BLUE",SUP-8663G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 2-0 CT 27IN MONOFILAMENT ABSORBABLE",SUP-801H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"UHC [10700]","United Healthcare",,17.09,63.3,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR SURGICAL KATZ EXTR FOREIGN BODY REM OTO-RHINO STERILE",SUP-FB5000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1368.96,410.69,"CIGNA [10200]","Cigna Open Access",,778.94,56.9,,,,,0,159.21,1163.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FRCP OLSEN DISPOSABLE",SUP-20-1415KI,CDM,S27200284,LOCAL,0272,RC,,,both,,,404.70,121.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,185.76,45.9,,,,,0,47.07,344,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL TWIST 70MM 3.5MM SCP",SUP-829032070,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEDTRONIC COBALT MRI CRT-D",SUP-DTPB2QQ,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"MULTIPLAN [10600]",Multiplan,,65407.5,85,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 7CM 18GA 2 PART MODIFIED PROC PERCUTANEOUS DISPOSABLE",SUP-G00018,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.21,23.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.14,41.1,,,,,0,9.1,66.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PINPOINT DISPOSABLE RIGID SCOPE INTRODUCER PAQ",SUP-PP9050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1452.19,435.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,596.85,41.1,,,,,0,168.89,1234.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 5-0 P-3 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8698G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ADENOID 5/BX",SUP-MM4000SS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1327.95,398.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,545.79,41.1,,,,,0,154.44,1128.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUSHER SURGICAL 195CM TRUPUSH EMBOLIZATION COIL .016IN",SUP-632774X,CDM,S27200284,LOCAL,0272,RC,,,both,,,3933.00,1179.9,"AETNA [10100]","Aetna HMO/PPO",,3126.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,457.41,3343.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG GERMICIDAL 12X1IN MAXORB EXTRA CALCIUM ALGINATE IONIC",SUP-MSC9412EP,CDM,S27200284,LOCAL,0272,RC,,,both,,,44.96,13.49,"CIGNA [10200]",Cigna,,30.57,68,,,,,0,5.23,38.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD BARDEX 22FR URETHRAL SILICONE ELASTOMER NATURAL",SUP-0166V22S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3.68,1.1,"NOVANET [10819]",Novanet,,2.76,75,,,,,0,0.43,3.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO BIOPSY 10CM 19GA 20GA ACHIEVE UNIVERSAL COAXIAL",SUP-PP1910,CDM,S27200284,LOCAL,0272,RC,,,both,,,114.41,34.32,"MULTIPLAN [10600]",Multiplan,,97.25,85,,,,,0,13.31,97.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL SHALLCROSS S 7.13IN CYSTIC DUCT",SUP-51-3510,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL KNIFE 24FR TUIP OLYMPUS OES PRO",SUP-M0068802671,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,212.27,41.1,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 88MM 1.5MM K WIRE ATTACH THREAD HOLE NONSTERILE",SUP-03.130.300,CDM,S27200284,LOCAL,0272,RC,,,both,,,576.07,172.82,"CIGNA [10200]",Cigna,,391.73,68,,,,,0,67,489.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2-0 KS 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8623H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS FIRSTCHOICE 20 MEQ POTASSIUM CHLORIDE 0.9%",SUP-711509,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,37.18,45.9,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 25MM 3.3MM STERILE DISPOSABLE",SUP-7005-3325S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL L270MM DIA12MM NONSTERILE 3 FLUTED CANNULATED LARG",SUP-03.010.439,CDM,S27200284,LOCAL,0272,RC,,,both,,,2926.35,877.9,"UHC [10700]","United Healthcare",,1852.38,63.3,,,,,0,340.33,2487.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 3.2MM INTERTAN LAG SCR",SUP-71674540,CDM,S27200284,LOCAL,0272,RC,,,both,,,5071.85,1521.55,"CIGNA [10200]",Cigna,,3448.86,68,,,,,0,589.86,4311.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-0 TH-50 48IN NONABSORBABLE",SUP-0U01A,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.35,88.3,"CIGNA [10200]","Cigna Local Plus",,157.48,53.5,,,,,0,34.23,250.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 32X6.3MM THK.8MM STERNUM STERILE LATEX FREE",SUP-0298-097-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.70,55.41,"CIGNA [10200]",Cigna,,125.6,68,,,,,0,21.48,157,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.75CM NATRELLE INSPIRA P6CM FULL PROFILE ROUND",SUP-MSZ-F695,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW .36IN TPS THK.017IN .73IN THIN SMALL BONE SAGITTAL",SUP-KM-3105,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,42,68,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ANGLE RIGHT 24FR PERKASH STERILE",SUP-RAK-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,770.89,231.27,"NOVANET [10819]",Novanet,,578.17,75,,,,,0,89.65,655.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACCESS PORT GASTRIC BAND RAPIDPORT EZ LAP-BAND STD KIT HIGH",SUP-C-2304,CDM,S27200284,LOCAL,0272,RC,,,both,,,5692.50,1707.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,674.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NOZZLE BONE CEMENT THIN FLEXIBLE STERILE DISPOSABLE",SUP-0206515000,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.37,36.71,"FIRST HEALTH [10303]","First Health",,97.9,80,,,,,0,14.23,104.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER QUICKPASS SUTURELASSO 45D SMALL LEFT CURVE 7MM CANN",SUP-AR-6068-45L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CIGNA [10200]","Cigna Open Access",,774.3,56.9,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 3 PREASSEMBLE BLADE STD HANDLE LED LIGHT",SUP-040-04-0430U,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.42,18.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25.65,41.1,,,,,0,7.26,53.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 110MM 2.8MM QUICK CONNECT STERILE",SUP-03.133.108S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1084.10,325.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,126.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,126.08,921.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SURGICAL ARTHREX NANONEEDLE HIGH FLOW OPERATIVE 125MM",SUP-AR-3210-0051,CDM,S27200284,LOCAL,0272,RC,,,both,,,931.50,279.45,"AETNA [10100]","Aetna HMO/PPO",,740.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING ORANGE 90CM 5FR ENTERAL SILICONE HUB END HOLE",SUP-ENFSI9050LD,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.36,32.21,"PHCS [10601]",PHCS,,75.15,70,,,,,0,12.49,91.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 18MM 1.75MM FLO-THRU INTRALUMINAL",SUP-FT12175,CDM,S27200284,LOCAL,0272,RC,,,both,,,763.91,229.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,313.97,41.1,,,,,0,88.84,649.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VIOLET MONOCRYL PLUS 3-0 SH 27IN MONOFILAMENT",SUP-MCP316H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"CIGNA [10200]",Cigna,,18.36,68,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM 1.7-2.4FR .017IN",SUP-M003C1715ST0,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"CIGNA [10200]","Cigna Open Access",,4392.25,56.9,,,,,0,897.75,6561.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERLOOP TIGERWIRE 2 STRAIGHT 20IN BRAID MULTISTRAND",SUP-AR-7234T,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG ALGINATE 16X8IN ACTICOAT POLYETHYLENE NANOCRYSTALLINE",SUP-20301,CDM,S27200284,LOCAL,0272,RC,,,both,,,357.51,107.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,42.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.58,303.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG OSTOMY DRAINABLE DEEP CONVEX FLEXIBLE OVAL",SUP-40-7554-DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.09,33.33,"KAISER [10500]",Kaiser,,74.43,67,,,,,0,12.92,94.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 4FR 100CM TRIFORCE FLEXOR PEEL-AWAY STRAIGHT TAPER",SUP-G56416,CDM,S27200284,LOCAL,0272,RC,,,both,,,2711.18,813.35,"NOVANET [10819]",Novanet,,2033.39,75,,,,,0,315.31,2304.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 3-0 PS-2 SPIRAL 45CM SUT",SUP-SXPP1B105,CDM,S27200284,LOCAL,0272,RC,,,both,,,224.03,67.21,"CIGNA [10200]","Cigna Open Access",,127.47,56.9,,,,,0,26.05,190.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 12CM 2.51MM 2MM SONOPET IQ LARGE SOFT TISSUE",SUP-5500-25S-316,CDM,S27200284,LOCAL,0272,RC,,,both,,,8082.83,2424.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3322.04,41.1,,,,,0,940.03,6870.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SILICONE 700ML BREAST RESTERILIZABLE GEL",SUP-RSZ-7004,CDM,S27200284,LOCAL,0272,RC,,,both,,,127.64,38.29,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,52.46,41.1,,,,,0,14.84,108.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 1 BACKWARD DOWN OFFSET 9.5IN KARLIN LUMBAR HANDLE",SUP-46-3138,CDM,S27200284,LOCAL,0272,RC,,,both,,,1195.16,358.55,"UHC [10700]","United Healthcare",,756.54,63.3,,,,,0,139,1015.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAVER BLADE 4MM 40DEG ROTATABLE WINDOW  CLOSED",SUP-SB4040RC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1541.46,462.44,"CIGNA [10200]","Cigna Local Plus",,824.68,53.5,,,,,0,179.27,1310.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC INTERPULSE BONE CLEANING TIP SUCTION PULSED LAVAGE",SUP-0210-110-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.14,99.04,"CIGNA [10200]","Cigna Local Plus",,176.62,53.5,,,,,0,38.4,280.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STIM PROXIMATE GENITOURINARY HANDSET NONSTERILE LATEX",SUP-TH90P01,CDM,S27200284,LOCAL,0272,RC,,,both,,,12516.60,3754.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5745.12,45.9,,,,,0,1455.68,10639.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING 1 WAY VALVE DUCK BILL SWIVEL CNCT",SUP-L599-180,CDM,S27200284,LOCAL,0272,RC,,,both,,,120.70,36.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,55.4,45.9,,,,,0,14.04,102.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) CATH TURNPIKE 135CM 2.2-2.9FR 1.6FR GUIDING LOW PROF",SUP-5638,CDM,S27200284,LOCAL,0272,RC,,,both,,,3967.50,1190.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1630.64,41.1,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM SOLERA COCR SPINAL MULTIAXIAL CANNULATED",SUP-54840005040,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"NOVANET [10819]",Novanet,,7160.14,75,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PM CRT EDORA 8 QDPL HF-T",SUP-407137,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9236.16,40,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 16MM PERSONA 7-9 C-D KNEE LEFT CONDYLAR",SUP-42512800516,CDM,C1776,HCPCS,0278,RC,,,both,,,16308.84,4892.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1896.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1896.72,13862.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 10MM",SUP-SPL12510X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"FIRST HEALTH [10303]","First Health",,421.2,80,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 52CM .016IN BRADY FIRM",SUP-6042,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,170.52,39.2,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATHETER TRAPLINER 150CM 13CM 5.7FR INTERVENTIONAL HY",SUP-5567,CDM,C1887,HCPCS,0272,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 16MM 144CM 3.5MM CORONARY STENT",SUP-H7493911416350,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1083.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL 60MM NAIL-EX SPIRAL FEMUR TITANIUM",SUP-04.013.044S,CDM,C1713,HCPCS,0278,RC,,,both,,,3437.70,1031.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1577.9,45.9,,,,,0,399.8,2922.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC THK.25IN 12.5SQ CM .75X2.5IN MICROFIBRILLAR",SUP-1050020,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.81,39.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.33,112.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT COMPREHENSIVE GLENOID SHOULDER TRABECULA",SUP-98000900027,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19937.61,41.1,,6417.48,6417.48,6417.48,"1 through 10",5641.71,41233.5,"percent of total billed charges",
"LENS IOL +20 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.200,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL MONOFILAMENT LIGHTWEIGHT ABSORBABLE LOW",SUP-5955610,CDM,C1781,HCPCS,0278,RC,,,both,,,5082.00,1524.6,"KAISER [10500]",Kaiser,,3404.94,67,,,,,0,591.04,4319.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 6MM 3.75MM BALLOON DILATATION",SUP-H7493912406370,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE INTUITION VASCULAR STRAIGHT 180CM HYDRO-TRACK",SUP-INTU180HS,CDM,C1769,HCPCS,0272,RC,,,both,,,502.20,150.66,"PHCS [10601]",PHCS,,351.54,70,,,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 15D 12.5-14 XL MALE CONTACT CLSR",SUP-HS1005-16,CDM,S27000186,LOCAL,0270,RC,,,both,,,128.06,38.42,"PHCS [10601]",PHCS,,89.64,70,,,,,0,14.89,108.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 14MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650514,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3757.02,28.62,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOOT PROCEDURES WITH CC",504,MS-DRG,,,,,,,inpatient,,,77462.59,23238.78,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 24MM 140CM 2.5MM CORONARY STENT",SUP-LUN250R24US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESPONSE 120CM 6FR 2-5-2MM SPACING CRD CURVE",SUP-401305,CDM,C1730,HCPCS,0272,RC,,,both,,,1134.00,340.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,466.07,41.1,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE PT VASCULAR 182CM .014IN STAINLESS STEEL",SUP-H74912161011,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE TIBIAL 10MM LEGION 5-6 FULL KNEE SCR STEP",SUP-71423059,CDM,C1776,HCPCS,0278,RC,,,both,,,16601.40,4980.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1967.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1930.74,14111.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RIFAXIMIN 550 MG TABLET",RX-104604,CDM,,,0637,RC,65649-0303-03,NDC,both,1,UN,277.53,83.26,"AETNA [10100]","Aetna HMO/PPO",,220.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.28,235.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 80MM 3MM BALLOON DILATATION DURALYN",SUP-48003008S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 22MM 52MM SHOULDER ANATOMIC RESTORATION",SUP-AR-9152-22P,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"BLUE CROSS [10001]","Blue Cross PPO",,3104.64,39.2,,3949.44,3949.44,3949.44,"1 through 10",921.1,6732,"percent of total billed charges",
"BLADE CORNEAL 8.5MM STAINLESS STEEL TREPHINE STERILE LATEX",SUP-K20-2160,CDM,S27200284,LOCAL,0272,RC,,,both,,,430.65,129.19,"FIRST HEALTH [10303]","First Health",,344.52,80,,,,,0,50.08,366.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pulmonary Stress Testing",PX-482000006,CDM,94618,CPT,0460,RC,,,both,,,270.62,81.19,"CIGNA [10200]","Cigna Open Access",,153.98,56.9,,,,,0,31.47,230.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC SMALL 48X40X6.5MM EDORA PROMRI ATRIUM",SUP-407145,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"BLUE CROSS [10001]","Blue Cross PPO",,16307.2,39.2,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 14MM PERSONA 3-7 C-D KNEE LEFT",SUP-42511200414,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,956.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Aero Presump ID Drainage",PX-306000014,CDM,87070,CPT,0306,RC,,,both,,,397.00,119.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7.76,,,,,,,0.01,337.45,"fee schedule",
"HC Cult Aerobic Presump ID Cornea",PX-306000030,CDM,87070,CPT,0306,RC,,,both,,,382.00,114.6,"MULTIPLAN [10600]",Multiplan,,324.7,85,,,,,0,0.01,324.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Pseudoaneurysm Perc Non Extrem",PX-361000617,CDM,37799,CPT,0361,RC,,,both,,,1745.00,523.5,"AETNA [10100]","Aetna HMO/PPO",,1387.28,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,202.94,1745,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo Small Intest Cntrl Bld",PX-750000206,CDM,44366,CPT,0750,RC,,,both,,,3668.65,1100.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3668.65,,"Case rate ($4,617). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,426.66,3668.65,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 7CM 7FR DUODENAL BEND BILIARY PLASTIC TEMPORARY RAPID",SUP-M00545560,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"BLUE CROSS [10001]","Blue Cross PPO",,334.29,39.2,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X8MM MODULUS 10D XL WIDE STERILE LATEX FREE",SUP-1221850P2,CDM,C1889,HCPCS,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,9172.16,8555.87,9172.16,"1 through 10",3297.11,24097.5,"percent of total billed charges",
"CATH NC EUPHORA 142CM 6MM 2.25MM BALLOON DILATATION DURATRAC",SUP-NCEUP22506X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 75CM 60MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171030670,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VASCUTRAK 140CM 15CM 7FR 6MM .018IN BALLOON DILATATION",SUP-V1860150,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 150CM 300MM 6MM BALLOON DILATATION DURALYN",SUP-48006030X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 135CM 40MM 12MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171120410,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH METACROSS RX 135CM 40MM 6MM BALLOON DILATATION SMALL",SUP-BD-L60040CR,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PCP050100150 PLUS US D5L100UL1500",SUP-PCP050100150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 135CM 80MM 5MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171050810,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING SL MONORAIL 150CM 120MM 3.8-3.4FR 3.5MM LOW",SUP-39147-35121,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 014 150CM 10CM 3MM BALLOON DILATATION",SUP-U4150310,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH COYOTE 150CM 100MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939186251010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATH 4FR 18GA 20CM 1 LUMEN MIDLINE MAXIMAL BARR",SUP-4154108D,CDM,C1752,HCPCS,0272,RC,,,both,,,899.10,269.73,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EVERCROSS BEVEL 360 135CM 30MM 6MM .035IN BALLOON",SUP-AB35W06030135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MALECOT 38FR NEPHRSTMY DRAIN 4 WING STERILE LATEX",SUP-086038,CDM,C1729,HCPCS,0272,RC,,,both,,,105.62,31.69,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POST OP BRA 36D BLACK",SUP-B01G-36D-B,CDM,S27000186,LOCAL,0270,RC,,,both,,,178.18,53.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EUPHORA 142CM 20MM 2MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2020X,CDM,C1725,HCPCS,0272,RC,,,both,,,558.90,167.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH COYOTE 150CM 220MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939186252210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MAC-LOC 40CM 16CM 8.5FR DRNG ULTRATHANE HYDROPHILIC",SUP-G13359,CDM,C1729,HCPCS,0272,RC,,,both,,,801.82,240.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TYSHAK II 100CM 5CM 9FR 23MM BALLOON DILATATION",SUP-611941,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PCP070100150 PLUS US D7L100UL1500",SUP-PCP070100150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMERGE MONORAIL 144CM 15MM 6FR 3MM .07IN BALLOON",SUP-H7493918915300,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 3X80 135CM SL",SUP-48003008R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 11CMX8MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-2-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FLEXTOME 142CM 10MM 4MM BALLOON DILATATION NYLON",SUP-H749CBM3400100,CDM,C1725,HCPCS,0272,RC,,,both,,,5395.80,1618.74,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 6X80 80CM SL",SUP-48006008N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SPRINTER FASTRAC 138CM 15MM 3.2-2.4-2.6FR 1.5MM BALLOON",SUP-SPR1515W,CDM,C1725,HCPCS,0272,RC,,,both,,,607.50,182.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE II PRO 10MM 4MM BALLOON DILATATION STERILE",SUP-240-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VASCUTRAK 140CM 6CM 6MM 7FR BALLOON DILATATION",SUP-V186060,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 12MM",SUP-SPL22512X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 90CM 40MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TREK 145CM 25MM 2.75MM ULTRA LOW PROFILE BALLOON",SUP-1012273-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC TREK NEO 15MM 145CM 4MM BALLOON DILATATION HYDROCOAT",SUP-1400400-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MINI TREK II 145CM 8MM 2MM ULTRA LOW PROFILE BALLOON",SUP-1012403-08A,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH Z-MED 100CM 9CM 9FR 26MM .035IN BALLOON DILATATION",SUP-611682,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"MULTIPLAN [10600]",Multiplan,,4520.33,85,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 120MM 5MM BALLOON DILATATION RAPID EXCHANGE",SUP-47550120S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PHCS [10601]",PHCS,,1116.99,70,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X80 40CM SL",SUP-48003008P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 20CM 3MM BALLOON DILATATION HYDROPHILIC",SUP-V1430200,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"AETNA [10100]","Aetna HMO/PPO",,4360.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 30CM 13FR POWER-TRIALYSIS STRAIGHT 3 LUMEN SHORT",SUP-5605300,CDM,C1752,HCPCS,0272,RC,,,both,,,1614.33,484.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,740.98,45.9,,,,,0,187.75,1372.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 150MM 6MM BALLOON DILATATION RAPID",SUP-47560150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PHCS [10601]",PHCS,,1116.99,70,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 40MM 2.5MM .014IN BALLOON DILATATION",SUP-AB14W025040150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"AETNA [10100]","Aetna HMO/PPO",,1101.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 15MM 6FR 2.5MM",SUP-H7493926715250,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 80CM 37MM 10-14FR SEPTAL CATH GORE 18-25",SUP-ASD37A,CDM,C1817,HCPCS,0278,RC,,,both,,,54495.00,16348.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,21798,40,,,,,0,6337.77,46320.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WALKER PATIENT MEDIUM STD PLASTIC FOAM ROCKER BOTTOM",SUP-15500033,CDM,S27000186,LOCAL,0270,RC,,,both,,,249.86,74.96,"UHC [10700]","United Healthcare",,158.16,63.3,,,,,0,29.06,212.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION",RX-108063,CDM,J3262,HCPCS,0636,RC,50242-0137-01,NDC,both,20,ML,16030.51,4809.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7173.65,44.75,,,,,0,1899.62,13625.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Stent & Ather",PX-361000159,CDM,37231,CPT,0361,RC,,,both,,,21707.51,6512.25,"CIGNA [10200]",Cigna,,7680,,"Case rate ($7,680). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2524.58,18451.38,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 25MM 2.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2525X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 8CM 7MM BALLOON DILATATION",SUP-DR8078,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS",RX-87834,CDM,,,0250,RC,70069-0651-01,NDC,both,5,ML,1232.15,369.64,"MULTIPLAN [10600]",Multiplan,,1047.33,85,,,,,0,143.3,1047.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION",RX-77411,CDM,,,0250,RC,72485-0110-10,NDC,both,3,ML,150.21,45.06,"FIRST HEALTH [10303]","First Health",,120.17,80,,,,,0,17.47,127.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOLNAFTATE 1 % TOPICAL CREAM",RX-8020,CDM,,,0250,RC,10939-0563-33,NDC,both,15,GR,29.53,8.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,20.08,68,,,,,0,3.43,25.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 420CC NATRELLE INSPIRA COHESIVE STERILE",SUP-SCX-420,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PHCS [10601]",PHCS,,5288.85,70,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION",RX-8120,CDM,J3301,HCPCS,0636,RC,00003-0293-05,NDC,both,1,ML,84.79,25.44,"CIGNA [10200]","Cigna Open Access",,7.98,,,,,,,3.48,72.07,"fee schedule",
"WITCH HAZEL-GLYCERIN (HAMAMEL) TOPICAL PADS SUPERORDERABLE",RX-40811678,CDM,,,0250,RC,50289-3250-01,NDC,both,1,UN,80.00,24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.3,68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLOTRIMAZOLE 2 % VAGINAL CREAM",RX-33986,CDM,,,0250,RC,51672-2062-00,NDC,both,21,GR,66.71,20.01,"NOVANET [10819]",Novanet,,50.03,75,,,,,0,7.76,56.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 40MM 80CM 10MM 8FR STRAIGHT VASCULAR COVER",SUP-AVSM10040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"NOVANET [10819]",Novanet,,13702.5,75,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER SUPPORT L150CM DIA0.0375IN COMPATIBLE GUIDEWIRE 0.0",SUP-P1VC-018STR-150,CDM,C1894,HCPCS,0272,RC,,,both,,,1458.00,437.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,169.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 420MM FEMORAL EXPERT INTRAMEDULLARY FLUTE",SUP-04.013.664S,CDM,C1713,HCPCS,0278,RC,,,both,,,8319.74,2495.92,"CIGNA [10200]","Cigna Local Plus",,4451.06,53.5,,3978.14,359.25,3978.14,24,967.59,7071.78,"percent of total billed charges",
"HC MRI Lwr Ext Jnt WO Cntrst",PX-610000034,CDM,73721,CPT,0610,RC,,,both,,,3895.32,1168.6,"NOVANET [10819]",Novanet,,2921.49,75,,,,,0,360.71,3311.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachytx Isodose Plan Simple",PX-333000064,CDM,77316,CPT,0333,RC,,,both,,,2249.39,674.82,"KAISER [10500]",Kaiser,,1507.09,67,,,,,0,261.6,2249.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 800ML GEL SMOOTH MEMORYGEL SILICONE P5.1CM","SUP-3508001 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"KAISER [10500]",Kaiser,,2462.25,67,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Test Definitiv 8-14 Class",PX-301000671,CDM,G0481,HCPCS,0301,RC,,,both,,,313.00,93.9,"BLUE CROSS [10001]","Blue Cross PPO",,0.31,.1,,,,,0,0.31,266.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Train for Caregiver Add 15 (Gn)",PX-440000026,CDM,G0540,HCPCS,0440,RC,,,both,,,37.00,11.1,"BLUE CROSS [10001]","Blue Cross PPO",,0.04,.1,,,,,0,0.04,37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lyse Chest Fibrin Subq Day",PX-361000428,CDM,32562,CPT,0361,RC,,,both,,,1675.07,502.52,"MULTIPLAN [10600]",Multiplan,,1423.81,85,,,,,0,194.81,1675.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION",RX-156549,CDM,,,0250,RC,00121-4675-05,NDC,both,5,ML,12.54,3.76,"CIGNA [10200]","Cigna Local Plus",,6.71,53.5,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vitamin B2",PX-301000392,CDM,84252,CPT,0301,RC,,,both,,,359.78,107.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.66,,"Fee schedule rate ($21.66). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,305.81,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CW003, 5MMX42CM EPIX ES SMK EVAC ANG NDL",SUP-CW003,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ZEBRA 025/150 STRT (BX/5)",SUP-M0066701081,CDM,C1769,HCPCS,0272,RC,,,both,,,447.74,134.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NAVICROSS 90CM 40MM 60MM SPACE SPRT STAINLESS STEEL",SUP-NC18900,CDM,C1887,HCPCS,0272,RC,,,both,,,1462.05,438.61,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 15MM 3.2MM RINGLOC+ ACETABULAR STERILE DISPOSABLE",SUP-31-323215,CDM,S27000186,LOCAL,0270,RC,,,both,,,896.67,269,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACIFIC PLUS 130CM 60MM 4FR 2MM .018IN BALLOON",SUP-PCP020060130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL DISSECTING BALL DIAMOND 140MM 4MM MIDAS REX LEGEND",SUP-14BA40D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.17,412.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dgtz Gls Mcrscp Sl Imm Ea 1 / Add on 88341",PX-312000098,CDM,0761T,CPT,0312,RC,,,both,,,100.00,30,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EVAC SMOKE ELIMINATION PUSH BUTTON QUIET PNEUVIEW XE STERILE",SUP-9660-XE,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET STENT 26CM 6FR RESONANCE URETER METAL RADIOPAQUE POS",SUP-G34111,CDM,C2625,HCPCS,0272,RC,,,both,,,7887.39,2366.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 30MM 6FR 2.25MM",SUP-H7493926730220,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-592504022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 12MM 145CM 3.5MM BALLOON DILATATION",SUP-1400350-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 14LP 170CM 16CM 4FR 4MM .014IN BALLOON",SUP-G50339,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"FIRST HEALTH [10303]","First Health",,1889.94,80,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 250MM 5MM BALLOON DILATATION RAPID",SUP-47550250M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"AETNA [10100]","Aetna HMO/PPO",,1609.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 12MM 6FR 3.5MM .07IN BALLOON",SUP-H7493918912350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES 144CM 40MM 2MM .014IN BALLOON DILATATION OTW",SUP-39134-20401,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 15MM 3.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3515X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"AETNA [10100]","Aetna HMO/PPO",,418.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 80MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560080L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Ish Ea Adl 1",PX-312000082,CDM,0849T,CPT,0312,RC,,,both,,,104.00,31.2,"KAISER [10500]",Kaiser,,69.68,67,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 12MM",SUP-SPL35012X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 180MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-08181,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 80MM 8MM .035IN BALLOON",SUP-AB35W08080135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,460.47,68,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 60MM 6FR 4MM BALLOON DILATATION PEBAX",SUP-39032-40601,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"KAISER [10500]",Kaiser,,1004,67,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 40MM 3MM BALLOON DILATATION ZGLIDE PTFE",SUP-H7493918940300,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,233.04,41.1,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EX 139CM 15MM 2.5MM LONG RECTANGLE HELIX",SUP-2034-2515,CDM,C1725,HCPCS,0272,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP060300150 PLUS US D6L300UL1500",SUP-PCP060300150,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,863.38,68,,,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EX 139CM 15MM 2.5MM LONG RECTANGLE HELIX",SUP-2034-2515,CDM,C1725,HCPCS,0272,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 40CM 11CM 10FR 2CM PIGTAIL CURVE DRNG",SUP-RBDC-10-038,CDM,C1729,HCPCS,0272,RC,,,both,,,558.90,167.67,"KAISER [10500]",Kaiser,,374.46,67,,,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT 137CM 6MM 2MM RECTANGLE HELIX TAPER BALLOON",SUP-2200-2006,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2410.52,41.1,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X200 135CM SL",SUP-48005020R,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"NOVANET [10819]",Novanet,,747.83,75,,,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 17CM 7MM BALLOON DILATATION",SUP-DR135717,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"FIRST HEALTH [10303]","First Health",,1101.6,80,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER CHOCOLATE 150CM 120MM 3MM .014IN BALLOON DILATATION",SUP-CB1415030120OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"PHCS [10601]",PHCS,,4008.9,70,,,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 80MM 5FR 10MM BALLOON DILATATION OTW",SUP-39032-10808,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 28FR NEPHRSTMY NATURAL RUBBER 4 WING DRAIN",SUP-086028,CDM,C1729,HCPCS,0272,RC,,,both,,,105.62,31.69,"NOVANET [10819]",Novanet,,79.22,75,,,,,0,12.28,89.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 20CM 12FR MAHURKAR 3 LUMEN STRAIGHT EXT",SUP-8888104003HP,CDM,C1752,HCPCS,0272,RC,,,both,,,1178.06,353.42,"PHCS [10601]",PHCS,,824.64,70,,,,,0,137.01,1001.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 40MM 8MM BALLOON DILATATION PEBAX",SUP-H74939032804010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 15MM 2.25MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP22515X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"KAISER [10500]",Kaiser,,352.76,67,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PARACENTESIS KIT SAFETY",SUP-K12T-08155,CDM,C1729,HCPCS,0272,RC,,,both,,,533.14,159.94,"NOVANET [10819]",Novanet,,399.86,75,,,,,0,62,453.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY DRNG 14FR FLEXIBLE REVOLUTION SECUREMENT DEVICE RESOLVE",SUP-RLC-NV-14-REV,CDM,C1729,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UHC [10700]","United Healthcare",,794.73,63.3,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 8CM 6MM BALLOON DILATATION",SUP-DR8068,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"NOVANET [10819]",Novanet,,1032.75,75,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 9MM BALLOON",SUP-U357598,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 12CM 4MM BALLOON",SUP-G52255,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"FIRST HEALTH [10303]","First Health",,767.82,80,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AVIATOR PLUS 142CM 2CM 3.3FR 4MM .014IN BALLOON",SUP-4244020W,CDM,C1725,HCPCS,0272,RC,,,both,,,1438.80,431.64,"NOVANET [10819]",Novanet,,1079.1,75,,,,,0,167.33,1222.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 200MM 5.7FR 7MM BALLOON DILATATION 2",SUP-BD-L70200CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.7,68,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AVIATOR PLUS 142CM 2CM 3.3FR 4MM .014IN BALLOON",SUP-4244020W,CDM,C1725,HCPCS,0272,RC,,,both,,,1438.80,431.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,170.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.33,1222.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 120MM 7MM .035IN BALLOON",SUP-AB35W07120135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"NOVANET [10819]",Novanet,,507.87,75,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ercp Lithotripsy",PX-750000049,CDM,43265,CPT,0750,RC,,,both,,,8345.15,2503.54,"BLUE CROSS [10001]","Blue Cross PPO",,8345.15,,"Case rate ($9,364.21). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,970.54,8345.15,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ercp Lithotripsy",PX-750000049,CDM,43265,CPT,0750,RC,,,both,,,8345.15,2503.54,"FIRST HEALTH [10303]","First Health",,6676.12,80,,,,,0,970.54,8345.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Set Rad Ther Field Int",PX-333000005,CDM,77285,CPT,0333,RC,,,both,,,1628.16,488.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,408.8,,"Per diem ($408.80).",,,,0,189.36,1628.16,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIVAV FLX INFUSION SYSTEM 021X120CM",SUP-FLX-21120-35,CDM,C1982,HCPCS,0272,RC,,,both,,,50292.90,15087.87,"CIGNA [10200]",Cigna,,34199.17,68,,,,,0,5849.06,42748.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC 7IN UNIVERSAL 10.5-17IN SHOULDER ABDUCTION",SUP-06AB,CDM,L3670,HCPCS,0274,RC,,,both,,,286.06,85.82,"CIGNA [10200]","Cigna Open Access",,162.77,56.9,,,,,0,33.27,243.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC 7IN UNIVERSAL 10.5-17IN SHOULDER ABDUCTION",SUP-06AB,CDM,L3670,HCPCS,0274,RC,,,both,,,286.06,85.82,"BLUE CROSS [10001]","Blue Cross PPO",,112.14,39.2,,,,,0,33.27,243.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADMIRAL XTREME 130CM 150MM 4MM BALLOON DILATATION",SUP-ADM040150130,CDM,C1725,HCPCS,0272,RC,,,both,,,1638.75,491.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1114.35,68,,,,,0,190.59,1392.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC MEDIUM SHOULDER ELASTIC FOAM",SUP-A111006,CDM,L3670,HCPCS,0274,RC,,,both,,,58.03,17.41,"KAISER [10500]",Kaiser,,38.88,67,,,,,0,6.75,58.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE (PF) 1 MG/ML INJECTION SOLUTION",RX-15852,CDM,J2274,HCPCS,0636,RC,00641-6019-01,NDC,both,10,ML,287.55,86.26,"KAISER [10500]",Kaiser,,192.66,67,,,,,0,14.06,244.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOPSY PUNSCH 5MM",SUP-M50550,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.91,24.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,55.02,68,,,,,0,9.41,68.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Thy Uptake Sngl/Mult",PX-341000059,CDM,78012,CPT,0341,RC,,,both,,,2148.24,644.47,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,982.43,,,,,,,113.49,1826,"fee schedule",
"RTRCTR FREEHOLD TRIO HEXAGON LOW PROFILE FULL ADJUSTABLE",SUP-FRE-T-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,183.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Syphilis Test Qual",PX-302000093,CDM,86592,CPT,0302,RC,,,both,,,141.55,42.46,"CIGNA [10200]",Cigna,,9.39,,,,,,,0.01,120.32,"fee schedule",
"PLATE CURVE 336MM STAINLESS STEEL 4.5MM SCR 16 HOLE 4 COLUMN",SUP-02.124.417S,CDM,C1713,HCPCS,0278,RC,,,both,,,15619.25,4685.77,"PHCS [10601]",PHCS,,10933.48,70,,,,,0,1816.52,13276.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dtap Vaccine < 7 Yrs Im",PX-771000015,CDM,90700,CPT,0636,RC,,,both,,,113.27,33.98,"CIGNA [10200]","Cigna Local Plus",,60.6,53.5,,,,,0,13.42,96.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 520CC SMOOTH SHELL SURFACE COHESIVE GEL 1 LUMEN",SUP-SRF-520,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"AETNA [10100]","Aetna HMO/PPO",,4360.97,79.5,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRIMONIDINE 0.2 % EYE DROPS",RX-17881,CDM,,,0250,RC,24208-0411-05,NDC,both,5,ML,114.04,34.21,"PHCS [10601]",PHCS,,79.83,70,,,,,0,13.26,96.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH",RX-82504,CDM,,,0250,RC,00378-9070-16,NDC,both,1,UN,84.99,25.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,57.79,68,,,,,0,9.88,72.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 695CC SMOOTH SHELL SURFACE NATRELLE INSPIRA FULL",SUP-SRF-695,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2698.92,68,,,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPOUNDING VEHICLE NO.8 ORAL LIQUID",RX-122802,CDM,,,0250,RC,38779-2511-08,NDC,both,473,ML,389.75,116.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,178.9,45.9,,,,,0,45.33,331.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SUPERORDERABLE",RX-40814984,CDM,,,0250,RC,63323-0462-37,NDC,both,30,ML,118.01,35.4,"UHC [10700]","United Healthcare",,74.7,63.3,,,,,0,13.72,100.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIANEAL LOW CALCIUM (2.5 MEQ/L) PERITONEAL DIALYSIS SOLUTION",SUP-6AB9747E,CDM,S27200284,LOCAL,0272,RC,,,both,,,46.05,13.81,"UHC [10700]","United Healthcare",,29.15,63.3,,,,,0,5.36,39.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR DYNASTY A-CLASS 15D 28MM POLY BIOFOAM HIP",SUP-DLXPLB28,CDM,C1776,HCPCS,0278,RC,,,both,,,7507.20,2252.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2148.56,28.62,,,,,0,873.09,6381.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR PRESSURE MONITOR ACUMEN IQ L84 IN",SUP-AIQS85,CDM,S27200284,LOCAL,0272,RC,,,both,,,2760.00,828,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,320.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,320.99,2346,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 20MM 3.5MM BALLOON DILATATION RAPID",SUP-47535020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"MULTIPLAN [10600]",Multiplan,,1356.35,85,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA2-17-75-5.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,9177.00,2753.1,"FIRST HEALTH [10303]","First Health",,7341.6,80,,,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Analysis Semen Complt",PX-309000109,CDM,89320,CPT,0309,RC,,,both,,,361.00,108.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,19.36,,,,,,,3.91,306.85,"fee schedule",
"HC Analysis Semen Complt",PX-309000109,CDM,89320,CPT,0309,RC,,,both,,,361.00,108.3,"CIGNA [10200]","Cigna Open Access",,27.08,,,,,,,3.91,306.85,"fee schedule",
"HC Interrog Eval Card Module",PX-480000092,CDM,0418T,CPT,0480,RC,,,both,,,299.00,89.7,"CIGNA [10200]",Cigna,,203.32,68,,,,,0,34.77,299,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLOWGUARD 14CM 16FR HEMODIALYSIS PEEL AWAY VALVE",SUP-DCVP1600,CDM,C1894,HCPCS,0272,RC,,,both,,,261.00,78.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE 10CM 2.5CM 9FR INTRO STAINLESS STEEL",SUP-RSS902,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE PLATINUM PLUS VASCULAR STRAIGHT 180CM 3CM .018IN",SUP-M001467310,CDM,C1769,HCPCS,0272,RC,,,both,,,526.18,157.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE TRACER METRO DIRECT ENDOSCOPIC ANGLE 480CM 5CM .035IN",SUP-G25687,CDM,C1769,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE PLATINUM PLUS VASCULAR 180CM 3CM .018IN MEDIGLIDE",SUP-M001466040,CDM,C1769,HCPCS,0272,RC,,,both,,,1539.00,461.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE MAILMAN VASCULAR 182CM .014IN POLYMER HYDROPHILIC",SUP-H74912136011,CDM,C1769,HCPCS,0272,RC,,,both,,,589.03,176.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 6MM 40MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890006040,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"GWIRE ZIPWIRE UROLOGICAL ANGLE 150CM 3CM .032IN NITINOL",SUP-M006630213B1,CDM,C1769,HCPCS,0272,RC,,,both,,,311.88,93.56,"FIRST HEALTH [10303]","First Health",,249.5,80,,,,,0,36.27,265.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STARTER BENTSON VASCULAR STD TAPER 150CM 15CM .035IN",SUP-M001491751,CDM,C1769,HCPCS,0272,RC,,,both,,,227.94,68.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,155,68,,,,,0,26.51,193.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFARI2 EXTRA SPRT VASCULAR XS CURVE 275X2.9X3.2CM",SUP-H74939598ESXS0,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 55MM SPINE POLYAXIAL REVOLVE",SUP-185.487,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]",Cigna,,6491.86,68,,1831.33,1831.33,1831.33,16,1110.3,8114.82,"percent of total billed charges",
"STENT CONTOUR SENSOR DUAL-FLEX 26CM 3CM 6FR .035IN PIGTAIL",SUP-M006180223090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"FIRST HEALTH [10303]","First Health",,1064.21,80,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Antibody Screen RBC",PX-302000182,CDM,86850,CPT,0302,RC,,,both,,,371.54,111.46,"CIGNA [10200]","Cigna Open Access",,21.49,,,,,,,8.2,315.81,"fee schedule",
"HC Antibody Screen RBC",PX-302000182,CDM,86850,CPT,0302,RC,,,both,,,371.54,111.46,"CIGNA [10200]",Cigna,,21.49,,,,,,,8.2,315.81,"fee schedule",
"FILL KIT SYSTEM",SUP-350-8600,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"CIGNA [10200]","Cigna Local Plus",,116.36,53.5,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL PERSONA AB CONE KNEE CENTRAL STERILE LATEX FREE",SUP-42545000508,CDM,C1776,HCPCS,0278,RC,,,both,,,29901.06,8970.32,"PHCS [10601]",PHCS,,20930.74,70,,,,,0,3477.49,25415.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 20MM 3.25MM ULTRA LOW PROFILE BALLOON",SUP-1012275-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BIOLOGICAL 4.5X4.2IN PURACOL PLUS SILVER CLLGN",SUP-MSC8744EP,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.32,54.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,83.68,45.9,,,,,0,21.2,154.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aud Distort Evoked Oto Emiss",PX-471000011,CDM,92587,CPT,0471,RC,,,both,,,497.30,149.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 6CM 4MM TARGET HELICAL PLATINUM DETACHABLE",SUP-M0035434060,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"BLUE CROSS [10001]","Blue Cross PPO",,3589.81,39.2,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION ACTIVENT SHEEHY",SUP-1026145,CDM,S27800098,LOCAL,0278,RC,,,both,,,194.76,58.43,"CIGNA [10200]",Cigna,,132.44,68,,,,,0,22.65,165.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL SHAFT ALLOGRAFT FROZEN 100MM 10+ MM",SUP-450430,CDM,S27800098,LOCAL,0278,RC,,,both,,,6785.46,2035.64,"PHCS [10601]",PHCS,,4749.82,70,,,,,0,789.15,5767.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 12X26X55MM 10",SUP-6212155,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Local Plus",,7541.1,31.5,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26MMX13MM CAPSTONE PEEK PTC LUMBAR INTERBODY",SUP-3992613,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Local Plus",,6945.75,31.5,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 65CM 16MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1665CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"KAISER [10500]",Kaiser,,5316.45,67,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TLIF CRESCENT 11MM",SUP-293011,CDM,S27800098,LOCAL,0278,RC,,,both,,,24290.28,7287.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2878.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2824.96,20646.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POD XL 6MMX20CM",SUP-RBYPODXL0620,CDM,S27800098,LOCAL,0278,RC,,,both,,,13731.00,4119.3,"UHC [10700]","United Healthcare",,8691.72,63.3,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE SERVICES",SUP-9441026,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross HMO",,6762,39.2,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 12X26X55MM 10",SUP-6212155,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,9384.48,39.2,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE CORTICAL LORDOTIC 11X11X6MM SPINE",SUP-340911,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32MMX12MM X-PAC PARALLEL",SUP-EI2449P,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PHCS [10601]",PHCS,,19845,70,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-02006,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"BLUE CROSS [10001]","Blue Cross HMO",,4054.5,39.2,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X7MM OVAL PARALLEL SPINE CORTICAL",SUP-17107,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 331011 ACSR 10X11X11 SRVC FEE",SUP-331011,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23MMX10MM ELEVATE XLORDOTIC PEEK TITANIUM",SUP-8881023,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]",Cigna,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23MMX10MM ELEVATE XLORDOTIC PEEK TITANIUM",SUP-8881023,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX8MM VERTE-STACK CAPSTONE PEEK-OPTIMA END",SUP-2960822,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6359.04,40,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 55MM LCP STAINLESS STEEL FULL THREAD CONDYLAR",SUP-02.207.055,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE A CURVE",SUP-D7TAL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2039.01,41.1,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 52MM STAINLESS STEEL T8 ELBOW METAPHYSEAL",SUP-02.118.552,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"KAISER [10500]",Kaiser,,351.02,67,,,,,0,60.93,445.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE 0.5 % (5 MG/ML) INJECTION SUPERORDERABLE",RX-4081223,CDM,J0665,HCPCS,0636,RC,00409-1162-01,NDC,both,10,ML,25.07,7.52,"KAISER [10500]",Kaiser,,16.8,67,,,,,0,1.17,21.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2/0 CARDIOXYL NO PLEDGET 18MM",SUP-73P30T,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,55.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.4,397.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN AMPLATZ LEFT1.5 CURVE GUIDING",SUP-LA7AL15,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Sclp/Ax/Tr/Ext 12.6-20 Int",PX-450000034,CDM,12035,CPT,0450,RC,,,both,,,1979.00,593.7,"BLUE CROSS [10001]","Blue Cross PPO",,1.98,.1,,,,,0,1.98,1979,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDEPATH 47CM 42CM 14.5FR STRAIGHT HEMODIALYSIS",SUP-5393420,CDM,C1750,HCPCS,0278,RC,,,both,,,2062.50,618.75,"CIGNA [10200]","Cigna Open Access",,1173.56,56.9,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FUROSEMIDE 10 MG/ML INJECTION SOLUTION - 10 ML VIAL",RX-411654,CDM,J1938,HCPCS,0636,RC,00409-6102-37,NDC,both,10,ML,45.38,13.61,"UHC [10700]","United Healthcare",,4,,,,,,,2.33,38.57,"fee schedule",
"STENT EXPRESS SD MONORAIL 15MM 150CM 5MM BILIARY STAINLESS",SUP-H74937911515150,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"BLUE CROSS [10001]","Blue Cross PPO",,1956.86,39.2,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH XXL 75CM 40MM 5.8FR 16MM .035IN BALLOON DILATATION",SUP-M001145520,CDM,C1725,HCPCS,0272,RC,,,both,,,1709.63,512.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOE POSTOPERATIVE LARGE MALE BEIGE CANVAS RUBBER CLOSED",SUP-2041-03,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.42,14.23,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PAD STAIN REM BIOFLEX",SUP-1358224,CDM,S27000186,LOCAL,0270,RC,,,both,,,100.22,30.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 16MM 144CM 4MM",SUP-H7493941216400,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"BLUE CROSS [10001]","Blue Cross PPO",,3042.9,39.2,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 18MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-207.018,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,32.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,31.82,232.58,"percent of total billed charges",
"CATH INFINITI THRULUMEN 100CM 6FR AMPLATZ LEFT 2 CURVE",SUP-534646T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,35.76,41.1,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC",615,MS-DRG,,,,,,,inpatient,,,86871.33,26061.4,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,8940.35,,"Case rate ($8,679.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,059.92, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,991.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,070.57. The transfer operating threshold is the transfer adjustment factor * $8,059.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.37. The transfer capital threshold is the transfer adjustment factor * $609.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,40853.96,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anes 1st Hr",PX-370000001,CDM,9999104,LOCAL,0370,RC,,,both,,,2313.00,693.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,269,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,269,1966.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP LOCKING REAMER IRR ASPIR INTRAMEDULLARY BONE HARVEST",SUP-352.260S,CDM,S27200284,LOCAL,0272,RC,,,both,,,557.69,167.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dest L/S Facet Jnt Add Bi",PX-510000158,CDM,64636,CPT,0761,RC,,,both,,,1990.72,597.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 10CM 4FR 21GA MERIT S-MAK .018IN STIFFENED DIL",SUP-S-MAK405,CDM,C1894,HCPCS,0272,RC,,,both,,,321.90,96.57,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LASSO REDEL 115CM 7FR 25MM 8MM SPACE ELECTROPHYSIOLOGY",SUP-D7L1025RT,CDM,C1730,HCPCS,0272,RC,,,both,,,7507.20,2252.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INVESTIGATIONAL DRUG PO (DOSE BY STUDY PROTOCOL)",RX-410998,CDM,,,0250,RC,99999-4109-98,NDC,both,1,UN,0.01,,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,,41.1,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Test Car Seat/Bed 60 Min",PX-920000005,CDM,94780,CPT,0920,RC,,,both,,,300.64,90.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,137.99,45.9,,,,,0,34.96,255.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 12CM MR8 3MM MATCH HEAD DISSECTING",SUP-MR8-12MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1089.86,326.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ATLAS 75CM 6CM 16MM 8FR BALLOON DILATATION PERIPHERAL",SUP-AT75166,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.25MM X 8.0MM",SUP-493250812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SHOCKWAVE E8 150CM 80MM 4MM LITHOTRIPSY PERIPHERAL",SUP-E8IVL040080,CDM,C1725,HCPCS,0272,RC,,,both,,,29610.00,8883,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH JADE 135CM 20MM 7MM BALLOON DILATATION HYDROPHILIC",SUP-607002022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 40MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540040M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 150CM 40MM 3MM BALLOON DILATATION PEBAX",SUP-H74939032300410,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 150CM 2CM 6MM BALLOON DILATATION ILIAC",SUP-G34333,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 60MM 4MM BALLOON DILATATION DURALYN",SUP-48004006S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EUPHORA 142CM 15MM 2.25MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP22515X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 10IN 17FR CORONARY ARTERY OSTIAL BODY SOFT",SUP-30317,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 135CM 20MM 10MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171100210,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 35 135CM 120MM 6MM .035IN LOW PROFILE BALLOON",SUP-B2060-120,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 82X12.7X1.2MM NARROW STAINLESS STEEL 2 CUT",SUP-2108-158,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 10X40 80CM SL",SUP-48010004N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPTA PRO 135CM 4CM 5FR 7MM 7.5MM BALLOON DILATATION",SUP-4197040X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 80MM 3MM BALLOON DILATATION DURALYN",SUP-48003008S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GASTROENTEROLOGY TWISTER PLUS.STANDARD.15 MM.120 CM.5.7F.1.7",SUP-TWIST15-PULM,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL SURGICAL ULTRABRIDGE 4MM STERILE LATEX FREE DISPOSABLE",SUP-72205698,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 100CM 150MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOLOIST 110CM 6FR 5MM SPACING COURNAND LONG CURVE",SUP-44516U,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EVERCROSS BEVEL 360 135CM 20MM 9MM .035IN BALLOON",SUP-AB35W09020135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 135CM 40MM 6FR 9MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-09041,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 135CM 80MM 7MM BALLOON DILATATION OTW NONCOMPLIANT",SUP-H74939206070810,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM 3 HOLE EMPHASYS",SUP-471046300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"FIRST HEALTH [10303]","First Health",,14364,80,,,,,0,2088.17,15261.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 250MM 7MM BALLOON DILATATION",SUP-PCU070250130,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"PHCS [10601]",PHCS,,888.78,70,,,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 60MM 4MM BALLOON DILATATION OTW STERILE",SUP-584006022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 11GA 6IN SNARECOIL BONE MARROW",SUP-RBN-116,CDM,S27200284,LOCAL,0272,RC,,,both,,,400.20,120.06,"CIGNA [10200]",Cigna,,272.14,68,,,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCP ELLIPSYS S 21 GAX7 CM ECHO-TIP MICROPUNCTURE NDL",SUP-K21-00022,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"KAISER [10500]",Kaiser,,428.73,67,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 15MM 1.25MM BALLOON DILATATION RAPID",SUP-47512015L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 15MM 1.25MM BALLOON DILATATION RAPID",SUP-47512015L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D +3 CYL BICONVEX 13MM 6MM POSTERIOR CHMBR 1 PIECE",SUP-SN6AT5,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"KAISER [10500]",Kaiser,,231.15,67,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC T4 Free",PX-301000412,CDM,84439,CPT,0301,RC,,,both,,,200.20,60.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.47,,"Fee schedule rate ($9.47). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",9.47,9.47,9.47,"1 through 10",0.2,170.17,"fee schedule",
"CURET 4-0 8IN BRUNS OVAL CUP ANGLE TIP SURGICAL STAINLESS",SUP-240086,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 15MM 1.50MM BALLOON DILATATION PEBAX",SUP-1400150-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VASOVIEW 6 SHORT VESSEL HARVESTING 30ML BLUNT TIP",SUP-C-VH-2004,CDM,S27200284,LOCAL,0272,RC,,,both,,,880.10,264.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,104.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,102.36,748.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 2.5% DEXTROSE 2000ML BAG SPIKE AMBU-FLEX II DIALYSIS",SUP-L5B5177,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.62,40.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.89,116.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 60MM 6MM BALLOON DILATATION DURALYN",SUP-48006006S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,160.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SENSATION 221MM 6IN 7FR 15MM .018IN IAB 34ML INSRT KIT",SUP-0684-00-0469-01U,CDM,C1725,HCPCS,0272,RC,,,both,,,6627.52,1988.26,"NOVANET [10819]",Novanet,,4970.64,75,,,,,0,770.78,5633.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 120MM 6MM BALLOON",SUP-U3575612,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL OVITEX PRS LONG TERM RESORBABLE 3 LAYER",SUP-P20263-1020G,CDM,C1781,HCPCS,0278,RC,,,both,,,20981.27,6294.38,"CIGNA [10200]",Cigna,,8392.51,40,,,,,0,2440.12,17834.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 76.2CM 23FR 3/8IN VENOUS INTRO HEMOSTASIS CAP",SUP-96670-123,CDM,S27200284,LOCAL,0272,RC,,,both,,,3073.95,922.18,"CIGNA [10200]","Cigna Local Plus",,1644.56,53.5,,,,,0,357.5,2612.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN AMPLATZ LEFT 1 CURVE",SUP-DXT5AL10,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"PHCS [10601]",PHCS,,57.86,70,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"I-GEL, SINGLE USE SUPRAGLOTTIC AIRWAY, SIZE 2",SUP-8202000,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.13,23.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.2,67.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 0 STRAIGHT OVAL 8IN SURGICAL SPINAL FUSION",SUP-29-5030,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.68,68.9,"MULTIPLAN [10600]",Multiplan,,195.23,85,,,,,0,26.71,195.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 8CM 10MM BALLOON DILATATION OTW LOW",SUP-G30930,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bilimask",PX-E27200039,CDM,E27200039,LOCAL,0272,RC,,,both,,,67.10,20.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.8,57.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 20MM 4MM .035IN BALLOON DILATATION NYBAX",SUP-39171-04024,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 14CM 80CM 14MM .035IN BILIARY VENA CAVA SELF",SUP-G35625,CDM,C1732,HCPCS,0624,RC,,,both,,,6210.00,1863,"PHCS [10601]",PHCS,,4347,70,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 25MM X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-325,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"NOVANET [10819]",Novanet,,10093.84,75,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Psg >4 Param",PX-740000004,CDM,95810,CPT,0920,RC,,,both,,,6504.89,1951.47,"BLUE CROSS [10001]","Blue Cross PPO",,2354.58,,"Per diem ($2,354.58).",,,,0,756.52,5529.16,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELLIPSE NEXT GENERATION DR 36 DF4 CONNECTOR",SUP-CD2411-36Q,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"BLUE CROSS [10001]","Blue Cross PPO",,15899.52,39.2,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txcath Occl/Embl Non Cns",PX-361000252,CDM,61626,CPT,0361,RC,,,both,,,10981.20,3294.36,"CIGNA [10200]","Cigna Open Access",,6428,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1277.11,10242,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 300CM 3CM",SUP-1020015,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 27GA GRIESHABER DSP SOFT TIP SILICONE END",SUP-8065149529,CDM,S27200284,LOCAL,0272,RC,,,both,,,377.32,113.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,155.08,41.1,,,,,0,43.88,320.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Antibody Screen RBC",PX-302000182,CDM,86850,CPT,0302,RC,,,both,,,371.54,111.46,"KAISER [10500]",Kaiser,,248.93,67,,,,,0,8.2,315.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN GUIDE 75MM 3MM STERILE",SUP-9722908,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"PHCS [10601]",PHCS,,1089.2,70,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 5MM TARGET 360D STD PLATINUM",SUP-M0035465200,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4039.61,28.62,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 G NEUTRAL 40MM E1 HIP",SUP-010000865,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"CIGNA [10200]","Cigna Open Access",,5833.4,56.9,,5302.19,4377.88,6578.61,27,1192.31,8714.22,"percent of total billed charges",
"MARKER MRI GUIDED RIGID DEPLOYMENT DEVICE TRIMARK BREAST","SUP-TRIMARK TD 13MR",CDM,A4648,HCPCS,0278,RC,,,both,,,628.56,188.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,288.51,45.9,,,,,0,73.1,534.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 7X10CM KERECIS OR OMEGA3 MESH STERILE LATEX FREE",SUP-50205N03D0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,27354.60,8206.38,"NOVANET [10819]",Novanet,,20515.95,75,,,,,0,180.89,23251.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 10D F HIP X3 TRIDENT",SUP-623-10-36F,CDM,C1776,HCPCS,0278,RC,,,both,,,6879.60,2063.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,815.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,800.1,5847.66,"percent of total billed charges",
"SABERX RADIANZ 4MM20CM 190",SUP-R51004020L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"UHC [10700]","United Healthcare",,1577.36,63.3,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 19MM 135CM 5MM 8MM 7FR .035IN",SUP-BXA051902A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE 10X1CM",SUP-7509211,CDM,S27800098,LOCAL,0278,RC,,,both,,,12558.00,3767.4,"PHCS [10601]",PHCS,,8790.6,70,,,,,0,1460.5,10674.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 20MM 31MM 28.4MM EPIC TISSUE STENT REDEFINE",SUP-E200-31M,CDM,S27800098,LOCAL,0278,RC,,,both,,,26775.00,8032.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3113.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) QUALBREATH SIZES S",SUP-QB-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"NOVANET [10819]",Novanet,,622.08,75,,,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 3 KNEE CEMENT ROTATE PLATFORM STERILE",SUP-150680003,CDM,C1776,HCPCS,0278,RC,,,both,,,17225.85,5167.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4930.04,28.62,,,,,0,2003.37,14641.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL L HOOK 32CM 5MM UNIVERSAL PLUS",SUP-60-5272-132,CDM,S27200284,LOCAL,0272,RC,,,both,,,176.52,52.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TAKERU 8MM 2.5MM BALLOON DILATATION RAPID EXCHANGE PTCA",SUP-DC-RZ2508UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE GUIDERIGHT VASCULAR STD STRAIGHT 150CM 6CM .035IN",SUP-404840,CDM,C1769,HCPCS,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL 4 9MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530-G-409,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3996.79,45.9,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X12X7MM ENDOSKELETON TC 6D SMALL LORDOTIC",SUP-5146-1207,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS [10001]","Blue Cross HMO",,2617.94,39.2,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 9.8X7.9IN XENMATRIX AB RECTANGLE DERMAL CLLGN",SUP-1152025,CDM,C1781,HCPCS,0278,RC,,,both,,,66918.00,20075.4,"FIRST HEALTH [10303]","First Health",,53534.4,80,,,,,0,7782.56,56880.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 47.5MM TRIGEN FEMUR LOW PROFILE",SUP-71645047,CDM,C1713,HCPCS,0278,RC,,,both,,,2314.95,694.48,"PHCS [10601]",PHCS,,1620.47,70,,,,,0,269.23,1967.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 100MM 135CM 7MM 5FR VASCULAR NITINOL LOW",SUP-5F071003CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"NOVANET [10819]",Novanet,,11385,75,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE NITREX VASCULAR 15D 300CM 5CM .014IN TUNGSTEN NITINOL",SUP-N143001,CDM,C1769,HCPCS,0272,RC,,,both,,,2250.00,675,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1530,68,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT AMNIOTIC 4.0 X 3.0 CM",SUP-NX-10-4030,CDM,Q4148,HCPCS,0636,RC,,,both,,,16767.00,5030.1,"KAISER [10500]",Kaiser,,11233.89,67,,,,,0,332.85,14251.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet/CT Tumor Skull to Thigh",PX-404000004,CDM,78815,CPT,0404,RC,,,both,,,7540.46,2262.14,"BLUE CROSS [10001]","Blue Cross PPO",,7434.72,,"Per diem ($7,434.72).",,,,0,876.96,7540.46,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NUVISION 10FR ULTRASOUND ICE NAV",SUP-FG12081,CDM,C1759,HCPCS,0272,RC,,,both,,,21369.60,6410.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2485.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2485.28,18164.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pta Baln Vein Initial",PX-361000445,CDM,37248,CPT,0361,RC,,,both,,,23508.64,7052.59,"PHCS [10601]",PHCS,,16456.05,70,,,,,0,2734.05,19982.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Culture Bronchial",PX-306000035,CDM,87070,CPT,0306,RC,,,both,,,462.65,138.79,"BLUE CROSS [10001]","Blue Cross PPO",,11.01,,"Fee schedule rate ($11.01).",,,,0,0.01,393.25,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Culture Bronchial",PX-306000035,CDM,87070,CPT,0306,RC,,,both,,,462.65,138.79,"KAISER [10500]",Kaiser,,309.98,67,,,,,0,0.01,393.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Screen Group B Strep",PX-306000057,CDM,87081,CPT,0306,RC,,,both,,,419.90,125.97,"CIGNA [10200]","Cigna Local Plus",,14.59,,,,,,,0.01,356.92,"fee schedule",
"HC Bx Tissue Back Soft Superfic",PX-360000052,CDM,21920,CPT,0360,RC,,,both,,,2787.94,836.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,330.37,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,324.24,2787.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cystoscopy",PX-361000355,CDM,52000,CPT,0361,RC,,,both,,,4285.99,1285.8,"AETNA [10100]","Aetna HMO/PPO",,3407.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,498.46,4285.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colposcopy Cervix/Vagina",PX-361000429,CDM,57452,CPT,0361,RC,,,both,,,1855.26,556.58,"KAISER [10500]",Kaiser,,1243.02,67,,,,,0,215.77,1855.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM MITRAL CARPENTIER-EDWARDS PHYSIO II",SUP-520028MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]",Cigna,,6072,40,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM INTERLOCK IDC OCCLUSION SYSTEM",SUP-M001361480,CDM,S27800098,LOCAL,0278,RC,,,both,,,2400.00,720,"FIRST HEALTH [10303]","First Health",,1920,80,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tte 2d W Dplr Complt W Contr",PX-483000025,CDM,93306,CPT,0483,RC,,,both,,,3991.16,1197.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,472.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",468.63,468.63,468.63,"1 through 10",464.17,3392.49,"percent of total billed charges",
"SCR BONE 3MM 4MM 1.2MM 14MM 6MM STAINLESS STEEL LONG THREAD",SUP-202.714,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,129.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",129.1,943.52,"percent of total billed charges",
"PACEMKR CARDIAC SMALL 48X40X6.5MM EDORA PROMRI ATRIUM",SUP-407157,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10209.24,41.1,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC 7.5MM 42.9X43.3MM ADAPTA SR ATRIUM VENTRICLE",SUP-ADSR06,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7109.21,28.62,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 60MM 8MM BALLOON DILATATION DURALYN",SUP-48008006X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM .0115IN AXIUM PRIME HELIX",SUP-APB-4-6-HX-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,7169.10,2150.73,"NOVANET [10819]",Novanet,,5376.83,75,,,,,0,833.77,6093.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 10X22X55MM 10DEG LORDOTIC WIDE MODULUS XL-W",SUP-1221055P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 12MM AZUR DETACHABLE HYDROGEL",SUP-45-451230,CDM,S27800098,LOCAL,0278,RC,,,both,,,8832.00,2649.6,"CIGNA [10200]",Cigna,,6005.76,68,,,,,0,1027.16,7507.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM HELIFORM XTRASOFT XL MICRO",SUP-XHE120204,CDM,S27800098,LOCAL,0278,RC,,,both,,,11314.48,3394.34,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1315.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1315.87,9617.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT 12MM ALIF",SUP-3W3212,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2505.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X7MM ENDOSKELETON TC 6D 12MM SMALL TITANIUM",SUP-5146-1207-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1203.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4MM 5MM PUSHABLE .035IN 2D HELICAL",SUP-M0013725051,CDM,S27800098,LOCAL,0278,RC,,,both,,,769.50,230.85,"CIGNA [10200]",Cigna,,523.26,68,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV",RX-156003,CDM,,,0250,RC,44567-0642-01,NDC,both,250,ML,476.59,142.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR",RX-6212,CDM,,,0250,RC,60687-0671-40,NDC,both,5,ML,46.22,13.87,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT ORTHOPEDIC MEDIUM 8IN WRIST RIGHT 4 WAY STRETCH",SUP-351MR,CDM,S27000186,LOCAL,0270,RC,,,both,,,121.28,36.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE BALLOON DILATATION 6FR LIQUID FOGARTY BILIARY 1.25ML",SUP-410236FP,CDM,C1757,HCPCS,0272,RC,,,both,,,510.14,153.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH .038IN SR0 CURVE 8FR 63CM HEMOSTASIS GWIRE",SUP-406844,CDM,C1893,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,482.72,41.1,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X14MM CASCADIA 8D TITANIUM POROUS LATERAL",SUP-6101-2185514LL8-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 3 % FOR NEBULIZATION",RX-7327,CDM,,,0250,RC,00378-6997-89,NDC,both,15,ML,12.54,3.76,"CIGNA [10200]",Cigna,,8.53,68,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE BARD NICORE ENDOSCOPIC 150CM .035IN NITINOL",SUP-150NFS35,CDM,C1769,HCPCS,0272,RC,,,both,,,301.63,90.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,123.97,41.1,,,,,0,35.08,256.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 80CM 6MM FLEX DISTAFLO SMALL 2 BRANCH",SUP-DFM8006SC,CDM,C1768,HCPCS,0278,RC,,,both,,,9401.24,2820.37,"CIGNA [10200]","Cigna Local Plus",,5029.66,53.5,,,,,0,1093.36,7991.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,MINOR",651,APR-DRG,,,,,,,inpatient,,,43401.55,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $6,488.24. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%.",,,,0,,,other,"SOI-1 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"SCHIZOPHRENIA AND OTHER SEVERE PSYCHOTIC DISORDERS,MINOR",750,APR-DRG,,,,,,,inpatient,,,34671.51,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,460.88. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE WHISPER LS VASCULAR J CURVE 190CM 3CM .014IN",SUP-1005351HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAREON UVA VIVITY TORIC AUTONOME",SUP-CCAET6,CDM,V2787,HCPCS,0276,RC,,,both,,,880.00,264,"KAISER [10500]",Kaiser,,589.6,67,,,,,0,102.34,748,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEWIRE VASCULAR 0.025INX145CM J TIP 3MM STAINLESS STEEL P",SUP-0684-00-0254-09,CDM,C1769,HCPCS,0272,RC,,,both,,,200.27,60.08,"UHC [10700]","United Healthcare",,126.77,63.3,,,,,0,23.29,170.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JAGWIRE JAGTOME AUTOTOME ENDOSCOPIC STRAIGHT 20MM 5MM",SUP-M00584260,CDM,C1769,HCPCS,0272,RC,,,both,,,3112.43,933.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,368.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,361.98,2645.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEWIRE VASCULAR 0.025INX145CM J TIP 3MM STAINLESS STEEL P",SUP-0684-00-0254-09,CDM,C1769,HCPCS,0272,RC,,,both,,,200.27,60.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,82.31,41.1,,,,,0,23.29,170.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +20 DIOPTER BICONVEX 10.7MM 6MM POSTERIOR CHMBR",SUP-AO60P2000,CDM,V2632,HCPCS,0276,RC,,,both,,,1036.80,311.04,"CIGNA [10200]","Cigna Local Plus",,554.69,53.5,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 15MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1550CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"PHCS [10601]",PHCS,,5554.5,70,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 19MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-519,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"FIRST HEALTH [10303]","First Health",,7864.42,80,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4F QUAD 2-5-2 MPA 120CM",SUP-901482,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Sol D5 Nacl",PX-E27200282,CDM,E27200282,LOCAL,0272,RC,,,both,,,119.90,35.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VERSACROSS SHEATH 63CM 55DEG D0",SUP-VXS0203,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"PHCS [10601]",PHCS,,1134,70,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POUCH 34.5CM 10MM ENDO CATCH GOLD MINIMIZE SPILLAGE",SUP-173050G,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"CIGNA [10200]",Cigna,,236.64,68,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC ANGIOGRAPHY 48IN MERITRANS NONWING HOUSING MALE",SUP-K11-00137,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.44,26.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.17,74.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 18CM 3.5MM SKIMMER 15D 2 CURVED ANGLED TIP LOW",SUP-1883525,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"UHC [10700]","United Healthcare",,2620.62,63.3,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 8MM 3.5MM CORONARY STENT COCR RAPID",SUP-1007849-08,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR 15X10CM THK.5MM COCR SILICONE RUBBER",SUP-4700,CDM,C1768,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1382.35,28.62,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 6X6IN AQUACEL EXTRA HYDROFIBER ABSORBENT NONWOVEN",SUP-420673,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.41,18.12,"NOVANET [10819]",Novanet,,45.31,75,,,,,0,7.03,51.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 30CM 7FR 2.1FR POLARIS ULTRA NAUTILUS ZIPWIRE .035",SUP-M006192145180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"BLUE CROSS [10001]","Blue Cross PPO",,623.23,39.2,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 180MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309018,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"MULTIPLAN [10600]",Multiplan,,32097.87,85,,,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATFORM ACCESS 9X4CM GELPOINT PATH GELSEAL TRANSANAL",SUP-CNB12,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"PHCS [10601]",PHCS,,4226.25,70,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 32MM LCP ANKLE FOOT STAINLESS STEEL 2X3 HOLE T",SUP-249.685,CDM,C1713,HCPCS,0278,RC,,,both,,,3883.32,1165,"CIGNA [10200]","Cigna Local Plus",,2077.58,53.5,,3978.14,359.25,3978.14,24,451.63,3300.82,"percent of total billed charges",
"BLADE SHAVER 110MM 4MM SKIMMER 40D SINUS CURVED STERILE",SUP-1884006,CDM,S27200284,LOCAL,0272,RC,,,both,,,1914.00,574.2,"KAISER [10500]",Kaiser,,1282.38,67,,,,,0,222.6,1626.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FEEDER INFANT HABERMAN MINI-SPECIALNEEDS SILICONE BISPHENOL",SUP-6100093S,CDM,S27200284,LOCAL,0272,RC,,,both,,,97.12,29.14,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 018 150CM 30CM 3.5MM BALLOON DILATATION",SUP-U81503H30,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE NC PLUS 10MM 3.25MM BALLOON DILATATION STERILE",SUP-232-103-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT STAINLESS STEEL 4-0 FS-2 18IN MONOFILAMENT NONABSORBABLE",SUP-603G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD SUT ASSISTANT 2-0 ES-9 7IN COATED ENDO STITCH BRALON",SUP-170011,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) IMPLANT DELIVERY SYSTEM 49-18",SUP-FG-1001-05,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE ARTHROSCOPIC SMOOTH CUTTER BITE STRYKER STERILE LATEX",SUP-475333000,CDM,S27200284,LOCAL,0272,RC,,,both,,,752.77,225.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,511.88,68,,,,,0,87.55,639.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 2-0 V-34 SPIRAL 9IN CLSR",SUP-SXPP1B458,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.35,67.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,93.03,41.1,,,,,0,26.32,192.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 25MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDS32525,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"UHC [10700]","United Healthcare",,52554.65,63.3,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 54.5MM 4MM ROUND STAINLESS STEEL 6 FLUTE FAST",SUP-1608-006-151,CDM,S27200284,LOCAL,0272,RC,,,both,,,375.49,112.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,172.35,45.9,,,,,0,43.67,319.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL THK1/16IN LARGE THERMOPLASTIC SEPTUM PERFORATED",SUP-PS1693,CDM,S27000186,LOCAL,0270,RC,,,both,,,90.48,27.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,61.53,68,,,,,0,10.52,76.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT DELTA CSF REGULAR CONTOURED LOW PRESSURE STERILE",SUP-42322,CDM,S27800098,LOCAL,0278,RC,,,both,,,7576.75,2273.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,897.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,881.18,6440.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL INFANT PROSOFT NONSTERILE LATEX FREE DISPOSABLE",SUP-PROSOFT-INF,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.06,33.62,"UHC [10700]","United Healthcare",,70.93,63.3,,,,,0,13.03,95.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HURRICANE 180CM 4CM 5.8FR 6MM 11 ATM BALLOON DILATATION",SUP-M00545920,CDM,C1726,HCPCS,0272,RC,,,both,,,1849.50,554.85,"PHCS [10601]",PHCS,,1294.65,70,,,,,0,215.1,1572.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 560CC SMOOTH SHELL SURFACE NATRELLE INSPIRA FULL",SUP-SRF-560,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2517.84,45.9,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 30MM 2.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2530X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AETNA [10100]","Aetna HMO/PPO",,450.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STIM HANDHELD LOC VARI-STIM III NERVE STD SUBDERMAL",SUP-8562010,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 250MM SCHANZ STAINLESS STEEL CONDYLAR HIP SELF",SUP-294.788,CDM,C1713,HCPCS,0278,RC,,,both,,,1042.88,312.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,121.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",121.29,886.45,"percent of total billed charges",
"VALVE AORTIC INSPIRIS RESILIA 21MM BOVINE PERICARDIUM",SUP-11500A21,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"CIGNA [10200]","Cigna Local Plus",,14288.4,31.5,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL E KNEE RIGHT LPS-FLEX NEXGEN POROUS",SUP-00596201552,CDM,C1776,HCPCS,0278,RC,,,both,,,22776.39,6832.92,"MULTIPLAN [10600]",Multiplan,,19359.93,85,,,,,0,2648.89,19359.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NEURON 125CM 6FR SIMMONS CURVE THROMBECTOMY SELECT",SUP-PNS6F125SIM,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 14CM 7FR 10MM .035IN BALLOON",SUP-G52298,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMBOLECTOMY 80CM 5FR 11MM STAINLESS STEEL SILICONE",SUP-NL5EMB80T,CDM,C1757,HCPCS,0272,RC,,,both,,,413.60,124.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC20ST-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,19530.00,5859,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SUT VICRYL 5-0 PS-4 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J506G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dest Hemm Extrnl",PX-450000267,CDM,46924,CPT,0450,RC,,,both,,,9344.52,2803.36,"UHC [10700]","United Healthcare",,2260,,"Per diem ($2,260).",,,,0,67.13,7942.84,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 80CM 14CM 10MM BALLOON",SUP-G52378,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.64,68,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins/Rplc Pcmkr Vent",PX-480000003,CDM,33207,CPT,0481,RC,,,both,,,8559.03,2567.71,"CIGNA [10200]","Cigna Local Plus",,8559.03,,"Case rate ($13,926). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,995.42,8559.03,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC",573,MS-DRG,,,,,,,inpatient,,,206342.36,61902.71,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,41857.9,,"Case rate ($40,638.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $37,735.82, add-ons for qualifying new technology services are included. If operating cost exceeds $70,775.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $4,235.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12. The base transfer operating payment is the transfer adjustment factor * $37,785.72. The transfer operating threshold is the transfer adjustment factor * $37,735.82 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,853.01. The transfer capital threshold is the transfer adjustment factor * $2,853.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,191274.67,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM CARBO-SEAL ASCENDING AORTA VALSALVA",SUP-CP-025,CDM,S27800098,LOCAL,0278,RC,,,both,,,29408.40,8822.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3484.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3420.2,24997.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE XPRESS LOPROFILE 18MM 7MM BALLOON INFLATION FIBER",SUP-LPLF-107,CDM,C1726,HCPCS,0272,RC,,,both,,,11074.50,3322.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1312.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",379.61,375.47,414.12,"1 through 10",1287.96,9413.33,"percent of total billed charges",
"URETEROSCOPE FLEXIBLE ASCOPE 5 URETERO REVERSE DEFLECTION",SUP-605101000,CDM,C1747,HCPCS,0272,RC,,,both,,,8581.88,2574.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1016.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,998.07,7294.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.433,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.21,68,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 8MM .8MM GOLDENBERG TORP EAR HEAD PLASTIPORE",SUP-14-0917,CDM,C1713,HCPCS,0278,RC,,,both,,,2968.65,890.59,"BLUE CROSS [10001]","Blue Cross PPO",,1163.71,39.2,,957.42,570.23,957.42,28,345.25,2523.35,"percent of total billed charges",
"LEAD ICD 59CM ENDOTAK RELIANCE ENDOCARDIUM 4 SITE 2 COIL",SUP-265,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]","Cigna Local Plus",,4781.7,31.5,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE MEDIUM PATIENT ROCKER BOTTOM APB BLACK",SUP-199650,CDM,S27000186,LOCAL,0270,RC,,,both,,,256.91,77.07,"CIGNA [10200]","Cigna Local Plus",,137.45,53.5,,,,,0,29.88,218.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC .062IN TROCAR TIP DISPOSABLE 5MM SCR",SUP-AR-8750K,CDM,C1713,HCPCS,0278,RC,,,both,,,130.50,39.15,"KAISER [10500]",Kaiser,,87.44,67,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10MM CREO MIS SPINE POLYAXIAL TULIP REDUCTION",SUP-1134.0110,CDM,C1713,HCPCS,0278,RC,,,both,,,3555.00,1066.5,"MULTIPLAN [10600]",Multiplan,,3021.75,85,,,,,0,413.45,3021.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOFT TISSUE PROCEDURES WITH CC",501,MS-DRG,,,,,,,inpatient,,,54587.06,16376.12,"AETNA [10100]","Aetna HMO/PPO",,32890.5,,"Fee schedule rate ($32,890.50). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,51037.53,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 8MM 60MM TITANIUM FULL THREAD T25 TIBIA LOCK",SUP-04.015.550S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT 200X25X8MM SIGNAFUSE GLASS CLLGN TYPE 1",SUP-SGFS-040,CDM,C1713,HCPCS,0278,RC,,,both,,,51168.60,15350.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13815.52,27,,,,,0,5950.91,43493.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 300MM 3.5MM BALLOON DILATATION RAPID",SUP-47535300S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1377,68,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM AXSOS STAINLESS STEEL T15 FEMUR HUMERUS",SUP-371540,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"MULTIPLAN [10600]",Multiplan,,757.35,85,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 55CM 6FR .07IN LIMA CURVE GUIDING PTFE PERIPHERAL",SUP-M001196620,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"NOVANET [10819]",Novanet,,447.85,75,,,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 80CM 27MM 8-15MM GORE CARDIOFORM ATRIAL",SUP-ASD27A,CDM,C1817,HCPCS,0278,RC,,,both,,,54495.00,16348.5,"KAISER [10500]",Kaiser,,36511.65,67,,,,,0,6337.77,46320.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 28CM INTERSTIM SPINAL CORD TINED",SUP-3889-28,CDM,C1778,HCPCS,0278,RC,,,both,,,20834.10,6250.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8562.82,41.1,,,,,0,2423.01,17708.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH INSRT 6IN 7.5FR SENSATION PLUS REINFORCED SHEATH",SUP-0884-00-0019-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,1217.27,365.18,"CIGNA [10200]","Cigna Local Plus",,651.24,53.5,,,,,0,141.57,1034.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nrv Condct 11-12 Studies",PX-959000024,CDM,95912,CPT,0922,RC,,,both,,,8234.00,2470.2,"FIRST HEALTH [10303]","First Health",,6587.2,80,,,,,0,957.61,6998.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER CHOCOLATE 150CM 80MM 2.5MM .014IN BALLOON DILATATIO",SUP-CB1415025080OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"UHC [10700]","United Healthcare",,3625.19,63.3,,,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8.5MM 12/14 TAPER 36MM HIP BIOLOX DELTA",SUP-1365-36-330,CDM,C1776,HCPCS,0278,RC,,,both,,,12268.20,3680.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3511.16,28.62,,,,,0,1426.79,10427.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLARED SECUR-FIT HYDROXYAPATITE 6 HIP",SUP-S-2337-HF06,CDM,C1776,HCPCS,0278,RC,,,both,,,16482.96,4944.89,"BLUE CROSS [10001]","Blue Cross PPO",,6461.32,39.2,,3949.44,3949.44,3949.44,"1 through 10",1916.97,14010.52,"percent of total billed charges",
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX SMALL C6 5.2MM D",SUP-T600106,CDM,S27800098,LOCAL,0278,RC,,,both,,,2100.00,630,"MULTIPLAN [10600]",Multiplan,,1785,85,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 10X40 40CM SL",SUP-48010004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 2MM BALLOON DILATATION RAPID EXCHANGE PTCA",SUP-DC-RY2012UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 12MM 140CM 4MM CORONARY",SUP-RSINT40012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"BLUE CROSS [10001]","Blue Cross HMO",,2173.25,39.2,,9776.84,9776.84,9776.84,"1 through 10",644.77,4712.4,"percent of total billed charges",
"SCR BONE 3.5MM 16MM TIBIA CORTICAL DISTAL NONLOCK NONSTERILE",SUP-815037016,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"FIRST HEALTH [10303]","First Health",,631.8,80,,,,,0,91.85,671.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK 24IN THERAPEUTIC MOIST HEAT THERMAL COLOR CODED TABS",SUP-561727,CDM,S27000186,LOCAL,0270,RC,,,both,,,239.16,71.75,"NOVANET [10819]",Novanet,,179.37,75,,,,,0,27.81,203.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 5 X 6 HELICAL PICO COIL",SUP-10USH05006,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"FIRST HEALTH [10303]","First Health",,9378.48,80,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYOSURE 1.8MM 54MM 140ML/MIN 300 MMHG 14MM 32CM 3MM",SUP-10-403,CDM,S27200284,LOCAL,0272,RC,,,both,,,6670.00,2001,"PHCS [10601]",PHCS,,4669,70,,,,,0,775.72,5669.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 20MM 2.25MM BALLOON DILATATION PACLITAXEL",SUP-H7493960820220,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"CIGNA [10200]","Cigna Open Access",,22135.52,56.9,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CIRCUIT EVAQUA 2 2 LIMB HEAT INFANT",SUP-RT266,CDM,S27000186,LOCAL,0270,RC,,,both,,,324.51,97.35,"KAISER [10500]",Kaiser,,217.42,67,,,,,0,37.74,275.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 018 100CM 300MM 6MM BALLOON DILATATION STERILE",SUP-LX1810063005F,CDM,C2623,HCPCS,0272,RC,,,both,,,18270.00,5481,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2124.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 22MM MODULAR RESTORATION BOWED CONICAL",SUP-6276-7-222,CDM,C1776,HCPCS,0278,RC,,,both,,,11695.32,3508.6,"AETNA [10100]","Aetna HMO/PPO",,9297.78,79.5,,10981.53,8986.79,12413.38,12,1360.17,9941.02,"percent of total billed charges",
"PASSER SUPER SHUTTLE 3 HIGH STRENGTH EYELET BRAIDED RESIST",SUP-C6005,CDM,S27200284,LOCAL,0272,RC,,,both,,,611.31,183.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,71.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,71.1,519.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADHSV SKIN CLSR BSA GLUTARALDEHYDE BIOGLUE SYR APPLR TIP 5ML",SUP-BG3515-5-US,CDM,S27200284,LOCAL,0272,RC,,,both,,,5947.80,1784.34,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2730.04,45.9,,,,,0,691.73,5055.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE XPRESS 18MM 6MM BALLOON INFLATION LOW PROFILE",SUP-LPLF-106,CDM,C1726,HCPCS,0272,RC,,,both,,,11074.50,3322.35,"AETNA [10100]","Aetna HMO/PPO",,8804.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1287.96,9413.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION 2.8MM MAGNUM2 KNOTLESS",SUP-OM1502,CDM,C1713,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]",Cigna,,2295,68,,1831.33,1831.33,1831.33,16,392.51,2868.75,"percent of total billed charges",
"STEM FEMORAL C-STEM AMT 5 12/14 STANDARD OFFSET TAPER L124 M",SUP-157004110,CDM,C1776,HCPCS,0278,RC,,,both,,,20317.50,6095.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2407.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2362.93,17269.88,"percent of total billed charges",
"HC Eps W Arryth",PX-481000054,CDM,93620,CPT,0481,RC,,,both,,,20057.57,6017.27,"UHC [10700]","United Healthcare",,16259,,"Case rate ($16,259). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,2332.7,20057.57,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL DURAL DURAGEN 2X 2IN SQUARE CALLAGEN DURAMATRIX REPAIR",SUP-DMR22,CDM,,,0278,RC,,,both,,,6154.80,1846.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,715.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.15,5231.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL COMFORT FLO PLUS MEDIUM",SUP-2412-12,CDM,S27000186,LOCAL,0270,RC,,,both,,,166.39,49.92,"CIGNA [10200]",Cigna,,113.15,68,,,,,0,19.35,141.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 5MM 24FR STERILE DISPOSABLE YELLOW",SUP-27050NK/6,CDM,S27200284,LOCAL,0272,RC,,,both,,,1126.85,338.05,"AETNA [10100]","Aetna HMO/PPO",,895.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.05,957.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 9MM APTUS TRILOCK TITANIUM PHALANGEAL HAND",SUP-A-5250.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"KAISER [10500]",Kaiser,,1079.97,67,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMOXICILLIN 250 MG CAPSULE, IMMEDIATE RELEASE",RX-450,CDM,,,0637,RC,60687-0776-11,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,3.57,56.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSORB GT1 8MM 2.5MM CORONARY EVEROLIMUS ELUTING POLY",SUP-1235250-08,CDM,C1874,HCPCS,0278,RC,,,both,,,1702.50,510.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,201.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,198,1447.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA SURG VELC STRP ZIP SM 30-32IN",SUP-958-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,333.99,100.2,"NOVANET [10819]",Novanet,,250.49,75,,,,,0,38.84,283.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM CREO ONE SPINE ROBOTIC MODULAR",SUP-1134.1645,CDM,C1713,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5621.02,68,,,,,0,961.36,7026.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2.5MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN02502,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"NOVANET [10819]",Novanet,,7757.33,75,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE HYDROSET XT HA INJECTABLE STERILE LATEX FREE",SUP-897003,CDM,C1713,HCPCS,0278,RC,,,both,,,2812.50,843.75,"KAISER [10500]",Kaiser,,1884.38,67,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 2.7CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-24-2.7,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,320.19,41.1,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM 3.5MM SCR ELLI",SUP-682.104,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,468.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752840,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,106.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Incisional Biopsy Skin Sgl",PX-761000063,CDM,11106,CPT,0761,RC,,,both,,,2168.00,650.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1474.24,68,,,,,0,252.14,2168,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP UNIPOLAR HEAD AND ADAPTER",SUP-OSC365963,CDM,C1776,HCPCS,0278,RC,,,both,,,3750.00,1125,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS HIGHFLOW 100CM 7FR IM CURVE ANGIOGRAPHIC DUCOR",SUP-527760,CDM,C1887,HCPCS,0272,RC,,,both,,,137.11,41.13,"PHCS [10601]",PHCS,,95.98,70,,,,,0,15.95,116.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE U -POROUS NEXGEN FEMUR",SUP-CAP-U-NEXGEN,CDM,C1776,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross PPO",,1470,39.2,,3949.44,3949.44,3949.44,"1 through 10",436.13,3187.5,"percent of total billed charges",
"HC Prealbumin",PX-301000368,CDM,84134,CPT,0301,RC,,,both,,,263.00,78.9,"PHCS [10601]",PHCS,,184.1,70,,,,,0,0.01,223.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG 127MM STAINLESS STEEL 2.7/3.5MM SCR 7 HOLE",SUP-02.117.007S,CDM,C1713,HCPCS,0278,RC,,,both,,,7192.84,2157.85,"CIGNA [10200]",Cigna,,4891.13,68,,1831.33,1831.33,1831.33,16,836.53,6113.91,"percent of total billed charges",
"CATH INDIGO 135CM 6FR THROMBECTOMY ASPIRATION DYNAMIC TUBING",SUP-CAT6KIT,CDM,C1757,HCPCS,0272,RC,,,both,,,15352.50,4605.75,"FIRST HEALTH [10303]","First Health",,12282,80,,,,,0,1785.5,13049.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 26CM 6FR .038IN PIGTAIL CURVE",SUP-M006180223120,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"MULTIPLAN [10600]",Multiplan,,1130.72,85,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.0MM X 11MM TI",SUP-VAN-20110-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Local Plus",,520.02,53.5,,3978.14,359.25,3978.14,24,113.04,826.2,"percent of total billed charges",
"CATH IMAGER II 65CM 5FR BERN CURVE ANGIOGRAPHIC CEREBRAL",SUP-M001314101,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,47.91,41.1,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 39MM CEMENTLESS OFFSET SECUR-FIT MAX 127D",SUP-6052-0730S,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"CIGNA [10200]",Cigna,,6259.68,40,,5873.17,5873.17,5873.17,"1 through 10",1820,13301.82,"percent of total billed charges",
"SCR BONE 6.5MM 25MM REFLECTION R3 CONTOUR HIP ACETABULAR",SUP-71332525,CDM,C1713,HCPCS,0278,RC,,,both,,,1287.90,386.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,875.77,68,,,,,0,149.78,1094.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 50MM LCP STAINLESS STEEL LONG THREAD FEMORAL",SUP-207.750,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,120.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",120.96,884.03,"percent of total billed charges",
"ROD SPINAL 55MM 5.5MM CD HORIZON CURVE TITANIUM CP4",SUP-1553201055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"LINER ACETABULAR R3 0D 60MM 28MM XLPE HIP",SUP-71337560,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"BLUE CROSS [10001]","Blue Cross HMO",,4369.6,39.2,,5311.50,4717.44,5388.59,31,1296.39,9474.91,"percent of total billed charges",
"SCREW VARIABLE ANGLE LOCKING 1.5MM X 30MM COCR",SUP-VAL-15300-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]","Cigna Open Access",,811.17,56.9,,1144.80,304.56,2275.09,66,165.8,1211.76,"percent of total billed charges",
"HC Eeg Incl Awake & Drowsy",PX-740000010,CDM,95816,CPT,0740,RC,,,both,,,1470.61,441.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,675.01,45.9,,,,,0,171.03,1470.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE (RSP) MONOBLOCK REVISION HUMERAL STEM, 220MM, 10X220",SUP-510-10-220,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5040,40,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 16MM OSTEOLOCK TITANIUM CANCELLOUS HIP",SUP-5260-5-016,CDM,C1713,HCPCS,0278,RC,,,both,,,580.01,174,"NOVANET [10819]",Novanet,,435.01,75,,,,,0,67.46,493.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GASTROENTEROLOGY TWISTER PLUS.STANDARD.15 MM.120 CM.5.7F.1.7",SUP-TWIST15-PULM,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,408.97,45.9,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP TUBE 16MM CRANIOFIX TITANIUM ABSORB CRANIAL FIXATION",SUP-FF017,CDM,C1713,HCPCS,0278,RC,,,both,,,2107.05,632.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,249.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,245.05,1790.99,"percent of total billed charges",
"VENTRICULAR SHUNT PROCEDURES WITH MCC",031,MS-DRG,,,,,,,inpatient,,,156227.23,46868.17,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,29738.31,,"Case rate ($27,792.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $25,807.51, add-ons for qualifying new technology services are included. If operating cost exceeds $58,847.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,333.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $25,841.64. The transfer operating threshold is the transfer adjustment factor * $25,807.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,951.17. The transfer capital threshold is the transfer adjustment factor * $1,951.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,130812.68,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"TUMARK VISION 12CM",SUP-351232,CDM,A4648,HCPCS,0278,RC,,,both,,,942.84,282.85,"BLUE CROSS [10001]","Blue Cross HMO",,369.59,39.2,,,,,0,109.65,801.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 440MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.064S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"UHC [10700]","United Healthcare",,7860.81,63.3,,5023.51,2672.93,6679.78,18,1444.25,10555.59,"percent of total billed charges",
"CATH LEMAITRE 80CM 3FR 8MM EMBOLECTOMY .20ML STERILE LATEX",SUP-E1601-38,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,407.59,68,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 5 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022215,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"NOVANET [10819]",Novanet,,12466.58,75,,,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 60MM 135CM 8MM VASCULAR NITINOL",SUP-1012536-60,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross HMO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL TEMP PACING WIRE 2-0 SH SKS-3 24IN 2 ARM",SUP-TPW30,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.32,37.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.69,107.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 331344 ACSR 13X14X14 SRVC FEE",SUP-331344,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 4.50 X 8MM",SUP-H7493942808450,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross HMO",,2434.32,39.2,,9776.84,9776.84,9776.84,"1 through 10",722.22,5278.5,"percent of total billed charges",
"BAND ANNULOPLASTY 40MM SIMULUS ANNULUS POSTERIOR POLYESTER",SUP-800SC40,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5388.21,41.1,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 2.4MM 26MM TITANIUM CORTICAL HAND SELF TAPPING NO",SUP-401.526.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"BLUE CROSS [10001]","Blue Cross PPO",,233.82,39.2,,957.42,570.23,957.42,28,69.37,507.01,"percent of total billed charges",
"DEVICE PIPELINE FLEX 55D 12MM 2.75MM EMBOLIZATION 75% COCR",SUP-PED-275-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"BLUE CROSS [10001]","Blue Cross HMO",,30164.4,39.2,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 119MM 14MM ESOPHAGEAL FULL COVER STERILE LATEX",SUP-M00517420,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Transducer Neonate",PX-E27000131,CDM,E27000131,LOCAL,0270,RC,,,both,,,94.60,28.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11,80.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL CANNULATED 2 MM 2.4 MM SCREWS",SUP-210-24-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.00,495,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,191.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 45CM .016IN BRADY FIRM",SUP-6057,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPIDCROSS 170CM 40MM 2.5MM .014IN BALLOON DILATATION",SUP-A14BX025040170,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.87,68,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOCYCLINE HCL 100 MG/5ML IV (WET SOLR VIAL)",RX-41510612,CDM,,,0250,RC,70842-0160-01,NDC,both,1,UN,1560.31,468.09,"CIGNA [10200]","Cigna Open Access",,887.82,56.9,,,,,0,181.46,1326.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1-2 9MM KNEE XLPE POSTERIOR STABILIZED HIGH",SUP-71453201,CDM,C1776,HCPCS,0278,RC,,,both,,,15628.50,4688.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1851.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1817.59,13284.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM GLUCONATE 10% TOPICAL",RX-411652,CDM,J0612,HCPCS,0636,RC,63323-0360-01,NDC,both,10,ML,75.61,22.68,"MULTIPLAN [10600]",Multiplan,,64.27,85,,,,,0,3.52,64.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 100X12-13MM",SUP-400751,CDM,S27800098,LOCAL,0278,RC,,,both,,,4868.64,1460.59,"BLUE CROSS [10001]","Blue Cross HMO",,1908.51,39.2,,,,,0,566.22,4138.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ECHELON CONTOUR GST RELOAD (BLUE)",SUP-GCR40B,CDM,S27200284,LOCAL,0272,RC,,,both,,,2994.05,898.21,"FIRST HEALTH [10303]","First Health",,2395.24,80,,,,,0,348.21,2544.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 11MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-111-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]","Cigna Local Plus",,3790.58,31.5,,5372.07,4581.20,7242.98,23,1399.51,10228.56,"percent of total billed charges",
"PLATE 85MM 4 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-44F85V,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 120MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206051210,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPYGLASS DISCOVER 65CM 40MM 6MM BALLOON DILATION",SUP-M00543000,CDM,C1726,HCPCS,0272,RC,,,both,,,593991.30,178197.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,244130.42,41.1,,,,,0,69081.19,504892.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 25MM LCP STAINLESS STEEL PROXIMAL FEMORAL",SUP-02.205.025,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",146.92,1073.79,"percent of total billed charges",
"TISSUE MARKER 2 X 2 BIOZORB",SUP-F0202,CDM,A4648,HCPCS,0278,RC,,,both,,,8383.50,2515.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,993.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,975,7125.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 5FR .058IN JUDKINS LEFT 4 CURVE GUIDING NYLON",SUP-LA5JL40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON DISECT LAPAROSCOPIC KII 100MM 12MM 1 LATERAL",SUP-C0K16,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"CIGNA [10200]",Cigna,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTNSL CUTLERY SPOON FINGER CONTOUR LIGHTWEIGHT STAINLESS",SUP-AA5553,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.30,21.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,33.19,45.9,,,,,0,8.41,61.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175263170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"NOVANET [10819]",Novanet,,949.04,75,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 120MM 12-14MM 13FR 10FR TRIVASCULAR OVATION",SUP-TV-IL1412120-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"UHC [10700]","United Healthcare",,21135.87,63.3,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM NARROW BLADE RAMP 5.5",SUP-7541143,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX13MM FRA 8D 30D LORDOTIC NARROW",SUP-10213,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"KAISER [10500]",Kaiser,,12663,67,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 100MM 3MM BALLOON DILATATION RAPID",SUP-47530100L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR AR2 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916599862,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]",Cigna,,52.07,68,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP ACETABULAR 56MM MODULAR MULTIHOLE REVISION HIP",SUP-00620205620,CDM,C1776,HCPCS,0278,RC,,,both,,,17500.14,5250.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2073.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2035.27,14875.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH STRAIGHT 26FR ENDOSCOPIC INNER OBTR RESECTION",SUP-A22042A,CDM,C1894,HCPCS,0272,RC,,,both,,,10024.39,3007.32,"KAISER [10500]",Kaiser,,6716.34,67,,,,,0,1165.84,8520.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 30CM SMALL VALVE ASSEMB RADIOPAQUE BAND",SUP-G08867,CDM,C1894,HCPCS,0272,RC,,,both,,,415.08,124.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,170.6,41.1,,,,,0,48.27,352.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 15X15MM DYNANITE NITINOL COMPRESSION LOW PROFILE",SUP-AR-8719DS-1515,CDM,C1713,HCPCS,0278,RC,,,both,,,15835.50,4750.65,"NOVANET [10819]",Novanet,,11876.63,75,,,,,0,1841.67,13460.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIGASURE ATLAS SEAL DIV 20CM",SUP-LS1020,CDM,S27200284,LOCAL,0272,RC,,,both,,,2537.18,761.15,"AETNA [10100]","Aetna HMO/PPO",,2017.06,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,295.07,2156.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 9MM BENGAL 4D LARGE STACKABLE TOP",SUP-177304209,CDM,S27800098,LOCAL,0278,RC,,,both,,,7184.28,2155.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,851.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,835.53,6106.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 30MM CG FUTURE FLEXIBLE LOW PROFILE EYELET",SUP-638BL30,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UHC [10700]","United Healthcare",,8298.63,63.3,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 53X43X.64MM FAN CORE OFFSET",SUP-5400134285,CDM,S27200284,LOCAL,0272,RC,,,both,,,361.83,108.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,42.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.08,307.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM 47.8MM HIP 3 SCR HOLE CLUSTER HA",SUP-542-11-46D,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"NOVANET [10819]",Novanet,,5218.29,75,,,,,0,809.18,5914.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER VASCULAR 8FR LEFTBU3.75 MACH 1",SUP-H749343587150,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.44,109.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER FLEXIVA ID 550UM FLEXSHIELD HIGH POWER NONTAPER",SUP-M006R8403931,CDM,S27200284,LOCAL,0272,RC,,,both,,,2976.66,893,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1223.41,41.1,,,,,0,346.19,2530.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 45MM 1.2MM TAPER CARBIDE SIDE CUT STERILE",SUP-1607-002-105,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.18,26.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.37,75.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHMBR HUMD 2 FLOAT AUTO FILL COMPRESSIBLE VOLUME MR SERIES",SUP-MR290V,CDM,S27000186,LOCAL,0270,RC,,,both,,,94.50,28.35,"KAISER [10500]",Kaiser,,63.32,67,,,,,0,10.99,80.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 10FT INTERPULSE SUCTION TUBE HNDPC STERILE LATEX FREE",SUP-210100000,CDM,S27000186,LOCAL,0270,RC,,,both,,,249.50,74.85,"KAISER [10500]",Kaiser,,167.17,67,,,,,0,29.02,212.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE UNICORTICAL DOWEL ALLOGRAFT FREEZE DRIED 11-21MM",SUP-400205,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"NOVANET [10819]",Novanet,,3182.63,75,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK VITRECTOMY 25GA STELLARIS ELITE POSTERIOR MID FIELD",SUP-SE5425MV,CDM,S27200284,LOCAL,0272,RC,,,both,,,4126.20,1237.86,"UHC [10700]","United Healthcare",,2611.88,63.3,,,,,0,479.88,3507.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 57MM STAINLESS STEEL SMALL FRAGMENT SET 5 HOLE 1/3",SUP-241.351,CDM,C1713,HCPCS,0278,RC,,,both,,,1149.80,344.94,"PHCS [10601]",PHCS,,804.86,70,,,,,0,133.72,977.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 71MMX5MM VANGUARD 360 UNIVERSAL KNEE REVISION",SUP-185223,CDM,C1776,HCPCS,0278,RC,,,both,,,7577.58,2273.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,897.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,881.27,6440.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLIDESHEATH SLENDER SS KIT, 0.025 GW, 5 FR, 10CM",SUP-80-1055,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 33MM FOGARTY SMALL ATRAUMATIC OCCLUSION SOFT",SUP-A0801,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"UHC [10700]","United Healthcare",,99.13,63.3,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTECH DEMINERALIZED BONE FIBER 3CC ALLOGRAFT",SUP-T50103,CDM,C1713,HCPCS,0278,RC,,,both,,,4761.00,1428.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1362.6,28.62,,,,,0,553.7,4046.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 80MM 1.5MM BALLOON DILATATION RAPID",SUP-47515080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"MULTIPLAN [10600]",Multiplan,,1356.35,85,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 130CM 150MM 6MM BALLOON DILATATION",SUP-LX3513061505F,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYR ANGIOGRAPHY HEMOSTASIS VALVE GWIRE INSRT TOOL MONARCH",SUP-IN2430,CDM,S27200284,LOCAL,0272,RC,,,both,,,504.14,151.24,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(COMM) ARCH SINUS NASAL STENT",SUP-712-001,CDM,C2625,HCPCS,0272,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP BIOPSY NDL 240CM 2.8MM RADIAL JAW 4 3.2MM JUMBO",SUP-M00513371,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.38,85.61,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 40CM 30MM 6MM .035IN BALLOON DILATATION NYBAX",SUP-39171-06034,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS PRIMOPAC 4FR STRAIGHT PIGTAIL JR4 JL4 CURVE",SUP-538499P,CDM,S27200284,LOCAL,0272,RC,,,both,,,232.73,69.82,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER ALLOGRAFT 12.5X15X10MM CONVEX SPINE CORTICOCANCELLOUS",SUP-17510,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE CHECKER 150CM 22CM 2MM BALLOON DILATATION",SUP-U4150222,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bcr/Abl1 Gene Major Bp",PX-309000003,CDM,81206,CPT,0310,RC,,,both,,,613.60,184.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,582.04,,,,,,,0.01,582.04,"fee schedule",
"STENT CONTOUR 30CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805250,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"MULTIPLAN [10600]",Multiplan,,766.85,85,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL BLOCK 14X11X5",SUP-245541,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +12 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.120,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 8MM 144CM 3MM CORONARY STENT",SUP-H7493952808300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,647.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTALINK 135CM 1.25MM ATHERECTOMY BURR EXCHANGE",SUP-H749393001250,CDM,C1724,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 40X54.6MM HALL THK.4MM STAINLESS STEEL OSCILLATE",SUP-5059-279,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.57,30.17,"UHC [10700]","United Healthcare",,63.66,63.3,,,,,0,11.7,85.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA E KNEE LEFT 2 PEG TIVANIUM STERILE",SUP-42530007101,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"FIRST HEALTH [10303]","First Health",,11348.02,80,,,,,0,1649.72,12057.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 36MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-036,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"PHCS [10601]",PHCS,,14875.56,70,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Laser Capsulotomy",PX-761000008,CDM,66821,CPT,0761,RC,,,both,,,1088.00,326.4,"KAISER [10500]",Kaiser,,728.96,67,,,,,0,1.09,1088,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dx Mammo Incl Cad Bi",PX-401000011,CDM,77066,CPT,0401,RC,,,both,,,818.46,245.54,"CIGNA [10200]",Cigna,,252,,"Per diem ($252).",,,,0,95.19,695.69,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY NONSPIKED SMOOTH FLEXIBLE ERGONOMIC HANDLE 160CM",SUP-G53006,CDM,S27200284,LOCAL,0272,RC,,,both,,,324.51,97.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MARKER SURGICAL 200MM WIRE 3MM DISPOSABLE STERILE",SUP-7020100,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C",768,MS-DRG,,,,,,,inpatient,,,38137.05,11441.11,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS MULTIPASS 5-0 PS-2 18IN ANTIBACTERIAL UNDYED",SUP-PDP495G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TENDYNE RETRIEVAL SYSTEM",SUP-TENDV-RS-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SCOUTPRO 55CM 7.3FR 8.7FR HOOK CURVE GUIDING","SUP-375 530",CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SHAVER 7CM 3MM COOLCUT ROUND SMALL JOINT 8 FLUTE",SUP-AR-7300RBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH METACROSS 135CM 150MM 5.4FR 4MM BALLOON DILATATION 2",SUP-BD-L40150CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM",RX-29424,CDM,,,0250,RC,00168-0258-15,NDC,both,15,GR,127.28,38.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,86.55,68,,,,,0,14.8,108.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SUBSTITUTE DEMINERALIZED CANCELLOUS ALLOGRAFT BLO",SUP-PBB12,CDM,S27800098,LOCAL,0278,RC,,,both,,,4944.71,1483.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,575.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,575.07,4203,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL OVITEX PRS-RESTELLA 20X16CM STERILE LATEX FREE",SUP-R20143-1620P,CDM,C1781,HCPCS,0278,RC,,,both,,,34968.78,10490.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10008.06,28.62,,,,,0,4066.87,29723.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 190CM 3CM",SUP-1020014,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 15MM 8MM BICEPTOR BIOSURE SCR",SUP-72202300,CDM,C1713,HCPCS,0278,RC,,,both,,,2895.75,868.72,"BLUE CROSS [10001]","Blue Cross HMO",,1135.13,39.2,,957.42,156.86,7483.26,51,336.78,2461.39,"percent of total billed charges",
"SHELL BIPOLAR 51MM 36MM GLADIATOR HIP COCR XLPE UHMWPE LOCK",SUP-GLBP3651,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"FIRST HEALTH [10303]","First Health",,8280,80,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X8X7MM RISE NONSTERILE",SUP-193.001,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 125CM 5FR ULT1 CURVE ANGIOGRAPHIC PEBAX",SUP-PV512538U1SH,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"FIRST HEALTH [10303]","First Health",,408.24,80,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP PHACOEMULSIFICATION 25GA GRIESHABER REVOLUTION DSP 360D",SUP-337.84,CDM,S27200284,LOCAL,0272,RC,,,both,,,786.43,235.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,360.97,45.9,,,,,0,91.46,668.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION",RX-9938,CDM,J0885,HCPCS,0636,RC,59676-0310-00,NDC,both,1,ML,1613.12,483.94,"BLUE CROSS [10001]","Blue Cross PPO",,99.53,,,,,,,90.92,1371.15,"fee schedule",
"SCR BONE 8.5MM 45MM SPINAL POLYAXIAL 5.5MM ROD",SUP-8458545,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"MULTIPLAN [10600]",Multiplan,,4116.21,85,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 8IN SPETZLER-MALIS 1.5MM 2 IRRIGATE DISPOSABLE",SUP-6770-200-015,CDM,S27200284,LOCAL,0272,RC,,,both,,,3282.98,984.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2232.43,68,,,,,0,381.81,2790.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENSIONER SURGICAL CUTTER 2-0/0 FIBERWIRE SUT",SUP-AR-5815,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"AETNA [10100]","Aetna HMO/PPO",,1183.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOTHYROXINE 100 MCG TABLET",RX-4423,CDM,,,0637,RC,00904-6953-61,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 25X3.5MM TITANIUM ENDOSCOPIC LINEAR CUTTER",SUP-EEAXL2535,CDM,S27200284,LOCAL,0272,RC,,,both,,,2399.55,719.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,284.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,279.07,2039.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCTIC FRONT ADVANCE TM COABLATION CATHETER",SUP-AFAPRO23,CDM,C1733,HCPCS,0272,RC,,,both,,,27720.00,8316,"UHC [10700]","United Healthcare",,17546.76,63.3,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM DELTAXSFT 10 COIL",SUP-DLX100202,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"KAISER [10500]",Kaiser,,6065.38,67,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 43IN 10FR TEFLON POLYURETHANE SILICONE",SUP-30-1431,CDM,S27200284,LOCAL,0272,RC,,,both,,,626.37,187.91,"NOVANET [10819]",Novanet,,469.78,75,,,,,0,72.85,532.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABIL 40MM 200CM 8MM ENDOPROSTHESIS METAL NO",SUP-VSWVN0804,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 8FR 40D GUIDING DURAFORM PTFE",SUP-M003101440,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"FIRST HEALTH [10303]","First Health",,2002.5,80,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSSEOFLEX KIT W/ BIOPSY NEEDLE",SUP-OCP-0222,CDM,S27200284,LOCAL,0272,RC,,,both,,,15290.40,4587.12,"CIGNA [10200]",Cigna,,10397.47,68,,,,,0,1778.27,12996.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 12 G-H KNEE",SUP-42512101011,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS [10001]","Blue Cross HMO",,4224.36,39.2,,5311.50,4717.44,5388.59,31,1253.3,9159.96,"percent of total billed charges",
"CATH NC EUPHORA 142CM 15MM 2MM BALLOON DILATATION DURATRAC",SUP-NCEUP2015X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR EBU3.5 CURVE GUIDING CORONARY",SUP-LA6EBU355,CDM,C1887,HCPCS,0272,RC,,,both,,,339.30,101.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CARTO 3 THERMOCOOL SF 7.5FR B-B CURVE ELECTROPHYSIOLOGY",SUP-BNI35BBCT,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"GWIRE SYNCHRO2 VASCULAR 300CM 35CM .014IN NITINOL STAINLESS",SUP-M00326510,CDM,C1769,HCPCS,0272,RC,,,both,,,5206.74,1562.02,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE NASOPHARYNGEAL 67MM 32FR ADJUSTABLE FLANGE SOFT RED",SUP-125200-000320,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.91,23.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG VISCERAL PROTECTIVE LAYER DRAPE TUBING SET PERFORATED",SUP-370605/5.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4926.57,1477.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RESPIRATORY NEOPLASMS WITHOUT CC/MCC",182,MS-DRG,,,,,,,inpatient,,,61119.45,18335.83,"UHC [10700]","United Healthcare",,18799.02,,"Fee schedule rate ($18,799.02). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,4675.87,18799.02,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM PRESTIGE PLUS HELICAL ULTRA",SUP-PRES4510CPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVED 278MM STAINLESS STEEL 4.5MM SCR 12 HOLE LOCKING",SUP-02.001.322,CDM,C1713,HCPCS,0278,RC,,,both,,,9833.88,2950.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4513.75,45.9,,,,,0,1143.68,8358.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1 LEFT MEDIAL RIGHT LATERAL PARTIAL KNEE",SUP-5610-F-101,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4590.96,45.9,,,,,0,1163.24,8501.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 217MM 17MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-417,CDM,C1776,HCPCS,0278,RC,,,both,,,19885.95,5965.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7954.38,40,,,,,0,2312.74,16903.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS LOC LARGE CARDIAC PERCUTANEOUS 3D STERILE",SUP-DS2C300-42,CDM,C1893,HCPCS,0272,RC,,,both,,,2250.00,675,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,266.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC .99CM 5.37X8.18CM RESONATE HEARTLOGIC RIGHT",SUP-G447,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"PHCS [10601]",PHCS,,40404,70,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 45MMX12MMX15CM 26FR",SUP-TAC124515A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21614.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VEST 1 FRONT ZIP ADJUSTABLE SHOULDER STRAP CUP POSTOPERATIVE",SUP-111901,CDM,S27000186,LOCAL,0270,RC,,,both,,,945.03,283.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,642.62,68,,,,,0,109.91,803.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 10MM 1.5MM BALLOON DILATATION STERILE",SUP-215-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 72CM PALINDROME SPORT PRECISION SYMMETRICAL TIP 55",SUP-8888145018P,CDM,C1750,HCPCS,0278,RC,,,both,,,2876.79,863.04,"BLUE CROSS [10001]","Blue Cross HMO",,1127.7,39.2,,,,,0,334.57,2445.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 75CM 40MM 5MM VASCULAR METAL SUPERFICIAL",SUP-H74939293054070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2216.97,45.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 300MM 2.5MM BALLOON DILATATION RAPID",SUP-47525300M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,239.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STARTER BENTSON VASCULAR STRAIGHT SPRING COIL 150CM 15",SUP-M001491451,CDM,C1769,HCPCS,0272,RC,,,both,,,82.65,24.79,"PHCS [10601]",PHCS,,57.86,70,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOLTR TRANSCATHETER AORTIC VALVE-23MM - THE 23MM EVOLTR TRA",SUP-EVOLUTR-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS [10001]","Blue Cross HMO",,67032,39.2,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM TRILOGY TIVANIUM ALLOY HIP ACETABULAR",SUP-00625006525,CDM,C1713,HCPCS,0278,RC,,,both,,,691.60,207.48,"MULTIPLAN [10600]",Multiplan,,587.86,85,,,,,0,80.43,587.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 11CM 7FR PANCREATIC POLYETHYLENE DRAIN OBSTRUCT",SUP-G22466,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"NOVANET [10819]",Novanet,,473.85,75,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6IN 3IN FREEFORM MINI",SUP-MCR093060,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1567.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMIODARONE 200 MG TABLET",RX-9066,CDM,,,0637,RC,60687-0437-01,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PLEUR-EVAC 21IN 28FR ANGLE RIGHT DRNG PVC THORAX SEAL",SUP-DRAC-28S,CDM,C1729,HCPCS,0272,RC,,,both,,,70.47,21.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.2,59.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE 42IN MERITRANS FIXED FEMALE CNCT ROTATING",SUP-K11-00202A,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.22,27.67,"UHC [10700]","United Healthcare",,58.38,63.3,,,,,0,10.73,78.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 10MM THORACIC AORTA WOVEN",SUP-IGW0010-30,CDM,C1768,HCPCS,0278,RC,,,both,,,2894.40,868.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,342.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,336.62,2460.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 15X18MM DYNANITE SUPERMX NITINOL COMPRESSION LOW",SUP-AR-8719MX-1815,CDM,C1713,HCPCS,0278,RC,,,both,,,14455.50,4336.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5941.21,41.1,,,,,0,1681.17,12287.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AMPLATZER TORQVUE 2 120CM 5FR INTRO POLYMER PTFE",SUP-9-TV2-05F120,CDM,S27200284,LOCAL,0272,RC,,,both,,,5754.60,1726.38,"CIGNA [10200]","Cigna Open Access",,3274.37,56.9,,,,,0,669.26,4891.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING SUCTION 6FT BERKELEY VACRET PLASTIC COLL SET SWIVEL",SUP-610,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.55,34.96,"PHCS [10601]",PHCS,,81.59,70,,,,,0,13.55,99.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM STAINLESS STEEL 2.4MM SCR 7X3 HOLE 2 COLUMN",SUP-02.111.730,CDM,C1713,HCPCS,0278,RC,,,both,,,3884.70,1165.41,"NOVANET [10819]",Novanet,,2913.53,75,,,,,0,451.79,3302,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X21MM ENDOSKELETON TAS 7D 12MM STD TITANIUM",SUP-2307-0112,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNITY - TIBIAL INSERT MC #6 Th9 R",SUP-1127609,CDM,C1776,HCPCS,0278,RC,,,both,,,4140.00,1242,"AMERIGROUP MEDICAID [20100]",Amerigroup,,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENECTEPLASE 25 MG INTRAVENOUS SOLUTION",RX-245287,CDM,J3101,HCPCS,0636,RC,50242-0009-01,NDC,both,1,UN,50082.25,15024.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9114.75,,,,,,,5018.06,42569.91,"fee schedule",
"STEM EXT 125MM 14MM LPS STRAIGHT FLUTE KNEE FEMUR COCR",SUP-198725414,CDM,C1776,HCPCS,0278,RC,,,both,,,37609.11,11282.73,"AETNA [10100]","Aetna HMO/PPO",,29899.24,79.5,,10981.53,8986.79,12413.38,12,4373.94,31967.74,"percent of total billed charges",
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 11MM X 14MM",SUP-4W7411,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"PHCS [10601]",PHCS,,4830,70,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DILATOR VASCULAR 5FR L17CM GUIDEWIRE 0.035IN WITH LUER HUB F",SUP-504405X,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.26,26.18,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SIDE RAIL CLAMP 1.25IN MARKED",SUP-50235-001ES,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH C315J02",SUP-C315J02,CDM,C1887,HCPCS,0272,RC,,,both,,,2175.00,652.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR ENDOWRIST DA VINCI S/SI GRAPTOR GRASP ENDOSCOPIC",SUP-420318,CDM,S27000186,LOCAL,0270,RC,,,both,,,1890.00,567,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cult Yersinia",PX-306000009,CDM,87046,CPT,0306,RC,,,both,,,294.00,88.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,33.53,,,,,,,0.01,249.9,"fee schedule",
"SNAP(R) DRESSING KIT WITH GAUZE - 10 KIT CASE",SUP-SKTA15X15,CDM,S27200284,LOCAL,0272,RC,,,both,,,384.98,115.49,"KAISER [10500]",Kaiser,,257.94,67,,,,,0,44.77,327.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Proc Cv Unlisted",PX-480000065,CDM,93799,CPT,0481,RC,,,both,,,8520.00,2556,"NOVANET [10819]",Novanet,,6390,75,,,,,0,990.88,7242,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION WATER 1000ML PLASTIC POUR BOTTLE STERILE",SUP-2F7114,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY REFSTAR PLUS QWIKPATCH",SUP-XRPP8Y,CDM,S27000186,LOCAL,0270,RC,,,both,,,3142.50,942.75,"UHC [10700]","United Healthcare",,1989.2,63.3,,,,,0,365.47,2671.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 12MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-1517-10-412,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"BLUE CROSS [10001]","Blue Cross PPO",,5799.09,39.2,,3949.44,3949.44,3949.44,"1 through 10",1720.5,12574.56,"percent of total billed charges",
"LARYNSCP VIDEO SMALL STYLET SURESIGHT",SUP-321900010,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.00,26.1,"FIRST HEALTH [10303]","First Health",,69.6,80,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1-2 16MM KNEE LEFT UHMWPE PCL SUBSTITUTING",SUP-2141-1-1216,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross HMO",,1396.5,39.2,,5311.50,4717.44,5388.59,31,414.32,3028.13,"percent of total billed charges",
"STENT MARDIS 20CM 7FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251400,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,352.3,28.62,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE AXOGUARD HA+ STERILE LATEX FREE",SUP-AGHA36,CDM,C1763,HCPCS,0278,RC,,,both,,,24242.40,7272.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2819.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2819.39,20606.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +18 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030180,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CIGNA [10200]","Cigna Open Access",,668.29,56.9,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 8 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022218,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"FIRST HEALTH [10303]","First Health",,13297.68,80,,,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBOHAWK MEC 135CM 5.9CM 2-4MM ATHERECTOMY CALCIUM",SUP-THS-SX-C,CDM,C1714,HCPCS,0272,RC,,,both,,,20128.50,6038.55,"MULTIPLAN [10600]",Multiplan,,17109.23,85,,,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 0 CT-2 18IN CONTROL RELEASE BRAID 8",SUP-C027D,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.49,30.75,"KAISER [10500]",Kaiser,,68.67,67,,,,,0,11.92,87.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 48MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.448TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"CIGNA [10200]",Cigna,,1374.65,68,,1831.33,1831.33,1831.33,16,235.11,1718.32,"percent of total billed charges",
"HEAD FEMORAL +6MM 11/13 TAPER 44MM HIP M SPECIFICATION METAL",SUP-136564500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"NOVANET [10819]",Novanet,,8308.46,75,,,,,0,1288.37,9416.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 12 G-H KNEE RIGHT TIBIA FIX",SUP-42522101013,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AETNA [10100]","Aetna HMO/PPO",,8567.25,79.5,,10981.53,8986.79,12413.38,12,1253.3,9159.96,"percent of total billed charges",
"BIT DRILL 195MM 4.5MM STAINLESS STEEL QUICK COUPLING",SUP-310.48,CDM,S27000186,LOCAL,0270,RC,,,both,,,814.21,244.26,"AETNA [10100]","Aetna HMO/PPO",,647.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.69,692.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL 3.3MM ARTHROWAND COVAC 2O 20D HOOK",SUP-AC434001,CDM,S27200284,LOCAL,0272,RC,,,both,,,3692.25,1107.67,"CIGNA [10200]","Cigna Open Access",,2100.89,56.9,,,,,0,429.41,3138.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 2 X 2 COMPLEX FRAMING COIL",SUP-10CFR-02002,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1389.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 6MMX19MM 7FR 80CMCATH HEPARIN",SUP-BXB061901A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALIF SPACER, ANTERIOR: 9MM (H) X 22-24MM (L) X 27-32MM (W):",SUP-10609,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CIGNA [10200]",Cigna,,12600,40,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VICTORY 18 300 CM 12G 1-PACK",SUP-H74939472300120,CDM,C1769,HCPCS,0272,RC,,,both,,,2077.50,623.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1412.7,68,,,,,0,241.61,1765.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 45MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840005045,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 390-420ML STYLE 68MP SMOOTH ANTERIOR DIAPH VALVE",SUP-68-390,CDM,C1789,HCPCS,0278,RC,,,both,,,2250.00,675,"BLUE CROSS [10001]","Blue Cross HMO",,882,39.2,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ILLMNTR OPHTHALMIC 25GA CONSTELLATION EDGEPLUS 106D RADIO",SUP-8065751577,CDM,S27200284,LOCAL,0272,RC,,,both,,,1079.08,323.72,"CIGNA [10200]","Cigna Local Plus",,577.31,53.5,,,,,0,125.5,917.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X20 135CM SL",SUP-48006002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 120MM 3MM BALLOON DILATATION STERILE LATEX",SUP-583012022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE WHISPER MS VASCULAR J 300CM 3CM .014IN",SUP-1005359HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OPTIFLOW JUNIOR 2 VENTILATOR TRANSITION KIT - S",SUP-OJR412VT,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 20MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATH 5FR 12CM CENTRAL VENOUS SPECTRUM 3 LUMEN CURVE NDL",SUP-G44015,CDM,C1751,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLING PATIENT FLITES MEDIUM DISPOSABLE",SUP-MFA1000M-M,CDM,S27000186,LOCAL,0270,RC,,,both,,,268.66,80.6,"PHCS [10601]",PHCS,,188.06,70,,,,,0,31.25,228.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E FEMUR PATELLA TIBIA INSRT",SUP-98000200118,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"KAISER [10500]",Kaiser,,16461.9,67,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL L HOOK LATEX 33CM 5MM DAVOL",SUP-5600160,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,40.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.46,288.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC",067,MS-DRG,,,,,,,inpatient,,,51686.11,15505.83,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,9748.17,,"Case rate ($9,110.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,459.66, add-ons for qualifying new technology services are included. If operating cost exceeds $41,499.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,021.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,470.84. The transfer operating threshold is the transfer adjustment factor * $8,459.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $639.59. The transfer capital threshold is the transfer adjustment factor * $639.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,36627.91,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO LARGE STYLET SURESIGHT",SUP-321900030,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.00,26.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,59.16,68,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR FREEHOLD DUO HEXAGON LOW PROFILE FULL ADJUSTABLE HOOK",SUP-FRE-D-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,1174.50,352.35,"CIGNA [10200]","Cigna Open Access",,668.29,56.9,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE FLOPPY II EXTRA SPORT VASCULAR STRAIGHT 300",SUP-22359M-901,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 87.5MM 2.3MM STAINLESS STEEL STERILE",SUP-180014000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 32MM DARCO FULL THREAD HEAD",SUP-777453202,CDM,C1713,HCPCS,0278,RC,,,both,,,1740.00,522,"FIRST HEALTH [10303]","First Health",,1392,80,,,,,0,202.36,1479,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc De Stnt Sngl Maj Cor Arty",PX-481000076,CDM,C9600,HCPCS,0481,RC,,,both,,,31274.02,9382.21,"PHCS [10601]",PHCS,,21891.81,70,,,,,0,3637.17,26582.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 3CM 75CM 8-9-10MM PULMONARY BALLOON",SUP-M00550330,CDM,C1726,HCPCS,0272,RC,,,both,,,2278.65,683.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,936.53,41.1,,,,,0,265.01,1936.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +17.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-SY60WF.175,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TRIA 30CM 6FR URETERAL SOFT",SUP-M0061903250,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC",345,MS-DRG,,,,,,,inpatient,,,56562.03,16968.61,"AETNA [10100]","Aetna HMO/PPO",,28310.93,,"Fee schedule rate ($28,310.93). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,43931.22,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"UROLIFT 2 IMPLANT CARTRIDGE HANDLE BOX",SUP-UL2-C,CDM,L8699,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]","Cigna Local Plus",,3876.08,53.5,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERCI 95CM 8FR 5.9FR .038IN GUIDING SILICONE BALLOON",SUP-90073,CDM,C1887,HCPCS,0272,RC,,,both,,,6037.50,1811.25,"KAISER [10500]",Kaiser,,4045.13,67,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 30.5",SUP-DIB00U0305,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.0MM PHALANX LNTRAMEDULLARY NAIL 3MM X 37.5MM TI",SUP-IHFN-PHX-30037,CDM,C1713,HCPCS,0278,RC,,,both,,,8052.30,2415.69,"CIGNA [10200]",Cigna,,5475.56,68,,1831.33,1831.33,1831.33,16,936.48,6844.46,"percent of total billed charges",
"CATH ADVANCE 35LP 135CM 8CM 7FR 12MM .035IN BALLOON",SUP-G52300,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"KAISER [10500]",Kaiser,,643.05,67,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 79MM 12.2MM 7.6MM CUFFLESS NONFENESTRATE DISPOSABLE",SUP-8DCFS,CDM,S27200284,LOCAL,0272,RC,,,both,,,308.24,92.47,"FIRST HEALTH [10303]","First Health",,246.59,80,,,,,0,35.85,262,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST 59MM 80CM 9MM ENDOVASCULAR STAINLESS STEEL PTFE",SUP-48959,CDM,C1874,HCPCS,0278,RC,,,both,,,18881.10,5664.33,"UHC [10700]","United Healthcare",,11951.74,63.3,,,,,0,2195.87,16048.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPLR ANASTOMOSIS 3MM FLOW RING PIN ULTRASONIC DOPPLER 20MHZ",SUP-GEM2754-FC,CDM,S27200284,LOCAL,0272,RC,,,both,,,7569.30,2270.79,"MULTIPLAN [10600]",Multiplan,,6433.91,85,,,,,0,880.31,6433.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.6CM MEMORYGEL COHESIVE I P4.5CM MODERATE PLUS",SUP-RSZ-5501S,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"NOVANET [10819]",Novanet,,115.67,75,,,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 545CC 12.5CM 6.1CM PROJECTION HIGH PROFILE SM",SUP-SHPB545,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,903.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLUX SPARC 10CC",SUP-IFLX-CM-10,CDM,S27800098,LOCAL,0278,RC,,,both,,,22995.00,6898.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6581.17,28.62,,,,,0,2674.32,19545.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR HSII CURVE GUIDING NYLON CORONARY",SUP-LA6HSII,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HUMERAL CUP - 40MM DIA X 4MM THK",SUP-5570-4004,CDM,C1776,HCPCS,0278,RC,,,both,,,7980.00,2394,"NOVANET [10819]",Novanet,,5985,75,,,,,0,928.07,6783,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS 75CM 2CM 8FR 16MM LARGE DIAMETER BALLOON",SUP-AT75162,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"KAISER [10500]",Kaiser,,1381.88,67,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC No Pt Prsnt Train Add 15 (Gp)",PX-420000191,CDM,G0542,HCPCS,0420,RC,,,both,,,37.00,11.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.04,37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL ACUTRAK REGULAR CANNULATED TAPERED STERILE",SUP-AT-7032,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 LEFT MEDIAL RIGHT LATERAL PARTIAL KNEE",SUP-5610-F-301,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"PHCS [10601]",PHCS,,7001.47,70,,,,,0,1163.24,8501.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 12MM 3MM BALLOON DILATATION PEBAX",SUP-1400300-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE LADDER 2.0",SUP-PRT-LDR-020,CDM,C1713,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3293.78,45.9,,,,,0,834.57,6099.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 15FR JACKSON-PRATT SILICONE END PERFORATE",SUP-SU130-0323,CDM,S27200284,LOCAL,0272,RC,,,both,,,118.67,35.6,"NOVANET [10819]",Novanet,,89,75,,,,,0,13.8,100.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UROLIFT 2 IMPLANT CARTRIDGE HANDLE BOX",SUP-UL2-C,CDM,L8699,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"FIRST HEALTH [10303]","First Health",,5796,80,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X40 135CM SL",SUP-48005004R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION",RX-3037,CDM,J3010,HCPCS,0636,RC,63323-0806-14,NDC,both,20,ML,102.20,30.66,"FIRST HEALTH [10303]","First Health",,81.76,80,,,,,0,12.11,86.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM 1 HOLE BONE FEMUR NECK STERILE",SUP-04.168.000S,CDM,C1713,HCPCS,0278,RC,,,both,,,4532.47,1359.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3082.08,68,,,,,0,527.13,3852.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 18LP 80CM 10CM 4FR 6MM .018IN BALLOON",SUP-G50252,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 120MM 130CM 6MM LONG VASCULAR NITINOL",SUP-SC6120LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2567.21,28.62,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT TRACTION SMALL LEG BUCK FOAM NONSTERILE LATEX FREE",SUP-A155005,CDM,S27000186,LOCAL,0270,RC,,,both,,,99.09,29.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,40.73,41.1,,,,,0,11.52,84.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 20MM VARIAX T8 FULL THREAD NONSTERILE",SUP-656120,CDM,C1713,HCPCS,0278,RC,,,both,,,779.22,233.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,92.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",90.62,662.34,"percent of total billed charges",
"STY LD 52CM .013IN ATR J SFT",SUP-6051,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IPG W3DR01 AZURE S DR MRI",SUP-W3DR01,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"CIGNA [10200]","Cigna Local Plus",,13104,31.5,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE STD OVAL 5.5CM 2.5CM 7FR ACUSNARE 1 PIECE ENDOSCOPIC",SUP-G22629,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.43,49.33,"MULTIPLAN [10600]",Multiplan,,139.77,85,,,,,0,19.12,139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 10.8MM SHILEY CUFF DISPOSABLE INNER CANN BEVEL",SUP-6CN75A,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.10,109.83,"KAISER [10500]",Kaiser,,245.29,67,,,,,0,42.58,311.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF CONDUCTR 110CM 55-75MM 7FR 2-5-2MM SPACING ABLATION",SUP-FND-019-06,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CIGNA [10200]",Cigna,,925.34,68,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM ARTHREX TITANIUM T15 LARGE FULL THREAD",SUP-AR-8750-50H,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross PPO",,1396.5,39.2,,957.42,570.23,957.42,28,414.32,3028.13,"percent of total billed charges",
"YOKE TIBIAL OSS KNEE REINFORCE",SUP-150493,CDM,C1776,HCPCS,0278,RC,,,both,,,8034.36,2410.31,"PHCS [10601]",PHCS,,5624.05,70,,,,,0,934.4,6829.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE EXT 2IN MALE FEMALE LUER LOCK CNCT SILICONE",SUP-3223,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.40,22.62,"MULTIPLAN [10600]",Multiplan,,64.09,85,,,,,0,8.77,64.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL TISSUE ALLOGRAFT BLOCK 15-18MM",SUP-800124,CDM,S27800098,LOCAL,0278,RC,,,both,,,5501.37,1650.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3740.93,68,,,,,0,639.81,4676.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 12MM REVISION MODULAR ARCOS STS TITANIUM",SUP-11-300812,CDM,C1776,HCPCS,0278,RC,,,both,,,20372.94,6111.88,"KAISER [10500]",Kaiser,,13649.87,67,,,,,0,2369.37,17317,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0233,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]","Cigna Local Plus",,507.02,53.5,,3978.14,359.25,3978.14,24,110.22,805.55,"percent of total billed charges",
"COIL EMBOLIZATION 5CM 2.5MM PRESTIGE PLUS HELICAL ULTRA",SUP-PRES0255CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 645CC",SUP-SMPX645,CDM,C1789,HCPCS,0278,RC,,,both,,,6382.50,1914.75,"CIGNA [10200]","Cigna Open Access",,3631.64,56.9,,5166.00,5166.00,5166.00,"1 through 10",742.28,5425.13,"percent of total billed charges",
"INSRT TIBIAL 4 22MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-422,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]","Cigna Open Access",,6493.77,56.9,,5302.19,4377.88,6578.61,27,1327.29,9700.71,"percent of total billed charges",
"EXT STEM 30MM 15MM PFC 46IN KNEE TIBIA CEMENT",SUP-866403,CDM,C1776,HCPCS,0278,RC,,,both,,,5092.20,1527.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3462.7,68,,,,,0,592.22,4328.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL WEIL-BLAKESLEY 2 5MM STRAIGHT 7.5IN NASAL",SUP-63-2011,CDM,S27200284,LOCAL,0272,RC,,,both,,,1801.88,540.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 90X19MM M-CLASS HALL THK1.27MM STAINLESS STEEL",SUP-T190-127-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,553.72,166.12,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) CATHETER TRAPLINER 150CM 13CM 6.5FR INTERVENTIONAL HY",SUP-5568,CDM,C1887,HCPCS,0272,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 216MM 2.5MM AXSOS SHORT NONLOCK NONSTERILE LATEX",SUP-705025,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT 250CM 7.5FR BILIARY FLEXIMA TEFLON NASAL TUBE",SUP-M00540130,CDM,C2617,HCPCS,0272,RC,,,both,,,859.33,257.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL 14CM MR8 4MM BALL DISSECTING STERILE DISPOSABLE",SUP-MR8-14BA40,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.19,388.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cann Aortic Ez Glide Std 24f",PX-E27200376,CDM,E27200376,LOCAL,0272,RC,,,both,,,194.70,58.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GLIDECATH XP 65CM 15CM 5FR COBRA 2 CURVE ANGIOGRAPHIC",SUP-RF*ZB5510GM,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X22X14MM COROENT XL WIDE PEEK LUMBAR",SUP-6914255,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS [10001]","Blue Cross PPO",,9313.92,39.2,,9172.16,8555.87,9172.16,"1 through 10",2763.29,20196,"percent of total billed charges",
"LENS IOL 10 D +26 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.260,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 112MM STAINLESS STEEL 2.7/3.5MM SCR 6 HOLE LCP",SUP-02.112.143S,CDM,C1713,HCPCS,0278,RC,,,both,,,3617.25,1085.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1035.26,28.62,,,,,0,420.69,3074.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 90MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.413,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"FIRST HEALTH [10303]","First Health",,1107.3,80,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 40MX19.5MMX.4MM STERILE",SUP-KM-3231,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"CIGNA [10200]","Cigna Open Access",,35.15,56.9,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 20MM 4.5FR SEGURA HEMISPHERE",SUP-M0063801180,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1006.09,68,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTITORQUE 110CM 6FR 4MM RADIALTIGER CURVE ANGIOGRAPHIC",SUP-40-6013,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"CIGNA [10200]","Cigna Local Plus",,167.56,53.5,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS SURGICAL DISPOSABLE LONG SMOOTH",SUP-NF07,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"FIRST HEALTH [10303]","First Health",,160.08,80,,,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RETROMAX PLUS 26CM 7-14FR THIN WALL PIGTAIL CURVE",SUP-M0061451490,CDM,C2617,HCPCS,0278,RC,,,both,,,1557.47,467.24,"NOVANET [10819]",Novanet,,1168.1,75,,,,,0,181.13,1323.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT FLAT FIBERTAK FIBERWIRE ROTATOR CUFF TAPE BRAID",SUP-AR-3632,CDM,C1713,HCPCS,0278,RC,,,both,,,2913.75,874.12,"PHCS [10601]",PHCS,,2039.63,70,,,,,0,338.87,2476.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 100MM 80CM 14MM BILIARY VENOUS DELIVERY",SUP-G57445,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"CIGNA [10200]","Cigna Local Plus",,4564.35,31.5,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colon Stoma W Eus Fna/Bx",PX-750000167,CDM,44407,CPT,0750,RC,,,both,,,4281.00,1284.3,"UHC [10700]","United Healthcare",,3833,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,497.88,4281,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 2-0 GS-21 .5 CIRCLE 9IN TAPER POINT",SUP-VLOCL0345,CDM,S27200284,LOCAL,0272,RC,,,both,,,405.94,121.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,186.33,45.9,,,,,0,47.21,345.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 7MM GRAFTECH LARGE LORDOTIC CORTICAL",SUP-4421407,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 120CM 135CM 25-30MM 10FR COLONIC NITINOL",SUP-M00565090,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX10MM VANGUARD ARCOM KNEE POSTERIOR STABILIZE",SUP-183640,CDM,C1776,HCPCS,0278,RC,,,both,,,8259.30,2477.79,"MULTIPLAN [10600]",Multiplan,,7020.41,85,,,,,0,960.56,7020.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 38.5MM 50.5MM TENDYNE 3SQ CM 39M CONTOUR 156MM","SUP-TENDYNE 39M SYSTEM",CDM,S27800098,LOCAL,0278,RC,,,both,,,319200.00,95760,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,37122.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37122.96,271320,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 7X3CM OMEGA3 WOUND FENESTRATE",SUP-50200F02B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,9170.10,2751.03,"FIRST HEALTH [10303]","First Health",,7336.08,80,,,,,0,180.89,7794.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 126MM 2MM STAINLESS STEEL QUICK CONNECT 100MM",SUP-KM166-310-21,CDM,S27000186,LOCAL,0270,RC,,,both,,,198.53,59.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,23.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.09,168.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 55MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.123,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,101.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",99.7,728.71,"percent of total billed charges",
"MINERAL OIL ENEMA",RX-5087,CDM,,,0637,RC,00132-0301-40,NDC,both,133,ML,13.39,4.02,"FIRST HEALTH [10303]","First Health",,10.71,80,,,,,0,1.56,11.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 220MM 1.6MM TROCAR TIP STERILE",SUP-03.333.003.01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,625.48,187.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,425.33,68,,,,,0,72.74,531.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOMATRIX C DEMINERALIZED BONE MATRIX CANCELLOUS",SUP-86XC1000,CDM,C1713,HCPCS,0278,RC,,,both,,,9239.10,2771.73,"CIGNA [10200]",Cigna,,6282.59,68,,1831.33,1831.33,1831.33,16,1074.51,7853.24,"percent of total billed charges",
"(EVAL) CATHETER TURNPIKE LP 135CM 2.2-2.9FR 1.6FR INTERVENTI",SUP-5638,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER GD 90CM 6FR RWY AL2 CRV",SUP-H74938969200,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"MULTIPLAN [10600]",Multiplan,,311.47,85,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ELUVIA 80MM 130CM 6MM VASCULAR DRUG ELUTE DELIVERY",SUP-H74939294600810,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 60MM 80CM 8MM VASCULAR PERIPHERAL SELF",SUP-1012530-60,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 13MM GEMINUS TITANIUM DISTAL CORTEX VOLAR",SUP-COLS-35130-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,631.80,189.54,"MULTIPLAN [10600]",Multiplan,,537.03,85,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 18MM 5MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG50018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,751.28,28.62,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYPROPYLENE 10X6IN PERMANENT GRID 1 SMOOTH",SUP-F10246-0610P,CDM,C1781,HCPCS,0278,RC,,,both,,,6483.24,1944.97,"CIGNA [10200]","Cigna Local Plus",,3468.53,53.5,,3096.73,1.00,3096.73,"1 through 10",754,5510.75,"percent of total billed charges",
"HC Pack Vavd Ecmo Perfusion",PX-E27200269,CDM,E27200269,LOCAL,0272,RC,,,both,,,190.32,57.1,"CIGNA [10200]",Cigna,,129.42,68,,,,,0,22.13,161.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT 137CM 6MM 2.5MM RECTANGLE HELIX TAPER",SUP-2200-2506,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"UHC [10700]","United Healthcare",,3712.55,63.3,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 5MM4CM 190",SUP-R51005004L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"UHC [10700]","United Healthcare",,1248.12,63.3,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANEXAMIC ACID 650 MG TABLET",RX-104576,CDM,,,0637,RC,60687-0750-11,NDC,both,1,UN,25.19,7.56,"NOVANET [10819]",Novanet,,18.89,75,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 15MM 3MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG30015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"MULTIPLAN [10600]",Multiplan,,2295,85,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL 17X5MM MOBI-C 13MM CERVICAL TITANIUM COCRMO UHMWPE","SUP-MB 3375",CDM,S27800098,LOCAL,0278,RC,,,both,,,33075.00,9922.5,"BLUE CROSS [10001]","Blue Cross HMO",,12965.4,39.2,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pinworm Prep",PX-306000077,CDM,87172,CPT,0306,RC,,,both,,,123.00,36.9,"AETNA [10100]","Aetna HMO/PPO",,97.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,104.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Coronary Artery 14f",PX-E27200384,CDM,E27200384,LOCAL,0272,RC,,,both,,,140.80,42.24,"FIRST HEALTH [10303]","First Health",,112.64,80,,,,,0,16.38,119.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DRNG 29CM 9FR 18GA STAINLESS STEEL VINYL PTFE THORACIC 1",SUP-G03301,CDM,C1729,HCPCS,0272,RC,,,both,,,1931.25,579.37,"UHC [10700]","United Healthcare",,1222.48,63.3,,,,,0,224.6,1641.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APEX 143CM 8MM 2.5MM BALLOON DILATATION OPTILEAP",SUP-H7493895908250,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 30D .35IN 24FR STERILE",SUP-A22205C,CDM,S27200284,LOCAL,0272,RC,,,both,,,710.34,213.1,"KAISER [10500]",Kaiser,,475.93,67,,,,,0,82.61,603.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +16 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-AR40E00160,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"FIRST HEALTH [10303]","First Health",,745.2,80,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) QUALIBREATH 5XL  SIZE",SUP-QB-5XL,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,380.71,45.9,,,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Nose to Rectum Child",PX-320000165,CDM,76010,CPT,0320,RC,,,both,,,381.65,114.49,"CIGNA [10200]","Cigna Open Access",,46.09,,,,,,,32.95,324.4,"fee schedule",
"SCR BONE 3.5MM 10MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.101,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,101.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",99.7,728.71,"percent of total billed charges",
"STEM HUMERAL 123MM 10MM PRESS FIT REUNION SHOULDER STERILE",SUP-5569-P-2010,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 8FR PIGTAIL CURVE DRNG FLEXIMA BILIARY REGULAR",SUP-M001271560,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 9MM X 20CM",SUP-M0035479200,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]",Cigna,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 5MM 6FR ENDOPROSTHESIS HEPARIN",SUP-VBJ051002,CDM,C1874,HCPCS,0278,RC,,,both,,,21218.40,6365.52,"FIRST HEALTH [10303]","First Health",,16974.72,80,,,,,0,2467.7,18035.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOGRAPHIC RADIALTIGER CURVE 6FR 4.5MM 100CM CORONARY",SUP-40-6012,CDM,C1713,HCPCS,0278,RC,,,both,,,313.20,93.96,"BLUE CROSS [10001]","Blue Cross PPO",,122.77,39.2,,957.42,570.23,957.42,28,36.43,266.22,"percent of total billed charges",
"OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC",320,MS-DRG,,,,,,,inpatient,,,93056.58,27916.97,"BLUE CROSS [10001]","Blue Cross PPO",,59379.76,,,,,,,7561,70225.14,"case rate",
"SCR BONE 2MM 10MM LCP",SUP-201.360.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,49.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,48.16,352,"percent of total billed charges",
"DEVICE V-LOC 180 0 GS-21 .5 CIRCLE 24IN 37MM CLSR TAPER",SUP-VLOCL0336,CDM,S27200284,LOCAL,0272,RC,,,both,,,262.83,78.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,120.64,45.9,,,,,0,30.57,223.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER PACING LEAD ACUITY 10.5FR LONG",SUP-667474-001,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006175272170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS [10001]","Blue Cross PPO",,496.03,39.2,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTICUL/EZE FEMORAL HEAD 40 MM +1.5",SUP-473440015,CDM,C1776,HCPCS,0278,RC,,,both,,,17961.30,5388.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2128.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2088.9,15267.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TACTIFLEX ABLATION CATHETER, SENSOR ENABLED",SUP-A-TFSE-F-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO 425MM 2MM SWISS LITHOCLAST PNEUMATIC LATEX FREE",SUP-M0068407370,CDM,S27200284,LOCAL,0272,RC,,,both,,,1680.60,504.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,199.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,195.45,1428.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPIDCROSS 170CM 40MM 2.5MM .014IN BALLOON DILATATION",SUP-A14BX025040170,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"FIRST HEALTH [10303]","First Health",,1108.08,80,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X21MM ENDOSKELETON TAS 7D 12MM STD TITANIUM",SUP-2307-0112,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"MULTIPLAN [10600]",Multiplan,,24097.5,85,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PULMONARY EMBOLISM WITHOUT MCC",176,MS-DRG,,,,,,,inpatient,,,31732.94,9519.88,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,5143.27,,"Case rate ($4,993.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,636.77, add-ons for qualifying new technology services are included. If operating cost exceeds $37,676.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,732.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,642.90. The transfer operating threshold is the transfer adjustment factor * $4,636.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.56. The transfer capital threshold is the transfer adjustment factor * $350.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4993.47,20075.9,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE PSI KIT (HUMERAL AND GLENOID)",SUP-1235-7152-003,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3167.1,45.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM COCR SPINE MULTIAXIAL CANNULATED 5.5MM",SUP-55840015540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"SOL DIALYSATE 4 MEQ/L POTASSIUM 1.2 MEQ/L MAGNESIUM 140",SUP-110411,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"CIGNA [10200]","Cigna Local Plus",,111.71,53.5,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 20MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"NOVANET [10819]",Novanet,,1196.78,75,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHOCKWAVE M5 60MM 110CM 3.5MM 7MM BALLOON DILATATION",SUP-M5PIVL3560,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2575.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2527.78,18474.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 8MM SWIVELOCK TENODESIS SHOULDER BICEPS CLOSED",SUP-AR-1662BCC-8,CDM,C1713,HCPCS,0272,RC,,,both,,,3425.63,1027.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1407.93,41.1,,,,,0,1407.93,2168.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE VASCULAR STRAIGHT 190CM 3CM .014IN",SUP-28000-HC,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH PEEL-AWAY STERILE DISPOSABLE ACCEPTS .038IN",SUP-G06496,CDM,C1892,HCPCS,0272,RC,,,both,,,382.71,114.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,157.29,41.1,,,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 23MM 145CM 3.5MM CORONARY STENT",SUP-1145350-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross HMO",,2288.5,39.2,,9776.84,9776.84,9776.84,"1 through 10",678.96,4962.3,"percent of total billed charges",
"SYSTEM CHOLANGIOGRAM RAPID EXCHANGE LOCK DEVICE BIOPSY CAP",SUP-M00545281,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.69,32.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.41,90.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JEIL POWER DRIVER, SINGLE USE",SUP-111-ED-050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,169.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA 5D D KNEE LEFT CEMENT STEM TIVANIUM",SUP-42532006701,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"KAISER [10500]",Kaiser,,7325.61,67,,,,,0,1271.59,9293.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BILIARY 10FR 10CM GENTLE CURVE TAPERED TIP SOFT",SUP-G21807,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA [10200]","Cigna Local Plus",,338.01,,,,,,,73.48,537.03,"percent of total billed charges",
"STENT ONYX FRONTIER 26MM 2.75MM CORONARY RAPID EXCHANGE",SUP-ONYXNG27526UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"AETNA [10100]","Aetna HMO/PPO",,2086.88,79.5,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR GUIDE 27MM PERSONA KNEE STAINLESS STEEL",SUP-579104300,CDM,C1713,HCPCS,0278,RC,,,both,,,763.83,229.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,90.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,88.83,649.26,"percent of total billed charges",
"RTRCTR 13.5IN MURPHY-LANE SURGICAL",SUP-FK193R,CDM,S27200284,LOCAL,0272,RC,,,both,,,734.67,220.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,337.21,45.9,,,,,0,85.44,624.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 62MM 32MM XLPE HIP",SUP-71337662,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4572.89,41.1,,6417.48,6417.48,6417.48,"1 through 10",1293.98,9457.31,"percent of total billed charges",
"IMPL BREAST 14.4-14.8CM P5.6-6.5CM MODERATE PLUS PROFILE",SUP-3502650,CDM,C1789,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 CORKSCREW FIBERWIRE ROTATOR CUFF TITANIUM",SUP-AR-1928SNF,CDM,C1713,HCPCS,0278,RC,,,both,,,1198.50,359.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,343.01,28.62,,,,,0,139.39,1018.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 100MM 80CM 16MM BILIARY VENOUS DELIVERY",SUP-G57448,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"CIGNA [10200]",Cigna,,5796,40,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 550ML STYLE 9300 TEXTURED SELF SEALING PATCH",SUP-3549314,CDM,C1789,HCPCS,0278,RC,,,both,,,6720.00,2016,"NOVANET [10819]",Novanet,,5040,75,,,,,0,781.54,5712,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT 6 KNEE CEMENT ROTATE PLATFORM",SUP-129431160,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Critical Care 30-74min",PX-450000321,CDM,99291,CPT,0450,RC,,,both,,,4692.00,1407.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,559.4,,,,,,,559.4,3988.2,"case rate",
"UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION",RX-169057,CDM,,,0637,RC,00173-0873-10,NDC,both,1,UN,89.09,26.73,"NOVANET [10819]",Novanet,,66.82,75,,,,,0,10.36,75.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X40 135CM SL",SUP-48005004R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"MULTIPLAN [10600]",Multiplan,,730.16,85,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ALEXIS 12X100MM EXTRACTION 6500ML BALLOON BLUNT TIP",SUP-GTK17,CDM,S27200284,LOCAL,0272,RC,,,both,,,2812.50,843.75,"KAISER [10500]",Kaiser,,1884.38,67,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 20MM 6FR 3.5MM 4FR BALLOON",SUP-39031-35201,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 5.5MM CD HORIZON LEGACY TITANIUM PREBENT",SUP-8690060,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2024.19,45.9,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +14.5 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z900200145,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,694.01,68,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 4.8FR L12CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902060,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,,,,,,,189.34,1383.8,"percent of total billed charges",
"SYSTEM OPTIFIX FIXATION POLY-DL-LACTIDE 15 ABSORBABLE SMOOTH",SUP-0113127,CDM,S27200284,LOCAL,0272,RC,,,both,,,524.88,157.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.04,446.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? X CABLE PLATE KIT",SUP-94-1200-08,CDM,C1713,HCPCS,0278,RC,,,both,,,11488.50,3446.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4721.77,41.1,,,,,0,1336.11,9765.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 80MM 3.2MM ORTHOSOFT STRAIGHT CAS",SUP-20800000011,CDM,S27200284,LOCAL,0272,RC,,,both,,,963.90,289.17,"MULTIPLAN [10600]",Multiplan,,819.32,85,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM DVR TITANIUM RADIUS CORTICAL DISTAL",SUP-CS10,CDM,C1713,HCPCS,0278,RC,,,both,,,777.60,233.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,92.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,90.43,660.96,"percent of total billed charges",
"HC Mra Lwr Ext WO Cntrst",PX-610000038,CDM,73725,CPT,0610,RC,,,both,,,4149.00,1244.7,"MULTIPLAN [10600]",Multiplan,,3526.65,85,,,,,0,482.53,3526.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165CM 10.5-12MM OTSC 6MM NITINOL GC",SUP-100.27,CDM,C1760,HCPCS,0278,RC,,,both,,,4547.10,1364.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,528.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,528.83,3865.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PULMONARY AERO OTW FULLY COVERED TRACHEOBRONCHIAL STENT 18MM",SUP-90129-203,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"KAISER [10500]",Kaiser,,11557.5,67,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chest Closure Icu Bedside",PX-361000300,CDM,361000300,LOCAL,0361,RC,,,both,,,8167.55,2450.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,967.85,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,949.89,6942.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Iliac W Pta Cmplx Ea Add",PX-361000698,CDM,37257,CPT,0361,RC,,,both,,,7309.72,2192.92,"MULTIPLAN [10600]",Multiplan,,6213.26,85,,,,,0,7.31,7309.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch Ebus Sampling 2< Node",PX-750000181,CDM,31652,CPT,0750,RC,,,both,,,6145.87,1843.76,"PHCS [10601]",PHCS,,4302.11,70,,,,,0,714.76,6145.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX 1S REINFORCED TISSUE MATRIX, LONG-TERM RESORBABLE REI",SUP-F10266-1020G,CDM,C1781,HCPCS,0278,RC,,,both,,,19731.60,5919.48,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5327.53,27,,,,,0,2294.79,16771.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath IV Peripheral Powerglide 20 G X 10 Cm",PX-E27200307,CDM,E27200307,LOCAL,0272,RC,,,both,,,573.10,171.93,"NOVANET [10819]",Novanet,,429.83,75,,,,,0,66.65,487.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIGHTED SIGMOIDOSCOPE KIT 1 LIGHTED SCOPE RECTO MAXI 1 BULB",SUP-ASDSK01,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.00,194.4,"CIGNA [10200]","Cigna Open Access",,368.71,56.9,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOLVAPTAN 30 MG TABLET",RX-97894,CDM,,,0637,RC,67877-0636-33,NDC,both,1,UN,2064.07,619.22,"UHC [10700]","United Healthcare",,1306.56,63.3,,,,,0,240.05,1754.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 28CM 3CM 5FR .035IN",SUP-M006192124190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"FIRST HEALTH [10303]","First Health",,1116.18,80,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NIPPER SURGICAL 1.5MM 5IN 75MM HOUSE-DIETERS MALLEUS",SUP-61-0158,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON UVA VIVITY TORIC AUTONOME",SUP-CCAET4,CDM,V2787,HCPCS,0276,RC,,,both,,,880.00,264,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,598.4,68,,,,,0,102.34,748,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 4-0 RB-1 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-U203H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 11.4MM 8MM SHILEY TAPERGUARD FLEXIBLE CUFF INNER",SUP-7CN80A,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.97,110.09,"CIGNA [10200]","Cigna Open Access",,208.81,56.9,,,,,0,42.68,311.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC INTERVERTEBRAL 18MM 6MM PRESTIGE LP CERVICAL SPINE",SUP-6972860,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 70MM 16MM DARCO FOOT ANKLE HEAD",SUP-777657062,CDM,C1713,HCPCS,0278,RC,,,both,,,2617.50,785.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1201.43,45.9,,,,,0,304.42,2224.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +29.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-PCB0000295,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH X-FORCE U30 10CM 6FR 6MM BALLOON DILATATION",SUP-998610,CDM,C1726,HCPCS,0272,RC,,,both,,,1854.00,556.2,"NOVANET [10819]",Novanet,,1390.5,75,,,,,0,215.62,1575.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 4MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-04004,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"CIGNA [10200]","Cigna Open Access",,5100,56.9,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 20MM 130CM 5MM VASCULAR SELF EXPAND RADIOPAQUE",SUP-H74939293050230,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"NOVANET [10819]",Novanet,,3622.5,75,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANAL AND STOMAL PROCEDURES WITH CC",348,MS-DRG,,,,,,,inpatient,,,56932.90,17079.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,20867.15,,,,,,,7561,38211.72,"case rate",
"HC Antiannexin V-Igg",PX-301000261,CDM,83520,CPT,0301,RC,,,both,,,373.00,111.9,"CIGNA [10200]",Cigna,,37.99,,,,,,,0.37,317.05,"fee schedule",
"CATH EXPO 100CM 6FR .056IN FEMORAL RIGHT 4 CURVE",SUP-H74908641022,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]",Cigna,,52.07,68,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 4MM 58MM NAIL-EX TITANIUM FULL THREAD HUMERAL TIB",SUP-04.005.448,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"MULTIPLAN [10600]",Multiplan,,983.18,85,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 137MM CEMENT ACCOLADE C 127D 4 46MM OFFSET HIP",SUP-6057-0435D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1911.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1911.88,13973.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 18MM ACUTRAK 2 TITANIUM MINI ORTHOPEDIC STERILE",SUP-AT2-M18-S,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"CIGNA [10200]","Cigna Open Access",,1813.69,56.9,,1144.80,304.56,2275.09,66,370.71,2709.38,"percent of total billed charges",
"LENS IOL +20 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.200,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION HEXAGON KIT",SUP-531-78-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 2.6MM 3MM SUTURETAK",SUP-AR-1938D,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.03,267.91,"NOVANET [10819]",Novanet,,669.77,75,,,,,0,103.86,759.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 26MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.826,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,115.17,45.9,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 8MM 23- D MEGA 49.7CM ROBOTIC SUTURECUT ENDOWRIST",SUP-420309,CDM,S27000186,LOCAL,0270,RC,,,both,,,1890.00,567,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,219.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.75MM 34MM TITANIUM PARTIAL THREAD SHOULDER",SUP-AR-7000-34,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 24CM 150CM 8FR .038IN 3CM BLADDER LOOP",SUP-M006155252170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,965.83,68,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 19MM 80CM 6MM 8MM 7FR .035IN",SUP-BXA061901A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 12CM 5FR 2.1FR POLARIS ULTRA NAUTILUS ZIPWIRE .038",SUP-M006192112170,CDM,C2617,HCPCS,0278,RC,,,both,,,1357.24,407.17,"FIRST HEALTH [10303]","First Health",,1085.79,80,,,,,0,157.85,1153.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION 10MM GRAFTBOLT TIBIA RECONSTRUCTION SCR",SUP-AR-5100-10,CDM,C1713,HCPCS,0278,RC,,,both,,,3110.63,933.19,"BLUE CROSS [10001]","Blue Cross HMO",,1219.37,39.2,,957.42,156.86,7483.26,51,361.77,2644.04,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS 30CM 3CM 7FR .038IN 2 PIGTAIL",SUP-M006192145010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]","Cigna Local Plus",,642.31,,,,,,,139.63,1020.49,"percent of total billed charges",
"BIT DRILL 3.7MM CANNULATED",SUP-CSS07237,CDM,S27200284,LOCAL,0272,RC,,,both,,,1506.60,451.98,"PHCS [10601]",PHCS,,1054.62,70,,,,,0,175.22,1280.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 10MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630510,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]","Cigna Local Plus",,4135.08,31.5,,5372.07,4581.20,7242.98,23,1526.7,11158.16,"percent of total billed charges",
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 12MMX8MMX6CM",SUP-TSB081206A,CDM,C1874,HCPCS,0278,RC,,,both,,,49140.00,14742,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5823.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5714.98,41769,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 28CM 8FR POLARIS ULTRA .035IN PERCUFLEX HYDROPLUS",SUP-M006192154090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,176.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 80MM 2MM .014IN BALLOON DILATATION",SUP-AB14W020080150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"NOVANET [10819]",Novanet,,1038.83,75,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 15CM 20GA ACCURIAN STRAIGHT SHARP 10MM",SUP-AC0013,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.91,41.1,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 42.5MM ATLANTIS VISION ELITE BONE SPINE",SUP-7200042,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1262.14,28.62,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 18FR SILICONE NATURAL RUBBER STD MIC",SUP-0200-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,451.93,41.1,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP BIOFOAM DYNASTY",SUP-DSBFGB48,CDM,C1776,HCPCS,0278,RC,,,both,,,18918.90,5675.67,"UHC [10700]","United Healthcare",,11975.66,63.3,,8601.07,8395.67,8601.07,"1 through 10",2200.27,16081.07,"percent of total billed charges",
"GWIRE VASCULAR 275X4.9X5CM .035IN STREAMLINE DEVICE DELIVERY",SUP-H74939407L0,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"UHC [10700]","United Healthcare",,0.01,63.3,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 80CM 5FR SOS OMNI 2 CURVE ANGIOGRAPHIC VISCERAL",SUP-H787107204055,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD LINER MP6 GRAY 34MM",SUP-932-34-250,CDM,C1776,HCPCS,0278,RC,,,both,,,12462.02,3738.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1476.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1449.33,10592.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 26CM 8FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552530,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,139.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 35MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75445035,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,3978.14,359.25,3978.14,24,441.36,3225.75,"percent of total billed charges",
"GRSP ENDOSCOPIC FLEXIBLE STERILE LATEX FREE DISPOSABLE",SUP-FG-253SX,CDM,S27200284,LOCAL,0272,RC,,,both,,,575.34,172.6,"MULTIPLAN [10600]",Multiplan,,489.04,85,,,,,0,66.91,489.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.195,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20GA 22GA 12CM 1.5IN .025IN GWIRE NDL SYR DRAPE","SUP-AK-04-150-E-S IS",CDM,S27200284,LOCAL,0272,RC,,,both,,,185.73,55.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,22.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.6,157.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE WHOLEY VASCULAR STRAIGHT 145CM .035IN PERIPHERAL",SUP-WWSS35145,CDM,C1769,HCPCS,0272,RC,,,both,,,510.30,153.09,"UHC [10700]","United Healthcare",,323.02,63.3,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 3 KNEE LEFT BICRUCIATE STABILIZE",SUP-74022223,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6648.84,40,,,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HYDRA JAGWIRE ENDOSCOPIC STRAIGHT 260CM .035IN",SUP-M00556021,CDM,C1769,HCPCS,0272,RC,,,both,,,1422.36,426.71,"MULTIPLAN [10600]",Multiplan,,1209.01,85,,,,,0,165.42,1209.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 30MM COCR SPINAL MULTIAXIAL CANNULATED",SUP-54840015530,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"KAISER [10500]",Kaiser,,6396.39,67,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg Crbral Death Eval",PX-740000013,CDM,95824,CPT,0740,RC,,,both,,,1503.45,451.03,"PHCS [10601]",PHCS,,1052.42,70,,,,,0,174.85,1503.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM MAXTORQUE SHORT THREAD ANKLE FOOT",SUP-MSD01055045S,CDM,C1713,HCPCS,0278,RC,,,both,,,1190.70,357.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,141.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",138.48,1012.1,"percent of total billed charges",
"SUT ACS 10-0 CU-5 12IN 2 ARM MONOFILAMENT BLACK",SUP-8065192101,CDM,S27200284,LOCAL,0272,RC,,,both,,,265.96,79.79,"MULTIPLAN [10600]",Multiplan,,226.07,85,,,,,0,30.93,226.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP GREEN SNAPLIGHT MACINTOSH 3 FIBER OPTIC ADULT",SUP-2203300,CDM,S27000186,LOCAL,0270,RC,,,both,,,268.40,80.52,"AETNA [10100]","Aetna HMO/PPO",,213.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.21,228.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP SENSOR SPO2 NEONATAL",SUP-M1133A,CDM,S27000186,LOCAL,0270,RC,,,both,,,93.02,27.91,"UHC [10700]","United Healthcare",,58.88,63.3,,,,,0,10.82,79.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X4MM VERTE-STACK CORNERSTONE PSR 11MM",SUP-6277441,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 2 6MM",SUP-TPS-030-062S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPEEDBRIDGE JUMPSTART FIXATION PEEK ACHILLES STERILE",SUP-AR-8928PJ-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,14453.78,4336.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1712.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1680.97,12285.71,"percent of total billed charges",
"CATH ADVANCE 80CM 6CM 10MM BALLOON DILATATION OTW LOW",SUP-G30929,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 18FR JEJUNAL TRANSGASTRIC FEEDING TUBE MIC",SUP-98436A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1649.78,494.93,"CIGNA [10200]","Cigna Open Access",,938.72,56.9,,,,,0,191.87,1402.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +9.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.095,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross PPO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET",RX-184099,CDM,,,0637,RC,00310-1110-01,NDC,both,1,UN,173.34,52,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,79.56,45.9,,,,,0,20.16,147.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC SHORT 17IN KNEE DUAL AXIS POLYCENTRIC HINGE",SUP-A402550,CDM,S27000186,LOCAL,0270,RC,,,both,,,551.37,165.41,"AETNA [10100]","Aetna HMO/PPO",,438.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.12,468.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 46MM 28MM XLPE HIP",SUP-71337546,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4572.89,41.1,,6417.48,6417.48,6417.48,"1 through 10",1293.98,9457.31,"percent of total billed charges",
"CMPNT PATELLAR 7.5MM 35MM RESURFACING GENESIS II",SUP-71932637,CDM,C1776,HCPCS,0278,RC,,,both,,,6882.75,2064.82,"NOVANET [10819]",Novanet,,5162.06,75,,,,,0,800.46,5850.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL LEAD DELIVERY EMBLEM STERILE LATEX FREE DISPOSABLE ELEC",SUP-4712,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"UHC [10700]","United Healthcare",,4367.7,63.3,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC",022,MS-DRG,,,,,,,inpatient,,,181948.80,54584.64,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,20300.89,,"Case rate ($19,709.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $18,301.70, add-ons for qualifying new technology services are included. If operating cost exceeds $51,341.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,765.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $18,325.91. The transfer operating threshold is the transfer adjustment factor * $18,301.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,383.70. The transfer capital threshold is the transfer adjustment factor * $1,383.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,92767.37,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE HAND TITANIUM H EXTENDED 1.3 MM SCR NONSTERILE",SUP-421.321,CDM,C1713,HCPCS,0278,RC,,,both,,,2652.30,795.69,"CIGNA [10200]",Cigna,,1803.56,68,,1831.33,1831.33,1831.33,16,308.46,2254.46,"percent of total billed charges",
"SHELL ACETABULAR 46MM 47.8MM HIP 3 SCR HOLE CLUSTER HA",SUP-542-11-46D,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"PHCS [10601]",PHCS,,4870.4,70,,,,,0,809.18,5914.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET OPHTHALMIC 2.5IN 20GA .8MM SEIFF 3/8IN .08IN LACRIMAL",SUP-585192,CDM,S27200284,LOCAL,0272,RC,,,both,,,383.15,114.94,"AETNA [10100]","Aetna HMO/PPO",,304.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.56,325.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 38MM COOKIE CUTTER FREEMAN AREOLA BREAST BIOPSY 5.5IN",SUP-67-0038,CDM,A4648,HCPCS,0278,RC,,,both,,,539.30,161.79,"BLUE CROSS [10001]","Blue Cross PPO",,211.41,39.2,,,,,0,62.72,458.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SCR CD HORIZON SPIRE M4 BREAKOFF",SUP-9240150,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"CIGNA [10200]","Cigna Open Access",,1369.36,56.9,,1144.80,304.56,2275.09,66,279.89,2045.61,"percent of total billed charges",
"MARKER RADIOLOGY 5X4IN 2MM GUIDELINES NECK BIOPSY GRID CT",SUP-117,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.50,14.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,32.98,68,,,,,0,5.64,41.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD MEDIUM 5.5MM TSRH-3D OPEN OFFSET TITANIUM POSTERIOR",SUP-8379121,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"FIRST HEALTH [10303]","First Health",,2850,80,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW TITANIUM 3 HOLE GEMINUS BONE LEFT DISTAL VOLAR",SUP-GMN-LTN-3HL,CDM,C1713,HCPCS,0278,RC,,,both,,,5023.20,1506.96,"CIGNA [10200]","Cigna Local Plus",,2687.41,53.5,,3978.14,359.25,3978.14,24,584.2,4269.72,"percent of total billed charges",
"TRAY TIBIAL INBONE 5 STD ANKLE LEFT",SUP-200252905,CDM,C1776,HCPCS,0278,RC,,,both,,,11847.30,3554.19,"UHC [10700]","United Healthcare",,7499.34,63.3,,8601.07,8395.67,8601.07,"1 through 10",1377.84,10070.21,"percent of total billed charges",
"RING ANNULOPLASTY 26MM TRICUSPID 1 SEAM 2 WRAP ANATOMIC",SUP-4900T26,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1484.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 4FR .042IN JUDKINS LEFT 5",SUP-538422,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,41.09,45.9,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 15CM SILICONE SCHON XL BASIC ACUTE HEMODIALYSIS",SUP-H787108007015,CDM,C1752,HCPCS,0278,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR SUREFORM 60 WHITE",SUP-48360W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.25,543.37,"NOVANET [10819]",Novanet,,1358.44,75,,,,,0,210.65,1539.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM AXSOS STAINLESS STEEL 2.5MM FULL THREAD",SUP-338622,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,65.88,28.62,,,,,0,26.77,195.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 7 KNEE CEMENTED FIX BEARING STERILE",SUP-150600007,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1777.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1744.97,12753.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21.5 DIOPTER HAPTIC C BICONVEX 13MM 6MM 1 PIECE",SUP-PCB0000215,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD SENTUS PROMRI LEFT VENTRICULAR OTW QUADRIPOLAR",SUP-408719,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"FIRST HEALTH [10303]","First Health",,4485.6,80,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE FLEXIBLE 600MM 3.8MM 1.2MM AMBU ASCOPE 3 SLIM",SUP-402001000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1326,68,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL GREGORY XS 4 7/8IN PROFUNDA",SUP-55-6090,CDM,S27200284,LOCAL,0272,RC,,,both,,,1349.06,404.72,"MULTIPLAN [10600]",Multiplan,,1146.7,85,,,,,0,156.9,1146.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC",356,MS-DRG,,,,,,,inpatient,,,161549.45,48464.83,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,29156.22,,"Case rate ($27,248.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $25,302.36, add-ons for qualifying new technology services are included. If operating cost exceeds $58,342.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,294.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $25,335.82. The transfer operating threshold is the transfer adjustment factor * $25,302.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.98. The transfer capital threshold is the transfer adjustment factor * $1,912.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,128252.19,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"V.A.C. VERAFLO CLEANSE CHOICE DRESSING, MEDIUM",SUP-ULTVCC05MD,CDM,A6550,HCPCS,0272,RC,,,both,,,1061.91,318.57,"NOVANET [10819]",Novanet,,796.43,75,,,,,0,26.26,902.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 5-0 FS-2 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J421H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 48MM SAPPHIRE BONE ANTERIOR CERVICAL SPINE",SUP-26003-048,CDM,S27800098,LOCAL,0278,RC,,,both,,,5292.00,1587.6,"AETNA [10100]","Aetna HMO/PPO",,4207.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER SMOKE EVAC 7/8IN TELEVAC ULPA BERCHTOLD TELEVAC LT",SUP-BTLD004,CDM,S27000186,LOCAL,0270,RC,,,both,,,1350.27,405.08,"UHC [10700]","United Healthcare",,854.72,63.3,,,,,0,157.04,1147.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 60ML .1-4MM CANCELLOUS ALLOGRAFT FREEZE",SUP-400085,CDM,C1713,HCPCS,0278,RC,,,both,,,6665.40,1999.62,"NOVANET [10819]",Novanet,,4999.05,75,,,,,0,775.19,5665.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"29.0 DIOPTER, SENSAR MONOFOCAL 3-PIECE FOLDABLE IOL, MODEL A",SUP-AR40E00290,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"CIGNA [10200]","Cigna Local Plus",,498.35,53.5,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
RADIOTHERAPY,849,MS-DRG,,,,,,,inpatient,,,163131.53,48939.46,"AMBETTER EXCHANGE  [11102]",Ambetter,,16807.2,,"Case rate ($16,807.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $15,606.62, add-ons for qualifying new technology services are included. If operating cost exceeds $48,646.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,561.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $15,627.26. The transfer operating threshold is the transfer adjustment factor * $15,606.62 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,179.94. The transfer capital threshold is the transfer adjustment factor * $1,179.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,10994,67572.22,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE GLIDE TECHNOLOGY VASCULAR STD ANGLE 260CM 3CM",SUP-GR3809,CDM,C1769,HCPCS,0272,RC,,,both,,,408.90,122.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,278.05,68,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX LPR 9 CM CIRCLE",SUP-F10244-0909L,CDM,C1781,HCPCS,0278,RC,,,both,,,7268.46,2180.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4942.55,68,,,,,0,845.32,6178.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 124MM CEMENTED NECK ACCOLADE 127D 2 39MM OFFSET",SUP-6057-0230D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"BLUE CROSS [10001]","Blue Cross PPO",,6444.19,39.2,,3949.44,3949.44,3949.44,"1 through 10",1911.88,13973.36,"percent of total billed charges",
"GRAFT CARDIOROOT VALSALVA 26MM",SUP-HEWROOT0026,CDM,C1768,HCPCS,0278,RC,,,both,,,13998.17,4199.45,"BLUE CROSS [10001]","Blue Cross PPO",,5487.28,39.2,,,,,0,1627.99,11898.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 67.5MM KNEE RIGHT POSTERIOR STABILIZE OPEN BOX",SUP-184510,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"PHCS [10601]",PHCS,,17378.05,70,,,,,0,2887.24,21101.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIGHTED SIGMOIDOSCOPE KIT LATEX FREE 1 LIGHTED SCOPE RECTO M",SUP-ASDSK02,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,316.02,45.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 5YDX.5IN ALGIDEX SILVER GAUZE PK LATEX FREE",SUP-46-PG12,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.55,19.36,"FIRST HEALTH [10303]","First Health",,51.64,80,,,,,0,7.51,54.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE COOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-CRKA-17-50-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL SF F-J CURVE ABLATION",SUP-D134804,CDM,C1732,HCPCS,0272,RC,,,both,,,20897.10,6269.13,"MULTIPLAN [10600]",Multiplan,,17762.54,85,,,,,0,2430.33,17762.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH INTRDCR FR7 LONG - EACH",SUP-668000-001,CDM,C1892,HCPCS,0272,RC,,,both,,,1174.50,352.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,136.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 16MM NESTER MICROCOIL PLATINUM .035IN",SUP-G47348,CDM,S27800098,LOCAL,0278,RC,,,both,,,1020.52,306.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,120.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.69,867.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 8MM FALOPE-RING DUAL INCISION PREMOUNTED WITHOUT",SUP-006889-901,CDM,S27200284,LOCAL,0272,RC,,,both,,,1361.69,408.51,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONQUEST 75CM 4CM 5MM 6FR BALLOON DILATATION PERIPHERAL",SUP-CQ7554,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 18GA 20CM CHIBA ASPIRATION STERILE DISPOSABLE",SUP-G01047,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.31,31.29,"AETNA [10100]","Aetna HMO/PPO",,82.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.13,88.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Extract Nuc Ag Ea Ab",PX-302000038,CDM,86235,CPT,0302,RC,,,both,,,348.65,104.59,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,28.2,,,,,,,0.35,296.35,"fee schedule",
"CATH BALLOON DILATATION .018IN 4FR 7MM 135CM 8CM PTA LOW",SUP-G50262,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR NEONATAL LNCS 36IN FINGER OXIMETER ADHESIVE LOW NOISE",SUP-2329,CDM,S27000186,LOCAL,0270,RC,,,both,,,71.00,21.3,"AETNA [10100]","Aetna HMO/PPO",,56.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.26,60.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUTURING ENDO STITCH SURGIDAC GREEN 0 ES-9 48IN",SUP-173024,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"CIGNA [10200]","Cigna Local Plus",,77.13,53.5,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enteroscopy W Tattoo(Ing) Submuc Inj",PX-750000248,CDM,44799,CPT,0750,RC,,,both,,,2809.93,842.98,"NOVANET [10819]",Novanet,,2107.45,75,,,,,0,326.79,2809.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 17MM ARCHON SPINE SELF DRILL VARIABLE ANGLE",SUP-8780217,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,396.9,39.2,,957.42,570.23,957.42,28,117.75,860.63,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 8MM 145CM 2.5MM CORONARY STENT",SUP-1125250-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 14.5IN 28FR PHILLIPS 1/56IN PLASTIC 1 EYE MALE",SUP-346128,CDM,S27200284,LOCAL,0272,RC,,,both,,,151.38,45.41,"MULTIPLAN [10600]",Multiplan,,128.67,85,,,,,0,17.61,128.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 8FR LARGE REGULAR PIGTAIL CURVE URETERAL GLIDEX",SUP-M001245500,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"MULTIPLAN [10600]",Multiplan,,757.35,85,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEV TRQ TIP INTRO",SUP-4071,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,19.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 24CM 3CM 6FR .035IN PIGTAIL CURVE",SUP-M006180222180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA [10200]","Cigna Open Access",,830.8,,,,,,,169.81,1241.09,"percent of total billed charges",
"STENT EXPEL TWIST-LOC 12CM 8FR URETERAL FLEXITHANE",SUP-H7493936108120,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,146.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM OSTEOGRIP NANO SPINE SHANK",SUP-55904507540,CDM,C1713,HCPCS,0278,RC,,,both,,,8193.75,2458.12,"CIGNA [10200]","Cigna Local Plus",,4383.66,53.5,,3978.14,359.25,3978.14,24,952.93,6964.69,"percent of total billed charges",
"COIL EMBOLIZATION 2CM 1MM TARGET NANO 360D DETACHABLE",SUP-M0035421020,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"FIRST HEALTH [10303]","First Health",,11291.71,80,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 19MM KNEE X3 CONDYLAR STABILIZED PRIMARY",SUP-5531G319,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1109.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 170MM 130CM 7MM 6FR .035IN VASCULAR NITINOL",SUP-EX071703CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"CIGNA [10200]",Cigna,,8303.4,40,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 30MM STEALTH 1 SOFT TRACTION STERILE LATEX FREE",SUP-A0A01,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"KAISER [10500]",Kaiser,,104.92,67,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 2MM 60MM ECHELON FLEX ENDOPATH STAINLESS STEEL",SUP-ECR60M,CDM,S27200284,LOCAL,0272,RC,,,both,,,3907.19,1172.16,"FIRST HEALTH [10303]","First Health",,3125.75,80,,,,,0,454.41,3321.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 52MM 28MM 20D CUP REVISION",SUP-3856,CDM,C1776,HCPCS,0278,RC,,,both,,,3388.35,1016.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1555.25,45.9,,,,,0,394.07,2880.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Spine Thorac>=4v",PX-320000041,CDM,72074,CPT,0320,RC,,,both,,,718.34,215.5,"BLUE CROSS [10001]","Blue Cross HMO",,106.28,,"Fee schedule rate ($106.28).",106.27,106.27,106.27,"1 through 10",51.75,610.59,"fee schedule",
"(EVAL) 28 FR. THORAGUARD CHEST TUBE KIT (BOX OF 10)",SUP-TGCT120028,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1074.06,68,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 9MM 33MM METAL BACKED SYMMETRIC RESURFACING",SUP-5556-L-339,CDM,C1776,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Open Access",,2509.29,56.9,,5302.19,4377.88,6578.61,27,512.88,3748.5,"percent of total billed charges",
"SUB BONE GRAFT OSTEOMATRIX+ 2 STRIP 18CC STERILE",SUP-OMP-18,CDM,C1713,HCPCS,0278,RC,,,both,,,6776.66,2033,"FIRST HEALTH [10303]","First Health",,5421.33,80,,,,,0,788.13,5760.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL STD",SUP-500DM31,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9450,40,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR BROAD LORDOTIC 12 DEGREE",SUP-12417,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Local Plus",,5953.5,31.5,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 60MM KNEE LEFT POSTERIOR STABILIZE CEMENT OPEN",SUP-183124,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"BLUE CROSS [10001]","Blue Cross HMO",,8492.95,39.2,,5311.50,4717.44,5388.59,31,2519.72,18415.85,"percent of total billed charges",
"CAP CONSTRUCT TOTAL HIP POLAR CUP CEMENTED STEM DELTA HEAD",SUP-71703510,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE AUG REAMER BUSH SURGICAL",SUP-110031869,CDM,S27200284,LOCAL,0272,RC,,,both,,,650.75,195.22,"KAISER [10500]",Kaiser,,436,67,,,,,0,75.68,553.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 20MM 144CM 2.5MM CORONARY STENT EVEROLIMUS",SUP-H7493926120250,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1022.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VICI VENOUS STENT 120MM 100MM 16MM ENDOPROSTHESIS",SUP-H74916120100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"MULTIPLAN [10600]",Multiplan,,11143.5,85,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 230MM STAINLESS STEEL 4.5MM SCR 10 HOLE 4 COLUMN",SUP-02.124.411S,CDM,C1713,HCPCS,0278,RC,,,both,,,13765.64,4129.69,"AETNA [10100]","Aetna HMO/PPO",,10943.68,79.5,,1521.93,481.35,16760.95,30,1600.94,11700.79,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 26CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006155243170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CIGNA [10200]","Cigna Open Access",,808.17,,,,,,,165.19,1207.29,"percent of total billed charges",
"SURFACE ARTICULAR 10MM PERSONA MEDIAL CONGRUENT 6-7 E-F KNEE",SUP-42522100710,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"FIRST HEALTH [10303]","First Health",,8621.14,80,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Carbamazepine Free",PX-301000037,CDM,80157,CPT,0301,RC,,,both,,,337.00,101.1,"BLUE CROSS [10001]","Blue Cross PPO",,16.93,,"Fee schedule rate ($16.93).",,,,0,0.01,286.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL PERSONA AB CONE KNEE CENTRAL STERILE LATEX FREE",SUP-42545000508,CDM,C1776,HCPCS,0278,RC,,,both,,,29901.06,8970.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3543.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3477.49,25415.9,"percent of total billed charges",
"SPACER SPINAL 14X16MM VERTE-STACK CORNERSTONE PSR 8MM",SUP-6240864,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SKIN PURPLE 5CM SOFT TISSUE DELIVERY SYSTEM STERILE",SUP-SMARTCLIPLT-PURP-5,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA [10200]",Cigna,,1836,68,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 11.5MM HEAD SIDE CUT MEDULLARY NONSTERILE",SUP-352.115,CDM,S27000186,LOCAL,0270,RC,,,both,,,2194.20,658.26,"PHCS [10601]",PHCS,,1535.94,70,,,,,0,255.19,1865.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL KNEE 2A POROUS/HYBRID PROPRIETARY))/STRYKER X3 W/TRITA",SUP-CAP-K-2A,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"KAISER [10500]",Kaiser,,14773.5,67,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 0 CT 36IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z358T,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 17CM 5MM BALLOON DILATATION OTW LOW",SUP-G34167,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.105,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,393.5,45.9,,,,,0,99.7,728.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 10MM LCP STAINLESS STEEL DISTAL RADIAL SELF",SUP-212.810,CDM,C1713,HCPCS,0278,RC,,,both,,,802.87,240.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,93.37,682.44,"percent of total billed charges",
"SCR BONE 4.5MM 36MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.536,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"BLUE CROSS [10001]","Blue Cross HMO",,429.8,39.2,,957.42,156.86,7483.26,51,127.51,931.96,"percent of total billed charges",
"LINER ACETABULAR PINNACLE NEUTRAL 56MM 32MM MARATHON HIP",SUP-121932056,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,841.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,841.39,6149.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 5.5MM 6MM SPINE TITANIUM EXT NONSTERILE",SUP-04.633.002,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1635.19,45.9,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL TRIATHLON X3 5 H16 MM KNEE TOTAL STABILIZE PLU",SUP-5537-G-516-E,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"AETNA [10100]","Aetna HMO/PPO",,10699.47,79.5,,10981.53,8986.79,12413.38,12,1565.22,11439.68,"percent of total billed charges",
"SCR BONE 6.5MM 35MM EVEREST SPINE POLYAXIAL CANNULATED",SUP-M5111-06535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"SLEEVE TIBIAL 29X26X40MM MBT KNEE METAPHYSEAL POROUS",SUP-129454000,CDM,C1776,HCPCS,0278,RC,,,both,,,15133.08,4539.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1793.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1759.98,12863.12,"percent of total billed charges",
"DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION",RX-9812,CDM,J3490,HCPCS,0258,RC,00264-7616-00,NDC,both,1000,ML,100.65,30.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 STD KNEE LEFT CRUCIATE RETAIN CEMENT PERSONA",SUP-42572606401,CDM,C1776,HCPCS,0278,RC,,,both,,,26429.76,7928.93,"CIGNA [10200]","Cigna Local Plus",,8325.37,31.5,,5372.07,4581.20,7242.98,23,3073.78,22465.3,"percent of total billed charges",
"TISSUE 853916 CP STRUT 16MM SRVC FEE",SUP-853916,CDM,S27800098,LOCAL,0278,RC,,,both,,,3412.50,1023.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1566.34,45.9,,,,,0,396.87,2900.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ASPIRATION 130CM 20GA 1.8MM EXCELON TRANSBRONCHIAL",SUP-M00564111,CDM,S27200284,LOCAL,0272,RC,,,both,,,664.10,199.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,304.82,45.9,,,,,0,77.23,564.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) SYSTEM AVEIR 19.5F PACEMKR LEADLESS PACEMKR 38.5MM RV",SUP-LSP112V,CDM,C1786,HCPCS,0275,RC,,,both,,,44100.00,13230,"UHC [10700]","United Healthcare",,27915.3,63.3,,,,,0,5128.83,37485,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 22MM 53MM SHOULDER ECLIPSE STERILE ARTHROPLASTY",SUP-AR-9353-22,CDM,C1776,HCPCS,0278,RC,,,both,,,4105.50,1231.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,486.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,477.47,3489.68,"percent of total billed charges",
"SURFACE ARTICULAR 12MM NEXGEN LPS-FLEX 7-10 G-H KNEE UHMWPE",SUP-596405012,CDM,C1776,HCPCS,0278,RC,,,both,,,7394.04,2218.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,876.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,859.93,6284.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTHROSCOPE RIGID QUICKLATCH 1 STPCOCK SHEATH 4 MM SCOPE",SUP-T5801,CDM,S27200284,LOCAL,0272,RC,,,both,,,1600.56,480.17,"CIGNA [10200]","Cigna Open Access",,910.72,56.9,,,,,0,186.15,1360.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE 24FR INCISION STORZ 1 STEM",SUP-M0068805011,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,60.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X16MM VERTE-STACK CORNERSTONE PSR 7MM",SUP-6240764,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MELATONIN 3 MG TABLET",RX-16830,CDM,,,0637,RC,20555-0036-00,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 8MM 2.7MM 55MM 22MM DHS DCS STAINLESS STEEL",SUP-280.255S,CDM,C1713,HCPCS,0278,RC,,,both,,,2333.10,699.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1586.51,68,,,,,0,271.34,1983.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM TARGET NANO HELICAL DETACHABLE",SUP-M0035452040,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1065.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY 15CM 11GA TREK BONE MARROW AUTOMATIC BRAKE",SUP-TKM1115,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"CIGNA [10200]","Cigna Local Plus",,902.81,53.5,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18 DIOPTER UV ABSORBENT CLAREON AUTONOME",SUP-CCA0T0.180,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 16MM TITANIUM CERVICAL SPINE LOCKING NONSTERILE",SUP-04.617.816,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 69.9MM 4MM LONG CARBIDE ROUND 8 FLUTED 5092228",SUP-5300020511,CDM,S27000186,LOCAL,0270,RC,,,both,,,271.18,81.35,"CIGNA [10200]","Cigna Local Plus",,145.08,53.5,,,,,0,31.54,230.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 650CC COHESIVE NATRELLE INSPIRA STERILE LATEX",SUP-SCF-650,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,878.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 3DEMIN ALLOGRAFT BOAT PLIABLE OSTEOCONDUCTIVE",SUP-109785,CDM,C1713,HCPCS,0278,RC,,,both,,,16422.00,4926.6,"BLUE CROSS [10001]","Blue Cross PPO",,6437.42,39.2,,957.42,570.23,957.42,28,1909.88,13958.7,"percent of total billed charges",
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 6 STD OFFSET HIP",SUP-71935566,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4329.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 100MM 3.5MM BALLOON DILATATION PEBAX",SUP-H74939148351010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Orbit/Face/Nck W Cntrst",PX-610000004,CDM,70542,CPT,0610,RC,,,both,,,4506.80,1352.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,683,,"Per diem ($683). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,524.14,3830.78,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM TRIATHLON 2 LEFT MEDIAL RIGHT LATERAL TOTAL",SUP-5546-A-201,CDM,C1776,HCPCS,0278,RC,,,both,,,5971.95,1791.58,"CIGNA [10200]","Cigna Local Plus",,3194.99,53.5,,5372.07,4581.20,7242.98,23,694.54,5076.16,"percent of total billed charges",
"STENT LIFESTENT 60MM 130CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-EX060603CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"BLUE CROSS [10001]","Blue Cross PPO",,4598.16,39.2,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712540,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE ENDOBRONCHIAL ZEPHYR OD 5.5- 8.5MM LOW PROFILE",SUP-EBV-TS-5.5-LP,CDM,S27800098,LOCAL,0278,RC,,,both,,,17112.00,5133.6,"FIRST HEALTH [10303]","First Health",,13689.6,80,,,,,0,1990.13,14545.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Infliximab",PX-301000623,CDM,80230,CPT,0301,RC,,,both,,,223.25,66.97,"PHCS [10601]",PHCS,,156.28,70,,,,,0,0.01,189.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch W Bronch/Endobronch Bx",PX-750000007,CDM,31625,CPT,0750,RC,,,both,,,3922.62,1176.79,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,456.2,3922.62,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG ALGINATE 4X4IN ACTICOAT FLEX 3 POLYESTER",SUP-66800406,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.19,19.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,44.33,68,,,,,0,7.58,55.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"GRAFT SKIN READIGRAFT CRYOSKIN 154SQ CM FIBROBLAST",SUP-SK-F,CDM,Q4433,HCPCS,0636,RC,,,both,,,3360.30,1008.09,"CIGNA [10200]",Cigna,,2285,68,,,,,0,247.92,2856.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WOUND DEBRIDEMENTS FOR INJURIES WITH CC",902,MS-DRG,,,,,,,inpatient,,,79923.41,23977.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,36331.47,,"Fee schedule rate ($36,331.47). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,55895.74,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"BNDG TG FIX 25MR WHITE COMPRESSION LATEX WIDE MESH HIGHLY",SUP-568261,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.98,15.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.16,45.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG VIAL",RX-10581,CDM,J2919,HCPCS,0636,RC,43598-0128-11,NDC,both,1,UN,199.32,59.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,23.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.62,169.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR INTERNAL MAMMARY",SUP-67019000,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,171.63,41.1,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 76MM 10.8MM 15MM 6.4MM WITHOUT CUFF REUSABLE INNER CANN",SUP-6CFS,CDM,S27200284,LOCAL,0272,RC,,,both,,,700.49,210.15,"FIRST HEALTH [10303]","First Health",,560.39,80,,,,,0,81.47,595.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 20MM 135CM 5MM 160CM",SUP-M001711010,CDM,C1876,HCPCS,0278,RC,,,both,,,8728.50,2618.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1034.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1015.12,7419.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN REGULAR",SUP-67008000,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,171.63,41.1,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT POSITIONING SHOULDER SUSPENSION KIT COBANT WRAP ARM",SUP-72200195,CDM,S27000186,LOCAL,0270,RC,,,both,,,558.90,167.67,"CIGNA [10200]",Cigna,,380.05,68,,,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemorrhoidectomy in/Ext",PX-360000056,CDM,46260,CPT,0360,RC,,,both,,,7450.10,2235.03,"CIGNA [10200]","Cigna Open Access",,3307,,"Case rate ($3,307). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,866.45,7450.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMIPRAMINE 10 MG TABLET",RX-3860,CDM,,,0637,RC,69584-0425-10,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 3MM MREYE ARTERIAL VENOUS PLATINUM 5.3",SUP-G42458,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,567.27,68,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET SILASTIC 2X2X.125IN SILICONE TRIMMABLE",SUP-1532540,CDM,S27800098,LOCAL,0278,RC,,,both,,,198.36,59.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.07,168.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR ANGLE 80CM .018IN HYDROPHILIC FIX CORE",SUP-H2OSTDA1880,CDM,C1769,HCPCS,0272,RC,,,both,,,408.47,122.54,"KAISER [10500]",Kaiser,,273.67,67,,,,,0,47.51,347.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN .045IN STEINMANN ORTHOPEDIC STAINLESS STEEL",SUP-KM173-29-45,CDM,C1713,HCPCS,0278,RC,,,both,,,59.29,17.79,"BLUE CROSS [10001]","Blue Cross PPO",,23.24,39.2,,957.42,570.23,957.42,28,6.9,50.4,"percent of total billed charges",
"CANN VACUUM ASPIRATION CURVE SEMIRIGID ROUND TIP STERILE",SUP-21552,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.07,1.22,"UHC [10700]","United Healthcare",,2.58,63.3,,,,,0,0.47,3.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X12MM COROENT WIDE XL",SUP-6912250,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"AETNA [10100]","Aetna HMO/PPO",,18889.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 30MM 6FR 2MM .07IN BALLOON",SUP-H7493918930200,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NUROLON 1 CT-1 30IN BRAID BLACK NONABSORBABLE",SUP-5425H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SMART CONTROL MICROMARKER 100MM 120CM 6MM VASCULAR",SUP-C06100ML,CDM,C1876,HCPCS,0278,RC,,,both,,,4657.50,1397.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,551.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 15MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934387,CDM,C1776,HCPCS,0278,RC,,,both,,,18947.25,5684.17,"NOVANET [10819]",Novanet,,14210.44,75,,,,,0,2203.57,16105.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT MEDIAL LEFT LATERAL RESTORIS",SUP-180517,CDM,C1776,HCPCS,0278,RC,,,both,,,12440.70,3732.21,"AETNA [10100]","Aetna HMO/PPO",,9890.36,79.5,,10981.53,8986.79,12413.38,12,1446.85,10574.6,"percent of total billed charges",
"CATH 3.5CM 18FR GUIDING BALLOON LOW PROFILE",SUP-8117,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"UHC [10700]","United Healthcare",,2350.01,63.3,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW MULTI-THREAD LOCKING 3.5MM X 14MM TI",SUP-MTLS-35140-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1320.30,396.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,156.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,153.55,1122.26,"percent of total billed charges",
"MESH SURGICAL PHASIX 14X14IN FULL RESORBABLE KNIT",SUP-1193535,CDM,C1781,HCPCS,0272,RC,,,both,,,108418.56,32525.57,"UHC [10700]","United Healthcare",,68628.95,63.3,,,,,0,44560.03,68628.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 29CM 16FR ATALA-SHEPARD COAXIAL BALLOON SET",SUP-G17273,CDM,C1726,HCPCS,0272,RC,,,both,,,798.90,239.67,"NOVANET [10819]",Novanet,,599.18,75,,,,,0,92.91,679.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HYPERFLEX ARTHROSCOPIC 14IN .062IN NITINOL FLEXIBLE",SUP-8572,CDM,C1769,HCPCS,0272,RC,,,both,,,186.27,55.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,22.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.66,158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GALLIUM-67 CITRATE INTRAVENOUS SOLUTION (0-1 MCI)",RX-188102,CDM,A9556,HCPCS,0343,RC,08888-8878-21,NDC,both,1,UN,404.00,121.2,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,343.4,"fee schedule",
"CATH LUTONIX 035 130CM 60MM 4MM BALLOON DILATATION",SUP-LX351304605F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,782.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3518,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"PHCS [10601]",PHCS,,1048.95,70,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 2.5FR UMBILICAL POLYURETHANE 1 LUMEN RADIOPAQUE SMOOTH",SUP-P1UVC-2530,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.20,41.76,"CIGNA [10200]","Cigna Open Access",,79.2,56.9,,,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX39MM 8FR 135CMCATH HEPARIN",SUP-BXB093902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2311.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OLYMPUS 4MM 15 DEG SERRATED SHAVER",SUP-SB4015SC,CDM,S27200284,LOCAL,0272,RC,,,both,,,4205.69,1261.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,498.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,489.12,3574.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.5X70MM LORDOSED ROD",SUP-30100-070,CDM,S27800098,LOCAL,0278,RC,,,both,,,1410.00,423,"FIRST HEALTH [10303]","First Health",,1128,80,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 GEOALIGN 130CM 120MM 7MM BALLOON DILATATION",SUP-LX3513071205F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"KAISER [10500]",Kaiser,,4507.43,67,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 20MM 3.5MM BALLOON DILATATION STERILE",SUP-235-203-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5F DECA 2-2-2 MPA 120CM",SUP-901521,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,351.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL ICONIX 2.3MM DISPOSABLE",SUP-3910500569,CDM,S27200284,LOCAL,0272,RC,,,both,,,1312.20,393.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,539.31,41.1,,,,,0,152.61,1115.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PRIMARY CEMENTED KNEE",SUP-TKASTND-CEM,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"AETNA [10100]","Aetna HMO/PPO",,15025.5,79.5,,10981.53,8986.79,12413.38,12,2198.07,16065,"percent of total billed charges",
"AVENIR 10 2.5 X 3 COMPLEX FINISHING COIL",SUP-10CFN-02503,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UHC [10700]","United Healthcare",,7420.72,63.3,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Lwr Ext WO Cntrst",PX-359000004,CDM,73700,CPT,0352,RC,,,both,,,2107.53,632.26,"UHC [10700]","United Healthcare",,261.88,,,,,,,245.11,1933,"fee schedule",
"HEAD UNIPOLAR 58MM UNITRAX HIP FEMORAL MODULAR EXETER V40",SUP-6942-5-058,CDM,C1776,HCPCS,0278,RC,,,both,,,4291.80,1287.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,499.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,499.14,3648.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SKATER 40CM 12FR PIGTAIL CURVE DRNG BILIARY LOCK",SUP-755312040,CDM,C1729,HCPCS,0272,RC,,,both,,,651.24,195.37,"NOVANET [10819]",Novanet,,488.43,75,,,,,0,75.74,553.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 12MM INTERLOCK IDC OCCLUSION SYSTEM",SUP-M0013614120,CDM,S27800098,LOCAL,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 12CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155212190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CIGNA [10200]","Cigna Local Plus",,759.88,,,,,,,165.19,1207.29,"percent of total billed charges",
"HC Egd W Rmvl Snare",PX-750000040,CDM,43251,CPT,0750,RC,,,both,,,2979.73,893.92,"UHC [10700]","United Healthcare",,2979.73,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,346.54,2979.73,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUROFORM ATLAS STENT SYSTEM 4.0 X 21MM WITHOUT TIP ZERO (PM",SUP-M003UZAS40210,CDM,C1874,HCPCS,0278,RC,,,both,,,52885.22,15865.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,14279.01,27,,,,,0,6150.55,44952.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GIRAFFE 45D 2MM 5.25IN FRONTAL SINUS 2 ACTION",SUP-63-8845,CDM,S27200284,LOCAL,0272,RC,,,both,,,3430.28,1029.08,"KAISER [10500]",Kaiser,,2298.29,67,,,,,0,398.94,2915.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL 2MR CO2 O2 HIGH HUMIDITY SAMPLING LINE ADULT",SUP-704-3837-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,127.18,38.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,58.38,45.9,,,,,0,14.79,108.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 2 KNEE LEFT CRUCIATE RETAINING PFC SIGMA P",SUP-940012,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"FIRST HEALTH [10303]","First Health",,20711.88,80,,,,,0,3010.99,22006.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST GEL SMOOTH ROUND MODERATE PLUS PROFILE 265CC",SUP-SMPB265,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"PHCS [10601]",PHCS,,5337.15,70,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 158MM STAINLESS STEEL 3.5MM SCREWS 6 HOLE LCP BONE",SUP-02.104.006S,CDM,C1713,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"MULTIPLAN [10600]",Multiplan,,7389.9,85,,,,,0,1011.11,7389.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 11IN FOREARM WRIST 2 PANEL",SUP-1000285,CDM,L3908,HCPCS,0274,RC,,,both,,,70.04,21.01,"KAISER [10500]",Kaiser,,46.93,67,,,,,0,8.15,59.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 2 ACTION ROTATE RATCHET HANDLE 39CM 5MM",SUP-91-5035,CDM,S27200284,LOCAL,0272,RC,,,both,,,3526.43,1057.93,"FIRST HEALTH [10303]","First Health",,2821.14,80,,,,,0,410.12,2997.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 19IN 24FR STRAIGHT DRNG PVC THORAX 5 EYELET FIRM",SUP-15024,CDM,C1729,HCPCS,0272,RC,,,both,,,61.17,18.35,"NOVANET [10819]",Novanet,,45.88,75,,,,,0,7.11,51.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT BLACK 22CM 6FR 2 PIGTAIL CURVE STRAIGHT URETERAL",SUP-G46438,CDM,C2617,HCPCS,0278,RC,,,both,,,1194.75,358.42,"NOVANET [10819]",Novanet,,896.06,75,,,,,0,138.95,1015.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2MM 16MM FOSSA RADIUS DISTAL VOLAR SMOOTH LOCK",SUP-SPLS-20160-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,639.90,191.97,"NOVANET [10819]",Novanet,,479.93,75,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CENTRAL VENOUS 28CM PALINDROME",SUP-8888145064,CDM,C1750,HCPCS,0278,RC,,,both,,,2487.65,746.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,711.97,28.62,,,,,0,289.31,2114.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 60MM STEALTH 3 SOFT STERILE LATEX FREE",SUP-A0A13,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"CIGNA [10200]","Cigna Local Plus",,83.78,53.5,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 0 CT-1 30IN BRAID BLACK NONABSORBABLE",SUP-424H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH GORE DRYSEAL FLEX 65CM 8.2MM 22FR INTRO HYDROPHILIC",SUP-GDSF2265,CDM,C1894,HCPCS,0272,RC,,,both,,,6858.60,2057.58,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2818.88,41.1,,,,,0,797.66,5829.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 5MM 24MM 2.5MM TITANIUM FULL THREAD CORTEX",SUP-402.824,CDM,C1713,HCPCS,0278,RC,,,both,,,380.02,114.01,"NOVANET [10819]",Novanet,,285.02,75,,,,,0,44.2,323.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL NAVISTAR 115CM 8FR 3.5MM DD CURVE",SUP-D132701,CDM,C1732,HCPCS,0272,RC,,,both,,,19845.00,5953.5,"FIRST HEALTH [10303]","First Health",,15876,80,,,,,0,2307.97,16868.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 7MM STD WALL GORE-TEX LINE STERILE LATEX",SUP-V07040L,CDM,C1768,HCPCS,0278,RC,,,both,,,2775.00,832.5,"KAISER [10500]",Kaiser,,1859.25,67,,,,,0,322.73,2358.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +25.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2550,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR SIMMONS 1 CURVE",SUP-G08677,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"FIRST HEALTH [10303]","First Health",,189.99,80,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 20MM 3MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3020X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR PULSE LATITUDE NXT 83.1X69.1MM EMBLEM S-ICD 12.7MM",SUP-A219,CDM,C1722,HCPCS,0278,RC,,,both,,,59280.00,17784,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,23712,40,,,,,0,6894.26,50388,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X17MM 8D CONVEX LORDOTIC WEDGE",SUP-010617,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CIGNA [10200]","Cigna Open Access",,10552.5,33.5,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 135CM 3.1FR 50MM SPACE SPRT RADIOPAQUE",SUP-518-037,CDM,C1887,HCPCS,0272,RC,,,both,,,972.00,291.6,"MULTIPLAN [10600]",Multiplan,,826.2,85,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Not Feeynolm 2.6-7.5cm",PX-450000020,CDM,12002,CPT,0361,RC,,,both,,,1025.43,307.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,119.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,119.26,1025.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH LAB CONVENIENCE",SUP-K09-07759H,CDM,S27200284,LOCAL,0272,RC,,,both,,,434.22,130.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.5,369.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Leukocytes Feces",PX-306000175,CDM,89055,CPT,0309,RC,,,both,,,159.60,47.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.47,,"Fee schedule rate ($3.47). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,135.66,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORTIVA 1MM TAILORED ALLOGRAFT DERMIS,MEDIUM, 9.2 X 19.2CM",SUP-DMM140,CDM,S27800098,LOCAL,0278,RC,,,both,,,26947.81,8084.34,"AETNA [10100]","Aetna HMO/PPO",,21423.51,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3134.03,22905.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT RESTRN SMALL TRIANGLE COTTON FLANNEL STRAP BODY HOLDER",SUP-MF117-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,78.47,23.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.25,41.1,,,,,0,9.13,66.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PREGABALIN 75 MG CAPSULE",RX-42164,CDM,,,0637,RC,00071-1014-41,NDC,both,1,UN,73.57,22.07,"CIGNA [10200]",Cigna,,50.03,68,,,,,0,8.56,62.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 1.5% DEXTROSE 6000ML 1 BAG CNTNR LOW CALCIUM LUER",SUP-L5B9710,CDM,S27200284,LOCAL,0272,RC,,,both,,,413.69,124.11,"NOVANET [10819]",Novanet,,310.27,75,,,,,0,48.11,351.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 G 40MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30104007,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4705.68,45.9,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM 3.5MM SCR ELLI",SUP-682.104,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"PHCS [10601]",PHCS,,2769.48,70,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ROCHESTER-PEAN CURVE 14IN HEMOSTATIC",SUP-16-1130,CDM,S27200284,LOCAL,0272,RC,,,both,,,456.52,136.96,"FIRST HEALTH [10303]","First Health",,365.22,80,,,,,0,53.09,388.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cryoglobulin",PX-301000170,CDM,82595,CPT,0301,RC,,,both,,,105.30,31.59,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,89.51,"per diem",
"SHELL ACETABULAR 50MM HIP MULTIHOLE R3 STD STERILE",SUP-71338664,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"FIRST HEALTH [10303]","First Health",,12709.8,80,,,,,0,1847.69,13504.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GATEWAY 135CM 20MM 2MM BALLOON DILATATION HYDROPHILIC",SUP-M0032072220200,CDM,C1725,HCPCS,0272,RC,,,both,,,9423.88,2827.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1116.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1096,8010.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 70MM CD HORIZON SPINE MULTIAXIAL CANNULATED",SUP-25630017570,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"CATH STERLING MONORAIL 135CM 40MM 6FR 4.5MM 4FR BALLOON",SUP-H74939031454010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Proctoidsigmoidoscopy W Bx",PX-750000144,CDM,45305,CPT,0750,RC,,,both,,,2377.00,713.1,"AETNA [10100]","Aetna HMO/PPO",,1889.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,276.45,2377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VORICONAZOLE 200 MG VIAL",RX-33010,CDM,J3465,HCPCS,0636,RC,00049-3190-28,NDC,both,1,UN,455.15,136.54,"CIGNA [10200]",Cigna,,40.47,,,,,,,17.95,386.88,"fee schedule",
"HC Mlh1 Gene Full Seq",PX-309000052,CDM,81292,CPT,0310,RC,,,both,,,2420.00,726,"KAISER [10500]",Kaiser,,1621.4,67,,,,,0,2.42,2057,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CORDIS PALMAZ 30MM 10MM XL BILIARY STAINLESS STEEL",SUP-P3110,CDM,C1876,HCPCS,0278,RC,,,both,,,4278.00,1283.4,"BLUE CROSS [10001]","Blue Cross HMO",,1676.98,39.2,,,,,0,497.53,3636.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 4MM 7FR 1-7-4MM SPACE J CURVE ABLATION",SUP-118332S,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"NOVANET [10819]",Novanet,,10298.25,75,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL MONOBLOCK UNIVERS REVERS CALCIUM PHOSPHATE 135D",SUP-AR-9501-04-135P,CDM,C1776,HCPCS,0278,RC,,,both,,,25760.70,7728.21,"CIGNA [10200]","Cigna Open Access",,8629.83,33.5,,5302.19,4377.88,6578.61,27,2995.97,21896.6,"percent of total billed charges",
"NDL BIOPSY PRECISIONPOINT TRANSPERINEAL ACC SYS BX",SUP-P1002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1777.50,533.25,"MULTIPLAN [10600]",Multiplan,,1510.88,85,,,,,0,206.72,1510.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 15FTX6IN WRIST IMMOB ROLL INTERLOCK",SUP-OG-6L2,CDM,S27000186,LOCAL,0270,RC,,,both,,,738.07,221.42,"FIRST HEALTH [10303]","First Health",,590.46,80,,,,,0,85.84,627.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRA-THIN DIAMOND 120CM 4CM 5FR 5MM .035IN BALLOON",SUP-M001164440,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"PHCS [10601]",PHCS,,992.25,70,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL ARTHREX UNIVERS REVERS 12 SHOULDER STERILE",SUP-AR-9501-12P,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"CIGNA [10200]","Cigna Local Plus",,5648,53.5,,5372.07,4581.20,7242.98,23,1227.78,8973.45,"percent of total billed charges",
"TIP CAUT 8MM ONE DA VINCI SI ENDOWRIST VESSEL SEALER",SUP-410322,CDM,S27000186,LOCAL,0270,RC,,,both,,,4105.50,1231.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2791.74,68,,,,,0,477.47,3489.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 4.5MM 8MM EVOS T8 CORTEX SELF TAP MINI PLATE",SUP-72402708,CDM,C1713,HCPCS,0278,RC,,,both,,,363.14,108.94,"CIGNA [10200]","Cigna Open Access",,206.63,56.9,,1144.80,304.56,2275.09,66,42.23,308.67,"percent of total billed charges",
"PHENOBARBITAL SODIUM 130 MG/ML VIAL FOR IM USE",RX-411684,CDM,J2560,HCPCS,0636,RC,00641-0477-21,NDC,both,1,ML,372.40,111.72,"BLUE CROSS [10001]","Blue Cross PPO",,70.33,,,,,,,7.76,316.54,"fee schedule",
"SCR BONE 5MM 62MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.062S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"CENTRALIZER STEM C-STEM PMMA OD14 MM HIP FEMUR CEMENT VOID S",SUP-961214500,CDM,C1776,HCPCS,0278,RC,,,both,,,842.40,252.72,"BLUE CROSS [10001]","Blue Cross HMO",,330.22,39.2,,5311.50,4717.44,5388.59,31,97.97,716.04,"percent of total billed charges",
"FRCP SURGICAL ALLIS 12IN TISSUE 5X6 TEETH STD PATTERN",SUP-50-0226,CDM,S27200284,LOCAL,0272,RC,,,both,,,671.33,201.4,"CIGNA [10200]","Cigna Open Access",,381.99,56.9,,,,,0,78.08,570.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KWIRE, HSC, 1.1MM X 127MM, DOUBLE TROCAR",SUP-KWIR-DT-11127,CDM,S27000186,LOCAL,0270,RC,,,both,,,234.90,70.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.32,199.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 10MM KNEE GVF POLYETHYLENE ROTATE",SUP-129405610,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1123.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 14X4MM COLOSSEUM 3.5D 12MM NONSTERILE LATEX",SUP-156.264,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"KAISER [10500]",Kaiser,,2306.48,67,,,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 300MM 6MM .018IN BALLOON",SUP-R51006030L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"MULTIPLAN [10600]",Multiplan,,2118.1,85,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBJR051002A,CDM,C1874,HCPCS,0278,RC,,,both,,,22163.40,6649.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6343.17,28.62,,,,,0,2577.6,18838.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL D 64X57.5MM LEFT SET SCR OPTION NEXGEN LCCK",SUP-00599401491,CDM,C1776,HCPCS,0278,RC,,,both,,,41440.14,12432.04,"CIGNA [10200]","Cigna Local Plus",,13053.64,31.5,,5372.07,4581.20,7242.98,23,4819.49,35224.12,"percent of total billed charges",
"STEM FEMORAL 17MM CEMENT FEMUR",SUP-71316017,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"CIGNA [10200]","Cigna Open Access",,7122.94,33.5,,5302.19,4377.88,6578.61,27,2472.83,18073.13,"percent of total billed charges",
"AUG FEMORAL 10MM TRIATHLON 3 RIGHT DISTAL KNEE TOTAL",SUP-5541-A-302,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,565.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,554.87,4055.34,"percent of total billed charges",
"LENS IOL +16 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.160,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502605602,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"FIRST HEALTH [10303]","First Health",,18290.16,80,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLYFLEX 50MM 9MM 12MM AIRWAY POLYESTER SILICONE SELF",SUP-7009,CDM,C1887,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2269.5,68,,,,,0,388.15,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 38X28X14MM BRIGADE 8D",SUP-6941438,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"BLUE CROSS [10001]","Blue Cross HMO",,13436.04,39.2,,8555.87,8555.87,8996.26,"1 through 10",3986.25,29134.26,"percent of total billed charges",
"INSRT TIBIAL 5 12MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-512-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]","Cigna Open Access",,4031.26,33.5,,5302.19,4377.88,6578.61,27,1399.51,10228.56,"percent of total billed charges",
"LENS IOL +5.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM POSTERIOR",SUP-PCB0000055,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BRACHYTHERAPY INTERFACE CONTROL SYSTEM BRACHYBALLOON",SUP-610-898,CDM,S27200284,LOCAL,0272,RC,,,both,,,584.62,175.39,"FIRST HEALTH [10303]","First Health",,467.7,80,,,,,0,67.99,496.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 12IN 4 PANEL ELASTIC CONTACT CLSR PROCARE",SUP-79-89220,CDM,S27000186,LOCAL,0270,RC,,,both,,,81.08,24.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.32,41.1,,,,,0,9.43,68.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM 2MM CHARCOT GORILLA GRIP PRECISION GUIDE BONE",SUP-P53-109-R212,CDM,C1713,HCPCS,0278,RC,,,both,,,13263.53,3979.06,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5451.31,41.1,,,,,0,1542.55,11274,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL COCHLEAR 8MM 4MM DERMALOCK BAHA TITANIUM HA 1 STAGE",SUP-93330,CDM,L8690,HCPCS,0278,RC,,,both,,,21042.00,6312.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2493.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2447.18,17885.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE VARIABLE ANGLE SELF TAPPING STERILE ANTERIOR",SUP-876-813,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRGMR NEROSTIMLTR MYSTIM MRI TECHNOLOGY EXT",SUP-97740,CDM,C1787,HCPCS,0270,RC,,,both,,,4830.00,1449,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,561.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 20MM GORE-TEX STD WALL STD WALLED RING",SUP-R20030030,CDM,C1768,HCPCS,0278,RC,,,both,,,6141.00,1842.3,"CIGNA [10200]","Cigna Local Plus",,3285.44,53.5,,,,,0,714.2,5219.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 5MM .0115IN AXIUM PRIME HELICAL",SUP-APB-5-15-HX-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,7169.10,2150.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2051.8,28.62,,,,,0,833.77,6093.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X20X5.9MM TITAN NANOLOCK 6D 8MM ANTERALIGN",SUP-46260855,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"CIGNA [10200]",Cigna,,17136,40,,,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE 14X11X7MM",SUP-245741,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 9MM 140CM 3MM CORONARY STERILE LATEX",SUP-453928,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.215,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 24MM THORACIC 2 PASS SEWING WOVEN",SUP-M00202175124P0,CDM,C1768,HCPCS,0278,RC,,,both,,,2857.58,857.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1943.15,68,,,,,0,332.34,2428.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DIVERGENCE-L 15X9.4X8MM ANTERIOR OBLIQUE LUMBAR",SUP-736528,CDM,S27800098,LOCAL,0278,RC,,,both,,,9177.00,2753.1,"KAISER [10500]",Kaiser,,6148.59,67,,,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45MMX10MM CLYDESDALE 6D PEEK-OPTIMA RADIOPAQUE",SUP-2968045,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"UHC [10700]","United Healthcare",,15154.02,63.3,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X18X11MM TRANSCONTINENTAL 6D SMALL PEEK",SUP-375.111CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3732.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 2 X 1 HELICAL FINISHING COIL",SUP-10HFN-02001,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"BLUE CROSS [10001]","Blue Cross PPO",,4054.5,39.2,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 401222A MDII 22X23 SVC FEE",SUP-401222A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 6MM X 10CM",SUP-M0035476100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS [10001]","Blue Cross PPO",,5532.94,39.2,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SPINAL SPACER W14.5XH7XL12MM 7DEG CERVICAL LORDOSIS PR",SUP-VG1C-T57P,CDM,S27800098,LOCAL,0278,RC,,,both,,,5865.00,1759.5,"BLUE CROSS [10001]","Blue Cross PPO",,2299.08,39.2,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 10MM EXTREME LATERAL INTERBODY FUSION 2 SIDE MODULAR",SUP-1941110P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3726,27,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VIA CANCELLOUS DEMINERALIZE CORTICAL BONE 10CC",SUP-VCAFMX-100000,CDM,S27800098,LOCAL,0278,RC,,,both,,,20790.00,6237,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2463.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 36MM TRICUSPID CONTOUR 3D TITANIUM",SUP-690R36,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Open Access",,4391.85,33.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT NEUROSURGICAL CSF REGULAR MEDIUM PRESSURE UNITIZED KIT",SUP-46024,CDM,S27800098,LOCAL,0278,RC,,,both,,,9284.23,2785.27,"CIGNA [10200]",Cigna,,6313.28,68,,,,,0,1079.76,7891.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM UNIVERS REVERS POROUS GLENOID PERIPHERAL",SUP-AR-9563-40,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"BLUE CROSS [10001]","Blue Cross HMO",,234.17,39.2,,957.42,156.86,7483.26,51,69.48,507.77,"percent of total billed charges",
"HEAD FEMORAL 40MM HIP BIOLOX DELTA BIOLOX OPTION G7",SUP-650-1058,CDM,C1776,HCPCS,0278,RC,,,both,,,13896.60,4168.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3752.08,27,,,,,0,1616.17,11812.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE FEMORAL 30MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-151101202,CDM,C1776,HCPCS,0278,RC,,,both,,,16151.52,4845.46,"BLUE CROSS [10001]","Blue Cross PPO",,6331.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",1878.42,13728.79,"percent of total billed charges",
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC",242,MS-DRG,,,,,,,inpatient,,,128980.84,38694.25,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mra Abdomen W Cntrst",PX-610000043,CDM,74185,CPT,0610,RC,,,both,,,4617.90,1385.37,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($970.52). Procedures 2 - 999, Per diem ($485.26).",,,,0,,,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 130CM 80MM 5MM BALLOON DILATATION",SUP-ADM05008013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 152MM",SUP-9402-VC-006,CDM,C1830,HCPCS,0272,RC,,,both,,,1096.20,328.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 150MM 4MM BALLOON",SUP-U3575415,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AMINO ACID 4.25 % NO.1 IN DEXTROSE 5 % INTRAVENOUS SOLUTION",RX-27927,CDM,J3490,HCPCS,0258,RC,00338-1089-04,NDC,both,2000,ML,452.70,135.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Kit Cvp Cath Triple",PX-E27200241,CDM,C1751,HCPCS,0272,RC,,,both,,,599.50,179.85,"FIRST HEALTH [10303]","First Health",,479.6,80,,,,,0,69.72,509.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETERIZATION 4FR 21GA 3 1/8IN .018IN 2 LUMEN SPRING",SUP-AK-15402,CDM,C1751,HCPCS,0272,RC,,,both,,,302.76,90.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,124.43,41.1,,,,,0,35.21,257.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4MM SABRETOOTH COOLCUT CURVE STAINLESS",SUP-AR-8400CST,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"CIGNA [10200]",Cigna,,381.7,68,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +26 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.260,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plasma Hemoglobin",PX-301000458,CDM,83051,CPT,0301,RC,,,both,,,189.05,56.71,"CIGNA [10200]","Cigna Local Plus",,16.08,,,,,,,0.01,160.69,"fee schedule",
"BIT DRILL 1.9MM STD TWIST",SUP-MFT-072-19,CDM,S27200284,LOCAL,0272,RC,,,both,,,1409.40,422.82,"CIGNA [10200]",Cigna,,958.39,68,,,,,0,163.91,1197.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X18X8MM COROENT XL PEEK TLIF RADIOLUCENT",SUP-6908855,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9765.36,41.1,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 150CM 200MM 7MM BALLOON DILATATION PACLITAXEL",SUP-H74939419702010,CDM,C2623,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9149.4,68,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 140MM 22MM DHS/DCS STAINLESS STEEL CONDYLAR",SUP-280.4,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1236.5,68,,,,,0,211.48,1545.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR .083IN 13CM ROBUST VALVE SPLITTABLE WITHOUT",SUP-PLSX-1006,CDM,C1892,HCPCS,0272,RC,,,both,,,304.50,91.35,"FIRST HEALTH [10303]","First Health",,243.6,80,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Thorac Spine WO Cntrst",PX-352000011,CDM,72128,CPT,0352,RC,,,both,,,2953.08,885.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($377.70). Procedures 2 - 999, Per diem ($188.85).",,,,0,,,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 27MM 4MM BALLOON DILATATION DURATRAC",SUP-NCEUP4027X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET",RX-24216,CDM,,,0637,RC,00904-7440-61,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SWAN-GANZ VIP 110CM 7.5FR PULMONARY ARTERY OXIMETRY",SUP-782F75M,CDM,C1751,HCPCS,0272,RC,,,both,,,1595.54,478.66,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DXTERITY 100CM 6FR .056IN JUDKINS RIGHT 5 CURVE",SUP-DXT6JR50,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 7X4CM AXIS TUTOPLAST DERMIS ALLOGRAFT",SUP-939247,CDM,C1762,HCPCS,0278,RC,,,both,,,10294.80,3088.44,"CIGNA [10200]","Cigna Local Plus",,5507.72,53.5,,,,,0,1197.29,8750.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 1.5MM 3MM 1MM MICRON PORP EAR TITANIUM",SUP-70142036,CDM,L8613,HCPCS,0278,RC,,,both,,,2189.85,656.95,"BLUE CROSS [10001]","Blue Cross PPO",,858.42,39.2,,,,,0,232.31,1861.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 5592-53  LEAD CAP SP BI SIL DWNSIZE",SUP-5592-53,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]","Cigna Local Plus",,2999.75,53.5,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM FASTPITCH LOCK HIGH PITCH STERILE LATEX FREE",SUP-SD21,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUE DILATATION 110CM 4.5CM 28MM BALLOON DILATATION OTW",SUP-0284514,CDM,C1725,HCPCS,0272,RC,,,both,,,7590.00,2277,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5161.2,68,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH THERMOCOOL SF 115CM 8FR 3.5MM FJ CURVE",SUP-BNI35FJH,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH WOLVERINE CUTTING BALLOON (MR) 6MM X 3.25",SUP-H74939401063250,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 90X12.5X1.19MM INTREX",SUP-507134300,CDM,S27200284,LOCAL,0272,RC,,,both,,,323.12,96.94,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 5CMX10MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-3-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2.7MM 20MM T10 FULL THREAD STARDRIVE NONSTERILE",SUP-657120,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"MULTIPLAN [10600]",Multiplan,,687.4,85,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 TWINFIX ULTRA ULTRABRAID PRELOAD COBRAID",SUP-72202613,CDM,C1713,HCPCS,0278,RC,,,both,,,2039.63,611.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,583.74,28.62,,,,,0,237.21,1733.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM T10 FULL THREAD STARDRIVE NONSTERILE",SUP-657120,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"BLUE CROSS [10001]","Blue Cross HMO",,317.01,39.2,,957.42,156.86,7483.26,51,94.05,687.4,"percent of total billed charges",
"ANCHOR SUT 5MM HEALICOIL PK KNOTLESS SELF TAP",SUP-72205138,CDM,C1713,HCPCS,0278,RC,,,both,,,3368.25,1010.47,"CIGNA [10200]","Cigna Open Access",,1916.53,56.9,,1144.80,304.56,2275.09,66,391.73,2863.01,"percent of total billed charges",
"ANCHOR SUT 4.75MM OMEGA 1 ARM KNOTLESS PEEK STERILE LATEX",SUP-3910500471,CDM,C1713,HCPCS,0278,RC,,,both,,,2962.50,888.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,344.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",344.54,2518.13,"percent of total billed charges",
"SCREW BONE 2.4MM 30MM TITANIUM CORTICAL HAND SELF TAPPING NO",SUP-401.530.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"FIRST HEALTH [10303]","First Health",,477.18,80,,,,,0,69.37,507.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 22MM DCP STAINLESS STEEL CORTICAL HAND SELF",SUP-200.822,CDM,C1713,HCPCS,0278,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross PPO",,143.24,39.2,,957.42,570.23,957.42,28,42.5,310.59,"percent of total billed charges",
"SCR BONE 12.7MM 90MM DHS/DCS STAINLESS STEEL CONDYLE HIP LAG",SUP-280.290S,CDM,C1713,HCPCS,0278,RC,,,both,,,2333.10,699.93,"AETNA [10100]","Aetna HMO/PPO",,1854.81,79.5,,1521.93,481.35,16760.95,30,271.34,1983.14,"percent of total billed charges",
"SCR BONE 3.5MM 5MM 52MM LCP STAINLESS STEEL TIBIA T15",SUP-212.122,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"CIGNA [10200]","Cigna Open Access",,487.8,56.9,,1144.80,304.56,2275.09,66,99.7,728.71,"percent of total billed charges",
"SCR BONE 3.5MM 20MM T15 LOCK MULTIDIRECTIONAL NONSTERILE",SUP-110018020,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,219.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",215.88,1577.81,"percent of total billed charges",
"CORTICAL SCREW 4MM X 42MM",SUP-HTN-U-4-42,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"MULTIPLAN [10600]",Multiplan,,1321.92,85,,,,,0,180.87,1321.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM TRIGEN FEMUR LOW PROFILE",SUP-71645435,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,245.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",240.69,1759.12,"percent of total billed charges",
"SCR INTERFERENCE REGENESORB 25MM 10MM SOLID OPEN",SUP-72204408,CDM,C1713,HCPCS,0272,RC,,,both,,,2774.03,832.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1140.13,41.1,,,,,0,1140.13,1755.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 22MM PRESS FIT FLUTED TRIATHLON KNEE",SUP-5565-S-022,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"MULTIPLAN [10600]",Multiplan,,4026.54,85,,,,,0,550.92,4026.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 20MM 4.5MM AEQUALIS REVERSED GLENOID TITANIUM",SUP-VDV220,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,445.33,28.62,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 25MM COMPREHENSIVE 3.5MM SHOULDER FIX ANGLE",SUP-180552,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"NOVANET [10819]",Novanet,,1167,75,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.405,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"NOVANET [10819]",Novanet,,1038.1,75,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 420MM 4.75MM 3.5MM CCM PLUS STAINLESS STEEL",SUP-7753806,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8MM 255MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-408-255,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM AEQUALIS TITANIUM SHOULDER LOCKING",SUP-DWD035,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"KAISER [10500]",Kaiser,,1042.52,67,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 360MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.257S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"BLUE CROSS [10001]","Blue Cross PPO",,4867.99,39.2,,957.42,570.23,957.42,28,1444.25,10555.59,"percent of total billed charges",
"PLATE SPINAL 42MM CODA ANTERIOR CERVICAL LEVEL 3 NONSTERILE",SUP-102203042,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM AEQUALIS TITANIUM SHOULDER LOCKING",SUP-DWD035,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",180.96,1322.6,"percent of total billed charges",
"SCR BONE 7.5MM 80MM TITANIUM SELF TAP CANNULATED STERILE",SUP-04.353.880S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1128.86,45.9,,,,,0,286.03,2090.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 360MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.257S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"MULTIPLAN [10600]",Multiplan,,10555.59,85,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9.5MM 11MM 160MM HUMERAL LEFT MULTILOC INTRAMEDULLARY",SUP-04.016.039S,CDM,C1713,HCPCS,0278,RC,,,both,,,10722.60,3216.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4406.99,41.1,,,,,0,1247.04,9114.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.9MM SHORT PUSHLOCK BIOCOMPOSITE",SUP-AR-8923BC,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.00,945,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,373.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,366.35,2677.5,"percent of total billed charges",
"PLATE 14X6MM COALITION AGX BONE SPINE",SUP-1128.1206,CDM,C1713,HCPCS,0278,RC,,,both,,,12420.00,3726,"KAISER [10500]",Kaiser,,8321.4,67,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM 32X16X2.5MM TITANIUM 2 LEVEL PREBENT SKYLINE BONE",SUP-186802032,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1262.14,28.62,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW LOWPROFILE 6.5X25MM",SUP-010-55-025,CDM,C1713,HCPCS,0278,RC,,,both,,,2799.97,839.99,"AETNA [10100]","Aetna HMO/PPO",,2225.98,79.5,,1521.93,481.35,16760.95,30,325.64,2379.97,"percent of total billed charges",
"SCR BONE 5MM 35MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4435,CDM,C1713,HCPCS,0278,RC,,,both,,,3112.50,933.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,368.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",361.98,2645.63,"percent of total billed charges",
"SCREW POLYAXIAL LOCKING 3.0MM X 10MM CANNULATED COCR",SUP-PALS-30100-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,189.34,1383.8,"percent of total billed charges",
"SCR INTERFERENCE HA PLLA 20MM 6MM ACL PCL ABSORBABLE BIOSURE",SUP-72201768,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"ANCHOR SUT 4.5MM HEALIX ACL/PCL ARTHROSCOPIC PEEK",SUP-222205,CDM,C1713,HCPCS,0278,RC,,,both,,,4160.70,1248.21,"CIGNA [10200]","Cigna Open Access",,2367.44,56.9,,1144.80,304.56,2275.09,66,483.89,3536.6,"percent of total billed charges",
"SCR BONE 8.5MM 35MM TSRH-3D TITANIUM SHORT POST SPINE",SUP-8372835,CDM,C1713,HCPCS,0278,RC,,,both,,,2361.60,708.48,"KAISER [10500]",Kaiser,,1582.27,67,,,,,0,274.65,2007.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 500MM 6MM EVEREST CONTOUR TITANIUM 2 HEXAGONAL",SUP-2901-B660500,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 4.75MM SOLERA CD HORIZON CURVE PREBENT COCR",SUP-1475001090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW POLYAXIAL LOCKING 3.0MM X 38MM CANNULATED COCR",SUP-PALS-30380-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1822.50,546.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,215.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",211.96,1549.13,"percent of total billed charges",
"RING EXTERNAL FIXATION 150MM MAXFRAME FULL ALUMINUM",SUP-03.312.150,CDM,C1713,HCPCS,0278,RC,,,both,,,8122.27,2436.68,"PHCS [10601]",PHCS,,5685.59,70,,,,,0,944.62,6903.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TIGHTROPE II FIBERTAPE FIXATION BONE TENDON BONE",SUP-AR-1588BTB-IB,CDM,C1713,HCPCS,0278,RC,,,both,,,4673.03,1401.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,543.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",543.47,3972.08,"percent of total billed charges",
"ROD SPINAL 40MM VIPER 2 LORDOTIC TITANIUM MIS",SUP-186788040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"PLATE 58MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SYSTEM 6",SUP-02.527.069,CDM,C1713,HCPCS,0278,RC,,,both,,,7813.91,2344.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,925.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,908.76,6641.82,"percent of total billed charges",
"SCR INTERFERENCE HA 20MM 9MM ACL BIOSURE",SUP-72201780,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL STRAIGHT 90MM TITANIUM 3X1 HOLE COMPRESSION 3DI",SUP-5920601L,CDM,C1713,HCPCS,0278,RC,,,both,,,14848.80,4454.64,"AETNA [10100]","Aetna HMO/PPO",,11804.8,79.5,,1521.93,481.35,16760.95,30,1726.92,12621.48,"percent of total billed charges",
"IMPL TOE JOINT 2.75MM HAMMERTUBE 10D PEEK CANNULATED KIT",SUP-P40-002-0275-SK,CDM,C1713,HCPCS,0278,RC,,,both,,,8607.75,2582.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3537.79,41.1,,,,,0,1001.08,7316.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 1 CTX 18IN CONTROL RELEASE MONOFILAMENT MULTIPACK",SUP-Z765D,CDM,S27200284,LOCAL,0272,RC,,,both,,,221.15,66.34,"KAISER [10500]",Kaiser,,148.17,67,,,,,0,25.72,187.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM RADIUS DISTAL VOLAR NONLOCK 3 LEAD TAPER",SUP-131227212,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"BLUE CROSS [10001]","Blue Cross PPO",,333.4,39.2,,957.42,570.23,957.42,28,98.91,722.93,"percent of total billed charges",
"NAIL 11MM 440MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.164S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5103.94,41.1,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELLIPSE NEXT GENERATION DR 36",SUP-CD2411-36C,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"BLUE CROSS [10001]","Blue Cross PPO",,15899.52,39.2,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aep Thrshld Est Mlt Freq I&R",PX-471000014,CDM,92652,CPT,0471,RC,,,both,,,1504.00,451.2,"FIRST HEALTH [10303]","First Health",,1203.2,80,,,,,0,174.92,1278.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aep Thrshld Est Mlt Freq I&R",PX-471000014,CDM,92652,CPT,0471,RC,,,both,,,1504.00,451.2,"CIGNA [10200]","Cigna Open Access",,855.78,56.9,,,,,0,174.92,1278.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.118,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"PHCS [10601]",PHCS,,792.89,70,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORTHOLOC 3DI FOOT RECONSTRUCTION SYSTEM NON-LOCKING SCREW N",SUP-58812716,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"CIGNA [10200]","Cigna Local Plus",,455.02,53.5,,3978.14,359.25,3978.14,24,98.91,722.93,"percent of total billed charges",
"FIXTR EXTERNAL FIXATION MINIRAIL HORIZONTAL AXIS ARTICULATE",SUP-M111,CDM,C1713,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"CIGNA [10200]",Cigna,,4785.84,68,,1831.33,1831.33,1831.33,16,818.52,5982.3,"percent of total billed charges",
"ROD SPINAL 90MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000090,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,188.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",188.41,1377,"percent of total billed charges",
"SCR BONE 7.3MM 95MM LCP STAINLESS STEEL FULL THREAD CONDYLAR",SUP-02.207.095,CDM,C1713,HCPCS,0278,RC,,,both,,,1705.35,511.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1159.64,68,,,,,0,198.33,1449.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8-6.5MM 40MM CREO SPINE 2 OUTER DIAMETER",SUP-5119.2242,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AR40E +10.5 D 3 PIECE LENS",SUP-AR40E00105,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"BLUE CROSS [10001]","Blue Cross PPO",,365.15,39.2,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT FLOWABLE 5CC OSTEOAMP SELECT",SUP-OAFL-05,CDM,C1713,HCPCS,0278,RC,,,both,,,12209.90,3662.97,"CIGNA [10200]",Cigna,,4883.96,40,,1831.33,1831.33,1831.33,16,1420.01,10378.42,"percent of total billed charges",
"CATH LAUNCHER 6FR .071IN SHORT AMPLATZ LEFT 1 CURVE GUIDING",SUP-LA6SAL10,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"UHC [10700]","United Healthcare",,231.3,63.3,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE MICRO 90CM 10CM 3MM BALLOON DILATATION",SUP-G26608,CDM,C1725,HCPCS,0272,RC,,,both,,,3112.43,933.73,"FIRST HEALTH [10303]","First Health",,2489.94,80,,,,,0,361.98,2645.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION 3.5MM CERCLAGE HEXAGONAL T25 STARDRIVE",SUP-04.221.003S,CDM,C1713,HCPCS,0278,RC,,,both,,,1147.61,344.28,"BLUE CROSS [10001]","Blue Cross PPO",,449.86,39.2,,957.42,570.23,957.42,28,133.47,975.47,"percent of total billed charges",
"CMPNT PATELLAR 10MM 27MM SYMMETRIC DURACON DURATION KNEE",SUP-6642-2-627,CDM,C1776,HCPCS,0278,RC,,,both,,,3506.63,1051.99,"AETNA [10100]","Aetna HMO/PPO",,2787.77,79.5,,10981.53,8986.79,12413.38,12,407.82,2980.64,"percent of total billed charges",
"SCR BONE 2.7MM 5MM 24MM DCP STAINLESS STEEL STD CORTICAL",SUP-202.024,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CIGNA [10200]","Cigna Open Access",,199.9,56.9,,1144.80,304.56,2275.09,66,40.86,298.61,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 28CM 5FR .035",SUP-M006192124090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,173.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINR ACTB G7 G 36MM E1 HIP HW",SUP-010000937,CDM,C1776,HCPCS,0278,RC,,,both,,,12282.00,3684.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1428.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1428.4,10439.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN SX ENDO HEPARIN 35 RO 9MMX7.5CM 8FR 120CMCATH",SUP-VBHR090702A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"PHCS [10601]",PHCS,,14888.16,70,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 11MM 38MM ASYMMETRIC TRIATHLON POLYETHYLENE",SUP-5551-L-381,CDM,C1776,HCPCS,0278,RC,,,both,,,4478.10,1343.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,520.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,520.8,3806.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 180CM 5.5CM 18-19-20MM 7.5FR ESOPHAGEAL",SUP-M00558440,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"NOVANET [10819]",Novanet,,1236.77,75,,,,,0,1236.77,1236.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 200MM 5FR 4MM .018IN SHORT BALLOON",SUP-V1840200,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,650.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 90MM 18MM 75CM ENDOPROSTHESIS VENOUS CATH",SUP-H74912044189070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"KAISER [10500]",Kaiser,,5778.75,67,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 8MM KNEE UNICONDYLAR RIGHT MEDIAL LEFT",SUP-102408600,CDM,C1776,HCPCS,0278,RC,,,both,,,15980.40,4794.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4314.71,27,,,,,0,1858.52,13583.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 7 KNEE CEMENT REVISION ROTATE PLATFORM",SUP-1506-60-007,CDM,C1776,HCPCS,0278,RC,,,both,,,22629.60,6788.88,"AETNA [10100]","Aetna HMO/PPO",,17990.53,79.5,,10981.53,8986.79,12413.38,12,2631.82,19235.16,"percent of total billed charges",
"SCR BONE 10.5MM 90MM GAMMA3 TITANIUM TROCHANTERIC HIP LAG",SUP-3060-0090S,CDM,C1713,HCPCS,0278,RC,,,both,,,3906.00,1171.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,462.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",454.27,3320.1,"percent of total billed charges",
"CMPNT FEMORAL CRUCIATE STABILIZE CEMENTED PFC SIGMA TC3 4 71",SUP-960089,CDM,C1776,HCPCS,0278,RC,,,both,,,27588.96,8276.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3269.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3208.6,23450.62,"percent of total billed charges",
"HC Ins Mark Thor for Rt Perq",PX-361000452,CDM,32553,CPT,0360,RC,,,both,,,8006.06,2401.82,"FIRST HEALTH [10303]","First Health",,6404.85,80,,,,,0,8.01,6805.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD 70CM 5FR URETERAL POLYURETHANE CONE TIP ADPTR KINK",SUP-138008,CDM,C1758,HCPCS,0272,RC,,,both,,,103.05,30.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,70.07,68,,,,,0,11.98,87.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Access Av Grft Thromb Stent",PX-361000439,CDM,36906,CPT,0361,RC,,,both,,,49992.03,14997.61,"FIRST HEALTH [10303]","First Health",,39993.62,80,,,,,0,5284,42493.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCALE SPRING C5KG 8X2X1IN .01ML",SUP-5K3582Z,CDM,S27000186,LOCAL,0270,RC,,,both,,,241.43,72.43,"AETNA [10100]","Aetna HMO/PPO",,191.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.08,205.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 130CM 250MM 5MM BALLOON DILATATION",SUP-ADM05025013P,CDM,C2623,HCPCS,0272,RC,,,both,,,14007.00,4202.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR 5MM ACMI ELITE",SUP-M0068804111,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MALECOT 35CM 24FR SUPRAPUBIC STENT LARGE OPEN NEPHRSTMY",SUP-M001224130,CDM,C1729,HCPCS,0272,RC,,,both,,,599.40,179.82,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CPLR ANASTOMOSIS RING PIN ULTRASONIC DOPPLER 20MHZ GEM",SUP-GEM2755-FC,CDM,S27200284,LOCAL,0272,RC,,,both,,,7569.30,2270.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX 75CM 60MM 4MM BALLOON DILATATION DRUG COATED",SUP-LX3575460V,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT SURGICAL OSTEOCOOL BONE ACCESS 10GA",SUP-OCN002,CDM,C1886,HCPCS,0272,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RANGER 135CM 60MM 5MM BALLOON DILATATION PACLITAXEL OTW",SUP-H74939419500610,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM SHILEY BRONCHO-CATH STD CPAP ADJUSTABLE VALVE 2",SUP-85006,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.23,58.57,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MESH SURGICAL PARIETEX 6X4IN HERNIA 2D FLAT SHEET RIGID",SUP-VTX1510,CDM,C1781,HCPCS,0278,RC,,,both,,,702.51,210.75,"BLUE CROSS [10001]","Blue Cross PPO",,275.38,39.2,,,,,0,81.7,597.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ANESTHESIA 21GA 4IN ANGLE MULTIPLE SURFACE INSULATE",SUP-ES-21100,CDM,S27200284,LOCAL,0272,RC,,,both,,,8107.50,2432.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,960.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 220MM 4MM BALLOON",SUP-LX1813042204F,CDM,C2623,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"PHCS [10601]",PHCS,,8452.5,70,,,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STELLAREX 135CM 200MM 6MM BALLOON DILATATION OTW DRUG",SUP-AB35SX060200135,CDM,C2623,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9149.4,68,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXIMA 70CM 4FR URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002001,CDM,C1758,HCPCS,0272,RC,,,both,,,82.25,24.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.57,69.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLOWGATE2 85CM 8FR GUIDING STAINLESS STEEL LARGE LUMEN",SUP-90485,CDM,C1725,HCPCS,0272,RC,,,both,,,9696.36,2908.91,"MULTIPLAN [10600]",Multiplan,,8241.91,85,,,,,0,1127.69,8241.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEDG CARDIOVASCULAR WHITE 9.5X4.8MM THK1.5MM Y PTFE FIRM",SUP-PCP30,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Local Plus",,13.38,53.5,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM BONE CEMENT KIT PREPARATION PLUG INSRT BRUSH CURET",SUP-0206710000,CDM,S27800098,LOCAL,0278,RC,,,both,,,752.88,225.86,"FIRST HEALTH [10303]","First Health",,602.3,80,,,,,0,87.56,639.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 28MM TI",SUP-MTC-37280-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"BLUE CROSS [10001]","Blue Cross HMO",,488.98,39.2,,957.42,156.86,7483.26,51,145.07,1060.29,"percent of total billed charges",
"LEAD 4965-15  LEAD-UNI EPI STEROID 15CM",SUP-4965-15,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3812.76,68,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 20MM 2.5MM BALLOON DILATATION STERILE",SUP-225-203-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION",RX-10162,CDM,J1631,HCPCS,0636,RC,70710-1463-01,NDC,both,1,ML,332.11,99.63,"BLUE CROSS [10001]","Blue Cross HMO",,10.26,,,,,,,7.88,282.29,"fee schedule",
"STENT SUPERA 80MM 120CM 4.5MM 6FR VASCULAR NITINOL",SUP-S-45-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1192.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 6MM ROUND CARBIDE STERILE LATEX FREE",SUP-5820110060C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1910.03,573.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1298.82,68,,,,,0,222.14,1623.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERPICC 70CM 6FR .018IN CENTRAL VENOUS STAINLESS",SUP-3386155,CDM,C1751,HCPCS,0272,RC,,,both,,,769.50,230.85,"KAISER [10500]",Kaiser,,515.57,67,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 18GA 8CM POWERGLIDE PRO BIOPATCH FULL INSRT",SUP-F318088T,CDM,C1751,HCPCS,0272,RC,,,both,,,884.36,265.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,102.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,102.85,751.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM TITANIUM CORTICAL",SUP-PANL-35280-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,899.10,269.73,"FIRST HEALTH [10303]","First Health",,719.28,80,,,,,0,104.57,764.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IFUSE IMPL SYSTEM 40MM 7MM SPINAL FIXATION SACROILIAC",SUP-7040M-90,CDM,C1713,HCPCS,0278,RC,,,both,,,21082.95,6324.88,"NOVANET [10819]",Novanet,,15812.21,75,,,,,0,2451.95,17920.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH HEARTSPAN 120D FIX CURVE TAPER 60CM 8.5FR GUIDING",SUP-FCL-160-03,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VISTA BRITE TIP GUIDE CATHETER 6F .070 XB 3.5 ECO PK",SUP-6700540E,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"KAISER [10500]",Kaiser,,279.79,67,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.9H 58MM 3 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009358,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"FILLER BONE VOID 10CC 1-2MM GRANULE MAGNETOS EASYPACK PUTTY",SUP-703-053-US,CDM,C1713,HCPCS,0278,RC,,,both,,,20317.50,6095.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2362.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",2362.93,17269.88,"percent of total billed charges",
"ROD EXTERNAL FIXATION 600MM 11MM CARBON FIBER MR CONDITIONAL",SUP-394.91,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"SCR BONE 3MM 24MM 8MM STAINLESS STEEL LONG THREAD FOOT HAND",SUP-02.226.124,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"MULTIPLAN [10600]",Multiplan,,1398.42,85,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 229MM 2.4MM STEINMANN STYLE 6",SUP-18700269,CDM,C1713,HCPCS,0278,RC,,,both,,,152.25,45.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,43.57,28.62,,,,,0,17.71,129.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPEEDBRIDGE FIBERTAK 3.9MM FIXATION BIOCOMPOSITE",SUP-AR-9928BC-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,18488.93,5546.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2190.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2150.26,15715.59,"percent of total billed charges",
"SCR BONE 2MM 12MM MINI-MONSTER SHORT THREAD HEAD NONSTERILE",SUP-P20-120-012S,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,164.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",164.86,1204.88,"percent of total billed charges",
"ANCHOR SUT 5.5MM 2 FULL THREAD BIO-CORKSCREW TIGERTAIL",SUP-AR-1927BFT,CDM,C1713,HCPCS,0278,RC,,,both,,,1433.50,430.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,166.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",166.72,1218.48,"percent of total billed charges",
"WASHER ORTHOPEDIC 4 MM CANNULATED SCR STERILE",SUP-04.353.904S,CDM,C1713,HCPCS,0278,RC,,,both,,,258.56,77.57,"MULTIPLAN [10600]",Multiplan,,219.78,85,,,,,0,30.07,219.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM MOUNTAINEER TITANIUM SPINE OCCIPITOCERVICAL",SUP-188362025,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG BONE 20MM 2.3MM CORTICAL SMOOTH LOCKING STERILE",SUP-CO-S2320,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,517.75,68,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 60MM 5.5MM XL",SUP-5485560,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,348.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,341.92,2499,"percent of total billed charges",
"PLATE STD 39MM STAINLESS STEEL 2.4/2.7MM SCR VARIABLE ANGLE",SUP-02.211.246,CDM,C1713,HCPCS,0278,RC,,,both,,,5823.05,1746.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,677.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",677.22,4949.59,"percent of total billed charges",
"SCR BONE 3.5MM 20MM VUEPOINT II SPINE FAVORED ANGLE",SUP-8975520,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"MULTIPLAN [10600]",Multiplan,,3570,85,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 44MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.216,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"BLUE CROSS [10001]","Blue Cross PPO",,342.29,39.2,,957.42,570.23,957.42,28,101.55,742.2,"percent of total billed charges",
"ANCHOR SUT 4.75MM SWIVELOCK SHOULDER SELF PUNCH VENT",SUP-AR-2324BCM,CDM,C1713,HCPCS,0278,RC,,,both,,,1880.00,564,"BLUE CROSS [10001]","Blue Cross PPO",,736.96,39.2,,957.42,570.23,957.42,28,218.64,1598,"percent of total billed charges",
"STENT MEROPACK NASAL CLLGN HYALURONIC ACID SINUS DRSG",SUP-1520000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1080.00,324,"CIGNA [10200]",Cigna,,734.4,68,,,,,0,125.6,918,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE ENDOSCOPIC DISECT BRUSH FINISH RADIOPAQUE TIP 38CM 5",SUP-KT-9101,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.21,36.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.33,104.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 16MM LCP STAINLESS STEEL DISTAL RADIAL",SUP-02.210.116,CDM,C1713,HCPCS,0278,RC,,,both,,,959.36,287.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,440.35,45.9,,,,,0,111.57,815.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE CORTICAL 4.5 MM DIAMETER 58 MM LENGTH CANNULATED",SUP-214.76,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.61,466.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1057.81,68,,,,,0,180.92,1322.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 20MM PINNACLE GRIPTION TF DOME 4 POINT CUT",SUP-121720500,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"CIGNA [10200]","Cigna Local Plus",,613.19,53.5,,3978.14,359.25,3978.14,24,133.3,974.23,"percent of total billed charges",
"SCR SET STAINLESS STEEL MULTIAXIAL CD HORIZON MODULEX",SUP-559200006,CDM,C1713,HCPCS,0278,RC,,,both,,,4140.00,1242,"KAISER [10500]",Kaiser,,2773.8,67,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 240MM 3.2MM STD",SUP-3602240,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.2MM 28MM CORTICAL HEXAGON",SUP-HEX3.2-28,CDM,C1713,HCPCS,0278,RC,,,both,,,729.00,218.7,"NOVANET [10819]",Novanet,,546.75,75,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM VARIAX NONSTERILE",SUP-657414,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",94.05,687.4,"percent of total billed charges",
"FILLER BONE VOID 60CC .1-4MM CANCELLOUS ALLOGRAFT CHIPS",SUP-450754,CDM,C1713,HCPCS,0278,RC,,,both,,,7803.90,2341.17,"KAISER [10500]",Kaiser,,5228.61,67,,,,,0,907.59,6633.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE TITANIUM 20MM 7MM 1.5MM ACL PCL CANNULATED",SUP-7207001,CDM,C1713,HCPCS,0278,RC,,,both,,,1342.66,402.8,"PHCS [10601]",PHCS,,939.86,70,,,,,0,156.15,1141.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 25MM 3.5MM VERTEX SELECT PRECUT",SUP-7753725,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]","Cigna Local Plus",,754.35,53.5,,3978.14,359.25,3978.14,24,163.98,1198.5,"percent of total billed charges",
"INTRO TUBE 35CM 8FR 1.6MM FROVA RAPI-FIT INTUBATE ANGLE TIP",SUP-G57646,CDM,C1894,HCPCS,0272,RC,,,both,,,938.79,281.64,"FIRST HEALTH [10303]","First Health",,751.03,80,,,,,0,109.18,797.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Hypogastric Plexus",PX-761000051,CDM,64517,CPT,0761,RC,,,both,,,5968.00,1790.4,"CIGNA [10200]",Cigna,,2606,,"Per diem ($2,606).",,,,0,694.08,5968,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25X1.27MM INTREX",SUP-00507132400,CDM,S27200284,LOCAL,0272,RC,,,both,,,323.12,96.94,"CIGNA [10200]",Cigna,,219.72,68,,,,,0,37.58,274.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 15MM 4MM STAINLESS STEEL 1.1MM SHORT THREAD",SUP-02.226.015,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"NOVANET [10819]",Novanet,,1233.9,75,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X20 135CM SL",SUP-48007002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,99.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 NARROW KNEE LEFT CRUCIATE RETAIN CEMENT",SUP-42502006201,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"UHC [10700]","United Healthcare",,14472.09,63.3,,8601.07,8395.67,8601.07,"1 through 10",2658.93,19433.3,"percent of total billed charges",
"CATH WEBSTER 92CM 4MM 6FR 2-5-2MM SPACE D CURVE",SUP-D6DL252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,5326.80,1598.04,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE .038IN 10CM 2.5CM 5FR GUIDING STAINLESS",SUP-RSS502,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACEMKR CARDIAC .75CM 4.45X5.88CM ACCOLADE MRI LATITUDE NXT",SUP-L331,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"BLUE CROSS [10001]","Blue Cross PPO",,16307.2,39.2,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER TUMARK BREAST BIOPSY VISION BREVERA STD",SUP-TUMARK-BREV-S-V-02,CDM,A4648,HCPCS,0278,RC,,,both,,,942.84,282.85,"MULTIPLAN [10600]",Multiplan,,801.41,85,,,,,0,109.65,801.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FG GATEWAY OTW  US 3.50MM X 15MM",SUP-M0032072215350,CDM,C1725,HCPCS,0272,RC,,,both,,,9423.88,2827.16,"AETNA [10100]","Aetna HMO/PPO",,7491.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1096,8010.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC .99CM 5.37X8.18CM RESONATE HEARTLOGIC RIGHT",SUP-G447,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA [10200]",Cigna,,23088,40,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE 3X2IN ORIGINAL SURGICEL",SUP-1953S,CDM,S27200284,LOCAL,0272,RC,,,both,,,709.63,212.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,82.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,82.53,603.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON DISECT LAPAROSCOPIC KII 100MM 12MM 1 LATERAL",SUP-C0K16,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE STD 24.5CMX2MM POLYESTER SILICONE",SUP-TR200000,CDM,C1763,HCPCS,0278,RC,,,both,,,6955.20,2086.56,"MULTIPLAN [10600]",Multiplan,,5911.92,85,,,,,0,808.89,5911.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION BLUE 1.14MM ARMSTRONG V BEVEL GROMMET EAR",SUP-7014-0396,CDM,S27800098,LOCAL,0278,RC,,,both,,,108.80,32.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.65,92.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 3MM 1.5MM CORTEX CRANIOMAXILLOFACIAL TITANIUM",SUP-400.807.96,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,37.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",37.68,275.39,"percent of total billed charges",
"SCR BONE 5MM 45MM NAIL-EX TITANIUM FULL THREAD TIBIAL T25",SUP-04.015.535,CDM,C1713,HCPCS,0278,RC,,,both,,,1313.17,393.95,"MULTIPLAN [10600]",Multiplan,,1116.19,85,,,,,0,152.72,1116.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 29MM TORNIER AEQUALIS PERFORM STD SHOULDER",SUP-DWJ411,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1098.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1098.22,8026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CARTO XP THERMOCOOL SF 7.5FR B-D CURVE",SUP-BNI35BDH,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"AETNA [10100]","Aetna HMO/PPO",,14359.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 93MM TYPE 1 PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51108040,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7851.97,28.62,,,,,0,3190.72,23319.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN JUDKINS LEFT 5 CURVE",SUP-DXT6JL50,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 018 150CM 6CM 4MM BALLOON DILATATION",SUP-U815046,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IN.PACT 018 4.0 MM X 150 MM X 130 CM",SUP-IPU04015013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5489.64,68,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Arm/Hnd Lt",PX-510000098,CDM,29584,CPT,0761,RC,,,both,,,802.84,240.85,"CIGNA [10200]","Cigna Open Access",,802.84,,"Per diem ($2,181).",,,,0,93.37,802.84,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy",PX-750000087,CDM,,,0750,RC,,,both,,,3549.30,1064.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,420.59,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,412.78,3016.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 45X4.8MM DST SERIES TA TITANIUM THICK TISSUE",SUP-TA4548L,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.89,114.87,"PHCS [10601]",PHCS,,268.02,70,,,,,0,44.53,325.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM EDWARDS SAPIEN 3 COMMANDER DELIVERY SYSTEM",SUP-9600CM23A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21544.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR ANGIOGRAPHY NAMIC 3 200 PSI 5/16IN 28 THREAD ORIGINAL",SUP-H965914000311,CDM,S27000186,LOCAL,0270,RC,,,both,,,119.17,35.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.86,101.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BUSH URETERAL 5 FR",SUP-84120,CDM,C1758,HCPCS,0272,RC,,,both,,,1385.10,415.53,"FIRST HEALTH [10303]","First Health",,1108.08,80,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER VACUUM ASPIRATION DISPOSABLE DISPOSA-FILTER UTERINE",SUP-54298,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.72,14.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"REMIFENTANIL 2 MG INTRAVENOUS SOLUTION",RX-18400,CDM,,,0250,RC,63323-0724-01,NDC,both,1,UN,801.54,240.46,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Kit Transducer Neonatal",PX-E27200187,CDM,E27200187,LOCAL,0272,RC,,,both,,,118.80,35.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL STD 10MM KNEE GVF POLYETHYLENE ROTATE PLATFORM",SUP-129405410,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"MULTIPLAN [10600]",Multiplan,,8213.93,85,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE",RX-108850,CDM,,,0637,RC,77333-0951-25,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Screening Tramadol",PX-301000689,CDM,80373,CPT,0301,RC,,,both,,,88.00,26.4,"BLUE CROSS [10001]","Blue Cross PPO",,30.68,,"Fee schedule rate ($30.68).",,,,0,0.01,88,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM PROFILE 3D",SUP-680R34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"MULTIPLAN [10600]",Multiplan,,11143.5,85,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5-6 11MM KNEE XLPE POSTERIOR STABILIZED HIGH",SUP-71453222,CDM,C1776,HCPCS,0278,RC,,,both,,,13420.50,4026.15,"BLUE CROSS [10001]","Blue Cross HMO",,5260.84,39.2,,5311.50,4717.44,5388.59,31,1560.8,11407.43,"percent of total billed charges",
"AIRWAY LARYNGEAL 4.5 AIR-Q INTUBATING REMOVABLE CNCT MASK",SUP-10-3045,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.25,19.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.59,55.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Complex Procedure",PX-450000383,CDM,450000383,LOCAL,0361,RC,,,both,,,5625.90,1687.77,"CIGNA [10200]","Cigna Local Plus",,3009.86,53.5,,,,,0,654.29,4782.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) JENAVALVE PERICARDIAL TRANSCATHETER HEART VALVE SIZE",SUP-JV-2000-PY27,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"NOVANET [10819]",Novanet,,128250,75,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 5CM MIDAS REX MR8 3MM BALL DISSECTING DIAMOND LP",SUP-MR8-LP05BA30D,CDM,S27200284,LOCAL,0272,RC,,,both,,,2179.13,653.74,"NOVANET [10819]",Novanet,,1634.35,75,,,,,0,253.43,1852.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 1.5% DEXTROSE 2L LOW CALCIUM DIANEAL DIALYSIS PERITONEAL",SUP-5B9766,CDM,S27200284,LOCAL,0272,RC,,,both,,,463.90,139.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHELL ACETABULAR 54MM HIP SECTOR POROCOAT PINNACLE STERILE",SUP-121722054,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"CIGNA [10200]","Cigna Open Access",,3818.42,56.9,,5302.19,4377.88,6578.61,27,780.46,5704.15,"percent of total billed charges",
"INSRT TIBIAL 3 STD 12MM KNEE LEFT CRUCIATE SUB EVOLUTION MP",SUP-EIS3S12L,CDM,C1776,HCPCS,0278,RC,,,both,,,7569.30,2270.79,"CIGNA [10200]","Cigna Local Plus",,4049.58,53.5,,5372.07,4581.20,7242.98,23,880.31,6433.91,"percent of total billed charges",
"CATH GUIDER SOFTIP XF 100CM 5FR STRAIGHT GUIDING DURAFORM",SUP-M003101640,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"CIGNA [10200]","Cigna Open Access",,1424.28,56.9,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL 4.6 X 300MM CANNULATED 3/16  SQ. CONNECTION",SUP-P99-110-4630,CDM,S27000186,LOCAL,0270,RC,,,both,,,2085.00,625.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,242.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,242.49,1772.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL STANDARD+ KNEE LEFT CEMENT REVISION LCS",SUP-129429050,CDM,C1776,HCPCS,0278,RC,,,both,,,25958.52,7787.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7429.33,28.62,,,,,0,3018.98,22064.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET .75IN 20GA ANGLE DOWN INFUSION Y INJECTION SITE POWER",SUP-0672034,CDM,C2625,HCPCS,0272,RC,,,both,,,54.64,16.39,"NOVANET [10819]",Novanet,,40.98,75,,,,,0,6.35,46.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE? NC PLUS BALLOON NON-COMPLIANT 3.5 MM X 18 MM",SUP-235-183-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET",RX-24559,CDM,,,0250,RC,77333-0948-25,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 92CM 4MM 6FR 2-5-2MM SPACE A CURVE",SUP-D6TAL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"PHCS [10601]",PHCS,,3472.77,70,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SLIP-CATH BEACON TIP 40CM 4FR ANGLE KUMPE CURVE",SUP-G31018,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 37MMX12MMX20CM 24FR",SUP-TAC123720A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21614.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZEBRA UROLOGICAL 150CM 3CM .025IN URO-GLIDE NITINOL",SUP-M0066701091,CDM,C1769,HCPCS,0272,RC,,,both,,,447.74,134.32,"KAISER [10500]",Kaiser,,299.99,67,,,,,0,52.07,380.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM PFC SIGMA TC3 4 KNEE LEFT TITANIUM CEMENTED",SUP-960880,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"BLUE CROSS [10001]","Blue Cross PPO",,2011.29,39.2,,3949.44,3949.44,3949.44,"1 through 10",596.72,4361.21,"percent of total billed charges",
"PACK HEATING 24X15IN THERMAL-PAK OVER COTTON CANVAS NYLON",SUP-561728,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 30MM 135CM 7MM VASCULAR PERIPHERAL OTW",SUP-1012535-30,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE SMALL OVAL 240CM 2.4MM SENSATION LOOP SHORT THROW",SUP-M00562692,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.45,37.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,85.31,68,,,,,0,14.59,106.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR DISTRACTION 14MM SPINE CERVICAL ANTERIOR STAINLESS STEEL",SUP-MDS9091414,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.88,68.96,"MULTIPLAN [10600]",Multiplan,,195.4,85,,,,,0,26.74,195.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN JUDKINS LEFT 4 CURVE GUIDING",SUP-LA7JL40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 4IN 18GA 20GA PAJUNK SONOLONG TUOHY",SUP-TDL107,CDM,C9814,HCPCS,0272,RC,,,both,,,591.30,177.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,271.41,45.9,,,,,0,68.77,502.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL BLOCK 14X13",SUP-245341,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GERALD 7IN TISSUE IMPREGNATE TUNGSTEN CARBIDE",SUP-55-9049,CDM,S27200284,LOCAL,0272,RC,,,both,,,1302.56,390.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,597.88,45.9,,,,,0,151.49,1107.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GERALD 7IN TISSUE IMPREGNATE TUNGSTEN CARBIDE",SUP-55-9049,CDM,S27200284,LOCAL,0272,RC,,,both,,,1302.56,390.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,154.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,151.49,1107.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 34X24X12MM BRIGADE 8D NONSTERILE LATEX FREE",SUP-6941234,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"CIGNA [10200]","Cigna Local Plus",,10796.81,31.5,,16168.95,16168.95,16168.95,"1 through 10",3986.25,29134.26,"percent of total billed charges",
"EDWARDS EVOQUE VALVE (EVOQUE VALVE) 44 MM",SUP-9850EV44,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Puraply Am per Sq Cm",PX-E63600034,CDM,Q4196,HCPCS,0636,RC,,,both,,,753.50,226.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,89.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.29,640.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 10MM LCP STAINLESS STEEL DISTAL FIBULA T8",SUP-202.210,CDM,C1713,HCPCS,0278,RC,,,both,,,748.44,224.53,"CIGNA [10200]",Cigna,,508.94,68,,1831.33,1831.33,1831.33,16,87.04,636.17,"percent of total billed charges",
"CANN PERFUSION 15FR CORONARY ARTERY OSTIAL BEVELED TIP SOFT",SUP-30315,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 20CM 6FR .038IN PIGTAIL CURVE",SUP-M006155230120,CDM,C2617,HCPCS,0278,RC,,,both,,,1325.65,397.69,"PHCS [10601]",PHCS,,927.96,70,,,,,0,154.17,1126.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM CD HORIZON VOYAGER SPINE NONSTERILE",SUP-55850047545,CDM,C1713,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"FIRST HEALTH [10303]","First Health",,5934,80,,,,,0,862.66,6304.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC HIP GEL BAG COMPRESSION NONSTERILE LATEX",SUP-H-24-6-IP,CDM,S27000186,LOCAL,0270,RC,,,both,,,377.61,113.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,44.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.92,320.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 CT-3 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J328H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 12MM 140CM 4MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927412400,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]",Cigna,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR",RX-169394,CDM,,,0637,RC,59011-0410-20,NDC,both,1,UN,44.47,13.34,"NOVANET [10819]",Novanet,,33.35,75,,,,,0,5.17,37.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD STIMULATOR SPINE 70CM 4X8",SUP-SC-8336-70,CDM,C1778,HCPCS,0278,RC,,,both,,,31500.00,9450,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3732.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP POLAR CUP POROUS STEM COBALT CHROME",SUP-71703515,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]",Cigna,,9576,40,,5873.17,5873.17,5873.17,"1 through 10",2784.22,20349,"percent of total billed charges",
"SHIELD CONTAMINATION BLUE CATH-GARD 7-7.5FR CATH",SUP-ST-09880,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.14,31.84,"PHCS [10601]",PHCS,,74.3,70,,,,,0,12.34,90.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 13CM MIDAS REX MR8 3MM MATCH HEAD DISSECTING ND STERILE",SUP-MR8-ND13MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"AETNA [10100]","Aetna HMO/PPO",,2193.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT MASTERGRAFT MINI GRANULES PUTTY VOID FILLER 5",SUP-8600105,CDM,C1713,HCPCS,0278,RC,,,both,,,2593.50,778.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,307.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",301.62,2204.48,"percent of total billed charges",
"PROS OSSICULAR 2.5MM 3MM 1MM MICRON PORP EAR TITANIUM",SUP-70142028,CDM,S27000186,LOCAL,0270,RC,,,both,,,2235.00,670.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1519.8,68,,,,,0,259.93,1899.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 34MM CG FUTURE FLEXIBLE LOW PROFILE EYELET",SUP-638BL34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH SURGICAL 7.25MM BARRON CORNEAL NONVACUUM 4 GUIDE POST",SUP-K20-2075,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"KAISER [10500]",Kaiser,,358.18,67,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-207.014,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"KAISER [10500]",Kaiser,,183.33,67,,,,,0,31.82,232.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 7MM CEREPAK FREEFORM DETACHABLE",SUP-SCR120715,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS [10001]","Blue Cross PPO",,5184.53,39.2,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X5MM DIVERGENCE 12MM LORDOTIC NUCLEUS PULPOSUS",SUP-G6626525,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"PHCS [10601]",PHCS,,8694,70,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X5MM OVAL PARALLEL SPINE CORTICAL",SUP-17105,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BIOLOGICAL 2X2IN INTEGRA BOVINE CLLGN GLYCOSAMINOGLYCAN",SUP-MWM2021,CDM,C9363,HCPCS,0278,RC,,,both,,,28085.27,8425.58,"AETNA [10100]","Aetna HMO/PPO",,22327.79,79.5,,,,,0,3266.32,23872.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VERSATEX 15X15CM MONOFILAMENT POLYESTER",SUP-VTX1515X3,CDM,C1781,HCPCS,0278,RC,,,both,,,964.06,289.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,275.91,28.62,,,,,0,112.12,819.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 5MM ROUND STAINLESS STEEL DIAMOND FINE",SUP-E6250,CDM,S27200284,LOCAL,0272,RC,,,both,,,463.08,138.92,"PHCS [10601]",PHCS,,324.16,70,,,,,0,53.86,393.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 30MM QUICKSET 1 PIECE FLEXIBLE",SUP-227430500,CDM,C1713,HCPCS,0278,RC,,,both,,,3998.55,1199.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,473.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,465.03,3398.77,"percent of total billed charges",
"KIT DRNG 25CM 10FR 21GA FLEXIMA PLATINUM HYDROPHILIC",SUP-M001271970,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 LEFT KNEE POSTERIOR STABILIZED CEMENTED",SUP-5515F201,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4110,41.1,,6417.48,6417.48,6417.48,"1 through 10",1163,8500,"percent of total billed charges",
"SET INTRO 27IN 16FR FEMUR PTFE CURVED SHEATH HELICAL LOOP",SUP-LR-CSS16,CDM,C1893,HCPCS,0272,RC,,,both,,,3536.25,1060.87,"PHCS [10601]",PHCS,,2475.38,70,,,,,0,411.27,3005.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL CERVICAL 8X14X12MM 7DEG LORDOTIC PEEK COHERE",SUP-4081427P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"AMERIGROUP MEDICAID [20100]",Amerigroup,,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.25 X 12 RX US",SUP-1804325-12,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBJR060202A,CDM,C1874,HCPCS,0278,RC,,,both,,,19895.40,5968.62,"PHCS [10601]",PHCS,,13926.78,70,,,,,0,2313.84,16911.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VICTORY 18 300 CM 18G 1-PACK",SUP-H74939472300180,CDM,C1769,HCPCS,0272,RC,,,both,,,2077.50,623.25,"MULTIPLAN [10600]",Multiplan,,1765.88,85,,,,,0,241.61,1765.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRR 0.9PCT NACL 1000ML STRL",SUP-2B7231,CDM,S27200284,LOCAL,0272,RC,,,both,,,916.65,274.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,376.74,41.1,,,,,0,106.61,779.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28X10X11MM 8D EIT TLIF STERILE LATEX FREE",SUP-TUI81128,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM VERTEX STERILE",SUP-6956010,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"CIGNA [10200]","Cigna Open Access",,2251.19,56.9,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 8MM TI",SUP-VAN-25080-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"FIRST HEALTH [10303]","First Health",,777.6,80,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR CEMENTLESS HIGH OFFSET Z1 TITANIUM ALLOY",SUP-611202030,CDM,C1776,HCPCS,0278,RC,,,both,,,28967.40,8690.22,"AETNA [10100]","Aetna HMO/PPO",,23029.08,79.5,,10981.53,8986.79,12413.38,12,3368.91,24622.29,"percent of total billed charges",
"STYLET LEAD 75CM KIT STIFF QUICKSITE LEFT HEART TAPER 15CM",SUP-4078S/75/15,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,68.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PULLEY EXERCISE RANGEMASTER ECONORANGER SHOULDER NYLON 2",SUP-566516,CDM,S27000186,LOCAL,0270,RC,,,both,,,69.43,20.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,31.87,45.9,,,,,0,8.07,59.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 22MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G522,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4590,45.9,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ENDOSCOPIC 210CM MARK SPRING TIP STERILE DISPOSABLE",SUP-000150,CDM,C1769,HCPCS,0272,RC,,,both,,,761.40,228.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,88.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X20X8MM PIVOX 0D LATERAL OLIF25",SUP-2110150,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"CIGNA [10200]",Cigna,,10584,40,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM CROSSFT KNOTLESS BIOCOMPOSITE STERILE LATEX",SUP-CFKB-55S,CDM,C1713,HCPCS,0272,RC,,,both,,,4385.23,1315.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1802.33,41.1,,,,,0,1802.33,2775.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP BIPOLAR HIP SYSTEM WITH PRESS-FIT STEM",SUP-98000700019,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1226.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1203.71,8797.5,"percent of total billed charges",
"EXT NEROSTIMLTR 35CM SPINAL CORD PHASE III",SUP-SC-3138-35,CDM,C1883,HCPCS,0278,RC,,,both,,,3525.00,1057.5,"CIGNA [10200]",Cigna,,2397,68,,,,,0,409.96,2996.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 16FR 30CM RADIOPAQUE DRNG TRANSITIONLESS",SUP-G08322,CDM,C1892,HCPCS,0272,RC,,,both,,,526.42,157.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.22,447.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 24FR URETHRAL SILASTIC 30CC 2 WAY 2 STAGGER DRNG EYE",SUP-33424,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.11,15.03,"UHC [10700]","United Healthcare",,31.72,63.3,,,,,0,5.83,42.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BONE BIOPSY REVOLVE ACCESS BEVEL TIP 11GA",SUP-685.031S,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL METRX BAYONET STERILE DISPOSABLE",SUP-9560659,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.60,562.68,"CIGNA [10200]",Cigna,,1275.41,68,,,,,0,218.13,1594.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP060100090 PLUS US D6L100UL900",SUP-PCP060100090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 6FR 40D GUIDING DURAFORM PTFE",SUP-M003101420,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1028.79,41.1,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 5MM AVENIR 10 HELICAL FINISH STERILE",SUP-10HFN-05008,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA [10200]","Cigna Local Plus",,5533.56,53.5,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOQUE TRICUSPID VALVE REPLACEMENT SYSTEM 44MM",SUP-EVQ1US44,CDM,S27800098,LOCAL,0278,RC,,,both,,,245100.00,73530,"UHC [10700]","United Healthcare",,155148.3,63.3,,,,,0,28505.13,208335,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SUCTION MERCEDES 3MM 30CM 2 PORT 8MM DISPOSABLE",SUP-PAL-304LL,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"AETNA [10100]","Aetna HMO/PPO",,508.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE BIOMET 40GM",SUP-110035368,CDM,C1713,HCPCS,0278,RC,,,both,,,525.61,157.68,"KAISER [10500]",Kaiser,,352.16,67,,,,,0,61.13,446.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR SURGICAL 12FR EIGR INVUITY WAVEGUIDE SABER MIS",SUP-1911273,CDM,S27200284,LOCAL,0272,RC,,,both,,,1991.25,597.37,"UHC [10700]","United Healthcare",,1260.46,63.3,,,,,0,231.58,1692.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 0 FSL 18IN BRAID BLACK NONABSORBABLE",SUP-678G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 10MM 35MM SYMMETRIC TRIATHLON X3 KNEE",SUP-5551-G-350,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"CIGNA [10200]","Cigna Open Access",,2456.81,56.9,,5302.19,4377.88,6578.61,27,502.16,3670.1,"percent of total billed charges",
"SCR BONE 5MM 75MM STAINLESS STEEL T25 VARIABLE ANGLE SELF",SUP-02.231.275,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,374.3,28.62,,,,,0,152.1,1111.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR .09IN EXTRA BACKUP LEFT 3.75 CURVE",SUP-LA8EBU375,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 30CM 14FR 22GA FLEXIMA POLYURETHANE 3 WAY STPCOCK 2",SUP-M001273070,CDM,C1729,HCPCS,0272,RC,,,both,,,1950.00,585,"NOVANET [10819]",Novanet,,1462.5,75,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 120MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530120S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"MULTIPLAN [10600]",Multiplan,,1356.35,85,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MM 6MM CAPSTONE TITANIUM PEEK LUMBAR",SUP-2990622,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8490.24,40,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT MONOLITHIC 14MM PLIF",SUP-3W3114,CDM,S27800098,LOCAL,0278,RC,,,both,,,12487.62,3746.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1479.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1452.31,10614.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 1MM ELITE ROUND DIAMOND 5 STEP NOTCH STERILE",SUP-5820012010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1119.18,335.75,"UHC [10700]","United Healthcare",,708.44,63.3,,,,,0,130.16,951.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 FULL THREAD CROSSFT HI-FI NDL CANNULATED",SUP-CFBC-4502N,CDM,C1713,HCPCS,0278,RC,,,both,,,3467.25,1040.17,"BLUE CROSS [10001]","Blue Cross PPO",,1359.16,39.2,,957.42,570.23,957.42,28,403.24,2947.16,"percent of total billed charges",
"IMPL BREAST 550ML GEL SMOOTH ROUND MEMORYGEL COHESIVE I","SUP-350-5504 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4457.4,68,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 4-0 PS-2 18IN MONOFILAMENT PLIABILIZE",SUP-1667G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FUZEFIX OD1.7 MM CALIBRATE CANNULATED HEADLES",SUP-CD-FX-1017,CDM,S27000186,LOCAL,0270,RC,,,both,,,2130.00,639,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EUPHORA 142CM 12MM 3.75MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP37512X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUFF TRNQT 12IN ATS 1 PORT 1 BLADDER LUER LOCK CNCT STERILE",SUP-60707505200,CDM,S27200284,LOCAL,0272,RC,,,both,,,198.36,59.51,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Nrv Condct 9-10 Studies",PX-922000023,CDM,95911,CPT,0922,RC,,,both,,,6810.24,2043.07,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RENEGADE HI-FLO 105CM 20CM 3-2.8FR .027IN MICRO",SUP-M001182990,CDM,C1887,HCPCS,0272,RC,,,both,,,4726.50,1417.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SEEKER 135CM SPRT HYDROPHILIC PERIPHERAL RADIOPAQUE",SUP-SK13514,CDM,C1887,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE 100MM STAINLESS STEEL LARGE FRAGMENT SET 5 HOLE SPOON",SUP-240.05,CDM,C1713,HCPCS,0278,RC,,,both,,,1823.25,546.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,216.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,212.04,1549.76,"percent of total billed charges",
"CAP CONSTRUCT KNEE HA POROUS WITH CEMENTED PATELLA CONCELOC",SUP-71704616,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9324,40,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Particle Agglutination Ea",PX-302000089,CDM,86403,CPT,0302,RC,,,both,,,547.00,164.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.75,,"Fee schedule rate ($11.75). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.91,464.95,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"YOKE TIBIAL OSS KNEE REINFORCE",SUP-150493,CDM,C1776,HCPCS,0278,RC,,,both,,,8034.36,2410.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,952.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,934.4,6829.21,"percent of total billed charges",
"CATH BARD 16IN 8FR URETHRAL RUBBER FOLEY INTERMITTENT ALL",SUP-0094080,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.32,0.1,"MULTIPLAN [10600]",Multiplan,,0.27,85,,,,,0,0.04,0.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SR LORDOTIC ALLOGRAFT 14X11X4MM",SUP-400441,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 2 9MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530-P-209,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]",Cigna,,5682.01,68,,5873.17,5873.17,5873.17,"1 through 10",971.79,7102.52,"percent of total billed charges",
"COMPONENT FEMORAL E KNEE LEFT LPS-FLEX NEXGEN POROUS",SUP-00596201551,CDM,C1776,HCPCS,0278,RC,,,both,,,18622.80,5586.84,"FIRST HEALTH [10303]","First Health",,14898.24,80,,,,,0,2165.83,15829.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID .1-4MM CANCELLOUS ALLOGRAFT CHIPS FREEZE",SUP-400080,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 90MM 9MM 5.4MM 14FR ZENITH SPIRAL-Z",SUP-G55221,CDM,C1874,HCPCS,0278,RC,,,both,,,20160.00,6048,"CIGNA [10200]","Cigna Local Plus",,6350.4,31.5,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 38MM 140CM .91-1.12MM 2.75MM CORONARY",SUP-RONYX27538W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"PHCS [10601]",PHCS,,3807.3,70,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.2MM 6MM RELIEVE SPINE SELF DRILL NONSTERILE LATEX",SUP-136.406,CDM,C1713,HCPCS,0278,RC,,,both,,,1077.30,323.19,"CIGNA [10200]","Cigna Local Plus",,576.36,53.5,,3978.14,359.25,3978.14,24,125.29,915.71,"percent of total billed charges",
"RCRD CARDIAC REVEAL DX INSERTABLE AUTOMATICALLY ACTIVATED",SUP-9529,CDM,C1764,HCPCS,0278,RC,,,both,,,20884.50,6265.35,"MULTIPLAN [10600]",Multiplan,,17751.83,85,,,,,0,2428.87,17751.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 74X44X14MM NEXGEN 4-6 E KNEE UHMWPE",SUP-588005014,CDM,C1776,HCPCS,0278,RC,,,both,,,13183.14,3954.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3773.01,28.62,,,,,0,1533.2,11205.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GATEWAY 135CM 9MM 2.25MM BALLOON DILATATION HYDROPHILIC",SUP-M0032072209220,CDM,C1725,HCPCS,0272,RC,,,both,,,9423.88,2827.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1116.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1096,8010.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Wrap Polar Pad Universal Xl",PX-E27000184,CDM,E27000184,LOCAL,0270,RC,,,both,,,213.40,64.02,"AETNA [10100]","Aetna HMO/PPO",,169.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.82,181.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ketosteroids 17 Total",PX-301000290,CDM,83586,CPT,0301,RC,,,both,,,241.00,72.3,"CIGNA [10200]",Cigna,,28.16,,,,,,,0.01,204.85,"fee schedule",
"CAGE SPINAL CASCADIA TITANIUM POROUS 0 D PARALLEL L50 MM X W",SUP-6101-21805012LP-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 10MM CEMENTRALIZER HIP FEMUR PMMA CEMENT SUMMIT",SUP-137648000,CDM,C1776,HCPCS,0278,RC,,,both,,,846.45,253.93,"CIGNA [10200]",Cigna,,575.59,68,,5873.17,5873.17,5873.17,"1 through 10",98.44,719.48,"percent of total billed charges",
"PLATE RIGHT PROXIMAL TIBIAL 118MM STAINLESS STEEL 4.5MM SCR",SUP-240.038,CDM,C1713,HCPCS,0278,RC,,,both,,,8699.80,2609.94,"CIGNA [10200]",Cigna,,5915.86,68,,1831.33,1831.33,1831.33,16,1011.79,7394.83,"percent of total billed charges",
"CATH ADVANCE PLIAFORM STARCAST 135CM 4CM 8MM BALLOON",SUP-G52279,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELEMENT 17 F VASCULAR ACCESS SYSTEM 33CM",SUP-ELMNT17F33,CDM,C1887,HCPCS,0272,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FIBER LASER ACCUTRAC 200UM FLEXSHIELD HOLMIUM FLEXIBLE",SUP-M0068404112,CDM,S27200284,LOCAL,0272,RC,,,both,,,3284.22,985.27,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SENSOR ADULT LNCS ADTX-3 3FT OXIMETER ADHSV LATEX FREE",SUP-2317,CDM,S27000186,LOCAL,0270,RC,,,both,,,64.38,19.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.49,54.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 12MM 6FR 1.5MM .07IN BALLOON",SUP-H7493918912150,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"KAISER [10500]",Kaiser,,379.89,67,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 11MM 2.4FR GEMINI HELICAL",SUP-M0063303060,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1006.09,68,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 105MM DHS/DCS STAINLESS STEEL CONDYLAR HIP",SUP-280.305,CDM,C1713,HCPCS,0278,RC,,,both,,,2043.30,612.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,584.79,28.62,,,,,0,237.64,1736.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 26CM 11FR SHORT LENGTH URETERAL",SUP-H7493936110260,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"CIGNA [10200]","Cigna Open Access",,705.16,,,,,,,144.13,1053.41,"percent of total billed charges",
"CATH SOLOIST 110CM 6FR 2-5-2MM SPACING JOSEPHSON CURVE",SUP-2035U,CDM,S27000186,LOCAL,0270,RC,,,both,,,1579.50,473.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,187.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE SIMPLEX P RADIOPAQUE FULL DOSE STERILE 40GM",SUP-6191-1-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,486.00,145.8,"BLUE CROSS [10001]","Blue Cross PPO",,190.51,39.2,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED 100CM 4CM 11FR 35MM BALLOON DILATATION RADIOPAQUE",SUP-611671,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"MULTIPLAN [10600]",Multiplan,,4520.33,85,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CESAREAN SECTION WITHOUT STERILIZATION WITH MCC",786,MS-DRG,,,,,,,inpatient,,,52281.03,15684.31,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,10948.19,,"Case rate ($10,231.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,501.06, add-ons for qualifying new technology services are included. If operating cost exceeds $42,540.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,100.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $9,513.62. The transfer operating threshold is the transfer adjustment factor * $9,501.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.33. The transfer capital threshold is the transfer adjustment factor * $718.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,5464,21998.69,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION TROCAR POINT STYLE BOTH END 15.2CM .035IN",SUP-00018604400,CDM,C1713,HCPCS,0278,RC,,,both,,,119.63,35.89,"CIGNA [10200]",Cigna,,81.35,68,,1831.33,1831.33,1831.33,16,13.91,101.69,"percent of total billed charges",
"SEAL TISSUE CLSR VISTASEAL FIBRIN HUMAN 2ML",SUP-VST02,CDM,S25000001,LOCAL,0250,RC,,,both,,,1459.86,437.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,992.7,68,,,,,0,169.78,1240.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 39MM 135CM 10MM 13MM 8FR .035IN",SUP-BXA103902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"KAISER [10500]",Kaiser,,13068.22,67,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 23CM LUER LOCK HUB WITHOUT GWIRE KIT LONG",SUP-490006,CDM,C1894,HCPCS,0272,RC,,,both,,,737.10,221.13,"NOVANET [10819]",Novanet,,552.83,75,,,,,0,85.72,626.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER LUMENIS XPEEDA 550UM 45-120W HOLMIUM CUSTOM 2",SUP-AC-1000729,CDM,S27200284,LOCAL,0272,RC,,,both,,,7668.18,2300.45,"MULTIPLAN [10600]",Multiplan,,6517.95,85,,,,,0,891.81,6517.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 7FR .081IN AMPLATZ RIGHT 1 CURVE GUIDING NYLON",SUP-LA7AR10,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPLATZ RENAL SHEATH SET 24-30F",SUP-M0062601500,CDM,C1894,HCPCS,0272,RC,,,both,,,830.57,249.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,98.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,96.6,705.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL SYMMETRY .6-1.5MM APPROXIMATOR WITHOUT FRAME",SUP-ABB-22VB,CDM,S27200284,LOCAL,0272,RC,,,both,,,1895.55,568.66,"AETNA [10100]","Aetna HMO/PPO",,1506.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,220.45,1611.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY TORIC",SUP-CNWET4,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"BLUE CROSS [10001]","Blue Cross HMO",,339.08,39.2,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) BRIOVAD BATTERY KIT",SUP-490025,CDM,Q0506,HCPCS,0624,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SPINAL 16MM 4MM CODA ANTERIOR CERVICAL SELF TAP VARIABLE",SUP-102254016,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,117.75,860.63,"percent of total billed charges",
"CATH AXS VECTA 46 L 125CM LUMEN INNTER DIAMETER .046IN",SUP-INC-11814-125,CDM,S27200284,LOCAL,0272,RC,,,both,,,9627.29,2888.19,"MULTIPLAN [10600]",Multiplan,,8183.2,85,,,,,0,1119.65,8183.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25MM 81.5MM THK1.27MM WIDE STAINLESS STEEL",SUP-2108189000,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,109.74,45.9,,,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 20MM 4.5MM AEQUALIS SHOULDER TITANIUM LOCK",SUP-DWD020,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CIGNA [10200]","Cigna Open Access",,885.36,56.9,,5302.19,4377.88,6578.61,27,180.96,1322.6,"percent of total billed charges",
"HC Declot Cannula W Baln",PX-361000127,CDM,36861,CPT,0361,RC,,,both,,,4928.23,1478.47,"PHCS [10601]",PHCS,,4928.23,,"Case rate ($8,239). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,573.15,4928.23,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM PFC SIGMA TC3 4 KNEE LEFT TITANIUM CEMENTED",SUP-960880,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1468.45,28.62,,,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 5MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR050202A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"KAISER [10500]",Kaiser,,11326.35,67,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 9MM KNEE POSTERIOR STABILIZE HIGH",SUP-71421508,CDM,C1776,HCPCS,0278,RC,,,both,,,10774.35,3232.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3083.62,28.62,,,,,0,1253.06,9158.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22-24X27-32X9MM LUMINARY CC BICONVEX SPINE",SUP-6809,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"FIRST HEALTH [10303]","First Health",,26611.2,80,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16027535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vasc Embol Occl Arterial Trinav",PX-361000637,CDM,C9797,HCPCS,0361,RC,,,both,,,13815.00,4144.5,"FIRST HEALTH [10303]","First Health",,11052,80,,,,,0,1606.68,11835.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 4.8MM TITANIUM LINEAR CUTTER DLU HELICAL",SUP-174023,CDM,S27200284,LOCAL,0272,RC,,,both,,,1154.09,346.23,"FIRST HEALTH [10303]","First Health",,923.27,80,,,,,0,134.22,980.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SMARTCLAW 145CM 20MM 5FR THROMBECTOMY NITINOL",SUP-FD0660-01,CDM,C1757,HCPCS,0272,RC,,,both,,,25168.50,7550.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2982.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2927.1,21393.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 45MM ENDOWRIST GREEN",SUP-41445G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"CIGNA [10200]",Cigna,,991.44,68,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACURATE NE02TM AORTIC VALVE M - CLINICAL",SUP-SYM-SV25-006-C,CDM,S62400003,LOCAL,0624,RC,,,both,,,159600.00,47880,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,73256.4,45.9,,,,,0,18561.48,135660,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 135CM 5MM 30MM",SUP-H74938047530130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"KAISER [10500]",Kaiser,,3344.64,67,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 10FR LARGE REGULAR PIGTAIL CURVE URETERAL",SUP-M001245590,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA [10200]","Cigna Local Plus",,476.69,,,,,,,103.62,757.35,"percent of total billed charges",
"SPACER ALLOGRAFT 23-27MMX19MM FRA 8D NARROW WEDGE SPINE",SUP-19,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"KAISER [10500]",Kaiser,,12663,67,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alkaloids Nos Nicotine",PX-301000487,CDM,80323,CPT,0301,RC,,,both,,,213.75,64.12,"KAISER [10500]",Kaiser,,143.21,67,,,,,0,0.21,213.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 100CM 8FR IM CURVE GUIDING PTFE PERIPHERAL LARGE",SUP-H74934358260,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"PHCS [10601]",PHCS,,256.51,70,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE EXAMINATION BFLEX LARGE 5.8 SINGLE USE X2",SUP-0570-0450,CDM,S27200284,LOCAL,0272,RC,,,both,,,2295.00,688.5,"NOVANET [10819]",Novanet,,1721.25,75,,,,,0,266.91,1950.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE T2 ORTHOPEDIC 1250MM 3MM BALL TIP STERILE",SUP-1806-1250S,CDM,C1769,HCPCS,0272,RC,,,both,,,1279.15,383.74,"FIRST HEALTH [10303]","First Health",,1023.32,80,,,,,0,148.77,1087.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 22MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-822,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3444.02,28.62,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION FAST-FIX FLEX BENDER CANN SET",SUP-72205325,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO BIOPSY 10CM 19GA 20GA ACHIEVE UNIVERSAL COAXIAL",SUP-PP1910,CDM,S27200284,LOCAL,0272,RC,,,both,,,114.41,34.32,"NOVANET [10819]",Novanet,,85.81,75,,,,,0,13.31,97.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0165,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 8X4CM ACTISHIELD AMNIOTIC BARR MEMB",SUP-AM204X08,CDM,V2790,HCPCS,0278,RC,,,both,,,18729.90,5618.97,"AETNA [10100]","Aetna HMO/PPO",,14890.27,79.5,,,,,0,2178.29,15920.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 3-5 E-F KNEE RIGHT TIBIA",SUP-42521400610,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"KAISER [10500]",Kaiser,,5410.76,67,,,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 6MM 3.2-2.4-2.6FR 2MM BALLOON",SUP-SPR2006W,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 97MM 18MM ESOPHAGEAL FULL COVER STERILE LATEX",SUP-M00517450,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS 7.5FR PASSAGE METAL SILICONE POLYCARBONATE",SUP-MAP101,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.36,34.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.18,96.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR061502A,CDM,C1874,HCPCS,0278,RC,,,both,,,24374.70,7312.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9749.88,40,,,,,0,2834.78,20718.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 34MM 2 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800234,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",521.61,3812.25,"percent of total billed charges",
"SCR BONE 7.5MM 50MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55840017550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"TORSEMIDE 20 MG TABLET",RX-18293,CDM,,,0637,RC,50268-0756-11,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 9MM KNEE XLPE POSTERIOR STABILIZED HIGH",SUP-71453211,CDM,C1776,HCPCS,0278,RC,,,both,,,15628.50,4688.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4472.88,28.62,,,,,0,1817.59,13284.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 75CM 4CM 10MM BALLOON DILATATION PERIPHERAL",SUP-CQ75104,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"UHC [10700]","United Healthcare",,846,63.3,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 30MM 4MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012278-30,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEMANTINE 10 MG TABLET, IMMEDIATE RELEASE",RX-36966,CDM,,,0637,RC,00591-3875-45,NDC,both,1,UN,25.19,7.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM 5MM S-ROM ZTT 18D LARGE HIP POROUS",SUP-550524,CDM,C1776,HCPCS,0278,RC,,,both,,,6466.32,1939.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,766.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,752.03,5496.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 38MM 144CM 3.5MM CORONARY STENT",SUP-H7493911438350,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X8MM VERTE-STACK HYDROSORB PEEK ANATOMIC",SUP-6240841,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,791.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 15MM",SUP-SPL12515X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 8.2MM 70MM 22MM DHS/DCS STAINLESS STEEL",SUP-280.7,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,520.42,28.62,,,,,0,211.48,1545.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MONTELUKAST 10 MG TABLET",RX-22509,CDM,,,0637,RC,68084-0875-11,NDC,both,1,UN,25.19,7.56,"NOVANET [10819]",Novanet,,18.89,75,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTERED TC 99M-SODIUM THIOSULFATE SOLUTION (0-20 MCI)",RX-411525,CDM,A9541,HCPCS,0343,RC,08888-8878-63,NDC,both,1,UN,746.77,224.03,"BLUE CROSS [10001]","Blue Cross HMO",,311.62,,,,,,,86.85,746.77,"fee schedule",
"TUBE 12IN 20FR 3CM SILICONE LOW PROFILE BALLOON RADIOPAQUE",SUP-0120-20-3.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CIGNA [10200]","Cigna Local Plus",,416.8,53.5,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 9MM CATALYFT PL40 SHORT",SUP-6069093,CDM,S27800098,LOCAL,0278,RC,,,both,,,39060.00,11718,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15624,40,,,,,0,4542.68,33201,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Levetiracetam",PX-301000075,CDM,80177,CPT,0301,RC,,,both,,,314.93,94.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,267.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC No Pt Prsnt Train Add 15 (Go)",PX-430000071,CDM,G0542,HCPCS,0430,RC,,,both,,,37.00,11.1,"BLUE CROSS [10001]","Blue Cross PPO",,0.04,.1,,,,,0,0.04,37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH SAFESHEATH II INTRO HEMOSTASIS",SUP-7469,CDM,C1894,HCPCS,0272,RC,,,both,,,261.00,78.3,"PHCS [10601]",PHCS,,182.7,70,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 45MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0318,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,644.44,68,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER MAPPING 7FR WEBSTER CS 2-8-2MM SPACE F-J CURVE STER",SUP-BD710FJ282RTSR,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,991.44,68,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION",RX-225383,CDM,J0248,HCPCS,0636,RC,61958-2901-02,NDC,both,1,UN,2615.60,784.68,"FIRST HEALTH [10303]","First Health",,2092.48,80,,,,,0,622.5,2223.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 72.5MM KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-183133,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"CIGNA [10200]","Cigna Local Plus",,6824.7,31.5,,5372.07,4581.20,7242.98,23,2519.72,18415.85,"percent of total billed charges",
"TROCAR LAPAROSCOPIC 100MM 5-11MM VISIPORT PLUS RPF VERSAPORT",SUP-176673P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1305.88,391.76,"FIRST HEALTH [10303]","First Health",,1044.7,80,,,,,0,151.87,1110,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 32MM BEVEL STERILE LATEX FREE MIS",SUP-SF3032,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,588.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",577.78,4222.8,"percent of total billed charges",
"CLAREONPANOPTIX PRO(UVA)",SUP-PXCWT0,CDM,V2788,HCPCS,0276,RC,,,both,,,915.00,274.5,"BLUE CROSS [10001]","Blue Cross PPO",,358.68,39.2,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Screen Gc",PX-306000056,CDM,87081,CPT,0306,RC,,,both,,,386.65,115.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10.43,,,,,,,0.01,328.65,"fee schedule",
"STEM FEMORAL 135D 42MM STD OFFSET 38.5MM STERILE 160MM 14MM",SUP-3L92514,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"FIRST HEALTH [10303]","First Health",,12669.7,80,,,,,0,1841.86,13461.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 100MM 2.4MM STAINLESS STEEL QUICK COUPLING",SUP-310.53,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Methotrexate",PX-301000696,CDM,80204,CPT,0301,RC,,,both,,,128.00,38.4,"BLUE CROSS [10001]","Blue Cross HMO",,0.13,.1,,,,,0,0.13,108.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Desoxycorticosterone",PX-301000534,CDM,82633,CPT,0301,RC,,,both,,,375.00,112.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,32.53,,"Fee schedule rate ($32.53). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",80.11,80.11,80.11,"1 through 10",0.01,318.75,"fee schedule",
"HC Impulse Oscillometry",PX-460000012,CDM,94728,CPT,0460,RC,,,both,,,290.67,87.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,133.42,45.9,,,,,0,33.8,247.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Heated Tc99m Lbld RBC per Study",PX-343000039,CDM,A9560,HCPCS,0343,RC,,,both,,,5851.21,1755.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,680.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.55,4973.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET INTUBATION SMALL GLIDERITE DISPOSABLE",SUP-0270-0916,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.38,16.91,"CIGNA [10200]","Cigna Open Access",,32.08,56.9,,,,,0,6.56,47.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT",SUP-M006145361170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,768.37,68,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION",RX-15706,CDM,,,0250,RC,00121-0595-15,NDC,both,15,ML,36.80,11.04,"PHCS [10601]",PHCS,,25.76,70,,,,,0,4.28,31.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SPINAL 5MM SPINEJACK",SUP-0909-000-050,CDM,C1062,HCPCS,0278,RC,,,both,,,24560.17,7368.05,"CIGNA [10200]",Cigna,,9824.07,40,,,,,0,2856.35,20876.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LG DOUBLE ARTERIAL CLAMP","SUP-GEM TKL-2",CDM,S27200284,LOCAL,0272,RC,,,both,,,582.39,174.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,69.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.73,495.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 60MM 80CM 8MM 6FR VASCULAR NITINOL",SUP-G43857,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1081.84,28.62,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON PANOPTIX TORIC UVA",SUP-CCWTT6,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,102.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM OSTEOGRIP NANO SPINE SHANK",SUP-55904506545,CDM,C1713,HCPCS,0278,RC,,,both,,,8193.75,2458.12,"AETNA [10100]","Aetna HMO/PPO",,6514.03,79.5,,1521.93,481.35,16760.95,30,952.93,6964.69,"percent of total billed charges",
"SCR BONE 3MM 14MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0304,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,434.99,45.9,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL ARTHREX UNIVERS REVERS 10 SHOULDER STERILE",SUP-AR-9501-10P,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4845.66,45.9,,,,,0,1227.78,8973.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 5FR 21GA MERIT MAK .018IN STAINLESS STEEL",SUP-MAK505-PED,CDM,C1894,HCPCS,0272,RC,,,both,,,230.55,69.16,"FIRST HEALTH [10303]","First Health",,184.44,80,,,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 17MM 140CM 2.75MM CORONARY STENT",SUP-LUN275R17US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Proc Surgical Path Unlistd",PX-312000051,CDM,88399,CPT,0312,RC,,,both,,,253.65,76.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,46.47,,,,,,,0.01,215.6,"fee schedule",
"STEM FEMORAL 40MM PRIMARY SECUR-FIT MAX HA 132D 12 HIP",SUP-6051-1240S,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"BLUE CROSS [10001]","Blue Cross PPO",,6134.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",1820,13301.82,"percent of total billed charges",
"SCR BASEPLT 20MM 4.5MM AEQUALIS SHOULDER TITANIUM LOCK",SUP-DWD020,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"FIRST HEALTH [10303]","First Health",,1244.8,80,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PULMONARY AEROMINI FULLY COVERED 10MMX15MM",SUP-AERO1015,CDM,C1874,HCPCS,0278,RC,,,both,,,16215.00,4864.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1885.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1885.8,13782.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 75CM 60MM 5MM VASCULAR METAL SUPERFICIAL",SUP-H74939293056070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2216.97,45.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 24MM FUSION ACUTRAK 2.4MM 24MM SCR",SUP-ATF-024,CDM,S27200284,LOCAL,0272,RC,,,both,,,1657.50,497.25,"PHCS [10601]",PHCS,,1160.25,70,,,,,0,192.77,1408.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 10MM NESTER PLATINUM FIBER 4.5 LOOP",SUP-G47325,CDM,S27800098,LOCAL,0278,RC,,,both,,,890.92,267.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,605.83,68,,,,,0,103.61,757.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC",069,MS-DRG,,,,,,,inpatient,,,33623.13,10086.94,"AETNA [10100]","Aetna HMO/PPO",,15029.42,,"Fee schedule rate ($15,029.42). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,4955.01,19921.27,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FEMORAL IDENTITY IMPRINT 4 KNEE POSTERIOR STABILIZE",SUP-TPS-101-F04S,CDM,C1776,HCPCS,0278,RC,,,both,,,11716.20,3514.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4686.48,40,,,,,0,1362.59,9958.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH PASSPORT ENCORE GWIRE LOW PROFILE BALLOON 3FR 12FR",SUP-M0062181200,CDM,C1726,HCPCS,0272,RC,,,both,,,2191.88,657.56,"FIRST HEALTH [10303]","First Health",,1753.5,80,,,,,0,254.92,1863.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135D 39.5MM STD OFFSET 38.5MM 140MM 10MM COLLAR",SUP-3L92500,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1876.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1841.86,13461.55,"percent of total billed charges",
"PIPERACILLIN-TAZOBACTAM 3.375 G VIAL",RX-18303,CDM,J2543,HCPCS,0636,RC,55150-0120-30,NDC,both,1,UN,49.83,14.95,"BLUE CROSS [10001]","Blue Cross HMO",,3.74,,,,,,,3.74,42.36,"fee schedule",
"RING ANNULOPLASTY 32MM MITRAL VALVE STIFFNESS COMPOSITE LOW",SUP-638RL32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"AETNA [10100]","Aetna HMO/PPO",,10422.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 4MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0420CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"MULTIPLAN [10600]",Multiplan,,5571.75,85,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 4MM WIDENING COUNTSINK BAHA AUDITORY",SUP-92141,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"MULTIPLAN [10600]",Multiplan,,1434.38,85,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ptca Sngl Maj Cor Arty/Br",PX-481000071,CDM,92920,CPT,0481,RC,,,both,,,19091.70,5727.51,"PHCS [10601]",PHCS,,13364.19,70,,,,,0,2220.36,19091.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ptca Sngl Maj Cor Arty/Br",PX-481000071,CDM,92920,CPT,0481,RC,,,both,,,19091.70,5727.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,13394.16,,"Case rate ($13,394.16). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,2220.36,19091.7,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 122MM STAINLESS STEEL 2.7/3.5MM SCR 6 HOLE LCP BONE",SUP-02.112.142,CDM,C1713,HCPCS,0278,RC,,,both,,,3144.75,943.42,"CIGNA [10200]",Cigna,,2138.43,68,,1831.33,1831.33,1831.33,16,365.73,2673.04,"percent of total billed charges",
"NDL BRACHYTHERAPY 10CM 18GA 1 LOOSE SOURCE IODINE 125",SUP-10172-2,CDM,C1715,HCPCS,0272,RC,,,both,,,963.90,289.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,655.45,68,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING IRRIGATION FMS SOLO ARTHROSCOPIC FLUID MANAGEMENT EXT",SUP-281103,CDM,S27200284,LOCAL,0272,RC,,,both,,,201.91,60.57,"KAISER [10500]",Kaiser,,135.28,67,,,,,0,23.48,171.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 8IN STARDUST CURVE DELICATE JAW ROUND HANDLE",SUP-278103,CDM,S27200284,LOCAL,0272,RC,,,both,,,2069.85,620.95,"CIGNA [10200]","Cigna Open Access",,1177.74,56.9,,,,,0,240.72,1759.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 36MM SALVATION ORTHOLOC TITANIUM ANKLE",SUP-59215536,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,628.92,28.62,,,,,0,255.57,1867.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 11CM GREEN HUB HEMOSTASIS VALVE PRELUDE",SUP-PSI-6F-11,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.8,64.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 54MM LCP STAINLESS STEEL LONG THREAD SMALL BONE",SUP-207.654,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,123.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",120.96,884.03,"percent of total billed charges",
"SCR BONE 3.5MM 20MM COMPRESSION FT TITANIUM MINI FULL THREAD",SUP-AR-8730-20H,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"NOVANET [10819]",Novanet,,1968.75,75,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL HIP 47MM 28MM ACETABULAR MODULAR HEAD SHELL ENDOPROSTH",SUP-205547000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON OSSEOFLEX SB STRAIGHT 10GA 4ML",SUP-OT-0224,CDM,S27200284,LOCAL,0272,RC,,,both,,,4554.00,1366.2,"NOVANET [10819]",Novanet,,3415.5,75,,,,,0,529.63,3870.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM REVOLVE SPINE PEDICLE POLYAXIAL",SUP-185.453,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"MULTIPLAN [10600]",Multiplan,,8114.82,85,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endovenous Ablation Chem Ext 1",PX-361000554,CDM,36482,CPT,0361,RC,,,both,,,9701.49,2910.45,"PHCS [10601]",PHCS,,6791.04,70,,,,,0,1128.28,9679,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC",069,MS-DRG,,,,,,,inpatient,,,33623.13,10086.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12948.55,,"Fee schedule rate ($12,948.55). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,4955.01,19921.27,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE SMARTSET 40GM MEDIUM VISCOSITY STERILE",SUP-3122040,CDM,C1713,HCPCS,0278,RC,,,both,,,469.80,140.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,134.46,28.62,,,,,0,54.64,399.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 15MM CLEVERCUT3V PRELOAD DISTAL TIP STERILE",SUP-KD-VC412Q-0215,CDM,C1769,HCPCS,0272,RC,,,both,,,1500.61,450.18,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP BIPOLAR 6MM ENDOWRIST SP FENESTRATED NONSTERILE",SUP-430151,CDM,S27000186,LOCAL,0270,RC,,,both,,,2583.00,774.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RANGER 150CM 200MM 5MM BALLOON DILATATION PACLITAXEL",SUP-H74939419502010,CDM,C2623,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,inpatient,,,23361.17,7008.35,"BLUE CROSS [10001]","Blue Cross HMO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 150MM 5MM BALLOON DILATATION OTW",SUP-H74939206051510,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP SURGICAL STEALTH LATIS 6MM LOW PROFILE 30MM .5 SPRING",SUP-A1601,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT POLYFLEX 30MM 9MM 14MM AIRWAY POLYESTER SILICONE SELF",SUP-7011,CDM,C1887,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SAFE-T-J VASCULAR 1.5MM J ROSEN CURVE 80CM .035IN",SUP-G01774,CDM,C1769,HCPCS,0272,RC,,,both,,,119.02,35.71,"FIRST HEALTH [10303]","First Health",,95.22,80,,,,,0,13.84,101.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC ELATION 100CM 3CM 10-11-12MM PULMONARY 3",SUP-P10L30,CDM,C1726,HCPCS,0272,RC,,,both,,,2137.50,641.25,"AETNA [10100]","Aetna HMO/PPO",,1699.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 8CM 6FR 10MM .035IN BALLOON",SUP-G52295,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UHC [10700]","United Healthcare",,607.53,63.3,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +1MM 12/14 TAPER 32MM HIP BIOLOX DELTA",SUP-136532310,CDM,C1776,HCPCS,0278,RC,,,both,,,6844.32,2053.3,"CIGNA [10200]",Cigna,,4654.14,68,,5873.17,5873.17,5873.17,"1 through 10",795.99,5817.67,"percent of total billed charges",
"OTITIS MEDIA AND URI WITH MCC",152,MS-DRG,,,,,,,inpatient,,,34029.10,10208.73,"AETNA [10100]","Aetna HMO/PPO",,22243.09,,"Fee schedule rate ($22,243.09). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7333.27,29482.89,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17.8MM 25MM 32MM 23.4MM ON-X 25 STD CYLINDRICAL",SUP-ONXAE-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"UHC [10700]","United Healthcare",,23927.4,63.3,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 110MM 16MM LCP STAINLESS STEEL CANCELLOUS",SUP-216.110,CDM,C1713,HCPCS,0278,RC,,,both,,,302.06,90.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,138.65,45.9,,,,,0,35.13,256.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM CEMENTED OMNIFIT HFX 132D 11 46MM OFFSET",SUP-6070-1140A,CDM,C1776,HCPCS,0278,RC,,,both,,,9473.94,2842.18,"CIGNA [10200]",Cigna,,6442.28,68,,5873.17,5873.17,5873.17,"1 through 10",1101.82,8052.85,"percent of total billed charges",
"CERTUS XT LK ABLATION PROBE 20",SUP-LK20XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,14524.50,4357.35,"UHC [10700]","United Healthcare",,9194.01,63.3,,,,,0,1689.2,12345.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 18MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71933736,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"CIGNA [10200]",Cigna,,4868.64,40,,5873.17,5873.17,5873.17,"1 through 10",1415.56,10345.86,"percent of total billed charges",
"CATH CELSIUS REDEL 90CM 4MM 8FR 2-5-2MM SPACE D CURVE",SUP-D8BRDL252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,5326.80,1598.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,619.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,619.51,4527.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00175,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"NOVANET [10819]",Novanet,,820.13,75,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45MMX12MM CLYDESDALE 6D PEEK-OPTIMA RADIOPAQUE",SUP-2968245,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"UHC [10700]","United Healthcare",,15154.02,63.3,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM OPHTHALMIC 1IN BLADE EYE ALFONSO 5MM NEONATE",SUP-60-1974,CDM,S27200284,LOCAL,0272,RC,,,both,,,337.91,101.37,"PHCS [10601]",PHCS,,236.54,70,,,,,0,39.3,287.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR MRESS CURVE GUIDING NYLON CORONARY",SUP-LA6MRESS,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"FIRST HEALTH [10303]","First Health",,292.32,80,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELIANCE 4 FRONT ACTIVE FIXATION DUAL COIL 59CM",SUP-0675,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 14FR URETHRAL BACTI-GUARD RUBBER HYDROGEL 5CC",SUP-0168SI14,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.14,33.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,50.55,45.9,,,,,0,12.81,93.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL CONTOUR TIMAX 10 HOLE LOW PROFILE ALPS BONE",SUP-131218600,CDM,S27200284,LOCAL,0272,RC,,,both,,,9987.75,2996.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1161.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1161.58,8489.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 2-0 PS 18IN MONOFILAMENT BLACK NONABSORBABLE",SUP-585H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"KAISER [10500]",Kaiser,,16.75,67,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 9 MICRO ANGLE RIGHT 7.5IN RETRACTION SEMISHARP 2MM",SUP-RN6209,CDM,S27200284,LOCAL,0272,RC,,,both,,,425.34,127.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,195.23,45.9,,,,,0,49.47,361.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 100MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171081010,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"MULTIPLAN [10600]",Multiplan,,998.33,85,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TANDEMHEART- T72/A17",SUP-5810-7217,CDM,S27200284,LOCAL,0272,RC,,,both,,,105450.00,31635,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12495.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12263.84,89632.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 20MM 3.5MM RECTANGLE HELIX BALLOON",SUP-2039-3520,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"NOVANET [10819]",Novanet,,4398.75,75,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOGUARD RX 100UM 180CM .014IN 4MM EMBOLIC",SUP-401814RMC,CDM,C1884,HCPCS,0272,RC,,,both,,,6520.50,1956.15,"FIRST HEALTH [10303]","First Health",,5216.4,80,,,,,0,758.33,5542.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 5MMX29MM 7FR 80CMCATH HEPARIN",SUP-BXB052901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"FIRST HEALTH [10303]","First Health",,15603.84,80,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 5CM BLURR COOLCUT BLADE",SUP-AR-8500BL,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.01,257.7,"UHC [10700]","United Healthcare",,543.75,63.3,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 2X2IN DURAGEN PLUS DURAL BOVINE CLLGN PATCH",SUP-DP5022,CDM,,,0278,RC,,,both,,,2208.65,662.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,261.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.21,1877.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 33MM STD SEWING CUFF",SUP-M7-033,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9062.55,41.1,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER PINK 4.5MM RAZORCUT DYONICS ARTHROSCOPIC",SUP-7205318,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.00,84.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 25CM 12FR PIGTAIL CURVE NEPHRSTMY FLEXIMA POLYURETHANE",SUP-M001271810,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE PLIAFORM STARCAST 135CM 14CM 6MM BALLOON",SUP-G52270,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE STRPR 9MM QUADRICEPS TENDON GRAFT CUT DISPOSABLE",SUP-AR-2385-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR STD JCL4 CURVE GUIDING NYLON",SUP-LA6JCL40,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 90CM 20MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM XIENCE ALPINE 23MM 145CM 2.5MM CORONARY STENT",SUP-1145250-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1670.84,28.62,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK NASAL DRSG SINU-KNIT",SUP-RR600,CDM,S27200284,LOCAL,0272,RC,,,both,,,389.78,116.93,"CIGNA [10200]","Cigna Local Plus",,208.53,53.5,,,,,0,45.33,331.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 9CM 18MM 18.5FR LOW PROFILE ESOPHAGEAL",SUP-M00516910,CDM,C1874,HCPCS,0278,RC,,,both,,,10022.00,3006.6,"MULTIPLAN [10600]",Multiplan,,8518.7,85,,,,,0,1165.56,8518.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 220MM 2.6MM AO SCALE",SUP-703901,CDM,S27200284,LOCAL,0272,RC,,,both,,,1207.71,362.31,"MULTIPLAN [10600]",Multiplan,,1026.55,85,,,,,0,140.46,1026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AICD LEAD PROCEDURES",265,MS-DRG,,,,,,,inpatient,,,82933.12,24879.94,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ALEXIS 2XS SHORT RING ATRAUMATIC SELF RETAIN WOUND",SUP-C8323,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SHAVER 12.5CM 5MM XPS 15D ROUND CURVE DIAMOND HIGH",SUP-1885061HS,CDM,S27200284,LOCAL,0272,RC,,,both,,,3060.00,918,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL SURGICAL 2.2MM LINDEMANN STERILE",SUP-1608002043,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 100MM 3MM BALLOON DILATATION DURALYN",SUP-48003010S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR .071IN AMPLATZ LEFT .75 CURVE",SUP-LA6AL75,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ASAHI PROWATER PTCA GUIDE WIRE J TIP 180 CM",SUP-AGH146000J,CDM,C1769,HCPCS,0272,RC,,,both,,,769.50,230.85,"KAISER [10500]",Kaiser,,515.57,67,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 2.5CM 18FR SILICONE MIC-KEY RADIOPAQUE LOW",SUP-0230-18-2.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,170.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 50MM CALIBRATED SURGICAL CANCELLOUS SPINAL 3.5 SCREWS",SUP-311.349,CDM,S27000186,LOCAL,0270,RC,,,both,,,1856.25,556.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,219.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 4MM LORDOSIS TITANIUM",SUP-102064055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL UTERINE HANK 2 END 10.75IN 25/26FR",SUP-52-3725,CDM,S27000186,LOCAL,0270,RC,,,both,,,184.96,55.49,"MULTIPLAN [10600]",Multiplan,,157.22,85,,,,,0,21.51,157.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLATE, GLENOSPHERE, INSERT, TRAY, STEM, SCREWS, DISPOSAB",SUP-CAP-E-RSA1,CDM,C1776,HCPCS,0278,RC,,,both,,,49140.00,14742,"CIGNA [10200]","Cigna Local Plus",,15479.1,31.5,,5372.07,4581.20,7242.98,23,5714.98,41769,"percent of total billed charges",
"STENT 20CM 3CM 7FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175270110,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,146.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 80MM 80CM 14MM 6FR .035IN BILIARY NITINOL",SUP-G36236,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross PPO",,1481.76,39.2,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 19MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G719,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"BLUE CROSS [10001]","Blue Cross PPO",,3413.38,39.2,,3949.44,3949.44,3949.44,"1 through 10",1012.7,7401.47,"percent of total billed charges",
"RTRCTR ALEXIS 360D MEDIUM LARGE WOUND PROTCT ULTIMATE",SUP-HR005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARDEX LUBRICATH 22FR URETHRAL NYLON NATURAL RUBBER",SUP-2551H22,CDM,S27200284,LOCAL,0272,RC,,,both,,,176.78,53.03,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 150CM 60MM 2.5MM BALLOON DILATATION PEBAX",SUP-H74939032250610,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH REDEL 90CM 4MM 8FR 2-5-2MM SPACE C CURVE ABLATION 10",SUP-D8BRCG252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,5326.80,1598.04,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SENSOR UROLOGICAL ANGLE 150CM 3CM .035IN NITINOL",SUP-M0066703061,CDM,C1769,HCPCS,0272,RC,,,both,,,355.45,106.63,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TENDYNE POSITIONING SYSTEM",SUP-TENDV-PS-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 40X54.6MM HALL THK.4MM STAINLESS STEEL OSCILLATE",SUP-5059-279,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.57,30.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PATELLA COMP., 30MM, 9.0MM DOME CE",SUP-P306-0090-W,CDM,C1776,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"BLUE CROSS [10001]","Blue Cross HMO",,1323,39.2,,5311.50,4717.44,5388.59,31,392.51,2868.75,"percent of total billed charges",
"MINERAL OIL ENEMA",RX-5087,CDM,,,0637,RC,00132-0301-40,NDC,both,133,ML,13.39,4.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9.11,68,,,,,0,1.56,11.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM TSRH THINLINE OSTEOGRIP",SUP-83565359,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1110.3,8114.82,"percent of total billed charges",
"CATH JADE 150CM 240MM 4MM BALLOON DILATATION STERILE LATEX",SUP-594024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"FIRST HEALTH [10303]","First Health",,1166.4,80,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 20CM PUMP SET",SUP-ES2820,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16929,27,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +18.5 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z900200185,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"NOVANET [10819]",Novanet,,765.45,75,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 2CM 7MM BALLOON",SUP-G52271,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 2.5MM 45CM RADIOPAQUE SMALL VALVE FLEXOR",SUP-G09810,CDM,C1894,HCPCS,0272,RC,,,both,,,468.67,140.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POUCH SURGICAL TISSUE 6X4IN LAPSAC DRAWSTRING 200ML STERILE",SUP-G16495,CDM,S27200284,LOCAL,0272,RC,,,both,,,438.99,131.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE ACQUIRE 25GA BIOPSY ENDOBRONCHIAL ULTRASOUND FINE NDL",SUP-M00552400,CDM,S27200284,LOCAL,0272,RC,,,both,,,2742.38,822.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,324.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,318.94,2331.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 9MM APTUS TITANIUM 6MM HEAD HAND CORTICAL LOCK",SUP-A-5400.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,149.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER RYDER 7IN SERRATE JAW SURGICAL TUNGSTEN CARBIDE 1MM",SUP-32-467,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.96,105.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.05,300.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA MEDIAL CONGRUENT 12 G-H KNEE",SUP-42512101010,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7327.97,68,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOTUS INTRODUCER SMALL REPRISE III",SUP-H749NTR180,CDM,C1894,HCPCS,0272,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MILL BONE MEDIUM BIOPSY DISPOSABLE",SUP-5400-701-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2556.18,766.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC TREK NEO 15MM 145CM 4.5MM BALLOON DILATATION",SUP-1400450-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE CONNECT 250T VASCULAR 300CM .018IN DURASTEEL",SUP-1012595,CDM,C1769,HCPCS,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC TREK NEO 8MM 145CM 5MM BALLOON DILATATION HYDROCOAT",SUP-1400500-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTW TAKERU PTCA BALLOON 2.25MM X 15MM",SUP-DC-PY2215UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC CT Thorax Lung Cancer Scr C-",PX-352000038,CDM,71271,CPT,0352,RC,,,both,,,646.25,193.87,"NOVANET [10819]",Novanet,,484.69,75,,,,,0,75.16,646.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.185,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOTHYROXINE 112 MCG TABLET",RX-10404,CDM,,,0637,RC,42292-0039-01,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRI-SIL IC 60IN 22FR URETHRAL BACTI-GUARD SILICONE",SUP-0170SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,193.66,58.1,"FIRST HEALTH [10303]","First Health",,154.93,80,,,,,0,22.52,164.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ VASCULAR STRAIGHT 260CM .025IN PTFE STAINLESS",SUP-G04047,CDM,C1769,HCPCS,0272,RC,,,both,,,165.21,49.56,"NOVANET [10819]",Novanet,,123.91,75,,,,,0,19.21,140.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 5MM 6FR ENDOPROSTHESIS HEPARIN",SUP-VBJ050502,CDM,C1874,HCPCS,0278,RC,,,both,,,18622.80,5586.84,"BLUE CROSS [10001]","Blue Cross PPO",,7300.14,39.2,,,,,0,2165.83,15829.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL BABCOCK STRAIGHT 9 3/8IN INTESTINAL SERRATE",SUP-50-1123,CDM,S27200284,LOCAL,0272,RC,,,both,,,1023.19,306.96,"CIGNA [10200]",Cigna,,695.77,68,,,,,0,119,869.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SCLEROTHERAPY 25GA 2.3MM OPTIC TIP SHEATH STERILE LATEX",SUP-218,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"MULTIPLAN [10600]",Multiplan,,147.9,85,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONVEY 5FR .058IN CONTRALATERAL SPRT 4 CURVE GUIDING",SUP-H749392285750,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,150.61,41.1,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Outr Maternal Quad Sreen Serum",PX-300000024,CDM,81511,CPT,0310,RC,,,both,,,302.00,90.6,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,302,"per diem",
"CATH THERMOCOOL SF D-F CURVE ABLATION BIDIRECTIONAL",SUP-BDI35DFRT,CDM,C1732,HCPCS,0272,RC,,,both,,,11350.50,3405.15,"KAISER [10500]",Kaiser,,7604.84,67,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER HUMERAL RSP DJO SURGICAL +8MM MONOBLOCK STERILE",SUP-510-08-000,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"AETNA [10100]","Aetna HMO/PPO",,8013.6,79.5,,10981.53,8986.79,12413.38,12,1172.3,8568,"percent of total billed charges",
"PUMP CANSTR LID FILTER TUBING NONSTERILE",SUP-PAPS1,CDM,S27000186,LOCAL,0270,RC,,,both,,,1620.00,486,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.6MM 14MM STD SPINE VARIABLE ANGLE SELF DRILL",SUP-184.154,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"BLUE CROSS [10001]","Blue Cross PPO",,368.48,39.2,,957.42,570.23,957.42,28,109.32,799,"percent of total billed charges",
"SCR BONE 5MM 47.5MM T2 TITANIUM FULL THREAD FEMUR HUMERUS",SUP-1896-5047S,CDM,C1713,HCPCS,0278,RC,,,both,,,1279.15,383.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,151.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",148.77,1087.28,"percent of total billed charges",
"SCR BONE 8-6.5MM 80MM CREO SPINE PREASSEMBLE 2 OUTER",SUP-5119.2282,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",601.85,4398.75,"percent of total billed charges",
"CMPNT FEMORAL G RIGHT KNEE POSTERIOR STABILIZED NEXGEN",SUP-00576401752,CDM,C1776,HCPCS,0278,RC,,,both,,,16934.40,5080.32,"UHC [10700]","United Healthcare",,10719.48,63.3,,8601.07,8395.67,8601.07,"1 through 10",1969.47,14394.24,"percent of total billed charges",
"RASP SURGICAL 7IN MILLER STAINLESS STEEL 2 END NONSTERILE",SUP-260-205,CDM,S27100035,LOCAL,0271,RC,,,both,,,447.85,134.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 20GA 10CM POWERGLIDE 5ML/SEC FULL MIDLINE POWER",SUP-M120101,CDM,C1751,HCPCS,0272,RC,,,both,,,664.20,199.26,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DUODENOSCOPE FLEXIBLE 1240MM 15.1MM 11.3MM 4.2MM EXALT MODEL",SUP-M00542421,CDM,C1748,HCPCS,0272,RC,,,both,,,18459.00,5537.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"ELECTRD ELECTROSURGICAL LOOP 24FR CIRCON CLASSIC",SUP-M0068802581,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS,MAJOR",894,APR-DRG,,,,,,,inpatient,,,49857.93,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $5,120.11. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,482.05) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,MAJOR",042,APR-DRG,,,,,,,inpatient,,,63442.04,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $6,845.88. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($43,454.08) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ARTHROSCOPIC STAINLESS STEEL 3.4MM HOOK 90D 5MM MARK",SUP-AR-10010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1428.84,428.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,169.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.17,1214.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X3CM PRO3 THICK AMNIOTIC MEMB UMBILICAL",SUP-P01-AMC-0203,CDM,V2790,HCPCS,0278,RC,,,both,,,11022.75,3306.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7495.47,68,,,,,0,1281.95,9369.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 9IN .5MM SENTINEL ROUNDED ECCENTRIC MONO FLUTED",SUP-S8585,CDM,S27200284,LOCAL,0272,RC,,,both,,,1593.51,478.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,654.93,41.1,,,,,0,185.33,1354.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X6MM HEDRON C 7D 14MM STERILE LATEX FREE",SUP-1211.4616S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross PPO",,2434.32,39.2,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDING BALLOON",SUP-BVCS6180,CDM,C1725,HCPCS,0272,RC,,,both,,,672.30,201.69,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ASTATO XS 20, PERIPHERAL GUIDE WIRE,300CM",SUP-PAGH143392,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARD BARDEX 16FR URETHRAL SILICONE ELASTOMER NATURAL",SUP-0166V16S,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.59,28.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACIFIC PLUS 130CM 80MM 4FR 6MM .018IN BALLOON",SUP-PCP060080130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AEON ENDOSTAPLER CURVED TIP RELOAD 60MM PURPLE",SUP-AESC60P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 150CM 15CM 4MM BALLOON DILATATION OTW LOW",SUP-G30950,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SCEPTER XC 150CM 11MM 2.1-2.8FR 4MM 5MM BALLOON",SUP-BC0411XC,CDM,C2628,HCPCS,0272,RC,,,both,,,11730.00,3519,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE 44MM 7.1MM 5MM CUFFLESS ROUND TIP OBTR SMOOTH SOFT","SUP-5.0 PED",CDM,S27200284,LOCAL,0272,RC,,,both,,,279.49,83.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PACKAGED ACCESSORIES",SUP-ES0542,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 9X60 40CM SL",SUP-48009006P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE TRACH 6 74MM 10.8MM SHILEY UNCUFF DISPOSABLE INNER CANN",SUP-6UN75H,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.56,98.27,"CIGNA [10200]","Cigna Local Plus",,175.24,53.5,,,,,0,38.1,278.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CXI 65CM 2.6FR ANGLE SPRT STAINLESS STEEL TUNGSTEN",SUP-G18368,CDM,C1887,HCPCS,0272,RC,,,both,,,1255.50,376.65,"MULTIPLAN [10600]",Multiplan,,1067.18,85,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 16MM 11MM LATERALIZE NECK CEMENTLESS",SUP-563517,CDM,C1776,HCPCS,0278,RC,,,both,,,11104.56,3331.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5096.99,45.9,,,,,0,1291.46,9438.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 120CM 135CM 25-30MM 10FR COLONIC NITINOL",SUP-M00565090,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 SWIVELOCK PEEK 19.1MM",SUP-AR-2324KPSLC,CDM,C1713,HCPCS,0278,RC,,,both,,,3425.63,1027.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,405.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,398.4,2911.79,"percent of total billed charges",
"SNARE HEXAGONAL 230CM 2.4MM TRAXTION OLYMPUS ACTIVE CORD",SUP-00711113,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,147.9,68,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 12MM 3MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012407-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL ULTRAPRO 11X6CM PARTIAL ABSORBABLE LIGHTWEIGHT",SUP-UMS3,CDM,C1781,HCPCS,0278,RC,,,both,,,826.66,248,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,379.44,45.9,,,,,0,96.14,702.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 60MM 130CM 7MM LONG VASCULAR NITINOL ILIAC",SUP-SC760LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"BLUE CROSS [10001]","Blue Cross PPO",,2840.04,39.2,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP DUAL MOBILITY HIP",SUP-THAPRE,CDM,C1776,HCPCS,0278,RC,,,both,,,26460.00,7938,"NOVANET [10819]",Novanet,,19845,75,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.195,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLIDESHEATH SLENDER SS KIT, 0.021 GW, 7 FR, 10CM",SUP-80-1070,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,302.94,68,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 55IN 8FR ANTICLOG RADIOPAQUE BOW TIP BOLUS",SUP-40-9558,CDM,S27200284,LOCAL,0272,RC,,,both,,,160.37,48.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.65,136.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM CREO TITANIUM COCR SPINE POLYAXIAL",SUP-5146.1647,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 250MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030250M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"PHCS [10601]",PHCS,,1312.5,70,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG UROLOGICAL TABLE 36X20IN UROVIEW DRAIN CYSTOFLOW",SUP-3170NS,CDM,S27100035,LOCAL,0271,RC,,,both,,,113.92,34.18,"KAISER [10500]",Kaiser,,76.33,67,,,,,0,13.25,96.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 31MMX8MMX20CM 22FR",SUP-TAC083120A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"CIGNA [10200]",Cigna,,72960,40,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1",SUP-179715645,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"PROBE ELECTROSURGICAL 220CM 2.3MM FIAPC FLEXIBLE SIDEFIRE",SUP-20132-217,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"CIGNA [10200]","Cigna Local Plus",,1003.13,53.5,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELAN 4 2-RING DISP OVAL BURR D4.0",SUP-GP382SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,1289.12,386.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPRT ORTHOPEDIC 14-15IN NYLON ANKLE ELASTIC CUFF CLSR LOW",SUP-AB2900-18,CDM,S27000186,LOCAL,0270,RC,,,both,,,108.05,32.41,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE 2O VASCULAR ANGLE 80CM .035IN HYDROPHILIC FIX CORE",SUP-H2OSTFA3580,CDM,C1769,HCPCS,0272,RC,,,both,,,278.40,83.52,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSERT TIB CONGR 12MM LEFT .5",SUP-2041-0-1212,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,414.32,3028.13,"percent of total billed charges",
"COIL EMBOLIZATION 177CM 6MM EMBOLD PLATINUM TUNGSTUN NITINOL",SUP-M001394240060100,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"CIGNA [10200]",Cigna,,4635.7,68,,,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175250090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"PHCS [10601]",PHCS,,931.18,70,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L19 MM OD3.5 MM SPINE CERVICAL ANTERIOR SELF TAP",SUP-18008419,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILFRM URETHRAL 18IN 6FR DILATION CATH WOVEN STRAIGHT TIP",SUP-021806,CDM,S27200284,LOCAL,0272,RC,,,both,,,1162.76,348.83,"CIGNA [10200]",Cigna,,790.68,68,,,,,0,135.23,988.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hfe Gene",PX-309000034,CDM,81256,CPT,0310,RC,,,both,,,854.25,256.27,"CIGNA [10200]","Cigna Open Access",,143.79,,,,,,,0.01,726.11,"fee schedule",
"TRAY CATH 20CM 11.5FR FULL SILICONE HEMO-CATH SAFETY SCPL",SUP-MCDLTSL20,CDM,C1750,HCPCS,0278,RC,,,both,,,988.20,296.46,"CIGNA [10200]","Cigna Open Access",,562.29,56.9,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 23MM 145CM 3MM CORONARY STENT",SUP-1145300-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]","Cigna Open Access",,3321.82,56.9,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION DEB 2.25X35",SUP-SCA14U-225035D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT CALCIUM PHOSPHATE 5ML MASTERGRAFT VOID FILLER",SUP-7600105,CDM,C1713,HCPCS,0278,RC,,,both,,,1879.50,563.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,222.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",218.59,1597.58,"percent of total billed charges",
"SLEEVE CENTERING V40 2.5MM UNIVERSAL KNEE ADPTR",SUP-6519-T-025,CDM,C1776,HCPCS,0278,RC,,,both,,,1000.82,300.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,118.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,116.4,850.7,"percent of total billed charges",
"FXBRIDGE TUBEROSITY REPAIR SYSTEM",SUP-AR-9517,CDM,S27200284,LOCAL,0272,RC,,,both,,,8168.63,2450.59,"KAISER [10500]",Kaiser,,5472.98,67,,,,,0,950.01,6943.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)MARKER SKIN GREEN 7.5CM SOFT TISSUE DELIVERY SYSTEM ST",SUP-SMARTCLIPLT-GRN-7.5,CDM,A4648,HCPCS,0278,RC,,,both,,,2625.00,787.5,"KAISER [10500]",Kaiser,,1758.75,67,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3MM 2 BIO-SUTURETAK FIBERWIRE ROTATOR CUFF",SUP-AR-1934BF,CDM,C1713,HCPCS,0278,RC,,,both,,,1929.38,578.81,"CIGNA [10200]","Cigna Open Access",,1097.82,56.9,,1144.80,304.56,2275.09,66,224.39,1639.97,"percent of total billed charges",
"BIT DRILL 330MM 5MM 3 FLUTE QUICK COUPLING CALIBRATED 100MM",SUP-03.010.062,CDM,S27200284,LOCAL,0272,RC,,,both,,,1617.08,485.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.07,1374.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL BIT ASSY, CARBIDE, HUDSON END, 3 MM, SINGLE USE",SUP-SBT002,CDM,S27000186,LOCAL,0270,RC,,,both,,,2212.50,663.75,"FIRST HEALTH [10303]","First Health",,1770,80,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 180MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-410-180,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM ATRIUM RIGHT VENTRICLE TRANSVENOUS 4 TINE",SUP-407452,CDM,C1898,HCPCS,0275,RC,,,both,,,2250.00,675,"AETNA [10100]","Aetna HMO/PPO",,1788.75,79.5,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 6MM ENDOWRIST SP NONSTERILE LATEX FREE REUSABLE",SUP-430006,CDM,S27000186,LOCAL,0270,RC,,,both,,,2324.70,697.41,"NOVANET [10819]",Novanet,,1743.53,75,,,,,0,270.36,1976,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 9IN RETRACTION CUSHING GANGLION",SUP-20-2240,CDM,S27200284,LOCAL,0272,RC,,,both,,,297.80,89.34,"AMERIGROUP MEDICAID [20100]",Amerigroup,,35.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.63,253.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SURGICAL SPHERZ 5 SNAP ON PASSIVE WIRELESS DISPOSABLE",SUP-PM8005,CDM,S27200284,LOCAL,0272,RC,,,both,,,57.86,17.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23.78,41.1,,,,,0,6.73,49.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11.75CM NATRELLE INSPIRA P3.9CM MODERATE PROFILE",SUP-MSZ-M295,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"KAISER [10500]",Kaiser,,105.98,67,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 4IN 18GA 20GA PAJUNK SONOLONG TUOHY",SUP-TDL105,CDM,C9814,HCPCS,0272,RC,,,both,,,567.00,170.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,260.25,45.9,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR HD 36CM 11-13FR ACCESS STAINLESS STEEL",SUP-M0062502220,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"PHCS [10601]",PHCS,,686.47,70,,,,,0,114.05,833.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14IN 28FR VENOUS 90D OPEN LIGHTHOUSE 1 STAGE",SUP-TF028L90,CDM,S27200284,LOCAL,0272,RC,,,both,,,277.18,83.15,"KAISER [10500]",Kaiser,,185.71,67,,,,,0,32.24,235.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE ACHILLES TENDON FROZEN STRUT",SUP-02B002-55,CDM,C1762,HCPCS,0278,RC,,,both,,,10563.90,3169.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1251.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1228.58,8979.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X8MM COLONIAL 12MM LARGE PARALLEL TITANIUM",SUP-365.308CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TF (-T) CRADLE ASSEMBLY LHR-0078",SUP-LHR-0078,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,,41.1,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL ROLLER BALL 3MM 26FR CIRCON CLASSIC",SUP-M0068802561,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Xr Spine Lumbosacral >=4v",PX-320000045,CDM,72110,CPT,0320,RC,,,both,,,1142.39,342.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,96.07,,,,,,,62.2,971.03,"fee schedule",
"BEARING HUMERAL 36MM COMPREHENSIVE STD SHOULDER VIVACIT-E",SUP-110031424,CDM,C1776,HCPCS,0278,RC,,,both,,,7755.60,2326.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,919.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,901.98,6592.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 80MM 5MM .018IN BALLOON DILATATION",SUP-R51005008L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"FIRST HEALTH [10303]","First Health",,1577.4,80,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla Xm Flow Cyto Add Smpl/Dil",PX-302000181,CDM,86826,CPT,0302,RC,,,both,,,179.00,53.7,"MULTIPLAN [10600]",Multiplan,,152.15,85,,,,,0,21.21,152.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE ORTHOPEDIC COCR 1.8MM 24IN HIP 7X7 STRAND",SUP-1739-28-000,CDM,C1713,HCPCS,0278,RC,,,both,,,2553.00,765.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1171.83,45.9,,,,,0,296.91,2170.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cors&Graft Angio W Rt&Lt Cath",PX-481000029,CDM,93461,CPT,0481,RC,,,both,,,24395.60,7318.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6079.88,,"Case rate ($6,079.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,1566.32,20736.26,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 12MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640212,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"AETNA [10100]","Aetna HMO/PPO",,8946.85,79.5,,10981.53,8986.79,12413.38,12,1308.83,9565.82,"percent of total billed charges",
"HC Inf Agent Zika Amp",PX-306000233,CDM,87662,CPT,0306,RC,,,both,,,997.50,299.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,80.71,,,,,,,0.01,847.88,"fee schedule",
"DEVICE MYNX CONTROL 5FR CLSR 10ML 2 MODE BALLOON CATH SEAL",SUP-MX5060,CDM,C1760,HCPCS,0278,RC,,,both,,,1680.00,504,"PHCS [10601]",PHCS,,1176,70,,,,,0,195.38,1428,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM STAINLESS STEEL 2.4MM SCR 6X3 HOLE 2 COLUMN",SUP-02.111.630,CDM,C1713,HCPCS,0278,RC,,,both,,,3834.68,1150.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1760.12,45.9,,,,,0,445.97,3259.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HELIOS STELLAR IDE -CLINICAL HANDLE",SUP-D1389-03-SI,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE X-CORE TITANIUM SPINE LOCK NONSTERILE",SUP-7162000,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.93,488.68,"CIGNA [10200]","Cigna Local Plus",,871.48,53.5,,3978.14,359.25,3978.14,24,189.44,1384.59,"percent of total billed charges",
"STENT ULTRAFLEX 30MM 15MM 14MM 24FR 95CM 4MM",SUP-M00576570,CDM,C1874,HCPCS,0278,RC,,,both,,,19467.00,5840.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2264.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2264.01,16546.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNR SM OVL 13MM SNS MED STF",SUP-6032,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 10MM LCP STAINLESS STEEL FULL THREAD CANCELLOUS",SUP-206.010,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,32.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",31.82,232.58,"percent of total billed charges",
"STENT GORE VIATORR 4CM 2CM 10MM ENDOPROSTHESIS NITINOL",SUP-PTB104275,CDM,C1874,HCPCS,0278,RC,,,both,,,27801.90,8340.57,"CIGNA [10200]","Cigna Open Access",,9313.64,33.5,,,,,0,3233.36,23631.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 71CM 18GA PROC TRANSSEPTAL 86D HEARTSPAN",SUP-FND01902,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 65MM 2.1MM 1703 3 CARBIDE STERILE LATEX FREE",SUP-1030040-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.25,19.57,"UHC [10700]","United Healthcare",,41.3,63.3,,,,,0,7.59,55.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALPHAGRAFT DEMINERALIZED BONE MATRIX FIBER 5CC",SUP-1008-050,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"PHCS [10601]",PHCS,,2625,70,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEDG CARDIOVASCULAR LARGE 3X3/8IN FIRM",SUP-Z-705,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.03,122.41,"CIGNA [10200]","Cigna Local Plus",,218.3,53.5,,,,,0,47.45,346.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SHINOBI VASCULAR STRAIGHT 300CM 3CM .014IN STEERABLE",SUP-547114X,CDM,C1769,HCPCS,0272,RC,,,both,,,617.06,185.12,"UHC [10700]","United Healthcare",,390.6,63.3,,,,,0,71.76,524.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 64MM MULTIHOLE EMPHASYS",SUP-471064900,CDM,C1776,HCPCS,0278,RC,,,both,,,21485.52,6445.66,"BLUE CROSS [10001]","Blue Cross HMO",,8422.32,39.2,,5311.50,4717.44,5388.59,31,2498.77,18262.69,"percent of total billed charges",
"CMPNT FEMORAL 8 STD KNEE LEFT CRUCIATE RETAIN CEMENT PERSONA",SUP-42502606401,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6543.3,28.62,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UROLOGICAL STD STRAIGHT 145CM 3CM .038IN STAINLESS",SUP-G14731,CDM,C1769,HCPCS,0272,RC,,,both,,,153.99,46.2,"MULTIPLAN [10600]",Multiplan,,130.89,85,,,,,0,17.91,130.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.4MM 70MM STAINLESS STEEL 4MM PARTIAL THREAD",SUP-02.205.270,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"PHCS [10601]",PHCS,,1089.1,70,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 90MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.190,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"CIGNA [10200]",Cigna,,770.24,68,,1831.33,1831.33,1831.33,16,131.73,962.8,"percent of total billed charges",
"AUG FEMORAL 15MM TRIATHLON 1 KNEE RIGHT DISTAL TOTAL",SUP-5542-A-102,CDM,C1776,HCPCS,0278,RC,,,both,,,7027.65,2108.29,"CIGNA [10200]","Cigna Open Access",,3998.73,56.9,,5302.19,4377.88,6578.61,27,817.32,5973.5,"percent of total billed charges",
"CATH INFINITI THRULUMEN 100CM 5FR INTERNAL MAMMARY CURVE",SUP-534560T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"KAISER [10500]",Kaiser,,62.67,67,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD TITANIUM ACU-LOC BONE LEFT DISTAL DORSAL RADIAL",SUP-70-0055,CDM,C1713,HCPCS,0278,RC,,,both,,,6451.50,1935.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,750.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",750.31,5483.78,"percent of total billed charges",
"SLEEVE COMPRESSION LARGE FOOT SCD EXPRESS ANTIEMBOLISM CUFF",SUP-5898,CDM,S27000186,LOCAL,0270,RC,,,both,,,158.31,47.49,"UHC [10700]","United Healthcare",,100.21,63.3,,,,,0,18.41,134.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM ACCOLADE HFX 127D 8 54MM OFFSET HIP",SUP-6077-0840,CDM,C1776,HCPCS,0278,RC,,,both,,,8983.80,2695.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4123.56,45.9,,,,,0,1044.82,7636.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM LAVA 18 EMBOLIC 2ML LIQUID",SUP-SLLES182,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1925.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 6MM BALLOON DILATATION STERILE LATEX",SUP-596015022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"MULTIPLAN [10600]",Multiplan,,1239.3,85,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 45CM 11MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1145CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]","Cigna Open Access",,4122.41,56.9,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STYLET ASSORTED 58CM UNIVERSAL J STRAIGHT REPOSITIONING",SUP-DS06003/58,CDM,S27200284,LOCAL,0272,RC,,,both,,,453.60,136.08,"KAISER [10500]",Kaiser,,303.91,67,,,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM 11MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192011,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"CIGNA [10200]",Cigna,,9499.39,40,,5873.17,5873.17,5873.17,"1 through 10",2761.95,20186.21,"percent of total billed charges",
"SUT MONOCRYL 3-0 RB-1 27IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y215H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 RIGHT MEDIAL LEFT LATERAL PARTIAL KNEE",SUP-5610-F-602,CDM,C1776,HCPCS,0278,RC,,,both,,,13720.65,4116.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5488.26,40,,,,,0,1595.71,11662.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP ARTHROSCOPIC 130MM NANO STRAIGHT DISPOSABLE",SUP-AR-10913D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1878.20,563.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,771.94,41.1,,,,,0,218.43,1596.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MERSILENE 2 MO-7 30IN BRAID D SPECIAL GREEN LIGHT GREEN",SUP-D8649,CDM,S27200284,LOCAL,0272,RC,,,both,,,776.02,232.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,90.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.25,659.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 5MM CANNULATED",SUP-71177134,CDM,S27200284,LOCAL,0272,RC,,,both,,,4305.32,1291.6,"UHC [10700]","United Healthcare",,2725.27,63.3,,,,,0,500.71,3659.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 28MM 4.5MM CORONARY STENT PLATINUM",SUP-H7493926028450,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"UHC [10700]","United Healthcare",,5896.4,63.3,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 135CM 7MM 11MM 7FR .035IN",SUP-BXA077902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"MULTIPLAN [10600]",Multiplan,,18196.29,85,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 650ML STYLE 9300 TEXTURED SELF SEALING PATCH",SUP-3549315,CDM,C1789,HCPCS,0278,RC,,,both,,,6720.00,2016,"PHCS [10601]",PHCS,,4704,70,,,,,0,781.54,5712,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOCYCLINE 100 MG CAPSULE",RX-5110,CDM,,,0637,RC,60687-0336-11,NDC,both,1,UN,6.64,1.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.77,5.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 40CM 4CM 6MM BALLOON DILATATION",SUP-DR4064,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC",515,MS-DRG,,,,,,,inpatient,,,132899.47,39869.84,"UHC [10700]","United Healthcare",,93044.73,,"Fee schedule rate ($93,044.73). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,93044.73,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TALON ORTHOPEDIC 600MM 3MM TROCAR TIP",SUP-SLN-T35,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPYSCOPE DSII DIGITAL ACCESS",SUP-M00546610,CDM,S27200284,LOCAL,0272,RC,,,both,,,16905.00,5071.5,"CIGNA [10200]",Cigna,,11495.4,68,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREONPANOPTIX PROTORIC",SUP-PXCAT3,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"BLUE CROSS [10001]","Blue Cross PPO",,358.68,39.2,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUMP INTRATHECAL 40ML SYNCHROMED III",SUP-8667-40,CDM,C1772,HCPCS,0278,RC,,,both,,,67117.50,20135.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,19209.03,28.62,,,,,0,7805.77,57049.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM MITRAL CARPENTIER-EDWARDS PHYSIO II",SUP-5200M34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1635.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 11.5CM 18MM 14.5-16.5MM GORE EXCLUDER",SUP-PLC181200,CDM,C1874,HCPCS,0278,RC,,,both,,,27997.20,8399.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8012.8,28.62,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL MICRO NDL STRAIGHT 4IN TUNGSTEN",SUP-E16514,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.10,61.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,140.15,68,,,,,0,23.97,175.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 22MM 3MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG30022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1239.3,45.9,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 22MM 1 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-41F22V,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,3978.14,359.25,3978.14,24,521.61,3812.25,"percent of total billed charges",
"SCR BONE 3.5MM 15MM GEMINUS TITANIUM CORTEX LOCK NONSTERILE",SUP-COLS-35150-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,631.80,189.54,"MULTIPLAN [10600]",Multiplan,,537.03,85,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.35IN 10-24FR HEYMAN PLASTIC DILATION CATH",SUP-021300,CDM,S27200284,LOCAL,0272,RC,,,both,,,1699.50,509.85,"CIGNA [10200]",Cigna,,1155.66,68,,,,,0,197.65,1444.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE AMBICOR 18CM 12.5MM CYL PUMP INFLATABLE",SUP-72401452,CDM,C1813,HCPCS,0278,RC,,,both,,,127708.50,38312.55,"CIGNA [10200]","Cigna Local Plus",,40228.18,31.5,,,,,0,14852.5,108552.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 44MM STAINLESS STEEL FULL THREAD FOOT",SUP-214.744,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"KAISER [10500]",Kaiser,,752.83,67,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER SHORT TIP RELOAD 60MM PURPLE",SUP-ASR60PS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"CIGNA [10200]","Cigna Local Plus",,780.03,53.5,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE TITANIUM 20MM 7MM 1.5MM ACL PCL CANNULATED",SUP-7207001,CDM,C1713,HCPCS,0278,RC,,,both,,,1342.66,402.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,384.27,28.62,,,,,0,156.15,1141.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRL MIC TPS MED 3.5X21.5MM",SUP-5120100035,CDM,S27200284,LOCAL,0272,RC,,,both,,,506.17,151.85,"PHCS [10601]",PHCS,,354.32,70,,,,,0,58.87,430.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 144MM 12MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-103120,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2868.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2814.85,20572.84,"percent of total billed charges",
"CATH REDEL 115CM 1MM 6FR 10MM SPACE STD F CURVE",SUP-F6HF010RT,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"FIRST HEALTH [10303]","First Health",,1166.4,80,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION",RX-2364,CDM,J3490,HCPCS,0258,RC,00264-7510-00,NDC,both,1000,ML,100.65,30.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,48.92,48.6,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRECEPT SCREW, 7.5X35MM POLYAXIAL",SUP-8807535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"FIRST HEALTH [10303]","First Health",,7637.48,80,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135D 42MM STD OFFSET 38.5MM STERILE 160MM 14MM",SUP-3L92514,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"BLUE CROSS [10001]","Blue Cross HMO",,6208.15,39.2,,5311.50,4717.44,5388.59,31,1841.86,13461.55,"percent of total billed charges",
"CATH LAUNCHER 100CM 6FR EBU3.25 CURVE GUIDING NYLON CORONARY",SUP-LA6EBU325,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE LIGHT MAXCESS LIGHT GUIDE STERILE DISPOSABLE",SUP-3200220,CDM,S27000186,LOCAL,0270,RC,,,both,,,2973.75,892.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1222.21,41.1,,,,,0,345.85,2527.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 55MM 6.5MM MODULEX OSTEOGRIP SPINE",SUP-55900506555,CDM,C1713,HCPCS,0278,RC,,,both,,,4519.50,1355.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,525.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",525.62,3841.58,"percent of total billed charges",
"SLEEVE ORTHOPEDIC THK1/8IN SMALL 13IN NEOPRENE KNEE EXTRA",SUP-79-82003,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.72,17.02,"AETNA [10100]","Aetna HMO/PPO",,45.09,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.6,48.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CENTEZE 6FR DRNG CENTESIS STERILE LATEX FREE DISPOSABLE",SUP-DRC-002-06,CDM,C1729,HCPCS,0272,RC,,,both,,,163.39,49.02,"UHC [10700]","United Healthcare",,103.43,63.3,,,,,0,19,138.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 80CM 10MM 13MM 8FR .035IN",SUP-BXA102901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2311.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.45 % IV BOLUS",RX-400292,CDM,,,0250,RC,00264-7802-10,NDC,both,500,ML,100.65,30.19,"PHCS [10601]",PHCS,,70.46,70,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR SURGICAL 40CM 2 LUMEN SPRAY TIP FILTER REG STERILE",SUP-0600030,CDM,S27200284,LOCAL,0272,RC,,,both,,,837.56,251.27,"CIGNA [10200]",Cigna,,569.54,68,,,,,0,97.41,711.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 8MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620208,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"FIRST HEALTH [10303]","First Health",,9003.12,80,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP UNIPOLAR HEAD AND ADAPTER",SUP-OSC365963,CDM,C1776,HCPCS,0278,RC,,,both,,,3750.00,1125,"KAISER [10500]",Kaiser,,2512.5,67,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 10MM 11FR ENDOPROSTHESIS HEPARIN",SUP-VBH101002A,CDM,C1874,HCPCS,0278,RC,,,both,,,20160.00,6048,"NOVANET [10819]",Novanet,,15120,75,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 80CM 4FR RDC1 CURVE ANGIOGRAPHIC NYLON NEON SLX",SUP-451446S0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"MULTIPLAN [10600]",Multiplan,,88.74,85,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +9.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.095,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brucella Ab",PX-302000104,CDM,86622,CPT,0302,RC,,,both,,,427.50,128.25,"KAISER [10500]",Kaiser,,286.43,67,,,,,0,0.01,363.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ihc Addnl Antibody per Spec",PX-312000060,CDM,88341,CPT,0312,RC,,,both,,,595.65,178.69,"NOVANET [10819]",Novanet,,446.74,75,,,,,0,0.01,506.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trauma Response Lvl II W/O Pre-Notification",PX-682000002,CDM,TTARU,HCPCS,0450,RC,,,both,,,8607.00,2582.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,725,,,,,,,67.13,7315.95,"case rate",
"HC Drug Test Definitiv 8-14 Class",PX-301000671,CDM,G0481,HCPCS,0301,RC,,,both,,,313.00,93.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,212.84,68,,,,,0,0.31,266.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 59CM ENDOCARDIUM 2 COIL IS-1 CNCT BIPOLAR",SUP-180,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS [10001]","Blue Cross PPO",,6731.42,39.2,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 15MM 3.3-3.6FR 6.5MM BALLOON",SUP-1008199-15,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"FIRST HEALTH [10303]","First Health",,1134,80,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP LARGE LEAK 1 ENTRAINMENT ELBOW CAPSTRAP HEADGEAR",SUP-989805628751,CDM,S27000186,LOCAL,0270,RC,,,both,,,224.74,67.42,"MULTIPLAN [10600]",Multiplan,,191.03,85,,,,,0,26.14,191.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 75MM 5.5MM DENALI CONTOUR BULLET TITANIUM",SUP-1001-E5575,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEMENT 7 PACK - ELEMENT 17 F VASCULAR ACCESS SYSTEM 65CM",SUP-ELMNT17F65PK7,CDM,C1887,HCPCS,0272,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEPILEX BORDER SACRUM 16X20CM",SUP-282055,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.72,14.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19.61,41.1,,,,,0,5.55,40.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-27333,CDM,,,0637,RC,00904-7208-06,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,3.35,53.5,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE SURGICAL 1.5X.5IN 2 LONG THREAD XRAY DETECTABLE",SUP-23276-250,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.47,22.34,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,50.64,68,,,,,0,8.66,63.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL OXFORD C KNEE LEFT MEDIAL COCRMO",SUP-154722,CDM,C1776,HCPCS,0278,RC,,,both,,,11195.94,3358.78,"NOVANET [10819]",Novanet,,8396.96,75,,,,,0,1302.09,9516.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMINO ACID 10 % INTRAVENOUS SOLUTION",RX-112907,CDM,,,0258,RC,00264-1933-10,NDC,both,500,ML,269.11,80.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,123.52,45.9,,,,,0,31.3,228.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SKATER CHOICE LOCK 25CM 12FR PIGTAIL CURVE DRNG",SUP-756612025,CDM,C1729,HCPCS,0272,RC,,,both,,,651.24,195.37,"FIRST HEALTH [10303]","First Health",,520.99,80,,,,,0,75.74,553.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRANSFORM 20MM 4MM BALLOON OCCLUSION 1 LUMEN COMPLIANT",SUP-M003SRC04200,CDM,C1725,HCPCS,0272,RC,,,both,,,11760.02,3528.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1367.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1367.69,9996.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 12.75CM NATRELLE INSPIRA P4.2CM MODERATE PROFILE",SUP-SRM-360,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,650.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 15CM 16GA ACCURIAN CURVE SHARP 10MM",SUP-AC0003,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"CIGNA [10200]",Cigna,,70.99,68,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP 55.9CM 8MM DA VINCI S/SI ENDOWRIST 45- D LARGE",SUP-420230,CDM,S27000186,LOCAL,0270,RC,,,both,,,700.41,210.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.46,595.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 7CM 10MM GORE EXCLUDER ILIAC INTERNAL",SUP-HGB161007A,CDM,S27800098,LOCAL,0278,RC,,,both,,,19089.00,5726.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7845.58,41.1,,,,,0,2220.05,16225.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER/DIVIDER BIPOLAR PURPLE 44CM 5MM LIGASURE 350D",SUP-LF1944,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CRE 5.5CM 8-9-10MM BALLOON DILATATION PEBAX ADULT RAPID",SUP-M00558870,CDM,C1726,HCPCS,0272,RC,,,both,,,2085.75,625.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,247.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",379.61,375.47,414.12,"1 through 10",242.57,1772.89,"percent of total billed charges",
"GRAFT SOFT TISSUE 50CMX.49MM 16/8MM HEMAGARD VASCULAR BOVINE",SUP-HGK1608,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 26CM 3CM 8FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155253050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]",Cigna,,837.05,68,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 22MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0285,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,110.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",110.22,805.55,"percent of total billed charges",
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 66MM 32MM MARATHON",SUP-121932466,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,961.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PERFORM STEM HEMI",SUP-CAP1179,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Local Plus",,6945.75,31.5,,5372.07,4581.20,7242.98,23,2564.42,18742.5,"percent of total billed charges",
"AVENIR 10, 5 X 10 COMPLEX PICO COIL",SUP-10USC05010,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3742.21,28.62,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE ENFORM 16X20CM INTRAPERITONEAL",SUP-GBFR1620,CDM,C1781,HCPCS,0278,RC,,,both,,,36477.00,10943.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4322.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4242.28,31005.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL PROC 15CM 18GA HAWKINS-AKINS PENCIL POINT STYLET BLUNT",SUP-G05045,CDM,S27200284,LOCAL,0272,RC,,,both,,,369.66,110.9,"KAISER [10500]",Kaiser,,247.67,67,,,,,0,42.99,314.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pulm Func Test Lung Vol",PX-460000011,CDM,94727,CPT,0460,RC,,,both,,,591.36,177.41,"CIGNA [10200]",Cigna,,402.12,68,,,,,0,68.78,502.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +9 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR 1",SUP-MTA4U0.090,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS13030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UHC [10700]","United Healthcare",,7420.72,63.3,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETERIZATION FOLEY URINE METER 16FR",SUP-81-080516,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.45,69.43,"MULTIPLAN [10600]",Multiplan,,196.73,85,,,,,0,26.92,196.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ACAPELLA DM 15- LPM 22MM PEP VIBRATORY MOUTHPC LOW",SUP-26-21-1015,CDM,S27000186,LOCAL,0270,RC,,,both,,,323.03,96.91,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.57,274.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X12MM COROENT XL FIXATION",SUP-7861250,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"BLUE CROSS [10001]","Blue Cross HMO",,13436.04,39.2,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHARTIS PRECISION 145CM 13MM PULMONARY ARTERY STERILE",SUP-CHR-CA-15.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,8176.50,2452.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5560.02,68,,,,,0,950.93,6950.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 20MM 80CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-G43844,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"NOVANET [10819]",Novanet,,2835,75,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 200CM 2.8MM 5.5FR SOEHENDRA BII PANCREATIC 2 LUMEN",SUP-G21732,CDM,S27200284,LOCAL,0272,RC,,,both,,,1680.00,504,"AMERIGROUP MEDICAID [20100]",Amerigroup,,199.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,195.38,1428,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT GRAFTON PLUS DEMINERALIZED BONE MATRIX PASTE",SUP-T45001,CDM,C1713,HCPCS,0278,RC,,,both,,,844.00,253.2,"BLUE CROSS [10001]","Blue Cross HMO",,330.85,39.2,,957.42,156.86,7483.26,51,98.16,717.4,"percent of total billed charges",
"HC Indwelling Trach Insert",PX-E27400044,CDM,L8511,HCPCS,0274,RC,,,both,,,180.40,54.12,"MULTIPLAN [10600]",Multiplan,,153.34,85,,,,,0,20.98,153.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STAPLER 2MM 2.5MM 3MM THK1.5-2.25MM 30MM ENDO GIA MED",SUP-SIG30AVM,CDM,S27200284,LOCAL,0272,RC,,,both,,,1060.37,318.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,125.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,123.32,901.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTSC SYSTEM SET, 12/3T - (220 CM)",SUP-100.29,CDM,C1760,HCPCS,0278,RC,,,both,,,4133.10,1239.93,"MULTIPLAN [10600]",Multiplan,,3513.14,85,,,,,0,480.68,3513.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR MP10 NEUTRAL 40MM HXE+ HIP NONSTERILE",SUP-931-40-760,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"CIGNA [10200]","Cigna Local Plus",,3506.93,53.5,,5372.07,4581.20,7242.98,23,762.35,5571.75,"percent of total billed charges",
"DRSG ROUND DRAPE SENSATRAC PAD CNCT POLYURETHANE VAC",SUP-M8275075/10.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,337.70,101.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,39.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.27,287.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 34MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ334,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.88,817.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI 100CM 6FR JL6 CURVE ANGIOGRAPHIC VESTAN",SUP-534624T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,39.93,45.9,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 65CM 3.1FR 50MM SPACE SPRT RADIOPAQUE",SUP-518-066,CDM,C1887,HCPCS,0272,RC,,,both,,,972.00,291.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,660.96,68,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 18FR SILICONE BOLUS FEED INTERNAL RETENTION BALLOON",SUP-8110-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,128.46,45.9,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME PATELLAR 9MM 38MM KNEE E PLUS 3 PEG STERILE",SUP-130-03-738,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY PRO 54CM 9FR GUIDING STERILE LATEX FREE",SUP-8104,CDM,C1887,HCPCS,0272,RC,,,both,,,1386.50,415.95,"KAISER [10500]",Kaiser,,928.96,67,,,,,0,161.25,1178.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X2CM MATRION PLACENTAL MEMB TROPHOBLAST",SUP-PAC06M,CDM,Q4201,HCPCS,0636,RC,,,both,,,3300.00,990,"KAISER [10500]",Kaiser,,2211,67,,,,,0,204.57,2805,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 31CM E-Z CLEAN LAPAROSCOPIC L HOOK",SUP-0063,CDM,S27200284,LOCAL,0272,RC,,,both,,,421.95,126.58,"KAISER [10500]",Kaiser,,282.71,67,,,,,0,49.07,358.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tmvr Perc Initial Prosthesis",PX-361000382,CDM,33418,CPT,0361,RC,,,both,,,35106.48,10531.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4160.12,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2491,29840.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 100MM 80CM 16MM BILIARY VENOUS DELIVERY",SUP-G57448,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3912.3,27,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 24CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805420,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]",Cigna,,613.48,68,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 20X20IN RESORBABLE GRID 2",SUP-F10258-2020G,CDM,C1781,HCPCS,0278,RC,,,both,,,49593.60,14878.08,"KAISER [10500]",Kaiser,,33227.71,67,,,,,0,5767.74,42154.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BONE 1.1MM INTRAMEDULLARY LOCKING DEVICE IMPLANTABLE",SUP-SBFS045,CDM,C1713,HCPCS,0278,RC,,,both,,,3864.00,1159.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1773.58,45.9,,,,,0,449.38,3284.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 4MM DELTAFILL 18 COIL",SUP-DLF180415,CDM,S27800098,LOCAL,0278,RC,,,both,,,14145.00,4243.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1676.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1645.06,12023.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Et Tube Endobronchial",PX-E27200242,CDM,9999115,LOCAL,0272,RC,,,both,,,730.95,219.28,"CIGNA [10200]",Cigna,,497.05,68,,,,,0,85.01,621.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ACCESS VISUALASE NEURO STERILE LATEX FREE DISPOSABLE",SUP-9735571,CDM,S27200284,LOCAL,0272,RC,,,both,,,15504.30,4651.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10542.92,68,,,,,0,1803.15,13178.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 100CM 5FR SIM2 CURVE ANGIOGRAPHIC",SUP-G47027,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"CIGNA [10200]","Cigna Open Access",,119.79,56.9,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 50MM 6.5MM CORTICAL",SUP-55900106550,CDM,C1713,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"PHCS [10601]",PHCS,,4105.5,70,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 55MM 17MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113617,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3402,27,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Foley",PX-E27200055,CDM,E27200055,LOCAL,0272,RC,,,both,,,88.00,26.4,"MULTIPLAN [10600]",Multiplan,,74.8,85,,,,,0,58.96,74.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNAP(R) CARTRIDGE - 125 MM HG - 10 IN A CASE",SUP-SNPA125,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"PHCS [10601]",PHCS,,714.42,70,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 102MM 2.7MM STAINLESS STEEL QUICK CONNECT 76MM",SUP-KM166-310-26,CDM,S27200284,LOCAL,0272,RC,,,both,,,198.53,59.56,"MULTIPLAN [10600]",Multiplan,,168.75,85,,,,,0,23.09,168.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X7MM PARALLEL SPINE",SUP-17307,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 3.5MM25CM 190",SUP-R51003525L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1694.48,68,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT WALLFLEX 90CM 135CM 25-30",SUP-6508,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,170.52,39.2,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 70X12.5X.8MM STAINLESS STEEL 2 SIDED RECIPROCATING",SUP-0277096276,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.41,87.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,133.3,45.9,,,,,0,33.77,246.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROLENE 4X1.8IN KNIT NONABSORBABLE PRESHAPE",SUP-PMSK,CDM,C1781,HCPCS,0278,RC,,,both,,,594.43,178.33,"CIGNA [10200]",Cigna,,404.21,68,,,,,0,69.13,505.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 4-5 C-D KNEE",SUP-42512100312,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 190MM 5.5MM RELINE STRAIGHT TITANIUM MAS",SUP-12355190,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"HC Sol Dialysate 106.5meq/Cl 100meq/Na 4meq",PX-E25000002,CDM,E25000002,LOCAL,0250,RC,,,both,,,56.45,16.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.57,47.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH LAB RIGHT HEART",SUP-K11-00761,CDM,S27200284,LOCAL,0272,RC,,,both,,,132.68,39.8,"NOVANET [10819]",Novanet,,99.51,75,,,,,0,15.43,112.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28MMX10MM X-PAC PARALLEL",SUP-EI2500P,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PHCS [10601]",PHCS,,19845,70,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.5MM LCP SUP ANT CLAVICLE PL W/LAT EXTN 5H/LT/94MM-STER",SUP-02.112.013S,CDM,C1713,HCPCS,0278,RC,,,both,,,6058.75,1817.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,704.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",704.63,5149.94,"percent of total billed charges",
"NAIL 9MM 230MM HUMERAL EXPERT INTRAMEDULLARY CANNULATED",SUP-04.001.426S,CDM,C1713,HCPCS,0278,RC,,,both,,,9216.74,2765.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1092.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1071.91,7834.23,"percent of total billed charges",
"CATH METACROSS 135CM 200MM 5.7FR 7MM BALLOON DILATATION 2",SUP-BD-L70200CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"UHC [10700]","United Healthcare",,607.59,63.3,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE INCISION WOLF RESECTOSCOPE",SUP-M0068805411,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,237.06,45.9,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR SILICONE RADIOPAQUE EXTERNAL RETENTION RING",SUP-8150-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,592.52,177.76,"CIGNA [10200]",Cigna,,402.91,68,,,,,0,68.91,503.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035422060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"MULTIPLAN [10600]",Multiplan,,11997.44,85,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 3MM 270MM DARCO KIRSCHNER LONG THREAD TIP HEAD",SUP-707093003,CDM,C1713,HCPCS,0278,RC,,,both,,,191.40,57.42,"KAISER [10500]",Kaiser,,128.24,67,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,inpatient,,,61939.99,18582,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,11098.59,,"Case rate ($10,775.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,005.63, add-ons for qualifying new technology services are included. If operating cost exceeds $43,045.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,138.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,018.86. The transfer operating threshold is the transfer adjustment factor * $10,005.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.47. The transfer capital threshold is the transfer adjustment factor * $756.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,50716.37,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 145MM 4.5MM STAINLESS STEEL QUICK COUPLING",SUP-310.44,CDM,S27200284,LOCAL,0272,RC,,,both,,,823.61,247.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,97.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,95.79,700.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BOWTIE SURECROSS 150CM 40CM 5FR .044IN 15MM SPACE SPRT",SUP-SC18150,CDM,C1887,HCPCS,0272,RC,,,both,,,891.00,267.3,"PHCS [10601]",PHCS,,623.7,70,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Punc Shunt Tube/Rsvr Asp/Inj",PX-361000249,CDM,61070,CPT,0361,RC,,,both,,,3722.77,1116.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1550,,"Case rate ($1,550). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,432.96,3722.77,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON RETRIEVAL EXTR PRO RX 200CM 6-7FR 12-15MM BILIARY 3",SUP-M00547040,CDM,C1889,HCPCS,0278,RC,,,both,,,810.00,243,"CIGNA [10200]","Cigna Local Plus",,433.35,53.5,,16168.95,16168.95,16168.95,"1 through 10",94.2,688.5,"percent of total billed charges",
"CATH RF MARINR MC 110CM 7FR 2-5-2MM SPACE ELECTROPHYSIOLOGY",SUP-075302,CDM,C1733,HCPCS,0272,RC,,,both,,,3967.50,1190.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1630.64,41.1,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14.8IN 24FR AORTA 3/8IN CURVE AUTO DILATE TIP",SUP-EZF24A,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"UHC [10700]","United Healthcare",,307.64,63.3,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT 12IN 1.75IN OSTOMY 2 PIECE DRAINABLE POUCH LOW PRESSURE",SUP-SQU416919,CDM,S27000186,LOCAL,0270,RC,,,both,,,236.62,70.99,"NOVANET [10819]",Novanet,,177.47,75,,,,,0,27.52,201.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE K-WIRE 2.4MM",SUP-20072,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"AMERIGROUP MEDICAID [20100]",Amerigroup,,23.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 8MM 3.25MM BALLOON DILATATION DURATRAC",SUP-NCEUP32508X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"FIRST HEALTH [10303]","First Health",,453.6,80,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET SPINE OCCIPITOCERVICOTHORACIC YUKON NONSTERILE LATEX",SUP-7601-10001,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,99.6,28.62,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR EXTRICATION ORANGE 3IN PROCARE REGULAR FLAT CONTOUR",SUP-79-83025,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.12,17.44,"AETNA [10100]","Aetna HMO/PPO",,46.21,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.76,49.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM STAINLESS STEEL T15 METAPHYSEAL SELF TAP",SUP-02.127.130,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"BLUE CROSS [10001]","Blue Cross HMO",,444.02,39.2,,957.42,156.86,7483.26,51,131.73,962.8,"percent of total billed charges",
"CHARGER 12.0 X60  75CM",SUP-H74939206120670,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT FIBERTAK 2 LOAD NDL",SUP-AR-3730SP,CDM,C1713,HCPCS,0278,RC,,,both,,,3346.88,1004.06,"BLUE CROSS [10001]","Blue Cross HMO",,1311.98,39.2,,957.42,156.86,7483.26,51,389.24,2844.85,"percent of total billed charges",
"TUBE TRACH 8 79MM 12.2MM SHILEY UNCUFF REUSABLE INNER CANN",SUP-8UN85R,CDM,S27200284,LOCAL,0272,RC,,,both,,,484.06,145.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,57.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.3,411.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR MEDIALIZE DOME 38MM CEMENT ATTUNE AOX KNEE",SUP-1518-20-038,CDM,C1776,HCPCS,0278,RC,,,both,,,5409.60,1622.88,"NOVANET [10819]",Novanet,,4057.2,75,,,,,0,629.14,4598.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 7MM SWIVELOCK TENODESIS SHOULDER BICEPS FORK",SUP-AR-1662PSL-7,CDM,C1713,HCPCS,0278,RC,,,both,,,3189.38,956.81,"PHCS [10601]",PHCS,,2232.57,70,,,,,0,370.92,2710.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SILICONE 300ML BREAST RESTERILIZABLE GEL",SUP-RSZ-7300MC,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"CIGNA [10200]","Cigna Open Access",,87.76,56.9,,,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
HEMASORB,SUP-OS-401,CDM,S27200284,LOCAL,0272,RC,,,both,,,749.25,224.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,88.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.14,636.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 2 LR 20IN BRAID GREEN NONABSORBABLE",SUP-X406T,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 9.3MM 19.5MM ATS OPEN PIVOT STD TITANIUM",SUP-500FA19,CDM,S27800098,LOCAL,0278,RC,,,both,,,25011.00,7503.3,"AETNA [10100]","Aetna HMO/PPO",,19883.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2908.78,21259.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"9MM DIA WASHER 2MM THKNESS",SUP-323.529,CDM,C1713,HCPCS,0278,RC,,,both,,,3165.00,949.5,"CIGNA [10200]",Cigna,,2152.2,68,,1831.33,1831.33,1831.33,16,368.09,2690.25,"percent of total billed charges",
"XIENCE SKYPOINT EVEROLIMUS ELUTING CORONARY STENT SYSTEM 4.5",SUP-1804450-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Airway Nasopharyngeal",PX-E27000038,CDM,E27000038,LOCAL,0270,RC,,,both,,,35.48,10.64,"KAISER [10500]",Kaiser,,23.77,67,,,,,0,4.13,30.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 22-38CMX6-12MM 6-12MM POSTERIOR TIBIALIS",SUP-430340,CDM,S27800098,LOCAL,0278,RC,,,both,,,11730.00,3519,"PHCS [10601]",PHCS,,8211,70,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR REFLECTION 20D E 50-52MM 32MM XLPE HIP",SUP-71333334,CDM,C1776,HCPCS,0278,RC,,,both,,,20487.60,6146.28,"MULTIPLAN [10600]",Multiplan,,17414.46,85,,,,,0,2382.71,17414.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 7FR STRAIGHT GUIDING DURAFORM",SUP-M003101510,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) EFS SIEGEL TAVR TRANSCATHETER AORTIC VALVE - 23MM","SUP-30-1-0123 -EFS",CDM,S62400003,LOCAL,0624,RC,,,both,,,182400.00,54720,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"BIT DRILL 2.8MM SHORT CALIBRATED STOP NONSTERILE",SUP-03.112.003,CDM,S27000186,LOCAL,0270,RC,,,both,,,998.57,299.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"2.50MM X 10MM  SCOREFLEX  NC",SUP-625-104-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BUPIVACAINE 0.5 % (5 MG/ML) INJECTION SUPERORDERABLE",RX-4081223,CDM,J0665,HCPCS,0636,RC,00409-1162-01,NDC,both,10,ML,25.07,7.52,"BLUE CROSS [10001]","Blue Cross PPO",,1.17,,,,,,,1.17,21.31,"fee schedule",
"INSRT TIBIAL 1 9MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G109,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"AETNA [10100]","Aetna HMO/PPO",,7950,79.5,,10981.53,8986.79,12413.38,12,1163,8500,"percent of total billed charges",
"STENT ABRE 150MM 10MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U10150090,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"FIRST HEALTH [10303]","First Health",,9384,80,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 130MM TITANIUM 12 HOLE LOCKING ACUMED BONE MEDIAL",SUP-PL-LEM12,CDM,C1713,HCPCS,0278,RC,,,both,,,6755.10,2026.53,"NOVANET [10819]",Novanet,,5066.33,75,,,,,0,785.62,5741.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 9MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G209,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"BLUE CROSS [10001]","Blue Cross PPO",,3413.38,39.2,,3949.44,3949.44,3949.44,"1 through 10",1012.7,7401.47,"percent of total billed charges",
"FRCP SURGICAL GRIFFITHS-BROWN 110MM TISSUE DELICATE TEETH 5",SUP-N5423,CDM,S27200284,LOCAL,0272,RC,,,both,,,1923.53,577.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1308,68,,,,,0,223.71,1635,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEMMED ANATOMIC PSI KIT (HUMERAL AND GLENOID)",SUP-1235-7153-003,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Local Plus",,3691.5,53.5,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM 39.6MM 31.9MM MITRAL TRICUSPID 3D",SUP-460032MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7741.8,68,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL FOGARTY 10MM 1 SOFTJAW 1 TRACTIONJAW",SUP-HCSOFT10,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.72,15.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,23.28,45.9,,,,,0,5.9,43.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMART ABLATE DISPOSABLE CABLES",SUP-M4900633,CDM,S27000186,LOCAL,0270,RC,,,both,,,3052.50,915.75,"MULTIPLAN [10600]",Multiplan,,2594.63,85,,,,,0,355.01,2594.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 32CM LEFT TROCHANTERIC INTRAMEDULLARY 125D LONG",SUP-456.393S,CDM,C1713,HCPCS,0278,RC,,,both,,,12838.83,3851.65,"MULTIPLAN [10600]",Multiplan,,10913.01,85,,,,,0,1493.16,10913.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUE DILATATION 110CM 4.5CM 10FR 20MM BALLOON",SUP-0204511,CDM,C1725,HCPCS,0272,RC,,,both,,,7590.00,2277,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5161.2,68,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 110MM 4MM RAD 40 STRAIGHTSHOT M4 SINUS CURVED",SUP-1884006HR,CDM,S27200284,LOCAL,0272,RC,,,both,,,2083.50,625.05,"CIGNA [10200]","Cigna Open Access",,1185.51,56.9,,,,,0,242.31,1770.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL 6MM SAPHENOUS VEIN RENAL ARTERY .75 SPRING",SUP-A1801,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"KAISER [10500]",Kaiser,,104.92,67,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIR STPLR TRIEEA25MT MEDTHK WT",SUP-TRIEEA25MT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2162.78,648.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,251.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,251.53,1838.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP BIPOLAR HIP",SUP-THABIP,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1226.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1203.71,8797.5,"percent of total billed charges",
"SUT PDS II MULTIPASS 4-0 P-3 18IN MONOFILAMENT UNDYED",SUP-Z494G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEQUALIS PERFORM GLENOID (PEGGED)- L40",SUP-DWE321,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"NOVANET [10819]",Novanet,,6987,75,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEPHRSTMY 18FR 21GA DUROMETER NDL CATH DIL LOCK 25CM",SUP-M001271900,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION",RX-3037,CDM,J3010,HCPCS,0636,RC,00641-6247-25,NDC,both,1,ML,44.00,13.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1.28,,,,,,,1.28,37.4,"fee schedule",
"SCR BONE 4.5MM 40MM SOLERA CD HORIZON OSTEOGRIP TITANIUM",SUP-54840004540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"KAISER [10500]",Kaiser,,6396.39,67,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 105D XIA OFFSET PLATE TITANIUM SPINE",SUP-03820132,CDM,S27800098,LOCAL,0278,RC,,,both,,,3562.50,1068.75,"MULTIPLAN [10600]",Multiplan,,3028.13,85,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 16MM ALPS TIMAX HAND CORTICAL NONLOCK SQUARE",SUP-131220516,CDM,C1713,HCPCS,0278,RC,,,both,,,1032.75,309.82,"FIRST HEALTH [10303]","First Health",,826.2,80,,,,,0,120.11,877.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nwpt >50 Sq Cm Disp (Gp)",PX-420000044,CDM,97608,CPT,0420,RC,,,both,,,2308.00,692.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,426,,"Per diem ($426).",,,,0,215,1961.8,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 21.5X10.7CM ALLODERM SELECT THK2-2.8MM CONTOUR",SUP-CL1519P,CDM,Q4116,HCPCS,0636,RC,,,both,,,31380.30,9414.09,"NOVANET [10819]",Novanet,,23535.23,75,,,,,0,247.92,26673.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NEURON 120CM 9CM 5FR .04IN 035IN .038IN 1 CURVE",SUP-PNS5F120H1,CDM,C1757,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 80MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UHC [10700]","United Healthcare",,907.53,63.3,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM AVENIR HELICAL 10 FINISH STERILE",SUP-10HFN-03004,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA [10200]",Cigna,,7033.31,68,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3.5MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-03506,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3165.24,27,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 250MM 2.5MM BALLOON DILATATION",SUP-48002525S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,936.36,68,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 9CM 5MM MIDAS REX LEGEND BALL DIAMOND COARSE",SUP-9BA50DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.17,412.25,"CIGNA [10200]","Cigna Open Access",,781.9,56.9,,,,,0,159.82,1168.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 90MM ANTIROTATE STERILE FEMORAL NECK SYSTEM",SUP-04.168.490S,CDM,C1713,HCPCS,0278,RC,,,both,,,1642.20,492.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,470,28.62,,,,,0,190.99,1395.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 10MM LCP STAINLESS STEEL SHORT THREAD FIBULA",SUP-207.610,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"BLUE CROSS [10001]","Blue Cross PPO",,407.7,39.2,,957.42,570.23,957.42,28,120.96,884.03,"percent of total billed charges",
"THORECON? SINGLE USE PLATE/CABLE CUTTER",SUP-94-PLATECUTTER,CDM,S27200284,LOCAL,0272,RC,,,both,,,3037.50,911.25,"AETNA [10100]","Aetna HMO/PPO",,2414.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,353.26,2581.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 42MM TITANIUM T25 SELF TAP LOCK STARDRIVE",SUP-412.215S,CDM,C1713,HCPCS,0278,RC,,,both,,,1220.18,366.05,"BLUE CROSS [10001]","Blue Cross PPO",,478.31,39.2,,957.42,570.23,957.42,28,141.91,1037.15,"percent of total billed charges",
"SCR BONE 3.5MM 20MM ORTHOLOC LONG CORTEX ANKLE FOOT 3DI",SUP-58803520,CDM,C1713,HCPCS,0278,RC,,,both,,,1506.60,451.98,"PHCS [10601]",PHCS,,1054.62,70,,,,,0,175.22,1280.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE RIGHT MIDFACE 2X2 HOLE L RIGID 1.5MM SCREWS BONE",SUP-1/1/8679,CDM,C1713,HCPCS,0278,RC,,,both,,,1702.50,510.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,781.45,45.9,,,,,0,198,1447.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC CURVE TIP RELOAD AEON 60MMX2.5MM STERILE",SUP-AESC60W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"PHCS [10601]",PHCS,,1020.6,70,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 35MM 25MM AEQUALIS 2MM LATERAL OFFSET STD",SUP-DWE735,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"FIRST HEALTH [10303]","First Health",,7554.4,80,,,,,0,1098.22,8026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Access Av Grft Thromb Stent",PX-361000439,CDM,36906,CPT,0361,RC,,,both,,,49992.03,14997.61,"MULTIPLAN [10600]",Multiplan,,42493.23,85,,,,,0,5284,42493.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 54IN BRAID ANTIBACTERIAL COATED UNDYED",SUP-VCP607H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD LAPAROSCOPIC 28CM VALLEYLAB CURVE SPAT HOLLOW",SUP-E3781-28,CDM,S27200284,LOCAL,0272,RC,,,both,,,163.73,49.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.04,139.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI 100CM 6FR MPB2 CURVE ANGIOGRAPHIC VESTAN",SUP-534649T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"CIGNA [10200]",Cigna,,59.16,68,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 54MM",SUP-626-00-54I,CDM,S27800098,LOCAL,0278,RC,,,both,,,9500.40,2850.12,"NOVANET [10819]",Novanet,,7125.3,75,,,,,0,1104.9,8075.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 18CM NARROW BASE INFRAPUBIC NARROW CORPORA",SUP-EN8818,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7292.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 45MM COMMON ILLIAC SEG 41MM EXTERNAL",SUP-G60344,CDM,C1874,HCPCS,0278,RC,,,both,,,68399.94,20519.98,"CIGNA [10200]","Cigna Open Access",,22913.98,33.5,,,,,0,7954.91,58139.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE HEMIPATELLAR TENDON STRUT",SUP-46B002,CDM,S27800098,LOCAL,0278,RC,,,both,,,12057.75,3617.32,"KAISER [10500]",Kaiser,,8078.69,67,,,,,0,1402.32,10249.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Guide Wire",PX-E27200130,CDM,C1769,HCPCS,0272,RC,,,both,,,135.99,40.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.82,115.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SALINE 375-450ML ROUND MODERATE PLUS PROFILE",SUP-351-2375SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,349.56,41.1,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 120MM 4FR 7MM LOW PROFILE BALLOON",SUP-PCP070120130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,837.22,68,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 150CM 60MM 5MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013468-060,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"FIRST HEALTH [10303]","First Health",,1004.4,80,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE 12.5-14 XL MALE PATIENT 2 PADDED POSTOPERATIVE SQUARE",SUP-MQM4B,CDM,S27000186,LOCAL,0270,RC,,,both,,,78.91,23.67,"UHC [10700]","United Healthcare",,49.95,63.3,,,,,0,9.18,67.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Orbit/Ear/Fossa W Cntrst",PX-351000006,CDM,70481,CPT,0351,RC,,,both,,,3533.18,1059.95,"CIGNA [10200]","Cigna Open Access",,475,,"Per diem ($475). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,405,3003.2,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER 6.5MM DARCO ORTHOPEDIC",SUP-707657501,CDM,C1713,HCPCS,0278,RC,,,both,,,226.20,67.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,26.31,192.27,"percent of total billed charges",
".035 INTERLOCK 2D 18MM X 40CM",SUP-M001363670,CDM,C1725,HCPCS,0272,RC,,,both,,,5181.90,1554.57,"MULTIPLAN [10600]",Multiplan,,4404.62,85,,,,,0,602.65,4404.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 6MM 4MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP4006X,CDM,C1725,HCPCS,0272,RC,,,both,,,607.50,182.25,"MULTIPLAN [10600]",Multiplan,,516.38,85,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP TRUNCATE OSTEOTOM 56MM HEMISPHERE",SUP-00705305610,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,536.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 6.5MM 40MM CD HORIZON SOLERA VOYAGER SPINE MULTIA",SUP-5585-001-6540,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"CLOBETASOL 0.05 % TOPICAL CREAM",RX-9630,CDM,,,0250,RC,69238-1532-05,NDC,both,15,GR,806.60,241.98,"CIGNA [10200]","Cigna Open Access",,458.96,56.9,,,,,0,93.81,685.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE PATIENT SPECIFIC INSTRUMENTATION PSI GUIDE PIN",SUP-CAP-U-PSI,CDM,C1776,HCPCS,0278,RC,,,both,,,1620.00,486,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1101.6,68,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SIGNAFUSE BIPHASIC CALCIUM PHOSPHATE BIOACTIVE",SUP-SGF-150,CDM,C1713,HCPCS,0278,RC,,,both,,,12972.00,3891.6,"KAISER [10500]",Kaiser,,8691.24,67,,,,,0,1508.64,11026.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 35X10MM HALL THK.6MM STERNUM STAINLESS STEEL",SUP-505953200,CDM,S27200284,LOCAL,0272,RC,,,both,,,86.30,25.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.04,73.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 3-0 PS-2 18IN MONOFILAMENT UNDYED",SUP-Y497G,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRANSFORM 10MM 4MM BALLOON OCCLUSION 1 LUMEN SUPER",SUP-M003SSC04100,CDM,C1725,HCPCS,0272,RC,,,both,,,11760.02,3528.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1393.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1367.69,9996.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS",RX-24932,CDM,J2916,HCPCS,0636,RC,00143-9570-01,NDC,both,5,ML,288.11,86.43,"CIGNA [10200]",Cigna,,29.78,,,,,,,11.77,244.89,"fee schedule",
"HC Transplant Eval Renal Day 1 New Pt",PX-761000011,CDM,99205,CPT,0761,RC,,,both,,,2483.00,744.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,288.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.48,2483,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC",464,MS-DRG,,,,,,,inpatient,,,104301.44,31290.43,"CIGNA [10200]","Cigna Local Plus",,32140.59,,"Fee schedule rate ($32,140.59). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,90936.78,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SPAT SURGICAL 7X.75IN DAVIS BRAIN MALLEABLE",SUP-22-0066,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.46,43.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,58.96,41.1,,,,,0,16.68,121.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE 16MM 4.5MM EMBOLIZATION",SUP-PED2-450-16,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"AETNA [10100]","Aetna HMO/PPO",,64234.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 25MM 3.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3525X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"MULTIPLAN [10600]",Multiplan,,447.53,85,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM 8MM RUBY POD COMPLEX OCCULUSION",SUP-RBYPOD8,CDM,S27800098,LOCAL,0278,RC,,,both,,,11661.00,3498.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4664.4,40,,,,,0,1356.17,9911.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 12MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50012,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"UHC [10700]","United Healthcare",,52554.65,63.3,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 22CM 10.2FR RB AMPLATZ PIGTAIL CURVE URETER",SUP-G09712,CDM,C2625,HCPCS,0278,RC,,,both,,,1227.07,368.12,"CIGNA [10200]","Cigna Local Plus",,656.48,53.5,,,,,0,142.71,1043.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 30MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.030,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,140.32,68,,,,,0,24,175.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM TIMAX FULL THREAD ELBOW CORTICAL NONLOCK",SUP-815037030,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,93.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",91.85,671.29,"percent of total billed charges",
"CAP CONSTRUCT TOTAL KNEE LEGION COCR FEMUR LEGION INSERT JOU",SUP-71704626,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7767.9,41.1,,6417.48,6417.48,6417.48,"1 through 10",2198.07,16065,"percent of total billed charges",
"STENT ULTRAFLEX 40MM 25MM 18MM 27FR 95CM 5.1MM",SUP-M00576640,CDM,C1874,HCPCS,0278,RC,,,both,,,19467.00,5840.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8000.94,41.1,,,,,0,2264.01,16546.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 330611 ACSR 6X11X11 SRVC FEE",SUP-330611,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 26MM 52MM OFFSET 4MM TOTAL SHOULDER REPLACEMENT",SUP-5552-E-5226,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4171.76,45.9,,,,,0,1057.03,7725.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DOYEN CURVE 9IN INTESTINE",SUP-50-1773,CDM,S27200284,LOCAL,0272,RC,,,both,,,1455.41,436.62,"CIGNA [10200]","Cigna Open Access",,828.13,56.9,,,,,0,169.26,1237.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR ENDOSCOPIC BALLOON FIBER OPTIC BF-UC160F",SUP-MAJ-1352,CDM,S27200284,LOCAL,0272,RC,,,both,,,801.33,240.4,"MULTIPLAN [10600]",Multiplan,,681.13,85,,,,,0,93.19,681.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trauma Response Lvl II W/O Pre-Notification",PX-682000002,CDM,TTARU,HCPCS,0450,RC,,,both,,,8607.00,2582.1,"UHC [10700]","United Healthcare",,2260,,"Per diem ($2,260).",,,,0,67.13,7315.95,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Splint Leg Full Pneu Prefb Ots",PX-E27400061,CDM,L4370,HCPCS,0274,RC,,,both,,,1683.00,504.9,"BLUE CROSS [10001]","Blue Cross PPO",,659.74,39.2,,,,,0,138.46,1430.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 8MM NESTER MICROCOIL PLATINUM ACCEPTS",SUP-G47375,CDM,S27800098,LOCAL,0278,RC,,,both,,,890.92,267.28,"NOVANET [10819]",Novanet,,668.19,75,,,,,0,103.61,757.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE X-PEDION VASCULAR 200CM 10CM .01IN PLATINUM STAINLESS",SUP-103-0605-200,CDM,C1769,HCPCS,0272,RC,,,both,,,2235.00,670.5,"PHCS [10601]",PHCS,,1564.5,70,,,,,0,259.93,1899.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 45X20X5MM DEMINERALIZED CANCELLOUS CONFORM",SUP-0W1045,CDM,S27800098,LOCAL,0278,RC,,,both,,,13455.00,4036.5,"MULTIPLAN [10600]",Multiplan,,11436.75,85,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONCIERGE 100CM 8FR SBS4.5 MOD CURVE GUIDING STAINLESS",SUP-CGC8100SBS45SH-M,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"FIRST HEALTH [10303]","First Health",,356.4,80,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE FLEXIBLE 600MM 5.6MM 2.8MM AMBU ASCOPE STERILE",SUP-622001000US,CDM,C1601,HCPCS,0272,RC,,,both,,,2362.50,708.75,"KAISER [10500]",Kaiser,,1582.88,67,,,,,0,274.76,2008.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP CLUSTER HOLE SNAP FIT INTEGRATED",SUP-00875705201,CDM,C1776,HCPCS,0278,RC,,,both,,,11012.40,3303.72,"CIGNA [10200]",Cigna,,7488.43,68,,5873.17,5873.17,5873.17,"1 through 10",1280.74,9360.54,"percent of total billed charges",
"CATH ADVANCE 150CM 2CM 4MM BALLOON DILATATION ILIAC",SUP-G34323,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 300MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050300S,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"FIRST HEALTH [10303]","First Health",,1500,80,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER UMBILICAL UMBILI-CATH POLYURETHANE NEONATE L34 CM O",SUP-4183505,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.36,31.01,"UHC [10700]","United Healthcare",,65.43,63.3,,,,,0,12.02,87.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2728.13,818.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1252.21,45.9,,,,,0,317.28,2318.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXODUS SURGICAL HIP STEM REMOVAL",SUP-51040000,CDM,S27200284,LOCAL,0272,RC,,,both,,,12589.05,3776.71,"AETNA [10100]","Aetna HMO/PPO",,10008.29,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1464.11,10700.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 12MM 140CM 2.25MM CORONARY STENT PLATINUM",SUP-H7493927412220,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"MULTIPLAN [10600]",Multiplan,,3187.5,85,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL PRONG RETENTION UNOBTRUSIVE OPTIFLOW XL JUNIOR 2",SUP-OJR418,CDM,S27000186,LOCAL,0270,RC,,,both,,,404.77,121.43,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC",310,MS-DRG,,,,,,,inpatient,,,20255.38,6076.61,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIGERTAPE SUTURE 1.7X17 0FIBERWIRE W/ND",SUP-AR-7273-17TN,CDM,S27200284,LOCAL,0272,RC,,,both,,,646.38,193.91,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEFIBRILLATOR IMPLANTS,MODERATE",179,APR-DRG,,,,,,,inpatient,,,159742.85,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $28,462.19. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($98,294.60) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 645CC",SUP-RSZ-MPX-645S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 5IN PARKER SMALL 2 END SURGICAL",SUP-22-1413,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.42,18.13,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 60MM 2MM BALLOON DILATATION OTW STERILE",SUP-582006022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL +15.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00155,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"MULTIPLAN [10600]",Multiplan,,929.48,85,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM 6FR ATRIUM VENTRICLE RIGHT IS-1 BIPOLAR",SUP-5076-65,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"NOVANET [10819]",Novanet,,1674.38,75,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL RESTORELLE SMARTMESH 30X30CM ULTRA LIGHTWEIGHT",SUP-501330,CDM,C1781,HCPCS,0278,RC,,,both,,,11812.80,3543.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1399.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1373.83,10040.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ELECTROSURGICAL 100MM 17GA MULTICOOL RADIOFREQUENCY",SUP-MCKA3-17-100-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,13179.00,3953.7,"CIGNA [10200]","Cigna Local Plus",,7050.77,53.5,,,,,0,1532.72,11202.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 20MM 2.75MM BALLOON DILATATION STERILE",SUP-227-203-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UHC [10700]","United Healthcare",,512.73,63.3,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 3MM BALLOON",SUP-U357536,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON RETRIEVAL EXTR PRO XL 200CM 6-7FR 12-15MM BILIARY 3",SUP-M00547140,CDM,C1726,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 90CM CORONARY VENOUS IS-1 EASYTRAK 2",SUP-4543,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"AETNA [10100]","Aetna HMO/PPO",,4457.57,79.5,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EMTRICITABINE 200 MG CAPSULE",RX-36252,CDM,,,0637,RC,61958-0601-01,NDC,both,1,UN,81.12,24.34,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.43,68.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL SABRELOC 6-0 S-14 18IN 2 ARM BRAID COATED UNDYED",SUP-J670G,CDM,S27200284,LOCAL,0272,RC,,,both,,,161.07,48.32,"FIRST HEALTH [10303]","First Health",,128.86,80,,,,,0,18.73,136.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 12FR NEPHRSTMY NATURAL RUBBER 4 WING DRAIN",SUP-086012,CDM,C1729,HCPCS,0272,RC,,,both,,,105.65,31.69,"AETNA [10100]","Aetna HMO/PPO",,83.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.29,89.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM TITANIUM T25 SELF TAP LOCK STARDRIVE",SUP-412.219S,CDM,C1713,HCPCS,0278,RC,,,both,,,1220.18,366.05,"MULTIPLAN [10600]",Multiplan,,1037.15,85,,,,,0,141.91,1037.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN AMPLATZ LEFT 2 CURVE",SUP-DXT5AL20,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.97,41.1,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM TITANIUM NIOBIUM ALUMINUM X25 FEMORAL",SUP-04.045.040TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 80MM CD HORIZON SPINE MULTIAXIAL CANNULATED",SUP-25840017580,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 8MM THORACIC KNIT HEMASHIELD GOLD",SUP-M002020951080,CDM,C1768,HCPCS,0278,RC,,,both,,,2540.03,762.01,"BLUE CROSS [10001]","Blue Cross PPO",,995.69,39.2,,,,,0,295.41,2159.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STBL SURGICAL OCTOPUS 3 EVOLUTION TISSUE",SUP-TS2500,CDM,S27200284,LOCAL,0272,RC,,,both,,,9902.88,2970.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1151.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1151.7,8417.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIG GLEN CT GD/BONE MODEL SET",SUP-110004347,CDM,C1776,HCPCS,0278,RC,,,both,,,4200.00,1260,"KAISER [10500]",Kaiser,,2814,67,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Hemodialysis",PX-E27200057,CDM,C1750,HCPCS,0272,RC,,,both,,,1500.40,450.12,"CIGNA [10200]","Cigna Local Plus",,802.71,53.5,,,,,0,174.5,1275.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 42MM 10MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044104270,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"FIRST HEALTH [10303]","First Health",,6900,80,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 30MM 8MM BALLOON DILATATION DURALYN",SUP-48008003S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,163.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 34MM 1 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800134,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,1144.80,304.56,2275.09,66,521.61,3812.25,"percent of total billed charges",
"CATH EVERCROSS CROSSTEC 135CM 40MM 7MM .035IN BALLOON",SUP-AB35W07040135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"UHC [10700]","United Healthcare",,428.64,63.3,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 87/91MMX14MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183584,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1534.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1506.4,11009.78,"percent of total billed charges",
"STENT COMPLETE SE 150MM 130CM 6MM BILIARY SELF EXPANDING",SUP-SC6150L,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"BLUE CROSS [10001]","Blue Cross HMO",,3516.24,39.2,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 4MM LORDOSIS TITANIUM",SUP-102064065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH-PROFILE BOOST, 500CC",SUP-SMHB500,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3499.65,45.9,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 3MM RADIUS STRAIGHT 65CM 8.5-8.9CM .035IN",SUP-395899,CDM,C1769,HCPCS,0272,RC,,,both,,,294.06,88.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SYNTHETIC ETHIBOND EXCEL 2-0 V-5 30IN 2 ARM BRAID FIRM",SUP-PXX52N,CDM,S27200284,LOCAL,0272,RC,,,both,,,681.53,204.46,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ANGIOJET ULTRA SOLENT PROXI THROMBECTOMY PERIPHERAL",SUP-109676-001,CDM,C1757,HCPCS,0272,RC,,,both,,,26365.50,7909.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"METOPROLOL TARTRATE 6.25 MG TABLET (PARTIAL OF 25 MG TABLET)",RX-410804,CDM,,,0637,RC,09999-9999-19,NDC,both,6.25,ME,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH AMPHIRION DEEP 150CM 150MM 2.5MM BROAD TAPER BALLOON",SUP-AMP025150152,CDM,C1725,HCPCS,0272,RC,,,both,,,2671.88,801.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH REDEL 110CM 1MM 4FR 5MM SPACE REGULAR F CURVE",SUP-D4S04FR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT ZIPWIRE 20CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175250080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"FIRST HEALTH [10303]","First Health",,991.5,80,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH IRIS STERILE LATEX FREE DISPOSABLE",SUP-220180518,CDM,S27200284,LOCAL,0272,RC,,,both,,,2157.21,647.16,"UHC [10700]","United Healthcare",,1365.51,63.3,,,,,0,250.88,1833.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ALLIS 6IN INTESTINAL 4X5 TEETH GRASPING",SUP-EA015R,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BLOOD PUMP 15FR 24FR TANDEMLIFE TANDEMHEART TANDEMLUNG",SUP-5740-2415,CDM,S27200284,LOCAL,0272,RC,,,both,,,88350.00,26505,"CIGNA [10200]","Cigna Open Access",,50271.15,56.9,,,,,0,10275.11,75097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 18MM 41MM SHOULDER ECLIPSE STERILE ARTHROPLASTY",SUP-AR-9341-18,CDM,C1776,HCPCS,0278,RC,,,both,,,4105.50,1231.65,"FIRST HEALTH [10303]","First Health",,3284.4,80,,,,,0,477.47,3489.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION",RX-10330,CDM,Q9958,HCPCS,0636,RC,00019-0862-50,NDC,both,250,ML,500.00,150,"MULTIPLAN [10600]",Multiplan,,425,85,,,,,0,35,425,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 2.4MM INTREPID ANGLE 2 BEVEL MICRO COAXIAL",SUP-8065982465,CDM,S27200284,LOCAL,0272,RC,,,both,,,464.21,139.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,55.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.99,394.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATHETER TURNPIKE 135CM 2.9FR SPIRAL VASCULAR MULTILA",SUP-5640,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NUCEL LG",SUP-NC-1002,CDM,S27800098,LOCAL,0278,RC,,,both,,,18270.00,5481,"NOVANET [10819]",Novanet,,13702.5,75,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
".035 INTERLOCK DIAMOND 4MM",SUP-M001363910,CDM,C1725,HCPCS,0272,RC,,,both,,,2827.50,848.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,335.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,328.84,2403.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 30MM 154CM 6MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200063020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,481.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH ARTHROSCOPIC 15D UP TIP XL STRAIGHT SERIES 1 DESIGN",SUP-AR-11240XL,CDM,S27200284,LOCAL,0272,RC,,,both,,,7933.28,2379.98,"FIRST HEALTH [10303]","First Health",,6346.62,80,,,,,0,922.64,6743.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CORDIS STBL VASCULAR STRAIGHT 180CM 3CM .014IN",SUP-518224,CDM,C1769,HCPCS,0272,RC,,,both,,,617.06,185.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,419.6,68,,,,,0,71.76,524.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71MMX10MM VANGUARD E1 KNEE ANTERIOR STABILIZE TIBIAL",SUP-EP189060,CDM,C1776,HCPCS,0278,RC,,,both,,,13372.20,4011.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3827.12,28.62,,,,,0,1555.19,11366.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 92CM LEFT VENTRICULAR QUADRIPOLAR QUARTET",SUP-1458Q/92,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1604.72,28.62,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 12MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50012,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,23761.67,28.62,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 3004069 ZEVO 69MM 4 LVL",SUP-3004069,CDM,C1713,HCPCS,0278,RC,,,both,,,4620.00,1386,"AETNA [10100]","Aetna HMO/PPO",,3672.9,79.5,,1521.93,481.35,16760.95,30,537.31,3927,"percent of total billed charges",
"IMPL BREAST 14X12.9CM 520ML STYLE 410 NATRELLE SILICONE P6.5",SUP-MX-410520,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"NOVANET [10819]",Novanet,,4173.75,75,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 3-0 V-20 12IN CLSR ABSORBABLE VIOLET",SUP-VLOCM0614,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"MULTIPLAN [10600]",Multiplan,,166.46,85,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCOUT 7.5CM DELIVERY NEEDLE ULTRASOUND",SUP-SSR75S-01,CDM,A4648,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 15ML 1.7-7MM DEMINERALIZED CANCELLOUS",SUP-420035,CDM,C1713,HCPCS,0278,RC,,,both,,,2543.63,763.09,"BLUE CROSS [10001]","Blue Cross PPO",,997.1,39.2,,957.42,570.23,957.42,28,295.82,2162.09,"percent of total billed charges",
"CATH INPACT AV 80CM 40MM 6MM BALLOON DILATATION PACLITAXEL",SUP-IAV05004008P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"FIRST HEALTH [10303]","First Health",,6458.4,80,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRN2PR,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,10981.53,8986.79,12413.38,12,2014.9,14726.25,"percent of total billed charges",
"GWIRE ZIPWIRE VASCULAR 150CM 3CM .035IN HYDROPHILIC STIFF",SUP-M00146305B1,CDM,C1769,HCPCS,0272,RC,,,both,,,339.13,101.74,"UHC [10700]","United Healthcare",,214.67,63.3,,,,,0,39.44,288.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 3.0X25MM",SUP-PRV030025CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 40MM 5MM .014IN BALLOON DILATATION",SUP-AB14W050040150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"UHC [10700]","United Healthcare",,876.77,63.3,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 80CM 5FR ANGLE",SUP-G09312,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CIGNA [10200]","Cigna Open Access",,135.13,56.9,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE APPROACH VASCULAR TAPER 300CM .014IN STAINLESS STEEL",SUP-G50792,CDM,C1769,HCPCS,0272,RC,,,both,,,1251.37,375.41,"NOVANET [10819]",Novanet,,938.53,75,,,,,0,145.53,1063.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THERAPEUTIC CABLES, 3 FT.  M004653S0",SUP-MS4653S0,CDM,S27200284,LOCAL,0272,RC,,,both,,,2537.63,761.29,"KAISER [10500]",Kaiser,,1700.21,67,,,,,0,295.13,2156.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG REGULAR Y MIDFACE 5 HOLE 1.5MM SCR BONE TRAUMAONE",SUP-01-7102,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"MULTIPLAN [10600]",Multiplan,,1211.76,85,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SALVATION FLANGE NUT 10MM",SUP-SEF33001,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"KAISER [10500]",Kaiser,,596.97,67,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PILOT 50 VASCULAR J 300CM 3CM .014IN",SUP-1010483-HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACCU-VU 70CM 2CM 5FR PIGTAIL CURVE ANGIOGRAPHIC",SUP-H787137091015,CDM,C1887,HCPCS,0272,RC,,,both,,,376.71,113.01,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,154.83,41.1,,,,,0,43.81,320.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD LUBRI-SIL 6FR URETHRAL SILICONE HYDROGEL 1.5CC 2",SUP-175806N,CDM,S27200284,LOCAL,0272,RC,,,both,,,201.23,60.37,"CIGNA [10200]","Cigna Open Access",,114.5,56.9,,,,,0,23.4,171.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 13.6CM 8MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR180813,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"FIRST HEALTH [10303]","First Health",,9505.44,80,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Power Module Combo Vad, Rep",PX-E27400026,CDM,Q0479,HCPCS,0274,RC,,,both,,,35830.15,10749.04,"MULTIPLAN [10600]",Multiplan,,30455.63,85,,,,,0,4167.05,30455.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 STD KNEE LEFT CRUCIATE RETAINING PERSONA",SUP-42502806401,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3360.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 30CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155225190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS [10001]","Blue Cross PPO",,556.77,39.2,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CREO SPINE PREASSEMBLE THREAD",SUP-5119.1652,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,1144.80,304.56,2275.09,66,441.36,3225.75,"percent of total billed charges",
"BRACE WALKING SMALL WIDE FOOT ANKLE 2 ADJUSTABLE DISTAL",SUP-01F-S,CDM,L4360,HCPCS,0274,RC,,,both,,,955.64,286.69,"FIRST HEALTH [10303]","First Health",,764.51,80,,,,,0,111.14,812.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF CONTACTR 110CM 5MM 7FR 2-15-2MM SPACING DUAL CURVE",SUP-041002UM,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 9.5MM 3MM S-ROM ZTT 18B SMALL HIP POROUS",SUP-521483,CDM,C1776,HCPCS,0278,RC,,,both,,,6466.32,1939.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2968.04,45.9,,,,,0,752.03,5496.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT STEM 100MM 145MM 18MM REPLACEMENT SCR FEMUR KNEE",SUP-00598801018,CDM,C1776,HCPCS,0278,RC,,,both,,,4909.80,1472.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,581.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,571.01,4173.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 19.5MM THK.38MM 41MM MICRO OSCILLATE SAGITTAL 2",SUP-5400-003-254,CDM,S27200284,LOCAL,0272,RC,,,both,,,430.48,129.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,197.59,45.9,,,,,0,50.06,365.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemoglobin A2 Quant",PX-301000222,CDM,83020,CPT,0301,RC,,,both,,,195.00,58.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.63,,,,,,,0.01,165.75,"fee schedule",
"ROD SPINAL 240MM 3.5MM VUEPOINT II TITANIUM NONSTERILE LATEX",SUP-8976124,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"HC Bcr/Abl1 Gene Other Bp",PX-309000005,CDM,81208,CPT,0310,RC,,,both,,,1002.00,300.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,117.81,,"Fee schedule rate ($117.81). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,851.7,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 240MM SEMITENDINOSUS",SUP-81B003,CDM,C1762,HCPCS,0278,RC,,,both,,,6537.75,1961.32,"CIGNA [10200]",Cigna,,4445.67,68,,,,,0,760.34,5557.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Parathyroid Planar Img",PX-341000007,CDM,78070,CPT,0341,RC,,,both,,,2241.53,672.46,"PHCS [10601]",PHCS,,1569.07,70,,,,,0,260.69,1905.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Bn Age Study",PX-320000179,CDM,77072,CPT,0320,RC,,,both,,,383.34,115,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,38.41,,"Fee schedule rate ($38.41).",,,,0,26.69,325.84,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 48MM M/G KNEE UNICOMPARTMENTAL",SUP-579104200,CDM,C1713,HCPCS,0278,RC,,,both,,,530.96,159.29,"FIRST HEALTH [10303]","First Health",,424.77,80,,,,,0,61.75,451.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE EVERFLEX 40MM 120CM 5MM .079IN BILIARY NITINOL",SUP-PRB35-05-040-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Local Plus",,2977.28,53.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 6 STRAIGHT OVAL 9IN BRUNS SPINE SURGICAL",SUP-29-5356,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.25,71.77,"KAISER [10500]",Kaiser,,160.3,67,,,,,0,27.82,203.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 12MM 2.75MM CORONARY STENT EVEROLIMUS",SUP-1550275-12,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 2.50 X 28 MM",SUP-1212250-28,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross HMO",,6762,39.2,,9776.84,9776.84,9776.84,"1 through 10",2006.18,14662.5,"percent of total billed charges",
"SCR BONE 4.5MM 34MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.534,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,441.36,3225.75,"percent of total billed charges",
"INTRO ENDOSCOPIC 19FR MINOP DISPOSABLE",SUP-FH604SU,CDM,C1894,HCPCS,0272,RC,,,both,,,2063.57,619.07,"UHC [10700]","United Healthcare",,1306.24,63.3,,,,,0,239.99,1754.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH QUICKLATCH ENDOSCOPIC REPLACEMENT LOCKING NUT STPCOCK",SUP-T4905,CDM,C1894,HCPCS,0272,RC,,,both,,,388.46,116.54,"KAISER [10500]",Kaiser,,260.27,67,,,,,0,45.18,330.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTED TOTAL KNEE SYSTEM INCLUDING CONSTRAINED WITH ON",SUP-98000200376,CDM,C1776,HCPCS,0278,RC,,,both,,,27090.00,8127,"KAISER [10500]",Kaiser,,18150.3,67,,,,,0,3150.57,23026.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Aerobic Defin ID Ea Isol",PX-306000054,CDM,87077,CPT,0306,RC,,,both,,,180.50,54.15,"CIGNA [10200]",Cigna,,17.78,,,,,,,0.01,153.43,"fee schedule",
"CATH BARDEX IC 22FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0166SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.21,20.46,"CIGNA [10200]","Cigna Open Access",,38.81,56.9,,,,,0,7.93,57.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TPAK 10 GAUGE DECOMPRESSION NEEDLE",SUP-TM-310,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.12,20.44,"MULTIPLAN [10600]",Multiplan,,57.9,85,,,,,0,7.92,57.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC",903,MS-DRG,,,,,,,inpatient,,,68762.20,20628.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10549.79,,"Fee schedule rate ($10,549.79). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,7255.1,34147.64,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 18GA 3.5IN NDL SYR CATH WING PERIFIX HUSTEAD",SUP-332249,CDM,C1755,HCPCS,0278,RC,,,both,,,116.60,34.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,33.37,28.62,,,,,0,13.56,99.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 3 HIGH OFFSET HIP",SUP-71935575,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"AETNA [10100]","Aetna HMO/PPO",,29044.29,79.5,,10981.53,8986.79,12413.38,12,4248.87,31053.65,"percent of total billed charges",
"CATH MALECOT 16FR NEPHRSTMY NATURAL RUBBER 4 WING DRAIN",SUP-086016,CDM,C1729,HCPCS,0272,RC,,,both,,,105.65,31.69,"PHCS [10601]",PHCS,,73.96,70,,,,,0,12.29,89.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ko Elastic W Condylar",PX-E27400073,CDM,L1820,HCPCS,0274,RC,,,both,,,397.10,119.13,"BLUE CROSS [10001]","Blue Cross PPO",,155.66,39.2,,,,,0,46.18,337.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 20MM MATRION PLACENTAL MEMB TROPHOBLAST",SUP-PAC20MM,CDM,Q4201,HCPCS,0636,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,153.58,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END 0MM T25 STARDRIVE TITANIUM NIOBIUM ALUMINUM STERILE",SUP-04.019.000S,CDM,C1713,HCPCS,0278,RC,,,both,,,1372.14,411.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,933.06,68,,,,,0,159.58,1166.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ECHELON CONTOUR GST RELOAD (BLUE)",SUP-GCR40B,CDM,S27200284,LOCAL,0272,RC,,,both,,,2994.05,898.21,"NOVANET [10819]",Novanet,,2245.54,75,,,,,0,348.21,2544.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENROUTE STENT FLEX 20MM X 57CM X 6CM",SUP-SR-0620-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 55MM LOW PROFILE SCREWS TITANIUM PARTIAL",SUP-AR-8945-55PT,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"CIGNA [10200]","Cigna Open Access",,806.56,56.9,,1144.80,304.56,2275.09,66,164.86,1204.88,"percent of total billed charges",
"PERCUFLEX STENT 8F X 26CM W/O WIRE",SUP-M0061453820,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"CIGNA [10200]","Cigna Local Plus",,338.71,,,,,,,73.63,538.14,"percent of total billed charges",
"PROBE LITHO 425MM 2MM SWISS LITHOCLAST PNEUMATIC LATEX FREE",SUP-M0068407370,CDM,S27200284,LOCAL,0272,RC,,,both,,,1680.60,504.18,"CIGNA [10200]","Cigna Local Plus",,899.12,53.5,,,,,0,195.45,1428.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 85MM TFN-ADVANCED STERILE",SUP-04.038.185S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 40MM 7MM BALLOON",SUP-LX181307405F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,797.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL ALL KNEE ROTATING HINGE",SUP-6481-2-140,CDM,S27000186,LOCAL,0270,RC,,,both,,,2966.25,889.87,"CIGNA [10200]",Cigna,,2017.05,68,,,,,0,344.97,2521.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR OPTISEAL",SUP-7440,CDM,C1894,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HANDLE WIRE SAW GIGLI HOOK",SUP-FH480R,CDM,S27000186,LOCAL,0270,RC,,,both,,,165.39,49.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNARE XS OVAL 240CM 2.4MM CAPTIFLEX LOOP FLEXIBLE STIFFNESS",SUP-M00562471,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.84,35.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 35 135CM 40MM 8MM .035IN LOW PROFILE BALLOON",SUP-B2080-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT ENEMA 26MM PROCTOWASH INTERMARK",SUP-INT-PR01,CDM,S27000186,LOCAL,0270,RC,,,both,,,1687.50,506.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) CATHETER TURNPIKE 150CM 2.9FR SPIRAL GUIDING MULTILAY",SUP-5641,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"UHC [10700]","United Healthcare",,0.01,63.3,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 34MM 140CM 2.25MM 2.1-2.7FR CORONARY",SUP-RONYX22534UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3543.75,1063.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2409.75,68,,,,,0,412.14,3012.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD TITANIUM ACU-LOC BONE LEFT DISTAL DORSAL RADIAL",SUP-70-0055,CDM,C1713,HCPCS,0278,RC,,,both,,,6451.50,1935.45,"NOVANET [10819]",Novanet,,4838.63,75,,,,,0,750.31,5483.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 48MM 3 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.348,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,627.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,615.46,4498.2,"percent of total billed charges",
"CANN PERFUSION 16IN 32FR VENOUS RETURN LIGHTHOUSE STRAIGHT 1",SUP-RV-40032,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"CIGNA [10200]",Cigna,,212.98,68,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 57MM 135CM 6MM 60MM BILIARY STAINLESS STEEL",SUP-PXB35-06-57-135,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"BLUE CROSS [10001]","Blue Cross PPO",,1711.86,39.2,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 9MM KNEE X3 BEARING CRUCIATE RETAIN TRIATHLON",SUP-5530-G-509-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4690.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",1327.29,9700.71,"percent of total billed charges",
"BLADE SHAVER 95X19.5X1.27MM OSCILLATING STERILE",SUP-00507112300,CDM,S27200284,LOCAL,0272,RC,,,both,,,159.65,47.89,"KAISER [10500]",Kaiser,,106.97,67,,,,,0,18.57,135.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GALAFORM 3D 15.5X5.3CM MONOFILAMENT",SUP-FR3D01,CDM,C1781,HCPCS,0278,RC,,,both,,,8970.00,2691,"NOVANET [10819]",Novanet,,6727.5,75,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HIP FEM POROUS OFFSET  11",SUP-425-96-011,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5043.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,4949.55,36174.68,"percent of total billed charges",
"HNDPC ELECTROSURGICAL 9IN ABC BEND-A-BEAM 1 FUNCTION",SUP-134009,CDM,S27200284,LOCAL,0272,RC,,,both,,,921.80,276.54,"KAISER [10500]",Kaiser,,617.61,67,,,,,0,107.21,783.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLED SOFT MED 1/4X1/8X1/16",SUP-K-705,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASE TIB STEM #2 LEFT PEGLESS",SUP-2585-0-0002,CDM,C1776,HCPCS,0278,RC,,,both,,,6210.00,1863,"MULTIPLAN [10600]",Multiplan,,5278.5,85,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 11MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530G811,CDM,C1776,HCPCS,0278,RC,,,both,,,8868.13,2660.44,"CIGNA [10200]","Cigna Open Access",,5045.97,56.9,,5302.19,4377.88,6578.61,27,1031.36,7537.91,"percent of total billed charges",
"SUT CHROMIC MICROPOINT 4-0 M-1 12IN 2 ARM MONOFILAMENT",SUP-744G,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.82,24.25,"AETNA [10100]","Aetna HMO/PPO",,64.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.4,68.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 28-30MM TITANIUM 5.5MM SCR MULTISPAN X10 XLNK BONE",SUP-8115528,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELUPRO ANTIBIOTIC-ELUTING BIOENVELOPE, M, SINGLE PACK",SUP-CMCV-124-MED,CDM,S27800098,LOCAL,0278,RC,,,both,,,6865.50,2059.65,"CIGNA [10200]","Cigna Local Plus",,3673.04,53.5,,,,,0,798.46,5835.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 160MM 18-14MM 13FR 11FR TRIVASCULAR OVATION",SUP-TV-IL1418160-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"PHCS [10601]",PHCS,,23373,70,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17CM 7MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140717,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"AETNA [10100]","Aetna HMO/PPO",,9446.03,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUTURE BONE ARTHROSCOPIC DELIVERY",SUP-4403,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"CATH CARTO XP LASSO 115CM 7FR 15MM 6MM SPACING D CURVE",SUP-DLN2215CT,CDM,C1732,HCPCS,0272,RC,,,both,,,12889.20,3866.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1527.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1499.01,10955.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM OSTEOGRIP",SUP-83565559,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6491.86,68,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR CORTICAL LORDOTIC 14X14X6MM",SUP-340644,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 6FR ENDOCARDIUM ACTIVE FIXATION BIPOLAR IS",SUP-2088TC/58,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"MULTIPLAN [10600]",Multiplan,,1897.63,85,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 20MM 120CM 7MM 6FR VASCULAR NITINOL PERIPHERAL",SUP-S-70-020-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"KAISER [10500]",Kaiser,,6125.48,67,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE STRAIGHT 2.5MM NARROW SHAFT SHARP ALL AROUND BEAVER",SUP-377210,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.70,55.41,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER PACING LEAD ACUITY 10FR LONG",SUP-667473-001,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM MITROFLOW BOVINE PERICARDIUM",SUP-LXA27,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST EXTERNAL FIXATION TRUELOK 2 HOLE NONSTERILE LATEX FREE",SUP-54-11610,CDM,C1713,HCPCS,0278,RC,,,both,,,1165.10,349.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,534.78,45.9,,,,,0,135.5,990.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 2-5.6MM 4MM 3.25MM DORNHOFFER PORP TITANIUM",SUP-695,CDM,L8613,HCPCS,0278,RC,,,both,,,3445.35,1033.6,"KAISER [10500]",Kaiser,,2308.38,67,,,,,0,232.31,2928.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.75/15",SUP-401743,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 30X11X8MM MODULUS 8D TLIF-A STERILE LATEX FREE",SUP-1081308P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 12MM 2.5MM CORONARY STENT FULCRUM COCR",SUP-INT25012UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,280.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.5MM 18MM HAND THREAD MULTIDIRECTIONAL ALPS",SUP-131211118,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,1831.33,1831.33,1831.33,16,189.34,1383.8,"percent of total billed charges",
"HC Chg Tube Tracheotomy",PX-410000020,CDM,31502,CPT,0410,RC,,,both,,,4994.00,1498.2,"FIRST HEALTH [10303]","First Health",,3995.2,80,,,,,0,254,4244.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC DRN Mouth Lesion Cmplx",PX-450000245,CDM,40801,CPT,0450,RC,,,both,,,4068.00,1220.4,"MULTIPLAN [10600]",Multiplan,,3457.8,85,,,,,0,67.13,4068,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135MM 40MM 14MM .035IN LOW PROFILE BALLOON",SUP-B2140-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,316.26,41.1,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 60MM 6FR 4MM BALLOON DILATATION PEBAX",SUP-39032-40601,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"UHC [10700]","United Healthcare",,948.55,63.3,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cytogen Microarray Copy Nmbr",PX-309000023,CDM,81228,CPT,0310,RC,,,both,,,9903.75,2971.12,"NOVANET [10819]",Novanet,,7427.81,75,,,,,0,9.9,8418.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Transducer Neonatal",PX-E27200187,CDM,E27200187,LOCAL,0272,RC,,,both,,,118.80,35.64,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 3X3CM DERMACELL THK.2-1MM DERMIS ALLOGRAFT",SUP-DCELL111,CDM,Q4122,HCPCS,0636,RC,,,both,,,6334.96,1900.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 3X5CM AMINOEFFECT PURION PLACENTAL MEMB",SUP-LS-5350,CDM,Q4433,HCPCS,0636,RC,,,both,,,13130.70,3939.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ROLL 24INX6IN VINYL POSITIONING PEDIATRIC TUMBLE FORMS 2",SUP-2794B,CDM,S27000186,LOCAL,0270,RC,,,both,,,806.11,241.83,"PHCS [10601]",PHCS,,564.28,70,,,,,0,93.75,685.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHMBR HUMD 2 FLOAT AUTO FILL COMPRESSIBLE VOLUME MR SERIES",SUP-MR290V,CDM,S27000186,LOCAL,0270,RC,,,both,,,94.50,28.35,"CIGNA [10200]","Cigna Open Access",,53.77,56.9,,,,,0,10.99,80.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXERCISER HAND ROLYAN BLACK RUBBER ERGONOMIC LATEX FREE",SUP-A3481,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.33,13.6,"CIGNA [10200]","Cigna Local Plus",,24.25,53.5,,,,,0,5.27,38.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL SMALL 2.25IN PHILADELPHIA CHIN REST TRACHEA",SUP-A9918-11,CDM,S27000186,LOCAL,0270,RC,,,both,,,97.27,29.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.31,82.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL COLOR CODED O RING ADPTR SOFT PRONG KINK",SUP-N4903,CDM,S27000186,LOCAL,0270,RC,,,both,,,97.44,29.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.33,82.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE MONOPOLAR 4MR 8MM 3MM ERBE SOCKET NONSTERILE LATEX",SUP-20192-130,CDM,S27000186,LOCAL,0270,RC,,,both,,,1052.60,315.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,483.14,45.9,,,,,0,122.42,894.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL RUSSIAN 8IN TISSUE MATTE FINISH STAINLESS",SUP-129392,CDM,S27000186,LOCAL,0270,RC,,,both,,,98.31,29.49,"CIGNA [10200]",Cigna,,66.85,68,,,,,0,11.43,83.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Voriconazole",PX-301000626,CDM,80285,CPT,0301,RC,,,both,,,314.93,94.48,"KAISER [10500]",Kaiser,,211,67,,,,,0,0.01,267.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE POSITIONING 22X20X10IN TUMBLE FORMS 2 VELCRO VINYL",SUP-2795J,CDM,S27000186,LOCAL,0270,RC,,,both,,,1217.51,365.25,"AETNA [10100]","Aetna HMO/PPO",,967.92,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.6,1034.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 130MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.930,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"NOVANET [10819]",Novanet,,1030.81,75,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL PEDIATRIC 1 22-33IN",SUP-100277-000,CDM,S27000186,LOCAL,0270,RC,,,both,,,307.63,92.29,"MULTIPLAN [10600]",Multiplan,,261.49,85,,,,,0,35.78,261.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) QUALIBREATH  SIZE 4X L",SUP-QB-4XL,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"CIGNA [10200]",Cigna,,564.02,68,,,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRAP CLAVICLE ADULT LARGE DELUXE ADJUSTABLE CRISSCROSS",SUP-3004-04,CDM,S27000186,LOCAL,0270,RC,,,both,,,59.86,17.96,"AETNA [10100]","Aetna HMO/PPO",,47.59,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.96,50.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY ESOPHAGEAL 4 STD 6MM 5MM ADULT LMA UNIQUE LARYNGEAL",SUP-125040,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.20,15.66,"CIGNA [10200]","Cigna Open Access",,29.7,56.9,,,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ICD-DR DDBB1D4 EVERA XT IS1/DF4 US",SUP-DDBB1D4,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16670.16,41.1,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM 3.5MM 2.1-2.7FR CORONARY",SUP-RONYX35030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"KAISER [10500]",Kaiser,,2487.38,67,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP STERILE DISPOSABLE LATEX FREE",SUP-26055G-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1113.89,334.17,"PHCS [10601]",PHCS,,779.72,70,,,,,0,129.55,946.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Video Larynscp Disp",PX-E27200457,CDM,E27200457,LOCAL,0272,RC,,,both,,,125.30,37.59,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACEMKR CARDIAC MICRA VR2 LEADLESS BUNDLE",SUP-MICRAVR2SYSTEM,CDM,C1786,HCPCS,0275,RC,,,both,,,59283.00,17784.9,"BLUE CROSS [10001]","Blue Cross PPO",,23238.94,39.2,,,,,0,6894.61,50390.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY PREP ON-Q T-BLOC STERILE",SUP-TBT02,CDM,S27200305,LOCAL,0272,RC,,,both,,,250.02,75.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,170.01,68,,,,,0,29.08,212.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Paracentesis",PX-E27200175,CDM,E27200175,LOCAL,0272,RC,,,both,,,423.50,127.05,"AETNA [10100]","Aetna HMO/PPO",,336.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,49.25,359.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CAPIO SLIM 3MM SUTURING 1 HAND ACTIVATE PLUNGER",SUP-831-825,CDM,C2631,HCPCS,0278,RC,,,both,,,6037.50,1811.25,"FIRST HEALTH [10303]","First Health",,4830,80,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPLATZER PFO OCCLUDER 35MM",SUP-9-PFO-035,CDM,C1817,HCPCS,0278,RC,,,both,,,56668.50,17000.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,22667.4,40,,,,,0,6590.55,48168.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 15MM 3.25MM BALLOON DILATATION STERILE",SUP-232-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 12CM 4MM BALLOON DILATATION OTW LOW",SUP-G30949,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 150MM 5MM .018IN BALLOON",SUP-R51005015L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,237.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SKATER CHOICE LOCK 25CM 8FR PIGTAIL CURVE DRNG",SUP-756608025,CDM,C1729,HCPCS,0272,RC,,,both,,,651.24,195.37,"AETNA [10100]","Aetna HMO/PPO",,517.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.74,553.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 20MM 6MM BALLOON DILATATION OTW STERILE",SUP-586002022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"PHCS [10601]",PHCS,,1048.95,70,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 10MM 3MM BALLOON DILATATION STERILE",SUP-230-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 150MM 3.8FR 3MM BALLOON DILATATION",SUP-39148-30151,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 15MM 2MM ULTRA LOW PROFILE BALLOON",SUP-1012270-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Wound Cytal 6-Layer 5x5cm",PX-E63600042,CDM,Q4166,HCPCS,0636,RC,,,both,,,345.40,103.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.93,293.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEROPENEM 2 GRAM INTRAVENOUS SOLUTION",RX-238220,CDM,J2183,HCPCS,0636,RC,44567-0402-01,NDC,both,1,UN,248.33,74.5,"CIGNA [10200]","Cigna Open Access",,84.36,,,,,,,29.43,211.08,"fee schedule",
"SLING ORTHOPEDIC LARGE 13+ IN ARM DEROTATION STRAP HOOK",SUP-11-0449-4-06000,CDM,S27000186,LOCAL,0270,RC,,,both,,,401.07,120.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,164.84,41.1,,,,,0,46.64,340.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX10MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183560,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"FIRST HEALTH [10303]","First Health",,10362.14,80,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX13MM FRA 8D LORDOTIC NARROW WEDGE",SUP-10013,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 SWIVELOCK SUTURETAPE KNOTLESS PEEK 19.1MM",SUP-AR-2323KPSLC,CDM,C1713,HCPCS,0278,RC,,,both,,,3425.63,1027.69,"AETNA [10100]","Aetna HMO/PPO",,2723.38,79.5,,1521.93,481.35,16760.95,30,398.4,2911.79,"percent of total billed charges",
"HC Kit Iabp Insertion",PX-E27200167,CDM,E27200167,LOCAL,0272,RC,,,both,,,865.70,259.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,102.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,100.68,735.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.5MM KIRSCHNER DARCO HEADED",SUP-NK112527,CDM,C1713,HCPCS,0278,RC,,,both,,,191.40,57.42,"CIGNA [10200]","Cigna Local Plus",,102.4,53.5,,3978.14,359.25,3978.14,24,22.26,162.69,"percent of total billed charges",
"HC Ins Impl Drug Deliv Non-Biodeg",PX-361000531,CDM,11981,CPT,0361,RC,,,both,,,770.23,231.07,"FIRST HEALTH [10303]","First Health",,616.18,80,,,,,0,89.58,770.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 14MM 3FR GEMINI HELICAL URETERAL",SUP-M0063302040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"MULTIPLAN [10600]",Multiplan,,1257.62,85,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL JACOBSON 7.5IN CURVED DELICATE",SUP-BH187R,CDM,S27200284,LOCAL,0272,RC,,,both,,,655.78,196.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,77.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,76.27,557.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREONPANOPTIX PROTORIC(BLF)",SUP-PXYWT4,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,419.99,45.9,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NALBUPHINE 10 MG/ML INJECTION SOLUTION",RX-5339,CDM,J2300,HCPCS,0636,RC,70069-0671-01,NDC,both,1,ML,58.39,17.52,"FIRST HEALTH [10303]","First Health",,46.71,80,,,,,0,1.25,49.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Carboxyhemoglobin Quant",PX-301000131,CDM,82375,CPT,0301,RC,,,both,,,202.34,60.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,43.73,,,,,,,0.01,171.99,"fee schedule",
"HC Xr Rib Uni>=3v Incl Pa Chst",PX-320000028,CDM,71101,CPT,0320,RC,,,both,,,770.92,231.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46.53,,,,,,,46.53,655.28,"fee schedule",
"MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION",RX-29464,CDM,J2274,HCPCS,0636,RC,00641-6020-01,NDC,both,10,ML,287.55,86.26,"MULTIPLAN [10600]",Multiplan,,244.42,85,,,,,0,14.06,244.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN HCL 1 G/20ML IV (WET SOLR VIAL)",RX-4158442,CDM,J3373,HCPCS,0636,RC,00409-6533-11,NDC,both,1,UN,147.51,44.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,100.31,68,,,,,0,3.5,125.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insert Tunneled Pleural Cath",PX-361000055,CDM,32550,CPT,0361,RC,,,both,,,11344.57,3403.37,"BLUE CROSS [10001]","Blue Cross HMO",,4025.22,,"Case rate ($4,025.22). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1319.37,10015,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VAN ANDEL 80CM 3CM 6.3FR BALLOON DILATATION ACCEPTS",SUP-G01383,CDM,C1758,HCPCS,0272,RC,,,both,,,502.20,150.66,"KAISER [10500]",Kaiser,,336.47,67,,,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Triact",PX-E27200124,CDM,E27200124,LOCAL,0272,RC,,,both,,,152.90,45.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.78,129.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC SPRINTER FASTRAC 138CM 21MM 2.4/2.6-1.9FR 2.5MM",SUP-NCSP2521X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREONPANOPTIX PROTORIC(BLF)",SUP-PXYWT6,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,419.99,45.9,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXIMA 70CM 6FR URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002021,CDM,C1758,HCPCS,0272,RC,,,both,,,82.25,24.67,"PHCS [10601]",PHCS,,57.58,70,,,,,0,9.57,69.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC 30D LARGE 13IN ARM RIGHT DEROTATIONAL",SUP-11-1345-4,CDM,L3670,HCPCS,0274,RC,,,both,,,495.23,148.57,"NOVANET [10819]",Novanet,,371.42,75,,,,,0,57.6,420.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Ctrl Blood",PX-750000041,CDM,43255,CPT,0750,RC,,,both,,,3783.74,1135.12,"CIGNA [10200]","Cigna Open Access",,2751,,"Case rate ($2,751). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,440.05,3783.74,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 180MM 8MM BALLOON DILATATION OTW",SUP-H74939206081810,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 180CM 120MM 4FR 2MM .018IN BALLOON",SUP-PCP020120180,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PHCS [10601]",PHCS,,861.84,70,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 14CM 6FR 8MM .035IN BALLOON",SUP-G52364,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AETNA [10100]","Aetna HMO/PPO",,763.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 20MM 190CM 3MM",SUP-R51003002L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"KAISER [10500]",Kaiser,,1321.07,67,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFAZOLIN 1 G VIAL|DISCARDED DRUG NOT ADMINISTE",RX-1445,CDM,J0690,HCPCS,0636,RC,44567-0707-25,NDC,both,1,UN,14.95,4.48,"MULTIPLAN [10600]",Multiplan,JW,12.71,85,,,,,0,1.41,12.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tomosynthesis Breast Dgtl Dx Bi",PX-401000009,CDM,77062,CPT,0401,RC,,,both,,,621.66,186.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,73.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.3,528.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esophagosc W/Sclero Inject",PX-750000199,CDM,43204,CPT,0750,RC,,,both,,,2075.00,622.5,"KAISER [10500]",Kaiser,,1390.25,67,,,,,0,241.32,2075,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cardiolipin Ab Ea Ig Class",PX-302000017,CDM,86147,CPT,0302,RC,,,both,,,313.50,94.05,"CIGNA [10200]","Cigna Local Plus",,55.99,,,,,,,0.01,266.48,"fee schedule",
"HC Observation Careve-Out - Respiratory",PX-762000015,CDM,G0378,HCPCS,0762,RC,,,both,,,66.00,19.8,"MULTIPLAN [10600]",Multiplan,,56.1,85,,,,,0,7.68,66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Observation Careve-Out - Respiratory",PX-762000015,CDM,G0378,HCPCS,0762,RC,,,both,,,66.00,19.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,66,,,,,,,7.68,66,"case rate",
"HC Observation Careve-Out - Respiratory",PX-762000015,CDM,G0378,HCPCS,0762,RC,,,both,,,66.00,19.8,"CIGNA [10200]","Cigna Open Access",,66,,,,,,,7.68,66,"case rate",
"HC Tube Trach Holder",PX-E27200232,CDM,E27200232,LOCAL,0272,RC,,,both,,,37.88,11.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dressing Wound Duoderm",PX-E27200109,CDM,E27200109,LOCAL,0272,RC,,,both,,,123.87,37.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHUNT GLAUCOMA EX-PRESS 2.64MM 50UM VERTICAL CHANNEL",SUP-47053,CDM,C1783,HCPCS,0278,RC,,,both,,,7723.86,2317.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,915.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,898.28,6565.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ACAPELLA DM 15- LPM 22MM PEP VIBRATORY MOUTHPC LOW",SUP-26-21-1015,CDM,S27000186,LOCAL,0270,RC,,,both,,,323.03,96.91,"AETNA [10100]","Aetna HMO/PPO",,256.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.57,274.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SCRDRVR 80MM 2MM MAXDRIVE 1.5MM SCR",SUP-25-438-97-07,CDM,S27000186,LOCAL,0270,RC,,,both,,,1287.01,386.1,"KAISER [10500]",Kaiser,,862.3,67,,,,,0,149.68,1093.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIAGON FLEXTUBE 4MM","SUP-FFT-E 01 2106",CDM,S27000186,LOCAL,0270,RC,,,both,,,1629.00,488.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.72,68,,,,,0,189.45,1384.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD THERAPEUTIC WRAP ON POLAR HIP",SUP-04750,CDM,S27000186,LOCAL,0270,RC,,,both,,,249.60,74.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,169.73,68,,,,,0,29.03,212.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC MEDIUM RIGHT WRIST FOREARM PREFORM PAD",SUP-9101-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,72.38,21.71,"CIGNA [10200]",Cigna,,49.22,68,,,,,0,8.42,61.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE COMPRESSION MEDIUM THIGH HIGH SCD EXPRESS",SUP-9530,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.33,61.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,94.71,45.9,,,,,0,24,175.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP MEDIUM LEAK 1 ENTRAINMENT ELBOW CAPSTRAP HEADGEAR",SUP-989805628741,CDM,S27000186,LOCAL,0270,RC,,,both,,,224.74,67.42,"AETNA [10100]","Aetna HMO/PPO",,178.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.14,191.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CRYO/CUFF IC MEDIUM 13-23IN COMPRESSION THERAPY KNEE",SUP-51A11A,CDM,S27000186,LOCAL,0270,RC,,,both,,,649.78,194.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.57,552.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LRNSCP 3 MCNTSH EURO PRFL GLS",SUP-4003VS,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.88,13.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18.86,41.1,,,,,0,5.34,39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LRNSCP 3 MCNTSH EURO PRFL GLS",SUP-4003VS,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.88,13.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.34,39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 5.5MM CANNULATED REVOLVE SURGICAL SPINE GLOB",SUP-685.055,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"MULTIPLAN [10600]",Multiplan,,3362.94,85,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR ADULT SOMASENSOR SMALL OXIMETER PATIENTS GREATER THAN",SUP-SAFB-SM/USA,CDM,S27000186,LOCAL,0270,RC,,,both,,,899.28,269.78,"KAISER [10500]",Kaiser,,602.52,67,,,,,0,104.59,764.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL SILICONE DOYLE II SEPTUM COMPRESSED HOLE IN",SUP-1524055,CDM,S27000186,LOCAL,0270,RC,,,both,,,469.80,140.94,"FIRST HEALTH [10303]","First Health",,375.84,80,,,,,0,54.64,399.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEON 12 NEONATAL EEG DEVICE CAN BE USED WITH ANY MULTI CHANN",SUP-TF01-MBS19,CDM,S27000186,LOCAL,0270,RC,,,both,,,729.00,218.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,334.61,45.9,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK 12X10IN THERAPEUTIC MOIST HEAT THERMAL COLOR CODED TABS",SUP-561725,CDM,S27000186,LOCAL,0270,RC,,,both,,,201.58,60.47,"NOVANET [10819]",Novanet,,151.19,75,,,,,0,23.44,171.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45 REPOSABLE DA VINCI SI ENDOWRIST",SUP-410298,CDM,S27000186,LOCAL,0270,RC,,,both,,,1134.00,340.2,"CIGNA [10200]","Cigna Local Plus",,606.69,53.5,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER SMOKE EVAC 7/8IN VIROSAFE 1 PORT FEMALE PORT TUBE",SUP-VS06004,CDM,S27000186,LOCAL,0270,RC,,,both,,,1008.45,302.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.28,857.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 33.53CM 8MM DA VINCI XI PROGRASP ENDOWRIST",SUP-471093,CDM,S27000186,LOCAL,0270,RC,,,both,,,1275.75,382.72,"MULTIPLAN [10600]",Multiplan,,1084.39,85,,,,,0,148.37,1084.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR NEONATE LNCS NEO-3 3FT OXIMETER ADHSV SPO2 STERILE",SUP-2604,CDM,S27000186,LOCAL,0270,RC,,,both,,,148.77,44.63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.3,126.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT RIB MEDIUM 31X6IN 2 PANEL ELASTIC HOOK LOOP CLSR",SUP-13790306,CDM,S27000186,LOCAL,0270,RC,,,both,,,59.25,17.77,"KAISER [10500]",Kaiser,,39.7,67,,,,,0,6.89,50.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 16MM XTEND SPINE VARIABLE ANGLE SELF DRILL",SUP-161.016,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"KAISER [10500]",Kaiser,,944.7,67,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURESIGHT BLADE HYPERANGULATED SIZE 4",SUP-390241000,CDM,S27000186,LOCAL,0270,RC,,,both,,,321.90,96.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,38.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER PLATE BB-TAK LARGE TITANIUM",SUP-AR-8970-09,CDM,S27000186,LOCAL,0270,RC,,,both,,,1093.50,328.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,129.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER PLATE BB-TAK LARGE TITANIUM",SUP-AR-8970-09,CDM,S27000186,LOCAL,0270,RC,,,both,,,1093.50,328.05,"NOVANET [10819]",Novanet,,820.13,75,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet Brain Meta Eval",PX-404000001,CDM,78608,CPT,0404,RC,,,both,,,7426.81,2228.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2608,,"Per diem ($2,608). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,146.44,7426.81,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE DRILL 6MM 5MM LONG THREADED NONSTERILE",SUP-395.923,CDM,S27000186,LOCAL,0270,RC,,,both,,,1047.01,314.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,711.97,68,,,,,0,121.77,889.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE MORCELLATION 20MM STERILE",SUP-53-000020,CDM,C1782,HCPCS,0272,RC,,,both,,,2325.00,697.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,275.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,270.4,1976.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL NEONATE PROSOFT NONSTERILE LATEX FREE DISPOSABLE",SUP-PROSOFT-NEO,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.06,33.62,"CIGNA [10200]",Cigna,,76.2,68,,,,,0,13.03,95.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ORTHOPEDIC XL 23-25.5IN KNEE NEOPRENE SLEEVE OPEN",SUP-NE7702-05,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.70,30.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,69.16,68,,,,,0,11.83,86.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Lacosamide",PX-301000624,CDM,80235,CPT,0301,RC,,,both,,,195.00,58.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,24.4,,,,,,,0.01,165.75,"fee schedule",
"PERCSSR PNEUMATIC ADULT 33-43IN WRAP AIRWAY CLEARANCE SYSTEM",SUP-P300631005,CDM,S27000186,LOCAL,0270,RC,,,both,,,548.99,164.7,"MULTIPLAN [10600]",Multiplan,,466.64,85,,,,,0,63.85,466.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X4CM CYGNUS DUAL THK.2MM 16SQ CM AMNION",SUP-585-002,CDM,Q4282,HCPCS,0636,RC,,,both,,,46620.00,13986,"CIGNA [10200]",Cigna,,905.02,,,,,,,247.92,39627,"fee schedule",
"WRAP THERAPEUTIC MEDI-THERM SMALL MEDIUM",SUP-8001061550,CDM,S27000186,LOCAL,0270,RC,,,both,,,1140.48,342.14,"KAISER [10500]",Kaiser,,764.12,67,,,,,0,132.64,969.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT HAND/WRIST/FOREARM M SIZE 3.5-4.5IN LEFT WHITE PREFOR",SUP-A311303,CDM,S27000186,LOCAL,0270,RC,,,both,,,260.13,78.04,"CIGNA [10200]","Cigna Local Plus",,139.17,53.5,,,,,0,30.25,221.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SHAMP 21X16IN SLEEK CURVE PLASTIC LOOP STRAP HIGH RIM",SUP-81565027,CDM,S27000186,LOCAL,0270,RC,,,both,,,225.33,67.6,"CIGNA [10200]","Cigna Local Plus",,120.55,53.5,,,,,0,26.21,191.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT FLITES MEDIUM DISPOSABLE",SUP-MFA1000M-M,CDM,S27000186,LOCAL,0270,RC,,,both,,,268.66,80.6,"CIGNA [10200]","Cigna Local Plus",,143.73,53.5,,,,,0,31.25,228.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 15MM 1.1MM MEDLINE UNITE",SUP-MPPF1115,CDM,S27000186,LOCAL,0270,RC,,,both,,,567.00,170.1,"CIGNA [10200]","Cigna Open Access",,322.62,56.9,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,J3420,HCPCS,0636,RC,63323-0044-00,NDC,both,1,ML,30.80,9.24,"FIRST HEALTH [10303]","First Health",,24.64,80,,,,,0,0.31,26.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,J3420,HCPCS,0636,RC,63323-0044-00,NDC,both,1,ML,30.80,9.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1.71,,,,,,,0.31,26.18,"fee schedule",
"SPLINT ORTHOPEDIC 15FTX5IN PREPADDED ROLL FIBERGLASS",SUP-OG5L,CDM,S27000186,LOCAL,0270,RC,,,both,,,615.03,184.51,"CIGNA [10200]","Cigna Open Access",,349.95,56.9,,,,,0,71.53,522.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sulfatide Autoantibody",PX-301000278,CDM,83520,CPT,0301,RC,,,both,,,350.00,105,"BLUE CROSS [10001]","Blue Cross PPO",,0.35,.1,,,,,0,0.35,297.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mnt Reassess Indv Ea 15min",PX-942000005,CDM,97803,CPT,0942,RC,,,both,,,81.19,24.36,"AETNA [10100]","Aetna HMO/PPO",,64.55,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.44,81.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABSORBENT CARBON DIOXIDE 2 PACK CANSTR 4.5KG MEDISORB VITAL",SUP-8570043,CDM,S27000186,LOCAL,0270,RC,,,both,,,165.74,49.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.28,140.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE ORTHOTIC 6.5-8.5 9-11 MEDIUM PROCARE OFF LOAD DIABETIC",SUP-79-81515,CDM,S27000186,LOCAL,0270,RC,,,both,,,237.16,71.15,"MULTIPLAN [10600]",Multiplan,,201.59,85,,,,,0,27.58,201.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 300MM 4.3MM PERCUTANEOUS QUICK COUPLING CALIBRATED",SUP-324.213,CDM,S27000186,LOCAL,0270,RC,,,both,,,1183.90,355.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,543.41,45.9,,,,,0,137.69,1006.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 45X5IN PRECUT PADDED FIBERGLASS",SUP-OG-545PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,170.00,51,"FIRST HEALTH [10303]","First Health",,136,80,,,,,0,19.77,144.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING HIGH PERFORMANCE VENTILATOR DRY GAS LINE 4",SUP-RT130,CDM,S27000186,LOCAL,0270,RC,,,both,,,157.47,47.24,"NOVANET [10819]",Novanet,,118.1,75,,,,,0,18.31,133.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 15MM 2.25MM BALLOON DILATATION PACLITAXEL",SUP-H7493960815220,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,26453.7,68,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 152MM .9MM KIRSCHNER STD STAINLESS STEEL TIP",SUP-KWIR-STD-09152,CDM,S27000186,LOCAL,0270,RC,,,both,,,200.10,60.03,"PHCS [10601]",PHCS,,140.07,70,,,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) QUALIBREATH SIZE XXXL",SUP-QB-XXXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"KAISER [10500]",Kaiser,,555.72,67,,,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 100MM 4MM BALLOON DILATATION RAPID",SUP-47540100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"FIRST HEALTH [10303]","First Health",,1276.56,80,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 155CM 100MM 6FR 3MM .014IN BALLOON",SUP-2216-30100,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"UHC [10700]","United Healthcare",,5241.24,63.3,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPLATZER TALISMAN PFO OCCLUDER 18-18MM",SUP-9-PFO-1818,CDM,C1817,HCPCS,0278,RC,,,both,,,56668.50,17000.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23290.75,41.1,,,,,0,6590.55,48168.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 8 STD 55MM PROVOX LIFE LARYTUBE ADHSV TUBEHOLDER",SUP-7411,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"MULTIPLAN [10600]",Multiplan,,1015.67,85,,,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Belt/Vest Elec/Combo Vad Rep",PX-E27400005,CDM,Q0499,HCPCS,0274,RC,,,both,,,2033.82,610.15,"CIGNA [10200]",Cigna,,1383,68,,,,,0,236.53,1728.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT OUTRIGGER PHOENIX STD CURVE RADIAL MCP RUBBER 4 SLOT",SUP-927201,CDM,S27000186,LOCAL,0270,RC,,,both,,,427.34,128.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,175.64,41.1,,,,,0,49.7,363.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT OUTRIGGER PHOENIX STD CURVE RADIAL MCP RUBBER 4 SLOT",SUP-927201,CDM,S27000186,LOCAL,0270,RC,,,both,,,427.34,128.2,"UHC [10700]","United Healthcare",,270.51,63.3,,,,,0,49.7,363.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABSORBER CARBON DIOXIDE PREFILL SEAL CANSTR MEDISORB EF EX",SUP-2079797-001,CDM,S27000186,LOCAL,0270,RC,,,both,,,169.74,50.92,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.74,144.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPHENHYDRAMINE 50MG/ML SUPERORDERABLE",RX-4082508,CDM,J1200,HCPCS,0636,RC,00641-0376-25,NDC,both,1,ML,18.92,5.68,"BLUE CROSS [10001]","Blue Cross HMO",,0.89,,,,,,,0.83,16.08,"fee schedule",
"SHEATH TOURGUIDE 180D 90CM 9MM 7FR CATH HYDROPHOBIC",SUP-TG0709009,CDM,C1766,HCPCS,0272,RC,,,both,,,4388.40,1316.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,520.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,510.37,3730.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C Telopeptide Crosslinks",PX-301000153,CDM,82523,CPT,0301,RC,,,both,,,697.30,209.19,"KAISER [10500]",Kaiser,,467.19,67,,,,,0,0.01,592.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAT TRANSFER 39X49IN HALFMATS HALF MAT AIR WEIGHT LIMIT 500",SUP-3230,CDM,S27100035,LOCAL,0271,RC,,,both,,,526.50,157.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,241.66,45.9,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT GAIT 2IN 60IN POLYETHYLENE POSEY QUICK CLEAN ECONOMY",SUP-552545,CDM,S27100035,LOCAL,0271,RC,,,both,,,224.20,67.26,"CIGNA [10200]","Cigna Local Plus",,119.95,53.5,,,,,0,26.07,190.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UNI-FUSE FLOW-THRU HUB 90CM 2CM 5FR THROMBECTOMY",SUP-H787124018415,CDM,C1757,HCPCS,0272,RC,,,both,,,1417.50,425.25,"UHC [10700]","United Healthcare",,897.28,63.3,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN ALLOPATH 12X8CM THIN MESH",SUP-WC2812,CDM,Q4433,HCPCS,0636,RC,,,both,,,34691.71,10407.51,"AETNA [10100]","Aetna HMO/PPO",,27579.91,79.5,,,,,0,247.92,29487.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Dialysis Low Ca",PX-E27200287,CDM,E27200287,LOCAL,0272,RC,,,both,,,206.80,62.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.05,175.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Foramen Sngl",PX-510000124,CDM,64479,CPT,0761,RC,,,both,,,6332.53,1899.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1793,,"Per diem ($1,793).",,,,0,736.47,5382.65,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM NEXGEN LPS-FLEX 5-6 C-D KNEE PROLONG",SUP-596204110,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2266.26,28.62,,,,,0,920.91,6730.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 59CM STD ENDOCARDIUM 1 COIL ACTIVE DF4 TERMINAL",SUP-0292,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6868.8,40,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 6MM 1.5MM BALLOON DILATATION PEBAX",SUP-1012269-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vitamin A",PX-301000438,CDM,84590,CPT,0301,RC,,,both,,,163.80,49.14,"MULTIPLAN [10600]",Multiplan,,139.23,85,,,,,0,0.16,139.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 4.00 X 18 RX US",SUP-1804400-18,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 63MM ASCENT MAXIM KNEE INTERLOK COCR 1 PIECE",SUP-141231,CDM,C1776,HCPCS,0278,RC,,,both,,,11379.48,3413.84,"AETNA [10100]","Aetna HMO/PPO",,9046.69,79.5,,10981.53,8986.79,12413.38,12,1323.43,9672.56,"percent of total billed charges",
"CAP LOCKING ELLIPSE SPINE OCCIPITOCERVICOTHORACIC POSTERIOR",SUP-182.500,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"BLUE CROSS [10001]","Blue Cross PPO",,943.39,39.2,,957.42,570.23,957.42,28,279.89,2045.61,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 33MM 145CM 4MM CORONARY STENT",SUP-1125400-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]",Cigna,,3969.84,68,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 10MM CEMENTRALIZER HIP FEMUR PMMA CEMENT SUMMIT",SUP-137648000,CDM,C1776,HCPCS,0278,RC,,,both,,,846.45,253.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,242.25,28.62,,,,,0,98.44,719.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 5.5MM ARMADA TITANIUM PREBENT",SUP-8052045,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Open Access",,2509.29,56.9,,1144.80,304.56,2275.09,66,512.88,3748.5,"percent of total billed charges",
"STENT ORSIRO 2.75/40",SUP-404674,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR EMPHASYS NEUTRAL 54MM 40MM AOX HIP",SUP-472254040,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT GLENOID REVERSE EXT SHOULDER TRABECULAR METAL",SUP-98850090103,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5748.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALAMINE 8 %-ZINC OXIDE 8 % LOTION",RX-28055,CDM,,,0637,RC,00904-2533-21,NDC,both,177,ML,14.47,4.34,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.68,12.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Shuntogram Nonvasc Shunt Si",PX-323000028,CDM,75809,CPT,0320,RC,,,both,,,668.30,200.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,134.04,,"Fee schedule rate ($134.04).",,,,0,77.72,568.06,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE EMBOTRAP III 45MM 6.5MM THROMBECTOMY",SUP-ET309645,CDM,C1757,HCPCS,0272,RC,,,both,,,40320.00,12096,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4777.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4689.22,34272,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PRUITT 24CM 12FR 43MM BALLOON OCCLUSION AORTA",SUP-E2120-12,CDM,C2628,HCPCS,0272,RC,,,both,,,3292.50,987.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2238.9,68,,,,,0,382.92,2798.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING URETHRAL VIRTUE ALEXIS MALE",SUP-50020,CDM,C1771,HCPCS,0278,RC,,,both,,,33604.20,10081.26,"BLUE CROSS [10001]","Blue Cross PPO",,13172.85,39.2,,,,,0,3908.17,28563.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE DRILL 2.4MM UNIVERSAL NONSTERILE",SUP-323.202,CDM,S27100035,LOCAL,0271,RC,,,both,,,3884.98,1165.49,"PHCS [10601]",PHCS,,2719.49,70,,,,,0,451.82,3302.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREPARATION OF TC-99M-TETROFOSMIN 1.38 MG IV SOLUTION",RX-169822,CDM,A9502,HCPCS,0343,RC,08888-8878-17,NDC,both,1,UN,206.95,62.08,"BLUE CROSS [10001]","Blue Cross PPO",,99.38,,,,,,,24.07,206.95,"fee schedule",
"HC Creatinine Blood",PX-301000166,CDM,82565,CPT,0301,RC,,,both,,,67.60,20.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.48,,"Fee schedule rate ($5.48). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.07,57.46,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVEIR VR LEADLESS PACEMAKER",SUP-LSP112V,CDM,C1786,HCPCS,0624,RC,,,both,,,51660.00,15498,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6121.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6008.06,43911,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Cerv/Thorac Sngl WO Img",PX-510000203,CDM,62320,CPT,0761,RC,,,both,,,4263.00,1278.9,"CIGNA [10200]","Cigna Local Plus",,2051,,"Per diem ($2,051).",,,,0,4.26,3623.55,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 014 150CM 12CM 2.5MM BALLOON DILATATION",SUP-U41502H12,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 15MM 6FR 6MM .07",SUP-H7493926715600,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 35 80CM 100MM 5FR 6MM .035IN LOW PROFILE BALLOON",SUP-B1060-100,CDM,C1725,HCPCS,0272,RC,,,both,,,891.00,267.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BALLOON DILATATION 3.5MM 8MM CORONARY OSTIUM",SUP-OCB3508BA,CDM,C1725,HCPCS,0272,RC,,,both,,,6900.00,2070,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 100MM 4MM BALLOON DILATATION DURALYN",SUP-48004010S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRA-THIN SDS 75CM 40MM 5.8FR 9MM STD BALLOON",SUP-M001177110,CDM,C1725,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPRT ORTHOPEDIC MEDIUM 18-20.5IN KNEE NEOPRENE SLEEVE OPEN",SUP-NE7702-03,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.70,30.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOE POSTOPERATIVE MEDIUM FEMALE",SUP-100612-030,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.99,17.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Mod Sedat Add 15min",PX-371000009,CDM,99153,CPT,0371,RC,,,both,,,387.75,116.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACK 24IN THERAPEUTIC MOIST HEAT CONTOUR NECK CHATTANOOGA",SUP-553795,CDM,S27000186,LOCAL,0270,RC,,,both,,,108.92,32.68,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RESUS MANUAL INFANT TUBE RESVR LATEX FREE DISPOSABLE AMBU",SUP-544212001,CDM,S27000186,LOCAL,0270,RC,,,both,,,65.84,19.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOE POSTOPERATIVE 5-6.5 SMALL UNIVERSAL MALE SUEDE RUBBER",SUP-2007-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.43,23.23,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 30MM 3.5MM BALLOON DILATATION DURALYN",SUP-48003503S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"3.50MM X 15MM  SCOREFLEX  NC",SUP-635-154-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 150CM 20MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRA E-Z ON POST-OP SUPER 50-54",SUP-958-SUPERQUEEN,CDM,S27000186,LOCAL,0270,RC,,,both,,,557.04,167.11,"NOVANET [10819]",Novanet,,417.78,75,,,,,0,64.78,473.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ELECTRODE KIT (ENSITE X PATCH)",SUP-ENSITE-SEK-5-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,7526.18,2257.85,"FIRST HEALTH [10303]","First Health",,6020.94,80,,,,,0,875.29,6397.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Txcath Inf Cessation",PX-361000279,CDM,37214,CPT,0361,RC,,,both,,,9833.26,2949.98,"PHCS [10601]",PHCS,,6883.28,70,,,,,0,1143.61,9833.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Amylase",PX-301000105,CDM,82150,CPT,0301,RC,,,both,,,255.55,76.66,"KAISER [10500]",Kaiser,,171.22,67,,,,,0,0.26,217.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repo Impl Elect Subq Icd",PX-481000105,CDM,33273,CPT,0481,RC,,,both,,,6653.00,1995.9,"KAISER [10500]",Kaiser,,4457.51,67,,,,,0,773.74,6653,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER COMPRESSION LARGE FOOT IMPAD AV IMPULSE SYSTEM RIGID",SUP-5075,CDM,S27000186,LOCAL,0270,RC,,,both,,,339.10,101.73,"NOVANET [10819]",Novanet,,254.33,75,,,,,0,39.44,288.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 50MM 1.5MM TWIST NOTCH STERILE",SUP-25-449-16,CDM,S27000186,LOCAL,0270,RC,,,both,,,1200.26,360.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,816.18,68,,,,,0,139.59,1020.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE LUNDERQUIST VASCULAR 5CM CURVE 300CM 4CM .035IN",SUP-G45408,CDM,C1769,HCPCS,0272,RC,,,both,,,874.80,262.44,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DIAMONDBACK 360 145CM 30MM .079IN 2MM ATHERECTOMY",SUP-DBP-EX-200SOL145,CDM,C1724,HCPCS,0272,RC,,,both,,,23278.50,6983.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"REAMER SURGICAL 3.1MM T HANDLE ROD SYSTEM WRIST HAND 300MM",SUP-RMT3130,CDM,S27200284,LOCAL,0272,RC,,,both,,,1287.90,386.37,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 48MM 1MM E9000 ROUND DIAMOND COARSE STERILE",SUP-E5210,CDM,S27200284,LOCAL,0272,RC,,,both,,,472.88,141.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT PHACOEMULSIFICATION .9MM INTREPID MICROSMOOTH ULTRA",SUP-8065750517,CDM,S27200284,LOCAL,0272,RC,,,both,,,266.57,79.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BONE VOID FILLER - SYTHETIC 50MM X 10MM X 5MM - 2 STRIPS",SUP-BF2-50X10-05,CDM,C1713,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"AETNA [10100]","Aetna HMO/PPO",,4168.98,79.5,,1521.93,481.35,16760.95,30,609.88,4457.4,"percent of total billed charges",
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET HOUSING POS",SUP-AR-1204AF-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"NOVANET [10819]",Novanet,,1919.54,75,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 3.2MM STEINMANN COMPREHENSIVE STAINLESS",SUP-405800,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"FIRST HEALTH [10303]","First Health",,1244.8,80,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 13CM 4MM PRESTIGE PLUS HELICAL ULTRA",SUP-PRES0413CPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,776.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X14MM CLYDESDALE 0D PEEK CAGE INTERBODY",SUP-2969455,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"PHCS [10601]",PHCS,,16632,70,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 5MM 1.27MM TOUMA EAR T GROMMET BEVELED TAB",SUP-1026014,CDM,S27800098,LOCAL,0278,RC,,,both,,,182.70,54.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,52.29,28.62,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 3DEMIN ALLOGRAFT STRIP PLIABLE OSTEOCONDUCTIVE",SUP-109771,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"FIRST HEALTH [10303]","First Health",,8252.4,80,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRI-SIL IC 20FR URETHRAL BACTI-GUARD SILICONE",SUP-70520SI,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.40,32.52,"PHCS [10601]",PHCS,,75.88,70,,,,,0,12.61,92.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET TUBING DUALWAVE CASSETTE OUTFLOW ARTHROSCOPY PUMP",SUP-AR-6430,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 6MM KIT EMG",SUP-2010460,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,708.98,41.1,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Calculi Infrared Spect",PX-301000129,CDM,82365,CPT,0301,RC,,,both,,,330.20,99.06,"CIGNA [10200]","Cigna Open Access",,28.38,,,,,,,0.01,280.67,"fee schedule",
"PLATE UNIVERSAL FIFTH METATARSAL FRACTURE SYSTEM HOOK BONE",SUP-AR-8956-01,CDM,C1713,HCPCS,0278,RC,,,both,,,9121.80,2736.54,"CIGNA [10200]","Cigna Open Access",,5190.3,56.9,,1144.80,304.56,2275.09,66,1060.87,7753.53,"percent of total billed charges",
"SCR BONE 5.5MM 35MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75445535,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 800107 CANC CRSHD 1-10MM 15CC FZN",SUP-800107,CDM,S27800098,LOCAL,0278,RC,,,both,,,1632.75,489.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1110.27,68,,,,,0,189.89,1387.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL RESTORELLE DIRECTFIX ANTERIOR",SUP-501450,CDM,C1781,HCPCS,0278,RC,,,both,,,1099.80,329.94,"MULTIPLAN [10600]",Multiplan,,934.83,85,,,,,0,127.91,934.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CREO LARGE WIDE LAMINA THREAD",SUP-1119.9850,CDM,C1713,HCPCS,0278,RC,,,both,,,3277.50,983.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1504.37,45.9,,,,,0,381.17,2785.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 90CM 3FR ODEC16MM 4 WIRE STONE",SUP-M0063901020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1416.61,424.98,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACEMKR CARDIAC AGILIS HISPRO SLITTER",SUP-DS3A001,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT STAINLESS STEEL ETHI-PACK 2-0 18IN MONOFILAMENT PRECUT",SUP-DS28,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.35,22.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INFINITI THRULUMEN 100CM 5FR RIGHT CORONARY 3D CURVE",SUP-534576T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 8.25MM HANNA SURGICAL",SUP-17171D825,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL HARTMANN BABY MOSQUITO CURVE 4IN ARTERY",SUP-15-3309,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.61,24.48,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SHAVER 19CM 4MM COOLCUT 8 FLUTE HIP LENGTH STERILE",SUP-AR-6400RBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,654.89,196.47,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TMPLT SIZING ASSORTED STERILE",SUP-EL-DTS,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATHETERIZATION BARDEX IC 16FR 350ML FOLEY INFECTION",SUP-303316A,CDM,S27200284,LOCAL,0272,RC,,,both,,,155.56,46.67,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IDENTITY IMPRINT PS TIBIAL INSERTR TRIAL SIZE 2 8MM",SUP-TPS-030-082S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ERCP TAPER TANDEM RX 195CM 7-5.5FR BILIARY STERILE",SUP-M00545820,CDM,S27200284,LOCAL,0272,RC,,,both,,,483.89,145.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL SURGICAL 2.6MM 3MM SUTURETAK",SUP-AR-1938D,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.03,267.91,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEAD REAMER 14MM DEEP FLUTE STAINLESS STEEL CONICAL TIP",SUP-352.254S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2560.05,768.01,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1052.18,41.1,,,,,0,297.73,2176.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 5-0 P-3 18IN MONOFILAMENT BLACK NONABSORBABLE",SUP-698G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lidocaine",PX-301000045,CDM,80176,CPT,0301,RC,,,both,,,397.10,119.13,"CIGNA [10200]",Cigna,,32.32,,,,,,,0.4,337.54,"fee schedule",
"PORT IMPLANTABLE INFUSION POWERPORT CLEARVUE AIRGUARD",SUP-1608062,CDM,C1788,HCPCS,0278,RC,,,both,,,2700.00,810,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,314.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 5MM 8.25IN STAINLESS STEEL GARRETT MALLEABLE",SUP-25-8024,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.12,22.24,"CIGNA [10200]","Cigna Local Plus",,39.65,53.5,,,,,0,8.62,63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET .241IN 77IN NONVENT PIERCE PIN LARGE BORE TUBE SIGHT",SUP-06544-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.20,15.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR ADULT NELLCOR LOSAT 18IN C50+ KG NASAL OXIMETER SPO2",SUP-MAXR,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.79,51.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.1,146.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 11MM 2.4FR GEMINI HELICAL",SUP-M0063303040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"CIGNA [10200]","Cigna Open Access",,841.86,56.9,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT ISP MRI AIRGUARD",SUP-1808060,CDM,C1788,HCPCS,0278,RC,,,both,,,1905.00,571.5,"CIGNA [10200]",Cigna,,1295.4,68,,,,,0,221.55,1619.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT ISP MRI AIRGUARD",SUP-1808060,CDM,C1788,HCPCS,0278,RC,,,both,,,1905.00,571.5,"BLUE CROSS [10001]","Blue Cross PPO",,746.76,39.2,,,,,0,221.55,1619.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC 7.5MM MODIFIED ELLIPSE 44.5X47MM INGENIO",SUP-K173,CDM,C1785,HCPCS,0275,RC,,,both,,,17250.00,5175,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7089.75,41.1,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC 7.5MM MODIFIED ELLIPSE 44.5X47MM INGENIO",SUP-K173,CDM,C1785,HCPCS,0275,RC,,,both,,,17250.00,5175,"FIRST HEALTH [10303]","First Health",,13800,80,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEARTMATE 3? LVAD SURGICAL ACCESSORIES SPARES KIT (APICAL CU",SUP-10006827,CDM,S27200284,LOCAL,0272,RC,,,both,,,11488.50,3446.55,"NOVANET [10819]",Novanet,,8616.38,75,,,,,0,1336.11,9765.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Selct Plc Cath Cca/Innom Neck",PX-361000288,CDM,36222,CPT,0361,RC,,,both,,,9187.29,2756.19,"CIGNA [10200]","Cigna Local Plus",,6044,,"Case rate ($6,044). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1068.48,7883,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGSEED 7CM",SUP-SM18-1-07,CDM,A4648,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1062.52,28.62,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest C/Th Facet Jnt Add Bi",PX-510000154,CDM,64634,CPT,0761,RC,,,both,,,3199.92,959.98,"NOVANET [10819]",Novanet,,2399.94,75,,,,,0,372.15,2719.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Laser Capsulotomy",PX-761000008,CDM,66821,CPT,0361,RC,,,both,,,1088.00,326.4,"UHC [10700]","United Healthcare",,1088,,"Case rate ($2,385). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1088,1088,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 64X43MM PFC SIGMA 2 KNEE CEMENT MODULAR PLUS FIX",SUP-860122,CDM,C1776,HCPCS,0278,RC,,,both,,,16046.64,4813.99,"UHC [10700]","United Healthcare",,10157.52,63.3,,8601.07,8395.67,8601.07,"1 through 10",1866.22,13639.64,"percent of total billed charges",
"INSRT TIBIAL 1.5 CURVE PLUS 12.5MM KNEE XLK FIX BEARING",SUP-970422,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7598.69,68,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Lumb Spine WO Cntrst",PX-612000005,CDM,72148,CPT,0612,RC,,,both,,,4396.55,1318.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,511.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,360.71,3737.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Convert Cath Biliary DRN Extrnl",PX-361000402,CDM,47535,CPT,0361,RC,,,both,,,5988.74,1796.62,"UHC [10700]","United Healthcare",,5988.74,,"Case rate ($7,311). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,696.49,5988.74,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lymph Vessel X-Ray Trunk",PX-323000040,CDM,75805,CPT,0320,RC,,,both,,,6091.05,1827.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,721.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,339.44,6091.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Outr/Ua Assay of Urine Sulfate",PX-300000030,CDM,84392,CPT,0301,RC,,,both,,,41.60,12.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.76,,"Fee schedule rate ($5.76). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,35.36,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fungitell (1-3) B D Glucan Assay",PX-306000113,CDM,87449,CPT,0306,RC,,,both,,,502.55,150.76,"FIRST HEALTH [10303]","First Health",,402.04,80,,,,,0,0.01,427.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC App Traction Mech (Gp)",PX-420000013,CDM,97012,CPT,0420,RC,,,both,,,164.07,49.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.08,164.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rom Measurement Hnd (Go)",PX-430000006,CDM,95852,CPT,0430,RC,,,both,,,253.00,75.9,"AETNA [10100]","Aetna HMO/PPO",,201.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.42,253,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 SURGALLOY 3-0 CV-23 TAPER POINT 6IN CLSR",SUP-VLOCM0804,CDM,S27200284,LOCAL,0272,RC,,,both,,,406.03,121.81,"AETNA [10100]","Aetna HMO/PPO",,322.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.22,345.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE INQWIRE VASCULAR 3MM RADIUS STD J CURVE 150CM .035IN",SUP-IQ35F150J3,CDM,C1769,HCPCS,0272,RC,,,both,,,63.68,19.1,"UHC [10700]","United Healthcare",,40.31,63.3,,,,,0,7.41,54.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 11 STD KNEE LEFT POSTERIOR STABILIZE PERSONA",SUP-42500807001,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"KAISER [10500]",Kaiser,,19360.04,67,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Explr Pntrate Wnd Ext",PX-450000064,CDM,20103,CPT,0450,RC,,,both,,,7667.00,2300.1,"CIGNA [10200]","Cigna Local Plus",,1442,,,,,,,67.13,6516.95,"case rate",
"HC Growth Hormone Stimulat Panel",PX-301000679,CDM,80428,CPT,0301,RC,,,both,,,856.00,256.8,"CIGNA [10200]",Cigna,,146.74,,,,,,,0.01,727.6,"fee schedule",
"DRSG WOUND 4X4IN MELGISORB SILVER CALCIUM ALGINATE HIGH",SUP-255100,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.11,14.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.6,40.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM CSF Flow Shunt Eval",PX-341000041,CDM,78645,CPT,0341,RC,,,both,,,1242.66,372.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,903.39,,,,,,,144.52,1242.66,"fee schedule",
"KIT CATHETERIZATION EXTERNAL BARD PUREWICK FEMALE",SUP-PWF030K,CDM,S27000186,LOCAL,0270,RC,,,both,,,68.12,20.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,28,41.1,,,,,0,7.92,57.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNAP(R) LONG DRESSING KIT - 10 KIT CASE",SUP-SKTF14X34,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 3.25MM ULTRA LOW PROFILE BALLOON",SUP-1012275-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 5MM BALLOON DILATATION STERILE LATEX",SUP-585012022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,177.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 14LP 170CM 6CM 4FR 2MM .014IN BALLOON",SUP-G50315,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,279.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (MR) 6MM X 2.50",SUP-H74939401062500,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3683.22,68,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 90CM 220MM 3.5MM BALLOON DILATATION NYBAX",SUP-H74939186352290,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPEL APD TWIST-LOC 15CM 10FR SHORT LENGTH PIGTAIL",SUP-H7493931110150,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,92.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 18LP 80CM 6FR 4FR 4MM .018IN BALLOON DILATATION",SUP-G50229,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 12X20 135CM SL",SUP-48012002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,584.13,68,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 90CM 120MM 2.5MM .014IN BALLOON DILATATION",SUP-AB14W025120090,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"NOVANET [10819]",Novanet,,1038.83,75,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DEBAKEY-DIETHRICH 7.75INX1.5MM CORONARY ARTERY",SUP-320-114,CDM,S27000186,LOCAL,0270,RC,,,both,,,447.36,134.21,"FIRST HEALTH [10303]","First Health",,357.89,80,,,,,0,52.03,380.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 25CM 10FR PIGTAIL CURVE NEPHRSTMY FLEXIMA POLYURETHANE",SUP-M001271830,CDM,C1729,HCPCS,0272,RC,,,both,,,615.60,184.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,71.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,71.59,523.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
".035 INTERLOCK 2D 10MM X 20CM",SUP-M001363600,CDM,C1725,HCPCS,0272,RC,,,both,,,3891.60,1167.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,461.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,452.59,3307.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABLE, 12X26MM, 7-14MM, 15%C2%B0",SUP-1172.4121S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"NOVANET [10819]",Novanet,,25987.5,75,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE EMERALD VASCULAR 3MM RADIUS 260CM 7CM .032IN HEPARIN",SUP-502454,CDM,C1769,HCPCS,0272,RC,,,both,,,106.58,31.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH GORE DRYSEAL FLEX 33CM 7.5MM 20FR INTRO HYDROPHILIC",SUP-GDSF2033,CDM,C1894,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO CATH 13CM 12FR PERFORMER CHECK-FLO DISPOSABLE STERILE",SUP-G07601,CDM,C1894,HCPCS,0272,RC,,,both,,,463.32,139,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 10CM 21GA 3FR MERIT PAK .018IN 40CM MINI PEDAL",SUP-PAKM4NPD7,CDM,C1894,HCPCS,0272,RC,,,both,,,389.06,116.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET INTRO 40CM 5FR 21GA MICROPUNCTURE PUSH-PLUS .018IN",SUP-G48008,CDM,C1894,HCPCS,0272,RC,,,both,,,208.80,62.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH GORE DRYSEAL FLEX 33CM 16FR 6.1MM 5.3MM INTRO",SUP-GDSF1633,CDM,C1894,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH HEARTSPAN 55D FIX CURVE TAPER 79.4CM 8.5FR GUIDING",SUP-FCL-160-07,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 35LP 80CM 12CM 7FR 10MM .035IN BALLOON",SUP-G52377,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AETNA [10100]","Aetna HMO/PPO",,763.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION",RX-160048,CDM,,,0250,RC,00121-0945-10,NDC,both,10,ML,31.58,9.47,"AETNA [10100]","Aetna HMO/PPO",,25.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.67,26.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATCH POINT SYSTEM RSP PATIENT MATCHED GLENOID DRILL GUIDE",SUP-804-03-057,CDM,C1776,HCPCS,0278,RC,,,both,,,4200.00,1260,"BLUE CROSS [10001]","Blue Cross PPO",,1646.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",488.46,3570,"percent of total billed charges",
"IMPL BIOABSORBABLE REGENETEN LARGE ROTATOR CUFF BOVINE",SUP-4566,CDM,S27800098,LOCAL,0278,RC,,,both,,,14490.00,4347,"PHCS [10601]",PHCS,,10143,70,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 45MM ECHELON ENDOSCOPIC LINEAR CUTTER",SUP-ECR45M,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET, IMMEDIATE RELEASE",RX-33227,CDM,,,0250,RC,42571-0161-01,NDC,both,1,UN,19.04,5.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12.95,68,,,,,0,2.21,16.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SPINAL 5.8MM SPINEJACK EXPANSION",SUP-0909-200-058,CDM,S27200284,LOCAL,0272,RC,,,both,,,8966.41,2689.92,"FIRST HEALTH [10303]","First Health",,7173.13,80,,,,,0,1042.79,7621.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LITHIUM CARBONATE 300 MG CAPSULE, IMMEDIATE RELEASE",RX-4529,CDM,,,0637,RC,00054-8527-25,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 7MMX29MM 7FR 80CMCATH HEPARIN",SUP-BXB072901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS [10001]","Blue Cross PPO",,7645.88,39.2,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDIGO CATHETER 12 115CM HTORQ + LIGHTNING BOLT ASPIRATION T",SUP-LITNGFB12HT115,CDM,C1757,HCPCS,0272,RC,,,both,,,60480.00,18144,"PHCS [10601]",PHCS,,42336,70,,,,,0,7033.82,51408,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 20FR 20CM RADIOPAQUE STERILE DISPOSABLE STD",SUP-G01471,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.44,31.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,70.34,68,,,,,0,12.03,87.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Electron Micro Dx",PX-312000044,CDM,88348,CPT,0312,RC,,,both,,,1164.80,349.44,"CIGNA [10200]",Cigna,,898.92,,,,,,,0.01,990.08,"fee schedule",
"RELOAD STPLR REGULAR 45MM ECHELON STAINLESS STEEL VASCULAR",SUP-ECR45D,CDM,S27200284,LOCAL,0272,RC,,,both,,,3762.58,1128.77,"AETNA [10100]","Aetna HMO/PPO",,2991.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,437.59,3198.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 60MM 36MM MARATHON HIP",SUP-121936160,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"KAISER [10500]",Kaiser,,6594.71,67,,,,,0,1144.72,8366.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HI-FLO RENEGADE 135CM 38CM 3-2.8FR .027IN MICRO",SUP-M001183010,CDM,C1887,HCPCS,0272,RC,,,both,,,4726.50,1417.95,"KAISER [10500]",Kaiser,,3166.76,67,,,,,0,549.69,4017.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FAT EMULSION 20 % IV RATE BASED",RX-40840048,CDM,,,0250,RC,00264-4460-10,NDC,both,500,ML,206.23,61.87,"KAISER [10500]",Kaiser,,138.17,67,,,,,0,23.98,175.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 36X21X2MM TITANIUM 2 LEVEL CLOVERLEAF CAUDAL HOLE LOCK",SUP-450.228,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 200MM 5MM BALLOON DILATATION DURALYN",SUP-48005020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"MULTIPLAN [10600]",Multiplan,,1170.45,85,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR STRAIGHT URETERAL STAINLESS STEEL",SUP-M0064003021,CDM,C1758,HCPCS,0272,RC,,,both,,,149.15,44.74,"KAISER [10500]",Kaiser,,99.93,67,,,,,0,17.35,126.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 200ML P3.2CM MODERATE PLUS PROFILE HIGH",SUP-350-2001BC,CDM,C1789,HCPCS,0278,RC,,,both,,,4823.10,1446.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,571.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",560.93,4099.64,"percent of total billed charges",
"HC NM Salivary Gland",PX-341000081,CDM,78230,CPT,0341,RC,,,both,,,1730.90,519.27,"AETNA [10100]","Aetna HMO/PPO",,1376.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,201.3,1471.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET",RX-24559,CDM,,,0250,RC,77333-0948-25,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 10X9.4CM 195ML GEL TEXTURE ORIENTATION MARK",SUP-3341005,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross HMO",,3583.86,39.2,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 10X9.4CM 195ML GEL TEXTURE ORIENTATION MARK",SUP-3341005,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2616.58,28.62,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Presumpt ID Ea Isol Urine",PX-306000064,CDM,87088,CPT,0306,RC,,,both,,,17.00,5.1,"CIGNA [10200]","Cigna Open Access",,17,,,,,,,0.01,17,"fee schedule",
"EXP TISSUE 350ML STYLE 9200 SUT TAB CPX4 P6.6CM CONTOUR",SUP-3549212,CDM,C1789,HCPCS,0278,RC,,,both,,,9694.50,2908.35,"UHC [10700]","United Healthcare",,6136.62,63.3,,,,,0,1127.47,8240.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Exc Bone Les S/N/Ex",PX-761000012,CDM,11426,CPT,0761,RC,,,both,,,18588.00,5576.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12639.84,68,,,,,0,1793,15799.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 15.5X16CM 775CC STYLE 410FX HIGHLY COHESIVE",SUP-FX-410775,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1592.7,28.62,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Calculi Glbldr Duct",PX-361000411,CDM,47544,CPT,0361,RC,,,both,,,6908.00,2072.4,"MULTIPLAN [10600]",Multiplan,,5871.8,85,,,,,0,803.4,6908,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SUPERORDERABLE",RX-40814984,CDM,,,0250,RC,06332-3462-04,NDC,both,10,ML,26.12,7.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.04,22.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIMOLOL MALEATE 0.5 % EYE DROPS",RX-11562,CDM,,,0250,RC,61314-0227-05,NDC,both,5,ML,106.93,32.08,"CIGNA [10200]","Cigna Open Access",,60.84,56.9,,,,,0,12.44,90.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE SOFT TOUCH SMOOTH",SUP-SSF-605,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNAP(R) CARTRIDGE - 75 MM HG - 10 IN A CASE",SUP-SNPA075,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,468.46,45.9,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 17.75IN 10FR 8FR SUPER ARROW-FLEX PERCUTANEOUS",SUP-CL-07045,CDM,C1894,HCPCS,0272,RC,,,both,,,767.88,230.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,90.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.3,652.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 500-700UM 2ML MICROSPHERES PREFILLED",SUP-S620GH,CDM,S27800098,LOCAL,0278,RC,,,both,,,1860.00,558,"CIGNA [10200]",Cigna,,1264.8,68,,,,,0,216.32,1581,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 1 CT 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J359H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 10MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192110,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"CIGNA [10200]","Cigna Local Plus",,7480.77,31.5,,5372.07,4581.20,7242.98,23,2761.95,20186.21,"percent of total billed charges",
"TIP MEDIUM SURGILAV SHIELD SPLASH PULSED LAVAGE",SUP-0207068000,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.60,22.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.68,63.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL",RX-177586,CDM,,,0250,RC,48582-0512-01,NDC,both,42,GR,29.59,8.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12.16,41.1,,,,,0,3.44,25.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GABAPENTIN 250 MG/5 ML ORAL SOLUTION SUPERORDERABLE",RX-408898,CDM,,,0250,RC,42192-0608-05,NDC,both,5,ML,45.38,13.61,"PHCS [10601]",PHCS,,31.77,70,,,,,0,5.28,38.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lipase",PX-301000298,CDM,83690,CPT,0301,RC,,,both,,,256.11,76.83,"BLUE CROSS [10001]","Blue Cross HMO",,0.26,.1,,,,,0,0.26,217.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL 29MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-151111201,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,5311.50,4717.44,5388.59,31,2014.9,14726.25,"percent of total billed charges",
"CATH PERFORMA 65CM 5FR .052IN .035IN PIGTAIL ANGIOGRAPHIC",SUP-7602-41,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.41,41.1,,,,,0,12,87.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 180CM 30MM 1.75MM ATHERECTOMY PERIPHERAL",SUP-DBP-175SOLID180,CDM,C1724,HCPCS,0272,RC,,,both,,,22648.50,6794.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"DRSG WOUND 18X1.2IN MELGISORB SILVER CALCIUM ALGINATE HIGH",SUP-255600,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.08,19.52,"MULTIPLAN [10600]",Multiplan,,55.32,85,,,,,0,7.57,55.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 360 145CM 20MM .079IN 2MM ATHERECTOMY",SUP-DBP-CART-200CLA145,CDM,C1724,HCPCS,0272,RC,,,both,,,17250.00,5175,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 137MM 9MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-103090,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"CIGNA [10200]",Cigna,,9681.34,40,,5873.17,5873.17,5873.17,"1 through 10",2814.85,20572.84,"percent of total billed charges",
"STENT CONTOUR SENSOR DUAL-FLEX 24CM 3CM 6FR .035IN PIGTAIL",SUP-M006180222190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"FIRST HEALTH [10303]","First Health",,1012.3,80,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 79MM 34MM 30MM 20FR ZENITH TX2 PRO-FORM",SUP-G47453,CDM,C1874,HCPCS,0278,RC,,,both,,,98041.65,29412.49,"BLUE CROSS [10001]","Blue Cross HMO",,38432.33,39.2,,9776.84,9776.84,9776.84,"1 through 10",11402.24,83335.4,"percent of total billed charges",
"FENOFIBRATE 160 MG TABLET",RX-28252,CDM,,,0637,RC,50268-0313-11,NDC,both,1,UN,25.19,7.56,"CIGNA [10200]",Cigna,,17.13,68,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EYE90 MICROSPHERES UNIT DOSE GEN II",SUP-P-0556,CDM,C1889,HCPCS,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL STD CONDUIT INFLOW SEAL FLEXIBILITY HEARTMATE II",SUP-104142,CDM,L8670,HCPCS,0278,RC,,,both,,,37170.00,11151,"KAISER [10500]",Kaiser,,24903.9,67,,,,,0,427.53,31594.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 19MM 90CM 4MM BILIARY STAINLESS",SUP-H74937912419900,CDM,C1876,HCPCS,0278,RC,,,both,,,3967.50,1190.25,"CIGNA [10200]","Cigna Local Plus",,2122.61,53.5,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE (RSP) MONOBLOCK REVISION HUMERAL STEM, 175MM, 12X175",SUP-510-12-175,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1465.38,10710,"percent of total billed charges",
"STEM HUMERAL ARTHREX UNIVERS REVERS 10 SHOULDER STERILE",SUP-AR-9501-10P,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1251,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1227.78,8973.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hu Immunoreactivity",PX-301000269,CDM,86255,CPT,0301,RC,,,both,,,229.00,68.7,"PHCS [10601]",PHCS,,160.3,70,,,,,0,0.23,194.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LACTULOSE 10 GRAM/15 ML ORAL SOLUTION",RX-38245,CDM,,,0250,RC,45963-0439-65,NDC,both,946,ML,422.48,126.74,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FILTER TRANSFUSION BLOOD MICROAGGREGATE PLEAT LOW RESIDUAL",SUP-SQ40S,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.65,25.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"6F DECA 5-5-5-20-3-3-3-3-3- MPA 120CM",SUP-901827,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GENTAMICIN 0.1 % TOPICAL CREAM",RX-3423,CDM,,,0250,RC,45802-0056-35,NDC,both,15,GR,310.60,93.18,"NOVANET [10819]",Novanet,,232.95,75,,,,,0,36.12,264.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Co2",PX-301000130,CDM,82374,CPT,0301,RC,,,both,,,70.00,21,"CIGNA [10200]",Cigna,,10.74,,,,,,,0.01,59.5,"fee schedule",
"REMIFENTANIL 2 MG INTRAVENOUS SOLUTION",RX-18400,CDM,,,0250,RC,63323-0724-01,NDC,both,1,UN,801.54,240.46,"AETNA [10100]","Aetna HMO/PPO",,637.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,93.22,681.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fo Pip/Dip Joint/Spring Pre Ot",PX-E27400052,CDM,L3925,HCPCS,0274,RC,,,both,,,182.60,54.78,"FIRST HEALTH [10303]","First Health",,146.08,80,,,,,0,21.24,155.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH",RX-82505,CDM,,,0250,RC,00378-9071-16,NDC,both,1,UN,84.99,25.5,"PHCS [10601]",PHCS,,59.49,70,,,,,0,9.88,72.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3514,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"KAISER [10500]",Kaiser,,1004,67,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE SPINE LOCK FIXATION NONSTERILE MAS PLIF",SUP-7070003,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",40.47,295.8,"percent of total billed charges",
"FIBER LASER FLEXIVA 200UM FLEXSHIELD HIGH POWER POLISH",SUP-M0068403910,CDM,S27200284,LOCAL,0272,RC,,,both,,,2752.13,825.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1871.45,68,,,,,0,320.07,2339.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FLUID TRANSFER 122CM NATRELLE UNIVERSAL 2 WAY CHECK",SUP-30-00033,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"UHC [10700]","United Healthcare",,49.56,63.3,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35LL 135CM 200MM 6FR 6MM .035IN LOW PROFILE",SUP-B2060-200,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP LIMIT HOLE COLOR CODED OSSEOTI G7",SUP-110010246,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,5873.17,5873.17,5873.17,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"BURR SURGICAL 9.5MM 4MM MICRO EGG STERILE",SUP-1607235,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 3MM 6MM TITANIUM CORTEX HAND SELF TAPPING",SUP-400.806,CDM,C1713,HCPCS,0278,RC,,,both,,,401.94,120.58,"KAISER [10500]",Kaiser,,269.3,67,,,,,0,46.75,341.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890006555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 300MM 5.5MM CREO TITANIUM HEXAGON END",SUP-1119.6300,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"SCR BONE 2.4MM 12MM LCP TITANIUM DISTAL VOLAR RADIUS LOCKING",SUP-04.210.112,CDM,C1713,HCPCS,0278,RC,,,both,,,1063.69,319.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,723.31,68,,,,,0,123.71,904.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPREME 120CM 5FR 2-5-2MM SPACING JSN CURVE",SUP-401450,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"FIRST HEALTH [10303]","First Health",,583.2,80,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION",RX-8878,CDM,,,0250,RC,00517-6101-25,NDC,both,10,ML,278.14,83.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,127.67,45.9,,,,,0,32.35,236.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 V-7 48IN 2 ARM MONOFILAMENT BLUE",SUP-D6175,CDM,S27200284,LOCAL,0272,RC,,,both,,,720.72,216.22,"CIGNA [10200]",Cigna,,490.09,68,,,,,0,83.82,612.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLOTRIMAZOLE 2 % VAGINAL CREAM",RX-33986,CDM,,,0250,RC,51672-2062-00,NDC,both,21,GR,66.71,20.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.76,56.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 130MM 9MM REVERSE FRACTURE AEQUALIS SHOULDER",SUP-DWD902,CDM,C1776,HCPCS,0278,RC,,,both,,,16560.00,4968,"UHC [10700]","United Healthcare",,10482.48,63.3,,8601.07,8395.67,8601.07,"1 through 10",1925.93,14076,"percent of total billed charges",
"CATH LASSO 115CM 6MM 7FR 20MM J CURVE ELECTROPHYSIOLOGY",SUP-122073S,CDM,C1730,HCPCS,0272,RC,,,both,,,7507.20,2252.16,"FIRST HEALTH [10303]","First Health",,6005.76,80,,,,,0,873.09,6381.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 5FR 5MM SPACE L CURVE ELECTROPHYSIOLOGY",SUP-F5QF252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TREK 145CM 30MM 2.25MM BALLOON DILATATION PEBAX",SUP-1012271-30,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LEAD PACING 60CM 3 CHMBR SOLIA T",SUP-377181,CDM,C1898,HCPCS,0275,RC,,,both,,,2250.00,675,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,643.95,28.62,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 60CM 3 CHMBR SOLIA T",SUP-377181,CDM,C1898,HCPCS,0275,RC,,,both,,,2250.00,675,"CIGNA [10200]",Cigna,,1530,68,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERTAPE TIGERWIRE 2 2MM 8IN BLUE 24IN NONABSORBABLE",SUP-AR-7275T,CDM,S27200284,LOCAL,0272,RC,,,both,,,595.35,178.6,"FIRST HEALTH [10303]","First Health",,476.28,80,,,,,0,69.24,506.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 25CM 6.6FR MYOCARDIUM UNIPOLAR FIXED SCR IS-1",SUP-5071-25,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]",Cigna,,3812.76,68,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 25CM 6.6FR MYOCARDIUM UNIPOLAR FIXED SCR IS-1",SUP-5071-25,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2573.61,45.9,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 6FR 2MM 17MM SPACE SMALL STRAIGHT VENTRICLE",SUP-5054-52,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"PHCS [10601]",PHCS,,1562.75,70,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH",RX-27507,CDM,,,0250,RC,00378-0873-16,NDC,both,1,UN,389.12,116.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.25,330.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD PACING 125CM 7FR BARD NBIH 1CM PROXIMAL BIPOLAR",SUP-007406P,CDM,C1730,HCPCS,0272,RC,,,both,,,7072.50,2121.75,"UHC [10700]","United Healthcare",,4476.89,63.3,,,,,0,822.53,6011.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM PINNACLE GRIPTION TF DOME 4 POINT CUT",SUP-121730500,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,133.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",133.3,974.23,"percent of total billed charges",
"CATH 100CM 11FR 15MM AIRWAY EXCHANGE 2 LUMEN TIP",SUP-G57627,CDM,S27200284,LOCAL,0272,RC,,,both,,,785.70,235.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,91.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,91.38,667.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 20MM AXSOS STAINLESS STEEL T20 FEMUR HUMERUS",SUP-370120,CDM,C1713,HCPCS,0278,RC,,,both,,,1219.05,365.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,348.89,28.62,,,,,0,141.78,1036.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP040100150 PLUS US D4L100UL1500",SUP-PCP040100150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PHCS [10601]",PHCS,,861.84,70,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 75CM 8MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200084070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 23MM 4MM CORONARY STENT COCR RAPID",SUP-1007850-23,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE ROUND",SUP-02.107.202S,CDM,C1713,HCPCS,0278,RC,,,both,,,6423.90,1927.17,"BLUE CROSS [10001]","Blue Cross HMO",,2518.17,39.2,,957.42,156.86,7483.26,51,747.1,5460.32,"percent of total billed charges",
"SCR BONE 2.4MM 26MM LCP STAINLESS STEEL DISTAL RADIAL T8",SUP-212.826,CDM,C1713,HCPCS,0278,RC,,,both,,,802.87,240.86,"CIGNA [10200]",Cigna,,545.95,68,,1831.33,1831.33,1831.33,16,93.37,682.44,"percent of total billed charges",
"STENT SURPASS ELITE 17MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE50017,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"NOVANET [10819]",Novanet,,62748.45,75,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 40MM 80CM 12MM 6FR .035IN BILIARY NITINOL",SUP-G36229,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Open Access",,2150.82,56.9,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 20MM 80CM 8MM 6FR .035IN VASCULAR NITINOL",SUP-G43854,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross HMO",,1481.76,39.2,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 40MM 125CM 8MM VASCULAR NITINOL ILIAC",SUP-G43832,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"FIRST HEALTH [10303]","First Health",,3024,80,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 40MM 125CM 8MM VASCULAR NITINOL ILIAC",SUP-G43832,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"NOVANET [10819]",Novanet,,2835,75,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.6MM 150MM KIRSCHNER TROCAR POINT STERILE",SUP-71161016,CDM,C1713,HCPCS,0278,RC,,,both,,,65.09,19.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,18.63,28.62,,,,,0,7.57,55.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.3MM 2.4MM 6MM TITANIUM CORTEX HAND SELF TAPPING",SUP-400.686,CDM,C1713,HCPCS,0278,RC,,,both,,,650.92,195.28,"CIGNA [10200]","Cigna Local Plus",,348.24,53.5,,3978.14,359.25,3978.14,24,75.7,553.28,"percent of total billed charges",
"CEMENT BONE HYDROSET CALCIUM PHOSPHATE INJECTABLE 10CC BONE",SUP-79-43910,CDM,C1713,HCPCS,0278,RC,,,both,,,17983.73,5395.12,"CIGNA [10200]","Cigna Open Access",,6024.55,33.5,,1144.80,304.56,2275.09,66,2091.51,15286.17,"percent of total billed charges",
"SMOOTH PEG LOCKING 6.0MM X 60MM TI",SUP-SPL-60600-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,188.41,1377,"percent of total billed charges",
"NAIL 12MM 380MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED",SUP-04.037.258S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"PHCS [10601]",PHCS,,8692.84,70,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 14MM ASSURE TITANIUM ANTERIOR CERVICAL SPINE",SUP-110.514,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,647.19,45.9,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT ORTHOPEDIC 75MM FEMORAL NECK SYSTEM STERILE",SUP-04.168.275S,CDM,C1713,HCPCS,0278,RC,,,both,,,2435.70,730.71,"CIGNA [10200]","Cigna Local Plus",,1303.1,53.5,,3978.14,359.25,3978.14,24,283.27,2070.35,"percent of total billed charges",
"SCR BONE 4.6MM 14MM VIP SPINE SELF DRILL VARIABLE ANGLE",SUP-171.014,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"BLUE CROSS [10001]","Blue Cross PPO",,552.72,39.2,,957.42,570.23,957.42,28,163.98,1198.5,"percent of total billed charges",
"PLATE 78MM STAINLESS STEEL 3.5MM SCR 6 HOLE LOW PROFILE DCP",SUP-02.100.016,CDM,C1713,HCPCS,0278,RC,,,both,,,5631.78,1689.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,654.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",654.98,4787.01,"percent of total billed charges",
"SUB BONE GRAFT 36CM MASTERGRAFT",SUP-7800336,CDM,C1713,HCPCS,0278,RC,,,both,,,16324.00,4897.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1898.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1898.48,13875.4,"percent of total billed charges",
"SCR BONE 5.5MM 45MM TSRH OSTEOGRIP THINLINE TITANIUM SHORT",SUP-83555458,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.10,1106.73,"KAISER [10500]",Kaiser,,2471.7,67,,,,,0,429.04,3135.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE L OBLIQUE LEFT 34MM STAINLESS STEEL 7MM SCR MINI",SUP-242.33,CDM,C1713,HCPCS,0278,RC,,,both,,,2072.70,621.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,245.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,241.06,1761.8,"percent of total billed charges",
"CATH ADVANCE 150CM 12CM 3MM BALLOON DILATATION OTW LOW",SUP-G30943,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 56MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.056S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"PLATE 54MM 3 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800354,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"SCR BONE 5MM 65MM TITANIUM ANKLE CALCANEUS THREAD HEAD",SUP-99-T775065,CDM,C1713,HCPCS,0278,RC,,,both,,,1754.10,526.23,"MULTIPLAN [10600]",Multiplan,,1490.99,85,,,,,0,204,1490.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 28MM SIMULUS ANNULUS POSTERIOR POLYESTER",SUP-800SC28,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5388.21,41.1,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X18X10MM COROENT 10D XL PEEK-OPTIMA XLIF",SUP-6981060,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS [10001]","Blue Cross HMO",,9313.92,39.2,,8555.87,8555.87,8996.26,"1 through 10",2763.29,20196,"percent of total billed charges",
"GRAFT VASCULAR SLIDER GDS VGTS",SUP-25129,CDM,C1768,HCPCS,0278,RC,,,both,,,9982.09,2994.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1182.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1160.92,8484.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 14CM 23MM 18.5-21.5MM EXCLUDER",SUP-PLC231400,CDM,C1874,HCPCS,0278,RC,,,both,,,27997.20,8399.16,"AETNA [10100]","Aetna HMO/PPO",,22257.77,79.5,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINERAL OIL ORAL",RX-5086,CDM,,,0250,RC,48433-0202-30,NDC,both,30,ML,15.10,4.53,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6.21,41.1,,,,,0,1.76,12.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIPROFLOXACIN 250 MG TABLET",RX-25118,CDM,,,0250,RC,43547-0688-10,NDC,both,1,UN,22.31,6.69,"NOVANET [10819]",Novanet,,16.73,75,,,,,0,2.59,18.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENZOCAINE 20 % MUCOSAL SPRAY",RX-27666,CDM,,,0250,RC,00283-0610-43,NDC,both,1,UN,80.00,24,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.88,41.1,,,,,0,9.3,68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 2.25MM CORONARY STENT PEBAX",SUP-H7493926032220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AETNA [10100]","Aetna HMO/PPO",,4424.18,79.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 8MM 3.5MM CORONARY STENT COCR RAPID",SUP-1007849-08,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 24MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.824,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,238.89,68,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 50MM 6.5MM RELINE 2C SPINE MODULAR MAS NONSTERILE",SUP-16186550,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG 127MM STAINLESS STEEL 2.7/3.5MM SCR 7 HOLE",SUP-02.117.007S,CDM,C1713,HCPCS,0278,RC,,,both,,,7192.84,2157.85,"BLUE CROSS [10001]","Blue Cross PPO",,2819.59,39.2,,957.42,570.23,957.42,28,836.53,6113.91,"percent of total billed charges",
"SCR BONE 4MM 36MM QUICKFIX TITANIUM SHORT PARTIAL THREAD T15",SUP-AR-8740-36PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 30MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.830,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,29.18,213.27,"percent of total billed charges",
"SCR BONE 2.7MM 22MM LOW PROFILE SCREWS STAINLESS STEEL T10",SUP-AR-8827-22,CDM,C1713,HCPCS,0278,RC,,,both,,,522.45,156.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,61.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,60.76,444.08,"percent of total billed charges",
"ROD SPINAL 30MM 3.5MM RELINE-C PRE BENT TITANIUM NONSTERILE",SUP-3943030,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 20MM PRECISION CANNULATED CHAMFER MIS BUNION",SUP-P27-130-0020,CDM,C1713,HCPCS,0278,RC,,,both,,,5492.40,1647.72,"AETNA [10100]","Aetna HMO/PPO",,4366.46,79.5,,1521.93,481.35,16760.95,30,638.77,4668.54,"percent of total billed charges",
"PLATE 14X8MM COALITION AGX BONE SPINE",SUP-1128.1208,CDM,C1713,HCPCS,0278,RC,,,both,,,18000.00,5400,"PHCS [10601]",PHCS,,12600,70,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BN 2MM 16MM LEIBINGER UNV 2",SUP-5020416,CDM,C1713,HCPCS,0278,RC,,,both,,,458.02,137.41,"KAISER [10500]",Kaiser,,306.87,67,,,,,0,53.27,389.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 7MM 210MM HUMERAL EXPERT INTRAMEDULLARY ROUND",SUP-04.001.222S,CDM,C1713,HCPCS,0278,RC,,,both,,,9598.18,2879.45,"BLUE CROSS [10001]","Blue Cross PPO",,3762.49,39.2,,957.42,570.23,957.42,28,1116.27,8158.45,"percent of total billed charges",
"COIL EMBOLIZATION 4CM 1.5MM TARGET NANO HELICAL DETACHABLE",SUP-M0035431540,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1085.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE MULTIAXIAL STERILE 7.5MM 50MM CD HORIZON LEGACY",SUP-75447550,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3292.97,68,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM CD HORIZON SPINE MULTIAXIAL FENESTRATE",SUP-55840024540T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"SCR BONE 3.5MM 24MM CLAW II",SUP-40233524,CDM,C1713,HCPCS,0278,RC,,,both,,,1474.20,442.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1002.46,68,,,,,0,171.45,1253.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM VERTEX MAX TITANIUM SPINE MULTIAXIAL",SUP-6958710,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,488.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",488.46,3570,"percent of total billed charges",
"PLATE 34MM 2 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.234,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"TM REVERSE STEM 10MM X130MM",SUP-00434901013,CDM,C1776,HCPCS,0278,RC,,,both,,,17863.20,5358.96,"CIGNA [10200]","Cigna Local Plus",,5626.91,31.5,,5372.07,4581.20,7242.98,23,2077.49,15183.72,"percent of total billed charges",
"STENT ABSOLUTE PRO 80MM 80CM 10MM VASCULAR PERIPHERAL SELF",SUP-1012532-80,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 84MM TITANIUIM 7 HOLE LOCKING ACUMED BONE MEDIAL",SUP-PL-LEM7,CDM,C1713,HCPCS,0278,RC,,,both,,,6755.10,2026.53,"CIGNA [10200]","Cigna Local Plus",,3613.98,53.5,,3978.14,359.25,3978.14,24,785.62,5741.84,"percent of total billed charges",
"PLATE CONTOUR 93MM STAINLESS STEEL 3.5MM SCR 4 HOLE LIMIT",SUP-239.954S,CDM,C1713,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1030.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1011.11,7389.9,"percent of total billed charges",
"CATH OCCL 100CM 7FR 34FR BALLOON OCCLUSION 1 INFLATION PORT",SUP-M0062201100,CDM,C2628,HCPCS,0272,RC,,,both,,,1155.14,346.54,"PHCS [10601]",PHCS,,808.6,70,,,,,0,134.34,981.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 30X6MM CRANIOFACIAL TITANIUM 16 HOLE STRUT 1MM",SUP-42001,CDM,C1713,HCPCS,0278,RC,,,both,,,2932.50,879.75,"MULTIPLAN [10600]",Multiplan,,2492.63,85,,,,,0,341.05,2492.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG REGULAR Y MIDFACE 5 HOLE 1.5MM SCR BONE TRAUMAONE",SUP-01-7102,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"KAISER [10500]",Kaiser,,955.15,67,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 50MM TI",SUP-MTC-37500-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,357.01,28.62,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.5IN ANKLE STERILE",SUP-351-90-21,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,578.34,68,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM CREO SPINE POLYAXIAL PREASSEMBLE",SUP-5119.1242,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"PLATE 16MM GROWTH GUIDE EIGHT-PLATE BONE PEDIATRIC 32MM",SUP-GP400CE,CDM,C1713,HCPCS,0278,RC,,,both,,,1847.55,554.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,848.03,45.9,,,,,0,214.87,1570.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 5.5MM ARMADA TITANIUM PREBENT",SUP-8052045,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,512.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",512.88,3748.5,"percent of total billed charges",
"PLATE TITANIUM 1.5 MM SCREW 11 HOLE Y BONE HAND NONSTERILE",SUP-446.612,CDM,C1713,HCPCS,0278,RC,,,both,,,2629.20,788.76,"PHCS [10601]",PHCS,,1840.44,70,,,,,0,305.78,2234.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 15MM TRIDENT II LOW PROFILE HEXAGONAL STERILE",SUP-7030-6515,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,90.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,88.55,647.19,"percent of total billed charges",
"SCREW BONE 1.5MM 10MM TITANIUM CORTICAL HAND SELF TAPPING NO",SUP-400.810.96,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,92.73,28.62,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 15MM TRIDENT II LOW PROFILE HEXAGONAL STERILE",SUP-7030-6515,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"KAISER [10500]",Kaiser,,510.14,67,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 57MM 135CM 9MM 60MM",SUP-38047-96013,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 15MM COCR",SUP-VAL-20150-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"NOVANET [10819]",Novanet,,1069.2,75,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 18X8MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2508,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3970.26,41.1,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 2.5IN 1/8IN STEINMANN STAINLESS STEEL THREADED",SUP-406669,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,184.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,180.96,1322.6,"percent of total billed charges",
"GWIRE HI-TORQUE PILOT 50 VASCULAR J 300CM 3CM .014IN",SUP-1010483-HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 40MM 6.5MM MODULEX OSTEOGRIP SPINE",SUP-55900506540,CDM,C1713,HCPCS,0278,RC,,,both,,,4519.50,1355.85,"CIGNA [10200]",Cigna,,3073.26,68,,1831.33,1831.33,1831.33,16,525.62,3841.58,"percent of total billed charges",
"SCR BONE 4.5MM 24MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.724,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,764.07,68,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVED 94X10X3.6MM STAINLESS STEEL 3.5MM CORTICAL SCR",SUP-245.31,CDM,C1713,HCPCS,0278,RC,,,both,,,4248.47,1274.54,"NOVANET [10819]",Novanet,,3186.35,75,,,,,0,494.1,3611.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 26MM CHARLOTTE STAINLESS STEEL FOOT ANKLE",SUP-44110009,CDM,C1713,HCPCS,0278,RC,,,both,,,1672.50,501.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,198.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",194.51,1421.63,"percent of total billed charges",
"SCR BONE 2.7MM 32MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0336,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,112.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,110.22,805.55,"percent of total billed charges",
"SCR BONE 6.5MM 20MM PINNACLE GRIPTION TF DOME 4 POINT CUT",SUP-121720500,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"NOVANET [10819]",Novanet,,859.61,75,,,,,0,133.3,974.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW CANN MINI-MON 2.0X16MM",SUP-P20-120-016S,CDM,C1713,HCPCS,0278,RC,,,both,,,1559.25,467.77,"PHCS [10601]",PHCS,,1091.48,70,,,,,0,181.34,1325.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM NONSTERILE GORILLA R3CON",SUP-P50-453-3526,CDM,C1713,HCPCS,0278,RC,,,both,,,1069.20,320.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,126.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",124.35,908.82,"percent of total billed charges",
"MOLD CEMENT 60MM STAGEONE HIP SILICONE REINFORCEMENT SPACER",SUP-431184,CDM,C1713,HCPCS,0278,RC,,,both,,,7955.01,2386.5,"BLUE CROSS [10001]","Blue Cross PPO",,3118.36,39.2,,957.42,570.23,957.42,28,925.17,6761.76,"percent of total billed charges",
"KIT GASTROJEJUNOSTOMY TUBE 18FR STOMA L2.7CM JEJUNAL L30CM S",SUP-8270-18-2.7-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 8MM 70MM EXPERT TITANIUM 3.5MM FULL THREAD",SUP-450.866,CDM,C1713,HCPCS,0278,RC,,,both,,,1576.91,473.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,186.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",183.39,1340.37,"percent of total billed charges",
"PLATE 88MM STAINLESS STEEL 2.4MM SCREW MINI FRAGMENT SET 12",SUP-247.366,CDM,C1713,HCPCS,0278,RC,,,both,,,2679.60,803.88,"MULTIPLAN [10600]",Multiplan,,2277.66,85,,,,,0,311.64,2277.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 20MM LEVEL 1 HELIX BONE SPINE",SUP-7800120,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1202.04,28.62,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW TITANIUM ALUMINUM VANADIUM PERIPROSTHETIC NCB",SUP-0202263301,CDM,C1713,HCPCS,0278,RC,,,both,,,9729.00,2918.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1131.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1131.48,8269.65,"percent of total billed charges",
"SCR BONE 3MM 4MM 1.2MM 18MM 8MM STAINLESS STEEL LONG THREAD",SUP-202.718,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"NOVANET [10819]",Novanet,,832.52,75,,,,,0,129.1,943.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 6 HOLE LOW PROFILE BONE RIGHT CLAVICLE",SUP-70-0297,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,768.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",768.77,5618.67,"percent of total billed charges",
"SCR BONE 3.5MM 22MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0262,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross HMO",,371.5,39.2,,957.42,156.86,7483.26,51,110.22,805.55,"percent of total billed charges",
"SCR BONE 18MM 2.4MM CORTICAL HAND TITANIUM SELF TAPPING",SUP-401.518.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,170.71,28.62,,,,,0,69.37,507.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM FIBERTAG TIGHTROPE 9MM FIXATION ACL",SUP-AR-1288QT-90,CDM,C1713,HCPCS,0278,RC,,,both,,,7063.88,2119.16,"CIGNA [10200]","Cigna Local Plus",,3779.18,53.5,,3978.14,359.25,3978.14,24,821.53,6004.3,"percent of total billed charges",
"NAIL 12MM 170MM FEMORAL PROXIMAL TFN-ADVANCED LATERAL RELIEF",SUP-04.037.212S,CDM,C1713,HCPCS,0278,RC,,,both,,,8273.93,2482.18,"MULTIPLAN [10600]",Multiplan,,7032.84,85,,,,,0,962.26,7032.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 500MM 4.75MM COCR MOLYBDENUM STRAIGHT NONSTERILE",SUP-1475000500,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"PLATE 79MM STAINLESS STEEL 2.7MM SCR 3 HOLE CONTOUR SHAFT",SUP-02.118.400S,CDM,C1713,HCPCS,0278,RC,,,both,,,4398.75,1319.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2991.15,68,,,,,0,511.57,3738.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETERAL 5.8FR 10MM 75CM 8CM KIT HIGH PRESSURE LEVEEN",SUP-M0062251310,CDM,C1726,HCPCS,0272,RC,,,both,,,1904.70,571.41,"KAISER [10500]",Kaiser,,1276.15,67,,,,,0,221.52,1619,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM CHARLOTTE STAINLESS STEEL FOOT ANKLE",SUP-56016545,CDM,C1713,HCPCS,0278,RC,,,both,,,7514.10,2254.23,"PHCS [10601]",PHCS,,5259.87,70,,,,,0,873.89,6386.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 380MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.259S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CIGNA [10200]",Cigna,,4967.34,40,,1831.33,1831.33,1831.33,16,1444.25,10555.59,"percent of total billed charges",
"SCR BONE 3.5MM 28MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.110,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,245.36,28.62,,,,,0,99.7,728.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 55MM STAINLESS STEEL 2.4MM SCR 7 HOLE HEAD 3 HOLE",SUP-02.111.731S,CDM,C1713,HCPCS,0278,RC,,,both,,,4274.55,1282.36,"CIGNA [10200]","Cigna Open Access",,2432.22,56.9,,1144.80,304.56,2275.09,66,497.13,3633.37,"percent of total billed charges",
"CATH ULTRAVERSE 018 150CM 15CM 3.5MM BALLOON DILATATION",SUP-U81503H15,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 10MM 4MM ACL TENODESIS STERILE",SUP-AR-1540BC,CDM,C1713,HCPCS,0278,RC,,,both,,,2716.88,815.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1247.05,45.9,,,,,0,315.97,2309.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 8.2MM 115MM 22MM DHS/DCS STAINLESS STEEL",SUP-280.15,CDM,C1713,HCPCS,0278,RC,,,both,,,2264.18,679.25,"CIGNA [10200]","Cigna Open Access",,1288.32,56.9,,1144.80,304.56,2275.09,66,263.32,1924.55,"percent of total billed charges",
"CNCT ROD 60MM 5.5MM ARMADA SPINE TITANIUM FIX CROSS",SUP-8450160,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"NOVANET [10819]",Novanet,,2671.88,75,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 52MM STAINLESS STEEL T8 ELBOW METAPHYSEAL",SUP-02.118.552,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"NOVANET [10819]",Novanet,,392.93,75,,,,,0,60.93,445.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOCKING COMPRESSION SCREW 1.8MM X 5.0MM COCR",SUP-CMP-18005-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORTHOLOC 3DI ANKLE FUSION SYSTEM NON-LOCKING SCREW 5.5MM NON",SUP-59225540,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,285.14,28.62,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 5D SMALL FUSION MEDLINE UNITE BONE METATARSOPHALANGEAL",SUP-MPP1002L,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1222.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1199.69,8768.18,"percent of total billed charges",
"STEM FEMORAL 150MM 16MM REVISION MODULAR ARCOS STS TITANIUM",SUP-11-300816,CDM,C1776,HCPCS,0278,RC,,,both,,,20372.94,6111.88,"PHCS [10601]",PHCS,,14261.06,70,,,,,0,2369.37,17317,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM ATLANTIS TITANIUM SPINAL CANCELLOUS",SUP-876-815,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 8 HOLE BONE LEFT CLAVICLE",SUP-70-0290,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,783.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",768.77,5618.67,"percent of total billed charges",
"SCR BONE 5.5MM 45MM LUMBAR SPINE STERILE",SUP-2140145,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,743.58,45.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 87MM STAINLESS STEEL 3.5MM SCR 4 HOLE VARIABLE ANGLE",SUP-02.127.211S,CDM,C1713,HCPCS,0278,RC,,,both,,,9729.00,2918.7,"MULTIPLAN [10600]",Multiplan,,8269.65,85,,,,,0,1131.48,8269.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 4IN 18GA 20GA TUOHY EPILONG CLOSED TIP LUER",SUP-TAL103,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,34.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DIEGO ELITE TUBING DECLOC",SUP-TS101DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1764.53,529.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,809.92,45.9,,,,,0,205.21,1499.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.2MM 130MM JOUST MEDIUM THREAD CANNULATED BEAM",SUP-P26-572-130M,CDM,C1713,HCPCS,0278,RC,,,both,,,7533.08,2259.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2155.97,28.62,,,,,0,876.1,6403.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE C SCREW, 3.5X16MM FA",SUP-3913516,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM LOW PROFILE SCREWS STAINLESS STEEL FULL",SUP-AR-8827L-18,CDM,C1713,HCPCS,0278,RC,,,both,,,931.50,279.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,108.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",108.33,791.78,"percent of total billed charges",
"CANN ARTHROSCOPIC GREEN 76MM OBTR TROCAR SEAL STERILE",SUP-012421,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"PHCS [10601]",PHCS,,170.52,70,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Muga Bld Pool Mult",PX-341000030,CDM,78473,CPT,0341,RC,,,both,,,2635.28,790.58,"CIGNA [10200]",Cigna,,440.75,,,,,,,2.64,2239.99,"fee schedule",
"PLATE CONTOUR 190MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-240.043S,CDM,C1713,HCPCS,0278,RC,,,both,,,9779.78,2933.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1137.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1137.39,8312.81,"percent of total billed charges",
"SCR BONE 3.5MM 12MM STAINLESS STEEL T15 CORTEX SELF TAP LOW",SUP-02.206.212S,CDM,C1713,HCPCS,0278,RC,,,both,,,725.76,217.73,"NOVANET [10819]",Novanet,,544.32,75,,,,,0,84.41,616.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM STALIF C NO-PROFILE ABO TITANIUM STD SPINE",SUP-ABS1440,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"CIGNA [10200]","Cigna Open Access",,534.86,56.9,,1144.80,304.56,2275.09,66,109.32,799,"percent of total billed charges",
"SCR BONE 3.5MM 20MM COMPRESSION FT TITANIUM MINI FULL THREAD",SUP-AR-8730-20H,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA [10200]","Cigna Open Access",,1493.63,56.9,,1144.80,304.56,2275.09,66,305.29,2231.25,"percent of total billed charges",
"SCR BONE 8.5MM 80MM CD HORIZON SPINE MULTIAXIAL CANNULATED",SUP-25840018580,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL2712,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,687.81,45.9,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 30ML 1.7-7MM DEMINERALIZED CANCELLOUS",SUP-420037,CDM,C1713,HCPCS,0278,RC,,,both,,,3874.01,1162.2,"CIGNA [10200]","Cigna Open Access",,2204.31,56.9,,1144.80,304.56,2275.09,66,450.55,3292.91,"percent of total billed charges",
"SCR BONE 5MM 50MM LCP STAINLESS STEEL FULL THREAD PROXIMAL",SUP-02.205.050,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"CIGNA [10200]","Cigna Local Plus",,675.85,53.5,,3978.14,359.25,3978.14,24,146.92,1073.79,"percent of total billed charges",
"SCR BONE 5MM 80MM LCP STAINLESS STEEL T25 CONDYLE VARIABLE",SUP-02.231.280,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"KAISER [10500]",Kaiser,,876.25,67,,,,,0,152.1,1111.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.432,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",160.97,1176.51,"percent of total billed charges",
"SCR BONE 3MM 12MM TITANIUM STERNAL SELF DRILLING NONSTERILE",SUP-04.501.112.01,CDM,C1713,HCPCS,0278,RC,,,both,,,854.96,256.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,244.69,28.62,,,,,0,99.43,726.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLENOSPHERE LOCKING BOLT_MEDIUM/LONG M4 X 0.7 X 26MM",SUP-2R1GB40826,CDM,C1713,HCPCS,0278,RC,,,both,,,756.22,226.87,"KAISER [10500]",Kaiser,,506.67,67,,,,,0,87.95,642.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET IMPL 6MM 4.5MM CANNULATED DRILL GUIDPN INTERFERENCE SCR",SUP-AR-1360C-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10773.32,3232,"BLUE CROSS [10001]","Blue Cross PPO",,4223.14,39.2,,957.42,570.23,957.42,28,1252.94,9157.32,"percent of total billed charges",
"SCR BONE 8.5MM 35MM LEGACY CD HORIZON TITANIUM FLUTE SPINE G",SUP-75448535,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 22MM LCP STAINLESS STEEL SMALL BONE SELF",SUP-202.222,CDM,C1713,HCPCS,0278,RC,,,both,,,748.44,224.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,88.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,87.04,636.17,"percent of total billed charges",
"PLATE STD CONTOUR TITANIUM LAPIDUS 5 HOLE LOW PROFILE",SUP-3814000L,CDM,C1713,HCPCS,0278,RC,,,both,,,16560.00,4968,"CIGNA [10200]","Cigna Open Access",,5547.6,33.5,,1144.80,304.56,2275.09,66,1925.93,14076,"percent of total billed charges",
"SCR BONE 3MM 16MM ZERO-P TITANIUM SPINE CERVICAL SELF TAP",SUP-04.617.816.02S,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"NOVANET [10819]",Novanet,,1406.25,75,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 1.5MM 18MM TITANIUM CORTICAL HAND SELF TAPPING NO",SUP-400.818.96,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"NOVANET [10819]",Novanet,,242.99,75,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTILUME BALLOON DRUG COATED BALLOON 30FRX5CM OPTILUME",SUP-OPTBDL7011B,CDM,C1726,HCPCS,0272,RC,,,both,,,16525.50,4957.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1958.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 42MM LEVEL 2 TRANSLATIONAL BONE SPINE",SUP-201-42D42,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULAR HEAD - TOP LOADING LATERAL CONNECTOR, 5.5 TOP LOADIN",SUP-1175.7202,CDM,C1713,HCPCS,0278,RC,,,both,,,16215.00,4864.5,"AETNA [10100]","Aetna HMO/PPO",,12890.93,79.5,,1521.93,481.35,16760.95,30,1885.8,13782.75,"percent of total billed charges",
"DIL ENDOSCOPIC QUANTUM TTC 320CM 3CM 6MM 6.8-4.5FR BILIARY",SUP-G22765,CDM,C1726,HCPCS,0272,RC,,,both,,,3045.00,913.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,354.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,354.13,2588.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 V5 ETHIBOND GII QUICKANCHOR PLUS ROTATOR CUFF",SUP-212035,CDM,C1713,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"NOVANET [10819]",Novanet,,5045.63,75,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM GORILLA R3CON LOCK",SUP-P50-353-3524,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,382.51,28.62,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM SKYLINE TITANIUM SPINE CERVICAL ANTERIOR",SUP-186862014,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPEEDBRIDGE JUMPSTART FIXATION BIOCOMPOSITE ACHILLES",SUP-AR-8928BCJ-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"MULTIPLAN [10600]",Multiplan,,11700.68,85,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE FIBER 6CC ALLOGRAFT",SUP-T50306,CDM,C1713,HCPCS,0278,RC,,,both,,,9522.00,2856.6,"CIGNA [10200]","Cigna Open Access",,5418.02,56.9,,1144.80,304.56,2275.09,66,1107.41,8093.7,"percent of total billed charges",
"SCR BONE 3MM 2MM 27MM 10MM STAINLESS STEEL 1.1MM LONG THREAD",SUP-02.226.127,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"BLUE CROSS [10001]","Blue Cross PPO",,644.92,39.2,,957.42,570.23,957.42,28,191.34,1398.42,"percent of total billed charges",
"SCR BONE 6.5MM 25MM DYNASTY LINEAGE BIOFOAM ACETABULAR",SUP-18080302,CDM,C1713,HCPCS,0278,RC,,,both,,,1101.60,330.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,315.28,28.62,,,,,0,128.12,936.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 154MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT SET 8",SUP-240.041,CDM,C1713,HCPCS,0278,RC,,,both,,,8796.40,2638.92,"MULTIPLAN [10600]",Multiplan,,7476.94,85,,,,,0,1023.02,7476.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.3MM 38MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.528,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"AMERIGROUP MEDICAID [20100]",Amerigroup,,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",134.52,983.18,"percent of total billed charges",
"LATERAL LUMBAR ANCHOR 22MM",SUP-1219.0022,CDM,C1713,HCPCS,0278,RC,,,both,,,3277.50,983.25,"PHCS [10601]",PHCS,,2294.25,70,,,,,0,381.17,2785.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 22.9CM .063IN KIRSCHNER STAINLESS STEEL BOTH",SUP-00018607800,CDM,C1713,HCPCS,0278,RC,,,both,,,119.63,35.89,"FIRST HEALTH [10303]","First Health",,95.7,80,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE FIBER 6CC ALLOGRAFT",SUP-T50306,CDM,C1713,HCPCS,0278,RC,,,both,,,9522.00,2856.6,"CIGNA [10200]",Cigna,,6474.96,68,,1831.33,1831.33,1831.33,16,1107.41,8093.7,"percent of total billed charges",
"PLATE 154MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT SET 8",SUP-240.041,CDM,C1713,HCPCS,0278,RC,,,both,,,8796.40,2638.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3615.32,41.1,,,,,0,1023.02,7476.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 45MM 7.5MM MODULEX OSTEOGRIP SPINE",SUP-55900507545,CDM,C1713,HCPCS,0278,RC,,,both,,,4519.50,1355.85,"BLUE CROSS [10001]","Blue Cross HMO",,1771.64,39.2,,957.42,156.86,7483.26,51,525.62,3841.58,"percent of total billed charges",
"ROD SPINAL 80MM 5.5MM CD HORIZON LEGACY TITANIUM PREBENT CP",SUP-8690080,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET IMPL 68MM KNEE LEFT FUSION NAIL MODULAR STERILE",SUP-15-0028/07,CDM,C1713,HCPCS,0278,RC,,,both,,,43703.48,13111.04,"CIGNA [10200]","Cigna Open Access",,14640.67,33.5,,1144.80,304.56,2275.09,66,5082.71,37147.96,"percent of total billed charges",
"SCR BONE 12.7MM 140MM 22MM DHS/DCS STAINLESS STEEL CONDYLAR",SUP-280.4,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"CIGNA [10200]","Cigna Open Access",,1034.66,56.9,,1144.80,304.56,2275.09,66,211.48,1545.62,"percent of total billed charges",
"SCR BONE 4.5MM 12MM SKYLINE TITANIUM 5- D OVERSIZE LARGE",SUP-186864012,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",117.75,860.63,"percent of total billed charges",
"PLATE 35MM TITANIUM SPIRE BONE SPINAL",SUP-9240200,CDM,C1713,HCPCS,0278,RC,,,both,,,17798.40,5339.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7315.14,41.1,,,,,0,2069.95,15128.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 95MM LCP STAINLESS STEEL PERIARTICULAR FEMORAL",SUP-02.205.295,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"FIRST HEALTH [10303]","First Health",,1244.68,80,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD SMALL TSRH TITANIUM SPINAL 3DX",SUP-8351520,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AETNA [10100]","Aetna HMO/PPO",,7589.75,79.5,,1521.93,481.35,16760.95,30,1110.3,8114.82,"percent of total billed charges",
"SCR BONE 4MM 40MM TALON DISTALFIX CORTICAL",SUP-HTN-U-4-40,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,445.1,28.62,,,,,0,180.87,1321.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8840-14,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,1831.33,1831.33,1831.33,16,50.59,369.75,"percent of total billed charges",
"SCR BONE 4MM 26MM ASNIS III TITANIUM 1/3 THREAD REVERSE CUT",SUP-604626S,CDM,C1713,HCPCS,0278,RC,,,both,,,1319.00,395.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,156.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",153.4,1121.15,"percent of total billed charges",
"PLATE BONE SILVER .75MM LEIBINGER UNIVERSAL 2 100D MINI L",SUP-55-08521,CDM,C1713,HCPCS,0278,RC,,,both,,,1985.18,595.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,235.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",230.88,1687.4,"percent of total billed charges",
"SCR BONE 9MM 100MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704999,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"SCR INTERFERENCE BIOCOMPOSITE 15MM 5.5MM ACL TENODESIS",SUP-AR-1555BC,CDM,C1713,HCPCS,0278,RC,,,both,,,2716.88,815.06,"PHCS [10601]",PHCS,,1901.82,70,,,,,0,315.97,2309.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE LEVEL ONE LONG CRANIOFACIAL TITANIUM 2 HOLE ULTRA",SUP-25-153-12-09,CDM,C1713,HCPCS,0278,RC,,,both,,,927.13,278.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,265.34,28.62,,,,,0,107.83,788.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM EVEREST SPINE CANNULATED POLYAXIAL MIS",SUP-M5111-07550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION TROCAR POINT STYLE BOTH END 15.2CM .063IN",SUP-00018607600,CDM,C1713,HCPCS,0278,RC,,,both,,,119.63,35.89,"KAISER [10500]",Kaiser,,80.15,67,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9MM 100MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704999,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 75MM TITANIUM THICK GASTROINTESTINAL THORACIC",SUP-TCT75,CDM,S27200284,LOCAL,0272,RC,,,both,,,3049.82,914.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2073.88,68,,,,,0,354.69,2592.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION DISTAL FEMORAL KNEE MODULAR TRIATHLON",SUP-5575-X-000,CDM,C1776,HCPCS,0278,RC,,,both,,,1891.66,567.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,224.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,220,1607.91,"percent of total billed charges",
"STAPLE BONE 10X10MM FUSEFORCE HAND STERILE",SUP-FFNS1010,CDM,C1713,HCPCS,0278,RC,,,both,,,5582.10,1674.63,"FIRST HEALTH [10303]","First Health",,4465.68,80,,,,,0,649.2,4744.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 5MM 12MM LCP TITANIUM FULL THREAD DISTAL",SUP-402.812,CDM,C1713,HCPCS,0278,RC,,,both,,,380.02,114.01,"NOVANET [10819]",Novanet,,285.02,75,,,,,0,44.2,323.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 54MM 2 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800254,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"SCREW BONE L48MM DIA5MM CARBURIZED VARIABLE ANGLE LOCKING SE",SUP-42.231.248,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"PHCS [10601]",PHCS,,946.78,70,,,,,0,157.3,1149.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM TITANIUM LEVEL 1 ASSURE BONE SPINE CERVICAL",SUP-110.114,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PHCS [10601]",PHCS,,2940,70,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 32-37MM TITANIUM 4.75MM SCR MULTISPAN XLNK BONE SPINE",SUP-5442132,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,561.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",561.73,4105.5,"percent of total billed charges",
"DYNABRIDGE LAPILOCK KIT",SUP-DB-LL-7000,CDM,C1713,HCPCS,0278,RC,,,both,,,28350.00,8505,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7654.5,27,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM UNIVERSAL 25MM STAINLESS STEEL 2.7/3.5MM SCR 4",SUP-40240425,CDM,C1713,HCPCS,0278,RC,,,both,,,15000.60,4500.18,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6165.25,41.1,,,,,0,1744.57,12750.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 3.5 MM SCREWS 2 HOLE LOW PROFILE",SUP-02.100.302S,CDM,C1713,HCPCS,0278,RC,,,both,,,1800.00,540,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,515.16,28.62,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 54MM TITANIUM 3 LEVEL ASSURE BONE SPINE CERVICAL",SUP-110.354,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"FIRST HEALTH [10303]","First Health",,4233.6,80,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 26MM COCR",SUP-VAL-20260-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"FIRST HEALTH [10303]","First Health",,1140.48,80,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 32MM PERIPHERAL STERILE",SUP-AR-9562-32NL,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"CIGNA [10200]",Cigna,,406.22,68,,1831.33,1831.33,1831.33,16,69.48,507.77,"percent of total billed charges",
"SCR BONE 18MM ACUTRAK 2 TITANIUM MINI ORTHOPEDIC STERILE",SUP-AT2-M18-S,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,912.26,28.62,,,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE REGENESORB 20MM 7MM OPEN ARCHITECTURE",SUP-72204394,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1273.28,45.9,,,,,0,322.62,2357.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM CD HORIZON VOYAGER SPINE MULTIAXIAL",SUP-55850015535,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"AETNA [10100]","Aetna HMO/PPO",,5211.23,79.5,,1521.93,481.35,16760.95,30,762.35,5571.75,"percent of total billed charges",
"SCR BONE 7.5MM 50MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840007550,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"ROD SPINAL 120MM 3.5MM ELLIPSE TITANIUM",SUP-182.802,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,647.19,45.9,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM WIDE BLADE RAMP 5.5MM",SUP-7541133,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8.5MM 9.5MM 270MM HUMERAL RIGHT MULTILOC INTRAMEDULLARY",SUP-04.018.270S,CDM,C1713,HCPCS,0278,RC,,,both,,,11172.76,3351.83,"NOVANET [10819]",Novanet,,8379.57,75,,,,,0,1299.39,9496.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM WIDE BLADE RAMP 5.5MM",SUP-7541133,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",348.9,2550,"percent of total billed charges",
"SCR BONE 2.7MM 20MM STAINLESS STEEL T8 METAPHYSEAL SELF TAP",SUP-02.118.520,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"BLUE CROSS [10001]","Blue Cross HMO",,205.37,39.2,,957.42,156.86,7483.26,51,60.93,445.32,"percent of total billed charges",
"SCR BONE 7.5MM 45MM PRECEPT SPINE POLYAXIAL NONSTERILE",SUP-8807545A,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"NAIL 8.5MM 9.5MM 270MM HUMERAL RIGHT MULTILOC INTRAMEDULLARY",SUP-04.018.270S,CDM,C1713,HCPCS,0278,RC,,,both,,,11172.76,3351.83,"MULTIPLAN [10600]",Multiplan,,9496.85,85,,,,,0,1299.39,9496.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD 1553200500 5.5 TICP4 NS STR LN 500MM",SUP-1553200500,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]",Cigna,,2998.8,68,,1831.33,1831.33,1831.33,16,512.88,3748.5,"percent of total billed charges",
"WASHER SPINAL MOUNTAINEER SPINE OCCIPITOCERVICAL LATERAL",SUP-188365000,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL LEGION 6 L 10DX10P KNEE SCR",SUP-71421754,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,957.42,156.86,7483.26,51,2014.9,14726.25,"percent of total billed charges",
"SUB BONE GRAFT XEMPLIFI DEMINERALIZE BONE MATRIX PLUS 10ML",SUP-8103.0210S,CDM,C1713,HCPCS,0278,RC,,,both,,,9301.20,2790.36,"MULTIPLAN [10600]",Multiplan,,7906.02,85,,,,,0,1081.73,7906.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM 1.1MM KIRSCHNER DART-FIRE",SUP-DSDS1011,CDM,C1713,HCPCS,0278,RC,,,both,,,191.40,57.42,"BLUE CROSS [10001]","Blue Cross HMO",,75.03,39.2,,957.42,156.86,7483.26,51,22.26,162.69,"percent of total billed charges",
"BLADE FIXATION 100MM LCP DHHS HIP STAINLESS STEEL",SUP-282.239,CDM,C1713,HCPCS,0278,RC,,,both,,,2658.38,797.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1807.7,68,,,,,0,309.17,2259.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 7",SUP-223.57,CDM,C1713,HCPCS,0278,RC,,,both,,,2041.20,612.36,"PHCS [10601]",PHCS,,1428.84,70,,,,,0,237.39,1735.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM POLYAXIAL 5.5MM ROD",SUP-8456555,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,563.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",563.19,4116.21,"percent of total billed charges",
"GWIRE ORTHOPEDIC 80CM 2.6MM BEAD TIP DISPOSABLE PHOENIX",SUP-14-410002,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BNDG TG FIX 25MR WHITE COMPRESSION LATEX WIDE MESH HIGHLY",SUP-568261,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.98,15.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,24.32,45.9,,,,,0,6.16,45.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 16X6MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2406,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3970.26,41.1,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW LOCK SCR ANATOMIC VARIAX BONE RADIUS RIGHT",SUP-54-25384,CDM,C1713,HCPCS,0278,RC,,,both,,,6383.05,1914.91,"BLUE CROSS [10001]","Blue Cross PPO",,2502.16,39.2,,957.42,570.23,957.42,28,742.35,5425.59,"percent of total billed charges",
"ANCHOR SUT 5.5MM BIO-SWIVELOCK SELF PUNCH 24.5MM STERILE",SUP-AR-2323PSLM,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.00,945,"CIGNA [10200]","Cigna Open Access",,1792.35,56.9,,1144.80,304.56,2275.09,66,366.35,2677.5,"percent of total billed charges",
"SCR BONE 7.3MM 120MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.920,CDM,C1713,HCPCS,0278,RC,,,both,,,1510.49,453.15,"NOVANET [10819]",Novanet,,1132.87,75,,,,,0,175.67,1283.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE .4MM 58MM UNIVERSAL NEURO III LARGE ROUND",SUP-53-00466,CDM,C1713,HCPCS,0278,RC,,,both,,,6807.20,2042.16,"CIGNA [10200]","Cigna Open Access",,3873.3,56.9,,1144.80,304.56,2275.09,66,791.68,5786.12,"percent of total billed charges",
"LEAD PACING 45CM 6FR J CURVE ATRIUM MRI PASSIVE FIXATION",SUP-7735,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CIGNA [10200]","Cigna Open Access",,1270.29,56.9,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 3.5MM RELINE-C PRE BENT TITANIUM NONSTERILE",SUP-3943040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"HOOK SPINAL 4.5MM LAMINA LEFT OFFSET",SUP-7756073L,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",348.9,2550,"percent of total billed charges",
"PLATE CONTOUR LOW BEND 102MM STAINLESS STEEL 3.5MM SCR 6",SUP-02.124.204,CDM,C1713,HCPCS,0278,RC,,,both,,,7998.48,2399.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,930.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",930.22,6798.71,"percent of total billed charges",
"ANCHOR SUT 1.9MM 1 SUTUREFIX ULTRA ULTRABRAID COBRAID",SUP-72203854,CDM,C1713,HCPCS,0278,RC,,,both,,,3025.28,907.58,"PHCS [10601]",PHCS,,2117.7,70,,,,,0,351.84,2571.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE FIXED ANGLE SELF TAPPING STERILE 4MM 13MM ATLANTIS",SUP-876-713,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.75MM 34MM TITANIUM PARTIAL THREAD SHOULDER",SUP-AR-7000-34,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"SCR BONE 6.5MM 50MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840006550,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3923.76,41.1,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHANTOM? HINDFOOT NAIL HEADLESS SCREW 7.2MM X 80MM",SUP-P31-772-080F,CDM,C1713,HCPCS,0278,RC,,,both,,,6582.60,1974.78,"BLUE CROSS [10001]","Blue Cross PPO",,2580.38,39.2,,957.42,570.23,957.42,28,765.56,5595.21,"percent of total billed charges",
"SCR BONE 2.7MM 44MM LCP STAINLESS STEEL ELBOW SELF TAPPING",SUP-02.211.044,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"BLUE CROSS [10001]","Blue Cross HMO",,352.07,39.2,,957.42,156.86,7483.26,51,104.45,763.41,"percent of total billed charges",
"BALLOON ENDOSCOPIC 8CM 75CM 30MM 16FR ESOPHAGUS CATH",SUP-G24893,CDM,C1726,HCPCS,0272,RC,,,both,,,2782.50,834.75,"NOVANET [10819]",Novanet,,2086.88,75,,,,,0,323.6,2365.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 60MM LCP STAINLESS STEEL PROXIMAL TIBIAL SELF",SUP-212.424,CDM,C1713,HCPCS,0278,RC,,,both,,,1158.79,347.64,"KAISER [10500]",Kaiser,,776.39,67,,,,,0,134.77,984.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE LEVEL ONE MEDIUM CURVE CRANIOFACIAL TITANIUM",SUP-25-153-21-09,CDM,C1713,HCPCS,0278,RC,,,both,,,2349.83,704.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,278.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",273.29,1997.36,"percent of total billed charges",
"WAX BONE 3.5GM WATER SOLUBLE MECHANICAL BARR ALKYLENE OXIDE",SUP-1503831,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.24,228.37,"PHCS [10601]",PHCS,,532.87,70,,,,,0,88.53,647.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 36MM COMPRESSION FT TITANIUM STD FULL THREAD",SUP-AR-8740-36H,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"PHCS [10601]",PHCS,,1837.5,70,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 28MM ACUMED TITANIUM THREADED DISTAL RADIAL",SUP-CO-T2328,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"BLUE CROSS [10001]","Blue Cross PPO",,298.47,39.2,,957.42,570.23,957.42,28,88.55,647.19,"percent of total billed charges",
"SCR BONE 3.5MM 34MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0268,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,110.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",110.22,805.55,"percent of total billed charges",
"SCR BONE 5MM 22MM LCP STAINLESS STEEL PROXIMAL MEDIAL TIBIAL",SUP-212.205,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"CIGNA [10200]",Cigna,,593.76,68,,1831.33,1831.33,1831.33,16,101.55,742.2,"percent of total billed charges",
"RELINE MAS-R SCREW,8.5X90MM POLYILIAC 2C",SUP-16028590,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"PLATE BONE .4MM UNIVERSAL NEURO III RECTANGLE",SUP-53-34300,CDM,C1713,HCPCS,0278,RC,,,both,,,2249.63,674.89,"NOVANET [10819]",Novanet,,1687.22,75,,,,,0,261.63,1912.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN SCREW 3.2MMX89MM FLUTED DISP",SUP-GS901.089.032-4P,CDM,C1713,HCPCS,0278,RC,,,both,,,605.48,181.64,"BLUE CROSS [10001]","Blue Cross HMO",,237.35,39.2,,957.42,156.86,7483.26,51,70.42,514.66,"percent of total billed charges",
"PLATE 11MM 1 LEVEL SAPPHIRE BONE SPINE CERVICAL ANTERIOR",SUP-26001-011,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"NOVANET [10819]",Novanet,,3150,75,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHALANX CORONAL TRANSFIXION SCREW 1.5MM X 8.0MM COCR",SUP-PTS-15008-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.90,337.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,133.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",130.94,957.02,"percent of total billed charges",
"SMOOTH PEG LOCKING 6.0MM X 42MM TI",SUP-SPL-60420-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL TAN 100MM 10.35MM TFN-ADVANCED",SUP-04.038.400S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,463.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",463.09,3384.57,"percent of total billed charges",
"SCR BONE 6.5MM 25MM COMPREHENSIVE 3.5MM CENTRAL HEXAGON",SUP-115395,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,445.33,28.62,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM MAS SPINE CANNULATED EXT TAB 4.75MM ROD",SUP-54850017540,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"CIGNA [10200]","Cigna Local Plus",,3506.93,53.5,,3978.14,359.25,3978.14,24,762.35,5571.75,"percent of total billed charges",
"SCREW DISTRACTION 12MM STERILE DISPOSABLE",SUP-73-2591-S5,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,170.52,39.2,,957.42,156.86,7483.26,51,50.59,369.75,"percent of total billed charges",
"SCR BONE 2.7MM 18MM GORILLA R3CON LOCK",SUP-P50-353-2718,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",155.43,1136.03,"percent of total billed charges",
"SCR BONE 6.5MM 45MM CREO CREO AMP SPINE MODULAR",SUP-1067.1645,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS [10001]","Blue Cross PPO",,3742.37,39.2,,957.42,570.23,957.42,28,1110.3,8114.82,"percent of total billed charges",
"PLATE LONG CONTOUR 162MM STAINLESS STEEL 19 HOLE LOW PROFILE",SUP-4953110R,CDM,C1713,HCPCS,0278,RC,,,both,,,8521.50,2556.45,"AETNA [10100]","Aetna HMO/PPO",,6774.59,79.5,,1521.93,481.35,16760.95,30,991.05,7243.28,"percent of total billed charges",
"PLATE 38MM STAINLESS STEEL 2MM SCR MINI FRAGMENT SET 5 HOLE",SUP-247.345,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM CD HORIZON LEGACY TITANIUM PEDICLE BREAKOFF",SUP-7540020,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"NOVANET [10819]",Novanet,,1804.95,75,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 34MM 1 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800134,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",521.61,3812.25,"percent of total billed charges",
"SCR BONE 4MM 24MM VERTEX MAX TITANIUM SPINE MULTIAXIAL BLUE",SUP-6958824,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1927.8,45.9,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 140MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS",SUP-654000140,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]",Cigna,,1101.6,68,,1831.33,1831.33,1831.33,16,188.41,1377,"percent of total billed charges",
"STEM FEMORAL 140MM 18MM REVISION 20 GRIT BLAST SURFACE",SUP-197618140,CDM,C1776,HCPCS,0278,RC,,,both,,,17952.48,5385.74,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4847.17,27,,,,,0,2087.87,15259.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 3.6MM TWIST STERILE",SUP-KM166-10-05,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RADPICC RADSTIC 70CM 3FR IV TUNGSTEN POLYURETHANE 1",SUP-3163155,CDM,C1751,HCPCS,0272,RC,,,both,,,379.32,113.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PENICILLIN V POTASSIUM 250 MG TABLET",RX-6092,CDM,,,0250,RC,57237-0040-01,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACK SURGICAL IVTM QUATTRO SOLEX 7 START UP DISPOSABLE 6FT",SUP-8700-000868-01,CDM,C1751,HCPCS,0272,RC,,,both,,,28649.19,8594.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SUT ETHILON 4-0 PS-2 18IN MONOFILAMENT GREEN NONABSORBABLE",SUP-G667G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GROSHONG PEEL-APART SURECUFF 8FR CENTRAL VENOUS",SUP-7711800,CDM,C1751,HCPCS,0272,RC,,,both,,,1620.00,486,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,665.82,41.1,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cytpath Fna I&R",PX-311000013,CDM,88173,CPT,0311,RC,,,both,,,539.60,161.88,"PHCS [10601]",PHCS,,377.72,70,,,,,0,0.54,458.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 50MM 7MM TITANIUM FOOT HEADLESS",SUP-DC001650,CDM,C1713,HCPCS,0278,RC,,,both,,,4629.90,1388.97,"BLUE CROSS [10001]","Blue Cross HMO",,1814.92,39.2,,957.42,156.86,7483.26,51,538.46,3935.42,"percent of total billed charges",
"HC Thrpy Txcath Art Inf Init Day",PX-361000276,CDM,37211,CPT,0361,RC,,,both,,,4940.57,1482.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4940.57,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,574.59,4940.57,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Txcath Art Inf Init Day",PX-361000276,CDM,37211,CPT,0361,RC,,,both,,,4940.57,1482.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,574.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,574.59,4940.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC",057,MS-DRG,,,,,,,inpatient,,,42657.30,12797.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,21001.68,,"Fee schedule rate ($21,001.68). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,32310.97,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 30CM 16FR TUNGSTEN SILICONE MIC-KEY",SUP-0270-16-2.7-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,311.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 12CMX8CMX.8MM DERMACELL AWM DERMIS",SUP-DCELL159,CDM,Q4122,HCPCS,0636,RC,,,both,,,44775.68,13432.7,"CIGNA [10200]","Cigna Open Access",,25477.36,56.9,,,,,0,5305.92,38059.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) HELO PE THROMBECTOMY CATHETER, GEN 2",SUP-10002,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 16.25MM 1.5MM AXIUS CORONARY INTERNAL",SUP-OF-1500,CDM,S27200284,LOCAL,0272,RC,,,both,,,813.05,243.91,"KAISER [10500]",Kaiser,,544.74,67,,,,,0,94.56,691.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT UTERINE NOVASURE V5",SUP-NSV5KITUS-003,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Open Access",,3926.1,56.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 130CM 250MM 5MM BALLOON DILATATION",SUP-ADM05025013P,CDM,C2623,HCPCS,0272,RC,,,both,,,14007.00,4202.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9524.76,68,,,,,0,1629.01,11905.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE STIM SONOPLEX CANN TIP ULTRASOUND WAVE ECHOGENIC",SUP-001187-74,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.62,34.09,"MULTIPLAN [10600]",Multiplan,,96.58,85,,,,,0,13.21,96.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 80CM 60MM 5MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV05006008P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,956.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL ENDOSCOPIC LINEAR CUTTER RELOADABLE 100X3.8MM",SUP-GIA10038S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1456.38,436.91,"NOVANET [10819]",Novanet,,1092.29,75,,,,,0,169.38,1237.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MONARQ TTVR SYSTEM MEDIUM IMPLANT",SUP-DWG-4700,CDM,S62400003,LOCAL,0624,RC,,,both,,,182400.00,54720,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21614.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 130CM 120MM 4MM BALLOON DILATATION",SUP-LX3513041205F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"FIRST HEALTH [10303]","First Health",,5382,80,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 16FR 20CM HYDROPHILIC RADIOPAQUE STERILE",SUP-G10206,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,45.49,68,,,,,0,7.78,56.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bag Infusor Pressure",PX-E27000046,CDM,E27000046,LOCAL,0270,RC,,,both,,,157.30,47.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,72.2,45.9,,,,,0,18.29,133.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ZEBRA 6F  115CM ACCESS SYSTEM SIM2",SUP-AC6074-115-30,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"FIRST HEALTH [10303]","First Health",,7148.4,80,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 1300MM 150MM 4MM BALLOON DILATATION",SUP-ADM04015013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,956.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sensor Pulse Ox Peds",PX-E27000153,CDM,E27000153,LOCAL,0270,RC,,,both,,,110.55,33.16,"CIGNA [10200]","Cigna Local Plus",,59.14,53.5,,,,,0,12.86,93.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CRIMPER",SUP-PRO-5934,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SINGLE COMMERCIAL SYSTEM -READER KIT, DELIVERY SYSTEM",SUP-CRDLA001US,CDM,S62400003,LOCAL,0624,RC,,,both,,,116850.00,35055,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,79458,68,,,,,0,13589.66,99322.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg WO Vid Ea 12-26hr Unmntr",PX-740000043,CDM,95708,CPT,0740,RC,,,both,,,4168.00,1250.4,"CIGNA [10200]","Cigna Open Access",,2371.59,56.9,,,,,0,484.74,3542.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM TRIATHLON 7 LEFT MEDIAL RIGHT LATERAL TOTAL",SUP-5545-A-701,CDM,C1776,HCPCS,0278,RC,,,both,,,4327.60,1298.28,"BLUE CROSS [10001]","Blue Cross HMO",,1696.42,39.2,,5311.50,4717.44,5388.59,31,503.3,3678.46,"percent of total billed charges",
"SCR BONE 6.5MM 40MM CD HORIZON SPINAL FENESTRATE MULTIAXIAL",SUP-55840026540T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"STENT CONTOUR SENSOR DUAL-FLEX 20CM 3CM 7FR .035IN PIGTAIL",SUP-M006180230190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS [10001]","Blue Cross HMO",,496.03,39.2,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,inpatient,,,45402.67,13620.8,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,22041.78,,"Case rate ($10,824.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,051.71, add-ons for qualifying new technology services are included. If operating cost exceeds $43,091.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,141.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,065.00. The transfer operating threshold is the transfer adjustment factor * $10,051.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.96. The transfer capital threshold is the transfer adjustment factor * $759.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,1958,43521.05,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 32MM CANNULATED IFUSE IMPL SYSTEM 7MM",SUP-500076,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1815.99,45.9,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MINAMO VASCULAR 190CM .014IN STERILE LATEX FREE",SUP-AH14R026S,CDM,C1769,HCPCS,0272,RC,,,both,,,810.00,243,"UHC [10700]","United Healthcare",,512.73,63.3,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE ANXIETY AND STRESS SYNDROMES,EXTREME",756,APR-DRG,,,,,,,inpatient,,,60336.89,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $7,223.73. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($43,385.01) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTICROSS HD ULTRASOUND CORONARY BAGLESS NONCE IMAGE",SUP-H74939352050,CDM,C1753,HCPCS,0272,RC,,,both,,,5037.00,1511.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH THERMOSET MNTR 3 WAY STPCOCK THERMODILUTION THERMAL",SUP-41424-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.31,28.89,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 75X25MM 3 TONGUE DAVIS",SUP-45-5113,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.96,81.59,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE DESTINATION TUOHY-BORST STRAIGHT 90CM 60CM 8",SUP-54-89006,CDM,C1894,HCPCS,0272,RC,,,both,,,785.70,235.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAMP SURGICAL MEDIUM VENOUS 2","SUP-GEM TKMV-2",CDM,S27200284,LOCAL,0272,RC,,,both,,,582.39,174.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTESTINAL OBSTRUCTION,MAJOR",247,APR-DRG,,,,,,,inpatient,,,33126.21,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $7,152.09. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($48,733.80) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 92CM 4MM 6FR 2-5-2MM SPACE D CURVE",SUP-D6TDL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC QUANTUM APEX 143CM 20MM 2.75MM BALLOON DILATATION",SUP-H7493912420270,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND 2-0 SH 30IN CONTROL RELEASE BRAID 8",SUP-C016D,CDM,S27200284,LOCAL,0272,RC,,,both,,,112.10,33.63,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DORADO CHECKER 80CM 6CM 8MM BALLOON DILATATION",SUP-DR8086,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"MULTIPLAN [10600]",Multiplan,,1170.45,85,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM FIBERTAG TIGHTROPE II FLIPCUTTER III FIBERSNARE",SUP-AR-1288RTT2-FC3,CDM,C1713,HCPCS,0278,RC,,,both,,,7353.68,2206.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3375.34,45.9,,,,,0,855.23,6250.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752720,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,106.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 100MM 5MM BALLOON DILATATION DURALYN",SUP-48005010S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT 7.5IN RHOTON 45D BALL SURGICAL 4MM",SUP-58-6072,CDM,S27200284,LOCAL,0272,RC,,,both,,,524.07,157.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.95,445.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ERTAPENEM 500 MG VIAL IV PUSH (1 G VIAL)",RX-408331,CDM,J1335,HCPCS,0636,RC,16714-0889-01,NDC,both,1,UN,733.31,219.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,22.98,,,,,,,21.52,623.31,"fee schedule",
"LINER ACETABULAR PINNACLE 10D +4MM 58MM 32MM MARATHON HIP",SUP-121932158,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2321.35,28.62,,,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Ven Single Stage 40f",PX-E27200372,CDM,E27200372,LOCAL,0272,RC,,,both,,,144.10,43.23,"AETNA [10100]","Aetna HMO/PPO",,114.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.76,122.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON SUPRAMID EXTRA II 4-0 BB 12IN LOOPED MONOFILAMENT",SUP-HEA-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.92,41.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,64.22,45.9,,,,,0,16.27,118.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT GLENOID PATIENT SPECIFIC INSTRUMENTATION AB",SUP-98B00900133,CDM,C1776,HCPCS,0278,RC,,,both,,,54810.00,16443,"UHC [10700]","United Healthcare",,34694.73,63.3,,8601.07,8395.67,8601.07,"1 through 10",6374.4,46588.5,"percent of total billed charges",
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 40MMX12MMX20CM 26FR",SUP-TAC124020A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"FIRST HEALTH [10303]","First Health",,145920,80,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2MM SMALL 6.75IN SPRAGUE EAR SURGICAL",SUP-61-0015,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.05,81.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.41,229.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 18MM 3.75MM EMBOLIZATION",SUP-PED2-375-18,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9574.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA 5D H KNEE LEFT CEMENT STEM TIVANIUM",SUP-42532008301,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7434.94,68,,,,,0,1271.59,9293.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 135CM 30MM 6MM .035IN BALLOON",SUP-AB35W06030135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"MULTIPLAN [10600]",Multiplan,,575.59,85,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 8MM 3.5MM CORONARY STENT COCR RAPID",SUP-1007849-08,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 12IN 2 PORT 1 BLADDER PUMP LINE CNCT ATS DURABLE",SUP-60707010200,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"FIRST HEALTH [10303]","First Health",,59.16,80,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 30ML .5-5MM 80% CORTICAL 20% CANCELLOUS",SUP-450776,CDM,C1713,HCPCS,0278,RC,,,both,,,3184.88,955.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,377.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,370.4,2707.15,"percent of total billed charges",
"HC Analysis Dev Pcmkr Sys",PX-480000058,CDM,93288,CPT,0480,RC,,,both,,,328.65,98.59,"PHCS [10601]",PHCS,,230.06,70,,,,,0,38.22,328.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 14MM CANNULATED LARGE QUICK COUPLING FLEXIBLE",SUP-03.033.004,CDM,S27200284,LOCAL,0272,RC,,,both,,,4724.98,1417.49,"NOVANET [10819]",Novanet,,3543.74,75,,,,,0,549.52,4016.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 28MM 144CM 2.75MM CORONARY STENT PEBAX",SUP-H7493926028270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross HMO",,2181.48,39.2,,9776.84,9776.84,9776.84,"1 through 10",647.21,4730.25,"percent of total billed charges",
"SCR INTERFERENCE 30MM 11MM 60 FULL THREAD COMPOSITCP",SUP-905263,CDM,C1713,HCPCS,0278,RC,,,both,,,3075.00,922.5,"CIGNA [10200]","Cigna Open Access",,1749.68,56.9,,1144.80,304.56,2275.09,66,357.62,2613.75,"percent of total billed charges",
"SHELL ACETABULAR 50MM HIP 3 HOLE QUADRANT GROUP C BIOFOAM",SUP-DBFPGC50,CDM,C1776,HCPCS,0278,RC,,,both,,,18194.40,5458.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2116.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2116.01,15465.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 280016 UNCRT DWL 16MM SRVC FEE",SUP-280016,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 37MM 80CM 5MM 40MM BILIARY STAINLESS STEEL",SUP-PXB35-05-37-080,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"FIRST HEALTH [10303]","First Health",,3493.6,80,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE EMERALD VASCULAR BENSTON LLT CURVE 150CM 20CM .035IN",SUP-502560,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"FIRST HEALTH [10303]","First Health",,76.56,80,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION",RX-170282,CDM,J0714,HCPCS,0636,RC,00456-2700-01,NDC,both,1,UN,2507.14,752.14,"BLUE CROSS [10001]","Blue Cross HMO",,488.25,,,,,,,297.1,2131.07,"fee schedule",
"LENS IOL 5 D +17 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1700,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 12X18MM FORTIFY DEPTH 12MM NONSTERILE LATEX",SUP-151.050,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9186.59,28.62,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM FEMORAL POROUS HIP",SUP-OSC366414,CDM,C1776,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Local Plus",,3322.35,53.5,,5372.07,4581.20,7242.98,23,722.22,5278.5,"percent of total billed charges",
"SCR BONE 2.5MM 16MM TITANIUM COMPRESSION CANNULATED",SUP-04.333.116,CDM,C1713,HCPCS,0278,RC,,,both,,,2518.50,755.55,"CIGNA [10200]","Cigna Local Plus",,1347.4,53.5,,3978.14,359.25,3978.14,24,292.9,2140.73,"percent of total billed charges",
"STEM HUMERAL 175MM 10MM SMALL SHELL REVISION ALTIVATE",SUP-533-10-175,CDM,C1776,HCPCS,0278,RC,,,both,,,43228.40,12968.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5122.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5027.46,36744.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE ZIPWIRE VASCULAR 260CM 3CM .035IN HYDROPHILIC",SUP-M00146154B1,CDM,C1769,HCPCS,0272,RC,,,both,,,312.66,93.8,"MULTIPLAN [10600]",Multiplan,,265.76,85,,,,,0,36.36,265.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 65CM 10MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1065CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"FIRST HEALTH [10303]","First Health",,6348,80,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERTORQUE PLUS 110CM 5.2FR PIGTAIL CURVE ANGIOGRAPHIC",SUP-533533,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"CIGNA [10200]","Cigna Open Access",,46.83,56.9,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VEIN DISTENTION GRAFT TUNNELING",SUP-26050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1278.75,383.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,869.55,68,,,,,0,148.72,1086.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 420MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.062S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CIGNA [10200]","Cigna Open Access",,4160.14,33.5,,1144.80,304.56,2275.09,66,1444.25,10555.59,"percent of total billed charges",
"CAGE SPINAL 17X8MM 14MM LORDOTIC NARROW PROFILE",SUP-G6626748,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1444.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL 60CC ALLOGRAFT BULK 55MM",SUP-800128,CDM,S27800098,LOCAL,0278,RC,,,both,,,14161.56,4248.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3823.62,27,,,,,0,1646.99,12037.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +2.5MM 26MM HIP C TAPER INTERLOK COCR LFIT",SUP-S-1400-HH62,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA [10200]","Cigna Local Plus",,1673.32,53.5,,5372.07,4581.20,7242.98,23,363.75,2658.55,"percent of total billed charges",
"FRCP SURGICAL 8IN 1.5MM BAYONET TIP",SUP-20-1410,CDM,S27200284,LOCAL,0272,RC,,,both,,,276.32,82.9,"AETNA [10100]","Aetna HMO/PPO",,219.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.14,234.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BARR ADHESION 5X3IN BIORESORBABLE 2 SHEET DEHP FREE",SUP-6642-01,CDM,C1765,HCPCS,0278,RC,,,both,,,4258.56,1277.57,"NOVANET [10819]",Novanet,,3193.92,75,,,,,0,495.27,3619.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 65CM RVOT KIT MOND STAINLESS STEEL WIDE",SUP-4151/65,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"KAISER [10500]",Kaiser,,385.32,67,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX SPIRAL MONOCRYL PLUS 3-0 PS-1 SPIRAL 30CM",SUP-SXMP1B101,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.03,65.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,89.61,41.1,,,,,0,25.36,185.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 64MM HIP MULTIHOLE RIM TRITANIUM X3 MDM",SUP-509-02-64G,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4616.35,41.1,,6417.48,6417.48,6417.48,"1 through 10",1306.28,9547.2,"percent of total billed charges",
"SCR BONE 5MM 80MM AXSOS OMEGA3 STAINLESS STEEL T20 FEMUR",SUP-370380,CDM,C1713,HCPCS,0278,RC,,,both,,,1376.51,412.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,393.96,28.62,,,,,0,160.09,1170.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE COBALT GENTAMICIN 40GM HIGH VISCOSITY STERILE",SUP-402283,CDM,C1713,HCPCS,0278,RC,,,both,,,2340.00,702,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,669.71,28.62,,,,,0,272.14,1989,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25.5X9.5X.6MM THIN OSCILLATING SAGITTAL STERILE",SUP-KM-3101C,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"NOVANET [10819]",Novanet,,46.33,75,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SUT NO5 MAXBRAID CURVED TAPERED NDL NONABSORBABLE 2PK",SUP-CM0225N,CDM,S27200284,LOCAL,0272,RC,,,both,,,737.10,221.13,"CIGNA [10200]",Cigna,,501.23,68,,,,,0,85.72,626.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BREAST BIOPSY 9GA STD INTRO LOCALIZATION ATEC 0914-20MR","SUP-ILS 0914-20",CDM,S27200284,LOCAL,0272,RC,,,both,,,1571.40,471.42,"AETNA [10100]","Aetna HMO/PPO",,1249.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,182.75,1335.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 22MM 3.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG35022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA [10200]",Cigna,,1836,68,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 41X14X.38MM HALL MICRO STAINLESS STEEL SAGITTAL",SUP-5301025033,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.29,43.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,98.8,68,,,,,0,16.9,123.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +6MM OFFSET 32MM HIP TYPE 1 MODULAR COCR G7",SUP-110025134,CDM,C1776,HCPCS,0278,RC,,,both,,,9255.66,2776.7,"UHC [10700]","United Healthcare",,5858.83,63.3,,8601.07,8395.67,8601.07,"1 through 10",1076.43,7867.31,"percent of total billed charges",
"SUT NUROLON 1 CT-1 30IN BRAID BLACK NONABSORBABLE",SUP-5425H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 390MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.458S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"KAISER [10500]",Kaiser,,5569.33,67,,,,,0,966.74,7065.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP MULTIHOLE R3 STD STERILE",SUP-71338666,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"CIGNA [10200]","Cigna Local Plus",,5004.48,31.5,,5372.07,4581.20,7242.98,23,1847.69,13504.16,"percent of total billed charges",
"HC Plc Extracranial Vert Stent Init",PX-361000005,CDM,0075T,CPT,0361,RC,,,both,,,18245.72,5473.72,"BLUE CROSS [10001]","Blue Cross HMO",,4025.22,,"Case rate ($4,025.22). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2121.98,15508.86,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Extracranial Vert Stent Init",PX-361000005,CDM,0075T,CPT,0361,RC,,,both,,,18245.72,5473.72,"PHCS [10601]",PHCS,,12772,70,,,,,0,2121.98,15508.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Extracranial Vert Stent Init",PX-361000005,CDM,0075T,CPT,0361,RC,,,both,,,18245.72,5473.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2795.56,,"Fee schedule rate ($2,795.56).",,,,0,2121.98,15508.86,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 26X9X10MM CONDUIT 12D STRAIGHT EIT ROUGH ELEVATE",SUP-PUI31006,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 19MM 80CM 6MM 8MM 7FR .035IN",SUP-BXA061901A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC",981,MS-DRG,,,,,,,inpatient,,,173901.28,52170.38,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,31140.77,,"Case rate ($29,103.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $27,024.59, add-ons for qualifying new technology services are included. If operating cost exceeds $60,064.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,425.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $27,060.33. The transfer operating threshold is the transfer adjustment factor * $27,024.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,043.19. The transfer capital threshold is the transfer adjustment factor * $2,043.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,10994,136981.79,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,inpatient,,,53611.13,16083.34,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,19127.3,,"Case rate ($17,875.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $16,599.06, add-ons for qualifying new technology services are included. If operating cost exceeds $49,638.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,636.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $16,621.01. The transfer operating threshold is the transfer adjustment factor * $16,599.06 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,254.97. The transfer capital threshold is the transfer adjustment factor * $1,254.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,53611.13,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC ZONENAVIGATOR LEFT POSTERIOR MIDDLE",SUP-AR-7910L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1275.75,382.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,867.51,68,,,,,0,148.37,1084.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PRECISION ALLOGRAFT FREEZE DRIED 26MMX18MM",SUP-439018,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 24IN 2 PORT 1 BLADDER WITHOUT SLEEVE ATS STERILE",SUP-60707010400,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"NOVANET [10819]",Novanet,,55.46,75,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .018IN 4FR 7MM 135CM 4CM PTA LOW",SUP-G50257,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON SUPRAMID EXTRA 2-0 GS-1 30IN MONOFILAMENT WHITE",SUP-2GS-1-30W,CDM,S27200284,LOCAL,0272,RC,,,both,,,160.23,48.07,"NOVANET [10819]",Novanet,,120.17,75,,,,,0,18.63,136.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 100MM 6MM BALLOON DILATATION DURALYN",SUP-48006010S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"NOVANET [10819]",Novanet,,941.63,75,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE CARDIOFORM SEPTAL OCCLUDER 20MM 10FR",SUP-00733132631018,CDM,C1817,HCPCS,0278,RC,,,both,,,60826.50,18247.95,"UHC [10700]","United Healthcare",,38503.17,63.3,,,,,0,7074.12,51702.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 16MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P516,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,990.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,971.79,7102.52,"percent of total billed charges",
"MESH SURGICAL 3DMAX 6.2X4.1IN ABDOMINAL LEFT MONOFILAMENT",SUP-0117311,CDM,C1781,HCPCS,0278,RC,,,both,,,1008.80,302.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.32,857.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTP W1TR03 SOLARA CRTP MRI US",SUP-W1TR03,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9236.16,40,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ttvr Perc Approach 1st Prosthe",PX-360000058,CDM,0569T,CPT,0360,RC,,,both,,,23074.95,6922.48,"KAISER [10500]",Kaiser,,15460.22,67,,,,,0,2491,19613.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 24/26FR STERILE DISPOSABLE",SUP-27040GP1-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3100.64,930.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1423.19,45.9,,,,,0,360.6,2635.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X5MM ADVANCED CONVEX SPINE",SUP-17805,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross HMO",,3245.76,39.2,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Phenotype Inf Agt Drug",PX-306000189,CDM,87900,CPT,0306,RC,,,both,,,3697.40,1109.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,3142.79,"per diem",
"COIL EMBOLIZATION 2.5CM 2MM .01IN MICRUSFRAME .0105IN MICRO",SUP-MFR100202,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"KAISER [10500]",Kaiser,,7960.81,67,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM STALIF C NO-PROFILE ABO TITANIUM STD SPINE",SUP-ABS1440,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,269.03,28.62,,,,,0,109.32,799,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 80MM 80CM 14MM 6FR .035IN BILIARY NITINOL",SUP-G36236,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"AETNA [10100]","Aetna HMO/PPO",,3005.1,79.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE TITANIUM 5 HOLE LOW PROFILE VARIAX SMARTLOCK",SUP-40-15013,CDM,C1713,HCPCS,0278,RC,,,both,,,4614.17,1384.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,536.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",536.63,3922.04,"percent of total billed charges",
"MARKER TUMARK BREAST BIOPSY PROFESSIONAL Q BREVERA PETITE",SUP-TUMARK-BREV-P-Q-02,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,77.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION",RX-9603,CDM,J0743,HCPCS,0636,RC,63323-0322-01,NDC,both,1,UN,226.52,67.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.68,,"Fee schedule rate ($16.68). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.68,192.54,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION",RX-9603,CDM,J0743,HCPCS,0636,RC,63323-0322-01,NDC,both,1,UN,226.52,67.96,"KAISER [10500]",Kaiser,,151.77,67,,,,,0,16.68,192.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC SMALL 8IN WRIST LEFT COCK UP CLSR VELCRO",SUP-5059-06,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.06,33.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.03,95.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 1.5IN RICHARDSON 1.5IN LOOP HANDLE SURGICAL",SUP-202-157,CDM,S27000186,LOCAL,0270,RC,,,both,,,197.32,59.2,"CIGNA [10200]","Cigna Open Access",,112.28,56.9,,,,,0,22.95,167.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 76X51MM PFC SIGMA 4 KNEE CEMENT MODULAR PLUS FIX",SUP-860124,CDM,C1776,HCPCS,0278,RC,,,both,,,16046.64,4813.99,"BLUE CROSS [10001]","Blue Cross PPO",,6290.28,39.2,,3949.44,3949.44,3949.44,"1 through 10",1866.22,13639.64,"percent of total billed charges",
"HC Bx Endometrial",PX-361000465,CDM,58100,CPT,0361,RC,,,both,,,567.46,170.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,567.46,,"Case rate ($4,937). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,66,567.46,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2-0 SMALL BRAID SWEDGE LOW KNOT PROFILE",SUP-AR-7223SM,CDM,S27200284,LOCAL,0272,RC,,,both,,,612.36,183.71,"PHCS [10601]",PHCS,,428.65,70,,,,,0,71.22,520.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +24 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-ZA90030240,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 4FR 20CM RADIOPAQUE GWIRE STERILE DISPOSABLE",SUP-G02366,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.99,22.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.72,63.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER COMPRESSION XL FOOT IMPAD A-V IMPULSE SYSTEM RIGID",SUP-5107,CDM,S27000186,LOCAL,0270,RC,,,both,,,316.72,95.02,"MULTIPLAN [10600]",Multiplan,,269.21,85,,,,,0,36.83,269.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAYONET 9IN CURVE TIP DN6219",SUP-DN6219,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"UHC [10700]","United Healthcare",,1025.46,63.3,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP 42MM 160CM 10MM 135CM ENDOPROSTHESIS",SUP-M001711350,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"FIRST HEALTH [10303]","First Health",,6762,80,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 7X11X35MM 12",SUP-5871352,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3412.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR AVENIR COMPLETE 5 STD HIP STERILE LATEX",SUP-574201050,CDM,C1776,HCPCS,0278,RC,,,both,,,23461.20,7038.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6334.52,27,,,,,0,2728.54,19942.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 NARROW KNEE LEFT CEMENTED CRUCIATE RETAINING",SUP-150400126,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8957.34,40,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO CYBERWAND RENAL BLADDER ULTRASONIC STERILE",SUP-CW-USLRBP,CDM,S27200284,LOCAL,0272,RC,,,both,,,4583.05,1374.91,"MULTIPLAN [10600]",Multiplan,,3895.59,85,,,,,0,533.01,3895.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 102.5MM TYPE 1 TAPERLOC MICROPLASTY PPS 133D 9",SUP-51106090,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11275.88,41.1,,6417.48,6417.48,6417.48,"1 through 10",3190.72,23319.95,"percent of total billed charges",
"SCR BONE 2.3MM 14MM TITANIUM DISTAL RADIAL CORTICAL WRIST",SUP-CO-T2314,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,217.91,28.62,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY 15CM 11GA TREK BONE MARROW AUTOMATIC BRAKE",SUP-TKM1115,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"UHC [10700]","United Healthcare",,1068.19,63.3,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 405CC 11.2CM 5.6CM PROJECTION HIGH PROFILE SM",SUP-SHPB405,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,903.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",886.73,6480.83,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 20CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155240190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"MULTIPLAN [10600]",Multiplan,,1207.29,85,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AVIATOR PLUS 142CM 30MM 4MM .014IN BALLOON DILATATION",SUP-4244030W,CDM,C1725,HCPCS,0272,RC,,,both,,,1438.80,431.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,978.38,68,,,,,0,167.33,1222.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 18CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192115010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,142.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 POPLOK HI-FI KNOTLESS SUBCORTICAL WING",SUP-CKP-4502,CDM,C1713,HCPCS,0278,RC,,,both,,,3653.25,1095.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1045.56,28.62,,,,,0,424.87,3105.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Sincalide 5ug",PX-636000011,CDM,J2805,HCPCS,0636,RC,,,both,,,313.59,94.08,"BLUE CROSS [10001]","Blue Cross PPO",,143.78,,,,,,,47.48,296.12,"fee schedule",
"HC Inj Sincalide 5ug",PX-636000011,CDM,J2805,HCPCS,0636,RC,,,both,,,313.59,94.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,214.75,,,,,,,47.48,296.12,"fee schedule",
"DEVICE BARD PRESSURE MNTR INTRAABDOMINAL KIT FOLEY CATH",SUP-IAP001,CDM,S27200284,LOCAL,0272,RC,,,both,,,589.28,176.78,"NOVANET [10819]",Novanet,,441.96,75,,,,,0,68.53,500.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +34 DIOPTER MODIFIED C BICONVEX 13MM 6MM POSTERIOR",SUP-PCB0000340,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LC BEAD LUMI SIZE 40 - 90 MICRON",SUP-RO2L000,CDM,S27800098,LOCAL,0278,RC,,,both,,,20475.00,6142.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8190,40,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 74MM 4 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800474,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL L HOOK STD 32CM 5MM STERILE",SUP-60-5163-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,251.69,75.51,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.27,213.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 56MM 26MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-56-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,502.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 55MM KNEE RIGHT CRUCIATE RETAINING CEMENTED",SUP-183000,CDM,C1776,HCPCS,0278,RC,,,both,,,19467.00,5840.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2306.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2264.01,16546.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 3CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175284010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CIGNA [10200]","Cigna Local Plus",,572.85,,,,,,,124.53,910.13,"percent of total billed charges",
"STENT 22CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX TAPER TIP",SUP-M0061453500,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,73.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL E STD 68X61.5MM KNEE RIGHT POSTERIOR STABILIZE",SUP-599201502,CDM,C1776,HCPCS,0278,RC,,,both,,,15214.50,4564.35,"KAISER [10500]",Kaiser,,10193.72,67,,,,,0,1769.45,12932.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD CURVE .6MM MIDFACE 4 HOLE BAR 1.7MM SCR BONE",SUP-55-06754,CDM,C1713,HCPCS,0278,RC,,,both,,,1139.99,342,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,775.19,68,,,,,0,132.58,968.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Factor VIII 1 Stage",PX-305000018,CDM,85240,CPT,0305,RC,,,both,,,563.11,168.93,"UHC [10700]","United Healthcare",,16.11,,,,,,,0.01,478.64,"fee schedule",
"IMPL BREAST 275ML GEL ROUND SMOOTH MEMORYGEL SILICONE P3CM","SUP-3507275 MC",CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"CIGNA [10200]","Cigna Open Access",,2031.33,56.9,,5166.00,5166.00,5166.00,"1 through 10",415.19,3034.5,"percent of total billed charges",
"SCR BONE 2.3MM 16MM VARIAX SMARTLOCK TITANIUM RADIUS DISTAL",SUP-52-23616,CDM,C1713,HCPCS,0278,RC,,,both,,,1513.32,454,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1029.06,68,,,,,0,176,1286.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.4CM MEMORYGEL BOOST P6.6CM HIGH PROFILE",SUP-RSZHPB775S,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"KAISER [10500]",Kaiser,,119.23,67,,,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SAPPHIRE 3 CORONARY DILATATION CATHETER 1.0 X 10MM",SUP-54100-100-02,CDM,C1725,HCPCS,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS INTRAOCULAR CLAREON TORIC ASPHERIC HYDROPHOBIC ACRYLIC",SUP-CNW0T6,CDM,V2787,HCPCS,0276,RC,,,both,,,355.00,106.5,"KAISER [10500]",Kaiser,,237.85,67,,,,,0,41.29,301.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 150MM .062IN TROCAR TIP DISPOSABLE",SUP-AR-8941K,CDM,C1769,HCPCS,0272,RC,,,both,,,130.50,39.15,"UHC [10700]","United Healthcare",,82.61,63.3,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2-0 V-5 36IN 2 ARM MONOFILAMENT BLUE",SUP-8937H,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.29,24.69,"KAISER [10500]",Kaiser,,55.13,67,,,,,0,9.57,69.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pulmonary Stress Testing",PX-482000006,CDM,94618,CPT,0460,RC,,,both,,,270.62,81.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,184.02,68,,,,,0,31.47,230.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND SPINAL 4.5MM HOOK END PET VERSATIE",SUP-86101245,CDM,C1713,HCPCS,0278,RC,,,both,,,6257.13,1877.14,"BLUE CROSS [10001]","Blue Cross HMO",,2452.79,39.2,,957.42,156.86,7483.26,51,727.7,5318.56,"percent of total billed charges",
"PACEMKR CARDIAC .75CM 4.45X6.17CM VALITUDE X4 RIGHT ATRIUM",SUP-U128,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"BLUE CROSS [10001]","Blue Cross PPO",,9051.44,39.2,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUR RND SKEETER OTO-FLEX 0.5MM CARB VIOL",SUP-3155635,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 STD 12MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS5S12R,CDM,C1776,HCPCS,0278,RC,,,both,,,7569.30,2270.79,"CIGNA [10200]","Cigna Open Access",,4306.93,56.9,,5302.19,4377.88,6578.61,27,880.31,6433.91,"percent of total billed charges",
"CATH SOFT-VU 80CM 5FR SOS OMNI 1 CURVE ANGIOGRAPHIC VISCERAL",SUP-10720401,CDM,C1887,HCPCS,0272,RC,,,both,,,209.32,62.8,"KAISER [10500]",Kaiser,,140.24,67,,,,,0,24.34,177.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED DUAL MOBILITY HIP SYSTEM + CER HD",SUP-98000500322,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7484.4,27,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30X3.5MM TITANIUM REGULAR ENDOSCOPIC LINEAR",SUP-TA3035S,CDM,S27200284,LOCAL,0272,RC,,,both,,,568.94,170.68,"CIGNA [10200]","Cigna Local Plus",,304.38,53.5,,,,,0,66.17,483.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 7.9X7.9IN XENMATRIX AQUAPURE RECTANGLE",SUP-1162020,CDM,C1781,HCPCS,0278,RC,,,both,,,56688.03,17006.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6717.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6592.82,48184.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE CATH REPLACEMENT RADIOPAQUE ROCKET INDWELL PLEURAL",SUP-R54410-00-VV,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TRUDI NAVWIRE ORTHOPEDIC SINUS NAVIGATION STERILE",SUP-TDNW001,CDM,C1769,HCPCS,0272,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTD DTMB1D1 AMPLIA MRI US DF1",SUP-DTMB1D1,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"BLUE CROSS [10001]","Blue Cross HMO",,22626.24,39.2,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 20FTX3IN ROLL PLASTER OF PARIS GYPSONA",SUP-GPS-315,CDM,S27000186,LOCAL,0270,RC,,,both,,,496.21,148.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,337.42,68,,,,,0,57.71,421.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ALEXIS O 360D SMALL RIGID RING ATRAUMATIC SELF",SUP-C8401,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"CIGNA [10200]",Cigna,,212.98,68,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Ulnar Styloid",PX-450000117,CDM,25650,CPT,0450,RC,,,both,,,1347.00,404.1,"UHC [10700]","United Healthcare",,1347,,"Per diem ($2,260).",,,,0,67.13,1347,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) SHEATH AMPLATZER TORQVUE 45D 100CM 14FR .215IN .184IN",SUP-9-TV45X45-14F-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,5244.00,1573.2,"MULTIPLAN [10600]",Multiplan,,4457.4,85,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION STAR STERILE",SUP-100-0071,CDM,C1776,HCPCS,0278,RC,,,both,,,7932.24,2379.67,"CIGNA [10200]","Cigna Local Plus",,4243.75,53.5,,5372.07,4581.20,7242.98,23,922.52,6742.4,"percent of total billed charges",
"BLADE SAW 45X6MM THK.61MM SAGITTAL STERILE LATEX FREE",SUP-SM-4506,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 38MM 2 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.238,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",512.88,3748.5,"percent of total billed charges",
"KNEE CONSTRUCT 2",SUP-CAP-MI-K-2,CDM,C1776,HCPCS,0278,RC,,,both,,,19530.00,5859,"BLUE CROSS [10001]","Blue Cross HMO",,7655.76,39.2,,5311.50,4717.44,5388.59,31,2271.34,16600.5,"percent of total billed charges",
"COIL EMBOLIZATION 15CM 3MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0315,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,786.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 6 STD KNEE RIGHT KEEL NONPOROUS",SUP-ETPKN6SR,CDM,C1776,HCPCS,0278,RC,,,both,,,11060.70,3318.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7521.28,68,,,,,0,1286.36,9401.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TL INS 7FR TRANSVALVULAR",SUP-379469,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"PHCS [10601]",PHCS,,286.23,70,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 200MM 8MM BALLOON DILATATION OTW",SUP-H74939206082010,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SCLEROTHERAPY 25GA 7FR EXTEND TIP LUER SLIP HANDLE",SUP-G21649,CDM,S27200284,LOCAL,0272,RC,,,both,,,469.80,140.94,"UHC [10700]","United Healthcare",,297.38,63.3,,,,,0,54.64,399.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 45D HOOK 8.5IN 3/32IN STERILE EDGE",SUP-E1511,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.38,44.21,"FIRST HEALTH [10303]","First Health",,117.9,80,,,,,0,17.14,125.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE COMPRESSION SMALL KNEE LENGTH KENDALL SCD SEQUENTIAL",SUP-74021,CDM,S27000186,LOCAL,0270,RC,,,both,,,228.58,68.57,"MULTIPLAN [10600]",Multiplan,,194.29,85,,,,,0,26.58,194.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM NEXGEN F DISTAL KNEE TRABECULAR METAL",SUP-00549003610,CDM,C1776,HCPCS,0278,RC,,,both,,,7761.60,2328.48,"AETNA [10100]","Aetna HMO/PPO",,6170.47,79.5,,10981.53,8986.79,12413.38,12,902.67,6597.36,"percent of total billed charges",
"CATH SLIP-CATH BEACON TIP 135CM 4FR ANGLE ANGIOGRAPHIC",SUP-G48153,CDM,S27200284,LOCAL,0272,RC,,,both,,,708.75,212.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,82.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,82.43,602.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VANSONNENBERG 25CM 14FR DRNG GLIDEX PERCUFLEX METAL",SUP-M001245140,CDM,C1729,HCPCS,0272,RC,,,both,,,729.00,218.7,"UHC [10700]","United Healthcare",,461.46,63.3,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12.5IN 15FR CORONARY SINUS ADULT RETROGRADE",SUP-94115T,CDM,S27200284,LOCAL,0272,RC,,,both,,,793.01,237.9,"MULTIPLAN [10600]",Multiplan,,674.06,85,,,,,0,92.23,674.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 20MM 130CM 10MM LONG VASCULAR NITINOL",SUP-SC1020LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]",Cigna,,4926.6,68,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RAMROD LUBRI-FLEX 26CM 4.5FR 270D KIDNEY BLADDER CURL",SUP-5554526,CDM,C2617,HCPCS,0278,RC,,,both,,,719.52,215.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,330.26,45.9,,,,,0,83.68,611.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 485CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRM-485,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"PHCS [10601]",PHCS,,3839.85,70,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG PERFUSION HEMOCONCENTRATION WASTE",SUP-020585504,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"CIGNA [10200]",Cigna,,118.32,68,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 5MM SPACE L CURVE ELECTROPHYSIOLOGY",SUP-F6QL005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"AETNA [10100]","Aetna HMO/PPO",,721.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALLET SURGICAL 7.5IN 1.5IN HEATH HEAVYWEIGHT 2LB",SUP-27-0880,CDM,S27200284,LOCAL,0272,RC,,,both,,,920.16,276.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,625.71,68,,,,,0,107.01,782.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) OCCL CARDIOVASCULAR 10X25-28MM 31MM 38MM HEMOSTASIS",SUP-9-ACP2-010-031,CDM,C1817,HCPCS,0278,RC,,,both,,,102600.00,30780,"PHCS [10601]",PHCS,,71820,70,,,,,0,11932.38,87210,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"400 SINGLE USE FLAT TIP HOLMIUM FIBER",SUP-HOL400SBX,CDM,S27200284,LOCAL,0272,RC,,,both,,,1677.50,503.25,"CIGNA [10200]","Cigna Open Access",,954.5,56.9,,,,,0,195.09,1425.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 6MM 3MM BALLOON DILATATION DURATRAC",SUP-NCEUP3006X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000170,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 3 WAY STPCOCK TRNSDUC 3 FLUSH DEVICE",SUP-PX3X3272,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 82-94X12IN 4 PANEL ELASTIC VELCRO CLSR 2XL",SUP-820,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 38-41MM TITANIUM 4.75MM SCR MULTISPAN XLNK BONE SPINE",SUP-5442138,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]",Cigna,,3284.4,68,,1831.33,1831.33,1831.33,16,561.73,4105.5,"percent of total billed charges",
"SLDFR FLUID 20L UROLOGY FLUIDRAIN LSS DISPOSABLE",SUP-337220,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"UHC [10700]","United Healthcare",,165.21,63.3,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 80MM 159CM 8MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200088020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross HMO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Needle Cath Yueh",PX-E27200195,CDM,E27200195,LOCAL,0272,RC,,,both,,,166.10,49.83,"CIGNA [10200]","Cigna Open Access",,94.51,56.9,,,,,0,19.32,141.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 7MM AXIUM 3D NEUROVASCULAR FRAME V01",SUP-FC-7-12-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,13765.50,4129.65,"AETNA [10100]","Aetna HMO/PPO",,10943.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPREME 120CM 5FR 5MM SPACE JOSEPHSON CURVE",SUP-401443,CDM,C1730,HCPCS,0272,RC,,,both,,,468.00,140.4,"AETNA [10100]","Aetna HMO/PPO",,372.06,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.43,397.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 35MM FLEXIBLE REFLECTION STERILE LATEX FREE",SUP-71362935,CDM,S27200284,LOCAL,0272,RC,,,both,,,1538.19,461.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,632.2,41.1,,,,,0,178.89,1307.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL FREEZE DRIED RING MACHINED 16MM 26MM",SUP-439016,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACTOR, STRIPPED SCREW, 3 MM, 6"" LONG, SINGLE USE",SUP-SXT010-ST3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,351.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 13MM 51X71MM SURESCAN CLARIA MRI PHYSIOCURVE",SUP-DTMA1D1,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6839.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 NARROW KNEE LEFT POSTERIOR STABILIZE PERSONA",SUP-42500206201,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"FIRST HEALTH [10303]","First Health",,23116.46,80,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM PRECISION CONVEX SPINE",SUP-17512,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Guide Tiss Ablt",PX-352000037,CDM,77013,CPT,0352,RC,,,both,,,3026.02,907.81,"AETNA [10100]","Aetna HMO/PPO",,1933,,"Per diem ($1,933). Each eligible service on a given day will be paid its own per diem rate.",,,,0,351.93,2572.12,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC COLD BIOPSY NDL 240CM 2.4FR 2.8MM RADIAL JAW",SUP-M00513331,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.37,38.51,"NOVANET [10819]",Novanet,,96.28,75,,,,,0,14.93,109.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 85MM ATLANTIS VISION ELITE BONE SPINE",SUP-7200185,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"HC Xr Bn Survey Infant",PX-320000182,CDM,77076,CPT,0320,RC,,,both,,,453.73,136.12,"PHCS [10601]",PHCS,,317.61,70,,,,,0,52.77,385.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7.5CM 3.5MM CEREPAK FREEFORM DETACHABLE",SUP-SCR123575,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS [10001]","Blue Cross PPO",,5184.53,39.2,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17MM 27MM 25MM BIOCOR FLEXFIT STENTED LOW",SUP-B100-27A-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,30744.00,9223.2,"PHCS [10601]",PHCS,,21520.8,70,,,,,0,3575.53,26132.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Del Vag Only",PX-450000288,CDM,59409,CPT,0450,RC,,,both,,,4627.00,1388.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1469,,"Per diem ($1,469).",,,,0,67.13,3932.95,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER FEMORAL CATHCART ARTICUL/EZE -3MM 12/14 TAPER HIP",SUP-136308000,CDM,C1776,HCPCS,0278,RC,,,both,,,1650.00,495,"AMERIGROUP MEDICAID [20100]",Amerigroup,,195.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM INTERLOCK FIBERED IDC DETACHABLE",SUP-M001361640,CDM,S27800098,LOCAL,0278,RC,,,both,,,2079.00,623.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,954.26,45.9,,,,,0,241.79,1767.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 12IN 4 PANEL KNIT ELASTIC PREMIUM HOOK LOOP",SUP-13960000,CDM,S27000186,LOCAL,0270,RC,,,both,,,160.17,48.05,"AETNA [10100]","Aetna HMO/PPO",,127.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.63,136.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2MM TARGET NANO 360D DETACHABLE",SUP-M0035442030,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]","Cigna Open Access",,4728.4,33.5,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DECANAV CARTO 3 115CM 7FR 2MM 2-8-2MM D CURVE ABLATION",SUP-R7D282CT,CDM,C1732,HCPCS,0272,RC,,,both,,,7417.50,2225.25,"UHC [10700]","United Healthcare",,4695.28,63.3,,,,,0,862.66,6304.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 6MM 16MM TITANIUM 2.5MM FULL THREAD CORTEX",SUP-404.816,CDM,C1713,HCPCS,0278,RC,,,both,,,258.83,77.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,30.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",30.1,220.01,"percent of total billed charges",
"TREVO NXT 3X32+TRAK21+CAT5L 3-PACK - US",SUP-SFP913100,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,9268.88,53.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 22MM QUICKFIX TITANIUM 1.5MM MICRO FULL",SUP-AR-8725-22H,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,305.29,2231.25,"percent of total billed charges",
"SHEATH FLEXOR CHECK-FLO ANL1 CURVE 70CM 7FR 2.5MM GUIDING",SUP-G56227,CDM,C1894,HCPCS,0272,RC,,,both,,,558.09,167.43,"PHCS [10601]",PHCS,,390.66,70,,,,,0,64.91,474.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 25X9X15MM CONCORDE 10D THORACOLUMBAR CFRP INLINE",SUP-187855215,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6806.16,41.1,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT THR HIP E1 POROUS CUP 2 MOBILITY AA STD LINER INSRT",SUP-98000100046,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7933.46,28.62,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 180CM 150MM 4FR 2.5MM .018IN BALLOON",SUP-PCP025150180,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD LAPAROSCOPIC VALLEYLAB L HOOK RETRACTABLE ASPIRATION",SUP-E3784R-28ASP,CDM,S27200284,LOCAL,0272,RC,,,both,,,254.91,76.47,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING MONORAIL 135CM 20MM 3.8-3.4FR 7MM LOW PROFILE",SUP-H74939031702010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EMPAGLIFLOZIN 25 MG TABLET",RX-167819,CDM,,,0637,RC,00597-0153-37,NDC,both,1,UN,52.92,15.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL ROCHESTER-OSCHNER STRAIGHT 7.25IN 1X2 TEETH",SUP-16-1218,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.99,22.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OSTEOTOME 5INX14MM RADIAL REVISION HIP SURGICAL LATEX FREE",SUP-270904014,CDM,S27200284,LOCAL,0272,RC,,,both,,,1019.71,305.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 10CM 3MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0310,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"FIRST HEALTH [10303]","First Health",,5409.6,80,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155234050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"MULTIPLAN [10600]",Multiplan,,1046.32,85,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SR CORTICAL FREEZE DRY BLOCK 11X11X8",SUP-200811,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT 36CM MASTERGRAFT",SUP-7800336,CDM,C1713,HCPCS,0278,RC,,,both,,,16324.00,4897.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1934.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1898.48,13875.4,"percent of total billed charges",
"PLATE BONE LEVEL ONE SHORT CRANIOFACIAL TITANIUM 4 HOLE",SUP-25-153-14-09,CDM,C1713,HCPCS,0278,RC,,,both,,,1304.26,391.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,151.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",151.69,1108.62,"percent of total billed charges",
"CATH ARCADIA 30MM BALLOON DILATATION 8CC HIGH PRESSURE",SUP-ARC30ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,5978.16,1793.45,"CIGNA [10200]","Cigna Open Access",,3401.57,56.9,,,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 39MM UNIVERS REVERS +6MM MEDIUM SHOULDER",SUP-AR-9503M-06,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"CIGNA [10200]",Cigna,,1999.2,68,,5873.17,5873.17,5873.17,"1 through 10",341.92,2499,"percent of total billed charges",
"RISPERIDONE 0.25 MG TABLET",RX-25519,CDM,,,0637,RC,68084-0270-01,NDC,both,1,UN,19.58,5.87,"KAISER [10500]",Kaiser,,13.12,67,,,,,0,2.28,16.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAPE FIBERWIRE 2 TAPER 54IN BRAID BLUE 36INX2MM",SUP-AR-7237,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.03,267.91,"CIGNA [10200]","Cigna Open Access",,508.13,56.9,,,,,0,103.86,759.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR 35CM 12FR ACCESS AQ URETERAL DILATION",SUP-G19168,CDM,C1894,HCPCS,0272,RC,,,both,,,1244.97,373.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,147.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.79,1058.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL 5MM LEGION 5 KNEE SCR",SUP-71421664,CDM,C1776,HCPCS,0278,RC,,,both,,,11995.65,3598.69,"AETNA [10100]","Aetna HMO/PPO",,9536.54,79.5,,10981.53,8986.79,12413.38,12,1395.09,10196.3,"percent of total billed charges",
"SYSTEM LINX 15 BEAD 1.5 TESLA IMPL GASTROINTESTINAL GERD",SUP-LXMC15,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"NOVANET [10819]",Novanet,,25987.5,75,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 17IN 21FR PERCUTANEOUS FEMORAL ARTERIAL ADULT",SUP-96530-021,CDM,S27200284,LOCAL,0272,RC,,,both,,,1903.58,571.07,"CIGNA [10200]","Cigna Open Access",,1083.14,56.9,,,,,0,221.39,1618.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PACING LEAD REPAIR",SUP-6946,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR HEMI 3HL 64MM",SUP-430-98-064,CDM,C1776,HCPCS,0278,RC,,,both,,,16956.34,5086.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2009.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1972.02,14412.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.25/18",SUP-401747,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 80CM 200MM 6MM BALLOON DILATATION","SUP-ADM 060 200 08P",CDM,C2623,HCPCS,0272,RC,,,both,,,12730.50,3819.15,"FIRST HEALTH [10303]","First Health",,10184.4,80,,,,,0,1480.56,10820.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 4.5MM X 15.0MM",SUP-494501512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 40MM TSRH OSTEOGRIP TITANIUM SPINE NONSTERILE",SUP-83585401,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"AETNA [10100]","Aetna HMO/PPO",,2046.33,79.5,,1521.93,481.35,16760.95,30,299.36,2187.9,"percent of total billed charges",
"GRAFT CARDIOROOT VALSALVA 24MM",SUP-HEWROOT0024,CDM,C1768,HCPCS,0278,RC,,,both,,,13998.17,4199.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5599.27,40,,,,,0,1627.99,11898.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLOSED WOUND FACIAL DRAINS (TWO) FLAT 4MM SILICONE WITH BIFU",SUP-412ATSX,CDM,S27200284,LOCAL,0272,RC,,,both,,,401.68,120.5,"PHCS [10601]",PHCS,,281.18,70,,,,,0,46.72,341.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Legionella Ab",PX-302000151,CDM,86713,CPT,0302,RC,,,both,,,365.75,109.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,54.32,,,,,,,0.01,310.89,"fee schedule",
"SPACER SPINAL 22MM 6MM CAPSTONE TITANIUM PEEK LUMBAR",SUP-2990622,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"CIGNA [10200]","Cigna Open Access",,7110.58,33.5,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 24MM 140CM 2.5MM CORONARY STENT",SUP-LUN250R24US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 18LP 80CM 2CM 4FR 6MM .018IN BALLOON DILATATION",SUP-G50244,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bonnet Infant Flow",PX-E27000063,CDM,E27000063,LOCAL,0270,RC,,,both,,,70.40,21.12,"KAISER [10500]",Kaiser,,47.17,67,,,,,0,8.19,59.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Upr Ext Arty Bi",PX-921000008,CDM,93930,CPT,0921,RC,,,both,,,1429.82,428.95,"KAISER [10500]",Kaiser,,957.98,67,,,,,0,166.29,1215.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BD ANGIOCATH 1.88IN 18GA STD INTRAVENOUS FEP PERIPHERAL",SUP-381147,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.83,15.85,"KAISER [10500]",Kaiser,,35.4,67,,,,,0,6.14,44.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X5MM CERVICAL ANATOMIC",SUP-6940564,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Leflunomide",PX-301000709,CDM,80193,CPT,0301,RC,,,both,,,230.00,69,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,195.5,"per diem",
"HC Myelin Basic Protein",PX-301000316,CDM,83873,CPT,0301,RC,,,both,,,283.40,85.02,"AETNA [10100]","Aetna HMO/PPO",,225.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,240.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 650CC",SUP-SSZ-F650,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"KAISER [10500]",Kaiser,,998.57,67,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Collar Cerv Vst Dial Ht",PX-E27400068,CDM,L0140,HCPCS,0274,RC,,,both,,,226.60,67.98,"KAISER [10500]",Kaiser,,151.82,67,,,,,0,26.35,192.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 4MM CARBIDE OVAL PS STERILE",SUP-2296100026,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.40,83.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,189.31,68,,,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR INLINE SENSOR INJECTATE SYR COOL COIL",SUP-680000,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.44,81.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,32.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.57,230.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rem Contraceptive Capsule",PX-761000072,CDM,11976,CPT,0761,RC,,,both,,,1523.00,456.9,"PHCS [10601]",PHCS,,1066.1,70,,,,,0,177.12,1523,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Thorax W/WO Cntrst Dx",PX-352000006,CDM,71270,CPT,0352,RC,,,both,,,3904.65,1171.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,454.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,384.26,3318.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLP Routine Visit",PX-441000003,CDM,G0153,HCPCS,0441,RC,,,outpatient,,,261.00,78.3,"FIRST HEALTH [10303]","First Health",,208.8,80,,,,,0,174.87,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 20MM 140CM 4MM CORONARY STENT CARBOSIL",SUP-LUN400R20US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 95MM 11MM 6MM CUFFLESS DISTAL EXT EXTEND LENGTH SOFT",SUP-60XLTUD,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 6X60 80CM SL",SUP-48006006N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LARYNSCP VIDEO S4 HYPERANGULATE LOW PROFILE BLADE GLIDESCOPE",SUP-0270-1084,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RUBICON 65CM 5FR .035IN GUIDING",SUP-H74939240035061,CDM,C1887,HCPCS,0272,RC,,,both,,,1449.90,434.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAREON UVA TORIC AUTONOME",SUP-CCA0T6,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"BLUE CROSS [10001]","Blue Cross PPO",,145.04,39.2,,,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM ON-X",SUP-ONXACE-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,21780.00,6534,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6233.44,28.62,,,,,0,2533.01,18513,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LISINOPRIL 40 MG TABLET",RX-10450,CDM,,,0637,RC,60687-0678-11,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 25MM LCP STAINLESS STEEL PROXIMAL FEMORAL",SUP-02.205.025,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,579.85,45.9,,,,,0,146.92,1073.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 32MM 80MM MEDLINE UNITE FOOT ANKLE HEAD",SUP-MSD17080,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"NOVANET [10819]",Novanet,,1968.75,75,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL D KNEE RIGHT LPS-FLEX NEXGEN POROUS",SUP-00596201452,CDM,C1776,HCPCS,0278,RC,,,both,,,28570.50,8571.15,"MULTIPLAN [10600]",Multiplan,,24284.93,85,,,,,0,3322.75,24284.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FIBERTAG FIXATION ACL ABS DISPOSABLE",SUP-AR-1588TNT,CDM,C1713,HCPCS,0278,RC,,,both,,,2638.13,791.44,"AETNA [10100]","Aetna HMO/PPO",,2097.31,79.5,,1521.93,481.35,16760.95,30,306.81,2242.41,"percent of total billed charges",
"SCR BASEPLT 35MM 9.5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ235,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"NOVANET [10819]",Novanet,,6770.79,75,,,,,0,1049.92,7673.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 25MM 18MM PATENT FORAMEN OVALE 2 DISK",SUP-9-PFO-025,CDM,C1817,HCPCS,0278,RC,,,both,,,56668.50,17000.55,"PHCS [10601]",PHCS,,39667.95,70,,,,,0,6590.55,48168.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 32MM 5MM CORONARY STENT PLATINUM",SUP-H7493926032500,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"BLUE CROSS [10001]","Blue Cross HMO",,3651.48,39.2,,9776.84,9776.84,9776.84,"1 through 10",1083.33,7917.75,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 38MM 145CM 3.25MM CORONARY STENT",SUP-1125325-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 19MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-319-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]",Cigna,,7760.57,68,,5873.17,5873.17,5873.17,"1 through 10",1327.29,9700.71,"percent of total billed charges",
"BIT DRILL 5MM LONG CANNULATED LARGE QUICK COUPLING STERILE",SUP-03.333.112S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3257.10,977.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1495.01,45.9,,,,,0,378.8,2768.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IRRIGATION NEEDLE",SUP-6172.0012S,CDM,S27200284,LOCAL,0272,RC,,,both,,,972.00,291.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,113.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 10MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0101000,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"KAISER [10500]",Kaiser,,3404.84,67,,,,,0,591.02,4319.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI MIRACLEBROS 4.5 VASCULAR STRAIGHT 300CM 11CM",SUP-14936-01,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP ELECTROSURGICAL 7.5INX1.5MM HARDY IRRIGATE 3.5IN LATEX",SUP-US416SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,2487.93,746.38,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRA-THIN SDS 75CM 40MM 5.8FR 10MM STD BALLOON",SUP-M001177360,CDM,C1725,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COLLAR EXTRICATION 5.25IN 16-19IN PROCARE LARGE CERVICAL",SUP-79-83157,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.17,26.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE UROLOGICAL 150CM 3CM .035IN PTFE STRAIGHT FLEXIBLE TIP",SUP-M0066201200,CDM,C1769,HCPCS,0272,RC,,,both,,,93.35,28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ARTEMIS NEURO EVACUATION DEVICE 1.5",SUP-AP15,CDM,S27200284,LOCAL,0272,RC,,,both,,,45328.50,13598.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SCR BONE CREO AMP QUAD SPINE RIGHT 2 HEAD THREAD NONSTERILE",SUP-1119.0165,CDM,C1713,HCPCS,0278,RC,,,both,,,18314.10,5494.23,"UHC [10700]","United Healthcare",,11592.83,63.3,,5023.51,2672.93,6679.78,18,2129.93,15566.99,"percent of total billed charges",
"CATH DIREXION FATHOM 155CM 180CM 2.4-3FR .021IN MICRO",SUP-M001195620,CDM,C1887,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"FIRST HEALTH [10303]","First Health",,5796,80,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 80CM .018IN STAINLESS STEEL MANDRELL SS TIP",SUP-06507210,CDM,C1769,HCPCS,0272,RC,,,both,,,200.54,60.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,23.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.32,170.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTEMIS NEURO EVACUATION DEVICE 1.5",SUP-AP15,CDM,S27200284,LOCAL,0272,RC,,,both,,,45328.50,13598.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5271.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5271.7,38529.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH UROMAX ULTRA QUADRA-FOLD ENCORE HIGH PRESSURE KINK",SUP-M0062251230,CDM,C1726,HCPCS,0272,RC,,,both,,,1904.70,571.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,782.83,41.1,,,,,0,221.52,1619,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 36MM X25 LOCK INTRAMEDULLARY NAIL",SUP-04.045.036S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC",229,MS-DRG,,,,,,,inpatient,,,185247.33,55574.2,"AETNA [10100]","Aetna HMO/PPO",,59257.84,,"Fee schedule rate ($59,257.84). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,19536.54,91952.8,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOZORB MARKER LP, 2CM X 2CM X 1CM",SUP-F0221,CDM,A4648,HCPCS,0278,RC,,,both,,,5250.00,1575,"AETNA [10100]","Aetna HMO/PPO",,4173.75,79.5,,,,,0,610.58,4462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 44MM 2 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800244,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 7IN FREEMAN 7 PRONG CORONAL BROW LIFT SURGICAL",SUP-22-2008,CDM,S27200284,LOCAL,0272,RC,,,both,,,1679.10,503.73,"CIGNA [10200]","Cigna Open Access",,955.41,56.9,,,,,0,195.28,1427.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL CERTUS 20CM 17GA ABLATION",SUP-LK20,CDM,C2618,HCPCS,0272,RC,,,both,,,14524.50,4357.35,"MULTIPLAN [10600]",Multiplan,,12345.83,85,,,,,0,1689.2,12345.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOPLASTY L150CM BALLOON L150MM DIA6MM PERIPHERAL",SUP-1013470-150,CDM,S27200284,LOCAL,0272,RC,,,both,,,1255.50,376.65,"MULTIPLAN [10600]",Multiplan,,1067.18,85,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR ANGLE 300CM .014IN",SUP-GA1430,CDM,C1769,HCPCS,0272,RC,,,both,,,1803.75,541.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,741.34,41.1,,,,,0,209.78,1533.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 6MM GORE INTERING THIN WALL PTFE RADIAL",SUP-IRST06080080L,CDM,C1768,HCPCS,0278,RC,,,both,,,11605.80,3481.74,"MULTIPLAN [10600]",Multiplan,,9864.93,85,,,,,0,1349.75,9864.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 9MM 140CM 2.5MM CORONARY STERILE LATEX",SUP-453926,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,inpatient,,,34647.33,10394.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,14240.94,,,,,,,5540.57,22275.51,"case rate",
"HC Hemoglobin A1c",PX-301000228,CDM,83036,CPT,0301,RC,,,both,,,179.50,53.85,"MULTIPLAN [10600]",Multiplan,,152.58,85,,,,,0,0.18,152.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST TAPER 32MM 12MM HEMICAP CONTOUR OVOID SHOULDER TITANIUM",SUP-8156-0032-A,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NAVIGATION KNEE",SUP-20-8000-000-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,2996.25,898.87,"CIGNA [10200]","Cigna Local Plus",,1602.99,53.5,,,,,0,348.46,2546.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPR LD 6MM",SUP-501204,CDM,C1883,HCPCS,0278,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE SHEET 9X9CM DEHYDRATED AMNION CHORION MEM",SUP-APS-5990,CDM,Q4433,HCPCS,0636,RC,,,both,,,36426.60,10927.98,"NOVANET [10819]",Novanet,,27319.95,75,,,,,0,247.92,30962.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPR LD 6MM",SUP-501204,CDM,C1883,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INQUIRY AFOCUS II 110CM 7FR 20MM 4MM SPACING",SUP-IBI-87008,CDM,C1730,HCPCS,0272,RC,,,both,,,10177.50,3053.25,"MULTIPLAN [10600]",Multiplan,,8650.88,85,,,,,0,1183.64,8650.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CRANIOTOMY 5/8IN 25GA RAZOR BETADINE SWAB NDL SAFETY SYR",SUP-INS-HITH,CDM,S27200284,LOCAL,0272,RC,,,both,,,3373.95,1012.18,"KAISER [10500]",Kaiser,,2260.55,67,,,,,0,392.39,2867.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR PULSE LATITUDE NXT 83.1X69.1MM EMBLEM S-ICD 12.7MM",SUP-A219,CDM,C1722,HCPCS,0278,RC,,,both,,,59280.00,17784,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7024.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6894.26,50388,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC",858,MS-DRG,,,,,,,inpatient,,,63335.79,19000.74,"CIGNA [10200]","Cigna Local Plus",,14373.34,,"Fee schedule rate ($14,373.34). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,40667.11,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT UNIVERSAL EXTREMITY PREVALON HEEL PILLOW STYLE",SUP-7300,CDM,E0190,HCPCS,0271,RC,,,both,,,364.31,109.29,"MULTIPLAN [10600]",Multiplan,,309.66,85,,,,,0,42.37,309.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL GENESIS II 4 LEFT KNEE CEMENT TITANIUM",SUP-71420166,CDM,C1776,HCPCS,0278,RC,,,both,,,14593.50,4378.05,"NOVANET [10819]",Novanet,,10945.13,75,,,,,0,1697.22,12404.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Amputation Toe IP Joint",PX-761000029,CDM,28825,CPT,0761,RC,,,both,,,9356.00,2806.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1088.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1088.1,7952.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER FAST PEG 20MM 2MM SURGICAL DVRA TRAY SYSTEM",SUP-FPD20,CDM,S27200284,LOCAL,0272,RC,,,both,,,668.25,200.47,"AETNA [10100]","Aetna HMO/PPO",,531.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.72,568.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 100MM 80CM 14MM BILIARY VENOUS DELIVERY",SUP-G57445,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1685.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT",838,MS-DRG,,,,,,,inpatient,,,65693.64,19708.09,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,13725.17,,"Case rate ($12,948.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,023.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,063.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,291.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,039.25. The transfer operating threshold is the transfer adjustment factor * $12,023.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $909.02. The transfer capital threshold is the transfer adjustment factor * $909.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,52057.67,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 150MM 5MM SCHANZ SELF DRILL CALCANEAL FRACTURE",SUP-AR-8954-01,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"AMERIGROUP MEDICAID [20100]",Amerigroup,,266.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",261.68,1912.5,"percent of total billed charges",
"LINER ACETABULAR RINGLOC MAX-ROM 24 32MM E-POLY HIP",SUP-EP-105934,CDM,C1776,HCPCS,0278,RC,,,both,,,14076.00,4222.8,"UHC [10700]","United Healthcare",,8910.11,63.3,,8601.07,8395.67,8601.07,"1 through 10",1637.04,11964.6,"percent of total billed charges",
"OTHER VASCULAR PROCEDURES WITHOUT CC/MCC",254,MS-DRG,,,,,,,inpatient,,,94164.32,28249.3,"CIGNA [10200]","Cigna Open Access",,19552.38,,"Fee schedule rate ($19,552.38). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,52018.51,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 230MM STAINLESS STEEL 3.5MM SCREWS 10 HOLE LCP BONE",SUP-02.104.010,CDM,C1713,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"CIGNA [10200]","Cigna Open Access",,4946.89,56.9,,1144.80,304.56,2275.09,66,1011.11,7389.9,"percent of total billed charges",
"CATH TYSHAK II 100CM 6CM 8FR 18MM BALLOON DILATATION DEHP",SUP-611930,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"MULTIPLAN [10600]",Multiplan,,3231.03,85,,,,,0,442.08,3231.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP GRIPTION PINNACLE STERILE LATEX",SUP-121731050,CDM,C1776,HCPCS,0278,RC,,,both,,,8971.20,2691.36,"PHCS [10601]",PHCS,,6279.84,70,,,,,0,1043.35,7625.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS SOLN DEX 1.5 % CA+ 3.5 MEQ/L&LOW MAG 0.5 MEQ/L",RX-27797,CDM,,,0250,RC,00941-0426-52,NDC,both,2000,ML,211.26,63.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,86.83,41.1,,,,,0,24.57,179.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL LARGE 4.25IN NECK 2 PIECE SEMIRIGID",SUP-11344,CDM,S27000186,LOCAL,0270,RC,,,both,,,129.54,38.86,"CIGNA [10200]","Cigna Open Access",,73.71,56.9,,,,,0,15.07,110.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL 6.5IN PAPARELLA 20D INCUDOSTAPEDIAL BLADE 1.5",SUP-61-0435,CDM,S27200284,LOCAL,0272,RC,,,both,,,465.99,139.8,"AETNA [10100]","Aetna HMO/PPO",,370.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.19,396.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 6.5MM CONICAL STOP NONSTERILE",SUP-03.019.018,CDM,S27200284,LOCAL,0272,RC,,,both,,,1982.40,594.72,"FIRST HEALTH [10303]","First Health",,1585.92,80,,,,,0,230.55,1685.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 12X11X30MM 15",SUP-5821305,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3412.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 150MM 12.5MM LPS BOW KNEE FEMUR POROCOAT COCR",SUP-198716211,CDM,C1776,HCPCS,0278,RC,,,both,,,42547.68,12764.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17019.07,40,,,,,0,4948.3,36165.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 28MM 144CM 2.25MM",SUP-H7493941228220,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CIGNA [10200]","Cigna Local Plus",,4152.94,53.5,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM ATRIAL VENTRICULAR BIPOLAR SCR IN ELECTRD",SUP-407665,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,264.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENROUTE ENFLATE TRANSCAROTID RX BALLOON DILATATION CATHETER",SUP-SR-4535-BC,CDM,C1725,HCPCS,0272,RC,,,both,,,2625.00,787.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN ULCERS WITHOUT CC/MCC",594,MS-DRG,,,,,,,inpatient,,,30474.58,9142.37,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,5699.43,,"Case rate ($5,376.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,992.74, add-ons for qualifying new technology services are included. If operating cost exceeds $38,032.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,759.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $4,999.34. The transfer operating threshold is the transfer adjustment factor * $4,992.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $377.48. The transfer capital threshold is the transfer adjustment factor * $377.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,5376.82,21617.13,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 200MM 5.5MM VIPER 2 STRAIGHT TITANIUM MIS",SUP-186789200,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 STD KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508606601,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7084.32,27,,,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,inpatient,,,113902.06,34170.62,"AETNA [10100]","Aetna HMO/PPO",,66966.35,,"Fee schedule rate ($66,966.35). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,103914.4,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 52MM TI",SUP-SPL-60520-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Open Access",,921.78,56.9,,1144.80,304.56,2275.09,66,188.41,1377,"percent of total billed charges",
"OTHER HEART ASSIST SYSTEM IMPLANT",215,MS-DRG,,,,,,,inpatient,,,339748.21,101924.46,"AETNA [10100]","Aetna HMO/PPO",,187340.96,,"Fee schedule rate ($187,340.96). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,61763.88,290704.57,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 28MMX8MM ELEVATE STD PEEK TITANIUM STERILE",SUP-7770828,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]",Cigna,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASSURANT COBALT 30MM 80CM 9MM BILIARY COCR 2 LUMEN",SUP-ASC930SV,CDM,C1876,HCPCS,0278,RC,,,both,,,6444.60,1933.38,"BLUE CROSS [10001]","Blue Cross PPO",,2526.28,39.2,,,,,0,749.51,5477.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX LARGE C6 9.5MM X",SUP-T600306,CDM,S27800098,LOCAL,0278,RC,,,both,,,3150.00,945,"BLUE CROSS [10001]","Blue Cross PPO",,1234.8,39.2,,,,,0,366.35,2677.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN IV SOLUTION",RX-123320,CDM,A9537,HCPCS,0343,RC,08888-8878-09,NDC,both,1,UN,258.59,77.58,"UHC [10700]","United Healthcare",,221.25,,,,,,,30.07,221.25,"fee schedule",
"SHEATH GORE DRYSEAL FLEX 33CM 5.6MM 15FR INTRO HYDROPHILIC",SUP-GDSF1533,CDM,C1894,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"UHC [10700]","United Healthcare",,2380.4,63.3,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE COROLENE 4-0 3/8X18 MM",SUP-20S15AJ,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.82,14.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH BRITE TIP 35CM 5FR INTRO KINK RESISTANT CANN",SUP-401535M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE WHISPER LS VASCULAR J 300CM 3CM .014IN",SUP-1005353HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH HEMOSTASIS VALVE TEAR AWAY SIDEPORT SAFESHEATH",SUP-HLS2509,CDM,C1894,HCPCS,0272,RC,,,both,,,411.51,123.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW MARK SPRING TIP",SUP-CG-06-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MOMETASONE 0.1 % TOPICAL CREAM",RX-10646,CDM,,,0250,RC,45802-0257-35,NDC,both,15,GR,183.42,55.03,"KAISER [10500]",Kaiser,,122.89,67,,,,,0,21.33,155.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 50MM 28MM H VIVACIT-E LUMEN STERILE LATEX FREE",SUP-110031015,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"FIRST HEALTH [10303]","First Health",,8285.52,80,,,,,0,1204.51,8803.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT EPTFE GORE-TEX CV-2 TF-25 36IN MONOFILAMENT DOUBLE ARM",SUP-2N19A,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.15,90.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,35.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.91,255.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX14MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183564,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1534.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP POLAR STEM POLAR CUP OXI HEAD",SUP-71703506,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"NOVANET [10819]",Novanet,,17955,75,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 15MM PLYMOUTH BONE SPINE THORACOLUMBAR NONSTERILE",SUP-1105.1009,CDM,C1713,HCPCS,0278,RC,,,both,,,17250.00,5175,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2006.18,14662.5,"percent of total billed charges",
"CATH ELECTROPHYSIOLOGY 2-10-2MM SPACING SUPER LARGE CURL 7FR",SUP-401904R,CDM,C1731,HCPCS,0272,RC,,,both,,,2100.00,630,"AETNA [10100]","Aetna HMO/PPO",,1669.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL PRECISION 3 MM SCR",SUP-P27-940-0030,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Skin Tags Add 10",PX-450000015,CDM,11201,CPT,0450,RC,,,both,,,814.18,244.25,"UHC [10700]","United Healthcare",,814.18,,"Per diem ($2,260).",,,,0,67.13,814.18,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 26FR 5MM ACMI ELITE",SUP-M0068804121,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"KAISER [10500]",Kaiser,,346.04,67,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM ACCOLADE HFX 127D 6 49MM OFFSET HIP",SUP-6077-0637,CDM,C1776,HCPCS,0278,RC,,,both,,,8983.80,2695.14,"KAISER [10500]",Kaiser,,6019.15,67,,,,,0,1044.82,7636.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 29MM 3 PEG OPTETRAK POLYETHYLENE KNEE STERILE",SUP-200-02-29,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CIRCUIT EVAQUA 2 2 LIMB NO FILTER ADULT LATEX FREE",SUP-RT280,CDM,S27000186,LOCAL,0270,RC,,,both,,,276.23,82.87,"NOVANET [10819]",Novanet,,207.17,75,,,,,0,32.13,234.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 20IN 12FR STRAIGHT",SUP-8888570507,CDM,C1729,HCPCS,0272,RC,,,both,,,83.25,24.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.68,70.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 19MM 16.7MM MASTERS HP MECHANICAL ROTATABLE STD",SUP-19MHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"FIRST HEALTH [10303]","First Health",,23295.38,80,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 2IN 18GA ROSEN EAR 60MM",SUP-61-1038,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.91,23.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.43,41.1,,,,,0,9.18,67.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 7MM 3 SEAL COMPLETE SYSTEM 90MM CLEAR-TRAC",SUP-72200440,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 19MM KNEE X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G219,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"NOVANET [10819]",Novanet,,7024.56,75,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC .99CM 6.17X7.45CM TELIGEN VR ATRIUM VENTRICLE",SUP-E102,CDM,C1722,HCPCS,0278,RC,,,both,,,65019.90,19505.97,"MULTIPLAN [10600]",Multiplan,,55266.92,85,,,,,0,7561.81,55266.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GASTROJEJUNOSTOMY TUBE 14FR STOMA L2.5CM JEJUNAL L30CM S",SUP-8270-14-2.5-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,3027.60,908.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1244.34,41.1,,,,,0,352.11,2573.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BRACHYTHERAPY 20CM 18GA MICK APPLR SEED IMPLANTATION",SUP-918201,CDM,C1715,HCPCS,0272,RC,,,both,,,74.21,22.26,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MACH1 90CM 8FR AL.75ST CURVE GUIDING PTFE FEMORAL",SUP-H749343581910,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 160MM 2.7MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.67,CDM,S27000186,LOCAL,0270,RC,,,both,,,2111.40,633.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE GLDEWIRE VASCULAR ANGLE TAPER 260CM 1CM .035IN NITINOL",SUP-GR3517,CDM,C1769,HCPCS,0272,RC,,,both,,,408.90,122.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR STORZ 1 STEM",SUP-M0068802051,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 11.4IN CORONARY ARTERY 5MM 3MM RIGHT ANGLE",SUP-415806,CDM,S27200284,LOCAL,0272,RC,,,both,,,801.90,240.57,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNARE SMALL OVAL 240CM 2.4MM SENSATION LOOP SHORT THROW",SUP-M00562692,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.45,37.63,"PHCS [10601]",PHCS,,87.82,70,,,,,0,14.59,106.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 485CC",SUP-SSZ-M485,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CIGNA [10200]","Cigna Local Plus",,797.36,53.5,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENOBARBITAL 32.4 MG TABLET",RX-6217,CDM,,,0637,RC,00904-6575-61,NDC,both,1,UN,12.54,3.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)CORONARY IVL CATHETER, 2.5MM X 20MM, RX IDE",SUP-501050-005,CDM,C1761,HCPCS,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BARREL 22FR 3MM STERILE DISPOSABLE",SUP-26055RK,CDM,S27000186,LOCAL,0270,RC,,,both,,,1123.40,337.02,"NOVANET [10819]",Novanet,,842.55,75,,,,,0,130.65,954.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 40MX19.5MMX.4MM STERILE",SUP-KM-3231,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"MULTIPLAN [10600]",Multiplan,,52.5,85,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL MEDIUM 16MM KNEE DURATION POSTERIOR STABILIZE",SUP-6742-1-216,CDM,C1776,HCPCS,0278,RC,,,both,,,5709.75,1712.92,"FIRST HEALTH [10303]","First Health",,4567.8,80,,,,,0,664.04,4853.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.475,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA [10200]","Cigna Local Plus",,2590.79,53.5,,3978.14,359.25,3978.14,24,563.19,4116.21,"percent of total billed charges",
"TRAY CATH 4FR 20CM POWERMIDLINE MICROEZ FLEXURA STATLOCK",SUP-P4154108,CDM,C1751,HCPCS,0272,RC,,,both,,,941.87,282.56,"UHC [10700]","United Healthcare",,596.2,63.3,,,,,0,109.54,800.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 20CM 5FR .035",SUP-M006192120090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"CIGNA [10200]","Cigna Local Plus",,798.45,,,,,,,173.57,1268.57,"percent of total billed charges",
"NAIL 10MM 46CM LEFT TROCHANTERIC INTRAMEDULLARY 130D LONG",SUP-456.367S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"KAISER [10500]",Kaiser,,9159.18,67,,,,,0,1589.87,11619.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM RELINE 2C SPINE POLYAXIAL NONSTERILE",SUP-16016545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS [10001]","Blue Cross HMO",,3742.37,39.2,,957.42,156.86,7483.26,51,1110.3,8114.82,"percent of total billed charges",
"PLATE CURVE 195MM STAINLESS STEEL 4.5MM SCR 8 HOLE 4 COLUMN",SUP-02.124.408S,CDM,C1713,HCPCS,0278,RC,,,both,,,13302.23,3990.67,"NOVANET [10819]",Novanet,,9976.67,75,,,,,0,1547.05,11306.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL ICONIX 1.4MM STERILE DISPOSABLE",SUP-3910500568,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"CIGNA [10200]","Cigna Open Access",,718.99,56.9,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRACCATH, LARGE",SUP-4640-02,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 22MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-122,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"BLUE CROSS [10001]","Blue Cross HMO",,4717.17,39.2,,5311.50,4717.44,5388.59,31,1399.51,10228.56,"percent of total billed charges",
"HEAD FEMORAL -3.5MM 12/14 SMALL 28MM HIP ACETABULAR BIOLOX",SUP-00-8775-028-01,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2821.57,28.62,,,,,0,1146.57,8379.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 200MM SCHANZ STAINLESS STEEL CONDYLE HIP SELF",SUP-294.786,CDM,C1713,HCPCS,0278,RC,,,both,,,1042.88,312.86,"KAISER [10500]",Kaiser,,698.73,67,,,,,0,121.29,886.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 2CM 5MM BALLOON DILATATION",SUP-DR8052,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"AETNA [10100]","Aetna HMO/PPO",,1094.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET DIAGNOSTIC EXPLORA ENDOMETRIAL UTERINE 3MM BIOPSY",SUP-MX120,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.16,24.65,"PHCS [10601]",PHCS,,57.51,70,,,,,0,9.56,69.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION DEB 2.25X40",SUP-SCA14U-225040D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PG PRO 2.8FR/140CM/STRAIGHT",SUP-PGP28140STR,CDM,C1887,HCPCS,0272,RC,,,both,,,3697.50,1109.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,438.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,430.02,3142.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIANEAL LOW CALCIUM (2.5 MEQ/L) PERITONEAL DIALYSIS SOLUTION",SUP-6AB9747E,CDM,S27200284,LOCAL,0272,RC,,,both,,,46.05,13.81,"KAISER [10500]",Kaiser,,30.85,67,,,,,0,5.36,39.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN OMEGA3 MARIGEN 16MM CIRCULAR FISH SKIN STERILE",SUP-50200S16B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,180.89,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM .02IN 3MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0305,CDM,S27800098,LOCAL,0278,RC,,,both,,,4158.00,1247.4,"AETNA [10100]","Aetna HMO/PPO",,3305.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,483.58,3534.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 14MM 140CM 2.5MM",SUP-RSINT25014UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"NOVANET [10819]",Novanet,,4158,75,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.270 CLAREON",SUP-SY60WF.270,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUNAV CRYSTAL 9FR ULTRASOUND STERILE LATEX FREE",SUP-11510825,CDM,C1759,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CIRCULATORY SYSTEM O.R. PROCEDURES",264,MS-DRG,,,,,,,inpatient,,,113503.96,34051.19,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,22172.48,,"Case rate ($20,721.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $19,241.73, add-ons for qualifying new technology services are included. If operating cost exceeds $52,281.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,836.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $19,267.18. The transfer operating threshold is the transfer adjustment factor * $19,241.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,454.77. The transfer capital threshold is the transfer adjustment factor * $1,454.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,97532.16,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 27CM 14.5FR STD STRAIGHT POLYURETHANE PTFE HEMOSTAR",SUP-5833270,CDM,C1750,HCPCS,0278,RC,,,both,,,1563.30,468.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1063.04,68,,,,,0,181.81,1328.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 12MM 3.25MM EMBOLIZATION",SUP-PED2-325-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"AETNA [10100]","Aetna HMO/PPO",,64234.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 3.5MM 42MM OMEGA3 STAINLESS STEEL FULL THREAD",SUP-340640,CDM,C1713,HCPCS,0278,RC,,,both,,,255.78,76.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,73.2,28.62,,,,,0,29.75,217.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM .02IN 2MM PENUMBRA COIL 400 RUBY",SUP-RBY4C0201,CDM,S27800098,LOCAL,0278,RC,,,both,,,4158.00,1247.4,"CIGNA [10200]","Cigna Open Access",,2365.9,56.9,,,,,0,483.58,3534.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 26MM TI",SUP-MTC-37260-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,147.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,145.07,1060.29,"percent of total billed charges",
"SPACER SPINAL 37X27X16MM SOVEREIGN 8D MEDIUM",SUP-7968816,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"CIGNA [10200]","Cigna Open Access",,11482.33,33.5,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 26MM SPINE PEDICLE PLY NONSTERILE 4MM ROD",SUP-102050226,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM NARROW BLADE LIPPED",SUP-7541223,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,1831.33,1831.33,1831.33,16,348.9,2550,"percent of total billed charges",
"BEARING 71/75MMX10MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183740,CDM,C1776,HCPCS,0278,RC,,,both,,,13241.10,3972.33,"KAISER [10500]",Kaiser,,8871.54,67,,,,,0,1539.94,11254.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT RED 18X4IN STD ARM 1 FILL LINE POSITIVE LOCK CNCT",SUP-ASP-564006,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.71,40.41,"FIRST HEALTH [10303]","First Health",,107.77,80,,,,,0,15.67,114.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 7MM 3 SEAL COMPLETE SYSTEM 90MM CLEAR-TRAC",SUP-72200440,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"UHC [10700]","United Healthcare",,165.21,63.3,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON SIZING 47.5MM BARRX 360 ESOPHAGEAL SOFT STERILE",SUP-3441B,CDM,S27200284,LOCAL,0272,RC,,,both,,,3383.55,1015.06,"FIRST HEALTH [10303]","First Health",,2706.84,80,,,,,0,393.51,2876.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA EXTRA FULL PROFILE SOFT TOUCH",SUP-SSX-650,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PHCS [10601]",PHCS,,5288.85,70,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 9CM 23MM 18.5FR ESOPHAGEAL PERMALUME",SUP-M00516940,CDM,C1874,HCPCS,0278,RC,,,both,,,10022.00,3006.6,"UHC [10700]","United Healthcare",,6343.93,63.3,,,,,0,1165.56,8518.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL ANGLE SELF CENTERING FORTIFY I",SUP-676.703,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"NOVANET [10819]",Novanet,,2967.3,75,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 220MM 3MM BALLOON DILATATION PEBAX",SUP-H74939032302210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL WEIL-BLAKESLEY 0 3.5MM 7.5IN NASAL FENESTRATE",SUP-63-2009,CDM,S27200284,LOCAL,0272,RC,,,both,,,1920.45,576.13,"KAISER [10500]",Kaiser,,1286.7,67,,,,,0,223.35,1632.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.250,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCKER SPINAL MANTIS PEDICLE REDUCTION",SUP-48289999,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"CIGNA [10200]","Cigna Open Access",,198.01,56.9,,1144.80,304.56,2275.09,66,40.47,295.8,"percent of total billed charges",
"CATHETER C304S5905 SELECTSITE GLOBAL",SUP-C304S5905,CDM,C1887,HCPCS,0272,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 195MM 4.5MM STAINLESS STEEL QUICK COUPLING",SUP-310.48,CDM,S27000186,LOCAL,0270,RC,,,both,,,814.21,244.26,"CIGNA [10200]","Cigna Open Access",,463.29,56.9,,,,,0,94.69,692.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TIBIAL CORTICAL THK3-15MM HALF ALLOGRAFT FROZEN",SUP-450540,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6227.22,68,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PLUS PROFILE SILICONE",SUP-SCLP-190,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA 46IN AUGMENTATION HEAVIER ADJUSTABLE STRAP FRONT ZIPPER",SUP-2-8124C-46,CDM,S27000186,LOCAL,0270,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AMPLATZ 17CM 16FR ACCESS PTFE RENAL FIRM TAPER TIP",SUP-M0062601460,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"KAISER [10500]",Kaiser,,224.18,67,,,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN STD JUDKINS RIGHT",SUP-534621T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Asp Breast Cyst Add",PX-361000016,CDM,19001,CPT,0361,RC,,,both,,,2720.78,816.23,"MULTIPLAN [10600]",Multiplan,,2312.66,85,,,,,0,316.43,2720.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE CONNECT FLEX VASCULAR 195CM .018IN DURASTEEL",SUP-1012591,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"PHCS [10601]",PHCS,,674.73,70,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CLLGN FIBERTAPE FIBERWIRE 2 TAPER 7INX2MM BRAID BLUE",SUP-AR-7237-7B,CDM,S27200284,LOCAL,0272,RC,,,both,,,637.88,191.36,"CIGNA [10200]","Cigna Local Plus",,341.27,53.5,,,,,0,74.19,542.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EMPAGLIFLOZIN 25 MG TABLET",RX-167819,CDM,,,0637,RC,00597-0153-37,NDC,both,1,UN,52.92,15.88,"KAISER [10500]",Kaiser,,35.46,67,,,,,0,6.15,44.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM 6IN SIMS VAGINAL 75X30MM",SUP-EL408R,CDM,S27200284,LOCAL,0272,RC,,,both,,,257.78,77.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,105.95,41.1,,,,,0,29.98,219.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 100MM 9MM BALLOON DILATATION DURALYN",SUP-48009010S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,163.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 52MM 36MM ALTRX HIP",SUP-122136052,CDM,C1776,HCPCS,0278,RC,,,both,,,6186.60,1855.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,733.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,719.5,5258.61,"percent of total billed charges",
"HC Wb or RBC L/R Cmv Neg Ea",PX-390000015,CDM,P9051,HCPCS,0390,RC,,,both,,,1489.50,446.85,"AETNA [10100]","Aetna HMO/PPO",,1184.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.23,1266.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 80MM MEDIUM NOTCH 35MM",SUP-38-051-80-07,CDM,S27000186,LOCAL,0270,RC,,,both,,,1407.78,422.33,"CIGNA [10200]","Cigna Open Access",,801.03,56.9,,,,,0,163.72,1196.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE CONNECTING 30CM 14FR 1 WAY STPCOCK DRNG BAG CNCT",SUP-G02278,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.36,35.21,"CIGNA [10200]","Cigna Open Access",,66.78,56.9,,,,,0,13.65,99.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 21GA 4CM TUBE RADIOPAQUE REMOVABLE STPCOCK",SUP-PSS-7F-4MT,CDM,C1894,HCPCS,0272,RC,,,both,,,165.30,49.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER 6248V-130L ATTAIN SELECT II",SUP-6248V-130L,CDM,C1887,HCPCS,0272,RC,,,both,,,2272.50,681.75,"UHC [10700]","United Healthcare",,1438.49,63.3,,,,,0,264.29,1931.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 26CM 3CM 5FR .035IN 2",SUP-M006192123180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"MULTIPLAN [10600]",Multiplan,,1351.39,85,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 120CM 8MM 9FR STRAIGHT VASCULAR",SUP-AVSL08100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]","Cigna Local Plus",,5755.05,31.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.6MM 150MM KIRSCHNER MONSTER HINDFOOT SCR",SUP-P99-192-1615,CDM,C1713,HCPCS,0278,RC,,,both,,,146.16,43.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,67.09,45.9,,,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCIVA VR",SUP-D400,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4535.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 3.50 X 18 MM",SUP-1212350-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"NOVANET [10819]",Novanet,,12937.5,75,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE UBER FLEX 40MM 57CM 9MM .078IN VASCULAR",SUP-SR-0940-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL STD KNEE RIGHT STABILIZE CEMENT ROTATE",SUP-129411040,CDM,C1776,HCPCS,0278,RC,,,both,,,31285.80,9385.74,"CIGNA [10200]","Cigna Local Plus",,9855.03,31.5,,5372.07,4581.20,7242.98,23,3638.54,26592.93,"percent of total billed charges",
"HC Hematocrit (Fluid)",PX-305000079,CDM,85013,CPT,0305,RC,,,both,,,89.00,26.7,"NOVANET [10819]",Novanet,,66.75,75,,,,,0,1.61,75.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC",316,MS-DRG,,,,,,,inpatient,,,30036.29,9010.89,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,9096.89,,"Case rate ($4,231.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,928.87, add-ons for qualifying new technology services are included. If operating cost exceeds $36,968.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,679.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,934.07. The transfer operating threshold is the transfer adjustment factor * $3,928.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.04. The transfer capital threshold is the transfer adjustment factor * $297.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,4231.11,17010.89,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) HEARTBEAM AIMIGO VECG DEVICE (W/ CHARGING CABLE AND DOC","SUP-SN A000113",CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AXIS TUTOPLAST PROCESSED DERMIS 6CM X 16CM",SUP-939616,CDM,C1762,HCPCS,0278,RC,,,both,,,23870.70,7161.21,"UHC [10700]","United Healthcare",,15110.15,63.3,,,,,0,2776.16,20290.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 8MM PRIMARY MONOBLOCK DJO SURGICAL REVERSE RSP",SUP-510-00-008,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH BLUPERC PERCUTANEOUS DILATION STERILE LATEX FREE",SUP-101/561/070,CDM,S27200284,LOCAL,0272,RC,,,both,,,2872.20,861.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMPULSE 100CM 5FR AR1 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916391842,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN OPHTHALMIC 25GA .8MM GRIESHABER SHORT SOFT TIP STERILE",SUP-8065149530,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.01,60,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NERVOUS SYSTEM MALIGNANCY,EXTREME",041,APR-DRG,,,,,,,inpatient,,,59718.58,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $11,310.81. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($77,112.87) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"MIGRAINE AND OTHER HEADACHES,MODERATE",054,APR-DRG,,,,,,,inpatient,,,46756.32,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $4,291.60. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%.",,,,0,,,other,"SOI-2 Shortstay; Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF GALLBLADDER AND BILIARY TRACT,MINOR",284,APR-DRG,,,,,,,inpatient,,,33317.46,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $3,643.35. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%.",,,,0,,,other,"SOI-1 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 60MM 10MM 8.5FR BILIARY PERMALUME RAPID",SUP-7053,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 50.8MM 2MM MEDIUM WIRE PASS STERILE",SUP-5300010071,CDM,S27200284,LOCAL,0272,RC,,,both,,,293.10,87.93,"FIRST HEALTH [10303]","First Health",,234.48,80,,,,,0,34.09,249.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Frozen Section 1st Block",PX-312000037,CDM,88331,CPT,0312,RC,,,both,,,569.50,170.85,"UHC [10700]","United Healthcare",,146.47,,,,,,,0.01,484.08,"fee schedule",
"CAP SYSTEM PERSONA TKR VIVACIT-E XLPE FEMUR PATELLA TIBIA CE",SUP-98000200090,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6123.6,27,,,,,0,2637.68,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAC-LOC 40CM 12FR DRNG ULTRATHANE HYDROPHILIC BILIARY",SUP-G09499,CDM,C1729,HCPCS,0272,RC,,,both,,,801.82,240.55,"UHC [10700]","United Healthcare",,507.55,63.3,,,,,0,93.25,681.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PLATE 3 66X42MM STEMMED NEXGEN PRECOAT TIVANIUM",SUP-00598003701,CDM,C1776,HCPCS,0278,RC,,,both,,,8643.60,2593.08,"BLUE CROSS [10001]","Blue Cross PPO",,3388.29,39.2,,3949.44,3949.44,3949.44,"1 through 10",1005.25,7347.06,"percent of total billed charges",
"COMPONENT FEM POR LEFT SZ 12",SUP-427-01-120,CDM,C1776,HCPCS,0278,RC,,,both,,,32703.43,9811.03,"NOVANET [10819]",Novanet,,24527.57,75,,,,,0,3803.41,27797.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Iliac W Stent Cmplx Init",PX-361000701,CDM,37260,CPT,0361,RC,,,both,,,19230.05,5769.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7883,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2236.45,16345.54,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP 3 HOLE PUREFIX HYDROXYAPATITE",SUP-542-11-62H,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"PHCS [10601]",PHCS,,4870.4,70,,,,,0,809.18,5914.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SILVERHAWK MEC 110CM 6CM 3.5-5MM 2.7MM ATHERECTOMY",SUP-P4056,CDM,C1714,HCPCS,0272,RC,,,both,,,17955.00,5386.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2127.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2088.17,15261.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOJET ULTRA CROSS-STREAM SPIROFLEX THROMBECTOMY",SUP-106553-001,CDM,C1757,HCPCS,0272,RC,,,both,,,12891.96,3867.59,"KAISER [10500]",Kaiser,,8637.61,67,,,,,0,1499.33,10958.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 13MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532-P-113,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]",Cigna,,5682.01,68,,5873.17,5873.17,5873.17,"1 through 10",971.79,7102.52,"percent of total billed charges",
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 15MM 6FR 3.75MM",SUP-H7493926715370,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"KAISER [10500]",Kaiser,,379.89,67,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL BABCOCK 14IN TISSUE",SUP-50-1026,CDM,S27200284,LOCAL,0272,RC,,,both,,,840.86,252.26,"CIGNA [10200]","Cigna Local Plus",,449.86,53.5,,,,,0,97.79,714.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006175283190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]",Cigna,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DROXIDOPA 100 MG CAPSULE",RX-167748,CDM,,,0250,RC,31722-0014-90,NDC,both,1,UN,139.02,41.71,"MULTIPLAN [10600]",Multiplan,,118.17,85,,,,,0,16.17,118.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 8.25INX1.5MM OLSEN BIPOLAR BAYONET",SUP-20-0431R,CDM,S27200284,LOCAL,0272,RC,,,both,,,843.15,252.94,"CIGNA [10200]","Cigna Open Access",,479.75,56.9,,,,,0,98.06,716.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 6MM GORE PROPATEN EPTFE HEPARIN THIN",SUP-HT066080A,CDM,C1768,HCPCS,0278,RC,,,both,,,18011.70,5403.51,"BLUE CROSS [10001]","Blue Cross HMO",,7060.59,39.2,,,,,0,2094.76,15309.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175263170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS [10001]","Blue Cross PPO",,496.03,39.2,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Androstenedione",PX-301000106,CDM,82157,CPT,0301,RC,,,both,,,217.65,65.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,103.92,,,,,,,0.01,185,"fee schedule",
"CATH RELIEVA SPIN RELIEVA VORTEX 2 16MM 6MM F-70 GUIDING",SUP-RSF70,CDM,S27200284,LOCAL,0272,RC,,,both,,,2400.00,720,"CIGNA [10200]","Cigna Open Access",,1365.6,56.9,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR RESPIRATORY PAD LEVEL SARNS DISPOSABLE",SUP-195240,CDM,S27000186,LOCAL,0270,RC,,,both,,,156.60,46.98,"PHCS [10601]",PHCS,,109.62,70,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 35MM 9.5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ235,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"FIRST HEALTH [10303]","First Health",,7222.18,80,,,,,0,1049.92,7673.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 14MM STD WALL GORE-TEX RING 30CM STERILE",SUP-R14030030,CDM,C1768,HCPCS,0278,RC,,,both,,,7969.50,2390.85,"CIGNA [10200]","Cigna Local Plus",,4263.68,53.5,,,,,0,926.85,6774.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183662,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"FIRST HEALTH [10303]","First Health",,10550.93,80,,,,,0,1533.84,11210.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCKER SPINAL MANTIS PEDICLE REDUCTION",SUP-48289999,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"BLUE CROSS [10001]","Blue Cross HMO",,136.42,39.2,,957.42,156.86,7483.26,51,40.47,295.8,"percent of total billed charges",
"KIT ENDOSCOPIC INSTR 1.35-1.6MM DRILL GUIDE GWIRE DISPOSABLE",SUP-AR-8990DS,CDM,C1769,HCPCS,0272,RC,,,both,,,2165.63,649.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,890.07,41.1,,,,,0,251.86,1840.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 7MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0750CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"BLUE CROSS [10001]","Blue Cross PPO",,3110.52,39.2,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14IN 28FR VENOUS ADULT 3/8IN CONNECTION SITE",SUP-69328,CDM,S27200284,LOCAL,0272,RC,,,both,,,369.61,110.88,"MULTIPLAN [10600]",Multiplan,,314.17,85,,,,,0,42.99,314.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE FEEDING TUBE ENFIT FARRELL ENTERAL GASTRIC PRESSURE",SUP-43-4100,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.63,16.99,"MULTIPLAN [10600]",Multiplan,,48.14,85,,,,,0,6.59,48.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +19.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.195,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 60X22X7MM RISE-L 3D LORDOTIC NONSTERILE",SUP-193.606,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9270.45,27,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 13MM SPINE CERVICAL ANTERIOR SELF DRILL FIX",SUP-7742113,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT CEMENTED CRUCIATE RETAINING",SUP-150400207,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2604.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM ROUND CARBIDE STERILE LATEX FREE",SUP-5820-110-040C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1910.03,573.01,"AETNA [10100]","Aetna HMO/PPO",,1518.47,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,222.14,1623.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC 130CM 1.2MM COREDX MINI STERILE DISPOSABLE",SUP-M00515220,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 10CM 4MM 5FR BALLOON DILATATION",SUP-DR135410,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"AETNA [10100]","Aetna HMO/PPO",,1094.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE UBER FLEX 40MM 57CM 8MM .065IN VASCULAR",SUP-SR-0840-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 6X 59MM CATH 120CM ENDOVASCULAR",SUP-42659,CDM,C1874,HCPCS,0278,RC,,,both,,,18881.10,5664.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7760.13,41.1,,,,,0,2195.87,16048.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME PATELLAR 35MM PFC SIGMA SMALL OVAL KNEE UHMWPE CEMENTED",SUP-960101,CDM,C1776,HCPCS,0278,RC,,,both,,,4723.05,1416.91,"FIRST HEALTH [10303]","First Health",,3778.44,80,,,,,0,549.29,4014.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC20ST-LK,CDM,S27200284,LOCAL,0272,RC,,,both,,,17640.00,5292,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11995.2,68,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SPINAL I-PAS III INSULATED PEDICLE ACCESS SYSTEM BEVELED",SUP-2010029,CDM,S27200284,LOCAL,0272,RC,,,both,,,2342.00,702.6,"FIRST HEALTH [10303]","First Health",,1873.6,80,,,,,0,272.37,1990.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 30CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175265080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"KAISER [10500]",Kaiser,,830.38,67,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vasc Embol Occl Arterial Trinav",PX-361000637,CDM,C9797,HCPCS,0361,RC,,,both,,,13815.00,4144.5,"NOVANET [10819]",Novanet,,10361.25,75,,,,,0,1606.68,11835.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.2MM X 14MM COCR",SUP-VAN-12014-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 485CC NATRELLE INSPIRA COHESIVE STERILE",SUP-TCM-485,CDM,C1789,HCPCS,0278,RC,,,both,,,8280.00,2484,"NOVANET [10819]",Novanet,,6210,75,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUITY PRO LEAD DELIVERY SYSTEM",SUP-PLDS,CDM,S27200284,LOCAL,0272,RC,,,both,,,3339.00,1001.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,395.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,388.33,2838.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 8X20 40CM SL",SUP-48008002P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 8 HOLE STERNALOCK BLU BONE STERNAL",SUP-73-1952,CDM,C1713,HCPCS,0278,RC,,,both,,,4754.10,1426.23,"BLUE CROSS [10001]","Blue Cross HMO",,1863.61,39.2,,957.42,156.86,7483.26,51,552.9,4040.99,"percent of total billed charges",
"CMPNT FEMORAL 6 KNEE RIGHT POSTERIOR STABILIZE GENESIS II",SUP-71421206,CDM,C1776,HCPCS,0278,RC,,,both,,,29077.65,8723.29,"MULTIPLAN [10600]",Multiplan,,24716,85,,,,,0,3381.73,24716,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXTOME 142CM 10MM 3.75MM BALLOON DILATATION NYLON",SUP-H749CBM3375100,CDM,C1725,HCPCS,0272,RC,,,both,,,5395.80,1618.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,627.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,627.53,4586.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 30MM RSP P2 STERILE",SUP-508-32-204,CDM,C1776,HCPCS,0278,RC,,,both,,,9442.80,2832.84,"FIRST HEALTH [10303]","First Health",,7554.24,80,,,,,0,1098.2,8026.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT",RX-122493,CDM,,,0637,RC,41100-0811-63,NDC,both,42.5,GR,14.17,4.25,"CIGNA [10200]",Cigna,,9.64,68,,,,,0,1.65,12.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM EVEREST SPINE CANNULATED POLYAXIAL MIS",SUP-M5111-07550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"PLATE 20MM 4 HOLE POLYAXIAL CLAW II BONE ANKLE FOOT",SUP-40240420,CDM,C1713,HCPCS,0278,RC,,,both,,,15000.60,4500.18,"BLUE CROSS [10001]","Blue Cross HMO",,5880.24,39.2,,957.42,156.86,7483.26,51,1744.57,12750.51,"percent of total billed charges",
"SCR BONE 3.5MM 2.5MM 55MM AXSOS STAINLESS STEEL CORTICAL",SUP-338655,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"BLUE CROSS [10001]","Blue Cross HMO",,90.24,39.2,,957.42,156.86,7483.26,51,26.77,195.67,"percent of total billed charges",
"6.0MM X 13MM SENSAR INTRAOCULAR LENS, BICONVEX, 19.0 DIOPTER",SUP-AR40E00190,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"KAISER [10500]",Kaiser,,624.11,67,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 4.5MM 32MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.532.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,70.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",69.37,507.01,"percent of total billed charges",
"SUTURE POLYPROPYLENE CAPIO TAPERCUT 0 36IN 2 ARM MONOFILAMEN",SUP-M0068332351,CDM,S27200284,LOCAL,0272,RC,,,both,,,546.75,164.02,"CIGNA [10200]","Cigna Open Access",,311.1,56.9,,,,,0,63.59,464.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 10FR PIGTAIL CURVE NEPHROURETERAL PERCUFLEX METAL",SUP-M001221400,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"KAISER [10500]",Kaiser,,596.97,67,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 24MM MITRAL SEMIRIGID MEMO 3D",SUP-SMD24,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1512.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 100MM 5FR 4MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-04101,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR SKIN 4.1X6.5MM 35 WIDE STAPLE CRTDG LATEX FREE APPOSE",SUP-8886803712,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.55,1.36,"PHCS [10601]",PHCS,,3.19,70,,,,,0,0.53,3.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM PK COIL LP STERILE LATEX FREE",SUP-RBYPCLP60,CDM,S27800098,LOCAL,0278,RC,,,both,,,8832.00,2649.6,"UHC [10700]","United Healthcare",,5590.66,63.3,,,,,0,1027.16,7507.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX10MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183520,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"PHCS [10601]",PHCS,,9066.88,70,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 4-0 SH 30IN BRAID BLACK NONABSORBABLE",SUP-K831H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RIGIFLEX II 90CM 10CM 14FR 40MM BALLOON DILATATION",SUP-M00554520,CDM,C1726,HCPCS,0272,RC,,,both,,,4370.81,1311.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,517.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,508.33,3715.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 110CM 5FR PIGTAIL CURVE ANGIOGRAPHIC RADIOPAQUE",SUP-H787107085035,CDM,C1887,HCPCS,0272,RC,,,both,,,218.37,65.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.4,185.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY FLEXIBLE 640MM 5FR",SUP-A2421,CDM,S27200284,LOCAL,0272,RC,,,both,,,5497.23,1649.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2259.36,41.1,,,,,0,639.33,4672.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 7-8 13MM KNEE POSTERIOR STABILIZE HIGH",SUP-71453233,CDM,C1776,HCPCS,0278,RC,,,both,,,14665.95,4399.78,"KAISER [10500]",Kaiser,,9826.19,67,,,,,0,1705.65,12466.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO BALKIN CURVE 40CM 8FR 2.9MM GUIDING",SUP-G32216,CDM,C1894,HCPCS,0272,RC,,,both,,,432.22,129.67,"UHC [10700]","United Healthcare",,273.6,63.3,,,,,0,50.27,367.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 40MM HIP BIOLOX DELTA BIOLOX OPTION G7",SUP-650-1058,CDM,C1776,HCPCS,0278,RC,,,both,,,13896.60,4168.98,"AETNA [10100]","Aetna HMO/PPO",,11047.8,79.5,,10981.53,8986.79,12413.38,12,1616.17,11812.11,"percent of total billed charges",
"COIL EMBOLIZATION 10CM 3MM TARGET HELICAL PLATINUM",SUP-M0035433100,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"CIGNA [10200]","Cigna Open Access",,5210.72,56.9,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 20MM 130CM 9MM 6FR VASCULAR NITINOL 2",SUP-SC920LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"KAISER [10500]",Kaiser,,4854.15,67,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 2.5IN STAINLESS STEEL FLEXIBLE QUICK RELEASE COUPLING",SUP-430053,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"CIGNA [10200]","Cigna Local Plus",,1103.44,53.5,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D 15.5D MODIFY L 13MM 6MM POSTERIOR CHMBR FOLDABLE",SUP-SY60WF.155,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY SHORT TOOTH",SUP-NF03,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.32,22.6,"AETNA [10100]","Aetna HMO/PPO",,59.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.76,64.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 2CM 4MM BALLOON DILATATION HYDROPHILIC",SUP-G50334,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"AETNA [10100]","Aetna HMO/PPO",,1878.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 2.4MM SCR 4 HOLE LOW PROFILE 2 SIDE",SUP-73-2636,CDM,C1713,HCPCS,0278,RC,,,both,,,2437.50,731.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,697.61,28.62,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 118MM CEMENTLESS NECK ACCOLADE TMZF 127D 2.5 40",SUP-6021-2530,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"AETNA [10100]","Aetna HMO/PPO",,18143.29,79.5,,10981.53,8986.79,12413.38,12,2654.17,19398.49,"percent of total billed charges",
"DEVICE LMA MADGIC 30-100UM 8.5IN .18IN DRUG DELIVERY 3ML .25",SUP-MAD600,CDM,S27000186,LOCAL,0270,RC,,,both,,,86.15,25.84,"FIRST HEALTH [10303]","First Health",,68.92,80,,,,,0,10.02,73.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3.8MM 2.9MM MATCH HEAD",SUP-KM-AM8U,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 61CM 12MM ENDO PADDLE RETRACT CURVE JAW DISPOSABLE",SUP-173046,CDM,S27200284,LOCAL,0272,RC,,,both,,,749.17,224.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,343.87,45.9,,,,,0,87.13,636.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM LARGE PRATT RECTAL",SUP-475100,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.88,262.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,359.58,41.1,,,,,0,101.75,743.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 28MM PERIPHERAL STERILE",SUP-AR-9562-28NL,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"BLUE CROSS [10001]","Blue Cross HMO",,234.17,39.2,,957.42,156.86,7483.26,51,69.48,507.77,"percent of total billed charges",
"SCR BONE 3MM 2MM 28MM 6MM STAINLESS STEEL 1.1MM SHORT THREAD",SUP-02.226.028,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,194.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,191.34,1398.42,"percent of total billed charges",
"GUIDE NDL 3 ANGLE INSRT LATEX FREE STERILE 10-20GA",SUP-UA1336,CDM,S27200284,LOCAL,0272,RC,,,both,,,263.61,79.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,31.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.66,224.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 28CM 8FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001245660,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"CIGNA [10200]","Cigna Open Access",,981.53,,,,,,,200.62,1466.25,"percent of total billed charges",
"REAMER SURGICAL SPARE TUBE COMPLETE 1.5MM SCR HOLLOW",SUP-309.150,CDM,S27200284,LOCAL,0272,RC,,,both,,,2173.50,652.05,"CIGNA [10200]","Cigna Open Access",,1236.72,56.9,,,,,0,252.78,1847.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRI-STAPLE 2.0 RELOAD 60MM VASCULAR/MEDIUM TISSUE TAN",SUP-SIG60AVM,CDM,S27200284,LOCAL,0272,RC,,,both,,,1576.18,472.85,"FIRST HEALTH [10303]","First Health",,1260.94,80,,,,,0,183.31,1339.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit Level 4 W Proc",PX-450000318,CDM,99284,CPT,0450,RC,,,both,,,2129.58,638.87,"CIGNA [10200]",Cigna,,1833,,,,,,,419.55,2129.58,"case rate",
"SHEATH AMPLATZ 17CM 30FR ACCESS RENAL RADIOPAQUE STRIPE",SUP-G57469,CDM,C1894,HCPCS,0272,RC,,,both,,,494.10,148.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,335.99,68,,,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 15CM 7FR 6MM .018IN BALLOON DILATATION",SUP-V1860150,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"MULTIPLAN [10600]",Multiplan,,4662.68,85,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABIL 8CM 40CM 10MM ENDOPROSTHESIS GORE-TEX NITINOL",SUP-VH1008040,CDM,C1874,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Local Plus",,6945.75,31.5,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 7CM 5FR STRAIGHT PANCREATIC POLYMER RADIOPAQUE",SUP-M00536410,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"KAISER [10500]",Kaiser,,428.3,67,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.230,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Open Access",,391.76,56.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tmvi W/Pros Vlv Perc Approach",PX-480000070,CDM,0483T,CPT,0481,RC,,,both,,,48360.36,14508.11,"BLUE CROSS [10001]","Blue Cross PPO",,9549.81,,"Case rate ($9,549.81). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2491,41106.31,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 48MM UNITRAX FEMORAL HIP MODULAR",SUP-6942-5-048,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"PHCS [10601]",PHCS,,2189.39,70,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mopath Procedure Level 1",PX-309000093,CDM,81400,CPT,0310,RC,,,both,,,1109.85,332.95,"FIRST HEALTH [10303]","First Health",,887.88,80,,,,,0,0.01,943.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Afo Spiral Plastic Pf",PX-E27400079,CDM,L1951,HCPCS,0274,RC,,,both,,,2768.70,830.61,"CIGNA [10200]","Cigna Local Plus",,1481.25,53.5,,,,,0,322,2353.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Afo Spiral Plastic Pf",PX-E27400079,CDM,L1951,HCPCS,0274,RC,,,both,,,2768.70,830.61,"KAISER [10500]",Kaiser,,1855.03,67,,,,,0,322,2353.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemo Cns",PX-331000006,CDM,96450,CPT,0331,RC,,,both,,,872.12,261.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,101.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,101.43,872.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA 34-36IN B-D MEDIUM FRONT HOOK LOOP CLSR SOFT SPRT",SUP-702,CDM,S27000186,LOCAL,0270,RC,,,both,,,353.83,106.15,"AETNA [10100]","Aetna HMO/PPO",,281.29,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.27,300.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIOFLON 2/0 1/2KL 20MM DA 75CM",SUP-19P30U,CDM,S27200284,LOCAL,0272,RC,,,both,,,604.80,181.44,"CIGNA [10200]","Cigna Open Access",,344.13,56.9,,,,,0,70.34,514.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) CATH LITHOPLASTY 110CM 60MM 5.5MM .064IN ULTRASOUND",SUP-M732LPBC5560DX1,CDM,C1725,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 4MM 7FR 2-5-2MM SPACE A CURVE ABLATION 10",SUP-D7AL252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,5326.80,1598.04,"PHCS [10601]",PHCS,,3728.76,70,,,,,0,619.51,4527.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX PROGRIP 30X15CM SELF GRIP FLAT SHEET",SUP-TEM3015G,CDM,C1781,HCPCS,0278,RC,,,both,,,3099.38,929.81,"KAISER [10500]",Kaiser,,2076.58,67,,,,,0,360.46,2634.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR 3MM OLYMPUS OES",SUP-M0068802351,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,212.27,41.1,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOGA SURGICAL STERI-SHIELD XL HYTREL ZIPPER DISPOSABLE",SUP-400851000,CDM,S27000186,LOCAL,0270,RC,,,both,,,415.76,124.73,"CIGNA [10200]","Cigna Open Access",,236.57,56.9,,,,,0,48.35,353.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 23MM 33MM HANCOCK II CINCH PORCINE",SUP-T510C33,CDM,S27800098,LOCAL,0278,RC,,,both,,,21420.00,6426,"CIGNA [10200]","Cigna Local Plus",,6747.3,31.5,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF UROLOGICAL J 145CM 3CM .038IN PTFE",SUP-M0066401071,CDM,C1769,HCPCS,0272,RC,,,both,,,250.91,75.27,"KAISER [10500]",Kaiser,,168.11,67,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTITORQUE 110CM 5FR SARAH RADIAL 4 CURVE ANGIOGRAPHIC",SUP-40-5024,CDM,C1887,HCPCS,0272,RC,,,both,,,313.20,93.96,"UHC [10700]","United Healthcare",,198.26,63.3,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH ACCESS CLEARPETRA L13 CM OD20 FR ID18 FR NEPHROSTOMY",SUP-90121813,CDM,C1894,HCPCS,0272,RC,,,both,,,3157.50,947.25,"KAISER [10500]",Kaiser,,2115.53,67,,,,,0,367.22,2683.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 12MM 5FR 2MM BALLOON DILATATION PEBAX",SUP-1012403-12,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"AETNA [10100]","Aetna HMO/PPO",,579.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 8MM 6MM SMALL CEMENT SURGICAL PLASTIC 2LB STERILE",SUP-OR1201,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.75,41.02,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.9,116.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TSRH THINLINE OSTEOGRIP",SUP-83565409,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"KAISER [10500]",Kaiser,,6396.39,67,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT 17GA 50MM ELECTROTHERAPY COOLIEF STERILE LATEX FREE",SUP-CRK-17-50-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH GLIDELIGHT 25-80HZ 50CM 14FR 9.5FR 10.2FR 14.7FR",SUP-500-302,CDM,C2629,HCPCS,0272,RC,,,both,,,19624.50,5887.35,"AETNA [10100]","Aetna HMO/PPO",,15601.48,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2282.33,16680.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) AGENT DCB CATHETER 3.0MM X 40MM",SUP-H7493960840300,CDM,C9610,HCPCS,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE WIRE SAW 20IN TWISTED STAINLESS STEEL GIGLI",SUP-751004,CDM,S27000186,LOCAL,0270,RC,,,both,,,161.82,48.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,66.51,41.1,,,,,0,18.82,137.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 16CM PUMP SET",SUP-ES2916,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7429.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL CANNULATED 4.0MM X 20MM",SUP-DRLL-CDC-40020,CDM,S27000186,LOCAL,0270,RC,,,both,,,2107.50,632.25,"CIGNA [10200]","Cigna Local Plus",,1127.51,53.5,,,,,0,245.1,1791.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY PRO 45CM 9FR WIDE CURVE GUIDING CORONARY SINUS",SUP-8110,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"MULTIPLAN [10600]",Multiplan,,3155.63,85,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 25CM 8FR PIGTAIL CURVE NEPHRSTMY LOCK REGULAR DUROMETER",SUP-M001271860,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 5MM CANNULATED LARGE QUICK COUPLING",SUP-03.333.112,CDM,S27000186,LOCAL,0270,RC,,,both,,,3111.08,933.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1278.65,41.1,,,,,0,361.82,2644.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 8MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620608,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Local Plus",,6020.84,53.5,,5372.07,4581.20,7242.98,23,1308.83,9565.82,"percent of total billed charges",
"CATH SABERX 150CM 100MM 2.5MM BALLOON DILATATION RAPID",SUP-47525100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 80MM 5MM BALLOON",SUP-LX181305805F,CDM,C2623,HCPCS,0272,RC,,,both,,,13110.00,3933,"KAISER [10500]",Kaiser,,8783.7,67,,,,,0,782.41,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 80CM 8MM 9FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM08100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"NOVANET [10819]",Novanet,,13702.5,75,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM VARIAX TORX TITANIUM FULL THREAD T10",SUP-40-35012,CDM,C1713,HCPCS,0278,RC,,,both,,,612.36,183.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,72.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,71.22,520.51,"percent of total billed charges",
"KIT PRESSURE MNTR TRANSPAC SAFESET 3 BRANCH INTRAVENOUS HIGH",SUP-46115-71,CDM,S27200284,LOCAL,0272,RC,,,both,,,257.61,77.28,"AETNA [10100]","Aetna HMO/PPO",,204.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.96,218.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Submuc Inj",PX-750000090,CDM,45381,CPT,0750,RC,,,both,,,2559.50,767.85,"MULTIPLAN [10600]",Multiplan,,2175.58,85,,,,,0,297.67,2559.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC SPRINTER FASTRAC 138CM 6MM 2.4/2.6-1.9FR 2.25MM",SUP-NCSP22506X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 20CM 40MM GORE TAG THORACIC ACTIVE CONTROL",SUP-TGMR404020,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"PHCS [10601]",PHCS,,81180.54,70,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BONE CEMENT 15CM 18GA NDL ACCESS CHIBA",SUP-K12-08326,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.10,33.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.15,96.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE ABSORBABLE 4X3IN HELISTAT HEMOSTATIC AGENT 5ML",SUP-3410ZX,CDM,S27200284,LOCAL,0272,RC,,,both,,,1551.97,465.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,183.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,180.49,1319.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET .241IN 24IN 2 NONVENT SECONDARY PIERCE PIN CNTNR CLAMP",SUP-654202,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.52,25.06,"MULTIPLAN [10600]",Multiplan,,70.99,85,,,,,0,9.71,70.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VISIGLIDE ENDOSCOPIC ANGLE 2700MM .025IN FLUORINE",SUP-G-240-2527A,CDM,C1769,HCPCS,0272,RC,,,both,,,1288.95,386.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,529.76,41.1,,,,,0,149.9,1095.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X6MM PARALLEL SPINE",SUP-17306,CDM,S27800098,LOCAL,0278,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 60MM 4MM TAPER BALLOON DILATATION JET",SUP-A2040-060,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"UHC [10700]","United Healthcare",,846,63.3,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-54840005540,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS EVOQUE VALVE (EVOQUE VALVE)48 MM",SUP-9850EV48CL,CDM,S62400003,LOCAL,0624,RC,,,both,,,216600.00,64980,"AETNA [10100]","Aetna HMO/PPO",,172197,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25190.58,184110,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH ENDOSCP 4MM 11.8MM ROUND EDGE STERILE LATEX FREE",SUP-D-201-11304,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.26,63.08,"AETNA [10100]","Aetna HMO/PPO",,167.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.45,178.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 10FR 11CM NO MINI GWIRE NO OBTR HEXCUSPID VALVE",SUP-504610A,CDM,C1894,HCPCS,0272,RC,,,both,,,72.65,21.79,"NOVANET [10819]",Novanet,,54.49,75,,,,,0,8.45,61.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Human Growth Hormone",PX-301000216,CDM,83003,CPT,0301,RC,,,both,,,158.65,47.59,"CIGNA [10200]",Cigna,,36.67,,,,,,,0.01,134.85,"fee schedule",
"SCR BONE 7.5MM 40MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4740,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,1466.08,39.2,,957.42,570.23,957.42,28,434.96,3179,"percent of total billed charges",
"TALON? DISTALFIX? HUMERAL NAIL 9MM X 315MM",SUP-HTN-409-315,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 8MM 12-10MM 18MM DUCT SELF EXPANDABLE",SUP-9-PDA-007,CDM,C1817,HCPCS,0278,RC,,,both,,,34398.00,10319.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4000.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4000.49,29238.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 13- IN THUMB LEFT WRIST PALMAR",SUP-79-87490,CDM,S27000186,LOCAL,0270,RC,,,both,,,122.76,36.83,"NOVANET [10819]",Novanet,,92.07,75,,,,,0,14.28,104.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 40MM 5MM .014IN LOW PROFILE",SUP-1008193-40,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"UHC [10700]","United Healthcare",,897.28,63.3,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 22CM 4MM TRICUT 2 CURVE LARYNGEAL ANGLE TIP",SUP-1884030HRE,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"NOVANET [10819]",Novanet,,3394.8,75,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 14MM TITANIUM LOW PROFILE FOOT HAND ANKLE",SUP-AR-8724V-14,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Open Access",,921.78,56.9,,1144.80,304.56,2275.09,66,188.41,1377,"percent of total billed charges",
"GORE CARDIOFORM SEPTAL OCCLUDER 30MM 10FR",SUP-00733132631032,CDM,C1817,HCPCS,0278,RC,,,both,,,60826.50,18247.95,"BLUE CROSS [10001]","Blue Cross PPO",,23843.99,39.2,,,,,0,7074.12,51702.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 40MM STARDRIVE STAINLESS STEEL T15 CORTEX",SUP-02.206.240,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,148.71,45.9,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 59MM STAINLESS STEEL 2MM SCR MINI FRAGMENT SET 8 HOLE",SUP-247.348,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,1144.80,304.56,2275.09,66,189.34,1383.8,"percent of total billed charges",
"CAP CONSTRUCT TOTAL HIP POLAR CUP CEMENTED STEM DELTA HEAD",SUP-71703510,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"UHC [10700]","United Healthcare",,15154.02,63.3,,8601.07,8395.67,8601.07,"1 through 10",2784.22,20349,"percent of total billed charges",
"SUB BONE GRAFT MASTERGRAFT MATRIX BLOCK EXTEND 20CC",SUP-7610320,CDM,C1713,HCPCS,0278,RC,,,both,,,10311.02,3093.31,"NOVANET [10819]",Novanet,,7733.27,75,,,,,0,1199.17,8764.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 80CM 4CM 5MM BALLOON",SUP-G52338,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.47,41.1,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNGOSCOPE VIDEO 2 STAT BLADE GLIDESCOPE GVL DISPOSABLE ST",SUP-0270-0429,CDM,S27200284,LOCAL,0272,RC,,,both,,,216.11,64.83,"MULTIPLAN [10600]",Multiplan,,183.69,85,,,,,0,25.13,183.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL SPARE HOLLOW TUBE NONSTERILE 309250",SUP-309.280,CDM,S27000186,LOCAL,0270,RC,,,both,,,1531.39,459.42,"MULTIPLAN [10600]",Multiplan,,1301.68,85,,,,,0,178.1,1301.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE HEMI PELVIS 1/3 ALLOGRAFT",SUP-450417,CDM,S27800098,LOCAL,0278,RC,,,both,,,17724.42,5317.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2100.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2061.35,15065.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 8MM BALLOON",SUP-U357586,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM 7.5FR VENTRICULAR UNIPOLAR DF-1 TRANSVENE",SUP-6937A-65,CDM,C1896,HCPCS,0278,RC,,,both,,,6900.00,2070,"FIRST HEALTH [10303]","First Health",,5520,80,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE COAGULATION PURPLE 350CM 7FR BRIGHTON GASTROINTESTINAL",SUP-BP-7F-SP-350,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4.5MM TARGET TETRA DETACHABLE STERILE",SUP-TG5414510,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1641.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X3CM MATRION PLACENTAL MEMB TROPHOBLAST",SUP-PAC12,CDM,Q4201,HCPCS,0636,RC,,,both,,,5451.00,1635.3,"FIRST HEALTH [10303]","First Health",,4360.8,80,,,,,0,204.57,4633.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX PROGRIP 5X3IN LEFT HERNIA PRECUT FLAP",SUP-TEM1208GL,CDM,C1781,HCPCS,0278,RC,,,both,,,1663.28,498.98,"BLUE CROSS [10001]","Blue Cross PPO",,652.01,39.2,,,,,0,193.44,1413.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 8 HOLE LOW PROFILE STRAIGHT BONE RIGHT CLAVICLE",SUP-70-0299,CDM,S27800098,LOCAL,0278,RC,,,both,,,6610.20,1983.06,"KAISER [10500]",Kaiser,,4428.83,67,,,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTALINK 135CM 2MM ATHERECTOMY BURR EXCHANGE",SUP-H749393002000,CDM,C1724,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 5MM LONG ROUND FLUTE STERILE",SUP-5230010050,CDM,S27200284,LOCAL,0272,RC,,,both,,,756.95,227.08,"KAISER [10500]",Kaiser,,507.16,67,,,,,0,88.03,643.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ELECTROSURGICAL 8.25IN OLSEN BAYONET BIPOLAR FRCP SMOOTH",SUP-20-1440KI,CDM,S27200284,LOCAL,0272,RC,,,both,,,388.65,116.59,"KAISER [10500]",Kaiser,,260.4,67,,,,,0,45.2,330.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM PRECISION CONVEX SPINE",SUP-17512,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 20MM G7 DOME HIP ACETABULAR LOW PROFILE",SUP-010000997,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,677.48,68,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 25MM SHOULDER CENTRAL",SUP-550025600,CDM,C1713,HCPCS,0278,RC,,,both,,,2796.00,838.8,"CIGNA [10200]","Cigna Open Access",,1590.92,56.9,,1144.80,304.56,2275.09,66,325.17,2376.6,"percent of total billed charges",
"LENS IOL 0 D +10 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.100,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFARI2 VASCULAR LARGE CURVE 275X4.9X5CM .035IN (COMM)",SUP-H74939406L1,CDM,C1769,HCPCS,0272,RC,,,both,,,1498.50,449.55,"UHC [10700]","United Healthcare",,948.55,63.3,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 17MM 20 GRIT BLAST SURFACE FINISH RECLAIM",SUP-197617140,CDM,C1776,HCPCS,0278,RC,,,both,,,11104.56,3331.37,"NOVANET [10819]",Novanet,,8328.42,75,,,,,0,1291.46,9438.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAWSON-MUELLER 15CM 6.3FR .035IN DRNG HYDROPHILIC",SUP-G51594,CDM,C1729,HCPCS,0272,RC,,,both,,,688.42,206.53,"FIRST HEALTH [10303]","First Health",,550.74,80,,,,,0,80.06,585.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET SURGICAL INSTR 10GA IVAS BEVEL STERILE LATEX FREE",SUP-0306-531-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,597.70,179.31,"FIRST HEALTH [10303]","First Health",,478.16,80,,,,,0,69.51,508.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL PROCISE MAX COBLATION PLASMA FLAT",SUP-EICA889801,CDM,S27200284,LOCAL,0272,RC,,,both,,,2042.40,612.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,839.43,41.1,,,,,0,237.53,1736.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMOTE MNTR INSPIRE 2",SUP-2580,CDM,S27200284,LOCAL,0272,RC,,,both,,,9660.00,2898,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3970.26,41.1,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS LIGAPAK 0 54IN BRAID ANTIBACTERIAL COATED",SUP-VCP287G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 CT-2 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J269H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR REDUCTION NUT NONSTERILE",SUP-03.113.016,CDM,C1713,HCPCS,0278,RC,,,both,,,1408.43,422.53,"PHCS [10601]",PHCS,,985.9,70,,,,,0,163.8,1197.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIATHLON TRITANIUM BASEPLATE SIZE 7",SUP-5536-B-700,CDM,C1776,HCPCS,0278,RC,,,both,,,10139.04,3041.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2901.79,28.62,,,,,0,1179.17,8618.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.50 X 38 MM  RX FDA",SUP-1203350-38,CDM,C1874,HCPCS,0272,RC,,,both,,,17250.00,5175,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7089.75,41.1,,,,,0,7089.75,10919.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 4-0 PS-2 SPIRAL 45CM",SUP-SXMP1B118,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"FIRST HEALTH [10303]","First Health",,171.12,80,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 12CM 10FR DUODENAL BEND BILIARY",SUP-M00534350,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,500.06,45.9,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTRA 42CM 7FR 130D GUIDING STERILE LATEX FREE",SUP-451790,CDM,C1893,HCPCS,0272,RC,,,both,,,1800.00,540,"UHC [10700]","United Healthcare",,1139.4,63.3,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 12CM 10FR DUODENAL BEND BILIARY",SUP-M00534350,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"PHCS [10601]",PHCS,,762.62,70,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 8MM 48MM STAINLESS STEEL STD CORTEX LARGE",SUP-214.048,CDM,C1713,HCPCS,0278,RC,,,both,,,464.78,139.43,"BLUE CROSS [10001]","Blue Cross HMO",,182.19,39.2,,957.42,156.86,7483.26,51,54.05,395.06,"percent of total billed charges",
"GWIRE SYNCHRO SELECT VASCULAR STRAIGHT STD 300CM .014IN",SUP-SSTD300STR,CDM,C1769,HCPCS,0272,RC,,,both,,,5686.57,1705.97,"UHC [10700]","United Healthcare",,3599.6,63.3,,,,,0,661.35,4833.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 130MM 5.5MM REVOLVE XLORDOTIC",SUP-185.930,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 40MM 125CM 8MM VASCULAR PERIPHERAL OTW DRUG",SUP-G38495,CDM,C1874,HCPCS,0278,RC,,,both,,,7803.87,2341.16,"CIGNA [10200]","Cigna Local Plus",,4175.07,53.5,,,,,0,907.59,6633.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC THK7.5MM 3.2MM 42.9X42.9MM ADAPTA SR ATRIUM",SUP-ADSR03,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10209.24,41.1,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP UNIPOLAR LOW END CEMENTED FEMORAL CO",SUP-71700025,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3970.26,41.1,,6417.48,6417.48,6417.48,"1 through 10",1123.46,8211,"percent of total billed charges",
"VISE TORQUE ACCEPTS .025-.038 IN GWIRE",SUP-M001465501,CDM,S27200284,LOCAL,0272,RC,,,both,,,44.95,13.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.23,38.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS 5-0 P-2 18IN MONOFILAMENT ANTIBACTERIAL UNDYED",SUP-PDP503G,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.24,22.57,"CIGNA [10200]",Cigna,,51.16,68,,,,,0,8.75,63.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 9 STD 36MM PROVOX LIFE LARYTUBE SILICONE",SUP-7413,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"FIRST HEALTH [10303]","First Health",,955.93,80,,,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 2.5MM CORONARY STENT",SUP-1125250-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross PPO",,2288.5,39.2,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE 80MM 80CM 8MM 8FR VASCULAR NITINOL 2",SUP-SC880FV,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3325.46,45.9,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM 20MM 15MM STD NECK S-ROM CERAMIC 135D",SUP-523394,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"FIRST HEALTH [10303]","First Health",,15561,80,,,,,0,2262.18,16533.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 20CM 2MM BALLOON DILATATION PERIPHERAL",SUP-G30940,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 6.5MM EVOLVE +4MM ELBOW PROLINE MODULAR",SUP-496S465,CDM,C1776,HCPCS,0278,RC,,,both,,,14614.20,4384.26,"AETNA [10100]","Aetna HMO/PPO",,11618.29,79.5,,10981.53,8986.79,12413.38,12,1699.63,12422.07,"percent of total billed charges",
"WIRE FIXATION .8MM 70MM KIRSCHNER STAINLESS STEEL TROCAR",SUP-292.08,CDM,C1713,HCPCS,0278,RC,,,both,,,52.86,15.86,"MULTIPLAN [10600]",Multiplan,,44.93,85,,,,,0,6.15,44.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X18X7MM RISE 3-15D",SUP-193.502,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"BLUE CROSS [10001]","Blue Cross HMO",,13459.32,39.2,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX18MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183568,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"CIGNA [10200]",Cigna,,5331.05,68,,5873.17,5873.17,5873.17,"1 through 10",911.77,6663.81,"percent of total billed charges",
"COMPONENT TIBIAL PERSONA NONPOROUS E KNEE LEFT REVISION FIXA",SUP-42542007101,CDM,C1776,HCPCS,0278,RC,,,both,,,23892.50,7167.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2778.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2778.7,20308.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VIZADISC NAVIGATION HIP TRACK KIT STERILE LATEX FREE",SUP-107130,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 175MM 8MM SMALL SHELL REVISION ALTIVATE REVERSE",SUP-533-08-175,CDM,C1776,HCPCS,0278,RC,,,both,,,43228.40,12968.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17291.36,40,,,,,0,5027.46,36744.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 100MM 6MM BALLOON",SUP-LX1813061005F,CDM,C2623,HCPCS,0272,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8914.8,68,,,,,0,782.41,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 30MM 14MM ATTUNE KNEE CEMENT REVISION STERILE",SUP-1512-14-030,CDM,C1776,HCPCS,0278,RC,,,both,,,5230.20,1569.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,608.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,608.27,4445.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X9MM 5D LORDOTIC OVAL SPINE CORTICAL",SUP-17209,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL STOP 2.7MM DISPOSABLE",SUP-110040202,CDM,S27200284,LOCAL,0272,RC,,,both,,,1301.51,390.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,151.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,151.37,1106.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL STOP 2.7MM DISPOSABLE",SUP-110040202,CDM,S27200284,LOCAL,0272,RC,,,both,,,1301.51,390.45,"FIRST HEALTH [10303]","First Health",,1041.21,80,,,,,0,151.37,1106.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL MALE 19MM METATARSOPHALANGEAL CONE SPIN",SUP-P01-900-1903,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"UHC [10700]","United Healthcare",,1234.35,63.3,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 110MM QUICK CONNECT PERIARTICULAR ZPS 3.5MM",SUP-00480611035,CDM,S27000186,LOCAL,0270,RC,,,both,,,1275.75,382.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,585.57,45.9,,,,,0,148.37,1084.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL STD 10MM KNEE GVF POLYETHYLENE ROTATE PLATFORM",SUP-129405410,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"PHCS [10601]",PHCS,,6764.42,70,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +24.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2450,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 36MM DCP LC-DCP STAINLESS STEEL PROXIMAL",SUP-204.236,CDM,C1713,HCPCS,0278,RC,,,both,,,177.48,53.24,"KAISER [10500]",Kaiser,,118.91,67,,,,,0,20.64,150.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 2.5IN HARRINGTON-PEMBERTON HAND HELD CARDIOVASCULAR",SUP-200-178,CDM,S27200284,LOCAL,0272,RC,,,both,,,977.10,293.13,"AETNA [10100]","Aetna HMO/PPO",,776.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.64,830.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLYFLEX 50MM 13MM 22MM TRACHEOBRONCHIAL SILICONE SELF",SUP-M00570310,CDM,C1874,HCPCS,0278,RC,,,both,,,8375.00,2512.5,"FIRST HEALTH [10303]","First Health",,6700,80,,,,,0,974.01,7118.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR CANCELLOUS CORTICAL LORDOTIC",SUP-345811,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE LIFEGRD SAFETY 20X1/2",SUP-LG-20-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.38,17.81,"KAISER [10500]",Kaiser,,39.78,67,,,,,0,6.91,50.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL SHAFT SMALL FREEZE DRIED 100-125MM",SUP-72A002,CDM,S27800098,LOCAL,0278,RC,,,both,,,3360.00,1008,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,961.63,28.62,,,,,0,390.77,2856,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE NORIAN CALCIUM PHOSPHATE FIBER 10CC DRILLABLE",SUP-07.704.110S,CDM,C1713,HCPCS,0278,RC,,,both,,,15870.00,4761,"PHCS [10601]",PHCS,,11109,70,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 3.5MM VERTEX SELECT PRECUT",SUP-7753745,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT VITOSS BA2X",SUP-2102-2110,CDM,C1713,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"UHC [10700]","United Healthcare",,5459.63,63.3,,5023.51,2672.93,6679.78,18,1003.09,7331.25,"percent of total billed charges",
"CATHETER SOLOIST 110CM 6FR 5MM SPACING COURNAND LONG CURVE E",SUP-44516U,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"NOVANET [10819]",Novanet,,234.9,75,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? X CABLE PLATE KIT",SUP-94-1200-08,CDM,C1713,HCPCS,0278,RC,,,both,,,11488.50,3446.55,"BLUE CROSS [10001]","Blue Cross HMO",,4503.49,39.2,,957.42,156.86,7483.26,51,1336.11,9765.23,"percent of total billed charges",
"CATH IMPULSE 100CM 5FR FR4 CURVE ANGIOGRAPHIC VENTRICULAR 2",SUP-H74916391021,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"FIRST HEALTH [10303]","First Health",,61.26,80,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X6MM DIVERGENCE 12MM LORDOTIC NUCLEUS PULPOSUS",SUP-G6626526,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1471.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR CATH GATEWAY PLUS Y",SUP-M001153223,CDM,S27200284,LOCAL,0272,RC,,,both,,,346.83,104.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.34,294.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEMLESS SHOULDER : HUMERAL HEAD, INSETGLENOID, STEMLESS",SUP-SI-TSA-SLA,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]",Cigna,,11340,40,,5873.17,5873.17,5873.17,"1 through 10",3297.11,24097.5,"percent of total billed charges",
"SCR BONE 2MM 11MM TITANIUM CORTEX SELF TAP STARDRIVE",SUP-401.361.97,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,170.52,39.2,,957.42,156.86,7483.26,51,50.59,369.75,"percent of total billed charges",
"STENT GORE VIABAHN 59MM 80CM 11MM 16SQ MM 8FR .035IN",SUP-BXA115901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS [10001]","Blue Cross PPO",,7645.88,39.2,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 16MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P316,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"KAISER [10500]",Kaiser,,5598.45,67,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 15ML 1.7-10MM CHIP FROZEN TRADITIONAL",SUP-T20035,CDM,S27800098,LOCAL,0278,RC,,,both,,,1795.50,538.65,"CIGNA [10200]","Cigna Open Access",,1021.64,56.9,,,,,0,208.82,1526.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION GREEN HOFFMANN II 4/5/6MM 10 HOLE",SUP-4921-2-060,CDM,C1713,HCPCS,0278,RC,,,both,,,6531.26,1959.38,"KAISER [10500]",Kaiser,,4375.94,67,,,,,0,759.59,5551.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 80CM 5FR .038IN RLG CURVE ANGIOGRAPHIC",SUP-G27853,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,97.61,41.1,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-512-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"NOVANET [10819]",Novanet,,9025.2,75,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 12X10IN RESORBABLE REINFORCE",SUP-F10254-1012G,CDM,C1781,HCPCS,0278,RC,,,both,,,6789.60,2036.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4616.93,68,,,,,0,789.63,5771.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2-0 3/8 CIRCLE TAPER 38IN BRAID TIES",SUP-AR-7221,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.84,57.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,78.85,41.1,,,,,0,22.31,163.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Carbamazepine -10 11-Epoxide",PX-301000676,CDM,80161,CPT,0301,RC,,,both,,,57.00,17.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.06,.1,,,,,0,0.06,48.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3522,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,177.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",174.28,1273.73,"percent of total billed charges",
"TRIATHLON CR X3 TIBIAL INSERT",SUP-5530-G-816,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1352.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM ARSENAL ANKLE",SUP-307-27-016,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"KAISER [10500]",Kaiser,,732.65,67,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR 50MM MULTIPOLAR HIP METAL STERILE",SUP-00500105000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,5311.50,4717.44,5388.59,31,434.96,3179,"percent of total billed charges",
"HC Sputum Obtn Specimen Aero",PX-300000015,CDM,89220,CPT,0300,RC,,,both,,,189.00,56.7,"MULTIPLAN [10600]",Multiplan,,160.65,85,,,,,0,0.01,160.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCK AUGMENTATION NEXGEN 4 HALF 5MM KNEE TIBIA PRECOAT",SUP-598800426,CDM,C1776,HCPCS,0278,RC,,,both,,,7158.06,2147.42,"FIRST HEALTH [10303]","First Health",,5726.45,80,,,,,0,832.48,6084.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 57MM STAINLESS STEEL SMALL FRAGMENT SET 5 HOLE 1/3",SUP-241.351,CDM,C1713,HCPCS,0278,RC,,,both,,,1149.80,344.94,"NOVANET [10819]",Novanet,,862.35,75,,,,,0,133.72,977.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTRIAXONE SODIUM 1 G/10ML IJ (WET SOLR VIAL)",RX-4159487,CDM,J0696,HCPCS,0636,RC,00143-9857-01,NDC,both,1,UN,18.92,5.68,"CIGNA [10200]",Cigna,,5.02,,,,,,,2,16.08,"fee schedule",
"AUG TIBIAL 5MM TRIATHLON 1 RIGHT MEDIAL LEFT LATERAL TOTAL",SUP-5545-A-102,CDM,C1776,HCPCS,0278,RC,,,both,,,6068.55,1820.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2785.46,45.9,,,,,0,705.77,5158.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR F 46MM COCR HIP MODULAR DUAL MOBILITY",SUP-626-00-46F,CDM,C1776,HCPCS,0278,RC,,,both,,,8517.60,2555.28,"FIRST HEALTH [10303]","First Health",,6814.08,80,,,,,0,990.6,7239.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 10FR LARGE REGULAR PIGTAIL CURVE URETERAL GLIDEX",SUP-M001245570,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"BLUE CROSS [10001]","Blue Cross HMO",,349.27,39.2,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -2 40MM CERAMIC ARTICUL/EZE",SUP-473440920,CDM,C1776,HCPCS,0278,RC,,,both,,,17961.30,5388.39,"NOVANET [10819]",Novanet,,13470.98,75,,,,,0,2088.9,15267.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUPERCORE ECHOGENIC 9CM 4.2CM 20GA 19GA BIOPSY",SUP-701220090,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.53,140.26,"NOVANET [10819]",Novanet,,350.65,75,,,,,0,54.37,397.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 7.5FR 10.5FR SUBCUTANEOUS DF-1 CNCT",SUP-6996SQ58,CDM,C1896,HCPCS,0278,RC,,,both,,,12420.00,3726,"UHC [10700]","United Healthcare",,7861.86,63.3,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immunoelectrophoresis Serum",PX-302000066,CDM,86320,CPT,0302,RC,,,both,,,364.00,109.2,"UHC [10700]","United Healthcare",,26.93,,,,,,,0.01,309.4,"fee schedule",
"SCR BONE 2.7MM 4.5MM 38MM EVOS MINI CORTEX T8 DRIVER SELF",SUP-72402738,CDM,C1713,HCPCS,0278,RC,,,both,,,363.14,108.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",42.23,308.67,"percent of total billed charges",
"SEALER BIPOLAR AQUAMAN EDIDURAL VIEN",SUP-23-121-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC",615,MS-DRG,,,,,,,inpatient,,,86871.33,26061.4,"BLUE CROSS [10001]","Blue Cross HMO",,32123.44,,,,,,,7561,40853.96,"case rate",
"SYSTEM INTEGRITY 22MM 2.25MM CORONARY STENT FULCRUM COCR",SUP-INT22522UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,286.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 40MM 80CM 7MM 8FR STRAIGHT VASCULAR",SUP-AVSM07040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"KAISER [10500]",Kaiser,,12240.9,67,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS EVOQUE VALVE (EVOQUE VALVE) 48 MM",SUP-9850EV48PCL,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23640.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 22-14MM 15MM 12FR TRIVASCULAR OVATION",SUP-TV-IL1422100-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"MULTIPLAN [10600]",Multiplan,,28381.5,85,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 65X8-15MM ELSA 6D 20MM",SUP-1122.0165,CDM,S27800098,LOCAL,0278,RC,,,both,,,50400.00,15120,"BLUE CROSS [10001]","Blue Cross HMO",,19756.8,39.2,,,,,0,5861.52,42840,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP UNIPOLAR POUROUS FEMUR WITH UNIPOLAR",SUP-71701037,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"FIRST HEALTH [10303]","First Health",,8280,80,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 15MM INTERLOCK FIBERED IDC 35 COIL",SUP-M001363820,CDM,S27800098,LOCAL,0278,RC,,,both,,,5181.90,1554.57,"PHCS [10601]",PHCS,,3627.33,70,,,,,0,602.65,4404.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM TRIDENT SECUR-FIT TITANIUM CANCELLOUS",SUP-2030-6550-1,CDM,C1713,HCPCS,0278,RC,,,both,,,571.90,171.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,66.51,486.12,"percent of total billed charges",
"STNT WALLFLEX 60MM 48MM 10MM",SUP-7473,CDM,C1894,HCPCS,0272,RC,,,both,,,261.00,78.3,"KAISER [10500]",Kaiser,,174.87,67,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 16MM STAINLESS STEEL CONDYLAR SELF TAP VARIABLE",SUP-42.231.016S,CDM,C1713,HCPCS,0278,RC,,,both,,,2101.05,630.31,"NOVANET [10819]",Novanet,,1575.79,75,,,,,0,244.35,1785.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 14MM TARGET 360D 2XL DETACHABLE",SUP-M0036181450,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COCAINE 4 % SOLUTION SUPERORDERABLE",RX-409212,CDM,,,0250,RC,70839-0362-04,NDC,both,4,ML,1962.17,588.65,"KAISER [10500]",Kaiser,,1314.65,67,,,,,0,228.2,1667.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEADACHES WITHOUT MCC",103,MS-DRG,,,,,,,inpatient,,,30826.86,9248.06,"BLUE CROSS [10001]","Blue Cross PPO",,20645.78,,,,,,,5187.62,20856.49,"case rate",
"CATH WOLVERINE CUTTING BALLOON (MR) 6MM X 2.50",SUP-H74939401062500,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,629.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 10MM SPACE L CURVE",SUP-F6QL010ST,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"MULTIPLAN [10600]",Multiplan,,1969.88,85,,,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 40CM 16FR .038IN DRNG ULTRATHANE HYDROPHILIC BILIARY 32",SUP-G09205,CDM,C1729,HCPCS,0272,RC,,,both,,,963.82,289.15,"AETNA [10100]","Aetna HMO/PPO",,766.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.09,819.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 16X12CM RIGHT",SUP-DXT1612AR,CDM,C1781,HCPCS,0278,RC,,,both,,,1616.68,485,"FIRST HEALTH [10303]","First Health",,1293.34,80,,,,,0,188.02,1374.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 50.8MM 2MM MEDIUM WIRE PASS STERILE",SUP-5300010071,CDM,S27200284,LOCAL,0272,RC,,,both,,,293.10,87.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,34.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.09,249.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 5-0 RB-1 30IN 2 ARM BRAID GREEN",SUP-X550H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM 2.75MM 2.1-2.7FR CORONARY",SUP-RONYX27530UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"AETNA [10100]","Aetna HMO/PPO",,2683.13,79.5,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR DEFIB CROME PIN PLUG MRI HIGH FREQUENCY CRT-D",SUP-DTPC2D1,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"CIGNA [10200]","Cigna Local Plus",,24239.25,31.5,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ALAR NASAL VALVE COLLAPSE LATEX FREE",SUP-15000,CDM,S27800098,LOCAL,0278,RC,,,both,,,1695.00,508.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1152.6,68,,,,,0,197.13,1440.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 17MM ATLANTIS TITANIUM ANTERIOR CERVICAL SPINE",SUP-3120417,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]",Cigna,,958.8,68,,1831.33,1831.33,1831.33,16,163.98,1198.5,"percent of total billed charges",
"VIRAL ILLNESS WITH MCC",865,MS-DRG,,,,,,,inpatient,,,44127.08,13238.12,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,9944.62,,"Case rate ($9,294.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,630.15, add-ons for qualifying new technology services are included. If operating cost exceeds $41,669.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,034.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,641.56. The transfer operating threshold is the transfer adjustment factor * $8,630.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $652.48. The transfer capital threshold is the transfer adjustment factor * $652.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,37366.1,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cold Agglut Titer",PX-302000019,CDM,86157,CPT,0302,RC,,,both,,,214.50,64.35,"UHC [10700]","United Healthcare",,7.25,,,,,,,0.01,182.33,"fee schedule",
"HC Cold Agglut Titer",PX-302000019,CDM,86157,CPT,0302,RC,,,both,,,214.50,64.35,"AETNA [10100]","Aetna HMO/PPO",,170.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,182.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7- KNEE RIGHT PRESS FIT EMPOWR KNEE STERILE BP",SUP-353-04-107,CDM,C1776,HCPCS,0278,RC,,,both,,,15979.64,4793.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4314.5,27,,,,,0,1858.43,13582.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Allergen Igg Quant/Semi Ea",PX-302000004,CDM,86001,CPT,0302,RC,,,both,,,61.10,18.33,"FIRST HEALTH [10303]","First Health",,48.88,80,,,,,0,0.01,51.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER REDEL 115CM 4MM 7FR 1-7-4MM SPACE D-D CURVE",SUP-BD7TDD4L,CDM,C1733,HCPCS,0272,RC,,,both,,,6113.40,1834.02,"NOVANET [10819]",Novanet,,4585.05,75,,,,,0,710.99,5196.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP INSRT TIBIAL POROUS ROTATE PLATFORM ATTUNE",SUP-OSC367989,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"PHCS [10601]",PHCS,,16317,70,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla Xm Flow Cyto 1st Smpl/Dil",PX-302000180,CDM,86825,CPT,0302,RC,,,both,,,850.00,255,"CIGNA [10200]",Cigna,,240.88,,,,,,,97.51,722.5,"fee schedule",
"MESH SURGICAL PROLENE 12X12IN HERNIA NONABSORBABLE SOFT",SUP-PML,CDM,C1781,HCPCS,0278,RC,,,both,,,1322.83,396.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,153.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,153.85,1124.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ELUVIA 60MM 130CM 6MM VASCULAR DRUG ELUTE DELIVERY",SUP-H74939294600610,CDM,C1874,HCPCS,0278,RC,,,both,,,15835.50,4750.65,"CIGNA [10200]","Cigna Open Access",,5304.89,33.5,,,,,0,1841.67,13460.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SQUARE 2.4MM SCR 12 HOLE LOW PROFILE 2 SIDE STERNALOCK",SUP-73-2632,CDM,C1713,HCPCS,0278,RC,,,both,,,4754.10,1426.23,"NOVANET [10819]",Novanet,,3565.58,75,,,,,0,552.9,4040.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ACCESS 7CM 5FR CHECK-FLO PERFORMER .018IN RADIAL ARTERY",SUP-G10268,CDM,C1894,HCPCS,0272,RC,,,both,,,326.16,97.85,"FIRST HEALTH [10303]","First Health",,260.93,80,,,,,0,37.93,277.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL CANNULATED LARGE QUICK COUPLING 6.5 MM 7.5",SUP-03.333.214,CDM,S27000186,LOCAL,0270,RC,,,both,,,2965.05,889.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2016.23,68,,,,,0,344.84,2520.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TF (-T) CRADLE ASSEMBLY LHR-0078",SUP-LHR-0078,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 7.5% IN WATER INFUSION",RX-410561,CDM,,,0258,RC,08888-8879-92,NDC,both,250,ML,100.65,30.19,"FIRST HEALTH [10303]","First Health",,80.52,80,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 120MM 5.4FR 3MM BALLOON DILATATION 2",SUP-BD-L30120CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"AETNA [10100]","Aetna HMO/PPO",,763.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST FIXATION 30MM 4.5MM LOW PROFILE KNEE BICORTICAL",SUP-AR-1365-30,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"CIGNA [10200]",Cigna,,578.34,68,,1831.33,1831.33,1831.33,16,98.91,722.93,"percent of total billed charges",
"HC Xr Knee >=4v Complt",PX-320000083,CDM,73564,CPT,0320,RC,,,both,,,665.76,199.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,78.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.97,565.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 2MM 12MM DCP STAINLESS STEEL SMALL BONE SELF TAPP",SUP-201.882,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"KAISER [10500]",Kaiser,,472.58,67,,,,,0,82.03,599.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FEMORAL IDENTITY IMPRINT 3 NARROW KNEE POSTERIOR",SUP-TPS-101-F03N,CDM,C1776,HCPCS,0278,RC,,,both,,,11716.20,3514.86,"CIGNA [10200]","Cigna Open Access",,3924.93,33.5,,5302.19,4377.88,6578.61,27,1362.59,9958.77,"percent of total billed charges",
"PASSER FIBERTAPE STRAIGHT CERCLAGE TROCHANTERIC SUT",SUP-AR-7823,CDM,S27200284,LOCAL,0272,RC,,,both,,,1771.88,531.56,"AETNA [10100]","Aetna HMO/PPO",,1408.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,206.07,1506.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 12MM ORTHOLOC FOREFOOT NONLOCKING",SUP-5201124012,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,88.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",88.55,647.19,"percent of total billed charges",
"CATH ADVANCE 80CM 4CM 10MM BALLOON DILATATION OTW LOW",SUP-G30928,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WATCHMAN FLX PROCEDURE  TRUSEAL ACCESS SYSTEM",SUP-WMFLXTRUACCPERPROC,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Local Plus",,3691.5,53.5,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE SHEET 9X9CM DEHYDRATED AMNION/CHORION MEM",SUP-APS-5915,CDM,Q4433,HCPCS,0636,RC,,,both,,,60694.20,18208.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,39451.23,65,,,,,0,247.92,51590.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 19MM 51MM SHOULDER ECLIPSE STERILE ARTHROPLASTY",SUP-AR-9351-19,CDM,C1776,HCPCS,0278,RC,,,both,,,4105.50,1231.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,486.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,477.47,3489.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 24MM COCR",SUP-VAL-20240-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"BLUE CROSS [10001]","Blue Cross HMO",,558.84,39.2,,957.42,156.86,7483.26,51,165.8,1211.76,"percent of total billed charges",
"SCR BONE 7MM 70X16MM DARCO FOOT HEADLESS",SUP-DC001670,CDM,C1713,HCPCS,0278,RC,,,both,,,4629.90,1388.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,548.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,538.46,3935.42,"percent of total billed charges",
"SYSTEM PROMUS PREMIER 28MM 144CM 2.5MM CORONARY STENT",SUP-H7493952828250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"FIRST HEALTH [10303]","First Health",,4452,80,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TRISOL DELIVERY SYSTEM KIT",SUP-DMS-14630,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 8.5MM COMPLETE SYSTEM 45MM CLEAR-TRAC",SUP-72200904,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"UHC [10700]","United Healthcare",,132.17,63.3,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 5-0 RB-1 30IN 2 ARM BRAID GREEN",SUP-X550H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UHC [10700]","United Healthcare",,15.83,63.3,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 4CM 10MM BALLOON DILATATION",SUP-DR80104,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"AETNA [10100]","Aetna HMO/PPO",,1094.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULATED DRIVER SHAFT, CREO FENESTRATED",SUP-6192.004,CDM,S27200284,LOCAL,0272,RC,,,both,,,2070.00,621,"UHC [10700]","United Healthcare",,1310.31,63.3,,,,,0,240.74,1759.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DUO-DECA 2-8-2 MPD-H 100CM",SUP-901673,CDM,C1731,HCPCS,0272,RC,,,both,,,4761.00,1428.3,"AETNA [10100]","Aetna HMO/PPO",,3785,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,553.7,4046.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 1-2 15MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934381,CDM,C1776,HCPCS,0278,RC,,,both,,,19429.20,5828.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2302.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2259.62,16514.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661038,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"FIRST HEALTH [10303]","First Health",,1044.58,80,,,,,0,151.86,1109.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEDG CARDIOVASCULAR 16X9.5MM PTFE BUFF SUT SOFT STERILE",SUP-X-4612,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.15,55.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,84.52,45.9,,,,,0,21.42,156.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 24CM 6FR .035",SUP-M006192132090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"CIGNA [10200]","Cigna Open Access",,849.19,,,,,,,173.57,1268.57,"percent of total billed charges",
"GRAFT VASCULAR 70CM 10MM THIN WALL GORE-TEX REMOVABLE RING",SUP-RRT10070070L,CDM,C1768,HCPCS,0278,RC,,,both,,,9204.60,2761.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3783.09,41.1,,,,,0,1070.49,7823.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SURGICAL LARGE CIRCLE 3.2IN UMBILICAL HERNIA REPAIR",SUP-0010303,CDM,C1781,HCPCS,0278,RC,,,both,,,2370.82,711.25,"AETNA [10100]","Aetna HMO/PPO",,1884.8,79.5,,,,,0,275.73,2015.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 23X9X11MM CONCORDE PARALLEL BULLET NOSE",SUP-187823111,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"PHCS [10601]",PHCS,,11592,70,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ETHAMBUTOL 100 MG TABLET",RX-9982,CDM,,,0637,RC,68180-0280-01,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,3.35,53.5,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 77.5X11.2MM RECIPROCATE SURGICAL STERILE",SUP-KM-325R,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.49,33.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.85,93.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 2 13MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-213,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"PHCS [10601]",PHCS,,6881.36,70,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 180MM HIP TROCHANTERIC GAMMA3 INTRAMEDULLARY 125D",SUP-3125-1180S,CDM,C1713,HCPCS,0278,RC,,,both,,,9576.00,2872.8,"CIGNA [10200]","Cigna Open Access",,5448.74,56.9,,1144.80,304.56,2275.09,66,1113.69,8139.6,"percent of total billed charges",
"GRASPER LAPAROSCOPIC OMNI L13 IN OD.12 IN MOVEABLE THUMB RIN",SUP-OMNI-G-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1867.50,560.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4.3MM 46MM CHARLOTTE STAINLESS STEEL SHORT FIRST",SUP-44110030,CDM,S27200284,LOCAL,0272,RC,,,both,,,2055.00,616.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE 62MM NONFENESTRATE CUFF DISPOSABLE INNER CANN SMOOTH",SUP-4DCT,CDM,S27200284,LOCAL,0272,RC,,,both,,,325.99,97.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN NASAL ADULT VAPOTHERM PROSOFT LONG NONSTERILE LATEX",SUP-PROSOFT-XL,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.06,33.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CORPLEX 2X2 CM",SUP-CX-2020,CDM,Q4232,HCPCS,0636,RC,,,both,,,8404.20,2521.26,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH HEARTRAIL III 100CM 6FR IKARI RIGHT 1.5 CURVE GUIDING",SUP-40-6381,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL 12CM LEGEND 2.5MM 2 FLUTE MATCH HEAD DISSECTING BURR",SUP-T12MH25M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS 3-0 SH 36IN BRAID ANTIBACTERIAL COATED",SUP-VCP527H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL IV 0.9% SODIUM CHLORIDE 500ML PVC FREE DEHP FREE VISIV",SUP-7983-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRSP LAPAROSCOPIC SPIN LOCK 33CM 5MM ROTICULATOR ENDO GRASP",SUP-174233,CDM,S27200284,LOCAL,0272,RC,,,both,,,619.73,185.92,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR DISTRACTION 16MM SPINE CERVICAL ANTERIOR STAINLESS STEEL",SUP-MDS9091616,CDM,S27200284,LOCAL,0272,RC,,,both,,,212.18,63.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,87.21,41.1,,,,,0,24.68,180.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 22CM 8FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001274160,CDM,C2617,HCPCS,0278,RC,,,both,,,999.00,299.7,"KAISER [10500]",Kaiser,,669.33,67,,,,,0,116.18,849.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16026555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"CATH CORDIS SABER 90CM 60MM 7MM BALLOON DILATATION DURALYN",SUP-48007006S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AETNA [10100]","Aetna HMO/PPO",,998.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URETHRAL PROCEDURES WITH CC/MCC",671,MS-DRG,,,,,,,inpatient,,,55333.71,16600.11,"CIGNA [10200]","Cigna Local Plus",,18522.61,,"Fee schedule rate ($18,522.61). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,52406.82,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION TROCAR END PERFORATION RADIOPAQUE STRIPE 3/16",SUP-DC7032,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.90,17.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,27.04,45.9,,,,,0,6.85,50.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 4.5/6.5 MM SCR LARGE FRAGMENT SET NONSTERILE",SUP-310.99,CDM,S27200284,LOCAL,0272,RC,,,both,,,2257.50,677.25,"FIRST HEALTH [10303]","First Health",,1806,80,,,,,0,262.55,1918.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 2.5MM25CM 190",SUP-R51002525L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1024.16,41.1,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 CURVE PLUS 20MM KNEE XLK FIX BEARING SIGMA",SUP-970455,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3198.16,28.62,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 9.5MM S-ROM ZTT 14F SMALL HIP PROXIMAL",SUP-550505,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4996.1,45.9,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CM 28MM 10MM THORAX 2 VELOUR 1 BRANCH",SUP-M00202175828P0,CDM,C1768,HCPCS,0278,RC,,,both,,,8540.68,2562.2,"CIGNA [10200]","Cigna Open Access",,4859.65,56.9,,,,,0,993.28,7259.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR MP1 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389691380,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"PHCS [10601]",PHCS,,256.51,70,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)MARKER SKIN GREEN 7.5CM SOFT TISSUE DELIVERY SYSTEM ST",SUP-SMARTCLIPLT-GRN-7.5,CDM,A4648,HCPCS,0278,RC,,,both,,,2625.00,787.5,"AETNA [10100]","Aetna HMO/PPO",,2086.88,79.5,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 33MM 9MM ALIGN 15MM TITANIUM SIDE LOAD HYBRID",SUP-ALN-RST-0900,CDM,C1776,HCPCS,0278,RC,,,both,,,14138.10,4241.43,"BLUE CROSS [10001]","Blue Cross PPO",,5542.14,39.2,,3949.44,3949.44,3949.44,"1 through 10",1644.26,12017.39,"percent of total billed charges",
"SCR BONE 2.7MM 5MM 30MM DCP STAINLESS STEEL CORTEX CLAVICLE",SUP-202.830,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",40.86,298.61,"percent of total billed charges",
"BASEPLT TIBIAL TRIATHLON 8 KNEE PRIMARY CEMENTED",SUP-5520B800,CDM,C1776,HCPCS,0278,RC,,,both,,,7151.76,2145.53,"KAISER [10500]",Kaiser,,4791.68,67,,,,,0,831.75,6079,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TYSHAK NUCLEUS 100CM 4CM 10FR 20MM .035IN 8FR 2 TAPER",SUP-612094,CDM,C1725,HCPCS,0272,RC,,,both,,,5345.43,1603.63,"AETNA [10100]","Aetna HMO/PPO",,4249.62,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,621.67,4543.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP MEDIUM ALLOGRAFT COMPRESSIBLE SPONGE 30",SUP-13812409,CDM,C1713,HCPCS,0278,RC,,,both,,,14185.17,4255.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1680.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1649.74,12057.39,"percent of total billed charges",
"SCR BONE 6MM 45MM MATRIX TITANIUM T25 SPINE THORACOLUMBAR",SUP-04.632.645,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"IN.PACT 018 4.0 MM X 40 MM X 130 CM",SUP-IPU04004013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"NOVANET [10819]",Novanet,,6054.75,75,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-1504-40-105,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"CIGNA [10200]","Cigna Local Plus",,9485.91,31.5,,5372.07,4581.20,7242.98,23,3502.26,25596.9,"percent of total billed charges",
"ATTACH ENDOSCP 4MM 11.8MM ROUND EDGE STERILE LATEX FREE",SUP-D-201-11304,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.26,63.08,"CIGNA [10200]","Cigna Open Access",,119.64,56.9,,,,,0,24.45,178.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X9MM CORNERSTONE PSR PEEK LUMBAR",SUP-6277941,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS [10001]","Blue Cross PPO",,2617.94,39.2,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR MIKELSON CURVE ANGIOGRAPHIC VISCERAL",SUP-M001314771,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,47.91,41.1,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"30.0 DIOPTER, SENSAR MONOFOCAL 3-PIECE FOLDABLE IOL, MODEL A",SUP-AR40E00300,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"CIGNA [10200]","Cigna Open Access",,530.02,56.9,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CRYO/CUFF LARGE 20-31IN COMPRESSION THERAPY KNEE",SUP-11B,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch Lung Bx Add",PX-750000014,CDM,31632,CPT,0750,RC,,,both,,,3774.12,1132.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,447.23,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,438.93,3774.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LASSO REDEL 115CM 7FR 15MM 4.5MM SPACE",SUP-D7L2015RT,CDM,C1731,HCPCS,0272,RC,,,both,,,10950.30,3285.09,"FIRST HEALTH [10303]","First Health",,8760.24,80,,,,,0,1273.52,9307.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 20MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158126120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"KAISER [10500]",Kaiser,,7486.95,67,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XLNK SPINAL 5.5MM PASS LP MEDIUM DISTANCE NONSTERILE LATEX",SUP-B02265520,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,414.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",414.32,3028.13,"percent of total billed charges",
"STENT CONTOUR 28CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805240,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]",Cigna,,613.48,68,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR COBRA 2 CURVE ANGIOGRAPHIC VISCERAL",SUP-M001314681,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.04,22.81,"NOVANET [10819]",Novanet,,57.03,75,,,,,0,8.84,64.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 22MM STAINLESS STEEL T6 SELF TAP LOCK VARIABLE",SUP-02.130.322,CDM,C1713,HCPCS,0278,RC,,,both,,,841.43,252.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,99.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,97.86,715.22,"percent of total billed charges",
"LEAD PACING 64CM ENDOCARDIUM 4 SITE 2 COIL ACTIVE DF-4",SUP-0296,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS [10001]","Blue Cross HMO",,6731.42,39.2,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC 18IN KNEE 3 PANEL ADJUSTABLE BUCKLE PLASTIC",SUP-VP40105-030,CDM,L1830,HCPCS,0274,RC,,,both,,,160.08,48.02,"CIGNA [10200]","Cigna Local Plus",,85.64,53.5,,,,,0,18.62,136.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 60MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712660,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,1831.33,1831.33,1831.33,16,441.36,3225.75,"percent of total billed charges",
"SCR BONE 5MM 34MM LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.034S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER TISSUE 25CM ENSEAL X1 CURVE JAW SHAFT STERILE LATEX",SUP-NSLX125C,CDM,S27200284,LOCAL,0272,RC,,,both,,,3109.07,932.72,"FIRST HEALTH [10303]","First Health",,2487.26,80,,,,,0,361.58,2642.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM MITRAL FLEXIBLE HOLDER KNIT SEW",SUP-4450M26,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1349.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM STABILIT SHORT BONE CEMENT DELIVERY",SUP-DF-4011S,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 100CM 5FR 8MM AMPLATZER .056IN TYPE II",SUP-9-AVP2-008,CDM,S27800098,LOCAL,0278,RC,,,both,,,6589.50,1976.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1885.91,28.62,,,,,0,766.36,5601.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LASER OG CURVED",SUP-14410,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CERVICAL SPINAL FUSION WITH CC",472,MS-DRG,,,,,,,inpatient,,,96375.40,28912.62,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,,,"Fee schedule rate ($0). Wage-adjusted base payment rate plus any adjustments related to capital costs, indirect medical education (IME), disproportionate share hospital (DSH) adjustors, new technology, hemophilia, sole community hospital (SCH) and Medicare Dependent Hospital (MDH) adjustors, transfers, and outliers.",,,,0,,,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FOOT AND TOE PROCEDURES,MINOR",314,APR-DRG,,,,,,,inpatient,,,44872.94,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $6,773.66. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($35,560.39) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CARDIOTHORACIC AND THORACIC CIRCULATORY PROCEDURES,MINOR",167,APR-DRG,,,,,,,inpatient,,,196935.51,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $17,606.08. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($58,304.32) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 CTX 18IN 8 STRAND CONTROL RELEASE BRAID",SUP-VCP724D,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.49,38.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CMPNT GLENOID 40MM SMALL PEG PERFORM SHOULDER ALL POLY",SUP-DWE303,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"CIGNA [10200]","Cigna Open Access",,5300.8,56.9,,5302.19,4377.88,6578.61,27,1083.45,7918.6,"percent of total billed charges",
"SCR BONE 5.5MM 45MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890005545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 20.5MM 29MM 38MM 26MM MOSAIC CINCH RING HEART P",SUP-310C29,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"FIRST HEALTH [10303]","First Health",,21924,80,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 15MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE45015,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"CIGNA [10200]",Cigna,,33465.84,40,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG VARIABLE ANGLE LOCKING 1.8MM X 15MM",SUP-SPLS-18150-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",165.8,1211.76,"percent of total billed charges",
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 45MMX12MMX20CM 26FR",SUP-TAC124520A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"KAISER [10500]",Kaiser,,122208,67,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FINISHING WIRE UNIVERSAL 80CM",SUP-6004,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,466.07,41.1,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175274180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"NOVANET [10819]",Novanet,,1095.08,75,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE EYE 14MM NONSTERILE PMMA",SUP-14152-1,CDM,S27800098,LOCAL,0278,RC,,,both,,,147.90,44.37,"NOVANET [10819]",Novanet,,110.93,75,,,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8MM 70MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712870,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX OTW CORONARY STENT   2.00 X 08MM",SUP-RONYX20008W,CDM,C1874,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"MULTIPLAN [10600]",Multiplan,,3028.13,85,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 77MM STAINLESS STEEL 2.4MM SCR 5X7 HOLE 2 COLUMN",SUP-02.111.750,CDM,C1713,HCPCS,0278,RC,,,both,,,4198.65,1259.59,"CIGNA [10200]",Cigna,,2855.08,68,,1831.33,1831.33,1831.33,16,488.3,3568.85,"percent of total billed charges",
"TUBE VENTILATION 1.29MM 1.27MM 1.29MM MORETZ EAR",SUP-7014-2043,CDM,S27800098,LOCAL,0278,RC,,,both,,,118.54,35.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.79,100.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 160MM 2.7MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.67,CDM,S27000186,LOCAL,0270,RC,,,both,,,2111.40,633.42,"AETNA [10100]","Aetna HMO/PPO",,1678.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,245.56,1794.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60MM TITANIUM XTHICK VASCULAR ARTICULATING",SUP-SIG60AXT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1919.18,575.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,788.78,41.1,,,,,0,223.2,1631.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 12MM 3.75MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP37512X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL PACEMKR FLEXTEND FIXATION SPRT ACCESS",SUP-6616,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"UHC [10700]","United Healthcare",,165.21,63.3,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION KIRSCHNER THREAD BLUNT TIP",SUP-6133.0399S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Neuromuscular Junction Test",PX-740000034,CDM,95937,CPT,0740,RC,,,both,,,387.00,116.1,"NOVANET [10819]",Novanet,,290.25,75,,,,,0,45.01,387,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 88MM AEQUALIS ASCEND FLEX PTC 132.5D 1B LONG",SUP-DWF611B,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1465.38,10710,"percent of total billed charges",
"(EVAL)CORONARY IVL CATHETER, 2.5MM X 12MM, RX IDE",SUP-501050-001,CDM,C1761,HCPCS,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM T15 LOCK MULTIDIRECTIONAL NONSTERILE",SUP-110018020,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,215.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",215.88,1577.81,"percent of total billed charges",
"ROD SPINAL 90MM 4.75MM LONGITUDE II STRAIGHT CCM",SUP-1475006090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"KIT STENT 22CM 6FR .038IN PIGTAIL CURVE TAPER URETER GLIDEX",SUP-M001245730,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1173,68,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 5568-53 CAPSUREFIX LEAD-CAPFIX ATR",SUP-5568-53,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross HMO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM NASAL 9IN HARDY BLADE BIVALVE 80X13MM",SUP-57-3556,CDM,S27200284,LOCAL,0272,RC,,,both,,,3050.55,915.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,361.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,354.78,2592.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 37X27X16MM 12D MEDIUM",SUP-7968216,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4061.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 150CM 8FR .035IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145381190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,131.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE READIGRAFT CANCELLOUS 15CC 4-10MM ALLOGRAFT","SUP-CAN15 410BP",CDM,S27800098,LOCAL,0278,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.3MM 4-0 C-1 MICRO QUICKANCHOR PLUS ORTHOCORD",SUP-212041,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"STENT 20CM 10FR LARGE REGULAR PIGTAIL CURVE URETERAL GLIDEX",SUP-M001245570,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"KAISER [10500]",Kaiser,,596.97,67,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL DRIVE SHAFT ELASTOMERIC REAMER IRR ASPIR STERILE",SUP-351.718S,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.00,27.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,37.81,41.1,,,,,0,10.7,78.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI PROWATERFLEX PTCA GUIDE WIRE 180 CM",SUP-AGH147000,CDM,C1769,HCPCS,0272,RC,,,both,,,769.50,230.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,523.26,68,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR FL3.5 CURVE ANGIOGRAPHIC FEMORAL 2",SUP-H74916391212,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"AETNA [10100]","Aetna HMO/PPO",,60.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM ATS SPINE MULTIAXIAL 4.75MM ROD",SUP-54840046540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]",Cigna,,6491.86,68,,1831.33,1831.33,1831.33,16,1110.3,8114.82,"percent of total billed charges",
"BURR SURGICAL 6MM ACORN STERILE",SUP-5620030060,CDM,S27200284,LOCAL,0272,RC,,,both,,,1164.29,349.29,"CIGNA [10200]","Cigna Local Plus",,622.9,53.5,,,,,0,135.41,989.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL AMPLATZ FIRM KINK RESISTANT GRADUATE TAPER 35CM",SUP-M0062601120,CDM,C1894,HCPCS,0272,RC,,,both,,,362.44,108.73,"MULTIPLAN [10600]",Multiplan,,308.07,85,,,,,0,42.15,308.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE V-18 CONTROLWIRE VASCULAR STRAIGHT 150CM 12CM .018IN",SUP-M001468560,CDM,C1769,HCPCS,0272,RC,,,both,,,602.64,180.79,"UHC [10700]","United Healthcare",,381.47,63.3,,,,,0,70.09,512.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 30MM MESENTERY THIN TISSUE ARTICULATE CURVE TIP",SUP-SIG30CTAV,CDM,S27200284,LOCAL,0272,RC,,,both,,,1461.81,438.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,994.03,68,,,,,0,170.01,1242.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NUROLON 4-0 FS 18IN CONTROL RELEASE BRAID 8 STRAND BLACK",SUP-C570D,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.67,51.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.08,146.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 8MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620308,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"MULTIPLAN [10600]",Multiplan,,9565.82,85,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 30ML FREEZE DRIED CHIP 1-4MM",SUP-100030,CDM,S27800098,LOCAL,0278,RC,,,both,,,3192.00,957.6,"MULTIPLAN [10600]",Multiplan,,2713.2,85,,,,,0,371.23,2713.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8-6.5MM 35MM CREO SPINE 2 OUTER DIAMETER",SUP-5119.2237,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,1831.33,1831.33,1831.33,16,601.85,4398.75,"percent of total billed charges",
"SOL IV FIRSTCHOICE 20 MEQ POTASSIUM CHLORIDE WATER 50ML",SUP-07077-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"KAISER [10500]",Kaiser,,54.27,67,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STIM PROXIMATE GENITOURINARY HANDSET NONSTERILE LATEX",SUP-TH90P01,CDM,S27200284,LOCAL,0272,RC,,,both,,,12516.60,3754.98,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT C-FLEX 5CM 10FR 2 PIGTAIL CURVE BILIARY PLASTIC",SUP-M00532040,CDM,C2617,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT ORTHOPEDIC LARGE 24IN 19-22IN KNEE CONTACT CLSR",SUP-79-80037,CDM,S27000186,LOCAL,0270,RC,,,both,,,117.10,35.13,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BAG PRESSURE INFUSION 1L NYLON INFUSOR DUAL PRESSURE RELIEF",SUP-PIB1000,CDM,S27000186,LOCAL,0270,RC,,,both,,,95.00,28.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR ENDOSCOPIC CURVE TIP RELOAD AEON 60MMX2.5MM STERILE",SUP-AESC60W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARD 20FR URETHRAL NATURAL RUBBER SILICONE ELASTOMER 5",SUP-265720,CDM,S27200284,LOCAL,0272,RC,,,both,,,1.84,0.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DIREXION HI-FLO 105CM 2.8-3FR .027IN MICRO INFUSION",SUP-M001195490,CDM,C1887,HCPCS,0272,RC,,,both,,,4416.00,1324.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 7.5MM 45MM CREO AMP HA SPINE CANNULATED MODULAR",SUP-1067.4746S,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"MULTIPLAN [10600]",Multiplan,,2550,85,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 66MM 36MM MARATHON HIP",SUP-121936166,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4045.41,41.1,,6417.48,6417.48,6417.48,"1 through 10",1144.72,8366.42,"percent of total billed charges",
"SCR BONE 5MM 37MM LOCK STERILE",SUP-2361-5037S,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.05,506.11,"CIGNA [10200]","Cigna Open Access",,959.93,56.9,,1144.80,304.56,2275.09,66,196.2,1433.99,"percent of total billed charges",
"STEM FEMORAL 11MM SECUR-FIT PLUS 5 HIP STERILE",SUP-6054-0511S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1880.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1880.04,13740.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30X10X8-15MM RISE 10D",SUP-193.123,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"NOVANET [10819]",Novanet,,21262.5,75,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG RESUS 10FT SPUR II MEDIUM O2 RESVR PEEP ADULT",SUP-520611011,CDM,S27000186,LOCAL,0270,RC,,,both,,,85.85,25.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.98,72.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12-15IN 28FR VENOUS ADULT 3/8IN CNCT 1 STAGE",SUP-68128,CDM,S27200284,LOCAL,0272,RC,,,both,,,340.62,102.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,156.34,45.9,,,,,0,39.61,289.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTENDER LEAD BIS-BIS-17 17CM OSCOR",SUP-BIS-BIS-17,CDM,C1883,HCPCS,0278,RC,,,both,,,1875.00,562.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 100MM 6MM XIA 3 TITANIUM",SUP-48238100,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL GOLD 75MM 12.5MM EXPERT SPIRAL",SUP-04.013.047S,CDM,C1713,HCPCS,0278,RC,,,both,,,3676.05,1102.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1687.31,45.9,,,,,0,427.52,3124.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT",RX-10512,CDM,90707,HCPCS,0636,RC,00006-4681-01,NDC,both,1,UN,589.21,176.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,400.66,68,,,,,0,11.97,500.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 38MM MEDIALIZE DOME ATTUNE",SUP-151810038,CDM,C1776,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"CIGNA [10200]",Cigna,,4879.68,68,,5873.17,5873.17,5873.17,"1 through 10",834.57,6099.6,"percent of total billed charges",
"PLATE 60MM LOCKING ATLANTIS VISION ELITE BONE ANTERIOR",SUP-7200060,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"PHCS [10601]",PHCS,,3704.4,70,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXAMETHASONE 4 MG TABLET",RX-2327,CDM,J8540,HCPCS,0637,RC,00054-8175-25,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,0.46,,,,,,,0.46,5.33,"fee schedule",
"CAGE SPINAL 25X9X15MM CONCORDE 10D THORACOLUMBAR CFRP INLINE",SUP-187855215,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6624,40,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO 425MM 2MM SWISS LITHOCLAST PNEUMATIC LATEX FREE",SUP-M0068407370,CDM,S27200284,LOCAL,0272,RC,,,both,,,1680.60,504.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1142.81,68,,,,,0,195.45,1428.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIPLE LUMEN CATH KIT",SUP-ECVC1500,CDM,C1751,HCPCS,0272,RC,,,both,,,1245.20,373.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,511.78,41.1,,,,,0,144.82,1058.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X6MM COLONIAL 7D LORDOTIC 14MM XL TITANIUM",SUP-365.806CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 22.9CM .045IN KIRSCHNER STAINLESS STEEL BOTH",SUP-00018606200,CDM,C1713,HCPCS,0278,RC,,,both,,,119.63,35.89,"NOVANET [10819]",Novanet,,89.72,75,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDSWITCH ELECTROSURGICAL LCD IX10",SUP-E2750-NSB,CDM,S27000186,LOCAL,0270,RC,,,both,,,253.78,76.13,"CIGNA [10200]",Cigna,,172.57,68,,,,,0,29.51,215.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 120MM 4MM BALLOON",SUP-U3575412,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT SOCKET RSP DJO SURGICAL +4MM STD HUMERAL HXE+ STERILE",SUP-509-00-432,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1069.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1049.92,7673.56,"percent of total billed charges",
"SPACER ALLOGRAFT 21-26X27-32X21MM 8D LORDOTIC RING WEDGE",SUP-621,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"KAISER [10500]",Kaiser,,21105,67,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 60MM 3 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-43F60V,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"KIT INSRT BIO-MEDICUS VENOUS",SUP-96551,CDM,C1769,HCPCS,0272,RC,,,both,,,713.69,214.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,293.33,41.1,,,,,0,83,606.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cntrst Locm 300-399mg per 1ml",PX-255000010,CDM,Q9967,HCPCS,0255,RC,,,both,,,22.00,6.6,"NOVANET [10819]",Novanet,,16.5,75,,,,,0,2.56,18.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 12MM 2MM BALLOON DILATATION",SUP-H7493912412200,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR UNIVERSAL 60MMX2.5MM ENDO GIA ROTICULATOR",SUP-030457,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUSHER SURGICAL 177CM 16 COIL .016IN .020IN",SUP-401216,CDM,S27200284,LOCAL,0272,RC,,,both,,,1174.50,352.35,"CIGNA [10200]","Cigna Local Plus",,628.36,53.5,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETENE 12X8CM LEFT SELF GRIP ANATOMIC",SUP-PP1208DL,CDM,C1781,HCPCS,0278,RC,,,both,,,1892.63,567.79,"PHCS [10601]",PHCS,,1324.84,70,,,,,0,220.11,1608.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 14.5FR 3.1ML PALINDROME SYMMETRIC TIP",SUP-8888145018,CDM,C1750,HCPCS,0278,RC,,,both,,,2935.50,880.65,"BLUE CROSS [10001]","Blue Cross PPO",,1150.72,39.2,,,,,0,341.4,2495.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) REGULAR ACCESS SHEATH SINGLE CURVE",SUP-30-00215,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SUCTION BIG YANK 11/32IN 10IN OPEN NONVENTED TUBE 10FT",SUP-0034970U,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.66,30.8,"CIGNA [10200]",Cigna,,69.81,68,,,,,0,11.94,87.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONCUSSION WITHOUT CC/MCC",090,MS-DRG,,,,,,,inpatient,,,49755.35,14329.13,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,5336.15,,"Case rate ($5,106.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,741.60, add-ons for qualifying new technology services are included. If operating cost exceeds $37,781.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,740.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,747.87. The transfer operating threshold is the transfer adjustment factor * $4,741.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $358.49. The transfer capital threshold is the transfer adjustment factor * $358.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,5106.36,20529.78,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 40MM 29MM AEQUALIS 2MM LATERAL OFFSET",SUP-DWE840,CDM,C1776,HCPCS,0278,RC,,,both,,,9442.80,2832.84,"MULTIPLAN [10600]",Multiplan,,8026.38,85,,,,,0,1098.2,8026.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 52MM STAINLESS STEEL 2MM SCREW MINI FRAGMENT SET 7 HOL",SUP-247.347,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,957.42,570.23,957.42,28,189.34,1383.8,"percent of total billed charges",
"LEAD PACING 52CM 7FR 10MM SPACING S CURVE ATRIUM BIPOLAR",SUP-1944/52,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CIGNA [10200]","Cigna Open Access",,1270.29,56.9,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 100MM 120CM 20MM .035IN 3MM VASCULAR VENOUS",SUP-VENUL20100,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"CIGNA [10200]","Cigna Local Plus",,7342.65,31.5,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC",854,MS-DRG,,,,,,,inpatient,,,64962.71,19488.81,"PHCS [10601]",PHCS,,7561,,,,,,,7561,58336.53,"per diem","Estimated amount calculated based on 4 day length of stay."
"HC Somatomedin",PX-301000401,CDM,84305,CPT,0301,RC,,,both,,,236.00,70.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,75.48,,,,,,,0.24,200.6,"fee schedule",
"STENT CONTOUR 28CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006180244010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"FIRST HEALTH [10303]","First Health",,856.59,80,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 3.3MM 40MM STARDRIVE NAIL-EX TITANIUM 7%",SUP-04.005.430,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"PHCS [10601]",PHCS,,809.68,70,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT HAND ACCESS 150MM OBTR OPTICAL TIP AUTOMATIC VENT",SUP-IAS12-150LPI,CDM,S27200284,LOCAL,0272,RC,,,both,,,756.22,226.87,"CIGNA [10200]",Cigna,,514.23,68,,,,,0,87.95,642.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE STABILIT MX VERTEBRAL SATURATE MIX SYSTEM",SUP-4457,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"AMERIGROUP MEDICAID [20100]",Amerigroup,,266.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",261.68,1912.5,"percent of total billed charges",
"BINDER ABDOMINAL 12IN LARGE",SUP-U2-712,CDM,S27000186,LOCAL,0270,RC,,,both,,,226.20,67.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE 20MM 4.5MM EMBOLIZATION",SUP-PED2-450-20,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"BLUE CROSS [10001]","Blue Cross PPO",,31672.62,39.2,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER HAPTIC C BICONVEX 13MM 6MM 1 PIECE",SUP-PCB0000165,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ACCULINK 30MM 132CM 6-8MM TAPER VASCULAR NITINOL",SUP-1011343-30,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"BLUE CROSS [10001]","Blue Cross PPO",,3669.12,39.2,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 58CM .016IN KNOB CAP KT",SUP-6037,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM MULTIPOLAR THR CERAMIC CEMENTED STEM CUP LINER HE",SUP-98000100701,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3970.26,41.1,,6417.48,6417.48,6417.48,"1 through 10",1123.46,8211,"percent of total billed charges",
"TUBE CONNECTING 14.5FR PLASTIC FITTING HIGH PRESSURE FMRA",SUP-G09435,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.43,20.23,"AETNA [10100]","Aetna HMO/PPO",,53.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.84,57.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURGICAL CURETTES OR LOOPS OR CURETTE SET",SUP-MPN52010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Lwr Ext WO Cntrst",PX-359000004,CDM,73700,CPT,0352,RC,,,both,,,2107.53,632.26,"AETNA [10100]","Aetna HMO/PPO",,1933,,"Per diem ($1,933). Each eligible service on a given day will be paid its own per diem rate.",,,,0,245.11,1933,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 20MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158101120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1299.6,9498.37,"percent of total billed charges",
"CATH ADVANCE 150CM 17CM 6MM BALLOON DILATATION OTW LOW",SUP-G30963,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM ATLANTIS TITANIUM SPINE CERVICAL ANTERIOR",SUP-3120414,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]",Cigna,,688.5,68,,1831.33,1831.33,1831.33,16,117.75,860.63,"percent of total billed charges",
"STENT POLARIS 28CM 7FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552440,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,551.07,45.9,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 1/8IN HEADLESS SQUARE END 2.5IN STAINLESS STEEL",SUP-7650-2038A,CDM,C1776,HCPCS,0278,RC,,,both,,,2947.50,884.25,"CIGNA [10200]",Cigna,,2004.3,68,,5873.17,5873.17,5873.17,"1 through 10",342.79,2505.38,"percent of total billed charges",
"BLADE WIRE SAW 51CM HANDLE STAINLESS STEEL GIGLI STERILE",SUP-00280800200,CDM,S27000186,LOCAL,0270,RC,,,both,,,241.95,72.58,"UHC [10700]","United Healthcare",,153.15,63.3,,,,,0,28.14,205.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 80CM 6MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM06100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"AETNA [10100]","Aetna HMO/PPO",,14524.65,79.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 400MM 11MM CARBON FIBER MR CONDITIONAL",SUP-394.87,CDM,C1713,HCPCS,0278,RC,,,both,,,1581.53,474.46,"NOVANET [10819]",Novanet,,1186.15,75,,,,,0,183.93,1344.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 180MM 5MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171051810,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 140MM 80CM 14MM BILIARY VENOUS DELIVERY",SUP-G57446,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"UHC [10700]","United Healthcare",,9172.17,63.3,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CERVICAL L82.5MM BILATERAL 5 LEVEL TITANIUM ANTERIOR L",SUP-7200182,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"SCREW BONE 5MM 100MM NAIL-EX TITANIUM FULL THREAD FEMORAL TI",SUP-04.005.590,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"CIGNA [10200]",Cigna,,786.54,68,,1831.33,1831.33,1831.33,16,134.52,983.18,"percent of total billed charges",
"GRAFT BONE CORNERSTONE SR LORDOTIC ALLOGRAFT 14X11X4MM",SUP-400441,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DECA 4-4-34-4-4-4-4-4-50 MPA 120CM",SUP-950824,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"AETNA [10100]","Aetna HMO/PPO",,2355.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT  RAD GRACILIS 3X260 FZ",SUP-50R501,CDM,C1713,HCPCS,0278,RC,,,both,,,6537.75,1961.32,"AETNA [10100]","Aetna HMO/PPO",,5197.51,79.5,,1521.93,481.35,16760.95,30,760.34,5557.09,"percent of total billed charges",
"IMMOB ORTHOPEDIC XL 41X6IN SHOULDER ELASTIC CONTOURED RIB",SUP-9008-04,CDM,S27000186,LOCAL,0270,RC,,,both,,,103.62,31.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.05,88.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CITATION TMZF HA 6 SHORT HIP RIGHT",SUP-6265-5216,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"NOVANET [10819]",Novanet,,18316.46,75,,,,,0,2840.27,20758.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR .09IN MP1 CURVE GUIDING CORONARY",SUP-LA8MP1SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X10MM COHERE XLW 15D STERILE LATEX FREE",SUP-8151050P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,29925.00,8977.5,"KAISER [10500]",Kaiser,,20049.75,67,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 1CM 16FR RADIOPAQUE LOW PROFILE TAPER DISTAL TIP",SUP-0120-16-1.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,529.76,68,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC in Situ Hybridization (Fish)",PX-312000048,CDM,88365,CPT,0312,RC,,,both,,,916.50,274.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,54.43,,"Fee schedule rate ($54.43). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,779.03,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 1.6MM TWIST STERILE",SUP-KM166-00-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.04,24.01,"FIRST HEALTH [10303]","First Health",,64.03,80,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC",829,MS-DRG,,,,,,,inpatient,,,127470.32,38241.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,59967.32,,"Fee schedule rate ($59,967.32). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,10994,92259.36,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 80MM 4MM 4FR .018IN BALLOON",SUP-39147-40801,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ENT BUR 4MM FLUTED BALL TS SHORT ANSPACH",SUP-SA-FB4,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE DESTINATION MULTIPURPOSE CURVE 45CM 5CM 6FR",SUP-RSR03,CDM,C1887,HCPCS,0272,RC,,,both,,,672.30,201.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MATRIX WOUND 24SQ CM 2.4X1.6IN CLLGN SILICONE PORCINE TENDON",SUP-TG-B4060,CDM,A2008,HCPCS,0636,RC,,,both,,,13422.57,4026.77,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC",804,MS-DRG,,,,,,,inpatient,,,75029.50,22508.85,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 20MM 2.5MM BALLOON DILATATION PEBAX",SUP-1012272-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 12IN 22FR ARTERIAL ADULT 3/8IN CNCT VENTED",SUP-77622,CDM,C1769,HCPCS,0272,RC,,,both,,,541.37,162.41,"KAISER [10500]",Kaiser,,362.72,67,,,,,0,62.96,460.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE PRIME 33MM 143CM 3.5MM CORONARY STENT",SUP-1011734-33,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"MULTIPLAN [10600]",Multiplan,,8152.35,85,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION",RX-106348,CDM,J2405,HCPCS,0636,RC,00641-6080-01,NDC,both,2,ML,18.92,5.68,"CIGNA [10200]","Cigna Local Plus",,1.03,,,,,,,0.42,16.08,"fee schedule",
"CATHETER ANGIOPLASTY L150CM BALLOON L120MM DIA5MM COMPATIBLE",SUP-1013468-120,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"FIRST HEALTH [10303]","First Health",,1004.4,80,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 50MM VARIAX TITANIUM ELBOW SELF TAP",SUP-614850,CDM,C1713,HCPCS,0278,RC,,,both,,,574.94,172.48,"CIGNA [10200]",Cigna,,390.96,68,,1831.33,1831.33,1831.33,16,66.87,488.7,"percent of total billed charges",
"SCR BONE 5MM 60MM LCP STAINLESS STEEL T25 MEDIAL PROXIMAL",SUP-212.221,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"CIGNA [10200]","Cigna Local Plus",,467.15,53.5,,3978.14,359.25,3978.14,24,101.55,742.2,"percent of total billed charges",
"SCR BONE SPINAL MULTIAXIAL LOCKING",SUP-8800000,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,285.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",279.89,2045.61,"percent of total billed charges",
"SPACER ALLOGRAFT 23-27MMX19MM FRA 8D 30D LORDOTIC NARROW",SUP-10219,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"KAISER [10500]",Kaiser,,12663,67,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 160MM 16-14MM 14MM 11FR TRIVASCULAR OVATION",SUP-TV-IL1416160-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13356,40,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM CEMENT SUMMIT 5 12/14 STD OFFSET TAPER",SUP-157003110,CDM,C1776,HCPCS,0278,RC,,,both,,,18219.60,5465.88,"NOVANET [10819]",Novanet,,13664.7,75,,,,,0,2118.94,15486.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L14MM DIA3.5MM PROXIMAL TIBIAL STAINLESS STEEL SE",SUP-02.127.114,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"BLUE CROSS [10001]","Blue Cross PPO",,444.02,39.2,,957.42,570.23,957.42,28,131.73,962.8,"percent of total billed charges",
"LENS IOL +14 DIOPTER +3 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT300140,CDM,V2787,HCPCS,0276,RC,,,both,,,495.00,148.5,"CIGNA [10200]",Cigna,,336.6,68,,,,,0,57.57,420.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER PELLO 40D 4MM",SUP-6290-112-040-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,1837.50,551.25,"CIGNA [10200]","Cigna Local Plus",,983.06,53.5,,,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Paravrt Jt L/S 1 Lvl",PX-510000138,CDM,64493,CPT,0761,RC,,,both,,,6149.00,1844.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1729.39,,"Case rate ($1,729.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,715.13,5226.65,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 9.5MM S-ROM ZTT 24D SMALL HIP PROXIMAL",SUP-550564,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"NOVANET [10819]",Novanet,,8163.56,75,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REDUC LAPAROSCOPIC ENDOPATH ONESEAL 5-12MM UNIVERSAL STERILE",SUP-1SEAL,CDM,S27200284,LOCAL,0272,RC,,,both,,,540.45,162.13,"UHC [10700]","United Healthcare",,342.1,63.3,,,,,0,62.85,459.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYOSURE REACH TISSUE REMOVAL 3 DEVICES PER BOX",SUP-10-403FC-NMS,CDM,S27200284,LOCAL,0272,RC,,,both,,,5692.50,1707.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,674.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X14MM CLYDESDALE 0D PEEK CAGE INTERBODY",SUP-2969455,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"AETNA [10100]","Aetna HMO/PPO",,18889.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 11 HOLE CLUSTER GORILLA BONE FIBULA LEFT",SUP-P53-203-L011,CDM,C1713,HCPCS,0278,RC,,,both,,,9468.53,2840.56,"PHCS [10601]",PHCS,,6627.97,70,,,,,0,1101.19,8048.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR FL4 CURVE ANGIOGRAPHIC FEMORAL 2 WIRE",SUP-H74916599220,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"AETNA [10100]","Aetna HMO/PPO",,60.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SR LORDOTIC ALLOGRAFT",SUP-400541,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 100MM 5MM .018IN BALLOON",SUP-R51005010L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MONOCRYL MULTIPASS 4-0 PS-2 18IN MONOFILAMENT UNDYED",SUP-Y496G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4.5MM 50MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.838,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"KAISER [10500]",Kaiser,,235.38,67,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 10MM MANDIBLE LOCK CROSS DRIVE GOLD LORENZ",SUP-41-2410,CDM,C1713,HCPCS,0278,RC,,,both,,,1142.10,342.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,776.63,68,,,,,0,132.83,970.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR 75CM 7CM .035IN STAINLESS",SUP-M001465631,CDM,C1769,HCPCS,0272,RC,,,both,,,494.10,148.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,58.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 4FR MICROPUNCTURE TRANSITIONLESS ACCESS",SUP-G56201,CDM,C1894,HCPCS,0272,RC,,,both,,,229.59,68.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.7,195.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID .1-4MM CANCELLOUS ALLOGRAFT CHIPS FREEZE",SUP-400080,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MICROMARKER SMART CONTROL 30MM 80CM 12MM .035IN",SUP-C12030SB,CDM,C1876,HCPCS,0278,RC,,,both,,,2812.50,843.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,804.94,28.62,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 15CM 23MM 18.5FR ESOPHAGEAL PARTIAL COVER",SUP-M00517740,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UHC [10700]","United Healthcare",,11564.91,63.3,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE NOVASURE UTERINE ENDOMETRIUM KIT ABLATION IMPEDANCE",SUP-NS2013US,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2835.9,41.1,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 38MM AXSOS TITANIUM CORTEX NONSTERILE",SUP-661738,CDM,C1713,HCPCS,0278,RC,,,both,,,330.25,99.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,38.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",38.41,280.71,"percent of total billed charges",
"CATH SABERX 200CM 100MM 3MM BALLOON DILATATION RAPID",SUP-47530100L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 6947100  LEAD-QUADRIPOLAR RV/SVC 10",SUP-6947-100,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2034.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 100MM 10MM BALLOON DILATATION DURALYN",SUP-48010010S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 46MM ASNIS III TITANIUM 1/3 THREAD REVERSE CUT",SUP-604646S,CDM,C1713,HCPCS,0278,RC,,,both,,,1319.00,395.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,605.42,45.9,,,,,0,153.4,1121.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK15MM 51X64MM PROTECTA XT DR ATRIUM",SUP-D314DRG,CDM,C1721,HCPCS,0278,RC,,,both,,,63000.00,18900,"NOVANET [10819]",Novanet,,47250,75,,,,,0,7326.9,53550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aquaporin-4 Antb Cba Each",PX-302000251,CDM,86052,CPT,0302,RC,,,both,,,751.45,225.43,"CIGNA [10200]","Cigna Local Plus",,26.51,,,,,,,0.01,638.73,"fee schedule",
"SCR BONE 1MM 1.6MM 6MM TITANIUM CORTEX HAND SELF TAPPING",SUP-400.526,CDM,C1713,HCPCS,0278,RC,,,both,,,526.18,157.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,150.59,28.62,,,,,0,61.19,447.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING RTRCTR 11-17CM XL ALEXIS C SECTION 11-17CM",SUP-G6304,CDM,S27200284,LOCAL,0272,RC,,,both,,,558.90,167.67,"FIRST HEALTH [10303]","First Health",,447.12,80,,,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESPONSE 65CM 7FR 2-8-2MM SPACING CSL CURVE",SUP-401130,CDM,C1730,HCPCS,0272,RC,,,both,,,2677.50,803.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,317.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,311.39,2275.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661140,CDM,C1713,HCPCS,0278,RC,,,both,,,1377.32,413.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,632.19,45.9,,,,,0,160.18,1170.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE 30X20CM PREPERITONEAL KNIT WEB SYNECOR",SUP-GKWR2030,CDM,C1781,HCPCS,0278,RC,,,both,,,27442.80,8232.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7854.13,28.62,,,,,0,3191.6,23326.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L48MM DIA5MM CARBURIZED VARIABLE ANGLE LOCKING SE",SUP-42.231.248,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,160.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,157.3,1149.66,"percent of total billed charges",
"FRCP SURGICAL AESCULAP 1.5MM 228MM STERILE DISPOSABLE 101MM",SUP-US809SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,3194.16,958.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1312.8,41.1,,,,,0,371.48,2715.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE EXTRA SPORT VASCULAR STRAIGHT 175CM 3CM .014",SUP-22225M-175,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH 1 55CM 6FR .07IN RENAL DOUBLE CURVE 1 GUIDING PTFE",SUP-M001196960,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"UHC [10700]","United Healthcare",,377.98,63.3,,,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PERFORM STEM TSA-PERFORM+",SUP-CAP1185,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"CIGNA [10200]","Cigna Open Access",,8969.63,33.5,,5302.19,4377.88,6578.61,27,3113.93,22758.75,"percent of total billed charges",
"CONCUSSION WITH CC",089,MS-DRG,,,,,,,inpatient,,,66280.16,19007.5,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,7019.12,,"Case rate ($6,814.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,327.89, add-ons for qualifying new technology services are included. If operating cost exceeds $39,367.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,860.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,336.26. The transfer operating threshold is the transfer adjustment factor * $6,327.89 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $478.42. The transfer capital threshold is the transfer adjustment factor * $478.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7019.12,7561,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY",RX-164922,CDM,,,0637,RC,00536-1186-12,NDC,both,1,UN,12.54,3.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5.76,45.9,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L15 MM OD3.5 MM SPINE CERVICAL ANTERIOR SELF TAP",SUP-18008415,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,3978.14,359.25,3978.14,24,117.75,860.63,"percent of total billed charges",
"STEM EXT 100MM 11MM NEXGEN OFFSET KNEE FEMUR 145MM STERILE",SUP-00598802011,CDM,C1776,HCPCS,0278,RC,,,both,,,10435.56,3130.67,"CIGNA [10200]",Cigna,,7096.18,68,,5873.17,5873.17,5873.17,"1 through 10",1213.66,8870.23,"percent of total billed charges",
"SPACER SPINAL 40X18X7MM RISE 3-15D",SUP-193.502,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CIGNA [10200]",Cigna,,13734,40,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP STERILE DISPOSABLE LATEX FREE",SUP-26055G-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1113.89,334.17,"AETNA [10100]","Aetna HMO/PPO",,885.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,129.55,946.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC CROME DR 2 CHMBR DF-1 PIN PLUG RADIOPAQUE",SUP-DDPC3D1,CDM,C1882,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23951.03,41.1,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X13MM 9/11MM SPINE CORTICAL FROZEN DISTAL",SUP-4913,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"PHCS [10601]",PHCS,,11592,70,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BNDG 10YDX3IN UNNA-Z UNNA BOOT ZINC OXIDE PLASTIC WITHOUT",SUP-NONUNNA13,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.27,14.18,"MULTIPLAN [10600]",Multiplan,,40.18,85,,,,,0,5.5,40.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 CURVE 12.5MM KNEE GVF ROTATE PLATFORM PFC",SUP-972002,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"PHCS [10601]",PHCS,,6474.62,70,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis B Surface Ag Eia",PX-306000103,CDM,87340,CPT,0306,RC,,,both,,,216.50,64.95,"CIGNA [10200]","Cigna Open Access",,22.73,,,,,,,0.22,184.03,"fee schedule",
"SCR BONE 4.5MM 30MM AXSOS STAINLESS STEEL 3.5MM FULL THREAD",SUP-340630,CDM,C1713,HCPCS,0278,RC,,,both,,,255.78,76.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,29.75,217.41,"percent of total billed charges",
"HC Rpr Cvc WO Port",PX-361000117,CDM,36575,CPT,0361,RC,,,both,,,2685.39,805.62,"UHC [10700]","United Healthcare",,2385,,"Case rate ($2,385). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,2.69,2685.39,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 150MM 135CM 6MM 5FR VASCULAR NITINOL LOW",SUP-5F061503CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20128.50,6038.55,"KAISER [10500]",Kaiser,,13486.1,67,,,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TIGHTRAIL 20FR 18.7IN 13FR 25FR 13.2FR DIL ROTATE",SUP-545-513,CDM,C1773,HCPCS,0272,RC,,,both,,,15766.50,4729.95,"KAISER [10500]",Kaiser,,10563.56,67,,,,,0,1833.64,13401.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICONAZOLE NITRATE 2 % TOPICAL POWDER",RX-10599,CDM,,,0250,RC,80196-0528-56,NDC,both,85,GR,8.75,2.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3.6,41.1,,,,,0,1.02,7.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM DVR TITANIUM RADIUS CORTICAL DISTAL",SUP-CS12000,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"CIGNA [10200]","Cigna Open Access",,622.2,56.9,,1144.80,304.56,2275.09,66,127.17,929.48,"percent of total billed charges",
"HC Train for Caregiver Add 15 (Go)",PX-430000069,CDM,G0540,HCPCS,0430,RC,,,both,,,37.00,11.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.04,37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 8MM 30MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.420,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,134.52,983.18,"percent of total billed charges",
"INSERT TIB PCL SUBS 1-2X12MM L",SUP-2141-1-1212,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON CABLE BLUE 2.5MM FEMUR TITANIUM ALUMINUM VANADIUM",SUP-47223206001,CDM,C1713,HCPCS,0278,RC,,,both,,,1912.50,573.75,"FIRST HEALTH [10303]","First Health",,1530,80,,,,,0,222.42,1625.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,,,0250,RC,60219-1585-03,NDC,both,5,ML,467.44,140.23,"KAISER [10500]",Kaiser,,313.18,67,,,,,0,54.36,397.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN AMPLATZ LEFT 2 CURVE ANGIOGRAPHIC",SUP-H74908526982,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PHCS [10601]",PHCS,,53.61,70,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 C-H STD 66X42X12MM KNEE PROLONG NEXGEN",SUP-00595203012,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"MULTIPLAN [10600]",Multiplan,,6663.81,85,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 126D 65MM HIP NECK SEG",SUP-17296426,CDM,C1776,HCPCS,0278,RC,,,both,,,29432.09,8829.63,"CIGNA [10200]","Cigna Local Plus",,9271.11,31.5,,5372.07,4581.20,7242.98,23,3422.95,25017.28,"percent of total billed charges",
"IMMOB ORTHOPEDIC XL LARGE SHOULDER HOOK LOOP CLSR SWATHE",SUP-ORT16020LXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.24,15.37,"FIRST HEALTH [10303]","First Health",,40.99,80,,,,,0,5.96,43.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASPIRA HOME DRAINAGE SYSTEM ASPIRA REPAIR KIT",SUP-4992306,CDM,S27200284,LOCAL,0272,RC,,,both,,,426.30,127.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,289.88,68,,,,,0,49.58,362.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE REVERSE REVISION HUMERAL STEM, SZ 14X175MM",SUP-530-14-175,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Open Access",,4221,33.5,,5302.19,4377.88,6578.61,27,1465.38,10710,"percent of total billed charges",
"SUT VICRYL PLUS 1 CTX 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP765D,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.49,38.55,"AETNA [10100]","Aetna HMO/PPO",,102.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.94,109.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE NAKAO SPIDER-NET STD 230CM 5.5X2.5CM SPECIMEN",SUP-00230A,CDM,S27000186,LOCAL,0270,RC,,,both,,,486.00,145.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,199.75,41.1,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE RIGHT LATERAL FEMORAL CORTICAL THK3-15MM THIRD",SUP-450974,CDM,S27800098,LOCAL,0278,RC,,,both,,,5775.30,1732.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,684.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,671.67,4909.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP 3 HOLE QUADRANT GROUP C BIOFOAM",SUP-DBFPGC50,CDM,C1776,HCPCS,0278,RC,,,both,,,18194.40,5458.32,"BLUE CROSS [10001]","Blue Cross PPO",,7132.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",2116.01,15465.24,"percent of total billed charges",
"ACUTE LEUKEMIA WITH OTHER PROCEDURES",850,MS-DRG,,,,,,,inpatient,,,100128.76,30038.63,"UHC [10700]","United Healthcare",,100128.76,,"Fee schedule rate ($252,822.76). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,100128.76,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 1-2 13MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934380,CDM,C1776,HCPCS,0278,RC,,,both,,,18947.25,5684.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7578.9,40,,,,,0,2203.57,16105.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 38MM PROFILE 3D",SUP-680R38,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"MULTIPLAN [10600]",Multiplan,,11143.5,85,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 4MM AZUR .018IN",SUP-45-480405,CDM,S27800098,LOCAL,0278,RC,,,both,,,5361.30,1608.39,"BLUE CROSS [10001]","Blue Cross PPO",,2101.63,39.2,,,,,0,623.52,4557.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 34MM 1 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-41F34V,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 C-H STD 66X42X14MM KNEE PROLONG NEXGEN",SUP-00595203014,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5331.05,68,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grad Compression Gauntlet",PX-E27100007,CDM,S8428,HCPCS,0292,RC,,,both,,,210.00,63,"CIGNA [10200]","Cigna Local Plus",,112.35,53.5,,,,,0,24.42,178.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL CERVICAL 10X14X12MM 7DEG LORDOTIC PEEK COHERE",SUP-4101427P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"AETNA [10100]","Aetna HMO/PPO",,4936.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 35MM ENDOPATH ECHELON TITANIUM VASCULAR TISSUE",SUP-VASECR35,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14CM NATRELLE INSPIRA P4.6CM MODERATE PROFILE",SUP-MSZ-M485,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA [10200]",Cigna,,107.56,68,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 340MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.155S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CIGNA [10200]",Cigna,,4967.34,40,,1831.33,1831.33,1831.33,16,1444.25,10555.59,"percent of total billed charges",
"CATH LAUNCHER 8FR .09IN HOCKEY STICK 1 CURVE GUIDING NYLON",SUP-LA8HSI,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AETNA [10100]","Aetna HMO/PPO",,311.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INFLATION INDEFLATOR PLUS 30 .096IN CORONARY ROTATE",SUP-1000185,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE LONG STEM",SUP-CAP-T-1060,CDM,C1776,HCPCS,0278,RC,,,both,,,3750.00,1125,"AMERIGROUP MEDICAID [20100]",Amerigroup,,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM TRIDENT SECUR-FIT TITANIUM CANCELLOUS",SUP-2030-6535-1,CDM,C1713,HCPCS,0278,RC,,,both,,,571.90,171.57,"FIRST HEALTH [10303]","First Health",,457.52,80,,,,,0,66.51,486.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Syphilis Test Qual",PX-302000093,CDM,86592,CPT,0302,RC,,,both,,,141.55,42.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15.15,,,,,,,0.01,120.32,"fee schedule",
"LEAD PACING 88CM 4FR DISTAL 2 CURVE LEFT HEART TRANSVENOUS",SUP-419388,CDM,C1900,HCPCS,0278,RC,,,both,,,6064.80,1819.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2783.74,45.9,,,,,0,705.34,5155.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 3MM EICKEN ELECTROMAGNETIC MALLEABLE 10 TIME",SUP-8000050006,CDM,S27200284,LOCAL,0272,RC,,,both,,,16242.60,4872.78,"PHCS [10601]",PHCS,,11369.82,70,,,,,0,1889.01,13806.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 9IN LAMBOTTE SPINE SURGICAL CURVE .5IN",SUP-28-9462,CDM,S27200284,LOCAL,0272,RC,,,both,,,232.99,69.9,"NOVANET [10819]",Novanet,,174.74,75,,,,,0,27.1,198.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX21MM FRA 8D NARROW WEDGE SPINE",SUP-10021,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"KAISER [10500]",Kaiser,,12663,67,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 18MM 80CM 7MM 3.3-3.5FR VASCULAR COCR",SUP-1011504-18,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2891.7,45.9,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT LOWAX 9CM 230CM 25MM 10.2FR COLONIC",SUP-CNJF-25-090-230,CDM,C1876,HCPCS,0278,RC,,,both,,,15104.24,4531.27,"AETNA [10100]","Aetna HMO/PPO",,12007.87,79.5,,,,,0,1756.62,12838.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 15IN 36FR VENOUS ADULT .5IN CONNECTION SITE 1",SUP-68136,CDM,S27200284,LOCAL,0272,RC,,,both,,,353.47,106.04,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT VIABAHN 10CM 75MM 8MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR081001A,CDM,C1874,HCPCS,0278,RC,,,both,,,17545.50,5263.65,"PHCS [10601]",PHCS,,12281.85,70,,,,,0,2040.54,14913.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM PRECISION CONVEX SPINE",SUP-17512,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD LUBRI-SIL IC 20FR URETHRAL BACTI-GUARD SILICONE",SUP-1758SI20,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.35,24.4,"CIGNA [10200]",Cigna,,55.32,68,,,,,0,9.46,69.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ASCEND FLEX REV W PERF REV LAT BASEPLATE",SUP-CAP1132,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"BLUE CROSS [10001]","Blue Cross HMO",,19015.92,39.2,,5311.50,4717.44,5388.59,31,5641.71,41233.5,"percent of total billed charges",
"GRAFT STENT 10CM 31MM TAG THORACIC ACTIVE CONTROL",SUP-TGMR313110,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"CIGNA [10200]","Cigna Local Plus",,36531.24,31.5,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X20 135CM SL",SUP-48005002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"AETNA [10100]","Aetna HMO/PPO",,682.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BIOPSY 15CM 13GA OSTEO-SITE BONE CANN TROCAR TIP STYLET",SUP-G12500,CDM,S27200284,LOCAL,0272,RC,,,both,,,374.10,112.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,171.71,45.9,,,,,0,43.51,317.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE GRAFT 3CC AUG INJECTABLE",SUP-K300003010,CDM,C1734,HCPCS,0278,RC,,,both,,,18900.00,5670,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 8MM 3MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012407-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH ADULT 48CM 15.5FR POLYURETHANE BIOFLO DURAMAX",SUP-H787103028235,CDM,C1750,HCPCS,0278,RC,,,both,,,910.00,273,"CIGNA [10200]","Cigna Open Access",,517.79,56.9,,,,,0,105.83,773.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 15MM HELIX R SPINE SELF TAP FIX ANGLE",SUP-7806215,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,1144.80,304.56,2275.09,66,117.75,860.63,"percent of total billed charges",
"FOL URETHRAL 14.5IN 22FR PHILLIPS 1/56IN HOLLOW PLASTIC 1",SUP-346122,CDM,S27200284,LOCAL,0272,RC,,,both,,,141.81,42.54,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE SUCTION KAMVAC MINI CURVE STERILE LATEX FREE",SUP-5300-20-500,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RUNWAY 100CM 6FR ART4 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389695000,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 20MM 6FR 5MM .07",SUP-H7493926720500,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INSRT FEMORAL VENOUS CANN BIO-MEDICUS NEXTGEN 23FR",SUP-96600-123,CDM,S27200284,LOCAL,0272,RC,,,both,,,3022.88,906.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VANSONNENBERG 25CM 14FR DRNG GLIDEX PERCUFLEX METAL",SUP-M001245140,CDM,C1729,HCPCS,0272,RC,,,both,,,729.00,218.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 33MM 2.5MM CORONARY STENT EVEROLIMUS",SUP-1550250-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 160MM 2.7MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.67,CDM,S27000186,LOCAL,0270,RC,,,both,,,2111.40,633.42,"UHC [10700]","United Healthcare",,1336.52,63.3,,,,,0,245.56,1794.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 15CM 18MM 10.5MM ESOPHAGEAL DELIVERY",SUP-G57331,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"NOVANET [10819]",Novanet,,13192.2,75,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM 16.7MM MASTERS HP 85D SUPRA ANNULAR",SUP-19AEHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"FIRST HEALTH [10303]","First Health",,23295.38,80,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 490CC",SUP-RSZ-SHPX-490S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pericardiocentesis W Img",PX-450000386,CDM,33016,CPT,0361,RC,,,both,,,3472.28,1041.68,"CIGNA [10200]","Cigna Open Access",,3472.28,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,403.83,3472.28,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 STD 14MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS3S14L,CDM,C1776,HCPCS,0278,RC,,,both,,,7569.30,2270.79,"BLUE CROSS [10001]","Blue Cross HMO",,2967.17,39.2,,5311.50,4717.44,5388.59,31,880.31,6433.91,"percent of total billed charges",
"PLATE 99MM STAINLESS STEEL 2.7/3.5MM SCREWS 5 HOLE LCP BONE",SUP-02.112.141S,CDM,C1713,HCPCS,0278,RC,,,both,,,3538.50,1061.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1624.17,45.9,,,,,0,411.53,3007.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 3-0 RB-1 SPIRAL 30CM KNOTLESS",SUP-SXMP1B425,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.03,65.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,89.61,41.1,,,,,0,25.36,185.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Amylase",PX-301000105,CDM,82150,CPT,0301,RC,,,both,,,255.55,76.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.39,,,,,,,0.26,217.22,"fee schedule",
"COIL EMBOLIZATION 15CM 6MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0615CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross PPO",,2569.56,39.2,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURESIGHT BLADE HYPERANGULATED SIZE 4",SUP-390241000,CDM,S27000186,LOCAL,0270,RC,,,both,,,321.90,96.57,"CIGNA [10200]","Cigna Open Access",,183.16,56.9,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST EXTERNAL FIXATION MAXFRAME 3 HIGH MOUNT MULTIPARALLEL",SUP-03.313.859,CDM,C1713,HCPCS,0278,RC,,,both,,,1341.85,402.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,912.46,68,,,,,0,156.06,1140.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 1.5MM WIRE PASS STERILE",SUP-1608002059,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 4.5IN 9FR FRAZIER ANGLE",SUP-70-1080,CDM,S27200284,LOCAL,0272,RC,,,both,,,189.83,56.95,"CIGNA [10200]","Cigna Open Access",,108.01,56.9,,,,,0,22.08,161.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 44MM TITANIUM T25 FULL THREAD SELF TAP LOCK",SUP-04.005.534S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"CIGNA [10200]",Cigna,,1017.88,68,,1831.33,1831.33,1831.33,16,174.09,1272.35,"percent of total billed charges",
"SIZER IMPL 10CM NATRELLE INSPIRA P4.2CM FULL PROFILE ROUND",SUP-MSZ-F220,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 150CM 200MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050200M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP ELECTROSURGICAL 8.75IN BUZZ RUGGLES REDMOND 1MM BAYONET",SUP-N24BS10,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT ENDOVASCULAR 131MM 36MM 22FR ZENITH FLEX Z-TRAK 2",SUP-G48434,CDM,C1874,HCPCS,0278,RC,,,both,,,50122.80,15036.84,"KAISER [10500]",Kaiser,,33582.28,67,,,,,0,5829.28,42604.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 120MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UHC [10700]","United Healthcare",,907.53,63.3,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT BLACK 24CM 6FR 2 PIGTAIL CURVE STRAIGHT URETERAL",SUP-G46439,CDM,C2617,HCPCS,0278,RC,,,both,,,1194.75,358.42,"CIGNA [10200]",Cigna,,812.43,68,,,,,0,138.95,1015.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM CORTEX SELF TAP STARDRIVE NONSTERILE",SUP-02.200.014,CDM,C1713,HCPCS,0278,RC,,,both,,,240.38,72.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,27.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",27.96,204.32,"percent of total billed charges",
"VALVE HEMOSTASIS PASSAGE 500 PSI TUBING EXT Y ADPTR 6IN",SUP-K12-00040,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"KAISER [10500]",Kaiser,,69.95,67,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PROGRESS 40 VASCULAR STRAIGHT 190CM 3CM .014",SUP-1011836,CDM,C1769,HCPCS,0272,RC,,,both,,,1036.80,311.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,122.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUCTION LUER ADPTR MALLEABLE MICROLITE PLASTIC 20GA",SUP-1359260,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.59,15.18,"FIRST HEALTH [10303]","First Health",,40.47,80,,,,,0,5.88,43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 1 GS-21 18IN CLSR NONABSORBABLE BLUE",SUP-VLOCN0327,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.33,69.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.9,196.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 7MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS07030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"MULTIPLAN [10600]",Multiplan,,9964.64,85,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 20X20MM JAWS STRAIGHT NITINOL",SUP-P71-020-2020-S,CDM,C1713,HCPCS,0278,RC,,,both,,,8952.75,2685.82,"UHC [10700]","United Healthcare",,5667.09,63.3,,5023.51,2672.93,6679.78,18,1041.2,7609.84,"percent of total billed charges",
"TUBE JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE MIC-KEY",SUP-0270-18-2.0-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"PHCS [10601]",PHCS,,1842.96,70,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 250MM 2.5MM 95MM QUICK COUPLING STOP CALIBRATE",SUP-03.113.023,CDM,S27200284,LOCAL,0272,RC,,,both,,,827.82,248.35,"KAISER [10500]",Kaiser,,554.64,67,,,,,0,96.28,703.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR LEFT CORONARY",SUP-67018000,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,171.63,41.1,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 360 145CM 20MM 2MM 6FR 2MM ATHERECTOMY",SUP-DBP-200CLASS145,CDM,C1724,HCPCS,0272,RC,,,both,,,21388.50,6416.55,"NOVANET [10819]",Novanet,,16041.38,75,,,,,0,2487.48,18180.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 12MM LOW PROFILE SCREWS TITANIUM ANKLE VARIABLE",SUP-AR-8933V-12,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"CIGNA [10200]","Cigna Open Access",,806.56,56.9,,1144.80,304.56,2275.09,66,164.86,1204.88,"percent of total billed charges",
"CMPNT FEMORAL 8 KNEE PERSONA STERILE LATEX FREE",SUP-42572606402,CDM,C1776,HCPCS,0278,RC,,,both,,,26429.76,7928.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10571.9,40,,,,,0,3073.78,22465.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SOLITAIRE PARAMETRIC 50MM 40MM 4MM 10MM SPACE 3-1",SUP-SFR4-4-40-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,40761.00,12228.3,"UHC [10700]","United Healthcare",,25801.71,63.3,,,,,0,4740.5,34646.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHTH 9FR 5CM KT HMSTS EP",SUP-6275,CDM,C1894,HCPCS,0272,RC,,,both,,,139.20,41.76,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ATHEROSCLEROSIS WITH MCC",302,MS-DRG,,,,,,,inpatient,,,43825.96,13147.79,"BLUE CROSS [10001]","Blue Cross HMO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) AVEIR DELIVERY CATHETER",SUP-LSCD201,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT NASAL 65X35MM SMALL VELCRO ALUMINUM DENVER SEPTUM 2",SUP-10-1500-05KS,CDM,S27000186,LOCAL,0270,RC,,,both,,,546.02,163.81,"UHC [10700]","United Healthcare",,345.63,63.3,,,,,0,63.5,464.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ROUND ALLOGRAFT FREEZE DRY 40X9-14MM",SUP-400722,CDM,S27800098,LOCAL,0278,RC,,,both,,,3978.54,1193.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1138.66,28.62,,,,,0,462.7,3381.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 13CM 4.2MM DISTAL TIP STEALTH FRR DIAMOND LIKE CARBON",SUP-S9247A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1044.90,313.47,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,429.45,41.1,,,,,0,121.52,888.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL AMPLATZ FIRM KINK RESISTANT GRADUATE TAPER 35CM",SUP-M0062601030,CDM,C1894,HCPCS,0272,RC,,,both,,,362.44,108.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.15,308.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR ANGLE KMP CURVE",SUP-G09469,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,109.01,45.9,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT VITOSS B-TCP CLLGN VOID FILLER FOAM PACK 5ML",SUP-2102-1405,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"CIGNA [10200]","Cigna Local Plus",,2307.19,53.5,,3978.14,359.25,3978.14,24,501.54,3665.63,"percent of total billed charges",
"3.0MM PHALANX LNTRAMEDULLARY NAIL 3MM X 47.5MM TI",SUP-IHFN-PHX-30047,CDM,C1713,HCPCS,0278,RC,,,both,,,8052.30,2415.69,"AETNA [10100]","Aetna HMO/PPO",,6401.58,79.5,,1521.93,481.35,16760.95,30,936.48,6844.46,"percent of total billed charges",
"PIRANHA CERVICAL VARIABLE SCREW 4.0 MM X 14 MM",SUP-SK-CSV-40-14,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"SCR BONE 5MM 26MM NAIL-EX TITANIUM FEMUR TIBIA LOCKING",SUP-04.005.516,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"BLUE CROSS [10001]","Blue Cross HMO",,453.42,39.2,,957.42,156.86,7483.26,51,134.52,983.18,"percent of total billed charges",
"IMPL BREAST 180CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-200,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 8CM 10MM BALLOON DILATATION OTW LOW",SUP-G30930,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 85MM X40 RECONSTRUCTION STERILE",SUP-04.046.685S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",189.34,1383.8,"percent of total billed charges",
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 20MM 2.5MM",SUP-SPL25020X,CDM,C1725,HCPCS,0272,RC,,,both,,,546.75,164.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,64.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,63.59,464.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 300MM 2.8MM THREAD",SUP-03.333.015.04,CDM,S27200284,LOCAL,0272,RC,,,both,,,1123.33,337,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,461.69,41.1,,,,,0,130.64,954.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 10 12MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151621012,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"KAISER [10500]",Kaiser,,7540.11,67,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSELECT DEMINERALIZED BONE MATRIX 1CC",SUP-359010,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,520.51,45.9,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 4.5MM CANNULATED SPINAL CREO MIS",SUP-6134.0045,CDM,S27000186,LOCAL,0270,RC,,,both,,,583.20,174.96,"MULTIPLAN [10600]",Multiplan,,495.72,85,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 9MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-609-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4813.44,40,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE UNICORTICAL DOWEL ALLOGRAFT FREEZE DRIED 14-40MM",SUP-400201,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"FIRST HEALTH [10303]","First Health",,3394.8,80,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX LARGE C9 9.5MM X",SUP-T600309,CDM,S27800098,LOCAL,0278,RC,,,both,,,3150.00,945,"AMERIGROUP MEDICAID [20100]",Amerigroup,,373.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,366.35,2677.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 20MM 3.5MM BALLOON DILATATION RAPID",SUP-47535020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"KAISER [10500]",Kaiser,,1069.12,67,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 55MM 6MM ROUND STAINLESS STEEL STERILE",SUP-1608002015,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X11X8MM ALLOCRAFT 5D LORDOSIS CORTICAL",SUP-6183-7-008,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEPHROSTOMY SHEATH 22-24FR X 13CM",SUP-90122213,CDM,C1894,HCPCS,0272,RC,,,both,,,3157.50,947.25,"MULTIPLAN [10600]",Multiplan,,2683.88,85,,,,,0,367.22,2683.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 20MM 2.5MM BALLOON DILATATION",SUP-2200-2520-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3988.2,68,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE 12IN MERITRANS BONDED PIGITAIL CABLE 1 WAY",SUP-K11-00099,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"FIRST HEALTH [10303]","First Health",,62.64,80,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR COAGULATION CORD LATEX FREE DISPOSABLE",SUP-DN9100,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.16,17.75,"CIGNA [10200]",Cigna,,40.23,68,,,,,0,6.88,50.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET .75IN 20GA INFUSION 2 LUMEN PORT POWER INJECTABLE",SUP-0142075,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.07,14.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.47,40.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txcath Retrev Intrvas FB",PX-361000295,CDM,37197,CPT,0361,RC,,,both,,,10102.49,3030.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2795.56,,"Case rate ($2,795.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,1174.92,10015,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,inpatient,,,71069.28,21320.78,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,32012.73,,"of the excess amount. Final payment is multiplied by 107%.",,,,0,2462,64324.65,"case rate","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH VASCULAR 8X.8CM XENOSURE BOVINE PERICARDIAL TISSUE",SUP-E0.8P8,CDM,C1768,HCPCS,0278,RC,,,both,,,1980.00,594,"KAISER [10500]",Kaiser,,1326.6,67,,,,,0,189.34,1683,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 10MM GORE-TEX THIN WALL PTFE STRETCH",SUP-ST1008,CDM,C1768,HCPCS,0278,RC,,,both,,,8535.30,2560.59,"PHCS [10601]",PHCS,,5974.71,70,,,,,0,992.66,7255.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 28MM 8MM DELTA TAPER SHOULDER",SUP-AR-5028C-08,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"BLUE CROSS [10001]","Blue Cross HMO",,725.45,39.2,,957.42,156.86,7483.26,51,215.23,1573.04,"percent of total billed charges",
"GRAFT BONE ILIAC CREST TRICORTICAL THK19-21MM WEDGE",SUP-400410,CDM,S27800098,LOCAL,0278,RC,,,both,,,6305.22,1891.57,"CIGNA [10200]","Cigna Local Plus",,3373.29,53.5,,,,,0,733.3,5359.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VISTA BRITE TIP GUIDE CATHETER 6F .070 JR4 ECO PK",SUP-6700820E,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,283.97,68,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 3.5/20",SUP-434895,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"BLUE CROSS [10001]","Blue Cross HMO",,7742.2,39.2,,9776.84,9776.84,9776.84,"1 through 10",2296.98,16787.93,"percent of total billed charges",
"SHIELD RADIOLOGY 16X16IN RADBARRIER LARGE POSITIONAL FREE",SUP-RBFPS101,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.67,83.9,"UHC [10700]","United Healthcare",,177.03,63.3,,,,,0,32.53,237.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 8CM 9MM BALLOON DILATATION OTW LOW",SUP-G30980,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 38MM FREEMAN AREOLA BREAST BIOPSY STAINLESS STEEL",SUP-P464,CDM,S27200284,LOCAL,0272,RC,,,both,,,532.33,159.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,244.34,45.9,,,,,0,61.91,452.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUSH WC 17X17IN WAFFLE PREINFLATE VALVELESS NONSTERILE LATEX",SUP-2200WCIX120,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.04,24.01,"CIGNA [10200]","Cigna Local Plus",,42.82,53.5,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC INSPIRIS RESILIA 23MM BOVINE PERICARDIUM",SUP-11500A23,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"UHC [10700]","United Healthcare",,28712.88,63.3,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.25MM 150MM KIRSCHNER STAINLESS STEEL TROCAR",SUP-292.12,CDM,C1713,HCPCS,0278,RC,,,both,,,61.14,18.34,"KAISER [10500]",Kaiser,,40.96,67,,,,,0,7.11,51.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE LEAD DISP 3/5 LEAD SZ 9",SUP-LS-229,CDM,S27000186,LOCAL,0270,RC,,,both,,,121.62,36.49,"CIGNA [10200]",Cigna,,82.7,68,,,,,0,14.14,103.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FRACTURE STABILIT MX SHORT FULL VERTEBROPLASTY SYSTEM",SUP-MX-2100S,CDM,S27200284,LOCAL,0272,RC,,,both,,,15870.00,4761,"FIRST HEALTH [10303]","First Health",,12696,80,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120MM 8MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR080202A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4564.35,27,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 65CM 20MM 5.4FR 3MM BALLOON DILATATION 2",SUP-BD-L30020SW,CDM,C1725,HCPCS,0272,RC,,,both,,,923.40,277.02,"KAISER [10500]",Kaiser,,618.68,67,,,,,0,107.39,784.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 14FR SILICONE MEDICATION PORT RADIOPAQUE STRIPE",SUP-0100-14LV,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"CIGNA [10200]","Cigna Local Plus",,149.74,53.5,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 4FR 6MM LOW PROFILE",SUP-39031-60401,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM SPIDERFX 320CM 190CM 3.2-4.2FR 5MM EMBOLIC PROTECTION",SUP-SPD2-US-050-320,CDM,C1884,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CHMBR HUMD 2 FLOAT AUTO FILL COMPRESSIBLE VOLUME MR SERIES",SUP-MR290V,CDM,S27000186,LOCAL,0270,RC,,,both,,,94.50,28.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOFT-VU 40CM 5FR ANGLE KUMPE CURVE ANGIOGRAPHIC",SUP-H787107327025,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE MERIT MAK VASCULAR 40CM .018IN PLATINUM STAINLESS",SUP-MAK005,CDM,C1894,HCPCS,0272,RC,,,both,,,188.36,56.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CONNECTIVE TISSUE DISORDERS WITH CC",546,MS-DRG,,,,,,,inpatient,,,45670.54,13701.16,"CIGNA [10200]","Cigna Local Plus",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11.25CM NATRELLE INSPIRA P2.9CM LOW PLUS PROFILE",SUP-MSZ-LP205,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.69,42.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM RESOLUTE ONYX 8MM 140CM 3.5MM 2.1-2.7FR CORONARY",SUP-RONYX35008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1062.52,28.62,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 19MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532-P-119,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2391.46,28.62,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL LARGE KNEE RIGHT LCS COMPLETE POROCOAT",SUP-129403060,CDM,C1776,HCPCS,0278,RC,,,both,,,28683.90,8605.17,"BLUE CROSS [10001]","Blue Cross HMO",,11244.09,39.2,,5311.50,4717.44,5388.59,31,3335.94,24381.32,"percent of total billed charges",
"HC Xr Nasal Bn>=3v",PX-320000010,CDM,70160,CPT,0320,RC,,,both,,,604.70,181.41,"CIGNA [10200]",Cigna,,65.08,,,,,,,46.53,514,"fee schedule",
"CATH APD 20CM 6FR DRNG FLEXIMA METAL HYDROPHILIC REGULAR",SUP-M001271280,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 80CM 8FR 45MM BALLOON OCCLUSION VASCULAR",SUP-62080822F,CDM,C2628,HCPCS,0272,RC,,,both,,,741.31,222.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,87.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.21,630.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT POSTERIOR STABILIZE CEMENT LEGION",SUP-71423224,CDM,C1776,HCPCS,0278,RC,,,both,,,21886.20,6565.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8754.48,40,,,,,0,2545.37,18603.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 60X16MM DARCO FOOT HEADLESS",SUP-DC001660,CDM,C1713,HCPCS,0278,RC,,,both,,,4629.90,1388.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2125.12,45.9,,,,,0,538.46,3935.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM CD HORIZON REDUCTION MULTIAXIAL",SUP-55890007550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 5MM ACORN STERILE",SUP-5620030050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1066.37,319.91,"NOVANET [10819]",Novanet,,799.78,75,,,,,0,124.02,906.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ASCEND FLEX SHOULDER - HEMI (INCLUSIVE OF ASCEND FLEX ST",SUP-CAPFLEXHEM,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9062.55,41.1,,6417.48,6417.48,6417.48,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"STIM HANDHELD LOC VARI-STIM III NERVE STD SUBDERMAL",SUP-8562010,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 475ML GEL SMOOTH SILICONE P5.3CM HIGH PROFILE",SUP-3504754BC,CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Local Plus",,2022.3,,,,,,,439.61,3213,"percent of total billed charges",
"INSRT ARTICULAR 7-8 11MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934388,CDM,C1776,HCPCS,0278,RC,,,both,,,18947.25,5684.17,"CIGNA [10200]",Cigna,,7578.9,40,,5873.17,5873.17,5873.17,"1 through 10",2203.57,16105.16,"percent of total billed charges",
"CATH LUBRI-SIL 18FR URETHRAL SILICONE 30ML FOLEY 3 WAY",SUP-73018L,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.78,26.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,36.9,41.1,,,,,0,10.44,76.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SR BONE 5X14X11",SUP-200541,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006175284190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,147.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 150CM 8FR .038IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145383170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CIGNA [10200]",Cigna,,768.37,68,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 6MM 2 8MM TENOLOK HI-FI 2 EXPAND GUIDE PIN DRILL",SUP-T60S80,CDM,C1713,HCPCS,0278,RC,,,both,,,8016.83,2405.05,"PHCS [10601]",PHCS,,5611.78,70,,,,,0,932.36,6814.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR BLADDER PROCEDURES WITHOUT CC/MCC",655,MS-DRG,,,,,,,inpatient,,,126074.95,37822.48,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,14048.46,,"Case rate ($13,129.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,191.54, add-ons for qualifying new technology services are included. If operating cost exceeds $45,231.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,303.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,207.66. The transfer operating threshold is the transfer adjustment factor * $12,191.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $921.74. The transfer capital threshold is the transfer adjustment factor * $921.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,61796.25,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 10MM IPOLY XE POSTERIOR STABILIZE ITOTAL",SUP-TPS-020-1000,CDM,C1776,HCPCS,0278,RC,,,both,,,2130.00,639,"CIGNA [10200]",Cigna,,1448.4,68,,5873.17,5873.17,5873.17,"1 through 10",247.72,1810.5,"percent of total billed charges",
"IMPL BREAST SMOOTH MOD + PROF XTRA 215CC",SUP-SMPX215,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"CIGNA [10200]","Cigna Local Plus",,3986.82,,,,,,,866.67,6334.2,"percent of total billed charges",
"TUBE ENDOTRACHEAL 8.2MM 7MM NASAL ORAL CUFF MURPHY EYE",SUP-86550,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.14,53.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.72,151.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 7-0 BV175-6 30IN 2 ARM MONOFILAMENT 4 STRAND",SUP-M8733,CDM,S27200284,LOCAL,0272,RC,,,both,,,475.47,142.64,"KAISER [10500]",Kaiser,,318.56,67,,,,,0,55.3,404.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEWIRE NON-THREADED 1.6MM",SUP-292.727,CDM,C1769,HCPCS,0272,RC,,,both,,,276.49,82.95,"NOVANET [10819]",Novanet,,207.37,75,,,,,0,32.16,235.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UMBILI-CATH 34CM 5FR UMBILICAL POLYURETHANE NEONATE 1",SUP-4185005,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.36,31.01,"CIGNA [10200]",Cigna,,70.28,68,,,,,0,12.02,87.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 40MM 130CM 6MM LONG VASCULAR NITINOL ILIAC",SUP-SC640LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"MULTIPLAN [10600]",Multiplan,,6158.25,85,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 36X24MM ENDOSKELETON TAS 12D 12MM LARGE TITANIUM",SUP-2312-0212,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"MULTIPLAN [10600]",Multiplan,,24097.5,85,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LEMAITRE 80CM 6FR 13.5MM EMBOLECTOMY 16ML STERILE LATEX",SUP-E1601-68,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"UHC [10700]","United Healthcare",,379.42,63.3,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFT TOUCH",SUP-SSM-405,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,878.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,inpatient,,,27970.34,8391.1,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,8339.38,,"Case rate ($7,867.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,305.36, add-ons for qualifying new technology services are included. If operating cost exceeds $40,345.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,934.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,315.02. The transfer operating threshold is the transfer adjustment factor * $7,305.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $552.32. The transfer capital threshold is the transfer adjustment factor * $552.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,27970.34,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 47.5MM TRIGEN FEMUR LOW PROFILE",SUP-71645047,CDM,C1713,HCPCS,0278,RC,,,both,,,2314.95,694.48,"NOVANET [10819]",Novanet,,1736.21,75,,,,,0,269.23,1967.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT OUTRIGGER 4IN ROLYAN 4IN SMALL PREBENT FINGER METACARPUS",SUP-A6012,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL ASPIRATION STERILE LATEX FREE DISPOSABLE",SUP-NA-U200H-8025,CDM,S27200284,LOCAL,0272,RC,,,both,,,1173.69,352.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH POLARIS DX 105CM 6FR 2.5-5-2.5MM SPACE STD CURVE",SUP-M0047003D0,CDM,C1732,HCPCS,0272,RC,,,both,,,5002.50,1500.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE LARYNSCP SPECTRUM 0 STERILE DISPOSABLE",SUP-0270-0966,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POINTER NAVIGATION AXIEM TRACER STERILE LATEX FREE",SUP-9735317,CDM,S27200284,LOCAL,0272,RC,,,both,,,3919.20,1175.76,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL 3.6 X 160MM SOLID MEASURING LONG AO",SUP-P99-100-3616,CDM,S27000186,LOCAL,0270,RC,,,both,,,1004.40,301.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TISSUE 6940741 ANATOMIC 7X14X11 SRVCFEE",SUP-6940741,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 44-36MM COMPREHENSIVE +3MM SHOULDER E1",SUP-EP-115395,CDM,C1776,HCPCS,0278,RC,,,both,,,8854.00,2656.2,"AETNA [10100]","Aetna HMO/PPO",,7038.93,79.5,,10981.53,8986.79,12413.38,12,1029.72,7525.9,"percent of total billed charges",
"AUG FEMORAL 5MM TRIATHLON 1 RIGHT DISTAL KNEE TOTAL",SUP-5540-A-102,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"AETNA [10100]","Aetna HMO/PPO",,3612.33,79.5,,10981.53,8986.79,12413.38,12,528.45,3862.24,"percent of total billed charges",
"(EVAL) 20 FR. THORAGUARD CHEST TUBE KIT (BOX OF 10)",SUP-TGCT120020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"KAISER [10500]",Kaiser,,1058.27,67,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE 22-PIN SENSOR ENABLED DIAGNOSTIC CATHETER CABLE",SUP-D-AVSE-CBL22,CDM,S27000186,LOCAL,0270,RC,,,both,,,2362.50,708.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1606.5,68,,,,,0,274.76,2008.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +23.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.235,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 80MM 125CM 12MM 6FR BILIARY NITINOL",SUP-G36241,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"AETNA [10100]","Aetna HMO/PPO",,3005.1,79.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC",072,MS-DRG,,,,,,,inpatient,,,38490.61,11547.18,"BLUE CROSS [10001]","Blue Cross PPO",,18668.35,,,,,,,4690.75,18858.87,"case rate",
"SET STENT 28CM 5FR 2.1FR POLARIS ULTRA NAUTILUS ZIPWIRE .035",SUP-M006192124180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"BLUE CROSS [10001]","Blue Cross PPO",,623.23,39.2,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT STABILIT VP SHORT VERTEBROPLASTY",SUP-VP-1110S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"CIGNA [10200]","Cigna Local Plus",,2584.05,53.5,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT FX 26MM",SUP-EVOLUTFX-26,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]","Cigna Open Access",,57285,33.5,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT PRESS FIT EMPOWR KNEE STERILE BP",SUP-353-01-107,CDM,C1776,HCPCS,0278,RC,,,both,,,15979.64,4793.89,"PHCS [10601]",PHCS,,11185.75,70,,,,,0,1858.43,13582.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 5FR JCL4 CURVE GUIDING NYLON CORONARY",SUP-LA5JCL40,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"FIRST HEALTH [10303]","First Health",,292.32,80,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - TIBIAL KIT (CR) - SIZE 6",SUP-5555-2326,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX10MM VANGUARD ARCOM KNEE CRUCIATE RETAINING",SUP-183420,CDM,C1776,HCPCS,0278,RC,,,both,,,7565.85,2269.75,"MULTIPLAN [10600]",Multiplan,,6430.97,85,,,,,0,879.91,6430.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 38MM 144CM 2.5MM CORONARY STENT PEBAX",SUP-H7493926038250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Open Access",,3166.49,56.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 44MM HIP SOLID BACK METAL HA TRIDENT B",SUP-500-11-44B,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.85,2973.55,"CIGNA [10200]","Cigna Local Plus",,5302.84,53.5,,5372.07,4581.20,7242.98,23,1152.75,8425.07,"percent of total billed charges",
"DIL SURGICAL SET STIMULATED NIM",SUP-945NSD2750,CDM,S27200284,LOCAL,0272,RC,,,both,,,3245.00,973.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,384.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,377.39,2758.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACTOR, BROKEN SCREW, 2 MM, 6"" LONG, SINGLE USE",SUP-SXT003-BR3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"UHC [10700]","United Healthcare",,1875.26,63.3,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC 8IN MEDIUM 15IN SHOULDER SLING SOFT CONTACT",SUP-79-84165,CDM,L3660,HCPCS,0274,RC,,,both,,,44.20,13.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,30.06,68,,,,,0,5.14,44.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT SL II SITEMARK 57.7CM 54CM 9FR 7FR WIDE",SUP-DS2C014,CDM,C1887,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,445.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 44MM 28MM F VIVACIT-E LUMEN STERILE LATEX FREE",SUP-110031012,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4753.82,45.9,,,,,0,1204.51,8803.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 4.75IN SNAGFREE SATIN FINISH NDL FINE STERILE",SUP-66355,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.53,17.56,"UHC [10700]","United Healthcare",,37.05,63.3,,,,,0,6.81,49.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 33MM 140CM 4MM CORONARY STENT CARBOSIL",SUP-LUN400R33US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.225,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Open Access",,391.76,56.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 30MM 6FR 4MM .07IN BALLOON",SUP-H7493918930400,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"FIRST HEALTH [10303]","First Health",,453.6,80,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER FIBERTAPE MEDIUM CERCLAGE STRAIGHT SUT DISPOSABLE",SUP-AR-7821,CDM,S27200284,LOCAL,0272,RC,,,both,,,1771.88,531.56,"CIGNA [10200]","Cigna Open Access",,1008.2,56.9,,,,,0,206.07,1506.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tavi/Tavr Perc Fem Approach",PX-361000343,CDM,33361,CPT,0481,RC,,,both,,,55614.16,16684.25,"PHCS [10601]",PHCS,,38929.91,70,,,,,0,2491,47272.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 2 KNEE LEFT",SUP-5542-A-201,CDM,C1776,HCPCS,0278,RC,,,both,,,7027.65,2108.29,"CIGNA [10200]","Cigna Open Access",,3998.73,56.9,,5302.19,4377.88,6578.61,27,817.32,5973.5,"percent of total billed charges",
"CATH ROYAL FLUSH 125CM 4FR .035IN PIGTAIL CURVE ANGIOGRAPHIC",SUP-G27864,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,71.88,45.9,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON SUT 1.1MM MICROLINK HI-FI 2 BACKSTOP RADIOPAQUE",SUP-ASBR-K,CDM,C1713,HCPCS,0278,RC,,,both,,,18616.50,5584.95,"CIGNA [10200]","Cigna Open Access",,6236.53,33.5,,1144.80,304.56,2275.09,66,2165.1,15824.03,"percent of total billed charges",
"SYSTEM XIENCE SIERRA 18MM 2.25MM CORONARY STENT EVEROLIMUS",SUP-1550225-18,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 25X12CM VERITAS BOVINE CLLGN MATRIX",SUP-RM1225,CDM,C9354,HCPCS,0278,RC,,,both,,,41479.20,12443.76,"NOVANET [10819]",Novanet,,31109.4,75,,,,,0,4824.03,35257.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV",RX-18315,CDM,J1250,HCPCS,0636,RC,00338-1075-02,NDC,both,250,ML,362.40,108.72,"CIGNA [10200]",Cigna,,43.15,,,,,,,13.41,308.04,"fee schedule",
"S MEGATRON US MR 4.50 X 28MM",SUP-H7493942828450,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Local Plus",,3322.35,53.5,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIG WATER STRL 1000-MSO",SUP-2F7114,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]",Cigna,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tte Stress W Contr",PX-483000016,CDM,93350,CPT,0483,RC,,,both,,,4038.65,1211.59,"UHC [10700]","United Healthcare",,2556.47,63.3,,,,,0,302.63,3432.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR MALE PELVIC PROCEDURES WITH CC/MCC",707,MS-DRG,,,,,,,inpatient,,,123733.47,37120.04,"UHC [10700]","United Healthcare",,58400.76,,"Fee schedule rate ($58,400.76). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,58400.76,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 80CM 7FR 14MM ROUND EMBOLECTOMY STAINLESS STEEL",SUP-120807F,CDM,C1757,HCPCS,0272,RC,,,both,,,376.01,112.8,"MULTIPLAN [10600]",Multiplan,,319.61,85,,,,,0,43.73,319.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 6FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856140,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"BLUE CROSS [10001]","Blue Cross HMO",,429.89,39.2,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 110CM 4FR OMNI FLUSH CURVE ANGIOGRAPHIC",SUP-H787117323035,CDM,C1887,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUR 12.5CM 2CM ROUND DISTAL BEND DENTAL DIAMOND IBUR",SUP-8431-012-020D,CDM,S27200284,LOCAL,0272,RC,,,both,,,3045.45,913.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1397.86,45.9,,,,,0,354.19,2588.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING IRRIGATION FMS SOLO ARTHROSCOPIC FLUID MANAGEMENT",SUP-284504,CDM,S27200284,LOCAL,0272,RC,,,both,,,436.39,130.92,"MULTIPLAN [10600]",Multiplan,,370.93,85,,,,,0,50.75,370.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 9.5CM 20MM 16.5-18.5MM EXCLUDER",SUP-PLC201000,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3256.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM ORTHOLOC LONG CORTEX ANKLE FOOT 3DI",SUP-58802714,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X12MM VERTE-STACK CORNERSTONE PSR 11MM",SUP-6287241,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ARTHROSCOPIC GRAFT 11MM ACL STERILE DISPOSABLE",SUP-232111,CDM,S27200284,LOCAL,0272,RC,,,both,,,2434.50,730.35,"NOVANET [10819]",Novanet,,1825.88,75,,,,,0,283.13,2069.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 1.52MM ALCON A-OK 15D STD BLADE FULL HANDLE",SUP-8065921501,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.04,22.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,31.25,41.1,,,,,0,8.84,64.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE FLOPPY II VASCULAR STRAIGHT 190CM 2CM .014IN",SUP-22339M,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL XS KNEE LEFT TAPER FEMALE ANTIROTATION TAB LPS",SUP-198713105,CDM,C1776,HCPCS,0278,RC,,,both,,,77842.62,23352.79,"CIGNA [10200]",Cigna,,31137.05,40,,5873.17,5873.17,5873.17,"1 through 10",9053.1,66166.23,"percent of total billed charges",
"SUB BONE GRAFT GRAFTON SMALL DEFECT DEMINERALIZED BONE",SUP-T44145,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"CIGNA [10200]","Cigna Open Access",,2453.81,56.9,,1144.80,304.56,2275.09,66,501.54,3665.63,"percent of total billed charges",
"GWIRE HI-TORQUE ALL STAR VASCULAR 300CM 3CM .014IN STAINLESS",SUP-1001741,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SIMPLICITI W PERFORM+ GLENOID",SUP-CAP1112,CDM,C1776,HCPCS,0278,RC,,,both,,,31500.00,9450,"UHC [10700]","United Healthcare",,19939.5,63.3,,8601.07,8395.67,8601.07,"1 through 10",3663.45,26775,"percent of total billed charges",
"IMPL BREAST 225ML GEL SMOOTH ROUND COHESIVE I SILICONE P3.3","SUP-3502251 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"MULTIPLAN [10600]",Multiplan,,3123.75,85,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 RIGHT KNEE POSTERIOR STABILIZED BEADED",SUP-5516F302,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2013.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2013.96,14719.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 30MM LCP STAINLESS STEEL DISTAL FIBULA T8",SUP-202.230,CDM,C1713,HCPCS,0278,RC,,,both,,,748.44,224.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,87.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",87.04,636.17,"percent of total billed charges",
"CMPNT FEMORAL 7 STD KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500606202,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"CIGNA [10200]","Cigna Open Access",,7659,33.5,,5302.19,4377.88,6578.61,27,2658.93,19433.3,"percent of total billed charges",
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 8-11 E-F",SUP-42522100812,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"NOVANET [10819]",Novanet,,8082.32,75,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER INDEN 15MM 15DEG 26X34",SUP-3135.0715,CDM,S27800098,LOCAL,0278,RC,,,both,,,30870.00,9261,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3658.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3590.18,26239.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 75MM STAINLESS STEEL SELF TAP VARIABLE ANGLE",SUP-42.231.275,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"CIGNA [10200]","Cigna Open Access",,769.6,56.9,,1144.80,304.56,2275.09,66,157.3,1149.66,"percent of total billed charges",
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 16MM 144CM 2.75MM",SUP-H7493941216270,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3562.99,45.9,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 25CM 14FR PIGTAIL CURVE NEPHRSTMY FLEXIMA POLYURETHANE",SUP-M001271850,CDM,C1729,HCPCS,0272,RC,,,both,,,615.60,184.68,"NOVANET [10819]",Novanet,,461.7,75,,,,,0,71.59,523.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL MBT LCS COMPLETE 3 KNEE POROUS CEMENTED KEEL",SUP-129434130,CDM,C1776,HCPCS,0278,RC,,,both,,,17561.25,5268.37,"FIRST HEALTH [10303]","First Health",,14049,80,,,,,0,2042.37,14927.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 8MM 2.25MM BALLOON DILATATION PEBAX",SUP-1012271-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD 12X12IN MONOFILAMENT SOFT LIGHTWEIGHT LOW",SUP-0117016,CDM,C1781,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,11235.02,819.42,11235.02,"1 through 10",521.61,3812.25,"percent of total billed charges",
"TUBE CONNECTING STERILE DISPOSABLE 248CM",SUP-MAJ-1681,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.12,70.24,"CIGNA [10200]",Cigna,,159.2,68,,,,,0,27.23,199,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 6MM 3.2-2.4-2.6FR 2.25MM BALLOON",SUP-SPR22506W,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLENIC PROCEDURES WITHOUT CC/MCC",801,MS-DRG,,,,,,,inpatient,,,79104.56,23731.37,"BLUE CROSS [10001]","Blue Cross HMO",,43822.22,,,,,,,7561,55732.24,"case rate",
"HC Colonoscopy Stoma W Stent",PX-750000162,CDM,44402,CPT,0750,RC,,,both,,,4561.00,1368.3,"NOVANET [10819]",Novanet,,3420.75,75,,,,,0,530.44,4561,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM PRECISION .014IN TRIAL LINEAR STRAIGHT",SUP-SC-2218-50E,CDM,C1778,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE TAPE BROADBAND 5 BLACK WHITE CUTTING CORELESS SINGLE",SUP-110045775,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 40MM 6MM .035IN BALLOON DILATATION NYBAX",SUP-39171-06044,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PHCS [10601]",PHCS,,822.15,70,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 3MM PRESTIGE PLUS HELICAL HELICAL",SUP-PRES0315HXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,776.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ADVANCE 180CM 2.5MM CPSL DELIVERY STERILE",SUP-BX00711144,CDM,S27000186,LOCAL,0270,RC,,,both,,,1471.50,441.45,"CIGNA [10200]","Cigna Open Access",,837.28,56.9,,,,,0,171.14,1250.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 10.25IN AUFRANC COBRA SERRATE POINT TIP STAINLESS",SUP-225470,CDM,S27200284,LOCAL,0272,RC,,,both,,,552.34,165.7,"CIGNA [10200]","Cigna Local Plus",,295.5,53.5,,,,,0,64.24,469.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 20MM 80CM 10MM VASCULAR NITINOL OTW",SUP-1012532-20,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"AMERIGROUP MEDICAID [20100]",Amerigroup,,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 50MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75448550,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM DIVERGENCE-L SPINE",SUP-2150125,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,743.58,45.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP - HIP CONSTRUCT 2: PRESS-FIT, POLY SURFACE - PRESS",SUP-CAP-H-2,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10080,40,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX18MM VANGUARD ARCOM KNEE POSTERIOR STABILIZE",SUP-183648,CDM,C1776,HCPCS,0278,RC,,,both,,,8259.30,2477.79,"MULTIPLAN [10600]",Multiplan,,7020.41,85,,,,,0,960.56,7020.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 6MM XIA 3 TITANIUM RADIOLUCENT",SUP-48238080,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 80CM 6MM 8MM 7FR .035IN",SUP-BXA062901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"NOVANET [10819]",Novanet,,14628.6,75,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN",RX-163725,CDM,,,0250,RC,00942-0641-04,NDC,both,1000,ML,100.65,30.19,"MULTIPLAN [10600]",Multiplan,,85.55,85,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALIBER SPACER 10 X 22MM 9-13MM",SUP-194.422,CDM,S27800098,LOCAL,0278,RC,,,both,,,25200.00,7560,"BLUE CROSS [10001]","Blue Cross PPO",,9878.4,39.2,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMEDY SPECTRUM GV FEMORAL STEM LG",SUP-GVSTLG,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 26CM MR8 3MM MATCH HEAD DISSECTING STERILE DISPOSABLE",SUP-MR8-26MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"CIGNA [10200]","Cigna Open Access",,718.99,56.9,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 3.543X.984IN SYSTEM 6 THK.38IN SAGITTAL HEAVY DUTY",SUP-6125-097-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPPORTER ADULT 3 IN WAISTBAND SM",SUP-202460,CDM,S27000186,LOCAL,0270,RC,,,both,,,71.78,21.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,32.95,45.9,,,,,0,8.35,61.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID UPPER LEG REDUCTION KIT- LONG, WIDE",SUP-25302317,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"FIRST HEALTH [10303]","First Health",,1004.4,80,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN JUDKINS",SUP-77808000,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM VERTEX MAX TITANIUM SPINE MULTIAXIAL",SUP-6958732,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"NOVANET [10819]",Novanet,,3150,75,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8.5MM 12/14 TAPER 36MM HIP BIOLOX DELTA",SUP-1365-36-330,CDM,C1776,HCPCS,0278,RC,,,both,,,12268.20,3680.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1453.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1426.79,10427.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON ULTIMA 10-0 CS160-6 6IN 2 ARM MONOFILAMENT BLACK",SUP-9001G,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.51,73.95,"CIGNA [10200]",Cigna,,167.63,68,,,,,0,28.67,209.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NIFEDIPINE ER 30 MG TABLET EXTENDED RELEASE SUPERORDERABLE",RX-408831,CDM,,,0637,RC,50268-0597-11,NDC,both,1,UN,6.60,1.98,"NOVANET [10819]",Novanet,,4.95,75,,,,,0,0.77,5.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM CEMENT SUMMIT 5 12/14 HIGH OFFSET TAPER",SUP-157013110,CDM,C1776,HCPCS,0278,RC,,,both,,,18219.60,5465.88,"CIGNA [10200]","Cigna Open Access",,6103.57,33.5,,5302.19,4377.88,6578.61,27,2118.94,15486.66,"percent of total billed charges",
"PK PAPYRUS 4.5/15",SUP-434891,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"CIGNA [10200]","Cigna Open Access",,6616.42,33.5,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 285MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-409-285,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,957.42,156.86,7483.26,51,2014.9,14726.25,"percent of total billed charges",
"PACK CATH 33CM 14.5FR PALINDROME TAL VENATRAC STERILE LATEX",SUP-8888133504P,CDM,C1750,HCPCS,0278,RC,,,both,,,2649.68,794.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,308.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,308.16,2252.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 10X10MM FUSEFORCE 2MM FOREFOOT MIDFOOT REARFOOT",SUP-FFS1010,CDM,C1713,HCPCS,0278,RC,,,both,,,5582.10,1674.63,"KAISER [10500]",Kaiser,,3740.01,67,,,,,0,649.2,4744.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ASCEND FLEX REV W PERF REV AUG BASEPLATE",SUP-CAP1133,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"MULTIPLAN [10600]",Multiplan,,41233.5,85,,,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERSNARE 2 26IN CLOSED LOOP BLUE WHITE 2IN",SUP-AR-7209SNL,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.03,267.91,"KAISER [10500]",Kaiser,,598.33,67,,,,,0,103.86,759.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 80MM 135CM 5MM 160CM",SUP-M001711070,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1001.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH VERSACROSS 1 PIGTAIL 72CM 230CM GUIDING TRANSSEPTAL",SUP-VSTK0122,CDM,C1766,HCPCS,0272,RC,,,both,,,11212.50,3363.75,"KAISER [10500]",Kaiser,,7512.38,67,,,,,0,1304.01,9530.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 55MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.855,CDM,C1713,HCPCS,0278,RC,,,both,,,367.84,110.35,"CIGNA [10200]",Cigna,,250.13,68,,1831.33,1831.33,1831.33,16,42.78,312.66,"percent of total billed charges",
"GRAFT SOFT TISSUE 3X3IN DURAGEN CRANIUM BOVINE CLLGN MATRIX",SUP-DURS3391,CDM,,,0278,RC,,,both,,,7552.19,2265.66,"PHCS [10601]",PHCS,,5286.53,70,,,,,0,7.55,6419.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURESIGHT BLADE HYPERANGULATED SIZE 3 CHANNELED",SUP-390531000,CDM,S27000186,LOCAL,0270,RC,,,both,,,321.90,96.57,"AETNA [10100]","Aetna HMO/PPO",,255.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Dplr Fu/Ltd",PX-483000013,CDM,93321,CPT,0483,RC,,,both,,,877.78,263.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,104.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.29,746.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS GOLD 80CM 4CM 16MM LARGE DIAMETER BALLOON",SUP-ATG80164,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) AMPLATZ EXTRA STIFF GUIDE WIRE (COOK MEDICAL)",SUP-G03460,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 100CM 5FR AR2 CURVE ANGIOGRAPHIC PEBAX",SUP-7528-23,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.74,23.62,"FIRST HEALTH [10303]","First Health",,62.99,80,,,,,0,9.16,66.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP POROUS FEMUR COCR HEAD ANTEVERTED LINER R3",SUP-71703323,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Open Access",,8019.9,33.5,,5302.19,4377.88,6578.61,27,2784.22,20349,"percent of total billed charges",
"PIN FIXATION 4MM 140MM KNEE STERILE",SUP-144140-,CDM,S27200284,LOCAL,0272,RC,,,both,,,1010.88,303.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.57,859.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Irrig Blad Smpl",PX-450000270,CDM,51700,CPT,0361,RC,,,both,,,1458.58,437.57,"BLUE CROSS [10001]","Blue Cross HMO",,1.46,.1,,,,,0,1.46,1458.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 5MM CEREPAK XL UNIFORM DETACHABLE",SUP-FCX180510,CDM,S27800098,LOCAL,0278,RC,,,both,,,15872.28,4761.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1880.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1845.95,13491.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tte Stress W Cont Ecg W Contr",PX-483000026,CDM,93351,CPT,0483,RC,,,both,,,3125.00,937.5,"PHCS [10601]",PHCS,,2187.5,70,,,,,0,363.44,2656.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON SUT PERCHIK STERILE DISPOSABLE",SUP-H787138002015,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.12,19.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,30.35,45.9,,,,,0,7.69,56.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEDSURG COMMIT BARD VASCULAR ACCESS PICCS AND MIDLINES",SUP-F420088PT,CDM,C1751,HCPCS,0272,RC,,,both,,,955.07,286.52,"KAISER [10500]",Kaiser,,639.9,67,,,,,0,111.07,811.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Iliac W Pta Cmplx Init",PX-361000697,CDM,37256,CPT,0361,RC,,,both,,,10816.36,3244.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10.82,.1,,,,,0,10.82,9679,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25X9MM TPS PRECISION MEDIUM OSCILLATING SAGITTAL",SUP-2296003111,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.45,67.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,151.95,68,,,,,0,25.99,189.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 155CM 8MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200084020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 5IN ON-Q T-BLOC 3 LATERAL PORT ECHOGENIC STERILE",SUP-QB15016SGC,CDM,S27200305,LOCAL,0272,RC,,,both,,,328.86,98.66,"CIGNA [10200]",Cigna,,223.62,68,,,,,0,38.25,279.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 80MM 80CM 12MM .079IN LARGE DIAMETER",SUP-SERB65-12-80-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 60MM 125CM 9MM 5FR VASCULAR NITINOL ILIAC",SUP-G43787,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2841.72,68,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO 70CM 8FR 2.9MM GUIDING RAABE",SUP-G11637,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"FIRST HEALTH [10303]","First Health",,356.4,80,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION BARD LUBRICATH STATLOCK SURESTEP 16FR",SUP-A800361,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.26,25.58,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.92,72.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16026535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 73MM 37.7MM 29MM DURAN ANCORE 31.7MM 2",SUP-620BG29,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UHC [10700]","United Healthcare",,8298.63,63.3,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REFINITY ULTRASOUND INTRAVASCULAR ROTATIONAL STERILE",SUP-89800,CDM,C1759,HCPCS,0272,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 48MM UNITRAX FEMORAL HIP MODULAR",SUP-6942-5-048,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,370.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,363.75,2658.55,"percent of total billed charges",
"COIL EMBOLIZATION 50CM 16MM AXIUM 3D NEUROVASCULAR FRAME V01",SUP-FC-16-50-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6791.98,41.1,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +14 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.140,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 13.5X12.5CM 445ML STYLE 410 GEL TEXTURED",SUP-MX-410445,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"NOVANET [10819]",Novanet,,4173.75,75,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 22FR 20CM RADIOPAQUE STD ACCEPTS .038IN GWIRE",SUP-G01472,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.44,31.03,"PHCS [10601]",PHCS,,72.41,70,,,,,0,12.03,87.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) SHEATH AMPLATZER TORQVUE 45D 100CM 12FR .189IN .157IN",SUP-9-TV45X45-12F-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,5244.00,1573.2,"FIRST HEALTH [10303]","First Health",,4195.2,80,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER SUT TAG TRANSPORTER STERILE LATEX FREE DISPOSABLE",SUP-14617,CDM,S27200284,LOCAL,0272,RC,,,both,,,961.07,288.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,653.53,68,,,,,0,111.77,816.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 25MM RESTORATION +20MM HIP MODULAR REVISION",SUP-6276-1-225,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"NOVANET [10819]",Novanet,,16691.06,75,,,,,0,2588.23,18916.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR PULSE ATTESTA DR MRI IMPLANTABLE LONGEVITY",SUP-ATDRL1,CDM,C1785,HCPCS,0275,RC,,,both,,,15525.00,4657.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1839.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 4-0 RB-1 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP304H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOGUARD 100UM 180CM .014IN 5MM EMBOLIC PROTECTION",SUP-501814RMC,CDM,C1884,HCPCS,0272,RC,,,both,,,6520.50,1956.15,"CIGNA [10200]","Cigna Open Access",,3710.16,56.9,,,,,0,758.33,5542.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 4-0 RB-1 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP304H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT TOE SWANSON METATARSOPHALANGEAL FLEXIBLE HINGE STERILE",SUP-G4260003,CDM,C1776,HCPCS,0278,RC,,,both,,,7265.70,2179.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,860.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,845,6175.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 6CM 6MM BALLOON DILATATION ILIAC",SUP-G34335,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ABLATION 8FR F CURVE THERMOCOOL SF UNIDIRECTIONAL",SUP-D131803,CDM,C2630,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 20MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UHC [10700]","United Healthcare",,907.53,63.3,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tlpa Renal Arty",PX-481000002,CDM,0234T,CPT,0481,RC,,,both,,,18540.00,5562,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6657,,"Case rate ($6,657). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,18.54,15759,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JEFFREY VASCULAR 21GA 18CM 15CM .018IN 8FR 6.5FR",SUP-G12015,CDM,C1769,HCPCS,0272,RC,,,both,,,1004.32,301.3,"NOVANET [10819]",Novanet,,753.24,75,,,,,0,116.8,853.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECTRUM DVM S4",SUP-0270-0933,CDM,S27200284,LOCAL,0272,RC,,,both,,,328.86,98.66,"CIGNA [10200]",Cigna,,223.62,68,,,,,0,38.25,279.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 LEFT MEDIAL RIGHT LATERAL PARTIAL KNEE",SUP-5610-F-301,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"AETNA [10100]","Aetna HMO/PPO",,7951.67,79.5,,10981.53,8986.79,12413.38,12,1163.24,8501.79,"percent of total billed charges",
"PACK VITRECTOMY CONSTELLATION ENGAUGE V-LOCITY C3F8 SF6 GAS",SUP-8065751014,CDM,S27200284,LOCAL,0272,RC,,,both,,,671.65,201.49,"NOVANET [10819]",Novanet,,503.74,75,,,,,0,78.11,570.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 10MM NATURAL LORDOTIC CORTICOCANCELLOUS",SUP-18410,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM PRESTIGE PLUS HELICAL HELICAL",SUP-PRES0410HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STYLET 100CM SJ4",SUP-DS06003/85,CDM,S27500001,LOCAL,0275,RC,,,both,,,453.60,136.08,"FIRST HEALTH [10303]","First Health",,362.88,80,,,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 12MM 135CM 4MM .018IN BILIARY STAINLESS",SUP-G56618,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"BLUE CROSS [10001]","Blue Cross PPO",,1975.68,39.2,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG VASCULAR  10MM",SUP-9-PLUG-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"NOVANET [10819]",Novanet,,4631.63,75,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2.5MM TARGET HELICAL PLATINUM",SUP-M0035432560,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"CIGNA [10200]","Cigna Local Plus",,4899.36,53.5,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE 35.5CM INFLATION SYR EXT TUBING 3 WAY STPCOCK MEDIUM",SUP-IN1125,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 265CC P3.2CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-265,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"FIRST HEALTH [10303]","First Health",,6044.4,80,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 13MM KNEE POSTERIOR STABILIZE HIGH",SUP-71421510,CDM,C1776,HCPCS,0278,RC,,,both,,,10774.35,3232.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3083.62,28.62,,,,,0,1253.06,9158.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2.5MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-02504,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1202.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP GLOBAL UNITE REVER",SUP-OSC379179,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18642.96,41.1,,6417.48,6417.48,6417.48,"1 through 10",5275.37,38556,"percent of total billed charges",
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 52MM COCR",SUP-VAL-35520-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,601.02,28.62,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hep C Ampl Probe",PX-306000132,CDM,87521,CPT,0306,RC,,,both,,,414.20,124.26,"UHC [10700]","United Healthcare",,31.58,,,,,,,0.01,352.07,"fee schedule",
"DEVICE STAT TACK FIXATION TITANIUM 15 TACK SHORT SHAFT",SUP-OMS-TTSS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1468.21,440.46,"AETNA [10100]","Aetna HMO/PPO",,1167.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,170.75,1247.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 15MM 6FR 2MM .07IN BALLOON",SUP-H7493918915200,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM TRICUSPID 1 SEAM 2 WRAP ANATOMIC",SUP-4900T28,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"BLUE CROSS [10001]","Blue Cross PPO",,5003.88,39.2,,,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC SABERLOC 5-0 S-14 18IN MONOFILAMENT BLUE",SUP-1792G,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.56,58.67,"UHC [10700]","United Healthcare",,123.79,63.3,,,,,0,22.74,166.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.6MM 14MM VIP SPINE CERVICAL ANTERIOR FIX ANGLE",SUP-171.614,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"MULTIPLAN [10600]",Multiplan,,1198.5,85,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNGOSCOPE VIDEO 2 STAT BLADE GLIDESCOPE GVL DISPOSABLE ST",SUP-0270-0429,CDM,S27200284,LOCAL,0272,RC,,,both,,,216.11,64.83,"PHCS [10601]",PHCS,,151.28,70,,,,,0,25.13,183.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 28X10X8-7.2MM T-PAL 5D BULLET NOSE PEEK",SUP-08.812.008,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4739.47,28.62,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR INJECTION MEDRAD STELLANT FLEX 2 LARGE SALINE SMALL",SUP-FLEXD-150-SCS,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.47,31.34,"UHC [10700]","United Healthcare",,66.13,63.3,,,,,0,12.15,88.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 250MM 4MM BALLOON DILATATION RAPID",SUP-47540250L,CDM,C1725,HCPCS,0272,RC,,,both,,,1890.00,567,"AMERIGROUP MEDICAID [20100]",Amerigroup,,223.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 3.5 X 8 HELICAL FINISHING COIL",SUP-10HFN-03508,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1225.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SKIN TI CLSR STERILE",SUP-4840764,CDM,S27200284,LOCAL,0272,RC,,,both,,,1070.24,321.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,124.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.47,909.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC N-Invas Detcj Heart Failure Drv Augmnt Alys Echo",PX-480000114,CDM,0932T,CPT,0483,RC,,,both,,,462.00,138.6,"CIGNA [10200]",Cigna,,314.16,68,,,,,0,53.73,392.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NATEGLINIDE 60 MG TABLET",RX-29437,CDM,,,0637,RC,55111-0328-90,NDC,both,1,UN,8.36,2.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3.84,45.9,,,,,0,0.97,7.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 STD 10MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS2S10L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2974.02,28.62,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CETIRIZINE 5 MG/5 ML ORAL SOLUTION",RX-97141,CDM,,,0250,RC,68094-0004-59,NDC,both,5,ML,21.76,6.53,"KAISER [10500]",Kaiser,,14.58,67,,,,,0,2.53,18.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC",056,MS-DRG,,,,,,,inpatient,,,32875.68,9862.7,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,30982.23,,"Case rate ($14,410.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,380.97, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,393.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $13,398.66. The transfer operating threshold is the transfer adjustment factor * $13,380.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.67. The transfer capital threshold is the transfer adjustment factor * $1,011.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,32875.68,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 2IN 18GA E-CATH SAFERSONIC CONTINUOUS",SUP-TDL133,CDM,S27200284,LOCAL,0272,RC,,,both,,,595.35,178.6,"NOVANET [10819]",Novanet,,446.51,75,,,,,0,69.24,506.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 54MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.644,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,331.04,28.62,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH VERSACROSS SMALL CURL 72CM 180CM 8.5FR GUIDING",SUP-VSTK0018,CDM,C1766,HCPCS,0272,RC,,,both,,,11212.50,3363.75,"FIRST HEALTH [10303]","First Health",,8970,80,,,,,0,1304.01,9530.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC SHORT UNIVERSAL 17IN 36- IN KNEE 2 AXIS",SUP-79-94230,CDM,S27000186,LOCAL,0270,RC,,,both,,,363.57,109.07,"PHCS [10601]",PHCS,,254.5,70,,,,,0,42.28,309.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 3.9MM 32MM MULTILOC TITANIUM NIOBIUM ALUMINUM",SUP-04.019.032S,CDM,C1713,HCPCS,0278,RC,,,both,,,1747.20,524.16,"PHCS [10601]",PHCS,,1223.04,70,,,,,0,203.2,1485.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 24MM PRESS FIT TRIATHLON TITANIUM KNEE",SUP-5566-S-024,CDM,C1776,HCPCS,0278,RC,,,both,,,7345.05,2203.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4994.63,68,,,,,0,854.23,6243.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X10MM COHERE XLW 15D STERILE LATEX FREE",SUP-8151050P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,29925.00,8977.5,"BLUE CROSS [10001]","Blue Cross PPO",,11730.6,39.2,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Emg 2 Ext",PX-922000002,CDM,95861,CPT,0922,RC,,,both,,,1641.00,492.3,"CIGNA [10200]","Cigna Open Access",,933.73,56.9,,,,,0,190.85,1394.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 15MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25015W,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE MATRIX .25CC PUTTY SYR",SUP-T43204,CDM,C1713,HCPCS,0278,RC,,,both,,,432.39,129.72,"FIRST HEALTH [10303]","First Health",,345.91,80,,,,,0,50.29,367.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP FRCP 25 PLUS GRIESHABER REVOLUTION ASYMMETRICAL GRASPING",SUP-705.45P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 110MM 3.5MM STAINLESS STEEL QUICK COUPLING STERILE",SUP-310.35S,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.57,257.87,"CIGNA [10200]","Cigna Open Access",,489.1,56.9,,,,,0,99.97,730.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST EXTERNAL FIXATION SHORT WIRE MRI SAFE NONSTERILE",SUP-03.311.070,CDM,S27800098,LOCAL,0278,RC,,,both,,,1499.55,449.86,"PHCS [10601]",PHCS,,1049.69,70,,,,,0,174.4,1274.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER SURGICAL ACUITY UNIVERSAL SPIRAL",SUP-7060,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 415CC",SUP-SSZ-F415,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"NOVANET [10819]",Novanet,,1117.8,75,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 5X5CM ALLOPATCH HD THK.4-.7MM THIN ACELLULAR",SUP-470505,CDM,Q4128,HCPCS,0636,RC,,,both,,,10101.60,3030.48,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,247.92,,,,,,,80.43,8586.36,"fee schedule",
"PATCH SURGICAL 5.5X4.3IN SPRING OPEN BIORESORBABLE SELF",SUP-5950040,CDM,C1781,HCPCS,0278,RC,,,both,,,3318.00,995.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,393.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,385.88,2820.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 12IN 4 PANEL KNIT ELASTIC PREMIUM HOOK LOOP",SUP-13960000,CDM,S27000186,LOCAL,0270,RC,,,both,,,160.17,48.05,"CIGNA [10200]",Cigna,,108.92,68,,,,,0,18.63,136.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAL LENS",SUP-60005-3,CDM,V2787,HCPCS,0276,RC,,,both,,,730.00,219,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.9,620.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.034TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"WRENCH SURGICAL 36KHZ TORQUE CUSA EXCEL+ DISPOSABLE STERILE",SUP-C5602,CDM,S27200284,LOCAL,0272,RC,,,both,,,1124.39,337.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,130.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,130.77,955.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD SENTUS PROMRI LEFT VENTRICULAR OTW QUADRIPOLAR",SUP-406081,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"PHCS [10601]",PHCS,,3924.9,70,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Bone Marrow",PX-610000055,CDM,77084,CPT,0610,RC,,,both,,,3916.00,1174.8,"UHC [10700]","United Healthcare",,583.68,,,,,,,455.43,3328.6,"fee schedule",
"BUPROPION HCL 100 MG TABLET, IMMEDIATE RELEASE",RX-9321,CDM,,,0637,RC,00904-6636-61,NDC,both,1,UN,9.89,2.97,"KAISER [10500]",Kaiser,,6.63,67,,,,,0,1.15,8.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVICROSS 150CM ANGIOGRAPHIC STAINLESS STEEL",SUP-NC35150,CDM,C1887,HCPCS,0272,RC,,,both,,,1462.05,438.61,"AETNA [10100]","Aetna HMO/PPO",,1162.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,170.04,1242.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM REVERE TITANIUM SPINE PEDICLE NONSTERILE",SUP-124.474,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"AETNA [10100]","Aetna HMO/PPO",,3849.87,79.5,,1521.93,481.35,16760.95,30,563.19,4116.21,"percent of total billed charges",
"HC Bx Tissue Back Soft Deep",PX-360000053,CDM,21925,CPT,0360,RC,,,both,,,3285.23,985.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2262,,"Case rate ($2,262). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,382.07,3285.23,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,,,0250,RC,45802-0059-35,NDC,both,15,GR,110.11,33.03,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE WHOLEY VASCULAR MODIFY J CURVE 175CM .035IN",SUP-WWIJ35175,CDM,C1769,HCPCS,0272,RC,,,both,,,534.60,160.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRONTERA, 10P, DIA 25MM LOOP SI",SUP-D1390-06-SI,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 014 150CM 12CM 4MM BALLOON DILATATION",SUP-U4150412,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT ABLATION STAR POWERCURVE SHORT BLISTER TRAY TUMOR",SUP-RF-0510S-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,22680.00,6804,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"INTRO SHEATH 5.5FR 5CM 80CM DENNY MODIFICATION SET PEEL-AWAY",SUP-G11558,CDM,C1892,HCPCS,0272,RC,,,both,,,745.77,223.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUB BONE GRAFT XEMPLIFI DEMINERALIZED BONE MATRIX PLUS 8ML",SUP-8103.0208S,CDM,C1713,HCPCS,0278,RC,,,both,,,7438.20,2231.46,"BLUE CROSS [10001]","Blue Cross HMO",,2915.77,39.2,,957.42,156.86,7483.26,51,865.06,6322.47,"percent of total billed charges",
"CATH MAX NEURON SELECT 105CM 9CM 6FR .04IN .035IN .038IN 1",SUP-PNS6F105H1,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,416.14,41.1,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14X12.4CM MEMORYSHAPE P5.9CM MODERATE PLUS",SUP-RSZ1407S,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.55,69.16,"MULTIPLAN [10600]",Multiplan,,195.97,85,,,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Hand>=3v",PX-320000073,CDM,73130,CPT,0320,RC,,,both,,,513.25,153.97,"CIGNA [10200]","Cigna Local Plus",,63.62,,,,,,,45.49,436.26,"fee schedule",
"COIL EMBOLIZATION 8CM 4MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-04008,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"KAISER [10500]",Kaiser,,6005.28,67,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT LABRALTAPE 1.5MM 36IN BLACK WHITE NONABSORBABLE",SUP-AR-7276T,CDM,S27200284,LOCAL,0272,RC,,,both,,,595.35,178.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,70.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.24,506.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 38MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR38,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 41MM 4.5MM AEQUALIS SHOULDER TITANIUM LOCK",SUP-DWD041,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,184.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,180.96,1322.6,"percent of total billed charges",
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7612,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]",Cigna,,4692,68,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 8MM 6FR 3.5MM .07IN BALLOON",SUP-H7493918908350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM REVERE TITANIUM SPINE PEDICLE NONSTERILE",SUP-124.474,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"MULTIPLAN [10600]",Multiplan,,4116.21,85,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X36MM COLOSSEUM 12MM CURVE MESH NONSTERILE",SUP-156.209,CDM,S27800098,LOCAL,0278,RC,,,both,,,28343.70,8503.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3358.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3296.37,24092.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 150CM 120MM 7MM BALLOON DILATATION PACLITAXEL",SUP-H74939419701210,CDM,C2623,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"FIRST HEALTH [10303]","First Health",,7452,80,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL SHORT HINDFOOT VALOR 4.3MM SCR IMPL KIT",SUP-415S002351,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,204.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 5-0 PC-1 18IN MONOFILAMENT BLUE",SUP-8618G,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.80,20.64,"UHC [10700]","United Healthcare",,43.55,63.3,,,,,0,8,58.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SENTAI FIGHTER VASCULAR 300CM SPECIALITY CROSS",SUP-H749393033002,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"UHC [10700]","United Healthcare",,615.28,63.3,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUCONAZOLE 40 MG/ML ORAL SUSPENSION",RX-14233,CDM,,,0637,RC,16714-0696-01,NDC,both,35,ML,814.56,244.37,"FIRST HEALTH [10303]","First Health",,651.65,80,,,,,0,94.73,692.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 60MM LCP ANKLE FOOT STAINLESS STEEL 7 HOLE 2.4MM",SUP-247.377,CDM,C1713,HCPCS,0278,RC,,,both,,,2299.50,689.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,267.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",267.43,1954.58,"percent of total billed charges",
"HC Esoph Flex Trnsoral W Dil",PX-750000133,CDM,43214,CPT,0750,RC,,,both,,,5886.00,1765.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4031,,"Case rate ($4,031). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,684.54,5859,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC",476,MS-DRG,,,,,,,inpatient,,,58758.08,17627.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10645.4,,"Fee schedule rate ($10,645.40). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,7320.85,34457.12,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM TITANIUM CORTICAL",SUP-PANL-35260-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,899.10,269.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,106.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",104.57,764.24,"percent of total billed charges",
"SIZER IMPL 15CM NATRELLE INSPIRA P4.9CM MODERATE PROFILE",SUP-SSZ-M600,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"AETNA [10100]","Aetna HMO/PPO",,1184.87,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESG PLASMALOOP - MEDIUM 30",SUP-WA22706S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3215.54,964.66,"KAISER [10500]",Kaiser,,2154.41,67,,,,,0,373.97,2733.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN HCL 750 MG/15ML IV (WET SOLR VIAL)",RX-41597371,CDM,J3373,HCPCS,0636,RC,00409-6531-11,NDC,both,1,UN,60.53,18.16,"FIRST HEALTH [10303]","First Health",,48.42,80,,,,,0,2.62,51.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 30MM 4.5MM .014IN LOW PROFILE",SUP-1008191-30,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"FIRST HEALTH [10303]","First Health",,1134,80,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 12X18MM FORTIFY DEPTH 12MM NONSTERILE LATEX",SUP-151.050,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"CIGNA [10200]",Cigna,,12839.4,40,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM CEMENT SUMMIT 5 12/14 HIGH OFFSET TAPER",SUP-157013110,CDM,C1776,HCPCS,0278,RC,,,both,,,18219.60,5465.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5214.45,28.62,,,,,0,2118.94,15486.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION SWIVELOCK PEEK MENISCAL ROOT REPAIR",SUP-AR-4550P,CDM,C1713,HCPCS,0278,RC,,,both,,,10106.78,3032.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6872.61,68,,,,,0,1175.42,8590.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP UNISTEP PLUS 66MM 75CM 8MM 6FR 100CM",SUP-M001712220,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3473.98,41.1,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EGIA RADIAL MED THK RELOAD",SUP-SIGRADMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2461.50,738.45,"PHCS [10601]",PHCS,,1723.05,70,,,,,0,286.27,2092.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAUT ELECTROSURGICAL .5IN ACCU-TEMP 1205C HIGH VARIABLE",SUP-8443000,CDM,S27200284,LOCAL,0272,RC,,,both,,,153.81,46.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.89,130.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HERMETIC 35CM 38CM LARGE EXTERNAL DRNG VENTRICULAR SET",SUP-INS4500,CDM,C1729,HCPCS,0272,RC,,,both,,,1984.05,595.21,"AETNA [10100]","Aetna HMO/PPO",,1577.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,230.75,1686.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 20MM 144CM 3.5MM CORONARY STENT PEBAX",SUP-H7493926020350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"NOVANET [10819]",Novanet,,4173.75,75,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM SHORT 26MM HIP OFFSET TAPER PRIMARY COCR",SUP-6260-9-026,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2126.84,68,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALLET SURGICAL 11IN 1 3/8IN LARGE BONE STAINLESS STEEL",SUP-250405,CDM,S27200284,LOCAL,0272,RC,,,both,,,646.38,193.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.17,549.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE 35.5CM INFLATION SYR EXT TUBING 3 WAY STPCOCK MEDIUM",SUP-IN1125,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 13MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934383,CDM,C1776,HCPCS,0278,RC,,,both,,,18947.25,5684.17,"PHCS [10601]",PHCS,,13263.08,70,,,,,0,2203.57,16105.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X3 HUMERAL INSERT - 32MM X 4MM STANDARD",SUP-5571-S-3204,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"PHCS [10601]",PHCS,,7056,70,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER 7MM ORTHOPEDIC",SUP-AR-8870W,CDM,C1713,HCPCS,0278,RC,,,both,,,400.20,120.06,"CIGNA [10200]",Cigna,,272.14,68,,1831.33,1831.33,1831.33,16,46.54,340.17,"percent of total billed charges",
"RESTRICT CEMENT MEDIUM UNIVERSAL",SUP-B000-0240,CDM,S27800098,LOCAL,0278,RC,,,both,,,620.57,186.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,73.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.17,527.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 209MM 40-44MM 39MM ZENITH ALPHA CAPTOR",SUP-G38216,CDM,C1874,HCPCS,0278,RC,,,both,,,89876.46,26962.94,"BLUE CROSS [10001]","Blue Cross HMO",,35231.57,39.2,,9776.84,9776.84,9776.84,"1 through 10",10452.63,76394.99,"percent of total billed charges",
"HC Ihc Addnl Antibody per Spec",PX-312000060,CDM,88341,CPT,0312,RC,,,both,,,595.65,178.69,"KAISER [10500]",Kaiser,,399.09,67,,,,,0,0.01,506.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM TRANSITION HA SPINE PEDICLE POLYAXIAL",SUP-152.776S,CDM,C1713,HCPCS,0278,RC,,,both,,,10791.60,3237.48,"BLUE CROSS [10001]","Blue Cross HMO",,4230.31,39.2,,957.42,156.86,7483.26,51,1255.06,9172.86,"percent of total billed charges",
"PHALANX CORONAL TRANSFIXION SCREW 1.5MM X 18.0MM COCR",SUP-PTS-15018-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.90,337.77,"KAISER [10500]",Kaiser,,754.35,67,,,,,0,130.94,957.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX 20MM 135CM 6MM VASCULAR NITINOL CAROTID",SUP-PC0620RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"AMERIGROUP MEDICAID [20100]",Amerigroup,,899.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP BIPOLAR HIP",SUP-THABIP,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2962.17,28.62,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUBICON 90CM 5.1FR 2.84FR 50MM SPACE GUIDING NYLON",SUP-H74939240035091,CDM,C1887,HCPCS,0272,RC,,,both,,,1449.90,434.97,"AETNA [10100]","Aetna HMO/PPO",,1152.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) AGENT DCB CATHETER 2.0MM X 40MM",SUP-H7493960840200,CDM,C9610,HCPCS,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNEE CONSTRUCT 2",SUP-CAP-Z-K-2,CDM,C1776,HCPCS,0278,RC,,,both,,,19530.00,5859,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5589.49,28.62,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 128MM 12MM PRESS FIT REUNION SHOULDER STERILE",SUP-5569-P-2012,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1465.38,10710,"percent of total billed charges",
"COAGULATOR SUCTION 6IN 10FR FOOTSWITCH ACTIVATION STERILE",SUP-E2505-10FR,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.90,17.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.62,48.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 13MM UNIVERS APEX OPTIFIT",SUP-AR-9100-13M,CDM,C1776,HCPCS,0278,RC,,,both,,,26302.50,7890.75,"FIRST HEALTH [10303]","First Health",,21042,80,,,,,0,3058.98,22357.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER WEBSTER 60CM 1MM 6FR 2-8-2MM SPACE P CURVE ELECTROP",SUP-F6A-DP-282-RTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,2040.00,612,"CIGNA [10200]","Cigna Local Plus",,1091.4,53.5,,,,,0,237.25,1734,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, ALL-POLY PEGGED GLENOID, SIZE 54, E-PLUS",SUP-521-07-254,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"FIRST HEALTH [10303]","First Health",,7331.52,80,,,,,0,1065.82,7789.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 32MM 0D D HIP X3 TRIDENT STERILE LATEX FREE",SUP-723-00-32D,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1012.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,993.86,7263.8,"percent of total billed charges",
"CMPNT FEMORAL 4 KNEE LEFT PRESS FIT EMPOWR 3D KNEE STERILE",SUP-243-01-104,CDM,C1776,HCPCS,0278,RC,,,both,,,27824.45,8347.33,"BLUE CROSS [10001]","Blue Cross HMO",,10907.18,39.2,,5311.50,4717.44,5388.59,31,3235.98,23650.78,"percent of total billed charges",
"GWIRE HI-TORQUE PILOT 200 VASCULAR STRAIGHT 300CM 3CM .014IN",SUP-1010485-H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BRACHYTHERAPY 20CM 18GA MICK APPLR SEED IMPLANTATION",SUP-918201,CDM,C1715,HCPCS,0272,RC,,,both,,,74.21,22.26,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL 9CM MR8 4MM BALL DISSECTING DIAMOND",SUP-MR8-9BA40D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.17,412.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 8FR 15.5CM PEEL-AWAY PERCUTANEOUS STERILE",SUP-G00930,CDM,C1894,HCPCS,0272,RC,,,both,,,382.71,114.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE II PRO 12MM 3.25MM BALLOON DILATATION STERILE",SUP-232-123-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT CLAMP 90MM STEALTH 5 SOFT STERILE LATEX FREE",SUP-A0A14,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC",829,MS-DRG,,,,,,,inpatient,,,127470.32,38241.1,"CIGNA [10200]",Cigna,,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 55.9%. Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS 75CM 4CM 14MM 7FR BALLOON DILATATION PERIPHERAL",SUP-AT75144,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4MM 44MM NAIL-EX TITANIUM FULL THREAD HUMERAL",SUP-04.005.434,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,331.04,28.62,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL STD OFFSET 28MM HIP TYPE 1 COCR G7",SUP-163662,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2934.13,28.62,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AXIOS 10MM 20MM PANCREATIC STERILE LATEX FREE",SUP-M00553660,CDM,C1874,HCPCS,0278,RC,,,both,,,32412.56,9723.77,"CIGNA [10200]","Cigna Local Plus",,10209.96,31.5,,,,,0,3769.58,27550.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 34MM THORACIC WOVEN SMOOTH NDL",SUP-M00202175434P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3797.28,1139.18,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.78,28.62,,,,,0,441.62,3227.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Knee >=4v Complt",PX-320000083,CDM,73564,CPT,0320,RC,,,both,,,665.76,199.73,"CIGNA [10200]",Cigna,,79.68,,,,,,,56.97,565.9,"fee schedule",
"HC Tc99m Choletec Up to 15mci",PX-343000011,CDM,A9537,HCPCS,0343,RC,,,both,,,258.59,77.58,"FIRST HEALTH [10303]","First Health",,206.87,80,,,,,0,30.07,221.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0930CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"NOVANET [10819]",Novanet,,4916.25,75,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM F HIP ELEVATE RIM X3 TRIDENT",SUP-643-00-36F,CDM,C1776,HCPCS,0278,RC,,,both,,,9915.30,2974.59,"MULTIPLAN [10600]",Multiplan,,8428.01,85,,,,,0,1153.15,8428.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD 20CM 8FR DRNG FLEXIMA METAL HYDROPHILIC REGULAR",SUP-M001271270,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 12MM 6MM STD WALL THIN WALL 2 BRANCH",SUP-SBT1202D,CDM,C1768,HCPCS,0278,RC,,,both,,,8611.20,2583.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3539.2,41.1,,,,,0,1001.48,7319.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM CORTICAL",SUP-HTN-U-4-26,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"BLUE CROSS [10001]","Blue Cross HMO",,609.64,39.2,,957.42,156.86,7483.26,51,180.87,1321.92,"percent of total billed charges",
"SABER .035 10X20 40CM SL",SUP-48010002P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,667.85,68,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE 14X2IN",SUP-1951S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1151.35,345.4,"UHC [10700]","United Healthcare",,728.8,63.3,,,,,0,133.9,978.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX LARGE C6 9.5MM X",SUP-T600306,CDM,S27800098,LOCAL,0278,RC,,,both,,,3150.00,945,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,901.53,28.62,,,,,0,366.35,2677.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL APOLLORF 90D MULTIPORT",SUP-AR-9811,CDM,S27200284,LOCAL,0272,RC,,,both,,,1615.95,484.78,"AETNA [10100]","Aetna HMO/PPO",,1284.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,187.93,1373.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIVIGEN CELLULAR BONE MATRIX 1CC CRYO",SUP-BL-1500-001,CDM,C1713,HCPCS,0278,RC,,,both,,,3315.00,994.5,"BLUE CROSS [10001]","Blue Cross PPO",,1299.48,39.2,,957.42,570.23,957.42,28,385.53,2817.75,"percent of total billed charges",
"SYSTEM MITRACLIP DELIVERY KIT SGC0101 CDS0201",SUP-MSK0101,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS [10001]","Blue Cross PPO",,67032,39.2,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 40MM 2.5MM GEMINUS SOLID SIDE CUT NONSTERILE",SUP-DRLL-SSC-25040,CDM,S27200284,LOCAL,0272,RC,,,both,,,753.30,225.99,"MULTIPLAN [10600]",Multiplan,,640.31,85,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD 12FR URETHRAL NATURAL RUBBER SILICONE ELASTOMER 5",SUP-265712,CDM,S27200284,LOCAL,0272,RC,,,both,,,1.84,0.55,"NOVANET [10819]",Novanet,,1.38,75,,,,,0,0.21,1.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 4CM 4MM BALLOON DILATATION",SUP-U815044,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 8X38X28MM 20 DEGREE",SUP-1921050P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA [10200]",Cigna,,13860,40,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14X14.5CM NATRELLE P5.2CM MODERATE PROJECTION",SUP-MSZFM500,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 9MM KNEE BEARING POSTERIOR STABILIZE",SUP-5532-G-609-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1352.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DELIVERY SYSTEM 45D 10FR .163IN .13IN 80CM SOFT",SUP-9-ITV10F45/80,CDM,C1773,HCPCS,0272,RC,,,both,,,4912.80,1473.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,582.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,571.36,4175.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPLICATIONS OF TREATMENT WITH MCC",919,MS-DRG,,,,,,,inpatient,,,40813.41,12244.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,29189.78,,,,,,,7561,40813.41,"case rate",
"HC Cult Enteropathogenic E Coli",PX-306000006,CDM,87046,CPT,0306,RC,,,both,,,289.75,86.92,"CIGNA [10200]",Cigna,,20.77,,,,,,,0.01,246.29,"fee schedule",
"TOTAL HIP 6 UNIPOLAR/BIPOLAR - FX STEM/STRYKER",SUP-CAP-H-6,CDM,C1776,HCPCS,0278,RC,,,both,,,6720.00,2016,"CIGNA [10200]",Cigna,,4569.6,68,,5873.17,5873.17,5873.17,"1 through 10",781.54,5712,"percent of total billed charges",
"CMPNT PATELLAR STRIPED PURPLE YELLOW GREEN BLUE 38MM NEXGEN",SUP-00597206538,CDM,C1776,HCPCS,0278,RC,,,both,,,3469.20,1040.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,411.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,403.47,2948.82,"percent of total billed charges",
"SPLINT ORTHOPEDIC THK1/8IN SMALL 2.5-3.5IN HAND LEFT WRIST",SUP-A311301,CDM,S27000186,LOCAL,0270,RC,,,both,,,260.13,78.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,106.91,41.1,,,,,0,30.25,221.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT STD PRECHAMBER MEDIUM HIGH PRESSURE RANGE",SUP-823009,CDM,S27800098,LOCAL,0278,RC,,,both,,,6094.49,1828.35,"KAISER [10500]",Kaiser,,4083.31,67,,,,,0,708.79,5180.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM SUMMIT POROCOAT 2 12/14 STD OFFSET TAPER",SUP-157001080,CDM,C1776,HCPCS,0278,RC,,,both,,,14221.44,4266.43,"PHCS [10601]",PHCS,,9955.01,70,,,,,0,1653.95,12088.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 10 KNEE CEMENT ROTATE PLATFORM STERILE",SUP-150680010,CDM,C1776,HCPCS,0278,RC,,,both,,,17225.85,5167.75,"UHC [10700]","United Healthcare",,10903.96,63.3,,8601.07,8395.67,8601.07,"1 through 10",2003.37,14641.97,"percent of total billed charges",
"SCR BONE 5MM 80MM LOCK STERILE",SUP-2361-5080S,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.05,506.11,"CIGNA [10200]",Cigna,,1147.19,68,,1831.33,1831.33,1831.33,16,196.2,1433.99,"percent of total billed charges",
"AVENIR 10, 2.5 X 3 COMPLEX PICO COIL",SUP-10USC02503,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"UHC [10700]","United Healthcare",,8276.79,63.3,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SCIS ENDOCT",SUP-3142,CDM,S27200284,LOCAL,0272,RC,,,both,,,238.70,71.61,"NOVANET [10819]",Novanet,,179.03,75,,,,,0,27.76,202.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT HYDROSET HA INJECTABLE OSTEOCONDUCTIVE",SUP-397005,CDM,C1713,HCPCS,0278,RC,,,both,,,10684.65,3205.39,"MULTIPLAN [10600]",Multiplan,,9081.95,85,,,,,0,1242.62,9081.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 1 SMALL HYPERINFLATION PEDIATRIC .5L 2 PLEAT BAG 1",SUP-HS4151,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.88,30.56,"PHCS [10601]",PHCS,,71.32,70,,,,,0,11.85,86.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRILL 3MM",SUP-DK-300,CDM,S27200284,LOCAL,0272,RC,,,both,,,1714.50,514.35,"CIGNA [10200]","Cigna Local Plus",,917.26,53.5,,,,,0,199.4,1457.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 80X25.4MM THK1.3MM LONG WIDE STAINLESS STEEL",SUP-2108118,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT STRAIGHT RETRACTION 60MM MARS 26MM",SUP-632.466S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2880.00,864,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 16FR URETHRAL SILICONE 10ML FOLEY 2 WAY COUDE TIP",SUP-DYND11592,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.03,37.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL BLUNT TIP 3.0MM X 70MM",SUP-DRLL-BT-30070,CDM,S27000186,LOCAL,0270,RC,,,both,,,3781.20,1134.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TAKERU 12MM 2MM BALLOON DILATATION OTW PTCA",SUP-DC-PY2012UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT STENT TRIVASCULAR OVATION PRIME PTFE DELIVERY CATH",SUP-TV-AI01-E,CDM,S27200284,LOCAL,0272,RC,,,both,,,801.90,240.57,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MALECOT 12FR NEPHRSTMY NATURAL RUBBER 4 WING DRAIN",SUP-086012,CDM,C1729,HCPCS,0272,RC,,,both,,,105.65,31.69,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASKET STONE RETRIEVAL 2.5CM 1.8CM 8.5FR WITTICH BILIARY",SUP-G07313,CDM,S27200284,LOCAL,0272,RC,,,both,,,3682.43,1104.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHOCOLATE XD 140CM 20MM 3MM BALLOON DILATATION NITINOL","SUP-CX14-140-3020 RX",CDM,C1725,HCPCS,0272,RC,,,both,,,5333.70,1600.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE GLDEWIRE VASCULAR ANGLE 80CM 3CM .035IN NITINOL",SUP-GR3513,CDM,C1769,HCPCS,0272,RC,,,both,,,265.35,79.6,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ROTAWIRE DRIVE FLOPPY 5 PACK",SUP-H74939462005,CDM,C1769,HCPCS,0272,RC,,,both,,,1849.50,554.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE FATHOM VASCULAR STRAIGHT 140CM 35CM .016IN PERIPHERAL",SUP-M001509010,CDM,C1769,HCPCS,0272,RC,,,both,,,1792.50,537.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAREON PANOPTIX TORIC UVA",SUP-CCWTT3,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,397.04,45.9,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM PRECISION 7D TRAPEZOID SPINE",SUP-7412,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 100MM 120CM 7.5MM 6FR VASCULAR NITINOL",SUP-S-75-100-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4196.41,45.9,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 40MM 3.5MM BALLOON DILATATION",SUP-48003504X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA MEDIAL CONGRUENT 8-11 E-F",SUP-42512100810,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4429.11,41.1,,6417.48,6417.48,6417.48,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"LENS IOL SY60WF.160 CLAREON",SUP-SY60WF.160,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 5YDX.5IN ALGIDEX SILVER GAUZE PK LATEX FREE",SUP-46-PG12,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.55,19.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,26.53,41.1,,,,,0,7.51,54.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 6MM GORE STD WALL HEPARIN PROPATEN PTFE",SUP-H060040A,CDM,C1768,HCPCS,0278,RC,,,both,,,7562.40,2268.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,896.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,879.51,6428.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE WHISPER LS VASCULAR STRAIGHT 190CM 3CM .014",SUP-1005351H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIGHT WIDE FLAT RTRCTR PHOTONGUIDE FIBEROPTIC STERILE LATEX",SUP-104015,CDM,S27200284,LOCAL,0272,RC,,,both,,,2343.75,703.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1075.78,45.9,,,,,0,272.58,1992.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP FEEDING MEDICINE GRADUATED LATEX FREE REUSABLE STAINLESS",SUP-2,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.87,23.96,"PHCS [10601]",PHCS,,55.91,70,,,,,0,9.29,67.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT SPRT LARGE NONSTERILE LATEX FREE REUSABLE",SUP-FP9000L,CDM,S27000186,LOCAL,0270,RC,,,both,,,408.90,122.67,"CIGNA [10200]","Cigna Local Plus",,218.76,53.5,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE ARISTA MPH PLANT STARCH BIONERT 1GM",SUP-SM0005USA,CDM,S27200284,LOCAL,0272,RC,,,both,,,634.04,190.21,"CIGNA [10200]","Cigna Local Plus",,339.21,53.5,,,,,0,73.74,538.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 40MM 120CM 10MM .079IN LARGE",SUP-SERB65-10-40-120,CDM,C1876,HCPCS,0278,RC,,,both,,,3360.00,1008,"AMERIGROUP MEDICAID [20100]",Amerigroup,,398.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,390.77,2856,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 5.5MM COOLCUT FLUSHCUT 8 FLUTE OVAL STERILE",SUP-AR-8550FOE,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,257.65,45.9,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OLANZAPINE 2.5 MG TABLET",RX-21057,CDM,,,0637,RC,60505-3110-00,NDC,both,1,UN,42.33,12.7,"MULTIPLAN [10600]",Multiplan,,35.98,85,,,,,0,4.92,35.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 100MM 7MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171071070,CDM,C1726,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UHC [10700]","United Healthcare",,743.46,63.3,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TNLR SURGICAL BULLET TIP KELLY-WICK 12MM VASCULAR STERILE",SUP-KWT012,CDM,S27200284,LOCAL,0272,RC,,,both,,,421.95,126.58,"UHC [10700]","United Healthcare",,267.09,63.3,,,,,0,49.07,358.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X18X7-14MM RISE-L",SUP-193.302,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"KAISER [10500]",Kaiser,,23004.45,67,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ca Urine Quant Timed Specimen",PX-301000126,CDM,82340,CPT,0301,RC,,,both,,,110.74,33.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,94.13,"per diem",
"STBL ORTHOPEDIC XL AIRMESH KNEE LATERAL LEFT LOW PROFILE J",SUP-11045,CDM,L1830,HCPCS,0274,RC,,,both,,,227.07,68.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,154.41,68,,,,,0,26.41,193.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rad Tx Del Lvl 1 Sd",PX-333000068,CDM,77402,CPT,0333,RC,,,both,,,1665.36,499.61,"FIRST HEALTH [10303]","First Health",,1332.29,80,,,,,0,193.68,1665.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 6FR 4MM .07IN",SUP-H7493926708400,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prcrd Drg 6yr+ WO Cgen Car",PX-450000387,CDM,33017,CPT,0361,RC,,,both,,,3999.64,1199.89,"CIGNA [10200]","Cigna Local Plus",,3999.64,,"Case rate ($6,044). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,465.16,3999.64,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 11MM QUICKFIX TITANIUM FULL THREAD FOOT HAND",SUP-AR-8930-11,CDM,C1713,HCPCS,0278,RC,,,both,,,1800.00,540,"CIGNA [10200]","Cigna Local Plus",,963,53.5,,3978.14,359.25,3978.14,24,209.34,1530,"percent of total billed charges",
"SET ACCESS 50.5CM 10FR 16GA TRANSJUGULAR INTRAHEPATIC 38.5CM",SUP-G29769,CDM,C1887,HCPCS,0272,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM GLUCONATE 100 MG/ML (10 %) IV VIAL",RX-1312,CDM,J0612,HCPCS,0636,RC,63323-0360-01,NDC,both,10,ML,90.75,27.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.52,,"Fee schedule rate ($3.52). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.52,77.14,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN FULL LENGTH WILLIAMS RIGHT CURVE",SUP-H74908526502,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,52.07,68,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COHERE XL 12X18X50MM 10°",SUP-8181250P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 50X14MM STD OSCILLATE ERGONOMIC LIGHTWEIGHT THK.6",SUP-519.150S,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"UHC [10700]","United Healthcare",,323.02,63.3,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 86MM STAINLESS STEEL 2.7/3.5MM SCR 4 HOLE LCP BONE",SUP-02.112.139,CDM,C1713,HCPCS,0278,RC,,,both,,,3031.88,909.56,"CIGNA [10200]",Cigna,,2061.68,68,,1831.33,1831.33,1831.33,16,352.61,2577.1,"percent of total billed charges",
"SCR BONE 4MM 54MM LCP STAINLESS STEEL LONG THREAD SMALL BONE",SUP-207.654,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,123.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,120.96,884.03,"percent of total billed charges",
"DEVICE FLOSWITCH 1050 PSI FLOW CONTROL 1 WAY HIGH PRESSURE",SUP-M00144200,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.22,18.97,"NOVANET [10819]",Novanet,,47.42,75,,,,,0,7.35,53.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 60CC .1-4MM CANCELLOUS ALLOGRAFT CHIPS",SUP-450754,CDM,C1713,HCPCS,0278,RC,,,both,,,7803.90,2341.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2233.48,28.62,,,,,0,907.59,6633.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PTCA CATHETER 4.0 X 20MM (640-204-1U) SCOREFLEX NC SCORING",SUP-SD36003-24,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.170 CLAREON",SUP-SY60WF.170,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 F 36MM LONGEVITY HIP STERILE LUMEN LATEX",SUP-20103606,CDM,C1776,HCPCS,0278,RC,,,both,,,8101.98,2430.59,"BLUE CROSS [10001]","Blue Cross HMO",,3175.98,39.2,,5311.50,4717.44,5388.59,31,942.26,6886.68,"percent of total billed charges",
"STENT PROTEGE GPS EXPRT 40MM 120CM 9MM BILIARY NITINOL OTW",SUP-SERB65-09-40-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"NOVANET [10819]",Novanet,,4173.75,75,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM MULTILOC TITANIUM NIOBIUM ALUMINUM 3.8MM",SUP-04.019.040S,CDM,C1713,HCPCS,0278,RC,,,both,,,1747.20,524.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1188.1,68,,,,,0,203.2,1485.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM VUEPOINT II SPINE MULTIAXIAL NONSTERILE",SUP-8975310,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14CM NATRELLE INSPIRA P4.6CM MODERATE PROFILE",SUP-MSZ-M485,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,72.6,45.9,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 90CM 106CM SMOOTH TRANSITION STEERABLE",SUP-MAP690,CDM,S27200284,LOCAL,0272,RC,,,both,,,4071.00,1221.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,473.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 8.25MM 7CM TWIST-IN SHOULDER NOTCH TYE",SUP-AR-6530N,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"PHCS [10601]",PHCS,,159.87,70,,,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00190,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"PHCS [10601]",PHCS,,765.45,70,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 100CM 7FR .078IN SHORT TIP JUDKINS",SUP-77809100,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"FIRST HEALTH [10303]","First Health",,334.08,80,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X9MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7209,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"AETNA [10100]","Aetna HMO/PPO",,5485.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 80CM 2CM 5FR 4MM 7.5MM BALLOON DILATATION",SUP-4194020S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-H, 6X22X50MM 20",SUP-6200650,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"CIGNA [10200]","Cigna Open Access",,11482.33,33.5,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE 30X20CM PREPERITONEAL KNIT WEB SYNECOR",SUP-GKWR2030,CDM,C1781,HCPCS,0278,RC,,,both,,,27442.80,8232.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3251.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3191.6,23326.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 10X42X32MM 15 DEGREE",SUP-1921087P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4029.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM VARIAX LOCK NONSTERILE",SUP-657318,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,425.53,28.62,,,,,0,172.92,1263.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 14MM 3FR GEMINI HELICAL URETERAL",SUP-M0063302090,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"PHCS [10601]",PHCS,,1035.69,70,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 89MM TITANIUM 4 HOLE VARIAX BONE RIGHT OLECRANON ELBOW",SUP-629364,CDM,C1713,HCPCS,0278,RC,,,both,,,7272.88,2181.86,"CIGNA [10200]",Cigna,,4945.56,68,,1831.33,1831.33,1831.33,16,845.84,6181.95,"percent of total billed charges",
"COIL EMBOLIZATION 6CM 3MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-3-6-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1385.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 5MM BALLOON DILATATION STERILE LATEX",SUP-585015022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL GENESIS II 5 LEFT KNEE CEMENT TITANIUM",SUP-71420168,CDM,C1776,HCPCS,0278,RC,,,both,,,14593.50,4378.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1729.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1697.22,12404.48,"percent of total billed charges",
"GRAFT SYNTHETIC TISSUE OSTEOCONDUCTIVE MATRIX DEMINERALIZED",SUP-OCMP2,CDM,C1713,HCPCS,0278,RC,,,both,,,1458.00,437.4,"NOVANET [10819]",Novanet,,1093.5,75,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 315MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.034.343S,CDM,C1713,HCPCS,0278,RC,,,both,,,8166.56,2449.97,"PHCS [10601]",PHCS,,5716.59,70,,,,,0,949.77,6941.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502606402,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2709.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 38MM UNITRAX HIP FEMORAL MODULAR EXETER V40",SUP-6942-5-038,CDM,C1776,HCPCS,0278,RC,,,both,,,3753.24,1125.97,"KAISER [10500]",Kaiser,,2514.67,67,,,,,0,436.5,3190.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE LOCKING CANNULATED 5MM 75MM LCP STAINLESS STEEL",SUP-02.205.075,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,361.55,28.62,,,,,0,146.92,1073.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 8MM GORE-TEX THIN WALL PTFE THIN WALLED",SUP-SRRT08070080L,CDM,C1768,HCPCS,0278,RC,,,both,,,11267.70,3380.31,"NOVANET [10819]",Novanet,,8450.78,75,,,,,0,1310.43,9577.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 60MM 6FR 6MM 4FR BALLOON",SUP-39031-60601,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE CHECKER 150CM 22CM 2MM BALLOON DILATATION",SUP-U4150222,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,881.28,68,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYSTOSCOPE FLEXIBLE 390MM 6MM ASCOPE 4 STERILE LATEX FREE",SUP-601101000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1498.50,449.55,"MULTIPLAN [10600]",Multiplan,,1273.73,85,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON SUT 3.5MM STERILE",SUP-AR-8920,CDM,C1713,HCPCS,0278,RC,,,both,,,807.98,242.39,"BLUE CROSS [10001]","Blue Cross HMO",,316.73,39.2,,957.42,156.86,7483.26,51,93.97,686.78,"percent of total billed charges",
"CMPNT GLENOID 41MM STD GLENOSPHERE COLOR CODED COMPREHENSIVE",SUP-115320,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"AETNA [10100]","Aetna HMO/PPO",,9693.44,79.5,,10981.53,8986.79,12413.38,12,1418.05,10364.05,"percent of total billed charges",
"ROD SPINAL 50MM 6.35MM TSRH-3D TITANIUM PREBENT PRECUT",SUP-8371050,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross PPO",,1728.72,39.2,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION",RX-170702,CDM,,,0250,RC,00597-0155-70,NDC,both,4,GR,452.70,135.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,52.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.65,384.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 10X7CM CYTAL FENESTRATE MATRIX 6 LAYER",SUP-WSX0710,CDM,Q4166,HCPCS,0636,RC,,,both,,,19505.30,5851.59,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,53.69,,,,,,,53.69,16579.51,"fee schedule",
"SHEATH AMPLATZER TORQVUE 2 120CM 6FR INTRO POLYMER PTFE",SUP-9-TV2-06F120,CDM,S27200284,LOCAL,0272,RC,,,both,,,5754.60,1726.38,"AETNA [10100]","Aetna HMO/PPO",,4574.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,669.26,4891.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG BLACK 18X12.5CM GRANUFOAM SENSATRAC VAC THK3.3CM",SUP-M8275052/5.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,371.16,111.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG 9 1/5INX9 1/5IN SELF ADHERENT ABSORBENT PAD MOISTURE",SUP-282400,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.52,26.26,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SWAN-GANZ CCOMBO VIP 110CM 8FR STD PULMONARY ARTERY",SUP-746F8,CDM,C1751,HCPCS,0272,RC,,,both,,,1782.30,534.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MATRIX TISSUE 20X16CM ALLODERM THK.4-1.6MM MEDIUM",SUP-1518320,CDM,Q4116,HCPCS,0636,RC,,,both,,,59453.10,17835.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH OPTA PRO 110CM 4CM 5FR 5MM 7.5MM BALLOON DILATATION",SUP-4195040L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) OSCOR GUIDESTAR 10F SHEATH 22MM","SUP-D-1433-02-SI (22MM)",CDM,C1887,HCPCS,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BINDER QUEEN ZIPPER BRA RECOVERY MAMMARY",SUP-958-QUEEN,CDM,S27000186,LOCAL,0270,RC,,,both,,,449.39,134.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CPS AIM SL 7.62FR OBTUSE GUIDING STERILE LATEX FREE",SUP-DS2N028-65,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP PULSED LAVAGE SIMPULSE VARICARE SMALL 1.75IN RETRACTABLE",SUP-0067320,CDM,S27000186,LOCAL,0270,RC,,,both,,,386.28,115.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,158.76,41.1,,,,,0,44.92,328.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 8MM 2.5MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT25008UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"AETNA [10100]","Aetna HMO/PPO",,1919.93,79.5,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER SLIMLINE 200UM SMART ID SYSTEM",SUP-M0068409230,CDM,S27200284,LOCAL,0272,RC,,,both,,,8334.51,2500.35,"AETNA [10100]","Aetna HMO/PPO",,6625.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,969.3,7084.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 380MM RIGHT TROCHANTERIC INTRAMEDULLARY 130D LONG",SUP-456.358S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"KAISER [10500]",Kaiser,,9159.18,67,,,,,0,1589.87,11619.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 365CC",SUP-SSZ-F365,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,612.55,41.1,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 56MM 40MM ALTRX HIP",SUP-122140056,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1605.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1605.34,11732.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +8 DIOPTER MODIFY L BICONVEX 13MM 6MM POSTERIOR",SUP-CC60WF.080,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ASAHI CARAVEL ACT ONE 135CM 70CM .85-.62MM .48MM .55MM",SUP-CRV135-19P,CDM,C1887,HCPCS,0272,RC,,,both,,,3187.50,956.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,377.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL LEGION 4 LEFT KNEE REVISION",SUP-71424004,CDM,C1776,HCPCS,0278,RC,,,both,,,23133.60,6940.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6246.07,27,,,,,0,2690.44,19663.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 800-850ML STYLE 68 SMOOTH NATRELLE SALINE P5.6CM",SUP-68-800,CDM,C1789,HCPCS,0278,RC,,,both,,,2250.00,675,"NOVANET [10819]",Novanet,,1687.5,75,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 100CM 6FR XBC3.5 CURVE GUIDING",SUP-67007200,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,49.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 60MM 135CM 6MM 5FR VASCULAR NITINOL LOW",SUP-5F060603CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3167.1,27,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR .074IN 55CM ANL0 CURVE STRAIGHT TIP ANSEL",SUP-G56230,CDM,C1894,HCPCS,0272,RC,,,both,,,472.23,141.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,55.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.92,401.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET GRAFT HARVEST ACL 11MM 10MM ALIGNMENT ROD CORE EXTRUDER",SUP-AR-1981-10S,CDM,S27200284,LOCAL,0272,RC,,,both,,,5126.70,1538.01,"PHCS [10601]",PHCS,,3588.69,70,,,,,0,596.24,4357.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BARD INLAY 28CM 6FR 2 PIGTAIL CURVE URETERAL",SUP-778628,CDM,C2617,HCPCS,0278,RC,,,both,,,625.73,187.72,"MULTIPLAN [10600]",Multiplan,,531.87,85,,,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 8FR L30CM SOFT WITHOUT GUIDEWIRE TRIA",SUP-M0061903450,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 100MM 2MM BALLOON DILATATION RAPID",SUP-47520100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 34MM SALVATION ORTHOLOC 3DI LOW PROFILE FOOT",SUP-59215534,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"KAISER [10500]",Kaiser,,1472.33,67,,,,,0,255.57,1867.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER REDEL 115CM 4MM 7FR 1-7-4MM SPACE D-F CURVE",SUP-BD7TCDF4L,CDM,C1733,HCPCS,0272,RC,,,both,,,6113.40,1834.02,"KAISER [10500]",Kaiser,,4095.98,67,,,,,0,710.99,5196.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER BREAST BIOPSY TUMARK ECONOMY Q CLIP 18G X 12CM",SUP-271500,CDM,A4648,HCPCS,0278,RC,,,both,,,391.50,117.45,"CIGNA [10200]","Cigna Local Plus",,209.45,53.5,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING OXFORD KNEE LEFT MEDIAL RIGHT LATERAL",SUP-154720,CDM,C1776,HCPCS,0278,RC,,,both,,,11195.94,3358.78,"CIGNA [10200]","Cigna Local Plus",,5989.83,53.5,,5372.07,4581.20,7242.98,23,1302.09,9516.55,"percent of total billed charges",
"CATH NC EUPHORA 142CM 6MM 2.75MM BALLOON DILATATION DURATRAC",SUP-NCEUP27506X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 6MM 2.75MM BALLOON DILATATION DURATRAC",SUP-NCEUP27506X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,233.04,41.1,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROCAINAMIDE 100 MG/ML INJECTION SOLUTION",RX-6562,CDM,J2690,HCPCS,0636,RC,14789-0901-07,NDC,both,10,ML,4528.80,1358.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3079.58,68,,,,,0,4.25,3849.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT CONGR SZ.5X10MM RT",SUP-2042-0-1210,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM 7FR ENDOCARDIUM TRUE BIPOLAR ACTIVE",SUP-7171Q/65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"NOVANET [10819]",Novanet,,12879,75,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY ESOPHAGEAL 2 STD 4.5MM 3.5MM PEDIATRIC LMA UNIQUE",SUP-125020,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.20,15.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 5X4IN ANTIMICROBIAL SAFETAC SILVER POLYURETHANE STERILE",SUP-287090,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.67,23.3,"CIGNA [10200]","Cigna Local Plus",,41.55,53.5,,,,,0,9.03,66.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM STAINLESS STEEL T8 METAPHYSEAL SELF TAP",SUP-02.118.516,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"CIGNA [10200]","Cigna Open Access",,298.1,56.9,,1144.80,304.56,2275.09,66,60.93,445.32,"percent of total billed charges",
"MESH HERNIA POLYPROPYLENE 20X16IN PERMANENT REINFORCE LOCK",SUP-F10244-1620P,CDM,C1781,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 22FR STD URETHRAL NATURAL RUBBER",SUP-0119L22,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.52,23.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.02,65.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR .09IN JUDKINS LEFT 4.5 CURVE GUIDING",SUP-LA8JL45,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-3 TH-26 36IN MONOFILAMENT 2 ARM UNDYED",SUP-3N08A,CDM,S27200284,LOCAL,0272,RC,,,both,,,276.95,83.08,"CIGNA [10200]",Cigna,,188.33,68,,,,,0,32.21,235.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVOLUTION 10CM 230CM 25MM 30MM COLONIC CONTROLLED",SUP-G48038,CDM,C1876,HCPCS,0278,RC,,,both,,,17854.20,5356.26,"FIRST HEALTH [10303]","First Health",,14283.36,80,,,,,0,2076.44,15176.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.8MM SALVATION ORTHOLOC 3DI 5.5MM SCR DISPOSABLE",SUP-59250038,CDM,S27200284,LOCAL,0272,RC,,,both,,,1287.90,386.37,"CIGNA [10200]","Cigna Open Access",,732.82,56.9,,,,,0,149.78,1094.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Prox Fib/Shaft WO Manip",PX-450000160,CDM,27780,CPT,0450,RC,,,both,,,1347.00,404.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,694.48,,,,,,,67.13,1347,"case rate",
"TRAY NERVE BLOCK 51MM 18GA 21GA E-CATH PLUS SONOPLEX",SUP-TDL141,CDM,C9812,HCPCS,0272,RC,,,both,,,611.55,183.46,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,EXTREME",651,APR-DRG,,,,,,,inpatient,,,232974.11,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $28,390.55. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($146,266.86) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATHETER TURNPIKE 150CM 2.2-2.9FR 1.6FR GUIDING LOW P",SUP-5639,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HNDPC BREAST BIOPSY 12CM 12GA ATEC 20MM ULTRASOUND FAST","SUP-ATEC 1212-20",CDM,S27200284,LOCAL,0272,RC,,,both,,,1696.50,508.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CELOS OXIDIZED 4X4IN ABSORBABLE HEMOSTAT SURGICEL SNOW",SUP-2083,CDM,S27200284,LOCAL,0272,RC,,,both,,,1865.48,559.64,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,inpatient,,,250756.63,75226.99,"CIGNA [10200]","Cigna Open Access",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 46.8%. Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,inpatient,,,106136.80,31841.04,"CIGNA [10200]","Cigna Open Access",,35539.3,,"Fee schedule rate ($35,539.30). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,94551.25,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW CONTOUR TITANIUM 3 HOLE EXTEND SLOT GRAFT",SUP-AR-8916VNR-03,CDM,C1713,HCPCS,0278,RC,,,both,,,7838.40,2351.52,"CIGNA [10200]","Cigna Open Access",,4460.05,56.9,,1144.80,304.56,2275.09,66,911.61,6662.64,"percent of total billed charges",
"SPACER SPINAL 22X10X7MM SABLE 15D STERILE LATEX FREE",SUP-1172.2021S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"NOVANET [10819]",Novanet,,25987.5,75,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION",RX-105640,CDM,J0665,HCPCS,0636,RC,00409-1162-19,NDC,both,30,ML,24.24,7.27,"NOVANET [10819]",Novanet,,18.18,75,,,,,0,2.87,20.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X8MM SUSTAIN SMALL OBLIQUE PEEK TITANIUM",SUP-304.088CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,18207.00,5462.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2157.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2117.47,15475.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 50MM 3 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800350,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"CURET ENDOSCOPIC IVAS LATEX FREE 11GA",SUP-0306-621-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,4372.53,1311.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,508.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,508.53,3716.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 0 UR-4 27IN MONOFILAMENT ABSORBABLE",SUP-U256H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 0 UR-4 27IN MONOFILAMENT ABSORBABLE",SUP-U256H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALENDRONATE 70 MG TABLET",RX-29048,CDM,,,0637,RC,16714-0633-01,NDC,both,1,UN,77.16,23.15,"FIRST HEALTH [10303]","First Health",,61.73,80,,,,,0,8.97,65.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 4 62MM 9.4MM SHILEY CUFF DISPOSABLE INNER CANN",SUP-4CN65H,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.97,110.09,"MULTIPLAN [10600]",Multiplan,,311.92,85,,,,,0,42.68,311.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE CONDYLAR LEFT 12 HOLE STERILE CURVED 266MM STAINL",SUP-02.124.413S,CDM,C1713,HCPCS,0278,RC,,,both,,,13990.99,4197.3,"CIGNA [10200]","Cigna Local Plus",,4407.16,31.5,,3978.14,359.25,3978.14,24,1627.15,11892.34,"percent of total billed charges",
"SPACER ALLOGRAFT 16X14X7MM SPINE CERVICAL",SUP-6940764,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 5-0 S-14 18IN 2 ARM BRAID COATED UNDYED",SUP-J671G,CDM,S27200284,LOCAL,0272,RC,,,both,,,159.52,47.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,65.56,41.1,,,,,0,18.55,135.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 6MM 3.25MM BALLOON DILATATION DURATRAC",SUP-NCEUP32506X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM ATLANTIS TITANIUM CANCELLOUS ANTERIOR",SUP-876-714,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 425ML GEL SMOOTH SILICONE P4.1CM MODERATE PLUS","SUP-3504251 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"PHCS [10601]",PHCS,,2572.5,70,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 7 KNEE LEFT BICRUCIATE STABILIZE",SUP-74022227,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"CIGNA [10200]","Cigna Open Access",,5568.4,33.5,,5302.19,4377.88,6578.61,27,1933.15,14128.79,"percent of total billed charges",
"PLUG VASCULAR  10MM",SUP-9-PLUG-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"BLUE CROSS [10001]","Blue Cross PPO",,2420.8,39.2,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 214MM 16MM CANNULATED HOLLOW LARGE QUICK COUPLING",SUP-03.037.004,CDM,S27200284,LOCAL,0272,RC,,,both,,,4712.15,1413.64,"NOVANET [10819]",Novanet,,3534.11,75,,,,,0,548.02,4005.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRODE BIPOLAR 5FR TWIZZLE TIP HYSTEROSCOPIC VERSAPOINT",SUP-WA47782A,CDM,S27200284,LOCAL,0272,RC,,,both,,,3439.80,1031.94,"CIGNA [10200]","Cigna Local Plus",,1840.29,53.5,,,,,0,400.05,2923.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 75CM 1.3MM VECTRIS SURESCAN 4MM SPACE 1X8",SUP-977A275,CDM,C1778,HCPCS,0278,RC,,,both,,,13800.00,4140,"FIRST HEALTH [10303]","First Health",,11040,80,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 8MM SWIVELOCK TENODESIS SHOULDER BICEPS CLOSED",SUP-AR-1662BCC-8,CDM,C1713,HCPCS,0278,RC,,,both,,,3425.63,1027.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2329.43,68,,,,,0,398.4,2911.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABRE VENOUS SELF-EXPADING STENT16X150X90",SUP-AB9T16150090,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 23MM 52MM SHOULDER SIMPLICITI",SUP-7122876,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"MULTIPLAN [10600]",Multiplan,,8516.15,85,,,,,0,1165.21,8516.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 40CM RADIOPAQUE BAND CHECK-FLO FLEXOR .038",SUP-G12884,CDM,C1894,HCPCS,0272,RC,,,both,,,441.45,132.43,"FIRST HEALTH [10303]","First Health",,353.16,80,,,,,0,51.34,375.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 30CM 150CM 8FR .035IN PIGTAIL CURVE",SUP-M006180245180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"BLUE CROSS [10001]","Blue Cross PPO",,572.36,39.2,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPREME EP EXT. CABLE GREY  150 CM",SUP-401982R,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"KAISER [10500]",Kaiser,,192.36,67,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 22CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155241050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"PHCS [10601]",PHCS,,861.67,70,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP 20MM 160CM 10MM 135CM ENDOPROSTHESIS",SUP-M001712330,CDM,C1876,HCPCS,0278,RC,,,both,,,8728.50,2618.55,"BLUE CROSS [10001]","Blue Cross HMO",,3421.57,39.2,,,,,0,1015.12,7419.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Platelet Neutralization",PX-305000056,CDM,85597,CPT,0305,RC,,,both,,,292.50,87.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.18,,,,,,,0.01,248.63,"fee schedule",
"FILTER EMBOLIZATION 49MM 65CM VENA CAVA RADIOPAQUE PRELOAD",SUP-G34502,CDM,C1880,HCPCS,0278,RC,,,both,,,7621.05,2286.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,903.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,886.33,6477.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 11MM STAINLESS STEEL T4 CORTEX SELF TAP",SUP-02.214.111,CDM,C1713,HCPCS,0278,RC,,,both,,,418.99,125.7,"KAISER [10500]",Kaiser,,280.72,67,,,,,0,48.73,356.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE KORE FIBER CORTICAL BONE FIBER 1CC ALLOGRAFT",SUP-423201,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CIGNA [10200]","Cigna Local Plus",,922.88,53.5,,3978.14,359.25,3978.14,24,200.62,1466.25,"percent of total billed charges",
"SPACER ALLOGRAFT CORNERSTONE L-SR",SUP-400841,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC",871,MS-DRG,,,,,,,inpatient,,,47206.78,14162.03,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,12410.92,,"Case rate ($12,049.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,188.73, add-ons for qualifying new technology services are included. If operating cost exceeds $44,228.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,227.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,203.52. The transfer operating threshold is the transfer adjustment factor * $11,188.73 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.92. The transfer capital threshold is the transfer adjustment factor * $845.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,47206.78,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175262170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"PHCS [10601]",PHCS,,885.77,70,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC THK1/8IN MEDIUM WRIST THUMB SPICA 2%",SUP-550407,CDM,S27000186,LOCAL,0270,RC,,,both,,,110.84,33.25,"CIGNA [10200]","Cigna Local Plus",,59.3,53.5,,,,,0,12.89,94.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 3MM AXOGUARD NERVE CAP SIS MATRIX END TAB",SUP-AGT315,CDM,C1763,HCPCS,0278,RC,,,both,,,15304.20,4591.26,"CIGNA [10200]",Cigna,,6121.68,40,,,,,0,1779.88,13008.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 18.5X5.5X.4MM HALL MICRO STAINLESS STEEL",SUP-5023-162,CDM,S27200284,LOCAL,0272,RC,,,both,,,220.37,66.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.63,187.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 300MM 5.5MM RELINE STRAIGHT TITANIUM MAS",SUP-12355300,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 6 SLOT LEFT TI",SUP-PHPF-C6L,CDM,C1713,HCPCS,0278,RC,,,both,,,18144.00,5443.2,"KAISER [10500]",Kaiser,,12156.48,67,,,,,0,2110.15,15422.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 39MM 135CM 8MM 11MM 7FR .035IN",SUP-BXA083902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5582.27,28.62,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM SOLERA SPINAL MULTIAXIAL CANNULATED",SUP-54840045545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UHC [10700]","United Healthcare",,6043.16,63.3,,5023.51,2672.93,6679.78,18,1110.3,8114.82,"percent of total billed charges",
"PLATE 0D 2SHORT 1.3MM 2 HOLE DORSIFLEXION PRIMARY GORILLA",SUP-P53-103-L004,CDM,C1713,HCPCS,0278,RC,,,both,,,8159.25,2447.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2335.18,28.62,,,,,0,948.92,6935.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 6-9 E-F KNEE LEFT",SUP-42511400710,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,956.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,939.21,6864.4,"percent of total billed charges",
"CATH SABER 150CM 40MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015040M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UHC [10700]","United Healthcare",,907.53,63.3,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Retroperitoneal Complete",PX-402000010,CDM,76770,CPT,0402,RC,,,both,,,1285.72,385.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,225.09,,,,,,,115.44,1092.86,"fee schedule",
"GRAFT BONE CARTIMAX CARTILAGE ALLOGRAFT VIABLE",SUP-401205,CDM,C1713,HCPCS,0278,RC,,,both,,,28350.00,8505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",3297.11,24097.5,"percent of total billed charges",
"CATH ATHLETIS 135CM 40MM 9MM BALLOON DILATATION STERILE",SUP-H74939347090410,CDM,C1725,HCPCS,0272,RC,,,both,,,1449.90,434.97,"MULTIPLAN [10600]",Multiplan,,1232.42,85,,,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 43MM TITANIUM LEVEL 2 ZEVO BONE SPINE CERVICAL",SUP-3002043,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,957.42,570.23,957.42,28,521.61,3812.25,"percent of total billed charges",
"4PK QUATTRO PREMIUM AND HQ START UP KIT 6FT USA 1 BOX OF 4 CAT",SUP-8700-001043-01,CDM,C1751,HCPCS,0272,RC,,,both,,,34612.70,10383.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4101.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4025.46,29420.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL SMALL 4.25IN NECK 2 PIECE SEMIRIGID",SUP-11342,CDM,S27000186,LOCAL,0270,RC,,,both,,,129.54,38.86,"FIRST HEALTH [10303]","First Health",,103.63,80,,,,,0,15.07,110.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Filter Gas Cobe",PX-E27000110,CDM,E27000110,LOCAL,0270,RC,,,both,,,58.30,17.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,39.64,68,,,,,0,6.78,49.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SRGITLG LP SRGDAC 2/0 21""3""LP",SUP-ED-21-L,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"NOVANET [10819]",Novanet,,108.12,75,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM VERTEX MAX TITANIUM SPINE MULTIAXIAL",SUP-6958734,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lgh Gene Rearrange Amp Meth",PX-309000037,CDM,81261,CPT,0310,RC,,,both,,,1046.90,314.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,311.44,,,,,,,0.01,889.87,"fee schedule",
"HC Sigmoid Flex W Rmvl FB",PX-750000077,CDM,45332,CPT,0750,RC,,,both,,,2206.73,662.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,261.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,256.64,2206.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esoph Flex Trnsnasl Dx Brush",PX-750000124,CDM,43197,CPT,0750,RC,,,both,,,4531.00,1359.3,"CIGNA [10200]","Cigna Local Plus",,3109,,"Case rate ($3,109). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,526.96,4531,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 6CM QUICK-CORE LIGHTWEIGHT PRECISE BEVEL",SUP-G27008,CDM,S27200284,LOCAL,0272,RC,,,both,,,326.25,97.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,221.85,68,,,,,0,37.94,277.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X9MM 9/11MM SPINE CORTICAL FROZEN DISTAL",SUP-4909,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6806.16,41.1,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL CHIN 50X38X1MM 1 CHANNEL HIGH DENSITY ORBITAL FLOOR",SUP-8305,CDM,S27800098,LOCAL,0278,RC,,,both,,,4665.78,1399.73,"PHCS [10601]",PHCS,,3266.05,70,,,,,0,542.63,3965.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR BLUE 41MM 28MM RINGLOC ECCENTRIC HIP",SUP-11-165206,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"BLUE CROSS [10001]","Blue Cross HMO",,2610.67,39.2,,5311.50,4717.44,5388.59,31,774.54,5660.9,"percent of total billed charges",
"ELECTRD BIPOLAR CELONPROBREATH STERILE LATEX FREE DISPOSABLE",SUP-WB990310,CDM,S27200284,LOCAL,0272,RC,,,both,,,1406.44,421.93,"CIGNA [10200]","Cigna Open Access",,800.26,56.9,,,,,0,163.57,1195.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PALIPERIDONE PALMITATE 117 MG/0.75 ML INTRAMUSCULAR SYRINGE",RX-108108,CDM,J2426,HCPCS,0636,RC,50458-0562-01,NDC,both,.75,ML,10771.54,3231.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2060.45,,,,,,,1276.43,9155.81,"fee schedule",
"BIOPSY PUNSCH 5MM",SUP-M50550,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.91,24.27,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.25,41.1,,,,,0,9.41,68.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Leukocytes Feces",PX-306000175,CDM,89055,CPT,0309,RC,,,both,,,159.60,47.88,"KAISER [10500]",Kaiser,,106.93,67,,,,,0,0.01,135.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Beta 2 Glycoprotein I Ab Ea",PX-302000016,CDM,86146,CPT,0302,RC,,,both,,,324.90,97.47,"CIGNA [10200]","Cigna Open Access",,55.99,,,,,,,0.01,276.17,"fee schedule",
"HC Beta 2 Glycoprotein I Ab Ea",PX-302000016,CDM,86146,CPT,0302,RC,,,both,,,324.90,97.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.23,,,,,,,0.01,276.17,"fee schedule",
"NAIL 8.5MM 9.5MM 225MM HUMERAL RIGHT MULTILOC INTRAMEDULLARY",SUP-04.018.225S,CDM,C1713,HCPCS,0278,RC,,,both,,,11172.76,3351.83,"PHCS [10601]",PHCS,,7820.93,70,,,,,0,1299.39,9496.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 54MM HAND TITANIUM 2X8 HOLE T 2.4MM SCR",SUP-449.913,CDM,C1713,HCPCS,0278,RC,,,both,,,3755.81,1126.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1074.91,28.62,,,,,0,436.8,3192.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 7.6CM 3MM LEGEND CARBIDE METAL CUTTING FINAL",SUP-MC30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5MM STRAIGHT 84MM NARROW SHAFT SICKLE EDGE BEAVER",SUP-377300,CDM,S27200284,LOCAL,0272,RC,,,both,,,545.45,163.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,370.91,68,,,,,0,63.44,463.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORD ELECTROSURGICAL GREEN 12FT PLASTIC BIPOLAR STERILE",SUP-10-4000,CDM,S27200284,LOCAL,0272,RC,,,both,,,118.32,35.5,"NOVANET [10819]",Novanet,,88.74,75,,,,,0,13.76,100.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 150CM 20MM 2MM BALLOON DILATATION",SUP-H74939031202010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 3.5MM RELINE-C PRE BENT TITANIUM NONSTERILE",SUP-3943050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"AUG FEMORAL 8MM ATTUNE 3 KNEE POSTERIOR CEMENT REVISION",SUP-1549-03-002,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"PHCS [10601]",PHCS,,4250.4,70,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM ATTUNE 3 KNEE POSTERIOR CEMENT REVISION",SUP-1549-03-002,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"NOVANET [10819]",Novanet,,4554,75,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 4 132D",SUP-6720-0435,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9848.4,41.1,,6417.48,6417.48,6417.48,"1 through 10",2786.79,20367.74,"percent of total billed charges",
"SCR BONE 2.4MM 4.5MM 28MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.528.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"MULTIPLAN [10600]",Multiplan,,507.01,85,,,,,0,69.37,507.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Arthcs Asp/Inj Sm Jt",PX-450000067,CDM,20600,CPT,0361,RC,,,both,,,1275.39,382.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275.39,,"Case rate ($30,606). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,148.33,1275.39,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ercp FB Removal",PX-750000140,CDM,43275,CPT,0750,RC,,,both,,,4763.62,1429.09,"UHC [10700]","United Healthcare",,3833,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,554.01,4763.62,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pt Re-Eval Est Plan Care",PX-420000156,CDM,97164,CPT,0424,RC,,,both,,,336.19,100.86,"CIGNA [10200]","Cigna Open Access",,309,,"Per diem ($309).",,,,0,39.1,336.19,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC De Revasc Bypass Grft Addl Br",PX-481000086,CDM,C9605,HCPCS,0481,RC,,,both,,,25789.00,7736.7,"AETNA [10100]","Aetna HMO/PPO",,20502.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2999.26,25681,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC De Revasc Bypass Grft Addl Br",PX-481000086,CDM,C9605,HCPCS,0481,RC,,,both,,,25789.00,7736.7,"CIGNA [10200]","Cigna Local Plus",,20211,,"Case rate ($20,211). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2999.26,25681,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Eynoel 1.1-2.5cm Cmplx",PX-450000056,CDM,13151,CPT,0450,RC,,,both,,,1861.00,558.3,"MULTIPLAN [10600]",Multiplan,,1581.85,85,,,,,0,67.13,1861,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Pilonidal Cyst Smpl",PX-450000006,CDM,10080,CPT,0361,RC,,,both,,,3381.00,1014.3,"UHC [10700]","United Healthcare",,2385,,"Case rate ($2,385). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,393.21,3381,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 60X22X14MM 10D XL WIDE PEEK LORDOTIC",SUP-6921460,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS [10001]","Blue Cross PPO",,9313.92,39.2,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 STD 10MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS2S10R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7066.15,68,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 23MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.230,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"AMERIGROUP MEDICAID [20100]",Amerigroup,,348.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",341.92,2499,"percent of total billed charges",
"MEMB MNTR 3X2CM NUSHIELD ORTHO",SUP-NO-1230,CDM,Q4160,HCPCS,0636,RC,,,both,,,5485.50,1645.65,"FIRST HEALTH [10303]","First Health",,4388.4,80,,,,,0,650.03,5485.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS 75CM 4CM 24MM 10FR BALLOON DILATATION PERIPHERAL",SUP-AT75244,CDM,C1725,HCPCS,0272,RC,,,both,,,3187.50,956.25,"KAISER [10500]",Kaiser,,2135.63,67,,,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revasc Cto Cor Art/Br/Grf Sngl",PX-481000089,CDM,92943,CPT,0481,RC,,,both,,,30344.63,9103.39,"BLUE CROSS [10001]","Blue Cross HMO",,19285.75,,"Case rate ($19,285.75). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3529.08,25792.94,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Orbit MRI Screen",PX-351000017,CDM,70480,CPT,0351,RC,,,both,,,2767.89,830.37,"AETNA [10100]","Aetna HMO/PPO",,1933,,"Per diem ($1,933). Each eligible service on a given day will be paid its own per diem rate.",,,,0,261.88,2352.71,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH RED 150CM RESPONSE ELECTROPHYSIOLOGY HEXAPOLAR",SUP-401977,CDM,C1769,HCPCS,0272,RC,,,both,,,491.00,147.3,"NOVANET [10819]",Novanet,,368.25,75,,,,,0,57.1,417.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 90MM 5 HOLE LOW PROFILE BONE LEFT OLECRANON ELBOW",SUP-70-0304,CDM,C1713,HCPCS,0278,RC,,,both,,,7051.80,2115.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3236.78,45.9,,,,,0,820.12,5994.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 900-1200UM 2ML MICROSPHERES PREFILLED",SUP-S1020GH,CDM,S27800098,LOCAL,0278,RC,,,both,,,1860.00,558,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1264.8,68,,,,,0,216.32,1581,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC",267,MS-DRG,,,,,,,inpatient,,,289642.88,86892.86,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,30417.48,,"Case rate ($29,531.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $27,422.03, add-ons for qualifying new technology services are included. If operating cost exceeds $60,461.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,455.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $27,458.29. The transfer operating threshold is the transfer adjustment factor * $27,422.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,073.24. The transfer capital threshold is the transfer adjustment factor * $2,073.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.",,,,0,7561,138996.32,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 120MM 20GA SONOPLEX II FACET TIP INJECTION",SUP-001287-72,CDM,C9812,HCPCS,0272,RC,,,both,,,153.12,45.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.81,130.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 150MM 7FR 5MM BALLOON DILATATION PEBAX",SUP-H74939032501510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Outr/Thin Prep Imager Pap Scre",PX-300000042,CDM,88175,CPT,0311,RC,,,both,,,91.00,27.3,"BLUE CROSS [10001]","Blue Cross PPO",,34,,"Fee schedule rate ($34.00).",,,,0,0.01,91,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM 22MM EMBOLD NITINOL FIBER DETACHABLE",SUP-M001394240220600,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1021.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 18GA 1.25MM ACCUCATH ACE DOT",SUP-AC1181252,CDM,S27200284,LOCAL,0272,RC,,,both,,,323.03,96.91,"CIGNA [10200]","Cigna Open Access",,183.8,56.9,,,,,0,37.57,274.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH THREADER POWERCOIL 105CM 12MM 1.2MM MICRO SMALL THIN",SUP-H7493927012120,CDM,C1725,HCPCS,0272,RC,,,both,,,3300.00,990,"UHC [10700]","United Healthcare",,2088.9,63.3,,,,,0,383.79,2805,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 50CM 5FR 21GA MICROPUNCTURE .018IN LONG NDL WIRE",SUP-G49471,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 150MM 6MM BALLOON DILATATION DURALYN",SUP-48006015S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"MULTIPLAN [10600]",Multiplan,,1170.45,85,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 20MM 75CM 8MM VASCULAR METAL SUPERFICIAL",SUP-H74939293080270,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2216.97,45.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL RADIOLOGY GOLD 20CM 17GA 1.2MM KNURL SOFT TISSUE",SUP-MTNW887825,CDM,A4648,HCPCS,0278,RC,,,both,,,1665.00,499.5,"CIGNA [10200]","Cigna Open Access",,947.39,56.9,,,,,0,193.64,1415.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOGUARD 100UM 180CM .014IN 6MM EMBOLIC PROTECTION",SUP-601814RMC,CDM,C1884,HCPCS,0272,RC,,,both,,,6520.50,1956.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2679.93,41.1,,,,,0,758.33,5542.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25MMX11MM CRESCENT PEEK-OPTIMA VERTEBRAL BODY",SUP-9392511,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6806.16,41.1,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 2X133MM GOLDENBERG EAR HA FOOTPLATE SHOE",SUP-140914,CDM,L8613,HCPCS,0278,RC,,,both,,,1710.08,513.02,"BLUE CROSS [10001]","Blue Cross HMO",,670.35,39.2,,,,,0,198.88,1453.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 110CM 7.5CM 6FR .054IN .038IN PIGTAIL 155",SUP-7509-33,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"UHC [10700]","United Healthcare",,51.82,63.3,,,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 8MM 145CM 4MM CORONARY STENT EVEROLIMUS",SUP-1145400-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 78MM PRESS FIT AEQUALIS ASCEND FLEX PTC 132.5D",SUP-DWF604B,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1465.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER HUMERAL 36MM EQUINOXE +0MM STERILE LATEX FREE",SUP-322-36-00,CDM,C1776,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,5372.07,4581.20,7242.98,23,601.85,4398.75,"percent of total billed charges",
"CATH APD 25CM 8FR PIGTAIL CURVE DRNG GLIDEX PERCUFLEX METAL",SUP-M001245071,CDM,C1729,HCPCS,0272,RC,,,both,,,850.50,255.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,349.56,41.1,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 10 X 30 HELICAL FILLING COIL",SUP-10HFL-10030,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"AETNA [10100]","Aetna HMO/PPO",,7125.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 15MM 48MM SHOULDER SOFT TISSUE BALANCE",SUP-7122883,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"MULTIPLAN [10600]",Multiplan,,8516.15,85,,,,,0,1165.21,8516.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT LARGE 11 CC MORSEL BIOACTIV",SUP-77000110,CDM,C1713,HCPCS,0278,RC,,,both,,,9563.40,2869.02,"BLUE CROSS [10001]","Blue Cross HMO",,3748.85,39.2,,957.42,156.86,7483.26,51,1112.22,8128.89,"percent of total billed charges",
"MATRIX WOUND W 10CM 20CM POLYURETHANE NOVOSORB MTX SINGLE",SUP-MTX-1020,CDM,A2006,HCPCS,0636,RC,,,both,,,22680.00,6804,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,14742,65,,,,,0,247.92,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 3-0 PS-1 27IN MONOFILAMENT UNDYED",SUP-Y936H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"NOVANET [10819]",Novanet,,20.25,75,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Impulse Oscillometry",PX-460000012,CDM,94728,CPT,0460,RC,,,both,,,290.67,87.2,"CIGNA [10200]","Cigna Local Plus",,155.51,53.5,,,,,0,33.8,247.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEWIRE VASCULAR L180CM DIA0.035IN TAPER L7CM FLOPPY TIP L",SUP-G03565,CDM,C1769,HCPCS,0272,RC,,,both,,,147.81,44.34,"KAISER [10500]",Kaiser,,99.03,67,,,,,0,17.19,125.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Lwr Ext Jnt W Cntrst",PX-610000035,CDM,73722,CPT,0610,RC,,,both,,,4389.77,1316.93,"NOVANET [10819]",Novanet,,3292.33,75,,,,,0,510.53,3731.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP070100150 PLUS US D7L100UL1500",SUP-PCP070100150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,506.02,41.1,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Flt3 Gene Analysis Tkd Variant",PX-310000001,CDM,81246,CPT,0310,RC,,,both,,,535.80,160.74,"MULTIPLAN [10600]",Multiplan,,455.43,85,,,,,0,0.01,455.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Touch Prep Add Site",PX-312000040,CDM,88334,CPT,0312,RC,,,both,,,240.50,72.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.82,,,,,,,0.01,204.43,"fee schedule",
"LENS IOL +10.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.105,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CRE 240CM 5.5CM 7.5FR 12-15MM BALLOON DILATATION PEBAX",SUP-M00558480,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"NOVANET [10819]",Novanet,,1236.77,75,,,,,0,1236.77,1236.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 440CC",SUP-RSZ-MPX-440S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES",483,MS-DRG,,,,,,,inpatient,,,161169.88,48350.96,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,17710.09,,"Case rate ($17,194.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $15,966.04, add-ons for qualifying new technology services are included. If operating cost exceeds $49,005.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,589.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $15,987.15. The transfer operating threshold is the transfer adjustment factor * $15,966.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,207.11. The transfer capital threshold is the transfer adjustment factor * $1,207.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,80928.39,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +21.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-SY60WF.215,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL 28MM BIPOLAR RETAINING",SUP-205516000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1781.25,534.37,"FIRST HEALTH [10303]","First Health",,1425,80,,,,,0,207.16,1514.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD 4X1.8IN PRESHAPE ROUND EDGE MONOFILAMENT",SUP-0112700,CDM,C1781,HCPCS,0278,RC,,,both,,,159.50,47.85,"BLUE CROSS [10001]","Blue Cross HMO",,62.52,39.2,,,,,0,18.55,135.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC MEDIUM 16X10IN ARM ELEV 2 ICE BAG CANVAS",SUP-8011-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,108.58,32.57,"CIGNA [10200]","Cigna Open Access",,61.78,56.9,,,,,0,12.63,92.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X60 135CM SL",SUP-48005006R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"MULTIPLAN [10600]",Multiplan,,730.16,85,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT GREEN 5CM 3FR GEENEN PANCREATIC POLYETHYLENE PUSH",SUP-G27181,CDM,C2625,HCPCS,0278,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 300MM 4MM BALLOON DILATATION RAPID",SUP-47540300M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,235.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII POSTERIOR STABILIZED OXI",SUP-71704570,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]",Cigna,,8820,40,,5873.17,5873.17,5873.17,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"BRACE ORTHOPEDIC LONG UNIVERSAL 26IN 36- IN KNEE 2 AXIS",SUP-79-94240,CDM,S27000186,LOCAL,0270,RC,,,both,,,363.57,109.07,"NOVANET [10819]",Novanet,,272.68,75,,,,,0,42.28,309.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP SURESIGHT 1 HYPERANGULATED NONSTERILE",SUP-390211000,CDM,S27000186,LOCAL,0270,RC,,,both,,,445.50,133.65,"AETNA [10100]","Aetna HMO/PPO",,354.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 250MM 5MM BALLOON DILATATION RAPID",SUP-47550250M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"FIRST HEALTH [10303]","First Health",,1620,80,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 35D MEDIUM AUG CORTILOC SHOULDER RIGHT",SUP-DWK404RA35S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1244.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1221.15,8925,"percent of total billed charges",
"LINER ACETABULAR R3 0D 60MM 28MM XLPE HIP",SUP-71337560,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1320.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1296.39,9474.91,"percent of total billed charges",
"(EVAL) PREVAIL DCB 3.0X15MM",SUP-PRV030015CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PDS II MULTIPASS 4-0 P-3 18IN MONOFILAMENT UNDYED",SUP-Z494G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL SURGICAL THORATEC HEARTMATE 3 CORING STERILE LATEX FREE",SUP-10005872,CDM,S27200284,LOCAL,0272,RC,,,both,,,3604.50,1081.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW OXFORD CEMENTED",SUP-506298,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 35 135CM 100MM 6MM .035IN LOW PROFILE BALLOON",SUP-B2060-100,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE BIODESIGN SURGISIS .4CM PORCINE SMALL",SUP-G54613,CDM,C1763,HCPCS,0278,RC,,,both,,,8590.50,2577.15,"KAISER [10500]",Kaiser,,5755.64,67,,,,,0,999.08,7301.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MITRACLIP DELIVERY KIT SGC0101 CDS0201",SUP-MSK0101,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"KAISER [10500]",Kaiser,,114570,67,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM ARTHREX SWIVELOCK 2 LOAD PEEK STERILE",SUP-AR-2324PSLC-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,3110.63,933.19,"CIGNA [10200]",Cigna,,2115.23,68,,,,,0,361.77,2644.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG ALGINATE 8X4IN ACTICOAT POLYETHYLENE NANOCRYSTALLINE",SUP-20201,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.34,30.7,"CIGNA [10200]","Cigna Open Access",,58.23,56.9,,,,,0,11.9,86.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 28MM 140CM 2.75MM CORONARY STENT",SUP-LUN275R28US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP MULTIHOLE R3 STD STERILE",SUP-71338663,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"UHC [10700]","United Healthcare",,10056.63,63.3,,8601.07,8395.67,8601.07,"1 through 10",1847.69,13504.16,"percent of total billed charges",
"GRAFT BONE CAPSTONE ALLOGRAFT FREEZE DRIED 22MMX10MM",SUP-9441022,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"UHC [10700]","United Healthcare",,10919.25,63.3,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 6FR STD JL4.5 CURVE GUIDING NYLON",SUP-LA6JL45A,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 100MM 22MM DHS/DCS STAINLESS STEEL LARGE",SUP-280,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,834.64,45.9,,,,,0,211.48,1545.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Tube Nasal/Orogast W Fl",PX-361000172,CDM,43752,CPT,0361,RC,,,both,,,1425.27,427.58,"MULTIPLAN [10600]",Multiplan,,1211.48,85,,,,,0,165.76,1425.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC",301,MS-DRG,,,,,,,inpatient,,,31559.65,9467.89,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,9598.33,,"Case rate ($4,464.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,145.44, add-ons for qualifying new technology services are included. If operating cost exceeds $37,185.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,695.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,150.93. The transfer operating threshold is the transfer adjustment factor * $4,145.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $313.42. The transfer capital threshold is the transfer adjustment factor * $313.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,4464.34,17948.6,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 5MM CEREPAK FREEFORM DETACHABLE",SUP-SCR120515,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"KAISER [10500]",Kaiser,,8861.32,67,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PRECISIONPASS 15MM LAPAROSCOPIC MESH",SUP-0118100,CDM,S27200284,LOCAL,0272,RC,,,both,,,576.72,173.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,392.17,68,,,,,0,67.07,490.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 6MM 1.2MM BALLOON DILATATION PEBAX",SUP-1012268-06U,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMUR SHAFT 70MM",SUP-800140,CDM,S27800098,LOCAL,0278,RC,,,both,,,5602.80,1680.84,"FIRST HEALTH [10303]","First Health",,4482.24,80,,,,,0,651.61,4762.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Thorac Spine W/WO Cntrst",PX-352000013,CDM,72130,CPT,0352,RC,,,both,,,3677.36,1103.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($377.70). Procedures 2 - 999, Per diem ($188.85).",,,,0,,,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"VEST, CUP LARGE","SUP-16V LARGE",CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GUIDE WIRE GWR419488 108CM",SUP-GWR419488,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE CATH 10FT CARTO 3 34 PIN HYPERTRONIC ELECTROPHYSIOLOGY",SUP-D128624,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 14.4CM NATRELLE BIOCELL P3.9CM MODERATE PROFILE",SUP-MSZ10450,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 20CM 18G BIOPINCE ULTRA CO AXIAL INTRO NDL",SUP-360-2080-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.84,161.35,"CIGNA [10200]","Cigna Local Plus",,287.74,53.5,,,,,0,62.55,457.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 3.5MM TORPEDO TAPER TIP SMALL HUB SCISSORS CUT",SUP-AR-9350TD,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.01,257.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,99.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPS DIRECT« UPSIZED, X-WIDE 54CM-DS2C029",SUP-DS2C029,CDM,C1893,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,445.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X2CM ACTISHIELD AMNIOTIC BARR MEMB",SUP-AM202X04,CDM,V2790,HCPCS,0278,RC,,,both,,,9577.20,2873.16,"CIGNA [10200]",Cigna,,6512.5,68,,,,,0,1113.83,8140.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 32MM CANNULATED IFUSE IMPL SYSTEM 7MM",SUP-500076,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"UHC [10700]","United Healthcare",,2504.4,63.3,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR STD CRUCIFORM MOBILE BEARING REPLACEMENT LCS",SUP-129409340,CDM,C1776,HCPCS,0278,RC,,,both,,,4131.72,1239.52,"AETNA [10100]","Aetna HMO/PPO",,3284.72,79.5,,10981.53,8986.79,12413.38,12,480.52,3511.96,"percent of total billed charges",
"CATH TAKERU 8MM 3.5MM BALLOON DILATATION PTCA",SUP-DC-RZ3508UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,117.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.5MM CRTX SCREW/LOW PROF HD SELF-TAPPING/STAR DRIVE/14MM",SUP-02.206.214,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"MULTIPLAN [10600]",Multiplan,,275.39,85,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175280010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CIGNA [10200]","Cigna Local Plus",,572.85,,,,,,,124.53,910.13,"percent of total billed charges",
"SCR BONE 4.5MM 48MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.548,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,503.26,45.9,,,,,0,127.51,931.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 52CM .014IN SOFT STIFFNESS KNOB CAP INGEVITY",SUP-5013,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 14/16 BALL TAPER 28MM HIP COCR STERILE",SUP-101813000,CDM,C1776,HCPCS,0278,RC,,,both,,,4783.08,1434.92,"PHCS [10601]",PHCS,,3348.16,70,,,,,0,556.27,4065.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 9 STD 55MM 13.5MM 10.5MM PROVOX LIFE LARYTUBE",SUP-7414,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"NOVANET [10819]",Novanet,,896.18,75,,,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERGLIDE PRO 8CM 18GA IV NITINOL POLYURETHANE MIDLINE",SUP-F118080,CDM,C1751,HCPCS,0272,RC,,,both,,,469.80,140.94,"FIRST HEALTH [10303]","First Health",,375.84,80,,,,,0,54.64,399.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cellular Function W/Stim",PX-302000076,CDM,86352,CPT,0302,RC,,,both,,,1484.85,445.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,175.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1262.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Bone Multiple",PX-341000078,CDM,78305,CPT,0341,RC,,,both,,,2646.92,794.08,"NOVANET [10819]",Novanet,,1985.19,75,,,,,0,307.84,2249.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 60MM 75CM 18MM 10FR 100CM",SUP-40412,CDM,C1876,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"BLUE CROSS [10001]","Blue Cross PPO",,2637.18,39.2,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 64MM 36MM ALTRX HIP",SUP-122136164,CDM,C1776,HCPCS,0278,RC,,,both,,,11405.70,3421.71,"MULTIPLAN [10600]",Multiplan,,9694.85,85,,,,,0,1326.48,9694.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Stnt Intracranial",PX-361000254,CDM,61635,CPT,0361,RC,,,both,,,7619.02,2285.71,"NOVANET [10819]",Novanet,,5714.27,75,,,,,0,886.09,7619.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -4MM OFFSET TAPER 32MM HIP ALUMINA CERAMIC V40",SUP-6565-0-032,CDM,C1776,HCPCS,0278,RC,,,both,,,7383.00,2214.9,"MULTIPLAN [10600]",Multiplan,,6275.55,85,,,,,0,858.64,6275.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC XL 20IN 36- IN KNEE ADJUSTABLE 3 PANEL",SUP-VP40105-055,CDM,L1830,HCPCS,0274,RC,,,both,,,160.08,48.02,"BLUE CROSS [10001]","Blue Cross HMO",,62.75,39.2,,,,,0,18.62,136.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 NANO 1MM X 3CM",SUP-M0035421030,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]","Cigna Local Plus",,4446.11,31.5,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 100MM 4MM BALLOON DILATATION HYDROPHILIC",SUP-604015022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE THK1.5MM 3-0 SH 36IN 2 ARM MONOFILAMENT FIRM",SUP-P8522H,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.29,24.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,56.64,68,,,,,0,9.69,70.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG DOME HOLE TRIDENT II HEX STERILE LATEX FREE DISPOSABLE",SUP-7060-0000,CDM,C1713,HCPCS,0278,RC,,,both,,,810.00,243,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,371.79,45.9,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 285CC",SUP-RSZ-SHPX-285S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET THORACENTESIS 10CM 5FR STRAIGHT 1 STEP VALVE CENTESIS",SUP-TAPS-5F-10LT,CDM,C1729,HCPCS,0272,RC,,,both,,,365.40,109.62,"MULTIPLAN [10600]",Multiplan,,310.59,85,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Venous Rv 36f",PX-E27200392,CDM,E27200392,LOCAL,0272,RC,,,both,,,172.70,51.81,"KAISER [10500]",Kaiser,,115.71,67,,,,,0,20.09,146.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 24MM 33.6MM 25.9MM MITRAL TRICUSPID FLEXIB",SUP-460024MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"NOVANET [10819]",Novanet,,8538.75,75,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 20CM 12FR .035IN MAHURKAR TRIPLE LUMEN HIGH",SUP-8888102003HP,CDM,C1752,HCPCS,0272,RC,,,both,,,995.43,298.63,"MULTIPLAN [10600]",Multiplan,,846.12,85,,,,,0,115.77,846.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 4 X 15 HELICAL FILLING COIL",SUP-10HFL-04015,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"CIGNA [10200]","Cigna Local Plus",,4795.26,53.5,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL CERVICAL THORACIC MA 55MM X 35MM RELINE-C",SUP-3935535,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2.5 X 4 COMPLEX PICO COIL",SUP-10USC02504,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"AETNA [10100]","Aetna HMO/PPO",,10395.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION 10MM 3.4MM 3MM TOE 2 STEP HAMMER",SUP-204-30-010,CDM,C1713,HCPCS,0278,RC,,,both,,,6141.00,1842.3,"CIGNA [10200]","Cigna Open Access",,3494.23,56.9,,1144.80,304.56,2275.09,66,714.2,5219.85,"percent of total billed charges",
"CATH VISTA BRITE TIP TRUELUMEN 100CM 8FR JUDKINS LEFT 5",SUP-588853,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 235MM 16MM MODULAR RESTORATION BOWED CONICAL",SUP-6276-7-316,CDM,C1776,HCPCS,0278,RC,,,both,,,12862.80,3858.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5145.12,40,,,,,0,1495.94,10933.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 65CM 5FR KA2 CURVE ANGIOGRAPHIC PEBAX",SUP-5582-43,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.44,55.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,125.42,68,,,,,0,21.45,156.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +12 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.120,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PRESSURE MNTR INTRAABDOMINAL KIT FOLEY CATH STERILE",SUP-BRDIAP001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1419.40,425.82,"FIRST HEALTH [10303]","First Health",,1135.52,80,,,,,0,165.08,1206.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 336MM STAINLESS STEEL 4.5MM SCR 16 HOLE 4 COLUMN",SUP-02.124.417,CDM,C1713,HCPCS,0278,RC,,,both,,,14200.48,4260.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4064.18,28.62,,,,,0,1651.52,12070.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP 5MM 11IN TITANIUM ENDOSCOPIC PISTOL GRIP",SUP-176630,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"AETNA [10100]","Aetna HMO/PPO",,708.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8.5FR 71CM 50MM STEERABLE ERGONOMIC HANDLE",SUP-G408324,CDM,C1766,HCPCS,0272,RC,,,both,,,5830.50,1749.15,"AETNA [10100]","Aetna HMO/PPO",,4635.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.09,4955.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 15MM 4MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP4015X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"NOVANET [10819]",Novanet,,394.88,75,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL XS KNEE AVON",SUP-6430-0-050,CDM,C1776,HCPCS,0278,RC,,,both,,,22635.90,6790.77,"BLUE CROSS [10001]","Blue Cross PPO",,8873.27,39.2,,3949.44,3949.44,3949.44,"1 through 10",2632.56,19240.52,"percent of total billed charges",
"COIL EMBOLIZATION 45CM 10MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1045CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"BLUE CROSS [10001]","Blue Cross HMO",,2840.04,39.2,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEPIN NON-THREADED 2.5 X 200MM",SUP-MSG25200,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"NOVANET [10819]",Novanet,,228.38,75,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM ATS OPEN PIVOT STD SERIES",SUP-500FA25,CDM,S27800098,LOCAL,0278,RC,,,both,,,25011.00,7503.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2908.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2908.78,21259.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 40CM 6FR EMBOLECTOMY ARTERY THRULUMEN BALLOON",SUP-12TLW406F,CDM,C1757,HCPCS,0272,RC,,,both,,,746.58,223.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,88.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.83,634.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 70CM 15MM 4FR 6 WIRE STONE UROLOGY",SUP-GU6359,CDM,S27200284,LOCAL,0272,RC,,,both,,,479.36,143.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,55.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.75,407.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 20X45X17MM ORACLE 8D SPINE LUMBAR FREEZE",SUP-14517,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FIXATION UHMWPE ACL ATTACHABLE",SUP-AR-1588TN,CDM,C1713,HCPCS,0278,RC,,,both,,,1564.92,469.48,"CIGNA [10200]","Cigna Local Plus",,837.23,53.5,,3978.14,359.25,3978.14,24,182,1330.18,"percent of total billed charges",
"PERIPHERAL VASCULAR DISORDERS WITH CC",300,MS-DRG,,,,,,,inpatient,,,36492.03,10947.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,17304.18,,"Fee schedule rate ($17,304.18). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,6621.77,26622.38,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4+ 12MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS4P12L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"BLUE CROSS [10001]","Blue Cross HMO",,4073.43,39.2,,5311.50,4717.44,5388.59,31,1208.52,8832.69,"percent of total billed charges",
"SCR BONE 2.4MM 14MM T8 FULL THREAD LOCK STARDRIVE NONSTERILE",SUP-656014,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"KAISER [10500]",Kaiser,,894.58,67,,,,,0,155.28,1134.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER TRANSTRACHEAL L5 CM OD6 FR ODSEC15 GA COIL REINFORC",SUP-G10338,CDM,C1769,HCPCS,0272,RC,,,both,,,636.42,190.93,"KAISER [10500]",Kaiser,,426.4,67,,,,,0,74.02,540.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID SMALL 4MM BASE MODULAR COMPREHENSIVE HYBRID",SUP-113952,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.00,2749.2,"KAISER [10500]",Kaiser,,6139.88,67,,,,,0,1065.77,7789.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 20CM 7FR URETERAL",SUP-M0061456170,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,286.99,45.9,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 8MM 12-10MM 18MM DUCT SELF EXPANDABLE",SUP-9-PDA-007,CDM,C1817,HCPCS,0278,RC,,,both,,,34398.00,10319.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9287.46,27,,,,,0,4000.49,29238.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED II 100CM 4CM 11FR 28MM BALLOON DILATATION",SUP-611660,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3616.27,68,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 11/13 TAPER 40MM HIP M SPECIFICATION",SUP-136547500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"FIRST HEALTH [10303]","First Health",,8862.36,80,,,,,0,1288.37,9416.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 119MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT 7 HOLE",SUP-222.07,CDM,C1713,HCPCS,0278,RC,,,both,,,1365.98,409.79,"CIGNA [10200]","Cigna Open Access",,777.24,56.9,,1144.80,304.56,2275.09,66,158.86,1161.08,"percent of total billed charges",
"POLYMYXIN B SULFATE 500,000 UNITS/5ML (WET SOLR VIAL)",RX-4156393,CDM,,,0250,RC,70860-0124-41,NDC,both,1,UN,49.38,14.81,"NOVANET [10819]",Novanet,,37.04,75,,,,,0,5.74,41.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Kidney Img Flow W Drug Mult",PX-341000046,CDM,78709,CPT,0341,RC,,,both,,,3154.08,946.22,"PHCS [10601]",PHCS,,2207.86,70,,,,,0,366.82,2680.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REINFORCEMENT STAPLE LINE UNIVERSAL 6 FIRING 3 GEL TUBE","SUP-PSD 4506-UN",CDM,S27200284,LOCAL,0272,RC,,,both,,,1256.85,377.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.17,1068.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 3-0 18IN BRAID TIES 12 STRAND GREEN",SUP-X184H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 18MM COMPRESSION FT TITANIUM 1.5MM MICRO FULL",SUP-AR-8725-18H,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"BLUE CROSS [10001]","Blue Cross HMO",,1029,39.2,,957.42,156.86,7483.26,51,305.29,2231.25,"percent of total billed charges",
"INTROSTLE 1.9 FR",SUP-384021,CDM,C1894,HCPCS,0272,RC,,,both,,,558.90,167.67,"PHCS [10601]",PHCS,,391.23,70,,,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 8X4IN KALTOSTAT CALCIUM ALGINATE ABSORBENT",SUP-168214,CDM,S27200284,LOCAL,0272,RC,,,both,,,46.34,13.9,"CIGNA [10200]",Cigna,,31.51,68,,,,,0,5.39,39.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL LUMBAR ALIF ANTERIOR CONVEX 12 DEGRE",SUP-12421,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER DELIVERY MULTIPURPOSE SSPC",SUP-9182,CDM,C1887,HCPCS,0272,RC,,,both,,,3375.00,1012.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,399.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 90CM 9FR ENDOTAK RELIANCE ENDOCARDIAL STEROID",SUP-149,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"UHC [10700]","United Healthcare",,9608.94,63.3,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 6MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT060040A,CDM,C1768,HCPCS,0278,RC,,,both,,,8763.00,2628.9,"CIGNA [10200]",Cigna,,5958.84,68,,,,,0,1019.14,7448.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 50CM 23CM ORANGE HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-7F-23-038,CDM,C1894,HCPCS,0272,RC,,,both,,,117.45,35.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,48.27,41.1,,,,,0,13.66,99.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOPSY PUNSCH 5MM",SUP-M50550,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.91,24.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,37.14,45.9,,,,,0,9.41,68.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32MMX8MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2990832,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4292.35,27,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 10X7CM MATRIX",SUP-SMRS0710,CDM,S27800098,LOCAL,0278,RC,,,both,,,6665.40,1999.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,775.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,775.19,5665.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDELINER 145CM 20CM 6FR .07IN .056IN INTERVENTIONAL",SUP-5571,CDM,C1887,HCPCS,0272,RC,,,both,,,2775.00,832.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1140.53,41.1,,,,,0,322.73,2358.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIROFIBAN 12.5 MG/250 ML (50 MCG/ML)-0.9 % SODIUM CHLORIDE INTRAVENOUS",RX-122431,CDM,J3246,HCPCS,0636,RC,25208-0002-02,NDC,both,250,ML,1442.35,432.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,463.13,,,,,,,202.8,1226,"fee schedule",
"DRILL SURGICAL 110MM QUICK CONNECT PERIARTICULAR ZPS 3.5MM",SUP-00480611035,CDM,S27000186,LOCAL,0270,RC,,,both,,,1275.75,382.72,"AETNA [10100]","Aetna HMO/PPO",,1014.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,148.37,1084.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 4.5MM SURGICAL SPINAL BONE",SUP-655.214,CDM,S27000186,LOCAL,0270,RC,,,both,,,534.60,160.38,"CIGNA [10200]","Cigna Local Plus",,286.01,53.5,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 110CM 8CM 5FR 7MM 7.5MM BALLOON DILATATION",SUP-4197080L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 12MM 140CM 3MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927412300,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"PHCS [10601]",PHCS,,2625,70,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 40X18X8MM CLYDESDALE PTC 0D PEEK TITANIUM",SUP-4980840,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPLORER ST 110CM 10CM 5FR 5MM SPACE JOSEPHSON CURVE",SUP-5418R,CDM,C1730,HCPCS,0272,RC,,,both,,,572.00,171.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,235.09,41.1,,,,,0,66.52,486.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thromblys Crbrl",PX-361000139,CDM,37195,CPT,0361,RC,,,both,,,3799.10,1139.73,"BLUE CROSS [10001]","Blue Cross HMO",,3.8,.1,,,,,0,3.8,3799.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000030,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1101.6,68,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 45MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-45,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,50.59,369.75,"percent of total billed charges",
"CATH ACCU-VU 70CM 20CM 5FR OMNI CURVE ANGIOGRAPHIC",SUP-H787137097015,CDM,C1887,HCPCS,0272,RC,,,both,,,1099.98,329.99,"AETNA [10100]","Aetna HMO/PPO",,874.48,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.93,934.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
NEUROSTIMULATOR,SUP-353101,CDM,C1787,HCPCS,0270,RC,,,both,,,2565.00,769.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1177.34,45.9,,,,,0,298.31,2180.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X11X9MM TISSUE ANATOMIC",SUP-6940941,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL STANDARD+ KNEE LEFT CEMENT REVISION LCS",SUP-129429050,CDM,C1776,HCPCS,0278,RC,,,both,,,25958.52,7787.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10668.95,41.1,,6417.48,6417.48,6417.48,"1 through 10",3018.98,22064.74,"percent of total billed charges",
"HC Estradiol Free Direct Measure",PX-301000677,CDM,82681,CPT,0301,RC,,,both,,,53.00,15.9,"BLUE CROSS [10001]","Blue Cross PPO",,35.7,,"Fee schedule rate ($35.70).",,,,0,0.01,53,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"2/0 CARDIOXYL NO PLEDGET 18MM",SUP-73P30T,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,54.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.4,397.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL RUSSIAN 6IN TISSUE",SUP-07-1515,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.21,22.86,"FIRST HEALTH [10303]","First Health",,60.97,80,,,,,0,8.86,64.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANAL AND STOMAL PROCEDURES WITH CC",348,MS-DRG,,,,,,,inpatient,,,56932.90,17079.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11805.38,,"Fee schedule rate ($11,805.38). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,7561,38211.72,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 14X12CM 500CC STYLE 133S SMOOTH SUT TAB NATRELLE",SUP-133S-SX-14-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9991.20,2997.36,"CIGNA [10200]","Cigna Open Access",,5684.99,56.9,,5166.00,5166.00,5166.00,"1 through 10",1161.98,8492.52,"percent of total billed charges",
"DEVICE INFLATION DEFLATION",SUP-OF-0008,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,105.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 145CM 7MM .052- MM 1.25MM .014IN",SUP-DBP-EX-125MIC145,CDM,C1724,HCPCS,0272,RC,,,both,,,23278.50,6983.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9567.46,41.1,,,,,0,2707.29,19786.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SIGNAFUSE BIPHASIC CALCIUM PHOSPHATE BIOACTIVE",SUP-SGF-075,CDM,C1713,HCPCS,0278,RC,,,both,,,7783.20,2334.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,922.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",905.19,6615.72,"percent of total billed charges",
"MOLD FEMORAL HEAD 52MM STAGEONE SELECT HIP SILICONE 2 40G",SUP-431182,CDM,S27200284,LOCAL,0272,RC,,,both,,,7955.01,2386.5,"FIRST HEALTH [10303]","First Health",,6364.01,80,,,,,0,925.17,6761.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE? NC PLUS BALLOON NON-COMPLIANT 2.25 MM X 18 MM",SUP-222-183-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 6.5MM 2 TWINFIX ULTRA SHOULDER LOW PROFILE",SUP-72202605,CDM,C1713,HCPCS,0278,RC,,,both,,,1724.63,517.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,204.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",200.57,1465.94,"percent of total billed charges",
"PLATE 125MMX2MM TITANIUM 7 HOLE LOCK LOW PROFILE VARIAX",SUP-40-20907,CDM,C1713,HCPCS,0278,RC,,,both,,,5059.08,1517.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3440.17,68,,,,,0,588.37,4300.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH VERSACROSS 45D 1 CURVE J TIP 63CM 180CM 8.5FR GUIDING",SUP-VXSK0002,CDM,C1893,HCPCS,0272,RC,,,both,,,6175.50,1852.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4199.34,68,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 10X60 135CM SL",SUP-48010006R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,584.13,68,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 80MM 22MM FINNED CEMENTLESS SMR TITANIUM",SUP-1304.15.220,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,921.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT 2-0 ABSORBABLE",SUP-021030,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR .071IN EXTRA BACKUP 3 LEFT CURVE",SUP-LA6EBU30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 80CM 80MM 4.8FR 9MM BALLOON DILATATION OTW",SUP-39032-90808,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OXYCODONE 15 MG TABLET, IMMEDIATE RELEASE",RX-28899,CDM,,,0250,RC,00406-8515-23,NDC,both,1,UN,19.37,5.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RCC,SELF INFLAT, LONG,SMOOTH, MD, RIGID",SUP-RSR-M014S-L,CDM,S27200284,LOCAL,0272,RC,,,both,,,659.83,197.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 20MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-581502022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPO 100CM 6FR .056IN AMPLATZ LEFT 2 CURVE ANGIOGRAPHIC",SUP-08461-98,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CPS AIM 7.62FR 90D GUIDING NONSTEERABLE",SUP-DS2N027-59,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT JEJUNOSTOMY 45CM 18FR TUNGSTEN SILICONE 3.5CM MIC-KEY",SUP-0270-18-3.5-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Prep Wnd Hd/Ext 100scm",PX-510000048,CDM,15004,CPT,0761,RC,,,both,,,2103.29,630.99,"KAISER [10500]",Kaiser,,1409.2,67,,,,,0,244.61,2103.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT TAPERED COMPONENT",SUP-G47468,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"CIGNA [10200]","Cigna Local Plus",,32327.98,31.5,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 120MM 80CM 6MM VASCULAR PERIPHERAL 3 WAVE",SUP-PRB35-06-120-080,CDM,C1876,HCPCS,0278,RC,,,both,,,6930.00,2079,"CIGNA [10200]","Cigna Open Access",,3943.17,56.9,,,,,0,805.96,5890.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD GLENOID 42MM UNIVERS REVERS +4MM LARGE UNIVERSAL",SUP-AR-9504L-04,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"CIGNA [10200]","Cigna Local Plus",,3840.86,31.5,,5372.07,4581.20,7242.98,23,1418.07,10364.22,"percent of total billed charges",
"SCR BONE 3.5MM 12MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0234,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"FIRST HEALTH [10303]","First Health",,758.16,80,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE 70% PLDLA 30% BETA TRI-CALCIUM PHOSPHATE 25",SUP-110004612,CDM,C1713,HCPCS,0278,RC,,,both,,,2835.00,850.5,"NOVANET [10819]",Novanet,,2126.25,75,,,,,0,329.71,2409.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SPINAL NIM-SPINE NDL PEDICLE",SUP-9450020,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXFIT SEAMLESS BRA FRONT CLOSURE-40 D/E-BLACK","SUP-B01G-40 D/E-B",CDM,S27000186,LOCAL,0270,RC,,,both,,,200.45,60.13,"MULTIPLAN [10600]",Multiplan,,170.38,85,,,,,0,23.31,170.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 7MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS07030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]",Cigna,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SKIN PURPLE 5CM SOFT TISSUE DELIVERY SYSTEM STERILE",SUP-SMARTCLIPLT-PURP-5,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"NOVANET [10819]",Novanet,,2025,75,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE CARDIOFORM ASD OCCLUDER 44MM 12FR",SUP-00733132636518,CDM,C1817,HCPCS,0278,RC,,,both,,,52321.50,15696.45,"PHCS [10601]",PHCS,,36625.05,70,,,,,0,6084.99,44473.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP MEDIUM LEAK 1 ENTRAINMENT ELBOW CAPSTRAP HEADGEAR",SUP-989805628741,CDM,S27000186,LOCAL,0270,RC,,,both,,,224.74,67.42,"PHCS [10601]",PHCS,,157.32,70,,,,,0,26.14,191.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 11CM 26MM 36MM 23.4MM GELWEAVE VALSALVA ON-X",SUP-ONXAAP-27/29,CDM,S27800098,LOCAL,0278,RC,,,both,,,51187.50,15356.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13820.63,27,,,,,0,5953.11,43509.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 150MM 11 HOLE LOW PROFILE BONE LEFT OLECRANON",SUP-70-0308,CDM,C1713,HCPCS,0278,RC,,,both,,,7051.80,2115.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2018.23,28.62,,,,,0,820.12,5994.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP CONSTRUCT 2 W TRITANTIUM",SUP-CAP-STY-H2,CDM,C1776,HCPCS,0278,RC,,,both,,,25830.00,7749,"NOVANET [10819]",Novanet,,19372.5,75,,,,,0,3004.03,21955.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Disruption Fibrin Sheath",PX-361000608,CDM,37799,CPT,0361,RC,,,both,,,1154.65,346.39,"UHC [10700]","United Healthcare",,1154.65,,"Case rate ($2,385). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,134.29,1154.65,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 38MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.038TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",189.34,1383.8,"percent of total billed charges",
"FIBER LASER FLEXIVA ID 200UM FLEXSHIELD HIGH POWER NONTAPER",SUP-M006R8403911,CDM,S27200284,LOCAL,0272,RC,,,both,,,2720.04,816.01,"KAISER [10500]",Kaiser,,1822.43,67,,,,,0,316.34,2312.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTAPRO ATHERECTOMY PRECONNECT EXCHANGEABLE BURR",SUP-H749394671250,CDM,C1724,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11781,68,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-55840016540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DARUNAVIR 800 MG TABLET",RX-160155,CDM,,,0250,RC,59651-0086-30,NDC,both,1,UN,285.13,85.54,"MULTIPLAN [10600]",Multiplan,,242.36,85,,,,,0,33.16,242.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 60MM 3MM BALLOON DILATATION HYDROPHILIC",SUP-603006022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,84.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 23X9X9MM CONCORDE PARALLEL BULLET NOSE",SUP-187823109,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA [10200]","Cigna Local Plus",,5216.4,31.5,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 120MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"PHCS [10601]",PHCS,,1003.59,70,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC SPRINTER FASTRAC 138CM 6MM 2.4/2.6-1.9FR 2.25MM",SUP-NCSP22506X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 80MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"PHCS [10601]",PHCS,,1003.59,70,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) CATHETER WALRUS STRAIGHT BALLOON DILATATION VARIABLE",SUP-BG8087-095,CDM,C1887,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"NOVANET [10819]",Novanet,,8538.75,75,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 130CM 80MM 4MM BALLOON DILATATION",SUP-LX351304805F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,782.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC or OP Cmplx 1st Hr",PX-360000017,CDM,9999169,LOCAL,0360,RC,,,both,,,17381.36,5214.41,"PHCS [10601]",PHCS,,12166.95,70,,,,,0,2021.45,14774.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 5CM 4FR STRAIGHT PANCREATIC POLYMER NO LEAD",SUP-M00537480,CDM,C2625,HCPCS,0278,RC,,,both,,,1411.18,423.35,"MULTIPLAN [10600]",Multiplan,,1199.5,85,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR SPETZLER MICRO CLAW 25KHZ SUPERLONG BONE",SUP-5450800303,CDM,S27200284,LOCAL,0272,RC,,,both,,,5934.35,1780.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4035.36,68,,,,,0,690.16,5044.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Cisternography",PX-341000040,CDM,78630,CPT,0341,RC,,,both,,,1846.31,553.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,214.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,214.73,1569.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 46MM STAINLESS STEEL 2MM SCR 7 HOLE LCP BONE DISTAL",SUP-242.531S,CDM,C1713,HCPCS,0278,RC,,,both,,,4659.98,1397.99,"BLUE CROSS [10001]","Blue Cross HMO",,1826.71,39.2,,957.42,156.86,7483.26,51,541.96,3960.98,"percent of total billed charges",
"NDL 2 BEVEL TIP PACK PROC SPINAL DISPOSABLE METRX",SUP-PK1001,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 8MM 2.75MM BALLOON DILATATION PEBAX",SUP-1012273-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAYMAN MI LATERAL SCREWS SELF STARTING  5.0X44 MM",SUP-4501-15044,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"FIRST HEALTH [10303]","First Health",,1296,80,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +18 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.180,CDM,V2632,HCPCS,0276,RC,,,both,,,3292.50,987.75,"KAISER [10500]",Kaiser,,2205.98,67,,,,,0,382.92,2798.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABLE, 12X30MM, 7-14MM, 15%C2%B0",SUP-1172.4221S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9916.83,28.62,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL CATALYFT SM 6MM ANT EXPANDABLE STERILE",SUP-981023322,CDM,S27800098,LOCAL,0278,RC,,,both,,,49770.00,14931,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5897.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5788.25,42304.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GRAFT HARVEST RIA 2",SUP-03.404.000S,CDM,S27200284,LOCAL,0272,RC,,,both,,,22413.51,6724.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10287.8,45.9,,,,,0,2606.69,19051.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 31MM TITANIUM MINI FRAGMENT SET 4 HOLE .25 TUBULAR",SUP-442.04,CDM,C1713,HCPCS,0278,RC,,,both,,,2546.85,764.05,"PHCS [10601]",PHCS,,1782.8,70,,,,,0,296.2,2164.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 11MM HELIX R SPINE SELF DRILL VARIABLE ANGLE",SUP-7801111,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 5MM CANNULATED GS",SUP-86PS1005,CDM,C1713,HCPCS,0278,RC,,,both,,,2535.00,760.5,"KAISER [10500]",Kaiser,,1698.45,67,,,,,0,294.82,2154.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE ROUND 202MM STAINLESS STEEL 12 HOLE 1 THREADED LOCKING",SUP-437112S,CDM,C1713,HCPCS,0278,RC,,,both,,,8594.64,2578.39,"NOVANET [10819]",Novanet,,6445.98,75,,,,,0,999.56,7305.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC",737,MS-DRG,,,,,,,inpatient,,,108598.58,32579.57,"CIGNA [10200]","Cigna Open Access",,22613.02,,"Fee schedule rate ($22,613.02). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,60161.28,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 42MM DARCO FULL THREAD HEAD",SUP-777404202,CDM,C1713,HCPCS,0278,RC,,,both,,,1695.00,508.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1152.6,68,,,,,0,197.13,1440.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25008W,CDM,C1874,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,414.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERCI 180CM 5MM 2MM CORKSCREW THROMBECTOMY NITINOL",SUP-90110,CDM,C1757,HCPCS,0272,RC,,,both,,,19530.00,5859,"NOVANET [10819]",Novanet,,14647.5,75,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 44MM STARDRIVE STAINLESS STEEL T8 METAPHYSEAL",SUP-02.118.544,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"FIRST HEALTH [10303]","First Health",,419.13,80,,,,,0,60.93,445.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plas Shoe Insert Jnt",PX-E27400080,CDM,L2180,HCPCS,0274,RC,,,both,,,309.10,92.73,"BLUE CROSS [10001]","Blue Cross HMO",,121.17,39.2,,,,,0,35.95,262.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trb Gene Rearrange Amplify",PX-309000074,CDM,81340,CPT,0310,RC,,,both,,,1573.20,471.96,"MULTIPLAN [10600]",Multiplan,,1337.22,85,,,,,0,0.01,1337.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cytp Urne 3-5 Probes Ea Spec",PX-311000037,CDM,88120,CPT,0311,RC,,,both,,,3075.00,922.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,146.47,,,,,,,0.01,2613.75,"fee schedule",
"HC Urography Retro W/WO Kub",PX-320000118,CDM,74420,CPT,0320,RC,,,both,,,1193.00,357.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,811.24,68,,,,,0,84.64,1014.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN JUDKINS",SUP-77800200,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RETRIEVER 55CM 8FR 40MM VASCULAR ENDOSCOPIC LATEX FREE INDY",SUP-G51835,CDM,C1773,HCPCS,0272,RC,,,both,,,3607.50,1082.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC20ST-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,19530.00,5859,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH SABERX 150CM 120MM 3.5MM BALLOON DILATATION RAPID",SUP-47535120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EVERCROSS CROSSTEC 135CM 20MM 8MM .035IN BALLOON",SUP-AB35W08020135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CODA 140CM 46MM OCCLUSION POLYURETHANE BALLOON ACCEPTS",SUP-G23773,CDM,C2628,HCPCS,0272,RC,,,both,,,3588.75,1076.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CESAREAN SECTION WITHOUT STERILIZATION,MAJOR",540,APR-DRG,,,,,,,inpatient,,,54628.02,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $6,940.63. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($35,502.70) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 5MM UNIVERS APEX OPTIFIT",SUP-AR-9100-05M,CDM,C1776,HCPCS,0278,RC,,,both,,,26302.50,7890.75,"KAISER [10500]",Kaiser,,17622.68,67,,,,,0,3058.98,22357.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.8MM 150MM KIRSCHNER TITANIUM TROCAR POINT",SUP-04.110.300,CDM,C1713,HCPCS,0278,RC,,,both,,,72.11,21.63,"FIRST HEALTH [10303]","First Health",,57.69,80,,,,,0,8.39,61.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 7-0 BV-1 18IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8701,CDM,S27200284,LOCAL,0272,RC,,,both,,,644.96,193.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,296.04,45.9,,,,,0,75.01,548.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1 X 4 COMPLEX PICO COIL",SUP-10USC01004,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"BLUE CROSS [10001]","Blue Cross PPO",,5125.6,39.2,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 7MMX19MM 7FR 135CMCATH HEPARIN",SUP-BXB071902A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO PEEL-AWAY SAFE-T-J PERCUTANEOUS STAINLESS STEEL 2",SUP-G04502,CDM,C1892,HCPCS,0272,RC,,,both,,,818.10,245.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,336.24,41.1,,,,,0,95.15,695.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE 104.5 MEQ/L CHLORINE 100 MEQ/L SODIUM 4 MEQ/L",SUP-08-1251-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.36,19.91,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.72,56.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 4FR POWERPICC PLACEMENT LATEX FREE",SUP-1174108D4,CDM,C1751,HCPCS,0272,RC,,,both,,,1764.30,529.29,"PHCS [10601]",PHCS,,1235.01,70,,,,,0,205.19,1499.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SURGIDAC SURGIWIP 0 SK 48IN BRAID COATED GREEN",SUP-EDW-52,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"CIGNA [10200]",Cigna,,98.03,68,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3.8MM 1.6MM 7 MICRO MEDIUM",SUP-00-5091-272-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.03,41.71,"FIRST HEALTH [10303]","First Health",,111.22,80,,,,,0,16.17,118.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 15MM STAINLESS STEEL 3.5MM SCREWS 7 HOLE HOOK LCP BONE",SUP-241.105S,CDM,C1713,HCPCS,0278,RC,,,both,,,7970.54,2391.16,"CIGNA [10200]",Cigna,,5419.97,68,,1831.33,1831.33,1831.33,16,926.97,6774.96,"percent of total billed charges",
"COIL EMBOLIZATION 65CM 24MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES2465CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"NOVANET [10819]",Novanet,,5951.25,75,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 7.75MM TANNE UNIVERSAL TREPHINE UNIQUE HUB","SUP-E3050 7.75",CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"CIGNA [10200]","Cigna Local Plus",,295.76,53.5,,,,,0,64.29,469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BLOOD SYSTEM CARDIOPLEGIA",SUP-027958201,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.76,161.33,"MULTIPLAN [10600]",Multiplan,,457.1,85,,,,,0,62.54,457.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 38MM 144CM 2.5MM CORONARY STENT PEBAX",SUP-H7493926038250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"MULTIPLAN [10600]",Multiplan,,4730.25,85,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 60CC FINE 1-4MM LATEX FREE",SUP-800111,CDM,S27800098,LOCAL,0278,RC,,,both,,,6399.75,1919.92,"NOVANET [10819]",Novanet,,4799.81,75,,,,,0,744.29,5439.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4.5CM 2.5MM GALAXY G3 MINI FREEFORM",SUP-MCR092545,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5290.34,40,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 2MM .064MM 10MM COVERED SHEATH THICKER",SUP-BC-202D-2010,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.76,38.63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.97,109.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REG VACUUM 0-300 MMHG CONTINUOUS INTERMITTENT TUBING NIPPLE",SUP-VR-CIUT-OMD,CDM,S27200284,LOCAL,0272,RC,,,both,,,2452.58,735.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1667.75,68,,,,,0,285.24,2084.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cannula Perfusion General",PX-E27200292,CDM,E27200292,LOCAL,0272,RC,,,both,,,322.30,96.69,"PHCS [10601]",PHCS,,225.61,70,,,,,0,37.48,273.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION",RX-109817,CDM,J0883,HCPCS,0636,RC,00143-9559-01,NDC,both,50,ML,1793.88,538.16,"FIRST HEALTH [10303]","First Health",,1435.1,80,,,,,0,46.62,1524.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Cannula Hemodialysis",PX-361000125,CDM,36800,CPT,0361,RC,,,both,,,4928.23,1478.47,"BLUE CROSS [10001]","Blue Cross PPO",,4928.23,,"Case rate ($5,379.15). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,573.15,4928.23,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 9IN MEYERDING 1 2IN SMALL SET SURGICAL 5/8IN",SUP-23-6301,CDM,S27200284,LOCAL,0272,RC,,,both,,,297.11,89.13,"CIGNA [10200]","Cigna Local Plus",,158.95,53.5,,,,,0,34.55,252.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 65MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75447565,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,441.36,3225.75,"percent of total billed charges",
"SABER .035 6X100 135CM SL",SUP-48006010R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"AETNA [10100]","Aetna HMO/PPO",,682.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 28MM TI",SUP-MTLS-37280-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,523.91,39.2,,957.42,570.23,957.42,28,155.43,1136.03,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL 25CM 6.4FR STARBURST TALON SEMI-FLEX",SUP-700-102845,CDM,S27200284,LOCAL,0272,RC,,,both,,,20216.70,6065.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2395.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2351.2,17184.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 34MMX8MMX20CM 24FR",SUP-TAC083420A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,49248,27,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL TRANSEPTAL 81CM ACQCROSS SL1",SUP-900309,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL WEDGE ALLOGRAFT FREEZE DRY 20MMX10MM",SUP-171020,CDM,S27800098,LOCAL,0278,RC,,,both,,,12572.49,3771.75,"BLUE CROSS [10001]","Blue Cross PPO",,4928.42,39.2,,,,,0,1462.18,10686.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 205CC P2.9CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-205,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM PRECISION .014IN LINEAR TRIAL PRELOAD",SUP-SC-2158-50E,CDM,C1778,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 119MM 10MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771101020,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5642.9,27,,,,,0,2430.63,17764.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 88CM 4FR DISTAL 2 CURVE LEFT HEART TRANSVENOUS",SUP-419388,CDM,C1900,HCPCS,0278,RC,,,both,,,6064.80,1819.44,"FIRST HEALTH [10303]","First Health",,4851.84,80,,,,,0,705.34,5155.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH 1 90CM 8FR .091IN STRAIGHT TIP CURVE GUIDING PTFE",SUP-M001198480,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"NOVANET [10819]",Novanet,,447.85,75,,,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 3 5/8IN CONVERSE 2 STAINLESS STEEL SURGICAL 28X13MM",SUP-410236,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.10,85.53,"CIGNA [10200]",Cigna,,193.87,68,,,,,0,33.16,242.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM PERIPHERAL",SUP-5572-4540,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"MULTIPLAN [10600]",Multiplan,,1322.35,85,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOPROSTHESIS STENT AORTOILIAC L39MM DIA7MM VIABAHN V",SUP-BXB073902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"KAISER [10500]",Kaiser,,13068.22,67,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 24MM 144CM 2.5MM",SUP-H7493941224250,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CIGNA [10200]",Cigna,,5278.5,68,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 30MM 140CM 2.75MM",SUP-RSINT27530UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]",Cigna,,3769.92,68,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 135CM 8MM 20MM",SUP-38047-82013,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL CONTOUR TIMAX 10 HOLE LOW PROFILE ALPS BONE",SUP-131218600,CDM,S27200284,LOCAL,0272,RC,,,both,,,9987.75,2996.32,"KAISER [10500]",Kaiser,,6691.79,67,,,,,0,1161.58,8489.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 16MM 135CM 6MM .018IN BILIARY STAINLESS",SUP-G56626,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,586.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X2CM GRAFIX CORE",SUP-PS12023,CDM,Q4132,HCPCS,0636,RC,,,both,,,6865.50,2059.65,"CIGNA [10200]",Cigna,,286.88,,,,,,,286.88,5835.68,"fee schedule",
"COIL EMBOLIZATION 20CM 6MM CEREPAK XTRASOFT FREEFORM",SUP-XCR120620,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"FIRST HEALTH [10303]","First Health",,10580.68,80,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD MOP FOAM WITH LAMINATED POLYESTER FABRIC FOR QUICKLEAN",SUP-TASK0100,CDM,C1776,HCPCS,0278,RC,,,both,,,47.58,14.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.53,40.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 64MM 36MM MARATHON HIP",SUP-121936064,CDM,C1776,HCPCS,0278,RC,,,both,,,8942.40,2682.72,"CIGNA [10200]","Cigna Open Access",,5088.23,56.9,,5302.19,4377.88,6578.61,27,1040,7601.04,"percent of total billed charges",
"PLATE SMALL CONTOUR TIMAX 10 HOLE LOW PROFILE ALPS BONE",SUP-131218600,CDM,S27200284,LOCAL,0272,RC,,,both,,,9987.75,2996.32,"PHCS [10601]",PHCS,,6991.43,70,,,,,0,1161.58,8489.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR NARROW LORDOTIC 12 DEGRE",SUP-12321,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS [10001]","Blue Cross HMO",,7408.8,39.2,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHIELD ADHESIVE, 15 MM DIAMETER",SUP-50215H50B0D,CDM,A2019,HCPCS,0636,RC,,,both,,,6216.90,1865.07,"CIGNA [10200]","Cigna Open Access",,3537.42,56.9,,,,,0,247.92,5284.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 52MM RESURFACING BHR",SUP-74123152,CDM,C1776,HCPCS,0278,RC,,,both,,,27319.95,8195.98,"CIGNA [10200]","Cigna Open Access",,9152.18,33.5,,5302.19,4377.88,6578.61,27,3177.31,23221.96,"percent of total billed charges",
"BIT DRILL 9/64MM 19/64IN STAINLESS STEEL STYRKER",SUP-0277-082-086S1,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.80,262.44,"CIGNA [10200]","Cigna Local Plus",,468.02,53.5,,,,,0,101.74,743.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE MG II NEXGEN TIVANIUM KNEE SELF TAPPING FLEX TAPER",SUP-00596009900,CDM,C1713,HCPCS,0278,RC,,,both,,,3234.00,970.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1484.41,45.9,,,,,0,376.11,2748.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION FIBER STITCH REVERSE CURVE 2",SUP-AR-4580R,CDM,C1713,HCPCS,0278,RC,,,both,,,3984.75,1195.42,"AETNA [10100]","Aetna HMO/PPO",,3167.88,79.5,,1521.93,481.35,16760.95,30,463.43,3387.04,"percent of total billed charges",
"CATH DIAMONDBACK 360 145CM 20MM .079IN 2MM ATHERECTOMY",SUP-DBP-CART-200CLA145,CDM,C1724,HCPCS,0272,RC,,,both,,,17250.00,5175,"NOVANET [10819]",Novanet,,12937.5,75,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFUSION 45D .014IN 1.9FR .0165IN 150CM 5CM",SUP-606S155FX,CDM,C1887,HCPCS,0272,RC,,,both,,,7390.38,2217.11,"AETNA [10100]","Aetna HMO/PPO",,5875.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,859.5,6281.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grad Compression Knee 20-30",PX-E27100023,CDM,A6530,HCPCS,0292,RC,,,both,,,122.10,36.63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.2,103.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9CM 3.5MM GALAXY G3 XTRASOFT NEUROVASCULAR",SUP-GLX123509,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Perf Art Fem Flex 22fr",PX-E27200360,CDM,E27200360,LOCAL,0272,RC,,,both,,,321.20,96.36,"CIGNA [10200]","Cigna Open Access",,182.76,56.9,,,,,0,37.36,273.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 4MM COOLCUT 8 FLUTE ROUND STERILE",SUP-AR-8400RBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"KAISER [10500]",Kaiser,,336.21,67,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 65CM 4FR PIGTAIL CURVE ANGIOGRAPHIC PEBAX",SUP-7742-2M65SH,CDM,S27200284,LOCAL,0272,RC,,,both,,,235.94,70.78,"CIGNA [10200]","Cigna Local Plus",,126.23,53.5,,,,,0,27.44,200.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit Level 1 W Proc",PX-450000312,CDM,99281,CPT,0450,RC,,,both,,,770.92,231.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,770.92,,,,,,,55.94,770.92,"case rate",
"SPACER SPINAL 55X18X18MM COROENT XLIF 10D",SUP-7871855,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14087.27,41.1,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH",RX-27474,CDM,,,0250,RC,00378-9112-16,NDC,both,1,UN,13.67,4.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.59,11.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN SUCTION 4MM 5.6MM 30CM PORT FLARED MERCEDES TIP",SUP-PAL-408LL,CDM,S27200284,LOCAL,0272,RC,,,both,,,680.40,204.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,279.64,41.1,,,,,0,79.13,578.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 85CM 18FR 5.9MM LARGE PERFORMER RADIOPAQUE BAND",SUP-G27025,CDM,C1894,HCPCS,0272,RC,,,both,,,963.82,289.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,114.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.09,819.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM HILAL EMBOLIZATION MICROCOIL STRAIGHT",SUP-G04523,CDM,S27800098,LOCAL,0278,RC,,,both,,,362.57,108.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,246.55,68,,,,,0,42.17,308.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 100MM 14MM NEXGEN OFFSET KNEE FEMUR 145MM STERILE",SUP-598802014,CDM,C1776,HCPCS,0278,RC,,,both,,,10435.56,3130.67,"NOVANET [10819]",Novanet,,7826.67,75,,,,,0,1213.66,8870.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 4MM CAUT SPAT TIP HIGHLY INSULATED BENDABLE SHAFT",SUP-PS200-040,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"CIGNA [10200]","Cigna Open Access",,1173.56,56.9,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 2.5CM 10CM WITHOUT MINI GWIRE DIL PINNACLE",SUP-RSS604,CDM,C1894,HCPCS,0272,RC,,,both,,,73.95,22.18,"MULTIPLAN [10600]",Multiplan,,62.86,85,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.180 CLAREON",SUP-SY60WF.180,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIBUCAINE 1 % TOPICAL OINTMENT",RX-2412,CDM,,,0637,RC,00536-1211-95,NDC,both,28,GR,36.99,11.1,"MULTIPLAN [10600]",Multiplan,,31.44,85,,,,,0,4.3,31.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 18FR DELIVERY SYSTEM",SUP-ENVPRO-14-US,CDM,S27200284,LOCAL,0272,RC,,,both,,,14559.00,4367.7,"NOVANET [10819]",Novanet,,10919.25,75,,,,,0,1693.21,12375.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP 5 SCR HOLE CLUSTER METAL HA",SUP-502-11-54E,CDM,C1776,HCPCS,0278,RC,,,both,,,9525.45,2857.63,"AETNA [10100]","Aetna HMO/PPO",,7572.73,79.5,,10981.53,8986.79,12413.38,12,1107.81,8096.63,"percent of total billed charges",
"HC Psg >4 Param Incomplt",PX-740000005,CDM,95810,CPT,0920,RC,,,both,,,3284.00,985.2,"MULTIPLAN [10600]",Multiplan,,2791.4,85,,,,,0,381.93,2791.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALIF SPACER, ANTERIOR: 9MM (H) X 22-24MM (L) X 27-32MM (W):",SUP-10609,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"BLUE CROSS [10001]","Blue Cross PPO",,12348,39.2,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD 48MM 3.5MM CORONARY STENT EVEROLIMUS",SUP-H7493941848350,CDM,C1874,HCPCS,0278,RC,,,both,,,5002.50,1500.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,592.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POD XL 6MMX20CM",SUP-RBYPODXL0620,CDM,S27800098,LOCAL,0278,RC,,,both,,,13731.00,4119.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5643.44,41.1,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GS SPECTRUM QC, MAC S1, BOX-10",SUP-0270-1140,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.26,129.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,294.62,68,,,,,0,50.39,368.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP HUMERAL 4MM 36MM REUNION SHOULDER STERILE LATEX FREE",SUP-5570-3604,CDM,C1776,HCPCS,0278,RC,,,both,,,7980.00,2394,"MULTIPLAN [10600]",Multiplan,,6783,85,,,,,0,928.07,6783,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 250MM 4MM BALLOON DILATATION DURALYN",SUP-48004025X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC De Revasc Cto Cor Art/Br/Grf",PX-481000090,CDM,C9607,HCPCS,0481,RC,,,both,,,27922.64,8376.79,"CIGNA [10200]","Cigna Open Access",,21495,,"Case rate ($21,495). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3247.4,25681,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X17MM LUMINARY CC BICONVEX SPINE",SUP-6817,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13671.5,41.1,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR CHEST TRAUMA WITH MCC",183,MS-DRG,,,,,,,inpatient,,,53642.01,16092.6,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,10059.47,,"Case rate ($9,490.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,812.17, add-ons for qualifying new technology services are included. If operating cost exceeds $41,851.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,048.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $8,823.82. The transfer operating threshold is the transfer adjustment factor * $8,812.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $666.24. The transfer capital threshold is the transfer adjustment factor * $666.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,38154.18,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BROWN 48MM 28MM SELF-CENTERING HIP FEMUR",SUP-103548000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,363.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,356.38,2604.67,"percent of total billed charges",
"GWIRE HI-TORQUE COMMAND VASCULAR STRAIGHT 210CM 10CM .018IN",SUP-1013730,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,112.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 67.1X44.2X4.8MM MBT 2.5MM KNEE CEMENTED REVISION",SUP-129435125,CDM,C1776,HCPCS,0278,RC,,,both,,,22385.16,6715.55,"PHCS [10601]",PHCS,,15669.61,70,,,,,0,2603.39,19027.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.5/18",SUP-401751,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"KAISER [10500]",Kaiser,,3004.95,67,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 3MM OXFORD ARCOM KNEE RIGHT MENISCUS PHASE 3","SUP-BRNG 3MM O",CDM,C1776,HCPCS,0278,RC,,,both,,,5270.22,1581.07,"MULTIPLAN [10600]",Multiplan,,4479.69,85,,,,,0,612.93,4479.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALARM WC POSEY SELF RELEASE BELT DISPOSABLE",SUP-8399,CDM,S27100035,LOCAL,0271,RC,,,both,,,229.16,68.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,105.18,45.9,,,,,0,26.65,194.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC VIVA S CRT-D PHYSIOCURVE CARDIOSYNC SMARTSHOCK",SUP-DTBB1D4,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6839.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS 28 AND ICODEXTRIN 7.5 % CA 3.5 MEQ/L-MAG 0.5 MEQ/L",RX-120693,CDM,,,0250,RC,00941-0679-53,NDC,both,2500,ML,892.83,267.85,"FIRST HEALTH [10303]","First Health",,714.26,80,,,,,0,103.84,758.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE EXPRT GPS 40MM 135CM 7-10MM 6FR TAPER VASCULAR",SUP-SECX-10-7-40-135,CDM,C1876,HCPCS,0278,RC,,,both,,,12420.00,3726,"BLUE CROSS [10001]","Blue Cross HMO",,4868.64,39.2,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENROUTE TRANSCAROTID STENT SYSTEM 9 X 30",SUP-SR-0930-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.50 X 23 RX US",SUP-1804250-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK THERAPEUTIC OVERSIZE HOT",SUP-3504,CDM,S27000186,LOCAL,0270,RC,,,both,,,158.69,47.61,"CIGNA [10200]","Cigna Open Access",,90.29,56.9,,,,,0,18.46,134.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 11MM KII Z THREAD SLEEVE SHIELD",SUP-CTB33,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTOLOZANE-TAZOBACTAM 1.5 G/11.4ML IV (WET SOLR VIAL)",RX-415169198,CDM,J0695,HCPCS,0636,RC,67919-0030-01,NDC,both,1,UN,1052.44,315.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,210.27,,"Fee schedule rate ($210.27). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.71,894.57,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 90MM TITANIUM T25 SELF TAP TIP SELF RETENTION",SUP-04.003.028S,CDM,C1713,HCPCS,0278,RC,,,both,,,1442.45,432.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,170.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",167.76,1226.08,"percent of total billed charges",
"GRAFT SOFT TISSUE 3X2CM AMNIOFIX POSTERIOR",SUP-APS-5230,CDM,Q4433,HCPCS,0636,RC,,,both,,,5485.50,1645.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,247.92,,,,,,,247.92,4662.68,"fee schedule",
"CAP KIT REPLACEMENT STD SHOULDER HUMERAL GLENOID TRABECULAR",SUP-98000972000,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3480.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X15-12.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-4815,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4005.45,27,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 12CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175196180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA [10200]",Cigna,,992.87,68,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.24,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275,68,,,,,0,188.41,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON PANOPTIX TORIC",SUP-CNWTT6,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,102.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM PRESS FIT BASIC SUMMIT 6 12/14 TAPER HIP",SUP-157005120,CDM,C1776,HCPCS,0278,RC,,,both,,,9090.75,2727.22,"FIRST HEALTH [10303]","First Health",,7272.6,80,,,,,0,1057.25,7727.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL 11MM LORDOTIC",SUP-345641,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 12MM 3MM BALLOON DILATATION PACLITAXEL RADIOPAQUE",SUP-H7493960812300,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4609.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IPG W3SR01 AZURE S SR MRI",SUP-W3SR01,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"MULTIPLAN [10600]",Multiplan,,21114,85,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE BARD NICORE ENDOSCOPIC 150CM .035IN NITINOL",SUP-150NFA35,CDM,C1769,HCPCS,0272,RC,,,both,,,301.63,90.49,"UHC [10700]","United Healthcare",,190.93,63.3,,,,,0,35.08,256.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 80MM 4MM BALLOON",SUP-U3513048,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 21MM MITROFLOW BOVINE PERICARDIUM",SUP-LXA21,CDM,S27800098,LOCAL,0278,RC,,,both,,,29200.50,8760.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3396.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3396.02,24820.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INJECTOR BONE CEMENT NORIAN CALCIUM PHOSPHATE FIBER",SUP-07.704.010S,CDM,C1713,HCPCS,0278,RC,,,both,,,15870.00,4761,"BLUE CROSS [10001]","Blue Cross HMO",,6221.04,39.2,,957.42,156.86,7483.26,51,1845.68,13489.5,"percent of total billed charges",
"INTRO SHEATH 9FR 2.5CM 25CM WITHOUT MINI GWIRE DIL PINNACLE",SUP-RSS906,CDM,C1894,HCPCS,0272,RC,,,both,,,156.60,46.98,"NOVANET [10819]",Novanet,,117.45,75,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 70MM KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-183112,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"BLUE CROSS [10001]","Blue Cross PPO",,8492.95,39.2,,3949.44,3949.44,3949.44,"1 through 10",2519.72,18415.85,"percent of total billed charges",
"NEUROFORM 3 EZ 4.0 X 20MM",SUP-M003N3EZ40200,CDM,C1874,HCPCS,0278,RC,,,both,,,47878.17,14363.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,19151.27,40,,,,,0,5568.23,40696.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN EXTRA BACKUP LEFT 3.75 CURVE",SUP-LA7EBU375,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 16IN 28FR VEIN ANGLE RIGHT LIGHTHOUSE 1 STAGE",SUP-RV-41028,CDM,S27200284,LOCAL,0272,RC,,,both,,,444.69,133.41,"NOVANET [10819]",Novanet,,333.52,75,,,,,0,51.72,377.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 6-7 C-D KNEE",SUP-42512100412,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1253.3,9159.96,"percent of total billed charges",
"HC Apc Resistance",PX-305000036,CDM,85307,CPT,0305,RC,,,both,,,514.80,154.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.38,,,,,,,0.01,437.58,"fee schedule",
"HC Erector Spinae Plane (Esp) Block",PX-361000647,CDM,64999,CPT,0361,RC,,,both,,,2899.73,869.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1249,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,337.24,2899.73,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH C2 CRYOBALLOON 30MM STD ABLATION FOCAL STERILE LATEX",SUP-FG-1028,CDM,S27200284,LOCAL,0272,RC,,,both,,,14490.00,4347,"UHC [10700]","United Healthcare",,9172.17,63.3,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TALUS VANTAGE 3 STERILE LATEX FREE",SUP-350-10-03,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"FIRST HEALTH [10303]","First Health",,777.6,80,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP7PL,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"PHCS [10601]",PHCS,,15051.33,70,,,,,0,2500.67,18276.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX OI BLOCK- 12MM",SUP-441012,CDM,S27800098,LOCAL,0278,RC,,,both,,,8383.50,2515.05,"BLUE CROSS [10001]","Blue Cross PPO",,3286.33,39.2,,,,,0,975,7125.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROGRIP 16X12CM INGUINAL LEFT SELF FIXATION",SUP-LPG1612AL,CDM,C1781,HCPCS,0278,RC,,,both,,,3591.45,1077.43,"CIGNA [10200]","Cigna Local Plus",,1921.43,53.5,,3096.73,1.00,3096.73,"1 through 10",417.69,3052.73,"percent of total billed charges",
"BEARING 79/83MMX16MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183566,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"CIGNA [10200]","Cigna Local Plus",,4080.09,31.5,,5372.07,4581.20,7242.98,23,1506.4,11009.78,"percent of total billed charges",
"CUP HUMERAL 36MM UNIVERS REVERS +2 SHOULDER LEFT SUT",SUP-AR-9502F-36LCPC,CDM,C1776,HCPCS,0278,RC,,,both,,,7980.00,2394,"FIRST HEALTH [10303]","First Health",,6384,80,,,,,0,928.07,6783,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cytopath Smear Other Source",PX-311000077,CDM,88160,CPT,0311,RC,,,both,,,183.35,55,"MULTIPLAN [10600]",Multiplan,,155.85,85,,,,,0,0.18,155.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 21MM ATLANTIS VISION ELITE BONE SPINAL",SUP-7200021,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"KAISER [10500]",Kaiser,,2814,67,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE LUNDERQUIST UROLOGICAL STD 150CM 3CM .032IN LUBRIGLIDE",SUP-M0066001060,CDM,C1769,HCPCS,0272,RC,,,both,,,254.39,76.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,104.55,41.1,,,,,0,29.59,216.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 60MM 130CM 7MM LONG VASCULAR NITINOL ILIAC",SUP-SC760LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"MULTIPLAN [10600]",Multiplan,,6158.25,85,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 22MM LCP STAINLESS STEEL SMALL BONE SELF",SUP-202.222,CDM,C1713,HCPCS,0278,RC,,,both,,,748.44,224.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,88.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",87.04,636.17,"percent of total billed charges",
"SLING ORTHOPEDIC LARGE 13+ IN ARM DEROTATION STRAP HOOK",SUP-11-0449-4-06000,CDM,S27000186,LOCAL,0270,RC,,,both,,,401.07,120.32,"FIRST HEALTH [10303]","First Health",,320.86,80,,,,,0,46.64,340.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 2 STD KNEE RIGHT KEEL NONPOROUS",SUP-ETPKN2SR,CDM,C1776,HCPCS,0278,RC,,,both,,,15193.80,4558.14,"CIGNA [10200]",Cigna,,6077.52,40,,5873.17,5873.17,5873.17,"1 through 10",1767.04,12914.73,"percent of total billed charges",
"CLIP 11MM OPEN 235CM INTERNAL RESOLUTION RADIOPAQUE USER",SUP-M00522610,CDM,S27200284,LOCAL,0272,RC,,,both,,,1347.76,404.33,"AETNA [10100]","Aetna HMO/PPO",,1071.47,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,156.74,1145.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 360MM FEMUR RIGHT GAMMA3 INTRAMEDULLARY 125D R1.5",SUP-3425-0360S,CDM,C1713,HCPCS,0278,RC,,,both,,,13435.13,4030.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1592.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1562.51,11419.86,"percent of total billed charges",
"PROTCT LARGE 9-14CM INCISION ALEXIS FLEXIBLE RETRACTION RING",SUP-C8303,CDM,S27200284,LOCAL,0272,RC,,,both,,,445.50,133.65,"CIGNA [10200]",Cigna,,302.94,68,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X2CM GRAFIX CORE",SUP-PS12023,CDM,Q4132,HCPCS,0636,RC,,,both,,,6865.50,2059.65,"PHCS [10601]",PHCS,,4805.85,70,,,,,0,286.88,5835.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 18CM PUMP INFRAPUBIC",SUP-ES8818,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7292.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CRE RX 5.5CM 12-13.5-15MM BALLOON DILATATION BILIARY",SUP-M00558890,CDM,C1726,HCPCS,0272,RC,,,both,,,2085.75,625.72,"NOVANET [10819]",Novanet,,1564.31,75,,,,,0,242.57,1772.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE TITANIUM 30MM 9MM FULL THREAD ROUND ACL PCL",SUP-AR-1392T,CDM,C1713,HCPCS,0278,RC,,,both,,,807.98,242.39,"CIGNA [10200]","Cigna Local Plus",,432.27,53.5,,3978.14,359.25,3978.14,24,93.97,686.78,"percent of total billed charges",
"NAIL 11MM 34CM HIP LEFT FEMUR AFFIXUS INTRAMEDULLARY 130D",SUP-814611340,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"BLUE CROSS [10001]","Blue Cross HMO",,8131.16,39.2,,957.42,156.86,7483.26,51,2412.38,17631.34,"percent of total billed charges",
"KIT MICROINTRODUCER 7CM 5FR 21GA MINI STICK MAX TUNGSTEN",SUP-H965457591,CDM,C1894,HCPCS,0272,RC,,,both,,,220.98,66.29,"AETNA [10100]","Aetna HMO/PPO",,175.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.7,187.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Diphtheria Ab",PX-302000113,CDM,86648,CPT,0302,RC,,,both,,,228.95,68.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,194.61,"per diem",
"SCR BONE 3.5MM 75MM AXSOS 3 TITANIUM CORTEX SELF TAP LOCK",SUP-661475,CDM,C1713,HCPCS,0278,RC,,,both,,,289.54,86.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,34.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",33.67,246.11,"percent of total billed charges",
"BUTTON 3.5CM 20FR RADIOPAQUE LOW PROFILE TAPER DISTAL TIP",SUP-0120-20-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"AETNA [10100]","Aetna HMO/PPO",,619.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.25 X 38 RX US",SUP-1804325-38,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 445CC NATRELLE INSPIRA COHESIVE STERILE LATEX",SUP-SCM-445,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"NOVANET [10819]",Novanet,,5666.63,75,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVOLUTION FLEXOR 9CM 22MM 27MM DUODENAL METAL CONTROL",SUP-G48026,CDM,C1876,HCPCS,0278,RC,,,both,,,17854.20,5356.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2115.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2076.44,15176.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUWAVE LAP SURGICAL PROBE, 35CM, 11GATO 13GA, TABPERED (2.9",SUP-PRS35,CDM,C1886,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLENOSPHERE - 36MM DIA X 6MM THK CONCENTRIC",SUP-5573-C-3606,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"BLUE CROSS [10001]","Blue Cross PPO",,4779.73,39.2,,3949.44,3949.44,3949.44,"1 through 10",1418.07,10364.22,"percent of total billed charges",
"SUT ACS 10-0 CU-5 12IN 2 ARM MONOFILAMENT BLACK",SUP-8065192101,CDM,S27200284,LOCAL,0272,RC,,,both,,,265.96,79.79,"CIGNA [10200]","Cigna Local Plus",,142.29,53.5,,,,,0,30.93,226.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Lacosamide",PX-301000624,CDM,80235,CPT,0301,RC,,,both,,,195.00,58.5,"CIGNA [10200]","Cigna Local Plus",,59.64,,,,,,,0.01,165.75,"fee schedule",
"GWIRE MERIT MAK VASCULAR 60CM .018IN PLATINUM STAINLESS",SUP-MAK005-60,CDM,C1894,HCPCS,0272,RC,,,both,,,255.78,76.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.75,217.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 30MM 30MM CONDYLAR STABILIZED NECK OMNIFIT EON",SUP-6098-0530,CDM,C1776,HCPCS,0278,RC,,,both,,,10292.40,3087.72,"KAISER [10500]",Kaiser,,6895.91,67,,,,,0,1197.01,8748.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Paraffin Bath (Gp)",PX-420000015,CDM,97018,CPT,0420,RC,,,both,,,131.00,39.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.24,131,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Herpes Simplex Nonspecific Ab",PX-302000138,CDM,86694,CPT,0302,RC,,,both,,,127.30,38.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,51.1,,,,,,,0.01,108.21,"fee schedule",
"CATH TRAILBLAZER PUSHPLUS 135CM 50MM SPACE SPRT CROSSCOAT",SUP-SC-035-135,CDM,C1887,HCPCS,0272,RC,,,both,,,1053.00,315.9,"UHC [10700]","United Healthcare",,666.55,63.3,,,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RHINOLARYNGOSCOPE FLEXIBLE 300MM 3MM 3.5MM AMBU ASCOPE 4",SUP-510101000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM TITANIUM 2.4MM SCR 6X2 HOLE 2 COLUMN VARIABLE",SUP-04.111.621,CDM,C1713,HCPCS,0278,RC,,,both,,,4102.05,1230.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1882.84,45.9,,,,,0,477.07,3486.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 8MM BALLOON",SUP-U357586,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Adapter Temp Pacemaker",PX-E27200031,CDM,E27200031,LOCAL,0272,RC,,,both,,,124.30,37.29,"CIGNA [10200]",Cigna,,84.52,68,,,,,0,14.46,105.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ndl Emg Ea Extremity Comp",PX-922000012,CDM,95886,CPT,0922,RC,,,both,,,406.32,121.9,"NOVANET [10819]",Novanet,,304.74,75,,,,,0,47.26,345.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ecmo Init Veno-Venous",PX-361000361,CDM,33946,CPT,0361,RC,,,both,,,5586.00,1675.8,"PHCS [10601]",PHCS,,3910.2,70,,,,,0,649.65,5586,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ecmo Init Veno-Venous",PX-361000361,CDM,33946,CPT,0361,RC,,,both,,,5586.00,1675.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,661.94,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,649.65,5586,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd Flex Trnsoral Ablate",PX-750000135,CDM,43270,CPT,0750,RC,,,both,,,3449.38,1034.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3449.38,,"Case rate ($5,469). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,401.16,3449.38,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABERGOLINE 0.5 MG TABLET",RX-19226,CDM,Q2001,HCPCS,0637,RC,70069-0824-08,NDC,both,1,UN,138.57,41.57,"PHCS [10601]",PHCS,,97,70,,,,,0,16.12,117.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Splint Fiberglass",PX-E27000164,CDM,E27000164,LOCAL,0270,RC,,,both,,,143.00,42.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.63,121.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Splint Fiberglass",PX-E27000164,CDM,E27000164,LOCAL,0270,RC,,,both,,,143.00,42.9,"CIGNA [10200]","Cigna Open Access",,81.37,56.9,,,,,0,16.63,121.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Coccidioides Ab",PX-302000108,CDM,86635,CPT,0302,RC,,,both,,,518.70,155.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.77,,,,,,,0.01,440.9,"fee schedule",
"HC Prevnt Group Counsel 60 Min",PX-510000186,CDM,99412,CPT,0761,RC,,,both,,,104.00,31.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.32,104,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CITATION TMZF HA 2 SHORT HIP RIGHT",SUP-6265-5212,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"UHC [10700]","United Healthcare",,15459.09,63.3,,8601.07,8395.67,8601.07,"1 through 10",2840.27,20758.66,"percent of total billed charges",
"HEAD FEMORAL +6MM 11/13 32MM HIP ALUMINA S-ROM",SUP-528330,CDM,C1776,HCPCS,0278,RC,,,both,,,8956.20,2686.86,"CIGNA [10200]","Cigna Local Plus",,4791.57,53.5,,5372.07,4581.20,7242.98,23,1041.61,7612.77,"percent of total billed charges",
"BOWL BONE CEMENT SMARTMIX CTS MIX SYSTEM LATEX FREE",SUP-540176501,CDM,S27200284,LOCAL,0272,RC,,,both,,,1762.50,528.75,"AETNA [10100]","Aetna HMO/PPO",,1401.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET",RX-76950,CDM,,,0637,RC,48433-0104-01,NDC,both,1,UN,6.27,1.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2.58,41.1,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 13MM SPINE CERVICAL ANTERIOR NONSTERILE LATEX",SUP-7786713,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 22MM KNEE X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G722,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA [10200]","Cigna Open Access",,5690,56.9,,5302.19,4377.88,6578.61,27,1163,8500,"percent of total billed charges",
"DRILL SURGICAL 5.3MM TAPER STOP EXT KIT STPLR A1 STERILE",SUP-5.30K,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1525.84,41.1,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 4 KNEE LEFT CRUCIATE RETAIN CEMENTLESS ATT",SUP-150401104,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3409.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3346.56,24458.96,"percent of total billed charges",
"KIT BIOPSY BONE MARROW ASPIRATION ILIAC CREST",SUP-691.100S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2752.50,825.75,"NOVANET [10819]",Novanet,,2064.38,75,,,,,0,320.12,2339.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI STRAIGHT 1MM MANDIBLE 16 HOLE 2/2.3MM SCR BONE",SUP-55-10516,CDM,C1713,HCPCS,0278,RC,,,both,,,1289.68,386.9,"CIGNA [10200]","Cigna Local Plus",,689.98,53.5,,3978.14,359.25,3978.14,24,149.99,1096.23,"percent of total billed charges",
"VALVE AORTIC 21MM MITROFLOW BOVINE PERICARDIUM",SUP-LXA21,CDM,S27800098,LOCAL,0278,RC,,,both,,,29200.50,8760.15,"AETNA [10100]","Aetna HMO/PPO",,23214.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3396.02,24820.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 8CM 5FR ZIMMON PIGTAIL CURVE PANCREATIC",SUP-G21926,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"KAISER [10500]",Kaiser,,824.9,67,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL PEDIATRIC MASK O2 RESVR TUBE LATEX FREE",SUP-531613000,CDM,S27000186,LOCAL,0270,RC,,,both,,,60.44,18.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.03,51.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE PULMONARY 27MM CRYOVALVE SG HEART WITHOUT CONDUIT",SUP-SGPV10-27-99,CDM,S27800098,LOCAL,0278,RC,,,both,,,145293.00,43587.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,59715.42,41.1,,,,,0,16897.58,123499.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STBL SURGICAL OCTOPUS NUVO",SUP-TSMICS1,CDM,S27200284,LOCAL,0272,RC,,,both,,,11890.08,3567.02,"CIGNA [10200]",Cigna,,8085.25,68,,,,,0,1382.82,10106.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP 15CC ALLOGRAFT PUTTY",SUP-14100601,CDM,C1713,HCPCS,0278,RC,,,both,,,16831.31,5049.39,"CIGNA [10200]","Cigna Local Plus",,5301.86,31.5,,3978.14,359.25,3978.14,24,1957.48,14306.61,"percent of total billed charges",
"CABLE ORTHOPEDIC VITALLIUM 2MM 22MM HIP GRIP DALL-MILES 2",SUP-67040310,CDM,C1713,HCPCS,0278,RC,,,both,,,3832.92,1149.88,"NOVANET [10819]",Novanet,,2874.69,75,,,,,0,445.77,3257.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL GRAY 40MM 5.5MM CONTOUR",SUP-101-65540,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]",Cigna,,2998.8,68,,1831.33,1831.33,1831.33,16,512.88,3748.5,"percent of total billed charges",
"REAMER SURGICAL 20MM CANNULATED PROXIMAL 1.6MM KWIRE",SUP-03.211.120,CDM,S27200284,LOCAL,0272,RC,,,both,,,2436.00,730.8,"NOVANET [10819]",Novanet,,1827,75,,,,,0,283.31,2070.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 57MM TRIGEN FEMUR LOW PROFILE",SUP-71645057,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,949.92,45.9,,,,,0,240.69,1759.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH UROMAX ULTRA QUADRA-FOLD ENCORE HIGH PRESSURE KINK",SUP-M0062251280,CDM,C1726,HCPCS,0272,RC,,,both,,,1892.70,567.81,"PHCS [10601]",PHCS,,1324.89,70,,,,,0,220.12,1608.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE 15IN 5FR 18GA 21GA UMBILICAL POLYURETHANE",SUP-8888160556,CDM,S27200284,LOCAL,0272,RC,,,both,,,305.39,91.62,"CIGNA [10200]",Cigna,,207.67,68,,,,,0,35.52,259.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X2CM NUSHIELD MEMB",SUP-NO-1240,CDM,Q4160,HCPCS,0636,RC,,,both,,,6555.00,1966.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4260.75,65,,,,,0,776.77,6555,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE LEGACY DBM 10CC ALLOGRAFT NONSTERILE LATEX FREE",SUP-420810,CDM,C1713,HCPCS,0278,RC,,,both,,,6210.00,1863,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,722.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",722.22,5278.5,"percent of total billed charges",
"STEM FEMORAL 150MM 13MM CEMENTLESS TOTAL STABILIZED",SUP-5566-S-013,CDM,C1776,HCPCS,0278,RC,,,both,,,5447.65,1634.29,"NOVANET [10819]",Novanet,,4085.74,75,,,,,0,633.56,4630.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"1000 SINGLE USE FLAT TIP HOLMIUM FIBER",SUP-HOL1000SBX,CDM,S27200284,LOCAL,0272,RC,,,both,,,4183.70,1255.11,"CIGNA [10200]","Cigna Open Access",,2380.53,56.9,,,,,0,486.56,3556.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 15MM 6FR 6MM .07",SUP-H7493926715600,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"NOVANET [10819]",Novanet,,425.25,75,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM SOLID BACK PRIMARY TRITANIUM D HEMISPH",SUP-500-03-52D,CDM,C1776,HCPCS,0278,RC,,,both,,,9167.76,2750.33,"MULTIPLAN [10600]",Multiplan,,7792.6,85,,,,,0,1066.21,7792.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARD ID BINAXNOW STREPTOCOCCUS PNEUMONIAE 5 POSITIVE 5",SUP-710-010,CDM,S27000186,LOCAL,0270,RC,,,both,,,326.42,97.93,"CIGNA [10200]","Cigna Open Access",,185.73,56.9,,,,,0,37.96,277.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR STRAIGHT SPEAR DISPOSABLE",SUP-AR-3600D,CDM,C1713,HCPCS,0278,RC,,,both,,,1528.00,458.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,437.31,28.62,,,,,0,177.71,1298.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 36MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR36,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1524.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CITATION TMZF HA 6 SHORT HIP LEFT",SUP-6265-5206,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6593.93,27,,,,,0,2840.27,20758.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME PATELLAR 8MM 32MM KNEE E PLUS 3 PEG STERILE",SUP-130-03-732,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"MULTIPLAN [10600]",Multiplan,,2550,85,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 35CM 10FR FLEXIMA POLYURETHANE HYDROPHILIC BILIARY",SUP-M001271640,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tracheostomy/Laryngectomy Shower Protector",PX-E27000255,CDM,A7523,HCPCS,0270,RC,,,both,,,330.00,99,"AETNA [10100]","Aetna HMO/PPO",,262.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.38,280.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 54X22MM STAINLESS STEEL 2.4MM SCR 6X3 HOLE 2",SUP-02.111.631,CDM,C1713,HCPCS,0278,RC,,,both,,,3834.68,1150.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2607.58,68,,,,,0,445.97,3259.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 2.25X20MM",SUP-PRV022520CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHUNT CARDIOVASCULAR 18MM 3MM FLO-THRU INTRALUMINAL",SUP-FT12300,CDM,S27200284,LOCAL,0272,RC,,,both,,,741.67,222.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WIRE FIXATION KIRSCHNER L203 MM OD.9 MM 1 TROCAR NONSTERILE",SUP-KWIR-ST-09203,CDM,S27200284,LOCAL,0272,RC,,,both,,,426.30,127.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PREVAIL DCB 2.25X20MM",SUP-PRV022520CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE 73MM TITANIUM 4 LEVEL ZEVO BONE SPINE CERVICAL",SUP-3004073,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION",RX-170831,CDM,J1459,HCPCS,0636,RC,44206-0437-10,NDC,both,100,ML,10718.16,3215.45,"PHCS [10601]",PHCS,,7502.71,70,,,,,0,1181.28,9110.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT VALEO 36MM 120CM 7MM 6FR .035IN BILIARY SELF",SUP-EV07362CD,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1062.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE WIDE TITANIUM 4 HOLE GEMINUS BONE RADIAL LEFT DISTAL",SUP-GMN-LTW-4HL,CDM,C1713,HCPCS,0278,RC,,,both,,,5161.20,1548.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,611.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",600.25,4387.02,"percent of total billed charges",
"DTECT BLOOD FLOW GEM FLOW NOW PERIPHERAL VESSELS SILICONE",SUP-GEM2770FN,CDM,S27200284,LOCAL,0272,RC,,,both,,,4795.50,1438.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1970.95,41.1,,,,,0,557.72,4076.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS13030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]",Cigna,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 28FR CUT WOLF RESECTOSCOPE",SUP-M0068802491,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"UHC [10700]","United Healthcare",,302.71,63.3,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEADACHES WITHOUT MCC",103,MS-DRG,,,,,,,inpatient,,,30826.86,9248.06,"UHC [10700]","United Healthcare",,20856.49,,"Fee schedule rate ($20,856.49). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,5187.62,20856.49,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE COAGULATION PURPLE 350CM 7FR BRIGHTON GASTROINTESTINAL",SUP-BP-7F-DP-350,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Observation Carve-Out - Radiology",PX-762000012,CDM,G0378,HCPCS,0762,RC,,,both,,,66.00,19.8,"CIGNA [10200]",Cigna,,66,,,,,,,7.68,66,"case rate",
"SCR BONE 5.5MM 23MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.230,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,341.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",341.92,2499,"percent of total billed charges",
"BLADE 13CM 5.5MM DISTAL TIP STEALTH FRR DIAMOND LIKE CARBON",SUP-S9246A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1044.90,313.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,710.53,68,,,,,0,121.52,888.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL UNOBTRUSIVE PRONG RETENTION OPTIFLOW WAVEFLEX",SUP-OJR412,CDM,S27000186,LOCAL,0270,RC,,,both,,,404.77,121.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,47.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.07,344.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP MANIP 6.7MM RUMI II UTERUS ARTICULATE LOCK HANDLE SOFT",SUP-UMG670,CDM,S27200284,LOCAL,0272,RC,,,both,,,602.62,180.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,71.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.08,512.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 135CM 200MM 7MM .035IN BALLOON",SUP-AB35W07200135,CDM,C1725,HCPCS,0272,RC,,,both,,,1061.91,318.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,722.1,68,,,,,0,123.5,902.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC ATLAS+ DR THK14MM IMPLANTABLE 38ML 78GM",SUP-V-243,CDM,C1721,HCPCS,0278,RC,,,both,,,70537.50,21161.25,"UHC [10700]","United Healthcare",,44650.24,63.3,,,,,0,8203.51,59956.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP 11MM OPEN 235CM INTERNAL RESOLUTION RADIOPAQUE USER",SUP-M00522610,CDM,S27200284,LOCAL,0272,RC,,,both,,,1347.76,404.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,159.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,156.74,1145.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATHLETIS 135CM 40MM 12MM BALLOON DILATATION STERILE",SUP-H74939347120410,CDM,C1725,HCPCS,0272,RC,,,both,,,1449.90,434.97,"FIRST HEALTH [10303]","First Health",,1159.92,80,,,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 38MM 144CM 3.5MM CORONARY STENT",SUP-H7493911438350,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"FIRST HEALTH [10303]","First Health",,7314,80,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.245,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"PHCS [10601]",PHCS,,1134,70,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE LEGION G2 PS POROUS FEMUR HI DEMAND INSER",SUP-71704651,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"FIRST HEALTH [10303]","First Health",,18648,80,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 V5 ETHIBOND GII QUICKANCHOR PLUS ROTATOR CUFF",SUP-212035,CDM,C1713,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"BLUE CROSS [10001]","Blue Cross HMO",,2637.18,39.2,,957.42,156.86,7483.26,51,782.41,5718.38,"percent of total billed charges",
"OSTEOTOM SURGICAL SQUARE STERILE LATEX FREE DISPOSABLE",SUP-SN24,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"UHC [10700]","United Healthcare",,2350.01,63.3,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 36MM ORTHOLOC TITANIUM CORTICAL SELF TAP",SUP-59224536,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,457.3,45.9,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOWL BONE CEMENT SMARTMIX CTS MIX SYSTEM LATEX FREE",SUP-540176501,CDM,S27200284,LOCAL,0272,RC,,,both,,,1762.50,528.75,"FIRST HEALTH [10303]","First Health",,1410,80,,,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOWL BONE CEMENT SMARTMIX CTS MIX SYSTEM LATEX FREE",SUP-540176501,CDM,S27200284,LOCAL,0272,RC,,,both,,,1762.50,528.75,"MULTIPLAN [10600]",Multiplan,,1498.13,85,,,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 5CM 5FR 1 PIGTAIL CURVE PANCREATIC POLYMER KIT",SUP-M00537450,CDM,C2625,HCPCS,0278,RC,,,both,,,1411.18,423.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,403.88,28.62,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 300MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040300S,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"KAISER [10500]",Kaiser,,1256.25,67,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 17MM SEPTAL 2 DISK NITINOL MESH SELF",SUP-9-ASD-017,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"CIGNA [10200]",Cigna,,8500.32,40,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM PRIMARY CEMENT DISTAL BULLET TIP SYNERGY",SUP-71316215,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2519.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2472.83,18073.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 36X21X2MM TITANIUM 2 LEVEL CLOVERLEAF CAUDAL HOLE LOCK",SUP-450.228,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 320105 TRICORT BLK 5MM SRVC FEE",SUP-320105,CDM,S27800098,LOCAL,0278,RC,,,both,,,3412.50,1023.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,404.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,396.87,2900.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORTHOLOC 3DI FOOT RECONSTRUCTION SYSTEM HALLUX PLATES - LAP",SUP-58510000,CDM,C1713,HCPCS,0278,RC,,,both,,,12420.00,3726,"PHCS [10601]",PHCS,,8694,70,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 300MM 4MM .018IN BALLOON",SUP-R51004030L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1024.16,41.1,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTED TOTAL KNEE SYSTEM INCLUDING CONSTRAINED",SUP-98000200262,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS [10001]","Blue Cross HMO",,7408.8,39.2,,5311.50,4717.44,5388.59,31,2198.07,16065,"percent of total billed charges",
"CATH NC EUPHORA 142CM 8MM 3MM BALLOON DILATATION DURATRAC",SUP-NCEUP3008X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 32MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661032,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,154.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",151.86,1109.86,"percent of total billed charges",
"SPACER ALLOGRAFT 12.5X15X8MM ADVANCED PARALLEL SPINE",SUP-17608,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross PPO",,3245.76,39.2,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 12/14 28MM HIP TAPER NECK PRIMARY COCR",SUP-71302804,CDM,C1713,HCPCS,0278,RC,,,both,,,5847.75,1754.32,"PHCS [10601]",PHCS,,4093.43,70,,,,,0,680.09,4970.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT AIRGUARD CHRONOFLEX",SUP-1706061,CDM,C1788,HCPCS,0278,RC,,,both,,,1905.00,571.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,225.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",255.04,255.04,255.04,"1 through 10",221.55,1619.25,"percent of total billed charges",
"DEVICE LEAD LOCKING .43-.66MM SLS II 2 .017-.026IN ICD LEAD",SUP-518-019,CDM,C1773,HCPCS,0272,RC,,,both,,,4071.00,1221.3,"FIRST HEALTH [10303]","First Health",,3256.8,80,,,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 15% IN WATER INFUSION",RX-410563,CDM,,,0258,RC,08888-8879-93,NDC,both,250,ML,100.65,30.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68.44,68,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .067IN .047IN AMPLATZ",SUP-534541T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"FIRST HEALTH [10303]","First Health",,74.82,80,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.4MM 2-0 MICRO STRAIGHT FORWARD TAPER",SUP-AR-1322BCNF,CDM,C1713,HCPCS,0278,RC,,,both,,,2437.50,731.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1657.5,68,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID 0.8 MG TABLET",RX-29833,CDM,,,0637,RC,60258-0160-01,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,3.35,53.5,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 730CC P5.1CM MODERATE PLUS PROFILE COHESIVE GEL",SUP-SMPB730,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"BLUE CROSS [10001]","Blue Cross PPO",,2988.8,39.2,,16595.83,16595.83,16595.83,"1 through 10",886.73,6480.83,"percent of total billed charges",
"CAGE SPINAL 15MM INDEPENDENCE 15D NONSTERILE LATEX FREE",SUP-376.515,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13710.24,40,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ISONIAZID 300 MG TABLET",RX-4027,CDM,,,0637,RC,51079-0083-01,NDC,both,1,UN,6.48,1.94,"FIRST HEALTH [10303]","First Health",,5.18,80,,,,,0,0.75,5.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL LIGHT GREEN 28X32X6.9-10.5MM SYNFIX 10D SMALL",SUP-08.815.141S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM LAPIPLASTY S4A INTERNAL FIXATION MULTIPLANAR ANATOMIC",SUP-SK39,CDM,C1713,HCPCS,0278,RC,,,both,,,31468.50,9440.55,"UHC [10700]","United Healthcare",,19919.56,63.3,,5023.51,2672.93,6679.78,18,3659.79,26748.23,"percent of total billed charges",
"CATH CORDIS SABER 90CM 300MM 2.5MM BALLOON DILATATION",SUP-48002530S,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNETOS BIPHASIC CALCIUM PHOSPHATE 10CC 1-2MM",SUP-703-021-US,CDM,C1713,HCPCS,0278,RC,,,both,,,18868.50,5660.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2235.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2194.41,16038.23,"percent of total billed charges",
"CATH CORDIS SABER 90CM 300MM 2.5MM BALLOON DILATATION",SUP-48002530S,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM 48X16X2.5MM TITANIUM 3 LEVEL PREBENT SKYLINE BONE",SUP-186803048,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3598.56,68,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Phencyclidine (PCP)",PX-301000552,CDM,83992,CPT,0301,RC,,,both,,,148.00,44.4,"MULTIPLAN [10600]",Multiplan,,125.8,85,,,,,0,0.15,148,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 28FR CUT WOLF RESECTOSCOPE",SUP-M0068802491,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,219.5,45.9,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACCU-VU 70CM 20CM 5FR OMNI CURVE ANGIOGRAPHIC",SUP-H787137097015,CDM,C1887,HCPCS,0272,RC,,,both,,,1099.98,329.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,130.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.93,934.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 1.8MM BUTTRESS VARIABLE ANGLE LOCKING T8",SUP-04.210.094,CDM,C1713,HCPCS,0278,RC,,,both,,,872.78,261.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,400.61,45.9,,,,,0,101.5,741.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 8MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140820,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"FIRST HEALTH [10303]","First Health",,9505.44,80,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 46MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.746,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"NOVANET [10819]",Novanet,,842.72,75,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 22CM PUMP SET",SUP-ES2922,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"KAISER [10500]",Kaiser,,42009,67,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP POLAR CUP CEMENTED STEM COBALT CHROM",SUP-71703500,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"NOVANET [10819]",Novanet,,17955,75,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.2MM PERIPHERAL SCR STERILE",SUP-MWJ126,CDM,S27200284,LOCAL,0272,RC,,,both,,,1556.00,466.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIR STPLR TRIEEA25MT MEDTHK WT",SUP-TRIEEA25MT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2162.78,648.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,256.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,251.53,1838.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 6IN 16MM BITE SLIGHT CURVE 3MM KLEINERT-KUTZ",SUP-31-0553,CDM,S27200284,LOCAL,0272,RC,,,both,,,1715.18,514.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,704.94,41.1,,,,,0,199.48,1457.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM TYPE 1 TAPERLOC MICROPLASTY PPS 133D 15",SUP-51106150,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11275.88,41.1,,6417.48,6417.48,6417.48,"1 through 10",3190.72,23319.95,"percent of total billed charges",
"PAPAVERINE 30 MG/ML INJECTION SOLUTION",RX-6030,CDM,J2440,HCPCS,0637,RC,00517-4002-25,NDC,both,2,ML,375.18,112.55,"CIGNA [10200]",Cigna,,255.12,68,,,,,0,43.63,318.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR 5MM OES",SUP-M0068804311,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"PHCS [10601]",PHCS,,361.54,70,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Punc Shunt Tube/Rsvr Asp/Inj",PX-361000249,CDM,61070,CPT,0361,RC,,,both,,,3722.77,1116.83,"PHCS [10601]",PHCS,,3722.77,,"Case rate ($4,710). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,432.96,3722.77,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Sclp/Limb 2.6-7.5cm Cmplx",PX-450000050,CDM,13121,CPT,0450,RC,,,both,,,1861.00,558.3,"CIGNA [10200]",Cigna,,1833,,,,,,,67.13,1861,"case rate",
"CATH POWERFLEX P3 80CM 8CM 5FR 7MM BALLOON DILATATION",SUP-4207080S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM .91-1.12MM 2.75MM CORONARY",SUP-RONYX27530W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1556.64,28.62,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 6.5MM MICRO100 MICROPOWER 10MM FLUTE ROUND",SUP-509123200,CDM,S27200284,LOCAL,0272,RC,,,both,,,388.11,116.43,"CIGNA [10200]",Cigna,,263.91,68,,,,,0,45.14,329.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM TARGET 360D STD PLATINUM",SUP-M0035466200,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1672.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 50MM TI",SUP-MTLS-37500-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,1144.80,304.56,2275.09,66,155.43,1136.03,"percent of total billed charges",
"CATH STERLING 135CM 60MM 6FR 5MM BALLOON DILATATION PEBAX",SUP-39032-50601,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 26-29MM 0-43MM COREVALVE 31MM HEART PORCINE",SUP-MCS-P3-31-AOA-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,70281,41.1,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 6MM",SUP-SPL27506X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT T-5 .5 CIRCLE TAPER 26.5MM LOOP BIO-TENODESIS",SUP-AR-7281,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.57,52.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.19,147.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 2-0 CT-2 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Y333H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 8.25IN 1.5MM BAYONET IRRIGATE SMOOTH INSULATE",SUP-20-0431,CDM,S27200284,LOCAL,0272,RC,,,both,,,512.78,153.83,"KAISER [10500]",Kaiser,,343.56,67,,,,,0,59.64,435.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 26CM 6FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251330,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOLUTION DEXTROSE 70  2000ML",SUP-712007,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.17,24.95,"AETNA [10100]","Aetna HMO/PPO",,66.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.67,70.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 34MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40034W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,644.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X12MM CLYDESDALE PTC 6D PEEK TITANIUM",SUP-4986250,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 20MM CLEVERCUT3V PRELOAD DISTAL TIP STERILE",SUP-KD-VC631Q-07201A,CDM,C1769,HCPCS,0272,RC,,,both,,,2817.75,845.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1916.07,68,,,,,0,327.7,2395.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 60MM 135CM 6MM 160CM",SUP-M001711130,CDM,C1876,HCPCS,0278,RC,,,both,,,8728.50,2618.55,"AETNA [10100]","Aetna HMO/PPO",,6939.16,79.5,,,,,0,1015.12,7419.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 9.75IN .018IN 2 END SPRING STRAIGHT SOFT TIP",SUP-AW-04018,CDM,C1769,HCPCS,0272,RC,,,both,,,78.65,23.59,"FIRST HEALTH [10303]","First Health",,62.92,80,,,,,0,9.15,66.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 8FR JUDKINS RIGHT 4",SUP-588831,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachytx Isodose Complx",PX-333000066,CDM,77318,CPT,0333,RC,,,both,,,4264.02,1279.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,408.8,,"Per diem ($408.80).",,,,0,408.8,4264.02,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 34MM 140CM 4MM CORONARY",SUP-RSINT40034UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]","Cigna Local Plus",,2966.04,53.5,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 56MM 11MM 5.4MM 4.7MM ZENITH SPIRAL-Z",SUP-G55225,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"CIGNA [10200]",Cigna,,8469.72,40,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 26MM 2.25MM CORONARY STENT FULCRUM COCR",SUP-INT22526UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"BLUE CROSS [10001]","Blue Cross HMO",,946.68,39.2,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 5 38IN BRAID TIES MULTISTRAND LOWER KNOT",SUP-AR-7210,CDM,S27200284,LOCAL,0272,RC,,,both,,,347.13,104.14,"CIGNA [10200]",Cigna,,236.05,68,,,,,0,40.37,295.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 68MM 10MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044106870,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3544.88,41.1,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 33MM 3MM CORONARY STENT EVEROLIMUS",SUP-1550300-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM INFINITY SPINE MULTIAXIAL NONSTANDARD",SUP-G3603510,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",441.36,3225.75,"percent of total billed charges",
"HC Rmvl Benign Skin Lesn Sngl",PX-510000013,CDM,11055,CPT,0761,RC,,,both,,,525.21,157.56,"MULTIPLAN [10600]",Multiplan,,446.43,85,,,,,0,61.08,525.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID PACBAND- LARGE",SUP-38350017,CDM,S27000186,LOCAL,0270,RC,,,both,,,180.96,54.29,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,74.37,41.1,,,,,0,21.05,153.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT 6 .5 CIRCLE 1.092IN .043IN REGULAR EYE REVERSE CUT",SUP-2164-06,CDM,S27200284,LOCAL,0272,RC,,,both,,,86.54,25.96,"KAISER [10500]",Kaiser,,57.98,67,,,,,0,10.06,73.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,inpatient,,,123931.08,37179.32,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,34824.03,,"Case rate ($17,102.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $15,880.79, add-ons for qualifying new technology services are included. If operating cost exceeds $48,920.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,582.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $15,901.79. The transfer operating threshold is the transfer adjustment factor * $15,880.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,200.67. The transfer capital threshold is the transfer adjustment factor * $1,200.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,10994,68759.32,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.265,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAHURKAR DOUBLE-D ULTEM 20CM 12FR 350ML/MIN",SUP-8888101003,CDM,C1752,HCPCS,0272,RC,,,both,,,1573.52,472.06,"UHC [10700]","United Healthcare",,996.04,63.3,,,,,0,183,1337.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR NONABSORBABLE SAFFRON FIXATION STERILE LATEX FREE",SUP-520340,CDM,S27200284,LOCAL,0272,RC,,,both,,,3898.50,1169.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,461.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,453.4,3313.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC 17-Hydroxypregnenolone",PX-301000372,CDM,84143,CPT,0301,RC,,,both,,,388.00,116.4,"PHCS [10601]",PHCS,,271.6,70,,,,,0,0.01,329.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR RMT HYPERTRONICS 125CM 4MM 7FR 1-7-4MM SPACE",SUP-NR7TCS4YU,CDM,C1732,HCPCS,0272,RC,,,both,,,16256.40,4876.92,"UHC [10700]","United Healthcare",,10290.3,63.3,,,,,0,1890.62,13817.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 10MM KNEE POLYETHYLENE STABILIZE ROTATE",SUP-129416610,CDM,C1776,HCPCS,0278,RC,,,both,,,12447.60,3734.28,"CIGNA [10200]","Cigna Local Plus",,3920.99,31.5,,5372.07,4581.20,7242.98,23,1447.66,10580.46,"percent of total billed charges",
"GENRTR PULSE ATTESTA SR MRI IMPLANTABLE",SUP-ATSR01,CDM,C1786,HCPCS,0275,RC,,,both,,,14490.00,4347,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4147.04,28.62,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 150MM 1.1MM STERILE",SUP-03.333.001S,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135CM 40MM 12MM .035IN LOW PROFILE BALLOON",SUP-B2120-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ON-Q I-FLOW 2ML/HOUR DRUG DELIVERY DEHP 270ML CUSTOM",SUP-P270X2,CDM,C9804,HCPCS,0272,RC,,,both,,,931.10,279.33,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL RED WHITE 2.3MM OTO-FLEX DIAMOND STERILE",SUP-3155642,CDM,S27200284,LOCAL,0272,RC,,,both,,,1972.50,591.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SINGLE USE INSTRUMENTS - FEMORAL KIT (PS) - SIZE 2",SUP-5555-2252,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AMILORIDE 5 MG TABLET",RX-391,CDM,,,0637,RC,00574-0292-01,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IMPRESS RADIOLOGY CATHETER SIMMONS 2 5FR 100CM .038",SUP-510038SIM2,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Bilicheck Tips",PX-E27000057,CDM,E27000057,LOCAL,0270,RC,,,both,,,55.00,16.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS 2-0 CP-1 36IN BRAID ANTIBACTERIAL COATED",SUP-VCP472H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP CAUT DA VINCI XI ENDOWRIST CAUT MONOPOLAR VESSEL SEALER",SUP-480322,CDM,S27000186,LOCAL,0270,RC,,,both,,,4105.50,1231.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STPLR STAINLESS STEEL WIDE .56MM 35 STAPLE STERILE",SUP-050284,CDM,S27200284,LOCAL,0272,RC,,,both,,,160.95,48.28,"MULTIPLAN [10600]",Multiplan,,136.81,85,,,,,0,18.72,136.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH VIZIGO 17MM SMALL CURVE 71CM 11.5FR 8.5FR INTRO",SUP-D138501,CDM,C1892,HCPCS,0272,RC,,,both,,,6824.10,2047.23,"NOVANET [10819]",Novanet,,5118.08,75,,,,,0,793.64,5800.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN RIGHT CORONARY 3D",SUP-534676T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"FIRST HEALTH [10303]","First Health",,69.6,80,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 15MM STAINLESS STEEL T6 CORTEX SELF TAP SELF",SUP-201.365.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,190.08,45.9,,,,,0,48.16,352,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC",737,MS-DRG,,,,,,,inpatient,,,108598.58,32579.57,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,13357.21,,"Case rate ($12,782.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,868.98, add-ons for qualifying new technology services are included. If operating cost exceeds $44,908.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,279.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,884.67. The transfer operating threshold is the transfer adjustment factor * $11,868.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.35. The transfer capital threshold is the transfer adjustment factor * $897.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,60161.28,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Spine Lumbosacral 2-3v",PX-320000044,CDM,72100,CPT,0320,RC,,,both,,,915.10,274.53,"MULTIPLAN [10600]",Multiplan,,777.84,85,,,,,0,46.01,777.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +13.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.135,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"KAISER [10500]",Kaiser,,231.15,67,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 10MM 11FR ENDOPROSTHESIS HEPARIN",SUP-VBH101002,CDM,C1874,HCPCS,0278,RC,,,both,,,19939.50,5981.85,"NOVANET [10819]",Novanet,,14954.63,75,,,,,0,2318.96,16948.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Gastric Band Adjustment",PX-361000268,CDM,S2083,HCPCS,0361,RC,,,both,,,899.29,269.79,"AETNA [10100]","Aetna HMO/PPO",,714.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.59,764.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIFIX 40IN 20GA EPIDURAL POLYAMIDE CNCT THREAD ASSIST",SUP-333520,CDM,S27200284,LOCAL,0272,RC,,,both,,,44.68,13.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.2,37.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANT BREAST DISORDERS WITH MCC",597,MS-DRG,,,,,,,inpatient,,,57976.37,17392.91,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,27023.69,,"Fee schedule rate ($27,023.69). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,41575.81,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"QUARTET, WIDE SPACING - 1458QL/75",SUP-1458QL/75,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]",Cigna,,3812.76,68,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 30MM 80CM 14MM .079IN LARGE DIAMETER",SUP-SERB65-14-30-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGNETOS FLEX MATRIX, SMALL",SUP-703-056-US,CDM,C1713,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,818.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",818.52,5982.3,"percent of total billed charges",
"SYSTEM SMARTMIX BONE CEMENT TOWER CRTDG",SUP-540198000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2580.00,774,"CIGNA [10200]","Cigna Open Access",,1468.02,56.9,,,,,0,300.05,2193,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP ANTHOLOGY AFIT WITH OXI HEAD AND R3 MULTI",SUP-71705320,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 28MM CG FUTURE HOLDER EYELET DESIGN CROSS",SUP-638BL28,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]",Cigna,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 16IN 29FR VEIN STD OPEN LIGHTHOUSE 3 STAGE 2",SUP-TF292902,CDM,S27200284,LOCAL,0272,RC,,,both,,,356.18,106.85,"CIGNA [10200]","Cigna Open Access",,202.67,56.9,,,,,0,41.42,302.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ARM M FOR 18-24IN CHEST LEFT HUMERAL ELASTIC KNIT HARN",SUP-A653-3,CDM,S27000186,LOCAL,0270,RC,,,both,,,388.89,116.67,"NOVANET [10819]",Novanet,,291.67,75,,,,,0,45.23,330.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY 115CM 6FR LIVEWIRE 2-5-2MM SPACING 1",SUP-401575R,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ABLATION 115CM 8FR 3.5MM F CURVE SMARTTOUCH THERMOCOOL",SUP-D133602,CDM,C1732,HCPCS,0272,RC,,,both,,,19845.00,5953.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SUT VICRYL PLUS 2-0 CP-1 36IN BRAID ANTIBACTERIAL COATED",SUP-VCP472H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SKIN ULCERS WITH CC",593,MS-DRG,,,,,,,inpatient,,,34769.12,10430.74,"BLUE CROSS [10001]","Blue Cross PPO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 80MM 4MM BALLOON DILATATION STERILE LATEX",SUP-584008022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 14 STD OFFSET HIP",SUP-71935574,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"CIGNA [10200]",Cigna,,14613.48,40,,5873.17,5873.17,5873.17,"1 through 10",4248.87,31053.65,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 23MM 145CM 4MM CORONARY STENT",SUP-1145400-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PHCS [10601]",PHCS,,4086.6,70,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL TITAN INFLATABLE PENILE PROS TUBE STERILE LATEX",SUP-519150,CDM,S27200284,LOCAL,0272,RC,,,both,,,4671.30,1401.39,"AETNA [10100]","Aetna HMO/PPO",,3713.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,543.27,3970.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEM POR LEFT SZ 9",SUP-427-01-090,CDM,C1776,HCPCS,0278,RC,,,both,,,32703.43,9811.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3875.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3803.41,27797.92,"percent of total billed charges",
"SUT STRATAFIX SYMMETRIC PDS PLUS 0 CT-1 24IN VIOLET",SUP-SXPP1A440,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 14 STD OFFSET HIP",SUP-71935574,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9864.1,27,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 240CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-240,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3467.97,45.9,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Icd Gen Only",PX-480000029,CDM,33240,CPT,0481,RC,,,both,,,7251.00,2175.3,"BLUE CROSS [10001]","Blue Cross HMO",,7251,,"Case rate ($25,005.81). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,843.29,7251,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 135+ MM 14MM PERSONA 3MM OFFSET KNEE STERILE LATEX",SUP-42560313514,CDM,C1776,HCPCS,0278,RC,,,both,,,16990.56,5097.17,"PHCS [10601]",PHCS,,11893.39,70,,,,,0,1976,14441.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 2.25MM ULTRA LOW PROFILE BALLOON",SUP-1012404-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM MAS PLIF PREBENT NONSTERILE",SUP-7242040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 20CM 6FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251300,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"KAISER [10500]",Kaiser,,824.74,67,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2.5CM 2MM .0135IN MICRUSFRAME MICRO",SUP-MFR140225,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 30MM 30MM CONDYLAR STABILIZED NECK OMNIFIT EON",SUP-6098-0530,CDM,C1776,HCPCS,0278,RC,,,both,,,10292.40,3087.72,"CIGNA [10200]",Cigna,,6998.83,68,,5873.17,5873.17,5873.17,"1 through 10",1197.01,8748.54,"percent of total billed charges",
"CATH ONE STEP 10CM 5FR DRNG PERCUTANEOUS 4 SIDEHOLE SLIP FIT",SUP-OSC-5F-10T,CDM,C1729,HCPCS,0272,RC,,,both,,,178.35,53.5,"KAISER [10500]",Kaiser,,119.49,67,,,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26MMX9MM CAPSTONE PEEK PTC LUMBAR INTERBODY",SUP-3992609,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5953.5,27,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 20MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.220,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"KAISER [10500]",Kaiser,,1969.8,67,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 15MM 2MM",SUP-SPL20015X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"FIRST HEALTH [10303]","First Health",,421.2,80,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IPRISM SX",SUP-SX1,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,199.75,41.1,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 5MM 32MM REUNION SHOULDER PERIPHERAL STERILE",SUP-5572-4532,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"BLUE CROSS [10001]","Blue Cross HMO",,609.83,39.2,,957.42,156.86,7483.26,51,180.93,1322.35,"percent of total billed charges",
"CATH CPS AIM 65MM 2.46MM 8FR UNIVERSAL GUIDE II SLITTABLE",SUP-DS2N103-65,CDM,C1893,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 200MM 6FR 5MM .014IN BALLOON",SUP-2249-50200,CDM,C1725,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1083.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM ADVANCED LORDOTIC SPINE",SUP-017712,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"NOVANET [10819]",Novanet,,6210,75,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK CATH 50CM 14.5FR HEPARIN SILVER PALINDROME SYMMETRIC",SUP-8888133500P,CDM,C1750,HCPCS,0278,RC,,,both,,,2649.68,794.9,"KAISER [10500]",Kaiser,,1775.29,67,,,,,0,308.16,2252.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0240,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]","Cigna Local Plus",,507.02,53.5,,3978.14,359.25,3978.14,24,110.22,805.55,"percent of total billed charges",
"SCR BIOABSORBABLE 23MM 7MM MILAGRO ACL PLGA TCP RESORBABLE",SUP-231800,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",434.96,3179,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 15CM 22MM THORAX KNIT SOFT FLEXIBLE",SUP-M002020951220,CDM,C1768,HCPCS,0278,RC,,,both,,,2698.73,809.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,319.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,313.86,2293.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 5 HIP",SUP-PRTLE025,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS [10001]","Blue Cross HMO",,7408.8,39.2,,5311.50,4717.44,5388.59,31,2198.07,16065,"percent of total billed charges",
"HEMI - REUNION PARTIAL CEMENTED TSA",SUP-S1,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"AETNA [10100]","Aetna HMO/PPO",,16277.63,79.5,,10981.53,8986.79,12413.38,12,2381.24,17403.75,"percent of total billed charges",
"SPACER SPINAL 25MMX8MM CRESCENT PEEK-OPTIMA VERTEBRAL BODY",SUP-9392508,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1925.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 17.75IN 5MM 15GA ASPIR PUNCTURE",SUP-90-5051L,CDM,S27200284,LOCAL,0272,RC,,,both,,,524.07,157.22,"NOVANET [10819]",Novanet,,393.05,75,,,,,0,60.95,445.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABIL 10CM 200CM 10MM ENDOPROSTHESIS BILIARY",SUP-VSWVH1010,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYPROPYLENE 20X10CM PERMANENT GRID 1 SMOOTH",SUP-F10246-1020P,CDM,C1781,HCPCS,0278,RC,,,both,,,19731.60,5919.48,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5327.53,27,,,,,0,2294.79,16771.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RIFAXIMIN 550 MG TABLET",RX-104604,CDM,,,0637,RC,65649-0303-03,NDC,both,1,UN,277.53,83.26,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,114.06,41.1,,,,,0,32.28,235.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR MICROVASIVE CIRCON",SUP-M0068802151,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"FIRST HEALTH [10303]","First Health",,413.18,80,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX SEPRA 6X4IN MONOFILAMENT RESORBABLE",SUP-1201015,CDM,C1781,HCPCS,0278,RC,,,both,,,19733.49,5920.05,"BLUE CROSS [10001]","Blue Cross HMO",,7735.53,39.2,,,,,0,2295,16773.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CROTALIDAE POLYVAL IMMUNE FAB 1 GRAM SOLUTION FOR INJECTION",RX-29313,CDM,J0840,HCPCS,0636,RC,50633-0110-12,NDC,both,1,UN,19303.13,5790.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2287.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2131.37,16407.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Hip Bil 2v",PX-320000206,CDM,73521,CPT,0320,RC,,,both,,,589.43,176.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,69.29,,"Fee schedule rate ($69.29).",,,,0,48.1,501.02,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mech Thromb Venous Add",PX-361000135,CDM,37188,CPT,0361,RC,,,both,,,8693.76,2608.13,"UHC [10700]","United Healthcare",,7311,,"Case rate ($7,311). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1011.08,8693.76,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 10FR PIGTAIL CURVE DRNG FLEXIMA BILIARY FLEXIBLE",SUP-M001271600,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16016555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"CATH TREK 145CM 20MM 3.25MM ULTRA LOW PROFILE BALLOON",SUP-1012275-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 55MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75447555,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM BI MENTUM THR PRESS FIT",SUP-OSC371199,CDM,C1776,HCPCS,0278,RC,,,both,,,26460.00,7938,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3135.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3077.3,22491,"percent of total billed charges",
"CATH MUSTANG 75CM 80MM 10MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171100870,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PHCS [10601]",PHCS,,822.15,70,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UROLIFT 2 IMPLANT CARTRIDGE HANDLE KIT",SUP-UL2-CHK,CDM,L8699,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]",Cigna,,4926.6,68,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 8IN .094IN TROCAR TIP THREAD DISPOSABLE",SUP-AR-8967KT,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,30.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309116,CDM,C1776,HCPCS,0278,RC,,,both,,,37771.65,11331.49,"FIRST HEALTH [10303]","First Health",,30217.32,80,,,,,0,4392.84,32105.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM DARCO TITANIUM FOOT LOCK",SUP-DC2820024,CDM,C1713,HCPCS,0278,RC,,,both,,,1223.10,366.93,"NOVANET [10819]",Novanet,,917.33,75,,,,,0,142.25,1039.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM STAINLESS STEEL 3.5MM SCR 3 HOLE LCP BONE",SUP-241.901,CDM,C1713,HCPCS,0278,RC,,,both,,,9928.27,2978.48,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4080.52,41.1,,,,,0,1154.66,8439.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 6-7 E-F KNEE",SUP-42522100712,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS [10001]","Blue Cross HMO",,4224.36,39.2,,5311.50,4717.44,5388.59,31,1253.3,9159.96,"percent of total billed charges",
"SCR BONE 3.5MM 44MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.844,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"BLUE CROSS [10001]","Blue Cross PPO",,92.76,39.2,,957.42,570.23,957.42,28,27.52,201.14,"percent of total billed charges",
"PARTIAL HIP CONSTRUCT 2",SUP-CAP-SN-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1144.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT DEK MX BL MF 7-0 XT-6 2N 24X4",SUP-D-7004M4K,CDM,S27200284,LOCAL,0272,RC,,,both,,,413.25,123.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"THD SLIDE PATIENT KIT DISPOSABLE",SUP-800070,CDM,S27200284,LOCAL,0272,RC,,,both,,,4260.06,1278.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GOLD PROBE 300CM 7FR ELECTROHEMOSTASIS HEMOGLIDE",SUP-M00560071,CDM,S27200284,LOCAL,0272,RC,,,both,,,1017.42,305.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL REMOVAL HANDLE TRAPEZIECTOMY STERILE",SUP-AR-8919-01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1968.75,590.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 7FR .092IN 13CM ROBUST VALVE SPLITTABLE WITHOUT",SUP-PLSX-1007,CDM,C1892,HCPCS,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE CORNEAL 8.25MM CORNEAL STAINLESS STEEL TREPHINE",SUP-K20-2159,CDM,S27200284,LOCAL,0272,RC,,,both,,,430.65,129.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) EDWARDS EVOQUE VALVE (EVOQUE VALVE) 56 MM",SUP-9850EV56ACL,CDM,S62400003,LOCAL,0624,RC,,,both,,,216600.00,64980,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SUT VICRYL 2-0 X-1 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J459H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 6.5MM 35MM SPINAL POLYAXIAL 5.5MM ROD",SUP-8456535,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"KAISER [10500]",Kaiser,,3244.54,67,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REFERENCE TOE 1ST MTP IMPLANT WITH GROMMETS  SIZE 3","SUP-M30 SE030",CDM,C1776,HCPCS,0278,RC,,,both,,,11937.00,3581.1,"AETNA [10100]","Aetna HMO/PPO",,9489.92,79.5,,10981.53,8986.79,12413.38,12,1388.27,10146.45,"percent of total billed charges",
"WRAP THERAPEUTIC 76-91CM SMARTVEST MEDIUM",SUP-SW-30/36-1,CDM,S27000186,LOCAL,0270,RC,,,both,,,437.40,131.22,"UHC [10700]","United Healthcare",,276.87,63.3,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis Be Ag Eia",PX-306000104,CDM,87350,CPT,0306,RC,,,both,,,176.02,52.81,"AETNA [10100]","Aetna HMO/PPO",,139.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,149.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY AND URINARY TRACT INFECTIONS WITH MCC",689,MS-DRG,,,,,,,inpatient,,,29840.22,8952.07,"UHC [10700]","United Healthcare",,28936.72,,"Fee schedule rate ($28,936.72). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7197.41,28936.72,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC TRIFECTA GLIDE 25",SUP-TFGT-25A,CDM,S27800098,LOCAL,0278,RC,,,both,,,38367.00,11510.1,"FIRST HEALTH [10303]","First Health",,30693.6,80,,,,,0,4462.08,32611.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 6CM 3MM GALAXY G3 MINI STRETCH",SUP-GLM930060,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT PHOTOTHERAPY BILISOFT LARGE NEST DISPOSABLE",SUP-M1093123,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.94,25.18,"PHCS [10601]",PHCS,,58.76,70,,,,,0,9.76,71.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 80MM 194CM 8MM 8.5FR 68MM BILIARY PERMALUME",SUP-M00570710,CDM,C1874,HCPCS,0278,RC,,,both,,,17108.55,5132.56,"BLUE CROSS [10001]","Blue Cross PPO",,6706.55,39.2,,,,,0,1989.72,14542.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 3.75 X 18 MM",SUP-1212375-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"MULTIPLAN [10600]",Multiplan,,14662.5,85,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM AZUR DETACHABLE HYDROGEL",SUP-45-450620,CDM,S27800098,LOCAL,0278,RC,,,both,,,9083.85,2725.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4169.49,45.9,,,,,0,1056.45,7721.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prevnt Indv Counsel 45 Min",PX-510000183,CDM,99403,CPT,0761,RC,,,both,,,94.00,28.2,"CIGNA [10200]",Cigna,,94,,"Per diem ($2,606).",,,,0,11.14,94,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cytpath Fna I&R",PX-311000013,CDM,88173,CPT,0311,RC,,,both,,,539.60,161.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,29.56,,"Fee schedule rate ($29.56). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.54,458.66,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Maxfac W/WO Cntrst",PX-351000010,CDM,70488,CPT,0351,RC,,,both,,,3344.91,1003.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,742,,,,,,,389.01,2843.17,"per diem",
"STENT ASCERTA 26CM 4.8FR URETERAL FIRM STERILE LATEX FREE",SUP-M0061456420,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"MULTIPLAN [10600]",Multiplan,,531.45,85,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Icd Gen Dual Lead Sys",PX-480000034,CDM,33263,CPT,0481,RC,,,both,,,31043.85,9313.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3678.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2795,31043.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EDS II 46CM 1.65MM .76MM DRNG SILICONE LUMBAR LUER LOCK",SUP-821706,CDM,C1729,HCPCS,0272,RC,,,both,,,1553.82,466.15,"FIRST HEALTH [10303]","First Health",,1243.06,80,,,,,0,180.71,1320.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH PASSPORT ENCORE GWIRE LOW PROFILE BALLOON 3FR 12FR",SUP-M0062181210,CDM,C1726,HCPCS,0272,RC,,,both,,,2191.88,657.56,"AETNA [10100]","Aetna HMO/PPO",,1742.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,254.92,1863.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 3CM 8FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145380010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"MULTIPLAN [10600]",Multiplan,,821.87,85,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC INTERVERTEBRAL 17X7MM MOBI-C 15MM SPINE CERVICAL COCRMO",SUP-MB3577,CDM,S27800098,LOCAL,0278,RC,,,both,,,33075.00,9922.5,"BLUE CROSS [10001]","Blue Cross PPO",,12965.4,39.2,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PLASMABUTTON RESECTION LOOP NDL",SUP-WA22657S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3062.33,918.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,362.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,356.15,2602.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC",815,MS-DRG,,,,,,,inpatient,,,46054.82,13816.45,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 60MM 6FR 5MM BALLOON DILATATION PEBAX",SUP-39032-50601,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND 4-0 SH 18IN CONTROL RELEASE BRAID 8",SUP-C014D,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.40,29.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BUTTON 1.5CM 24FR RADIOPAQUE LOW PROFILE PROXIMAL ANTIREFLUX",SUP-0120-24-1.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FLECAINIDE 100 MG TABLET",RX-10041,CDM,,,0637,RC,00054-0011-20,NDC,both,1,UN,18.01,5.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASKET SPECIMEN RETRIEVAL 120CM 12MM .8MM AIRWAY ZERO TIP",SUP-M00513200,CDM,S27200284,LOCAL,0272,RC,,,both,,,1932.90,579.87,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SENSOR DUAL-FLEX UROLOGICAL 10CM 150CM 3CM .035IN",SUP-M0066703081,CDM,C1769,HCPCS,0272,RC,,,both,,,369.40,110.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ASAHI PROWATER VASCULAR STRAIGHT 180CM 3CM .014IN",SUP-AGH146000,CDM,C1769,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC US OB > 1st Trimst Txabd Sngl",PX-402000016,CDM,76805,CPT,0402,RC,,,both,,,1394.28,418.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure count. Procedure 1, Fee schedule rate ($288.45). Procedures 2 - 999, Fee schedule rate ($144.23).",,,,0,,,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 13X4IN SILVERLON FOAM ISLAND FLEXIBLE MULTILAYER",SUP-ID-413,CDM,S27200284,LOCAL,0272,RC,,,both,,,324.91,97.47,"PHCS [10601]",PHCS,,227.44,70,,,,,0,37.79,276.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 18MM LOW PROFILE SCREWS TITANIUM T15 FULL",SUP-AR-8940-18,CDM,C1713,HCPCS,0278,RC,,,both,,,696.60,208.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,473.69,68,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION COMPLETE CARE ADD-A-FOLEY STATLOCK 350",SUP-304400A,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.83,29.05,"FIRST HEALTH [10303]","First Health",,77.46,80,,,,,0,11.26,82.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 STD KNEE RIGHT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB8SR,CDM,C1776,HCPCS,0278,RC,,,both,,,13668.90,4100.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5617.92,41.1,,6417.48,6417.48,6417.48,"1 through 10",1589.69,11618.57,"percent of total billed charges",
"SCREW NON-LOCKING 2.5MM X 22MM TI",SUP-VAN-25220-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Local Plus",,520.02,53.5,,3978.14,359.25,3978.14,24,113.04,826.2,"percent of total billed charges",
"HC Respiratory Syncytial Virus",PX-306000109,CDM,87420,CPT,0306,RC,,,both,,,502.55,150.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,42.56,,,,,,,0.5,427.17,"fee schedule",
"VALVE AORTIC 27MM OPEN PIVOT STD HEART ANNULUS TISSUE",SUP-500FA27,CDM,S27800098,LOCAL,0278,RC,,,both,,,25011.00,7503.3,"BLUE CROSS [10001]","Blue Cross HMO",,9804.31,39.2,,,,,0,2908.78,21259.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PUREWICK URETHRAL NATURAL (LATEX-FREE)",SUP-PWF030F,CDM,S27000186,LOCAL,0270,RC,,,both,,,64.38,19.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.49,54.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESPONSE 120CM 6FR 2-5-2MM SPACING CRD CURVE",SUP-401305,CDM,C1730,HCPCS,0272,RC,,,both,,,1134.00,340.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,771.12,68,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Respiratory Syncytial Virus",PX-306000109,CDM,87420,CPT,0306,RC,,,both,,,502.55,150.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.12,,,,,,,0.5,427.17,"fee schedule",
"STENT VIABAHN 10CM 120CM 13MM 12FR ENDOPROSTHESIS HEPARIN",SUP-VBH131002A,CDM,C1874,HCPCS,0278,RC,,,both,,,20160.00,6048,"AETNA [10100]","Aetna HMO/PPO",,16027.2,79.5,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 4MM 1.2MM 38MM 8MM STAINLESS STEEL SHORT THREAD",SUP-202.638,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"PHCS [10601]",PHCS,,777.01,70,,,,,0,129.1,943.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 CT 36IN BRAID ANTIBACTERIAL COATED VIOLET",SUP-VCP358H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X7MM COALITION MIS 7D 12MM",SUP-3136.1107,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"FIRST HEALTH [10303]","First Health",,14400,80,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1 X 2.5 COMPLEX PICO COIL",SUP-10USC0102H,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5230.2,40,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 9MM COCR",SUP-VAL-25090-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,654.35,45.9,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 39MM 135CM 10MM LOW PROFILE THIN",SUP-1012633-39,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,976.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 10MM LEIBINGER UNIVERSAL 2 TITANIUM",SUP-5020410,CDM,C1713,HCPCS,0278,RC,,,both,,,458.02,137.41,"MULTIPLAN [10600]",Multiplan,,389.32,85,,,,,0,53.27,389.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALBUTEROL SULFATE 2 MG TABLET, IMMEDIATE RELEASE",RX-253,CDM,,,0637,RC,69238-1344-01,NDC,both,1,UN,25.19,7.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.35,41.1,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER SUT YELLOW 3/8IN SMALL MINI OPEN STRESS RISER",SUP-9892,CDM,S27200284,LOCAL,0272,RC,,,both,,,376.36,112.91,"FIRST HEALTH [10303]","First Health",,301.09,80,,,,,0,43.77,319.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM DHS/DCS STAINLESS STEEL CORTICAL SMALL",SUP-214.040,CDM,C1713,HCPCS,0278,RC,,,both,,,464.78,139.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,54.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",54.05,395.06,"percent of total billed charges",
"STENT BILIARY 10MM 8.5FR 40MM FULLY COVERED TRANSHEPATIC WAL",SUP-M00574770,CDM,C1874,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Local Plus",,6945.75,31.5,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UNI-FUSE FLOW-THRU HUB 90CM 20CM 5FR THROMBECTOMY",SUP-12401807,CDM,C1757,HCPCS,0272,RC,,,both,,,1641.75,492.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1116.39,68,,,,,0,190.94,1395.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AS6AT6-AS TORIC ASPHERIC UV ABSB, GENERIC",SUP-SA6AT6,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"MULTIPLAN [10600]",Multiplan,,293.25,85,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD PACING 125CM 7FR BARD NBIH 1CM PROXIMAL BIPOLAR",SUP-007406P,CDM,C1730,HCPCS,0272,RC,,,both,,,7072.50,2121.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PDS II 2-0 CT-1 27IN MONOFILAMENT CLEAR ABSORBABLE",SUP-Z259H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPEL APD TWIST-LOC 45CM 10FR LONG LENGTH LOOP PIGTAIL",SUP-H7493931110450,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID",RX-3071,CDM,,,0637,RC,00121-0530-05,NDC,both,5,ML,25.60,7.68,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL 8 12MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620812,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS [10001]","Blue Cross HMO",,4411.53,39.2,,5311.50,4717.44,5388.59,31,1308.83,9565.82,"percent of total billed charges",
"IMMOB ORTHOPEDIC STD 20IN 25- IN KNEE 1 PANEL FINGER POCKET",SUP-VP40101-050,CDM,L1830,HCPCS,0274,RC,,,both,,,132.94,39.88,"BLUE CROSS [10001]","Blue Cross HMO",,52.11,39.2,,,,,0,15.46,113,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 5.5MM REINFORCE CUFF MURPHY EYE LOW",SUP-DYNJAARC55,CDM,S27200284,LOCAL,0272,RC,,,both,,,312.04,93.61,"FIRST HEALTH [10303]","First Health",,249.63,80,,,,,0,36.29,265.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 30MM 109CM 12MM 75CM VASCULAR NITINOL ILIAC",SUP-H74939200123070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP 3 HOLE CEMENTLESS EMPHASYS",SUP-471048300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5138.72,28.62,,,,,0,2088.17,15261.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CM 6MM 5CM HYBRID REINFORCED COATED",SUP-0650HYB0705A,CDM,C1768,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"CIGNA [10200]","Cigna Open Access",,5663.18,33.5,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINUS AND MASTOID PROCEDURES WITH CC/MCC",135,MS-DRG,,,,,,,inpatient,,,74098.21,22229.46,"AETNA [10100]","Aetna HMO/PPO",,40828.55,,"Fee schedule rate ($40,828.55). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,63355.32,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOQUE TRICUSPID VALVE REPLACEMENT SYSTEM (56 MM VALVE)",SUP-EVQ1A2US56,CDM,S27800098,LOCAL,0278,RC,,,both,,,245100.00,73530,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,100736.1,41.1,,,,,0,28505.13,208335,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 3.1X3.1IN XENMATRIX AQUAPURE SQUARE ACELLULAR",SUP-1160808,CDM,C1781,HCPCS,0278,RC,,,both,,,10750.20,3225.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1250.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1250.25,9137.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 76MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 8",SUP-247.372,CDM,C1713,HCPCS,0278,RC,,,both,,,2429.70,728.91,"BLUE CROSS [10001]","Blue Cross HMO",,952.44,39.2,,957.42,156.86,7483.26,51,282.57,2065.25,"percent of total billed charges",
"KIT TRACH PORTEX STERILE LATEX FREE DISPOSABLE",SUP-101/596/080,CDM,S27200284,LOCAL,0272,RC,,,both,,,3247.05,974.11,"MULTIPLAN [10600]",Multiplan,,2759.99,85,,,,,0,377.63,2759.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 160MM 16MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424049,CDM,C1776,HCPCS,0278,RC,,,both,,,12181.95,3654.58,"MULTIPLAN [10600]",Multiplan,,10354.66,85,,,,,0,1416.76,10354.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 70MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET",SUP-241.62,CDM,C1713,HCPCS,0278,RC,,,both,,,6287.28,1886.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,745.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,731.21,5344.19,"percent of total billed charges",
"CNTRLZR STEM 15MM CEMENTRALIZER HIP FEMUR CEMENT STERILE",SUP-137637000,CDM,C1776,HCPCS,0278,RC,,,both,,,846.45,253.93,"BLUE CROSS [10001]","Blue Cross PPO",,331.81,39.2,,3949.44,3949.44,3949.44,"1 through 10",98.44,719.48,"percent of total billed charges",
"SCR BONE 4.5MM 6MM MOUNTAINEER TITANIUM SPINE",SUP-188362006,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL KNIFE 24FR TUIP OLYMPUS OES PRO",SUP-M0068802671,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,61.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL REMEDY MEDIUM KNEE STEM STERILE",SUP-RSKTMD,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2006.18,14662.5,"percent of total billed charges",
"(EVAL) SELUTION DEB 3.0X35",SUP-SCA14U-300035D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 15MM CEMENTLESS TOTAL STABILIZE TRIATHLON",SUP-5566-S-015,CDM,C1776,HCPCS,0278,RC,,,both,,,7345.05,2203.51,"CIGNA [10200]","Cigna Open Access",,4179.33,56.9,,5302.19,4377.88,6578.61,27,854.23,6243.29,"percent of total billed charges",
"STENT ZIPWIRE 24CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175272190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"KAISER [10500]",Kaiser,,847.8,67,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3.5MM 12/14 SMALL 32MM HIP ACETABULAR BIOLOX",SUP-877503201,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"BLUE CROSS [10001]","Blue Cross PPO",,3864.62,39.2,,3949.44,3949.44,3949.44,"1 through 10",1146.57,8379.91,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT VALLEYLAB EDGE",SUP-SEP6015,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.94,67.18,"CIGNA [10200]","Cigna Open Access",,127.42,56.9,,,,,0,26.04,190.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 41FR LEFT ANGLE ADJUSTABLE VALVE",SUP-125141-,CDM,S27200284,LOCAL,0272,RC,,,both,,,442.50,132.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,203.11,45.9,,,,,0,51.46,376.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR DISPOSABLE 4.5/14MM BIOCOMPOSITE CORKSCREW",SUP-AR-8927DSC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,611.72,41.1,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP FRCP GRIESHABER REVOLUTION DSP 360D 25GA TISSUE BACK",SUP-337.83,CDM,S27200284,LOCAL,0272,RC,,,both,,,759.70,227.91,"CIGNA [10200]","Cigna Open Access",,432.27,56.9,,,,,0,88.35,645.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIBRILLATOR 65CM 8FR OPTISURE ENDOCARDIUM 2 COIL DF4",SUP-LDA220Q/65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS [10001]","Blue Cross HMO",,6731.42,39.2,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 22-30CM 3CM 7FR .035IN",SUP-M006180157190,CDM,C2617,HCPCS,0278,RC,,,both,,,1271.86,381.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,147.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.92,1081.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 4 20MM KNEE POSTERIOR STABILIZE ROTATE PLATFOR",SUP-151650420,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"NOVANET [10819]",Novanet,,9845.44,75,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 35X10MM HALL MICRO STERNUM STAINLESS STEEL",SUP-5301-040-032,CDM,S27200284,LOCAL,0272,RC,,,both,,,98.66,29.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,45.28,45.9,,,,,0,11.47,83.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) IMPLANT DELIVERY SYSTEM WITH IMPLANT LOADING TOOL",SUP-FG-1001-04,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 13.5X11.7CM BREAST 550CC STYLE 8200 SUT TAB CPX4",SUP-3548214,CDM,C1789,HCPCS,0278,RC,,,both,,,9694.50,2908.35,"NOVANET [10819]",Novanet,,7270.88,75,,,,,0,1127.47,8240.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 20MM 3MM BALLOON DILATATION OTW STERILE",SUP-593002022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 18FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G01328,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"PHCS [10601]",PHCS,,34.53,70,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY HOT 240CM 2.2MM RADIAL JAW 4 +2.8MM DISPOSABLE",SUP-M00515031,CDM,S27200284,LOCAL,0272,RC,,,both,,,322.60,96.78,"CIGNA [10200]","Cigna Open Access",,183.56,56.9,,,,,0,37.52,274.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 83MM 18GA 21GA E-CATH PLUS SONOPLEX",SUP-TDL142,CDM,C9812,HCPCS,0272,RC,,,both,,,611.55,183.46,"AETNA [10100]","Aetna HMO/PPO",,486.18,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,71.12,519.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEERABLE SHEATH, 55CM, 7MM CURVE",SUP-DST0655507D2,CDM,S27200284,LOCAL,0272,RC,,,both,,,6382.50,1914.75,"MULTIPLAN [10600]",Multiplan,,5425.13,85,,,,,0,742.28,5425.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LEFT OFFSET STAINLESS STEEL 3.2MM SCR 6 HOLE HOOK",SUP-OHOOKL-6,CDM,C1713,HCPCS,0278,RC,,,both,,,5761.50,1728.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2644.53,45.9,,,,,0,670.06,4897.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 4X28+TRAK21+CAT6 3-PACK - US",SUP-SFP913170,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PT Admission Visit",PX-421000003,CDM,G0151,HCPCS,0421,RC,,,outpatient,,,363.00,108.9,"KAISER [10500]",Kaiser,,243.21,67,,,,,0,243.21,308.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX79MM 8FR 80CMCATH HEPARIN",SUP-BXB097901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8798.44,41.1,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT POSITIONING KNEE",SUP-FP-KNEEPOS,CDM,S27200284,LOCAL,0272,RC,,,both,,,151.41,45.42,"AETNA [10100]","Aetna HMO/PPO",,120.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.61,128.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 9.75IN .018IN 2 END SPRING STRAIGHT SOFT TIP",SUP-AW-04018,CDM,C1769,HCPCS,0272,RC,,,both,,,78.65,23.59,"UHC [10700]","United Healthcare",,49.79,63.3,,,,,0,9.15,66.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Irr Water Sterile 1000ml",PX-E27200207,CDM,E27200207,LOCAL,0272,RC,,,both,,,39.81,11.94,"KAISER [10500]",Kaiser,,26.67,67,,,,,0,4.63,33.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RIFAXIMIN 550 MG TABLET",RX-104604,CDM,,,0637,RC,65649-0303-03,NDC,both,1,UN,277.53,83.26,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,32.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.28,235.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D F KNEE LEFT CEMENT KEEL",SUP-42536007501,CDM,C1776,HCPCS,0278,RC,,,both,,,10619.10,3185.73,"FIRST HEALTH [10303]","First Health",,8495.28,80,,,,,0,1235,9026.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repl Trach Puncture Dilator",PX-E27400047,CDM,L8514,HCPCS,0274,RC,,,both,,,234.30,70.29,"BLUE CROSS [10001]","Blue Cross PPO",,91.85,39.2,,,,,0,27.25,199.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 6.75IN STRAIGHT 2.5MM LEMPERT SLENDER SURGICAL",SUP-30-7620,CDM,S27200284,LOCAL,0272,RC,,,both,,,769.99,231,"AMERIGROUP MEDICAID [20100]",Amerigroup,,91.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.55,654.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL 45CM 5MM PALPATION GRADUATED",SUP-600-496,CDM,S27200284,LOCAL,0272,RC,,,both,,,518.89,155.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,213.26,41.1,,,,,0,60.35,441.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 8CM 5FR 7MM .035IN BALLOON",SUP-G52274,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.64,68,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 16MM 140CM 2.75MM CORONARY STENT PLATINUM",SUP-H7493927416270,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 6-0 PC-1 18IN MONOFILAMENT BLUE",SUP-8617G,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.14,21.04,"NOVANET [10819]",Novanet,,52.61,75,,,,,0,8.16,59.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR NETRAC LXD 2 BLADE CORDLESS LED LIGHT SOURCE SMOKE",SUP-C100270,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 10MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620210,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"MULTIPLAN [10600]",Multiplan,,9565.82,85,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVOLUTION SUTURE PASSER",SUP-FG0008,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"CIGNA [10200]","Cigna Local Plus",,1183.69,53.5,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STEERABLEBALLOON CA",SUP-ARC15SB-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,18270.00,5481,"MULTIPLAN [10600]",Multiplan,,15529.5,85,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 30MM 4MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP4030X,CDM,C1725,HCPCS,0272,RC,,,both,,,891.00,267.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,103.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION LUBRI-SIL COMPLETE CARE STATLOCK 16FR",SUP-303416A,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.87,51.86,"KAISER [10500]",Kaiser,,115.82,67,,,,,0,20.1,146.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45MMX12MM CLYDESDALE 6D PEEK-OPTIMA RADIOPAQUE",SUP-2968245,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6851.63,28.62,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 12FR SILICONE MIC-KEY SECUR-LOK ENFIT BOLUS",SUP-8200-12LV,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,451.93,41.1,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION REFERENCE 100MM PERCUTANEOUS STERILE",SUP-9733235,CDM,S27200284,LOCAL,0272,RC,,,both,,,2122.50,636.75,"CIGNA [10200]","Cigna Local Plus",,1135.54,53.5,,,,,0,246.85,1804.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TITANIUM DOME HIP ACETABULAR CANCELLOUS",SUP-103535,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"BLUE CROSS [10001]","Blue Cross HMO",,390.55,39.2,,957.42,156.86,7483.26,51,115.87,846.86,"percent of total billed charges",
"SCR BONE 2.7MM 10MM STAINLESS STEEL CORTICAL TRIMED CLAVICLE",SUP-HEX2.7-10,CDM,C1713,HCPCS,0278,RC,,,both,,,729.00,218.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,495.72,68,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT PL SITEMARK 51CM 47CM 9FR 7FR STRAIGHT CURVE",SUP-410170,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2524.5,68,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM RELINE 2C SPINE POLYAXIAL NONSTERILE",SUP-16016540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"NOVANET [10819]",Novanet,,7160.14,75,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN JUDKINS",SUP-77801400,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ISOSORBIDE DINITRATE 10 MG TABLET, IMMEDIATE RELEASE",RX-4064,CDM,,,0637,RC,63739-0569-10,NDC,both,1,UN,6.27,1.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UNI-FUSE FLOW-THRU HUB 90CM 20CM 5FR THROMBECTOMY",SUP-12401807,CDM,C1757,HCPCS,0272,RC,,,both,,,1641.75,492.52,"FIRST HEALTH [10303]","First Health",,1313.4,80,,,,,0,190.94,1395.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 150MM 20MM VASCULAR NITINOL VENOUS ILIOFEMORAL",SUP-AB9U20150090,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"CIGNA [10200]",Cigna,,4692,40,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 6-0 S-29 12IN 2 ARM BRAID COATED VIOLET",SUP-J556G,CDM,S27200284,LOCAL,0272,RC,,,both,,,162.65,48.79,"FIRST HEALTH [10303]","First Health",,130.12,80,,,,,0,18.92,138.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 28MM TI",SUP-SPL-35280-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPHTH,PERTUS(AC)TETANUS VAC(PF) 2 LF-(5-3-5MCG)-5 LF/0.5ML IM SUPERORDERABLE",RX-408121993,CDM,90715,HCPCS,0636,RC,58160-0842-43,NDC,both,.5,ML,471.91,141.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,77.4,,,,,,,46.4,401.12,"fee schedule",
"PATCH SURGICAL 10.1X6.1IN SPRING OPEN BIORESORBABLE SELF",SUP-5950060,CDM,C1781,HCPCS,0278,RC,,,both,,,6917.40,2075.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,804.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,804.49,5879.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 24MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR24,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Local Plus",,4129.65,31.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR VL3.5 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H74938969720,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"PHCS [10601]",PHCS,,256.51,70,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA EXTRA FULL PROFILE SOFT TOUCH",SUP-SSX-615,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PHCS [10601]",PHCS,,5288.85,70,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 60MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.060,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"CIGNA [10200]",Cigna,,140.32,68,,1831.33,1831.33,1831.33,16,24,175.41,"percent of total billed charges",
"COIL EMBOLIZATION 6CM 2MM CONCERTO 3D",SUP-PV-2-6-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cpap Generator Infant Flow",PX-E27000100,CDM,E27000100,LOCAL,0270,RC,,,both,,,361.89,108.57,"NOVANET [10819]",Novanet,,271.42,75,,,,,0,42.09,307.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 4 VIVID LED BLADE HANDLE MERCURY FREE",SUP-301-LED-104S,CDM,S27200284,LOCAL,0272,RC,,,both,,,98.96,29.69,"FIRST HEALTH [10303]","First Health",,79.17,80,,,,,0,11.51,84.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 2-0 GS-21 .5 CIRCLE 9IN 37MM CLSR TAPER",SUP-VLOCM0345,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"CIGNA [10200]","Cigna Local Plus",,104.77,53.5,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Factor XIII",PX-305000027,CDM,85290,CPT,0305,RC,,,both,,,715.00,214.5,"FIRST HEALTH [10303]","First Health",,572,80,,,,,0,0.01,607.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 5.0MM X 15.0MM",SUP-495001512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 10MM IPOLY XE POSTERIOR STABILIZE ITOTAL",SUP-TPS-020-1000,CDM,C1776,HCPCS,0278,RC,,,both,,,2130.00,639,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,977.67,45.9,,,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 90CM 7FR 5.6FR STRAIGHT GUIDING",SUP-H965100510,CDM,C1887,HCPCS,0272,RC,,,both,,,2503.13,750.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1702.13,68,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CARDIOMEMS CARDIAC PULMONARY ARTERY SENSOR DELIVERY","SUP-CM PATIENT SYSTEM",CDM,C2624,HCPCS,0278,RC,,,both,,,102600.00,30780,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,41040,40,,,,,0,11932.38,87210,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cryptosporidium Ag Eia",PX-306000100,CDM,87328,CPT,0306,RC,,,both,,,66.30,19.89,"CIGNA [10200]",Cigna,,30.4,,,,,,,0.01,56.36,"fee schedule",
"ASPIRATION NEEDLE, 5MMX42CM, 15 GAUGE NEEDLE 10/BOX",SUP-MY3015,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"KAISER [10500]",Kaiser,,145.73,67,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE FLOPPY II VASCULAR STRAIGHT 300CM 2CM .014IN",SUP-22359M,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 135+ MM 14MM PERSONA 3MM OFFSET KNEE STERILE LATEX",SUP-42560313514,CDM,C1776,HCPCS,0278,RC,,,both,,,16990.56,5097.17,"KAISER [10500]",Kaiser,,11383.68,67,,,,,0,1976,14441.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 6-0 PC-1 18IN MONOFILAMENT BLUE",SUP-8617G,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.14,21.04,"UHC [10700]","United Healthcare",,44.4,63.3,,,,,0,8.16,59.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN HOCKEY",SUP-77827800,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM SPINE PLY NONSTERILE 4MM ROD",SUP-102035118,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"INSRT TIBIAL 2 10MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620210,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"FIRST HEALTH [10303]","First Health",,9003.12,80,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 40MM 20MM 75CM ENDOPROSTHESIS VENOUS CATH",SUP-H74912044204070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1003.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 200MM 120CM 8MM VASCULAR PERIPHERAL SELF",SUP-PRB35-08-200-120,CDM,C1876,HCPCS,0278,RC,,,both,,,11625.00,3487.5,"CIGNA [10200]","Cigna Local Plus",,3661.88,31.5,,,,,0,1351.99,9881.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE FLOPPY II VASCULAR J CURVE 300CM 2CM .014IN",SUP-22359MJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICKSTICK 25CM 10FR LOOP DRNG FLEXIMA HYDROPHILIC",SUP-M001271470,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 200MM 120CM 8MM VASCULAR PERIPHERAL SELF",SUP-PRB35-08-200-120,CDM,C1876,HCPCS,0278,RC,,,both,,,11625.00,3487.5,"CIGNA [10200]","Cigna Open Access",,3894.38,33.5,,,,,0,1351.99,9881.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 45MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0318,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"MULTIPLAN [10600]",Multiplan,,805.55,85,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Avul Nail Plate Smpl",PX-510000036,CDM,11730,CPT,0761,RC,,,both,,,2956.01,886.8,"MULTIPLAN [10600]",Multiplan,,2512.61,85,,,,,0,343.78,2740.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 4IN JEWELERS .4MM INSULATE",SUP-US337,CDM,S27200284,LOCAL,0272,RC,,,both,,,2826.08,847.82,"FIRST HEALTH [10303]","First Health",,2260.86,80,,,,,0,328.67,2402.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM QUADLINK 10MM IMPL",SUP-AR-1288QIS-100,CDM,C1713,HCPCS,0278,RC,,,both,,,15757.88,4727.36,"AETNA [10100]","Aetna HMO/PPO",,12527.51,79.5,,1521.93,481.35,16760.95,30,1832.64,13394.2,"percent of total billed charges",
"SCR BONE 2.4MM 28MM LCP STAINLESS STEEL DISTAL RADIAL SELF",SUP-212.828,CDM,C1713,HCPCS,0278,RC,,,both,,,802.87,240.86,"CIGNA [10200]","Cigna Local Plus",,429.54,53.5,,3978.14,359.25,3978.14,24,93.37,682.44,"percent of total billed charges",
"SCREW BONE L58 MM OD5 MM FEMORAL LOW PROFILE STERILE RFN-ADV",SUP-04.045.358TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"CIGNA [10200]",Cigna,,1271.53,68,,1831.33,1831.33,1831.33,16,217.47,1589.42,"percent of total billed charges",
"EXP TISSUE 15X13CM BREAST 650ML STYLE 133SX-T TEXTURED TAB",SUP-133SX-15-T,CDM,C1789,HCPCS,0278,RC,,,both,,,6510.00,1953,"NOVANET [10819]",Novanet,,4882.5,75,,,,,0,757.11,5533.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 10.5IN 26FR SILICONE Y PORT GRADUATE SHAFT OPEN DISTAL",SUP-8884720265E,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.71,111.81,"MULTIPLAN [10600]",Multiplan,,316.8,85,,,,,0,43.35,316.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachytx Isodose Complx",PX-333000066,CDM,77318,CPT,0333,RC,,,both,,,4264.02,1279.21,"CIGNA [10200]",Cigna,,2899.53,68,,,,,0,408.8,4264.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 144MM 12MM PRESS FIT FULL PROFILE TAPERLOC PPS",SUP-51-101120,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"UHC [10700]","United Healthcare",,15320.71,63.3,,8601.07,8395.67,8601.07,"1 through 10",2814.85,20572.84,"percent of total billed charges",
"KIT CRICO 6MM PCK PORTEX SOFT SEAL CUFF VARESS NDL TUBE",SUP-100/465/060,CDM,C1713,HCPCS,0278,RC,,,both,,,1266.60,379.98,"KAISER [10500]",Kaiser,,848.62,67,,,,,0,147.31,1076.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX9MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2990922,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"PHCS [10601]",PHCS,,11128.32,70,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 90MM 22MM DUODENAL NITINOL PYLORUS UNCOVER",SUP-DNJF-22-090-230,CDM,C1876,HCPCS,0278,RC,,,both,,,15104.24,4531.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1789.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1756.62,12838.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 8-11 E-F",SUP-42522100812,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS [10001]","Blue Cross HMO",,4224.36,39.2,,5311.50,4717.44,5388.59,31,1253.3,9159.96,"percent of total billed charges",
"COIL EMBOLIZATION 20CM 6MM TARGET 360D STD PLATINUM",SUP-M0035466200,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1641.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Punc Shunt Tube/Rsvr Asp/Inj",PX-361000249,CDM,61070,CPT,0361,RC,,,both,,,3722.77,1116.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1718,,"Case rate ($1,718). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,432.96,3722.77,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT 3d WO Postprocess",PX-350000001,CDM,76376,CPT,0350,RC,,,both,,,1694.50,508.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,742,,,,,,,150.67,1694.5,"per diem",
"INSRT TIBIAL 2 10MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158101110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PHCS [10601]",PHCS,,7822.19,70,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Trach Cuffed Fenestrated",PX-E27200229,CDM,E27200229,LOCAL,0272,RC,,,both,,,311.43,93.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,36.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.22,264.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE LEFT CRUCIATE RETAIN ATTUNE POROCOAT",SUP-150401108,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"CIGNA [10200]","Cigna Local Plus",,9064.2,31.5,,5372.07,4581.20,7242.98,23,3346.56,24458.96,"percent of total billed charges",
"HC Occult Bld Othr Sources",PX-301000117,CDM,82271,CPT,0301,RC,,,both,,,55.90,16.77,"MULTIPLAN [10600]",Multiplan,,47.52,85,,,,,0,0.01,47.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Design Mlc Dvc for Imrt",PX-333000021,CDM,77338,CPT,0333,RC,,,both,,,11443.57,3433.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1533,,"Per diem ($1,533).",,,,0,1330.89,9727.03,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Design Mlc Dvc for Imrt",PX-333000021,CDM,77338,CPT,0333,RC,,,both,,,11443.57,3433.07,"CIGNA [10200]","Cigna Local Plus",,6122.31,53.5,,,,,0,1330.89,9727.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 22CM 10FR LARGE PROXIMAL PIGTAIL CURVE",SUP-M001235580,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,408.97,45.9,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR HEAD TITANIUM STD TAPER COMPREHENSIVE VERSA-DIAL",SUP-118001,CDM,C1776,HCPCS,0278,RC,,,both,,,9089.00,2726.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3735.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",1057.05,7725.65,"percent of total billed charges",
"PLATE 14MM 14X16X2.5MM TITANIUM 1 LEVEL PREBENT SKYLINE BONE",SUP-186801014,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,497.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,488.46,3570,"percent of total billed charges",
"STY LD 59CM .016IN FIRM KNOB",SUP-6604,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT LAPAROSCOPIC CLLGN 32CM 8MM FALOPE-RING BAND TROCAR",SUP-005280-901,CDM,S27200284,LOCAL,0272,RC,,,both,,,2296.88,689.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,272.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,267.13,1952.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL CORTICAL THK3-12MM HALVED ALLOGRAFT STRUT",SUP-450481,CDM,S27800098,LOCAL,0278,RC,,,both,,,7973.64,2392.09,"CIGNA [10200]","Cigna Open Access",,4537,56.9,,,,,0,927.33,6777.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 3.50 X 12MM",SUP-H7493942812350,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"AMERIGROUP MEDICAID [20100]",Amerigroup,,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL CORTICAL THK3-12MM HALVED ALLOGRAFT STRUT",SUP-450481,CDM,S27800098,LOCAL,0278,RC,,,both,,,7973.64,2392.09,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,927.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,927.33,6777.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 10CM 10FR DUODENAL BEND BILIARY FLEXIMA PLASTIC",SUP-M00539320,CDM,C2625,HCPCS,0278,RC,,,both,,,755.24,226.57,"BLUE CROSS [10001]","Blue Cross HMO",,296.05,39.2,,,,,0,87.83,641.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLUX FIBERS 10CC",SUP-IFLX-CF-10,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1324.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 12MM INDEPENDENCE SPINE FIX ANGLE",SUP-176.12,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.50,506.25,"FIRST HEALTH [10303]","First Health",,1350,80,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SENSOR 28CM 5CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX",SUP-M006175284110,CDM,C2617,HCPCS,0278,RC,,,both,,,1205.77,361.73,"NOVANET [10819]",Novanet,,904.33,75,,,,,0,140.23,1024.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Icd Gen Only",PX-480000029,CDM,33240,CPT,0481,RC,,,both,,,7251.00,2175.3,"KAISER [10500]",Kaiser,,4858.17,67,,,,,0,843.29,7251,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 014 150CM 8CM 2.5MM BALLOON DILATATION",SUP-U41502H8,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC",615,MS-DRG,,,,,,,inpatient,,,86871.33,26061.4,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 12MM 4MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP4012X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT RETRIEVER 20MM 4MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0032PK42010001,CDM,S27200284,LOCAL,0272,RC,,,both,,,29495.34,8848.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"TROCAR LAPAROSCOPIC 150MM 5MM KII 2 PACK ACCESS SYSTEM Z",SUP-CTB10,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"MULTIPLAN [10600]",Multiplan,,184.88,85,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 12.5CM 4MM IBUR DISTAL BEND ROUND DIAMOND",SUP-8431-013-040DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,2737.50,821.25,"KAISER [10500]",Kaiser,,1834.13,67,,,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SPECTRUM MVP 45D RIGHT HOOK SUT STERILE DISPOSABLE",SUP-C6410,CDM,S27200284,LOCAL,0272,RC,,,both,,,1799.93,539.98,"CIGNA [10200]",Cigna,,1223.95,68,,,,,0,209.33,1529.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X22X10MM MODULUS 15D XL WIDE STERILE LATEX",SUP-1225055P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,29925.00,8977.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3546.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 11CMX8MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-2-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"CIGNA [10200]","Cigna Local Plus",,780.03,53.5,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PYRAZINAMIDE 500 MG TABLET",RX-6738,CDM,,,0637,RC,33342-0447-11,NDC,both,1,UN,25.19,7.56,"MULTIPLAN [10600]",Multiplan,,21.41,85,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 V-47 14IN 2 ARM MONOFILAMENT BLUE",SUP-8592G,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.97,18.29,"KAISER [10500]",Kaiser,,40.85,67,,,,,0,7.09,51.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 1.5MM X 5MM COCR",SUP-VAL-15050-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]",Cigna,,969.41,68,,1831.33,1831.33,1831.33,16,165.8,1211.76,"percent of total billed charges",
"OSTEOTOME HOKE 5 1/2IN 5/16IN",SUP-28-4958,CDM,S27200284,LOCAL,0272,RC,,,both,,,190.36,57.11,"CIGNA [10200]","Cigna Local Plus",,101.84,53.5,,,,,0,22.14,161.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 38MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25038W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"BLUE CROSS [10001]","Blue Cross HMO",,1323,39.2,,9776.84,9776.84,9776.84,"1 through 10",392.51,2868.75,"percent of total billed charges",
"GRAFT BONE PRECISION ALLOGRAFT 26MMX12MM",SUP-451266A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRENCH SURGICAL HEXAGON MICRO100",SUP-136500500,CDM,S27000186,LOCAL,0270,RC,,,both,,,457.33,137.2,"NOVANET [10819]",Novanet,,343,75,,,,,0,53.19,388.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM CD HORIZON LEGACY TITANIUM PEDICLE",SUP-75445540,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"VXSK-180P RF WIRE 63CM/55DEG/D1 SHEATH",SUP-VXSK0124,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4199.34,68,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 380MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.159S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3554.13,28.62,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNGOSCOPE SPECTRUM LOPRO 2 TITANIUM GLIDESCOPE DISP",SUP-0270-0877,CDM,S27200284,LOCAL,0272,RC,,,both,,,414.99,124.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,282.19,68,,,,,0,48.26,352.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X6MM ANATOMIC 14MM PEEK RADIOPAQUE CERVICAL",SUP-4240664,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 3-0 SH 30IN 2 ARM BRAIDED GREEN",SUP-X562H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETENE 30X30CM MONOFILAMENT STERILE",SUP-PPM3030,CDM,C1781,HCPCS,0278,RC,,,both,,,882.58,264.77,"KAISER [10500]",Kaiser,,591.33,67,,,,,0,102.64,750.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 12MM 3.2-2.4-2.6FR 2.25MM",SUP-SPR22512W,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE LEFT TOTAL STBL TRIATHLON COCR",SUP-5512-F-201,CDM,C1776,HCPCS,0278,RC,,,both,,,20599.49,6179.85,"FIRST HEALTH [10303]","First Health",,16479.59,80,,,,,0,2395.72,17509.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE NARROW SAGITTAL MICS SURGICAL DISPOSABLE",SUP-116171,CDM,S27200284,LOCAL,0272,RC,,,both,,,2287.50,686.25,"UHC [10700]","United Healthcare",,1447.99,63.3,,,,,0,266.04,1944.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 2.75MM BALLOON DILATATION PEBAX",SUP-1012273-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 157MM 28MM 22FR VALIANT CAPTIVIA SINUSOIDAL",SUP-VAMF2828C150TU,CDM,C1874,HCPCS,0278,RC,,,both,,,96985.50,29095.65,"KAISER [10500]",Kaiser,,64980.29,67,,,,,0,11279.41,82437.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F701,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"PHCS [10601]",PHCS,,11998.02,70,,,,,0,1993.39,14569.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Scrn Low Risk",PX-750000194,CDM,G0121,HCPCS,0750,RC,,,both,,,3920.00,1176,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,464.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",458.96,458.96,458.96,"1 through 10",455.9,3920,"percent of total billed charges",
"SLEEVE PROTECTION LONG FLEXIBLE 8-11MM NAIL STERILE",SUP-03.043.033S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1633.13,489.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1110.53,68,,,,,0,189.93,1388.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC",696,MS-DRG,,,,,,,inpatient,,,28870.46,8661.14,"AETNA [10100]","Aetna HMO/PPO",,12963.54,,"Fee schedule rate ($12,963.54). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,4273.91,17182.97,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SENSOR DUAL-FLEX 26CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175263120,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"CIGNA [10200]","Cigna Local Plus",,711.69,,,,,,,154.71,1130.72,"percent of total billed charges",
"BLADE SAW 70.8X12.5MM THK1MM THK1.12MM LARGE BONE",SUP-KM-277R,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.18,55.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,75.7,41.1,,,,,0,21.42,156.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENOL 1.4 % MUCOSAL AEROSOL SPRAY",RX-27889,CDM,,,0250,RC,00904-6305-21,NDC,both,177,ML,80.00,24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.3,68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 4.0/20",SUP-434896,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"AETNA [10100]","Aetna HMO/PPO",,15701.65,79.5,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT GPS MEDIUM 6 CC PUTTY BIOAC",SUP-76000060,CDM,C1713,HCPCS,0278,RC,,,both,,,9108.00,2732.4,"FIRST HEALTH [10303]","First Health",,7286.4,80,,,,,0,1059.26,7741.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 20MM 190CM 5MM",SUP-R51005002L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"NOVANET [10819]",Novanet,,1478.81,75,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 6-8 SMALL MALE BEIGE CANVAS RUBBER RIGID",SUP-2041-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.42,14.23,"CIGNA [10200]","Cigna Open Access",,26.98,56.9,,,,,0,5.51,40.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL BROWN WHITE 1.8MM OTO-FLEX DIAMOND STERILE",SUP-3155645,CDM,S27200284,LOCAL,0272,RC,,,both,,,1482.30,444.69,"PHCS [10601]",PHCS,,1037.61,70,,,,,0,172.39,1259.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 25MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75447525,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,3978.14,359.25,3978.14,24,441.36,3225.75,"percent of total billed charges",
"NUT EXTERNAL FIXATION SQUARE MRI SAFE",SUP-03.311.060,CDM,S27800098,LOCAL,0278,RC,,,both,,,666.95,200.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,306.13,45.9,,,,,0,77.57,566.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET",RX-10384,CDM,,,0637,RC,64980-0146-98,NDC,both,1,UN,10.22,3.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4.2,41.1,,,,,0,1.19,8.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hrdtry Brst Ca-Rlatd Do 5+",PX-310000040,CDM,81432,CPT,0310,RC,,,both,,,4514.00,1354.2,"CIGNA [10200]",Cigna,,1493.91,,,,,,,0.01,3836.9,"fee schedule",
"ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML SUPERORDERABLE ORAL SOLUTION",RX-409531,CDM,,,0250,RC,08888-8879-14,NDC,both,5,ML,25.19,7.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXS OFFSET 150CM .05IN GUIDING STERILE LATEX FREE",SUP-M003DC050150A0,CDM,S27200284,LOCAL,0272,RC,,,both,,,7523.76,2257.13,"CIGNA [10200]",Cigna,,5116.16,68,,,,,0,875.01,6395.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 56CM 22GA 19CM PROC CURVE STERILE BROCKENBROUGH",SUP-EP003997S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Glomerular Basement Membrane",PX-301000267,CDM,83520,CPT,0301,RC,,,both,,,354.35,106.3,"MULTIPLAN [10600]",Multiplan,,301.2,85,,,,,0,0.35,301.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE POSTERIOR STABILIZED TRIATHLON",SUP-5532P211,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Open Access",,4754.51,56.9,,5302.19,4377.88,6578.61,27,971.79,7102.52,"percent of total billed charges",
"SCR BASEPLT 38MM 4.5MM AEQUALIS REVERSED GLENOID TITANIUM",SUP-VDV238,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"BLUE CROSS [10001]","Blue Cross HMO",,609.95,39.2,,5311.50,4717.44,5388.59,31,180.96,1322.6,"percent of total billed charges",
"HC Analysis Dev Imp Loop Recorder",PX-480000060,CDM,93291,CPT,0480,RC,,,both,,,329.49,98.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,151.24,45.9,,,,,0,38.32,329.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Analysis Dev Imp Loop Recorder",PX-480000060,CDM,93291,CPT,0480,RC,,,both,,,329.49,98.85,"CIGNA [10200]","Cigna Local Plus",,176.28,53.5,,,,,0,38.32,329.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Knee Arthgm",PX-361000048,CDM,27369,CPT,0361,RC,,,both,,,1007.62,302.29,"KAISER [10500]",Kaiser,,675.11,67,,,,,0,117.19,1007.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CRE 5.5CM 6-7-8MM 18-21-24FR BALLOON DILATATION BILIARY",SUP-M00558860,CDM,C1726,HCPCS,0272,RC,,,both,,,2085.75,625.72,"FIRST HEALTH [10303]","First Health",,1668.6,80,,,,,0,242.57,1772.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC MICROPOINT 4-0 M-1 12IN 2 ARM MONOFILAMENT",SUP-744G,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.82,24.25,"UHC [10700]","United Healthcare",,51.16,63.3,,,,,0,9.4,68.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4+ 10MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS4P10R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"CIGNA [10200]",Cigna,,7066.15,68,,5873.17,5873.17,5873.17,"1 through 10",1208.52,8832.69,"percent of total billed charges",
"IVABRADINE 5 MG TABLET",RX-170267,CDM,,,0637,RC,55513-0800-60,NDC,both,1,UN,47.32,14.2,"FIRST HEALTH [10303]","First Health",,37.86,80,,,,,0,5.5,40.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM SUMMIT POROCOAT 9 12/14 HIGH OFFSET TAPER",SUP-157011165,CDM,C1776,HCPCS,0278,RC,,,both,,,25247.25,7574.17,"UHC [10700]","United Healthcare",,15981.51,63.3,,8601.07,8395.67,8601.07,"1 through 10",2936.26,21460.16,"percent of total billed charges",
"GRAFT BONE CORNERSTONE CRYOPRESERVED 7MM",SUP-270070,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 72.5MM KNEE LEFT POSTERIOR STABILIZE OPEN BOX",SUP-184533,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2887.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2887.24,21101.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ercp Biliary&Pancreas Si",PX-320000112,CDM,74330,CPT,0320,RC,,,both,,,2002.00,600.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1361.36,68,,,,,0,167.32,1701.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US OB > 1st Trimst Txabd Sngl",PX-402000016,CDM,76805,CPT,0402,RC,,,both,,,1394.28,418.28,"FIRST HEALTH [10303]","First Health",,1115.42,80,,,,,0,139.53,1185.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 10MM 3.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3510X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR .071IN AMPLATZ LEFT 3 CURVE GUIDING NYLON",SUP-LA6AL30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.5MM X 30MM TI",SUP-VAN-15300-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"FIRST HEALTH [10303]","First Health",,777.6,80,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLYFLEX 40MM 9MM 12MM AIRWAY POLYESTER SILICONE SELF",SUP-7008,CDM,C1887,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,395.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,388.15,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X8MM COLONIAL 7D LORDOTIC 14MM XL TITANIUM",SUP-365.808CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC MEDIUM 24IN 16-18IN KNEE 2 AXIS 1 PIECE",SUP-79-94255,CDM,S27000186,LOCAL,0270,RC,,,both,,,410.12,123.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,48.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.7,348.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ABLATION RADIOFREQUENCY",SUP-64082,CDM,C1886,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 25.4IN 6MM DA VINCI SP 9.8MM",SUP-430200,CDM,S27000186,LOCAL,0270,RC,,,both,,,2324.70,697.41,"MULTIPLAN [10600]",Multiplan,,1976,85,,,,,0,270.36,1976,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 22FR SILICONE RADIOPAQUE BOLUS ENTERAL FEED INTERNAL",SUP-0110-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"CIGNA [10200]","Cigna Local Plus",,149.74,53.5,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 13.3MM 24.2MM 22.8MM ATS OPEN PIVOT AP360 24MM",SUP-505DM24,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"NOVANET [10819]",Novanet,,17718.75,75,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 4-0 P-3 18IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP494G,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.78,20.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,46.77,68,,,,,0,8,58.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +20 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2000,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 8IN MICROVASCULAR SERRATE NDL TUNGSTEN CARBIDE",SUP-32-327,CDM,S27200284,LOCAL,0272,RC,,,both,,,690.85,207.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,283.94,41.1,,,,,0,80.35,587.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETA HOODED PMP E+ MP11",SUP-932-44-764,CDM,C1776,HCPCS,0278,RC,,,both,,,16186.99,4856.1,"BLUE CROSS [10001]","Blue Cross PPO",,6345.3,39.2,,3949.44,3949.44,3949.44,"1 through 10",1882.55,13758.94,"percent of total billed charges",
"SLING URETHRAL VIRTUE ALEXIS MALE",SUP-50020,CDM,C1771,HCPCS,0278,RC,,,both,,,33604.20,10081.26,"AETNA [10100]","Aetna HMO/PPO",,26715.34,79.5,,,,,0,3908.17,28563.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enterovirus Ab",PX-302000125,CDM,86658,CPT,0302,RC,,,both,,,77.00,23.1,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,65.45,"per diem",
"BLADE SAW .5IN SIGMA STRYKER LATEX FREE",SUP-562711500,CDM,S27200284,LOCAL,0272,RC,,,both,,,446.16,133.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.89,379.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CM Z1 ST/G7 CP/XL AA/DM/CER HD/INS",SUP-98-0001-003-51,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"NOVANET [10819]",Novanet,,20790,75,,,,,0,20790,20790,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 60CM 10FR TAPER URETERAL 2 LUMEN TORQUE STABLE SHAFT",SUP-608BX,CDM,C1758,HCPCS,0272,RC,,,both,,,374.55,112.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,254.69,68,,,,,0,43.56,318.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL LEGION 6 L 10DX10P KNEE SCR",SUP-71421754,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 22CM PUMP SET INFLATABLE FLUID FILL SOFT",SUP-ES8822,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"UHC [10700]","United Healthcare",,39689.1,63.3,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 E-F 17MM KNEE FIX BEARING PROLONG NEXGEN",SUP-00596204017,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2266.26,28.62,,,,,0,920.91,6730.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE COMMAND VASCULAR STRAIGHT 300CM 10CM .018IN",SUP-1013731,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,114.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACE E-PLUS NEUT 10D HD40",SUP-932-40-756,CDM,C1776,HCPCS,0278,RC,,,both,,,16186.99,4856.1,"BLUE CROSS [10001]","Blue Cross PPO",,6345.3,39.2,,3949.44,3949.44,3949.44,"1 through 10",1882.55,13758.94,"percent of total billed charges",
"DEFIB CARDIAC VIVA S CRT-D ICD DF-1 PHYSIOCURVE DESIGN",SUP-DTBB1D1,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"BLUE CROSS [10001]","Blue Cross HMO",,22626.24,39.2,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NONABSORB PROPLENE W/NEEDL",SUP-M0068332351,CDM,S27200284,LOCAL,0272,RC,,,both,,,519.75,155.92,"CIGNA [10200]","Cigna Open Access",,295.74,56.9,,,,,0,60.45,441.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 100MM 125CM 5MM 6FR BILIARY",SUP-G50162,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"AMERIGROUP MEDICAID [20100]",Amerigroup,,721.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARMSTRONG VT 1.14MM ID BLUE FLPL",SUP-525-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,188.25,56.47,"BLUE CROSS [10001]","Blue Cross PPO",,73.79,39.2,,,,,0,21.89,160.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER 365UM FLEXIVA FLEXSHIELD HIGH POWER POLISH",SUP-M006R8403921,CDM,S27200284,LOCAL,0272,RC,,,both,,,2258.15,677.44,"NOVANET [10819]",Novanet,,1693.61,75,,,,,0,262.62,1919.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC SMALL 20X8IN LEG FEMUR POSTERIOR MALLEABLE",SUP-79-72293,CDM,S27000186,LOCAL,0270,RC,,,both,,,215.76,64.73,"CIGNA [10200]","Cigna Open Access",,122.77,56.9,,,,,0,25.09,183.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 12MM 2.75MM CORONARY STENT COCR",SUP-1007847-12,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Prostate Transrectal US Guided",PX-361000741,CDM,55707,CPT,0361,RC,,,both,,,4814.28,1444.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4814.28,,"Case rate ($5,284). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,559.9,4814.28,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 100MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,166.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 14MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620414,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS [10001]","Blue Cross HMO",,4411.53,39.2,,5311.50,4717.44,5388.59,31,1308.83,9565.82,"percent of total billed charges",
"HC Bun POC",PX-301000429,CDM,84520,CPT,0301,RC,,,both,,,106.00,31.8,"CIGNA [10200]",Cigna,,8.69,,,,,,,0.11,90.1,"fee schedule",
"NDL BIOPSY 8GA 4IN BONE MARROW",SUP-RBN-84,CDM,S27200284,LOCAL,0272,RC,,,both,,,400.20,120.06,"CIGNA [10200]",Cigna,,272.14,68,,,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 18MM 25MM MOSAIC CINCH PORCINE BIOPROSTHESIS",SUP-310-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3297.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENDOMAXX 150MM 90CM 19MM 24FR ESOPHAGEAL SILICONE OTW",SUP-MAXX-1915,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840007550,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULTI-TAP ADAPTER A22 AAC DISPOSABLE",SUP-A22,CDM,S27000186,LOCAL,0270,RC,,,both,,,261.00,78.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,119.8,45.9,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 156MM 26-34MM 30MM 20FR ZENITH TX2",SUP-G47472,CDM,C1874,HCPCS,0278,RC,,,both,,,98041.65,29412.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,40295.12,41.1,,,,,0,11402.24,83335.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE MINI HEXAGONAL 2.5CM 1.5CM 7FR ACUSNARE 1 PIECE BRAID",SUP-G22701,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.43,49.33,"CIGNA [10200]",Cigna,,111.81,68,,,,,0,19.12,139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 285MM 3MM KIRSCHNER T2 WCH STERILE",SUP-1806-1417S,CDM,C1713,HCPCS,0278,RC,,,both,,,843.70,253.11,"BLUE CROSS [10001]","Blue Cross PPO",,330.73,39.2,,957.42,570.23,957.42,28,98.12,717.15,"percent of total billed charges",
"PK 8CM SINUS NASAL ABSORBENT FIRM NASOPORE NONSTERILE LATEX",SUP-5400020008,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X300 135CM SL",SUP-48003030R,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,707.89,68,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 26CM 6FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251330,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS [10001]","Blue Cross HMO",,496.03,39.2,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL STD 65MM KNEE RIGHT GMRS COCR",SUP-64952040,CDM,C1776,HCPCS,0278,RC,,,both,,,34568.10,10370.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4096.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,4020.27,29382.89,"percent of total billed charges",
"STEM EXT 110MM 14MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-1513-14-110,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,979.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,961.36,7026.27,"percent of total billed charges",
"OXIMETER PULSE RAD-5 PORTABLE CONFIGURABLE HANDHELD BOOT",SUP-9196,CDM,S27000186,LOCAL,0270,RC,,,both,,,4416.00,1324.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3002.88,68,,,,,0,513.58,3753.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 20MM CANCELLOUS",SUP-117220000,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"BLUE CROSS [10001]","Blue Cross PPO",,449.29,39.2,,957.42,570.23,957.42,28,133.3,974.23,"percent of total billed charges",
"PLATE 135D STD BARREL 62X19X5.8MM STAINLESS STEEL 4.5MM",SUP-281.131S,CDM,C1713,HCPCS,0278,RC,,,both,,,3765.33,1129.6,"AETNA [10100]","Aetna HMO/PPO",,2993.44,79.5,,1521.93,481.35,16760.95,30,437.91,3200.53,"percent of total billed charges",
"SCR BONE 5.5MM 50MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840005550,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 100MM 120CM 6MM 6FR VASCULAR PERIPHERAL",SUP-S-60-100-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"MULTIPLAN [10600]",Multiplan,,8552.7,85,,,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"16MM AMPLATZER MUSCULAR VSD OCCLUDER",SUP-9-VSD-MUSC-016,CDM,C1817,HCPCS,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS [10001]","Blue Cross PPO",,24578.4,39.2,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 V-47 14IN 2 ARM MONOFILAMENT BLUE",SUP-8592G,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.97,18.29,"PHCS [10601]",PHCS,,42.68,70,,,,,0,7.09,51.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 13MM 80L/20D L POLYLACTIC ACID 1.1MM CONTOUR",SUP-541113,CDM,C1713,HCPCS,0278,RC,,,both,,,1218.08,365.42,"KAISER [10500]",Kaiser,,816.11,67,,,,,0,141.66,1035.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 3 PREASSEMBLE BLADE STD HANDLE LED LIGHT",SUP-040-04-0430U,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.42,18.73,"CIGNA [10200]","Cigna Open Access",,35.52,56.9,,,,,0,7.26,53.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX SYMMETRIC PDS PLUS 0 CT-1 24IN VIOLET",SUP-SXPP1A440,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"CIGNA [10200]","Cigna Local Plus",,128.56,53.5,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP TUBE 11MM CRANIOFIX 2 CRANIAL FLAP TITANIUM SECURE",SUP-FF490T,CDM,C1713,HCPCS,0278,RC,,,both,,,1044.90,313.47,"NOVANET [10819]",Novanet,,783.68,75,,,,,0,121.52,888.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 350ML GEL TEXTURED SILTEX SILICONE P4.9CM HIGH",SUP-3544350,CDM,C1789,HCPCS,0278,RC,,,both,,,3885.00,1165.5,"BLUE CROSS [10001]","Blue Cross PPO",,1522.92,39.2,,16595.83,16595.83,16595.83,"1 through 10",451.83,3302.25,"percent of total billed charges",
"PLATE STAINLESS STEEL LOCK HOLE COMPRESSION SLOT PRECONTOUR",SUP-AR-2652CR,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ CONTROLCATH 110CM 6FR C PULMONARY ARTERY",SUP-C145F6N,CDM,C1751,HCPCS,0272,RC,,,both,,,926.07,277.82,"UHC [10700]","United Healthcare",,586.2,63.3,,,,,0,107.7,787.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION",RX-234450,CDM,A9573,HCPCS,0636,RC,00270-7025-40,NDC,both,7.5,ML,225.00,67.5,"FIRST HEALTH [10303]","First Health",,180,80,,,,,0,26.66,191.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FARAWAVE 4MM ABLATION PULSED FIELD STERILE LATEX FREE",SUP-M004PF41M402,CDM,C1733,HCPCS,0272,RC,,,both,,,53235.00,15970.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,36199.8,68,,,,,0,6191.23,45249.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP XL CURVE 32CM POLYMER LIGATE WECK",SUP-544990,CDM,S27200284,LOCAL,0272,RC,,,both,,,16387.50,4916.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7521.86,45.9,,,,,0,1905.87,13929.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 20MM 8MM BALLOON",SUP-U357582,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 4MM 40MM REUNION STD X3 STERILE",SUP-5571-S-4004,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6854.4,68,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST EXTERNAL FIXATION MAXFRAME 1 HIGH MOUNT MULTIPARALLEL",SUP-03.313.857,CDM,C1713,HCPCS,0278,RC,,,both,,,1280.37,384.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,870.65,68,,,,,0,148.91,1088.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7.5CM 3.5MM GALAXY G3 NEUROVASCULAR 12",SUP-GLY123575,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3400.57,28.62,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Pulm Img Perfsn",PX-341000031,CDM,78580,CPT,0341,RC,,,both,,,1836.14,550.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,420.96,,"Fee schedule rate ($420.96).",,,,0,213.54,1560.72,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CALCAR 25MM RESTORATION +30MM OFFSET HIP MODULAR",SUP-6276-4-325,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2749.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2698.86,19725.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE+ 12.5MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405712,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4435.52,45.9,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL NOTTINGHAM ONE-STEP HYDROPLUS TAPER 70CM 4CM",SUP-M0062301100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1005.78,301.73,"NOVANET [10819]",Novanet,,754.34,75,,,,,0,116.97,854.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR IMC CURVE ANGIOGRAPHIC TRILON BRACHIAL",SUP-H749085262031,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 43MM TITANIUM 2 LEVEL VECTRA BONE 34MM ANTERIOR",SUP-04.613.134,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,521.61,3812.25,"percent of total billed charges",
"FILLER BONE VOID 10CC DBX ALLOGRAFT FREEZE DRIED PASTE",SUP-28100,CDM,C1713,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2850.39,45.9,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 5.5MM CURVE NONSTERILE",SUP-1555501060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TENFUSE PIP ANGLED ALLOGRAFT 15X2MM STERILE",SUP-TFF2015A,CDM,C1762,HCPCS,0278,RC,,,both,,,8763.00,2628.9,"BLUE CROSS [10001]","Blue Cross PPO",,3435.1,39.2,,,,,0,1019.14,7448.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE ORTHOPEDIC COCR 1.7MM 750MM TITANIUM CRIMP CERCLAGE",SUP-611.105.01S,CDM,C1713,HCPCS,0278,RC,,,both,,,2845.50,853.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1306.08,45.9,,,,,0,330.93,2418.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 8.5-10 MEDIUM MALE BEIGE CANVAS RUBBER",SUP-2041-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.42,14.23,"AETNA [10100]","Aetna HMO/PPO",,37.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.51,40.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Vad Complt Tunl W Pump",PX-361000119,CDM,36583,CPT,0361,RC,,,both,,,9864.48,2959.34,"FIRST HEALTH [10303]","First Health",,7891.58,80,,,,,0,1147.24,9679,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL MICROPOINT 6-0 G-6 18IN 2 ARM BRAID COATED VIOLET",SUP-J551G,CDM,S27200284,LOCAL,0272,RC,,,both,,,155.31,46.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.06,132.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Pulm Img Perfsn",PX-341000031,CDM,78580,CPT,0341,RC,,,both,,,1836.14,550.84,"CIGNA [10200]","Cigna Local Plus",,400.49,,,,,,,213.54,1560.72,"fee schedule",
"HC Rpr Eynoel 2.6-7.5cm Cmplx",PX-450000057,CDM,13152,CPT,0361,RC,,,both,,,1861.00,558.3,"MULTIPLAN [10600]",Multiplan,,1581.85,85,,,,,0,216.43,1861,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ASCEND FLEX SHOULDER - TOTAL SHOULDER (INCLUSIVE OF ASCE",SUP-CAPFLEXTSA,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"NOVANET [10819]",Novanet,,20081.25,75,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 8MM 110MM 22MM DHS/DCS STAINLESS STEEL",SUP-280.1,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1236.5,68,,,,,0,211.48,1545.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 4MM 7FR 1-7-4MM SPACING D CURVE ABLATION",SUP-NS7TCDL174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1596.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL 5D ALLOGRAFT 6MM LATEX FREE",SUP-3W3006,CDM,S27800098,LOCAL,0278,RC,,,both,,,5896.74,1769.02,"PHCS [10601]",PHCS,,4127.72,70,,,,,0,685.79,5012.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC 76-91CM SMARTVEST MEDIUM",SUP-SW-30/36-1,CDM,S27000186,LOCAL,0270,RC,,,both,,,437.40,131.22,"CIGNA [10200]",Cigna,,297.43,68,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPENDIX PROCEDURES WITH CC",398,MS-DRG,,,,,,,inpatient,,,60476.49,18142.95,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,9952.29,,"Case rate ($9,388.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,718.28, add-ons for qualifying new technology services are included. If operating cost exceeds $41,757.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,041.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,729.81. The transfer operating threshold is the transfer adjustment factor * $8,718.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $659.14. The transfer capital threshold is the transfer adjustment factor * $659.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,44191.07,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3.5MM 28MM HIP SHORT NECK SUPER FINISH COCR",SUP-26000017,CDM,C1776,HCPCS,0278,RC,,,both,,,8887.20,2666.16,"BLUE CROSS [10001]","Blue Cross PPO",,3483.78,39.2,,3949.44,3949.44,3949.44,"1 through 10",1033.58,7554.12,"percent of total billed charges",
"CUFF TRNQT BLUE 34X4IN LONG LEG 1 FILL LINE POSITIVE LOCK",SUP-ASP-564012,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.00,58.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,80.15,41.1,,,,,0,22.68,165.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 4MM 40MM REUNION STD X3 STERILE",SUP-5571-S-4004,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1194.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1172.3,8568,"percent of total billed charges",
"DEFIB CARDIAC MRI SURESCAN VENTRICULAR 1 CHMBR EV4 LATEX",SUP-DVEA3E4,CDM,C1722,HCPCS,0278,RC,,,both,,,118275.00,35482.5,"CIGNA [10200]","Cigna Open Access",,39622.13,33.5,,,,,0,13755.38,100533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 34MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40034W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"NOVANET [10819]",Novanet,,4079.25,75,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Needle Brachythrpy",PX-E27200193,CDM,C1715,HCPCS,0272,RC,,,both,,,39.60,11.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,26.93,68,,,,,0,4.61,33.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION INTERNALBRACE",SUP-AR-1789J-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1222.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1199.69,8768.18,"percent of total billed charges",
"STENT POLYFLEX 70MM 11MM 18MM TRACHEOBRONCHIAL SILICONE SELF",SUP-M00570240,CDM,C1887,HCPCS,0272,RC,,,both,,,13187.14,3956.14,"UHC [10700]","United Healthcare",,8347.46,63.3,,,,,0,1533.66,11209.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Desensitization Rapid Ea Hr",PX-510000211,CDM,95180,CPT,0761,RC,,,both,,,310.00,93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,36.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.74,310,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 8MM .021IN AZUR DETACHABLE .018IN",SUP-45-480815,CDM,S27800098,LOCAL,0278,RC,,,both,,,6037.50,1811.25,"MULTIPLAN [10600]",Multiplan,,5131.88,85,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ACTIVAPATCH IONTOGO 4 SHUNT DRUG DELIVERY 2CC",SUP-7101336,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.20,17.46,"FIRST HEALTH [10303]","First Health",,46.56,80,,,,,0,6.77,49.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 30MM TITANIUM ALLOY LOCKING ATLANTIS VISION BONE",SUP-976-130,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN JUDKINS LEFT 3.5 CURVE",SUP-LA6JL35SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 30MM 80CM 8MM 6FR VASCULAR NITINOL",SUP-G43855,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross HMO",,1481.76,39.2,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BIOLOGICAL TISSUE 40X30MM TAPESTRY BIOINTEGRATIVE",SUP-TP-4030-01,CDM,C1781,HCPCS,0278,RC,,,both,,,17633.70,5290.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7053.48,40,,,,,0,2050.8,14988.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 21MM 8MM STAINLESS STEEL 1.1MM LONG THREAD",SUP-02.226.121,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"CIGNA [10200]",Cigna,,1118.74,68,,1831.33,1831.33,1831.33,16,191.34,1398.42,"percent of total billed charges",
"LENS IOL 0 D +10.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-SY60WF.105,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 44MM TI",SUP-MTC-37440-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"CIGNA [10200]",Cigna,,848.23,68,,1831.33,1831.33,1831.33,16,145.07,1060.29,"percent of total billed charges",
"CATH BALLOON DILATATION .018IN LONG 4FR 5MM 120CM 15CM PTA",SUP-4365015L,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 0.9% SODIUM CHLORIDE 150ML VIAFLEX LATEX",SUP-2B1321,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ VASCULAR J CURVE 260CM 3CM .035IN STAINLESS",SUP-G03460,CDM,C1769,HCPCS,0272,RC,,,both,,,200.01,60,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.26,170.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP TSS TOTAL SHOULDER ARTHROPLASTY W-LONG STEM",SUP-71701420,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"UHC [10700]","United Healthcare",,16948.58,63.3,,8601.07,8395.67,8601.07,"1 through 10",3113.93,22758.75,"percent of total billed charges",
"DEFIB CARDIAC THK15MM 51X66MM CONSULTA CRT-D ATRIUM",SUP-D204TRM,CDM,C1882,HCPCS,0278,RC,,,both,,,84445.50,25333.65,"BLUE CROSS [10001]","Blue Cross PPO",,33102.64,39.2,,,,,0,9821.01,71778.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RATE BASED",RX-409152,CDM,,,0250,RC,00990-7930-09,NDC,both,1000,ML,100.65,30.19,"CIGNA [10200]",Cigna,,68.44,68,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYOSCYAMINE 0.125 MG DISINTEGRATING TABLET",RX-29822,CDM,,,0637,RC,42192-0338-01,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QDOT MICRO FJ CURVE ABLATION BIDIRECTIONAL",SUP-D139504,CDM,C1732,HCPCS,0272,RC,,,both,,,22560.30,6768.09,"PHCS [10601]",PHCS,,15792.21,70,,,,,0,2623.76,19176.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PT Routine Visit",PX-421000006,CDM,G0151,HCPCS,0421,RC,,,outpatient,,,261.00,78.3,"MULTIPLAN [10600]",Multiplan,,221.85,85,,,,,0,174.87,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 23CM AVANTI+ MID LENGTH LATEX FREE ORANGE",SUP-504607D,CDM,C1894,HCPCS,0272,RC,,,both,,,200.54,60.16,"FIRST HEALTH [10303]","First Health",,160.43,80,,,,,0,23.32,170.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MERSILENE 4-0 FS-2 18IN BRAID WHITE NONABSORBABLE",SUP-R633H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 60MM 2MM .014IN BALLOON DILATATION",SUP-AB14W020060150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.87,68,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 12MM NONLOCKING",SUP-CO-N2312,CDM,C1713,HCPCS,0278,RC,,,both,,,720.90,216.27,"CIGNA [10200]","Cigna Local Plus",,385.68,53.5,,3978.14,359.25,3978.14,24,83.84,612.77,"percent of total billed charges",
"SHIELD CONTAMINATION BLUE CATH-GARD 7-7.5FR CATH",SUP-ST-09880,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.14,31.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.34,90.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 8MM 6FR 1.2MM .07IN ULTRA LOW",SUP-H7493918908120,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION .045IN 9IN KIRSCHNER STAINLESS STEEL 2 END",SUP-KM173-49-45,CDM,C1713,HCPCS,0278,RC,,,both,,,355.74,106.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,101.81,28.62,,,,,0,41.37,302.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.3MM 35MM TITANIUM FOOT TIBIA LOCK LOW PROFILE",SUP-99-T774035,CDM,C1713,HCPCS,0278,RC,,,both,,,1492.91,447.87,"PHCS [10601]",PHCS,,1045.04,70,,,,,0,173.63,1268.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR 5X2CM ENCAP TECHNOLOGY PERICARDIAL",SUP-C0205,CDM,C1768,HCPCS,0278,RC,,,both,,,2874.38,862.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,334.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.29,2443.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 3.5X30MM",SUP-PRV035030CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 17IN 15FR FEMUR ARTERY ADULT 3/8IN CNCT VENT",SUP-96530-015,CDM,S27200284,LOCAL,0272,RC,,,both,,,1903.58,571.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,225.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,221.39,1618.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 20CM 7-24FR MALECOT NEPHRSTMY CATH STENT STYLET",SUP-G14510,CDM,C1729,HCPCS,0272,RC,,,both,,,836.73,251.02,"KAISER [10500]",Kaiser,,560.61,67,,,,,0,97.31,711.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 3-0 CP-2 18IN CONTROL RELEASE MONOFILAMENT 8",SUP-Z761D,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.63,80.89,"NOVANET [10819]",Novanet,,202.22,75,,,,,0,31.36,229.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 12MM 4MM STAINLESS STEEL SHORT THREAD HAND",SUP-02.226.212,CDM,C1713,HCPCS,0278,RC,,,both,,,1647.00,494.1,"FIRST HEALTH [10303]","First Health",,1317.6,80,,,,,0,191.55,1399.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cryptosporidium Ag Eia",PX-306000100,CDM,87328,CPT,0306,RC,,,both,,,66.30,19.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12.44,,,,,,,0.01,56.36,"fee schedule",
"EPIC VASCULAR 6X60X120",SUP-H74939200066020,CDM,C1725,HCPCS,0272,RC,,,both,,,4140.00,1242,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MITRACLIP DELIVERY G5",SUP-MCG50100,CDM,S27800098,LOCAL,0278,RC,,,both,,,188100.00,56430,"CIGNA [10200]","Cigna Local Plus",,59251.5,31.5,,,,,0,21876.03,159885,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT 13CM 5.5MM AGGRESSIVE SURGICAL STERILE DISPOSABLE",SUP-AR-8550DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,58.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Targeted Genomic Seq Analysis",PX-301000564,CDM,81445,CPT,0310,RC,,,both,,,5525.00,1657.5,"CIGNA [10200]","Cigna Local Plus",,1315.4,,,,,,,0.01,4696.25,"fee schedule",
"STENT POLARIS ZIPWIRE 26CM 150CM 8FR .035IN 3CM BLADDER LOOP",SUP-M006155253180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,190.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COPE MAC-LOC 24CM 10.2FR PIGTAIL CURVE",SUP-G48164,CDM,C2617,HCPCS,0278,RC,,,both,,,996.22,298.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,115.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,115.86,846.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 80CM 20MM 6MM BALLOON DILATATION PEBAX NYLON",SUP-48006002N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,353.05,41.1,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CPS COURIER VASCULAR .014IN STAINLESS STEEL PLATINUM",SUP-DS2G001,CDM,C1769,HCPCS,0272,RC,,,both,,,607.50,182.25,"PHCS [10601]",PHCS,,425.25,70,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 20MM 2.5MM BALLOON DILATATION STERILE",SUP-225-203-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ARGON PLUS VALLEYLAB HANDSET",SUP-E3520H,CDM,S27200284,LOCAL,0272,RC,,,both,,,357.48,107.24,"PHCS [10601]",PHCS,,250.24,70,,,,,0,41.57,303.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPLATZER TALISMAN PFO OCCLUDER 18-18MM",SUP-9-PFO-1818,CDM,C1817,HCPCS,0278,RC,,,both,,,56668.50,17000.55,"MULTIPLAN [10600]",Multiplan,,48168.23,85,,,,,0,6590.55,48168.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 12 EXTREME LATERAL INTERBODY FUSION 4 HOLE DECADE BONE",SUP-7140412,CDM,C1713,HCPCS,0278,RC,,,both,,,13800.00,4140,"PHCS [10601]",PHCS,,9660,70,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LACRIMAL 5IN BOWMAN STAINLESS STEEL 2 ENDED SET",SUP-360-270,CDM,S27000186,LOCAL,0270,RC,,,both,,,751.52,225.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,511.03,68,,,,,0,87.4,638.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4F QUAD 2-5-2 MPA 120CM",SUP-901482,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX13MM 12D BROAD LORDOTIC SPINE",SUP-2413,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"UHC [10700]","United Healthcare",,11963.7,63.3,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Rib Uni 2v",PX-320000027,CDM,71100,CPT,0320,RC,,,both,,,587.73,176.32,"BLUE CROSS [10001]","Blue Cross HMO",,85.66,,"Fee schedule rate ($85.66).",,,,0,41.31,499.57,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 20MM 6FR 3.25MM .07IN BALLOON",SUP-H7493918920320,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 5.25IN 9GA AORTIC ROOT ADULT STD VENT LINE",SUP-24009,CDM,S27200284,LOCAL,0272,RC,,,both,,,253.90,76.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.53,215.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 17X14X7MM COROENT INTERLOCK II 10D TITANIUM",SUP-6770710CP2,CDM,C1889,HCPCS,0278,RC,,,both,,,12420.00,3726,"FIRST HEALTH [10303]","First Health",,9936,80,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9 % IV BOLUS 1000 ML",RX-410650,CDM,,,0258,RC,00990-7983-09,NDC,both,1000,ML,100.65,30.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Circumcision Neonate",PX-361000238,CDM,54160,CPT,0361,RC,,,both,,,3893.94,1168.18,"BLUE CROSS [10001]","Blue Cross PPO",,2740.57,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,452.87,3893.94,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT BLUE GRAY SURGISLEEVE ALEXIS 3X FILM ELASTIC",SUP-WPXLGR1117,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.80,114.84,"CIGNA [10200]",Cigna,,260.3,68,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PULSE GENRTR WAVEWRITER ALPHA PRIME 16 THK11.6MM",SUP-SC-1416,CDM,C1820,HCPCS,0278,RC,,,both,,,95760.00,28728,"CIGNA [10200]","Cigna Open Access",,32079.6,33.5,,,,,0,11136.89,81396,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP POLAR CUP CEMENTED STEM OXINIUM HEAD",SUP-71703505,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]",Cigna,,9576,40,,5873.17,5873.17,5873.17,"1 through 10",2784.22,20349,"percent of total billed charges",
"HC Re-ED Neuromscl Ea 15min (Go)",PX-430000015,CDM,97112,CPT,0430,RC,,,both,,,167.73,50.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.51,167.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 55MM EVOLVE STAINLESS STEEL CANCELLOUS ELBOW",SUP-4983555N,CDM,C1713,HCPCS,0278,RC,,,both,,,785.70,235.71,"BLUE CROSS [10001]","Blue Cross HMO",,307.99,39.2,,957.42,156.86,7483.26,51,91.38,667.85,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 28MM 145CM 4MM CORONARY STENT",SUP-1145400-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"KAISER [10500]",Kaiser,,3911.46,67,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Benign Skin Lesn >4",PX-510000015,CDM,11057,CPT,0761,RC,,,both,,,572.00,171.6,"BLUE CROSS [10001]","Blue Cross PPO",,572,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,66.52,572,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREONPANOPTIX PROTORIC(BLF)",SUP-PXYWT3,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"CIGNA [10200]","Cigna Open Access",,520.64,56.9,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR RIGHT CORONARY",SUP-67018200,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"MULTIPLAN [10600]",Multiplan,,354.96,85,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TALAR 1 LARGE 10MM ANKLE",SUP-200347901,CDM,C1776,HCPCS,0278,RC,,,both,,,7424.40,2227.32,"BLUE CROSS [10001]","Blue Cross HMO",,2910.36,39.2,,5311.50,4717.44,5388.59,31,863.46,6310.74,"percent of total billed charges",
"TAP 5.5MM STRAIGHT SHAFT SURGICAL INTERCONTINENTAL FORTIFY I",SUP-687.526,CDM,S27000186,LOCAL,0270,RC,,,both,,,3120.00,936,"NOVANET [10819]",Novanet,,2340,75,,,,,0,362.86,2652,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CEMENTED OMNIFIT HFX 132D 10 35MM HIP",SUP-6070-1035A,CDM,C1776,HCPCS,0278,RC,,,both,,,12970.28,3891.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5188.11,40,,,,,0,1508.44,11024.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5F DECA 4-4-4-29-3-3-3-3-3 MPA 120CM",SUP-901578,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"UHC [10700]","United Healthcare",,1875.26,63.3,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPR LD SFSHTH INR CATH SLF SL",SUP-410195,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL GLASSMAN VMUELLER RIGHT ANGLE 10IN FULLY",SUP-SU6130,CDM,S27200284,LOCAL,0272,RC,,,both,,,1931.18,579.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1313.2,68,,,,,0,224.6,1641.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 16MM LOW PROFILE SCREWS TITANIUM FULL THREAD",SUP-AR-8933-16,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,105.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,103.62,757.35,"percent of total billed charges",
"SCR BONE 5MM 24MM SPINE PEDICLE PLY NONSTERILE 4MM ROD",SUP-102050224,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"(EVAL)MARKER SKIN PINK 7.5CM SOFT TISSUE DELIVERY SYSTEM STE",SUP-SMARTCLIPLT-PNK-7.5,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"AMERIGROUP MEDICAID [20100]",Amerigroup,,319.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM STALIF C NO-PROFILE ABO TITANIUM STD SPINE",SUP-ABS1440,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,109.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",109.32,799,"percent of total billed charges",
"LEAD DEFIB 64CM 7.3FR RELIANCE 4-FRONT RIGHT VENTRICLE MP35N",SUP-676,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]",Cigna,,6072,40,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 12MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640612,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Open Access",,6403.47,56.9,,5302.19,4377.88,6578.61,27,1308.83,9565.82,"percent of total billed charges",
"KETAMINE 10 MG/ML INJECTION SOLUTION SUPERORDERABLE (STATUS EPILEPTICUS)",RX-410194,CDM,,,0250,RC,55150-0438-01,NDC,both,20,ML,207.45,62.23,"PHCS [10601]",PHCS,,145.22,70,,,,,0,24.13,176.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 40MM 4MM RECTANGLE HELIX BALLOON",SUP-2076-4040,CDM,C1725,HCPCS,0272,RC,,,both,,,6865.50,2059.65,"AETNA [10100]","Aetna HMO/PPO",,5458.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,798.46,5835.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 9MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-609-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3249.07,27,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 15MM 2.75MM BALLOON DILATATION PACLITAXEL",SUP-H7493960815270,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"MULTIPLAN [10600]",Multiplan,,33067.13,85,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE ROUND 240MM 15MM 2.4MM CAPTIVATOR II STIFF BRAID WIRE",SUP-M00561233,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.04,23.71,"PHCS [10601]",PHCS,,55.33,70,,,,,0,9.19,67.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.25 X 18 RX US",SUP-1804325-18,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM AXSOS 3 TITANIUM CORTICAL NONSTERILE",SUP-661430,CDM,C1713,HCPCS,0278,RC,,,both,,,289.54,86.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,82.87,28.62,,,,,0,33.67,246.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER 6250V-45S ATTAIN COMMAND",SUP-6250V-45S,CDM,C1887,HCPCS,0272,RC,,,both,,,2602.50,780.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1069.63,41.1,,,,,0,302.67,2212.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 122MM 9.5-13MM 6 SHOOTER SAEED 6 BAND STERILE",SUP-MBL-6,CDM,S27200284,LOCAL,0272,RC,,,both,,,3247.50,974.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"6F DUO-DECA 2-10-2 MPD-H 100CM",SUP-901670,CDM,C1731,HCPCS,0272,RC,,,both,,,4761.00,1428.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PERFORMA 125CM 5FR JR6 CURVE ANGIOGRAPHIC PEBAX",SUP-7523-83,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.74,23.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SELUTION SLR PTCA DEB 3.5X15MM",SUP-SCA14U-350015D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL 12CM MR8 2.5MM MATCH HEAD TELESCOPE DISSECTING DIAMOND",SUP-MR8-T12MH25D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DORADO CHECKER 80CM 2CM 5MM BALLOON DILATATION",SUP-DR8052,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOE POSTOPERATIVE 8-10 MEDIUM MALE ROCKER COMFORTABLE D",SUP-798505,CDM,S27000186,LOCAL,0270,RC,,,both,,,61.07,18.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.1,51.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT CRUCIATE RETAIN GENESIS II LEGION",SUP-71421235,CDM,C1776,HCPCS,0278,RC,,,both,,,28831.95,8649.58,"CIGNA [10200]",Cigna,,11532.78,40,,5873.17,5873.17,5873.17,"1 through 10",3353.16,24507.16,"percent of total billed charges",
"FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION",RX-3208,CDM,,,0250,RC,60219-1585-03,NDC,both,5,ML,467.44,140.23,"UHC [10700]","United Healthcare",,295.89,63.3,,,,,0,54.36,397.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE SINGLE DIAMOND 0.9MM X 89MM COCR",SUP-KWCC-SD-09089,CDM,S27000186,LOCAL,0270,RC,,,both,,,400.20,120.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,47.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER EMBOLIZATION 48MM FEMORAL VENA CAVA 3 WAY STPCOCK",SUP-G48373,CDM,C1880,HCPCS,0278,RC,,,both,,,7621.05,2286.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,903.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,886.33,6477.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 3CM 1MM GALAXY G3 MINI STRETCH",SUP-GLM910030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]",Cigna,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE 0.25 % (2.5 MG/ML) INJECTION SUPERORDERABLE",RX-4081222,CDM,J0665,HCPCS,0636,RC,00409-1159-09,NDC,both,30,ML,18.92,5.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12.87,68,,,,,0,1.75,16.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175262070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"KAISER [10500]",Kaiser,,668.28,67,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 2-0 CTX 27IN MONOFILAMENT ABSORBABLE",SUP-863H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM HELIFORM XTRASOFT XL MICRO",SUP-XHE120204,CDM,S27800098,LOCAL,0278,RC,,,both,,,11314.48,3394.34,"UHC [10700]","United Healthcare",,7162.07,63.3,,,,,0,1315.87,9617.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 20MM 1.5MM ULTRA LOW PROFILE BALLOON",SUP-1012269-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Biopatch",PX-E27200089,CDM,E27200089,LOCAL,0272,RC,,,both,,,32.47,9.74,"NOVANET [10819]",Novanet,,24.35,75,,,,,0,3.78,27.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC",195,MS-DRG,,,,,,,inpatient,,,12358.99,3707.7,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,4171.53,,"Case rate ($3,898.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,620.14, add-ons for qualifying new technology services are included. If operating cost exceeds $36,659.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,655.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,624.92. The transfer operating threshold is the transfer adjustment factor * $3,620.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $273.70. The transfer capital threshold is the transfer adjustment factor * $273.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,3898.63,12358.99,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +28 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.280,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
FACEPLATE,SUP-06001-I,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 25.4MM .8MM LONG DIAMOND DISK STERILE",SUP-5130-130-250,CDM,S27200284,LOCAL,0272,RC,,,both,,,1027.32,308.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,471.54,45.9,,,,,0,119.48,873.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 12MM AXIUM 3D NEUROVASCULAR FRAME V01",SUP-FC-12-50-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"CIGNA [10200]",Cigna,,6610.2,40,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX14MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183664,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3560.94,27,,,,,0,1533.84,11210.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIRANHA CERVICAL VARIABLE SCREW 4.0 MM X 16 MM",SUP-SK-CSV-40-16,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"MANIP CUP ENDOSCOPIC VCARE PLUS XL 40MM CERVICAL UTERINE",SUP-60-6085-203A,CDM,S27200284,LOCAL,0272,RC,,,both,,,522.45,156.73,"CIGNA [10200]",Cigna,,355.27,68,,,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 19MM 52MM SHOULDER SIMPLICITI",SUP-7122875,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"BLUE CROSS [10001]","Blue Cross PPO",,3927.45,39.2,,3949.44,3949.44,3949.44,"1 through 10",1165.21,8516.15,"percent of total billed charges",
"HC Nrv Condct 7-8 Studies",PX-922000022,CDM,95910,CPT,0922,RC,,,both,,,5376.18,1612.85,"UHC [10700]","United Healthcare",,3403.12,63.3,,,,,0,625.25,4569.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOGLIDE 0 53IN MONOFILAMENT PURPLE ABSORBABLE",SUP-021506,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"MULTIPLAN [10600]",Multiplan,,244.04,85,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE CARDIOFORM ASD OCCLUDER 44MM 12FR",SUP-00733132636518,CDM,C1817,HCPCS,0278,RC,,,both,,,52321.50,15696.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,21504.14,41.1,,,,,0,6084.99,44473.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM ORTHOLOC FULL THREAD FOOT ANKLE CORTICAL",SUP-58813514,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"KAISER [10500]",Kaiser,,515.57,67,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER 4421405 GTECH CORT LORD LG 5MM",SUP-4421405,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR THK.4MM 9X2CM GORE-TEX STERILE",SUP-1802009004,CDM,C1768,HCPCS,0278,RC,,,both,,,1740.00,522,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,798.66,45.9,,,,,0,202.36,1479,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR NEROSTIMLTR INSPIRE 1 TORQUE HEX WRENCH LEAD CNCT",SUP-3150,CDM,C1767,HCPCS,0278,RC,,,both,,,123120.00,36936,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,33242.4,27,,,,,0,14318.86,104652,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,J0735,HCPCS,0636,RC,00143-9724-01,NDC,both,10,ML,380.52,114.16,"MULTIPLAN [10600]",Multiplan,,323.44,85,,,,,0,21.18,323.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT CAST NYLON 3-5 XS ROCKER BOTTOM STRETCHABLE UPPER",SUP-79-98432,CDM,S27000186,LOCAL,0270,RC,,,both,,,94.83,28.45,"UHC [10700]","United Healthcare",,60.03,63.3,,,,,0,11.03,80.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT FULL THREAD CORKSCREW TAPE BIOCOMPOSITE 4.75MM",SUP-AR-1927BCT-475,CDM,C1713,HCPCS,0278,RC,,,both,,,2795.63,838.69,"CIGNA [10200]","Cigna Open Access",,1590.71,56.9,,1144.80,304.56,2275.09,66,325.13,2376.29,"percent of total billed charges",
"COIL EMBOLIZATION 6CM 2MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035422060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"UHC [10700]","United Healthcare",,8934.57,63.3,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEDIA XYLENE SHANDON EZ MOUNT 500ML HIGH VISCOSITY MOUNTING",SUP-9999120,CDM,S27000186,LOCAL,0270,RC,,,both,,,403.38,121.01,"MULTIPLAN [10600]",Multiplan,,342.87,85,,,,,0,46.91,342.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 1 CT 45CM SUT ABSORBABLE KNOTLESS",SUP-SXPP1A405,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,98.76,41.1,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBOHAWK MEC 110CM 6CM 3.5-7MM ATHERECTOMY PERIPHERAL",SUP-THS-LS-C,CDM,C1714,HCPCS,0272,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 140MM 80CM 9MM 6FR .035IN BILIARY",SUP-G50137,CDM,C1876,HCPCS,0278,RC,,,both,,,7350.00,2205,"BLUE CROSS [10001]","Blue Cross HMO",,2881.2,39.2,,,,,0,854.81,6247.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)MARKER SKIN PINK 7.5CM SOFT TISSUE DELIVERY SYSTEM STE",SUP-SMARTCLIPLT-PNK-7.5,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"FIRST HEALTH [10303]","First Health",,2160,80,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR JOINT PREPARATION ORTHOLOC 2 STERILE",SUP-9914PK01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1093.50,328.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 255CC P2.9CM MODERATE CLASSIC PROFILE STD",SUP-350-7255MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 100MM 6.35MM TSRH-2D PRECUT BENT",SUP-8371100,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 4IN .04IN THERAHONEY SQUARE HONEY FOAM STERILE",SUP-MNK1344,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.21,25.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,39.11,45.9,,,,,0,9.91,72.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SQUARE MIDFACE 1.5MM SCREWS BONE LORENZ TITANIUM",SUP-1/1/7131,CDM,C1713,HCPCS,0278,RC,,,both,,,2055.00,616.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1397.4,68,,,,,0,239,1746.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM ALPS TITANIUM T15 CORTICAL LOW PROFILE",SUP-110017710,CDM,C1713,HCPCS,0278,RC,,,both,,,668.25,200.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,77.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",77.72,568.01,"percent of total billed charges",
"INSERT TIBIAL 10 7MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151621007,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3220.87,28.62,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH R2P METACROSS 200CM 80MM 5MM BALLOON DILATATION",SUP-BD-P50080ER,CDM,C1769,HCPCS,0272,RC,,,both,,,2028.75,608.62,"UHC [10700]","United Healthcare",,1284.2,63.3,,,,,0,235.94,1724.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRINITY EVOLUTION DEMINERALIZE CORTICAL BONE XL A",SUP-410004,CDM,C1713,HCPCS,0278,RC,,,both,,,26082.63,7824.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3090.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",3033.41,22170.24,"percent of total billed charges",
"SPACER SPINAL 34X17MM HEDRON IA 15D 26MM STERILE LATEX FREE",SUP-1212.0717S,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8505,27,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIFLUFOLASTAT F-18 IV SYRINGE (10-11 MCI)",RX-411827,CDM,A9595,HCPCS,0343,RC,08888-8877-81,NDC,both,1,UN,16868.88,5060.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1961.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,696,14338.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR EXTERNAL FIXATION 70MM 3-2.5MM 3MM XCALIBER FOOT CORTEX",SUP-M316,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",89.49,654.08,"percent of total billed charges",
"FILLER BONE VOID 10CC 20CC CALCIUM SULFATE STIMULAN RAPID",SUP-620-010,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1144.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1123.46,8211,"percent of total billed charges",
"SPACER ALLOGRAFT 12X14X10MM OVAL PARALLEL SPINE CORTICAL",SUP-17110,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cystine Quant Urine",PX-301000101,CDM,82131,CPT,0301,RC,,,both,,,379.48,113.84,"MULTIPLAN [10600]",Multiplan,,322.56,85,,,,,0,0.01,322.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE REGENERATION",SUP-345111,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETERIZATION 8IN 20GA ARTERY BIOPATH LATEX FREE",SUP-NA-04550-X1A,CDM,S27200284,LOCAL,0272,RC,,,both,,,939.60,281.88,"UHC [10700]","United Healthcare",,594.77,63.3,,,,,0,109.28,798.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 24CM 3CM 6FR .035IN PIGTAIL",SUP-M006180222190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]",Cigna,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOUTH PROCEDURES WITHOUT CC/MCC",138,MS-DRG,,,,,,,inpatient,,,46644.69,13993.41,"CIGNA [10200]",Cigna,,11619.85,,"Fee schedule rate ($11,619.85). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,5497.15,25873.5,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD MEDIUM TSRH TITANIUM SPINAL 3DX",SUP-8351521,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2732.31,28.62,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 8MM 145CM 2.5MM CORONARY STENT",SUP-1145250-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,678.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,inpatient,,,78246.80,23474.04,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,9596.57,,"Case rate ($9,053.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,406.67, add-ons for qualifying new technology services are included. If operating cost exceeds $41,446.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,017.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $8,417.78. The transfer operating threshold is the transfer adjustment factor * $8,406.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.58. The transfer capital threshold is the transfer adjustment factor * $635.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,42611.56,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 22.5MM THK.025IN SHORT RECIPROCATING TAPERED",SUP-5100-037-133,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.38,176.51,"AETNA [10100]","Aetna HMO/PPO",,467.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.43,500.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 36MM AXSOS STAINLESS STEEL 2.5MM FULL THREAD",SUP-338636,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,156.54,68,,,,,0,26.77,195.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL SOFT/FIBRA 6MM 6MM .5 FORCE SPRING ATRAUMATIC",SUP-G-6052,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]",Cigna,,153.82,68,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 22.5MM THK.025IN SHORT RECIPROCATING TAPERED",SUP-5100-037-133,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.38,176.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,241.82,41.1,,,,,0,68.43,500.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 8MM 140CM 2.75MM CORONARY STENT PLATINUM",SUP-H7493927408270,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1073.25,28.62,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Graftjacket per Sq Cm",PX-E63600020,CDM,Q4107,HCPCS,0636,RC,,,both,,,445.50,133.65,"CIGNA [10200]",Cigna,,302.94,68,,,,,0,52.79,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM VERTEX MAX TITANIUM SPINE MULTIAXIAL",SUP-6958730,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS LOOP URETERAL",SUP-M0061902330,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XLNK SPINAL 5.5MM PASS LP MEDIUM DISTANCE NONSTERILE LATEX",SUP-B02265520,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2422.5,68,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +20 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SA60WF.200,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 6 SLOT RIGHT TI",SUP-PHPF-C6R,CDM,C1713,HCPCS,0278,RC,,,both,,,18144.00,5443.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2110.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",2110.15,15422.4,"percent of total billed charges",
"(EVAL) CRADLE SUPPORT INTPD-TF-S",SUP-INTPD-TF-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 5MM RETRACTION SHARP ELASTIC STAY LONE STAR STAINLESS",SUP-3311-1G,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.05,27.31,"FIRST HEALTH [10303]","First Health",,72.84,80,,,,,0,10.59,77.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28X10X9MM COALESCE LORDOTIC STRAIGHT STERILE",SUP-2000-00-100908,CDM,C1889,HCPCS,0278,RC,,,both,,,21420.00,6426,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2538.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHOCOLATE 135CM 80MM 4MM .014IN BALLOON DILATATION",SUP-CB1413540080OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"FIRST HEALTH [10303]","First Health",,4581.6,80,,,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEWIRE ENDOSCOPIC SPYGLASS DISCOVER JAGWIRE",SUP-M00542971,CDM,C1769,HCPCS,0272,RC,,,both,,,1042.88,312.86,"PHCS [10601]",PHCS,,730.02,70,,,,,0,121.29,886.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET .016-.032IN 140CM LOCK LEAD EXTRACTION THREADABLE",SUP-G26550,CDM,C1773,HCPCS,0272,RC,,,both,,,4692.00,1407.6,"UHC [10700]","United Healthcare",,2970.04,63.3,,,,,0,545.68,3988.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENICILLIN VK DESENSITIZATION ORAL (5 MG/ML)",RX-411687,CDM,,,0250,RC,08888-8877-43,NDC,both,20,ML,12.54,3.76,"CIGNA [10200]","Cigna Local Plus",,6.71,53.5,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 26MM 140CM 3.5MM CORONARY STERILE LATEX",SUP-453959,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUROFORM 3 EZ 4.0 X 30MM",SUP-M003N3EZ40300,CDM,C1874,HCPCS,0278,RC,,,both,,,47878.17,14363.45,"MULTIPLAN [10600]",Multiplan,,40696.44,85,,,,,0,5568.23,40696.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 19MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-319,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"NOVANET [10819]",Novanet,,7372.89,75,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM NCB PROTASUL-64 3.5MM SELF TAP 2 LEAD",SUP-0203150034,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"NOVANET [10819]",Novanet,,1392.19,75,,,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO SMALL BLADE GLIDESCOPE GVL STAT DISPOSABLE",SUP-0270-0626,CDM,S27200284,LOCAL,0272,RC,,,both,,,169.91,50.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.76,144.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM POD J PACK SOFT",SUP-RBYPODJ5,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"MULTIPLAN [10600]",Multiplan,,5747.7,85,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.8MM 3MM PRECISION NEURO STERILE LATEX FREE",SUP-5820-107-530,CDM,S27200284,LOCAL,0272,RC,,,both,,,1119.18,335.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,513.7,45.9,,,,,0,130.16,951.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SURGICAL BIOSEAL CUSTOM BONE FLAP STERILE DISPOSABLE",SUP-BBF001/10,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.09,51.03,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.78,144.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC NDL 160CM 2.8MM RADIAL JAW 4 LARGE CAPACITY",SUP-M00513311,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.37,38.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.93,109.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 4X2CM ALLODERM SELECT THK.3-.8MM THIN",SUP-141408,CDM,Q4116,HCPCS,0636,RC,,,both,,,3337.50,1001.25,"KAISER [10500]",Kaiser,,2236.13,67,,,,,0,247.92,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L20 MM OD4.5 MM GLENOID PERIPHERAL LOCK",SUP-1230-7511-003,CDM,C1713,HCPCS,0278,RC,,,both,,,1159.92,347.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,134.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",134.9,985.93,"percent of total billed charges",
"SUT PDS II MULTIPASS 4-0 PS-4 18IN MONOFILAMENT UNDYED",SUP-Z507G,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.55,19.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.74,56.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 5.5MM STRAIGHT SHAFT SURGICAL INTERCONTINENTAL FORTIFY I",SUP-687.526,CDM,S27000186,LOCAL,0270,RC,,,both,,,3120.00,936,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,362.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,362.86,2652,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 609004 4MM FACET SHIM SERVICE FEE",SUP-609004,CDM,S27800098,LOCAL,0278,RC,,,both,,,3412.50,1023.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,404.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,396.87,2900.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1 DIAMOND POINT SUTURETAK SMALL JOINT 2 NDL",SUP-AR-8934BCNF,CDM,C1713,HCPCS,0278,RC,,,both,,,2559.38,767.81,"BLUE CROSS [10001]","Blue Cross HMO",,1003.28,39.2,,957.42,156.86,7483.26,51,297.66,2175.47,"percent of total billed charges",
"COIL EMBOLIZATION 12CM 8MM AZUR CX DETACHABLE SOFT SOLID",SUP-45-750812,CDM,S27800098,LOCAL,0278,RC,,,both,,,7672.80,2301.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5217.5,68,,,,,0,892.35,6521.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 12MM 144CM 2.75MM",SUP-H7493941212270,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,919.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WATCHMAN FLX PROCEDURE  TRUSEAL ACCESS SYSTEM",SUP-WMFLXTRUACCPERPROC,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"MULTIPLAN [10600]",Multiplan,,5865,85,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER TISSUE 25CM ENSEAL X1 CURVE JAW SHAFT STERILE LATEX",SUP-NSLX125C,CDM,S27200284,LOCAL,0272,RC,,,both,,,3109.07,932.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1277.83,41.1,,,,,0,361.58,2642.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 16CM TOUCH NARROW BASE PENOSCROTAL NARROW",SUP-EN2916,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"UHC [10700]","United Healthcare",,39689.1,63.3,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ERCP TAPER TANDEM RX 195CM 7-5.5FR BILIARY STERILE",SUP-M00545820,CDM,S27200284,LOCAL,0272,RC,,,both,,,483.89,145.17,"CIGNA [10200]","Cigna Local Plus",,258.88,53.5,,,,,0,56.28,411.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ESOPHAGUS PYLORIC 6FR 15-18MM 180CM 8CM FIXED WIRE HIGH",SUP-M00558370,CDM,C1726,HCPCS,0272,RC,,,both,,,1562.98,468.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,181.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,181.77,1328.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0230,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 75MM FOGARTY",SUP-G-7555,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 100MM 3MM BALLOON DILATATION OTW",SUP-H74939206031010,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 6-0 PS-3 18IN MONOFILAMENT BLUE",SUP-8680G,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.80,19.74,"PHCS [10601]",PHCS,,46.06,70,,,,,0,7.65,55.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERLOOP TIGERWIRE 2 STRAIGHT 20IN BRAID MULTISTRAND",SUP-AR-7234T,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM MITRAL CARPENTIER-EDWARDS PHYSIO II",SUP-5200M32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"FIRST HEALTH [10303]","First Health",,11040,80,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTOURA BREAST TISSUE EXPANDER ULTRA HIGH PROJECTION 650 CC",SUP-TEXP130RUH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"CIGNA [10200]","Cigna Local Plus",,4336.13,,,,,,,1600.93,11700.68,"percent of total billed charges",
"CATH SELECTRA 45CM 8.7FR 7.3FR AL6 CURVE GUIDING PEBAX","SUP-375 519",CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 110CM 6FR AP2 CURVE ANGIOGRAPHIC",SUP-G05739,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"FIRST HEALTH [10303]","First Health",,388.8,80,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL VASCULAR 30MM 2.5MM FLO-RESTER VESSEL SILICONE",SUP-60250,CDM,S27200284,LOCAL,0272,RC,,,both,,,634.52,190.36,"MULTIPLAN [10600]",Multiplan,,539.34,85,,,,,0,73.79,539.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 95MM TITANIUM ATLANTIS VISION ELITE BONE SPINE",SUP-7200095,CDM,C1713,HCPCS,0278,RC,,,both,,,4620.00,1386,"KAISER [10500]",Kaiser,,3095.4,67,,,,,0,537.31,3927,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 6MM OCCIPITAL",SUP-7750506,CDM,C1713,HCPCS,0278,RC,,,both,,,1931.70,579.51,"CIGNA [10200]","Cigna Open Access",,1099.14,56.9,,1144.80,304.56,2275.09,66,224.66,1641.95,"percent of total billed charges",
"CATH LUTONIX ULTRAVERSE 130CM 150MM 7MM BALLOON DILATATION",SUP-LX1813071505F,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,983.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 300MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025300S,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 45CM 16X8MM PERIPHERAL ABDOMINAL",SUP-631608,CDM,C1768,HCPCS,0278,RC,,,both,,,7521.00,2256.3,"CIGNA [10200]","Cigna Open Access",,4279.45,56.9,,,,,0,874.69,6392.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 3 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022213,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"MULTIPLAN [10600]",Multiplan,,14128.79,85,,,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X36MM COLOSSEUM 12MM CURVE MESH NONSTERILE",SUP-156.209,CDM,S27800098,LOCAL,0278,RC,,,both,,,28343.70,8503.11,"NOVANET [10819]",Novanet,,21257.78,75,,,,,0,3296.37,24092.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 14MM 200MM SUPRACONDYLAR T2 INTRAMEDULLARY",SUP-1826-1420S,CDM,C1713,HCPCS,0278,RC,,,both,,,11554.33,3466.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1369.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1343.77,9821.18,"percent of total billed charges",
"EXT AORTIC 4.5CM 23MM EXCLUDER CONFORMABLE ACTIVE CONTROL",SUP-CXA230005,CDM,C1874,HCPCS,0278,RC,,,both,,,27612.90,8283.87,"KAISER [10500]",Kaiser,,18500.64,67,,,,,0,3211.38,23470.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL TORIC 13MM 6MM POSTERIOR CHMBR ANTERIOR ASPHERIC UV",SUP-CNW0T5,CDM,V2787,HCPCS,0276,RC,,,both,,,355.00,106.5,"CIGNA [10200]","Cigna Local Plus",,189.93,53.5,,,,,0,41.29,301.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS FIRSTCHOICE 5% DEXTROSE 30 MEQ POTASSIUM",SUP-790309,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.29,41.1,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BIO AVS 0D LORDOSIS 12MM ALLOGRAFT C PLUG 14X8MM",SUP-77102080,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.7MM 11MM VARIAX T5 LOCK NONSTERILE",SUP-662511,CDM,C1713,HCPCS,0278,RC,,,both,,,1075.03,322.51,"CIGNA [10200]","Cigna Local Plus",,575.14,53.5,,3978.14,359.25,3978.14,24,125.03,913.78,"percent of total billed charges",
"HC Ablt Perc Liver Tmr Ire",PX-361000742,CDM,47384,CPT,0361,RC,,,both,,,16726.00,5017.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1982.03,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1945.23,14217.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VENTRALIGHT ST ECHO 2 20X15CM ELLIPSE",SUP-5991520,CDM,C1781,HCPCS,0278,RC,,,both,,,8155.80,2446.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,966.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,948.52,6932.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 150CM .021IN TRINAV 1.5-3.5MM",SUP-TNV-21150-35,CDM,C1982,HCPCS,0272,RC,,,both,,,50292.90,15087.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5959.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5849.06,42748.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Npm1 Gene",PX-309000065,CDM,81310,CPT,0310,RC,,,both,,,1072.50,321.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,47.89,,"Fee schedule rate ($47.89). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,911.63,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH CLOTTRIEVER 13FR",SUP-50-101,CDM,C1757,HCPCS,0272,RC,,,both,,,13800.00,4140,"PHCS [10601]",PHCS,,9660,70,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 36CM 14.5FR 15FR STD STRAIGHT POLYURETHANE",SUP-5393310,CDM,C1750,HCPCS,0278,RC,,,both,,,2062.50,618.75,"CIGNA [10200]",Cigna,,1402.5,68,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"7F DUO-DECA 2-2-2 PV18 110CM",SUP-903952,CDM,C1731,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"MULTIPLAN [10600]",Multiplan,,5718.38,85,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC",091,MS-DRG,,,,,,,inpatient,,,55863.17,16758.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,15840.92,,"Fee schedule rate ($15,840.92). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,10893.81,43797.87,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 4FR RIGHT CORONARY BYPASS",SUP-538470,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"PHCS [10601]",PHCS,,62.66,70,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE 4% TOPICAL CREAM SUPERORDERABLE",RX-408782,CDM,,,0637,RC,24357-0701-06,NDC,both,5,GR,26.42,7.93,"KAISER [10500]",Kaiser,,17.7,67,,,,,0,3.07,22.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEM POROUS RT SZ12",SUP-427-02-120,CDM,C1776,HCPCS,0278,RC,,,both,,,32703.43,9811.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13081.37,40,,,,,0,3803.41,27797.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE NON HA POROUS WITH CEMENTED PATELLA CONCE",SUP-71704618,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"AETNA [10100]","Aetna HMO/PPO",,18531.45,79.5,,10981.53,8986.79,12413.38,12,2710.95,19813.5,"percent of total billed charges",
"PAPARELLA VT W/TAB SI 1.27MM",SUP-510-072,CDM,S27800098,LOCAL,0278,RC,,,both,,,153.80,46.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.89,130.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 50CM INFINION 1X16 SPLITTER TRIAL LEAD",SUP-SC-2316-50E,CDM,C1897,HCPCS,0278,RC,,,both,,,11040.00,3312,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4537.44,41.1,,,,,0,1283.95,9384,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 24D 2-0 CURVE FIBERSTITCH FIBERWIRE POLYESTER",SUP-AR-4570-24,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,434.96,3179,"percent of total billed charges",
"CMPNT FEMORAL 4 NARROW KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-71933649,CDM,C1776,HCPCS,0278,RC,,,both,,,22273.65,6682.09,"MULTIPLAN [10600]",Multiplan,,18932.6,85,,,,,0,2590.43,18932.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transplant Eval Renal Day 1 New Pt",PX-761000011,CDM,99205,CPT,0761,RC,,,both,,,2483.00,744.9,"FIRST HEALTH [10303]","First Health",,1986.4,80,,,,,0,2.48,2483,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING 14FR STOMA L2.7CM TAIL L30CM GASTRIC JEJUNAL LO",SUP-8270-14-2.7-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,3027.60,908.28,"MULTIPLAN [10600]",Multiplan,,2573.46,85,,,,,0,352.11,2573.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL FLUTELESS",SUP-6975150,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",50.59,369.75,"percent of total billed charges",
"DEVICE ABSORBATACK SHORT 5MM FIXATION 20 TACK ABSORBABLE",SUP-ABSTACK20S,CDM,C1713,HCPCS,0278,RC,,,both,,,3237.98,971.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,926.71,28.62,,,,,0,376.58,2752.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 100CM 5FR 6MM AMPLATZER II .056IN",SUP-9-AVP2-006,CDM,S27800098,LOCAL,0278,RC,,,both,,,6589.50,1976.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4480.86,68,,,,,0,766.36,5601.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 TWINFIX ULTRABRAID COBRAIDED PEEK-OPTIMA",SUP-72202600,CDM,C1713,HCPCS,0278,RC,,,both,,,1724.63,517.39,"BLUE CROSS [10001]","Blue Cross HMO",,676.05,39.2,,957.42,156.86,7483.26,51,200.57,1465.94,"percent of total billed charges",
"CMPNT FEMORAL 6 STD KNEE RIGHT CRUCIATE RETAIN PERSONA PPS",SUP-42508606002,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"AETNA [10100]","Aetna HMO/PPO",,20859.4,79.5,,10981.53,8986.79,12413.38,12,3051.51,22302.5,"percent of total billed charges",
"DEVICE ZIP 24CM SKIN CLSR STERILE LATEX FREE DISPOSABLE",SUP-PS1240,CDM,S27200284,LOCAL,0272,RC,,,both,,,911.25,273.37,"PHCS [10601]",PHCS,,637.88,70,,,,,0,105.98,774.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 10FR .131IN 25CM ROBUST VALVE SPLITTABLE",SUP-PLSX-2510,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo Intestine Sm WO Ilium Dx",PX-750000062,CDM,44360,CPT,0750,RC,,,both,,,4990.45,1497.13,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,580.39,4990.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TFN-ADVANCED ORTHOPEDIC 475MM 3.2MM FEMORAL PROXIMAL",SUP-09.037.010,CDM,C1769,HCPCS,0272,RC,,,both,,,768.93,230.68,"PHCS [10601]",PHCS,,538.25,70,,,,,0,89.43,653.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 28MM HIP BIOLOX DELTA V40",SUP-6570-0-128,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1163,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 44MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.544,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,503.26,45.9,,,,,0,127.51,931.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cannula Nasal",PX-E27000076,CDM,E27000076,LOCAL,0270,RC,,,both,,,60.43,18.13,"FIRST HEALTH [10303]","First Health",,48.34,80,,,,,0,7.03,51.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 12MM 5MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012280-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB PEDIATRIC MULTIFUNCTION PAD PEDI-PADZ",SUP-8900-2065,CDM,S27000186,LOCAL,0270,RC,,,both,,,328.58,98.57,"MULTIPLAN [10600]",Multiplan,,279.29,85,,,,,0,38.21,279.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - TIBIAL KIT (PS) - SIZE 7",SUP-5555-2367,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ZIP 24CM SKIN CLSR STERILE LATEX FREE DISPOSABLE",SUP-PS1240,CDM,S27200284,LOCAL,0272,RC,,,both,,,911.25,273.37,"CIGNA [10200]","Cigna Open Access",,518.5,56.9,,,,,0,105.98,774.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HIWIRE VASCULAR STRAIGHT TAPER 145CM 15CM .035IN PTFE",SUP-TSFNB-35-145,CDM,C1769,HCPCS,0272,RC,,,both,,,121.71,36.51,"PHCS [10601]",PHCS,,85.2,70,,,,,0,14.15,103.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 36MM COMPREHENSIVE STD SHOULDER VIVACIT-E",SUP-110031424,CDM,C1776,HCPCS,0278,RC,,,both,,,7755.60,2326.68,"CIGNA [10200]","Cigna Local Plus",,4149.25,53.5,,5372.07,4581.20,7242.98,23,901.98,6592.26,"percent of total billed charges",
"HC Rpr Face/Ax/Ext 1.1-2.5 Cmplx",PX-450000052,CDM,13131,CPT,0361,RC,,,both,,,2630.00,789,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.66,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.87,2630,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ekg Rhythm 1-3 Lead Trace Only",PX-730000003,CDM,93041,CPT,0730,RC,,,both,,,149.00,44.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.33,149,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Splint Ankle",PX-E27000162,CDM,E27000162,LOCAL,0270,RC,,,both,,,756.80,227.04,"UHC [10700]","United Healthcare",,479.05,63.3,,,,,0,88.02,643.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eo W/O Joints Cf",PX-E27400027,CDM,L3702,HCPCS,0274,RC,,,both,,,594.00,178.2,"NOVANET [10819]",Novanet,,445.5,75,,,,,0,69.08,504.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mnt Subq Ea 15min Reassess",PX-942000009,CDM,G0270,HCPCS,0942,RC,,,both,,,75.00,22.5,"KAISER [10500]",Kaiser,,50.25,67,,,,,0,8.72,75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Interrogation Vad in Person",PX-480000001,CDM,93750,CPT,0480,RC,,,both,,,747.18,224.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,86.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.9,635.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 7.9X5.9IN XENMATRIX AQUAPURE RECTANGLE",SUP-1161520,CDM,C1781,HCPCS,0278,RC,,,both,,,29877.12,8963.14,"NOVANET [10819]",Novanet,,22407.84,75,,,,,0,3474.71,25395.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 28MM TI",SUP-MTC-37280-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"MULTIPLAN [10600]",Multiplan,,1060.29,85,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DISTAL FEMUR 5D KIDNEY BEAN ANATOMIC BIPLANAR",SUP-PLP-3005,CDM,S27800098,LOCAL,0278,RC,,,both,,,10177.50,3053.25,"NOVANET [10819]",Novanet,,7633.13,75,,,,,0,1183.64,8650.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 35FR LEFT ANGLE ADJUSTABLE VALVE STYLET 2",SUP-125035,CDM,S27200284,LOCAL,0272,RC,,,both,,,439.99,132,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,52.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.17,373.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 20MM 5MM BALLOON DILATATION RAPID EXCHANGE",SUP-47550020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENCIL SMOKE EVAC 10FT 3/8IN PLUMEPEN ELITE 7/8IN ULTRA SLIM",SUP-PLP2020,CDM,S27200284,LOCAL,0272,RC,,,both,,,233.41,70.02,"KAISER [10500]",Kaiser,,156.38,67,,,,,0,27.15,208.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC",053,MS-DRG,,,,,,,inpatient,,,39987.42,11996.23,"CIGNA [10200]","Cigna Local Plus",,10104.36,,"Fee schedule rate ($10,104.36). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,6074.03,24420.27,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 CP-2 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP761D,CDM,S27200284,LOCAL,0272,RC,,,both,,,160.73,48.22,"CIGNA [10200]","Cigna Local Plus",,85.99,53.5,,,,,0,18.69,136.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 7 EXTEND LENGTH 100MM 12.3MM SHILEY XLT UNCUFF",SUP-70XLTUD,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"AETNA [10100]","Aetna HMO/PPO",,385.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.44,412.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT225200,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross HMO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 195MM STAINLESS STEEL 4.5MM SCR 8 HOLE 4 COLUMN",SUP-02.124.408S,CDM,C1713,HCPCS,0278,RC,,,both,,,13302.23,3990.67,"KAISER [10500]",Kaiser,,8912.49,67,,,,,0,1547.05,11306.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE U -POROUS NEXGEN FEMUR",SUP-CAP-U-NEXGEN,CDM,C1776,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Local Plus",,2006.25,53.5,,5372.07,4581.20,7242.98,23,436.13,3187.5,"percent of total billed charges",
"STENT EPIC 100MM 120CM 8MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200091020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAVARY-GILLIARD ENDOSCOPIC 360CM",SUP-G57282,CDM,C1769,HCPCS,0272,RC,,,both,,,1336.50,400.95,"UHC [10700]","United Healthcare",,846,63.3,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14X14.5CM NATRELLE P5.2CM MODERATE PROJECTION",SUP-MSZFM500,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,81.68,45.9,,,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 2.9MM 45CM RADIOPAQUE SMALL VALVE FLEXOR",SUP-G09601,CDM,C1894,HCPCS,0272,RC,,,both,,,468.67,140.6,"AETNA [10100]","Aetna HMO/PPO",,372.59,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.51,398.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION (HIE THERAPY ONLY)",RX-411809,CDM,J1815,HCPCS,0637,RC,00002-8215-01,NDC,both,10,ML,404.15,121.24,"MULTIPLAN [10600]",Multiplan,,343.53,85,,,,,0,47,343.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 160CM 2.8-3.2FR .027IN MARKSMAN",SUP-FA-55160-1030,CDM,S27200284,LOCAL,0272,RC,,,both,,,7741.80,2322.54,"PHCS [10601]",PHCS,,5419.26,70,,,,,0,900.37,6580.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 0 OS-2 MINI QUICKANCHOR PLUS ETHIBOND",SUP-212133,CDM,C1713,HCPCS,0278,RC,,,both,,,4843.80,1453.14,"BLUE CROSS [10001]","Blue Cross PPO",,1898.77,39.2,,957.42,570.23,957.42,28,563.33,4117.23,"percent of total billed charges",
"SCR BONE 2.7MM 16MM LOW PROFILE SCREWS STAINLESS STEEL FULL",SUP-AR-8827L-16,CDM,C1713,HCPCS,0278,RC,,,both,,,931.50,279.45,"BLUE CROSS [10001]","Blue Cross HMO",,365.15,39.2,,957.42,156.86,7483.26,51,108.33,791.78,"percent of total billed charges",
"SUT FIBERTAPE CERCLAGE LOADER NONABSORBABLE",SUP-AR-7268,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.63,1122.19,"BLUE CROSS [10001]","Blue Cross HMO",,1466.33,39.2,,957.42,156.86,7483.26,51,435.04,3179.54,"percent of total billed charges",
"NDL 71CM 18GA PROC TRANSSEPTAL 50D HEARTSPAN",SUP-FND01901,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 44MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-44-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2597.02,45.9,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 20IN 36FR STRAIGHT",SUP-8888570564,CDM,C1729,HCPCS,0272,RC,,,both,,,88.88,26.66,"FIRST HEALTH [10303]","First Health",,71.1,80,,,,,0,10.34,75.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 450ML STYLE 10 SMOOTH NATRELLE SILICONE P3.9CM",SUP-10-450,CDM,C1789,HCPCS,0278,RC,,,both,,,4933.50,1480.05,"KAISER [10500]",Kaiser,,3305.45,67,,,,,0,573.77,4193.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 20MM 144CM 2.75MM CORONARY STENT PEBAX",SUP-H7493926020270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross PPO",,2181.48,39.2,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPANDER TISSUE BREAST 850CC STYLE 133S SMOOTH 3 SUTURE TAB",SUP-133S-MX-16-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA [10200]","Cigna Local Plus",,4983.53,,,,,,,1083.33,7917.75,"percent of total billed charges",
"CATH CORDIS SABER 90CM 80MM 3MM BALLOON DILATATION DURALYN",SUP-48003008S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UHC [10700]","United Healthcare",,794.73,63.3,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 20MM 6MM BALLOON",SUP-U3513062,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 105MM COLLAR ACTIS DUOFIX 5 12/14 HIGH OFFSET",SUP-101012050,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"AETNA [10100]","Aetna HMO/PPO",,24228.62,79.5,,10981.53,8986.79,12413.38,12,3544.39,25904.81,"percent of total billed charges",
"STEM EXT 120MM 12MM LEGION STRAIGHT KNEE TITANIUM CEMENT",SUP-71424184,CDM,C1776,HCPCS,0278,RC,,,both,,,12357.90,3707.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1437.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1437.22,10504.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 40MM 4FR 2.5MM ROUND TAPER LOW PROFILE",SUP-A2025-040,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 100CM 5FR SIDEWINDER SIMMONS TECHNIQUE 1 CURVE",SUP-11709009,CDM,C1887,HCPCS,0272,RC,,,both,,,344.52,103.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,234.27,68,,,,,0,40.07,292.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROXYCHLOROQUINE 200 MG TABLET",RX-10235,CDM,,,0637,RC,50268-0412-11,NDC,both,1,UN,21.88,6.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.54,18.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPLATZ RENAL SHEATH SET 24-30F",SUP-M0062601500,CDM,C1894,HCPCS,0272,RC,,,both,,,830.57,249.17,"FIRST HEALTH [10303]","First Health",,664.46,80,,,,,0,96.6,705.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 22CM 3MM BALLOON DILATATION",SUP-U8150322,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 105MM COLLAR ACTIS DUOFIX 5 12/14 HIGH OFFSET",SUP-101012050,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"BLUE CROSS [10001]","Blue Cross PPO",,11946.69,39.2,,3949.44,3949.44,3949.44,"1 through 10",3544.39,25904.81,"percent of total billed charges",
"GRAFT SOFT TISSUE MTF SMALL DIAMETER ANTERIOR TIBIALIS",SUP-430337,CDM,S27800098,LOCAL,0278,RC,,,both,,,10522.50,3156.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7155.3,68,,,,,0,1223.77,8944.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH INTRDCR FR10.5 LONG - EACH",SUP-668004-001,CDM,C1892,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PHCS [10601]",PHCS,,822.15,70,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE MTF SMALL DIAMETER ANTERIOR TIBIALIS",SUP-430337,CDM,S27800098,LOCAL,0278,RC,,,both,,,10522.50,3156.75,"CIGNA [10200]","Cigna Open Access",,5987.3,56.9,,,,,0,1223.77,8944.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL SURGICAL THORATEC HEARTMATE 3 CORING STERILE LATEX FREE",SUP-10005872,CDM,S27200284,LOCAL,0272,RC,,,both,,,3604.50,1081.35,"CIGNA [10200]",Cigna,,2451.06,68,,,,,0,419.2,3063.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 15IN 36FR VENOUS ADULT 3/8IN CONNECTION SITE",SUP-66236,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.63,85.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,33.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.22,242.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT R2P MISAGO 200CM 120MM 6FR 6MM VASCULAR PERIPHERAL",SUP-SXR06120R,CDM,C1876,HCPCS,0278,RC,,,both,,,6099.60,1829.88,"KAISER [10500]",Kaiser,,4086.73,67,,,,,0,709.38,5184.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 9FR 19CM RADIALEASE LATEX FREE VESSEL ACCEPTS",SUP-504509X,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.26,26.18,"UHC [10700]","United Healthcare",,55.24,63.3,,,,,0,10.15,74.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SUCTION ORCAPOD ORCA SEAL AIR WATER SILICONE FREE",SUP-SUV-629-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.20,24.06,"PHCS [10601]",PHCS,,56.14,70,,,,,0,9.33,68.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH SAFIRE ELECTROPHYSIOLOGY GENRTR INTERFACE",SUP-402578,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON DISECT LAPAROSCOPIC PDB SPACEMAKER EXTRA VIEW",SUP-OMS-PDBS2,CDM,C1727,HCPCS,0272,RC,,,both,,,2061.53,618.46,"AETNA [10100]","Aetna HMO/PPO",,1638.92,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.76,1752.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 8-11 G-H KNEE RIGHT TIBIA FIX",SUP-42522100911,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"MULTIPLAN [10600]",Multiplan,,9159.96,85,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 43IN 10FR ANTICLOG RADIOPAQUE SMOOTH BOLUS",SUP-40-4431,CDM,S27200284,LOCAL,0272,RC,,,both,,,127.29,38.19,"KAISER [10500]",Kaiser,,85.28,67,,,,,0,14.8,108.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 75MM 20MM ASNIS III TITANIUM PARTIAL THREAD",SUP-602675,CDM,C1713,HCPCS,0278,RC,,,both,,,1866.45,559.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,217.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",217.07,1586.48,"percent of total billed charges",
"ELECTRD MONOPOLAR 12.5IN 5MM OLSEN J HOOK REUSABLE",SUP-90-9525,CDM,S27000186,LOCAL,0270,RC,,,both,,,965.03,289.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,396.63,41.1,,,,,0,112.23,820.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 4IN ALM BLUNT SELF RETAINING SURGICAL",SUP-BV011R,CDM,S27200284,LOCAL,0272,RC,,,both,,,393.24,117.97,"CIGNA [10200]",Cigna,,267.4,68,,,,,0,45.73,334.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING 43IN 8FR CORFLO-ULTRA ENTERAL POLYURETHANE",SUP-8884710867,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.70,22.41,"CIGNA [10200]",Cigna,,50.8,68,,,,,0,8.69,63.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER QUICKPASS SUTURELASSO 90D SMALL STRAIGHT 7MM CANN",SUP-AR-6068-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,624.61,45.9,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAPE FIBERWIRE 2 TAPER 54IN BRAID BLUE 36INX2MM",SUP-AR-7237,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.03,267.91,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,367.04,41.1,,,,,0,103.86,759.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 133MM CEMENTLESS NECK ACCOLADE TMZF 132D 5.5 45",SUP-6020-5537,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"FIRST HEALTH [10303]","First Health",,18257.4,80,,,,,0,2654.17,19398.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARM ENDOSCP 2.77X.93IN STD SILICONE AIRWAY STERILE LATEX",SUP-890914,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.87,41.66,"AETNA [10100]","Aetna HMO/PPO",,110.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.15,118.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEQUALIS PERFORM GLENOID (CORTILOC)- XL60",SUP-DWE433,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"KAISER [10500]",Kaiser,,6241.72,67,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 80MM 2.3MM NONSTERILE LATEX FREE DISPOSABLE",SUP-DRILL-2.3/080,CDM,S27000186,LOCAL,0270,RC,,,both,,,1012.50,303.75,"UHC [10700]","United Healthcare",,640.91,63.3,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 32MM 144CM 4.5MM CORONARY STENT",SUP-H7493941832450,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Brain W Cntrst",PX-611000002,CDM,70552,CPT,0611,RC,,,both,,,4600.94,1380.28,"CIGNA [10200]","Cigna Local Plus",,752,,"Per diem ($752). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,529.64,3910.8,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC RIVACOR 1 CHMBR DF-4 CNCT LATEX FREE VRT",SUP-429536,CDM,C1722,HCPCS,0278,RC,,,both,,,56385.00,16915.5,"BLUE CROSS [10001]","Blue Cross HMO",,22102.92,39.2,,,,,0,6557.58,47927.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 24MM 144CM 4MM CORONARY STENT",SUP-H7493941824400,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,9776.84,9776.84,9776.84,"1 through 10",348.9,2550,"percent of total billed charges",
"SODIUM CHLORIDE 0.9 % IV BOLUS 1000 ML FOR SEPSIS ORDER SET",RX-408131,CDM,,,0258,RC,00990-7983-09,NDC,both,1000,ML,100.65,30.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 41FR RIGHT ADJUSTABLE VALVE RADIOPAQUE 2",SUP-126141,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.14,153.04,"CIGNA [10200]","Cigna Local Plus",,272.92,53.5,,,,,0,59.33,433.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 56MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.756,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,321.58,28.62,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 100MM 130MM 5MM LONG VASCULAR NITINOL",SUP-SC5100LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2567.21,28.62,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 18.8CM RIBFIX TITAN NONSTERILE LATEX FREE REUSABLE",SUP-323.8001,CDM,S27000186,LOCAL,0270,RC,,,both,,,4422.90,1326.87,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC TREK 143CM 20MM 3.75MM ROUND BALLOON DILATATION",SUP-1012452-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"3.5MM X 40MM S4 CATHETER",SUP-FG63091-3540,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR CORDIS EMERALD HEPARIN PTFE 3 MM RADIUS J",SUP-502587,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER PACING LEAD ACUITY 9FR LONG",SUP-667472-001,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE FINALE STD 10IN COMPRESSION RADIAL ARTERY BAND",SUP-FCD100,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.05,30.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TORCON NB ADVANTAGE BEACON 100CM 5FR MPA CURVE",SUP-G11205,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY INTRO XPANDER ONE-STEP KYPHOPAK KYPHX FIRST FRACTURE",SUP-KPT1005,CDM,C1894,HCPCS,0272,RC,,,both,,,11021.40,3306.42,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SELUTION DEB 3.0X35",SUP-SCA14U-300035D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PERITONEAL ADHESIOLYSIS,MINOR",224,APR-DRG,,,,,,,inpatient,,,63441.50,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488.00. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.20. DRG Reimbursement is equal to $8,278.15. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%.",,,,0,,,other,"SOI-1 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIPWIRE .035IN STRAIGHT TIP",SUP-M0066802051,CDM,C1769,HCPCS,0272,RC,,,both,,,320.58,96.17,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ACTIVAPATCH IONTOGO 4 SHUNT DRUG DELIVERY 2CC",SUP-7101336,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.20,17.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EVERCROSS CROSSTEC 135CM 100MM 6MM .035IN BALLOON",SUP-AB35W06100135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 135CM 80MM 7FR 6MM 5FR BALLOON DILATATION",SUP-39032-60801,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EPHEDRINE SULFATE 50 MG/ML INJECTION SOLUTION SUPERORDERABLE",RX-408679,CDM,,,0250,RC,42023-0216-01,NDC,both,1,ML,226.52,67.96,"CIGNA [10200]","Cigna Local Plus",,121.19,53.5,,,,,0,26.34,192.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0220,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,523.91,39.2,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 11.9CM 6MM CEREPAK MICRO UNIFORM",SUP-FCX100611,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"KAISER [10500]",Kaiser,,8861.32,67,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Perq Arterial Translum Thromec",PX-361000507,CDM,61645,CPT,0361,RC,,,both,,,1306.00,391.8,"BLUE CROSS [10001]","Blue Cross PPO",,1.31,.1,,,,,0,1.31,1306,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 130D STD BARREL 80MM STAINLESS STEEL 3 HOLE",SUP-121125,CDM,S27800098,LOCAL,0278,RC,,,both,,,5149.13,1544.74,"NOVANET [10819]",Novanet,,3861.85,75,,,,,0,598.84,4376.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 2X2IN CUTIMED EPIONA 90% NATIVE CLLGN 10%",SUP-7322700,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.60,26.88,"FIRST HEALTH [10303]","First Health",,71.68,80,,,,,0,10.42,76.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONVEY 5FR .058IN CONTRALATERAL SPRT 4 CURVE GUIDING",SUP-H749392285750,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"MULTIPLAN [10600]",Multiplan,,311.47,85,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL DURAL DURAGEN 2X 2IN SQUARE CALLAGEN DURAMATRIX REPAIR",SUP-DMR22,CDM,,,0278,RC,,,both,,,6154.80,1846.44,"CIGNA [10200]",Cigna,,4185.26,68,,,,,0,6.15,5231.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD 10CM OSCOR UNIVERSAL IMPLANTABLE BIPOLAR IS-1","SUP-355 914",CDM,S27200284,LOCAL,0272,RC,,,both,,,4947.30,1484.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,586.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,575.37,4205.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8MM 40MM HIP PRIMARY TAPER OFFSET COCR LFIT",SUP-6260-9-340,CDM,C1776,HCPCS,0278,RC,,,both,,,6224.40,1867.32,"KAISER [10500]",Kaiser,,4170.35,67,,,,,0,723.9,5290.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 15CM 6.6FR MYOCARDIUM UNIPOLAR FIX SCR IS-1",SUP-5071-15,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1604.72,28.62,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 275ML GEL ROUND SMOOTH MEMORYGEL SILICONE P3CM","SUP-3507275 MC",CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"BLUE CROSS [10001]","Blue Cross HMO",,1399.44,39.2,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 420MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.263S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1471.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1444.25,10555.59,"percent of total billed charges",
"SCR BONE 6.5MM 115MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.418,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",160.97,1176.51,"percent of total billed charges",
"BLADE SAW 25MM 9MM THK.38MM AGGRESSIVE THIN SAGITTAL",SUP-2296003525,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.45,67.03,"AETNA [10100]","Aetna HMO/PPO",,177.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.99,189.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RX TAKERU 12MM 1.5MM BALLOON DILATATION TIGHT REWRAP",SUP-DC-RY1512UA1,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"UHC [10700]","United Healthcare",,625.53,63.3,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Imrt Radiother Plan Dose",PX-333000009,CDM,77301,CPT,0333,RC,,,both,,,15941.20,4782.36,"KAISER [10500]",Kaiser,,10680.6,67,,,,,0,1533,13550.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR 28CM 13-15FR ACCESS STAINLESS STEEL",SUP-M0062502071,CDM,C1894,HCPCS,0272,RC,,,both,,,815.04,244.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,554.23,68,,,,,0,94.79,692.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 8MM 24MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.414S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"CIGNA [10200]","Cigna Open Access",,851.72,56.9,,1144.80,304.56,2275.09,66,174.09,1272.35,"percent of total billed charges",
"MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC",508,MS-DRG,,,,,,,inpatient,,,64547.71,19364.31,"PHCS [10601]",PHCS,,7561,,,,,,,7561,44214.42,"per diem","Estimated amount calculated based on 7 day length of stay."
"BLADE RTRCTR 20MM MARS 3V SYSTEM DOCK PIN",SUP-698.315S,CDM,C1713,HCPCS,0278,RC,,,both,,,2640.00,792,"NOVANET [10819]",Novanet,,1980,75,,,,,0,307.03,2244,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 14CM PUMP SET NARROW",SUP-EN8814,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"AETNA [10100]","Aetna HMO/PPO",,49846.5,79.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO2 VASCULAR STD STRAIGHT 215CM .014IN",SUP-SSTD215STR,CDM,C1769,HCPCS,0272,RC,,,both,,,4186.64,1255.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,486.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.91,3558.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 40MM HIP C TAPER COCR LFIT",SUP-06-4000,CDM,C1776,HCPCS,0278,RC,,,both,,,6224.40,1867.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2857,45.9,,,,,0,723.9,5290.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE INCISION STORZ 2 STEM",SUP-M0068805211,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,212.27,41.1,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRAP CLAVICLE ADULT LARGE DELUXE ADJUSTABLE CRISSCROSS",SUP-3004-04,CDM,S27000186,LOCAL,0270,RC,,,both,,,59.86,17.96,"CIGNA [10200]",Cigna,,40.7,68,,,,,0,6.96,50.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 34X21X2MM TITANIUM 1 LEVEL CLOVERLEAF CAUDAL HOLE LOCK",SUP-450.126,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 60MM 135CM 6MM 5FR VASCULAR NITINOL LOW",SUP-5F060603CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3357.13,28.62,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dialysis",PX-801000003,CDM,9999122,LOCAL,0829,RC,,,both,,,4725.00,1417.5,"CIGNA [10200]","Cigna Local Plus",,2527.88,53.5,,,,,0,549.52,4016.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 52MM CATHCART BALL HIP FEMORAL ORTHOCHROME",SUP-136352000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,5873.17,5873.17,5873.17,"1 through 10",434.96,3179,"percent of total billed charges",
"SLEEVE CENTERING 9.5MM S-ROM ZTT 22F SMALL HIP PROXIMAL",SUP-550737,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1289.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Spine Lumbosacral 2-3v",PX-320000044,CDM,72100,CPT,0320,RC,,,both,,,915.10,274.53,"CIGNA [10200]","Cigna Open Access",,64.35,,,,,,,46.01,777.84,"fee schedule",
"SPACER SPINAL 32X23X10MM SOVEREIGN 8D SMALL",SUP-7967810,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9254.41,27,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TISSUE CLSR PRIMA DUPLOJECT TISSEEL PREFILL SYR FROZEN",SUP-1506078,CDM,S27200284,LOCAL,0272,RC,,,both,,,763.67,229.1,"CIGNA [10200]",Cigna,,519.3,68,,,,,0,88.81,649.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 20MM 150MM 4MM BALLOON DILATATION",SUP-PCP040020150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"FIRST HEALTH [10303]","First Health",,984.96,80,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 345CC SMOOTH SHELL SURFACE NATRELLE INSPIRA FULL",SUP-SRF-345,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2698.92,68,,,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DUMBBELL EXERCISE CAST IRON NEOPRENE 1-10LB",SUP-81513878,CDM,S27000186,LOCAL,0270,RC,,,both,,,725.19,217.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,84.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.34,616.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 38MM MULTILOC TITANIUM NIOBIUM ALUMINUM 3.8MM",SUP-04.019.038S,CDM,C1713,HCPCS,0278,RC,,,both,,,1747.20,524.16,"BLUE CROSS [10001]","Blue Cross PPO",,684.9,39.2,,957.42,570.23,957.42,28,203.2,1485.12,"percent of total billed charges",
"KIT FRACTURE STABILIT MX LONG FULL VERTEBROPLASTY SYSTEM",SUP-MX-2100L,CDM,S27200284,LOCAL,0272,RC,,,both,,,12420.00,3726,"CIGNA [10200]",Cigna,,8445.6,68,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 28MM TALON DISTALFIX CORTICAL",SUP-HTN-U-4-28,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,184.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",180.87,1321.92,"percent of total billed charges",
"STENT ZILVER 635 FLEXOR 30MM 80CM 8MM 6FR VASCULAR NITINOL",SUP-G43855,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,439.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 7CM 4FR .018IN 2.9FR MICROPUNCTURE CHECK-FLO",SUP-G02972,CDM,C1894,HCPCS,0272,RC,,,both,,,394.28,118.28,"NOVANET [10819]",Novanet,,295.71,75,,,,,0,45.85,335.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo Bowel Pouch Diag",PX-750000148,CDM,44385,CPT,0750,RC,,,both,,,4224.73,1267.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4224.73,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,491.34,4224.73,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 100MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171081010,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT 25X25X8MM SIGNAFUSE GLASS CLLGN TYPE 1",SUP-SGFS-005,CDM,C1713,HCPCS,0278,RC,,,both,,,7783.20,2334.96,"KAISER [10500]",Kaiser,,5214.74,67,,,,,0,905.19,6615.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION MRI SILICONE PLASTIC 9.6FR 1 LUMEN",SUP-602680,CDM,C1788,HCPCS,0278,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,405.69,28.62,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STBL VASCULAR STRAIGHT 300CM 3CM .014IN SOFT TIP",SUP-507714X,CDM,C1769,HCPCS,0272,RC,,,both,,,636.58,190.97,"KAISER [10500]",Kaiser,,426.51,67,,,,,0,74.03,541.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT XXL PASSIVE LOOP 600LB DISPOSABLE",SUP-MFA2100-XXL-L1,CDM,S27000186,LOCAL,0270,RC,,,both,,,231.51,69.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.92,196.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 1-2 13MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934380,CDM,C1776,HCPCS,0278,RC,,,both,,,18947.25,5684.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2203.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2203.57,16105.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM EGG",SUP-5820-015-040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,129.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREONPANOPTIX PROTORIC(UVA)",SUP-PXCWT6,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"KAISER [10500]",Kaiser,,613.05,67,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP PULSED LAVAGE SIMPULSE VARICARE SMALL 1.75IN RETRACTABLE",SUP-0067320,CDM,S27000186,LOCAL,0270,RC,,,both,,,386.28,115.88,"CIGNA [10200]",Cigna,,262.67,68,,,,,0,44.92,328.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT BLUE 34X4IN LONG LEG 1 FILL LINE POSITIVE LOCK",SUP-ASP-564012,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.00,58.5,"PHCS [10601]",PHCS,,136.5,70,,,,,0,22.68,165.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ 110CM 7FR PULMONARY ARTERY 2 LUMEN MNTR",SUP-111F7P,CDM,C1751,HCPCS,0272,RC,,,both,,,731.84,219.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,497.65,68,,,,,0,85.11,622.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVO NITRX KNEE",SUP-55500014,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"KAISER [10500]",Kaiser,,15617.7,67,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK",RX-121729,CDM,J3475,HCPCS,0636,RC,44567-0420-24,NDC,both,50,ML,100.65,30.19,"KAISER [10500]",Kaiser,,67.44,67,,,,,0,0.24,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 8MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035478300,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4039.61,28.62,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION .5CM HILAL EMBOLIZATION MICROCOILS",SUP-G04524,CDM,S27800098,LOCAL,0278,RC,,,both,,,675.14,202.54,"CIGNA [10200]","Cigna Local Plus",,361.2,53.5,,,,,0,78.52,573.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE 1X10",SUP-7509211,CDM,S27800098,LOCAL,0278,RC,,,both,,,12696.00,3808.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3427.92,27,,,,,0,1476.54,10791.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 13MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P513,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3835.36,45.9,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 16MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532-P-116,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,971.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 62CM RIGHT VENTRICLE TRIPOLAR SCR IN EXTENDABLE",SUP-6935M62,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2034.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL PFC SIGMA 4 KNEE TITANIUM FIX BEARING MODULAR CE",SUP-866024,CDM,C1776,HCPCS,0278,RC,,,both,,,12119.85,3635.95,"PHCS [10601]",PHCS,,8483.9,70,,,,,0,1409.54,10301.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 26MM RADIUS DISTAL VOLAR 3 LEAD THREAD",SUP-131227326,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"PLATE 14X6MM COALITION AGX BONE SPINE",SUP-1128.1206,CDM,C1713,HCPCS,0278,RC,,,both,,,12420.00,3726,"UHC [10700]","United Healthcare",,7861.86,63.3,,5023.51,2672.93,6679.78,18,1444.45,10557,"percent of total billed charges",
"CATH 3.5FR UMBILICAL POLYURETHANE 1 LUMEN DEHP FREE",SUP-P1UVC-3540,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.38,43.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.68,121.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 10FR DRNG FLEXIMA METAL BILIARY RADIOPAQUE MARKER",SUP-27-261,CDM,C1729,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 150MM 3.8FR 4MM BALLOON DILATATION",SUP-H74939148401510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Asp Breast Cyst",PX-361000015,CDM,19000,CPT,0361,RC,,,both,,,1679.93,503.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,199.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,195.38,1679.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADVISOR SENSOR ENABLED HD GRID X MAPPING BI-DIRECTIONAL CATH",SUP-D-AVHDX-DF16,CDM,C1732,HCPCS,0272,RC,,,both,,,17250.00,5175,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11730,68,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 24MM 144CM 2.25MM CORONARY STENT",SUP-H7493952824220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"FIRST HEALTH [10303]","First Health",,4452,80,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 14MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192114,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"BLUE CROSS [10001]","Blue Cross PPO",,9309.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",2761.95,20186.21,"percent of total billed charges",
"SYSTEM SYNERGY XD MONORAIL 32MM 144CM 2.25MM CORONARY STENT",SUP-H7493941832220,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 3.5 X 4 COMPLEX PICO COIL",SUP-10USC03504,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"CIGNA [10200]","Cigna Open Access",,4380.29,33.5,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 300MM 4MM BALLOON DILATATION",SUP-PCU040300130,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,147.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 80MM 3.5MM BALLOON DILATATION RAPID",SUP-47535080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH THERMOSET MNTR 3 WAY STPCOCK THERMODILUTION THERMAL",SUP-41424-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.31,28.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,44.21,45.9,,,,,0,11.2,81.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 CURVE 15MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962053,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"FIRST HEALTH [10303]","First Health",,7399.56,80,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 5MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620605,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Open Access",,6403.47,56.9,,5302.19,4377.88,6578.61,27,1308.83,9565.82,"percent of total billed charges",
"BLADE SAW 25.5X9.5X.4MM MICRO 100 MICROPOWER SAGITTAL FINE",SUP-507112300,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.42,71.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,162.81,68,,,,,0,27.84,203.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X16MM VERTE-STACK CORNERSTONE PSR 6MM",SUP-6240064,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 8FR 15CM RADIOPAQUE GWIRE STERILE DISPOSABLE",SUP-G00999,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"AETNA [10100]","Aetna HMO/PPO",,39.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH IRIS STERILE LATEX FREE DISPOSABLE",SUP-220180518,CDM,S27200284,LOCAL,0272,RC,,,both,,,2157.21,647.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,255.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,250.88,1833.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN FULL LENGTH RIGHT CORONARY BYPASS",SUP-H749085261902,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"FIRST HEALTH [10303]","First Health",,61.26,80,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 1.5 X 6 HELICAL FINISHING COIL",SUP-10HFN-01506,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA [10200]","Cigna Open Access",,5885.22,56.9,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Stapler Skin",PX-E27200212,CDM,E27200212,LOCAL,0272,RC,,,both,,,47.30,14.19,"NOVANET [10819]",Novanet,,35.48,75,,,,,0,5.5,40.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD 55CM 1.3MM PRECISION S8 MP35N PLATINUM IRIDIUM",SUP-SC-9208-55,CDM,C1883,HCPCS,0278,RC,,,both,,,3525.00,1057.5,"NOVANET [10819]",Novanet,,2643.75,75,,,,,0,409.96,2996.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVICROSS 90CM 30D 12MM SPRT STAINLESS STEEL",SUP-NC35901,CDM,C1887,HCPCS,0272,RC,,,both,,,1462.05,438.61,"MULTIPLAN [10600]",Multiplan,,1242.74,85,,,,,0,170.04,1242.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE REAMER 21MM SPIN GUARD PROTCT FEMALE",SUP-P01-911-2102,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"UHC [10700]","United Healthcare",,799.86,63.3,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 155CM 10MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200104020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"KAISER [10500]",Kaiser,,2773.8,67,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 5.5MM CURVE NONSTERILE",SUP-1555501055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"POS OR LEG KIT DISPOSABLE",SUP-111618,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"AETNA [10100]","Aetna HMO/PPO",,248.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 5.5CM 4FR CHECK-FLO PERFORMER MICROPUNCTURE .018IN",SUP-G27022,CDM,C1894,HCPCS,0272,RC,,,both,,,326.16,97.85,"AETNA [10100]","Aetna HMO/PPO",,259.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.93,277.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP SECTOR POROCOAT PINNACLE STERILE",SUP-121722054,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"AETNA [10100]","Aetna HMO/PPO",,5335.05,79.5,,10981.53,8986.79,12413.38,12,780.46,5704.15,"percent of total billed charges",
"TROCAR LAPAROSCOPIC 100MM 5MM KII BLUNT TIP BALLOON STERILE",SUP-C0Q20,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 24MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR24,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"MULTIPLAN [10600]",Multiplan,,11143.5,85,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 20MM 190CM 5MM",SUP-R51005002L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,233.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 485CC NATRELLE INSPIRA COHESIVE STERILE",SUP-TCM-485,CDM,C1789,HCPCS,0278,RC,,,both,,,8280.00,2484,"MULTIPLAN [10600]",Multiplan,,7038,85,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATCH POINT SYSTEM RSP PATIENT MATCHED GLENOID DRILL GUIDE",SUP-804-03-057,CDM,C1776,HCPCS,0278,RC,,,both,,,4200.00,1260,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1927.8,45.9,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,inpatient,,,36356.65,10906.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,22683.74,,"Fee schedule rate ($22,683.74). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7088.24,28497.8,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE LUNDERQUIST VASCULAR STRAIGHT 300CM 4CM .035IN PTFE",SUP-G45352,CDM,C1769,HCPCS,0272,RC,,,both,,,937.98,281.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,637.83,68,,,,,0,109.09,797.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 3.5MM VUEPOINT II TITANIUM NONSTERILE LATEX",SUP-8976112,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 25MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G225,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"MULTIPLAN [10600]",Multiplan,,8500,85,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309116,CDM,C1776,HCPCS,0278,RC,,,both,,,37771.65,11331.49,"CIGNA [10200]","Cigna Open Access",,12653.5,33.5,,5302.19,4377.88,6578.61,27,4392.84,32105.9,"percent of total billed charges",
"SCR BONE 7.5MM 35MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13177535,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 32X6.3MM THK.8MM STERNUM STERILE LATEX FREE",SUP-0298-097-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.70,55.41,"UHC [10700]","United Healthcare",,116.92,63.3,,,,,0,21.48,157,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SMART CONTROL 60MM 120CM 14MM BILIARY NITINOL SELF",SUP-C14060MB,CDM,C1876,HCPCS,0278,RC,,,both,,,6037.50,1811.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,715.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 32MM LCP STAINLESS STEEL CORTEX FOREFOOT",SUP-202.892,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"CIGNA [10200]","Cigna Local Plus",,173.33,53.5,,3978.14,359.25,3978.14,24,37.68,275.39,"percent of total billed charges",
"CATH TREK 145CM 15MM 2.25MM BALLOON DILATATION PEBAX",SUP-1012271-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 9CM 20GA GHIATAS BARBED WIRE STIFFENED",SUP-49920,CDM,A4648,HCPCS,0278,RC,,,both,,,182.79,54.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.26,155.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 120MM 28-14MM 13FR TRIVASCULAR OVATION PRIME",SUP-TV-IL1428120-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"KAISER [10500]",Kaiser,,22371.3,67,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 10X6.8IN MEPITEL ONE NONADHERENT LATEX FREE",SUP-081532332,CDM,S27200284,LOCAL,0272,RC,,,both,,,363.03,108.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,246.86,68,,,,,0,42.22,308.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 3-0 SH 30IN 2 ARM BRAIDED GREEN",SUP-X562H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 12MM MONSTER SHORT THREAD BITE NONSTERILE",SUP-P24-020-012S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"LINER BIPOLAR 47/48/49MM 26MM LEGACY HIP UHMWPE STERILE",SUP-00500104726,CDM,C1776,HCPCS,0278,RC,,,both,,,2365.50,709.65,"BLUE CROSS [10001]","Blue Cross PPO",,927.28,39.2,,3949.44,3949.44,3949.44,"1 through 10",275.11,2010.68,"percent of total billed charges",
"FRCP BIOPSY PRECISE BITE CONSISTENT SAMPLE RETENTION",SUP-M00515182,CDM,S27000186,LOCAL,0270,RC,,,both,,,224.03,67.21,"CIGNA [10200]",Cigna,,152.34,68,,,,,0,26.05,190.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 12MM 140CM 3MM CORONARY STENT CARBOSIL",SUP-LUN300R12US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X120 135CM SL",SUP-48005012R,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"NOVANET [10819]",Novanet,,747.83,75,,,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK 21X11IN THERAPEUTIC COLD PLIABLE SOFT OVERSIZE LATEX",SUP-3548D,CDM,S27000186,LOCAL,0270,RC,,,both,,,132.76,39.83,"UHC [10700]","United Healthcare",,84.04,63.3,,,,,0,15.44,112.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP INSRT TIBIAL KNEE ROTATE PLATFORM HYBRID ATTUNE",SUP-OSC370780,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"PHCS [10601]",PHCS,,15435,70,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 17GA 11CM 5CM ACHIEVE LIGHTWEIGHT SOFT",SUP-CA1811,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165CM 8.5-11MM OTSC 6MM NITINOL STERILE",SUP-100.09,CDM,C1760,HCPCS,0278,RC,,,both,,,3667.50,1100.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1049.64,28.62,,,,,0,426.53,3117.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG TITANIUM ACU-LOC BONE RIGHT DISTAL VOLAR ULNAR",SUP-70-0048,CDM,C1713,HCPCS,0278,RC,,,both,,,5754.60,1726.38,"CIGNA [10200]",Cigna,,3913.13,68,,1831.33,1831.33,1831.33,16,669.26,4891.41,"percent of total billed charges",
"CATH STERLING SL MONORAIL 150CM 120MM 3.8-3.4FR 3MM LOW",SUP-39147-30121,CDM,C1725,HCPCS,0272,RC,,,both,,,1762.50,528.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,204.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC E-Stim Man Ea 15min (Go)",PX-430000010,CDM,97032,CPT,0430,RC,,,both,,,130.38,39.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,130.38,,"Per diem ($215).",,,,0,15.16,130.38,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echogr Transrec/Pros Vol Stdy",PX-402000031,CDM,76873,CPT,0402,RC,,,both,,,1190.00,357,"CIGNA [10200]","Cigna Local Plus",,219.96,,,,,,,138.4,1011.5,"fee schedule",
"HC Tx Cdisloc I-P W Manip WO Anes",PX-450000133,CDM,26770,CPT,0450,RC,,,both,,,909.00,272.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,107.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.91,909,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION .035IN 9IN KIRSCHNER STAINLESS STEEL 2 END",SUP-KM173-29-35,CDM,C1713,HCPCS,0278,RC,,,both,,,59.29,17.79,"CIGNA [10200]",Cigna,,40.32,68,,1831.33,1831.33,1831.33,16,6.9,50.4,"percent of total billed charges",
"SURFACE ARTICULAR 12MM PERSONA 6-9 C-D KNEE RIGHT TIBIA",SUP-42522400512,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1253.3,9159.96,"percent of total billed charges",
"DEVICE ELECTROSURGICAL 23CM LIGASURE MARYLAND 350D OPEN",SUP-LF1923,CDM,S27200284,LOCAL,0272,RC,,,both,,,3441.08,1032.32,"CIGNA [10200]","Cigna Open Access",,1957.97,56.9,,,,,0,400.2,2924.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR JR4 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389696920,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"NOVANET [10819]",Novanet,,274.83,75,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 150CM 120MM 5MM BALLOON DILATATION PACLITAXEL",SUP-H74939419501210,CDM,C2623,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1103.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 20MM 4 HOLE POLYAXIAL CLAW II BONE ANKLE FOOT",SUP-40240420,CDM,C1713,HCPCS,0278,RC,,,both,,,15000.60,4500.18,"CIGNA [10200]","Cigna Local Plus",,4725.19,31.5,,3978.14,359.25,3978.14,24,1744.57,12750.51,"percent of total billed charges",
"LINER ACETABULAR DYNASTY A-CLASS STD 36MM BIOFOAM POLY HIP",SUP-DLXPGG36,CDM,C1776,HCPCS,0278,RC,,,both,,,12771.90,3831.57,"BLUE CROSS [10001]","Blue Cross PPO",,5006.58,39.2,,3949.44,3949.44,3949.44,"1 through 10",1485.37,10856.12,"percent of total billed charges",
"PLATE BONE LCP ANKLE FOOT STAINLESS STEEL 2X7 HOLE MODULAR T",SUP-247.351,CDM,C1713,HCPCS,0278,RC,,,both,,,2541.00,762.3,"CIGNA [10200]","Cigna Local Plus",,1359.44,53.5,,3978.14,359.25,3978.14,24,295.52,2159.85,"percent of total billed charges",
"CATH HERMETIC 35CM 38CM LARGE EXTERNAL DRNG VENTRICULAR SET",SUP-INS4500,CDM,C1729,HCPCS,0272,RC,,,both,,,1984.05,595.21,"FIRST HEALTH [10303]","First Health",,1587.24,80,,,,,0,230.75,1686.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Posaconazole",PX-301000622,CDM,80187,CPT,0301,RC,,,both,,,382.00,114.6,"FIRST HEALTH [10303]","First Health",,305.6,80,,,,,0,0.01,324.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABACAVIR 300 MG TABLET",RX-24438,CDM,,,0637,RC,50268-0049-11,NDC,both,1,UN,37.95,11.38,"CIGNA [10200]",Cigna,,25.81,68,,,,,0,4.41,32.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 54MM 3 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-43F54V,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"GORE CARDIOFORM ASD OCCLUDER 32MM 10FR",SUP-00733132636495,CDM,C1817,HCPCS,0278,RC,,,both,,,52321.50,15696.45,"CIGNA [10200]","Cigna Local Plus",,16481.27,31.5,,,,,0,6084.99,44473.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASCOPE 4 BRONCHO LARGE SAMPLER SET",SUP-478501000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2302.50,690.75,"NOVANET [10819]",Novanet,,1726.88,75,,,,,0,267.78,1957.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12-15IN 26FR 3/8IN VENOUS TAPER 1 STAGE 1",SUP-66126,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.63,85.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,33.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.22,242.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,inpatient,,,84889.64,25466.89,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,16439.5,,"Case rate ($15,731.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,607.84, add-ons for qualifying new technology services are included. If operating cost exceeds $47,647.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,486.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,627.16. The transfer operating threshold is the transfer adjustment factor * $14,607.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,104.42. The transfer capital threshold is the transfer adjustment factor * $1,104.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",16439.45,16439.45,16439.45,"1 through 10",7561,74043.98,other,"IP DRG"
"EXP TISSUE 15X10.9CM 550CC STYLE 9100 TEXTURE SURFACE 3 SUT",SUP-354-9114,CDM,C1789,HCPCS,0278,RC,,,both,,,9694.50,2908.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6592.26,68,,,,,0,1127.47,8240.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 300MM 2.5MM DRILL TIP NONSTERILE",SUP-03.120.026,CDM,C1769,HCPCS,0272,RC,,,both,,,437.72,131.32,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Nasopharyngoscopy With Endosco",PX-450000378,CDM,92511,CPT,0361,RC,,,both,,,535.23,160.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL 0 CP-2 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J870H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 39X13MM PRECISION THK.015IN MICRO THIN STAINLESS",SUP-2296-033-108,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.50,90.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LEAD DEFIBRILLATOR 65CM 8FR OPTISURE ENDOCARDIUM 2 COIL DF1",SUP-LDA220-65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"UHC [10700]","United Healthcare",,10869.88,63.3,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 115CM 5MM 7FR 2-5-2MM SPACE D CURVE",SUP-D7BTD5L252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,587.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 P 16MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530P116,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"UHC [10700]","United Healthcare",,5289.28,63.3,,8601.07,8395.67,8601.07,"1 through 10",971.79,7102.52,"percent of total billed charges",
"SUT ETHIBOND 1 CT-1 30IN BRAID GREEN NONABSORBABLE",SUP-X425H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION MENISCAL ROOT REPAIR",SUP-AR-4550,CDM,S27200284,LOCAL,0272,RC,,,both,,,7208.78,2162.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4901.97,68,,,,,0,838.38,6127.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 1 CT-1 30IN BRAID GREEN NONABSORBABLE",SUP-X425H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE EMBOSHIELD NAV6 BAREWIRE WORKHORSE VASCULAR 315CM .014",SUP-22440-31,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"NOVANET [10819]",Novanet,,729,75,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840005535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"FIRST HEALTH [10303]","First Health",,7637.48,80,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 165CM DUALKNIFE J STERILE CERAMIC 2",SUP-KD-655L,CDM,S27200284,LOCAL,0272,RC,,,both,,,5520.35,1656.1,"NOVANET [10819]",Novanet,,4140.26,75,,,,,0,642.02,4692.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 320MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.152S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"FIRST HEALTH [10303]","First Health",,9934.67,80,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X11X5MM PTC PEEK TANTALUM TITANIUM CERVICAL",SUP-5030541,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"MULTIPLAN [10600]",Multiplan,,5676.66,85,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION INTERNALBRACE",SUP-AR-1789J-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"PHCS [10601]",PHCS,,7220.85,70,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS STREAMLINE 25MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-M003SFD050250,CDM,C1874,HCPCS,0278,RC,,,both,,,85681.49,25704.45,"BLUE CROSS [10001]","Blue Cross PPO",,33587.14,39.2,,,,,0,9964.76,72829.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 65MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.065,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"FIRST HEALTH [10303]","First Health",,165.09,80,,,,,0,24,175.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII ALLOGRAFT 16MM 23MM",SUP-401216A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 4IN 17GA 19GA TUOHY EPILONG CONTINUOUS CLOSE",SUP-TAL101,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"PHCS [10601]",PHCS,,231.42,70,,,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 115CM 5MM 7FR 2-5-2MM SPACE D CURVE",SUP-D7BTD5L252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"KAISER [10500]",Kaiser,,3323.94,67,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 1/8IN STEINMANN ORTHOPEDIC STAINLESS STEEL",SUP-KM169-29-18,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",7.4,54.07,"percent of total billed charges",
"CLAREON PANOPTIX TORIC UVA",SUP-CCWTT3,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"CIGNA [10200]","Cigna Open Access",,492.19,56.9,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 12MM 2.75MM BALLOON DILATATION",SUP-H7493912412270,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 180MM 4.75MM STRAIGHT PERCUTANEOUS CCM PLUS",SUP-1476006180,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 12MM 145CM 5.5MM BALLOON DILATATION",SUP-1400550-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 80CM 125CM 8MM VASCULAR HIWIRE NITINOL",SUP-G43783,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"NOVANET [10819]",Novanet,,3134.25,75,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM TITANIUM SPIRE BONE SPINE",SUP-9240545,CDM,C1713,HCPCS,0278,RC,,,both,,,17798.40,5339.52,"MULTIPLAN [10600]",Multiplan,,15128.64,85,,,,,0,2069.95,15128.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL STEALTH 12MM 12MM ATRAUMATIC OCCLUSION FULL",SUP-G-1250,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]","Cigna Open Access",,128.71,56.9,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC ANATOMIC SOCKET FLIPCUTTER II SHORT KNEE",SUP-AR-1204AS-75,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1174.76,45.9,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IMPL GLUTEUS MEDIUS",SUP-AR-2941GM-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,9201.15,2760.34,"PHCS [10601]",PHCS,,6440.81,70,,,,,0,1070.09,7820.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET",RX-1300,CDM,,,0637,RC,00904-1883-61,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM AFFIX II BONE LUMBAR SPINE",SUP-7577045,CDM,S27800098,LOCAL,0278,RC,,,both,,,24141.60,7242.48,"MULTIPLAN [10600]",Multiplan,,20520.36,85,,,,,0,2807.67,20520.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 5.5FR 15CM MIDLINE ARROW CHLORAG+ARD 2 LUMEN",SUP-CDC-41552-MPK1A,CDM,C1751,HCPCS,0272,RC,,,both,,,1331.64,399.49,"MULTIPLAN [10600]",Multiplan,,1131.89,85,,,,,0,154.87,1131.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER SURGICAL 203MM MAXFIRE DISPOSABLE",SUP-905732,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 36MM CG FUTURE FLEXIBLE LOW PROFILE EYELET",SUP-638BL36,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5388.21,41.1,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 14CM 5FR 3MM .035IN BALLOON",SUP-G52330,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"MULTIPLAN [10600]",Multiplan,,815.8,85,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 3.1X3.1IN XENMATRIX AQUAPURE SQUARE ACELLULAR",SUP-1160808,CDM,C1781,HCPCS,0278,RC,,,both,,,10750.20,3225.06,"NOVANET [10819]",Novanet,,8062.65,75,,,,,0,1250.25,9137.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR GREEN 45MM 28MM RINGLOC ECCENTRIC HIP",SUP-11-165214,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"NOVANET [10819]",Novanet,,4994.91,75,,,,,0,774.54,5660.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESVR DRNG SILICONE JACKSON-PRATT BULB 400CC STERILE LATEX",SUP-SU130-1000,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.53,54.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,122.76,68,,,,,0,21,153.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 90CM 7FR 40D GUIDING DURAFORM PTFE",SUP-H965100430,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"AETNA [10100]","Aetna HMO/PPO",,1989.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 2-0 CT-1 36IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y945H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC .75CM 4.45X5.02CM ACCOLADE LATITUDE NXT",SUP-L301,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,11905.92,28.62,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 500MM 5.5MM CD HORIZON CURVE COBALT LINE STERILE",SUP-1476200500,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"CANN PERFUSION 11.4IN CORONARY ARTERY 4MM 2.1MM RIGHT ANGLE",SUP-415804,CDM,S27200284,LOCAL,0272,RC,,,both,,,801.90,240.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,93.26,681.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 20MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530020L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 22MM TI",SUP-VAN-25220-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,446.15,45.9,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Observation Carve-Out Cardiology",PX-762000014,CDM,G0378,HCPCS,0762,RC,,,both,,,66.00,19.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,66,,"Per diem ($3,918).",,,,0,7.68,66,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP FEM N/POROUS SIZE 3 RIGHT",SUP-2154-0-0003,CDM,C1776,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]",Cigna,,5630.4,68,,5873.17,5873.17,5873.17,"1 through 10",962.96,7038,"percent of total billed charges",
"CATH CPS DIRECT PL SITEMARK 51CM 47CM 9FR 7FR 135D GUIDING",SUP-410173,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,439.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM ASNIS III TITANIUM 1/3 THREAD REVERSE CUT",SUP-604638S,CDM,C1713,HCPCS,0278,RC,,,both,,,1319.00,395.7,"CIGNA [10200]","Cigna Local Plus",,705.67,53.5,,3978.14,359.25,3978.14,24,153.4,1121.15,"percent of total billed charges",
"STENT ORSIRO 2.25/9",SUP-401729,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,9776.84,9776.84,9776.84,"1 through 10",521.61,3812.25,"percent of total billed charges",
"SYSTEM RETENTION PANNUS WITH ADHESIVE PAD MEDICAL GRADE HOOK",SUP-CZ-PRS-04,CDM,S27200284,LOCAL,0272,RC,,,both,,,571.05,171.31,"CIGNA [10200]",Cigna,,388.31,68,,,,,0,66.41,485.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL SABRELOC 6-0 S-14 18IN 2 ARM BRAID COATED UNDYED",SUP-J670G,CDM,S27200284,LOCAL,0272,RC,,,both,,,161.07,48.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.73,136.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 64MM 40MM ALTRX HIP",SUP-122140164,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3726.93,27,,,,,0,1605.34,11732.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 25MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962327,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"KAISER [10500]",Kaiser,,9717.55,67,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 45D JJ ELEVATED 54MM 36MM LONGEVITY HIP",SUP-00875201136,CDM,C1776,HCPCS,0278,RC,,,both,,,6497.40,1949.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,769.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,755.65,5522.79,"percent of total billed charges",
"STENT GORE VIABAHN 15MM 135CM 5MM 8MM 7FR .035IN",SUP-BXA051502A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE VASCULAR STRAIGHT 300CM 3CM .014IN",SUP-28001,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX SAFE PERFORMAXX 40MM 80CM 10MM 6FR .035IN",SUP-ZBM10040,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6803.4,68,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE STIM 4IN 21GA SONOPLEX CANN TIP ULTRASOUND WAVE",SUP-001185-77,CDM,C9812,HCPCS,0272,RC,,,both,,,126.24,37.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,51.88,41.1,,,,,0,14.68,107.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX 8X6IN MONOFILAMENT SCAFFOLD FULL",SUP-1190300,CDM,C1781,HCPCS,0278,RC,,,both,,,14328.00,4298.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5731.2,40,,,,,0,1666.35,12178.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD SUT ASSISTANT 2-0 ES-9 48IN COATED ENDO STITCH",SUP-173023,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"CIGNA [10200]",Cigna,,98.03,68,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAUT ELECTROSURGICAL 5/8IN DIAGNOSTICK 2250F HIGH",SUP-65410-181,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.54,35.26,"MULTIPLAN [10600]",Multiplan,,99.91,85,,,,,0,13.67,99.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING DRNG 30CM 12FR SILICONE SOFT PLIABLE T",SUP-SU130-1238,CDM,S27200284,LOCAL,0272,RC,,,both,,,2175.00,652.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1479,68,,,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 80MM 4.8FR 7MM BALLOON DILATATION OTW",SUP-39032-70808,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 1/8IN HEADLESS SQUARE END 3.5IN STAINLESS STEEL",SUP-7650-2038,CDM,S27200284,LOCAL,0272,RC,,,both,,,2947.50,884.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL 7CM MR8 5MM BALL DISSECTING CARBIDE",SUP-MR8-7BA50C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1089.86,326.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BALLOON DILATATION .018IN 4FR 4MM 150CM 2CM PTA OTW LOW",SUP-435402X,CDM,C1725,HCPCS,0272,RC,,,both,,,2137.50,641.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PACKAGED DELIVERY SYSTEM",SUP-ES0200,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,MINOR",229,APR-DRG,,,,,,,inpatient,,,85490.36,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTIVE KNEE JOINT REPLACEMENT,MINOR",326,APR-DRG,,,,,,,inpatient,,,117574.66,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488.00. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.20. DRG Reimbursement is equal to $9,105.50. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%.",,,,0,,,other,"SOI-1 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT GAIT 2IN 60IN POLYETHYLENE POSEY QUICK CLEAN ECONOMY",SUP-552545,CDM,S27100035,LOCAL,0271,RC,,,both,,,224.20,67.26,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP ASPIR 4.50IN .10IN .08IN CUSA CLARITY 36KHZ CURVE STD",SUP-C7414S,CDM,S27200284,LOCAL,0272,RC,,,both,,,5913.51,1774.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CIRCUIT BREATHING SHORT HEAT WIRE HUMD FLEXIBLE UNFILTER 38",SUP-773996,CDM,S27000186,LOCAL,0270,RC,,,both,,,992.23,297.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 5MM 30MM TRIGEN FEMUR LOW PROFILE",SUP-71645030,CDM,C1713,HCPCS,0278,RC,,,both,,,2314.95,694.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,274.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",269.23,1967.71,"percent of total billed charges",
"INSRT TIBIAL 5 15MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158125115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL SYMBOTEX 8CM 2 SIDE COMPOSITE 3D BIOABSORBABLE",SUP-SYM8OS,CDM,C1781,HCPCS,0278,RC,,,both,,,3068.10,920.43,"NOVANET [10819]",Novanet,,2301.08,75,,,,,0,356.82,2607.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 21GA 40CM 4CM BLUE HUB TUBING STAINLESS",SUP-PSS-8F-4-018MT,CDM,C1894,HCPCS,0272,RC,,,both,,,286.67,86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,33.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.34,243.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL LARGE KNEE LEFT LCS COMPLETE POROCOAT",SUP-129404060,CDM,C1776,HCPCS,0278,RC,,,both,,,28683.90,8605.17,"UHC [10700]","United Healthcare",,18156.91,63.3,,8601.07,8395.67,8601.07,"1 through 10",3335.94,24381.32,"percent of total billed charges",
"CAGE SPINAL 14X12X8MM COHERE 7D LORDOSIS CERVICAL INTERBODY",SUP-1000-00-0814,CDM,C1889,HCPCS,0278,RC,,,both,,,6210.00,1863,"MULTIPLAN [10600]",Multiplan,,5278.5,85,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 63CM SUPERSTIFF GWIRE GUIDING HEMOSTASIS",SUP-407436,CDM,C1893,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 16MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-116,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"CIGNA [10200]","Cigna Local Plus",,4239.41,31.5,,5372.07,4581.20,7242.98,23,1565.22,11439.68,"percent of total billed charges",
"TROCAR LAPAROSCOPIC 100MM 12MM ENDOPATH XCEL BLUNT TIP",SUP-H12LP,CDM,S27200284,LOCAL,0272,RC,,,both,,,1189.82,356.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,489.02,41.1,,,,,0,138.38,1011.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 100MM 130CM 6MM 6FR .035IN HELICAL VASCULAR",SUP-EX061003CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS [10001]","Blue Cross HMO",,5950.56,39.2,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 54MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.054TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"CNCT ROD 21-23MM 3.5MM ELLIPSE STRAIGHT TITANIUM SPINE",SUP-182.923,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1382.35,28.62,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM CLAW II",SUP-40233524,CDM,C1713,HCPCS,0278,RC,,,both,,,1474.20,442.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,676.66,45.9,,,,,0,171.45,1253.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Npwt >50 Sq Cm W/Dme (Gp)",PX-420000036,CDM,97606,CPT,0420,RC,,,both,,,907.00,272.1,"CIGNA [10200]","Cigna Open Access",,309,,"Per diem ($309).",,,,0,105.48,770.95,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 120MM 120CM 18MM .035IN 3MM VASCULAR VENOUS",SUP-VENUL18120,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"KAISER [10500]",Kaiser,,15617.7,67,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 65CM 24MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES2465CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,922.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 56MM 36MM ALTRX HIP",SUP-122136156,CDM,C1776,HCPCS,0278,RC,,,both,,,6814.08,2044.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4633.57,68,,,,,0,792.48,5791.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP LIMIT HOLE OSSEOTI G7 F",SUP-110010245,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORQR 90CM 5FR 2-5-2MM SPACING CORONARY SINUS CURVE",SUP-041590CS,CDM,C1730,HCPCS,0272,RC,,,both,,,2250.00,675,"UHC [10700]","United Healthcare",,1424.25,63.3,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 58CM .016IN KNOB CAP KT",SUP-6037,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 58MM 135CM 6MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU1350658,CDM,C1874,HCPCS,0278,RC,,,both,,,15870.00,4761,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1880.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.9MM ULTRAFIX RC SHOULDER ARTHROSCOPIC STAINLESS",SUP-10139,CDM,C1713,HCPCS,0278,RC,,,both,,,1535.11,460.53,"CIGNA [10200]",Cigna,,1043.87,68,,1831.33,1831.33,1831.33,16,178.53,1304.84,"percent of total billed charges",
"TRAY PERICARDIOCENTESIS 40CM 8.3FR 18GA PIGTAIL CURVE",SUP-G10210,CDM,C1729,HCPCS,0272,RC,,,both,,,1498.50,449.55,"AETNA [10100]","Aetna HMO/PPO",,1191.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL 30CM 7FR .038IN URETERAL PERCUFLEX",SUP-M0061856310,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEROPENEM 500 MG/10 ML IV (WET SOLR VIAL)",RX-41517379,CDM,J2185,HCPCS,0636,RC,63323-0507-21,NDC,both,1,UN,27.18,8.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2.45,,,,,,,2.23,23.1,"fee schedule",
"KIT BONE CEMENT AUTOPLEX VERTAPLEX HV M4 MIXER STERILE LATEX",SUP-0707-000-000,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross HMO",,2569.56,39.2,,957.42,156.86,7483.26,51,762.35,5571.75,"percent of total billed charges",
"GWIRE JAGWIRE ENDOSCOPIC STRAIGHT TRIM 260CM .035IN BILIARY",SUP-M00556641,CDM,C1769,HCPCS,0272,RC,,,both,,,811.01,243.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.32,689.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 26X9X10MM CONDUIT 12D STRAIGHT EIT ROUGH ELEVATE",SUP-PUI31006,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bag Infusor Pressure",PX-E27000046,CDM,E27000046,LOCAL,0270,RC,,,both,,,157.30,47.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.29,133.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BARR SKIN PROTECTANT HYPOALLERGENIC WATERPROOF 3M CAVILON",SUP-5050,CDM,S27000186,LOCAL,0270,RC,,,both,,,66.00,19.8,"CIGNA [10200]","Cigna Local Plus",,35.31,53.5,,,,,0,7.68,56.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE FEMORAL 35MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-1511-01-203,CDM,C1776,HCPCS,0278,RC,,,both,,,16151.52,4845.46,"BLUE CROSS [10001]","Blue Cross PPO",,6331.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",1878.42,13728.79,"percent of total billed charges",
"3.5MM LCP PERIARTIC PROX HUM PLATE 8H/199MM RT-STERILE",SUP-02.123.026S,CDM,C1713,HCPCS,0278,RC,,,both,,,14057.65,4217.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1634.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1634.9,11949,"percent of total billed charges",
"PEG FIXATION 2.3MM 23MM DISTAL VOLAR RADIUS FOSSA THREADED",SUP-TPLS-23230-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,680.40,204.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,462.67,68,,,,,0,79.13,578.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE RIGHT CEMENTED POSTERIOR STABILIZE",SUP-5515-F-802,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA [10200]","Cigna Open Access",,5690,56.9,,5302.19,4377.88,6578.61,27,1163,8500,"percent of total billed charges",
"LEADLESS DR PM 19.5 F 32.2 MM RA",SUP-LSP203A,CDM,C1786,HCPCS,0275,RC,,,both,,,73530.00,22059,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,19853.1,27,,,,,0,8551.54,62500.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS03010,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Iud",PX-450000342,CDM,58301,CPT,0361,RC,,,both,,,302.23,90.67,"AETNA [10100]","Aetna HMO/PPO",,240.27,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.15,302.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 370CC",SUP-SMPX370,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"AETNA [10100]","Aetna HMO/PPO",,5924.34,79.5,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 15MM 80CM 6MM 8MM 7FR .035IN",SUP-BXA061501A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 30MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-030,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"BLUE CROSS [10001]","Blue Cross HMO",,8330.31,39.2,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TI LOW PROFILE TRANSCONNECTOR 42MM-55MM FOR 6.0MM RODS",SUP-497.798,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,1470,39.2,,957.42,156.86,7483.26,51,436.13,3187.5,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 47CM 30MM ABDOMEN THORAX WOVEN SOFT",SUP-M00202175430T0,CDM,L8670,HCPCS,0278,RC,,,both,,,13481.36,4044.41,"BLUE CROSS [10001]","Blue Cross HMO",,5284.69,39.2,,,,,0,427.53,11459.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23-26MM 0-43MM COREVALVE 29MM HEART PORCINE",SUP-MCS-P3-29-AOA-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"NOVANET [10819]",Novanet,,128250,75,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 2 KNEE LEFT",SUP-5542-A-201,CDM,C1776,HCPCS,0278,RC,,,both,,,7027.65,2108.29,"FIRST HEALTH [10303]","First Health",,5622.12,80,,,,,0,817.32,5973.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 FREEDOM H 36MM E1 HIP CONSTRAIN",SUP-010000986,CDM,C1776,HCPCS,0278,RC,,,both,,,19199.88,5759.96,"KAISER [10500]",Kaiser,,12863.92,67,,,,,0,2232.95,16319.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 12MM STD WALL GORE-TEX RING 30CM STERILE",SUP-R12030030,CDM,C1768,HCPCS,0278,RC,,,both,,,7969.50,2390.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,926.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,926.85,6774.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 9CM 22MM DUODENAL NITINOL SOFT ANCHOR LOCK",SUP-M00555870,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 2.5MM 55MM AXSOS STAINLESS STEEL CORTICAL",SUP-338655,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",26.77,195.67,"percent of total billed charges",
"LINER ACETABULAR FMP EPLUS 36",SUP-932-36-752,CDM,C1776,HCPCS,0278,RC,,,both,,,5638.37,1691.51,"PHCS [10601]",PHCS,,3946.86,70,,,,,0,655.74,4792.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,inpatient,,,34737.02,10421.11,"CIGNA [10200]","Cigna Local Plus",,9960.93,,"Fee schedule rate ($9,960.93). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,5987.82,24073.62,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CYCLOPENTOLATE 1 % EYE DROPS",RX-2025,CDM,,,0250,RC,24208-0735-01,NDC,both,2,ML,102.72,30.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.95,87.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC INTERVERTEBRAL 18MM 6MM PRESTIGE LP CERVICAL SPINE",SUP-6972860,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7654.5,27,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORPAC 90CM STD PERITONEAL BARIUM CARDIAC IMPREGNATE",SUP-43103,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Perm Gen Sngl Lead",PX-480000021,CDM,33227,CPT,0481,RC,,,both,,,9765.02,2929.51,"BLUE CROSS [10001]","Blue Cross HMO",,9765.02,,"Case rate ($14,709.67). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1135.67,9765.02,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Perm Gen Sngl Lead",PX-480000021,CDM,33227,CPT,0481,RC,,,both,,,9765.02,2929.51,"MULTIPLAN [10600]",Multiplan,,8300.27,85,,,,,0,1135.67,9765.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Perm Gen Sngl Lead",PX-480000021,CDM,33227,CPT,0481,RC,,,both,,,9765.02,2929.51,"PHCS [10601]",PHCS,,6835.51,70,,,,,0,1135.67,9765.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 20MM 1.5MM BALLOON DILATATION RAPID",SUP-47515020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"MULTIPLAN [10600]",Multiplan,,1356.35,85,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 12.7CM 4.5MM STAINLESS STEEL STRAIGHT SHANK",SUP-231804506,CDM,S27000186,LOCAL,0270,RC,,,both,,,424.13,127.24,"AETNA [10100]","Aetna HMO/PPO",,337.18,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,49.33,360.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR FLOW SMALL STATURE DISPOSABLE HT70 PLUS SEN3420A",SUP-KIT3420A,CDM,S27000186,LOCAL,0270,RC,,,both,,,796.80,239.04,"MULTIPLAN [10600]",Multiplan,,677.28,85,,,,,0,92.67,677.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INQUIRY 110CM 1MM 4FR 2-5-2MM SPACE MEDIUM CURVE",SUP-81531,CDM,C1730,HCPCS,0272,RC,,,both,,,3750.00,1125,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,436.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.240 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.240,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 5.00 X 16MM",SUP-H7493942816500,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]",Cigna,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 22CM 5FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49964,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"CIGNA [10200]",Cigna,,512.24,68,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 18MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1850CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,940.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10.5MM 320MM TIBIAL INTRAMEDULLARY STERILE",SUP-40632,CDM,C1713,HCPCS,0278,RC,,,both,,,16922.25,5076.67,"CIGNA [10200]",Cigna,,6768.9,40,,1831.33,1831.33,1831.33,16,1968.06,14383.91,"percent of total billed charges",
"PLATE 90MM TITANIUM 5 LEVEL ATLANTIS VISION ELITE BONE SPINE",SUP-7200090,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"SYSTEM ENDEAVOR SPRINT 30MM 142CM 3.5MM CORONARY STENT",SUP-ENSP35030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]","Cigna Local Plus",,2966.04,53.5,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 24CM 6FR UNIVERSA 2 PIGTAIL CURVE URETER AQ",SUP-G23405,CDM,C2617,HCPCS,0278,RC,,,both,,,535.41,160.62,"CIGNA [10200]","Cigna Local Plus",,286.44,,,,,,,62.27,455.1,"percent of total billed charges",
"CATH DYNAMIC TIP 110CM 6FR 2-5-2MM SPACE LARGE CURVE",SUP-6DYNTP001R,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"AETNA [10100]","Aetna HMO/PPO",,804.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 100CM 6FR JL6 CURVE GUIDING STAINLESS",SUP-67001000,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"UHC [10700]","United Healthcare",,264.34,63.3,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC",414,MS-DRG,,,,,,,inpatient,,,138816.43,41644.93,"PHCS [10601]",PHCS,,7561,,,,,,,7561,104013.67,"per diem","Estimated amount calculated based on 6 day length of stay."
"CEPHEA MITRAL VALVE TRACK 2 32MM",SUP-23032,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER AIR NONSTERILE AIRVO 2 HUMD LATEX FREE DISPOSABLE",SUP-900PT913,CDM,S27000186,LOCAL,0270,RC,,,both,,,160.95,48.28,"CIGNA [10200]",Cigna,,109.45,68,,,,,0,18.72,136.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X13-10.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-014813,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"PHCS [10601]",PHCS,,10384.5,70,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL COCHLEAR 10MM 4MM DERMALOCK BAHA TITANIUM HA 1 STAGE",SUP-93331,CDM,L8690,HCPCS,0278,RC,,,both,,,21042.00,6312.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2493.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2447.18,17885.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONVEY 100CM 7FR LEFTBU3.75 CURVE GUIDING HYDROPHILIC",SUP-H749392657150,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY LARYNGEAL 3 PEDIATRIC SILICONE LMA UNIQUE MASK CUFF",SUP-105300-000030,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.85,14.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19.67,41.1,,,,,0,5.56,40.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 96MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 7X3",SUP-241.071,CDM,S27800098,LOCAL,0278,RC,,,both,,,2463.30,738.99,"BLUE CROSS [10001]","Blue Cross PPO",,965.61,39.2,,,,,0,286.48,2093.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 14MM 4MM STAINLESS STEEL 1.1MM SHORT THREAD",SUP-02.226.014,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"BLUE CROSS [10001]","Blue Cross PPO",,644.92,39.2,,957.42,570.23,957.42,28,191.34,1398.42,"percent of total billed charges",
"JADA SYSTEM 2.0 VACUUM INDUCED HEMORRHAGE CONTROL SYSTEM",SUP-1047196,CDM,S27200284,LOCAL,0272,RC,,,both,,,8935.50,2680.65,"UHC [10700]","United Healthcare",,5656.17,63.3,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCPOINT PULMONARY NEEDLE 21GA",SUP-ILS-2100-PN,CDM,S27200284,LOCAL,0272,RC,,,both,,,1857.00,557.1,"CIGNA [10200]","Cigna Open Access",,1056.63,56.9,,,,,0,215.97,1578.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 8MM LCP STAINLESS STEEL SMALL BONE SELF",SUP-202.208,CDM,C1713,HCPCS,0278,RC,,,both,,,748.44,224.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,214.2,28.62,,,,,0,87.04,636.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE JOURNEY II FEMORAL CR COCR COMPONEN",SUP-71701670,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 ANGLE BACKWARD OFFSET 9.5IN KARLIN LUMBAR HANDLE",SUP-46-3135,CDM,S27200284,LOCAL,0272,RC,,,both,,,1195.16,358.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,141.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139,1015.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 56MM CATHCART BALL HIP FEMORAL ORTHOCHROME",SUP-136356000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,5302.19,4377.88,6578.61,27,434.96,3179,"percent of total billed charges",
"CATH STERLING 150CM 220MM 7FR 5MM 5FR BALLOON DILATATION",SUP-H74939032502210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 8MM PRIMARY MONOBLOCK DJO SURGICAL REVERSE RSP",SUP-510-00-008,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1465.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM HANCOCK II",SUP-T510C29,CDM,S27800098,LOCAL,0278,RC,,,both,,,21420.00,6426,"BLUE CROSS [10001]","Blue Cross PPO",,8396.64,39.2,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 26MM 140CM 3.5MM",SUP-RSINT35026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]",Cigna,,3769.92,68,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 30CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155225190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,406.5,28.62,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO PERFORMER CHECK-FLO STERILE DISPOSABLE",SUP-G07369,CDM,C1894,HCPCS,0272,RC,,,both,,,378.19,113.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,44.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.98,321.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 2.953X.433IN THK.058IN STAINLESS STEEL 2 CUT",SUP-4111-147-075,CDM,S27200284,LOCAL,0272,RC,,,both,,,393.85,118.15,"NOVANET [10819]",Novanet,,295.39,75,,,,,0,45.8,334.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ELUVIA 60MM 130CM 6MM VASCULAR DRUG ELUTE DELIVERY",SUP-H74939294600610,CDM,C1874,HCPCS,0278,RC,,,both,,,15835.50,4750.65,"MULTIPLAN [10600]",Multiplan,,13460.18,85,,,,,0,1841.67,13460.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IV 20 MEQ POTASSIUM CHLORIDE 5% DEXTROSE 0.45% SODIUM",SUP-L6350,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACK 24IN THERAPEUTIC MOIST HEAT CONTOUR NECK CHATTANOOGA",SUP-553795,CDM,S27000186,LOCAL,0270,RC,,,both,,,108.92,32.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN RADIOFREQUENCY 10CM 20GA ACCURIAN CURVE BLUNT 10MM",SUP-AC0011,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPEL APD TWIST-LOC 15CM 6FR J SHORT LENGTH DRNG",SUP-H7493931106150,CDM,C1729,HCPCS,0272,RC,,,both,,,712.80,213.84,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM HALYARD 12IN 14FR 15MM SUCTION ADULT CLOSED CATH T",SUP-220135,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.50,15.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.11,44.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 7MM CEREPAK FREEFORM DETACHABLE",SUP-SCR120715,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"PHCS [10601]",PHCS,,9258.1,70,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 28MM 144CM 2.25MM",SUP-H7493941228220,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"KAISER [10500]",Kaiser,,5200.88,67,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 55MM 6.5MM MODULEX OSTEOGRIP SPINE",SUP-55900506555,CDM,C1713,HCPCS,0278,RC,,,both,,,4519.50,1355.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2074.45,45.9,,,,,0,525.62,3841.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 145D STD BARREL 110MM STAINLESS STEEL 6 HOLE",SUP-281.360,CDM,C1713,HCPCS,0278,RC,,,both,,,2156.11,646.83,"KAISER [10500]",Kaiser,,1444.59,67,,,,,0,250.76,1832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM VUEPOINT II",SUP-8977010,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 16MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620916,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Open Access",,6403.47,56.9,,5302.19,4377.88,6578.61,27,1308.83,9565.82,"percent of total billed charges",
"CATH LAUNCHER 90CM 7FR .081IN GUIDING",SUP-LA7EBU375D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM INTERCONTINENTAL HA SPINE VARIABLE ANGLE",SUP-187.235S,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA [10200]",Cigna,,1785,68,,1831.33,1831.33,1831.33,16,305.29,2231.25,"percent of total billed charges",
"PROBE BREAST BIOPSY 11GA MAMMOTOME 3 COIL TITANIUM FLEXIBLE",SUP-4010-01-11-T3,CDM,A4648,HCPCS,0278,RC,,,both,,,640.49,192.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,75.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.49,544.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE PASSER WITH GUIDE SUTURE PASSING PUNCTURE CLOSURE DEV",SUP-RSG-14F,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.80,52.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,71.84,41.1,,,,,0,20.33,148.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 12.5MM KNEE GVF POLYETHYLENE ROTATE",SUP-129405612,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"KAISER [10500]",Kaiser,,6474.51,67,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 40- IN CLAVICLE MOVABLE D RING",SUP-79-85100,CDM,S27000186,LOCAL,0270,RC,,,both,,,76.65,22.99,"CIGNA [10200]",Cigna,,52.12,68,,,,,0,8.91,65.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC THK1/8IN LARGE 4.5+ IN HAND LEFT",SUP-A311LL,CDM,S27000186,LOCAL,0270,RC,,,both,,,160.86,48.26,"AETNA [10100]","Aetna HMO/PPO",,127.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.71,136.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOEHENDRA TRACER METRO DIRECT 200CM 3CM 7-4FR .035IN",SUP-G21573,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,327.18,45.9,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPS QUARTET INNER- CN-ALII 65CM-DS2N030-65",SUP-DS2N030-65,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 82X50X12MM NEXGEN LCCK 7-10 E-F STD KNEE",SUP-599405112,CDM,C1776,HCPCS,0278,RC,,,both,,,16256.40,4876.92,"UHC [10700]","United Healthcare",,10290.3,63.3,,8601.07,8395.67,8601.07,"1 through 10",1890.62,13817.94,"percent of total billed charges",
"SCR BONE 3MM 28MM QUICKFIX TITANIUM T10 PARTIAL THREAD",SUP-AR-8730-28PT,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT QUILL MONODERM 0 T9 36X36CM BRB CLR",SUP-YA1029Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,212.21,63.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.68,180.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 15X10CM GENTRIX PORCINE URINARY BLADDER",SUP-PSM1015,CDM,C1781,HCPCS,0278,RC,,,both,,,10432.80,3129.84,"CIGNA [10200]",Cigna,,7094.3,68,,,,,0,1213.33,8867.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 22.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962336,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"FIRST HEALTH [10303]","First Health",,11603.04,80,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PILOT 50 VASCULAR J 190CM 3CM .014IN",SUP-1010480-HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM SWIVELOCK KNOTLESS PEEK STERILE LATEX FREE",SUP-AR-1665KPSL,CDM,C1713,HCPCS,0278,RC,,,both,,,6049.58,1814.87,"CIGNA [10200]",Cigna,,4113.71,68,,1831.33,1831.33,1831.33,16,703.57,5142.14,"percent of total billed charges",
"CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC",234,MS-DRG,,,,,,,inpatient,,,309505.23,92851.57,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,35918.59,,"Case rate ($33,885.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $31,464.95, add-ons for qualifying new technology services are included. If operating cost exceeds $64,504.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,760.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $31,506.56. The transfer operating threshold is the transfer adjustment factor * $31,464.95 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,378.90. The transfer capital threshold is the transfer adjustment factor * $2,378.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,33885.46,159488.99,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 170X17.5X5.2MM STAINLESS STEEL 4.5MM SCR LARGE",SUP-226.591,CDM,C1713,HCPCS,0278,RC,,,both,,,3355.80,1006.74,"MULTIPLAN [10600]",Multiplan,,2852.43,85,,,,,0,390.28,2852.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 4FR 11CM RED HUB HEMOSTASIS VALVE PRELUDE",SUP-PSI-4F-11,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.8,64.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cta Neck W/WO Cntrst",PX-351000015,CDM,70498,CPT,0351,RC,,,both,,,4327.01,1298.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,405,,"Per diem ($405). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,405,3677.96,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AXIOS 10MM 146MM 10MM 21MM 138MM 10.8FR PANCREATIC",SUP-M00553740,CDM,C1874,HCPCS,0278,RC,,,both,,,24658.20,7397.46,"PHCS [10601]",PHCS,,17260.74,70,,,,,0,2867.75,20959.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SPINAL 5IN 20GA INTERSTIM FORAMEN OPAQUE HUB LOCK STYLET",SUP-041829,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"MULTIPLAN [10600]",Multiplan,,1530,85,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW MULTI-THREAD LOCKING 3.5MM X 14MM TI",SUP-MTLS-35140-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1320.30,396.09,"KAISER [10500]",Kaiser,,884.6,67,,,,,0,153.55,1122.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Ven Thin-Flex 30f",PX-E27200390,CDM,E27200390,LOCAL,0272,RC,,,both,,,168.30,50.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.57,143.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLYFLEX 50MM 12MM 20MM AIRWAY SILICONE SELF EXPANDING",SUP-7027,CDM,C1887,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,395.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,388.15,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 20MM 4.5MM AEQUALIS REVERSED GLENOID TITANIUM",SUP-VDV220,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CIGNA [10200]","Cigna Open Access",,885.36,56.9,,5302.19,4377.88,6578.61,27,180.96,1322.6,"percent of total billed charges",
"TISSUE 330544 ACSR 5X14X14 SRVC FEE",SUP-330544,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 220MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939186252210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 60MM 150MM 4MM BALLOON DILATATION",SUP-PCP040060150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AETNA [10100]","Aetna HMO/PPO",,978.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 200MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025200S,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"AETNA [10100]","Aetna HMO/PPO",,1490.63,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Thoracentesis",PX-E27200183,CDM,E27200183,LOCAL,0272,RC,,,both,,,286.00,85.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET EXT 3CM 18FR MIC-KEY SECUR-LOK ENFIT SILICONE RADIOPAQUE",SUP-8140-18-3.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING MONORAIL 135CM 30MM 6FR 5MM 4FR BALLOON",SUP-H74939031503010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC",370,MS-DRG,,,,,,,inpatient,,,35269.29,10580.79,"AETNA [10100]","Aetna HMO/PPO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY INTRO XPANDER ONE-STEP KYPHOPAK KYPHX FIRST FRACTURE",SUP-KPT1005,CDM,C1894,HCPCS,0272,RC,,,both,,,11021.40,3306.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING MONORAIL 135CM 30MM 6FR 6MM 4FR BALLOON",SUP-H74939031603010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CELSIUS 90CM 4MM 8FR 2-5-2MM SPACE F CURVE ABLATION 10",SUP-D8BTCFL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT ORTHOPEDIC LARGE 24IN 19-22IN KNEE CONTACT CLSR",SUP-79-80037,CDM,S27000186,LOCAL,0270,RC,,,both,,,117.10,35.13,"KAISER [10500]",Kaiser,,78.46,67,,,,,0,13.62,99.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RELIEVA SPIN 16MM 6MM 0D S-0 GUIDING SPHENOID SINUS",SUP-RSS0,CDM,S27200284,LOCAL,0272,RC,,,both,,,2400.00,720,"UHC [10700]","United Healthcare",,1519.2,63.3,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 3CM 6FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175263110,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,354.71,28.62,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEILD SPIRAL, 80 MM DIAMETER",SUP-50215L54B0D,CDM,A2019,HCPCS,0636,RC,,,both,,,130900.50,39270.15,"CIGNA [10200]",Cigna,,89012.34,68,,,,,0,247.92,111265.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 26CM 8FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251530,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS [10001]","Blue Cross PPO",,482.54,39.2,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT TUBE 2 WAY STPCOCK DISMANTLING LUER LOCK STERILE",SUP-27502,CDM,S27200284,LOCAL,0272,RC,,,both,,,1147.93,344.38,"AETNA [10100]","Aetna HMO/PPO",,912.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,133.5,975.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bld Gases W Direct Meas O2 Sat",PX-301000199,CDM,82805,CPT,0301,RC,,,both,,,619.50,185.85,"BLUE CROSS [10001]","Blue Cross PPO",,100.64,,"Fee schedule rate ($100.64).",,,,0,19.23,526.58,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.7MM CANNULATED",SUP-CSS07237SQ,CDM,S27200284,LOCAL,0272,RC,,,both,,,1506.60,451.98,"NOVANET [10819]",Novanet,,1129.95,75,,,,,0,175.22,1280.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 150MM SCHANZ STAINLESS STEEL ORTHOPEDIC BLUNTED",SUP-294.54,CDM,C1713,HCPCS,0278,RC,,,both,,,528.53,158.56,"CIGNA [10200]","Cigna Open Access",,300.73,56.9,,1144.80,304.56,2275.09,66,61.47,449.25,"percent of total billed charges",
"GRAFT BONE FEMORAL CORTICAL THK3-12MM ALLOGRAFT STRUT FREEZE",SUP-400610,CDM,S27800098,LOCAL,0278,RC,,,both,,,2245.50,673.65,"BLUE CROSS [10001]","Blue Cross HMO",,880.24,39.2,,,,,0,261.15,1908.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACING TEMPORARY BIPOLAR BALLOON SHROUD PIN XTW INTRO",SUP-AI-07155-KS,CDM,C1733,HCPCS,0272,RC,,,both,,,1657.50,497.25,"AETNA [10100]","Aetna HMO/PPO",,1317.71,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,192.77,1408.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 200MM 5.5MM VIPER 2 STRAIGHT TITANIUM MIS",SUP-186789200,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 260MM 8MM ANTERIOR TIBIALIS TENDON FROZEN",SUP-81B001,CDM,S27800098,LOCAL,0278,RC,,,both,,,8852.70,2655.81,"CIGNA [10200]","Cigna Local Plus",,4736.19,53.5,,,,,0,1029.57,7524.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 10X7CM SURGISIS BIODESIGN PORCINE",SUP-C-PHR-7X10-U,CDM,C1763,HCPCS,0278,RC,,,both,,,7208.78,2162.63,"MULTIPLAN [10600]",Multiplan,,6127.46,85,,,,,0,838.38,6127.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 16MM TRIDENT SECUR-FIT TITANIUM CANCELLOUS",SUP-2030-6516-1,CDM,C1713,HCPCS,0278,RC,,,both,,,571.90,171.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",66.51,486.12,"percent of total billed charges",
"TUBE JEJUNOSTOMY 45CM 18FR SILICONE MIC SECUR-LOK UNIVERSAL",SUP-0260-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,2567.55,770.26,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1055.26,41.1,,,,,0,298.61,2182.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TM REVERSE STEM 14MM X 130MM",SUP-00434901413,CDM,C1776,HCPCS,0278,RC,,,both,,,17863.20,5358.96,"MULTIPLAN [10600]",Multiplan,,15183.72,85,,,,,0,2077.49,15183.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22.5 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150225,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross HMO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 40 75CM 4CM 7MM BALLOON DILATATION PERIPHERAL",SUP-CQF7574,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT ULNAR SM L3IN RIGHT ELBOW TIVANIUM PLASMA INTERCHA",SUP-32810505302,CDM,C1776,HCPCS,0278,RC,,,both,,,31147.20,9344.16,"FIRST HEALTH [10303]","First Health",,24917.76,80,,,,,0,3622.42,26475.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFE-T-J VASCULAR 3MM RADIUS J CURVE TAPER 145CM 6CM",SUP-G00511,CDM,C1769,HCPCS,0272,RC,,,both,,,121.71,36.51,"FIRST HEALTH [10303]","First Health",,97.37,80,,,,,0,14.15,103.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.7MM 14MM VARIAX TITANIUM LOW PROFILE HAND WRIST",SUP-53-17014E,CDM,C1713,HCPCS,0278,RC,,,both,,,734.83,220.45,"FIRST HEALTH [10303]","First Health",,587.86,80,,,,,0,85.46,624.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 135CM EXCELSIOR XT-27 STRAIGHT",SUP-M003XT2735810,CDM,S27200284,LOCAL,0272,RC,,,both,,,8474.58,2542.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1004.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,985.59,7203.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 58MM 28MM XLPE HIP",SUP-71334958,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4581.4,41.1,,6417.48,6417.48,6417.48,"1 through 10",1296.39,9474.91,"percent of total billed charges",
"PIN FIXATION 9IN 3/16IN STEINMANN STAINLESS STEEL 2 END",SUP-KM169-29-31,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",7.4,54.07,"percent of total billed charges",
"KIT NEPHRSTMY 8FR CONNECT TUBE INTRO STPCOCK FLOPPY TIP",SUP-H749393410825K1,CDM,C1729,HCPCS,0272,RC,,,both,,,1441.80,432.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,170.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.68,1225.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 65MM TITANIUM LOCK TRANSLATIONAL ATLANTIS BONE SPINE",SUP-6190065,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"LINER ACETABULAR R3 0D 48MM 28MM XLPE HIP",SUP-71337548,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"NOVANET [10819]",Novanet,,8344.69,75,,,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Wnd Rmvl Tis Non-Sel (Gp)",PX-420000034,CDM,97602,CPT,0420,RC,,,both,,,625.00,187.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,215,,"Per diem ($215).",,,,0,72.69,625,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 17IN 21FR FEMUR ARTERY ADULT 3/8IN CNCT 1",SUP-96570-021,CDM,S27200284,LOCAL,0272,RC,,,both,,,2120.63,636.19,"FIRST HEALTH [10303]","First Health",,1696.5,80,,,,,0,246.63,1802.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 7.9X5.9IN XENMATRIX AQUAPURE RECTANGLE",SUP-1161520,CDM,C1781,HCPCS,0278,RC,,,both,,,29877.12,8963.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3474.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3474.71,25395.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREONPANOPTIX PRO(BLF)",SUP-PXYAT5,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"FIRST HEALTH [10303]","First Health",,732,80,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ptt Plasma Substitution Ea",PX-305000066,CDM,85732,CPT,0305,RC,,,both,,,174.20,52.26,"PHCS [10601]",PHCS,,121.94,70,,,,,0,0.01,148.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE ALLODERM SELECT ACELLULAR DERMIS THK1.2-2 MM M",SUP-1518128,CDM,Q4116,HCPCS,0636,RC,,,both,,,23782.50,7134.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11558.3,48.6,,,,,0,247.92,20215.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vitamin B6",PX-301000386,CDM,84207,CPT,0301,RC,,,both,,,270.40,81.12,"FIRST HEALTH [10303]","First Health",,216.32,80,,,,,0,0.01,229.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHMBR HUMD 2 FLOAT AUTO FILL COMPRESSIBLE VOLUME MR SERIES",SUP-MR290V,CDM,S27000186,LOCAL,0270,RC,,,both,,,94.50,28.35,"MULTIPLAN [10600]",Multiplan,,80.33,85,,,,,0,10.99,80.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM 8MM RUBY POD COMPLEX OCCULUSION",SUP-RBYPOD8,CDM,S27800098,LOCAL,0278,RC,,,both,,,11661.00,3498.3,"AETNA [10100]","Aetna HMO/PPO",,9270.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1356.17,9911.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON SABRELOC 5-0 RD-1 18IN 2 ARM MONOFILAMENT BLACK",SUP-749G,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.65,34.99,"UHC [10700]","United Healthcare",,73.84,63.3,,,,,0,13.57,124.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR STD 34MM 3 PEG KNEE SERIES A",SUP-184766,CDM,C1776,HCPCS,0278,RC,,,both,,,4824.48,1447.34,"BLUE CROSS [10001]","Blue Cross PPO",,1891.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",561.09,4100.81,"percent of total billed charges",
"COMPONENT FEMORAL 3 NARROW KNEE RIGHT CEMENTED CRUCIATE RETA",SUP-150400223,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6408.98,28.62,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Ac Jnt Bilat",PX-320000064,CDM,73050,CPT,0320,RC,,,both,,,604.70,181.41,"CIGNA [10200]",Cigna,,43.91,,,,,,,31.4,514,"fee schedule",
"CATH UNI-FUSE FLOW-THRU HUB 90CM 30CM 5FR THROMBECTOMY",SUP-H787124018085,CDM,C1757,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER BIPOLAR AQUAMANTYS 30 D 6 MM SPACING L.226 IN L5.1 IN",SUP-23-112-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,2812.50,843.75,"CIGNA [10200]",Cigna,,1912.5,68,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL MEDIUM KNEE STEM REMEDY STERILE",SUP-RSKFMD,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL 5.5IN TISSUE 1X2 TEETH FLUTED HANDLE MATTE",SUP-130-161,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.69,23.31,"AETNA [10100]","Aetna HMO/PPO",,61.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.04,66.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM CONCERTO DETACHABLE",SUP-NV-4-10-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X12X6MM COHERE 7D LORDOSIS SCORIA PEEK LOW",SUP-1000-00-0614,CDM,C1889,HCPCS,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1777.3,28.62,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHERRY FLAVOR (BULK) ORAL SYRUP",RX-246031,CDM,,,0637,RC,31722-0938-47,NDC,both,473,ML,127.93,38.38,"FIRST HEALTH [10303]","First Health",,102.34,80,,,,,0,14.88,108.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BACLOFEN 5 MG/ML ORAL SUSPENSION",RX-408875,CDM,,,0637,RC,08888-8885-91,NDC,both,30,ML,233.23,69.97,"NOVANET [10819]",Novanet,,174.92,75,,,,,0,27.12,198.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBEROS 10CC",SUP-FB100,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"SHEATH GORE DRYSEAL FLEX 65CM 6.7MM 18FR INTRO HYDROPHILIC",SUP-GDSF1865,CDM,C1894,HCPCS,0272,RC,,,both,,,6858.60,2057.58,"AETNA [10100]","Aetna HMO/PPO",,5452.59,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,797.66,5829.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTERVENTIONAL ROSCH-UCHIDA LIVER TRANSJUGULAR ACCESS",SUP-G06929,CDM,C1887,HCPCS,0272,RC,,,both,,,3674.93,1102.48,"PHCS [10601]",PHCS,,2572.45,70,,,,,0,427.39,3123.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-407,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3544.36,27,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM TITANIUM CORTICAL",SUP-PANL-35260-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,899.10,269.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,257.32,28.62,,,,,0,104.57,764.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 2 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022212,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"CIGNA [10200]","Cigna Open Access",,5568.4,33.5,,5302.19,4377.88,6578.61,27,1933.15,14128.79,"percent of total billed charges",
"STENT UNISTEP PLUS WALLSTENT RP 20MM 135CM 8MM 160CM",SUP-M001712170,CDM,C1876,HCPCS,0278,RC,,,both,,,8728.50,2618.55,"BLUE CROSS [10001]","Blue Cross HMO",,3421.57,39.2,,,,,0,1015.12,7419.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 285MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-409-285,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,1144.80,304.56,2275.09,66,2014.9,14726.25,"percent of total billed charges",
"BIT DRILL CHARLOTTE STAINLESS STEEL CANNULATED 4.3 MM SCR",SUP-44112003,CDM,S27200284,LOCAL,0272,RC,,,both,,,1296.00,388.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 20MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158123120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3017.13,27,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SURGICAL OSTEOCOOL BONE ACCESS 10GA",SUP-OCN002,CDM,C1886,HCPCS,0272,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 8X8MM JAWS STRAIGHT NITINOL",SUP-P71-008-0808-S,CDM,C1713,HCPCS,0278,RC,,,both,,,8330.03,2499.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,968.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",968.78,7080.53,"percent of total billed charges",
"CAGE SPINAL 28MMX12MM X-PAC PARALLEL",SUP-EI2448P,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +1.5MM 12/14 TAPER 36MM HIP CEMENTLESS M",SUP-136551000,CDM,C1776,HCPCS,0278,RC,,,both,,,3991.68,1197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2714.34,68,,,,,0,464.23,3392.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 5-0 RB-1 30IN 2 ARM MONOFILAMENT VIOLET",SUP-Z320H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.00,19.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.68,56.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 0 PREASSEMBLE BLADE MINI HANDLE LED LIGHT",SUP-040-06-0401U,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.42,18.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.26,53.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 0 CT-1 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J346H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL STD 17.5MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405417,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4435.52,45.9,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 40MM STARDRIVE STAINLESS STEEL T15 CORTEX",SUP-02.206.240,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,92.73,28.62,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 60MM 80CM 10MM .035IN 3MM VASCULAR VENOUS",SUP-VENUM10060,CDM,C1876,HCPCS,0278,RC,,,both,,,22680.00,6804,"BLUE CROSS [10001]","Blue Cross PPO",,8890.56,39.2,,,,,0,2637.68,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SHUNT CSF Y STAINLESS STEEL 1.8MM 1.2MM STERILE",SUP-901412,CDM,S27200284,LOCAL,0272,RC,,,both,,,8582.91,2574.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1017.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,998.19,7295.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPNDR TISS",SUP-3611-ES74-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,12558.00,3767.4,"PHCS [10601]",PHCS,,8790.6,70,,,,,0,1460.5,10674.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X22X8MM RISE-L 6D NONSTERILE",SUP-193.422,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3993.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Hydrofera",PX-E27200112,CDM,E27200112,LOCAL,0272,RC,,,both,,,98.38,29.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,66.9,68,,,,,0,11.44,83.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 6",SUP-249.682,CDM,C1713,HCPCS,0278,RC,,,both,,,2429.70,728.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1652.2,68,,,,,0,282.57,2065.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 5MM20CM 190",SUP-R51005020L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"MULTIPLAN [10600]",Multiplan,,2118.1,85,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 20MM 6FR 3.5MM",SUP-H7493926720350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER DIAGNOSTIC 6FR L100CM GUIDEWIRE 0.038IN POLYURETHAN",SUP-533640,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 30MM 140CM 4MM CORONARY STERILE LATEX",SUP-453966,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS HONOR METAL GWIRE INSRT TOOL",SUP-MAP301,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.19,61.86,"CIGNA [10200]","Cigna Open Access",,117.32,56.9,,,,,0,23.98,175.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR LNCS NEO-3 3FT ASSORTED OXIMETER LOW NOISE CABLED SOL",SUP-2320,CDM,S27000186,LOCAL,0270,RC,,,both,,,4.95,1.48,"MULTIPLAN [10600]",Multiplan,,4.21,85,,,,,0,0.58,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3.5MM TARGET TETRA DETACHABLE STERILE",SUP-TG5413560,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]","Cigna Open Access",,4728.4,33.5,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH GORE DRYSEAL FLEX 33CM 4MM 10FR INTRO HYDROPHILIC",SUP-GDSF1033,CDM,C1894,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,445.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT FX 29MM",SUP-EVOLUTFX-29,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19887.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS LAPAROSCOPIC 45CM 2 EDGE BLADE ROTATION DIAL",SUP-CB040,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"CIGNA [10200]","Cigna Open Access",,148.51,56.9,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC IV Inf Ther Add Hr",PX-260000004,CDM,96366,CPT,0260,RC,,,both,,,293.52,88.06,"BLUE CROSS [10001]","Blue Cross PPO",,201.35,68.6,,,,,0,34.14,293.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC IV Inf Ther Add Hr",PX-260000004,CDM,96366,CPT,0260,RC,,,both,,,293.52,88.06,"CIGNA [10200]",Cigna,,293.52,,"Per diem ($571).",,,,0,34.14,293.52,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit B Level 4",PX-450000331,CDM,G0383,HCPCS,0450,RC,,,both,,,1807.00,542.1,"UHC [10700]","United Healthcare",,1807,,"Per diem ($2,260).",,,,0,67.13,1807,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit B Level 4",PX-450000331,CDM,G0383,HCPCS,0450,RC,,,both,,,1807.00,542.1,"BLUE CROSS [10001]","Blue Cross PPO",,1807,,,,,,,67.13,1807,"case rate",
"TIP PULSED LAVAGE INTERPULSE SOFT TISSUE IRRIGATION FAN",SUP-0210-012-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.99,28.2,"FIRST HEALTH [10303]","First Health",,75.19,80,,,,,0,10.93,79.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM ADVANCED PARALLEL SPINE",SUP-17612,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3800.52,45.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 20MM 3.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP3520X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"FIRST HEALTH [10303]","First Health",,421.2,80,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) INNOVALVE CRIMPER FOR TMVR TRANSCATHETER MITRAL VALVE",SUP-PRO-17269,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING ORANGE 20IN 5FR ENTERAL POLYURETHANE HUB END",SUP-ENFPU2050LD,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.84,17.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACIFIC PLUS 130CM 20MM 4FR 3MM .018IN BALLOON",SUP-PCP030020130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW MARK SPRING TIP",SUP-CG-06-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC",272,MS-DRG,,,,,,,inpatient,,,121931.81,36579.54,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK 10X1.5X2.5CM LARGE NASAL COMPRESSED QUICK EFFECTIVE",SUP-440406,CDM,S27000186,LOCAL,0270,RC,,,both,,,284.49,85.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DISECT BIPOLAR ENDOWRIST 8MM CURVE CAUT",SUP-420344,CDM,S27000186,LOCAL,0270,RC,,,both,,,2025.00,607.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUB SKIN 20X16CM STRATTICE PORCINE DERMAL MATRIX FIRM PATCH",SUP-1620002,CDM,Q4130,HCPCS,0636,RC,,,both,,,48900.60,14670.18,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"MIXER BONE CEMENT OSSEOFLEX CD-H",SUP-OP-0005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1587.60,476.28,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHILON MULTIPASS 5-0 FS-2 18IN MONOFILAMENT PLIABILIZED",SUP-661H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 6MM 40MM COCR SPINE MULTIAXIAL 5.5MM ROD",SUP-55840006040,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 5X 38MM CATH 120CM ENDOVASCULAR",SUP-42538,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"BLUE CROSS [10001]","Blue Cross PPO",,6867.96,39.2,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 10FT INTERPULSE SUCTION TUBE HNDPC STERILE LATEX FREE",SUP-210100000,CDM,S27000186,LOCAL,0270,RC,,,both,,,249.50,74.85,"NOVANET [10819]",Novanet,,187.13,75,,,,,0,29.02,212.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC MEDIUM 16IN 16-19IN KNEE CONTACT CLSR",SUP-79-80015,CDM,S27000186,LOCAL,0270,RC,,,both,,,98.92,29.68,"PHCS [10601]",PHCS,,69.24,70,,,,,0,11.5,84.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 84MM STAINLESS STEEL 2MM SCR MINI FRAGMENT SET 10 HOLE",SUP-247.364,CDM,C1713,HCPCS,0278,RC,,,both,,,2299.50,689.85,"CIGNA [10200]",Cigna,,1563.66,68,,1831.33,1831.33,1831.33,16,267.43,1954.58,"percent of total billed charges",
"SPACER ALLOGRAFT 12.5X15X11MM ADVANCED LORDOTIC SPINE",SUP-017711,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]","Cigna Local Plus",,4429.8,53.5,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 220MM 3.5MM BALLOON DILATATION NYBAX",SUP-H74939186352210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 40MM 125CM 7MM 6FR VASCULAR NITINOL",SUP-G43826,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"NOVANET [10819]",Novanet,,2835,75,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 11/13 TAPER 36MM HIP MODULAR BIOLOX DELTA",SUP-136536210,CDM,C1776,HCPCS,0278,RC,,,both,,,7290.36,2187.11,"BLUE CROSS [10001]","Blue Cross PPO",,2857.82,39.2,,3949.44,3949.44,3949.44,"1 through 10",847.87,6196.81,"percent of total billed charges",
"SHOE POSTOPERATIVE MEDIUM MALE",SUP-100611-030,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.99,17.7,"FIRST HEALTH [10303]","First Health",,47.19,80,,,,,0,6.86,50.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 6-9 C-D KNEE RIGHT VIVACIT-E",SUP-42522400510,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"NOVANET [10819]",Novanet,,8082.32,75,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER +3 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT300205,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"NOVANET [10819]",Novanet,,258.75,75,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CREO SPINE CANNULATED NONSTERILE LATEX",SUP-5120.4649,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"HOOK 50MM RETRACTION MULTIPLE TOOTHED SHADOW-LINE MCCULLOCH",SUP-S-1844,CDM,S27200284,LOCAL,0272,RC,,,both,,,995.98,298.79,"CIGNA [10200]",Cigna,,677.27,68,,,,,0,115.83,846.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM 49.8MM HIP 3 SCR HOLE CLUSTER RIM",SUP-542-11-48D,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"MULTIPLAN [10600]",Multiplan,,5914.06,85,,,,,0,809.18,5914.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X22X10MM COROENT XL WIDE PEEK LUMBAR",SUP-6910245,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9765.36,41.1,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO 1000093013 OPTISEAL GLBL11FR25CM",SUP-1000093013,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 28MM 144CM 2.75MM CORONARY STENT EVEROLIMUS",SUP-H7493926128270,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"MULTIPLAN [10600]",Multiplan,,7331.25,85,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 5MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBH050502,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - TIBIAL KIT (PS) - SIZE 8",SUP-5555-2368,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"UHC [10700]","United Healthcare",,640.91,63.3,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 6MM CANNULATED REAMER STERILE",SUP-AR-1218-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT 2.5 KNEE CEMENT ROTATE PLATFORM",SUP-129431125,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 5CM 5FR TAPER CONTOUR SPIRAL OFFSET PANCREATIC",SUP-G21803,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,143.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 2.50X10MM",SUP-PRV025010CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 17.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962334,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"BLUE CROSS [10001]","Blue Cross PPO",,5685.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",1686.79,12328.23,"percent of total billed charges",
"COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION",RX-9686,CDM,J0834,HCPCS,0636,RC,00781-3440-71,NDC,both,1,UN,484.09,145.23,"UHC [10700]","United Healthcare",,40.27,,,,,,,24.26,411.48,"fee schedule",
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION",RX-108021,CDM,J0131,HCPCS,0636,RC,31722-0205-31,NDC,both,100,ML,98.15,29.44,"CIGNA [10200]","Cigna Open Access",,14.25,,,,,,,6.99,83.43,"fee schedule",
"SET BUNDLE CATH PUMP + COMPANTION SHEATH IMPELLA BLOOD PUMP",SUP-4000021,CDM,S27800098,LOCAL,0278,RC,,,both,,,153900.00,46170,"AETNA [10100]","Aetna HMO/PPO",,122350.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17898.57,130815,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 6MM 2MM BALLOON DILATATION PEBAX",SUP-1012270-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 CURVE PLUS 15MM KNEE XLK FIX BEARING SIGMA",SUP-970433,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AETNA [10100]","Aetna HMO/PPO",,8883.77,79.5,,10981.53,8986.79,12413.38,12,1299.6,9498.37,"percent of total billed charges",
"EXP TISSUE 350ML STYLE 133SX-T TEXTURED TAB MAGNASITE",SUP-133SX-12-T,CDM,C1789,HCPCS,0278,RC,,,both,,,10695.00,3208.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4395.65,41.1,,,,,0,1243.83,9090.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 15MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424028,CDM,C1776,HCPCS,0278,RC,,,both,,,11747.25,3524.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3171.76,27,,,,,0,1366.21,9985.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL 12D ALLOGRAFT 28X26X14MM ALIF",SUP-3W4214,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"BLUE CROSS [10001]","Blue Cross HMO",,8288.97,39.2,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR061002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5742.58,27,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 28CM 8FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251540,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,565.01,45.9,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR PREPARATION OF TC 99M-SODIUM THIOSULFATE SOLUTION",RX-123715,CDM,A9541,HCPCS,0343,RC,08888-8878-22,NDC,both,1,UN,738.32,221.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,311.62,,,,,,,85.87,738.32,"fee schedule",
"CATH IMPULSE 100CM 6FR RADIAL CURVE ANGIOGRAPHIC BRACHIAL 2",SUP-H749165991740,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]","Cigna Local Plus",,40.97,53.5,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Rmvl Hot Bx",PX-750000039,CDM,43250,CPT,0750,RC,,,both,,,2848.46,854.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,331.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,331.28,2848.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2-0 CURVE FIBERSTITCH FIBERWIRE POLYESTER",SUP-AR-4570,CDM,C1713,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"BLUE CROSS [10001]","Blue Cross HMO",,1455.3,39.2,,957.42,156.86,7483.26,51,431.76,3155.63,"percent of total billed charges",
"CIRCUIT BREATHING FLEXIBLE SHORT HEATED WIRE UNFILTER 21V",SUP-771465,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.15,328.24,"NOVANET [10819]",Novanet,,820.61,75,,,,,0,127.25,930.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG BLACK 26X15CM GRANUFOAM VAC THK1.6CM THIN PRECUT",SUP-M8275081/5.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,441.46,132.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,52.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.34,375.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 4CM 5MM 6FR BALLOON DILATATION",SUP-V185040,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"AETNA [10100]","Aetna HMO/PPO",,4360.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM ACORN STERILE",SUP-5620030040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1164.29,349.29,"CIGNA [10200]",Cigna,,791.72,68,,,,,0,135.41,989.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE EMG NIM CURVE LUMBAR",SUP-PK1014,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,377.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Muscle Test Cran Nrv Unil",PX-922000026,CDM,95867,CPT,0922,RC,,,both,,,842.00,252.6,"PHCS [10601]",PHCS,,589.4,70,,,,,0,97.92,715.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5-6 15MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71933739,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"CIGNA [10200]",Cigna,,4868.64,40,,5873.17,5873.17,5873.17,"1 through 10",1415.56,10345.86,"percent of total billed charges",
"INSRT TIBIAL 7 10MM KNEE LEFT E-PLUS EMPOWR 3D KNEE STERILE",SUP-341-10-707,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross PPO",,2569.56,39.2,,3949.44,3949.44,3949.44,"1 through 10",762.35,5571.75,"percent of total billed charges",
"STPLR INTERNAL 30X2.5MM VASCULAR CRTDG LOADING UNIT TITANIUM",SUP-010911L,CDM,S27200284,LOCAL,0272,RC,,,both,,,738.32,221.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,338.89,45.9,,,,,0,85.87,627.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC",097,MS-DRG,,,,,,,inpatient,,,148266.63,44479.99,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,23972.5,,"Case rate ($22,404.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,803.83, add-ons for qualifying new technology services are included. If operating cost exceeds $53,843.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,954.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $20,831.34. The transfer operating threshold is the transfer adjustment factor * $20,803.83 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,572.87. The transfer capital threshold is the transfer adjustment factor * $1,572.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,90074.68,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 13MM LCP STAINLESS STEEL SMALL BONE T6",SUP-201.883,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,201.87,28.62,,,,,0,82.03,599.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 10FT CARTO 3 34 PIN HYPERTRONIC ELECTROPHYSIOLOGY",SUP-D128624,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"UHC [10700]","United Healthcare",,2131.63,63.3,,,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lipoprotein A",PX-301000299,CDM,83695,CPT,0301,RC,,,both,,,164.75,49.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12.89,,,,,,,0.16,140.04,"fee schedule",
"BIT DRILL 195MM 4.5MM STAINLESS STEEL 3 FLUTED QUICK",SUP-315.48,CDM,S27000186,LOCAL,0270,RC,,,both,,,943.49,283.05,"CIGNA [10200]",Cigna,,641.57,68,,,,,0,109.73,801.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM 3.5MM 2.1-2.7FR CORONARY",SUP-RONYX35030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,431.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 360 1.5MM ATHERECTOMY PERIPHERAL CLASSIC",SUP-DBP-150SOLID145,CDM,C1724,HCPCS,0272,RC,,,both,,,21388.50,6416.55,"KAISER [10500]",Kaiser,,14330.3,67,,,,,0,2487.48,18180.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 10CM 7FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22355,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +30.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000305,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IOTHALAMATE SODIUM 0.1 % INTRAVENOUS SOLUTION 20-30 MICROCURIES",RX-411485,CDM,A9554,HCPCS,0343,RC,08888-8878-49,NDC,both,1,UN,13286.75,3986.02,"BLUE CROSS [10001]","Blue Cross HMO",,131.12,,,,,,,131.12,11293.74,"fee schedule",
"WEDGE FEMORAL LEGION 3 5D 5P L KNEE SCR",SUP-71421721,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 5-0 PS-2 18IN MONOFILAMENT UNDYED",SUP-Y495G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nushield per Sq Cm",PX-E63600040,CDM,Q4160,HCPCS,0636,RC,,,both,,,843.70,253.11,"NOVANET [10819]",Novanet,,632.78,75,,,,,0,99.98,843.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 15.5CM 9FR PEEL-AWAY PERCUTANEOUS STERILE",SUP-G01697,CDM,C1894,HCPCS,0272,RC,,,both,,,382.71,114.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,45.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS LOC LARGE EXTRA LONG CARDIAC PERCUTANEOUS 3D",SUP-DS2C300-45,CDM,C1893,HCPCS,0272,RC,,,both,,,2250.00,675,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE 76MM 10.8MM 15MM 6.4MM WITHOUT CUFF REUSABLE INNER CANN",SUP-6CFS,CDM,S27200284,LOCAL,0272,RC,,,both,,,700.49,210.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY TRACH 8.5FR SHILEY BLUE RHINO PERCUTANEOUS FLEXIBLE",SUP-G57717,CDM,S27200284,LOCAL,0272,RC,,,both,,,4398.75,1319.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 61CM 12MM ENDO PADDLE RETRACT CURVE JAW DISPOSABLE",SUP-173046,CDM,S27200284,LOCAL,0272,RC,,,both,,,749.17,224.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIGNS AND SYMPTOMS WITH MCC",947,MS-DRG,,,,,,,inpatient,,,32839.66,9851.9,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 5-11MM VISIPORT PLUS RPF VERSAPORT",SUP-176673P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1305.88,391.76,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 32CM 10MM ENDO RETRACT II CURVE JAW STERILE LATEX",SUP-176647,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.42,206.53,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOBRONCHIAL 41FR 5.4MM RIGHT CUFF RADIOPAQUE SLIGHT",SUP-126041,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE EVERPOINT 8-0 BV175-6 24IN 2 ARM MONOFILAMENT 4",SUP-EPM8741,CDM,S27200284,LOCAL,0272,RC,,,both,,,1269.11,380.73,"KAISER [10500]",Kaiser,,850.3,67,,,,,0,147.6,1078.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 32.26CM 8MM DA VINCI ENDOWRIST SPAT",SUP-470184,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,120.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 100MM 4MM BALLOON DILATATION PEBAX",SUP-H74939148401010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CALCANEUS THK13-15MM ALLOGRAFT FREEZE DRIED CROSS",SUP-400482,CDM,S27800098,LOCAL,0278,RC,,,both,,,4765.14,1429.54,"MULTIPLAN [10600]",Multiplan,,4050.37,85,,,,,0,554.19,4050.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-593515022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DRNG 6CM 8.5FR 15GA VINYL PNEUMOTHORAX CHEST DRAIN VALVE",SUP-G13722,CDM,C1729,HCPCS,0272,RC,,,both,,,1453.95,436.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,172.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.09,1235.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 65CM STREAMLINE MOND RIGHT VENTRICULAR OUTFLOW",SUP-4140/65,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"BLUE CROSS [10001]","Blue Cross PPO",,225.44,39.2,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 60MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171030670,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNID PATIENT SPECIFIC DATA PLAN AND RODS",SUP-M200000B116,CDM,C1713,HCPCS,0278,RC,,,both,,,25200.00,7560,"UHC [10700]","United Healthcare",,15951.6,63.3,,5023.51,2672.93,6679.78,18,2930.76,21420,"percent of total billed charges",
"PUMP DEFLATION TITAN TOUCH 1 TOUCH RELEASE",SUP-517750,CDM,C1813,HCPCS,0278,RC,,,both,,,31506.30,9451.89,"FIRST HEALTH [10303]","First Health",,25205.04,80,,,,,0,3664.18,26780.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 1.3CC 11X11X11MM DEMINERALIZED CANCELLOUS",SUP-0W1011,CDM,S27800098,LOCAL,0278,RC,,,both,,,4623.00,1386.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2121.96,45.9,,,,,0,537.65,3929.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 5/64IN STEINMANN 2 END TROCAR POINT",SUP-162438000,CDM,C1713,HCPCS,0278,RC,,,both,,,102.95,30.88,"FIRST HEALTH [10303]","First Health",,82.36,80,,,,,0,11.97,87.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL CANN 5MM DA VINCI ENDOWRIST DISPOSABLE",SUP-400161,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.90,44.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL KNEE 8MM IDENTITY IMPRINT 3 TIBIAL INSRT POSTERIOR",SUP-TPS-030-083S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 495CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRX-495,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"FIRST HEALTH [10303]","First Health",,3175.2,80,,,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 335CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-335,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 9CM 5MM MIDAS REX LEGEND BALL DIAMOND COARSE",SUP-9BA50DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.17,412.25,"CIGNA [10200]",Cigna,,934.44,68,,,,,0,159.82,1168.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK 4X2.4CM THK.3CM NASAL EPISTAXIS SOFT ATRAUMATIC PLACEMENT",SUP-XG-108,CDM,S27200284,LOCAL,0272,RC,,,both,,,1083.38,325.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,128.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,126,920.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC TRANSLUCENT GRAY 85MM 6MM DRY-DOC ROUND",SUP-C7359,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.63,90.49,"MULTIPLAN [10600]",Multiplan,,256.39,85,,,,,0,35.08,256.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 15CM 2MM BALLOON DILATATION OTW LOW",SUP-G30938,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PRECISION CORTICAL RING ALLOGRAFT FREEZE DRIED 26",SUP-439010,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM GORILLA NONSTERILE R3CON NON LOCK PLATE",SUP-P50-453-3522,CDM,C1713,HCPCS,0278,RC,,,both,,,1069.20,320.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,126.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",124.35,908.82,"percent of total billed charges",
"GWIRE VASCULAR ANGLE 260CM 3CM .035IN HYDROPHILIC STIFF",SUP-LWSTFA35260EX,CDM,C1769,HCPCS,0272,RC,,,both,,,295.80,88.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,35.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.4,251.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 23MM 18.6MM MASTERS PYROLYTIC CARBON PTFE",SUP-23MTJ-503,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850016535,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"CIGNA [10200]","Cigna Local Plus",,3506.93,53.5,,3978.14,359.25,3978.14,24,762.35,5571.75,"percent of total billed charges",
"PIN FIXATION 4MM SCHANZ CALCANEUS AO CONNECTION",SUP-P99-300-4013,CDM,C1713,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS [10001]","Blue Cross PPO",,247.67,39.2,,957.42,570.23,957.42,28,73.48,537.03,"percent of total billed charges",
"PLATE 24X5.5X1.25MM TITANIUM 2MM SCR 4 HOLE MODULAR LC-DCP",SUP-449.931,CDM,C1713,HCPCS,0278,RC,,,both,,,2175.60,652.68,"AETNA [10100]","Aetna HMO/PPO",,1729.6,79.5,,1521.93,481.35,16760.95,30,253.02,1849.26,"percent of total billed charges",
"HC Surg Path Gross Micro Level 3",PX-312000006,CDM,88304,CPT,0312,RC,,,both,,,495.21,148.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,50.18,,,,,,,0.01,420.93,"fee schedule",
"INSRT TIBIAL 4 13MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-413-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7760.57,68,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TIBIAL 6 KNEE TRABECULAR METAL MODULAR FIXED BEARING S",SUP-00595404702,CDM,C1713,HCPCS,0278,RC,,,both,,,9576.00,2872.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4395.38,45.9,,,,,0,1113.69,8139.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 26MM 4MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT40026UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"KAISER [10500]",Kaiser,,1618.05,67,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG LINGEMAN CYSTOLOGY SEIMENS TABLE",SUP-LG1000,CDM,S27000186,LOCAL,0270,RC,,,both,,,70.99,21.3,"CIGNA [10200]","Cigna Open Access",,40.39,56.9,,,,,0,8.26,60.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 6.5MM HIGH VOLUME LOW PRESSURE TAPER CUFF",SUP-HUD512613,CDM,S27200284,LOCAL,0272,RC,,,both,,,391.60,117.48,"CIGNA [10200]",Cigna,,266.29,68,,,,,0,45.54,332.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM THK5-30MM ALLOGRAFT STRIP",SUP-400500,CDM,S27800098,LOCAL,0278,RC,,,both,,,9940.14,2982.04,"BLUE CROSS [10001]","Blue Cross HMO",,3896.53,39.2,,,,,0,1156.04,8449.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL URETERAL TAPER NOTTINGHAM ONE-STEP 70CM 4CM 6-10FR",SUP-M0062301000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1005.78,301.73,"CIGNA [10200]",Cigna,,683.93,68,,,,,0,116.97,854.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tiss Marker Seed I-125",PX-E27800025,CDM,A4648,HCPCS,0278,RC,,,both,,,749.10,224.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,214.39,28.62,,,,,0,87.12,636.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2.5MM TARGET NANO HELICAL DETACHABLE",SUP-M0035452540,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"KAISER [10500]",Kaiser,,6135.65,67,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Njx Cth Slct Pulm Vn Angrph",PX-481000376,CDM,93574,CPT,0481,RC,,,both,,,3045.00,913.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,360.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,354.13,3045,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 3MM OVAL SMALL JOINT 10 FLUTE",SUP-AR-7300OBT,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER MONOFOCAL UV ABSORBENT CLAREON",SUP-CC60WF.210,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 23MM 145CM 3MM CORONARY STENT",SUP-1145300-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,678.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROGRIP 16X12CM INGUINAL RIGHT SELF FIXATION",SUP-LPG1612AR,CDM,C1781,HCPCS,0278,RC,,,both,,,3591.45,1077.43,"CIGNA [10200]","Cigna Local Plus",,1921.43,53.5,,3096.73,1.00,3096.73,"1 through 10",417.69,3052.73,"percent of total billed charges",
"HEAD FEMORAL MEDIUM 28MM HIP BIOLOX DELTA",SUP-PHA04404,CDM,C1776,HCPCS,0278,RC,,,both,,,14234.70,4270.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5850.46,41.1,,6417.48,6417.48,6417.48,"1 through 10",1655.5,12099.5,"percent of total billed charges",
"BLADE THK.048IN 77.5X11X1.23MM RECIPROCATE STAINLESS STEEL",SUP-0277-096-326,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.85,90.25,"CIGNA [10200]","Cigna Local Plus",,160.95,53.5,,,,,0,34.99,255.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TM REVERSE STEM 10MM X130MM",SUP-00434901013,CDM,C1776,HCPCS,0278,RC,,,both,,,17863.20,5358.96,"CIGNA [10200]","Cigna Open Access",,5984.17,33.5,,5302.19,4377.88,6578.61,27,2077.49,15183.72,"percent of total billed charges",
"SUBSTITUTE BONE GRAFT FIBERGRAFT LARGE 12.5 CC MATRIX BIOACT",SUP-74000125,CDM,C1713,HCPCS,0278,RC,,,both,,,18113.76,5434.13,"CIGNA [10200]","Cigna Open Access",,6068.11,33.5,,1144.80,304.56,2275.09,66,2106.63,15396.7,"percent of total billed charges",
"SCR BONE 5MM 70MM OPTILINK SELF TAP VARIABLE ANGLE STARDRIVE",SUP-42.231.270,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"FIRST HEALTH [10303]","First Health",,1082.03,80,,,,,0,157.3,1149.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 12CM 10MM .035IN BILIARY SELF EXPAND GWIRE",SUP-G23816,CDM,C1876,HCPCS,0278,RC,,,both,,,13275.60,3982.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5310.24,40,,,,,0,1543.95,11284.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 59MM 135CM 9MM THIN VASCULAR COCR",SUP-1012632-59,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"CIGNA [10200]",Cigna,,5712,68,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE TORIC II INTRAOCULAR LENS, 1-PIE",SUP-DIU150U205,CDM,V2787,HCPCS,0276,RC,,,both,,,445.00,133.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.75,378.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 9CM 10FR ZIMMON .035IN 2 PIGTAIL CURVE",SUP-G21862,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"CIGNA [10200]",Cigna,,837.22,68,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 6MM 1.14MM 6MM GOODE 6MM EAR SILICONE",SUP-24752,CDM,S27200284,LOCAL,0272,RC,,,both,,,356.70,107.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,41.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.48,303.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 70MM LCP",SUP-212.326,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.25,337.57,"PHCS [10601]",PHCS,,787.68,70,,,,,0,130.87,956.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 0 GS-21 TAPER POINT 18IN CLSR NONABSORBABLE",SUP-VLOCN0326,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.33,69.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,157.3,68,,,,,0,26.9,196.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 6CM 6FR 10MM .035IN BALLOON",SUP-G52374,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 65MM TI",SUP-SPL-60650-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,463.64,28.62,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 60MM 6MM BALLOON DILATATION HYDROPHILIC",SUP-606006022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,84.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 12X15MM FORTIFY 0D 12MM NO SPIKE NONSTERILE",SUP-151.001,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"NOVANET [10819]",Novanet,,24073.88,75,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT STRETCH VL 22-30CM 3CM 6FR .038IN PIGTAIL CURVE",SUP-M006185156010,CDM,C2617,HCPCS,0278,RC,,,both,,,1038.34,311.5,"KAISER [10500]",Kaiser,,695.69,67,,,,,0,120.76,882.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 12X12.5CM 335CC STYLE 410FF GEL TEXTURE HIGH",SUP-FF-410335,CDM,C1789,HCPCS,0278,RC,,,both,,,8280.00,2484,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",962.96,7038,"percent of total billed charges",
"STENT GORE VIABAHN 120CM 7.5CM 8MM VASCULAR HEPARIN CATH",SUP-VBJR080702A,CDM,C1874,HCPCS,0278,RC,,,both,,,22163.40,6649.02,"UHC [10700]","United Healthcare",,14029.43,63.3,,,,,0,2577.6,18838.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 54.7CM 8MM MEGA DA VINCI S/SI ENDOWRIST 30- D 1.3",SUP-420194,CDM,S27000186,LOCAL,0270,RC,,,both,,,1732.50,519.75,"PHCS [10601]",PHCS,,1212.75,70,,,,,0,201.49,1472.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 120MM 150CM 8MM VASCULAR NICKEL",SUP-EVD35-08-120-150,CDM,C1876,HCPCS,0278,RC,,,both,,,7665.00,2299.5,"NOVANET [10819]",Novanet,,5748.75,75,,,,,0,891.44,6515.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC",067,MS-DRG,,,,,,,inpatient,,,51686.11,15505.83,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,9383.75,,"Case rate ($9,110.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,459.66, add-ons for qualifying new technology services are included. If operating cost exceeds $41,499.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,021.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,470.84. The transfer operating threshold is the transfer adjustment factor * $8,459.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $639.59. The transfer capital threshold is the transfer adjustment factor * $639.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,36627.91,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL COMPREHENSIVE +6MM +10MM SHOULDER REVERSE",SUP-110031407,CDM,C1776,HCPCS,0278,RC,,,both,,,8473.20,2541.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1004.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,985.43,7202.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 4X28+TRAK21 2-PACK - US",SUP-91313,CDM,S27200284,LOCAL,0272,RC,,,both,,,24624.97,7387.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11302.86,45.9,,,,,0,2863.88,20931.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING .48MM ATRIAL UNIPOLAR TEMPORARY STREAMLINE 3MM",SUP-6492F,CDM,C1898,HCPCS,0275,RC,,,both,,,304.50,91.35,"KAISER [10500]",Kaiser,,204.02,67,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 12IN 4 PANEL KNIT ELASTIC PREMIUM HOOK LOOP",SUP-13960000,CDM,S27000186,LOCAL,0270,RC,,,both,,,160.17,48.05,"PHCS [10601]",PHCS,,112.12,70,,,,,0,18.63,136.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 3.8MM SABRE COOLCUT STERILE DISPOSABLE",SUP-AR-8380SR,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"CIGNA [10200]",Cigna,,341.22,68,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE",RX-31921,CDM,J1650,HCPCS,0636,RC,63323-0589-21,NDC,both,1,ML,126.48,37.94,"BLUE CROSS [10001]","Blue Cross HMO",,10.31,,,,,,,10.31,107.51,"fee schedule",
"CMPNT FEMORAL 5 62X56MM KNEE LEFT POSTERIOR STABILIZE",SUP-81-4405L,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6487.38,40,,,,,0,1886.21,13785.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ZIPTIGHT ZIPLOOP FIXATION TITANIUM ANKLE KNOTLESS LOW",SUP-909853,CDM,S27200284,LOCAL,0272,RC,,,both,,,8355.90,2506.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3835.36,45.9,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM SOLERA CD HORIZON SPINE MULTIAXIAL",SUP-54850015545,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3008.75,45.9,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD LAPAROSCOPIC VALLEYLAB L HOOK RETRACTABLE ASPIRATION",SUP-E3784R-28ASP,CDM,S27200284,LOCAL,0272,RC,,,both,,,254.91,76.47,"UHC [10700]","United Healthcare",,161.36,63.3,,,,,0,29.65,216.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Agglut Febrile Ea Ag",PX-302000003,CDM,86000,CPT,0302,RC,,,both,,,130.00,39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.47,,"Fee schedule rate ($7.47). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,110.5,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Protein Total Urine",PX-301000379,CDM,84156,CPT,0301,RC,,,both,,,152.95,45.88,"MULTIPLAN [10600]",Multiplan,,130.01,85,,,,,0,0.15,130.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tiss Cult Skin or Solid Tumor",PX-311000026,CDM,88233,CPT,0311,RC,,,both,,,1359.45,407.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.33,,,,,,,0.01,1155.53,"fee schedule",
"CATH EZ STEER REDEL 115CM 4MM 7FR 1-7-4MM SPACE F-F CURVE",SUP-BD7TFF4L,CDM,C1733,HCPCS,0272,RC,,,both,,,6113.40,1834.02,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,710.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,710.99,5196.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 5 CCS-1 38IN BRAID TIES MULTISTRAND LOWER KNOT",SUP-AR-7211,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 26MM 140CM 2.5MM CORONARY STERILE LATEX",SUP-453956,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 25MM 3.5MM VERTEX SELECT PRECUT",SUP-7753725,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"MULTIPLAN [10600]",Multiplan,,1198.5,85,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit B Level 2",PX-450000327,CDM,G0381,HCPCS,0450,RC,,,both,,,714.00,214.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,714,,,,,,,67.13,714,"case rate",
"HC Coagulation Time Activated",PX-305000038,CDM,85347,CPT,0305,RC,,,both,,,86.59,25.98,"CIGNA [10200]","Cigna Open Access",,9.42,,,,,,,0.01,73.6,"fee schedule",
"DOXAZOSIN 4 MG TABLET, IMMEDIATE RELEASE",RX-9896,CDM,,,0637,RC,68084-0862-11,NDC,both,1,UN,6.27,1.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2.58,41.1,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 28MM 144CM 3MM CORONARY STENT EVEROLIMUS",SUP-H7493926128300,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"MULTIPLAN [10600]",Multiplan,,7331.25,85,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 3.5MM CORONARY STENT EVEROLIMUS",SUP-H7493926132350,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5865,68,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 35MM 160CM 9MM",SUP-M001712270,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2419.11,28.62,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE ABSORBABLE 8X6.25CM HEMOSTAT PORCINE GELATIN",SUP-1973,CDM,S27200284,LOCAL,0272,RC,,,both,,,256.87,77.06,"PHCS [10601]",PHCS,,179.81,70,,,,,0,29.87,218.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MINITAPE COBRAID NDL NONABSORBABLE",SUP-72205427,CDM,S27200284,LOCAL,0272,RC,,,both,,,484.79,145.44,"MULTIPLAN [10600]",Multiplan,,412.07,85,,,,,0,56.38,412.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cns Dna Amp Probe Type 12-25",PX-306000224,CDM,87483,CPT,0306,RC,,,both,,,998.25,299.47,"KAISER [10500]",Kaiser,,668.83,67,,,,,0,0.01,998.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veno Skull Si",PX-320000138,CDM,75870,CPT,0320,RC,,,both,,,2758.00,827.4,"BLUE CROSS [10001]","Blue Cross PPO",,318.7,,"Fee schedule rate ($318.70).",,,,0,153.62,2758,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acetylcholn Rcptr Modlg Antb",PX-301000693,CDM,86043,CPT,0301,RC,,,both,,,269.10,80.73,"MULTIPLAN [10600]",Multiplan,,228.74,85,,,,,0,0.01,228.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE STIM SONOPLEX CANN TIP ULTRASOUND WAVE ECHOGENIC",SUP-001187-74,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.62,34.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.21,96.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEIGHT EYELID THK1MM GOLD CONTOUR 1.2GM IMPL 3 DIMENSIONAL","SUP-LL 3012",CDM,L8699,HCPCS,0278,RC,,,both,,,1987.50,596.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,231.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,231.15,1689.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +9 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.090,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEMORYGEL SMOOTH ROUND ULTRA HIGH BREAST IMPLANT 750 CC","SUP-3505750 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HIWIRE VASCULAR STRAIGHT 180CM 15CM .035IN NITINOL",SUP-G36324,CDM,C1769,HCPCS,0272,RC,,,both,,,257.94,77.38,"FIRST HEALTH [10303]","First Health",,206.35,80,,,,,0,30,219.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 7CM MR8 2MM BALL FINE GRIT DISSECTING DIAMOND",SUP-MR8-7BA20DF,CDM,S27200284,LOCAL,0272,RC,,,both,,,1142.51,342.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,135.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,132.87,971.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NUVISION ICE CATHETER,  10F",SUP-FG12080,CDM,C1759,HCPCS,0272,RC,,,both,,,20160.00,6048,"UHC [10700]","United Healthcare",,12761.28,63.3,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Liver Dis 10 Serum Alg W/Nash",PX-301000675,CDM,0003M,CPT,0301,RC,,,both,,,692.00,207.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Liver Dis 10 Serum Alg W/Nash",PX-301000675,CDM,0003M,CPT,0301,RC,,,both,,,692.00,207.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RADIUM RA-223 DICHLOR INTRAVENOUS SOLN",RX-162677,CDM,A9606,HCPCS,0344,RC,08888-8877-03,NDC,both,1,UN,10.00,3,"MULTIPLAN [10600]",Multiplan,,8.5,85,,,,,0,1.16,10,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACTOR, STRIPPED SCREW, 5 MM, 6"" LONG, SINGLE USE",SUP-SXT012-ST3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"PHCS [10601]",PHCS,,2073.75,70,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM .91-1.12MM 2.75MM CORONARY",SUP-RONYX27526W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"CIGNA [10200]","Cigna Local Plus",,2909.87,53.5,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR 47MM MULTIPOLAR HIP METAL STERILE",SUP-00500104700,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT RADIAL MANIFOLD",SUP-K09-11393,CDM,S27200284,LOCAL,0272,RC,,,both,,,308.85,92.65,"NOVANET [10819]",Novanet,,231.64,75,,,,,0,35.92,262.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z2 100CM 6FR MP1 CURVE GUIDING PERIPHERAL STERILE LATEX",SUP-Z26MP1,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"MULTIPLAN [10600]",Multiplan,,310.59,85,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 14CM 7FR 10MM .035IN BALLOON",SUP-G52298,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PHCS [10601]",PHCS,,671.84,70,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Abd Complete",PX-402000008,CDM,76700,CPT,0402,RC,,,both,,,1493.50,448.05,"AETNA [10100]","Aetna HMO/PPO",,1187.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",1187.33,1078.02,1187.33,"1 through 10",123.34,1269.48,"percent of total billed charges",
"PISTON OSSICULAR 4.5MM .5MM RICHARDS PLATINUM FLUOROPLASTIC",SUP-140816,CDM,L8613,HCPCS,0278,RC,,,both,,,1209.90,362.97,"MULTIPLAN [10600]",Multiplan,,1028.42,85,,,,,0,140.71,1028.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Bn/Jnt Img 3 Phase",PX-341000024,CDM,78315,CPT,0341,RC,,,both,,,3278.75,983.62,"MULTIPLAN [10600]",Multiplan,,2786.94,85,,,,,0,381.32,2786.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION",RX-76338,CDM,J3473,HCPCS,0636,RC,18657-0117-01,NDC,both,1,ML,421.18,126.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,49.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,49.91,358,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T TITANIUM 3MM SCR 4 HOLE LOW PROFILE BONE FOOT",SUP-AR-8952TT-04,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Arterial Line",PX-E27200143,CDM,E27200143,LOCAL,0272,RC,,,both,,,128.70,38.61,"CIGNA [10200]","Cigna Local Plus",,68.85,53.5,,,,,0,14.97,109.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ACETABULAR 50MM DURALOC DYNAMIC HIP LOCK STERILE LATEX",SUP-124950000,CDM,C1776,HCPCS,0278,RC,,,both,,,1878.00,563.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,222.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.41,1596.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTITIS MEDIA AND URI WITHOUT MCC",153,MS-DRG,,,,,,,inpatient,,,22981.45,6894.43,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,4899.63,,"Case rate ($4,579.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,252, add-ons for qualifying new technology services are included. If operating cost exceeds $37,291.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,703.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,257.63. The transfer operating threshold is the transfer adjustment factor * $4,252.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $321.47. The transfer capital threshold is the transfer adjustment factor * $321.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,4579.09,18409.97,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 150MM 3.5MM BALLOON",SUP-H74939147351510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACETIC ACID 0.25 % IRRIGATION SOLUTION",RX-8963,CDM,,,0250,RC,00990-6143-22,NDC,both,250,ML,100.65,30.19,"CIGNA [10200]",Cigna,,68.44,68,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.7MM 40MM 18MM LOW PROFILE SCREWS TITANIUM 3.5MM",SUP-AR-8967-1840,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,218.06,1593.75,"percent of total billed charges",
"KIT BIOPSY PINK 16CM 18GA 17GA BARD MISSION TRUGUIDE 10MM 20",SUP-1816MSK,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"PHCS [10601]",PHCS,,286.23,70,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 E-F 14MM KNEE FIX BEARING PROLONG",SUP-00596203214,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"BLUE CROSS [10001]","Blue Cross HMO",,3104.03,39.2,,5311.50,4717.44,5388.59,31,920.91,6730.67,"percent of total billed charges",
"CMPNT PATELLAR 32MM PERSONA ALL POLY KNEE LATEX FREE",SUP-42540000032,CDM,C1776,HCPCS,0278,RC,,,both,,,4667.16,1400.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2142.23,45.9,,,,,0,542.79,3967.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT VITOSS FOAM BIMODAL FOAM PACK 2.5CC",SUP-2102-1902,CDM,C1713,HCPCS,0278,RC,,,both,,,6629.18,1988.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,785.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,770.97,5634.8,"percent of total billed charges",
"GRAFT BONE NEVOS DEMINERALIZED BONE MATRIX 2.5CC ALLOGRAFT",SUP-BNEPP0025,CDM,C1713,HCPCS,0278,RC,,,both,,,2343.75,703.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1593.75,68,,,,,0,272.58,1992.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC 25-30IN SMARTVEST SMALL HIGH FREQUENCY",SUP-SW-25/30-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL SOFT/FIBRA 6MM .25 FORCE SPRING ATRAUMATIC",SUP-G-6054,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"AETNA [10100]","Aetna HMO/PPO",,179.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 200MM 3MM STERILE DISPOSABLE",SUP-7020140,CDM,C1713,HCPCS,0278,RC,,,both,,,955.80,286.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,649.94,68,,,,,0,111.16,812.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD .99CM 5.37X8.18CM",SUP-G247,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA [10200]","Cigna Local Plus",,18181.8,31.5,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 11.8X9.8IN XENMATRIX AB RECTANGLE PORCINE",SUP-1152530,CDM,C1781,HCPCS,0278,RC,,,both,,,110903.19,33270.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12898.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12898.04,94267.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL RATCHET",SUP-58-0065,CDM,S27200284,LOCAL,0272,RC,,,both,,,3224.03,967.21,"UHC [10700]","United Healthcare",,2040.81,63.3,,,,,0,374.95,2740.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Fungi Presumpt ID Other",PX-306000066,CDM,87102,CPT,0306,RC,,,both,,,396.15,118.84,"BLUE CROSS [10001]","Blue Cross HMO",,0.4,.1,,,,,0,0.01,336.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPRESS ULTRA 6MMX20MM",SUP-ULF-106,CDM,C1726,HCPCS,0272,RC,,,both,,,11364.30,3409.29,"KAISER [10500]",Kaiser,,7614.08,67,,,,,0,1321.67,9659.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 12CM LEGEND 3MM 2 FLUTE MATCH HEAD DISSECTING BURR",SUP-T12MH30M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"PHCS [10601]",PHCS,,818.18,70,,,,,0,135.93,993.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR DURALOC 10D +4MM 58MM 36MM MARATHON HIP",SUP-122036558,CDM,C1776,HCPCS,0278,RC,,,both,,,10372.08,3111.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1206.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1206.27,8816.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SILICONE 450ML BREAST GEL SMOOTH",SUP-RSZ-4504,CDM,S27200284,LOCAL,0272,RC,,,both,,,127.64,38.29,"PHCS [10601]",PHCS,,89.35,70,,,,,0,14.84,108.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM TARGET TETRA DETACHABLE STERILE",SUP-TG5412060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5801.12,41.1,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 2.25MM CORONARY STENT",SUP-H7493941820220,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aquaporin-4 Antb Elisa",PX-302000250,CDM,86051,CPT,0302,RC,,,both,,,791.00,237.3,"MULTIPLAN [10600]",Multiplan,,672.35,85,,,,,0,0.01,672.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR061002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2473.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 10MM TARGET XL LARGE HELICAL",SUP-M0036111040,CDM,S27800098,LOCAL,0278,RC,,,both,,,12419.24,3725.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5104.31,41.1,,,,,0,1444.36,10556.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 12/14 TAPER 32MM HIP CEMENTLESS SLEEVE",SUP-136532720,CDM,C1776,HCPCS,0278,RC,,,both,,,12408.96,3722.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1470.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1443.16,10547.62,"percent of total billed charges",
"RING ANNULOPLASTY 34MM TRICUSPID CONTOUR 3D TITANIUM",SUP-690R34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 19MM KNEE X3 BEARING CRUCIATE RETAIN",SUP-5530-G-119,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1352.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERLOOP ARTHREX SUTURETAPE NDL BLACK WHITE",SUP-AR-7534T,CDM,S27200284,LOCAL,0272,RC,,,both,,,595.35,178.6,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXTR PRO RX 200CM 7-6FR 15-18MM BALLOON DILATATION",SUP-M00547020,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLIDE POLY L LYSINE 75X25MM MICROSCOPE 1 END 2 SIDE FROST",SUP-P-4981,CDM,S27000186,LOCAL,0270,RC,,,both,,,166.30,49.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE ARTHROSCOPIC LARGE HUB STERLING GREAT WHITE 2500-6000",SUP-9399A,CDM,S27200284,LOCAL,0272,RC,,,both,,,503.82,151.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE QUILL 2-0 3/8 CIRCLE 14X14CM 26MM CLSR MONODERM",SUP-YA-1015Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,159.70,47.91,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SUPERORDERABLE",RX-40814984,CDM,,,0250,RC,63323-0462-37,NDC,both,30,ML,118.01,35.4,"NOVANET [10819]",Novanet,,88.51,75,,,,,0,13.72,100.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP070150150 PLUS US D7L150UL1500",SUP-PCP070150150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REGULAR 5FR INTRO STAINLESS STEEL ECHOGENIC NDL GWIRE",SUP-70-5130,CDM,C1894,HCPCS,0272,RC,,,both,,,295.80,88.74,"FIRST HEALTH [10303]","First Health",,236.64,80,,,,,0,34.4,251.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT RETRIEVER 30MM 4MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0032PK43010001,CDM,S27200284,LOCAL,0272,RC,,,both,,,29495.34,8848.6,"AETNA [10100]","Aetna HMO/PPO",,23448.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3430.31,25071.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX LOW PROFILE REINFORCED TISSUE MATRIX, LONG-TERM RESOR",SUP-F10264-1515L,CDM,C1781,HCPCS,0278,RC,,,both,,,17700.98,5310.29,"AETNA [10100]","Aetna HMO/PPO",,14072.28,79.5,,,,,0,2058.62,15045.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X12MM CLYDESDALE 6D PEEK-OPTIMA LUMBAR",SUP-2968255,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS [10001]","Blue Cross PPO",,9313.92,39.2,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER PURPLE 3.5MM RAZORCUT DYONICS STRAIGHT",SUP-7205317,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"CIGNA [10200]",Cigna,,236.64,68,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXTR PRO XL 200CM 7-6FR 15-18MM BALLOON DILATATION",SUP-M00547120,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 120CM 18MM 18.5FR FLARE LOW PROFILE",SUP-M00516710,CDM,C1874,HCPCS,0278,RC,,,both,,,10076.00,3022.8,"FIRST HEALTH [10303]","First Health",,8060.8,80,,,,,0,1171.84,8564.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 11FR 11CM NO OBTR KINK RESISTANT CANN ROTATE",SUP-504611X,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"KAISER [10500]",Kaiser,,52.46,67,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 10MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-410-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"FIRST HEALTH [10303]","First Health",,9626.88,80,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 20-23MM EVOLUT FX+ 26MM ANNULUS",SUP-EVFXPLUS-26,CDM,S27800098,LOCAL,0278,RC,,,both,,,182400.00,54720,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,72960,40,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 10CM 6MM BALLOON",SUP-G52268,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"KAISER [10500]",Kaiser,,643.05,67,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL HIP 2",SUP-CAP-S-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"KAISER [10500]",Kaiser,,6934.5,67,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 24FR POWERBALL UROLOGY RESECTOSCOPE",SUP-M0068802111,CDM,S27200284,LOCAL,0272,RC,,,both,,,956.45,286.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,650.39,68,,,,,0,111.24,812.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 90D BLADE 2.75IN 3/32IN EDGE SAFETY",SUP-E1455BNSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.24,14.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.73,41.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 36MM LCP STAINLESS STEEL LONG THREAD FEMORAL",SUP-207.736,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"FIRST HEALTH [10303]","First Health",,832.03,80,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LOW PROFILE STAINLESS STEEL 4 HOLE LOCK MODULAR BONE",SUP-AR-8943BL-04,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,1521.93,481.35,16760.95,30,441.36,3225.75,"percent of total billed charges",
"BIT DRILL 6.5MM DARCO DISPOSABLE",SUP-IW706522,CDM,S27200284,LOCAL,0272,RC,,,both,,,1271.70,381.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FILTER EMBOLIZATION 55CM VENA CAVA FEMUR JUGULAR PERMANENT",SUP-466P306AU,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BALLOON DILATATION .035IN 5FR 12MM 110CM 4CM PTA 2",SUP-4202040L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EUPHORA 142CM 8MM 5MM BALLOON DILATATION DURATRAC",SUP-NCEUP5008X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SAPPHIRE 3 CORONARY DILATATION CATHETER 1.25 X 5MM",SUP-54125-050-02,CDM,C1725,HCPCS,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NON-EXTENSIVE BURNS",935,MS-DRG,,,,,,,inpatient,,,29457.93,8837.38,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,13672.78,,"Case rate ($12,778.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,865.52, add-ons for qualifying new technology services are included. If operating cost exceeds $44,905.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,279.10, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,881.21. The transfer operating threshold is the transfer adjustment factor * $11,865.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $897.09. The transfer capital threshold is the transfer adjustment factor * $897.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,29457.93,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X3.1-6MM ROI-C VERTEBRIDGE 7D 12MM LORDOTIC","SUP-MC 1442 P",CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4860,27,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ASPIRA PLEURAL DRSG LATEX FREE DISPOSABLE",SUP-4991503,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,91.85,45.9,,,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY ESOPHAGEAL 3 7.6MM LMA FLEXIBLE REINFORCE LARYNGEAL",SUP-115030,CDM,S27200284,LOCAL,0272,RC,,,both,,,160.95,48.28,"PHCS [10601]",PHCS,,112.67,70,,,,,0,18.72,136.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONDUIT VALVE 23MM ATS OPEN PIVOT MECHANICAL GRAFT STERILE",SUP-502AG23,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"BLUE CROSS [10001]","Blue Cross HMO",,10372.32,39.2,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BURN INCISION PATCH STRIP 20CM PREVENA",SUP-PRE1055US.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2091.15,627.34,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1421.98,68,,,,,0,243.2,1777.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 135CM 11MM 16SQ MM 8FR .035IN",SUP-BXA112902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]","Cigna Local Plus",,6144.01,31.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TRICLIP DELIVERY 4TH GENERATION TEER",SUP-TCG40100,CDM,S27800098,LOCAL,0278,RC,,,both,,,205200.00,61560,"PHCS [10601]",PHCS,,143640,70,,,,,0,23864.76,174420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 4.75MM CD HORIZON SOLERA COCRMO CAP",SUP-641003065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT STRETCH VL ZIPWIRE 22-30CM 3CM 7FR .035IN PIGTAIL",SUP-M006185157190,CDM,C2617,HCPCS,0278,RC,,,both,,,1199.37,359.81,"NOVANET [10819]",Novanet,,899.53,75,,,,,0,139.49,1019.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.50MM X 20MM  SCOREFLEX  NC",SUP-625-204-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON SUT 3.5MM STERILE",SUP-AR-8920,CDM,C1713,HCPCS,0278,RC,,,both,,,807.98,242.39,"BLUE CROSS [10001]","Blue Cross PPO",,316.73,39.2,,957.42,570.23,957.42,28,93.97,686.78,"percent of total billed charges",
"3.4 X 3.0 X 12MM TWO-STEP HAMMER TOE IMPLANT",SUP-204-30-012,CDM,C1713,HCPCS,0278,RC,,,both,,,6141.00,1842.3,"KAISER [10500]",Kaiser,,4114.47,67,,,,,0,714.2,5219.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MIDAS REX MR8 3MM MATCH HEAD DISSECTING SP STERILE",SUP-MR8-SP14MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,326.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 124MM CEMENTLESS OFFSET ACCOLADE TMZF 132D 3.5",SUP-6020-3535,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"CIGNA [10200]","Cigna Local Plus",,4929.5,31.5,,5372.07,4581.20,7242.98,23,1820,13301.82,"percent of total billed charges",
"SUB BONE GRAFT MASTERGRAFT MINI GRANULES VOID FILLER 1ML",SUP-8600101,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE EMG STIMULUS HNDPC NV M5",SUP-2012021,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.00,495,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1122,68,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC SURGILAV PLUS SET MULTIORIFICE TIP SPLASH SHIELD",SUP-207-559,CDM,S27200284,LOCAL,0272,RC,,,both,,,337.68,101.3,"FIRST HEALTH [10303]","First Health",,270.14,80,,,,,0,39.27,287.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 115MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.915,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"BLUE CROSS [10001]","Blue Cross HMO",,538.77,39.2,,957.42,156.86,7483.26,51,159.84,1168.25,"percent of total billed charges",
"CAP HIP HYBRID AND DISP",SUP-98000100224,CDM,C1776,HCPCS,0278,RC,,,both,,,32760.00,9828,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9375.91,28.62,,,,,0,3809.99,27846,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY ALLIGATOR JAW FENESTRATE CUP 115CM 5MM ENDOJAW",SUP-FB-211D.A,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.94,65.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.35,185.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-593512022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG VARIABLE ANGLE LOCKING 1.8MM X 11MM",SUP-SPLS-18110-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",165.8,1211.76,"percent of total billed charges",
"GRAFT BONE ACHILLES TENDON STRUT",SUP-02B002,CDM,S27800098,LOCAL,0278,RC,,,both,,,8073.00,2421.9,"MULTIPLAN [10600]",Multiplan,,6862.05,85,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 SH-1 30IN 2 ARM BRAID 4 STRAND GREEN",SUP-MX763,CDM,S27200284,LOCAL,0272,RC,,,both,,,161.47,48.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,66.36,41.1,,,,,0,18.78,137.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Initial Care Training 30 M (Gn)",PX-440000025,CDM,G0539,HCPCS,0440,RC,,,both,,,70.00,21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.07,.1,,,,,0,0.07,70,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 23MM 145CM 3MM CORONARY STENT",SUP-1145300-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]","Cigna Local Plus",,3123.33,53.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 14MM NESTER 3.2 LOOP .035IN PLATINUM",SUP-G52751,CDM,S27800098,LOCAL,0278,RC,,,both,,,748.04,224.41,"KAISER [10500]",Kaiser,,501.19,67,,,,,0,87,635.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 25MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G725,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1163,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH UROMAX ULTRA QUADRA-FOLD ENCORE HIGH PRESSURE KINK",SUP-M0062251380,CDM,C1726,HCPCS,0272,RC,,,both,,,1904.70,571.41,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,225.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",379.61,375.47,414.12,"1 through 10",221.52,1619,"percent of total billed charges",
"GWIRE VASCULAR STRAIGHT 180CM .014IN CORONARY TIP",SUP-TFC14180S,CDM,C1769,HCPCS,0272,RC,,,both,,,2250.00,675,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,261.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 25MM 3.25MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012408-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 4-0 PS-2 18IN MONOFILAMENT GREEN NONABSORBABLE",SUP-G667G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTICULATION NEXEL 4",SUP-00840009400,CDM,S27800098,LOCAL,0278,RC,,,both,,,9239.10,2771.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1094.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1074.51,7853.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE PLUS 100CM 6FR STD JUDKINS LEFT 4 CURVE",SUP-533620,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"CIGNA [10200]","Cigna Open Access",,46.83,56.9,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT NEROSTIMLTR 10CM INTERSTIM 13L SPINAL CORD LEAD TNLR",SUP-3095-10,CDM,C1883,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"BLUE CROSS [10001]","Blue Cross PPO",,1455.3,39.2,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 13MM AVENIR 10 COIL STERILE LATEX",SUP-10CFR13030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Local Plus",,3692.78,31.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +9.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-LI61AOR0950,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 65CM 25CM 5FR .047IN",SUP-CG505,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 60MM 3MM BALLOON DILATATION OTW STERILE",SUP-593006022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 145MM 4.2MM QUICK COUPLING NDL POINT 3 FLUTED",SUP-03.010.104,CDM,S27000186,LOCAL,0270,RC,,,both,,,1077.30,323.19,"PHCS [10601]",PHCS,,754.11,70,,,,,0,125.29,915.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPARIN (PORCINE) 25,000 UNIT/500 ML IN 0.45 % SODIUM CHLORIDE IV SOLN",RX-15848,CDM,J1644,HCPCS,0636,RC,63323-0518-01,NDC,both,500,ML,100.65,30.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.29,,"Fee schedule rate ($5.29). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.29,85.55,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INTRODUCER",SUP-MAJ1820,CDM,S27200284,LOCAL,0272,RC,,,both,,,549.50,164.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH BRIDGE PREP GWIRE SYR STPCOCK OCCLUSION BALLOON",SUP-591-001,CDM,C1769,HCPCS,0272,RC,,,both,,,2137.50,641.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 5MM 56MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.056TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,957.42,570.23,957.42,28,189.34,1383.8,"percent of total billed charges",
"HC Cardioassist Intrnl",PX-481000011,CDM,92970,CPT,0481,RC,,,both,,,5701.00,1710.3,"FIRST HEALTH [10303]","First Health",,4560.8,80,,,,,0,663.03,4845.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE .035IN 10CM 2.5CM 8FR INTRO STAINLESS STEEL",SUP-RSS801,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"FIRST HEALTH [10303]","First Health",,62.64,80,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MEDIUM BONE CEMENT FEMUR PROXIMAL PRSSZR SEAL STERILE",SUP-0206546000,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.37,36.71,"CIGNA [10200]","Cigna Local Plus",,65.47,53.5,,,,,0,14.23,104.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST 38MM 120CM 10MM VASCULAR STAINLESS STEEL PTFE",SUP-42038,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"CIGNA [10200]",Cigna,,7008.12,40,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145359010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,114.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIVIGEN CELLULAR BONE MATRIX 10CC CRYO",SUP-BL-1500-003,CDM,C1713,HCPCS,0278,RC,,,both,,,21168.00,6350.4,"MULTIPLAN [10600]",Multiplan,,17992.8,85,,,,,0,2461.84,17992.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 6.7IN SEWALL HANDHELD SURGICAL 70X13MM",SUP-N3324,CDM,S27200284,LOCAL,0272,RC,,,both,,,1357.80,407.34,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE ORTHOPEDIC THK1/8IN MEDIUM 13IN NEOPRENE KNEE EXTRA",SUP-79-82005,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.72,17.02,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL 8-0 TG140-8 12IN 2 ARM BRAID COATED VIOLET",SUP-J599G,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.98,46.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PREVAIL DCB 2.75X15MM",SUP-PRV027515CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STAPLE BONE COMPRESSION 20X20MM STAINLESS STEEL FOOT ANKLE",SUP-43110007,CDM,C1713,HCPCS,0278,RC,,,both,,,3682.50,1104.75,"NOVANET [10819]",Novanet,,2761.88,75,,,,,0,428.27,3130.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Blastomyces Ag Urine",PX-306000111,CDM,87449,CPT,0306,RC,,,both,,,256.10,76.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,18.84,,,,,,,0.01,217.69,"fee schedule",
"IMPLANT BREAST GEL , SMOOTH, ROUND, MODERATE, 600CC",SUP-10512-600MP,CDM,C1789,HCPCS,0278,RC,,,both,,,5106.00,1531.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1461.34,28.62,,,,,0,593.83,4340.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR 20CM 3CM 7FR .035IN 2 FLOPPY PIGTAIL",SUP-M006180230090,CDM,C2617,HCPCS,0278,RC,,,both,,,1294.14,388.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.51,1100.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 39MM 135CM 8MM LOW PROFILE THIN",SUP-1012631-39,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"CIGNA [10200]","Cigna Local Plus",,4494,53.5,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22-24X27-32X9MM 8D LORDOTIC RING WEDGE",SUP-609,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3732.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID ALLOSYNC CANCELLOUS DEMINERALIZED BONE",SUP-ABS-2015-03,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,,1521.93,481.35,16760.95,30,436.13,3187.5,"percent of total billed charges",
"CMPNT FEMORAL 12 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502607402,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"AETNA [10100]","Aetna HMO/PPO",,18175.85,79.5,,10981.53,8986.79,12413.38,12,2658.93,19433.3,"percent of total billed charges",
"STENT LIFESTENT 120MM 135CM 7MM 5FR VASCULAR NITINOL LOW",SUP-5F071203CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6072,40,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR STRAIGHT 145CM 7CM .035IN",SUP-46-523,CDM,C1769,HCPCS,0272,RC,,,both,,,204.45,61.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,139.03,68,,,,,0,23.78,173.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CENTRAL VENOUS 8.5FR 20CM EDWARDS .032IN 3 LUMEN OLIGON",SUP-XA3816SAFKT,CDM,C1751,HCPCS,0272,RC,,,both,,,2887.50,866.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1963.5,68,,,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH ACCESS 36CM 13-15FR NAVIGATOR URETERAL HYDROPHILIC",SUP-M0062502080,CDM,S27200284,LOCAL,0272,RC,,,both,,,895.54,268.66,"FIRST HEALTH [10303]","First Health",,716.43,80,,,,,0,104.15,761.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR CHEST PROCEDURES WITH MCC",163,MS-DRG,,,,,,,inpatient,,,156478.36,46943.51,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,29746.93,,"Case rate ($27,800.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $25,815, add-ons for qualifying new technology services are included. If operating cost exceeds $58,854.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $25,849.14. The transfer operating threshold is the transfer adjustment factor * $25,815.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,951.74. The transfer capital threshold is the transfer adjustment factor * $1,951.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,10994,130850.63,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 10 127D",SUP-6721-1040,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"CIGNA [10200]",Cigna,,9584.82,40,,5873.17,5873.17,5873.17,"1 through 10",2786.79,20367.74,"percent of total billed charges",
"HC Ph Probe",PX-E27200296,CDM,E27200296,LOCAL,0272,RC,,,both,,,760.10,228.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,348.89,45.9,,,,,0,88.4,646.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lyme Disease Dna Ampl Probe",PX-306000119,CDM,87476,CPT,0306,RC,,,both,,,2196.00,658.8,"CIGNA [10200]","Cigna Local Plus",,77.2,,,,,,,0.01,1866.6,"fee schedule",
"TISSUE 330944 ACSR 9X14X14 SRVC FEE",SUP-330944,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 6 KNEE LEFT BICRUCIATE STABILIZE",SUP-74022226,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"FIRST HEALTH [10303]","First Health",,13297.68,80,,,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 3MM CORONARY STENT",SUP-H7493941820300,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 22CM 9MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140922,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"FIRST HEALTH [10303]","First Health",,9505.44,80,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP 3 HOLE POLY POROUS R3 STD STERILE",SUP-71335554,CDM,C1776,HCPCS,0278,RC,,,both,,,14345.10,4303.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5738.04,40,,,,,0,1668.34,12193.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEUROSURGICAL ORACLE STERILE",SUP-03.809.002S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4585.05,1375.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3117.83,68,,,,,0,533.24,3897.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE STRAIGHT 2.5MM NARROW SHAFT SHARP ALL AROUND BEAVER",SUP-377210,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.70,55.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,75.91,41.1,,,,,0,21.48,157,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Est Eval Visit Level 3",PX-510000178,CDM,99213,CPT,0761,RC,,,both,,,397.91,119.37,"AETNA [10100]","Aetna HMO/PPO",,316.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.4,397.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Est Eval Visit Level 3",PX-510000178,CDM,99213,CPT,0761,RC,,,both,,,397.91,119.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,47.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.4,397.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION PRECEPT KIRSCHNER NITINOL LONG SPINE BEVEL TIP",SUP-8801269,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5MM 2MM 8-18 COIL FIBERED PLATINUM 10MM",SUP-M0013120211,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LASER ABLATION SYSTEM 15MM VISUALASE VCLAS 1.85MM CATH",SUP-9735561,CDM,S27200284,LOCAL,0272,RC,,,both,,,62700.00,18810,"NOVANET [10819]",Novanet,,47025,75,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 80MM 120CM 10MM .079IN LARGE",SUP-SERB65-10-80-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Open Access",,3166.49,56.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 94MM 10MM PRESS FIT REUNION S SHOULDER",SUP-5567-P-3010,CDM,C1776,HCPCS,0278,RC,,,both,,,26525.52,7957.66,"CIGNA [10200]","Cigna Local Plus",,8355.54,31.5,,5372.07,4581.20,7242.98,23,3084.92,22546.69,"percent of total billed charges",
"HC Bx Endolum Biliary Tree",PX-361000410,CDM,47543,CPT,0361,RC,,,both,,,6717.65,2015.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,796.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,781.26,6717.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR",RX-12098,CDM,,,0637,RC,00480-3310-01,NDC,both,1,UN,21.61,6.48,"FIRST HEALTH [10303]","First Health",,17.29,80,,,,,0,2.51,18.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT 58MM FULL EXTR",SUP-705305820,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"CIGNA [10200]","Cigna Local Plus",,2421.62,53.5,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR .5MM ULTRASHARP STRAIGHT STRAIGHT KNIFE SURGICAL",SUP-681.05,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 14CM 7FR 12MM .035IN BALLOON",SUP-G52303,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NAVIGATION KNEE TRACKING STERILE VIZADISC",SUP-107120,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM 2MM CORONARY STENT BIOLINX",SUP-RONYX20008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 4MM 4.5MM 5MM XTHICK TISSUE SLOPE CRTDG FACE",SUP-TRIEEA25XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2219.25,665.77,"AETNA [10100]","Aetna HMO/PPO",,1764.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,258.1,1886.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Iliac W Pta Add",PX-361000150,CDM,37222,CPT,0361,RC,,,both,,,7309.72,2192.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,866.2,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,850.12,7309.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 7CM 20GA KOPANS BEVEL TIP MODIFIED",SUP-G02601,CDM,A4648,HCPCS,0278,RC,,,both,,,224.55,67.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,64.27,28.62,,,,,0,26.12,190.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM 1.1MM KIRSCHNER DART-FIRE",SUP-DSDS1011,CDM,C1713,HCPCS,0278,RC,,,both,,,191.40,57.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,22.26,162.69,"percent of total billed charges",
"TRNSCONN ROD 33-38MM MATRIX 5 SPINE PEDICLE POSTERIOR",SUP-04.633.333,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"AETNA [10100]","Aetna HMO/PPO",,2832.19,79.5,,1521.93,481.35,16760.95,30,414.32,3028.13,"percent of total billed charges",
"CAP END 0MM FEMORAL EXTENDED STARDRIVE RECESS SPIRAL BLADE",SUP-04.013.000S,CDM,C1713,HCPCS,0278,RC,,,both,,,1585.33,475.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,727.67,45.9,,,,,0,184.37,1347.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Myocard Infarc",PX-341000028,CDM,78466,CPT,0341,RC,,,both,,,877.40,263.22,"NOVANET [10819]",Novanet,,658.05,75,,,,,0,0.88,877.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Myocard Infarc",PX-341000028,CDM,78466,CPT,0341,RC,,,both,,,877.40,263.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,877.4,,,,,,,0.88,877.4,"fee schedule",
"HC Angio Ext Uni Si",PX-323000015,CDM,75710,CPT,0323,RC,,,both,,,6701.38,2010.41,"KAISER [10500]",Kaiser,,4489.92,67,,,,,0,108.21,6701.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 16CM 9FR SHEATH PEEL AWAY SPLIT",SUP-00491114A,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"UHC [10700]","United Healthcare",,282,63.3,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 5MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140512,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]","Cigna Local Plus",,3742.77,31.5,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 55MM SPINE POLYAXIAL REVOLVE",SUP-185.487,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"KAISER [10500]",Kaiser,,6396.39,67,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 58MM 80CM 7MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU0800758,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"CIGNA [10200]",Cigna,,10458,40,,,,,0,3040.66,22223.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 345CC",SUP-SSZ-F345,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,173.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 4MM25CM 190",SUP-R51004025L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"NOVANET [10819]",Novanet,,1868.91,75,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Surg Path Gross Micro Level 4",PX-312000013,CDM,88305,CPT,0312,RC,,,both,,,745.75,223.72,"BLUE CROSS [10001]","Blue Cross PPO",,44.95,,"Fee schedule rate ($44.95).",,,,0,0.01,633.89,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 4FR .042IN AMPLATZ RIGHT 1",SUP-538441,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"UHC [10700]","United Healthcare",,56.67,63.3,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DECA 4-4-4-29-3-3-3-3-3 MPA 120CM",SUP-901822,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"PHCS [10601]",PHCS,,2073.75,70,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM ACCOLADE HFX 127D 6 49MM OFFSET HIP",SUP-6077-0637,CDM,C1776,HCPCS,0278,RC,,,both,,,8983.80,2695.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1044.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1044.82,7636.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER GABBAY-FRATER GUIDE ORG SUT VALVE IMPLANTATION",SUP-GFS-10A,CDM,S27000186,LOCAL,0270,RC,,,both,,,591.30,177.39,"CIGNA [10200]","Cigna Open Access",,336.45,56.9,,,,,0,68.77,502.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAPE FIBERWIRE 0 8INX1.7MM TAPER END BLUE 30IN",SUP-AR-7273-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CLEANGUIDE ENDOSCOPIC 4CM 80CM POLYVINYL ESOPHAGEAL",SUP-DIS150,CDM,C1769,HCPCS,0272,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING 43IN 8FR CORFLO-ULTRA ENTERAL POLYURETHANE",SUP-8884710867,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.70,22.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,30.7,41.1,,,,,0,8.69,63.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 80CM 5FR UNI SELECT I CURVE ANGIOGRAPHIC NEON SLX",SUP-451518S0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC",519,MS-DRG,,,,,,,inpatient,,,112416.67,33725,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,31890.65,,,,,,,7561,58397.84,"case rate",
"CATH FOGARTY 40CM 4FR EMBOLECTOMY 1 LUMEN BALLOON",SUP-E1601-44,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,71.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X2CM VIASHIELD AMNION 2 LAYER PATCH",SUP-8155.2002S,CDM,V2790,HCPCS,0278,RC,,,both,,,8970.00,2691,"BLUE CROSS [10001]","Blue Cross HMO",,3516.24,39.2,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS",RX-120089,CDM,,,0250,RC,50289-3250-01,NDC,both,1,UN,12.54,3.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X11MM LUMINARY CC 30D BICONVEX",SUP-6911,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3941.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 67.5MM KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-183110,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2567.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2519.72,18415.85,"percent of total billed charges",
"GRAFT ENDOVASCULAR 61MM 10MM ZENITH ILIAC BRANCH 41MM",SUP-G60342,CDM,C1874,HCPCS,0278,RC,,,both,,,68399.94,20519.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7954.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7954.91,58139.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST OP BRA 38D BLACK",SUP-B01G-38D-B,CDM,S27000186,LOCAL,0270,RC,,,both,,,178.18,53.45,"UHC [10700]","United Healthcare",,112.79,63.3,,,,,0,20.72,151.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.290 CLAREON",SUP-SY60WF.290,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 150MM 130CM 5MM VASCULAR METAL SUPERFICIAL",SUP-H74939293051530,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 36MM 22MM DHS/DCS STAINLESS STEEL CONDYLE",SUP-280.990S,CDM,C1713,HCPCS,0278,RC,,,both,,,650.67,195.2,"MULTIPLAN [10600]",Multiplan,,553.07,85,,,,,0,75.67,553.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8.5MM 12/14 OFFSET TAPER 40MM HIP M",SUP-136507000,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"BLUE CROSS [10001]","Blue Cross HMO",,4342.56,39.2,,5311.50,4717.44,5388.59,31,1288.37,9416.26,"percent of total billed charges",
"SPECLM 8IN 1 3/8IN FANSLER SURGICAL REMOVABLE OBTR",SUP-50-9610,CDM,S27200284,LOCAL,0272,RC,,,both,,,1308.56,392.57,"PHCS [10601]",PHCS,,915.99,70,,,,,0,152.19,1112.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 37CM 11MM MICRUSFRAME S 18 MICROCOIL",SUP-MFR181137,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7439.04,40,,,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION ENDOBUTTON 12MM 4MM ARTHROSCOPIC STERILE",SUP-013186,CDM,C1713,HCPCS,0278,RC,,,both,,,1271.70,381.51,"KAISER [10500]",Kaiser,,852.04,67,,,,,0,147.9,1080.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FULL THICK CALIBRATE DEPTH MARK CANNULATED",SUP-AR-1218-95,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AERO 30MM 62CM 14MM 16FR GEOMETRIC TRACHEOBRONCHIAL",SUP-90129-214,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"KAISER [10500]",Kaiser,,11557.5,67,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grft T/a/L <=100scm 1st 25 Sq Cm",PX-510000050,CDM,15271,CPT,0761,RC,,,both,,,1638.76,491.63,"CIGNA [10200]",Cigna,,1638.76,,"Per diem ($2,606).",495.25,495.25,495.25,"1 through 10",190.59,1638.76,"per diem",
"TRIAL SURGICAL 32MM LFIT C-TAPER -5MM HIP COCR HEAD",SUP-06-3299,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,363.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14.8IN 24FR AORTA 3/8IN CURVE AUTO DILATE TIP",SUP-EZC24TA,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,330.48,68,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE 18MM 5MM EMBOLIZATION",SUP-PED2-500-18,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"AETNA [10100]","Aetna HMO/PPO",,64234.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 50MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0250,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"FIRST HEALTH [10303]","First Health",,758.16,80,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION SORBITOL MANNITOL FLEXIBLE CNTNR 3L LATEX",SUP-07981-08,CDM,S27200284,LOCAL,0272,RC,,,both,,,112.93,33.88,"FIRST HEALTH [10303]","First Health",,90.34,80,,,,,0,13.13,95.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 6MM CADIERE DA VINCI SP",SUP-430009,CDM,S27000186,LOCAL,0270,RC,,,both,,,2063.40,619.02,"CIGNA [10200]",Cigna,,1403.11,68,,,,,0,239.97,1753.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 40MM 135CM 8MM VASCULAR OTW SELF EXPAND",SUP-1012536-40,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"AMERIGROUP MEDICAID [20100]",Amerigroup,,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SKATER 40CM 8FR PIGTAIL CURVE DRNG BILIARY LOCK ACCEPTS",SUP-755308040,CDM,C1729,HCPCS,0272,RC,,,both,,,651.24,195.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,77.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.74,553.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ICD-VR DVMB1D4 EVERA MRI XT DF4 US",SUP-DVMB1D4,CDM,C1721,HCPCS,0278,RC,,,both,,,39000.00,11700,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4621.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 85MM 5.5MM REVERE PEDICLE TITANIUM CURVED",SUP-124.685,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"MULTIPLAN [10600]",Multiplan,,3748.5,85,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 60MM 4FR 6MM .018IN BALLOON",SUP-PCP060060130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC",465,MS-DRG,,,,,,,inpatient,,,87286.29,26185.89,"UHC [10700]","United Healthcare",,,,"Fee schedule rate ($0). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,,,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SHAVER 4MM 8 FLUTE HIP LENGTH ROUND RETRACTABLE",SUP-AR-6400RRBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR",276,MS-DRG,,,,,,,inpatient,,,217382.44,65214.73,"CIGNA [10200]",Cigna,,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 55.9%. Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED 100CM 6CM 9FR 30MM BALLOON DILATATION RADIOPAQUE",SUP-611560,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TROCAR ENDOSCOPIC DIA12MM L100MM NON BLADED CANNULA STABILIT",SUP-CB12LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHILON 10-0 BV100-4 5IN MONOFILAMENT BLACK",SUP-2830G,CDM,S27200284,LOCAL,0272,RC,,,both,,,260.26,78.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM DYONICS 25 FLUID MANAGEMENT SUCTION INFLOW OUTFLOW",SUP-7211005,CDM,S27000186,LOCAL,0270,RC,,,both,,,451.98,135.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG WOUND 6X6IN AQUACEL EXTRA HYDROFIBER ABSORBENT NONWOVEN",SUP-420673,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.41,18.12,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MASK NEONATE RESUSCITATION SMALL DISPOSABLE",SUP-RD804-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.77,15.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.02,44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 80CM 6MM FLEX DISTAFLO SMALL 2 BRANCH",SUP-DFM8006SC,CDM,C1768,HCPCS,0278,RC,,,both,,,9401.24,2820.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1114.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1093.36,7991.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 65CM 4FR KUMPE CURVE LOW PROFILE",SUP-G51314,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"UHC [10700]","United Healthcare",,126.66,63.3,,,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETHRAL LUBRI-SIL IC 14FR FOLEY 2 WAY SILICONE 5ML",SUP-1758SI14,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.35,24.4,"FIRST HEALTH [10303]","First Health",,65.08,80,,,,,0,9.46,69.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Erythropoietin",PX-301000180,CDM,82668,CPT,0301,RC,,,both,,,313.40,94.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16.91,,,,,,,0.01,266.39,"fee schedule",
"DRILL 6.0MM X 70MM",SUP-DRLL-60070,CDM,S27000186,LOCAL,0270,RC,,,both,,,3781.20,1134.36,"PHCS [10601]",PHCS,,2646.84,70,,,,,0,439.75,3214.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 20CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061802300,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"MULTIPLAN [10600]",Multiplan,,766.85,85,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 23MM 18.5-21.5MM EXCLUDER",SUP-PLC231200,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3256.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 C 38MM COCR HIP 2 MOBILITY",SUP-110024461,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"UHC [10700]","United Healthcare",,8199.05,63.3,,8601.07,8395.67,8601.07,"1 through 10",1506.4,11009.78,"percent of total billed charges",
"SCR BONE 5MM 55MM OPTILINK SELF TAP VARIABLE ANGLE STARDRIVE",SUP-42.231.255,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"PHCS [10601]",PHCS,,946.78,70,,,,,0,157.3,1149.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 1.5MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES0156CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X5MM CORNERSTONE PSR PEEK LUMBAR",SUP-6277541,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA [10200]","Cigna Local Plus",,3572.95,53.5,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 23MM 18.6MM MASTERS PYROLYTIC CARBON PTFE",SUP-23MTJ-503,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"BLUE CROSS [10001]","Blue Cross HMO",,11414.74,39.2,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Head/Brain W/WO Cntrst",PX-351000004,CDM,70470,CPT,0351,RC,,,both,,,3265.19,979.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,405,,"Per diem ($405). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,379.74,2775.41,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM TRIATHLON 2 RIGHT MEDIAL LEFT LATERAL TOTAL",SUP-5545-A-202,CDM,C1776,HCPCS,0278,RC,,,both,,,4327.60,1298.28,"MULTIPLAN [10600]",Multiplan,,3678.46,85,,,,,0,503.3,3678.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 36-39MM TITANIUM 5.5MM ROD LOW PROFILE LEGACY",SUP-8115536,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]",Cigna,,2422.5,68,,1831.33,1831.33,1831.33,16,414.32,3028.13,"percent of total billed charges",
"KIT DRSG BLACK 26X15CM GRANUFOAM VAC THK3.3CM LARGE STD",SUP-M8275053/10,CDM,S27200284,LOCAL,0272,RC,,,both,,,405.92,121.78,"NOVANET [10819]",Novanet,,304.44,75,,,,,0,47.21,345.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 28MM 143CM 3.5MM CORONARY EVEROLIMUS ELUTING",SUP-1009542-28,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1115.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY 20CM 18GA BARD MARQUEE CORE ENHANCE TROCAR TIP",SUP-MQ1820,CDM,S27200284,LOCAL,0272,RC,,,both,,,514.35,154.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,236.09,45.9,,,,,0,59.82,437.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Nerve Root Block",PX-E27200174,CDM,E27200174,LOCAL,0272,RC,,,both,,,85.80,25.74,"CIGNA [10200]","Cigna Local Plus",,45.9,53.5,,,,,0,9.98,72.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 80MM 125CM 5MM 6FR BILIARY NITINOL",SUP-G36022,CDM,C1876,HCPCS,0278,RC,,,both,,,1233.75,370.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,353.1,28.62,,,,,0,143.49,1048.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 640CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRM-640,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"AETNA [10100]","Aetna HMO/PPO",,3155.36,79.5,,,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 158MM STAINLESS STEEL 3.5MM SCR 6 HOLE LCP BONE LEFT",SUP-02.104.026,CDM,C1713,HCPCS,0278,RC,,,both,,,8557.10,2567.13,"FIRST HEALTH [10303]","First Health",,6845.68,80,,,,,0,995.19,7273.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPICILLIN SODIUM 2 G/16ML IJ (WET SOLR VIAL)",RX-415472,CDM,J0290,HCPCS,0636,RC,55150-0114-20,NDC,both,1,UN,120.16,36.05,"BLUE CROSS [10001]","Blue Cross PPO",,2.56,,,,,,,2.56,102.14,"fee schedule",
"STENT ASCERTA 24CM 7FR URETERAL",SUP-M0061456190,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"CIGNA [10200]","Cigna Local Plus",,334.5,,,,,,,72.72,531.45,"percent of total billed charges",
"STENT ORSIRO MISSION 9MM 140CM 2.25MM CORONARY STERILE LATEX",SUP-453925,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP FRCP 25 PLUS GRIESHABER REVOLUTION ASYMMETRICAL GRASPING",SUP-705.45P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP MULTIHOLE PRIMARY MODULAR STERILE",SUP-620206220,CDM,C1776,HCPCS,0278,RC,,,both,,,17500.14,5250.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7192.56,41.1,,6417.48,6417.48,6417.48,"1 through 10",2035.27,14875.12,"percent of total billed charges",
"HC Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts",PX-306000255,CDM,87626,CPT,0306,RC,,,both,,,411.00,123.3,"CIGNA [10200]","Cigna Open Access",,233.86,56.9,,,,,0,0.01,349.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 2MM 120CM HANDLE BRONCHOSCOPIC STERILE",SUP-129,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.00,23.1,"MULTIPLAN [10600]",Multiplan,,65.45,85,,,,,0,8.96,65.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50MMX8MM CLYDESDALE 0D PEEK-OPTIMA RADIOPAQUE",SUP-2969850,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) DISPOSABLE COLLECTION CANISTER",SUP-01-90-3696,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 5X4CM TUTOPLAST FASCIA LATA",SUP-68014,CDM,C1762,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"AETNA [10100]","Aetna HMO/PPO",,4662.68,79.5,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER BREAST LARGE",SUP-L/L-BBIND,CDM,S27000186,LOCAL,0270,RC,,,both,,,165.30,49.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,67.94,41.1,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENDINI ROD BENDER",SUP-2040001,CDM,S27200284,LOCAL,0272,RC,,,both,,,11289.16,3386.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4639.84,41.1,,,,,0,1312.93,9595.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TLIF CRESCENT 9MM",SUP-293009,CDM,S27800098,LOCAL,0278,RC,,,both,,,24290.28,7287.08,"CIGNA [10200]","Cigna Open Access",,8137.24,33.5,,,,,0,2824.96,20646.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE TY 2.5",SUP-PRT-TY-025,CDM,C1713,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"NOVANET [10819]",Novanet,,4554,75,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 4.5MM 75MM EVOS MINI T8 LONG BONE SMALL BONE",SUP-72402775,CDM,C1713,HCPCS,0278,RC,,,both,,,456.52,136.96,"NOVANET [10819]",Novanet,,342.39,75,,,,,0,53.09,388.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW .23IN MICROCHOICE .8IN THK.022IN OSCILLATING",SUP-KM-3000,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"CIGNA [10200]","Cigna Local Plus",,33.05,53.5,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 40MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR40,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Local Plus",,4129.65,31.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE VASCULAR ANGLED 150CM 3CM .018IN HYDROPHILIC",SUP-GR1805,CDM,C1769,HCPCS,0272,RC,,,both,,,461.70,138.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,313.96,68,,,,,0,53.7,392.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM UCSS TITANIUM ALLOY CORTICAL CANNULATED",SUP-873-040,CDM,C1713,HCPCS,0278,RC,,,both,,,3315.00,994.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,385.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",385.53,2817.75,"percent of total billed charges",
"INTRODUCER KIT FOR IMPELLA 2.5",SUP-0052-0007,CDM,S27800098,LOCAL,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross PPO",,1893.36,39.2,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 26MM 7MM EXPLOR ELBOW MODULAR",SUP-11-210062,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"BLUE CROSS [10001]","Blue Cross HMO",,5571.89,39.2,,5311.50,4717.44,5388.59,31,1653.09,12081.9,"percent of total billed charges",
"ANCHOR SUT 6.5MM 2 TWINFIX ULTRABRAID COBRAIDED PEEK-OPTIMA",SUP-72202606,CDM,C1713,HCPCS,0278,RC,,,both,,,1724.63,517.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1172.75,68,,,,,0,200.57,1465.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 120MM 3MM BALLOON",SUP-U3575312,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Paravrt Jt L/S >= 3 Lvl",PX-510000142,CDM,64495,CPT,0761,RC,,,both,,,3656.00,1096.8,"CIGNA [10200]","Cigna Local Plus",,2051,,"Per diem ($2,051).",,,,0,425.19,3107.6,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cta Abd&Pelvis WO/W Cntrst",PX-351000016,CDM,74174,CPT,0352,RC,,,both,,,5824.71,1747.41,"UHC [10700]","United Healthcare",,916.05,,,,,,,405,4951,"fee schedule",
"SUT VICRYL 2-0 CT-1 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J345H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 98MM 34MM 8MM PERFORM 2+ LONG LENGTH SHOULDER",SUP-DWX2PL,CDM,C1776,HCPCS,0278,RC,,,both,,,30421.44,9126.43,"CIGNA [10200]",Cigna,,12168.58,40,,5873.17,5873.17,5873.17,"1 through 10",3538.01,25858.22,"percent of total billed charges",
"TRAY CATH 16CM 13.5FR .038IN POLYURETHANE MAHURKAR QPLUS 2",SUP-8888135165,CDM,C1752,HCPCS,0272,RC,,,both,,,860.01,258,"KAISER [10500]",Kaiser,,576.21,67,,,,,0,100.02,731.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ 110CM 7FR PULMONARY ARTERY ATRIUM VENTRICLE 4",SUP-D200F7,CDM,C1751,HCPCS,0272,RC,,,both,,,2166.90,650.07,"UHC [10700]","United Healthcare",,1371.65,63.3,,,,,0,252.01,1841.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 4FR 21GA MERIT S-MAK .018IN 40CM NITINOL",SUP-S-MAK401N,CDM,C1894,HCPCS,0272,RC,,,both,,,226.20,67.86,"AETNA [10100]","Aetna HMO/PPO",,179.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA 30CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006192155180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"CIGNA [10200]","Cigna Local Plus",,850.58,,,,,,,184.9,1351.39,"percent of total billed charges",
"INSRT TIBIAL 1 22MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-122,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1594.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1565.22,11439.68,"percent of total billed charges",
"GRAFT BONE MATRIGRAFT ILIAC CREST H12 MM ALLOGRAFT WEDGE",SUP-PICW2,CDM,S27800098,LOCAL,0278,RC,,,both,,,4549.86,1364.96,"BLUE CROSS [10001]","Blue Cross PPO",,1783.55,39.2,,,,,0,529.15,3867.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 100CM 5FR BENTSON 2",SUP-G08809,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CIGNA [10200]","Cigna Open Access",,135.13,56.9,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE COR-KNOT QUICK LOAD SUTURING TITANIUM 6 POUCH STERILE",SUP-030874,CDM,S27200284,LOCAL,0272,RC,,,both,,,2137.50,641.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,253.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 44MM UNIVERS REVERS GLENOID PERIPHERAL LOCK",SUP-AR-9563-44,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"CIGNA [10200]","Cigna Local Plus",,319.6,53.5,,3978.14,359.25,3978.14,24,69.48,507.77,"percent of total billed charges",
"SCR BONE 2.4MM 16MM TITANIUM T8 LOCK VARIABLE ANGLE TUBE",SUP-04.210.116TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1056.89,317.07,"NOVANET [10819]",Novanet,,792.67,75,,,,,0,122.92,898.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 34MM 140CM 2.25MM 2.1-2.7FR CORONARY",SUP-RONYX22534UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3543.75,1063.12,"NOVANET [10819]",Novanet,,2657.81,75,,,,,0,412.14,3012.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS ELECTROSURGICAL 36CM 5MM HARMONIC ACE+ TITANIUM",SUP-HAR36,CDM,S27200284,LOCAL,0272,RC,,,both,,,2369.00,710.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,275.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,275.51,2013.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED DUAL MOBILITY HIP SYSTEM + CER HD + VE + O",SUP-98000500332,CDM,C1776,HCPCS,0278,RC,,,both,,,32760.00,9828,"CIGNA [10200]","Cigna Open Access",,10974.6,33.5,,5302.19,4377.88,6578.61,27,3809.99,27846,"percent of total billed charges",
"SPONGE ABSORBABLE 12.5X8CM PORCINE GELATIN SURGIFOAM THK2MM",SUP-1975,CDM,S27200284,LOCAL,0272,RC,,,both,,,318.57,95.57,"PHCS [10601]",PHCS,,223,70,,,,,0,37.05,270.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 10MM DELTAFILL 18",SUP-DLF181040,CDM,S27800098,LOCAL,0278,RC,,,both,,,16974.00,5092.2,"MULTIPLAN [10600]",Multiplan,,14427.9,85,,,,,0,1974.08,14427.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 18MM 4MM NAIL-EX FULL THREAD HUMERAL TIBIAL",SUP-04.005.408,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"MULTIPLAN [10600]",Multiplan,,983.18,85,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 30CM 14FR TUNGSTEN SILICONE 2CM MIC-KEY",SUP-0270-14-2.0-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,3027.60,908.28,"CIGNA [10200]","Cigna Open Access",,1722.7,56.9,,,,,0,352.11,2573.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM ROUND CARBIDE STERILE LATEX FREE",SUP-5820-110-030C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1910.03,573.01,"NOVANET [10819]",Novanet,,1432.52,75,,,,,0,222.14,1623.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 18CM 3CM 4.8FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175199050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"KAISER [10500]",Kaiser,,717.4,67,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SURGICAL LARGE CIRCLE 3.2IN SPRING OPEN BIORESORBABLE",SUP-5950009,CDM,C1781,HCPCS,0278,RC,,,both,,,2352.00,705.6,"NOVANET [10819]",Novanet,,1764,75,,,,,0,273.54,1999.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40022W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"CIGNA [10200]",Cigna,,3698.52,68,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL ALTIVATE NEUTRAL SHOULDER STERILE REVERSE",SUP-508-07-000,CDM,C1776,HCPCS,0278,RC,,,both,,,15316.76,4595.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1781.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1781.34,13019.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 13MM CEMENTLESS SECUR-FIT PLUS HYDROXYAPATITE 9",SUP-6054-0913S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"MULTIPLAN [10600]",Multiplan,,13740.62,85,,,,,0,1880.04,13740.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Not Feeynolm 2.6-7.5cm",PX-450000020,CDM,12002,CPT,0361,RC,,,both,,,1025.43,307.63,"NOVANET [10819]",Novanet,,769.07,75,,,,,0,119.26,1025.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 90MM 25MM 20MM AFX2 2 BRANCH 30MM AAA STERILE",SUP-BEA25-90/I20-30,CDM,C1874,HCPCS,0278,RC,,,both,,,84559.50,25367.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10020.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9834.27,71875.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 44MM LCP STAINLESS STEEL ELBOW SELF TAPPING",SUP-02.211.044,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"CIGNA [10200]","Cigna Local Plus",,480.5,53.5,,3978.14,359.25,3978.14,24,104.45,763.41,"percent of total billed charges",
"SCR BONE 5MM 4.4MM 65MM LCP STAINLESS STEEL 4MM PARTIAL",SUP-02.205.265,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1057.98,68,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ugt1a1 Gene",PX-309000077,CDM,81350,CPT,0310,RC,,,both,,,322.40,96.72,"AETNA [10100]","Aetna HMO/PPO",,256.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,322.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X13MM M-CLASS HALL THK1.19MM STAINLESS STEEL",SUP-T130-119-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,553.72,166.12,"CIGNA [10200]",Cigna,,376.53,68,,,,,0,64.4,470.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) BANDIT GUIDEWIRE (200 CM)",SUP-7444,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,,41.1,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 5FR 18GA 50CM 11CM GRAY HUB DIL TUBING GWIRE",SUP-PRO-5F-11-038-18G,CDM,C1894,HCPCS,0272,RC,,,both,,,102.23,30.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTTER SURGICAL CLOWARD 5",SUP-76-5120,CDM,S27200284,LOCAL,0272,RC,,,both,,,1307.42,392.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EVERCROSS 135CM 60MM 10MM .035IN BALLOON DILATATION",SUP-AB35W10060135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Mask Cpap",PX-E27000134,CDM,E27000134,LOCAL,0270,RC,,,both,,,252.09,75.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) TRISOL DELIVERY SYSTEM KIT",SUP-DMS-14630,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL +11.5 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150115,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,158.36,45.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 120CM 4CM 6MM BALLOON DILATATION",SUP-DR12064,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,160.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC LARGE 17X9.25IN SHOULDER FRONT REAR STRAP",SUP-VP20105-040,CDM,L3670,HCPCS,0274,RC,,,both,,,59.94,17.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,59.94,,,,,,,6.97,59.94,"fee schedule",
"WAND ELECTROSURGICAL 3MM ARTHROWAND 45D BEVEL KNEE SHOULDER",SUP-AC2430-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1255.50,376.65,"AETNA [10100]","Aetna HMO/PPO",,998.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 14MM SYNERGY POROUS PLUS TITANIUM STD",SUP-71309014,CDM,C1776,HCPCS,0278,RC,,,both,,,32476.50,9742.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12990.6,40,,,,,0,3777.02,27605.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 14MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620214,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Open Access",,6403.47,56.9,,5302.19,4377.88,6578.61,27,1308.83,9565.82,"percent of total billed charges",
"HEAD HUMERAL 18MM 48MM SHOULDER AEQUALIS ASCEND FLEX COCR",SUP-DWF048,CDM,C1776,HCPCS,0278,RC,,,both,,,9475.00,2842.5,"NOVANET [10819]",Novanet,,7106.25,75,,,,,0,1101.94,8053.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL PASTE",RX-41818,CDM,,,0250,RC,53329-0156-44,NDC,both,113,GR,22.75,6.82,"CIGNA [10200]",Cigna,,15.47,68,,,,,0,2.65,19.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8.5MM 12/14 TAPER 28MM HIP CEMENTLESS BIOLOX",SUP-136528330,CDM,C1776,HCPCS,0278,RC,,,both,,,12268.20,3680.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5042.23,41.1,,6417.48,6417.48,6417.48,"1 through 10",1426.79,10427.97,"percent of total billed charges",
"CATH CRE RX 13.5MM 15MM 12MM BALLOON DILATATION BILIARY",SUP-M00558940,CDM,C1726,HCPCS,0272,RC,,,both,,,2085.75,625.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1418.31,68,,,,,0,242.57,1772.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 7CM 10FR CENTER BEND THIN WALL",SUP-M00534690,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,129.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM CREO SPINE PREASSEMBLE THREAD",SUP-5119.1552,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",441.36,3225.75,"percent of total billed charges",
"SCR BONE 3.5MM 10MM TITANIUM STERNAL SELF DRILLING",SUP-04.501.110.01,CDM,C1713,HCPCS,0278,RC,,,both,,,854.96,256.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,392.43,45.9,,,,,0,99.43,726.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT BONDEK 4 ABSORBABLE",SUP-B5853N,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.15,18.94,"CIGNA [10200]","Cigna Open Access",,35.93,56.9,,,,,0,7.34,53.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 12X4CM GENTRIX PORCINE URINARY BLADDER",SUP-PSM0412,CDM,C1781,HCPCS,0278,RC,,,both,,,3894.91,1168.47,"CIGNA [10200]","Cigna Open Access",,2216.2,56.9,,11235.02,819.42,11235.02,"1 through 10",452.98,3310.67,"percent of total billed charges",
"CATH SHEATHLESS EAUCATH 100CM 7.5FR .081IN AL1 CURVE GUIDING",SUP-G7AL10-0-L100,CDM,C1887,HCPCS,0272,RC,,,both,,,1053.00,315.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,122.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBOHAWK MEC 110CM 104MM 3.5-7MM 6CM ATHERECTOMY",SUP-TH-LS-M,CDM,C1714,HCPCS,0272,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 40MM 120CM 6MM 8FR STRAIGHT VASCULAR",SUP-AVSL06040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]",Cigna,,7308,40,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 125CM 5FR VTK CURVE ANGIOGRAPHIC",SUP-G47042,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"KAISER [10500]",Kaiser,,141.05,67,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 100CM 5FR STRAIGHT ANGIOGRAPHIC POLYETHYLENE PERIPHERAL",SUP-G00159,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.19,73.86,"FIRST HEALTH [10303]","First Health",,196.95,80,,,,,0,28.63,209.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ 110CM 7FR S CURVE ARTERIAL LINE 4 LUMEN",SUP-497536,CDM,C1751,HCPCS,0272,RC,,,both,,,631.80,189.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,73.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 125MM 12MM PRIMARY CEMENT SATIN FINISH VERSYS",SUP-785001200,CDM,C1776,HCPCS,0278,RC,,,both,,,18721.08,5616.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7694.36,41.1,,6417.48,6417.48,6417.48,"1 through 10",2177.26,15912.92,"percent of total billed charges",
"SCR BONE 10.5-9MM 70MM CREO SPINE 2 OUTER DIAMETER",SUP-5119.2172,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 8MM 145CM 3.5MM BALLOON DILATATION",SUP-1400350-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +24.5 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z900200245,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,120.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 60MM 80CM 6MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM06060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 90ML .1-4MM CANCELLOUS ALLOGRAFT FREEZE",SUP-400090,CDM,C1713,HCPCS,0278,RC,,,both,,,10246.50,3073.95,"KAISER [10500]",Kaiser,,6865.16,67,,,,,0,1191.67,8709.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERLINK FIBERWIRE 2 26IN BRAID TIES MULTISTRAND CLOSE",SUP-AR-7235,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"KAISER [10500]",Kaiser,,313.41,67,,,,,0,54.4,397.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE SMARTSET GENTAMICIN MEDIUM VISCOSITY 40GM",SUP-545050501,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"NOVANET [10819]",Novanet,,1215,75,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE MARKER 2 X 3 BIOZORB",SUP-F0203,CDM,A4648,HCPCS,0278,RC,,,both,,,8383.50,2515.05,"PHCS [10601]",PHCS,,5868.45,70,,,,,0,975,7125.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POWDER ABSORBABLE SURGIFOAM GELATIN HEMOSTATIC AGENT POWDER",SUP-1978,CDM,S27200284,LOCAL,0272,RC,,,both,,,1225.85,367.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,142.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,142.57,1041.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT GLENOID STD SHORT STEM INSRT REGENEREX",SUP-98B00900111,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"MULTIPLAN [10600]",Multiplan,,25436.25,85,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT MASTERGRAFT PUTTY KIT 6CC STERILE LATEX FREE",SUP-7600706,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 38MM LOCK BOLT",SUP-172-945/38,CDM,C1713,HCPCS,0278,RC,,,both,,,1828.05,548.41,"CIGNA [10200]","Cigna Local Plus",,978.01,53.5,,3978.14,359.25,3978.14,24,212.6,1553.84,"percent of total billed charges",
"FREEFIX PROXIMAL HUMERUS PLATE 2 SLOT RIGHT TI",SUP-PHPF-2R,CDM,C1713,HCPCS,0278,RC,,,both,,,16284.00,4885.2,"CIGNA [10200]","Cigna Local Plus",,5129.46,31.5,,3978.14,359.25,3978.14,24,1893.83,13841.4,"percent of total billed charges",
"CATHETER 1628-019M MERIT MED HK",SUP-1628-019M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1044.90,313.47,"AETNA [10100]","Aetna HMO/PPO",,830.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.52,888.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 60MM 6MM PRESS FIT REMOVABLE TRUNION SUT HOLE",SUP-AR-9100-06S,CDM,C1776,HCPCS,0278,RC,,,both,,,10713.60,3214.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1245.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1245.99,9106.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 40MM 75CM 10MM 8.5FR .035IN 48MM BILIARY",SUP-M00574730,CDM,C1874,HCPCS,0278,RC,,,both,,,19530.00,5859,"BLUE CROSS [10001]","Blue Cross PPO",,7655.76,39.2,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 13 STD OFFSET HIP",SUP-71935573,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"BLUE CROSS [10001]","Blue Cross HMO",,14321.21,39.2,,5311.50,4717.44,5388.59,31,4248.87,31053.65,"percent of total billed charges",
"CMPNT FEMORAL 6 NARROW KNEE RIGHT CRUCIATE RETAIN CEMENTLESS",SUP-150401226,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"MULTIPLAN [10600]",Multiplan,,24458.96,85,,,,,0,3346.56,24458.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 30IN 2 PORT 1 BLADDER PUMP LINE CNCT ATS STERILE",SUP-60707010500,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.05,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 42MM AEQUALIS SHOULDER COCR REVERSE TILT 29MM",SUP-DWD194,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1444.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1418.05,10364.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 6CM ACUSEAL PTFE 3 LAYER",SUP-ECH060040A,CDM,C1768,HCPCS,0278,RC,,,both,,,9266.70,2780.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1077.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1077.72,7876.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN SX ENDO HEPARIN 35 RO 11MMX10CM 10FR 120CMCATH",SUP-VBHR111002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"KAISER [10500]",Kaiser,,14250.1,67,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 12/14 TAPER 32MM HIP OXINIUM ECHELON",SUP-71343212,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"PHCS [10601]",PHCS,,10874.75,70,,,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 350-420ML STYLE 2000 SMOOTH ROUND SALINE",SUP-3502350,CDM,C1789,HCPCS,0278,RC,,,both,,,2350.00,705,"CIGNA [10200]","Cigna Local Plus",,1257.25,,,,,,,273.31,1997.5,"percent of total billed charges",
"CATH OPTITORQUE 110CM 5FR JACKY RADIAL 3.5 CURVE",SUP-40-5023,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 6FR .071IN AMPLATZ LEFT 3 CURVE GUIDING NYLON",SUP-LA6AL30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE MITRAL 25-33MM ON-X CONFORM-X CUFF",SUP-ONXMCE-25/33,CDM,S27800098,LOCAL,0278,RC,,,both,,,21780.00,6534,"KAISER [10500]",Kaiser,,14592.6,67,,,,,0,2533.01,18513,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP GILLINOV-COSGROVE STD 45MM CLSR NITINOL",SUP-ACH145,CDM,S27800098,LOCAL,0278,RC,,,both,,,8245.50,2473.65,"CIGNA [10200]","Cigna Local Plus",,4411.34,53.5,,,,,0,958.95,7008.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 6MM FLIXENE SLIDER GRADUATED WALL",SUP-25125,CDM,C1768,HCPCS,0278,RC,,,both,,,7174.62,2152.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,850.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,834.41,6098.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 CORKSCREW FIBERWIRE 2 FULL THREAD",SUP-AR-1927BCF-45,CDM,C1713,HCPCS,0278,RC,,,both,,,2559.38,767.81,"NOVANET [10819]",Novanet,,1919.54,75,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 30MM TSRH OSTEOGRIP THINLINE TITANIUM SPINE",SUP-83585309,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1181.47,45.9,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 110MM 6MM XIA TITANIUM",SUP-48238110,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 8FR 20CM HYDROPHILIC RADIOPAQUE STERILE",SUP-G10289,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"CIGNA [10200]","Cigna Open Access",,38.07,56.9,,,,,0,7.78,56.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 380MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.059S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"BLUE CROSS [10001]","Blue Cross PPO",,4867.99,39.2,,957.42,570.23,957.42,28,1444.25,10555.59,"percent of total billed charges",
"STEM HUMERAL ARTHREX UNIVERS REVERS UNIVERS APEX 11 SHOULDER",SUP-AR-9501-11S,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7178.76,68,,,,,0,1227.78,8973.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 3.5MM YUKON CONTOUR OCCIPITOCERVICOTHORACIC",SUP-7601-63555,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCUFLEX STENT 6F X 20CM W/O WIRE",SUP-M0061453590,CDM,C2617,HCPCS,0272,RC,,,both,,,633.10,189.93,"KAISER [10500]",Kaiser,,424.18,67,,,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL TWIST 50MM 1MM LORENZ 5MM STOP MANDIBLE",SUP-01-7142,CDM,S27000186,LOCAL,0270,RC,,,both,,,680.40,204.12,"MULTIPLAN [10600]",Multiplan,,578.34,85,,,,,0,79.13,578.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 6MMX19MM 7FR 80CMCATH HEPARIN",SUP-BXB061901A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION CODA PUSH STERILE",SUP-202250100S,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOMYELITIS WITH MCC",539,MS-DRG,,,,,,,inpatient,,,58170.26,17451.08,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,24878.64,,"Case rate ($12,218.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,345.40, add-ons for qualifying new technology services are included. If operating cost exceeds $44,385.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,239.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $11,360.40. The transfer operating threshold is the transfer adjustment factor * $11,345.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $857.77. The transfer capital threshold is the transfer adjustment factor * $857.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,49122.35,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +8.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200085,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"KAISER [10500]",Kaiser,,683.8,67,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|DISCARDED DRUG NOT ADMINISTE",RX-124102,CDM,J9217,HCPCS,0636,RC,00074-3642-03,NDC,both,1,UN,9735.66,2920.7,"AETNA [10100]","Aetna HMO/PPO",JW,7739.85,79.5,,,,,0,200.62,8275.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL SOFT/FIBRA 6MM .25 FORCE SPRING ATRAUMATIC",SUP-G-6054,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"KAISER [10500]",Kaiser,,151.55,67,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 5.5MM VIPER 2 LORDOTIC TITANIUM MIS",SUP-186788120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE ALLODERM ALLOGRAFT PERFORATE",SUP-1518320P,CDM,Q4116,HCPCS,0636,RC,,,both,,,60228.00,18068.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,39148.2,65,,,,,0,247.92,51193.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 49MM ACU-LOC 2 BONE RIGHT PROXIMAL DISTAL VOLAR",SUP-70-0351,CDM,C1713,HCPCS,0278,RC,,,both,,,6651.60,1995.48,"CIGNA [10200]","Cigna Open Access",,3784.76,56.9,,1144.80,304.56,2275.09,66,773.58,5653.86,"percent of total billed charges",
"CMPNT FEMORAL 67.5MM KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-183110,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"AETNA [10100]","Aetna HMO/PPO",,17224.23,79.5,,10981.53,8986.79,12413.38,12,2519.72,18415.85,"percent of total billed charges",
"CMPNT FEMORAL LARGE KNEE LEFT CEMENT LCS COMPLETE COCR",SUP-129402060,CDM,C1776,HCPCS,0278,RC,,,both,,,20635.65,6190.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2445.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2399.93,17540.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 4.8FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175252050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,126.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOCARNITINE 20 MG/ML INTRAVENOUS SOLUTION (NICU)",RX-408341,CDM,J1955,HCPCS,0636,RC,08888-8887-98,NDC,both,1,ML,66.63,19.99,"BLUE CROSS [10001]","Blue Cross HMO",,27.52,,,,,,,8.03,62.56,"fee schedule",
"BASEPLT GLENOID 29MM AEQUALIS PERFORM 35D SHOULDER HALF",SUP-DWJ514,CDM,C1776,HCPCS,0278,RC,,,both,,,11340.00,3402,"AETNA [10100]","Aetna HMO/PPO",,9015.3,79.5,,10981.53,8986.79,12413.38,12,1318.84,9639,"percent of total billed charges",
"DRILL TWIST 1.9MM SMALL",SUP-72203856,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.18,543.35,"NOVANET [10819]",Novanet,,1358.39,75,,,,,0,210.64,1539.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752530,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]","Cigna Local Plus",,482.67,,,,,,,104.92,766.85,"percent of total billed charges",
"STENT SUPERA 80MM 120CM 6.5MM 6FR VASCULAR NITINOL",SUP-S-65-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2616.58,28.62,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 200MM 1.6MM KIRSCHNER FULL THREAD FOOT VARIAX",SUP-45-80100,CDM,C1713,HCPCS,0278,RC,,,both,,,372.71,111.81,"CIGNA [10200]","Cigna Local Plus",,199.4,53.5,,3978.14,359.25,3978.14,24,43.35,316.8,"percent of total billed charges",
"RIVASTIGMINE 1.5 MG CAPSULE",RX-28278,CDM,,,0637,RC,00904-7107-61,NDC,both,1,UN,19.82,5.95,"MULTIPLAN [10600]",Multiplan,,16.85,85,,,,,0,2.31,16.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 3.5MM MAGILL CURVE NASAL ORAL CUFF",SUP-86443,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.13,18.94,"CIGNA [10200]","Cigna Open Access",,35.92,56.9,,,,,0,7.34,53.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL FLAT L HOOK 36CM CLEANCOAT COATED",SUP-E3774-36C,CDM,S27200284,LOCAL,0272,RC,,,both,,,251.00,75.3,"CIGNA [10200]","Cigna Open Access",,142.82,56.9,,,,,0,29.19,213.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +24.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.245,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM SENSAR INTRAOCULAR LENS, BICONVEX, 26.0 DIOPTER",SUP-AR40E00260,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,110.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL TOE JOINT 2.75MM HAMMERTUBE 10D PEEK CANNULATED KIT",SUP-P40-002-0275-SK,CDM,C1713,HCPCS,0278,RC,,,both,,,8607.75,2582.32,"CIGNA [10200]","Cigna Open Access",,4897.81,56.9,,1144.80,304.56,2275.09,66,1001.08,7316.59,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 22MM 140CM 2.75MM 2.1-2.7FR CORONARY",SUP-RONYX27522UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"BLUE CROSS [10001]","Blue Cross PPO",,1455.3,39.2,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 24FR 26FR CIAGLIA BLUE RHINO EZ PASS HYDROPHILIC J",SUP-G12115,CDM,C1894,HCPCS,0272,RC,,,both,,,2910.90,873.27,"NOVANET [10819]",Novanet,,2183.18,75,,,,,0,338.54,2474.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE VENTRICULAR ASSIST STD OUTFLOW GRAFT BEND RELIEF SEAL",SUP-103393,CDM,S27800098,LOCAL,0278,RC,,,both,,,30240.00,9072,"AETNA [10100]","Aetna HMO/PPO",,24040.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STBL XS VASCULAR 180CM 3CM .014IN STEERABLE SUPER SOFT",SUP-527914,CDM,C1769,HCPCS,0272,RC,,,both,,,613.25,183.97,"PHCS [10601]",PHCS,,429.28,70,,,,,0,71.32,521.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 9MM LEFT MEDIAL RIGHT LATERAL X3 PARTIAL KNEE",SUP-5630-G-309,CDM,C1776,HCPCS,0278,RC,,,both,,,5309.55,1592.86,"AETNA [10100]","Aetna HMO/PPO",,4221.09,79.5,,10981.53,8986.79,12413.38,12,617.5,4513.12,"percent of total billed charges",
"LEAD PACING 25CM ATRIAL VENTRICULAR BIPOLAR SCR IN ELECTRD",SUP-407625,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1024.72,45.9,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL UROLOGICAL AMS 800 OCCLUSIVE CUFF INHIBIZONE SILICONE",SUP-72404131,CDM,C1815,HCPCS,0278,RC,,,both,,,51282.00,15384.6,"MULTIPLAN [10600]",Multiplan,,43589.7,85,,,,,0,5964.1,43589.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 32MM BIOLOX",SUP-400-03-322,CDM,C1776,HCPCS,0278,RC,,,both,,,16953.92,5086.18,"BLUE CROSS [10001]","Blue Cross PPO",,6645.94,39.2,,3949.44,3949.44,3949.44,"1 through 10",1971.74,14410.83,"percent of total billed charges",
"PHASE III LEAD EXTENSION - 55 CM",SUP-SC-3138-55,CDM,C1883,HCPCS,0278,RC,,,both,,,3525.00,1057.5,"CIGNA [10200]","Cigna Local Plus",,1885.88,53.5,,,,,0,409.96,2996.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 4.75MM CD HORIZON SOLERA COCRMO CAP",SUP-641003060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"GORE  VIATORR TIPS ENDOPROSTHESIS WITH CONTROLLED EXPANSION,",SUP-PTB6106275,CDM,C1874,HCPCS,0278,RC,,,both,,,33364.80,10009.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3880.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3880.33,28360.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 65CM RVOT KIT MOND STAINLESS STEEL WIDE",SUP-4151/65,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,164.59,28.62,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.5MM 16MM FULL THREAD FOOT LOCKING SCR TIMAX F",SUP-FP16,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,743.58,68,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 7 LEVEL NEW LOCK ATLANTIS VISION BONE SPINAL",SUP-7200077,CDM,C1713,HCPCS,0278,RC,,,both,,,4620.00,1386,"BLUE CROSS [10001]","Blue Cross HMO",,1811.04,39.2,,957.42,156.86,7483.26,51,537.31,3927,"percent of total billed charges",
"MESH SURGICAL PROLENE 6X4IN HERNIA PATCH SOFT FLAT STERILE",SUP-0117010,CDM,C1781,HCPCS,0278,RC,,,both,,,460.08,138.02,"CIGNA [10200]","Cigna Open Access",,261.79,56.9,,11235.02,819.42,11235.02,"1 through 10",53.51,391.07,"percent of total billed charges",
"SCR BONE 3.5MM 24MM CHARLOTTE CLAW FOOT HEXAGONAL LOCKING",SUP-40133524,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +7.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200075,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CIGNA [10200]","Cigna Local Plus",,546.02,53.5,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP .5CC ALLOGRAFT PUTTY",SUP-14103501,CDM,C1713,HCPCS,0278,RC,,,both,,,2026.80,608.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,240.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",235.72,1722.78,"percent of total billed charges",
"SINGLE USE INSTRUMENTS - TIBIAL KIT (CR) - SIZE 4",SUP-5555-2324,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABIL 100MM 200CM 8MM ENDOPROSTHESIS METAL NO",SUP-VSWVN0810,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPLR ANASTOMOSIS 1.5MM GEM MICROVASCULAR STERILE DISPOSABLE",SUP-GEM2751,CDM,S27200284,LOCAL,0272,RC,,,both,,,2962.50,888.75,"CIGNA [10200]","Cigna Open Access",,1685.66,56.9,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABIL 100MM 200CM 8MM ENDOPROSTHESIS METAL NO",SUP-VSWVN0810,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WARMER GEL SCOPE",SUP-PS-500,CDM,S27000186,LOCAL,0270,RC,,,both,,,75.72,22.72,"UHC [10700]","United Healthcare",,47.93,63.3,,,,,0,8.81,64.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 53MM UNITRAX FEMORAL HIP MODULAR",SUP-6942-5-053,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2126.84,68,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II MULTIPASS 5-0 PS-2 18IN MONOFILAMENT UNDYED",SUP-Z495G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZONISAMIDE 25 MG CAPSULE",RX-36987,CDM,,,0637,RC,68001-0242-00,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 34MM TI",SUP-SPL-35340-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",155.43,1136.03,"percent of total billed charges",
"SPLINT ORTHOPEDIC UNIVERSAL 10.5IN WRIST LEFT ADJUSTABLE",SUP-VP30001-140,CDM,S27000186,LOCAL,0270,RC,,,both,,,92.74,27.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.79,78.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 27FR 1 STEM RESECTOSCOPE",SUP-M0068802061,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,237.06,45.9,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tubing Press Monitor Sep",PX-E27200272,CDM,E27200272,LOCAL,0272,RC,,,both,,,414.70,124.41,"CIGNA [10200]","Cigna Open Access",,235.96,56.9,,,,,0,48.23,352.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 15CM 5FR MERIT S-MAK STIFFENED DIL COAXIAL PAIR",SUP-S-MAK5F-15,CDM,C1894,HCPCS,0272,RC,,,both,,,224.81,67.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.15,191.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 10.2CM .4MM JEWELERS IRIS CURVED STRAIGHT",SUP-14-1080,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,83.86,45.9,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 65MM ATLANTIS VISION ELITE BONE SPINE",SUP-7200065,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"CATH ELECTROPHYSIOLOGY 2-10-2MM SPACING SUPER LARGE CURL 7FR",SUP-401904R,CDM,C1731,HCPCS,0272,RC,,,both,,,2100.00,630,"PHCS [10601]",PHCS,,1470,70,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET TUBING SONICONE OR STERILE LATEX FREE DISPOSABLE",SUP-120-31-13X2,CDM,S27200284,LOCAL,0272,RC,,,both,,,4684.62,1405.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1925.38,41.1,,,,,0,544.82,3981.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 4MM AZUR DETACHABLE .035IN HYDROGEL",SUP-45-450415,CDM,S27800098,LOCAL,0278,RC,,,both,,,8514.60,2554.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3499.5,41.1,,,,,0,990.25,7237.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER COMPLI REDEL 115CM 1MM 6FR 5MM SPACE A CURVE",SUP-F6CQA005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"PHCS [10601]",PHCS,,635.04,70,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X10MM PARALLEL SPINE CERVICAL",SUP-17910,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ZEBRA 6F  115CM ACCESS SYSTEM SIM2",SUP-AC6074-115-30,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"KAISER [10500]",Kaiser,,5986.79,67,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 100MM KNEE STEM EXT REMEDY STERILE",SUP-RSK100,CDM,C1776,HCPCS,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross HMO",,2434.32,39.2,,5311.50,4717.44,5388.59,31,722.22,5278.5,"percent of total billed charges",
"HC Chloride Urine",PX-301000142,CDM,82436,CPT,0301,RC,,,both,,,115.71,34.71,"CIGNA [10200]","Cigna Local Plus",,12.65,,,,,,,0.01,98.35,"fee schedule",
"HC Tlpa Iliac Arty Ea Vssl",PX-481000006,CDM,0238T,CPT,0481,RC,,,both,,,14891.09,4467.33,"BLUE CROSS [10001]","Blue Cross HMO",,10743.75,,"Case rate ($10,743.75). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1731.83,12657.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Arrest Agent Cassette Card",PX-E27200367,CDM,E27200367,LOCAL,0272,RC,,,both,,,180.40,54.12,"UHC [10700]","United Healthcare",,114.19,63.3,,,,,0,20.98,153.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DEMINERALIZED BONE MATRIX 1ML PUTTY STERILE",SUP-038010,CDM,C1713,HCPCS,0278,RC,,,both,,,1160.90,348.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,789.41,68,,,,,0,135.01,986.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 30CM 3CM 6FR .035IN PIGTAIL",SUP-M006180225190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"PHCS [10601]",PHCS,,885.77,70,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1.5MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR091520,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"MULTIPLAN [10600]",Multiplan,,11241.97,85,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 12MM ATTUNE 5 KNEE DISTAL CEMENT REVISION",SUP-1547-05-003,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"CIGNA [10200]","Cigna Local Plus",,3248.52,53.5,,5372.07,4581.20,7242.98,23,706.17,5161.2,"percent of total billed charges",
"WIRE FIXATION 2.5MM KIRSCHNER DARCO HEADED",SUP-NK112527,CDM,C1713,HCPCS,0278,RC,,,both,,,191.40,57.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",22.26,162.69,"percent of total billed charges",
"CATH Z-MED 100CM 9CM 9FR 26MM .035IN BALLOON DILATATION",SUP-611682,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,630.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 4MM BALLOON",SUP-U357546,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM T15 TIBIA CORTICAL DISTAL SELF TAP LOCK",SUP-816135030,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71MMX12MM VANGUARD E1 KNEE ANTERIOR STABILIZE TIBIAL",SUP-EP189062,CDM,C1776,HCPCS,0278,RC,,,both,,,13372.20,4011.66,"PHCS [10601]",PHCS,,9360.54,70,,,,,0,1555.19,11366.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035424060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"PHCS [10601]",PHCS,,9880.25,70,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 16MM 144CM 2.5MM CORONARY STENT EVEROLIMUS",SUP-H7493926116250,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1022.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT TAPERED COMPONENT",SUP-G47480,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"PHCS [10601]",PHCS,,71839.95,70,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"14 X 11 X 6MM 7 DEGREE POROUS COATE",SUP-P21411-706,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3065.39,45.9,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 3-0 SH-1 36IN 2 ARM BRAID GREEN",SUP-X762H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 74MM 10.8MM 6.4MM CUFF DISPOSABLE INNER CANN FENESTRATE",SUP-6DFEN,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.46,95.84,"MULTIPLAN [10600]",Multiplan,,271.54,85,,,,,0,37.15,271.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA MIV 110CM 5FR PIGTAIL LT CURVE ANGIOGRAPHIC",SUP-5RPL110-NB,CDM,S27200284,LOCAL,0272,RC,,,both,,,197.93,59.38,"FIRST HEALTH [10303]","First Health",,158.34,80,,,,,0,23.02,168.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE FUZEFIX MAX FULL THREAD L30 MM OD4.5 MM CANNULATE",SUP-FX-FT-4530,CDM,S27000186,LOCAL,0270,RC,,,both,,,3600.00,1080,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,426.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,418.68,3060,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER TUBE MACRO PEACH NEOBAR ENDOTRACHEAL GENTLE",SUP-602-N715F-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.02,40.51,"PHCS [10601]",PHCS,,94.51,70,,,,,0,15.7,114.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTRIAXONE 1 G VIAL IV PUSH|DISCARDED DRUG NOT ADMINISTE",RX-408304,CDM,J0696,HCPCS,0636,RC,00409-7332-21,NDC,both,1,UN,11.33,3.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,JW,5.75,,,,,,,2,9.63,"fee schedule",
"SCR BONE 4MM 12MM LCP STAINLESS STEEL FULL THREAD CANCELLOUS",SUP-206.012,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,32.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",31.82,232.58,"percent of total billed charges",
"BIT DRILL 4.3MM CANNULATED",SUP-AR-8610DB-65C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,650.63,45.9,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD COMPONENT UNITRAX 43MM END",SUP-6942-6-043,CDM,C1776,HCPCS,0278,RC,,,both,,,16025.25,4807.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1863.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1863.74,13621.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE EVERFLEX 60MM 120CM 5MM .079IN BILIARY NITINOL",SUP-PRB35-05-060-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE X-CORE TITANIUM SPINE LOCK NONSTERILE",SUP-7162000,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.93,488.68,"CIGNA [10200]",Cigna,,1107.67,68,,1831.33,1831.33,1831.33,16,189.44,1384.59,"percent of total billed charges",
"SCR BONE 5MM 20MM SELF TAP VARIABLE ANGLE LOCK STARDRIVE",SUP-02.231.220,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,152.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",152.1,1111.66,"percent of total billed charges",
"PLATE BEND GROOVE PREBENT 69X16.5X2.5MM TITANIUM 4/4.5MM SCR",SUP-04.613.360,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"INSRT TIBIAL 8 9MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-809-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"FIRST HEALTH [10303]","First Health",,9626.88,80,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D +4.5 CYL MODIFY L 13MM 6MM POSTERIOR CHMBR 1",SUP-CCW0T7,CDM,V2787,HCPCS,0276,RC,,,both,,,355.00,106.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,42.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.29,301.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TRIA 28CM 6FR URETERAL SOFT",SUP-M0061903240,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Hema Smpl",PX-510000003,CDM,10140,CPT,0761,RC,,,both,,,6600.15,1980.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2712.66,41.1,,,,,0,767.6,5610.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TRIA 28CM 6FR URETERAL SOFT",SUP-M0061903240,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT FEMORAL 50MM GMRS KNEE COCR",SUP-64956050,CDM,C1776,HCPCS,0278,RC,,,both,,,16025.25,4807.57,"UHC [10700]","United Healthcare",,10143.98,63.3,,8601.07,8395.67,8601.07,"1 through 10",1863.74,13621.46,"percent of total billed charges",
"HC Ribosomal Abs",PX-301000275,CDM,83516,CPT,0301,RC,,,both,,,146.90,44.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,18.14,,,,,,,0.01,124.87,"fee schedule",
"SYSTEM VASOVIEW SHORT BLUNT CONE VESSEL HARVESTING 30ML",SUP-VH-2004,CDM,S27200284,LOCAL,0272,RC,,,both,,,880.10,264.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,403.97,45.9,,,,,0,102.36,748.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 154MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-240.040S,CDM,C1713,HCPCS,0278,RC,,,both,,,9673.52,2902.06,"BLUE CROSS [10001]","Blue Cross HMO",,3792.02,39.2,,957.42,156.86,7483.26,51,1125.03,8222.49,"percent of total billed charges",
"GRAFT SOFT TISSUE 22+ MMX6+ MM 8-12MM POSTERIOR TIBIALIS",SUP-430343,CDM,S27800098,LOCAL,0278,RC,,,both,,,13403.25,4020.97,"CIGNA [10200]","Cigna Local Plus",,4222.02,31.5,,,,,0,1558.8,11392.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 STD 14MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS4S14R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"NOVANET [10819]",Novanet,,7793.55,75,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.7MM 65MM 18MM LOW PROFILE SCREWS TITANIUM 3.5MM",SUP-AR-8967-1865,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"BLUE CROSS [10001]","Blue Cross PPO",,735,39.2,,957.42,570.23,957.42,28,218.06,1593.75,"percent of total billed charges",
"TACROLIMUS 1 MG ORAL GRANULES IN PACKET",RX-186219,CDM,J7521,HCPCS,0636,RC,00469-1330-50,NDC,both,1,UN,35.20,10.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.17,35.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 10MM NONCOLLAR REDUCE PROXIMAL PROFILE",SUP-192410,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"FIRST HEALTH [10303]","First Health",,18998.78,80,,,,,0,2761.95,20186.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 9MM GRAFTECH LARGE LORDOTIC CORTICAL",SUP-4421409,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAPTOPRIL 12.5 MG TABLET",RX-9401,CDM,,,0637,RC,60687-0304-11,NDC,both,1,UN,8.54,2.56,"NOVANET [10819]",Novanet,,6.41,75,,,,,0,0.99,7.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY ARTHROGRAM 1 2 CONTRAST 4 NDL SYR EXT TUBING SPONGE",SUP-120020,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.01,32.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,43.98,41.1,,,,,0,12.45,90.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION",RX-38488,CDM,,,0250,RC,70954-0600-10,NDC,both,120,ML,741.97,222.59,"CIGNA [10200]",Cigna,,504.54,68,,,,,0,86.29,630.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 36CM 2.4MM OPTI2 LAPAROSCOPIC L HOOK",SUP-E2773-36,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.93,90.28,"CIGNA [10200]",Cigna,,204.63,68,,,,,0,35,255.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL POSTERIOR STABILIZED IPOLY ITOTAL 22MM",SUP-RPS0102200,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"KAISER [10500]",Kaiser,,3404.84,67,,,,,0,591.02,4319.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 60MM 5MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171050610,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AETNA [10100]","Aetna HMO/PPO",,933.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE CAST 12.5IN 5IN LARGE NONSKID SOLE",SUP-SA901007,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.55,17.56,"CIGNA [10200]","Cigna Open Access",,33.31,56.9,,,,,0,6.81,49.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo 3d During Tee/Tte for Chd",PX-483000027,CDM,93319,CPT,0483,RC,,,both,,,1291.00,387.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,152.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.14,1097.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Lwr Ext Nonjnt W&WO Cntrst",PX-610000033,CDM,73720,CPT,0610,RC,,,both,,,5585.59,1675.68,"PHCS [10601]",PHCS,,3909.91,70,,,,,0,649.6,4747.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablt Pulm Tumor Perc Cryo",PX-361000470,CDM,32994,CPT,0361,RC,,,both,,,9566.00,2869.8,"BLUE CROSS [10001]","Blue Cross HMO",,6134.53,,"Case rate ($6,134.53). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1112.53,9566,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 2 10MM",SUP-TPS-030-102S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"CIGNA [10200]","Cigna Local Plus",,433.35,53.5,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TIBIAL 80MM 12.5MM ASCENT MAXIM KNEE PRIMARY FIN",SUP-141318,CDM,C1776,HCPCS,0278,RC,,,both,,,4719.60,1415.88,"CIGNA [10200]",Cigna,,3209.33,68,,5873.17,5873.17,5873.17,"1 through 10",548.89,4011.66,"percent of total billed charges",
"PLATE 36MM 2 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.236,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",512.88,3748.5,"percent of total billed charges",
"HC Xr Tmj Bilat Open Clsd",PX-320000021,CDM,70330,CPT,0320,RC,,,both,,,904.07,271.22,"AETNA [10100]","Aetna HMO/PPO",,718.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.33,768.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROTAWIRE DRIVE EXTRA SUPPORT 5 PACK",SUP-H74939463005,CDM,C1769,HCPCS,0272,RC,,,both,,,1849.50,554.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,219.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,215.1,1572.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOQUE TRICUSPID VALVE REPLACEMENT SYSTEM (44 MM VALVE)",SUP-EVQ1A2US44,CDM,S27800098,LOCAL,0278,RC,,,both,,,245100.00,73530,"NOVANET [10819]",Novanet,,183825,75,,,,,0,28505.13,208335,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 10.5IN OLSEN STRAIGHT BAYONET SMOOTH INSULATE 6",SUP-20-1480I,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.83,125.35,"CIGNA [10200]","Cigna Local Plus",,223.54,53.5,,,,,0,48.59,355.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE ADPTR 34MM UNIVERSAL KNEE FEMORAL POROUS SIGMA LCS",SUP-129453226,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXCISOR BIOPSY FISCHER LARGE CERVICAL CONE SHALLOW STERILE",SUP-900-155,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.28,60.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,83.55,41.1,,,,,0,23.64,172.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR MEDIUM 52MM COCR",SUP-626-00-52H,CDM,S27800098,LOCAL,0278,RC,,,both,,,9500.40,2850.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1104.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1104.9,8075.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ENDARTERECTOMY 7MM 9MM 2 COAXIAL METAL RING",SUP-4500-05,CDM,S27200284,LOCAL,0272,RC,,,both,,,18893.70,5668.11,"AETNA [10100]","Aetna HMO/PPO",,15020.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2197.34,16059.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-04010,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1042.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 15X15.5CM NATRELLE P6.1CM FULL PROJECTION FULL",SUP-MSZFF655,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 26MM SIMUPLUS FLEXIBLE STERILE LATEX FREE",SUP-7700FB26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"NOVANET [10819]",Novanet,,9832.5,75,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 5MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0510,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"BLUE CROSS [10001]","Blue Cross PPO",,2650.7,39.2,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 5.5MM MATRIX 100MM RADIUS CURVE BULLET NOSE",SUP-04.651.080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"LENS IOL +32.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-PCB0000325,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEDTRONIC EVOLUT R 34 TRANSCATHETER AORTIC VALVE",SUP-EVOLUTR-34-C,CDM,S62400003,LOCAL,0624,RC,,,both,,,188100.00,56430,"KAISER [10500]",Kaiser,,126027,67,,,,,0,21876.03,159885,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC",516,MS-DRG,,,,,,,inpatient,,,107161.13,32148.34,"BLUE CROSS [10001]","Blue Cross PPO",,51302.16,,,,,,,7561,60672.21,"case rate",
"TUBE 89MM 10.9MM 8MM 1 CANN CUFF SMOOTH ROUND TIP OBTR",SUP-8SCT,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.54,64.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.95,182.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ VASCULAR 3MM RADIUS CURVE TAPER 3CM 80CM 7CM",SUP-G04237,CDM,C1769,HCPCS,0272,RC,,,both,,,260.91,78.27,"NOVANET [10819]",Novanet,,195.68,75,,,,,0,30.34,221.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Ankle Trimal WO Manip",PX-450000165,CDM,27816,CPT,0450,RC,,,both,,,1347.00,404.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1261,,,,,,,67.13,1347,"case rate",
"SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL",RX-177586,CDM,,,0250,RC,48582-0512-01,NDC,both,42,GR,29.59,8.88,"CIGNA [10200]","Cigna Local Plus",,15.83,53.5,,,,,0,3.44,25.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (0.5-1 MCI)",RX-411870,CDM,A9520,HCPCS,0343,RC,08888-8876-04,NDC,both,1,UN,4614.97,1384.49,"NOVANET [10819]",Novanet,,3461.23,75,,,,,0,536.72,3922.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KEY CHUCK JACOBS UNIVERSAL CORDLESS DRIVER 2 STERILE",SUP-4100131132,CDM,S27200284,LOCAL,0272,RC,,,both,,,403.85,121.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,274.62,68,,,,,0,46.97,343.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 3 POSTERIOR KNEE TOTAL STABILIZED",SUP-5543-A-300,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"CIGNA [10200]",Cigna,,3244.27,68,,5873.17,5873.17,5873.17,"1 through 10",554.87,4055.34,"percent of total billed charges",
"INTRO SHEATH PERITONEAL 70CM REPLACEMENT POLYPROPYLENE",SUP-9MD170,CDM,C1894,HCPCS,0272,RC,,,both,,,386.59,115.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,45.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.96,328.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 19MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-819,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"PHCS [10601]",PHCS,,7988.82,70,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CPS COURIER VASCULAR .014IN STAINLESS STEEL PLATINUM",SUP-DS2G004,CDM,C1769,HCPCS,0272,RC,,,both,,,607.50,182.25,"PHCS [10601]",PHCS,,425.25,70,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45MM FLEXIBLE ARTICULATING LINEAR CUTTER",SUP-ATS45,CDM,S27200284,LOCAL,0272,RC,,,both,,,4678.94,1403.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2147.63,45.9,,,,,0,544.16,3977.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 60MM 120CM 7.5MM 6FR VASCULAR NITINOL",SUP-S-75-060-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1063.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 8-0 BV130-5 24IN 2 ARM MONOFILAMENT BLUE",SUP-8732H,CDM,S27200284,LOCAL,0272,RC,,,both,,,258.69,77.61,"KAISER [10500]",Kaiser,,173.32,67,,,,,0,30.09,219.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE VOYANT MARYLAND 7MM 18MM 23CM 20MM LAPAROSCOPIC 1",SUP-EB217,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"MULTIPLAN [10600]",Multiplan,,2709.38,85,,,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANSTR SUCTION 800CC HIGH FLOW HI-FLOW TRUFREEZE SPRAY",SUP-8002055,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.71,14.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,33.8,68,,,,,0,5.78,42.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 78MM STAINLESS STEEL 3.5MM SCR 6 HOLE LOW PROFILE DCP",SUP-02.100.016,CDM,C1713,HCPCS,0278,RC,,,both,,,5631.78,1689.53,"KAISER [10500]",Kaiser,,3773.29,67,,,,,0,654.98,4787.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IV VIAFLEX 40 MEQ POTASSIUM CHLORIDE 5% DEXTROSE 0.45%",SUP-2B1674X,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.95,24.58,"MULTIPLAN [10600]",Multiplan,,69.66,85,,,,,0,9.53,69.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IRRIGATION FJ 2000 MIS STERILE LATEX FREE DISPOSABLE",SUP-P65-001-0006-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"PHCS [10601]",PHCS,,952.56,70,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCOPIC INSTR TIGHTROPE 1.6MM 2.7MM BUTTON CANNULATED",SUP-AR-8911DS,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,1144.80,304.56,2275.09,66,434.96,3179,"percent of total billed charges",
"CAGE SPINAL 40MMX10MM CLYDESDALE 6D PEEK-OPTIMA RADIOPAQUE",SUP-2968040,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"NOVANET [10819]",Novanet,,17955,75,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET",RX-70284,CDM,,,0637,RC,60258-0006-15,NDC,both,1,UN,12.54,3.76,"UHC [10700]","United Healthcare",,7.94,63.3,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL SHAFT ALLOGRAFT FROZEN 200MM",SUP-800143,CDM,S27800098,LOCAL,0278,RC,,,both,,,7472.01,2241.6,"BLUE CROSS [10001]","Blue Cross PPO",,2929.03,39.2,,,,,0,868.99,6351.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE IRON MAN VASCULAR STRAIGHT 300CM 3CM .014IN",SUP-1001311,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE STC-18 105CM 20CM 3-2.4FR .021IN MICRO GUIDING",SUP-M001181250,CDM,C1887,HCPCS,0272,RC,,,both,,,2287.50,686.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,271.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,266.04,1944.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22.5 DIOPTER UV ABSORBENT CLAREON AUTONOME",SUP-CCA0T0.225,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 55MM 20MM 75CM ENDOPROSTHESIS VENOUS CATH",SUP-H74912044205570,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3958.88,45.9,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM 6 HOLE STAR LOCKING BONE STERNAL NONSTERILE",SUP-460.035,CDM,C1713,HCPCS,0278,RC,,,both,,,7471.87,2241.56,"AETNA [10100]","Aetna HMO/PPO",,5940.14,79.5,,1521.93,481.35,16760.95,30,868.98,6351.09,"percent of total billed charges",
"SCR BONE 5.5MM CD HORIZON LEGACY TITANIUM PEDICLE BREAKOFF",SUP-7540020,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,279.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",279.89,2045.61,"percent of total billed charges",
"CATH SAPPHIRE II PRO 15MM 2.5MM BALLOON DILATATION STERILE",SUP-225-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UHC [10700]","United Healthcare",,512.73,63.3,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 22MM 140CM 2.5MM",SUP-RSINT25022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"NOVANET [10819]",Novanet,,4158,75,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VENTURA INTERATRIAL SHUNT",SUP-VIS-01-5.0-14F,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 199MM 16MM 16FR ENDURANT II ABDOMINAL",SUP-ETLW1616C199E,CDM,C1876,HCPCS,0278,RC,,,both,,,40918.50,12275.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4848.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4758.82,34780.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X300 135CM SL",SUP-48007030R,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,707.89,68,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM AVENIR 10 HELICAL FINISH STERILE",SUP-10HFN-03006,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"BLUE CROSS [10001]","Blue Cross PPO",,4054.5,39.2,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST EXTERNAL FIXATION 90D MRI",SUP-4921-2-160,CDM,S27800098,LOCAL,0278,RC,,,both,,,1470.47,441.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,420.85,28.62,,,,,0,171.02,1249.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COPE MAC-LOC 24CM 8.5FR PIGTAIL CURVE",SUP-G48176,CDM,C2617,HCPCS,0278,RC,,,both,,,980.02,294.01,"CIGNA [10200]",Cigna,,666.41,68,,,,,0,113.98,833.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL C-FLEX DOYLE BIVALVE SET",SUP-1524075,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.95,74.38,"MULTIPLAN [10600]",Multiplan,,210.76,85,,,,,0,28.84,210.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 10FR DRNG FLEXIMA HYDROPHILIC BILIARY RADIOPAQUE",SUP-M001272650,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE IRRIGATION",SUP-111613,CDM,S27200284,LOCAL,0272,RC,,,both,,,899.10,269.73,"CIGNA [10200]","Cigna Open Access",,511.59,56.9,,,,,0,104.57,764.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 12MM INTERLOCK IDC OCCLUSION SYSTEM",SUP-M0013614120,CDM,S27800098,LOCAL,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL WEIL-BLAKESLEY PEDIATRIC 45D UP 00 6.25IN",SUP-63-7424,CDM,S27200284,LOCAL,0272,RC,,,both,,,1913.63,574.09,"CIGNA [10200]","Cigna Open Access",,1088.86,56.9,,,,,0,222.56,1626.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TIBIAL SHAFT THK10+ MM ALLOGRAFT FROZEN 150MMX10+",SUP-450525,CDM,S27800098,LOCAL,0278,RC,,,both,,,9178.38,2753.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6241.3,68,,,,,0,1067.45,7801.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 100MM 20MM ASNIS III TITANIUM HIP FEMUR SELF",SUP-602700,CDM,C1713,HCPCS,0278,RC,,,both,,,1866.45,559.93,"FIRST HEALTH [10303]","First Health",,1493.16,80,,,,,0,217.07,1586.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 16MM KNEE POSTERIOR STABILIZE BEARING",SUP-5532P716,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"KAISER [10500]",Kaiser,,5598.45,67,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL SYMBOTEX 8CM 2 SIDE COMPOSITE 3D BIOABSORBABLE",SUP-SYM8OS,CDM,C1781,HCPCS,0278,RC,,,both,,,3068.10,920.43,"BLUE CROSS [10001]","Blue Cross HMO",,1202.7,39.2,,,,,0,356.82,2607.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE STD 24.5CMX4MM POLYESTER SILICONE",SUP-TR400000,CDM,C1763,HCPCS,0278,RC,,,both,,,6955.20,2086.56,"BLUE CROSS [10001]","Blue Cross PPO",,2726.44,39.2,,,,,0,808.89,5911.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE RIGHT CEMENTED POSTERIOR",SUP-150410225,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6408.98,28.62,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM VARIAX TORX TITANIUM FULL THREAD T10",SUP-40-35618,CDM,C1713,HCPCS,0278,RC,,,both,,,1211.11,363.33,"MULTIPLAN [10600]",Multiplan,,1029.44,85,,,,,0,140.85,1029.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061802330,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,104.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL NOTTINGHAM ONE-STEP HYDROPLUS TAPERED 70CM 4CM",SUP-M0062301150,CDM,C1726,HCPCS,0272,RC,,,both,,,1005.78,301.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,116.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.97,854.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN SUCTION MERCEDES 4MM 10MM 30CM PORT WITHOUT SLOT",SUP-PAL-405LL,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,293.71,45.9,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 20MM 5MM 3.9FR AUTOTOME BILIARY CANNULATED RAPID",SUP-M00545190,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM VARIAX TORX TITANIUM FULL THREAD T10",SUP-40-35616,CDM,C1713,HCPCS,0278,RC,,,both,,,1211.11,363.33,"CIGNA [10200]",Cigna,,823.55,68,,1831.33,1831.33,1831.33,16,140.85,1029.44,"percent of total billed charges",
"ROD SPINAL 80MM 5.5MM VIPER 2 PREBENT TITANIUM MIS",SUP-186788080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"BURR SURGICAL 45MM 2.1MM CARBIDE TAPERED SIDE CUTTING",SUP-1607002109,CDM,S27000186,LOCAL,0270,RC,,,both,,,93.87,28.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH COYOTE 90CM 220MM 2MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186202290,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LIVEWIRE 7FR MEDIUM CURL CURVE ELECTROPHYSIOLOGY DUO",SUP-401908,CDM,C1731,HCPCS,0272,RC,,,both,,,6348.00,1904.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC",259,MS-DRG,,,,,,,inpatient,,,82866.08,24859.82,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,13107.65,,"Case rate ($12,543.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,647.22, add-ons for qualifying new technology services are included. If operating cost exceeds $44,686.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,262.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $11,662.62. The transfer operating threshold is the transfer adjustment factor * $11,647.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.59. The transfer capital threshold is the transfer adjustment factor * $880.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 104.5%.",,,,0,7561,59037.23,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 PS-2 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J497H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 71CM 21GA 18GA PROC CURVE STERILE BROCKENBROUGH ADULT",SUP-04120DS,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 124MM CEMENTLESS OFFSET ACCOLADE TMZF 127D +0",SUP-6021-3535,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"CIGNA [10200]","Cigna Local Plus",,4929.5,31.5,,5372.07,4581.20,7242.98,23,1820,13301.82,"percent of total billed charges",
"SCR BONE 2.2MM 6MM RELIEVE SPINE SELF DRILL NONSTERILE LATEX",SUP-136.406,CDM,C1713,HCPCS,0278,RC,,,both,,,1077.30,323.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,127.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",125.29,915.71,"percent of total billed charges",
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET HOUSING POS",SUP-AR-1204AF-105,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1051.91,41.1,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TF DELIVERY SYSTEM (42MM) INTPD-TF-42DS",SUP-INTPDTF42DSG,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 28MM 143CM 2.75MM CORONARY EVEROLIMUS ELUTING",SUP-1009540-28,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4402.27,45.9,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 34MM ORTHOLOC TITANIUM CORTICAL SELF TAP",SUP-59225534,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"KAISER [10500]",Kaiser,,667.52,67,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 157MM STAINLESS STEEL 2.7MM SCR 9 HOLE CONTOUR SHAFT",SUP-02.118.411S,CDM,C1713,HCPCS,0278,RC,,,both,,,5592.31,1677.69,"FIRST HEALTH [10303]","First Health",,4473.85,80,,,,,0,650.39,4753.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X9MM CONVEX SPINE CORTICOCANCELLOUS",SUP-17509,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN JUDKINS",SUP-67008100,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,171.63,41.1,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE BELT",SUP-MI-ISBA-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1205.55,361.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,142.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.21,1024.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIRATION DIA1.9MM STANDARD SHORT AND TUBESET",SUP-130-35-1419,CDM,S27200284,LOCAL,0272,RC,,,both,,,5673.19,1701.96,"FIRST HEALTH [10303]","First Health",,4538.55,80,,,,,0,659.79,4822.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER COMPRESSION LARGE FOOT IMPAD AV IMPULSE SYSTEM RIGID",SUP-5075,CDM,S27000186,LOCAL,0270,RC,,,both,,,339.10,101.73,"KAISER [10500]",Kaiser,,227.2,67,,,,,0,39.44,288.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE RIGHT CRUCIATE RETAIN CEMENTLESS ATTUNE",SUP-150401208,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"BLUE CROSS [10001]","Blue Cross PPO",,11279.9,39.2,,3949.44,3949.44,3949.44,"1 through 10",3346.56,24458.96,"percent of total billed charges",
"CAP SYSTEM TKR VIVACIT-E PATELLOFEMORAL",SUP-98000660020,CDM,C1776,HCPCS,0278,RC,,,both,,,20160.00,6048,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8064,40,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 4MM 3.25MM DORNHOFFER EAR TITANIUM ADJUSTABLE",SUP-637,CDM,L8613,HCPCS,0278,RC,,,both,,,3661.65,1098.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,232.31,,,,,,,232.31,3112.4,"fee schedule",
"SCR BONE 5.5MM 40MM CAYMAN SPINE SELF START NONSTERILE",SUP-4501-15540,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 5-0 PC-5 18IN MONOFILAMENT BLUE",SUP-8630G,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.80,20.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8,58.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 5MM PRESS FIT FULL PROFILE TAPERLOC PPS",SUP-51-100050,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"AETNA [10100]","Aetna HMO/PPO",,19241.66,79.5,,10981.53,8986.79,12413.38,12,2814.85,20572.84,"percent of total billed charges",
"STEM FEMORAL 156MM 18MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-104180,CDM,C1776,HCPCS,0278,RC,,,both,,,27004.32,8101.3,"UHC [10700]","United Healthcare",,17093.73,63.3,,8601.07,8395.67,8601.07,"1 through 10",3140.6,22953.67,"percent of total billed charges",
"CATH FOX SV 150CM 40MM 4FR 2.5MM .018IN LARGE CRESCENT LOW",SUP-83376-02,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 33-39MM QUARTEX T SPINE 2 HEAD",SUP-1149.8302,CDM,C1713,HCPCS,0278,RC,,,both,,,3277.50,983.25,"PHCS [10601]",PHCS,,2294.25,70,,,,,0,381.17,2785.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 37MM 80CM 8MM 40MM BILIARY STAINLESS STEEL",SUP-PXB35-08-37-080,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"CIGNA [10200]","Cigna Open Access",,2484.82,56.9,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 38MM 140CM 3.5MM",SUP-RSINT35038UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"PHCS [10601]",PHCS,,3880.8,70,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM BALLARD 21.3IN 14FR SUCTION POLYURETHANE ADULT CLOSED",SUP-22705,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.46,30.74,"CIGNA [10200]",Cigna,,69.67,68,,,,,0,11.92,87.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 30CM 14FR 22GA FLEXIMA POLYURETHANE 3 WAY STPCOCK 2",SUP-M001273070,CDM,C1729,HCPCS,0272,RC,,,both,,,1950.00,585,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,231.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 45MM MATRIX TITANIUM SPINE THORACOLUMBAR",SUP-04.606.645,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"CMPNT FEMORAL 8 KNEE LEFT CEMENTED POSTERIOR STABILIZE",SUP-5515F801,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"KAISER [10500]",Kaiser,,6700,67,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 2MM SPACE A CURVE ELECTROPHYSIOLOGY",SUP-F6HA002RT,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,599.24,41.1,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUADRA ALLURE MP RF CRT-P, MER",SUP-1457Q/75,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,664.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 475CC SUT TAB INTEGRAL INJECTION DOME",SUP-SDC-130H,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"AETNA [10100]","Aetna HMO/PPO",,9462.49,79.5,,,,,0,1384.26,10117.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 240MM 6MM BALLOON DILATATION HYDROPHILIC",SUP-606024022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"KAISER [10500]",Kaiser,,488.43,67,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 480CC 12.2CM 5.8CM PROJECTION HIGH PROFILE SM",SUP-SHPB480,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,886.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION LCS SIGMA HIP THREAD HEAD STERILE",SUP-950502303,CDM,S27200284,LOCAL,0272,RC,,,both,,,1938.75,581.62,"AETNA [10100]","Aetna HMO/PPO",,1541.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,225.48,1647.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH R2P METACROSS 200CM 80MM 6MM BALLOON DILATATION",SUP-BD-P60080ER,CDM,C1769,HCPCS,0272,RC,,,both,,,2028.75,608.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,833.82,41.1,,,,,0,235.94,1724.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR INTERSTIM PERIPHERAL NERVE EVALUATION TEST",SUP-309101,CDM,C1897,HCPCS,0278,RC,,,both,,,607.50,182.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,278.84,45.9,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL PLIF 17 DEGREE 7MM X 11MM X 28MM MOD-EX",SUP-1937128P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"BLUE CROSS [10001]","Blue Cross HMO",,13582.8,39.2,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN JUDKINS",SUP-77801400,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL STD 15MM KNEE GVF ROTATE PLATFORM LCS COMPLETE",SUP-129405415,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"BLUE CROSS [10001]","Blue Cross HMO",,3788.07,39.2,,5311.50,4717.44,5388.59,31,1123.86,8213.93,"percent of total billed charges",
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 300CM 3CM",SUP-1020011,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C1q Complement",PX-302000022,CDM,86160,CPT,0302,RC,,,both,,,354.35,106.3,"CIGNA [10200]",Cigna,,26.4,,,,,,,0.35,301.2,"fee schedule",
"KIT STENT 20CM 8FR .038IN PIGTAIL CURVE TAPER URETER GLIDEX",SUP-M001245620,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,200.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 6FR 20CM HYDROPHILIC RADIOPAQUE STERILE",SUP-G10285,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"CIGNA [10200]","Cigna Local Plus",,35.79,53.5,,,,,0,7.78,56.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL SYMBOTEX 17X10CM 2 SIDE COMPOSITE 3D",SUP-SYM1710E,CDM,C1781,HCPCS,0278,RC,,,both,,,3229.65,968.89,"NOVANET [10819]",Novanet,,2422.24,75,,,,,0,375.61,2745.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL STEALTH 11MM 11MM VASCULAR SOFT WHITE",SUP-G-1100,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"UHC [10700]","United Healthcare",,99.13,63.3,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 87/91MMX10MM VANGUARD E1 KNEE CRUCIATE RETAINING",SUP-EP183480,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"BLUE CROSS [10001]","Blue Cross PPO",,5077.45,39.2,,3949.44,3949.44,3949.44,"1 through 10",1506.4,11009.78,"percent of total billed charges",
"LENS IOL 5 D +5 DIOPTER MODIFIED C MENISCUS 13MM 6MM",SUP-MA60MA.050,CDM,V2632,HCPCS,0276,RC,,,both,,,1085.40,325.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,498.2,45.9,,,,,0,126.23,922.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DABIGATRAN ETEXILATE 75 MG CAPSULE",RX-106490,CDM,,,0637,RC,00597-0355-56,NDC,both,1,UN,19.96,5.99,"CIGNA [10200]","Cigna Local Plus",,10.68,53.5,,,,,0,2.32,16.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS STREAMLINE 50MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-M003SFD050500,CDM,C1874,HCPCS,0278,RC,,,both,,,93183.77,27955.13,"CIGNA [10200]","Cigna Local Plus",,29352.89,31.5,,,,,0,10837.27,79206.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 11MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS11030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AETNA [10100]","Aetna HMO/PPO",,9319.86,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 17GA 2 TRIGGER PERMANENT ULTRASOUND VISIBILITY RIGID",SUP-864017D,CDM,A4648,HCPCS,0278,RC,,,both,,,526.34,157.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.21,447.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP CLUSTER HOLE SNAP FIT INTEGRATED",SUP-00875705401,CDM,C1776,HCPCS,0278,RC,,,both,,,9319.80,2795.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2667.33,28.62,,,,,0,1083.89,7921.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 150MM 3.2MM FLUTE CAS STERILE",SUP-20800000010,CDM,S27200284,LOCAL,0272,RC,,,both,,,963.90,289.17,"CIGNA [10200]",Cigna,,655.45,68,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PINPOINT DISPOSABLE RIGID SCOPE INTRODUCER PAQ",SUP-PP9050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1452.19,435.66,"UHC [10700]","United Healthcare",,919.24,63.3,,,,,0,168.89,1234.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 10MM 3.5MM BALLOON DILATATION STERILE",SUP-235-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD",SUP-98000500306,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"AETNA [10100]","Aetna HMO/PPO",,19032.3,79.5,,10981.53,8986.79,12413.38,12,2784.22,20349,"percent of total billed charges",
"SCR BONE 4.35MM 35MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1",SUP-179712435,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL PERICARDIOCENTESIS 15CM 5FR ONE STEP FIXED LUER",SUP-OSC-5F-15L,CDM,C1729,HCPCS,0272,RC,,,both,,,160.95,48.28,"MULTIPLAN [10600]",Multiplan,,136.81,85,,,,,0,18.72,136.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND 2CMX2CM SALERA MINI MEMB",SUP-WC4022,CDM,S27800098,LOCAL,0278,RC,,,both,,,4692.00,1407.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3190.56,68,,,,,0,545.68,3988.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETERIZATION MULTILUMEN CENTRAL VENOUS ARROW-HOWES",SUP-AK-22123-F,CDM,C1751,HCPCS,0272,RC,,,both,,,887.76,266.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,105.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.25,754.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 325ML P4.6CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-3254BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT 120MM SCP ACCUPORT 11GA END DELIVERY CANN",SUP-414.503,CDM,C1713,HCPCS,0278,RC,,,both,,,23486.40,7045.92,"PHCS [10601]",PHCS,,16440.48,70,,,,,0,2731.47,19963.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Elect Subq Icd",PX-481000104,CDM,33272,CPT,0481,RC,,,both,,,8391.10,2517.33,"CIGNA [10200]","Cigna Local Plus",,8391.1,,"Case rate ($29,596). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,975.88,8391.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X5MM ADVANCED LORDOTIC SPINE",SUP-017705,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"AMERIGROUP MEDICAID [20100]",Amerigroup,,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.24,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"BLUE CROSS [10001]","Blue Cross PPO",,735,39.2,,957.42,570.23,957.42,28,188.41,1593.75,"percent of total billed charges",
"SUT POLYESTER POLYDEK 2 KC-7 30IN BRAID GREEN NONABSORBABLE",SUP-69-557,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 5 % AND 0.45 % NACL IV BOLUS",RX-400295,CDM,,,0258,RC,00338-0085-04,NDC,both,1000,ML,100.65,30.19,"PHCS [10601]",PHCS,,70.46,70,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cors&Angio W Rt Hrt Cath",PX-481000024,CDM,93456,CPT,0481,RC,,,both,,,22211.74,6663.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6002,,"Case rate ($6,002). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1566.32,18879.98,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3.5MM AVENIR COMPLEX 10 COIL FRAME",SUP-10CFR03504,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]",Cigna,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X10X10-17MM RISE 15D",SUP-193.142,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 11FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G00994,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"KAISER [10500]",Kaiser,,33.05,67,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 13MM 57SQ CM 51X73MM COBALT TITANIUM",SUP-DTPA2D4,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"CIGNA [10200]",Cigna,,30780,40,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 180CM 5.5CM 7.5FR 8-9-10MM ESOPHAGUS",SUP-M00558610,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"UHC [10700]","United Healthcare",,1043.84,63.3,,,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBEROS 5CC",SUP-FB050,CDM,C1713,HCPCS,0278,RC,,,both,,,4140.00,1242,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 5IN .059IN STAINLESS STEEL",SUP-WS-1505ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,34.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH-PROFILE BOOST, 400CC",SUP-SMHB400,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"MULTIPLAN [10600]",Multiplan,,6480.83,85,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM .02IN 3MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0305,CDM,S27800098,LOCAL,0278,RC,,,both,,,4158.00,1247.4,"CIGNA [10200]","Cigna Open Access",,2365.9,56.9,,,,,0,483.58,3534.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO2 VASCULAR STD STRAIGHT 215CM .014IN",SUP-SSTD215STR,CDM,C1769,HCPCS,0272,RC,,,both,,,4186.64,1255.99,"UHC [10700]","United Healthcare",,2650.14,63.3,,,,,0,486.91,3558.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED + VE/",SUP-98000200448,CDM,C1776,HCPCS,0278,RC,,,both,,,25830.00,7749,"AETNA [10100]","Aetna HMO/PPO",,20534.85,79.5,,10981.53,8986.79,12413.38,12,3004.03,21955.5,"percent of total billed charges",
"HC Cytogenetics 10-30",PX-311000090,CDM,88273,CPT,0311,RC,,,both,,,400.00,120,"FIRST HEALTH [10303]","First Health",,320,80,,,,,0,0.01,340,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Compres Band Rosidal W>=3""<5""Yd",PX-E27000283,CDM,A6452,HCPCS,0270,RC,,,both,,,121.00,36.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.66,,,,,,,5.66,102.85,"fee schedule",
"HC Compres Band Rosidal W>=3""<5""Yd",PX-E27000283,CDM,A6452,HCPCS,0270,RC,,,both,,,121.00,36.3,"KAISER [10500]",Kaiser,,81.07,67,,,,,0,5.66,102.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BILIARY 8MM 8.5FR 60MM FULLY COVERED TRANSHEPATIC WALL",SUP-M00574750,CDM,C1874,HCPCS,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6310.71,28.62,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X10X8MM RISE 10D LORDOTIC NONSTERILE",SUP-193.122,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Local Plus",,8930.25,31.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Hip W Anes",PX-361000354,CDM,27095,CPT,0361,RC,,,both,,,1108.00,332.4,"PHCS [10601]",PHCS,,775.6,70,,,,,0,128.86,1108,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 0 UR-6 27IN MONOFILAMENT ABSORBABLE",SUP-N879H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"MULTIPLAN [10600]",Multiplan,,22.95,85,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 8MM NATURAL LARGE LORDOTIC",SUP-19408,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.175 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.175,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 60MM 157CM 12MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200126020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 10 X 34 COMPLEX FRAMING COIL",SUP-10CFR-10034,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]",Cigna,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 34MM QUICKFIX TITANIUM T15 SHORT THREAD",SUP-AR-8740-34PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",155.43,1136.03,"percent of total billed charges",
"INSOLE SHOE 6-8 SMALL MALE DARCO PEG-ASSIST REMOVABLE PEG",SUP-PTQM1,CDM,S27000186,LOCAL,0270,RC,,,both,,,100.92,30.28,"UHC [10700]","United Healthcare",,63.88,63.3,,,,,0,11.74,85.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 58MM 80CM 6MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU0800658,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"FIRST HEALTH [10303]","First Health",,20916,80,,,,,0,3040.66,22223.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LG DOME NON-T 4 POLE NON-BRAID",SUP-D7CL252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,5326.80,1598.04,"KAISER [10500]",Kaiser,,3568.96,67,,,,,0,619.51,4527.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MTRL SPLINTING THK1/8IN 24X18IN 19% PERFORATE OPTIPERF",SUP-A963101,CDM,S27000186,LOCAL,0270,RC,,,both,,,707.05,212.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,324.54,45.9,,,,,0,82.23,600.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMARTCLIP SOFT TISSUE MARKER AND DELIVERY SYSTEM, PURPLE 7.5",SUP-SMARTCLIPLT-PRUP-7.5,CDM,A4648,HCPCS,0278,RC,,,both,,,2625.00,787.5,"KAISER [10500]",Kaiser,,1758.75,67,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA MEDIAL CONGRUENT 4-5 C-D KNEE",SUP-42512100313,CDM,C1776,HCPCS,0278,RC,,,both,,,9466.80,2840.04,"NOVANET [10819]",Novanet,,7100.1,75,,,,,0,1100.99,8046.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0247,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,644.44,68,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE 25X20CM PREPERITONEAL KNIT WEB SYNECOR",SUP-GKWR2025,CDM,C1781,HCPCS,0278,RC,,,both,,,19435.50,5830.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7987.99,41.1,,,,,0,2260.35,16520.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 220MM 2.6MM AO SCALE",SUP-703901,CDM,S27200284,LOCAL,0272,RC,,,both,,,1207.71,362.31,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,496.37,41.1,,,,,0,140.46,1026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT TOTAL STBL TRIATHLON COCR",SUP-5512-F-301,CDM,C1776,HCPCS,0278,RC,,,both,,,20599.49,6179.85,"NOVANET [10819]",Novanet,,15449.62,75,,,,,0,2395.72,17509.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 8MM 6FR 3.5MM .07IN BALLOON",SUP-H7493918908350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +1.5MM 12/14 TAPER 36MM HIP BIOLOX DELTA",SUP-1365-36-310,CDM,C1776,HCPCS,0278,RC,,,both,,,12268.20,3680.46,"BLUE CROSS [10001]","Blue Cross PPO",,4809.13,39.2,,3949.44,3949.44,3949.44,"1 through 10",1426.79,10427.97,"percent of total billed charges",
"CATH ELECTROPHYSIOLOGY 7.5FR CARTO 3 THERMOCOOL SF F-J CURVE",SUP-BNI35FJCT,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"UHC [10700]","United Healthcare",,11433.31,63.3,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ITOTAL IDENTITY CR TIBIAL INSERT IPOLY XE CS SINGLE 7MM RIGH",SUP-TCR-023-070B,CDM,C1776,HCPCS,0278,RC,,,both,,,2130.00,639,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,977.67,45.9,,,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON UVA TORIC AUTONOME",SUP-CCA0T6,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 100D L 8MMX.6MM MDFC LT 6 HL",SUP-55-07764,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL VANTAGE THK6MM 2 ANKLE LEFT STERILE LATEX FREE",SUP-350-21-02,CDM,C1713,HCPCS,0278,RC,,,both,,,8832.00,2649.6,"CIGNA [10200]",Cigna,,6005.76,68,,1831.33,1831.33,1831.33,16,1027.16,7507.2,"percent of total billed charges",
"SUT STAINLESS STEEL TAPERCUT 5 V-56 30IN MONOFILAMENT 4",SUP-M435G,CDM,S27200284,LOCAL,0272,RC,,,both,,,132.05,39.61,"KAISER [10500]",Kaiser,,88.47,67,,,,,0,15.36,112.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE",450,MS-DRG,,,,,,,inpatient,,,251053.92,75316.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,105797.89,,"Fee schedule rate ($105,797.89). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,155603,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID ARM REDUCTION KIT- STANDARD, REGULAR",SUP-25401117,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 4X41+TRAK21 2-PACK - US",SUP-91314,CDM,S27200284,LOCAL,0272,RC,,,both,,,24624.97,7387.49,"KAISER [10500]",Kaiser,,16498.73,67,,,,,0,2863.88,20931.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 65MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712765,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,441.36,3225.75,"percent of total billed charges",
"SCR BONE 5MM 20MM SELF TAP VARIABLE ANGLE LOCK STARDRIVE",SUP-02.231.220,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"MULTIPLAN [10600]",Multiplan,,1111.66,85,,,,,0,152.1,1111.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR 53MM MULTIPOLAR HIP METAL STERILE",SUP-500105300,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FLIPCUTTER II 10MM FIXATION ACL 4 POINT",SUP-AR-1588BTB-02,CDM,C1713,HCPCS,0278,RC,,,both,,,5433.75,1630.12,"FIRST HEALTH [10303]","First Health",,4347,80,,,,,0,631.95,4618.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE WEB 2.0",SUP-PRT-WEB-020,CDM,C1713,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,834.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",834.57,6099.6,"percent of total billed charges",
"PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR",RX-6212,CDM,,,0250,RC,60687-0671-40,NDC,both,5,ML,46.22,13.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19,41.1,,,,,0,5.38,39.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 9MM KNEE X3 BEARING CRUCIATE RETAIN TRIATHLON",SUP-5530-G-409-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1352.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1327.29,9700.71,"percent of total billed charges",
"GRAFT CARDIOROOT VALSALVA 30MM",SUP-HEWROOT0030,CDM,C1768,HCPCS,0278,RC,,,both,,,13998.17,4199.45,"NOVANET [10819]",Novanet,,10498.63,75,,,,,0,1627.99,11898.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR PULL ENDOVIVE ENFIT STD",SUP-M00509041,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,199.75,41.1,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 40MM 80CM 12MM BILIARY VENOUS DELIVERY",SUP-G57432,CDM,C1876,HCPCS,0278,RC,,,both,,,12771.83,3831.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1513.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1485.36,10856.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET MULTIAXIAL 4 PK STERILE 559200008",SUP-559200008,CDM,C1713,HCPCS,0278,RC,,,both,,,4140.00,1242,"AMERIGROUP MEDICAID [20100]",Amerigroup,,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",481.48,3519,"percent of total billed charges",
"SPACER SPINAL 16X6MM COALITION AGX 0D 10MM NONSTERILE LATEX",SUP-3128.1406,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW DISTRACTION 12MM STERILE DISPOSABLE",SUP-73-2591-S5,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 28CM 3CM 6FR .038IN 2",SUP-M006192134170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"NOVANET [10819]",Novanet,,1046.42,75,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 22FR 20CM RADIOPAQUE STD ACCEPTS .038IN GWIRE",SUP-G01472,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.44,31.03,"AETNA [10100]","Aetna HMO/PPO",,82.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.03,87.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE BIOPSY 10.8CM BD TREK AUTOMATIC BRAKE CONTROL NDL",SUP-TKL1006,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KETAMINE 10 MG/ML INJECTION SOLUTION",RX-4236,CDM,,,0250,RC,55150-0438-01,NDC,both,20,ML,207.45,62.23,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT",RX-122493,CDM,,,0637,RC,41100-0811-63,NDC,both,42.5,GR,14.17,4.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 35 135CM 60MM 4MM .035IN LOW PROFILE BALLOON",SUP-B2040-060,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"MULTIPLAN [10600]",Multiplan,,654.08,85,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD MONOPOLAR 12.5IN 5MM OLSEN J HOOK REUSABLE",SUP-90-9525,CDM,S27000186,LOCAL,0270,RC,,,both,,,965.03,289.51,"UHC [10700]","United Healthcare",,610.86,63.3,,,,,0,112.23,820.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 6 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022216,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4757.25,28.62,,,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP MODIFIER LONG STEM",SUP-CAP1060,CDM,C1776,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1721.25,45.9,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM TRIATHLON 7 LEFT MEDIAL RIGHT LATERAL TOTAL",SUP-5545-A-701,CDM,C1776,HCPCS,0278,RC,,,both,,,4327.60,1298.28,"PHCS [10601]",PHCS,,3029.32,70,,,,,0,503.3,3678.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM OSSEOTI THR E1 CUP LINER INSRT",SUP-98B00100214,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"CIGNA [10200]","Cigna Open Access",,5909.4,33.5,,5302.19,4377.88,6578.61,27,2051.53,14994,"percent of total billed charges",
"PLATE 32MM 1 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800132,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,1831.33,1831.33,1831.33,16,521.61,3812.25,"percent of total billed charges",
"INSRT TIBIAL 1.5 CURVE 10MM KNEE GVF ROTATE PLATFORM PFC",SUP-972001,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"MULTIPLAN [10600]",Multiplan,,7862.03,85,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 17X8MM 14MM LORDOTIC NARROW PROFILE",SUP-G6626748,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3554.6,28.62,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 22CM 9MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140922,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]",Cigna,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 6.35MM TSR2D PRECUT BENT",SUP-8371090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"CATH SHOCKWAVE C2 AERO 138CM 12MM 2.5MM .044IN LITHOTRIPSY",SUP-C2AIVL2512,CDM,C1761,HCPCS,0272,RC,,,both,,,29610.00,8883,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12169.71,41.1,,,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 8CMX4CMX.2-.75MM DERMACELL DERMIS",SUP-DCELL154,CDM,Q4122,HCPCS,0636,RC,,,both,,,15278.81,4583.64,"KAISER [10500]",Kaiser,,10236.8,67,,,,,0,1810.54,12986.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYPROPYLENE 20X10IN PERMANENT REINFORCE LOCK",SUP-F10244-1020P,CDM,C1781,HCPCS,0278,RC,,,both,,,11316.00,3394.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7694.88,68,,,,,0,1316.05,9618.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB PCL SUBS 1-2X12MM L",SUP-2141-1-1212,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"NOVANET [10819]",Novanet,,2671.88,75,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROLENE 6X6IN KNIT NONABSORBABLE 2 DIRECTIONAL",SUP-SPMH,CDM,C1781,HCPCS,0278,RC,,,both,,,1873.59,562.08,"CIGNA [10200]","Cigna Local Plus",,1002.37,53.5,,3096.73,1.00,3096.73,"1 through 10",217.9,1592.55,"percent of total billed charges",
"PLUG BONE CEMENT 30MM LARGE INTRAMEDULLARY CANAL STERILE",SUP-6215-5-021,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,88.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",88.55,647.19,"percent of total billed charges",
"HEAD BIPOLAR 54MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-54-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"KAISER [10500]",Kaiser,,3790.86,67,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 6 SLOT RIGHT TI",SUP-PHPF-C6R,CDM,C1713,HCPCS,0278,RC,,,both,,,18144.00,5443.2,"UHC [10700]","United Healthcare",,11485.15,63.3,,5023.51,2672.93,6679.78,18,2110.15,15422.4,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 30CM 34MM THORACIC WOVEN SMOOTH NDL",SUP-M00202175434P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3797.28,1139.18,"PHCS [10601]",PHCS,,2658.1,70,,,,,0,441.62,3227.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 22GA ACCURIAN STRAIGHT SHARP 5MM",SUP-AC0017,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 014 150CM 4CM 5MM BALLOON DILATATION",SUP-U415054,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC .75CM 4.45X5.02CM ACCOLADE 2 CHMBR RA RV IS1",SUP-L311,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"MULTIPLAN [10600]",Multiplan,,35360,85,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 5 X 10 COMPLEX FRAMING COIL",SUP-10CFR05010,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"FIRST HEALTH [10303]","First Health",,9378.48,80,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 340MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.224S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4967.34,40,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE LEFT POSTERIOR STABILIZE CEMENT ATTUNE",SUP-150410102,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6408.98,28.62,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 5N 8MM",SUP-TPS-030-085N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOFTOUCH 65CM 5FR .044IN .035IN MOTARJEME CURVE",SUP-5572-13,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) IMPLANT DELIVERY SYSTEM AND IMPLANT (IMPLANT CATHETER",SUP-25100DST,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT HUMAN TISSUE SHEET 9X9CM DEHYDRATED AMNION/CHORION MEM",SUP-APS-5915,CDM,Q4433,HCPCS,0636,RC,,,both,,,60694.20,18208.26,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH JADE 150CM 60MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-593506022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE STRATAFIX MONOCRYL PLUS 2-0 CP-1 SPIRAL 70CM SUT",SUP-SXMP1B419,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER 6248V-90S ATTAIN SELECT II",SUP-6248V-90S,CDM,C1887,HCPCS,0272,RC,,,both,,,2272.50,681.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Rmvl Anal Tag or Papilla Sngl",PX-750000154,CDM,46220,CPT,0750,RC,,,both,,,7693.27,2307.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,911.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,894.73,6539.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Renl Ndl/Troc Perc",PX-361000210,CDM,50200,CPT,0361,RC,,,both,,,6338.08,1901.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2292.95,,"Case rate ($2,292.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,737.12,5387.37,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +14 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.140,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM OPHTHALMIC 14MM SPREAD BLADE EYE BARRAQUER ADULT",SUP-60-1963,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.92,27.88,"FIRST HEALTH [10303]","First Health",,74.34,80,,,,,0,10.81,78.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DISORDERS OF THE EYE WITHOUT MCC",125,MS-DRG,,,,,,,inpatient,,,38731.81,11619.54,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,4905.59,,"Case rate ($4,762.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,422.50, add-ons for qualifying new technology services are included. If operating cost exceeds $37,462.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,716.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,428.35. The transfer operating threshold is the transfer adjustment factor * $4,422.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $334.36. The transfer capital threshold is the transfer adjustment factor * $334.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4762.71,19148.16,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 30IN 23FR FEMUR VEIN ADULT .5IN CNCT 1 PIECE",SUP-96370-023,CDM,S27200284,LOCAL,0272,RC,,,both,,,2120.63,636.19,"CIGNA [10200]","Cigna Open Access",,1206.64,56.9,,,,,0,246.63,1802.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 8MM KII OPTICAL ACCESS SYSTEM Z",SUP-C0Q19,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC MEDIUM 24IN 16-19IN KNEE CONTACT CLSR",SUP-79-80035,CDM,S27000186,LOCAL,0270,RC,,,both,,,117.10,35.13,"FIRST HEALTH [10303]","First Health",,93.68,80,,,,,0,13.62,99.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE FIBER 6CC ALLOGRAFT",SUP-T50306,CDM,C1713,HCPCS,0278,RC,,,both,,,9522.00,2856.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1128.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1107.41,8093.7,"percent of total billed charges",
"CEMENTLESS KNEE SYSTEM",SUP-55500012,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"UHC [10700]","United Healthcare",,14755.23,63.3,,8601.07,8395.67,8601.07,"1 through 10",2710.95,19813.5,"percent of total billed charges",
"INSTR BIOPSY 20CM 18GA BARD MARQUEE CORE ENHANCE TROCAR TIP",SUP-MQ1820,CDM,S27200284,LOCAL,0272,RC,,,both,,,514.35,154.3,"UHC [10700]","United Healthcare",,325.58,63.3,,,,,0,59.82,437.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT HUMD LOW FLOW AEROSOL NONSTERILE LATEX FREE",SUP-PF-ADPC-LOW,CDM,S27000186,LOCAL,0270,RC,,,both,,,1220.40,366.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,144.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.93,1037.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 8CM 2MM BALLOON DILATATION OTW LOW",SUP-G30935,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 16MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036121650,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRN7PL,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,5873.17,5873.17,5873.17,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA2-17-75-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,9177.00,2753.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1067.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 18CM TITANIUM CURVE CIRCLE INTRALUMINAL",SUP-CDH21A,CDM,S27200284,LOCAL,0272,RC,,,both,,,5683.28,1704.98,"AETNA [10100]","Aetna HMO/PPO",,4518.21,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,660.97,4830.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 18IN ATS 1 PORT 1 BLADDER LUER LOCK CNCT STERILE",SUP-60707505300,CDM,S27200284,LOCAL,0272,RC,,,both,,,215.08,64.52,"CIGNA [10200]","Cigna Local Plus",,115.07,53.5,,,,,0,25.01,182.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC",982,MS-DRG,,,,,,,inpatient,,,75213.99,22564.2,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,15707.74,,"Case rate ($15,250.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,160.87, add-ons for qualifying new technology services are included. If operating cost exceeds $47,200.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,452.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,179.59. The transfer operating threshold is the transfer adjustment factor * $14,160.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,070.63. The transfer capital threshold is the transfer adjustment factor * $1,070.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,71778.37,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 80CM 5FR SOS OMNI 3 CURVE ANGIOGRAPHIC VISCERAL",SUP-H787107204065,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC LARGE SHOULDER ELASTIC FOAM",SUP-A111007,CDM,L3670,HCPCS,0274,RC,,,both,,,58.03,17.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,26.64,45.9,,,,,0,6.75,58.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ACROBAT ENDOSCOPIC 25CM SPRING COIL 260CM 4CM .025IN",SUP-G32758,CDM,C1769,HCPCS,0272,RC,,,both,,,1441.80,432.54,"PHCS [10601]",PHCS,,1009.26,70,,,,,0,167.68,1225.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.2MM X 10MM COCR",SUP-VAN-12010-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"CIGNA [10200]","Cigna Open Access",,737.42,56.9,,1144.80,304.56,2275.09,66,150.72,1101.6,"percent of total billed charges",
"PLATE BONE LEVEL ONE SQUARE CRANIOFACIAL TITANIUM 2X 2 HOLE",SUP-25-153-22-09,CDM,C1713,HCPCS,0278,RC,,,both,,,2087.93,626.38,"KAISER [10500]",Kaiser,,1398.91,67,,,,,0,242.83,1774.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM PRIMARY CLUSTER HOLE TRITANIUM F",SUP-502-03-60F,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"KAISER [10500]",Kaiser,,7012.77,67,,,,,0,1217.29,8896.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 1.5IN 18GA 10% PVP IODINE 1% LIDOCAINE CSR",SUP-181027,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.34,39.4,"UHC [10700]","United Healthcare",,83.14,63.3,,,,,0,15.27,111.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT CEMENTED CRUCIATE RETAINING ATTUNE",SUP-150400107,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2604.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pneumococcal Vaccine > 2 Yrs",PX-771000010,CDM,90732,CPT,0636,RC,,,both,,,392.78,117.83,"BLUE CROSS [10001]","Blue Cross HMO",,155.56,,,,,,,9.58,333.86,"fee schedule",
"STEM FEMORAL COLLAR ACTIS DUOFIX 10 STD OFFSET HIP STERILE",SUP-101011100,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"PHCS [10601]",PHCS,,21333.38,70,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PLLA HA 20MM 7MM 1.5MM ACL PCL CANNULATED",SUP-7207686,CDM,C1713,HCPCS,0278,RC,,,both,,,1839.23,551.77,"MULTIPLAN [10600]",Multiplan,,1563.35,85,,,,,0,213.9,1563.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 17MM TITANIUM LEVEL 1 ZEVO BONE SPINE CERVICAL",SUP-3001017,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1927.8,45.9,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URETEROSCOPE FLEXIBLE 9.5FR 7.7FR 3.6FR LITHOVUE STD",SUP-M0067913500,CDM,C1747,HCPCS,0272,RC,,,both,,,10350.00,3105,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4750.65,45.9,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 15MM 4.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP4515X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"UHC [10700]","United Healthcare",,333.27,63.3,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE3.5MM 32.5MM MAXLOCK EXTREME ANKLE FOOT NONLOCKING",SUP-MFT01135325,CDM,C1713,HCPCS,0278,RC,,,both,,,1239.30,371.79,"PHCS [10601]",PHCS,,867.51,70,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS SOLN DEX 2.5 % LOW CA+ 2.5 MEQ/L&MAG 0.5 MEQ/L",RX-27800,CDM,,,0250,RC,00941-0430-52,NDC,both,2000,ML,241.44,72.43,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CXI 150CM 4FR SPRT STAINLESS STEEL HYDROPHILIC LOW",SUP-G52544,CDM,C1887,HCPCS,0272,RC,,,both,,,1522.72,456.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 15MM",SUP-SPL30015X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPN NC 15MM 4.5MM 35 ATM BALLOON DILATATION THIN WALL",SUP-450-015-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRONCHOSCOPE EXAMINATION BFLEX ULTRASLIM 2.8 SINGLE USE X2",SUP-0570-0447,CDM,S27200284,LOCAL,0272,RC,,,both,,,2295.00,688.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 12.25CM NATRELLE INSPIRA P3.2CM LOW PLUS PROFILE",SUP-MSZ-LP265,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA [10200]","Cigna Local Plus",,84.63,53.5,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE RIGHT CRUCIATE RETAIN SIGMA STERILE",SUP-940026,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"BLUE CROSS [10001]","Blue Cross HMO",,10148.82,39.2,,5311.50,4717.44,5388.59,31,3010.99,22006.37,"percent of total billed charges",
"GRAFT VASCULAR 30CM 20MM GORE-TEX STD WALL STD WALLED RING",SUP-R20030030,CDM,C1768,HCPCS,0278,RC,,,both,,,6141.00,1842.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,714.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,714.2,5219.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 35MM 4.75MM CD HORIZON SOLERA COCRMO CAP",SUP-641003035,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 8- CM 19GA 1.83MM COCR SILICONE 137.5-147.5CM",SUP-M00555500,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 56MM 20MM 6MM 16FR ZENITH SPIRAL-Z 2",SUP-G55241,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"BLUE CROSS [10001]","Blue Cross PPO",,8300.33,39.2,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL STRAIGHT SPAT 36CM CLEANCOAT",SUP-E3770-36C,CDM,S27200284,LOCAL,0272,RC,,,both,,,251.00,75.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,29.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.19,213.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM SPINE PLY NONSTERILE 4MM ROD",SUP-102040112,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"SHEATH VERSACROSS 45D 1 CURVE J TIP 63CM 180CM 8.5FR GUIDING",SUP-VXSK0002,CDM,C1893,HCPCS,0272,RC,,,both,,,6175.50,1852.65,"FIRST HEALTH [10303]","First Health",,4940.4,80,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Elect Dual",PX-480000014,CDM,33220,CPT,0481,RC,,,both,,,5648.00,1694.4,"CIGNA [10200]",Cigna,,5648,,"Case rate ($17,696). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,656.86,5648,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 58MM 40MM ALTRX HIP",SUP-122140058,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"BLUE CROSS [10001]","Blue Cross HMO",,5410.95,39.2,,5311.50,4717.44,5388.59,31,1605.34,11732.93,"percent of total billed charges",
"EXT FEMORAL 50MM GMRS KNEE COCR",SUP-64956050,CDM,C1776,HCPCS,0278,RC,,,both,,,16025.25,4807.57,"CIGNA [10200]","Cigna Local Plus",,5047.95,31.5,,5372.07,4581.20,7242.98,23,1863.74,13621.46,"percent of total billed charges",
"AIRWAY LARYNGEAL MASK CHILD SIZE 3 OROGASTRIC TUBE 14FR 30ML",SUP-ALBF030SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.97,31.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.09,88.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE 10CM 2.5CM 4FR INTRO STAINLESS STEEL",SUP-RSS402,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"UHC [10700]","United Healthcare",,49.56,63.3,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION",RX-155788,CDM,J0650,HCPCS,0636,RC,63323-0649-07,NDC,both,1,UN,726.48,217.94,"CIGNA [10200]","Cigna Open Access",,160.74,,,,,,,80.07,617.51,"fee schedule",
"CATH SOFT-VU 80CM 5FR SOS OMNI 0 CURVE ANGIOGRAPHIC VISCERAL",SUP-H787107204085,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"PHCS [10601]",PHCS,,152.25,70,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL SYMMETRY .3MM MICRO 5.25INX9MM TYPE PLATFORM",SUP-78-0050,CDM,S27200284,LOCAL,0272,RC,,,both,,,528.53,158.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,242.6,45.9,,,,,0,61.47,449.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 8MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR180830,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"KAISER [10500]",Kaiser,,12460.39,67,,,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHOLANGIOGRAM 3.5IN 2.7MM INTRADUCER PERITONEAL",SUP-PI-104,CDM,C1894,HCPCS,0272,RC,,,both,,,322.77,96.83,"MULTIPLAN [10600]",Multiplan,,274.35,85,,,,,0,37.54,274.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTICROSS HD ULTRASOUND CORONARY BAGLESS NONCE IMAGE",SUP-H74939352050,CDM,C1753,HCPCS,0272,RC,,,both,,,5037.00,1511.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3425.16,68,,,,,0,585.8,4281.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 5CC DBX ALLOGRAFT PASTE FREEZE DRIED",SUP-028050,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Open Access",,2133.75,56.9,,1144.80,304.56,2275.09,66,436.13,3187.5,"percent of total billed charges",
"STENT COVERA 40MM 120CM 7MM 8FR STRAIGHT VASCULAR",SUP-AVSL07040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7508.97,41.1,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 5MM .0125IN AXIUM DETACHABLE SMOOTH",SUP-NV-5-20-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM TRILOGY TIVANIUM HIP CORTICAL ACETABULAR",SUP-00625006535,CDM,C1713,HCPCS,0278,RC,,,both,,,691.60,207.48,"KAISER [10500]",Kaiser,,463.37,67,,,,,0,80.43,587.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 36MM PERFORM THK+0MM .5IN SHOULDER STERILE",SUP-DWP3360,CDM,C1776,HCPCS,0278,RC,,,both,,,17388.00,5216.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4694.76,27,,,,,0,2022.22,14779.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SIDE RAIL CLAMP 1.25IN MARKED",SUP-50235-001ES,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHISEL SURGICAL 6.75IN 8MM V BALLENGER",SUP-63-0091,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 8MM DCP STAINLESS STEEL CORTICAL SELF TAPPING",SUP-202.808,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,100.54,28.62,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 10CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175195190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,149.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8MM 315MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-408-315,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 7 RIGHT DISTAL KNEE TOTAL",SUP-5540-A-702,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,538.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,528.45,3862.24,"percent of total billed charges",
"HC Analysis Semen Complt",PX-309000109,CDM,89320,CPT,0309,RC,,,both,,,361.00,108.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,42.79,,,,,,,3.91,306.85,"fee schedule",
"NDL BIOPSY 21GA 10CM CHIBA STERILE DISPOSABLE",SUP-G00933,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.00,28.5,"CIGNA [10200]","Cigna Open Access",,54.06,56.9,,,,,0,11.05,80.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION VENOUS RETURN 1 PIECE 3 STAGE TUBING CNCT",SUP-RTS-13029,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"CIGNA [10200]","Cigna Local Plus",,281.68,53.5,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2MM 150MM KIRSCHNER STAINLESS STEEL SET TROCAR",SUP-71161020,CDM,C1713,HCPCS,0278,RC,,,both,,,65.09,19.53,"CIGNA [10200]","Cigna Local Plus",,34.82,53.5,,3978.14,359.25,3978.14,24,7.57,55.33,"percent of total billed charges",
"STEM HUMERAL 170MM 7MM REVERSE CEMENT AEQUALIS LONG SHOULDER",SUP-DWD931,CDM,C1776,HCPCS,0278,RC,,,both,,,16560.00,4968,"CIGNA [10200]",Cigna,,6624,40,,5873.17,5873.17,5873.17,"1 through 10",1925.93,14076,"percent of total billed charges",
"SUT QUILL SRS PDS 2 CT-1 T-8 36X36CM ABSORBABLE",SUP-RX-1062Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.81,62.64,"CIGNA [10200]",Cigna,,141.99,68,,,,,0,24.28,177.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 15MM 6FR 3.5MM",SUP-H7493926715350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +22 DIOPTER +5.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT8.220,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,158.36,45.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK",RX-11074,CDM,J3480,HCPCS,0636,RC,00990-7074-26,NDC,both,100,ML,100.65,30.19,"MULTIPLAN [10600]",Multiplan,,85.55,85,,,,,0,0.12,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR MEDIALIZE DOME 41MM CEMENT ATTUNE AOX KNEE",SUP-1518-20-041,CDM,C1776,HCPCS,0278,RC,,,both,,,5409.60,1622.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,641.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.14,4598.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE LEFT CRUCIATE RETAIN CEMENTLESS",SUP-150401125,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"NOVANET [10819]",Novanet,,21581.44,75,,,,,0,3346.56,24458.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOCKING COMPRESSION SCREW 1.8MM X 9.0MM COCR",SUP-CMP-18009-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,881.28,68,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 5FR 1245ML/HR 1 LUMEN MICROINTRODUCER POWER",SUP-0700515,CDM,C1751,HCPCS,0272,RC,,,both,,,1717.50,515.25,"NOVANET [10819]",Novanet,,1288.13,75,,,,,0,199.75,1459.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anoscopy Diagnostic",PX-750000178,CDM,46601,CPT,0750,RC,,,both,,,711.00,213.3,"NOVANET [10819]",Novanet,,533.25,75,,,,,0,82.69,711,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ahg Indirct",PX-302000189,CDM,86885,CPT,0302,RC,,,both,,,226.20,67.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5.15,,,,,,,3.87,192.27,"fee schedule",
"CATH SABERX RADIANZ 190CM 40MM 6MM .018IN BALLOON DILATATION",SUP-R51006004L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,810.39,41.1,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN DEBRIDEMENT WITH MCC",570,MS-DRG,,,,,,,inpatient,,,87589.05,26276.71,"AMBETTER EXCHANGE  [11102]",Ambetter,,18243.82,,"Case rate ($18,243.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $16,940.63, add-ons for qualifying new technology services are included. If operating cost exceeds $49,980.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,662.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $16,963.03. The transfer operating threshold is the transfer adjustment factor * $16,940.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,280.79. The transfer capital threshold is the transfer adjustment factor * $1,280.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,85868.36,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 5.5MM MATRIX CURVE TITANIUM HARD NONSTERILE",SUP-04.636.040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL SF D-F CURVE ABLATION",SUP-D134805,CDM,C1732,HCPCS,0272,RC,,,both,,,21312.90,6393.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,14492.77,68,,,,,0,2478.69,18115.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION",RX-3037,CDM,J3010,HCPCS,0636,RC,00641-6028-01,NDC,both,5,ML,46.03,13.81,"BLUE CROSS [10001]","Blue Cross HMO",,3.85,,,,,,,3.85,39.13,"fee schedule",
"CMPNT FEMORAL 8 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-1504-40-108,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12376.85,41.1,,6417.48,6417.48,6417.48,"1 through 10",3502.26,25596.9,"percent of total billed charges",
"STENT VIABAHN 15CM 75CM 7MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR071501A,CDM,C1874,HCPCS,0278,RC,,,both,,,21577.50,6473.25,"NOVANET [10819]",Novanet,,16183.13,75,,,,,0,2509.46,18340.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 15MM 3.3-3.6FR 4MM BALLOON",SUP-1008189-15,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"AETNA [10100]","Aetna HMO/PPO",,1126.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 8 WIRE GUIDED FLOWERBASKET",SUP-FG-V431P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 12MM ENDOPATH XCEL BLUNT TIP",SUP-H12LP,CDM,S27200284,LOCAL,0272,RC,,,both,,,1189.82,356.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,140.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,138.38,1011.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 3-0 SH 18IN BRAID 8 STRAND BLACK",SUP-M13T,CDM,S27200284,LOCAL,0272,RC,,,both,,,86.41,25.92,"CIGNA [10200]","Cigna Open Access",,49.17,56.9,,,,,0,10.05,73.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CENTRAL LINE DRESSING CHANGE 132",SUP-03-5837,CDM,S27000186,LOCAL,0270,RC,,,both,,,86.21,25.86,"NOVANET [10819]",Novanet,,64.66,75,,,,,0,10.03,73.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POS STENT 45CM 7FR URETERAL RADIOPAQUE",SUP-M0061802021,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.15,26.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.25,74.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 75CM 1.3MM VECTRIS SURESCAN 4MM SPACE 1X8",SUP-977A275,CDM,C1778,HCPCS,0278,RC,,,both,,,13800.00,4140,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1635.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN FEMORAL RIGHT 5 CURVE",SUP-864103,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"UHC [10700]","United Healthcare",,44.89,63.3,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR 28CM 13-15FR ACCESS STAINLESS STEEL",SUP-M0062502071,CDM,C1894,HCPCS,0272,RC,,,both,,,815.04,244.51,"UHC [10700]","United Healthcare",,515.92,63.3,,,,,0,94.79,692.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION",RX-9722,CDM,J0895,HCPCS,0636,RC,00409-2337-15,NDC,both,1,UN,307.39,92.22,"UHC [10700]","United Healthcare",,66.08,,,,,,,39.8,261.28,"fee schedule",
"MODULUS ALIF BOLT, 5.0X22.5MM FIXATION",SUP-1450225,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,743.58,45.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LASSO NAVISTAR 7FR 20MM FIXED D CURVE ELECTROPHYSIOLOGY",SUP-D134903,CDM,C1732,HCPCS,0272,RC,,,both,,,11350.50,3405.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1320.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 55MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-54840007555,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"ANCHOR SUT 3-0 NANO CORKSCREW FT 2 NDL 1.35MM K WIRE",SUP-AR-1317FT,CDM,C1713,HCPCS,0278,RC,,,both,,,3346.88,1004.06,"BLUE CROSS [10001]","Blue Cross HMO",,1311.98,39.2,,957.42,156.86,7483.26,51,389.24,2844.85,"percent of total billed charges",
"SCR BONE 6.5MM 125MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.420,CDM,C1713,HCPCS,0278,RC,,,both,,,1519.48,455.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,434.88,28.62,,,,,0,176.72,1291.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAR EXTERNAL FIXATION 400MM JET-X UNILATERAL",SUP-71062400,CDM,C1713,HCPCS,0278,RC,,,both,,,3314.70,994.41,"CIGNA [10200]","Cigna Open Access",,1886.06,56.9,,1144.80,304.56,2275.09,66,385.5,2817.5,"percent of total billed charges",
"GENRTR NEROSTIMLTR INSPIRE 1 TORQUE HEX WRENCH LEAD CNCT",SUP-3150,CDM,C1767,HCPCS,0278,RC,,,both,,,123120.00,36936,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,50602.32,41.1,,,,,0,14318.86,104652,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM LAVA-18 EMBOLIC 6ML LIQUID",SUP-SLLES186,CDM,S27800098,LOCAL,0278,RC,,,both,,,36540.00,10962,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9865.8,27,,,,,0,4249.6,31059,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR .09IN EXTRA BACKUP LEFT 3.5 CURVE",SUP-LA8EBU35SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"FIRST HEALTH [10303]","First Health",,292.32,80,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 5CM 4FR PIGTAIL PANCREATIC POLYMER RADIOPAQUE",SUP-M00536890,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"FIRST HEALTH [10303]","First Health",,511.4,80,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Flt3 Gene Analysis Tkd Variant",PX-310000001,CDM,81246,CPT,0310,RC,,,both,,,535.80,160.74,"NOVANET [10819]",Novanet,,401.85,75,,,,,0,0.01,455.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Vag Brachtx Device",PX-333000058,CDM,57156,CPT,0361,RC,,,both,,,2858.96,857.69,"BLUE CROSS [10001]","Blue Cross PPO",,2740.57,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,332.5,2858.96,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL NAVISTAR 115CM 8FR 3.5MM JJ CURVE",SUP-D132703,CDM,C1732,HCPCS,0272,RC,,,both,,,19845.00,5953.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2351.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2307.97,16868.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE COOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-CRKA-17-75-5.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"UHC [10700]","United Healthcare",,3275.78,63.3,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM AEQUALIS TITANIUM SHOULDER LOCKING",SUP-DWD035,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"NOVANET [10819]",Novanet,,1167,75,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE F CURVE",SUP-D7BTFL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,576.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR SMALL 2X2X1MM 1MM APPLEBAUM INCUDOSTAPEDIAL",SUP-14-0956,CDM,L8613,HCPCS,0278,RC,,,both,,,2652.68,795.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1217.58,45.9,,,,,0,232.31,2254.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL NASAL 20MM LATERA ABSORBABLE STERILE LATEX FREE",SUP-LATSYS20,CDM,S27800098,LOCAL,0278,RC,,,both,,,14262.30,4278.69,"UHC [10700]","United Healthcare",,9028.04,63.3,,,,,0,1658.71,12122.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 20-23MM EVOLUT FX+ 26MM ANNULUS",SUP-EVFXPLUS-26,CDM,S27800098,LOCAL,0278,RC,,,both,,,182400.00,54720,"KAISER [10500]",Kaiser,,122208,67,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT STEM 80MM 10MM 1 AXIS PRESS FIT CEMENTED KNEE VITALLIUM",SUP-6478-6-395,CDM,C1776,HCPCS,0278,RC,,,both,,,3364.45,1009.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,962.91,28.62,,,,,0,391.29,2859.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 18 12 X 40 COMPLEX FRAMING COIL",SUP-18CFR-12040,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3742.21,28.62,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTERMSTIM SURESCAN  MRI LEAD KIT 4.32 MM SPACING -28 CM LEN",SUP-978B128,CDM,C1778,HCPCS,0278,RC,,,both,,,22050.00,6615,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5F DECA 4-4-4-23-4-4-4-4-4MPA 120CM",SUP-901579,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"KAISER [10500]",Kaiser,,1984.88,67,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPLANT 16CM NATRELLE INSPIRA P5.2CM MODERATE PROFILE",SUP-MSZ-M685,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PHCS [10601]",PHCS,,110.73,70,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 30MM TSRH OSTEOGRIP THINLINE TITANIUM SPINE",SUP-83585309,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,305.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,299.36,2187.9,"percent of total billed charges",
"HC Consult Surg WO Frozen",PX-312000036,CDM,88329,CPT,0312,RC,,,both,,,377.15,113.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.62,,,,,,,0.01,320.58,"fee schedule",
"COIL EMBOLIZATION 15CM 6MM .038IN AZUR DETACHABLE .035IN",SUP-45-450615,CDM,S27800098,LOCAL,0278,RC,,,both,,,1851.00,555.3,"FIRST HEALTH [10303]","First Health",,1480.8,80,,,,,0,215.27,1573.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 3-7MM 3.5MM 2.5MM ALTO EAR TITANIUM TOTAL",SUP-600,CDM,L8613,HCPCS,0278,RC,,,both,,,2641.50,792.45,"MULTIPLAN [10600]",Multiplan,,2245.28,85,,,,,0,232.31,2245.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 6CM 5.8FR 12FR BALLOON",SUP-M0062251060,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"PHCS [10601]",PHCS,,1198.74,70,,,,,0,199.16,1455.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 2.9MM JUGGERLOC TITANIUM",SUP-110007345,CDM,C1713,HCPCS,0278,RC,,,both,,,8983.80,2695.14,"KAISER [10500]",Kaiser,,6019.15,67,,,,,0,1044.82,7636.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Kidney Img Flow WO Drug",PX-341000044,CDM,78707,CPT,0341,RC,,,both,,,2827.57,848.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,269.12,,,,,,,269.12,2403.43,"fee schedule",
"ICD-VR DVFB1D4 VISIA MRI AF US DF4",SUP-DVFB1D4,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"CIGNA [10200]","Cigna Local Plus",,12285,31.5,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENT BUR 2.0MMDIA FINE DIAMOND SS 70MM LONG SHORT EXTENDED AN",SUP-SA-DB2L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,204.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 18MM STAINLESS STEEL SHORT THREAD ORTHOPEDIC",SUP-02.226.018,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"NOVANET [10819]",Novanet,,1233.9,75,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.0 PLY SCRW 3.5X24",SUP-102035124,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"HC US Guide Vasc Access",PX-402000037,CDM,76937,CPT,0402,RC,,,both,,,1042.47,312.74,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,277,,"Per diem ($277).",,,,0,49.54,886.1,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 3X3IN DURAGEN DURAL BOVINE CLLGN PATCH",SUP-ID3301,CDM,,,0278,RC,,,both,,,6468.89,1940.67,"MULTIPLAN [10600]",Multiplan,,5498.56,85,,,,,0,6.47,5498.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC ESOPHAGUS PYLORUS BILIARY INFLATE LATEX FREE",SUP-M00558640,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1121.34,68,,,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE RIGHT CRUCIATE RETAIN CEMENTLESS ATTUNE",SUP-150401206,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"PHCS [10601]",PHCS,,20142.68,70,,,,,0,3346.56,24458.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ethosuximide",PX-301000043,CDM,80168,CPT,0301,RC,,,both,,,245.00,73.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,25.7,,,,,,,0.01,208.25,"fee schedule",
"NDL BIOPSY 20GA 15CM CHIBA ECHOTIP STERILE LATEX DISPOSABLE",SUP-G03955,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.41,39.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.17,110.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 9CM ACHIEVE SPRING LOAD LIGHTWEIGHT",SUP-A209,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.39,103.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,141.13,41.1,,,,,0,39.94,291.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCPOINT PULMONARY NEEDLE 21GA",SUP-ILS-2100-PN,CDM,S27200284,LOCAL,0272,RC,,,both,,,1857.00,557.1,"CIGNA [10200]",Cigna,,1262.76,68,,,,,0,215.97,1578.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR LOW BEND 102MM STAINLESS STEEL 3.5MM SCR 6",SUP-02.124.204,CDM,C1713,HCPCS,0278,RC,,,both,,,7998.48,2399.54,"PHCS [10601]",PHCS,,5598.94,70,,,,,0,930.22,6798.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACETAZOLAMIDE SODIUM 500 MG/5ML IJ (WET SOLR VIAL)",RX-415114,CDM,J1120,HCPCS,0636,RC,23155-0313-31,NDC,both,1,UN,299.66,89.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.07,,"Fee schedule rate ($30.07). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.12,254.71,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR TRABECULAR METAL VIVACIT-E STEM CUP LINER STD",SUP-98000571503,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"KAISER [10500]",Kaiser,,16884,67,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACETAZOLAMIDE SODIUM 500 MG/5ML IJ (WET SOLR VIAL)",RX-415114,CDM,J1120,HCPCS,0636,RC,23155-0313-31,NDC,both,1,UN,299.66,89.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,42.38,,,,,,,23.12,254.71,"fee schedule",
"ACETAZOLAMIDE SODIUM 500 MG/5ML IJ (WET SOLR VIAL)",RX-415114,CDM,J1120,HCPCS,0636,RC,23155-0313-31,NDC,both,1,UN,299.66,89.9,"MULTIPLAN [10600]",Multiplan,,254.71,85,,,,,0,23.12,254.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DUO-DECA 2-8-2 MPD-L 100CM",SUP-901675,CDM,C1731,HCPCS,0272,RC,,,both,,,4761.00,1428.3,"UHC [10700]","United Healthcare",,3013.71,63.3,,,,,0,553.7,4046.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 TWINFIX PK ULTRABRAID COBRAID NDL",SUP-72202611,CDM,C1713,HCPCS,0278,RC,,,both,,,2355.75,706.72,"CIGNA [10200]","Cigna Local Plus",,1260.33,53.5,,3978.14,359.25,3978.14,24,273.97,2002.39,"percent of total billed charges",
"CATH VISTA BRITE TIP 100CM 8FR LCB CURVE GUIDING STAINLESS",SUP-588818,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 22MM KNEE X3 CRUCIATE SUB TRIATHLON",SUP-5531G622,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4110,41.1,,6417.48,6417.48,6417.48,"1 through 10",1163,8500,"percent of total billed charges",
"TISSUE MARKER 4 X 5 BIOZORB",SUP-F0405,CDM,A4648,HCPCS,0278,RC,,,both,,,7935.00,2380.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,940.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL CORTICAL THK3-12MM HALF ALLOGRAFT STRUT",SUP-450495,CDM,S27800098,LOCAL,0278,RC,,,both,,,6677.82,2003.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4540.92,68,,,,,0,776.63,5676.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL COMPREHENSIVE +6MM STD SHOULDER REVERSE",SUP-110031405,CDM,C1776,HCPCS,0278,RC,,,both,,,8224.80,2467.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,956.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,956.54,6991.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTERED TC 99M-SODIUM THIOSULFATE SOLUTION (20-40 MCI)",RX-411855,CDM,A9541,HCPCS,0343,RC,08888-8876-02,NDC,both,1,UN,746.77,224.03,"PHCS [10601]",PHCS,,522.74,70,,,,,0,86.85,746.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATHETER THE RINGER PERFUSION 20MM OD 3MM PERFUSION P",SUP-5884,CDM,C1725,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"OBTR ENDOSCOPIC SCHMIEDT TUBING INSRT 27040BO 27042B BZ",SUP-27050BK,CDM,S27200284,LOCAL,0272,RC,,,both,,,4963.58,1489.07,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MATRIX TISSUE 8X6CM BOVINE PERICARDIUM RESORBABLE SUTURABLE",SUP-BP10608,CDM,Q4432,HCPCS,0636,RC,,,both,,,4159.87,1247.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRONABINOL 2.5 MG CAPSULE",RX-9904,CDM,Q0167,HCPCS,0250,RC,67877-0753-60,NDC,both,1,UN,39.13,11.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC",465,MS-DRG,,,,,,,inpatient,,,87286.29,26185.89,"AETNA [10100]","Aetna HMO/PPO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 4.0X30MM",SUP-PRV040030CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC",220,MS-DRG,,,,,,,inpatient,,,310423.77,93127.13,"CIGNA [10200]",Cigna,,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 55.9%. Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC",097,MS-DRG,,,,,,,inpatient,,,148266.63,44479.99,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL RUSSIAN 14IN TISSUE",SUP-07-1535,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.31,262.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PEG FIXATION 2MM 18MM SMOOTH LOCKING DVR NONSTERILE ANATOMIC",SUP-P18000,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,501.92,45.9,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 64CM ENDOTAK RELIANCE ENDOCARDIAL STEROID SILICONE",SUP-148,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1765.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28X10X10MM COALESCE LORDOTIC STRAIGHT STERILE",SUP-2000-00-101008,CDM,C1889,HCPCS,0278,RC,,,both,,,21420.00,6426,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2491.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEDG CARDIOVASCULAR WHITE 9.5X4.8MM THK1.5MM Y TFE SOFT",SUP-PCP40,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.95,15.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,34.65,68,,,,,0,5.93,43.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH ENDOSCP 4MM 11.35MM ROUND EDGE STERILE LATEX FREE",SUP-D-201-10704,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.26,63.08,"FIRST HEALTH [10303]","First Health",,168.21,80,,,,,0,24.45,178.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +30 DIOPTER 0 D 13MM 6MM POSTERIOR CHMBR 1 PIECE",SUP-SN60WF.300,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 110MM 18 HOLE RESORBABLE BIOBRIDGE BONE RIB NONSTERILE",SUP-RRP1501,CDM,C1713,HCPCS,0278,RC,,,both,,,9204.60,2761.38,"CIGNA [10200]",Cigna,,6259.13,68,,1831.33,1831.33,1831.33,16,1070.49,7823.91,"percent of total billed charges",
"SCR BONE 2.7MM 62MM LCP STAINLESS STEEL T8 ELBOW METAPHYSEAL",SUP-02.118.562,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"NOVANET [10819]",Novanet,,392.93,75,,,,,0,60.93,445.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT PATIENT BLACK APB SMALL METASHANK SQUARE TOE",SUP-199649,CDM,S27000186,LOCAL,0270,RC,,,both,,,214.02,64.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.89,181.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 4MM 1.2MM 17MM 8MM STAINLESS STEEL LONG THREAD",SUP-202.717,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,131.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",129.1,943.52,"percent of total billed charges",
"CATH CARTO XP LASSO 115CM 7FR 25MM 6MM SPACING D CURVE",SUP-DLN2225CT,CDM,C1732,HCPCS,0272,RC,,,both,,,12889.20,3866.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1527.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1499.01,10955.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 10FR .131IN 25CM ROBUST VALVE SPLITTABLE",SUP-PLSX-2510,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 159MM STAINLESS STEEL 4.5MM SCR 6 HOLE 4 COLUMN",SUP-02.124.407S,CDM,C1713,HCPCS,0278,RC,,,both,,,13248.28,3974.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3791.66,28.62,,,,,0,1540.77,11261.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 8X38X28MM 10DEG",SUP-1921042P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9916.83,28.62,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 69MM 75CM 10MM 100CM",SUP-M001712380,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5747.7,68,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 15X13CM BREAST 650ML STYLE 133SX-T TEXTURED TAB",SUP-133SX-15-T,CDM,C1789,HCPCS,0278,RC,,,both,,,6510.00,1953,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,757.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,757.11,5533.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRACTURE REVERSE - REUNION FRACTURE RFX REVERSE",SUP-S4,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,18144,40,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAMINAR IMPLANT SIZE (12MM)",SUP-FG-6031,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC",097,MS-DRG,,,,,,,inpatient,,,148266.63,44479.99,"PHCS [10601]",PHCS,,7561,,,,,,,7561,90074.68,"per diem","Estimated amount calculated based on 14 day length of stay."
"HC New Eval Visit Level 4",PX-510000174,CDM,99204,CPT,0510,RC,,,both,,,512.72,153.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,60.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.76,60.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Stoma Bx",PX-750000069,CDM,44389,CPT,0750,RC,,,both,,,2060.19,618.06,"MULTIPLAN [10600]",Multiplan,,1751.16,85,,,,,0,239.6,2060.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURETTE MICRO 7 1/2IN RHOTON",SUP-58-6050,CDM,S27200284,LOCAL,0272,RC,,,both,,,524.07,157.22,"AETNA [10100]","Aetna HMO/PPO",,416.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.95,445.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTEPLASE 2 MG INTRA-CATHETER SOLUTION",RX-31310,CDM,J2997,HCPCS,0636,RC,50242-0041-64,NDC,both,1,UN,1117.67,335.3,"BLUE CROSS [10001]","Blue Cross HMO",,220.16,,,,,,,132.44,950.02,"fee schedule",
"HC Lampoon of Mitral Valve Leaflet",PX-361000642,CDM,33999,CPT,0361,RC,,,both,,,16913.00,5073.9,"BLUE CROSS [10001]","Blue Cross HMO",,4998.78,,"Case rate ($4,998.78). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1550,14376.05,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 RIGHT KNEE TRIATHLON",SUP-5610-F-102,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"CIGNA [10200]",Cigna,,6801.43,68,,5873.17,5873.17,5873.17,"1 through 10",1163.24,8501.79,"percent of total billed charges",
"CATH EVERCROSS BEVEL 360 135CM 120MM 3MM .035IN BALLOON",SUP-AB35W03120135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"KAISER [10500]",Kaiser,,453.7,67,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION 105CM 2.4FR MICRO BERN INFUSION NITINOL 1",SUP-M001195230,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 STD KNEE RIGHT CRUCIATE RETAIN PERSONA COCR",SUP-42502805602,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"CIGNA [10200]","Cigna Open Access",,9680.02,33.5,,5302.19,4377.88,6578.61,27,3360.56,24561.24,"percent of total billed charges",
"(EVAL) SUPIRA CATHETER",SUP-FG-03242,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165CM 10.5-12MM OTSC 3MM NITINOL",SUP-100.06,CDM,C1760,HCPCS,0278,RC,,,both,,,4133.10,1239.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,489.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,480.68,3513.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 11MM KNEE X3 CONDYLAR STABILIZED PRIMARY",SUP-5531G711,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"PHCS [10601]",PHCS,,6556.26,70,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plmt Ureter Stnt Exist",PX-361000417,CDM,50693,CPT,0361,RC,,,both,,,9829.56,2948.87,"BLUE CROSS [10001]","Blue Cross PPO",,3634.7,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1143.18,9829.56,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL C TAPER COBALT CHROME LFIT",SUP-06-3205,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"PHCS [10601]",PHCS,,2189.39,70,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +9MM 12/14 TAPER 32MM HIP BIOLOX DELTA",SUP-136532330,CDM,C1776,HCPCS,0278,RC,,,both,,,6844.32,2053.3,"CIGNA [10200]","Cigna Open Access",,3894.42,56.9,,5302.19,4377.88,6578.61,27,795.99,5817.67,"percent of total billed charges",
"SYSTEM ELUNIR THK90UM 12MM 140CM 3MM CORONARY STENT CARBOSIL",SUP-LUN300R12US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC MEDIUM 20IN 16-18IN KNEE CONTOUR POSTERIOR",SUP-4462-03,CDM,L1830,HCPCS,0274,RC,,,both,,,140.77,42.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,40.29,28.62,,,,,0,16.37,119.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 5.5MM ARMADA TITANIUM PREBENT",SUP-8052045,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross HMO",,1728.72,39.2,,957.42,156.86,7483.26,51,512.88,3748.5,"percent of total billed charges",
"SCR BONE 4MM 40MM UCSS TITANIUM ALLOY CORTICAL CANNULATED",SUP-873-040,CDM,C1713,HCPCS,0278,RC,,,both,,,3315.00,994.5,"NOVANET [10819]",Novanet,,2486.25,75,,,,,0,385.53,2817.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FUSION TITAN 190CM 4CM 18FR 6MM .035IN BALLOON",SUP-G49220,CDM,C1726,HCPCS,0272,RC,,,both,,,2452.50,735.75,"FIRST HEALTH [10303]","First Health",,1962,80,,,,,0,285.23,2084.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM SENSAR INTRAOCULAR LENS, BICONVEX, 21.0 DIOPTER",SUP-AR40E00210,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"NOVANET [10819]",Novanet,,698.63,75,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 30MM TI",SUP-SPL-35300-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 7FR ENDOCARDIUM TRUE BIPOLAR ACTIVE",SUP-7121Q/52,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4636.44,27,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1MM 10MM STAINLESS STEEL CORTICAL HAND SELF TAPPING",SUP-200.530,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"CIGNA [10200]",Cigna,,323.87,68,,1831.33,1831.33,1831.33,16,55.39,404.84,"percent of total billed charges",
"SCR BONE 4.5MM 6.5MM 62MM TITANIUM FULL THREAD CORTEX SELF",SUP-414.862,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,32.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",32.01,233.98,"percent of total billed charges",
"SCR BONE 5MM 70MM LOCK STERILE",SUP-2361-5070S,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.05,506.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,199.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",196.2,1433.99,"percent of total billed charges",
"SCR SPINAL 14MM 4MM CODA SPINE SELF TAP VARIABLE ANGLE",SUP-102254014,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.475,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"NOVANET [10819]",Novanet,,3631.95,75,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850016540,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"FIRST HEALTH [10303]","First Health",,5244,80,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC DF-4 CNCT 2 CHMBR CARDIOVERTER PULSE GENRTR",SUP-E162,CDM,C1721,HCPCS,0278,RC,,,both,,,63000.00,18900,"AETNA [10100]","Aetna HMO/PPO",,50085,79.5,,,,,0,7326.9,53550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL STD OFFSET 28MM HIP TYPE 1 COCR G7",SUP-163662,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"PHCS [10601]",PHCS,,7176.41,70,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT BLACK 20CM 6FR 2 PIGTAIL CURVE STRAIGHT URETERAL",SUP-G46443,CDM,C2617,HCPCS,0278,RC,,,both,,,1194.75,358.42,"KAISER [10500]",Kaiser,,800.48,67,,,,,0,138.95,1015.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE SPINAL ATLAS STAINLESS STEEL SINGLE INTEGRAL CRIMP",SUP-826-013,CDM,C1713,HCPCS,0278,RC,,,both,,,1988.40,596.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,235.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",231.25,1690.14,"percent of total billed charges",
"GRAFT BONE GRAFTON DBF 6CC ALLOGRAFT PUTTY",SUP-T50106,CDM,C1713,HCPCS,0278,RC,,,both,,,8970.00,2691,"PHCS [10601]",PHCS,,6279,70,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR EBU3.25 CURVE GUIDING NYLON CORONARY",SUP-LA6EBU325,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"FIRST HEALTH [10303]","First Health",,313.2,80,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT 2.8-8CM ALEXIS ATRAUMATIC FLEXIBLE RETRACTION RING",SUP-HR101,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR091020,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"MULTIPLAN [10600]",Multiplan,,11241.97,85,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAROTID ARTERY STENT PROCEDURES WITH MCC",034,MS-DRG,,,,,,,inpatient,,,166453.99,49936.2,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC",969,MS-DRG,,,,,,,inpatient,,,283392.97,85017.89,"CIGNA [10200]","Cigna Open Access",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 46.8%. Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE",450,MS-DRG,,,,,,,inpatient,,,251053.92,75316.18,"CIGNA [10200]","Cigna Local Plus",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 44%. Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EVOLUTE PRO+ 34MM DELIVERY LOAD INFLOW OUTFLOW CONE",SUP-L-EVPROP34US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2925.00,877.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Ext Ecg>48hr<7d Scan a/R",PX-731000006,CDM,93243,CPT,0731,RC,,,both,,,383.00,114.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,inpatient,,,31163.00,9348.9,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mlh1 Gene Full Seq",PX-309000052,CDM,81292,CPT,0310,RC,,,both,,,2420.00,726,"NOVANET [10819]",Novanet,,1815,75,,,,,0,2.42,2057,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest Hemm Extrnl",PX-450000267,CDM,46924,CPT,0450,RC,,,both,,,9344.52,2803.36,"NOVANET [10819]",Novanet,,7008.39,75,,,,,0,67.13,7942.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR",276,MS-DRG,,,,,,,inpatient,,,217382.44,65214.73,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,39494.86,,"Case rate ($37,259.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $34,597.79, add-ons for qualifying new technology services are included. If operating cost exceeds $67,637.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,997.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $34,643.54. The transfer operating threshold is the transfer adjustment factor * $34,597.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,615.76. The transfer capital threshold is the transfer adjustment factor * $2,615.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,10994,175368.69,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Gastric Emptying Sb Colon Multi",PX-341000069,CDM,78266,CPT,0341,RC,,,both,,,2794.10,838.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1281.22,,,,,,,324.95,2374.99,"fee schedule",
"HC Xr Bone Density Appendicular",PX-320000212,CDM,77081,CPT,0320,RC,,,both,,,448.64,134.59,"PHCS [10601]",PHCS,,314.05,70,,,,,0,35.05,381.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Paravrt Jt C/T 1 Lvl Bi",PX-510000133,CDM,64490,CPT,0761,RC,,,both,,,6156.44,1846.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,729.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,715.99,5232.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH X-FLOW 22FR URETHRAL SILICONE 50ML 3 WAY DUFOUR TIP",SUP-AB6322,CDM,C1729,HCPCS,0272,RC,,,both,,,169.65,50.89,"UHC [10700]","United Healthcare",,107.39,63.3,,,,,0,19.73,144.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 8MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158126108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PHCS [10601]",PHCS,,7822.19,70,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC",271,MS-DRG,,,,,,,inpatient,,,180964.81,54289.44,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,23604.14,,"Case rate ($22,059.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,484.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,523.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,930.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $20,511.24. The transfer operating threshold is the transfer adjustment factor * $20,484.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.70. The transfer capital threshold is the transfer adjustment factor * $1,548.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,10994,103829.73,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ligation Hemm Intrnl Sngl",PX-450000268,CDM,46945,CPT,0361,RC,,,both,,,11998.00,3599.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2292.95,,"Case rate ($2,292.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,1395.37,10198.3,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"PISTON OTOLOGY 3.75MM .5MM SMART INCUS STAPES NITINOL",SUP-7014-5920,CDM,L8613,HCPCS,0278,RC,,,both,,,1801.20,540.36,"CIGNA [10200]",Cigna,,1224.82,68,,,,,0,209.48,1531.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PISTON OTOLOGY 3.75MM .5MM SMART INCUS STAPES NITINOL",SUP-7014-5920,CDM,L8613,HCPCS,0278,RC,,,both,,,1801.20,540.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1224.82,68,,,,,0,209.48,1531.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PISTON OTOLOGY 3.75MM .5MM SMART INCUS STAPES NITINOL",SUP-7014-5920,CDM,L8613,HCPCS,0278,RC,,,both,,,1801.20,540.36,"MULTIPLAN [10600]",Multiplan,,1531.02,85,,,,,0,209.48,1531.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Analysis Dev Pcmkr Sys",PX-480000058,CDM,93288,CPT,0480,RC,,,both,,,328.65,98.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,38.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.22,328.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esophagosc W/Band Varices",PX-750000200,CDM,43205,CPT,0750,RC,,,both,,,2075.00,622.5,"AETNA [10100]","Aetna HMO/PPO",,1649.63,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,241.32,2075,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 2.5 MEQ/ML INTRAVENOUS SOLUTION",RX-7320,CDM,J7799,HCPCS,0636,RC,63323-0139-40,NDC,both,40,ML,50.13,15.04,"CIGNA [10200]","Cigna Open Access",,28.52,56.9,,,,,0,5.94,42.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trnscth Rnl Symp Dnrv Perc Uni",PX-481000146,CDM,0338T,CPT,0481,RC,,,both,,,9752.00,2925.6,"CIGNA [10200]","Cigna Local Plus",,7882,,"Case rate ($7,882). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1134.16,9752,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SYSTEM CVAC ASPIRATION STEERABLE URETERAL CATH BUILT",SUP-CVC127020-1,CDM,C1747,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8933.09,41.1,,,,,0,2527.78,18474.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 32MM 144CM 3MM CORONARY STENT",SUP-H7493941832300,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 16X10CM VERITAS BOVINE PERICARDIUM",SUP-RM1016,CDM,C9354,HCPCS,0278,RC,,,both,,,24605.47,7381.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2915.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2861.62,20914.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esoph Flex Trnsoral W Bx",PX-750000227,CDM,43202,CPT,0750,RC,,,both,,,2841.00,852.3,"FIRST HEALTH [10303]","First Health",,2272.8,80,,,,,0,330.41,2841,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION",RX-19333,CDM,J0735,HCPCS,0636,RC,00143-9724-01,NDC,both,10,ML,380.52,114.16,"KAISER [10500]",Kaiser,,254.95,67,,,,,0,21.18,323.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Retroperitoneal Complete",PX-402000010,CDM,76770,CPT,0402,RC,,,both,,,1285.72,385.72,"KAISER [10500]",Kaiser,,861.43,67,,861.43,861.43,861.43,"1 through 10",115.44,1092.86,"percent of total billed charges",
"DIGESTIVE MALIGNANCY WITH CC",375,MS-DRG,,,,,,,inpatient,,,40215.22,12064.57,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,8028.45,,"Case rate ($7,503.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,967.25, add-ons for qualifying new technology services are included. If operating cost exceeds $40,006.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,908.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,976.46. The transfer operating threshold is the transfer adjustment factor * $6,967.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $526.76. The transfer capital threshold is the transfer adjustment factor * $526.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7503.22,30166.21,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 50MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.850,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,162.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",159.84,1168.25,"percent of total billed charges",
"SCR BONE 2.7MM 38MM LCP STAINLESS STEEL SMALL BONE SELF",SUP-02.211.038,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"CIGNA [10200]",Cigna,,610.73,68,,1831.33,1831.33,1831.33,16,104.45,763.41,"percent of total billed charges",
"NDL RADIOLOGY GOLD 20CM 17GA 1.2MM KNURL SOFT TISSUE",SUP-MTNW887825,CDM,A4648,HCPCS,0278,RC,,,both,,,1665.00,499.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,197.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,193.64,1415.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Epidrm Autograft a/T/L <=100scm",PX-761000021,CDM,15110,CPT,0761,RC,,,both,,,2471.00,741.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,292.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.47,2471,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Cslt Compre",PX-312000073,CDM,0840T,CPT,0312,RC,,,both,,,104.00,31.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,47.74,45.9,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POUCH 34.5CM 10MM ENDO CATCH GOLD MINIMIZE SPILLAGE",SUP-173050G,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"CIGNA [10200]","Cigna Local Plus",,186.18,53.5,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATHETERIZATION 9IN 15FR 16FR 11 CANNON II PLUS",SUP-CS-15282-VSP,CDM,C1750,HCPCS,0278,RC,,,both,,,2400.00,720,"CIGNA [10200]","Cigna Local Plus",,1284,53.5,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nexplanon Implant",PX-E27800023,CDM,J7307,HCPCS,0278,RC,,,both,,,2686.20,805.86,"PHCS [10601]",PHCS,,1880.34,70,,,,,0,312.41,2283.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ext Ecg>48hr<7d Recording",PX-731000005,CDM,93242,CPT,0731,RC,,,both,,,383.00,114.9,"BLUE CROSS [10001]","Blue Cross PPO",,44.29,,"Fee schedule rate ($44.29).",,,,0,30.87,383,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM ROUND COARSE TRANSNASAL DIAMOND STERILE",SUP-TN30RCD,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"PHCS [10601]",PHCS,,1931.48,70,,,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE COROLENE 4-0",SUP-20S15AL,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.89,14.67,"UHC [10700]","United Healthcare",,30.95,63.3,,,,,0,5.69,41.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER FOREST GREEN 17MM 4.5MM SYNOVATOR CURVED",SUP-7205334,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"UHC [10700]","United Healthcare",,220.28,63.3,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL LATIS 6MM .5 FORCE SPRING LATIS/LATIS STERILE",SUP-A1611,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,103.83,45.9,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXCISOR BIOPSY .59X.472IN FISCHER 77D 15MM MEDIUM CONE",SUP-900-151,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.28,60.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,138.23,68,,,,,0,23.64,172.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL JACOBSON MOSQUITO MICRO CURVE 5IN VERY SLENDER",SUP-15-4182,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.39,53.82,"FIRST HEALTH [10303]","First Health",,143.51,80,,,,,0,20.86,152.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 3MM 8FR 2.5CM 2 LUMEN GWIRE FILFRM TIP FUSION",SUP-G31525,CDM,S27200284,LOCAL,0272,RC,,,both,,,1239.30,371.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,146.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 27CM 8MM AVENIR 10 COIL COMPLEX FINISH",SUP-10CFN08027,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AETNA [10100]","Aetna HMO/PPO",,9319.86,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 16 X 13 X 08MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-161308-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"NOVANET [10819]",Novanet,,4657.5,75,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTD DTMB1D4 AMPLIA MRI US DF4",SUP-DTMB1D4,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,15584.4,27,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION MRI CHRONOFLEX SILICONE",SUP-0605420,CDM,C1788,HCPCS,0278,RC,,,both,,,944.00,283.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,270.17,28.62,,,,,0,109.79,802.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE TRNSDUC 48IN MERITRANS MALE ROTATE LUER FEMALE FIX",SUP-K11-00392B,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.22,27.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.73,78.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL 6.25IN SMILLIE LEFT CURVE MENISCUS",SUP-77-5001,CDM,S27200284,LOCAL,0272,RC,,,both,,,541.65,162.49,"NOVANET [10819]",Novanet,,406.24,75,,,,,0,62.99,460.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 35X10X.1MM HALL STERNUM OSCILLATING STERILE",SUP-5059-032,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.18,30.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.88,86.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE 4X2IN NONWOVEN SURGICEL SNOW",SUP-2082,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.79,483.54,"PHCS [10601]",PHCS,,1128.25,70,,,,,0,187.45,1370.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 100CM 6.7FR GPC CURVE ANGIOGRAPHIC POLYETHYLENE",SUP-G00174,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.19,73.86,"FIRST HEALTH [10303]","First Health",,196.95,80,,,,,0,28.63,209.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 3MM TRUDI 0D STRAIGHT STERILE LATEX FREE",SUP-TSB3STR,CDM,S27200284,LOCAL,0272,RC,,,both,,,3562.50,1068.75,"KAISER [10500]",Kaiser,,2386.88,67,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fna W Fluoro Ea Addl",PX-361000480,CDM,10008,CPT,0361,RC,,,both,,,4962.00,1488.6,"KAISER [10500]",Kaiser,,3324.54,67,,,,,0,577.08,4217.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 46CM KIT STEERABLE LOCATOR PLUS 16MM",SUP-1292/46,CDM,S27500001,LOCAL,0275,RC,,,both,,,1972.50,591.75,"BLUE CROSS [10001]","Blue Cross HMO",,773.22,39.2,,,,,0,229.4,1676.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 70CM NEVRO 5MM SPACING TRAIL LEAD STERILE",SUP-TLEAD1058-70B,CDM,C1897,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]",Cigna,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 F 44MM COCR HIP 2 MOBILITY",SUP-110024464,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"KAISER [10500]",Kaiser,,8678.3,67,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 4CM 2MM BALLOON DILATATION OTW LOW",SUP-G30933,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHIBOND EXCEL 3-0 SH 30IN 2 ARM BRAIDED GREEN",SUP-X562H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE UROLOGICAL L150CM DIA0.035IN 3CM TAPERED NITINOL H",SUP-M0066802231,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPN NC 15MM 2.5MM BALLOON DILATATION CORONARY ACCEPTS 6",SUP-250-015-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL 5.2MMX1.5-2.2MM 22MM 25 3D GRIP SURFACE POWER",SUP-CDH25P,CDM,S27200284,LOCAL,0272,RC,,,both,,,8613.25,2583.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL INTRAVENOUS 5% DEXTROSE 500ML LIFECARE LIFECARE LATEX",SUP-792203,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 150CM 6CM 4MM BALLOON DILATATION ILIAC",SUP-G34325,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE,MINOR",930,APR-DRG,,,,,,,inpatient,,,43491.62,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $4,520.39. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%.",,,,0,,,other,"SOI-1 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIOMYOPATHY,MINOR",205,APR-DRG,,,,,,,inpatient,,,31465.45,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $2,918.84. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%.",,,,0,,,other,"SOI-1 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"CPS DIRECT« UPSIZED, STRAIGHT (OC-STR) 54CM-DS2C025",SUP-DS2C025,CDM,C1893,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2557.14,68,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH ADULT 24CM 15.5FR POLYURETHANE BIOFLO DURAMAX",SUP-H787103028185,CDM,C1750,HCPCS,0278,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TNLR SURGICAL 15CM PLASTIC HICKMAN BROVIAC LEONARD CATH",SUP-0601930,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,299.62,41.1,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28X10X11MM 8D EIT TLIF STERILE LATEX FREE",SUP-TUI81128,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"MULTIPLAN [10600]",Multiplan,,24097.5,85,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION ZIP-FIX STERNAL STAINLESS STEEL PEEK NDL",SUP-08.501.001.20S,CDM,S27800098,LOCAL,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X9MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7309,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3167.1,45.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 93MM 16-13MM 14FR ENDURANT II ABDOMEN",SUP-ETLW1613C93E,CDM,S27800098,LOCAL,0278,RC,,,both,,,30006.90,9002.07,"AETNA [10100]","Aetna HMO/PPO",,23855.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3489.8,25505.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE LEUKEMIA WITHOUT CC/MCC",836,MS-DRG,,,,,,,inpatient,,,19406.20,5821.86,"AMBETTER EXCHANGE  [11102]",Ambetter,,7564.63,,"Case rate ($7,564.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,024.27, add-ons for qualifying new technology services are included. If operating cost exceeds $40,063.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,913.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,033.56. The transfer operating threshold is the transfer adjustment factor * $7,024.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.07. The transfer capital threshold is the transfer adjustment factor * $531.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,19406.2,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 33MM 26.1MM MASTERS PYROLYTIC CARBON PTFE",SUP-33MTJ-503,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"NOVANET [10819]",Novanet,,21839.42,75,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 12X14X21MM SANTORINI 7D PEEK CORPECTOMY",SUP-1703-22114L,CDM,S27800098,LOCAL,0278,RC,,,both,,,39793.32,11938,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10744.2,27,,,,,0,4627.96,33824.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 100MM 75CM 8MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200081070,CDM,C1876,HCPCS,0278,RC,,,both,,,4515.00,1354.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3070.2,68,,,,,0,525.09,3837.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTUNE RP W/ REVISION TRAY",SUP-CAP-DS-K-3,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 NARROW KNEE LEFT CRUCIATE RETAINING PERSONA",SUP-42502206201,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"NOVANET [10819]",Novanet,,21671.69,75,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 14.2MM 25MM 23.4MM ON-X 34MM CYLINDRICAL HEART",SUP-ONXANE-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"FIRST HEALTH [10303]","First Health",,30240,80,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POD XL 5MMX10CM",SUP-RBYPODXL0510,CDM,S27800098,LOCAL,0278,RC,,,both,,,13731.00,4119.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5492.4,40,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 9MM XL LORDOTIC",SUP-365.709,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA [10200]","Cigna Local Plus",,3572.95,53.5,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM INTERLOCK FIBERED IDC 18 COIL",SUP-M001361570,CDM,S27800098,LOCAL,0278,RC,,,both,,,2079.00,623.7,"KAISER [10500]",Kaiser,,1392.93,67,,,,,0,241.79,1767.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX9MM FRA 8D NARROW WEDGE SPINE",SUP-9,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS [10001]","Blue Cross PPO",,7408.8,39.2,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INQUIRY 110CM 1MM 6FR 2-5-2MM SPACE LARGE CURVE",SUP-81809,CDM,C1730,HCPCS,0272,RC,,,both,,,2100.00,630,"FIRST HEALTH [10303]","First Health",,1680,80,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 3.5MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES3530CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4926.6,68,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS02006,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3165.24,27,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER 180CM 10FR GWIRE STENT BILIARY PANCREATIC STERILE",SUP-G22205,CDM,S27200284,LOCAL,0272,RC,,,both,,,1239.30,371.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,842.72,68,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM TARGET TETRA DETACHABLE STERILE",SUP-TG5413010,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3810.95,27,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 320110 TRICORT BLK 10MM SRVC FEE",SUP-320110,CDM,S27800098,LOCAL,0278,RC,,,both,,,3412.50,1023.75,"MULTIPLAN [10600]",Multiplan,,2900.63,85,,,,,0,396.87,2900.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABLE 12X26MM 9-16MM 8°",SUP-1172.4113S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"FIRST HEALTH [10303]","First Health",,27720,80,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLUX PROTEIIIOS GROWTH FACTOR MED",SUP-IFLX-GF-025,CDM,S27800098,LOCAL,0278,RC,,,both,,,8107.50,2432.25,"KAISER [10500]",Kaiser,,5432.03,67,,,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X13MM VERTE-STACK CORNERSTONE PSR 14MM PEEK-",SUP-6240364,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBTALAR DISTRACTION ARTHRODESIS WEDGE, 12 MM",SUP-PSBT-1206,CDM,S27800098,LOCAL,0278,RC,,,both,,,12851.25,3855.37,"NOVANET [10819]",Novanet,,9638.44,75,,,,,0,1494.6,10923.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX18MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183748,CDM,C1776,HCPCS,0278,RC,,,both,,,13241.10,3972.33,"FIRST HEALTH [10303]","First Health",,10592.88,80,,,,,0,1539.94,11254.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRIAD 14X11X7MM CERVICAL SPINE",SUP-5750007,CDM,S27800098,LOCAL,0278,RC,,,both,,,5841.00,1752.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3971.88,68,,,,,0,679.31,4964.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM PRESTIGE PLUS HELICAL COMPLEX XTRA",SUP-PRES0101CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X11MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7011,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"NOVANET [10819]",Novanet,,5175,75,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM TARGET HELICAL PLATINUM DETACHABLE",SUP-M0035433060,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"FIRST HEALTH [10303]","First Health",,7326.14,80,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL LUMBAR ALIF ANTERIOR CONVEX 12 DEGRE",SUP-12419,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5409.18,28.62,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +15 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.150,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]",Cigna,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL LAHEY 8 5/8IN DELICATE",SUP-305-373,CDM,S27000186,LOCAL,0270,RC,,,both,,,443.56,133.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,301.62,68,,,,,0,51.59,377.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS",RX-11082,CDM,J3480,HCPCS,0636,RC,00990-7116-09,NDC,both,1000,ML,100.65,30.19,"NOVANET [10819]",Novanet,,75.49,75,,,,,0,0.48,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTRA TWINFLEX TCH 69","SUP-392 292",CDM,C1893,HCPCS,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR VAMP PLUS STERILE",SUP-PXVP23X3AT3,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC 47X13IN UNIVERSAL SHOULDER FOAM COLD HOT",SUP-9381-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,216.11,64.83,"CIGNA [10200]","Cigna Local Plus",,115.62,53.5,,,,,0,25.13,183.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 119MM STAINLESS STEEL 3.5MM SCREWS 6 HOLE LCP BONE",SUP-239.956,CDM,C1713,HCPCS,0278,RC,,,both,,,9506.13,2851.84,"PHCS [10601]",PHCS,,6654.29,70,,,,,0,1105.56,8080.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 240MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-593524022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER 200UM FLEXIVA TRACTIP HOLMIUM HIGH POWER POLISH",SUP-M006R8403961,CDM,S27200284,LOCAL,0272,RC,,,both,,,3284.22,985.27,"CIGNA [10200]",Cigna,,2233.27,68,,,,,0,381.95,2791.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CBL PCNG ADPR PAC LOC SF DEV",SUP-344025,CDM,C1893,HCPCS,0272,RC,,,both,,,408.90,122.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,278.05,68,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 300-500UM 2ML MICROSPHERE PREFILLED",SUP-S420GH,CDM,S27800098,LOCAL,0278,RC,,,both,,,1860.00,558,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,220.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,216.32,1581,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PRECISION ALLOGRAFT FREEZE DRIED 26MMX18MM",SUP-439018,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 67CM 63CM HEMOSTASIS VALVE BRAID GWIRE",SUP-407439,CDM,C1893,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER EMBOLIZATION 40CM VENA CAVA FEMORAL STERILE",SUP-G06451,CDM,C1880,HCPCS,0278,RC,,,both,,,11730.00,3519,"CIGNA [10200]","Cigna Local Plus",,3694.95,31.5,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 6.5MM DARCO DISPOSABLE",SUP-IW706522,CDM,S27200284,LOCAL,0272,RC,,,both,,,1271.70,381.51,"FIRST HEALTH [10303]","First Health",,1017.36,80,,,,,0,147.9,1080.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON 6 6 NUROLON 4-0 RB-1 18IN CONTROL RELEASE BRAID 8",SUP-C554D,CDM,S27200284,LOCAL,0272,RC,,,both,,,148.81,44.64,"UHC [10700]","United Healthcare",,94.2,63.3,,,,,0,17.31,126.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM CEMENTLESS ACCOLADE TMZF 2 30MM HIP",SUP-6021-0230,CDM,S27800098,LOCAL,0278,RC,,,both,,,15649.20,4694.76,"UHC [10700]","United Healthcare",,9905.94,63.3,,,,,0,1820,13301.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 13MM SPINE CERVICAL ANTERIOR SELF DRILL FIX",SUP-7742113,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",117.75,860.63,"percent of total billed charges",
"SCR BONE 4MM 44MM AXSOS LOCK NONSTERILE",SUP-661044,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"FIRST HEALTH [10303]","First Health",,1044.58,80,,,,,0,151.86,1109.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 4MM 7FR 1-7-4MM SPACING B CURVE ABLATION",SUP-NS7TCBL174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9337.08,68,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP GRASPING VERSAGRASP STERILE DISPOSABLE",SUP-M0067802001,CDM,S27200284,LOCAL,0272,RC,,,both,,,704.70,211.41,"UHC [10700]","United Healthcare",,446.08,63.3,,,,,0,81.96,599,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM INTERLOCK IDC OCCLUSION .035IN 2D",SUP-M001363500,CDM,S27800098,LOCAL,0278,RC,,,both,,,2827.50,848.25,"CIGNA [10200]",Cigna,,1922.7,68,,,,,0,328.84,2403.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fluoro <1 Hr",PX-320000163,CDM,76000,CPT,0320,RC,,,both,,,1103.67,331.1,"MULTIPLAN [10600]",Multiplan,,938.12,85,,,,,0,43.92,938.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 38MM MEDIALIZE DOME ATTUNE",SUP-151810038,CDM,C1776,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"NOVANET [10819]",Novanet,,5382,75,,,,,0,834.57,6099.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRUG DRAPE SPY-PHI",SUP-HH9006,CDM,S25000001,LOCAL,0250,RC,,,both,,,4457.45,1337.23,"FIRST HEALTH [10303]","First Health",,3565.96,80,,,,,0,518.4,3788.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 90CM 3.1FR .05-.063IN 50MM SPACE SPRT",SUP-518-036,CDM,C1887,HCPCS,0272,RC,,,both,,,972.00,291.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,399.49,41.1,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 6CM 7MM BALLOON DILATATION ILIAC",SUP-G34340,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AERVIA NEONATAL SUPRAGLOTTIC AIRWAY DEVICE, X-LARGE, 3500-50",SUP-AVXL,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.47,70.34,"CIGNA [10200]","Cigna Open Access",,133.41,56.9,,,,,0,27.27,199.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 26FR MICROVASIVE CIRCON",SUP-M0068802161,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"CIGNA [10200]",Cigna,,351.21,68,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 58MM 80CM 7MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU0800758,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"PHCS [10601]",PHCS,,18301.5,70,,,,,0,3040.66,22223.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15.3CM 9MM CEREPAK XL UNIFORM DETACHABLE",SUP-FCX180915,CDM,S27800098,LOCAL,0278,RC,,,both,,,15872.28,4761.68,"AETNA [10100]","Aetna HMO/PPO",,12618.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1845.95,13491.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 13.3MM 24.2MM 22.8MM ATS OPEN PIVOT AP360 24MM",SUP-505DM24,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"KAISER [10500]",Kaiser,,15828.75,67,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9CM 6MM AZUR CX DETACHABLE SOFT SOLID CORE",SUP-45-750609,CDM,S27800098,LOCAL,0278,RC,,,both,,,7672.80,2301.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,909.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,892.35,6521.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"14 X 11 X 7MM 7 DEGREE POROUS COATE",SUP-P21411-707,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS [10001]","Blue Cross HMO",,2617.94,39.2,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM 14MM PRESS FIT UNIVERSAL FLUTE KNEE",SUP-867428,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"NOVANET [10819]",Novanet,,6075.45,75,,,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11MMX14MM 6 DEGREE CERVICAL CANCELLOUS",SUP-4W7206,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"FIRST HEALTH [10303]","First Health",,5520,80,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT CERTAS INLINE",SUP-828800PL,CDM,S27800098,LOCAL,0278,RC,,,both,,,34429.00,10328.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4079.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4004.09,29264.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT RICKHAM 100MM 2O PRECISION NO CATH PROGRAMMABLE",SUP-NS0568,CDM,S27800098,LOCAL,0278,RC,,,both,,,15669.90,4700.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6440.33,41.1,,,,,0,1822.41,13319.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM .0135IN AXIUM PRIME 3D FRAME",SUP-FC-9-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6610.2,40,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 6 X 6 HELICAL FINISHING COIL",SUP-10HFN-06006,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1225.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 230MM 7.5MM FLEXIGRAFT POSTERIOR TIBIALIS",SUP-FPOST.TIBIAL,CDM,S27800098,LOCAL,0278,RC,,,both,,,11612.70,3483.81,"NOVANET [10819]",Novanet,,8709.53,75,,,,,0,1350.56,9870.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VIA DEMINERALIZE MINERALIZE CORTICAL CANCELLOUS",SUP-VCAMX-100000,CDM,S27800098,LOCAL,0278,RC,,,both,,,20790.00,6237,"CIGNA [10200]",Cigna,,8316,40,,,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM 22MM EMBOLD NITINOL FIBER DETACHABLE",SUP-M001394240220600,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"CIGNA [10200]","Cigna Open Access",,4903.7,56.9,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE MASR CANCELLOUS CORTICAL LORDOTIC",SUP-645511,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X5MM VERTE-STACK CORNERSTONE PSR",SUP-6240541,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1911.36,28.62,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY INTRO EXPRESS KYPHOPAK ADDITIONAL FRACTURE 15/2",SUP-KPE1004,CDM,S27800098,LOCAL,0278,RC,,,both,,,8501.22,2550.37,"KAISER [10500]",Kaiser,,5695.82,67,,,,,0,988.69,7226.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT XL 20 CC MATRIX BIOACTIVE S",SUP-74000200,CDM,C1713,HCPCS,0278,RC,,,both,,,27720.00,8316,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7933.46,28.62,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL CORTICAL THK3-12MM THIRDS ALLOGRAFT STRUT",SUP-450486,CDM,S27800098,LOCAL,0278,RC,,,both,,,5249.52,1574.86,"CIGNA [10200]","Cigna Open Access",,2986.98,56.9,,,,,0,610.52,4462.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X21MM ENDOSKELETON TAS 7D 10MM STD TITANIUM",SUP-2307-0110,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 2MM X 4CM",SUP-M0035472040,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"NOVANET [10819]",Novanet,,10585.98,75,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2MM TARGET NANO HELICAL DETACHABLE",SUP-M0035452030,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"BLUE CROSS [10001]","Blue Cross HMO",,3589.81,39.2,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 2MM X 4CM",SUP-M0035472040,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS [10001]","Blue Cross HMO",,5532.94,39.2,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT SHOULDER GLENOID TRABECULAR METAL TOTAL",SUP-98000971501,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"MULTIPLAN [10600]",Multiplan,,25436.25,85,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VXSK-180P RF WIRE 63CM/55DEG/D1 SHEATH",SUP-VXSK0124,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2538.13,41.1,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 125CM 6FR .054IN .038IN PIGTAIL 145",SUP-7509-53,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"CIGNA [10200]","Cigna Local Plus",,43.8,53.5,,,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW PHTHALATE FREE",SUP-CG-14-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"PHCS [10601]",PHCS,,368.55,70,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR DISPOSABLE 4.5/14MM BIOCOMPOSITE CORKSCREW",SUP-AR-8927DSC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"CIGNA [10200]","Cigna Open Access",,846.89,56.9,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY 13CM 14GA BARD MARQUEE CORE ENHANCE TROCAR TIP",SUP-MQ1413,CDM,S27200284,LOCAL,0272,RC,,,both,,,514.35,154.3,"FIRST HEALTH [10303]","First Health",,411.48,80,,,,,0,59.82,437.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 18X5.5MM NARROW MEDIUM SAGITTAL OSCILLATING",SUP-2296033412,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.50,90.15,"NOVANET [10819]",Novanet,,225.38,75,,,,,0,34.95,255.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURETTE UTERINE 11IN SIMS",SUP-52-8154,CDM,S27200284,LOCAL,0272,RC,,,both,,,187.31,56.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,76.98,41.1,,,,,0,21.78,159.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL VASCU-STATT II 75-80GM CLAMPING PRESSURE MIDI",SUP-1001-532,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.36,32.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,44.95,41.1,,,,,0,12.72,92.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 80X3.8MM TITANIUM REGULAR ENDOSCOPIC LINEAR",SUP-GIA8038S,CDM,S27200284,LOCAL,0272,RC,,,both,,,939.28,281.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,109.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,109.24,798.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Benign Skin Lesn 2-4",PX-510000014,CDM,11056,CPT,0761,RC,,,both,,,502.00,150.6,"FIRST HEALTH [10303]","First Health",,401.6,80,,,,,0,58.38,502,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 40CM 5FR KUMPE CURVE ANGIOGRAPHIC DURATION",SUP-H787117327025,CDM,C1887,HCPCS,0272,RC,,,both,,,466.56,139.97,"FIRST HEALTH [10303]","First Health",,373.25,80,,,,,0,54.26,396.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSCOR SHEATH 13.5 FR",SUP-DCT1357125NM,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Nrv Si Jt W Img Bi",PX-510000532,CDM,64451,CPT,0761,RC,,,both,,,3235.89,970.77,"FIRST HEALTH [10303]","First Health",,2588.71,80,,,,,0,376.33,2750.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 1.7MM ATRIUM ENDOCARDIUM VENTRICLE BIPOLAR",SUP-4470,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"NOVANET [10819]",Novanet,,1674.38,75,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 862014 BICRT BLK 14X20 SRVC FEE",SUP-862014,CDM,S27800098,LOCAL,0278,RC,,,both,,,9785.58,2935.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4491.58,45.9,,,,,0,1138.06,8317.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"8MM HTR IMPLANT SYSTEM, STERILE",SUP-220-08-003,CDM,C1776,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross PPO",,1893.36,39.2,,3949.44,3949.44,3949.44,"1 through 10",561.73,4105.5,"percent of total billed charges",
"FLUCICLOVINE F-18 INTRAVENOUS SOLUTION (13-14 MCI)",RX-411839,CDM,A9588,HCPCS,0343,RC,08888-8877-91,NDC,both,1,UN,755.00,226.5,"BLUE CROSS [10001]","Blue Cross HMO",,755,,,,,,,87.81,755,"fee schedule",
"FLUCICLOVINE F-18 INTRAVENOUS SOLUTION (13-14 MCI)",RX-411839,CDM,A9588,HCPCS,0343,RC,08888-8877-91,NDC,both,1,UN,755.00,226.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,755,,,,,,,87.81,755,"fee schedule",
"BONE CORTICAL CORNERSTONE SR 7 X 14 X 11 MM BLOCK",SUP-200741,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASIC EVALUATION LEAD",SUP-306001,CDM,C1897,HCPCS,0278,RC,,,both,,,348.00,104.4,"FIRST HEALTH [10303]","First Health",,278.4,80,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE VISI-BLACK 5-0 C-1 24IN 2 ARM MONOFILAMENT BLUE",SUP-8325H,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.30,53.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ASAHI SION VASCULAR STRAIGHT 300CM .014IN STERILE",SUP-APW14R310S,CDM,C1769,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT JEJUNOSTOMY 45CM 22FR SILICONE MIC RADIOPAQUE FEED TUBE",SUP-8250-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RANGER 135CM 80MM 5MM BALLOON DILATATION PACLITAXEL OTW",SUP-H74939419500810,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT STRATAFIX MONOCRYL PLUS 4-0 PS-2 SPIRAL 45CM",SUP-SXMP1B118,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"PHCS [10601]",PHCS,,149.73,70,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 18GA SIDEKICK 2 10MM DEPLOYMENT",SUP-RFK-C101018S-ZK2-P,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.95,74.38,"CIGNA [10200]","Cigna Open Access",,141.08,56.9,,,,,0,28.84,210.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 650ML STYLE 7200 MEDIUM HEIGHT CENTERSCOPE",SUP-3547215,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA [10200]",Cigna,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) OCCL CARDIOVASCULAR 7.5X11-13MM 16MM 22MM HEMOSTASI",SUP-9-ACP2-007-016,CDM,C1817,HCPCS,0278,RC,,,both,,,102600.00,30780,"BLUE CROSS [10001]","Blue Cross HMO",,40219.2,39.2,,,,,0,11932.38,87210,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VOYANT INTELLIGENT ENERGY SYS 23CM MARYLAND SINGLE STEP ACTI",SUP-EB214,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"CIGNA [10200]","Cigna Local Plus",,1705.31,53.5,,,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE V-18 CONTROLWIRE VASCULAR TAPER 200CM 8CM .018IN",SUP-M001468520,CDM,C1769,HCPCS,0272,RC,,,both,,,1417.50,425.25,"PHCS [10601]",PHCS,,992.25,70,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 8MM ARCH TITANIUM SPINE CORTEX SELF DRILL",SUP-401.138.99,CDM,C1713,HCPCS,0278,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,206.39,39.2,,957.42,156.86,7483.26,51,61.23,447.53,"percent of total billed charges",
"CATH OCCL 100CM 5FR 26FR BALLOON OCCLUSION 1 INFLATION PORT",SUP-M0062201080,CDM,C2628,HCPCS,0272,RC,,,both,,,1155.14,346.54,"MULTIPLAN [10600]",Multiplan,,981.87,85,,,,,0,134.34,981.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Breast Local Dev Stereo",PX-361000314,CDM,19283,CPT,0361,RC,,,both,,,3031.00,909.3,"CIGNA [10200]","Cigna Open Access",,2090,,"Case rate ($2,090). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,352.51,3031,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANSURETHRAL PROCEDURES WITH CC",669,MS-DRG,,,,,,,inpatient,,,63375.59,19012.68,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,9915.96,,"Case rate ($9,627.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,939.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,979.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,057.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,951.28. The transfer operating threshold is the transfer adjustment factor * $8,939.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $675.87. The transfer capital threshold is the transfer adjustment factor * $675.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,45312.19,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT",SUP-M006145363170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,133.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 120MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.419,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"PHCS [10601]",PHCS,,968.89,70,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 23MM 2.25MM CORONARY STENT EVEROLIMUS",SUP-1550225-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 40CM 11CM 12FR 2CM PIGTAIL CURVE DRNG",SUP-RBDC-12-038,CDM,C1729,HCPCS,0272,RC,,,both,,,558.90,167.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,66.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15.3CM 9MM CEREPAK XL UNIFORM DETACHABLE",SUP-FCX180915,CDM,S27800098,LOCAL,0278,RC,,,both,,,15872.28,4761.68,"PHCS [10601]",PHCS,,11110.6,70,,,,,0,1845.95,13491.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE WATCHMAN 21MM 75CM 12FR 14FR OCCLUSION PEBAX NITINOL",SUP-M635WU21060,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VAGINAL DELIVERY,EXTREME",560,APR-DRG,,,,,,,inpatient,,,57300.17,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $6,249.63. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,767.63) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CONNECTIVE TISSUE DISORDERS,MAJOR",346,APR-DRG,,,,,,,inpatient,,,67006.24,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $8,985.32. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($49,312.41) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR STD STRAIGHT TAPER 260CM .035IN STAINLESS",SUP-G00655,CDM,C1769,HCPCS,0272,RC,,,both,,,104.31,31.29,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARDEX LUBRICATH 18FR STD URETHRAL RUBBER HYDROGEL MALE",SUP-0102L18,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.57,27.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER SPINAL 32X27X14MM SOVEREIGN 8D MEDIUM",SUP-7968814,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4061.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE NERVE STIM 23CM NIM BALL TIP",SUP-9450015,CDM,S27000186,LOCAL,0270,RC,,,both,,,899.10,269.73,"UHC [10700]","United Healthcare",,569.13,63.3,,,,,0,104.57,764.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ACCESS 2 ATTACHED COLLET PUMP SEG REVISION CATH CNCT",SUP-8784,CDM,C1755,HCPCS,0278,RC,,,both,,,4409.10,1322.73,"FIRST HEALTH [10303]","First Health",,3527.28,80,,,,,0,512.78,3747.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 10CM 23MM 18.5-21.5MM EXCLUDER",SUP-PLC231000,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"NOVANET [10819]",Novanet,,20997.9,75,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 30MM TI",SUP-MTLS-37300-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]",Cigna,,908.82,68,,1831.33,1831.33,1831.33,16,155.43,1136.03,"percent of total billed charges",
"PLATE CONTOUR 116MM STAINLESS STEEL 2.7/3.5MM SCR 6 HOLE LCP",SUP-02.112.112,CDM,C1713,HCPCS,0278,RC,,,both,,,3226.13,967.84,"KAISER [10500]",Kaiser,,2161.51,67,,,,,0,375.2,2742.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM PK DIEGO STRAIGHT SINUS SERRATE",SUP-7013-8000,CDM,S27200284,LOCAL,0272,RC,,,both,,,897.05,269.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,104.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.33,762.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Cslt Sld Els",PX-312000071,CDM,0838T,CPT,0311,RC,,,both,,,104.00,31.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,47.74,45.9,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 11MM PRIMARY SECUR-FIT PLUS HA 7 30MM HIP",SUP-6054-0711S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4626.55,28.62,,,,,0,1880.04,13740.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656314,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"CIGNA [10200]","Cigna Local Plus",,714.33,53.5,,3978.14,359.25,3978.14,24,155.28,1134.92,"percent of total billed charges",
"VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) VIAL",RX-20887,CDM,J3379,HCPCS,0636,RC,00143-9785-01,NDC,both,5,ML,63.42,19.03,"BLUE CROSS [10001]","Blue Cross HMO",,5.83,,,,,,,5.83,53.91,"fee schedule",
"(EVAL)CORONARY IVL CATHETER, 4.0MM X 20MM, RX IDE",SUP-501050-008,CDM,C1761,HCPCS,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 6-0 PS-3 18IN MONOFILAMENT PLIABILIZE",SUP-1665G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL JOINT PACK (TJUHR)215",SUP-SOP21TJU10,CDM,S27200284,LOCAL,0272,RC,,,both,,,976.86,293.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,115.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.61,830.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Gad-65",PX-301000252,CDM,83519,CPT,0301,RC,,,both,,,244.00,73.2,"KAISER [10500]",Kaiser,,163.48,67,,,,,0,0.01,207.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 12MM PFC SIGMA TC3 2 KNEE LEFT TITANIUM COMBO",SUP-960829,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"AETNA [10100]","Aetna HMO/PPO",,4079.02,79.5,,10981.53,8986.79,12413.38,12,596.72,4361.21,"percent of total billed charges",
"CANN NASAL PRONG O2 TUBE ADPTR DEHP FREE NEOTECH RAM CANN",SUP-N4905,CDM,S27000186,LOCAL,0270,RC,,,both,,,107.88,32.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.55,91.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 42MM LCP STAINLESS STEEL SHORT THREAD",SUP-207.642,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"PHCS [10601]",PHCS,,728.03,70,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSCONN ROD 26-31MM MATRIX 3 SPINE PEDICLE POSTERIOR",SUP-04.633.326,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross HMO",,1396.5,39.2,,957.42,156.86,7483.26,51,414.32,3028.13,"percent of total billed charges",
"SCR BONE 2.7MM 5MM 48MM STAINLESS STEEL CORTICAL SELF TAP",SUP-202.848,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,40.86,298.61,"percent of total billed charges",
"PLATE 96MM STAINLESS STEEL 3.5MM SCR 7X3 HOLE T OBLIQUE LEFT",SUP-241.971,CDM,S27800098,LOCAL,0278,RC,,,both,,,2465.40,739.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,292.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,286.73,2095.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 295CC",SUP-SMPX295,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,866.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 0 54IN MONOFILAMENT TIES YELLOWISH TAN ABSORBABLE",SUP-S104H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND MULTIPASS 5-0 PC-3 18IN BRAID BLACK",SUP-1925G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UHC [10700]","United Healthcare",,15.83,63.3,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 24FR CIRCON CLASSIC",SUP-M0068802581,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"AETNA [10100]","Aetna HMO/PPO",,380.18,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656314,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"CIGNA [10200]","Cigna Open Access",,759.73,56.9,,1144.80,304.56,2275.09,66,155.28,1134.92,"percent of total billed charges",
"CMPNT FEMORAL 9 KNEE LEFT CEMENTED POSTERIOR STABILIZE",SUP-150410109,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"NOVANET [10819]",Novanet,,16795.01,75,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 RIGHT KNEE CRUCIATE RETAINING CEMENTED",SUP-5510-F-302,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"FIRST HEALTH [10303]","First Health",,13118.28,80,,,,,0,1907.07,13938.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 11MM 38MM ASYMMETRIC TRIATHLON X3 KNEE",SUP-5551-G-381-E,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,670.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE OD43MM FEMORAL HEAD OSTEOARTICULAR ALLOGR",SUP-FFH,CDM,Q4433,HCPCS,0636,RC,,,both,,,7988.82,2396.65,"PHCS [10601]",PHCS,,5592.17,70,,,,,0,247.92,6790.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRENCH TORQ ULTRSNC SURG ASPIR CUSA 23 KHZ DISP",SUP-C5601,CDM,S27200284,LOCAL,0272,RC,,,both,,,1124.39,337.32,"FIRST HEALTH [10303]","First Health",,899.51,80,,,,,0,130.77,955.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mra Abdomen WO Cntrst",PX-610000044,CDM,74185,CPT,0610,RC,,,both,,,4010.00,1203,"UHC [10700]","United Healthcare",,645.88,,,,,,,466.36,3408.5,"fee schedule",
"ROD SPINAL 60MM 5.5MM MATRIX 100MM RADIUS CURVE BULLET NOSE",SUP-04.651.060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 44MM HIP SOLID BACK METAL HA TRIDENT B",SUP-500-11-44B,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.85,2973.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1152.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1152.75,8425.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL AVENIR COMPLETE 6 HIGH OFFSET HIP STERILE LATEX",SUP-574102060,CDM,C1776,HCPCS,0278,RC,,,both,,,23461.20,7038.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9642.55,41.1,,6417.48,6417.48,6417.48,"1 through 10",2728.54,19942.02,"percent of total billed charges",
"PLATE 40MM TITANIUM 1.5MM SCREW 4X8 HOLE T BONE HAND NONSTER",SUP-446.234,CDM,C1713,HCPCS,0278,RC,,,both,,,2736.30,820.89,"FIRST HEALTH [10303]","First Health",,2189.04,80,,,,,0,318.23,2325.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM TRICUSPID CONTOUR 3D TITANIUM",SUP-690R26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3539.7,27,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPRESS LOPROFILE 5X8MM",SUP-LPLF-205,CDM,C1726,HCPCS,0272,RC,,,both,,,11074.50,3322.35,"MULTIPLAN [10600]",Multiplan,,9413.33,85,,,,,0,1287.96,9413.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 11MM 38MM ASYMMETRIC TRIATHLON X3 KNEE",SUP-5551-G-381-E,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"NOVANET [10819]",Novanet,,4243.5,75,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR .071IN MULTIPURPOSE 1 CURVE GUIDING NYLON",SUP-LA6MP1SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"KAISER [10500]",Kaiser,,244.82,67,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 19FR SOLID CORE CENTER 4 CHANNEL RADIOPAQUE",SUP-2230,CDM,S27200284,LOCAL,0272,RC,,,both,,,155.21,46.56,"NOVANET [10819]",Novanet,,116.41,75,,,,,0,18.05,131.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP SMALL 2 DENSITY FOREHEAD PAD HOOK LOOP GRAB TAB",SUP-989805610251,CDM,S27000186,LOCAL,0270,RC,,,both,,,109.69,32.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,50.35,45.9,,,,,0,12.76,93.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 155CM 10MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200104020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 96MM STAINLESS STEEL 3.5MM SCR 7X3 HOLE T OBLIQUE LEFT",SUP-241.971,CDM,S27800098,LOCAL,0278,RC,,,both,,,2465.40,739.62,"FIRST HEALTH [10303]","First Health",,1972.32,80,,,,,0,286.73,2095.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT CEMENTED CRUCIATE RETAINING ATTUNE",SUP-150400105,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2653.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG BONE 22MM 2.3MM ACU-LOC CORTICAL SMOOTH LOCKING",SUP-CO-S2322,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"MULTIPLAN [10600]",Multiplan,,647.19,85,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 3MM 7MM TITANIUM CORTEX HAND SELF TAPPING",SUP-400.807,CDM,C1713,HCPCS,0278,RC,,,both,,,401.94,120.58,"BLUE CROSS [10001]","Blue Cross HMO",,157.56,39.2,,957.42,156.86,7483.26,51,46.75,341.65,"percent of total billed charges",
"BOOT TRACTION MEDIUM TRIANGLE BUCKLE HOOK CLSR VENTILATION",SUP-19404,CDM,S27000186,LOCAL,0270,RC,,,both,,,140.59,42.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,95.6,68,,,,,0,16.35,119.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RUBIDIUM RB-82 CHLORIDE INTRAVENOUS SOLUTION",RX-237393,CDM,A9555,HCPCS,0343,RC,08888-8878-36,NDC,both,1,UN,5032.00,1509.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,596.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,585.22,4277.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Est Eval Visit Level 4",PX-510000179,CDM,99214,CPT,0761,RC,,,both,,,444.10,133.23,"CIGNA [10200]","Cigna Open Access",,444.1,,"Per diem ($2,181).",,,,0,0.44,444.1,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-211-E,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"PHCS [10601]",PHCS,,9420.92,70,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 17MM ARCHON SPINE SELF DRILL VARIABLE ANGLE",SUP-8780217,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 60MM 120CM 6MM 6FR VASCULAR PERIPHERAL",SUP-S-60-060-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"FIRST HEALTH [10303]","First Health",,8049.6,80,,,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 24MM ARTHREX +4MM SHOULDER MODULAR STERILE",SUP-AR-9560-24-4,CDM,C1776,HCPCS,0278,RC,,,both,,,9335.70,2800.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6348.28,68,,,,,0,1085.74,7935.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR AMPLATZ LEFT 1",SUP-67003600,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,49.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 22-30CM 3CM 6FR .035IN",SUP-M006180156090,CDM,C2617,HCPCS,0278,RC,,,both,,,1336.82,401.05,"CIGNA [10200]","Cigna Open Access",,760.65,,,,,,,155.47,1136.3,"percent of total billed charges",
"IMPL BREAST 10.5X9.9CM 225ML GEL TEXTURE ORIENTATION MARK",SUP-334-1055,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1083.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CALCAR 25MM RESTORATION +30MM OFFSET HIP MODULAR",SUP-6276-4-325,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"BLUE CROSS [10001]","Blue Cross PPO",,9096.77,39.2,,3949.44,3949.44,3949.44,"1 through 10",2698.86,19725.14,"percent of total billed charges",
"STPLR POWER 60MM 60MM COMPACT ECHELON 3000 280MM SHAFT",SUP-ECH60C,CDM,S27200284,LOCAL,0272,RC,,,both,,,9634.19,2890.26,"MULTIPLAN [10600]",Multiplan,,8189.06,85,,,,,0,1120.46,8189.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM PRIMARY HEMISPHERICAL CLUSTER HOLE",SUP-5020362G,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2995.6,28.62,,,,,0,1217.29,8896.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL TRANSSEPTAL 98CM 86D",SUP-FND01906,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 19MM RESTORATION +10MM HIP MODULAR",SUP-6276-1-119,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"FIRST HEALTH [10303]","First Health",,11573.46,80,,,,,0,1682.49,12296.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 92CM 1MM 6FR 2-10-2-2-2-5-2MM SPACING REGULAR D CURVE",SUP-D6S08DRPRYRT,CDM,C1730,HCPCS,0272,RC,,,both,,,4388.40,1316.52,"MULTIPLAN [10600]",Multiplan,,3730.14,85,,,,,0,510.37,3730.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 156MM 26-34MM 30MM 20FR ZENITH TX2",SUP-G47472,CDM,C1874,HCPCS,0278,RC,,,both,,,98041.65,29412.49,"PHCS [10601]",PHCS,,68629.16,70,,,,,0,11402.24,83335.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG LEAD IS-1 MR CONDITIONAL PORT IMAGEREADY",SUP-7145,CDM,S27800098,LOCAL,0278,RC,,,both,,,2232.50,669.75,"BLUE CROSS [10001]","Blue Cross HMO",,875.14,39.2,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 3-0 SH 36IN 2 ARM MONOFILAMENT VIOLET ABSORBABLE",SUP-D6264,CDM,S27200284,LOCAL,0272,RC,,,both,,,404.88,121.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,47.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.09,344.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION",RX-9815,CDM,J7042,HCPCS,0636,RC,00990-7941-09,NDC,both,1000,ML,100.65,30.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3.29,,,,,,,0.74,85.55,"fee schedule",
"PLATE CONTOUR 129MM STAINLESS STEEL 2.7/3.5MM SCR 7 HOLE LCP",SUP-02.112.115S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 300MM 3MM BALLOON DILATATION DURALYN",SUP-48003030S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"PHCS [10601]",PHCS,,963.9,70,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.8MM 5MM LEVEL ONE ONEDRIVE CRANIOFACIAL EMERGENCY",SUP-99-576-76-08,CDM,C1713,HCPCS,0278,RC,,,both,,,552.10,165.63,"NOVANET [10819]",Novanet,,414.08,75,,,,,0,64.21,469.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 11.5CM 4MM MICRUSFRAME 10 COIL",SUP-MFR100412,CDM,S27800098,LOCAL,0278,RC,,,both,,,16974.00,5092.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4582.98,27,,,,,0,1974.08,14427.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP PHACOEMULSIFICATION 12MM .9MM OZIL 45D MINIFLARE",SUP-8065751177,CDM,S27200284,LOCAL,0272,RC,,,both,,,597.29,179.19,"PHCS [10601]",PHCS,,418.1,70,,,,,0,69.46,507.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 2.5MM CORONARY STENT",SUP-1145250-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"FIRST HEALTH [10303]","First Health",,4670.4,80,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ACL DISP",SUP-CM1501,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,841.43,28.62,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY 115CM 6FR LIVEWIRE 2-5-2MM SPACING 1",SUP-401575R,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Bn/Jnt Img Wb",PX-341000023,CDM,78306,CPT,0341,RC,,,both,,,3278.75,983.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,793.9,,,,,,,360.48,2786.94,"fee schedule",
"SCR BONE 5.5MM 16MM LOCK PERIPHERAL STERILE",SUP-AR-9563-16,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,69.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",69.48,507.77,"percent of total billed charges",
"CATH LAUNCHER 100CM 6FR .071IN RIGHT CORONARY BYPASS CURVE",SUP-LA6RCBSH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"KAISER [10500]",Kaiser,,262.31,67,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN RIGHT CORONARY BYPASS CURVE",SUP-LA6RCBSH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AETNA [10100]","Aetna HMO/PPO",,311.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 70.8X12.5MM THK1MM THK1.12MM LARGE BONE",SUP-KM-277R,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.18,55.25,"PHCS [10601]",PHCS,,128.93,70,,,,,0,21.42,156.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS 20CM HONOR METAL GWIRE INSRT TOOL BONDED",SUP-MAP352,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.63,63.19,"UHC [10700]","United Healthcare",,133.33,63.3,,,,,0,24.5,179.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT JUGGERKNOT SOFT TISSUE",SUP-912076,CDM,C1713,HCPCS,0278,RC,,,both,,,2835.00,850.5,"CIGNA [10200]","Cigna Open Access",,1613.12,56.9,,1144.80,304.56,2275.09,66,329.71,2409.75,"percent of total billed charges",
"ROPINIROLE ER 2 MG TABLET,EXTENDED RELEASE 24 HR",RX-92015,CDM,,,0637,RC,55111-0659-30,NDC,both,1,UN,13.76,4.13,"CIGNA [10200]",Cigna,,9.36,68,,,,,0,1.6,11.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL LEGION 6 L 5DX10P KNEE SCR",SUP-71421752,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIFLUFOLASTAT F-18 IV SYRINGE (13-14 MCI)",RX-411830,CDM,A9595,HCPCS,0343,RC,08888-8877-84,NDC,both,1,UN,16868.88,5060.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,696,,"Per diem ($696). Each quantity on the visit service is paid its own per diem rate. Each eligible service on a given day will be paid its own per diem rate.",,,,0,696,14338.55,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tte Cong W Contr Cmplt",PX-483000019,CDM,C8923,HCPCS,0480,RC,,,both,,,2274.00,682.2,"CIGNA [10200]","Cigna Open Access",,2274,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,264.47,2274,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SPINAL SCREW 7.5X50MM 2C MODULAR RELINE MAS",SUP-16187550,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM NCB PROTASUL-64 3.5MM SELF TAP 2 LEAD",SUP-0203150040,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"KAISER [10500]",Kaiser,,1243.69,67,,,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pulm Rhb W Cont Oximetry Mntr",PX-948000003,CDM,94626,CPT,0948,RC,,,both,,,301.15,90.34,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,35.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.02,301.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM 1.5 MM SCREW 7 HOLE BONE RIGHT CONDYLAR NONST",SUP-446.64.96,CDM,C1713,HCPCS,0278,RC,,,both,,,3271.80,981.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,380.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",380.51,2781.03,"percent of total billed charges",
"INSRT TIBIAL 6 22MM KNEE X3 CRUCIATE SUB TRIATHLON",SUP-5531G622,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"UHC [10700]","United Healthcare",,6330,63.3,,8601.07,8395.67,8601.07,"1 through 10",1163,8500,"percent of total billed charges",
"BLADE SAW 14X5.5MM OSCILLATING STERILE",SUP-KM-006,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.29,17.49,"UHC [10700]","United Healthcare",,36.9,63.3,,,,,0,6.78,49.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM TARGET 360D STD PLATINUM",SUP-M0035466200,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"AETNA [10100]","Aetna HMO/PPO",,11221.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD SUT ASSISTANT 0 ES-9 7IN COATED ENDO STITCH BRALON",SUP-170010,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"CIGNA [10200]","Cigna Open Access",,82.03,56.9,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE NOVAGOLD ENDOSCOPIC STRAIGHT 480CM .018IN BILIARY",SUP-M00552011,CDM,C1769,HCPCS,0272,RC,,,both,,,1460.03,438.01,"UHC [10700]","United Healthcare",,924.2,63.3,,,,,0,169.8,1241.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 26CM 3CM 5FR .038IN STRAIGHT URETERAL",SUP-M006155223010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]",Cigna,,837.05,68,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH TEAL 6FT 4 ELECTROGRAM CONDUCTOR",SUP-C6TMRMST4SA,CDM,S27000186,LOCAL,0270,RC,,,both,,,2115.00,634.5,"PHCS [10601]",PHCS,,1480.5,70,,,,,0,245.97,1797.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM OFFSET C TAPER 28MM HIP HIGH PERFORMANCE",SUP-18-2805,CDM,C1776,HCPCS,0278,RC,,,both,,,9121.80,2736.54,"AETNA [10100]","Aetna HMO/PPO",,7251.83,79.5,,10981.53,8986.79,12413.38,12,1060.87,7753.53,"percent of total billed charges",
"(EVAL) V-18 CONTROL WIRE, 300CM, 12CM TIP (BOSTON SCIENTIFIC",SUP-M001468600,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL KNIFE TUIP WOLF RESECTOSCOPE",SUP-M0068802471,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 16MM CANNULATED TFN-ADVANCED DHS/DCS QUICK",SUP-03.037.003,CDM,S27200284,LOCAL,0272,RC,,,both,,,4358.59,1307.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER 11CM 4MM RAD 12 XPS 360D 5000 RPM SINUS CURVED",SUP-1884012,CDM,S27200284,LOCAL,0272,RC,,,both,,,1902.00,570.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) MITRL VAL INTPDMVL48C INTREPID 48MM CLIN",SUP-INTPDMVL48C,CDM,S62400003,LOCAL,0624,RC,,,both,,,256500.00,76950,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SUT FIBERWIRE 5 T-5 CCS-1 38IN BRAID TIES MULTISTRAND LOWER",SUP-AR-7213,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) V-18 CONTROL WIRE, 300CM, 12CM TIP (BOSTON SCIENTIFIC",SUP-M001468600,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY EPIDURAL 4IN 17GA 19GA TUOHY EPILONG CONTINUOUS CLOSE",SUP-TAL101,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC",451,MS-DRG,,,,,,,inpatient,,,153195.27,45958.58,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE LEFT TOTAL STBL TRIATHLON COCR",SUP-5512-F-201,CDM,C1776,HCPCS,0278,RC,,,both,,,20599.49,6179.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2441.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2395.72,17509.57,"percent of total billed charges",
"SCREW HEADED MIS QUAD SPAR 33",SUP-5983-40-33,CDM,C1713,HCPCS,0278,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +9MM OFFSET 28MM HIP TYPE 1 SKIRT COCR G7",SUP-163665,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"BLUE CROSS [10001]","Blue Cross PPO",,1901.47,39.2,,3949.44,3949.44,3949.44,"1 through 10",564.14,4123.1,"percent of total billed charges",
"HC Sjogrens Abs",PX-302000045,CDM,86235,CPT,0302,RC,,,both,,,411.35,123.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16.14,,,,,,,0.41,349.65,"fee schedule",
"6.0MM X 13MM SENSAR INTRAOCULAR LENS, BICONVEX, 26.0 DIOPTER",SUP-AR40E00260,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"CIGNA [10200]","Cigna Open Access",,530.02,56.9,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STIM 70CM SURPASS LEAD STERILE LATEX FREE DISPOSABLE",SUP-LEAD3005-70B,CDM,C1778,HCPCS,0278,RC,,,both,,,8970.00,2691,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3686.67,41.1,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE MATRIX DEMINERALIZED",SUP-T50101,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,963.9,45.9,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Paravrt Jt L/S 1 Lvl",PX-510000138,CDM,64493,CPT,0361,RC,,,both,,,6149.00,1844.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1550,,"Case rate ($1,550). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1550,2385,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALLET SURGICAL 10.75IN 1 7/8IN 3LB",SUP-27-0899,CDM,S27200284,LOCAL,0272,RC,,,both,,,539.87,161.96,"KAISER [10500]",Kaiser,,361.71,67,,,,,0,62.79,458.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 40MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR40,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5388.21,41.1,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM CEMENTED OMNIFIT HFX 127D 9 35MM HIP",SUP-6076-0935A,CDM,C1776,HCPCS,0278,RC,,,both,,,7894.95,2368.48,"MULTIPLAN [10600]",Multiplan,,6710.71,85,,,,,0,918.18,6710.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA ARTERIAL BIOLINE L55 CM L20 CM OD25 FR ODSEC3/8 IN V","SUP-BEQ-PVL 2555-USA",CDM,S27200284,LOCAL,0272,RC,,,both,,,3822.60,1146.78,"NOVANET [10819]",Novanet,,2866.95,75,,,,,0,444.57,3249.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL SPINAL 50MM RELINE ONE VECTOR NAVIGATION NONSTERILE",SUP-24270050,CDM,S27000186,LOCAL,0270,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 109MM 13MM FULL PROXIMAL PROFILE ECHO BI-METRIC",SUP-19-3013,CDM,C1776,HCPCS,0278,RC,,,both,,,27578.88,8273.66,"PHCS [10601]",PHCS,,19305.22,70,,,,,0,3207.42,23442.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Picc With S&I < 5 Yr",PX-361000485,CDM,36572,CPT,0361,RC,,,both,,,5574.10,1672.23,"CIGNA [10200]","Cigna Local Plus",,3109,,"Case rate ($3,109). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,5.57,4737.99,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 45CM .014IN KNOB CAP KT",SUP-6061,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,170.52,39.2,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM SUMMIT POROCOAT 5 12/14 STD OFFSET TAPER",SUP-157001110,CDM,C1776,HCPCS,0278,RC,,,both,,,25247.25,7574.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2936.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2936.26,21460.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 13MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-313-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"NOVANET [10819]",Novanet,,8559.45,75,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM LCP STAINLESS STEEL SHORT THREAD SMALL",SUP-207.614,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"CIGNA [10200]","Cigna Open Access",,591.78,56.9,,1144.80,304.56,2275.09,66,120.96,884.03,"percent of total billed charges",
"NDL RADIOLOGY 20CM 17GA 1.2MM GOLD PLACEMENT KNURL MARKER 3",SUP-MTNW887830,CDM,A4648,HCPCS,0278,RC,,,both,,,696.60,208.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,319.74,45.9,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION",RX-9476,CDM,J0713,HCPCS,0636,RC,25021-0128-50,NDC,both,1,UN,99.66,29.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7.32,,,,,,,6.91,84.71,"fee schedule",
"STENT ADVANIX NAVIFLEX 9CM 10FR CENTER BEND THIN WALL",SUP-M00534700,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"BLUE CROSS [10001]","Blue Cross HMO",,427.06,39.2,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 22MM KNEE X3 CRUCIATE SUB TRIATHLON",SUP-5531G622,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"BLUE CROSS [10001]","Blue Cross HMO",,3920,39.2,,5311.50,4717.44,5388.59,31,1163,8500,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 30CM 10MM THORAX SOFT FLEXIBLE WOVEN",SUP-M00202175210P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 24FR 26FR CIAGLIA BLUE RHINO EZ PASS HYDROPHILIC J",SUP-G12115,CDM,C1894,HCPCS,0272,RC,,,both,,,2910.90,873.27,"KAISER [10500]",Kaiser,,1950.3,67,,,,,0,338.54,2474.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 30MM 3.5MM CORONARY STENT FULCRUM COCR",SUP-INT35030UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1642.2,68,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 24CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006155252010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"MULTIPLAN [10600]",Multiplan,,1046.32,85,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75445050,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,1144.80,304.56,2275.09,66,441.36,3225.75,"percent of total billed charges",
"CATH ULTRAVERSE 035 GEOALIGN 75CM 250MM 6MM BALLOON",SUP-U3575625,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 16MM 144CM 5MM CORONARY STENT",SUP-H7493926016500,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"BLUE CROSS [10001]","Blue Cross HMO",,3651.48,39.2,,9776.84,9776.84,9776.84,"1 through 10",1083.33,7917.75,"percent of total billed charges",
"CATH QUICK-CROSS SELECT 135CM 7MM 3.2FR .052-.059IN 45D 50MM",SUP-518-081,CDM,C1887,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMT BRIDLE PRO- 16 FR",SUP-4-4216,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,292.96,41.1,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS SELECT 135CM 7MM 3.2FR .052-.059IN 45D 50MM",SUP-518-081,CDM,C1887,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOGUARD RX 100UM 180CM .014IN 4MM EMBOLIC",SUP-401814RMC,CDM,C1884,HCPCS,0272,RC,,,both,,,6520.50,1956.15,"NOVANET [10819]",Novanet,,4890.38,75,,,,,0,758.33,5542.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 22MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656322,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"NOVANET [10819]",Novanet,,1001.4,75,,,,,0,155.28,1134.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)EDWARDS SAPIEN 3 THV 20MM",SUP-9600TFX20,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS [10001]","Blue Cross PPO",,67032,39.2,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 2-0 SH SPIRAL 30CM SUT ABSORBABLE",SUP-SXPP1B416,CDM,S27200284,LOCAL,0272,RC,,,both,,,224.03,67.21,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM 6.6CM 114CM 107CM 7FR 3.5-7MM ATHERECTOMY STD TIP",SUP-H1-LS,CDM,C1714,HCPCS,0272,RC,,,both,,,20128.50,6038.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 20MM 4MM BALLOON",SUP-U357542,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO LEAD CPS PLACEMENT KIT STD CORONARY SINUS","SUP-CPS STD PKG 01",CDM,C1893,HCPCS,0272,RC,,,both,,,7518.00,2255.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EPISPIN LOCK SOFT TRAY 17G X 3 1/2'' (90MM) TUOHY NEEDLE WIT",SUP-TCL121,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 135CM 20MM 6FR 4MM BALLOON DILATATION PEBAX",SUP-39032-40201,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH POWERGLIDE PRO 8CM 20GA IV NITINOL POLYURETHANE MIDLINE",SUP-F120080,CDM,C1751,HCPCS,0272,RC,,,both,,,469.80,140.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 100MM 4MM BALLOON DILATATION RAPID",SUP-47540100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INTELLANAV STABLEPOINT 4MM 8FR ABLATION RING ELECTRD",SUP-M004RFSDS9620K20,CDM,C2630,HCPCS,0272,RC,,,both,,,20160.00,6048,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"ELECTROPHYSIOLOGY BLUE 92CM 6FR WEBSTER 2-5-2MM SPACING D",SUP-D6DR252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,1400.60,420.18,"PHCS [10601]",PHCS,,980.42,70,,,,,0,162.89,1190.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 3.5MM VERTEX SELECT PRECUT",SUP-7753755,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"VALVE AORTIC 19MM FREESTYLE PORCINE BIOPROSTHESIS COMPLETE",SUP-995CS-19MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,38430.00,11529,"BLUE CROSS [10001]","Blue Cross HMO",,15064.56,39.2,,,,,0,4469.41,32665.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 8.5-10 MEDIUM MALE BEIGE CANVAS RUBBER",SUP-2041-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.42,14.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,21.77,45.9,,,,,0,5.51,40.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE RTRCTR 3.5X1.5IN SIMS",SUP-MB761R,CDM,S27200284,LOCAL,0272,RC,,,both,,,390.02,117.01,"KAISER [10500]",Kaiser,,261.31,67,,,,,0,45.36,331.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM 82MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE",SUP-02.117.802S,CDM,C1713,HCPCS,0278,RC,,,both,,,6974.52,2092.36,"MULTIPLAN [10600]",Multiplan,,5928.34,85,,,,,0,811.14,5928.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XACT 40MM 8-10MM TAPER VASCULAR NITINOL CAROTID ARTERY",SUP-82096-01,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"CIGNA [10200]","Cigna Open Access",,5325.84,56.9,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL MICRO NDL STRAIGHT 4IN TUNGSTEN",SUP-E16514,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.10,61.83,"KAISER [10500]",Kaiser,,138.09,67,,,,,0,23.97,175.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12IN 18FR ARTERIAL ADULT 3/8IN CNCT DIL TIP",SUP-77618,CDM,S27200284,LOCAL,0272,RC,,,both,,,541.37,162.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,222.5,41.1,,,,,0,62.96,460.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRINGER INSTR 8X2.5IN BAR",SUP-51-0008,CDM,S27000186,LOCAL,0270,RC,,,both,,,344.26,103.28,"FIRST HEALTH [10303]","First Health",,275.41,80,,,,,0,40.04,292.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FRACTURE STABILIT FIRST SHORT",SUP-3353,CDM,S27200284,LOCAL,0272,RC,,,both,,,21105.00,6331.5,"KAISER [10500]",Kaiser,,14140.35,67,,,,,0,2454.51,17939.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035423060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"AETNA [10100]","Aetna HMO/PPO",,11221.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP MULTIHOLE R3 STD STERILE",SUP-71338665,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"KAISER [10500]",Kaiser,,10644.46,67,,,,,0,1847.69,13504.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 00 8IN EPSTEIN SURGICAL",SUP-57-4621,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.74,104.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,143.74,41.1,,,,,0,40.67,297.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPLR ANASTOMOSIS 1MM GEM MICROVASCULAR STERILE DISPOSABLE",SUP-GEM2750,CDM,S27200284,LOCAL,0272,RC,,,both,,,2962.50,888.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1217.59,41.1,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 100MM 135CM 6MM 5FR VASCULAR NITINOL LOW",SUP-5F061003CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"PHCS [10601]",PHCS,,10626,70,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 13MM 140CM 3.5MM CORONARY STERILE LATEX",SUP-453935,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR TRABECULAR METAL VIVACIT-E STEM CUP LINER STD",SUP-98000571503,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6804,27,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM AXIUM PRIME HELIX DETACHABLE EXTRA",SUP-APB-3-6-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6076.14,68,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 45MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.845,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"BLUE CROSS [10001]","Blue Cross PPO",,137.71,39.2,,957.42,570.23,957.42,28,40.86,298.61,"percent of total billed charges",
"SYSTEM GRAFTMASTER 19MM 4.5MM CORONARY STENT STAINLESS STEEL",SUP-1012583-19,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6791.98,41.1,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 24CM 3CM 7FR .035IN PIGTAIL",SUP-M006180232090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,610.59,45.9,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCP CLAC PLXS US ECHO TIP 138-140CM 20 G X 6FR",SUP-G4927,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG WOUND 17.7X.8IN EXUFIBER FIBER FLUID RETENTION HIGH",SUP-603420,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.86,19.46,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL ENDOSCOPIC CRE 180CM 5.5CM 7.5FR 8-9-10MM ESOPHAGUS",SUP-M00558610,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE MITRAL MITRACLIP VALVE SYSTEM EVALVE",SUP-MSK01ST,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PUNCH CONE LONG HANDLE 5MM 2 CUT EDGE SHARP STERILE",SUP-APU550,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CURET 00 8IN EPSTEIN SURGICAL",SUP-57-4621,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.74,104.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET SUCTION DIAMOND SHAVER TUBE NEXUS BONE SCPL STERILE",SUP-110-31-1230,CDM,S27200284,LOCAL,0272,RC,,,both,,,4021.71,1206.51,"PHCS [10601]",PHCS,,2815.2,70,,,,,0,467.72,3418.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 40MM 80CM 7MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM07040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PHCS [10601]",PHCS,,12789,70,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Glomerular Basement Membrane",PX-301000267,CDM,83520,CPT,0301,RC,,,both,,,354.35,106.3,"CIGNA [10200]","Cigna Local Plus",,37.99,,,,,,,0.35,301.2,"fee schedule",
"HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION",RX-10162,CDM,J1631,HCPCS,0636,RC,70710-1463-01,NDC,both,1,ML,332.11,99.63,"UHC [10700]","United Healthcare",,15.36,,,,,,,7.88,282.29,"fee schedule",
"CATH METACROSS 135CM 150MM 5.7FR 7MM BALLOON DILATATION 2",SUP-BD-L70150CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"PHCS [10601]",PHCS,,671.9,70,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 7 HOLE DECREASE CURVATURE VARIAX BONE SUPERIOR",SUP-628007,CDM,C1713,HCPCS,0278,RC,,,both,,,7229.82,2168.95,"CIGNA [10200]","Cigna Local Plus",,3867.95,53.5,,3978.14,359.25,3978.14,24,840.83,6145.35,"percent of total billed charges",
"INTRO CATH 75CM 12FR .038IN ATRIAL CHECK-FLO HAUSDORF-LOCK",SUP-G28434,CDM,C1894,HCPCS,0272,RC,,,both,,,971.92,291.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,115.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.03,826.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 20MMX12MMX6CM",SUP-TSB122006A,CDM,C1874,HCPCS,0278,RC,,,both,,,49140.00,14742,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,19656,40,,,,,0,5714.98,41769,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT TKR VANGUARD STD FEMUR PATELLA TIBIA ARTICULAR SURFA",SUP-98000200187,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DULOXETINE 30 MG CAPSULE,DELAYED RELEASE",RX-39276,CDM,,,0637,RC,51991-0747-90,NDC,both,1,UN,28.51,8.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11.72,41.1,,,,,0,3.32,24.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC .3MM INTREPID CONICAL ANGLE POLYMER",SUP-8065752145,CDM,S27200284,LOCAL,0272,RC,,,both,,,163.73,49.12,"CIGNA [10200]","Cigna Local Plus",,87.6,53.5,,,,,0,19.04,139.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ekg Event Recording 30 Day",PX-730000005,CDM,93270,CPT,0730,RC,,,both,,,586.04,175.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,268.99,45.9,,,,,0,68.16,498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ekg Event Recording 30 Day",PX-730000005,CDM,93270,CPT,0730,RC,,,both,,,586.04,175.81,"NOVANET [10819]",Novanet,,439.53,75,,,,,0,68.16,498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP TUBE 11MM CRANIOFIX 2 CRANIAL FLAP TITANIUM SECURE",SUP-FF490T,CDM,C1713,HCPCS,0278,RC,,,both,,,1044.90,313.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,479.61,45.9,,,,,0,121.52,888.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Rib Uni 2v",PX-320000027,CDM,71100,CPT,0320,RC,,,both,,,587.73,176.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,68.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.31,499.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STANDALONE POCKET CONTROLLER",SUP-106762,CDM,Q0481,HCPCS,0274,RC,,,both,,,34650.00,10395,"KAISER [10500]",Kaiser,,23215.5,67,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 20MMX12MMX6CM",SUP-TSB122006A,CDM,C1874,HCPCS,0278,RC,,,both,,,49140.00,14742,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5823.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5714.98,41769,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS FIRSTCHOICE 5% DEXTROSE 40 MEQ POTASSIUM",SUP-07904-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 240MM 20MM REVISION MONOLITHIC REDAPT ROCKTITE",SUP-71354709,CDM,C1776,HCPCS,0278,RC,,,both,,,51237.90,15371.37,"FIRST HEALTH [10303]","First Health",,40990.32,80,,,,,0,5958.97,43552.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR INSIGNIA 10 HIGH",SUP-7000-6610,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"BLUE CROSS [10001]","Blue Cross HMO",,11984.97,39.2,,5311.50,4717.44,5388.59,31,3555.74,25987.82,"percent of total billed charges",
"INSERT TIBIAL 4 19MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530-P-419,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Local Plus",,4470.41,53.5,,5372.07,4581.20,7242.98,23,971.79,7102.52,"percent of total billed charges",
"KIT SPINAL 52CM STYLET FIXATION TOOL",SUP-DS06002/52,CDM,S27500001,LOCAL,0275,RC,,,both,,,729.00,218.7,"BLUE CROSS [10001]","Blue Cross HMO",,285.77,39.2,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 12MM INTERLOCK FIBERED IDC DETACHABLE",SUP-M001363630,CDM,S27800098,LOCAL,0278,RC,,,both,,,5181.90,1554.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2378.49,45.9,,,,,0,602.65,4404.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 200MM 3MM BALLOON DILATATION DURALYN",SUP-48003020X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KT PG 20FR XLCN SIL PUL METH",SUP-6646,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 11.75CM NATRELLE INSPIRA P3.9CM MODERATE PROFILE",SUP-SRM-295,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"BLUE CROSS [10001]","Blue Cross HMO",,2150.32,39.2,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intracard Ablt Discr Mech Arry",PX-481000095,CDM,93655,CPT,0481,RC,,,both,,,16017.22,4805.17,"CIGNA [10200]","Cigna Local Plus",,16017.22,,"Case rate ($21,645). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1862.8,16017.22,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bilirubin Transcutan",PX-309000102,CDM,88720,CPT,0301,RC,,,both,,,207.00,62.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7.9,,,,,,,0.21,175.95,"fee schedule",
"RETRIEVER ENDOSCOPIC 20MM 4MM TREVO XP PROVUE STERILE LATEX",SUP-90182,CDM,S27200284,LOCAL,0272,RC,,,both,,,47273.94,14182.18,"MULTIPLAN [10600]",Multiplan,,40182.85,85,,,,,0,5497.96,40182.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Benzodiazepines Flurazepam",PX-301000499,CDM,80346,CPT,0301,RC,,,both,,,90.00,27,"BLUE CROSS [10001]","Blue Cross PPO",,30.68,,"Fee schedule rate ($30.68).",,,,0,0.01,90,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 3-0 FS-1 27IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Z442H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.00MM X 10MM  SCOREFLEX  NC",SUP-620-104-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 12X26X50MM 10",SUP-6212150,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 5FR SIDEWINDER 1 CURVE ANGIOGRAPHIC",SUP-10719606,CDM,C1887,HCPCS,0272,RC,,,both,,,204.89,61.47,"KAISER [10500]",Kaiser,,137.28,67,,,,,0,23.83,174.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP7PL,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"MULTIPLAN [10600]",Multiplan,,18276.62,85,,,,,0,2500.67,18276.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 195MM 3.5MM STAINLESS STEEL QUICK COUPLING",SUP-310.37,CDM,S27200284,LOCAL,0272,RC,,,both,,,519.37,155.81,"UHC [10700]","United Healthcare",,328.76,63.3,,,,,0,60.4,441.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 2.25MM CORONARY STENT EVEROLIMUS",SUP-H7493926132220,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1022.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.25CM NATRELLE INSPIRA P5CM FULL PROFILE ROUND",SUP-MSZ-F385,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERSACROSS CONNECT LAAC 180P D0",SUP-VXAK0101,CDM,S27200284,LOCAL,0272,RC,,,both,,,6969.00,2090.7,"KAISER [10500]",Kaiser,,4669.23,67,,,,,0,810.49,5923.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL REUNION STANDARD RADIUS H19 MM OD44 MM SHOULDER",SUP-5552-E-4419,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1077.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1057.03,7725.48,"percent of total billed charges",
"SCR BONE 2.7MM 12MM VARIAX TITANIUM DISTAL RADIUS T7 DRIVE",SUP-53-27212E,CDM,C1713,HCPCS,0278,RC,,,both,,,571.54,171.46,"FIRST HEALTH [10303]","First Health",,457.23,80,,,,,0,66.47,485.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS06020,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1389.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LEFT FOOT 19MM STAINLESS STEEL 2MM SCR MINI FRAGMENT",SUP-243.33,CDM,C1713,HCPCS,0278,RC,,,both,,,1053.41,316.02,"CIGNA [10200]","Cigna Open Access",,599.39,56.9,,1144.80,304.56,2275.09,66,122.51,895.4,"percent of total billed charges",
"HC Rmvl/Rplc Pg Component Wcs",PX-480000076,CDM,0519T,CPT,0480,RC,,,both,,,6620.00,1986,"BLUE CROSS [10001]","Blue Cross PPO",,4431.65,,"Case rate ($4,431.65). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,769.91,6620,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CARTO XP THERMOCOOL SF 115CM 8FR 3.5MM JJ CURVE",SUP-BNI35JJH,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"UHC [10700]","United Healthcare",,11433.31,63.3,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SN6AT5.750 AS TORIC IQ REFERENCE",SUP-SN6AT5.750,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL LEGION 1 RIGHT KNEE REVISION",SUP-71424011,CDM,C1776,HCPCS,0278,RC,,,both,,,23133.60,6940.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2690.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2690.44,19663.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 100MM 2300MM 20MM 3.5MM ESOPHAGEAL NITINOL",SUP-ECBA-20-100-230,CDM,C1874,HCPCS,0278,RC,,,both,,,16425.45,4927.63,"BLUE CROSS [10001]","Blue Cross PPO",,6438.78,39.2,,,,,0,1910.28,13961.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS13030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"NOVANET [10819]",Novanet,,8792.33,75,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 22CM 3CM 6FR .038IN 2 PIGTAIL",SUP-M006192131010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,816.39,68,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 5 KNEE LEFT BICRUCIATE STABILIZE",SUP-74022225,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"UHC [10700]","United Healthcare",,10521.79,63.3,,8601.07,8395.67,8601.07,"1 through 10",1933.15,14128.79,"percent of total billed charges",
"DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION",RX-9812,CDM,J3490,HCPCS,0258,RC,00264-7616-00,NDC,both,1000,ML,100.65,30.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET",RX-123550,CDM,,,0637,RC,77333-0934-25,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 6MM INBOUND",SUP-200134,CDM,S27200284,LOCAL,0272,RC,,,both,,,1770.00,531,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLEDGET SMALL MITRAL 2-0 CARDOPXYL",SUP-73P30CR,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.11,29.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PUNCH SHORT HANDLE CONE 3.5MM 2 CUT EDGE SHARP STERILE",SUP-APU435,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 135CM 200MM 3MM BALLOON DILATATION OTW",SUP-H74939206032010,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC",940,MS-DRG,,,,,,,inpatient,,,107549.87,32264.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,37258.9,,,,,,,7561,68228.13,"case rate",
"KIT ORAL CARE ENCORE TONGUE SUSPENSION ADJUSTABLE KNOTLESS",SUP-FG0002,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LATERAL LUMBAR ANCHOR 30MM",SUP-1219.0030,CDM,C1713,HCPCS,0278,RC,,,both,,,3277.50,983.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,388.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",381.17,2785.88,"percent of total billed charges",
"CATH TREK 6MM 3MM ULTRA LOW PROFILE BALLOON DILATATION PEBAX",SUP-1012407-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 25MM 4MM NONSTERILE REUSABLE",SUP-7005-4025,CDM,S27200284,LOCAL,0272,RC,,,both,,,476.93,143.08,"CIGNA [10200]","Cigna Local Plus",,255.16,53.5,,,,,0,55.47,405.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 15MM TI",SUP-VAN-25150-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Local Plus",,520.02,53.5,,3978.14,359.25,3978.14,24,113.04,826.2,"percent of total billed charges",
"LEAD PACING 45CM 6FR STRAIGHT ATRIUM MRI POSITIVE FIXATION",SUP-7740,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,264.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYDEK 0 KHT-3 18IN GREEN NONABSORBABLE",SUP-69-5039,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.53,38.86,"KAISER [10500]",Kaiser,,86.79,67,,,,,0,15.06,110.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INLAY 28CM 4.7FR 2 PIGTAIL CURVE TAPER URETERAL",SUP-778428,CDM,C2625,HCPCS,0278,RC,,,both,,,625.73,187.72,"BLUE CROSS [10001]","Blue Cross PPO",,245.29,39.2,,,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2 X 4 COMPLEX PICO COIL",SUP-10USC02004,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"NOVANET [10819]",Novanet,,9806.63,75,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 135MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.935,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CIGNA [10200]",Cigna,,934.6,68,,1831.33,1831.33,1831.33,16,159.84,1168.25,"percent of total billed charges",
"CANN INNER SHILEY XLT 100MM 12.3MM 7MM ADULT EXTEND LENGTH",SUP-70XLTIN,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.83,1.45,"CIGNA [10200]",Cigna,,3.28,68,,,,,0,0.56,4.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 0 Q-FIX NEEDLES SUT STERILE LATEX FREE DISPOSABLE",SUP-72205691,CDM,C1713,HCPCS,0278,RC,,,both,,,3003.75,901.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,859.67,28.62,,,,,0,349.34,2553.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 11CM 8.9MM SECUR-FIT MAX HA 132D 5 29.4MM 25MM",SUP-6051-0525S,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"CIGNA [10200]",Cigna,,6259.68,40,,5873.17,5873.17,5873.17,"1 through 10",1820,13301.82,"percent of total billed charges",
"STENT AGILE 120MM 23MM ESOPHAGEAL PARTIAL COVER OTW STERILE",SUP-M00517730,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5228.87,28.62,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL BLUE 12MM SYNFIX 14D SMALL EVOLUTION 6.7MM 1.9",SUP-08.815.122S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AETNA [10100]","Aetna HMO/PPO",,22538.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ASSURE TITANIUM ANTERIOR CERVICAL SPINE",SUP-110.012,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 12MM 144CM 2.5MM CORONARY STENT PEBAX",SUP-H7493926012250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 177MM STAINLESS STEEL 2.7/3.5MM SCR 11 HOLE",SUP-02.112.152,CDM,C1713,HCPCS,0278,RC,,,both,,,3423.00,1026.9,"BLUE CROSS [10001]","Blue Cross PPO",,1341.82,39.2,,957.42,570.23,957.42,28,398.09,2909.55,"percent of total billed charges",
"SCR BONE 3.5MM 10MM RELINE C SPINE MULTIAXIAL NONSTERILE",SUP-3903510,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 36MM NCB PROTASUL-64 3.5MM SELF TAP 2 LEAD",SUP-0203150036,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,219.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,215.88,1577.81,"percent of total billed charges",
"CATH NANOCROSS 150CM 120MM 3MM 360D .014IN BALLOON",SUP-AB14W030120150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"KAISER [10500]",Kaiser,,928.02,67,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE DOPPLER DISPOSABLE 8MM",SUP-108260,CDM,S27200284,LOCAL,0272,RC,,,both,,,1061.10,318.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,125.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,123.41,901.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X18X1.19MM SAGITTAL 2 CUT STERILE",SUP-4118-119-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,393.85,118.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,180.78,45.9,,,,,0,45.8,334.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 12FR BALLOON 2-3ML SILICONE SECURELOK RIGHT",SUP-0200-12LV,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"PHCS [10601]",PHCS,,769.71,70,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 17MM 140CM 2.75MM CORONARY STENT",SUP-LUN275R17US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM 2.25MM 2.1-2.7FR CORONARY",SUP-RONYX22522UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2524.5,68,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRSSZR CEMENT YELLOW SMALL FEMUR CANAL",SUP-0206545000,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.71,37.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,51.26,41.1,,,,,0,14.5,106,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK .25IN STRAIGHT BLUNT TRIANGLE HANDLE 9IN NERVE",SUP-57-5000,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.09,56.43,"MULTIPLAN [10600]",Multiplan,,159.88,85,,,,,0,21.87,159.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ribosomal P Protein Igg Abs",PX-301000276,CDM,83516,CPT,0301,RC,,,both,,,113.00,33.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.38,,,,,,,0.01,96.05,"fee schedule",
"SCR SET MULTIAXIAL 4 PK STERILE 559200008",SUP-559200008,CDM,C1713,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC VIVA S CRT-D ICD DF-1 PHYSIOCURVE DESIGN",SUP-DTBB1D1,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"MULTIPLAN [10600]",Multiplan,,49062,85,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 0 GS-22 12IN CLSR ABSORBABLE GREEN",SUP-VLOCL2216,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.67,61.7,"NOVANET [10819]",Novanet,,154.25,75,,,,,0,23.92,174.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 0 GS-22 12IN CLSR ABSORBABLE GREEN",SUP-VLOCL2216,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.67,61.7,"UHC [10700]","United Healthcare",,130.19,63.3,,,,,0,23.92,174.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 7MM 9.5MM 255MM HUMERAL LEFT MULTILOC INTRAMEDULLARY",SUP-04.017.255S,CDM,C1713,HCPCS,0278,RC,,,both,,,11172.76,3351.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1323.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1299.39,9496.85,"percent of total billed charges",
"STPLR INTERNAL 45MM FLEXIBLE ARTICULATING LINEAR CUTTER",SUP-ATS45,CDM,S27200284,LOCAL,0272,RC,,,both,,,4678.94,1403.68,"AETNA [10100]","Aetna HMO/PPO",,3719.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,544.16,3977.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.0/18",SUP-401750,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 3MM 2.4MM 160CM RING HANDLE STERILE",SUP-163R,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.35,24.4,"CIGNA [10200]","Cigna Local Plus",,43.52,53.5,,,,,0,9.46,69.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 28MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.428TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"AETNA [10100]","Aetna HMO/PPO",,1607.13,79.5,,1521.93,481.35,16760.95,30,235.11,1718.32,"percent of total billed charges",
"LENS IOL +20 DIOPTER MODIFY C BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB0000200,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CIGNA [10200]","Cigna Open Access",,668.29,56.9,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEDG CARDIOVASCULAR WHITE 9.5X4.8MM THK1.5MM Y TFE SOFT",SUP-PCP40,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.95,15.28,"CIGNA [10200]","Cigna Open Access",,28.99,56.9,,,,,0,5.93,43.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 20MM 3MM BALLOON DILATATION DURALYN",SUP-48003002X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 7FR ENDOCARDIUM TRUE BIPOLAR ACTIVE",SUP-7170Q/58,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6868.8,40,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA XFULL PROFILE SOFTTOUCH SMOOTH",SUP-SSX-525,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]","Cigna Open Access",,4299.08,56.9,,5166.00,5166.00,5166.00,"1 through 10",878.7,6422.18,"percent of total billed charges",
"SHOE POSTOPERATIVE 15D 8.5-10 10.5-13 MEDIUM CONTACT CLSR",SUP-HS1005-12,CDM,S27000186,LOCAL,0270,RC,,,both,,,128.06,38.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH AMPLATZ 20CM 30FR ACCESS PTFE RENAL KINK RESISTANT",SUP-M0069001230,CDM,S27200284,LOCAL,0272,RC,,,both,,,325.03,97.51,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD DEFIB CPR-D PADZ PIECE AED PLUS DISPOSABLE",SUP-8900-0800-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,1135.30,340.59,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM RELIEVA SCOUT 24MM 6MM DIAGNOSTIC CATH SINUS LOW",SUP-SCT0624MFS,CDM,C1726,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE JEJUNOSTOMY 45CM 22FR SILICONE MIC SECUR-LOK 1 PORT",SUP-0200-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"AETNA [10100]","Aetna HMO/PPO",,874.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 6MM .038IN AZUR DETACHABLE .035IN",SUP-45-450615,CDM,S27800098,LOCAL,0278,RC,,,both,,,1851.00,555.3,"BLUE CROSS [10001]","Blue Cross PPO",,725.59,39.2,,,,,0,215.27,1573.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER HUMERAL 36MM SMR +6MM SHOULDER UHMWPE REVISION REVERSE",SUP-1360.50.820,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,348.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,341.92,2499,"percent of total billed charges",
"GORE CARDIOFORM ASD OCCLUDER 37MM 11FR",SUP-00733132636501,CDM,C1817,HCPCS,0278,RC,,,both,,,52321.50,15696.45,"UHC [10700]","United Healthcare",,33119.51,63.3,,,,,0,6084.99,44473.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE AUGMENTATION THK8MM 20MM 20MM BIOFOAM EVANS FOOTPRINT",SUP-46S52008,CDM,C1776,HCPCS,0278,RC,,,both,,,12489.00,3746.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5132.98,41.1,,6417.48,6417.48,6417.48,"1 through 10",1452.47,10615.65,"percent of total billed charges",
"GRAFT BONE CANCELLOUS 60ML .1-4MM ALLOGRAFT CRUSH FREEZE",SUP-T20027,CDM,S27800098,LOCAL,0278,RC,,,both,,,6399.75,1919.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4351.83,68,,,,,0,744.29,5439.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 15MM AEQUALIS 6 SHOULDER HA REVERSED STD",SUP-DWD003,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"PHCS [10601]",PHCS,,6610.1,70,,,,,0,1098.22,8026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 65CM .36MM FIRM TPR",SUP-344044,CDM,C1893,HCPCS,0272,RC,,,both,,,382.80,114.84,"FIRST HEALTH [10303]","First Health",,306.24,80,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.8CM MEMORYGEL BOOST P5CM MODERATE PLUS PROFILE",SUP-RSZMPB630S,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"UHC [10700]","United Healthcare",,112.64,63.3,,,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABIL 100MM 200CM 8MM ENDOPROSTHESIS METAL NO",SUP-VSWVN0810,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL ADULT REGULAR CONTOUR 3IN ATLAS PROCARE 2",SUP-79-83285,CDM,S27000186,LOCAL,0270,RC,,,both,,,245.69,73.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,100.98,41.1,,,,,0,28.57,208.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 20CM 11.5FR PRECURVE POLYURETHANE DUO-FLOW",SUP-MCDLT118IJ-2,CDM,C1752,HCPCS,0272,RC,,,both,,,701.46,210.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,83.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.58,596.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 8FR MP CURVE GUIDING DURAFORM",SUP-M003101480,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"PHCS [10601]",PHCS,,1752.19,70,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 2-0 KS 30IN MONOFILAMENT BLACK NONABSORBABLE",SUP-628H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 38FR NEPHRSTMY DRAIN 4 WING STERILE LATEX",SUP-086038,CDM,C1729,HCPCS,0272,RC,,,both,,,105.62,31.69,"NOVANET [10819]",Novanet,,79.22,75,,,,,0,12.28,89.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL H14MM OD20MM UNIVERSAL COBALT CHROME ANTERIOR DI",SUP-11-210024,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"BLUE CROSS [10001]","Blue Cross HMO",,5571.89,39.2,,5311.50,4717.44,5388.59,31,1653.09,12081.9,"percent of total billed charges",
"TENDYNE MITRAL VALVE SP 33B",SUP-TENDV-SP-33B-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"CIGNA [10200]","Cigna Local Plus",,91485,53.5,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE STRAIGHT/ROTATION 1.5",SUP-PRT-STR-015,CDM,C1713,HCPCS,0278,RC,,,both,,,6624.00,1987.2,"PHCS [10601]",PHCS,,4636.8,70,,,,,0,770.37,5630.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 0 CT-2 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8412H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 SWIVELOCK C KNOTLESS CLOSED EYELET TWIST IN",SUP-AR-2323KBCC,CDM,C1713,HCPCS,0272,RC,,,both,,,3622.50,1086.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1488.85,41.1,,,,,0,1488.85,2293.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM 48X16X2.5MM TITANIUM 3 LEVEL PREBENT SKYLINE BONE",SUP-186803048,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"NOVANET [10819]",Novanet,,3969,75,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 FIBERTAK SWIVELOCK C TIGERTAIL 2 LOAD",SUP-AR-2323BCT-2,CDM,C1713,HCPCS,0278,RC,,,both,,,3346.88,1004.06,"CIGNA [10200]","Cigna Open Access",,1904.37,56.9,,1144.80,304.56,2275.09,66,389.24,2844.85,"percent of total billed charges",
"BMA NEEDLE 74285-02M 11 GAUGE X 15CM",SUP-7428502M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.00,513,"CIGNA [10200]","Cigna Local Plus",,914.85,53.5,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 8MM 16MM STAINLESS STEEL STD CORTEX LARGE",SUP-214.016,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 60MM 125CM 7MM 6FR VASCULAR NITINOL",SUP-G43827,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1735.02,45.9,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D E KNEE LEFT OSSEOTI KEEL",SUP-42535007101,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3939.69,28.62,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 1.8MM BUTTRESS VARIABLE ANGLE LOCKING T8",SUP-04.210.094,CDM,C1713,HCPCS,0278,RC,,,both,,,872.78,261.83,"CIGNA [10200]","Cigna Local Plus",,466.94,53.5,,3978.14,359.25,3978.14,24,101.5,741.86,"percent of total billed charges",
"INSERT TIBIAL 6 16MM KNEE POLYETHYLENE CRUCIATE RETAINING TR",SUP-5530-P-616,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]",Cigna,,5682.01,68,,5873.17,5873.17,5873.17,"1 through 10",971.79,7102.52,"percent of total billed charges",
"RTRCTR 5.75IN DAVIS 2 END STAINLESS STEEL SURGICAL",SUP-410230,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.33,38.5,"CIGNA [10200]","Cigna Local Plus",,68.66,53.5,,,,,0,14.92,109.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER II HTD 110CM 4MM 7FR 2.5MM SPACE STD SMALL CURVE",SUP-5031TK1,CDM,C1733,HCPCS,0272,RC,,,both,,,6382.50,1914.75,"UHC [10700]","United Healthcare",,4040.12,63.3,,,,,0,742.28,5425.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +15.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.155,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 19GA 9CM COAXIAL OPTIONAL",SUP-MCXS2009LY,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.64,44.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,101.76,68,,,,,0,17.4,127.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 26MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710626,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"BLUE CROSS [10001]","Blue Cross PPO",,5799.09,39.2,,3949.44,3949.44,3949.44,"1 through 10",1720.5,12574.56,"percent of total billed charges",
"HC Exam/Biopsy of Vag W/Scope",PX-761000089,CDM,57421,CPT,0761,RC,,,both,,,2081.70,624.51,"NOVANET [10819]",Novanet,,1561.28,75,,,,,0,242.1,2081.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 95MM 28MM AFX VELA ENDOVASCULAR STRATA AORTIC",SUP-A28-28/C95-O20V,CDM,C1874,HCPCS,0278,RC,,,both,,,35406.00,10621.8,"CIGNA [10200]",Cigna,,14162.4,40,,,,,0,4117.72,30095.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Picc WO Port/Img <5yr",PX-361000270,CDM,36568,CPT,0361,RC,,,both,,,7800.82,2340.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7800.82,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,7.8,7800.82,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 150MM 20GA 8-10MM VENOM V ACTIVE TIP 10",SUP-0406-660-225,CDM,S27200284,LOCAL,0272,RC,,,both,,,591.43,177.43,"CIGNA [10200]","Cigna Open Access",,336.52,56.9,,,,,0,68.78,502.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL SEMKEN 4.75IN TISSUE 1X2 TEETH STAINLESS STEEL",SUP-130-280,CDM,S27200284,LOCAL,0272,RC,,,both,,,98.31,29.49,"PHCS [10601]",PHCS,,68.82,70,,,,,0,11.43,83.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X120 135CM SL",SUP-48006012R,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,118.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 5MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-05008,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Open Access",,3927.24,33.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACURATE PRIME AORTIC VALVE XL",SUP-SYM-SV29-009-C,CDM,S62400003,LOCAL,0624,RC,,,both,,,127680.00,38304,"KAISER [10500]",Kaiser,,85545.6,67,,,,,0,14849.18,108528,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEK DUO",SUP-5190-0020,CDM,S27200284,LOCAL,0272,RC,,,both,,,111150.00,33345,"AETNA [10100]","Aetna HMO/PPO",,88364.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12926.75,94477.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 20MM 109CM 6MM 75CM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200062070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Open Access",,2355.66,56.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 6MM 14MM LCP TITANIUM FULL THREAD PROXIMAL",SUP-404.814,CDM,C1713,HCPCS,0278,RC,,,both,,,258.83,77.65,"CIGNA [10200]","Cigna Open Access",,147.27,56.9,,1144.80,304.56,2275.09,66,30.1,220.01,"percent of total billed charges",
"SHEATH HEARTSPAN MR0 CURVE 63CM 8.5FR GUIDING PEBAX STEEL",SUP-FCB8563MR0,CDM,C1894,HCPCS,0272,RC,,,both,,,1432.08,429.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,166.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.55,1217.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 24MM MITRAL 3D REDUCED CURVATURE SEWING","SUP-4100 M24",CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"PHCS [10601]",PHCS,,12075,70,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INSTR GMK SPHERE DISPOSABLE MIS",SUP-11.01002,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 24FR AORTA EMBOL-X SLIM PLASTIC",SUP-EXGF24D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1222.86,366.86,"MULTIPLAN [10600]",Multiplan,,1039.43,85,,,,,0,142.22,1039.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM VARIAX NONSTERILE",SUP-657422,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,94.05,687.4,"percent of total billed charges",
"PACEMKR CARDIAC CROME 2 CHMBR DF4 INLINE CNCT IS4 INLINE",SUP-DTPC2QQ,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"UHC [10700]","United Healthcare",,48709.35,63.3,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 30MM 190CM 4MM",SUP-R51004003L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"FIRST HEALTH [10303]","First Health",,1577.4,80,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE 15IN 5FR 18GA 21GA UMBILICAL POLYURETHANE",SUP-8888160556,CDM,S27200284,LOCAL,0272,RC,,,both,,,305.39,91.62,"AETNA [10100]","Aetna HMO/PPO",,242.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.52,259.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 18MM 2MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG20018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXERCISER HAND CANDO DIGI-FLEX CALIBRATE SPRING RACK BASE",SUP-A39710,CDM,S27000186,LOCAL,0270,RC,,,both,,,629.21,188.76,"NOVANET [10819]",Novanet,,471.91,75,,,,,0,73.18,534.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 20MM 144CM 3.5MM CORONARY STENT",SUP-H7493911420350,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"NOVANET [10819]",Novanet,,6856.88,75,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 12/14 TAPER 32MM HIP OXINIUM ECHELON",SUP-71343212,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1840.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN 3-11.5GA LOCK DIAMOND TIP STYLET DELIVARY",SUP-975,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL STANDARD+ 17.5MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405517,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"CIGNA [10200]",Cigna,,6571.15,68,,5873.17,5873.17,5873.17,"1 through 10",1123.86,8213.93,"percent of total billed charges",
"CATH EXTR PRO 200CM 7-6FR 9-12MM BALLOON DILATATION NATURAL",SUP-4700,CDM,C1726,HCPCS,0272,RC,,,both,,,1202.04,360.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,139.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.8,1021.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY TORIC",SUP-CNWET4,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"FIRST HEALTH [10303]","First Health",,692,80,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 235MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.015S,CDM,C1713,HCPCS,0278,RC,,,both,,,9346.95,2804.08,"CIGNA [10200]","Cigna Open Access",,5318.41,56.9,,1144.80,304.56,2275.09,66,1087.05,7944.91,"percent of total billed charges",
"PACK SURGICAL CATARACT",SUP-SA60WF.245,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER DIA4MM TOMCAT RESECTION FOR SMALL JOINT FORMULA",SUP-375-545-000R,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,118.32,68,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SURGICAL CATARACT",SUP-SA60WF.245,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X8MM HEDRON C 7D 14MM STERILE LATEX FREE",SUP-1211.4618S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"AMERIGROUP MEDICAID [20100]",Amerigroup,,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 5D MEDIUM 47MM 3DI FUSION LOW PROFILE COMPRESSION SLOT",SUP-587225LT,CDM,S27200284,LOCAL,0272,RC,,,both,,,12420.00,3726,"NOVANET [10819]",Novanet,,9315,75,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 24MM MITRAL 3D REDUCED CURVATURE SEWING","SUP-4100 M24",CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross PPO",,6762,39.2,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 3-0 SH SPIRAL 70CM KNOTLESS",SUP-SXMP1B428,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"UHC [10700]","United Healthcare",,135.4,63.3,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP SMF WITH UNIPOLAR HEAD",SUP-71705615,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross PPO",,4057.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"INTRO 1000093011 OPTISEAL GLBL9FR25CM",SUP-1000093011,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPEL TWIST-LOC 25CM 14FR NEPHRSTMY FLEXITHANE METAL",SUP-H7493934114250,CDM,C1729,HCPCS,0272,RC,,,both,,,826.20,247.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,339.57,41.1,,,,,0,96.09,702.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 2.25X20MM",SUP-PRV022520CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 105MM 4.2MM RHINOTEC GATOR 30D BENDABLE",SUP-E9360,CDM,S27200284,LOCAL,0272,RC,,,both,,,741.96,222.59,"CIGNA [10200]",Cigna,,504.53,68,,,,,0,86.29,630.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sleeve Compression",PX-E27000157,CDM,E27000157,LOCAL,0270,RC,,,both,,,458.70,137.61,"PHCS [10601]",PHCS,,321.09,70,,,,,0,53.35,389.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 20MM 154CM 6MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200062020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]",Cigna,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SURGICAL CATARACT",SUP-SA60WF.170,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 60X22X14MM 10D XL WIDE PEEK LORDOTIC",SUP-6921460,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"FIRST HEALTH [10303]","First Health",,19008,80,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 45MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.055,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"PHCS [10601]",PHCS,,3389.82,70,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER SMALL 5-24MM GRAFT MULTIPACK PLASTIC LATEX FREE",SUP-M002363200201,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.75,26.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,inpatient,,,123931.08,37179.32,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 18FR SILICONE MIC RADIOPAQUE FEED TUBE",SUP-8250-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER GUIDING 100CM 8FR .091IN MACH 1 KIESZ RIGHT 4 HORIZ",SUP-H749343586490,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 6IN CORONARY ARTERY OSTIAL SOFT FLANGE",SUP-30055,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.85,74.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER SPINAL 26X12X7MM RISE NONSTERILE",SUP-193.202,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 38MM 144CM 2.5MM CORONARY STENT EVEROLIMUS",SUP-H7493926138250,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1022.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 18MM 2.75MM CORONARY STENT FULCRUM COCR",SUP-INT27518UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"MULTIPLAN [10600]",Multiplan,,2052.75,85,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALARM WC POSEY SELF RELEASE BELT DISPOSABLE",SUP-8399,CDM,S27100035,LOCAL,0271,RC,,,both,,,229.16,68.75,"NOVANET [10819]",Novanet,,171.87,75,,,,,0,26.65,194.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 300CM 3CM",SUP-1020016,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT CONSTRAIN LEGION OXINIUM",SUP-71421167,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"NOVANET [10819]",Novanet,,43375.5,75,,,,,0,6726.09,49158.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +11.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000115,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION HIP DRILL GUIDE OBTR Q-FIX 1.8MM",SUP-251811,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Local Plus",,715.03,53.5,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 40MM REGULAR GASTROINTESTINAL MUSCLE LINEAR",SUP-CS40B,CDM,S27200284,LOCAL,0272,RC,,,both,,,4374.74,1312.42,"NOVANET [10819]",Novanet,,3281.06,75,,,,,0,508.78,3718.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 12CM 10FR .035IN GENTLE CURVE BILIARY",SUP-G21810,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 4IN LEAD SCRDRVR ACCESS PAI",SUP-3550-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM 10MM PRESS FIT UNIVERSAL FLUTE KNEE",SUP-867424,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5508.41,68,,,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 12MM 22MM EXPLOR ELBOW MODULAR",SUP-11-210032,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1684.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1653.09,12081.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER HUMERAL 39MM UNIVERS REVERS +6MM SHOULDER TITANIUM",SUP-AR-9505-06,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1349.46,45.9,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ARTHROSCOPIC STERILE ARTHREX APOLLO RF DISPOSABLE 50D",SUP-AR-9835,CDM,S27200284,LOCAL,0272,RC,,,both,,,2047.50,614.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,242.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,238.12,1740.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEART FAILURE AND SHOCK WITH MCC",291,MS-DRG,,,,,,,inpatient,,,31504.22,9451.27,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,8520.93,,"Case rate ($7,963.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,394.64, add-ons for qualifying new technology services are included. If operating cost exceeds $40,434.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,941.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,404.42. The transfer operating threshold is the transfer adjustment factor * $7,394.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $559.07. The transfer capital threshold is the transfer adjustment factor * $559.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,31504.22,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 3 KNEE LEFT BICRUCIATE STABILIZE",SUP-74022223,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4487.97,27,,,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 95D 238MM PROTASUL-64 PERIPROSTHETIC 9 HOLE NCB BONE",SUP-0202264109,CDM,C1713,HCPCS,0278,RC,,,both,,,13144.50,3943.35,"KAISER [10500]",Kaiser,,8806.82,67,,,,,0,1528.71,11172.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 95MM 5MM XLONG CARBIDE ROUND 8 FLUTED LINVATEC",SUP-5300030513,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.18,81.35,"FIRST HEALTH [10303]","First Health",,216.94,80,,,,,0,31.54,230.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 30MM 3.8-3.4FR 6.5MM LOW",SUP-H74939031653010,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"KAISER [10500]",Kaiser,,1004,67,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLS-1006 CLASSICSHEATH STANDARD",SUP-398711,CDM,C1894,HCPCS,0272,RC,,,both,,,3339.00,1001.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,395.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,388.33,2838.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Thorax W Cntrst Dx",PX-352000005,CDM,71260,CPT,0352,RC,,,both,,,3286.81,986.04,"AETNA [10100]","Aetna HMO/PPO",,1933,,"Per diem ($1,933). Each eligible service on a given day will be paid its own per diem rate.",1824.00,1824.00,1824.00,"1 through 10",382.26,2793.79,"per diem",
"HC Tc99m Sestamibi per Study",PX-343000002,CDM,A9500,HCPCS,0343,RC,,,both,,,252.40,75.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.35,252.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Breast Local Dev Stereo",PX-361000314,CDM,19283,CPT,0361,RC,,,both,,,3031.00,909.3,"UHC [10700]","United Healthcare",,2385,,"Case rate ($2,385). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,352.51,3031,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 3MM 2.4MM 160CM RING HANDLE STERILE",SUP-163R,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.35,24.4,"UHC [10700]","United Healthcare",,51.49,63.3,,,,,0,9.46,69.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER DIALYZER DIACAP PRO 16H DEHP FREE STERILE LATEX FREE",SUP-720DH16,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.18,46.85,"CIGNA [10200]","Cigna Local Plus",,83.56,53.5,,,,,0,18.16,132.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC",661,MS-DRG,,,,,,,inpatient,,,39926.03,11977.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9339.31,,"Fee schedule rate ($9,339.31). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,6422.65,30229.54,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER BIPOLAR 44MM 28MM TANDEM HIP COCR UHMW POLYETHYLENE",SUP-71322044,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"BLUE CROSS [10001]","Blue Cross HMO",,3274.16,39.2,,5311.50,4717.44,5388.59,31,971.39,7099.58,"percent of total billed charges",
"CMPNT FEMORAL 1 KNEE RIGHT TOTAL STBL TRIATHLON COCR",SUP-5512-F-102,CDM,C1776,HCPCS,0278,RC,,,both,,,20599.49,6179.85,"FIRST HEALTH [10303]","First Health",,16479.59,80,,,,,0,2395.72,17509.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AUROUS 100CM 5FR PIGTAIL ANGIOGRAPHIC 10 SIDEPORT",SUP-G47308,CDM,S27200284,LOCAL,0272,RC,,,both,,,1025.44,307.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,470.68,45.9,,,,,0,119.26,871.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 1.2MM RAP-PAC KNEE GWIRE STERILE LATEX",SUP-72202798,CDM,S27200284,LOCAL,0272,RC,,,both,,,1883.25,564.97,"PHCS [10601]",PHCS,,1318.28,70,,,,,0,219.02,1600.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER DIALYZER DIACAP PRO 16H DEHP FREE STERILE LATEX FREE",SUP-720DH16,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.18,46.85,"NOVANET [10819]",Novanet,,117.14,75,,,,,0,18.16,132.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"SYSTEM ELUNIR THK90UM 8MM 140CM 2.75MM CORONARY STENT",SUP-LUN275R08US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SPECIMEN RETRIEVAL 90CM 2.4FR HOOK PRONG GRASP RETRACT",SUP-M0063701100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1376.11,412.83,"AETNA [10100]","Aetna HMO/PPO",,1094.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.04,1169.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION",RX-114,CDM,J1120,HCPCS,0636,RC,23155-0313-31,NDC,both,1,UN,299.66,89.9,"CIGNA [10200]",Cigna,,68.83,,,,,,,23.12,254.71,"fee schedule",
"PLATE CS2 STAINLESS STEEL 2.7MM SCR VARIABLE ANGLE LCP BONE",SUP-02.112.623S,CDM,C1713,HCPCS,0278,RC,,,both,,,6605.09,1981.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3031.74,45.9,,,,,0,768.17,5614.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 100MM .8MM STERILE",SUP-03.333.000S,CDM,C1713,HCPCS,0278,RC,,,both,,,394.86,118.46,"CIGNA [10200]",Cigna,,268.5,68,,1831.33,1831.33,1831.33,16,45.92,335.63,"percent of total billed charges",
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD + OSS LH",SUP-98000700021,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7933.46,28.62,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 18MM 140CM 2.75MM 2.1-2.7FR CORONARY",SUP-RONYX27518UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 6MM ZERO-P LORDOTIC VARIABLE ANGLE STERILE",SUP-04.647.126S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3353.4,27,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS AIM SL 65CM 7FR GUIDING SLITTABLE INNER STERILE",SUP-DS2N104-65,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DEBAKEY ANGLE 11.75IN VASCULAR TISSUE 2MM",SUP-55-2017,CDM,S27200284,LOCAL,0272,RC,,,both,,,623.54,187.06,"MULTIPLAN [10600]",Multiplan,,530.01,85,,,,,0,72.52,530.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ALEXIS 2XS SHORT RING ATRAUMATIC SELF RETAIN WOUND",SUP-C8323,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,128.73,41.1,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.50 X 33 RX US",SUP-1804250-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 11MM CEMENT BOW LPS KNEE",SUP-198715211,CDM,C1776,HCPCS,0278,RC,,,both,,,39860.10,11958.03,"AETNA [10100]","Aetna HMO/PPO",,31688.78,79.5,,10981.53,8986.79,12413.38,12,4635.73,33881.09,"percent of total billed charges",
"FIBER LASER 2.6MR FLEXIVA PULSE TRACTIP 365UM HIGH POWER",SUP-M006L8405920,CDM,S27200284,LOCAL,0272,RC,,,both,,,2390.40,717.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INVESTIGATIONAL DRUG IV (INDICATE DOSE IN SPECIAL INSTRUCTIONS)",RX-410999,CDM,,,0250,RC,99999-4109-99,NDC,both,1,UN,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT ENDOSCOPIC HISTOLOCK 230CM 27X14MM 2.4MM RESECTION",SUP-BX00711117,CDM,C1773,HCPCS,0272,RC,,,both,,,607.50,182.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEAD FEMORAL +15.5MM 12/14 OFFSET TAPER 40MM HIP M",SUP-136509000,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"BLUE CROSS [10001]","Blue Cross HMO",,4342.56,39.2,,5311.50,4717.44,5388.59,31,1288.37,9416.26,"percent of total billed charges",
"SCR BONE 3.5MM 10MM RELINE C SPINE MULTIAXIAL NONSTERILE",SUP-3903510,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,1831.33,1831.33,1831.33,16,521.61,3812.25,"percent of total billed charges",
"SCR BONE 6.5MM 45MM OSTEOGRIP NANO SPINE SHANK",SUP-55904506545,CDM,C1713,HCPCS,0278,RC,,,both,,,8193.75,2458.12,"PHCS [10601]",PHCS,,5735.63,70,,,,,0,952.93,6964.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI MIRACLEBROS 3 VASCULAR 180CM 11CM .014IN",SUP-AG14M050,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 30MM 135CM 6MM VASCULAR NITINOL",SUP-1012534-30,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"MULTIPLAN [10600]",Multiplan,,3519,85,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 8MM LEMAITRE BOVINE CAROTID ARTERY",SUP-AG1030,CDM,C1768,HCPCS,0278,RC,,,both,,,26390.70,7917.21,"BLUE CROSS [10001]","Blue Cross PPO",,10345.15,39.2,,,,,0,3069.24,22432.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 135MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.935,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"PHCS [10601]",PHCS,,962.09,70,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 110CM 1MM 5FR 5MM SPACE D CURVE ELECTROPHYSIOLOGY 10",SUP-F5CQD005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"UHC [10700]","United Healthcare",,574.26,63.3,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sleeve Compression",PX-E27000157,CDM,E27000157,LOCAL,0270,RC,,,both,,,458.70,137.61,"UHC [10700]","United Healthcare",,290.36,63.3,,,,,0,53.35,389.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP 3 HOLE EMPHASYS",SUP-471062300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"BLUE CROSS [10001]","Blue Cross HMO",,7038.36,39.2,,5311.50,4717.44,5388.59,31,2088.17,15261.75,"percent of total billed charges",
"INTRO CATH 35CM 16FR 5.3MM CHECK-FLO PERFORMER RADIOPAQUE",SUP-G27023,CDM,C1894,HCPCS,0272,RC,,,both,,,813.24,243.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,334.24,41.1,,,,,0,94.58,691.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM DCP LC-DCP STAINLESS STEEL PROXIMAL",SUP-204.224,CDM,C1713,HCPCS,0278,RC,,,both,,,117.28,35.18,"CIGNA [10200]","Cigna Local Plus",,62.74,53.5,,3978.14,359.25,3978.14,24,13.64,99.69,"percent of total billed charges",
"STENT WALLSTENT RP 20MM 100CM 10MM 75CM ENDOPROSTHESIS METAL",SUP-M001712320,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"BLUE CROSS [10001]","Blue Cross HMO",,3313.38,39.2,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 09.0",SUP-DIB00U0090,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Local Plus",,715.03,53.5,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 10MM KNEE POLYETHYLENE STABILIZE ROTATE",SUP-129416610,CDM,C1776,HCPCS,0278,RC,,,both,,,12447.60,3734.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1447.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1447.66,10580.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPI-FIT 83CM 14FR 3MM AIRWAY EXCHANGE ADPTR LUER LOCK",SUP-G57622,CDM,S27200284,LOCAL,0272,RC,,,both,,,672.30,201.69,"MULTIPLAN [10600]",Multiplan,,571.46,85,,,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +6 DIOPTER MODIFIED C CONVEXOPLANO 13.5MM 5.5MM",SUP-MTA5U0.060,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 15D 60MM 32MM MARATHON HIP STERILE",SUP-121932260,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,961.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,943.3,6894.31,"percent of total billed charges",
"INTRO SHEATH 5FR 18GA 50CM 11CM GRAY HUB DIL GWIRE",SUP-PSI-5F-11-038-18G,CDM,C1894,HCPCS,0272,RC,,,both,,,102.23,30.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.89,86.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM SURGICAL SQUARE STERILE LATEX FREE DISPOSABLE",SUP-SN24,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2524.5,68,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 12MM 6FR 3MM .07IN BALLOON",SUP-H7493918912300,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"FIRST HEALTH [10303]","First Health",,453.6,80,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 12FR 4.1MM 80CM VALVE RADIOPAQUE BAND GWIRE",SUP-G49487,CDM,C1894,HCPCS,0272,RC,,,both,,,657.72,197.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,447.25,68,,,,,0,76.49,559.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.6MM CHARLOTTE",SUP-43512600,CDM,S27200284,LOCAL,0272,RC,,,both,,,1635.00,490.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,190.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,190.15,1389.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER SHORT TIP RELOAD 30MM ORANGE",SUP-ASR30RS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM MASTER-SERIES PYROLYTIC CARBON PTFE",SUP-23AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]",Cigna,,11647.69,40,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 100MM 2MM VARIAX STOP 4.5MM NONSTERILE",SUP-703818,CDM,C1713,HCPCS,0278,RC,,,both,,,629.37,188.81,"MULTIPLAN [10600]",Multiplan,,534.96,85,,,,,0,73.2,534.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 14CM 23MM 18.5-21.5MM EXCLUDER",SUP-PLC231400,CDM,C1874,HCPCS,0278,RC,,,both,,,27997.20,8399.16,"BLUE CROSS [10001]","Blue Cross HMO",,10974.9,39.2,,9776.84,9776.84,9776.84,"1 through 10",3256.07,23797.62,"percent of total billed charges",
"STEM FEMORAL 140MM 12MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192012,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9499.39,40,,,,,0,2761.95,20186.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 148MM TYPE 1 PRESS FIT REDUCE TAPERLOC PPS 133D",SUP-51103140,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"BLUE CROSS [10001]","Blue Cross HMO",,9487.71,39.2,,5311.50,4717.44,5388.59,31,2814.85,20572.84,"percent of total billed charges",
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,inpatient,,,99303.02,29790.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,27866.83,,"Fee schedule rate ($27,866.83). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,8707.87,35009.37,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD",SUP-98000500306,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,9384.48,39.2,,3949.44,3949.44,3949.44,"1 through 10",2784.22,20349,"percent of total billed charges",
"LINER ACETABULAR PINNACLE 10D +4MM 52MM 36MM ALTRX HIP",SUP-122136152,CDM,C1776,HCPCS,0278,RC,,,both,,,6814.08,2044.22,"NOVANET [10819]",Novanet,,5110.56,75,,,,,0,792.48,5791.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM WIDE BLADE TRANSVERSE",SUP-7541113,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",348.9,2550,"percent of total billed charges",
"KNIFE ELECTROSURGICAL 3MM ORISE",SUP-M00519371,CDM,S27200284,LOCAL,0272,RC,,,both,,,5863.28,1758.98,"NOVANET [10819]",Novanet,,4397.46,75,,,,,0,681.9,4983.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEPPERMINT OIL",RX-6116,CDM,,,0637,RC,00395-2015-91,NDC,both,30,ML,160.96,48.29,"MULTIPLAN [10600]",Multiplan,,136.82,85,,,,,0,18.72,136.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 12X22X60MM 5DEG LORDOTIC TITANIUM ALLOY MODULUS",SUP-1223260P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross HMO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 110CM 4CM 5FR 9MM 7.5MM BALLOON DILATATION",SUP-4199040L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METRONIDAZOLE 5 MG/ML IVPB",RX-40840043,CDM,J1836,HCPCS,0636,RC,00338-1055-48,NDC,both,100,ML,100.65,30.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4.28,,,,,,,1.75,85.55,"fee schedule",
"HC Dialysis Periton O/P 1 Eval",PX-761000034,CDM,90945,CPT,0835,RC,,,both,,,1403.22,420.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,954.19,68,,,,,0,61.04,1192.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER SHORT TIP RELOAD 30MM GRAY",SUP-ASR30GS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"KAISER [10500]",Kaiser,,949.73,67,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 20MM 6FR 9MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206090210,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 8.25IN OLSEN STRAIGHT BAYONET INSULATE NONSTICK",SUP-20-1410IMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,631.80,189.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR LARGE 2.5X2X1.2MM 1MM APPLEBAUM",SUP-14-0957,CDM,L8613,HCPCS,0278,RC,,,both,,,2652.68,795.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,759.2,28.62,,,,,0,232.31,2254.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-4 TT-17 36IN 2 ARM MONOFILAMENT WHITE",SUP-4N04A,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.85,83.95,"KAISER [10500]",Kaiser,,187.5,67,,,,,0,32.55,237.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION DEB 3.0X35",SUP-SCA14U-300035D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSELECT PLUS DEMINERALIZED BONE MATRIX 5CC",SUP-359450,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1234.24,28.62,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 2 RIGHT MEDIAL LEFT LATERAL PARTIAL",SUP-5620-B-202,CDM,C1776,HCPCS,0278,RC,,,both,,,6899.21,2069.76,"PHCS [10601]",PHCS,,4829.45,70,,,,,0,802.38,5864.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 9CM 18MM 18.5FR LOW PROFILE ESOPHAGEAL",SUP-M00516910,CDM,C1874,HCPCS,0278,RC,,,both,,,10022.00,3006.6,"PHCS [10601]",PHCS,,7015.4,70,,,,,0,1165.56,8518.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 100MM 80CM 9MM VASCULAR NITINOL",SUP-1012531-100,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1184.87,28.62,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 128MM 2.8MM TWIST STERILE",SUP-0277-082-085S2,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.80,262.44,"CIGNA [10200]",Cigna,,594.86,68,,,,,0,101.74,743.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 18MM 48MM SHOULDER SOFT TISSUE BALANCE",SUP-7122884,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"AMERIGROUP MEDICAID [20100]",Amerigroup,,938.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Consult Comprehensive 3",PX-312000035,CDM,88325,CPT,0312,RC,,,both,,,1691.00,507.3,"NOVANET [10819]",Novanet,,1268.25,75,,,,,0,0.01,1437.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 13.5MM 19MM MOSAIC ULTRA CINCH PORCINE",SUP-305U219,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"MULTIPLAN [10600]",Multiplan,,23294.25,85,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE GLIDE TECHNOLOGY VASCULAR STD STRAIGHT 180CM",SUP-GS3503,CDM,C1769,HCPCS,0272,RC,,,both,,,426.30,127.89,"KAISER [10500]",Kaiser,,285.62,67,,,,,0,49.58,362.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE RELINE L40 MM OD5.5 MM SPINE POLYAXIAL 2 FULL CAN",SUP-16215540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP HUMERAL 33MM UNIVERS REVERS NEUTRAL SUT",SUP-AR-9502F-33CPC,CDM,C1776,HCPCS,0278,RC,,,both,,,7576.20,2272.86,"MULTIPLAN [10600]",Multiplan,,6439.77,85,,,,,0,881.11,6439.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 NARROW KNEE RIGHT POSTERIOR STABILIZE",SUP-42500206402,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"UHC [10700]","United Healthcare",,18290.9,63.3,,8601.07,8395.67,8601.07,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"HC Protozoa Ab Nos",PX-302000157,CDM,86753,CPT,0302,RC,,,both,,,169.00,50.7,"CIGNA [10200]","Cigna Open Access",,27.26,,,,,,,0.01,143.65,"fee schedule",
"SCR BONE CONICAL CANNULATED 5MM 75MM LCP STAINLESS STEEL",SUP-02.205.275,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,714.14,45.9,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 6MM INTERLOCK OCCLUSION SYSTEM",SUP-M001363720,CDM,S27800098,LOCAL,0278,RC,,,both,,,2827.50,848.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1297.82,45.9,,,,,0,328.84,2403.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-27333,CDM,,,0637,RC,00904-7208-06,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM 20MM 15MM STD NECK S-ROM CERAMIC 135D",SUP-523194,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5251.84,27,,,,,0,2262.18,16533.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 150MM .053IN ANKLE THREAD TROCAR DISPOSABLE",SUP-AR-8943-38,CDM,C1769,HCPCS,0272,RC,,,both,,,252.30,75.69,"UHC [10700]","United Healthcare",,159.71,63.3,,,,,0,29.34,214.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 128MM 12MM PRIMARY PRESSFIT TRABECULAR METAL",SUP-00786401220,CDM,S27800098,LOCAL,0278,RC,,,both,,,30164.40,9049.32,"UHC [10700]","United Healthcare",,19094.07,63.3,,,,,0,3508.12,25639.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 6MM .0115IN AXIUM PRIME HELICAL",SUP-APB-6-12-HX-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,7169.10,2150.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,833.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,833.77,6093.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE CARDIOFORM ASD OCCLUDER 44MM 12FR",SUP-00733132636518,CDM,C1817,HCPCS,0278,RC,,,both,,,52321.50,15696.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6200.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6084.99,44473.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 15CM 120CM 10MM ENDOPROSTHESIS LUMEN CATH",SUP-VBCR101502A,CDM,C1874,HCPCS,0278,RC,,,both,,,21577.50,6473.25,"FIRST HEALTH [10303]","First Health",,17262,80,,,,,0,2509.46,18340.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 140MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.423,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"BLUE CROSS [10001]","Blue Cross PPO",,542.58,39.2,,957.42,570.23,957.42,28,160.97,1176.51,"percent of total billed charges",
"COIL EMBOLIZATION 2CM 2MM AZUR CX HYDROCOIL DETACHABLE LOOP",SUP-45-780202,CDM,S27800098,LOCAL,0278,RC,,,both,,,5275.05,1582.51,"FIRST HEALTH [10303]","First Health",,4220.04,80,,,,,0,613.49,4483.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 7CM 7FR 21GA .018IN STRAIGHT MICRO 1 END GWIRE",SUP-MIS-7F07,CDM,C1894,HCPCS,0272,RC,,,both,,,174.00,52.2,"FIRST HEALTH [10303]","First Health",,139.2,80,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 60MM 5FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206060670,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT 10GA OSSEOFLEX STEERABLE NDL BALLOON",SUP-OCP-0224,CDM,S27200284,LOCAL,0272,RC,,,both,,,15290.40,4587.12,"FIRST HEALTH [10303]","First Health",,12232.32,80,,,,,0,1778.27,12996.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR .092IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1007,CDM,C1892,HCPCS,0272,RC,,,both,,,298.32,89.5,"NOVANET [10819]",Novanet,,223.74,75,,,,,0,34.69,253.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI: REGULAR Y 1MM CRANIOMAXILLOFACIAL 5 HOLE 2MM SCR",SUP-55-08250,CDM,C1713,HCPCS,0278,RC,,,both,,,1552.45,465.73,"BLUE CROSS [10001]","Blue Cross PPO",,608.56,39.2,,957.42,570.23,957.42,28,180.55,1319.58,"percent of total billed charges",
"KETAMINE 50 MG/ML INJECTION SOLUTION",RX-4238,CDM,,,0250,RC,72572-0320-01,NDC,both,10,ML,60.00,18,"AETNA [10100]","Aetna HMO/PPO",,47.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.98,51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY 100CM 1.8MM RADIAL JAW STD PULMONARY DISPOSABLE",SUP-M00515181,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.48,104.84,"PHCS [10601]",PHCS,,244.64,70,,,,,0,40.64,297.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fluorescent Ab Screen Ea",PX-302000051,CDM,86255,CPT,0302,RC,,,both,,,115.00,34.5,"BLUE CROSS [10001]","Blue Cross HMO",,0.12,.1,,,,,0,0.12,97.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE CROSS-IT 100XT VASCULAR STRAIGHT 300CM 3CM",SUP-1003310H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 24FR POWERBALL OLYMPUS OES",SUP-M0068802311,CDM,S27200284,LOCAL,0272,RC,,,both,,,956.45,286.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.24,812.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE EQUINOXE SHOULDER GLENOSPHERE LOCK REVERSE",SUP-320-15-05,CDM,C1713,HCPCS,0278,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 11/13 TAPER 28MM HIP BIOLOX DELTA CERAMIC",SUP-136528210,CDM,C1776,HCPCS,0278,RC,,,both,,,12385.50,3715.65,"CIGNA [10200]","Cigna Open Access",,4149.14,33.5,,5302.19,4377.88,6578.61,27,1440.43,10527.68,"percent of total billed charges",
"SPACER SPINAL 26X10X6MM SABLE 8D STERILE LATEX FREE",SUP-1172.2110S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"NOVANET [10819]",Novanet,,25987.5,75,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Resection",PX-750000175,CDM,45390,CPT,0750,RC,,,both,,,4291.85,1287.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2292.95,,"Case rate ($2,292.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,499.14,4291.85,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 3CM 5FR .035IN STRAIGHT URETERAL",SUP-M006155224050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROLENE 4X1.8IN KNIT NONABSORBABLE PRESHAPE",SUP-PMSK,CDM,C1781,HCPCS,0278,RC,,,both,,,594.43,178.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,70.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.13,505.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM ORTHOLOC FULL THREAD FOOT ANKLE CORTICAL",SUP-58813514,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,353.2,45.9,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22-24X27-32X9MM LUMINARY CC BICONVEX SPINE",SUP-16809,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"BLUE CROSS [10001]","Blue Cross PPO",,13039.49,39.2,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CITATION TMZF HA 5 SHORT HIP LEFT",SUP-6265-5205,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"BLUE CROSS [10001]","Blue Cross PPO",,9573.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",2840.27,20758.66,"percent of total billed charges",
"HC Cath for Urine Specimen",PX-450000335,CDM,P9612,HCPCS,0300,RC,,,both,,,177.00,53.1,"FIRST HEALTH [10303]","First Health",,141.6,80,,,,,0,0.18,150.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ewho Rigid W/O Jnts Cf",PX-E27400104,CDM,L3763,HCPCS,0274,RC,,,both,,,2009.70,602.91,"CIGNA [10200]","Cigna Local Plus",,1075.19,53.5,,,,,0,233.73,1708.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cytomegalovirus (Cmv) Ab",PX-302000111,CDM,86644,CPT,0302,RC,,,both,,,349.60,104.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12.95,,,,,,,0.01,297.16,"fee schedule",
"HC Battery Elec/Combo Vad, Rep",PX-E27400023,CDM,Q0496,HCPCS,0274,RC,,,both,,,543.40,163.02,"BLUE CROSS [10001]","Blue Cross PPO",,213.01,39.2,,,,,0,63.2,461.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,J0561,HCPCS,0636,RC,60793-0700-01,NDC,both,1,ML,1414.74,424.42,"BLUE CROSS [10001]","Blue Cross HMO",,209.86,,,,,,,167.65,1202.53,"fee schedule",
"HC Perc Cath Portal Vein",PX-361000104,CDM,36481,CPT,0361,RC,,,both,,,1237.84,371.35,"UHC [10700]","United Healthcare",,1237.84,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,143.96,1237.84,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 137MM 9MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-103090,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2814.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Benzodiazepines",PX-301000035,CDM,80347,CPT,0301,RC,,,both,,,262.00,78.6,"KAISER [10500]",Kaiser,,175.54,67,,,,,0,0.26,251.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Benzodiazepines",PX-301000035,CDM,80347,CPT,0301,RC,,,both,,,262.00,78.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,180,,,,,,,0.26,251.75,"fee schedule",
"HC Assay of Blood Pku",PX-300000027,CDM,84030,CPT,0301,RC,,,both,,,64.00,19.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.77,,"Fee schedule rate ($5.77). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,54.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS .096- IN COPILOT KIT BLEEDBACK CONTROL",SUP-1003330,CDM,C1769,HCPCS,0272,RC,,,both,,,321.90,96.57,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT POLYETHYLENE SUTURETAPE 1.3MM 36IN .5 CIRCLE TAPER NDL",SUP-AR-7500,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.73,95.92,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) INNOVALVE VALVE PROTHESIS FOR TMVR (TRANSCATHETER MIT",SUP-PRO-5813,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX ULTRAVERSE 100CM 150MM 7MM BALLOON DILATATION",SUP-LX1810071505F,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 150CM 30MM 3MM BALLOON DILATATION DURALYN",SUP-48003003X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,inpatient,,,177891.25,53367.37,"CIGNA [10200]",Cigna,,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 55.9%. Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 9 STD 55MM 13.5MM 10.5MM PROVOX LIFE LARYTUBE",SUP-7414,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN NASAL 2.5MR ETCO2 O2 NONINTUBATE SIDESTREAM PEDIATRIC",SUP-989803144461,CDM,S27000186,LOCAL,0270,RC,,,both,,,132.81,39.84,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DAT515. AS UVA VIVITY",SUP-DAT515,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,100.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 95MM 5.5MM CREO CURVE TITANIUM NONSTERILE",SUP-1119.7095,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"XTRA ASPIRATION AND ANTICOAGULATION LINE (AAL) 1/4",SUP-4373,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"AETNA [10100]","Aetna HMO/PPO",,152.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 35MM DARCO TITANIUM FOOT NONLOCK",SUP-DC2820135,CDM,C1713,HCPCS,0278,RC,,,both,,,672.30,201.69,"KAISER [10500]",Kaiser,,450.44,67,,,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JEIL POWER DRIVER, SINGLE USE",SUP-111-ED-050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"PHCS [10601]",PHCS,,1020.6,70,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE 30MM 11MM 60 FULL THREAD COMPOSITCP",SUP-905263,CDM,C1713,HCPCS,0278,RC,,,both,,,3075.00,922.5,"BLUE CROSS [10001]","Blue Cross HMO",,1205.4,39.2,,957.42,156.86,7483.26,51,357.62,2613.75,"percent of total billed charges",
"WIRE FIXATION REUNION NITINOL PILOT STERILE LATEX FREE",SUP-5901-6072,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA [10200]","Cigna Open Access",,433.24,56.9,,1144.80,304.56,2275.09,66,88.55,647.19,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS 26CM 3CM 6FR .038IN 2 PIGTAIL",SUP-M006192133010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]","Cigna Local Plus",,642.31,,,,,,,139.63,1020.49,"percent of total billed charges",
"GASTROINTESTINAL OBSTRUCTION WITH MCC",388,MS-DRG,,,,,,,inpatient,,,28005.88,8401.76,"PHCS [10601]",PHCS,,7561,,,,,,,7561,28005.88,"per diem","Estimated amount calculated based on 4 day length of stay."
"MARKER ULTRASOUND STEREOTACTIC GUIDED RIGID DEPLOYMENT",SUP-SMARK-ATEC-13-12,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,191.14,28.62,,,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 10 NARROW KNEE LEFT CRUCIATE RETAIN PERSONA",SUP-42508006801,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"MULTIPLAN [10600]",Multiplan,,22302.5,85,,,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3.5MM 26MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.826.96,CDM,C1713,HCPCS,0278,RC,,,both,,,319.12,95.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",37.11,271.25,"percent of total billed charges",
"INSRT TIBIAL LARGE+ 12.5MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405712,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"BLUE CROSS [10001]","Blue Cross HMO",,3788.07,39.2,,5311.50,4717.44,5388.59,31,1123.86,8213.93,"percent of total billed charges",
"BRACE WALKING 10-13 11-14 LARGE LOW PROFILE 1 PIECE",SUP-79-95077,CDM,S27000186,LOCAL,0270,RC,,,both,,,294.76,88.43,"CIGNA [10200]",Cigna,,200.44,68,,,,,0,34.28,250.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GASTRO 20FR INTRO ANCHOR HEMOSTAT SCPL DIL MIC-KEY",SUP-10240,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.93,543.58,"NOVANET [10819]",Novanet,,1358.95,75,,,,,0,210.73,1540.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET",RX-31864,CDM,,,0250,RC,00406-0523-23,NDC,both,1,UN,31.21,9.36,"UHC [10700]","United Healthcare",,19.76,63.3,,,,,0,3.63,26.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 130D STD BARREL 80MM STAINLESS STEEL 3 HOLE",SUP-121125,CDM,S27800098,LOCAL,0278,RC,,,both,,,5149.13,1544.74,"FIRST HEALTH [10303]","First Health",,4119.3,80,,,,,0,598.84,4376.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TRANSITION HA SPINE PEDICLE POLYAXIAL",SUP-152.764S,CDM,C1713,HCPCS,0278,RC,,,both,,,10791.60,3237.48,"CIGNA [10200]","Cigna Open Access",,6140.42,56.9,,1144.80,304.56,2275.09,66,1255.06,9172.86,"percent of total billed charges",
"APPLR SURGICAL 7IN 20GA 2 CANN STERILE DISPOSABLE FIBRIJET",SUP-SA-3619,CDM,S27200284,LOCAL,0272,RC,,,both,,,157.38,47.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,64.68,41.1,,,,,0,18.3,133.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 4MM LORDOSIS TITANIUM",SUP-102064120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 65CM 4FR UNIVERSAL ANGIOGRAPHIC NEON SLX NYLON 5",SUP-451404V5,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UHC [10700]","United Healthcare",,66.09,63.3,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 22CM 3CM 5FR .035IN STRAIGHT URETERAL",SUP-M006155221180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 15MM 6FR 5MM .07",SUP-H7493926715500,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"FIRST HEALTH [10303]","First Health",,453.6,80,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 240MM 2MM TROCAR TIP CANNULATED HUMERAL",SUP-03.010.025,CDM,C1769,HCPCS,0272,RC,,,both,,,233.86,70.16,"NOVANET [10819]",Novanet,,175.4,75,,,,,0,27.2,198.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 39X12X3.8MM STAINLESS STEEL 4.5MM SCR LARGE",SUP-224.02,CDM,C1713,HCPCS,0278,RC,,,both,,,2336.48,700.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,668.7,28.62,,,,,0,271.73,1986.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X10MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7310,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"AETNA [10100]","Aetna HMO/PPO",,5485.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION TOGGLELOC ZIPLOOP MAXBRAID 2 2.4MM",SUP-909874,CDM,C1713,HCPCS,0278,RC,,,both,,,11040.00,3312,"BLUE CROSS [10001]","Blue Cross PPO",,4327.68,39.2,,957.42,570.23,957.42,28,1283.95,9384,"percent of total billed charges",
"HYDROMORPHONE 0.2 MG/ML IN 0.9 % NACL IV PCA SUPERORDERABLE - BASAL RATE ONLY",RX-411637,CDM,J1171,HCPCS,0636,RC,70004-0300-16,NDC,both,30,ML,100.39,30.12,"UHC [10700]","United Healthcare",,16.2,,,,,,,6.99,85.33,"fee schedule",
"CMPNT FEMORAL 5 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP5PL,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"KAISER [10500]",Kaiser,,14406.27,67,,,,,0,2500.67,18276.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 17.5MM 5MM BASE TITANIUM VARIABLE ANGLE",SUP-6955172,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,188.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",188.41,1377,"percent of total billed charges",
"LEAD PACING 86CM 4.3FR MICRO LEFT VENTRICULAR S CURVE IS 1",SUP-1258T/86,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]","Cigna Open Access",,3190.38,56.9,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165CM 10.5-12MM OTSC 3MM NITINOL",SUP-100.05,CDM,C1760,HCPCS,0278,RC,,,both,,,4133.10,1239.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1897.09,45.9,,,,,0,480.68,3513.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.0MM X 14MM TI",SUP-VAN-20140-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"BLUE CROSS [10001]","Blue Cross PPO",,381.02,39.2,,957.42,570.23,957.42,28,113.04,826.2,"percent of total billed charges",
"STENT COVERA 60MM 80CM 8MM 8FR STRAIGHT VASCULAR COVER",SUP-AVSM08060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4932.9,27,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 5.5MM 5.5MM CD HORIZON SPINE TITANIUM SIDE LOAD",SUP-779145555,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",414.32,3028.13,"percent of total billed charges",
"PLATE T 53MM STAINLESS STEEL 2MM SCR MINI FRAGMENT SET 7",SUP-247.615,CDM,C1713,HCPCS,0278,RC,,,both,,,2541.00,762.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1727.88,68,,,,,0,295.52,2159.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST TRICORTICAL THK16-18MM WEDGE",SUP-400412,CDM,S27800098,LOCAL,0278,RC,,,both,,,6023.70,1807.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1723.98,28.62,,,,,0,700.56,5120.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3.5MM TARGET TETRA DETACHABLE STERILE",SUP-TG5413510,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"UHC [10700]","United Healthcare",,8934.57,63.3,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 15MM 135CM 5MM 8MM 7FR .035IN",SUP-BXA051502A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE MYRINGOTOMY SPEAR SPEAR STERILE DISPOSABLE",SUP-1458276,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.95,20.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,28.75,41.1,,,,,0,8.14,59.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URETHRAL PROCEDURES WITH CC/MCC",671,MS-DRG,,,,,,,inpatient,,,55333.71,16600.11,"CIGNA [10200]","Cigna Open Access",,19698.33,,"Fee schedule rate ($19,698.33). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,52406.82,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 7MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT076080A,CDM,C1768,HCPCS,0278,RC,,,both,,,18225.90,5467.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4920.99,27,,,,,0,2119.67,15492.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 38CM 10FR 2CM BASKET RAPID ATRAUMATIC TIPLESS",SUP-G32862,CDM,S27200284,LOCAL,0272,RC,,,both,,,1266.03,379.81,"KAISER [10500]",Kaiser,,848.24,67,,,,,0,147.24,1076.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 5CM 120CM 10MM ENDOPROSTHESIS LUMEN CATH",SUP-VBCR100502A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"BLUE CROSS [10001]","Blue Cross HMO",,6626.76,39.2,,9776.84,9776.84,9776.84,"1 through 10",1966.05,14369.25,"percent of total billed charges",
"STENT TAEWOONG NITI-S 6CM 180CM 18MM 10.5FR ESOPHAGEAL",SUP-G57305,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4749.19,27,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACYCLOVIR 200 MG CAPSULE",RX-8969,CDM,,,0637,RC,00904-7519-61,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 11MM ARCHON SPINE SELF DRILL VARIABLE ANGLE",SUP-8780211,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 289MM 4.3MM AXSOS CALIBRATE 4MM SMALL FRAGMENT",SUP-702742,CDM,S27200284,LOCAL,0272,RC,,,both,,,1010.39,303.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.51,858.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 28MM PERIPHERAL STERILE",SUP-AR-9562-28NL,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,406.22,68,,,,,0,69.48,507.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 6-0 P-1 18IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y489G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDEAVOR SPRINT 18MM 142CM 3MM CORONARY STENT",SUP-ENSP30018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"KAISER [10500]",Kaiser,,3714.48,67,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25MM THK1.27MM STAINLESS STEEL SAGITTAL 2 CUT",SUP-4125127090,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.02,114.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,45.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.43,324.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INNATE INSTRUMENT KIT, FOR 4.5MM",SUP-EXINN914500,CDM,S27000186,LOCAL,0270,RC,,,both,,,1875.00,562.5,"CIGNA [10200]",Cigna,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 20MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC BEAVER 3MM NDL CUT EDGE",SUP-375910,CDM,S27200284,LOCAL,0272,RC,,,both,,,456.76,137.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,54.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.12,388.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC",804,MS-DRG,,,,,,,inpatient,,,75029.50,22508.85,"UHC [10700]","United Healthcare",,39589.78,,"Fee schedule rate ($39,589.78). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,39589.78,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 45MM ENDOWRIST BLUE",SUP-41645B,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,991.44,68,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 11MM GEMINUS TITANIUM CORTEX LOCK NONSTERILE",SUP-COLS-35110-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,631.80,189.54,"FIRST HEALTH [10303]","First Health",,505.44,80,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 11MM KNEE X3 CONDYLAR STABILIZED PRIMARY",SUP-5531G711,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"CIGNA [10200]","Cigna Open Access",,5329.3,56.9,,5302.19,4377.88,6578.61,27,1089.28,7961.17,"percent of total billed charges",
"HC Hu Immunoreactivity",PX-301000269,CDM,86255,CPT,0301,RC,,,both,,,229.00,68.7,"NOVANET [10819]",Novanet,,171.75,75,,,,,0,0.23,194.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 88MM RADIUS J 182X10.2X2.7MM STAINLESS STEEL 3.5MM SCR",SUP-245.934,CDM,C1713,HCPCS,0278,RC,,,both,,,4436.91,1331.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,516.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",516.01,3771.37,"percent of total billed charges",
"GRAFT SOFT TISSUE 15MM 1-2MM AVANCE NERVE ALLOGRAFT",SUP-111215,CDM,C1762,HCPCS,0278,RC,,,both,,,17734.50,5320.35,"NOVANET [10819]",Novanet,,13300.88,75,,,,,0,2062.52,15074.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 2.9MM WEDGE 3 STERILE LATEX FREE DISPOSABLE",SUP-TM22913,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1015.54,45.9,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XACT 40MM 136CM 8-6MM TAPER VASCULAR NITINOL CAROTID",SUP-82090-01,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6364.8,68,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 8MM NATURAL STD PARALLEL CERVICAL",SUP-18308,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 8 LEVEL NEW LOCK ATLANTIS VISION BONE SPINAL",SUP-7200085,CDM,C1713,HCPCS,0278,RC,,,both,,,4620.00,1386,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,547.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,537.31,3927,"percent of total billed charges",
"RTRCTR 6IN MAYO-COLLIN 2 END SURGICAL",SUP-22-1255,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.96,25.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.88,72.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP MACINTOSH 4 STAINLESS STEEL FIBER OPTIC",SUP-040-914U,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM TITANIUM ALUMINUM VANADIUM FEMUR",SUP-00493503201,CDM,C1713,HCPCS,0278,RC,,,both,,,607.50,182.25,"BLUE CROSS [10001]","Blue Cross HMO",,238.14,39.2,,957.42,156.86,7483.26,51,70.65,516.38,"percent of total billed charges",
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN AMPLATZ",SUP-67004200,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,MINOR",174,APR-DRG,,,,,,,inpatient,,,124065.12,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FEMALE REPRODUCTIVE SYSTEM INFECTIONS,MODERATE",531,APR-DRG,,,,,,,inpatient,,,31260.26,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $3,966.90. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP MEDIUM LARGE 5.5MM INTERNAL LIGACLIP EXTRA TITANIUM",SUP-LT300,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.11,35.13,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLOBETASOL 0.05 % TOPICAL CREAM",RX-9630,CDM,,,0250,RC,69238-1532-05,NDC,both,15,GR,806.60,241.98,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 90CM 8FR ULTRASOUND STERILE DISPOSABLE REPROCESSED",SUP-10135936,CDM,C1759,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"TNLR SURGICAL BULLET TIP 8MM",SUP-BTT08,CDM,S27200284,LOCAL,0272,RC,,,both,,,785.70,235.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL 4 13MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P413,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"KAISER [10500]",Kaiser,,5598.45,67,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Consult Comprehensive 3",PX-312000035,CDM,88325,CPT,0312,RC,,,both,,,1691.00,507.3,"CIGNA [10200]","Cigna Local Plus",,287.98,,,,,,,0.01,1437.35,"fee schedule",
"CATH APD FADER TIP 19CM 8FR DRNG PERCUFLEX LOCK PIGTAIL LOOP",SUP-M0064102020,CDM,C1729,HCPCS,0272,RC,,,both,,,713.85,214.15,"UHC [10700]","United Healthcare",,451.87,63.3,,,,,0,83.02,606.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL THK.5MM STD THIN FLUOROPLASTIC REUTER SEPTUM",SUP-1527005,CDM,S27000186,LOCAL,0270,RC,,,both,,,269.70,80.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,123.79,45.9,,,,,0,31.37,229.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 7FR MP CURVE GUIDING DURAFORM",SUP-M003101470,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1148.94,45.9,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 100CM 8MM THIN WALL PERIPHERAL GORE-TEX",SUP-SRRT08070100L,CDM,C1768,HCPCS,0278,RC,,,both,,,13137.60,3941.28,"BLUE CROSS [10001]","Blue Cross PPO",,5149.94,39.2,,,,,0,1527.9,11166.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LASER ABLATION SYSTEM 10MM VISUALASE .4MM FIBER CORE TIP",SUP-9735560,CDM,S27200284,LOCAL,0272,RC,,,both,,,62700.00,18810,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7429.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG BULB 100ML",SUP-K10-03450,CDM,S27000186,LOCAL,0270,RC,,,both,,,230.12,69.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,156.48,68,,,,,0,26.76,195.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 RIGHT KNEE CRUCIATE RETAINING CEMENTED",SUP-5510-F-602,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1907.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1907.07,13938.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Charger Elec/Combo Vad, Rep",PX-E27400014,CDM,Q0495,HCPCS,0274,RC,,,both,,,31785.72,9535.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9097.07,28.62,,,,,0,3696.68,27017.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tte 2d W Dplr Complt",PX-483000003,CDM,93306,CPT,0483,RC,,,both,,,3991.16,1197.35,"FIRST HEALTH [10303]","First Health",,3192.93,80,,,,,0,464.17,3392.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.5MM 120MM AFFIXUS 6.5MM HIP LAG REVERSE BUTTRESS",SUP-814510120,CDM,C1713,HCPCS,0278,RC,,,both,,,6417.00,1925.1,"BLUE CROSS [10001]","Blue Cross HMO",,2515.46,39.2,,957.42,156.86,7483.26,51,746.3,5454.45,"percent of total billed charges",
"MESH SURGICAL PROLENE 6X4IN HERNIA PATCH SOFT FLAT STERILE",SUP-0117010,CDM,C1781,HCPCS,0278,RC,,,both,,,460.08,138.02,"MULTIPLAN [10600]",Multiplan,,391.07,85,,,,,0,53.51,391.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 24MM SPINE PEDICLE PLY NONSTERILE 4MM ROD",SUP-102055224,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 15D 54MM 32MM MARATHON HIP STERILE",SUP-121932254,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"BLUE CROSS [10001]","Blue Cross PPO",,3179.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",943.3,6894.31,"percent of total billed charges",
"SPACER SPINAL 32MMX8MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2990832,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"CIGNA [10200]",Cigna,,6359.04,40,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT",SUP-M006145361170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CIGNA [10200]","Cigna Local Plus",,604.52,,,,,,,131.41,960.46,"percent of total billed charges",
"SCR BONE 4MM 25MM SOLERA CD HORIZON OSTEOGRIP TITANIUM COCR",SUP-54840004025,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"FIRST HEALTH [10303]","First Health",,7637.48,80,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FINISHING LEVEL 1 SUPPORTRAK 72CM",SUP-6682,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"PHCS [10601]",PHCS,,793.8,70,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT",RX-9682,CDM,,,0250,RC,50484-0010-30,NDC,both,30,GR,2516.13,754.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1034.13,41.1,,,,,0,292.63,2138.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WARFARIN 1.25 MG TABLET (PARTIAL OF 2.5 MG TABLET)",RX-408648,CDM,,,0637,RC,08888-8886-81,NDC,both,1.25,ME,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 3IN ON-Q QUIKBLOC DEHP OVER THE NDL STERILE",SUP-QB10016SGC,CDM,S27200305,LOCAL,0272,RC,,,both,,,328.86,98.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,38.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.25,279.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X11X12MM VERTEX PEEK-OPTIMA ANATOMIC",SUP-6240241,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA [10200]","Cigna Local Plus",,3572.95,53.5,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 5 132D",SUP-6720-0535,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"PHCS [10601]",PHCS,,16773.44,70,,,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)EDWARDS SAPIEN 3 ULTRA THV 26MM",SUP-9750FX26,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"PHCS [10601]",PHCS,,119700,70,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701052,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"PHCS [10601]",PHCS,,7945.35,70,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE 100 MEQ SODIUM 3 MEQ POTASSIUM 2.25 MEQ",SUP-08-3231-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,44.59,13.38,"AETNA [10100]","Aetna HMO/PPO",,35.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.19,37.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 V5 ETHIBOND GII QUICKANCHOR PLUS ROTATOR CUFF",SUP-212035,CDM,C1713,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"CIGNA [10200]","Cigna Local Plus",,3599.21,53.5,,3978.14,359.25,3978.14,24,782.41,5718.38,"percent of total billed charges",
"TORSEMIDE 20 MG TABLET",RX-18293,CDM,,,0637,RC,50268-0756-11,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE XPRESS 18MM 6MM BALLOON INFLATION LOW PROFILE",SUP-LPLF-106,CDM,C1726,HCPCS,0272,RC,,,both,,,11074.50,3322.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 1 7MM",SUP-TPS-030-071S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANSTR VACUUM REPLACEMENT 800CC MAMMOTOME REVOLVE SYSTEM",SUP-MCANISTER1,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.68,19.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT ORTHOPEDIC LARGE 8IN WRIST LEFT BLACK",SUP-A120107,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.46,17.54,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RETAINER VISCERA LARGE PLIABLE MATERIAL GLASSMAN",SUP-RMD3206,CDM,S27200284,LOCAL,0272,RC,,,both,,,272.40,81.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE PILOT 150 VASCULAR J CURVE 300CM 3CM .014IN",SUP-1010484-HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 40MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-592504022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH GUIDING 62CM 8FR .11IN PREFACE MULTIPURPOSE SHORT",SUP-301803MS,CDM,C1893,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLOTRIMAZOLE 10 MG TROCHE",RX-9644,CDM,,,0250,RC,00054-8146-22,NDC,both,1,UN,21.61,6.48,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 4X120 80CM SL",SUP-48004012N,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 75CM 6FR BALLOON OCCLUSION SILICONE URETEROPELVIC",SUP-G14337,CDM,C2628,HCPCS,0272,RC,,,both,,,1283.85,385.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MAXI LD 80CM 4CM 7FR 25MM LARGE DIAMETER BALLOON",SUP-4172540S,CDM,C1725,HCPCS,0272,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"C2 IVL CATHETER, 2.5 X 12 MM",SUP-C2IVL2512,CDM,C1761,HCPCS,0272,RC,,,both,,,29610.00,8883,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SUT VICRYL PLUS MULTIPASS 5-0 PC-1 18IN BRAID ANTIBACTERIAL",SUP-VCP834G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Exercise Test for Bronchospasm",PX-482000005,CDM,94617,CPT,0460,RC,,,both,,,191.00,57.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 15MM 6FR 2.25MM",SUP-H7493926715220,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET NDL .75IN 2X2IN 20GA PORT ACCESS SYR PAD Y SITE 10ML",SUP-PA0031YN,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.87,28.76,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOFT-VU 110CM 5FR PIGTAIL CURVE ANGIOGRAPHIC RADIOPAQUE",SUP-H787107085065,CDM,C1887,HCPCS,0272,RC,,,both,,,218.37,65.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) 28MM PERCUTANEOUS CLARITY VALVE",SUP-635000,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 3-0 FSL 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8675H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADMIRAL XTREME 130CM 80MM 5MM BALLOON DILATATION",SUP-ADM050080130,CDM,C1725,HCPCS,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOTRACHEAL 10.2MM 7.5MM NASAL ORAL TAPER CUFF MURPHY",SUP-18775,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.76,19.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GAR047 CO2 SOURCE TUBING",SUP-K10037012,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.08,20.12,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SPRINTER FASTRAC 138CM 20MM 3.2-2.4-2.6FR 2.5MM BALLOON",SUP-SPR2520W,CDM,C1725,HCPCS,0272,RC,,,both,,,607.50,182.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 80CM 40MM 4MM BALLOON DILATATION PEBAX",SUP-H74939032404080,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 018 150CM 8CM 2.5MM BALLOON DILATATION",SUP-U81502H8,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC US Fetal Doppler Echo F/U",PX-402000059,CDM,76828,CPT,0402,RC,,,both,,,368.00,110.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure count. Procedure 1, Fee schedule rate ($74.83). Procedures 2 - 999, Fee schedule rate ($37.41).",,,,0,,,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 350ML P4.8CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-3504BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"FIRST HEALTH [10303]","First Health",,4195.2,80,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 10MM TRI-LOCK APTUS TITANIUM HEXADRIVE 6 TAPER",SUP-A-5450.10/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,739.86,45.9,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 6 5MM KNEE AOX CRUCIATE RETAINING ROTATE PLATF",SUP-151630605,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1526.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN AMPLATZ",SUP-77804800,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DORZOLAMIDE 2 % EYE DROPS",RX-14471,CDM,,,0250,RC,42571-0141-26,NDC,both,10,ML,420.17,126.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,49.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.87,357.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 6 SLOT LEFT TI",SUP-PHPF-C6L,CDM,C1713,HCPCS,0278,RC,,,both,,,18144.00,5443.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5192.81,28.62,,,,,0,2110.15,15422.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLODERM (RTU) CONTOUR MEDIUM - THICK",SUP-CM1520,CDM,Q4116,HCPCS,0636,RC,,,both,,,23877.00,7163.1,"CIGNA [10200]","Cigna Open Access",,13586.01,56.9,,,,,0,247.92,20295.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Critical Care 30-74min",PX-450000321,CDM,99291,CPT,0450,RC,,,both,,,4692.00,1407.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1261,,,,,,,559.4,3988.2,"case rate",
"TRAY CATHETERIZATION SURESTEP LUBRI-SIL STATLOCK PERI-CARE",SUP-A947318,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.14,31.84,"KAISER [10500]",Kaiser,,71.11,67,,,,,0,12.34,90.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS 135CM 100MM 7MM .035IN BALLOON DILATATION",SUP-AB35W07100135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,80.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 5.0 MM X 80 MM X 130 CM",SUP-IPU05008013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3318,41.1,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 39MM TORNIER AEQUALIS PERFORM +3MM SHOULDER",SUP-DWJ023,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"BLUE CROSS [10001]","Blue Cross HMO",,4779.66,39.2,,5311.50,4717.44,5388.59,31,1418.05,10364.05,"percent of total billed charges",
"STAPLER INTERNAL 31X4.8MM TITANIUM XL CIRCLE STAPLE ENDOSCOP",SUP-EEAXL31,CDM,S27200284,LOCAL,0272,RC,,,both,,,2269.80,680.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,932.89,41.1,,,,,0,263.98,1929.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 85MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.785S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"CIGNA [10200]",Cigna,,1672.39,68,,1831.33,1831.33,1831.33,16,286.03,2090.49,"percent of total billed charges",
"BRACE ANKLE M ADULT BILATERAL UNISEX STRAP CLOSURE FASTEN OP",SUP-AB2360-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,141.46,42.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.45,120.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 13MM CEMENTLESS SECUR-FIT PLUS HYDROXYAPATITE 9",SUP-6054-0913S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"NOVANET [10819]",Novanet,,12124.08,75,,,,,0,1880.04,13740.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 150CM 7FR .035IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145374190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"MULTIPLAN [10600]",Multiplan,,960.46,85,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 12MM 3.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG35012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHTH 8FR 1 SYS LNG",SUP-8001,CDM,C1892,HCPCS,0272,RC,,,both,,,252.30,75.69,"NOVANET [10819]",Novanet,,189.23,75,,,,,0,29.34,214.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC",461,MS-DRG,,,,,,,inpatient,,,226474.50,67942.35,"CIGNA [10200]","Cigna Local Plus",,56991.84,,"Fee schedule rate ($56,991.84). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,161249.51,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE BENTSON VASCULAR STD 145CM 6CM .035IN STAINLESS STEEL",SUP-G00691,CDM,C1769,HCPCS,0272,RC,,,both,,,178.26,53.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.73,151.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 60MM STEALTH 3 FIBRA STERILE LATEX FREE",SUP-A0G13,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]",Cigna,,153.82,68,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE MEDIUM BREATHABLE SQUARE TOE OFFLOAD 10FT",SUP-VP50201-040,CDM,S27000186,LOCAL,0270,RC,,,both,,,126.15,37.84,"CIGNA [10200]","Cigna Open Access",,71.78,56.9,,,,,0,14.67,107.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 4.5FR 3IN TAUT STERILE 20018-M55 18305 18400",SUP-PI-63,CDM,C1894,HCPCS,0272,RC,,,both,,,244.47,73.34,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.43,207.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE-O SCREW 6.5X40MM TRACTION POLY",SUP-13116540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3923.76,41.1,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 41 SHORT DISTAL SCR GRADUATE 4.3MM STERILE",SUP-211201406,CDM,S27200284,LOCAL,0272,RC,,,both,,,2700.00,810,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1109.7,41.1,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HARVESTER BONE YELLOW AVITUS 8MM CUT TIP FILTER DEPTH MARK",SUP-BH-110,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,9268.88,53.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 9IN LAMBOTTE SPINE SURGICAL CURVE .5IN",SUP-28-9462,CDM,S27200284,LOCAL,0272,RC,,,both,,,232.99,69.9,"CIGNA [10200]",Cigna,,158.43,68,,,,,0,27.1,198.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ARTHREX TIGERLINK SUTURETAPE .9MM BLACK WHITE",SUP-AR-7559T,CDM,S27200284,LOCAL,0272,RC,,,both,,,807.98,242.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC",192,MS-DRG,,,,,,,inpatient,,,29091.05,8727.31,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 120MM 5MM BALLOON DILATATION RAPID",SUP-47550120L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VIRAL MENINGITIS WITHOUT CC/MCC",076,MS-DRG,,,,,,,inpatient,,,30054.41,9016.32,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPREME 120CM 6FR 2-5-2MM SPACING JSN CURVE",SUP-401451,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT POLARIS SENSOR 16CM 5FR .035IN BLADDER LOOP LOW",SUP-M006155214090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,161.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP BLADDER TUMOR RESECTION",SUP-M0065051641,CDM,S27200284,LOCAL,0272,RC,,,both,,,446.34,133.9,"CIGNA [10200]","Cigna Local Plus",,238.79,53.5,,,,,0,51.91,379.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 1.5MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR091530,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS [10001]","Blue Cross HMO",,5184.53,39.2,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCUFLEX STENT 6F X 20CM W/O WIRE",SUP-M0061453590,CDM,C2617,HCPCS,0272,RC,,,both,,,633.10,189.93,"PHCS [10601]",PHCS,,443.17,70,,,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 8MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158124108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7598.69,68,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RABINOV 30CM 27GA .016IN SIALOGRAPHY SUBMANDIBULAR DUCT",SUP-G01346,CDM,S27200284,LOCAL,0272,RC,,,both,,,347.91,104.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.46,295.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM  RESOLUTE ONYX OTW CORONARY STENT  2.00 X 30MM",SUP-RONYX20030W,CDM,C1874,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross PPO",,1396.5,39.2,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM ALLOGRAFT STRIP FREEZE DRIED 60",SUP-T00248,CDM,S27800098,LOCAL,0278,RC,,,both,,,15794.10,4738.23,"KAISER [10500]",Kaiser,,10582.05,67,,,,,0,1836.85,13424.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER BURR HOLE 15MM MATRIXNEURO TITANIUM NONSTERILE",SUP-04.503.022,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"NOVANET [10819]",Novanet,,2805,75,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 7CM 7FR DUODENAL BEND BILIARY PLASTIC TEMPORARY RAPID",SUP-M00545560,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,244.06,28.62,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 15X6MM THK.4MM SAGITTAL FINE TEETH",SUP-532.041S,CDM,S27200284,LOCAL,0272,RC,,,both,,,605.07,181.52,"FIRST HEALTH [10303]","First Health",,484.06,80,,,,,0,70.37,514.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 15MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45015,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9838.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 30MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45030,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"UHC [10700]","United Healthcare",,52554.65,63.3,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 8MM TITANIUM CORTICAL HAND SELF TAPPING",SUP-400.808,CDM,C1713,HCPCS,0278,RC,,,both,,,421.52,126.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,193.48,45.9,,,,,0,49.02,358.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN JUDKINS RIGHT 4 CURVE",SUP-DXT6JR40,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA [10200]","Cigna Local Plus",,44.22,53.5,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 24CM 10FR LARGE PROXIMAL PIGTAIL CURVE",SUP-M001235590,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,103.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 26FR SILICONE MEDICATION PORT BALLOON RETENTION RING",SUP-0100-26,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,33.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD 2 BIPOLAR IS 1",SUP-ILINK-BIS-10,CDM,C1883,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO BLACK 23CM 9FR BRITE TIP CANN INTERVENTIONAL",SUP-401923M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 3-0 CT 54IN 2 ARM MONOFILAMENT BROWN ABSORBABLE",SUP-990H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.11,19.83,"KAISER [10500]",Kaiser,,44.29,67,,,,,0,7.69,56.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 24MM 144CM 5MM CORONARY STENT",SUP-H7493941824500,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C1 Complement Esterase Inhib",PX-302000031,CDM,86161,CPT,0302,RC,,,both,,,237.90,71.37,"BLUE CROSS [10001]","Blue Cross PPO",,15.33,,"Fee schedule rate ($15.33).",,,,0,0.01,202.22,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 3-0 CT 54IN 2 ARM MONOFILAMENT BROWN ABSORBABLE",SUP-990H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.11,19.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.69,56.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH CONE SHORT HANDLE 5.2MM 2 CUT EDGE SHARP STERILE",SUP-APU452,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"NOVANET [10819]",Novanet,,217.48,75,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 40MM TITANIUM 1.3MM SCR 12 HOLE PRECONTOURED",SUP-421.312,CDM,C1713,HCPCS,0278,RC,,,both,,,2400.30,720.09,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,279.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",279.15,2040.26,"percent of total billed charges",
"FRCP SURGICAL BALLENTINE STRAIGHT 8.25IN 1 TEETH",SUP-52-5510,CDM,S27200284,LOCAL,0272,RC,,,both,,,443.72,133.12,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DENTAL AND ORAL DISEASES WITHOUT CC/MCC",159,MS-DRG,,,,,,,inpatient,,,19512.79,5853.84,"BLUE CROSS [10001]","Blue Cross HMO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BONE CEMENT 120MM 11GA ACCUPORT SIDE DELIVERY STERILE",SUP-307.032,CDM,S27200284,LOCAL,0272,RC,,,both,,,3360.00,1008,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE TRUDI NAVWIRE ORTHOPEDIC SINUS NAVIGATION STERILE",SUP-TDNW001,CDM,C1769,HCPCS,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOTRACHEAL 8MM CUFFED HOODED MURPHY EYE LOW PRESSURE",SUP-8229508,CDM,S27200284,LOCAL,0272,RC,,,both,,,3487.50,1046.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH HALO90 BARRX 160CM 40X13",SUP-90-9200,CDM,C1886,HCPCS,0272,RC,,,both,,,16532.40,4959.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CIRCUIT HUMD HVT PATIENT 2.0 NONSTERILE LATEX FREE",SUP-HVT-DPC,CDM,S27000186,LOCAL,0270,RC,,,both,,,1033.56,310.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION",RX-113609,CDM,,,0250,RC,63323-0083-05,NDC,both,5,ML,213.18,63.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATH 4FR 1 LUMEN MAX BARR TPS STYLET CENTRAL VENOUS",SUP-1194108D,CDM,C1751,HCPCS,0272,RC,,,both,,,1666.05,499.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE FEEDING ORANGE 40CM 6.5FR NUTRIO TWISTLOK ENTERAL",SUP-ENSI6065,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.36,32.21,"CIGNA [10200]",Cigna,,73,68,,,,,0,12.49,91.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD + VE",SUP-98000700015,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"UHC [10700]","United Healthcare",,15951.6,63.3,,8601.07,8395.67,8601.07,"1 through 10",2930.76,21420,"percent of total billed charges",
"SCR BONE 3.5MM 40MM AXSOS 3 TITANIUM CORTICAL NONSTERILE",SUP-661440,CDM,C1713,HCPCS,0278,RC,,,both,,,289.54,86.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,34.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,33.67,246.11,"percent of total billed charges",
"STEM FEMORAL 128MM 12MM PRIMARY PRESSFIT TRABECULAR METAL",SUP-00786401220,CDM,S27800098,LOCAL,0278,RC,,,both,,,30164.40,9049.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8144.39,27,,,,,0,3508.12,25639.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP SURGICAL VCARE PLUS CERVICAL CUP 37MM LARGE",SUP-60-6085-202A,CDM,S27200284,LOCAL,0272,RC,,,both,,,659.98,197.99,"UHC [10700]","United Healthcare",,417.77,63.3,,,,,0,76.76,560.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X7MM PARALLEL SPINE",SUP-17307,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 250MM 2.5MM 95MM QUICK COUPLING STOP CALIBRATE",SUP-03.113.023,CDM,S27200284,LOCAL,0272,RC,,,both,,,827.82,248.35,"FIRST HEALTH [10303]","First Health",,662.26,80,,,,,0,96.28,703.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL CORTICAL THK3MM ALLOGRAFT FROZEN STRUT",SUP-T20673,CDM,S27800098,LOCAL,0278,RC,,,both,,,6109.95,1832.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1748.67,28.62,,,,,0,710.59,5193.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 20CC DBX ALLOGRAFT FREEZE DRY MIX",SUP-58200,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1805.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UROLOGICAL 150CM 3CM .035IN PTFE STIFF BODY FIX CORE J",SUP-M0066201110,CDM,C1769,HCPCS,0272,RC,,,both,,,107.97,32.39,"KAISER [10500]",Kaiser,,72.34,67,,,,,0,12.56,91.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH RADIFOCUS 100CM 5FR SIM3 CURVE ANGIOGRAPHIC",SUP-CG512,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC TB Test Cell Immunity Measure",PX-302000092,CDM,86480,CPT,0302,RC,,,both,,,553.85,166.15,"PHCS [10601]",PHCS,,387.7,70,,,,,0,0.55,470.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS FIRSTCHOICE 40 MEQ POTASSIUM CHLORIDE 0.9%",SUP-07116-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT CRUCIATE RETAIN SIGMA STERILE",SUP-940013,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3067.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3010.99,22006.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (2.5-3 MCI)",RX-411874,CDM,A9520,HCPCS,0343,RC,08888-8876-08,NDC,both,1,UN,4614.97,1384.49,"NOVANET [10819]",Novanet,,3461.23,75,,,,,0,536.72,4614.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 5FR ANGLE KUMPE CURVE ANGIOGRAPHIC",SUP-10732703,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"AETNA [10100]","Aetna HMO/PPO",,172.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET PACEMAKER SOFT STRAIGHT 59CM LENGTH",SUP-6521,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 110CM 6FR 145D PIGTAIL CURVE ANGIOGRAPHIC",SUP-H74916599412,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]",Cigna,,52.07,68,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo US-Guide Hep Porto Grad",PX-750000216,CDM,C9768,HCPCS,0750,RC,,,both,,,6251.00,1875.3,"FIRST HEALTH [10303]","First Health",,5000.8,80,,,,,0,726.99,5313.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sodium Serum POC",PX-301000398,CDM,84295,CPT,0301,RC,,,both,,,101.02,30.31,"AETNA [10100]","Aetna HMO/PPO",,80.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,85.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 85MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000085,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,743.58,45.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUMP IAB IMPELLA 5L/MIN CATH MICROAXIAL",SUP-005062,CDM,S27800098,LOCAL,0278,RC,,,both,,,159600.00,47880,"UHC [10700]","United Healthcare",,101026.8,63.3,,,,,0,18561.48,135660,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 26CM 3CM 6FR .035IN PIGTAIL",SUP-M006180223190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,580.81,45.9,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ION ENDOSCOPIC NONSTERILE LATEX FREE REUSABLE",SUP-490105,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3167.1,45.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 45CM .014IN KNOB CAP KT",SUP-6038,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FLOSWITCH 1050 PSI FLOW CONTROL 1 WAY HIGH PRESSURE",SUP-M001442001,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.22,18.97,"CIGNA [10200]","Cigna Open Access",,35.97,56.9,,,,,0,7.35,53.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION PLATE HOLDING DISPOSABLE",SUP-7080902,CDM,S27800098,LOCAL,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,170.52,39.2,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 7.75IN 17.5MM STAINLESS STEEL LANGENBECK",SUP-250492,CDM,S27200284,LOCAL,0272,RC,,,both,,,252.21,75.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,171.5,68,,,,,0,29.33,214.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE XPRESS LOPROFILE 18MM 5MM BALLOON INFLATION",SUP-LPLF-105,CDM,C1726,HCPCS,0272,RC,,,both,,,11074.50,3322.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1287.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1287.96,9413.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.3MM 14MM CORTICAL LOCKING TITANIUM NONSTERILE",SUP-CO-S2314,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,217.91,28.62,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 100CM 5FR 8MM AMPLATZER .056IN TYPE II",SUP-9-AVP2-008,CDM,S27800098,LOCAL,0278,RC,,,both,,,6589.50,1976.85,"MULTIPLAN [10600]",Multiplan,,5601.08,85,,,,,0,766.36,5601.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 7.5CM 20GA HAWKINS I REPOSITIONABLE BREAST",SUP-251075,CDM,A4648,HCPCS,0278,RC,,,both,,,378.21,113.46,"CIGNA [10200]",Cigna,,257.18,68,,,,,0,43.99,321.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM MITRAL CARPENTIER-EDWARDS PHYSIO II",SUP-5200M32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3949.56,28.62,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SQUARE 2.4MM SCR 12 HOLE LOW PROFILE 2 SIDE STERNALOCK",SUP-73-2632,CDM,C1713,HCPCS,0278,RC,,,both,,,4754.10,1426.23,"MULTIPLAN [10600]",Multiplan,,4040.99,85,,,,,0,552.9,4040.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C1 Complement Esterase Inhib",PX-302000031,CDM,86161,CPT,0302,RC,,,both,,,237.90,71.37,"FIRST HEALTH [10303]","First Health",,190.32,80,,,,,0,0.01,202.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COPPER CU-64 DOTATATE INTRAVENOUS SOLUTION (2-3 MCI)",RX-411821,CDM,A9592,HCPCS,0343,RC,08888-8877-76,NDC,both,1,UN,20412.00,6123.6,"BLUE CROSS [10001]","Blue Cross PPO",,3365.38,,,,,,,1155,17350.2,"fee schedule",
"ROD SPINAL 95MM 5.5MM CREO CURVE TITANIUM NONSTERILE",SUP-1119.7095,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"INSRT TIBIAL 1 9MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P109,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Open Access",,4754.51,56.9,,5302.19,4377.88,6578.61,27,971.79,7102.52,"percent of total billed charges",
"BLADE SAW 50MM STERILE",SUP-MDS3021050,CDM,S27200284,LOCAL,0272,RC,,,both,,,316.94,95.08,"MULTIPLAN [10600]",Multiplan,,269.4,85,,,,,0,36.86,269.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG GERMICIDAL 12X8IN AQUACEL AG",SUP-422302,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.25,69.07,"FIRST HEALTH [10303]","First Health",,184.2,80,,,,,0,26.78,195.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,inpatient,,,162263.37,48679.01,"BLUE CROSS [10001]","Blue Cross PPO",,71597.38,,,,,,,7561,84674.24,"case rate",
"DEVICE PIPELINE 14MM 4MM EMBOLIZATION",SUP-PED2-400-14,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9396.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 30IN 23FR FEMUR VEIN ADULT .5IN CNCT 1 PIECE",SUP-96370-023,CDM,S27200284,LOCAL,0272,RC,,,both,,,2120.63,636.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,251.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,246.63,1802.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 8 HOLE BONE LATERAL ANTERIOR",SUP-70-0118,CDM,C1713,HCPCS,0278,RC,,,both,,,6651.60,1995.48,"CIGNA [10200]","Cigna Local Plus",,3558.61,53.5,,3978.14,359.25,3978.14,24,773.58,5653.86,"percent of total billed charges",
"BOLT EXTERNAL FIXATION SCHANZ CANNULATED RING MOUNT",SUP-03.311.058,CDM,C1713,HCPCS,0278,RC,,,both,,,1681.43,504.43,"FIRST HEALTH [10303]","First Health",,1345.14,80,,,,,0,195.55,1429.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.50 X 38 MM  RX FDA",SUP-1203350-38,CDM,C1874,HCPCS,0272,RC,,,both,,,17250.00,5175,"UHC [10700]","United Healthcare",,10919.25,63.3,,,,,0,7089.75,10919.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ASPIRATION ANTICOAGULATION LINE ELECTA ESSENTIAL CONCEPT",SUP-AAL,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"AETNA [10100]","Aetna HMO/PPO",,179.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 50MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4850,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,1831.33,1831.33,1831.33,16,434.96,3179,"percent of total billed charges",
"KIT BONE CEMENT CONFIDENCE HALF DOSE 5CC LATEX FREE",SUP-283905000,CDM,C1713,HCPCS,0278,RC,,,both,,,8424.90,2527.47,"CIGNA [10200]",Cigna,,5728.93,68,,1831.33,1831.33,1831.33,16,979.82,7161.17,"percent of total billed charges",
"VILAZODONE 20 MG TABLET",RX-109403,CDM,,,0637,RC,72205-0261-30,NDC,both,1,UN,38.92,11.68,"CIGNA [10200]","Cigna Local Plus",,20.82,53.5,,,,,0,4.53,33.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL INFANT 40CM 2O TETHER DUST CAP PRESSURE RELIEF",SUP-8527MP,CDM,S27000186,LOCAL,0270,RC,,,both,,,96.40,28.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.21,81.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 25MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962347,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3916.03,27,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +15 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030150,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"MULTIPLAN [10600]",Multiplan,,998.33,85,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE SURGICEL OXIDIZED REGENERATED CELOS",SUP-3013SP,CDM,S27200284,LOCAL,0272,RC,,,both,,,2581.88,774.56,"KAISER [10500]",Kaiser,,1729.86,67,,,,,0,300.27,2194.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X2CM CYGNUS DUAL THK.2MM 6SQ CM AMNION",SUP-585-001,CDM,Q4282,HCPCS,0636,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,247.92,,,,,,,247.92,14726.25,"fee schedule",
"SUT VICRYL PLUS 2 OS-8 18IN CONTROL RELEASE BRAID 3 STRAND",SUP-VCP719T,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Local Plus",,13.38,53.5,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM 19MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-019,CDM,C1776,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"NOVANET [10819]",Novanet,,13140.23,75,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTRUMENT BIOPSY SUPERCORE L20 CM OD20 GA SEMIAUTOMATIC LIG",SUP-701120200,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.65,103.09,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,39.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.97,292.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SUTURETAPE 2 .5 CIRCLE 36.6MM TAPER NDL BLACK WHITE 1.3",SUP-AR-7506T,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 200MM 5.4FR 4MM BALLOON DILATATION 2",SUP-BD-L40200CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.7,68,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Retroperitoneal Complete",PX-402000010,CDM,76770,CPT,0402,RC,,,both,,,1285.72,385.72,"UHC [10700]","United Healthcare",,426,,"Per diem ($426).",1042.00,1042.00,1042.00,"1 through 10",115.44,1092.86,"per diem",
"GRAFT VASCULAR 40CM 6MM FLIXENE SLIDER GRADUATED WALL",SUP-25061,CDM,C1768,HCPCS,0278,RC,,,both,,,7430.33,2229.1,"BLUE CROSS [10001]","Blue Cross HMO",,2912.69,39.2,,,,,0,864.15,6315.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 18MM 13MM STD NECK S-ROM CERAMIC 135D",SUP-523393,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"AETNA [10100]","Aetna HMO/PPO",,15463.74,79.5,,10981.53,8986.79,12413.38,12,2262.18,16533.56,"percent of total billed charges",
"STEM FEMORAL 135MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309009,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"KAISER [10500]",Kaiser,,25300.67,67,,,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 5 3/8IN .018IN SPRING TUBE POSITIVE PLACEMENT",SUP-RW-04018,CDM,C1769,HCPCS,0272,RC,,,both,,,62.29,18.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.24,52.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX11MM FRA 8D LORDOTIC NARROW WEDGE",SUP-11,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE 5L PRISMASOL 3.5X2IN",SUP-110243,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"MULTIPLAN [10600]",Multiplan,,192.27,85,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 8MM KNEE UNICONDYLAR RIGHT MEDIAL LEFT",SUP-102408600,CDM,C1776,HCPCS,0278,RC,,,both,,,15980.40,4794.12,"CIGNA [10200]",Cigna,,6392.16,40,,5873.17,5873.17,5873.17,"1 through 10",1858.52,13583.34,"percent of total billed charges",
"GUIDE NDL 36X5.5IN FLEX COVER STERILE DISPOSABLE ULTRA-PRO",SUP-610-608,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.64,52.09,"KAISER [10500]",Kaiser,,116.34,67,,,,,0,20.19,147.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"O.R. PROCEDURES FOR OBESITY WITH MCC",619,MS-DRG,,,,,,,inpatient,,,114444.88,34333.46,"CIGNA [10200]","Cigna Local Plus",,29795.08,,"Fee schedule rate ($29,795.08). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,10994,84300.53,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS STREAMLINE 30MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-M003SFD040300,CDM,C1874,HCPCS,0278,RC,,,both,,,85681.49,25704.45,"CIGNA [10200]","Cigna Local Plus",,26989.67,31.5,,,,,0,9964.76,72829.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18.5 DIOPTER +3 CYL MODIFIED C BICONVEX 13MM 6MM","SUP-ZCT300 18.5",CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM SPINE POLYAXIAL REVOLVE",SUP-185.454,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PHCS [10601]",PHCS,,6682.8,70,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO 90D 2.3MM ELBOW SHOULDER WIRE LOOP SUT",SUP-AR-4065-90W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1105.65,331.69,"UHC [10700]","United Healthcare",,699.88,63.3,,,,,0,128.59,939.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 52MM 28MM 10D HIP CROSSFIRE OMNIFIT STERILE",SUP-2041C-2852,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3230.44,45.9,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM SPINE POLYAXIAL REVOLVE",SUP-185.454,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Open Access",,5432.16,56.9,,1144.80,304.56,2275.09,66,1110.3,8114.82,"percent of total billed charges",
"STEM FEMORAL SECUR-FIT MAX HYDROXYAPATITE 127D 6 HIP STERILE",SUP-6052-0625S,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"UHC [10700]","United Healthcare",,9905.94,63.3,,8601.07,8395.67,8601.07,"1 through 10",1820,13301.82,"percent of total billed charges",
"HC MRI Upr Ext Nonjnt WO Cntrst",PX-610000024,CDM,73218,CPT,0610,RC,,,both,,,3640.89,1092.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,423.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,423.44,3094.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER URETERAL LASER 3 FR 115CM",SUP-G15020,CDM,C1758,HCPCS,0272,RC,,,both,,,119.19,35.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,81.05,68,,,,,0,13.86,101.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 84.5X21MM THK.89MM MEDIUM LONG STAINLESS STEEL",SUP-2108-109,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.40,22.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.65,63.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 42MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.442TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"NOVANET [10819]",Novanet,,1516.16,75,,,,,0,235.11,1718.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 SURGALLOY 3-0 V-20 .5 CIRCLE 9IN 26MM CLSR",SUP-VLOCL0644,CDM,S27200284,LOCAL,0272,RC,,,both,,,405.94,121.78,"NOVANET [10819]",Novanet,,304.46,75,,,,,0,47.21,345.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELIANCE 4 FRONT PASSIVE FIXATION SINGLE COIL 70CM",SUP-0650,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"FIRST HEALTH [10303]","First Health",,12144,80,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 90X4.8MM DST SERIES TA TITANIUM THICK TISSUE",SUP-TA9048L,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.47,98.24,"KAISER [10500]",Kaiser,,219.4,67,,,,,0,38.08,278.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS ENDOSCOPIC L230CM DIA2.4MM OPENING 8MM GRASPING ALLI",SUP-M00527451,CDM,S27200284,LOCAL,0272,RC,,,both,,,625.73,187.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,257.18,41.1,,,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 43MM CATHCART BALL HIP FEMUR ORTHOCHROME",SUP-136343000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 22CM FEMUR PROXIMAL TALON DISTALFIX",SUP-SLN-120-220,CDM,C1713,HCPCS,0278,RC,,,both,,,13227.30,3968.19,"MULTIPLAN [10600]",Multiplan,,11243.21,85,,,,,0,1538.33,11243.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +18.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM POST",SUP-ZA90030185,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CIGNA [10200]","Cigna Open Access",,668.29,56.9,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE RIGHT CEMENT REVISION CONSTRAIN ATTUNE",SUP-150440206,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"AETNA [10100]","Aetna HMO/PPO",,23940.63,79.5,,10981.53,8986.79,12413.38,12,3502.26,25596.9,"percent of total billed charges",
"NDL BIOPSY 20GA 15CM FINE ASPIRATION CM MARK COLOR CODED HUB",SUP-MSPN2006,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,50.77,41.1,,,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EMBOLIC PROTECTION 100CM VENA CAVA FILTER INTRO",SUP-352506100E,CDM,C1880,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"AETNA [10100]","Aetna HMO/PPO",,6856.88,79.5,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 32MM 21MM FREESTYLE ROOT PORCINE PHYSIOLOGIC",SUP-FR995-21,CDM,S27800098,LOCAL,0278,RC,,,both,,,38430.00,11529,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15372,40,,,,,0,4469.41,32665.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 43MM TRUNION ECLIPSE SHOULDER",SUP-AR-9301-43CPC,CDM,C1776,HCPCS,0278,RC,,,both,,,9239.10,2771.73,"CIGNA [10200]","Cigna Local Plus",,4942.92,53.5,,5372.07,4581.20,7242.98,23,1074.51,7853.24,"percent of total billed charges",
"SUT MONOCRYL 2-0 SH 27IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y417H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY",RX-114231,CDM,,,0250,RC,00472-1738-03,NDC,both,1,UN,59.59,17.88,"UHC [10700]","United Healthcare",,37.72,63.3,,,,,0,6.93,50.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL SHAFT ALLOGRAFT FROZEN 200MM 10+ MM",SUP-450450,CDM,S27800098,LOCAL,0278,RC,,,both,,,11703.78,3511.13,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3349.62,28.62,,,,,0,1361.15,9948.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Culture Stool",PX-306000002,CDM,87045,CPT,0306,RC,,,both,,,286.90,86.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.26,243.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +12.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200125,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CIGNA [10200]",Cigna,,694.01,68,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X6MM PARALLEL SPINE CERVICAL",SUP-17906,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ALEXIS LARGE RING C SECTION 9-14CM SURGICAL STERILE",SUP-G6303,CDM,S27200284,LOCAL,0272,RC,,,both,,,445.50,133.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,302.94,68,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL G KNEE LEFT LPS-FLEX GENDER SOLUTIONS NEXG",SUP-00576201751,CDM,C1776,HCPCS,0278,RC,,,both,,,31059.00,9317.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12423.6,40,,,,,0,3612.16,26400.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY PINK 100MM 18GA SURE-GRIP PLATINUM CURVE",SUP-PMF18-100-10CS,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.83,52.15,"MULTIPLAN [10600]",Multiplan,,147.76,85,,,,,0,20.22,147.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 15CM 7MM BALLOON DILATATION OTW LOW",SUP-G30968,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CGUARD PRIME CAROTID STENT SYSTEM 135CM 9MM LENGTH  30MM",SUP-CND0930,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8531.74,41.1,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 99MM STAINLESS STEEL 2.7/3.5MM SCR 5 HOLE ANATOMICALLY",SUP-02.112.141,CDM,C1713,HCPCS,0278,RC,,,both,,,3076.50,922.95,"PHCS [10601]",PHCS,,2153.55,70,,,,,0,357.8,2615.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veeg 2-12 Hr Intmt Mntr",PX-740000047,CDM,95712,CPT,0740,RC,,,both,,,5043.88,1513.16,"MULTIPLAN [10600]",Multiplan,,4287.3,85,,,,,0,5.04,4287.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Re-ED Neuromscl Ea 15min (Go)",PX-430000015,CDM,97112,CPT,0430,RC,,,both,,,167.73,50.32,"BLUE CROSS [10001]","Blue Cross PPO",,167.73,,"Per diem ($371.22).",,,,0,19.51,167.73,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 75X13X1.27MM SAGITTAL",SUP-6113127075,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL STD OFFSET 28MM HIP TYPE 1 COCR G7",SUP-163662,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6971.37,68,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM CEMENTLESS OFFSET ACCOLADE TMZF 127D 5 48",SUP-6021-0537,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4478.8,28.62,,,,,0,1820,13301.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 6FR .071IN EXTRA BACKUP 4A LEFT CURVE",SUP-LA6EBU40A,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,266.22,68,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SOAKER CATH ON-Q PAINBUSTER 4ML/HR 5IN PAIN PUMP 400",SUP-PM028,CDM,C9804,HCPCS,0272,RC,,,both,,,1810.50,543.15,"CIGNA [10200]",Cigna,,1231.14,68,,,,,0,210.56,1538.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 8 5MM KNEE CRUCIATE RETAINING ROTATE PLATFORM",SUP-151630805,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"BLUE CROSS [10001]","Blue Cross HMO",,5145.88,39.2,,5311.50,4717.44,5388.59,31,1526.7,11158.16,"percent of total billed charges",
"SCR BONE 3.5MM 10MM TITANIUM STERNAL SELF DRILLING",SUP-04.501.110.01,CDM,C1713,HCPCS,0278,RC,,,both,,,854.96,256.49,"KAISER [10500]",Kaiser,,572.82,67,,,,,0,99.43,726.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Histone-Dna Cmplx Igg Autoabs",PX-301000268,CDM,83520,CPT,0301,RC,,,both,,,208.00,62.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.21,.1,,,,,0,0.21,176.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 110MM 10MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-1513-10-110,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"KAISER [10500]",Kaiser,,5538.35,67,,,,,0,961.36,7026.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 475ML STYLE 20 SMOOTH NATRELLE SILICONE P5.5CM",SUP-20-475,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"BLUE CROSS [10001]","Blue Cross HMO",,1399.44,39.2,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM STAINLESS STEEL STD CORTEX SPHERICAL",SUP-202.012,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"BLUE CROSS [10001]","Blue Cross HMO",,137.71,39.2,,957.42,156.86,7483.26,51,40.86,298.61,"percent of total billed charges",
"PLATE CURVE 336MM TITANIUM 4.5MM SCR 16 HOLE VARIABLE ANGLE",SUP-04.124.416S,CDM,C1713,HCPCS,0278,RC,,,both,,,15619.25,4685.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6247.7,40,,,,,0,1816.52,13276.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM ORTHOLOC 3DI LOW PROFILE FOOT ANKLE",SUP-58812718,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,243.41,28.62,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 2MM AXOGUARD NERVE CAP SIS MATRIX END TAB",SUP-AGT215,CDM,C1763,HCPCS,0278,RC,,,both,,,15304.20,4591.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6121.68,40,,,,,0,1779.88,13008.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 80MM 80CM 9MM .079IN LARGE DIAMETER",SUP-SERB65-09-80-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross HMO",,2181.48,39.2,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 17MM ATLANTIS TITANIUM ANTERIOR CERVICAL SPINE",SUP-876-717,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFTTOUCH",SUP-SSM-685,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]",Cigna,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 140MM 5.5MM STRAIGHT PERCUTANEOUS CCM",SUP-1555006140,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"HC Zika Virus Igm Antibody",PX-302000227,CDM,86794,CPT,0302,RC,,,both,,,77.00,23.1,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,65.45,"per diem",
"HC Zika Virus Igm Antibody",PX-302000227,CDM,86794,CPT,0302,RC,,,both,,,77.00,23.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.69,,"Fee schedule rate ($17.69). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,65.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 30MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE45030,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22589.44,27,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 100MM 11MM NEXGEN OFFSET KNEE FEMUR 145MM STERILE",SUP-00598802011,CDM,C1776,HCPCS,0278,RC,,,both,,,10435.56,3130.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2986.66,28.62,,,,,0,1213.66,8870.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.432,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"BLUE CROSS [10001]","Blue Cross HMO",,542.58,39.2,,957.42,156.86,7483.26,51,160.97,1176.51,"percent of total billed charges",
"HEAD RADIAL 22MM LEFT ELBOW LEFT ANGLE STERILE",SUP-TR-H220L-S,CDM,C1776,HCPCS,0278,RC,,,both,,,13489.50,4046.85,"AETNA [10100]","Aetna HMO/PPO",,10724.15,79.5,,10981.53,8986.79,12413.38,12,1568.83,11466.08,"percent of total billed charges",
"STEM FEMORAL PROFEMUR TL CLASSIC 2 SHORT NECK EXTEND OFFSET",SUP-PRTLE022,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"UHC [10700]","United Healthcare",,11963.7,63.3,,8601.07,8395.67,8601.07,"1 through 10",2198.07,16065,"percent of total billed charges",
"KIT ELBOW JOINT SM REGULAR HUMERAL PIN BUSHING REPLACEMENT C",SUP-32810502501,CDM,C1713,HCPCS,0278,RC,,,both,,,8279.66,2483.9,"CIGNA [10200]","Cigna Open Access",,4711.13,56.9,,1144.80,304.56,2275.09,66,962.92,7037.71,"percent of total billed charges",
"SCR BONE 5.5MM 35MM 3DX TSRH OSTEOGRIP THINLINE TITANIUM",SUP-83555359,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UHC [10700]","United Healthcare",,6043.16,63.3,,5023.51,2672.93,6679.78,18,1110.3,8114.82,"percent of total billed charges",
"KIT TUBING VIVASIGHT 2 LUMEN ENDOBRONCHIAL TUBE",SUP-412391000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"NOVANET [10819]",Novanet,,1462.5,75,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 5MM 6FR ENDOPROSTHESIS HEPARIN",SUP-VBJ051502,CDM,C1874,HCPCS,0278,RC,,,both,,,24462.90,7338.87,"PHCS [10601]",PHCS,,17124.03,70,,,,,0,2845.04,20793.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL TROUTMAN-BARRAQUER 45D .12MM 3IN ANGLED 2X3",SUP-60-1463,CDM,S27200284,LOCAL,0272,RC,,,both,,,1402.60,420.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,576.47,41.1,,,,,0,163.12,1192.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BARR ADHESION 4X3IN ABSORBABLE CONTROL BEYOND CLSR GYNECARE",SUP-4350,CDM,C1765,HCPCS,0278,RC,,,both,,,2316.00,694.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,274.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,269.35,1968.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL ADULT UNIVERSAL VISTA PROCARE 2 PIECE",SUP-79-83380,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Hemodialysis Temp",PX-E27200058,CDM,C1752,HCPCS,0272,RC,,,both,,,941.16,282.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,639.99,68,,,,,0,109.46,799.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40022W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,644.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 140MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.423,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"FIRST HEALTH [10303]","First Health",,1107.3,80,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER PLATE BB-TAK THREAD DISPOSABLE",SUP-AR-13226T,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2.5 KNEE RIGHT CEMENTED POSTERIOR STABILIZE",SUP-196050250,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"MULTIPLAN [10600]",Multiplan,,8500,85,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 80X14-18MM",SUP-400740,CDM,S27800098,LOCAL,0278,RC,,,both,,,4545.72,1363.72,"BLUE CROSS [10001]","Blue Cross HMO",,1781.92,39.2,,,,,0,528.67,3863.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP FLEX-MINI 45MM CLSR POLYESTER LOW PROFILE",SUP-ACHM45,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"CIGNA [10200]","Cigna Local Plus",,4890.38,31.5,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SCOUT BX 12.3CM 15GA DELIVERY END DEPLOY REFLECTOR",SUP-SSR13B-01,CDM,A4648,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KETAMINE 50 MG/ML INJECTION SOLUTION",RX-4238,CDM,,,0250,RC,72572-0320-01,NDC,both,10,ML,60.00,18,"PHCS [10601]",PHCS,,42,70,,,,,0,6.98,51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 G NEUTRAL 40MM E1 HIP",SUP-010000865,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"BLUE CROSS [10001]","Blue Cross PPO",,4018.79,39.2,,3949.44,3949.44,3949.44,"1 through 10",1192.31,8714.22,"percent of total billed charges",
"STENT EVOLUTION 10CM 8MM 20MM 25MM ESOPHAGEAL SILICONE",SUP-G48031,CDM,C1876,HCPCS,0278,RC,,,both,,,14283.00,4284.9,"CIGNA [10200]","Cigna Local Plus",,4499.15,31.5,,,,,0,1661.11,12140.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POD XL 6MMX55CM",SUP-RBYPODXL0655,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7534.8,40,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR RELIATACK ARTICULATE 8 DEEP ABSORBABLE TACK",SUP-RELTACK8RDPTSW,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.51,388.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.67,1101.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 10MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240100500,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1021.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 8MM INTERLOCK OCCLUSION SYSTEM",SUP-M001363760,CDM,S27800098,LOCAL,0278,RC,,,both,,,3891.60,1167.48,"FIRST HEALTH [10303]","First Health",,3113.28,80,,,,,0,452.59,3307.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE INFUSE RHBMP-2 XS KIT LUMBAR SPINE LUMBAR TAPERED",SUP-7510100,CDM,,,0278,RC,,,both,,,16187.40,4856.22,"CIGNA [10200]","Cigna Open Access",,9210.63,56.9,,,,,0,16.19,13759.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT 17GA 50MM ELECTROTHERAPY COOLIEF STERILE LATEX FREE",SUP-CRK-17-50-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN SCREW SPECIALTY 3.1MMX62MM NAVI",SUP-GS903.062.032-2P,CDM,C1713,HCPCS,0278,RC,,,both,,,605.48,181.64,"NOVANET [10819]",Novanet,,454.11,75,,,,,0,70.42,514.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 37MM 80CM 7MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU0800737,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7482.7,28.62,,,,,0,3040.66,22223.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 20IN 24FR ANGLE RIGHT",SUP-8888571034,CDM,C1729,HCPCS,0272,RC,,,both,,,1364.61,409.38,"MULTIPLAN [10600]",Multiplan,,1159.92,85,,,,,0,158.7,1159.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 25MM CD HORIZON LEGACY TITANIUM SPINE SELF TAP",SUP-7542525,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"SHEATH TOURGUIDE 180D 90CM 9MM 7FR CATH HYDROPHOBIC",SUP-TG0709009,CDM,C1766,HCPCS,0272,RC,,,both,,,4388.40,1316.52,"PHCS [10601]",PHCS,,3071.88,70,,,,,0,510.37,3730.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE LEAD LOCKING CORONARY SINUS",SUP-518-039,CDM,C1773,HCPCS,0272,RC,,,both,,,4071.00,1221.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1673.18,41.1,,,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 26-42MM LARGE BALLOON OCCLUSION TAG THORAX TRILOBE",SUP-BCL2645,CDM,C1725,HCPCS,0272,RC,,,both,,,4843.80,1453.14,"AETNA [10100]","Aetna HMO/PPO",,3850.82,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,563.33,4117.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 7MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640507,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"NOVANET [10819]",Novanet,,8440.43,75,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 80CM 8FR SUPER ARROW-FLEX PERCUTANEOUS 3 WAY",SUP-CL-07880,CDM,C1894,HCPCS,0272,RC,,,both,,,972.00,291.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,113.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION .045IN 9IN BUSA KIRSCHNER STAINLESS STEEL FULL",SUP-KM173-39-45,CDM,C1713,HCPCS,0278,RC,,,both,,,59.29,17.79,"MULTIPLAN [10600]",Multiplan,,50.4,85,,,,,0,6.9,50.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7609,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"AETNA [10100]","Aetna HMO/PPO",,5485.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 14MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-414-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"AETNA [10100]","Aetna HMO/PPO",,9566.71,79.5,,10981.53,8986.79,12413.38,12,1399.51,10228.56,"percent of total billed charges",
"AUG TIBIAL 5MM TRIATHLON 3 LEFT MEDIAL RIGHT LATERAL",SUP-5612-A-351,CDM,C1776,HCPCS,0278,RC,,,both,,,9878.04,2963.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6717.07,68,,,,,0,1148.82,8396.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CINCH AND LOCK CATHETER",SUP-5700,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 41X19MM MICRO SMALL BONE SAGITTAL STERILE",SUP-KM-231,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"NOVANET [10819]",Novanet,,46.33,75,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 58MM 36MM MARATHON HIP",SUP-121936058,CDM,C1776,HCPCS,0278,RC,,,both,,,8942.40,2682.72,"CIGNA [10200]",Cigna,,6080.83,68,,5873.17,5873.17,5873.17,"1 through 10",1040,7601.04,"percent of total billed charges",
"SHEET TRANSFER 77X60IN MAXISLIDE FLITES PREMIUM LATEX FREE",SUP-NPAV5000,CDM,S27000186,LOCAL,0270,RC,,,both,,,203.06,60.92,"KAISER [10500]",Kaiser,,136.05,67,,,,,0,23.62,172.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 5FR NEWTON 3 CURVE ANGIOGRAPHIC CEREBRAL",SUP-H787107098065,CDM,C1887,HCPCS,0272,RC,,,both,,,156.60,46.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC SMALL 8IN WRIST RIGHT REMOVABLE PALMAR STAY",SUP-92722001,CDM,L3908,HCPCS,0274,RC,,,both,,,148.86,44.66,"BLUE CROSS [10001]","Blue Cross HMO",,58.35,39.2,,,,,0,17.31,126.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rh Phenotyping Complete",PX-302000197,CDM,86906,CPT,0302,RC,,,both,,,354.90,106.47,"CIGNA [10200]",Cigna,,17.05,,,,,,,0.01,301.67,"fee schedule",
"IMPL BREAST 220CC P3CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-220,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",878.7,6422.18,"percent of total billed charges",
"PAD THERAPEUTIC 12X11.34IN COLD WRAP ON REGULAR HOSE XL",SUP-11-0681-9-00000,CDM,S27000187,LOCAL,0270,RC,,,both,,,157.38,47.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,64.68,41.1,,,,,0,18.3,133.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM SPINAL POLYAXIAL",SUP-8806535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Local Plus",,5107.56,53.5,,3978.14,359.25,3978.14,24,1110.3,8114.82,"percent of total billed charges",
"STENT ZILVER VENA 140MM 12MM 7FR BILIARY VENOUS SELF EXPAND",SUP-G57435,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"KAISER [10500]",Kaiser,,9708.3,67,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE FLOWMETER 9-12 PIN ASSEMBLY FOR BREATHING CIRCUIT",SUP-775363-103,CDM,S27000186,LOCAL,0270,RC,,,both,,,1468.21,440.46,"UHC [10700]","United Healthcare",,929.38,63.3,,,,,0,170.75,1247.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON UVA TORIC AUTONOME",SUP-CCA0T6,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"NOVANET [10819]",Novanet,,277.5,75,,,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP MANIP 6.7MM RUMI UTERUS TIP SYSTEM 6CM STERILE LATEX",SUP-UMW676,CDM,S27200284,LOCAL,0272,RC,,,both,,,602.62,180.79,"CIGNA [10200]","Cigna Local Plus",,322.4,53.5,,,,,0,70.08,512.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIABETES WITHOUT CC/MCC",639,MS-DRG,,,,,,,inpatient,,,27014.10,8104.23,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,4123.07,,"Case rate ($3,853.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,578.09, add-ons for qualifying new technology services are included. If operating cost exceeds $36,617.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,652.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,582.82. The transfer operating threshold is the transfer adjustment factor * $3,578.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $270.52. The transfer capital threshold is the transfer adjustment factor * $270.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,3853.34,15492.11,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +31.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000315,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X250 135CM SL",SUP-48005025R,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,123.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (MR) 10MM X 4.00",SUP-H74939401104000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"UHC [10700]","United Healthcare",,3428.64,63.3,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR",RX-3781,CDM,,,0250,RC,09999-9998-62,NDC,both,5,ML,12.54,3.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE WEDGE ALLOGRAFT IMPACT FREEZE DRIED 20MMX8MM",SUP-170820,CDM,S27800098,LOCAL,0278,RC,,,both,,,12572.49,3771.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1489.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1462.18,10686.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO ORTHOPEDIC 3.6MM DFINE LONG BEVEL TIP",SUP-1467,CDM,S27200284,LOCAL,0272,RC,,,both,,,1312.20,393.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,539.31,41.1,,,,,0,152.61,1115.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 8MM THORACIC 2 VELOUR STRAIGHT",SUP-M00202175208P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Arm/Hnd Bi",PX-510000095,CDM,29584,CPT,0761,RC,,,both,,,892.05,267.61,"AETNA [10100]","Aetna HMO/PPO",,709.18,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.75,892.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X6MM ADVANCED PARALLEL TRAPEZOIDAL",SUP-7606,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"FIRST HEALTH [10303]","First Health",,6624,80,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 20MM 7FR 12MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206120210,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X22X14MM 10D",SUP-6921450,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"NOVANET [10819]",Novanet,,17820,75,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE X-CORE TITANIUM SPINE LOCK NONSTERILE",SUP-7162000,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.93,488.68,"NOVANET [10819]",Novanet,,1221.7,75,,,,,0,189.44,1384.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX LPR 12 CM CIRCLE",SUP-F10244-1212L,CDM,C1781,HCPCS,0278,RC,,,both,,,12924.53,3877.36,"PHCS [10601]",PHCS,,9047.17,70,,,,,0,1503.12,10985.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Circumcision Neonate",PX-361000238,CDM,54160,CPT,0361,RC,,,both,,,3893.94,1168.18,"AETNA [10100]","Aetna HMO/PPO",,3095.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,452.87,3893.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 62MM 1.5MM K WIRE ATTACH GLIDE HOLE NONSTERILE",SUP-03.130.210,CDM,S27200284,LOCAL,0272,RC,,,both,,,576.07,172.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,391.73,68,,,,,0,67,489.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Tum Loc Plnr Sgl Area 1 Day",PX-341000076,CDM,78800,CPT,0341,RC,,,both,,,1257.73,377.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,463.13,,"Fee schedule rate ($463.13).",,,,0,146.27,1069.07,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 2CM 6MM 7FR BALLOON DILATATION",SUP-V186020,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH",RX-82505,CDM,,,0250,RC,00378-9071-16,NDC,both,1,UN,84.99,25.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MATRIX WOUND 4.7X9.4IN SILICONE PORCINE THERAGENESIS 2 LAYER",SUP-TG-M120240,CDM,A2008,HCPCS,0636,RC,,,both,,,36426.60,10927.98,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"OTHER FEMALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,MODERATE",518,APR-DRG,,,,,,,inpatient,,,94507.90,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $7,209.29. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($48,313.37) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR HORNET 14  300CM  STRAIGHT-TIP",SUP-H749393073002,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PHYTONADIONE (VITAMIN K1) 5 MG TABLET",RX-11024,CDM,,,0637,RC,60687-0381-11,NDC,both,1,UN,305.61,91.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL 10 D +18 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z9002180,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"FIRST HEALTH [10303]","First Health",,816.48,80,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 150MM 2MM BALLOON DILATATION PEBAX",SUP-H74939147201510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL .4MM MICRO STRAIGHT FLAT HANDLE 4.25INX9MM",SUP-78-0070,CDM,S27200284,LOCAL,0272,RC,,,both,,,345.83,103.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.22,293.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 59MM STAINLESS STEEL 2MM SCR MINI FRAGMENT SET 8 HOLE",SUP-247.348,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC IV Push Add Seq Drug",PX-260000009,CDM,96376,CPT,0260,RC,,,both,,,315.72,94.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,158.11,50.08,,,,,0,36.72,315.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ANGLE STERILE DISPOSABLE CUT LATEX",SUP-27054G-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1113.89,334.17,"FIRST HEALTH [10303]","First Health",,891.11,80,,,,,0,129.55,946.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 4.00 X 38 RX US",SUP-1804400-38,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 20MM 190CM 3MM",SUP-R51003002L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"NOVANET [10819]",Novanet,,1478.81,75,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH R2P METACROSS 200CM 80MM 6MM BALLOON DILATATION",SUP-BD-P60080ER,CDM,C1769,HCPCS,0272,RC,,,both,,,2028.75,608.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1379.55,68,,,,,0,235.94,1724.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION",RX-9266,CDM,J0702,HCPCS,0636,RC,00517-0720-01,NDC,both,5,ML,498.60,149.58,"BLUE CROSS [10001]","Blue Cross PPO",,81.12,,,,,,,72.78,423.81,"fee schedule",
"HEAD FEMORAL +7MM 12/14 STD TAPER 22.225MM HIP CEMENTLESS",SUP-136530000,CDM,C1776,HCPCS,0278,RC,,,both,,,4457.40,1337.22,"PHCS [10601]",PHCS,,3120.18,70,,,,,0,518.4,3788.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.3MM 42MM NAIL-EX TITANIUM FULL THREAD HUMERAL",SUP-04.005.532,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"MULTIPLAN [10600]",Multiplan,,983.18,85,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BMT SPLINED KNEE STM V2 12X120",SUP-148315,CDM,C1776,HCPCS,0278,RC,,,both,,,11903.88,3571.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1410.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1384.42,10118.3,"percent of total billed charges",
"CAP INSRT TIBIAL POROUS ROTATE PLATFORM ATTUNE",SUP-OSC367989,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"CIGNA [10200]","Cigna Open Access",,7808.85,33.5,,5302.19,4377.88,6578.61,27,2710.95,19813.5,"percent of total billed charges",
"PLATE 230MM STAINLESS STEEL 3.5MM SCREWS 10 HOLE LCP BONE",SUP-02.104.010,CDM,C1713,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"NOVANET [10819]",Novanet,,6520.5,75,,,,,0,1011.11,7389.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP MULTIHOLE TRIDENT F HEMISPHERE",SUP-508-11-56F,CDM,C1776,HCPCS,0278,RC,,,both,,,11233.20,3369.96,"CIGNA [10200]","Cigna Local Plus",,6009.76,53.5,,5372.07,4581.20,7242.98,23,1306.42,9548.22,"percent of total billed charges",
"SET .241IN 77IN GRAVITY FLOW LARGE BORE NONVENT PIERCING PIN",SUP-654401,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.09,1.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1.88,45.9,,,,,0,0.48,3.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1/3 TUBE 47MM STAINLESS STEEL 4 HOLE LOCK BONE ANKLE",SUP-AR-8943T-04,CDM,C1713,HCPCS,0278,RC,,,both,,,2415.00,724.5,"AETNA [10100]","Aetna HMO/PPO",,1919.93,79.5,,1521.93,481.35,16760.95,30,280.86,2052.75,"percent of total billed charges",
"FRACTURES OF HIP AND PELVIS WITHOUT MCC",536,MS-DRG,,,,,,,inpatient,,,30392.55,9117.76,"AETNA [10100]","Aetna HMO/PPO",,15194.99,,"Fee schedule rate ($15,194.99). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,5009.59,20140.74,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 G NEUTRAL 36MM E1 HIP",SUP-010000859,CDM,C1776,HCPCS,0278,RC,,,both,,,12282.00,3684.6,"CIGNA [10200]",Cigna,,4912.8,40,,5873.17,5873.17,5873.17,"1 through 10",1428.4,10439.7,"percent of total billed charges",
"CUP ACETABULAR 46MM PINNACLE BANTAM MULTIHOLE II HIP STERILE",SUP-121720046,CDM,C1776,HCPCS,0278,RC,,,both,,,13299.75,3989.92,"CIGNA [10200]",Cigna,,5319.9,40,,5873.17,5873.17,5873.17,"1 through 10",1546.76,11304.79,"percent of total billed charges",
"INSRT TIBIAL 6 CURVE PLUS 10MM KNEE XLK FIX BEARING SIGMA",SUP-970481,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7598.69,68,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIDEPLATE BONE 54MM LCP DHHS 135D SHORT BARREL HIP STAINLESS",SUP-282.676S,CDM,C1713,HCPCS,0278,RC,,,both,,,4730.36,1419.11,"BLUE CROSS [10001]","Blue Cross PPO",,1854.3,39.2,,957.42,570.23,957.42,28,550.14,4020.81,"percent of total billed charges",
"CATH INFUSION 2.8-2.5FR .021IN 150CM 30CM MICROCATHETER",SUP-600350A,CDM,C1887,HCPCS,0272,RC,,,both,,,3864.00,1159.2,"NOVANET [10819]",Novanet,,2898,75,,,,,0,449.38,3284.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 5CM 5FR STRAIGHT PANCREATIC POLYMER RADIOPAQUE",SUP-M00536270,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"CIGNA [10200]","Cigna Open Access",,363.73,,,,,,,74.34,543.36,"percent of total billed charges",
"CATH IMPULSE 100CM 5FR FL3.5 CURVE ANGIOGRAPHIC FEMORAL 2",SUP-H74916391211,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"NOVANET [10819]",Novanet,,57.44,75,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PREDNISONE 1 MG TABLET",RX-6493,CDM,J7512,HCPCS,0636,RC,00054-8739-25,NDC,both,1,UN,6.27,1.88,"FIRST HEALTH [10303]","First Health",,5.02,80,,,,,0,0.01,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 45CM 6FR ATRIUM TRANSVENOUS BIPOLAR TINE IS-1",SUP-5592-45,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross HMO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 11.2CM STAINLESS STEEL 2.7/3.5MM SCR 6 HOLE LCP BONE",SUP-02.112.143,CDM,C1713,HCPCS,0278,RC,,,both,,,3144.75,943.42,"CIGNA [10200]","Cigna Open Access",,1789.36,56.9,,1144.80,304.56,2275.09,66,365.73,2673.04,"percent of total billed charges",
"HC Rev Skin Pocket Pcmkr",PX-480000016,CDM,33222,CPT,0481,RC,,,both,,,2776.00,832.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,322.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,322.85,2776,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP SMALL LEAK 1 ENTRAINMENT NEB ELBOW",SUP-73-1061733,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.58,61.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,84.9,41.1,,,,,0,24.03,175.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 10MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-410-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4813.44,40,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 7MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT070080A,CDM,C1768,HCPCS,0278,RC,,,both,,,17056.80,5117.04,"FIRST HEALTH [10303]","First Health",,13645.44,80,,,,,0,1983.71,14498.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ECHOTIP CLEARCORE EUS BIOPSY NEEDLE 22 GA NEEDLE GAGE 5.3 FR",SUP-G60992,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"AETNA [10100]","Aetna HMO/PPO",,2683.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC",798,MS-DRG,,,,,,,inpatient,,,42958.55,12887.56,"PHCS [10601]",PHCS,,7561,,,,,,,5936.95,12764.44,"per diem","Estimated amount calculated based on 4 day length of stay."
"STENT ZIMMON 8CM 5FR PIGTAIL CURVE TAPER PANCREATIC",SUP-G22361,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,290,45.9,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 10CM 6MM BALLOON DILATATION 2 LUMEN",SUP-G52348,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER SHOULDER 36MM +4 REVERSE",SUP-550036004,CDM,C1776,HCPCS,0278,RC,,,both,,,8420.76,2526.23,"KAISER [10500]",Kaiser,,5641.91,67,,,,,0,979.33,7157.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AERVIA NEONATAL SUPRAGLOTTIC AIRWAY DEVICE, X-LARGE, 3500-50",SUP-AVXL,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.47,70.34,"NOVANET [10819]",Novanet,,175.85,75,,,,,0,27.27,199.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUBICON 135CM 5.1FR 2.84FR 50MM SPACE GUIDING NYLON",SUP-H74939240035131,CDM,C1887,HCPCS,0272,RC,,,both,,,1449.90,434.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,171.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC XL 20IN 36- IN KNEE ADJUSTABLE 3 PANEL",SUP-VP40105-055,CDM,L1830,HCPCS,0274,RC,,,both,,,160.08,48.02,"KAISER [10500]",Kaiser,,107.25,67,,,,,0,18.62,136.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 3 PREASSEMBLE BLADE STD HANDLE LED LIGHT",SUP-040-04-0130U,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.42,18.73,"NOVANET [10819]",Novanet,,46.82,75,,,,,0,7.26,53.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rh Phenotyping Complete",PX-302000197,CDM,86906,CPT,0302,RC,,,both,,,354.90,106.47,"AETNA [10100]","Aetna HMO/PPO",,282.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,301.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 12MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650412,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"AETNA [10100]","Aetna HMO/PPO",,10436.16,79.5,,10981.53,8986.79,12413.38,12,1526.7,11158.16,"percent of total billed charges",
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,inpatient,,,92393.02,27717.91,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,9220.19,,"Case rate ($8,951.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,312.20, add-ons for qualifying new technology services are included. If operating cost exceeds $41,351.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,010.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,323.19. The transfer operating threshold is the transfer adjustment factor * $8,312.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.44. The transfer capital threshold is the transfer adjustment factor * $628.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,42132.75,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL EDSLAB 6MM PARALLEL 2 TRACTIONJAW SPRING",SUP-CPARAL6,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.76,14.93,"NOVANET [10819]",Novanet,,37.32,75,,,,,0,5.79,42.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 24CM 5FR .035",SUP-M006192122090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,176.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ENDOSCOPIC AFFIRM ULTRA INTRO TROCAR",SUP-658.505S,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"CIGNA [10200]","Cigna Local Plus",,286.01,53.5,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM TARGET HELICAL PLATINUM DETACHABLE",SUP-M0035434060,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1065.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 14X14.5CM 535ML STYLE FF HIGHLY COHESIVE GEL",SUP-FF-410535,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"MULTIPLAN [10600]",Multiplan,,4730.25,85,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 145MM 5MM SHORT 3 FLUTE QUICK COUPLING NDL POINT",SUP-03.010.105,CDM,S27200284,LOCAL,0272,RC,,,both,,,1152.14,345.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,136.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,133.99,979.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Perq Tcat Ther Rx Dlvr Ntrac Rx Balo Separate",PX-481000409,CDM,0914T,CPT,0481,RC,,,both,,,8782.00,2634.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1040.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1021.35,7680,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X11MM 8D LORDOTIC RING WEDGE",SUP-611,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"FIRST HEALTH [10303]","First Health",,25200,80,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X40 135CM SL",SUP-48003004R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,584.13,68,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 16CM 8FR URETERAL FLEXITHANE",SUP-H7493936108160,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,354.69,28.62,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Urinalysis Auto W Micro",PX-307000002,CDM,81001,CPT,0307,RC,,,both,,,210.90,63.27,"FIRST HEALTH [10303]","First Health",,168.72,80,,,,,0,0.21,179.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHASIX UMBILICAL LARGE CIRCLE W/ STRAP (8.0CM)",SUP-1230009,CDM,C1781,HCPCS,0278,RC,,,both,,,12144.00,3643.2,"NOVANET [10819]",Novanet,,9108,75,,,,,0,1412.35,10322.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 300ML GEL TEXTURED SILTEX SILICONE P4.7CM HIGH",SUP-3544300,CDM,C1789,HCPCS,0278,RC,,,both,,,3885.00,1165.5,"BLUE CROSS [10001]","Blue Cross PPO",,1522.92,39.2,,16595.83,16595.83,16595.83,"1 through 10",451.83,3302.25,"percent of total billed charges",
"TROCAR LAPAROSCOPIC 150MM 5MM KII 2 PACK ACCESS SYSTEM Z",SUP-CTB10,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"NOVANET [10819]",Novanet,,163.13,75,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLYCOPYRROLATE 0.2 MG/ML INJECTION SUPERORDERABLE",RX-409346,CDM,J1596,HCPCS,0636,RC,00143-9681-01,NDC,both,2,ML,21.74,6.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.79,18.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT THROMBECTOMY REPERFUSION CATHETER 0.06INX160CM LUMEN 0.0",SUP-RED43KIT160,CDM,C1757,HCPCS,0272,RC,,,both,,,17608.50,5282.55,"PHCS [10601]",PHCS,,12325.95,70,,,,,0,2047.87,14967.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Proc Dx Unlisted",PX-320000172,CDM,76499,CPT,0320,RC,,,both,,,1329.98,398.99,"CIGNA [10200]","Cigna Open Access",,756.76,56.9,,,,,0,154.68,1130.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PALMAZ GENESIS AVIATOR FLEXSEGMENT 14MM 135CM 4MM 17MM",SUP-PG1540BAX,CDM,C1876,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2122.89,28.62,,,,,0,862.66,6304.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Proc Dx Unlisted",PX-320000172,CDM,76499,CPT,0320,RC,,,both,,,1329.98,398.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,610.46,45.9,,,,,0,154.68,1130.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 30CM 3CM 5FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155225050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,352.3,28.62,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 28MM TALON DISTALFIX CORTICAL",SUP-HTN-U-4-28,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1057.54,68,,,,,0,180.87,1321.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM AXSOS TITANIUM CORTEX NONSTERILE",SUP-661422,CDM,C1713,HCPCS,0278,RC,,,both,,,289.54,86.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,33.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",33.67,246.11,"percent of total billed charges",
"KIT TKR IDUO IPOLY PATIENT SPECIFIC BICOMPARTMENTAL STERILE",SUP-BKA1111111,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross HMO",,9384.48,39.2,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CRYOSURGICAL TRUFREEZE PASSIVE VENT CATH",SUP-CO8407030501,CDM,C2618,HCPCS,0272,RC,,,both,,,13075.50,3922.65,"MULTIPLAN [10600]",Multiplan,,11114.18,85,,,,,0,1520.68,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vn Titer Sars Cov-2 Covid-19",PX-300000413,CDM,86409,CPT,0300,RC,,,both,,,228.00,68.4,"CIGNA [10200]","Cigna Open Access",,129.73,56.9,,,,,0,13.35,193.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Occult Bld Othr Than Screening",PX-301000118,CDM,82272,CPT,0301,RC,,,both,,,70.45,21.13,"BLUE CROSS [10001]","Blue Cross HMO",,5.42,,"Fee schedule rate ($5.42).",,,,0,2.18,59.88,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER +4 CYL HAPTIC C BICONVEX 13MM 6MM",SUP-ZMB00U0210,CDM,V2632,HCPCS,0276,RC,,,both,,,6175.50,1852.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2834.55,45.9,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ambu Bag & Mask",PX-E27000040,CDM,E27000040,LOCAL,0270,RC,,,both,,,216.28,64.88,"NOVANET [10819]",Novanet,,162.21,75,,,,,0,25.15,183.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TRUEPATH .017IN 165CM .018IN ATHERECTOMY DIAMOND",SUP-H74939208181650,CDM,C1769,HCPCS,0272,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8914.8,68,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +29 DIOPTER +5.25 CYL MODIFY L 13MM 6MM",SUP-CNW0T8,CDM,V2787,HCPCS,0276,RC,,,both,,,355.00,106.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,42.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.29,301.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 7.5MM CANNULATED ACL LOW PROFILE STERILE",SUP-AR-1407LP-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ACCUSTICK II FLOPPY 60CM 20CM 6FR 4FR INTRO DIL",SUP-M001207040,CDM,C1894,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SALINE 175-200ML 2 WAY CHECK VALVE SMOOTH",SUP-351-175SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"UHC [10700]","United Healthcare",,538.37,63.3,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX TAPER TIP",SUP-M0061453800,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"MULTIPLAN [10600]",Multiplan,,538.14,85,,,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADHSV SKIN CLSR 2-OCTYL CYANOACRYLATE SKIN AFFIX HIGH",SUP-MSC091040,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.46,24.74,"NOVANET [10819]",Novanet,,61.85,75,,,,,0,9.59,70.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE VASCULAR ANGLED 150CM 3CM .018IN HYDROPHILIC",SUP-GR1805,CDM,C1769,HCPCS,0272,RC,,,both,,,461.70,138.51,"FIRST HEALTH [10303]","First Health",,369.36,80,,,,,0,53.7,392.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA F KNEE RIGHT 2 PEG TIVANIUM STERILE",SUP-42530007502,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"PHCS [10601]",PHCS,,9929.51,70,,,,,0,1649.72,12057.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 17MM 140CM 3.5MM CORONARY STENT",SUP-LUN350R17US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC RBC Ea Unit",PX-390000021,CDM,P9021,HCPCS,0390,RC,,,both,,,335.00,100.5,"CIGNA [10200]","Cigna Local Plus",,179.23,53.5,,,,,0,38.96,284.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING RTRCTR AMS 700 SKW DEEP SCROTAL",SUP-72403867,CDM,S27200284,LOCAL,0272,RC,,,both,,,3864.00,1159.2,"MULTIPLAN [10600]",Multiplan,,3284.4,85,,,,,0,449.38,3284.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM TITANIUM T8 SELF TAP VARIABLE ANGLE LOCK",SUP-04.211.016,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"BLUE CROSS [10001]","Blue Cross PPO",,386.74,39.2,,957.42,570.23,957.42,28,114.74,838.59,"percent of total billed charges",
"STENT 30CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752850,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,106.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END FOOT ANKLE NAIL VALOR",SUP-4151200003,CDM,C1713,HCPCS,0278,RC,,,both,,,2077.50,623.25,"CIGNA [10200]","Cigna Open Access",,1182.1,56.9,,1144.80,304.56,2275.09,66,241.61,1765.88,"percent of total billed charges",
"GRAFT BONE CORNERSTONE-SR CORTICAL LORDOTIC 11X11X6MM",SUP-200611,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 14MM MOUNTAINEER TITANIUM SPINE",SUP-188362014,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR PRESSURE MNTR 60IN ACUMEN IQ VAMP ADULT SYSTEM",SUP-AIQS6AZ5,CDM,S27200284,LOCAL,0272,RC,,,both,,,2760.00,828,"CIGNA [10200]",Cigna,,1876.8,68,,,,,0,320.99,2346,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 150CM 150MM 5MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013468-150,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"KAISER [10500]",Kaiser,,841.19,67,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM 13.5MM NECK SECUR-FIT MAX HA 127D 11 51MM",SUP-6052-1140S,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2654.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2654.17,19398.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM .91-1.12MM 3MM CORONARY",SUP-RONYX30026W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1556.64,28.62,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM WIDE BLADE LIPPED 5.5",SUP-7541213,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 CURVE PLUS 10MM KNEE XLK FIX BEARING SIGMA",SUP-970451,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]","Cigna Open Access",,6358.32,56.9,,5302.19,4377.88,6578.61,27,1299.6,9498.37,"percent of total billed charges",
"INSERT TIBIAL 1 13MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530G113,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"FIRST HEALTH [10303]","First Health",,6966.09,80,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC .3MM INTREPID CONICAL ANGLE POLYMER",SUP-8065752145,CDM,S27200284,LOCAL,0272,RC,,,both,,,163.73,49.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.04,139.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENDO CLOSE 10MM SUTURING TROCAR SITE SPRING LOAD",SUP-173022,CDM,S27200284,LOCAL,0272,RC,,,both,,,634.55,190.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,431.49,68,,,,,0,73.8,539.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 7 9MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-709,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"AETNA [10100]","Aetna HMO/PPO",,7815.26,79.5,,10981.53,8986.79,12413.38,12,1143.29,8355.94,"percent of total billed charges",
"WRAP THERAPEUTIC 76-91CM SMARTVEST MEDIUM",SUP-SW-30/36-1,CDM,S27000186,LOCAL,0270,RC,,,both,,,437.40,131.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 17MM 135CM 5MM 20MM BILIARY STAINLESS STEEL",SUP-PXB35-05-17-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2004.45,45.9,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 7CM 4FR PIGTAIL PANCREATIC POLYMER RADIOPAQUE",SUP-M00536910,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"BLUE CROSS [10001]","Blue Cross PPO",,250.59,39.2,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 75CM 7MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR071001A,CDM,C1874,HCPCS,0278,RC,,,both,,,17545.50,5263.65,"CIGNA [10200]","Cigna Open Access",,5877.74,33.5,,,,,0,2040.54,14913.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 15MM 2.25MM BALLOON DILATATION STERILE",SUP-222-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7.5CM 3.5MM CEREPAK XTRASOFT FREEFORM",SUP-XCR123575,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS [10001]","Blue Cross PPO",,5184.53,39.2,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP",RX-9015,CDM,,,0637,RC,00121-1762-30,NDC,both,30,ML,28.49,8.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.31,24.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pretreat RBC Ab ID Drug",PX-302000209,CDM,86970,CPT,0302,RC,,,both,,,159.90,47.97,"FIRST HEALTH [10303]","First Health",,127.92,80,,,,,0,0.01,135.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 13MM PRESSFIT LEGION KNEE",SUP-71424046,CDM,C1776,HCPCS,0278,RC,,,both,,,12181.95,3654.58,"KAISER [10500]",Kaiser,,8161.91,67,,,,,0,1416.76,10354.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM HIP LIMIT HOLE COLOR CODED OSSEOTI G7",SUP-110010241,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE 1417151 EPIDISC TM PERF PATCH KIT",SUP-1417151,CDM,C1763,HCPCS,0278,RC,,,both,,,1404.95,421.48,"MULTIPLAN [10600]",Multiplan,,1194.21,85,,,,,0,163.4,1194.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 640CC P4.3CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-640,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",878.7,6422.18,"percent of total billed charges",
"PLATE LOW PROFILE 35MM TITANIUM INTEGRATE LOCK MECHANISM",SUP-9790035,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",521.61,3812.25,"percent of total billed charges",
"LENS IOL 10 D +25.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.255,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8MM 60MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712860,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"TUBE TRACH 6 74MM 10.8MM SHILEY UNCUFF DISPOSABLE INNER CANN",SUP-6UN75H,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.56,98.27,"PHCS [10601]",PHCS,,229.29,70,,,,,0,38.1,278.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 48MM STAINLESS STEEL CORTEX SELF TAP LOW",SUP-02.206.048S,CDM,C1713,HCPCS,0278,RC,,,both,,,725.76,217.73,"NOVANET [10819]",Novanet,,544.32,75,,,,,0,84.41,616.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 54MM 32MM XLPE HIP STERILE",SUP-71339554,CDM,C1776,HCPCS,0278,RC,,,both,,,11457.45,3437.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4709.01,41.1,,6417.48,6417.48,6417.48,"1 through 10",1332.5,9738.83,"percent of total billed charges",
"SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA",RX-120921,CDM,,,0250,RC,00132-0202-20,NDC,both,66,ML,12.54,3.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 22CM 10FR LARGE PROXIMAL PIGTAIL CURVE",SUP-M001235580,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"KAISER [10500]",Kaiser,,596.97,67,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Perfusion Ven Fem 24f",PX-E27200333,CDM,E27200333,LOCAL,0272,RC,,,both,,,2347.40,704.22,"MULTIPLAN [10600]",Multiplan,,1995.29,85,,,,,0,273,1995.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FUROSEMIDE 20 MG TABLET",RX-3294,CDM,,,0637,RC,00054-8297-25,NDC,both,1,UN,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR REFLECTION 20D F 54-56MM 36MM XLPE HIP",SUP-71333345,CDM,C1776,HCPCS,0278,RC,,,both,,,21564.90,6469.47,"UHC [10700]","United Healthcare",,13650.58,63.3,,8601.07,8395.67,8601.07,"1 through 10",2508,18330.17,"percent of total billed charges",
"HC Pt Eval Mod Complex 30 Min",PX-420000154,CDM,97162,CPT,0424,RC,,,both,,,454.45,136.33,"NOVANET [10819]",Novanet,,340.84,75,,,,,0,52.85,426,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC UNIVERSAL 22IN 25IN 19IN KNEE THIGH 3 PANEL",SUP-ORT2411022,CDM,S27000186,LOCAL,0270,RC,,,both,,,141.38,42.41,"FIRST HEALTH [10303]","First Health",,113.1,80,,,,,0,16.44,120.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 80MM 2.2MM MIDAS REX LEGEND MATCH HEAD",SUP-8MH22,CDM,S27200284,LOCAL,0272,RC,,,both,,,974.03,292.21,"AETNA [10100]","Aetna HMO/PPO",,774.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.28,827.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE TIBIAL 10MM DURACON S1 FULL FLAT KNEE REVISION",SUP-6630-6-510,CDM,C1776,HCPCS,0278,RC,,,both,,,8062.65,2418.79,"PHCS [10601]",PHCS,,5643.86,70,,,,,0,937.69,6853.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT FINGER SWANSON 1 METACARPOPHALANGEAL GROMMET HIGH",SUP-4700001,CDM,C1776,HCPCS,0278,RC,,,both,,,5733.90,1720.17,"NOVANET [10819]",Novanet,,4300.43,75,,,,,0,666.85,4873.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 30MM 2.5MM BALLOON DILATATION",SUP-H7493912430250,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Aa&/Strd Sciatic Nrv Cont Nfs Cath Img",PX-761000136,CDM,64446,CPT,0761,RC,,,both,,,1737.00,521.1,"KAISER [10500]",Kaiser,,1163.79,67,,,,,0,202.01,1737,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 SH-1 36IN 2 ARM BRAID GREEN",SUP-X763H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UHC [10700]","United Healthcare",,15.83,63.3,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LASMIDITAN 50 MG TABLET",RX-189200,CDM,,,0637,RC,00002-4312-01,NDC,both,1,UN,400.08,120.02,"PHCS [10601]",PHCS,,280.06,70,,,,,0,46.53,340.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 40MM 130CM 5MM 6FR SHORT VASCULAR 2",SUP-SC540LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,842.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE LESLIE PARACHUTE 120CM 5CM 11MM 3.1FR SPECIMEN",SUP-M0063203030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1464.48,439.34,"UHC [10700]","United Healthcare",,927.02,63.3,,,,,0,170.32,1244.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT 70MM 2O CYLINDRICAL STRAIGHT CNCT MEDIUM LOW",SUP-823084,CDM,S27800098,LOCAL,0278,RC,,,both,,,7991.37,2397.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5434.13,68,,,,,0,929.4,6792.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Lwr Ext Infant>=2v",PX-320000086,CDM,73592,CPT,0320,RC,,,both,,,383.34,115,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,55.81,,,,,,,37.66,325.84,"fee schedule",
"GRAFT BONE NEVOS FIBER CORTICAL BONE 5CC OSTEOCONDUCTIVE",SUP-BNEF0005,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"KAISER [10500]",Kaiser,,2889.38,67,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 65CM 3.1FR 50MM SPACE SPRT RADIOPAQUE",SUP-518-066,CDM,C1887,HCPCS,0272,RC,,,both,,,972.00,291.6,"MULTIPLAN [10600]",Multiplan,,826.2,85,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP 12 SCALLOP CLUSTER HOLE SNAP FIT",SUP-00875705001,CDM,C1776,HCPCS,0278,RC,,,both,,,11012.40,3303.72,"NOVANET [10819]",Novanet,,8259.3,75,,,,,0,1280.74,9360.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 4-5 E-F KNEE",SUP-42-5121-006-12,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"MULTIPLAN [10600]",Multiplan,,9159.96,85,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTRUMENT MINI-HOHMANN RETRACTOR SMALL",SUP-INST-MHR-SM,CDM,S27000186,LOCAL,0270,RC,,,both,,,1755.00,526.5,"FIRST HEALTH [10303]","First Health",,1404,80,,,,,0,204.11,1491.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 7 TITANIUM ZERO-P BONE SPINE STERILE NATURAL",SUP-04.617.707S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"CIGNA [10200]",Cigna,,4968,40,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +20.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.205,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,158.36,45.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insulin Free",PX-301000286,CDM,83527,CPT,0301,RC,,,both,,,283.00,84.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11.66,,,,,,,0.01,240.55,"fee schedule",
"HC Xr Rib Bilat 3v",PX-320000029,CDM,71110,CPT,0320,RC,,,both,,,619.96,185.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,47.57,,,,,,,47.57,526.97,"fee schedule",
"HC RBC Deglycerolized Ea Unit",PX-390000012,CDM,P9039,HCPCS,0390,RC,,,both,,,1922.00,576.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1306.96,68,,,,,0,223.53,1633.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APREPITANT 32 MG/4.4 ML (7.2 MG/ML) INTRAVENOUS EMULSION",RX-240358,CDM,C9145,HCPCS,0636,RC,47426-0401-01,NDC,both,4.4,ML,565.90,169.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,384.81,68,,,,,0,67.06,481.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 17MM 27MM 24.5MM EPIC TISSUE STENT REDEFINE",SUP-E200-27M,CDM,S27800098,LOCAL,0278,RC,,,both,,,26775.00,8032.5,"CIGNA [10200]","Cigna Local Plus",,8434.13,31.5,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prgrmg Evl Ldls Pm 1chmbr IP",PX-481000393,CDM,0826T,CPT,0481,RC,,,both,,,58.00,17.4,"NOVANET [10819]",Novanet,,43.5,75,,,,,0,6.75,58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 21MM 43MM 42MM SHOULDER COMPREHENSIVE",SUP-113034,CDM,C1776,HCPCS,0278,RC,,,both,,,9089.00,2726.7,"BLUE CROSS [10001]","Blue Cross HMO",,3562.89,39.2,,5311.50,4717.44,5388.59,31,1057.05,7725.65,"percent of total billed charges",
"CATH MUSTANG 40CM 40MM 5MM .035IN BALLOON DILATATION NYBAX",SUP-39171-05044,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AETNA [10100]","Aetna HMO/PPO",,933.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Npwt >50 Sq Cm W/Dme (Go)",PX-430000028,CDM,97606,CPT,0430,RC,,,both,,,907.00,272.1,"NOVANET [10819]",Novanet,,680.25,75,,,,,0,105.48,770.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INFUSION PORT WITHOUT Y SITE ACCESS 20GA POWERLOC .75IN",SUP-2652034,CDM,C1788,HCPCS,0278,RC,,,both,,,97.79,29.34,"FIRST HEALTH [10303]","First Health",,78.23,80,,,,,0,11.37,83.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHYGMTR ANEROID GAUGE INFLATION SYSTEM ADULT LATEX FREE",SUP-2344,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.26,51.68,"UHC [10700]","United Healthcare",,109.04,63.3,,,,,0,20.03,146.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT MASTERGRAFT MINI GRANULES VOID FILLER .5ML",SUP-8600100,CDM,C1713,HCPCS,0278,RC,,,both,,,506.25,151.87,"KAISER [10500]",Kaiser,,339.19,67,,,,,0,58.88,430.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 200MM 2MM ASNIS JONES FRACTURE FIXATION",SUP-705355,CDM,C1769,HCPCS,0272,RC,,,both,,,574.94,172.48,"FIRST HEALTH [10303]","First Health",,459.95,80,,,,,0,66.87,488.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL AESCULAP 1.5MM 228MM STERILE DISPOSABLE 101MM",SUP-US809SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,3194.16,958.25,"PHCS [10601]",PHCS,,2235.91,70,,,,,0,371.48,2715.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT LAPAROSCOPIC STRAIGHT JAW ULTRASONIC CORDLESS 1",SUP-SCD13,CDM,S27200284,LOCAL,0272,RC,,,both,,,2437.50,731.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1001.81,41.1,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 18MM 11MM C-LETZ MEDIUM CONIZATION",SUP-DCE-115,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.32,61.6,"CIGNA [10200]","Cigna Open Access",,116.83,56.9,,,,,0,23.88,174.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 4MM LORDOSIS TITANIUM",SUP-102064090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 175MM 40MM SCHANZ STAINLESS STEEL ORTHOPEDIC",SUP-294.779,CDM,C1713,HCPCS,0278,RC,,,both,,,1094.39,328.32,"PHCS [10601]",PHCS,,766.07,70,,,,,0,127.28,930.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX PROGRIP 20X15CM SELF FIX FLAT SHEET",SUP-TEM2015G,CDM,C1781,HCPCS,0278,RC,,,both,,,2225.18,667.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1513.12,68,,,,,0,258.79,1891.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ATLANTIS TITANIUM ANTERIOR CERVICAL SPINE",SUP-3120212,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,167.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,163.98,1198.5,"percent of total billed charges",
"STENT RX BILIARY SYSTEM 15CM 8.5FR DUODENAL BEND BILIARY",SUP-M00545690,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,244.06,28.62,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BUTTON 6MM 5CM PASSPORT BUTTON SILICONE CURVE HIP 1",SUP-AR-6592-06-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"AETNA [10100]","Aetna HMO/PPO",,232.39,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ACQUIRE S FRANSEEN 22GA BIOPSY ULTRASOUND FINE NDL",SUP-M00555640,CDM,S27200284,LOCAL,0272,RC,,,both,,,3051.38,915.41,"NOVANET [10819]",Novanet,,2288.54,75,,,,,0,354.88,2593.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 12MM 144CM 4.5MM CORONARY STENT",SUP-H7493941812450,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 57X10X3.4MM STAINLESS STEEL 3.5MM SCR HOLE LOCK LOW",SUP-02.100.004,CDM,C1713,HCPCS,0278,RC,,,both,,,4679.30,1403.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,554.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",544.2,3977.41,"percent of total billed charges",
"SCR BONE 6.5MM 25MM DIVERGENCE-L SPINE",SUP-2150125,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SURGICAL 19 1/8INX12 5/8INX5/8IN MAYO STAINLESS STEEL",SUP-19,CDM,S27200284,LOCAL,0272,RC,,,both,,,511.43,153.43,"NOVANET [10819]",Novanet,,383.57,75,,,,,0,59.48,434.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 12.5MM KNEE XLK POSTERIOR LIPPED FIX",SUP-158102112,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1299.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 8- CM 19GA 1.83MM COCR SILICONE 137.5-147.5CM",SUP-M00555500,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL FLUTELESS",SUP-6975150,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL 5D ALLOGRAFT 9MM LATEX FREE",SUP-3W3009,CDM,S27800098,LOCAL,0278,RC,,,both,,,5896.74,1769.02,"KAISER [10500]",Kaiser,,3950.82,67,,,,,0,685.79,5012.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-0 TH-50 48IN NONABSORBABLE",SUP-0U01A,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.35,88.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,135.11,45.9,,,,,0,34.23,250.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE OTSC 4MM 165CM 12MM 3.2MM ENDOSCOPIC TISSUE ANCHOR",SUP-200.1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3742.50,1122.75,"CIGNA [10200]","Cigna Local Plus",,2002.24,53.5,,,,,0,435.25,3181.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETAINER VISCERA LARGE FISH",SUP-CFUHS32061,CDM,S27200284,LOCAL,0272,RC,,,both,,,512.07,153.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,59.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.55,435.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 110CM 10CM 5FR 7MM 7.5MM BALLOON DILATATION",SUP-4197000L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 27CM 10MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-10027,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION MRI GROSHONG SEPTUM-FINDER",SUP-0605920,CDM,C1788,HCPCS,0278,RC,,,both,,,2250.00,675,"FIRST HEALTH [10303]","First Health",,1800,80,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 7IN DUROGRIP DEBAKEY NDL TUNGSTEN CARBIDE",SUP-BM035R,CDM,S27000186,LOCAL,0270,RC,,,both,,,410.29,123.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,48.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.72,348.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PLLA HA 25MM 9MM 1.5MM ACL PCL CANNULATED",SUP-7207681,CDM,C1713,HCPCS,0278,RC,,,both,,,1882.13,564.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1279.85,68,,,,,0,218.89,1599.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI 24MM TITANIUM 1 LEVEL HELIX BONE SPINE CERVICAL",SUP-7740124,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION SMART PORT FLUOROMAX VORTEX",SUP-CT80STPD,CDM,C1788,HCPCS,0278,RC,,,both,,,2274.00,682.2,"CIGNA [10200]","Cigna Local Plus",,1216.59,53.5,,,,,0,264.47,1932.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED + VE/",SUP-98000200464,CDM,C1776,HCPCS,0278,RC,,,both,,,25830.00,7749,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10332,40,,,,,0,3004.03,21955.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 1MM 1MM ANGLED SIDEPORT CLEARCUT SURGICAL STERILE",SUP-8065921540,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.62,32.89,"CIGNA [10200]","Cigna Local Plus",,58.65,53.5,,,,,0,12.75,93.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM TITANIUM SPINAL SET NON BRAKE OFF NONSTERILE",SUP-5440130,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"MULTIPLAN [10600]",Multiplan,,2045.61,85,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 3.75MM .017IN",SUP-H7493926708370,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC",351,MS-DRG,,,,,,,inpatient,,,44461.40,13338.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,30262.85,,"Fee schedule rate ($30,262.85). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,44461.4,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 700ML GEL SMOOTH MEMORYGEL SILICONE P5.8CM HIGH","SUP-3507004 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2570.4,68,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELIANCE DF4 NON-GORE ACTIVE FIXATION SINGLE COIL 64 CM, IRO",SUP-0273,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]",Cigna,,6072,40,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX9MM FRA 8D LORDOTIC NARROW WEDGE",SUP-10009,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5409.18,28.62,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE AUGMENTATION THK12MM 22MM 22MM TRICORTICAL ILIUM",SUP-MWEV0012,CDM,C1713,HCPCS,0278,RC,,,both,,,12075.00,3622.5,"CIGNA [10200]",Cigna,,4830,40,,1831.33,1831.33,1831.33,16,1404.32,10263.75,"percent of total billed charges",
"BLADE 11CMX14MM OSTEOTOM CUP NONSTERILE DISPOSABLE",SUP-SBLDCUP-3-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"FIRST HEALTH [10303]","First Health",,1166.4,80,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM TARGET NANO HELICAL DETACHABLE",SUP-M0035431010,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"MULTIPLAN [10600]",Multiplan,,7784.03,85,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION COMPLETE CARE BARDEX IC STATLOCK",SUP-301216A,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.57,83.57,"AETNA [10100]","Aetna HMO/PPO",,221.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.4,236.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 79MM ASCENT MAXIM KNEE INTERLOK COCR 1 PIECE",SUP-141235,CDM,C1776,HCPCS,0278,RC,,,both,,,11379.48,3413.84,"MULTIPLAN [10600]",Multiplan,,9672.56,85,,,,,0,1323.43,9672.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 28MM 8MM BLUNT FULL THREAD",SUP-AR-1380TC,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"CIGNA [10200]",Cigna,,1258.43,68,,1831.33,1831.33,1831.33,16,215.23,1573.04,"percent of total billed charges",
"INTRO SHEATH PEDIATRIC 6FR 5.5CM HEXCUSPID VALVE KINK",SUP-504606P,CDM,C1894,HCPCS,0272,RC,,,both,,,200.54,60.16,"NOVANET [10819]",Novanet,,150.41,75,,,,,0,23.32,170.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION CONCERTO 3D",SUP-PV-14-40-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.50 X 18 RX US",SUP-1804250-18,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 1ML DRY BIOCOMPATIBLE INLINE CPLR",SUP-TOR2520,CDM,S27800098,LOCAL,0278,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tee Plc Only",PX-483000010,CDM,93313,CPT,0483,RC,,,both,,,2122.00,636.6,"KAISER [10500]",Kaiser,,1421.74,67,,,,,0,246.79,1803.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 4MM CANNULATED AO COUPLING 4MM SCR NONSTERILE",SUP-702446,CDM,S27200284,LOCAL,0272,RC,,,both,,,2060.10,618.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1400.87,68,,,,,0,239.59,1751.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) WISE DELIVERY CATHETER","SUP-MODEL 2000",CDM,S62400003,LOCAL,0624,RC,,,both,,,13800.00,4140,"MULTIPLAN [10600]",Multiplan,,11730,85,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM CREO TITANIUM COCR SPINE POLYAXIAL",SUP-5146.1647,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM VUEPOINT II SPINE FAVORED ANGLE",SUP-8975520,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PHCS [10601]",PHCS,,2940,70,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 862514 BICRT BLK 14X25 SRVC FEE",SUP-862514,CDM,S27800098,LOCAL,0278,RC,,,both,,,9785.58,2935.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1138.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1138.06,8317.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Perc Ather Ea Addl Br Cor Arty",PX-481000074,CDM,92925,CPT,0481,RC,,,both,,,30209.00,9062.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,17669,,"Case rate ($17,669). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3513.31,25681,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 170MM PERFORM 14 LONG SHOULDER STERILE LATEX",SUP-PFX14170,CDM,C1776,HCPCS,0278,RC,,,both,,,42493.50,12748.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16997.4,40,,,,,0,4941.99,36119.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION BLUE 1.02MM PAPARELLA EAR ULTRASIL TAB",SUP-70241044,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.01,40.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,91.81,68,,,,,0,15.7,114.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC RBC Lr Cmv Neg Irrad Ea Unit",PX-390000019,CDM,P9058,HCPCS,0390,RC,,,both,,,1505.00,451.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1023.4,68,,,,,0,175.03,1279.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 21MM 52MM SHOULDER SOFT TISSUE BALANCE",SUP-7122888,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,921.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPREME EP EXT. CABLE GREY  150 CM",SUP-401982R,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,34.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 38MM PHOENIX TITANIUM CORTICAL SELF TAP 2 LEAD",SUP-14-405038,CDM,C1713,HCPCS,0278,RC,,,both,,,2475.00,742.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,293.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,287.84,2103.75,"percent of total billed charges",
"IMPL BREAST 640CC NATRELLE INSPIRA COHESIVE STERILE",SUP-TCM-640,CDM,C1789,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3800.52,45.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 20MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.220,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"AETNA [10100]","Aetna HMO/PPO",,2337.3,79.5,,1521.93,481.35,16760.95,30,341.92,2499,"percent of total billed charges",
"CATH CORDIS SABER 150CM 80MM 7MM BALLOON DILATATION DURALYN",SUP-48007008X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"FIRST HEALTH [10303]","First Health",,1004.4,80,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA STD TKR VIVACIT-E CERAMIC FEMUR PATELLA T",SUP-98000644700,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"MULTIPLAN [10600]",Multiplan,,19813.5,85,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 75MM 25MM AFX VELA SUPRARENAL STRATA AORTIC EXT",SUP-A25-25/C75-O20V,CDM,C1874,HCPCS,0278,RC,,,both,,,35406.00,10621.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4117.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4117.72,30095.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FUSION ZILVER 6CM 208CM 10MM 7FR .035IN BILIARY",SUP-G31560,CDM,C1876,HCPCS,0278,RC,,,both,,,9597.90,2879.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1116.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1116.24,8158.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT GLENOID SHOULDER TRABECULAR METAL VIVACI",SUP-98000900026,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"KAISER [10500]",Kaiser,,32501.7,67,,,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 25CM 8FR PIGTAIL CURVE NEPHRSTMY FLEXIMA POLYURETHANE",SUP-M001271770,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM SWIVELOCK C CLOSED EYELET VENT",SUP-AR-2324BCC,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.00,945,"AMERIGROUP MEDICAID [20100]",Amerigroup,,373.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",366.35,2677.5,"percent of total billed charges",
"KIT PEG 20FR SILICONE PULL METHOD SAFETY PONSKY STERILE",SUP-003029,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ATLANTIS TITANIUM SPINAL CANCELLOUS",SUP-876-812,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL SF 8FR F-J CURVE ABLATION",SUP-D134804,CDM,C1732,HCPCS,0272,RC,,,both,,,21312.90,6393.87,"KAISER [10500]",Kaiser,,14279.64,67,,,,,0,2478.69,18115.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 11.9CM 6MM CEREPAK MICRO UNIFORM",SUP-FCX100611,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3785.24,28.62,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE KYPHX KYPHON 3 BONE BIOPSY SPINE",SUP-F05A,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MTRL SPLINTING THERMOPLASTIC THK1/8IN 24X18IN SOLID",SUP-A29215,CDM,S27000186,LOCAL,0270,RC,,,both,,,240.13,72.04,"CIGNA [10200]","Cigna Open Access",,136.63,56.9,,,,,0,27.93,204.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE EVERFLEX 80MM 120CM 5MM .079IN BILIARY NITINOL",SUP-PRB35-05-080-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD .99CM 5.37X8.18CM",SUP-G247,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,15584.4,27,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ASPIRATION 18GA ARCPOINT PULMONARY STERILE LATEX FREE",SUP-ILS-1800-PN,CDM,S27200284,LOCAL,0272,RC,,,both,,,1785.00,535.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,211.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,207.6,1517.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY LARYNGEAL MASK ADULT SIZE 4 ELONGATED CUFF 45ML CLEAR",SUP-ALBF040SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.97,31.19,"CIGNA [10200]","Cigna Open Access",,59.16,56.9,,,,,0,12.09,88.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE EMBOLIZATION GREEN EMBOSPHERE 700-900UM TRISACRYL",SUP-S810GH,CDM,S27800098,LOCAL,0278,RC,,,both,,,1777.50,533.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,815.87,45.9,,,,,0,206.72,1510.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL PRONG RETENTION UNOBTRUSIVE OPTIFLOW XL JUNIOR 2",SUP-OJR418,CDM,S27000186,LOCAL,0270,RC,,,both,,,404.77,121.43,"CIGNA [10200]","Cigna Local Plus",,216.55,53.5,,,,,0,47.07,344.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOOP ENDOSCOPIC MONOPOLAR CABLE ESU CNCT LINA GOLD LOOP 240",SUP-EL-240-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,2981.25,894.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2027.25,68,,,,,0,346.72,2534.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 5MM TITANIUM T4 HAND SELF TAP VARIABLE ANGLE",SUP-04.130.205,CDM,C1713,HCPCS,0278,RC,,,both,,,925.34,277.6,"NOVANET [10819]",Novanet,,694.01,75,,,,,0,107.62,786.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SURGIDAC SURGIWIP 0 SK 48IN BRAID COATED GREEN",SUP-EDW-52,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,66.17,45.9,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 3-0 18IN BRAID TIES 12 STRAND GREEN",SUP-X184H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 6MM 3.50MM .017IN",SUP-H7493926706350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 8MM 3.5MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012276-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Apligraf per Sq Cm",PX-E63600017,CDM,Q4101,HCPCS,0636,RC,,,both,,,189.20,56.76,"FIRST HEALTH [10303]","First Health",,151.36,80,,,,,0,22.42,189.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50MMX8MM CLYDESDALE 0D PEEK-OPTIMA RADIOPAQUE",SUP-2969850,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL PFC SIGMA TC3 4 71X65MM KNEE LEFT CEMENTED",SUP-960083,CDM,C1776,HCPCS,0278,RC,,,both,,,27588.96,8276.69,"CIGNA [10200]","Cigna Open Access",,9242.3,33.5,,5302.19,4377.88,6578.61,27,3208.6,23450.62,"percent of total billed charges",
"HC Pet Myocard Perf Multi Stdy",PX-404000007,CDM,78492,CPT,0404,RC,,,both,,,4902.00,1470.6,"PHCS [10601]",PHCS,,3431.4,70,,,,,0,570.1,4902,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 220CM 3.2MM OTSC 2-2.5MM NITINOL",SUP-200.11,CDM,S27200284,LOCAL,0272,RC,,,both,,,3742.50,1122.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,435.25,3181.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revasc Litho Stent Ather",PX-481000125,CDM,C9767,HCPCS,0481,RC,,,both,,,28266.25,8479.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,12974.21,45.9,,,,,0,3287.36,24026.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NOVII FETAL MNTR PATCH",SUP-107-PT-004-50,CDM,S27000186,LOCAL,0270,RC,,,both,,,373.94,112.18,"AETNA [10100]","Aetna HMO/PPO",,297.28,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.49,317.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25MMX13MM CRESCENT PEEK-OPTIMA VERTEBRAL BODY",SUP-9392513,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"MULTIPLAN [10600]",Multiplan,,14076,85,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 100MM 5.5MM EXPEDIUM TITANIUM LINE PREBENT",SUP-179771100,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"KIT CATH 27CM 14.5FR 360D STD 2 BRANCH STRAIGHT POLYURETHANE",SUP-5733270,CDM,S27200284,LOCAL,0272,RC,,,both,,,1897.50,569.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,224.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,220.68,1612.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 55MM 16MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113616,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UHC [10700]","United Healthcare",,7975.8,63.3,,8601.07,8395.67,8601.07,"1 through 10",1465.38,10710,"percent of total billed charges",
"CATH AMPHIRION DEEP 150CM 120MM 2.8-3.9FR 3MM TAPER BALLOON",SUP-AMP030120152,CDM,C1725,HCPCS,0272,RC,,,both,,,2422.50,726.75,"KAISER [10500]",Kaiser,,1623.08,67,,,,,0,281.74,2059.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2MM 18MM FOSSA RADIUS DISTAL VOLAR SMOOTH LOCK",SUP-SPLS-20180-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,639.90,191.97,"NOVANET [10819]",Novanet,,479.93,75,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 2.5CM 10CM DIL KINK RESISTANT SMOOTH",SUP-RSB712,CDM,C1894,HCPCS,0272,RC,,,both,,,217.50,65.25,"MULTIPLAN [10600]",Multiplan,,184.88,85,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM EXPANDED CUFF",SUP-23AFGN-756,CDM,S27800098,LOCAL,0278,RC,,,both,,,31229.42,9368.83,"BLUE CROSS [10001]","Blue Cross HMO",,12241.93,39.2,,,,,0,3631.98,26545.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 5-0 PS-3 18IN MONOFILAMENT PLIABILIZE",SUP-1668H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 28MMX3.5MM TITANIUM STD CIRCULAR LINEAR",SUP-EEA2835,CDM,S27200284,LOCAL,0272,RC,,,both,,,1978.05,593.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1345.07,68,,,,,0,230.05,1681.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC",073,MS-DRG,,,,,,,inpatient,,,54588.84,16376.65,"CIGNA [10200]","Cigna Local Plus",,16554.77,,"Fee schedule rate ($16,554.77). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,40009.64,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 235MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.144S,CDM,C1713,HCPCS,0278,RC,,,both,,,9346.95,2804.08,"NOVANET [10819]",Novanet,,7010.21,75,,,,,0,1087.05,7944.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 33MM FOGARTY SMALL ATRAUMATIC OCCLUSION SOFT",SUP-A0801,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SR CORTICAL BLOCK 11X11X7MM CERVICAL",SUP-200711,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAC 125CM 5.2FR .057IN GUIDING DISTAL ACCESS STERILE",SUP-90731,CDM,S27200284,LOCAL,0272,RC,,,both,,,9066.95,2720.08,"MULTIPLAN [10600]",Multiplan,,7706.91,85,,,,,0,1054.49,7706.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.2MM TWIST STERILE",SUP-KM166-00-04,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.04,24.01,"AETNA [10100]","Aetna HMO/PPO",,63.63,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 RIGHT KNEE POSTERIOR STABILIZED CEMENTED",SUP-5515-F-702,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"PHCS [10601]",PHCS,,7000,70,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 195CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCM-195,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM MREYE 4.2 LOOP PLATINUM ARTERIAL",SUP-G42414,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,97.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER BALLOON DILATATION EVERCROSS BEVEL 360 CROSSCOAT NY",SUP-AB35W09020080,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"AETNA [10100]","Aetna HMO/PPO",,538.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE SMALL OVAL 240CM 2.4MM SENSATION LOOP FLEXIBLE SHORT",SUP-M00562691,CDM,S27200284,LOCAL,0272,RC,,,both,,,161.30,48.39,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOBRONCHIAL 35FR RIGHT RIGHT ANGLED 2 LUMEN HIGH",SUP-126035,CDM,S27200284,LOCAL,0272,RC,,,both,,,474.09,142.23,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) ENDOFLATOR (29MM) 45ML",SUP-30-10-8045,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 130CM 40MM 4MM BALLOON",SUP-U3513044,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WEBSTER 92CM 1MM 6FR 2-5-2MM SPACE D CURVE",SUP-D6-DR-252-RTR,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,inpatient,,,303597.46,91079.24,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,38654,,"Case rate ($36,989.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $34,347.23, add-ons for qualifying new technology services are included. If operating cost exceeds $67,386.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,978.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $34,392.65. The transfer operating threshold is the transfer adjustment factor * $34,347.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,596.82. The transfer capital threshold is the transfer adjustment factor * $2,596.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,174098.67,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDCAP SPINAL 16MM CORE DIA14MM ROUND PARALLEL MINI VBR SYST",SUP-5960400,CDM,S27800098,LOCAL,0278,RC,,,both,,,6345.24,1903.57,"PHCS [10601]",PHCS,,4441.67,70,,,,,0,737.95,5393.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY FIXATION LOCKING SET HELICAL",SUP-456.305,CDM,C1713,HCPCS,0278,RC,,,both,,,3964.33,1189.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,469.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",461.05,3369.68,"percent of total billed charges",
"TIP SUCTION SMART THERMAL DRAPE PISTON HEAT DEVICE",SUP-7013-1013,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.28,73.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.64,209.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 50MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0250,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"KAISER [10500]",Kaiser,,634.96,67,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 1 8MM",SUP-TPS-030-081S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 12MM 140CM 4MM CORONARY STENT CARBOSIL",SUP-LUN400R12US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NUT EXTERNAL FIXATION 10MM TRUELOK STAINLESS STEEL",SUP-50-1008M,CDM,C1713,HCPCS,0278,RC,,,both,,,246.30,73.89,"MULTIPLAN [10600]",Multiplan,,209.36,85,,,,,0,28.64,209.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR FREEHOLD TRIO HEXAGON LOW PROFILE FULL ADJUSTABLE",SUP-FRE-T-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,187.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE UNICOMPARTMENTAL JUK COCR FEMUR TIBIA AND",SUP-71701845,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Open Access",,6331.5,33.5,,5302.19,4377.88,6578.61,27,2198.07,16065,"percent of total billed charges",
"MICROCATHETER CEREBROVASCULAR 150CM EXCELSIOR XT-27 STRAIGHT",SUP-M003XT2750810,CDM,S27200284,LOCAL,0272,RC,,,both,,,8474.58,2542.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5762.71,68,,,,,0,985.59,7203.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI CHIKAI 10 VASCULAR 3CM STRAIGHT 200CM 9.5CM .26",SUP-WAIN-CKI-10-200,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"UHC [10700]","United Healthcare",,2373.75,63.3,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3.5MM TARGET TETRA DETACHABLE STERILE",SUP-TG5413510,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]",Cigna,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE TY 2.0",SUP-PRT-TY-020,CDM,C1713,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"AETNA [10100]","Aetna HMO/PPO",,4827.24,79.5,,1521.93,481.35,16760.95,30,706.17,5161.2,"percent of total billed charges",
"CATH POWERPICC SHERLOCK 3CG 5FR CENTRAL VENOUS 3 LUMEN",SUP-1385108QD,CDM,C1751,HCPCS,0272,RC,,,both,,,1872.23,561.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,769.49,41.1,,,,,0,217.74,1591.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 10.7MM 8MM STD LOW PROFILE DEPH FREE",SUP-8229708,CDM,S27200284,LOCAL,0272,RC,,,both,,,2895.00,868.5,"FIRST HEALTH [10303]","First Health",,2316,80,,,,,0,336.69,2460.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cebpa Gene Full Sequence",PX-309000127,CDM,81218,CPT,0310,RC,,,both,,,255.00,76.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,255,,,,,,,0.01,255,"fee schedule",
"NDL CRYOABLATION 17.5CM 14GA ICEPEARL 2.1CX STRAIGHT IMAGE",SUP-FPRPR3603,CDM,C2618,HCPCS,0272,RC,,,both,,,13110.00,3933,"MULTIPLAN [10600]",Multiplan,,11143.5,85,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR DIALYSIS 4IN PERITONEAL LUER LOCK ANCILLARY STAY-SAFE",SUP-050-95003,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.53,56.56,"CIGNA [10200]","Cigna Local Plus",,100.86,53.5,,,,,0,21.93,160.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 8X 59MM CATH 120CM ENDOVASCULAR",SUP-42859,CDM,C1874,HCPCS,0278,RC,,,both,,,18881.10,5664.33,"NOVANET [10819]",Novanet,,14160.83,75,,,,,0,2195.87,16048.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF THE BILIARY TRACT WITH MCC",444,MS-DRG,,,,,,,inpatient,,,43316.06,12994.82,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,11090.23,,"Case rate ($10,364.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,624.32, add-ons for qualifying new technology services are included. If operating cost exceeds $42,664.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,109.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,637.05. The transfer operating threshold is the transfer adjustment factor * $9,624.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $727.65. The transfer capital threshold is the transfer adjustment factor * $727.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,41670.58,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANSURETHRAL PROSTATECTOMY WITH CC/MCC",713,MS-DRG,,,,,,,inpatient,,,69216.27,20764.88,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,18988.97,,"Case rate ($9,325.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,659.53, add-ons for qualifying new technology services are included. If operating cost exceeds $41,699.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,036.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $8,670.98. The transfer operating threshold is the transfer adjustment factor * $8,659.53 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $654.70. The transfer capital threshold is the transfer adjustment factor * $654.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,43893.27,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 8MM 105MM LCP STAINLESS STEEL CORTEX CONDYLE",SUP-214.905,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE SURGICEL OXIDIZED REGENERATED CELOS",SUP-3013SP,CDM,S27200284,LOCAL,0272,RC,,,both,,,2581.88,774.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,300.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,300.27,2194.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PSN REV CCK VE 12MM R 7-9+ EF",SUP-42-5228-007-12,CDM,C1776,HCPCS,0278,RC,,,both,,,16308.84,4892.65,"BLUE CROSS [10001]","Blue Cross PPO",,6393.07,39.2,,3949.44,3949.44,3949.44,"1 through 10",1896.72,13862.51,"percent of total billed charges",
"HEAD HUMERAL 16MM 43MM SHOULDER AEQUALIS ASCEND FLEX COCR",SUP-DWF143,CDM,C1776,HCPCS,0278,RC,,,both,,,10004.00,3001.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1185.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1163.47,8503.4,"percent of total billed charges",
"COENZYME Q10 100 MG CAPSULE",RX-24678,CDM,,,0637,RC,87701-0408-16,NDC,both,1,UN,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL MODULUS 7 D L17 MM X W14 MM X H7 MM CERVICAL STE",SUP-67940037P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1777.3,28.62,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL SHOULDER RESURFACE COPELAND HA 6",SUP-11114646,CDM,C1776,HCPCS,0278,RC,,,both,,,16174.80,4852.44,"CIGNA [10200]","Cigna Open Access",,5418.56,33.5,,5302.19,4377.88,6578.61,27,1881.13,13748.58,"percent of total billed charges",
"SPONGE ABSORBABLE HEMOSTATIC AGENT GELATIN GELFOAM 100 LARGE",SUP-9034201,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.64,54.19,"CIGNA [10200]","Cigna Open Access",,102.78,56.9,,,,,0,21.01,153.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WATER FOR IRRIGATION, STERILE SOLUTION",RX-7485,CDM,,,0250,RC,00990-6139-03,NDC,both,500,ML,100.65,30.19,"CIGNA [10200]","Cigna Open Access",,57.27,56.9,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN LEFT CORONARY BYPASS CURVE",SUP-LA6LCBSH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AETNA [10100]","Aetna HMO/PPO",,311.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 3.5 MM SCREWS 1 HOLE LOW PROFILE",SUP-02.100.301S,CDM,C1713,HCPCS,0278,RC,,,both,,,2629.20,788.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,752.48,28.62,,,,,0,305.78,2234.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE ABSORBABLE HEMOSTATIC AGENT GELATIN GELFOAM 100 LARGE",SUP-9034201,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.64,54.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.01,153.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULTIVITAMIN WITH FOLIC ACID 400 MCG TABLET",RX-155943,CDM,,,0637,RC,00904-0530-61,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 2 KNEE LEFT BICRUCIATE STABILIZE",SUP-74022222,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"CIGNA [10200]",Cigna,,6648.84,40,,5873.17,5873.17,5873.17,"1 through 10",1933.15,14128.79,"percent of total billed charges",
"BODY HUMERAL SMR MEDIUM SHOULDER TITANIUM LOCKING SCR",SUP-1350.15.010,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CIGNA [10200]",Cigna,,5385.6,68,,5873.17,5873.17,5873.17,"1 through 10",921.1,6732,"percent of total billed charges",
"BODY CONE 27MM RESTORATION +30MM HIP MODULAR",SUP-6276-1-327,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"FIRST HEALTH [10303]","First Health",,11573.46,80,,,,,0,1682.49,12296.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL MODULUS 7 D L17 MM X W14 MM X H7 MM CERVICAL STE",SUP-67940037P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL 2.9MM TURBINATOR COBLATION ANGLE TIP",SUP-EICA689501,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 12CM 5FR .035",SUP-M006192112090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,176.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 15CM 31MM 14.5MM EXCLUDER C3 TRUNK",SUP-RLT311415,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"PHCS [10601]",PHCS,,43890,70,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL MINI",SUP-AT2M-L1813,CDM,S27200284,LOCAL,0272,RC,,,both,,,1702.50,510.75,"PHCS [10601]",PHCS,,1191.75,70,,,,,0,198,1447.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE ENDOSCOPIC 45D 400CM .035IN HYDROPHILIC STIFF",SUP-GS3540,CDM,C1769,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 1 8MM",SUP-TPS-030-081S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 140MM 16MM 3MM VASCULAR VENOUS ILIOFEMORAL VEIN",SUP-VENUM16140,CDM,C1876,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6463.8,27,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL MINI",SUP-AT2M-L1813,CDM,S27200284,LOCAL,0272,RC,,,both,,,1702.50,510.75,"FIRST HEALTH [10303]","First Health",,1362,80,,,,,0,198,1447.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 24MM 144CM 3MM CORONARY STENT",SUP-H7493952824300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Local Plus",,2977.28,53.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 8MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650408,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"PHCS [10601]",PHCS,,9189.08,70,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES 143CM 20MM 4MM .014IN BALLOON DILATATION OTW",SUP-39134-40201,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 1.6IN WING SARNS",SUP-824370,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.90,44.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,67.89,45.9,,,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25MMX13MM CRESCENT PEEK-OPTIMA VERTEBRAL BODY",SUP-9392513,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4739.47,28.62,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 40MM 22GA SONOPLEX II FACET TIP INJECTION",SUP-001285-70,CDM,C9812,HCPCS,0272,RC,,,both,,,119.63,35.89,"KAISER [10500]",Kaiser,,80.15,67,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BONE SEMI-TENDINOSUS FRZN 7X240MM",SUP-81B005,CDM,C1762,HCPCS,0278,RC,,,both,,,8869.95,2660.98,"FIRST HEALTH [10303]","First Health",,7095.96,80,,,,,0,1031.58,7539.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO ANL1 CURVE 70CM 8FR 2.9MM GUIDING",SUP-G56228,CDM,C1894,HCPCS,0272,RC,,,both,,,558.09,167.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,66.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.91,474.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM EAR 7.5MM ROUND EBONY FINISH STAINLESS STEEL",SUP-130675,CDM,S27200284,LOCAL,0272,RC,,,both,,,535.98,160.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH INSRT 18GA .038IN VEIN PERCUTANEOUS 11 SCPL INSRT",SUP-PIKV,CDM,S27200284,LOCAL,0272,RC,,,both,,,353.43,106.03,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE REAMER SPARE 309.200 SCR REMOVAL NONSTERILE",SUP-309.18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1564.68,469.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX 035 130CM 100MM 4MM BALLOON DILATATION",SUP-LX3513041005F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ARTHROSCOPIC 7MM 7CM TWIST-IN 3 DAM SIDEPORT LUER LOCK",SUP-AR-6570TDNV,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,inpatient,,,222121.71,66636.51,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 1 CTX 36IN BRAID COATED UNDYED ABSORBABLE",SUP-J977H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASKET SPECIMEN RETRIEVAL 180CM 5CM 2.5CM RAPID EXCHANGE",SUP-M00510880,CDM,S27200284,LOCAL,0272,RC,,,both,,,2036.93,611.08,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER SUPPORT L150CM DIA0.0375IN COMPATIBLE GUIDEWIRE 0.0",SUP-P1VC-014STR-150,CDM,C1894,HCPCS,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPN NC 10MM 6FR 1.5MM BALLOON DILATATION TWIN WALL",SUP-150-010-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TROCAR LAPAROSCOPIC 100MM 5MM KII FIOS FIRST ENTRY Z THREAD",SUP-CTF03,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.00,40.2,"KAISER [10500]",Kaiser,,89.78,67,,,,,0,15.58,113.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE ORTHOPEDIC THK1/8IN 2XL 13IN NEOPRENE KNEE EXTRA",SUP-79-82009,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.72,17.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,38.57,68,,,,,0,6.6,48.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X8MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7208,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"AMERIGROUP MEDICAID [20100]",Amerigroup,,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 35-40MM SPINE CROSS ROD TO ROD NONSTERILE",SUP-102024004,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"KAISER [10500]",Kaiser,,2386.88,67,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 100MM 125CM 6MM VASCULAR PACLITAXEL",SUP-G38481,CDM,C1874,HCPCS,0278,RC,,,both,,,11921.68,3576.5,"BLUE CROSS [10001]","Blue Cross HMO",,4673.3,39.2,,9776.84,9776.84,9776.84,"1 through 10",1386.49,10133.43,"percent of total billed charges",
"HC Scl70 Igg",PX-302000043,CDM,86235,CPT,0302,RC,,,both,,,568.68,170.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.57,.1,,,,,0,0.57,483.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 120MM 22MM DHS/DCS STAINLESS STEEL CONDYLAR",SUP-280.2,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"CIGNA [10200]","Cigna Local Plus",,972.83,53.5,,3978.14,359.25,3978.14,24,211.48,1545.62,"percent of total billed charges",
"PLATE 95MMX2.6MM STAINLESS STEEL 2.7MM SCR 10 HOLE LC-DCP",SUP-242.22,CDM,C1713,HCPCS,0278,RC,,,both,,,2619.83,785.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,310.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",304.69,2226.86,"percent of total billed charges",
"BINDER ABDOMINAL 15IN LARGE",SUP-D-497-LRG,CDM,S27000186,LOCAL,0270,RC,,,both,,,178.35,53.5,"AETNA [10100]","Aetna HMO/PPO",,141.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE SMALL OVAL 195CMX13MM 2.4MM TRU-TORQUE ROTATABLE STAR",SUP-M00561821,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.26,51.08,"PHCS [10601]",PHCS,,119.18,70,,,,,0,19.8,144.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +20.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030205,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,336.14,28.62,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X8MM OVAL PARALLEL SPINE CORTICAL",SUP-17108,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HALO XP 110CM 7FR 2-8-2MM SPACING TRICUSPID CURVE",SUP-D7T20282CT,CDM,C1731,HCPCS,0272,RC,,,both,,,7086.30,2125.89,"UHC [10700]","United Healthcare",,4485.63,63.3,,,,,0,824.14,6023.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLOTRIMAZOLE 2 % VAGINAL CREAM",RX-33986,CDM,,,0250,RC,51672-2062-00,NDC,both,21,GR,66.71,20.01,"UHC [10700]","United Healthcare",,42.23,63.3,,,,,0,7.76,56.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 30CM 3CM 7FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006180235050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"CIGNA [10200]","Cigna Open Access",,592.66,,,,,,,121.14,885.34,"percent of total billed charges",
"SCR BONE 7.5MM 50MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13177550,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS EVOQUE VALVE (EVOQUE VALVE)48 MM",SUP-9850EV48CL,CDM,S62400003,LOCAL,0624,RC,,,both,,,216600.00,64980,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25667.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25190.58,184110,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 35MM TSRH-3D TITANIUM SHORT POST SPINE",SUP-8372835,CDM,C1713,HCPCS,0278,RC,,,both,,,2361.60,708.48,"PHCS [10601]",PHCS,,1653.12,70,,,,,0,274.65,2007.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT",SUP-G47451,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"CIGNA [10200]","Cigna Local Plus",,32327.98,31.5,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 45MM EXPEDIUM TITANIUM SPINE CORTICAL FIX 5.5MM",SUP-186731645,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"IMPL FIXATION LAPIPLASTY SPEEDPLATE RAPID COMPRESSION",SUP-SK53,CDM,C1713,HCPCS,0278,RC,,,both,,,22465.80,6739.74,"CIGNA [10200]","Cigna Open Access",,7526.04,33.5,,1144.80,304.56,2275.09,66,2612.77,19095.93,"percent of total billed charges",
"SCR BONE 5.5MM 35MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.453,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"NOVANET [10819]",Novanet,,3631.95,75,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR 14X14X11MM",SUP-345144,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL BECK COOLEY LARGE MEDIUM CURVE STRAIGHT 6IN",SUP-55-5037,CDM,S27200284,LOCAL,0272,RC,,,both,,,1191.92,357.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,547.09,45.9,,,,,0,138.62,1013.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM AXSOS STAINLESS STEEL T20 FEMUR HUMERUS",SUP-371340,CDM,C1713,HCPCS,0278,RC,,,both,,,991.44,297.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,117.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,115.3,842.72,"percent of total billed charges",
"CATH SABERX 150CM 120MM 2MM BALLOON DILATATION RAPID",SUP-47520120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"AETNA [10100]","Aetna HMO/PPO",,1268.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 6MM 2MM BALLOON DILATATION HYDROPHILIC",SUP-2200-2006-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3988.2,68,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IRRIGATION FJ 2000 MIS STERILE LATEX FREE DISPOSABLE",SUP-P65-001-0006-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CIGNA [10200]","Cigna Local Plus",,728.03,53.5,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 3CM 2MM GALAXY G3 MINI STRETCH",SUP-GLM920030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"UHC [10700]","United Healthcare",,7521.18,63.3,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 48MM TI",SUP-SPL-60480-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,463.64,28.62,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 18.5MM 27MM MOSAIC ULTRA CINCH PORCINE",SUP-305U227,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"BLUE CROSS [10001]","Blue Cross HMO",,10742.76,39.2,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM POLYAXIAL 5.5MM ROD",SUP-8456555,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"BLUE CROSS [10001]","Blue Cross HMO",,1898.3,39.2,,957.42,156.86,7483.26,51,563.19,4116.21,"percent of total billed charges",
"SCR BONE 4MM 38MM TITANIUM SHORT THREAD CANNULATED",SUP-04.353.438,CDM,C1713,HCPCS,0278,RC,,,both,,,1972.50,591.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,233.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",229.4,1676.63,"percent of total billed charges",
"OCCL CARDIOVASCULAR 30MM SEPTAL 2 DISK NITINOL MESH SELF",SUP-9-ASD-MF-030,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"CIGNA [10200]",Cigna,,8500.32,40,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 15CM 5MM BALLOON DILATATION",SUP-U8150515,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 4-0 V-7 36IN 2 ARM MONOFILAMENT BLUE",SUP-8975H,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.96,25.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.76,71.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 TWINFIX ULTRABRAID COBRAIDED PEEK-OPTIMA",SUP-72202625,CDM,C1713,HCPCS,0278,RC,,,both,,,1724.63,517.39,"FIRST HEALTH [10303]","First Health",,1379.7,80,,,,,0,200.57,1465.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM .91-1.12MM 2.25MM CORONARY",SUP-RONYX22508W,CDM,C1874,HCPCS,0278,RC,,,both,,,1875.00,562.5,"CIGNA [10200]",Cigna,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL INGUINAL HERNIA 30CM X 45CM RECTANGULAR POLYES",SUP-PPM4530,CDM,C1781,HCPCS,0278,RC,,,both,,,1806.00,541.8,"FIRST HEALTH [10303]","First Health",,1444.8,80,,,,,0,210.04,1535.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR 5MM STORZ 1 STEM",SUP-M0068804011,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"FIRST HEALTH [10303]","First Health",,413.18,80,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 24MM T2 TITANIUM FULL THREAD FEMUR HUMERUS",SUP-1896-4024S,CDM,C1713,HCPCS,0278,RC,,,both,,,1299.56,389.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,151.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",151.14,1104.63,"percent of total billed charges",
"ARTOURA BREAST TISSUE EXPANDER HIGH PROJECTION 750 CC",SUP-TEXP150RH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"KAISER [10500]",Kaiser,,9222.89,67,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 TAPER UNIVERSAL 28MM HIP COCR",SUP-802202802,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"BLUE CROSS [10001]","Blue Cross PPO",,1901.47,39.2,,3949.44,3949.44,3949.44,"1 through 10",564.14,4123.1,"percent of total billed charges",
"IMPL BREAST 550CC P5.6CM HIGH PROFILE ROUND SILTEX TEXTURE",SUP-354-4550,CDM,C1789,HCPCS,0278,RC,,,both,,,4823.10,1446.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2213.8,45.9,,,,,0,560.93,4099.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Potassium POC",PX-301000364,CDM,84132,CPT,0301,RC,,,both,,,122.67,36.8,"BLUE CROSS [10001]","Blue Cross PPO",,0.12,.1,,,,,0,0.12,104.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 24CM 7FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251420,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"NOVANET [10819]",Novanet,,923.22,75,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 11MM ECHO FX COCR STD OFFSET HIP STERILE",SUP-12151311,CDM,C1776,HCPCS,0278,RC,,,both,,,8941.02,2682.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1059.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1039.84,7599.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +9.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.095,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER ORANGE 5.5MM DYONICS BONE CUTTER ARTHROSCOPIC",SUP-7206010,CDM,S27200284,LOCAL,0272,RC,,,both,,,513.00,153.9,"CIGNA [10200]",Cigna,,348.84,68,,,,,0,59.66,436.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 24MM T2 TITANIUM FULL THREAD FEMUR HUMERUS",SUP-1896-4024S,CDM,C1713,HCPCS,0278,RC,,,both,,,1299.56,389.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,883.7,68,,,,,0,151.14,1104.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORTIFY ASSURA NEXT GENERATION DR 40 DF4 CONNECTOR",SUP-CD2357-40Q,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"NOVANET [10819]",Novanet,,30420,75,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.165 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.165,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,345.41,28.62,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 20MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,974.92,68,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 150MM 18MM VASCULAR NITINOL ILIOFEMORAL VEIN SELF",SUP-AB9U18150090,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4821.03,41.1,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 400MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.061S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"BLUE CROSS [10001]","Blue Cross HMO",,4867.99,39.2,,957.42,156.86,7483.26,51,1444.25,10555.59,"percent of total billed charges",
"CMPNT FEMORAL 5 KNEE RIGHT MEDIAL LEFT LATERAL RESTORIS",SUP-180515,CDM,C1776,HCPCS,0278,RC,,,both,,,12440.70,3732.21,"FIRST HEALTH [10303]","First Health",,9952.56,80,,,,,0,1446.85,10574.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 5-0 RB-1 36IN 2 ARM MONOFILAMENT BLUE",SUP-8556H,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.78,18.23,"KAISER [10500]",Kaiser,,40.72,67,,,,,0,7.07,51.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL AMPLATZ SHEATH 10FR RENAL",SUP-G01688,CDM,C1894,HCPCS,0272,RC,,,both,,,510.30,153.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,60.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 44MM 15MM STAINLESS STEEL PARTIAL THREAD",SUP-121844,CDM,C1713,HCPCS,0278,RC,,,both,,,2006.40,601.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,237.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,233.34,1705.44,"percent of total billed charges",
"STENT POLARIS SENSOR DUAL-FLEX 22CM 6FR .035IN URETERAL",SUP-M006155231090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"CIGNA [10200]",Cigna,,926.66,68,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 4-0 P-3 18IN MONOFILAMENT UNDYED",SUP-8604G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 7IN MOLT 2 END SHARP/SHARP",SUP-DO543R,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.53,83.86,"CIGNA [10200]","Cigna Local Plus",,149.55,53.5,,,,,0,32.51,237.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OCTARAY 3-3-3-3-3MM SPCAE D CURVE ELECTROPHYSIOLOGY",SUP-D160903,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"FIRST HEALTH [10303]","First Health",,12696,80,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 2 KNEE LEFT BICRUCIATE STABILIZE",SUP-74022222,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"KAISER [10500]",Kaiser,,11136.81,67,,,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 15MM 4MM STAINLESS STEEL SHORT THREAD HAND",SUP-02.226.215,CDM,C1713,HCPCS,0278,RC,,,both,,,1647.00,494.1,"FIRST HEALTH [10303]","First Health",,1317.6,80,,,,,0,191.55,1399.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 28MM REUNION SHOULDER STERILE LATEX FREE",SUP-5572-2800,CDM,C1776,HCPCS,0278,RC,,,both,,,9442.80,2832.84,"CIGNA [10200]",Cigna,,6421.1,68,,5873.17,5873.17,5873.17,"1 through 10",1098.2,8026.38,"percent of total billed charges",
"HC Mog-Igg1 Antb Cba Each",PX-302000255,CDM,86362,CPT,0302,RC,,,both,,,1158.05,347.41,"CIGNA [10200]",Cigna,,26.51,,,,,,,0.01,984.34,"fee schedule",
"LENS IOL 0 D +26 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-SY60WF.260,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grft T/a/L <=100scm 1st 25 Sq Cm",PX-510000050,CDM,15271,CPT,0761,RC,,,both,,,1638.76,491.63,"BLUE CROSS [10001]","Blue Cross HMO",,1638.76,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,190.59,1638.76,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myelography Lumb Inj >=2 Region Si",PX-361000374,CDM,62305,CPT,0361,RC,,,both,,,6762.75,2028.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3311,,"Case rate ($3,311). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,786.51,5748.34,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enteroscopy W Rmvl FB",PX-750000228,CDM,44363,CPT,0750,RC,,,both,,,3196.00,958.8,"CIGNA [10200]","Cigna Open Access",,2751,,"Case rate ($2,751). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,371.69,3196,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CELOS OXIDIZED 14X2IN ABSORBABLE HEMOSTATIC AGENT FLEXIBLE",SUP-1951,CDM,S27200284,LOCAL,0272,RC,,,both,,,487.43,146.23,"CIGNA [10200]","Cigna Local Plus",,260.78,53.5,,,,,0,56.69,414.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2MM 2MM .018IN HELICAL STRAIGHT PLATINUM",SUP-M0013120021,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OCTARAY 3-3-3-3-3MM SPCAE F CURVE ELECTROPHYSIOLOGY",SUP-D160906,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"UHC [10700]","United Healthcare",,10045.71,63.3,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRITANIUM SYMMETRIC METAL BACKED PATELLA S36X10",SUP-5556-L-360,CDM,C1776,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]",Cigna,,2998.8,68,,5873.17,5873.17,5873.17,"1 through 10",512.88,3748.5,"percent of total billed charges",
"PLATE T 53MM STAINLESS STEEL 2MM SCR MINI FRAGMENT SET 7",SUP-247.615,CDM,C1713,HCPCS,0278,RC,,,both,,,2541.00,762.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,301.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",295.52,2159.85,"percent of total billed charges",
"STENT ZIPWIRE 22CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175271180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA [10200]",Cigna,,992.87,68,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X9X9MM COROENT 4D PEEK LARGE IMPACT NONSTERILE",SUP-6709932,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4471.2,27,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH CHECK-FLO FLEXOR .018/.038IN ANL3 CURVE 45CM 6FR .087",SUP-G29984,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"UHC [10700]","United Healthcare",,333.27,63.3,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE ALLODERM SELECT ACELLULAR DERMIS THK1.2-2 MM M",SUP-1518128,CDM,Q4116,HCPCS,0636,RC,,,both,,,23782.50,7134.75,"PHCS [10601]",PHCS,,16647.75,70,,,,,0,247.92,20215.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH GORE DRYSEAL FLEX 65CM 26FR 9.5MM 8.7MM INTRO",SUP-GDSF2665,CDM,C1894,HCPCS,0272,RC,,,both,,,6858.60,2057.58,"FIRST HEALTH [10303]","First Health",,5486.88,80,,,,,0,797.66,5829.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ADDWIRE FORTE VASCULAR STRAIGHT FLOPPY SPRING COIL 185",SUP-H74934949010,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"KAISER [10500]",Kaiser,,379.89,67,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CANTATA 150CM 2.5FR .021IN MICRO INTERVENTIONAL",SUP-G54532,CDM,S27200284,LOCAL,0272,RC,,,both,,,2774.93,832.48,"MULTIPLAN [10600]",Multiplan,,2358.69,85,,,,,0,322.72,2358.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 4FR 21GA 3FR MERIT PAK .018IN 40CM PEDAL",SUP-PAKS4NPD4,CDM,C1894,HCPCS,0272,RC,,,both,,,497.02,149.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,58.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.8,422.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE LEFT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F201,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6856.01,40,,,,,0,1993.39,14569.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.316,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2856,68,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING HME FILTER MASK BAG SAMPLE ELBOW PORT 70IN",SUP-NCF375-6121Z,CDM,S27000186,LOCAL,0270,RC,,,both,,,88.04,26.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.24,74.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOUGIE 24FR OTIS A BOULE SURGICAL",SUP-51-7224,CDM,S27200284,LOCAL,0272,RC,,,both,,,416.82,125.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,49.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.48,354.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SHUNT ACCU-FLO CSF RIGHT ANGLE BEVELED END GROOVED",SUP-821507,CDM,S27800098,LOCAL,0278,RC,,,both,,,1201.39,360.42,"BLUE CROSS [10001]","Blue Cross HMO",,470.94,39.2,,,,,0,139.72,1021.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 16CM 28.5MM 12MM 24-26MM 10-11MM GORE",SUP-RLT281216,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 18 X 14 X 07MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-181407-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross PPO",,2434.32,39.2,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 10MM STAINLESS STEEL T8 CORTEX TUBE STARDRIVE",SUP-201.760TS,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,55.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",55.39,404.84,"percent of total billed charges",
"SCOUT 7.5CM DELIVERY NEEDLE ULTRASOUND",SUP-SSR75S-01,CDM,A4648,HCPCS,0278,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHYTONADIONE 1 MG/ML ORAL SOLUTION",RX-408176,CDM,J3430,HCPCS,0636,RC,08888-8887-16,NDC,both,1,ML,36.41,10.92,"CIGNA [10200]","Cigna Open Access",,7.55,,,,,,,3.18,30.95,"fee schedule",
"SPACER ALLOGRAFT 7MM GRAFTECH LARGE LORDOTIC CORTICAL",SUP-4421407,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE TOTAL LEGION GII PS OXI NP TIB HI DMD INS",SUP-71704572,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2564.42,18742.5,"percent of total billed charges",
"ROD SPINAL 110MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"GRAFT STENT 160MM 22-14MM 14FR 12FR TRIVASCULAR OVATION",SUP-TV-IL1422160-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"NOVANET [10819]",Novanet,,25042.5,75,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION",RX-10266,CDM,,,0250,RC,70100-0424-01,NDC,both,1,UN,1281.08,384.32,"CIGNA [10200]",Cigna,,871.13,68,,,,,0,148.99,1088.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 240MM 6MM BALLOON DILATATION STERILE LATEX",SUP-586024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH HIGH PROFILE XTRA 790CC",SUP-SHPX790,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,883.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE 35MM 5MM EMBOLIZATION",SUP-PED2-500-35,CDM,S27800098,LOCAL,0278,RC,,,both,,,85465.80,25639.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,34186.32,40,,,,,0,9939.67,72645.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +6.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.065,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL OVITEX TELA BIO 40X25CM PERMANENT REINFORCE 6",SUP-F10246-2540P,CDM,C1781,HCPCS,0278,RC,,,both,,,70794.00,21238.2,"BLUE CROSS [10001]","Blue Cross PPO",,27751.25,39.2,,,,,0,8233.34,60174.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER FLEXIVA 1000UM FLEXSHIELD HIGH POWER POLISH",SUP-M0068403941,CDM,S27200284,LOCAL,0272,RC,,,both,,,4603.54,1381.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,535.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,535.39,3913.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM LCP STAINLESS STEEL PERIARTICULAR FEMORAL",SUP-02.205.250,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,714.14,45.9,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 8MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBJR080202A,CDM,C1874,HCPCS,0278,RC,,,both,,,19895.40,5968.62,"NOVANET [10819]",Novanet,,14921.55,75,,,,,0,2313.84,16911.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.5CM MEMORYGEL P3.9CM MODERATE PLUS PROFILE",SUP-RSZ-3501S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"KAISER [10500]",Kaiser,,1058.27,67,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 57MM 75CM 5MM 60MM",SUP-H74938046560750,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"AETNA [10100]","Aetna HMO/PPO",,3291.3,79.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH II SS9.5",SUP-398347,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"PHCS [10601]",PHCS,,368.55,70,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL INSUFFLATION 15CM 14GA PNEUMOPERITONEUM BAND INDCTR",SUP-60-6050-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,163.47,49.04,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNR LG OVL 240CM 2.4MM SNS",SUP-6265,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEPARATOR SURGICAL 7IN HORSLEY DURA STAINLESS STEEL",SUP-285325,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.34,73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VASCUTRAK 140CM 4CM 3MM BALLOON DILATATION HYDROPHILIC",SUP-V143040,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Stimulus Evoked Response",PX-361000449,CDM,51792,CPT,0361,RC,,,both,,,594.00,178.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHELL THERASHELLS VENTED FRONT STERILE BREAST",SUP-89930S,CDM,S27000186,LOCAL,0270,RC,,,both,,,64.21,19.26,"CIGNA [10200]",Cigna,,43.66,68,,,,,0,7.47,54.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 175MM 5.5MM STRAIGHT TITANIUM EXTRA HARD",SUP-04.616.275,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"STENT ZILVER 635 20MM 125CM 6MM VASCULAR NITINOL ILIAC",SUP-G43829,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,439.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 45MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890006045,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANT BREAST DISORDERS WITHOUT CC/MCC",599,MS-DRG,,,,,,,inpatient,,,49345.54,14803.66,"AMBETTER EXCHANGE  [11102]",Ambetter,,4772.64,,"Case rate ($4,772.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,431.72, add-ons for qualifying new technology services are included. If operating cost exceeds $37,471.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,717.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,437.58. The transfer operating threshold is the transfer adjustment factor * $4,431.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.06. The transfer capital threshold is the transfer adjustment factor * $335.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,4772.64,19188.07,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.5MM 95MM GAMMA3 TITANIUM HIP TROCHANTER LAG",SUP-3060-0095S,CDM,C1713,HCPCS,0278,RC,,,both,,,3906.00,1171.8,"PHCS [10601]",PHCS,,2734.2,70,,,,,0,454.27,3320.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM 6 HOLE LOCKING BONE STERNAL NONSTERILE",SUP-460.038,CDM,C1713,HCPCS,0278,RC,,,both,,,3769.95,1130.98,"MULTIPLAN [10600]",Multiplan,,3204.46,85,,,,,0,438.45,3204.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT 5-13CM ALEXIS ATRAUMATIC FLEXIBLE RETRACTION RING",SUP-HR104,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"AMERIGROUP MEDICAID [20100]",Amerigroup,,213.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immobilization Grid",PX-E27000219,CDM,E27000219,LOCAL,0270,RC,,,both,,,149.60,44.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,61.49,41.1,,,,,0,17.4,127.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRI-SIL 60IN 22FR URETHRAL BACTI-GUARD SILICONE",SUP-0172SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.66,57.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.29,162.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 4MM 1.2MM 17MM 8MM STAINLESS STEEL LONG THREAD",SUP-202.717,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,131.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,129.1,943.52,"percent of total billed charges",
"CATH SUREFIRE 65CM 5FR .056IN COBRA 1 CURVE GUIDING STEEL",SUP-SGC-5065-COBRA1,CDM,C1887,HCPCS,0272,RC,,,both,,,1875.00,562.5,"MULTIPLAN [10600]",Multiplan,,1593.75,85,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 10MM 13MM 8FR .035IN",SUP-BXA107901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2536.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET WEIGHT GREEN THERABAND ANKLE WRIST NEOPRENE TERRYCLOTH",SUP-81510411,CDM,S27000186,LOCAL,0270,RC,,,both,,,195.05,58.51,"CIGNA [10200]",Cigna,,132.63,68,,,,,0,22.68,165.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 40X20MM READIGRAFT SMALL PERICARDIUM","SUP-PERI S",CDM,S27800098,LOCAL,0278,RC,,,both,,,1279.40,383.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,151.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,148.79,1087.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC STRAIGHT ROUND TIP MENISCECTOMY ACUFEX",SUP-010620,CDM,S27200284,LOCAL,0272,RC,,,both,,,381.83,114.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,44.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.41,324.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWER MIDLINE CATH KIT 20CM 4FR INFUSION SINGLE LUMEN",SUP-PP4154108DBP,CDM,C1751,HCPCS,0272,RC,,,both,,,1264.09,379.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.01,1074.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 10-14MM 13FR 10FR TRIVASCULAR OVATION",SUP-TV-IL1410100-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CIGNA [10200]","Cigna Local Plus",,10517.85,31.5,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X80 135CM SL",SUP-48007008R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"UHC [10700]","United Healthcare",,543.75,63.3,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 100MM TITANIUM ENDOSCOPIC LINEAR CUTTER",SUP-TLC10,CDM,S27200284,LOCAL,0272,RC,,,both,,,3934.93,1180.48,"CIGNA [10200]","Cigna Open Access",,2238.98,56.9,,,,,0,457.63,3344.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VIA CANCELLOUS DEMINERALIZE CORTICAL BONE 10CC",SUP-VCAFMX-100000,CDM,S27800098,LOCAL,0278,RC,,,both,,,20790.00,6237,"KAISER [10500]",Kaiser,,13929.3,67,,,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM TKR POROUS MIS",SUP-98000225521,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Open Access",,7386.75,33.5,,5302.19,4377.88,6578.61,27,2564.42,18742.5,"percent of total billed charges",
"CORDELLA SYSTEM (CHFS) KIT",SUP-100171-00,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TIBIAL SHAFT THK10+ MM ALLOGRAFT FROZEN 150MMX10+",SUP-450525,CDM,S27800098,LOCAL,0278,RC,,,both,,,9178.38,2753.51,"AETNA [10100]","Aetna HMO/PPO",,7296.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1067.45,7801.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 CURVE PLUS 10MM KNEE XLK FIX BEARING SIGMA",SUP-970421,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3198.16,28.62,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +10.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.105,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 15MM 140CM 4MM CORONARY",SUP-RSINT40015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]",Cigna,,3769.92,68,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Whole Bld Separation",PX-E27200264,CDM,E27200264,LOCAL,0272,RC,,,both,,,1007.60,302.28,"UHC [10700]","United Healthcare",,637.81,63.3,,,,,0,117.18,856.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plasma Solvent/Detergent Tx",PX-390000008,CDM,P9023,HCPCS,0390,RC,,,both,,,622.00,186.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,422.96,68,,,,,0,72.34,528.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA 30CM 8FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061921550,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"PHCS [10601]",PHCS,,794.93,70,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X14X7MM ENDOSKELETON TCS 6D MEDIUM LORDOTIC",SUP-5366-1407,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2133,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Syphilis Test Qual",PX-302000093,CDM,86592,CPT,0302,RC,,,both,,,141.55,42.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4.57,,"Fee schedule rate ($4.57). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,120.32,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Glutamic Acid Decarboxylase",PX-301000253,CDM,83519,CPT,0301,RC,,,both,,,272.00,81.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16.56,,,,,,,0.01,231.2,"fee schedule",
"TISSUE 331344 ACSR 13X14X14 SRVC FEE",SUP-331344,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 42MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.542,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"BLUE CROSS [10001]","Blue Cross PPO",,429.8,39.2,,957.42,570.23,957.42,28,127.51,931.96,"percent of total billed charges",
"SCREW BONE 5X80MM LOCKING STERILE FOR MEDULLARY NAIL XL25",SUP-04.045.080TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY PRESHAPE RADIAL TIP 50CM 2.2MM BIPAL INTERNAL",SUP-502402B,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 5MM 5MM LUER LOCK SPRING LOAD HANDLE",SUP-BX00711812,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"CIGNA [10200]","Cigna Local Plus",,176.87,53.5,,,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW .36IN CORE PRECISION THK.015IN .98IN THIN OFFSET",SUP-2296003511,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,183.75,68,,,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 4X300 80CM SL",SUP-48004030N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"FIRST HEALTH [10303]","First Health",,832.81,80,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mog-Igg1 Antb Cba Each",PX-302000255,CDM,86362,CPT,0302,RC,,,both,,,1158.05,347.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,18.95,,,,,,,0.01,984.34,"fee schedule",
"SCR BONE 4.5MM 30MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.730,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"BLUE CROSS [10001]","Blue Cross PPO",,440.46,39.2,,957.42,570.23,957.42,28,130.68,955.09,"percent of total billed charges",
"SUT POLYESTER ETHIBOND 0 MO-6 18IN CONTROL RELEASE BRAID 8",SUP-CX45D,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.15,44.74,"FIRST HEALTH [10303]","First Health",,119.32,80,,,,,0,17.35,126.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.285,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"FIRST HEALTH [10303]","First Health",,276,80,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 90MM 24MM 6MM 16FR ZENITH SPIRAL-Z",SUP-G55247,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2509.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 RB-1 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J306H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE AMS 700MS 21CM ERECTILE RESTORATION TACTILE PUMP",SUP-72404233-12,CDM,C1813,HCPCS,0278,RC,,,both,,,76351.50,22905.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,20614.91,27,,,,,0,8879.68,64898.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 85MM 5.5MM REVERE PEDICLE TITANIUM CURVED",SUP-124.685,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Open Access",,2509.29,56.9,,1144.80,304.56,2275.09,66,512.88,3748.5,"percent of total billed charges",
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U165,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,341.96,45.9,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 4MM 9MM 3MM DUCT TYPE II SELF EXPANDING",SUP-9-PDA2-03-04,CDM,C1817,HCPCS,0278,RC,,,both,,,15444.00,4633.2,"NOVANET [10819]",Novanet,,11583,75,,,,,0,1796.14,13127.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID LOWER LEG REDUCTION KIT- STANDARD, WIDE",SUP-25102217,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"AETNA [10100]","Aetna HMO/PPO",,998.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC SMALL KNEE OPEN BACK AIRMESH ROADRUNNER",SUP-14142,CDM,S27000186,LOCAL,0270,RC,,,both,,,614.55,184.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,71.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,71.47,522.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 20X50X11MM ORACLE 0D PARALLEL SPINE LUMBAR",SUP-15041,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"PHCS [10601]",PHCS,,16758,70,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK DURAGEN DURAL REGMAX  2X2",SUP-DRM1022,CDM,S27800098,LOCAL,0278,RC,,,both,,,4508.60,1352.58,"AETNA [10100]","Aetna HMO/PPO",,3584.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,524.35,3832.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SPINAL 5MM SPINEJACK EXPANSION",SUP-0909-200-050,CDM,S27200284,LOCAL,0272,RC,,,both,,,8966.41,2689.92,"UHC [10700]","United Healthcare",,5675.74,63.3,,,,,0,1042.79,7621.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM 85MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE",SUP-02.117.602S,CDM,C1713,HCPCS,0278,RC,,,both,,,7192.84,2157.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2058.59,28.62,,,,,0,836.53,6113.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE RELINE L45 MM OD5.5 MM SPINE POLYAXIAL 2 FULL CAN",SUP-16215545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 38CM 10FR 2CM BASKET RAPID ATRAUMATIC TIPLESS",SUP-G32862,CDM,S27200284,LOCAL,0272,RC,,,both,,,1266.03,379.81,"UHC [10700]","United Healthcare",,801.4,63.3,,,,,0,147.24,1076.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X14X7MM ENDOSKELETON TCS 6D MEDIUM LORDOTIC",SUP-5366-1407,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"MULTIPLAN [10600]",Multiplan,,15300,85,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FAST-FIX 360D STRAIGHT FIXATION 2 ANCHOR PRETIE 2-0 5",SUP-72202467,CDM,C1713,HCPCS,0278,RC,,,both,,,3300.75,990.22,"NOVANET [10819]",Novanet,,2475.56,75,,,,,0,383.88,2805.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC MICROPOINT 7-0 TG140-8 18IN 2 ARM MONOFILAMENT",SUP-1797G,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.84,88.45,"UHC [10700]","United Healthcare",,186.63,63.3,,,,,0,34.29,250.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM 6 HOLE LOCKING BONE STERNAL NONSTERILE",SUP-460.038,CDM,C1713,HCPCS,0278,RC,,,both,,,3769.95,1130.98,"CIGNA [10200]",Cigna,,2563.57,68,,1831.33,1831.33,1831.33,16,438.45,3204.46,"percent of total billed charges",
"PACK PHACOEMULSIFICATION .9MM CENTURION INTREPID 30D BEVEL",SUP-8065752200,CDM,S27200284,LOCAL,0272,RC,,,both,,,833.00,249.9,"PHCS [10601]",PHCS,,583.1,70,,,,,0,96.88,708.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX21MM 12D LORDOTIC BROAD ANTERIOR",SUP-2421,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]",Cigna,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 54MM 3MM ROUND DIAMOND COARSE STERILE",SUP-1608006091,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"KAISER [10500]",Kaiser,,390.74,67,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP POLAR CUP CEMENTED STEM OXINIUM HEAD",SUP-71703505,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6851.63,28.62,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 150CM 4.8FR .035IN 3CM STD STRAIGHT URETERAL",SUP-M006145353190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,768.37,68,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 650CC",SUP-RSZ-SHPX-650S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"FIRST HEALTH [10303]","First Health",,132.87,80,,,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +29.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200295,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"NOVANET [10819]",Novanet,,765.45,75,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 24X5.5X1.25MM TITANIUM 2MM SCR 4 HOLE MODULAR LC-DCP",SUP-449.931,CDM,C1713,HCPCS,0278,RC,,,both,,,2175.60,652.68,"PHCS [10601]",PHCS,,1522.92,70,,,,,0,253.02,1849.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 100CM 6FR 12MM AMPLATZER .086IN TYPE II",SUP-9-AVP2-012,CDM,S27800098,LOCAL,0278,RC,,,both,,,6589.50,1976.85,"KAISER [10500]",Kaiser,,4414.97,67,,,,,0,766.36,5601.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 109MM 32MM HANDL-B ONE-SHOT ZENITH",SUP-G32539,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7292.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVICROSS 150CM ANGIOGRAPHIC STAINLESS STEEL",SUP-NC35150,CDM,C1887,HCPCS,0272,RC,,,both,,,1462.05,438.61,"NOVANET [10819]",Novanet,,1096.54,75,,,,,0,170.04,1242.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 2MM TWIST STERILE",SUP-KM166-10-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,70.16,68,,,,,0,12,87.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVICROSS 150CM ANGIOGRAPHIC STAINLESS STEEL",SUP-NC35150,CDM,C1887,HCPCS,0272,RC,,,both,,,1462.05,438.61,"MULTIPLAN [10600]",Multiplan,,1242.74,85,,,,,0,170.04,1242.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFE-T-J VASCULAR 3MM RADIUS J CURVE TAPER 145CM 6CM",SUP-G00511,CDM,C1769,HCPCS,0272,RC,,,both,,,121.71,36.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.15,103.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +20 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.200,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Proc Unlisted",PX-402000044,CDM,76999,CPT,0402,RC,,,both,,,837.00,251.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT POLYPROPYLENE PROLENE VISI-BLACK 7-0 BV-1 18IN 2 ARM",SUP-8701H,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.44,53.83,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT CLAMP 86MM STEALTH FIBRA SOFT LATEX FREE",SUP-G-8655,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SELUTION SLR PTCA DEB 2.0X15MM",SUP-SCA14U-200015D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT TKR 40MM LPS TITANIUM MALE TO FEMALE TAPER ANTIROTATION",SUP-198707040,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"CATH TORCON NB ADVANTAGE BEACON TIP 80CM 5FR ANGLE",SUP-G09312,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL CANCELLOUS THK12MM ALLOGRAFT STRUT",SUP-400607,CDM,S27800098,LOCAL,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12MM KNEE POLYETHYLENE POSTERIOR STABILIZED",SUP-72-15-0512,CDM,C1776,HCPCS,0278,RC,,,both,,,7362.30,2208.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,872.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,856.24,6257.96,"percent of total billed charges",
"SHEATH NAVIGATOR HD 36CM 11-13FR ACCESS STAINLESS STEEL",SUP-M0062502220,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.05,833.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 405CC",SUP-SSZ-M405,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"AETNA [10100]","Aetna HMO/PPO",,1184.87,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 12CM 8.5FR BILIARY FLEXIMA PLASTIC TEMPORARY DELIVERY",SUP-M00539280,CDM,C2625,HCPCS,0278,RC,,,both,,,755.24,226.57,"MULTIPLAN [10600]",Multiplan,,641.95,85,,,,,0,87.83,641.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3514,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,428.87,28.62,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 125D 48MM HIGH OFFSET 40.3MM 150MM 12MM COLLAR",SUP-3L93712,CDM,C1776,HCPCS,0278,RC,,,both,,,30866.40,9259.92,"CIGNA [10200]",Cigna,,12346.56,40,,5873.17,5873.17,5873.17,"1 through 10",3589.76,26236.44,"percent of total billed charges",
"LEAD NERVE STIM RESPIRATORY",SUP-4340,CDM,C1778,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2472.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2472.83,18073.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 130MM 4.2MM T2 AO COUPLING CENTER TIPPED",SUP-18064280S,CDM,S27000186,LOCAL,0270,RC,,,both,,,147.00,44.1,"FIRST HEALTH [10303]","First Health",,117.6,80,,,,,0,17.1,124.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X7MM SABLE 15D STERILE LATEX FREE",SUP-1172.2021S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"FIRST HEALTH [10303]","First Health",,27720,80,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 45MM 5.5MM ARMADA SPINE TITANIUM FIX CROSS",SUP-8450145,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"MULTIPLAN [10600]",Multiplan,,3028.13,85,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL UROLOGICAL AMS 800 OCCLUSIVE CUFF URINARY CONTROL",SUP-72404133,CDM,C1815,HCPCS,0278,RC,,,both,,,51282.00,15384.6,"BLUE CROSS [10001]","Blue Cross HMO",,20102.54,39.2,,,,,0,5964.1,43589.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 18-20MM 0-34MM COREVALVE EVOLUT 23MM HEART",SUP-MCS-P4-23-AOA-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]","Cigna Open Access",,57285,33.5,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR SL5ST CURVE GUIDING CORONARY",SUP-LA7SL50,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JAGWIRE ENDOSCOPIC STRAIGHT 260CM 5CM .035IN BILIARY",SUP-M00556631,CDM,C1769,HCPCS,0272,RC,,,both,,,811.01,243.3,"KAISER [10500]",Kaiser,,543.38,67,,,,,0,94.32,689.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH HERO ARTERIAL GRAFT CMPNT LATEX FREE",SUP-HEROGRAFT,CDM,C1768,HCPCS,0278,RC,,,both,,,8349.00,2504.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5677.32,68,,,,,0,970.99,7096.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FIX 12MM",SUP-288301112,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1626.08,41.1,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM ADVANCED CONVEX SPINE",SUP-17812,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross PPO",,3245.76,39.2,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROMORPHONE 0.2 MG/ML IN 0.9 % NACL IV PCA SUPERORDERABLE",RX-409380,CDM,J1171,HCPCS,0636,RC,70004-0300-16,NDC,both,30,ML,100.39,30.12,"CIGNA [10200]","Cigna Open Access",,22.23,,,,,,,6.99,85.33,"fee schedule",
"CEFAZOLIN SODIUM 10 G/50ML IJ (WET SOLR VIAL)",RX-4151446,CDM,J0690,HCPCS,0636,RC,00143-9261-01,NDC,both,1,UN,77.01,23.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,44.46,,,,,,,14.13,65.46,"fee schedule",
"TIP ASPIR 25KHZ SUPERLONG STRAIGHT SONOPET UNIVERSAL HNDPC",SUP-5450800301,CDM,S27200284,LOCAL,0272,RC,,,both,,,4903.83,1471.15,"CIGNA [10200]","Cigna Open Access",,2790.28,56.9,,,,,0,570.32,4168.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE HINGE REVISION TRIATHLON",SUP-5612-P-211,CDM,C1776,HCPCS,0278,RC,,,both,,,16199.82,4859.95,"PHCS [10601]",PHCS,,11339.87,70,,,,,0,1884.04,13769.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30X10X7MM SABLE 15D STERILE LATEX FREE",SUP-1172.2221S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"AETNA [10100]","Aetna HMO/PPO",,27546.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEPHEA TMVR DELIVERY SYSTEM",SUP-FG-004,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT BLUE 7CM 5FR COTTON-LEUNG BILIARY POLYETHYLENE",SUP-G22278,CDM,C2625,HCPCS,0278,RC,,,both,,,1328.40,398.52,"CIGNA [10200]",Cigna,,903.31,68,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE REGENEATION GRAFT 14MM DISK",SUP-GS-5140,CDM,Q4186,HCPCS,0636,RC,,,both,,,2557.50,767.25,"NOVANET [10819]",Novanet,,1918.13,75,,,,,0,303.06,2173.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION",RX-234450,CDM,A9573,HCPCS,0636,RC,00270-7030-42,NDC,both,10,ML,300.00,90,"CIGNA [10200]",Cigna,,88.64,,,,,,,35.55,255,"fee schedule",
"BODY CONE 29MM RESTORATION +20MM HIP PROXIMAL MODULAR",SUP-6276-1-229,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"UHC [10700]","United Healthcare",,14087.26,63.3,,8601.07,8395.67,8601.07,"1 through 10",2588.23,18916.54,"percent of total billed charges",
"INSERT TIBIAL 4 22MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G422,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4945.81,41.1,,6417.48,6417.48,6417.48,"1 through 10",1399.51,10228.56,"percent of total billed charges",
"LENS IOL 5 D +11 DIOPTER MODIFIED C BICONVEX TECNIS OPTIEDGE",SUP-ZA90030110,CDM,V2632,HCPCS,0276,RC,,,both,,,955.80,286.74,"CIGNA [10200]","Cigna Local Plus",,511.35,53.5,,,,,0,111.16,812.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC",026,MS-DRG,,,,,,,inpatient,,,150443.61,45133.08,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,20636.63,,"Case rate ($19,286.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $17,908.88, add-ons for qualifying new technology services are included. If operating cost exceeds $50,948.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,736.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $17,932.56. The transfer operating threshold is the transfer adjustment factor * $17,908.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,354.00. The transfer capital threshold is the transfer adjustment factor * $1,354.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,7561,90776.2,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM PROFILE 3D",SUP-680R34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Open Access",,4391.85,33.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VITALYST DELIVERY WIRE .018",SUP-H749396770010,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM 11MM NONCOLLAR REDUCE PROXIMAL PROFILE",SUP-192411,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9499.39,40,,,,,0,2761.95,20186.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 2CM 7MM BALLOON DILATATION",SUP-DR13572,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"MULTIPLAN [10600]",Multiplan,,1170.45,85,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 27MM 80CM 6MM 30MM BILIARY STAINLESS STEEL",SUP-PXB35-06-27-080,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"BLUE CROSS [10001]","Blue Cross PPO",,1711.86,39.2,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ALEXIS 360D SMALL WOUND PROTCT ULTIMATE VERSATILITY",SUP-HR001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 61MM FOGARTY 2 STD ATRAUMATIC OCCLUSION SOFT",SUP-A0802,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"PHCS [10601]",PHCS,,109.62,70,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPARIN LOCK FLUSH (PORCINE) 10 UNIT/ML IV SUPERORDERABLE",RX-4083626,CDM,J1642,HCPCS,0636,RC,64253-0222-35,NDC,both,5,ML,18.92,5.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.54,,,,,,,0.12,16.08,"fee schedule",
"CATH NC SPRINTER FASTRAC 138CM 6MM 2.4/2.6-1.9FR 3.75MM",SUP-NCSP37506X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 9MM 31MM SYMMETRIC TRIATHLON X3 KNEE",SUP-5550-G-319,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"AETNA [10100]","Aetna HMO/PPO",,3432.63,79.5,,10981.53,8986.79,12413.38,12,502.16,3670.1,"percent of total billed charges",
"SCR BONE 5MM 26MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.207,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,249.9,28.62,,,,,0,101.55,742.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR INFLATION XPANDER KYPHX VERTEBRA BALLOON DIGITAL GAUGE",SUP-A08A,CDM,S27200284,LOCAL,0272,RC,,,both,,,784.89,235.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,91.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,91.28,667.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Triglycerides",PX-301000420,CDM,84478,CPT,0301,RC,,,both,,,132.86,39.86,"CIGNA [10200]","Cigna Local Plus",,12.63,,,,,,,0.01,112.93,"fee schedule",
"SCR BONE 4MM 26MM VERTEX MAX TITANIUM SPINAL MULTIAXIAL GOLD",SUP-6958826,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"BLUE CROSS [10001]","Blue Cross PPO",,1646.4,39.2,,957.42,570.23,957.42,28,488.46,3570,"percent of total billed charges",
"PROBE SLEEP PNUEMO-OPT UPAT",SUP-AC2101300,CDM,S27200284,LOCAL,0272,RC,,,both,,,355.25,106.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,42.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.32,301.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP UNISTEP PLUS 66MM 75CM 8MM 6FR 100CM",SUP-M001712220,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"CIGNA [10200]","Cigna Open Access",,4809.47,56.9,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET TITANIUM 4MM SPINE CERVICAL ANTERIOR SELF TAP RIGID",SUP-110.050,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"BLUE CROSS [10001]","Blue Cross HMO",,943.39,39.2,,957.42,156.86,7483.26,51,279.89,2045.61,"percent of total billed charges",
"PROTCT NERVE 8CMX4N AXOGUARD HA+ NERVE PROTCT EXTRACELLULAR",SUP-AGHA48,CDM,C1763,HCPCS,0278,RC,,,both,,,33005.70,9901.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3911.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3838.56,28054.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL GOLD 30MM 3.5MM SYNAPSE CURVE TITANIUM PREBENT",SUP-04.614.730,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Reposition G-J Tube",PX-750000250,CDM,44799,CPT,0750,RC,,,both,,,7119.00,2135.7,"KAISER [10500]",Kaiser,,4769.73,67,,,,,0,827.94,7119,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 KNEE LEFT CEMENTED CRUCIATE RETAINING ATTUNE",SUP-150400109,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"FIRST HEALTH [10303]","First Health",,17914.68,80,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"I-125 CALIBRATED SOURCE",SUP-10113-C,CDM,C2638,HCPCS,0278,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross PPO",,317.52,39.2,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 10MM PRESS FIT ECHO PF TITANIUM STD OFFSET HIP",SUP-12-150310,CDM,C1776,HCPCS,0278,RC,,,both,,,8336.51,2500.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2385.91,28.62,,,,,0,969.54,7086.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM 5MM 2.1-2.7FR CORONARY STENT",SUP-RONYX50030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5754.00,1726.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,681.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,669.19,4890.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enteroscopy W Ileum W Ins Stnt",PX-750000231,CDM,44379,CPT,0750,RC,,,both,,,9903.00,2970.9,"BLUE CROSS [10001]","Blue Cross HMO",,4884.67,,"Case rate ($4,884.67). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1151.72,9903,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 15MM 140CM 2.75MM CORONARY STERILE",SUP-453939,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 20MM 4MM BALLOON DILATATION OTW STERILE",SUP-594002022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 11FR 45MM 11CM KINK RESISTANT CANN RADIOPAQUE",SUP-401111M,CDM,C1894,HCPCS,0272,RC,,,both,,,60.90,18.27,"AETNA [10100]","Aetna HMO/PPO",,48.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.08,51.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COOK-Z 5CM 15MM 14FR TRACHEOBRONCHIAL STAINLESS STEEL",SUP-G08552,CDM,C1877,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2841.72,68,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 14MM 3MM CLEARVIEW INTRACORONARY",SUP-31300,CDM,S27800098,LOCAL,0278,RC,,,both,,,645.41,193.62,"CIGNA [10200]","Cigna Open Access",,367.24,56.9,,,,,0,75.06,548.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 35MM MEDIALIZE DOME ATTUNE",SUP-151810035,CDM,C1776,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"KAISER [10500]",Kaiser,,4807.92,67,,,,,0,834.57,6099.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11.5MM 150MM RIGHT VALOR INTRAMEDULLARY SMALL SILVER",SUP-415101115R,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 12FR CATH STERILE LATEX FREE DISPOSABLE",SUP-DIL-600-12,CDM,C1894,HCPCS,0272,RC,,,both,,,66.99,20.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.79,56.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 20MM 7FR 12MM BALLOON DILATATION NONCOMPLIANT",SUP-H74939206120270,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Skin Protectant",PX-E27000156,CDM,E27000156,LOCAL,0270,RC,,,both,,,57.20,17.16,"KAISER [10500]",Kaiser,,38.32,67,,,,,0,6.65,48.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 8MM GORE-TEX THIN WALL PTFE THIN WALLED",SUP-SRRT08030040L,CDM,C1768,HCPCS,0278,RC,,,both,,,6244.50,1873.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4246.26,68,,,,,0,726.24,5307.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 40MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR40,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross PPO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT SLIM CLEARVUE AIRGUARD",SUP-1616000,CDM,C1788,HCPCS,0278,RC,,,both,,,2700.00,810,"NOVANET [10819]",Novanet,,2025,75,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3528,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"NOVANET [10819]",Novanet,,1123.88,75,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 500MM 6MM CREO COCR HEXAGON END",SUP-7120.25,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 170ML GEL ROUND TEXTURED MEMORYGEL SILTEX P2.",SUP-3541707MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 700ML GEL SMOOTH ROUND",SUP-3507004BC,CDM,C1789,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]",Cigna,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESONATE EL VR DF4",SUP-D432,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10530,27,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 36IN CPC CNCT HOSE PORT DUAL LATEX FREE",SUP-60181210100,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.55,19.66,"PHCS [10601]",PHCS,,45.89,70,,,,,0,7.62,55.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5F DECA 5-5-5-20-3-3-3-3-3 MPA 120CM",SUP-901583,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,351.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 80MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"AETNA [10100]","Aetna HMO/PPO",,1139.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +10.5 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.105,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM LCP STAINLESS STEEL LONG FEMORAL",SUP-207.716,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"MULTIPLAN [10600]",Multiplan,,884.03,85,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cr West Nile Virus Igm-Expl832",PX-300000032,CDM,86788,CPT,0302,RC,,,both,,,358.00,107.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.03,,"Fee schedule rate ($18.03). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,304.3,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEPHRSTMY 10FR REPLACEMENT 25CM JINRO PERCUTANEOUS",SUP-M0064202080,CDM,C1729,HCPCS,0272,RC,,,both,,,154.77,46.43,"AETNA [10100]","Aetna HMO/PPO",,123.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18,131.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYNTHETIC TISSUE SCAFFOLD PATCH 6X9 CM",SUP-31049,CDM,C1763,HCPCS,0278,RC,,,both,,,19782.00,5934.6,"CIGNA [10200]","Cigna Open Access",,6626.97,33.5,,,,,0,2300.65,16814.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 6FR 10MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206100410,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROPINIROLE 1 MG TABLET, IMMEDIATE RELEASE",RX-21689,CDM,,,0637,RC,00904-6374-61,NDC,both,1,UN,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENV ABSORBABLE LARGE 3.35X3IN POLYARYLATE MINOCYCLINE",SUP-NMRM6133,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"CIGNA [10200]","Cigna Open Access",,3513.86,56.9,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM ULNAR 75MM NEXEL 5 LEFT",SUP-00840001507,CDM,C1776,HCPCS,0278,RC,,,both,,,31971.49,9591.45,"KAISER [10500]",Kaiser,,21420.9,67,,,,,0,3718.28,27175.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE COBALT GENTAMICIN 40GM HIGH VISCOSITY STERILE",SUP-402283,CDM,C1713,HCPCS,0278,RC,,,both,,,2340.00,702,"AETNA [10100]","Aetna HMO/PPO",,1860.3,79.5,,1521.93,481.35,16760.95,30,272.14,1989,"percent of total billed charges",
"VALVE AORTIC 26MM SAPIEN HEART 3 TRANSCATHETER",SUP-9600TFX,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,76137.75,41.1,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 NARROW KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508005601,CDM,C1776,HCPCS,0278,RC,,,both,,,29326.50,8797.95,"BLUE CROSS [10001]","Blue Cross PPO",,11495.99,39.2,,3949.44,3949.44,3949.44,"1 through 10",3410.67,24927.53,"percent of total billed charges",
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 22MM 140CM 2.75MM",SUP-RSINT27522UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]","Cigna Open Access",,3154.54,56.9,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 5.5X.25IN HOKE STAINLESS STEEL SURGICAL STRAIGHT",SUP-250-282,CDM,S27100035,LOCAL,0271,RC,,,both,,,250.13,75.04,"FIRST HEALTH [10303]","First Health",,200.1,80,,,,,0,29.09,212.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 90MM ANTIROTATE STERILE FEMORAL NECK SYSTEM",SUP-04.168.490S,CDM,C1713,HCPCS,0278,RC,,,both,,,1642.20,492.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1116.7,68,,,,,0,190.99,1395.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC M Environment/Sterility Cultur",PX-300000017,CDM,87999,CPT,0300,RC,,,both,,,58.00,17.4,"PHCS [10601]",PHCS,,40.6,70,,,,,0,0.06,49.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM CLUSTER HOLE PUREFIX HYDROXYAPATITE",SUP-542-11-54F,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"MULTIPLAN [10600]",Multiplan,,5914.06,85,,,,,0,809.18,5914.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COCR 12/14 FEM HEAD 36MM +4",SUP-71303604,CDM,C1776,HCPCS,0278,RC,,,both,,,10236.15,3070.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1190.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1190.46,8700.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SPECIMEN RETRIEVAL 120CM 2.4FR URETERAL STONE 3 PRONG",SUP-M0063701110,CDM,S27200284,LOCAL,0272,RC,,,both,,,1390.04,417.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.66,1181.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 3FT THERMISTOR",SUP-M0046510,CDM,S27200284,LOCAL,0272,RC,,,both,,,2537.63,761.29,"MULTIPLAN [10600]",Multiplan,,2156.99,85,,,,,0,295.13,2156.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 15.5CM 78CM 23MM 18.5FR 28MM FLARE ESOPHAGEAL",SUP-M00516750,CDM,C1874,HCPCS,0278,RC,,,both,,,10076.00,3022.8,"NOVANET [10819]",Novanet,,7557,75,,,,,0,1171.84,8564.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED + VE/",SUP-98000200512,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3434.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3370.37,24633,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 98MM 34MM 8MM PERFORM 2+ LONG LENGTH SHOULDER",SUP-DWX2PL,CDM,C1776,HCPCS,0278,RC,,,both,,,30421.44,9126.43,"BLUE CROSS [10001]","Blue Cross PPO",,11925.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",3538.01,25858.22,"percent of total billed charges",
"COIL EMBOLIZATION 12CM 3.5MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES3512CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"MULTIPLAN [10600]",Multiplan,,5571.75,85,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Corset Lumbar Sacral",PX-E27400003,CDM,E27400003,LOCAL,0274,RC,,,both,,,1235.30,370.59,"NOVANET [10819]",Novanet,,926.48,75,,,,,0,143.67,1050.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 65CM 4FR .040IN .038IN KA2 CURVE ANGIOGRAPHIC",SUP-46538KA2,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,44.7,41.1,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TRILOGY TIVANIUM ALLOY HIP CORTICAL",SUP-00625006540,CDM,C1713,HCPCS,0278,RC,,,both,,,691.60,207.48,"MULTIPLAN [10600]",Multiplan,,587.86,85,,,,,0,80.43,587.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.7MM 2-0 3/8 CIRCLE MINI FULL THREAD TAPER",SUP-AR-1319FT,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,261.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",261.02,1907.72,"percent of total billed charges",
"SET STENT 20CM 7FR POLARIS ULTRA NAUTILUS ZIPWIRE .035IN 2",SUP-M006192140190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,165.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 10.5FR .138IN 25CM ROBUST VALVE SPLITTABLE",SUP-PLSX-2510.5,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 15.5CM NATRELLE INSPIRA P5CM MODERATE PROFILE",SUP-MSZ-M640,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"KAISER [10500]",Kaiser,,105.98,67,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLACK 24-26FR USA ELITE SYSTEM USA",SUP-RE,CDM,S27200284,LOCAL,0272,RC,,,both,,,780.88,234.26,"PHCS [10601]",PHCS,,546.62,70,,,,,0,90.82,663.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 30ML .1-2MM 80% CORTICAL 20% CANCELLOUS",SUP-400063,CDM,C1713,HCPCS,0278,RC,,,both,,,2842.88,852.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,336.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",330.63,2416.45,"percent of total billed charges",
"COIL EMBOLIZATION 12CM 3.5MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES3512CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"KAISER [10500]",Kaiser,,4391.85,67,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 1 30IN BRAID TIE 6 STRAND PRECUT BLACK",SUP-A307H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rlcj Pg Wcs Lv Battery Only",PX-481000395,CDM,0862T,CPT,0481,RC,,,both,,,2793.00,837.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2793,,"Case rate ($6,891). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,324.83,2793,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rlcj Pg Wcs Lv Battery Only",PX-481000395,CDM,0862T,CPT,0481,RC,,,both,,,2793.00,837.9,"BLUE CROSS [10001]","Blue Cross PPO",,2793,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,324.83,2793,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lh (Lutenizing Hormone)",PX-301000215,CDM,83002,CPT,0301,RC,,,both,,,235.30,70.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,19.82,,"Fee schedule rate ($19.82). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",27.89,27.89,27.89,"1 through 10",0.24,200.01,"fee schedule",
"SLING ORTHOPEDIC MEDIUM 11-13IN ARM QUICK RELEASE BUCKLE",SUP-11-0449-3,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEAL CANN 5MM DA VINCI ENDOWRIST DISPOSABLE",SUP-400161,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.90,44.37,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 150MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-593515022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 1.7MM ORTHOPEDIC CANNULATED",SUP-DSDS0017,CDM,S27200284,LOCAL,0272,RC,,,both,,,1271.70,381.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SINGLE USE INSTRUMENTS - TIBIAL KIT (CR) - SIZE 8",SUP-5555-2328,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DTERG INSTR 5GL NEUTRAL DISINFECTOR VALSURE LATEX FREE",SUP-1C5405,CDM,S27200284,LOCAL,0272,RC,,,both,,,358.01,107.4,"CIGNA [10200]",Cigna,,243.45,68,,,,,0,41.64,304.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 6MM 2MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2006X,CDM,C1725,HCPCS,0272,RC,,,both,,,607.50,182.25,"NOVANET [10819]",Novanet,,455.63,75,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHYLPREDNISOLONE 4 MG TABLET",RX-4993,CDM,J7509,HCPCS,0636,RC,68084-0149-11,NDC,both,1,UN,10.83,3.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7.36,68,,,,,0,0.13,9.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC MEDIUM 11-13IN ARM QUICK RELEASE BUCKLE",SUP-11-0449-3,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intro Ndl/Cath Aortic Tranlum",PX-361000080,CDM,36160,CPT,0361,RC,,,both,,,989.27,296.78,"AETNA [10100]","Aetna HMO/PPO",,786.47,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,115.05,989.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM VIPER 2 LORDOTIC",SUP-186788055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"STRUT EXTERNAL FIXATION MAXFRAME MEDIUM QUICK ADJUST",SUP-03.312.812,CDM,C1713,HCPCS,0278,RC,,,both,,,7801.69,2340.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3580.98,45.9,,,,,0,907.34,6631.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X15MM 8D CONVEX LORDOTIC WEDGE",SUP-010615,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9015.3,28.62,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 9MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P209,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Open Access",,4754.51,56.9,,5302.19,4377.88,6578.61,27,971.79,7102.52,"percent of total billed charges",
"STENT WALLFLEX 15.5CM 78CM 23MM 18.5FR 28MM FLARE ESOPHAGEAL",SUP-M00516750,CDM,C1874,HCPCS,0278,RC,,,both,,,10076.00,3022.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6851.68,68,,,,,0,1171.84,8564.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 30MM 2.75MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012406-30,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH 160MM 2.5MM LONG HANDLE AORTIC",SUP-APU525,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"PHCS [10601]",PHCS,,202.98,70,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Drawtex",PX-E27200249,CDM,E27200249,LOCAL,0272,RC,,,both,,,79.18,23.75,"CIGNA [10200]","Cigna Open Access",,45.05,56.9,,,,,0,9.21,67.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 9-0 BV130-3 5IN MONOFILAMENT BLACK NONABSORBABLE",SUP-2819G,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.45,53.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,120.67,68,,,,,0,20.64,150.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM HYPOCHLORITE 0.125 % SOLUTION",RX-76720,CDM,,,0250,RC,00436-0672-16,NDC,both,473,ML,86.28,25.88,"PHCS [10601]",PHCS,,60.4,70,,,,,0,10.03,73.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 3.5MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES3512CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"FIRST HEALTH [10303]","First Health",,5244,80,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 6.5MM 30MM CANCELLOUS STERILE",SUP-117230000,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"FIRST HEALTH [10303]","First Health",,916.92,80,,,,,0,133.3,974.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR CEMENTLESS STD Z1 TITANIUM ALLOY 6",SUP-611201060,CDM,C1776,HCPCS,0278,RC,,,both,,,28967.40,8690.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8290.47,28.62,,,,,0,3368.91,24622.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Drawtex",PX-E27200249,CDM,E27200249,LOCAL,0272,RC,,,both,,,79.18,23.75,"AETNA [10100]","Aetna HMO/PPO",,62.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.21,67.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 100MM 120CM 10MM BILIARY VENA CAVA OTW DELIVERY",SUP-G57438,CDM,C1876,HCPCS,0278,RC,,,both,,,13109.93,3932.98,"BLUE CROSS [10001]","Blue Cross HMO",,5139.09,39.2,,,,,0,1524.68,11143.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPICILLIN-SULBACTAM 1.5 G/4ML IJ (WET SOLR VIAL)",RX-41532470,CDM,J0295,HCPCS,0636,RC,00641-6116-01,NDC,both,1,UN,38.05,11.41,"FIRST HEALTH [10303]","First Health",,30.44,80,,,,,0,1.56,32.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27858,CDM,,,0637,RC,68084-0709-11,NDC,both,1,UN,21.11,6.33,"CIGNA [10200]","Cigna Local Plus",,11.29,53.5,,,,,0,2.46,17.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET IRRIGATION CLEARVISION II TUBE STERILE DISPOSABLE",SUP-031229-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.98,70.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.33,199.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tee Img Acqusit I&R",PX-483000011,CDM,93314,CPT,0483,RC,,,both,,,243.00,72.9,"CIGNA [10200]","Cigna Open Access",,138.27,56.9,,,,,0,28.26,243,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP MEDIUM LARGE 8MM INTERNAL LAPRO-CLIP TITANIUM LIGATE",SUP-8886848882,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.42,67.03,"CIGNA [10200]","Cigna Open Access",,127.13,56.9,,,,,0,25.98,189.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 STRAIGHT 8IN BRUNS OVAL CUP SURGICAL STAINLESS STEEL",SUP-240076,CDM,S27200284,LOCAL,0272,RC,,,both,,,425.60,127.68,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PRESSURE INJECTABLE ARROWGARD BLUE ADVANCETHREE-LUMEN PICC",SUP-DLX-45563-VPSB,CDM,C1751,HCPCS,0272,RC,,,both,,,2790.00,837,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SODIUM HYPOCHLORITE 0.125 % SOLUTION",RX-76720,CDM,,,0250,RC,00436-0672-16,NDC,both,473,ML,86.28,25.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CELSIUS RMT REDEL 125CM 4MM 7FR 2-5-2MM SPACE ABLATION",SUP-CR7TCS4RTU,CDM,C1733,HCPCS,0272,RC,,,both,,,8142.00,2442.6,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 2.5MM CORONARY STENT",SUP-H7493941820250,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,9776.84,9776.84,9776.84,"1 through 10",348.9,2550,"percent of total billed charges",
"HC Bronch W Brushing",PX-750000005,CDM,31623,CPT,0750,RC,,,both,,,3922.62,1176.79,"CIGNA [10200]","Cigna Local Plus",,2587,,"Case rate ($2,587). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,456.2,3922.62,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL EPIDURAL 22GA 3.5IN TUOHY PLASTIC HUB",SUP-183107,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.64,19.99,"MULTIPLAN [10600]",Multiplan,,56.64,85,,,,,0,7.75,56.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 12MM 144CM 4MM CORONARY STENT",SUP-H7493941812400,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC",740,MS-DRG,,,,,,,inpatient,,,101647.07,30494.12,"CIGNA [10200]","Cigna Open Access",,19858.55,,"Fee schedule rate ($19,858.55). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,52833.08,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE RELINE L45 MM OD5.5 MM SPINE POLYAXIAL 2 FULL CAN",SUP-16215545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LD 6.1MM TRM CNCT KT",SUP-6810,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,99.83,45.9,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION INTERMEDIATE KIT 2 LUMEN",SUP-1829500,CDM,C1788,HCPCS,0278,RC,,,both,,,2625.00,787.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1785,68,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT CYL 30X4IN 1 BLADDER 2 PORT QUICK COLOR CUFF 40IN",SUP-5921-030-235,CDM,S27200284,LOCAL,0272,RC,,,both,,,201.14,60.34,"UHC [10700]","United Healthcare",,127.32,63.3,,,,,0,23.39,170.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X17MM 8D CONVEX LORDOTIC WEDGE",SUP-010617,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"NOVANET [10819]",Novanet,,23625,75,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.175 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.175,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM REVOLVE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-185.467,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6491.86,68,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM TITANIUM SPINAL SET NON BRAKE OFF NONSTERILE",SUP-5440130,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"CIGNA [10200]","Cigna Open Access",,1369.36,56.9,,1144.80,304.56,2275.09,66,279.89,2045.61,"percent of total billed charges",
"PACK PERFUSION PUMP TUBING",SUP-020471101,CDM,S27200284,LOCAL,0272,RC,,,both,,,227.59,68.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.47,193.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 36MM FLEX +9MM POLYETHYLENE",SUP-DWF362B,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3710.51,41.1,,6417.48,6417.48,6417.48,"1 through 10",1049.96,7673.8,"percent of total billed charges",
"DEVICE COLPASSIST PESSARY VAGINAL 2 END POSITION FLAT SUT",SUP-M0068318210,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 5MM ELITE STRAIGHT FLUTE BARREL NEURO STERILE",SUP-5820018050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SECONDARY ANCHOR DELIVERY CATHETER, SHAPE 03",SUP-4740-03,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CARTO XP LASSO 115CM 7FR 15MM 6MM SPACING D CURVE",SUP-DLN2215CT,CDM,C1732,HCPCS,0272,RC,,,both,,,12889.20,3866.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OBTR LAPAROSCOPIC 8MM DA VINCI XI LONG BLUNT",SUP-470009,CDM,S27200284,LOCAL,0272,RC,,,both,,,4278.00,1283.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH AXS VECTA 46 L 125CM LUMEN INNTER DIAMETER .046IN",SUP-INC-11814-125,CDM,S27200284,LOCAL,0272,RC,,,both,,,9627.29,2888.19,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 6FR 2.5CM 10CM GWIRE DIL RADIOPAQUE KINK",SUP-RSB612,CDM,C1894,HCPCS,0272,RC,,,both,,,217.50,65.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Kit Balloon Vag Pack Sys",PX-E27200309,CDM,E27200309,LOCAL,0272,RC,,,both,,,3016.20,904.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BEARING 75MMX14MM VANGUARD E1 KNEE ANTERIOR STABILIZE TIBIAL",SUP-EP189084,CDM,C1776,HCPCS,0278,RC,,,both,,,13372.20,4011.66,"MULTIPLAN [10600]",Multiplan,,11366.37,85,,,,,0,1555.19,11366.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 9.5MM THK.6MM 25.7MM MICRO SMALL BONE SAGITTAL",SUP-KM-3101,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"CIGNA [10200]","Cigna Open Access",,35.15,56.9,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER VASCULAR 8FR LEFTBU3.75 MACH 1",SUP-H749343587150,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.44,109.93,"PHCS [10601]",PHCS,,256.51,70,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 16MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G816,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2862,28.62,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT EXTERNAL FIXATION HOFFMANN STRUT CONNECTION LIMB",SUP-4933-1-702,CDM,C1713,HCPCS,0278,RC,,,both,,,234.90,70.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,107.82,45.9,,,,,0,27.32,199.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SCREW SPINAL MINI UNIVERSAL ENDCAP FOR VBR SYSTEM X-CORE",SUP-5960011,CDM,S27800098,LOCAL,0278,RC,,,both,,,1629.00,488.7,"BLUE CROSS [10001]","Blue Cross PPO",,638.57,39.2,,,,,0,189.45,1384.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Urogram Inf/Bolus W Nephrotom",PX-320000117,CDM,74415,CPT,0320,RC,,,both,,,1220.00,366,"KAISER [10500]",Kaiser,,817.4,67,,,,,0,141.89,1037,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHISEL SURGICAL 6.25IN 4MM V BALLENGER",SUP-63-0089,CDM,S27200284,LOCAL,0272,RC,,,both,,,415.43,124.63,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE .035IN 10CM 2.5CM 8FR INTRO STAINLESS STEEL",SUP-RSS801,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC",578,MS-DRG,,,,,,,inpatient,,,197441.45,59232.43,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 46MM TITANIUM LOCK SELF TAP AXSOS 3",SUP-661046,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"CIGNA [10200]",Cigna,,887.89,68,,1831.33,1831.33,1831.33,16,151.86,1109.86,"percent of total billed charges",
"TRAY TIBIAL LCS COMPLETE MBT SIGMA 6 KNEE POROCOAT",SUP-129434160,CDM,C1776,HCPCS,0278,RC,,,both,,,17561.25,5268.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5026.03,28.62,,,,,0,2042.37,14927.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 99MM TYPE 1 PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51109070,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11275.88,41.1,,6417.48,6417.48,6417.48,"1 through 10",3190.72,23319.95,"percent of total billed charges",
"CATH LIVEWIRE 95CM 2MM 7FR 2-8-2MM SPACING ELECTROPHYSIOLOGY",SUP-401932,CDM,C1731,HCPCS,0272,RC,,,both,,,6796.50,2038.95,"PHCS [10601]",PHCS,,4757.55,70,,,,,0,790.43,5777.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 85X25X1.19MM WIDE THICK STAINLESS STEEL SAGITTAL",SUP-2108151000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"NOVANET [10819]",Novanet,,143.69,75,,,,,0,22.28,162.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TI VECTRA(TM) PLATE 2 LEVEL/38MM",SUP-04.613.138,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,3978.14,359.25,3978.14,24,521.61,3812.25,"percent of total billed charges",
"STENT VIABAHN 2.5CM 120MM 8MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR080202A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"CIGNA [10200]",Cigna,,6762,40,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 14MM RETRACTA DETACHABLE .035IN",SUP-G34192,CDM,S27800098,LOCAL,0278,RC,,,both,,,4308.98,1292.69,"FIRST HEALTH [10303]","First Health",,3447.18,80,,,,,0,501.13,3662.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC",740,MS-DRG,,,,,,,inpatient,,,101647.07,30494.12,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,11561.81,,"Case rate ($11,225.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,423.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,462.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,170.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $10,437.01. The transfer operating threshold is the transfer adjustment factor * $10,423.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.05. The transfer capital threshold is the transfer adjustment factor * $788.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,52833.08,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT Y-KNOT PRO RC 2 RIBBON",SUP-YPRC02R,CDM,C1713,HCPCS,0278,RC,,,both,,,3644.70,1093.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,431.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",423.88,3098,"percent of total billed charges",
"MICROCATHETER INFUSION 150CM 2.1-2.7FR .0175 .0157IN",SUP-221-15-1000U,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"MULTIPLAN [10600]",Multiplan,,2868.75,85,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC",428,MS-DRG,,,,,,,inpatient,,,289637.14,86891.14,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 100MM 2MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.19,CDM,S27000186,LOCAL,0270,RC,,,both,,,329.00,98.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT POSITIONING FOAM LEG ELEVATION",SUP-M60-331,CDM,S27000186,LOCAL,0270,RC,,,both,,,124.95,37.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 90X25X1.37MM SYSTEM 6 THK.054IN BEVEL SAGITTAL",SUP-6125-137-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH CHECK-FLO FLEXOR .018/.035IN ANL0 CURVE 90CM 4FR .059",SUP-G48188,CDM,C1894,HCPCS,0272,RC,,,both,,,842.40,252.72,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RESOLVE 25CM 8.5FR PIGTAIL CURVE DRNG POLYURETHANE",SUP-RLC-8-038,CDM,C1729,HCPCS,0272,RC,,,both,,,531.36,159.41,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Newborn Metabolic Screening",PX-300000016,CDM,S3620,HCPCS,0300,RC,,,both,,,223.60,67.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TREK 145CM 8MM 2.25MM BALLOON DILATATION PEBAX",SUP-1012271-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ANGIOSCULPT XL 155CM 40MM 3MM RECTANGLE HELIX BALLOON",SUP-2155-3040,CDM,C1725,HCPCS,0272,RC,,,both,,,6865.50,2059.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2821.72,41.1,,,,,0,798.46,5835.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3-4MM CANNULATED",SUP-210-40-001,CDM,S27000186,LOCAL,0270,RC,,,both,,,1650.00,495,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,195.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 129MM STAINLESS STEEL 2.7/3.5MM SCR 7 HOLE LCP",SUP-02.112.114S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG NASAL WHITE 4CM NASOPORE OTOPORE STD SINUS FOAM FIRM",SUP-5400020004,CDM,S27200284,LOCAL,0272,RC,,,both,,,1124.90,337.47,"NOVANET [10819]",Novanet,,843.68,75,,,,,0,130.83,956.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 10MM THIN WALL GORE-TEX REMOVABLE RING",SUP-RRT10070080L,CDM,C1768,HCPCS,0278,RC,,,both,,,10108.50,3032.55,"KAISER [10500]",Kaiser,,6772.7,67,,,,,0,1175.62,8592.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 51MM 2MM SHORT CARBIDE ROUND STERILE",SUP-04-C0105,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.21,18.66,"KAISER [10500]",Kaiser,,41.68,67,,,,,0,7.24,52.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 26FR CUT ACMI CLASSIC",SUP-M0068802541,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"CIGNA [10200]","Cigna Open Access",,272.11,56.9,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pregnancy Test Urine",PX-307000008,CDM,81025,CPT,0307,RC,,,both,,,383.80,115.14,"CIGNA [10200]",Cigna,,18.94,,,,,,,4.29,326.23,"fee schedule",
"HEAD FEMORAL +1.5MM 12/14 TAPER 36MM HIP M SPECIFICATION",SUP-1365-51-000,CDM,C1776,HCPCS,0278,RC,,,both,,,6720.60,2016.18,"PHCS [10601]",PHCS,,4704.42,70,,,,,0,781.61,5712.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061755840,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,106.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 6MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0615CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"PHCS [10601]",PHCS,,4588.5,70,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 55MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.855,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,934.6,68,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT 8X16CM ALLOGRAFT DERMIS CORTIVA",SUP-DH0816,CDM,S27800098,LOCAL,0278,RC,,,both,,,20932.88,6279.86,"BLUE CROSS [10001]","Blue Cross PPO",,8205.69,39.2,,,,,0,2434.49,17792.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM CD HORIZON SPINAL FENESTRATE MULTIAXIAL",SUP-55840025540T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"DFBR CRD .99CM 5.37X8.08CM",SUP-G138,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23722.92,41.1,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG LAPAROSCOPIC TROCAR R-MED DISPOSABLE 12MM",SUP-10154,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.20,15.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,35.5,68,,,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT LARGE 11 CC PUTTY BIOACTIVE",SUP-78000110,CDM,C1713,HCPCS,0278,RC,,,both,,,13662.00,4098.6,"KAISER [10500]",Kaiser,,9153.54,67,,,,,0,1588.89,11612.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx/Exc Cervix Local",PX-361000528,CDM,57500,CPT,0361,RC,,,both,,,3042.37,912.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,360.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,353.83,3042.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 300MM 3.5MM BALLOON DILATATION",SUP-48003530S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"PHCS [10601]",PHCS,,963.9,70,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 6.5IN MEYERDING SELF RETAINING SURGICAL 57X25MM",SUP-MF065R,CDM,S27200284,LOCAL,0272,RC,,,both,,,2005.28,601.58,"CIGNA [10200]","Cigna Open Access",,1141,56.9,,,,,0,233.21,1704.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U165,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"NOVANET [10819]",Novanet,,558.75,75,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP MULTIHOLE COLOR CODED OSSEOTI G7 F",SUP-110010265,CDM,C1776,HCPCS,0278,RC,,,both,,,20755.98,6226.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5940.36,28.62,,,,,0,2413.92,17642.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER FLEXIVA 365UM FLEXSHIELD HIGH POWER POLISH",SUP-M0068403921,CDM,S27200284,LOCAL,0272,RC,,,both,,,2258.15,677.44,"NOVANET [10819]",Novanet,,1693.61,75,,,,,0,262.62,1919.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 80MM 5MM .035IN BALLOON",SUP-AB35W05080135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,278.31,41.1,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 45MM EXPEDIUM TITANIUM SPINE CORTICAL FIX 5.5MM",SUP-186731645,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 SURGALLOY 3-0 P-14 18IN CLSR ABSORBABLE",SUP-VLOCM0124,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.73,70.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.3,199.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 0D 4.8MM MULTIFIRE ENDO HERNIA TITANIUM STERILE",SUP-174007,CDM,S27200284,LOCAL,0272,RC,,,both,,,388.11,116.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.14,329.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,,,0637,RC,60687-0390-11,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,3.35,53.5,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"BLUE CROSS [10001]","Blue Cross PPO",,3651.48,39.2,,,,,0,1083.33,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 100CM INTERSTIM PERCUTANEOUS ELECTRD",SUP-3560022,CDM,C1883,HCPCS,0278,RC,,,both,,,1747.50,524.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,207.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,203.23,1485.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 80MM 80CM 10MM .035IN 3MM VASCULAR VENOUS",SUP-VENUM10080,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"AETNA [10100]","Aetna HMO/PPO",,17529.75,79.5,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE VARIABLE",SUP-02.107.202,CDM,C1713,HCPCS,0278,RC,,,both,,,5840.44,1752.13,"CIGNA [10200]","Cigna Open Access",,3323.21,56.9,,1144.80,304.56,2275.09,66,679.24,4964.37,"percent of total billed charges",
"CATH CONCIERGE 5FR SBS3.75 MOD CURVE GUIDING BACKUP SPRT",SUP-CGC5100SBS375-M,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,183.1,41.1,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR 45CM 12FR ACCESS URETERAL CONTINUOUS WORK",SUP-G46168,CDM,C1894,HCPCS,0272,RC,,,both,,,1244.97,373.49,"FIRST HEALTH [10303]","First Health",,995.98,80,,,,,0,144.79,1058.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VICI VENOUS STENT 60MM 100MM 16MM ENDOPROSTHESIS",SUP-H74916060100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"PHCS [10601]",PHCS,,9177,70,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 27.5MM TITANIUM INTEGRATE LOCK MIDLINE ALIGNMENT NOTCH",SUP-9790027,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV",RX-110258,CDM,J0283,HCPCS,0636,RC,43066-0360-20,NDC,both,200,ML,278.66,83.6,"KAISER [10500]",Kaiser,,186.7,67,,,,,0,33.02,236.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION",RX-8878,CDM,,,0250,RC,00517-6101-25,NDC,both,10,ML,278.14,83.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,32.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.35,236.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL RUSSIAN 10IN TISSUE",SUP-07-1525,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.50,36.75,"MULTIPLAN [10600]",Multiplan,,104.13,85,,,,,0,14.25,104.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 23MM 18.6MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-23MECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 83MM REGENEREX KNEE PRIMARY CRUCIATE RETAIN",SUP-141276,CDM,C1776,HCPCS,0278,RC,,,both,,,11964.60,3589.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1391.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1391.48,10169.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP 25.4IN 6MM DA VINCI SP M-L 14.5MM",SUP-430250,CDM,S27000186,LOCAL,0270,RC,,,both,,,365.40,109.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOTRACHEAL 10MM 4MM VIVASIGHT 2 LUMEN NONSTERILE LATEX",SUP-412351000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1326,68,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID",RX-42219,CDM,,,0250,RC,70677-1107-01,NDC,both,120,ML,25.66,7.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM SHILEY BRONCHO-CATH STD CPAP ADJUSTABLE VALVE 2",SUP-85006,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.23,58.57,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANNULA PERFUSION DLP STAINLESS STEEL L5.5 IN OD14 GA AORTIC",SUP-20014,CDM,S27200284,LOCAL,0272,RC,,,both,,,196.65,58.99,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE NC PLUS 10MM 2.5MM BALLOON DILATATION STERILE",SUP-225-103-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH VERSACROSS 45D 1 CURVE J TIP 63CM 180CM 8.5FR GUIDING",SUP-VXSK0002,CDM,C1893,HCPCS,0272,RC,,,both,,,6175.50,1852.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT IRRIGATION ENDOGATOR NONSTERILE LATEX FREE REUSABLE",SUP-4005470,CDM,S27000186,LOCAL,0270,RC,,,both,,,278.40,83.52,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER MAPPING 7FR WEBSTER CS 2-8-2MM SPACE F-J CURVE STER",SUP-BD710FJ282RTSR,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUFF TRNQT CYL 30X4IN 1 BLADDER 2 PORT QUICK COLOR CUFF 40IN",SUP-5921-030-235,CDM,S27200284,LOCAL,0272,RC,,,both,,,201.14,60.34,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUFF TRNQT CYL 34X4IN 2 PORT TUBING LIMB PROTECTION SLEEVE",SUP-5921-034-235,CDM,S27200284,LOCAL,0272,RC,,,both,,,215.15,64.54,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC High Mw Kininogen",PX-305000029,CDM,85293,CPT,0305,RC,,,both,,,857.00,257.1,"FIRST HEALTH [10303]","First Health",,685.6,80,,,,,0,0.01,728.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESTRICT CEMENT 24MM FEMORAL HIP",SUP-EBO0101,CDM,S27800098,LOCAL,0278,RC,,,both,,,1150.20,345.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,527.94,45.9,,,,,0,133.77,977.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 10 KNEE RIGHT CRUCIATE RETAIN CEMENT ATTUNE",SUP-150400209,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6408.98,28.62,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 40MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020040M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"MULTIPLAN [10600]",Multiplan,,1218.65,85,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 8MM 29MM SYMMETRIC TRIATHLON X3 TOTAL KNEE",SUP-5550-G-298,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"KAISER [10500]",Kaiser,,2892.91,67,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 15MM 2.25MM CORONARY STENT",SUP-1007822-15,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM CREO SPINE MULTIAXIAL",SUP-5119.1545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 40MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020040M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"KAISER [10500]",Kaiser,,960.58,67,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM DYNASTY LINEAGE BIOFOAM ACETABULAR",SUP-18080303,CDM,C1713,HCPCS,0278,RC,,,both,,,1101.60,330.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,130.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,128.12,936.36,"percent of total billed charges",
"NAIL 12MM 340MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.255S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"NOVANET [10819]",Novanet,,9313.76,75,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +14.5 DIOPTER MODIFIED C BICONVEX 13.5MM 6.5MM",SUP-MC50BD.145,CDM,V2632,HCPCS,0276,RC,,,both,,,810.00,243,"CIGNA [10200]","Cigna Open Access",,460.89,56.9,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 12MM 1.14MM 6MM GOODE T EAR SILICONE FLANGE",SUP-24751,CDM,S27800098,LOCAL,0278,RC,,,both,,,229.87,68.96,"KAISER [10500]",Kaiser,,154.01,67,,,,,0,26.73,195.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT FINGER SWANSON 3 METACARPOPHALANGEAL SILICONE GROMMET",SUP-G4700003,CDM,C1776,HCPCS,0278,RC,,,both,,,5733.90,1720.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2631.86,45.9,,,,,0,666.85,4873.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 22MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-822,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7760.57,68,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRESSURE INFUSER 1000CC",SUP-FCZIT1000,CDM,S27000186,LOCAL,0270,RC,,,both,,,69.51,20.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,28.57,41.1,,,,,0,8.08,59.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Tap Block Bilat Abdominal",PX-361000534,CDM,64488,CPT,0361,RC,,,both,,,7686.64,2305.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1249,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,893.96,7686.64,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Abd/Retroperitnl Mass Perc",PX-361000201,CDM,49180,CPT,0361,RC,,,both,,,3810.90,1143.27,"PHCS [10601]",PHCS,,3810.9,,"Case rate ($4,710). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,443.21,3810.9,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Transplant Kidney Dplr",PX-402000012,CDM,76776,CPT,0402,RC,,,both,,,219.00,65.7,"UHC [10700]","United Healthcare",,219,,"Per diem ($426).",,,,0,25.47,219,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPIDCROSS 170CM 40MM 2.5MM .014IN BALLOON DILATATION",SUP-A14BX025040170,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"AETNA [10100]","Aetna HMO/PPO",,1101.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ph Impedance Catheter",PX-E27200295,CDM,E27200295,LOCAL,0272,RC,,,both,,,715.00,214.5,"AETNA [10100]","Aetna HMO/PPO",,568.43,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,83.15,607.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTUNE KNEE SYSTEM REVISION CRS TOTATIN PLATFORM INSERT  SIZ",SUP-151710522,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5917.44,40,,,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEPHRSTMY 6.3FR PERCUTANEOUS ACCESS PIGTAIL CATH 20CM",SUP-M0064202000,CDM,C1729,HCPCS,0272,RC,,,both,,,123.71,37.11,"KAISER [10500]",Kaiser,,82.89,67,,,,,0,14.39,105.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 8FR L24CM FIRM TRI LAYER DESIGN RAW COLORANT",SUP-M0061902420,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 56MM 40MM ALTRX HIP",SUP-122140056,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3950.55,28.62,,,,,0,1605.34,11732.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UROLOGICAL STRAIGHT 150CM 3CM .035IN PTFE STIFF BODY",SUP-M0066201100,CDM,C1769,HCPCS,0272,RC,,,both,,,100.40,30.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,41.26,41.1,,,,,0,11.68,85.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ABLATION 3FR THERMOCOOL SF J CURVE DEFLECTABLE",SUP-D131804,CDM,C1732,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 8CM ECHOTIP INSIGHT 25GA 5.2FR",SUP-G46560,CDM,S27200284,LOCAL,0272,RC,,,both,,,13558.50,4067.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6223.35,45.9,,,,,0,1576.85,11524.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 9IN SLIGHT CURVE 5MM LEKSELL 2 ACTION SURGICAL",SUP-31-5105,CDM,S27200284,LOCAL,0272,RC,,,both,,,1192.40,357.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,141.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,138.68,1013.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 018 100CM 300MM 6MM BALLOON DILATATION STERILE",SUP-LX1810063005F,CDM,C2623,HCPCS,0272,RC,,,both,,,18270.00,5481,"NOVANET [10819]",Novanet,,13702.5,75,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ON-Q PAINBUSTER T-PEEL 8IN DRUG DELIVERY NDL INTRO",SUP-ACC03,CDM,S27200305,LOCAL,0272,RC,,,both,,,103.64,31.09,"CIGNA [10200]",Cigna,,70.48,68,,,,,0,12.05,88.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA EXTRA FULL PROFILE SOFT TOUCH",SUP-SSX-650,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2162.38,28.62,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEM POROUS LT SZ13.5",SUP-427-01-135,CDM,C1776,HCPCS,0278,RC,,,both,,,32703.43,9811.03,"MULTIPLAN [10600]",Multiplan,,27797.92,85,,,,,0,3803.41,27797.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 7CM 10MM GORE EXCLUDER ILIAC EXT AAA",SUP-PLL161007,CDM,C1874,HCPCS,0278,RC,,,both,,,19725.30,5917.59,"UHC [10700]","United Healthcare",,12486.11,63.3,,,,,0,2294.05,16766.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 39MM 80CM 8MM 11MM 7FR .035IN",SUP-BXA083901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]","Cigna Open Access",,6534.11,33.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 35X11MM CONTINENTAL 8D LORDOTIC 24MM MEDIUM",SUP-364.511,CDM,S27800098,LOCAL,0278,RC,,,both,,,23184.00,6955.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2696.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2696.3,19706.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH PEEL-AWAY STERILE DISPOSABLE ACCEPTS .038IN",SUP-G06492,CDM,C1894,HCPCS,0272,RC,,,both,,,382.71,114.81,"FIRST HEALTH [10303]","First Health",,306.17,80,,,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175260180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"MULTIPLAN [10600]",Multiplan,,1241.09,85,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 36MM TI",SUP-MTC-37360-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"MULTIPLAN [10600]",Multiplan,,1060.29,85,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 3MM TAPER DISSECTING",SUP-MR8-14TA30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.19,388.56,"PHCS [10601]",PHCS,,906.63,70,,,,,0,150.63,1100.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 65CM PLEXA PROMRI S DF-1",SUP-413997,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1765.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 59CM ENDOCARDIAL DF4-LLHO CNCT 1 COIL EXTEND",SUP-272,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4098.6,27,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 5MMX79MM 7FR 135CMCATH HEPARIN",SUP-BXB057902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"MULTIPLAN [10600]",Multiplan,,18196.29,85,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 130CM 6CM 5MM BALLOON DILATATION",SUP-U813056,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET MULTIAXIAL 2 PK STERILE 559200007",SUP-559200007,CDM,C1713,HCPCS,0278,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,481.48,3519,"percent of total billed charges",
"CMPNT PATELLAR 29MM VIVACIT-E ALL POLY KNEE LATEX FREE",SUP-42540200029,CDM,C1776,HCPCS,0278,RC,,,both,,,5322.66,1596.8,"NOVANET [10819]",Novanet,,3992,75,,,,,0,619.03,4524.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 5FR 70CM RADPICC 1 LUMEN GWIRE MICROINTRODUCER",SUP-3165155,CDM,C1751,HCPCS,0272,RC,,,both,,,399.33,119.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,271.54,68,,,,,0,46.44,339.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Therapypro//Dx Inj Ia",PX-260000011,CDM,96373,CPT,0260,RC,,,both,,,211.25,63.37,"CIGNA [10200]",Cigna,,211.25,,"Per diem ($571).",,,,0,24.57,211.25,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE 100 MEQ SODIUM 3 MEQ CALCIUM 1 MEQ POTASSIUM 1",SUP-08-1301-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.29,15.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.2,45.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X8MM CASCADIA 0D PARALLEL TITANIUM POROUS",SUP-6101-2185008LP-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,42048.72,12614.62,"UHC [10700]","United Healthcare",,26616.84,63.3,,,,,0,4890.27,35741.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 24MM OSTEOLOCK TITANIUM HIP ACETABULAR",SUP-5260-5-024,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA [10200]",Cigna,,517.75,68,,1831.33,1831.33,1831.33,16,88.55,647.19,"percent of total billed charges",
"FILTERED TC 99M-SODIUM THIOSULFATE SOLUTION (0-20 MCI)",RX-411525,CDM,A9541,HCPCS,0343,RC,08888-8878-63,NDC,both,1,UN,746.77,224.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,311.62,,,,,,,86.85,746.77,"fee schedule",
"HMII GOGEAR SHWR BG-PCTRL,EP14",SUP-104232,CDM,Q0501,HCPCS,0274,RC,,,both,,,1822.50,546.75,"KAISER [10500]",Kaiser,,1221.08,67,,,,,0,211.96,1549.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS MULTIPASS 5-0 PC-1 18IN BRAID ANTIBACTERIAL",SUP-VCP834G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"NOVANET [10819]",Novanet,,18.75,75,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 25.4MM .8MM LONG DIAMOND DISK STERILE",SUP-5130-130-250,CDM,S27200284,LOCAL,0272,RC,,,both,,,1027.32,308.2,"KAISER [10500]",Kaiser,,688.3,67,,,,,0,119.48,873.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE AVIVE SOFT 3CM X 6CM",SUP-CA0306,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 2.9MM 75 DEG STD SERRATED DS",SUP-SB2975SC,CDM,S27200284,LOCAL,0272,RC,,,both,,,987.42,296.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.84,839.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE 100 MEQ SODIUM 3 MEQ POTASSIUM 2.25 MEQ",SUP-08-3231-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,44.59,13.38,"CIGNA [10200]","Cigna Local Plus",,23.86,53.5,,,,,0,5.19,37.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM REVOLVE SPINE PEDICLE POLYAXIAL",SUP-185.453,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UHC [10700]","United Healthcare",,6043.16,63.3,,5023.51,2672.93,6679.78,18,1110.3,8114.82,"percent of total billed charges",
"BEARING 79/83MMX16MM VANGUARD SSK POLYETHYLENE KNEE",SUP-185106,CDM,C1776,HCPCS,0278,RC,,,both,,,14683.20,4404.96,"KAISER [10500]",Kaiser,,9837.74,67,,,,,0,1707.66,12480.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH PALINDROME PRECISION CHRONIC",SUP-8888146044P,CDM,C1750,HCPCS,0278,RC,,,both,,,2876.79,863.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1956.22,68,,,,,0,334.57,2445.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR RAABE 90CM 5FR 1.9MM GUIDING AQ CHECK-FLO",SUP-G13069,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,183.1,41.1,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE .4MM 58MM UNIVERSAL NEURO III LARGE ROUND",SUP-53-00466,CDM,C1713,HCPCS,0278,RC,,,both,,,6807.20,2042.16,"AETNA [10100]","Aetna HMO/PPO",,5411.72,79.5,,1521.93,481.35,16760.95,30,791.68,5786.12,"percent of total billed charges",
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT TAPERED COMPONENT",SUP-G47481,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"UHC [10700]","United Healthcare",,64963.84,63.3,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 4 KNEE LEFT CRUCIATE RETAIN CEMENTLESS ATT",SUP-150401104,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"FIRST HEALTH [10303]","First Health",,23020.2,80,,,,,0,3346.56,24458.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTIX-PPP ARTIX PRICE PER PROCEDURE",SUP-ARTIX-PPP,CDM,C1757,HCPCS,0272,RC,,,both,,,47250.00,14175,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,32130,68,,,,,0,5495.18,40162.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER YELLOW 4.5MM ORBIT FULL RADIUS ARTHROSCOPIC",SUP-7205323,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"AETNA [10100]","Aetna HMO/PPO",,276.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Candida Species Direct Probe",PX-306000120,CDM,87480,CPT,0306,RC,,,both,,,607.05,182.11,"CIGNA [10200]",Cigna,,44.11,,,,,,,0.61,515.99,"fee schedule",
"ANCHOR SUT 2.2MM 2-0 3/8 CIRCLE MICRO FULL THREAD TAPER",SUP-AR-1318FT,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"KAISER [10500]",Kaiser,,1503.73,67,,,,,0,261.02,1907.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXIMA 70CM 7FR 12FR URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002131,CDM,C1758,HCPCS,0272,RC,,,both,,,80.01,24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,54.41,68,,,,,0,9.31,68.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT STRETCH VL SENSOR 22-30CM 5CM 4.8FR .035IN PIGTAIL",SUP-M006185155080,CDM,C2617,HCPCS,0278,RC,,,both,,,1271.86,381.56,"NOVANET [10819]",Novanet,,953.9,75,,,,,0,147.92,1081.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 17MM 135CM 7MM 20MM BILIARY STAINLESS STEEL",SUP-PXB35-07-17-135,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"PHCS [10601]",PHCS,,3056.9,70,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 18CM 3.3MM DUODENAL BEND BILIARY PLASTIC",SUP-M00533040,CDM,C2617,HCPCS,0278,RC,,,both,,,447.93,134.38,"CIGNA [10200]",Cigna,,304.59,68,,,,,0,52.09,380.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 235MM 14MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-314,CDM,C1776,HCPCS,0278,RC,,,both,,,18758.25,5627.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7503.3,40,,,,,0,2181.58,15944.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHIELD CONTAMINATION YELLOW 80CM TWISTLOCK CATH-GARD",SUP-ST-09875,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.71,33.51,"UHC [10700]","United Healthcare",,70.71,63.3,,,,,0,12.99,94.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURESIGHT BLADE HYPERANGULATED SIZE 3 CHANNELED",SUP-390531000,CDM,S27000186,LOCAL,0270,RC,,,both,,,321.90,96.57,"NOVANET [10819]",Novanet,,241.43,75,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENV DEFIB 2.795X3.1IN AIGISRX ICD ANTIBACTERIAL DISPOSABLE",SUP-CMRM-3133-B,CDM,C1781,HCPCS,0278,RC,,,both,,,5619.71,1685.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3821.4,68,,,,,0,653.57,4776.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 9IN SPETZLER MALIS 2 IRRIGATE 1.5MM DISPOSABLE",SUP-6770-230-015,CDM,S27200284,LOCAL,0272,RC,,,both,,,3282.98,984.89,"KAISER [10500]",Kaiser,,2199.6,67,,,,,0,381.81,2790.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH ADULT 40CM 15.5FR DURATHANE DURAFLOW EMBOSAFE BASIC",SUP-H787103012055,CDM,C1750,HCPCS,0278,RC,,,both,,,1104.50,331.35,"KAISER [10500]",Kaiser,,740.02,67,,,,,0,128.45,938.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE NDL 21GA 48IN KIT ULTRASOUND STERILE DISPOSABLE LATEX",SUP-900013B01,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.12,70.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.23,199,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 1.1MM TIGHTROPE KIRSCHNER MINI",SUP-AR-8919DS,CDM,C1713,HCPCS,0278,RC,,,both,,,6484.28,1945.28,"CIGNA [10200]",Cigna,,4409.31,68,,1831.33,1831.33,1831.33,16,754.12,5511.64,"percent of total billed charges",
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 11MM X 14MM",SUP-4W7405,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1974.78,28.62,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 150MM 18MM VASCULAR NITINOL ILIOFEMORAL VEIN SELF",SUP-AB9U18150090,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"CIGNA [10200]",Cigna,,4692,40,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 100MM 5MM BALLOON DILATATION RAPID",SUP-47550100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 18MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0306,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"KAISER [10500]",Kaiser,,634.96,67,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 65CM 5FR BERENSTEIN CURVE ANGIOGRAPHIC DURATION",SUP-H787117221045,CDM,C1887,HCPCS,0272,RC,,,both,,,466.56,139.97,"PHCS [10601]",PHCS,,326.59,70,,,,,0,54.26,396.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 18MM RETRACTA DETACHABLE .035IN",SUP-G34203,CDM,S27800098,LOCAL,0278,RC,,,both,,,4674.68,1402.4,"CIGNA [10200]","Cigna Open Access",,2659.89,56.9,,,,,0,543.67,3973.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 26FR STD URETHRAL NATURAL RUBBER",SUP-0119L26,CDM,C1726,HCPCS,0272,RC,,,both,,,77.52,23.26,"NOVANET [10819]",Novanet,,58.14,75,,,,,0,9.02,65.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPEL APD TWIST-LOC 15CM 6FR J SHORT LENGTH DRNG",SUP-H7493931106150,CDM,C1729,HCPCS,0272,RC,,,both,,,712.80,213.84,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TAMP 10GA STRAIGHT STEERABLE BALLOON RADIOPAQUE INFLATABLE",SUP-OT-0222,CDM,S27200284,LOCAL,0272,RC,,,both,,,4554.00,1366.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 20GA 19GA 11CM 5CM ADJUSTABLE COAXIAL TEMNO",SUP-ACT2011,CDM,S27200284,LOCAL,0272,RC,,,both,,,473.85,142.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN OPHTHALMIC 25GA SILICONE DISPOSABLE",SUP-8065149525,CDM,S27200284,LOCAL,0272,RC,,,both,,,201.93,60.58,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHTH 8FR 1 SYS LNG",SUP-8001,CDM,C1892,HCPCS,0272,RC,,,both,,,252.30,75.69,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RETAINER VISCERA FISH",SUP-HS3204-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,272.40,81.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE UROLOGICAL 150CM 3CM .035IN PTFE STIFF BODY FIX CORE J",SUP-M0066201110,CDM,C1769,HCPCS,0272,RC,,,both,,,107.97,32.39,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH FLEXOR CHECK-FLO STRAIGHT 55CM 8FR 2.9MM GUIDING",SUP-G56233,CDM,C1894,HCPCS,0272,RC,,,both,,,472.23,141.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,55.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.92,401.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 100CM 25CM 5FR .047IN",SUP-CG510,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 32CM 10MM .021-.027IN AZUR CX HYDROCOIL",SUP-45-781032,CDM,S27800098,LOCAL,0278,RC,,,both,,,5278.50,1583.55,"BLUE CROSS [10001]","Blue Cross PPO",,2069.17,39.2,,,,,0,613.89,4486.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 3MM AXOGUARD NERVE CAP SIS MATRIX END TAB",SUP-AGT315,CDM,C1763,HCPCS,0278,RC,,,both,,,15304.20,4591.26,"PHCS [10601]",PHCS,,10712.94,70,,,,,0,1779.88,13008.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 8MM KNEE UNICONDYLAR RIGHT MEDIAL LEFT",SUP-102408600,CDM,C1776,HCPCS,0278,RC,,,both,,,15980.40,4794.12,"CIGNA [10200]","Cigna Open Access",,5353.43,33.5,,5302.19,4377.88,6578.61,27,1858.52,13583.34,"percent of total billed charges",
"PAD 5YDX12INX1/32IN MOLESKIN ADHSV BACK SOFT LINE CAST",SUP-AC3002-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,440.40,132.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.22,374.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Excsn Thromb Hemm Extrnl",PX-450000266,CDM,46320,CPT,0450,RC,,,both,,,9333.00,2799.9,"NOVANET [10819]",Novanet,,6999.75,75,,,,,0,67.13,7933.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 75CM 12MM 110CM VASCULAR NITINOL ILIAC",SUP-H74939200124070,CDM,C1876,HCPCS,0278,RC,,,both,,,4515.00,1354.5,"BLUE CROSS [10001]","Blue Cross PPO",,1769.88,39.2,,,,,0,525.09,3837.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 13 HIGH OFFSET HIP",SUP-71935585,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"CIGNA [10200]",Cigna,,14613.48,40,,5873.17,5873.17,5873.17,"1 through 10",4248.87,31053.65,"percent of total billed charges",
"SCR BONE 4MM 40MM AXSOS LOCK NONSTERILE",SUP-661040,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"MULTIPLAN [10600]",Multiplan,,1109.86,85,,,,,0,151.86,1109.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 18MM 2 VELOUR KNIT HEMASHIELD GOLD",SUP-M002020951180,CDM,C1768,HCPCS,0278,RC,,,both,,,2698.73,809.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1835.14,68,,,,,0,313.86,2293.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 45D OO 64MM 36MM LONGEVITY HIP CONSTRAINED",SUP-00875801636,CDM,C1776,HCPCS,0278,RC,,,both,,,18074.70,5422.41,"NOVANET [10819]",Novanet,,13556.03,75,,,,,0,2102.09,15363.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 28MM 143CM 3MM CORONARY EVEROLIMUS ELUTING",SUP-1009541-28,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1136.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS MULTIPASS 4-0 P-3 18IN ANTIBACTERIAL UNDYED",SUP-PDP494G,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.63,18.79,"FIRST HEALTH [10303]","First Health",,50.1,80,,,,,0,7.28,53.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 1026X50MM",SUP-6210050,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,9384.48,39.2,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FUSION TITAN 190CM 4CM 30FR 10MM .035IN BALLOON",SUP-G49222,CDM,C1726,HCPCS,0272,RC,,,both,,,2452.50,735.75,"KAISER [10500]",Kaiser,,1643.18,67,,,,,0,285.23,2084.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN SX ENDO HEPARIN 35 RO 10MMX10CM 8FR 120CMCATH",SUP-VBHR101002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"CIGNA [10200]",Cigna,,8507.52,40,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 2 N 8MM",SUP-TPS-030-082N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PLASTIBELL 1.3CM CIRCUMCISION PLASTIC PEDIATRIC",SUP-9233,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.69,17.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,39.91,68,,,,,0,6.83,49.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 5FR 22CM WITHOUT GWIRE POLARIS ULTRA",SUP-M0061921210,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,132.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 10MM MONOBLOCK RSP",SUP-510-00-010,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1465.38,10710,"percent of total billed charges",
"STPLR INTERNAL 60MM 4MM 4.5MM 5MM XTHICK PURPLE",SUP-GIA60XTS,CDM,S27200284,LOCAL,0272,RC,,,both,,,769.42,230.83,"CIGNA [10200]",Cigna,,523.21,68,,,,,0,89.48,654.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex",PX-750000075,CDM,45330,CPT,0750,RC,,,both,,,3094.10,928.23,"CIGNA [10200]","Cigna Local Plus",,1965,,"Case rate ($1,965). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",2382.48,47.16,2382.48,"1 through 10",359.84,3094.1,"fee schedule",
"CATH CLASSIC FLEX-NECK 62CM 14CM 5CM SMALL COIL DIALYSIS",SUP-CF-5250,CDM,C1750,HCPCS,0278,RC,,,both,,,1409.40,422.82,"CIGNA [10200]","Cigna Local Plus",,754.03,53.5,,,,,0,163.91,1197.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trauma Response Lvl III W/O Pre-Notification",PX-683000002,CDM,TTARU,HCPCS,0450,RC,,,both,,,9037.35,2711.2,"AETNA [10100]","Aetna HMO/PPO",,7184.69,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.13,7681.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 74MM HIP MULTIHOLE RIM TRITANIUM X3 MDM",SUP-509-02-74J,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"SHANK SCR 45MM 7.5MM MODULEX OSTEOGRIP SPINE",SUP-55900507545,CDM,C1713,HCPCS,0278,RC,,,both,,,4519.50,1355.85,"CIGNA [10200]","Cigna Local Plus",,2417.93,53.5,,3978.14,359.25,3978.14,24,525.62,3841.58,"percent of total billed charges",
"STEM FEMORAL 155MM 21MM STRAIGHT CONICAL MODULAR RESTORATION",SUP-6276-7-021,CDM,C1776,HCPCS,0278,RC,,,both,,,10468.22,3140.47,"BLUE CROSS [10001]","Blue Cross HMO",,4103.54,39.2,,5311.50,4717.44,5388.59,31,1217.45,8897.99,"percent of total billed charges",
"STENT ZILVER 518 FLEXOR 20MM 125CM 6MM 5FR LOW PROFILE",SUP-G43769,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"NOVANET [10819]",Novanet,,3134.25,75,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL URETERAL 60CM 12-6FR LONG HYDROPHILIC TAPERED",SUP-G17636,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.55,69.16,"CIGNA [10200]",Cigna,,156.77,68,,,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cta Chest W/WO Cntrst",PX-352000007,CDM,71275,CPT,0352,RC,,,both,,,3807.97,1142.39,"NOVANET [10819]",Novanet,,2855.98,75,,,,,0,405,3236.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 7MM CANNULATED",SUP-400146,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"NOVANET [10819]",Novanet,,455.63,75,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 18MM COCR",SUP-VAL-20180-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"NOVANET [10819]",Novanet,,1069.2,75,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Vad Complt Tunl W Port",PX-361000118,CDM,36582,CPT,0361,RC,,,both,,,5946.72,1784.02,"CIGNA [10200]",Cigna,,3951,,"Case rate ($3,951). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,691.6,5946.72,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPHOTERICIN B LIPOSOME 50 MG/12.5ML IV (WET SUSR VIAL)|DISCARDED DRUG NOT ADMINISTE",RX-41521900,CDM,J0289,HCPCS,0636,RC,00469-3051-30,NDC,both,1,UN,1921.31,576.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",JW,202,,,,,,,125.17,1633.11,"fee schedule",
"RING ANNULOPLASTY 30MM 34.9MM 28.9MM MITRAL FLEXIBLE HOLDER",SUP-4450M30,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"CIGNA [10200]","Cigna Open Access",,6478.07,56.9,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 60MM 80CM 10MM .035IN 3MM VASCULAR VENOUS",SUP-VENUM10060,CDM,C1876,HCPCS,0278,RC,,,both,,,22680.00,6804,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2687.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2637.68,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER DS NAV 115CM 8MM 7FR 1-7-4MM SPACE D-F CURVE",SUP-BN7TCDF8L,CDM,C1732,HCPCS,0272,RC,,,both,,,16477.20,4943.16,"MULTIPLAN [10600]",Multiplan,,14005.62,85,,,,,0,1916.3,14005.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Co-Set Baxter",PX-E27000098,CDM,E27000098,LOCAL,0270,RC,,,both,,,122.35,36.7,"CIGNA [10200]","Cigna Local Plus",,65.46,53.5,,,,,0,14.23,104,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cardiovsn Elect Extrnl",PX-450000309,CDM,92960,CPT,0480,RC,,,both,,,3810.51,1143.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2591.15,68,,,,,0,443.16,3238.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 62MM 9.4MM 5MM CUFFED LOW PRESSURE FENESTRATED INNER",SUP-4DFEN,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.46,95.84,"UHC [10700]","United Healthcare",,202.22,63.3,,,,,0,37.15,271.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 12CM 8MM 6IN .035IN BILIARY SELF EXPAND",SUP-G23814,CDM,C1876,HCPCS,0278,RC,,,both,,,13275.60,3982.68,"PHCS [10601]",PHCS,,9292.92,70,,,,,0,1543.95,11284.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 12CM 8MM 6IN .035IN BILIARY SELF EXPAND",SUP-G23814,CDM,C1876,HCPCS,0278,RC,,,both,,,13275.60,3982.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5456.27,41.1,,,,,0,1543.95,11284.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 19MM KNEE X3 BEARING CRUCIATE RETAIN",SUP-5530-G-219,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]",Cigna,,7760.57,68,,5873.17,5873.17,5873.17,"1 through 10",1327.29,9700.71,"percent of total billed charges",
"STENT ONYX FRONTIER 15MM 2.75MM CORONARY RAPID EXCHANGE",SUP-ONYXNG27515UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2925.00,877.5,"CIGNA [10200]",Cigna,,1989,68,,,,,0,340.18,2486.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 30MM 19MM FREESTYLE ROOT PORCINE BIOPROSTHESIS",SUP-FR995-19,CDM,S27800098,LOCAL,0278,RC,,,both,,,38430.00,11529,"AETNA [10100]","Aetna HMO/PPO",,30551.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4469.41,32665.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemoglobin F",PX-301000225,CDM,83021,CPT,0301,RC,,,both,,,126.00,37.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16.25,,,,,,,0.01,107.1,"fee schedule",
"KIT ENDOSCOPIC INSTR PUSHLOCK 17GA 2.9MM CANN DRILL NDL",SUP-AR-1923PK,CDM,C1713,HCPCS,0278,RC,,,both,,,1732.50,519.75,"PHCS [10601]",PHCS,,1212.75,70,,,,,0,201.49,1472.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRIMARY REVERSE SHOULDER",SUP-SMRREV,CDM,C1776,HCPCS,0278,RC,,,both,,,51502.50,15450.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,21167.53,41.1,,6417.48,6417.48,6417.48,"1 through 10",5989.74,43777.13,"percent of total billed charges",
"SPACER SPINAL 34X11MM HEDRON IA 8D 26MM STERILE LATEX FREE",SUP-1212.0611S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"UHC [10700]","United Healthcare",,21933.45,63.3,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 6FR AL1 CURVE GUIDING NYLON CORONARY",SUP-LA6AL10A,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 100MM 10MM BALLOON",SUP-U35751010,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 60X3.8MM REGULAR THICK TISSUE 6 ROW STERILE",SUP-ECR60D,CDM,S27200284,LOCAL,0272,RC,,,both,,,4076.34,1222.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,483.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,474.08,3464.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 5ML 1-5MM CANCELLOUS ALLOGRAFT MILLED CHIP",SUP-400105,CDM,C1713,HCPCS,0278,RC,,,both,,,1619.03,485.71,"CIGNA [10200]","Cigna Local Plus",,866.18,53.5,,3978.14,359.25,3978.14,24,188.29,1376.18,"percent of total billed charges",
"SUT STRATAFIX PDS PLUS 4-0 SH-1 SPIRAL 9IN KNOTLESS VIOLET",SUP-SXPP1B454,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.35,67.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.32,192.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX14MM ASCENT ARCOM KNEE PRIMARY DIRECT",SUP-179362,CDM,C1776,HCPCS,0278,RC,,,both,,,9057.91,2717.37,"FIRST HEALTH [10303]","First Health",,7246.33,80,,,,,0,1053.43,7699.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 345CC",SUP-SSZ-F345,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CIGNA [10200]",Cigna,,1013.47,68,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 4X19MM ANTERIOR CERVICAL VARIABLE ANGLE SELF TA",SUP-18008519,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Paracentesis",PX-E27200175,CDM,E27200175,LOCAL,0272,RC,,,both,,,423.50,127.05,"CIGNA [10200]","Cigna Open Access",,240.97,56.9,,,,,0,49.25,359.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EAGLE EYE 150CM 5FR 20MM 20MHZ SHORT TAPER ULTRASOUND",SUP-85900PST,CDM,C1753,HCPCS,0272,RC,,,both,,,5002.50,1500.75,"PHCS [10601]",PHCS,,3501.75,70,,,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 12MM 2.25MM CORONARY STENT EVEROLIMUS",SUP-1550225-12,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"WASHER ORTHOPEDIC 6.5 MM CANNULATED SCR STERILE",SUP-04.353.907S,CDM,C1713,HCPCS,0278,RC,,,both,,,258.56,77.57,"NOVANET [10819]",Novanet,,193.92,75,,,,,0,30.07,219.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 48MM 28MM TANDEM HIP COCR UHMWPE SHELL",SUP-71322048,CDM,C1776,HCPCS,0278,RC,,,both,,,7003.50,2101.05,"PHCS [10601]",PHCS,,4902.45,70,,,,,0,814.51,5952.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ANGIO-SEAL STS PLUS 8FR .038IN CLSR TGA CLLGN POLYMER",SUP-610121,CDM,C1760,HCPCS,0278,RC,,,both,,,1650.00,495,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,757.35,45.9,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR .09IN AMPLATZ LEFT 2 CURVE GUIDING",SUP-LA8AL20,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE RIGHT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F302,CDM,C1776,HCPCS,0278,RC,,,both,,,29995.06,8998.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11998.02,40,,,,,0,3488.43,25495.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 1000-1180UM 5 VIAL CONTOUR PVA",SUP-M0017601151,CDM,S27800098,LOCAL,0278,RC,,,both,,,1377.00,413.1,"BLUE CROSS [10001]","Blue Cross PPO",,539.78,39.2,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE HEARTMATE 3 VENTRICULAR ASSIST LEFT MODULAR CABLE",SUP-106525US,CDM,Q0508,HCPCS,0274,RC,,,both,,,33679.80,10103.94,"CIGNA [10200]","Cigna Local Plus",,10609.14,31.5,,,,,0,3916.96,28627.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STINGRAY VASCULAR 28D 300CM 20CM .014IN HYDROPHILIC",SUP-H749M3004A0,CDM,C1769,HCPCS,0272,RC,,,both,,,2784.38,835.31,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1144.38,41.1,,,,,0,323.82,2366.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 150MM 11 HOLE LOW PROFILE BONE LEFT OLECRANON",SUP-70-0308,CDM,C1713,HCPCS,0278,RC,,,both,,,7051.80,2115.54,"AETNA [10100]","Aetna HMO/PPO",,5606.18,79.5,,1521.93,481.35,16760.95,30,820.12,5994.03,"percent of total billed charges",
"SCR BONE 2.7MM 26MM DCP STAINLESS STEEL CORTEX SELF TAPPING",SUP-202.826,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"FIRST HEALTH [10303]","First Health",,281.05,80,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 6MMX29MM 7FR 135CMCATH HEPARIN",SUP-BXB062902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"NOVANET [10819]",Novanet,,14628.6,75,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXFIT SEAMLESS BRA FRONT CLOSURE-40 D/E-BLACK","SUP-B01G-40 D/E-B",CDM,S27000186,LOCAL,0270,RC,,,both,,,200.45,60.13,"CIGNA [10200]","Cigna Local Plus",,107.24,53.5,,,,,0,23.31,170.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165CM 10.5-12MM OTSC 3MM NITINOL",SUP-100.06,CDM,C1760,HCPCS,0272,RC,,,both,,,4133.10,1239.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1698.7,41.1,,,,,0,1698.7,2616.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 14.6X15.3CM BREAST 750ML STYLE 9300 TEXTURED SELF",SUP-3549316,CDM,C1789,HCPCS,0278,RC,,,both,,,9694.50,2908.35,"FIRST HEALTH [10303]","First Health",,7755.6,80,,,,,0,1127.47,8240.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 10-0 CS160-6 12IN 2 ARM MONOFILAMENT BLACK",SUP-9000G,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.29,68.79,"UHC [10700]","United Healthcare",,145.14,63.3,,,,,0,26.67,194.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM .02IN 6MM PENUMBRA COIL 400 RUBY",SUP-RBY4C0620,CDM,S27800098,LOCAL,0278,RC,,,both,,,6258.00,1877.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,741.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,727.81,5319.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 5.5MM 6.35MM TOP NOTCH SPINE TITANIUM 2 OPEN",SUP-179771655,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"KAISER [10500]",Kaiser,,2386.88,67,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH ADULT 32CM 15.5FR DURATHANE DURAFLOW EMBOSAFE BASIC",SUP-H787103012035,CDM,C1750,HCPCS,0278,RC,,,both,,,1104.50,331.35,"MULTIPLAN [10600]",Multiplan,,938.83,85,,,,,0,128.45,938.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 14CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192113010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,343.61,28.62,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELIANCE 4 FRONT PASSIVE FIXATION DUAL COIL 59CM",SUP-0665,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"UHC [10700]","United Healthcare",,9608.94,63.3,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM 2MM CORONARY STENT BIOLINX",SUP-RONYX20008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LOW PROFILE 22MM TITANIUM 5.5MM ROD FIX LEGACY X10",SUP-8115522,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Local Plus",,1905.94,53.5,,3978.14,359.25,3978.14,24,414.32,3028.13,"percent of total billed charges",
"INSRT TIBIAL 3 15MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962343,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"PHCS [10601]",PHCS,,10152.66,70,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PRIME HD DBM 10CC ALLOGRAFT LATEX FREE",SUP-421100,CDM,C1713,HCPCS,0278,RC,,,both,,,6210.00,1863,"NOVANET [10819]",Novanet,,4657.5,75,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 45D COOLCUT STERILE ABLATOR",SUP-AR-9802M-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,931.50,279.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATH 4FR 135CM POWERPICC 1 LUMEN MAXIMAL BARR NURSING",SUP-3174335,CDM,C1751,HCPCS,0272,RC,,,both,,,792.67,237.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Pulm Func Test Lung Vol",PX-460000011,CDM,94727,CPT,0460,RC,,,both,,,591.36,177.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PIN FIXATION TEMPORARY ANTERIOR CERVICAL PLATING SYSTEM",SUP-7786703,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 75CM 20MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206080270,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR SKIN ABSORB WOUND CLSR STERILE INSORB",SUP-2030,CDM,C1894,HCPCS,0272,RC,,,both,,,406.00,121.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SKIN 12X6CM ALLODERM THICK READY TO USE",SUP-152072,CDM,Q4116,HCPCS,0636,RC,,,both,,,13496.40,4048.92,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC",909,MS-DRG,,,,,,,inpatient,,,41193.05,12357.91,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,8712.75,,"Case rate ($8,142.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,561.10, add-ons for qualifying new technology services are included. If operating cost exceeds $40,600.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,953.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $7,571.10. The transfer operating threshold is the transfer adjustment factor * $7,561.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.66. The transfer capital threshold is the transfer adjustment factor * $571.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,38325.59,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 00 PREASSEMBLE BLADE MINI HANDLE LED LIGHT",SUP-040-06-0400U,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.42,18.73,"FIRST HEALTH [10303]","First Health",,49.94,80,,,,,0,7.26,53.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM DIGNISHIELD FECAL MANAGEMENT 60CC CATH SYR COLL BAG",SUP-SMS002,CDM,S27000186,LOCAL,0270,RC,,,both,,,1093.50,328.05,"CIGNA [10200]","Cigna Local Plus",,585.02,53.5,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUPLER ANSTM 4MM RNG PIN ULTSNC",SUP-GEM2756-FC,CDM,S27200284,LOCAL,0272,RC,,,both,,,7569.30,2270.79,"CIGNA [10200]","Cigna Open Access",,4306.93,56.9,,,,,0,880.31,6433.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM REFLECTION FULL THREAD HIP ACETABULAR",SUP-71336540,CDM,C1713,HCPCS,0278,RC,,,both,,,1341.36,402.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,912.12,68,,,,,0,156,1140.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 150CM 2.1-2.7FR .0175 .0157IN",SUP-221-15-1000U,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]","Cigna Local Plus",,1805.63,53.5,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9CM 3.5MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY123509,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]",Cigna,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 4MM CORONARY STENT",SUP-1125400-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross PPO",,2288.5,39.2,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-150440108,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"CIGNA [10200]",Cigna,,12045.6,40,,5873.17,5873.17,5873.17,"1 through 10",3502.26,25596.9,"percent of total billed charges",
"STEM FEMORAL CITATION TMZF HA 3 SHORT HIP RIGHT",SUP-6265-5213,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2894,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2840.27,20758.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Heavy Metal Quant Nes",PX-301000219,CDM,83018,CPT,0301,RC,,,both,,,279.08,83.72,"CIGNA [10200]",Cigna,,48.31,,,,,,,0.28,237.22,"fee schedule",
"CAGE SPINAL 45MMX12MM CLYDESDALE 0D PEEK-OPTIMA RADIOPAQUE",SUP-2969245,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,9384.48,39.2,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 10MM 2.5MM BALLOON DILATATION STERILE",SUP-225-103-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Creatinine Clearance",PX-301000169,CDM,82575,CPT,0301,RC,,,both,,,353.40,106.02,"MULTIPLAN [10600]",Multiplan,,300.39,85,,,,,0,0.35,300.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA PERFUSION DLP STAINLESS STEEL L5.5 IN OD14 GA AORTIC",SUP-20014,CDM,S27200284,LOCAL,0272,RC,,,both,,,196.65,58.99,"CIGNA [10200]","Cigna Open Access",,111.89,56.9,,,,,0,22.87,167.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 19MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-019,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3221.23,68,,,,,0,550.92,4026.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE SEMITENDINOSUS TENDON",SUP-FST,CDM,C1762,HCPCS,0278,RC,,,both,,,10439.70,3131.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1214.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1214.14,8873.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOLOIST 110CM 6FR 5MM SPACING JSN CURVE",SUP-44516J,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"FIRST HEALTH [10303]","First Health",,583.2,80,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC MICROPOINT 5-0 G-3 18IN 2 ARM MONOFILAMENT",SUP-792G,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.58,54.17,"AETNA [10100]","Aetna HMO/PPO",,143.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21,153.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X5MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7307,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,802.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SURGICAL GRAFT STAINLESS STEEL STERILE DISTAL",SUP-AMGM-SD,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.39,26.52,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) 28MM CLARITY MITRAL HEART VALVE LAV LARGE ANNULUS VAL",SUP-637000,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STELLAREX 135CM 120MM 4MM BALLOON DILATATION ENDURACOAT",SUP-AB35SX040120135,CDM,C2623,HCPCS,0272,RC,,,both,,,11005.50,3301.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL 36CM 2.4MM OPTI2 LAPAROSCOPIC L HOOK",SUP-E2773-36,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.93,90.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC",729,MS-DRG,,,,,,,inpatient,,,23918.59,7175.58,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.5MM SOLID STERILE",SUP-829029070,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SURFACE ARTICULAR 10MM PERSONA MEDIAL CONGRUENT 6-7 C-D KNEE",SUP-42512100410,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PHCS [10601]",PHCS,,7543.49,70,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENROUTE ENFLATE TRANSCAROTID RX BALLOON DILATATION CATHETER",SUP-SR-5035-BC,CDM,C1725,HCPCS,0272,RC,,,both,,,2625.00,787.5,"MULTIPLAN [10600]",Multiplan,,2231.25,85,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 12MM 2.25MM CORONARY STENT",SUP-1007822-12,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 RB-1 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8871H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL LONG HINDFOOT VALOR 4.3MM SCR IMPL KIT",SUP-415S002352,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP BIPOLAR 8.5IN 1MM ISOCOOL TIP 3.5IN DISPOSABLE",SUP-823510GL,CDM,S27200284,LOCAL,0272,RC,,,both,,,3845.09,1153.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LASSO REDEL 60CM 1MM 5FR 2-8-2MM SPACE P CURVE",SUP-F5ADP282RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2040.00,612,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 1.25IN SHORT SMALL RTRCTR 1IN INITIAL INCISION",SUP-225-502,CDM,S27000186,LOCAL,0270,RC,,,both,,,517.43,155.23,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TRUE DILATATION 110CM 4.5CM 28MM BALLOON DILATATION OTW",SUP-0284514,CDM,C1725,HCPCS,0272,RC,,,both,,,7590.00,2277,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET EXT 2.5CM 18FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-18-2.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG NASAL WHITE 4CM NASOPORE OTOPORE STD SINUS FOAM FIRM",SUP-5400020004,CDM,S27200284,LOCAL,0272,RC,,,both,,,1124.90,337.47,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC",871,MS-DRG,,,,,,,inpatient,,,47206.78,14162.03,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT SURGICAL T8 SELF RETAIN QUICK COUPLING ZERO-P SPINE",SUP-03.617.904,CDM,S27200284,LOCAL,0272,RC,,,both,,,923.40,277.02,"AETNA [10100]","Aetna HMO/PPO",,734.1,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,107.39,784.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH II SS10.5",SUP-398349,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"AETNA [10100]","Aetna HMO/PPO",,418.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TFN-ADVANCED ORTHOPEDIC 475MM 3.2MM FEMORAL PROXIMAL",SUP-09.037.010,CDM,C1769,HCPCS,0272,RC,,,both,,,768.93,230.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,91.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.43,653.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 12D-30D LONG OVAL BUTTON 24FR",SUP-WA22741S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 36MM GLENOSPHERE STERILE TRABECULAR METAL",SUP-00434903611,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,683.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 4.5/15",SUP-434891,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"CIGNA [10200]",Cigna,,7900.2,40,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00180,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,129.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM ROUND COARSE TRANSNASAL DIAMOND STERILE",SUP-TN30RCD,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,326.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 30X4IN WRIST PRECUT FIBERGLASS ORTHO-GLASS",SUP-OG-430PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,102.16,30.65,"CIGNA [10200]",Cigna,,69.47,68,,,,,0,11.88,86.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULAR THK10MM WEDGE ALLOGRAFT FREEZE DRIED",SUP-400421,CDM,S27800098,LOCAL,0278,RC,,,both,,,4656.67,1397,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,541.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,541.57,3958.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 22CM 6FR .035",SUP-M006192131090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"PHCS [10601]",PHCS,,1044.7,70,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR NEUROLOGICAL RD SEDLINE",SUP-4248,CDM,S27000186,LOCAL,0270,RC,,,both,,,95.70,28.71,"MULTIPLAN [10600]",Multiplan,,81.35,85,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 25MM 3.3MM MODULAR STERILE",SUP-21073325,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 15CM 19GA 5FR 4 SIDEPORT CATH HOLLOW STYLET PROC",SUP-G10100,CDM,S27200284,LOCAL,0272,RC,,,both,,,369.66,110.9,"CIGNA [10200]",Cigna,,251.37,68,,,,,0,42.99,314.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.438TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"PHCS [10601]",PHCS,,1415.09,70,,,,,0,235.11,1718.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.200,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]",Cigna,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X11MM LUMINARY CC SPINE LUMBAR",SUP-16811,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"CIGNA [10200]","Cigna Open Access",,11143.44,33.5,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL GOLD 36MM EXPERT SPIRAL HUMERAL",SUP-462.636S,CDM,C1713,HCPCS,0278,RC,,,both,,,3518.55,1055.56,"NOVANET [10819]",Novanet,,2638.91,75,,,,,0,409.21,2990.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sensor Lnop Oximeter",PX-E27000150,CDM,E27000150,LOCAL,0270,RC,,,both,,,290.40,87.12,"PHCS [10601]",PHCS,,203.28,70,,,,,0,33.77,246.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 45X2MM ENDO GIA ROTICULATOR TITANIUM VASCULAR",SUP-030453,CDM,S27200284,LOCAL,0272,RC,,,both,,,1550.99,465.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,180.38,1318.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL TRIATHLON 1-2 HINGE BEARING",SUP-5612-0-001,CDM,C1776,HCPCS,0278,RC,,,both,,,28659.96,8597.99,"BLUE CROSS [10001]","Blue Cross HMO",,11234.7,39.2,,5311.50,4717.44,5388.59,31,3333.15,24360.97,"percent of total billed charges",
"MATRIX TISSUE 4X2CM ALLODERM SELECT THK.3-.8MM THIN",SUP-141408,CDM,Q4116,HCPCS,0636,RC,,,both,,,3337.50,1001.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1493.53,44.75,,,,,0,247.92,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 6FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G00868,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 4MM BALL COARSE DISSECTING DIAMOND",SUP-MR8-14BA40DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1358.37,407.51,"PHCS [10601]",PHCS,,950.86,70,,,,,0,157.98,1154.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 5FR IMA CURVE GUIDING NYLON PERIPHERAL",SUP-LA5IMA,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DORADO CHECKER 80CM 10CM 6MM BALLOON DILATATION",SUP-DR80610,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SAFE-T-J VASCULAR 1.5MM ROSEN CURVE 145CM .035IN",SUP-G01382,CDM,C1769,HCPCS,0272,RC,,,both,,,133.81,40.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM NEGATIVE PRESSURE 6X6IN PICO DRSG STERILE DISPOSABLE",SUP-66022005,CDM,S27200284,LOCAL,0272,RC,,,both,,,2130.00,639,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPEL APD TWIST-LOC 20CM 6FR DRNG FLEXITHANE METAL",SUP-H7493931006200,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT ZIPWIRE 28CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT",SUP-M006145363170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"BLUE CROSS [10001]","Blue Cross HMO",,442.94,39.2,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MOTIV SCAFFOLD 3.0MMX12MM","SUP-930030-12 (72)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM CEMENT OMNIFIT HFX 127D 8 30MM HIP",SUP-6076-0830A,CDM,C1776,HCPCS,0278,RC,,,both,,,7894.95,2368.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,935.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,918.18,6710.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPRESS ULTRA 5X8MM",SUP-ULF-205,CDM,C1726,HCPCS,0272,RC,,,both,,,11364.30,3409.29,"NOVANET [10819]",Novanet,,8523.23,75,,,,,0,1321.67,9659.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY PRECISIONPOINT TRANSPERINEAL ACC SYS BX",SUP-P1002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1777.50,533.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,730.55,41.1,,,,,0,206.72,1510.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 130MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.930,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"BLUE CROSS [10001]","Blue Cross HMO",,538.77,39.2,,957.42,156.86,7483.26,51,159.84,1168.25,"percent of total billed charges",
"GRAFT VASCULAR 40CM 6CM ACUSEAL PTFE 3 LAYER",SUP-ECH060040A,CDM,C1768,HCPCS,0278,RC,,,both,,,9266.70,2780.01,"UHC [10700]","United Healthcare",,5865.82,63.3,,,,,0,1077.72,7876.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEART FAILURE AND SHOCK WITH MCC",291,MS-DRG,,,,,,,inpatient,,,31504.22,9451.27,"PHCS [10601]",PHCS,,7561,,,,,,,7561,31504.22,"per diem","Estimated amount calculated based on 3 day length of stay."
"STENT COMPLETE SE 80MM 130CM 7MM LONG VASCULAR NITINOL ILIAC",SUP-SC780LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3325.46,45.9,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D +4MM 54MM 36MM XLPE HIP STERILE",SUP-71338554,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"NOVANET [10819]",Novanet,,8344.69,75,,,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 1 7MM",SUP-TPS-030-071S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 8CM 6MM BALLOON DILATATION",SUP-DR8068,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,936.36,68,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC SHORT 17IN KNEE DUAL AXIS POLYCENTRIC HINGE",SUP-A402550,CDM,S27000186,LOCAL,0270,RC,,,both,,,551.37,165.41,"MULTIPLAN [10600]",Multiplan,,468.66,85,,,,,0,64.12,468.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC",353,MS-DRG,,,,,,,inpatient,,,108272.60,32481.78,"CIGNA [10200]","Cigna Local Plus",,29945.74,,"Fee schedule rate ($29,945.74). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,84726.79,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 70MM 4MM DIAMOND STERILE",SUP-MD747,CDM,S27200284,LOCAL,0272,RC,,,both,,,385.06,115.52,"FIRST HEALTH [10303]","First Health",,308.05,80,,,,,0,44.78,327.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 35CM 7MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0735CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"MULTIPLAN [10600]",Multiplan,,6158.25,85,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE POSITIONING 22X12X9IN DEVON FOAM BODY ALIGNMENT 30322",SUP-31143392,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.90,23.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.02,41.1,,,,,0,9.06,66.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL PURPLE 115MM 1.8MM VOLT 1 BAND AO QUICK COUPLING",SUP-03.424.180,CDM,S27000186,LOCAL,0270,RC,,,both,,,2062.50,618.75,"PHCS [10601]",PHCS,,1443.75,70,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6D SMALL 66X62MM KNEE LEFT ROTATE HINGE PIN",SUP-623411L,CDM,C1776,HCPCS,0278,RC,,,both,,,30350.88,9105.26,"MULTIPLAN [10600]",Multiplan,,25798.25,85,,,,,0,3529.81,25798.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 60MM 8MM 8FR BILIARY RAPID EXCHANGE DELIVERY",SUP-M00570610,CDM,C1876,HCPCS,0278,RC,,,both,,,11927.41,3578.22,"UHC [10700]","United Healthcare",,7550.05,63.3,,,,,0,1387.16,10138.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 100MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.415,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"FIRST HEALTH [10303]","First Health",,1107.3,80,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE STEELCORE VASCULAR STRAIGHT 190CM 3CM .018IN",SUP-1007709,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.35MM 45MM VIPER EXPEDIUM TITANIUM SPINE CORTICAL",SUP-186731445,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"VALVE AORTIC 26MM EDWARDS SAPIEN NOVAFLEX TRANSFEMORAL",SUP-9355NF26A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"MULTIPLAN [10600]",Multiplan,,157462.5,85,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Shoulder Complt>=2v",PX-320000063,CDM,73030,CPT,0320,RC,,,both,,,558.59,167.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,66.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.79,474.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rp Quan Meas Single Area",PX-341000075,CDM,78835,CPT,0341,RC,,,both,,,973.00,291.9,"KAISER [10500]",Kaiser,,651.91,67,,,,,0,0.97,827.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR ATHERECTOMY 135CM 1.5MM ROTABLATOR ROTALINK PLUS",SUP-M0011401500,CDM,C1724,HCPCS,0272,RC,,,both,,,16525.50,4957.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"(EVAL) SYSTEM TRUFILL EMBOLIC 1GM KIT LIQUID",SUP-631500,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HYDRA JAGWIRE DREAM TIP ENDOSCOPIC 260CM .035IN",SUP-M00556001,CDM,C1769,HCPCS,0272,RC,,,both,,,1422.36,426.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BIOPSY 20CM 20GA 19GA MISSION TRUGUIDE 10MM 20MM BLUNT",SUP-2020MSK,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,48.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 25MM BRIGADE LUMBAR SPINE",SUP-8595525,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"MULTIPLAN [10600]",Multiplan,,2499,85,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORTICAL SCREW 4MM X 48MM",SUP-HTN-U-4-48,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",180.87,1321.92,"percent of total billed charges",
"STEM FEMORAL 180MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309018,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"BLUE CROSS [10001]","Blue Cross HMO",,14802.78,39.2,,5311.50,4717.44,5388.59,31,4391.74,32097.87,"percent of total billed charges",
"BLADE INTRAMEDULLARY NAIL GOLD 36MM EXPERT SPIRAL HUMERAL",SUP-462.636S,CDM,C1713,HCPCS,0278,RC,,,both,,,3518.55,1055.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,416.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",409.21,2990.77,"percent of total billed charges",
"STENT ONYX FRONTIER 26MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,751.28,28.62,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 8- CM 19GA 1.83MM COCR SILICONE 137.5-147.5CM",SUP-M00555500,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 35MM 5MM EMBOLIZATION NEUROVASCULAR 48",SUP-PED-500-35,CDM,S27800098,LOCAL,0278,RC,,,both,,,81396.00,24418.8,"PHCS [10601]",PHCS,,56977.2,70,,,,,0,9466.35,69186.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURECLIP REPOSITIONABLE 11MM 235CM",SUP-RC30141,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"UHC [10700]","United Healthcare",,564,63.3,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOSE F/SMARTVEST AIRWAY CLEARANCE SYSTEM 6IN DISPOSABLE",SUP-SV-HOSE-SPU,CDM,S27000186,LOCAL,0270,RC,,,both,,,104.40,31.32,"FIRST HEALTH [10303]","First Health",,83.52,80,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED II 100CM 6CM 8FR 20MM .035IN BALLOON DILATATION",SUP-611759,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"NOVANET [10819]",Novanet,,3988.53,75,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC CURVE TIP RELOAD AEON 60MMX3.25MM STERILE",SUP-AESC60R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 28MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-828,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5531.42,41.1,,6417.48,6417.48,6417.48,"1 through 10",1565.22,11439.68,"percent of total billed charges",
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FROZEN 100MMX5+ MM",SUP-450630,CDM,S27800098,LOCAL,0278,RC,,,both,,,5241.24,1572.37,"CIGNA [10200]","Cigna Open Access",,2982.27,56.9,,,,,0,609.56,4455.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 8 HOLE STRAIGHT BONE LEFT CLAVICLE",SUP-70-0298,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"MULTIPLAN [10600]",Multiplan,,5618.67,85,,,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER BURR HOLE 7MM MEDPOR LOW PROFILE TITANIUM TAB STERILE",SUP-53-34507,CDM,C1713,HCPCS,0278,RC,,,both,,,1858.35,557.5,"CIGNA [10200]","Cigna Open Access",,1057.4,56.9,,1144.80,304.56,2275.09,66,216.13,1579.6,"percent of total billed charges",
"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION",RX-3037,CDM,J3010,HCPCS,0636,RC,63323-0806-14,NDC,both,20,ML,102.20,30.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.98,,"Fee schedule rate ($13.98). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",13.40,10.10,265.13,262,12.11,86.87,"fee schedule",
"NUT EXTERNAL FIXATION HEX MRI SAFE NONSTERILE",SUP-03.311.061.10,CDM,S27800098,LOCAL,0278,RC,,,both,,,66.83,20.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,30.67,45.9,,,,,0,7.77,56.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH SAFESHEATH HS CURVE 60CM 7FR",SUP-WORLEY/B-60-07-HS,CDM,C1893,HCPCS,0272,RC,,,both,,,3345.00,1003.5,"PHCS [10601]",PHCS,,2341.5,70,,,,,0,389.02,2843.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 22MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532-G-322,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"NOVANET [10819]",Novanet,,8559.45,75,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC HANDLE AEON MEDIUM STERILE LATEX FREE",SUP-AESH160,CDM,S27200284,LOCAL,0272,RC,,,both,,,1134.00,340.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,466.07,41.1,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 21GA 10CM CHIBA STERILE DISPOSABLE",SUP-G00933,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.00,28.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.05,80.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 12MM ACCESS SYSTEM 100MM KII ABDOMINAL Z",SUP-CTS22,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.25,25.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,35.04,41.1,,,,,0,9.91,72.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 7FR MULTIPURPOSE A1",SUP-77827000,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 150MM 130CM 7MM LONG VASCULAR ILIAC ARTERY",SUP-SC7150LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"CIGNA [10200]","Cigna Open Access",,5103.93,56.9,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 25CM 8FR 21GA FLEXIMA PLATINUM REGULAR DUROMETER",SUP-M001271960,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.6MM 16MM COALITION SPINE SELF TAP VARIABLE ANGLE",SUP-184.116,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,431.46,45.9,,,,,0,109.32,799,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS AIM SL 62CM 59CM 7FR 5FR 90D GUIDING PEBAX",SUP-DS2N022-59,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 19MM RESTORATION +20MM HIP MODULAR",SUP-6276-1-219,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5786.73,40,,,,,0,1682.49,12296.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENDOMAXX 120MM 90CM 19MM 24FR ESOPHAGEAL SILICONE",SUP-MAXX-1912,CDM,C1874,HCPCS,0278,RC,,,both,,,17640.00,5292,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5048.57,28.62,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 152MM 16MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-104160,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"FIRST HEALTH [10303]","First Health",,19362.67,80,,,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTICROSS 8FR ULTRASOUND PERIPHERAL STERILE LATEX FREE",SUP-H7493932800350,CDM,C1753,HCPCS,0272,RC,,,both,,,11695.50,3508.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1385.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 7MM CUFFED HOODED MURPHY EYE LOW PRESSURE",SUP-8229507,CDM,S27200284,LOCAL,0272,RC,,,both,,,3487.50,1046.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1600.76,45.9,,,,,0,405.6,2964.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 6MM 2.25MM BALLOON DILATATION PEBAX",SUP-1400225-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 24MM 144CM 2.5MM",SUP-H7493941224250,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"NOVANET [10819]",Novanet,,5821.88,75,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ACCESS ASCENDA 2 ATTACH COLLET SPINAL SEG REVISION CATH",SUP-8782,CDM,C1755,HCPCS,0278,RC,,,both,,,4843.80,1453.14,"KAISER [10500]",Kaiser,,3245.35,67,,,,,0,563.33,4117.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 20MM COCR",SUP-VAL-20200-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]","Cigna Local Plus",,762.7,53.5,,3978.14,359.25,3978.14,24,165.8,1211.76,"percent of total billed charges",
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 275CC",SUP-SSZ-M275,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"AETNA [10100]","Aetna HMO/PPO",,1184.87,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENT BUR 4MM FLUTED BALL TS SHORT ANSPACH",SUP-SA-FB4,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"FIRST HEALTH [10303]","First Health",,1380,80,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA 5D C KNEE RIGHT CEMENT STEM 16MM",SUP-42532006402,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"FIRST HEALTH [10303]","First Health",,8746.99,80,,,,,0,1271.59,9293.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txcath Retrev Intrvas FB",PX-361000295,CDM,37197,CPT,0361,RC,,,both,,,10102.49,3030.75,"MULTIPLAN [10600]",Multiplan,,8587.12,85,,,,,0,1174.92,10015,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE REGENESORB 20MM 9MM OPEN ARCHITECTURE",SUP-72204403,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"CIGNA [10200]","Cigna Open Access",,1578.42,56.9,,1144.80,304.56,2275.09,66,322.62,2357.93,"percent of total billed charges",
"SPLINT ORTHOPEDIC XL 24IN 22-26IN KNEE LOOP LOCK CLSR",SUP-79-80038,CDM,S27000186,LOCAL,0270,RC,,,both,,,117.10,35.13,"PHCS [10601]",PHCS,,81.97,70,,,,,0,13.62,99.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BN 2MM 12MM LEIBINGER UNV 2 7955",SUP-50-20412,CDM,C1713,HCPCS,0278,RC,,,both,,,458.06,137.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,311.48,68,,,,,0,53.27,389.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUTURING 9MM 2-0 48IN LOADING UNIT ENDO STITCH",SUP-170053,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X22X14MM COROENT 15D XL WIDE PEEK NONSTERILE",SUP-7151460,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]",Cigna,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 3DMAX 5X3IN GROIN RIGHT CONTOUR SEAL EDGE",SUP-0115320,CDM,C1781,HCPCS,0278,RC,,,both,,,816.30,244.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,233.63,28.62,,,,,0,94.94,693.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 90MM 5 HOLE LOW PROFILE BONE LEFT OLECRANON ELBOW",SUP-70-0304,CDM,C1713,HCPCS,0278,RC,,,both,,,7051.80,2115.54,"NOVANET [10819]",Novanet,,5288.85,75,,,,,0,820.12,5994.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPLATZER TALISMAN DELIVERY SHEATH 8F 80",SUP-9-TDS-08F45-80,CDM,S27200284,LOCAL,0272,RC,,,both,,,5154.30,1546.29,"MULTIPLAN [10600]",Multiplan,,4381.16,85,,,,,0,599.45,4381.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUITY WHISPER VIEW DS CS-J - EACH",SUP-664643-001,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"UHC [10700]","United Healthcare",,717.82,63.3,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 8X6CM AXIS TUTOPLAST DERMIS ALLOGRAFT",SUP-939268,CDM,C1762,HCPCS,0278,RC,,,both,,,16629.00,4988.7,"PHCS [10601]",PHCS,,11640.3,70,,,,,0,1933.95,14134.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC IV Push Add Seq Drug",PX-260000009,CDM,96376,CPT,0260,RC,,,both,,,315.72,94.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,37.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",40.83,37.43,40.83,"1 through 10",36.72,315.72,"percent of total billed charges",
"SCR BONE 3.5MM 6MM 60MM 2.5MM PELVIC CORTEX SELF TAP SMALL",SUP-204.66,CDM,C1713,HCPCS,0278,RC,,,both,,,179.48,53.84,"BLUE CROSS [10001]","Blue Cross HMO",,70.36,39.2,,957.42,156.86,7483.26,51,20.87,152.56,"percent of total billed charges",
"IMPL BREAST 145CC P2.6CM LOW PLUS PROFILE ROUND SMOOTH SOFT",SUP-SSLP-145,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,878.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 15IN 34-38FR VENOUS ATRIAL CAVAL ADULT 3/8IN",SUP-93463,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.70,87.81,"CIGNA [10200]","Cigna Local Plus",,156.59,53.5,,,,,0,34.04,248.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 160MM 15MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424048,CDM,C1776,HCPCS,0278,RC,,,both,,,12181.95,3654.58,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1416.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1416.76,10354.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 12MM 5FR 2MM BALLOON DILATATION PEBAX",SUP-1012403-12,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"NOVANET [10819]",Novanet,,546.75,75,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1.5MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-01501,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4251.01,41.1,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM TIMAX 2.5MM TIBIA CORTICAL DISTAL",SUP-8150-37-026,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,362.5,45.9,,,,,0,91.85,671.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 TAPER 36MM HIP COCR SPECTRON EF",SUP-71303600,CDM,C1776,HCPCS,0278,RC,,,both,,,10236.15,3070.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4207.06,41.1,,6417.48,6417.48,6417.48,"1 through 10",1190.46,8700.73,"percent of total billed charges",
"SET INTRO PEEL-AWAY SAFE-T-J PERCUTANEOUS STAINLESS STEEL 2",SUP-G04502,CDM,C1892,HCPCS,0272,RC,,,both,,,818.10,245.43,"KAISER [10500]",Kaiser,,548.13,67,,,,,0,95.15,695.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TENOR VASCULAR MICRO STD ANGLE 165CM .018MM PLATINUM",SUP-TNR2811,CDM,C1769,HCPCS,0272,RC,,,both,,,1705.20,511.56,"NOVANET [10819]",Novanet,,1278.9,75,,,,,0,198.31,1449.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR JR4 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389696920,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"UHC [10700]","United Healthcare",,231.96,63.3,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZIPWIRE VASCULAR STD CORE TAPER 180CM 3CM .018IN",SUP-M00146236B1,CDM,C1769,HCPCS,0272,RC,,,both,,,339.13,101.74,"FIRST HEALTH [10303]","First Health",,271.3,80,,,,,0,39.44,288.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 20X16CM RESORBABLE GRID 1",SUP-F10256-1620G,CDM,C1781,HCPCS,0278,RC,,,both,,,31570.56,9471.17,"BLUE CROSS [10001]","Blue Cross HMO",,12375.66,39.2,,,,,0,3671.66,26834.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER XL POSTOPERATIVE FRONT HOOK AND EYE CLSR MAMMARY",SUP-131555,CDM,S27000186,LOCAL,0270,RC,,,both,,,191.40,57.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,130.15,68,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE HOFFMANN II MRI EXTERNAL FIXATION FRAME 6 PIN YELLOW",SUP-4921-1-100,CDM,S27800098,LOCAL,0278,RC,,,both,,,3638.25,1091.47,"MULTIPLAN [10600]",Multiplan,,3092.51,85,,,,,0,423.13,3092.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 11MM SECUR-FIT PLUS 5 HIP STERILE",SUP-6054-0511S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"UHC [10700]","United Healthcare",,10232.72,63.3,,8601.07,8395.67,8601.07,"1 through 10",1880.04,13740.62,"percent of total billed charges",
"SNARE SMALL OVAL 230CM 2.3MM SINGULAR SOFT LOOP WIRE",SUP-984,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,35.76,41.1,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drsg Interdry 3ft",PX-E27200318,CDM,E27200318,LOCAL,0272,RC,,,both,,,294.25,88.27,"KAISER [10500]",Kaiser,,197.15,67,,,,,0,34.22,250.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION 7.2FR 8FR DETACH CATH LOW PROFILE",SUP-P12355K,CDM,C1788,HCPCS,0278,RC,,,both,,,5092.20,1527.66,"KAISER [10500]",Kaiser,,3411.77,67,,,,,0,592.22,4328.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1 CP-2 ETHIBOND GII QUICKANCHOR PLUS ROTATOR CUFF",SUP-212031,CDM,C1713,HCPCS,0278,RC,,,both,,,5782.20,1734.66,"MULTIPLAN [10600]",Multiplan,,4914.87,85,,,,,0,672.47,4914.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL SHOULDER CAP",SUP-HSA1,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"BLUE CROSS [10001]","Blue Cross HMO",,8026.2,39.2,,5311.50,4717.44,5388.59,31,2381.24,17403.75,"percent of total billed charges",
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 12MM 6FR 5.5MM",SUP-H7493926712550,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"FIRST HEALTH [10303]","First Health",,453.6,80,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCK AUGMENTATION NEXGEN G 5MM KNEE DISTAL PRECOAT ROTATE",SUP-00599003710,CDM,C1776,HCPCS,0278,RC,,,both,,,7289.16,2186.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,863.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,847.73,6195.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH VERSACROSS 1 PIGTAIL 72CM 230CM GUIDING TRANSSEPTAL",SUP-VSTK0122,CDM,C1766,HCPCS,0272,RC,,,both,,,11212.50,3363.75,"UHC [10700]","United Healthcare",,7097.51,63.3,,,,,0,1304.01,9530.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 2-0 GS-21 .5 CIRCLE 9IN 37MM CLSR TAPER",SUP-VLOCM0345,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"NOVANET [10819]",Novanet,,146.88,75,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 135CM 6MM 20MM",SUP-H74938047620130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"NOVANET [10819]",Novanet,,3744,75,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chrom Count 5/1",PX-311000070,CDM,88261,CPT,0311,RC,,,both,,,128.70,38.61,"MULTIPLAN [10600]",Multiplan,,109.4,85,,,,,0,0.01,128.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 100MM 135CM 6MM 5FR VASCULAR NITINOL LOW",SUP-5F061003CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6072,40,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT WALKING 17.4IN AIRSELECT 10-13 11-15 LARGE STD",SUP-01EF-L,CDM,L4360,HCPCS,0274,RC,,,both,,,409.16,122.75,"NOVANET [10819]",Novanet,,306.87,75,,,,,0,47.59,347.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 266MM STAINLESS STEEL 4.5MM SCR 12 HOLE 4 COLUMN",SUP-02.124.413,CDM,C1713,HCPCS,0278,RC,,,both,,,10660.50,3198.15,"AETNA [10100]","Aetna HMO/PPO",,8475.1,79.5,,1521.93,481.35,16760.95,30,1239.82,9061.43,"percent of total billed charges",
"IMPL BREAST SMOOTH MOD + PROF XTRA 270CC",SUP-SMPX270,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,883.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",866.67,6334.2,"percent of total billed charges",
"LEAD PACING 80CM CORONARY VENOUS STEERABLE BIPOLAR ACUITY",SUP-4554,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"MULTIPLAN [10600]",Multiplan,,4765.95,85,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM PFC SIGMA TC3 2 KNEE POSTERIOR TITANIUM",SUP-960828,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"BLUE CROSS [10001]","Blue Cross PPO",,2011.29,39.2,,3949.44,3949.44,3949.44,"1 through 10",596.72,4361.21,"percent of total billed charges",
"OBLIQUE TLIF TI, 10X10X25MM 4",SUP-5400254,CDM,C1889,HCPCS,0278,RC,,,both,,,21225.60,6367.68,"UHC [10700]","United Healthcare",,13435.8,63.3,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .62IN 5FR .056IN LONG",SUP-5560040L,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"UHC [10700]","United Healthcare",,264.34,63.3,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM STAINLESS STEEL PARTIAL THREAD",SUP-214.540,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,129.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",127.51,931.96,"percent of total billed charges",
"CAGE SPINAL 45X18X10MM CASCADIA 0D PARALLEL TITANIUM POROUS",SUP-6101-2184510LP-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,42048.72,12614.62,"CIGNA [10200]","Cigna Open Access",,14086.32,33.5,,,,,0,4890.27,35741.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cold Agglutinin Screen",PX-302000224,CDM,86156,CPT,0302,RC,,,both,,,920.00,276,"NOVANET [10819]",Novanet,,690,75,,,,,0,0.01,782,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL PEDIATRIC XS 2.25IN PROCARE 2 PIECE CHIN",SUP-79-83161,CDM,S27000186,LOCAL,0270,RC,,,both,,,78.21,23.46,"CIGNA [10200]","Cigna Local Plus",,41.84,53.5,,,,,0,9.1,66.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.3MM 55MM CHARLOTTE STAINLESS STEEL LONG THREAD",SUP-44110041,CDM,C1713,HCPCS,0278,RC,,,both,,,2055.00,616.5,"AETNA [10100]","Aetna HMO/PPO",,1633.73,79.5,,1521.93,481.35,16760.95,30,239,1746.75,"percent of total billed charges",
"FIDAXOMICIN 200 MG TABLET",RX-110360,CDM,,,0637,RC,52015-0080-01,NDC,both,1,UN,1180.49,354.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,485.18,41.1,,,,,0,137.29,1003.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE ORTHOPEDIC THK1/8IN 2XL 13IN NEOPRENE KNEE EXTRA",SUP-79-82009,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.72,17.02,"CIGNA [10200]","Cigna Open Access",,32.27,56.9,,,,,0,6.6,48.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION FEMUR STD INSRT KIT BIO-MEDICUS",SUP-96550,CDM,S27200284,LOCAL,0272,RC,,,both,,,429.69,128.91,"AMERIGROUP MEDICAID [20100]",Amerigroup,,50.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,49.97,365.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE SIMPLEX HV 20ML 40GM STERILE",SUP-6194-1-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,658.29,197.49,"MULTIPLAN [10600]",Multiplan,,559.55,85,,,,,0,76.56,559.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 10MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0325,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross PPO",,371.5,39.2,,957.42,570.23,957.42,28,110.22,805.55,"percent of total billed charges",
"CATH EMBOLECTOMY 80CM 4FR 9MM STAINLESS STEEL SILICONE",SUP-NL4EMB80,CDM,C1757,HCPCS,0272,RC,,,both,,,376.01,112.8,"KAISER [10500]",Kaiser,,251.93,67,,,,,0,43.73,319.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERCI 95CM 8FR 5.9FR .038IN GUIDING SILICONE BALLOON",SUP-90073,CDM,C1887,HCPCS,0272,RC,,,both,,,6037.50,1811.25,"AETNA [10100]","Aetna HMO/PPO",,4799.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF CONDUCTR 110CM 7FR 2-5-2MM SPACING 55-75MM REACH",SUP-041005JM,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 40MM LPS TITANIUM MALE TO FEMALE TAPER ANTIROTATION",SUP-198707040,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"30.0 DIOPTER, SENSAR MONOFOCAL 3-PIECE FOLDABLE IOL, MODEL A",SUP-AR40E00300,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"KAISER [10500]",Kaiser,,624.11,67,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 2.5MM 55MM AXSOS STAINLESS STEEL CORTICAL",SUP-338655,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"CIGNA [10200]","Cigna Open Access",,130.98,56.9,,1144.80,304.56,2275.09,66,26.77,195.67,"percent of total billed charges",
"SUT SILK PERMA-HAND 2-0 FS 18IN BRAID BLACK NONABSORBABLE",SUP-685G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM ROUND FLUTE",SUP-5540010040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1288.63,386.59,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,591.48,45.9,,,,,0,149.87,1095.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC PULSED LAVAGE 14MM VERSAJET II 15D EXACT SET NARROWER",SUP-66800040,CDM,S27200284,LOCAL,0272,RC,,,both,,,4278.00,1283.4,"KAISER [10500]",Kaiser,,2866.26,67,,,,,0,497.53,3636.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS VISTA BRITE TIP 100CM 6FR JL4.5ST CURVE GUIDING",SUP-67001600,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"AETNA [10100]","Aetna HMO/PPO",,331.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE VARIABLE",SUP-02.107.202,CDM,C1713,HCPCS,0278,RC,,,both,,,5840.44,1752.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2680.76,45.9,,,,,0,679.24,4964.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP AEQRVS II SHD (RVS STEM,METP,RVS II INSERT,RVS II BPLATE",SUP-CAP1013,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"CIGNA [10200]",Cigna,,18144,40,,5873.17,5873.17,5873.17,"1 through 10",5275.37,38556,"percent of total billed charges",
"SUT POLYPROPYLENE PROLENE 5-0 C-1 36IN 2 ARM MONOFILAMENT",SUP-8321H,CDM,S27200284,LOCAL,0272,RC,,,both,,,176.54,52.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.53,150.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 90CM 20MM 4FR 6MM .018IN BALLOON",SUP-PCP060020090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"MULTIPLAN [10600]",Multiplan,,1046.52,85,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM RELINE C SPINE MULTIAXIAL NONSTERILE",SUP-3903514,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD XLNK MEDIUM SPINE",SUP-7752536,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1382.35,28.62,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 18X18MM DYNANITE SUPERMX NITINOL COMPRESSION LOW",SUP-AR-8719MXDS-1818,CDM,C1713,HCPCS,0278,RC,,,both,,,17215.50,5164.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2040.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,2002.16,14633.18,"percent of total billed charges",
"BONE CORT CANC BLK CRNRSTN ASR 11X14X11MM",SUP-245141,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 6FR 20CM COONS STERILE DISPOSABLE TAPER ACCEPTS",SUP-G04221,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.92,32.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,49.08,45.9,,,,,0,12.43,90.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VISIGLIDE ENDOSCOPIC ANGLE 2700MM .025IN FLUORINE",SUP-G-240-2527A,CDM,C1769,HCPCS,0272,RC,,,both,,,1288.95,386.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,152.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,149.9,1095.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RABINOV 30CM 30GA .012IN SIALOGRAPHY SUBMANDIBULAR DUCT",SUP-G01323,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.91,101.97,"AETNA [10100]","Aetna HMO/PPO",,270.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.53,288.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT 12MM ALIF",SUP-3W3212,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"MULTIPLAN [10600]",Multiplan,,17973.52,85,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT STEM 75MM 14MM NEXGEN FLUTE KNEE TIBIA TIVANIUM SHARP",SUP-598801514,CDM,C1776,HCPCS,0278,RC,,,both,,,7446.48,2233.94,"NOVANET [10819]",Novanet,,5584.86,75,,,,,0,866.03,6329.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STATLOCK SECUREMENT PERCUTANEOUS SHEATH INTRO",SUP-0684-00-0493,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.58,49.67,"MULTIPLAN [10600]",Multiplan,,140.74,85,,,,,0,19.26,140.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 60MM 75CM 16MM 9FR 100CM",SUP-H965403320,CDM,C1876,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 5MM 40MM VIPER PRIME TITANIUM SPINE POLYAXIAL EXT",SUP-186750240,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STYLET ASSORTED 100CM UNIVERSAL J STRAIGHT REPOSITIONING",SUP-DS06003/100,CDM,S27500001,LOCAL,0275,RC,,,both,,,453.60,136.08,"BLUE CROSS [10001]","Blue Cross PPO",,177.81,39.2,,,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,inpatient,,,111735.95,33520.78,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,13285.61,,"Case rate ($12,898.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,977.27, add-ons for qualifying new technology services are included. If operating cost exceeds $45,016.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,287.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $11,993.10. The transfer operating threshold is the transfer adjustment factor * $11,977.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.54. The transfer capital threshold is the transfer adjustment factor * $905.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,60710.16,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"EPS EXT CABLE B/T/Q BLK 150 US",SUP-401980R,CDM,S27000186,LOCAL,0270,RC,,,both,,,518.40,155.52,"CIGNA [10200]","Cigna Open Access",,294.97,56.9,,,,,0,60.29,440.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE HEARTMATE VENTRICULAR ASSIST UNIVERSAL BTTRY CHRG",SUP-1440,CDM,Q0495,HCPCS,0274,RC,,,both,,,44089.92,13226.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,12618.54,28.62,,,,,0,5127.66,37476.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEQUALIS PERFORM GLENOID (KEELED)- L40",SUP-DWE521,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4276.04,45.9,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 8X20 135CM SL",SUP-48008002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,99.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 24CM 6FR URETERAL FLEXITHANE METAL",SUP-H7493936106240,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"CIGNA [10200]",Cigna,,842.72,68,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE OPHTHALMIC .9MM MICROSMOOTH SMALL PARTS KIT STERILE",SUP-8065750159,CDM,S27200284,LOCAL,0272,RC,,,both,,,227.94,68.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.51,193.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT VITOSS FOAM BIMODAL 1.2CC",SUP-2102-1901,CDM,C1713,HCPCS,0278,RC,,,both,,,3868.83,1160.65,"CIGNA [10200]",Cigna,,2630.8,68,,1831.33,1831.33,1831.33,16,449.94,3288.51,"percent of total billed charges",
"GWIRE SHEPHERD ANGIOGRAPHIC STRAIGHT .018IN 6GM PERIPHERAL",SUP-PSP18S-30006,CDM,C1769,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 12CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192112010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,139.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL JACOBSON MOSQUITO MICRO CURVE 5IN VERY SLENDER",SUP-15-4182,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.39,53.82,"PHCS [10601]",PHCS,,125.57,70,,,,,0,20.86,152.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.5CM NATRELLE INSPIRA P2.7CM LOW PROFILE ROUND",SUP-MSZ-L320,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.69,42.81,"CIGNA [10200]",Cigna,,97.03,68,,,,,0,16.59,121.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Hemodialysis Temp",PX-E27200058,CDM,C1752,HCPCS,0272,RC,,,both,,,941.16,282.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,109.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,109.46,799.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Aerobic Presump ID Cornea",PX-306000030,CDM,87070,CPT,0306,RC,,,both,,,382.00,114.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7.76,,,,,,,0.01,324.7,"fee schedule",
"HC Bronch W Dest Tumor Laser/Cryo",PX-750000018,CDM,31641,CPT,0750,RC,,,both,,,6667.30,2000.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4656,,"Case rate ($4,656). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,775.41,6667.3,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intravasc Litho Iliac",PX-361000703,CDM,37262,CPT,0361,RC,,,both,,,6377.03,1913.11,"MULTIPLAN [10600]",Multiplan,,5420.48,85,,,,,0,6.38,6377.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM PFC SIGMA TC3 4 KNEE RIGHT TITANIUM CEMENTED",SUP-960883,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"CIGNA [10200]","Cigna Open Access",,2919.45,56.9,,5302.19,4377.88,6578.61,27,596.72,4361.21,"percent of total billed charges",
"GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION",RX-41137,CDM,A9577,HCPCS,0636,RC,00270-5164-13,NDC,both,10,ML,300.00,90,"UHC [10700]","United Healthcare",,35.1,,,,,,,35.1,255,"fee schedule",
"HC Vasc Embol Occl Venous",PX-361000320,CDM,37241,CPT,0361,RC,,,both,,,13861.00,4158.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6657,,"Case rate ($6,657). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1612.03,11781.85,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUSELECT 155CM 2-2.8FR .021IN MICRO EMBOLIZATION",SUP-M001394101550,CDM,C1887,HCPCS,0272,RC,,,both,,,5102.55,1530.76,"AETNA [10100]","Aetna HMO/PPO",,4056.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,593.43,4337.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 30CM 3CM 6FR .035IN",SUP-M006192135190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,399.31,28.62,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEMLESS",SUP-CP-ECLIPSE,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",3297.11,24097.5,"percent of total billed charges",
"VALVE MITRAL 20.5MM 29MM 38MM 26MM MOSAIC CINCH RING HEART P",SUP-310C29,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10962,40,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 20.5MM 29MM 38MM 26MM MOSAIC CINCH RING HEART P",SUP-310C29,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7843.31,28.62,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET 32MM .25IN STD SPINAL CAP",SUP-779170005,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"AETNA [10100]","Aetna HMO/PPO",,1913.25,79.5,,1521.93,481.35,16760.95,30,279.89,2045.61,"percent of total billed charges",
"SCR BONE 3.5MM 16MM TITANIUM T15 FULL THREAD SELF TAP LOCK",SUP-412.104,CDM,C1713,HCPCS,0278,RC,,,both,,,954.83,286.45,"KAISER [10500]",Kaiser,,639.74,67,,,,,0,111.05,811.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL SF J CURVE ABLATION",SUP-D134703,CDM,C1732,HCPCS,0272,RC,,,both,,,20304.90,6091.47,"FIRST HEALTH [10303]","First Health",,16243.92,80,,,,,0,2361.46,17259.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 125CM 5FR VTK CURVE ANGIOGRAPHIC",SUP-G47042,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"UHC [10700]","United Healthcare",,133.26,63.3,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 10MM 2.75MM BALLOON DILATATION STERILE",SUP-227-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VERIPATH 50CM 8FR .088IN LIMA CURVE GUIDING STAINLESS",SUP-1005597-08,CDM,C1887,HCPCS,0272,RC,,,both,,,382.80,114.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,157.33,41.1,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE",RX-122469,CDM,,,0250,RC,70092-1119-44,NDC,both,5,ML,59.92,17.98,"AETNA [10100]","Aetna HMO/PPO",,47.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.97,50.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR TRITANIUM F HEMISPHERICAL OD60 MM SOLID BAC",SUP-500-03-60F,CDM,C1776,HCPCS,0278,RC,,,both,,,12551.10,3765.33,"FIRST HEALTH [10303]","First Health",,10040.88,80,,,,,0,1459.69,10668.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD 12FR URETHRAL NATURAL RUBBER SILICONE ELASTOMER 5",SUP-265712,CDM,S27200284,LOCAL,0272,RC,,,both,,,1.84,0.55,"PHCS [10601]",PHCS,,1.29,70,,,,,0,0.21,1.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sugars Single Ql",PX-300000045,CDM,84376,CPT,0301,RC,,,both,,,71.00,21.3,"MULTIPLAN [10600]",Multiplan,,60.35,85,,,,,0,0.01,60.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 485CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-485,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"MULTIPLAN [10600]",Multiplan,,6422.18,85,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY 10CM 10GA 12GA ARROW ONCONTROL BONE LESION 14CM",SUP-9463-VC-006,CDM,C1830,HCPCS,0272,RC,,,both,,,3237.50,971.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,383.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,376.52,2751.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Fetal Doppler Echo F/U",PX-402000059,CDM,76828,CPT,0402,RC,,,both,,,368.00,110.4,"FIRST HEALTH [10303]","First Health",,294.4,80,,,,,0,35.57,368,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Ribbon Mesalt",PX-E27200122,CDM,E27200122,LOCAL,0272,RC,,,both,,,40.73,12.22,"KAISER [10500]",Kaiser,,27.29,67,,,,,0,4.74,34.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Preg Nuch Meas Addl Gest",PX-402000058,CDM,76814,CPT,0402,RC,,,both,,,195.83,58.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.78,195.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTNR DRSG 25YD 7 SMALL TUBULAR MT SPANDAGE ELASTIC NET LATEX",SUP-MT07,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.17,23.15,"CIGNA [10200]","Cigna Open Access",,43.91,56.9,,,,,0,8.97,65.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 5-0 C-1 36IN 2 ARM MONOFILAMENT BLUE",SUP-8720ZH,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"NOVANET [10819]",Novanet,,18.75,75,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT 22MM ALIF",SUP-3W3222,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"NOVANET [10819]",Novanet,,15858.99,75,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL 22-30CM 7FR .038IN STRAIGHT URETERAL",SUP-M006180157010,CDM,C2617,HCPCS,0278,RC,,,both,,,1077.22,323.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,127.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,125.28,915.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMB BLADE SMARTRELEASE STERILE DISPOSABLE ECTR",SUP-81010-6,CDM,S27200284,LOCAL,0272,RC,,,both,,,1900.00,570,"AETNA [10100]","Aetna HMO/PPO",,1510.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,220.97,1615,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATENOLOL 25 MG TABLET",RX-717,CDM,,,0637,RC,51079-0759-01,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC CROME DR 2 CHMBR DF-1 PIN PLUG RADIOPAQUE",SUP-DDPC3D1,CDM,C1882,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"CIGNA [10200]","Cigna Open Access",,19522.13,33.5,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 60MM 16MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U16060090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4750.65,45.9,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 5MM KII FIOS FIRST ENTRY ADVANCED",SUP-CFF01,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"CIGNA [10200]",Cigna,,97.61,68,,,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL IO-FLEX MICROBLADE SHAVER SPINE CANN FLEXIBLE",SUP-IO-IP,CDM,S27200284,LOCAL,0272,RC,,,both,,,1599.75,479.92,"FIRST HEALTH [10303]","First Health",,1279.8,80,,,,,0,186.05,1359.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XACT 40MM 136CM 8-6MM TAPER VASCULAR NITINOL CAROTID",SUP-82090-01,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"CIGNA [10200]",Cigna,,6364.8,68,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE STANDARD TIP HPS PLS 1.1 MM X 152 MM",SUP-KWIR-HPS-PLS,CDM,S27000186,LOCAL,0270,RC,,,both,,,356.70,107.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,163.73,45.9,,,,,0,41.48,303.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC",390,MS-DRG,,,,,,,inpatient,,,19097.53,5729.26,"PHCS [10601]",PHCS,,7561,,,,,,,3374.47,13566.82,"per diem","Estimated amount calculated based on 2 day length of stay."
"CATH MARINER 40CM 5FR KUMPE CURVE ANGIOGRAPHIC DURATION",SUP-H787117327025,CDM,C1887,HCPCS,0272,RC,,,both,,,466.56,139.97,"AETNA [10100]","Aetna HMO/PPO",,370.92,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.26,396.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 45MM 28MM 13FR TRIVASCULAR OVATION PRIME OVATION",SUP-TV-EX282845-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3956.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 12MM STD WALL GORE-TEX RING 30CM STERILE",SUP-R12030030,CDM,C1768,HCPCS,0278,RC,,,both,,,7969.50,2390.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2280.87,28.62,,,,,0,926.85,6774.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING PASSIVE FIXATION BIPOLAR DUAL COIL 65CM 17CM",SUP-1570,CDM,C1895,HCPCS,0278,RC,,,both,,,20538.00,6161.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5545.26,27,,,,,0,2388.57,17457.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.324,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,441.36,3225.75,"percent of total billed charges",
"SCR BONE 4MM 35MM SOLERA CD HORIZON OSTEOGRIP TITANIUM COCR",SUP-54840004035,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UHC [10700]","United Healthcare",,6043.16,63.3,,5023.51,2672.93,6679.78,18,1110.3,8114.82,"percent of total billed charges",
"SCR BONE 6.5MM 105MM 20MM ASNIS III TITANIUM HIP FEMUR SELF",SUP-602705,CDM,C1713,HCPCS,0278,RC,,,both,,,1866.45,559.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,217.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",217.07,1586.48,"percent of total billed charges",
"LENS IOL +29 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.290,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC INVENTRA 7 HOME MON IMPLANTABLE DF4/IS4 HF-T",SUP-393012,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6839.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 18MM OSTEOLOCK TITANIUM HIP ACETABULAR",SUP-5260-5-018,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,217.91,28.62,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 C-H STD 66X42X10MM KNEE PROLONG NEXGEN",SUP-00595203010,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"NOVANET [10819]",Novanet,,5879.84,75,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VENTRALIGHT ST ECHO 2 25X20CM ELLIPSE",SUP-5992025,CDM,C1781,HCPCS,0278,RC,,,both,,,13069.29,3920.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5227.72,40,,,,,0,1519.96,11108.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 4CM 3MM BALLOON DILATATION HYDROPHILIC",SUP-G50328,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1606.45,68,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VORICONAZOLE 200 MG TABLET",RX-33009,CDM,,,0637,RC,65862-0892-30,NDC,both,1,UN,189.93,56.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,129.15,68,,,,,0,22.09,161.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Orbit MRI Screen",PX-351000017,CDM,70480,CPT,0351,RC,,,both,,,2767.89,830.37,"PHCS [10601]",PHCS,,1937.52,70,,,,,0,261.88,2352.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION 14MM LAPIPLASTY MICRO-QUAD RAPID COMPRESSION",SUP-SK61,CDM,C1713,HCPCS,0278,RC,,,both,,,24406.20,7321.86,"UHC [10700]","United Healthcare",,15449.12,63.3,,5023.51,2672.93,6679.78,18,2838.44,20745.27,"percent of total billed charges",
"CATH STERLING MONORAIL 135CM 30MM 3.8-3.4FR 5.5MM LOW",SUP-H74939031553010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP CURAPLEX CURAVIEW MILLER 000 MINI LED STERILE",SUP-301-LED-1000M,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.97,29.09,"KAISER [10500]",Kaiser,,64.97,67,,,,,0,11.28,82.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alpha1 Antitrypsin Phenotype",PX-301000096,CDM,82104,CPT,0301,RC,,,both,,,981.35,294.4,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,834.15,"per diem",
"INSRT TIBIAL 4 13MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P413,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"AETNA [10100]","Aetna HMO/PPO",,6642.94,79.5,,10981.53,8986.79,12413.38,12,971.79,7102.52,"percent of total billed charges",
"HC MRI Brain Functional",PX-611000004,CDM,70554,CPT,0611,RC,,,both,,,3373.00,1011.9,"AETNA [10100]","Aetna HMO/PPO",,2816,,"Per diem ($2,816). Each eligible service on a given day will be paid its own per diem rate.",,,,0,392.28,2867.05,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.75CM NATRELLE INSPIRA P4.2CM MODERATE PROFILE",SUP-MSZ-M360,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"UHC [10700]","United Healthcare",,100.13,63.3,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP RIGHT TITANIUM RESTORATION GAP II",SUP-2082-0056R,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Stimulus Evoked Response",PX-361000449,CDM,51792,CPT,0361,RC,,,both,,,594.00,178.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,70.39,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.08,594,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LOCKING AEQUALIS FLEX REVIVE SHOULDER",SUP-ARS655200,CDM,C1713,HCPCS,0278,RC,,,both,,,2261.00,678.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,267.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,262.95,1921.85,"percent of total billed charges",
"CATH PROGREAT 110CM 2.4-2.9FR .022IN MICRO INTERVENTIONAL",SUP-MC*PB2411Y,CDM,C1887,HCPCS,0272,RC,,,both,,,2463.75,739.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1675.35,68,,,,,0,286.53,2094.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 10MM 4MM OFFSET KNEE HEMICAPWAVE 36/35MM",SUP-PX02-1004-W,CDM,C1776,HCPCS,0278,RC,,,both,,,27216.00,8164.8,"CIGNA [10200]",Cigna,,10886.4,40,,5873.17,5873.17,5873.17,"1 through 10",3165.22,23133.6,"percent of total billed charges",
"ANCHOR SUT 2 SUPER REVO HI-FI",SUP-C6140HB,CDM,C1713,HCPCS,0278,RC,,,both,,,1568.48,470.54,"BLUE CROSS [10001]","Blue Cross PPO",,614.84,39.2,,957.42,570.23,957.42,28,182.41,1333.21,"percent of total billed charges",
"GRAFT BONE ALLOMATRIX C CANCELLOUS 5ML PUTTY MOLDABLE",SUP-860C0500,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1421.84,28.62,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 1 11MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530-P-111,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"FIRST HEALTH [10303]","First Health",,6684.72,80,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 7FR .081IN GUIDING",SUP-LA7EBU375D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 5-0 RB-1 36IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8556,CDM,S27200284,LOCAL,0272,RC,,,both,,,255.14,76.54,"PHCS [10601]",PHCS,,178.6,70,,,,,0,29.67,216.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM 12/14 TAPER 28MM HIP OXINIUM ECHELON",SUP-71342803,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4194.54,27,,,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFE-T-J VASCULAR 15MM RADIUS TAPER 6CM 145CM 6CM .035",SUP-G00509,CDM,C1769,HCPCS,0272,RC,,,both,,,121.71,36.51,"NOVANET [10819]",Novanet,,91.28,75,,,,,0,14.15,103.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 65CM 22MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES2265CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"NOVANET [10819]",Novanet,,5951.25,75,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 80MM 2.2MM MIDAS REX LEGEND MATCH HEAD",SUP-8MH22,CDM,S27200284,LOCAL,0272,RC,,,both,,,974.03,292.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,115.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.28,827.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 37.5MM SHORT THREAD ANKLE FOOT CANNULATED",SUP-MSD01040375S,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross HMO",,555.66,39.2,,957.42,156.86,7483.26,51,164.86,1204.88,"percent of total billed charges",
"TOURNIQUET DSP CUF SPSB STL34",SUP-60707510600,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.84,63.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,24.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.52,179.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 75MM 16MM UNIVERSAL FLUTE KNEE PRESS FIT",SUP-86-7416,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"CIGNA [10200]","Cigna Local Plus",,4333.82,53.5,,5372.07,4581.20,7242.98,23,942.1,6885.51,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 8MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25008W,CDM,C1874,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Local Plus",,1905.94,53.5,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 80MM 130CM 8MM VASCULAR NITINOL ILIAC",SUP-SC880LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]",Cigna,,4926.6,68,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR HEMI 3HL 50MM",SUP-430-98-050,CDM,C1776,HCPCS,0278,RC,,,both,,,3200.74,960.22,"CIGNA [10200]",Cigna,,2176.5,68,,5873.17,5873.17,5873.17,"1 through 10",372.25,2720.63,"percent of total billed charges",
"CATH EMERGE MONORAIL 144CM 15MM 6FR 3.5MM .07IN BALLOON",SUP-H7493918915350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"NOVANET [10819]",Novanet,,425.25,75,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 128MM 12MM PRIMARY PRESS FIT STD OFFSET TAPERED",SUP-00786401200,CDM,C1776,HCPCS,0278,RC,,,both,,,30164.40,9049.32,"FIRST HEALTH [10303]","First Health",,24131.52,80,,,,,0,3508.12,25639.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ERCP TAPER TANDEM RX 195CM 7-5.5FR BILIARY STERILE",SUP-M00545820,CDM,S27200284,LOCAL,0272,RC,,,both,,,483.89,145.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,57.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.28,411.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 22MM LOW PROFILE SCREWS TITANIUM VARIABLE",SUP-AR-8724V-22,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",188.41,1377,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL 24FR POWERBALL UROLOGY RESECTOSCOPE",SUP-M0068802111,CDM,S27200284,LOCAL,0272,RC,,,both,,,956.45,286.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,393.1,41.1,,,,,0,111.24,812.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PEELAWAY 6 FR",SUP-INT-106-16,CDM,C1887,HCPCS,0272,RC,,,both,,,130.50,39.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE ESC 10D +4MM 52MM 32MM GVF",SUP-121832752,CDM,C1776,HCPCS,0278,RC,,,both,,,20472.48,6141.74,"MULTIPLAN [10600]",Multiplan,,17401.61,85,,,,,0,2380.95,17401.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4535,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,1831.33,1831.33,1831.33,16,348.9,2550,"percent of total billed charges",
"TUBE CALIBRATION ENDOLUMIK 40FR GASTRIC CALIBRATION TUBE M",SUP-EGCT40M,CDM,S27000186,LOCAL,0270,RC,,,both,,,1950.00,585,"CIGNA [10200]","Cigna Open Access",,1109.55,56.9,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 15MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158104115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3198.16,28.62,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE ESC +4MM NEUTRAL 48MM 28MM GVF",SUP-121828648,CDM,C1776,HCPCS,0278,RC,,,both,,,20986.56,6295.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8394.62,40,,,,,0,2440.74,17838.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CGUARD PRIME CAROTID STENT SYSTEM 135CM 08MM LENGTH 30MM",SUP-CND0830,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"CIGNA [10200]","Cigna Open Access",,6954.1,33.5,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 20MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206080210,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER SHORT TIP RELOAD 30MM GRAY",SUP-ASR30GS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +19.5 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.195,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross HMO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pinworm Prep",PX-306000077,CDM,87172,CPT,0306,RC,,,both,,,123.00,36.9,"CIGNA [10200]","Cigna Open Access",,9.39,,,,,,,0.01,104.55,"fee schedule",
"IMPL COCHLEAR 12MM 4MM DERMALOCK BAHA TITANIUM HA 1 STAGE",SUP-93332,CDM,L8690,HCPCS,0278,RC,,,both,,,21042.00,6312.6,"BLUE CROSS [10001]","Blue Cross HMO",,8248.46,39.2,,,,,0,2447.18,17885.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.0 PLY SCRW CFX 5.0X22",SUP-102050222,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,3978.14,359.25,3978.14,24,641.98,4692,"percent of total billed charges",
"CATH SELECT 125CM 90CM 6FR BERENSTEIN CURVE DELIVERY SYSTEM",SUP-BMX9690BER125,CDM,S27200284,LOCAL,0272,RC,,,both,,,6727.50,2018.25,"NOVANET [10819]",Novanet,,5045.63,75,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 10-0 BV100-4 5IN MONOFILAMENT BLACK",SUP-2830G,CDM,S27200284,LOCAL,0272,RC,,,both,,,260.26,78.08,"AETNA [10100]","Aetna HMO/PPO",,206.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.27,221.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 100MM 3MM BALLOON DILATATION RAPID",SUP-47530100L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 30MM 80CM 8MM VASCULAR PERIPHERAL SELF",SUP-1012530-30,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 3/16IN 8IN TRACHEAL RETRACTION SHARP STAINLESS STEEL",SUP-4115,CDM,S27200284,LOCAL,0272,RC,,,both,,,215.93,64.78,"PHCS [10601]",PHCS,,151.15,70,,,,,0,25.11,183.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 6.0 MM X 80 MM X 130 CM",SUP-IPU06008013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,956.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 35CM .02IN 8MM PENUMBRA COIL 400 RUBY",SUP-RBY4C0835,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.00,2003.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,776.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.65,5676.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG LIEBEL-FLARSHEIM URODRAIN EXPANDABLE TUBING",SUP-335563,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.96,32.69,"FIRST HEALTH [10303]","First Health",,87.17,80,,,,,0,12.67,92.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 85MM TITANIUM T25 XL FULL THREAD COMPRESSION",SUP-AR-8770-85H,CDM,C1713,HCPCS,0278,RC,,,both,,,4795.50,1438.65,"CIGNA [10200]","Cigna Local Plus",,2565.59,53.5,,3978.14,359.25,3978.14,24,557.72,4076.18,"percent of total billed charges",
"CMPNT TIBIAL PERSONA 0D F KNEE RIGHT OSSEOTI KEEL",SUP-42535007502,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"KAISER [10500]",Kaiser,,9222.89,67,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAYONET 8IN STR TIP DN6214",SUP-DN6214,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,188.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +7.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000075,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 60MM 150CM 7MM VASCULAR NICKEL",SUP-EVD35-07-060-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"BLUE CROSS [10001]","Blue Cross HMO",,2463.72,39.2,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL CANNULATED QUICK COUPLING 3.5/4 MM HEAD SCR",SUP-03.333.212S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3103.65,931.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1275.6,41.1,,,,,0,360.95,2638.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP 12 SCALLOP CLUSTER HOLE SNAP FIT",SUP-00875705001,CDM,C1776,HCPCS,0278,RC,,,both,,,11012.40,3303.72,"CIGNA [10200]",Cigna,,7488.43,68,,5873.17,5873.17,5873.17,"1 through 10",1280.74,9360.54,"percent of total billed charges",
"LEAD NEROSTIMLTR AXONICS PERCUTANEOUS NERVE EVALUATION",SUP-1901,CDM,C1897,HCPCS,0278,RC,,,both,,,348.00,104.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,236.64,68,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 100MM 16MM NEXGEN STRAIGHT KNEE ROTATE HINGE 145MM",SUP-00598801016,CDM,C1776,HCPCS,0278,RC,,,both,,,8049.54,2414.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,953.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,936.16,6842.11,"percent of total billed charges",
"KIT MICROINTRODUCER NITINOL MANDREL",SUP-9220V,CDM,C1894,HCPCS,0272,RC,,,both,,,169.65,50.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,69.73,41.1,,,,,0,19.73,144.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VENTRICULAR SHUNT PROCEDURES WITH MCC",031,MS-DRG,,,,,,,inpatient,,,156227.23,46868.17,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE ER 100 MG TABLET,EXTENDED RELEASE",RX-20919,CDM,,,0250,RC,00406-8390-01,NDC,both,1,UN,52.66,15.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Transport Advanced One Way",PX-546000003,CDM,A0427,HCPCS,0546,RC,,,both,,,2466.12,739.84,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VXSK-180J RF WIRE 63CM/45DEG/D1 SHEATH",SUP-VXSK0102,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"I-GEL, SINGLE USE SUPRAGLOTTIC AIRWAY, SIZE 2",SUP-8202000,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.13,23.74,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNAP(R) LONG DRESSING KIT - 10 KIT CASE",SUP-SKTF14X34,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL 50 MCG/ML INJECTION SUPERORDERABLE|DISCARDED DRUG NOT ADMINISTE",RX-4083037,CDM,J3010,HCPCS,0636,RC,00641-6029-01,NDC,both,20,ML,72.48,21.74,"FIRST HEALTH [10303]","First Health",JW,57.98,80,,,,,0,8.59,61.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM LAVA-34 EMBOLIC 2ML LIQUID",SUP-SLLES342,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1962.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN EXTRA BACKUP 4.5 LEFT CURVE",SUP-LA6EBU45,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 90CC 1.7-10MM CANCELLOUS ALLOGRAFT FREEZE",SUP-400160,CDM,C1713,HCPCS,0278,RC,,,both,,,7182.90,2154.87,"MULTIPLAN [10600]",Multiplan,,6105.47,85,,,,,0,835.37,6105.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 14X12.9CM 520ML STYLE 410 NATRELLE SILICONE P6.5",SUP-MX-410520,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2554.34,45.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CELECOXIB 200 MG CAPSULE",RX-24501,CDM,,,0637,RC,50268-0169-11,NDC,both,1,UN,12.21,3.66,"PHCS [10601]",PHCS,,8.55,70,,,,,0,1.42,10.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 330CC W11XH11.5CM P5.6CM SILICONE GEL FILLED",SUP-334-1104,CDM,C1789,HCPCS,0278,RC,,,both,,,7583.10,2274.93,"KAISER [10500]",Kaiser,,5080.68,67,,,,,0,881.91,6445.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 100MM 3MM .018IN BALLOON",SUP-R51003010L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"KAISER [10500]",Kaiser,,1367.81,67,,,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING 43IN 8FR CORFLO-ULTRA ENTERAL POLYURETHANE",SUP-8884710867,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.70,22.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.69,63.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD INSULATION CARDIAC ADULT",SUP-ACIP,CDM,S27200284,LOCAL,0272,RC,,,both,,,148.38,44.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.26,126.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL BLOCK",SUP-345744,CDM,S27800098,LOCAL,0278,RC,,,both,,,4975.00,1492.5,"MULTIPLAN [10600]",Multiplan,,4228.75,85,,,,,0,578.59,4228.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 9CM 7FR PIGTAIL CURVE PANCREATIC POLYMER",SUP-M00537280,CDM,C2617,HCPCS,0278,RC,,,both,,,722.28,216.68,"BLUE CROSS [10001]","Blue Cross HMO",,283.13,39.2,,,,,0,84,613.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 5FR JCL4 CURVE GUIDING NYLON CORONARY",SUP-LA5JCL40,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 30MM 6FR 3MM .07IN BALLOON",SUP-H7493918930300,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AETNA [10100]","Aetna HMO/PPO",,450.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH PORTEX STERILE LATEX FREE DISPOSABLE",SUP-101/595/090,CDM,S27200284,LOCAL,0272,RC,,,both,,,3080.70,924.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,365.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,358.29,2618.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA ALLOGRAFT STRUT FROZEN 110X6.5MM",SUP-450656,CDM,S27800098,LOCAL,0278,RC,,,both,,,6632.28,1989.68,"PHCS [10601]",PHCS,,4642.6,70,,,,,0,771.33,5637.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 390MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.358S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"MULTIPLAN [10600]",Multiplan,,7065.57,85,,,,,0,966.74,7065.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ORTHOPEDIC 13-14IN NYLON ANKLE ELASTIC CUFF CLSR LOW",SUP-AB2900-16,CDM,S27000186,LOCAL,0270,RC,,,both,,,108.05,32.41,"KAISER [10500]",Kaiser,,72.39,67,,,,,0,12.57,91.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM TKR PATELLOFEMORAL",SUP-98000661000,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Local Plus",,5953.5,31.5,,5372.07,4581.20,7242.98,23,2198.07,16065,"percent of total billed charges",
"SCREW NON-LOCKING 1.5MM X 15MM TI",SUP-VAN-15150-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,113.04,826.2,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 18CM 3CM 5FR .038IN 2",SUP-M006192115170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"KAISER [10500]",Kaiser,,934.8,67,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 800ML STYLE 20 SMOOTH NATRELLE SILICONE P6.1CM",SUP-20-800,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,423.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",415.19,3034.5,"percent of total billed charges",
"INFLUX PROTEIIIOS GROWTH FACTOR XL",SUP-IFLX-GF-100,CDM,S27800098,LOCAL,0278,RC,,,both,,,26019.00,7805.7,"UHC [10700]","United Healthcare",,16470.03,63.3,,,,,0,3026.01,22116.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 103MM COLLAR ACTIS DUOFIX 4 12/14 HIGH OFFSET",SUP-101012040,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12190.5,40,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 8FR L28CM FIRM TRI LAYER DESIGN RAW COLORANT",SUP-M0061902440,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 10X9X6MM ARCH PARALLEL SPINE FREEZE DRIED",SUP-15110,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR NONABSORBABLE SAFFRON STERILE LATEX FREE DISPOSABLE",SUP-520350,CDM,S27800098,LOCAL,0278,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 7X10CM KERECIS OMEGA3 MARIGEN FISH SKIN STERILE",SUP-50200S03B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,25143.30,7542.99,"AETNA [10100]","Aetna HMO/PPO",,19988.92,79.5,,,,,0,180.89,21371.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 NARROW KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508006401,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"KAISER [10500]",Kaiser,,17579.62,67,,,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSORB GT1 28MM 3MM CORONARY EVEROLIMUS ELUTING POLY L",SUP-1235300-28,CDM,C1874,HCPCS,0278,RC,,,both,,,8280.00,2484,"NOVANET [10819]",Novanet,,6210,75,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP SURGICAL 3CM ADVINCULA DELINEATOR KOH-EFFICIENT KOH",SUP-AD750-KE30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +24 DIOPTER +3 CYL MODIFIED C BICONVEX 13MM 6MM","SUP-ZCT300 24.0",CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT PRESS FIT EMPOWR 3D KNEE STERILE",SUP-243-01-104,CDM,C1776,HCPCS,0278,RC,,,both,,,27824.45,8347.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11435.85,41.1,,6417.48,6417.48,6417.48,"1 through 10",3235.98,23650.78,"percent of total billed charges",
"HC I&D Wnd Post-OP Cmplx",PX-510000005,CDM,10180,CPT,0761,RC,,,both,,,16672.00,5001.6,"BLUE CROSS [10001]","Blue Cross PPO",,4431.65,,"Case rate ($4,431.65). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1793,14171.2,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 1/8IN HEADLESS SQUARE END 3.5IN STAINLESS STEEL",SUP-7650-2038,CDM,S27200284,LOCAL,0272,RC,,,both,,,2947.50,884.25,"CIGNA [10200]","Cigna Local Plus",,1576.91,53.5,,,,,0,342.79,2505.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT GPS SMALL 4 CC PUTTY BIOACT",SUP-76000040,CDM,C1713,HCPCS,0278,RC,,,both,,,6624.00,1987.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,784.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",770.37,5630.4,"percent of total billed charges",
"SUT CHROMIC 1 MO-4 27IN MONOFILAMENT 1 STRAND BROWN",SUP-4925H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 14MM LEGION STRAIGHT KNEE TITANIUM CEMENT",SUP-71424186,CDM,C1776,HCPCS,0278,RC,,,both,,,12357.90,3707.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5079.1,41.1,,6417.48,6417.48,6417.48,"1 through 10",1437.22,10504.22,"percent of total billed charges",
"STENT ZILVER 518 FLEXOR 40MM 125CM 4MM 7FR BILIARY NITINOL",SUP-G31439,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,495.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 96MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 7X3",SUP-241.071,CDM,S27800098,LOCAL,0278,RC,,,both,,,2463.30,738.99,"CIGNA [10200]",Cigna,,1675.04,68,,,,,0,286.48,2093.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 110MM 2.5MM XPS CURVE DIAMOND",SUP-1882569HS,CDM,S27200284,LOCAL,0272,RC,,,both,,,2492.50,747.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,295.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,289.88,2118.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 13MM 360MM HIP RIGHT FEMUR AFFIXUS INTRAMEDULLARY 125D",SUP-814313360,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"AETNA [10100]","Aetna HMO/PPO",,16490.49,79.5,,1521.93,481.35,16760.95,30,2412.38,17631.34,"percent of total billed charges",
"BASEPLT TIBIAL TRIATHLON 2 LEFT MEDIAL RIGHT LATERAL PARTIAL",SUP-5620-B-201,CDM,C1776,HCPCS,0278,RC,,,both,,,6899.26,2069.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,817.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,802.38,5864.37,"percent of total billed charges",
"SCR BONE 6.5MM 25MM SMR TITANIUM SHOULDER MODULAR",SUP-8420.15.020,CDM,C1713,HCPCS,0278,RC,,,both,,,550.80,165.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,157.64,28.62,,,,,0,64.06,468.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 20MM LOW PROFILE SCREWS TITANIUM FULL THREAD",SUP-AR-8933-20,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"KAISER [10500]",Kaiser,,596.97,67,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL BLUE 100X4.8MM TITANIUM REGULAR THICK TISSUE",SUP-GIA10048L,CDM,S27200284,LOCAL,0272,RC,,,both,,,766.99,230.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.2,651.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IVAS ELITE 10MM 11GA DIAGNOSTIC CATH STERILE LATEX",SUP-0808-110-800,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,9268.88,53.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WATCHMAN TRUSEAL PROCEDURE ACCESS SYSTEM",SUP-WMPERPROTRUACC25,CDM,S27800098,LOCAL,0278,RC,,,both,,,9660.00,2898,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2764.69,28.62,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC ADVANCE POWDER HEMOSTAT APPLR AIR COMPR 5GM",SUP-EPK2305-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Local Plus",,5537.25,53.5,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 11CMX20MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-8-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"KAISER [10500]",Kaiser,,976.86,67,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM INFINITY SPINE MULTIAXIAL",SUP-3603524,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,441.36,3225.75,"percent of total billed charges",
"AVEIR VR PACER SYSTEM",SUP-VR-SYSTEM-AVEIR,CDM,C1786,HCPCS,0275,RC,,,both,,,58905.00,17671.5,"UHC [10700]","United Healthcare",,37286.87,63.3,,,,,0,6850.65,50069.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 24FR REPLACEMENT STRAIGHT ANGLE BOLST GASTRO ENDOVIVE",SUP-M00509941,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.82,72.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,110.54,45.9,,,,,0,28.01,204.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 37CM 11MM AVENIR 18 COIL COMPLEX FRAME",SUP-18CFR-11037,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5230.2,40,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUNAV 90CM 8FR ULTRASOUND INTRACARDIAC 4 WAY STEER",SUP-10135910R,CDM,C1759,HCPCS,0272,RC,,,both,,,6037.50,1811.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,702.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.25MM X 10.0MM",SUP-493251012,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 36MM LC-DCP HAND TITANIUM 6 HOLE 2MM SCR",SUP-449.936,CDM,S27800098,LOCAL,0278,RC,,,both,,,2562.00,768.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,297.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,297.96,2177.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZIPWIRE VASCULAR 150CM 3CM .035IN HYDROPHILIC STIFF",SUP-M00146305B1,CDM,C1769,HCPCS,0272,RC,,,both,,,339.13,101.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,39.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.44,288.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PENTARAY 115CM 7FR 2-6-2MM SPACE F CURVE",SUP-D128208,CDM,C1732,HCPCS,0272,RC,,,both,,,13634.40,4090.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1615.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1585.68,11589.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X21X10MM COUGAR LS LORDOTIC LATERAL NONSTERILE",SUP-189150810,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 9.25MM CEMENTRALIZER HIP FEMUR PMMA CEMENT",SUP-137647000,CDM,C1776,HCPCS,0278,RC,,,both,,,846.45,253.93,"FIRST HEALTH [10303]","First Health",,677.16,80,,,,,0,98.44,719.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION .062IN 9IN KIRSCHNER STAINLESS STEEL 1 END",SUP-KM173-39-62,CDM,C1713,HCPCS,0278,RC,,,both,,,59.29,17.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,6.9,50.4,"percent of total billed charges",
"CAGE SPINAL 32X9X11MM COROENT 4D PEEK LARGE IMPACT",SUP-6711932,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"PHCS [10601]",PHCS,,11592,70,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 47CM 14MM PRESTIGE PLUS HELICAL COMPLEX 18",SUP-PRES1447COM18,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"FIRST HEALTH [10303]","First Health",,6348,80,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 NARROW KNEE LEFT CRUCIATE RETAIN CEMENTLESS",SUP-150401124,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"CIGNA [10200]","Cigna Open Access",,9639.71,33.5,,5302.19,4377.88,6578.61,27,3346.56,24458.96,"percent of total billed charges",
"COMPONENT FEMORAL 3 KNEE RIGHT CRUCIATE RETAIN CEMENTLESS AT",SUP-150401203,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"FIRST HEALTH [10303]","First Health",,23020.2,80,,,,,0,3346.56,24458.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION",RX-36989,CDM,J0878,HCPCS,0636,RC,71288-0016-95,NDC,both,1,UN,168.44,50.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.44,,,,,,,17.48,168.44,"fee schedule",
"ADPTR LEAD 55CM 1.3MM PRECISION S8 MP35N PLATINUM IRIDIUM",SUP-SC-9208-55,CDM,C1883,HCPCS,0278,RC,,,both,,,3525.00,1057.5,"FIRST HEALTH [10303]","First Health",,2820,80,,,,,0,409.96,2996.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT PRESS FIT EMPOWR KNEE STERILE BP",SUP-353-01-107,CDM,C1776,HCPCS,0278,RC,,,both,,,15979.64,4793.89,"UHC [10700]","United Healthcare",,10115.11,63.3,,8601.07,8395.67,8601.07,"1 through 10",1858.43,13582.69,"percent of total billed charges",
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.25MM X 8.0MM",SUP-493250812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUDEOXYGLUCOSE F-18 20 MCI TO 300 MCI/ML INTRAVENOUS SOLUTION",RX-164696,CDM,A9552,HCPCS,0343,RC,08888-8878-25,NDC,both,1,UN,755.00,226.5,"NOVANET [10819]",Novanet,,566.25,75,,,,,0,87.81,755,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 22CM 3CM 5FR .035IN STRAIGHT URETERAL",SUP-M006155221190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,965.83,68,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 50MM T2 TITANIUM FULL THREAD FEMUR HUMERUS",SUP-1896-4050S,CDM,C1713,HCPCS,0278,RC,,,both,,,1309.77,392.93,"PHCS [10601]",PHCS,,916.84,70,,,,,0,152.33,1113.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 15MM 140CM .91-1.12MM 3.5MM CORONARY",SUP-RONYX35015W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"NOVANET [10819]",Novanet,,4079.25,75,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1.5MM AXIUM PRIME HELIX DETACHABLE",SUP-APB-1.5-2-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3672.49,41.1,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET",RX-34711,CDM,,,0637,RC,60687-0481-11,NDC,both,1,UN,18.70,5.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12.72,68,,,,,0,2.17,15.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 23MM CHORDAL GUIDE DURAN ANCORE LATEX FREE",SUP-620RG23,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50MMX8MM CLYDESDALE 6D PEEK-OPTIMA RADIOPAQUE",SUP-2968850,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"UHC [10700]","United Healthcare",,15154.02,63.3,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVEIR AR2 PACER SYSTEM","SUP-AR 2-SYSTEM-AVEIR",CDM,C1786,HCPCS,0275,RC,,,both,,,86925.00,26077.5,"CIGNA [10200]","Cigna Local Plus",,27381.38,31.5,,,,,0,10109.38,73886.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 360MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.257S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"BLUE CROSS [10001]","Blue Cross HMO",,4867.99,39.2,,957.42,156.86,7483.26,51,1444.25,10555.59,"percent of total billed charges",
"LOTUS EDGE VALVE SYSTEM 27MM REPRISE III CLINICAL STUDY (EXC",SUP-H749LVSCL270,CDM,S62400003,LOCAL,0624,RC,,,both,,,142500.00,42750,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16886.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16572.75,121125,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 6-0 S-14 18IN 2 ARM BRAID COATED VIOLET",SUP-J570G,CDM,S27200284,LOCAL,0272,RC,,,both,,,161.82,48.55,"CIGNA [10200]","Cigna Open Access",,92.08,56.9,,,,,0,18.82,137.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 2.75MM CORONARY STENT PEBAX",SUP-H7493926032270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross HMO",,2181.48,39.2,,9776.84,9776.84,9776.84,"1 through 10",647.21,4730.25,"percent of total billed charges",
"BLADE SAW 19.8X6.8X.5MM MICRO SAGITTAL STERILE",SUP-KM-12005,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.29,16.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.55,47.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION BLUE 1.14MM ARMSTRONG V BEVEL GROMMET EAR",SUP-7014-0396,CDM,S27800098,LOCAL,0278,RC,,,both,,,108.80,32.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,31.14,28.62,,,,,0,12.65,92.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 111MM 6MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771100620,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"MULTIPLAN [10600]",Multiplan,,17764.68,85,,,,,0,2430.63,17764.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP R3 POROUS WITH OXINIUM HEAD AND ANTI",SUP-71703328,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]",Cigna,,9576,40,,5873.17,5873.17,5873.17,"1 through 10",2784.22,20349,"percent of total billed charges",
"DEVICE ADVANCE 180CM 2.5MM CPSL DELIVERY STERILE",SUP-BX00711144,CDM,S27000186,LOCAL,0270,RC,,,both,,,1471.50,441.45,"KAISER [10500]",Kaiser,,985.91,67,,,,,0,171.14,1250.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OCTARAY 3-3-3-3-3MM SPCAE F CURVE ELECTROPHYSIOLOGY",SUP-D160906,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1880.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WARFARIN 0.5 MG TABLET (PARTIAL OF 1 MG TABLET)",RX-408647,CDM,,,0637,RC,08888-8886-80,NDC,both,.5,UN,6.27,1.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2.58,41.1,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME PATELLAR 38MM PFC SIGMA OVAL KNEE UHMWPE CEMENTED 3 PEG",SUP-960102,CDM,C1776,HCPCS,0278,RC,,,both,,,4723.05,1416.91,"BLUE CROSS [10001]","Blue Cross PPO",,1851.44,39.2,,3949.44,3949.44,3949.44,"1 through 10",549.29,4014.59,"percent of total billed charges",
"MESH SURGICAL PARIETENE DS 20X15CM COMPOSITE ABSORBABLE FILM",SUP-PPDS2015,CDM,C1781,HCPCS,0278,RC,,,both,,,4333.06,1299.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1988.87,45.9,,,,,0,503.93,3683.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 18FR MEDIUM URETHRAL HYDROPHILIC",SUP-0174L18,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.47,22.94,"KAISER [10500]",Kaiser,,51.23,67,,,,,0,8.89,65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICS BALL BURR",SUP-110135,CDM,S27200284,LOCAL,0272,RC,,,both,,,578.34,173.5,"CIGNA [10200]","Cigna Local Plus",,309.41,53.5,,,,,0,67.26,491.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM 11MM PRIMARY VERSYS TIVANIUM FIBER METAL",SUP-786201100,CDM,C1776,HCPCS,0278,RC,,,both,,,26645.22,7993.57,"CIGNA [10200]","Cigna Local Plus",,8393.24,31.5,,5372.07,4581.20,7242.98,23,3098.84,22648.44,"percent of total billed charges",
"SCR BONE 5MM 22MM LCP STAINLESS STEEL PROXIMAL MEDIAL TIBIAL",SUP-212.205,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"CIGNA [10200]","Cigna Local Plus",,467.15,53.5,,3978.14,359.25,3978.14,24,101.55,742.2,"percent of total billed charges",
"SPACER ALLOGRAFT 30X9MM LUMINARY 10/11MM SPINE DEMINERALIZED",SUP-4709,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"PHCS [10601]",PHCS,,22050,70,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 15MM STAINLESS STEEL 3.5MM SCREWS 7 HOLE HOOK LCP BONE",SUP-241.105S,CDM,C1713,HCPCS,0278,RC,,,both,,,7970.54,2391.16,"MULTIPLAN [10600]",Multiplan,,6774.96,85,,,,,0,926.97,6774.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INLAY OPTIMA 28CM 6FR URETERAL POLYMER PHREECOAT",SUP-788628,CDM,C2617,HCPCS,0278,RC,,,both,,,834.30,250.29,"NOVANET [10819]",Novanet,,625.73,75,,,,,0,97.03,709.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 275X4.9X5CM .035IN STREAMLINE DEVICE DELIVERY",SUP-H74939407L0,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SYNETURE V-LOC 2-0 GS-22 6IN CLSR ABSORBABLE BLUE",SUP-VLOCN2105,CDM,S27200284,LOCAL,0272,RC,,,both,,,222.37,66.71,"KAISER [10500]",Kaiser,,148.99,67,,,,,0,25.86,189.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5CMX10MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-3-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +7.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.750,CDM,V2632,HCPCS,0276,RC,,,both,,,3712.50,1113.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2524.5,68,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 27MM SIMULUS FULLY FLEXIBLE",SUP-700FC27,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3752.08,28.62,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST TRICORTICAL THK13-15MM WEDGE",SUP-400407,CDM,S27800098,LOCAL,0278,RC,,,both,,,5261.94,1578.58,"CIGNA [10200]","Cigna Open Access",,2994.04,56.9,,,,,0,611.96,4472.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Cytp Oth Xtn / Add on 88162",PX-311000085,CDM,0834T,CPT,0311,RC,,,both,,,104.00,31.2,"CIGNA [10200]",Cigna,,70.72,68,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 4MAX REPERFUSION TUBING STERILE LATEX FREE",SUP-4MAXCKIT,CDM,C1757,HCPCS,0272,RC,,,both,,,13765.50,4129.65,"PHCS [10601]",PHCS,,9635.85,70,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM SOLID BACK PRIMARY TRITANIUM E",SUP-500-03-54E,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"KAISER [10500]",Kaiser,,7012.77,67,,,,,0,1217.29,8896.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 25.4MM WHEEL DISSECTING",SUP-MR8-9MC254,CDM,S27200284,LOCAL,0272,RC,,,both,,,1416.29,424.89,"CIGNA [10200]","Cigna Open Access",,805.87,56.9,,,,,0,164.71,1203.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 45MM 10MM ZENITH ILIAC BRANCH 58MM",SUP-G60341,CDM,C1874,HCPCS,0278,RC,,,both,,,68399.94,20519.98,"BLUE CROSS [10001]","Blue Cross PPO",,26812.78,39.2,,,,,0,7954.91,58139.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC LARGE XL SHOULDER GEL COLD",SUP-02815,CDM,S27000186,LOCAL,0270,RC,,,both,,,156.95,47.08,"MULTIPLAN [10600]",Multiplan,,133.41,85,,,,,0,18.25,133.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 4.75MM SOLERA CURVED COCR MOLYBDENUM",SUP-1475501030,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 7.9MM 5.5MM MAGILL CURVE NASAL ORAL 2 CUFF",SUP-86395,CDM,S27200284,LOCAL,0272,RC,,,both,,,8390.91,2517.27,"UHC [10700]","United Healthcare",,5311.45,63.3,,,,,0,975.86,7132.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SKIN W5MMXL6 1/4IN JOSEPH",SUP-20-5005,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.72,41.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.02,117.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 9FR 18GA 6.35CM .035IN 2 LUMEN GWIRE NDL DRAPE",SUP-AK-11142-SPCS,CDM,C1751,HCPCS,0272,RC,,,both,,,850.50,255.15,"KAISER [10500]",Kaiser,,569.84,67,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOPROSTHESIS STENT AORTOILIAC L79MM DIA8MM VIABAHN V",SUP-BXBL087902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5780,27,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 30MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45030,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA [10200]","Cigna Local Plus",,26152.79,31.5,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 9FR 18GA 6.35CM .035IN 2 LUMEN GWIRE NDL DRAPE",SUP-AK-11142-SPCS,CDM,C1751,HCPCS,0272,RC,,,both,,,850.50,255.15,"UHC [10700]","United Healthcare",,538.37,63.3,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC",059,MS-DRG,,,,,,,inpatient,,,51090.24,15327.07,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,16549.37,,"Case rate ($7,697.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,147.54, add-ons for qualifying new technology services are included. If operating cost exceeds $40,187.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,922.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,156.99. The transfer operating threshold is the transfer adjustment factor * $7,147.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.39. The transfer capital threshold is the transfer adjustment factor * $540.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,30946.81,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 28MM 6MM STAINLESS STEEL 1.1MM SHORT THREAD",SUP-02.226.028,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"BLUE CROSS [10001]","Blue Cross PPO",,644.92,39.2,,957.42,570.23,957.42,28,191.34,1398.42,"percent of total billed charges",
"SCR BONE 2.4MM 26MM LCP STAINLESS STEEL DISTAL CORTICAL",SUP-201.776,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,50.59,369.75,"percent of total billed charges",
"SCR BONE 3.5MM 40MM TITANIUM ALUMINUM VANADIUM FEMUR",SUP-00493504001,CDM,C1713,HCPCS,0278,RC,,,both,,,607.50,182.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,70.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",70.65,516.38,"percent of total billed charges",
"PLATE 95D 238MM TI6AL4V PERIPROSTHETIC 9 HOLE NCB BONE FEMUR",SUP-0202264009,CDM,C1713,HCPCS,0278,RC,,,both,,,13144.50,3943.35,"BLUE CROSS [10001]","Blue Cross PPO",,5152.64,39.2,,957.42,570.23,957.42,28,1528.71,11172.83,"percent of total billed charges",
"STENT ZIPWIRE 30CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006175285180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"PHCS [10601]",PHCS,,1022.08,70,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE BGK2/0 POLYOLEFIN 5000ML NONPVC 2 COMPARTMENT",SUP-110244,CDM,S27200284,LOCAL,0272,RC,,,both,,,332.60,99.78,"CIGNA [10200]","Cigna Local Plus",,177.94,53.5,,,,,0,38.68,282.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 4.25% DEXTROSE 3L LOW CALCIUM ULTRABAG DIANEAL DIALYSIS",SUP-5B9759,CDM,S27200284,LOCAL,0272,RC,,,both,,,355.14,106.54,"KAISER [10500]",Kaiser,,237.94,67,,,,,0,41.3,301.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 7MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT074050A,CDM,C1768,HCPCS,0278,RC,,,both,,,12978.90,3893.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5334.33,41.1,,,,,0,1509.45,11032.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 42MM UNITRAX FEMORAL HIP MODULAR",SUP-6942-5-042,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,895.15,28.62,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 4MM 4.5MM 5MM XTHICK EEA BLACK 28MM",SUP-TRIEEA28XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2227.65,668.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1514.8,68,,,,,0,259.08,1893.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Transplant Kidney Dplr",PX-402000012,CDM,76776,CPT,0402,RC,,,both,,,219.00,65.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,219,,"Per diem ($277).",,,,0,25.47,219,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC DRN Pertnl/Retrtnl Vag/Rect",PX-361000338,CDM,49407,CPT,0361,RC,,,both,,,5283.00,1584.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,614.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.28,4617,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCIVA VR",SUP-D400,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"BLUE CROSS [10001]","Blue Cross HMO",,15288,39.2,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 7.2INX1MM OLSEN STRAIGHT BAYONET",SUP-20-1440I,CDM,S27200284,LOCAL,0272,RC,,,both,,,332.16,99.65,"KAISER [10500]",Kaiser,,222.55,67,,,,,0,38.63,282.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZTRK 90CM 6FR BLNOCC COR",SUP-6714,CDM,C2628,HCPCS,0272,RC,,,both,,,261.00,78.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,30.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT SL II SITEMARK 50.7CM 47CM 9FR 7FR 135D",SUP-DS2C003,CDM,C1887,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"NOVANET [10819]",Novanet,,2820.38,75,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo Intestine Sm WO Ilium Dx",PX-750000062,CDM,44360,CPT,0750,RC,,,both,,,4990.45,1497.13,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,580.39,4990.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 535CC STERILE ARTOURA ULTRA HIGH PROFILE ROUND",SUP-TEXP120RUH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"FIRST HEALTH [10303]","First Health",,11012.4,80,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11MM CORNERSTONE PSR 11MM PEEK-OPTIMA LIF",SUP-6287141,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1911.36,28.62,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM INSET SHOULDER LOCK REVERSE",SUP-2R1PT45035,CDM,C1713,HCPCS,0278,RC,,,both,,,865.08,259.52,"CIGNA [10200]",Cigna,,588.25,68,,1831.33,1831.33,1831.33,16,100.61,735.32,"percent of total billed charges",
"SCR BONE 3.5MM 18MM SECUR-FIT X-TRA TITANIUM T15 CORTICAL",SUP-131218018,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"BLUE CROSS [10001]","Blue Cross PPO",,309.58,39.2,,957.42,570.23,957.42,28,91.85,671.29,"percent of total billed charges",
"CATH X-FORCE U30 6CM 6FR 4MM BALLOON DILATATION PERCUTANEOUS",SUP-998406,CDM,C1726,HCPCS,0272,RC,,,both,,,1854.00,556.2,"UHC [10700]","United Healthcare",,1173.58,63.3,,,,,0,215.62,1575.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM 2 FULL THREAD CORKSCREW TIGERTAIL",SUP-AR-1927BCF-475,CDM,C1713,HCPCS,0278,RC,,,both,,,2795.63,838.69,"FIRST HEALTH [10303]","First Health",,2236.5,80,,,,,0,325.13,2376.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HYBRID TOTAL KNEE SYSTEM (EITHER POROUS FEMUR OR TIBIA)",SUP-98000200313,CDM,C1776,HCPCS,0278,RC,,,both,,,26460.00,7938,"FIRST HEALTH [10303]","First Health",,21168,80,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 15CM ADJUSTABLE STOP CM MARKING FRANSEEN",SUP-MFN2006,CDM,S27200284,LOCAL,0272,RC,,,both,,,153.82,46.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.89,130.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 45MM TSRH OSTEOGRIP THINLINE TITANIUM SPINE",SUP-83545459,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"BLUE CROSS [10001]","Blue Cross PPO",,1009.01,39.2,,957.42,570.23,957.42,28,299.36,2187.9,"percent of total billed charges",
"STEM FEMORAL 235MM 16MM MODULAR RESTORATION BOWED CONICAL",SUP-6276-7-316,CDM,C1776,HCPCS,0278,RC,,,both,,,12862.80,3858.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3472.96,27,,,,,0,1495.94,10933.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 4.25MM .6MM MCGEE STAPES PISTON RIBBON LOOP",SUP-14-0332,CDM,L8613,HCPCS,0278,RC,,,both,,,981.07,294.32,"CIGNA [10200]","Cigna Local Plus",,524.87,53.5,,,,,0,114.1,833.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X40 40CM SL",SUP-48003004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"FIRST HEALTH [10303]","First Health",,785.7,80,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Catecholamines Fractionated",PX-301000136,CDM,82384,CPT,0301,RC,,,both,,,306.80,92.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,39.72,,,,,,,0.01,260.78,"fee schedule",
"KIT PRESSURE MNTR 3 WAY STPCOCK TRNSDUC 3 FLUSH DEVICE",SUP-PX3X3272,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL SHOULDER CAP",SUP-HSA1,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"AETNA [10100]","Aetna HMO/PPO",,16277.63,79.5,,10981.53,8986.79,12413.38,12,2381.24,17403.75,"percent of total billed charges",
"STEM FEMORAL 195MM 18MM RESTORATION HA STRAIGHT CONICAL HIP",SUP-6276-7-118,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LD PCNG VL NS LF",SUP-106157,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"UHC [10700]","United Healthcare",,258.83,63.3,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV",RX-122732,CDM,,,0250,RC,15082-0860-25,NDC,both,250,ML,100.65,30.19,"FIRST HEALTH [10303]","First Health",,80.52,80,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM 14MM STAINLESS STEEL CANNULATED STERILE",SUP-121840,CDM,C1713,HCPCS,0278,RC,,,both,,,2006.40,601.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,237.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,233.34,1705.44,"percent of total billed charges",
"REAMER SURGICAL 7MM PILOT HEAD STERILE",SUP-AR-1452,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL SHOULDER REVERSE SYSTEM",SUP-98000900052,CDM,C1776,HCPCS,0278,RC,,,both,,,51660.00,15498,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13948.2,27,,,,,0,6008.06,43911,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT STEM 80MM 11MM CEMENT FEMORAL VITALLIUM SCORPIO 1 AXIS",SUP-6478-6-396,CDM,C1776,HCPCS,0278,RC,,,both,,,4905.90,1471.77,"NOVANET [10819]",Novanet,,3679.43,75,,,,,0,570.56,4170.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-207.026,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,186.06,68,,,,,0,31.82,232.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT GAIT 2IN 60IN POLYETHYLENE POSEY QUICK CLEAN ECONOMY",SUP-552545,CDM,S27100035,LOCAL,0271,RC,,,both,,,224.20,67.26,"MULTIPLAN [10600]",Multiplan,,190.57,85,,,,,0,26.07,190.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER 3MR FLEXIVA PULSE TRACTIP 242UM HIGH POWER",SUP-M006L8405910,CDM,S27200284,LOCAL,0272,RC,,,both,,,2856.45,856.93,"MULTIPLAN [10600]",Multiplan,,2427.98,85,,,,,0,332.21,2427.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIPOLAR HIP 2:  FX OR CEMENTED STEM",SUP-CAP-STY-BP2,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7038,68,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM PFC SIGMA TC3 2.5 KNEE POSTERIOR TITANIUM",SUP-960846,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,608,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,596.72,4361.21,"percent of total billed charges",
"ROD SPINAL 70MM 6MM XIA 3 TITANIUM RADIOLUCENT",SUP-48238070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARCTIC FRONT ADVANCE 95CM 23MM 10.5FR 28MM CRYOABLATION",SUP-2AF284,CDM,C2630,HCPCS,0272,RC,,,both,,,26460.00,7938,"FIRST HEALTH [10303]","First Health",,21168,80,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 20X10CM RESORBABLE GRID 1",SUP-F10256-1020G,CDM,C1781,HCPCS,0278,RC,,,both,,,19731.60,5919.48,"CIGNA [10200]","Cigna Local Plus",,6215.45,31.5,,3096.73,1.00,3096.73,"1 through 10",2294.79,16771.86,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 30CM 150CM 5FR .038IN 3CM BLADDER LOOP",SUP-M006155225170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,168.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DEBAKEY STRAIGHT 14IN VASCULAR TISSUE FLUTE",SUP-55-2065,CDM,S27200284,LOCAL,0272,RC,,,both,,,851.39,255.42,"CIGNA [10200]","Cigna Local Plus",,455.49,53.5,,,,,0,99.02,723.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER ENDOSCOPIC INSTR WINGMAN TUBE SET",SUP-0240240003,CDM,S27200284,LOCAL,0272,RC,,,both,,,347.04,104.11,"MULTIPLAN [10600]",Multiplan,,294.98,85,,,,,0,40.36,294.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 45CM 5MM FIBROUS MATRIX WOVEN CROSS",SUP-AG645,CDM,C1768,HCPCS,0278,RC,,,both,,,27272.70,8181.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3171.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3171.82,23181.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSOLE SHOE 10.5-12 LARGE MALE DARCO PEG-ASSIST REMOVABLE",SUP-PTQM3,CDM,S27000186,LOCAL,0270,RC,,,both,,,100.49,30.15,"CIGNA [10200]",Cigna,,68.33,68,,,,,0,11.69,85.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM STAINLESS STEEL CORTICAL TRIMED CLAVICLE",SUP-HEX2.7-14,CDM,C1713,HCPCS,0278,RC,,,both,,,729.00,218.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",84.78,619.65,"percent of total billed charges",
"STENT OMNILINK ELITE 29MM 80CM 10MM THIN VASCULAR COCR",SUP-1012626-29,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3452.4,41.1,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 14MM 24MM EXPLOR ELBOW MODULAR",SUP-11-210043,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"PHCS [10601]",PHCS,,9949.8,70,,,,,0,1653.09,12081.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STOCKING COMPRESSION LARGE TUBULAR SOFT TENSOGRIP",SUP-13202,CDM,S27000186,LOCAL,0270,RC,,,both,,,494.42,148.33,"AETNA [10100]","Aetna HMO/PPO",,393.06,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.5,420.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEMENT 7 PACK - ELEMENT 17 F VASCULAR ACCESS SYSTEM 45CM",SUP-ELMNT17F45PK7,CDM,C1887,HCPCS,0272,RC,,,both,,,28350.00,8505,"PHCS [10601]",PHCS,,19845,70,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 7.5X50MM POLYAXIAL 4S RELINE-O",SUP-13117550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 20MM ORTHOPEDIC TENND GFORC",SUP-86PS0620,CDM,C1713,HCPCS,0278,RC,,,both,,,3037.50,911.25,"BLUE CROSS [10001]","Blue Cross PPO",,1190.7,39.2,,957.42,570.23,957.42,28,353.26,2581.88,"percent of total billed charges",
"EXPANDER TISSUE CPX4TABS 800ML",SUP-3549216,CDM,C1789,HCPCS,0278,RC,,,both,,,9694.50,2908.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1148.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",1127.47,8240.33,"percent of total billed charges",
"CATH VASCUTRAK 140CM 10CM 3MM BALLOON DILATATION HYDROPHILIC",SUP-V1430100,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"MULTIPLAN [10600]",Multiplan,,4662.68,85,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHALANX CORONAL TRANSFIXION SCREW 1.5MM X 14.0MM COCR",SUP-PTS-15014-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.90,337.77,"CIGNA [10200]","Cigna Local Plus",,602.36,53.5,,3978.14,359.25,3978.14,24,130.94,957.02,"percent of total billed charges",
"DEFIB CARDIAC THK15MM 51X64MM PROTECTA DR VENTRICLE 2 CHMBR",SUP-D334DRG,CDM,C1721,HCPCS,0278,RC,,,both,,,63000.00,18900,"CIGNA [10200]","Cigna Open Access",,21105,33.5,,,,,0,7326.9,53550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 6.75IN 8FR FRAZIER ANGLE 5-9CM CALIBRATE",SUP-63-7558,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 6X5CM AMNIOBAND 30SQ CM ALLOGRAFT",SUP-WC3056,CDM,Q4151,HCPCS,0636,RC,,,both,,,35544.60,10663.38,"AETNA [10100]","Aetna HMO/PPO",,28257.96,79.5,,,,,0,362.66,30212.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHORD-X 2-0 .5 CIRCLE 18MM 32MM 2 ARM LOOP PLEDG 3",SUP-CXL-20-1812-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"AMERIGROUP MEDICAID [20100]",Amerigroup,,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LOCKING 5.5MM MATRIX FLAT SPINE COCR TITANIUM STEP",SUP-09.632.099,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,236.64,68,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE ESC +4MM NEUTRAL 52MM 32MM GVF",SUP-121832652,CDM,C1776,HCPCS,0278,RC,,,both,,,20986.56,6295.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5666.37,27,,,,,0,2440.74,17838.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 4CM 2MM GALAXY G3 MINI STRETCH",SUP-GLM920040,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3400.57,28.62,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 50CMX.49MM 14/7MM HEMAGARD VASCULAR BOVINE",SUP-HGK1407,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 140MM 80CM 5MM 6FR .035IN BILIARY",SUP-G50115,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"KAISER [10500]",Kaiser,,4080.3,67,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 110CM 4FR OMNI FLUSH CURVE ANGIOGRAPHIC",SUP-H787117323035,CDM,C1887,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SURGICAL CEREBRAL RETROGRADE",SUP-3T70R,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"FIRST HEALTH [10303]","First Health",,83.52,80,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hep C Quant",PX-306000134,CDM,87522,CPT,0306,RC,,,both,,,918.65,275.59,"BLUE CROSS [10001]","Blue Cross PPO",,54.73,,"Fee schedule rate ($54.73).",,,,0,0.01,780.85,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 62MM 32MM MARATHON HIP",SUP-121932162,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"BLUE CROSS [10001]","Blue Cross PPO",,3179.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",943.3,6894.31,"percent of total billed charges",
"SET ADMIN AMIA CASSETTE AUTOMATE PERITONEAL DIALYSIS SYSTEM",SUP-5C5479,CDM,S27200284,LOCAL,0272,RC,,,both,,,258.25,77.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,118.54,45.9,,,,,0,30.03,219.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS ILM 25+SHARKSKIN DSP",SUP-705.88P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1171.10,351.33,"MULTIPLAN [10600]",Multiplan,,995.44,85,,,,,0,136.2,995.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 9IN .035IN KIRSCHNER 2 TROCAR POINT BOTH END",SUP-163834000,CDM,C1713,HCPCS,0278,RC,,,both,,,185.60,55.68,"BLUE CROSS [10001]","Blue Cross PPO",,72.76,39.2,,957.42,570.23,957.42,28,21.59,157.76,"percent of total billed charges",
"SCR BONE 3MM 4MM 1.2MM 23MM 10MM STAINLESS STEEL LONG THREAD",SUP-202.723,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"CIGNA [10200]",Cigna,,754.81,68,,1831.33,1831.33,1831.33,16,129.1,943.52,"percent of total billed charges",
"KIT CATH 40CM 18GA .038IN J STRAIGHT OVAL STAINLESS STEEL",SUP-8817749001,CDM,C1750,HCPCS,0278,RC,,,both,,,1124.82,337.45,"NOVANET [10819]",Novanet,,843.62,75,,,,,0,130.82,956.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.5/22",SUP-401757,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 30MM LCP STAINLESS STEEL SUPERIOR ANTERIOR",SUP-02.211.030,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,257.04,28.62,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Donath-Landsteiner Abs",PX-301000264,CDM,83520,CPT,0301,RC,,,both,,,325.00,97.5,"FIRST HEALTH [10303]","First Health",,260,80,,,,,0,0.33,276.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 18MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-018,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"MULTIPLAN [10600]",Multiplan,,4026.54,85,,,,,0,550.92,4026.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 6.0 MM X 120 MM X 130 CM",SUP-IPU06012013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,956.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 150MM 2MM BALLOON DILATATION RAPID",SUP-47520150L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTNR STRLZTN 23.25X10.75X5.25IN SOLID BOTTOM",SUP-JK442,CDM,S27200284,LOCAL,0272,RC,,,both,,,2055.83,616.75,"NOVANET [10819]",Novanet,,1541.87,75,,,,,0,239.09,1747.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE RIGHT CRUCIATE RETAIN PERSONA",SUP-42502205802,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8269.91,28.62,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION|DISCARDED DRUG NOT ADMINISTE",RX-3037,CDM,J3010,HCPCS,0636,RC,00641-6028-01,NDC,both,5,ML,20.84,6.25,"NOVANET [10819]",Novanet,JW,15.63,75,,,,,0,2.47,17.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA ALLOGRAFT STRUT FROZEN 110X8MM",SUP-450658,CDM,S27800098,LOCAL,0278,RC,,,both,,,7025.58,2107.67,"CIGNA [10200]","Cigna Open Access",,3997.56,56.9,,,,,0,817.07,5971.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Metanephrines",PX-301000313,CDM,83835,CPT,0301,RC,,,both,,,424.03,127.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15.25,,,,,,,0.01,360.43,"fee schedule",
"STEM HUMERAL ARTHREX UNIVERS REVERS 7 SHOULDER STERILE",SUP-AR-9501-07S,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4338.93,41.1,,6417.48,6417.48,6417.48,"1 through 10",1227.78,8973.45,"percent of total billed charges",
"SUT PLAIN LIGAPAK 2-0 54IN MONOFILAMENT REEL YELLOWISH TAN",SUP-L103G,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"PHCS [10601]",PHCS,,18.9,70,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 22MM QUARTEX SPINE POLYAXIAL NONSTERILE LATEX",SUP-1149.4022,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 157CM 2.4-2FR .017IN TREVO XP",SUP-90231,CDM,S27200284,LOCAL,0272,RC,,,both,,,7221.82,2166.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,855.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,839.9,6138.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Legion Pneumo Dna Amp Prob",PX-306000260,CDM,87541,CPT,0306,RC,,,both,,,100.00,30,"KAISER [10500]",Kaiser,,67,67,,,,,0,0.01,100,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM TRICUSPID 1 SEAM 2 WRAP ANATOMIC",SUP-4900T28,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1512.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC",475,MS-DRG,,,,,,,inpatient,,,77802.01,23340.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,45174.92,,"Fee schedule rate ($45,174.92). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,66441.34,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 75X18MM THK.89MM STAINLESS STEEL SAGITTAL DUAL CUT",SUP-4118089075,CDM,S27200284,LOCAL,0272,RC,,,both,,,393.85,118.15,"CIGNA [10200]","Cigna Open Access",,224.1,56.9,,,,,0,45.8,334.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE 65CM 5FR .6CM RADIUS SMALL JUDKINS 3 CURVE",SUP-532523,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.91,41.1,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 20MM 75CM 16MM 100CM",SUP-H965403300,CDM,C1876,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,797.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 10MM CONCERTO DETACHABLE HELIX PERIPH",SUP-NV-10-30-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 0 CT-2 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8412H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PLATE 5 74X46MM CEMENTED STEMMED MODULAR NEXGEN",SUP-00598004701,CDM,C1776,HCPCS,0278,RC,,,both,,,8643.60,2593.08,"KAISER [10500]",Kaiser,,5791.21,67,,,,,0,1005.25,7347.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDIUM IN-111 OXYQUINOLINE INTRAVENOUS SOLUTION 0.5-1 MCI",RX-411588,CDM,A9547,HCPCS,0343,RC,08888-8877-01,NDC,both,1,UN,11022.18,3306.65,"PHCS [10601]",PHCS,,7715.53,70,,,,,0,1281.88,9368.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TRACH CIAGLIA BLUE RHINO SHILEY PERCUTANEOUS STERILE",SUP-CPTISY100HCPERC6,CDM,S27200284,LOCAL,0272,RC,,,both,,,3288.30,986.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,389.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,382.43,2795.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIRROR 2 LARYNGEAL SURGICAL HANDLE",SUP-460103,CDM,S27000186,LOCAL,0270,RC,,,both,,,80.39,24.12,"CIGNA [10200]",Cigna,,54.67,68,,,,,0,9.35,68.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 12MM 6MM STD WALL THIN WALL 2 BRANCH",SUP-SBT1202D,CDM,C1768,HCPCS,0278,RC,,,both,,,8611.20,2583.36,"MULTIPLAN [10600]",Multiplan,,7319.52,85,,,,,0,1001.48,7319.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 28MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.828,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"FIRST HEALTH [10303]","First Health",,281.05,80,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA ALLOGRAFT STRUT FROZEN 110X8MM",SUP-450658,CDM,S27800098,LOCAL,0278,RC,,,both,,,7025.58,2107.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,832.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,817.07,5971.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INFLATION INDEFLATOR PLUS 30 .096IN CORONARY ROTATE",SUP-1000185,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI 38MM TITANIUM 2 LEVEL HELIX BONE SPINE CERVICAL",SUP-7740238,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cell Marker Study",PX-311000018,CDM,88182,CPT,0311,RC,,,both,,,586.00,175.8,"KAISER [10500]",Kaiser,,392.62,67,,,,,0,0.01,498.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 60MM 7MM .035IN LOW PROFILE BALLOON",SUP-B1070-060,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"AETNA [10100]","Aetna HMO/PPO",,611.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 158MM STAINLESS STEEL 5MM SCR BASIC FRAGMENT 10 HOLE",SUP-427170S,CDM,C1713,HCPCS,0278,RC,,,both,,,3687.00,1106.1,"AETNA [10100]","Aetna HMO/PPO",,2931.17,79.5,,1521.93,481.35,16760.95,30,428.8,3133.95,"percent of total billed charges",
"HC Perq Njx Algc Fluor Lmbr Ea",PX-361000548,CDM,0628T,CPT,0361,RC,,,both,,,2677.00,803.1,"KAISER [10500]",Kaiser,,1793.59,67,,,,,0,311.34,2275.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Wire/Pin Skeletal Tract",PX-450000360,CDM,20650,CPT,0361,RC,,,both,,,5339.00,1601.7,"MULTIPLAN [10600]",Multiplan,,4538.15,85,,,,,0,620.93,5339,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dipropylacetic Acid Free",PX-301000522,CDM,80165,CPT,0301,RC,,,both,,,332.50,99.75,"CIGNA [10200]","Cigna Local Plus",,29.79,,,,,,,0.01,282.63,"fee schedule",
"HC Dipropylacetic Acid Free",PX-301000522,CDM,80165,CPT,0301,RC,,,both,,,332.50,99.75,"AETNA [10100]","Aetna HMO/PPO",,264.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,282.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Swallowing Study W Video",PX-320000098,CDM,74230,CPT,0320,RC,,,both,,,837.92,251.38,"UHC [10700]","United Healthcare",,437.65,,,,,,,97.45,712.23,"fee schedule",
"SCR BONE 2.7MM 30MM LCP STAINLESS STEEL SUPERIOR ANTERIOR",SUP-02.211.030,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"NOVANET [10819]",Novanet,,673.6,75,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM CARBO-SEAL ASCENDING AORTA VALSALVA",SUP-CP-023,CDM,S27800098,LOCAL,0278,RC,,,both,,,27720.00,8316,"CIGNA [10200]","Cigna Open Access",,9286.2,33.5,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TRANSITION HA SPINE PEDICLE POLYAXIAL",SUP-152.764S,CDM,C1713,HCPCS,0278,RC,,,both,,,10791.60,3237.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1278.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1255.06,9172.86,"percent of total billed charges",
"NDL BIOPSY 19GA 9CM COAXIAL OPTIONAL",SUP-MCXS2009LY,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.64,44.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM NEGATIVE PRESSURE 6X1IN PICO DRSG STERILE DISPOSABLE",SUP-66022007,CDM,S27200284,LOCAL,0272,RC,,,both,,,1995.00,598.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GARM COMPRESSION 50-60HZ 25VA LARGE UNIVERSAL CALF VELCRO",SUP-DVT20,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.58,33.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS HIGHFLOW 100CM 7FR JL5 CURVE ANGIOGRAPHIC DUCOR",SUP-527722,CDM,C1887,HCPCS,0272,RC,,,both,,,137.11,41.13,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL LOOP 27FR CUT STORZ 1 STEM",SUP-M0068802041,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER DELIVERY EXTENDED HOOK SSPC",SUP-9183,CDM,C1887,HCPCS,0272,RC,,,both,,,3375.00,1012.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT FIBERWIRE 4-0 DE-10 18IN BRAID TIES MULTISTRAND LOWER",SUP-AR-7228,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 120MM 7MM BALLOON",SUP-U3575712,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EZ STEER NAV 115CM 4MM 7FR 1-7-4MM SPACE D-D CURVE",SUP-BN7TCDD4L,CDM,C1732,HCPCS,0272,RC,,,both,,,15366.30,4609.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"PALACOS MV+G PRO 80",SUP-5081291,CDM,C1713,HCPCS,0278,RC,,,both,,,3829.50,1148.85,"BLUE CROSS [10001]","Blue Cross HMO",,1501.16,39.2,,957.42,156.86,7483.26,51,445.37,3255.08,"percent of total billed charges",
"DEFIB CARDIAC LUMAX 740 HF-T BIVENTRICULAR CARDIAC",SUP-393803,CDM,C1882,HCPCS,0278,RC,,,both,,,84445.50,25333.65,"CIGNA [10200]",Cigna,,33778.2,40,,,,,0,9821.01,71778.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE",RX-10911,CDM,,,0637,RC,60505-0033-06,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM EDWARDS INTUITY ELITE STERILE LATEX FREE",SUP-8300KITB25A,CDM,S27800098,LOCAL,0278,RC,,,both,,,68400.00,20520,"CIGNA [10200]","Cigna Local Plus",,21546,31.5,,,,,0,7954.92,58140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Evasc Stnt Rpr Thrc/Aa Acrs Br",PX-481000135,CDM,33894,CPT,0481,RC,,,both,,,45298.00,13589.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5367.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2491,38503.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SOF-CURL 24CM 7FR URETERAL TEMPORARY INDWELL CATH",SUP-SSC7024,CDM,C2617,HCPCS,0278,RC,,,both,,,760.51,228.15,"CIGNA [10200]","Cigna Open Access",,432.73,,,,,,,88.45,646.43,"percent of total billed charges",
"DEVICE FUSION LOCKING BILE PANCREATIC GWIRE STERILE",SUP-G31522,CDM,C1769,HCPCS,0272,RC,,,both,,,149.64,44.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.4,127.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 100MM 2MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.19,CDM,S27000186,LOCAL,0270,RC,,,both,,,329.00,98.7,"NOVANET [10819]",Novanet,,246.75,75,,,,,0,38.26,279.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 24MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.724,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"KAISER [10500]",Kaiser,,752.83,67,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE REAMER 26MM PILOT HOLE KNEE PATELLA STAINLESS STEEL",SUP-597909526,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.02,350.41,"NOVANET [10819]",Novanet,,876.02,75,,,,,0,135.84,992.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM 33.6MM 25.9MM MITRAL TRICUSPID",SUP-460026MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1349.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 19CM 14.5FR PALINDROME 2 LUMEN LATEX FREE",SUP-8888145014P,CDM,C1750,HCPCS,0278,RC,,,both,,,2876.79,863.04,"FIRST HEALTH [10303]","First Health",,2301.43,80,,,,,0,334.57,2445.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT AORTIC 4.5CM 26MM EXCLUDER CONFORMABLE ACTIVE CONTROL",SUP-CXA260005,CDM,C1874,HCPCS,0278,RC,,,both,,,27612.90,8283.87,"CIGNA [10200]",Cigna,,11045.16,40,,,,,0,3211.38,23470.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 360MM FEMORAL PIRIFORMIS FOSSA RIGHT",SUP-04.033.036S,CDM,C1713,HCPCS,0278,RC,,,both,,,12217.14,3665.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3496.55,28.62,,,,,0,1420.85,10384.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 10CM 6MM BALLOON DILATATION PERIPHERAL",SUP-G50253,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 14X26X60MM",SUP-6214060,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"UHC [10700]","United Healthcare",,15154.02,63.3,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 150CM 4.8FR .035IN 3CM STD STRAIGHT URETERAL",SUP-M006145353190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CIGNA [10200]",Cigna,,768.37,68,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC 25.5X14IN KNEE FOAM 4 COLD PACK ADJUSTABLE",SUP-9383-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,188.36,56.51,"FIRST HEALTH [10303]","First Health",,150.69,80,,,,,0,21.91,160.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Sel Opn Wnd<=20scm",PX-510000166,CDM,97597,CPT,0761,RC,,,both,,,1190.27,357.08,"BLUE CROSS [10001]","Blue Cross PPO",,1190.27,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,138.43,1190.27,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM WATCHMAN TRUSTEER 2 CURVE 17FR 12FR ACCESS PEBAX PTFE",SUP-M635TU90050,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1226.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SCLEROTHERAPY 23GA 1.8MM INJECTION THERAPY DISPOSABLE",SUP-M00518101,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.66,81.2,"CIGNA [10200]","Cigna Open Access",,154.01,56.9,,,,,0,31.48,230.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR MYOSURE HYSTEROSCOPE OUTFLOW CHANNEL",SUP-40-250,CDM,S27200284,LOCAL,0272,RC,,,both,,,31468.50,9440.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12933.55,41.1,,,,,0,3659.79,26748.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 16GA ACCURIAN CURVE SHARP 10MM",SUP-AC0002,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"KAISER [10500]",Kaiser,,69.95,67,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE LEUKEMIA WITH OTHER PROCEDURES",850,MS-DRG,,,,,,,inpatient,,,100128.76,30038.63,"AETNA [10100]","Aetna HMO/PPO",,100128.76,,"Fee schedule rate ($162,928.49). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,100128.76,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 5 1/8IN DUROGRIP HALSEY SERRATE NDL TUNGSTEN CARBIDE",SUP-BM012R,CDM,S27000186,LOCAL,0270,RC,,,both,,,323.21,96.96,"CIGNA [10200]","Cigna Open Access",,183.91,56.9,,,,,0,37.59,274.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 60MM 120CM 7MM VASCULAR PERIPHERAL SELF",SUP-PRB35-07-060-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERLINK SUTURETAPE CLOSE LOOP BLACK WHITE 1.7MM",SUP-AR-7538T,CDM,S27200284,LOCAL,0272,RC,,,both,,,807.98,242.39,"CIGNA [10200]",Cigna,,549.43,68,,,,,0,93.97,686.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 100MM 2.5MM BALLOON DILATATION",SUP-48002510X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM PUSHLOCK SELF PUNCH PEEK 28MM STERILE",SUP-AR-1922PSM,CDM,C1713,HCPCS,0278,RC,,,both,,,3071.25,921.37,"KAISER [10500]",Kaiser,,2057.74,67,,,,,0,357.19,2610.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE STERILE 7MM 90MM 16MM STAINLESS STEEL ORTHOPEDIC",SUP-71127090,CDM,C1713,HCPCS,0278,RC,,,both,,,2479.50,743.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1686.06,68,,,,,0,288.37,2107.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR 51MM CARBIDE 2.3MM ROUND 8 FLUTE DENTAL",SUP-04-C0106,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.59,14.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.77,42.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBLIQUE TLIF TI, 8X10X30MM 4",SUP-5480304,CDM,C1889,HCPCS,0278,RC,,,both,,,21225.60,6367.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8490.24,40,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .035IN 14MM 135CM 40MM PERIPHERAL",SUP-10343-40,CDM,C1725,HCPCS,0272,RC,,,both,,,1539.00,461.7,"NOVANET [10819]",Novanet,,1154.25,75,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 180CM 120MM 4FR 3MM LOW PROFILE COAXIAL",SUP-PCP030120180,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"MULTIPLAN [10600]",Multiplan,,1046.52,85,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE TITANIUM 25MM 8MM ACL PCL CANNULATED",SUP-AR-1381,CDM,C1713,HCPCS,0278,RC,,,both,,,807.98,242.39,"BLUE CROSS [10001]","Blue Cross PPO",,316.73,39.2,,957.42,570.23,957.42,28,93.97,686.78,"percent of total billed charges",
"SABER .035 9X60 40CM SL",SUP-48009006P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,116.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 18MM 2.75MM CORONARY STENT COCR",SUP-1007847-18,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTAPRO 135CM .58IN 2.5MM ATHERECTOMY PRECONNECT BURR",SUP-H749394672500,CDM,C1724,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"PHCS [10601]",PHCS,,9418.5,70,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHALANX CORONAL TRANSFIXION SCREW 1.5MM X 14.0MM COCR",SUP-PTS-15014-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.90,337.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,322.23,28.62,,,,,0,130.94,957.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS GWIRE INSRT TOOL TORQUE DEVICE",SUP-MAP403,CDM,S27200284,LOCAL,0272,RC,,,both,,,202.19,60.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.51,171.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 4FR 2.7MM CAMINO INTRACRANIAL TRNSDUC TIP",SUP-1104B,CDM,S27200284,LOCAL,0272,RC,,,both,,,5510.75,1653.22,"UHC [10700]","United Healthcare",,3488.3,63.3,,,,,0,640.9,4684.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLENOSPHERE - 36MM DIA X 2MM THK 2MM ECCENTRIC",SUP-5573-2E-3602,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5011.41,41.1,,6417.48,6417.48,6417.48,"1 through 10",1418.07,10364.22,"percent of total billed charges",
"CNCT ROD 5-6MM 5-6MM RELINE-O MEDIUM SPINE 2 OPEN NONSTERILE",SUP-11101255,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1635.19,45.9,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 55MM MINI-MONSTER LONG THREAD CANNULATED",SUP-P20-140-055L,CDM,C1713,HCPCS,0278,RC,,,both,,,1629.38,488.81,"PHCS [10601]",PHCS,,1140.57,70,,,,,0,189.5,1384.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 300MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020300M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"NOVANET [10819]",Novanet,,1196.78,75,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 3.3MM 50MM TITANIUM T25 FULL THREAD TIBIAL LOCK",SUP-04.005.440,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"CIGNA [10200]",Cigna,,786.54,68,,1831.33,1831.33,1831.33,16,134.52,983.18,"percent of total billed charges",
"SCR BONE 4.2MM 42MM GORILLA R3CON LOCK",SUP-P50-353-4242,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",155.43,1136.03,"percent of total billed charges",
"GRAFT SOFT TISSUE 10MM PATELLAR TENDON",SUP-47B010,CDM,C1762,HCPCS,0278,RC,,,both,,,15970.05,4791.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6388.02,40,,,,,0,1857.32,13574.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 8MM NATURAL LORDOTIC CORTICOCANCELLOUS",SUP-018408,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.35MM 14MM CSLP TITANIUM STD SPINE CANCELLOUS",SUP-488.814,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lso Flex Surg Support",PX-E27400071,CDM,L0628,HCPCS,0274,RC,,,both,,,575.30,172.59,"NOVANET [10819]",Novanet,,431.48,75,,,,,0,52.83,489.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"22MM X 45MM X 15MM 12 LLIF CAGE POROUS COATED",SUP-P12245-215,CDM,S27800098,LOCAL,0278,RC,,,both,,,25200.00,7560,"BLUE CROSS [10001]","Blue Cross HMO",,9878.4,39.2,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 95MM 16MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-216.095,CDM,C1713,HCPCS,0278,RC,,,both,,,485.35,145.6,"CIGNA [10200]","Cigna Local Plus",,259.66,53.5,,3978.14,359.25,3978.14,24,56.45,412.55,"percent of total billed charges",
"STBL SURGICAL OCTOPUS 4 TISSUE 2 VACUUM TUBE REINFORCE ARM",SUP-29400,CDM,S27200284,LOCAL,0272,RC,,,both,,,7915.68,2374.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5382.66,68,,,,,0,920.59,6728.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 11MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-611-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"AETNA [10100]","Aetna HMO/PPO",,9566.71,79.5,,10981.53,8986.79,12413.38,12,1399.51,10228.56,"percent of total billed charges",
"SYSTEM ALEXIS GELPOINT RTRCTR 6500ML CONTAIN EXTRACTION",SUP-GTG17,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2216.97,45.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE WALKING 11-13 12-13.5 LARGE STD FOOT ANKLE CLOSED HEEL",SUP-15590067,CDM,S27000186,LOCAL,0270,RC,,,both,,,223.94,67.18,"NOVANET [10819]",Novanet,,167.96,75,,,,,0,26.04,190.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP STEM OR3O WITH COCR HEAD R3 CATALYST",SUP-71703331,CDM,C1776,HCPCS,0278,RC,,,both,,,31815.00,9544.5,"CIGNA [10200]","Cigna Local Plus",,10021.73,31.5,,5372.07,4581.20,7242.98,23,3700.08,27042.75,"percent of total billed charges",
"RONGEUR 6.25IN STRAIGHT INTERVERTEBRAL DISC 12X2MM CASPAR",SUP-57-2912,CDM,S27200284,LOCAL,0272,RC,,,both,,,2786.25,835.87,"FIRST HEALTH [10303]","First Health",,2229,80,,,,,0,324.04,2368.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732050,CDM,C1776,HCPCS,0278,RC,,,both,,,9510.48,2853.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6467.13,68,,,,,0,1106.07,8083.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENVEO R DELIVERY LOAD",SUP-LS-ENVEOR2629US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2925.00,877.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,346.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,340.18,2486.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPEEDBRIDGE SWIVELOCK FIBERTAPE 4.75MM FIXATION 2",SUP-AR-2600SBS-9,CDM,C1713,HCPCS,0278,RC,,,both,,,13837.95,4151.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1639.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1609.35,11762.26,"percent of total billed charges",
"KIT ARTICULATION NEXEL 4",SUP-00840009400,CDM,S27800098,LOCAL,0278,RC,,,both,,,9239.10,2771.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3797.27,41.1,,,,,0,1074.51,7853.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 47CM 16MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181647,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2203.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCITRIOL 0.25 MCG CAPSULE",RX-9350,CDM,,,0637,RC,60687-0345-11,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 31CM 5MM HARMONIC SCPL ULTRACISION",SUP-HBC05,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.41,432.72,"FIRST HEALTH [10303]","First Health",,1153.93,80,,,,,0,167.75,1226.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LEAD 50CM 9FR 18GA WORLEY CSG BRAID CORE SHEATH GWIRE",SUP-WOR-CSG-B2-09,CDM,C1892,HCPCS,0272,RC,,,both,,,2730.00,819,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1122.03,41.1,,,,,0,317.5,2320.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 82MM MALLEABLE SHAFT BEVEL 3MM SURGICAL MYRINGOTOMY",SUP-N0522,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.43,22.63,"MULTIPLAN [10600]",Multiplan,,64.12,85,,,,,0,8.77,64.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM AXIUM PRIME HELIX EXTRA SOFT",SUP-APB-2-6-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"BLUE CROSS [10001]","Blue Cross HMO",,3502.72,39.2,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 125MM 12MM PRIMARY VERSYS TIVANIUM FIBER METAL",SUP-786201200,CDM,C1776,HCPCS,0278,RC,,,both,,,26645.22,7993.57,"MULTIPLAN [10600]",Multiplan,,22648.44,85,,,,,0,3098.84,22648.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE 150CM 10CM 2.5-3FR .021IN MICRO GUIDING VORTEC",SUP-M001182510,CDM,C1887,HCPCS,0272,RC,,,both,,,2100.00,630,"FIRST HEALTH [10303]","First Health",,1680,80,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETHRAL BARDEX IC 22FR FOLEY 2 WAY COUNCIL TIP 2",SUP-0196SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.25,42.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.54,120.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC ITREVIA 7 HF-T",SUP-393014,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"MULTIPLAN [10600]",Multiplan,,49062,85,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP PROV 50MM CLSR TIP FIRST OPEN END CLIP LEFT",SUP-PROV50,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9916.83,28.62,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR AL1 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916599962,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]",Cigna,,52.07,68,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY ESOPHAGEAL 5 8.7MM ADULT LMA FLEXIBLE LARYNGEAL MASK",SUP-115050,CDM,S27200284,LOCAL,0272,RC,,,both,,,160.95,48.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.72,136.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 10FR LARGE REGULAR PIGTAIL CURVE URETERAL GLIDEX",SUP-M001245570,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,103.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 50MM TSRH OSTEOGRIP THINLINE TITANIUM SPINE",SUP-83545509,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"FIRST HEALTH [10303]","First Health",,2059.2,80,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 6 HOLE LOCKING BONE ANTERIOR LATERAL",SUP-70-0122,CDM,C1713,HCPCS,0278,RC,,,both,,,6651.60,1995.48,"CIGNA [10200]",Cigna,,4523.09,68,,1831.33,1831.33,1831.33,16,773.58,5653.86,"percent of total billed charges",
"MOUTHPC ENDOSCOPIC REUSABLE",SUP-MB-142,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.09,25.53,"KAISER [10500]",Kaiser,,57.01,67,,,,,0,9.9,72.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 28GA SPLITTABLE NDL BREAKAWAY MIDLINE CATH PICC",SUP-384061,CDM,C1892,HCPCS,0272,RC,,,both,,,327.38,98.21,"PHCS [10601]",PHCS,,229.17,70,,,,,0,38.07,278.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 14.5IN 28FR PHILLIPS 1/56IN PLASTIC 1 EYE MALE",SUP-346128,CDM,S27200284,LOCAL,0272,RC,,,both,,,151.38,45.41,"PHCS [10601]",PHCS,,105.97,70,,,,,0,17.61,128.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE 1.67FT TEMPERATURE CARE EXT PROBE LATEX FREE",SUP-2021700-001,CDM,S27000186,LOCAL,0270,RC,,,both,,,567.24,170.17,"PHCS [10601]",PHCS,,397.07,70,,,,,0,65.97,482.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 18GA 50CM 11CM GRAY HUB DIL GWIRE",SUP-PSI-5F-11-038-18G,CDM,C1894,HCPCS,0272,RC,,,both,,,102.23,30.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AIRWAY ESOPHAGEAL 5 STD 7MM 5.5MM ADULT LMA UNIQUE LARYNGEAL",SUP-125050,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.20,15.66,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 90CM 8FR AL2 CURVE GUIDING CORONARY",SUP-LA8AL20D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET LEAD RADIOLUCENT SOLID GEL AAMI COLOR CODED SOCKET FOAM",SUP-989803156261,CDM,S27000186,LOCAL,0270,RC,,,both,,,73.39,22.02,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PERITONEAL ADHESIOLYSIS WITH MCC",335,MS-DRG,,,,,,,inpatient,,,149543.47,44863.04,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP FULL OSTEOTOM 52MM HEMISPHERE ACETABULAR",SUP-00705305220,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOE POSTOPERATIVE 6-8 SMALL MALE NYLON MESH ROCKER",SUP-798504,CDM,S27000186,LOCAL,0270,RC,,,both,,,61.07,18.32,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Microsatellite Instability",PX-309000061,CDM,81301,CPT,0310,RC,,,both,,,2072.00,621.6,"BLUE CROSS [10001]","Blue Cross PPO",,445.32,,"Fee schedule rate ($445.32).",,,,0,0.01,1761.2,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Shave Ext Lesn 0.6-1.0cm",PX-510000019,CDM,11301,CPT,0761,RC,,,both,,,347.00,104.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,347,,"Per diem ($1,793).",,,,0,40.36,347,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Sacroiliac Jt",PX-510000069,CDM,27096,CPT,0761,RC,,,both,,,5417.97,1625.39,"BLUE CROSS [10001]","Blue Cross PPO",,2740.57,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,630.11,4605.27,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 142MM TYPE 1 PRESS FIT REDUCE TAPERLOC PPS 133D",SUP-51103110,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"UHC [10700]","United Healthcare",,15320.71,63.3,,8601.07,8395.67,8601.07,"1 through 10",2814.85,20572.84,"percent of total billed charges",
"CATH CHRG 75CM 80MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-08087,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP HUMERAL 33MM UNIVERS REVERS +2 RIGHT SUT",SUP-AR-9502F-33LCPC,CDM,C1776,HCPCS,0278,RC,,,both,,,7576.20,2272.86,"FIRST HEALTH [10303]","First Health",,6060.96,80,,,,,0,881.11,6439.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X12MM COROENT XL FIXATION",SUP-7861250,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"CIGNA [10200]","Cigna Local Plus",,10796.81,31.5,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL CANCELLOUS 7D ALLOGRAFT 10MM",SUP-3W5210,CDM,S27800098,LOCAL,0278,RC,,,both,,,21094.92,6328.48,"MULTIPLAN [10600]",Multiplan,,17930.68,85,,,,,0,2453.34,17930.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX MONORAIL 143CM 20MM 3.25MM BALLOON",SUP-H7493912420320,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE HI-FLO TRANSEND 105CM 10CM 3-2.8FR .027IN 135",SUP-M001182980,CDM,C1887,HCPCS,0272,RC,,,both,,,4726.50,1417.95,"KAISER [10500]",Kaiser,,3166.76,67,,,,,0,549.69,4017.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 15X12MM 12MM X-CORE 7D LORDOTIC MINI TITANIUM",SUP-5962526,CDM,S27800098,LOCAL,0278,RC,,,both,,,6345.24,1903.57,"BLUE CROSS [10001]","Blue Cross PPO",,2487.33,39.2,,,,,0,737.95,5393.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL SYMMETRY .4-1MM VESSEL 1",SUP-B-1VB,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.30,176.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,69.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.42,500.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 22MM LCP STAINLESS STEEL LONG THREAD FEMORAL",SUP-207.722,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"CIGNA [10200]","Cigna Open Access",,591.78,56.9,,1144.80,304.56,2275.09,66,120.96,884.03,"percent of total billed charges",
"STENT VENOVO 100MM 80CM 14MM VASCULAR VENOUS ILIOFEMORAL",SUP-VENUM14100,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Open Access",,7386.75,33.5,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Arterial Punc",PX-450000235,CDM,36600,CPT,0361,RC,,,both,,,329.64,98.89,"BLUE CROSS [10001]","Blue Cross PPO",,329.64,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,38.34,329.64,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Asp Bladder W Trocar",PX-361000231,CDM,51101,CPT,0361,RC,,,both,,,11400.78,3420.23,"UHC [10700]","United Healthcare",,3833,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1325.91,9690.66,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM 8.1FR RIGHT VENTRICLE TRANSVENOUS 1 PASS 2",SUP-5038-65,CDM,C1779,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"AETNA [10100]","Aetna HMO/PPO",,4457.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Esophagus W Cntrst",PX-320000097,CDM,74220,CPT,0320,RC,,,both,,,882.87,264.86,"PHCS [10601]",PHCS,,618.01,70,,,,,0,102.68,750.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM DARCO TITANIUM FOOT NONLOCK",SUP-DC2825116,CDM,C1713,HCPCS,0278,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",65.94,481.95,"percent of total billed charges",
"POST EXTERNAL FIXATION TRUELOK 1 HOLE NONSTERILE LATEX FREE",SUP-54-11600,CDM,C1713,HCPCS,0278,RC,,,both,,,1064.18,319.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,488.46,45.9,,,,,0,123.76,904.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS 28 AND ICODEXTRIN 7.5 % CA 3.5 MEQ/L-MAG 0.5 MEQ/L",RX-120693,CDM,,,0250,RC,00941-0679-53,NDC,both,2500,ML,892.83,267.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,607.12,68,,,,,0,103.84,758.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Jak2 Gene",PX-309000045,CDM,81270,CPT,0310,RC,,,both,,,1442.10,432.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,84.58,,"Fee schedule rate ($84.58). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1225.79,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 142MM STAINLESS STEEL 4.5MM SCR 6 HOLE LIMIT",SUP-239.986S,CDM,C1713,HCPCS,0278,RC,,,both,,,11207.39,3362.22,"CIGNA [10200]","Cigna Open Access",,6377,56.9,,1144.80,304.56,2275.09,66,1303.42,9526.28,"percent of total billed charges",
"HC Esoph Balloon Distension Tst",PX-750000237,CDM,91040,CPT,0750,RC,,,both,,,896.67,269,"AETNA [10100]","Aetna HMO/PPO",,712.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.28,896.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE BIODESIGN SURGISIS .2CM PORCINE SMALL",SUP-G54612,CDM,C1763,HCPCS,0278,RC,,,both,,,9404.70,2821.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1093.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1093.77,7994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 44-36MM COMPREHENSIVE +3MM STD SHOULDER E1",SUP-EP-115394,CDM,C1776,HCPCS,0278,RC,,,both,,,8853.60,2656.08,"NOVANET [10819]",Novanet,,6640.2,75,,,,,0,1029.67,7525.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFACLOR 250 MG CAPSULE, IMMEDIATE RELEASE",RX-9430,CDM,,,0637,RC,61442-0171-30,NDC,both,1,UN,13.01,3.9,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPHINTOM 25MM 320CM 6-5FR CLASSIC COTTON CANNULATOME II 2",SUP-G22732,CDM,C1769,HCPCS,0272,RC,,,both,,,3022.50,906.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT ABRE 100MM 20MM VASCULAR NITINOL VENOUS ILIOFEMORAL",SUP-AB9U20100090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1203.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTLINK INTERNALBRACE IMPL",SUP-AR-1588AL-CP2,CDM,C1713,HCPCS,0278,RC,,,both,,,14163.98,4249.19,"CIGNA [10200]","Cigna Open Access",,4744.93,33.5,,1144.80,304.56,2275.09,66,1647.27,12039.38,"percent of total billed charges",
"HC Ethylene Glycol",PX-301000186,CDM,82693,CPT,0301,RC,,,both,,,312.54,93.76,"KAISER [10500]",Kaiser,,209.4,67,,,,,0,0.01,265.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Slp Stdy Unatnd W Hrt/O2/Pat/Time",PX-740000066,CDM,95800,CPT,0920,RC,,,both,,,2079.00,623.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1725,,"Per diem ($1,725).",,,,0,241.79,2079,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UNI-FUSE FLOW-THRU HUB 135CM 20CM 4FR THROMBECTOMY",SUP-12401822,CDM,C1757,HCPCS,0272,RC,,,both,,,3112.50,933.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,361.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2 X 4 COMPLEX PICO COIL",SUP-10USC02004,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"AETNA [10100]","Aetna HMO/PPO",,10395.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.5MM 95MM AFFIXUS 6.5MM HIP SELF TAP SQUARE DRIVE",SUP-814510095,CDM,C1713,HCPCS,0278,RC,,,both,,,6417.00,1925.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2945.4,45.9,,,,,0,746.3,5454.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 2.9MM JUGGERLOC TITANIUM",SUP-110007345,CDM,C1713,HCPCS,0278,RC,,,both,,,8983.80,2695.14,"BLUE CROSS [10001]","Blue Cross PPO",,3521.65,39.2,,957.42,570.23,957.42,28,1044.82,7636.23,"percent of total billed charges",
"PLATE 42MM TITANIUM 2 LEVEL CLOVERLEAF CAUDAL HOLE LOCK CSLP",SUP-450.234,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,1144.80,304.56,2275.09,66,521.61,3812.25,"percent of total billed charges",
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML ORAL SOLUTION SUPERORDERABLE (FROM INJ)",RX-411456,CDM,J1100,HCPCS,0636,RC,67457-0419-00,NDC,both,1,ML,12.54,3.76,"MULTIPLAN [10600]",Multiplan,,10.66,85,,,,,0,0.42,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.35IN 24FR HEYMAN PLASTIC DILATION CATH",SUP-021124,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.15,65.14,"FIRST HEALTH [10303]","First Health",,173.72,80,,,,,0,25.25,184.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN MARIGEN OMEGA3 5X7 KERECIS",SUP-50200S05B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,9918.75,2975.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 10.25IN AUFRANC COBRA SERRATE BLUNT TIP STAINLESS",SUP-225471,CDM,S27200284,LOCAL,0272,RC,,,both,,,552.34,165.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IMPL BREAST 320CC P3.2CM MODERATE CLASSIC PROFILE STD",SUP-350-7320MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC",575,MS-DRG,,,,,,,inpatient,,,47798.08,14339.42,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 4FR 2.7MM CAMINO INTRACRANIAL TRNSDUC TIP",SUP-1104B,CDM,S27200284,LOCAL,0272,RC,,,both,,,5510.75,1653.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARDEX IC 24FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0119SI24,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.53,33.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Onc Pncrs Dna&Mrna Seq 74",PX-310000038,CDM,0313U,CPT,0310,RC,,,both,,,1500.00,450,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Onc Pncrs Dna&Mrna Seq 74",PX-310000038,CDM,0313U,CPT,0310,RC,,,both,,,1500.00,450,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC",436,MS-DRG,,,,,,,inpatient,,,51970.92,15591.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 4-0 PS-1 18IN MONOFILAMENT UNDYED",SUP-Y682H,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.63,20.59,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT FIBERWIRE 2 .5 CIRCLE STRAIGHT DIAMOND POINT 38IN BRAID",SUP-AR-7201,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.73,95.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ATHLETIS 75CM 40MM 7MM BALLOON DILATATION STERILE LATEX",SUP-H74939347070470,CDM,C1725,HCPCS,0272,RC,,,both,,,1449.90,434.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,168.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemorrhoidectomy in/Ext",PX-360000056,CDM,46260,CPT,0360,RC,,,both,,,7450.10,2235.03,"FIRST HEALTH [10303]","First Health",,5960.08,80,,,,,0,866.45,7450.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 33X4.8MM TITANIUM ENDOSCOPIC LINEAR CUTTER",SUP-HEM3348,CDM,S27200284,LOCAL,0272,RC,,,both,,,2404.95,721.48,"FIRST HEALTH [10303]","First Health",,1923.96,80,,,,,0,279.7,2044.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Metanephrines",PX-301000313,CDM,83835,CPT,0301,RC,,,both,,,424.03,127.21,"CIGNA [10200]","Cigna Open Access",,37.27,,,,,,,0.01,360.43,"fee schedule",
"SCR BONE 4MM 24MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661024,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,151.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",151.86,1109.86,"percent of total billed charges",
"ALENDRONATE 70 MG TABLET",RX-29048,CDM,,,0637,RC,16714-0633-01,NDC,both,1,UN,77.16,23.15,"NOVANET [10819]",Novanet,,57.87,75,,,,,0,8.97,65.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 3.0X15MM",SUP-PRV030015CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DIL HYDROPLUS GWIRE .038IN 6-16FR URETERAL UD3000",SUP-M0062401000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1200.58,360.17,"CIGNA [10200]","Cigna Open Access",,683.13,56.9,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL WOUND CLEANSING BACTISURE ETHANOL ACETIC ACID SODIUM",SUP-00888700100,CDM,S27000186,LOCAL,0270,RC,,,both,,,5175.00,1552.5,"UHC [10700]","United Healthcare",,3275.78,63.3,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 80X6.4X.6MM LONG STAINLESS STEEL RECIPROCATE",SUP-0277-096-300,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.85,90.25,"MULTIPLAN [10600]",Multiplan,,255.72,85,,,,,0,34.99,255.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUE DILATATION 110CM 4.5CM 12FR 22MM BALLOON",SUP-0224512,CDM,C1725,HCPCS,0272,RC,,,both,,,7590.00,2277,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5161.2,68,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL SMALL KNEE AVON",SUP-6430-0-100,CDM,C1776,HCPCS,0278,RC,,,both,,,22635.90,6790.77,"MULTIPLAN [10600]",Multiplan,,19240.52,85,,,,,0,2632.56,19240.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Chest W Cntrst",PX-610000013,CDM,71551,CPT,0610,RC,,,both,,,3865.00,1159.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,458,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,449.5,3285.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)THORAGUARD CHEST TUBE KIT - 28 FR",SUP-TGCT120028,CDM,S27200284,LOCAL,0272,RC,,,both,,,1615.95,484.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1098.85,68,,,,,0,187.93,1373.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Progr Dev Eval in Person",PX-480000079,CDM,0522T,CPT,0480,RC,,,both,,,299.00,89.7,"KAISER [10500]",Kaiser,,200.33,67,,,,,0,34.77,299,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Cytp Oth Prp / Add on 88161",PX-311000084,CDM,0833T,CPT,0311,RC,,,both,,,104.00,31.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 16FR 5CM 30CM MULTIPURPOSE PEEL-AWAY",SUP-G02950,CDM,C1894,HCPCS,0272,RC,,,both,,,530.47,159.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,218.02,41.1,,,,,0,61.69,450.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE-O SCREW, 5.5X30MM TRACTION POLY",SUP-13115530,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AETNA [10100]","Aetna HMO/PPO",,7589.75,79.5,,1521.93,481.35,16760.95,30,1110.3,8114.82,"percent of total billed charges",
"BLADE SHAVER YELLOW 4.5MM 4.5MM DYONICS CURVED FULL RADIUS",SUP-7205349,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,236.64,68,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 48MM PERIPHERAL",SUP-5572-4548,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"MULTIPLAN [10600]",Multiplan,,1322.35,85,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE KIWI PROCUP PALM PUMP VACUUM EXTRACTION RIGID STEM",SUP-VAC-6000S,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"AETNA [10100]","Aetna HMO/PPO",,193.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 95MM 36MM 8.5MM 22FR ZENITH FLEX Z-TRAK",SUP-G48432,CDM,C1874,HCPCS,0278,RC,,,both,,,53285.40,15985.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6314.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6197.09,45292.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30X12X10-17MM RISE 15D",SUP-193.243,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 14MM 9MM STD NECK S-ROM CERAMIC 135D",SUP-523251,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2304.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2262.18,16533.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 24CM 3CM 7FR .035IN STRAIGHT PIGTAIL CURVE",SUP-M006180232050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"CIGNA [10200]","Cigna Local Plus",,557.25,,,,,,,121.14,885.34,"percent of total billed charges",
"SPACER ALLOGRAFT 12X14X11MM PARALLEL SPINE CERVICAL",SUP-17911,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25MMX11MM CRESCENT PEEK-OPTIMA VERTEBRAL BODY",SUP-9392511,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA [10200]","Cigna Open Access",,5547.6,33.5,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 28.5CM TIBIAL NAIL-EX INTRAMEDULLARY CANNULATED",SUP-04.004.637S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"KAISER [10500]",Kaiser,,5569.33,67,,,,,0,966.74,7065.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U150,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,213.22,28.62,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL DARK BLUE 15MM SYNFIX 18D MEDIUM EVOLUTION 6.9",SUP-08.815.264S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TANGENT 4D ALLOGRAFT FREEZE DRIED WEDGE IMPACTED",SUP-171426,CDM,S27800098,LOCAL,0278,RC,,,both,,,12572.49,3771.75,"FIRST HEALTH [10303]","First Health",,10057.99,80,,,,,0,1462.18,10686.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE WEDGE ALLOGRAFT IMPACT FRESH FROZEN 26MMX12MM",SUP-161226,CDM,S27800098,LOCAL,0278,RC,,,both,,,12572.49,3771.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1489.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1462.18,10686.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION",RX-9929,CDM,,,0250,RC,43598-0169-11,NDC,both,2,ML,85.90,25.77,"KAISER [10500]",Kaiser,,57.55,67,,,,,0,9.99,73.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 5.5MM TSRH-2D CONTOUR PEDICLE TITANIUM",SUP-8370065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"CAGE SPINAL 17X6MM DIVERGENCE 14MM LORDOTIC NUCLEUS PULPOSUS",SUP-G6626746,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5104.62,41.1,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 2MM SPACE K CURVE ELECTROPHYSIOLOGY",SUP-F6QK002RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"AETNA [10100]","Aetna HMO/PPO",,721.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REG VACUUM 0-300 MMHG CONTINUOUS INTERMITTENT TUBING NIPPLE",SUP-VR-CIUT-OMD,CDM,S27200284,LOCAL,0272,RC,,,both,,,2452.58,735.77,"FIRST HEALTH [10303]","First Health",,1962.06,80,,,,,0,285.24,2084.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOLIC ACID 1 MG TABLET",RX-3233,CDM,,,0637,RC,00904-7224-61,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IPG ADDRS1 ADAPTA  DR  IS-1  SMALL  US",SUP-ADDRS1,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"PHCS [10601]",PHCS,,29120,70,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 26MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.526,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,745.57,68,,,,,0,127.51,931.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 30MM 80CM 7MM 8FR STRAIGHT VASCULAR",SUP-AVSM07030,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"NOVANET [10819]",Novanet,,13702.5,75,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 4CM 5FR STRAIGHT PANCREATIC POLYMER DRNG HOLE",SUP-M00536260,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"FIRST HEALTH [10303]","First Health",,511.4,80,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 60X16MM DARCO FOOT HEADLESS",SUP-DC001660,CDM,C1713,HCPCS,0278,RC,,,both,,,4629.90,1388.97,"NOVANET [10819]",Novanet,,3472.43,75,,,,,0,538.46,3935.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 4IN 5FR 21GA MAK .018IN PLATINUM COIL TIP NITINOL",SUP-MAK501NBT,CDM,C1894,HCPCS,0272,RC,,,both,,,250.56,75.17,"PHCS [10601]",PHCS,,175.39,70,,,,,0,29.14,212.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 7-12 GH 10MM KNEE RIGHT CRUCIATE RETAINING",SUP-42522000610,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7327.97,68,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 20MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-592502022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,549.3,41.1,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SIEGEL TAVR DELIVERY SYSTEM - HANDLE BALLOON CATHETER",SUP-30-1-0223,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MARROW CELLUTION 3.5IN 11GA ASPIRATION 10ML BONE",SUP-7427901M,CDM,S27200284,LOCAL,0272,RC,,,both,,,6718.88,2015.66,"KAISER [10500]",Kaiser,,4501.65,67,,,,,0,781.41,5711.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 19MM 150CM 5MM BILIARY STAINLESS",SUP-37912-51915,CDM,C1876,HCPCS,0278,RC,,,both,,,3967.50,1190.25,"PHCS [10601]",PHCS,,2777.25,70,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM TSRH OSTEOGRIP TITANIUM SHORT SPINE",SUP-83575508,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.10,1106.73,"BLUE CROSS [10001]","Blue Cross PPO",,1446.13,39.2,,957.42,570.23,957.42,28,429.04,3135.74,"percent of total billed charges",
"PIN FIXATION CODA PUSH STERILE",SUP-202250100S,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVERSTITCH ENDOSCOPIC SUTURE SYSTEM",SUP-M00505410,CDM,S27200284,LOCAL,0272,RC,,,both,,,8797.50,2639.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1042.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1023.15,7477.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 20CM 150CM 6FR .035IN PIGTAIL CURVE",SUP-M006180220180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"KAISER [10500]",Kaiser,,978.27,67,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 80MM 80CM 9MM 6FR .035IN VASCULAR NITINOL",SUP-G43863,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1735.02,45.9,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO SD 90D UP STRAIGHT 1.8MM 3.8MM SHOULDER",SUP-AR-4068-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,1190.70,357.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,489.38,41.1,,,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 5MM CHARLOTTE STAINLESS STEEL CANNULATED STERILE",SUP-44180010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT",RX-854,CDM,,,0250,RC,00713-0268-31,NDC,both,28.4,GR,22.62,6.79,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10.38,45.9,,,,,0,2.63,19.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM SPINAL POLYAXIAL 5.5MM ROD",SUP-8457540,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,573.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",563.19,4116.21,"percent of total billed charges",
"MESH HERNIA POLYGLYCOLIC ACID 20X10IN RESORBABLE GRID 2",SUP-F10258-1020G,CDM,C1781,HCPCS,0278,RC,,,both,,,25704.00,7711.2,"PHCS [10601]",PHCS,,17992.8,70,,,,,0,2989.38,21848.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 10MM REUSABLE HANDLE ACL PCL SURGICAL PARALLEL GRAFT",SUP-AR-2285-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,429.35,128.8,"CIGNA [10200]",Cigna,,291.96,68,,,,,0,49.93,364.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1MM 8MM STAINLESS STEEL CORTICAL HAND SELF TAPPING",SUP-200.528,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"CIGNA [10200]","Cigna Open Access",,271,56.9,,1144.80,304.56,2275.09,66,55.39,404.84,"percent of total billed charges",
"CAP CONSTRUCT TOTAL KNEE LEGION GII CRUCIATE RETAINING HYBRI",SUP-71704525,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS [10001]","Blue Cross PPO",,8643.6,39.2,,3949.44,3949.44,3949.44,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"IMMOB ORTHOPEDIC SMALL 20IN 14-16IN KNEE CONTOURED",SUP-4462-02,CDM,L1830,HCPCS,0274,RC,,,both,,,140.77,42.23,"CIGNA [10200]",Cigna,,95.72,68,,,,,0,16.37,119.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE INCORE PRECISION POST PLUG GUIDE CORRECTION LAPIDUS",SUP-ICLAP35P,CDM,C1713,HCPCS,0278,RC,,,both,,,3136.35,940.9,"KAISER [10500]",Kaiser,,2101.35,67,,,,,0,364.76,2665.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VLV SHNT CERTAS INLN SPHGRD",SUP-828804PL,CDM,S27800098,LOCAL,0278,RC,,,both,,,38643.57,11593.07,"NOVANET [10819]",Novanet,,28982.68,75,,,,,0,4494.25,32847.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 605CC",SUP-RSZ-MPX-605S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5CM KNEE LEFT RESURFACE STERILE",SUP-151808,CDM,C1776,HCPCS,0278,RC,,,both,,,50549.31,15164.79,"CIGNA [10200]",Cigna,,20219.72,40,,5873.17,5873.17,5873.17,"1 through 10",5878.88,42966.91,"percent of total billed charges",
"CATH SOFT-VU 65CM 5FR ANGLE KUMPE CURVE ANGIOGRAPHIC",SUP-H787107327015,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RF MARINR MC 110CM 7FR 2-5-2MM SPACE ELECTROPHYSIOLOGY",SUP-075302,CDM,C1733,HCPCS,0272,RC,,,both,,,3967.50,1190.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH FLEXOR 45CM 10.7FR ACCESS URETER DILATION CONTINUOUS",SUP-G34880,CDM,C1894,HCPCS,0272,RC,,,both,,,1253.88,376.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC",486,MS-DRG,,,,,,,inpatient,,,99782.19,29934.66,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR AVENIR COMPLETE 6.5 HIGH OFFSET HIP",SUP-574202065,CDM,C1776,HCPCS,0278,RC,,,both,,,23461.20,7038.36,"BLUE CROSS [10001]","Blue Cross PPO",,9196.79,39.2,,3949.44,3949.44,3949.44,"1 through 10",2728.54,19942.02,"percent of total billed charges",
"CMPNT FEMORAL 5 RIGHT KNEE POSTERIOR STABILIZED BEADED",SUP-5516F502,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4675.57,27,,,,,0,2013.96,14719.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GAG MOUTH 3 BLADE TONGUE GUARD MCIVOR",SUP-45-5320X,CDM,S27000186,LOCAL,0270,RC,,,both,,,88.65,26.59,"CIGNA [10200]",Cigna,,60.28,68,,,,,0,10.31,75.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Sacroiliac Jt <3v",PX-320000050,CDM,72200,CPT,0320,RC,,,both,,,374.86,112.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,44.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.75,318.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ACCESS AMS 700 PENILE IMPL",SUP-72401850,CDM,C1813,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,919.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP CLUSTER HOLE HA TRIDENT II PSL E",SUP-742-11-54E,CDM,C1776,HCPCS,0278,RC,,,both,,,9502.96,2850.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1126.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1105.19,8077.52,"percent of total billed charges",
"HC Rplc Periph Ins Impl Vad",PX-361000120,CDM,36585,CPT,0361,RC,,,both,,,7533.44,2260.03,"PHCS [10601]",PHCS,,7533.44,,"Case rate ($8,239). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,876.14,7533.44,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 10 HIP",SUP-PRTLE030,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2198.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 32MM 144CM 3.5MM CORONARY STENT",SUP-H7493911432350,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"PHCS [10601]",PHCS,,6399.75,70,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ACS 10-0 CU-5 12IN 2 ARM MONOFILAMENT BLACK",SUP-8065192101,CDM,S27200284,LOCAL,0272,RC,,,both,,,265.96,79.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,180.85,68,,,,,0,30.93,226.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GARM COMPRESSION 50-60HZ 25VA LARGE UNIVERSAL CALF VELCRO",SUP-DVT20,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.58,33.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,51.67,45.9,,,,,0,6.55,95.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3.5MM 12/14 TAPER 32MM HIP COCR VERSYS STERILE",SUP-801803203,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"CIGNA [10200]","Cigna Local Plus",,2595.12,53.5,,5372.07,4581.20,7242.98,23,564.14,4123.1,"percent of total billed charges",
"IMPL BREAST 730CC P5.1CM MODERATE PLUS PROFILE COHESIVE GEL",SUP-SMPB730,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"AETNA [10100]","Aetna HMO/PPO",,6061.48,79.5,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 18GA SIDEKICK 2 10MM DEPLOYMENT",SUP-RFK-C101018S-ZK2-P,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.95,74.38,"CIGNA [10200]",Cigna,,168.61,68,,,,,0,28.84,210.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet/CT Tumor Wb",PX-404000005,CDM,78816,CPT,0404,RC,,,both,,,7540.46,2262.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,876.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,876.96,7540.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 7-0 BV175-6 30IN 2 ARM MONOFILAMENT 4 STRAND",SUP-M8733,CDM,S27200284,LOCAL,0272,RC,,,both,,,475.47,142.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,56.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.3,404.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPIDCROSS 170CM 210MM 2MM .014IN BALLOON DILATATION",SUP-A14BX020210170,CDM,C1725,HCPCS,0272,RC,,,both,,,1638.75,491.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,194.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,190.59,1392.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 4-6 SMALL FEMALE BEIGE CANVAS RUBBER",SUP-2041-07,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.42,14.23,"AETNA [10100]","Aetna HMO/PPO",,37.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.51,40.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE QVS GENTAMICIN HVY",SUP-200-00-002,CDM,C1713,HCPCS,0278,RC,,,both,,,796.50,238.95,"CIGNA [10200]","Cigna Open Access",,453.21,56.9,,1144.80,304.56,2275.09,66,92.63,677.03,"percent of total billed charges",
"COLLAR CERVICAL SHORT ASPEN SET REPLACEMENT PAD LATEX FREE",SUP-AM983128,CDM,S27000186,LOCAL,0270,RC,,,both,,,586.76,176.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,241.16,41.1,,,,,0,68.24,498.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 30CM SPECIFY 5-6-5 LEAD 16 CONTACT PADDLE",SUP-39565-30,CDM,C1778,HCPCS,0278,RC,,,both,,,30240.00,9072,"BLUE CROSS [10001]","Blue Cross HMO",,11854.08,39.2,,,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25022W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,399.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 130MM 4.2MM T2 AO COUPLING CENTER TIPPED",SUP-18064280S,CDM,S27000186,LOCAL,0270,RC,,,both,,,147.00,44.1,"CIGNA [10200]","Cigna Local Plus",,78.65,53.5,,,,,0,17.1,124.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 7 RIGHT DISTAL KNEE TOTAL",SUP-5540-A-702,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"CIGNA [10200]","Cigna Local Plus",,2430.94,53.5,,5372.07,4581.20,7242.98,23,528.45,3862.24,"percent of total billed charges",
"STEM FEMORAL 195MM 19MM STRAIGHT CONICAL MODULAR RESTORATION",SUP-6276-7-119,CDM,C1776,HCPCS,0278,RC,,,both,,,11080.37,3324.11,"FIRST HEALTH [10303]","First Health",,8864.3,80,,,,,0,1288.65,9418.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,inpatient,,,32209.95,9662.98,"CIGNA [10200]",Cigna,,13344.08,,"Fee schedule rate ($13,344.08). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,6312.86,25380.42,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"MEPERIDINE (PF) 100 MG/ML INJECTION SUPERORDERABLE",RX-408863,CDM,J2175,HCPCS,0636,RC,00641-6054-01,NDC,both,1,ML,51.43,15.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,21.92,,,,,,,1.7,43.72,"fee schedule",
"SMOOTH PEG LOCKING 3.5MM X 20MM TI",SUP-SPL-35200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 15MM KNEE XLPE POSTERIOR STABILIZE LEGION",SUP-71453249,CDM,C1776,HCPCS,0278,RC,,,both,,,14831.55,4449.46,"FIRST HEALTH [10303]","First Health",,11865.24,80,,,,,0,1724.91,12606.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION 105CM 2.4-3FR .021IN MICRO INFUSION NITINOL",SUP-M001195290,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"NOVANET [10819]",Novanet,,2812.5,75,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 88CM 5.3FR 2 CURVE LEFT HEART TRANSVENOUS",SUP-4296-88,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]",Cigna,,3812.76,68,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 5CM 5FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G24574,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA [10200]",Cigna,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE",RX-78310,CDM,,,0637,RC,00904-6832-04,NDC,both,1,UN,56.65,16.99,"CIGNA [10200]",Cigna,,38.52,68,,,,,0,6.59,48.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM CONCERTO DETACHABLE HELIX",SUP-NV-2-6-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 SH-1 30IN 2 ARM BRAID 4 STRAND GREEN",SUP-MX763,CDM,S27200284,LOCAL,0272,RC,,,both,,,161.47,48.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,74.11,45.9,,,,,0,18.78,137.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 B 32MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30123202,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"KAISER [10500]",Kaiser,,6868.85,67,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Lumb Spine W Cntrst",PX-612000006,CDM,72149,CPT,0612,RC,,,both,,,4838.41,1451.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,529.95,,,,,,,529.95,4112.65,"fee schedule",
"PIN FIXATION ATTUNE THREAD PACK HEAD HEADLESS DISPOSABLE",SUP-254400111,CDM,C1713,HCPCS,0278,RC,,,both,,,2043.75,613.12,"CIGNA [10200]","Cigna Open Access",,1162.89,56.9,,1144.80,304.56,2275.09,66,237.69,1737.19,"percent of total billed charges",
"HC Inj Anes Foramen Epi Lumb Sngl",PX-510000128,CDM,64483,CPT,0761,RC,,,both,,,4057.93,1217.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1729.39,,"Case rate ($1,729.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,471.94,4057.93,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ABLATION RADIOFREQUENCY",SUP-64082,CDM,C1886,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 80MM 2.5MM BALLOON DILATATION STERILE LATEX",SUP-582508022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"FIRST HEALTH [10303]","First Health",,1198.8,80,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +16.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1650,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 4FR 65CM TRIFORCE FLEXOR PEEL-AWAY STRAIGHT CURVE",SUP-G56414,CDM,S27200284,LOCAL,0272,RC,,,both,,,2711.18,813.35,"PHCS [10601]",PHCS,,1897.83,70,,,,,0,315.31,2304.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD HEMOSTATIC 4X4CM CLO-SUR PAD VASCULAR POLYPROLATE",SUP-SCV22P-AB,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.40,83.52,"CIGNA [10200]","Cigna Local Plus",,148.94,53.5,,,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 4FR 65CM TRIFORCE FLEXOR PEEL-AWAY STRAIGHT CURVE",SUP-G56414,CDM,S27200284,LOCAL,0272,RC,,,both,,,2711.18,813.35,"CIGNA [10200]",Cigna,,1843.6,68,,,,,0,315.31,2304.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 25MM PRESS FIT FLUTED TRIATHLON KNEE",SUP-5565-S-025,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,561.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,550.92,4026.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT 24MM ALIF",SUP-3W3224,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"UHC [10700]","United Healthcare",,13384.99,63.3,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.9MM SHORT PUSHLOCK HIP BIOCOMPOSITE 12.5MM",SUP-AR-2923BCH,CDM,C1713,HCPCS,0278,RC,,,both,,,3307.50,992.25,"FIRST HEALTH [10303]","First Health",,2646,80,,,,,0,384.66,2811.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 40 SMALL PEG AEQUALIS PERFORM CORTILOC",SUP-DWE403,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"UHC [10700]","United Healthcare",,5897.03,63.3,,8601.07,8395.67,8601.07,"1 through 10",1083.45,7918.6,"percent of total billed charges",
"HC Ndl Asp Absc/Hema/Bulla/Cyst",PX-510000004,CDM,10160,CPT,0761,RC,,,both,,,7071.53,2121.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,837.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,822.42,6010.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 50MM 32MM ALTRX HIP",SUP-122132150,CDM,C1776,HCPCS,0278,RC,,,both,,,5531.40,1659.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1583.09,28.62,,,,,0,643.3,4701.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30MM 4MM COMPLEX .018IN HELIX PLATINUM",SUP-M0013120431,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 3-0 RB-1 SPIRAL 17MM SUT",SUP-SXPP1B422,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.96,69.59,"UHC [10700]","United Healthcare",,146.83,63.3,,,,,0,26.98,197.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Vad Prph W Port Age 5 Yr/>",PX-361000116,CDM,36571,CPT,0361,RC,,,both,,,8900.42,2670.13,"CIGNA [10200]","Cigna Open Access",,3307,,"Case rate ($3,307). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,8.9,8239,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISPOSABLE CLIP LIMB SLING",SUP-VIG22000-L1,CDM,S27000186,LOCAL,0270,RC,,,both,,,145.43,43.63,"PHCS [10601]",PHCS,,101.8,70,,,,,0,16.91,123.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER PINK 4.5MM RAZORCUT DYONICS ARTHROSCOPIC",SUP-7205318,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.00,84.9,"MULTIPLAN [10600]",Multiplan,,240.55,85,,,,,0,32.91,240.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PENCIL 10FT VALLEYLAB NONSTERILE",SUP-E2515HS-NSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.90,17.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,38.69,68,,,,,0,6.62,48.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 240CM 5.5CM 7.5FR 12-15MM ESOPHAGEAL",SUP-M00558480,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"MULTIPLAN [10600]",Multiplan,,1401.68,85,,,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 2-0 FSL 36IN MONOFILAMENT ABSORBABLE",SUP-Y932H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Open Access",,14.23,56.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 3.5MM LORDOSIS TITANIUM",SUP-102063060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"NDL BONE CEMENT AVAFLEX CURVE STERILE LATEX FREE DISPOSABLE",SUP-1025-011-500,CDM,S27200284,LOCAL,0272,RC,,,both,,,2798.33,839.5,"MULTIPLAN [10600]",Multiplan,,2378.58,85,,,,,0,325.45,2378.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Asp Inj Thyroid Cyst",PX-361000247,CDM,60300,CPT,0361,RC,,,both,,,3590.00,1077,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,425.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,417.52,3590,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 4MM WIDENING COUNTSINK BAHA AUDITORY",SUP-92141,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,196.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.5MM 18MM PARTIAL THREAD DISTAL VOLAR RADIUS",SUP-TP18000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1093.50,328.05,"CIGNA [10200]",Cigna,,743.58,68,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR ACTIS DUOFIX 1 HIGH OFFSET HIP STERILE",SUP-101012010,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"KAISER [10500]",Kaiser,,20419.09,67,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM PRESS FIT BASIC SUMMIT 8 12/14 TAPER HIP",SUP-157005150,CDM,C1776,HCPCS,0278,RC,,,both,,,9090.75,2727.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1057.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1057.25,7727.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 22MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-214.822,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"CIGNA [10200]","Cigna Local Plus",,134.24,53.5,,3978.14,359.25,3978.14,24,29.18,213.27,"percent of total billed charges",
"NEUROFORM ATLAS STENT SYSTEM 4.0 X 24MM WITHOUT TIP ZERO (PM",SUP-M003UZAS40240,CDM,C1874,HCPCS,0278,RC,,,both,,,52885.22,15865.57,"UHC [10700]","United Healthcare",,33476.34,63.3,,,,,0,6150.55,44952.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR PRESSURE MNTR 60IN ACUMEN IQ VAMP ADULT SYSTEM",SUP-AIQS6AZ5,CDM,S27200284,LOCAL,0272,RC,,,both,,,2760.00,828,"CIGNA [10200]","Cigna Open Access",,1570.44,56.9,,,,,0,320.99,2346,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 640CC P4.3CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-640,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PHCS [10601]",PHCS,,5288.85,70,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER EMBOLIZATION NAVALIGN DELIVERY UNISET STERILE",SUP-G34505,CDM,C1880,HCPCS,0278,RC,,,both,,,7621.05,2286.31,"BLUE CROSS [10001]","Blue Cross PPO",,2987.45,39.2,,,,,0,886.33,6477.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER QUEEN ZIPPER BRA RECOVERY MAMMARY",SUP-958-QUEEN,CDM,S27000186,LOCAL,0270,RC,,,both,,,449.39,134.82,"NOVANET [10819]",Novanet,,337.04,75,,,,,0,52.26,381.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 E-F 17MM KNEE FIX BEARING PROLONG NEXGEN",SUP-00596204017,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"KAISER [10500]",Kaiser,,5305.35,67,,,,,0,920.91,6730.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DEBAKEY-DIETHRICH 7.75INX1.5MM CORONARY ARTERY",SUP-320-114,CDM,S27000186,LOCAL,0270,RC,,,both,,,447.36,134.21,"AETNA [10100]","Aetna HMO/PPO",,355.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.03,380.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 23MM 2MM CORONARY STENT COCR",SUP-1007821-23,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LOW PROFILE 35MM TITANIUM INTEGRATE LOCK MECHANISM",SUP-9790035,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,957.42,570.23,957.42,28,521.61,3812.25,"percent of total billed charges",
"TRAY NERVE BLOCK 1.5IN 18GA 10% PVP IODINE 1% LIDOCAINE CSR",SUP-181058,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.54,41.86,"UHC [10700]","United Healthcare",,88.33,63.3,,,,,0,16.23,118.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD TITANIUM 4 HOLE GEMINUS BONE LEFT DISTAL VOLAR",SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,0278,RC,,,both,,,5161.20,1548.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3509.62,68,,,,,0,600.25,4387.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X4CM VIALIZE PLACENTAL MEMB ALLOGRAFT",SUP-VL-4040,CDM,,,0278,RC,,,both,,,10281.00,3084.3,"BLUE CROSS [10001]","Blue Cross PPO",,10.28,.1,,,,,0,10.28,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 60MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-060-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1083.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1083.33,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 22CM 3CM 5FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155221050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"PHCS [10601]",PHCS,,861.67,70,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL C TAPER COBALT CHROME LFIT",SUP-06-3205,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"MULTIPLAN [10600]",Multiplan,,2658.55,85,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 150MM 4MM BALLOON DILATATION RAPID",SUP-47540150L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Test Defin 22+ Class",PX-301000669,CDM,G0483,HCPCS,0301,RC,,,both,,,509.83,152.95,"BLUE CROSS [10001]","Blue Cross PPO",,315.46,,"Fee schedule rate ($315.46).",,,,0,0.01,433.36,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN JUDKINS LEFT 6 CURVE",SUP-DXT6JL60,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CURET 0 8IN EPSTEIN SPINE SURGICAL",SUP-57-4622,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.74,104.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET CATH 20CM SILICONE SCHON XL BASIC ACUTE HEMODIALYSIS",SUP-H787108007025,CDM,C1752,HCPCS,0278,RC,,,both,,,538.65,161.59,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,62.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.64,457.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 5 KNEE RIGHT CRUCIATE RETAINING PFC SIGMA",SUP-940025,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"PHCS [10601]",PHCS,,18122.9,70,,,,,0,3010.99,22006.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 83MM 18GA 21GA E-CATH PLUS SONOPLEX",SUP-TDL142,CDM,C9812,HCPCS,0272,RC,,,both,,,611.55,183.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,415.85,68,,,,,0,71.12,519.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 56MM 9MM 5.4MM 4.7MM ZENITH SPIRAL-Z",SUP-G55219,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"CIGNA [10200]",Cigna,,8469.72,40,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Opioids and Opiate Analogs",PX-301000570,CDM,80364,CPT,0301,RC,,,both,,,645.00,193.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,110.56,,"Fee schedule rate ($110.56). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.65,548.25,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ISOSORBIDE DINITRATE 10 MG TABLET, IMMEDIATE RELEASE",RX-4064,CDM,,,0637,RC,63739-0569-10,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 3INX1 3/8IN HILL-FERGUSON MIRROR SATIN FINISH RECTAL",SUP-SU180,CDM,S27200284,LOCAL,0272,RC,,,both,,,1372.79,411.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,564.22,41.1,,,,,0,159.66,1166.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT TAPERED COMPONENT",SUP-G47481,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"CIGNA [10200]","Cigna Open Access",,34380.55,33.5,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 5ML 1-5MM CANCELLOUS ALLOGRAFT MILLED CHIP",SUP-400105,CDM,C1713,HCPCS,0278,RC,,,both,,,1619.03,485.71,"CIGNA [10200]",Cigna,,1100.94,68,,1831.33,1831.33,1831.33,16,188.29,1376.18,"percent of total billed charges",
"CATH COYOTE 90CM 100MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939186251090,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 19MM TITANIUM 5.5MM ROD LOW PROFILE FIX LEGACY X10",SUP-8115519,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]",Cigna,,2422.5,68,,1831.33,1831.33,1831.33,16,414.32,3028.13,"percent of total billed charges",
"HC Neu Prksn Msfl Î±-Syncln Prtn",PX-310000034,CDM,0393U,CPT,0310,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,1190.18,,,,,,,355.5,2550,"fee schedule",
"SHELL BIPOLAR 48MM MULTIPOLAR HIP METAL STERILE",SUP-500104800,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,434.96,3179,"percent of total billed charges",
"SCR BONE 2.7MM 32MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0336,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross HMO",,371.5,39.2,,957.42,156.86,7483.26,51,110.22,805.55,"percent of total billed charges",
"CNTNR TRANSPEC DEVICE PERFORATED COMPRESSION PLATE SPECIMEN",SUP-600101,CDM,S27000186,LOCAL,0270,RC,,,both,,,171.52,51.46,"MULTIPLAN [10600]",Multiplan,,145.79,85,,,,,0,19.95,145.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 80MM 6FR 10MM .035IN LOW PROFILE BALLOON",SUP-B1100-080,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"FIRST HEALTH [10303]","First Health",,615.6,80,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 25CM .02IN 7MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0725,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.00,2003.4,"CIGNA [10200]","Cigna Open Access",,3799.78,56.9,,,,,0,776.65,5676.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 6.0 MM X 100 MM X 130 CM",SUP-IPU06010013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"PHCS [10601]",PHCS,,5651.1,70,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT 3/32IN EDGE",SUP-E2350H-GNSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.71,1.41,"FIRST HEALTH [10303]","First Health",,3.77,80,,,,,0,0.55,4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREONPANOPTIX PROTORIC(UVA)",SUP-PXCWT4,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"BLUE CROSS [10001]","Blue Cross PPO",,358.68,39.2,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 58CM .016IN KNOB CAP KT",SUP-6059,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXERCISER HAND THERABAND XL GREEN",SUP-927807,CDM,S27000186,LOCAL,0270,RC,,,both,,,91.44,27.43,"KAISER [10500]",Kaiser,,61.26,67,,,,,0,10.63,77.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Impl Cardiac Event Record",PX-361000059,CDM,33286,CPT,0361,RC,,,both,,,2510.76,753.23,"CIGNA [10200]","Cigna Local Plus",,2510.76,,"Case rate ($2,587). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,292,2510.76,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER RADIOLOGY 4MM 17GA ULTRACLIP II 3MM TISSUE COIL",SUP-864017,CDM,A4648,HCPCS,0278,RC,,,both,,,640.63,192.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,183.35,28.62,,,,,0,74.51,544.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 30CM 3CM 6FR .038IN 2",SUP-M006192135170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CIGNA [10200]","Cigna Open Access",,793.89,,,,,,,162.27,1185.95,"percent of total billed charges",
"HC Enteroscopy W Rmvl FB",PX-750000228,CDM,44363,CPT,0750,RC,,,both,,,3196.00,958.8,"BLUE CROSS [10001]","Blue Cross PPO",,3196,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,371.69,3196,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM CONCERTO DETACHABLE HELIX",SUP-NV-4-8-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC",419,MS-DRG,,,,,,,inpatient,,,61213.47,18364.04,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,18215.1,,"Case rate ($8,472.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,866.96, add-ons for qualifying new technology services are included. If operating cost exceeds $40,906.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,976.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $7,877.36. The transfer operating threshold is the transfer adjustment factor * $7,866.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.78. The transfer capital threshold is the transfer adjustment factor * $594.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,39875.9,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Band Lig",PX-750000033,CDM,43244,CPT,0750,RC,,,both,,,4230.01,1269,"CIGNA [10200]",Cigna,,3287,,"Case rate ($3,287). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,491.95,4230.01,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 40MM UNITRAX HIP FEMORAL MODULAR EXETER V40",SUP-6942-5-040,CDM,C1776,HCPCS,0278,RC,,,both,,,3753.24,1125.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1074.18,28.62,,,,,0,436.5,3190.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET .241IN 24IN 2 NONVENT SECONDARY PIERCE PIN CNTNR CLAMP",SUP-654202,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.52,25.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,56.79,68,,,,,0,9.71,70.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 20MM 75CM 8MM 100CM",SUP-M001712160,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"CIGNA [10200]","Cigna Local Plus",,4522.09,53.5,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 225MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-410-225,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR PREPARATION OF TC-99M-EXAMETAZIME INTRAVENOUS SOLUTION",RX-186705,CDM,A9521,HCPCS,0343,RC,08888-8878-39,NDC,both,1,UN,9958.79,2987.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1180.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1158.21,8464.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC",700,MS-DRG,,,,,,,inpatient,,,32478.87,9743.66,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,4407.87,,"Case rate ($4,279.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,973.80, add-ons for qualifying new technology services are included. If operating cost exceeds $37,013.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,682.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $3,979.05. The transfer operating threshold is the transfer adjustment factor * $3,973.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $300.44. The transfer capital threshold is the transfer adjustment factor * $300.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4279.49,17205.42,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM RIGHT VENTRICLE IS-1 CNCT BIPOLAR FIXATION","SUP-365 501",CDM,C1777,HCPCS,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross PPO",,6762,39.2,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 1.2MM CROSS CUT FISSURE STERILE LATEX FREE",SUP-5820-066-012,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"PHCS [10601]",PHCS,,766.47,70,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Retrograde Gundry 15fr",PX-E27200353,CDM,E27200353,LOCAL,0272,RC,,,both,,,521.40,156.42,"CIGNA [10200]","Cigna Local Plus",,278.95,53.5,,,,,0,60.64,443.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC TB Test Cell Immunity Measure",PX-302000092,CDM,86480,CPT,0302,RC,,,both,,,553.85,166.15,"KAISER [10500]",Kaiser,,371.08,67,,,,,0,0.55,470.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ASCEND FLEX REV W PERF REV LAT BASEPLATE",SUP-CAP1132,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"UHC [10700]","United Healthcare",,30706.83,63.3,,8601.07,8395.67,8601.07,"1 through 10",5641.71,41233.5,"percent of total billed charges",
"CATH LUTONIX 75CM 40MM 12MM BALLOON DILATATION DRUG COATED",SUP-LX35751240V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"MULTIPLAN [10600]",Multiplan,,7184.63,85,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (OTW)  2.50MM X 10MM",SUP-H74939402102500,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,629.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER RESECTOR F SERIES REPROCESSED",SUP-0375552000,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"MULTIPLAN [10600]",Multiplan,,273.62,85,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 30MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0312,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"MULTIPLAN [10600]",Multiplan,,805.55,85,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 12MM 3MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT30012UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"PHCS [10601]",PHCS,,1690.5,70,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 130MM 11.7MM 8MM ADJUSTABLE NECK FLANGE CLIP IN OBTR",SUP-75HA80,CDM,S27200284,LOCAL,0272,RC,,,both,,,1619.19,485.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.31,1376.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 28MM 144CM 3MM CORONARY STENT EVEROLIMUS",SUP-H7493926128300,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"FIRST HEALTH [10303]","First Health",,6900,80,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT225220,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"NOVANET [10819]",Novanet,,258.75,75,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 15CM SUPERCORE COAXIAL ECHOGENIC TIP INTRO",SUP-701118150,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.65,103.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,233.68,68,,,,,0,39.97,292.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 14CM 23MM 12MM 19-21MM 10-11MM GORE",SUP-RLT231214,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,17944.74,28.62,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 75MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.410,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"MULTIPLAN [10600]",Multiplan,,1176.51,85,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 30MM 2.5MM BALLOON DILATATION DRUG COATED",SUP-H7493960830250,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4524.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCOPIC ENDOTRAC HOOK BLADE STERILE LATEX FREE",SUP-2056-6,CDM,S27200284,LOCAL,0272,RC,,,both,,,2044.35,613.3,"CIGNA [10200]",Cigna,,1390.16,68,,,,,0,237.76,1737.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB RESUSCITATION COMPLETE AMBULATORY CARE ONESTEP",SUP-8900-0214-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,575.59,172.68,"UHC [10700]","United Healthcare",,364.35,63.3,,,,,0,65.66,489.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SURGICAL BIOSEAL CUSTOM BONE FLAP STERILE DISPOSABLE",SUP-BBF001/10,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.09,51.03,"NOVANET [10819]",Novanet,,127.57,75,,,,,0,19.78,144.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 56MM 20MM 6MM 16FR ZENITH SPIRAL-Z 2",SUP-G55241,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"CIGNA [10200]","Cigna Local Plus",,6669.9,31.5,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM VERTEX MAX TITANIUM SPINE MULTIAXIAL",SUP-6958730,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 22MM STD XLONG 109MM STAINLESS STEEL 2.4/2.7MM SCR 6",SUP-02.111.671S,CDM,C1713,HCPCS,0278,RC,,,both,,,8192.03,2457.61,"CIGNA [10200]","Cigna Open Access",,4661.27,56.9,,1144.80,304.56,2275.09,66,952.73,6963.23,"percent of total billed charges",
"STENT ZIMMON 10CM 5FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22362,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 800ML STYLE 20 SMOOTH NATRELLE SILICONE P6.1CM",SUP-20-800,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1021.73,28.62,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10D MODIFY C BICONVEX 13MM 6MM POSTERIOR CHMBR",SUP-MA60AC,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 140MM 28-14MM 13FR TRIVASCULAR OVATION PRIME",SUP-TV-IL1428140-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13356,40,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT225220,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 5ML 1.7-10MM ALLOGRAFT CHIPS FREEZE",SUP-T00030,CDM,S27800098,LOCAL,0278,RC,,,both,,,992.25,297.67,"CIGNA [10200]","Cigna Local Plus",,530.85,53.5,,,,,0,115.4,843.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FEBUXOSTAT 40 MG TABLET",RX-97133,CDM,,,0637,RC,60687-0538-11,NDC,both,1,UN,15.09,4.53,"FIRST HEALTH [10303]","First Health",,12.07,80,,,,,0,1.75,12.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB PEDIATRIC 4.25X3IN MULTIFUNCTION",SUP-22770P,CDM,S27200284,LOCAL,0272,RC,,,both,,,159.68,47.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,65.63,41.1,,,,,0,18.57,135.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 28MM 144CM 2.25MM CORONARY STENT",SUP-H7493952828220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]",Cigna,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Intro Vascular Kit",PX-E27200304,CDM,E27200304,LOCAL,0272,RC,,,both,,,1090.52,327.16,"CIGNA [10200]","Cigna Open Access",,620.51,56.9,,,,,0,126.83,926.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Intro Vascular Kit",PX-E27200304,CDM,E27200304,LOCAL,0272,RC,,,both,,,1090.52,327.16,"AETNA [10100]","Aetna HMO/PPO",,866.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,126.83,926.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 20MM 6MM .014IN LOW PROFILE",SUP-1008197-20,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"KAISER [10500]",Kaiser,,949.73,67,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM TITANIUM T8 SELF TAP LOCK VARIABLE ANGLE",SUP-04.211.012,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",114.74,838.59,"percent of total billed charges",
"BALLOON DISECT LAPAROSCOPIC KII 100MM 12MM 2 LATERAL BLUNT",SUP-C0K17,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,770.63,41.1,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 63MM STAINLESS STEEL 2.4MM SCREWS 6X4 HOLES 2",SUP-02.111.541,CDM,C1713,HCPCS,0278,RC,,,both,,,4041.68,1212.5,"NOVANET [10819]",Novanet,,3031.26,75,,,,,0,470.05,3435.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION",RX-20954,CDM,J1955,HCPCS,0636,RC,00517-1045-01,NDC,both,5,ML,323.18,96.95,"BLUE CROSS [10001]","Blue Cross PPO",,27.52,,,,,,,8.03,274.7,"fee schedule",
"ROD SPINAL 60MM 6MM XIA 3 TITANIUM RADIOLUCENT",SUP-48238060,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CROSSTIE? CORTICAL BONE ALLOGRAFT 3.0MM X 3.0MM X 10DEG",SUP-4200-3310,CDM,C1713,HCPCS,0278,RC,,,both,,,7917.75,2375.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3634.25,45.9,,,,,0,920.83,6730.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM DYNASTY LINEAGE BIOFOAM ACETABULAR",SUP-18080303,CDM,C1713,HCPCS,0278,RC,,,both,,,1101.60,330.48,"KAISER [10500]",Kaiser,,738.07,67,,,,,0,128.12,936.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC 91-112CM 36-44IN SMARTVEST LARGE",SUP-SW-36/44-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 36MM +6MM GLENOSPHERE COLOR CODED",SUP-115316,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"CIGNA [10200]","Cigna Local Plus",,3840.8,31.5,,5372.07,4581.20,7242.98,23,1418.05,10364.05,"percent of total billed charges",
"CATH MACH1 100CM 8FR AL1.5 CURVE GUIDING PTFE FEMORAL",SUP-H74934358850,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"FIRST HEALTH [10303]","First Health",,293.15,80,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25.5X9.5MM HALL MICROPOWER MICRO100 .6MM THK.4MM",SUP-502314300,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.93,38.68,"NOVANET [10819]",Novanet,,96.7,75,,,,,0,14.99,109.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL SABRELOC 6-0 S-28 18IN 2 ARM BRAID COATED VIOLET",SUP-J562G,CDM,S27200284,LOCAL,0272,RC,,,both,,,160.41,48.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,19.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.66,136.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL STANDARD+ KNEE RIGHT STABILIZE CEMENT ROTATE",SUP-129411050,CDM,C1776,HCPCS,0278,RC,,,both,,,31285.80,9385.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3638.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3638.54,26592.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X9-6.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-4809,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"KAISER [10500]",Kaiser,,9939.45,67,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Amino Acids 6/> Amino Acids Quantitative Ea Spe",PX-301000103,CDM,82139,CPT,0301,RC,,,both,,,453.70,136.11,"BLUE CROSS [10001]","Blue Cross PPO",,21.55,,"Fee schedule rate ($21.55).",,,,0,0.01,385.65,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM REVISION TRITANIUM E",SUP-509-02-56E,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"CIGNA [10200]",Cigna,,7637.76,68,,5873.17,5873.17,5873.17,"1 through 10",1306.28,9547.2,"percent of total billed charges",
"CATH ARMADA 35LL 135CM 250MM 5MM .035IN LOW PROFILE BALLOON",SUP-B2050-250,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CPIO",SUP-M0068331141,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE IRRIGATION 7CM STERILE LATEX FREE DISPOSABLE",SUP-5407-010-450,CDM,S27200284,LOCAL,0272,RC,,,both,,,585.74,175.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,268.85,45.9,,,,,0,68.12,497.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 20MM 3.75MM BALLOON DILATATION",SUP-H7493912420370,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 100MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,166.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 75CM .36MM FIRM TPR",SUP-124437,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,44.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 4FR 5CM CENTRAL VENOUS SPECTRUM 2 LUMEN CURVE NDL",SUP-G43992,CDM,C1751,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 15ML 85% BTCP 15% HA MASTERGRAFT GRANULE",SUP-7600115,CDM,C1713,HCPCS,0278,RC,,,both,,,5840.51,1752.15,"NOVANET [10819]",Novanet,,4380.38,75,,,,,0,679.25,4964.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE-O SCREW 6.5X35MM TRACTION POLY",SUP-13116535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2732.31,28.62,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 24MM TI",SUP-VAN-25240-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"KAISER [10500]",Kaiser,,651.24,67,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 45MM SPINAL POLYAXIAL 5.5MM ROD",SUP-8458545,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"KAISER [10500]",Kaiser,,3244.54,67,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRODE DEFIBRILLATOR PRO-PADZ TIN ADULT L6.5 IN X W5 IN B",SUP-8900-2303-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,260.46,78.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.29,221.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT PAT SZ 3 OVAL10",SUP-2766-0-1003,CDM,C1776,HCPCS,0278,RC,,,both,,,1875.00,562.5,"PHCS [10601]",PHCS,,1312.5,70,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 15MM 140CM 4MM CORONARY STERILE LATEX",SUP-453942,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 6.5MM 2 FULL THREAD CORKSCREW FIBERWIRE TITANIUM",SUP-AR-1929SF-3,CDM,C1713,HCPCS,0278,RC,,,both,,,1929.38,578.81,"FIRST HEALTH [10303]","First Health",,1543.5,80,,,,,0,224.39,1639.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 80CM 5FR NEFF CURVE ANGIOGRAPHIC",SUP-G47077,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA [10200]","Cigna Open Access",,103.96,56.9,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RIGIFLEX II 90CM 10CM 14FR 40MM BALLOON DILATATION",SUP-M00554520,CDM,C1726,HCPCS,0272,RC,,,both,,,4370.81,1311.24,"MULTIPLAN [10600]",Multiplan,,3715.19,85,,,,,0,508.33,3715.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5INX10MM OSTEOTOM LONG MRI STERILE LATEX FREE",SUP-47998602126,CDM,S27200284,LOCAL,0272,RC,,,both,,,996.30,298.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,409.48,41.1,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 22CM 150CM 8FR .035IN PIGTAIL CURVE",SUP-M006180241180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,992.87,68,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 80MM 120CM 6MM 6FR VASCULAR PERIPHERAL",SUP-S-60-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"CIGNA [10200]","Cigna Local Plus",,5383.17,53.5,,,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI GAIA NEXT 3 VASCULAR 190CM .014IN STERILE LATEX",SUP-AH14R021P,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 429888 ATTAIN PERFORMA",SUP-429888,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3812.76,68,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 12IN STAINLESS STEEL 4.5MM SCREWS 11 HOLE 12",SUP-3704-3-130,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"KAISER [10500]",Kaiser,,1507.5,67,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 20FR STD URETHRAL RUBBER HYDROGEL MALE",SUP-0102L20,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.57,27.77,"UHC [10700]","United Healthcare",,58.6,63.3,,,,,0,10.77,78.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 26CM 5FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49966,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"NOVANET [10819]",Novanet,,564.98,75,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA MEDIAL CONGRUENT 8-11 G-H",SUP-42522100910,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]",Cigna,,7327.97,68,,5873.17,5873.17,5873.17,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"CAGE SPINAL 45MMX12MM CLYDESDALE 0D PEEK-OPTIMA RADIOPAQUE",SUP-2969245,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"FIRST HEALTH [10303]","First Health",,19152,80,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE EXTERNAL FIXATION 400MM 1.8MM TRUELOK STAINLESS STEEL",SUP-54-1215,CDM,C1713,HCPCS,0278,RC,,,both,,,1254.93,376.48,"KAISER [10500]",Kaiser,,840.8,67,,,,,0,145.95,1066.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLENOSPHERE - 36MM DIA X 6MM THK 2MM ECCENTRIC",SUP-5573-2E-3606,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"AETNA [10100]","Aetna HMO/PPO",,9693.59,79.5,,10981.53,8986.79,12413.38,12,1418.07,10364.22,"percent of total billed charges",
"SPLINT POSITIONING VELCRO FOAM WRIST",SUP-3560,CDM,S27000186,LOCAL,0270,RC,,,both,,,256.65,76.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,117.8,45.9,,,,,0,29.85,218.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 12MM TRAUMAONE LORENZ MANDIBLE LOCK CROSS",SUP-41-2412,CDM,C1713,HCPCS,0278,RC,,,both,,,1142.10,342.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,326.87,28.62,,,,,0,132.83,970.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 11GA 6IN T-LOK 2 DIAMOND STYLET POINT ASPIRATION",SUP-DBMNJ1106TL,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.25,99.07,"AETNA [10100]","Aetna HMO/PPO",,262.55,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.41,280.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD 37MM 135CM 9MM 7MM 6FR BILIARY METAL",SUP-H74938047740130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,580.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 34MM 2.7MM LCP CORTICAL FOREFOOT MIDFOOT STAINLESS",SUP-202.894,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,37.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",37.68,275.39,"percent of total billed charges",
"IMPL HIP STEM 107MM NK 38.5MM INSIGNIA 6 HIGH STEM HIGH",SUP-7000-6606,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3555.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3555.74,25987.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 150MM .062IN TROCAR TIP DISPOSABLE",SUP-AR-8941K,CDM,C1769,HCPCS,0272,RC,,,both,,,130.50,39.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM EXOFIN FUSION 60CM SKIN CLSR 2-OCTYL CYANOACRYLATE",SUP-EF70466,CDM,S27200284,LOCAL,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TEMPTIP 35CM 8FR DRNG FLEXIMA POLYURETHANE HYDROPHILIC",SUP-M001281560,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC",229,MS-DRG,,,,,,,inpatient,,,185247.33,55574.2,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 15MM 3MM BALLOON DILATATION PEBAX",SUP-1400300-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOFT-VU 100CM 5FR SIDEWINDER 1 CURVE ANGIOGRAPHIC",SUP-H787107090065,CDM,C1887,HCPCS,0272,RC,,,both,,,182.70,54.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM FEMORAL 120MM PRIMARY ANTHOLOGY POROUS 131D 11 STD",SUP-71356011,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"MULTIPLAN [10600]",Multiplan,,28169.98,85,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 79MM 8.9MM UNCUFFED FENESTRATED INNER CANN SHILEY TRACH",SUP-10DCFN,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.84,87.85,"KAISER [10500]",Kaiser,,196.2,67,,,,,0,34.06,248.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM CEMENT ACCOLADE C 127D 5 48MM OFFSET HIP",SUP-6057-0537D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"CIGNA [10200]","Cigna Local Plus",,5178.36,31.5,,5372.07,4581.20,7242.98,23,1911.88,13973.36,"percent of total billed charges",
"HC Pancreatic Elastase Fecal",PX-301000474,CDM,82656,CPT,0301,RC,,,both,,,1153.00,345.9,"CIGNA [10200]","Cigna Local Plus",,25.37,,,,,,,1.15,980.05,"fee schedule",
"GRAFT SOFT TISSUE 3X5CM AMINOEFFECT PURION PLACENTAL MEMB",SUP-LS-5350,CDM,Q4433,HCPCS,0636,RC,,,both,,,13130.70,3939.21,"MULTIPLAN [10600]",Multiplan,,11161.1,85,,,,,0,247.92,11161.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUROSTIMULATOR IMPLANTABLE 2INX1.7IN INTERSTIM II 10-14HZ 0",SUP-97800,CDM,C1767,HCPCS,0278,RC,,,both,,,62700.00,18810,"UHC [10700]","United Healthcare",,39689.1,63.3,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CALCAR 25MM RESTORATION +10MM OFFSET HIP MODULAR",SUP-6276-4-125,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2749.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2698.86,19725.14,"percent of total billed charges",
"PLUG OCCLUSION 12X5.3MM 3MM MVP PTFE MECHANICALLY DETACHABLE",SUP-MVP-3Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,10695.00,3208.5,"MULTIPLAN [10600]",Multiplan,,9090.75,85,,,,,0,1243.83,9090.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT 70MM 2O CYLINDRICAL STRAIGHT CNCT MEDIUM LOW",SUP-823084,CDM,S27800098,LOCAL,0278,RC,,,both,,,7991.37,2397.41,"PHCS [10601]",PHCS,,5593.96,70,,,,,0,929.4,6792.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EKOSONIC .035IN 106CM 30CM 5.4FR DRUG DELIVERY",SUP-500-55130,CDM,C1887,HCPCS,0272,RC,,,both,,,37894.50,11368.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15574.64,41.1,,,,,0,4407.13,32210.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH II SS9.5",SUP-398347,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 42MM STAINLESS STEEL T15 SELF TAP VARIABLE",SUP-02.127.142,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,324.18,28.62,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD CURVE .6MM MIDFACE 4 HOLE BAR 1.7MM SCR BONE",SUP-55-06754,CDM,C1713,HCPCS,0278,RC,,,both,,,1139.99,342,"CIGNA [10200]",Cigna,,775.19,68,,1831.33,1831.33,1831.33,16,132.58,968.99,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 15MM 140CM 2.75MM 2.1-2.7FR CORONARY",SUP-RONYX27515UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 5.5MM COOLCUT 8 FLUTE ROUND STERILE",SUP-AR-8550RBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"PHCS [10601]",PHCS,,351.26,70,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 6MM TRANSFIXATION 225MM ORTHOPEDIC STEINMANN",SUP-294.95,CDM,S27000186,LOCAL,0270,RC,,,both,,,736.21,220.86,"UHC [10700]","United Healthcare",,466.02,63.3,,,,,0,85.62,625.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 8MM 90MM STAINLESS STEEL FULL THREAD",SUP-218.09,CDM,C1713,HCPCS,0278,RC,,,both,,,228.98,68.69,"CIGNA [10200]",Cigna,,155.71,68,,1831.33,1831.33,1831.33,16,26.63,194.63,"percent of total billed charges",
"RING ANNULOPLASTY 26MM RIGID SADDLE SUT CUFF TITANIUM",SUP-RSAR-26,CDM,S27800098,LOCAL,0278,RC,,,both,,,14801.54,4440.46,"CIGNA [10200]","Cigna Open Access",,4958.52,33.5,,,,,0,1721.42,12581.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Ather Sf Ea Add",PX-361000730,CDM,37289,CPT,0361,RC,,,both,,,8353.79,2506.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8.35,.1,,,,,0,8.35,7883,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT NRV HUM AVANCE 3-4X50MM",SUP-311250,CDM,C1762,HCPCS,0278,RC,,,both,,,48724.20,14617.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,19489.68,40,,,,,0,5666.62,41415.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL GLASSMAN RIGHT ANGLE 9.75IN FULLY SERRATED",SUP-SU6129,CDM,S27200284,LOCAL,0272,RC,,,both,,,1931.18,579.35,"FIRST HEALTH [10303]","First Health",,1544.94,80,,,,,0,224.6,1641.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 170MM 4.75MM SOLERA STRAIGHT PERCUTANEOUS COCR",SUP-1476006170,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERTORQUE 100CM 6FR JUDKINS LEFT CORONARY 4.5 CURVE",SUP-532627,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"FIRST HEALTH [10303]","First Health",,66.12,80,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TUBING 37FR VIVASIGHT LUNG LEFT DOUBLE LUMEN VIDEO",SUP-412371000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,895.05,45.9,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 15MM 2MM BALLOON DILATATION PEBAX",SUP-1400200-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL CANCELLOUS 7D ALLOGRAFT 16MM",SUP-3W5216,CDM,S27800098,LOCAL,0278,RC,,,both,,,21094.92,6328.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8437.97,40,,,,,0,2453.34,17930.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC",221,MS-DRG,,,,,,,inpatient,,,274838.04,82451.41,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,63661.1,,"Case rate ($31,264.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $29,031.36, add-ons for qualifying new technology services are included. If operating cost exceeds $62,071.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,576.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,069.75. The transfer operating threshold is the transfer adjustment factor * $29,031.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,194.91. The transfer capital threshold is the transfer adjustment factor * $2,194.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 203.62%.",,,,0,31264.66,147153.68,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 40MM 5.5MM ARMADA SPINE TITANIUM FIX CROSS",SUP-8450140,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Local Plus",,1905.94,53.5,,3978.14,359.25,3978.14,24,414.32,3028.13,"percent of total billed charges",
"(EVAL) LAMINAR IMPLANT SIZE (12MM)",SUP-FG-6031,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 50CM 11CM GRAY HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-5F-11-035,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"PHCS [10601]",PHCS,,56.03,70,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE ASP 15CM 8GA BN MRW ACC",SUP-RAN-815N,CDM,S27200284,LOCAL,0272,RC,,,both,,,993.20,297.96,"CIGNA [10200]","Cigna Local Plus",,531.36,53.5,,,,,0,115.51,844.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO MICRO STRAIGHT BRAID MATRS STITCH SUT",SUP-AR-8703,CDM,S27200284,LOCAL,0272,RC,,,both,,,1190.70,357.21,"CIGNA [10200]",Cigna,,809.68,68,,,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT ULFLX 80MM 95CM 20MM",SUP-6931,CDM,C1883,HCPCS,0278,RC,,,both,,,2625.00,787.5,"KAISER [10500]",Kaiser,,1758.75,67,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CONNECTING 8FT SHROUDED 4 PIN TORQR MEDTRONIC VG REPRO",SUP-05508SPR,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"KAISER [10500]",Kaiser,,209.84,67,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL F 72X65.5MM LEFT SET SCR OPTION NEXGEN LCCK",SUP-00599401691,CDM,C1776,HCPCS,0278,RC,,,both,,,22881.60,6864.48,"FIRST HEALTH [10303]","First Health",,18305.28,80,,,,,0,2661.13,19449.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 12MM 8MM DRILL-FREE MAXDRIVE STAINLESS STEEL",SUP-25-092-38-91,CDM,C1713,HCPCS,0278,RC,,,both,,,821.34,246.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,97.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,95.52,698.14,"percent of total billed charges",
"CATH PACEL 110CM 2MM 5FR 10CM 1CM SPACE RIGHT HEART CURVE",SUP-401763,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 15MM 140CM 2.25MM CORONARY STERILE",SUP-453937,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 8MM 144CM 2.75MM CORONARY STENT PEBAX",SUP-H7493926008270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Open Access",,3166.49,56.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE",RX-10724,CDM,,,0637,RC,00185-0122-01,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,3.57,56.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC",424,MS-DRG,,,,,,,inpatient,,,100166.47,30049.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,41519.78,,"Fee schedule rate ($41,519.78). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,63877.93,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cyclic Citrullinated Pept Ab",PX-302000034,CDM,86200,CPT,0302,RC,,,both,,,314.93,94.48,"PHCS [10601]",PHCS,,220.45,70,,,,,0,0.31,267.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STIM SENZA II IMPLANTABLE PULSE GENRTR NONSTERILE LATEX",SUP-NIPG2500,CDM,C1822,HCPCS,0278,RC,,,both,,,148200.00,44460,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,42414.84,28.62,,,,,0,17235.66,125970,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +28 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.280,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 7MM THIN WALL PERIPHERAL GORE-TEX",SUP-ST0708,CDM,C1768,HCPCS,0278,RC,,,both,,,8535.30,2560.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1011.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,992.66,7255.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Breast Uni Complete",PX-402000048,CDM,76641,CPT,0402,RC,,,both,,,1193.28,357.98,"AETNA [10100]","Aetna HMO/PPO",,948.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,107.09,1014.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.0/35",SUP-404669,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 17.5MM KNEE XLK POSTERIOR LIPPED FIX",SUP-158100117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]","Cigna Open Access",,6358.32,56.9,,5302.19,4377.88,6578.61,27,1299.6,9498.37,"percent of total billed charges",
"CATH CORDIS AVIATOR PLUS 142CM 30MM 6MM .014IN BALLOON",SUP-4246030W,CDM,C1725,HCPCS,0272,RC,,,both,,,1438.80,431.64,"KAISER [10500]",Kaiser,,964,67,,,,,0,167.33,1222.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX12MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183542,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2243.75,28.62,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX SAFE PERFORMAXX 20MM 80CM 8MM 6FR .035IN",SUP-ZBM08020,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"MULTIPLAN [10600]",Multiplan,,8504.25,85,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH PORTEX STERILE LATEX FREE DISPOSABLE",SUP-101/596/090,CDM,S27200284,LOCAL,0272,RC,,,both,,,3247.05,974.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1490.4,45.9,,,,,0,377.63,2759.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 98MM 14MM PRESS FIT REUNION S SHOULDER",SUP-5567P3014,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"PHCS [10601]",PHCS,,12075,70,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM POD J-SOFT PACK STERILE LATEX FREE",SUP-RBYPODJ60,CDM,S27800098,LOCAL,0278,RC,,,both,,,8832.00,2649.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6005.76,68,,,,,0,1027.16,7507.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 37X27X12MM CRESCENT SOVEREIGN 12D MEDIUM PEEK",SUP-7968212,CDM,C1713,HCPCS,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 22CM 4MM TRICUT 2 CURVE LARYNGEAL ANGLE TIP",SUP-1884030HRE,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,536.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 37X27X12MM CRESCENT SOVEREIGN 12D MEDIUM PEEK",SUP-7968212,CDM,C1713,HCPCS,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 22CM 4MM TRICUT 2 CURVE LARYNGEAL ANGLE TIP",SUP-1884030HRE,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2077.62,45.9,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 6MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120615,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"PHCS [10601]",PHCS,,8317.26,70,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 170MM 4.5MM STAINLESS STEEL QUICK COUPLING",SUP-310.66,CDM,S27000186,LOCAL,0270,RC,,,both,,,2304.00,691.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,273.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,267.96,1958.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 32MM 144CM 4MM CORONARY STENT",SUP-H7493911432400,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"UHC [10700]","United Healthcare",,5787.2,63.3,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X9-6.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-4809,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"NOVANET [10819]",Novanet,,11126.25,75,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM REVISION TRITANIUM E",SUP-509-02-56E,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"KAISER [10500]",Kaiser,,7525.44,67,,,,,0,1306.28,9547.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICROINTRODUCER 7CM 21GA NDL",SUP-SR-4F21G7D-MP,CDM,C1894,HCPCS,0272,RC,,,both,,,1417.50,425.25,"NOVANET [10819]",Novanet,,1063.13,75,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 0 CP 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J479H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL LONG TEETH",SUP-NF02,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.32,23.5,"FIRST HEALTH [10303]","First Health",,62.66,80,,,,,0,9.11,66.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 14CM 3MM MIDAS REX LEGEND 3 FLUTE PROXIMAL",SUP-SP14MH30T,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,320.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP7PR,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"MULTIPLAN [10600]",Multiplan,,18276.62,85,,,,,0,2500.67,18276.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 150MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171081510,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,136.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS LAPAROSCOPIC 35CM 2 EDGE BLADE ROTATION DIAL",SUP-CB030,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,107.27,41.1,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 135MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.422,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,396.14,28.62,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR STD JR3 CURVE GUIDING NYLON CORONARY",SUP-LA6JR30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 50MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0319,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross PPO",,371.5,39.2,,957.42,570.23,957.42,28,110.22,805.55,"percent of total billed charges",
"CATH MUSTANG 40CM 20MM 8MM .035IN BALLOON DILATATION NYBAX",SUP-39171-08024,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,136.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 180CM 5.5CM 7.5FR 12-13.5-15MM ESOPHAGUS",SUP-M00558630,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"AETNA [10100]","Aetna HMO/PPO",,1310.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 25CM 12FR MAC-LOC SUPRAPUBIC ULTRATHANE NDL OBTR",SUP-G30404,CDM,C2627,HCPCS,0272,RC,,,both,,,1219.86,365.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,829.5,68,,,,,0,141.87,1036.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 7CM 11.5FR DUODENAL BEND BILIARY PLASTIC TEMPORARY",SUP-M00545710,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,99.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ARROW ARROW ADVANCER VASCULAR J CURVE STRAIGHT 26.75IN",SUP-AW-14725,CDM,C1769,HCPCS,0272,RC,,,both,,,105.79,31.74,"FIRST HEALTH [10303]","First Health",,84.63,80,,,,,0,12.3,89.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 3 STD KNEE RIGHT KEEL NONPOROUS",SUP-ETPKN3SR,CDM,C1776,HCPCS,0278,RC,,,both,,,15193.80,4558.14,"UHC [10700]","United Healthcare",,9617.68,63.3,,8601.07,8395.67,8601.07,"1 through 10",1767.04,12914.73,"percent of total billed charges",
"SUT VICRYL 3-0 CT-1 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J344H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 BIOKNOTLESS PLUS ORTHOCORD ROTATOR CUFF",SUP-212722,CDM,C1713,HCPCS,0278,RC,,,both,,,5664.90,1699.47,"KAISER [10500]",Kaiser,,3795.48,67,,,,,0,658.83,4815.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 20MM 3FR SEGURA HEMISPHERE",SUP-M0063801100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"CIGNA [10200]","Cigna Open Access",,841.86,56.9,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 180CM 81CM SUPERSTIFF GUIEWIRE GUIDING",SUP-407450,CDM,C1893,HCPCS,0272,RC,,,both,,,1409.40,422.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,958.39,68,,,,,0,163.91,1197.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN EXTRA BACKUP LEFT 3.75 CURVE",SUP-LA7EBU375SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VERSACROSS VASCULAR 1 PIGTAIL CURVE 93CM 180CM 9MM",SUP-VXAK0041,CDM,S27200284,LOCAL,0272,RC,,,both,,,6969.00,2090.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,825.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,810.49,5923.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB CONGR 12MM LEFT .5",SUP-2041-0-1212,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"NOVANET [10819]",Novanet,,2671.88,75,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 5-11MM VISIPORT PLUS RPF VERSAPORT",SUP-176673P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1305.88,391.76,"MULTIPLAN [10600]",Multiplan,,1110,85,,,,,0,151.87,1110,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 12IN 3/32IN PVC 3 SPRING EVAC TROCAR Y CNCT TUBE",SUP-0043600,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.12,19.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.69,56.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL CANN 5MM DA VINCI ENDOWRIST DISPOSABLE",SUP-400161,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.90,44.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,60.79,41.1,,,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 60MM 12MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-151312060,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"FIRST HEALTH [10303]","First Health",,6612.96,80,,,,,0,961.36,7026.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STYLET ASSORTED 58CM UNIVERSAL J STRAIGHT REPOSITIONING",SUP-DS06003/58,CDM,S27200284,LOCAL,0272,RC,,,both,,,453.60,136.08,"UHC [10700]","United Healthcare",,287.13,63.3,,,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR",RX-34418,CDM,,,0637,RC,68084-0310-11,NDC,both,1,UN,12.31,3.69,"CIGNA [10200]","Cigna Open Access",,7,56.9,,,,,0,1.43,10.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR IMPLANTABLE AXONICS SNM SYSTEM STERILE LATEX",SUP-4101,CDM,C1767,HCPCS,0278,RC,,,both,,,64615.20,19384.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,17446.1,27,,,,,0,7514.75,54922.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC MEDIUM 11-13IN ARM QUICK RELEASE BUCKLE",SUP-11-0449-3,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2MM AVENIR 10 COIL FINISH COMPLEX",SUP-10CFN-02003,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"NOVANET [10819]",Novanet,,8792.33,75,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUMP DEFLATION TITAN TOUCH 1 TOUCH RELEASE",SUP-517750,CDM,C1813,HCPCS,0278,RC,,,both,,,31506.30,9451.89,"AETNA [10100]","Aetna HMO/PPO",,25047.51,79.5,,,,,0,3664.18,26780.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 10MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158126110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AETNA [10100]","Aetna HMO/PPO",,8883.77,79.5,,10981.53,8986.79,12413.38,12,1299.6,9498.37,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL 2CM WIRE LARGE RADIUS LOOP UNIVERSAL",SUP-R2020,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.17,46.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,106.2,68,,,,,0,18.16,132.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL SHORT AO QUICK CONNECT 2MM DISPOSABLE",SUP-71174910,CDM,S27200284,LOCAL,0272,RC,,,both,,,880.88,264.26,"CIGNA [10200]",Cigna,,599,68,,,,,0,102.45,748.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 20CM 7FR POLARIS ULTRA NAUTILUS ZIPWIRE .035IN 2",SUP-M006192140190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,165.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Lymphedema Lrg Arm",PX-E27000187,CDM,E27000187,LOCAL,0270,RC,,,both,,,607.00,182.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,249.48,41.1,,,,,0,70.59,515.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY CATH 80CM SFT",SUP-6690,CDM,S27500001,LOCAL,0275,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 2.5MM 28MM AXSOS STAINLESS STEEL FULL THREAD",SUP-338628,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,27.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",26.77,195.67,"percent of total billed charges",
"TUBE 18FR SILICONE LOW VOLUME GASTRO MIC SECUR-LOK 3-5ML",SUP-0100-18LV,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"UHC [10700]","United Healthcare",,177.16,63.3,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL KNEE 8MM IDENTITY IMPRINT 3 TIBIAL INSRT POSTERIOR",SUP-TPS-030-083S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"CIGNA [10200]","Cigna Local Plus",,433.35,53.5,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 0D H HIP X3 TRIDENT",SUP-623-00-36H,CDM,C1776,HCPCS,0278,RC,,,both,,,6879.60,2063.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1968.94,28.62,,,,,0,800.1,5847.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Arthcs Asp/Inj Mjr Jt",PX-361000032,CDM,20610,CPT,0361,RC,,,both,,,2650.00,795,"CIGNA [10200]",Cigna,,2497,,"Case rate ($2,497). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,308.2,2650,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 10 X 30 HELICAL FILLING COIL",SUP-10HFL-10030,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"UHC [10700]","United Healthcare",,5673.64,63.3,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Cvc Nontunl Complt",PX-450000227,CDM,36580,CPT,0361,RC,,,both,,,6710.01,2013,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,780.37,6710.01,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 2MM .76MM MORETZ TYTAN EAR TAB TITANIUM",SUP-1066108,CDM,S27800098,LOCAL,0278,RC,,,both,,,179.42,53.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.87,152.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 16MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-416,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4512.21,45.9,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 30ML .1-2MM 80% CORTICAL 20% CANCELLOUS",SUP-400063,CDM,C1713,HCPCS,0278,RC,,,both,,,2842.88,852.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1933.16,68,,,,,0,330.63,2416.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TRILOGY TIVANIUM ALLOY HIP CORTICAL",SUP-00625006540,CDM,C1713,HCPCS,0278,RC,,,both,,,691.60,207.48,"KAISER [10500]",Kaiser,,463.37,67,,,,,0,80.43,587.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET PRESSURE MONITOR QUICK CHAMBER SYRINGE SIDE PORTED NEEDL",SUP-0295-004-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA2-17-150-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,9177.00,2753.1,"AETNA [10100]","Aetna HMO/PPO",,7295.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 90MM ANTIROTATE STERILE FEMORAL NECK SYSTEM",SUP-04.168.490S,CDM,C1713,HCPCS,0278,RC,,,both,,,1642.20,492.66,"BLUE CROSS [10001]","Blue Cross HMO",,643.74,39.2,,957.42,156.86,7483.26,51,190.99,1395.87,"percent of total billed charges",
"ADPTR CATH 9FR CHECK-FLO SELF ADJUSTING SEAL SIDE CONNECTION",SUP-G06002,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.87,25.76,"KAISER [10500]",Kaiser,,57.53,67,,,,,0,9.99,72.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL 6MM STD VASCULAR 2 TRACTION SPRING STEALTH",SUP-AVD-6025,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"CIGNA [10200]",Cigna,,106.49,68,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E PATELLA CEMENT SURFACE",SUP-98000674130,CDM,C1776,HCPCS,0278,RC,,,both,,,20790.00,6237,"BLUE CROSS [10001]","Blue Cross PPO",,8149.68,39.2,,3949.44,3949.44,3949.44,"1 through 10",2417.88,17671.5,"percent of total billed charges",
"PASSER SPECTRUM MVP 45D LEFT HOOK SUT STERILE DISPOSABLE",SUP-C6420,CDM,S27200284,LOCAL,0272,RC,,,both,,,1799.93,539.98,"MULTIPLAN [10600]",Multiplan,,1529.94,85,,,,,0,209.33,1529.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLACK 24-26FR USA ELITE SYSTEM USA",SUP-RE,CDM,S27200284,LOCAL,0272,RC,,,both,,,780.88,234.26,"CIGNA [10200]",Cigna,,531,68,,,,,0,90.82,663.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE LARGE REGULAR SPIKED 23.22X14.29MM COCR",SUP-128696,CDM,C1713,HCPCS,0278,RC,,,both,,,2300.10,690.03,"PHCS [10601]",PHCS,,1610.07,70,,,,,0,267.5,1955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +8 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-PCB0000080,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5-6 11MM KNEE XLPE CRUCIATE RETAINING HIGH",SUP-71453122,CDM,C1776,HCPCS,0278,RC,,,both,,,15556.05,4666.81,"CIGNA [10200]","Cigna Open Access",,5211.28,33.5,,5302.19,4377.88,6578.61,27,1809.17,13222.64,"percent of total billed charges",
"AUG FEMORAL 15MM TRIATHLON 5 RIGHT DISTAL KNEE TOTAL",SUP-5542-A-502,CDM,C1776,HCPCS,0278,RC,,,both,,,5009.55,1502.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3406.49,68,,,,,0,582.61,4258.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 125CM 6FR .052IN MULTIPURPOSE A 2 CURVE",SUP-H749086411222,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]",Cigna,,52.07,68,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 2.5MM 28MM AXSOS STAINLESS STEEL FULL THREAD",SUP-338628,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"NOVANET [10819]",Novanet,,172.65,75,,,,,0,26.77,195.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 18MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036121850,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT RIB XL 43X6IN 2 PANEL ELASTIC HOOK LOOP CLSR NONSTERILE",SUP-13790308,CDM,S27000186,LOCAL,0270,RC,,,both,,,59.25,17.77,"NOVANET [10819]",Novanet,,44.44,75,,,,,0,6.89,50.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 6.5MM 30MM CANCELLOUS STERILE",SUP-117230000,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,526.08,45.9,,,,,0,133.3,974.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT DYNAMIC 110X13MM 25/40X10MM Y TRACHEOBRONCHIAL",SUP-M00570680,CDM,C1875,HCPCS,0278,RC,,,both,,,22226.40,6667.92,"BLUE CROSS [10001]","Blue Cross PPO",,8712.75,39.2,,,,,0,2584.93,18892.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E PATELLA CEMENT SURFACE",SUP-98000674130,CDM,C1776,HCPCS,0278,RC,,,both,,,20790.00,6237,"KAISER [10500]",Kaiser,,13929.3,67,,,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INFUSION 118IN SMARTSITE TEXIUM ALARIS 20 GTT",SUP-10013361T,CDM,S27200284,LOCAL,0272,RC,,,both,,,51.50,15.45,"CIGNA [10200]","Cigna Open Access",,29.3,56.9,,,,,0,5.99,43.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 30.5-43MM 6MM CREO LONG SPINE LOW PROFILE CROSS",SUP-1119.0243,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross HMO",,1396.5,39.2,,957.42,156.86,7483.26,51,414.32,3028.13,"percent of total billed charges",
"KIT CATH ADULT 36CM 15.5FR DURATHANE DURAFLOW EMBOSAFE BASIC",SUP-H787103012045,CDM,C1750,HCPCS,0278,RC,,,both,,,1104.50,331.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,506.97,45.9,,,,,0,128.45,938.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR 30CM 6FR .038IN BLADDER LOOP LOW",SUP-M006155235120,CDM,C2617,HCPCS,0278,RC,,,both,,,1325.65,397.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,154.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.17,1126.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 39CM 20MM AZUR CX DETACHABLE CROSS",SUP-45-752039,CDM,S27800098,LOCAL,0278,RC,,,both,,,7672.80,2301.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,892.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,892.35,6521.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet Wb Melanoma Non Cov",PX-404000009,CDM,G0219,HCPCS,0404,RC,,,both,,,9139.00,2741.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2608,,"Per diem ($2,608). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,9.14,7768.15,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Proc Nosebleed",PX-E27000129,CDM,E27000129,LOCAL,0270,RC,,,both,,,177.10,53.13,"CIGNA [10200]",Cigna,,120.43,68,,,,,0,20.6,150.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TNLR SURGICAL SHEATH ON-Q 12IN 11GA DISPOSABLE",SUP-T11X12,CDM,S27200305,LOCAL,0272,RC,,,both,,,250.93,75.28,"AETNA [10100]","Aetna HMO/PPO",,199.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.18,213.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Compres Band Medigrip per Linear Yd",PX-E27000194,CDM,A6457,HCPCS,0270,RC,,,both,,,10.43,3.13,"MULTIPLAN [10600]",Multiplan,,8.87,85,,,,,0,1.09,8.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 45CM BIPOLAR ACTIVE FIXATION SOLIA S STEROID",SUP-377176,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,264.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 28MM 10D D HIP X3 TRIDENT",SUP-623-10-28D,CDM,C1776,HCPCS,0278,RC,,,both,,,6242.04,1872.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4244.59,68,,,,,0,725.95,5305.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 50MM 5.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE52550,CDM,C1876,HCPCS,0278,RC,,,both,,,90839.19,27251.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10564.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10564.6,77213.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 150MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"FIRST HEALTH [10303]","First Health",,1146.96,80,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR ENDOSCOPIC 11MM REPROCESSED 100MM ENDOPATH XCEL",SUP-B11LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"NOVANET [10819]",Novanet,,117.45,75,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640406,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"KAISER [10500]",Kaiser,,7540.11,67,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TITAN ZERO DEGREE - SCROTAL ZERO ANGLE CYLINDER/PUMP SET",SUP-ES8924,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25769.7,41.1,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 68MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 8",SUP-244.08,CDM,C1713,HCPCS,0278,RC,,,both,,,3348.00,1004.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,396.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",389.37,2845.8,"percent of total billed charges",
"BURR SURGICAL 12.5CM 3MM IBUR DISTAL BEND ROUND DIAMOND",SUP-8431-012-030D,CDM,S27200284,LOCAL,0272,RC,,,both,,,3045.45,913.63,"NOVANET [10819]",Novanet,,2284.09,75,,,,,0,354.19,2588.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 28MM 10D D HIP X3 TRIDENT",SUP-623-10-28D,CDM,C1776,HCPCS,0278,RC,,,both,,,6242.04,1872.61,"CIGNA [10200]","Cigna Open Access",,3551.72,56.9,,5302.19,4377.88,6578.61,27,725.95,5305.73,"percent of total billed charges",
"SET INTRO BLUE RHINO G2 PERCUTANEOUS MULTI",SUP-G57682,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GAS INTRAOCULAR ISPAN SULFUR HEXAFLUORIDE 450GM RETINAL",SUP-8065797001,CDM,C1784,HCPCS,0278,RC,,,both,,,28090.76,8427.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3328.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3266.96,23877.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 5 X 8 HELICAL PICO COIL",SUP-10USH05008,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3165.24,27,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR STRAIGHT 260CM 7CM .035IN",SUP-M001465260,CDM,C1769,HCPCS,0272,RC,,,both,,,494.10,148.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,58.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP LATIS STEALTH 5 90MM MESH LATEX FREE",SUP-A0C04,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,92.97,41.1,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG 8 HOLE LOW PROFILE BONE LEFT CLAVICLE",SUP-70-0288,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1891.84,28.62,,,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 120MM 125CM 6MM VASCULAR PERIPHERAL DRUG",SUP-G38482,CDM,C1874,HCPCS,0278,RC,,,both,,,13250.00,3975,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5445.75,41.1,,,,,0,1540.98,11262.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR BLADDER PROCEDURES WITHOUT CC/MCC",655,MS-DRG,,,,,,,inpatient,,,126074.95,37822.48,"AETNA [10100]","Aetna HMO/PPO",,39823.83,,"Fee schedule rate ($39,823.83). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,61796.25,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 100MM TITANIUM 1.5MM SCREWS MINI FRAGMENT SET 20 HOLE",SUP-446.19,CDM,C1713,HCPCS,0278,RC,,,both,,,2865.60,859.68,"CIGNA [10200]",Cigna,,1948.61,68,,1831.33,1831.33,1831.33,16,333.27,2435.76,"percent of total billed charges",
"CLAREON UVA TORIC AUTONOME",SUP-CCA0T6,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"CIGNA [10200]",Cigna,,251.6,68,,,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.35IN 16FR HEYMAN PLASTIC COUDE TIP DILATION",SUP-021316,CDM,S27200284,LOCAL,0272,RC,,,both,,,242.30,72.69,"CIGNA [10200]","Cigna Local Plus",,129.63,53.5,,,,,0,28.18,205.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFARI2 EXTRA SPRT VASCULAR LARGE CURVE 275X4.9X5CM",SUP-H74939598ESL0,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT AORTIC 4.5CM 23MM EXCLUDER CONFORMABLE ACTIVE CONTROL",SUP-CXA230005,CDM,C1874,HCPCS,0278,RC,,,both,,,27612.90,8283.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3272.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3211.38,23470.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Allergen Igg Quant/Semi Ea",PX-302000004,CDM,86001,CPT,0302,RC,,,both,,,61.10,18.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,51.94,"per diem",
"BURR SURGICAL 7.5MM ROUND STERILE LATEX FREE DISPOSABLE",SUP-5820110075,CDM,S27200284,LOCAL,0272,RC,,,both,,,1164.70,349.41,"PHCS [10601]",PHCS,,815.29,70,,,,,0,135.45,990,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PLATE 5 74X46MM STEMMED ANTERIOR POSTERIOR",SUP-00598800500,CDM,C1776,HCPCS,0278,RC,,,both,,,10113.60,3034.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4642.14,45.9,,,,,0,1176.21,8596.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM TKR CEMENT FLEX",SUP-98000670100,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 8MM 2.75MM CORONARY STENT EVEROLIMUS",SUP-1550275-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"PROBE BREAST BIOPSY 11GA MAMMOTOME 3 COIL TITANIUM FLEXIBLE",SUP-4010-01-11-T3,CDM,A4648,HCPCS,0278,RC,,,both,,,640.49,192.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,183.31,28.62,,,,,0,74.49,544.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 12.5MM KNEE GVF POLYETHYLENE ROTATE",SUP-129405612,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2765.68,28.62,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPLANT 14.5CM NATRELLE INSPIRA P4.8CM MODERATE PROFIL",SUP-MSZ-M520,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GA-68-GOZETOTIDE INTRAVENOUS SOLUTION (3 MCI)",RX-411538,CDM,A9596,HCPCS,0343,RC,08888-8878-69,NDC,both,1,UN,24796.80,7439.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2799.33,,,,,,,1181,21077.28,"fee schedule",
"LENS IOL +20.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0205,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Submandib Sp Intraoral",PX-450000345,CDM,41008,CPT,0450,RC,,,both,,,7415.00,2224.5,"NOVANET [10819]",Novanet,,5561.25,75,,,,,0,67.13,6302.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Vag Injury",PX-450000287,CDM,57200,CPT,0361,RC,,,both,,,4627.00,1388.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4627,,"Case rate ($4,656). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,538.12,4627,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING IS-1 BIPOLAR PASSIVE FIXATION INSULATION 2",SUP-4548,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"KAISER [10500]",Kaiser,,3756.69,67,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COTTON 200CM 4CM 8.5FR 7-5FR .035IN BALLOON DILATATION",SUP-G22061,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 37MM 80CM 8MM VASCULAR BALLOON EXPANDABLE",SUP-LSMU0800837,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"BLUE CROSS [10001]","Blue Cross HMO",,10248.84,39.2,,9776.84,9776.84,9776.84,"1 through 10",3040.66,22223.25,"percent of total billed charges",
"CATH HYPERFORM X-PEDION 150CM 15MM 2.2-2.8FR 3MM .01IN 4MM",SUP-104-4315,CDM,C1725,HCPCS,0272,RC,,,both,,,8790.60,2637.18,"NOVANET [10819]",Novanet,,6592.95,75,,,,,0,1022.35,7472.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Procalcitonin",PX-301000374,CDM,84145,CPT,0301,RC,,,both,,,444.60,133.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,95.12,,,,,,,0.01,377.91,"fee schedule",
"VALVE AORTIC 23MM 24MM GELWEAVE VALSALVA MASTERS HP POROUS",SUP-23VAVGJ-515,CDM,S27800098,LOCAL,0278,RC,,,both,,,36805.86,11041.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15127.21,41.1,,,,,0,4280.52,31284.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION",RX-4996,CDM,J1010,HCPCS,0636,RC,70121-1574-01,NDC,both,1,ML,147.83,44.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.28,,"Fee schedule rate ($11.28). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",66.17,66.17,66.17,"1 through 10",11.19,125.66,"fee schedule",
"COIL EMBOLIZATION CONCERTO 3D",SUP-PV-14-40-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 150CM 4.8FR .035IN 3CM STD STRAIGHT URETERAL",SUP-M006145351190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"FIRST HEALTH [10303]","First Health",,903.96,80,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 6FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175260010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"PHCS [10601]",PHCS,,749.52,70,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALISKIREN 300 MG TABLET",RX-78654,CDM,,,0637,RC,66993-0142-30,NDC,both,1,UN,37.26,11.18,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15.31,41.1,,,,,0,4.33,31.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8MM 44MM HIP BIOLOX DELTA FMP",SUP-400-03-444,CDM,C1776,HCPCS,0278,RC,,,both,,,16953.92,5086.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1971.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1971.74,14410.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR BLUE 5/8IN 25GA INTERSTIM REGULAR WALL",SUP-305901,CDM,C1778,HCPCS,0278,RC,,,both,,,321.90,96.57,"MULTIPLAN [10600]",Multiplan,,273.62,85,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 2-0 CP-1 SPIRAL 70CM SUT",SUP-SXMP1B419,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,87.91,41.1,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 10CM 7MM THIN WALL PERIPHERAL GORE-TEX",SUP-ST0701,CDM,C1768,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTDG PULSED LAVAGE ERBEJET 2 PUMP STERILE DISPOSABLE",SUP-20150-300,CDM,S27200284,LOCAL,0272,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRINITY EVOLUTION 1ML",SUP-410101,CDM,S27800098,LOCAL,0278,RC,,,both,,,4105.50,1231.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,486.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,477.47,3489.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 60MM 80CM 7MM VASCULAR PERIPHERAL SELF",SUP-1012529-60,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross PPO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 300MM 2.5MM BALLOON DILATATION RAPID",SUP-47525300L,CDM,C1725,HCPCS,0272,RC,,,both,,,1890.00,567,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1285.2,68,,,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Trnsduc Tipped Intrauterine Koala",PX-E27200250,CDM,E27200250,LOCAL,0272,RC,,,both,,,205.70,61.71,"PHCS [10601]",PHCS,,143.99,70,,,,,0,23.92,174.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-1-2-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"CIGNA [10200]","Cigna Open Access",,3917.99,33.5,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGNESIUM CITRATE ORAL SOLUTION",RX-4712,CDM,,,0250,RC,70677-1112-01,NDC,both,296,ML,16.76,5.03,"NOVANET [10819]",Novanet,,12.57,75,,,,,0,1.95,14.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +19.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.195,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPARIN, PORCINE (PF) 10 UNIT/ML INTRAVENOUS SYRINGE",RX-105460,CDM,J1642,HCPCS,0636,RC,64253-0222-35,NDC,both,5,ML,18.92,5.68,"FIRST HEALTH [10303]","First Health",,15.14,80,,,,,0,0.12,16.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Methylenedioxyamphetamines",PX-301000551,CDM,80359,CPT,0301,RC,,,both,,,90.00,27,"CIGNA [10200]","Cigna Local Plus",,90,,,,,,,0.09,90,"fee schedule",
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 20MM 6FR 3.5MM",SUP-H7493926720350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AETNA [10100]","Aetna HMO/PPO",,450.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 16MM DCP STAINLESS STEEL CORTICAL SELF",SUP-200.816,CDM,C1713,HCPCS,0278,RC,,,both,,,365.40,109.62,"MULTIPLAN [10600]",Multiplan,,310.59,85,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS EVOQUE DILATOR KIT",SUP-9850DKCL,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X9MM RISE NONSTERILE",SUP-193.151,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"I-GEL, SINGLE USE SUPRAGLOTTIC AIRWAY, SIZE 1.5",SUP-8215000,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.13,23.74,"NOVANET [10819]",Novanet,,59.35,75,,,,,0,9.2,67.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 80MM 12MM BALLOON",SUP-U35130128,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 12X20 40CM SL",SUP-48012002P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,116.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS MULTIPASS 4-0 PS-1 27IN MONOFILAMENT",SUP-MCP935H,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.57,21.17,"CIGNA [10200]",Cigna,,47.99,68,,,,,0,8.21,59.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 5CM BLURR COOLCUT BLADE",SUP-AR-8500BL,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.01,257.7,"CIGNA [10200]","Cigna Local Plus",,459.57,53.5,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 90D BLADE 2.75IN 3/32IN EDGE SAFETY",SUP-E1455BNSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.24,14.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22.6,45.9,,,,,0,5.73,41.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 25MM SOLERA CD HORIZON OSTEOGRIP TITANIUM",SUP-54840004525,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS [10001]","Blue Cross HMO",,3742.37,39.2,,957.42,156.86,7483.26,51,1110.3,8114.82,"percent of total billed charges",
"FOL URETHRAL 13.35IN 20FR HEYMAN PLASTIC DILATION CATH",SUP-021120,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.13,65.14,"MULTIPLAN [10600]",Multiplan,,184.56,85,,,,,0,25.25,184.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 3.5MM YUKON CONTOUR TITANIUM",SUP-7601-63545,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD .99CM 5.37X7.68CM",SUP-D233,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"MULTIPLAN [10600]",Multiplan,,34476,85,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM G7 ACTIVE ARTICULATION THR E1 CERAMIC HIP CEMENT",SUP-98000100187,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"KAISER [10500]",Kaiser,,19416.6,67,,,,,0,3370.37,24633,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT TRACTION UNIVERSAL FOOT TOE 4 CLSR ADJUSTABLE STRAP",SUP-79-99890,CDM,S27000186,LOCAL,0270,RC,,,both,,,99.79,29.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.61,84.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.7MM 2.6 KNOTLESS TIGERTAPE FIBERTAK LOOP SELF",SUP-AR-3653TSP,CDM,C1713,HCPCS,0278,RC,,,both,,,3839.85,1151.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1762.49,45.9,,,,,0,446.57,3263.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE LOCALIZATION 20CM 20GA GHIATAS BREAST BEAD NDL 9CM",SUP-47920,CDM,A4648,HCPCS,0278,RC,,,both,,,182.79,54.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,124.3,68,,,,,0,21.26,155.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 6.5X50MM MIDLINE SYSTEM POLYAXIAL CORTICAL 4S R",SUP-14616550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 75CM 3CM 12-15MM PULMONARY RADIOPAQUE",SUP-M00550350,CDM,C1726,HCPCS,0272,RC,,,both,,,2278.65,683.59,"PHCS [10601]",PHCS,,1595.06,70,,,,,0,265.01,1936.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE EMERALD VASCULAR BENSTON LLT CURVE 150CM 20CM .035IN",SUP-502560,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"PHCS [10601]",PHCS,,66.99,70,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP050060150 PLUS US D5L60UL1500",SUP-PCP050060150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"NOVANET [10819]",Novanet,,923.4,75,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY THRULUMEN 40CM 4FR 9MM EMBOLECTOMY STAINLESS",SUP-12TLW404F,CDM,C1757,HCPCS,0272,RC,,,both,,,746.58,223.97,"KAISER [10500]",Kaiser,,500.21,67,,,,,0,86.83,634.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX PROGRIP 5.5X3.5IN LEFT FLAP SELF FIX",SUP-TEM1409GL,CDM,C1781,HCPCS,0278,RC,,,both,,,1948.20,584.46,"CIGNA [10200]","Cigna Local Plus",,1042.29,53.5,,3096.73,1.00,3096.73,"1 through 10",226.58,1655.97,"percent of total billed charges",
"SCR BONE 3.5MM 26MM SECUR-FIT X-TRA TITANIUM T15 CORTICAL",SUP-131218026,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,93.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,91.85,671.29,"percent of total billed charges",
"AUG TIBIAL 10MM PERSONA EF KNEE LEFT MEDIAL HALF BLOCK",SUP-42555805310,CDM,C1776,HCPCS,0278,RC,,,both,,,7236.72,2171.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2071.15,28.62,,,,,0,841.63,6151.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Screening Clo Test",PX-306000060,CDM,87081,CPT,0306,RC,,,both,,,260.00,78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.49,,,,,,,0.01,221,"fee schedule",
"CATH TYSHAK NUCLEUS 100CM 4CM 10FR 20MM .035IN 8FR 2 TAPER",SUP-612094,CDM,C1725,HCPCS,0272,RC,,,both,,,5345.43,1603.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,621.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,621.67,4543.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR IMPLANTABLE 55CM PRECISION M-1 CNCT",SUP-SC-9004-55,CDM,C1883,HCPCS,0278,RC,,,both,,,3525.00,1057.5,"CIGNA [10200]",Cigna,,2397,68,,,,,0,409.96,2996.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC FLIPCUTTER II OD9.5 MM ACL PCL DRILL PIN",SUP-AR-1204AF-95,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1174.76,45.9,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DANTROLENE 20 MG INTRAVENOUS SOLUTION",RX-9716,CDM,,,0250,RC,78670-0003-67,NDC,both,1,UN,471.91,141.57,"PHCS [10601]",PHCS,,330.34,70,,,,,0,54.88,401.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MERSILENE 2 MO-7 30IN BRAID D SPECIAL GREEN LIGHT GREEN",SUP-D8649,CDM,S27200284,LOCAL,0272,RC,,,both,,,776.02,232.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,527.69,68,,,,,0,90.25,659.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Phosphorus",PX-301000359,CDM,84100,CPT,0301,RC,,,both,,,116.60,34.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16.82,,,,,,,0.12,99.11,"fee schedule",
"CMPNT FEMORAL 7 KNEE LEFT TOTAL STBL TRIATHLON COCR",SUP-5512-F-701,CDM,C1776,HCPCS,0278,RC,,,both,,,20599.49,6179.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5561.86,27,,,,,0,2395.72,17509.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 34MM ABDOMEN THORAX SUT RETENTION",SUP-733034,CDM,C1768,HCPCS,0278,RC,,,both,,,7104.24,2131.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3260.85,45.9,,,,,0,826.22,6038.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grft F/N/H/F/G <=100scm 1st 25 Sq Cm",PX-510000054,CDM,15275,CPT,0761,RC,,,both,,,1638.76,491.63,"BLUE CROSS [10001]","Blue Cross PPO",,1638.76,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,190.59,1638.76,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 81MM 41.8MM 33MM DURAN ANCORE 35.8MM 2",SUP-620BG33,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3752.08,28.62,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RECTAL RESECTION WITHOUT CC/MCC",334,MS-DRG,,,,,,,inpatient,,,90693.67,27208.1,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,21843.98,,"Case rate ($10,159.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,434.24, add-ons for qualifying new technology services are included. If operating cost exceeds $42,473.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,095.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $9,446.72. The transfer operating threshold is the transfer adjustment factor * $9,434.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.27. The transfer capital threshold is the transfer adjustment factor * $713.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,47820.13,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"NALOXONE 1 MG/ML INTRANASAL SOLUTION",RX-411889,CDM,J2312,HCPCS,0636,RC,76329-3369-01,NDC,both,2,ML,298.98,89.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.45,,"Fee schedule rate ($16.45). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.45,254.13,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 28CM 3CM 7FR .038IN 2 PIGTAIL",SUP-M006192144010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"KAISER [10500]",Kaiser,,804.39,67,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 60MM 36MM XLPE HIP STERILE",SUP-71335760,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"CIGNA [10200]","Cigna Open Access",,6330.84,56.9,,5302.19,4377.88,6578.61,27,1293.98,9457.31,"percent of total billed charges",
"BASEPLT TIBIAL JOURNEY 1 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022211,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1969.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT NEROSTIMLTR AXONICS PERCUTANEOUS STERILE LATEX FREE",SUP-9009,CDM,C1883,HCPCS,0278,RC,,,both,,,737.10,221.13,"KAISER [10500]",Kaiser,,493.86,67,,,,,0,85.72,626.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 40MM 135CM 6MM VASCULAR SELF EXPANDABLE",SUP-1012534-40,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 89X12.5X1.5MM HALL MICROPOWER MICRO100 RECIPROCATE",SUP-5052-261,CDM,S27200284,LOCAL,0272,RC,,,both,,,98.66,29.6,"CIGNA [10200]","Cigna Local Plus",,52.78,53.5,,,,,0,11.47,83.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY LARYNGEAL 3 PEDIATRIC SILICONE LMA UNIQUE MASK CUFF",SUP-105300-000030,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.85,14.35,"PHCS [10601]",PHCS,,33.5,70,,,,,0,5.56,40.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 89X12.5X1.5MM HALL MICROPOWER MICRO100 RECIPROCATE",SUP-5052-261,CDM,S27200284,LOCAL,0272,RC,,,both,,,98.66,29.6,"CIGNA [10200]",Cigna,,67.09,68,,,,,0,11.47,83.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 166MM 32-16MM 20FR ENDURANT II ABDOMEN",SUP-ETBF3216C166E,CDM,C1876,HCPCS,0278,RC,,,both,,,62842.50,18852.75,"CIGNA [10200]","Cigna Open Access",,21052.24,33.5,,,,,0,7308.58,53416.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE 107 MEQ CHLORINE 100 MEQ SODIUM 3 MEQ",SUP-08-3301-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.05,53.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,121.07,68,,,,,0,20.71,151.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RADSTAT STD COMPRESSION WRIST RADIAL ARTERY 3 BAND",SUP-RADSTD,CDM,S27200284,LOCAL,0272,RC,,,both,,,204.45,61.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.78,173.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANSURETHRAL PROCEDURES WITHOUT CC/MCC",670,MS-DRG,,,,,,,inpatient,,,37883.74,11365.12,"CIGNA [10200]","Cigna Local Plus",,10084.76,,"Fee schedule rate ($10,084.76). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,6062.26,28533.25,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 22CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155231190,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"BLUE CROSS [10001]","Blue Cross PPO",,572.36,39.2,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Scl70 Igg",PX-302000043,CDM,86235,CPT,0302,RC,,,both,,,568.68,170.6,"PHCS [10601]",PHCS,,398.08,70,,,,,0,0.57,483.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEPHEA MITRAL VALVE TRACK 2 32MM",SUP-23032,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 2-0 CT-2 SPIRAL 15CM CLSR",SUP-SXPP1B413,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.96,69.59,"NOVANET [10819]",Novanet,,173.97,75,,,,,0,26.98,197.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 42.5-67MM 6MM CREO LONG SPINE CROSS LOW PROFILE",SUP-1119.0267,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]",Cigna,,2422.5,68,,1831.33,1831.33,1831.33,16,414.32,3187.5,"percent of total billed charges",
"COIL EMBOLIZATION 6CM 4MM CEREPAK XTRASOFT FREEFORM",SUP-XCR120406,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS [10001]","Blue Cross HMO",,5184.53,39.2,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 6MM 2.25MM BALLOON DILATATION PEBAX",SUP-1012271-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 12 STD KNEE LEFT CRUCIATE RETAIN PERSONA COCR",SUP-42502807401,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11876.08,41.1,,6417.48,6417.48,6417.48,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"SET .241IN 96IN CNCT SECONDARY PIERCE PIN IRRIGATION Y 85ML",SUP-06543-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.00,25.5,"KAISER [10500]",Kaiser,,56.95,67,,,,,0,9.89,72.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 12 STD KNEE LEFT CRUCIATE RETAIN PERSONA COCR",SUP-42502807401,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3424.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK",RX-10049,CDM,J1450,HCPCS,0636,RC,25021-0184-82,NDC,both,100,ML,100.65,30.19,"CIGNA [10200]","Cigna Open Access",,12.06,,,,,,,2.63,85.55,"fee schedule",
"HC Xr Shoulder Complt>=2v",PX-320000063,CDM,73030,CPT,0320,RC,,,both,,,558.59,167.58,"CIGNA [10200]",Cigna,,57.05,,,,,,,40.79,474.8,"fee schedule",
"BURR SURGICAL STAINLESS STEEL ROUND L54 MM OD3.2 MM ROUND ST",SUP-1608002011,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE MATRIX 5CC ALLOGRAFT",SUP-T44105,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2932.5,68,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3.5MM BIO-PUSHLOCK 19.5MM STERILE DISPOSABLE",SUP-AR-1926B,CDM,C1713,HCPCS,0278,RC,,,both,,,2835.00,850.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,335.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",329.71,2409.75,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 22CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155231190,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"MULTIPLAN [10600]",Multiplan,,1241.09,85,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 2.5MM 8.25IN STAINLESS STEEL GARRETT MALLEABLE",SUP-25-8019,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.43,22.03,"CIGNA [10200]","Cigna Open Access",,41.78,56.9,,,,,0,8.54,62.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL COCHLEAR 10MM 4MM DERMALOCK BAHA TITANIUM HA 1 STAGE",SUP-93331,CDM,L8690,HCPCS,0278,RC,,,both,,,21042.00,6312.6,"CIGNA [10200]",Cigna,,8416.8,40,,,,,0,2447.18,17885.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE C SCREW, 3.5X16MM FA",SUP-3913516,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 11MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-311,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"KAISER [10500]",Kaiser,,6586.45,67,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Tegasorb",PX-E27200123,CDM,E27200123,LOCAL,0272,RC,,,both,,,33.00,9.9,"AETNA [10100]","Aetna HMO/PPO",,26.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.84,28.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drain Cyst Ovarian Abd Appr",PX-350000006,CDM,58805,CPT,0350,RC,,,both,,,2355.41,706.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,279.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,273.93,2355.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 2.4MM 3MM 230CM COLONOSCOPE STERILE",SUP-00711499,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 16MM STAINLESS STEEL T8 SELF TAP LOCK",SUP-02.210.116TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1011.53,303.46,"CIGNA [10200]",Cigna,,687.84,68,,1831.33,1831.33,1831.33,16,117.64,859.8,"percent of total billed charges",
"CATH ADVANCE 18LP 80CM 4CM 4FR 6MM .018IN BALLOON DILATATION",SUP-G50246,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 89X12.5X1.5MM HALL MICROPOWER MICRO100 RECIPROCATE",SUP-5052-261,CDM,S27200284,LOCAL,0272,RC,,,both,,,98.66,29.6,"MULTIPLAN [10600]",Multiplan,,83.86,85,,,,,0,11.47,83.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SPINAL 28MM 4MM VUEPOINT II MULTIAXIAL",SUP-8975428,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RADSTAT STD COMPRESSION WRIST RADIAL ARTERY 3 BAND",SUP-RADSTD,CDM,S27200284,LOCAL,0272,RC,,,both,,,204.45,61.33,"PHCS [10601]",PHCS,,143.12,70,,,,,0,23.78,173.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 95MMX2.6MM STAINLESS STEEL 2.7MM SCR 10 HOLE LC-DCP",SUP-242.22,CDM,C1713,HCPCS,0278,RC,,,both,,,2619.83,785.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,310.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,304.69,2226.86,"percent of total billed charges",
"CNCT ROD 42.5-67MM 6MM CREO LONG SPINE CROSS LOW PROFILE",SUP-1119.0267,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1721.25,45.9,,,,,0,414.32,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 6MM 2.25MM BALLOON DILATATION PEBAX",SUP-1012271-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 89X12.5X1.5MM HALL MICROPOWER MICRO100 RECIPROCATE",SUP-5052-261,CDM,S27200284,LOCAL,0272,RC,,,both,,,98.66,29.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.47,83.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 2.5MM 8.25IN STAINLESS STEEL GARRETT MALLEABLE",SUP-25-8019,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.43,22.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,49.93,68,,,,,0,8.54,62.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MERSILENE 5MM MO-4 12IN WOVEN WHITE NONABSORBABLE",SUP-RS23,CDM,S27200284,LOCAL,0272,RC,,,both,,,385.71,115.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,45.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.86,327.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT LOWAX 6CM 230CM 25MM 10.2FR COLONIC",SUP-CNJF-25-060-230,CDM,C1876,HCPCS,0278,RC,,,both,,,15104.24,4531.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6041.7,40,,,,,0,1756.62,12838.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Allergen Ige Quant/Semi Ea",PX-302000005,CDM,86003,CPT,0302,RC,,,both,,,94.05,28.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.59,,"Fee schedule rate ($5.59). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,79.94,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L60 MM OD5 MM FEMORAL LOW PROFILE LOCK TUBE STERI",SUP-04.045.360TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,221.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",217.47,1589.42,"percent of total billed charges",
"CMPNT FEMORAL 9 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502606602,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6543.3,28.62,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE CANNULATED STERILE 7MM 75MM 16MM STAINLESS STEEL",SUP-71127075,CDM,C1713,HCPCS,0278,RC,,,both,,,2479.50,743.85,"BLUE CROSS [10001]","Blue Cross PPO",,971.96,39.2,,957.42,570.23,957.42,28,288.37,2107.58,"percent of total billed charges",
"SPACER ALLOGRAFT 11X14X8MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7208,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]",Cigna,,4692,68,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE COMPRESSION SMALL THIGH SCD EXPRESS ANTIEMBOLISM",SUP-9545,CDM,S27000186,LOCAL,0270,RC,,,both,,,356.77,107.03,"FIRST HEALTH [10303]","First Health",,285.42,80,,,,,0,41.49,303.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 8MM 8FR ENDOPROSTHESIS HEPARIN",SUP-VBH080502,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONVEY 100CM 7FR LEFTBU3.75 CURVE GUIDING HYDROPHILIC",SUP-H749392657150,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 7FR 65CM HICKMAN PEEL-APART 2 LUMEN LOW PROFILE",SUP-0600570,CDM,C1751,HCPCS,0272,RC,,,both,,,1385.10,415.53,"PHCS [10601]",PHCS,,969.57,70,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 47-60MM TITANIUM 4.75MM SCR SOLERA X10 XLNK CD HORIZON",SUP-5442147,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"AETNA [10100]","Aetna HMO/PPO",,2832.19,79.5,,1521.93,481.35,16760.95,30,414.32,3028.13,"percent of total billed charges",
"SYSTEM MULTI-LINK VISION 23MM 3MM CORONARY STENT COCR RAPID",SUP-1007848-23,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 18CM 28.5MM 12MM 24-26MM 10-11MM GORE",SUP-RLT281218,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"AETNA [10100]","Aetna HMO/PPO",,49846.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA HAND SUTUPAK 1 24IN BRAID TIES 13 STRAND",SUP-SA77G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RTRCTR SAPHLITE VESSEL HARVESTING",SUP-89-2717K,CDM,S27200284,LOCAL,0272,RC,,,both,,,3376.41,1012.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2295.96,68,,,,,0,392.68,2869.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH II SS6",SUP-398339,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X21MM 8D CONVEX LORDOTIC WEDGE",SUP-10621,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12600,40,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Chest WO Cntrst",PX-610000012,CDM,71550,CPT,0610,RC,,,both,,,3979.29,1193.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,471.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.31,3382.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 17CM 5MM BALLOON DILATATION OTW LOW",SUP-G34167,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MONTEREY AL STAND-ALONE ANTERIOR LUMBAR SCREW  5.5 MM X 25 M",SUP-480115525,CDM,S27800098,LOCAL,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]",Cigna,,1101.6,68,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"E-CATH CATHETER-OVER-NEEDLE PNB CATHETER SYSTEM 18G X 4 (100",SUP-261285-40E,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP CEMENTED FEMUR COCR HEAD ANTEVERTED LINER",SUP-71703322,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"NOVANET [10819]",Novanet,,17955,75,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS ACCESS PLUS VALUELINK LARGE BORE",SUP-MAP150,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.10,32.73,"CIGNA [10200]","Cigna Open Access",,62.08,56.9,,,,,0,12.69,92.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADHSV SKIN CLSR BSA GLUTARALDEHYDE BIOGLUE SYR APPLR TIP 5ML",SUP-BG3515-5-US,CDM,S27200284,LOCAL,0272,RC,,,both,,,5947.80,1784.34,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,704.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,691.73,5055.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +24 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-ZA90030240,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,539.1,45.9,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 11MM KII FIOS FIRST ENTRY ADVANCE",SUP-CFF34,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0250,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEOCHORD ARTIFICIAL CHORDAE DELIVERY SYSTEM",SUP-DS1000,CDM,S62400003,LOCAL,0624,RC,,,both,,,63000.00,18900,"MULTIPLAN [10600]",Multiplan,,53550,85,,,,,0,7326.9,53550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET RETRIEVAL 80CM 6.3FR 11FR GUNTHER TULIP VENA CAVA 3 WAY",SUP-G13287,CDM,C1773,HCPCS,0272,RC,,,both,,,2194.50,658.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,901.94,41.1,,,,,0,255.22,1865.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE FIAPC 1.5MM 9.8FT SIDEFR",SUP-20132-219,CDM,S27200284,LOCAL,0272,RC,,,both,,,2092.50,627.75,"KAISER [10500]",Kaiser,,1401.98,67,,,,,0,243.36,1778.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 30MM 8MM BALLOON DILATATION DURALYN",SUP-48008003X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 18MM 140CM 2.75MM",SUP-RSINT27518UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2544.7,45.9,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR091020,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS [10001]","Blue Cross PPO",,5184.53,39.2,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 40CM 4FR 9MM ROUND EMBOLECTOMY STAINLESS STEEL",SUP-120404F,CDM,C1757,HCPCS,0272,RC,,,both,,,376.01,112.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,154.54,41.1,,,,,0,43.73,319.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN FEMORAL LEFT 4 CURVE ANGIOGRAPHIC",SUP-H74908641222,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,31.47,41.1,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 20MM 9MM .035IN BALLOON DILATATION NYBAX",SUP-39171-09024,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APEX 143CM 8MM 2.5MM BALLOON DILATATION OPTILEAP",SUP-H7493895908250,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 6FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856120,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"KAISER [10500]",Kaiser,,734.76,67,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 15CM 5FR MERIT MAK COAXIAL PAIR MINI ACCESS",SUP-MAK5F-15,CDM,C1894,HCPCS,0272,RC,,,both,,,161.39,48.42,"PHCS [10601]",PHCS,,112.97,70,,,,,0,18.77,137.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 2.75MM CORONARY STENT",SUP-1145275-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PHCS [10601]",PHCS,,4086.6,70,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 500-700UM 2ML MICROSPHERES PREFILLED",SUP-S620GH,CDM,S27800098,LOCAL,0278,RC,,,both,,,1860.00,558,"FIRST HEALTH [10303]","First Health",,1488,80,,,,,0,216.32,1581,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG GERMICIDAL DISK .75IN 1.5MM BIOPATCH CHG ANTIMICROBIAL",SUP-4151,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.49,14.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL SURGICAL 1.6MM FIBERTAK",SUP-AR-3600D-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.03,267.91,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 40CM 40MM 7MM .035IN BALLOON DILATATION NYBAX",SUP-H74939171070440,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAFESHEATH II SS6",SUP-398339,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 89X12.5X1.5MM HALL MICROPOWER MICRO100 RECIPROCATE",SUP-5052-261,CDM,S27200284,LOCAL,0272,RC,,,both,,,98.66,29.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"REMIFENTANIL 2 MG INTRAVENOUS SOLUTION",RX-18400,CDM,,,0250,RC,63323-0724-01,NDC,both,1,UN,801.54,240.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 7FR INTROFLEX STD C",SUP-I550BF7C,CDM,C1894,HCPCS,0272,RC,,,both,,,481.54,144.46,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE VASCULAR STRAIGHT 33CM .025IN 2 END SPRING SOFT LATEX",SUP-AW-04025,CDM,C1769,HCPCS,0272,RC,,,both,,,78.65,23.59,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH BRIDGE PREP GWIRE SYR STPCOCK OCCLUSION BALLOON",SUP-591-001,CDM,C1769,HCPCS,0272,RC,,,both,,,2137.50,641.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dressing Wound Tegasorb",PX-E27200123,CDM,E27200123,LOCAL,0272,RC,,,both,,,33.00,9.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR INTERFERENCE REGENESORB 25MM 6MM BIOSURE",SUP-72204392,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"NOVANET [10819]",Novanet,,2080.52,75,,,,,0,322.62,2357.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 18CM 28.5MM 12MM 24-26MM 10-11MM GORE",SUP-RLT281218,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7429.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 230CM 120CM 22-27MM 10FR COLONIC ENTERAL",SUP-M00565120,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 40MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,655.83,41.1,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-02002,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4747.48,45.9,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG GERMICIDAL DISK 1IN 7MM BIOPATCH CHG ANTIMICROBIAL",SUP-4152,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.49,14.85,"CIGNA [10200]","Cigna Open Access",,28.16,56.9,,,,,0,5.76,42.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY 1MM 2MM SUPER LARGE CURL 7FR 95CM DUO",SUP-401918R,CDM,C1731,HCPCS,0272,RC,,,both,,,2100.00,630,"KAISER [10500]",Kaiser,,1407,67,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM STENT GRAFT 124MM 16-10MM 14FR ENDURANT II ABDOMEN",SUP-ETLW1610C124E,CDM,S27800098,LOCAL,0278,RC,,,both,,,30315.60,9094.68,"CIGNA [10200]","Cigna Local Plus",,9549.41,31.5,,,,,0,3525.7,25768.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG GERMICIDAL DISK .75IN 1.5MM BIOPATCH CHG ANTIMICROBIAL",SUP-4151,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.49,14.85,"KAISER [10500]",Kaiser,,33.16,67,,,,,0,5.76,42.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 59CM ENDOTAK RELIANCE G ENDOCARDIAL STEROID",SUP-174,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"NOVANET [10819]",Novanet,,11385,75,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RADSTAT STD COMPRESSION WRIST RADIAL ARTERY 3 BAND",SUP-RADSTD,CDM,S27200284,LOCAL,0272,RC,,,both,,,204.45,61.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,139.03,68,,,,,0,23.78,173.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nfct Ds 22 Trgt Sars-Cov-2",PX-300000414,CDM,0202U,CPT,0300,RC,,,both,,,1106.30,331.89,"MULTIPLAN [10600]",Multiplan,,940.36,85,,,,,0,1.11,940.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 15MM REFLECTION FULL THREAD HIP ACETABULAR",SUP-71336515,CDM,C1713,HCPCS,0278,RC,,,both,,,1341.36,402.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,615.68,45.9,,,,,0,156,1140.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DIVERGENCE-L 15X9.4X5MM ANTERIOR OBLIQUE LUMBAR",SUP-736525,CDM,S27800098,LOCAL,0278,RC,,,both,,,9177.00,2753.1,"BLUE CROSS [10001]","Blue Cross PPO",,3597.38,39.2,,,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1MM 1.6MM 9MM TITANIUM CORTEX HAND SELF TAPPING",SUP-400.529,CDM,C1713,HCPCS,0278,RC,,,both,,,526.18,157.85,"CIGNA [10200]","Cigna Open Access",,299.4,56.9,,1144.80,304.56,2275.09,66,61.19,447.25,"percent of total billed charges",
"DIL VASCULAR 2.5MM 8.25IN STAINLESS STEEL GARRETT MALLEABLE",SUP-25-8019,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.43,22.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.54,62.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9 % IVPB-ADDV/MBP",RX-120160,CDM,J3490,HCPCS,0258,RC,00338-0553-11,NDC,both,50,ML,100.65,30.19,"CIGNA [10200]","Cigna Open Access",,57.27,56.9,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"Y-MESH LITE VERTESSA 26X4X3",SUP-CAL-VLY2643,CDM,C1781,HCPCS,0278,RC,,,both,,,5582.10,1674.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1597.6,28.62,,,,,0,649.2,4744.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOWRIST STAPLER 30 GREEN RELOAD",SUP-48630G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1453.28,435.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,169.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.02,1235.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS BLOCK ALLOGRAFT 10MM",SUP-291041,CDM,S27800098,LOCAL,0278,RC,,,both,,,3839.85,1151.95,"PHCS [10601]",PHCS,,2687.9,70,,,,,0,446.57,3263.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 11MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-311,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"AETNA [10100]","Aetna HMO/PPO",,7815.26,79.5,,10981.53,8986.79,12413.38,12,1143.29,8355.94,"percent of total billed charges",
"SHELL ACETABULAR 58MM HIP 5 SCR HOLE CLUSTER TRITANIUM",SUP-702-04-58F,CDM,C1776,HCPCS,0278,RC,,,both,,,12551.10,3765.33,"AETNA [10100]","Aetna HMO/PPO",,9978.12,79.5,,10981.53,8986.79,12413.38,12,1459.69,10668.44,"percent of total billed charges",
"SODIUM CHLORIDE 0.9 % IVPB-ADDV/MBP",RX-120160,CDM,J3490,HCPCS,0258,RC,00338-0553-11,NDC,both,50,ML,100.65,30.19,"UHC [10700]","United Healthcare",,50.33,50,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 20MM EMBOLD NITINOL FIBER DETACHABLE",SUP-M001394240200500,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"AETNA [10100]","Aetna HMO/PPO",,6851.39,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON UVA VIVITY AUTONOME",SUP-CCAET0,CDM,V2788,HCPCS,0276,RC,,,both,,,880.00,264,"AMERIGROUP MEDICAID [20100]",Amerigroup,,104.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,102.34,748,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 8MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT084050A,CDM,C1768,HCPCS,0278,RC,,,both,,,12827.10,3848.13,"BLUE CROSS [10001]","Blue Cross HMO",,5028.22,39.2,,,,,0,1491.79,10903.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE ENDOSCOPIC LESIONHUNTER METAL NITINOL THK.18 MM THIN O",SUP-CS50061,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"NOVANET [10819]",Novanet,,97.88,75,,,,,0,97.88,97.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM PINNACLE ACETABULAR CANCELLOUS STERILE",SUP-1217-25-500,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"BLUE CROSS [10001]","Blue Cross HMO",,449.29,39.2,,957.42,156.86,7483.26,51,133.3,974.23,"percent of total billed charges",
"AUG FEMORAL 15MM TRIATHLON 6 RIGHT DISTAL KNEE",SUP-5542-A-602,CDM,C1776,HCPCS,0278,RC,,,both,,,6011.46,1803.44,"BLUE CROSS [10001]","Blue Cross HMO",,2356.49,39.2,,5311.50,4717.44,5388.59,31,699.13,5109.74,"percent of total billed charges",
"KIT ENDOSCOPIC EMR KIT 165CM 13.9MM RIM DYE SPRAY CATH",SUP-K-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1489.02,446.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PDS PLUS MULTIPASS 3-0 PS-1 18IN MONOFILAMENT",SUP-PDP683G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH AMPLATZER 70CM 5.5CM 8FR 40MM .035IN BALLOON DILATATION",SUP-9-SB-034,CDM,S27200284,LOCAL,0272,RC,,,both,,,2445.00,733.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TREK CROSSFLEX SLIM SEAL 15MM 4.5MM BALLOON DILATATION",SUP-1012412-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Kit Autotransfusion Bowl",PX-E27200259,CDM,E27200259,LOCAL,0272,RC,,,both,,,349.07,104.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STEERABLEBALLOON CA",SUP-ARC25SB-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"HC Nwpt >50 Sq Cm Disp (Gp)",PX-420000044,CDM,97608,CPT,0420,RC,,,both,,,2308.00,692.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,268.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,215,1961.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 137MM CEMENT ACCOLADE C 132D 4 42MM OFFSET HIP",SUP-6058-0435D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6575.7,40,,,,,0,1911.88,13973.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 10MM LEIBINGER UNIVERSAL 2 TITANIUM",SUP-50-20510,CDM,C1713,HCPCS,0278,RC,,,both,,,788.29,236.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,536.04,68,,,,,0,91.68,670.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION ARCHON ACP SPINE TEMPORARY",SUP-8789733,CDM,C1713,HCPCS,0278,RC,,,both,,,1424.81,427.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,653.99,45.9,,,,,0,165.71,1211.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 30MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962348,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"MULTIPLAN [10600]",Multiplan,,12328.23,85,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 3CM 5FR ADVANIX NAVIFLEX STRAIGHT PANCREATIC",SUP-M00537500,CDM,C2625,HCPCS,0272,RC,,,both,,,1411.18,423.35,"PHCS [10601]",PHCS,,987.83,70,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL ENDOWRIST SP BIPOLAR FENESTRATE",SUP-430011,CDM,S27000186,LOCAL,0270,RC,,,both,,,2583.00,774.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,300.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,300.4,2195.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 4MM SPACE TITANIUM 2.7MM SCR OPEN WEDGE OSTEOTOMY",SUP-DC2832024,CDM,C1713,HCPCS,0278,RC,,,both,,,7548.60,2264.58,"CIGNA [10200]","Cigna Local Plus",,4038.5,53.5,,3978.14,359.25,3978.14,24,877.9,6416.31,"percent of total billed charges",
"CATH 115CM 1MM 6FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY FIX",SUP-F6QF005CT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"KAISER [10500]",Kaiser,,607.82,67,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND SUTUPAK 4-0 18IN BRAID TIES 17 STRAND",SUP-SA63H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SWIVELOCK 19.1MM 4.75MM FIXATION BIOCOMPOSITE",SUP-AR-2600SBS-4,CDM,C1713,HCPCS,0278,RC,,,both,,,12606.30,3781.89,"BLUE CROSS [10001]","Blue Cross PPO",,4941.67,39.2,,957.42,570.23,957.42,28,1466.11,10715.36,"percent of total billed charges",
"INSRT TIBIAL 8 19MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-819,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"BLUE CROSS [10001]","Blue Cross PPO",,5275.71,39.2,,3949.44,3949.44,3949.44,"1 through 10",1565.22,11439.68,"percent of total billed charges",
"CATH STERLING MONORAIL 135CM 40MM 6FR 3.5MM 4FR BALLOON",SUP-39031-35401,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX11MM FRA 8D LORDOTIC NARROW WEDGE",SUP-10011,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"AETNA [10100]","Aetna HMO/PPO",,15025.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 20MM 3.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP3520X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"NOVANET [10819]",Novanet,,394.88,75,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AFTERCARE WITH CC/MCC",949,MS-DRG,,,,,,,inpatient,,,69874.09,20962.23,"AMBETTER EXCHANGE  [11102]",Ambetter,,7379.78,,"Case rate ($7,379.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,852.63, add-ons for qualifying new technology services are included. If operating cost exceeds $39,892.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,900.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $6,861.69. The transfer operating threshold is the transfer adjustment factor * $6,852.63 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $518.09. The transfer capital threshold is the transfer adjustment factor * $518.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,2462,38264.95,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT SPINAL RELINE ONE L40 MM VECTOR NAVIGATION NONSTERIL",SUP-24270040,CDM,S27000186,LOCAL,0270,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rem/Rep Card Sys Gen Only",PX-480000088,CDM,0414T,CPT,0480,RC,,,both,,,38311.00,11493.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7461.64,,"Fee schedule rate ($7,461.64).",,,,0,2041,32564.35,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pta Baln Artery Initial",PX-361000443,CDM,37246,CPT,0361,RC,,,both,,,26423.02,7926.91,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3131.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3073,22459.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 85MM 5.5MM EXPEDIUM PREBENT TITANIUM LINE",SUP-179771085,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"DEVICE XPRESS ULTRA 1.5MM BALL SUPER SLEEK PROFILE 8MM 2.5FR",SUP-ULF-206,CDM,C1726,HCPCS,0272,RC,,,both,,,11364.30,3409.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1321.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1321.67,9659.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE 30MM 57CM 9-7MM TAPER VASCULAR NITINOL",SUP-SR-090730-TCS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Arrest Agent Cassette Card",PX-E27200367,CDM,E27200367,LOCAL,0272,RC,,,both,,,180.40,54.12,"FIRST HEALTH [10303]","First Health",,144.32,80,,,,,0,20.98,153.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SPINAL 1IN 22GA NEOMED NEONATAL STERILE LUMBAR PUNCTURE",SUP-LN2210,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.01,14.1,"NOVANET [10819]",Novanet,,35.26,75,,,,,0,5.47,39.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 5FR 22CM WITHOUT GWIRE POLARIS ULTRA",SUP-M0061921210,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"FIRST HEALTH [10303]","First Health",,908.5,80,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN AMPLATZ RIGHT 1 CURVE",SUP-DXT6AR10,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 150MM 5MM BALLOON",SUP-U3575515,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STOP DRILL 3.0MM X 70MM",SUP-DRLL-30070,CDM,S27000186,LOCAL,0270,RC,,,both,,,3781.20,1134.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 2-0 MO-6 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8417H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Plc Cath Abd Ea 1st Ord",PX-361000087,CDM,36245,CPT,0361,RC,,,both,,,2189.02,656.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SKIN GRAFT FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES,MINOR",312,APR-DRG,,,,,,,inpatient,,,33568.76,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $7,271.11. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($44,959.66) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"15 FR ISLEEVE INTRODUCER (REPRISE IV)",SUP-H74939350150,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE SOFT TOUCH SMOOTH",SUP-SSF-560,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AETNA [10100]","Aetna HMO/PPO",,6006.62,79.5,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG SILVER SILICONE GENTLE BORDER ADHSV ANTIBACTERIAL 5X5IN",SUP-66800453,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.98,23.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,35.33,45.9,,,,,0,8.95,65.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 5MM CURVE BAYONET LEFT 9.5IN HARDY SYMMETRY SURGICAL",SUP-58-7525,CDM,S27200284,LOCAL,0272,RC,,,both,,,680.72,204.22,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 15.5CM NATRELLE INSPIRA P6CM FULL PROFILE ROUND",SUP-MSZ-F770,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARDEX LUBRICATH 20FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0196L20,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.32,32.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL UCSS CANNULATED STERILE",SUP-8730006,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Phenobarbital",PX-301000048,CDM,80184,CPT,0301,RC,,,both,,,233.70,70.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.37,,"Fee schedule rate ($16.37). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,198.65,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Thyroid Mets Wb",PX-341000006,CDM,78018,CPT,0341,RC,,,both,,,3209.21,962.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,385.61,,,,,,,373.23,2727.83,"fee schedule",
"HC NM Thyroid Mets Wb",PX-341000006,CDM,78018,CPT,0341,RC,,,both,,,3209.21,962.76,"BLUE CROSS [10001]","Blue Cross HMO",,817.57,,"Fee schedule rate ($817.57).",,,,0,373.23,2727.83,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Thyroid Mets Wb",PX-341000006,CDM,78018,CPT,0341,RC,,,both,,,3209.21,962.76,"CIGNA [10200]",Cigna,,539.31,,,,,,,373.23,2727.83,"fee schedule",
"DIL SURGICAL AMPLATZ FIRM KINK RESISTANT GRADUATE TAPER 35CM",SUP-M0062601020,CDM,C1894,HCPCS,0272,RC,,,both,,,362.44,108.73,"FIRST HEALTH [10303]","First Health",,289.95,80,,,,,0,42.15,308.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TIBIAL 80MM 12.5MM ASCENT MAXIM KNEE PRIMARY FIN",SUP-141318,CDM,C1776,HCPCS,0278,RC,,,both,,,4719.60,1415.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1350.75,28.62,,,,,0,548.89,4011.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 5MM EMBOLD PLATINUM TUNGSTUN NITINOL",SUP-M001394240050150,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"CIGNA [10200]","Cigna Local Plus",,3647.2,53.5,,,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM TI HARD ROD 100MM",SUP-498.104,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"PASSER FIBERTAPE STRAIGHT LARGE CERCLAGE SUT DISPOSABLE",SUP-AR-7822,CDM,S27200284,LOCAL,0272,RC,,,both,,,1771.88,531.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1204.88,68,,,,,0,206.07,1506.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +6.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.065,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEPHEA MITRAL VALVE",SUP-FG22500,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 113MM 30-12MM 7.7MM 20FR ZENITH RENU",SUP-G55382,CDM,C1874,HCPCS,0278,RC,,,both,,,43501.50,13050.45,"CIGNA [10200]",Cigna,,17400.6,40,,,,,0,5059.22,36976.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS LIFECARE 5% DEXTROSE QUAD PACK 100ML LATEX",SUP-07923-37,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"FIRST HEALTH [10303]","First Health",,64.8,80,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BN 2.3MM 10MM LEIBINGER UNV 2",SUP-50-23410,CDM,C1713,HCPCS,0278,RC,,,both,,,559.22,167.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,256.68,45.9,,,,,0,65.04,475.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MECOBALAMIN-LEVOMEFOLATE CALCIUM-PYRIDOXAL PHOS 2 MG-3 MG-35 MG TABLET",RX-40506,CDM,,,0637,RC,51991-0813-90,NDC,both,1,UN,7.26,2.18,"CIGNA [10200]","Cigna Local Plus",,3.88,53.5,,,,,0,0.84,6.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X10MM 10MM CAPSTONE PEEK INTERBODY",SUP-2991026,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2515.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.6MM 229MM KIRSCHNER STAINLESS STEEL 1 END",SUP-18600369,CDM,C1713,HCPCS,0278,RC,,,both,,,119.63,35.89,"BLUE CROSS [10001]","Blue Cross HMO",,46.89,39.2,,957.42,156.86,7483.26,51,13.91,101.69,"percent of total billed charges",
"SLEEVE CENTERING 13.5MM S-ROM ZTT 20B LARGE HIP PROXIMAL",SUP-521405,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"CIGNA [10200]","Cigna Open Access",,6193.42,56.9,,5302.19,4377.88,6578.61,27,1265.9,9252.04,"percent of total billed charges",
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 12MM 140CM 3MM CORONARY",SUP-RSINT30012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]","Cigna Local Plus",,2966.04,53.5,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +23 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-CC60WF.230,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 16MM 1 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.116,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1927.8,45.9,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 33CM 9MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR180933,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"CIGNA [10200]","Cigna Local Plus",,5858.24,31.5,,,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE LMA MADGIC 30-100UM 8.5IN .18IN DRUG DELIVERY 3ML .25",SUP-MAD600,CDM,S27000186,LOCAL,0270,RC,,,both,,,86.15,25.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.02,73.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rad Tx Del Lvl 3 Sd",PX-333000072,CDM,77412,CPT,0333,RC,,,both,,,3045.45,913.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3045.45,,"Per diem ($3,244).",,,,0,354.19,3045.45,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 440MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.165S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"FIRST HEALTH [10303]","First Health",,9934.67,80,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Midline",PX-E27200256,CDM,C1751,HCPCS,0272,RC,,,both,,,667.03,200.11,"PHCS [10601]",PHCS,,466.92,70,,,,,0,77.58,566.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 14FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G00996,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,20.27,41.1,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Felbamate",PX-301000678,CDM,80167,CPT,0301,RC,,,both,,,52.00,15.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,29.32,,,,,,,0.01,44.2,"fee schedule",
"HC Drug Assay Felbamate",PX-301000678,CDM,80167,CPT,0301,RC,,,both,,,52.00,15.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,44.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 3.5IN 18GA 20GA PERIFIX TUOHY METAL GLASS LOR",SUP-332236,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.73,44.32,"AETNA [10100]","Aetna HMO/PPO",,117.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.18,125.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 30MM 29MM AEQUALIS REVERSED II 2MM OFFSET",SUP-DWE830,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"CIGNA [10200]",Cigna,,6421.24,68,,5873.17,5873.17,5873.17,"1 through 10",1098.22,8026.55,"percent of total billed charges",
"GRAFT BONE LEGACY DBM 5CC ALLOGRAFT NONSTERILE LATEX FREE",SUP-420805,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Local Plus",,2006.25,53.5,,3978.14,359.25,3978.14,24,436.13,3187.5,"percent of total billed charges",
"SOL DIALYSATE BGK2/0 5000ML PVC FREE 2 COMPARTMENT BAG PEEL",SUP-110244S,CDM,S27200284,LOCAL,0272,RC,,,both,,,322.60,96.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,148.07,45.9,,,,,0,37.52,274.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Abd Complete",PX-402000008,CDM,76700,CPT,0402,RC,,,both,,,1493.50,448.05,"CIGNA [10200]","Cigna Open Access",,172.5,,,,,,,123.34,1269.48,"fee schedule",
"HC Consult Rad Physics/ Week",PX-333000020,CDM,77336,CPT,0333,RC,,,both,,,1181.32,354.4,"FIRST HEALTH [10303]","First Health",,945.06,80,,,,,0,137.39,1181.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE 43CM 5MM CENTIMETER MARKING PALPATION ENDOSCOPIC",SUP-26178T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 66MM HIP CLUSTER 5 SCR HOLE METAL HA",SUP-502-11-66H,CDM,C1776,HCPCS,0278,RC,,,both,,,9525.45,2857.63,"CIGNA [10200]",Cigna,,6477.31,68,,5873.17,5873.17,5873.17,"1 through 10",1107.81,8096.63,"percent of total billed charges",
"SYSTEM SYNERGY 32MM 144CM 2.5MM CORONARY STENT EVEROLIMUS",SUP-H7493926132250,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2468.48,28.62,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 110MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 6",SUP-71357006,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3927.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 30MM ORTHOLOC STAINLESS STEEL FULL THREAD",SUP-58812730,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"KAISER [10500]",Kaiser,,569.84,67,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Line Ext Cardioplegia",PX-E27200368,CDM,E27200368,LOCAL,0272,RC,,,both,,,180.40,54.12,"FIRST HEALTH [10303]","First Health",,144.32,80,,,,,0,20.98,153.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Line Ext Cardioplegia",PX-E27200368,CDM,E27200368,LOCAL,0272,RC,,,both,,,180.40,54.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.98,153.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 8MM 4MM XLONG CARBIDE OVAL 8 FLUTED STERILE",SUP-00509323600,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.27,56.48,"CIGNA [10200]",Cigna,,128.02,68,,,,,0,21.9,160.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175250090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,157.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 7MM 6FR VASCULAR NITINOL PERIPHERAL",SUP-S-70-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"MULTIPLAN [10600]",Multiplan,,7771.13,85,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DENTAL AND ORAL DISEASES WITH CC",158,MS-DRG,,,,,,,inpatient,,,28872.17,8661.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,18060.44,,"Fee schedule rate ($18,060.44). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,5643.54,22689.5,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 22MM CORTICAL LOCK NONSTERILE LATEX FREE",SUP-131227122,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"PHCS [10601]",PHCS,,935.55,70,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN POSITIONING 5MM STAINLESS STEEL CRIMP STERILE",SUP-02.221.005S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION",RX-156258,CDM,J0780,HCPCS,0636,RC,23155-0497-31,NDC,both,2,ML,81.54,24.46,"CIGNA [10200]","Cigna Open Access",,6.78,,,,,,,2.11,69.31,"fee schedule",
"HC Htlv/Hiv Ab Confirm",PX-302000136,CDM,86689,CPT,0302,RC,,,both,,,663.00,198.9,"BLUE CROSS [10001]","Blue Cross PPO",,24.72,,"Fee schedule rate ($24.72).",,,,0,0.01,563.55,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 11MM 11FR ENDOPROSTHESIS HEPARIN",SUP-VBH110502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18566.10,5569.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7426.44,40,,,,,0,2159.24,15781.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 3.5MM YUKON CONTOUR OCCIPITOCERVICOTHORACIC",SUP-7601-63555,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"SCR BONE 4.5MM 20MM PERIPHERAL",SUP-5572-4520,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",180.93,1322.35,"percent of total billed charges",
"SYSTEM SYNERGY 38MM 144CM 2.75MM CORONARY STENT EVEROLIMUS",SUP-H7493926138270,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"FIRST HEALTH [10303]","First Health",,6900,80,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 20MM 6FR 1.2MM .07IN BALLOON",SUP-H7493918920120,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"NOVANET [10819]",Novanet,,425.25,75,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 16MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P316,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS [10001]","Blue Cross HMO",,3275.51,39.2,,5311.50,4717.44,5388.59,31,971.79,7102.52,"percent of total billed charges",
"CMPNT FEMORAL 6 KNEE RIGHT MEDIAL LEFT LATERAL RESTORIS",SUP-180516,CDM,C1776,HCPCS,0278,RC,,,both,,,12440.70,3732.21,"CIGNA [10200]","Cigna Open Access",,4167.63,33.5,,5302.19,4377.88,6578.61,27,1446.85,10574.6,"percent of total billed charges",
"SPACER SPINAL 40X18X7-14MM RISE-L",SUP-193.302,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"AETNA [10100]","Aetna HMO/PPO",,27296.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Breast Local Dev Stereo Add",PX-361000315,CDM,19284,CPT,0361,RC,,,both,,,2725.49,817.65,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,316.97,2725.49,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23MMX11MM ELEVATE XLORDOTIC PEEK TITANIUM",SUP-8881123,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PHCS [10601]",PHCS,,19845,70,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 65CM 5FR COBRA 2 CURVE ANGIOGRAPHIC SLX TUNGSTEN",SUP-451543V0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER DILATATION L150CM BALLOON L12CM DIA4MM SHEATH 4FR G",SUP-U8150412,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 14FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G00996,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,33.54,68,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL PFC SIGMA 4 KNEE COCR CEMENTED MODULAR FIX",SUP-158140000,CDM,C1776,HCPCS,0278,RC,,,both,,,8603.28,2580.98,"UHC [10700]","United Healthcare",,5445.88,63.3,,8601.07,8395.67,8601.07,"1 through 10",1000.56,7312.79,"percent of total billed charges",
"GRAFT BONE SUBSTITUTE DEMINERALIZED CANCELLOUS ALLOGRAFT BLO",SUP-PBB12,CDM,S27800098,LOCAL,0278,RC,,,both,,,4944.71,1483.41,"CIGNA [10200]","Cigna Local Plus",,2645.42,53.5,,,,,0,575.07,4203,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.2MM 230MM PRECISION KIRSCHNER SMOOTH",SUP-P27-192-3023,CDM,S27000186,LOCAL,0270,RC,,,both,,,237.51,71.25,"NOVANET [10819]",Novanet,,178.13,75,,,,,0,27.62,201.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MINAMO VASCULAR STRAIGHT 300CM .014IN STERILE LATEX",SUP-AH14R326S,CDM,C1769,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR BENTSON PLUS STRAIGHT TAPER 260CM 15CM .035IN",SUP-G10126,CDM,C1769,HCPCS,0272,RC,,,both,,,213.06,63.92,"MULTIPLAN [10600]",Multiplan,,181.1,85,,,,,0,24.78,181.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOUGIE 24FR OTIS A BOULE SURGICAL",SUP-51-7224,CDM,S27200284,LOCAL,0272,RC,,,both,,,416.82,125.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,283.44,68,,,,,0,48.48,354.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 180CM 120MM 4FR 3MM LOW PROFILE COAXIAL",SUP-PCP030120180,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 5MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630405,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"FIRST HEALTH [10303]","First Health",,10501.8,80,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mycoplasma Ab",PX-302000155,CDM,86738,CPT,0302,RC,,,both,,,481.65,144.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.97,,,,,,,0.01,409.4,"fee schedule",
"TOLVAPTAN 15 MG TABLET",RX-97893,CDM,,,0637,RC,49884-0768-52,NDC,both,1,UN,2123.53,637.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,251.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,246.97,1805,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 55MM 5MM KII LOW PROFILE Z THREAD BLADED",SUP-CTB21,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.90,44.37,"PHCS [10601]",PHCS,,103.53,70,,,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE 16MM 4.5MM EMBOLIZATION",SUP-PED2-450-16,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"PHCS [10601]",PHCS,,56558.25,70,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOLOIST 110CM 6FR 2-5-2MM SPACING JOSEPHSON CURVE",SUP-44216J,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 STD 10MM KNEE LEFT CRUCIATE SUB EVOLUTION MP",SUP-EIS6S10L,CDM,C1776,HCPCS,0278,RC,,,both,,,7569.30,2270.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,896.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,880.31,6433.91,"percent of total billed charges",
"HC Dest L/S Facet Jnt Add Bi",PX-510000158,CDM,64636,CPT,0361,RC,,,both,,,1990.72,597.22,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1249,1922,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 45MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4345,CDM,C1713,HCPCS,0278,RC,,,both,,,3112.50,933.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1428.64,45.9,,,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 5MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650705,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5395.3,41.1,,6417.48,6417.48,6417.48,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"BLADE 1 SMALL REVERSE CURVE 12MM ADENOTOME LAFORCE SHAMBAUGH",SUP-71-1061,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.74,49.72,"UHC [10700]","United Healthcare",,104.91,63.3,,,,,0,19.28,140.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DIL GARRETT 8.25IN",SUP-25-8015,CDM,S27200284,LOCAL,0272,RC,,,both,,,1366.71,410.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,161.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.95,1161.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 2.5CM 1MM GALAXY G3 MINI STRETCH",SUP-GLM910025,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"PHCS [10601]",PHCS,,8317.26,70,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60X4.8MM TITANIUM REGULAR THICK TISSUE",SUP-GIA6048S,CDM,S27200284,LOCAL,0272,RC,,,both,,,630.67,189.2,"MULTIPLAN [10600]",Multiplan,,536.07,85,,,,,0,73.35,536.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 12MM XTEND SPINE VARIABLE ANGLE SELF DRILL",SUP-161.012,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]",Cigna,,958.8,68,,1831.33,1831.33,1831.33,16,163.98,1198.5,"percent of total billed charges",
"SPACER ALLOGRAFT 23-27MMX13MM FRA 8D LORDOTIC NARROW WEDGE",SUP-13,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"AETNA [10100]","Aetna HMO/PPO",,15025.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE PEEP 10 CMW 22MM 10CM TRUE THRESHOLD RESISTOR ADPTR",SUP-9010B,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.67,33.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.1,95.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING 16FR 20ML SILICONE GASTROSTOMY WITH Y PORT KANG",SUP-8884720163,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.27,54.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.08,154.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VICRYL 12X12IN ABSORBABLE WOVEN FLAT HERNIA",SUP-VWML,CDM,C1781,HCPCS,0278,RC,,,both,,,5296.14,1588.84,"AETNA [10100]","Aetna HMO/PPO",,4210.43,79.5,,,,,0,615.94,4501.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRENCH EXTERNAL FIXATION T BONE SCR",SUP-M210,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",189.34,1383.8,"percent of total billed charges",
"TUBE NASOGASTRIC 43IN 8FR NASOINTESTINAL RADIOPAQUE ANTICLOG",SUP-40-9438,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.65,40.09,"KAISER [10500]",Kaiser,,89.55,67,,,,,0,15.54,113.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 42MM LCP STAINLESS STEEL CORTICAL PERIARTICULAR",SUP-02.204.042,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",114.74,838.59,"percent of total billed charges",
"IMPL BREAST 340ML GEL ROUND TEXTURED MEMORYGEL SILTEX P3.4CM",SUP-3543407MC,CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]",Cigna,,2570.4,68,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON DISECT LAPAROSCOPIC KII 100MM 12MM 1 LATERAL",SUP-C0K18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"FIRST HEALTH [10303]","First Health",,1500,80,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 12MM 5MM EMBOLIZATION BRAID SOFT DISTAL",SUP-PED-500-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"AETNA [10100]","Aetna HMO/PPO",,61175.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 39MM STAINLESS STEEL MINI FRAGMENT 4 HOLE .25 TUBULAR",SUP-242.05,CDM,C1713,HCPCS,0278,RC,,,both,,,1077.30,323.19,"CIGNA [10200]","Cigna Open Access",,612.98,56.9,,1144.80,304.56,2275.09,66,125.29,915.71,"percent of total billed charges",
"SPACER SPINAL 36X28X17MM CHESAPEAKE 15D LORDOTIC",SUP-2013-21736L15,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4061.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD REAMER 950MM 2.5MM BALL TIP STERILE DISPOSABLE",SUP-351.706S,CDM,S27200284,LOCAL,0272,RC,,,both,,,910.85,273.25,"NOVANET [10819]",Novanet,,683.14,75,,,,,0,105.93,774.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 7 POSTERIOR TOTAL STABILIZE",SUP-5543-A-700,CDM,C1776,HCPCS,0278,RC,,,both,,,6699.90,2009.97,"BLUE CROSS [10001]","Blue Cross PPO",,2626.36,39.2,,3949.44,3949.44,3949.44,"1 through 10",779.2,5694.92,"percent of total billed charges",
"HC Glucose Bld Quant",PX-301000204,CDM,82947,CPT,0301,RC,,,both,,,130.15,39.04,"FIRST HEALTH [10303]","First Health",,104.12,80,,,,,0,2.66,110.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URETEROSCOPE FLEXIBLE LITHOVUE GLOBAL REVERSE DISPOSABLE",SUP-M0067913600,CDM,C1747,HCPCS,0272,RC,,,both,,,10350.00,3105,"PHCS [10601]",PHCS,,7245,70,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 15MM RADIUS DISTAL VOLAR NONLOCK 3 LEAD TAPER",SUP-131227215,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"FIRST HEALTH [10303]","First Health",,680.4,80,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SMART CONTROL MICROMARKER 80MM 120CM 6MM VASCULAR",SUP-C06080ML,CDM,C1876,HCPCS,0278,RC,,,both,,,2812.50,843.75,"CIGNA [10200]","Cigna Open Access",,1600.31,56.9,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aldolase",PX-301000093,CDM,82085,CPT,0301,RC,,,both,,,178.25,53.47,"FIRST HEALTH [10303]","First Health",,142.6,80,,,,,0,0.01,151.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 10X5CM REPLIFORM PELVIC FLOOR ACELLULAR DERMAL",SUP-M0068202450,CDM,C1762,HCPCS,0278,RC,,,both,,,9918.09,2975.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4552.4,45.9,,,,,0,1153.47,8430.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEWIRE DISTAL SUPPORT J TIP HI TORQUE WHISPER 014IN",SUP-4586,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"MULTIPLAN [10600]",Multiplan,,963.9,85,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM 37.6MM 30MM MITRAL TRICUSPID FLEXIBLE",SUP-460030MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1349.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 12MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192012,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"BLUE CROSS [10001]","Blue Cross PPO",,9309.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",2761.95,20186.21,"percent of total billed charges",
"UPCH - TRUMATCH GL",SUP-OSC371062,CDM,C1776,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER FEMORAL 20MM MP FEMUR PROXIMAL COCRMO LEG LENGTHENER",SUP-172-950/20,CDM,C1776,HCPCS,0278,RC,,,both,,,2285.10,685.53,"MULTIPLAN [10600]",Multiplan,,1942.34,85,,,,,0,265.76,1942.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 22X9X9MM CONDUIT 12D STRAIGHT EIT ROUGH ELEVATE",SUP-PUI30902,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3297.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PICK SURGICAL 13CM 1.5MM 45D XL POWERPICK POWER TROCAR",SUP-AR-8150PX-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.01,257.7,"CIGNA [10200]","Cigna Local Plus",,459.57,53.5,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Proctoidsigmoidoscopy Diag",PX-750000145,CDM,45300,CPT,0750,RC,,,both,,,1835.00,550.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1550,,"Case rate ($1,550). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,213.41,1835,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPEL APD TWIST-LOC 20CM 8FR J DRNG FLEXITHANE METAL",SUP-H7493931008200,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"UHC [10700]","United Healthcare",,492.22,63.3,,,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 NARROW KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508006201,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3109.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH RADIALEASE LONG MULTIPURPOSE CURVE 96CM 7FR INTRO",SUP-501613A,CDM,C1894,HCPCS,0272,RC,,,both,,,246.65,73.99,"AETNA [10100]","Aetna HMO/PPO",,196.09,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.69,209.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3.33MM LARGE REGULAR PIGTAIL CURVE URETERAL",SUP-M001274050,CDM,C2617,HCPCS,0278,RC,,,both,,,1053.00,315.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,122.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 9CM 5FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22981,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"KAISER [10500]",Kaiser,,423.31,67,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 4 132D",SUP-6720-0435,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"CIGNA [10200]","Cigna Local Plus",,7548.05,31.5,,5372.07,4581.20,7242.98,23,2786.79,20367.74,"percent of total billed charges",
"PIN FIXATION 45MM 2.5MM IJS AXIS",SUP-IJS-EAP-25450,CDM,C1713,HCPCS,0278,RC,,,both,,,2212.50,663.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,262.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",257.31,1880.63,"percent of total billed charges",
"SCR BASEPLT 30MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ330,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"CIGNA [10200]","Cigna Open Access",,547.38,56.9,,5302.19,4377.88,6578.61,27,111.88,817.7,"percent of total billed charges",
"NAIL 11MM 180MM HIP TROCHANTERIC GAMMA3 INTRAMEDULLARY 125D",SUP-3125-1180S,CDM,C1713,HCPCS,0278,RC,,,both,,,9576.00,2872.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1134.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1113.69,8139.6,"percent of total billed charges",
"GWIRE TENOR VASCULAR MICRO STD ANGLE 165CM .018MM PLATINUM",SUP-TNR2811,CDM,C1769,HCPCS,0272,RC,,,both,,,1705.20,511.56,"KAISER [10500]",Kaiser,,1142.48,67,,,,,0,198.31,1449.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST SURG NON WGT BEARING RIGID DRG",SUP-L5450,CDM,L5450,HCPCS,0274,RC,,,both,,,2968.58,890.57,"MULTIPLAN [10600]",Multiplan,,2523.29,85,,,,,0,319.87,2523.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 4MM 3.25MM DORNHOFFER EAR TITANIUM ADJUSTABLE",SUP-635,CDM,L8613,HCPCS,0278,RC,,,both,,,3445.35,1033.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,400.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,232.31,2928.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Guidance Radiation Tx Sd",PX-333000061,CDM,77387,CPT,0333,RC,,,both,,,3171.03,951.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2156.3,68,,,,,0,368.79,3171.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS 6-0 RB-2 30IN 2 ARM ANTIBACTERIAL VIOLET",SUP-PDP149H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND MULTIPASS 3-0 FSL 30IN BRAID BLACK",SUP-675H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BAYONET 9IN STR TIP DN621",SUP-DN6218,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER PACING LEAD ACUITY 6FR LONG",SUP-667469-001,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTTER ENDARTERECTOMY 9MM 11MM 2 COAXIAL METAL RING",SUP-4500-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,18893.70,5668.11,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"COIL EMBOLIZATION 6CM 2MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035422060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1641.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 9 SLOT RIGHT TI",SUP-PHPF-C9R,CDM,C1713,HCPCS,0278,RC,,,both,,,21924.00,6577.2,"CIGNA [10200]",Cigna,,8769.6,40,,1831.33,1831.33,1831.33,16,2549.76,18635.4,"percent of total billed charges",
"STENT ZILVER 635 80MM 80CM 14MM 6FR .035IN BILIARY NITINOL",SUP-G36236,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"PHCS [10601]",PHCS,,2646,70,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VOLT, AGILIS 13F MED CURVE, ICE SE",SUP-K-VOLT-I-M,CDM,C1732,HCPCS,0272,RC,,,both,,,62700.00,18810,"AETNA [10100]","Aetna HMO/PPO",,49846.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X11X10MM VERTEX PEEK-OPTIMA ANATOMIC",SUP-6240041,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS [10001]","Blue Cross PPO",,2617.94,39.2,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Fetal Echo W/W/O M",PX-402000064,CDM,76825,CPT,0402,RC,,,both,,,1275.85,382.75,"KAISER [10500]",Kaiser,,854.82,67,,,,,0,148.38,1084.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DESARA TVEZ BLUE SLING SYSTEM - 2.7MM STERILE SINGLE USE 5/B",SUP-CAL-DS01BTV27,CDM,C1771,HCPCS,0278,RC,,,both,,,6334.20,1900.26,"BLUE CROSS [10001]","Blue Cross PPO",,2483.01,39.2,,,,,0,736.67,5384.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 3CM 4.8FR .035IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145353050,CDM,C2617,HCPCS,0278,RC,,,both,,,940.57,282.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,109.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,109.39,799.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TACTIFLEX ABLATION CATHETER, SENSOR ENABLED",SUP-A-TFSE-J-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8MM 12/14 TAPER 28MM HIP OXINIUM ECHELON",SUP-71342808,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"NOVANET [10819]",Novanet,,11651.51,75,,,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE WIRE GWR419478 98CM",SUP-GWR419478,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 39FR 5.3MM RIGHT CUFF RADIOPAQUE SLIGHT",SUP-126039,CDM,S27200284,LOCAL,0272,RC,,,both,,,474.09,142.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,56.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.14,402.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 15X18MM DYNANITE SUPERMX NITINOL COMPRESSION LOW",SUP-AR-8719MXDS-1815,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,3978.14,359.25,3978.14,24,2014.9,14726.25,"percent of total billed charges",
"SIZER IMPL 12.6-12.5CM NATRELLE P5.6-6.1CM HIGH PROFILE",SUP-SZHP68465,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,35.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Coxsackie Abs",PX-302000119,CDM,86658,CPT,0302,RC,,,both,,,306.80,92.04,"BLUE CROSS [10001]","Blue Cross PPO",,16.65,,"Fee schedule rate ($16.65).",,,,0,0.01,260.78,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 09.5",SUP-DIB00U0095,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,382.51,28.62,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE",RX-165066,CDM,J1447,HCPCS,0636,RC,63459-0912-18,NDC,both,.8,ML,2879.78,863.93,"UHC [10700]","United Healthcare",,235.2,,,,,,,140.96,2447.81,"fee schedule",
"SABER .035 8X80 40CM SL",SUP-48008008P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"NOVANET [10819]",Novanet,,736.6,75,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 9MM CATALYFT PL SHORT",SUP-6068093,CDM,S27800098,LOCAL,0278,RC,,,both,,,39060.00,11718,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10546.2,27,,,,,0,4542.68,33201,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE COROLENE 5-0 MULTI",SUP-20P10Z,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.03,58.51,"PHCS [10601]",PHCS,,136.52,70,,,,,0,22.68,165.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 5.5MM EXPEDIUM PREBENT TITANIUM LINE",SUP-179771040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DROXIDOPA 100 MG CAPSULE",RX-167748,CDM,,,0250,RC,31722-0014-90,NDC,both,1,UN,139.02,41.71,"KAISER [10500]",Kaiser,,93.14,67,,,,,0,16.17,118.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 180CM 8CM 6FR 15-18MM ESOPHAGUS PYLORUS",SUP-M00558371,CDM,C1726,HCPCS,0272,RC,,,both,,,1391.47,417.44,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TRUE FLOW 110CM 3.5CM 20MM 11FR PERFUSION VALVULOPLASTY",SUP-TF0203511,CDM,C1725,HCPCS,0272,RC,,,both,,,11730.00,3519,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NANOCROSS 150CM 200MM 6MM .014IN BALLOON DILATATION",SUP-AB14W060200150,CDM,C1725,HCPCS,0272,RC,,,both,,,1638.75,491.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CAP SYSTEM OXFORD TKR FEMUR TIBIA CEMENT MONOBLOCK BLADE INS",SUP-98B00200165,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 110MM 7 HOLE LOW PROFILE BONE RIGHT OLECRANON",SUP-70-0307,CDM,C1713,HCPCS,0278,RC,,,both,,,7051.80,2115.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,835.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",820.12,5994.03,"percent of total billed charges",
"CATH FLEX-NECK 62CM 5.3MM 4.5CM 3.5MM 30D SMALL DIALYSIS",SUP-CF-5450,CDM,C1750,HCPCS,0278,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT NEUROSURGICAL CSF REGULAR MEDIUM PRESSURE UNITIZED KIT",SUP-46024,CDM,S27800098,LOCAL,0278,RC,,,both,,,9284.23,2785.27,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1100.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1079.76,7891.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309015,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"AETNA [10100]","Aetna HMO/PPO",,30020.95,79.5,,10981.53,8986.79,12413.38,12,4391.74,32097.87,"percent of total billed charges",
"BASEPLT TIBIAL ATTUNE 5 KNEE CEMENTED ROTATE PLATFORM",SUP-150610005,CDM,C1776,HCPCS,0278,RC,,,both,,,16694.55,5008.36,"UHC [10700]","United Healthcare",,10567.65,63.3,,8601.07,8395.67,8601.07,"1 through 10",1941.58,14190.37,"percent of total billed charges",
"WIRE FIXATION .045IN 9IN BUSA KIRSCHNER STAINLESS STEEL FULL",SUP-KM173-39-45,CDM,C1713,HCPCS,0278,RC,,,both,,,59.29,17.79,"KAISER [10500]",Kaiser,,39.72,67,,,,,0,6.9,50.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP GLOBAL UNITE REVER",SUP-OSC379179,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"KAISER [10500]",Kaiser,,30391.2,67,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Vad Complt Tunl W Port",PX-361000118,CDM,36582,CPT,0361,RC,,,both,,,5946.72,1784.02,"FIRST HEALTH [10303]","First Health",,4757.38,80,,,,,0,691.6,5946.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 5CM 2.83MM DUODENAL BEND BILIARY",SUP-M00534260,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"KAISER [10500]",Kaiser,,729.93,67,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 4.5IN .08IN CUSA EXCEL 36KHZ STD CURVE EXTEND FLUE",SUP-C4614S,CDM,S27200284,LOCAL,0272,RC,,,both,,,8287.78,2486.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Klhl11 Antb Sr/CSF Asy Qual",PX-310000048,CDM,0432U,CPT,0310,RC,,,both,,,72.00,21.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT STRATAFIX PDS PLUS 1 OS-6 24IN VIOLET ABSORBABLE",SUP-SXPP1A203,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) TF (-T) SHEATH AND DILATOR LPINTPD-TF-ISDLP",SUP-INTPD-TF-ISDLP,CDM,C1894,HCPCS,0272,RC,,,both,,,0.01,,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,,41.1,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH URETHRAL BARDEX IC 22FR FOLEY 2 WAY COUNCIL TIP 2",SUP-0196SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.25,42.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MATRIX TISSUE AXIOFILL HUMAN PLACENTAL EXTRACELLULAR MATRIX",SUP-PCM-0250,CDM,Q4433,HCPCS,0636,RC,,,both,,,3946.80,1184.04,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PCP040200150 PLUS US D4L200UL1500",SUP-PCP040200150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PREVAIL DCB 2.00X20MM",SUP-PRV020020CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,MODERATE",351,APR-DRG,,,,,,,inpatient,,,28218.95,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,774.03. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($32,105.15) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 545CC 12.5CM 6.1CM PROJECTION HIGH PROFILE SM",SUP-SHPB545,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"CIGNA [10200]",Cigna,,5184.66,68,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 200MM REVISION COLLAR HORIZONTAL GROOVE CORAIL",SUP-L98114,CDM,C1776,HCPCS,0278,RC,,,both,,,38243.52,11473.06,"NOVANET [10819]",Novanet,,28682.64,75,,,,,0,4447.72,32506.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY 9.5IN THOMAS-GAYLOR S UTERUS",SUP-52-6610,CDM,S27200284,LOCAL,0272,RC,,,both,,,618.68,185.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,420.7,68,,,,,0,71.95,525.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM 82MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE",SUP-02.117.805,CDM,C1713,HCPCS,0278,RC,,,both,,,6336.96,1901.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2908.66,45.9,,,,,0,736.99,5386.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135MM 20MM 7FR 14MM .035IN LOW PROFILE",SUP-B2140-020,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM QUADLINK 9MM IMPL DISPOSABLE",SUP-AR-1288QAI-90,CDM,C1713,HCPCS,0278,RC,,,both,,,19785.15,5935.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5662.51,28.62,,,,,0,2301.01,16817.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH MICROBIOLOGY 1MM 1.8MM 110CM STERILE DISPOSABLE",SUP-130,CDM,S27200284,LOCAL,0272,RC,,,both,,,151.03,45.31,"CIGNA [10200]","Cigna Local Plus",,80.8,53.5,,,,,0,17.56,128.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 60MM 10MM 9FR FLUENCY PLUS CARBON EPTFE 2",SUP-FEM10060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE 25CM 2.5CM 5FR INTRO STAINLESS STEEL",SUP-RSS506,CDM,C1894,HCPCS,0272,RC,,,both,,,156.60,46.98,"AETNA [10100]","Aetna HMO/PPO",,124.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SERVICE RENTAL SYSTEM CPAP INFANT AIRLIFE",SUP-842033,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.45,61.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,84.85,41.1,,,,,0,24.01,175.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 440MM LONG LINEAR CUTTER ECHELON FLEX POWERED",SUP-PLEE45A,CDM,S27200284,LOCAL,0272,RC,,,both,,,6690.40,2007.12,"UHC [10700]","United Healthcare",,4235.02,63.3,,,,,0,778.09,5686.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BARR ADHESION 3X5IN PROC PACK BIORESORBABLE MEMB SEPRAFILM",SUP-5086-02,CDM,C1765,HCPCS,0278,RC,,,both,,,5187.63,1556.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,603.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,603.32,4409.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADHSV SKIN CLSR PURIFIED SILK FIBROIN MESH SYLKE WATER",SUP-SYL-WC-32-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"AETNA [10100]","Aetna HMO/PPO",,450.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732060,CDM,C1776,HCPCS,0278,RC,,,both,,,9510.48,2853.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4365.31,45.9,,,,,0,1106.07,8083.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 8MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158126108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"MULTIPLAN [10600]",Multiplan,,9498.37,85,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 100MM 12MM BALLOON",SUP-U35751210,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 8-0 BV130-3 5IN MONOFILAMENT BLACK NONABSORBABLE",SUP-2822G,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.37,52.31,"AETNA [10100]","Aetna HMO/PPO",,138.62,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.28,148.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE VASCULAR STRAIGHT 150CM 3CM .035IN",SUP-GS3501,CDM,C1769,HCPCS,0272,RC,,,both,,,413.25,123.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,169.85,41.1,,,,,0,48.06,351.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 8MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0278,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]","Cigna Local Plus",,507.02,53.5,,3978.14,359.25,3978.14,24,110.22,805.55,"percent of total billed charges",
"SCR BONE 4MM 17MM TITANIUM SPINAL SELF TAPPING VARIABLE",SUP-3120317,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"BLUE CROSS [10001]","Blue Cross HMO",,552.72,39.2,,957.42,156.86,7483.26,51,163.98,1198.5,"percent of total billed charges",
"INSRT TIBIAL 7 9MM KNEE BEARING CRUCIATE RETAIN TRIATHLON",SUP-5530-G-709-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]","Cigna Open Access",,6493.77,56.9,,5302.19,4377.88,6578.61,27,1327.29,9700.71,"percent of total billed charges",
"CNCT ROD 5.5MM EXPEDIUM SPINE TITANIUM CLOSED SEMIOPEN 2",SUP-179755155,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"AETNA [10100]","Aetna HMO/PPO",,2832.19,79.5,,1521.93,481.35,16760.95,30,414.32,3028.13,"percent of total billed charges",
"3.5 X 14MM SELF-DRILLING LOCKING SCREW (BLUE)",SUP-100.035.14,CDM,C1713,HCPCS,0278,RC,,,both,,,426.30,127.89,"CIGNA [10200]",Cigna,,289.88,68,,1831.33,1831.33,1831.33,16,49.58,362.36,"percent of total billed charges",
"MEPERIDINE (PF) 50 MG/ML INJECTION SUPERORDERABLE",RX-408866,CDM,J2175,HCPCS,0636,RC,00641-6053-01,NDC,both,1,ML,49.12,14.74,"CIGNA [10200]",Cigna,,21.92,,,,,,,1.7,41.75,"fee schedule",
"STENT POLARIS SENSOR DUAL-FLEX 22CM 7FR .035IN URETERAL",SUP-M006155241090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,926.66,68,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST TRICORTICAL THK9MM WEDGE ALLOGRAFT",SUP-450912,CDM,S27800098,LOCAL,0278,RC,,,both,,,5021.82,1506.55,"NOVANET [10819]",Novanet,,3766.37,75,,,,,0,584.04,4268.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 1.3FR 6-11MM OPTIFLEX SMALL",SUP-M0063903000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1652.33,495.7,"KAISER [10500]",Kaiser,,1107.06,67,,,,,0,192.17,1404.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOCKWAVE C2+ IVL CATHETER 3.5X12 MM",SUP-C2PIVL3512,CDM,C1761,HCPCS,0272,RC,,,both,,,29610.00,8883,"CIGNA [10200]","Cigna Local Plus",,15841.35,53.5,,,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 25CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR052502A,CDM,C1874,HCPCS,0278,RC,,,both,,,40635.00,12190.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16254,40,,,,,0,4725.85,34539.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 525CC NATRELLE INSPIRA COHESIVE STERILE",SUP-SCX-525,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"KAISER [10500]",Kaiser,,5062.19,67,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 31CM REPLACEMENT SPARE 30675ND SPLIT",SUP-26175NE,CDM,S27200284,LOCAL,0272,RC,,,both,,,1123.88,337.16,"MULTIPLAN [10600]",Multiplan,,955.3,85,,,,,0,130.71,955.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-FLO RENEGADE FATHOM VASCULAR 105CM 10CM .016IN",SUP-M001184500,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"UHC [10700]","United Healthcare",,2373.75,63.3,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 60MM ORTHOLOC LOCK",SUP-59215560,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,260.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,255.57,1867.88,"percent of total billed charges",
"CATH JAVELINE LITHOTRIPSY PERIPHERAL IVL CATH",SUP-JVNPIVLF,CDM,C1725,HCPCS,0272,RC,,,both,,,29610.00,8883,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3508.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE OSTEOCONDUCTIVE MATRIX DEMINERALIZED",SUP-OCMP2,CDM,C1713,HCPCS,0278,RC,,,both,,,1458.00,437.4,"FIRST HEALTH [10303]","First Health",,1166.4,80,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 40 75CM 4CM 6MM BALLOON DILATATION PERIPHERAL",SUP-CQF7564,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 65CM 25CM 5FR .047IN COBRA 2",SUP-CG502,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Observation Carve-Out Dialysis",PX-762000018,CDM,G0378,HCPCS,0762,RC,,,both,,,66.00,19.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,66,,"Per diem ($419.55). Each eligible service on a given day will be paid its own per diem rate.",18.24,8.74,22.08,113,7.68,66,"per diem",
"STENT VISI-PRO 37MM 80CM 5MM 40MM BILIARY STAINLESS STEEL",SUP-PXB35-05-37-080,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"MULTIPLAN [10600]",Multiplan,,3711.95,85,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT LARGE SOLO HIGHBACK 25",SUP-P3525916-2,CDM,S27000186,LOCAL,0270,RC,,,both,,,308.50,92.55,"CIGNA [10200]",Cigna,,209.78,68,,,,,0,35.88,262.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR ENDOSCOPIC DIA12MM L100MM NON BLADED CANNULA STABILIT",SUP-CB12LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Wnd Rmvl Tis Non-Sel (Go)",PX-430000026,CDM,97602,CPT,0430,RC,,,both,,,625.00,187.5,"BLUE CROSS [10001]","Blue Cross HMO",,625,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,72.69,625,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPREME EXTENSION CABLE RED  150 CM",SUP-401983,CDM,S27200284,LOCAL,0272,RC,,,both,,,248.00,74.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GW SUPPORTRAK VASC 100CM IS-1",SUP-6669,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BENZTROPINE 1 MG TABLET",RX-999,CDM,,,0637,RC,68084-0388-11,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER 6250V-MPX ATTAIN COMMAND",SUP-6250V-MPX,CDM,C1887,HCPCS,0272,RC,,,both,,,2602.50,780.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RETRIEVER SURGICAL 30X12MM",SUP-691.004S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Mod Sedat Endo Svc > 5y",PX-371000013,CDM,G0500,HCPCS,0371,RC,,,both,,,359.29,107.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR SPINAL 14MM 3.5MM CODA ANTERIOR CERVICAL SELF DRILL",SUP-102250014,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 FS 18IN BRAID BLACK NONABSORBABLE",SUP-685G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 8MM MREYE 2 LOOP PLATINUM ARTERIAL",SUP-G42423,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,98.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT DIALYSIS 2 PART FLEX-NECK CATH TITANIUM STERILE",SUP-CC-2300,CDM,S27200284,LOCAL,0272,RC,,,both,,,1223.10,366.93,"MULTIPLAN [10600]",Multiplan,,1039.64,85,,,,,0,142.25,1039.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO CATH GWIRE NDL SHEATH INTEGRAL HEMOSTASIS VALVE 10",SUP-AK-09903-CDC,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 6MM NESTER MICROCOIL PLATINUM ACCEPTS",SUP-G47374,CDM,S27800098,LOCAL,0278,RC,,,both,,,890.92,267.28,"CIGNA [10200]","Cigna Local Plus",,476.64,53.5,,,,,0,103.61,757.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG AUTOTRANSFUSION 400ML CARDIOPAT ORTHOPAT REPLACEMENT RBC",SUP-01200-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.68,40.4,"PHCS [10601]",PHCS,,94.28,70,,,,,0,15.66,114.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 9CM 7FR PIGTAIL CURVE PANCREATIC POLYMER",SUP-M00537280,CDM,C2617,HCPCS,0278,RC,,,both,,,722.28,216.68,"CIGNA [10200]","Cigna Open Access",,410.98,,,,,,,84,613.94,"percent of total billed charges",
"(EVAL) 5MM CATHETER",SUP-AVSPV5060,CDM,C1761,HCPCS,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE XLONG TITANIUM 14 HOLE BONE RIGHT LATERAL EPICONDYLAR",SUP-PL-LEL14R,CDM,C1713,HCPCS,0278,RC,,,both,,,6755.10,2026.53,"CIGNA [10200]",Cigna,,4593.47,68,,1831.33,1831.33,1831.33,16,785.62,5741.84,"percent of total billed charges",
"BRACE ORTHOPEDIC SHORT UNIVERSAL 17IN 36- IN KNEE 2 AXIS",SUP-79-94230,CDM,S27000186,LOCAL,0270,RC,,,both,,,363.57,109.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.28,309.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL TITAN TUBE",SUP-517770,CDM,C1813,HCPCS,0278,RC,,,both,,,31506.30,9451.89,"AETNA [10100]","Aetna HMO/PPO",,25047.51,79.5,,,,,0,3664.18,26780.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE 8X8CM BIO-A BIOABSORBABLE",SUP-FS0808,CDM,C1781,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,3096.73,1.00,3096.73,"1 through 10",348.9,2550,"percent of total billed charges",
"PROS PENILE TITAN 16CM NARROW BASE PENOSCROTAL NARROW",SUP-EN8916,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"AETNA [10100]","Aetna HMO/PPO",,49846.5,79.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING ORANGE 16IN 5FR ENTERAL POLYURETHANE HUB END",SUP-ENFPU1650LD,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.84,17.65,"KAISER [10500]",Kaiser,,39.42,67,,,,,0,6.84,50.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTMASTER 16MM 4.8MM CORONARY STENT STAINLESS STEEL",SUP-1012584-16,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4729.6,28.62,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRIMARY HIP 1",SUP-CAP-S-H-1,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"NOVANET [10819]",Novanet,,17955,75,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM GALAXY G3 XTRASOFT NEUROVASCULAR",SUP-GLX120304,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"KAISER [10500]",Kaiser,,7960.81,67,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION",RX-10734,CDM,,,0250,RC,00143-9318-01,NDC,both,4,ML,45.30,13.59,"KAISER [10500]",Kaiser,,30.35,67,,,,,0,5.27,38.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 9MM 9FR ENDOPROSTHESIS HEPARIN ILIAC",SUP-VBH090502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18566.10,5569.83,"PHCS [10601]",PHCS,,12996.27,70,,,,,0,2159.24,15781.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 80MM 135CM 8MM 160CM",SUP-M001711310,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5747.7,68,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ARTHROCELL PLUS DEMINERALIZE CORTICAL CANCELLOUS",SUP-ABS-2090-05,CDM,C1734,HCPCS,0278,RC,,,both,,,22050.00,6615,"UHC [10700]","United Healthcare",,13957.65,63.3,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERTORQUE PLUS 100CM 6FR AMPLATZ RIGHT 2 MODIFIED",SUP-533643,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SKIN PURPLE 7.5CM 15GA SMARTCLIP LITE 3-4MM SOFT",SUP-SMARTCLIPLT-PURP-7.5,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,772.74,28.62,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 47-62MM 5.5/6MM MATRIX 7 SPINE TITANIUM TRANSVERSE",SUP-04.633.347,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]",Cigna,,2422.5,68,,1831.33,1831.33,1831.33,16,414.32,3028.13,"percent of total billed charges",
"GRAFT STENT 40MM 13.5MM 10FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEL14040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross HMO",,7161.84,39.2,,9776.84,9776.84,9776.84,"1 through 10",2124.8,15529.5,"percent of total billed charges",
"SCR BONE 2.7MM 24MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0332,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross HMO",,371.5,39.2,,957.42,156.86,7483.26,51,110.22,805.55,"percent of total billed charges",
"SYSTEM PREVENA PLUS 125- MMHG NEGATIVE PRESSURE 0.019% IONIC",SUP-PRE4000US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2490.72,747.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1023.69,41.1,,,,,0,289.67,2117.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE LITHOCATCH 110CM 2.2FR 7MM STONE REMOVAL POLYIMIDE 12",SUP-M0068404120,CDM,S27200284,LOCAL,0272,RC,,,both,,,1502.39,450.72,"CIGNA [10200]","Cigna Local Plus",,803.78,53.5,,,,,0,174.73,1277.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 70MM CD HORIZON SPINE MULTIAXIAL CANNULATED",SUP-25840018570,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"(EVAL) CATHETER TURNPIKE 135CM 2.9FR 2.1FR VASCULAR GOLD MUL",SUP-5621,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT POSTERIOR STABILIZE BEAD TRIATHLON",SUP-5516F601,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"BLUE CROSS [10001]","Blue Cross HMO",,6788.24,39.2,,5311.50,4717.44,5388.59,31,2013.96,14719.4,"percent of total billed charges",
"BIT DRILL 12MM SPINE",SUP-610.712,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"AETNA [10100]","Aetna HMO/PPO",,463.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT NERVE 15MM 7MM AXOGUARD PORCINE EXTRACELLULAR MATRIX",SUP-AGX715,CDM,C1763,HCPCS,0278,RC,,,both,,,15366.30,4609.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1820.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1787.1,13061.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 49MM UNITRAX FEMORAL HIP MODULAR",SUP-6942-5-049,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1435.61,45.9,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.3/4F DECA 2-10-2 S 120CM",SUP-903221,CDM,C1730,HCPCS,0272,RC,,,both,,,6210.00,1863,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC",867,MS-DRG,,,,,,,inpatient,,,67719.49,20315.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,41552.11,,"Fee schedule rate ($41,552.11). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,52202.31,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 8MM 6MM SMALL CEMENT SURGICAL PLASTIC 2LB STERILE",SUP-OR1201,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.75,41.02,"MULTIPLAN [10600]",Multiplan,,116.24,85,,,,,0,15.9,116.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRA-THIN SDS 90CM 40MM 5.3FR 6MM STD BALLOON",SUP-M001176270,CDM,C1725,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CENTRIFUGAL PLATELET RICH PLASMA PROCESS ANGEL",SUP-976000501,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"CIGNA [10200]","Cigna Open Access",,1258.91,56.9,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 9MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530P609,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"MULTIPLAN [10600]",Multiplan,,7102.52,85,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 7.5CM 5MM LEGEND MIDAS REX SYMMETRICAL",SUP-75BA50T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1326.78,398.03,"KAISER [10500]",Kaiser,,888.94,67,,,,,0,154.3,1127.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +29 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.290,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"KAISER [10500]",Kaiser,,231.15,67,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 105MM ANTIROTATE STERILE FEMORAL NECK SYSTEM",SUP-04.168.505S,CDM,C1713,HCPCS,0278,RC,,,both,,,1642.20,492.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,753.77,45.9,,,,,0,190.99,1395.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 1.3FR 6-11MM OPTIFLEX SMALL",SUP-M0063903000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1652.33,495.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,679.11,41.1,,,,,0,192.17,1404.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 39X29X15MM INDEPENDENCE MIS 20D NONSTERILE",SUP-3135.1315,CDM,S27800098,LOCAL,0278,RC,,,both,,,30870.00,9261,"MULTIPLAN [10600]",Multiplan,,26239.5,85,,,,,0,3590.18,26239.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 25MM 2.75MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012406-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 15MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424028,CDM,C1776,HCPCS,0278,RC,,,both,,,11747.25,3524.17,"FIRST HEALTH [10303]","First Health",,9397.8,80,,,,,0,1366.21,9985.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRESSING ALGINATE 3.5IN X 8IN",SUP-423560,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.16,87.65,"AETNA [10100]","Aetna HMO/PPO",,232.27,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.98,248.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBTR SHEATH 13.5CM 5FR INFUSION PRESSURE MNTR KINK RESISTANT",SUP-502190,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.83,25.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.87,72.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM PRESTIGE PLUS HELICAL ULTRA",SUP-PRES0310CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH BLUE 10FT CARTO 3 HYPERTONICS 34 PIN TO LEMO 10",SUP-CB3410CT,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,391.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 60MM 800MM 14MM VASCULAR VENOUS",SUP-VENUM14060,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6310.71,28.62,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL MAUVE 4MM ACROMIONIZER DYONICS STRAIGHT",SUP-7205326,CDM,S27000186,LOCAL,0270,RC,,,both,,,314.00,94.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,129.05,41.1,,,,,0,36.52,266.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 4.3MM LONG CALIBRATED STERILE",SUP-03.313.701S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 35.5X5MM TITANIUM VASCULAR 30 HELICAL",SUP-174006,CDM,S27200284,LOCAL,0272,RC,,,both,,,2215.95,664.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,257.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,250.45,1883.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 6MM XIA 3 TITANIUM RADIOLUCENT",SUP-48238090,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRACTURES OF FEMUR WITHOUT MCC",534,MS-DRG,,,,,,,inpatient,,,30880.39,9264.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,12852.24,,,,,,,5000.29,20103.33,"case rate",
"BRUSH CYTOLOGY 7FR 3MM 240CM BRISTLE STERILE DISPOSABLE RED",SUP-G22108,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 60MM 36MM ALTRX HIP",SUP-122136060,CDM,C1776,HCPCS,0278,RC,,,both,,,6186.60,1855.98,"MULTIPLAN [10600]",Multiplan,,5258.61,85,,,,,0,719.5,5258.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla Class II High Def Qual",PX-302000219,CDM,86833,CPT,0302,RC,,,both,,,845.00,253.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,845,,,,,,,0.85,845,"fee schedule",
"OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC",393,MS-DRG,,,,,,,inpatient,,,33120.72,9936.22,"PHCS [10601]",PHCS,,7561,,,,,,,7561,33120.72,"per diem","Estimated amount calculated based on 5 day length of stay."
"2/0 CARDIOXYL NO PLEDGET 18MM",SUP-73P30T,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"MULTIPLAN [10600]",Multiplan,,397.61,85,,,,,0,54.4,397.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 6.5X105MM STERILE STARDRIVE RECESS CANNULATED SHO",SUP-04.353.701S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"FIRST HEALTH [10303]","First Health",,1967.52,80,,,,,0,286.03,2090.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 300MM TIBIA EXPERT INTRAMEDULLARY ROUND BARREL",SUP-04.034.340S,CDM,C1713,HCPCS,0278,RC,,,both,,,8737.47,2621.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1016.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1016.17,7426.85,"percent of total billed charges",
"SURFACE ARTICULAR 13MM PERSONA MEDIAL CONGRUENT 12 G-H KNEE",SUP-42512101013,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UHC [10700]","United Healthcare",,6821.47,63.3,,8601.07,8395.67,8601.07,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"STEM KNEE 135MM 10MM 16MM ENDO-MODEL-M CONICAL TILASTAN",SUP-15-2952/05,CDM,C1776,HCPCS,0278,RC,,,both,,,17756.24,5326.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2104.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2065.05,15092.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 11FR 2.5CM 10CM MINI GWIRE DIL PINNACLE",SUP-RSS102,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"AETNA [10100]","Aetna HMO/PPO",,62.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERAPAMIL 120 MG TABLET, IMMEDIATE RELEASE",RX-8528,CDM,,,0637,RC,00591-0345-01,NDC,both,1,UN,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 70X13.8X1.2MM SAGITTAL",SUP-6213-127-070,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR TRILOGY STD NEUTRAL 6.8MM 50/52/54MM 36MM",SUP-00630505036,CDM,C1776,HCPCS,0278,RC,,,both,,,6497.40,1949.22,"CIGNA [10200]",Cigna,,4418.23,68,,5873.17,5873.17,5873.17,"1 through 10",755.65,5522.79,"percent of total billed charges",
"IMPL FIXATION FIBERSTITCH 1.5 2-0 STRAIGHT ROTATOR CUFF",SUP-AR-19032S,CDM,C1713,HCPCS,0278,RC,,,both,,,3984.75,1195.42,"CIGNA [10200]","Cigna Local Plus",,2131.84,53.5,,3978.14,359.25,3978.14,24,463.43,3387.04,"percent of total billed charges",
"SCR BONE 7.5MM 40MM TRANSITION HA SPINE PEDICLE POLYAXIAL",SUP-152.774S,CDM,C1713,HCPCS,0278,RC,,,both,,,10791.60,3237.48,"CIGNA [10200]","Cigna Open Access",,6140.42,56.9,,1144.80,304.56,2275.09,66,1255.06,9172.86,"percent of total billed charges",
"BEARING HUMERAL 40MM COMPREHENSIVE +3MM SHOULDER VIVACIT-E",SUP-110031429,CDM,C1776,HCPCS,0278,RC,,,both,,,7755.60,2326.68,"NOVANET [10819]",Novanet,,5816.7,75,,,,,0,901.98,6592.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 5FR 67CM DEFLECTABLE REMOVABLE RADIOPAQUE",SUP-G14178,CDM,S27200284,LOCAL,0272,RC,,,both,,,796.23,238.87,"AETNA [10100]","Aetna HMO/PPO",,633,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,92.6,676.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 12CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175196180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"BLUE CROSS [10001]","Blue Cross PPO",,572.36,39.2,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 5FR 8CM CENTRAL VENOUS SPECTRUM 3 LUMEN CURVE NDL",SUP-G44013,CDM,C1751,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000105,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 30MM 1-2MM AVANCE NERVE NATURAL CONNECTION",SUP-111230,CDM,C1762,HCPCS,0278,RC,,,both,,,29288.70,8786.61,"BLUE CROSS [10001]","Blue Cross PPO",,11481.17,39.2,,,,,0,3406.28,24895.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 150CM 7FR .038IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145373170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"NOVANET [10819]",Novanet,,847.46,75,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL RFN-ADVANCED INTRAMEDULLARY POLYMER INLAY STERILE LATEX",SUP-08.233.001S,CDM,C1713,HCPCS,0278,RC,,,both,,,2409.00,722.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,280.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",280.17,2047.65,"percent of total billed charges",
"PIN FIXATION 21.6CM 3.2MM RUSH J INTRAMEDULLARY STAINLESS",SUP-00080300111,CDM,C1713,HCPCS,0278,RC,,,both,,,1275.75,382.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,151.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",148.37,1084.39,"percent of total billed charges",
"SUT ETHIBOND MULTIPASS 4-0 PS-4 18IN BRAID WHITE",SUP-X695G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 FLEXOR 30MM 125CM 8MM 5FR LOW PROFILE",SUP-G43780,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"NOVANET [10819]",Novanet,,3134.25,75,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE LOOPTIP FUSION ENDOSCOPIC 480CM 4X2MM .035IN NITINOL",SUP-G50977,CDM,C1769,HCPCS,0272,RC,,,both,,,1360.80,408.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,161.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR CHEST PROCEDURES WITH MCC",163,MS-DRG,,,,,,,inpatient,,,156478.36,46943.51,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,29051.91,,"Case rate ($27,800.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $25,815, add-ons for qualifying new technology services are included. If operating cost exceeds $58,854.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,333.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $25,849.14. The transfer operating threshold is the transfer adjustment factor * $25,815.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,951.74. The transfer capital threshold is the transfer adjustment factor * $1,951.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,10994,130850.63,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC AVALUS 21MM 400 SERIES LATEX FREE",SUP-40021,CDM,S27800098,LOCAL,0278,RC,,,both,,,33390.00,10017,"CIGNA [10200]","Cigna Local Plus",,10517.85,31.5,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM MITROFLOW BOVINE PERICARDIUM",SUP-LXA25,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 36MM TITANIUM LOCK SELF TAP AXSOS 3",SUP-661036,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"BLUE CROSS [10001]","Blue Cross HMO",,511.84,39.2,,957.42,156.86,7483.26,51,151.86,1109.86,"percent of total billed charges",
"CATH SABERX 90CM 120MM 3.5MM BALLOON DILATATION RAPID",SUP-47535120S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"MULTIPLAN [10600]",Multiplan,,1356.35,85,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 120MM 3.5MM BALLOON DILATATION RAPID",SUP-47535120S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"FIRST HEALTH [10303]","First Health",,1276.56,80,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 23MM 145CM 2.75MM CORONARY STENT",SUP-1125275-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]","Cigna Local Plus",,3123.33,53.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 18MM 9MM STD WALL THIN WALL 2 BRANCH",SUP-SBT1802D,CDM,C1768,HCPCS,0278,RC,,,both,,,8611.20,2583.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1020.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1001.48,7319.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELLIPSE NEXT GENERATION DR 36 DF4 CONNECTOR",SUP-CD2411-36Q,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"CIGNA [10200]",Cigna,,16224,40,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 4CM 200CM 2CM 5FR 8 WIRE PIN VISE",SUP-G21538,CDM,S27200284,LOCAL,0272,RC,,,both,,,2805.00,841.5,"PHCS [10601]",PHCS,,1963.5,70,,,,,0,326.22,2384.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM AZUR CX HYDROCOIL DETACHABLE LOOP",SUP-45-780202,CDM,S27800098,LOCAL,0278,RC,,,both,,,5275.05,1582.51,"KAISER [10500]",Kaiser,,3534.28,67,,,,,0,613.49,4483.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"O.R. PROCEDURES FOR OBESITY WITH MCC",619,MS-DRG,,,,,,,inpatient,,,114444.88,34333.46,"CIGNA [10200]",Cigna,,37859.59,,"Fee schedule rate ($37,859.59). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,10994,84300.53,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.180 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.180,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM CHARLOTTE CLAW FOOT HEXAGONAL LOCKING",SUP-40133522,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 70MM LCP STAINLESS STEEL PROXIMAL FEMORAL",SUP-02.205.070,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,361.55,28.62,,,,,0,146.92,1073.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICROINTRODUCER 45CM 5FR .018IN TUNGSTEN NITINOL GWIRE",SUP-H787065970535,CDM,C1894,HCPCS,0272,RC,,,both,,,268.13,80.44,"KAISER [10500]",Kaiser,,179.65,67,,,,,0,31.18,227.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR REFLECTION 20D E 50-52MM 32MM XLPE HIP",SUP-71333334,CDM,C1776,HCPCS,0278,RC,,,both,,,20487.60,6146.28,"BLUE CROSS [10001]","Blue Cross HMO",,8031.14,39.2,,5311.50,4717.44,5388.59,31,2382.71,17414.46,"percent of total billed charges",
"SCR BONE 3.5MM 46MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.846,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"FIRST HEALTH [10303]","First Health",,189.31,80,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC ARTIFICIAL 16X14MM 7MM SECURE-C SPINE ASSEMB",SUP-414.307S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"PHCS [10601]",PHCS,,4830,70,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 3MM MREYE 3.1 LOOP PLATINUM ARTERIAL",SUP-G42408,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"BLUE CROSS [10001]","Blue Cross PPO",,327.01,39.2,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX SEPRA 4.5IN MONOFILAMENT RESORBABLE",SUP-1200011,CDM,C1781,HCPCS,0278,RC,,,both,,,15810.66,4743.2,"AETNA [10100]","Aetna HMO/PPO",,12569.47,79.5,,,,,0,1838.78,13439.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 7MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640707,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]",Cigna,,7652.65,68,,5873.17,5873.17,5873.17,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"INSRT ARTICULAR 3-4 15MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934384,CDM,C1776,HCPCS,0278,RC,,,both,,,18947.25,5684.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2203.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2203.57,16105.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER HUMERAL INSPACE LARGE",SUP-0132,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4479.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 40MM 10MM 8.5FR .035IN BILIARY RAPID EXCHANGE",SUP-M00570890,CDM,C1876,HCPCS,0278,RC,,,both,,,11927.41,3578.22,"CIGNA [10200]","Cigna Local Plus",,3757.13,31.5,,,,,0,1387.16,10138.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BROW FIXATION 3.5MM ENDOTINE TRANSBLEPH UPPER EYELID",SUP-CFD-080-0167,CDM,S27800098,LOCAL,0278,RC,,,both,,,2475.00,742.5,"NOVANET [10819]",Novanet,,1856.25,75,,,,,0,287.84,2103.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 32MM DARCO FULL THREAD HEAD",SUP-777453202,CDM,C1713,HCPCS,0278,RC,,,both,,,1740.00,522,"CIGNA [10200]","Cigna Local Plus",,930.9,53.5,,3978.14,359.25,3978.14,24,202.36,1479,"percent of total billed charges",
"KNEE CONSTRUCT 1",SUP-CAP-MI-K-1,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"MULTIPLAN [10600]",Multiplan,,14994,85,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 235CC P3.1CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-235,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS [10001]","Blue Cross HMO",,2961.76,39.2,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 22CM 8FR .038",SUP-M006192151120,CDM,C2617,HCPCS,0278,RC,,,both,,,1487.32,446.2,"KAISER [10500]",Kaiser,,996.5,67,,,,,0,172.98,1264.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE WATCHMAN FXD CURVE 15FR 12FR CLSR 2 CURVE ACCESS",SUP-M635TU80020,CDM,C1894,HCPCS,0272,RC,,,both,,,6900.00,2070,"NOVANET [10819]",Novanet,,5175,75,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT NERVE 15MM 5MM AXOGUARD PORCINE EXTRACELLULAR MATRIX",SUP-AGX515,CDM,C1763,HCPCS,0278,RC,,,both,,,15366.30,4609.89,"AETNA [10100]","Aetna HMO/PPO",,12216.21,79.5,,,,,0,1787.1,13061.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS STREAMLINE 15MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-M003SFD040150,CDM,C1874,HCPCS,0278,RC,,,both,,,85681.49,25704.45,"CIGNA [10200]","Cigna Local Plus",,26989.67,31.5,,,,,0,9964.76,72829.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.45MM 2 1.5MM JUGGERKNOT MAXBRAID 1 LOAD RIGID",SUP-CM-99145BRN,CDM,C1713,HCPCS,0278,RC,,,both,,,3450.00,1035,"CIGNA [10200]",Cigna,,2346,68,,1831.33,1831.33,1831.33,16,401.24,2932.5,"percent of total billed charges",
"RTRCTR 13X5IN RIBBON 2 END MALLEABLE STAINLESS STEEL SPINE",SUP-22-0259,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.55,68.56,"FIRST HEALTH [10303]","First Health",,182.84,80,,,,,0,26.58,194.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.5MM 105MM AFFIXUS 6.5MM HIP LAG STERILE",SUP-814510105,CDM,C1713,HCPCS,0278,RC,,,both,,,6417.00,1925.1,"FIRST HEALTH [10303]","First Health",,5133.6,80,,,,,0,746.3,5454.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER GRAFT PLUNGER GRADUATED 100ML REAMER IRR ASPIR",SUP-352.229S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2310.60,693.18,"PHCS [10601]",PHCS,,1617.42,70,,,,,0,268.72,1964.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .62IN 5FR .056IN AR2",SUP-5561120L,CDM,C1713,HCPCS,0278,RC,,,both,,,417.60,125.28,"CIGNA [10200]","Cigna Local Plus",,223.42,53.5,,3978.14,359.25,3978.14,24,48.57,354.96,"percent of total billed charges",
"COIL EMBOLIZATION 10CM 5MM .0115IN AXIUM PRIME HELICAL",SUP-APB-5-10-HX-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,7169.10,2150.73,"FIRST HEALTH [10303]","First Health",,5735.28,80,,,,,0,833.77,6093.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 5.5MM CREO CURVE TITANIUM NONSTERILE",SUP-1119.7055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"AUG FEMORAL 15MM TRIATHLON 6 RIGHT DISTAL KNEE",SUP-5542-A-602,CDM,C1776,HCPCS,0278,RC,,,both,,,6011.46,1803.44,"CIGNA [10200]",Cigna,,4087.79,68,,5873.17,5873.17,5873.17,"1 through 10",699.13,5109.74,"percent of total billed charges",
"SUT SILK PERMA HAND SUTUPAK 1 24IN BRAID TIES 13 STRAND",SUP-SA77G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-02002,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"BLUE CROSS [10001]","Blue Cross PPO",,4054.5,39.2,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 20CM 6FR .035",SUP-M006192130090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"FIRST HEALTH [10303]","First Health",,1193.94,80,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE SINGLE DIAMOND TIP WITH STOP 1.5MM X 229MM",SUP-KWIR-SD-15229,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7605,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"FIRST HEALTH [10303]","First Health",,5520,80,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7605,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"AMERIGROUP MEDICAID [20100]",Amerigroup,,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 3CM 5FR ADVANIX NAVIFLEX STRAIGHT PANCREATIC",SUP-M00537500,CDM,C2625,HCPCS,0272,RC,,,both,,,1411.18,423.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 11GA 7.8CM TRUGUIDE COAXIAL DISPOSABLE",SUP-C1210A,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.14,31.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DIREXION HI-FLO TRANSEND 130CM 165CM 2.8FR .018IN MICRO",SUP-M001195940,CDM,C1887,HCPCS,0272,RC,,,both,,,6382.50,1914.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GARM FACIAL LARGE SPRT ELASTIC FACIOPLASTY",SUP-111827,CDM,S27000186,LOCAL,0270,RC,,,both,,,366.53,109.96,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE TRACH 4 62MM 9.4MM SHILEY CUFF DISPOSABLE INNER CANN",SUP-4CN65H,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.97,110.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL SPINAL 5IN 20GA INTERSTIM FORAMEN OPAQUE HUB LOCK STYLET",SUP-041829,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ROD SPINAL 50MM 6MM XIA 3 TITANIUM RADIOLUCENT",SUP-48238050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"SABER .035 10X20 40CM SL",SUP-48010002P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,116.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 84MM X25 LOCK LOW PROFILE STERILE",SUP-04.045.084S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 75CM 40MM 4MM BALLOON DILATATION DRUG COATED",SUP-LX3575440V,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"PHCS [10601]",PHCS,,4709.25,70,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Di-Dak Sol Pint",PX-HHE27000224,CDM,HHE27000224,LOCAL,0270,RC,,,outpatient,,,70.00,21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,47.6,68,,,,,0,8.14,59.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X5MM VERTE-STACK HYDROSORB PEEK ANATOMIC",SUP-6241041,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"AETNA [10100]","Aetna HMO/PPO",,5309.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 51MM 1.5MM 6 FLUTE STRAIGHT ORAL CARBIDE",SUP-04-C0306,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.21,18.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25.57,41.1,,,,,0,7.24,52.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 145MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.424,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"KAISER [10500]",Kaiser,,927.37,67,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 40MM 6MM BALLOON",SUP-U357564,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LONG SURGICAL 8-11MM NAIL STERILE",SUP-03.043.008S,CDM,S27200284,LOCAL,0272,RC,,,both,,,795.02,238.51,"KAISER [10500]",Kaiser,,532.66,67,,,,,0,92.46,675.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 2.75MM CORONARY STENT",SUP-H7493941820270,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM NARROW BLADE RAMP 5.5",SUP-7541143,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,,1521.93,481.35,16760.95,30,348.9,2550,"percent of total billed charges",
"IMPL BREAST 235ML SMOOTH MEMORYGEL SILICONE MALE P2.9CM","SUP-3507235 MC",CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"KAISER [10500]",Kaiser,,2391.9,67,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT CLEARVUE AIRGUARD",SUP-1608362,CDM,C1788,HCPCS,0278,RC,,,both,,,2887.50,866.25,"FIRST HEALTH [10303]","First Health",,2310,80,,,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE 10 MG/ML INJECTION SOLUTION",RX-5168,CDM,J2272,HCPCS,0636,RC,63323-0451-00,NDC,both,1,ML,52.82,15.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13.2,,,,,,,6.26,44.9,"fee schedule",
"CATH ROTALINK 135CM 2.38MM ATHERECTOMY BURR",SUP-H749393002380,CDM,C1724,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repo Perc Vad Sep Session",PX-361000286,CDM,33993,CPT,0361,RC,,,both,,,2181.37,654.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2181.37,,"Case rate ($5,284). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,253.69,2181.37,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 44MM TI",SUP-SPL-35440-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 40MM 80CM 10MM 6FR VASCULAR NITINOL",SUP-G43866,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,447.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED + VE",SUP-98000200485,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"NOVANET [10819]",Novanet,,18427.5,75,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Oxydronate Up to 30mci",PX-343000037,CDM,A9561,HCPCS,0343,RC,,,both,,,180.00,54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,153,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pudendal Electrode",PX-E27000201,CDM,E27000201,LOCAL,0270,RC,,,both,,,103.40,31.02,"AETNA [10100]","Aetna HMO/PPO",,82.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.03,87.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 80MM 5MM BALLOON DILATATION DURALYN",SUP-48005008X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRSP LAPAROSCOPIC RATCHET HANDLE INSULATED SHAFT ROTATION",SUP-5BB,CDM,S27200284,LOCAL,0272,RC,,,both,,,702.00,210.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH XPRESS-WAY 140CM 10MM 5.1FR 6FR .014IN EXTRACTION",SUP-T2R6SA4A,CDM,C1757,HCPCS,0272,RC,,,both,,,2437.50,731.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1657.5,68,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUBICON 150CM SPRT CONTROL STERILE DISPOSABLE ACCEPTS",SUP-H749394321415A0,CDM,C1887,HCPCS,0272,RC,,,both,,,1987.50,596.25,"AETNA [10100]","Aetna HMO/PPO",,1580.06,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,231.15,1689.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 15MM",SUP-SPL15015X,CDM,C1725,HCPCS,0272,RC,,,both,,,546.75,164.02,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,63.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,63.59,464.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 12MM 135CM 6.5MM 3.3-3.5FR 6FR LOW",SUP-1011502-12,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"FIRST HEALTH [10303]","First Health",,5040,80,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 18MM 140CM 2.5MM 2.1-2.7FR CORONARY",SUP-RONYX25018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,439.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHORD-X 2-0 .5 CIRCLE 18MM 2 ARM LOOP PLEDG 3 CHORDAL 20",SUP-CXL-20-1812-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR AEROSOL VAPOTHERM PRECISION FLOW AEROGEN LATEX FREE",SUP-AAA-1,CDM,S27000186,LOCAL,0270,RC,,,both,,,83.52,25.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.71,70.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 27MM 4MM BALLOON DILATATION DURATRAC",SUP-NCEUP4027X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AETNA [10100]","Aetna HMO/PPO",,450.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KETAMINE 10 MG/ML INJECTION SOLUTION SUPERORDERABLE",RX-408817,CDM,,,0250,RC,55150-0438-01,NDC,both,20,ML,207.45,62.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,95.22,45.9,,,,,0,24.13,176.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBTR ENDOSCOPIC SCHMIEDT TUBING INSRT 27040BO 27042B BZ",SUP-27050BK,CDM,S27200284,LOCAL,0272,RC,,,both,,,4963.58,1489.07,"PHCS [10601]",PHCS,,3474.51,70,,,,,0,577.26,4219.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 20MM 2.75MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012406-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.2MM 2-0 3/8 CIRCLE MICRO FULL THREAD TAPER",SUP-AR-1318FT,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1526.18,68,,,,,0,261.02,1907.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX29MM 8FR 135CMCATH HEPARIN",SUP-BXB092902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7801.92,40,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol D5 Lactated Ringer",PX-E27200285,CDM,E27200285,LOCAL,0272,RC,,,both,,,122.10,36.63,"PHCS [10601]",PHCS,,85.47,70,,,,,0,14.2,103.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM XIA SERRATO SPINE POLYAXIAL NONSTERILE 3",SUP-482616550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"SOL INTRAVENOUS 5% DEXTROSE 0.225% SODIUM CHLORIDE 1L",SUP-792409,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"MULTIPLAN [10600]",Multiplan,,68.85,85,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 3.5MM PRECUT",SUP-3603740,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"SPACER SPINAL 40X18X7MM RISE 3-15D",SUP-193.502,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"KAISER [10500]",Kaiser,,23004.45,67,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 9 HIGH OFFSET HIP",SUP-71935581,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,14613.48,40,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 20MM 5MM .035IN BALLOON DILATATION NYBAX",SUP-H74939171050270,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UHC [10700]","United Healthcare",,743.46,63.3,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemoglobin Electrophoresis",PX-301000223,CDM,83020,CPT,0301,RC,,,both,,,218.00,65.4,"UHC [10700]","United Healthcare",,11.58,,,,,,,0.01,185.3,"fee schedule",
"ARTOURA BREAST TISSUE EXPANDER HIGH PROJECTION 500 CC",SUP-TEXP135RH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"KAISER [10500]",Kaiser,,9222.89,67,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL PERIPHERAL SCR",SUP-750510105,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"PHCS [10601]",PHCS,,532.98,70,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vrtplsty Lumb/Sac W Img",PX-361000376,CDM,22511,CPT,0361,RC,,,both,,,9378.00,2813.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6891,,"Case rate ($6,891). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1090.66,9378,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL BAND RAPIDPORT EZ ACCESS PORT ADJUSTABLE LAP-BAND AP",SUP-C-20390,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"AMERIGROUP MEDICAID [20100]",Amerigroup,,213.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -2.5MM 36MM HIP BIOLOX DELTA V40",SUP-6570-0-436,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"UHC [10700]","United Healthcare",,6330,63.3,,8601.07,8395.67,8601.07,"1 through 10",1163,8500,"percent of total billed charges",
"AUG FEMORAL 10MM TRIATHLON 8 KNEE LEFT DISTAL TOTAL",SUP-5541-A-801,CDM,C1776,HCPCS,0278,RC,,,both,,,6699.90,2009.97,"CIGNA [10200]","Cigna Open Access",,3812.24,56.9,,5302.19,4377.88,6578.61,27,779.2,5694.92,"percent of total billed charges",
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 9MM COCR",SUP-VAL-25090-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"MULTIPLAN [10600]",Multiplan,,1211.76,85,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 80MM 22-14MM 15MM 12FR TRIVASCULAR OVATION PRIME",SUP-TV-IL142280-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3883.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 6.35MM TSRH-3D TITANIUM PREBENT PRECUT",SUP-8371040,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,512.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 28MM 3.25MM CORONARY STENT EVEROLIMUS",SUP-1550325-28,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +16.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.165,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRESSING ANTIMICROBIAL 3.5 X 12 INCH AQUACEL AG ADVANTAGE",SUP-422606,CDM,S27200284,LOCAL,0272,RC,,,both,,,325.56,97.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,133.81,41.1,,,,,0,37.86,276.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 6FR EBU3.75 CURVE GUIDING NYLON CORONARY",SUP-LA6EBU375A,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 70MM 6MM DISTAFLO SMALL BEAD MINI CUFF",SUP-DFX7006SC,CDM,C1768,HCPCS,0278,RC,,,both,,,15906.23,4771.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1849.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1849.89,13520.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 36MM FLEX +9MM POLYETHYLENE",SUP-DWF362B,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"CIGNA [10200]",Cigna,,6139.04,68,,5873.17,5873.17,5873.17,"1 through 10",1049.96,7673.8,"percent of total billed charges",
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 2.5MM CORONARY STENT",SUP-H7493941820250,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTFR BIOPSY SITE CELEROMARK DISPOSABLE",SUP-CELEROMARK,CDM,A4648,HCPCS,0278,RC,,,both,,,628.56,188.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,74.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.1,534.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 1 TP-1 54IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z879G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION",RX-10325,CDM,Q9966,HCPCS,0636,RC,00270-1411-25,NDC,both,20,ML,300.00,90,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15.6,,,,,,,15.6,255,"fee schedule",
"CATH PCP070120150 PLUS US D7L120UL1500",SUP-PCP070120150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,837.22,68,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - TIBIAL KIT (CR) - SIZE 2",SUP-5555-2322,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.5X80MM LORDOSED ROD",SUP-30100-080,CDM,S27800098,LOCAL,0278,RC,,,both,,,1410.00,423,"BLUE CROSS [10001]","Blue Cross HMO",,552.72,39.2,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +2.5MM 26MM HIP C TAPER INTERLOK COCR LFIT",SUP-S-1400-HH62,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,370.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,363.75,2658.55,"percent of total billed charges",
"SUT PLAIN 2-0 CT 27IN MONOFILAMENT ABSORBABLE",SUP-853H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD + VE",SUP-98000700015,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2930.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS 75CM 4CM 16MM 8FR BALLOON DILATATION PERIPHERAL",SUP-AT75164,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH COYOTE 150CM 120MM 4MM BALLOON DILATATION NYBAX",SUP-H74939186401210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 65CM 1MM 6FR 2-8-2MM SPACING D CURVE ELECTROPHYSIOLOGY",SUP-D6A10DRP10RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRKT SUCTION CANSTR 9.5IN GUARDIAN RING PREATTACH TUBE 1200",SUP-65652-173,CDM,S27000186,LOCAL,0270,RC,,,both,,,75.43,22.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE .4MM UNIVERSAL NEURO III RECTANGLE",SUP-53-34300,CDM,C1713,HCPCS,0278,RC,,,both,,,2249.63,674.89,"BLUE CROSS [10001]","Blue Cross HMO",,881.85,39.2,,957.42,156.86,7483.26,51,261.63,1912.19,"percent of total billed charges",
"APPLR SURGICAL 22CM COSEAL 2 LUMEN MALLEABLE SEAL EXTEND",SUP-934034,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.79,104.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,41.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.56,296.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST TRICORTICAL THK25-30MM WEDGE",SUP-450914,CDM,S27800098,LOCAL,0278,RC,,,both,,,7828.74,2348.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3593.39,45.9,,,,,0,910.48,6654.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 34MM LCP STAINLESS STEEL METATARSAL LOCKING",SUP-02.211.034,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"MULTIPLAN [10600]",Multiplan,,763.41,85,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS 17.0 DIOPTER",SUP-MTA3UO170,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK ULTRA 28MM 4.5MM CORONARY STENT XCELON",SUP-1003381-28,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Open Access",,1707,56.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 19MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-019,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"BLUE CROSS [10001]","Blue Cross PPO",,8330.31,39.2,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 1.7CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-24-1.7,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CIGNA [10200]","Cigna Local Plus",,416.8,53.5,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FUZEFIX MAX FT OD3 MM CALIBRATE CANNULATED NO",SUP-CD-FT-1030,CDM,S27000186,LOCAL,0270,RC,,,both,,,2130.00,639,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1448.4,68,,,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 20CM 3CM 7FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006180230050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"BLUE CROSS [10001]","Blue Cross PPO",,408.3,39.2,,,,,0,121.14,885.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 26MM PERSONA VIVACIT-E ALL POLY KNEE STERILE",SUP-42-5402-000-26,CDM,C1776,HCPCS,0278,RC,,,both,,,5322.66,1596.8,"CIGNA [10200]","Cigna Local Plus",,2847.62,53.5,,5372.07,4581.20,7242.98,23,619.03,4524.26,"percent of total billed charges",
"REVISION OF HIP OR KNEE REPLACEMENT WITH CC",467,MS-DRG,,,,,,,inpatient,,,134114.11,40234.23,"AETNA [10100]","Aetna HMO/PPO",,66352.98,,"Fee schedule rate ($66,352.98). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,21875.71,102962.61,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 8CM 2.9MM STERLING LARGE SPHERE SMALL JOINT",SUP-C9911A,CDM,S27200284,LOCAL,0272,RC,,,both,,,638.28,191.48,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,262.33,41.1,,,,,0,74.23,542.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM XIA SERRATO SPINE POLYAXIAL NONSTERILE 3",SUP-482616540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"STENT ZILVER 100MM 120CM 14MM BILIARY VENA CAVA OTW DELIVERY",SUP-G57451,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"CIGNA [10200]","Cigna Open Access",,4854.15,33.5,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE WEDGE ALLOGRAFT IMPACT 26MMX10MM",SUP-161026,CDM,S27800098,LOCAL,0278,RC,,,both,,,12572.49,3771.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5029,40,,,,,0,1462.18,10686.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 3.5IN 18GA 27GA PERIFIX ESPOCAN PENCAN TUOHY",SUP-333194,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.07,83.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,127.63,45.9,,,,,0,32.34,236.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Manual Ea 15min (Gp)",PX-420000026,CDM,97140,CPT,0420,RC,,,both,,,276.79,83.04,"BLUE CROSS [10001]","Blue Cross PPO",,276.79,,"Per diem ($371.22).",,,,0,32.19,276.79,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Blood Typing Ag",PX-302000194,CDM,86902,CPT,0302,RC,,,both,,,499.20,149.76,"MULTIPLAN [10600]",Multiplan,,424.32,85,,,,,0,0.01,424.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.2MM STRAIGHT CANNULATED 5MM SCR DISPOSABLE",SUP-AR-8750-04,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"FIRST HEALTH [10303]","First Health",,1134,80,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TITAN ZERO DEGREE - INFRAPUBIC  ZERO ANGLE CYLINDER/PUMP SE",SUP-ES8824,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]","Cigna Local Plus",,19750.5,31.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ammonia",PX-301000104,CDM,82140,CPT,0301,RC,,,both,,,293.80,88.14,"CIGNA [10200]","Cigna Local Plus",,32.05,,,,,,,0.29,249.73,"fee schedule",
"CATH EZ STEER THERMOCOOL 115CM 3.5MM 7.5FR 2-5-2MM SPACE F-F",SUP-BDI75TCFFRT,CDM,C2630,HCPCS,0272,RC,,,both,,,10626.00,3187.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1259.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1235.8,9032.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nephrostomy W Drainage",PX-361000341,CDM,50040,CPT,0361,RC,,,both,,,7683.79,2305.14,"CIGNA [10200]","Cigna Local Plus",,6044,,"Case rate ($6,044). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,893.62,7680,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER RP 360 DEGREE FLEXIBLE NDL SUT DISPOSABLE",SUP-3910900091,CDM,S27200284,LOCAL,0272,RC,,,both,,,1125.90,337.77,"AETNA [10100]","Aetna HMO/PPO",,895.09,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,130.94,957.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 50CMX.49MM 18/9MM HEMAGARD 2 BRANCH",SUP-HGK1809,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 13CM 8FR CHECK-FLO PERFORMER SIDEARM FITTING SIDE",SUP-G07432,CDM,C1894,HCPCS,0272,RC,,,both,,,139.90,41.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Drsg Wound Mepitel One 10x6in",PX-HHE27200402,CDM,HHE27200402,LOCAL,0270,RC,,,outpatient,,,118.00,35.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASKET STONE RETRIEVAL 2.5CM 1.8CM 8.5FR WITTICH BILIARY",SUP-G07313,CDM,S27200284,LOCAL,0272,RC,,,both,,,3682.43,1104.73,"UHC [10700]","United Healthcare",,2330.98,63.3,,,,,0,428.27,3130.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KT INTRO 13CM 10FR SFSHTH",SUP-6268,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"AETNA [10100]","Aetna HMO/PPO",,69.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CROSSFLOW INTEGRATED CASSETTE TUBING",SUP-450000300,CDM,S27000186,LOCAL,0270,RC,,,both,,,637.20,191.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,261.89,41.1,,,,,0,74.11,541.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 20MM STARDRIVE STAINLESS STEEL PROXIMAL FEMORAL",SUP-212.204,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,400.79,45.9,,,,,0,101.55,742.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 3MM BALL DISSECTING STERILE DISPOSABLE",SUP-MR8-14BA30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.19,388.56,"MULTIPLAN [10600]",Multiplan,,1100.91,85,,,,,0,150.63,1100.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP INTERNAL HULKA VESSEL STERILE",SUP-4986.09,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.48,103.04,"KAISER [10500]",Kaiser,,230.13,67,,,,,0,39.95,291.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 6MM ENDOWRIST SP CADIERE NONSTERILE LATEX",SUP-431300,CDM,S27000186,LOCAL,0270,RC,,,both,,,2063.40,619.02,"CIGNA [10200]","Cigna Open Access",,1174.07,56.9,,,,,0,239.97,1753.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR STD AMPLATZ LEFT CORONARY",SUP-534545T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"CIGNA [10200]","Cigna Open Access",,53.22,56.9,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR .056IN IM CURVE ANGIOGRAPHIC",SUP-H749165992010,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"AETNA [10100]","Aetna HMO/PPO",,60.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HIP HYBRID AND DISP",SUP-98000100224,CDM,C1776,HCPCS,0278,RC,,,both,,,32760.00,9828,"CIGNA [10200]",Cigna,,13104,40,,5873.17,5873.17,5873.17,"1 through 10",3809.99,27846,"percent of total billed charges",
"GRAFT SKIN 4CMX2CMX.2-.4MM DERMAMATRIX ACELLULAR DERMAL",SUP-19407,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 10MM 3.2-2.4-2.6FR 2.5MM BALLOON",SUP-SPR2510W,CDM,C1725,HCPCS,0272,RC,,,both,,,631.80,189.54,"KAISER [10500]",Kaiser,,423.31,67,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 116MM PRIMARY ANTHOLOGY POROUS 131D 9 STD",SUP-71356009,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9485,28.62,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBRANT 15CC 12MM OPEN ALLOGRAFT 2 LEVEL PAK",SUP-IFLX-FBG-LG-DC,CDM,S27800098,LOCAL,0278,RC,,,both,,,39690.00,11907,"FIRST HEALTH [10303]","First Health",,31752,80,,,,,0,4615.95,33736.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HEARTSTRING III 4.3MM PROXIMAL SEAL AORTIC CUTTER",SUP-HSK-3043,CDM,S27200284,LOCAL,0272,RC,,,both,,,3809.28,1142.78,"AETNA [10100]","Aetna HMO/PPO",,3028.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,443.02,3237.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 30MM AXSOS STAINLESS STEEL 3.5MM FULL THREAD",SUP-340630,CDM,C1713,HCPCS,0278,RC,,,both,,,255.78,76.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,73.2,28.62,,,,,0,29.75,217.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 4965-25 UNIPOLAR",SUP-4965-25,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross HMO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM TRIFECTA TISSUE ANNULUS",SUP-TF-23A,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ORTHOBLAST II CANCELLOUS DEMINERALIZED BONE",SUP-02-2110-050,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,436.13,3187.5,"percent of total billed charges",
"(EVAL) PREVAIL DCB 3.0X25MM",SUP-PRV030025CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MILL BONE BIOPSY MEDIUM STERILE DISPOSABLE",SUP-5420-MED-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,4122.97,1236.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1694.54,41.1,,,,,0,479.5,3504.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 120MM 3.8FR 3MM BALLOON DILATATION",SUP-H74939148301210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION",RX-105640,CDM,J0665,HCPCS,0636,RC,00409-1162-19,NDC,both,30,ML,24.24,7.27,"UHC [10700]","United Healthcare",,6,,,,,,,2.87,20.6,"fee schedule",
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 15MM 6FR 4.5MM",SUP-H7493926715450,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 62.5MM KNEE LEFT CRUCIATE RETAIN CEMENT",SUP-183066,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2868.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2814.85,20572.84,"percent of total billed charges",
"SHELL ACETABULAR 52MM HIP LIMIT HOLE FIN RINGLOC+ 23 STERILE",SUP-16-104152,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"CIGNA [10200]",Cigna,,4785.84,68,,5873.17,5873.17,5873.17,"1 through 10",818.52,5982.3,"percent of total billed charges",
"IMPL HIP STEM 96MM NK 33.5MM INSIGNIA 1 HIGH STEM HIGH",SUP-7000-6601,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"BLUE CROSS [10001]","Blue Cross PPO",,11984.97,39.2,,3949.44,3949.44,3949.44,"1 through 10",3555.74,25987.82,"percent of total billed charges",
"IMPL BREAST 350ML P3.9CM MODERATE PLUS PROFILE HIGH",SUP-350-3501BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3565.92,68,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY SHARP JAW RADIOPAQUE 50CM 5.5FR 1.85MM STAINLESS",SUP-504302,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25MM 81.5MM THK1.27MM WIDE STAINLESS STEEL",SUP-2108189000,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"UHC [10700]","United Healthcare",,151.34,63.3,,,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 152MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-226.581,CDM,C1713,HCPCS,0278,RC,,,both,,,3099.60,929.88,"CIGNA [10200]",Cigna,,2107.73,68,,1831.33,1831.33,1831.33,16,360.48,2634.66,"percent of total billed charges",
"SYSTEM WATCHMAN TRUSTEER 2 CURVE 17FR 12FR ACCESS PEBAX PTFE",SUP-M635TU90050,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1203.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 2MM STAINLESS STEEL QUICK COUPLING",SUP-310.21,CDM,S27000186,LOCAL,0270,RC,,,both,,,519.37,155.81,"CIGNA [10200]","Cigna Open Access",,295.52,56.9,,,,,0,60.4,441.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 95CM 3.9-5.2FR 2.6FR 4CM SPACE LEFT VENTRICULAR",SUP-4672,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"MULTIPLAN [10600]",Multiplan,,4765.95,85,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR HYPERTRONICS 115CM 4MM 7FR 1-7-4MM SPACE C",SUP-NS7TCCL174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1627.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 87/91MMX10MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183680,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"MULTIPLAN [10600]",Multiplan,,11210.36,85,,,,,0,1533.84,11210.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM PFC SIGMA TC3 2.5 KNEE LEFT TITANIUM",SUP-960840,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"FIRST HEALTH [10303]","First Health",,4104.67,80,,,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION",RX-1649,CDM,J3230,HCPCS,0636,RC,00641-1397-31,NDC,both,1,ML,226.52,67.96,"FIRST HEALTH [10303]","First Health",,181.22,80,,,,,0,9.53,192.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC IV Push Init Drug",PX-260000007,CDM,96374,CPT,0260,RC,,,both,,,452.19,135.66,"PHCS [10601]",PHCS,,316.53,70,,,,,0,52.59,452.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROMETHAZINE 25 MG TABLET",RX-6622,CDM,Q0169,HCPCS,0250,RC,68084-0155-11,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 8IN STAINLESS STEEL 4.5MM SCREWS 7 HOLE 8 GROOVE",SUP-3704-3-110,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"AMERIGROUP MEDICAID [20100]",Amerigroup,,266.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",261.68,1912.5,"percent of total billed charges",
"HC Prekallikrein",PX-305000028,CDM,85292,CPT,0305,RC,,,both,,,1164.00,349.2,"FIRST HEALTH [10303]","First Health",,931.2,80,,,,,0,0.01,989.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD GLENOID 36MM UNIVERS REVERS +2.5MM SMALL UNIVERSAL",SUP-AR-9504S-02,CDM,C1776,HCPCS,0278,RC,,,both,,,34473.60,10342.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13789.44,40,,,,,0,4009.28,29302.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE RIGHT POSTERIOR STABILIZE BEAD",SUP-5516F202,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"KAISER [10500]",Kaiser,,11602.35,67,,,,,0,2013.96,14719.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG LEAD DF-1 PORT",SUP-6996,CDM,S27800098,LOCAL,0278,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross HMO",,119.36,39.2,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 4.5MM 65MM T7 CORTEX SELF RETAINING SCRDRVR",SUP-72402765,CDM,C1713,HCPCS,0278,RC,,,both,,,456.52,136.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,53.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",53.09,388.04,"percent of total billed charges",
"GRAFT ENDOVASCULAR 16CM 28.5MM 14.5MM 24-26MM 12-13.5MM GORE",SUP-RLT281416,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"NOVANET [10819]",Novanet,,47025,75,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE .4MM UNIVERSAL NEURO III SMALL BOX",SUP-53-34228,CDM,C1713,HCPCS,0278,RC,,,both,,,1597.00,479.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",185.73,1357.45,"percent of total billed charges",
"GRAFT SOFT TISSUE 3.5X3.5CM AMNIOGRAFT THK50-100UM C",SUP-AG-3535,CDM,V2790,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"KAISER [10500]",Kaiser,,5663.18,67,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Suprvlv Aortography Si",PX-481000042,CDM,93567,CPT,0481,RC,,,both,,,3354.24,1006.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3354.24,,"Case rate ($6,079.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,390.1,3354.24,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 9.5CM 16MM 13.5-14.5MM EXCLUDER",SUP-PLC161000,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"CIGNA [10200]","Cigna Local Plus",,8819.12,31.5,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 13MM HELIX R SPINE SELF DRILL FIX ANGLE",SUP-7802213,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM CARPENTIER-EDWARDS PERIMOUNT MAGNA",SUP-3000TFX19MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"UHC [10700]","United Healthcare",,20318.35,63.3,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 6MM EMBOLD PLATINUM TUNGSTUN NITINOL",SUP-M001394240060200,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"BLUE CROSS [10001]","Blue Cross HMO",,2672.34,39.2,,,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH LONG 95CM .079IN 10.7FR INTRO RADIAL",SUP-107F-079-95,CDM,C1894,HCPCS,0272,RC,,,both,,,8093.70,2428.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,941.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,941.3,6879.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 210MM 3.5-4MM .014IN BALLOON DILATATION",SUP-AB14W040210150,CDM,C1725,HCPCS,0272,RC,,,both,,,1638.75,491.62,"PHCS [10601]",PHCS,,1147.13,70,,,,,0,190.59,1392.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 2.75MM CORONARY RAPID EXCHANGE",SUP-ONYXNG27508UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2812.50,843.75,"CIGNA [10200]","Cigna Local Plus",,1504.69,53.5,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 190CM 3CM",SUP-1020010,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 11MM 14X10MM ACSR",SUP-331041,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM PRECEPT SPINE POLYAXIAL NONSTERILE",SUP-8807545A,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"ADHSV SKIN CLSR EXOFIN HIGH VISCOSITY TISSUE",SUP-EX70410-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.49,32.55,"FIRST HEALTH [10303]","First Health",,86.79,80,,,,,0,12.62,92.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL BROWN WHITE 1.8MM OTO-FLEX DIAMOND STERILE",SUP-3155645,CDM,S27200284,LOCAL,0272,RC,,,both,,,1482.30,444.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,175.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,172.39,1259.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 16X15CM BREAST 700ML STYLE 133MV TEXTURE",SUP-133MV-16,CDM,C1789,HCPCS,0278,RC,,,both,,,5460.00,1638,"KAISER [10500]",Kaiser,,3658.2,67,,,,,0,635,4641,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 21MM SPIN GUARD FEMALE 21MM MTP 4 FLUTE",SUP-P01-900-2102,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"CIGNA [10200]","Cigna Local Plus",,1043.25,53.5,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY FEMORAL 105MM 24MM RECLAIM 45MM 12/14 OFFSET MINI TAPER",SUP-197524105,CDM,C1776,HCPCS,0278,RC,,,both,,,22082.76,6624.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6320.09,28.62,,,,,0,2568.22,18770.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC ILESTO VR-T DX",SUP-383594,CDM,C1722,HCPCS,0278,RC,,,both,,,63000.00,18900,"AETNA [10100]","Aetna HMO/PPO",,50085,79.5,,,,,0,7326.9,53550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 20MM STERNALOCK BLU STERNAL CANCELLOUS SELF",SUP-73-2420,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,112.05,28.62,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 110MM 5.5MM REVOLVE XLORDOTIC",SUP-185.910,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"BLADE SHAVER SAGE GREEN 7CM 3.5MM DYONICS POWERMINI INCISOR",SUP-72201514,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 100CM 11FR AIRWAY EXCHANGE EXTRA FIRM SOFT TIP LUER",SUP-G57628,CDM,S27200284,LOCAL,0272,RC,,,both,,,785.70,235.71,"UHC [10700]","United Healthcare",,497.35,63.3,,,,,0,91.38,667.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR TRILOGY 7.4MM 58MM 32MM LONGEVITY HIP",SUP-00633405832,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"BLUE CROSS [10001]","Blue Cross HMO",,9487.71,39.2,,5311.50,4717.44,5388.59,31,2814.85,20572.84,"percent of total billed charges",
"SCR SET TITANIUM 5.5-6MM SPINE NONBREAK OFF CD HORIZON",SUP-5540130,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,99.6,28.62,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 60MM 112CM 6MM 75CM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200066070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 3 KNEE CEMENTED ROTATE PLATFORM",SUP-150610003,CDM,C1776,HCPCS,0278,RC,,,both,,,16694.55,5008.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1941.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1941.58,14190.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 15CM 180CM 18MM 10.5FR ESOPHAGEAL",SUP-G57330,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"CIGNA [10200]",Cigna,,7035.84,40,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 180CM 63CM HEMOSTASIS VALVE SUPER STIFF",SUP-406948,CDM,C1893,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PHCS [10601]",PHCS,,878.85,70,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 8MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT084050A,CDM,C1768,HCPCS,0278,RC,,,both,,,12827.10,3848.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1520.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1491.79,10903.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER BREAST BIOPSY ATEC TRIMARK SECOND DISPOSABLE",SUP-TRIMARKTD-2S-13-MR,CDM,A4648,HCPCS,0278,RC,,,both,,,628.56,188.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,179.89,28.62,,,,,0,73.1,534.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC EVERA MRI S DR SURESCAN 2 CHMBR ICD",SUP-DDMC3D4,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"MULTIPLAN [10600]",Multiplan,,34476,85,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2728.13,818.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,323.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,317.28,2318.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 14CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175197180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,992.87,68,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD SCR MATRIX SPINE TITANIUM TOP LOAD POLYAXIAL",SUP-04.632.001,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EVOLUT R 23MM DELIVERY AORTIC VALVE LOAD",SUP-LS-MDT2-23-US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2925.00,877.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,346.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,340.18,2486.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 28CM 3CM 6FR .038IN 2 PIGTAIL",SUP-M006192134010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"MULTIPLAN [10600]",Multiplan,,1020.49,85,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE VITRECTOMY 20GA ULTRAVIT CONSTELLATION ANTERIOR CURVED",SUP-8065751020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1716.68,515,"CIGNA [10200]","Cigna Local Plus",,918.42,53.5,,,,,0,199.65,1459.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SCR HUMERUS",SUP-00840009000,CDM,C1713,HCPCS,0278,RC,,,both,,,2703.75,811.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1838.55,68,,,,,0,314.45,2298.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 64.6X42.6X25MM MBT 2+ MM KNEE CEMENTED REVISION",SUP-129435225,CDM,C1776,HCPCS,0278,RC,,,both,,,35980.56,10794.17,"BLUE CROSS [10001]","Blue Cross PPO",,14104.38,39.2,,3949.44,3949.44,3949.44,"1 through 10",4184.54,30583.48,"percent of total billed charges",
"STENT TEMPTIP 26CM 8FR LARGE PROXIMAL PIGTAIL CURVE URETERAL",SUP-M001231380,CDM,C2617,HCPCS,0278,RC,,,both,,,931.50,279.45,"KAISER [10500]",Kaiser,,624.11,67,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 40MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-05047,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CRYO/CUFF IC LARGE 20-31IN COMPRESSION THERAPY KNEE",SUP-51A11B,CDM,S27000186,LOCAL,0270,RC,,,both,,,649.78,194.93,"UHC [10700]","United Healthcare",,411.31,63.3,,,,,0,75.57,552.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL VASCULAR 190",SUP-1009660,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY 14.8CM 13GA 11GA BD TREK AUTOMATIC BRAKE CONTROL",SUP-TKL1110,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"PHCS [10601]",PHCS,,2362.5,70,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE B CURVE",SUP-D7TCBG252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE PRELUDESYNC 29CM COMPRESSION 20ML RADIAL BAND SOFT",SUP-SRB29MED,CDM,S27000186,LOCAL,0270,RC,,,both,,,217.50,65.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPTA PRO 80CM 4CM 5FR 10MM 7.5MM BALLOON DILATATION",SUP-4190040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"6F DECA 4-4-34-4-4-4-4-4-50 MPA 120CM",SUP-950824,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 6.25X5/16IN SENN .75IN 2 END 3 BLUNT PRONG SURGICAL",SUP-20-0509,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.34,20.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE VASCULAR 275X2.9X3.2CM .035IN STREAMLINE DEVICE",SUP-H74939407XS0,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM VEIN DISTENTION GRAFT TUNNELING",SUP-26050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1278.75,383.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 6CM 3MM EMBOLD NITINOL FIBER DETACHABLE",SUP-M001394240030060,CDM,S27800098,LOCAL,0278,RC,,,both,,,6127.20,1838.16,"BLUE CROSS [10001]","Blue Cross HMO",,2401.86,39.2,,,,,0,712.59,5208.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 66X42X17MM NEXGEN LCCK 3-4 C-D STD KNEE",SUP-599403017,CDM,C1776,HCPCS,0278,RC,,,both,,,16256.40,4876.92,"FIRST HEALTH [10303]","First Health",,13005.12,80,,,,,0,1890.62,13817.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE COUGAR XT VASCULAR J 300CM .014IN HYDRO-TRACK EXTRA",SUP-CGRXT300HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,502.20,150.66,"KAISER [10500]",Kaiser,,336.47,67,,,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) CATH LITHOPLASTY 110CM 60MM 4.5MM .064IN ULTRASOUND",SUP-M732LPBC4560DX1,CDM,C1725,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 475ML GEL SMOOTH SILICONE P5.3CM HIGH PROFILE",SUP-3504754BC,CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Open Access",,2150.82,56.9,,5166.00,5166.00,5166.00,"1 through 10",439.61,3213,"percent of total billed charges",
"INSRT TIBIAL SMALL+ 10MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405210,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"CIGNA [10200]","Cigna Local Plus",,5169.95,53.5,,5372.07,4581.20,7242.98,23,1123.86,8213.93,"percent of total billed charges",
"SHEATH INTRO BLACK 23CM 9FR BRITE TIP CANN INTERVENTIONAL",SUP-401923M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"FIRST HEALTH [10303]","First Health",,83.52,80,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 1IN 19GA ANGLE DOWN INFUSION 2 LUMEN PORT WITHOUT Y",SUP-0651910,CDM,S27200284,LOCAL,0272,RC,,,both,,,54.64,16.39,"CIGNA [10200]","Cigna Local Plus",,29.23,53.5,,,,,0,6.35,46.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CHAMPIONIR DES SYSTEM US 6-40",SUP-412600400USRD,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAWSON-MUELLER MAC-LOC INTRO-TIP 25CM 8.5FR DRNG",SUP-G09705,CDM,C1729,HCPCS,0272,RC,,,both,,,660.07,198.02,"AMERIGROUP MEDICAID [20100]",Amerigroup,,78.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,76.77,561.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THREADED CAP",SUP-32500-000,CDM,S27800098,LOCAL,0278,RC,,,both,,,2406.60,721.98,"KAISER [10500]",Kaiser,,1612.42,67,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 150CM 8FR .038IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145380170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,133.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7.5FR 11CM MINI GWIRE AVANTI+ .038IN ORANGE",SUP-504657X,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.18,41.1,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY HUMERAL SMR SHOULDER TITANIUM FINNED REVERSE LOCKING",SUP-1352.15.050,CDM,C1776,HCPCS,0278,RC,,,both,,,10713.60,3214.08,"KAISER [10500]",Kaiser,,7178.11,67,,,,,0,1245.99,9106.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.50 X 18 MM  RX FDA",SUP-1203350-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2006.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 150MM 2.5MM BALLOON DILATATION RAPID",SUP-47525150L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4MM SABRETOOTH COOLCUT CURVE STAINLESS",SUP-AR-8400CST,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"MULTIPLAN [10600]",Multiplan,,477.13,85,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OXYCODONE 15 MG TABLET, IMMEDIATE RELEASE",RX-28899,CDM,,,0250,RC,00406-8515-23,NDC,both,1,UN,19.37,5.81,"CIGNA [10200]","Cigna Open Access",,11.02,56.9,,,,,0,2.25,16.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM POD J PACK SOFT",SUP-RBYPODJ5,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3103.76,45.9,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BRACHYTHERAPY 20CM 18GA MICK APPLR ULTRA SHARP TIP",SUP-918205,CDM,C1715,HCPCS,0272,RC,,,both,,,80.13,24.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.32,68.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRIAD CANCELLOUS CORTICAL ALLOGRAFT 14X11X7MM",SUP-5740107,CDM,C1713,HCPCS,0278,RC,,,both,,,7935.00,2380.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,922.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",922.84,6744.75,"percent of total billed charges",
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL TITANIUM LOW",SUP-AR-8719MXDS-1515,CDM,C1713,HCPCS,0278,RC,,,both,,,17215.50,5164.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2040.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2002.16,14633.18,"percent of total billed charges",
"WRAP THERAPEUTIC 54-66IN SMARTVEST 2XL HIGH FREQUENCY CHEST",SUP-SW-54/66-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 110CM 6FR .057IN .042 145D PIGTAIL",SUP-534652S,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER MAPPING 7FR WEBSTER CS 2-8-2MM SPACE F-J CURVE STER",SUP-BD710FJ282RTSR,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG 18X12.5CM GRANUFOAM SENSATRAC VAC THK3.3CM MEDIUM",SUP-M8275052/10,CDM,S27200284,LOCAL,0272,RC,,,both,,,336.35,100.9,"NOVANET [10819]",Novanet,,252.26,75,,,,,0,39.12,285.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 24MM COCR",SUP-VAL-20240-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"FIRST HEALTH [10303]","First Health",,1140.48,80,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL SYMBOTEX 25X20CM 3.3X2.3MM 2 SIDE MONOFILAMENT",SUP-SYM2520OS,CDM,C1781,HCPCS,0278,RC,,,both,,,9718.51,2915.55,"MULTIPLAN [10600]",Multiplan,,8260.73,85,,,,,0,1130.26,8260.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL CORTICAL THK3-12MM HALVED ALLOGRAFT STRUT",SUP-450481,CDM,S27800098,LOCAL,0278,RC,,,both,,,7973.64,2392.09,"CIGNA [10200]","Cigna Local Plus",,4265.9,53.5,,,,,0,927.33,6777.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS SURGICAL L4 1/4IN 0.12MM 1X2 TEETH SUTURE WITH PLATF",SUP-607100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1183.65,355.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) INNOVALVE VALVE PROTHESIS FOR TMVR (TRANSCATHETER MIT",SUP-PRO-5813,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 7FR 65CM GUIDING PINNACLE DESTINATION",SUP-RSP04,CDM,C1887,HCPCS,0272,RC,,,both,,,769.50,230.85,"FIRST HEALTH [10303]","First Health",,615.6,80,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 75CM .4MM FIRM TPR",SUP-124208,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"CIGNA [10200]",Cigna,,260.3,68,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3MM 2 SUTURETAK TIGERWIRE FIBERWIRE BIOCOMPOSITE",SUP-AR-1934BCF-2,CDM,C1713,HCPCS,0278,RC,,,both,,,2520.00,756,"AETNA [10100]","Aetna HMO/PPO",,2003.4,79.5,,1521.93,481.35,16760.95,30,293.08,2142,"percent of total billed charges",
"PACEMKR CARDIAC .75CM 13.2CU CM 4.45X4.81CM ESSENTIO",SUP-L100,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7109.21,28.62,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 4MM INTERLOCK IDC OCCLUSION SYSTEM",SUP-M0013614040,CDM,S27800098,LOCAL,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 8 KNEE CEMENT ROTATE PLATFORM STERILE",SUP-150680008,CDM,C1776,HCPCS,0278,RC,,,both,,,17225.85,5167.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4650.98,27,,,,,0,2003.37,14641.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 60MM 120CM 12MM .079IN LARGE",SUP-SERB65-12-60-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AETNA [10100]","Aetna HMO/PPO",,4424.18,79.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END 5MM TIBIAL T40 STARDRIVE RECESS EXT CANNULATED",SUP-04.004.001,CDM,C1713,HCPCS,0278,RC,,,both,,,1399.36,419.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,165.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",162.75,1189.46,"percent of total billed charges",
"STENT FRMLA 418 16MM 135CM 4MM .018IN BILIARY STAINLESS",SUP-G56619,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,586.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 114MM CEMENT SUMMIT 4 12/14 HIGH OFFSET TAPER",SUP-157013100,CDM,C1776,HCPCS,0278,RC,,,both,,,18219.60,5465.88,"NOVANET [10819]",Novanet,,13664.7,75,,,,,0,2118.94,15486.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 11MM 1 LEVEL SAPPHIRE BONE SPINE CERVICAL ANTERIOR",SUP-26001-011,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CIGNA [10200]",Cigna,,2856,68,,1831.33,1831.33,1831.33,16,488.46,3570,"percent of total billed charges",
"CATH METACROSS RX 90CM 60MM 5.7-3.9FR 6MM BALLOON DILATATION",SUP-BD-L60060MR,CDM,C1725,HCPCS,0272,RC,,,both,,,923.40,277.02,"AETNA [10100]","Aetna HMO/PPO",,734.1,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,107.39,784.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 12/14 TAPER 28MM HIP OXINIUM ECHELON",SUP-71342804,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"CIGNA [10200]",Cigna,,6214.14,40,,5873.17,5873.17,5873.17,"1 through 10",1806.76,13205.05,"percent of total billed charges",
"STENT ABRE 150MM 14MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U14150090,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"UHC [10700]","United Healthcare",,7425.09,63.3,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT FIBERTAK ROTATOR CUFF STERILE LATEX FREE",SUP-AR-3641,CDM,C1713,HCPCS,0278,RC,,,both,,,3543.75,1063.12,"BLUE CROSS [10001]","Blue Cross HMO",,1389.15,39.2,,957.42,156.86,7483.26,51,412.14,3012.19,"percent of total billed charges",
"TISSUE 400741  L SR SRVC FEE",SUP-400741,CDM,S27800098,LOCAL,0278,RC,,,both,,,4975.00,1492.5,"CIGNA [10200]","Cigna Local Plus",,2661.63,53.5,,,,,0,578.59,4228.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE COOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-CRKA-17-100-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Parvovirus B19 Detector",PX-306000148,CDM,87798,CPT,0306,RC,,,both,,,811.30,243.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,28.98,,"Fee schedule rate ($28.98). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,689.61,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 16MM 144CM 2.25MM CORONARY STENT EVEROLIMUS",SUP-H7493926116220,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3544.88,41.1,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Consult Surg WO Frozen",PX-312000036,CDM,88329,CPT,0312,RC,,,both,,,377.15,113.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,320.58,"per diem",
"BLADE SHAVER 13CM 5MM EXCALIBUR COOLCUT STERILE DISPOSABLE",SUP-AR-8500EX,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,59.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ARTHROSCOPIC STERILE ARTHREX APOLLO RF DISPOSABLE 50D",SUP-AR-9835,CDM,S27200284,LOCAL,0272,RC,,,both,,,2047.50,614.25,"PHCS [10601]",PHCS,,1433.25,70,,,,,0,238.12,1740.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR MULTIPURPOSE A1",SUP-67027000,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,48.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9.7CM 5MM CEREPAK MICRO UNIFORM DETACHABLE",SUP-FCX100509,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3570.98,27,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14X12.4CM MEMORYSHAPE P5.9CM MODERATE PLUS",SUP-RSZ1407S,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.55,69.16,"UHC [10700]","United Healthcare",,145.94,63.3,,,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD SUT ASSISTANT 2-0 ES-9 7IN COATED ENDO STITCH BRALON",SUP-170011,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"PHCS [10601]",PHCS,,100.91,70,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BREVERA BREAST BIOPSY SYSTEM SINGLE CHAMBER TISSUE FILTER",SUP-BREVTF01,CDM,S27200284,LOCAL,0272,RC,,,both,,,141.78,42.53,"CIGNA [10200]","Cigna Open Access",,80.67,56.9,,,,,0,16.49,120.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 7MM 28MM REUNION SHOULDER CENTRAL STERILE",SUP-5573-6528,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"BLUE CROSS [10001]","Blue Cross HMO",,609.83,39.2,,957.42,156.86,7483.26,51,180.93,1322.35,"percent of total billed charges",
"WIRE FIXATION .062IN 9IN KIRSCHNER STAINLESS STEEL 2 END",SUP-KM173-29-62,CDM,C1713,HCPCS,0278,RC,,,both,,,59.29,17.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,16.97,28.62,,,,,0,6.9,50.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 156MM 24-16MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1624C156E,CDM,C1876,HCPCS,0278,RC,,,both,,,40320.00,12096,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16571.52,41.1,,,,,0,4689.22,34272,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 12MM LCP TITANIUM DISTAL VOLAR RADIUS LOCKING",SUP-04.210.112,CDM,C1713,HCPCS,0278,RC,,,both,,,1063.69,319.11,"BLUE CROSS [10001]","Blue Cross PPO",,416.97,39.2,,957.42,570.23,957.42,28,123.71,904.14,"percent of total billed charges",
"HC Egd W Ctrl Blood",PX-750000041,CDM,43255,CPT,0750,RC,,,both,,,3783.74,1135.12,"CIGNA [10200]",Cigna,,3287,,"Case rate ($3,287). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,440.05,3783.74,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER FIBERTAPE STRAIGHT CERCLAGE TROCHANTERIC SUT",SUP-AR-7823,CDM,S27200284,LOCAL,0272,RC,,,both,,,1771.88,531.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,206.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,206.07,1506.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE X 8 HOLE 1 CABLE TRITIUM BONE STERNAL NONSTERILE",SUP-86-200,CDM,C1713,HCPCS,0278,RC,,,both,,,5720.10,1716.03,"AETNA [10100]","Aetna HMO/PPO",,4547.48,79.5,,1521.93,481.35,16760.95,30,665.25,4862.09,"percent of total billed charges",
"CATH ULTRAVERSE 014 150CM 4CM 5MM BALLOON DILATATION",SUP-U415054,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 65CM 5FR .046IN .038IN C2 CURVE ANGIOGRAPHIC",SUP-56538CB2,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"KAISER [10500]",Kaiser,,72.86,67,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TOURGUIDE 180D 45CM 17MM 7FR CATH HYDROPHOBIC",SUP-TG0704517,CDM,C1887,HCPCS,0272,RC,,,both,,,4209.00,1262.7,"PHCS [10601]",PHCS,,2946.3,70,,,,,0,489.51,3577.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 156MM 18MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-103180,CDM,C1776,HCPCS,0278,RC,,,both,,,27004.32,8101.3,"UHC [10700]","United Healthcare",,17093.73,63.3,,8601.07,8395.67,8601.07,"1 through 10",3140.6,22953.67,"percent of total billed charges",
"STENT CONTOUR VL 22-30CM 6FR .038IN STRAIGHT URETERAL",SUP-M006180156010,CDM,C2617,HCPCS,0278,RC,,,both,,,1077.22,323.17,"MULTIPLAN [10600]",Multiplan,,915.64,85,,,,,0,125.28,915.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MOTIV SCAFFOLD 3.0MMX60MM","SUP-930030-60 (360)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYNX CONTROL 5FR CLSR 10ML 2 MODE BALLOON CATH SEAL",SUP-MX5060,CDM,C1760,HCPCS,0278,RC,,,both,,,1680.00,504,"FIRST HEALTH [10303]","First Health",,1344,80,,,,,0,195.38,1428,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE GASTROSTOMY FEEDING 20FR STOMA L5CM BALLOON 5ML SILICON",SUP-8140-20-5.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,92.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 5 X 8 HELICAL PICO COIL",SUP-10USH05008,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1363.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OMNIWIRE 185 CM STRAIGHT TIP",SUP-89185,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"KAISER [10500]",Kaiser,,2773.8,67,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 7 X 30 HELICAL FILLING COIL",SUP-10HFL-07030,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"CIGNA [10200]","Cigna Open Access",,5100,56.9,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PG PRO 2.8FR/140CM/STRAIGHT",SUP-PGP28140STR,CDM,C1887,HCPCS,0272,RC,,,both,,,3697.50,1109.25,"AETNA [10100]","Aetna HMO/PPO",,2939.51,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,430.02,3142.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII ALLOGRAFT 18MM 23MM",SUP-401218A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 92CM 1MM 6FR 2-5-2MM SPACING F CURVE ELECTROPHYSIOLOGY",SUP-D610FR252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"AETNA [10100]","Aetna HMO/PPO",,2963.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXTOME 142CM 10MM 3MM BALLOON DILATATION NYLON",SUP-H749CBM3300100,CDM,C1725,HCPCS,0272,RC,,,both,,,5395.80,1618.74,"KAISER [10500]",Kaiser,,3615.19,67,,,,,0,627.53,4586.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 4-5 E-F KNEE RIGHT TIBIA FIX",SUP-42522100610,CDM,C1776,HCPCS,0278,RC,,,both,,,9466.80,2840.04,"BLUE CROSS [10001]","Blue Cross HMO",,3710.99,39.2,,5311.50,4717.44,5388.59,31,1100.99,8046.78,"percent of total billed charges",
"(EVAL) PREVAIL DCB 2.50X10MM",SUP-PRV025010CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 36CM 14.5FR 15FR STD STRAIGHT POLYURETHANE",SUP-5393310,CDM,C1750,HCPCS,0278,RC,,,both,,,2062.50,618.75,"CIGNA [10200]","Cigna Local Plus",,1103.44,53.5,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS STREAMLINE 20MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-M003SFD040200,CDM,C1874,HCPCS,0278,RC,,,both,,,85681.49,25704.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10153.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9964.76,72829.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 SH-1 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP311H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Open Access",,14.23,56.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 12MM 5MM EMBOLIZATION BRAID SOFT DISTAL",SUP-PED-500-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,30780,40,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TFNT50 PANOPTIX TORIC",SUP-TFNT50,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,574.6,68,,,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM G7 ACTIVE ARTICULATION THR E1 CERAMIC HIP 2 MOBIL",SUP-98000100157,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7824.6,27,,,,,0,3370.37,24633,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 13MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530-G-313,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"FIRST HEALTH [10303]","First Health",,6966.09,80,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11MM NATURAL LORDOTIC CORTICOCANCELLOUS",SUP-18411,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALL POLY PAT VE 32 MM DIA",SUP-42-5402-000-32,CDM,C1776,HCPCS,0278,RC,,,both,,,5322.66,1596.8,"CIGNA [10200]","Cigna Open Access",,3028.59,56.9,,5302.19,4377.88,6578.61,27,619.03,4524.26,"percent of total billed charges",
"SCR BONE 2.4MM 28MM LCP STAINLESS STEEL DISTAL CORTEX RADIUS",SUP-201.778,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,1831.33,1831.33,1831.33,16,50.59,369.75,"percent of total billed charges",
"BIT DRILL 2MM",SUP-0277082085S4,CDM,S27000186,LOCAL,0270,RC,,,both,,,528.20,158.46,"CIGNA [10200]","Cigna Open Access",,300.55,56.9,,,,,0,61.43,448.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG VARIABLE ANGLE LOCKING 1.8MM X 10MM",SUP-SPLS-18100-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",165.8,1211.76,"percent of total billed charges",
"SUT VICRYL PLUS 3-0 X-1 18IN CONTROL RELEASE 8 STRAND",SUP-VCP790D,CDM,S27200284,LOCAL,0272,RC,,,both,,,190.01,57,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH UROMAX ULTRA QUADRA-FOLD ENCORE HIGH PRESSURE KINK",SUP-M0062251250,CDM,C1726,HCPCS,0272,RC,,,both,,,1904.70,571.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTTER SUT REMOVAL FIBERTAPE ARTHROSCOPY",SUP-AR-13250,CDM,S27200284,LOCAL,0272,RC,,,both,,,7607.25,2282.17,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE VENTILATION BLUE 4.8MM 1.32MM T EAR SILICONE MODIFY",SUP-70245017,CDM,S27200284,LOCAL,0272,RC,,,both,,,152.90,45.87,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COLLAR CERVICAL ADULT L H2.25IN FOR 16-19IN NONTOXIC HYPOALL",SUP-A9918-13,CDM,S27000186,LOCAL,0270,RC,,,both,,,97.27,29.18,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE VENTILATION NUMBER 2 1.14MM BLUE ULTRASIL GROMMET BEVEL",SUP-70245755,CDM,S27800098,LOCAL,0278,RC,,,both,,,104.91,31.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,30.03,28.62,,,,,0,12.2,89.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5-6 13MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71933738,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4868.64,40,,,,,0,1415.56,10345.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 54MM LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.054S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"SHOE SMALL PATIENT POSTOPERATIVE SHORT WEDGE HEELWEDGE",SUP-92732602,CDM,S27000186,LOCAL,0270,RC,,,both,,,256.65,76.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.85,218.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Probe Flow",PX-E27200274,CDM,E27200274,LOCAL,0272,RC,,,both,,,324.50,97.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,38.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.74,275.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RELIEVA SPIN PLUS 16MM 6MM BALLOON DILATATION",SUP-RSP0616MFS,CDM,S27200284,LOCAL,0272,RC,,,both,,,13455.00,4036.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9149.4,68,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 135D STD BARREL DHS/DCP HIP STERILE 46MM STAINLESS",SUP-281.102S,CDM,C1713,HCPCS,0278,RC,,,both,,,3765.33,1129.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1077.64,28.62,,,,,0,437.91,3200.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE SPINAL ATLAS STAINLESS STEEL SINGLE INTEGRAL CRIMP",SUP-826-013,CDM,C1713,HCPCS,0278,RC,,,both,,,1988.40,596.52,"KAISER [10500]",Kaiser,,1332.23,67,,,,,0,231.25,1690.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOSE F/SMARTVEST AIRWAY CLEARANCE SYSTEM 6IN DISPOSABLE",SUP-SV-HOSE-SPU,CDM,S27000186,LOCAL,0270,RC,,,both,,,104.40,31.32,"CIGNA [10200]",Cigna,,70.99,68,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 58MM 36MM XLPE HIP STERILE",SUP-71335758,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"PHCS [10601]",PHCS,,7788.38,70,,,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 2CM 8MM BALLOON DILATATION PERIPHERAL",SUP-G50265,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 1X1IN DURAMATRIX SUTURABLE",SUP-DMS11,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR SAL.75 CURVE GUIDING NYLON",SUP-LA6SAL75,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colposcopy W/ Bx Cervix",PX-510000542,CDM,57455,CPT,0761,RC,,,both,,,1459.50,437.85,"BLUE CROSS [10001]","Blue Cross PPO",,1459.5,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,169.74,1459.5,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RED BLOOD CELL DISORDERS WITH MCC",811,MS-DRG,,,,,,,inpatient,,,34848.88,10454.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,22763.7,,"Fee schedule rate ($22,763.70). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,34848.88,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Splenoportograpy Si",PX-320000128,CDM,75810,CPT,0320,RC,,,both,,,3159.00,947.7,"CIGNA [10200]",Cigna,,844.38,,,,,,,367.39,3159,"fee schedule",
"PLATE NARROW 56MMX2MM LOCK VARIAX BONE RADIUS LEFT DISTAL",SUP-54-25374,CDM,C1713,HCPCS,0278,RC,,,both,,,6383.05,1914.91,"CIGNA [10200]",Cigna,,4340.47,68,,1831.33,1831.33,1831.33,16,742.35,5425.59,"percent of total billed charges",
"SPACER SPINAL 22MMX10MM 10MM CAPSTONE PEEK INTERBODY",SUP-2991022,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"NOVANET [10819]",Novanet,,15919.2,75,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 44MM 7.1MM 5MM CUFFLESS ROUND TIP OBTR SMOOTH SOFT","SUP-5.0 PED",CDM,S27200284,LOCAL,0272,RC,,,both,,,279.49,83.85,"CIGNA [10200]",Cigna,,190.05,68,,,,,0,32.5,237.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPIN ACCESS CATH 180D BRACHYTHERAPY OLYMPUS 190 SCOPE",SUP-INS-5915,CDM,S27200284,LOCAL,0272,RC,,,both,,,7452.00,2235.6,"MULTIPLAN [10600]",Multiplan,,6334.2,85,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Blastomyces Ag Urine",PX-306000111,CDM,87449,CPT,0306,RC,,,both,,,256.10,76.83,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,217.69,"per diem",
"LINER ACETABULAR DYNASTY A-CLASS 15D 36MM POLY BIOFOAM HIP",SUP-DLXPLD36,CDM,C1776,HCPCS,0278,RC,,,both,,,7507.20,2252.16,"FIRST HEALTH [10303]","First Health",,6005.76,80,,,,,0,873.09,6381.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 16MM DCP STAINLESS STEEL CORTICAL SELF",SUP-200.816,CDM,C1713,HCPCS,0278,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL 3.6 X 160MM SOLID MEASURING LONG AO",SUP-P99-100-3616,CDM,S27000186,LOCAL,0270,RC,,,both,,,1004.40,301.32,"CIGNA [10200]","Cigna Open Access",,571.5,56.9,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL SMALL+ 10MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405210,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"FIRST HEALTH [10303]","First Health",,7730.76,80,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X6MM PARALLEL SPINE CERVICAL",SUP-17906,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TIBIAL 100MM 10MM GENESIS II LONG KNEE TITANIUM",SUP-71420628,CDM,C1776,HCPCS,0278,RC,,,both,,,11540.25,3462.07,"CIGNA [10200]","Cigna Open Access",,3865.98,33.5,,5302.19,4377.88,6578.61,27,1342.13,9809.21,"percent of total billed charges",
"TAP 6.5MM CANNULATED BONE CREO MIS",SUP-6134.0065,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"NOVANET [10819]",Novanet,,437.4,75,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLIER INTERNAL CLIP 15CM HORIZON TITANIUM MICRO ENDOSCOPIC",SUP-005200,CDM,S27200284,LOCAL,0272,RC,,,both,,,645.38,193.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,438.86,68,,,,,0,75.06,548.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 33CM TIBIAL T2 INTRAMEDULLARY STD LOCK TITANIUM",SUP-1822-0933S,CDM,C1713,HCPCS,0278,RC,,,both,,,8804.12,2641.24,"CIGNA [10200]",Cigna,,5986.8,68,,1831.33,1831.33,1831.33,16,1023.92,7483.5,"percent of total billed charges",
"SPECLM SEPTUM 90MMX7MM KILLIAN SCR JOINT",SUP-OK094R,CDM,S27200284,LOCAL,0272,RC,,,both,,,658.13,197.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,77.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,76.54,559.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINE ANGIOGRAPHY 60IN .142IN .071IN 1200 PSI FEMALE LUER",SUP-91051602,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.25,26.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.26,75.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Swan Ganz Standard",PX-E27200074,CDM,C1751,HCPCS,0272,RC,,,both,,,1033.69,310.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,120.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,120.22,878.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL KNEE RIGHT 2.5 63X59MM CEMENTED CRUCIATE",SUP-960092,CDM,C1776,HCPCS,0278,RC,,,both,,,27588.96,8276.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11035.58,40,,,,,0,3208.6,23450.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC SHORT TIP RELOAD AEON 60MMX2.5MM STERILE",SUP-ASR60WS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RED 43 160CM 1.52MM .043IN REPERFUSION",SUP-RED43160,CDM,C1757,HCPCS,0272,RC,,,both,,,16767.00,5030.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SUT PDO QUILL 2 .5 CIRCLE TAPER POINT 70CM MONOFILAMENT",SUP-VLP-2010,CDM,S27200284,LOCAL,0272,RC,,,both,,,150.19,45.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 18X2.5X.38MM PRECISION SHORT XNARROW STAINLESS",SUP-2296003413,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ZIPWIRE VASCULAR STRAIGHT 180CM .035IN NITINOL POLYMER",SUP-M00146309B1,CDM,C1769,HCPCS,0272,RC,,,both,,,339.13,101.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC MRI Lwr Ext Nonjnt WO Cntrst",PX-610000031,CDM,73718,CPT,0610,RC,,,both,,,4076.82,1223.05,"CIGNA [10200]","Cigna Open Access",,799,,"Per diem ($799). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,430.75,3465.3,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLF TORIC AUTONOME",SUP-CNA0T5,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 230MM STAINLESS STEEL 4.5MM SCR 10 HOLE 4 COLUMN",SUP-02.124.410S,CDM,C1713,HCPCS,0278,RC,,,both,,,13765.64,4129.69,"KAISER [10500]",Kaiser,,9222.98,67,,,,,0,1600.94,11700.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 330ML STYLE 10 SMOOTH NATRELLE SILICONE P3.6CM",SUP-10-330,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"KAISER [10500]",Kaiser,,2391.9,67,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 150MM 3MM BALLOON",SUP-U3575315,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sensor Pulse Ox Peds",PX-E27000153,CDM,E27000153,LOCAL,0270,RC,,,both,,,110.55,33.16,"PHCS [10601]",PHCS,,77.39,70,,,,,0,12.86,93.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM OASYS TITANIUM SPINE",SUP-48552314,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 165CM TRIANGLETIP KNIFE J STERILE",SUP-KD-645L,CDM,S27200284,LOCAL,0272,RC,,,both,,,6099.60,1829.88,"MULTIPLAN [10600]",Multiplan,,5184.66,85,,,,,0,709.38,5184.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) CATH NUVISION ICE 10FR ULTRASOUND",SUP-FG10593,CDM,C1759,HCPCS,0272,RC,,,both,,,20160.00,6048,"UHC [10700]","United Healthcare",,12761.28,63.3,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 4.5MM .6MM RICHARDS EAR PISTON RIBBON LOOP",SUP-140785,CDM,L8613,HCPCS,0278,RC,,,both,,,1209.90,362.97,"MULTIPLAN [10600]",Multiplan,,1028.42,85,,,,,0,140.71,1028.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PLLA HA 25MM 7MM 1.5MM ACL PCL CANNULATED",SUP-7207674,CDM,C1713,HCPCS,0278,RC,,,both,,,1839.23,551.77,"CIGNA [10200]","Cigna Open Access",,1046.52,56.9,,1144.80,304.56,2275.09,66,213.9,1563.35,"percent of total billed charges",
"NDL ASPIRATION 15MM 21GA 1.95MM SMOOTHSHOT 2MM SMOOTH SHOT",SUP-NA-401D-1521,CDM,S27200284,LOCAL,0272,RC,,,both,,,471.83,141.55,"FIRST HEALTH [10303]","First Health",,377.46,80,,,,,0,54.87,401.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY PRO 45CM 9FR WIDE CURVE GUIDING CORONARY SINUS",SUP-8110,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,431.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890006555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"RELOAD SUT ASSISTANT 10MM 3-0 ES-9 7IN 1 STITCH ENDO STITCH",SUP-170070,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"CIGNA [10200]","Cigna Local Plus",,77.13,53.5,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL 10MM LEGION 6 KNEE SCR",SUP-71421668,CDM,C1776,HCPCS,0278,RC,,,both,,,11995.65,3598.69,"BLUE CROSS [10001]","Blue Cross HMO",,4702.29,39.2,,5311.50,4717.44,5388.59,31,1395.09,10196.3,"percent of total billed charges",
"CATHETER EZ STEER 7FR 2-8-2MM SPACING D-F CURVE ABLATION COR",SUP-BD710DF282CT,CDM,C1733,HCPCS,0272,RC,,,both,,,1458.00,437.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,991.44,68,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 3.8-3.4FR 6.5MM LOW",SUP-H74939031654010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE DOPPLER HIGH SENSITIVITY NONDIRECTIONAL TRNSDUC 2MHZ",SUP-OP2-HS,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 28MM 140CM 2.75MM CORONARY STENT",SUP-LUN275R28US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 65MM STAINLESS STEEL 3.5MM FLUTE CANNULATED",SUP-02.231.665,CDM,C1713,HCPCS,0278,RC,,,both,,,1631.85,489.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,193.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,189.78,1387.07,"percent of total billed charges",
"CATH LUTONIX 035 GEOALIGN 130CM 100MM 7MM BALLOON DILATATION",SUP-LX3513071005F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,797.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +15 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030150,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CIGNA [10200]",Cigna,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 STD 10MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS3S10L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1231.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1208.52,8832.69,"percent of total billed charges",
"CATH TRAILBLAZER 90CM .056IN 50MM ANGLE SPRT STAINLESS STEEL",SUP-ASC-035-090,CDM,C1887,HCPCS,0272,RC,,,both,,,1377.00,413.1,"MULTIPLAN [10600]",Multiplan,,1170.45,85,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM OFFSET 36MM HIP TYPE 1 COCR G7",SUP-11363661,CDM,C1776,HCPCS,0278,RC,,,both,,,5296.44,1588.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2431.07,45.9,,,,,0,615.98,4501.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 3-0 4IN ENDO STITCH V-LOC POLYBUTESTER LOAD",SUP-VLOCN304L,CDM,S27200284,LOCAL,0272,RC,,,both,,,249.43,74.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,169.61,68,,,,,0,29.01,212.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LARGE 33.4MMX1.5MM TITANIUM 2.7MM SCR 4 HOLE",SUP-DC2805115,CDM,C1713,HCPCS,0278,RC,,,both,,,7286.40,2185.92,"CIGNA [10200]",Cigna,,4954.75,68,,1831.33,1831.33,1831.33,16,847.41,6193.44,"percent of total billed charges",
"ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC",267,MS-DRG,,,,,,,inpatient,,,289642.88,86892.86,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,30860.45,,"Case rate ($29,531.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $27,422.03, add-ons for qualifying new technology services are included. If operating cost exceeds $60,461.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,455.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $27,458.29. The transfer operating threshold is the transfer adjustment factor * $27,422.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,073.24. The transfer capital threshold is the transfer adjustment factor * $2,073.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 104.5%.",,,,0,7561,138996.32,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 47.5MM OFFSET SAGITTAL 2108 SERIES STERILE LATEX",SUP-2108-130-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"AETNA [10100]","Aetna HMO/PPO",,190.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 6MM GORE STD WALL HEPARIN PROPATEN PTFE",SUP-H060040A,CDM,C1768,HCPCS,0278,RC,,,both,,,7562.40,2268.72,"NOVANET [10819]",Novanet,,5671.8,75,,,,,0,879.51,6428.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 20MM 5MM 4.9FR MERGING LUMEN TECHNOLOGY AUTOTOME RX",SUP-M00545150,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Phenotype Inf Agt Drug",PX-306000189,CDM,87900,CPT,0306,RC,,,both,,,3697.40,1109.22,"AETNA [10100]","Aetna HMO/PPO",,2939.43,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,3142.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 40MM 28MM D VIVACIT-E LUMEN STERILE LATEX FREE",SUP-110031010,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"MULTIPLAN [10600]",Multiplan,,8803.37,85,,,,,0,1204.51,8803.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 55MM BIO-MOORE II ENDO II HIP ACETABULAR",SUP-12-139034,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"KAISER [10500]",Kaiser,,1871.31,67,,,,,0,324.83,2374.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM OFFSET TAPER 32MM HIP ALUMINA CERAMIC V40",SUP-6565-0-132,CDM,C1776,HCPCS,0278,RC,,,both,,,7383.00,2214.9,"PHCS [10601]",PHCS,,5168.1,70,,,,,0,858.64,6275.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +28.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.285,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,345.41,28.62,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM SENSAR INTRAOCULAR LENS, BICONVEX, 19.0 DIOPTER",SUP-AR40E00190,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,110.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +14.5 DIOPTER MODIFIED C BICONVEX 12.5MM 7MM",SUP-CZ70BD.145,CDM,V2632,HCPCS,0276,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 180MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309018,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10195.79,27,,,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTAREX 110CM 8FR ATHERECTOMY SET GWIRE STERILE",SUP-80239,CDM,C1724,HCPCS,0272,RC,,,both,,,23625.00,7087.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2799.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 7 132D",SUP-6720-0737,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2786.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +12.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200125,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CIGNA [10200]","Cigna Open Access",,580.72,56.9,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 75MM 14MM UNIVERSAL FLUTE KNEE FEMUR PRESS FIT",SUP-867414,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,942.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL 29MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-1511-11-201,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Tissue Pelvis/Hip Superfic",PX-361000503,CDM,27040,CPT,0361,RC,,,both,,,3583.00,1074.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1550,,"Case rate ($1,550). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,416.7,3583,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 7MM FLIXENE 1 SLIDER GDS GRADUATED WALL",SUP-25059,CDM,C1768,HCPCS,0278,RC,,,both,,,8102.19,2430.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,942.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,942.28,6886.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 40MM 28MM ACTIVE ARTICULATION E1 UHMWPE",SUP-EP-200146,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"UHC [10700]","United Healthcare",,6555.92,63.3,,8601.07,8395.67,8601.07,"1 through 10",1204.51,8803.37,"percent of total billed charges",
"INSRT TIBIAL 5 11MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532-G-511,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3996.79,45.9,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL REVISION RSP DJO SURGICAL STERILE",SUP-510-10-175,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"KAISER [10500]",Kaiser,,8442,67,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 12/14 TAPER 36MM HIP CEMENTLESS BIOLOX",SUP-136536340,CDM,C1776,HCPCS,0278,RC,,,both,,,7222.32,2166.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4911.18,68,,,,,0,839.96,6138.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 13MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G213,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"KAISER [10500]",Kaiser,,5834.1,67,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT SIGMA 1.5 KNEE POROCOAT",SUP-129434115,CDM,C1776,HCPCS,0278,RC,,,both,,,17561.25,5268.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7024.5,40,,,,,0,2042.37,14927.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 25MM 45MM SHOULDER MODULAR REMEDY PMMA",SUP-RSHHMD,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5859.95,28.62,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM 15MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-015,CDM,C1776,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"CIGNA [10200]","Cigna Open Access",,5869.3,33.5,,5302.19,4377.88,6578.61,27,2037.61,14892.26,"percent of total billed charges",
"INSERT TIBIAL 9 5MM KNEE CRUCIATE RETAIN ROTATE PLATFORM ATT",SUP-151630905,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5250.9,40,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT SHOULDER HUMERAL GLENOID TRABECULAR META",SUP-98000972001,CDM,C1776,HCPCS,0278,RC,,,both,,,33075.00,9922.5,"CIGNA [10200]",Cigna,,13230,40,,5873.17,5873.17,5873.17,"1 through 10",3846.62,28113.75,"percent of total billed charges",
"STEM FEMORAL 100MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 1",SUP-71357001,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8948.11,27,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (1.5-2 MCI)",RX-411872,CDM,A9520,HCPCS,0343,RC,08888-8876-06,NDC,both,1,UN,4614.97,1384.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,546.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,536.72,3922.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HIWIRE VASCULAR TAPER 145CM 7CM .018IN STAINLESS STEEL",SUP-G00587,CDM,C1769,HCPCS,0272,RC,,,both,,,178.26,53.48,"FIRST HEALTH [10303]","First Health",,142.61,80,,,,,0,20.73,151.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 10MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630610,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"KAISER [10500]",Kaiser,,8795.26,67,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP CLUSTER HOLE SNAP FIT INTEGRATED",SUP-00875705401,CDM,C1776,HCPCS,0278,RC,,,both,,,9319.80,2795.94,"CIGNA [10200]","Cigna Open Access",,5302.97,56.9,,5302.19,4377.88,6578.61,27,1083.89,7921.83,"percent of total billed charges",
"CAP: FX STEMS (+) CENT",SUP-OSC368806,CDM,C1776,HCPCS,0278,RC,,,both,,,4830.00,1449,"KAISER [10500]",Kaiser,,3236.1,67,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 70MM KNEE LEFT POSTERIOR STABILIZE OPEN BOX",SUP-183326,CDM,C1776,HCPCS,0278,RC,,,both,,,40793.76,12238.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16317.5,40,,,,,0,4744.31,34674.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 STD 65X59MM KNEE LEFT CRUCIATE RETAIN CEMENT",SUP-112.001.08,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"CIGNA [10200]","Cigna Open Access",,5496.54,56.9,,5302.19,4377.88,6578.61,27,1123.46,8211,"percent of total billed charges",
"INSRT TIBIAL 2 17.5MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158121117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1299.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X10MM STD XL PEEK PLATE FUSION",SUP-7861060,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4061.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 30MM 5MM 4.4FR DREAMTOME DREAMWIRE BILIARY PRELOAD",SUP-M00584050,CDM,C1769,HCPCS,0272,RC,,,both,,,3112.43,933.73,"UHC [10700]","United Healthcare",,1970.17,63.3,,,,,0,361.98,2645.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HIWIRE VASCULAR STRAIGHT 180CM 15CM .035IN NITINOL",SUP-G36324,CDM,C1769,HCPCS,0272,RC,,,both,,,257.94,77.38,"KAISER [10500]",Kaiser,,172.82,67,,,,,0,30,219.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 11FR NONHEMOSTASIS GUIDING ELECTROPHYSIOLOGICAL",SUP-7097,CDM,C1894,HCPCS,0272,RC,,,both,,,3339.00,1001.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,395.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,388.33,2838.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Ren Arty >=2nd Ord Bi",PX-361000094,CDM,36254,CPT,0361,RC,,,both,,,18727.81,5618.34,"MULTIPLAN [10600]",Multiplan,,15918.64,85,,,,,0,2178.04,15918.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 40MM 80CM 9MM 6FR VASCULAR NITINOL",SUP-G43861,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]",Cigna,,2570.4,68,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 18MM 143CM 2.25MM CORONARY EVEROLIMUS ELUTING",SUP-1009544-18,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3941.9,41.1,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ VASCULAR 3CM STRAIGHT 180CM 8CM .035IN",SUP-G28781,CDM,C1769,HCPCS,0272,RC,,,both,,,247.86,74.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,168.54,68,,,,,0,28.83,210.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PROGRESS 80 VASCULAR STRAIGHT 190CM 3CM .014",SUP-1011838,CDM,C1769,HCPCS,0272,RC,,,both,,,1036.80,311.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,122.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 FULL THREAD CORKSCREW FIBERWIRE 3",SUP-AR-1927BCF-3,CDM,C1713,HCPCS,0278,RC,,,both,,,2677.50,803.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1820.7,68,,,,,0,311.39,2275.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS LARGE PLUG CRUSHED 12MM",SUP-291298,CDM,S27800098,LOCAL,0278,RC,,,both,,,4805.85,1441.75,"AETNA [10100]","Aetna HMO/PPO",,3820.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,558.92,4084.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE HI-FLO 150CM 20CM 3-2.8FR .027IN .018IN",SUP-M001182910,CDM,C1887,HCPCS,0272,RC,,,both,,,2100.00,630,"MULTIPLAN [10600]",Multiplan,,1785,85,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cautery High Temp Fine Tip",PX-E27000077,CDM,E27000077,LOCAL,0270,RC,,,both,,,85.80,25.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,58.34,68,,,,,0,9.98,72.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cautery High Temp Fine Tip",PX-E27000077,CDM,E27000077,LOCAL,0270,RC,,,both,,,85.80,25.74,"PHCS [10601]",PHCS,,60.06,70,,,,,0,9.98,72.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THD SLIDE PATIENT KIT DISPOSABLE",SUP-800070,CDM,S27200284,LOCAL,0272,RC,,,both,,,4260.06,1278.02,"AETNA [10100]","Aetna HMO/PPO",,3386.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,495.44,3621.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ VASCULAR J CURVE 180CM 3MM .032IN STAINLESS",SUP-G03584,CDM,C1769,HCPCS,0272,RC,,,both,,,200.01,60,"MULTIPLAN [10600]",Multiplan,,170.01,85,,,,,0,23.26,170.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE FATHOM VASCULAR 10CM ANGLE 180CM 25CM .016IN STAINLESS",SUP-M001509120,CDM,C1769,HCPCS,0272,RC,,,both,,,1815.00,544.5,"FIRST HEALTH [10303]","First Health",,1452,80,,,,,0,211.08,1542.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 40CM 5MM FIBROUS MATRIX WOVEN CROSS",SUP-AG640,CDM,C1768,HCPCS,0278,RC,,,both,,,18515.70,5554.71,"CIGNA [10200]","Cigna Open Access",,6202.76,33.5,,,,,0,2153.38,15738.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE DREAMWIRE DREAM TIP ENDOSCOPIC STD 450CM 10CM .035IN 3",SUP-M00556141,CDM,C1769,HCPCS,0272,RC,,,both,,,1422.36,426.71,"KAISER [10500]",Kaiser,,952.98,67,,,,,0,165.42,1209.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 15MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158125115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]",Cigna,,7598.69,68,,5873.17,5873.17,5873.17,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"INSRT TIBIAL 5 8MM RIGHT MEDIAL LEFT LATERAL X3 PARTIAL KNEE",SUP-5630-G-528,CDM,C1776,HCPCS,0278,RC,,,both,,,5309.55,1592.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,629.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,617.5,4513.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE GT VASCULAR 180CM .018IN STD FLEXIBLE TIP SET",SUP-RG*ES1818SP,CDM,C1769,HCPCS,0272,RC,,,both,,,1445.85,433.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,168.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.15,1228.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3.8MM 3MM ELITE DIAMOND NEURO STERILE",SUP-5820107130,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"CIGNA [10200]",Cigna,,744.57,68,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Vent Lt Heart Dlp 20f",PX-E27200330,CDM,E27200330,LOCAL,0272,RC,,,both,,,170.50,51.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,115.94,68,,,,,0,19.83,144.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X4CM NUSHIELD ALLOGRAFT",SUP-NO-1440,CDM,Q4160,HCPCS,0636,RC,,,both,,,9832.50,2949.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG WOUND 7X10CM KERECIS OR OMEGA3 MESH STERILE LATEX FREE",SUP-50205N03D0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,27354.60,8206.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"DRSG WOUND 7X10CM KERECIS OR OMEGA3 MESH STERILE LATEX FREE",SUP-50205N03D0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,27354.60,8206.38,"CIGNA [10200]","Cigna Local Plus",,180.89,,,,,,,180.89,23251.41,"fee schedule",
"GRAFT VASCULAR 70CM 10MM THIN WALL GORE-TEX REMOVABLE RING",SUP-RRT10070070L,CDM,C1768,HCPCS,0278,RC,,,both,,,9204.60,2761.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1090.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1070.49,7823.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING URETHRAL ARIS THK.3MM POLYPROPYLENE MACROPOROUS HEAT",SUP-934400,CDM,C1763,HCPCS,0278,RC,,,both,,,7431.30,2229.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3410.97,45.9,,,,,0,864.26,6316.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mecp2 Gene Full Sequence",PX-309000062,CDM,81302,CPT,0310,RC,,,both,,,5251.00,1575.3,"FIRST HEALTH [10303]","First Health",,4200.8,80,,,,,0,5.25,4463.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 40MM 80CM 12MM .079IN LARGE DIAMETER",SUP-SERB65-12-40-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1592.7,28.62,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC T Strap Add to Lower Ext",PX-E27400081,CDM,L2270,HCPCS,0274,RC,,,both,,,269.50,80.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,183.26,68,,,,,0,31.34,229.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH VASCULAR 8X.8CM TAPER BOVINE PERICARDIAL",SUP-DP08X8,CDM,C1768,HCPCS,0278,RC,,,both,,,1310.50,393.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,155.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,152.41,1113.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 18CM PUMP INFRAPUBIC",SUP-ES8818,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"FIRST HEALTH [10303]","First Health",,50160,80,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP 3 HOLE CEMENTLESS EMPHASYS",SUP-471048300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2127.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2088.17,15261.75,"percent of total billed charges",
"SHELL ACETABULAR 52MM HIP MULTIHOLE R3 STD STERILE",SUP-71338665,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"CIGNA [10200]",Cigna,,6354.9,40,,5873.17,5873.17,5873.17,"1 through 10",1847.69,13504.16,"percent of total billed charges",
"REAMER SURGICAL HEAD SHORT DHS NONSTERILE",SUP-338.44,CDM,S27200284,LOCAL,0272,RC,,,both,,,6520.50,1956.15,"PHCS [10601]",PHCS,,4564.35,70,,,,,0,758.33,5542.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Resp Virus 6-11 Targets",PX-306000231,CDM,87632,CPT,0306,RC,,,both,,,4400.40,1320.12,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,3740.34,"per diem",
"HC Ortho Mgmt/Train Ea 15min (Go)",PX-430000030,CDM,97760,CPT,0430,RC,,,both,,,205.82,61.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,205.82,,"Per diem ($426).",,,,0,23.94,205.82,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 30MM 190CM 2.5",SUP-R51002503L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"KAISER [10500]",Kaiser,,1321.07,67,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 12.5MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962342,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"BLUE CROSS [10001]","Blue Cross PPO",,5685.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",1686.79,12328.23,"percent of total billed charges",
"INSRT TIBIAL 5 8MM KNEE XLK POSTERIOR LIPPED FIX BEARING PFC",SUP-158105108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross PPO",,4380.42,39.2,,3949.44,3949.44,3949.44,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"SLEEVE CENTERING 13.5MM S-ROM ZTT 24B LARGE HIP PROXIMAL",SUP-550562,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"AETNA [10100]","Aetna HMO/PPO",,8653.38,79.5,,10981.53,8986.79,12413.38,12,1265.9,9252.04,"percent of total billed charges",
"INSRT TIBIAL 2 STD 12MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS2S12R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"AETNA [10100]","Aetna HMO/PPO",,8261.16,79.5,,10981.53,8986.79,12413.38,12,1208.52,8832.69,"percent of total billed charges",
"SHELL ACETABULAR 48MM PRIMARY HEMISPHERICAL CLUSTER HOLE",SUP-502-03-48C,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"CIGNA [10200]","Cigna Local Plus",,5599.75,53.5,,5372.07,4581.20,7242.98,23,1217.29,8896.8,"percent of total billed charges",
"CMPNT FEMORAL 7 LEFT KNEE CEMENTED CRUCIATE RETAINING",SUP-5510-F-701,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4427.42,27,,,,,0,1907.07,13938.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP CLUSTER HOLE HA TRIDENT II PSL G",SUP-742-11-60G,CDM,C1776,HCPCS,0278,RC,,,both,,,9502.96,2850.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3905.72,41.1,,6417.48,6417.48,6417.48,"1 through 10",1105.19,8077.52,"percent of total billed charges",
"HUMERAL SPACER, 36 +6MM",SUP-AR-9555-06,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"KAISER [10500]",Kaiser,,1969.8,67,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +19 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.190,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE UBER FLEX 40MM 57CM 9MM .078IN VASCULAR",SUP-SR-0940-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAMP 10MM 2MM 21MM LOW PROFILE INFLATABLE BALLOON SURGICAL",SUP-K15A,CDM,S27200284,LOCAL,0272,RC,,,both,,,4242.42,1272.73,"PHCS [10601]",PHCS,,2969.69,70,,,,,0,493.39,3606.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM CHARLOTTE STAINLESS STEEL FOOT ANKLE",SUP-56015550,CDM,C1713,HCPCS,0278,RC,,,both,,,7514.10,2254.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2150.54,28.62,,,,,0,873.89,6386.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 8MM .0135IN AXIUM PRIME 3D FRAME",SUP-FC-8-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4461.89,27,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 CURVE PLUS 17.5MM KNEE XLK FIX BEARING SIGMA",SUP-970464,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]","Cigna Local Plus",,5978.38,53.5,,5372.07,4581.20,7242.98,23,1299.6,9498.37,"percent of total billed charges",
"LINER ACETABULAR PINNACLE 15D 52MM 32MM MARATHON HIP STERILE",SUP-121932252,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"CIGNA [10200]",Cigna,,5515.45,68,,5873.17,5873.17,5873.17,"1 through 10",943.3,6894.31,"percent of total billed charges",
"IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION",RX-10325,CDM,Q9966,HCPCS,0636,RC,00270-1411-25,NDC,both,20,ML,300.00,90,"KAISER [10500]",Kaiser,,201,67,,,,,0,15.6,255,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY HUMERAL 11MM AEQUALIS FLEX REVIVE SHOULDER",SUP-ARS741702,CDM,C1776,HCPCS,0278,RC,,,both,,,18558.00,5567.4,"CIGNA [10200]",Cigna,,7423.2,40,,5873.17,5873.17,5873.17,"1 through 10",2158.3,15774.3,"percent of total billed charges",
"HEAD FEMORAL +0MM OFFSET C TAPER 40MM HIP COCR LFIT STERILE",SUP-614000,CDM,C1776,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Open Access",,2355.66,56.9,,5302.19,4377.88,6578.61,27,481.48,3519,"percent of total billed charges",
"BODY HUMERAL 11MM AEQUALIS FLEX REVIVE SHOULDER",SUP-ARS741702,CDM,C1776,HCPCS,0278,RC,,,both,,,18558.00,5567.4,"AETNA [10100]","Aetna HMO/PPO",,14753.61,79.5,,10981.53,8986.79,12413.38,12,2158.3,15774.3,"percent of total billed charges",
"MESH SURGICAL 20X20CM SELF GRIP RESORBING",SUP-TSB2020,CDM,C1781,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"BLUE CROSS [10001]","Blue Cross PPO",,11730.6,39.2,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C1 Complement Esterase Inhib",PX-302000031,CDM,86161,CPT,0302,RC,,,both,,,237.90,71.37,"MULTIPLAN [10600]",Multiplan,,202.22,85,,,,,0,0.01,202.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 82X50X12MM NEXGEN LCCK 7-10 E-F STD KNEE",SUP-599405112,CDM,C1776,HCPCS,0278,RC,,,both,,,16256.40,4876.92,"CIGNA [10200]","Cigna Open Access",,5445.89,33.5,,5302.19,4377.88,6578.61,27,1890.62,13817.94,"percent of total billed charges",
"STEM FEMORAL 93MM PRESS FIT ACCOLADE II V40 PUREFIX TITANIUM",SUP-6720-0027,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9584.82,40,,,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X3 HUMERAL INSERT - 40MM X 4 CONSTRAINED",SUP-5571-C-4004,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"FIRST HEALTH [10303]","First Health",,8064,80,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL ULTRAPRO 5CM HERNIA PLUG THERMOFORMED ONLAY",SUP-UPPL2,CDM,C1781,HCPCS,0278,RC,,,both,,,1554.31,466.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,713.43,45.9,,,,,0,180.77,1321.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 14MM STD SHELL DJO SURGICAL ALTIVATE",SUP-530-14-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"NOVANET [10819]",Novanet,,35620.83,75,,,,,0,5523.6,40370.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 108MM ALTIVATE DJO SURGICAL 12 STD SHOULDER",SUP-530-12-108,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3402,27,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 12.5MM KNEE GVF STABILIZE ROTATE PLATFORM PFC",SUP-962162,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"NOVANET [10819]",Novanet,,7653.83,75,,,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 14MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-514-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"AETNA [10100]","Aetna HMO/PPO",,9566.71,79.5,,10981.53,8986.79,12413.38,12,1399.51,10228.56,"percent of total billed charges",
"IMMOB ORTHOPEDIC 18IN KNEE 3 PANEL ADJUSTABLE BUCKLE PLASTIC",SUP-VP40105-030,CDM,L1830,HCPCS,0274,RC,,,both,,,160.08,48.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.62,136.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 62MM 36MM MARATHON HIP",SUP-121936062,CDM,C1776,HCPCS,0278,RC,,,both,,,8942.40,2682.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3675.33,41.1,,6417.48,6417.48,6417.48,"1 through 10",1040,7601.04,"percent of total billed charges",
"CMPNT PATELLAR 38MM ONLAY ADVANCE METAL KNEE STERILE",SUP-KPON38MB,CDM,C1776,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 2 RIGHT DISTAL KNEE",SUP-5542-A-202,CDM,C1776,HCPCS,0278,RC,,,both,,,5009.55,1502.86,"CIGNA [10200]",Cigna,,3406.49,68,,5873.17,5873.17,5873.17,"1 through 10",582.61,4258.12,"percent of total billed charges",
"CAP GLOBAL UNITE SHORT",SUP-OSC378959,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"CIGNA [10200]",Cigna,,8190,40,,5873.17,5873.17,5873.17,"1 through 10",2381.24,17403.75,"percent of total billed charges",
"CNTRLZR STEM 10MM RELIANCE HIP FEMUR FRACTURE PRODUCTS F R",SUP-6259-8-100,CDM,C1776,HCPCS,0278,RC,,,both,,,810.00,243,"CIGNA [10200]","Cigna Local Plus",,433.35,53.5,,5372.07,4581.20,7242.98,23,94.2,688.5,"percent of total billed charges",
"SPHERE GLENOID 42MM TORNIER AEQUALIS PERFORM STD SHOULDER",SUP-DWJ014,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3489.64,28.62,,,,,0,1418.05,10364.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183562,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"CIGNA [10200]",Cigna,,5181.07,40,,5873.17,5873.17,5873.17,"1 through 10",1506.4,11009.78,"percent of total billed charges",
"STEM HUMERAL 16MM DJO SURGICAL ALTIVATE SHORT SHOULDER",SUP-520-14-000,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"BLUE CROSS [10001]","Blue Cross PPO",,3104.64,39.2,,3949.44,3949.44,3949.44,"1 through 10",921.1,6732,"percent of total billed charges",
"SURFACE ARTICULAR 14MM PERSONA MEDIAL CONGRUENT 8-11 E-F",SUP-42522100814,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -4 40MM HIP BIOLOX DELTA FMP STERILE LATEX FREE",SUP-400-03-401,CDM,C1776,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL IUNI TIBIAL IPOLY STERILE",SUP-UKA1111111,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9062.55,41.1,,6417.48,6417.48,6417.48,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"HEAD FEMORAL +8MM 12/14 TAPER 36MM HIP COCR SPECTRON EF",SUP-71303608,CDM,C1776,HCPCS,0278,RC,,,both,,,10236.15,3070.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1212.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1190.46,8700.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 104MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 3",SUP-71357103,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13621.01,41.1,,6417.48,6417.48,6417.48,"1 through 10",3854.32,28169.98,"percent of total billed charges",
"LINER ACETABULAR PINNACLE NEUTRAL 54MM 36MM ALTRX HIP",SUP-122136054,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"FIRST HEALTH [10303]","First Health",,8280,80,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 19MM KNEE X3 CONDYLAR STABILIZED PRIMARY",SUP-5531G319,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"FIRST HEALTH [10303]","First Health",,7492.86,80,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 73X69MM KNEE LEFT CRUCIATE RETAIN CEMENT PFC",SUP-960084,CDM,C1776,HCPCS,0278,RC,,,both,,,27588.96,8276.69,"AETNA [10100]","Aetna HMO/PPO",,21933.22,79.5,,10981.53,8986.79,12413.38,12,3208.6,23450.62,"percent of total billed charges",
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 8-11 E-F",SUP-42512100812,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]",Cigna,,7327.97,68,,5873.17,5873.17,5873.17,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"LENS IOL 0 D +30 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.300,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM PFC SIGMA TC3 2 KNEE LEFT TITANIUM CEMENTED",SUP-960822,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"BLUE CROSS [10001]","Blue Cross PPO",,2011.29,39.2,,3949.44,3949.44,3949.44,"1 through 10",596.72,4361.21,"percent of total billed charges",
"STEM FEMORAL COLLAR AVENIR COMPLETE 0 HIP STERILE LATEX FREE",SUP-574203000,CDM,C1776,HCPCS,0278,RC,,,both,,,26190.36,7857.11,"FIRST HEALTH [10303]","First Health",,20952.29,80,,,,,0,3045.94,22261.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 30ML 1.7-10MM ALLOGRAFT CHIPS FREEZE",SUP-T00040,CDM,S27800098,LOCAL,0278,RC,,,both,,,2940.00,882,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1349.46,45.9,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE RIGHT POSTERIOR STABILIZE GENESIS II",SUP-71421204,CDM,C1776,HCPCS,0278,RC,,,both,,,24507.00,7352.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6616.89,27,,,,,0,2850.16,20830.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR ACTIS DUOFIX 6 STD OFFSET HIP STERILE",SUP-101011060,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"FIRST HEALTH [10303]","First Health",,24381,80,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP POLAR CUP POROUS STEM COBALT CHROME",SUP-71703515,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"AETNA [10100]","Aetna HMO/PPO",,19032.3,79.5,,10981.53,8986.79,12413.38,12,2784.22,20349,"percent of total billed charges",
"STEM FEMORAL ACCOLADE II 5 132D",SUP-6720-0535,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"MULTIPLAN [10600]",Multiplan,,20367.74,85,,,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 20F LARGE HIP PROXIMAL",SUP-550728,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3115.22,28.62,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE LEGION G2 PS POROUS FEMUR HI DEMAND INSER",SUP-71704651,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2710.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701050,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7718.34,68,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 40 MEDIUM KEEL AEQUALIS PERFORM SHOULDER",SUP-DWE513,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"MULTIPLAN [10600]",Multiplan,,7918.6,85,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 19MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-219,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1164.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 4 16MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620416,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7652.65,68,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ASCEND FLEX REV W PERF REV LAT BASEPLATE",SUP-CAP1132,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"MULTIPLAN [10600]",Multiplan,,41233.5,85,,,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 8MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620508,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"MULTIPLAN [10600]",Multiplan,,9565.82,85,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 8 132D",SUP-6720-0837,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"CIGNA [10200]","Cigna Local Plus",,7548.05,31.5,,5372.07,4581.20,7242.98,23,2786.79,20367.74,"percent of total billed charges",
"AUG FEMORAL 5MM TRIATHLON 6 KNEE RIGHT TOTAL STABILIZE",SUP-5540-A-602,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"MULTIPLAN [10600]",Multiplan,,3862.24,85,,,,,0,528.45,3862.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 10MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158120110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"FIRST HEALTH [10303]","First Health",,8939.64,80,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 10 8MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151621008,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"KAISER [10500]",Kaiser,,7540.11,67,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL CUSHING STRAIGHT 8IN THORACIC CARDIOVASCULAR",SUP-130445,CDM,S27200284,LOCAL,0272,RC,,,both,,,222.55,66.76,"CIGNA [10200]","Cigna Open Access",,126.63,56.9,,,,,0,25.88,189.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM TRIDENT II LOW PROFILE HEXAGONAL STERILE",SUP-7030-6525,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,349.48,45.9,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 100MM 5MM BILIARY SELF EXPANDING",SUP-SC5100L,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"NOVANET [10819]",Novanet,,6727.5,75,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 7CM 12MM GORE EXCLUDER ILIAC INTERNAL",SUP-HGB161207A,CDM,S27800098,LOCAL,0278,RC,,,both,,,19089.00,5726.7,"MULTIPLAN [10600]",Multiplan,,16225.65,85,,,,,0,2220.05,16225.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 5.5IN WEITLANER 17MM BLUNT 3X4 PRONG STAINLESS STEEL",SUP-205151,CDM,S27100035,LOCAL,0271,RC,,,both,,,546.67,164,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,224.68,41.1,,,,,0,63.58,464.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM DARCO TITANIUM FOOT LOCK",SUP-DC2825018,CDM,C1713,HCPCS,0278,RC,,,both,,,1036.80,311.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,475.89,45.9,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 1IN 27GA HYDRODISSECTION NUCLEUS VERTICAL",SUP-118-27S,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.85,17.95,"CIGNA [10200]","Cigna Open Access",,34.05,56.9,,,,,0,6.96,50.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM FREESTYLE SUBCORONARY PORCINE",SUP-995CS23,CDM,S27800098,LOCAL,0278,RC,,,both,,,38430.00,11529,"AETNA [10100]","Aetna HMO/PPO",,30551.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4469.41,32665.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SYNTHETIC ETHIBOND EXCEL 2-0 V-7 36IN 2 ARM BRAID FIRM",SUP-PXX79N,CDM,S27200284,LOCAL,0272,RC,,,both,,,745.06,223.52,"MULTIPLAN [10600]",Multiplan,,633.3,85,,,,,0,86.65,633.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETHRAL BARDEX IC 22FR FOLEY 2 WAY COUDE TIP 1 EYE",SUP-0168SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.14,33.04,"FIRST HEALTH [10303]","First Health",,88.11,80,,,,,0,12.81,93.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM LCP STAINLESS STEEL SHORT THREAD RADIUS",SUP-207.630,CDM,C1713,HCPCS,0278,RC,,,both,,,1144.85,343.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,327.66,28.62,,,,,0,133.15,973.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ISTO CORTICAL FIBERS - 10CC",SUP-ISTO-CF-10,CDM,S27800098,LOCAL,0278,RC,,,both,,,8797.50,2639.25,"CIGNA [10200]",Cigna,,5982.3,68,,,,,0,1023.15,7477.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEQUALIS PERFORM GLENOID (CORTILOC)- S30",SUP-DWE401,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"UHC [10700]","United Healthcare",,5897.03,63.3,,8601.07,8395.67,8601.07,"1 through 10",1083.45,7918.6,"percent of total billed charges",
"CATHETER KIT RAPID AV SPRAY TRUFREEZE SYSTEM",SUP-2000177,CDM,C2618,HCPCS,0272,RC,,,both,,,13075.50,3922.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1520.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 30MM NAIL-EX TITANIUM TIBIAL 2 CORE LOCKING",SUP-04.015.520,CDM,C1713,HCPCS,0278,RC,,,both,,,1313.17,393.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,892.96,68,,,,,0,152.72,1116.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SURGIDAC SURGIWIP 0 SK 48IN BRAID COATED GREEN",SUP-EDW-52,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"KAISER [10500]",Kaiser,,96.59,67,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) AGENT DCB CATHETER 3.0MM X 40MM",SUP-H7493960840300,CDM,C9610,HCPCS,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 40MM 6MM .014IN BALLOON DILATATION",SUP-AB14W060040150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036129300,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 8MM 4MM MICRO100 MICROPOWER 8MM FLUTE ROUND",SUP-00509223600,CDM,S27200284,LOCAL,0272,RC,,,both,,,207.76,62.33,"UHC [10700]","United Healthcare",,131.51,63.3,,,,,0,24.16,176.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAPARELLA VT W/TAB SI 1.27MM",SUP-510-072,CDM,S27800098,LOCAL,0278,RC,,,both,,,153.80,46.14,"FIRST HEALTH [10303]","First Health",,123.04,80,,,,,0,17.89,130.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.3MM 55MM CHARLOTTE STAINLESS STEEL LONG THREAD",SUP-44110041,CDM,C1713,HCPCS,0278,RC,,,both,,,2055.00,616.5,"KAISER [10500]",Kaiser,,1376.85,67,,,,,0,239,1746.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701060,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1345.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 370CC",SUP-SMPX370,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,883.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",866.67,6334.2,"percent of total billed charges",
"BEARING 79/83MMX10MM VANGUARD SSK POLYETHYLENE KNEE",SUP-185100,CDM,C1776,HCPCS,0278,RC,,,both,,,14683.20,4404.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3964.46,27,,,,,0,1707.66,12480.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 29MM TORNIER AEQUALIS PERFORM +6MM SHOULDER",SUP-DWJ513,CDM,C1776,HCPCS,0278,RC,,,both,,,11340.00,3402,"PHCS [10601]",PHCS,,7938,70,,,,,0,1318.84,9639,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 24/26FR STERILE DISPOSABLE YELLOW",SUP-27040BL1-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3100.64,930.19,"NOVANET [10819]",Novanet,,2325.48,75,,,,,0,360.6,2635.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32X23X10MM SOVEREIGN 8D SMALL",SUP-7967810,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"KAISER [10500]",Kaiser,,22964.65,67,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 80MM LCP STAINLESS STEEL PROXIMAL FEMORAL",SUP-02.205.080,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"PHCS [10601]",PHCS,,884.3,70,,,,,0,146.92,1073.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL BEND 147MM STAINLESS STEEL 3.5MM SCR 8 HOLE",SUP-02.127.230S,CDM,C1713,HCPCS,0278,RC,,,both,,,11005.50,3301.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7483.74,68,,,,,0,1279.94,9354.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 7MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640607,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Local Plus",,6020.84,53.5,,5372.07,4581.20,7242.98,23,1308.83,9565.82,"percent of total billed charges",
"CANN BONE CEMENT STABILIT LONG VERTEBRAL LOCK DELIVERY",SUP-1426,CDM,S27200284,LOCAL,0272,RC,,,both,,,1607.45,482.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,186.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,186.95,1366.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC",178,MS-DRG,,,,,,,inpatient,,,35718.36,10715.51,"UHC [10700]","United Healthcare",,24340.46,,"Fee schedule rate ($24,340.46). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,6054.18,24340.46,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 4.75IN TROUTMAN DELICATE NDL CURVE ROUND HANDLE 9MM",SUP-60-1899,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 25D MEDIUM AUG CORTILOC SHOULDER LEFT",SUP-DWK404LA25S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"FIRST HEALTH [10303]","First Health",,8400,80,,,,,0,1221.15,8925,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETHRAL BARDEX IC 20FR FOLEY 2 WAY COUNCIL TIP 2",SUP-0196SI20,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.25,42.67,"CIGNA [10200]","Cigna Open Access",,80.94,56.9,,,,,0,16.54,120.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 34CM LEFT TROCHANTERIC INTRAMEDULLARY 130D",SUP-456.355S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5618.54,41.1,,,,,0,1589.87,11619.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 234ML STYLE 15 SMOOTH NATRELLE SILICONE P3.6CM",SUP-15-234,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"AMERIGROUP MEDICAID [20100]",Amerigroup,,423.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 45MM 7.5MM MODULEX OSTEOGRIP SPINE",SUP-55900507545,CDM,C1713,HCPCS,0278,RC,,,both,,,4519.50,1355.85,"FIRST HEALTH [10303]","First Health",,3615.6,80,,,,,0,525.62,3841.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARM ENDOSCP 2.77X.93IN STD SILICONE AIRWAY STERILE LATEX",SUP-890914,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.87,41.66,"MULTIPLAN [10600]",Multiplan,,118.04,85,,,,,0,16.15,118.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT RESECTOSCOPE OES PRO 9MM 8FR WORKING ANTIBLOCKING",SUP-A42091A,CDM,S27800098,LOCAL,0278,RC,,,both,,,4515.00,1354.5,"PHCS [10601]",PHCS,,3160.5,70,,,,,0,525.09,3837.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 110CM 6FR BLNDIL GW PRSS",SUP-6747,CDM,C2628,HCPCS,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER SUPPORT L150CM DIA0.0375IN COMPATIBLE GUIDEWIRE 0.0",SUP-P1VC-018STR-150,CDM,C1894,HCPCS,0272,RC,,,both,,,1458.00,437.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 45MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840005045,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 30CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006175285080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"FIRST HEALTH [10303]","First Health",,991.5,80,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA XFULL PROFILE SOFTTOUCH SMOOTH",SUP-SSX-800,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"MULTIPLAN [10600]",Multiplan,,6422.18,85,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 STD KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500606002,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9396.57,41.1,,6417.48,6417.48,6417.48,"1 through 10",2658.93,19433.3,"percent of total billed charges",
"TARGET 360 NANO 1MM X 3CM",SUP-M0035421030,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG VIAL",RX-10581,CDM,J2919,HCPCS,0636,RC,43598-0128-11,NDC,both,1,UN,199.32,59.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,30.54,,"Fee schedule rate ($30.54). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.62,169.42,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 9MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-609,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"AETNA [10100]","Aetna HMO/PPO",,7815.26,79.5,,10981.53,8986.79,12413.38,12,1143.29,8355.94,"percent of total billed charges",
"SYSTEM INSPIRA AIR 24MM 8.5MM BALLOON DILATATION HIGH",SUP-BC8524A,CDM,C1726,HCPCS,0272,RC,,,both,,,4519.50,1355.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,535.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,525.62,3841.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE V-14 CONTROLWIRE VASCULAR SHORT TAPER STRAIGHT 182CM 8",SUP-H74939216718210,CDM,C1769,HCPCS,0272,RC,,,both,,,2295.00,688.5,"NOVANET [10819]",Novanet,,1721.25,75,,,,,0,266.91,1950.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 80CM 60MM 9MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV09006008P,CDM,C1725,HCPCS,0272,RC,,,both,,,10281.00,3084.3,"UHC [10700]","United Healthcare",,6507.87,63.3,,,,,0,1195.68,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NERVE STIM RESPIRATORY",SUP-4340,CDM,C1778,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"BLUE CROSS [10001]","Blue Cross HMO",,8334.9,39.2,,,,,0,2472.83,18073.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE DEMINERALIZED BONE MATRIX 10X1CM",SUP-7509111,CDM,S27800098,LOCAL,0278,RC,,,both,,,7728.00,2318.4,"CIGNA [10200]","Cigna Local Plus",,4134.48,53.5,,,,,0,898.77,6568.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X10MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7210,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"FIRST HEALTH [10303]","First Health",,5520,80,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 18MM 3.5MM CORONARY STENT EVEROLIMUS",SUP-1550350-18,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 6X37+TRAK21 2-PACK - US",SUP-91315,CDM,S27200284,LOCAL,0272,RC,,,both,,,24624.97,7387.49,"CIGNA [10200]","Cigna Open Access",,14011.61,56.9,,,,,0,2863.88,20931.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC",957,MS-DRG,,,,,,,inpatient,,,299460.93,89838.28,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,50102.7,,"Case rate ($47,266.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $43,890.34, add-ons for qualifying new technology services are included. If operating cost exceeds $76,930.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $4,700.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $43,948.38. The transfer operating threshold is the transfer adjustment factor * $43,890.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,318.32. The transfer capital threshold is the transfer adjustment factor * $3,318.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,222470.6,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 42MM LOW PROFILE SCREWS TITANIUM T15 FULL",SUP-AR-8935-42,CDM,C1713,HCPCS,0278,RC,,,both,,,696.60,208.98,"MULTIPLAN [10600]",Multiplan,,592.11,85,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 CURVE PLUS 10MM KNEE XLK FIX BEARING SIGMA",SUP-970441,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3198.16,28.62,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN HOLDING 1/8IN KNEE .75IN",SUP-201-78-15,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",50.59,369.75,"percent of total billed charges",
"HC Shave Ext Lesn 1.1-2.0cm",PX-510000020,CDM,11302,CPT,0761,RC,,,both,,,713.18,213.95,"MULTIPLAN [10600]",Multiplan,,606.2,85,,,,,0,82.94,713.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 15MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50015,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"KAISER [10500]",Kaiser,,55626.56,67,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 6-9 C-D KNEE RIGHT TIBIA",SUP-42522400512,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 10MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-210-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]",Cigna,,4813.44,40,,5873.17,5873.17,5873.17,"1 through 10",1399.51,10228.56,"percent of total billed charges",
"CMPNT FEMORAL ATTUNE STERILE 3 KNEE LEFT CEMENTED POSTERIOR",SUP-150410103,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2653.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE VASCULAR 45D 300CM 3CM .018IN HYDROPHILIC",SUP-GM1831,CDM,C1769,HCPCS,0272,RC,,,both,,,1462.05,438.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,173.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,170.04,1242.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.35MM 25MM VIPER EXPEDIUM TITANIUM SPINE CORTICAL",SUP-186731425,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EXTERNAL DRNG ACCUDRAIN LUMBAR CATH 910121 SP0234",SUP-31205,CDM,C1729,HCPCS,0272,RC,,,both,,,6044.40,1813.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,716.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,702.96,5137.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71-75X11MM VANGUARD VIVACIT-E KNEE CRUCIATE RETAIN",SUP-VE183441,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1506.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 7MM 7CM TWIST-IN 3 DAM SIDEPORT LUER LOCK",SUP-AR-6570TDNV,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"AETNA [10100]","Aetna HMO/PPO",,232.39,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CRIMPER ACTIVATOR",SUP-DMS-28829,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL INTERTAN 10X24X125DG",SUP-71934479,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT ELECTROSURGICAL 5IN 12FT MONOPOLAR SWITCH CORD",SUP-E0520,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.31,31.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.36,90.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.0MM X 40MM S4 CATHETER",SUP-FG63091-4040,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"UHC [10700]","United Healthcare",,0.01,63.3,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM GLUCONATE 100 MG/ML (10 %) IV VIAL",RX-1312,CDM,J0612,HCPCS,0636,RC,63323-0360-03,NDC,both,50,ML,244.62,73.39,"UHC [10700]","United Healthcare",,30,,,,,,,17.62,207.93,"fee schedule",
"IMMOB ORTHOPEDIC UNIVERSAL CONTOUR 18IN 27- IN KNEE 3",SUP-79-96318,CDM,L1830,HCPCS,0274,RC,,,both,,,414.21,124.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,190.12,45.9,,,,,0,48.17,352.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARCADIA 20MM 10GA BALLOON DILATATION HIGH PRESSURE",SUP-ARC20ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,5978.16,1793.45,"CIGNA [10200]",Cigna,,4065.15,68,,,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640606,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1308.83,9565.82,"percent of total billed charges",
"EPL 7F DUO 2/10 2M 95 S-LGCRL",SUP-401904R,CDM,S27200284,LOCAL,0272,RC,,,both,,,5851.20,1755.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3978.82,68,,,,,0,680.49,4973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM .02IN 5MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0520,CDM,S27800098,LOCAL,0278,RC,,,both,,,6258.00,1877.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4255.44,68,,,,,0,727.81,5319.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 6SQ CM THERASKIN ALLOGRAFT CRYOPRESERVE",SUP-100TSXS,CDM,Q4121,HCPCS,0636,RC,,,both,,,5658.00,1697.4,"AETNA [10100]","Aetna HMO/PPO",,4498.11,79.5,,,,,0,141.84,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins/Repo Subq Icd Elect & Ins Gen",PX-481000103,CDM,33270,CPT,0481,RC,,,both,,,42628.90,12788.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5051.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2795,42628.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,inpatient,,,40449.45,12134.83,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,4422.58,,"Case rate ($4,293.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,987.05, add-ons for qualifying new technology services are included. If operating cost exceeds $37,026.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,683.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $3,992.32. The transfer operating threshold is the transfer adjustment factor * $3,987.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $301.44. The transfer capital threshold is the transfer adjustment factor * $301.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4293.77,17262.78,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GA-68-GOZETOTIDE INTRAVENOUS SOLUTION (9 MCI)",RX-411559,CDM,A9596,HCPCS,0343,RC,08888-8878-84,NDC,both,1,UN,24796.80,7439.04,"FIRST HEALTH [10303]","First Health",,19837.44,80,,,,,0,1181,21077.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 30MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45030,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9655.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAS 54850016540 4.75 EXT TAB CANN 6.5X40",SUP-54850016540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"KAISER [10500]",Kaiser,,6396.39,67,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 3 POSTERIOR KNEE TOTAL STABILIZED",SUP-5543-A-300,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"NOVANET [10819]",Novanet,,3578.24,75,,,,,0,554.87,4055.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 3MM 3.5MM 4MM 45MM ENDO GIA MEDIUM THICK TISSUE",SUP-EGIA45AMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1230.39,369.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.09,1045.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165CM 10.5-12MM OTSC 3MM NITINOL",SUP-100.05,CDM,C1760,HCPCS,0278,RC,,,both,,,4133.10,1239.93,"CIGNA [10200]",Cigna,,2810.51,68,,,,,0,480.68,3513.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 200MM 6MM BALLOON",SUP-U3575620,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRIMARY KNEE 1 (INCLUDES PARTIAL KNEES)",SUP-CAP-S-K-1,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Open Access",,6331.5,33.5,,5302.19,4377.88,6578.61,27,2198.07,16065,"percent of total billed charges",
"SCR BONE 4.2MM 16MM XTEND SPINE VARIABLE ANGLE SELF DRILL",SUP-161.016,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"NOVANET [10819]",Novanet,,1057.5,75,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT 20MM ALIF",SUP-3W3220,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2459.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BTTRY PRODUCT SPECIFIC 14V SET HEARTMATE LITHIUM ION",SUP-2465,CDM,Q0506,HCPCS,0274,RC,,,both,,,4191.75,1257.52,"CIGNA [10200]",Cigna,,2850.39,68,,,,,0,487.5,3562.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anes 1st Hr",PX-370000001,CDM,9999104,LOCAL,0370,RC,,,both,,,2313.00,693.9,"CIGNA [10200]","Cigna Local Plus",,1237.46,53.5,,,,,0,269,1966.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 40 75CM 8CM 8MM BALLOON DILATATION PERIPHERAL",SUP-CQF7588,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR .09IN JUDKINS RIGHT 4 CURVE GUIDING",SUP-LA8JR40SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CARTO XP THERMOCOOL SF 7.5FR B-F CURVE",SUP-BNI35BFH,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"TRAY SURGICAL 19 1/8INX12 5/8INX5/8IN MAYO STAINLESS STEEL",SUP-19,CDM,S27200284,LOCAL,0272,RC,,,both,,,511.43,153.43,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC",002,MS-DRG,,,,,,,inpatient,,,337005.87,101101.76,"CIGNA [10200]","Cigna Open Access",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 46.8%. Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) FARAPOINT PFA CATHETER",SUP-M004PF81C310,CDM,C1733,HCPCS,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TAKERU 12MM 3.5MM BALLOON DILATATION PTCA",SUP-DC-RZ3512UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,671.98,68,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 58MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.648,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"PHCS [10601]",PHCS,,809.68,70,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYNTHETIC TISSUE SCAFFOLD PATCH 6X9 CM",SUP-31049,CDM,C1763,HCPCS,0278,RC,,,both,,,19782.00,5934.6,"BLUE CROSS [10001]","Blue Cross HMO",,7754.54,39.2,,,,,0,2300.65,16814.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR 30CM 6FR .038IN BLADDER LOOP LOW",SUP-M006155235120,CDM,C2617,HCPCS,0278,RC,,,both,,,1325.65,397.69,"PHCS [10601]",PHCS,,927.96,70,,,,,0,154.17,1126.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 59MM 80CM 11MM 16SQ MM 8FR .035IN",SUP-BXA115901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5266.3,27,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR 30CM 7FR .035IN BLADDER LOOP LOW",SUP-M006155245090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,158.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AGILITY ENDOSCOPIC STD XL 350CM 42CM .014IN",SUP-614491,CDM,C1769,HCPCS,0272,RC,,,both,,,3740.00,1122,"NOVANET [10819]",Novanet,,2805,75,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FS 40MM UTERINE DISTAL CUP TEXTURE HANDLE SOUND LATCH",SUP-110040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1539.00,461.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,706.4,45.9,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 90CM 40MM 3MM .014IN BALLOON DILATATION",SUP-AB14W030040090,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"UHC [10700]","United Healthcare",,876.77,63.3,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE NEOCLOSE 5/12 8/15 REGULAR CLSR PORT ANCHOR GUIDE KIT",SUP-NCAGRU,CDM,S27800098,LOCAL,0278,RC,,,both,,,457.20,137.16,"CIGNA [10200]","Cigna Open Access",,260.15,56.9,,,,,0,53.17,388.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 14MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.814,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"FIRST HEALTH [10303]","First Health",,200.73,80,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2.5MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-02504,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA [10200]",Cigna,,7033.31,68,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTIGRAFT VG1 7D 1 PIECE LORDOSIS SOLID CENTRAL",SUP-VG1C-T46P,CDM,C1713,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"CIGNA [10200]","Cigna Local Plus",,3137.78,53.5,,3978.14,359.25,3978.14,24,682.1,4985.25,"percent of total billed charges",
"CAGE SPINAL ROI-C PEEK-OPTIMA 7 D D12 MM W14 MM X H9 MM .53",SUP-MC1445P,CDM,S27800098,LOCAL,0278,RC,,,both,,,24570.00,7371,"MULTIPLAN [10600]",Multiplan,,20884.5,85,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUTURE BIOCOMP PUSHLOCK",SUP-AR-1922BCM,CDM,C1713,HCPCS,0278,RC,,,both,,,3268.13,980.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,380.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",380.08,2777.91,"percent of total billed charges",
"SCR BONE 2.4MM 24MM LCP STAINLESS STEEL DISTAL RADIAL T8",SUP-212.824,CDM,C1713,HCPCS,0278,RC,,,both,,,802.87,240.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,368.52,45.9,,,,,0,93.37,682.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ROCHESTER-OSCHNER STRAIGHT 7.25IN 1X2 TEETH",SUP-16-1218,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.99,22.5,"CIGNA [10200]","Cigna Open Access",,42.67,56.9,,,,,0,8.72,63.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA ARTERIAL SOFT-FLOW 3/8 IN L14 IN OD18 FR ANGLE TIP N",SUP-6392,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"CIGNA [10200]","Cigna Open Access",,319.4,56.9,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 40- IN CLAVICLE MOVABLE D RING",SUP-79-85100,CDM,S27000186,LOCAL,0270,RC,,,both,,,76.65,22.99,"FIRST HEALTH [10303]","First Health",,61.32,80,,,,,0,8.91,65.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPIFIX 18 MM DISK ""Q"" CODED",SUP-GS-5180,CDM,Q4186,HCPCS,0636,RC,,,both,,,4733.40,1420.02,"NOVANET [10819]",Novanet,,3550.05,75,,,,,0,406.44,4023.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000180,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drsg Wound Mepitel One 10x6in",PX-HHE27200402,CDM,HHE27200402,LOCAL,0270,RC,,,outpatient,,,118.00,35.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.72,100.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Strep a W Dir Optic Obv",PX-306000172,CDM,87880,CPT,0306,RC,,,both,,,240.35,72.1,"CIGNA [10200]","Cigna Open Access",,36.37,,,,,,,8.12,204.3,"fee schedule",
"CANN INNER 90MM 9.6MM 5MM SHILEY XLT EXTEND LENGTH FLEXIBLE",SUP-50XLTIN,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.83,1.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.56,4.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 70MM TI",SUP-MTLS-37700-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,523.91,39.2,,957.42,570.23,957.42,28,155.43,1136.03,"percent of total billed charges",
"CATH PUREWICK EXTERNAL MALE LATEX FREE",SUP-PWM030,CDM,S27000186,LOCAL,0270,RC,,,both,,,134.85,40.45,"MULTIPLAN [10600]",Multiplan,,114.62,85,,,,,0,15.68,114.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT HEMODIALYSIS SUPER HERO",SUP-SUPERHERO,CDM,C1750,HCPCS,0278,RC,,,both,,,27720.00,8316,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11088,40,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 16MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G416,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4299.03,45.9,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 8X11X30MM 15",SUP-5881305,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"MULTIPLAN [10600]",Multiplan,,24480,85,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Infect Ag Ia Sars/Corona",PX-306000232,CDM,87426,CPT,0306,RC,,,both,,,205.00,61.5,"BLUE CROSS [10001]","Blue Cross PPO",,45.14,,"Fee schedule rate ($45.14).",,,,0,19.49,174.25,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM REGENT FLEXCUFF 85D SUPRA ANNULAR",SUP-25AGFN-756,CDM,S27800098,LOCAL,0278,RC,,,both,,,31229.42,9368.83,"CIGNA [10200]","Cigna Open Access",,10461.86,33.5,,,,,0,3631.98,26545.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 E-F 17MM KNEE FIX BEARING PROLONG NEXGEN",SUP-00596204017,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"AETNA [10100]","Aetna HMO/PPO",,6295.16,79.5,,10981.53,8986.79,12413.38,12,920.91,6730.67,"percent of total billed charges",
"LENS IOL 10 D +25.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.255,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135D 41MM STD OFFSET 38.5MM STERILE 150MM 12MM",SUP-3L92512,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6509.06,41.1,,6417.48,6417.48,6417.48,"1 through 10",1841.86,13461.55,"percent of total billed charges",
"TISSUE 330644 ACSR 6X14X14 SRVC FEE",SUP-330644,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Intralesns >7 Lesns",PX-510000042,CDM,11901,CPT,0761,RC,,,both,,,853.00,255.9,"BLUE CROSS [10001]","Blue Cross HMO",,853,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,99.2,853,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 15MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962323,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5801.52,40,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.2MM STEINMANN BLUNT DISPOSABLE",SUP-500095,CDM,C1713,HCPCS,0278,RC,,,both,,,3326.40,997.92,"CIGNA [10200]",Cigna,,2261.95,68,,1831.33,1831.33,1831.33,16,386.86,2827.44,"percent of total billed charges",
"HOLDER 8IN MICROVASCULAR SERRATE NDL TUNGSTEN CARBIDE",SUP-32-327,CDM,S27200284,LOCAL,0272,RC,,,both,,,690.85,207.25,"CIGNA [10200]","Cigna Local Plus",,369.6,53.5,,,,,0,80.35,587.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Upr Ext Jnt W Cntrst",PX-610000028,CDM,73222,CPT,0610,RC,,,both,,,3889.39,1166.82,"UHC [10700]","United Healthcare",,1907.2,,,,,,,452.34,3305.98,"fee schedule",
"PENCIL BIPOLAR 25GA STRAIGHT 1 PIECE NONSTICK SEAMLESS",SUP-14-5011,CDM,S27200284,LOCAL,0272,RC,,,both,,,344.52,103.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,40.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.07,292.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 25MM 7FR FUSION OMNI-TOME BILIARY PANCREATIC",SUP-G31911,CDM,C1769,HCPCS,0272,RC,,,both,,,3082.50,924.75,"FIRST HEALTH [10303]","First Health",,2466,80,,,,,0,358.49,2620.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNGOSCOPE VIDEO I-VIEW DISPOSABLE",SUP-441-8008000EA,CDM,S27000186,LOCAL,0270,RC,,,both,,,706.23,211.87,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 135CM 10CM 6MM BALLOON DILATATION PERIPHERAL",SUP-G50253,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RETRIEVER SUT YELLOW 3/8IN SMALL MINI OPEN STRESS RISER",SUP-9892,CDM,S27200284,LOCAL,0272,RC,,,both,,,376.36,112.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNIFE OPHTHALMIC 3MM A-OK SATINSLIT ANGLE FULL HANDLE",SUP-8065992961,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.32,36.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) INNOVALVE TRANSSEPTAL DELIVERY SYSTEM FOR TMVR TRANSC",SUP-PRO-17320,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL CRYOABLATION 17.5CM 14GA ICEFORCE 2.1CX 90D DISTAL SHAFT",SUP-FPRPR3602,CDM,C2618,HCPCS,0272,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASEPLT GLENOID 29MM TORNIER AEQUALIS PERFORM +6MM SHOULDER",SUP-DWJ513,CDM,C1776,HCPCS,0278,RC,,,both,,,11340.00,3402,"FIRST HEALTH [10303]","First Health",,9072,80,,,,,0,1318.84,9639,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +25.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.255,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT HS FIBER ULTRALOOP #2 66CM NON-ABSORABLE 1.25IN MINITAPE",SUP-72205445,CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"CIGNA [10200]","Cigna Local Plus",,295.76,53.5,,,,,0,64.29,469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 12MM 2.25MM BALLOON DILATATION PEBAX",SUP-1012404-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL H+12MM 42MM AEQUALIS SHOULDER RETENTIVE",SUP-DWD978,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"KAISER [10500]",Kaiser,,6048.57,67,,,,,0,1049.92,7673.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR EIBERG STD LONG SURGICAL",SUP-E1SL,CDM,S27200284,LOCAL,0272,RC,,,both,,,22391.33,6717.4,"AETNA [10100]","Aetna HMO/PPO",,17801.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2604.11,19032.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CHOLANGIOGRAM 60CM 4FR FRANKLIN .025IN GWIRE 145CM",SUP-G10456,CDM,C1769,HCPCS,0272,RC,,,both,,,486.00,145.8,"FIRST HEALTH [10303]","First Health",,388.8,80,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 7CM 4FR PIGTAIL PANCREATIC POLYMER RADIOPAQUE",SUP-M00536910,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,75.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 17GA 15CM BIOPINCE ULTRA FULL CORE CO-AXIAL",SUP-360-1580-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.84,161.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,221.05,41.1,,,,,0,62.55,457.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XLNK SPINAL 4-72MM 5.5MM PASS LP MEDIUM NONSTERILE LATEX",SUP-B02465520,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1019.59,28.62,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 18MM 140CM 4MM 2.1-2.7FR CORONARY STENT",SUP-RONYX40018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2524.5,68,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASSURANT COBALT 60MM 80CM 8MM BILIARY COCR ILIAC 2",SUP-ASC860SV,CDM,C1876,HCPCS,0278,RC,,,both,,,6444.60,1933.38,"BLUE CROSS [10001]","Blue Cross HMO",,2526.28,39.2,,,,,0,749.51,5477.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 11MM KII Z THREAD SLEEVE NONBLADE",SUP-CTR33,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"FIRST HEALTH [10303]","First Health",,194.88,80,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEMI-FLOATING PACING CATH 6F 5",SUP-353234,CDM,C1893,HCPCS,0272,RC,,,both,,,382.80,114.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,44.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS MONOPOLAR ENDOWRIST SP CURVE NONSTERILE LATEX FREE",SUP-431100,CDM,S27000186,LOCAL,0270,RC,,,both,,,2772.00,831.6,"UHC [10700]","United Healthcare",,1754.68,63.3,,,,,0,322.38,2356.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 10MM 3MM BALLOON DILATATION STERILE",SUP-230-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 11MM KNEE BEARING POSTERIOR STABILIZE",SUP-5532-G-311-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3266.29,28.62,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 52MM 36MM ALTRX HIP",SUP-1221-36-052,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4253.85,41.1,,6417.48,6417.48,6417.48,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"SUT CARDIONYL 4-0 .5C 2 ARM BLUE NONABSORBABLE",SUP-721932,CDM,S27200284,LOCAL,0272,RC,,,both,,,55.34,16.6,"FIRST HEALTH [10303]","First Health",,44.27,80,,,,,0,6.44,47.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 5.5MM CD HORIZON LEGACY TITANIUM PREBENT CP",SUP-8690080,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"MULTIPLAN [10600]",Multiplan,,3748.5,85,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL URETERAL 60CM 12-6FR LONG HYDROPHILIC TAPERED",SUP-G17636,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.55,69.16,"PHCS [10601]",PHCS,,161.39,70,,,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 CT-1 36IN BRAID COATED UNDYED ABSORBABLE",SUP-VCP944H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATHLETIC SUPPORTER MALE 32 TO 38IN KNITTED STRETCH ELASTIC",SUP-2570-01M,CDM,S27000186,LOCAL,0270,RC,,,both,,,178.26,53.48,"KAISER [10500]",Kaiser,,119.43,67,,,,,0,20.73,151.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTW TAKERU PTCA BALLOON 1.50MM X 15MM",SUP-DC-PY1515UA1,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"KAISER [10500]",Kaiser,,662.09,67,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 22MM 140CM 2.5MM CORONARY STERILE LATEX",SUP-453950,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROMORPHONE (PF) 6 MG/30 ML (0.2 MG/ML) IN 0.9% NACL IV PCA SYRINGE",RX-155656,CDM,J1171,HCPCS,0636,RC,70004-0300-18,NDC,both,30,ML,97.90,29.37,"BLUE CROSS [10001]","Blue Cross PPO",,6.99,,,,,,,6.99,83.22,"fee schedule",
"SMOOTH PEG LOCKING 6.0MM X 48MM TI",SUP-SPL-60480-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,743.58,45.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 39X17MM HEDRON IA 15D 29MM STERILE LATEX FREE",SUP-1212.1217S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"KAISER [10500]",Kaiser,,23215.5,67,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUE DILATATION 110CM 4.5CM 25MM BALLOON DILATATION OTW",SUP-0254513,CDM,C1725,HCPCS,0272,RC,,,both,,,7590.00,2277,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,899.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60MM 12MM LONG 6 ROW 12 FIRING LINEAR CUTTER",SUP-LONG60A,CDM,S27200284,LOCAL,0272,RC,,,both,,,7539.06,2261.72,"CIGNA [10200]",Cigna,,5126.56,68,,,,,0,876.79,6408.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OXCARBAZEPINE 300 MG TABLET",RX-21061,CDM,,,0637,RC,60687-0722-11,NDC,both,1,UN,13.86,4.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9.42,68,,,,,0,1.61,11.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPIDCROSS 170CM 40MM 2.5MM .014IN BALLOON DILATATION",SUP-A14BX025040170,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,569.28,41.1,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 54MM 36MM XLPE HIP STERILE",SUP-71332754,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"CIGNA [10200]","Cigna Local Plus",,5952.54,53.5,,5372.07,4581.20,7242.98,23,1293.98,9457.31,"percent of total billed charges",
"SHEATH TOURGUIDE 180D 45CM 9MM 6.5FR CATH HYDROPHILIC",SUP-TG0654509,CDM,C1887,HCPCS,0272,RC,,,both,,,4209.00,1262.7,"UHC [10700]","United Healthcare",,2664.3,63.3,,,,,0,489.51,3577.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP ACETABULAR 62MM 56MM PINNACLE STD PROFILE 8 PERIPHERAL 5",SUP-121716062,CDM,C1776,HCPCS,0278,RC,,,both,,,18207.00,5462.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2157.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2117.47,15475.95,"percent of total billed charges",
"DEVICE STATLOCK UNIVERSAL PLUS LARGE 12-14FR SECUREMENT FOAM",SUP-VUPD1214,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.96,25.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,58.45,68,,,,,0,10,73.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL BREATHE-EASY STERILE",SUP-20-10500,CDM,S27200284,LOCAL,0272,RC,,,both,,,305.63,91.69,"AETNA [10100]","Aetna HMO/PPO",,242.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.54,259.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 34X24X12MM BRIGADE 8D NONSTERILE LATEX FREE",SUP-6941234,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"FIRST HEALTH [10303]","First Health",,27420.48,80,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 9CM 5FR STRAIGHT PANCREATIC POLYMER RADIOPAQUE",SUP-M00536430,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,293.42,45.9,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ZEPHYR 2.8MM 4 DELIVERY SYSTEM FLEXIBLE EMPHASYS",SUP-EDC-TS-4.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,3898.50,1169.55,"KAISER [10500]",Kaiser,,2612,67,,,,,0,453.4,3313.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIBRILLATOR 52CM 8FR OPTISURE ENDOCARDIUM 2 COIL DF4",SUP-LDA220Q-52,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7057.69,41.1,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM .02IN 20MM PENUMBRA COIL 400 RUBY",SUP-RBY2C2060,CDM,S27800098,LOCAL,0278,RC,,,both,,,7098.00,2129.4,"CIGNA [10200]","Cigna Local Plus",,3797.43,53.5,,,,,0,825.5,6033.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 11MM KII FIOS FIRST ENTRY ADVANCE",SUP-CFF34,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,124.24,68,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 90MMX4.8MM DST SERIES TA TITANIUM REGULAR",SUP-TA9048L,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.47,98.24,"CIGNA [10200]","Cigna Local Plus",,175.2,53.5,,,,,0,38.08,278.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPTIP APD 25CM 14FR DRNG FLEXIMA METAL POLYURETHANE",SUP-M001281390,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 9.5MM S-ROM ZTT 24B SMALL HIP PROXIMAL",SUP-550561,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1289.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE DIRECTINJECT HA 10CC",SUP-79-45910,CDM,C1713,HCPCS,0278,RC,,,both,,,24853.44,7456.03,"CIGNA [10200]","Cigna Local Plus",,7828.83,31.5,,3978.14,359.25,3978.14,24,2890.46,21125.42,"percent of total billed charges",
"SCR BONE 4MM 13MM ATLANTIS TITANIUM SPINAL SELF TAPPING",SUP-3120313,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"FIRST HEALTH [10303]","First Health",,1128,80,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prosth Ext Train Ea 15min (Go)",PX-430000050,CDM,97761,CPT,0430,RC,,,both,,,160.37,48.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,160.37,,"Per diem ($239.55).",,,,0,18.65,160.37,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DEMINERALIZED BONE MATRIX CANCELLOUS ALLOGRAFT",SUP-7777005,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"MULTIPLAN [10600]",Multiplan,,3665.63,85,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH GLIDELIGHT 25-80HZ 50CM 12FR 7.5FR 8.3FR 12.5FR LASER",SUP-500-301,CDM,C2629,HCPCS,0272,RC,,,both,,,19624.50,5887.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2325.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2282.33,16680.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 4.5MM X 15.0MM",SUP-494501512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 3.5MM CORONARY STENT",SUP-H7493941820350,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM RADIUS DISTAL VOLAR 3 LEAD THREAD",SUP-131227318,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,957.42,570.23,957.42,28,189.34,1383.8,"percent of total billed charges",
"AUG FEMORAL 4MM ATTUNE 6 KNEE DISTAL CEMENT REVISION STERILE",SUP-154706001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"KAISER [10500]",Kaiser,,4068.24,67,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL TRIATHLON X3 4 H12 MM KNEE CONDYLAR STABILIZE",SUP-5531-G-412-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1425.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1399.51,10228.56,"percent of total billed charges",
"VALVE AORTIC TRIFECTA GLIDE 25",SUP-TFGT-25A,CDM,S27800098,LOCAL,0278,RC,,,both,,,38367.00,11510.1,"PHCS [10601]",PHCS,,26856.9,70,,,,,0,4462.08,32611.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 CURVE 10MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962011,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1096.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1075.71,7862.03,"percent of total billed charges",
"BLADE SHAVER PINK 4.5MM RAZORCUT DYONICS ARTHROSCOPIC",SUP-7205318,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.00,84.9,"KAISER [10500]",Kaiser,,189.61,67,,,,,0,32.91,240.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII ALLOGRAFT 14MM 23MM",SUP-401214A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE CRYOPRESERVED 7MM",SUP-270070,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 22MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.822,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,40.86,298.61,"percent of total billed charges",
"RING ANNULOPLASTY SIZE 30 OD35MM ID28MM MITRAL VALVE SEMI RI",SUP-SARP-30,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"CIGNA [10200]","Cigna Local Plus",,3813.52,31.5,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X17MM 8D LORDOTIC RING WEDGE",SUP-617,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CIGNA [10200]",Cigna,,12600,40,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA MEDIAL CONGRUENT 6-7 E-F KNEE",SUP-42522100710,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS [10001]","Blue Cross HMO",,4224.36,39.2,,5311.50,4717.44,5388.59,31,1253.3,9159.96,"percent of total billed charges",
"CANN NASAL HIGH FLOW NEONATE VAPOTHERM 2000I SYSTEM 1.5MM",SUP-MN1100B,CDM,S27000186,LOCAL,0270,RC,,,both,,,60.20,18.06,"CIGNA [10200]","Cigna Local Plus",,32.21,53.5,,,,,0,7,51.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH ENDOSCP 4MM 13.4MM STRAIGHT ROUND SOFT SIDEHOLE",SUP-D-201-12704,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.26,63.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.45,178.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEMLESS SHOULDER",SUP-PHC-CONV,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"PHCS [10601]",PHCS,,19845,70,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 40MM 80CM 7MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM07040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UHC [10700]","United Healthcare",,11564.91,63.3,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 20MM 100CM 14MM 75CM",SUP-H965403100,CDM,C1876,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 22X9X11MM 12D EIT PLIF STERILE LATEX FREE",SUP-PUI31102,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"MULTIPLAN [10600]",Multiplan,,24097.5,85,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM GORILLA R3CON LOCK",SUP-P50-353-3526,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,155.43,1136.03,"percent of total billed charges",
"SPACER ALLOGRAFT 12X14X11MM OVAL PARALLEL SPINE CORTICAL",SUP-17111,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM T10 FULL THREAD STARDRIVE NONSTERILE",SUP-657120,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"FIRST HEALTH [10303]","First Health",,646.96,80,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revasc Lithotr-Stent Tib/Per",PX-481000130,CDM,C9773,HCPCS,0481,RC,,,both,,,28367.00,8510.1,"CIGNA [10200]","Cigna Open Access",,16140.82,56.9,,,,,0,3299.08,24111.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 50MM 5MM DECADE SMALL THREAD PLATE EXTREME",SUP-7145050,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]",Cigna,,1101.6,68,,1831.33,1831.33,1831.33,16,188.41,1377,"percent of total billed charges",
"NDL NERVE STIM SONOPLEX CANN TIP ULTRASOUND WAVE ECHOGENIC",SUP-001187-74,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.62,34.09,"KAISER [10500]",Kaiser,,76.13,67,,,,,0,13.21,96.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM SEMIRIGID OPEN ANTERIOR SEG SEWING",SUP-5300M26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5520,40,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE WIRE SAW 1.4MM 20IN 6 TWISTED WIRE GIGLI",SUP-FH415,CDM,S27000186,LOCAL,0270,RC,,,both,,,75.71,22.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,51.48,68,,,,,0,8.81,64.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 122MM STAINLESS STEEL 3.5MM SCREWS 4 HOLE LCP BONE",SUP-02.104.024,CDM,C1713,HCPCS,0278,RC,,,both,,,7481.12,2244.34,"CIGNA [10200]","Cigna Local Plus",,4002.4,53.5,,3978.14,359.25,3978.14,24,870.05,6358.95,"percent of total billed charges",
"CATH 100CM 5FR STRAIGHT ANGIOGRAPHIC POLYETHYLENE PERIPHERAL",SUP-G00159,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.19,73.86,"KAISER [10500]",Kaiser,,164.95,67,,,,,0,28.63,209.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 32MM 144CM 4.5MM CORONARY STENT",SUP-H7493941832450,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 47CM 28MM ABDOMEN THORAX WOVEN SOFT",SUP-M00202175428T0,CDM,L8670,HCPCS,0278,RC,,,both,,,16651.77,4995.53,"CIGNA [10200]","Cigna Open Access",,5578.34,33.5,,,,,0,427.53,14154,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIPHERAL CUTTING BALLOON 90CM 20MM 8MM BALLOON",SUP-PCB802090,CDM,C1725,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1914.23,41.1,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 18CM NARROW BASE PENOSCROTAL NARROW",SUP-EN8918,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.7MM 9MM VARIAX T5 LOCK NONSTERILE",SUP-662509,CDM,C1713,HCPCS,0278,RC,,,both,,,1075.03,322.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,127.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,125.03,913.78,"percent of total billed charges",
"HC Tx Inhal Aero Sputum",PX-410000004,CDM,94640,CPT,0410,RC,,,both,,,298.34,89.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,35.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",38.58,35.37,42.80,"1 through 10",34.7,298.34,"percent of total billed charges",
"DEVICE MAMMOSITE BRACHYTHERAPY BREAST CAVITY EVALUATION",SUP-9031,CDM,C1728,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MAMMOSITE BRACHYTHERAPY BREAST CAVITY EVALUATION",SUP-9031,CDM,C1728,HCPCS,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 5X5CM PURAPLY 25SQ CM","SUP-PURAPLY-COM 5X5",CDM,Q4195,HCPCS,0636,RC,,,both,,,15870.00,4761,"NOVANET [10819]",Novanet,,11902.5,75,,,,,0,263.34,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT 10MM ALIF",SUP-3W3210,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"BLUE CROSS [10001]","Blue Cross PPO",,8288.97,39.2,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 6MM 8D SMALL EIT CERVICAL INTERBODY FUSION",SUP-CUI8060S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"MULTIPLAN [10600]",Multiplan,,5278.5,85,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC",565,MS-DRG,,,,,,,inpatient,,,39169.44,11750.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15795.02,,"Fee schedule rate ($15,795.02). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,6044.26,24300.56,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 10CM 11.5FR DUODENAL BEND BILIARY PLASTIC TEMPORARY",SUP-M00545720,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,244.06,28.62,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 130CM 2FR .019IN PROGREAT",SUP-MC*PC2013Y,CDM,C1887,HCPCS,0272,RC,,,both,,,4754.10,1426.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1953.94,41.1,,,,,0,552.9,4040.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X100 135CM SL",SUP-48007010R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"NOVANET [10819]",Novanet,,644.26,75,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 7MM 6FR VASCULAR NITINOL PERIPHERAL",SUP-S-70-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross HMO",,3583.86,39.2,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 80MM 125CM 6MM 5FR .018IN VASCULAR NITINOL",SUP-G43773,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"CIGNA [10200]","Cigna Open Access",,2377.85,56.9,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 19MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P619,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Local Plus",,4470.41,53.5,,5372.07,4581.20,7242.98,23,971.79,7102.52,"percent of total billed charges",
"PLATE 12MM TITANIUM MULTIPLE HOLE OPEN DOOR PRECUT INTRINSIC",SUP-853-012,CDM,C1713,HCPCS,0278,RC,,,both,,,2624.40,787.32,"MULTIPLAN [10600]",Multiplan,,2230.74,85,,,,,0,305.22,2230.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"30FR X 3CM OPTILUME DCB, 24FR X 3CM BASIC BALLOON AND INFLAT",SUP-OPTBDL7010B,CDM,C1726,HCPCS,0272,RC,,,both,,,16525.50,4957.65,"AETNA [10100]","Aetna HMO/PPO",,13137.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET .241IN 77IN GRAVITY FLOW LARGE BORE NONVENT PIERCING PIN",SUP-654401,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.09,1.23,"NOVANET [10819]",Novanet,,3.07,75,,,,,0,0.48,3.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL BISHOP-HARMON .6MM 3.25IN IRIS SERRATE",SUP-355-123,CDM,S27000186,LOCAL,0270,RC,,,both,,,383.84,115.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,44.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.64,326.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 59CM STD ENDOCARDIUM 1 COIL ACTIVE DF4 TERMINAL",SUP-0292,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"UHC [10700]","United Healthcare",,10869.88,63.3,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FEMORAL IDENTITY IMPRINT 3 KNEE POSTERIOR STABILIZE",SUP-TPS-101-F03S,CDM,C1776,HCPCS,0278,RC,,,both,,,11716.20,3514.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3163.37,27,,,,,0,1362.59,9958.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PLLA HA 35MM 12MM 1.5MM ACL PCL CANNULATED",SUP-7209015,CDM,C1713,HCPCS,0278,RC,,,both,,,1839.23,551.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,526.39,28.62,,,,,0,213.9,1563.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION",RX-3037,CDM,J3010,HCPCS,0636,RC,00641-6247-25,NDC,both,1,ML,44.00,13.2,"CIGNA [10200]","Cigna Open Access",,3.19,,,,,,,1.28,37.4,"fee schedule",
"STENT ZILVER FLEX 35 100MM 125CM 6MM BILIARY NITINOL SELF",SUP-G50165,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"PHCS [10601]",PHCS,,4263,70,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE WIRE SAW 12 12IN STILLE BONE STAINLESS STEEL GIGLI",SUP-260-104,CDM,S27000186,LOCAL,0270,RC,,,both,,,552.66,165.8,"KAISER [10500]",Kaiser,,370.28,67,,,,,0,64.27,469.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM OFFSET 36MM HIP ACETABULAR MODULAR TYPE 1",SUP-650-0662,CDM,C1776,HCPCS,0278,RC,,,both,,,12375.84,3712.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1466.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1439.31,10519.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT LOWAX 90MM 22MM COLONIC NITINOL RECTAL",SUP-CNJF-22-090-230,CDM,C1876,HCPCS,0278,RC,,,both,,,15104.24,4531.27,"KAISER [10500]",Kaiser,,10119.84,67,,,,,0,1756.62,12838.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 125CM 5FR VERT CURVE",SUP-G12170,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"KAISER [10500]",Kaiser,,159.12,67,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 3MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140303,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1381.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 70CM 15MM 4FR 6 WIRE STONE UROLOGY",SUP-GU6359,CDM,S27200284,LOCAL,0272,RC,,,both,,,479.36,143.81,"UHC [10700]","United Healthcare",,303.43,63.3,,,,,0,55.75,407.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 91.44CM ADPTR QUICK CONNECT 6 POLE TO 9 POLE",SUP-0652,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6238.98,41.1,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 92CM 6FR 2-5-2MM SPACE D CURVE ELECTROPHYSIOLOGY",SUP-D610DR252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"NOVANET [10819]",Novanet,,2795.63,75,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN INNER SHILEY XLT 105MM 13.3MM 8MM ADULT EXTEND LENGTH",SUP-80XLTIN,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.83,1.45,"CIGNA [10200]","Cigna Local Plus",,2.58,53.5,,,,,0,0.56,4.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 50MM AXSOS STAINLESS STEEL 3.5MM FULL THREAD",SUP-340650,CDM,C1713,HCPCS,0278,RC,,,both,,,255.78,76.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,173.93,68,,,,,0,29.75,217.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 38MM 145CM 2.75MM CORONARY STENT",SUP-1125275-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]","Cigna Local Plus",,3123.33,53.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 18MM LOW PROFILE SCREWS TITANIUM T10 FULL",SUP-AR-8933-18,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,103.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",103.62,757.35,"percent of total billed charges",
"INSRT TIBIAL 7 11MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-711-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1425.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER SUT TAG TRANSPORTER STERILE LATEX FREE DISPOSABLE",SUP-14617,CDM,S27200284,LOCAL,0272,RC,,,both,,,961.07,288.32,"MULTIPLAN [10600]",Multiplan,,816.91,85,,,,,0,111.77,816.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION",RX-164538,CDM,J2250,HCPCS,0636,RC,00409-2308-22,NDC,both,2,ML,44.00,13.2,"FIRST HEALTH [10303]","First Health",,35.2,80,,,,,0,1.64,37.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X18X8MM COROENT 10D PEEK THORACOLUMBAR",SUP-6980855,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9504,40,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 6.5MM 85MM TITANIUM FULL THREAD CORTEX SELF",SUP-414.885,CDM,C1713,HCPCS,0278,RC,,,both,,,453.60,136.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,53.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",52.75,385.56,"percent of total billed charges",
"CATH AMPHIRION DEEP 150CM 210MM 2.5-3MM BROAD TAPER BALLOON",SUP-AMP253210152,CDM,C1725,HCPCS,0272,RC,,,both,,,2671.88,801.56,"PHCS [10601]",PHCS,,1870.32,70,,,,,0,310.74,2271.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEDG CARDIOVASCULAR LARGE 3X3/8IN FIRM",SUP-Z-705,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.03,122.41,"CIGNA [10200]","Cigna Open Access",,232.17,56.9,,,,,0,47.45,346.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 12MM .0145IN AXIUM PRIME 3D FRAME",SUP-FC-12-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1958.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEDG CARDIOVASCULAR 16X9.5MM PTFE BUFF SUT SOFT STERILE",SUP-X-4612,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.15,55.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,125.22,68,,,,,0,21.42,156.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CLSR 14GA 15CM SUT 1 HND",SUP-RSG-14F-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.80,52.44,"MULTIPLAN [10600]",Multiplan,,148.58,85,,,,,0,20.33,148.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X22X12MM COROENT WIDE XL",SUP-6912255,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"UHC [10700]","United Healthcare",,15040.08,63.3,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 140MM 2.4MM LONG SOLID MEASURE AO CONNECTION",SUP-P99-100-2414,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 C 38MM COCR HIP 2 MOBILITY",SUP-110024461,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"BLUE CROSS [10001]","Blue Cross HMO",,5077.45,39.2,,5311.50,4717.44,5388.59,31,1506.4,11009.78,"percent of total billed charges",
"CATH TEMPO AQUA 125CM 4FR 135D VERTEBRAL CURVE ANGIOGRAPHIC",SUP-SRD6108,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,22.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE 100CM 6FR .051IN .042IN STD JUDKINS LEFT",SUP-532620,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA [10200]",Cigna,,56.2,68,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC 2.8V 1.2AH 7.5MM 47.9X44.7MM SENSIA DR",SUP-SEDR01,CDM,C1785,HCPCS,0275,RC,,,both,,,17250.00,5175,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4936.95,28.62,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR",023,MS-DRG,,,,,,,inpatient,,,244377.61,73313.28,"AMBETTER EXCHANGE  [11102]",Ambetter,,35545.4,,"Case rate ($35,545.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $33,006.31, add-ons for qualifying new technology services are included. If operating cost exceeds $66,045.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,877.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $33,049.96. The transfer operating threshold is the transfer adjustment factor * $33,006.31 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,495.44. The transfer capital threshold is the transfer adjustment factor * $2,495.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,167301.84,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY",934,MS-DRG,,,,,,,inpatient,,,38385.89,11515.77,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,27921.35,,"Case rate ($13,712.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,732.97, add-ons for qualifying new technology services are included. If operating cost exceeds $45,772.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,344.68, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $12,749.81. The transfer operating threshold is the transfer adjustment factor * $12,732.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.67. The transfer capital threshold is the transfer adjustment factor * $962.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,38385.89,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC SPIN LOCK 33CM 5MM ROTICULATOR ENDO GRASP",SUP-174233,CDM,S27200284,LOCAL,0272,RC,,,both,,,619.73,185.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL DIALYSATE PHOXILLIUM PVC 5000ML 2 COMPARTMENT BAG",SUP-114905,CDM,S27200284,LOCAL,0272,RC,,,both,,,380.63,114.19,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSUFLOW PORT 12MM",SUP-4100-12,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSUFLOW PORT 12MM",SUP-4100-12,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER 110MM 2.9MM TRICUT 360D 5000 RPM SINUS M4",SUP-1882904HRE,CDM,S27200284,LOCAL,0272,RC,,,both,,,2025.00,607.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOTRACHEAL 7.5MM 5MM MAGILL CURVE NASAL ORAL 2 CUFF",SUP-86394,CDM,S27200284,LOCAL,0272,RC,,,both,,,399.33,119.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 1.5MM 5MM UNIVERSAL NEURO 3 SELF DRILL AXIAL",SUP-56-15935,CDM,C1713,HCPCS,0278,RC,,,both,,,645.25,193.57,"BLUE CROSS [10001]","Blue Cross HMO",,252.94,39.2,,957.42,156.86,7483.26,51,75.04,548.46,"percent of total billed charges",
"SYSTEM MULTI-LINK MINI VISION 8MM 2MM CORONARY STENT COCR",SUP-1007821-08,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRN5PL,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.0MM X 22.0MM",SUP-493002212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 11MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-811,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"PHCS [10601]",PHCS,,7988.82,70,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 45MM 2.5MM IJS AXIS",SUP-IJS-EAP-25450,CDM,C1713,HCPCS,0278,RC,,,both,,,2212.50,663.75,"BLUE CROSS [10001]","Blue Cross HMO",,867.3,39.2,,957.42,156.86,7483.26,51,257.31,1880.63,"percent of total billed charges",
"STEM FEMORAL 102.5MM 9MM PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51-107090,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11275.88,41.1,,6417.48,6417.48,6417.48,"1 through 10",3190.72,23319.95,"percent of total billed charges",
"PIN DISTRACTION 14MM ACIS STAINLESS STEEL NONSTERILE",SUP-02.600.024,CDM,C1713,HCPCS,0278,RC,,,both,,,635.85,190.75,"MULTIPLAN [10600]",Multiplan,,540.47,85,,,,,0,73.95,540.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE XL FEMALE SUEDE RUBBER BOTTOM WOOD SOLE",SUP-2007-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.43,23.23,"PHCS [10601]",PHCS,,54.2,70,,,,,0,9.01,65.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 28MM LCP TITANIUM DISTAL RADIUS LOCKING",SUP-04.210.128,CDM,C1713,HCPCS,0278,RC,,,both,,,1063.69,319.11,"PHCS [10601]",PHCS,,744.58,70,,,,,0,123.71,904.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X8MM ANATOMIC 11MM PEEK RADIOPAQUE CERVICAL",SUP-4240841,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 75MM 20MM ASNIS III TITANIUM PARTIAL THREAD",SUP-602675,CDM,C1713,HCPCS,0278,RC,,,both,,,1866.45,559.93,"CIGNA [10200]","Cigna Local Plus",,998.55,53.5,,3978.14,359.25,3978.14,24,217.07,1586.48,"percent of total billed charges",
"BLADE SAW 42X13.3X.61MM PRECISION THK.38MM XLONG WIDE THIN",SUP-2296-003-515,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,111.06,41.1,,,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL SIZE 5 L150MM CEMENTED CONSTRAINED NEXEL",SUP-840004515,CDM,C1776,HCPCS,0278,RC,,,both,,,36662.85,10998.85,"BLUE CROSS [10001]","Blue Cross HMO",,14371.84,39.2,,5311.50,4717.44,5388.59,31,4263.89,31163.42,"percent of total billed charges",
"SCR INTERFERENCE PEEK 30MM 9MM ARTHREX",SUP-AR-4030P-09,CDM,C1713,HCPCS,0278,RC,,,both,,,2323.13,696.94,"BLUE CROSS [10001]","Blue Cross HMO",,910.67,39.2,,957.42,156.86,7483.26,51,270.18,1974.66,"percent of total billed charges",
"SYSTEM SYNERGY XD MONORAIL 28MM 144CM 3.5MM CORONARY STENT",SUP-H7493941828350,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 38MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25038UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 4 132D",SUP-6720-0435,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2839.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2786.79,20367.74,"percent of total billed charges",
"CMPNT FEMORAL 3 66X61MM KNEE LEFT CEMENTED CRUCIATE",SUP-960003,CDM,C1776,HCPCS,0278,RC,,,both,,,18018.00,5405.4,"CIGNA [10200]","Cigna Local Plus",,5675.67,31.5,,5372.07,4581.20,7242.98,23,2095.49,15315.3,"percent of total billed charges",
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 58MM 32MM MARATHON",SUP-121932458,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,961.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 285MM 2.5MM KIRSCHNER STAINLESS STEEL TROCAR",SUP-292.26,CDM,C1713,HCPCS,0278,RC,,,both,,,75.76,22.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",8.81,64.4,"percent of total billed charges",
"VALVE MITRAL 17MM 27MM 24.5MM EPIC TISSUE STENT REDEFINE",SUP-E200-27M,CDM,S27800098,LOCAL,0278,RC,,,both,,,26775.00,8032.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3172.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 2 CURVE 14FR 12FR ACCESS PBAX PTFE SHEATH DIL",SUP-M635TU70020,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Local Plus",,3691.5,53.5,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM PYRENEES SPINE CERVICAL SELF STARTING",SUP-201-14014D,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,163.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",163.98,1198.5,"percent of total billed charges",
"HYDROCORTISONE 20 MG TABLET",RX-3734,CDM,,,0637,RC,59762-0075-01,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]",Cigna,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 3.5/4.5 MM SCR 10 HOLE VARIABLE ANGLE",SUP-02.221.122,CDM,C1713,HCPCS,0278,RC,,,both,,,16834.90,5050.47,"CIGNA [10200]","Cigna Local Plus",,5302.99,31.5,,3978.14,359.25,3978.14,24,1957.9,14309.67,"percent of total billed charges",
"STENT WALLSTENT MONORAIL 37MM 135CM 10MM ENDOPROSTHESIS",SUP-M001719060,CDM,C1876,HCPCS,0278,RC,,,both,,,16615.20,4984.56,"PHCS [10601]",PHCS,,11630.64,70,,,,,0,1932.35,14122.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 89MM 10.9MM 8MM 1 CANN CUFF SMOOTH ROUND TIP OBTR",SUP-8SCT,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.54,64.36,"PHCS [10601]",PHCS,,150.18,70,,,,,0,24.95,182.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 20MM 10MM STD WALL THIN WALL 2 BRANCH",SUP-SBT2002D,CDM,C1768,HCPCS,0278,RC,,,both,,,8611.20,2583.36,"UHC [10700]","United Healthcare",,5450.89,63.3,,,,,0,1001.48,7319.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SUCTION PORT INTUB SCOPE FLEXIBLE STERILE DISPOSABLE",SUP-11301CE/20,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.02,42.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,58.37,41.1,,,,,0,16.52,120.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 24MM 144CM 2.25MM CORONARY STENT",SUP-H7493941824220,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS RX 90CM 80MM 5.7-3.9FR 6MM BALLOON DILATATION",SUP-BD-L60080MR,CDM,C1725,HCPCS,0272,RC,,,both,,,923.40,277.02,"NOVANET [10819]",Novanet,,692.55,75,,,,,0,107.39,784.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULE ANALZR BD VERITOR PLUS",SUP-256066,CDM,S27000186,LOCAL,0270,RC,,,both,,,1846.28,553.88,"MULTIPLAN [10600]",Multiplan,,1569.34,85,,,,,0,214.72,1569.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SUPERORDERABLE - BASAL RATE ONLY",RX-411636,CDM,J2270,HCPCS,0636,RC,70092-1519-48,NDC,both,30,ML,102.20,30.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7.62,,,,,,,7.62,86.87,"fee schedule",
"INSRT TIBIAL 5 10MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158105110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"FIRST HEALTH [10303]","First Health",,8939.64,80,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1 CP-2 ETHIBOND GII QUICKANCHOR PLUS ROTATOR CUFF",SUP-212031,CDM,C1713,HCPCS,0278,RC,,,both,,,5782.20,1734.66,"AETNA [10100]","Aetna HMO/PPO",,4596.85,79.5,,1521.93,481.35,16760.95,30,672.47,4914.87,"percent of total billed charges",
"HIP STEM #8",SUP-1601-08127,CDM,C1776,HCPCS,0278,RC,,,both,,,21360.46,6408.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8544.18,40,,,,,0,2484.22,18156.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM LCP STAINLESS STEEL MEDIAL PROXIMAL",SUP-212.219,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"BLUE CROSS [10001]","Blue Cross HMO",,342.29,39.2,,957.42,156.86,7483.26,51,101.55,742.2,"percent of total billed charges",
"AVENIR 10, 1.5 X 3 COMPLEX PICO COIL",SUP-10USC01503,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5374.03,41.1,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE COOK 30 ATM INFLATION 20ML",SUP-G31027,CDM,S27200284,LOCAL,0272,RC,,,both,,,457.57,137.27,"PHCS [10601]",PHCS,,320.3,70,,,,,0,53.22,388.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUCICLOVINE F-18 INTRAVENOUS SOLUTION (9-10 MCI)|DISCARDED DRUG NOT ADMINISTE",RX-180065,CDM,A9588,HCPCS,0343,RC,08888-8878-27,NDC,both,1,UN,638.44,191.53,"MULTIPLAN [10600]",Multiplan,JW,542.67,85,,,,,0,74.25,638.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 24MM TI",SUP-SPL-35240-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,523.91,39.2,,957.42,570.23,957.42,28,155.43,1136.03,"percent of total billed charges",
"KIT WOODING SCOTT COMPLETE",SUP-66800212,CDM,S27000186,LOCAL,0270,RC,,,both,,,523.58,157.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,240.32,45.9,,,,,0,60.89,445.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX12MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183522,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"CIGNA [10200]","Cigna Local Plus",,4194.28,53.5,,5372.07,4581.20,7242.98,23,911.77,6663.81,"percent of total billed charges",
"SUT MONOCRYL 0 CT-1 36IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y946H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYPROPYLENE 20X20IN PERMANENT GRID 1 SMOOTH",SUP-F10246-2020P,CDM,C1781,HCPCS,0278,RC,,,both,,,39463.20,11838.96,"CIGNA [10200]",Cigna,,15785.28,40,,,,,0,4589.57,33543.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MNTR CARDIAC BIOMONITOR IV INJECTABLE",SUP-471155,CDM,C1764,HCPCS,0278,RC,,,both,,,23940.00,7182,"PHCS [10601]",PHCS,,16758,70,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 15MM 140CM .91-1.12MM 3MM CORONARY",SUP-RONYX30015W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"NOVANET [10819]",Novanet,,4079.25,75,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 50CM 11CM GREEN HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-6F-11-035,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"PHCS [10601]",PHCS,,56.03,70,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUTURING 2-0 48IN LOADING UNIT TRIPLE BRAIDED",SUP-170044,CDM,S27200284,LOCAL,0272,RC,,,both,,,376.71,113.01,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,154.83,41.1,,,,,0,43.81,320.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 15MM 2MM BALLOON DILATATION STERILE",SUP-220-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)VALVE AORTIC 23MM SAPIEN 3 ULTRA HEART TRANSCATHETER S",SUP-9750TFX23,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]","Cigna Open Access",,57285,33.5,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 8MM COCR",SUP-VAL-25080-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"NOVANET [10819]",Novanet,,1069.2,75,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 100CM 8FR ART4 CURVE GUIDING PTFE FEMORAL",SUP-H749343585000,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STIM NERVE AXONICS TRIAL NONSTERILE LATEX FREE DISPOSABLE",SUP-1601,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.00,495,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WOLVERINE CUTTING BALLOON (OTW)  4.00MM X 6MM",SUP-H74939402064000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT ZIPWIRE 20CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175270190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.3MM ICONIX XBRAID 2 STRAND INTELLIBRAID TAPE",SUP-3910500322,CDM,C1713,HCPCS,0278,RC,,,both,,,2797.50,839.25,"BLUE CROSS [10001]","Blue Cross PPO",,1096.62,39.2,,957.42,570.23,957.42,28,325.35,2377.88,"percent of total billed charges",
"HUMERAL CUP - 32MM DIA X 4MM THK",SUP-5570-3204,CDM,C1776,HCPCS,0278,RC,,,both,,,7980.00,2394,"BLUE CROSS [10001]","Blue Cross PPO",,3128.16,39.2,,3949.44,3949.44,3949.44,"1 through 10",928.07,6783,"percent of total billed charges",
"HEAD HUMERAL 18MM 41MM SHOULDER ECLIPSE STERILE ARTHROPLASTY",SUP-AR-9341-18,CDM,C1776,HCPCS,0278,RC,,,both,,,4105.50,1231.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1174.99,28.62,,,,,0,477.47,3489.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT TITANIUM 3MM SCR 2 HOLE LOW PROFILE BONE FOOT",SUP-AR-8952TS-02,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 35X18X9MM TRANSCONTINENTAL 10D LORDOTIC",SUP-375.392,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Varicell Zoster Dna Ultraquant",PX-306000167,CDM,87799,CPT,0306,RC,,,both,,,986.10,295.83,"NOVANET [10819]",Novanet,,739.58,75,,,,,0,0.99,838.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM RECONSTRUCTION VALVULAR RETRACTION",SUP-680R32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"NOVANET [10819]",Novanet,,9832.5,75,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 4 KNEE PRIMARY BEAD PA",SUP-5526-B-400,CDM,C1776,HCPCS,0278,RC,,,both,,,15783.75,4735.12,"CIGNA [10200]","Cigna Local Plus",,4971.88,31.5,,5372.07,4581.20,7242.98,23,1835.65,13416.19,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 30CM 5FR .035",SUP-M006192125090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,173.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 24CM 3CM 7FR .035IN",SUP-M006192142190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"MULTIPLAN [10600]",Multiplan,,1185.95,85,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 1.5 MM SCR H EXTENDED BONE LEFT HAND",SUP-246.483,CDM,C1713,HCPCS,0278,RC,,,both,,,2723.70,817.11,"KAISER [10500]",Kaiser,,1824.88,67,,,,,0,316.77,2315.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 200MM 5.5MM STRAIGHT PERCUTANEOUS CCM",SUP-1555006200,CDM,C1713,HCPCS,0278,RC,,,both,,,5819.00,1745.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,676.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",676.75,4946.15,"percent of total billed charges",
"STENT EXPEL TWIST-LOC 14CM 8FR SHORT LENGTH URETERAL",SUP-H7493936108140,CDM,C2617,HCPCS,0278,RC,,,both,,,1142.10,342.63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,135.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,132.83,970.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 15MM 145CM 3.5MM BALLOON DILATATION",SUP-1400350-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 80MM 6FR 10MM .035IN LOW PROFILE BALLOON",SUP-B1100-080,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"UHC [10700]","United Healthcare",,487.09,63.3,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SEEKER 150CM SPRT HYDROPHILIC PERIPHERAL RADIOPAQUE",SUP-SK15035M,CDM,C1887,HCPCS,0272,RC,,,both,,,1498.50,449.55,"AETNA [10100]","Aetna HMO/PPO",,1191.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL LEGION 4 LEFT KNEE REVISION",SUP-71424004,CDM,C1776,HCPCS,0278,RC,,,both,,,23133.60,6940.08,"CIGNA [10200]","Cigna Local Plus",,7287.08,31.5,,5372.07,4581.20,7242.98,23,2690.44,19663.56,"percent of total billed charges",
"STENT 24CM 3CM 7FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145371010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"MULTIPLAN [10600]",Multiplan,,821.87,85,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 4FR PIGTAIL CURVE ANGIOGRAPHIC RADIOPAQUE",SUP-H787107140025,CDM,C1887,HCPCS,0272,RC,,,both,,,190.36,57.11,"NOVANET [10819]",Novanet,,142.77,75,,,,,0,22.14,161.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cannula Nasal",PX-E27000076,CDM,E27000076,LOCAL,0270,RC,,,both,,,60.43,18.13,"KAISER [10500]",Kaiser,,40.49,67,,,,,0,7.03,51.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 8MM 140CM 3MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927408300,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 167MM 11MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-211,CDM,C1776,HCPCS,0278,RC,,,both,,,19885.95,5965.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5691.36,28.62,,,,,0,2312.74,16903.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION TENSION BAND SYSTEM 50MM ORTHOPEDIC STAINLESS",SUP-TB-1550K,CDM,C1713,HCPCS,0278,RC,,,both,,,2962.50,888.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,351.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",344.54,2518.13,"percent of total billed charges",
"GRAFT STENT 120MM 14MM 13FR 10FR TRIVASCULAR OVATION PRIME",SUP-TV-IL1414120-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13723.29,41.1,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 32MM 0D D HIP X3 TRIDENT STERILE LATEX FREE",SUP-723-00-32D,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"BLUE CROSS [10001]","Blue Cross PPO",,3349.89,39.2,,3949.44,3949.44,3949.44,"1 through 10",993.86,7263.8,"percent of total billed charges",
"SCR BONE 4MM 42MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.442TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"CIGNA [10200]","Cigna Local Plus",,1081.53,53.5,,3978.14,359.25,3978.14,24,235.11,1718.32,"percent of total billed charges",
"CAGE SPINAL 14X11X7MM COROENT 5D SMALL PEEK NONSTERILE LATEX",SUP-6807714,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 4MM DRNG SILICONE 100ML CENTER HOLE FLAT BULB",SUP-6649,CDM,S27200284,LOCAL,0272,RC,,,both,,,329.12,98.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.28,279.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 80MM 80CM 8MM 8FR STRAIGHT VASCULAR COVER",SUP-AVSM08080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +14.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-ZA90030145,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,136.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROLL 24INX6IN VINYL POSITIONING PEDIATRIC TUMBLE FORMS 2",SUP-2794B,CDM,S27000186,LOCAL,0270,RC,,,both,,,806.11,241.83,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DIREXION FATHOM 155CM 180CM 2.4-3FR .021IN MICRO",SUP-M001195620,CDM,C1887,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING MONORAIL 135CM 20MM 6FR 4.5MM 4FR BALLOON",SUP-H74939031452010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEXTROSE 40 % ORAL GEL",RX-27466,CDM,,,0637,RC,00574-0070-30,NDC,both,37.5,GR,24.77,7.43,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 135CM 180MM 5MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171051810,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TEMPO 80CM 5FR UNI SELECT I CURVE ANGIOGRAPHIC NEON SLX",SUP-451518S0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS POWERFLEX P3 80CM 20MM 5FR 4MM 7.5MM BALLOON",SUP-4204020S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BOTTLE DRNG DISCHARGE PACK ROCKET IPC 1000ML NONSTERILE",SUP-R51400DP,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,inpatient,,,39589.71,11876.91,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP HEMOSTATIC 2.8MM BRAID CATH ROTATION CONTROL KNOB",SUP-M00521231,CDM,S27200284,LOCAL,0272,RC,,,both,,,1449.90,434.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LANTERN 135CM .025IN MICRO DELIVERY SYSTEM HIGH FLOW",SUP-PXSLIMLAN135STR,CDM,S27200284,LOCAL,0272,RC,,,both,,,4071.00,1221.3,"CIGNA [10200]","Cigna Local Plus",,2177.99,53.5,,,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN RIGHT BACKUP 4 CURVE GUIDING",SUP-LA6RBU40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1 KNEE RIGHT POSTERIOR STABILIZE BEAD",SUP-5516-F-102,CDM,C1776,HCPCS,0278,RC,,,both,,,23001.30,6900.39,"CIGNA [10200]","Cigna Open Access",,7705.44,33.5,,5302.19,4377.88,6578.61,27,2675.05,19551.11,"percent of total billed charges",
"GRAFT BONE CORNERSTONE ASR CORTICAL LORDOTIC FREEZE DRIED",SUP-340541,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY PRO 69CM 7FR 130D GUIDING INNER STERILE LATEX",SUP-8102,CDM,C1887,HCPCS,0272,RC,,,both,,,1386.50,415.95,"MULTIPLAN [10600]",Multiplan,,1178.53,85,,,,,0,161.25,1178.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 59CM ENDOTAK RELIANCE S ENDOCARDIAL STEROID ELUTING",SUP-137,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]","Cigna Local Plus",,4781.7,31.5,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET XL 360 SOFT 5MM X 15CM",SUP-M0036125150,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR ANGIOGRAPHY 12ML CONTROL SOLID PLUNGER RING GRIP FIXED",SUP-STP601,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.20,15.66,"CIGNA [10200]","Cigna Local Plus",,27.93,53.5,,,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT FX 26MM",SUP-EVOLUTFX-26,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20263.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.6MM 12MM STD SPINE VARIABLE ANGLE SELF DRILL",SUP-184.152,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"CIGNA [10200]","Cigna Open Access",,534.86,56.9,,1144.80,304.56,2275.09,66,109.32,799,"percent of total billed charges",
"FOL URETHRAL 13.35IN 16FR HEYMAN PLASTIC DILATION CATH",SUP-021116,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.13,65.14,"UHC [10700]","United Healthcare",,137.44,63.3,,,,,0,25.25,184.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLACK USA ELITE SYSTEM USA SERIES",SUP-VE-F,CDM,S27200284,LOCAL,0272,RC,,,both,,,1214.65,364.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.26,1032.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 135CM 30MM 4MM .035IN BALLOON",SUP-AB35W04030135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"NOVANET [10819]",Novanet,,507.87,75,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 5.0MM X 26.0MM",SUP-495002612,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 18.5X9MM PRECISION MEDIUM MICRO THIN STAINLESS",SUP-2296003105,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.45,67.03,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.99,189.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNEE CONSTRUCT 1",SUP-CAP-Z-K-1,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7056,40,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION 120MM .018IN LOW PROFILE 4FR 2.5MM",SUP-83969-02,CDM,C1725,HCPCS,0272,RC,,,both,,,3037.50,911.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,359.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,353.26,2581.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED II 100CM 4CM 11FR 28MM BALLOON DILATATION",SUP-611660,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"AETNA [10100]","Aetna HMO/PPO",,4227.84,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC BLUE BEAVER MINI-BLADE STRAIGHT GRINDLESS",SUP-BEAVER6900,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.40,65.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,147.83,68,,,,,0,25.28,184.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Kidney Img Flow W Drug Mult",PX-341000046,CDM,78709,CPT,0341,RC,,,both,,,3154.08,946.22,"FIRST HEALTH [10303]","First Health",,2523.26,80,,,,,0,366.82,2680.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00165,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"PHCS [10601]",PHCS,,765.45,70,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 20MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520020L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR ACTIS DUOFIX 2 STD OFFSET HIP STERILE",SUP-101011020,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8228.59,27,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC",542,MS-DRG,,,,,,,inpatient,,,49552.32,14865.7,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,11286.44,,"Case rate ($10,957.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,174.97, add-ons for qualifying new technology services are included. If operating cost exceeds $43,214.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,151.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $10,188.43. The transfer operating threshold is the transfer adjustment factor * $10,174.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.28. The transfer capital threshold is the transfer adjustment factor * $769.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,44054.74,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 8.6FR HELIX VENTRICLE 1 COIL ACTIVE",SUP-693552,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"KAISER [10500]",Kaiser,,11505.24,67,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRD SURGICAL 10IN NARROW INGE LARGE PATTERN LAMINA ADULT 8",SUP-57-5506,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON SIZING 3.5CM 6FR AMPLATZER II .035IN CARDIOVASCULAR",SUP-9-SB-018,CDM,S27200284,LOCAL,0272,RC,,,both,,,2445.00,733.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,289.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,284.35,2078.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN DEBRIDEMENT WITHOUT CC/MCC",572,MS-DRG,,,,,,,inpatient,,,50848.66,15254.6,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST OP BRA 40D BLACK",SUP-B01G-40D-B,CDM,S27000186,LOCAL,0270,RC,,,both,,,178.18,53.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 125CM 6FR .07IN MPA CURVE",SUP-SM7477,CDM,C1887,HCPCS,0272,RC,,,both,,,1310.50,393.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER 4MM TRUDI 0D STRAIGHT STERILE LATEX FREE",SUP-TSB4STR,CDM,S27200284,LOCAL,0272,RC,,,both,,,3562.50,1068.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRACKER NAVIGATION 175MM 4MM ELECTROMAGNETIC 0D 30D 45D",SUP-8000060001,CDM,S27200284,LOCAL,0272,RC,,,both,,,8680.20,2604.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INDIGO CAT LIGHTNING 100CM 12FR THROMBECTOMY HTORQ",SUP-LITNG12HTORQ100,CDM,C1757,HCPCS,0272,RC,,,both,,,42147.00,12644.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"PROBE CRYOSURGICAL 3IN 2.4MM ERBOKRYO FLEXIBLE",SUP-20416-031,CDM,C2618,HCPCS,0272,RC,,,both,,,28318.50,8495.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"HEAD FEMORAL +4MM 44MM CERAMIC DELTA",SUP-400-03-443,CDM,S27200284,LOCAL,0272,RC,,,both,,,16953.92,5086.18,"KAISER [10500]",Kaiser,,11359.13,67,,,,,0,1971.74,14410.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Declot Impl Vad/Cath",PX-361000121,CDM,36593,CPT,0361,RC,,,both,,,1572.38,471.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1572.38,,"Case rate ($1,729.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,182.87,1572.38,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR STRAIGHT 145CM .038IN PTFE FIXED CORE",SUP-007042,CDM,C1769,HCPCS,0272,RC,,,both,,,87.00,26.1,"UHC [10700]","United Healthcare",,55.07,63.3,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT EVEROLIMUS ELUTING CORONARY STENT SYSTEM 5.0",SUP-1804500-15,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE-SR ALLOGRAFT FREEZE DRIED BLOCK 14X14",SUP-200744,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 70MM TITANIUM FULL THREAD CANCELLOUS NONSTERILE",SUP-607370,CDM,C1713,HCPCS,0278,RC,,,both,,,316.68,95,"CIGNA [10200]",Cigna,,215.34,68,,1831.33,1831.33,1831.33,16,36.83,269.18,"percent of total billed charges",
"KIT OXIMETER HANDHELD SENSOR RAD-5",SUP-9198,CDM,S27000186,LOCAL,0270,RC,,,both,,,4554.00,1366.2,"FIRST HEALTH [10303]","First Health",,3643.2,80,,,,,0,529.63,3870.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ER Thoracotomy W/Card Mas",PX-450000374,CDM,32160,CPT,0450,RC,,,both,,,2227.00,668.1,"CIGNA [10200]",Cigna,,1833,,,,,,,2.23,1892.95,"case rate",
"HC ER Thoracotomy W/Card Mas",PX-450000374,CDM,32160,CPT,0450,RC,,,both,,,2227.00,668.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1862,,,,,,,2.23,1892.95,"case rate",
"STEM FEMORAL 127MM 17MM MRS KNEE",SUP-6485-3-117,CDM,C1776,HCPCS,0278,RC,,,both,,,14800.50,4440.15,"BLUE CROSS [10001]","Blue Cross HMO",,5801.8,39.2,,5311.50,4717.44,5388.59,31,1721.3,12580.43,"percent of total billed charges",
"SCR GUIDE AUG REAM",SUP-110040300,CDM,S27200284,LOCAL,0272,RC,,,both,,,650.75,195.22,"UHC [10700]","United Healthcare",,411.92,63.3,,,,,0,75.68,553.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 70MM TITANIUM FULL THREAD CANCELLOUS NONSTERILE",SUP-607370,CDM,C1713,HCPCS,0278,RC,,,both,,,316.68,95,"KAISER [10500]",Kaiser,,212.18,67,,,,,0,36.83,269.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30X4.8MM TITANIUM LARGE THICK TISSUE LINEAR",SUP-4901T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1346.54,403.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,618.06,45.9,,,,,0,156.6,1144.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 10 16MM KNEE AOX CRUCIATE RETAIN FIX BEARING A",SUP-151621016,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1308.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYCLOPENTOLATE 2 % EYE DROPS",RX-9700,CDM,,,0637,RC,00065-0397-02,NDC,both,2,ML,210.31,63.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,143.01,68,,,,,0,24.46,178.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 90MM STEALTH 5 SOFT FIBRA STERILE LATEX FREE",SUP-A0G04,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 16MM PERSONA 7-9 C-D KNEE LEFT CONDYLAR",SUP-42512800516,CDM,C1776,HCPCS,0278,RC,,,both,,,16308.84,4892.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1932.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1896.72,13862.51,"percent of total billed charges",
"STENT PROTEGE EVERFLEX 20MM 120CM 5MM .079IN BILIARY NITINOL",SUP-PRB35-05-020-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]",Cigna,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brca1&2 Gen Full Seq Dup/Del",PX-310000039,CDM,81162,CPT,0310,RC,,,both,,,4300.00,1290,"FIRST HEALTH [10303]","First Health",,3440,80,,,,,0,0.01,4300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Hemo Cmpl Bi Std",PX-320000229,CDM,93985,CPT,0320,RC,,,both,,,2305.00,691.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1058,45.9,,,,,0,268.07,1959.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB SILVER WHITE 6X4.25IN PADPRO ZOLL A CARBON",SUP-2001Z-C,CDM,S27000186,LOCAL,0270,RC,,,both,,,1336.50,400.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,549.3,41.1,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 10-0 BV75-4 5IN MONOFILAMENT BLACK NONABSORBABLE",SUP-2850G,CDM,S27200284,LOCAL,0272,RC,,,both,,,296.50,88.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,136.09,45.9,,,,,0,34.48,252.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE OVITEX 15X15CM OVINE MONOFILAMENT",SUP-F10244-1520L,CDM,C1781,HCPCS,0278,RC,,,both,,,24580.84,7374.25,"FIRST HEALTH [10303]","First Health",,19664.67,80,,,,,0,2858.75,20893.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLUCAGON (HUMAN RECOMBINANT) 1 MG/ML INJECTION SUPERORDERABLE",RX-408807,CDM,J1611,HCPCS,0636,RC,63323-0594-03,NDC,both,1,UN,905.40,271.62,"KAISER [10500]",Kaiser,,606.62,67,,,,,0,107.29,769.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 8 16MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620816,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1308.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 50MM 22GA SONOPLEX II FACET S TIP INJECTION",SUP-001287-74,CDM,C9812,HCPCS,0272,RC,,,both,,,139.20,41.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 62MM 23MM ESOPHAGEAL PARTIAL COVER OTW STERILE",SUP-M00517710,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7508.97,41.1,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Upr Ext Nonjnt W Cntrst",PX-610000025,CDM,73219,CPT,0610,RC,,,both,,,4061.00,1218.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,683,,"Per diem ($683). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,472.29,3451.85,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION",RX-230757,CDM,J0613,HCPCS,0636,RC,44567-0622-01,NDC,both,100,ML,100.65,30.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18,,,,,,,10.49,85.55,"fee schedule",
"SUT PROLENE 2 TP-1 60IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8825G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IB KIT, MINI, PEEK, CC FT, W/ JUMPSTART",SUP-AR-1787PJ-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10831.28,3249.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3099.91,28.62,,,,,0,1259.68,9206.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL VLP MINIMOD 1.5MM LG",SUP-71177196,CDM,S27200284,LOCAL,0272,RC,,,both,,,1184.63,355.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,140.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,137.77,1006.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE FIBERSTICK 2-0 50IN 1 END STIFFEN BRAID",SUP-AR-7222,CDM,S27200284,LOCAL,0272,RC,,,both,,,383.67,115.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,45.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.62,326.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GAUGE DEPTH MEASURING 1.3 MM 1.5 MM SCREWS NONSTERILE",SUP-319.004,CDM,S27000186,LOCAL,0270,RC,,,both,,,6589.22,1976.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,780.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,766.33,5600.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 6MM 2 7.5MM TENOLOK HI-FI GUIDE PIN DRILL BIT",SUP-T60S75,CDM,C1713,HCPCS,0278,RC,,,both,,,8016.83,2405.05,"CIGNA [10200]",Cigna,,5451.44,68,,1831.33,1831.33,1831.33,16,932.36,6814.31,"percent of total billed charges",
"SET BILIARY 4CM 7FR ZIMMON .035IN GWIRE 2.8MM MINIMUM ACCESS",SUP-G21393,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,565.12,45.9,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 43MM HIP MODULAR ENDOPROSTHESIS UNITRAX HIP",SUP-6942-5-043,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA [10200]","Cigna Local Plus",,1673.32,53.5,,5372.07,4581.20,7242.98,23,363.75,2658.55,"percent of total billed charges",
"FEBUXOSTAT 40 MG TABLET",RX-97133,CDM,,,0637,RC,60687-0538-11,NDC,both,1,UN,15.09,4.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.75,12.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Infliximab",PX-301000623,CDM,80230,CPT,0301,RC,,,both,,,223.25,66.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,36.25,,"Fee schedule rate ($36.25). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,189.76,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.7MM CANNULATED STERILE",SUP-03.333.102S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3129.15,938.74,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1286.08,41.1,,,,,0,363.92,2659.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK PHACOEMULSIFICATION .9MM INFINITI KELMAN 45D MINI",SUP-8065751722,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"AETNA [10100]","Aetna HMO/PPO",,579.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 140MM 10-14MM 13FR 10FR TRIVASCULAR OVATION",SUP-TV-IL1410140-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"PHCS [10601]",PHCS,,23373,70,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK VITRECTOMY INFINITI ANTERIOR STERILE DISPOSABLE",SUP-8065750157,CDM,S27200284,LOCAL,0272,RC,,,both,,,1232.09,369.63,"AETNA [10100]","Aetna HMO/PPO",,979.51,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.29,1047.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 150D STD BARREL 94MM STAINLESS STEEL 5 HOLE",SUP-281.450,CDM,C1713,HCPCS,0278,RC,,,both,,,2156.11,646.83,"AETNA [10100]","Aetna HMO/PPO",,1714.11,79.5,,1521.93,481.35,16760.95,30,250.76,1832.69,"percent of total billed charges",
"CATH ATLANTIS SR PRO MONORAIL 135CM 3.2FR 40MHZ ULTRASOUND",SUP-H749389420,CDM,C1753,HCPCS,0272,RC,,,both,,,4554.00,1366.2,"PHCS [10601]",PHCS,,3187.8,70,,,,,0,529.63,3870.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEART FAILURE AND SHOCK WITH CC",292,MS-DRG,,,,,,,inpatient,,,20714.23,6214.27,"CIGNA [10200]",Cigna,,11132.09,,"Fee schedule rate ($11,132.09). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,5266.39,20714.23,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 26FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0165SI26,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.82,19.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.54,55.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE POSITIONING 22X12X9IN DEVON FOAM BODY ALIGNMENT 30322",SUP-31143392,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.90,23.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.06,66.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2 X 1 HELICAL PICO COIL",SUP-10USH02001,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AETNA [10100]","Aetna HMO/PPO",,9319.86,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP050250150 PLUS US D5L250UL1500",SUP-PCP050250150,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,150.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 2.5FR UMBILICAL POLYURETHANE 1 LUMEN RADIOPAQUE SMOOTH",SUP-P1UVC-2530,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.20,41.76,"NOVANET [10819]",Novanet,,104.4,75,,,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER BIPOLAR AQUAMAN EDIDURAL VIEN",SUP-23-121-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAXCESS-C SCREW, 12MM DISTRACTION",SUP-7670212,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP PRIMARY STEM 16MM MINI",SUP-113636,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"KAISER [10500]",Kaiser,,8442,67,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Mphmtrc Ea 1",PX-312000085,CDM,0852T,CPT,0312,RC,,,both,,,104.00,31.2,"CIGNA [10200]","Cigna Open Access",,59.18,56.9,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 6MM 1.14MM 6MM GOODE 6MM EAR SILICONE",SUP-24752,CDM,S27200284,LOCAL,0272,RC,,,both,,,356.70,107.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,42.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.48,303.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER FEMORAL 15MM ACCOLADE UNIVERSAL HIP DISTAL CEMENT",SUP-1067-0015,CDM,C1776,HCPCS,0278,RC,,,both,,,620.57,186.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,73.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,72.17,527.48,"percent of total billed charges",
"KIT NEUROSURGICAL 3MM VISUALASE LASER DIFFUSE TIP",SUP-NEUROKIT-400-T3,CDM,S27200284,LOCAL,0272,RC,,,both,,,68400.00,20520,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,28112.4,41.1,,,,,0,7954.92,58140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD 16FR URETHRAL NATURAL RUBBER SILICONE ELASTOMER 30",SUP-266716,CDM,S27200284,LOCAL,0272,RC,,,both,,,2.29,0.69,"UHC [10700]","United Healthcare",,1.45,63.3,,,,,0,0.27,1.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 22.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962336,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"NOVANET [10819]",Novanet,,10877.85,75,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732052,CDM,C1776,HCPCS,0278,RC,,,both,,,9510.48,2853.14,"CIGNA [10200]","Cigna Local Plus",,5088.11,53.5,,5372.07,4581.20,7242.98,23,1106.07,8083.91,"percent of total billed charges",
"HC Hepatitis B Surface Ag Eia",PX-306000103,CDM,87340,CPT,0306,RC,,,both,,,216.50,64.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,36.66,,,,,,,0.22,184.03,"fee schedule",
"BNDG 10YDX3IN UNNA-Z UNNA BOOT ZINC OXIDE PLASTIC WITHOUT",SUP-NONUNNA13,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.27,14.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.5,40.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ACCULINK 40MM 132CM 7MM STRAIGHT VASCULAR NITINOL",SUP-1011339-40,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1109.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.2MM OCCIPITOCERVICAL FLEXIBLE STERILE DISPOSABLE",SUP-G3600321,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC",520,MS-DRG,,,,,,,inpatient,,,88042.13,26412.64,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,9544.76,,"Case rate ($9,266.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,604.81, add-ons for qualifying new technology services are included. If operating cost exceeds $41,644.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,032.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,616.19. The transfer operating threshold is the transfer adjustment factor * $8,604.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.57. The transfer capital threshold is the transfer adjustment factor * $650.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,43615.9,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 3.5MM PRECUT",SUP-3603740,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 C 38MM COCR HIP 2 MOBILITY",SUP-110024461,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1534.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1506.4,11009.78,"percent of total billed charges",
"PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE",RX-26225,CDM,,,0637,RC,60687-0736-11,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 3MM SURGICAL NONSTERILE SINGLE USE",SUP-3606030,CDM,S27000186,LOCAL,0270,RC,,,both,,,1837.50,551.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,217.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 7MM 9.5MM 240MM HUMERAL LEFT MULTILOC INTRAMEDULLARY",SUP-04.017.240S,CDM,C1713,HCPCS,0278,RC,,,both,,,11172.76,3351.83,"MULTIPLAN [10600]",Multiplan,,9496.85,85,,,,,0,1299.39,9496.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NEURON 125CM 6FR SIMMONS CURVE THROMBECTOMY SELECT",SUP-PNS6F125SIM,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035424100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"UHC [10700]","United Healthcare",,8934.57,63.3,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR JB1 CURVE URETERAL STAINLESS STEEL",SUP-M0064003041,CDM,C1758,HCPCS,0272,RC,,,both,,,149.15,44.74,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,61.3,41.1,,,,,0,17.35,126.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRA-THIN/SDS 135CM 40MM 5.3FR 4MM .035IN STD BALLOON",SUP-M001175680,CDM,C1725,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 47CM 26MM ABDOMEN THORAX WOVEN SOFT",SUP-M00202175426T0,CDM,L8670,HCPCS,0278,RC,,,both,,,13481.36,4044.41,"UHC [10700]","United Healthcare",,8533.7,63.3,,,,,0,427.53,11459.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X16MM VERTE-STACK CORNERSTONE PSR 8MM",SUP-6240864,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 80MM 4FR 3MM ROUND LOW PROFILE TAPER",SUP-A2030-080,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 4.5MM 32MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.532.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,69.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",69.37,507.01,"percent of total billed charges",
"CATH SABER 150CM 20MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,589.25,41.1,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTENDER TIP PERCLOT L20 CM EXTENDER TIP",SUP-PCET020,CDM,S27200284,LOCAL,0272,RC,,,both,,,282.44,84.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,192.06,68,,,,,0,32.85,240.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SOFSILK 0 C-16 30IN BRAIDED COATED BLACK NONABSORBABLE",SUP-SS-680,CDM,S27200284,LOCAL,0272,RC,,,both,,,3134.70,940.41,"PHCS [10601]",PHCS,,2194.29,70,,,,,0,364.57,2664.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 10MM 1.5MM BALLOON DILATATION STERILE",SUP-215-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL ADULT L H2.25IN FOR 16-19IN NONTOXIC HYPOALL",SUP-A9918-13,CDM,S27000186,LOCAL,0270,RC,,,both,,,97.27,29.18,"CIGNA [10200]",Cigna,,66.14,68,,,,,0,11.31,82.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X7MM COALITION MIS 7D 12MM TITANIUM STERILE",SUP-1136.2477,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 2X1CM AXOGUARD HA+ NERVE PROTCT EXTRACELLULAR",SUP-AGHA12,CDM,C1763,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 15MM ATLANTIS TITANIUM SPINE CERVICAL",SUP-3125215,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM LCP STAINLESS STEEL FOREFOOT MIDFOOT",SUP-02.211.014,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"BLUE CROSS [10001]","Blue Cross HMO",,352.07,39.2,,957.42,156.86,7483.26,51,104.45,763.41,"percent of total billed charges",
"BIT DRILL 87MM 1.9MM PROFYLE TWIST HAND AO MODULAR SHAFT END",SUP-6019326,CDM,S27200284,LOCAL,0272,RC,,,both,,,724.63,217.39,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL ASPIRATION 130CM 20GA 1.8MM EXCELON TRANSBRONCHIAL",SUP-M00564111,CDM,S27200284,LOCAL,0272,RC,,,both,,,664.10,199.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEMOSTAT ABSORBABLE SURGICEL NU-KNIT LATEX FREE STERILE",SUP-1943S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1487.17,446.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP SURGICAL SOFT/FIBRA 6MM .25 FORCE SPRING ATRAUMATIC",SUP-G-6054,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OSTEOTOM 9.75INX8MM LAMBOTTE CURVED SURGICAL",SUP-FL781R,CDM,S27200284,LOCAL,0272,RC,,,both,,,298.50,89.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT NEUROSURGICAL 15MM LASER DIFFUSE",SUP-NEUROKIT-600-T15,CDM,S27200284,LOCAL,0272,RC,,,both,,,68400.00,20520,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"EXTRACTOR, BROKEN SCREW, 6 MM, 6"" LONG, SINGLE USE",SUP-SXT007-BR3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"KAISER [10500]",Kaiser,,1984.88,67,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 1 CT 36IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Y359H,CDM,S27200284,LOCAL,0272,RC,,,both,,,316.59,94.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,36.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.82,269.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VALVE AORTIC 23MM SAPIEN 3 EDWARDS HEART TRANSCATHETE",SUP-9750TFX23A,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]","Cigna Open Access",,57285,33.5,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 11MM 2.4FR GEMINI HELICAL",SUP-M0063303060,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"CIGNA [10200]","Cigna Local Plus",,791.56,53.5,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRI-STAPLE 2.0 RELOAD 45MM MEDIUM/THICK TISSUE PURPLE",SUP-SIG45AMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1328.81,398.64,"KAISER [10500]",Kaiser,,890.3,67,,,,,0,154.54,1129.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP BARDEX IC COMPLETE CARE",SUP-A319416AM,CDM,S27200284,LOCAL,0272,RC,,,both,,,268.66,80.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,31.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.25,228.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP FLEX-MINI 35MM CLSR LEFT ATRIAL APPENDAGE",SUP-ACHM35,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"CIGNA [10200]",Cigna,,6210,40,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SILVERHAWK MEC 135CM 6CM 2-3MM .08IN ATHERECTOMY",SUP-P4044,CDM,C1714,HCPCS,0272,RC,,,both,,,18238.50,5471.55,"AETNA [10100]","Aetna HMO/PPO",,14499.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2121.14,15502.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 12.5MM KNEE AOX STABILIZE ROTATE PLATFORM",SUP-196192112,CDM,C1776,HCPCS,0278,RC,,,both,,,13386.00,4015.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3614.22,27,,,,,0,1556.79,11378.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 6MM THORACIC KNIT HEMASHIELD GOLD",SUP-M002020951060,CDM,C1768,HCPCS,0278,RC,,,both,,,2540.03,762.01,"CIGNA [10200]",Cigna,,1727.22,68,,,,,0,295.41,2159.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 9MM KNEE XLPE CRUCIATE RETAINING HIGH",SUP-71453111,CDM,C1776,HCPCS,0278,RC,,,both,,,15556.05,4666.81,"UHC [10700]","United Healthcare",,9846.98,63.3,,8601.07,8395.67,8601.07,"1 through 10",1809.17,13222.64,"percent of total billed charges",
"IMPL BREAST 465-505ML STYLE 68HP SMOOTH ANTERIOR DIAPH VALVE",SUP-68HP-465,CDM,C1789,HCPCS,0278,RC,,,both,,,2250.00,675,"NOVANET [10819]",Novanet,,1687.5,75,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 15MM ENDO GIA TITANIUM EXTRA THICK TISSUE",SUP-SIGRADXT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2947.73,884.32,"FIRST HEALTH [10303]","First Health",,2358.18,80,,,,,0,342.82,2505.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 6MM TARGET 360D STD PLATINUM",SUP-M0035466150,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1641.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL TISSUE CLSR VISTASEAL FIBRIN HUMAN 2ML",SUP-VST02,CDM,S25000001,LOCAL,0250,RC,,,both,,,1459.86,437.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,600,41.1,,,,,0,169.78,1240.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 48MM PEG REUNION X3 STERILE LATEX FREE TOTAL",SUP-5542-P-0048,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"FIRST HEALTH [10303]","First Health",,7222.18,80,,,,,0,1049.92,7673.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ewhfo Rigid W/O Jnts Cf",PX-E27400029,CDM,L3765,HCPCS,0274,RC,,,both,,,2900.70,870.21,"CIGNA [10200]","Cigna Local Plus",,1551.87,53.5,,,,,0,337.35,2465.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 12/14 TAPER 32MM HIP BIOLOX DELTA",SUP-1365-32-320,CDM,C1776,HCPCS,0278,RC,,,both,,,12268.20,3680.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1453.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1426.79,10427.97,"percent of total billed charges",
"HC Chemiluminescent Assay",PX-301000138,CDM,82397,CPT,0301,RC,,,both,,,222.30,66.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.57,,,,,,,0.01,188.96,"fee schedule",
"HC Arthcs Asp/Inj Mjr Jt",PX-361000032,CDM,20610,CPT,0361,RC,,,both,,,2650.00,795,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,314.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,308.2,2650,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 125CM 6FR .052IN MULTIPURPOSE A 2 CURVE",SUP-H749086411222,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"KAISER [10500]",Kaiser,,51.31,67,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 5FR RACKET CURVE ANGIOGRAPHIC RADIOPAQUE",SUP-H787107095065,CDM,C1887,HCPCS,0272,RC,,,both,,,190.36,57.11,"KAISER [10500]",Kaiser,,127.54,67,,,,,0,22.14,161.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 10MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158126110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross PPO",,4380.42,39.2,,3949.44,3949.44,3949.44,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"SURFACE ARTICULAR 13MM PERSONA MEDIAL CONGRUENT 6-7 E-F KNEE",SUP-42522100713,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4429.11,41.1,,6417.48,6417.48,6417.48,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"INSRT TIBIAL 4 9MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531-G-409,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1425.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1089.28,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 4MM CARBIDE 3.5- 5MM SCR STERILE DISPOSABLE",SUP-309.004S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1728.30,518.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,710.33,41.1,,,,,0,201,1469.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW LOWPROFILE 6.5X35MM",SUP-010-55-035,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"MULTIPLAN [10600]",Multiplan,,258.83,85,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Ext Vein Uni",PX-921000012,CDM,93971,CPT,0921,RC,,,both,,,1421.25,426.37,"CIGNA [10200]","Cigna Local Plus",,760.37,53.5,,,,,0,165.29,1208.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Potassium Urine 24hr",PX-301000367,CDM,84133,CPT,0301,RC,,,both,,,137.00,41.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4.97,,"Fee schedule rate ($4.97). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,116.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRIMARY REVERSE SHOULDER",SUP-SMRREV,CDM,C1776,HCPCS,0278,RC,,,both,,,51502.50,15450.75,"KAISER [10500]",Kaiser,,34506.68,67,,,,,0,5989.74,43777.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"CATH ADVANCE 150CM 4CM 6MM BALLOON DILATATION ILIAC",SUP-G34334,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER FAST PEG 20MM 2MM SURGICAL DVRA TRAY SYSTEM",SUP-FPD20,CDM,S27200284,LOCAL,0272,RC,,,both,,,668.25,200.47,"CIGNA [10200]","Cigna Open Access",,380.23,56.9,,,,,0,77.72,568.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035423080,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS [10001]","Blue Cross HMO",,5532.94,39.2,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLF TORIC AUTONOME",SUP-CNA0T4,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,251.6,68,,,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Iron Binding Capacity (Tibc)",PX-301000288,CDM,83550,CPT,0301,RC,,,both,,,190.75,57.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,31.03,,,,,,,0.19,162.14,"fee schedule",
"VANCOMYCIN HCL 1 G/20ML IV (WET SOLR VIAL)",RX-4158442,CDM,J3373,HCPCS,0636,RC,00409-6533-11,NDC,both,1,UN,147.51,44.25,"CIGNA [10200]","Cigna Local Plus",,8.55,,,,,,,3.5,125.38,"fee schedule",
"HEAD HUMERAL 15MM 44MM SHOULDER SOFT TISSUE BALANCE",SUP-7122880,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,921.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Exercise Test for Bronchospasm",PX-482000005,CDM,94617,CPT,0460,RC,,,both,,,191.00,57.3,"NOVANET [10819]",Novanet,,143.25,75,,,,,0,22.21,162.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR ADULT LNCS 3FT OXIMETER SPO2 ADHSV SOFT STERILIZABLE",SUP-2653,CDM,S27000186,LOCAL,0270,RC,,,both,,,1490.40,447.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,176.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bag Pressure Infusion",PX-E27000048,CDM,E27000048,LOCAL,0270,RC,,,both,,,127.84,38.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,58.68,45.9,,,,,0,14.87,108.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM VUEPOINT II SPINE FAVOR ANGLE NONSTERILE",SUP-8975614,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,441.36,3225.75,"percent of total billed charges",
"STEM HUMERAL 48MM 10MM SMALL SHELL DJO SURGICAL ALTIVATE",SUP-533-10-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"NOVANET [10819]",Novanet,,35620.83,75,,,,,0,5523.6,40370.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 26MM DCP STAINLESS STEEL CORTEX SELF TAPPING",SUP-202.826,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"BLUE CROSS [10001]","Blue Cross PPO",,137.71,39.2,,957.42,570.23,957.42,28,40.86,298.61,"percent of total billed charges",
"IMPL BREAST 480-510ML STYLE 68MP SMOOTH ANTERIOR DIAPH VALVE",SUP-68-480,CDM,C1789,HCPCS,0278,RC,,,both,,,2250.00,675,"CIGNA [10200]",Cigna,,1530,68,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ENDOSCP SEALING 9.8-11.1MM MEDIUM RADIOFREQUENCY",SUP-CP-002A,CDM,S27200284,LOCAL,0272,RC,,,both,,,341.04,102.31,"PHCS [10601]",PHCS,,238.73,70,,,,,0,39.66,289.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 THK7MM NARROW KNEE LEFT RIGHT POSTERIOR",SUP-TPS-030-073N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 25MM TITANIUM 5.5MM ROD LOW PROFILE FIX LEGACY X10",SUP-8115525,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",414.32,3028.13,"percent of total billed charges",
"SUT PROLENE MULTIPASS 7-0 BV175-8 24IN 2 ARM MONOFILAMENT",SUP-8747H,CDM,S27200284,LOCAL,0272,RC,,,both,,,258.69,77.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,30.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.09,219.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DRNG 2.19FC AUTO EFFLUENT 12.6IN 22.44IN 13.39IN 4.83LB",SUP-115370,CDM,S27200284,LOCAL,0272,RC,,,both,,,579.90,173.97,"CIGNA [10200]",Cigna,,394.33,68,,,,,0,67.44,492.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH HEARTSPAN 120D FIX CURVE TAPER 60CM 8.5FR GUIDING",SUP-FCL-160-04,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTILUME 3CM 24FR BALLOON DRUG COATED BALLOON INFLATION",SUP-OPTBDL7002B,CDM,C1726,HCPCS,0272,RC,,,both,,,14455.50,4336.65,"PHCS [10601]",PHCS,,10118.85,70,,,,,0,1681.17,12287.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMNIOEFFECT 6 CM X 8 CM",SUP-LS-5680,CDM,Q4433,HCPCS,0636,RC,,,both,,,28847.70,8654.31,"AETNA [10100]","Aetna HMO/PPO",,22933.92,79.5,,,,,0,247.92,24520.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL THK28MM ALLOGRAFT FREEZE DRIED CROSS",SUP-400448,CDM,S27800098,LOCAL,0278,RC,,,both,,,6069.24,1820.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2785.78,45.9,,,,,0,705.85,5158.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Brain Complt Vasc Flow>=4v",PX-341000037,CDM,78606,CPT,0341,RC,,,both,,,2244.92,673.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2.24,.1,,,,,0,2.24,1908.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUT CATHETER",SUP-5040,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 5CMX12MM FLAT ROUND TIP OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-6-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE COONS VASCULAR 3.5CM STRAIGHT TAPER FLOPPY 180CM 15CM",SUP-G02621,CDM,C1769,HCPCS,0272,RC,,,both,,,243.51,73.05,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER 2.9MM CUDA HUB",SUP-C9952A,CDM,S27200284,LOCAL,0272,RC,,,both,,,490.21,147.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PAD THERAPEUTIC WRAP ON POLAR HIP",SUP-04750,CDM,S27000186,LOCAL,0270,RC,,,both,,,249.60,74.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 2 N 8MM",SUP-TPS-030-082N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NAIL 12MM 340MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.224S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"BLUE CROSS [10001]","Blue Cross HMO",,4867.99,39.2,,957.42,156.86,7483.26,51,1444.25,10555.59,"percent of total billed charges",
"SUT VICRYL PLUS 2 OS-8 18IN CONTROL RELEASE BRAID 3 STRAND",SUP-VCP719T,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 51MM BIO-MOORE II ENDO II HIP ACETABULAR",SUP-12-139026,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"CIGNA [10200]","Cigna Open Access",,1589.22,56.9,,5302.19,4377.88,6578.61,27,324.83,2374.05,"percent of total billed charges",
"MORCLTR SURGICAL 335MM 4.75MM DISPOSABLE",SUP-49700113,CDM,S27200284,LOCAL,0272,RC,,,both,,,2628.58,788.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1080.35,41.1,,,,,0,305.7,2234.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Iontophoresis 15min (Go)",PX-430000011,CDM,97033,CPT,0430,RC,,,both,,,226.00,67.8,"BLUE CROSS [10001]","Blue Cross HMO",,226,,"Per diem ($344.92).",,,,0,26.28,226,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR DURALOC +4MM NEUTRAL 50MM 28MM MARATHON HIP",SUP-122028450,CDM,C1776,HCPCS,0278,RC,,,both,,,8961.72,2688.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1042.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1042.25,7617.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 140MM 120CM 14MM BILIARY VENA CAVA OTW DELIVERY",SUP-G57452,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"PHCS [10601]",PHCS,,10143,70,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP CERAMIC R3 DELTA POROUS R3 XLPE LINER",SUP-71703415,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"AETNA [10100]","Aetna HMO/PPO",,19032.3,79.5,,10981.53,8986.79,12413.38,12,2784.22,20349,"percent of total billed charges",
"CUTTER OPHTHALMIC 19GA PACKER/CHANG COAXIAL LOW PROFILE",SUP-DFH-1012,CDM,S27200284,LOCAL,0272,RC,,,both,,,1167.75,350.32,"AETNA [10100]","Aetna HMO/PPO",,928.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,135.81,992.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE EXAMINATION BFLEX REGULAR 5 SINGLE USE X2",SUP-0570-0449,CDM,S27200284,LOCAL,0272,RC,,,both,,,1990.50,597.15,"CIGNA [10200]","Cigna Local Plus",,1064.92,53.5,,,,,0,231.5,1691.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER REDEL 115CM 4MM 7FR 1-7-4MM SPACE D-D CURVE",SUP-BD7TCDD4L,CDM,C1733,HCPCS,0272,RC,,,both,,,6113.40,1834.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2512.61,41.1,,,,,0,710.99,5196.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SCR HUMERUS",SUP-00840009000,CDM,C1713,HCPCS,0278,RC,,,both,,,2703.75,811.12,"AETNA [10100]","Aetna HMO/PPO",,2149.48,79.5,,1521.93,481.35,16760.95,30,314.45,2298.19,"percent of total billed charges",
"LENS IOL +17 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE 13",SUP-PCB0000170,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM QUADLINK 10MM IMPL",SUP-AR-1288QIS-100,CDM,C1713,HCPCS,0278,RC,,,both,,,15757.88,4727.36,"PHCS [10601]",PHCS,,11030.52,70,,,,,0,1832.64,13394.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLS-1009.5 CLASSICSHEATH STANDARD",SUP-398717,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"FIRST HEALTH [10303]","First Health",,421.2,80,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hpv High Risk",PX-306000192,CDM,87624,CPT,0306,RC,,,both,,,390.45,117.13,"CIGNA [10200]","Cigna Open Access",,77.2,,,,,,,0.01,331.88,"fee schedule",
"TISSUE 401118 MDII 18X20 SRVC FEE",SUP-401118,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 3.3MM 36MM STARDRIVE NAIL-EX TITANIUM 7%",SUP-04.005.426,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,530.92,45.9,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TI CERVICAL SPINE LOCKING",SUP-450.351,CDM,S27200284,LOCAL,0272,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 29MM 135CM 8MM THIN VASCULAR COCR",SUP-1012631-29,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"BLUE CROSS [10001]","Blue Cross PPO",,3292.8,39.2,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 20CC 50CC CALCIUM SULFATE STIMULAN RAPID",SUP-620-020,CDM,C1713,HCPCS,0278,RC,,,both,,,10080.00,3024,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1194.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1172.3,8568,"percent of total billed charges",
"SCR BONE 2MM 10MM TRI-LOCK APTUS TITANIUM HEXADRIVE 6 TAPER",SUP-A-5450.10/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"NOVANET [10819]",Novanet,,1208.93,75,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 50MM MATRIX TITANIUM T25 SPINE PEDICLE",SUP-04.639.650,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 60MM 12MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-151312060,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2365.79,28.62,,,,,0,961.36,7026.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.50 X 38 RX US",SUP-1804250-38,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE 814000 FIB STRUT 40MM SRVC FEE",SUP-814000,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 150MM NEXEL 4",SUP-00840004415,CDM,C1776,HCPCS,0278,RC,,,both,,,36662.85,10998.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10492.91,28.62,,,,,0,4263.89,31163.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED + VE/",SUP-98000200512,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7824.6,27,,,,,0,3370.37,24633,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 27MM 135CM 8MM 30MM BILIARY STAINLESS STEEL",SUP-PXB35-08-27-135,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,507.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 10MM LCP STAINLESS STEEL SHORT THREAD FIBULA",SUP-207.610,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"PHCS [10601]",PHCS,,728.03,70,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 80MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.411,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"FIRST HEALTH [10303]","First Health",,1107.3,80,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Inj Varices",PX-750000032,CDM,43243,CPT,0750,RC,,,both,,,3736.00,1120.8,"FIRST HEALTH [10303]","First Health",,2988.8,80,,,,,0,3.74,3736,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endoscopic Revision Gastrojejunostomy Anastomosis, Using Overstitch Device",PX-750000263,CDM,43999,CPT,0750,RC,,,both,,,1428.00,428.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,166.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.08,1428,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 6MM 2MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2006X,CDM,C1725,HCPCS,0272,RC,,,both,,,607.50,182.25,"FIRST HEALTH [10303]","First Health",,486,80,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 100CM 40MM 8MM BALLOON DILATATION DRUG COATED",SUP-LX35100840V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"KAISER [10500]",Kaiser,,5663.18,67,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cont Intraop Np Mon or Ea 15 M",PX-740000031,CDM,95940,CPT,0740,RC,,,both,,,234.00,70.2,"FIRST HEALTH [10303]","First Health",,187.2,80,,,,,0,27.21,234,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cont Intraop Np Mon or Ea 15 M",PX-740000031,CDM,95940,CPT,0740,RC,,,both,,,234.00,70.2,"MULTIPLAN [10600]",Multiplan,,198.9,85,,,,,0,27.21,234,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 130CM 40MM 12MM BALLOON DILATATION PACLITAXEL",SUP-IAV12004013P,CDM,C1725,HCPCS,0272,RC,,,both,,,10281.00,3084.3,"MULTIPLAN [10600]",Multiplan,,8738.85,85,,,,,0,1195.68,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 120MM 6MM BALLOON DILATATION RAPID",SUP-47560120L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"1.75MM X 10MM  SCOREFLEX NC",SUP-617-104-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR PREPARATION OF TC 99M-PENTETIC ACID IV SOLUTION (50-75 MCI)",RX-411852,CDM,A9539,HCPCS,0343,RC,08888-8876-01,NDC,both,1,UN,823.05,246.91,"UHC [10700]","United Healthcare",,168,,,,,,,95.72,699.59,"fee schedule",
"INSERT SURGICAL OD.3 MM SCREWDRIVER CRUCIFORM RECESS",SUP-80055,CDM,S27200284,LOCAL,0272,RC,,,both,,,4428.77,1328.63,"NOVANET [10819]",Novanet,,3321.58,75,,,,,0,515.07,3764.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.7MM 2-0 3/8 CIRCLE MINI FULL THREAD TAPER",SUP-AR-1319FT,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1526.18,68,,,,,0,261.02,1907.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 2.5/15",SUP-434887,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"AETNA [10100]","Aetna HMO/PPO",,15701.65,79.5,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 4-0 SH 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP773D,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.48,45.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 180MM 6MM BALLOON DILATATION OTW",SUP-H74939206061810,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 10.3MM 21.5MM ATS OPEN PIVOT STD TITANIUM",SUP-500FA21,CDM,S27800098,LOCAL,0278,RC,,,both,,,25011.00,7503.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10004.4,40,,,,,0,2908.78,21259.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805430,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,414.1,45.9,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 20MM 3FR SEGURA HEMISPHERE",SUP-M0063801100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1006.09,68,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 20CM 7FR POLARIS ULTRA NAUTILUS ZIPWIRE .035IN 2",SUP-M006192140190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"KAISER [10500]",Kaiser,,934.8,67,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5-6 11MM KNEE XLPE CRUCIATE RETAINING HIGH",SUP-71453122,CDM,C1776,HCPCS,0278,RC,,,both,,,15556.05,4666.81,"BLUE CROSS [10001]","Blue Cross HMO",,6097.97,39.2,,5311.50,4717.44,5388.59,31,1809.17,13222.64,"percent of total billed charges",
"CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,EXTREME",192,APR-DRG,,,,,,,inpatient,,,121460.34,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $20,751.98. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($122,225.07) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR ABDOMINAL VASCULAR PROCEDURES,MODERATE",169,APR-DRG,,,,,,,inpatient,,,201394.36,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $20,798.20. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%.",,,,0,,,other,"SOI-2 Shortstay; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK 143CM 20MM 4MM ROUND BALLOON DILATATION",SUP-1012453-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 7X40 40CM SL",SUP-48007004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INQUIRY 110CM 1MM 5FR 2-5-2MM SPACE LARGE CURVE",SUP-IBI-81174,CDM,C1730,HCPCS,0272,RC,,,both,,,2343.75,703.12,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Nitric Oxide Exp Gas Dterm",PX-460000018,CDM,95012,CPT,0460,RC,,,both,,,297.00,89.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,136.32,45.9,,,,,0,34.54,252.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nitric Oxide Exp Gas Dterm",PX-460000018,CDM,95012,CPT,0460,RC,,,both,,,297.00,89.1,"UHC [10700]","United Healthcare",,188,63.3,,,,,0,34.54,252.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X9MM 7D TRAPEZOID SPINE",SUP-017409,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 8FR PIGTAIL NEPHROURETERAL PERCUFLEX METAL",SUP-M001221360,CDM,C2617,HCPCS,0278,RC,,,both,,,811.20,243.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.34,689.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIALYZER HEMODIALYSIS OPTIFLUX POLYSULFONE LOW FLUX",SUP-0500308E,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.40,83.52,"NOVANET [10819]",Novanet,,208.8,75,,,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Cntrst Tube Check",PX-360000048,CDM,49465,CPT,0361,RC,,,both,,,821.89,246.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,821.89,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,95.59,821.89,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X9MM 7D TRAPEZOID SPINE",SUP-017409,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SCR 90MM 4.5MM INTERTAN TROCHANTER TITANIUM LAG",SUP-71677090,CDM,C1713,HCPCS,0278,RC,,,both,,,6986.94,2096.08,"CIGNA [10200]","Cigna Open Access",,3975.57,56.9,,1144.80,304.56,2275.09,66,812.58,5938.9,"percent of total billed charges",
"SLEEVE LAPAROSCOPIC 5MM 150MM KII ADVANCE FIXATION",SUP-CFS01,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"PHCS [10601]",PHCS,,48.72,70,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Breast MR Clip Plc",PX-361000310,CDM,19085,CPT,0361,RC,,,both,,,5365.30,1609.59,"FIRST HEALTH [10303]","First Health",,4292.24,80,,,,,0,623.98,5365.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM 2 MARKER SEMIRIGID WIRE STIFFENER",SUP-800SR26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX20MM VANGUARD POROUS KNEE POSTERIOR",SUP-183730,CDM,C1713,HCPCS,0278,RC,,,both,,,8757.48,2627.24,"CIGNA [10200]",Cigna,,5955.09,68,,1831.33,1831.33,1831.33,16,1018.49,7443.86,"percent of total billed charges",
"CMPNT FEMORAL 8 KNEE RIGHT POSTERIOR STABILIZE BEAD",SUP-5516F802,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"UHC [10700]","United Healthcare",,10961.62,63.3,,8601.07,8395.67,8601.07,"1 through 10",2013.96,14719.4,"percent of total billed charges",
"STEM FEMORAL 126MM 13.5MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771101300,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"CIGNA [10200]",Cigna,,8359.85,40,,5873.17,5873.17,5873.17,"1 through 10",2430.63,17764.68,"percent of total billed charges",
"INSRT ACETABULAR 28MM 10D E HIP X3 TRIDENT 9.9MM",SUP-623-10-28E,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"KAISER [10500]",Kaiser,,5725.59,67,,,,,0,993.86,7263.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 4MM 7FR 1-7-4MM SPACE D CURVE ABLATION",SUP-118330S,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"FIRST HEALTH [10303]","First Health",,10984.8,80,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 28MM 10D E HIP X3 TRIDENT 9.9MM",SUP-623-10-28E,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"FIRST HEALTH [10303]","First Health",,6836.52,80,,,,,0,993.86,7263.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 109MM TYPE 1 TAPERLOC MICROPLASTY PPS 133D 12",SUP-51106120,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7851.97,28.62,,,,,0,3190.72,23319.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM LCP STAINLESS STEEL FOREFOOT MIDFOOT T8",SUP-02.211.018,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"MULTIPLAN [10600]",Multiplan,,763.41,85,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET HELICAL ULTRA 2.5 MM X 3 CM",SUP-M0035432530,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1085.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 30MM INDEPENDENCE SPINE SELF DRILL VARIABLE",SUP-176.73,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Open Access",,921.78,56.9,,1144.80,304.56,2275.09,66,188.41,1377,"percent of total billed charges",
"COIL EMBOLIZATION 20CM 6MM PRESTIGE PLUS HELICAL HELICAL",SUP-PRES0620HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4457.4,68,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 35MM 6.5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ135,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4143.85,45.9,,,,,0,1049.96,7673.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 STANDARD 15 MM X 40 CM",SUP-M0035461540,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"NOVANET [10819]",Novanet,,10585.98,75,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL KNEE 6MM IDENTITY IMPRINT 4 TIBIAL INSRT POSTERIOR",SUP-TPS-030-064S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 26MM ORTHOLOC TITANIUM CORTICAL LOCK",SUP-59215526,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"FIRST HEALTH [10303]","First Health",,1758,80,,,,,0,255.57,1867.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL HULKA-KENWICK 10.75IN UTERUS ELEVATE",SUP-52-0849,CDM,S27200284,LOCAL,0272,RC,,,both,,,1008.61,302.58,"UHC [10700]","United Healthcare",,638.45,63.3,,,,,0,117.3,857.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 3MM 6MM TITANIUM CORTEX HAND SELF TAPPING LOW",SUP-400.806.96,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,220.31,68,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 30CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155245180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 12CM 5FR 2.1FR POLARIS ULTRA NAUTILUS .035IN 2",SUP-M006192112050,CDM,C2617,HCPCS,0278,RC,,,both,,,1142.10,342.63,"MULTIPLAN [10600]",Multiplan,,970.79,85,,,,,0,132.83,970.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIPERACILLIN-TAZOBACTAM 4.5 G/20ML IV (WET SOLR VIAL)",RX-41518302,CDM,J2543,HCPCS,0636,RC,00781-3114-91,NDC,both,1,UN,176.56,52.97,"BLUE CROSS [10001]","Blue Cross PPO",,4.99,,,,,,,4.99,150.08,"fee schedule",
"HC Bx Abd/Retroperitnl Mass Perc",PX-361000201,CDM,49180,CPT,0361,RC,,,both,,,3810.90,1143.27,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,443.21,3810.9,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX PDS PLUS 2-0 SH SPIRAL 5IN ABSORBABLE",SUP-256643,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.38,69.41,"KAISER [10500]",Kaiser,,155.02,67,,,,,0,26.91,196.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 15MM 1.5MM BALLOON DILATATION RAPID",SUP-47515015L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2MM KIRSCHNER DRILL TIP",SUP-705002,CDM,C1713,HCPCS,0278,RC,,,both,,,380.02,114.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,44.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",44.2,323.02,"percent of total billed charges",
"CMPNT FEMORAL ATTUNE STERILE 7 KNEE RIGHT CEMENTED POSTERIOR",SUP-150410207,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"CIGNA [10200]","Cigna Open Access",,7501.77,33.5,,5302.19,4377.88,6578.61,27,2604.35,19034.35,"percent of total billed charges",
"HC TB Intradermal Test",PX-300000014,CDM,86580,CPT,0302,RC,,,both,,,164.00,49.2,"NOVANET [10819]",Novanet,,123,75,,,,,0,0.16,139.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC TB Intradermal Test",PX-300000014,CDM,86580,CPT,0302,RC,,,both,,,164.00,49.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,23.84,,,,,,,0.16,139.4,"fee schedule",
"HC TB Intradermal Test",PX-300000014,CDM,86580,CPT,0302,RC,,,both,,,164.00,49.2,"CIGNA [10200]","Cigna Local Plus",,22.73,,,,,,,0.16,139.4,"fee schedule",
"HC Cann Ven Dual Stage 29f",PX-E27200382,CDM,E27200382,LOCAL,0272,RC,,,both,,,198.00,59.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,81.38,41.1,,,,,0,23.03,168.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 XLH 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP581G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Local Plus",,13.38,53.5,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM LCP STAINLESS STEEL LONG THREAD LONG",SUP-207.726,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"FIRST HEALTH [10303]","First Health",,832.03,80,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 10MM TI",SUP-VAN-25100-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"MULTIPLAN [10600]",Multiplan,,826.2,85,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM DARCO ORTHOLOC 3DI ANKLE CANNULATED",SUP-777654562,CDM,C1713,HCPCS,0278,RC,,,both,,,2617.50,785.25,"BLUE CROSS [10001]","Blue Cross HMO",,1026.06,39.2,,957.42,156.86,7483.26,51,304.42,2224.88,"percent of total billed charges",
"SYSTEM SYNERGY 38MM 144CM 2.75MM CORONARY STENT EVEROLIMUS",SUP-H7493926138270,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"AETNA [10100]","Aetna HMO/PPO",,6856.88,79.5,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXS VECTA 71 125CM .082-.085IN .071IN ASPIRATION SCOUT",SUP-INC-11129-125,CDM,S27200284,LOCAL,0272,RC,,,both,,,16943.99,5083.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7777.29,45.9,,,,,0,1970.59,14402.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIALYZER HEMODIALYSIS OPTIFLUX POLYSULFONE LOW FLUX",SUP-0500308E,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.40,83.52,"KAISER [10500]",Kaiser,,186.53,67,,,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 30MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840005530,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"FIRST HEALTH [10303]","First Health",,7637.48,80,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 20MM PERIPHERAL",SUP-5572-4520,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,184.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,180.93,1322.35,"percent of total billed charges",
"PROBE 17GA 10MM RADIOFREQUENCY ELECTROTHERAPY OSTEOCOOL 2MM",SUP-OCP210,CDM,S27200284,LOCAL,0272,RC,,,both,,,25389.00,7616.7,"CIGNA [10200]",Cigna,,17264.52,68,,,,,0,2952.74,21580.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 20GA ACCURIAN CURVE BLUNT 10MM",SUP-AC0011,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.91,41.1,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 40MM 140CM 2.5MM CORONARY STERILE LATEX",SUP-453974,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hiv-1 Dna Ampl Probe",PX-306000137,CDM,87535,CPT,0306,RC,,,both,,,542.45,162.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.54,,"Fee schedule rate ($29.54). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,461.08,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 39MM 80CM 8MM 16SQ MM 7FR .035IN",SUP-BXAL083901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"PHCS [10601]",PHCS,,13653.36,70,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 5CM 8.5FR CENTER BEND THIN WALL",SUP-M00534620,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"CIGNA [10200]",Cigna,,740.83,68,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 0 GS-22 23CM CLSR ABSORBABLE GREEN",SUP-VLOCL2246,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.67,61.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,24.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.92,174.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 6.35MM TSR2D PRECUT BENT",SUP-8371090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"ROD SPINAL 110MM 5.5MM STRAIGHT PERCUTANEOUS CCM",SUP-1555006110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endoluminal Bx Ureter Renal",PX-361000416,CDM,50606,CPT,0361,RC,,,both,,,3699.00,1109.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,430.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,430.19,3699,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 57MM 75CM 10MM 60MM",SUP-H74938046106070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1184.87,28.62,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM 20.4MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-25AECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS EVOQUE DILATOR KIT",SUP-9850DKCL,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 28MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.828,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,29.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",29.18,213.27,"percent of total billed charges",
"STENT SENSOR 22CM 7FR .035IN URETERAL PERCUFLEX PLUS",SUP-M006175271090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"PHCS [10601]",PHCS,,931.18,70,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 14FR 30CM RADIOPAQUE DRNG SILHOUETTE PEEL-AWAY",SUP-G08321,CDM,C1892,HCPCS,0272,RC,,,both,,,526.42,157.93,"MULTIPLAN [10600]",Multiplan,,447.46,85,,,,,0,61.22,447.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165CM 8.5-11MM OTSC 3MM NITINOL STERILE",SUP-100.04,CDM,C1760,HCPCS,0278,RC,,,both,,,3667.50,1100.25,"KAISER [10500]",Kaiser,,2457.23,67,,,,,0,426.53,3117.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TOURGUIDE 180D 45CM 17MM 7FR CATH HYDROPHOBIC",SUP-TG0704517,CDM,C1887,HCPCS,0272,RC,,,both,,,4209.00,1262.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,489.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,489.51,3577.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 1 GRAM TABLET SUPERORDERABLE",RX-409669,CDM,,,0637,RC,77333-0844-25,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit Level 3 W Proc",PX-450000316,CDM,99283,CPT,0450,RC,,,both,,,1619.02,485.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,279.7,,,,,,,279.7,1619.02,"case rate",
"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC",495,MS-DRG,,,,,,,inpatient,,,141821.79,42546.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,71973.77,,"Fee schedule rate ($71,973.77). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,105855.94,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"POST EXTERNAL FIXATION 11MM HOFFMANN 3 30D",SUP-4922-2-140,CDM,S27800098,LOCAL,0278,RC,,,both,,,1108.73,332.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,753.94,68,,,,,0,128.95,942.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR CORTICAL LORDOTIC 14X14X6MM",SUP-340644,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 40MM 80CM 8MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM08040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross HMO",,7161.84,39.2,,9776.84,9776.84,9776.84,"1 through 10",2124.8,15529.5,"percent of total billed charges",
"GRAFT BONE DEMINERALIZED BONE MATRIX 1ML PUTTY STERILE",SUP-038010,CDM,C1713,HCPCS,0278,RC,,,both,,,1160.90,348.27,"FIRST HEALTH [10303]","First Health",,928.72,80,,,,,0,135.01,986.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE UNICORTICAL DOWEL ALLOGRAFT FREEZE DRIED 30-40MM",SUP-400204,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"BLUE CROSS [10001]","Blue Cross PPO",,1663.45,39.2,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 13MM ATLANTIS TITANIUM SPINE SELF DRILLING",SUP-3120413,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,163.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",163.98,1198.5,"percent of total billed charges",
"CATH RAPIDCROSS 170CM 100MM 3MM .014IN BALLOON DILATATION",SUP-A14BX030100170,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,164.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRAUMA FIXATION 80MM META-TAN INTEGRATE LAG COMPRESSION",SUP-71642680,CDM,C1713,HCPCS,0278,RC,,,both,,,4950.06,1485.02,"PHCS [10601]",PHCS,,3465.04,70,,,,,0,575.69,4207.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND MICROPOINT 4-0 G-3 18IN 2 ARM BRAID",SUP-783G,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.02,40.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.59,113.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 15MM 140CM 3MM CORONARY STERILE LATEX",SUP-453940,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SPINAL 1IN 22GA NEOMED NEONATAL STERILE LUMBAR PUNCTURE",SUP-LN2210,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.01,14.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.47,39.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE XPRESS ULTRA 1.5MM BALL SUPER SLEEK PROFILE 8MM 2.5FR",SUP-ULF-206,CDM,C1726,HCPCS,0272,RC,,,both,,,11364.30,3409.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1346.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1321.67,9659.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.215,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,197.05,28.62,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM ORTHOLOC STAINLESS STEEL FULL THREAD",SUP-58813522,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross PPO",,301.64,39.2,,957.42,570.23,957.42,28,89.49,654.08,"percent of total billed charges",
"ROD SPINAL 60MM 5.5MM REVOLVE EXTRA LORDOTIC",SUP-185.86,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 7FR 19CM RADIALEASE LATEX FREE VESSEL ACCEPTS",SUP-504507X,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.26,26.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.15,74.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 28MM 144CM 2.75MM CORONARY STENT",SUP-H7493911428270,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2616.58,28.62,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18 DIOPTER +4.5 CYLINDER MODIFIED C BICONVEX 13MM",SUP-ZCT450U180,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross HMO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 8MM 3.75MM ULTRA LOW PROFILE BALLOON",SUP-1012277-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Inj Ileal Conduit",PX-361000228,CDM,50690,CPT,0361,RC,,,both,,,3241.44,972.43,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX GEOALIGN 130CM 60MM 5MM BALLOON DILATATION",SUP-LX181305605F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RUNWAY 100CM 6FR ART4 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389695000,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Ph Impedance Catheter",PX-E27200295,CDM,E27200295,LOCAL,0272,RC,,,both,,,715.00,214.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE IRRIGATION ELITE 12CM",SUP-5407-010-470,CDM,S27200284,LOCAL,0272,RC,,,both,,,585.74,175.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RUBICON 90CM 5.1FR 2.84FR 50MM SPACE GUIDING NYLON",SUP-H74939240035091,CDM,C1887,HCPCS,0272,RC,,,both,,,1449.90,434.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC",817,MS-DRG,,,,,,,inpatient,,,79527.86,23858.36,"BLUE CROSS [10001]","Blue Cross HMO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 3-0 SH 18IN BRAID 8 STRAND BLACK",SUP-M13T,CDM,S27200284,LOCAL,0272,RC,,,both,,,86.41,25.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL 45D COOLCUT STERILE ABLATOR",SUP-AR-9802M-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,931.50,279.45,"AETNA [10100]","Aetna HMO/PPO",,740.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPLORER ST 100CM 5FR 5MM SPACE COURNAND CURVE",SUP-4542,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross PPO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 17MM 135CM 6MM 20MM BILIARY STAINLESS STEEL",SUP-PXB35-06-17-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"PHCS [10601]",PHCS,,3056.9,70,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL MEDIUM KNEE REVISION CONCENTRIC CONE ATTUNE",SUP-151404140,CDM,C1776,HCPCS,0278,RC,,,both,,,31812.48,9543.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3769.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3699.79,27040.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dihydrotestosterone (Dht)",PX-301000572,CDM,82642,CPT,0301,RC,,,both,,,71.50,21.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,31.15,,"Fee schedule rate ($31.15). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,64.42,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL ARTHREX UNIVERS REVERS UNIVERS APEX 11 SHOULDER",SUP-AR-9501-11S,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"CIGNA [10200]",Cigna,,7178.76,68,,5873.17,5873.17,5873.17,"1 through 10",1227.78,8973.45,"percent of total billed charges",
"CATH SHOCKWAVE M5 60MM 110CM 6.5MM 7MM BALLOON DILATATION",SUP-M5PIVL6560,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"UHC [10700]","United Healthcare",,13758.26,63.3,,,,,0,2527.78,18474.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 6MM 2MM BALLOON DILATATION HYDROPHILIC",SUP-2200-2006-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"FIRST HEALTH [10303]","First Health",,4692,80,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 NARROW KNEE RIGHT POSTERIOR STABILIZE",SUP-42500206202,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"BLUE CROSS [10001]","Blue Cross HMO",,11327.07,39.2,,5311.50,4717.44,5388.59,31,3360.56,24561.24,"percent of total billed charges",
"ROD SPINAL 35MM 5.5MM CURVE CHROMALOY PLUS",SUP-1556001035,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"HC Rp Loc Tum Spect W CT 1 Day",PX-341000072,CDM,78830,CPT,0341,RC,,,both,,,3339.82,1001.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,395.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,388.42,3339.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acetylcholn Rcptr Blckg Antb",PX-301000692,CDM,86042,CPT,0301,RC,,,both,,,398.05,119.41,"CIGNA [10200]",Cigna,,40.48,,,,,,,0.01,338.34,"fee schedule",
"PACKING COILS XL 15CM",SUP-RBYPCXL15,CDM,S27800098,LOCAL,0278,RC,,,both,,,13731.00,4119.3,"UHC [10700]","United Healthcare",,8691.72,63.3,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 15.5CM 9FR PEEL-AWAY PERCUTANEOUS STERILE",SUP-G01697,CDM,C1894,HCPCS,0272,RC,,,both,,,382.71,114.81,"PHCS [10601]",PHCS,,267.9,70,,,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL COMPREHENSIVE +3MM STD SHOULDER REVERSE",SUP-110031402,CDM,C1776,HCPCS,0278,RC,,,both,,,8473.20,2541.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1004.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,985.43,7202.22,"percent of total billed charges",
"SCR BIOABSORBABLE PLLA HA 25MM 9MM 1.5MM ACL PCL CANNULATED",SUP-7207681,CDM,C1713,HCPCS,0278,RC,,,both,,,1882.13,564.64,"CIGNA [10200]","Cigna Open Access",,1070.93,56.9,,1144.80,304.56,2275.09,66,218.89,1599.81,"percent of total billed charges",
"SCR BONE 4MM 40MM AXSOS LOCK NONSTERILE",SUP-661040,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"PHCS [10601]",PHCS,,914,70,,,,,0,151.86,1109.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CW004, 5MMX42CM EPIX ES SMK EVAC STR SPT",SUP-CW004,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 4MM DART-FIRE HEADED",SUP-DSDS1040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1069.20,320.76,"CIGNA [10200]","Cigna Open Access",,608.37,56.9,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Hydrofera",PX-E27200112,CDM,E27200112,LOCAL,0272,RC,,,both,,,98.38,29.51,"UHC [10700]","United Healthcare",,62.27,63.3,,,,,0,11.44,83.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl/Bivalv Cast Boot/Body",PX-450000340,CDM,29700,CPT,0450,RC,,,both,,,1313.00,393.9,"CIGNA [10200]",Cigna,,1313,,,,,,,67.13,1313,"case rate",
"GRAFT STENT 140MM 14MM 13FR 10FR TRIVASCULAR OVATION PRIME",SUP-TV-IL1414140-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"MULTIPLAN [10600]",Multiplan,,28381.5,85,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT 10.06FR 135D GUIDING NONSTEERABLE",SUP-DS2C020,CDM,C1893,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"UHC [10700]","United Healthcare",,2380.4,63.3,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUTURING 10MM 0 ES-9 48IN 1 STITCH LOADING UNIT BRAID",SUP-170056,CDM,S27200284,LOCAL,0272,RC,,,both,,,1010.52,303.16,"CIGNA [10200]","Cigna Open Access",,574.99,56.9,,,,,0,117.52,858.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grad Compression Waist 18-20",PX-E27100015,CDM,A6539,HCPCS,0292,RC,,,both,,,336.60,100.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,228.89,68,,,,,0,39.15,286.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO HALYARD STERILE LATEX FREE DISPOSABLE MIC/MIC-KEY",SUP-10237,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.93,543.58,"FIRST HEALTH [10303]","First Health",,1449.54,80,,,,,0,210.73,1540.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 15MM 13.8MM 9.5MM 9MM SHILEY ADULT FLEXIBLE CUFF",SUP-10CN10A,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.97,110.09,"CIGNA [10200]",Cigna,,249.54,68,,,,,0,42.68,311.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND BLUE 4.25X4IN QWICK AQUACONDUCTIVE POLYACRYLATE",SUP-MSC5844,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.05,14.71,"MULTIPLAN [10600]",Multiplan,,41.69,85,,,,,0,5.7,41.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 6MM ENDOWRIST SP FENESTRATED NONSTERILE",SUP-430151,CDM,S27000186,LOCAL,0270,RC,,,both,,,2583.00,774.9,"CIGNA [10200]","Cigna Open Access",,1469.73,56.9,,,,,0,300.4,2195.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER INSTR 10X2.5IN WEINSTEIN STRINGER NONSTERILE",SUP-117-244,CDM,S27000186,LOCAL,0270,RC,,,both,,,309.72,92.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,142.16,45.9,,,,,0,36.02,263.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 74X50X14MM CURRENT PLUS VR 36J TITANIUM CAN",SUP-CD1211-36Q,CDM,C1722,HCPCS,0278,RC,,,both,,,62700.00,18810,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25769.7,41.1,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 9MM ZERO-P STD LORDOTIC PEEK-OPTIMA STERILE",SUP-04.647.129S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4968,40,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.824,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",27.52,201.14,"percent of total billed charges",
"SCR BONE 3.5MM 18MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.318,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"FIRST HEALTH [10303]","First Health",,3360,80,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 7MM MICRUSFRAME 10 COIL",SUP-MFR100730,CDM,S27800098,LOCAL,0278,RC,,,both,,,16974.00,5092.2,"PHCS [10601]",PHCS,,11881.8,70,,,,,0,1974.08,14427.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X14X8MM COALITION CERVICAL INTERBODY SVN",SUP-384.308,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7200,40,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 12FR 30CM STRAIGHT KELLER-TIMMERMANS STERILE",SUP-G09346,CDM,C1894,HCPCS,0272,RC,,,both,,,522.45,156.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,60.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LEAD 16CM 11FR PEEL AWAY",SUP-6095,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"FIRST HEALTH [10303]","First Health",,356.4,80,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR WEITLANER TESSA SELF RETAIN SURGICAL DISPOSABLE",SUP-NF08,CDM,S27200284,LOCAL,0272,RC,,,both,,,426.30,127.89,"CIGNA [10200]",Cigna,,289.88,68,,,,,0,49.58,362.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DRNG 29CM 10.2FR 18GA POLYURETHANE 20 SIDEPORT 1 WAY",SUP-G03302,CDM,C1729,HCPCS,0272,RC,,,both,,,1931.25,579.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,793.74,41.1,,,,,0,224.6,1641.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trcran Dplr Intrcr Complt",PX-921000003,CDM,93886,CPT,0921,RC,,,both,,,1764.05,529.21,"NOVANET [10819]",Novanet,,1323.04,75,,,,,0,205.16,1499.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 12MM 1.14MM 6MM GOODE T EAR SILICONE FLANGE",SUP-24751,CDM,S27800098,LOCAL,0278,RC,,,both,,,229.87,68.96,"CIGNA [10200]",Cigna,,156.31,68,,,,,0,26.73,195.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 300CC P3.1CM MODERATE CLASSIC PROFILE STD",SUP-350-7300MC,CDM,C1789,HCPCS,0278,RC,,,both,,,4823.10,1446.93,"BLUE CROSS [10001]","Blue Cross PPO",,1890.66,39.2,,16595.83,16595.83,16595.83,"1 through 10",560.93,4099.64,"percent of total billed charges",
"SCR BONE 1.2MM 10MM PROFYLE LOW PROFILE BLUNT ROUND HAND",SUP-58-12010E,CDM,C1713,HCPCS,0278,RC,,,both,,,605.56,181.67,"FIRST HEALTH [10303]","First Health",,484.45,80,,,,,0,70.43,514.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.5 X 20MM MA SCREWS",SUP-8975320,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.5 X 20MM MA SCREWS",SUP-8975320,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175280110,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"FIRST HEALTH [10303]","First Health",,991.5,80,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X11-8.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-14811,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"CIGNA [10200]",Cigna,,5934,40,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Irr Nacl 9 500ml",PX-E27200251,CDM,E27200251,LOCAL,0272,RC,,,both,,,37.40,11.22,"AETNA [10100]","Aetna HMO/PPO",,29.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.35,31.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 22CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006175281070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"MULTIPLAN [10600]",Multiplan,,847.82,85,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION SLR PTCA DEB 4.5X25MM",SUP-SCA14U-450025D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE KYPHON XPEDE SPINAL MIXER",SUP-CX01B,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.75,405.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,919.87,68,,,,,0,157.32,1149.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STATSEAL DISC MED 6-9FR",SUP-DM625,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"NOVANET [10819]",Novanet,,195.75,75,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 15.5CM NATRELLE INSPIRA P6CM FULL PROFILE ROUND",SUP-MSZ-F770,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"UHC [10700]","United Healthcare",,100.13,63.3,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 14CM INFLATABLE NARROW",SUP-EN8914,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"UHC [10700]","United Healthcare",,39689.1,63.3,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 20MM 125CM 7MM VASCULAR NITINOL ILIAC",SUP-G43824,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Open Access",,2150.82,56.9,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 64CM ENDOTAK RELIANCE ENDOCARDIAL STEROID SILICONE",SUP-158,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]",Cigna,,6072,40,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 48MM 26MM UHR UNIVERSAL ACETABULAR HIP COCR",SUP-UH1-48-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2936.08,68,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PULMONARY AERO OTW FULLY COVERED TRACHEOBRONCHIAL STENT 16MM",SUP-90129-206,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4657.5,27,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X9MM RISE NONSTERILE",SUP-193.151,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUTURE BONE ARTHROSCOPIC DELIVERY",SUP-4403,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"CAP CMPNT GLENOID SHORT STEM STD HEAD INSRT REGENEREX",SUP-98B00900107,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"BLUE CROSS [10001]","Blue Cross PPO",,11730.6,39.2,,3949.44,3949.44,3949.44,"1 through 10",3480.28,25436.25,"percent of total billed charges",
"PLATE 16X8MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2408,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"KAISER [10500]",Kaiser,,6472.2,67,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 3CM 75CM 8-9-10MM PULMONARY BALLOON",SUP-M00550330,CDM,C1726,HCPCS,0272,RC,,,both,,,2278.65,683.59,"AETNA [10100]","Aetna HMO/PPO",,1811.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,265.01,1936.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 59MM 80CM 8MM 16SQ MM 8FR .035IN",SUP-BXAL085901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"NOVANET [10819]",Novanet,,14628.6,75,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 8IN 15MM MODULAR SOL SYSTEM POROUS 12/14 LARGE",SUP-157202150,CDM,C1776,HCPCS,0278,RC,,,both,,,38107.44,11432.23,"CIGNA [10200]","Cigna Open Access",,12765.99,33.5,,5302.19,4377.88,6578.61,27,4431.9,32391.32,"percent of total billed charges",
"MODULE SENSOR VALVE REDUCTION STERILE",SUP-53-000032,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"FIRST HEALTH [10303]","First Health",,1770,80,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM LCP STAINLESS STEEL LONG THREAD LONG",SUP-207.726,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"CIGNA [10200]",Cigna,,707.23,68,,1831.33,1831.33,1831.33,16,120.96,884.03,"percent of total billed charges",
"STEM HUMERAL 10MM MONOBLOCK RSP",SUP-510-00-010,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"NOVANET [10819]",Novanet,,9450,75,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 10MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036121040,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X9MM 7D TRAPEZOID SPINE",SUP-017409,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 138MM 13MM PRIMARY PRESS FIT TIVANIUM 12/14 45",SUP-786401320,CDM,C1776,HCPCS,0278,RC,,,both,,,30164.40,9049.32,"AETNA [10100]","Aetna HMO/PPO",,23980.7,79.5,,10981.53,8986.79,12413.38,12,3508.12,25639.74,"percent of total billed charges",
"LINER ACETABULAR PINNACLE 10D +4MM 64MM 36MM ALTRX HIP",SUP-122136164,CDM,C1776,HCPCS,0278,RC,,,both,,,11405.70,3421.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1351.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1326.48,9694.85,"percent of total billed charges",
"POST EXTERNAL FIXATION 11MM HOFFMANN 3 30D",SUP-4922-2-140,CDM,S27800098,LOCAL,0278,RC,,,both,,,1108.73,332.62,"BLUE CROSS [10001]","Blue Cross HMO",,434.62,39.2,,,,,0,128.95,942.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 5FR FEMORAL LEFT 4 CURVE ANGIOGRAPHIC",SUP-H74908526222,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"MULTIPLAN [10600]",Multiplan,,65.09,85,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVRTB ENDOSCOPIC 25CM 10-11.7MM THERAPEUTIC CONSISTENT",SUP-00711147,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHOLESTYRAMINE 4 GRAM ORAL POWDER FOR SUSPENSION IN A PACKET",RX-243327,CDM,,,0637,RC,68382-0529-60,NDC,both,1,UN,21.08,6.32,"UHC [10700]","United Healthcare",,13.34,63.3,,,,,0,2.45,17.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM ENDOSKELETON TCS TITANIUM STD SPINE",SUP-5301-3514,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,3978.14,359.25,3978.14,24,117.75,860.63,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS 26CM 3CM 5FR .035IN 2 PIGTAIL",SUP-M006192123050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,142.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 45CM 4-7MM GORE PROPATEN EPTFE HEPARIN STD",SUP-H470045A,CDM,C1768,HCPCS,0278,RC,,,both,,,8921.70,2676.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6066.76,68,,,,,0,1037.59,7583.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 10CM 10MM GORE EXCLUDER ILIAC BRANCH",SUP-CEB231010A,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"KAISER [10500]",Kaiser,,42009,67,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 15MM 2.25MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP22515X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,inpatient,,,71618.94,21485.68,"PHCS [10601]",PHCS,,7561,,,,,,,7561,39283.22,"per diem","Estimated amount calculated based on 6 day length of stay."
"SYSTEM DESARA ONE URETHRAL SPRT 1 INCISION STERILE LATEX",SUP-CAL-DS2113,CDM,C1771,HCPCS,0278,RC,,,both,,,7410.60,2223.18,"MULTIPLAN [10600]",Multiplan,,6299.01,85,,,,,0,861.85,6299.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM MITRAL MEMO 3D",SUP-ICV0969,CDM,S27800098,LOCAL,0278,RC,,,both,,,13144.50,3943.35,"KAISER [10500]",Kaiser,,8806.82,67,,,,,0,1528.71,11172.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 140MM 125CM 5MM 6FR BILIARY",SUP-G50164,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"NOVANET [10819]",Novanet,,4567.5,75,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 32.77CM 8MM CADIERE DA VINCI XI ENDOWRIST",SUP-471049,CDM,S27000186,LOCAL,0270,RC,,,both,,,1275.75,382.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,524.33,41.1,,,,,0,148.37,1084.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL MINI FRAGMENT SET 4 HOLE .25 TUBULAR",SUP-242.04,CDM,C1713,HCPCS,0278,RC,,,both,,,1104.52,331.36,"MULTIPLAN [10600]",Multiplan,,938.84,85,,,,,0,128.46,938.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840006540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1110.3,8114.82,"percent of total billed charges",
"ELAN 4 2-RING DISP TAPER BURR TC D1.2",SUP-GP395TC-SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,1492.51,447.75,"MULTIPLAN [10600]",Multiplan,,1268.63,85,,,,,0,173.58,1268.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 20MM 145CM 5MM BALLOON DILATATION HYDROCOAT",SUP-1400500-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 100CM 4FR VERTEBRAL CURVE ANGIOGRAPHIC SLX",SUP-451414H0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"CIGNA [10200]","Cigna Open Access",,59.4,56.9,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +9.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.095,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT TOE SWANSON 4 GREAT TOE SILICONE REGULAR STEM FLEXIBLE",SUP-G4260004,CDM,C1776,HCPCS,0278,RC,,,both,,,7265.70,2179.71,"MULTIPLAN [10600]",Multiplan,,6175.85,85,,,,,0,845,6175.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUTURE HEALIX ADVANCE ORTHOCORD PEEK OD6.5 MM NEEDLE",SUP-222313,CDM,C1713,HCPCS,0278,RC,,,both,,,2812.50,843.75,"NOVANET [10819]",Novanet,,2109.38,75,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIAZEPAM 2.5 MG RECTAL KIT",RX-87865,CDM,,,0250,RC,68682-0650-20,NDC,both,1,UN,586.42,175.93,"UHC [10700]","United Healthcare",,371.2,63.3,,,,,0,68.2,498.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 40CM 29FR 3/8IN ADULT 3 STAGE VENOUS RETURN",SUP-RTS-11029,CDM,S27200284,LOCAL,0272,RC,,,both,,,589.68,176.9,"PHCS [10601]",PHCS,,412.78,70,,,,,0,68.58,501.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X7-14MM ELSA 20MM",SUP-1122.005,CDM,S27800098,LOCAL,0278,RC,,,both,,,50400.00,15120,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5972.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5861.52,42840,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ventil Mgmt IP Subq Day",PX-410000003,CDM,94003,CPT,0410,RC,,,both,,,2236.54,670.96,"NOVANET [10819]",Novanet,,1677.41,75,,,,,0,254,1901.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 39MM CEMENTLESS OFFSET SECUR-FIT MAX 127D",SUP-6052-0730S,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6431.82,41.1,,6417.48,6417.48,6417.48,"1 through 10",1820,13301.82,"percent of total billed charges",
"HC Laser Capsulotomy",PX-761000008,CDM,66821,CPT,0761,RC,,,both,,,1088.00,326.4,"PHCS [10601]",PHCS,,1088,,"Case rate ($6,277). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,1.09,1088,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.250 CLAREON",SUP-SY60WF.250,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 79.5X25X1.5MM SHORT NARROW THIN SAGITTAL STERILE",SUP-2108175000,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"MULTIPLAN [10600]",Multiplan,,203.22,85,,,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKAGED RADIAL STEM 10MM X -2MM",SUP-ALN-RST-10M2,CDM,C1776,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5844.79,41.1,,6417.48,6417.48,6417.48,"1 through 10",1653.89,12087.77,"percent of total billed charges",
"PACKAGED RADIAL STEM 10MM X -2MM",SUP-ALN-RST-10M2,CDM,C1776,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1685.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1653.89,12087.77,"percent of total billed charges",
"10GA 20MM BILATERAL KYPHOPLASTY KIT",SUP-VBRX-20-A-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,15352.50,4605.75,"AETNA [10100]","Aetna HMO/PPO",,12205.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1785.5,13049.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUMP INTRACARDIAC SUCTION 20FR .25IN DLP MULTIPORT VENT CNCT",SUP-12112,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.40,41.52,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,63.53,45.9,,,,,0,16.1,117.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 13MM ATLANTIS SPINAL TRI FLAT STERILE DISPOSABLE",SUP-876-443,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 25X20X5MM DEMINERALIZED CANCELLOUS BONE",SUP-0W1025,CDM,S27800098,LOCAL,0278,RC,,,both,,,7521.00,2256.3,"NOVANET [10819]",Novanet,,5640.75,75,,,,,0,874.69,6392.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINI-MONSTER CANNULATED SHORT THREAD SCREW HEADED 3.0 X",SUP-P20-130-018S,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,650.63,45.9,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Iliac W Pta Init",PX-361000148,CDM,37220,CPT,0361,RC,,,both,,,10816.36,3244.91,"BLUE CROSS [10001]","Blue Cross HMO",,7166.56,,"Case rate ($7,166.56). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1257.94,9193.91,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR SHORT TAPER 145CM 4CM",SUP-M001465241,CDM,C1769,HCPCS,0272,RC,,,both,,,187.92,56.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,77.24,41.1,,,,,0,21.86,159.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIGESTIVE MALIGNANCY WITH MCC",374,MS-DRG,,,,,,,inpatient,,,52372.47,15711.74,"CIGNA [10200]","Cigna Local Plus",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 27MM THK.25MM STERILE",SUP-GC906R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1834.50,550.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 5X120 80CM SL",SUP-48005012N,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 10CM 4FR GLIDESHEATH .021IN 45CM RADIAL ACCESS",SUP-40-1040,CDM,C1894,HCPCS,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ATLAS 80CM 4CM 8FR 18MM .035IN BALLOON DILATATION GOLD",SUP-ATG80184,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INFINITI THRULUMEN 100CM 6FR AMPLATZ LEFT 2 CURVE",SUP-534646T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 110CM 6FR AL1 CURVE GUIDING NYLON CORONARY",SUP-LA6AL10A,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARDEX LUBRICATH 16FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0196L16,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.32,32.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.5MM X 10.0MM",SUP-493501012,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS,MAJOR",421,APR-DRG,,,,,,,inpatient,,,28498.58,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $9,061.59. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($68,773.50) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP060120150 PLUS US D6L120UL1500",SUP-PCP060120150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MERSILENE 5MM MO-4 12IN WOVEN WHITE NONABSORBABLE",SUP-RS23,CDM,S27200284,LOCAL,0272,RC,,,both,,,385.71,115.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC",322,MS-DRG,,,,,,,inpatient,,,128524.42,38557.33,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT HYDROSET HA INJECTABLE OSTEOCONDUCTIVE",SUP-397005,CDM,C1713,HCPCS,0278,RC,,,both,,,10684.65,3205.39,"KAISER [10500]",Kaiser,,7158.72,67,,,,,0,1242.62,9081.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REINFORCEMENT STAPLE LINE UNIVERSAL 6 FIRING 3 GEL TUBE","SUP-PSD 4506-UN",CDM,S27200284,LOCAL,0272,RC,,,both,,,1256.85,377.05,"PHCS [10601]",PHCS,,879.8,70,,,,,0,146.17,1068.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (MR)  4.00MM X 15MM",SUP-H74939401154000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"UHC [10700]","United Healthcare",,3428.64,63.3,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 2.9 MM PUSHLOCK",SUP-AR-1923DL,CDM,S27200284,LOCAL,0272,RC,,,both,,,807.98,242.39,"KAISER [10500]",Kaiser,,541.35,67,,,,,0,93.97,686.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT 10X1CM GRAFTON DEMINERALIZED BONE MATRIX",SUP-T42275,CDM,S27800098,LOCAL,0278,RC,,,both,,,8073.00,2421.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5489.64,68,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Caffeine",PX-301000064,CDM,80155,CPT,0301,RC,,,both,,,133.00,39.9,"CIGNA [10200]",Cigna,,84.85,,,,,,,0.13,113.05,"fee schedule",
"25 MM LOTUS EDGE AORTIC VALVE SYSTEM AND LARGE LOTUS INTRODU",SUP-H749LVSUS250,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"BLUE CROSS [10001]","Blue Cross HMO",,72618,39.2,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 23.5 DIOPTER",SUP-SV25T0,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA [10200]","Cigna Open Access",,423.91,56.9,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DX DEFL 8 POLE",SUP-D708DR002RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3090.00,927,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,359.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,359.37,2626.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 22CM 3CM 5FR .035IN 2 PIGTAIL",SUP-M006192121050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"FIRST HEALTH [10303]","First Health",,960.46,80,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ASCEND FLEX SHOULDER - HEMI (INCLUSIVE OF ASCEND FLEX ST",SUP-CAPFLEXHEM,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"KAISER [10500]",Kaiser,,14773.5,67,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 80MM 125CM 10MM VASCULAR HIWIRE NITINOL",SUP-G43793,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2841.72,68,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 20MM EDWARDS SAPIEN 3 TRANSCATHETER ULTRA LOW",SUP-S3USTA120A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21952.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 5.5MM CD HORIZON LEGACY TITANIUM PREBENT",SUP-8690030,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LUTONIX 035 DRUG COATED PTA BALLOON",SUP-LX351307100,CDM,C2623,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1349.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC",098,MS-DRG,,,,,,,inpatient,,,88819.60,26645.88,"PHCS [10601]",PHCS,,7561,,,,,,,7561,57232.51,"per diem","Estimated amount calculated based on 11 day length of stay."
"CATH NC QUANTUM APEX 143CM 20MM 2.75MM BALLOON DILATATION",SUP-H7493912420270,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WINGSPAN 20MM 3MM INTRACRANIAL HYDROPHILIC SELF EXPAND",SUP-M003WS0300200,CDM,C1874,HCPCS,0278,RC,,,both,,,51979.47,15593.84,"CIGNA [10200]","Cigna Open Access",,17413.12,33.5,,,,,0,6045.21,44182.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC XS 8IN LEFT WRIST FOREARM VOLAR/DORSAL",SUP-A124104,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.24,15.37,"AETNA [10100]","Aetna HMO/PPO",,40.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.96,43.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO ORTHOPEDIC ONE-STEP KYPHX INTEGRATE ACCESS TROCAR",SUP-T05J,CDM,S27200284,LOCAL,0272,RC,,,both,,,5738.04,1721.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2358.33,41.1,,,,,0,667.33,4877.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 58MM LC-DCP DHS STAINLESS STEEL CORTICAL",SUP-214.058,CDM,C1713,HCPCS,0278,RC,,,both,,,464.78,139.43,"BLUE CROSS [10001]","Blue Cross HMO",,182.19,39.2,,957.42,156.86,7483.26,51,54.05,395.06,"percent of total billed charges",
"MARKER RIGID SHARP DELIVERY SYSTEM HYDROMARK BREAST BIOPSY",SUP-4010-02-15-T1,CDM,A4648,HCPCS,0278,RC,,,both,,,640.49,192.15,"KAISER [10500]",Kaiser,,429.13,67,,,,,0,74.49,544.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 23CM GREEN HUB HEMOSTASIS VALVE PRELUDE",SUP-PSI-6F-23,CDM,C1894,HCPCS,0272,RC,,,both,,,110.93,33.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.9,94.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD 2 BIPOLAR IS 1",SUP-ILINK-BIS-10,CDM,C1883,HCPCS,0278,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 30FR 10-12MM 12CM 55MM 1 STEP HIGH PRESSURE NEPHRSTMY",SUP-M0062101170,CDM,C1726,HCPCS,0272,RC,,,both,,,1802.55,540.76,"NOVANET [10819]",Novanet,,1351.91,75,,,,,0,209.64,1532.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR MULTIFIRE PREMIUM STAINLESS STEEL 35 WIDE",SUP-059038,CDM,S27200284,LOCAL,0272,RC,,,both,,,98.22,29.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,45.08,45.9,,,,,0,11.42,83.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POVIDONE-IODINE 5 % EYE SOLUTION",RX-19791,CDM,,,0250,RC,00065-0411-30,NDC,both,30,ML,96.99,29.1,"AETNA [10100]","Aetna HMO/PPO",,77.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.28,82.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 180CM 8CM 8-9-10MM 6FR ESOPHAGEAL BALLOON",SUP-M00558340,CDM,C1726,HCPCS,0272,RC,,,both,,,1562.98,468.89,"NOVANET [10819]",Novanet,,1172.24,75,,,,,0,1172.24,1172.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 30CM 150CM 7FR .038IN 3CM BLADDER LOOP",SUP-M006155245170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"MULTIPLAN [10600]",Multiplan,,1207.29,85,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 20MM 4.75MM EMBOLIZATION NEUROVASCULAR",SUP-PED-475-20,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,30780,40,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +24.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.245,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE",RX-1306,CDM,J0618,HCPCS,0636,RC,76329-3304-01,NDC,both,10,ML,95.13,28.54,"KAISER [10500]",Kaiser,,63.74,67,,,,,0,11.27,80.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP IDENTITY STEM/AUGMENTED GLENOID/PREMIUM POST/IDENTITY HE",SUP-98000900262,CDM,C1776,HCPCS,0278,RC,,,both,,,33075.00,9922.5,"AETNA [10100]","Aetna HMO/PPO",,26294.63,79.5,,10981.53,8986.79,12413.38,12,3846.62,28113.75,"percent of total billed charges",
"CAGE SPINAL 45X18X12MM COROENTXL PEEK-OPTIMA LATERAL LUMBAR",SUP-6912845,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"CIGNA [10200]","Cigna Local Plus",,7484.4,31.5,,16168.95,16168.95,16168.95,"1 through 10",2763.29,20196,"percent of total billed charges",
"STENT VIABAHN 5CM 75CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR060501A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"FIRST HEALTH [10303]","First Health",,15009.12,80,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET",RX-24559,CDM,,,0250,RC,77333-0948-25,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP BIOFOAM DYNASTY",SUP-DSBFGB48,CDM,C1776,HCPCS,0278,RC,,,both,,,18918.90,5675.67,"NOVANET [10819]",Novanet,,14189.18,75,,,,,0,2200.27,16081.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT RIBFIX TITAN INTRATHORACIC BUTTON WASHER TITANIUM",SUP-323.5002,CDM,C1713,HCPCS,0278,RC,,,both,,,22610.70,6783.21,"CIGNA [10200]","Cigna Local Plus",,7122.37,31.5,,3978.14,359.25,3978.14,24,2629.62,19219.1,"percent of total billed charges",
"BODY CONE 23MM 23MM RESTORATION 0MM STANDARD HIP MOD",SUP-6276-1-023,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1714.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1682.49,12296.8,"percent of total billed charges",
"HC Inj Sacroiliac Jt Bi",PX-510000070,CDM,27096,CPT,0761,RC,,,both,,,5417.97,1625.39,"NOVANET [10819]",Novanet,,4063.48,75,,,,,0,630.11,4605.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CRANIOTOMY NATUS NO RAZOR DRUG 2 DRILL BIT ACCESS",SUP-HITH1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3832.81,1149.84,"MULTIPLAN [10600]",Multiplan,,3257.89,85,,,,,0,445.76,3257.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 15CM 2.2MM MR8 MATCH HEAD STERILE DISPOSABLE",SUP-MR8-15MH22,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"CIGNA [10200]",Cigna,,794.8,68,,,,,0,135.93,993.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 650ML GEL SMOOTH MEMORYGEL SILICONE P5.7CM HIGH","SUP-3506504 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,439.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RIFAMPIN 600 MG INTRAVENOUS SOLUTION",RX-11291,CDM,J2804,HCPCS,0636,RC,00068-0597-01,NDC,both,1,UN,1077.78,323.33,"PHCS [10601]",PHCS,,754.45,70,,,,,0,97.9,916.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL TOE JOINT 2.75MM HAMMERTUBE 0D PEEK CANNULATED",SUP-P40-001-0275-S,CDM,C1713,HCPCS,0278,RC,,,both,,,6537.75,1961.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,774.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",760.34,5557.09,"percent of total billed charges",
"PROBE ELECTROSURGICAL 25CM ABLATION 13GA",SUP-NWSR25,CDM,C1886,HCPCS,0272,RC,,,both,,,14524.50,4357.35,"NOVANET [10819]",Novanet,,10893.38,75,,,,,0,1689.2,12345.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL MBT LCS COMPLETE 3 KNEE POROUS CEMENTED KEEL",SUP-129434130,CDM,C1776,HCPCS,0278,RC,,,both,,,17561.25,5268.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2081.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2042.37,14927.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 TAPER 32MM HIP OXINIUM ECHELON",SUP-71343200,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"BLUE CROSS [10001]","Blue Cross PPO",,6089.86,39.2,,3949.44,3949.44,3949.44,"1 through 10",1806.76,13205.05,"percent of total billed charges",
"LENS IOL 0 D +13 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.130,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCH FOOT CARBON FIBER 180MM",SUP-4934-6-180,CDM,S27800098,LOCAL,0278,RC,,,both,,,10574.39,3172.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1253.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1229.8,8988.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 45MM 18MM 14FR 11FR TRIVASCULAR OVATION PRIME",SUP-TV-EX181845-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"FIRST HEALTH [10303]","First Health",,26712,80,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 90MM DHS/DCS STAINLESS STEEL CONDYLAR HIP",SUP-280.290,CDM,C1713,HCPCS,0278,RC,,,both,,,2043.30,612.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,242.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,237.64,1736.81,"percent of total billed charges",
"BODY CONE 70MM ARCOS STD OFFSET C HIP FEMUR PROXIMAL",SUP-11-301323,CDM,C1776,HCPCS,0278,RC,,,both,,,39453.12,11835.94,"UHC [10700]","United Healthcare",,24973.82,63.3,,8601.07,8395.67,8601.07,"1 through 10",4588.4,33535.15,"percent of total billed charges",
"SUT PROLENE 5-0 RB-1 36IN 2 ARM MONOFILAMENT BLUE",SUP-8556H,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.78,18.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,41.33,68,,,,,0,7.07,51.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE ENDOSCOPIC 45D 400CM .035IN HYDROPHILIC STIFF",SUP-GS3540,CDM,C1769,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT POSTOPERATIVE 10.5-12 LARGE WIDE MALE BLACK ETHYLENE VI",SUP-199651,CDM,S27000186,LOCAL,0270,RC,,,both,,,217.50,65.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,99.83,45.9,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? DOUBLE CABLE PLATE KIT",SUP-94-1300-04,CDM,C1713,HCPCS,0278,RC,,,both,,,10867.50,3260.25,"UHC [10700]","United Healthcare",,6879.13,63.3,,5023.51,2672.93,6679.78,18,1263.89,9237.38,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 28CM 5FR .038",SUP-M006192124120,CDM,C2617,HCPCS,0278,RC,,,both,,,1528.96,458.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,177.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,177.82,1299.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH HYPERTONICS 34 PIN TO 25 PIN CNCT",SUP-CR3425CT,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"FIRST HEALTH [10303]","First Health",,2694,80,,,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 30CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006175285080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,842.78,68,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 17MM 14.8MM MASTERS HP MECHANICAL ROTATABLE STD",SUP-17MHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]",Cigna,,11647.69,40,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3.5MM 24MM TITANIUM CORTEX SELF TAP CRUCIFORM",SUP-401.824,CDM,C1713,HCPCS,0278,RC,,,both,,,397.07,119.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,46.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",46.18,337.51,"percent of total billed charges",
"GRAFT SOFT TISSUE REGENERATION",SUP-345111,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 80MM 4FR 2.5MM ROUND LOW PROFILE TAPER",SUP-A2025-080,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 10 79MM 13.8MM SHILEY UNCUFF REUSABLE INNER CANN",SUP-10UN10R,CDM,S27200284,LOCAL,0272,RC,,,both,,,484.06,145.22,"FIRST HEALTH [10303]","First Health",,387.25,80,,,,,0,56.3,411.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH DRYSEAL FLEX 45CM 10FR 4MM 3.3MM INTRO HYDROPHILIC",SUP-GDSF1045,CDM,C1894,HCPCS,0272,RC,,,both,,,5844.30,1753.29,"KAISER [10500]",Kaiser,,3915.68,67,,,,,0,679.69,4967.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 65CM 15CM 4FR .041IN ANGLE",SUP-CG415,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 3 HIGH OFFSET HIP",SUP-71935575,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15015.35,41.1,,6417.48,6417.48,6417.48,"1 through 10",4248.87,31053.65,"percent of total billed charges",
"CATH MUSTANG 40CM 60MM 6MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171060640,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSPONGE BLOCK 14X14X14MM",SUP-109614,CDM,S27800098,LOCAL,0278,RC,,,both,,,4398.75,1319.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2019.03,45.9,,,,,0,511.57,3738.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTICROSS 6HD 135CM 1.18MM ULTRASOUND CORONARY STERILE",SUP-H74939354090,CDM,C1753,HCPCS,0272,RC,,,both,,,5037.00,1511.1,"PHCS [10601]",PHCS,,3525.9,70,,,,,0,585.8,4281.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 58MM TI",SUP-MTLS-37580-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",155.43,1136.03,"percent of total billed charges",
"ANCHOR SUT 2 ICONIX XBRAID KNOTLESS STERILE LATEX FREE",SUP-3911-723-522,CDM,C1713,HCPCS,0278,RC,,,both,,,3864.00,1159.2,"PHCS [10601]",PHCS,,2704.8,70,,,,,0,449.38,3284.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 3CM 4FR STRAIGHT PANCREATIC PLASTIC TRAIL",SUP-M00536130,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"FIRST HEALTH [10303]","First Health",,511.4,80,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 7IN FREEMAN 4 SHARP OFFSET PRONG SURGICAL 38MM FACE",SUP-P509,CDM,S27200284,LOCAL,0272,RC,,,both,,,419.78,125.93,"KAISER [10500]",Kaiser,,281.25,67,,,,,0,48.82,356.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 8FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552540,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"FIRST HEALTH [10303]","First Health",,960.46,80,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 80CM 1MM 5FR 5-1-5MM SPACE P2 CURVE",SUP-D510P2R5155RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2534.7,68,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INDIGO LIGHTNING CAT12 HTORQ 115CM THROMBECTOMY",SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,0272,RC,,,both,,,42147.00,12644.1,"NOVANET [10819]",Novanet,,31610.25,75,,,,,0,4901.7,35824.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 70MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.870,CDM,C1713,HCPCS,0278,RC,,,both,,,1510.49,453.15,"MULTIPLAN [10600]",Multiplan,,1283.92,85,,,,,0,175.67,1283.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DSRCTOR 12MM TRIMLINE STERILE",SUP-875-087,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SECONDARY ANCHOR DELIVERY CATHETER, SHAPE 04",SUP-4740-04,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dressing Wound Drawtex",PX-E27200249,CDM,E27200249,LOCAL,0272,RC,,,both,,,79.18,23.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Innovamatrix Ac, per Sq Cm",PX-E63600050,CDM,A2001,HCPCS,0636,RC,,,both,,,767.80,230.34,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL 0 D +14 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-SY60WF.140,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.8MM 3MM PRECISION NEURO STERILE LATEX FREE",SUP-5820-107-530,CDM,S27200284,LOCAL,0272,RC,,,both,,,1119.18,335.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,132.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,130.16,951.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 88X10.9X2.5MM TIMAX 3.5MM SCR 9 HOLE LOW",SUP-131218702,CDM,C1713,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"CIGNA [10200]","Cigna Local Plus",,5648,53.5,,3978.14,359.25,3978.14,24,1227.78,8973.45,"percent of total billed charges",
"ANCHOR SUT 5MM FORCE FIBER WIRE",SUP-3910-900-050,CDM,C1713,HCPCS,0278,RC,,,both,,,212.02,63.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",24.66,180.22,"percent of total billed charges",
"STEM EXT 50MM 14MM ATTUNE KNEE CEMENT REVISION STERILE",SUP-1512-14-050,CDM,C1776,HCPCS,0278,RC,,,both,,,5230.20,1569.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2400.66,45.9,,,,,0,608.27,4445.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION",RX-27737,CDM,Q9967,HCPCS,0255,RC,00270-1315-35,NDC,both,100,ML,200.00,60,"PHCS [10601]",PHCS,,140,70,,,,,0,23.26,170,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cysto Uret/Pyelosc W/Litho",PX-361000511,CDM,52353,CPT,0361,RC,,,both,,,10398.48,3119.54,"NOVANET [10819]",Novanet,,7798.86,75,,,,,0,1209.34,10398.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cta Neck W/WO Cntrst",PX-351000015,CDM,70498,CPT,0351,RC,,,both,,,4327.01,1298.1,"NOVANET [10819]",Novanet,,3245.26,75,,,,,0,405,3677.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Suction",PX-E27200071,CDM,E27200071,LOCAL,0272,RC,,,both,,,97.42,29.23,"CIGNA [10200]",Cigna,,66.25,68,,,,,0,11.33,82.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alk Phosphatase",PX-301000355,CDM,84075,CPT,0301,RC,,,both,,,114.95,34.48,"KAISER [10500]",Kaiser,,77.02,67,,,,,0,0.01,97.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNID PATIENT SPECIFIC DATA PLAN AND RODS",SUP-M200000B116,CDM,C1713,HCPCS,0278,RC,,,both,,,25200.00,7560,"PHCS [10601]",PHCS,,17640,70,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTREPIDTM TMVR CRIMPER",SUP-ASM-0014,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 8.2MM 70MM 22MM DHS/DCS STAINLESS STEEL",SUP-280.7,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"CIGNA [10200]",Cigna,,1236.5,68,,1831.33,1831.33,1831.33,16,211.48,1545.62,"percent of total billed charges",
"SUT ETHILON 4-0 PSL 30IN MONOFILAMENT BLACK NONABSORBABLE",SUP-562H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) 28 FR. THORAGUARD CHEST TUBE KIT (BOX OF 10)",SUP-TGCT120028,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 18GA 15CM CANN SERRATE EDGE FRANSEEN LUNG STERILE",SUP-G01305,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) RDND1 GUIDE CATHETER",SUP-SB6RDNK1K,CDM,C1887,HCPCS,0272,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RAMIPRIL 2.5 MG CAPSULE",RX-11260,CDM,,,0637,RC,65862-0475-01,NDC,both,1,UN,9.09,2.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.06,7.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 400MM RIGHT TROCHANTERIC INTRAMEDULLARY 130D LONG",SUP-456.360S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"AETNA [10100]","Aetna HMO/PPO",,10867.98,79.5,,1521.93,481.35,16760.95,30,1589.87,11619.86,"percent of total billed charges",
"SCR BONE 3.5MM MOUNTAINEER TITANIUM SPINE OCCIPITOCERVICAL",SUP-188362025,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",50.59,369.75,"percent of total billed charges",
"VALVE MITRAL 25MM BOVINE PERICARDIUM LEAFLET COBALT CHROMIUM",SUP-11400M25,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"UHC [10700]","United Healthcare",,28712.88,63.3,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Proc Dx Unlisted",PX-320000172,CDM,76499,CPT,0320,RC,,,both,,,1329.98,398.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,904.39,68,,,,,0,154.68,1130.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Trach Cuffed Low Pressure",PX-E27200230,CDM,E27200230,LOCAL,0272,RC,,,both,,,279.62,83.89,"NOVANET [10819]",Novanet,,209.72,75,,,,,0,32.52,237.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 5CC ALLOGRAFT MOLDABLE",SUP-VCAMX-050000,CDM,S27800098,LOCAL,0278,RC,,,both,,,12075.00,3622.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4962.83,41.1,,,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 38MM TI",SUP-SPL-60380-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"PHCS [10601]",PHCS,,1134,70,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 6 13MM KNEE POSTERIOR STABILIZED BEARING TRIAT",SUP-5532P613,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]",Cigna,,5682.01,68,,5873.17,5873.17,5873.17,"1 through 10",971.79,7102.52,"percent of total billed charges",
"HOOK LAPAROSCOPIC 55.2CM 8MM DA VINCI S/SI ENDOWRIST CAUT",SUP-420183,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 6MMX29MM 7FR 135CMCATH HEPARIN",SUP-BXB062902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS [10001]","Blue Cross PPO",,7645.88,39.2,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 5X28MM STERILE XL25 RECESS LOCKING TITANIUM RFN A",SUP-04.045.028TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 65MM KNEE LEFT POSTERIOR STABILIZE OPEN BOX",SUP-184528,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"KAISER [10500]",Kaiser,,16633.27,67,,,,,0,2887.24,21101.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI L 8MMX1MM MID FACE RIGHT 4 HOLE BAR 2MM SCR BONE",SUP-55-08232,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 64CM 7.8FR 9MM KT FIRM",SUP-6768,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) CATH TURNPIKE 135CM 2.2-2.9FR 1.6FR GUIDING LOW PROF",SUP-5638,CDM,S27200284,LOCAL,0272,RC,,,both,,,3967.50,1190.25,"CIGNA [10200]",Cigna,,2697.9,68,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X22X7MM RISE-L 3D NONSTERILE",SUP-193.602,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14111.69,41.1,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 75MM 5MM KII FIOS 2 PACK ACCESS SYSTEM",SUP-CFF14,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"MULTIPLAN [10600]",Multiplan,,184.88,85,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM CEMENT BASIC SUMMIT 6 12/14 TAPER HIP",SUP-157006120,CDM,C1776,HCPCS,0278,RC,,,both,,,8135.10,2440.53,"MULTIPLAN [10600]",Multiplan,,6914.84,85,,,,,0,946.11,6914.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 46MM TI",SUP-SPL-35460-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Legionella Direct Ifa",PX-302000052,CDM,86255,CPT,0302,RC,,,both,,,228.00,68.4,"BLUE CROSS [10001]","Blue Cross HMO",,0.23,.1,,,,,0,0.23,193.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Proc Nfrosgrm Urtrgrm New",PX-361000412,CDM,50430,CPT,0361,RC,,,both,,,1532.56,459.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1532.56,,"Case rate ($2,719). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,178.24,1532.56,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cr West Nile Virus Igm-Expl832",PX-300000032,CDM,86788,CPT,0302,RC,,,both,,,358.00,107.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,26.51,,,,,,,0.01,304.3,"fee schedule",
"STENT VIABAHN 25CM 120CM 8MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR082502A,CDM,C1874,HCPCS,0278,RC,,,both,,,40635.00,12190.5,"AETNA [10100]","Aetna HMO/PPO",,32304.83,79.5,,,,,0,4725.85,34539.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 16GA CURVE SILICONIZE SHARP 10MM",SUP-RFK-C101016VZ-P,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,19.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 34CM 7FR VENTRICLE BIPOLAR PASSIVE FIXATION",SUP-1646T/34,CDM,C1898,HCPCS,0275,RC,,,both,,,1786.00,535.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,211.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,207.71,1518.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON SUPRAMID EXTRA 2-0 GS-1 30IN MONOFILAMENT WHITE",SUP-2GS-1-30W,CDM,S27200284,LOCAL,0272,RC,,,both,,,160.23,48.07,"AETNA [10100]","Aetna HMO/PPO",,127.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.63,136.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X7MM LUMINARY 10-11MM SPINE DEMINERALIZED",SUP-14707,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3663.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X60 40CM SL",SUP-48005006P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"UHC [10700]","United Healthcare",,621.69,63.3,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21.5 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6",SUP-ZCT225215,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross HMO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD REAMER 17.5MM STAINLESS STEEL RIA STERILE DISPOSABLE",SUP-352.262S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2533.80,760.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1163.01,45.9,,,,,0,294.68,2153.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 80CM 5FR SOS OMNI 0 CURVE ANGIOGRAPHIC VISCERAL",SUP-H787107204085,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"FIRST HEALTH [10303]","First Health",,174,80,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 72X6.3X1.25MM TITANIUM 2.4MM SCR 12 HOLE LOW",SUP-449.912,CDM,C1713,HCPCS,0278,RC,,,both,,,2862.30,858.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1313.8,45.9,,,,,0,332.89,2432.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9.5MM 90MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840009590,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",441.36,3225.75,"percent of total billed charges",
"HC Sigmoid Flex Bx",PX-750000076,CDM,45331,CPT,0750,RC,,,both,,,3094.10,928.23,"CIGNA [10200]","Cigna Local Plus",,1965,,"Case rate ($1,965). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,359.84,3094.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 12CM 2.5MM BALLOON DILATATION HYDROPHILIC",SUP-G50324,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"MULTIPLAN [10600]",Multiplan,,2008.07,85,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR MIKELSON CURVE ANGIOGRAPHIC VISCERA",SUP-M001314761,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"CIGNA [10200]",Cigna,,79.27,68,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL STD 2.7MM CANNULATED PROXIMAL LATERAL",SUP-00236020527,CDM,S27000186,LOCAL,0270,RC,,,both,,,2137.50,641.25,"CIGNA [10200]","Cigna Local Plus",,1143.56,53.5,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR 3 DIMENSIONAL RIGHT",SUP-67013000,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,283.97,68,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 3CM 7FR BILIARY POLYETHYLENE TAPERED TIP",SUP-G21679,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"FIRST HEALTH [10303]","First Health",,505.44,80,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 24MM 144CM 4MM CORONARY STENT EVEROLIMUS",SUP-H7493926124400,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS INTRAOCULAR +09.00 DIOPTER L13MM D5MM OPTIC BODY 6MM A",SUP-LI61AOR0900,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 25MM CEMENTED OMNIFIT HFX 132D 5 HIP",SUP-6070-0525A,CDM,C1776,HCPCS,0278,RC,,,both,,,7894.95,2368.48,"FIRST HEALTH [10303]","First Health",,6315.96,80,,,,,0,918.18,6710.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 150MM 6MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171061510,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BONE CEMENT 6.5IN 8GA OSSEOFLEX SB 2 CANN STEERABLE",SUP-OF-0021,CDM,S27200284,LOCAL,0272,RC,,,both,,,6161.70,1848.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,730.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,716.61,5237.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 45CM 4-7MM GORE INTERING STD WALL TAPER PTFE",SUP-IRS47045L,CDM,C1768,HCPCS,0278,RC,,,both,,,4774.80,1432.44,"AETNA [10100]","Aetna HMO/PPO",,3795.97,79.5,,,,,0,555.31,4058.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 24MM 144CM 2.75MM CORONARY STENT",SUP-H7493941824270,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135D 47MM MINI TAPER HIGH OFFSET 43.2MM 145MM",SUP-L20311,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"MULTIPLAN [10600]",Multiplan,,13461.55,85,,,,,0,1841.86,13461.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 30CM 8FR UNIVERSA 2 PIGTAIL CURVE URETER AQ",SUP-G49924,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,215.59,28.62,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 12MM 2.5MM BALLOON DILATATION STERILE",SUP-225-123-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 1026X55MM",SUP-6210055,CDM,C1889,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]",Cigna,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT EXTERNAL FIXATION SCHANZ CANNULATED POST MOUNT",SUP-03.311.059,CDM,S27800098,LOCAL,0278,RC,,,both,,,1898.33,569.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,871.33,45.9,,,,,0,220.78,1613.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 40CMX.49MM 20MM KNITTED REVERSE LOCKNIT",SUP-HGK0020-40,CDM,C1768,HCPCS,0278,RC,,,both,,,2588.55,776.56,"CIGNA [10200]","Cigna Open Access",,1472.88,56.9,,,,,0,301.05,2200.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM PFC SIGMA TC3 2 KNEE LEFT TITANIUM CEMENTED",SUP-960820,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,596.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM TI HARD ROD 100MM",SUP-498.104,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL UNITY KNEE 6 KNEE FIX BEARING",SUP-112.040.12,CDM,C1776,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"CIGNA [10200]",Cigna,,3988.2,68,,5873.17,5873.17,5873.17,"1 through 10",682.1,4985.25,"percent of total billed charges",
"VALVE AORTIC 16MM 23MM MOSAIC ULTRA CINCH RING PORCINE STENT",SUP-305U223,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"NOVANET [10819]",Novanet,,20553.75,75,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 78MM PRESS FIT AEQUALIS ASCEND FLEX PTC 137.5D",SUP-DWF604C,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT PRESS FIT EMPOWR 3D KNEE STERILE",SUP-243-01-107,CDM,C1776,HCPCS,0278,RC,,,both,,,27824.45,8347.33,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7512.6,27,,,,,0,3235.98,23650.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRPR SURGICAL DORMO-STRIP VEIN DISPOSABLE",SUP-VE-022,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.32,87.1,"CIGNA [10200]","Cigna Open Access",,165.19,56.9,,,,,0,33.76,246.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 10MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-010,CDM,C1776,HCPCS,0278,RC,,,both,,,5148.36,1544.51,"BLUE CROSS [10001]","Blue Cross PPO",,2018.16,39.2,,3949.44,3949.44,3949.44,"1 through 10",598.75,4376.11,"percent of total billed charges",
"DRAIN INCISION 12FR 12IN DEAVER NATURAL RUBBER 5IN T TUBE",SUP-0099810,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.29,18.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,41,68,,,,,0,7.01,51.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION",RX-9929,CDM,,,0250,RC,43598-0169-11,NDC,both,2,ML,85.90,25.77,"UHC [10700]","United Healthcare",,54.37,63.3,,,,,0,9.99,73.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HCGroup Caregiver Training (Gp)",PX-420000187,CDM,97552,CPT,0423,RC,,,both,,,22.00,6.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,22,,"Per diem ($426).",,,,0,0.02,22,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 22MM ORTHOLOC FOREFOOT NONLOCKING",SUP-5201124022,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,517.75,68,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ICD-DR DDBB1D1 EVERA XT IS1/DF1 US",SUP-DDBB1D1,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"MULTIPLAN [10600]",Multiplan,,34476,85,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPINAL PROCEDURES WITHOUT CC/MCC",030,MS-DRG,,,,,,,inpatient,,,108521.56,32556.47,"UHC [10700]","United Healthcare",,64091.06,,"Fee schedule rate ($64,091.06). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,10994,64091.06,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERLINK FIBERWIRE 2 26IN CLOSED LOOP BLACK WHITE",SUP-AR-7235T,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,192.26,41.1,,,,,0,54.4,397.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MITRACLIP DELIVERY G5",SUP-MCG50100,CDM,S27800098,LOCAL,0278,RC,,,both,,,188100.00,56430,"CIGNA [10200]",Cigna,,75240,40,,,,,0,21876.03,159885,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXS CATALYST 5 132CM .058IN GUIDING DISTAL ACCESS",SUP-M003IC0581320,CDM,S27200284,LOCAL,0272,RC,,,both,,,13688.22,4106.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6282.89,45.9,,,,,0,1591.94,11634.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 STANDARD 3MMX8CM",SUP-M0035463080,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1641.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONCUSSION WITH MCC",088,MS-DRG,,,,,,,inpatient,,,56617.48,19990.48,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,8888.42,,"Case rate ($8,385.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,786.32, add-ons for qualifying new technology services are included. If operating cost exceeds $40,826.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,970.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,796.61. The transfer operating threshold is the transfer adjustment factor * $7,786.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $588.68. The transfer capital threshold is the transfer adjustment factor * $588.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,8385.3,33712.54,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DEBAKEY STRAIGHT FLUTE HANDLE 14IN VASCULAR",SUP-55-2030,CDM,S27200284,LOCAL,0272,RC,,,both,,,830.09,249.03,"CIGNA [10200]","Cigna Local Plus",,444.1,53.5,,,,,0,96.54,705.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT HUMERAL 42MM AEQUALIS SHOULDER METAPHYSIS REVERSE",SUP-DWB961,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"MULTIPLAN [10600]",Multiplan,,8568,85,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 16MM 144CM 2.75MM CORONARY STENT",SUP-H7493941816270,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Open Access",,1707,56.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 62MM 32MM MARATHON HIP",SUP-121932062,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"BLUE CROSS [10001]","Blue Cross HMO",,2835.98,39.2,,5311.50,4717.44,5388.59,31,841.39,6149.45,"percent of total billed charges",
"STENT EVERFLEX 60MM 120CM 7MM VASCULAR PERIPHERAL SELF",SUP-PRB35-07-060-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Open Access",,3166.49,56.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM GAP II HIP ACETABULAR STERILE",SUP-2080-0060,CDM,C1713,HCPCS,0278,RC,,,both,,,866.70,260.01,"FIRST HEALTH [10303]","First Health",,693.36,80,,,,,0,100.8,736.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM LOW PROFILE SCREWS TITANIUM T15 FULL",SUP-AR-8935L-14,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-607,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1555.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPN NC 10MM 2.5MM BALLOON DILATATION CORONARY STERILE",SUP-250-010-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,962.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST TAPER 32MM 12MM HEMICAP CONTOUR OVOID SHOULDER TITANIUM",SUP-8156-0032-A,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 190CM 3CM",SUP-1020014,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERPICC SHERLOCK 3CG 5FR CENTRAL VENOUS POLYPROPYLENE",SUP-1275108D,CDM,C1751,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE COOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-CRKA-17-50-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 15MM 5MM OVAL",SUP-AR-300-B103,CDM,S27200284,LOCAL,0272,RC,,,both,,,2625.00,787.5,"CIGNA [10200]",Cigna,,1785,68,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL VARIABLE DISPOSABLE",SUP-11-1109-FD9-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TESTES PROCEDURES WITHOUT CC/MCC",712,MS-DRG,,,,,,,inpatient,,,42481.12,12744.34,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENCORE 26 INFLATION 20ML 1 PACK INLINE GAUGE",SUP-H74904526011,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.88,84.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Eeg WO Vid Ea 12-26hr Unmntr",PX-740000043,CDM,95708,CPT,0740,RC,,,both,,,4168.00,1250.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EVERCROSS 135CM 60MM 3MM .035IN BALLOON DILATATION",SUP-AB35W03060135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STPLR 45MM ENDOWRIST BLUE",SUP-41645B,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Kit Foley Cath",PX-E27200164,CDM,E27200164,LOCAL,0272,RC,,,both,,,130.90,39.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Endovenous Ablt Rf Subq Vein",PX-361000101,CDM,36476,CPT,0361,RC,,,both,,,3091.20,927.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL HARMONIC SCPL DISSECTING HOOK",SUP-SNGHK,CDM,S27200284,LOCAL,0272,RC,,,both,,,1862.06,558.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMPRESS 100CM 5FR VERT CURVE ANGIOGRAPHIC STAINLESS",SUP-510038VER,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER ALLOGRAFT 11X14X9MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7309,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Local Plus",,3691.5,53.5,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LASER FIBER 1000",SUP-HLFD1000C,CDM,S27200284,LOCAL,0272,RC,,,both,,,5750.00,1725,"CIGNA [10200]","Cigna Local Plus",,3076.25,53.5,,,,,0,668.73,4887.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Bartholins Gland Abscess",PX-450000283,CDM,56420,CPT,0450,RC,,,both,,,819.50,245.85,"CIGNA [10200]","Cigna Local Plus",,819.5,,,,,,,67.13,819.5,"case rate",
"CANN RADIOFREQUENCY 100MM 20GA 10MM",SUP-AC0009,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"KAISER [10500]",Kaiser,,69.95,67,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 36MM MITRAL FLEXIBLE HOLDER KNIT SEW",SUP-4450M36,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"BLUE CROSS [10001]","Blue Cross HMO",,4462.92,39.2,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP TRUNCATE OSTEOTOM 56MM HEMISPHERE",SUP-00705305610,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"UHC [10700]","United Healthcare",,2865.21,63.3,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 6CM 230CM 25-30MM 10FR 270CM COLONIC NITINOL",SUP-M00565040,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 2MM 60MM ECHELON FLEX ENDOPATH STAINLESS STEEL",SUP-ECR60M,CDM,S27200284,LOCAL,0272,RC,,,both,,,3907.19,1172.16,"AETNA [10100]","Aetna HMO/PPO",,3106.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,454.41,3321.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM NAVITOR TRANSCATHETER SELF EXPAND INTRA",SUP-NVTR-27,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,36936,27,,,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON ULTIMA 10-0 CS160-6 6IN 2 ARM MONOFILAMENT BLACK",SUP-9001G,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.51,73.95,"UHC [10700]","United Healthcare",,156.04,63.3,,,,,0,28.67,209.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 59MM 80CM 8MM 11MM 7FR .035IN",SUP-BXA085901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]",Cigna,,7801.92,40,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC BIOTRONIK HOME MON EDORA 8 3 CHMBR STERILE",SUP-407138,CDM,C2621,HCPCS,0275,RC,,,both,,,25200.00,7560,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6804,27,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X22X14MM 10D",SUP-6921450,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"CIGNA [10200]","Cigna Local Plus",,7484.4,31.5,,16168.95,16168.95,16168.95,"1 through 10",2763.29,20196,"percent of total billed charges",
"CATH SUPER TORQUE 100CM 4FR .0395IN SIDEWINDER SIMMONS",SUP-532415,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.91,41.1,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SMARTGUARD VISION TESTING DISPOSABLE",SUP-SG-200,CDM,S27000186,LOCAL,0270,RC,,,both,,,282.75,84.82,"NOVANET [10819]",Novanet,,212.06,75,,,,,0,32.88,240.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 100MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"MULTIPLAN [10600]",Multiplan,,1218.65,85,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP LUBRICATH STATLOCK 16FR 2",SUP-A119416M,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.94,69.58,"CIGNA [10200]","Cigna Open Access",,131.97,56.9,,,,,0,26.97,197.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 22MM 3.5MM CORONARY STENT FULCRUM COCR",SUP-INT35022UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1642.2,68,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 12D ALLOGRAFT 24MM ALIF",SUP-3W4224,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"AETNA [10100]","Aetna HMO/PPO",,16810.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 80MM 32MM NCB PROTASUL-64 3.5MM FEMUR",SUP-0203152080,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"SUT VICRYL PLUS 2 TP-1 27IN BRAID 2 STRAND ANTIBACTERIAL",SUP-VCP849G,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.55,24.16,"CIGNA [10200]","Cigna Local Plus",,43.09,53.5,,,,,0,9.37,68.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION",RX-12580,CDM,,,0250,RC,60687-0394-79,NDC,both,2.5,ML,12.54,3.76,"CIGNA [10200]","Cigna Open Access",,7.14,56.9,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 3 LEFT DISTAL KNEE TOTAL",SUP-5541-A-301,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3244.27,68,,,,,0,554.87,4055.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX8MM VERTE-STACK CAPSTONE PEEK-OPTIMA END",SUP-2960822,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6533.91,41.1,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE KORE FIBER CORTICAL BONE FIBER ALLOGRAFT STRIP",SUP-423310,CDM,C1713,HCPCS,0278,RC,,,both,,,20947.50,6284.25,"BLUE CROSS [10001]","Blue Cross HMO",,8211.42,39.2,,957.42,156.86,7483.26,51,2436.19,17805.38,"percent of total billed charges",
"CATH Z-MED-X 100CM 12X6CM 9FR 28MM .035IN BALLOON DILATATION",SUP-618451,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"KAISER [10500]",Kaiser,,3563.09,67,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA STD TKR FEMUR PATELLA TIBIA CEMENT STEM",SUP-98000600084,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"AETNA [10100]","Aetna HMO/PPO",,17529.75,79.5,,10981.53,8986.79,12413.38,12,2564.42,18742.5,"percent of total billed charges",
"SUB BONE GRAFT BTCP CLLGN 5ML VITOSS VOID FILLER FOAM PACK",SUP-2102-1605,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1234.24,28.62,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 20MM LOW PROFILE SCREWS TITANIUM FULL THREAD",SUP-AR-8933-20,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,103.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",103.62,757.35,"percent of total billed charges",
"CLAREONPANOPTIX PROTORIC(BLF)",SUP-PXYWT4,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"CIGNA [10200]",Cigna,,622.2,68,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 2MM STEINMANN STAINLESS STEEL TROCAR POINT",SUP-3593-1-090,CDM,C1713,HCPCS,0278,RC,,,both,,,179.05,53.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,20.82,152.19,"percent of total billed charges",
"STEM HUMERAL 70MM PRESS FIT AEQUALIS ASCEND FLEX PTC 132.5D",SUP-DWF602B,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"KAISER [10500]",Kaiser,,8442,67,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT SHOULDER HEMI",SUP-98000972500,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"UHC [10700]","United Healthcare",,12960.68,63.3,,8601.07,8395.67,8601.07,"1 through 10",2381.24,17403.75,"percent of total billed charges",
"CATH SABER 150CM 300MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050300M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"PHCS [10601]",PHCS,,1312.5,70,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE BONE SIGNATURE ONE ALLIANCE SURGICAL SHOULDER GLENOID",SUP-20-8090-008-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,7562.40,2268.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5142.43,68,,,,,0,879.51,6428.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM DISTALFIX CORTICAL",SUP-HTN-U-4-38,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"PHCS [10601]",PHCS,,1088.64,70,,,,,0,180.87,1321.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE C TI ROD, 3.5X60MM PRE BENT",SUP-3943060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 45MM ENDOWRIST GREEN",SUP-41445G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"NOVANET [10819]",Novanet,,1093.5,75,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFTON PUTTY 1CC",SUP-T43102,CDM,C1713,HCPCS,0278,RC,,,both,,,810.00,243,"CIGNA [10200]",Cigna,,550.8,68,,1831.33,1831.33,1831.33,16,94.2,688.5,"percent of total billed charges",
"PLATE 88MM RADIUS CURVE 104MM STAINLESS STEEL 3.5MM SCR 8",SUP-245.908,CDM,C1713,HCPCS,0278,RC,,,both,,,4488.04,1346.41,"PHCS [10601]",PHCS,,3141.63,70,,,,,0,521.96,3814.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 9.5MM S-ROM ZTT 20D SMALL HIP PROXIMAL",SUP-550533,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"CIGNA [10200]","Cigna Local Plus",,5823.34,53.5,,5372.07,4581.20,7242.98,23,1265.9,9252.04,"percent of total billed charges",
"BENZOCAINE 20 % MUCOSAL SPRAY",RX-27666,CDM,,,0250,RC,00283-0610-43,NDC,both,1,UN,80.00,24,"AETNA [10100]","Aetna HMO/PPO",,63.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.3,68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC",716,MS-DRG,,,,,,,inpatient,,,80981.54,24294.46,"AMBETTER EXCHANGE  [11102]",Ambetter,,9124.69,,"Case rate ($9,124.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,472.90, add-ons for qualifying new technology services are included. If operating cost exceeds $41,512.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,022.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $8,484.11. The transfer operating threshold is the transfer adjustment factor * $8,472.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.59. The transfer capital threshold is the transfer adjustment factor * $640.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,42947.32,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 18MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1239.3,45.9,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADHSV SURGICAL BIOGLUE SOFT TISSUE BOVINE SERUM ALBUMIN",SUP-BG3510-5-US,CDM,S27200284,LOCAL,0272,RC,,,both,,,6858.60,2057.58,"CIGNA [10200]","Cigna Local Plus",,3669.35,53.5,,,,,0,797.66,5829.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL PEDIATRIC MASK MANOMETER BAG RESVR O2 TUBE",SUP-530613030,CDM,S27000186,LOCAL,0270,RC,,,both,,,89.06,26.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.36,75.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG DOME HOLE CONTINUUM ACETABULAR LATEX FREE",SUP-875700001,CDM,C1713,HCPCS,0278,RC,,,both,,,597.78,179.33,"KAISER [10500]",Kaiser,,400.51,67,,,,,0,69.52,508.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 26CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006155233170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 24FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0119SI24,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.53,33.46,"CIGNA [10200]",Cigna,,75.84,68,,,,,0,12.97,94.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE NEUROSCOUT VASCULAR 205CM 43CM .014IN STAINLESS STEEL",SUP-601414,CDM,C1769,HCPCS,0272,RC,,,both,,,4071.00,1221.3,"FIRST HEALTH [10303]","First Health",,3256.8,80,,,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INDIGO SYSTEM 140CM .044IN THROMBECTOMY CORONARY",SUP-CATRXKIT,CDM,C1757,HCPCS,0272,RC,,,both,,,12420.00,3726,"NOVANET [10819]",Novanet,,9315,75,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 20MM .021-.027IN AZUR CX HYDROCOIL",SUP-45-782040,CDM,S27800098,LOCAL,0278,RC,,,both,,,5278.50,1583.55,"BLUE CROSS [10001]","Blue Cross PPO",,2069.17,39.2,,,,,0,613.89,4486.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Thorac Ea 1st Ord",PX-361000083,CDM,36215,CPT,0361,RC,,,both,,,3218.39,965.52,"KAISER [10500]",Kaiser,,2156.32,67,,,,,0,374.3,3218.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 105MM STAINLESS STEEL 2.7MM SCR 5 HOLE CONTOUR SHAFT",SUP-02.118.405,CDM,C1713,HCPCS,0278,RC,,,both,,,4378.26,1313.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,518.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,509.19,3721.52,"percent of total billed charges",
"TRAY CATH 9.5FR .036IN 5CM 2 LUMEN INTERMEDIATE SCPL SYR",SUP-0805910,CDM,C1751,HCPCS,0272,RC,,,both,,,2812.50,843.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET EXT 4.5CM 20FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-20-4.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEALER BIPOLAR AQUAMAN EDIDURAL VIEN",SUP-23-121-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE TALON ORTHOPEDIC 600MM 3MM ROUND TIP",SUP-SLN-T36,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC",001,MS-DRG,,,,,,,inpatient,,,1638727.54,491618.26,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 105MM 13.3MM 8MM CUFFLESS DISTAL EXT EXTEND LENGTH SOFT",SUP-80XLTUD,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INFUSION 45D .014IN 1.9FR .0165IN 150CM 5CM",SUP-606S155FX,CDM,C1887,HCPCS,0272,RC,,,both,,,7390.38,2217.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BLAZER II 110CM 5MM 8FR 7FR 2.5MM SPACE STD CURVE",SUP-M0045086TL0,CDM,C1733,HCPCS,0272,RC,,,both,,,8107.50,2432.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE 28FR SILICONE MEDICATION PORT RADIOPAQUE STRIPE",SUP-0100-28,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEMOSTAT ABSORBABLE GEL-FLOW NT GELATIN POWDER MATRIX 6ML",SUP-00009-1040-06,CDM,S27200284,LOCAL,0272,RC,,,both,,,2475.00,742.5,"UHC [10700]","United Healthcare",,1566.68,63.3,,,,,0,287.84,2103.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROTIGOTINE 4 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH",RX-82101,CDM,,,0637,RC,50474-0804-03,NDC,both,1,UN,173.83,52.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.22,147.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.75/35",SUP-404668,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GEL DRSG MEDIHONEY TUBE LATEX FREE STERILE 1.5OZ",SUP-31815,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.23,30.67,"MULTIPLAN [10600]",Multiplan,,86.9,85,,,,,0,11.89,86.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR VERITY ADX XL DR IMPLANTABLE 2 CHMBR AUTO REST RATE",SUP-5357M/S,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11232,27,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR RADIALUX 4 INTERCHANGEABLE BLADE CORDLESS LED",SUP-50-101-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN DEBRIDEMENT WITH CC",571,MS-DRG,,,,,,,inpatient,,,68950.84,20685.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32061.64,,"Fee schedule rate ($32,061.64). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,49326.64,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.6CM MEMORYGEL COHESIVE I P4.5CM MODERATE PLUS",SUP-RSZ-5501S,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"MULTIPLAN [10600]",Multiplan,,131.1,85,,,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY ALLIGATOR JAW FENESTRATE CUP 115CM 5MM ENDOJAW",SUP-FB-211D.A,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.94,65.38,"CIGNA [10200]",Cigna,,148.2,68,,,,,0,25.35,185.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +11 DIOPTER MODIFIED C BICONVEX TECNIS OPTIEDGE",SUP-ZA90030110,CDM,V2632,HCPCS,0276,RC,,,both,,,955.80,286.74,"CIGNA [10200]","Cigna Open Access",,543.85,56.9,,,,,0,111.16,812.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABIL 6CM 200CM 10MM ENDOPROSTHESIS BILIARY",SUP-VSWVH1006,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER SMOKE EVAC MEGADYNE MEGA VAC ULTRA LOW PENETRATE AIR",SUP-2211J,CDM,S27000186,LOCAL,0270,RC,,,both,,,327.66,98.3,"AETNA [10100]","Aetna HMO/PPO",,260.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.11,278.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Gastric Emptying Sb Colon Multi",PX-341000069,CDM,78266,CPT,0341,RC,,,both,,,2794.10,838.23,"AETNA [10100]","Aetna HMO/PPO",,2221.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,324.95,2374.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL ORBITAL MEDPOR TITAN BTB TITANIUM POLYETHYLENE 38X50X.6",SUP-81024,CDM,C1713,HCPCS,0278,RC,,,both,,,8317.26,2495.18,"KAISER [10500]",Kaiser,,5572.56,67,,,,,0,967.3,7069.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 45MM 28MM TANDEM HIP ACETABULAR COCR",SUP-71322045,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,989.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,971.39,7099.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 90MM 16MM DCP LC-DCP STAINLESS STEEL",SUP-216.090,CDM,C1713,HCPCS,0278,RC,,,both,,,302.06,90.62,"BLUE CROSS [10001]","Blue Cross HMO",,118.41,39.2,,957.42,156.86,7483.26,51,35.13,256.75,"percent of total billed charges",
"INSRT HUMERAL H+0MM 36MM PERFORM .75 SHOULDER REVERSE",SUP-DWP4360,CDM,C1776,HCPCS,0278,RC,,,both,,,17388.00,5216.4,"PHCS [10601]",PHCS,,12171.6,70,,,,,0,2022.22,14779.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 125CM 4FR .038IN ANGIOGRAPHIC PERIPHERAL BRAID",SUP-512538BER,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,49.92,45.9,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL HIP CONSTRUCT 2",SUP-CAP-MI-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"UHC [10700]","United Healthcare",,6114.78,63.3,,8601.07,8395.67,8601.07,"1 through 10",1123.46,8211,"percent of total billed charges",
"CLAMP SURGICAL CRYOFLEX 8IN PROBE 60CM1",SUP-60CM1,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,9268.88,53.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING FLUTED BALL DIAMOND 140MM 4MM MIDAS REX",SUP-14BA40,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.19,388.56,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INFINITI 100CM 4FR AMPLATZ RIGHT 2 MODIFY CURVE",SUP-538443,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INSRT BIO-MEDICUS VENOUS",SUP-96551,CDM,C1769,HCPCS,0272,RC,,,both,,,713.69,214.11,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 214MM 16MM CANNULATED HOLLOW LARGE QUICK COUPLING",SUP-03.037.004S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4978.76,1493.63,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONVEY 100CM 7FR LEFTBU3.75 CURVE GUIDING HYDROPHILIC",SUP-H749392657150,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NORMAL NEWBORN",795,MS-DRG,,,,,,,inpatient,,,5178.32,1553.5,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUTTY THERAPY THERAPUTTY PUTTYCISE 5 PIECE TOOL SET CARRY",SUP-562946,CDM,S27000186,LOCAL,0270,RC,,,both,,,841.67,252.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) LAMINAR IMPLANT SIZE (16MM)",SUP-FG-6032,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 150CM 200MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025200M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL 6 10MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-610-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]","Cigna Open Access",,4031.26,33.5,,5302.19,4377.88,6578.61,27,1399.51,10228.56,"percent of total billed charges",
"STEM FEMORAL 160MM SUMMIT POROCOAT 8 12/14 HIGH OFFSET TAPER",SUP-157011150,CDM,C1776,HCPCS,0278,RC,,,both,,,25247.25,7574.17,"BLUE CROSS [10001]","Blue Cross HMO",,9896.92,39.2,,5311.50,4717.44,5388.59,31,2936.26,21460.16,"percent of total billed charges",
"TOOL 7CM MR8 4MM BALL DISSECTING CARBIDE",SUP-MR8-7BA40C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1089.86,326.96,"PHCS [10601]",PHCS,,762.9,70,,,,,0,126.75,926.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD LINER MP8 BLUE 36MM",SUP-932-36-254,CDM,C1776,HCPCS,0278,RC,,,both,,,12462.02,3738.61,"KAISER [10500]",Kaiser,,8349.55,67,,,,,0,1449.33,10592.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.090 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.090,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 22CM 6FR SHORT LENGTH URETERAL",SUP-H7493936106220,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,354.69,28.62,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET",RX-2012,CDM,,,0637,RC,50268-0854-11,NDC,both,1,UN,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 6.5MM EVOLVE +2MM ELBOW PROLINE MODULAR",SUP-496S265,CDM,C1776,HCPCS,0278,RC,,,both,,,14614.20,4384.26,"CIGNA [10200]",Cigna,,5845.68,40,,5873.17,5873.17,5873.17,"1 through 10",1699.63,12422.07,"percent of total billed charges",
"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC",255,MS-DRG,,,,,,,inpatient,,,101783.94,30535.18,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,17234.1,,"Case rate ($16,732.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $15,536.92, add-ons for qualifying new technology services are included. If operating cost exceeds $48,576.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,556.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $15,557.47. The transfer operating threshold is the transfer adjustment factor * $15,536.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,174.67. The transfer capital threshold is the transfer adjustment factor * $1,174.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,78753.29,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE PRIME 38MM 143CM 3.5MM CORONARY STENT",SUP-1011734-38,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"CIGNA [10200]","Cigna Open Access",,5457.28,56.9,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR LOW BEND 102MM STAINLESS STEEL 3.5MM SCR 6",SUP-02.124.204,CDM,C1713,HCPCS,0278,RC,,,both,,,7998.48,2399.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2289.16,28.62,,,,,0,930.22,6798.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR PULSE LATITUDE NXT 83.1X69.1MM EMBLEM S-ICD 12.7MM",SUP-A219,CDM,C1722,HCPCS,0278,RC,,,both,,,59280.00,17784,"UHC [10700]","United Healthcare",,37524.24,63.3,,,,,0,6894.26,50388,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI CONFIANZA PRO 9 VASCULAR 180CM 20CM .009IN",SUP-AGH143090,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"UHC [10700]","United Healthcare",,717.82,63.3,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL BABCOCK 12IN TISSUE STD PATTERN",SUP-50-1024,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 12MM 144CM 2.25MM CORONARY STENT",SUP-H7493952812220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"MULTIPLAN [10600]",Multiplan,,4730.25,85,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC",659,MS-DRG,,,,,,,inpatient,,,58724.78,17617.43,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,16707.04,,"Case rate ($15,761.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,635.49, add-ons for qualifying new technology services are included. If operating cost exceeds $47,675.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,488.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $14,654.84. The transfer operating threshold is the transfer adjustment factor * $14,635.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,106.51. The transfer capital threshold is the transfer adjustment factor * $1,106.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,58724.78,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE KIWI PROCUP PALM PUMP VACUUM EXTRACTION RIGID STEM",SUP-VAC-6000S,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"PHCS [10601]",PHCS,,170.52,70,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 150MM 120CM 7MM VASCULAR PERIPHERAL SELF",SUP-PRB35-07-150-120,CDM,C1876,HCPCS,0278,RC,,,both,,,7560.00,2268,"AMERIGROUP MEDICAID [20100]",Amerigroup,,895.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,879.23,6426,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 1.5 X 3 COMPLEX FINISHING COIL",SUP-10CFN-01503,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"KAISER [10500]",Kaiser,,7854.48,67,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC MEDIUM 20IN 16-18IN KNEE CONTOUR POSTERIOR",SUP-4462-03,CDM,L1830,HCPCS,0274,RC,,,both,,,140.77,42.23,"BLUE CROSS [10001]","Blue Cross HMO",,55.18,39.2,,,,,0,16.37,119.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER FEMORAL CATHCART ARTICUL/EZE +0MM 12/14 TAPER HIP",SUP-136310000,CDM,C1776,HCPCS,0278,RC,,,both,,,1650.00,495,"PHCS [10601]",PHCS,,1155,70,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 120MM 125CM 8MM 6FR BILIARY",SUP-G50172,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CIGNA [10200]",Cigna,,4141.2,68,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR JUDKINS LEFT 3.5 CURVE",SUP-534518T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"AETNA [10100]","Aetna HMO/PPO",,74.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) V-18 CONTROL WIRE, 300CM, 12CM TIP (BOSTON SCIENTIFIC",SUP-M001468600,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT GLENOID REVERSE SHOULDER TRABECULAR METAL",SUP-98850090001,CDM,C1776,HCPCS,0278,RC,,,both,,,51660.00,15498,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13948.2,27,,,,,0,6008.06,43911,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CPS COURIER VASCULAR .014IN STAINLESS STEEL PLATINUM",SUP-DS2G001,CDM,C1769,HCPCS,0272,RC,,,both,,,607.50,182.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,413.1,68,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER 200UM DISPOSABLE",SUP-TFL-FBX200S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2690.00,807,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1234.71,45.9,,,,,0,312.85,2286.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 T TIP SURGICAL",SUP-A13A,CDM,S27200284,LOCAL,0272,RC,,,both,,,2437.50,731.25,"CIGNA [10200]",Cigna,,1657.5,68,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE PHALANX 1.5",SUP-PRT-PHX-015,CDM,C1713,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"BLUE CROSS [10001]","Blue Cross HMO",,2812.99,39.2,,957.42,156.86,7483.26,51,834.57,6099.6,"percent of total billed charges",
"CATH ARMADA 35LL 135CM 200MM 5MM .035IN LOW PROFILE BALLOON",SUP-B2050-200,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HIP FEM POROUS OFFSET  11",SUP-425-96-011,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"BLUE CROSS [10001]","Blue Cross PPO",,16682.91,39.2,,3949.44,3949.44,3949.44,"1 through 10",4949.55,36174.68,"percent of total billed charges",
"SCR BONE 3.5MM 20MM VARIAX NONSTERILE",SUP-657420,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,231.45,28.62,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA G KNEE LEFT 2 PEG TIVANIUM STERILE",SUP-42530007901,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4059.75,28.62,,,,,0,1649.72,12057.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STEERABLEBALLOON CA",SUP-ARC10SB-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,18270.00,5481,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7508.97,41.1,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL TRANSEPTAL 98CM 21GA 18GA NRG C1 CURVED CONVENTIONAL",SUP-NRG-98-C0,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"UHC [10700]","United Healthcare",,2350.01,63.3,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM CEMENT ACCOLADE C 132D 5 44MM OFFSET HIP",SUP-6058-0537D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4438.6,27,,,,,0,1911.88,13973.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 0 CT-1 18IN CONTROL RELEASE BRAID 8",SUP-C021D,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.49,30.75,"AETNA [10100]","Aetna HMO/PPO",,81.48,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.92,87.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 11.9CM 6MM CEREPAK MICRO UNIFORM",SUP-FCX100611,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1567.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 65MM 20-25MM AFX ILIAC LIMB STRATA AAA STERILE","SUP-IS20-25/C65 SA",CDM,C1874,HCPCS,0278,RC,,,both,,,23373.00,7011.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6689.35,28.62,,,,,0,2718.28,19867.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN 1500 MG/30ML INTRAVENOUS SOLUTION (WET SOLR VIAL)",RX-415185505,CDM,J3373,HCPCS,0636,RC,00409-3515-11,NDC,both,1,UN,220.64,66.19,"CIGNA [10200]","Cigna Local Plus",,12.83,,,,,,,5.24,187.54,"fee schedule",
"SHOE XS PATIENT POSTOPERATIVE ORTHOWEDGE",SUP-92732501,CDM,S27000186,LOCAL,0270,RC,,,both,,,194.45,58.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,132.23,68,,,,,0,22.61,165.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FREEHAND HINDFOOT VALOR 4.3MM SCR IMPL KIT",SUP-415S002350,CDM,S27200284,LOCAL,0272,RC,,,both,,,1972.50,591.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1341.3,68,,,,,0,229.4,1676.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN OMEGA3 MARIGEN 8SQ CM MICRO FISH SKIN STERILE",SUP-50200P01B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,4554.00,1366.2,"MULTIPLAN [10600]",Multiplan,,3870.9,85,,,,,0,180.89,3870.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 TF 36IN BRAID MONOFILAMENT BLUE",SUP-D4295,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.68,18.8,"KAISER [10500]",Kaiser,,42,67,,,,,0,7.29,53.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM GEMINUS TITANIUM DISTAL VOLAR RADIUS",SUP-PANL-35160-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,623.70,187.11,"NOVANET [10819]",Novanet,,467.78,75,,,,,0,72.54,530.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +6.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.065,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 28CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192124010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS [10001]","Blue Cross PPO",,470.63,39.2,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER POWER BLUE 4.5MM TURBOTRIMMER STRAIGHT",SUP-7205315,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.00,84.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,116.31,41.1,,,,,0,32.91,240.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FINALE LONG 12IN COMPRESSION RADIAL ARTERY BAND",SUP-FCD200,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.05,30.01,"CIGNA [10200]","Cigna Open Access",,56.93,56.9,,,,,0,11.64,85.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 25MM SUPRA STENTED LOW PROFILE FLEXFIT",SUP-BSP100-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,32715.90,9814.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13086.36,40,,,,,0,3804.86,27808.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,inpatient,,,222121.71,66636.51,"BLUE CROSS [10001]","Blue Cross PPO",,135050.51,,,,,,,7561,159716.72,"case rate",
"BASEPLT TIBIAL PERSONA D KNEE RIGHT 2 PEG TIVANIUM STERILE",SUP-42530006702,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"KAISER [10500]",Kaiser,,9503.96,67,,,,,0,1649.72,12057.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.4MM 65MM LCP STAINLESS STEEL 4MM PARTIAL",SUP-02.205.265,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,184.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,180.95,1322.47,"percent of total billed charges",
"SCR BONE 4.5MM 34MM VUEPOINT II SPINE MULTIAXIAL NONSTERILE",SUP-8975734,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"BIPOLAR UNIPOLAR HIP WITH ANY HIGHLY POROUS CEMENTLESS",SUP-CAP-DS-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,13455.00,4036.5,"NOVANET [10819]",Novanet,,10091.25,75,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 32MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.432TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"BLUE CROSS [10001]","Blue Cross HMO",,792.45,39.2,,957.42,156.86,7483.26,51,235.11,1718.32,"percent of total billed charges",
"SYSTEM CRYO/CUFF IC UNIVERSAL 45- IN COMPRESSION THERAPY",SUP-51A14A,CDM,S27000186,LOCAL,0270,RC,,,both,,,649.78,194.93,"AETNA [10100]","Aetna HMO/PPO",,516.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.57,552.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET STAINLESS STEEL MULTIAXIAL CD HORIZON MODULEX",SUP-559200006,CDM,C1713,HCPCS,0278,RC,,,both,,,4140.00,1242,"AETNA [10100]","Aetna HMO/PPO",,3291.3,79.5,,1521.93,481.35,16760.95,30,481.48,3519,"percent of total billed charges",
"VALVE AORTIC 29MM REDUCED",SUP-R5-029,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8820,40,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION TRANSEND-14 130CM 165CM 2.4-3FR .021IN .014IN",SUP-M001195810,CDM,C1887,HCPCS,0272,RC,,,both,,,6210.00,1863,"KAISER [10500]",Kaiser,,4160.7,67,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 40CM 11CM 10FR 2CM PIGTAIL CURVE DRNG",SUP-RBDC-10-038,CDM,C1729,HCPCS,0272,RC,,,both,,,558.90,167.67,"UHC [10700]","United Healthcare",,353.78,63.3,,,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC 57.3MM 5MM DA VINCI S/SI ENDOWRIST 30- D",SUP-420343,CDM,S27000186,LOCAL,0270,RC,,,both,,,1800.00,540,"NOVANET [10819]",Novanet,,1350,75,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 15.5CM NATRELLE INSPIRA P6.7CM EXTRA FULL PROFILE",SUP-MSZ-X800,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,107.56,68,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDOSCOPIC SUBMUCOSAL INJECTION",SUP-SIS-30-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 2.8MM 36MM ORTHOLOC FULL THREAD MIDFOOT",SUP-58803536,CDM,S27200284,LOCAL,0272,RC,,,both,,,1506.60,451.98,"CIGNA [10200]",Cigna,,1024.49,68,,,,,0,175.22,1280.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VASCULAR PACK (CAUHH)215",SUP-SCV21CAUHJ,CDM,S27200284,LOCAL,0272,RC,,,both,,,461.78,138.53,"KAISER [10500]",Kaiser,,309.39,67,,,,,0,53.71,392.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 24MM LCP",SUP-02.211.024,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"MULTIPLAN [10600]",Multiplan,,763.41,85,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 19GA 11CM ACHIEVE COAXIAL INTRO AUTOMATED",SUP-CA2011,CDM,S27200284,LOCAL,0272,RC,,,both,,,910.94,273.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,107.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.94,774.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILLSOLID 2.0",SUP-DRLL-STP-20,CDM,S27000186,LOCAL,0270,RC,,,both,,,1620.00,486,"KAISER [10500]",Kaiser,,1085.4,67,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE HEARTMATE II VENTRICULAR ASSIST MODULE POWER",SUP-1340,CDM,Q0479,HCPCS,0274,RC,,,both,,,47764.08,14329.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19631.04,41.1,,,,,0,5554.96,40599.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 120MM 3.5MM BALLOON DILATATION RAPID",SUP-47535120S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1085.08,68,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL MICROPOINT 9-0 TG140-8 12IN 2 ARM BRAID COATED",SUP-V549G,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.33,47.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.41,134.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 96MM STAINLESS STEEL 3.5MM SCR 7X3 HOLE T OBLIQUE LEFT",SUP-241.971,CDM,S27800098,LOCAL,0278,RC,,,both,,,2465.40,739.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,286.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,286.73,2095.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 180CM 120MM 5MM BALLOON DILATATION",SUP-PCP050120180,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 18INX3IN 36- IN KNEE CONTACT",SUP-79-96018,CDM,S27000186,LOCAL,0270,RC,,,both,,,119.28,35.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.87,101.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SLIC 8IN 7FR CENTRAL VENOUS POLYURETHANE PERCUTANEOUS 1",SUP-SC-14701,CDM,C1751,HCPCS,0272,RC,,,both,,,82.82,24.85,"FIRST HEALTH [10303]","First Health",,66.26,80,,,,,0,9.63,70.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 0 BP-1 27IN MONOFILAMENT ABSORBABLE",SUP-47T,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.13,36.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,83.73,68,,,,,0,14.32,104.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 8MM 144CM 2.5MM CORONARY STENT",SUP-H7493911408250,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 90CM 80MM 2MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186200890,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 7MM SHELF ADJACENT CANOPY BONE SPINE",SUP-1102.4007,CDM,C1713,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Local Plus",,5433.75,31.5,,3978.14,359.25,3978.14,24,2006.18,14662.5,"percent of total billed charges",
"SHOE 6-8 SMALL MALE PATIENT 2 PADDED POSTOPERATIVE SQUARE",SUP-MQM1B,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.43,23.83,"UHC [10700]","United Healthcare",,50.28,63.3,,,,,0,9.24,67.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 100CM 5FR SIM1 CURVE ANGIOGRAPHIC STAINLESS",SUP-510035SIM1,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,49.92,45.9,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 40X27MM ENDOSKELETON TAS 12D 13MM XL TITANIUM",SUP-2312-0313,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN LEFT CORONARY BYPASS CURVE",SUP-DXT5LCB,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,47.33,68,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 12MM KII FIOS FIRST ENTRY ADVANCED",SUP-CFF71,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,75.09,41.1,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 30MM 4MM MAXTORQUE",SUP-MSD01040030S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"FIRST HEALTH [10303]","First Health",,1134,80,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 22CM 150CM 7FR .038IN 3CM BLADDER LOOP",SUP-M006155251170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"NOVANET [10819]",Novanet,,1065.26,75,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM REVERE TITANIUM SPINE PEDICLE CANNULATED",SUP-124.365,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"STENT COVERA 60MM 80CM 6MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM06060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"AETNA [10100]","Aetna HMO/PPO",,14524.65,79.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VENASEAL CLSR",SUP-257965,CDM,S27200284,LOCAL,0272,RC,,,both,,,5368.20,1610.46,"UHC [10700]","United Healthcare",,3398.07,63.3,,,,,0,624.32,4562.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOJET ULTRA SOLENT PROXI THROMBECTOMY PERIPHERAL",SUP-109676-001,CDM,C1757,HCPCS,0272,RC,,,both,,,26365.50,7909.65,"FIRST HEALTH [10303]","First Health",,21092.4,80,,,,,0,3066.31,22410.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.9MM 1 SUTUREFIX ULTRA ULTRABRAID COBRAID",SUP-72203854,CDM,C1713,HCPCS,0278,RC,,,both,,,3025.28,907.58,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2057.19,68,,,,,0,351.84,2571.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 140MM 125CM 7MM 6FR BILIARY NITINOL",SUP-G50170,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"AETNA [10100]","Aetna HMO/PPO",,4841.55,79.5,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC 5MM DA VINCI SI SINGLE-SITE FUNDUS",SUP-428058,CDM,S27000186,LOCAL,0270,RC,,,both,,,963.90,289.17,"FIRST HEALTH [10303]","First Health",,771.12,80,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 5ML 1.7-10MM ALLOGRAFT CHIPS FREEZE",SUP-T00030,CDM,S27800098,LOCAL,0278,RC,,,both,,,992.25,297.67,"NOVANET [10819]",Novanet,,744.19,75,,,,,0,115.4,843.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE HISTOLOGY 2IN 2 EDGE RAZOR HANDLE DISPOSABLE",SUP-D2877,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STAPLER 2MM 2.5MM 3MM THK1.5-2.25MM 30MM ENDO GIA MED",SUP-SIG30AVM,CDM,S27200284,LOCAL,0272,RC,,,both,,,1060.37,318.11,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL 5-6 11MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71933737,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1442.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1415.56,10345.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR EXTRICATION BLUE 2.5IN PROCARE SHORT FLAT CONTOUR",SUP-79-83023,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.12,17.44,"CIGNA [10200]",Cigna,,39.52,68,,,,,0,6.76,49.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIVERSAL LAPILOCK KIT",SUP-XY-LL-7000,CDM,C1713,HCPCS,0278,RC,,,both,,,28350.00,8505,"AETNA [10100]","Aetna HMO/PPO",,22538.25,79.5,,1521.93,481.35,16760.95,30,3297.11,24097.5,"percent of total billed charges",
"SPACER SPINAL 22MMX13MM CAPSTONE PEEK PTC LUMBAR INTERBODY",SUP-3992213,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"UHC [10700]","United Healthcare",,13957.65,63.3,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 H 50MM COCR HIP 2 MOBILITY",SUP-110024466,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"BLUE CROSS [10001]","Blue Cross PPO",,5077.45,39.2,,3949.44,3949.44,3949.44,"1 through 10",1506.4,11009.78,"percent of total billed charges",
"DRILL SURGICAL 15MM FLEXIBLE SCR R3",SUP-71362915,CDM,S27200284,LOCAL,0272,RC,,,both,,,1538.19,461.46,"PHCS [10601]",PHCS,,1076.73,70,,,,,0,178.89,1307.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN SUCTION MERCEDES 4MM 30CM MERCEDES STYLE PORT POWER",SUP-PAL-404LL,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"MULTIPLAN [10600]",Multiplan,,543.92,85,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM 16MM COLLAR CEMENTLESS LOW PROFILE NECK",SUP-3L92506,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1876.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1841.86,13461.55,"percent of total billed charges",
"TIBIAL COMPONENT #8",SUP-5536-B-800,CDM,C1776,HCPCS,0278,RC,,,both,,,10139.04,3041.71,"KAISER [10500]",Kaiser,,6793.16,67,,,,,0,1179.17,8618.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 100MM 130MM 5MM LONG VASCULAR NITINOL",SUP-SC5100LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"UHC [10700]","United Healthcare",,5678.01,63.3,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL KOCHER-OCHSNER 6.25IN CURVED",SUP-BH643R,CDM,S27200284,LOCAL,0272,RC,,,both,,,201.58,60.47,"NOVANET [10819]",Novanet,,151.19,75,,,,,0,23.44,171.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR ANGIOGRAPHY 30ML INFLATION LATEX FREE MONARCH",SUP-IN2530,CDM,S27200284,LOCAL,0272,RC,,,both,,,504.14,151.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,231.4,45.9,,,,,0,58.63,428.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR NEROSTIMLTR",SUP-3028,CDM,C1767,HCPCS,0278,RC,,,both,,,103882.50,31164.75,"KAISER [10500]",Kaiser,,69601.28,67,,,,,0,12081.53,88300.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP CEMENTED OR3O WITH OXINIUM HEAD",SUP-71703485,CDM,C1776,HCPCS,0278,RC,,,both,,,30240.00,9072,"PHCS [10601]",PHCS,,21168,70,,,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 60MM 3.5MM BALLOON DILATATION PEBAX",SUP-H74939032350610,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM PRESTIGE PLUS HELICAL HELICAL XTRA",SUP-PRES0101HXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 650CC SUT TAB INTEGRAL INJECTION DOME",SUP-SDC130UH,CDM,C1789,HCPCS,0278,RC,,,both,,,12730.50,3819.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1508.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1480.56,10820.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 13MM ALPS COCR SQUARE HAND CORTICAL LOCK SELF",SUP-131220413,CDM,S27200284,LOCAL,0272,RC,,,both,,,1032.75,309.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,702.27,68,,,,,0,120.11,877.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 5.00 X 28MM",SUP-H7493942828500,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"NOVANET [10819]",Novanet,,4657.5,75,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 22-30CM 3CM 4.8FR .035IN",SUP-M006180155090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"NOVANET [10819]",Novanet,,997.7,75,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT ELECTROSURGICAL 25CM CURVED TIP ENSEAL TRIO 3MM",SUP-ETRIO325H,CDM,S27200284,LOCAL,0272,RC,,,both,,,3157.44,947.23,"AETNA [10100]","Aetna HMO/PPO",,2510.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,367.21,2683.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 STD KNEE LEFT CRUCIATE RETAIN CEMENT PERSONA",SUP-42572606401,CDM,C1776,HCPCS,0278,RC,,,both,,,26429.76,7928.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7136.04,27,,,,,0,3073.78,22465.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 200MM 5MM BALLOON DILATATION RAPID EXCHANGE",SUP-47550200S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"AETNA [10100]","Aetna HMO/PPO",,1609.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 12/14 28MM HIP TAPER NECK PRIMARY COCR",SUP-71302804,CDM,C1713,HCPCS,0278,RC,,,both,,,5847.75,1754.32,"NOVANET [10819]",Novanet,,4385.81,75,,,,,0,680.09,4970.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOPLASTY L75CM BALLOON L20MM DIA9MM 0.035IN 6ATM",SUP-U357592,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 C 32MM LONGEVITY HIP STERILE LUMEN LATEX",SUP-20123203,CDM,C1776,HCPCS,0278,RC,,,both,,,8101.98,2430.59,"BLUE CROSS [10001]","Blue Cross PPO",,3175.98,39.2,,3949.44,3949.44,3949.44,"1 through 10",942.26,6886.68,"percent of total billed charges",
"DEVICE PIPELINE 12MM 5MM EMBOLIZATION",SUP-PED2-500-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"UHC [10700]","United Healthcare",,51144.82,63.3,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM ULNAR 6 L115MM RIGHT NEXEL",SUP-840002611,CDM,C1776,HCPCS,0278,RC,,,both,,,31971.49,9591.45,"BLUE CROSS [10001]","Blue Cross PPO",,12532.82,39.2,,3949.44,3949.44,3949.44,"1 through 10",3718.28,27175.77,"percent of total billed charges",
"PLATE SMALL 92MM TITANIUM 2 HOLE SHAFT 2 COMPRESSION SLOT",SUP-59202010,CDM,C1713,HCPCS,0278,RC,,,both,,,14993.70,4498.11,"CIGNA [10200]","Cigna Open Access",,5022.89,33.5,,1144.80,304.56,2275.09,66,1743.77,12744.65,"percent of total billed charges",
"SCR BONE 4.5MM 54MM LCP STAINLESS STEEL CORTICAL CONDYLAR",SUP-214.854,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,29.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",29.18,213.27,"percent of total billed charges",
"CHOLECYSTECTOMY WITH C.D.E. WITH CC",412,MS-DRG,,,,,,,inpatient,,,106611.91,31983.57,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,28040.17,,"Case rate ($13,041.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,110.32, add-ons for qualifying new technology services are included. If operating cost exceeds $45,150.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,297.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $12,126.34. The transfer operating threshold is the transfer adjustment factor * $12,110.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $915.60. The transfer capital threshold is the transfer adjustment factor * $915.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,61384.59,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC",583,MS-DRG,,,,,,,inpatient,,,208387.21,62516.16,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,11338.35,,"Case rate ($10,696.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,932.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,132.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $9,945.61. The transfer operating threshold is the transfer adjustment factor * $9,932.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.94. The transfer capital threshold is the transfer adjustment factor * $750.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,10696.56,50345.58,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 140MM 2.4MM LONG SOLID MEASURE AO CONNECTION",SUP-P99-100-2414,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,682.99,68,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 25GA .8MM GRIESHABER SHORT SOFT TIP STERILE",SUP-8065149530,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.01,60,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.26,170.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMBLED FREEFIX DISTAL HUMERUS PLATE MEDIAL DIRECT 105MM R",SUP-DHPF-MDR-5HL,CDM,C1713,HCPCS,0278,RC,,,both,,,14897.10,4469.13,"CIGNA [10200]","Cigna Open Access",,4990.53,33.5,,1144.80,304.56,2275.09,66,1732.53,12662.54,"percent of total billed charges",
"CAGE SPINAL 55X21X10MM COUGAR LS LORDOTIC LATERAL NONSTERILE",SUP-189155810,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6851.63,28.62,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 45D HH 50MM 28MM LONGEVITY HIP STERILE",SUP-875800928,CDM,C1776,HCPCS,0278,RC,,,both,,,18074.70,5422.41,"CIGNA [10200]",Cigna,,7229.88,40,,5873.17,5873.17,5873.17,"1 through 10",2102.09,15363.5,"percent of total billed charges",
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 4.0MM X 26.0MM",SUP-494002612,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 6MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650906,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1555.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL SLATE 4.5MM HELICUT DYONICS STRAIGHT",SUP-7205727,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,278.84,45.9,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERTORQUE THRULUMEN 100CM 6FR .079IN .051IN SMALL",SUP-532619,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,56.2,68,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X22X8MM 10 XL PEEK",SUP-6808340,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"FIRST HEALTH [10303]","First Health",,19008,80,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADX GUIDEWIRE PTFE 035 X 180CM FC ST BENTSON",SUP-H7878141351801,CDM,C1769,HCPCS,0272,RC,,,both,,,121.80,36.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.17,103.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 5.5MM CURVE TITANIUM CP4 NONSTERILE",SUP-1553201030,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"GRAFT BONE CALCANEUS THK16-18MM ALLOGRAFT CROSS SECTION",SUP-400483,CDM,S27800098,LOCAL,0278,RC,,,both,,,4939.02,1481.71,"MULTIPLAN [10600]",Multiplan,,4198.17,85,,,,,0,574.41,4198.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE DUALMESH 34X26CM SOFT TISSUE BIOMATERIAL",SUP-1DLMC08,CDM,C1781,HCPCS,0278,RC,,,both,,,16284.00,4885.2,"CIGNA [10200]",Cigna,,6513.6,40,,,,,0,1893.83,13841.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 36MM HIP C TAPER COBALT CHROME LFIT",SUP-06-3605,CDM,C1776,HCPCS,0278,RC,,,both,,,6224.40,1867.32,"FIRST HEALTH [10303]","First Health",,4979.52,80,,,,,0,723.9,5290.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 300MM 2.5MM .018IN BALLOON",SUP-R51002530L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,295.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC PROCARE FOAM LARGE XL UNIVERSAL L55 IN X W1",SUP-79-92471,CDM,S27000186,LOCAL,0270,RC,,,both,,,53.42,16.03,"UHC [10700]","United Healthcare",,33.81,63.3,,,,,0,6.21,45.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 50MM 6.5MM RELINE 2C SPINE MODULAR MAS NONSTERILE",SUP-16186550,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,3978.14,359.25,3978.14,24,348.9,2550,"percent of total billed charges",
"AFTERCARE WITH CC/MCC",949,MS-DRG,,,,,,,inpatient,,,69874.09,20962.23,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,18865.51,,"of the excess amount. Final payment is multiplied by 106%.",,,,0,2462,38264.95,"case rate","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.215,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,158.36,45.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT TOTAL STBL TRIATHLON COCR",SUP-5512-F-601,CDM,C1776,HCPCS,0278,RC,,,both,,,20599.49,6179.85,"BLUE CROSS [10001]","Blue Cross PPO",,8075,39.2,,3949.44,3949.44,3949.44,"1 through 10",2395.72,17509.57,"percent of total billed charges",
"TIP PULSED LAVAGE INTERPULSE HIGH FLOW STERILE LATEX FREE",SUP-0210014000,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.44,28.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.22,81.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL MIXTER-CRAFOORD 90D 10IN ARTERY DISSECT",SUP-17-0775,CDM,S27200284,LOCAL,0272,RC,,,both,,,953.61,286.08,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 14 150CM 200MM 4FR 2MM ROUND LOW PROFILE TAPER",SUP-A2020-200,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL",RX-29676,CDM,,,0250,RC,10939-0955-85,NDC,both,44,ML,12.54,3.76,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH Z-MED 100CM 6CM 11FR 33MM .035IN BALLOON DILATATION",SUP-611670,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CAP LD TRM QDPL IS-1",SUP-4033,CDM,S27200284,LOCAL,0272,RC,,,both,,,295.80,88.74,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CIRCUIT 5FT AIRLIFE BIPAP 1 LIMB TEMPERATURE PROBE",SUP-RT219,CDM,S27000186,LOCAL,0270,RC,,,both,,,267.09,80.13,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR SMALL WING NAIL SURGICAL NONSTERILE LATEX FREE",SUP-2153-0001,CDM,S27200284,LOCAL,0272,RC,,,both,,,3157.50,947.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC",656,MS-DRG,,,,,,,inpatient,,,133265.07,39979.52,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 147MM 4.5MM STAINLESS STEEL QUICK CONNECT 121MM",SUP-KM166-310-44,CDM,S27000186,LOCAL,0270,RC,,,both,,,240.99,72.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.03,204.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURESIGHT BLADE HYPERANGULATED SIZE 3 CHANNELED",SUP-390531000,CDM,S27000186,LOCAL,0270,RC,,,both,,,321.90,96.57,"FIRST HEALTH [10303]","First Health",,257.52,80,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 100MM 10MM BALLOON",SUP-U35751010,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS SURGICAL 8MM DA VINCI S/SI ENDOWRIST HARMONIC ACE",SUP-420275,CDM,S27000186,LOCAL,0270,RC,,,both,,,445.50,133.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,204.48,45.9,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL 2.0MM X 124MM",SUP-DRLL-20124,CDM,S27000186,LOCAL,0270,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUCICLOVINE F-18 INTRAVENOUS SOLUTION (12-13 MCI)",RX-411838,CDM,A9588,HCPCS,0343,RC,08888-8877-90,NDC,both,1,UN,755.00,226.5,"UHC [10700]","United Healthcare",,755,,,,,,,87.81,755,"fee schedule",
"IMPL BREAST 450CC SMOOTH SHELL SURFACE NATRELLE INSPIRA FULL",SUP-SRF-450,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"CIGNA [10200]","Cigna Open Access",,3121.25,56.9,,5166.00,5166.00,5166.00,"1 through 10",637.96,4662.68,"percent of total billed charges",
"COIL EMBOLIZATION 50CM 22MM TARGET XL 360D STD LARGE",SUP-M0036102250,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 150MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-05151,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 1.8MM FLEXIBLE ALL SUT ANCHOR SYSTEM DISPOSABLE",SUP-Y18D,CDM,S27200284,LOCAL,0272,RC,,,both,,,733.54,220.06,"PHCS [10601]",PHCS,,513.48,70,,,,,0,85.31,623.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Artery Chemo W/Cutdown",PX-361000510,CDM,36640,CPT,0361,RC,,,both,,,5369.00,1610.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4752,,"Case rate ($4,752). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,624.41,5369,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEMORAL VANGUARD 360 5MM OFFSET KNEE REVISION SYSTEM",SUP-185211,CDM,C1776,HCPCS,0278,RC,,,both,,,5978.16,1793.45,"FIRST HEALTH [10303]","First Health",,4782.53,80,,,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"I-GEL, SINGLE USE SUPRAGLOTTIC AIRWAY, SIZE 5",SUP-8205000,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.19,23.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.55,41.1,,,,,0,9.21,67.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ZEBRA 7F 105CM ACCESS SYSTEM SIM2",SUP-AC7087-105-20-S,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"KAISER [10500]",Kaiser,,5986.79,67,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INLAY OPTIMA 28CM 8FR URETERAL PHREECOAT POLYMER",SUP-788828,CDM,C2625,HCPCS,0278,RC,,,both,,,834.30,250.29,"CIGNA [10200]","Cigna Local Plus",,446.35,53.5,,,,,0,97.03,709.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP060200090 PLUS US D6L200UL900",SUP-PCP060200090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,506.02,41.1,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 559458 CAPSURE SP NOVUS PACING SIL",SUP-559458,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,652.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 64CM ENDOTAK RELIANCE SILICONE 2 COIL DF 1 IS 1",SUP-185,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNETOS 1CC 1-2MM ALLOGRAFT GRANULE PUTTY GOLD",SUP-703-029-US,CDM,C1713,HCPCS,0278,RC,,,both,,,2550.00,765,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1170.45,45.9,,,,,0,296.57,2167.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 7FR LCB CURVE GUIDING NYLON CORONARY",SUP-LA7LCBD,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 100MM 5.4FR 5MM BALLOON DILATATION 2",SUP-BD-L50100CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE VICTORY VASCULAR 300CM 2CM .018IN 30GA STAINLESS STEEL",SUP-H74939233300300,CDM,C1726,HCPCS,0272,RC,,,both,,,1308.96,392.69,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE WATCHMAN FLX PRO 27MM CLSR LEFT ATRIAL APPENDAGE",SUP-M635WU60270,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LIDOCAINE 4 % TOPICAL CREAM",RX-23461,CDM,,,0637,RC,24357-0701-05,NDC,both,5,GR,26.42,7.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE BIG60 12 ATM 13IN INFLATION POLYCARBONATE 60ML 3 WAY",SUP-ENDO-AN6012,CDM,S27200284,LOCAL,0272,RC,,,both,,,298.41,89.52,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) V-18 CONTROL WIRE, 300CM, 12CM TIP (BOSTON SCIENTIFIC",SUP-M001468600,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CMPNT FEMORAL 1 KNEE RIGHT POSTERIOR STABILIZE BEAD",SUP-5516-F-102,CDM,C1776,HCPCS,0278,RC,,,both,,,23001.30,6900.39,"CIGNA [10200]",Cigna,,9200.52,40,,5873.17,5873.17,5873.17,"1 through 10",2675.05,19551.11,"percent of total billed charges",
"CRTDG GRSP 45CM 5MM BABCOCK DIRECT DRIVE STERILE DISPOSABLE",SUP-C4121,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Brain Scan Static <4v",PX-341000058,CDM,78600,CPT,0341,RC,,,both,,,1166.52,349.96,"BLUE CROSS [10001]","Blue Cross PPO",,1.17,.1,,,,,0,1.17,991.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL CORTICAL THK3-12MM HALF ALLOGRAFT STRUT",SUP-450497,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1407.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 100MM 6MM RECTANGLE HELIX BALLOON",SUP-2237-60100,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"UHC [10700]","United Healthcare",,5241.24,63.3,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 52CM .016IN BRADY FIRM",SUP-6584,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 90CM 8FR STRAIGHT GUIDING DURAFORM",SUP-H965100520,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"CIGNA [10200]","Cigna Open Access",,1424.28,56.9,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 5MM SPACEMAKER PRO ENDO-LUBE BLUNT TIP",SUP-SMBTTRNDX,CDM,C1727,HCPCS,0272,RC,,,both,,,3323.48,997.04,"PHCS [10601]",PHCS,,2326.44,70,,,,,0,386.52,2824.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOABLATION 17IN 8MM CRYOICE CRYOSPHERE STERILE LATEX",SUP-CRYOSP-L,CDM,C9808,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 3X4CM AMNIOBAND ALLOGRAFT",SUP-WC3034,CDM,Q4151,HCPCS,0636,RC,,,both,,,11419.50,3425.85,"FIRST HEALTH [10303]","First Health",,9135.6,80,,,,,0,362.66,9706.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 1 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND COATED",SUP-J741D,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.33,40,"PHCS [10601]",PHCS,,93.33,70,,,,,0,15.51,113.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INOUE 70CM 2.5CM 12FR 24-28MM BALLOON DILATATION PVC",SUP-PTMC-28,CDM,C1725,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DRNG DRSG PACK ROCKET IPC 1000ML STERILE LATEX FREE",SUP-R51411,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +1.5 CYL TORIC ACRYSOF IQ VIVITY",SUP-DFT315,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"BLUE CROSS [10001]","Blue Cross HMO",,331.24,39.2,,,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP 3 HOLE EMPHASYS",SUP-471052300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"FIRST HEALTH [10303]","First Health",,14364,80,,,,,0,2088.17,15261.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG SURGICAL 1.35X1IN GROIN MONOFILAMENT PERFIX BARD",SUP-0112950,CDM,C1781,HCPCS,0278,RC,,,both,,,714.87,214.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,84.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,83.14,607.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 7CMX5CMX.2-1MM DERMACELL DERMIS",SUP-DCELL102,CDM,Q4122,HCPCS,0636,RC,,,both,,,16555.17,4966.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7408.44,44.75,,,,,0,1961.79,14071.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 4CM 4MM BALLOON",SUP-G52252,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PHCS [10601]",PHCS,,671.84,70,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 56MM 32MM XLPE HIP STERILE",SUP-71339556,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7565.85,68,,,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL GAMMA3 CLOSED TUBE STERILE",SUP-13200125S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1041.01,312.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,121.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 19MM KNEE X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G719,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"BLUE CROSS [10001]","Blue Cross HMO",,3671.5,39.2,,5311.50,4717.44,5388.59,31,1089.28,7961.17,"percent of total billed charges",
"LENS IOL +12 DIOPTER +2.25 CYLINDER HAPTIC C BICONVEX 13MM 6",SUP-ZXT225U120,CDM,V2788,HCPCS,0276,RC,,,both,,,834.00,250.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,567.12,68,,,,,0,96.99,708.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 9.5IN RICHARDSON 2IN STD HANDLE BLADE SURGICAL .75IN",SUP-23-4504,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.63,40.09,"NOVANET [10819]",Novanet,,100.22,75,,,,,0,15.54,113.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Disruption Fibrin Sheath",PX-361000608,CDM,37799,CPT,0361,RC,,,both,,,1154.65,346.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1154.65,,"Case rate ($1,550). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,134.29,1154.65,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 5.5MM DYONICS HIP ABRADER HIGH VISIBILITY",SUP-72203127,CDM,S27200284,LOCAL,0272,RC,,,both,,,550.80,165.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,374.54,68,,,,,0,64.06,468.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 6.5MM 15MM CANCELLOUS STERILE",SUP-117215000,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"NOVANET [10819]",Novanet,,859.61,75,,,,,0,133.3,974.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE LOW PROFILE SELF DRILLING 4MM 1.5MM CORTICAL",SUP-400.834,CDM,C1713,HCPCS,0278,RC,,,both,,,1344.60,403.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,914.33,68,,,,,0,156.38,1142.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.9H 56MM 3 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009356,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"SHEATH NAVIGATOR 36CM 13-15FR ACCESS STAINLESS STEEL",SUP-M0062502091,CDM,C1894,HCPCS,0272,RC,,,both,,,815.04,244.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,334.98,41.1,,,,,0,94.79,692.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION TRANSEND 130CM 165CM 2.4FR .014IN MICRO BERN",SUP-M001195840,CDM,C1887,HCPCS,0272,RC,,,both,,,6382.50,1914.75,"KAISER [10500]",Kaiser,,4276.28,67,,,,,0,742.28,5425.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 345141FZ L-ASR 11X14X11 FZ SRVCFE",SUP-345141FZ,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC BLUE BEAVER MINI-BLADE STRAIGHT GRINDLESS",SUP-BEAVER6900,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.40,65.22,"CIGNA [10200]","Cigna Open Access",,123.7,56.9,,,,,0,25.28,184.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 35CM EPICARDIUM BIPOLAR ACTIVE FIXATION",SUP-511211,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"BLUE CROSS [10001]","Blue Cross HMO",,875.14,39.2,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNETOS BIPHASIC CALCIUM PHOSPHATE 10CC 1-2MM",SUP-703-021-US,CDM,C1713,HCPCS,0278,RC,,,both,,,18868.50,5660.55,"AETNA [10100]","Aetna HMO/PPO",,15000.46,79.5,,1521.93,481.35,16760.95,30,2194.41,16038.23,"percent of total billed charges",
"STENT ORSIRO MISSION 9MM 140CM 2.25MM CORONARY STERILE LATEX",SUP-453925,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR RADIALUX 4 INTERCHANGEABLE BLADE CORDLESS LED",SUP-50-101-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 3.5MM BALLOON DILATATION PTCA",SUP-DC-RZ3512UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,406.15,41.1,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10MM 80MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704080,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT HAKIM CSF 120CM RIGHT ANGLE SIPHONGUARD UNITIZED",SUP-823146,CDM,S27800098,LOCAL,0278,RC,,,both,,,44384.89,13315.47,"CIGNA [10200]","Cigna Open Access",,14868.94,33.5,,,,,0,5161.96,37727.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP CLUSTER HOLE 12 SCALLOP SNAP FIT",SUP-00875706001,CDM,C1776,HCPCS,0278,RC,,,both,,,11012.40,3303.72,"CIGNA [10200]","Cigna Local Plus",,5891.63,53.5,,5372.07,4581.20,7242.98,23,1280.74,9360.54,"percent of total billed charges",
"SURFACE ARTICULAR 10MM PERSONA 7-12 G-H KNEE LEFT",SUP-42511200610,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"BLUE CROSS [10001]","Blue Cross PPO",,3165.7,39.2,,3949.44,3949.44,3949.44,"1 through 10",939.21,6864.4,"percent of total billed charges",
"CATH EXPO 100CM 6FR .056IN WILLIAMS RIGHT CURVE ANGIOGRAPHIC",SUP-H74908641502,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER MAMMOTOME ELITE CORE NDL 14GA PROBE MAMMOMARK CORMARK",SUP-MAM3014,CDM,A4648,HCPCS,0278,RC,,,both,,,606.69,182.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,71.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.56,515.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RELIEVA SOLO PRO 16MM 6MM BALLOON DILATATION SINUS",SUP-BC0616SP,CDM,C1726,HCPCS,0272,RC,,,both,,,4719.60,1415.88,"AETNA [10100]","Aetna HMO/PPO",,3752.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,548.89,4011.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 30MM 120CM 6MM 6FR VASCULAR PERIPHERAL",SUP-S-60-030-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"BLUE CROSS [10001]","Blue Cross HMO",,3944.3,39.2,,,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR AVENIR COMPLETE 3 HIP STERILE LATEX FREE",SUP-574203030,CDM,C1776,HCPCS,0278,RC,,,both,,,23461.20,7038.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9642.55,41.1,,6417.48,6417.48,6417.48,"1 through 10",2728.54,19942.02,"percent of total billed charges",
"VALVE AORTIC 23MM FREESTYLE SUBCORONARY PORCINE",SUP-995CS23,CDM,S27800098,LOCAL,0278,RC,,,both,,,38430.00,11529,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4469.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4469.41,32665.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 100MM 7MM BALLOON DILATATION STERILE LATEX",SUP-597010022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"PHCS [10601]",PHCS,,1020.6,70,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRILL BIT RESTOR3D METATARSOPHALANGEAL CANNULATED STOP S",SUP-4103-D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"PHCS [10601]",PHCS,,1181.25,70,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA POWERTRAC 142CM 12MM 4.5MM BALLOON",SUP-NCEUP4512X,CDM,C1725,HCPCS,0272,RC,,,both,,,558.90,167.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,66.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM SUMMIT POROCOAT 2 12/14 HIGH OFFSET TAPER",SUP-157011080,CDM,C1776,HCPCS,0278,RC,,,both,,,25247.25,7574.17,"BLUE CROSS [10001]","Blue Cross PPO",,9896.92,39.2,,3949.44,3949.44,3949.44,"1 through 10",2936.26,21460.16,"percent of total billed charges",
"SCR BONE 2MM 12MM LCP STAINLESS STEEL CORTEX T6 STARDRIVE",SUP-201.362.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"KAISER [10500]",Kaiser,,277.46,67,,,,,0,48.16,352,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14IN 21FR AORTA 3/8IN STRAIGHT AUTO DILATE",SUP-EZS21TA,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"KAISER [10500]",Kaiser,,325.62,67,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 19MM ATLANTIS VISION ELITE BONE ANTERIOR CERVICAL",SUP-7200019,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"NOVANET [10819]",Novanet,,3150,75,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SLIP-CATH BEACON TIP SHUTTLE FLEXOR 125CM 5.5FR SIMMONS",SUP-G36360,CDM,S27200284,LOCAL,0272,RC,,,both,,,708.75,212.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,291.3,41.1,,,,,0,82.43,602.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXIVA PULSE ID 365 (BOX 5)",SUP-M006L8406921,CDM,S27200284,LOCAL,0272,RC,,,both,,,2343.77,703.13,"MULTIPLAN [10600]",Multiplan,,1992.2,85,,,,,0,272.58,1992.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3520,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,177.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,174.28,1273.73,"percent of total billed charges",
"SCR BONE 3.5MM 20MM DARCO TITANIUM FOOT LOCK",SUP-DC2820020,CDM,C1713,HCPCS,0278,RC,,,both,,,1223.10,366.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,350.05,28.62,,,,,0,142.25,1039.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 6X4IN FLAT SHEET STERILE POLYESTER",SUP-TET1510,CDM,C1781,HCPCS,0278,RC,,,both,,,912.47,273.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,108.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,106.12,775.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AVIATOR PLUS 142CM 30MM 4MM .014IN BALLOON DILATATION",SUP-4244030W,CDM,C1725,HCPCS,0272,RC,,,both,,,1438.80,431.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD DEFIB MEDI-TRACE CADENCE OVAL SILVER SILVER CHLORIDE",SUP-22550P,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.69,27.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC",087,MS-DRG,,,,,,,inpatient,,,41061.01,12318.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE PACEMKR RADIO FREQUENCY HEAD WAND COVER PRGMR HEAD",SUP-6177,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MAJOR ESOPHAGEAL DISORDERS WITH CC",369,MS-DRG,,,,,,,inpatient,,,42842.71,12852.81,"BLUE CROSS [10001]","Blue Cross HMO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPI-FIT 83CM 14FR 3MM AIRWAY EXCHANGE ADPTR LUER LOCK",SUP-G57622,CDM,S27200284,LOCAL,0272,RC,,,both,,,672.30,201.69,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RENEGADE STC-18 105CM 20CM 3-2.4FR .021IN MICRO GUIDING",SUP-M001181250,CDM,C1887,HCPCS,0272,RC,,,both,,,2287.50,686.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW MICROCHOICE SAGITTAL",SUP-KM-3107,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MINI TREK 145CM 20MM 1.5MM ULTRA LOW PROFILE BALLOON",SUP-1012269-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE 2O VASCULAR STRAIGHT 260CM .035IN HYDROPHILIC FIX CORE",SUP-H2OSTFS35260EX,CDM,C1769,HCPCS,0272,RC,,,both,,,348.00,104.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 24FR URETHRAL NATURAL RUBBER HYDROPHOBIC SILICONE",SUP-265724,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.64,15.79,"KAISER [10500]",Kaiser,,35.27,67,,,,,0,6.12,44.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 7.5MM PORTEX BLUSELECT UNCUFF STERILE LATEX FREE",SUP-101/816/075,CDM,S27200284,LOCAL,0272,RC,,,both,,,311.63,93.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,211.91,68,,,,,0,36.24,264.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 10MM ORTHOLOC TITANIUM NITRIDE FOREFOOT LOCK",SUP-5201024010,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"BLUE CROSS [10001]","Blue Cross PPO",,676.2,39.2,,957.42,570.23,957.42,28,200.62,1466.25,"percent of total billed charges",
"RING ANNULOPLASTY 28MM MITRAL EDWARDS GEOFORM",SUP-420028MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1925.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 5.5MM VIPER 2 LORDOTIC TITANIUM MIS",SUP-186788120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"IMPL BREAST 12X12.5CM 335CC STYLE 410FF GEL TEXTURE HIGH",SUP-FF-410335,CDM,C1789,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]","Cigna Open Access",,4711.32,56.9,,5166.00,5166.00,5166.00,"1 through 10",962.96,7038,"percent of total billed charges",
"ADPTR CATH 9FR CHECK-FLO SELF SEALING FEMALE LUER LOCK",SUP-G15476,CDM,S27000186,LOCAL,0270,RC,,,both,,,116.58,34.97,"MULTIPLAN [10600]",Multiplan,,99.09,85,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 125CM 5FR MULTIPURPOSE A 2 CURVE",SUP-534544T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"CIGNA [10200]","Cigna Open Access",,53.22,56.9,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 35MM ACCOLADE TMZF 4.5 HIP",SUP-6021-4535,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"AETNA [10100]","Aetna HMO/PPO",,12441.11,79.5,,10981.53,8986.79,12413.38,12,1820,13301.82,"percent of total billed charges",
"SCR BONE 6.5MM 140MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.423,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"MULTIPLAN [10600]",Multiplan,,1176.51,85,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 300MM 6MM BALLOON",SUP-U3575630,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER/DIVIDER LAPAROSCOPIC 23CM 5MM LIGASURE XP MARYLAND",SUP-LXMJ23S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 23MM BRIDGE LOCK POST ADVANTAGERIB BONE NONSTERILE",SUP-323.1013,CDM,C1713,HCPCS,0278,RC,,,both,,,23221.80,6966.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6646.08,28.62,,,,,0,2700.7,19738.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135CM 40MM 5MM .035IN LOW PROFILE BALLOON",SUP-B2050-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,523.26,68,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 10-11 E-F KNEE RIGHT TIBIA",SUP-42522400812,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]",Cigna,,7327.97,68,,5873.17,5873.17,5873.17,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"(COMM) PLATE BOX 4 HOLE BONE NONSTERILE LATEX FREE",SUP-115.103.04,CDM,C1713,HCPCS,0278,RC,,,both,,,2715.00,814.5,"NOVANET [10819]",Novanet,,2036.25,75,,,,,0,315.75,2307.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DBM T44125 5CC ORTHOBLEND LARGE DEFGRAFT",SUP-T44125,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2932.5,68,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) HELO BLOOD RETURN SYSTEM (HELO BRS)",SUP-5001,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM PRECEPT SPINE POLYAXIAL",SUP-8806545A,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS [10001]","Blue Cross HMO",,3742.37,39.2,,957.42,156.86,7483.26,51,1110.3,8114.82,"percent of total billed charges",
"BEARING 63/67MMX10MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183520,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"MULTIPLAN [10600]",Multiplan,,6663.81,85,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 24CM 4.8FR .035IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856070,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL LIGHT GREEN 28X36X6.4-10.5MM SYNFIX 10D MEDIUM",SUP-08.815.211S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8113.77,28.62,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN STD",SUP-67011100,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"KAISER [10500]",Kaiser,,279.79,67,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH 8MM PORTEX BLUPERC TUBE STERILE LATEX FREE",SUP-101/563/080,CDM,S27200284,LOCAL,0272,RC,,,both,,,3007.88,902.36,"PHCS [10601]",PHCS,,2105.52,70,,,,,0,349.82,2556.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3.5MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN03510,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1225.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 25MM 2.25MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP22525X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND VAC VERAFLO LARGE",SUP-ULTVCCO5LG,CDM,S27200284,LOCAL,0272,RC,,,both,,,1846.80,554.04,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABERX RADIANZ 9MM8CM 190",SUP-R51009008L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM PORTICO FLEXNAV 107CM 6MM DELIVERY",SUP-FNAV-DS-SM,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SECONDARY DELIVERY CATHETER, DISTAL",SUP-4850-03,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"6.0MM X 13MM TECNIS EYHANCE TORIC II INTRAOCULAR LENS, 1-PIE",SUP-DIU150U205,CDM,V2787,HCPCS,0276,RC,,,both,,,445.00,133.5,"BLUE CROSS [10001]","Blue Cross HMO",,174.44,39.2,,,,,0,51.75,378.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 SH 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J317H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 16MM KNEE X3 BEARING CRUCIATE RETAIN",SUP-5530-G-716,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"KAISER [10500]",Kaiser,,7646.44,67,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X3 HUMERAL INSERT - 36MM X 8MM STANDARD",SUP-5571-S-3608,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1172.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LASER OG CURVED",SUP-14410,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 12MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-612-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1425.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1399.51,10228.56,"percent of total billed charges",
"LINER ACETABULAR R3 20D 60MM 28MM XLPE HIP",SUP-71334960,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"CIGNA [10200]",Cigna,,7579.93,68,,5873.17,5873.17,5873.17,"1 through 10",1296.39,9474.91,"percent of total billed charges",
"BIT DRILL 2.5MM DVR STAINLESS STEEL ANATOMIC VOLAR PLATING",SUP-DB25,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER HAPTIC C BICONVEX 13MM 6MM POSTERIOR",SUP-ZXR00U0205,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"BLUE CROSS [10001]","Blue Cross HMO",,292.04,39.2,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 330541 ACSR 5X14X11 SRVC FEE",SUP-330541,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM TARGET TETRA DETACHABLE STERILE",SUP-TG5414010,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"UHC [10700]","United Healthcare",,8934.57,63.3,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 4.9MM ASNIS III LARGE CANNULATED AO FIT 6.5MM SCR",SUP-702601,CDM,S27200284,LOCAL,0272,RC,,,both,,,2838.15,851.44,"CIGNA [10200]","Cigna Local Plus",,1518.41,53.5,,,,,0,330.08,2412.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 18MM 2.4MM CORTICAL HAND TITANIUM SELF TAPPING",SUP-401.518.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,273.78,45.9,,,,,0,69.37,507.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BILIARY 8MM 6FR 24MM 135CM .035IN MEDIUM BALLOON",SUP-H739PG2480BPX3,CDM,C1876,HCPCS,0278,RC,,,both,,,6553.97,1966.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,762.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.23,5570.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 6X4CM THIN AMNION ALLOGRAFT",SUP-ABS-4100-046,CDM,C1762,HCPCS,0278,RC,,,both,,,19057.50,5717.25,"CIGNA [10200]",Cigna,,7623,40,,,,,0,2216.39,16198.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 55MM 5.5MM XL TITANIUM INTERBODY FUSION LORDOTIC",SUP-5485555,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,348.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,341.92,2499,"percent of total billed charges",
"GRAFT VASCULAR 40CM 8MM STD WALL PERIPHERAL GORE-TEX STRETCH",SUP-S0804,CDM,C1768,HCPCS,0278,RC,,,both,,,4002.00,1200.6,"BLUE CROSS [10001]","Blue Cross HMO",,1568.78,39.2,,,,,0,465.43,3401.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Protozoa Ab Nos",PX-302000157,CDM,86753,CPT,0302,RC,,,both,,,169.00,50.7,"AETNA [10100]","Aetna HMO/PPO",,134.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,143.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 8MM 6FR 3MM .07IN BALLOON",SUP-H7493918908300,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"KAISER [10500]",Kaiser,,379.89,67,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 11MM KNEE POSTERIOR STABILIZE UHMWPE",SUP-71420832,CDM,C1776,HCPCS,0278,RC,,,both,,,9998.10,2999.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1162.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1162.78,8498.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM EVOLVE STAINLESS STEEL CORTICAL ELBOW",SUP-4972714L,CDM,C1713,HCPCS,0278,RC,,,both,,,1710.00,513,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,784.89,45.9,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 70X40MM ARTHROFLEX THK1MM DECELLULARIZE",SUP-AFLEX401,CDM,Q4125,HCPCS,0636,RC,,,both,,,13196.25,3958.87,"CIGNA [10200]","Cigna Open Access",,7508.67,56.9,,107.85,107.85,107.85,28,1563.76,11216.81,"percent of total billed charges",
"INSRT TIBIAL 10MM IPOLY XE POSTERIOR STABILIZE ITOTAL",SUP-TPS-020-1000,CDM,C1776,HCPCS,0278,RC,,,both,,,2130.00,639,"AMERIGROUP MEDICAID [20100]",Amerigroup,,252.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 6MM DCP STAINLESS STEEL CORTICAL SELF TAPPING",SUP-202.806,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,40.86,298.61,"percent of total billed charges",
"KIT PRESSURE MNTR 3 WAY STPCOCK TRNSDUC FLUSH DEVICE",SUP-PX260,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.53,31.06,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.55,41.1,,,,,0,12.04,88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IV VIAFLEX 20 MEQ POTASSIUM CHLORIDE 5% DEXTROSE 0.2%",SUP-2B1614X,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.24,23.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,35.91,45.9,,,,,0,9.1,66.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 300MM 3.2MM PERCUTANEOUS QUICK COUPLING CALIBRATED",SUP-324.212,CDM,S27000186,LOCAL,0270,RC,,,both,,,1272.35,381.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,522.94,41.1,,,,,0,147.97,1081.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR BROAD LORDOTIC 12 DEGREE",SUP-012415,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7767.9,41.1,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 14MM PERSONA MEDIAL CONGRUENT 8-11 E-F",SUP-42522100814,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS [10001]","Blue Cross HMO",,4224.36,39.2,,5311.50,4717.44,5388.59,31,1253.3,9159.96,"percent of total billed charges",
"SYSTEM LAVA-34 EMBOLIC 2ML LIQUID",SUP-SLLES342,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"KAISER [10500]",Kaiser,,11095.2,67,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE COOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-CRKA-17-50-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DIL HYDROPHILIC LONG TAPER 45CM 16FR 18FR ENDOVASCULAR",SUP-G52834,CDM,S27200284,LOCAL,0272,RC,,,both,,,1498.50,449.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,615.88,41.1,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FG GATEWAY OTW  US 3.00MM X 15MM",SUP-M0032072215300,CDM,C1725,HCPCS,0272,RC,,,both,,,9423.88,2827.16,"FIRST HEALTH [10303]","First Health",,7539.1,80,,,,,0,1096,8010.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC10ST-LK,CDM,S27200284,LOCAL,0272,RC,,,both,,,17640.00,5292,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2090.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 60MM 80CM 7MM VASCULAR PERIPHERAL SELF",SUP-1012529-60,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ STIFF VASCULAR 145CM 8CM .035IN STAINLESS",SUP-THSF-35-145-ASG,CDM,C1769,HCPCS,0272,RC,,,both,,,347.91,104.37,"MULTIPLAN [10600]",Multiplan,,295.72,85,,,,,0,40.46,295.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 150MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171081510,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 170MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT SET 6",SUP-222.657,CDM,C1713,HCPCS,0278,RC,,,both,,,9026.30,2707.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2583.33,28.62,,,,,0,1049.76,7672.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT AUTOTRANSFUSION BOWL SET CENTRIFUGAL STD VOLUME ACCESS",SUP-007250100,CDM,S27000186,LOCAL,0270,RC,,,both,,,453.76,136.13,"PHCS [10601]",PHCS,,317.63,70,,,,,0,52.77,385.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 2.5FR UMBILICAL POLYURETHANE 1 LUMEN RADIOPAQUE SMOOTH",SUP-P1UVC-2530,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.20,41.76,"CIGNA [10200]",Cigna,,94.66,68,,,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP PRIMARY STEM 16MM MINI",SUP-113636,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"NOVANET [10819]",Novanet,,9450,75,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 7CM 6FR 21GA 4FR MERIT PAK .018IN 40CM PEDAL",SUP-PAKPHR47NPD7,CDM,C1894,HCPCS,0272,RC,,,both,,,631.80,189.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 4X250 80CM SL",SUP-48004025N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,123.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ECHELON 10 155CM 150CM 2.1-1.7FR 5FR .017IN MICRO",SUP-105-5091-150,CDM,C1751,HCPCS,0272,RC,,,both,,,5030.10,1509.03,"PHCS [10601]",PHCS,,3521.07,70,,,,,0,585,4275.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL VASCULAR 10CM 9FR INTRACLUDE 3 LUMEN CATH ELASTOMERIC",SUP-ICF100,CDM,C1817,HCPCS,0278,RC,,,both,,,25200.00,7560,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2986.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM DIGNISHIELD FECAL MANAGEMENT 60CC CATH SYR COLL BAG",SUP-SMS002,CDM,S27000186,LOCAL,0270,RC,,,both,,,1093.50,328.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,129.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 32.77CM 8MM DA VINCI XI MARYLAND ENDOWRIST",SUP-471172,CDM,S27000186,LOCAL,0270,RC,,,both,,,1850.89,555.27,"CIGNA [10200]",Cigna,,1258.61,68,,,,,0,215.26,1573.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 22.3MM 36MM EQUINOXE SHOULDER SMALL REVERSE",SUP-320-31-36,CDM,C1776,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2221.63,28.62,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL MEDIUM LARGE M2 2 10MM DISTAL BEARING MODULAR",SUP-64813310,CDM,C1776,HCPCS,0278,RC,,,both,,,6116.85,1835.05,"PHCS [10601]",PHCS,,4281.8,70,,,,,0,711.39,5199.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 13.8X7.5IN XENMATRIX AQUAPURE RECTANGLE",SUP-1161935,CDM,C1781,HCPCS,0278,RC,,,both,,,54991.77,16497.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6516.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6395.54,46743,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .047IN MULTIPURPOSE A 2",SUP-534542T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,42.93,45.9,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 23CM .5MM SPETZLER-MALIS STD DISPOSABLE",SUP-6760-230-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,2848.10,854.43,"CIGNA [10200]","Cigna Open Access",,1620.57,56.9,,,,,0,331.23,2420.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER OPHTHALMIC 19GA PACKER/CHANG COAXIAL LOW PROFILE",SUP-DFH-1012,CDM,S27200284,LOCAL,0272,RC,,,both,,,1167.75,350.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,138.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,135.81,992.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 13MM CEMENTLESS SECUR-FIT PLUS HYDROXYAPATITE 9",SUP-6054-0913S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"CIGNA [10200]","Cigna Open Access",,5415.42,33.5,,5302.19,4377.88,6578.61,27,1880.04,13740.62,"percent of total billed charges",
"BAG DRNG 5L EFFULENT FEMALE LUER LOCK CNCT STERILE",SUP-114423,CDM,S27000186,LOCAL,0270,RC,,,both,,,63.87,19.16,"MULTIPLAN [10600]",Multiplan,,54.29,85,,,,,0,7.43,54.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 5ML MASTERGRAFT MATRIX BLOCK EXT",SUP-7610305,CDM,C1713,HCPCS,0278,RC,,,both,,,3582.75,1074.82,"BLUE CROSS [10001]","Blue Cross HMO",,1404.44,39.2,,957.42,156.86,7483.26,51,416.67,3045.34,"percent of total billed charges",
"NDL LOCALIZATION 10CM 20GA HAWKINS III FLEXSTRAND",SUP-253100,CDM,A4648,HCPCS,0278,RC,,,both,,,310.59,93.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,142.56,45.9,,,,,0,36.12,264,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 350MM 11MM CARBON FIBER MR CONDITIONAL",SUP-394.86,CDM,C1713,HCPCS,0278,RC,,,both,,,1441.80,432.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,661.79,45.9,,,,,0,167.68,1225.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTRA 39CM 7FR 115D GUIDING STERILE LATEX FREE",SUP-443629,CDM,C1893,HCPCS,0272,RC,,,both,,,1800.00,540,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,209.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 G 36MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30103607,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"CIGNA [10200]",Cigna,,6971.37,68,,5873.17,5873.17,5873.17,"1 through 10",1192.31,8714.22,"percent of total billed charges",
"CAP COMPREHENSIVE SHORT STEM/TITANIUM GLENOID/TITANIUM HEAD",SUP-98B00900136,CDM,C1776,HCPCS,0278,RC,,,both,,,39375.00,11812.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16183.13,41.1,,6417.48,6417.48,6417.48,"1 through 10",4579.31,33468.75,"percent of total billed charges",
"DEFIB CARDIAC ACTICOR 7 HF-T",SUP-429523,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,20776.5,27,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE COALITION AGX 7D ALLOGRAFT 8X14X7MM",SUP-8128.1277S,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 5-6.5 SMALL UNIVERSAL MALE SUEDE RUBBER",SUP-2007-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.43,23.23,"FIRST HEALTH [10303]","First Health",,61.94,80,,,,,0,9.01,65.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 80CM 8FR 13MM THROMBECTOMY VENOUS BALLOON",SUP-320808F,CDM,C1757,HCPCS,0272,RC,,,both,,,708.99,212.7,"FIRST HEALTH [10303]","First Health",,567.19,80,,,,,0,82.46,602.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 11CMX8MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-2-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,669.22,45.9,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 16CM 13.5FR .038IN POLYURETHANE MAHURKAR QPLUS 2",SUP-8888135165,CDM,C1752,HCPCS,0272,RC,,,both,,,860.01,258,"NOVANET [10819]",Novanet,,645.01,75,,,,,0,100.02,731.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 40CM 3FR EMBOLECTOMY 1 LUMEN BALLOON",SUP-E1601-34,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,71.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL COMPOSIX 8.2X6.2IN PATCH LOW PROFILE",SUP-0134680,CDM,C1781,HCPCS,0278,RC,,,both,,,3087.00,926.1,"CIGNA [10200]","Cigna Local Plus",,1651.55,53.5,,3096.73,1.00,3096.73,"1 through 10",359.02,2623.95,"percent of total billed charges",
"DEFIB CARDIAC RIGHT ATRIUM RIGHT VENTRICLE DR TYPE IS-1 DF-1",SUP-D013,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"BLUE CROSS [10001]","Blue Cross PPO",,15899.52,39.2,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BROWN 51MM 28MM SELF-CENTERING HIP FEMUR",SUP-103551000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,363.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,356.38,2604.67,"percent of total billed charges",
"RING ANNULOPLASTY SIZE 36 OD43MM ID36MM MITRAL VALVE SEMI RI",SUP-SARP-36,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"BLUE CROSS [10001]","Blue Cross PPO",,4745.71,39.2,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 48MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-48-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,670.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SURGICAL 4X4IN CHLORAPREP CHEST TUBE PETROLATUM DRSG",SUP-DYND07603,CDM,S27200284,LOCAL,0272,RC,,,both,,,245.92,73.78,"CIGNA [10200]","Cigna Local Plus",,131.57,53.5,,,,,0,28.6,209.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 8MM TITANIUM T4 HAND SELF TAP VARIABLE ANGLE",SUP-04.130.208,CDM,C1713,HCPCS,0278,RC,,,both,,,925.34,277.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,107.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",107.62,786.54,"percent of total billed charges",
"RCC,SELF INFLAT, LONG,SMOOTH, MD, RIGID",SUP-RSR-M014S-L,CDM,S27200284,LOCAL,0272,RC,,,both,,,659.83,197.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,78.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,76.74,560.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3.5MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN03510,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA [10200]","Cigna Open Access",,5885.22,56.9,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -2.5MM 36MM HIP BIOLOX DELTA V40",SUP-6570-0-436,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"MULTIPLAN [10600]",Multiplan,,8500,85,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 10MM STD SHELL DJO SURGICAL ALTIVATE",SUP-530-10-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,18997.78,40,,,,,0,5523.6,40370.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION MRI GROSHONG SEPTUM-FINDER",SUP-0605920,CDM,C1788,HCPCS,0278,RC,,,both,,,2250.00,675,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1530,68,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROPRANOLOL 60 MG TABLET, IMMEDIATE RELEASE",RX-6659,CDM,,,0637,RC,69292-0536-01,NDC,both,1,UN,8.76,2.63,"AETNA [10100]","Aetna HMO/PPO",,6.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.02,7.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH UROPASS 38CM 6-12FR 14FR 12FR ACCESS STAINLESS STEEL",SUP-61238BX,CDM,C1758,HCPCS,0272,RC,,,both,,,1025.64,307.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,697.44,68,,,,,0,119.28,871.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X7MM COLONIAL 12MM LARGE PARALLEL TITANIUM",SUP-365.307CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 4MM FRMLA FLUTE HOLLOW 12 ARTHROSCOPIC STERILE",SUP-375940012,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"CIGNA [10200]",Cigna,,218.89,68,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERCI 95CM 9FR GUIDING SILICONE BALLOON STERILE LATEX",SUP-90074,CDM,C1725,HCPCS,0272,RC,,,both,,,9696.36,2908.91,"MULTIPLAN [10600]",Multiplan,,8241.91,85,,,,,0,1127.69,8241.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ganglioside Monosialic Acd Abs",PX-301000265,CDM,83520,CPT,0301,RC,,,both,,,354.35,106.3,"CIGNA [10200]","Cigna Open Access",,37.99,,,,,,,0.35,301.2,"fee schedule",
"CAP CONSTRUCT HIP CERAMIC R3 DELTA POROUS R3 XLPE LINER",SUP-71703415,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,9384.48,39.2,,3949.44,3949.44,3949.44,"1 through 10",2784.22,20349,"percent of total billed charges",
"SCR BONE DISTAL RADIAL WRIST HAND NONTOGGLING NONSTERILE 2.3",SUP-CO-N2318,CDM,C1713,HCPCS,0278,RC,,,both,,,720.90,216.27,"MULTIPLAN [10600]",Multiplan,,612.77,85,,,,,0,83.84,612.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT COATED VICRYL PLUS 3-0 PSL 27IN BRAID ANTIBACTERIAL",SUP-VCP502H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 38MM 140CM 2.25MM 2.1-2.7FR CORONARY",SUP-RONYX22538UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1704.04,45.9,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 100CM 1MM 4FR 5MM SPACE A CURVE ELECTROPHYSIOLOGY 10",SUP-F4QA005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,616.9,68,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 40CM 4FR ANGLE KUMPE CURVE ANGIOGRAPHIC",SUP-H787107343015,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM RELINE 2C SPINE POLYAXIAL NONSTERILE",SUP-16017550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"POST OP BRA 36D BLACK",SUP-B01G-36D-B,CDM,S27000186,LOCAL,0270,RC,,,both,,,178.18,53.45,"AETNA [10100]","Aetna HMO/PPO",,141.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.72,151.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR LARGE 2.5X2X1.2MM 1MM APPLEBAUM",SUP-14-0957,CDM,L8613,HCPCS,0278,RC,,,both,,,2652.68,795.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1803.82,68,,,,,0,232.31,2254.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 6.5MM FRACTURE EQUINOXE RIGHT SHOULDER",SUP-304-22-07,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5671.8,41.1,,6417.48,6417.48,6417.48,"1 through 10",1604.94,11730,"percent of total billed charges",
"GRAFT SOFT TISSUE 10X10MM BIOCLEANSE PATELLA TENDON",SUP-453002,CDM,C1762,HCPCS,0278,RC,,,both,,,22680.00,6804,"BLUE CROSS [10001]","Blue Cross HMO",,8890.56,39.2,,,,,0,2637.68,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 60MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET",SUP-241.61,CDM,C1713,HCPCS,0278,RC,,,both,,,6246.23,1873.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2867.02,45.9,,,,,0,726.44,5309.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 43MM 28MM TANDEM HIP COCR UHMWPE",SUP-71322043,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"FIRST HEALTH [10303]","First Health",,6681.96,80,,,,,0,971.39,7099.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LOW PROFILE STAINLESS STEEL 5 HOLE LOCK MODULAR BONE",SUP-AR-8943BL-05,CDM,C1713,HCPCS,0278,RC,,,both,,,6410.10,1923.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4358.87,68,,,,,0,745.49,5448.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 19MM KNEE X3 BEARING CRUCIATE RETAIN",SUP-5530-G-819,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]","Cigna Open Access",,6493.77,56.9,,5302.19,4377.88,6578.61,27,1327.29,9700.71,"percent of total billed charges",
"PLATE CURVE 336MM STAINLESS STEEL 4.5MM SCR 16 HOLE 4 COLUMN",SUP-02.124.416,CDM,C1713,HCPCS,0278,RC,,,both,,,11592.00,3477.6,"PHCS [10601]",PHCS,,8114.4,70,,,,,0,1348.15,9853.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 10CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061751950,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,258.2,28.62,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 130CM 60MM 6MM BALLOON DILATATION",SUP-ADM06006013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,956.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 22CM 8FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G23388,CDM,C2617,HCPCS,0278,RC,,,both,,,535.41,160.62,"BLUE CROSS [10001]","Blue Cross HMO",,209.88,39.2,,,,,0,62.27,455.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY ARTHROGRAM 1 2 CONTRAST 4 NDL SYR EXT TUBING SPONGE",SUP-120020,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.01,32.1,"AETNA [10100]","Aetna HMO/PPO",,85.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.45,90.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING EXPIRATION LIMB WYE 6FT DISPOSABLE 1.8MR",SUP-29657-001,CDM,S27000186,LOCAL,0270,RC,,,both,,,90.46,27.14,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE V-LOC 90 2-0 P-12 6IN CLSR ABSORBABLE PREMIUM REVERSE",SUP-VLOCM0005,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.00,51,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOTRACHEAL 7.5MM 5MM MAGILL CURVE NASAL ORAL 2 CUFF",SUP-86394,CDM,S27200284,LOCAL,0272,RC,,,both,,,399.33,119.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES,MAJOR",098,APR-DRG,,,,,,,inpatient,,,78713.14,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $9,765.30. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($71,498.79) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER ACCUTRAC 200UM FLEXSHIELD HOLMIUM FLEXIBLE",SUP-M0068404110,CDM,S27200284,LOCAL,0272,RC,,,both,,,3351.98,1005.59,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WIRE FIXATION FUZEFIX MAX FT STANDARD OD1.4 MM NONSTERILE",SUP-CD-FX-0014,CDM,S27000186,LOCAL,0270,RC,,,both,,,261.00,78.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXTR PRO 200CM 7-6FR 9-12MM BALLOON DILATATION NATURAL",SUP-4700,CDM,C1726,HCPCS,0272,RC,,,both,,,1202.04,360.61,"UHC [10700]","United Healthcare",,760.89,63.3,,,,,0,139.8,1021.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER 3992210 22MM X 10MM",SUP-3992210,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"NOVANET [10819]",Novanet,,15919.2,75,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 15MM 4MM CORONARY STENT COCR RAPID",SUP-1007850-15,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X12MM OVAL PARALLEL SPINE CORTICAL",SUP-17112,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 8MM 26MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.416S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,428.41,28.62,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL BLUE WHITE .6MM OTO-FLEX DIAMOND DIAMOND",SUP-3155646,CDM,S27200284,LOCAL,0272,RC,,,both,,,1972.50,591.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,233.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.4,1676.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 1.5% DEXTROSE 2000ML 1 BAG SPIKE CNTNR AMBU-FLEX II",SUP-L5B5166,CDM,S27200284,LOCAL,0272,RC,,,both,,,114.29,34.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.29,97.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 1.8MM BUTTRESS VARIABLE ANGLE LOCKING T8",SUP-04.210.094,CDM,C1713,HCPCS,0278,RC,,,both,,,872.78,261.83,"FIRST HEALTH [10303]","First Health",,698.22,80,,,,,0,101.5,741.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 3.5CM 16FR RADIOPAQUE LOW PROFILE PROXIMAL ANTIREFLUX",SUP-0120-16-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"AETNA [10100]","Aetna HMO/PPO",,619.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTICROSS 6 135CM 1.18MM ULTRASOUND CORONARY STERILE",SUP-H7495181360,CDM,C1753,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"KAISER [10500]",Kaiser,,3120.53,67,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 30ML 1.7-10MM 50% CORTICAL 50% CANCELLOUS",SUP-400045,CDM,C1713,HCPCS,0278,RC,,,both,,,2842.88,852.86,"CIGNA [10200]","Cigna Open Access",,1617.6,56.9,,1144.80,304.56,2275.09,66,330.63,2416.45,"percent of total billed charges",
"STENT ASCERTA 22CM 6FR URETERAL FIRM STERILE LATEX FREE",SUP-M0061456450,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"CIGNA [10200]",Cigna,,425.16,68,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 12MM AXIUM 3D FRAME V01",SUP-FC-12-40-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"PHCS [10601]",PHCS,,11567.85,70,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM 12MM MODULAR RESTORATION HIP DISTAL",SUP-6276-7-412,CDM,C1776,HCPCS,0278,RC,,,both,,,20188.35,6056.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2392.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2347.91,17160.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 75CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR061501A,CDM,C1874,HCPCS,0278,RC,,,both,,,24374.70,7312.41,"CIGNA [10200]","Cigna Open Access",,8165.52,33.5,,,,,0,2834.78,20718.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING SUCTION 6FT BERKELEY VACRET PLASTIC COLL SET SWIVEL",SUP-610,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.55,34.96,"UHC [10700]","United Healthcare",,73.78,63.3,,,,,0,13.55,99.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 22FR TUNGSTEN SILICONE 2.5CM MIC-KEY",SUP-8270-22-2.5-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"UHC [10700]","United Healthcare",,1666.56,63.3,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 5X5CM ALLOPATCH HD THK.8-1.7MM THICK ACELLULAR",SUP-471505,CDM,Q4128,HCPCS,0636,RC,,,both,,,10315.50,3094.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,247.92,,,,,,,80.43,8768.18,"fee schedule",
"ADPTR AEROSOL VAPOTHERM PRECISION FLOW AEROGEN LATEX FREE",SUP-AAA-1,CDM,S27000186,LOCAL,0270,RC,,,both,,,83.52,25.06,"AETNA [10100]","Aetna HMO/PPO",,66.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.71,70.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 33.58CM 8MM ENDOWRIST 42D BIPOLAR 2.8CM",SUP-471405,CDM,S27000186,LOCAL,0270,RC,,,both,,,1850.63,555.19,"CIGNA [10200]",Cigna,,1258.43,68,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150190,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Open Access",,196.31,56.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE CAST 11IN 4.75IN MEDIUM NONSKID SOLE",SUP-SA901005,CDM,S27000186,LOCAL,0270,RC,,,both,,,55.59,16.68,"UHC [10700]","United Healthcare",,35.19,63.3,,,,,0,6.47,47.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Streptococcus a Ampl Probe",PX-306000144,CDM,87651,CPT,0306,RC,,,both,,,432.25,129.67,"CIGNA [10200]","Cigna Local Plus",,77.2,,,,,,,0.01,367.41,"fee schedule",
"BLADE WIRE SAW 1.4MM 20IN 6 TWISTED WIRE GIGLI",SUP-FH415,CDM,S27000186,LOCAL,0270,RC,,,both,,,75.71,22.71,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,34.75,45.9,,,,,0,8.81,64.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC UNIVERSAL 10IN ANKLE FOREFOOT CLSR ELASTIC",SUP-79-81330,CDM,S27000186,LOCAL,0270,RC,,,both,,,107.01,32.1,"NOVANET [10819]",Novanet,,80.26,75,,,,,0,12.45,90.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 30MM 3.5MM BALLOON DILATATION PACLITAXEL",SUP-H7493960830350,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"MULTIPLAN [10600]",Multiplan,,33067.13,85,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION",RX-105640,CDM,J0665,HCPCS,0636,RC,00409-1162-19,NDC,both,30,ML,24.24,7.27,"CIGNA [10200]","Cigna Local Plus",,8.55,,,,,,,2.87,20.6,"fee schedule",
"RTRCTR LAPAROSCOPIC 56.7CM 8MM DA VINCI S/SI ENDOWRIST",SUP-420278,CDM,S27000186,LOCAL,0270,RC,,,both,,,1800.00,540,"NOVANET [10819]",Novanet,,1350,75,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CIRCUIT EVAQUA 2 2 LIMB HEAT INFANT",SUP-RT266,CDM,S27000186,LOCAL,0270,RC,,,both,,,324.51,97.35,"FIRST HEALTH [10303]","First Health",,259.61,80,,,,,0,37.74,275.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK 24IN THERAPEUTIC MOIST HEAT THERMAL COLOR CODED TABS",SUP-561727,CDM,S27000186,LOCAL,0270,RC,,,both,,,239.16,71.75,"FIRST HEALTH [10303]","First Health",,191.33,80,,,,,0,27.81,203.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) QUALIBRA ADVANCED XXXL",SUP-QADV-XXXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Dialysis Pd2",PX-E27200286,CDM,E27200286,LOCAL,0272,RC,,,both,,,161.70,48.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,74.22,45.9,,,,,0,18.81,137.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Cong Card Ltd W Contr",PX-483000024,CDM,93304,CPT,0483,RC,,,both,,,3326.00,997.8,"MULTIPLAN [10600]",Multiplan,,2827.1,85,,,,,0,307.78,2827.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GYNECARE TVT OBTURATOR SYSTEM (SINGLE USE DEVICE) LASER CUT",SUP-810081L,CDM,C1771,HCPCS,0278,RC,,,both,,,8539.72,2561.92,"PHCS [10601]",PHCS,,5977.8,70,,,,,0,993.17,7258.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING TRANSVAGINAL DESARA SHORT LENGTH TAPER FEMALE STRESS",SUP-CAL-DSO1BSL,CDM,C1771,HCPCS,0278,RC,,,both,,,7928.10,2378.43,"PHCS [10601]",PHCS,,5549.67,70,,,,,0,922.04,6738.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL TISSUE CLSR VISTASEAL FIBRIN HUMAN 10ML",SUP-VST10,CDM,S25000001,LOCAL,0250,RC,,,both,,,5774.82,1732.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2650.64,45.9,,,,,0,671.61,4908.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL TISSUE CLSR VISTASEAL FIBRIN HUMAN 10ML",SUP-VST10,CDM,S25000001,LOCAL,0250,RC,,,both,,,5774.82,1732.45,"CIGNA [10200]",Cigna,,3926.88,68,,,,,0,671.61,4908.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165MM 8.5-9.8MM OTSC 3MM MINI NITINOL T",SUP-100.02,CDM,C1760,HCPCS,0278,RC,,,both,,,3667.50,1100.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,434.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,426.53,3117.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drsg Foam Nonadhesive Rl 4x24",PX-E27200126,CDM,E27200126,LOCAL,0272,RC,,,both,,,144.10,43.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.76,122.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C-Peptide",PX-301000448,CDM,84681,CPT,0301,RC,,,both,,,344.50,103.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,73.9,,,,,,,0.34,292.83,"fee schedule",
"HC Calculate Rad Ther Dose",PX-333000008,CDM,77300,CPT,0333,RC,,,both,,,1177.32,353.2,"KAISER [10500]",Kaiser,,788.8,67,,,,,0,136.92,1177.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Potassium POC",PX-301000364,CDM,84132,CPT,0301,RC,,,both,,,122.67,36.8,"PHCS [10601]",PHCS,,85.87,70,,,,,0,0.12,104.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 7CM 5FR PANCREATIC POLYETHYLENE PUSH CATH",SUP-G22210,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Pack Perfusion Custom",PX-E27200369,CDM,E27200369,LOCAL,0272,RC,,,both,,,2772.00,831.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,328.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,322.38,2356.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ecmo Daily Mgmt Veno-Arterial",PX-361000385,CDM,33949,CPT,0361,RC,,,both,,,5388.36,1616.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2292.95,,"Fee schedule rate ($2,292.95).",,,,0,626.67,5388.36,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ecmo Daily Mgmt Veno-Arterial",PX-361000385,CDM,33949,CPT,0361,RC,,,both,,,5388.36,1616.51,"FIRST HEALTH [10303]","First Health",,4310.69,80,,,,,0,626.67,5388.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT DOUBLE-J 24CM 100CM 7FR .028IN URETERAL SILICONE PTFE",SUP-5204800,CDM,C2625,HCPCS,0278,RC,,,both,,,1212.57,363.77,"PHCS [10601]",PHCS,,848.8,70,,,,,0,141.02,1030.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Tunl Cvc W Port",PX-450000231,CDM,36590,CPT,0361,RC,,,both,,,5591.61,1677.48,"MULTIPLAN [10600]",Multiplan,,4752.87,85,,,,,0,650.3,5591.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Magnesium",PX-301000307,CDM,83735,CPT,0301,RC,,,both,,,150.00,45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.54,,,,,,,0.15,127.5,"fee schedule",
"STENT 7CM 10FR PROXIMAL BEND BILIARY 2 LAYER STERILE",SUP-PBD-421-1007,CDM,C2625,HCPCS,0278,RC,,,both,,,1387.85,416.35,"PHCS [10601]",PHCS,,971.5,70,,,,,0,161.41,1179.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PACING 37CM BIPOLAR IS-1",SUP-6984M,CDM,C1883,HCPCS,0278,RC,,,both,,,1069.20,320.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,490.76,45.9,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR IMPLANTABLE 55CM PRECISION M-1 CNCT",SUP-SC-9004-55,CDM,C1883,HCPCS,0278,RC,,,both,,,3525.00,1057.5,"KAISER [10500]",Kaiser,,2361.75,67,,,,,0,409.96,2996.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enterovirus Qpcr Plasma",PX-306000157,CDM,87799,CPT,0306,RC,,,both,,,1038.00,311.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,152.05,,,,,,,1.04,882.3,"fee schedule",
"CBL PCNG LD 301-CG",SUP-343586,CDM,C1883,HCPCS,0278,RC,,,both,,,408.90,122.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,48.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW .48IN THK.015IN 1.36IN MICRO LONG WIDE 2 CUT CUT",SUP-5400003206,CDM,S27200284,LOCAL,0272,RC,,,both,,,430.48,129.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SITAGLIPTIN PHOSPHATE 50 MG TABLET",RX-77616,CDM,,,0637,RC,00006-0112-01,NDC,both,1,UN,49.90,14.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SYNTHETIC ETHIBOND EXCEL 2-0 V-7 30IN 2 ARM BRAID FIRM",SUP-PXX77N,CDM,S27200284,LOCAL,0272,RC,,,both,,,676.31,202.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE ONO 300MM 12FR 7.5FR RETRIEVAL PEEL AWAY SHEATH",SUP-ONO12-100,CDM,C1773,HCPCS,0272,RC,,,both,,,59062.50,17718.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"MILL BNE FN",SUP-5400-702-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2130.15,639.04,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH UMBILI-CATH GESCO 43CM 3.5FR UMBILICAL SILICONE NEONATE",SUP-4273505,CDM,S27200284,LOCAL,0272,RC,,,both,,,274.49,82.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL DISSECTING 140MM 3MM MIDAS REX LEGEND MATCH HEAD",SUP-14MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1184.63,355.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT POLYPROPYLENE MONOFILAMENT BLUE NONABSORBABLE",SUP-85550H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 485CC",SUP-SSZ-M485,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR DISTRACTION 14MM SPINE CERVICAL ANTERIOR STAINLESS STEEL",SUP-MDS9091414,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.88,68.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNIFE SURGICAL 188MM BAYONET ANNULOTOMY ZEUS LATERAL RTRCTR",SUP-1563-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT EDGE ACCUVAC",SUP-E2450HSNSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.17,24.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PRIMIDONE 50 MG TABLET",RX-11129,CDM,,,0637,RC,50268-0686-11,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE STATLOCK UNIVERSAL PLUS SMALL 6-8.5FR SECUREMENT FOAM",SUP-VUPD68,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.96,25.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STEERABLEBALLOON CA",SUP-ARC30SB-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH WEBSTER 92CM 1MM 5FR 10MM SPACE D CURVE",SUP-D508DP10RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3090.00,927,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 5-0 RB-2 30IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8710,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.25,67.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT PROTEGE GPS EXPRT 30MM 120CM 9MM .079IN LARGE DIAMETER",SUP-SERB65-09-30-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]",Cigna,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 255CC",SUP-SSZ-M255,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"UHC [10700]","United Healthcare",,943.42,63.3,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 24FR SILICONE STD J MIC SECUR-LOK TRIMMABLE",SUP-0200-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,504.71,45.9,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AMPLATZER TORQVUE 80CM 9FR .15IN .118IN 45D DELIVERY",SUP-9-ITV09F45/80,CDM,C1773,HCPCS,0272,RC,,,both,,,4912.80,1473.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3340.7,68,,,,,0,571.36,4175.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DANTROLENE 25 MG CAPSULE",RX-9718,CDM,,,0637,RC,50268-0217-11,NDC,both,1,UN,11.96,3.59,"UHC [10700]","United Healthcare",,7.57,63.3,,,,,0,1.39,10.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 6-0 P-1 18IN MONOFILAMENT UNDYED NONABSORBABLE",SUP-689G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL ENDOSCOPIC INSTRUMEN 5-8MM DA VINCI XI UNIVERSAL",SUP-470361,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.43,49.33,"PHCS [10601]",PHCS,,115.1,70,,,,,0,19.12,139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH LEAD EXTRACTION STEADYSHEATH EVOLUTION 36.5CM 11FR",SUP-LR-TSS-11.0,CDM,C1773,HCPCS,0272,RC,,,both,,,1875.00,562.5,"AETNA [10100]","Aetna HMO/PPO",,1490.63,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ASPIRATION 80MM 25GA 1.85MM EZ SHOT 2 ROUND KNOB STYLET",SUP-NA-220H-8025,CDM,S27200284,LOCAL,0272,RC,,,both,,,1467.10,440.13,"FIRST HEALTH [10303]","First Health",,1173.68,80,,,,,0,170.62,1247.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Burn 2nd Degree 5-10%",PX-510000059,CDM,16025,CPT,0761,RC,,,both,,,1913.08,573.92,"CIGNA [10200]",Cigna,,1913.08,,"Per diem ($2,606).",,,,0,222.49,1913.08,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Burn 2nd Degree 5-10%",PX-510000059,CDM,16025,CPT,0761,RC,,,both,,,1913.08,573.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,226.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,222.49,1913.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC INTERPULSE BONE CLEANING TIP SUCTION PULSED LAVAGE",SUP-0210-110-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.14,99.04,"MULTIPLAN [10600]",Multiplan,,280.62,85,,,,,0,38.4,280.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 9.5MM 7MM STD LOW PROFILE DEPH FREE",SUP-8229707,CDM,S27200284,LOCAL,0272,RC,,,both,,,2895.00,868.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,343.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,336.69,2460.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUTURING ENDO STITCH SURGIDAC GREEN 0 ES-9 48IN",SUP-173024,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"CIGNA [10200]",Cigna,,98.03,68,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LACOSAMIDE 10 MG/ML ORAL SOLUTION",RX-105482,CDM,,,0637,RC,00121-2024-95,NDC,both,10,ML,436.17,130.85,"MULTIPLAN [10600]",Multiplan,,370.74,85,,,,,0,50.73,370.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FULL THICK CALIBRATE DEPTH MARK CANNULATED",SUP-AR-1218-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER POLYDEK 1 KC-6 30IN BRAID GREEN NONABSORBABLE",SUP-69-546,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATROPINE 1 % EYE DROPS",RX-736,CDM,,,0637,RC,70069-0582-01,NDC,both,5,ML,327.08,98.12,"UHC [10700]","United Healthcare",,207.04,63.3,,,,,0,38.04,278.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.25CM NATRELLE INSPIRA P6.6CM EXTRA FULL",SUP-MSZ-X700,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"FIRST HEALTH [10303]","First Health",,126.54,80,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 40MM 4MM BALLOON",SUP-LX181304404F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"UHC [10700]","United Healthcare",,4258.51,63.3,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER ETHIBOND 0 MO-7 18IN CONTROL RELEASE BRAID 8",SUP-CX41D,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.15,44.74,"NOVANET [10819]",Novanet,,111.86,75,,,,,0,17.35,126.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 22FR SILICONE UNIVERSAL FEEDING PORT CNCT MEDICATION",SUP-0100-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"PHCS [10601]",PHCS,,195.92,70,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 CT-3 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J328H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM FRMLA RESECTOR F LATEX FREE",SUP-0375542000,CDM,S27200284,LOCAL,0272,RC,,,both,,,183.74,55.12,"UHC [10700]","United Healthcare",,116.31,63.3,,,,,0,21.37,156.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 44MM CERAMIC DELTA",SUP-400-03-443,CDM,S27200284,LOCAL,0272,RC,,,both,,,16953.92,5086.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11528.67,68,,,,,0,1971.74,14410.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 13IN DEAVER 5 SURGICAL 2IN",SUP-SU3305,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.10,61.83,"KAISER [10500]",Kaiser,,138.09,67,,,,,0,23.97,175.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 3-0 KS 27IN MONOFILAMENT ABSORBABLE",SUP-665H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 25MM 6-5FR COTTON CANNULATOME II BILIARY PANCREATIC",SUP-G22241,CDM,S27200284,LOCAL,0272,RC,,,both,,,1642.50,492.75,"MULTIPLAN [10600]",Multiplan,,1396.13,85,,,,,0,191.02,1396.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPREME EXTENSION CABLE RED  150 CM",SUP-401983R,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"NOVANET [10819]",Novanet,,215.33,75,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATHETER EXTENSION ELECTROPHYSIOLOGY",SUP-85641R,CDM,S27200284,LOCAL,0272,RC,,,both,,,696.60,208.98,"CIGNA [10200]","Cigna Open Access",,396.37,56.9,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SLINGSHOT ZIPLINE 2 COBRAID GREEN WHITE NONABSORBABLE",SUP-CAT01585,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.13,54.34,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,74.44,41.1,,,,,0,21.07,153.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINERAL OIL ENEMA",RX-5087,CDM,,,0637,RC,00132-0301-40,NDC,both,133,ML,13.39,4.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY EPIDURAL 3.5IN 17GA 19GA PERIFIX TUOHY BPA DEHP PVC",SUP-332087,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.01,54.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AEON ENDOSTAPLER RELOAD 30MM WHITE",SUP-AESR30W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANSTR SUCTION LIPOFILTER 2 CHMBR ASPIRATION FAT HARVEST SYR",SUP-ASP-CAN-2S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOLUTION .9 SODCHL ADV Q 50ML",SUP-710166,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 3.8MM 2.9MM MATCH HEAD",SUP-KM-AM8U,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL 21X4.8MM TITANIUM XL CIRCULAR LARGE",SUP-EEAXL21,CDM,S27200284,LOCAL,0272,RC,,,both,,,2269.80,680.94,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE 2.5CM MIC-KEY",SUP-0270-18-2.5-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 10CM 8.5FR 18GA ARROW-FLEX .035IN PERCUTANEOUS",SUP-AK-09803-CDC,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 18FR SILICONE RADIOPAQUE BOLUS ENTERAL FEED INTERNAL",SUP-0110-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"CIGNA [10200]",Cigna,,190.32,68,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 80CM 4CM 4MM BALLOON",SUP-G52332,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"KAISER [10500]",Kaiser,,643.05,67,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 85MM 3.5MM LC-DCP CORTEX PELVIC STAINLESS STEEL",SUP-204.685,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"BLUE CROSS [10001]","Blue Cross PPO",,107.91,39.2,,957.42,570.23,957.42,28,32.01,233.98,"percent of total billed charges",
"CATH IMPRESS 40CM 2CM 5FR .046IN .035IN RIM STRAIGHT",SUP-54035RIM,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"NOVANET [10819]",Novanet,,78.3,75,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 18GA 50CM 11CM ORANGE HUB DIL GWIRE",SUP-PSI-7F-11-035-18G,CDM,C1894,HCPCS,0272,RC,,,both,,,102.23,30.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.02,41.1,,,,,0,11.89,86.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR SHUTTLE 90CM 7FR 2.5MM GUIDING ACCEPTS .038IN",SUP-G12835,CDM,C1894,HCPCS,0272,RC,,,both,,,838.35,251.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,99.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.5,712.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH HEARTSPAN 90D FIX CURVE TAPER 79.4CM 8.5FR GUIDING",SUP-FCL-160-08,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 7IN STRAIGHT 1.5MM CUSHING DELICATE SURGICAL",SUP-57-2001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2266.43,679.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1040.29,45.9,,,,,0,263.59,1926.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REGULAR 4FR INTRO NINITOL ECHOGENIC NDL FIXED CORE",SUP-70-4160,CDM,C1894,HCPCS,0272,RC,,,both,,,304.50,91.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,125.15,41.1,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THOMASMEDICAL INTRDCR FR10 LONG",SUP-6276,CDM,C1894,HCPCS,0272,RC,,,both,,,139.20,41.76,"AETNA [10100]","Aetna HMO/PPO",,110.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT TAPERED COMPONENT",SUP-G47480,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,27709.7,27,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE ROUND SILICONE",SUP-SRF-265,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,650.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",637.96,4662.68,"percent of total billed charges",
"BLADE LARYNSCP SURESIGHT 1 HYPERANGULATED NONSTERILE",SUP-390211000,CDM,S27000186,LOCAL,0270,RC,,,both,,,445.50,133.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,204.48,45.9,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LASER 25GA DIRECTIONAL EXTENDABLE STERILE DISPOSABLE",SUP-55.26.25E,CDM,S27200284,LOCAL,0272,RC,,,both,,,1425.39,427.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.77,1211.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH GORE DRYSEAL FLEX 33CM 4MM 10FR INTRO HYDROPHILIC",SUP-GDSF1033,CDM,C1894,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"FIRST HEALTH [10303]","First Health",,3008.4,80,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PERFORMER MULLINS CURVE 85CM 12FR 4MM GUIDING FEP",SUP-G09136,CDM,C1894,HCPCS,0272,RC,,,both,,,890.92,267.28,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FR10.5 OSCOR",SUP-6094,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 5FR 11CM MINI GWIRE AVANTI+ MID LENGTH",SUP-402605X,CDM,C1894,HCPCS,0272,RC,,,both,,,50.03,15.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 4-0 RB-1 36IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8557,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.06,68.72,"MULTIPLAN [10600]",Multiplan,,194.7,85,,,,,0,26.64,194.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +30 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.300,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 13X12CM BREAST 400ML STYLE 133MV TEXTURED STERILE",SUP-133MV-13,CDM,C1789,HCPCS,0278,RC,,,both,,,5460.00,1638,"NOVANET [10819]",Novanet,,4095,75,,,,,0,635,4641,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXTR PRO 200CM 7-6FR 9-12MM SPECIMEN RETRIEVAL NATURAL",SUP-M00547000,CDM,C1726,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 35MM LOW PROFILE SCREWS STAINLESS STEEL LONG .5",SUP-AR-8840CL-35,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 2 140CM 6CM 7FR 7MM .018IN BALLOON DILATATION",SUP-V187060,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"MULTIPLAN [10600]",Multiplan,,4662.68,85,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM CARBO-SEAL ASCENDING AORTA VALSALVA",SUP-CP-025,CDM,S27800098,LOCAL,0278,RC,,,both,,,29408.40,8822.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11763.36,40,,,,,0,3420.2,24997.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL INFANT MASK O2 RESVR BAG PRESSURE LIMIT VALVE",SUP-544211000,CDM,S27200284,LOCAL,0272,RC,,,both,,,57.55,17.26,"KAISER [10500]",Kaiser,,38.56,67,,,,,0,6.69,48.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION",RX-2367,CDM,J3490,HCPCS,0258,RC,00264-7387-50,NDC,both,2000,ML,113.22,33.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM PREVENA PLUS NEGATIVE PRESSURE STANDALONE EXTEND",SUP-PRE4010.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PLAIN LIGAPAK 3-0 54IN MONOFILAMENT REEL YELLOWISH TAN",SUP-L102G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STPLR 3MM 3.5MM 4MM 60MM ENDO GIA MEDIUM THICK TISSUE",SUP-EGIA60AMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1587.60,476.28,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE ELECTROSURGICAL 7FT 2IN 2.3MM FIAPC CIRCUMFERENTIAL",SUP-20132-218,CDM,S27200284,LOCAL,0272,RC,,,both,,,1902.75,570.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,782.03,41.1,,,,,0,221.29,1617.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 7.5MM ACORN DISSECTING",SUP-MR8-9AC75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,536.49,45.9,,,,,0,135.93,993.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM 3DX TSRH OSTEOGRIP THINLINE TITANIUM",SUP-83555359,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6491.86,68,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM 3.8MM NEURO STERILE",SUP-5820107430,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,129.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 2.8MM MIDFOOT SALVATION INTRAMEDULLARY DRILL",SUP-SMN10010,CDM,S27200284,LOCAL,0272,RC,,,both,,,3105.00,931.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BMA NEEDLE 74285-02M 11 GAUGE X 15CM",SUP-7428502M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.00,513,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PASSER CAPSULESTITCH SUT",SUP-AR-7070,CDM,S27200284,LOCAL,0272,RC,,,both,,,2323.13,696.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM RELIEVA SPIN RELIEVA VORTEX 2 F-70 16MM 6MM",SUP-RS0616F,CDM,S27200284,LOCAL,0272,RC,,,both,,,11557.50,3467.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GUIDER SOFTIP XF 90CM 8FR 40D GUIDING DURAFORM PTFE",SUP-H965100440,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE JEJUNOSTOMY 36IN 8FR TEFLON POLYURETHANE SILICONE",SUP-50-7368,CDM,S27200284,LOCAL,0272,RC,,,both,,,396.39,118.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COUNTSINK DRILL 7 MM HEAD SCR",SUP-P20-910-7000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1279.80,383.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KEY CHUCK JACOBS UNIVERSAL CORDLESS DRIVER 2 STERILE",SUP-4100131132,CDM,S27200284,LOCAL,0272,RC,,,both,,,403.85,121.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP OPHTHALMIC 25+ GA GRIESHABER MAXGRIP MICRO TEXTURE",SUP-705.13P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.84,388.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PLAIN 2-0 CT-1 27IN MONOFILAMENT YELLOWISH TAN",SUP-843H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OVERSTITCH NXT ENDOSCOPIC SUTURE SYSTEM",SUP-M00505430,CDM,S27200284,LOCAL,0272,RC,,,both,,,21712.32,6513.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"E-CATH PLUS TRAY 18G X 4 (100MM) INDWELLING CATHETER SONOPLE",SUP-TDL145,CDM,S27200284,LOCAL,0272,RC,,,both,,,611.55,183.46,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CRANIOTOMY INTEGRA WITHOUT PREP SOL STERILE LATEX FREE",SUP-INSHITHND,CDM,S27200284,LOCAL,0272,RC,,,both,,,3495.90,1048.77,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"APPL CLIP 35CM AUTOMATIC 5MM LATEX FREE STERILE WECK AUTO",SUP-AE05ML,CDM,S27200284,LOCAL,0272,RC,,,both,,,1117.80,335.34,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNIFE OPHTHALMIC 17.6X2.03X1.09MM LASEREDGE 1.1MM ANGLE",SUP-LP7592,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.68,34.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUTURE COATED VICRYL PLUS 0 27IN ABSORBABLE VIOLET ANTIBACTE",SUP-VCP340H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS 3-0 SH 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP864D,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.64,38.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WAND ELECTROSURGICAL CABLATOR PROCIZE EZ VIEW PLASMA 3",SUP-EICA887501,CDM,S27200284,LOCAL,0272,RC,,,both,,,2348.33,704.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ACC CABLE DSPL PSA - EACH",SUP-666651-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND 4-0 RB-1 24IN 2 ARM BRAID BLACK",SUP-K571H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO BIOPSY 6CM 17GA 18GA ACHIEVE UNIVERSAL COAXIAL",SUP-PP176,CDM,S27200284,LOCAL,0272,RC,,,both,,,114.41,34.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL YASARGIL RUGGLES REDMOND .3MM BAYONET 8.25IN",SUP-RN8030,CDM,S27200284,LOCAL,0272,RC,,,both,,,2174.10,652.23,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER BEIGE 7CM 3.5MM DYONICS FULL RADIUS RESECTOR",SUP-7205305,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.00,84.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE JEJUNOSTOMY 45CM 18FR SILICONE MIC SECUR-LOK UNIVERSAL",SUP-0250-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 4MM ROUND FLUTE",SUP-5540010040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1288.63,386.59,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOTRACHEAL 5MM NASAL ORAL UNCUFF REINFORCE MURPHY TIP",SUP-5-12910,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.11,36.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY NERVE BLOCK 2IN 18GA 20GA PAJUNK SONOLONG TUOHY",SUP-TDL108,CDM,S27200284,LOCAL,0272,RC,,,both,,,591.30,177.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEARS ELECTROSURGICAL 9CM HARMONIC FOCUS CURVED",SUP-FCS9,CDM,S27200284,LOCAL,0272,RC,,,both,,,2314.00,694.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PRSSZR CEMENT YELLOW SMALL FEMUR CANAL",SUP-0206545000,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.71,37.41,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP BIOPSY IMPROVE MICROMESH TEETH STREAMLINE CATH 100CM",SUP-M00515201,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.48,104.84,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOOKUP ENDOSCP 24 HOUR DSD REUSABLE",SUP-SB-110-HU1010,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.54,39.46,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP STONE RETRIEVAL 90CM 8MM 2.6FR GRASPIT NITINOL",SUP-M0063204000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 135X30MM EIKON LT LOW PROFILE NONCONDUCTIVE SURGICAL",SUP-C135,CDM,S27200284,LOCAL,0272,RC,,,both,,,7832.88,2349.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER MAMMARY SILICONE 225ML BREAST GEL ROUND SMOOTH",SUP-RSZ-2251,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNIFE NEUROSURGICAL APEX ARACHNOID KNIVES 65D ULTEM",SUP-AM-23-B,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW TPS THK.38MM MICRO RIGHT INFERIOR BORDER",SUP-5100037901,CDM,S27200284,LOCAL,0272,RC,,,both,,,854.23,256.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACEMKR CARDIAC .75CM 4.45X5.02CM ESSENTIO PACESAFE",SUP-L111,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"MULTIPLAN [10600]",Multiplan,,35360,85,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG VAC PEEL AND PLACE SMALL",SUP-EZ5SML,CDM,S27200284,LOCAL,0272,RC,,,both,,,813.55,244.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,373.42,45.9,,,,,0,94.62,691.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 12FR URETHRAL BACTI-GUARD HYDROGEL 5CC 1 EYE",SUP-0168SI12,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.14,33.04,"CIGNA [10200]","Cigna Open Access",,62.67,56.9,,,,,0,12.81,93.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 12.5CM 20GA HAWKINS III 9 STRAND CABLE",SUP-243125,CDM,A4648,HCPCS,0278,RC,,,both,,,310.59,93.18,"BLUE CROSS [10001]","Blue Cross PPO",,121.75,39.2,,,,,0,36.12,264,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL BUIE 6.25IN FISTULA STERLING SILVER",SUP-50-9420,CDM,S27200284,LOCAL,0272,RC,,,both,,,391.76,117.53,"AETNA [10100]","Aetna HMO/PPO",,311.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.56,333,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION DOME GROSHONG TITANIUM SILICONE",SUP-602870,CDM,C1788,HCPCS,0278,RC,,,both,,,1547.10,464.13,"NOVANET [10819]",Novanet,,1160.33,75,,,,,0,179.93,1315.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHAIT TRAPDOOR 20CM 6- CM 10.2FR SHORT CECOSTOMY",SUP-G11632,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILFRM URETHRAL 13IN 3FR STRAIGHT PVC PLASTIC STERILE LATEX",SUP-342103,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.96,28.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,43.13,45.9,,,,,0,10.93,79.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 1.8IN .08IN CUSA EXCEL 36KHZ STD ULTRASONIC FLUE",SUP-C4612S,CDM,S27200284,LOCAL,0272,RC,,,both,,,8372.22,2511.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3842.85,45.9,,,,,0,973.69,7116.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIVERSAL SEALRING 5MM CANNULAS",SUP-UCAN0005,CDM,S27200284,LOCAL,0272,RC,,,both,,,494.10,148.23,"CIGNA [10200]","Cigna Open Access",,281.14,56.9,,,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILFRM URETHRAL 13IN 3FR STRAIGHT PVC PLASTIC STERILE LATEX",SUP-342103,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.96,28.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,63.89,68,,,,,0,10.93,79.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW PROPHECY INBONE MICROAIRE NARROW HALL/LINVATEC",SUP-200138103S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1109.70,332.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,129.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,129.06,943.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR 6.7MM SILICONE NATURAL RUBBER PUSH FEED TUBE",SUP-7150-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,592.52,177.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,70.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.91,503.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG TERUFLEX 300ML TRANSFER PACK CPLR TRANSFUSION BLOOD",SUP-1BB*T030CB71,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.00,17.7,"AETNA [10100]","Aetna HMO/PPO",,46.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.86,50.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DRILL 4MM RETROBUTTON TIGHTROPE KNEE ACL OPEN EYELET",SUP-AR-1595T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1063.13,318.94,"CIGNA [10200]","Cigna Open Access",,604.92,56.9,,,,,0,123.64,903.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 3IN 5MM ARGONPLUS FLEXIBLE ACTIVE",SUP-E2530-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.83,54.55,"FIRST HEALTH [10303]","First Health",,145.46,80,,,,,0,21.15,154.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 BV-1 24IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8805,CDM,S27200284,LOCAL,0272,RC,,,both,,,608.01,182.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,72.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.71,516.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VAGINAL DELIVERY TRAY",SUP-PL21VDU17,CDM,S27200284,LOCAL,0272,RC,,,both,,,407.60,122.28,"CIGNA [10200]","Cigna Open Access",,231.92,56.9,,,,,0,47.4,346.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE V EPICUT SURGICAL STERILE DISPOSABLE",SUP-PL-4006,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"KAISER [10500]",Kaiser,,204.02,67,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VAGINAL DELIVERY TRAY",SUP-PL21VDU17,CDM,S27200284,LOCAL,0272,RC,,,both,,,407.60,122.28,"UHC [10700]","United Healthcare",,258.01,63.3,,,,,0,47.4,346.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO ENDOSCOPIC 8.5FR 5FR 195CM 1 ACTION RADIOPAQUE GUIDE",SUP-G31526,CDM,S27200284,LOCAL,0272,RC,,,both,,,1085.40,325.62,"CIGNA [10200]",Cigna,,738.07,68,,,,,0,126.23,922.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GASTROJEJUNOSTOMY TUBE 16FR STOMA L5CM JEJUNAL L45CM SIL",SUP-8270-16-5.0-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"UHC [10700]","United Healthcare",,1666.56,63.3,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4.2MM MERLIN 15D 6000 RPM PREBENT",SUP-C9241M,CDM,S27200284,LOCAL,0272,RC,,,both,,,693.77,208.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.69,589.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 80CM 5FR CHG-B CURVE",SUP-G13560,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 4 62MM 9.4MM SHILEY UNCUFF REUSABLE INNER CANN",SUP-4UN65R,CDM,S27200284,LOCAL,0272,RC,,,both,,,484.06,145.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,198.95,41.1,,,,,0,56.3,411.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 13MM APTUS TRILOCK TITANIUM PHALANGEAL HAND",SUP-A-5250.13/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"CIGNA [10200]",Cigna,,1096.09,68,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ASPIRATION 18GA ARCPOINT PULMONARY STERILE LATEX FREE",SUP-ILS-1800-PN,CDM,S27200284,LOCAL,0272,RC,,,both,,,1785.00,535.5,"CIGNA [10200]","Cigna Open Access",,1015.67,56.9,,,,,0,207.6,1517.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 1 XLH 30IN 2 ARM MONOFILAMENT BLUE NONABSORBABLE",SUP-8190G,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.96,27.59,"PHCS [10601]",PHCS,,64.37,70,,,,,0,10.69,78.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 6CM 3CM 3CM RAPID EXCHANGE LITHO",SUP-M00510890,CDM,S27200284,LOCAL,0272,RC,,,both,,,2036.93,611.08,"PHCS [10601]",PHCS,,1425.85,70,,,,,0,236.89,1731.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS ACCESS 9 GWIRE INSRT TOOL TORQUE DEVICE",SUP-MAP114,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.76,40.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.67,114.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 CT-1 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J339H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 6CM 3CM 3CM RAPID EXCHANGE LITHO",SUP-M00510890,CDM,S27200284,LOCAL,0272,RC,,,both,,,2036.93,611.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,236.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,236.89,1731.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD MONOPOLAR BLACK PROBE POWER POCKET SUCTION",SUP-7209654,CDM,S27200284,LOCAL,0272,RC,,,both,,,1522.80,456.84,"KAISER [10500]",Kaiser,,1020.28,67,,,,,0,177.1,1294.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 87.5MM 2.7MM STAINLESS STEEL STERILE",SUP-180016000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PERMA-HAND SUTUPAK 0 24IN BRAID TIES 13 STRAND PRECUT",SUP-SA76G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE EVERPOINT 6-0 RB-2 30IN 2 ARM MONOFILAMENT BLUE",SUP-EP8711H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE EVERPOINT 6-0 RB-2 30IN 2 ARM MONOFILAMENT BLUE",SUP-EP8711H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 14FR IMPELLA LONG STERILE LATEX DISPOSABLE",SUP-0052-0039,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NUROLON 1 CT-1 30IN BRAID BLACK NONABSORBABLE",SUP-5425H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD LUBRI-SIL IC 20FR URETHRAL BACTI-GUARD SILICONE",SUP-1768SI20,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.26,25.58,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,35.04,41.1,,,,,0,9.92,72.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 13X3IN RIBBON 2 END MALLEABLE STAINLESS STEEL SPINE",SUP-22-0257,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.13,26.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.25,74.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 7INX19MM DEAVER SURGICAL",SUP-BT600R,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.01,55.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.4,156.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 13X3IN RIBBON 2 END MALLEABLE STAINLESS STEEL SPINE",SUP-22-0257,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.13,26.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.25,74.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 11GA 6IN SNARECOIL BONE MARROW",SUP-RBN-116,CDM,S27200284,LOCAL,0272,RC,,,both,,,400.20,120.06,"AETNA [10100]","Aetna HMO/PPO",,318.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ERCP .025IN TAPERED TIP FLUORO TIP 210CM 5FR BILIARY",SUP-M00530980,CDM,S27200284,LOCAL,0272,RC,,,both,,,255.08,76.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,30.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.67,216.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FAST FIX FLX CRVD INSRTR BNDR CANN SET",SUP-72205324,CDM,S27200284,LOCAL,0272,RC,,,both,,,3742.50,1122.75,"CIGNA [10200]","Cigna Local Plus",,2002.24,53.5,,,,,0,435.25,3181.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH 9MM PORTEX BLUPERC TUBE STERILE LATEX FREE",SUP-101/563/090,CDM,S27200284,LOCAL,0272,RC,,,both,,,3007.88,902.36,"UHC [10700]","United Healthcare",,1903.99,63.3,,,,,0,349.82,2556.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 SH-2 30IN 2 ARM BRAID FIRM PLEDG",SUP-PX82H,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.67,20.3,"CIGNA [10200]","Cigna Local Plus",,36.2,53.5,,,,,0,7.87,57.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IV LACTATED RINGERS 1L EXCEL LATEX FREE",SUP-E7500,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.00,24,"CIGNA [10200]","Cigna Open Access",,45.52,56.9,,,,,0,9.3,68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX PDS PLUS 2-0 SH SPIRAL 6IN TAPER POINT",SUP-SXPP1B415,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.96,69.59,"CIGNA [10200]","Cigna Open Access",,131.99,56.9,,,,,0,26.98,197.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 29MM INTRALUMINAL ENDOSCOPIC LINEAR CUTTER",SUP-ECS29A,CDM,S27200284,LOCAL,0272,RC,,,both,,,6267.91,1880.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4262.18,68,,,,,0,728.96,5327.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 4-0 KS 30IN MONOFILAMENT BLACK NONABSORBABLE",SUP-626H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) AGENT DCB MR 3.50MM X 20MM",SUP-H74939436352010,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET",RX-28384,CDM,,,0250,RC,27808-0037-01,NDC,both,1,UN,12.54,3.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOSCOPIC WATER 200X173MM 385MM 230ML/MINUTE AUXILIARY",SUP-K10016135,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.01,40.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEAL DURAL ADHERUS AUTOSPRAY LOW SWELL EXTENDED TIP",SUP-NUS-109,CDM,S27200284,LOCAL,0272,RC,,,both,,,5692.50,1707.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ESOPHAGEAL PYLORIC 6FR 18-20MM 180CM 8CM FIXED WIRE",SUP-M00558380,CDM,C1726,HCPCS,0272,RC,,,both,,,1562.98,468.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP ELECTROSURGICAL 8.25INX1.5MM OLSEN BIPOLAR BAYONET",SUP-20-0431R,CDM,S27200284,LOCAL,0272,RC,,,both,,,843.15,252.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,573.34,68,,,,,0,98.06,716.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 5FR SIDEWINDER 1 CURVE ANGIOGRAPHIC",SUP-H787107090065,CDM,C1887,HCPCS,0272,RC,,,both,,,182.70,54.81,"AETNA [10100]","Aetna HMO/PPO",,145.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA",RX-120921,CDM,,,0250,RC,00132-0202-20,NDC,both,66,ML,12.54,3.76,"PHCS [10601]",PHCS,,8.78,70,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RELIEVA SPIN PLUS 16MM 5MM BALLOON DILATATION",SUP-RSP0516MFS,CDM,C1726,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"PHCS [10601]",PHCS,,9418.5,70,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC FLIPCUTTER II OD9.5 MM ACL PCL DRILL PIN",SUP-AR-1204AF-95,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"MULTIPLAN [10600]",Multiplan,,2175.47,85,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rheumatoid Factor Quant",PX-302000091,CDM,86431,CPT,0302,RC,,,both,,,250.80,75.24,"CIGNA [10200]","Cigna Open Access",,12.47,,,,,,,0.25,213.18,"fee schedule",
"SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK",RX-11359,CDM,,,0250,RC,12870-0001-01,NDC,both,1,UN,12.54,3.76,"UHC [10700]","United Healthcare",,7.94,63.3,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.6MM 150MM KIRSCHNER STAINLESS STEEL TROCAR",SUP-292.16,CDM,C1713,HCPCS,0278,RC,,,both,,,61.14,18.34,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",7.11,51.97,"percent of total billed charges",
"MATRIX OI BLOCK- 12MM",SUP-441012,CDM,S27800098,LOCAL,0278,RC,,,both,,,8383.50,2515.05,"CIGNA [10200]","Cigna Local Plus",,4485.17,53.5,,,,,0,975,7125.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 28MM TITANIUM CURVE CIRCLE 2 STAGGER LOW",SUP-111987,CDM,S27200284,LOCAL,0272,RC,,,both,,,2138.85,641.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,248.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,248.75,1818.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 5.5MM TITANIUM PREBENT",SUP-8052050,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 38MM 145CM 4MM CORONARY STENT",SUP-1125400-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"NOVANET [10819]",Novanet,,4378.5,75,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 ANGLE OVAL 9IN BRUNS SPINE SURGICAL",SUP-29-5392,CDM,S27200284,LOCAL,0272,RC,,,both,,,253.00,75.9,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 20MM 2.2MM SHANNON RECTA LARGA STERILE LATEX",SUP-TM12220,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE SUCTION 2IN 18GA ROSEN EAR 60MM",SUP-61-1038,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.91,23.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 3.937X.984IN STRYKER PERFORMANCE SERIES THK.05IN",SUP-6125-127-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN RADIOFREQUENCY 100MM 18GA CURVE SHARP TIP 10MM",SUP-AC0005,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ROPINIROLE 0.25 MG TABLET, IMMEDIATE RELEASE",RX-21688,CDM,,,0637,RC,00904-6373-61,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"REAMER SURGICAL 8.5MM HEAD FRONT CUT MEDULLARY NONSTERILE",SUP-352.085,CDM,S27200284,LOCAL,0272,RC,,,both,,,2176.73,653.02,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT FRACTURE 15MM 10GA IVAS ELITE STERILE LATEX FREE",SUP-0808-015-800,CDM,S27200284,LOCAL,0272,RC,,,both,,,16551.38,4965.41,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"30ATM INFLATION DEVICES AND ANGIOPLASTY PACKSBASIXCOMPAK30 INF",SUP-IN4530,CDM,S27200284,LOCAL,0272,RC,,,both,,,264.13,79.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER MAMMARY 650CC HP SILCONE",SUP-RSZ-6504,CDM,S27200284,LOCAL,0272,RC,,,both,,,127.64,38.29,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEAD REAMER 16.5MM STAINLESS STEEL RIA STERILE DISPOSABLE",SUP-352.259S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2560.05,768.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DISECT 7CM 3MM SURGICAL",SUP-AR-9300DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dgtz Gls Mcrscp Electron Mic",PX-312000087,CDM,0856T,CPT,0312,RC,,,both,,,104.00,31.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT PRESSURE MNTR 3 WAY STPCOCK TRNSDUC FLUSH DEVICE",SUP-PX272,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.27,30.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHIBOND EXCEL 2-0 V-7 36IN 2 ARM BRAID FIRM PLEDG GREEN",SUP-PX62H,CDM,S27200284,LOCAL,0272,RC,,,both,,,90.60,27.18,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEMMED ANATOMIC PSI KIT (GLENOID ONLY)",SUP-1235-7153-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 10CM 5FR 21GA MERIT S-MAK .018IN STIFFENED DIL",SUP-S-MAK501,CDM,C1894,HCPCS,0272,RC,,,both,,,307.63,92.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,209.19,68,,,,,0,35.78,261.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION BLUE 1.55MM 1.27MM 3MM SHEEHY 3MM BUTTON",SUP-1013301,CDM,S27800098,LOCAL,0278,RC,,,both,,,137.46,41.24,"NOVANET [10819]",Novanet,,103.1,75,,,,,0,15.99,116.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 650CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP130RUH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"NOVANET [10819]",Novanet,,8926.88,75,,,,,0,1384.26,10117.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VXSK-180J RF WIRE 63CM/55DEG/D1 SHEATH",SUP-VXSK0104,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"PHCS [10601]",PHCS,,4322.85,70,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 1 CT-1 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J261H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"KAISER [10500]",Kaiser,,16.75,67,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO ORANGE 90CM 7FR BRITE TIP CANN INTERVENTIONAL",SUP-401790M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"FIRST HEALTH [10303]","First Health",,83.52,80,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS",RX-11082,CDM,J3480,HCPCS,0636,RC,00990-7116-09,NDC,both,1000,ML,100.65,30.19,"FIRST HEALTH [10303]","First Health",,80.52,80,,,,,0,0.48,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR ANL1 CURVE 55CM 7FR .1IN GUIDING HYDROPHILIC",SUP-G29999,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"MULTIPLAN [10600]",Multiplan,,447.53,85,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 375CC NATRELLE INSPIRA COHESIVE STERILE LATEX",SUP-SCM-375,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"KAISER [10500]",Kaiser,,5062.19,67,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 295CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-295,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]","Cigna Open Access",,4299.08,56.9,,5166.00,5166.00,5166.00,"1 through 10",878.7,6422.18,"percent of total billed charges",
"EXTRACTOR, BROKEN SCREW, 7 MM, 6"" LONG, SINGLE USE",SUP-SXT008-BR3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,351.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL CHIN 50X38X1MM 1 CHANNEL HIGH DENSITY ORBITAL FLOOR",SUP-8305,CDM,S27800098,LOCAL,0278,RC,,,both,,,4665.78,1399.73,"NOVANET [10819]",Novanet,,3499.34,75,,,,,0,542.63,3965.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 4 X 10 HELICAL PICO COIL",SUP-10USH04010,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PHCS [10601]",PHCS,,8206.17,70,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.8MM 2 20MM TRUSHOT HI-FI NDL",SUP-Y18TN,CDM,C1713,HCPCS,0278,RC,,,both,,,6944.85,2083.45,"BLUE CROSS [10001]","Blue Cross PPO",,2722.38,39.2,,957.42,570.23,957.42,28,807.69,5903.12,"percent of total billed charges",
"CRTDG WOUND 5.2X2.3IN SNAP THK1IN 125 MMHG SMALL INDCTR",SUP-SNPA125US,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"UHC [10700]","United Healthcare",,646.04,63.3,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 390ML STYLE 10 SMOOTH NATRELLE SILICONE P3.7CM",SUP-10-390,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"CIGNA [10200]",Cigna,,2427.6,68,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 390ML STYLE 10 SMOOTH NATRELLE SILICONE P3.7CM",SUP-10-390,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"CIGNA [10200]","Cigna Local Plus",,1909.95,,,,,,,415.19,3034.5,"percent of total billed charges",
"TRAY INTRO EXPRESS KYPHOPAK FIRST FRACTURE 10/2",SUP-KPE1001-CDS,CDM,C1894,HCPCS,0272,RC,,,both,,,13098.00,3929.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8906.64,68,,,,,0,1523.3,11133.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE LOCALIZATION 20CM 20GA GHIATAS BREAST BEAD NDL 9CM",SUP-47920,CDM,A4648,HCPCS,0278,RC,,,both,,,182.79,54.84,"BLUE CROSS [10001]","Blue Cross HMO",,71.65,39.2,,,,,0,21.26,155.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH CHECK-FLO FLEXOR .018-.038IN ANL0 CURVE 45CM 6FR .087",SUP-G44154,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP MONOPOLAR 12.5IN 5MM ULTRA BULLET NOSE DISSECT",SUP-90-1033,CDM,S27200284,LOCAL,0272,RC,,,both,,,2356.88,707.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,274.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,274.11,2003.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 10MM 1.9FR BAGLEY HELICAL 3",SUP-M0063401220,CDM,S27200284,LOCAL,0272,RC,,,both,,,1247.08,374.12,"FIRST HEALTH [10303]","First Health",,997.66,80,,,,,0,145.04,1060.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Protein C Antigen",PX-305000032,CDM,85302,CPT,0305,RC,,,both,,,727.70,218.31,"CIGNA [10200]","Cigna Open Access",,26.42,,,,,,,0.01,618.55,"fee schedule",
"BURR SURGICAL 3MM CARBIDE MATCH HEAD STERILE LATEX FREE",SUP-5820107530C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1910.03,573.01,"CIGNA [10200]","Cigna Open Access",,1086.81,56.9,,,,,0,222.14,1623.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE COROLENE 5-0 RB",SUP-20S10Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.82,14.65,"KAISER [10500]",Kaiser,,32.71,67,,,,,0,5.68,41.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"1 EACH, REVOLVE FAT PROCESSING SYSTEM",SUP-RV0001,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1537.14,41.1,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZENITH 120MM 36MM 20-30MM 16MM 6FR VASCULAR AORTIC",SUP-G47492,CDM,C1876,HCPCS,0278,RC,,,both,,,87438.00,26231.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,34975.2,40,,,,,0,10169.04,74322.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE SURGISIS BIODESIGN .2MM RECTOVAGINAL",SUP-G48651,CDM,C1763,HCPCS,0278,RC,,,both,,,6994.19,2098.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,828.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,813.42,5945.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICAFUNGIN 100 MG VIAL",RX-77685,CDM,J2248,HCPCS,0636,RC,00143-9362-01,NDC,both,1,UN,362.30,108.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.37,,"Fee schedule rate ($29.37). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.37,307.96,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 4-0 P-12 18IN CLSR ABSORBABLE CLEAR",SUP-VLOCL0023,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.73,70.42,"MULTIPLAN [10600]",Multiplan,,199.52,85,,,,,0,27.3,199.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE LOCALIZATION 7.7CM 20GA DUALOK BREAST LESION MARK",SUP-LW0077,CDM,A4648,HCPCS,0278,RC,,,both,,,171.13,51.34,"FIRST HEALTH [10303]","First Health",,136.9,80,,,,,0,19.9,145.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN MARIGEN OMEGA3 5X7 KERECIS",SUP-50200S05B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,9918.75,2975.62,"NOVANET [10819]",Novanet,,7439.06,75,,,,,0,180.89,8430.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Deoxyribonuclease Ab",PX-302000035,CDM,86215,CPT,0302,RC,,,both,,,149.50,44.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11.93,,,,,,,0.01,127.08,"fee schedule",
"HC Hpv High Risk",PX-306000192,CDM,87624,CPT,0306,RC,,,both,,,390.45,117.13,"NOVANET [10819]",Novanet,,292.84,75,,,,,0,0.01,331.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL CORTICAL THK3MM-12MM THIRDS ALLOGRAFT",SUP-450488,CDM,S27800098,LOCAL,0278,RC,,,both,,,9112.14,2733.64,"MULTIPLAN [10600]",Multiplan,,7745.32,85,,,,,0,1059.74,7745.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aqaprn-4 Antb Flo Cytmtry Ea",PX-302000252,CDM,86053,CPT,0302,RC,,,both,,,751.45,225.43,"UHC [10700]","United Healthcare",,33.96,,,,,,,0.01,638.73,"fee schedule",
"HC Aldosterone",PX-301000094,CDM,82088,CPT,0301,RC,,,both,,,541.50,162.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.54,.1,,,,,0,0.54,460.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NOZZLE BONE CEMENT THIN FLEXIBLE STERILE DISPOSABLE",SUP-0206515000,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.37,36.71,"CIGNA [10200]","Cigna Open Access",,69.63,56.9,,,,,0,14.23,104.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 40MM 5MM AXOGUARD NERVE PORCINE EXTRACELLULAR",SUP-AG0540,CDM,C1763,HCPCS,0278,RC,,,both,,,19605.60,5881.68,"CIGNA [10200]","Cigna Open Access",,6567.88,33.5,,,,,0,2280.13,16664.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 40MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015040M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,974.92,68,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER RIGID SHARP DELIVERY SYSTEM HYDROMARK BREAST BIOPSY",SUP-4010-02-15-T4,CDM,A4648,HCPCS,0278,RC,,,both,,,640.49,192.15,"KAISER [10500]",Kaiser,,429.13,67,,,,,0,74.49,544.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 22GA 8CM POWERGLIDE PRO FULL COVER INSRT PERIPHERAL",SUP-F222088PT,CDM,C1751,HCPCS,0272,RC,,,both,,,909.39,272.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,105.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.76,772.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ercp Bx",PX-750000046,CDM,43261,CPT,0750,RC,,,both,,,4301.87,1290.56,"CIGNA [10200]","Cigna Open Access",,2751,,"Case rate ($2,751). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,500.31,4301.87,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 8X10CM OMEGA3 MARIGEN FISH SKIN STERILE LATEX",SUP-50200N13B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,31260.60,9378.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,180.89,,,,,,,180.89,26571.51,"fee schedule",
"CMPNT TIBIAL PERSONA E KNEE RIGHT NONPOROUS REVISION",SUP-42-5420-071-02,CDM,C1776,HCPCS,0278,RC,,,both,,,16335.06,4900.52,"NOVANET [10819]",Novanet,,12251.3,75,,,,,0,1899.77,13884.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 014 150CM 15CM 5MM BALLOON DILATATION",SUP-U4150515,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 150CM 220MM 3MM BALLOON DILATATION",SUP-H74939031302210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 20MM 3.2-2.4-2.6FR 2MM BALLOON",SUP-SPR2020W,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 18LP 80CM 6CM 4FR 6MM .018IN BALLOON DILATATION",SUP-G50248,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM NASAL 5.25IN 3 VIENNA 32MM LATEX FREE",SUP-MA349R,CDM,S27000186,LOCAL,0270,RC,,,both,,,599.08,179.72,"UHC [10700]","United Healthcare",,379.22,63.3,,,,,0,69.67,509.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXERCISER HAND THERABAND XL GREEN",SUP-927807,CDM,S27000186,LOCAL,0270,RC,,,both,,,91.44,27.43,"FIRST HEALTH [10303]","First Health",,73.15,80,,,,,0,10.63,77.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC MEDIUM 12IN 16-19IN KNEE LOOP LOCK CONTACT",SUP-79-80005,CDM,S27000186,LOCAL,0270,RC,,,both,,,89.35,26.8,"CIGNA [10200]","Cigna Local Plus",,47.8,53.5,,,,,0,10.39,75.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL 2.5MR ETCO2 O2 NONINTUBATE SIDESTREAM PEDIATRIC",SUP-989803144461,CDM,S27000186,LOCAL,0270,RC,,,both,,,132.81,39.84,"FIRST HEALTH [10303]","First Health",,106.25,80,,,,,0,15.45,112.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 80MM 3.5MM BALLOON DILATATION RAPID",SUP-47535080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"MULTIPLAN [10600]",Multiplan,,1356.35,85,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 80MM 2MM TAPER BALLOON DILATATION JET",SUP-A2020-080,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,549.3,41.1,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FORTREX 80CM 40MM 12MM .035IN BALLOON DILATATION OTW",SUP-A35HPV12040080,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AETNA [10100]","Aetna HMO/PPO",,978.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 15MM 4MM BALLOON DILATATION STERILE",SUP-240-153-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"I-GEL, SINGLE USE SUPRAGLOTTIC AIRWAY, SIZE 3",SUP-8203000,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.19,23.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,36.35,45.9,,,,,0,9.21,67.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ENDOSCP SEALING .1MM",SUP-A0298,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.79,14.34,"AETNA [10100]","Aetna HMO/PPO",,37.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.56,40.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Collar Aspen",PX-E27400062,CDM,L0172,HCPCS,0274,RC,,,both,,,991.10,297.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,283.65,28.62,,,,,0,112.15,842.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 200MM 8MM BALLOON",SUP-U3575820,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .035IN 5FR 8MM 135CM 4CM PTA 2 LUMEN",SUP-4208040X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo Outlet Restrict W/Tube",PX-750000255,CDM,C9785,HCPCS,0750,RC,,,both,,,19616.00,5884.8,"UHC [10700]","United Healthcare",,9679,,"Case rate ($9,679). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,2281.34,16673.6,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet/CT Tumor Ltd",PX-404000003,CDM,78814,CPT,0404,RC,,,both,,,7540.46,2262.14,"UHC [10700]","United Healthcare",,3726.5,,,,,,,876.96,7540.46,"fee schedule",
"CATH FOXCROSS 135CM 40MM 8MM BALLOON DILATATION JETCOAT",SUP-10338-40,CDM,C1725,HCPCS,0272,RC,,,both,,,1539.00,461.7,"NOVANET [10819]",Novanet,,1154.25,75,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 12FR DRNG FLEXIMA HYDROPHILIC BILIARY RADIOPAQUE",SUP-M001272670,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 150CM 80MM 6MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013470-080,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 120MM 4MM .014IN BALLOON DILATATION",SUP-AB14W040120150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 60MM 4MM BALLOON DILATATION HYDROPHILIC",SUP-604006022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"PHCS [10601]",PHCS,,510.3,70,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC FETAL MNTR 8FT NAUTILUS TOCO LOOP ABDOMEN WATERTIGHT",SUP-2264LAX,CDM,S27000186,LOCAL,0270,RC,,,both,,,2994.00,898.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2035.92,68,,,,,0,348.2,2544.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 110CM 8CM 5FR 7MM 7.5MM BALLOON DILATATION",SUP-4207080L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GAS INTRAOCULAR ISPAN SULFUR HEXAFLUORIDE 450GM RETINAL",SUP-8065797001,CDM,C1784,HCPCS,0278,RC,,,both,,,28090.76,8427.23,"KAISER [10500]",Kaiser,,18820.81,67,,,,,0,3266.96,23877.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Radrx Thrpy IV Admin",PX-342000012,CDM,79101,CPT,0342,RC,,,both,,,1444.31,433.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,171.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.19,1227.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 20MM 4MM .035IN BALLOON",SUP-AB35W04020135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,460.47,68,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 20MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,655.83,41.1,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 300MM 5MM BALLOON DILATATION RAPID",SUP-47550300M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1377,68,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PTS 80CM 3CM 8FR 20MM 2 TAPER SUPER THIN BALLOON",SUP-613700,CDM,C1725,HCPCS,0272,RC,,,both,,,2251.50,675.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1531.02,68,,,,,0,261.85,1913.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 220MM 3.5MM BALLOON DILATATION NYBAX",SUP-H74939186352210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 80MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,974.92,68,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VANSONNENBERG SUMP 35CM 14FR LOOP DRNG FLEXIMA",SUP-M001273040,CDM,C1729,HCPCS,0272,RC,,,both,,,1053.00,315.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,124.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC 17-27IN 30.5- IN KNEE ROM HINGE TRIMMABLE",SUP-8814,CDM,S27000186,LOCAL,0270,RC,,,both,,,611.71,183.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,415.96,68,,,,,0,71.14,519.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION",RX-24513,CDM,J0885,HCPCS,0636,RC,59676-0340-01,NDC,both,1,ML,6452.48,1935.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4194.11,65,,,,,0,363.69,5484.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID COMPRESSION ANKLET (STD)",SUP-RSANK001,CDM,S27000186,LOCAL,0270,RC,,,both,,,170.52,51.16,"KAISER [10500]",Kaiser,,114.25,67,,,,,0,19.83,144.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 10.5X3IN WRIST RIGHT DELUXE BETA PILE II",SUP-2970017617,CDM,S27000186,LOCAL,0270,RC,,,both,,,133.88,40.16,"KAISER [10500]",Kaiser,,89.7,67,,,,,0,15.57,113.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 30MM 3.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3530X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 80MM 7MM BALLOON DILATATION DURALYN",SUP-48007008X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS GOLD 120CM 4CM 14MM LARGE DIAMETER BALLOON",SUP-ATG120144,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 120MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030120S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,169.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .018IN 4FR 7MM 135CM 4CM PTA LOW",SUP-G50257,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 12MM PYRENESS SPINAL",SUP-201-90104,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,468.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLASSIC COLD THERAPY SYSTEM",SUP-11-0494,CDM,C9810,HCPCS,0270,RC,,,both,,,515.89,154.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,350.81,68,,,,,0,60,438.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tcat Rmvl/Dblk Icar Mas Suct Perq",PX-481000134,CDM,0644T,CPT,0481,RC,,,both,,,8753.00,2625.9,"BLUE CROSS [10001]","Blue Cross HMO",,7166.56,,"Case rate ($7,166.56). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1017.97,8753,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 15MM 2.50MM BALLOON DILATATION PEBAX",SUP-1400250-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 20MM 3.5MM BALLOON DILATATION",SUP-H7493912420350,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 8CM 6FR 9MM .035IN BALLOON DILATATION",SUP-G52368,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.64,68,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.0MM X 26.0MM",SUP-493002612,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC 56.6CM 5MM DA VINCI S/SI ENDOWRIST",SUP-420139,CDM,S27000186,LOCAL,0270,RC,,,both,,,27090.00,8127,"UHC [10700]","United Healthcare",,17147.97,63.3,,,,,0,3150.57,23026.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) WISE PULSE GENERATOR BATTERY","SUP-MODEL 3100",CDM,S62400003,LOCAL,0624,RC,,,both,,,31500.00,9450,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3663.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER BACTERIAL/VIRAL EXPIRATORY PURITAN BENNETT SERIES 980",SUP-10043551,CDM,S27000186,LOCAL,0270,RC,,,both,,,139.83,41.95,"PHCS [10601]",PHCS,,97.88,70,,,,,0,16.26,118.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPLANT 14.5CM NATRELLE INSPIRA P4.8CM MODERATE PROFIL",SUP-MSZ-M520,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA [10200]",Cigna,,107.56,68,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 13MM DIVERGENCE TITANIUM SPINAL CERVICAL",SUP-G7733513,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"BLUE CROSS [10001]","Blue Cross HMO",,735,39.2,,957.42,156.86,7483.26,51,218.06,1593.75,"percent of total billed charges",
"HOLDER 130MM WEBSTER DUROGRIP SMOOTH NDL TUNGSTEN CARBIDE",SUP-BM014R,CDM,S27000186,LOCAL,0270,RC,,,both,,,323.21,96.96,"FIRST HEALTH [10303]","First Health",,258.57,80,,,,,0,37.59,274.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SKIN PURPLE 10CM 15GA SMARTCLIP LITE 3-4MM SOFT",SUP-SMARTCLIPLT-PURP-10,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1836,68,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 7.9X3.9IN XENMATRIX AQUAPURE RECTANGLE",SUP-1161020,CDM,C1781,HCPCS,0278,RC,,,both,,,31593.24,9477.97,"NOVANET [10819]",Novanet,,23694.93,75,,,,,0,3674.29,26854.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE (RSP) MONOBLOCK REVISION HUMERAL STEM, 175MM, 8X175M",SUP-510-08-175,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1465.38,10710,"percent of total billed charges",
"COIL EMBOLIZATION 50CM 22MM TARGET 360D 2XL DETACHABLE",SUP-M0036182250,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR CONTRALATERAL CURVE ANGIOGRAPHIC",SUP-M001315281,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.04,22.81,"UHC [10700]","United Healthcare",,48.13,63.3,,,,,0,8.84,64.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 9MM CEMENT TRIATHLON COCR KNEE",SUP-5560-S-209,CDM,C1776,HCPCS,0278,RC,,,both,,,4271.90,1281.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,506.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,496.82,3631.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEADGEAR CPAP SMALL INFANT FLOW LATEX FREE DISPOSABLE LIGHT",SUP-139315,CDM,S27000186,LOCAL,0270,RC,,,both,,,116.53,34.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,79.24,68,,,,,0,13.55,99.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD REAMING 950MM 2.5MM BALL TIP EXT STERILE",SUP-351.707S,CDM,S27200284,LOCAL,0272,RC,,,both,,,910.85,273.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,418.08,45.9,,,,,0,105.93,774.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM TRIDENT TITANIUM HEMISPHERE ACETABULAR",SUP-2030-6545-1,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,517.75,68,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PEELAWAY 6 FR",SUP-INT-106-16,CDM,C1887,HCPCS,0272,RC,,,both,,,130.50,39.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,53.64,41.1,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 14FR IMPELLA SHORT STERILE LATEX DISPOSABLE",SUP-0052-0038,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"MULTIPLAN [10600]",Multiplan,,4105.5,85,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 16MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.816,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"KAISER [10500]",Kaiser,,168.11,67,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC 76-91CM SMARTVEST MEDIUM EFFECTIVE",SUP-SW-30/36-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG WOUND 13.75X4IN ACTICOAT POLYURETHANE NANOCRYSTALLINE",SUP-66800057,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.41,86.22,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT NDL MAYO 3 CATGUT .5 CIRCLE TROCAR POINT CATGUT STERILE",SUP-1826-3DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN SUCTION/IRRIGATION UNIVERSAL PLUS 5MM 32CM SPAT STEALTH",SUP-60-5274-032,CDM,S27200284,LOCAL,0272,RC,,,both,,,212.28,63.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,87.25,41.1,,,,,0,24.69,180.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA",SUP-72202283,CDM,C1713,HCPCS,0278,RC,,,both,,,1615.95,484.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1098.85,68,,,,,0,187.93,1373.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE-9 CATHETER",SUP-AFR-00001,CDM,C1733,HCPCS,0272,RC,,,both,,,53550.00,16065,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"ELECTRD ELECTROSURGICAL 24FR POWERBALL OLYMPUS OES PRO",SUP-M0068802661,CDM,S27200284,LOCAL,0272,RC,,,both,,,956.45,286.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE E CURVE",SUP-D7TEL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"NOVANET [10819]",Novanet,,3720.83,75,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION 14MM LAPIPLASTY MICRO-QUAD RAPID COMPRESSION",SUP-SK61,CDM,C1713,HCPCS,0278,RC,,,both,,,24406.20,7321.86,"NOVANET [10819]",Novanet,,18304.65,75,,,,,0,2838.44,20745.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 5.0 MM X 100 MM X 130 CM",SUP-IPU05010013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"KAISER [10500]",Kaiser,,5408.91,67,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 20MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.720,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.61,466.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",180.92,1322.27,"percent of total billed charges",
"BURR SURGICAL 4MM FRMLA ROUND 6 FLUTED ARTHROSCOPIC STERILE",SUP-0375940000,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,147.75,45.9,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINAGLIPTIN 5 MG TABLET",RX-109773,CDM,,,0637,RC,00597-0140-30,NDC,both,1,UN,79.39,23.82,"FIRST HEALTH [10303]","First Health",,63.51,80,,,,,0,9.23,67.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR IMPLANTABLE 2.4INX2.2IN ENTERRA II GASTRIC .5IN",SUP-37800,CDM,C1767,HCPCS,0278,RC,,,both,,,76950.00,23085,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8949.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG VARIABLE ANGLE LOCKING 1.8MM X 26MM",SUP-SPLS-18260-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"FIRST HEALTH [10303]","First Health",,1140.48,80,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 84MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 6",SUP-245.061,CDM,C1713,HCPCS,0278,RC,,,both,,,2927.40,878.22,"CIGNA [10200]","Cigna Local Plus",,1566.16,53.5,,3978.14,359.25,3978.14,24,340.46,2488.29,"percent of total billed charges",
"PLATE Y TITANIUM 1.3MM SCR 3X8 HOLE PRECONTOURED LOW PROFILE",SUP-421.335,CDM,C1713,HCPCS,0278,RC,,,both,,,2385.60,715.68,"BLUE CROSS [10001]","Blue Cross HMO",,935.16,39.2,,957.42,156.86,7483.26,51,277.45,2027.76,"percent of total billed charges",
"LD PCNG VL NS LF",SUP-106157,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"MULTIPLAN [10600]",Multiplan,,347.57,85,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS 115CM 4MM 7FR 2-5-2MM SPACING F CURVE ABLATION",SUP-D7BTCFL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"UHC [10700]","United Healthcare",,3140.38,63.3,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 60MM ARCOS A STD OFFSET HIP TITANIUM MODULAR",SUP-11301301,CDM,C1776,HCPCS,0278,RC,,,both,,,39453.12,11835.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10652.34,27,,,,,0,4588.4,33535.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IMPL ANTEROLATERAL LIGAMENT RECONSTRUCTION",SUP-AR-5522,CDM,C1713,HCPCS,0278,RC,,,both,,,7969.50,2390.85,"BLUE CROSS [10001]","Blue Cross PPO",,3124.04,39.2,,957.42,570.23,957.42,28,926.85,6774.08,"percent of total billed charges",
"CATH ADVANCE 150CM 12CM 2MM BALLOON DILATATION OTW LOW",SUP-G30937,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 81MM STAINLESS STEEL 2MM SCR MINI FRAGMENT SET 12 HOLE",SUP-247.362,CDM,C1713,HCPCS,0278,RC,,,both,,,2433.90,730.17,"NOVANET [10819]",Novanet,,1825.43,75,,,,,0,283.06,2068.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM GEMINUS TITANIUM CORTEX LOCK NONSTERILE",SUP-COLS-35120-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,631.80,189.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.4MM 1.2MM NANOTACK XBRAID TITANIUM STERILE",SUP-CAT02969,CDM,C1713,HCPCS,0278,RC,,,both,,,3555.00,1066.5,"KAISER [10500]",Kaiser,,2381.85,67,,,,,0,413.45,3021.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM ATLANTIS TITANIUM SPINAL CANCELLOUS",SUP-876-815,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL LEGION 3 L 10DX5P KNEE SCR",SUP-71421723,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,1144.80,304.56,2275.09,66,2014.9,14726.25,"percent of total billed charges",
"PLATE 79MM STAINLESS STEEL 2.7MM SCR 3 HOLE CONTOUR SHAFT",SUP-02.118.401,CDM,C1713,HCPCS,0278,RC,,,both,,,4008.76,1202.63,"BLUE CROSS [10001]","Blue Cross HMO",,1571.43,39.2,,957.42,156.86,7483.26,51,466.22,3407.45,"percent of total billed charges",
"SCR BONE 55MM 3.5MM LC-DCP CORTEX PELVIC STAINLESS STEEL",SUP-204.655,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"KAISER [10500]",Kaiser,,184.43,67,,,,,0,32.01,233.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.6MM KIRSCHNER TROCHAR TIP NONSTERILE",SUP-233500008,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"KAISER [10500]",Kaiser,,262.31,67,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 17MM ATLANTIS TITANIUM ANTERIOR CERVICAL SPINE",SUP-3120417,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"MULTIPLAN [10600]",Multiplan,,1198.5,85,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIGNS AND SYMPTOMS WITHOUT MCC",948,MS-DRG,,,,,,,inpatient,,,29162.51,8748.75,"CIGNA [10200]",Cigna,,10496.16,,"Fee schedule rate ($10,496.16). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,4965.55,19963.67,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC",083,MS-DRG,,,,,,,inpatient,,,49841.68,14952.5,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,9047.85,,"Case rate ($8,658.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,039.76, add-ons for qualifying new technology services are included. If operating cost exceeds $41,079.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,989.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,050.39. The transfer operating threshold is the transfer adjustment factor * $8,039.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.84. The transfer capital threshold is the transfer adjustment factor * $607.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,34809.86,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT",RX-124102,CDM,J9217,HCPCS,0636,RC,00074-3642-03,NDC,both,1,UN,9773.39,2932.02,"CIGNA [10200]",Cigna,,459.16,,,,,,,200.62,8307.38,"fee schedule",
"HC Probe Flow",PX-E27200274,CDM,E27200274,LOCAL,0272,RC,,,both,,,324.50,97.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,148.95,45.9,,,,,0,37.74,275.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL TAN 75MM 10.35MM TFN-ADVANCED",SUP-04.038.375S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"CIGNA [10200]",Cigna,,2707.66,68,,1831.33,1831.33,1831.33,16,463.09,3384.57,"percent of total billed charges",
"PLATE 22MM STD XLONG 109MM STAINLESS STEEL 2.4/2.7MM SCR 6",SUP-02.111.670S,CDM,C1713,HCPCS,0278,RC,,,both,,,8192.03,2457.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3760.14,45.9,,,,,0,952.73,6963.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM T10 FULL THREAD LOCK NONSTERILE",SUP-657018,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"BLUE CROSS [10001]","Blue Cross PPO",,582.84,39.2,,957.42,570.23,957.42,28,172.92,1263.81,"percent of total billed charges",
"KIT INTRAMEDULLARY NAIL .062IN SLOTTED AWL LOCKING DEVICE",SUP-SBFS062,CDM,C1713,HCPCS,0278,RC,,,both,,,4347.00,1304.1,"FIRST HEALTH [10303]","First Health",,3477.6,80,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 80MM 16MM CHARLOTTE STAINLESS STEEL MULTIUSE",SUP-44178016,CDM,C1713,HCPCS,0278,RC,,,both,,,4961.10,1488.33,"PHCS [10601]",PHCS,,3472.77,70,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 6 SLOT RIGHT TI",SUP-PHPF-C6R,CDM,C1713,HCPCS,0278,RC,,,both,,,18144.00,5443.2,"NOVANET [10819]",Novanet,,13608,75,,,,,0,2110.15,15422.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 3.5MM 75MM LC-DCP STAINLESS STEEL CORTEX PELVIC S",SUP-204.675,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"FIRST HEALTH [10303]","First Health",,220.22,80,,,,,0,32.01,233.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.109,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,99.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",99.7,728.71,"percent of total billed charges",
"WIRE FIXATION 70MM SLED NEUTRAL OLECRANON",SUP-OSN-70,CDM,C1713,HCPCS,0278,RC,,,both,,,6658.50,1997.55,"CIGNA [10200]","Cigna Open Access",,3788.69,56.9,,1144.80,304.56,2275.09,66,774.38,5659.73,"percent of total billed charges",
"PIN FIXATION 9IN 3/32IN STEINMANN 2 TROCAR NONSTERILE",SUP-KM169-29-33,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"NOVANET [10819]",Novanet,,47.71,75,,,,,0,7.4,54.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656316,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,155.28,1134.92,"percent of total billed charges",
"ANCHOR SUT 4.5MM PUSHLOCK BIOCOMPOSITE 24MM STERILE",SUP-AR-1922BC,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.00,945,"NOVANET [10819]",Novanet,,2362.5,75,,,,,0,366.35,2677.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 42X41X1MM ORBITAL FLOOR RIGHT MEDIAL WALL MESH EMBED",SUP-81032,CDM,C1713,HCPCS,0278,RC,,,both,,,8317.26,2495.18,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2380.4,28.62,,,,,0,967.3,7069.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 50MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0295,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]","Cigna Local Plus",,507.02,53.5,,3978.14,359.25,3978.14,24,110.22,805.55,"percent of total billed charges",
"ROD SPINAL 40MM 3.5MM PRECUT",SUP-3603740,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAXX 15CM 10MM NEPHRSTMY PTFE SET",SUP-G47649,CDM,C1726,HCPCS,0272,RC,,,both,,,2279.25,683.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1549.89,68,,,,,0,265.08,1937.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 195MM TITANIUM 4.5MM SCR 8 HOLE VARIABLE ANGLE",SUP-04.124.408S,CDM,C1713,HCPCS,0278,RC,,,both,,,13302.23,3990.67,"CIGNA [10200]",Cigna,,5320.89,40,,1831.33,1831.33,1831.33,16,1547.05,11306.9,"percent of total billed charges",
"PLATE 60MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 7",SUP-244.07,CDM,C1713,HCPCS,0278,RC,,,both,,,3031.80,909.54,"NOVANET [10819]",Novanet,,2273.85,75,,,,,0,352.6,2577.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X2CM EPICORD PURION PLUS AMNIOTIC",SUP-EC-5230,CDM,Q4187,HCPCS,0636,RC,,,both,,,9004.50,2701.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,659.55,,,,,,,659.55,7653.83,"fee schedule",
"SCR BONE 4MM 36MM ASNIS III TITANIUM 1/3 THREAD REVERSE CUT",SUP-604636S,CDM,C1713,HCPCS,0278,RC,,,both,,,1319.00,395.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,896.92,68,,,,,0,153.4,1121.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE WIDE ACU-LOC 2 BONE LEFT DISTAL VOLAR RADIAL STERILE",SUP-70-0360,CDM,C1713,HCPCS,0278,RC,,,both,,,6654.91,1996.47,"PHCS [10601]",PHCS,,4658.44,70,,,,,0,773.97,5656.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 7MM APTUS TITANIUM HAND CORTICAL HEXADRIVE 4",SUP-A-5200.07/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,579.99,45.9,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT CHPV CSF PROGRAMMABLE INLINE SIPHONGUARD DEVICE",SUP-823162,CDM,S27800098,LOCAL,0278,RC,,,both,,,44384.89,13315.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5161.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5161.96,37727.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 7MM COCR",SUP-VAL-20070-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]",Cigna,,969.41,68,,1831.33,1831.33,1831.33,16,165.8,1211.76,"percent of total billed charges",
"SCR BONE 2.7MM 26MM STAINLESS STEEL T8 ELBOW METAPHYSEAL",SUP-02.118.526,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"CIGNA [10200]","Cigna Local Plus",,280.29,53.5,,3978.14,359.25,3978.14,24,60.93,445.32,"percent of total billed charges",
"PLATE CONTOUR 109MM STAINLESS STEEL 3.5MM SCR 3 HOLE LIMIT",SUP-02.123.041S,CDM,C1713,HCPCS,0278,RC,,,both,,,12572.21,3771.66,"PHCS [10601]",PHCS,,8800.55,70,,,,,0,1462.15,10686.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3512,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,687.81,45.9,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE PS 2.0",SUP-PRT-PS-020,CDM,C1713,HCPCS,0278,RC,,,both,,,8280.00,2484,"KAISER [10500]",Kaiser,,5547.6,67,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRAMEDULLARY NAIL 360MM 11MM GAMMA 125D LONG R1.5",SUP-3525-1360S,CDM,C1713,HCPCS,0278,RC,,,both,,,13435.13,4030.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5374.05,40,,,,,0,1562.51,11419.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.2MM GUIDE",SUP-500373,CDM,C1713,HCPCS,0278,RC,,,both,,,607.50,182.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,71.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,70.65,516.38,"percent of total billed charges",
"GRAFT BONE PRIME HD DBM 2.5CC ALLOGRAFT LATEX FREE",SUP-421025,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,218.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",218.06,1593.75,"percent of total billed charges",
"CATH ELECTROPHYSIOLOGY 7FR 25-15MM LASSO D CURVE 22 POLE",SUP-LN222515CT,CDM,C1732,HCPCS,0272,RC,,,both,,,14055.30,4216.59,"FIRST HEALTH [10303]","First Health",,11244.24,80,,,,,0,1634.63,11947.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 35MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.835,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"PHCS [10601]",PHCS,,962.09,70,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10MM 35MM SI-LOK SPINE WASHER STERILE LATEX FREE",SUP-1202.6035S,CDM,C1713,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Local Plus",,5433.75,31.5,,3978.14,359.25,3978.14,24,2006.18,14662.5,"percent of total billed charges",
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 6CM 5.8FR 18FR BALLOON",SUP-M0062251080,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,202.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",379.61,375.47,414.12,"1 through 10",199.16,1455.61,"percent of total billed charges",
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 6CM 5.8FR 18FR BALLOON",SUP-M0062251080,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1164.49,68,,,,,0,199.16,1455.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 4MM LORDOSIS TITANIUM",SUP-102064050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"ROD SPINAL 120MM 5.5MM TITANIUM",SUP-8452120,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"MULTIPLAN [10600]",Multiplan,,3748.5,85,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 5.5MM TITANIUM",SUP-8452120,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Local Plus",,2359.35,53.5,,3978.14,359.25,3978.14,24,512.88,3748.5,"percent of total billed charges",
"MAJOR CHEST PROCEDURES WITH MCC",163,MS-DRG,,,,,,,inpatient,,,156478.36,46943.51,"PHCS [10601]",PHCS,,10994,,,,,,,10994,130850.63,"per diem","Estimated amount calculated based on 4 day length of stay."
"CMPNT FEMORAL LARGE+ KNEE LEFT LCS COMPLETE POROCOAT STERILE",SUP-129404070,CDM,C1776,HCPCS,0278,RC,,,both,,,28683.90,8605.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3399.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3335.94,24381.32,"percent of total billed charges",
"SCR BONE 12.7MM 100MM 22MM DHS/DCS STAINLESS STEEL LARGE",SUP-280,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,215.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,211.48,1545.62,"percent of total billed charges",
"SCR BONE 12.7MM 100MM 22MM DHS/DCS STAINLESS STEEL LARGE",SUP-280,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"CIGNA [10200]","Cigna Open Access",,1034.66,56.9,,1144.80,304.56,2275.09,66,211.48,1545.62,"percent of total billed charges",
"DEVICE VOYANT 5MM 44CM 5MM LAPAROSCOPIC FUSION",SUP-EB211,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"AETNA [10100]","Aetna HMO/PPO",,2534.06,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 340MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.154S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CIGNA [10200]","Cigna Open Access",,4160.14,33.5,,1144.80,304.56,2275.09,66,1444.25,10555.59,"percent of total billed charges",
"GRAFT BONE BIOEXPAND DEMINERALIZED CANCELLOUS ALLOGRAFT",SUP-77101020,CDM,C1713,HCPCS,0278,RC,,,both,,,8665.02,2599.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5892.21,68,,,,,0,1007.74,7365.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM PINNACLE GRIPTION TF HIP ACETABULAR",SUP-125740000,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"CIGNA [10200]",Cigna,,771.12,68,,1831.33,1831.33,1831.33,16,131.88,963.9,"percent of total billed charges",
"SCR BONE 4MM 16MM QUARTEX SPINE POLYAXIAL NONSTERILE LATEX",SUP-1149.4016,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T 32MM TITANIUM 1.3MM SCR 4X8 HOLE PRECONTOURED LOW",SUP-421.334,CDM,C1713,HCPCS,0278,RC,,,both,,,2450.70,735.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,290.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,285.02,2083.1,"percent of total billed charges",
"PLATE TITANIUM 1.5 MM SCREW 8 HOLE EXTENDED H BONE LEFT HAND",SUP-446.483,CDM,C1713,HCPCS,0278,RC,,,both,,,2635.50,790.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,312.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",306.51,2240.18,"percent of total billed charges",
"SCR BONE 5MM 46MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.536S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"FIRST HEALTH [10303]","First Health",,1197.5,80,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM INSET SHOULDER LOCK REVERSE",SUP-2R1PT45035,CDM,C1713,HCPCS,0278,RC,,,both,,,865.08,259.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,247.59,28.62,,,,,0,100.61,735.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc De Ea Addl Br Maj Cor",PX-481000078,CDM,C9601,HCPCS,0481,RC,,,both,,,24225.13,7267.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10353,,"Case rate ($10,353). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2817.38,24225.13,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 44MM UNIVERS REVERS GLENOID PERIPHERAL LOCK",SUP-AR-9563-44,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"NOVANET [10819]",Novanet,,448.04,75,,,,,0,69.48,507.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM HELIX R SPINE SELF TAP FIX ANGLE",SUP-7804215,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 50X76X.6MM TITANIUM POLYETHYLENE NONPOROUS MESH EMBED",SUP-81025,CDM,C1713,HCPCS,0278,RC,,,both,,,10082.14,3024.64,"CIGNA [10200]","Cigna Open Access",,5736.74,56.9,,1144.80,304.56,2275.09,66,1172.55,8569.82,"percent of total billed charges",
"CATH CARTO 3 THERMOCOOL SF 7.5FR B-B CURVE ELECTROPHYSIOLOGY",SUP-BNI35BBCT,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"MULTIPLAN [10600]",Multiplan,,15352.79,85,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR STRAIGHT 33CM .025IN 2 END SPRING SOFT LATEX",SUP-AW-04025,CDM,C1769,HCPCS,0272,RC,,,both,,,78.65,23.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 20GA 15CM CHIBA PEEL OPEN ASPIRATION PERCUTANEOUS",SUP-G00777,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.31,31.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FIBEROS 5CC",SUP-FB050,CDM,C1713,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1184.87,28.62,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 200MM SCHANZ STAINLESS STEEL CONDYLAR HIP",SUP-294.56,CDM,C1713,HCPCS,0278,RC,,,both,,,609.53,182.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,279.77,45.9,,,,,0,70.89,518.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 7MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS07015,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PHCS [10601]",PHCS,,8206.17,70,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE INCISION CIRCON",SUP-M0068805111,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,61.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Proc Cv Unlisted",PX-480000065,CDM,93799,CPT,0481,RC,,,both,,,8520.00,2556,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1009.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,990.88,7242,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 13MM RADIUS DISTAL VOLAR NONLOCK 3 LEAD TAPER",SUP-131227213,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,98.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",98.91,722.93,"percent of total billed charges",
"ANCHOR SUT 1.9MM 1 SUTUREFIX ULTRA ULTRABRAID COBRAID",SUP-72203854,CDM,C1713,HCPCS,0278,RC,,,both,,,3025.28,907.58,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,358.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,351.84,2571.49,"percent of total billed charges",
"PLATE 16MM 1 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.116,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,488.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",488.46,3570,"percent of total billed charges",
"PROBE ESOPHAGUS RECTUM 36IN PEDIATRIC PHONE PLUG THRMOMTR",SUP-989803105321,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.49,15.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.87,42.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.66-10MM 360MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED",SUP-04.037.056S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CIGNA [10200]","Cigna Local Plus",,3911.78,31.5,,3978.14,359.25,3978.14,24,1444.25,10555.59,"percent of total billed charges",
"PLATE 4.5MM 226MM STAINLESS STEEL 4.5MM SCREWS LARGE",SUP-240.045,CDM,C1713,HCPCS,0278,RC,,,both,,,8995.39,2698.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1065.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1046.16,7646.08,"percent of total billed charges",
"PEG FIXATION 2.7MM 20MM DISTAL VOLAR RADIUS FOSSA HIGH",SUP-HCLP-27200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,3978.14,359.25,3978.14,24,80.07,585.23,"percent of total billed charges",
"SCR BONE 4MM 30MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.430TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,578.57,28.62,,,,,0,235.11,1718.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 13MM ZEVO TITANIUM SPINE CERVICAL ANTERIOR SELF",SUP-7714013,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM 10 HOLE X BONE STERNAL NONSTERILE",SUP-460.037,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",434.96,3179,"percent of total billed charges",
"SCR BONE 8.5MM 55MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16018555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 6MM 70MM DCP LC-DCP STAINLESS STEEL CORTEX",SUP-204.67,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"BLUE CROSS [10001]","Blue Cross PPO",,107.91,39.2,,957.42,570.23,957.42,28,32.01,233.98,"percent of total billed charges",
"SCR BONE 5MM 50MM T2 TITANIUM FULL THREAD FEMUR PROXIMAL",SUP-1896-5050S,CDM,C1713,HCPCS,0278,RC,,,both,,,1279.15,383.74,"BLUE CROSS [10001]","Blue Cross PPO",,501.43,39.2,,957.42,570.23,957.42,28,148.77,1087.28,"percent of total billed charges",
"NAIL 15.5-11MM 22CM FEMUR PROXIMAL TALON DISTALFIX",SUP-SLN-125-220,CDM,C1713,HCPCS,0278,RC,,,both,,,13227.30,3968.19,"BLUE CROSS [10001]","Blue Cross HMO",,5185.1,39.2,,957.42,156.86,7483.26,51,1538.33,11243.21,"percent of total billed charges",
"ANCHOR SUT 1.8MM 2 20MM TRUSHOT HI-FI NDL",SUP-Y18TN,CDM,C1713,HCPCS,0278,RC,,,both,,,6944.85,2083.45,"MULTIPLAN [10600]",Multiplan,,5903.12,85,,,,,0,807.69,5903.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 22CM FEMUR PROXIMAL TALON DISTALFIX",SUP-SLN-125-220,CDM,C1713,HCPCS,0278,RC,,,both,,,13227.30,3968.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5436.42,41.1,,,,,0,1538.33,11243.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 80MM 80CM 8MM 6FR .035IN VASCULAR NITINOL",SUP-G43858,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]",Cigna,,2570.4,68,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE SP 35S",SUP-TENDV-SP-35S-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"MULTIPLAN [10600]",Multiplan,,145350,85,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Wnd Dehis Smpl",PX-510000043,CDM,12020,CPT,0761,RC,,,both,,,9320.00,2796,"MULTIPLAN [10600]",Multiplan,,7922,85,,,,,0,1083.92,7922,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 10CM 7FR .035IN GENTLE CURVE BILIARY",SUP-G21979,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS [10001]","Blue Cross PPO",,247.67,39.2,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE TIGRIS 80MM 120CM 5MM VASCULAR CBAS NITINOL",SUP-PHA050802A,CDM,C1874,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"CIGNA [10200]","Cigna Local Plus",,5518.79,53.5,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 20MM 2.75MM BALLOON DILATATION PEBAX",SUP-1012273-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 22X9X10MM 8D EIT PLIF STERILE LATEX FREE",SUP-PUI81002,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AETNA [10100]","Aetna HMO/PPO",,22538.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 10MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620710,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.5MM X 15MM TI",SUP-VAN-15150-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]",Cigna,,660.96,68,,1831.33,1831.33,1831.33,16,113.04,826.2,"percent of total billed charges",
"SCR BONE 7.3MM 125MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.925,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,934.6,68,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRA-THIN SDS 75CM 40MM 5.8FR 10MM STD BALLOON",SUP-M001177360,CDM,C1725,HCPCS,0272,RC,,,both,,,1012.50,303.75,"AETNA [10100]","Aetna HMO/PPO",,804.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 75MM LCP STAINLESS STEEL MEDIAL PROXIMAL",SUP-212.224,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,101.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",101.55,742.2,"percent of total billed charges",
"SCR BONE 6.5MM 35MM EVEREST SPINE POLYAXIAL",SUP-2911-06535,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,573.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",563.19,4116.21,"percent of total billed charges",
"PLATE 18X8MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2508,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1144.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1123.46,8211,"percent of total billed charges",
"HOOK SPINAL CD HORIZON THORACIC RIGHT TITANIUM ANGLE BLADE",SUP-7541188,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",348.9,2550,"percent of total billed charges",
"SCR BONE 5.5MM 40MM COCR SPINAL MULTIAXIAL CANNULATED",SUP-54840015540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]",Cigna,,6491.86,68,,1831.33,1831.33,1831.33,16,1110.3,8114.82,"percent of total billed charges",
"THORECON? SINGLE USE PLATE/CABLE CUTTER",SUP-94-PLATECUTTER,CDM,S27200284,LOCAL,0272,RC,,,both,,,3037.50,911.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,359.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,353.26,2581.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX79MM 8FR 135CMCATH HEPARIN",SUP-BXB097902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"FIRST HEALTH [10303]","First Health",,17125.92,80,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 6.0 MM X 80 MM X 130 CM",SUP-IPU06008013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"PHCS [10601]",PHCS,,5651.1,70,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT JOHLIN 20CM 10FR PANCREATIC WEDGE INTRO STERILE",SUP-G26827,CDM,C2625,HCPCS,0278,RC,,,both,,,1368.90,410.67,"CIGNA [10200]",Cigna,,930.85,68,,,,,0,159.2,1163.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 28CM 5FR URETERAL AQ FIRM POS NO GWIRE",SUP-G23399,CDM,C2617,HCPCS,0278,RC,,,both,,,535.41,160.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,153.23,28.62,,,,,0,62.27,455.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 6MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBH060502,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 4FR 11CM RED HUB HEMOSTASIS VALVE PRELUDE",SUP-PSI-4F-11,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.8,64.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE DRILL 4.8MM INFINITY INBONE TIBIA BICORTICAL PROXIMAL",SUP-33600048,CDM,S27200284,LOCAL,0272,RC,,,both,,,1603.80,481.14,"CIGNA [10200]","Cigna Open Access",,912.56,56.9,,,,,0,186.52,1363.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 6.5IN MEYERDING SELF RETAINING SURGICAL 57X25MM",SUP-MF065R,CDM,S27200284,LOCAL,0272,RC,,,both,,,2005.28,601.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,920.42,45.9,,,,,0,233.21,1704.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL MODULUS 7 D L17 MM X W14 MM X H7 MM CERVICAL STE",SUP-67940037P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"PHCS [10601]",PHCS,,4347,70,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 15MM CEMENTLESS MODULAR AML POROUS 45MM",SUP-155402150,CDM,C1776,HCPCS,0278,RC,,,both,,,15374.88,4612.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4400.29,28.62,,,,,0,1788.1,13068.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 20CM 150CM 8FR .038IN 3CM 2 PIGTAIL",SUP-M006155250170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS [10001]","Blue Cross HMO",,556.77,39.2,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 26CM 8FR URETERAL FLEXITHANE",SUP-H7493936108260,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,144.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC",358,MS-DRG,,,,,,,inpatient,,,67768.60,20330.58,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,9278.25,,"Case rate ($8,671.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,051.85, add-ons for qualifying new technology services are included. If operating cost exceeds $41,091.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,990.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,062.50. The transfer operating threshold is the transfer adjustment factor * $8,051.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.76. The transfer capital threshold is the transfer adjustment factor * $608.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,40813.09,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 34MM 2.75MM CORONARY RAPID EXCHANGE",SUP-ONYXNG27534UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2681.25,804.37,"CIGNA [10200]",Cigna,,1823.25,68,,,,,0,311.83,2279.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TACTIFLEX SE BID CURVE F-J",SUP-A-TFSE-FJ,CDM,C2630,HCPCS,0272,RC,,,both,,,23940.00,7182,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 6FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856140,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"BLUE CROSS [10001]","Blue Cross PPO",,429.89,39.2,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.5/22",SUP-401757,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,9776.84,9776.84,9776.84,"1 through 10",521.61,3812.25,"percent of total billed charges",
"GRAFT STENT 100MM 12-14MM 13FR 10FR TRIVASCULAR OVATION",SUP-TV-IL1412100-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CIGNA [10200]","Cigna Local Plus",,10517.85,31.5,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 28CM 6FR .035IN URETERAL",SUP-M006155234090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"MULTIPLAN [10600]",Multiplan,,1158.33,85,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN AL3 CURVE GUIDING CORONARY",SUP-LA7AL30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR051002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"CIGNA [10200]","Cigna Open Access",,7125.05,33.5,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 24MM 144CM 4MM CORONARY STENT PEBAX",SUP-H7493926024400,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]",Cigna,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 24MM 144CM 4MM CORONARY STENT PEBAX",SUP-H7493926024400,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,647.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREONPANOPTIX PRO",SUP-PXCAT0,CDM,V2788,HCPCS,0276,RC,,,both,,,915.00,274.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,419.99,45.9,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD 48MM 3MM CORONARY STENT EVEROLIMUS",SUP-H7493941848300,CDM,C1874,HCPCS,0278,RC,,,both,,,5002.50,1500.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2296.15,45.9,,,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 62MM 32MM MARATHON HIP",SUP-121932062,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"NOVANET [10819]",Novanet,,5425.99,75,,,,,0,841.39,6149.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175273180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,169.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION 130CM 2.4FR MICRO J INFUSION NITINOL 1",SUP-M001195270,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"PHCS [10601]",PHCS,,2625,70,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 18MM 140CM 5MM 2.1-2.7FR CORONARY STENT",SUP-RONYX50018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5754.00,1726.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,681.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,669.19,4890.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER SHORT TIP RELOAD 60MM PURPLE",SUP-ASR60PS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PERFORMA 65CM 5FR MOT CURVE ANGIOGRAPHIC PEBAX",SUP-5591-A3,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ENDOSCOPIC GF UM20 BILIARY ULTRASOUND BALLOON STERILE",SUP-MAJ-233,CDM,C1726,HCPCS,0272,RC,,,both,,,246.56,73.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ROD EXTERNAL FIXATION 250MM 11MM CARBON FIBER MR CONDITIONAL",SUP-394.84,CDM,C1713,HCPCS,0278,RC,,,both,,,1441.80,432.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,980.42,68,,,,,0,167.68,1225.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 16MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656016,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"BLUE CROSS [10001]","Blue Cross HMO",,523.4,39.2,,957.42,156.86,7483.26,51,155.28,1134.92,"percent of total billed charges",
"ROD SPINAL CERVICAL PRE BENT TITANIUM 3.5MM X 70MM RELINE-C",SUP-3943070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"ROD EXTERNAL FIXATION 250MM 11MM CARBON FIBER MR CONDITIONAL",SUP-394.84,CDM,C1713,HCPCS,0278,RC,,,both,,,1441.80,432.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,170.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",167.68,1225.53,"percent of total billed charges",
"SCR BONE 4.5MM 32MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.732,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,321.58,28.62,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 20MM STAINLESS STEEL T8 LOCK VARIABLE ANGLE",SUP-02.210.120TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1011.53,303.46,"CIGNA [10200]","Cigna Open Access",,575.56,56.9,,1144.80,304.56,2275.09,66,117.64,859.8,"percent of total billed charges",
"TI 4.0-4.0X220 ADJ ROD",SUP-102074220,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,1470,39.2,,957.42,156.86,7483.26,51,436.13,3187.5,"percent of total billed charges",
"SCR BONE 2.7MM 14MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0346,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,434.99,45.9,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY FIXATION GOLD 95MM 11MM TROCHANTERIC",SUP-456.304S,CDM,C1713,HCPCS,0278,RC,,,both,,,4361.08,1308.32,"CIGNA [10200]","Cigna Local Plus",,2333.18,53.5,,3978.14,359.25,3978.14,24,507.19,3706.92,"percent of total billed charges",
"SCR BONE 4MM 32MM QUICKFIX TITANIUM SHORT PARTIAL THREAD T15",SUP-AR-8740-32PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",155.43,1136.03,"percent of total billed charges",
"KIT ARTHROSCOPIC L7 MM FLEXOR HALLUCIS LONGUS",SUP-AR-1570BC-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10831.28,3249.38,"KAISER [10500]",Kaiser,,7256.96,67,,,,,0,1259.68,9206.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM VARIAX T8 FULL THREAD NONSTERILE",SUP-656416,CDM,C1713,HCPCS,0278,RC,,,both,,,779.22,233.77,"BLUE CROSS [10001]","Blue Cross HMO",,305.45,39.2,,957.42,156.86,7483.26,51,90.62,662.34,"percent of total billed charges",
"PEG FIXATION 2.3MM 22MM DISTAL VOLAR RADIUS FOSSA THREADED",SUP-TPLS-23220-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,680.40,204.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,462.67,68,,,,,0,79.13,578.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH THERMOCOOL SF 7.5FR F CURVE ABLATION UNIDIRECTIONAL",SUP-D131503,CDM,C1732,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,inpatient,,,45402.67,13620.8,"BLUE CROSS [10001]","Blue Cross PPO",,3131.13,,,,,,,1958,43521.05,"per diem","Estimated amount calculated based on 4 day length of stay."
"DRSG BIOLOGICAL 4X4IN BIOSTEP PORCINE CLLGN MATRIX 2 ACTION",SUP-66800125,CDM,A6021,HCPCS,0272,RC,,,both,,,119.82,35.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,49.25,41.1,,,,,0,13.94,101.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 45MM 6.5MM SPINE CORTICAL",SUP-55900106545,CDM,C1713,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"CIGNA [10200]","Cigna Open Access",,3337.19,56.9,,1144.80,304.56,2275.09,66,682.1,4985.25,"percent of total billed charges",
"CATH BARDEX IC 18FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0165SI18,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.82,19.45,"CIGNA [10200]",Cigna,,44.08,68,,,,,0,7.54,55.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.2MM 45MM CLICKX TITANIUM BUTTRESS SPINE PEDICLE",SUP-498.563,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1721.25,45.9,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM OSTEOGRIP",SUP-83565559,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UHC [10700]","United Healthcare",,6043.16,63.3,,5023.51,2672.93,6679.78,18,1110.3,8114.82,"percent of total billed charges",
"SCR BONE 3.5MM 2.9MM 75MM LCP STAINLESS STEEL CONE PARTIAL",SUP-212.427,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.25,337.57,"CIGNA [10200]",Cigna,,765.17,68,,1831.33,1831.33,1831.33,16,130.87,956.46,"percent of total billed charges",
"DEVICE XPRESS ULTRA 1.5MM BALL SUPER SLEEK PROFILE 8MM 2.5FR",SUP-ULF-206,CDM,C1726,HCPCS,0272,RC,,,both,,,11364.30,3409.29,"FIRST HEALTH [10303]","First Health",,9091.44,80,,,,,0,1321.67,9659.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 8MM SMARTLOCK TITANIUM MAXILLOMANDIBULAR SELF",SUP-5020598,CDM,C1713,HCPCS,0278,RC,,,both,,,1349.52,404.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,156.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",156.95,1147.09,"percent of total billed charges",
"ANCHOR SUT 4.5MM 2 CROSSFT BC",SUP-CFBC-4502,CDM,C1713,HCPCS,0278,RC,,,both,,,3395.93,1018.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2309.23,68,,,,,0,394.95,2886.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 5.5MM CD HORIZON LEGACY TITANIUM PREBENT",SUP-8690040,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Open Access",,2509.29,56.9,,1144.80,304.56,2275.09,66,512.88,3748.5,"percent of total billed charges",
"NAIL 10MM 36MM TIBIAL METAPHYSEAL META-NAIL INTRAMEDULLARY",SUP-71655136,CDM,C1713,HCPCS,0278,RC,,,both,,,15548.46,4664.54,"KAISER [10500]",Kaiser,,10417.47,67,,,,,0,1808.29,13216.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Protek Solo",PX-E27200440,CDM,E27200440,LOCAL,0272,RC,,,both,,,38695.80,11608.74,"AETNA [10100]","Aetna HMO/PPO",,30763.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4500.32,32891.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Protek Solo",PX-E27200440,CDM,E27200440,LOCAL,0272,RC,,,both,,,38695.80,11608.74,"PHCS [10601]",PHCS,,27087.06,70,,,,,0,4500.32,32891.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER MOSES 80HZ 120W 6J 550UM D/F/L LITHOTRIPSY",SUP-AC-10030120,CDM,S27200284,LOCAL,0272,RC,,,both,,,3759.05,1127.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PREVAIL DCB 2.00X20MM",SUP-PRV020020CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2.6MM 5MM CENTERPIECE TITANIUM SPINAL SELF TAPPING",SUP-853-465,CDM,C1713,HCPCS,0278,RC,,,both,,,443.23,132.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",51.55,376.75,"percent of total billed charges",
"PLATE BONE 35MM LCP ANKLE FOOT STAINLESS STEEL 2X3 HOLE L",SUP-249.687,CDM,C1713,HCPCS,0278,RC,,,both,,,2305.80,691.74,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1058.36,45.9,,,,,0,268.16,1959.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 30MM CREO MIS SPINE POLYAXIAL TULIP REDUCTION",SUP-1134.0100,CDM,C1713,HCPCS,0278,RC,,,both,,,3555.00,1066.5,"FIRST HEALTH [10303]","First Health",,2844,80,,,,,0,413.45,3021.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 32MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.622,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"MULTIPLAN [10600]",Multiplan,,983.18,85,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tumor Immunohistochem Cad",PX-312000046,CDM,88361,CPT,0312,RC,,,both,,,615.33,184.6,"KAISER [10500]",Kaiser,,412.27,67,,,,,0,0.01,523.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI L 4MMX1MM MID FACE LEFT 4 HOLE BAR 2MM SCR BONE",SUP-55-08235,CDM,C1713,HCPCS,0278,RC,,,both,,,1648.88,494.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,191.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",191.76,1401.55,"percent of total billed charges",
"SPACER SPINAL 5MM ZERO-P STANDARD LORDOTIC PEEK-OPTIMA TITAN",SUP-04.617.125S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1471.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 85MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.885,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CIGNA [10200]","Cigna Open Access",,782.04,56.9,,1144.80,304.56,2275.09,66,159.84,1168.25,"percent of total billed charges",
"ROD SPINAL 120MM 5.5MM RELINE LORDOTIC TITANIUM NONSTERILE",SUP-14355120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIFLUFOLASTAT F-18 IV SYRINGE (7-8 MCI)",RX-234817,CDM,A9595,HCPCS,0343,RC,08888-8878-46,NDC,both,1,UN,16868.88,5060.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1961.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,696,14338.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM GEMINUS TITANIUM DISTAL VOLAR RADIUS",SUP-PANL-35160-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,623.70,187.11,"KAISER [10500]",Kaiser,,417.88,67,,,,,0,72.54,530.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 40MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75448540,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,3978.14,359.25,3978.14,24,441.36,3225.75,"percent of total billed charges",
"SCR INTERFERENCE HA 30MM 8MM ACL BIOSURE",SUP-72201778,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",189.34,1383.8,"percent of total billed charges",
"HC Rpr Sclp/Ax/Tr/Ext 12.6-20 Int",PX-450000034,CDM,12035,CPT,0450,RC,,,both,,,1979.00,593.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1261,,,,,,,1.98,1979,"case rate",
"UPCHARGE SMR HUMERAL EXTENSION + 9 MM TI6AL4V",SUP-1352.15.001,CDM,C1776,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross PPO",,1893.36,39.2,,3949.44,3949.44,3949.44,"1 through 10",561.73,4105.5,"percent of total billed charges",
"SCR BONE 5MM 35MM T2 TITANIUM FULL THREAD PROXIMAL HUMERAL",SUP-1896-5035S,CDM,C1713,HCPCS,0278,RC,,,both,,,1234.80,370.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,143.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",143.61,1049.58,"percent of total billed charges",
"PLATE CONTOUR 103MM STAINLESS STEEL 2.7/3.5MM SCR 5 HOLE LCP",SUP-02.112.110,CDM,C1713,HCPCS,0278,RC,,,both,,,3178.88,953.66,"NOVANET [10819]",Novanet,,2384.16,75,,,,,0,369.7,2702.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Set 15in Dlp Multi 4 Legs Ca",PX-E27200385,CDM,E27200385,LOCAL,0272,RC,,,both,,,117.70,35.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) GUIDE SHEATH",SUP-25100GST,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 1 7/8IN WIDE RTRCTR 2.7MM MCCULLOCH BLACK FINISH",SUP-57-5729,CDM,S27200284,LOCAL,0272,RC,,,both,,,657.64,197.29,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ASAHI VASCULAR 180CM SION BLUE PTCA",SUP-AHW14R004S,CDM,C1769,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 5FR .058IN AMPLATZ LEFT .75 CURVE GUIDING",SUP-LA5AL75,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 44MM TI",SUP-MTC-37440-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,145.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",145.07,1060.29,"percent of total billed charges",
"FILLER BONE VOID 30ML 1.7-10MM 50% CORTICAL 50% CANCELLOUS",SUP-400045,CDM,C1713,HCPCS,0278,RC,,,both,,,2842.88,852.86,"BLUE CROSS [10001]","Blue Cross PPO",,1114.41,39.2,,957.42,570.23,957.42,28,330.63,2416.45,"percent of total billed charges",
"SCR BONE 5.5MM 45MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850015545,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"PHCS [10601]",PHCS,,4588.5,70,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X6MM ADVANCED PARALLEL TRAPEZOID",SUP-17606,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"NOVANET [10819]",Novanet,,6210,75,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 30MM 140CM 2.5MM CORONARY STERILE LATEX",SUP-453962,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 160MM 22-14MM 14FR 12FR TRIVASCULAR OVATION",SUP-TV-IL1422160-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3883.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 13MM LCP STAINLESS STEEL SMALL BONE T6",SUP-201.883,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"NOVANET [10819]",Novanet,,529.01,75,,,,,0,82.03,599.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 6.35MM TSR2D PRECUT BENT",SUP-8371090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM INFINITY SPINE OCCIPITOCERVICAL UPPER",SUP-3603520,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"PLATE SLANT T LISFRANC 3 HOLE COMPRESSION GORILLA BONE LEFT",SUP-P53-110-L000,CDM,C1713,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"FIRST HEALTH [10303]","First Health",,6210,80,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 TWINFIX ULTRABRAID COBRAIDED PEEK-OPTIMA",SUP-72202625,CDM,C1713,HCPCS,0278,RC,,,both,,,1724.63,517.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,200.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",200.57,1465.94,"percent of total billed charges",
"NUT EXTERNAL FIXATION 10MM TRUELOK PLUS CAPTURE WASHER",SUP-5013010,CDM,C1713,HCPCS,0278,RC,,,both,,,379.32,113.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,108.56,28.62,,,,,0,44.11,322.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END 0MM T25 STARDRIVE TITANIUM NIOBIUM ALUMINUM STERILE",SUP-04.019.000S,CDM,C1713,HCPCS,0278,RC,,,both,,,1372.14,411.64,"BLUE CROSS [10001]","Blue Cross PPO",,537.88,39.2,,957.42,570.23,957.42,28,159.58,1166.32,"percent of total billed charges",
"SCR BONE 7.3MM 90MM LCP STAINLESS STEEL FULL THREAD CONDYLAR",SUP-02.207.090,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"PLATE BONE 32MM LCP ANKLE FOOT STAINLESS STEEL 2X3 HOLE T",SUP-249.685,CDM,C1713,HCPCS,0278,RC,,,both,,,3883.32,1165,"AETNA [10100]","Aetna HMO/PPO",,3087.24,79.5,,1521.93,481.35,16760.95,30,451.63,3300.82,"percent of total billed charges",
"ROD SPINAL 120MM 4.75MM STRAIGHT PERCUTANEOUS CCM PLUS",SUP-1476006120,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,512.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",512.88,3748.5,"percent of total billed charges",
"STENT WALLFLEX 60MM 10MM 8FR BILIARY METAL UNCOVER RAPID",SUP-7064,CDM,C1887,HCPCS,0272,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE 1.3MM 2MM SCR MESH APTUS TRILOCK BONE HAND",SUP-A-4655.56,CDM,S27200284,LOCAL,0272,RC,,,both,,,8790.60,2637.18,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE LARYNSCP MACINTOSH 4 STAINLESS STEEL FIBER OPTIC",SUP-040-914U,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 3X200 80CM SL",SUP-48003020N,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AMILORIDE 5 MG TABLET",RX-391,CDM,,,0637,RC,00574-0292-01,NDC,both,1,UN,6.27,1.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EYE INFECTIONS AND OTHER EYE DISORDERS,MINOR",082,APR-DRG,,,,,,,inpatient,,,34628.92,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $3,076.57. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%.",,,,0,,,other,"SOI-1 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 6FR .071IN EXTRA BACKUP 4A LEFT CURVE",SUP-LA6EBU40A,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 12X20 40CM SL",SUP-48012002P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TRAILBLAZER 90CM 2.3FR 15MM ANGLE SPRT STAINLESS STEEL",SUP-ASC-014-090,CDM,C1887,HCPCS,0272,RC,,,both,,,1377.00,413.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONVEY 100CM 7FR LEFTBU3.5 CURVE GUIDING HYDROPHILIC",SUP-H749392657140,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC",191,MS-DRG,,,,,,,inpatient,,,24567.48,7370.24,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE APPROACH VASCULAR STRAIGHT TAPER 190CM .014IN PLATINUM",SUP-G52938,CDM,C1769,HCPCS,0272,RC,,,both,,,1389.07,416.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE TENOR VASCULAR MICRO STD ANGLE 165CM .018MM PLATINUM",SUP-TNR2811,CDM,C1769,HCPCS,0272,RC,,,both,,,1705.20,511.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,198.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,198.31,1449.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3.5MM BIO-PUSHLOCK 19.5MM STERILE DISPOSABLE",SUP-AR-1926B,CDM,C1713,HCPCS,0278,RC,,,both,,,2835.00,850.5,"BLUE CROSS [10001]","Blue Cross HMO",,1111.32,39.2,,957.42,156.86,7483.26,51,329.71,2409.75,"percent of total billed charges",
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,inpatient,,,250756.63,75226.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $119,403. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 37.7%. Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CANTATA 135CM 2.8FR .025IN NT2 CURVE MICRO",SUP-G23805,CDM,C1887,HCPCS,0272,RC,,,both,,,3142.43,942.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 10MM",SUP-SPL12510X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"APPL CLIP 8IN OPEN LIGATE SMALL CURVE WIDE HORIZON",SUP-137082,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GLIDECATH GLIDE TECHNOLOGY 100CM 15CM 4FR .041IN COBRA",SUP-CG410,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR .071IN EXTRA BACKUP 3.5 LEFT CURVE",SUP-LA6EBU35,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VTC 25CM 8FR PIGTAIL CURVE NEPHRSTMY METAL POLYURETHANE",SUP-M001245260,CDM,C1887,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RUNWAY 6FR .07IN KIESZ LEFT 3 HORIZONTAL CURVE GUIDING",SUP-H749389696110,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,150.61,41.1,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 80MM 12-14MM 13FR 10FR TRIVASCULAR OVATION PRIME",SUP-TV-IL141280-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"NOVANET [10819]",Novanet,,25042.5,75,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 3MM BALL DISSECTING DIAMOND STERILE DISPOSABLE",SUP-MR8-14BA30D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1358.37,407.51,"AETNA [10100]","Aetna HMO/PPO",,1079.9,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,157.98,1154.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE INCISION WOLF RESECTOSCOPE",SUP-M0068805411,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE HEMOSTASIS 20CM HONOR METAL GWIRE INSRT TOOL BONDED",SUP-MAP350,CDM,S27200284,LOCAL,0272,RC,,,both,,,193.75,58.12,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACIFIC PLUS 130CM 40MM 4FR 5MM .018IN BALLOON",SUP-PCP050040130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PCP040300090 PLUS US D4L300UL900",SUP-PCP040300090,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOFT-VU 65CM 5FR ANGLE KUMPE CURVE ANGIOGRAPHIC",SUP-H787107327015,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE NC PLUS 8MM 3.75MM BALLOON DILATATION",SUP-237-083-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TREK 145CM 15MM 2.75MM BALLOON DILATATION PEBAX",SUP-1012406-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 20MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-583502022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 9FR 19CM RADIALEASE LATEX FREE VESSEL ACCEPTS",SUP-504509X,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.26,26.18,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUTURE ETHILON NON-ABSORBABLE NYLON 4-0 18IN MONOFILAMENT DY",SUP-1667ZH,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPHINTOM 25MM 1.3MM 3.9FR AUTOTOME CANNULATE STERILE",SUP-M00584390,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 52MM 28MM MARATHON HIP",SUP-121928052,CDM,C1776,HCPCS,0278,RC,,,both,,,7631.40,2289.42,"FIRST HEALTH [10303]","First Health",,6105.12,80,,,,,0,887.53,6486.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLGRAFT 50MM 90CM 9MM 10FR 116CM",SUP-M001705950,CDM,C1874,HCPCS,0278,RC,,,both,,,14165.70,4249.71,"BLUE CROSS [10001]","Blue Cross PPO",,5552.95,39.2,,,,,0,1647.47,12040.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 28CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006180244010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"MULTIPLAN [10600]",Multiplan,,910.13,85,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 165MM 2.8MM TITANIUM QUICK COUPLING NONSTERILE",SUP-310.288,CDM,S27000186,LOCAL,0270,RC,,,both,,,576.07,172.82,"FIRST HEALTH [10303]","First Health",,460.86,80,,,,,0,67,489.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TALON? DISTALFIX? HUMERAL NAIL 9MM X 315MM",SUP-HTN-409-315,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"ANCHOR SUT 2 FULL THREAD CORKSCREW FIBERWIRE PEEK 14.7MM",SUP-AR-1927PSF-65,CDM,C1713,HCPCS,0278,RC,,,both,,,2323.13,696.94,"MULTIPLAN [10600]",Multiplan,,1974.66,85,,,,,0,270.18,1974.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ECHELON 10 150CM 1.7-2.1FR .017IN 45D MICRO INFUSION",SUP-145-5091-150,CDM,C1769,HCPCS,0272,RC,,,both,,,5016.30,1504.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2061.7,41.1,,,,,0,583.4,4263.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER FOREST GREEN 4.5MM SYNOVATOR DYONICS STRAIGHT",SUP-7205310,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"KAISER [10500]",Kaiser,,233.16,67,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMEDY SPECTRUM GV FEMORAL LONG STEM MD",SUP-GVLSMD,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Open Access",,6331.5,33.5,,5302.19,4377.88,6578.61,27,2198.07,16065,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 20CM 150CM 5FR .038IN 3CM BLADDER LOOP",SUP-M006155220170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ANGIO-SEAL EVOLUTION 6FR .035IN CLSR VASCULAR GWIRE",SUP-C610134,CDM,C1760,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CIGNA [10200]","Cigna Local Plus",,922.88,53.5,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 3.5 X 8 HELICAL PICO COIL",SUP-10USH03508,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"MULTIPLAN [10600]",Multiplan,,9964.64,85,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 40MM 9FR 10MM FLUENCY PLUS ENDOVASCULAR",SUP-FEM10040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL WEDGE ALLOGRAFT 8MM INTERSPINOUS PROCESS",SUP-4578108,CDM,S27800098,LOCAL,0278,RC,,,both,,,19921.48,5976.44,"KAISER [10500]",Kaiser,,13347.39,67,,,,,0,2316.87,16933.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Rt Dvc/Marker Pros",PX-333000003,CDM,55876,CPT,0333,RC,,,both,,,1780.05,534.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,210.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,207.02,1780.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 3-0 CT-1 27IN MONOFILAMENT ABSORBABLE",SUP-842H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLUX PROTEIIIOS GROWTH FACTOR L",SUP-IFLX-GF-050,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"BLUE CROSS [10001]","Blue Cross HMO",,6085.8,39.2,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 10FR 32IN SILICONE FLUTED TROCAR HUBLESS",SUP-072227,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.15,36.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,56.07,45.9,,,,,0,14.21,103.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4MM COOLCUT TORPEDO 2 INNER CUT",SUP-AR-8400TD,CDM,S27200284,LOCAL,0272,RC,,,both,,,818.10,245.43,"CIGNA [10200]","Cigna Open Access",,465.5,56.9,,,,,0,95.15,695.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ORTHOPEDIC LOCK HEX DRIVE NONSTERILE LATEX FREE",SUP-323.1205,CDM,C1713,HCPCS,0278,RC,,,both,,,2340.00,702,"CIGNA [10200]",Cigna,,1591.2,68,,1831.33,1831.33,1831.33,16,272.14,1989,"percent of total billed charges",
"CATH FOGARTY 80CM 4FR 9MM ROUND EMBOLECTOMY STAINLESS STEEL",SUP-120804FP,CDM,C1757,HCPCS,0272,RC,,,both,,,310.76,93.23,"FIRST HEALTH [10303]","First Health",,248.61,80,,,,,0,36.14,264.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM HIP CLUSTER 3 SCR HOLE METAL HA",SUP-502-11-46C,CDM,C1776,HCPCS,0278,RC,,,both,,,9525.45,2857.63,"UHC [10700]","United Healthcare",,6029.61,63.3,,8601.07,8395.67,8601.07,"1 through 10",1107.81,8096.63,"percent of total billed charges",
"SCR BONE 2.5MM 16MM TITANIUM COMPRESSION CANNULATED",SUP-04.333.116,CDM,C1713,HCPCS,0278,RC,,,both,,,2518.50,755.55,"AETNA [10100]","Aetna HMO/PPO",,2002.21,79.5,,1521.93,481.35,16760.95,30,292.9,2140.73,"percent of total billed charges",
"EXT AORTIC 4.5CM 26MM EXCLUDER CONFORMABLE ACTIVE CONTROL",SUP-CXA260005,CDM,C1874,HCPCS,0278,RC,,,both,,,27612.90,8283.87,"PHCS [10601]",PHCS,,19329.03,70,,,,,0,3211.38,23470.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 1/8IN PFC STEINMANN PRESERVATION KNEE KIT TWIST",SUP-864192,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET INTRO 25 5/8IN 7FR 8FR SUPER ARROW-FLEX PERCUTANEOUS 3",SUP-CL-07765,CDM,C1894,HCPCS,0272,RC,,,both,,,875.61,262.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 80MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-593508022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,EXTREME",174,APR-DRG,,,,,,,inpatient,,,178228.78,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC VALVE PROCEDURES WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MAJOR",162,APR-DRG,,,,,,,inpatient,,,346152.45,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $35,532.82. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($201,835.71) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DISORDERS OF THE EYE WITHOUT MCC",125,MS-DRG,,,,,,,inpatient,,,38731.81,11619.54,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,4905.59,,"Case rate ($4,762.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,422.50, add-ons for qualifying new technology services are included. If operating cost exceeds $37,462.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,716.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,428.35. The transfer operating threshold is the transfer adjustment factor * $4,422.50 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $334.36. The transfer capital threshold is the transfer adjustment factor * $334.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4762.71,19148.16,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GALLIUM-67 CITRATE INTRAVENOUS SOLUTION (1-2 MCI)",RX-411841,CDM,A9556,HCPCS,0343,RC,08888-8877-92,NDC,both,1,UN,404.00,121.2,"BLUE CROSS [10001]","Blue Cross PPO",,0.02,,,,,,,0.02,343.4,"fee schedule",
"HC Adhesive Cement Ostomy",PX-E27000032,CDM,E27000032,LOCAL,0270,RC,,,both,,,59.40,17.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GARM COMPRESSION STD UNIVERSAL THIGH FABRIC FLOWTRON 10.6X9",SUP-DVT30,CDM,S27000186,LOCAL,0270,RC,,,both,,,130.85,39.25,"CIGNA [10200]",Cigna,,88.98,68,,,,,0,15.22,111.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CW003, 5MMX42CM EPIX ES SMK EVAC ANG NDL",SUP-CW003,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION",RX-168527,CDM,,,0250,RC,00597-0100-51,NDC,both,4,GR,452.70,135.81,"KAISER [10500]",Kaiser,,303.31,67,,,,,0,52.65,384.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RECTAL RESECTION WITH MCC",332,MS-DRG,,,,,,,inpatient,,,152983.81,45895.14,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,24031.59,,"Case rate ($22,459.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,855.10, add-ons for qualifying new technology services are included. If operating cost exceeds $53,894.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,958.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $20,882.68. The transfer operating threshold is the transfer adjustment factor * $20,855.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,576.75. The transfer capital threshold is the transfer adjustment factor * $1,576.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,105709.96,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,inpatient,,,21091.49,6327.45,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,5116.85,,"Case rate ($4,827.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,482.40, add-ons for qualifying new technology services are included. If operating cost exceeds $37,522.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,720.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,488.33. The transfer operating threshold is the transfer adjustment factor * $4,482.40 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $338.89. The transfer capital threshold is the transfer adjustment factor * $338.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,4827.22,19407.53,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP SURGICAL 4CM ADVINCULA DELINEATOR KOH-EFFICIENT KOH",SUP-AD750-KE40,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 20-25.9CMX3-10MM SEMITENDINOSUS TENDON",SUP-430355,CDM,C1762,HCPCS,0278,RC,,,both,,,10551.96,3165.59,"MULTIPLAN [10600]",Multiplan,,8969.17,85,,,,,0,1227.19,8969.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,inpatient,,,81965.04,24589.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,32670.3,,,,,,,7561,59825.52,"case rate",
"SENTINEL CEREBRAL PROTECTION SYSTEM",SUP-CMS15-10C-US,CDM,C1884,HCPCS,0272,RC,,,both,,,25200.00,7560,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10357.2,41.1,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPIDERFX 320CM 190CM 3.2-4.2FR 5MM EMBOLIC PROTECTION",SUP-SPD2-US-050-320,CDM,C1884,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4926.6,68,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC",832,MS-DRG,,,,,,,inpatient,,,22420.49,6726.15,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,4789.46,,"Case rate ($4,476.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,156.39, add-ons for qualifying new technology services are included. If operating cost exceeds $37,196.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,696.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,161.89. The transfer operating threshold is the transfer adjustment factor * $4,156.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.24. The transfer capital threshold is the transfer adjustment factor * $314.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,4476.13,17995.98,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM VARIAX TITANIUM DISTAL RADIUS T7 DRIVE",SUP-53-27614E,CDM,C1713,HCPCS,0278,RC,,,both,,,762.05,228.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,349.78,45.9,,,,,0,88.63,647.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VESUVIUS PUTTY DBM PUTTY 100 5CC",SUP-4104-K5050DP,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1979.44,45.9,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 750ML GEL SMOOTH MEMORYGEL SILICONE P5.9CM HIGH","SUP-3507504 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"NOVANET [10819]",Novanet,,2835,75,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 85MM STAINLESS STEEL LARGE FRAGMENT SET 4 HOLE ANGLED",SUP-240.54,CDM,C1713,HCPCS,0278,RC,,,both,,,9574.16,2872.25,"PHCS [10601]",PHCS,,6701.91,70,,,,,0,1113.47,8138.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPLR ANASTOMOSIS 2.5MM GEM MICROVASCULAR STERILE DISPOSABLE",SUP-GEM2753,CDM,S27200284,LOCAL,0272,RC,,,both,,,2962.50,888.75,"PHCS [10601]",PHCS,,2073.75,70,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM OZARK SPINE CERVICAL SELF START VARIABLE",SUP-8801-04016DA,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X2CM VIALIZE PLACENTAL MEMB ALLOGRAFT",SUP-VL-2030,CDM,,,0278,RC,,,both,,,7431.30,2229.39,"KAISER [10500]",Kaiser,,4978.97,67,,,,,0,7.43,6316.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR HEMI 3HL 58M",SUP-430-98-058,CDM,C1776,HCPCS,0278,RC,,,both,,,5341.60,1602.48,"MULTIPLAN [10600]",Multiplan,,4540.36,85,,,,,0,621.23,4540.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 0 TIP STONE 3 WIRE HELICAL PAIRED",SUP-M0063301080,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"AETNA [10100]","Aetna HMO/PPO",,1176.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Neisseria Gonorr Dna Dir",PX-306000141,CDM,87590,CPT,0306,RC,,,both,,,290.00,87,"UHC [10700]","United Healthcare",,24.19,,,,,,,0.01,246.5,"fee schedule",
"WRAP TRACTION MCCONNELL LARGE HAND ARM HOLDER TRACTION STRAP",SUP-12-401,CDM,S27000186,LOCAL,0270,RC,,,both,,,304.50,91.35,"CIGNA [10200]","Cigna Local Plus",,162.91,53.5,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 5CM 120CM 11MM ENDOPROSTHESIS LUMEN CATH",SUP-VBCR110502A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2003.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 125CM 5FR MULTIPURPOSE A 2 CURVE",SUP-534544T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE COONS VASCULAR 3.5CM STRAIGHT TAPER FLOPPY 180CM 15CM",SUP-G02621,CDM,C1769,HCPCS,0272,RC,,,both,,,243.51,73.05,"NOVANET [10819]",Novanet,,182.63,75,,,,,0,28.32,206.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIATHLON CR TIBIAL INSERT",SUP-5530-P-219,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"UHC [10700]","United Healthcare",,5289.28,63.3,,8601.07,8395.67,8601.07,"1 through 10",971.79,7102.52,"percent of total billed charges",
"BASEPLT GLENOID 29MM AEQUALIS PERFORM 15D SHOULDER WEDGE AUG",SUP-DWJ515,CDM,C1776,HCPCS,0278,RC,,,both,,,11340.00,3402,"CIGNA [10200]","Cigna Local Plus",,6066.9,53.5,,5372.07,4581.20,7242.98,23,1318.84,9639,"percent of total billed charges",
"SCR BONE 3.5MM 44MM GORILLA R3CON LOCK",SUP-P50-353-3544,CDM,C1713,HCPCS,0278,RC,,,both,,,1470.15,441.04,"FIRST HEALTH [10303]","First Health",,1176.12,80,,,,,0,170.98,1249.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 12 HIGH OFFSET HIP",SUP-71935584,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"KAISER [10500]",Kaiser,,24477.58,67,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT POSTERIOR STABILIZE CEMENT ATTUNE",SUP-1504-10-106,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"BLUE CROSS [10001]","Blue Cross PPO",,8778.19,39.2,,3949.44,3949.44,3949.44,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"IMPL FIXATION NANOPLASTY SYSTEM BUNION CORRECTION STERILE",SUP-SK57,CDM,C1713,HCPCS,0278,RC,,,both,,,28318.50,8495.55,"BLUE CROSS [10001]","Blue Cross HMO",,11100.85,39.2,,957.42,156.86,7483.26,51,3293.44,24070.73,"percent of total billed charges",
"CATH BARDEX LUBRICATH 22FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0196L22,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.32,32.5,"UHC [10700]","United Healthcare",,68.57,63.3,,,,,0,12.6,92.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 33CM INTERSTIM MICRO TINE SSMRI",SUP-978A133,CDM,C1778,HCPCS,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS [10001]","Blue Cross PPO",,8643.6,39.2,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cmv Dna Quant",PX-306000126,CDM,87497,CPT,0306,RC,,,both,,,731.50,219.45,"PHCS [10601]",PHCS,,512.05,70,,,,,0,0.73,621.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UROLOGICAL 150CM 3MM .038IN PTFE J TIP MOVABLE CORE",SUP-M0066201220,CDM,C1769,HCPCS,0272,RC,,,both,,,153.29,45.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.83,130.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 52MM 32MM MARATHON HIP",SUP-121932052,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"MULTIPLAN [10600]",Multiplan,,6149.45,85,,,,,0,841.39,6149.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CROSSTELLA 90CM 60MM 4-4.1FR 6MM BALLOON DILATATION",SUP-BD-F60060MR,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"MULTIPLAN [10600]",Multiplan,,1273.73,85,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM 3.5MM 2.1-2.7FR CORONARY",SUP-RONYX35008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2524.5,68,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 5 LASER RESISTANT ETT MAGILL CUFFED RUSCH",SUP-102004-000050,CDM,S27200284,LOCAL,0272,RC,,,both,,,749.25,224.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,88.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.14,636.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 545CC",SUP-RSZ-MPX-545S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"UHC [10700]","United Healthcare",,1025.46,63.3,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 12CM 4MM BALLOON DILATATION OTW LOW",SUP-G30949,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELAN 4 2-RING DISP OVAL BURR D4.0",SUP-GP382SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,1289.12,386.74,"KAISER [10500]",Kaiser,,863.71,67,,,,,0,149.92,1095.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAPE FIBERWIRE 2 2MM 8IN BLUE 24IN NONABSORBABLE",SUP-AR-7275,CDM,S27200284,LOCAL,0272,RC,,,both,,,595.35,178.6,"FIRST HEALTH [10303]","First Health",,476.28,80,,,,,0,69.24,506.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 330544 ACSR 5X14X14 SRVC FEE",SUP-330544,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT DURAL 1X3IN DURAGEN PLUS CRANIAL CLLGN MATRIX PATCH",SUP-DP1013,CDM,S27800098,LOCAL,0278,RC,,,both,,,2156.55,646.96,"MULTIPLAN [10600]",Multiplan,,1833.07,85,,,,,0,250.81,1833.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 110CM 2CM 5FR 4MM 7.5MM BALLOON DILATATION",SUP-4194020L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT RETRIEVER 20MM 4MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0032PK42010001,CDM,S27200284,LOCAL,0272,RC,,,both,,,29495.34,8848.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3495.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3430.31,25071.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 2-0 CT-2 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Y333H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 12IN 4 PANEL HOOK LOOP CLSR 30-45IN SMALL",SUP-13651056,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.17,26.15,"CIGNA [10200]","Cigna Local Plus",,46.64,53.5,,,,,0,10.14,74.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 16MM XTEND SPINE VARIABLE ANGLE SELF DRILL",SUP-161.016,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"PHCS [10601]",PHCS,,987,70,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR STRAIGHT SPRING COIL 300CM 5CM",SUP-H74917521,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"KAISER [10500]",Kaiser,,379.89,67,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GASTRO 3.5CM 18FR SILICONE ENTERAL FEEDING TUBE",SUP-0120-18-3.5,CDM,C1713,HCPCS,0278,RC,,,both,,,779.06,233.72,"MULTIPLAN [10600]",Multiplan,,662.2,85,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 12MM MATRIXNEURO CRANIOMAXILLOFACIAL TITANIUM 2",SUP-04.503.062,CDM,C1713,HCPCS,0278,RC,,,both,,,1101.60,330.48,"CIGNA [10200]","Cigna Open Access",,626.81,56.9,,1144.80,304.56,2275.09,66,128.12,936.36,"percent of total billed charges",
"GRAFT BONE DEMINERALIZED BONE MATRIX FIBER 2.5CC ALLOGRAFT",SUP-MDBM1025,CDM,C1713,HCPCS,0278,RC,,,both,,,2343.75,703.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1593.75,68,,,,,0,272.58,1992.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION DETACHABLE PLATE TEMPORARY NONSTERILE",SUP-389.873,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3-0 NANO CORKSCREW FT 2 NDL 1.35MM K WIRE",SUP-AR-1317FT,CDM,C1713,HCPCS,0278,RC,,,both,,,3346.88,1004.06,"CIGNA [10200]",Cigna,,2275.88,68,,1831.33,1831.33,1831.33,16,389.24,2844.85,"percent of total billed charges",
"SCR BONE 3.5MM 54MM ALPS T15 TIBIA CORTICAL DISTAL LOCK SELF",SUP-816135054,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,957.42,570.23,957.42,28,189.34,1383.8,"percent of total billed charges",
"SCR BONE 4MM 14MM PYRENEES SPINE CERVICAL SELF STARTING",SUP-201-14014D,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"FIRST HEALTH [10303]","First Health",,1128,80,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION",RX-182382,CDM,,,0250,RC,67157-0101-50,NDC,both,50,ML,2451.49,735.45,"MULTIPLAN [10600]",Multiplan,,2083.77,85,,,,,0,285.11,2083.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0327,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,271.23,28.62,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM DVR TITANIUM RADIUS CORTICAL DISTAL",SUP-CS10000,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"FIRST HEALTH [10303]","First Health",,874.8,80,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840005545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,441.36,3225.75,"percent of total billed charges",
"OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC",166,MS-DRG,,,,,,,inpatient,,,100065.18,30019.55,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,47209.66,,"Case rate ($23,185.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $21,529.01, add-ons for qualifying new technology services are included. If operating cost exceeds $54,568.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,009.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $21,557.48. The transfer operating threshold is the transfer adjustment factor * $21,529.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,627.70. The transfer capital threshold is the transfer adjustment factor * $1,627.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,100065.18,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 18MM LOW PROFILE SCREWS TITANIUM T10 FULL",SUP-AR-8933-18,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"FIRST HEALTH [10303]","First Health",,712.8,80,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 35MM X-CHANGE HIP ACETABULUM SELF TAP SELF",SUP-0942-8-005,CDM,C1713,HCPCS,0278,RC,,,both,,,664.20,199.26,"MULTIPLAN [10600]",Multiplan,,564.57,85,,,,,0,77.25,564.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 11MM TITANIUM CORTEX SELF TAP STARDRIVE",SUP-401.361.97,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC",964,MS-DRG,,,,,,,inpatient,,,59010.67,17703.2,"BLUE CROSS [10001]","Blue Cross HMO",,35183.58,,"Fee schedule rate ($35,183.58). Includes an add-on of $3,230.48 when RC 0681-0684 total amount is above $1.",,,,0,7561,38221.51,other,"IP DRG + TRAUMA Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD MARLEX 6X3IN GROIN MONOFILAMENT GOLD STD",SUP-0112680,CDM,C1781,HCPCS,0278,RC,,,both,,,329.73,98.92,"FIRST HEALTH [10303]","First Health",,263.78,80,,,,,0,38.35,280.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 20MM LCP TITANIUM DISTAL VOLAR RADIUS LOCKING",SUP-04.210.120,CDM,C1713,HCPCS,0278,RC,,,both,,,1063.69,319.11,"PHCS [10601]",PHCS,,744.58,70,,,,,0,123.71,904.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 130MM 5.5MM REVOLVE XLORDOTIC",SUP-185.930,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 6MM 95MM LCP STAINLESS STEEL T8 CORTEX PELVIC",SUP-204.695,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,32.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",32.01,233.98,"percent of total billed charges",
"KIT SURGICAL PULSE HIP PIN STERILE DISPOSABLE 10CM LATEX",SUP-5050310,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"AETNA [10100]","Aetna HMO/PPO",,1788.75,79.5,,1521.93,481.35,16760.95,30,261.68,1912.5,"percent of total billed charges",
"GRAFT ENDOVASCULAR 90MM 13MM 5.4MM 14FR ZENITH SPIRAL-Z",SUP-G55233,CDM,C1874,HCPCS,0278,RC,,,both,,,33868.80,10160.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3938.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3938.94,28788.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT ALPHAVENT 3 STRAND HARD BODY PLATFORM PEEK 1.4 MM",SUP-3910-947-031,CDM,C1713,HCPCS,0278,RC,,,both,,,2737.50,821.25,"KAISER [10500]",Kaiser,,1834.13,67,,,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM VARIAX TORX TITANIUM FULL THREAD T10",SUP-40-35016,CDM,C1713,HCPCS,0278,RC,,,both,,,612.36,183.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,416.4,68,,,,,0,71.22,520.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 11MM 8.2MM 115MM TALON PROXIMAL FEMUR DISTALFIX",SUP-SLN-011-115,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"PHCS [10601]",PHCS,,3477.6,70,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNETOS 20CC 2-4MM ALLOGRAFT GRANULE",SUP-703-026-US,CDM,C1713,HCPCS,0278,RC,,,both,,,21420.00,6426,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8568,40,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM TIMAX T15 CORTEX SELF TAP LOCK TAPER",SUP-816135020,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,1144.80,304.56,2275.09,66,189.34,1383.8,"percent of total billed charges",
"CATH ULTRAVERSE 018 150CM 15CM 4MM BALLOON DILATATION",SUP-U8150415,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL RESTORIS 5 KNEE RIGHT MEDIAL LEFT LATERAL",SUP-180615,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4506.67,68,,,,,0,770.77,5633.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE CHISEL 40X10MM THK1MM STRAIGHT SMALL",SUP-75100517,CDM,S27200284,LOCAL,0272,RC,,,both,,,1489.59,446.88,"PHCS [10601]",PHCS,,1042.71,70,,,,,0,173.24,1266.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 96MM 12MM PRESS FIT REUNION SHOULDER",SUP-5567-P-3012,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"FIRST HEALTH [10303]","First Health",,13800,80,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mra Head W/WO Cntrst",PX-610000008,CDM,70546,CPT,0615,RC,,,both,,,4888.45,1466.53,"PHCS [10601]",PHCS,,3421.92,70,,,,,0,568.53,4155.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.6V 36MM 2 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18006236,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,1144.80,304.56,2275.09,66,521.61,3812.25,"percent of total billed charges",
"VALVE AORTIC 17MM 23MM 31MM 24.5MM EPIC MAX 13MM TISSUE",SUP-EMAX-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,27990.90,8397.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11196.36,40,,,,,0,3255.34,23792.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 26CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155233050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,565.01,45.9,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 5CM 7FR BILIARY PLASTIC RAPID EXCHANGE TEMPORARY TAPER",SUP-4555,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"NOVANET [10819]",Novanet,,4205.25,75,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 41MM UNITRAX FEMORAL HIP MODULAR",SUP-6942-5-041,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,370.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,363.75,2658.55,"percent of total billed charges",
"BUTTON FIXATION 3.5MM CERCLAGE HEXAGONAL T25 STARDRIVE",SUP-04.221.003S,CDM,C1713,HCPCS,0278,RC,,,both,,,1147.61,344.28,"FIRST HEALTH [10303]","First Health",,918.09,80,,,,,0,133.47,975.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 5MM 7-5FR 5FR RX BILIARY SYSTEM 3 LUMEN NEEDLEKNIFE",SUP-M00545840,CDM,S27200284,LOCAL,0272,RC,,,both,,,1555.12,466.54,"UHC [10700]","United Healthcare",,984.39,63.3,,,,,0,180.86,1321.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,inpatient,,,106182.45,31854.73,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,13193.23,,"Case rate ($12,446.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,557.36, add-ons for qualifying new technology services are included. If operating cost exceeds $44,597.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,255.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,572.65. The transfer operating threshold is the transfer adjustment factor * $11,557.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.79. The transfer capital threshold is the transfer adjustment factor * $873.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,58581.77,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL HIP CONSTRUCT 2",SUP-CAP-SN-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"FIRST HEALTH [10303]","First Health",,7728,80,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP4PR,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5805.51,27,,,,,0,2500.67,18276.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL CRYOFLEX 8IN PROBE 60CM1",SUP-60CM1,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAWSON-MUELLER 25CM 7FR .035IN DRNG HYDROPHILIC",SUP-G11020,CDM,C1729,HCPCS,0272,RC,,,both,,,660.07,198.02,"KAISER [10500]",Kaiser,,442.25,67,,,,,0,76.77,561.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 12MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240120300,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1002.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CREO ONE HA SPINE ROBOTIC MODULAR",SUP-1134.1651S,CDM,C1713,HCPCS,0278,RC,,,both,,,10336.20,3100.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1224.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1202.1,8785.77,"percent of total billed charges",
"TUBE ENDOTRACHEAL 8MM CUFFED HOODED MURPHY EYE LOW PRESSURE",SUP-8229508,CDM,S27200284,LOCAL,0272,RC,,,both,,,3487.50,1046.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,413.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,405.6,2964.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE MICRO SAG FINE 9X31X.4MM",SUP-5023-249,CDM,S27200284,LOCAL,0272,RC,,,both,,,207.67,62.3,"KAISER [10500]",Kaiser,,139.14,67,,,,,0,24.15,176.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHOCKWAVE M5 60MM 110CM 8MM 7MM BALLOON DILATATION",SUP-M5PIVL5560,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"MESH SURGICAL 3DMAX 5.3X3.1IN ABDOMINAL LEFT MONOFILAMENT",SUP-0117310,CDM,C1781,HCPCS,0278,RC,,,both,,,951.60,285.48,"KAISER [10500]",Kaiser,,637.57,67,,,,,0,110.67,808.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 8MMX29MM 7FR 80CMCATH HEPARIN",SUP-BXB082901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2268.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC 32.51CM 8MM COBRA ENDOWRIST DA VINCI XI 68",SUP-471190,CDM,S27000186,LOCAL,0270,RC,,,both,,,1530.90,459.27,"NOVANET [10819]",Novanet,,1148.18,75,,,,,0,178.04,1301.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH PROFILE BOOST, 190CC",SUP-SMHB190,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,886.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPLR ANASTOMOSIS 1.5MM GEM MICROVASCULAR STERILE DISPOSABLE",SUP-GEM2751,CDM,S27200284,LOCAL,0272,RC,,,both,,,2962.50,888.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1359.79,45.9,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT MICRORAPTOR KNOTLESS PEEK",SUP-72205021,CDM,C1713,HCPCS,0278,RC,,,both,,,2677.50,803.25,"CIGNA [10200]","Cigna Local Plus",,1432.46,53.5,,3978.14,359.25,3978.14,24,311.39,2275.88,"percent of total billed charges",
"HEAD FEMORAL STD 22.2MM HIP COCR V40 LFIT",SUP-6260-9-122,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,363.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trg Gene Rearrangement Anal",PX-309000076,CDM,81342,CPT,0310,RC,,,both,,,3483.65,1045.09,"FIRST HEALTH [10303]","First Health",,2786.92,80,,,,,0,0.01,2961.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X2CM NEOX CORD 1K THK1MM 6SQ CM AMNIOTIC",SUP-163599,CDM,Q4148,HCPCS,0636,RC,,,both,,,8935.50,2680.65,"FIRST HEALTH [10303]","First Health",,7148.4,80,,,,,0,332.85,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RADSTAT COMPRESSION RADIAL ARTERY",SUP-RADSRT,CDM,S27200284,LOCAL,0272,RC,,,both,,,204.45,61.33,"CIGNA [10200]",Cigna,,139.03,68,,,,,0,23.78,173.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X100 40CM SL",SUP-48006010P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"AETNA [10100]","Aetna HMO/PPO",,780.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 70MM 75CM 24MM 100CM",SUP-40512,CDM,C1876,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4574.7,68,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR MICRO SHOULDER 1.8MM BIT DRILL GUIDE PUNCH",SUP-AR-1320DSC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,173.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alk Phosphatase Isoenzymes",PX-301000357,CDM,84080,CPT,0301,RC,,,both,,,207.10,62.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.01,,,,,,,0.01,176.04,"fee schedule",
"PASSER FIRSTPASS ST SELF CAPTURE SUT",SUP-224038,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"NOVANET [10819]",Novanet,,1208.93,75,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC THK6MM 50X47MM ASSURITY MRI IS-1 CNCT 10.4CC",SUP-PM1272,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"UHC [10700]","United Healthcare",,15723.72,63.3,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 24MM 144CM 2.75MM CORONARY STENT",SUP-H7493911424270,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4196.41,45.9,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 40MM 120CM 12MM .079IN LARGE",SUP-SERB65-12-40-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross PPO",,2181.48,39.2,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP MEDIUM LEAK 1 ENTRAINMENT NEB ELBOW",SUP-73-1061734,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.58,61.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER MAMMARY SALINE 275-300ML 2 WAY CHECK VALVE SMOOTH",SUP-351-275SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) MOTIV SCAFFOLD 2.5MMX48MM","SUP-930025-48 (280)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FIBER LASER ACCUTRAC 200UM FLEXSHIELD HOLMIUM FLEXIBLE",SUP-M0068404112,CDM,S27200284,LOCAL,0272,RC,,,both,,,3284.22,985.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FOGARTY 80CM 8FR 45MM BALLOON OCCLUSION VASCULAR",SUP-62080822F,CDM,C2628,HCPCS,0272,RC,,,both,,,741.31,222.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OPTRELL CATHETER 36 ELECTRODES, D-F CURVE",SUP-D142901,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1880.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Assay of Corticosterone",PX-301000708,CDM,82528,CPT,0301,RC,,,both,,,300.00,90,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.25,,,,,,,0.01,255,"fee schedule",
"CATH 35CM 10FR DRNG FLEXIMA METAL BILIARY RADIOPAQUE MARKER",SUP-27-261,CDM,C1729,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DESMOPRESSIN 0.1 MG TABLET",RX-16052,CDM,,,0637,RC,60505-0257-01,NDC,both,1,UN,15.19,4.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AMNIOFIX INJECTABLE 40MG",SUP-AI-5050,CDM,Q4433,HCPCS,0636,RC,,,both,,,5002.50,1500.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARD 16FR URETHRAL NATURAL RUBBER SILICONE ELASTOMER 5",SUP-265716,CDM,S27200284,LOCAL,0272,RC,,,both,,,1.84,0.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FLEXABILITY SENSOR ENABLED ENSITE PRECISION MEDIGUIDE",SUP-A-FASE-FJ,CDM,S27200284,LOCAL,0272,RC,,,both,,,12765.00,3829.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARCADIA 10MM 16MM BALLOON DILATATION 3CC 2 LUMEN",SUP-ARC10SB,CDM,S27200284,LOCAL,0272,RC,,,both,,,5978.16,1793.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CSGWORBC19M SAFESHTH GDE",SUP-CSGWORBC19M,CDM,C1892,HCPCS,0272,RC,,,both,,,2887.50,866.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT PRESSURE MNTR 3 WAY STPCOCK TRNSDUC FLUSH DEVICE",SUP-PX272,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.27,30.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.01,87.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 6MM STD SHELL DJO SURGICAL ALTIVATE",SUP-530-06-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,18997.78,40,,,,,0,5523.6,40370.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 34X24X14IN 12D BRIGADE",SUP-6951434,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"MULTIPLAN [10600]",Multiplan,,29134.26,85,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 3.2MM STEINMANN THREAD ACCESS TOTAL",SUP-110003484,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"NOVANET [10819]",Novanet,,1167,75,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAT PATIENT 81X39IN PREVALON M2 MICROCLIMATE BODY PAD MOBILE",SUP-3242-R,CDM,S27000186,LOCAL,0270,RC,,,both,,,477.90,143.37,"CIGNA [10200]","Cigna Local Plus",,255.68,53.5,,,,,0,55.58,406.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH HIGH PROFILE XTRA 465CC",SUP-SHPX465,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,883.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 42MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.542,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,129.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",127.51,931.96,"percent of total billed charges",
"INSRT TIBIAL 4 STD 10MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS4S10R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"AETNA [10100]","Aetna HMO/PPO",,8261.16,79.5,,10981.53,8986.79,12413.38,12,1208.52,8832.69,"percent of total billed charges",
"SCR BONE 6.5MM 35MM TRIDENT II LOW PROFILE HEXAGONAL STERILE",SUP-7030-6535,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"FIRST HEALTH [10303]","First Health",,609.12,80,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT CYL 12X3.5IN 2 PORT 2 BLADDER POSITIVE LOCK CNCT",SUP-60708010100,CDM,S27200284,LOCAL,0272,RC,,,both,,,284.49,85.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,33.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.09,241.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ROADRUNNER NIMBLE VASCULAR ANGLE TAPER 145CM 12CM .035",SUP-G09607,CDM,C1769,HCPCS,0272,RC,,,both,,,313.11,93.93,"PHCS [10601]",PHCS,,219.18,70,,,,,0,36.41,266.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR SUREFORM 60 BLUE",SUP-48360B,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.25,543.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,214.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,210.65,1539.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 22MM 31MM MOSAIC CINCH PORCINE STENT HOLDER",SUP-310031,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"BLUE CROSS [10001]","Blue Cross HMO",,10742.76,39.2,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 170MM FEMORAL PROXIMAL TFN-ADVANCED LATERAL RELIEF",SUP-04.037.112S,CDM,C1713,HCPCS,0278,RC,,,both,,,8273.93,2482.18,"AETNA [10100]","Aetna HMO/PPO",,6577.77,79.5,,1521.93,481.35,16760.95,30,962.26,7032.84,"percent of total billed charges",
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET HOUSING POS",SUP-AR-1204AF-70,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1174.76,45.9,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE MEDIUM OVAL 240CM 2.4MM CAPTIVATOR LOOP STIFF",SUP-M00562321,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.33,36.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,49.87,41.1,,,,,0,14.11,103.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"7F DUO-DECA 2-8-2 MPD-H 100CM",SUP-901683,CDM,C1731,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,797.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC",315,MS-DRG,,,,,,,inpatient,,,28495.90,8548.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15615.09,,"Fee schedule rate ($15,615.09). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,5975.41,24023.74,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14X7MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2207,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"BLUE CROSS [10001]","Blue Cross PPO",,3786.72,39.2,,957.42,570.23,957.42,28,1123.46,8211,"percent of total billed charges",
"PORT IMPLANTABLE INFUSION SURECUFF METAL 14.3FR 2 POWER",SUP-0603000,CDM,C1788,HCPCS,0278,RC,,,both,,,1038.70,311.61,"PHCS [10601]",PHCS,,727.09,70,,,,,0,120.8,882.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20CM 13FR STRAIGHT POLYURETHANE POWER-TRIALYSIS 3",SUP-5603200,CDM,C1752,HCPCS,0272,RC,,,both,,,1245.78,373.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,571.81,45.9,,,,,0,144.88,1058.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 325ML GEL SMOOTH SILICONE P3.8CM MODERATE PLUS","SUP-3503251 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,435.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",427.4,3123.75,"percent of total billed charges",
"CAP STEM HUMERAL LONG POST BASEPLT TRABECULAR METAL SHOULDER",SUP-98000961000,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"NOVANET [10819]",Novanet,,36382.5,75,,,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2.5CM 1MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR091025,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1567.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM 3DX TSRH OSTEOGRIP THINLINE TITANIUM",SUP-83555401,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1181.47,45.9,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.3MM 300MM KIRSCHNER 1 END TROCAR TIP SMOOTH",SUP-P99-192-2330,CDM,C1713,HCPCS,0278,RC,,,both,,,146.16,43.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",17,124.24,"percent of total billed charges",
"GRAFT BONE CORTICAL WEDGE ALLOGRAFT 20MM",SUP-4578120,CDM,S27800098,LOCAL,0278,RC,,,both,,,19921.48,5976.44,"NOVANET [10819]",Novanet,,14941.11,75,,,,,0,2316.87,16933.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 40MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR40,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE SMOOTH 9 .062",SUP-1860379,CDM,C1713,HCPCS,0278,RC,,,both,,,119.63,35.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,81.35,68,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 30X5IN SAFETY PRECUT FIBERGLASS",SUP-SS-5PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,95.08,28.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.06,80.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 60MM KNEE LEFT POSTERIOR STABILIZE OPEN BOX",SUP-184524,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9930.31,40,,,,,0,2887.24,21101.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 25MM 7MM BIOSURE",SUP-72202263,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TIBIAL GREEN STRIPE 74X50MM NEXGEN 6 WEDGE KNEE",SUP-00598800600,CDM,C1713,HCPCS,0278,RC,,,both,,,15836.88,4751.06,"CIGNA [10200]",Cigna,,6334.75,40,,1831.33,1831.33,1831.33,16,1841.83,13461.35,"percent of total billed charges",
"AUG FEMORAL 10MM TRIATHLON 2 POSTERIOR KNEE TOTAL STABILIZED",SUP-5544-A-200,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"FIRST HEALTH [10303]","First Health",,3816.79,80,,,,,0,554.87,4055.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 3CM 18FR MIC-KEY SECUR-LOK ENFIT SILICONE RADIOPAQUE",SUP-8140-18-3.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,92.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPLANT KITS",SUP-28717,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 11X25MM VERTE-STACK CORNERSTONE PSR 11MM",SUP-6276025,CDM,S27800098,LOCAL,0278,RC,,,both,,,5299.20,1589.76,"MULTIPLAN [10600]",Multiplan,,4504.32,85,,,,,0,616.3,4504.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 150MM 6MM BALLOON DILATATION RAPID",SUP-47560150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 5.5MM CD HORIZON TITANIUM PREBENT CENTRAL",SUP-8690065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"COLLAR CERVICAL ADULT SHORT 2IN PROCARE XTEND 174 CHIN REST",SUP-79-83203,CDM,S27000186,LOCAL,0270,RC,,,both,,,362.70,108.81,"MULTIPLAN [10600]",Multiplan,,308.3,85,,,,,0,42.18,308.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JAGWIRE ENDOSCOPIC STRAIGHT 260CM 5CM .035IN BILIARY",SUP-M00556631,CDM,C1769,HCPCS,0272,RC,,,both,,,811.01,243.3,"MULTIPLAN [10600]",Multiplan,,689.36,85,,,,,0,94.32,689.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROEZ MICROINTRODUCER KIT",SUP-0228960,CDM,C1894,HCPCS,0272,RC,,,both,,,455.54,136.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,52.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.98,387.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC T Cell Absolute Count W Ratio",PX-302000081,CDM,86360,CPT,0302,RC,,,both,,,630.43,189.13,"KAISER [10500]",Kaiser,,422.39,67,,,,,0,0.01,535.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3.5MM 2.5MM 1 2.3MM .5 CIRCLE 2 DIAMOND POINT",SUP-AR-1915FT-2,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"BLUE CROSS [10001]","Blue Cross HMO",,879.8,39.2,,957.42,156.86,7483.26,51,261.02,1907.72,"percent of total billed charges",
"HEAD GLENOID 32MM RSP NEUTRAL RETAIN SCR",SUP-508-32-101,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"MULTIPLAN [10600]",Multiplan,,10364.22,85,,,,,0,1418.07,10364.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 13MM 12FR ENDOPROSTHESIS HEPARIN",SUP-VBH131002,CDM,C1874,HCPCS,0278,RC,,,both,,,19939.50,5981.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7975.8,40,,,,,0,2318.96,16948.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 NARROW 10MM KNEE POSTERIOR STABILIZE IDENTITY",SUP-TPS-020-103N,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"CIGNA [10200]",Cigna,,3997.58,68,,5873.17,5873.17,5873.17,"1 through 10",683.7,4996.98,"percent of total billed charges",
"MESH SURGICAL 3DMAX 7X5IN GROIN LEFT CONTOUR SEAL EDGE",SUP-0115312,CDM,C1781,HCPCS,0278,RC,,,both,,,983.58,295.07,"BLUE CROSS [10001]","Blue Cross HMO",,385.56,39.2,,,,,0,114.39,836.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rem FB Canal Aud Ext W/Anes",PX-450000353,CDM,69205,CPT,0450,RC,,,both,,,3261.00,978.3,"NOVANET [10819]",Novanet,,2445.75,75,,,,,0,67.13,3261,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 80MM 1.5MM BALLOON DILATATION RAPID",SUP-47515080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"MULTIPLAN [10600]",Multiplan,,1356.35,85,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 16MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G416,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"BLUE CROSS [10001]","Blue Cross PPO",,3671.5,39.2,,3949.44,3949.44,3949.44,"1 through 10",1089.28,7961.17,"percent of total billed charges",
"MESH SURGICAL ULTRAPRO 6X6IN HERNIA PARTIALLY ABSORBABLE",SUP-UMM3,CDM,C1781,HCPCS,0278,RC,,,both,,,1188.96,356.69,"FIRST HEALTH [10303]","First Health",,951.17,80,,,,,0,138.28,1010.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 30FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0166SI30,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.21,20.46,"FIRST HEALTH [10303]","First Health",,54.57,80,,,,,0,7.93,57.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Video Larynscp Disp",PX-E27200457,CDM,E27200457,LOCAL,0272,RC,,,both,,,125.30,37.59,"NOVANET [10819]",Novanet,,93.98,75,,,,,0,14.57,106.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 20MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962335,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"MULTIPLAN [10600]",Multiplan,,12328.23,85,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL PERSONA AB CONE KNEE CENTRAL STERILE LATEX FREE",SUP-42545000508,CDM,C1776,HCPCS,0278,RC,,,both,,,29901.06,8970.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11960.42,40,,,,,0,3477.49,25415.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COOK-Z 5CM 35MM 16FR TRACHEOBRONCHIAL STAINLESS STEEL",SUP-G08556,CDM,C1877,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,495.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 35CM 20FR SUPRAPUBIC STENT LARGE OPEN NEPHRSTMY",SUP-M001224120,CDM,C1729,HCPCS,0272,RC,,,both,,,599.40,179.82,"MULTIPLAN [10600]",Multiplan,,509.49,85,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERTION KIT SENSATION  40CC",SUP-D884-00-0019-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,1482.46,444.74,"UHC [10700]","United Healthcare",,938.4,63.3,,,,,0,172.41,1260.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enzyme Act Nonrad Subs",PX-301000558,CDM,82657,CPT,0301,RC,,,both,,,785.00,235.5,"CIGNA [10200]","Cigna Local Plus",,48.77,,,,,,,0.79,667.25,"fee schedule",
"MASK CPAP MEDIUM 4 POINT HEADGEAR LEAK 1 ENTRAINMENT ELBOW",SUP-989805628681,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.49,61.95,"AETNA [10100]","Aetna HMO/PPO",,164.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.01,175.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 LEFT KNEE POSTERIOR STABILIZED CEMENTED",SUP-5515-F-701,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA [10200]","Cigna Local Plus",,5350,53.5,,5372.07,4581.20,7242.98,23,1163,8500,"percent of total billed charges",
"NAIL 12MM 170MM FEMUR PROXIMAL TFN-ADVANCED INTRAMEDULLARY",SUP-04.037.242S,CDM,C1713,HCPCS,0278,RC,,,both,,,8273.93,2482.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,980.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,962.26,7032.84,"percent of total billed charges",
"STENT WALLFLEX 40MM 10MM 8.5FR .035IN BILIARY RAPID EXCHANGE",SUP-M00570890,CDM,C1876,HCPCS,0278,RC,,,both,,,11927.41,3578.22,"KAISER [10500]",Kaiser,,7991.36,67,,,,,0,1387.16,10138.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Perc Asp Interdiscal Dx",PX-510000103,CDM,62267,CPT,0761,RC,,,both,,,3272.43,981.73,"PHCS [10601]",PHCS,,2290.7,70,,,,,0,380.58,2781.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Eynoel Add<=5cm Cmplx",PX-450000058,CDM,13153,CPT,0361,RC,,,both,,,1347.00,404.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,156.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,156.66,1347,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT SURGICAL TANDEM CUSTOM HIP PROC BIPOLAR LOW DEMAND",SUP-71701440,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1144.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1123.46,8211,"percent of total billed charges",
"OCCL CARDIOVASCULAR 9MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-009,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"AETNA [10100]","Aetna HMO/PPO",,16894.39,79.5,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 12CM 7FR DUODENAL BEND BILIARY PLASTIC TEMPORARY RAPID",SUP-M00545580,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"BLUE CROSS [10001]","Blue Cross PPO",,334.29,39.2,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 12CM 7FR DUODENAL BEND BILIARY PLASTIC TEMPORARY RAPID",SUP-M00545580,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,101.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG SQUARE 6X6IN ABSORBENT PAD SELF ADHERENT SILICONE",SUP-294399,CDM,S27200284,LOCAL,0272,RC,,,both,,,46.46,13.94,"FIRST HEALTH [10303]","First Health",,37.17,80,,,,,0,5.4,39.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR 44.5MM CARBIDE 5MM ROUND 8 FLUTE DENTAL",SUP-14-C0109,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.55,40.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,61.3,45.9,,,,,0,15.53,113.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30X13MM HEDRON IA 15D 24MM STERILE LATEX FREE",SUP-1212.0213S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"BLUE CROSS [10001]","Blue Cross PPO",,13582.8,39.2,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE 40X40X2.5MM POLYETHYLENE MEDPOR TSI",SUP-82007,CDM,C1713,HCPCS,0278,RC,,,both,,,4347.97,1304.39,"BLUE CROSS [10001]","Blue Cross PPO",,1704.4,39.2,,957.42,570.23,957.42,28,505.67,3695.77,"percent of total billed charges",
"DEVICE V-LOC 180 2-0 P-14 24IN CLSR ABSORBABLE PREMIUM",SUP-VLOCL0135,CDM,S27200284,LOCAL,0272,RC,,,both,,,262.83,78.85,"MULTIPLAN [10600]",Multiplan,,223.41,85,,,,,0,30.57,223.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 15MM KNEE SCORPIO",SUP-82-7-0715,CDM,C1776,HCPCS,0278,RC,,,both,,,10798.50,3239.55,"MULTIPLAN [10600]",Multiplan,,9178.73,85,,,,,0,1255.87,9178.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 30MM 120CM 6.5MM 6FR VASCULAR NITINOL",SUP-S-65-030-120-P6,CDM,C1874,HCPCS,0278,RC,,,both,,,12385.50,3715.65,"BLUE CROSS [10001]","Blue Cross PPO",,4855.12,39.2,,,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 12MM Y 11.8CMX15MM STERILE",SUP-0460,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.20,28.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.19,81.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER/DIVIDER BIPOLAR 37CM LIGASURE MARYLAND 350D 18MM 1",SUP-LF1937,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"FIRST HEALTH [10303]","First Health",,2700,80,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID KINEX BIOACTIVE PUTTY 10CC",SUP-8115.0310S,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2764.69,28.62,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 6MM 3.5MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012276-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 38.5CM 10FR 16GA HASKAL FLEXOR CHECK-FLO LIVER",SUP-G36126,CDM,C1894,HCPCS,0272,RC,,,both,,,4082.25,1224.67,"AETNA [10100]","Aetna HMO/PPO",,3245.39,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,474.77,3469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VALVE AORTIC 13MM 23MM AVALUS ULTRA 23MM BOVINE PERIC",SUP-400U23,CDM,S27800098,LOCAL,0278,RC,,,both,,,36225.00,10867.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10367.6,28.62,,,,,0,4212.97,30791.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR .035IN RC2",SUP-G08470,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 7.5MM BALL DISSECTING",SUP-MR8-9BA75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1187.46,356.24,"PHCS [10601]",PHCS,,831.22,70,,,,,0,138.1,1009.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 20MM 2.25MM ULTRA LOW PROFILE BALLOON",SUP-1012404-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X6MM GRAFTECH 7D 11MM CERVICAL CANCELLOUS",SUP-A80056,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMBOCATH INFUSION",SUP-ECP100,CDM,C1751,HCPCS,0272,RC,,,both,,,2145.00,643.5,"KAISER [10500]",Kaiser,,1437.15,67,,,,,0,249.46,1823.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK 24IN THERAPEUTIC SET COVER HOT MOIST CONTOUR TERRY",SUP-5662-85,CDM,S27000186,LOCAL,0270,RC,,,both,,,334.95,100.48,"FIRST HEALTH [10303]","First Health",,267.96,80,,,,,0,38.95,284.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PLLA HA 25MM 10MM 1.5MM ACL PCL CANNULATED",SUP-7209016,CDM,C1713,HCPCS,0278,RC,,,both,,,1882.13,564.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,223.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,218.89,1599.81,"percent of total billed charges",
"CATH LUBRICATH 16FR STD URETHRAL NATURAL RUBBER HYDROGEL 5ML",SUP-0119L16,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.52,23.26,"NOVANET [10819]",Novanet,,58.14,75,,,,,0,9.02,65.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 7CM 12MM GORE EXCLUDER ILIAC INTERNAL",SUP-HGB161207A,CDM,S27800098,LOCAL,0278,RC,,,both,,,19089.00,5726.7,"CIGNA [10200]","Cigna Local Plus",,6013.04,31.5,,,,,0,2220.05,16225.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE HA 20MM 8MM ACL BIOSURE",SUP-72201775,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22-24X27-32X9MM 8D LORDOTIC RING WEDGE",SUP-609,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CIGNA [10200]",Cigna,,12600,40,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7612,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Open Access",,3926.1,56.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 28CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155244190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"NOVANET [10819]",Novanet,,1065.26,75,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LD 6.1MM TRM CNCT KT",SUP-6810,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT 137CM 10MM 6FR 3MM .014IN BALLOON",SUP-2200-3010,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"PHCS [10601]",PHCS,,4105.5,70,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 150MM 75CM 5MM VASCULAR METAL SUPERFICIAL",SUP-H74939293051570,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXS VECTA 74 115CM .083-.087IN .074IN ASPIRATION SCOUT",SUP-INC-11597-115,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 6FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175262110,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"NOVANET [10819]",Novanet,,929.54,75,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CRE RX 5.5CM 12-13.5-15MM BALLOON DILATATION BILIARY",SUP-M00558890,CDM,C1726,HCPCS,0272,RC,,,both,,,2085.75,625.72,"UHC [10700]","United Healthcare",,1320.28,63.3,,,,,0,242.57,1772.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VIA DEMINERALIZE MINERALIZE CORTICAL CANCELLOUS",SUP-VCAMX-100000,CDM,S27800098,LOCAL,0278,RC,,,both,,,20790.00,6237,"KAISER [10500]",Kaiser,,13929.3,67,,,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 20MM 144CM 4MM",SUP-H7493941220400,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3562.99,45.9,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE SMR TITANIUM L40 MM OD6.5 MM SHOULDER REVISION",SUP-8420.15.050,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",180.93,1322.35,"percent of total billed charges",
"BASEPLT TIBIAL ATTUNE 4 KNEE CEMENT REVISION ROTATE PLATFORM",SUP-150660004,CDM,C1776,HCPCS,0278,RC,,,both,,,22629.60,6788.88,"BLUE CROSS [10001]","Blue Cross HMO",,8870.8,39.2,,5311.50,4717.44,5388.59,31,2631.82,19235.16,"percent of total billed charges",
"STENT 24CM 3CM 6FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175262010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CIGNA [10200]","Cigna Local Plus",,572.85,,,,,,,124.53,910.13,"percent of total billed charges",
"CATH NC EUPHORA 142CM 15MM 2.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP2515X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TANDEM 2 DUO ANCHOR SYSTEM LARGE",SUP-PN0610-618,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM AXSOS STAINLESS STEEL 2.5MM FULL THREAD",SUP-338634,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"CIGNA [10200]",Cigna,,156.54,68,,1831.33,1831.33,1831.33,16,26.77,195.67,"percent of total billed charges",
"STENT COMPLETE SE 60MM 130CM 8MM LONG VASCULAR NITINOL ILIAC",SUP-SC860LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"KAISER [10500]",Kaiser,,4854.15,67,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR HD 36CM 12-14FR ACCESS STAINLESS STEEL",SUP-M0062502250,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"NOVANET [10819]",Novanet,,735.5,75,,,,,0,114.05,833.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 4.00 X 24MM",SUP-H7493942824400,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"PHCS [10601]",PHCS,,4347,70,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL BIT SCR BIO-TENODESIS 4MM",SUP-AR-1204D,CDM,C1713,HCPCS,0278,RC,,,both,,,978.08,293.42,"NOVANET [10819]",Novanet,,733.56,75,,,,,0,113.75,831.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701062,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"PHCS [10601]",PHCS,,7945.35,70,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL O2 LOW FLOW PEDIATRIC SMALL VAPOTHERM .073-.11IN",SUP-MPS1500,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.76,14.93,"KAISER [10500]",Kaiser,,33.34,67,,,,,0,5.79,42.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 0 PREASSEMBLE BLADE MINI HANDLE LED LIGHT",SUP-040-06-0401U,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.42,18.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,42.45,68,,,,,0,7.26,53.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 55MM SOLERA CD HORIZON OSTEOGRIP TITANIUM",SUP-54840005555,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1110.3,8114.82,"percent of total billed charges",
"PROBE LASER G-PROBE ILLUMINATE BOX STERILE LATEX FREE",SUP-16200,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,239.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR GUIDE 33MM 3.2MM 3.5MM NEXGEN HEXAGON",SUP-590103533,CDM,C1713,HCPCS,0278,RC,,,both,,,880.07,264.02,"MULTIPLAN [10600]",Multiplan,,748.06,85,,,,,0,102.35,748.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 4.75MM SOLERA COCR MOLYBDENUM CURVED",SUP-1475501070,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",512.88,3748.5,"percent of total billed charges",
"CATH HEMOSPLIT XK 42CM 14.5FR ALPHACURVE HEMODIALYSIS",SUP-5744420,CDM,C1725,HCPCS,0272,RC,,,both,,,1897.50,569.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,224.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,220.68,1612.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH CARE PROVOX TRUTONE PLUS 12 PULMONARY BASE",SUP-6141,CDM,S27000186,LOCAL,0270,RC,,,both,,,8264.52,2479.36,"CIGNA [10200]","Cigna Open Access",,4702.51,56.9,,,,,0,961.16,7024.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR050202A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"AETNA [10100]","Aetna HMO/PPO",,14915.31,79.5,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 60MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.860,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CIGNA [10200]","Cigna Local Plus",,735.31,53.5,,3978.14,359.25,3978.14,24,159.84,1168.25,"percent of total billed charges",
"HC Transferrin",PX-301000419,CDM,84466,CPT,0301,RC,,,both,,,293.80,88.14,"NOVANET [10819]",Novanet,,220.35,75,,,,,0,0.29,249.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM FEMORAL CEMENT HIP",SUP-OSC366411,CDM,C1776,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2216.97,45.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 20MM 140CM 2.5MM CORONARY STENT PLATINUM",SUP-H7493927420250,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"MULTIPLAN [10600]",Multiplan,,3187.5,85,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Wound Cytal 2-Layer 5x5cm",PX-E63600041,CDM,Q4166,HCPCS,0636,RC,,,both,,,217.80,65.34,"KAISER [10500]",Kaiser,,145.93,67,,,,,0,25.81,185.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.138,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"PHCS [10601]",PHCS,,792.89,70,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 180CM 5.5CM 7.5FR 12-15MM ESOPHAGUS",SUP-M00558420,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,677.75,41.1,,,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR INFLATION DEVICE BASIXTOUCH 13IN ANALOG DISPLAY",SUP-IN8403,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.44,105.73,"CIGNA [10200]","Cigna Open Access",,200.54,56.9,,,,,0,40.99,299.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 15MM 145CM 3MM CORONARY STENT",SUP-1145300-15,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"FIRST HEALTH [10303]","First Health",,4670.4,80,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2MM HALF CIRCLE 32MM",SUP-3910900024,CDM,C1713,HCPCS,0278,RC,,,both,,,252.30,75.69,"CIGNA [10200]","Cigna Open Access",,143.56,56.9,,1144.80,304.56,2275.09,66,29.34,214.46,"percent of total billed charges",
"DEVICE EMBOTRAP II 37MM 5MM THROMBECTOMY",SUP-ET309537,CDM,C1757,HCPCS,0272,RC,,,both,,,40320.00,12096,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4777.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4689.22,34272,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 15MM 2MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG20015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 1.8X1.8CM NATURALLY POROUS NON-SIDED THIN",SUP-DP-03,CDM,Q4122,HCPCS,0636,RC,,,both,,,2625.00,787.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,311.06,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 2CM 10FR .035IN GENTLE CURVE BILIARY",SUP-G21463,CDM,C2617,HCPCS,0278,RC,,,both,,,729.00,218.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 46MM PEGGED TURON SHOULDER ALL POLY",SUP-520-01-246,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"UHC [10700]","United Healthcare",,5801.07,63.3,,8601.07,8395.67,8601.07,"1 through 10",1065.82,7789.74,"percent of total billed charges",
"STATSEAL POWDER",SUP-LP636,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"CIGNA [10200]","Cigna Local Plus",,139.64,53.5,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC COBALT HF 2 CHMBR DF-1 PIN PLUG IS4 INLINE",SUP-DTPB2Q1,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9118.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 19MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532-P-819,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"FIRST HEALTH [10303]","First Health",,6684.72,80,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE REVISION HYBRID CONCELOC OXI WITH CEMENTE",SUP-71704640,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"UHC [10700]","United Healthcare",,14755.23,63.3,,8601.07,8395.67,8601.07,"1 through 10",2710.95,19813.5,"percent of total billed charges",
"CMPNT FEMORAL 10 NARROW KNEE LEFT CRUCIATE RETAIN PERSONA",SUP-42508006801,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"UHC [10700]","United Healthcare",,16608.81,63.3,,8601.07,8395.67,8601.07,"1 through 10",3051.51,22302.5,"percent of total billed charges",
"TRAY INSTR 446X49X88MM 2 TELESCOPE",SUP-WA05990A,CDM,S27000186,LOCAL,0270,RC,,,both,,,1913.03,573.91,"NOVANET [10819]",Novanet,,1434.77,75,,,,,0,222.49,1626.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTERMSTIM SURESCAN  MRI LEAD KIT 4.32 MM SPACING -33 CM LEN",SUP-978B133,CDM,C1778,HCPCS,0278,RC,,,both,,,22050.00,6615,"NOVANET [10819]",Novanet,,16537.5,75,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3.5CM 2.5MM CEREPAK XTRASOFT FREEFORM",SUP-XCR122535,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS [10001]","Blue Cross PPO",,5184.53,39.2,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM NEXGEN LPS-FLEX 5-6 C-D KNEE PROLONG",SUP-596204110,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,938.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,920.91,6730.67,"percent of total billed charges",
"HC Inj Paravrt Jt C/T >= 3 Lvl Bi",PX-510000137,CDM,64492,CPT,0761,RC,,,both,,,1734.00,520.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1734,,"Per diem ($1,793).",,,,0,201.66,1734,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECTRUM LOPRO S4 DISPOSABLE BLADES",SUP-0270-1079,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"CIGNA [10200]","Cigna Open Access",,198.01,56.9,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 42MM 22MM TANDEM HIP ACETABULAR COCR",SUP-71322042,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"CIGNA [10200]","Cigna Open Access",,4752.54,56.9,,5302.19,4377.88,6578.61,27,971.39,7099.58,"percent of total billed charges",
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 60X12-13MM",SUP-400731,CDM,S27800098,LOCAL,0278,RC,,,both,,,4264.20,1279.26,"CIGNA [10200]","Cigna Local Plus",,2281.35,53.5,,,,,0,495.93,3624.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL MITRACLIP BUNDLE 1 SGC0301 1 CDS0601 NTR 2",SUP-MBR0303,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]","Cigna Local Plus",,53865,31.5,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN SUCTION SHORT CURVE 3MM 5.75IN STAINLESS STEEL SINUS",SUP-63-7562,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.61,80.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,110.81,41.1,,,,,0,31.36,229.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7-8 9MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71934438,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"FIRST HEALTH [10303]","First Health",,9737.28,80,,,,,0,1415.56,10345.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 5FR 70CM POWERPICC 2 LUMEN GWIRE NITINOL .018IN",SUP-3275355,CDM,C1751,HCPCS,0272,RC,,,both,,,678.94,203.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,78.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.96,577.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 70CM 5FR MICROPUNCTURE .018IN LONG COAXIAL CATH",SUP-G49472,CDM,C1894,HCPCS,0272,RC,,,both,,,401.59,120.48,"NOVANET [10819]",Novanet,,301.19,75,,,,,0,46.7,341.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOCUSATE SODIUM 100 MG CAPSULE",RX-2566,CDM,,,0637,RC,60687-0129-11,NDC,both,1,UN,6.27,1.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2.58,41.1,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE 3CM 18-24MM CRYOVALVE AORTIC",SUP-AV00,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7292.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 55MM EVEREST SPINE CANNULATED POLYAXIAL MIS",SUP-M5111-07555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"INFLUX SPARC 1CC",SUP-IFLX-CM-01,CDM,S27800098,LOCAL,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SURGITIE 0 18IN LIGATING LOOP ANCHORED ABSORBABLE",SUP-SGL-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.14,32.44,"CIGNA [10200]",Cigna,,73.54,68,,,,,0,12.58,91.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 10.5X3IN WRIST RIGHT DELUXE BETA PILE II",SUP-95-985,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.69,33.81,"CIGNA [10200]","Cigna Open Access",,64.12,56.9,,,,,0,13.11,95.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDO 0 MH SPIRAL 30CM SUT ABSORBABLE",SUP-SXPD2B411,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.43,54.43,"CIGNA [10200]",Cigna,,123.37,68,,,,,0,21.1,154.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hfo W/Joint(S) Cf",PX-E27400035,CDM,L3921,HCPCS,0274,RC,,,both,,,815.10,244.53,"CIGNA [10200]","Cigna Open Access",,463.79,56.9,,,,,0,94.8,692.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINR 90CM 2MM 7FR 2-5-2MM SPACE 2XL CURVE ABLATION",SUP-072302,CDM,C1730,HCPCS,0272,RC,,,both,,,4209.00,1262.7,"AETNA [10100]","Aetna HMO/PPO",,3346.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,489.51,3577.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 34MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.534,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE UNICORTICAL DOWEL ALLOGRAFT FREEZE DRY 14-40MM 12",SUP-400200,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"NOVANET [10819]",Novanet,,3182.63,75,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 38MM 145CM 4MM CORONARY STENT",SUP-1125400-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) OCCLUDER CARDIOVASCULAR 10X22-25MM 28MM 35MM HEMOSTAS",SUP-9-ACP2-010-028,CDM,C1817,HCPCS,0278,RC,,,both,,,96900.00,29070,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11482.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11269.47,82365,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 15MM TRILOGY HIP ACETABULAR SELF TAP STERILE",SUP-00625006515,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,457.3,45.9,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 30X10X7MM 0D EXPAND NONSTERILE",SUP-823007,CDM,S27800098,LOCAL,0278,RC,,,both,,,6094.49,1828.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1744.24,28.62,,,,,0,708.79,5180.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE RIGHT POSTERIOR STABILIZE BEAD",SUP-5516F802,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7117.26,41.1,,6417.48,6417.48,6417.48,"1 through 10",2013.96,14719.4,"percent of total billed charges",
"LINER ACETABULAR VIVACIT-E JJ ELEVATED 54MM 36MM HIP",SUP-00885201136,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6971.37,68,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 8- CM 22GA 1.65MM NITINOL 2.4MM BEVEL 1 WAY",SUP-M00555511,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 16MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-816,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3266.29,28.62,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 35X13MM CONTINENTAL 15D 24MM MEDIUM PEEK",SUP-364.613CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE 20MM 8MM BIOSURE REGENESORB",SUP-72204398,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"BLUE CROSS [10001]","Blue Cross PPO",,1087.42,39.2,,957.42,570.23,957.42,28,322.62,2357.93,"percent of total billed charges",
"DEVICE STRATAFIX 0 CTX 45CM 48MM CLSR PDS PLUS VIOLET",SUP-SXPP1A402,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 3FT 9 POLE ABLATION QUICK CONNECT THERMISTOR POD",SUP-0651,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 12MMX.6MM UNIVERSAL NEURO III DOG",SUP-53-36212,CDM,C1713,HCPCS,0278,RC,,,both,,,913.44,274.03,"BLUE CROSS [10001]","Blue Cross PPO",,358.07,39.2,,957.42,570.23,957.42,28,106.23,776.42,"percent of total billed charges",
"LINER ACETABULAR PINNACLE NEUTRAL 54MM 36MM ALTRX HIP",SUP-122136054,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"AETNA [10100]","Aetna HMO/PPO",,8228.25,79.5,,10981.53,8986.79,12413.38,12,1203.71,8797.5,"percent of total billed charges",
"ROSUVASTATIN 5 MG TABLET",RX-36612,CDM,,,0637,RC,60687-0234-11,NDC,both,1,UN,27.01,8.1,"NOVANET [10819]",Novanet,,20.26,75,,,,,0,3.14,22.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 55MM 14MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113614,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3606.12,28.62,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 2.8MM MIDFOOT SALVATION INTRAMEDULLARY DRILL",SUP-SMN10010,CDM,S27200284,LOCAL,0272,RC,,,both,,,3105.00,931.5,"PHCS [10601]",PHCS,,2173.5,70,,,,,0,361.11,2639.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LEMAITRE 80CM 7FR 14MM C1.75ML EMBOLECTOMY 1 LUMEN",SUP-E1601-78,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,71.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP838D,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"KAISER [10500]",Kaiser,,16.75,67,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 4.9CC 17X17X17MM DEMINERALIZED CANCELLOUS",SUP-0W1017,CDM,S27800098,LOCAL,0278,RC,,,both,,,5658.00,1697.4,"FIRST HEALTH [10303]","First Health",,4526.4,80,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X9MM ADVANCED LORDOTIC TRAPEZOIDAL",SUP-7709,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"PHCS [10601]",PHCS,,5796,70,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT COMPREHENSIVE GLENOID SHOULDER TRABECULA",SUP-98000900027,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"KAISER [10500]",Kaiser,,32501.7,67,,,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 180MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-410-180,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASHIR ENDOVASCULAR CATHETER",SUP-7201,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 55CM .1IN 6FR .07IN",SUP-67027055,CDM,C1887,HCPCS,0272,RC,,,both,,,304.50,91.35,"NOVANET [10819]",Novanet,,228.38,75,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bag Infusor Pressure",PX-E27000046,CDM,E27000046,LOCAL,0270,RC,,,both,,,157.30,47.19,"CIGNA [10200]","Cigna Open Access",,89.5,56.9,,,,,0,18.29,133.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bag Infusor Pressure",PX-E27000046,CDM,E27000046,LOCAL,0270,RC,,,both,,,157.30,47.19,"NOVANET [10819]",Novanet,,117.98,75,,,,,0,18.29,133.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC",251,MS-DRG,,,,,,,inpatient,,,118993.67,35698.1,"BLUE CROSS [10001]","Blue Cross PPO",,36894.8,,,,,,,9270.48,43633.42,"case rate",
"BOLT SPINAL 30MM 5MM DECADE SMALL THREAD PLATE EXTREME",SUP-7145030,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,743.58,45.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXIBLE CRYOPROBE SINGLE USE 1.1 MM LENGTH 1150",SUP-20402-401,CDM,C2618,HCPCS,0272,RC,,,both,,,3442.50,1032.75,"MULTIPLAN [10600]",Multiplan,,2926.13,85,,,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Mphmtrc Alys / Add on 88360",PX-312000100,CDM,0763T,CPT,0312,RC,,,both,,,100.00,30,"CIGNA [10200]",Cigna,,68,68,,,,,0,11.85,85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,J1644,HCPCS,0636,RC,63323-0262-03,NDC,both,1,ML,37.69,11.31,"BLUE CROSS [10001]","Blue Cross HMO",,1.22,,,,,,,1.06,32.04,"fee schedule",
"CAP CONSTRUCT TOTAL SHOULDER/ WITH AUGMENTED GLENOID","SUP-CON ANATOMIC AG",CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"FIRST HEALTH [10303]","First Health",,23940,80,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 11CM 5FR TAPER PANCREATIC POLYETHYLENE SPIRAL",SUP-G27194,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"FIRST HEALTH [10303]","First Health",,505.44,80,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Venous Sampling Thru Cath Si",PX-323000033,CDM,75893,CPT,0323,RC,,,both,,,5060.84,1518.25,"BLUE CROSS [10001]","Blue Cross HMO",,256.98,,"Fee schedule rate ($256.98).",,,,0,125.43,5060.84,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 55MM 13MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113613,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS [10001]","Blue Cross HMO",,4939.2,39.2,,5311.50,4717.44,5388.59,31,1465.38,10710,"percent of total billed charges",
"SCISSORS OPHTHALMIC 25GA PINNACLE 360 MORRIS RETINA",SUP-10.24.25PIN,CDM,S27200284,LOCAL,0272,RC,,,both,,,1503.83,451.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1022.6,68,,,,,0,174.9,1278.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2-0 FS 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8685H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 345CC",SUP-SSZ-M345,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"KAISER [10500]",Kaiser,,998.57,67,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 4MM 1.2MM 32MM 14MM STAINLESS STEEL LONG THREAD",SUP-202.732,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,129.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",129.1,943.52,"percent of total billed charges",
"STEM FEMORAL 235MM 24MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-324,CDM,C1776,HCPCS,0278,RC,,,both,,,18758.25,5627.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2181.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2181.58,15944.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 1 KNEE PRIMARY CEMENT",SUP-5520B100,CDM,C1776,HCPCS,0278,RC,,,both,,,7151.76,2145.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,847.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,831.75,6079,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT COMPREHENSIVE VIVACIT-E TRABECULAR METAL",SUP-98000900075,CDM,C1776,HCPCS,0278,RC,,,both,,,54810.00,16443,"AETNA [10100]","Aetna HMO/PPO",,43573.95,79.5,,10981.53,8986.79,12413.38,12,6374.4,46588.5,"percent of total billed charges",
"INQUIRY 6F STEER OCT 1108-6-25-L",SUP-IBI-81809,CDM,C1730,HCPCS,0272,RC,,,both,,,2178.75,653.62,"AETNA [10100]","Aetna HMO/PPO",,1732.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,253.39,1851.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 10MM AXIUM 3D FRAME V01",SUP-FC-10-20-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1921.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 10X20 135CM SL",SUP-48010002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,584.13,68,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ivus Noncoronary Addl",PX-361000397,CDM,37253,CPT,0361,RC,,,both,,,3756.77,1127.03,"MULTIPLAN [10600]",Multiplan,,3193.25,85,,,,,0,436.91,3756.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 15MM KII Z THREAD SLEEVE LATEX",SUP-C0R39,CDM,S27200284,LOCAL,0272,RC,,,both,,,413.25,123.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,189.68,45.9,,,,,0,48.06,351.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 26FR 20CM 13CM DIL PEEL-AWAY LARGE PERCUTANEOUS",SUP-G06447,CDM,C1892,HCPCS,0272,RC,,,both,,,382.71,114.81,"NOVANET [10819]",Novanet,,287.03,75,,,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MONTEREY AL STAND-ALONE ANTERIOR LUMBAR ANTERIOR LUMBAR CAGE",SUP-480110531,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA [10200]","Cigna Local Plus",,10914.75,31.5,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE VISI-BLACK 5-0 C-1 24IN 2 ARM MONOFILAMENT BLUE",SUP-8725H,CDM,S27200284,LOCAL,0272,RC,,,both,,,150.18,45.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,68.93,45.9,,,,,0,17.47,127.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 7FR AL1 CURVE GUIDING CORONARY SIDEHOLE",SUP-LA7AL10SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"KAISER [10500]",Kaiser,,262.31,67,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 15MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50015,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,34123.16,41.1,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 10MM 9FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEM10100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"FIRST HEALTH [10303]","First Health",,14616,80,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM HEALIX ADVANCE CORD PEEK-OPTIMA",SUP-222303,CDM,C1713,HCPCS,0278,RC,,,both,,,2977.50,893.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,346.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",346.28,2530.88,"percent of total billed charges",
"SCR BONE 12.7MM 140MM 22MM DHS/DCS STAINLESS STEEL CONDYLAR",SUP-280.4,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"BLUE CROSS [10001]","Blue Cross PPO",,712.8,39.2,,957.42,570.23,957.42,28,211.48,1545.62,"percent of total billed charges",
"SCR BONE 7.5MM 50MM EVEREST SPINE CANNULATED POLYAXIAL MIS",SUP-M5111-07550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"SUT VICRYL 1 CT-1 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J347H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 14MM MINI-MONSTER SHORT THREAD CANNULATED",SUP-P20-120-014S,CDM,C1713,HCPCS,0278,RC,,,both,,,1559.25,467.77,"MULTIPLAN [10600]",Multiplan,,1325.36,85,,,,,0,181.34,1325.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00185,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,129.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 39MM UNIVERS REVERS +3MM MEDIUM SHOULDER",SUP-AR-9503M-03,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"NOVANET [10819]",Novanet,,2205,75,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINE SAMPLING L6.5FT CO2 DEHUMIDIFICATION WITH MALE LUER CON",SUP-2013069-002VY,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.45,26.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,40.14,45.9,,,,,0,10.17,74.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERSNARE 2 26IN CLOSED LOOP BLUE WHITE 2IN",SUP-AR-7209SNL,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.03,267.91,"AMERIGROUP MEDICAID [20100]",Amerigroup,,105.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.86,759.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM AXSOS STAINLESS STEEL 2.5MM FULL THREAD",SUP-338618,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,65.88,28.62,,,,,0,26.77,195.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 109MM 14MM INSIGNIA 7 14 HIGH OFFSET 41MM HIP",SUP-7000-6607,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"MULTIPLAN [10600]",Multiplan,,25987.82,85,,,,,0,3555.74,25987.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alk Phosphatase Isoenzymes",PX-301000357,CDM,84080,CPT,0301,RC,,,both,,,207.10,62.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,52.48,,,,,,,0.01,176.04,"fee schedule",
"SYSTEM TIGHTROPE FIXATION DELTOID LIGAMENT RECONSTRUCTION",SUP-AR-8918CP,CDM,C1713,HCPCS,0278,RC,,,both,,,14163.98,4249.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1678.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1647.27,12039.38,"percent of total billed charges",
"SUB SKIN 16X8CM STRATTICE PORCINE DERMAL MATRIX FIRM PATCH",SUP-0816001,CDM,Q4130,HCPCS,0636,RC,,,both,,,19555.20,5866.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2317.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2317.29,16621.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REVCORE THROMBECTOMY REVCORE THROMBECTOMY CATH STERILE",SUP-44-101,CDM,C1757,HCPCS,0272,RC,,,both,,,40950.00,12285,"AETNA [10100]","Aetna HMO/PPO",,32555.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4762.49,34807.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC .034IN CALIBRATE LASER LINE THREAD TROCAR",SUP-AR-8737-40,CDM,C1769,HCPCS,0272,RC,,,both,,,226.20,67.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US OB > 1st Trimst Txabd Sngl",PX-402000016,CDM,76805,CPT,0402,RC,,,both,,,1394.28,418.28,"MULTIPLAN [10600]",Multiplan,,1185.14,85,,,,,0,139.53,1185.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COENZYME Q10  50 MG CAPSULE",RX-35228,CDM,,,0637,RC,40093-0102-32,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,3.35,53.5,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 23X9X9MM CONCORDE PARALLEL BULLET NOSE",SUP-187823109,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"KAISER [10500]",Kaiser,,11095.2,67,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT",RX-120629,CDM,,,0250,RC,45802-0143-00,NDC,both,1,UN,12.54,3.76,"NOVANET [10819]",Novanet,,9.41,75,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION",RX-179846,CDM,,,0250,RC,46287-0020-20,NDC,both,5,ML,179.80,53.94,"FIRST HEALTH [10303]","First Health",,143.84,80,,,,,0,20.91,152.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 3IN ON-Q QUIKBLOC DEHP OVER THE NDL STERILE",SUP-QB10016SGC,CDM,S27200305,LOCAL,0272,RC,,,both,,,328.86,98.66,"FIRST HEALTH [10303]","First Health",,263.09,80,,,,,0,38.25,279.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WARFARIN 1.25 MG TABLET (PARTIAL OF 2.5 MG TABLET)",RX-408648,CDM,,,0637,RC,08888-8886-81,NDC,both,1.25,ME,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hba1/Hba2 Gene",PX-309000035,CDM,81257,CPT,0310,RC,,,both,,,494.00,148.2,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,419.9,"per diem",
"SHEATH HEARTSPAN 120D FIX CURVE TAPER 79.4CM 8.5FR GUIDING",SUP-FCL-160-09,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE 7FR CLSR VASCULAR LATEX FREE",SUP-EX700,CDM,C1760,HCPCS,0278,RC,,,both,,,1166.40,349.92,"KAISER [10500]",Kaiser,,781.49,67,,,,,0,135.65,991.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 100CM 40MM 6MM BALLOON",SUP-LX181006405F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"PHCS [10601]",PHCS,,4709.25,70,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOSCOPIC APPL 41 CM",SUP-0600225,CDM,S27200284,LOCAL,0272,RC,,,both,,,482.61,144.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,56.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.13,410.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CARTO XP LASSO 115CM 7FR 20MM 6MM SPACING D CURVE",SUP-DLN2220CT,CDM,C1732,HCPCS,0272,RC,,,both,,,12889.20,3866.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1499.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1499.01,10955.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 12.9CM MEMORYGEL P3.3CM MODERATE PROFILE SILTEX",SUP-3543207MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE RIGHT CRUCIATE RETAIN GENESIS II LEGION",SUP-71421224,CDM,C1776,HCPCS,0278,RC,,,both,,,28831.95,8649.58,"UHC [10700]","United Healthcare",,18250.62,63.3,,8601.07,8395.67,8601.07,"1 through 10",3353.16,24507.16,"percent of total billed charges",
"(EVAL) CATHETER ENDOSCOPIC 2200MM X 1.8MM BLUE HANDLE FOR SP",SUP-WP-18/2200,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.37,36.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.12,103.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM STAINLESS STEEL T8 SELF TAP LOCK",SUP-02.210.118TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1011.53,303.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,117.64,859.8,"percent of total billed charges",
"JOINT TOE LPT 3 REGULAR GREAT TOE",SUP-487S003,CDM,C1776,HCPCS,0278,RC,,,both,,,11585.10,3475.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4634.04,40,,,,,0,1347.35,9847.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 42MM GORILLA R3CON LOCK",SUP-P50-353-4242,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,523.91,39.2,,957.42,156.86,7483.26,51,155.43,1136.03,"percent of total billed charges",
"CLAMP CIRCUMCISION ADULT 21MM STAINLESS STEEL REUSABLE GOMCO",SUP-51-9921,CDM,S27200284,LOCAL,0272,RC,,,both,,,1462.78,438.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,173.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,170.12,1243.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP FEM N/POROUS SIZE 6 LEFT",SUP-2153-0-0006,CDM,C1776,HCPCS,0278,RC,,,both,,,10151.40,3045.42,"BLUE CROSS [10001]","Blue Cross HMO",,3979.35,39.2,,5311.50,4717.44,5388.59,31,1180.61,8628.69,"percent of total billed charges",
"STENT POLARIS SENSOR 30CM 8FR .035IN BLADDER LOOP LOW",SUP-M006155255090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"FIRST HEALTH [10303]","First Health",,1090.19,80,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 22MM MEDIUM HIP X3 38MM",SUP-1236-2-244,CDM,C1776,HCPCS,0278,RC,,,both,,,7518.42,2255.53,"NOVANET [10819]",Novanet,,5638.82,75,,,,,0,874.39,6390.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 10MM 6MM MEDIUM CARBIDE ROUND HEAD FLUTED TPS",SUP-5120-010-060,CDM,S27200284,LOCAL,0272,RC,,,both,,,668.25,200.47,"CIGNA [10200]","Cigna Local Plus",,357.51,53.5,,,,,0,77.72,568.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 160MM 10MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424043,CDM,C1776,HCPCS,0278,RC,,,both,,,12181.95,3654.58,"MULTIPLAN [10600]",Multiplan,,10354.66,85,,,,,0,1416.76,10354.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR TRUWAVE STERILE DISPOSABLE MODEL PX600F",SUP-PX284,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.36,35.21,"FIRST HEALTH [10303]","First Health",,93.89,80,,,,,0,13.65,99.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Cath Femoral Artery Arrow",PX-E27200151,CDM,E27200151,LOCAL,0272,RC,,,both,,,287.10,86.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,34.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION MEDIUM COMBINATION SELF HOLDING CLIP",SUP-390.031,CDM,S27000186,LOCAL,0270,RC,,,both,,,3469.20,1040.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,411.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,403.47,2948.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MTRL SPLINTING THK1/8IN SMALL STATURE 24X18IN OPTIPERF",SUP-550549,CDM,S27000186,LOCAL,0270,RC,,,both,,,630.50,189.15,"CIGNA [10200]",Cigna,,428.74,68,,,,,0,73.33,535.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 13MM LCP STAINLESS STEEL SMALL BONE T6",SUP-201.883,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"MULTIPLAN [10600]",Multiplan,,599.55,85,,,,,0,82.03,599.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 15D 10.5-12 13.5+ LARGE CONTACT CLSR",SUP-HS1005-14,CDM,S27000186,LOCAL,0270,RC,,,both,,,128.06,38.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.89,108.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABSORBER CARBON DIOXIDE PREFILL SEAL CANSTR MEDISORB EF EX",SUP-2079797-001,CDM,S27000186,LOCAL,0270,RC,,,both,,,169.74,50.92,"CIGNA [10200]","Cigna Open Access",,96.58,56.9,,,,,0,19.74,144.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 15D 10.5-12 13.5+ LARGE CONTACT CLSR",SUP-HS1005-14,CDM,S27000186,LOCAL,0270,RC,,,both,,,128.06,38.42,"PHCS [10601]",PHCS,,89.64,70,,,,,0,14.89,108.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 8.5IN CASTROVIEJO DUROGRIP SERRATE NDL TUNGSTEN",SUP-BM005R,CDM,S27000186,LOCAL,0270,RC,,,both,,,2035.95,610.78,"PHCS [10601]",PHCS,,1425.17,70,,,,,0,236.78,1730.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 8.5IN CASTROVIEJO DUROGRIP SERRATE NDL TUNGSTEN",SUP-BM005R,CDM,S27000186,LOCAL,0270,RC,,,both,,,2035.95,610.78,"MULTIPLAN [10600]",Multiplan,,1730.56,85,,,,,0,236.78,1730.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL BIT ORTHOPEDIC CANNULATED 1.8MM",SUP-DRLL-DIP-18,CDM,S27000186,LOCAL,0270,RC,,,both,,,1815.00,544.5,"UHC [10700]","United Healthcare",,1148.9,63.3,,,,,0,211.08,1542.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 87/91MMX12MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183582,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"NOVANET [10819]",Novanet,,5879.84,75,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VISIGI 3D 36FR GASTRIC LAVAGE BULB",SUP-5236B,CDM,S27000186,LOCAL,0270,RC,,,both,,,1792.50,537.75,"MULTIPLAN [10600]",Multiplan,,1523.63,85,,,,,0,208.47,1523.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION 4.5MM 8MM CORONARY OSTIUM",SUP-OCB4508BA,CDM,C1725,HCPCS,0272,RC,,,both,,,6900.00,2070,"AMERIGROUP MEDICAID [20100]",Amerigroup,,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 20FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0168L20,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.78,22.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,34.78,45.9,,,,,0,8.81,64.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Brain Perfsn W Cntrst W CT/Cta Add-On",PX-351000019,CDM,70472,CPT,0351,RC,,,both,,,1352.72,405.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,742,,,,,,,157.32,1352.72,"per diem",
"CNCT ROD MEDIUM TSRH TITANIUM SPINAL 3DX",SUP-8351521,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Open Access",,5432.16,56.9,,1144.80,304.56,2275.09,66,1110.3,8114.82,"percent of total billed charges",
"SCR BONE 7.5MM 50MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850017550,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1876.04,28.62,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD POSITIONING JACKSON SET TABLE",SUP-5808,CDM,S27000186,LOCAL,0270,RC,,,both,,,231.77,69.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,157.6,68,,,,,0,26.95,197,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000120,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,463.64,28.62,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 120MM GRAY FLEXIBLE SURGICAL 12MM STERILE",SUP-6210-0-710,CDM,S27200284,LOCAL,0272,RC,,,both,,,1965.00,589.5,"PHCS [10601]",PHCS,,1375.5,70,,,,,0,228.53,1670.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION VORTEX PEELPRO TITANIUM SILICONE",SUP-P5455K,CDM,C1788,HCPCS,0278,RC,,,both,,,6651.60,1995.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4523.09,68,,,,,0,773.58,5653.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 58.5MM 1.6MM LONG CROSS CUT TAPER CARBIDE",SUP-2296101216,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.64,16.99,"UHC [10700]","United Healthcare",,35.85,63.3,,,,,0,6.59,48.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 37.5MM TRIGEN FEMUR LOW PROFILE",SUP-71645037,CDM,C1713,HCPCS,0278,RC,,,both,,,2846.25,853.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,337.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,331.02,2419.31,"percent of total billed charges",
"AWL ORTHOPEDIC 4.75MM ALPHA VENT OMEGA AWL",SUP-3910-947-201,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.00,513,"KAISER [10500]",Kaiser,,1145.7,67,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM VARIAX TORX TITANIUM FULL THREAD T10",SUP-40-35018,CDM,C1713,HCPCS,0278,RC,,,both,,,612.36,183.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,175.26,28.62,,,,,0,71.22,520.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.165,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Open Access",,391.76,56.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch Unlstd Proc",PX-750000192,CDM,31899,CPT,0750,RC,,,both,,,3924.00,1177.2,"AETNA [10100]","Aetna HMO/PPO",,3119.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,456.36,3924,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DABIGATRAN ETEXILATE 75 MG CAPSULE",RX-106490,CDM,,,0637,RC,00597-0355-56,NDC,both,1,UN,19.96,5.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13.57,68,,,,,0,2.32,16.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 42MM NAIL-EX TITANIUM FULL THREAD HUMERAL",SUP-04.005.432,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"AMERIGROUP MEDICAID [20100]",Amerigroup,,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",134.52,983.18,"percent of total billed charges",
"HC Dest L/S Facet Jnt Add",PX-510000157,CDM,64636,CPT,0761,RC,,,both,,,1988.00,596.4,"NOVANET [10819]",Novanet,,1491,75,,,,,0,231.2,1988,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM SPINE PLY NONSTERILE 4MM ROD",SUP-102035114,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"HC Ins Cath Cv Tunlw/O Port<5yrs",PX-361000498,CDM,36557,CPT,0361,RC,,,both,,,8549.00,2564.7,"KAISER [10500]",Kaiser,,5727.83,67,,,,,0,994.25,8549,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 25CM 14FR .038IN DRNG HYDROPHILIC ULTRATHANE 6 SIDEPORT",SUP-G09504,CDM,C1729,HCPCS,0272,RC,,,both,,,761.32,228.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,90.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,88.54,647.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 90MM 16MM 5.4MM 14FR ZENITH SPIRAL-Z",SUP-G55239,CDM,C1874,HCPCS,0278,RC,,,both,,,19435.50,5830.65,"BLUE CROSS [10001]","Blue Cross PPO",,7618.72,39.2,,,,,0,2260.35,16520.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tomosynthesis Breast Dgtl Dx Bi",PX-401000009,CDM,77062,CPT,0401,RC,,,both,,,621.66,186.5,"NOVANET [10819]",Novanet,,466.25,75,,,,,0,72.3,528.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Impacted Cerumen",PX-450000304,CDM,69210,CPT,0361,RC,,,both,,,1527.04,458.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,177.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,177.59,1527.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL TWIST 125MM 2.4MM TWIST STERILE",SUP-166-00-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.04,24.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,36.74,45.9,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND SCLERAL 2X0.75MM TYPE 40 30MM 2.1MM SILICONE TYPE 70",SUP-S5.3000,CDM,S27800098,LOCAL,0278,RC,,,both,,,93.67,28.1,"MULTIPLAN [10600]",Multiplan,,79.62,85,,,,,0,10.89,79.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 18MM TARGET XL 360D STD LARGE",SUP-M0036101850,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 4 KNEE RIGHT CRUCIATE RETAIN BEAD TRIATHLO",SUP-5517F402,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"NOVANET [10819]",Novanet,,12855.02,75,,,,,0,1993.39,14569.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 31CM REPLACEMENT SPARE 30675ND SPLIT",SUP-26175NE,CDM,S27200284,LOCAL,0272,RC,,,both,,,1123.88,337.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,764.24,68,,,,,0,130.71,955.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 4CM 5.5MM TSRH SILO STD PEDICLE TITANIUM PREBENT",SUP-8370040,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"MULTIPLAN [10600]",Multiplan,,3748.5,85,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 15MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45015,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22416.67,27,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS",RX-15859,CDM,J2305,HCPCS,0636,RC,00338-1049-02,NDC,both,250,ML,203.85,61.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,29.6,,,,,,,17.37,173.27,"fee schedule",
"OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC",166,MS-DRG,,,,,,,inpatient,,,100065.18,30019.55,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,23880.74,,"Case rate ($23,185.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $21,529.01, add-ons for qualifying new technology services are included. If operating cost exceeds $54,568.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,009.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $21,557.48. The transfer operating threshold is the transfer adjustment factor * $21,529.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,627.70. The transfer capital threshold is the transfer adjustment factor * $1,627.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,100065.18,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 11CM ROTATE SUT COLLAR KINK RESISTANT CANN",SUP-504607A,CDM,C1894,HCPCS,0272,RC,,,both,,,72.65,21.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,49.4,68,,,,,0,8.45,61.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 194MM 100MM 8MM 9FR BILIARY PERMALUME",SUP-M00547460,CDM,C1874,HCPCS,0278,RC,,,both,,,17194.52,5158.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4642.52,27,,,,,0,1999.72,14615.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 3N 6MM",SUP-TPS-030-063N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 6FR HS2 CURVE GUIDING SIDEHOLE",SUP-LA6HS2SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"KAISER [10500]",Kaiser,,244.82,67,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM T15 LOCK MULTIDIRECTIONAL NONSTERILE",SUP-110018020,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,852.02,45.9,,,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 78CM LEFT VENTRICLE CORONARY VEIN OTW UNIPOLAR",SUP-419378,CDM,C1900,HCPCS,0278,RC,,,both,,,6064.80,1819.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,705.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,705.34,5155.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNAP(R) CARTRIDGE - 125 MM HG - 10 IN A CASE",SUP-SNPA125,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"NOVANET [10819]",Novanet,,765.45,75,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-55840016540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,3978.14,359.25,3978.14,24,641.98,4692,"percent of total billed charges",
"REVERSE RSP MONOBLOCK REVISION HUMERAL STEM, 220MM, 8X220MM",SUP-510-08-220,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"KAISER [10500]",Kaiser,,8442,67,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 11X11X7MM CORNERSTONE PSR PEEK LUMBAR",SUP-6276711,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,776.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL RESTORELLE Y CONTOUR MERIDIAN VPS POLYPROPYLEN",SUP-52081,CDM,C1781,HCPCS,0278,RC,,,both,,,10984.80,3295.44,"BLUE CROSS [10001]","Blue Cross HMO",,4306.04,39.2,,,,,0,1277.53,9337.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC",468,MS-DRG,,,,,,,inpatient,,,135034.45,40510.33,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,18239.23,,"Case rate ($17,046.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $15,828.38, add-ons for qualifying new technology services are included. If operating cost exceeds $48,868.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,578.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $15,849.31. The transfer operating threshold is the transfer adjustment factor * $15,828.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,196.70. The transfer capital threshold is the transfer adjustment factor * $1,196.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,17046.01,80230.61,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 120MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530120S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 8MM DCP STAINLESS STEEL CORTICAL SELF TAPPING",SUP-200.808,CDM,C1713,HCPCS,0278,RC,,,both,,,365.40,109.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",42.5,310.59,"percent of total billed charges",
"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC",497,MS-DRG,,,,,,,inpatient,,,46072.79,13821.84,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,7720.01,,"Case rate ($7,495.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,959.76, add-ons for qualifying new technology services are included. If operating cost exceeds $39,999.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,908.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $6,968.97. The transfer operating threshold is the transfer adjustment factor * $6,959.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $526.19. The transfer capital threshold is the transfer adjustment factor * $526.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7495.16,35277.53,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 11CM 2.9MM XPS INFERIOR TURBINATE STERILE",SUP-1882940,CDM,S27200284,LOCAL,0272,RC,,,both,,,2349.00,704.7,"MULTIPLAN [10600]",Multiplan,,1996.65,85,,,,,0,273.19,1996.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 7 STD KNEE RIGHT KEEL NONPOROUS",SUP-ETPKN7SR,CDM,C1776,HCPCS,0278,RC,,,both,,,15193.80,4558.14,"CIGNA [10200]","Cigna Local Plus",,4786.05,31.5,,5372.07,4581.20,7242.98,23,1767.04,12914.73,"percent of total billed charges",
"CATHETER GD 90CM 6FR RWY RCB CRV",SUP-H74938969240,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE 4 % TOPICAL CREAM",RX-23461,CDM,,,0637,RC,24357-0701-05,NDC,both,5,GR,26.42,7.93,"NOVANET [10819]",Novanet,,19.82,75,,,,,0,3.07,22.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLARED SECUR-FIT HYDROXYAPATITE 11 HIP",SUP-S-2337-HF11,CDM,C1776,HCPCS,0278,RC,,,both,,,16482.96,4944.89,"MULTIPLAN [10600]",Multiplan,,14010.52,85,,,,,0,1916.97,14010.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immunoassy Tumor Ca 125",PX-302000057,CDM,86304,CPT,0302,RC,,,both,,,511.10,153.33,"CIGNA [10200]","Cigna Local Plus",,45.78,,,,,,,0.01,434.44,"fee schedule",
"HEAD FEMORAL +3.5MM 12/14 LARGE 28MM HIP ACETABULAR BIOLOX",SUP-00-8775-028-03,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"MULTIPLAN [10600]",Multiplan,,8379.91,85,,,,,0,1146.57,8379.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE SP 37M",SUP-TENDV-SP-37M-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,78489,45.9,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 17GA 11CM 5CM ACHIEVE LIGHTWEIGHT SOFT",SUP-CA1811,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 67MMX15MM VANGUARD 360 KNEE LEFT MEDIAL RIGHT",SUP-185242,CDM,C1776,HCPCS,0278,RC,,,both,,,7577.58,2273.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3478.11,45.9,,,,,0,881.27,6440.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO 453MM 1.6MM SWISS LITHOCLAST PNEUMATIC LATEX",SUP-M0068407350,CDM,S27200284,LOCAL,0272,RC,,,both,,,1680.60,504.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,195.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,195.45,1428.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 8.5MM 3.5MM DX SWIVELOCK SL",SUP-AR-8978DS-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,2165.63,649.69,"AETNA [10100]","Aetna HMO/PPO",,1721.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,251.86,1840.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW STD 57.2X21.6MM TITANIUM 4 HOLE LOW PROFILE FIX",SUP-DVRANL,CDM,C1713,HCPCS,0278,RC,,,both,,,7607.25,2282.17,"CIGNA [10200]",Cigna,,5172.93,68,,1831.33,1831.33,1831.33,16,884.72,6466.16,"percent of total billed charges",
"SLING PUBOURETHRAL BLUE DESARA 1000UM TAPER POLYPROPYLENE",SUP-CAL-DS01BOV,CDM,C1771,HCPCS,0278,RC,,,both,,,6099.60,1829.88,"PHCS [10601]",PHCS,,4269.72,70,,,,,0,709.38,5184.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 5.5IN 12GA AORTIC ROOT ADULT ANTEGRADE INTRO",SUP-20012,CDM,S27200284,LOCAL,0272,RC,,,both,,,196.65,58.99,"NOVANET [10819]",Novanet,,147.49,75,,,,,0,22.87,167.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +13 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200130,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,120.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM PARALLEL SPINE",SUP-17312,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 15MM",SUP-SPL30015X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,216.39,41.1,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION",RX-9791,CDM,J3480,HCPCS,0636,RC,00264-7625-00,NDC,both,1000,ML,100.65,30.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68.44,68,,,,,0,0.24,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE JOURNEY II CRUCIATE RETAINING OXI W",SUP-71701652,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"UHC [10700]","United Healthcare",,13957.65,63.3,,8601.07,8395.67,8601.07,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"NDL NERVE BLOCK 30MM 24GA SONOPLEX II FACET INJECTION TUBE",SUP-001285-75,CDM,C9812,HCPCS,0272,RC,,,both,,,119.63,35.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,54.91,45.9,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL RAPIDE MULTIPASS 5-0 P-3 18IN BRAID COATED UNDYED",SUP-VR493,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.98,20.99,"MULTIPLAN [10600]",Multiplan,,59.48,85,,,,,0,8.14,59.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 34MM COCR",SUP-VAL-35340-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"MULTIPLAN [10600]",Multiplan,,1785,85,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OT Assessment Visit",PX-431000001,CDM,G0152,HCPCS,0431,RC,,,outpatient,,,261.00,78.3,"FIRST HEALTH [10303]","First Health",,208.8,80,,,,,0,174.87,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 15X4.5X3MM DERMIS ON DEMAND ALLOGRAFT",SUP-DOD15453,CDM,S27800098,LOCAL,0278,RC,,,both,,,4795.50,1438.65,"BLUE CROSS [10001]","Blue Cross PPO",,1879.84,39.2,,,,,0,557.72,4076.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANSTR SUCTION 800ML BOTTLE DISPOSABLE",SUP-MU10918,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.39,19.02,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,29.1,45.9,,,,,0,7.37,53.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXTERNAL DRNG SUBDURAL CSF EVACUATION SPECIALTY",SUP-951315,CDM,C1729,HCPCS,0272,RC,,,both,,,2349.38,704.81,"AETNA [10100]","Aetna HMO/PPO",,1867.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,273.23,1996.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMB LINER 47/48/49MM 28MM MULTIPOLAR HIP UHMWPE STERILE",SUP-500104728,CDM,C1776,HCPCS,0278,RC,,,both,,,2365.50,709.65,"CIGNA [10200]",Cigna,,1608.54,68,,5873.17,5873.17,5873.17,"1 through 10",275.11,2010.68,"percent of total billed charges",
"GRAFT VASCULAR 50CM 14MM 7MM STD WALL THIN WALL 2 BRANCH",SUP-SBT1402D,CDM,C1768,HCPCS,0278,RC,,,both,,,8611.20,2583.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1001.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1001.48,7319.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3MM 2 SUTURETAK FIBERWIRE ROTATOR CUFF PEEK 12.2",SUP-AR-1934PS-2,CDM,C1713,HCPCS,0278,RC,,,both,,,2008.13,602.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,237.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",233.55,1706.91,"percent of total billed charges",
"INSERT TIBIAL 10 7MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151621007,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS [10001]","Blue Cross PPO",,4411.53,39.2,,3949.44,3949.44,3949.44,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"SCR BONE 3.5MM 10MM ALPS TITANIUM T15 CORTICAL LOW PROFILE",SUP-110017710,CDM,C1713,HCPCS,0278,RC,,,both,,,668.25,200.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,79.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",77.72,568.01,"percent of total billed charges",
"WIRE REDUCTION 150MM 1.25MM STAINLESS STEEL THREAD TIP LARGE",SUP-02.111.501.10,CDM,C1713,HCPCS,0278,RC,,,both,,,93.53,28.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,42.93,45.9,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA SURG VELC STRP ZIP MED 34-36IN",SUP-958-V/M,CDM,S27000186,LOCAL,0270,RC,,,both,,,333.99,100.2,"CIGNA [10200]",Cigna,,227.11,68,,,,,0,38.84,283.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER CONNECTING PLATES 30MM TRUELOK",SUP-54-11660,CDM,C1713,HCPCS,0278,RC,,,both,,,756.86,227.06,"KAISER [10500]",Kaiser,,507.1,67,,,,,0,88.02,643.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TOTAL ABSCESSION BLUE SILK 30CM 12FR PIGTAIL CURVE DRNG",SUP-H787140008055,CDM,C1729,HCPCS,0272,RC,,,both,,,950.94,285.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,112.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,110.59,808.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC",086,MS-DRG,,,,,,,inpatient,,,43405.93,13021.78,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE 5-14FR SECUREMENT","SUP-680ME 5F-14F",CDM,S27200284,LOCAL,0272,RC,,,both,,,81.43,24.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR BROAD LORDOTIC 12 DEGREE",SUP-012415,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Open Access",,6331.5,33.5,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 5.75IN DUROGRIP CASTROVIEJO NDL TUNGSTEN CARBIDE",SUP-BM002R,CDM,S27000186,LOCAL,0270,RC,,,both,,,1771.05,531.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1204.31,68,,,,,0,205.97,1505.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SEQUENT 7 FIXATION CURVE NDL MENISCAL REPAIR SYSTEM",SUP-MR007C,CDM,C1713,HCPCS,0278,RC,,,both,,,9684.98,2905.49,"CIGNA [10200]","Cigna Local Plus",,5181.46,53.5,,3978.14,359.25,3978.14,24,1126.36,8232.23,"percent of total billed charges",
"SPACER HUMERAL 36MM UNIVERS REVERS +9MM SHOULDER TITANIUM",SUP-AR-9555-09,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"KAISER [10500]",Kaiser,,1969.8,67,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 8.5IN BECKMAN 3X4 PRONG SATIN FINISH SHARP HINGE ARM",SUP-SU3196,CDM,S27200284,LOCAL,0272,RC,,,both,,,1561.11,468.33,"AETNA [10100]","Aetna HMO/PPO",,1241.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,181.56,1326.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM 14MM STAINLESS STEEL CANNULATED STERILE",SUP-121840,CDM,C1713,HCPCS,0278,RC,,,both,,,2006.40,601.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,920.94,45.9,,,,,0,233.34,1705.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 3 LEFT DISTAL KNEE TOTAL",SUP-5541-A-301,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"MULTIPLAN [10600]",Multiplan,,4055.34,85,,,,,0,554.87,4055.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD INFINITY LARGE SPINE ROD TO ROD STERILE LATEX FREE",SUP-G3602537,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"FIRST HEALTH [10303]","First Health",,2850,80,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 4-0 PC-1 18IN MONOFILAMENT PLIABILIZED",SUP-1854G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE KORE FIBER CORTICAL BONE FIBER ALLOGRAFT STRIP",SUP-423302,CDM,C1713,HCPCS,0278,RC,,,both,,,13192.80,3957.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1563.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1534.32,11213.88,"percent of total billed charges",
"PUNCH 5.2MM LONG HANDLE AORTIC",SUP-APU552,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,133.1,45.9,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8MM 40MM HIP PRIMARY TAPER OFFSET COCR LFIT",SUP-6260-9-340,CDM,C1776,HCPCS,0278,RC,,,both,,,6224.40,1867.32,"MULTIPLAN [10600]",Multiplan,,5290.74,85,,,,,0,723.9,5290.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 16MM TITANIUM T8 LOCK VARIABLE ANGLE TUBE",SUP-04.210.116TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1056.89,317.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,302.48,28.62,,,,,0,122.92,898.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 30MM 2.25MM BALLOON DILATATION PEBAX",SUP-1012271-30,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 11.5CM MEMORYGEL P2.9CM MODERATE PROFILE SILTEX",SUP-3542157MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 2X2IN CUTIMED EPIONA 90% NATIVE CLLGN 10%",SUP-7322700,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.60,26.88,"CIGNA [10200]","Cigna Open Access",,50.98,56.9,,,,,0,10.42,76.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 8MM 2.5MM CORONARY STENT EVEROLIMUS",SUP-1550250-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"NEROSTIMLTR IMPLANTABLE 55CM PRECISION M-1 CNCT",SUP-SC-9004-55,CDM,C1883,HCPCS,0278,RC,,,both,,,3525.00,1057.5,"CIGNA [10200]","Cigna Local Plus",,1885.88,53.5,,,,,0,409.96,2996.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 6FR 5.5MM .07",SUP-H7493926708550,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP IDENTITY STEM/AUGMENTED GLENOID/PREMIUM POST/IDENTITY TI",SUP-98000900265,CDM,C1776,HCPCS,0278,RC,,,both,,,42525.00,12757.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17010,40,,,,,0,4945.66,36146.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE HA POROUS WITH CEMENTED PATELLA CONCELOC",SUP-71704616,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"KAISER [10500]",Kaiser,,15617.7,67,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Admin Flu Vacc",PX-771000004,CDM,G0008,HCPCS,0771,RC,,,both,,,108.94,32.68,"AETNA [10100]","Aetna HMO/PPO",,86.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.67,108.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE COOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-CRKA-17-75-5.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND 2CMX2CM SALERA MINI MEMB",SUP-WC4022,CDM,S27800098,LOCAL,0278,RC,,,both,,,4692.00,1407.6,"BLUE CROSS [10001]","Blue Cross HMO",,1839.26,39.2,,,,,0,545.68,3988.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE CAST CUTTER 2.5IN NITRIDE CAST SAW LATEX FREE",SUP-31-0168,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"FIRST HEALTH [10303]","First Health",,160.78,80,,,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOLUTION IV 170ML DEXTROSE 5% WATER",SUP-07923-23,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 16GA ACCURIAN CURVE SHARP 10MM",SUP-AC0002,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES",776,MS-DRG,,,,,,,inpatient,,,15477.34,4643.2,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,4304.82,,"Case rate ($4,061.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,771.05, add-ons for qualifying new technology services are included. If operating cost exceeds $36,810.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,667.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $3,776.03. The transfer operating threshold is the transfer adjustment factor * $3,771.05 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $285.11. The transfer capital threshold is the transfer adjustment factor * $285.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,4061.15,15477.34,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION INFINITY SHORT TALAR TEMPORARY GUIDE",SUP-33610003,CDM,C1713,HCPCS,0278,RC,,,both,,,680.40,204.12,"CIGNA [10200]","Cigna Open Access",,387.15,56.9,,1144.80,304.56,2275.09,66,79.13,578.34,"percent of total billed charges",
"SET STENT 22CM 10.2FR RB AMPLATZ PIGTAIL CURVE URETER",SUP-G09712,CDM,C2625,HCPCS,0278,RC,,,both,,,1227.07,368.12,"NOVANET [10819]",Novanet,,920.3,75,,,,,0,142.71,1043.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 12MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0280,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]","Cigna Open Access",,539.24,56.9,,1144.80,304.56,2275.09,66,110.22,805.55,"percent of total billed charges",
"FILLER BONE VOID 60ML .5-5MM 80% CORTICAL 20% CANCELLOUS",SUP-400058,CDM,C1713,HCPCS,0278,RC,,,both,,,4621.28,1386.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3142.47,68,,,,,0,537.45,3928.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Skin Protectant",PX-E27000156,CDM,E27000156,LOCAL,0270,RC,,,both,,,57.20,17.16,"PHCS [10601]",PHCS,,40.04,70,,,,,0,6.65,48.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HYDRAGLIDE XL 23IN 28FR STRAIGHT TAPER DRNG PVC",SUP-8028,CDM,C1729,HCPCS,0272,RC,,,both,,,58.46,17.54,"NOVANET [10819]",Novanet,,43.85,75,,,,,0,6.8,49.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW STRAIGHT 126MM MINI FRAGMENT 10 HOLE",SUP-629510,CDM,C1713,HCPCS,0278,RC,,,both,,,4459.88,1337.96,"CIGNA [10200]","Cigna Local Plus",,2386.04,53.5,,3978.14,359.25,3978.14,24,518.68,3790.9,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 47CM 30MM ABDOMEN THORAX WOVEN SOFT",SUP-M00202175430T0,CDM,L8670,HCPCS,0278,RC,,,both,,,13481.36,4044.41,"KAISER [10500]",Kaiser,,9032.51,67,,,,,0,427.53,11459.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 20MM 7MM BALLOON DILATATION DURALYN",SUP-48007002S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"NOVANET [10819]",Novanet,,941.63,75,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 40MM 5MM .014IN BALLOON DILATATION",SUP-AB14W050040150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,161.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 28CM 8FR POLARIS ULTRA .035IN URETERAL PERCUFLEX",SUP-M006192154190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,165.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW CANC PART THRD 4X60MM",SUP-207.06,CDM,S27800098,LOCAL,0278,RC,,,both,,,105.97,31.79,"CIGNA [10200]",Cigna,,72.06,68,,,,,0,12.32,90.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 14CM PUMP SET NARROW",SUP-EN8814,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7429.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 52X74X9MM KNEE RIGHT CRUCIATE RETAIN",SUP-74025651,CDM,C1776,HCPCS,0278,RC,,,both,,,20478.15,6143.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8191.26,40,,,,,0,2381.61,17406.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICROINTRODUCER 40CM 4FR .018IN SILICONE TUNGSTEN SOFT",SUP-7280V,CDM,C1894,HCPCS,0272,RC,,,both,,,178.35,53.5,"MULTIPLAN [10600]",Multiplan,,151.6,85,,,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUBICON 90CM 5.1FR 2.84FR 50MM SPACE GUIDING NYLON",SUP-H74939240035091,CDM,C1887,HCPCS,0272,RC,,,both,,,1449.90,434.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,171.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 8MM SMARTLOCK TITANIUM MAXILLOMANDIBULAR SELF",SUP-5020598,CDM,C1713,HCPCS,0278,RC,,,both,,,1349.52,404.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,619.43,45.9,,,,,0,156.95,1147.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 6MM FLIXENE SLIDER GRADUATED WALL",SUP-25058,CDM,C1768,HCPCS,0278,RC,,,both,,,8102.19,2430.66,"BLUE CROSS [10001]","Blue Cross PPO",,3176.06,39.2,,,,,0,942.28,6886.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 32MM 144CM 4MM CORONARY STENT",SUP-H7493911432400,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"NOVANET [10819]",Novanet,,6856.88,75,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 15MM 1.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP1515X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK PROC BARRIGEL NASHA PROSTATE SPACER ABSORBABLE",SUP-10263069,CDM,C1889,HCPCS,0278,RC,,,both,,,21105.00,6331.5,"CIGNA [10200]","Cigna Local Plus",,6648.08,31.5,,16168.95,16168.95,16168.95,"1 through 10",2454.51,17939.25,"percent of total billed charges",
"ROD SPINAL 45MM 5.5MM CREO CURVE TITANIUM",SUP-1119.7045,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Open Access",,2509.29,56.9,,1144.80,304.56,2275.09,66,512.88,3748.5,"percent of total billed charges",
"INSRT ACETABULAR 36MM G HIP ELEVATE RIM X3 TRIDENT",SUP-643-00-36G,CDM,C1776,HCPCS,0278,RC,,,both,,,9915.30,2974.59,"PHCS [10601]",PHCS,,6940.71,70,,,,,0,1153.15,8428.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC ELECTROSURGICAL 1IN ARGONPLUS RETRACTABLE BLADE",SUP-E2520H,CDM,S27200284,LOCAL,0272,RC,,,both,,,406.29,121.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,48.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.25,345.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 8MM 6FR 1.5MM .07IN BALLOON",SUP-H7493919008150,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 21 GAFR 3FR MERIT PAK .018IN 40CM MINI PEDAL",SUP-PAKM5NPD4,CDM,C1894,HCPCS,0272,RC,,,both,,,374.10,112.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,254.39,68,,,,,0,43.51,317.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 76.2CM 23FR 3/8IN VENOUS INTRO HEMOSTASIS CAP",SUP-96670-123,CDM,S27200284,LOCAL,0272,RC,,,both,,,3073.95,922.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1410.94,45.9,,,,,0,357.5,2612.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL TALL BREATHABLE PAD COTTON FOAM",SUP-100010-040,CDM,S27000186,LOCAL,0270,RC,,,both,,,275.09,82.53,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,113.06,41.1,,,,,0,31.99,233.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE KIRSCHNER ORTHOPEDIC 5.75IN .035IN SMALL BONE 1 TROCAR",SUP-WS-0906ST,CDM,C1769,HCPCS,0272,RC,,,both,,,287.10,86.13,"UHC [10700]","United Healthcare",,181.73,63.3,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X6MM SABLE 8D STERILE LATEX FREE",SUP-1172.2010S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA [10200]","Cigna Local Plus",,10914.75,31.5,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ENDOWRIST DA VINCI S/SI GRAPTOR GRASP ENDOSCOPIC",SUP-420318,CDM,S27000186,LOCAL,0270,RC,,,both,,,1890.00,567,"CIGNA [10200]",Cigna,,1285.2,68,,,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MANTA 14FR CLSR VASCULAR",SUP-2156,CDM,C1760,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,431.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL 22-30CM 3CM 4.8FR .035IN PIGTAIL CURVE",SUP-M006180155050,CDM,C2617,HCPCS,0278,RC,,,both,,,1047.90,314.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,124.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.87,890.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 20CM CENTRAL VENOUS 3 LUMEN OXIMETRY CONTINUOUS SCVO2",SUP-XA3820SAFKT,CDM,C1751,HCPCS,0272,RC,,,both,,,2887.50,866.25,"FIRST HEALTH [10303]","First Health",,2310,80,,,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REG VACUUM PUSH-TO-SET INTERMITTENT OHMEDA DIAMOND NIPPLE",SUP-8701-1251-901,CDM,S27200284,LOCAL,0272,RC,,,both,,,2674.50,802.35,"AETNA [10100]","Aetna HMO/PPO",,2126.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,311.04,2273.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 70MM 1800MM 10MM 2.33MM BILIARY NITINOL",SUP-SHS-10-070-180,CDM,C1874,HCPCS,0278,RC,,,both,,,6855.84,2056.75,"FIRST HEALTH [10303]","First Health",,5484.67,80,,,,,0,797.33,5827.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ROADRUNNER PC THE FIRM VASCULAR ANGLE LONG TAPER 145CM",SUP-G06866,CDM,C1769,HCPCS,0272,RC,,,both,,,313.11,93.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.41,266.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM DELTAXSFT 10 COIL",SUP-DLX100304,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6155.9,68,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN WOUND 20CMX7MM SILICONE FULL PERFORATION WITHOUT",SUP-SU130-1310,CDM,S27200284,LOCAL,0272,RC,,,both,,,57.68,17.3,"CIGNA [10200]","Cigna Local Plus",,30.86,53.5,,,,,0,6.71,49.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL SHAFT ALLOGRAFT FROZEN 30MM 10+ MM",SUP-450405,CDM,S27800098,LOCAL,0278,RC,,,both,,,4454.64,1336.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,527.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,518.07,3786.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 0MM 12/14 STRAIGHT 28MM HIP ZIMALOY LEGACY VERS",SUP-00801802802,CDM,C1776,HCPCS,0278,RC,,,both,,,3322.20,996.66,"AETNA [10100]","Aetna HMO/PPO",,2641.15,79.5,,10981.53,8986.79,12413.38,12,386.37,2823.87,"percent of total billed charges",
"TUBE FEEDING ORANGE 20IN 6.5FR ENTERAL POLYURETHANE HUB END",SUP-ENFPU2065LD,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.84,17.65,"PHCS [10601]",PHCS,,41.19,70,,,,,0,6.84,50.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hiv 2 Ab",PX-302000223,CDM,86702,CPT,0302,RC,,,both,,,385.70,115.71,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,21.27,,,,,,,0.01,327.85,"fee schedule",
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 26MM 140CM 4MM CORONARY",SUP-RSINT40026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"MULTIPLAN [10600]",Multiplan,,4712.4,85,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 12CM MR8 4MM BALL DISSECTING DIAMOND",SUP-MR8-12BA40D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,149.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER SUT 45D IDEAL SHUTTLE CRESCENT STRAIGHT LEFT",SUP-251003,CDM,S27200284,LOCAL,0272,RC,,,both,,,1328.40,398.52,"KAISER [10500]",Kaiser,,890.03,67,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC",981,MS-DRG,,,,,,,inpatient,,,173901.28,52170.38,"BLUE CROSS [10001]","Blue Cross HMO",,107708.67,,,,,,,10994,136981.79,"case rate",
"SCR BONE 3MM 2MM 14MM 4MM STAINLESS STEEL 1.1MM SHORT THREAD",SUP-02.226.014,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"CIGNA [10200]","Cigna Local Plus",,880.18,53.5,,3978.14,359.25,3978.14,24,191.34,1398.42,"percent of total billed charges",
"CATH RAPIDCROSS 170CM 40MM 2MM .014IN BALLOON DILATATION",SUP-A14BX020040170,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"NOVANET [10819]",Novanet,,1038.83,75,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 65CM 5FR KA2 CURVE ANGIOGRAPHIC PEBAX",SUP-5582-43,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.44,55.33,"CIGNA [10200]","Cigna Open Access",,104.95,56.9,,,,,0,21.45,156.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ULTRASONIC 20MM BONESCALPEL STD BLUNT STERILE LATEX FREE",SUP-MXB-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,3265.32,979.6,"CIGNA [10200]",Cigna,,2220.42,68,,,,,0,379.76,2775.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 12MM CEMENTED TOTAL STABILIZED TRIATHLON",SUP-5560-S-212,CDM,C1776,HCPCS,0278,RC,,,both,,,4271.90,1281.57,"BLUE CROSS [10001]","Blue Cross HMO",,1674.58,39.2,,5311.50,4717.44,5388.59,31,496.82,3631.12,"percent of total billed charges",
"CATH ARMADA 35 80CM 20MM 6FR 12MM .035IN LOW PROFILE BALLOON",SUP-B1120-020,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"KAISER [10500]",Kaiser,,515.57,67,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 117MM 11MM PRIMARY STD OFFSET PRESS FIT",SUP-00786401100,CDM,S27800098,LOCAL,0278,RC,,,both,,,30164.40,9049.32,"NOVANET [10819]",Novanet,,22623.3,75,,,,,0,3508.12,25639.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 21MM TITANIUM 6 HOLE DOUBLE Y LOW PROFILE",SUP-421.517,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,,1521.93,481.35,16760.95,30,434.96,3179,"percent of total billed charges",
"BURR SURGICAL 3.8MM 1.6MM 7 MICRO MEDIUM",SUP-00-5091-272-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.03,41.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,57.14,41.1,,,,,0,16.17,118.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE 2.8CM ROUND 240CM 2.4MM CAPTIVATOR II LOOP SHEATH",SUP-M00561243,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.04,23.71,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,36.28,45.9,,,,,0,9.19,67.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 2MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG20008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Open Access",,1707,56.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET VACUUM 9MM PLASTIC CANN STRAIGHT ROUND TIP SEMIRIGID",SUP-21552,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.34,19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,29.07,45.9,,,,,0,7.37,53.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 CURVE 12.5MM KNEE GVF UHMWPE ROTATE",SUP-962022,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1075.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8.5FR 63CM HEMOSTASIS GWIRE SWARTZ .032IN SL2",SUP-406850,CDM,C1893,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AETNA [10100]","Aetna HMO/PPO",,933.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 75MM 16MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-216.075,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"MULTIPLAN [10600]",Multiplan,,381.7,85,,,,,0,52.23,381.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL 11MM 2 KNEE ALL POLYETHYLENE CONDYLAR STABILIZE",SUP-5534-A-211,CDM,C1776,HCPCS,0278,RC,,,both,,,13872.45,4161.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3745.56,27,,,,,0,1613.37,11791.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla Typing a/B/C Sngl Ag",PX-302000177,CDM,86812,CPT,0302,RC,,,both,,,630.42,189.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,91.61,,,,,,,17.48,535.86,"fee schedule",
"STENT VIABAHN 5CM 75CM 7MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR070501A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4564.35,27,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +10.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000105,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM OFFSET TAPER 32MM HIP ALUMINA CERAMIC V40",SUP-6565-0-232,CDM,C1776,HCPCS,0278,RC,,,both,,,7383.00,2214.9,"KAISER [10500]",Kaiser,,4946.61,67,,,,,0,858.64,6275.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 36MM INSET 0D 0MM SHOULDER LATERAL REVERSE",SUP-2R1P100036,CDM,C1776,HCPCS,0278,RC,,,both,,,4728.23,1418.47,"PHCS [10601]",PHCS,,3309.76,70,,,,,0,549.89,4019,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KT ASCP FX 25MM 8MM BICEPTOR",SUP-72202358,CDM,C1713,HCPCS,0278,RC,,,both,,,2895.75,868.72,"CIGNA [10200]","Cigna Open Access",,1647.68,56.9,,1144.80,304.56,2275.09,66,336.78,2461.39,"percent of total billed charges",
"STENT SENSOR 28CM 5CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX",SUP-M006175284110,CDM,C2617,HCPCS,0278,RC,,,both,,,1205.77,361.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,345.09,28.62,,,,,0,140.23,1024.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 135+ MM 14MM PERSONA 3MM OFFSET KNEE STERILE LATEX",SUP-42560313514,CDM,C1776,HCPCS,0278,RC,,,both,,,16990.56,5097.17,"UHC [10700]","United Healthcare",,10755.02,63.3,,8601.07,8395.67,8601.07,"1 through 10",1976,14441.98,"percent of total billed charges",
"SCR BONE 3.5MM 24MM VARIAX T10 FULL THREAD FOOT ANKLE LOCK",SUP-657324,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,176.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",172.92,1263.81,"percent of total billed charges",
"MESH SURGICAL BARD MARLEX 4X1IN GROIN MONOFILAMENT GOLD STD",SUP-0112640,CDM,C1781,HCPCS,0278,RC,,,both,,,80.91,24.27,"KAISER [10500]",Kaiser,,54.21,67,,,,,0,9.41,68.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT TOTAL STBL TRIATHLON COCR",SUP-5512-F-701,CDM,C1776,HCPCS,0278,RC,,,both,,,20599.49,6179.85,"UHC [10700]","United Healthcare",,13039.48,63.3,,8601.07,8395.67,8601.07,"1 through 10",2395.72,17509.57,"percent of total billed charges",
"CATH LEMAITRE 80CM 7FR 14MM C1.75ML EMBOLECTOMY 1 LUMEN",SUP-E1601-78,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"UHC [10700]","United Healthcare",,379.42,63.3,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 14X13.2CM 620CC GEL TEXTURE ORIENTATION MARK",SUP-3341402,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"UHC [10700]","United Healthcare",,5787.2,63.3,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 330-400ML STYLE 3000 SMOOTH SALINE P4.8-6.2CM",SUP-3503330,CDM,C1789,HCPCS,0278,RC,,,both,,,2350.00,705,"PHCS [10601]",PHCS,,1645,70,,,,,0,273.31,1997.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 24MM 144CM 4MM CORONARY STENT",SUP-H7493911424400,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3757.57,41.1,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR MEDIALIZE DOME 41MM CEMENT ATTUNE AOX KNEE",SUP-1518-20-041,CDM,C1776,HCPCS,0278,RC,,,both,,,5409.60,1622.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3678.53,68,,,,,0,629.14,4598.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 5MM KII FIOS FIRST ENTRY Z THREAD",SUP-CTF01,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,65.89,45.9,,,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 210MM PERFORM 13 XLONG SHOULDER STERILE LATEX",SUP-PFX13210,CDM,C1776,HCPCS,0278,RC,,,both,,,51351.30,15405.39,"PHCS [10601]",PHCS,,35945.91,70,,,,,0,5972.16,43648.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X12MM LUMINARY 10-11MM SPINE",SUP-14712,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"PHCS [10601]",PHCS,,22050,70,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 36MM TI",SUP-SPL-60360-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR VIVACIT-E CERAMIC HIP STEM CUP LINER HEAD PRE",SUP-98000100021,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10357.2,41.1,,6417.48,6417.48,6417.48,"1 through 10",2930.76,21420,"percent of total billed charges",
"LENS IOL 0 D +7 DIOPTER +3 CYL BICONVEX 13MM 6MM POSTERIOR",SUP-SN6AT5.070,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,98.74,28.62,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRMLA SUPPLEMENTAL X COAT LINE",SUP-73696,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.72,40.12,"KAISER [10500]",Kaiser,,89.59,67,,,,,0,15.55,113.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB CONGR SZ 3/4X12MM",SUP-2042-0-3412,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Open Access",,2027.06,56.9,,5302.19,4377.88,6578.61,27,414.32,3028.13,"percent of total billed charges",
"DEVICE V-LOC 90 3-0 CV-23 12IN CLSR ABSORBABLE VIOLET",SUP-VLOCM0814,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 4.7MM 1 9IN BRUNS SURGICAL",SUP-NL6760-004,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.68,161.3,"FIRST HEALTH [10303]","First Health",,430.14,80,,,,,0,62.53,457.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE - AUGMENTED BASEPLATE AND POST",SUP-CAP-AR-UP-ABP,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX PDS PLUS 3-0 PS 45CM ANTIBACTERIAL",SUP-SXPP1B108,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.37,67.91,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.33,192.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 10MM X 30CM",SUP-M0035471030,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS [10001]","Blue Cross HMO",,5532.94,39.2,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT GAIT 2IN 60IN POLYETHYLENE POSEY QUICK CLEAN ECONOMY",SUP-552545,CDM,S27100035,LOCAL,0271,RC,,,both,,,224.20,67.26,"NOVANET [10819]",Novanet,,168.15,75,,,,,0,26.07,190.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 100MM 18MM 3MM VASCULAR VENOUS ILIOFEMORAL VEIN",SUP-VENUM18100,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"AETNA [10100]","Aetna HMO/PPO",,18531.45,79.5,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHANTOM? HINDFOOT NAIL HEADLESS SCREW 7.2MM X 80MM",SUP-P31-772-080F,CDM,C1713,HCPCS,0278,RC,,,both,,,6582.60,1974.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,765.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",765.56,5595.21,"percent of total billed charges",
"GRAFT BONE ILIAC CREST LARGE WEDGE FREEZE DRIED",SUP-40A001,CDM,S27800098,LOCAL,0278,RC,,,both,,,3977.85,1193.35,"AETNA [10100]","Aetna HMO/PPO",,3162.39,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,462.62,3381.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 12MM 140CM 2.25MM",SUP-RSINT22512UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]","Cigna Local Plus",,2966.04,53.5,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 20MM RETRACTA DETACHABLE .035IN",SUP-G34204,CDM,S27800098,LOCAL,0278,RC,,,both,,,4674.68,1402.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,553.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,543.67,3973.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 4-0 SH 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-G121H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 200ML GEL TEXTURED SILTEX SILICONE P4.1CM HIG",SUP-3544200,CDM,C1789,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM CEMENTLESS SUMMIT POROCOAT 4 12/14 HIGH",SUP-157011100,CDM,C1776,HCPCS,0278,RC,,,both,,,14221.44,4266.43,"AETNA [10100]","Aetna HMO/PPO",,11306.04,79.5,,10981.53,8986.79,12413.38,12,1653.95,12088.22,"percent of total billed charges",
"WEIGHT REHABILITATION SOFT GREEN THERABAND 4.5IN",SUP-929253,CDM,S27000186,LOCAL,0270,RC,,,both,,,152.25,45.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.71,129.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT PAT SZ 2 10MM",SUP-2766-0-1002,CDM,C1776,HCPCS,0278,RC,,,both,,,1875.00,562.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,218.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC",094,MS-DRG,,,,,,,inpatient,,,230905.42,69271.63,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,22813.45,,"Case rate ($21,831.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,271.61, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,914.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $20,298.42. The transfer operating threshold is the transfer adjustment factor * $20,271.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,532.63. The transfer capital threshold is the transfer adjustment factor * $1,532.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,8593,87770.32,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC CROME HF 2 CHMBR DF4 INLINE CNCT RADIOPAQUE",SUP-DTPC2D4,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"BLUE CROSS [10001]","Blue Cross PPO",,30164.4,39.2,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE MEDIUM OVAL 240CM 2.4MM CAPTIVATOR LOOP STIFF",SUP-M00562321,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.33,36.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.11,103.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 31MM LC-DCP HAND TITANIUM 4 HOLE 2.4MM SCR",SUP-449.924,CDM,C1713,HCPCS,0278,RC,,,both,,,3496.50,1048.95,"CIGNA [10200]","Cigna Open Access",,1989.51,56.9,,1144.80,304.56,2275.09,66,406.64,2972.03,"percent of total billed charges",
"BIT DRILL 152MM 4.3MM PHOENIX SHORT TWIST CROWE POINT TIBIAL",SUP-27984,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"NOVANET [10819]",Novanet,,1265.63,75,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCORTISONE 1 % TOPICAL CREAM",RX-3726,CDM,,,0250,RC,45802-0438-03,NDC,both,28,GR,25.19,7.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA 40IN SEMI SLIGHTLY CONTOURED FRONT HOOK AND EYE CLSR",SUP-2-8125-40,CDM,S27000186,LOCAL,0270,RC,,,both,,,313.20,93.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,37.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER/10 DEGREE HOODED-NEUTRAL MP10",SUP-932-44-760,CDM,C1776,HCPCS,0278,RC,,,both,,,16186.99,4856.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1918.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1882.55,13758.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM FRMLA TOMCAT LONG HIP STERILE",SUP-385545000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2287.50,686.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,940.16,41.1,,,,,0,266.04,1944.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 155CM 6MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200064020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 35MM CONDYLAR STABILIZED NECK OMNIFIT HFX 132D",SUP-6098-0835,CDM,C1776,HCPCS,0278,RC,,,both,,,10292.40,3087.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1219.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1197.01,8748.54,"percent of total billed charges",
"LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION",RX-4452,CDM,J2003,HCPCS,0636,RC,63323-0485-01,NDC,both,20,ML,30.65,9.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,14.9,48.6,,21.70,17.36,34.72,23,2.33,26.05,"percent of total billed charges",
"CATH SABERX 90CM 150MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"AETNA [10100]","Aetna HMO/PPO",,1268.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE VASCULAR STRAIGHT 182CM .014IN POLYMER",SUP-H74912133012,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 2MM PRESTIGE PLUS HELICAL HELICAL XTRA",SUP-PRES0208HXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOVIVE PLUS 15.0CC",SUP-203215,CDM,C1713,HCPCS,0278,RC,,,both,,,27090.00,8127,"CIGNA [10200]","Cigna Local Plus",,8533.35,31.5,,3978.14,359.25,3978.14,24,3150.57,23026.5,"percent of total billed charges",
"SCR BONE 4MM 18MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.418,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"NOVANET [10819]",Novanet,,3150,75,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 18MM IMPL CANNULATED",SUP-200-30-018,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"BLUE CROSS [10001]","Blue Cross HMO",,444.53,39.2,,957.42,156.86,7483.26,51,131.88,963.9,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 18CM 3CM 5FR .038IN 2",SUP-M006192115170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,399.31,28.62,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.125 CLAREON",SUP-SY60WF.125,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC",379,MS-DRG,,,,,,,inpatient,,,23864.19,7159.26,"CIGNA [10200]","Cigna Local Plus",,6505.1,,"Fee schedule rate ($6,505.10). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,3910.41,15721.55,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309015,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4474.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,4391.74,32097.87,"percent of total billed charges",
"BELT RIB MEDIUM 31X6IN 2 PANEL ELASTIC HOOK LOOP CLSR",SUP-13790306,CDM,S27000186,LOCAL,0270,RC,,,both,,,59.25,17.77,"MULTIPLAN [10600]",Multiplan,,50.36,85,,,,,0,6.89,50.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 40MM GORILLA R3CON LOCK",SUP-P50-353-4240,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAPPED ENDURANT II BUNDLE",SUP-ENDURANTIICAP,CDM,S27800098,LOCAL,0278,RC,,,both,,,108300.00,32490,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12833.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12595.29,92055,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL PEDIATRIC 1.5MM 5.2MM 9 7/8INX3MM BACKBITE",SUP-3712013,CDM,S27200284,LOCAL,0272,RC,,,both,,,8618.38,2585.51,"FIRST HEALTH [10303]","First Health",,6894.7,80,,,,,0,1002.32,7325.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL UNIVERSAL 40MM HIP BIOLOX DELTA TRITANIUM",SUP-6519-1-040,CDM,C1776,HCPCS,0278,RC,,,both,,,10008.84,3002.65,"CIGNA [10200]","Cigna Open Access",,5695.03,56.9,,5302.19,4377.88,6578.61,27,1164.03,8507.51,"percent of total billed charges",
"STENT ENDOMAXX 90CM 100CM 23MM 24FR ESOPHAGEAL SILICONE",SUP-MAXX-2310,CDM,C1874,HCPCS,0278,RC,,,both,,,17640.00,5292,"AETNA [10100]","Aetna HMO/PPO",,14023.8,79.5,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID PACBAND- STANDARD",SUP-38340017,CDM,S27000186,LOCAL,0270,RC,,,both,,,180.96,54.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.05,153.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 21MM KNEE CONSTRAIN UHMWPE GENESIS II",SUP-71420532,CDM,C1776,HCPCS,0278,RC,,,both,,,18474.75,5542.42,"AETNA [10100]","Aetna HMO/PPO",,14687.43,79.5,,10981.53,8986.79,12413.38,12,2148.61,15703.54,"percent of total billed charges",
"RTNR DRSG 25YDX41IN 10 RAYON POLYESTER TUBULAR STRETCH LATEX",SUP-NONNET10,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.71,84.51,"UHC [10700]","United Healthcare",,178.32,63.3,,,,,0,32.76,239.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM TITANIUM CORTICAL",SUP-PANL-35200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,899.10,269.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,104.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",104.57,764.24,"percent of total billed charges",
"GRAFT BONE ALLOQUENT CORTICAL CANCELLOUS 5D ALLOGRAFT 12MM",SUP-3W5012,CDM,S27800098,LOCAL,0278,RC,,,both,,,6216.90,1865.07,"FIRST HEALTH [10303]","First Health",,4973.52,80,,,,,0,723.03,5284.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 16MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-616,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"BLUE CROSS [10001]","Blue Cross HMO",,3853.56,39.2,,5311.50,4717.44,5388.59,31,1143.29,8355.94,"percent of total billed charges",
"IMPL BREAST 500ML P5.3CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-5004BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3565.92,68,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 57MM 135CM 7MM 60MM BILIARY TANTALUM",SUP-PXB35-07-57-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2969.56,68,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.5MM KIRSCHNER DARCO HEADED",SUP-NK112527,CDM,C1713,HCPCS,0278,RC,,,both,,,191.40,57.42,"BLUE CROSS [10001]","Blue Cross HMO",,75.03,39.2,,957.42,156.86,7483.26,51,22.26,162.69,"percent of total billed charges",
"CATH X-FORCE N30 15CM 7FR 10MM 30 ATM STRAIGHT BALLOON",SUP-995101,CDM,C1726,HCPCS,0272,RC,,,both,,,1931.25,579.37,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BIOPSY SPIN PERC",SUP-INS-5600,CDM,S27200284,LOCAL,0272,RC,,,both,,,4936.95,1481.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ELECTROPHYSIOLOGY 5MM SPACING CRD2 CURVE 5FR 120CM",SUP-401860,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 20GA 20GA 12CM .025IN GWIRE NDL SYR DRAPE CENTRAL",SUP-AK-04550-S,CDM,C1751,HCPCS,0272,RC,,,both,,,217.50,65.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 24FR 20CM STD RADIOPAQUE STERILE DISPOSABLE",SUP-G01884,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.44,31.03,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE STRATAFIX PDS PLUS 1 CTX 45CM SUT ABSORBABLE KNOTLESS",SUP-SXPP1A400,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"PHCS [10601]",PHCS,,168.21,70,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +1.5MM 12/14 TAPER 36MM HIP CEMENTLESS BIOLOX",SUP-136536310,CDM,C1776,HCPCS,0278,RC,,,both,,,7222.32,2166.7,"FIRST HEALTH [10303]","First Health",,5777.86,80,,,,,0,839.96,6138.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL VASCULAR 30MM 2MM FLO-RESTER CORONARY ARTERY SILICONE",SUP-60200BIOS,CDM,S27200284,LOCAL,0272,RC,,,both,,,741.67,222.5,"PHCS [10601]",PHCS,,519.17,70,,,,,0,86.26,630.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TIBIAL YELLOW STRIPE 66X42MM NEXGEN 3 WEDGE KNEE",SUP-598800300,CDM,C1713,HCPCS,0278,RC,,,both,,,15836.88,4751.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1876.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1841.83,13461.35,"percent of total billed charges",
"GRAFT BONE VIA CANCELLOUS DEMINERALIZE CORTICAL BONE 10CC",SUP-VCAFX-100000,CDM,S27800098,LOCAL,0278,RC,,,both,,,20790.00,6237,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5950.1,28.62,,,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PRIMARY HYBRID KNEE",SUP-TKASTND-HYB,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Open Access",,7386.75,33.5,,5302.19,4377.88,6578.61,27,2564.42,18742.5,"percent of total billed charges",
"CLP SURGICAL RECHARGEABLE",SUP-5513E,CDM,S27000186,LOCAL,0270,RC,,,both,,,304.50,91.35,"FIRST HEALTH [10303]","First Health",,243.6,80,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM CEMENT BASIC SUMMIT 6 12/14 TAPER HIP",SUP-1570-06-120,CDM,C1776,HCPCS,0278,RC,,,both,,,8135.10,2440.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5531.87,68,,,,,0,946.11,6914.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 9MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530G109,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CIGNA [10200]","Cigna Local Plus",,4658.57,53.5,,5372.07,4581.20,7242.98,23,1012.7,7401.47,"percent of total billed charges",
"STEM FEMORAL 115MM TRI-LOCK BPS GRIPTION 10 STANDARD OFFSET",SUP-101204100,CDM,C1776,HCPCS,0278,RC,,,both,,,29153.25,8745.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8343.66,28.62,,,,,0,3390.52,24780.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 24MM THORACIC 2 PASS SEWING WOVEN",SUP-M00202175124P0,CDM,C1768,HCPCS,0278,RC,,,both,,,2857.58,857.27,"CIGNA [10200]","Cigna Open Access",,1625.96,56.9,,,,,0,332.34,2428.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 20MM 6FR 4.5MM 4FR BALLOON",SUP-H74939031452010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cr West Nile Virus Igm-Expl832",PX-300000032,CDM,86788,CPT,0302,RC,,,both,,,358.00,107.4,"PHCS [10601]",PHCS,,250.6,70,,,,,0,0.01,304.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 13-16X15MM HIGHLY ELASTIC STAPLES SMALL FOREFOOT",SUP-ES-15X13X16,CDM,C1713,HCPCS,0278,RC,,,both,,,8590.50,2577.15,"BLUE CROSS [10001]","Blue Cross HMO",,3367.48,39.2,,957.42,156.86,7483.26,51,999.08,7301.93,"percent of total billed charges",
"LINER ACETABULAR PINNACLE 15D 58MM 32MM MARATHON HIP STERILE",SUP-121932258,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,961.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 60MM 32MM MARATHON",SUP-121932460,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"CIGNA [10200]","Cigna Local Plus",,4339.36,53.5,,5372.07,4581.20,7242.98,23,943.3,6894.31,"percent of total billed charges",
"CATH FLEXABILITY SENSOR ENABLED ENSITE PRECISION MEDIGUIDE",SUP-A-FASE-DF,CDM,S27200284,LOCAL,0272,RC,,,both,,,12765.00,3829.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5859.14,45.9,,,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY FIXATION GOLD 42MMX3.9MM 13MM HUMERUS",SUP-462.642S,CDM,C1713,HCPCS,0278,RC,,,both,,,3288.60,986.58,"FIRST HEALTH [10303]","First Health",,2630.88,80,,,,,0,382.46,2795.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENVEO PRO+ 23MM 29MM DELIVERY LOAD STERILE LATEX FREE",SUP-L-EVPROP2329US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2925.00,877.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,340.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,340.18,2486.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 14MM STAINLESS STEEL CONDYLAR SELF TAP VARIABLE",SUP-42.231.014S,CDM,C1713,HCPCS,0278,RC,,,both,,,2101.05,630.31,"CIGNA [10200]","Cigna Open Access",,1195.5,56.9,,1144.80,304.56,2275.09,66,244.35,1785.89,"percent of total billed charges",
"SENSOR NEONATAL LNCS 36IN FINGER OXIMETER ADHESIVE LOW NOISE",SUP-2329,CDM,S27000186,LOCAL,0270,RC,,,both,,,71.00,21.3,"CIGNA [10200]","Cigna Local Plus",,37.99,53.5,,,,,0,8.26,60.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TIBIAL 16MM INBONE ANKLE PLASMA MID",SUP-200010902,CDM,C1776,HCPCS,0278,RC,,,both,,,2520.00,756,"CIGNA [10200]","Cigna Open Access",,1433.88,56.9,,5302.19,4377.88,6578.61,27,293.08,2142,"percent of total billed charges",
"SUT GORE-TEX CV-5 TTC-13 36IN 2 ARM MONOFILAMENT UNDYED",SUP-5N02A,CDM,S27200284,LOCAL,0272,RC,,,both,,,303.78,91.13,"KAISER [10500]",Kaiser,,203.53,67,,,,,0,35.33,258.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE SP 41S",SUP-TENDV-SP-41S-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20263.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP UNIPOLAR POUROUS FEMUR WITH UNIPOLAR",SUP-71701037,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Local Plus",,5537.25,53.5,,5372.07,4581.20,7242.98,23,1203.71,8797.5,"percent of total billed charges",
"SCR BONE 4.5MM 30MM AXSOS STAINLESS STEEL 3.5MM FULL THREAD",SUP-340630,CDM,C1713,HCPCS,0278,RC,,,both,,,255.78,76.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,173.93,68,,,,,0,29.75,217.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 44MM HIP 3 HOLE POLY POROUS R3 SMALL",SUP-71335544,CDM,C1776,HCPCS,0278,RC,,,both,,,14614.20,4384.26,"CIGNA [10200]","Cigna Open Access",,4895.76,33.5,,5302.19,4377.88,6578.61,27,1699.63,12422.07,"percent of total billed charges",
"SCR BONE 2.4MM 8MM LCP STAINLESS STEEL DISTAL CORTICAL",SUP-201.758,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,170.52,39.2,,957.42,156.86,7483.26,51,50.59,369.75,"percent of total billed charges",
"PLATE 42MM ANTERIOR LUMBAR FUSION LEVEL 2 CONSTRAIN PYRENEES",SUP-208-42F42,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"KAISER [10500]",Kaiser,,2954.7,67,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BNDG 10YDX3IN UNNA-Z UNNA BOOT ZINC OXIDE PLASTIC WITHOUT",SUP-NONUNNA13,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.27,14.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.5,40.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 4MM 7FR 1-7-4MM SPACING E CURVE LARGE",SUP-NS7TCEL174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"FIRST HEALTH [10303]","First Health",,10984.8,80,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE JOURNEY II CRUCIAT RETAINING OXI VE",SUP-71701650,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"AETNA [10100]","Aetna HMO/PPO",,17529.75,79.5,,10981.53,8986.79,12413.38,12,2564.42,18742.5,"percent of total billed charges",
"BLADE SAW 34.5X9X.64MM SHORT NARROW THIN STAINLESS STEEL",SUP-2108148000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"UHC [10700]","United Healthcare",,121.27,63.3,,,,,0,22.28,162.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH BLUPERC PERCUTANEOUS DILATION",SUP-101/573/000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2370.98,711.29,"NOVANET [10819]",Novanet,,1778.24,75,,,,,0,275.74,2015.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 180MM HIP AFFIXUS INTRAMEDULLARY SHORT",SUP-814511180,CDM,C1713,HCPCS,0278,RC,,,both,,,16044.57,4813.37,"CIGNA [10200]","Cigna Local Plus",,5054.04,31.5,,3978.14,359.25,3978.14,24,1865.98,13637.88,"percent of total billed charges",
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN JUDKINS",SUP-77800300,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMOVAL KIT",SUP-R540000RKH,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.80,114.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,175.71,45.9,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPIN ACCESS CATH 180D BRACHYTHERAPY OLYMPUS 190 SCOPE",SUP-INS-5915,CDM,S27200284,LOCAL,0272,RC,,,both,,,7452.00,2235.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,883.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 5FR 5MM SPACE P CURVE ELECTROPHYSIOLOGY",SUP-D5S10PR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1532,41.1,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP REVERSE SHOULDER: SHORT STEM RSA W/ AUGMENTS",SUP-71701432,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13097.7,27,,,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.0 PLY SCRW 3.5X24",SUP-102035124,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,1144.80,304.56,2275.09,66,441.36,3225.75,"percent of total billed charges",
"TAP 4.5MM 130MM SHAFT SURGICAL CORTICAL SCR NONSTERILE",SUP-311.46,CDM,S27000186,LOCAL,0270,RC,,,both,,,1344.92,403.48,"MULTIPLAN [10600]",Multiplan,,1143.18,85,,,,,0,156.41,1143.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PLATE 6 74X50MM CEMENTED STEMMED MODULAR NEXGEN",SUP-00598004702,CDM,C1776,HCPCS,0278,RC,,,both,,,8643.60,2593.08,"FIRST HEALTH [10303]","First Health",,6914.88,80,,,,,0,1005.25,7347.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI T .8MM CRANIOMAXILLOFACIAL 8 HOLE 2MM SCR BONE",SUP-55-08542,CDM,C1713,HCPCS,0278,RC,,,both,,,1893.45,568.03,"BLUE CROSS [10001]","Blue Cross PPO",,742.23,39.2,,957.42,570.23,957.42,28,220.21,1609.43,"percent of total billed charges",
"SHELL ACETABULAR 66MM HIP MULTIHOLE RIM TRITANIUM X3 MDM",SUP-509-02-66H,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"KAISER [10500]",Kaiser,,7525.44,67,,,,,0,1306.28,9547.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8.5FR 60CM HEMOSTASIS GWIRE END HOLE FAST-CATH",SUP-406804,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 22MM STAINLESS STEEL T8 LOCK VARIABLE ANGLE",SUP-02.210.122TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1011.53,303.46,"PHCS [10601]",PHCS,,708.07,70,,,,,0,117.64,859.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TALUS VANTAGE 2 ANKLE LEFT STERILE LATEX FREE",SUP-350-01-02,CDM,C1776,HCPCS,0278,RC,,,both,,,24790.50,7437.15,"PHCS [10601]",PHCS,,17353.35,70,,,,,0,2883.14,21071.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 13MM APTUS TITANIUM 6MM HEAD HAND FOOT WRIST",SUP-A-5450.13/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET",RX-39255,CDM,J0750,HCPCS,0636,RC,00904-7172-07,NDC,both,1,UN,11.75,3.52,"UHC [10700]","United Healthcare",,2.61,,,,,,,1.39,9.99,"fee schedule",
"BRACE WALKING 3.5-7.5 4.5-8.5 SMALL LOW PROFILE 1 PIECE",SUP-79-95073,CDM,S27000186,LOCAL,0270,RC,,,both,,,294.76,88.43,"MULTIPLAN [10600]",Multiplan,,250.55,85,,,,,0,34.28,250.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 12MM 144CM 3.5MM CORONARY STENT",SUP-H7493941812350,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEMORAL PFC SIGMA 5D KNEE STERILE",SUP-96-0781,CDM,C1776,HCPCS,0278,RC,,,both,,,10187.16,3056.15,"BLUE CROSS [10001]","Blue Cross PPO",,3993.37,39.2,,3949.44,3949.44,3949.44,"1 through 10",1184.77,8659.09,"percent of total billed charges",
"CATH EVERCROSS CROSSTEC 135CM 120MM 5MM .035IN BALLOON",SUP-AB35W05120135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,460.47,68,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 4CM 8MM BALLOON DILATATION PERIPHERAL",SUP-G50268,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX BRITE TIP 30MM 135CM 7MM .065IN",SUP-PC0730RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,899.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 9CM 7.5MM LEGEND ACORN STERILE",SUP-9AC75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"AETNA [10100]","Aetna HMO/PPO",,929.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,135.93,993.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T 53MM TITANIUM 2X8 HOLE BONE HAND NONSTERILE",SUP-447.232,CDM,C1713,HCPCS,0278,RC,,,both,,,2461.20,738.36,"CIGNA [10200]",Cigna,,1673.62,68,,1831.33,1831.33,1831.33,16,286.24,2092.02,"percent of total billed charges",
"STENT URETERAL 7FR 26CM WITHOUT GWIRE POLARIS ULTRA",SUP-M0061921430,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"CIGNA [10200]",Cigna,,772.22,68,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 32MM 2 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.232,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",512.88,3748.5,"percent of total billed charges",
"WIRE FIXATION DIAMOND POINT STYLE BOTH END 15.2CM .063IN",SUP-00018609000,CDM,C1713,HCPCS,0278,RC,,,both,,,119.63,35.89,"CIGNA [10200]",Cigna,,81.35,68,,1831.33,1831.33,1831.33,16,13.91,101.69,"percent of total billed charges",
"SCR BONE FIXED ANGLE SELF TAPPING 4MM 13MM ATLANTIS TITANIUM",SUP-3120213,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"KAISER [10500]",Kaiser,,944.7,67,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 80CM 23CM ORANGE HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-7F-23-035,CDM,C1894,HCPCS,0272,RC,,,both,,,117.45,35.23,"UHC [10700]","United Healthcare",,74.35,63.3,,,,,0,13.66,99.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE INSTAFILL SIGNIFY 5CC ALLOGRAFT CRTDG GEL STERILE",SUP-8112.5105S,CDM,C1713,HCPCS,0278,RC,,,both,,,7852.20,2355.66,"KAISER [10500]",Kaiser,,5260.97,67,,,,,0,913.21,6674.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP070250090 PLUS US D7L250UL900",SUP-PCP070250090,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"FIRST HEALTH [10303]","First Health",,1015.74,80,,,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 22MM STAINLESS STEEL T8 CORTEX TUBE STARDRIVE",SUP-201.772TS,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,55.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",55.39,404.84,"percent of total billed charges",
"CAP SYSTEM TKR CEMENT",SUP-98000670000,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"PHCS [10601]",PHCS,,13230,70,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 68MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.568,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"CIGNA [10200]","Cigna Open Access",,623.86,56.9,,1144.80,304.56,2275.09,66,127.51,931.96,"percent of total billed charges",
"STEM FEMORAL 160MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309114,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10195.79,27,,,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +27 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.270,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Needle Biopsy Lymph Node",PX-361000273,CDM,38505,CPT,0361,RC,,,both,,,3339.05,1001.71,"BLUE CROSS [10001]","Blue Cross PPO",,3339.05,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,388.33,3339.05,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 75CM 8CM 7MM BALLOON DILATATION PERIPHERAL",SUP-CQF7578,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"AETNA [10100]","Aetna HMO/PPO",,1062.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 10.2MM 7.5MM NASAL ORAL TAPER CUFF MURPHY",SUP-18775S,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.56,19.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.74,56.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP CONSTRUCT 2 W TRITANTIUM",SUP-CAP-STY-H2,CDM,C1776,HCPCS,0278,RC,,,both,,,25830.00,7749,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10332,40,,,,,0,3004.03,21955.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAROXETINE 10 MG TABLET, IMMEDIATE RELEASE",RX-16632,CDM,,,0637,RC,00904-5676-61,NDC,both,1,UN,14.16,4.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET EPIDURAL EPILONG SOFT SONO",SUP-0631187-51,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"X-C PUMP PACK",SUP-76800-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,4736.85,1421.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SUPER TORQUE 110CM 6FR 145D PIGTAIL CURVE",SUP-532652S,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 20MM 6FR 4.5MM",SUP-H7493926720450,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES,MINOR",815,APR-DRG,,,,,,,inpatient,,,53516.07,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $2,389.62. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"WAX BONE MONTAGE STERILE",SUP-OS-MON-1001,CDM,S27200284,LOCAL,0272,RC,,,both,,,11419.50,3425.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1353.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1328.09,9706.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENV TISSUE 5.4X5CM CANGAROO SMALL SOFT SUPPLE POCKET NO",SUP-CMCV-010-SML,CDM,S27800098,LOCAL,0278,RC,,,both,,,31027.50,9308.25,"PHCS [10601]",PHCS,,21719.25,70,,,,,0,3608.5,26373.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY TORIC AUTONOME",SUP-CNAET5,CDM,V2787,HCPCS,0276,RC,,,both,,,880.00,264,"BLUE CROSS [10001]","Blue Cross HMO",,344.96,39.2,,,,,0,102.34,748,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO 3 C-MAC S MACINTOSH DISPOSABLE",SUP-051213-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,191.40,57.42,"CIGNA [10200]",Cigna,,130.15,68,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER TISSUE 45CM 5MM ENSEAL G2 CURVE ARTICULATE ETHICON",SUP-NSLG2C45A,CDM,S27200284,LOCAL,0272,RC,,,both,,,3679.46,1103.84,"PHCS [10601]",PHCS,,2575.62,70,,,,,0,427.92,3127.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Programming Device Eval Impl Ccm-D Sys in Person",PX-481000421,CDM,0926T,CPT,0481,RC,,,both,,,58.00,17.4,"NOVANET [10819]",Novanet,,43.5,75,,,,,0,6.75,58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 10MM INTERLOCK FIBERED IDC 35 COIL",SUP-M001363610,CDM,S27800098,LOCAL,0278,RC,,,both,,,5181.90,1554.57,"CIGNA [10200]","Cigna Local Plus",,2772.32,53.5,,,,,0,602.65,4404.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 30MMX3.5MM PI TITANIUM MEDIUM THICK TISSUE",SUP-4907T,CDM,S27200284,LOCAL,0272,RC,,,both,,,392.20,117.66,"AETNA [10100]","Aetna HMO/PPO",,311.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.61,333.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABIL 40MM 200CM 10MM ENDOPROSTHESIS METAL NO",SUP-VSWVN1004,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 16MM 144CM 2.25MM CORONARY STENT",SUP-H7493941816220,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X40 135CM SL",SUP-48003004R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"UHC [10700]","United Healthcare",,543.75,63.3,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 2.7MM RIGIDFIX BONE TISSUE BONE",SUP-256868,CDM,C1713,HCPCS,0278,RC,,,both,,,4533.30,1359.99,"KAISER [10500]",Kaiser,,3037.31,67,,,,,0,527.22,3853.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM CARPENTIER-EDWARDS PERIMOUNT MAGNA HEART",SUP-7300TFX25MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,36508.50,10952.55,"FIRST HEALTH [10303]","First Health",,29206.8,80,,,,,0,4245.94,31032.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X40 135CM SL",SUP-48003004R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,101.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SOLYX ADVANTAGE 9CM URETHRAL SPRT POLYPROPYLENE",SUP-M0068507001,CDM,C1771,HCPCS,0278,RC,,,both,,,15346.98,4604.09,"BLUE CROSS [10001]","Blue Cross HMO",,6016.02,39.2,,,,,0,1784.85,13044.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAC-LOC 40CM 16CM 8.5FR DRNG ULTRATHANE HYDROPHILIC",SUP-G13359,CDM,C1729,HCPCS,0272,RC,,,both,,,801.82,240.55,"MULTIPLAN [10600]",Multiplan,,681.55,85,,,,,0,93.25,681.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM VARIAX NONSTERILE",SUP-657418,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"FIRST HEALTH [10303]","First Health",,646.96,80,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 1 VIVID LED BLADE STD HANDLE MERCURY FREE",SUP-301-LED-101S,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.97,29.09,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.28,82.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BRACHYTHERAPY INTERFACE CONTROL SYSTEM BRACHYBALLOON",SUP-610-898,CDM,S27200284,LOCAL,0272,RC,,,both,,,584.62,175.39,"NOVANET [10819]",Novanet,,438.47,75,,,,,0,67.99,496.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 35CM MYOCARDIUM VENTRICLE IS-1 CNCT SCR FIXATION",SUP-4058,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1604.72,28.62,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 15FTX6IN WRIST IMMOB ROLL INTERLOCK",SUP-OG-6L2,CDM,S27000186,LOCAL,0270,RC,,,both,,,738.07,221.42,"KAISER [10500]",Kaiser,,494.51,67,,,,,0,85.84,627.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 80MM 2MM .014IN BALLOON DILATATION",SUP-AB14W020080150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"AETNA [10100]","Aetna HMO/PPO",,1101.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 13MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P413,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Local Plus",,4470.41,53.5,,5372.07,4581.20,7242.98,23,971.79,7102.52,"percent of total billed charges",
"HC Cath Vent Lt Heart Dlp 20f",PX-E27200330,CDM,E27200330,LOCAL,0272,RC,,,both,,,170.50,51.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.83,144.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 2MM CRANIOFACIAL TITANIUM SELF TAPPING LOW",SUP-400.856,CDM,C1713,HCPCS,0278,RC,,,both,,,615.60,184.68,"BLUE CROSS [10001]","Blue Cross HMO",,241.32,39.2,,957.42,156.86,7483.26,51,71.59,523.26,"percent of total billed charges",
"COIL EMBOLIZATION 3CM 2MM TARGET NANO 360D DETACHABLE",SUP-M0035442030,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1672.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FLEXSEGMENT PALMAZ GENESIS AVIATOR 11MM 135CM 5MM 4-6",SUP-H739PG1250BAX3,CDM,C1876,HCPCS,0278,RC,,,both,,,6554.03,1966.21,"KAISER [10500]",Kaiser,,4391.2,67,,,,,0,762.23,5570.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CINCH SUTURE FOR OVERSTITCH SUTURING SYSTEM",SUP-M00505530,CDM,S27200284,LOCAL,0272,RC,,,both,,,1343.22,402.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,913.39,68,,,,,0,156.22,1141.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 20MM 2.75MM BALLOON DILATATION PACLITAXEL",SUP-H7493960820270,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"CIGNA [10200]","Cigna Local Plus",,20812.84,53.5,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 14 X 12 X 08MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-141208-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,722.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY TORIC",SUP-CNWET5,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,102.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 9CM 8.5FR BILIARY POLYETHYLENE TAPERED",SUP-G21621,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"FIRST HEALTH [10303]","First Health",,505.44,80,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 8X4CM GRAFTJACKET NOW THK1-2MM STD ACELLULAR",SUP-86204X08,CDM,Q4107,HCPCS,0636,RC,,,both,,,17091.30,5127.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2025.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.92,14527.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALPRAZOLAM 1 MG TABLET, IMMEDIATE RELEASE",RX-326,CDM,,,0637,RC,00781-1079-01,NDC,both,1,UN,12.54,3.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5.76,45.9,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP 3 HOLE POLY POROUS R3 STD STERILE",SUP-71335560,CDM,C1776,HCPCS,0278,RC,,,both,,,14345.10,4303.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3873.18,27,,,,,0,1668.34,12193.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 10MM 2.5MM BALLOON DILATATION STERILE",SUP-225-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Benzodiazepines 1-12",PX-301000498,CDM,80346,CPT,0301,RC,,,both,,,189.00,56.7,"NOVANET [10819]",Novanet,,141.75,75,,,,,0,0.01,189,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X9MM VERTE-STACK CORNERSTONE PSR 11MM",SUP-6287941,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER UNIVERSAL QC T6",SUP-DRVR-UQC-T6,CDM,S27000186,LOCAL,0270,RC,,,both,,,907.20,272.16,"MULTIPLAN [10600]",Multiplan,,771.12,85,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE LCP ANKLE FOOT STAINLESS STEEL 2X7 HOLE MODULAR T",SUP-247.351,CDM,C1713,HCPCS,0278,RC,,,both,,,2541.00,762.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,301.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,295.52,2159.85,"percent of total billed charges",
"IMPL BREAST SMOOTH MOD + PROF XTRA 370CC",SUP-SMPX370,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,883.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 80CM 6MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM06100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 5.5MM TWINFIX ULTRA TITANIUM STERILE COBRAID",SUP-72202897,CDM,C1713,HCPCS,0278,RC,,,both,,,2155.13,646.54,"KAISER [10500]",Kaiser,,1443.94,67,,,,,0,250.64,1831.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AIRWAY 4-7MM ENDOBRONCHIAL 1 WAY LOW PROFILE ZEPHYR",SUP-EBV-TS-4.0-LP,CDM,S27800098,LOCAL,0278,RC,,,both,,,17112.00,5133.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4620.24,27,,,,,0,1990.13,14545.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 58.5MM 1.2MM CARBIDE CROSS CUT FISSURE STERILE",SUP-2296101212,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.77,16.13,"CIGNA [10200]","Cigna Open Access",,30.6,56.9,,,,,0,6.25,45.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM NEXGEN F DISTAL KNEE TRABECULAR METAL",SUP-00549003610,CDM,C1776,HCPCS,0278,RC,,,both,,,7761.60,2328.48,"KAISER [10500]",Kaiser,,5200.27,67,,,,,0,902.67,6597.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 20MM 144CM 3.5MM CORONARY STENT PEBAX",SUP-H7493926020350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Strep B (V/R) by Pcr",PX-306000186,CDM,87653,CPT,0306,RC,,,both,,,581.00,174.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,31.58,,,,,,,0.01,493.85,"fee schedule",
"STPLR INTERNAL 60X3.5MM TITANIUM STD ENDOSCOPIC LINEAR",SUP-TX60B,CDM,S27200284,LOCAL,0272,RC,,,both,,,1854.32,556.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,219.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,215.66,1576.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 8.5MM MONOBLOC FLEXIBLE STD DD",SUP-03.045.085,CDM,S27200284,LOCAL,0272,RC,,,both,,,4180.02,1254.01,"AETNA [10100]","Aetna HMO/PPO",,3323.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.14,3553.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 26FR WOLF RESECTOSCOPE",SUP-M0068802461,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,212.27,41.1,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRODE EMG NEEDLE 26GA L1.5IN RECORDING AREA 0.07SQMM GRE",SUP-S53156,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.11,30.03,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.64,85.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 20MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962345,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"PHCS [10601]",PHCS,,10152.66,70,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 13MM MONSTER SHORT THREAD BITE NONSTERILE",SUP-P24-020-013S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"CATH SABER 90CM 20MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"KAISER [10500]",Kaiser,,960.58,67,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GRIESHABER REVOLUTION 23GA END GRASPING FINE",SUP-706.43,CDM,S27200284,LOCAL,0272,RC,,,both,,,984.07,295.22,"FIRST HEALTH [10303]","First Health",,787.26,80,,,,,0,114.45,836.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 17GA RIGID NDL RADIOPAQUE ULTRACLIP II TISSUE BREAST",SUP-865017,CDM,A4648,HCPCS,0278,RC,,,both,,,1151.17,345.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,782.8,68,,,,,0,133.88,978.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 12MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192012,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"CIGNA [10200]","Cigna Local Plus",,7480.77,31.5,,5372.07,4581.20,7242.98,23,2761.95,20186.21,"percent of total billed charges",
"COHERE XL 12X18X50MM 10°",SUP-8181250P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 10MM ATLANTIS TITANIUM ANTERIOR CERVICAL SPINE",SUP-876-810,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"BLADE SAW 5.5MM CORE THK.51MM 25MM LONG NARROW SAGITTAL",SUP-2296-033-414,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.84,87.25,"UHC [10700]","United Healthcare",,184.1,63.3,,,,,0,33.82,247.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 11MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P511,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2391.46,28.62,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP840D,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.36,38.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.04,109.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 60CM RVOT KIT MOND STAINLESS STEEL WIDE",SUP-4151/60,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"NOVANET [10819]",Novanet,,431.33,75,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX13MM CAPSTONE PEEK PTC LUMBAR INTERBODY",SUP-3992213,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2564.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 8-11 E-F KNEE RIGHT TIBIA FIX",SUP-42-5221-008-20,CDM,C1776,HCPCS,0278,RC,,,both,,,12008.76,3602.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1396.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1396.62,10207.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 58MM 80CM 9MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU0800958,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"NOVANET [10819]",Novanet,,19608.75,75,,,,,0,3040.66,22223.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 13X1IN DEAVER 2 STD HANDLE HANDHELD STAINLESS STEEL",SUP-50-4304,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.91,23.07,"AETNA [10100]","Aetna HMO/PPO",,61.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.94,65.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LARGE 116MM TITANIUM 4 HOLE SHAFT 2 COMPRESSION SLOT",SUP-59202030,CDM,C1713,HCPCS,0278,RC,,,both,,,14993.70,4498.11,"NOVANET [10819]",Novanet,,11245.28,75,,,,,0,1743.77,12744.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD 25CM 14FR LOOP DRNG FLEXIMA METAL HYDROPHILIC",SUP-M001271390,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 F 36MM E1 HIP HIGH WALL",SUP-010000936,CDM,C1776,HCPCS,0278,RC,,,both,,,12282.00,3684.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5047.9,41.1,,6417.48,6417.48,6417.48,"1 through 10",1428.4,10439.7,"percent of total billed charges",
"PROBE BALLOON DILATATION 6FR RADIOPAQUE FOGARTY BILIARY 1.24",SUP-410236F,CDM,S27200284,LOCAL,0272,RC,,,both,,,617.30,185.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,419.76,68,,,,,0,71.79,524.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X25X10MM DIVERGENCE-L 6D SMALL ANTERIOR OLIF",SUP-2151110,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7144.2,27,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLATION KIT",SUP-K05-02862,CDM,S27200284,LOCAL,0272,RC,,,both,,,474.90,142.47,"NOVANET [10819]",Novanet,,356.18,75,,,,,0,55.23,403.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 20CM 6FR .035IN URETERAL",SUP-M006155230090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"PHCS [10601]",PHCS,,953.92,70,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY BREAST",SUP-MME-01782,CDM,S27200284,LOCAL,0272,RC,,,both,,,162.15,48.64,"NOVANET [10819]",Novanet,,121.61,75,,,,,0,18.86,137.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT UROSTOMY GENTLE TOUCH STOMAHESIVE SUR-FIT STANDARD L45 M",SUP-20936,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.25,125.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,48.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.53,354.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 250MM 3.9-4.2FR 6MM BALLOON",SUP-PCU060250130,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"MULTIPLAN [10600]",Multiplan,,1079.23,85,,,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM LCP STAINLESS STEEL PERIARTICULAR FEMORAL",SUP-02.205.250,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"BLUE CROSS [10001]","Blue Cross HMO",,609.89,39.2,,957.42,156.86,7483.26,51,180.95,1322.47,"percent of total billed charges",
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET RETROGRADE LOW",SUP-AR-1204AF-110,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"UHC [10700]","United Healthcare",,1620.09,63.3,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 5-0 FS-2 18IN MONOFILAMENT PLIABILIZED",SUP-661G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,,,0637,RC,00904-6407-61,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTERIAL BLUE 2X.1X.15IN CORONARY VEIN POLYPROPYLENE NO",SUP-82609,CDM,S27200284,LOCAL,0272,RC,,,both,,,114.71,34.41,"FIRST HEALTH [10303]","First Health",,91.77,80,,,,,0,13.34,97.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BULLET ALLOGRAFT REVISION DOWEL PREHYDRATE",SUP-PCD13,CDM,C1713,HCPCS,0278,RC,,,both,,,6744.75,2023.42,"BLUE CROSS [10001]","Blue Cross PPO",,2643.94,39.2,,957.42,570.23,957.42,28,784.41,5733.04,"percent of total billed charges",
"CUTTER ARTHROSCOPIC END COOLCUT 13CM STERILE DISPOSABLE 3.8",SUP-AR-8380EC,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"FIRST HEALTH [10303]","First Health",,59.16,80,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Observation Carve-Out - All Other",PX-762000016,CDM,G0378,HCPCS,0762,RC,,,both,,,66.00,19.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",172.34,80.22,336.95,776,7.68,66,"percent of total billed charges",
"PLATE 3003059 ZEVO 59MM 3 LVL",SUP-3003059,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"KAISER [10500]",Kaiser,,3545.64,67,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MAXXWIRE ENDOSCOPIC STRAIGHT 260CM .035IN SUPER STIFF",SUP-80129-406,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 8X4IN KALTOSTAT CALCIUM ALGINATE ABSORBENT",SUP-168214,CDM,S27200284,LOCAL,0272,RC,,,both,,,46.34,13.9,"MULTIPLAN [10600]",Multiplan,,39.39,85,,,,,0,5.39,39.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE 0.5%-EPI 1:100,000 BUFFERED W/SOD BICARB 8.4% SYRINGE 10 ML",RX-411236,CDM,,,0250,RC,08888-8879-62,NDC,both,10,ML,18.92,5.68,"NOVANET [10819]",Novanet,,14.19,75,,,,,0,2.2,16.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATALYST HUMERAL STEM SHORT - 36MM X8MM",SUP-1230-7523-001,CDM,C1776,HCPCS,0278,RC,,,both,,,27713.70,8314.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11390.33,41.1,,6417.48,6417.48,6417.48,"1 through 10",3223.1,23556.65,"percent of total billed charges",
"UNCOMPLICATED PEPTIC ULCER WITH MCC",383,MS-DRG,,,,,,,inpatient,,,51769.34,15530.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,22013.51,,,,,,,7561,34433.28,"case rate",
"RING ANNULOPLASTY 36MM SEMIRIGID OPEN ANTERIOR SEG SEWING",SUP-5300M36,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"BLUE CROSS [10001]","Blue Cross HMO",,5409.6,39.2,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NORTRIPTYLINE 25 MG CAPSULE",RX-5675,CDM,,,0637,RC,00093-0811-01,NDC,both,1,UN,7.38,2.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.86,6.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-593504022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,549.3,41.1,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 100MM 10MM BALLOON DILATATION DURALYN",SUP-48010010S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"PHCS [10601]",PHCS,,963.9,70,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 9FR ARROWG+ARD BLUE CATH-GARD PERCUTANEOUS",SUP-CDC-21142-XCN1A,CDM,C1894,HCPCS,0272,RC,,,both,,,1524.42,457.33,"FIRST HEALTH [10303]","First Health",,1219.54,80,,,,,0,177.29,1295.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB PEDI-PADZ II PEDIATRIC AED PLUS DISPOSABLE",SUP-8900-0810-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,638.60,191.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,75.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.27,542.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 LEFT REVISION TRIATHLON",SUP-5612-F-301,CDM,C1776,HCPCS,0278,RC,,,both,,,48062.70,14418.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19753.77,41.1,,6417.48,6417.48,6417.48,"1 through 10",5589.69,40853.3,"percent of total billed charges",
"STEM HUMERAL 48MM 12MM STD SHELL DJO SURGICAL ALTIVATE",SUP-530-12-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5523.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5523.6,40370.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 44MM CANCELLOUS CANNULATED LAG NONSTERILE",SUP-1437644,CDM,C1713,HCPCS,0278,RC,,,both,,,1968.75,590.62,"CIGNA [10200]","Cigna Open Access",,1120.22,56.9,,1144.80,304.56,2275.09,66,228.97,1673.44,"percent of total billed charges",
"INSRT ARTICULAR 3-7 CD 11MM KNEE RIGHT ULTRACONGRUENT",SUP-42522200411,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"MULTIPLAN [10600]",Multiplan,,9159.96,85,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM TRIATHLON 2 RIGHT MEDIAL LEFT LATERAL TOTAL",SUP-5545-A-202,CDM,C1776,HCPCS,0278,RC,,,both,,,4327.60,1298.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,512.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,503.3,3678.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13175540,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,3978.14,359.25,3978.14,24,348.9,2550,"percent of total billed charges",
"BLADE SAW 12X5.5MM THK.4MM THK.6MM SMALL BONE OSCILLATE",SUP-KM-3006,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,42,68,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 5 LEFT DISTAL KNEE",SUP-5541-A-501,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2189.88,45.9,,,,,0,554.87,4055.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Picc WO Port/Img >=5yr",PX-361000115,CDM,36569,CPT,0361,RC,,,both,,,7818.16,2345.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1550,,"Case rate ($1,550). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,909.25,7818.16,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Rib Uni>=3v Incl Pa Chst",PX-320000028,CDM,71101,CPT,0320,RC,,,both,,,770.92,231.28,"KAISER [10500]",Kaiser,,516.52,67,,,,,0,46.53,655.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER TEVDEK 2 K-61 30IN BRAIDED GREEN NONABSORBABLE",SUP-79-746,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.28,41.1,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPEL APD TWIST-LOC 45CM 12FR LONG LENGTH LOOP PIGTAIL",SUP-H7493931112450,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,92.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 SH 27IN BRAID COATED UNDYED ABSORBABLE",SUP-VCP417H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR JUDKINS LEFT CORONARY 5",SUP-534522T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"PHCS [10601]",PHCS,,65.47,70,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR061002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"AETNA [10100]","Aetna HMO/PPO",,16908.7,79.5,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE VASCULAR 175CM 3.2FR 2-4MM EN SNARE CATH 150MM",SUP-391003004,CDM,S27000186,LOCAL,0270,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Submuc Inj",PX-750000080,CDM,45335,CPT,0750,RC,,,both,,,2388.48,716.54,"CIGNA [10200]","Cigna Open Access",,2090,,"Case rate ($2,090). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,277.78,2388.48,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,,,0250,RC,45802-0059-35,NDC,both,15,GR,110.11,33.03,"CIGNA [10200]","Cigna Open Access",,62.65,56.9,,,,,0,12.81,93.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Chest 3v",PX-324000011,CDM,71047,CPT,0324,RC,,,both,,,426.52,127.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,66.28,,"Fee schedule rate ($66.28).",,,,0,46.01,362.54,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER CHOANAL ATRESIA",SUP-1884015RTD,CDM,S27200284,LOCAL,0272,RC,,,both,,,3843.30,1152.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2613.44,68,,,,,0,446.98,3266.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC",427,MS-DRG,,,,,,,inpatient,,,310602.19,93180.66,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,47464.05,,"Case rate ($44,777.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $41,578.86, add-ons for qualifying new technology services are included. If operating cost exceeds $74,618.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $4,525.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $41,633.85. The transfer operating threshold is the transfer adjustment factor * $41,578.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,143.56. The transfer capital threshold is the transfer adjustment factor * $3,143.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,210754.25,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 3-0 PS-1 18IN MONOFILAMENT PLIABILIZE",SUP-1663G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AETNA [10100]","Aetna HMO/PPO",,19.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.5MM MINI PUSHLOCK PEEK 8MM STERILE",SUP-AR-8825P,CDM,C1713,HCPCS,0278,RC,,,both,,,2835.00,850.5,"KAISER [10500]",Kaiser,,1899.45,67,,,,,0,329.71,2409.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 47MM STAINLESS STEEL 2.4MM SCR 7 HOLE HEAD 2 HOLE",SUP-02.111.721S,CDM,C1713,HCPCS,0278,RC,,,both,,,4126.20,1237.86,"AETNA [10100]","Aetna HMO/PPO",,3280.33,79.5,,1521.93,481.35,16760.95,30,479.88,3507.27,"percent of total billed charges",
"CATH SHOCKWAVE M5 60MM 110CM 4MM 7MM BALLOON DILATATION",SUP-M5PIVL4060,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8933.09,41.1,,,,,0,2527.78,18474.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Transplant Kidney Dplr",PX-402000012,CDM,76776,CPT,0402,RC,,,both,,,219.00,65.7,"CIGNA [10200]","Cigna Open Access",,219,,,,,,,25.47,219,"fee schedule",
"HEAD FEMORAL S-ROM +9MM 11/13 TAPER 36MM HIP M SPECIFICATION",SUP-136534000,CDM,C1776,HCPCS,0278,RC,,,both,,,6875.85,2062.75,"KAISER [10500]",Kaiser,,4606.82,67,,,,,0,799.66,5844.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 54MM 36MM NEUTRAL HIP CERAMIC STERILE LATEX",SUP-121887654,CDM,C1776,HCPCS,0278,RC,,,both,,,14835.00,4450.5,"BLUE CROSS [10001]","Blue Cross HMO",,5815.32,39.2,,5311.50,4717.44,5388.59,31,1725.31,12609.75,"percent of total billed charges",
"ROD SPINAL 40MM 3.5MM VERTEX PRECUT",SUP-7753740,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"KAISER [10500]",Kaiser,,944.7,67,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 2MM CRANIOFACIAL TITANIUM SELF TAPPING LOW",SUP-400.856,CDM,C1713,HCPCS,0278,RC,,,both,,,615.60,184.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,282.56,45.9,,,,,0,71.59,523.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 12MM 6FR 1.5MM .07IN BALLOON",SUP-H7493919012150,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR IMPLANTABLE INCEPTIV MRI STERILE LATEX FREE",SUP-977119,CDM,C1826,HCPCS,0278,RC,,,both,,,124830.00,37449,"BLUE CROSS [10001]","Blue Cross PPO",,48933.36,39.2,,,,,0,14517.73,106105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL ORBITAL ROUND MEDPOR POLYETHYLENE 18MM",SUP-6327,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 21MM KNEE RIGHT BICRUCIATE STABILIZE",SUP-74027235,CDM,C1776,HCPCS,0278,RC,,,both,,,20478.15,6143.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5860.85,28.62,,,,,0,2381.61,17406.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 25CM 10FR 21GA FLEXIMA PLATINUM HYDROPHILIC",SUP-M001271970,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,inpatient,,,83097.72,24929.32,"AETNA [10100]","Aetna HMO/PPO",,83097.72,,"Fee schedule rate ($93,837.93). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,83097.72,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 18CM PUMP SET INFLATABLE FLUID FILL SOFT",SUP-ES8918,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7292.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC EVERA S VR 1 CHMBR ICD DF4 SMARTSHOCK",SUP-DVBC3D4,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"NOVANET [10819]",Novanet,,29250,75,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIFLUFOLASTAT F-18 IV SYRINGE (12-13 MCI)",RX-411829,CDM,A9595,HCPCS,0343,RC,08888-8877-83,NDC,both,1,UN,16868.88,5060.66,"BLUE CROSS [10001]","Blue Cross PPO",,9319.08,,,,,,,696,14338.55,"fee schedule",
"GRAFT ENDOVASCULAR STENT 8-16MM X 59MM CATHETER 80CM INTRODU",SUP-BXBL085901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8016.47,41.1,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHITOZOLVE DISSOLVABLE CHITOSAN INTRANASAL SPLINT 1.5 CM X 5",SUP-CNS155,CDM,S27000186,LOCAL,0270,RC,,,both,,,891.00,267.3,"PHCS [10601]",PHCS,,623.7,70,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inhibin A",PX-302000072,CDM,86336,CPT,0302,RC,,,both,,,155.00,46.5,"BLUE CROSS [10001]","Blue Cross PPO",,19.92,,"Fee schedule rate ($19.92).",,,,0,0.01,131.75,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12CM NATRELLE INSPIRA P3.1CM LOW PLUS PROFILE",SUP-MSZ-LP250,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AETNA [10100]","Aetna HMO/PPO",,125.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH BIOFLO DURAMAX VASCPAK ENDEXO 2 VALVE ADULT 28CM",SUP-H787103028195,CDM,C1750,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 30MM 7MM BALLOON DILATATION DURALYN",SUP-48007003S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PHCS [10601]",PHCS,,878.85,70,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM 2.4-1.7FR .0165IN",SUP-M0031681810,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,914.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,897.75,6561.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LD SCOUTPRO TL SLTR","SUP-383 119",CDM,S27200284,LOCAL,0272,RC,,,both,,,801.90,240.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,93.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,93.26,681.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 22X9X11MM 8D",SUP-PUI81102,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 200MM 2MM BALLOON DILATATION RAPID",SUP-47520200L,CDM,C1725,HCPCS,0272,RC,,,both,,,1740.00,522,"KAISER [10500]",Kaiser,,1165.8,67,,,,,0,202.36,1479,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 7.75IN 17.5MM STAINLESS STEEL LANGENBECK",SUP-250492,CDM,S27200284,LOCAL,0272,RC,,,both,,,252.21,75.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.33,214.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 120CM 10MM 9FR STRAIGHT VASCULAR",SUP-AVSL10100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7308,40,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI 125CM 4FR MULTIPURPOSE A 2 CURVE ANGIOGRAPHIC",SUP-538444,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"CIGNA [10200]",Cigna,,60.87,68,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X13MM LUMINARY CC BICONVEX SPINE",SUP-16813,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"NOVANET [10819]",Novanet,,24948,75,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL MEMORYSHAPE MEDIUM HEIGHT MODERATE PLUS PROFILE",SUP-RSZ-1355S,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"AETNA [10100]","Aetna HMO/PPO",,179.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55840016550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPIN ACCESS CATH 180D BRACHYTHERAPY OLYMPUS 190 SCOPE",SUP-INS-5915,CDM,S27200284,LOCAL,0272,RC,,,both,,,7452.00,2235.6,"NOVANET [10819]",Novanet,,5589,75,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 4-0 T-12 18IN BRAID TIES MULTISTRAND LOWER",SUP-AR-7230-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"CIGNA [10200]","Cigna Local Plus",,107.52,53.5,,,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER HEMODIALYSIS DIACAP ULTRA BACTERIAL PYROGEN LATEX",SUP-7107367,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,60.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 8 5MM KNEE CRUCIATE RETAINING ROTATE PLATFORM",SUP-151630805,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]","Cigna Open Access",,4397.63,33.5,,5302.19,4377.88,6578.61,27,1526.7,11158.16,"percent of total billed charges",
"STENT GORE VIABAHN 59MM 80CM 7MM 11MM 7FR .035IN",SUP-BXA075901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7801.92,40,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Transducer Triple",PX-E27200279,CDM,E27200279,LOCAL,0272,RC,,,both,,,314.61,94.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,37.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.59,267.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ECHELON CONTOUR GST RELOAD (BLUE)",SUP-GCR40B,CDM,S27200284,LOCAL,0272,RC,,,both,,,2994.05,898.21,"UHC [10700]","United Healthcare",,1895.23,63.3,,,,,0,348.21,2544.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cortisol Blood Total",PX-301000158,CDM,82533,CPT,0301,RC,,,both,,,341.90,102.57,"BLUE CROSS [10001]","Blue Cross PPO",,20.82,,"Fee schedule rate ($20.82).",,,,0,0.01,290.62,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLOSED WOUND DRAIN FLAT 4MM SILICONE WITH CLOTSTOP",SUP-410ATSX,CDM,S27200284,LOCAL,0272,RC,,,both,,,392.34,117.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,180.08,45.9,,,,,0,45.63,333.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE CANCELLOUS CORTICAL 11X11X8MM SPINE",SUP-340811,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS LARGE BLOCK 20X20MM",SUP-800101,CDM,S27800098,LOCAL,0278,RC,,,both,,,5255.04,1576.51,"PHCS [10601]",PHCS,,3678.53,70,,,,,0,611.16,4466.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBO-TANDEM 110CM 7FR 2MM ATHERECTOMY LASER GUIDE",SUP-472-110,CDM,C1887,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 1X.6CM TUTOPLAST IOPATCH SCLERA DEHYDRATE",SUP-68337,CDM,C1762,HCPCS,0278,RC,,,both,,,2135.63,640.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,611.22,28.62,,,,,0,248.37,1815.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 50MM 14MM ATTUNE KNEE CEMENT REVISION STERILE",SUP-151214050,CDM,C1776,HCPCS,0278,RC,,,both,,,5230.20,1569.06,"MULTIPLAN [10600]",Multiplan,,4445.67,85,,,,,0,608.27,4445.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Dipyridamole 10 Mg",PX-636000007,CDM,J1245,HCPCS,0636,RC,,,both,,,73.70,22.11,"CIGNA [10200]",Cigna,,22.6,,,,,,,1.15,62.65,"fee schedule",
"ROD SPINAL 130MM PREBENT LINE",SUP-179771130,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"TROCAR SURGICAL FALLER DIALYSIS CATH",SUP-FT-1100,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,70.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13177550,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL SENSOR DUAL-FLEX 22-30CM 6FR .038IN PIGTAIL",SUP-M006180156120,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"CIGNA [10200]",Cigna,,842.78,68,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 52MM TI",SUP-SPL-35520-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,1144.80,304.56,2275.09,66,155.43,1136.03,"percent of total billed charges",
"SYSTEM PROMUS PREMIER 24MM 144CM 4MM CORONARY STENT",SUP-H7493952824400,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]",Cigna,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 80MM 125CM 6MM VASCULAR PERIPHERAL DRUG",SUP-G38480,CDM,C1874,HCPCS,0278,RC,,,both,,,11921.68,3576.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4899.81,41.1,,,,,0,1386.49,10133.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +12 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000120,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 30MM ATLANTIS VISION ELITE BONE ANTERIOR CERVICAL",SUP-7200030,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"BLUE CROSS [10001]","Blue Cross PPO",,1646.4,39.2,,957.42,570.23,957.42,28,488.46,3570,"percent of total billed charges",
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 10 STD OFFSET HIP",SUP-71935570,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"BLUE CROSS [10001]","Blue Cross PPO",,14321.21,39.2,,3949.44,3949.44,3949.44,"1 through 10",4248.87,31053.65,"percent of total billed charges",
"IMPL BREAST 11.5CM MEMORYGEL P2.9CM MODERATE PROFILE SILTEX",SUP-3542157MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 14CM 6FR 7MM .035IN BALLOON",SUP-G52277,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X7MM COLONIAL 12MM LARGE PARALLEL TITANIUM",SUP-365.307CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DECA 2-8-2 MPD-SL. 110CM",SUP-901718,CDM,C1730,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"FIRST HEALTH [10303]","First Health",,4388.4,80,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Lesn Vulva/Perineum One",PX-361000518,CDM,56605,CPT,0361,RC,,,both,,,2533.51,760.05,"UHC [10700]","United Healthcare",,2385,,"Case rate ($2,385). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,294.65,2533.51,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 2-0 GS-22 9IN CLSR ABSORBABLE VIOLET",SUP-VLOCM2145,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,80.49,41.1,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pt Pad Rehab per Session",PX-420000166,CDM,93668,CPT,0420,RC,,,both,,,117.00,35.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,117,,"Per diem ($426).",,,,0,13.61,117,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2MM 2MM .018IN HELICAL STRAIGHT PLATINUM",SUP-M0013120021,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 2 KNEE CEMENTED ROTATE PLATFORM",SUP-150610002,CDM,C1776,HCPCS,0278,RC,,,both,,,16694.55,5008.36,"CIGNA [10200]","Cigna Open Access",,5592.67,33.5,,5302.19,4377.88,6578.61,27,1941.58,14190.37,"percent of total billed charges",
"CATH DIREXION 130CM 2.4FR MICRO J INFUSION NITINOL 1",SUP-M001195270,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM PROFILE 3D",SUP-680R34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"PHCS [10601]",PHCS,,9177,70,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL STD 12.5MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405412,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"NOVANET [10819]",Novanet,,7247.59,75,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630512,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"KAISER [10500]",Kaiser,,8795.26,67,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK",RX-9626,CDM,J0736,HCPCS,0636,RC,00338-3612-50,NDC,both,50,ML,100.65,30.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68.44,68,,,,,0,4.27,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 33MM ADJUSTABLE FULL FLEXIBLE RADIOPAQUE",SUP-AFR-33,CDM,S27800098,LOCAL,0278,RC,,,both,,,16909.83,5072.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1966.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1966.61,14373.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEMORYGEL SMOOTH ROUND ULTRA HIGH BREAST IMPLANT 700 CC",SUP-3505700BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,621.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT PATELLAR PERSONA OSSEOTI OD38 MM KNEE 3 PEG CEMENT",SUP-42-5405-000-38,CDM,C1776,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2132.76,28.62,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 10MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620810,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Local Plus",,6020.84,53.5,,5372.07,4581.20,7242.98,23,1308.83,9565.82,"percent of total billed charges",
"FENTANYL (PF) 50 MCG/ML INTRAVENOUS SOLUTION",RX-123700,CDM,J3010,HCPCS,0636,RC,08888-8879-66,NDC,both,100,ML,447.99,134.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,69.89,,"Fee schedule rate ($69.89). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.09,380.79,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SURGICAL GRAFT STAINLESS STEEL STERILE DISTAL",SUP-AMGM-SD,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.39,26.52,"CIGNA [10200]","Cigna Local Plus",,47.29,53.5,,,,,0,10.28,75.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 12.5MM 5.5MM ANTERIOR CHMBR 1 PIECE PMMA STERILE",SUP-MTA5U0.055,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVICROSS 150CM 30D ANGIOGRAPHIC HYDROPHILIC STAINLESS",SUP-NC35151,CDM,C1887,HCPCS,0272,RC,,,both,,,1462.05,438.61,"FIRST HEALTH [10303]","First Health",,1169.64,80,,,,,0,170.04,1242.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXIMA 70CM 8FR URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002041,CDM,C1758,HCPCS,0272,RC,,,both,,,80.01,24,"AETNA [10100]","Aetna HMO/PPO",,63.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.31,68.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 7MM KNEE POSTERIOR STABILIZE IDENTITY IMPRINT",SUP-TPS-020-075S,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"NOVANET [10819]",Novanet,,4409.1,75,,,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM DRAINAGE LIMITORR 20 ML CSF CLOSED VOLUME LIMIT VALVE",SUP-INS9020,CDM,S27200284,LOCAL,0272,RC,,,both,,,2625.00,787.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1078.88,41.1,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR CHEST TRAUMA WITH CC",184,MS-DRG,,,,,,,inpatient,,,32048.25,9614.47,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,6897.72,,"Case rate ($6,600.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,129.18, add-ons for qualifying new technology services are included. If operating cost exceeds $39,168.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,845.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,137.28. The transfer operating threshold is the transfer adjustment factor * $6,129.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $463.40. The transfer capital threshold is the transfer adjustment factor * $463.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,6600.69,26537.59,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X3IN DURAGEN CRANIUM BOVINE CLLGN MATRIX",SUP-DURS3391,CDM,,,0278,RC,,,both,,,7552.19,2265.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7.55,.1,,,,,0,7.55,6419.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BN 2MM 12MM LEIBINGER UNV 2 7955",SUP-50-20412,CDM,C1713,HCPCS,0278,RC,,,both,,,458.06,137.42,"MULTIPLAN [10600]",Multiplan,,389.35,85,,,,,0,53.27,389.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUREFIRE 65CM 5FR .056IN COBRA 1 CURVE GUIDING STEEL",SUP-SGC-5065-COBRA1,CDM,C1887,HCPCS,0272,RC,,,both,,,1875.00,562.5,"NOVANET [10819]",Novanet,,1406.25,75,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MENTAL DISORDER DIAGNOSES",887,MS-DRG,,,,,,,inpatient,,,41043.36,12313.01,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,14282.13,,"Case rate ($6,642.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,168.34, add-ons for qualifying new technology services are included. If operating cost exceeds $39,208.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,848.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,176.50. The transfer operating threshold is the transfer adjustment factor * $6,168.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.36. The transfer capital threshold is the transfer adjustment factor * $466.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,1958,26707.18,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 64MM HIP SECTOR POROCOAT PINNACLE STERILE",SUP-121722064,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4563.32,68,,,,,0,780.46,5704.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 44MM 28MM F VIVACIT-E LUMEN STERILE LATEX FREE",SUP-110031012,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"KAISER [10500]",Kaiser,,6939.12,67,,,,,0,1204.51,8803.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT EXTREMITY SOF PRO UNIVERSAL HEEL ELBOW ELASTIC CUSH",SUP-MDT823298,CDM,S27000186,LOCAL,0270,RC,,,both,,,59.60,17.88,"CIGNA [10200]","Cigna Open Access",,33.91,56.9,,,,,0,6.93,50.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP MEDIUM LEAK 1 ENTRAINMENT NEB ELBOW",SUP-73-1061734,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.58,61.97,"FIRST HEALTH [10303]","First Health",,165.26,80,,,,,0,24.03,175.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 110MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 6",SUP-71357106,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"CIGNA [10200]","Cigna Open Access",,11102.29,33.5,,5302.19,4377.88,6578.61,27,3854.32,28169.98,"percent of total billed charges",
"CATH CODA 140CM 46MM OCCLUSION POLYURETHANE BALLOON ACCEPTS",SUP-G23773,CDM,C2628,HCPCS,0272,RC,,,both,,,3588.75,1076.62,"NOVANET [10819]",Novanet,,2691.56,75,,,,,0,417.37,3050.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ecmo Daily Mgmt Veno-Venous",PX-361000384,CDM,33948,CPT,0361,RC,,,both,,,4965.00,1489.5,"BLUE CROSS [10001]","Blue Cross PPO",,3634.7,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,577.43,4965,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Tum Loc Plnr Sgl Area 1 Day",PX-341000076,CDM,78800,CPT,0341,RC,,,both,,,1257.73,377.32,"FIRST HEALTH [10303]","First Health",,1006.18,80,,,,,0,146.27,1069.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMIODARONE HCL IN D5W 150 MG/100 ML (1.5 MG/ML) IV SUPERORDERABLE",RX-408123888,CDM,J0283,HCPCS,0636,RC,43066-0150-10,NDC,both,100,ML,314.08,94.22,"BLUE CROSS [10001]","Blue Cross HMO",,15.21,,,,,,,15.21,266.97,"fee schedule",
"HC Cyclic Citrullinated Pept Ab",PX-302000034,CDM,86200,CPT,0302,RC,,,both,,,314.93,94.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.31,.1,,,,,0,0.31,267.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM BLOCK 15MMX14MM",SUP-310114,CDM,S27800098,LOCAL,0278,RC,,,both,,,3139.50,941.85,"CIGNA [10200]","Cigna Open Access",,1786.38,56.9,,,,,0,365.12,2668.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPIDCROSS 170CM 20MM 2MM .014IN BALLOON DILATATION",SUP-A14BX020020170,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.87,68,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UNI-FUSE FLOW-THRU HUB 45CM 15CM 5FR THROMBECTOMY",SUP-12401803,CDM,C1757,HCPCS,0272,RC,,,both,,,1134.00,340.2,"KAISER [10500]",Kaiser,,759.78,67,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIGUARD 3 EMBOLIC PROTECTION DEVICE",SUP-FG00005,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 12MM 144CM 5MM CORONARY STENT",SUP-H7493941812500,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 8 HOLE STRAIGHT LOW PROFILE BONE CLAVICLE",SUP-70-0286,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1891.84,28.62,,,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND 10X10CM POLYURETHANE FOAM NOVOSORB BTM SEAL",SUP-BTM-1010,CDM,A2006,HCPCS,0636,RC,,,both,,,8625.00,2587.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,247.92,,,,,,,247.92,7331.25,"fee schedule",
"INSTR BIOPSY PINK 10CM 14GA BARD MAX-CORE ANGLE 22MM",SUP-MC1410,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.01,84.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,32.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.91,240.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ EXTRA STIFF VASCULAR 3MM FLOPPY STRAIGHT TAPER",SUP-G03290,CDM,C1769,HCPCS,0272,RC,,,both,,,133.81,40.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.56,113.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM VOLT STAINLESS STEEL T8 CORTEX",SUP-02.527.114,CDM,C1713,HCPCS,0278,RC,,,both,,,1033.56,310.07,"PHCS [10601]",PHCS,,723.49,70,,,,,0,120.2,878.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY",RX-16071,CDM,,,0250,RC,60505-0827-01,NDC,both,15,ML,602.05,180.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,70.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.02,511.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 6FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G00937,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"PHCS [10601]",PHCS,,34.53,70,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 26MM CLAW CHARLOTTE STAINLESS STEEL LOCK",SUP-40122726,CDM,C1713,HCPCS,0278,RC,,,both,,,1344.60,403.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,617.17,45.9,,,,,0,156.38,1142.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 12MM 2.5MM BALLOON DILATATION",SUP-H7493912412250,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SEQUENT 4 FIXATION CURVE NDL MENISCAL REPAIR SYSTEM",SUP-MR004C,CDM,C1713,HCPCS,0278,RC,,,both,,,7602.14,2280.64,"AETNA [10100]","Aetna HMO/PPO",,6043.7,79.5,,1521.93,481.35,16760.95,30,884.13,6461.82,"percent of total billed charges",
"CAGE SPINAL 14X12X8MM COHERE 7D LORDOSIS CERVICAL INTERBODY",SUP-1000-00-0814,CDM,C1889,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Local Plus",,3322.35,53.5,,16168.95,16168.95,16168.95,"1 through 10",722.22,5278.5,"percent of total billed charges",
"CATH SABERX 90CM 120MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540120S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1085.08,68,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ACCESS VISUALASE NEURO STERILE LATEX FREE DISPOSABLE",SUP-9735571,CDM,S27200284,LOCAL,0272,RC,,,both,,,15504.30,4651.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7116.47,45.9,,,,,0,1803.15,13178.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 12MM 144CM 3MM CORONARY STENT",SUP-H7493911412300,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross HMO",,3583.86,39.2,,9776.84,9776.84,9776.84,"1 through 10",1063.27,7771.13,"percent of total billed charges",
"KIT ARTHROSCOPIC FIXATION 15MM 9MM BICEPTOR DISPOSABLE",SUP-72202301,CDM,C1713,HCPCS,0278,RC,,,both,,,2895.75,868.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,343.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,336.78,2461.39,"percent of total billed charges",
"NAIL FIXATION GREEN 360MM 11MM 130D LEFT DISTAL TROCHANTERIC",SUP-456.417S,CDM,C1713,HCPCS,0278,RC,,,both,,,12838.83,3851.65,"UHC [10700]","United Healthcare",,8126.98,63.3,,5023.51,2672.93,6679.78,18,1493.16,10913.01,"percent of total billed charges",
"ROD SPINAL 50MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"HC Rhino Rocket",PX-E27000148,CDM,E27000148,LOCAL,0270,RC,,,both,,,234.30,70.29,"CIGNA [10200]","Cigna Open Access",,133.32,56.9,,,,,0,27.25,199.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUMP INTRATHECAL 20ML SYNCHROMED II DRUG DELIVERY THERAPY",SUP-8637-20,CDM,C1772,HCPCS,0278,RC,,,both,,,70600.20,21180.06,"KAISER [10500]",Kaiser,,47302.13,67,,,,,0,8210.8,60010.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4MM COOLCUT 2 CUT POWER SOFT TISSUE",SUP-AR-8400DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"AETNA [10100]","Aetna HMO/PPO",,398.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 48MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-48-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"PHCS [10601]",PHCS,,3960.6,70,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 1.5% DEXTROSE 6000ML 1 BAG CNTNR LOW CALCIUM LUER",SUP-L5B9710,CDM,S27200284,LOCAL,0272,RC,,,both,,,413.69,124.11,"PHCS [10601]",PHCS,,289.58,70,,,,,0,48.11,351.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CD HORIZON SOLERA SPINE MULTIAXIAL",SUP-54850016550,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1110.3,8114.82,"percent of total billed charges",
"LENS IOL 0 D +11.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.115,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Guide Amnio Si",PX-402000040,CDM,76946,CPT,0402,RC,,,both,,,151.12,45.34,"CIGNA [10200]","Cigna Local Plus",,80.85,53.5,,,,,0,17.58,151.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 3.9MM 34MM MULTILOC TITANIUM NIOBIUM ALUMINUM",SUP-04.019.034,CDM,C1713,HCPCS,0278,RC,,,both,,,1592.14,477.64,"KAISER [10500]",Kaiser,,1066.73,67,,,,,0,185.17,1353.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 20MM 2MM RECTANGLE HELIX BALLOON",SUP-2039-2020,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC",727,MS-DRG,,,,,,,inpatient,,,40477.12,12143.14,"BLUE CROSS [10001]","Blue Cross PPO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FREEZOR XTRA 1 108CM 6MM 7FR 2-5-2MM SPACING 49MM REACH",SUP-227F1,CDM,C1733,HCPCS,0272,RC,,,both,,,7935.00,2380.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WEBSTER CS L 115CM 7FR 2-8-2MM SPACE FJ CURVE MAPPING",SUP-BD710FJ282RTS,CDM,C1730,HCPCS,0272,RC,,,both,,,2142.00,642.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DORADO CHECKER 135CM 4CM 9MM BALLOON DILATATION",SUP-DR13594,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG GERMICIDAL DISK .75IN 1.5MM BIOPATCH CHG ANTIMICROBIAL",SUP-4151,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.49,14.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,20.34,41.1,,,,,0,5.76,42.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 22-30CM 4.8FR URETERAL",SUP-M0061456290,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"BLUE CROSS [10001]","Blue Cross PPO",,245.09,39.2,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.8MM 200MM 10MM LCP ANKLE COMPRESSION THREAD",SUP-03.118.010,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD 55CM 1.3MM PRECISION S8 MP35N PLATINUM IRIDIUM",SUP-SC-9208-55,CDM,C1883,HCPCS,0278,RC,,,both,,,3525.00,1057.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,417.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,409.96,2996.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 100CM 5FR JB1 CURVE ANGIOGRAPHIC",SUP-G47007,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"CIGNA [10200]","Cigna Local Plus",,112.63,53.5,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM .02IN 2MM PENUMBRA COIL 400 RUBY",SUP-RBY4C0202,CDM,S27800098,LOCAL,0278,RC,,,both,,,4158.00,1247.4,"CIGNA [10200]","Cigna Open Access",,2365.9,56.9,,,,,0,483.58,3534.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE POWERTURN ULTRAFLEX VASCULAR J CURVE 300CM",SUP-1044591J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 102MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 2",SUP-71357102,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13621.01,41.1,,6417.48,6417.48,6417.48,"1 through 10",3854.32,28169.98,"percent of total billed charges",
"EXT BONE GRAFT INQU HYALURONIC ACID POLY",SUP-IQSP-PP-102,CDM,C1713,HCPCS,0278,RC,,,both,,,2812.50,843.75,"FIRST HEALTH [10303]","First Health",,2250,80,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM TITANIUM 3 LEVEL ATLANTIS VISION ELITE BONE SPINE",SUP-7200145,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"GWIRE JAGWIRE ENDOSCOPIC STD STRAIGHT ROUND 260CM .025IN",SUP-M00556461,CDM,C1769,HCPCS,0272,RC,,,both,,,811.01,243.3,"PHCS [10601]",PHCS,,567.71,70,,,,,0,94.32,689.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachythrpy Grid",PX-E27200042,CDM,E27200042,LOCAL,0272,RC,,,both,,,363.00,108.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.22,308.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 60MM LOCK STERILE",SUP-2361-5060S,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.05,506.11,"PHCS [10601]",PHCS,,1180.94,70,,,,,0,196.2,1433.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VENTRALIGHT ST ECHO 2 25X20CM ELLIPSE",SUP-5992025,CDM,C1781,HCPCS,0278,RC,,,both,,,13069.29,3920.79,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3528.71,27,,,,,0,1519.96,11108.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE HIGH PROFILE STYLE 20 RESTERILIZABLE GEL",SUP-MSZ20500,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,72.6,45.9,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TACKING L160CM ENDOSCOPIC HELIX DISPOSABLE X-TACK",SUP-M00505500,CDM,S27200284,LOCAL,0272,RC,,,both,,,5706.30,1711.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3880.28,68,,,,,0,663.64,4850.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 4CM WITHOUT GWIRE DIL RADIOPAQUE MARKER",SUP-RSB605H,CDM,C1894,HCPCS,0272,RC,,,both,,,217.50,65.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DAT015 AS UVA VIVITY",SUP-DAT015,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,100.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM SPINE PLY NONSTERILE 4MM ROD",SUP-102035114,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET TRANSFER XSHORT 4IN EXTENDED TWIST CLAMP MINICAP",SUP-5C4483,CDM,S27200284,LOCAL,0272,RC,,,both,,,402.72,120.82,"UHC [10700]","United Healthcare",,254.92,63.3,,,,,0,46.84,342.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mercury Quant Urine",PX-301000312,CDM,83825,CPT,0301,RC,,,both,,,243.10,72.93,"KAISER [10500]",Kaiser,,162.88,67,,,,,0,0.01,206.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 7X 59MM CATH 80CM ENDOVASCULAR",SUP-48759,CDM,C1874,HCPCS,0278,RC,,,both,,,18881.10,5664.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5403.77,28.62,,,,,0,2195.87,16048.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS ENDOSCOPIC L230CM DIA1.8MM OPENING 7MM RAT TEETH GRI",SUP-M00527651,CDM,S27200284,LOCAL,0272,RC,,,both,,,625.73,187.72,"PHCS [10601]",PHCS,,438.01,70,,,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 6IN RAGNELL 2 ENDED SURGICAL",SUP-BT004R,CDM,S27100035,LOCAL,0271,RC,,,both,,,170.96,51.29,"NOVANET [10819]",Novanet,,128.22,75,,,,,0,19.88,145.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Evasc Rpr Taa WO Subcl",PX-360000027,CDM,33881,CPT,0361,RC,,,both,,,10559.62,3167.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5284,,"Case rate ($5,284). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1228.08,9549.81,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERTORQUE 100CM 5FR SIDEWINDER SIMMONS TECHNIQUE I I",SUP-532502,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"AETNA [10100]","Aetna HMO/PPO",,83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL CONTOUR 7.5IN 10- IN WRIST LEFT",SUP-79-87470,CDM,S27000186,LOCAL,0270,RC,,,both,,,68.64,20.59,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,31.51,45.9,,,,,0,7.98,58.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 18MM EMBOLD NITINOL FIBER DETACHABLE",SUP-M001394240180500,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"BLUE CROSS [10001]","Blue Cross PPO",,3378.3,39.2,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE -90D RIGHT 41MM STAINLESS STEEL 2.4MM SCR 2 HOLE HEAD",SUP-02.115.631S,CDM,C1713,HCPCS,0278,RC,,,both,,,4045.61,1213.68,"CIGNA [10200]","Cigna Open Access",,2301.95,56.9,,1144.80,304.56,2275.09,66,470.5,3438.77,"percent of total billed charges",
"INTRO SHEATH 9FR .118IN 25CM ROBUST VALVE SPLITTABLE WITHOUT",SUP-PLSX-2509,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE PIN ORTHOPEDIC 3MM RETRODRILL KNEE FEMUR TIBIA",SUP-AR-1250RP,CDM,S27200284,LOCAL,0272,RC,,,both,,,1233.23,369.97,"KAISER [10500]",Kaiser,,826.26,67,,,,,0,143.42,1048.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 20MM 150MM 4MM BALLOON DILATATION",SUP-PCP040020150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"KAISER [10500]",Kaiser,,824.9,67,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE POLYPECTOMY ENDOSCOPIC",SUP-M00562550,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VIA CANCELLOUS DEMINERALIZE CORTICAL BONE 100-300",SUP-VCAFMX-025000,CDM,S27800098,LOCAL,0278,RC,,,both,,,6037.50,1811.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1727.93,28.62,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM AZUR CX HYDROCOIL DETACHABLE LOOP",SUP-45-780202,CDM,S27800098,LOCAL,0278,RC,,,both,,,5275.05,1582.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,625.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,613.49,4483.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 23X9X9MM CONCORDE PARALLEL BULLET NOSE",SUP-187823109,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1962.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 8MM .038IN AZUR DETACHABLE .035IN",SUP-45-450820,CDM,S27800098,LOCAL,0278,RC,,,both,,,9083.85,2725.15,"BLUE CROSS [10001]","Blue Cross PPO",,3560.87,39.2,,,,,0,1056.45,7721.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9.5FR .125IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1009.5,CDM,C1894,HCPCS,0272,RC,,,both,,,255.78,76.73,"MULTIPLAN [10600]",Multiplan,,217.41,85,,,,,0,29.75,217.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 19MM 135CM 7MM THIN VASCULAR COCR",SUP-1012630-19,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5712,68,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 5FR MERIT MAK COAXIAL PAIR MINI ACCESS",SUP-MAK5F-10,CDM,C1894,HCPCS,0272,RC,,,both,,,152.25,45.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,62.57,41.1,,,,,0,17.71,129.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SURGICAL MARGINMARKER 6 COLOR STERILE",SUP-MMS6,CDM,S27200284,LOCAL,0272,RC,,,both,,,1437.83,431.35,"PHCS [10601]",PHCS,,1006.48,70,,,,,0,167.22,1222.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 15MM 3.5MM BALLOON DILATATION",SUP-H7493912415350,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 22GA 1.25MM ACCUCATH ACE DOT",SUP-AC1221252,CDM,S27200284,LOCAL,0272,RC,,,both,,,295.37,88.61,"CIGNA [10200]","Cigna Open Access",,168.07,56.9,,,,,0,34.35,251.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 60MM 13.5MM 10FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEL14060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7308,40,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 27.5CM 4MM TRICUT SUBGLOTTIC ANGLED TIP",SUP-1884031,CDM,S27200284,LOCAL,0272,RC,,,both,,,4073.30,1221.99,"CIGNA [10200]","Cigna Local Plus",,2179.22,53.5,,,,,0,473.72,3462.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM ORTHOLOC TITANIUM NITRIDE FOREFOOT ANKLE",SUP-5201024018,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CIGNA [10200]","Cigna Open Access",,981.53,56.9,,1144.80,304.56,2275.09,66,200.62,1466.25,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 12MM 145CM 2.75MM CORONARY STENT",SUP-1145275-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"MULTIPLAN [10600]",Multiplan,,4962.3,85,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 4MM STAINLESS STEEL REUSABLE",SUP-MSD07040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1174.50,352.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEADACHES WITH MCC",102,MS-DRG,,,,,,,inpatient,,,51929.06,15578.72,"AETNA [10100]","Aetna HMO/PPO",,21089.73,,"Fee schedule rate ($21,089.73). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,6953.01,27954.13,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 22MM WRIST VOLAR THREAD LOCK TORX",SUP-TPEG-22,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"NOVANET [10819]",Novanet,,637.88,75,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM 20MM 15MM STD NECK S-ROM CERAMIC 135D",SUP-523394,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"BLUE CROSS [10001]","Blue Cross HMO",,7624.89,39.2,,5311.50,4717.44,5388.59,31,2262.18,16533.56,"percent of total billed charges",
"VALVE AORTIC 31MM MASTERS ROTATABLE HEMASHIELD TECHNOLOGY",SUP-23AECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"KAISER [10500]",Kaiser,,19509.88,67,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 80MM 159CM 9MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200098020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE WIRE GWR419488 108CM",SUP-GWR419488,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RECIP SAWBLADE 8X50X1MM",SUP-351-91-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST ALLOGRAFT WEDGE 10-12MM",SUP-P00204,CDM,S27800098,LOCAL,0278,RC,,,both,,,4830.00,1449,"FIRST HEALTH [10303]","First Health",,3864,80,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAUT 18IN 4.5FR CHOLANGIOGRAM METAL SPRT TUBE LATEX",SUP-20018-M55,CDM,S27200284,LOCAL,0272,RC,,,both,,,455.22,136.57,"AETNA [10100]","Aetna HMO/PPO",,361.9,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.94,386.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABRE VENOUS SELF-EXPADING STENT18X100X90",SUP-AB9T18100090,CDM,C1876,HCPCS,0624,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Open Access",,1707,56.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE SURGICAL KNIFE CHUCK",SUP-1352321,CDM,S27200284,LOCAL,0272,RC,,,both,,,1134.00,340.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEARTRAIL III 100CM 6FR IKARI RIGHT 1.5 CURVE GUIDING",SUP-40-6381,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"AETNA [10100]","Aetna HMO/PPO",,463.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 48MM 28MM HIP ANATOMIC DUAL MOBILITY X3",SUP-1236-2-848,CDM,C1776,HCPCS,0278,RC,,,both,,,7518.42,2255.53,"PHCS [10601]",PHCS,,5262.89,70,,,,,0,874.39,6390.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION WATER 1000ML STERILE UROMATIC LATEX FREE",SUP-2B7114X,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MATRIX TISSUE AXIOFILL EXTRACELLULAR DRY PARTICULATE 2000MG",SUP-PCM-2000,CDM,Q4433,HCPCS,0636,RC,,,both,,,28860.30,8658.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"GWIRE CONFIDA BRECKER CURVE ORTHOPEDIC 26CM",SUP-GWBC30,CDM,C1769,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"PHCS [10601]",PHCS,,4709.25,70,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 48MM 28MM XLPE HIP",SUP-71334948,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1318.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1293.98,9457.31,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 33MM 145CM 3MM CORONARY STENT",SUP-1145300-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross PPO",,2288.5,39.2,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 5 X 10 HELICAL FINISHING COIL",SUP-10HFN-05010,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1225.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chromosome Karyotype Study Addl",PX-311000069,CDM,88280,CPT,0311,RC,,,both,,,598.50,179.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,35.82,,"Fee schedule rate ($35.82). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,508.73,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 34MM LCP STAINLESS STEEL SHORT THREAD",SUP-207.634,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,123.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,120.96,884.03,"percent of total billed charges",
"GENTAMICIN 0.3 % EYE DROPS",RX-3428,CDM,,,0250,RC,24208-0580-60,NDC,both,5,ML,269.53,80.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FAT EMULSION 20 % INTRAVENOUS",RX-10014,CDM,,,0250,RC,00264-4460-30,NDC,both,250,ML,162.22,48.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 5CMX10MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-3-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 1.6MM TPS ELITE 5 STEP NOTCH CROSS CUT FISSURE",SUP-5820-066-216,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT STAINLESS STEEL ETHI-PACK 1 18IN MONOFILAMENT PRECUT",SUP-DS25,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.39,22.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MESH SURGICAL VENTRALIGHT ST ECHO 2 15X10CM ELLIPSE",SUP-5991015,CDM,C1781,HCPCS,0278,RC,,,both,,,4358.04,1307.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2000.34,45.9,,,,,0,506.84,3704.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYNX CONTROL 5FR CLSR 10ML 2 MODE BALLOON CATH SEAL",SUP-MX5060,CDM,C1760,HCPCS,0278,RC,,,both,,,1680.00,504,"NOVANET [10819]",Novanet,,1260,75,,,,,0,195.38,1428,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,inpatient,,,111735.95,33520.78,"BLUE CROSS [10001]","Blue Cross PPO",,51334.25,,,,,,,7561,60710.16,"case rate",
"SLEEVE COMPRESSION SMALL THIGH SCD EXPRESS ANTIEMBOLISM",SUP-9545,CDM,S27000186,LOCAL,0270,RC,,,both,,,356.77,107.03,"CIGNA [10200]","Cigna Local Plus",,190.87,53.5,,,,,0,41.49,303.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK",RX-10049,CDM,J1450,HCPCS,0636,RC,25021-0184-82,NDC,both,100,ML,100.65,30.19,"BLUE CROSS [10001]","Blue Cross HMO",,2.63,,,,,,,2.63,85.55,"fee schedule",
"BLADE SAW 18X5.5X.43MM SAGITTAL STERILE",SUP-KM33-212,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.65,24.19,"CIGNA [10200]","Cigna Open Access",,45.89,56.9,,,,,0,9.38,68.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 150MM 2.5MM .014IN BALLOON DILATATION",SUP-AB14W025150150,CDM,C1725,HCPCS,0272,RC,,,both,,,1577.48,473.24,"KAISER [10500]",Kaiser,,1056.91,67,,,,,0,183.46,1340.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP POROCOAT PINNACLE 300 SERIES",SUP-121703060,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"PHCS [10601]",PHCS,,4697.53,70,,,,,0,780.46,5704.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 2.5% DEXTROSE 2L LOW CALCIUM DIANEAL DIALYSIS PERITONEAL",SUP-5B9776,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.13,61.54,"AETNA [10100]","Aetna HMO/PPO",,163.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.86,174.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 74MM 10.8MM 6.4MM CUFF DISPOSABLE INNER CANN FENESTRATE",SUP-6DFEN,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.46,95.84,"AETNA [10100]","Aetna HMO/PPO",,253.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.15,271.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Ureter Stnt Bi W Si",PX-361000214,CDM,50384,CPT,0361,RC,,,both,,,20084.00,6025.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2379.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1718,17071.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM ATTUNE 3 KNEE POSTERIOR CEMENT REVISION",SUP-154903001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"CIGNA [10200]","Cigna Local Plus",,3248.52,53.5,,5372.07,4581.20,7242.98,23,706.17,5161.2,"percent of total billed charges",
"SURFACE ARTICULAR 17MM NEXGEN LPS-FLEX 3-4 E-F KNEE PROLONG",SUP-596203217,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"CIGNA [10200]","Cigna Local Plus",,4236.37,53.5,,5372.07,4581.20,7242.98,23,920.91,6730.67,"percent of total billed charges",
"COIL EMBOLIZATION 10CM 6MM INTERLOCK OCCLUSION SYSTEM",SUP-M001363720,CDM,S27800098,LOCAL,0278,RC,,,both,,,2827.50,848.25,"KAISER [10500]",Kaiser,,1894.43,67,,,,,0,328.84,2403.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER O.R. PROCEDURES FOR INJURIES WITH MCC",907,MS-DRG,,,,,,,inpatient,,,102004.75,30601.42,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,25482.48,,"Case rate ($23,815.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $22,114.22, add-ons for qualifying new technology services are included. If operating cost exceeds $55,153.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,053.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $22,143.47. The transfer operating threshold is the transfer adjustment factor * $22,114.22 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,671.94. The transfer capital threshold is the transfer adjustment factor * $1,671.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,102004.75,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY CHORDAL GUIDE DURAN ANCORE",SUP-620RG35,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 75CM 2CM 5MM BALLOON DILATATION",SUP-U87552,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,881.28,68,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR ASYMMETRIC 10MM 32MM TRIATHLON X3 KNEE",SUP-5551-G-320,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"BLUE CROSS [10001]","Blue Cross HMO",,1692.57,39.2,,5311.50,4717.44,5388.59,31,502.16,3670.1,"percent of total billed charges",
"HC Myeloperoxidase",PX-301000706,CDM,83876,CPT,0301,RC,,,both,,,88.00,26.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.77,,"Fee schedule rate ($17.77). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,88,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUTTY THERAPY THERAPUTTY PUTTYCISE 5 PIECE TOOL SET CARRY",SUP-562946,CDM,S27000186,LOCAL,0270,RC,,,both,,,841.67,252.5,"MULTIPLAN [10600]",Multiplan,,715.42,85,,,,,0,97.89,715.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 5MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620905,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3038.55,27,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Consult Rad Physics Special",PX-333000022,CDM,77370,CPT,0333,RC,,,both,,,1219.53,365.86,"AETNA [10100]","Aetna HMO/PPO",,969.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.83,1219.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION .70MM 3.81MM 2.54MM 1.14MM ARMSTRONG R",SUP-510-282,CDM,S27800098,LOCAL,0278,RC,,,both,,,202.54,60.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,23.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.56,172.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 60MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET",SUP-241.61,CDM,C1713,HCPCS,0278,RC,,,both,,,6246.23,1873.87,"CIGNA [10200]",Cigna,,4247.44,68,,1831.33,1831.33,1831.33,16,726.44,5309.3,"percent of total billed charges",
"SPACER SPINAL 22MMX8-12MM CALIBER",SUP-194122,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11520,40,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 32MM LCP ANKLE FOOT STAINLESS STEEL 2X3 HOLE L",SUP-249.689,CDM,C1713,HCPCS,0278,RC,,,both,,,2305.80,691.74,"BLUE CROSS [10001]","Blue Cross HMO",,903.87,39.2,,957.42,156.86,7483.26,51,268.16,1959.93,"percent of total billed charges",
"MESH SURGICAL GORE DUALMESH 34X26CM SOFT TISSUE BIOMATERIAL",SUP-1DLMC08,CDM,C1781,HCPCS,0278,RC,,,both,,,16284.00,4885.2,"PHCS [10601]",PHCS,,11398.8,70,,,,,0,1893.83,13841.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 28MM 8MM BLUNT FULL THREAD",SUP-AR-1380TC,CDM,C1713,HCPCS,0272,RC,,,both,,,1850.63,555.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,760.61,41.1,,,,,0,760.61,1171.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) GUIDEWIRE VASCULAR .014INX200CM ZOOM WIRE 14 X-SUPPOR",SUP-Z14-200-003,CDM,C1769,HCPCS,0272,RC,,,both,,,4140.00,1242,"AMERIGROUP MEDICAID [20100]",Amerigroup,,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FG GATEWAY OTW  US 2.00MM X 9MM",SUP-M0032072209200,CDM,C1725,HCPCS,0272,RC,,,both,,,9423.88,2827.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1116.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1096,8010.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 CT-1 36IN BRAID ANTIBACTERIAL COATED",SUP-VCP945H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"KAISER [10500]",Kaiser,,16.75,67,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DRILL 4MM RETROBUTTON TIGHTROPE KNEE ACL OPEN EYELET",SUP-AR-1595T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1063.13,318.94,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,123.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,123.64,903.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE CATHETER, SHAPE 27",SUP-4679-08,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 18CM 3CM 5FR .035IN STRAIGHT URETERAL",SUP-M006155215180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"NOVANET [10819]",Novanet,,1207.28,75,,,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 28MM 140CM 2.5MM CORONARY STENT PLATINUM",SUP-H7493927428250,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"MULTIPLAN [10600]",Multiplan,,3187.5,85,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X6MM HEDRON C 7D 12MM STERILE LATEX FREE",SUP-1211.2416S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,722.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 34MMX12MMX20CM 24FR",SUP-TAC123420A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"MULTIPLAN [10600]",Multiplan,,155040,85,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TIGHTROPE II FLIPCUTTER III FIBERSTICK FIXATION BONE",SUP-AR-1288BTBIB-FC3,CDM,C1713,HCPCS,0278,RC,,,both,,,8223.08,2466.92,"CIGNA [10200]","Cigna Local Plus",,4399.35,53.5,,3978.14,359.25,3978.14,24,956.34,6989.62,"percent of total billed charges",
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 52MM 36MM ALTRX HIP",SUP-122136452,CDM,C1776,HCPCS,0278,RC,,,both,,,6814.08,2044.22,"CIGNA [10200]","Cigna Local Plus",,3645.53,53.5,,5372.07,4581.20,7242.98,23,792.48,5791.97,"percent of total billed charges",
"COIL EMBOLIZATION 4CM 2MM .0108IN AXIUM PRIME HELICAL",SUP-APB-2-4-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"NOVANET [10819]",Novanet,,6701.63,75,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION",RX-20472,CDM,,,0250,RC,72485-0508-01,NDC,both,10,ML,41.00,12.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16.85,41.1,,,,,0,4.77,34.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP3PL,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6153.84,28.62,,,,,0,2500.67,18276.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 23MM ATLANTIS VISION ELITE BONE ANTERIOR CERVICAL",SUP-7200023,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"AMERIGROUP MEDICAID [20100]",Amerigroup,,497.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",488.46,3570,"percent of total billed charges",
"CATH ADVANCE 35LP 135CM 12CM 5FR 3MM .035IN BALLOON",SUP-G52249,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"MULTIPLAN [10600]",Multiplan,,815.8,85,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE LARGE REGULAR SPIKED 23.22X14.29MM COCR",SUP-128696,CDM,C1713,HCPCS,0278,RC,,,both,,,2300.10,690.03,"KAISER [10500]",Kaiser,,1541.07,67,,,,,0,267.5,1955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 74.9X49.3X15MM MBT 4+ MM KNEE CEMENTED REVISION",SUP-129435415,CDM,C1776,HCPCS,0278,RC,,,both,,,35980.56,10794.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4263.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,4184.54,30583.48,"percent of total billed charges",
"CEMENTED TSA",SUP-S2A,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"AETNA [10100]","Aetna HMO/PPO",,21286.13,79.5,,10981.53,8986.79,12413.38,12,3113.93,22758.75,"percent of total billed charges",
"CATH SABERX 200CM 20MM 1.5MM BALLOON DILATATION RAPID",SUP-47515020L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON SUPRAMID EXTRA 2-0 GS-1 30IN MONOFILAMENT WHITE",SUP-2GS-1-30W,CDM,S27200284,LOCAL,0272,RC,,,both,,,160.23,48.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,73.55,45.9,,,,,0,18.63,136.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POLYETHYLENE GLYCOL 3350 ORAL POWDER BOTTLE",RX-24984,CDM,,,0250,RC,45802-0868-02,NDC,both,238,GR,56.89,17.07,"PHCS [10601]",PHCS,,39.82,70,,,,,0,6.62,48.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ACCESS 72CM 8.5FR VERSACROSS 1 SMALL TRANSSEPTAL PIGTAIL",SUP-VSTK0118,CDM,C1766,HCPCS,0272,RC,,,both,,,11212.50,3363.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7624.5,68,,,,,0,1304.01,9530.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 8MM 3.75MM BALLOON DILATATION DURATRAC",SUP-NCEUP37508X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,,,0250,RC,70748-0332-02,NDC,both,5,ML,332.11,99.63,"UHC [10700]","United Healthcare",,210.23,63.3,,,,,0,38.62,282.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 27CM 15FR 18GA .038IN POLYURETHANE CANNON II PLUS",SUP-CS-15322-VSP,CDM,C1750,HCPCS,0278,RC,,,both,,,2400.00,720,"AMERIGROUP MEDICAID [20100]",Amerigroup,,284.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM LOW PROFILE SCREWS STAINLESS STEEL FULL",SUP-AR-8827L-18,CDM,C1713,HCPCS,0278,RC,,,both,,,931.50,279.45,"MULTIPLAN [10600]",Multiplan,,791.78,85,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 135MM STAINLESS STEEL 4.5MM SCREWS LARGE",SUP-226.08,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,434.96,3179,"percent of total billed charges",
"SODIUM CHLORIDE 0.9 % IV BOLUS 500 ML",RX-400291,CDM,,,0258,RC,00990-7983-55,NDC,both,500,ML,100.65,30.19,"NOVANET [10819]",Novanet,,75.49,75,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 33MM 2.25MM CORONARY STENT EVEROLIMUS",SUP-1550225-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 44MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 5",SUP-244.05,CDM,C1713,HCPCS,0278,RC,,,both,,,3031.80,909.54,"NOVANET [10819]",Novanet,,2273.85,75,,,,,0,352.6,2577.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION MRI SILICONE PLASTIC 6.6FR 1 LUMEN",SUP-602690,CDM,C1788,HCPCS,0278,RC,,,both,,,1417.50,425.25,"PHCS [10601]",PHCS,,992.25,70,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT 4 .5 CIRCLE TROCAR POINT MAYO CATGUT STERILE LATEX",SUP-1826-4DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL 7 18IN MONOFILAMENT TIE 12 STRAND SILVER",SUP-DS18,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.57,22.67,"FIRST HEALTH [10303]","First Health",,60.46,80,,,,,0,8.79,64.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 18B LARGE HIP PROXIMAL",SUP-521485,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4473.63,41.1,,6417.48,6417.48,6417.48,"1 through 10",1265.9,9252.04,"percent of total billed charges",
"INTRO SHEATH 10FR 30CM TRANSITIONLESS RADIOPAQUE DIL DRNG",SUP-G08316,CDM,C1892,HCPCS,0272,RC,,,both,,,526.42,157.93,"MULTIPLAN [10600]",Multiplan,,447.46,85,,,,,0,61.22,447.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 120MM 5MM .035IN BALLOON",SUP-AB35W05120135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"UHC [10700]","United Healthcare",,428.64,63.3,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 67.5MM KNEE RIGHT CRUCIATE RETAINING CEMENTED",SUP-183010,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"MULTIPLAN [10600]",Multiplan,,17072.81,85,,,,,0,2335.96,17072.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 5MMX29MM 7FR 80CMCATH HEPARIN",SUP-BXB052901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UHC [10700]","United Healthcare",,12346.54,63.3,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +10.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.105,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESVR PROS 75ML TITAN COLOPLAST LOCK-OUT INFLATABLE SELF",SUP-ER8075,CDM,C1813,HCPCS,0278,RC,,,both,,,15166.20,4549.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1763.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1763.83,12891.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 10MM 2.5MM EMBOLIZATION",SUP-PED2-250-10,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"MULTIPLAN [10600]",Multiplan,,68677.88,85,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING SINGLE LIMB HEAT INFANT NONSTERILE 4 LPM",SUP-RT131,CDM,S27000186,LOCAL,0270,RC,,,both,,,157.47,47.24,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,64.72,41.1,,,,,0,18.31,133.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM SENSAR INTRAOCULAR LENS, BICONVEX, 23.0 DIOPTER",SUP-AR40E00230,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,110.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDPLATE SPINAL 16MM SECURE-C 6D 14MM SPHERICAL CYLINDRICAL",SUP-714.306S,CDM,C1713,HCPCS,0278,RC,,,both,,,22050.00,6615,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9062.55,41.1,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 12CM MR8 2.5MM MATCH HEAD TELESCOPE DISSECTING DIAMOND",SUP-MR8-T12MH25D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"UHC [10700]","United Healthcare",,799.86,63.3,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM ENDOCARDIUM 4 SITE 2 COIL ACTIVE DF-4",SUP-0296,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6868.8,40,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERTORQUE THRULUMEN 100CM 6FR .079IN .051IN SMALL",SUP-532619,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA [10200]","Cigna Open Access",,47.03,56.9,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 11CM 5FR GEENEN PANCREATIC POLYETHYLENE",SUP-G27151,CDM,C2625,HCPCS,0278,RC,,,both,,,1231.20,369.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,565.12,45.9,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DRNG ASEPT PLEURA VACUUM BOTTLE LUER LOCKING VALVE 1000",SUP-622273B,CDM,C1729,HCPCS,0272,RC,,,both,,,101.88,30.56,"AETNA [10100]","Aetna HMO/PPO",,80.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.85,86.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3MM DART-FIRE",SUP-DSDS0030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1271.70,381.51,"FIRST HEALTH [10303]","First Health",,1017.36,80,,,,,0,147.9,1080.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 22FR SILICONE MIC SECUR-LOK ENFIT FEED TUBE",SUP-8260-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,2567.55,770.26,"PHCS [10601]",PHCS,,1797.29,70,,,,,0,298.61,2182.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POLYAXIAL SCREW 7.5X100","SUP-SK- 10-7500",CDM,C1713,HCPCS,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross HMO",,2434.32,39.2,,957.42,156.86,7483.26,51,722.22,5278.5,"percent of total billed charges",
"CAP POROUS COATED DUAL MOBILITY HIP SYSTEM + VE",SUP-98000500323,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"FIRST HEALTH [10303]","First Health",,22176,80,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Sulfr Colloid Filtered Up to 20mci",PX-343000014,CDM,A9541,HCPCS,0343,RC,,,both,,,746.77,224.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,311.62,,,,,,,86.85,746.77,"fee schedule",
"CATH LAUNCHER 100CM 8FR .09IN LEFT CORONARY BYPASS CURVE",SUP-LA8LCBSH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CXI 150CM 4FR SPRT STAINLESS STEEL HYDROPHILIC LOW",SUP-G52544,CDM,C1887,HCPCS,0272,RC,,,both,,,1522.72,456.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,625.84,41.1,,,,,0,177.09,1294.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE LISFRANC REMOVAL",SUP-IB200051,CDM,C1713,HCPCS,0278,RC,,,both,,,1044.90,313.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,479.61,45.9,,,,,0,121.52,888.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12.5CM 10-4MM TORNADO PLATINUM ACCEPTS",SUP-G10428,CDM,S27800098,LOCAL,0278,RC,,,both,,,853.50,256.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,580.38,68,,,,,0,99.26,725.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POS STENT 45CM 4.8FR URETERAL",SUP-M0061802001,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.15,26.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,40.46,45.9,,,,,0,10.25,74.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER EMBOLIZATION 48MM FEMORAL VENA CAVA NAVALIGN DELIVERY",SUP-G52914,CDM,C1880,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross PPO",,2569.56,39.2,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL MITRACLIP BUNDLE 1 SGC0301 1 CDS0601 NTR 2",SUP-MBR0303,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]",Cigna,,68400,40,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 10CM 19GA 6FR 4 SIDEPORT HOLLOW STYLET CATH STRAIGHT",SUP-G12996,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.61,54.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,124.17,68,,,,,0,21.24,155.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 107MM 13MM 5.4MM 14FR SPIRAL-Z ZENITH",SUP-G55234,CDM,C1874,HCPCS,0278,RC,,,both,,,19435.50,5830.65,"BLUE CROSS [10001]","Blue Cross HMO",,7618.72,39.2,,9776.84,9776.84,9776.84,"1 through 10",2260.35,16520.18,"percent of total billed charges",
"TAP 147MM SURGICAL 4MM CANNULATED SCREWS",SUP-311.63,CDM,S27000186,LOCAL,0270,RC,,,both,,,3795.55,1138.66,"CIGNA [10200]",Cigna,,2580.97,68,,,,,0,441.42,3226.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE W8XL12CM THK2-2.79MM READY TO USE ALLODER",SUP-151996,CDM,C1889,HCPCS,0278,RC,,,both,,,17835.30,5350.59,"AETNA [10100]","Aetna HMO/PPO",,14179.06,79.5,,,,,0,2074.25,15160.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOABLATION 11IN OD 10MM ATRICURE PROBE W/ 10MM BALL",SUP-CRYOSMAX,CDM,C9808,HCPCS,0272,RC,,,both,,,17640.00,5292,"CIGNA [10200]",Cigna,,11995.2,68,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acquisition Liver Live Donor",PX-811000002,CDM,811000002,LOCAL,0811,RC,,,both,,,133855.00,40156.5,"NOVANET [10819]",Novanet,,100391.25,75,,,,,0,133.86,113776.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 25CM 6FR 20GA GLIDESHEATH .025IN 80CM STAINLESS",SUP-20-2565,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SINGLE USE INSTRUMENTS - TIBIAL KIT (CR) - SIZE 7",SUP-5555-2327,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 10GA SITE BREAST BIOPSY",SUP-SMARKEVIVA10,CDM,A4648,HCPCS,0278,RC,,,both,,,445.50,133.65,"CIGNA [10200]","Cigna Open Access",,253.49,56.9,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 28MM 2.75MM CORONARY STENT EVEROLIMUS",SUP-1550275-28,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 8FR .088IN EXTRA",SUP-5888103,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC MEDIUM REGULAR LENGTH 7IN 6.75-7.5IN WRIST",SUP-A60715,CDM,S27000186,LOCAL,0270,RC,,,both,,,141.03,42.31,"AETNA [10100]","Aetna HMO/PPO",,112.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.4,119.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 65CM 4FR KUMPE CURVE LOW PROFILE",SUP-G51314,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"KAISER [10500]",Kaiser,,134.07,67,,,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 25MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45025,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9838.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165CM 8.5-11MM OTSC 3MM NITINOL STERILE",SUP-100.03,CDM,C1760,HCPCS,0278,RC,,,both,,,3667.50,1100.25,"BLUE CROSS [10001]","Blue Cross HMO",,1437.66,39.2,,,,,0,426.53,3117.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 FLEXOR 30MM 125CM 8MM 5FR LOW PROFILE",SUP-G43780,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1196.03,28.62,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 8FR .088IN",SUP-588892,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 4X4IN MELGISORB SILVER CALCIUM ALGINATE HIGH",SUP-565976,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.72,23.92,"FIRST HEALTH [10303]","First Health",,63.78,80,,,,,0,9.27,67.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Klhl11 Antb Sr/CSF Asy Qual",PX-310000048,CDM,0432U,CPT,0310,RC,,,both,,,72.00,21.6,"KAISER [10500]",Kaiser,,48.24,67,,,,,0,8.53,61.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL CHARLOTTE STAINLESS STEEL CANNULATED 4.3 MM SCR",SUP-44112003,CDM,S27200284,LOCAL,0272,RC,,,both,,,1296.00,388.8,"CIGNA [10200]","Cigna Local Plus",,693.36,53.5,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 4MM OXFORD ARCOM KNEE LEFT MENISCAL PHASE 3",SUP-159548,CDM,C1776,HCPCS,0278,RC,,,both,,,5270.22,1581.07,"FIRST HEALTH [10303]","First Health",,4216.18,80,,,,,0,612.93,4479.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 2CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE RADIOPAQUE",SUP-8140-24-2.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,92.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSELTAMIVIR 75 MG CAPSULE",RX-26546,CDM,,,0637,RC,64380-0799-01,NDC,both,1,UN,58.43,17.53,"CIGNA [10200]","Cigna Open Access",,33.25,56.9,,,,,0,6.8,49.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SHEATH GUIDE KINK RESISTANT STOPPER",SUP-K-402,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND 4-0 RB-1 30IN BRAID BLACK NONABSORBABLE",SUP-K871H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE ENDOTRACHEAL 6.5MM 5MM NIM TRIVANTAGE EMG MON",SUP-8229705,CDM,S27200284,LOCAL,0272,RC,,,both,,,3007.50,902.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,inpatient,,,99343.25,29802.97,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP CIRCUMCISION 1.3CM CIRCLAMP BELL STERILE DISPOSABLE",SUP-330CR,CDM,S27200284,LOCAL,0272,RC,,,both,,,334.44,100.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WIRE REDUCTION 150MM 1.25MM STAINLESS STEEL THREAD TIP SMALL",SUP-02.111.500.10,CDM,C1713,HCPCS,0278,RC,,,both,,,1350.68,405.2,"CIGNA [10200]",Cigna,,918.46,68,,1831.33,1831.33,1831.33,16,157.08,1148.08,"percent of total billed charges",
"LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION",RX-4454,CDM,J2003,HCPCS,0636,RC,55150-0255-20,NDC,both,20,ML,38.05,11.41,"KAISER [10500]",Kaiser,,25.49,67,,,,,0,4.51,38.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION .035IN 5.5IN KIRSCHNER STAINLESS STEEL SMOOTH",SUP-1600-021,CDM,C1713,HCPCS,0278,RC,,,both,,,63.19,18.96,"MULTIPLAN [10600]",Multiplan,,53.71,85,,,,,0,7.35,53.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 50MM 1.6MM 7MM STOP TWIST 7MM STERILE",SUP-6016007,CDM,S27200284,LOCAL,0272,RC,,,both,,,1073.25,321.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,127.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.82,912.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 439014 PG 14X26 SRVC FEE FD",SUP-439014,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIANCE TRUELUMEN 150CM .0175IN .038IN BALLOON",SUP-VNC-FX-150,CDM,C1887,HCPCS,0272,RC,,,both,,,9219.00,2765.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1072.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1072.17,7836.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ENDARTERECTOMY 9MM 11MM 2 COAXIAL METAL RING",SUP-4500-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,18893.70,5668.11,"UHC [10700]","United Healthcare",,11959.71,63.3,,,,,0,2197.34,16059.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 55MM 4MM 16 FLUTES ROUND STERILE",SUP-1608002055,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY 9.5IN THOMAS-GAYLOR S UTERUS",SUP-52-6610,CDM,S27200284,LOCAL,0272,RC,,,both,,,618.68,185.6,"KAISER [10500]",Kaiser,,414.52,67,,,,,0,71.95,525.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 6.25IN CARB-BITE PETIT-POINT RYDER SERRATE JAW INSRT",SUP-121172,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.41,170.22,"NOVANET [10819]",Novanet,,425.56,75,,,,,0,65.99,482.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHADONE 10 MG TABLET",RX-4953,CDM,,,0637,RC,00406-5771-23,NDC,both,1,UN,12.54,3.76,"CIGNA [10200]","Cigna Local Plus",,6.71,53.5,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Upper GI Barium & Air",PX-320000101,CDM,74246,CPT,0320,RC,,,both,,,1725.88,517.76,"CIGNA [10200]","Cigna Open Access",,212.56,,,,,,,151.98,1467,"fee schedule",
"ATTACH ENDOSCP 4MM 11.8MM ROUND EDGE STERILE LATEX FREE",SUP-D-201-11304,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.26,63.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,96.51,45.9,,,,,0,24.45,178.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICROINTRODUCER 5FR 50CM GWIRE BEVEL A NDL SMOOTH DIL",SUP-0228950,CDM,C1894,HCPCS,0272,RC,,,both,,,438.05,131.41,"UHC [10700]","United Healthcare",,277.29,63.3,,,,,0,50.95,387.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS MBA LARGE BORE",SUP-MAP400,CDM,S27200284,LOCAL,0272,RC,,,both,,,185.40,55.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,126.07,68,,,,,0,21.56,157.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC .99CM 5.23X7.14CM PERCIVA HEARTLOGIC",SUP-D401,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4806.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 65X35MM SMALL VELCRO ALUMINUM DENVER SEPTUM 2",SUP-10-1500-05KS,CDM,S27000186,LOCAL,0270,RC,,,both,,,546.02,163.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,371.29,68,,,,,0,63.5,464.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP ANEURYSM BLADE L13MM 7.5MM OPENING 90GM STANDARD PHYNOX",SUP-FE801K,CDM,S27800098,LOCAL,0278,RC,,,both,,,3496.80,1049.04,"CIGNA [10200]",Cigna,,2377.82,68,,,,,0,406.68,2972.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 7MM BALLOON",SUP-U357576,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ECHELON CONTOUR GST RELOAD (BLUE)",SUP-GCR40B,CDM,S27200284,LOCAL,0272,RC,,,both,,,2994.05,898.21,"CIGNA [10200]","Cigna Open Access",,1703.61,56.9,,,,,0,348.21,2544.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR STORZ 1 STEM",SUP-M0068802051,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"AETNA [10100]","Aetna HMO/PPO",,410.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRINGER INSTR 6X2.5IN BAR",SUP-51-0006,CDM,S27000186,LOCAL,0270,RC,,,both,,,314.68,94.4,"CIGNA [10200]","Cigna Local Plus",,168.35,53.5,,,,,0,36.6,267.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DAPTOMYCIN 500 MG/10ML IV (WET SOLR VIAL)",RX-41536989,CDM,J0878,HCPCS,0636,RC,71288-0016-15,NDC,both,1,UN,226.52,67.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,17.48,,,,,,,17.48,226.52,"fee schedule",
"FIBER LASER FLEXIVA TRAC TIP 200UM FLEXSHIELD HOLMIUM",SUP-M0068403960,CDM,S27200284,LOCAL,0272,RC,,,both,,,3351.98,1005.59,"CIGNA [10200]","Cigna Open Access",,1907.28,56.9,,,,,0,389.84,2849.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 20FR 56CM 40CM VALVE DIL PERFORMER CHECK-FLO AQ",SUP-G12830,CDM,C1894,HCPCS,0272,RC,,,both,,,2667.38,800.21,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IDENTITY IMPRINT PS TIBIAL INSERT TRAIL SIZE 5N 6MM",SUP-TPS-030-065N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG BIOLOGICAL 10X7CM CYTAL PORCINE EXTRACELLULAR MATRIX 1",SUP-WS0710,CDM,Q4166,HCPCS,0636,RC,,,both,,,2160.00,648,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CEPHEA PREPARATION KIT",SUP-FG-019,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 10X9.5X.7MM OSCILLATING",SUP-KM-3261,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL LOOP MICRO WEDGE 26FR STERILE",SUP-M0068802141,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS MULTIPASS 3-0 PS-1 18IN BRAID ANTIBACTERIAL",SUP-VCP683G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 1 CT 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8435H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING MONORAIL 80CM 20MM 6FR 6MM 4FR BALLOON",SUP-H74939031602080,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 250MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025250S,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"FIRST HEALTH [10303]","First Health",,1500,80,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9% SOLUTION",SUP-798353,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.68,14.3,"FIRST HEALTH [10303]","First Health",,38.14,80,,,,,0,5.55,40.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT FEMORAL DOME FIX BEARING CEMENT ATTUNE",SUP-OSC379572,CDM,C1776,HCPCS,0278,RC,,,both,,,19530.00,5859,"CIGNA [10200]",Cigna,,7812,40,,5873.17,5873.17,5873.17,"1 through 10",2271.34,16600.5,"percent of total billed charges",
"POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS",RX-11081,CDM,J3480,HCPCS,0636,RC,00990-7115-09,NDC,both,1000,ML,100.65,30.19,"CIGNA [10200]",Cigna,,3.14,,,,,,,0.24,85.55,"fee schedule",
"CATH EMERGE 143CM 12MM 8FR 3MM .088IN ULTRA LOW PROFILE",SUP-H7493919112300,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 6CM 5.8FR 18FR BALLOON",SUP-M0062251080,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"FIRST HEALTH [10303]","First Health",,1369.98,80,,,,,0,199.16,1455.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR .9MM DORNHOFFER MICRO TITANIUM 3 POINT",SUP-7014-3253,CDM,L8613,HCPCS,0278,RC,,,both,,,1684.73,505.42,"CIGNA [10200]","Cigna Open Access",,958.61,56.9,,,,,0,195.93,1432.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON CERVICAL DILATATION 40CM 18FR COOK SILICONE RIPENING",SUP-G48149,CDM,C1726,HCPCS,0272,RC,,,both,,,527.60,158.28,"AETNA [10100]","Aetna HMO/PPO",,419.44,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.36,448.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D +1.5 CYL BICONVEX TORIC 13MM 6MM POSTERIOR CHMBR",SUP-SV25T3,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,341.96,45.9,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC",309,MS-DRG,,,,,,,inpatient,,,25811.57,7743.47,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,4700.49,,"Case rate ($4,563.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,237.60, add-ons for qualifying new technology services are included. If operating cost exceeds $37,277.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,702.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,243.21. The transfer operating threshold is the transfer adjustment factor * $4,237.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $320.38. The transfer capital threshold is the transfer adjustment factor * $320.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",4733.46,4733.46,4733.46,"1 through 10",4563.58,18347.62,other,"IP DRGs"
"ELECTRD ELECTROSURGICAL L HOOK LATEX 33CM 5MM DAVOL",SUP-5600160,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"FIRST HEALTH [10303]","First Health",,271.44,80,,,,,0,39.46,288.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CADENCE PRECISION INFLATION 1ML SYR INJECTOR THREAD",SUP-103-0304,CDM,S27200284,LOCAL,0272,RC,,,both,,,3592.50,1077.75,"NOVANET [10819]",Novanet,,2694.38,75,,,,,0,417.81,3053.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR TRABECULAR METAL CERAMIC HEAD",SUP-98786420000,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1604.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN INTERNAL MAMMARY ARTERY CURVE",SUP-DXT5IMA,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"FIRST HEALTH [10303]","First Health",,66.12,80,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM MITRAL SEMIRIGID MEMO 3D",SUP-SMD26,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5106,40,,,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE JOURNEY II COCR WITH XR INSERT AND",SUP-71709040,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"AETNA [10100]","Aetna HMO/PPO",,15025.5,79.5,,10981.53,8986.79,12413.38,12,2198.07,16065,"percent of total billed charges",
"STEM FEMORAL 125D 48.5MM HIGH OFFSET 40.3MM 155MM 13MM",SUP-3L93713,CDM,C1776,HCPCS,0278,RC,,,both,,,30866.40,9259.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8833.96,28.62,,,,,0,3589.76,26236.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION SWIVELOCK PEEK MENISCAL ROOT REPAIR",SUP-AR-4550P,CDM,C1713,HCPCS,0278,RC,,,both,,,10106.78,3032.03,"NOVANET [10819]",Novanet,,7580.09,75,,,,,0,1175.42,8590.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM ATS OPEN PIVOT MECHANICAL STD SERIES",SUP-500DM25,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9450,40,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUOXETINE 10 MG CAPSULE",RX-10069,CDM,,,0637,RC,16714-0720-02,NDC,both,1,UN,13.07,3.92,"KAISER [10500]",Kaiser,,8.76,67,,,,,0,1.52,11.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 62MM 23MM ESOPHAGEAL PARTIAL COVER OTW STERILE",SUP-M00517710,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross HMO",,7161.84,39.2,,9776.84,9776.84,9776.84,"1 through 10",2124.8,15529.5,"percent of total billed charges",
"CATH IMPULSE 100CM 6FR RCB CURVE ANGIOGRAPHIC CORONARY 2",SUP-H749165991902,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 15CM 23MM 18.5FR ESOPHAGEAL PARTIAL COVER",SUP-M00517740,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"MULTIPLAN [10600]",Multiplan,,15529.5,85,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 15CM 2.5MM STD DRNG VENTRICLE BARIUM IMPREGNATED PLAINT",SUP-41103,CDM,C1729,HCPCS,0272,RC,,,both,,,1470.15,441.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,604.23,41.1,,,,,0,170.98,1249.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 46CM 7FR VENTRICLE BIPOLAR TINED PASSIVE",SUP-1646T/46,CDM,C1898,HCPCS,0275,RC,,,both,,,1786.00,535.8,"CIGNA [10200]","Cigna Open Access",,1016.23,56.9,,,,,0,207.71,1518.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Toxoplasma Igm Ab",PX-302000166,CDM,86778,CPT,0302,RC,,,both,,,313.50,94.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12.97,,,,,,,0.01,266.48,"fee schedule",
"COIL EMBOLIZATION 2CM 1MM PRESTIGE PLUS HELICAL COMPLEX",SUP-PRES0102CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 3-0 30IN BRAID TIE 12 STRAND PRECUT",SUP-A304H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET VACUUM 14MM PLASTIC CANN CURVED ROUND TIP SEMIRIGID",SUP-21593A,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.38,21.71,"CIGNA [10200]","Cigna Local Plus",,38.72,53.5,,,,,0,8.42,61.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 4.0 MM X 40 MM X 130 CM",SUP-IPU04004013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3318,41.1,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN FULL LENGTH AMPLATZ RIGHT 2 CURVE",SUP-H74908641862,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]","Cigna Open Access",,43.57,56.9,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) STERILE TRICUSPID VALVE 180MM",SUP-ES0366-05,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POWERKNIT SUSPENDERED GIRDLE LARGE BLACK",SUP-4-4012B-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,623.70,187.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABERX RADIANZ 2.5MM20CM 190",SUP-R51002520L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RUNWAY 100CM 6FR JL3.5 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389696610,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) CATHETER GUIDELINER 150CM 25CM 8FR .088IN .071IN INTE",SUP-5573,CDM,C1887,HCPCS,0272,RC,,,both,,,0.01,,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,,41.1,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BOOT CONTRACTURE XL ANKLE ANTIROTATION BAR PAD TOE PIECE",SUP-4301E,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR ALEXIS 360D MEDIUM FLEXIBLE RING ATRAUMATIC SELF",SUP-C8302,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MFLD ANGIOGRAPHY 1 VALVE AUTODESK SHAPE MANAGER RIGHT OFF",SUP-H965700381071,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.86,43.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SHAVER MAROON 4MM DYONICS ELITE STONECUTTER STRAIGHT",SUP-72200728,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPN NC 15MM 3.5MM 35 ATM BALLOON DILATATION THIN WALL",SUP-350-015-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 130CM 80MM 6MM BALLOON",SUP-U3513068,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL ASPIRATION 15MM 21GA 1.95MM SMOOTHSHOT 2MM SMOOTH SHOT",SUP-NA-401D-1521,CDM,S27200284,LOCAL,0272,RC,,,both,,,471.83,141.55,"KAISER [10500]",Kaiser,,316.13,67,,,,,0,54.87,401.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE 6X5CM EPIFIX AMNIOTIC MEMB PURION STERILE",SUP-GS-5560,CDM,Q4186,HCPCS,0636,RC,,,both,,,36193.50,10858.05,"PHCS [10601]",PHCS,,25335.45,70,,,,,0,406.44,30764.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE 100CM 4FR .0395IN SIDEWINDER SIMMONS",SUP-532415,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,70.99,68,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X9-6.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-14809,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5934,40,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 30ML .212-.85MM DEMINERALIZED CORTICAL",SUP-420118,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM LC-DCP LCP STAINLESS STEEL FULL THREAD",SUP-218.040,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,305.36,68,,,,,0,52.23,381.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS ENDOSCOPIC GRASPING DISSECTING ATRAUMATIC TIP STRAIG",SUP-97-1051RC,CDM,S27100035,LOCAL,0271,RC,,,both,,,3525.60,1057.68,"CIGNA [10200]",Cigna,,2397.41,68,,,,,0,410.03,2996.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 450ML STYLE 7200 MEDIUM HEIGHT CENTERSCOPE",SUP-3549213,CDM,C1789,HCPCS,0278,RC,,,both,,,9694.50,2908.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3984.44,41.1,,,,,0,1127.47,8240.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC IPERIA 7 PROMRI DF-1 IMPLANTABLE",SUP-393007,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"UHC [10700]","United Healthcare",,36536.76,63.3,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NASAL VIOLET 50X40X.15MM PDS RECTANGLE PDO FLEXIBLE",SUP-ZFP8,CDM,S27800098,LOCAL,0278,RC,,,both,,,2242.50,672.75,"NOVANET [10819]",Novanet,,1681.88,75,,,,,0,260.8,1906.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 72CM 8.6FR TENSI-LOCK SPRINT QUATTRO HELIX STD",SUP-6947M72,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]","Cigna Local Plus",,5409.18,31.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 5MM 8MM 7FR .035IN",SUP-BXA057901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6126.8,28.62,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 20MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158101120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 4.75MM IMPL FLEXOR DIGITORUM LONGUS",SUP-AR-1547BC-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10831.28,3249.38,"CIGNA [10200]","Cigna Local Plus",,5794.73,53.5,,3978.14,359.25,3978.14,24,1259.68,9206.59,"percent of total billed charges",
"PK 10X1.5X2.5CM LARGE NASAL COMPRESSED QUICK EFFECTIVE",SUP-440406,CDM,S27000186,LOCAL,0270,RC,,,both,,,284.49,85.35,"UHC [10700]","United Healthcare",,180.08,63.3,,,,,0,33.09,241.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMCONC MINNTECH HEMOCOR HPH 1000 TUBE ADPTR SET PERFUSION",SUP-HPH-1000TS,CDM,S27200284,LOCAL,0272,RC,,,both,,,844.01,253.2,"KAISER [10500]",Kaiser,,565.49,67,,,,,0,98.16,717.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 2.8MM TWIST STERILE",SUP-KM166-00-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.04,24.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE NAVIGATION EXT",SUP-8000050011,CDM,S27200284,LOCAL,0272,RC,,,both,,,7038.00,2111.4,"MULTIPLAN [10600]",Multiplan,,5982.3,85,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 5CM MIDAS REX MR8 2MM BALL DISSECTING DIAMOND LP",SUP-MR8-LP05BA20D,CDM,S27200284,LOCAL,0272,RC,,,both,,,2179.13,653.74,"PHCS [10601]",PHCS,,1525.39,70,,,,,0,253.43,1852.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW S6 FLAT FAN OSCILLATE HUB",SUP-506119,CDM,S27200284,LOCAL,0272,RC,,,both,,,1053.00,315.9,"MULTIPLAN [10600]",Multiplan,,895.05,85,,,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAX BONE 3.5GM WATER SOLUBLE MECHANICAL BARR ALKYLENE OXIDE",SUP-1503831,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.24,228.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,349.41,45.9,,,,,0,88.53,647.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 65CM 5FR C3 CURVE ANGIOGRAPHIC",SUP-G06828,CDM,S27200284,LOCAL,0272,RC,,,both,,,631.80,189.54,"CIGNA [10200]","Cigna Local Plus",,338.01,53.5,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12.5IN 15FR CORONARY SINUS ADULT RETROGRADE",SUP-94115T,CDM,S27200284,LOCAL,0272,RC,,,both,,,793.01,237.9,"CIGNA [10200]",Cigna,,539.25,68,,,,,0,92.23,674.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 20MM 3.5MM BALLOON DILATATION",SUP-48003502X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Quadratus Lumborum (Ql) Block",PX-361000650,CDM,64999,CPT,0361,RC,,,both,,,2896.00,868.8,"FIRST HEALTH [10303]","First Health",,2316.8,80,,,,,0,336.8,2896,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEARTRAIL III 100CM 6FR TIG4 CURVE GUIDING CORONARY",SUP-40-6311,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,239.7,41.1,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CM 24MM 10MM THORAX WOVEN HEMOSTASIS",SUP-M00202175824P0,CDM,C1768,HCPCS,0278,RC,,,both,,,8352.73,2505.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3833.9,45.9,,,,,0,971.42,7099.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX PDS PLUS 2 CT-1 SPIRAL 12IN ABSORBABLE",SUP-SXPP2B403,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Open Access",,14.23,56.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM ALPS T15 TIBIA CORTICAL DISTAL LOCK SELF",SUP-816135012,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,1144.80,304.56,2275.09,66,189.34,1383.8,"percent of total billed charges",
"KIT STENT 28CM 8FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001274190,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 15MM 6FR 4.5MM",SUP-H7493926715450,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 240CM 5.5CM 7.5FR 15-18MM ESOPHAGEAL",SUP-M00558490,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"MULTIPLAN [10600]",Multiplan,,1401.68,85,,,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 30MM 80CM 7MM 6FR .035IN VASCULAR NITINOL",SUP-G43850,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Open Access",,2150.82,56.9,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAHURKAR 16CM 11.5FR HEMODIALYSIS 2 LUMEN STRAIGHT EXT",SUP-8830414001,CDM,C1752,HCPCS,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRI-SIL 16FR URETHRAL SILICONE 5CC FOLEY 2 WAY STD",SUP-0172L16,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.13,49.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,67.87,41.1,,,,,0,19.2,140.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE WALKING LARGE STD FOOT ANKLE 1 PIECE 2 LAYER MEMORY",SUP-SL8001-07,CDM,S27000186,LOCAL,0270,RC,,,both,,,228.03,68.41,"PHCS [10601]",PHCS,,159.62,70,,,,,0,26.52,193.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 3 % FOR NEBULIZATION",RX-7327,CDM,,,0250,RC,00378-6997-89,NDC,both,15,ML,12.54,3.76,"UHC [10700]","United Healthcare",,7.94,63.3,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 5-0 P-3 18IN MONOFILAMENT PLIABILIZE",SUP-698H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 6MM 3.75MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP37506X,CDM,C1725,HCPCS,0272,RC,,,both,,,538.65,161.59,"FIRST HEALTH [10303]","First Health",,430.92,80,,,,,0,62.64,457.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 CT-1 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J345H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL HARRINGTON 12IN THORAX CROSS SERRATE CLAMP",SUP-54-5013,CDM,S27200284,LOCAL,0272,RC,,,both,,,1058.18,317.45,"UHC [10700]","United Healthcare",,669.83,63.3,,,,,0,123.07,899.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 7CM 18GA BEST 1 LOOSE SOURCE IODINE-125",SUP-10172-11,CDM,C2639,HCPCS,0278,RC,,,both,,,882.90,264.87,"CIGNA [10200]","Cigna Local Plus",,472.35,53.5,,,,,0,102.68,750.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 80MM 3.5MM BALLOON",SUP-H74939147358010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE 25CM 2.5CM 8FR INTRO STAINLESS STEEL",SUP-RSS806,CDM,C1894,HCPCS,0272,RC,,,both,,,156.60,46.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,106.49,68,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 109MM 14MM INSIGNIA 7 14 HIGH OFFSET 41MM HIP",SUP-7000-6607,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3623.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3555.74,25987.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-2 THX-26 36IN 2 ARM MONOFILAMENT WHITE",SUP-2N06A,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.18,96.35,"NOVANET [10819]",Novanet,,240.89,75,,,,,0,37.35,273,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTIMED SORBION SORBACT 4X8",SUP-7269809,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.14,49.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.32,141.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL GREEN 4.7MM SQUARE CANNULATED",SUP-CSS07247SQ,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 5.5MM REVOLVE",SUP-185.320,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross PPO",,1728.72,39.2,,957.42,570.23,957.42,28,512.88,3748.5,"percent of total billed charges",
"INSRT ACETABULAR 58MM 36MM NEUTRAL HIP CERAMIC STERILE LATEX",SUP-121887658,CDM,C1776,HCPCS,0278,RC,,,both,,,14835.00,4450.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5934,40,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 15X15MM FUSEFORCE HAND 2MM REAMER STERILE",SUP-FFNS-1515,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"KAISER [10500]",Kaiser,,6472.2,67,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC .99CM 5.37X7.79CM MOMENTUM HEARTLOGIC RIGHT",SUP-D121,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"CIGNA [10200]","Cigna Open Access",,13587.6,33.5,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Frenotomy",PX-361000447,CDM,41010,CPT,0361,RC,,,both,,,2422.00,726.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2422,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,281.68,2422,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 25000 UNIT 500ML EXCEL INTRAVENOUS HEPARIN SODIUM 5%",SUP-P5771,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.68,42.8,"NOVANET [10819]",Novanet,,107.01,75,,,,,0,16.59,121.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE",RX-38315,CDM,,,0250,RC,00597-0075-75,NDC,both,1,UN,459.99,138,"CIGNA [10200]",Cigna,,312.79,68,,,,,0,53.5,390.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII ALLOGRAFT 18MM 23MM",SUP-401218A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOABLATION 18IN 8MM CRYOSPHERE 180D UP BALL TIP",SUP-CRYOS-L,CDM,C9808,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 2 CONTOUR 12IN 29- IN KNEE 2",SUP-79-96012,CDM,L1830,HCPCS,0274,RC,,,both,,,88.39,26.52,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,40.57,45.9,,,,,0,10.28,79.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX18MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183648,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"UHC [10700]","United Healthcare",,8348.42,63.3,,8601.07,8395.67,8601.07,"1 through 10",1533.84,11210.36,"percent of total billed charges",
"SUB BONE GRAFT MASTERGRAFT MATRIX EXT BLOCK 10CC",SUP-7610310,CDM,C1713,HCPCS,0278,RC,,,both,,,7734.90,2320.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3550.32,45.9,,,,,0,899.57,6574.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAC 105CM 6.3FR .07IN GUIDING DISTAL ACCESS STERILE",SUP-90770,CDM,S27200284,LOCAL,0272,RC,,,both,,,9066.95,2720.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1074.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1054.49,7706.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER 6250V-MPX ATTAIN COMMAND",SUP-6250V-MPX,CDM,C1887,HCPCS,0272,RC,,,both,,,2602.50,780.75,"UHC [10700]","United Healthcare",,1647.38,63.3,,,,,0,302.67,2212.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 60MM 12MM 135CM ENDOPROSTHESIS ELGILOY",SUP-H74912044126010,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"KAISER [10500]",Kaiser,,5778.75,67,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Non-Indwelling Cath Strt",PX-450000271,CDM,51701,CPT,0361,RC,,,both,,,1404.45,421.33,"FIRST HEALTH [10303]","First Health",,1123.56,80,,,,,0,163.34,1404.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HERMETIC 80CM 1.5MM .7MM DRNG LUMBAR CLOSED TIP LUER",SUP-INS5010,CDM,C1729,HCPCS,0272,RC,,,both,,,3102.68,930.8,"NOVANET [10819]",Novanet,,2327.01,75,,,,,0,360.84,2637.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 64MM X25 LOCK LOW PROFILE STERILE",SUP-04.045.364S,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,858.28,45.9,,,,,0,217.47,1589.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LEMAITRE 80CM 6FR 13.5MM EMBOLECTOMY 16ML STERILE LATEX",SUP-E1601-68,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE QUILL 2-0 3/8 CIRCLE 14X14CM 26MM CLSR MONODERM",SUP-YA-1015Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,159.70,47.91,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE ENDO ELECTROSURGICAL FLOATING BALL",SUP-12-201-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT CLAMP 60MM STEALTH 3 SOFT STERILE LATEX FREE",SUP-A0A13,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH THERMOCOOL 115CM 3.5MM 8FR 2-5-2MM SPACE F-J CURVE",SUP-BDI75TCFJRT,CDM,C2630,HCPCS,0272,RC,,,both,,,10626.00,3187.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,EXTREME",817,APR-DRG,,,,,,,inpatient,,,88858.97,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $10,730.74. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($68,875.61) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.255 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.255,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,345.41,28.62,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ACQUIRE S FRANSEEN 25GA BIOPSY ULTRASOUND FINE NDL",SUP-M00555660,CDM,S27200284,LOCAL,0272,RC,,,both,,,3051.38,915.41,"AETNA [10100]","Aetna HMO/PPO",,2425.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,354.88,2593.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL CINCHLOCK SS ANATOMIC LABRUM RESTORATION SYSTEM",SUP-CAT02463,CDM,S27200284,LOCAL,0272,RC,,,both,,,1279.80,383.94,"CIGNA [10200]",Cigna,,870.26,68,,,,,0,148.84,1087.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 210500 SELECT 5MM SRVC FEE",SUP-210500,CDM,S27800098,LOCAL,0278,RC,,,both,,,3018.75,905.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,351.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,351.08,2565.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trypsin",PX-301000259,CDM,83519,CPT,0301,RC,,,both,,,419.00,125.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16.56,,,,,,,0.01,356.15,"fee schedule",
"STENT DOUBLE-J 26CM 100CM 7FR .028IN URETERAL SILICONE PTFE",SUP-5204100,CDM,C2625,HCPCS,0278,RC,,,both,,,1212.57,363.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.02,1030.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 6MM 8MM 7FR .035IN",SUP-BXA067901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"NOVANET [10819]",Novanet,,16055.55,75,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP CLUSTER HOLE HA TRIDENT II PSL D",SUP-742-11-50D,CDM,C1776,HCPCS,0278,RC,,,both,,,9502.96,2850.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2719.75,28.62,,,,,0,1105.19,8077.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +15.5 DIOPTER +6 CYL MODIFY L 13MM 6MM",SUP-CCW0T9,CDM,V2787,HCPCS,0276,RC,,,both,,,355.00,106.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,162.95,45.9,,,,,0,41.29,301.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 4CM 2MM BALLOON DILATATION",SUP-U815024,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT 1.9FR CATH 1 LUMEN RADIOPAQUE PICC COMPLETE POLYURETHANE",SUP-P1PIC1.9-S,CDM,C1751,HCPCS,0272,RC,,,both,,,972.00,291.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 9FR 35MM 35CM KINK RESISTANT CANN",SUP-401935M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ACUTE AND SUBACUTE ENDOCARDITIS,EXTREME",193,APR-DRG,,,,,,,inpatient,,,80069.72,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $10,815.09. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($78,423.46) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLUE FLEXTIP 8IN 7FR CENTRAL VENOUS POLYURETHANE 2",SUP-ML-00702,CDM,C1751,HCPCS,0272,RC,,,both,,,241.86,72.56,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP 55CM 7FR .078IN ADULT RENAL CURVE",SUP-77821255,CDM,C1887,HCPCS,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH C-FLEX 70CM 7FR URETERAL TAPER TIP 1 LUMEN RADIOPAQUE",SUP-M0064001520,CDM,C1758,HCPCS,0272,RC,,,both,,,325.47,97.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE FACE 10X8X6MM TISSUE",SUP-609406,CDM,S27800098,LOCAL,0278,RC,,,both,,,3864.00,1159.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1773.58,45.9,,,,,0,449.38,3284.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +8.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.085,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 14CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155213190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,165.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY BROACHED RESTORATION 5 HIP FEMUR PROXIMAL REVISION",SUP-6276-3-005,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"KAISER [10500]",Kaiser,,14910.68,67,,,,,0,2588.23,18916.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 5FR GLIDESHEATH SLENDER RADIAL NITINOL",SUP-50-1050,CDM,C1894,HCPCS,0272,RC,,,both,,,591.30,177.39,"AETNA [10100]","Aetna HMO/PPO",,470.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.77,502.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO BALKIN CURVE 40CM 8FR 2.9MM GUIDING",SUP-G10385,CDM,C1894,HCPCS,0272,RC,,,both,,,405.25,121.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,47.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.13,344.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTAPRO 135CM .58IN 2.38MM ATHERECTOMY PRECONNECT BURR",SUP-H749394672380,CDM,C1724,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5530.01,41.1,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE LOCKING CANNULATED 5MM 85MM LCP STAINLESS STEEL",SUP-02.205.085,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,579.85,45.9,,,,,0,146.92,1073.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 44MM UNIVERS REVERS GLENOID PERIPHERAL LOCK",SUP-AR-9563-44,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"KAISER [10500]",Kaiser,,400.24,67,,,,,0,69.48,507.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X21MM LUMINARY CC BICONVEX SPINE",SUP-16821,CDM,S27800098,LOCAL,0278,RC,,,both,,,34524.00,10357.2,"UHC [10700]","United Healthcare",,21853.69,63.3,,,,,0,4015.14,29345.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM ACUMED TITANIUM CORTICAL ELBOW",SUP-CO-2718,CDM,C1713,HCPCS,0278,RC,,,both,,,696.60,208.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,473.69,68,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONE IRRIGATION VISI-FLOW STOMA",SUP-022736,CDM,S27000186,LOCAL,0270,RC,,,both,,,44.02,13.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.12,37.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 5.9X3.9IN XENMATRIX AQUAPURE RECTANGLE",SUP-1161015,CDM,C1781,HCPCS,0278,RC,,,both,,,14938.56,4481.57,"NOVANET [10819]",Novanet,,11203.92,75,,,,,0,1737.35,12697.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II MULTIPASS 3-0 PC-5 18IN MONOFILAMENT UNDYED",SUP-Z824G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 9MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G209,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2492.12,28.62,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SV VASCULAR 180CM 5CM .018IN PTFE PLATINUM NICKEL",SUP-503558,CDM,C1769,HCPCS,0272,RC,,,both,,,400.20,120.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,46.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 22CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006175281170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS [10001]","Blue Cross PPO",,496.03,39.2,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 6MM 3.25MM .017IN",SUP-H7493926706320,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 2.8MM MIDFOOT SALVATION INTRAMEDULLARY DRILL",SUP-SMN10010,CDM,S27200284,LOCAL,0272,RC,,,both,,,3105.00,931.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 54.5MM 2.4MM ROUND STAINLESS STEEL 8 FLUTE",SUP-1608-002-009,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACK VITRECTOMY 25+ GA TOTAL PLUS CONSTELLATION 5000 CPM",SUP-8065751462,CDM,S27200284,LOCAL,0272,RC,,,both,,,3742.50,1122.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL CANNULATED 4.0MM X 20MM",SUP-DRLL-CDC-40020,CDM,S27000186,LOCAL,0270,RC,,,both,,,2107.50,632.25,"PHCS [10601]",PHCS,,1475.25,70,,,,,0,245.1,1791.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 100CM 8FR XB4 CURVE GUIDING STAINLESS",SUP-588896,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CRADLE SUPPORT INTPD-TF-S",SUP-INTPD-TF-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL CANNULATED 6.5/7.5 MM SCR STERILE",SUP-03.333.204S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2718.60,815.58,"CIGNA [10200]",Cigna,,1848.65,68,,,,,0,316.17,2310.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +17.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1750,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-207.026,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"NOVANET [10819]",Novanet,,205.22,75,,,,,0,31.82,232.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE MYRINGOTOMY SPEAR SPEAR STERILE DISPOSABLE",SUP-1458276,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.95,20.98,"NOVANET [10819]",Novanet,,52.46,75,,,,,0,8.14,59.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 80% CANCELLOUS 20% CORTICAL 30CC ALLOGRAFT 4-10MM",SUP-800118,CDM,S27800098,LOCAL,0278,RC,,,both,,,2777.25,833.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,329.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,322.99,2360.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM LOW PROFILE SCREWS TITANIUM T15 FULL",SUP-AR-8935-14,CDM,C1713,HCPCS,0278,RC,,,both,,,486.00,145.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,330.48,68,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 60MM 2MM BALLOON DILATATION DURALYN",SUP-48002006X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UHC [10700]","United Healthcare",,794.73,63.3,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ERCP RAPID EXCHANGE TAPER TIP 210CM BILIARY ACCEPTS",SUP-M00545770,CDM,S27200284,LOCAL,0272,RC,,,both,,,590.25,177.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,68.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.65,501.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 100MM 80CM 8MM 6FR .035IN BILIARY",SUP-G50132,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"KAISER [10500]",Kaiser,,4080.3,67,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PREMIER THR OSSEOTI E1 CERAMIC HIP STEM CUP LINER",SUP-98000100203,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"FIRST HEALTH [10303]","First Health",,22176,80,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC",842,MS-DRG,,,,,,,inpatient,,,52367.36,15710.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,20057.45,,"Fee schedule rate ($20,057.45). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,6267.57,25198.37,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE 3CM 18-24MM CRYOVALVE AORTIC",SUP-AV00,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 5.5IN WEITLANER 3X4 PRONG BLUNT SELF RETAIN SURGICAL",SUP-24-2214,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.68,68.9,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAMADOL 50 MG TABLET, IMMEDIATE RELEASE",RX-14632,CDM,,,0637,RC,60687-0795-11,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMAGER II 100CM 5FR HEADHUNTER 1 CURVE ANGIOGRAPHIC",SUP-M001314141,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 150CM 8CM 3MM BALLOON DILATATION ILIAC",SUP-G34321,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LARYNSCP VIDEO S0 GLIDESCOPE SPECTRUM MILLER DISPOSABLE",SUP-0270-1087,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.40,131.22,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PENCIL SMOKE EVAC COATED PUSH BUTTON LATEX FREE",SUP-0703046000,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE EXPLANT HIP TRUNCATE OSTEOTOM 56MM HEMISPHERE",SUP-00705305610,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ISLEEVE 14  FR",SUP-H74939349140,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 7MM AXIUM 3D NEUROVASCULAR FRAME V01",SUP-FC-7-12-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,13765.50,4129.65,"PHCS [10601]",PHCS,,9635.85,70,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +7.5 DIOPTER +3 CYL BICONVEX 13MM 6MM POSTERIOR",SUP-SN6AT5.075,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"KAISER [10500]",Kaiser,,231.15,67,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION",RX-108061,CDM,J3262,HCPCS,0636,RC,50242-0135-01,NDC,both,4,ML,3206.08,961.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,875.2,,,,,,,379.92,2725.17,"fee schedule",
"HEAD FEMORAL +12MM OFFSET 28MM HIP TYPE 1 SKIRT COCR G7",SUP-163666,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"AETNA [10100]","Aetna HMO/PPO",,3856.31,79.5,,10981.53,8986.79,12413.38,12,564.14,4123.1,"percent of total billed charges",
"PIN POSITIONING 5MM STAINLESS STEEL CRIMP STERILE",SUP-02.221.005S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"CATH MUSTANG 40CM 40MM 6MM .035IN BALLOON DILATATION NYBAX",SUP-39171-06044,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.2MM 20MM FOREARM ELBOW CORTICAL LOCK",SUP-LCBS3.2-20,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,390.38,45.9,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR ANGIOGRAPHY NAMIC 3 200 PSI 5/16IN 28 THREAD ORIGINAL",SUP-H965914000311,CDM,S27000186,LOCAL,0270,RC,,,both,,,119.17,35.75,"CIGNA [10200]",Cigna,,81.04,68,,,,,0,13.86,101.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX PRS LONG-TERM RESORBABLE, 25X30 CM OVAL",SUP-P20363-2530G,CDM,C1781,HCPCS,0278,RC,,,both,,,86776.80,26033.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10283.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10092.14,73760.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTIGRAFT FIBULA SEG FREEZE DRIED CHIPS 20MM",SUP-FIB,CDM,C1713,HCPCS,0278,RC,,,both,,,4240.74,1272.22,"KAISER [10500]",Kaiser,,2841.3,67,,,,,0,493.2,3604.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 211200 SELECT 12MM SRVC FEE",SUP-211200,CDM,S27800098,LOCAL,0278,RC,,,both,,,3018.75,905.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2052.75,68,,,,,0,351.08,2565.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 35FR ANGLE 2 LEFT",SUP-M125135,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Admin Vacc Add",PX-771000002,CDM,90472,CPT,0771,RC,,,both,,,99.92,29.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.62,99.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Admin Vacc Add",PX-771000002,CDM,90472,CPT,0771,RC,,,both,,,99.92,29.98,"PHCS [10601]",PHCS,,69.94,70,,,,,0,11.62,99.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Gait Train Ea 15min (Gp)",PX-420000024,CDM,97116,CPT,0420,RC,,,both,,,181.96,54.59,"NOVANET [10819]",Novanet,,136.47,75,,,,,0,21.16,181.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE 10CM 2.5CM 8FR INTRO STAINLESS STEEL",SUP-RSS802,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"NOVANET [10819]",Novanet,,58.73,75,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM QUARTEX SPINE POLYAXIAL SHOULDER",SUP-1149.3728,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",441.36,3225.75,"percent of total billed charges",
"CATH TREK CROSSFLEX SLIM SEAL 12MM 4.5MM BALLOON DILATATION",SUP-1012412-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR WEITLANER TESSA SELF RETAIN SURGICAL DISPOSABLE",SUP-NF08,CDM,S27200284,LOCAL,0272,RC,,,both,,,426.30,127.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,49.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,49.58,362.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Consult Slide WO Prep",PX-312000030,CDM,88321,CPT,0312,RC,,,both,,,317.00,95.1,"KAISER [10500]",Kaiser,,212.39,67,,,,,0,0.01,269.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 80MM 5FR 10MM BALLOON DILATATION OTW",SUP-39032-10808,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 42MM CATHCART BALL HIP FEMUR MODULAR STERILE",SUP-136342000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH ADULT 24CM 15.5FR POLYURETHANE BIOFLO DURAMAX",SUP-H965103028031,CDM,C1750,HCPCS,0278,RC,,,both,,,2137.50,641.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,611.75,28.62,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X17MM LUMINARY CC 30D BICONVEX",SUP-6917,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3941.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 16CM 1.5MM MIDAS REX LEGEND TAPER FLUTE 11.1",SUP-16TA15,CDM,S27200284,LOCAL,0272,RC,,,both,,,1241.08,372.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,144.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.34,1054.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC UNIVERSAL LSO LOW PROFILE CUSTOMIZE XIPHOID",SUP-993735,CDM,S27000186,LOCAL,0270,RC,,,both,,,1442.12,432.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,592.71,41.1,,,,,0,167.72,1225.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SMART CONTROL MICROMARKER 100MM 120CM 7MM BILIARY",SUP-C07100ML,CDM,C1876,HCPCS,0278,RC,,,both,,,4657.50,1397.25,"KAISER [10500]",Kaiser,,3120.53,67,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 7MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650407,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5250.9,40,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +12.5 DIOPTER +4 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT400125,CDM,V2787,HCPCS,0276,RC,,,both,,,495.00,148.5,"CIGNA [10200]","Cigna Open Access",,281.66,56.9,,,,,0,57.57,420.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SET EXPEDIUM VERSE SPINE 2 5.5 MM ROD",SUP-199721000S,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"PLATE LEVEL 1 VIP BONE SPINE CERVICAL ANTERIOR",SUP-171.115,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2856,68,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Malaria Ab Plasmodium",PX-302000221,CDM,86750,CPT,0302,RC,,,both,,,380.00,114,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,46.81,,,,,,,0.01,323,"fee schedule",
"CATH CHRG 135CM 40MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206050410,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 120MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-120-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10782.00,3234.6,"FIRST HEALTH [10303]","First Health",,8625.6,80,,,,,0,1253.95,9164.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SUCTION 20MM UNILATERAL SERRATE BLADE TUBE NEXUS BONE",SUP-110-31-1121,CDM,S27200284,LOCAL,0272,RC,,,both,,,4021.71,1206.51,"NOVANET [10819]",Novanet,,3016.28,75,,,,,0,467.72,3418.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRANSITION VENTILATOR NASAL INTERFACE HIGH FLOW XSM OPTI",SUP-OJR410VT,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 2.5CM 24FR ENTERAL FEEDING TUBE RADIOPAQUE LOW",SUP-0120-24-2.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"PHCS [10601]",PHCS,,545.34,70,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 50MM CALIBRATED SURGICAL CANCELLOUS SPINAL 3.5 SCREWS",SUP-311.349,CDM,S27000186,LOCAL,0270,RC,,,both,,,1856.25,556.87,"FIRST HEALTH [10303]","First Health",,1485,80,,,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11CM NATRELLE INSPIRA P2.8CM LOW PLUS PROFILE",SUP-MSZ-LP190,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 20GA 8CM POWERGLIDE 1.3IN .014IN 5ML/SEC FULL",SUP-M020081,CDM,C1751,HCPCS,0272,RC,,,both,,,607.50,182.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 2MM CANNULATED NONSTERILE LATEX REUSABLE",SUP-MSN10002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL CANNULATED 3.7MM X 80MM",SUP-DRLL-CDC-37080,CDM,S27000186,LOCAL,0270,RC,,,both,,,1905.00,571.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Interrog Dev Eval Impl Ccm-D System in Person",PX-481000422,CDM,0927T,CPT,0481,RC,,,both,,,58.00,17.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EZ STEER NAV 115CM 4MM 7FR 1-7-4MM SPACE J-J CURVE",SUP-BN7TCJJ4L,CDM,C1732,HCPCS,0272,RC,,,both,,,15366.30,4609.89,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR .071IN AMPLATZ RIGHT 2 CURVE GUIDING",SUP-LA6AR20SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOOK BLUNT 6.25INX9MM NERVE TENDON RETRACTION",SUP-20-2059,CDM,S27200284,LOCAL,0272,RC,,,both,,,332.69,99.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL DISSECTING 16CM 1.5MM MIDAS REX LEGEND TAPER FLUTE 11.1",SUP-16TA15,CDM,S27200284,LOCAL,0272,RC,,,both,,,1241.08,372.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"THOMASMEDICAL INTRDCR FR9.5 - EACH",SUP-666267-001,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMERGE MONORAIL 144CM 8MM 6FR 2.25MM .07IN BALLOON",SUP-H7493918908220,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL 8IN THUMB SERRATED MATTE FINISH DRSG STERILE",SUP-130120,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.13,24.04,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARDEX LUBRICATH 22FR STD URETHRAL RUBBER 30CC 3 WAY 1",SUP-6003L22,CDM,S27200284,LOCAL,0272,RC,,,both,,,263.52,79.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cann Venous Rv 32f",PX-E27200394,CDM,E27200394,LOCAL,0272,RC,,,both,,,167.20,50.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER 6250V-EHXL ATTAIN COMMAND",SUP-6250V-EHXL,CDM,C1887,HCPCS,0272,RC,,,both,,,2602.50,780.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 5MM STRAIGHT 84MM NARROW SHAFT SICKLE EDGE BEAVER",SUP-377300,CDM,S27200284,LOCAL,0272,RC,,,both,,,545.45,163.63,"CIGNA [10200]",Cigna,,370.91,68,,,,,0,63.44,463.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR RELIATACK ARTICULATE 8 DEEP ABSORBABLE TACK",SUP-RELTACK8RDPTSW,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.51,388.65,"KAISER [10500]",Kaiser,,867.99,67,,,,,0,150.67,1101.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 50MM DCP STAINLESS STEEL SHORT THREAD DISTAL",SUP-202.850,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"MULTIPLAN [10600]",Multiplan,,298.61,85,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 55MMX2.59MM TITANIUM THIN VASCULAR TISSUE 4",SUP-TVC55,CDM,S27200284,LOCAL,0272,RC,,,both,,,2010.80,603.24,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,826.44,41.1,,,,,0,233.86,1709.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC BALLOON NONBLADE SUPERIOR RETENTION",SUP-CFR73,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"UHC [10700]","United Healthcare",,115.65,63.3,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER/DIVIDER MONOPOLAR 37CM 10MM LIGASURE ATLAS HAND",SUP-LS1037,CDM,S27200284,LOCAL,0272,RC,,,both,,,2537.18,761.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,295.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,295.07,2156.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 15CM FINE ASPIRATION CM MARK COLOR CODED HUB",SUP-MSPN2006,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 47MM 135CM 8MM 160CM",SUP-M001712210,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"CIGNA [10200]","Cigna Local Plus",,4522.09,53.5,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lo Flexible",PX-E27400070,CDM,L0625,HCPCS,0274,RC,,,both,,,227.63,68.29,"FIRST HEALTH [10303]","First Health",,182.1,80,,,,,0,26.47,193.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR SHOULDER DRILL SPEAR DISPOSABLE STERILE METAL 3.5",SUP-AR-1926DS,CDM,C1713,HCPCS,0278,RC,,,both,,,1488.38,446.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1012.1,68,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Tunl Cvc WO Port >=5yr",PX-450000224,CDM,36558,CPT,0361,RC,,,both,,,8372.60,2511.78,"CIGNA [10200]","Cigna Open Access",,2751,,"Case rate ($2,751). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,973.73,7883,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN RIGHT CORONARY 3D",SUP-534676T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"KAISER [10500]",Kaiser,,58.29,67,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.5MM X 18.0MM",SUP-492501812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cpap Init & Mgmt",PX-410000009,CDM,94660,CPT,0410,RC,,,both,,,1029.95,308.98,"KAISER [10500]",Kaiser,,690.07,67,,,,,0,119.78,875.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE REAMER 19MM SPIN GUARD PROTCT FEMALE",SUP-P01-911-1902,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"KAISER [10500]",Kaiser,,846.61,67,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 4.00 X 28 RX US",SUP-1804400-28,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC MEDIUM 11-13IN ARM QUICK RELEASE BUCKLE",SUP-11-0449-3,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 20MM 2.5MM .014IN BALLOON DILATATION",SUP-AB14W030020150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,161.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 5/64IN THREAD 9IN STEINMANN NONSTERILE",SUP-KM169-39-56,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"BLUE CROSS [10001]","Blue Cross PPO",,24.94,39.2,,957.42,570.23,957.42,28,7.4,54.07,"percent of total billed charges",
"KIT DRSG 17.5X14.7X3.3CM VAC SIMPLACE GRANUFOAM MEDIUM 1",SUP-M8275045/5.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,389.71,116.91,"FIRST HEALTH [10303]","First Health",,311.77,80,,,,,0,45.32,331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASE TIB STEM #1 LEFT PEGLESS",SUP-2585-0-0001,CDM,C1776,HCPCS,0278,RC,,,both,,,5939.00,1781.7,"MULTIPLAN [10600]",Multiplan,,5048.15,85,,,,,0,690.71,5048.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 80MM 2300MM 20MM 3.5MM ESOPHAGEAL NITINOL",SUP-ECBA-20-080-230,CDM,C1874,HCPCS,0278,RC,,,both,,,16425.45,4927.63,"FIRST HEALTH [10303]","First Health",,13140.36,80,,,,,0,1910.28,13961.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM SUMMIT POROCOAT 6 12/14 HIGH OFFSET TAPER",SUP-157011120,CDM,C1776,HCPCS,0278,RC,,,both,,,25247.25,7574.17,"CIGNA [10200]","Cigna Open Access",,8457.83,33.5,,5302.19,4377.88,6578.61,27,2936.26,21460.16,"percent of total billed charges",
"STENT ABSOLUTE PRO 60MM 135CM 9MM VASCULAR PERIPHERAL OTW",SUP-1012537-60,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"MULTIPLAN [10600]",Multiplan,,3519,85,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 12/14 STD TAPER 22.225MM HIP COCR",SUP-136529000,CDM,C1776,HCPCS,0278,RC,,,both,,,4457.40,1337.22,"KAISER [10500]",Kaiser,,2986.46,67,,,,,0,518.4,3788.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL CANNULATED 3.7MM X 80MM",SUP-DRLL-CDC-37080,CDM,S27000186,LOCAL,0270,RC,,,both,,,1905.00,571.5,"FIRST HEALTH [10303]","First Health",,1524,80,,,,,0,221.55,1619.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC CURVE TIP RELOAD AEON 60MMX3.25MM STERILE",SUP-AESC60R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,169.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"SHELL ACETABULAR 46MM HIP CLUSTER HOLE TRITANIUM TRIDENT II",SUP-702-04-46C,CDM,C1776,HCPCS,0278,RC,,,both,,,12551.10,3765.33,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3388.8,27,,,,,0,1459.69,10668.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHLORHEXIDINE GLUCONATE 2 % TOWELETTE",RX-88296,CDM,,,0250,RC,53462-0705-23,NDC,both,1,UN,27.62,8.29,"AETNA [10100]","Aetna HMO/PPO",,21.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.21,23.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 10CM 18MM 10.5MM ESOPHAGEAL DELIVERY",SUP-G57324,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"PHCS [10601]",PHCS,,12312.72,70,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TNLR SURGICAL RIGID 600MM STERILE LATEX FREE DISPOSABLE",SUP-FX003SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,1159.11,347.73,"CIGNA [10200]","Cigna Open Access",,659.53,56.9,,,,,0,134.8,985.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BRACHYTHERAPY 20CM 18GA MICK APPLR ULTRA SHARP TIP",SUP-918205,CDM,C1715,HCPCS,0272,RC,,,both,,,80.13,24.04,"UHC [10700]","United Healthcare",,50.72,63.3,,,,,0,9.32,68.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL URETERAL HYDROPLUS 70CM 12FR STERILE",SUP-M0062401130,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.52,130.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.42,368.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST TRICORTICAL THK16-18MM WEDGE",SUP-400412,CDM,S27800098,LOCAL,0278,RC,,,both,,,6023.70,1807.11,"CIGNA [10200]","Cigna Local Plus",,3222.68,53.5,,,,,0,700.56,5120.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM SUMMIT POROCOAT 6 12/14 HIGH OFFSET TAPER",SUP-157011120,CDM,C1776,HCPCS,0278,RC,,,both,,,25247.25,7574.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7225.76,28.62,,,,,0,2936.26,21460.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JETSTREAM G3 SMALL ATHERECTOMY FIXED CUTTER ROTATIONAL",SUP-PV3118F,CDM,C1724,HCPCS,0272,RC,,,both,,,22050.00,6615,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 40MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PHCS [10601]",PHCS,,1116.99,70,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 150MM 130CM 5MM VASCULAR METAL SUPERFICIAL",SUP-H74939293051530,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 28MM REUNION SHOULDER STERILE LATEX FREE",SUP-5572-2800,CDM,C1776,HCPCS,0278,RC,,,both,,,9442.80,2832.84,"PHCS [10601]",PHCS,,6609.96,70,,,,,0,1098.2,8026.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 28CM 8FR 2.1FR POLARIS ULTRA NAUTILUS .035IN 2",SUP-M006192154050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]",Cigna,,816.39,68,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 20MM HEMASHIELD PLATINUM STRAIGHT 2",SUP-M00202175420P0,CDM,L8670,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,427.53,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBO ELITE 150CM 2MM .080IN ATHERECTOMY PERIPHERAL",SUP-420-159,CDM,C1885,HCPCS,0272,RC,,,both,,,18868.50,5660.55,"AETNA [10100]","Aetna HMO/PPO",,15000.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2194.41,16038.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9CM 3MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036123090,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 24X4IN 16.5-23IN ATS CYLINDRICAL 1 PORT 1 BLADDER",SUP-60707515400,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.16,71.15,"CIGNA [10200]","Cigna Open Access",,134.94,56.9,,,,,0,27.58,201.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC KAHOOK 2 BLADE DISPOSABLE",SUP-KDB,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"FIRST HEALTH [10303]","First Health",,2970,80,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS ACCESS PLUS PLASTIC GWIRE INSRT TOOL",SUP-MAP153,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.89,35.37,"UHC [10700]","United Healthcare",,74.62,63.3,,,,,0,13.71,100.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS ACCESS PLUS PLASTIC GWIRE INSRT TOOL",SUP-MAP153,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.89,35.37,"CIGNA [10200]","Cigna Local Plus",,63.07,53.5,,,,,0,13.71,100.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 15FTX3IN CONFORMABLE PAD HYPOALLERGENIC",SUP-73003,CDM,S27000186,LOCAL,0270,RC,,,both,,,352.96,105.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,240.01,68,,,,,0,41.05,300.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE LIGHT GREEN 72MM 5MM NAIL-EX FEMORAL TIBIAL",SUP-04.005.562,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,134.52,983.18,"percent of total billed charges",
"BIT DRILL 102MM 2.7MM STAINLESS STEEL QUICK CONNECT 76MM",SUP-KM166-310-26,CDM,S27200284,LOCAL,0272,RC,,,both,,,198.53,59.56,"CIGNA [10200]","Cigna Open Access",,112.96,56.9,,,,,0,23.09,168.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HYDRAGLIDE XL 23IN 36FR STRAIGHT TAPER DRNG PVC",SUP-8036,CDM,C1729,HCPCS,0272,RC,,,both,,,58.98,17.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.86,50.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX GEOALIGN 130CM 100MM 5MM BALLOON DILATATION",SUP-LX1813051005F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4574.7,68,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 8 132D",SUP-6720-0837,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6469.75,27,,,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 14.5IN 22FR PHILLIPS 1/56IN HOLLOW PLASTIC 1",SUP-346122,CDM,S27200284,LOCAL,0272,RC,,,both,,,141.81,42.54,"UHC [10700]","United Healthcare",,89.77,63.3,,,,,0,16.49,120.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TISSUE LORDOTIC ALLOGRAFT ANTERIOR SEPTAL",SUP-345844,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR SKIN REGULAR 35 COUNT STERILE LATEX FREE VISISTAT",SUP-528135,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.15,20.44,"PHCS [10601]",PHCS,,47.71,70,,,,,0,7.93,57.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE RIGHT POSTERIOR STABILIZE BEAD",SUP-5516F802,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"AETNA [10100]","Aetna HMO/PPO",,13766.97,79.5,,10981.53,8986.79,12413.38,12,2013.96,14719.4,"percent of total billed charges",
"HC Cult Blood Isol W Pres ID",PX-306000005,CDM,87040,CPT,0306,RC,,,both,,,502.55,150.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16.23,,,,,,,0.5,427.17,"fee schedule",
"HC Tangntl Bx Skin Single Les",PX-761000059,CDM,11102,CPT,0761,RC,,,both,,,1954.02,586.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1793,,"Per diem ($1,793).",,,,0,227.25,1954.02,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 50MM 36MM XLPE HIP STERILE LATEX FREE",SUP-71935848,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.90,3024.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6855.01,68,,,,,0,1172.41,8568.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET THORACENTESIS 10CM 5FR STRAIGHT 1 STEP VALVE CENTESIS",SUP-TAPS-5F-10LT,CDM,C1729,HCPCS,0272,RC,,,both,,,365.40,109.62,"AETNA [10100]","Aetna HMO/PPO",,290.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 3-0 4IN ENDO STITCH V-LOC POLYBUTESTER LOAD",SUP-VLOCN304L,CDM,S27200284,LOCAL,0272,RC,,,both,,,249.43,74.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.01,212.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC STRAIGHT 130MM 2.75MM SHUTT MINI-AGGRESSOR",SUP-32.10034,CDM,S27200284,LOCAL,0272,RC,,,both,,,7971.71,2391.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,927.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,927.11,6775.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 23CM LUER LOCK HUB WITHOUT GWIRE KIT LONG",SUP-490006,CDM,C1894,HCPCS,0272,RC,,,both,,,737.10,221.13,"KAISER [10500]",Kaiser,,493.86,67,,,,,0,85.72,626.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 55MM 20-25MM AFX ILIAC LIMB STRATA AAA STERILE","SUP-IS20-25/C55 SA",CDM,C1874,HCPCS,0278,RC,,,both,,,23373.00,7011.9,"BLUE CROSS [10001]","Blue Cross PPO",,9162.22,39.2,,,,,0,2718.28,19867.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC So Neo Gsap Dna Mcrstl Ins",PX-310000017,CDM,81457,CPT,0310,RC,,,both,,,5525.00,1657.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,642.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.53,4696.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORTICAL FIX X-TAB 6X40MM TI",SUP-186760140,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT FINGER SWANSON 3 METACARPOPHALANGEAL SILICONE GROMMET",SUP-G4700003,CDM,C1776,HCPCS,0278,RC,,,both,,,5733.90,1720.17,"BLUE CROSS [10001]","Blue Cross PPO",,2247.69,39.2,,3949.44,3949.44,3949.44,"1 through 10",666.85,4873.82,"percent of total billed charges",
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U185,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"BLUE CROSS [10001]","Blue Cross HMO",,292.04,39.2,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 4CM 7FR PANCREATIC POLYETHYLENE PUSH CATH DRAIN",SUP-G21373,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA [10200]","Cigna Local Plus",,338.01,,,,,,,73.48,537.03,"percent of total billed charges",
"STEM FEMORAL COLLAR AVENIR COMPLETE 0 HIP STERILE LATEX FREE",SUP-574203000,CDM,C1776,HCPCS,0278,RC,,,both,,,26190.36,7857.11,"PHCS [10601]",PHCS,,18333.25,70,,,,,0,3045.94,22261.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL SF F CURVE ABLATION",SUP-D134702,CDM,C1732,HCPCS,0272,RC,,,both,,,20304.90,6091.47,"MULTIPLAN [10600]",Multiplan,,17259.17,85,,,,,0,2361.46,17259.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 3MM EICKEN ELECTROMAGNETIC MALLEABLE 10 TIME",SUP-8000050006,CDM,S27200284,LOCAL,0272,RC,,,both,,,16242.60,4872.78,"FIRST HEALTH [10303]","First Health",,12994.08,80,,,,,0,1889.01,13806.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 42MM LEVEL 2 TRANSLATIONAL BONE SPINE",SUP-201-42D42,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX14MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183664,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1562.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1533.84,11210.36,"percent of total billed charges",
"GRAFT BONE CORNERSTONE L-ASCR CORTICAL LORDOTIC ALLOGRAFT 14",SUP-341241,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +9 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-PCB0000090,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL IDENTITY IMPRINT 2 NARROW KNEE POSTERIOR",SUP-TPS-301-T02N,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1023.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1023.15,7477.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Psg W Cpap/Bipap Incomplt",PX-740000007,CDM,95811,CPT,0920,RC,,,both,,,6404.70,1921.41,"CIGNA [10200]",Cigna,,1733,,"Per diem ($1,733).",,,,0,744.87,5444,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBTR LAPAROSCOPIC 8MM DA VINCI XI LONG BLUNT",SUP-470009,CDM,S27200284,LOCAL,0272,RC,,,both,,,4278.00,1283.4,"NOVANET [10819]",Novanet,,3208.5,75,,,,,0,497.53,3636.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 100MM 2MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.19,CDM,S27000186,LOCAL,0270,RC,,,both,,,329.00,98.7,"MULTIPLAN [10600]",Multiplan,,279.65,85,,,,,0,38.26,279.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BONE SCREW T10 FULL THREAD 2.7MM/L1",SUP-657118,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,94.05,687.4,"percent of total billed charges",
"SYSTEM DIGNISHIELD FECAL MANAGEMENT 60CC CATH SYR COLL BAG",SUP-SMS002,CDM,S27000186,LOCAL,0270,RC,,,both,,,1093.50,328.05,"AETNA [10100]","Aetna HMO/PPO",,869.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PROC HYSTEROSCOPIC",SUP-7209827,CDM,C1894,HCPCS,0272,RC,,,both,,,2208.00,662.4,"FIRST HEALTH [10303]","First Health",,1766.4,80,,,,,0,256.79,1876.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERSACROSS SHEATH 63CM 55DEG D1",SUP-VXS0204,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"FIRST HEALTH [10303]","First Health",,1296,80,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL CENTERING PIN 4.5 MM SCREWS NONSTERILE",SUP-309.470,CDM,S27000186,LOCAL,0270,RC,,,both,,,961.31,288.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.8,817.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE  VIATORR TIPS ENDOPROSTHESIS WITH CONTROLLED EXPANSION,",SUP-PTB6105275,CDM,C1874,HCPCS,0278,RC,,,both,,,33364.80,10009.44,"KAISER [10500]",Kaiser,,22354.42,67,,,,,0,3880.33,28360.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET TUBING DUALWAVE CASSETTE OUTFLOW ARTHROSCOPY PUMP",SUP-AR-6430,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,150.18,41.1,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 10MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620410,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"NOVANET [10819]",Novanet,,8440.43,75,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 7MM 6MM MUSCLE 2 DISK SELF EXPANDABLE",SUP-9-VSD-MUSC-006,CDM,C1817,HCPCS,0278,RC,,,both,,,62700.00,18810,"NOVANET [10819]",Novanet,,47025,75,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 41MM CEMENTED MEDIALIZE ATTUNE AOX KNEE",SUP-151810041,CDM,C1776,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"CIGNA [10200]","Cigna Open Access",,4083.14,56.9,,5302.19,4377.88,6578.61,27,834.57,6099.6,"percent of total billed charges",
"HEAD FEMORAL 0MM OFFSET C TAPER 36MM HIP HIGH PERFORMANCE",SUP-18-3600,CDM,C1776,HCPCS,0278,RC,,,both,,,7340.76,2202.23,"CIGNA [10200]",Cigna,,4991.72,68,,5873.17,5873.17,5873.17,"1 through 10",853.73,6239.65,"percent of total billed charges",
"CATH LAUNCHER 100CM 6FR .071IN LEFT CORONARY BYPASS CURVE",SUP-LA6LCBSH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AXOLOTL DUALGRAFT  4CM X 4CM",SUP-HADG44,CDM,Q4332,HCPCS,0636,RC,,,both,,,27820.80,8346.24,"CIGNA [10200]",Cigna,,4520.56,,,,,,,247.92,23647.68,"fee schedule",
"PLATE 3.5 MM SCR 12 HOLE LOCKING BONE LEFT DISTAL",SUP-70-0112,CDM,S27800098,LOCAL,0278,RC,,,both,,,6651.60,1995.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,773.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,773.58,5653.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 10CM 3CM 5FR .035IN",SUP-M006192111190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CIGNA [10200]","Cigna Local Plus",,746.45,,,,,,,162.27,1185.95,"percent of total billed charges",
"MONTEREY AL STAND-ALONE ANTERIOR LUMBAR SCREW  6.0 MM X 20 M",SUP-480116020,CDM,S27800098,LOCAL,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Open Access",,921.78,56.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 10FR .134IN 45CM ANL0 CURVE STRAIGHT TIP ANSEL",SUP-G56278,CDM,C1894,HCPCS,0272,RC,,,both,,,472.23,141.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,55.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.92,401.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 24MM ARTHREX +2MM SHOULDER MODULAR",SUP-AR-9560-24-2,CDM,C1776,HCPCS,0278,RC,,,both,,,9335.70,2800.71,"KAISER [10500]",Kaiser,,6254.92,67,,,,,0,1085.74,7935.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 26MM 12MM 22-23MM 10-11MM GORE",SUP-RLT261212,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"NOVANET [10819]",Novanet,,47025,75,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 60MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0275,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]",Cigna,,644.44,68,,1831.33,1831.33,1831.33,16,110.22,805.55,"percent of total billed charges",
SHEATHS,SUP-FCL20100,CDM,C1893,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 60MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-060-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"AETNA [10100]","Aetna HMO/PPO",,7999.29,79.5,,,,,0,1083.33,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM 9FR ENDOCARDIUM 1 COIL ACTIVE FIXATION",SUP-0138,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7057.69,41.1,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOLUTION? MP CS INSERT SIZE 6 STANDARD 10MM RIGHT",SUP-EIS6S10R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"BLUE CROSS [10001]","Blue Cross HMO",,4073.43,39.2,,5311.50,4717.44,5388.59,31,1208.52,8832.69,"percent of total billed charges",
"HC Intra-Atrial Recording",PX-481000068,CDM,93602,CPT,0481,RC,,,both,,,6134.00,1840.2,"CIGNA [10200]","Cigna Local Plus",,6134,,"Case rate ($18,569). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,713.38,6134,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intra-Atrial Recording",PX-481000068,CDM,93602,CPT,0481,RC,,,both,,,6134.00,1840.2,"CIGNA [10200]",Cigna,,6134,,"Case rate ($23,595). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,713.38,6134,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intra-Atrial Recording",PX-481000068,CDM,93602,CPT,0481,RC,,,both,,,6134.00,1840.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2795,,"Case rate ($2,795). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,713.38,6134,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Progr Dev Eval Icd Sngl Lead",PX-480000053,CDM,93282,CPT,0480,RC,,,both,,,397.84,119.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,47.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.27,397.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Progr Dev Eval Icd Sngl Lead",PX-480000053,CDM,93282,CPT,0480,RC,,,both,,,397.84,119.35,"UHC [10700]","United Healthcare",,397.84,,"Per diem ($3,140).",,,,0,46.27,397.84,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR BROAD LORDOTIC 12 DEGREE",SUP-012411,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5409.18,28.62,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 10FR 2.5CM 10CM WITHOUT MINI GWIRE DIL PINNACLE",SUP-RSS004,CDM,C1894,HCPCS,0272,RC,,,both,,,73.95,22.18,"PHCS [10601]",PHCS,,51.77,70,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 20MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,169.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC LARGE 13X3.5-3.75IN RIGHT WRIST HAND",SUP-81096080,CDM,L3807,HCPCS,0274,RC,,,both,,,460.89,138.27,"KAISER [10500]",Kaiser,,308.8,67,,,,,0,53.6,391.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 20MM HEMASHIELD PLATINUM STRAIGHT 2",SUP-M00202175420P0,CDM,L8670,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,,,,0,427.53,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDRALAZINE 20 MG/ML INJECTION SOLUTION",RX-3697,CDM,J0360,HCPCS,0636,RC,63323-0614-00,NDC,both,1,ML,154.38,46.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6.53,,,,,,,5.16,131.22,"fee schedule",
"STEM FEMORAL 140MM 12MM PRESS FIT REDUCE PROXIMAL PROFILE",SUP-192512,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"FIRST HEALTH [10303]","First Health",,18998.78,80,,,,,0,2761.95,20186.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAPTOPRIL 12.5 MG TABLET",RX-9401,CDM,,,0637,RC,60687-0304-11,NDC,both,1,UN,8.54,2.56,"FIRST HEALTH [10303]","First Health",,6.83,80,,,,,0,0.99,7.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo Bowel Pouch W Biopsy",PX-750000149,CDM,44386,CPT,0750,RC,,,both,,,3837.27,1151.18,"NOVANET [10819]",Novanet,,2877.95,75,,,,,0,446.27,3837.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM TITANIUM T15 FULL THREAD HEXALOBE",SUP-AR-8935-32,CDM,C1713,HCPCS,0278,RC,,,both,,,486.00,145.8,"BLUE CROSS [10001]","Blue Cross HMO",,190.51,39.2,,957.42,156.86,7483.26,51,56.52,413.1,"percent of total billed charges",
"CATH SABER 90CM 20MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"KAISER [10500]",Kaiser,,960.58,67,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 28CM 3CM 7FR .035IN PIGTAIL CURVE",SUP-M006180234180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,169.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640506,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 16MM GROWTH GUIDE EIGHT-PLATE BONE PEDIATRIC 32MM",SUP-GP400CE,CDM,C1713,HCPCS,0278,RC,,,both,,,1847.55,554.26,"PHCS [10601]",PHCS,,1293.29,70,,,,,0,214.87,1570.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 14MM COCR",SUP-VAL-20140-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"NOVANET [10819]",Novanet,,1069.2,75,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 12MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620712,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"FIRST HEALTH [10303]","First Health",,9003.12,80,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT CLEARVUE AIRGUARD",SUP-1608062,CDM,C1788,HCPCS,0278,RC,,,both,,,2700.00,810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1836,68,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM SENSAR INTRAOCULAR LENS, BICONVEX, 14.5 DIOPTER",SUP-AR40E00145,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"FIRST HEALTH [10303]","First Health",,745.2,80,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT PLUM 12X3.5IN 2 FILL LINE POSITIVE LOCK CNCT",SUP-ASP-564003,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.06,39.32,"PHCS [10601]",PHCS,,91.74,70,,,,,0,15.24,111.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 9IN LAMBOTTE SPINE SURGICAL CURVE .5IN",SUP-28-9462,CDM,S27200284,LOCAL,0272,RC,,,both,,,232.99,69.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,106.94,45.9,,,,,0,27.1,198.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET TRANSFER XSHORT 4IN EXTENDED TWIST CLAMP MINICAP",SUP-5C4483,CDM,S27200284,LOCAL,0272,RC,,,both,,,402.72,120.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,46.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.84,342.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE XPRESS ULTRA 1.5MM BALL SUPER SLEEK PROFILE 8MM 2.5FR",SUP-ULF-206,CDM,C1726,HCPCS,0272,RC,,,both,,,11364.30,3409.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1346.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",379.61,375.47,414.12,"1 through 10",1321.67,9659.66,"percent of total billed charges",
"SYSTEM PROMUS ELEMENT PLUS 28MM 144CM 2.75MM CORONARY STENT",SUP-H7493911428270,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"KAISER [10500]",Kaiser,,6125.48,67,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Special Dosimetry",PX-333000016,CDM,77331,CPT,0333,RC,,,both,,,1139.76,341.93,"CIGNA [10200]","Cigna Open Access",,648.52,56.9,,,,,0,132.55,1139.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Adenosine Deaminase Fluid",PX-301000404,CDM,84311,CPT,0301,RC,,,both,,,337.25,101.17,"MULTIPLAN [10600]",Multiplan,,286.66,85,,,,,0,0.01,286.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BMT SPLINED KNEE STM V2 12X120",SUP-148315,CDM,C1776,HCPCS,0278,RC,,,both,,,11903.88,3571.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1410.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1384.42,10118.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 100MM 10MM 7FR BILIARY VENOUS SELF EXPAND",SUP-G57430,CDM,C1876,HCPCS,0278,RC,,,both,,,13109.93,3932.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5243.97,40,,,,,0,1524.68,11143.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 220MM 4MM BALLOON",SUP-LX1813042204F,CDM,C2623,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1430.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER MAROON 4MM STONECUTTER RESECTION ARTHROSCOPIC",SUP-7205330,CDM,S27000186,LOCAL,0270,RC,,,both,,,382.80,114.84,"MULTIPLAN [10600]",Multiplan,,325.38,85,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 16X8MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2408,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1144.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1123.46,8211,"percent of total billed charges",
"ANCHOR SUT 2.3MM 2 CURVED OSTEORAPTOR SOFT TISSUE 1",SUP-72203290,CDM,C1713,HCPCS,0278,RC,,,both,,,2504.25,751.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,296.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",291.24,2128.61,"percent of total billed charges",
"CLASSIC SHEATH KIT CONTAMINATION SLEEVE 80CM PUNCHED SANTOPR",SUP-CON-006-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.80,36.54,"CIGNA [10200]","Cigna Open Access",,69.3,56.9,,,,,0,14.17,103.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BMT SPLINED KNEE STM V2 12X120",SUP-148315,CDM,C1776,HCPCS,0278,RC,,,both,,,11903.88,3571.16,"AETNA [10100]","Aetna HMO/PPO",,9463.58,79.5,,10981.53,8986.79,12413.38,12,1384.42,10118.3,"percent of total billed charges",
"GRAFT STENT 160MM 18-14MM 13FR 11FR TRIVASCULAR OVATION",SUP-TV-IL1418160-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13356,40,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 21GA 45CM 11CM SPRING COIL WIRE STRAIGHT",SUP-PID6F11021SSC,CDM,C1894,HCPCS,0272,RC,,,both,,,607.50,182.25,"KAISER [10500]",Kaiser,,407.03,67,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 3.5IN 18GA 25GA PERIFIX TUOHY BPA PLASTIC LOR",SUP-332247,CDM,C1755,HCPCS,0278,RC,,,both,,,105.58,31.67,"FIRST HEALTH [10303]","First Health",,84.46,80,,,,,0,12.28,89.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 13MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G413,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4299.03,45.9,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Tmj Bilat Open Clsd",PX-320000021,CDM,70330,CPT,0320,RC,,,both,,,904.07,271.22,"NOVANET [10819]",Novanet,,678.05,75,,,,,0,65.33,768.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"Siegel TAVR Transcatheter Aortic Valve   29 mm",SUP-30-1-0129,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"NOVANET [10819]",Novanet,,149625,75,,,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD BIPOLAR 5FR VERSAPOINT SPRING TIP HYSTEROSCOPIC",SUP-WA47783A,CDM,S27200284,LOCAL,0272,RC,,,both,,,3439.80,1031.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2339.06,68,,,,,0,400.05,2923.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP - HIP CONSTRUCT 4A: BIPOLAR/PRESS FIT STEM -PRESS",SUP-CAP-H-4A,CDM,C1776,HCPCS,0278,RC,,,both,,,9240.00,2772,"CIGNA [10200]","Cigna Local Plus",,4943.4,53.5,,5372.07,4581.20,7242.98,23,1074.61,7854,"percent of total billed charges",
"STENT POLARIS 30CM 6FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552350,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]","Cigna Local Plus",,642.31,,,,,,,139.63,1020.49,"percent of total billed charges",
"GRAFT VASCULAR SLIDER GDS VGTS",SUP-25129,CDM,C1768,HCPCS,0278,RC,,,both,,,9982.09,2994.63,"BLUE CROSS [10001]","Blue Cross HMO",,3912.98,39.2,,,,,0,1160.92,8484.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 250MM 5MM BALLOON DILATATION DURALYN",SUP-48005025S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"FIRST HEALTH [10303]","First Health",,1101.6,80,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 50CM 11CM GWIRE KINK RESISTANT FLEXIBLE",SUP-PSI-8F-11-038,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"NOVANET [10819]",Novanet,,60.03,75,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC LARGE 13X3.5-3.75IN RIGHT WRIST HAND",SUP-81096080,CDM,L3807,HCPCS,0274,RC,,,both,,,460.89,138.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,313.41,68,,,,,0,53.6,391.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 GEOALIGN 130CM 150MM 7MM BALLOON DILATATION",SUP-LX3513071505F,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"FIRST HEALTH [10303]","First Health",,6762,80,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP POROCOAT PINNACLE 300 SERIES",SUP-121703062,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"CIGNA [10200]","Cigna Open Access",,6458.43,56.9,,5302.19,4377.88,6578.61,27,1320.06,9647.93,"percent of total billed charges",
"INTRO LEAD 16CM 11FR PEEL AWAY",SUP-6095,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"NOVANET [10819]",Novanet,,334.13,75,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 12MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620712,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1308.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DSRCTOR 100MM 2.5MM LATEX FREE",SUP-MPX25100,CDM,S27000186,LOCAL,0270,RC,,,both,,,445.50,133.65,"MULTIPLAN [10600]",Multiplan,,378.68,85,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 9MM TANNE UNIVERSAL TREPHINE STERILE","SUP-E3050 9.00",CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,64.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.29,469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 5.5MM SURGICAL SPINE REVERE",SUP-624.215,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1626.08,41.1,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DILATOR 7FR 19CM",SUP-405508,CDM,S27200284,LOCAL,0272,RC,,,both,,,5.00,1.5,"KAISER [10500]",Kaiser,,3.35,67,,,,,0,0.58,4.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 26CM 6MM MICRUSFRAME 10 COIL",SUP-MFR100626,CDM,S27800098,LOCAL,0278,RC,,,both,,,16974.00,5092.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4857.96,28.62,,,,,0,1974.08,14427.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 120MM 16-14MM 14MM 11FR TRIVASCULAR OVATION",SUP-TV-IL1416120-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CIGNA [10200]","Cigna Local Plus",,10517.85,31.5,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 12.7CM 2.5MM STAINLESS STEEL STRAIGHT SHANK",SUP-00-2318-025-06,CDM,S27200284,LOCAL,0272,RC,,,both,,,2193.75,658.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1491.75,68,,,,,0,255.13,1864.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERIT MAESTRO 130CM 2.9FR .027IN MICRO EMBOLECTOMY NO",SUP-29MC29130SN,CDM,C1751,HCPCS,0272,RC,,,both,,,2301.00,690.3,"KAISER [10500]",Kaiser,,1541.67,67,,,,,0,267.61,1955.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LEAD 23CM 9FR OSCOR PEEL AWAY LUER LOCK KINK",SUP-6663,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE",RX-10724,CDM,,,0637,RC,00185-0122-01,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTALINK 135CM .58IN 1.75MM ATHERECTOMY PTFE INTRO",SUP-H802227680040,CDM,C1724,HCPCS,0272,RC,,,both,,,6641.25,1992.37,"KAISER [10500]",Kaiser,,4449.64,67,,,,,0,772.38,5645.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 17MMX8MMX6CM",SUP-TSB081706A,CDM,C1874,HCPCS,0278,RC,,,both,,,49140.00,14742,"BLUE CROSS [10001]","Blue Cross PPO",,19262.88,39.2,,,,,0,5714.98,41769,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 201MM 32MM 28-29MM ZENITH ALPHA FLEXOR",SUP-G35348,CDM,C1874,HCPCS,0278,RC,,,both,,,96672.00,29001.6,"MULTIPLAN [10600]",Multiplan,,82171.2,85,,,,,0,11242.95,82171.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE ABSORBABLE 4X3IN HELISTAT HEMOSTATIC AGENT 5ML",SUP-3410ZX,CDM,S27200284,LOCAL,0272,RC,,,both,,,1551.97,465.59,"MULTIPLAN [10600]",Multiplan,,1319.17,85,,,,,0,180.49,1319.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dpyd Gene Common Variants",PX-309000132,CDM,81232,CPT,0310,RC,,,both,,,942.40,282.72,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,801.04,"per diem",
"HC Presence & Motility Sperm",PX-309000110,CDM,89321,CPT,0309,RC,,,both,,,338.00,101.4,"BLUE CROSS [10001]","Blue Cross HMO",,15.45,,"Fee schedule rate ($15.45).",,,,0,3.91,287.3,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 150MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TORCON NB ADVANTAGE BEACON TIP 80CM 5FR COBRA 2 CURVE",SUP-G08586,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 12MM BALLOON",SUP-U3575126,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER ALLOGRAFT 12.5X15X6MM ADVANCED LORDOTIC CERVICAL",SUP-7706,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]","Cigna Local Plus",,4429.8,53.5,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE 2 MG/ML INTRAVENOUS SYRINGE",RX-166018,CDM,J2270,HCPCS,0636,RC,00409-1890-01,NDC,both,1,ML,115.79,34.74,"BLUE CROSS [10001]","Blue Cross HMO",,2.54,,,,,,,2.54,98.42,"fee schedule",
"BALLOON KPA25 CATHETER 25MM UNIPEDICULAR",SUP-KPA25,CDM,S27200284,LOCAL,0272,RC,,,both,,,20790.00,6237,"UHC [10700]","United Healthcare",,13160.07,63.3,,,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 75CM 6MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR061501A,CDM,C1874,HCPCS,0278,RC,,,both,,,21577.50,6473.25,"PHCS [10601]",PHCS,,15104.25,70,,,,,0,2509.46,18340.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Presumpt ID Ea Isol Urine",PX-306000064,CDM,87088,CPT,0306,RC,,,both,,,17.00,5.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,12.73,,,,,,,0.01,17,"fee schedule",
"ELECTRD ELECTROSURGICAL 12D-30D LONG SMALL LOOP 24FR",SUP-WA22742S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3181.82,954.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,377.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,370.05,2704.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR NEROSTIMLTR",SUP-3028,CDM,C1767,HCPCS,0278,RC,,,both,,,103882.50,31164.75,"PHCS [10601]",PHCS,,72717.75,70,,,,,0,12081.53,88300.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Medihoney",PX-E27200098,CDM,E27200098,LOCAL,0272,RC,,,both,,,68.95,20.68,"PHCS [10601]",PHCS,,48.27,70,,,,,0,8.02,58.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAA - AMPLATZ CARDIAC PLUG 2-IDE-025",SUP-9-ACP2-IDE-025,CDM,S62400003,LOCAL,0624,RC,,,both,,,63452.40,19035.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7379.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7379.51,53934.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 35FR ANGLE 2 LEFT",SUP-M125135,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 150CM 8FR .038IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145380170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"NOVANET [10819]",Novanet,,847.46,75,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EZ-BLADE SAW BLADE 25.40MM 1.27MM","SUP-EZ2513P.L62 STE",CDM,S27200284,LOCAL,0272,RC,,,both,,,720.90,216.27,"FIRST HEALTH [10303]","First Health",,576.72,80,,,,,0,83.84,612.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE 10CM 2.5CM 8FR INTRO STAINLESS STEEL",SUP-RSS802,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"KAISER [10500]",Kaiser,,52.46,67,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX SAFE PERFORMAXX 20MM 80CM 7MM 6FR .035IN",SUP-ZBM07020,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1185.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 12FR 30CM STRAIGHT KELLER-TIMMERMANS STERILE",SUP-G09346,CDM,C1894,HCPCS,0272,RC,,,both,,,522.45,156.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,214.73,41.1,,,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC SUCTION 22GA EAR",SUP-230087,CDM,S27200284,LOCAL,0272,RC,,,both,,,613.90,184.17,"CIGNA [10200]","Cigna Open Access",,349.31,56.9,,,,,0,71.4,521.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BICORTICAL ILIUM THK3+ MM ALLOGRAFT FREEZE DRIED",SUP-400320,CDM,S27800098,LOCAL,0278,RC,,,both,,,5849.82,1754.95,"CIGNA [10200]","Cigna Open Access",,3328.55,56.9,,,,,0,680.33,4972.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 7MM MICRUSFRAME 10 COIL",SUP-MFR100730,CDM,S27800098,LOCAL,0278,RC,,,both,,,16974.00,5092.2,"CIGNA [10200]","Cigna Local Plus",,5346.81,31.5,,,,,0,1974.08,14427.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 10CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192111010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]","Cigna Local Plus",,642.31,,,,,,,139.63,1020.49,"percent of total billed charges",
"SCR BONE 2.7MM 14MM T10 FULL THREAD LOCK STARDRIVE",SUP-657014,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,176.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",172.92,1263.81,"percent of total billed charges",
"GRAFT BONE LEFT MEDIAL FEMORAL CORTICAL THK3-15MM THIRD",SUP-450970,CDM,S27800098,LOCAL,0278,RC,,,both,,,5775.30,1732.59,"AETNA [10100]","Aetna HMO/PPO",,4591.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,671.67,4909.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 150MM 75CM 5MM VASCULAR METAL SUPERFICIAL",SUP-H74939293051570,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET",RX-9285,CDM,,,0637,RC,00904-7205-46,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,3.35,53.5,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Fluoro Guide Ndl Plc",PX-320000174,CDM,77002,CPT,0320,RC,,,both,,,1538.45,461.53,"BLUE CROSS [10001]","Blue Cross HMO",,292.76,,"Fee schedule rate ($292.76).",,,,0,178.92,1307.68,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT",SUP-G47451,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42180.31,41.1,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TYSHAK II 100CM 6CM 9FR 25MM BALLOON DILATATION DEHP",SUP-611946,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,442.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,442.08,3231.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION",RX-10571,CDM,J2210,HCPCS,0636,RC,00517-0740-01,NDC,both,1,ML,236.10,70.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,41.65,,,,,,,6.63,200.69,"fee schedule",
"HC Colonoscopy W Rmvl Snare",PX-750000094,CDM,45385,CPT,0750,RC,,,both,,,3930.04,1179.01,"PHCS [10601]",PHCS,,3930.04,,"Case rate ($6,277). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,457.06,3930.04,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.453,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA [10200]","Cigna Open Access",,2755.44,56.9,,1144.80,304.56,2275.09,66,563.19,4116.21,"percent of total billed charges",
"STEM FEMORAL ACCOLADE II 132D 2",SUP-6720-0230,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"AETNA [10100]","Aetna HMO/PPO",,19049.83,79.5,,10981.53,8986.79,12413.38,12,2786.79,20367.74,"percent of total billed charges",
"SCR BONE 5MM 20MM OPTILINK T25 SELF TAP VARIABLE ANGLE",SUP-42.231.220,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"NOVANET [10819]",Novanet,,1014.41,75,,,,,0,157.3,1149.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 80MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.780S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"PHCS [10601]",PHCS,,1721.58,70,,,,,0,286.03,2090.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ALEXIS 360D SMALL FLEXIBLE RING ATRAUMATIC SELF",SUP-C8301,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"UHC [10700]","United Healthcare",,198.26,63.3,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI 110CM 5FR PIGTAIL 155D CURVE ANGIOGRAPHIC",SUP-534554S,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,42.93,45.9,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 5MM 5MM LUER LOCK SPRING LOAD HANDLE",SUP-BX00711812,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,151.75,45.9,,,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 22CM 8FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G23388,CDM,C2617,HCPCS,0278,RC,,,both,,,535.41,160.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,153.23,28.62,,,,,0,62.27,455.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enteroscopy W Rmvl FB",PX-750000228,CDM,44363,CPT,0750,RC,,,both,,,3196.00,958.8,"KAISER [10500]",Kaiser,,2141.32,67,,,,,0,371.69,3196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 150MM 130CM 5MM VASCULAR METAL SUPERFICIAL",SUP-H74939293051530,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AERO 30MM 62CM 14MM 16FR GEOMETRIC TRACHEOBRONCHIAL",SUP-90129-214,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2006.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 12MM BALLOON",SUP-U3575126,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 10.2CM .045IN KIRSCHNER STAINLESS STEEL BOTH",SUP-00018607000,CDM,C1713,HCPCS,0278,RC,,,both,,,119.63,35.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,13.91,101.69,"percent of total billed charges",
"GRAFT BONE PATELLAR HEMI THK16-18MM WEDGE ALLOGRAFT FREEZE",SUP-400570,CDM,S27800098,LOCAL,0278,RC,,,both,,,5112.90,1533.87,"AETNA [10100]","Aetna HMO/PPO",,4064.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,594.63,4345.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 13X12.1CM NATRELLE BIOCELL P6.1CM MODERATE HEGHT",SUP-MX-410410,CDM,C1789,HCPCS,0278,RC,,,both,,,8280.00,2484,"AMERIGROUP MEDICAID [20100]",Amerigroup,,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CERTUS XT LK ABLATION PROBE 15",SUP-LK15XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,14524.50,4357.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1721.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1689.2,12345.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 8X38X28MM 10DEG",SUP-1921042P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"PHCS [10601]",PHCS,,24255,70,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X3IN DURAGEN CRANIUM BOVINE CLLGN MATRIX",SUP-DURS3391,CDM,,,0278,RC,,,both,,,7552.19,2265.66,"BLUE CROSS [10001]","Blue Cross PPO",,7.55,.1,,,,,0,7.55,6419.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Txcath Art Inf Init Day",PX-361000276,CDM,37211,CPT,0361,RC,,,both,,,4940.57,1482.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,585.46,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,574.59,4940.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Barbiturate Confirmation",PX-301000508,CDM,80345,CPT,0301,RC,,,both,,,176.00,52.8,"KAISER [10500]",Kaiser,,117.92,67,,,,,0,0.01,176,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 28CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805240,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,106.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE OFFSET -3.5 ENCORE",SUP-411-00-035,CDM,C1776,HCPCS,0278,RC,,,both,,,947.54,284.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,434.92,45.9,,,,,0,110.2,805.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUSTOM PERFUSION FX PACK",SUP-75584,CDM,S27200284,LOCAL,0272,RC,,,both,,,2193.75,658.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1006.93,45.9,,,,,0,255.13,1864.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 5CM 5FR STRAIGHT PANCREATIC",SUP-M00537520,CDM,C2625,HCPCS,0278,RC,,,both,,,1411.18,423.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,403.88,28.62,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 9MM APTUS TITANIUM HEXADRIVE 4 HAND CORTICAL",SUP-A-5200.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"NOVANET [10819]",Novanet,,947.7,75,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Surg Path Gross Micro Level 3",PX-312000006,CDM,88304,CPT,0312,RC,,,both,,,495.21,148.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,420.93,"per diem",
"MESH SURGICAL GORE ENFORM 8X16CM INTRAPERITONEAL BIOMATERIAL",SUP-GBFR0816,CDM,C1781,HCPCS,0278,RC,,,both,,,15952.80,4785.84,"KAISER [10500]",Kaiser,,10688.38,67,,,,,0,1855.31,13559.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 40MM 6FR 7MM .018IN BALLOON DILATATION",SUP-39032-70408,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,615.88,41.1,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRENCH PACEMKR ORANGE BIDIRECTIONAL TORQUE",SUP-6628,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSORB GT1 12MM 2.5MM CORONARY EVEROLIMUS ELUTING POLY",SUP-1235250-12,CDM,C1874,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]","Cigna Open Access",,4711.32,56.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 28MM 144CM 2.75MM CORONARY STENT EVEROLIMUS",SUP-H7493926128270,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"FIRST HEALTH [10303]","First Health",,6900,80,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 5% DEXTROSE 500ML LIFECARE LIFECARE LATEX",SUP-792203,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"FIRST HEALTH [10303]","First Health",,64.8,80,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRAY COLD CRAMER BOTTLE 6OZ",SUP-7454,CDM,S27000186,LOCAL,0270,RC,,,both,,,70.38,21.11,"KAISER [10500]",Kaiser,,47.15,67,,,,,0,8.19,59.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SABRELOC 5-0 S-14 18IN 2 ARM MONOFILAMENT ABSORBABLE",SUP-1772G,CDM,S27200284,LOCAL,0272,RC,,,both,,,197.62,59.29,"AETNA [10100]","Aetna HMO/PPO",,157.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.98,167.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM OXFORD TKR FEMUR TIBIA CEMENT MONOBLOCK BLADE INS",SUP-98B00200165,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]",Cigna,,7560,40,,5873.17,5873.17,5873.17,"1 through 10",2198.07,16065,"percent of total billed charges",
"BEARING HIP 36MM 22.2MM ACTIVE ARTICULATION E1 B G7 2",SUP-010000991,CDM,C1776,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA [10200]","Cigna Open Access",,1536.3,56.9,,5302.19,4377.88,6578.61,27,314.01,2295,"percent of total billed charges",
"SYSTEM SPEEDBRIDGE 3.9MM FIXATION ACHILLES",SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,0278,RC,,,both,,,19150.43,5745.13,"FIRST HEALTH [10303]","First Health",,15320.34,80,,,,,0,2227.2,16277.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE UBER FLEX 30MM 57CM 6MM .065IN VASCULAR",SUP-SR-0630-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL OSS STD KNEE MODULAR 71MM STERILE",SUP-150422,CDM,C1776,HCPCS,0278,RC,,,both,,,23582.79,7074.84,"AETNA [10100]","Aetna HMO/PPO",,18748.32,79.5,,10981.53,8986.79,12413.38,12,2742.68,20045.37,"percent of total billed charges",
"STENT COVERA 80MM 120CM 8MM 8FR STRAIGHT VASCULAR",SUP-AVSL08080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7508.97,41.1,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COPE MAC-LOC 22CM 10.2FR PIGTAIL CURVE",SUP-G48162,CDM,C2617,HCPCS,0278,RC,,,both,,,996.22,298.87,"CIGNA [10200]","Cigna Open Access",,566.85,,,,,,,115.86,846.79,"percent of total billed charges",
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.5MM X 15.0MM",SUP-492501512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY THORACENTESIS 4.75IN 8FR 18GA ARROW-CLARKE PLEURA-SEAL",SUP-AK-01000,CDM,C1729,HCPCS,0272,RC,,,both,,,297.41,89.22,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"JADE OTW .014 150CM PTA BALLOONAND#59; 1.5 X 80MM",SUP-581508022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEXTROSE 10 % IV BOLUS",RX-400302,CDM,,,0250,RC,00338-0023-02,NDC,both,250,ML,100.65,30.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT CARDIOVASCULAR 30CM 16MM 2 VELOUR KNITTED STRAIGHT",SUP-M002020952160,CDM,C1768,HCPCS,0278,RC,,,both,,,2143.13,642.94,"NOVANET [10819]",Novanet,,1607.35,75,,,,,0,249.25,1821.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED + VE",SUP-98000200485,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10098.27,41.1,,6417.48,6417.48,6417.48,"1 through 10",2857.49,20884.5,"percent of total billed charges",
"SPACER SPINAL 22MMX14MM VERTE-STACK CAPSTONE PEEK-OPTIMA END",SUP-2961422,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"CIGNA [10200]",Cigna,,6359.04,40,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 80CM 250MM 5MM BALLOON DILATATION","SUP-ADM 050 250 08P",CDM,C2623,HCPCS,0272,RC,,,both,,,14007.00,4202.1,"KAISER [10500]",Kaiser,,9384.69,67,,,,,0,1629.01,11905.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TIBIAL 7 KNEE TRABECULAR METAL MIS STERILE",SUP-00595405701,CDM,C1713,HCPCS,0278,RC,,,both,,,13555.74,4066.72,"AETNA [10100]","Aetna HMO/PPO",,10776.81,79.5,,1521.93,481.35,16760.95,30,1576.53,11522.38,"percent of total billed charges",
"FRCP SURGICAL RUSSIAN 8IN TISSUE MATTE FINISH STAINLESS",SUP-129392,CDM,S27000186,LOCAL,0270,RC,,,both,,,98.31,29.49,"KAISER [10500]",Kaiser,,65.87,67,,,,,0,11.43,83.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 30MM 7MM STAINLESS STEEL 1.1MM SHORT THREAD",SUP-02.226.030,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"PHCS [10601]",PHCS,,1151.64,70,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA MIV 110CM 6FR PIGTAIL LT CURVE ANGIOGRAPHIC",SUP-6RPL110,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.84,61.75,"CIGNA [10200]",Cigna,,139.97,68,,,,,0,23.94,174.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ON-Q I-FLOW 4ML/HOUR DRUG DELIVERY DEHP 270ML CUSTOM",SUP-P270X4D,CDM,C9804,HCPCS,0272,RC,,,both,,,1066.53,319.96,"AETNA [10100]","Aetna HMO/PPO",,847.89,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.04,906.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE CRYOVALVE PULMONARY VALVE WITHOUT CONDUIT",SUP-SGPV10,CDM,C1768,HCPCS,0278,RC,,,both,,,145293.00,43587.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,59715.42,41.1,,,,,0,16897.58,123499.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR RINGLOC +3MM 26 40MM E-POLY HIP STERILE",SUP-EP-108426,CDM,C1776,HCPCS,0278,RC,,,both,,,14076.00,4222.8,"NOVANET [10819]",Novanet,,10557,75,,,,,0,1637.04,11964.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC",715,MS-DRG,,,,,,,inpatient,,,132254.08,39676.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42457.24,,"Fee schedule rate ($42,457.24). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,65320.21,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 45CM 13MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1345CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,858.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Breast Uni W Cntrst",PX-610000060,CDM,77048,CPT,0610,RC,,,both,,,4284.00,1285.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,498.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,437.65,3641.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,inpatient,,,33328.69,9998.61,"PHCS [10601]",PHCS,,7561,,,,,,,5685.11,22856.59,"per diem","Estimated amount calculated based on 5 day length of stay."
"STENT PRECISE PRO RX 20MM 135CM 9MM VASCULAR NITINOL CAROTID",SUP-PC0920RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,9418.50,2825.55,"AETNA [10100]","Aetna HMO/PPO",,7487.71,79.5,,,,,0,1095.37,8005.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.6MM 1.7MM FIBERTAK FIBERTAPE SUTURETAPE SELF",SUP-AR-3652TSP,CDM,C1713,HCPCS,0278,RC,,,both,,,3701.25,1110.37,"AETNA [10100]","Aetna HMO/PPO",,2942.49,79.5,,1521.93,481.35,16760.95,30,430.46,3146.06,"percent of total billed charges",
"ESCITALOPRAM 10 MG TABLET",RX-33512,CDM,,,0637,RC,00904-6426-61,NDC,both,1,UN,22.04,6.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.56,18.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLP SURGICAL RECHARGEABLE",SUP-5513E,CDM,S27000186,LOCAL,0270,RC,,,both,,,304.50,91.35,"AETNA [10100]","Aetna HMO/PPO",,242.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 100CM 5FR 6MM AMPLATZER II .056IN",SUP-9-AVP2-006,CDM,S27800098,LOCAL,0278,RC,,,both,,,6589.50,1976.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,780.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,766.36,5601.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE PULMONARY 29MM SAPIEN 3 HEART VALVE PULMONIC DELIVERY",SUP-S3PAS4045A,CDM,S27800098,LOCAL,0278,RC,,,both,,,236550.00,70965,"CIGNA [10200]",Cigna,,94620,40,,,,,0,27510.77,201067.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8.5FR .112IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLSX-1008.5,CDM,C1892,HCPCS,0272,RC,,,both,,,304.50,91.35,"AETNA [10100]","Aetna HMO/PPO",,242.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.034TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,1831.33,1831.33,1831.33,16,189.34,1383.8,"percent of total billed charges",
"SHEATH CLOTTRIEVER 13FR",SUP-50-101,CDM,C1757,HCPCS,0272,RC,,,both,,,13800.00,4140,"MULTIPLAN [10600]",Multiplan,,11730,85,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 12D ALLOGRAFT 18MM ALIF",SUP-3W4218,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2505.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTFR BIOPSY SITE CELEROMARK DISPOSABLE",SUP-CELEROMARK,CDM,A4648,HCPCS,0278,RC,,,both,,,628.56,188.57,"BLUE CROSS [10001]","Blue Cross HMO",,246.4,39.2,,,,,0,73.1,534.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.6V 16MM 1 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18006116,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,957.42,156.86,7483.26,51,521.61,3812.25,"percent of total billed charges",
"INSRT TIBIAL 5 6MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650506,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5395.3,41.1,,6417.48,6417.48,6417.48,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"SPRT SCROTAL WHITE BAUER AND BLACK XL COTTON SUSPENSORY LEG",SUP-201352,CDM,S27000186,LOCAL,0270,RC,,,both,,,127.48,38.24,"CIGNA [10200]","Cigna Local Plus",,68.2,53.5,,,,,0,14.83,108.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 30MM 6.5MM E9000 ROUND 10 FLUTE CARBIDE CUT",SUP-E8065LSO,CDM,S27200284,LOCAL,0272,RC,,,both,,,453.28,135.98,"CIGNA [10200]","Cigna Open Access",,257.92,56.9,,,,,0,52.72,385.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 80MM 14MM VASCULAR NITINOL VENOUS ILIOFEMORAL",SUP-AB9U14080090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"AETNA [10100]","Aetna HMO/PPO",,8228.25,79.5,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 8MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158120108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AETNA [10100]","Aetna HMO/PPO",,8883.77,79.5,,10981.53,8986.79,12413.38,12,1299.6,9498.37,"percent of total billed charges",
"PACK SURGICAL EZ-IO SOFT SIDE INTRAOSSEOUS VASCULAR ACCESS",SUP-9065,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,143.03,41.1,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM DCP STAINLESS STEEL CORTICAL NONSTERILE",SUP-202.014,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CIGNA [10200]","Cigna Local Plus",,187.95,53.5,,3978.14,359.25,3978.14,24,40.86,298.61,"percent of total billed charges",
"LENS IOL SQUARE EDGE 1 PIECE ANTERIOR ASPHERIC UV BLOCK",SUP-ZCB00300,CDM,C1780,HCPCS,0276,RC,,,both,,,1174.50,352.35,"MULTIPLAN [10600]",Multiplan,,998.33,85,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR EXTERNAL FIXATION 120MM 4MM SCHANZ SPADE POINT 25MM",SUP-294.46,CDM,C1713,HCPCS,0278,RC,,,both,,,571.54,171.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,66.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",66.47,485.81,"percent of total billed charges",
"CATH EXTERNAL DRNG SUBDURAL CSF EVACUATION SPECIALTY",SUP-951315,CDM,C1729,HCPCS,0272,RC,,,both,,,2349.38,704.81,"KAISER [10500]",Kaiser,,1574.08,67,,,,,0,273.23,1996.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 150MM 2.5MM BALLOON DILATATION PEBAX",SUP-H74939148251510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 100MM 32MM LC-DCP LCP STAINLESS STEEL PARTIAL",SUP-217.100,CDM,C1713,HCPCS,0278,RC,,,both,,,485.35,145.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,138.91,28.62,,,,,0,56.45,412.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 39X12-16MM MAGNIFY-S 8D 29MM STANDALONE",SUP-1126.2112,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"KAISER [10500]",Kaiser,,19296,67,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 45CM .013IN EXTRA SOFT STIFFNESS KNOB CAP",SUP-5003,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 119MM STAINLESS STEEL 3.5MM SCR 6 HOLE LCP BONE LEFT",SUP-239.957,CDM,C1713,HCPCS,0278,RC,,,both,,,9506.13,2851.84,"CIGNA [10200]",Cigna,,6464.17,68,,1831.33,1831.33,1831.33,16,1105.56,8080.21,"percent of total billed charges",
"SUT MONOCRYL MULTIPASS 4-0 PS-2 18IN MONOFILAMENT VIOLET",SUP-Y513G,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.23,19.27,"CIGNA [10200]","Cigna Open Access",,36.55,56.9,,,,,0,7.47,54.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE BASIXCOMPAK 30 ATM 13IN INFLATION POLYCARBONATE 20ML",SUP-IN4352,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.73,95.92,"CIGNA [10200]",Cigna,,217.42,68,,,,,0,37.18,271.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY JNS CURVE 5MM SPACING 5FR 120CM",SUP-401443,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"NOVANET [10819]",Novanet,,234.9,75,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR ADULT SOMASENSOR SMALL OXIMETER PATIENTS GREATER THAN",SUP-SAFB-SM/USA,CDM,S27000186,LOCAL,0270,RC,,,both,,,899.28,269.78,"UHC [10700]","United Healthcare",,569.24,63.3,,,,,0,104.59,764.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 25MM TITANIUM TILT TOP STERILE LATEX FREE",SUP-EEA25,CDM,S27200284,LOCAL,0272,RC,,,both,,,1880.70,564.21,"CIGNA [10200]","Cigna Open Access",,1070.12,56.9,,,,,0,218.73,1598.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 8MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640708,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3220.87,28.62,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 10CM 7FR DUODENAL BEND BILIARY PLASTIC TEMPORARY RAPID",SUP-M00545570,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,101.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONJUGATED ESTROGENS 0.625 MG TABLET",RX-9974,CDM,,,0637,RC,50742-0389-01,NDC,both,1,UN,30.47,9.14,"FIRST HEALTH [10303]","First Health",,24.38,80,,,,,0,3.54,25.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INLAY OPTIMA 24CM 6FR URETERAL PHREECOAT POLYMER",SUP-788624,CDM,C2617,HCPCS,0278,RC,,,both,,,834.30,250.29,"CIGNA [10200]","Cigna Open Access",,474.72,,,,,,,97.03,709.16,"percent of total billed charges",
"SPACER SPINAL 25X10X9MM 9MM CRESCENT 6D THORACOLUMBAR PEEK 4",SUP-9192509,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1925.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 525CC",SUP-RSZ-MPX-525S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,665.82,41.1,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR .09IN AMPLATZ LEFT 2 CURVE GUIDING",SUP-LA8AL20,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 FSL 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8675H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7+ KNEE CONDYLAR CEMENT CONSTRAIN PERSONA COCR",SUP-42-5046-062-12,CDM,C1776,HCPCS,0278,RC,,,both,,,49172.76,14751.83,"CIGNA [10200]","Cigna Open Access",,16472.87,33.5,,5302.19,4377.88,6578.61,27,5718.79,41796.85,"percent of total billed charges",
"HC Procainamide W Napa",PX-301000053,CDM,80192,CPT,0301,RC,,,both,,,338.00,101.4,"CIGNA [10200]","Cigna Open Access",,36.85,,,,,,,0.01,287.3,"fee schedule",
"LIDOCAINE 1%-EPI 1:100,000 BUFFERED WITH SOD BICARB (3 ML) INJ SYRINGE",RX-124329,CDM,,,0250,RC,70092-1663-43,NDC,both,3,ML,77.92,23.38,"KAISER [10500]",Kaiser,,52.21,67,,,,,0,9.06,66.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMUR SHAFT 70MM",SUP-800140,CDM,S27800098,LOCAL,0278,RC,,,both,,,5602.80,1680.84,"BLUE CROSS [10001]","Blue Cross HMO",,2196.3,39.2,,,,,0,651.61,4762.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 2.5 KNEE LEFT CRUCIATE RETAINING PFC SIGMA",SUP-940018,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6990.26,27,,,,,0,3010.99,22006.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM 3 HOLE EMPHASYS",SUP-471046300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"CIGNA [10200]",Cigna,,7182,40,,5873.17,5873.17,5873.17,"1 through 10",2088.17,15261.75,"percent of total billed charges",
"KIT INTRO 10CM 4FR 21GA MERIT MAK .018IN STD GWIRE NDL MINI",SUP-MAK401N,CDM,C1894,HCPCS,0272,RC,,,both,,,217.50,65.25,"PHCS [10601]",PHCS,,152.25,70,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Tissue Back Soft Deep",PX-360000053,CDM,21925,CPT,0360,RC,,,both,,,3285.23,985.57,"FIRST HEALTH [10303]","First Health",,2628.18,80,,,,,0,382.07,3285.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE MYRINGOTOMY SPEAR TIP",SUP-60-45070,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.35,18.7,"CIGNA [10200]",Cigna,,42.4,68,,,,,0,7.25,53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL LIGHT GREEN 28X36X8.4-10.5MM SYNFIX 6D MEDIUM",SUP-08.815.201S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 120MM 6MM .014IN BALLOON DILATATION",SUP-AB14W060120150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"MULTIPLAN [10600]",Multiplan,,1177.34,85,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 100MM 80CM 5MM 6FR .035IN BILIARY",SUP-G50112,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CIGNA [10200]","Cigna Local Plus",,3258.15,53.5,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH II SSL6",SUP-400209,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"FIRST HEALTH [10303]","First Health",,421.2,80,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM ENDOCARDIAL BIPOLAR SINGLE COIL ACTIVE",SUP-1582,CDM,C1777,HCPCS,0278,RC,,,both,,,20538.00,6161.4,"BLUE CROSS [10001]","Blue Cross HMO",,8050.9,39.2,,,,,0,2388.57,17457.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.104,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"CIGNA [10200]","Cigna Local Plus",,458.66,53.5,,3978.14,359.25,3978.14,24,99.7,728.71,"percent of total billed charges",
"BLADE INTRAMEDULLARY NAIL TAN 110MM 10.35MM TFN-ADVANCED",SUP-04.038.410S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,471.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,463.09,3384.57,"percent of total billed charges",
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 60MM 190CM 2.5",SUP-R51002506L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL CRYOABLATION 23CM 14GA ICEPEARL 2.1CX L 90D DISTAL SHAFT",SUP-FPRPR3617,CDM,C2618,HCPCS,0272,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PREVAIL DCB 2.50X10MM",SUP-PRV025010CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHUNT CAROTID BARD JAVID TAPER 27.5CM TYPE 1852 KINK",SUP-007714,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MARKER 45MM FREEMAN AREOLA BREAST BIOPSY STAINLESS STEEL",SUP-P467,CDM,S27200284,LOCAL,0272,RC,,,both,,,507.79,152.34,"FIRST HEALTH [10303]","First Health",,406.23,80,,,,,0,59.06,431.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 100CM 5FR KUMPE CURVE ANGIOGRAPHIC DURATION",SUP-H787117327035,CDM,C1887,HCPCS,0272,RC,,,both,,,2160.00,648,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1468.8,68,,,,,0,251.21,1836,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 13MM VENTURE TITANIUM ANTERIOR CERVICAL SPINE",SUP-9790213,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]","Cigna Open Access",,802.29,56.9,,1144.80,304.56,2275.09,66,163.98,1198.5,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 23MM 145CM 3.25MM CORONARY STENT",SUP-1145325-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PHCS [10601]",PHCS,,4086.6,70,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Primatrix per Sq Cm",PX-E63600039,CDM,Q4110,HCPCS,0636,RC,,,both,,,1582.90,474.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1076.37,68,,,,,0,175.85,1345.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 8X8CM MATRION PLACENTAL MEMB TROPHOBLAST",SUP-PAC64,CDM,Q4201,HCPCS,0636,RC,,,both,,,25987.50,7796.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16891.88,65,,,,,0,204.57,22089.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17CM 5MM AVENIR 10 COIL COMPLEX FINISH",SUP-10CFN05017,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]",Cigna,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 45MM 12MM ZENITH ILIAC BRANCH 58MM",SUP-G60346,CDM,C1874,HCPCS,0278,RC,,,both,,,68399.94,20519.98,"BLUE CROSS [10001]","Blue Cross HMO",,26812.78,39.2,,9776.84,9776.84,9776.84,"1 through 10",7954.91,58139.95,"percent of total billed charges",
"CATH SAPPHIRE NC PLUS 8MM 4MM BALLOON DILATATION STERILE",SUP-240-083-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 130CM 80MM 5MM BALLOON DILATATION",SUP-LX351305805F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"MULTIPLAN [10600]",Multiplan,,5718.38,85,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5-6MM 35MM CREO CREO AMP SPINE CORTICAL MODULAR",SUP-1119.1435,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"MULTIPLAN [10600]",Multiplan,,2550,85,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING EXTERNAL FIXATION 150MM HALF TITANIUM DISTRACTION",SUP-03.311.315,CDM,C1713,HCPCS,0278,RC,,,both,,,3182.85,954.85,"MULTIPLAN [10600]",Multiplan,,2705.42,85,,,,,0,370.17,2705.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DECANAV CARTO 3 115CM 7FR 2MM 2-8-2MM D CURVE ABLATION",SUP-R7D282CT,CDM,C1732,HCPCS,0272,RC,,,both,,,7417.50,2225.25,"AETNA [10100]","Aetna HMO/PPO",,5896.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,862.66,6304.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 24CM 3CM 5FR .035IN STRAIGHT URETERAL",SUP-M006155222190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS [10001]","Blue Cross HMO",,556.77,39.2,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 FLEXOR 30MM 125CM 7MM 5FR LOW PROFILE",SUP-G43775,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"NOVANET [10819]",Novanet,,3134.25,75,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL S-ROM +9MM 11/13 TAPER 36MM HIP M SPECIFICATION",SUP-136534000,CDM,C1776,HCPCS,0278,RC,,,both,,,6875.85,2062.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,814.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,799.66,5844.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ASPIRA PLEURAL DRSG LATEX FREE DISPOSABLE",SUP-4991503,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"AETNA [10100]","Aetna HMO/PPO",,159.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 55MM LOW PROFILE SCREWS TITANIUM PARTIAL",SUP-AR-8945-55PT,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,405.69,28.62,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X7MM FORGE CERVICAL",SUP-865.307S,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X100 80CM SL",SUP-48007010N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"NOVANET [10819]",Novanet,,644.26,75,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 75MM ASCENT MAXIM KNEE INTERLOK COCR 1 PIECE",SUP-141234,CDM,C1776,HCPCS,0278,RC,,,both,,,11379.48,3413.84,"UHC [10700]","United Healthcare",,7203.21,63.3,,8601.07,8395.67,8601.07,"1 through 10",1323.43,9672.56,"percent of total billed charges",
"RELOAD STPLR SUREFORM 60 BLACK",SUP-48360T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.25,543.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,744.42,41.1,,,,,0,210.65,1539.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bcr/Abl1 Gene Major Bp",PX-309000003,CDM,81206,CPT,0310,RC,,,both,,,613.60,184.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,147.56,,,,,,,0.01,582.04,"fee schedule",
"CATH STERLING 80CM 100MM 7MM BALLOON DILATATION PEBAX",SUP-H74939032701080,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT LOWAX 9CM 230CM 25MM 10.2FR COLONIC",SUP-CNJF-25-090-230,CDM,C1876,HCPCS,0278,RC,,,both,,,15104.24,4531.27,"CIGNA [10200]","Cigna Local Plus",,4757.84,31.5,,,,,0,1756.62,12838.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR 54.5MM STAINLESS STEEL 3.2MM ROUND 6 FLUTE DENTAL",SUP-16-S0107,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.36,33.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.95,94.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 57X10X3.4MM STAINLESS STEEL 3.5MM SCR HOLE LOCK LOW",SUP-02.100.004,CDM,C1713,HCPCS,0278,RC,,,both,,,4679.30,1403.79,"AETNA [10100]","Aetna HMO/PPO",,3720.04,79.5,,1521.93,481.35,16760.95,30,544.2,3977.41,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL 7/8IN BLADE 15FT 3/8IN PLUMEPEN",SUP-PLPUL2520,CDM,S27200284,LOCAL,0272,RC,,,both,,,277.08,83.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,127.18,45.9,,,,,0,32.22,235.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cors&Graft Angio W Lt Hrt Cath",PX-481000027,CDM,93459,CPT,0481,RC,,,both,,,20792.02,6237.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6079.88,,"Case rate ($6,079.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,1566.32,17673.22,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 15D SMALL AUG CORTILOC SHOULDER LEFT",SUP-DWK403LA15S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"NOVANET [10819]",Novanet,,7875,75,,,,,0,1221.15,8925,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE COMET II VASCULAR 185CM .014IN PRESSURE STERILE LATEX",SUP-H74939359110,CDM,C1769,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,541.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL 3.75MM 3MM SUPER MULTIVAC 50 ARTHROWAND",SUP-ASH483001,CDM,S27200284,LOCAL,0272,RC,,,both,,,972.00,291.6,"UHC [10700]","United Healthcare",,615.28,63.3,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 3CM 20GA HAWKINS III FLEXSTRAND HARDWIRE",SUP-253030,CDM,A4648,HCPCS,0278,RC,,,both,,,310.59,93.18,"CIGNA [10200]",Cigna,,211.2,68,,,,,0,36.12,264,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENHANCED NATUS EDS 3 EXTERNAL DRNG WIDE POLE CLAMP",SUP-821730C,CDM,C1729,HCPCS,0272,RC,,,both,,,1955.55,586.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,231.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,227.43,1662.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT PUSHLOCK HIP BIOCOMPOSITE",SUP-AR-1923BCH,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.00,945,"BLUE CROSS [10001]","Blue Cross PPO",,1234.8,39.2,,957.42,570.23,957.42,28,366.35,2677.5,"percent of total billed charges",
"ANCHOR SUT 2 SUPER REVO HI-FI",SUP-C6140HB,CDM,C1713,HCPCS,0278,RC,,,both,,,1568.48,470.54,"KAISER [10500]",Kaiser,,1050.88,67,,,,,0,182.41,1333.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 0 GS-21 9IN CLSR ABSORBABLE TAPER POINT",SUP-VLOCL0346,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,23.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESOMEPRAZOLE MAGNESIUM DR 40 MG GRANULES DELAYED RELEASE FOR SUSP",RX-78616,CDM,,,0250,RC,68382-0849-93,NDC,both,1,UN,61.37,18.41,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER",RX-81454,CDM,,,0250,RC,00186-0370-28,NDC,both,6,GR,960.93,288.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Immobilization Grid",PX-E27000219,CDM,E27000219,LOCAL,0270,RC,,,both,,,149.60,44.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRONTERA, 10P, DIA 20MM LOOP SI",SUP-D1390-05-SI,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 48MM ZUK HEAD STERILE LATEX FREE MIS",SUP-00598304048,CDM,S27200284,LOCAL,0272,RC,,,both,,,830.25,249.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ACUTE LEUKEMIA WITH CC",835,MS-DRG,,,,,,,inpatient,,,54934.58,16480.37,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 51MM TITANIUM 2.4MM SCR 6X3 HOLE 2 COLUMN",SUP-04.111.531,CDM,C1713,HCPCS,0278,RC,,,both,,,4217.63,1265.29,"NOVANET [10819]",Novanet,,3163.22,75,,,,,0,490.51,3584.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 149MM 18MM ESOPHAGEAL FULL COVER STERILE LATEX",SUP-M00517470,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]","Cigna Open Access",,6120.45,33.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT WALKING CNFRM AUTO-MOLD 10-11 FOOT LEFT FOAM 2 DENSITY",SUP-AL241110,CDM,S27000186,LOCAL,0270,RC,,,both,,,903.15,270.94,"NOVANET [10819]",Novanet,,677.36,75,,,,,0,105.04,767.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
PSYCHOSES,885,MS-DRG,,,,,,,inpatient,,,32205.02,9661.51,"BLUE CROSS [10001]","Blue Cross PPO",,3131.13,,,,,,,1958,32205.02,"per diem","Estimated amount calculated based on 6 day length of stay."
"KIT INSRT 1.1MM DRILL NDL PERCUTANEOUS INSRT PORTAL DIL WIRE",SUP-AR-1934PI,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM 24.2MM MASTERS HP PYROLYTIC CARBON",SUP-27AEHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]","Cigna Open Access",,9754.94,33.5,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 80MM KNEE RIGHT POSTERIOR STABILIZE OPEN BOX",SUP-184516,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"CIGNA [10200]","Cigna Open Access",,8316.64,33.5,,5302.19,4377.88,6578.61,27,2887.24,21101.91,"percent of total billed charges",
"NDL NERVE BLOCK 40MM 22GA SONOPLEX II FACET SPECIAL TIP",SUP-001287-70,CDM,C9812,HCPCS,0272,RC,,,both,,,119.63,35.89,"CIGNA [10200]","Cigna Open Access",,68.07,56.9,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR NEUROLOGICAL EASYFIT ENTROPY ADULT DISPOSABLE",SUP-M1174413,CDM,S27000186,LOCAL,0270,RC,,,both,,,133.43,40.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.52,113.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 7FR CWV SILICONE CLOT STOP ATRAUMATIC CLOSED",SUP-3640AT,CDM,S27000186,LOCAL,0270,RC,,,both,,,265.76,79.73,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT PEG 20FR SILICONE RADIOPAQUE EXTERNAL RETENTION RING",SUP-8170-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.81,228.54,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE EPI-SENSE 3CM COAGULATION GUIDE ELECTRD IRRIGATION",SUP-CDP-4330-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,66690.00,20007,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CANN BONE CEMENT 11GA IVAS VERTEPORT INFLATABLE VERTEBRAL",SUP-306511000,CDM,S27200284,LOCAL,0272,RC,,,both,,,612.17,183.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND 0 CT-1 18IN CONTROL RELEASE BRAID 8",SUP-C021D,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.49,30.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Echo Tee Txcath Intv",PX-481000109,CDM,93355,CPT,0483,RC,,,both,,,5776.41,1732.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW PHTHALATE FREE",SUP-CG-18-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COLLAR CERVICAL PEDIATRIC 1.5-2IN PATRIOT PROCARE SPINE 1",SUP-79-83130,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.33,15.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 135CM 20MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206080210,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT PEG 20FR SILICONE PULL METHOD FEED TUBE EXTERNAL",SUP-7160-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,592.52,177.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE WIRE SAW 20IN STAINLESS STEEL GIGLI STILLE NONSTERILE",SUP-260-106,CDM,S27000186,LOCAL,0270,RC,,,both,,,512.41,153.72,"CIGNA [10200]","Cigna Open Access",,291.56,56.9,,,,,0,59.59,435.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 40MM 80CM 6MM 6FR VASCULAR NITINOL",SUP-G43846,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"AMERIGROUP MEDICAID [20100]",Amerigroup,,447.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 20CC DBX ALLOGRAFT FREEZE DRY MIX",SUP-58200,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"NOVANET [10819]",Novanet,,11643.75,75,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 30IN 23FR FEMUR VEIN ADULT .5IN CNCT 1 PIECE",SUP-96370-023,CDM,S27200284,LOCAL,0272,RC,,,both,,,2120.63,636.19,"UHC [10700]","United Healthcare",,1342.36,63.3,,,,,0,246.63,1802.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE BIG60 12 ATM 13IN INFLATION POLYCARBONATE 60ML 3 WAY",SUP-ENDO-AN6012,CDM,S27200284,LOCAL,0272,RC,,,both,,,298.41,89.52,"NOVANET [10819]",Novanet,,223.81,75,,,,,0,34.71,253.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR BENTSON 24CM 15CM 6FR .035IN STRAIGHT URETERAL",SUP-M006180222060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"CIGNA [10200]","Cigna Local Plus",,533.63,,,,,,,116,847.82,"percent of total billed charges",
"IMPL BREAST 650ML P5.7CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-6504BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"NOVANET [10819]",Novanet,,3933,75,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MERITRANS RAPID RESPONSE KITSMERITRANS MER200 WITH A 3-WAY M",SUP-K11-00280C,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,53.64,41.1,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL GAMMA3 CLOSED TUBE STERILE",SUP-13200125S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1041.01,312.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,707.89,68,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SUB-ANNULAR IMPLANT",SUP-631105-28S,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSELTAMIVIR 30 MG CAPSULE",RX-88704,CDM,,,0637,RC,64380-0797-01,NDC,both,1,UN,53.60,16.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.23,45.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM 85MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE",SUP-02.117.602S,CDM,C1713,HCPCS,0278,RC,,,both,,,7192.84,2157.85,"PHCS [10601]",PHCS,,5034.99,70,,,,,0,836.53,6113.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 23MM 145CM 2.75MM CORONARY STENT",SUP-1145275-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3969.84,68,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEIZURES WITHOUT MCC",101,MS-DRG,,,,,,,inpatient,,,25266.07,7579.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17917.51,,"Fee schedule rate ($17,917.51). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,5598.88,22509.94,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE LEVEL ONE Y CRANIOFACIAL TITANIUM ULTRA LOW",SUP-25-153-07-09,CDM,C1713,HCPCS,0278,RC,,,both,,,2211.60,663.48,"AETNA [10100]","Aetna HMO/PPO",,1758.22,79.5,,1521.93,481.35,16760.95,30,257.21,1879.86,"percent of total billed charges",
"STPLR INTERNAL 60MM 12MM LONG 6 ROW 12 FIRING LINEAR CUTTER",SUP-LONG60A,CDM,S27200284,LOCAL,0272,RC,,,both,,,7539.06,2261.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3098.55,41.1,,,,,0,876.79,6408.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 4 VIVID LED BLADE HANDLE MERCURY FREE",SUP-301-LED-040S,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.97,29.09,"FIRST HEALTH [10303]","First Health",,77.58,80,,,,,0,11.28,82.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BONE DISEASES AND ARTHROPATHIES WITHOUT MCC",554,MS-DRG,,,,,,,inpatient,,,32420.55,9726.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,14922.69,,"Fee schedule rate ($14,922.69). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,7561,32420.55,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM PRECEPT SPINE SHANK MODULAR NONSTERILE",SUP-8896540,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"MULTIPLAN [10600]",Multiplan,,2550,85,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 10MM COCR",SUP-VAL-20100-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,969.41,68,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 175X30MM ONETRAC LX 2 SMOKE EVACUATION CHANNEL",SUP-C100220,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"CIGNA [10200]",Cigna,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 5MM 50MM NAIL-EX TITANIUM FULL THREAD FEMORAL TIB",SUP-04.005.540,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"BLUE CROSS [10001]","Blue Cross HMO",,453.42,39.2,,957.42,156.86,7483.26,51,134.52,983.18,"percent of total billed charges",
"INSTR BIOPSY PINK 10CM 14GA BARD MAX-CORE ANGLE 22MM",SUP-MC1410,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.01,84.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,192.45,68,,,,,0,32.91,240.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lt Hrt Cath Txsptl Punc",PX-481000030,CDM,93462,CPT,0481,RC,,,both,,,14303.21,4290.96,"BLUE CROSS [10001]","Blue Cross PPO",,9637.57,,"Case rate ($9,637.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1663.46,12157.73,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HAWKONE ATHERECTOMY H1-M",SUP-H1-M,CDM,C1714,HCPCS,0272,RC,,,both,,,20128.50,6038.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2340.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 130CM 150MM 6MM BALLOON DILATATION",SUP-ADM06015013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"KAISER [10500]",Kaiser,,5408.91,67,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 16MM 135CM 4MM .018IN BILIARY STAINLESS",SUP-G56619,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"AMERIGROUP MEDICAID [20100]",Amerigroup,,597.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 315MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.443S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"KAISER [10500]",Kaiser,,5569.33,67,,,,,0,966.74,7065.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 75MM PROXIMATE TITANIUM THICK TISSUE ENDOSCOPIC",SUP-TRT75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Thorac Spine W/WO Cntrst",PX-612000008,CDM,72157,CPT,0612,RC,,,both,,,5553.36,1666.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,683,,"Per diem ($683). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,645.86,4720.36,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 45ML 4-10MM COARSE 20% CORTICAL 80%",SUP-451780,CDM,C1713,HCPCS,0278,RC,,,both,,,7177.73,2153.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,850.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",834.77,6101.07,"percent of total billed charges",
"SCR BONE 2.7MM 56MM STAINLESS STEEL T8 SELF TAP LOCK",SUP-02.211.056,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"BLUE CROSS [10001]","Blue Cross PPO",,352.07,39.2,,957.42,570.23,957.42,28,104.45,763.41,"percent of total billed charges",
"TOOL DISSECTING 5CM 5MM BALL FLUTE BURR SHORT STRAIGHT",SUP-S-5B,CDM,S27200284,LOCAL,0272,RC,,,both,,,1474.20,442.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,174.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,171.45,1253.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Guide Intraoperative",PX-402000043,CDM,76998,CPT,0402,RC,,,both,,,1891.00,567.3,"KAISER [10500]",Kaiser,,1266.97,67,,,,,0,219.92,1607.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X11MM LUMINARY CC SPINE LUMBAR",SUP-16811,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"FIRST HEALTH [10303]","First Health",,26611.2,80,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 85MM 12.7MM DHS/DCS STAINLESS STEEL CONDYLAR",SUP-280.85,CDM,C1713,HCPCS,0278,RC,,,both,,,2264.18,679.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1539.64,68,,,,,0,263.32,1924.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH 12IN 9MM TNLR POLYMER VASCULAR RADIOPAQUE SMOOTH",SUP-9009-20,CDM,C1894,HCPCS,0272,RC,,,both,,,583.20,174.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,396.58,68,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 800ML P6CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-8004BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5347.50,1604.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2454.5,45.9,,,,,0,621.91,4545.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COPPER CU-64 DOTATATE INTRAVENOUS SOLUTION (2-3 MCI)",RX-411821,CDM,A9592,HCPCS,0343,RC,08888-8877-76,NDC,both,1,UN,20412.00,6123.6,"CIGNA [10200]","Cigna Open Access",,1155,,"Per diem ($1,155). Each quantity on the visit service is paid its own per diem rate. Each eligible service on a given day will be paid its own per diem rate.",,,,0,1155,17350.2,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY 11.6CM 11GA PARALLAX CORE-ASSURE BONE VERTEBRAL",SUP-KP-CA-1102-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,899.10,269.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,106.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.57,764.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 6MM INTERLOCK FIBERED IDC OCCLUSION",SUP-M001363540,CDM,S27800098,LOCAL,0278,RC,,,both,,,2827.50,848.25,"NOVANET [10819]",Novanet,,2120.63,75,,,,,0,328.84,2403.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUBICON 135CM 5.1FR 2.84FR 50MM SPACE GUIDING NYLON",SUP-H74939240035131,CDM,C1887,HCPCS,0272,RC,,,both,,,1449.90,434.97,"PHCS [10601]",PHCS,,1014.93,70,,,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE DIAMONDBACK 360 VIPERWIRE ADVANCE VASCULAR 325CM .014",SUP-GWC-12325LG-FT,CDM,C1769,HCPCS,0272,RC,,,both,,,1579.50,473.85,"NOVANET [10819]",Novanet,,1184.63,75,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bcr/Abl1 Gene Major Bp",PX-309000003,CDM,81206,CPT,0310,RC,,,both,,,613.60,184.08,"BLUE CROSS [10001]","Blue Cross PPO",,209.48,,"Fee schedule rate ($209.48).",,,,0,0.01,582.04,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE IV FOR SCAPE",RX-411694,CDM,J2305,HCPCS,0636,RC,00338-1049-02,NDC,both,250,ML,203.85,61.15,"FIRST HEALTH [10303]","First Health",,163.08,80,,,,,0,17.37,173.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 76MM 10.8MM 6.4MM CUFF LOW PRESSURE FENESTRATE INNER",SUP-6FEN,CDM,S27200284,LOCAL,0272,RC,,,both,,,399.33,119.8,"CIGNA [10200]",Cigna,,271.54,68,,,,,0,46.44,339.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENCIL BIPOLAR 18GA STELLARIS PC CURVE VITREORETINAL 2 PIN",SUP-E7918,CDM,S27200284,LOCAL,0272,RC,,,both,,,835.35,250.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,568.04,68,,,,,0,97.15,710.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE ASPIRATION 19GA L80MM WORKING L1400MM CHANNEL 2.8MM R",SUP-NA-U200H-8019S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2173.50,652.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,997.64,45.9,,,,,0,252.78,1847.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG VALU-BAGS BUTT-FLAP 8MM UNIVERSAL U FRAME UROLOGY",SUP-CMS-999,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.10,21.03,"PHCS [10601]",PHCS,,49.07,70,,,,,0,8.15,59.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 9MM HIP DISTAL PMMA POS ANSWER IMPACT INTEGRAL",SUP-162656,CDM,C1713,HCPCS,0278,RC,,,both,,,1195.56,358.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,139.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",139.04,1016.23,"percent of total billed charges",
"STENT GORE VIABAHN 79MM 80CM 10MM 13MM 8FR .035IN",SUP-BXA107901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"NOVANET [10819]",Novanet,,16055.55,75,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC",543,MS-DRG,,,,,,,inpatient,,,27121.19,8136.36,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,6663.69,,"Case rate ($6,376.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,921.24, add-ons for qualifying new technology services are included. If operating cost exceeds $38,960.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,829.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $5,929.07. The transfer operating threshold is the transfer adjustment factor * $5,921.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.67. The transfer capital threshold is the transfer adjustment factor * $447.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",6891.45,6891.45,6891.45,"1 through 10",6376.74,25637.29,other,"IP DRG"
"PORT INFUSION ATTACHED 7.5FR SMART PORT CT",SUP-CT75STSA,CDM,C1788,HCPCS,0278,RC,,,both,,,2437.50,731.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,283.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKAGED RADIAL STEM 11MM X -2MM",SUP-ALN-RST-11M2,CDM,C1776,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"AETNA [10100]","Aetna HMO/PPO",,11305.62,79.5,,10981.53,8986.79,12413.38,12,1653.89,12087.77,"percent of total billed charges",
"HC Beta 2 Microglobulin",PX-301000112,CDM,82232,CPT,0301,RC,,,both,,,230.10,69.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14.56,,,,,,,0.01,195.59,"fee schedule",
"SIZER IMPL 12.3-12.1CM NATRELLE P5.3-5.9CM HIGH PROFILE",SUP-SZHP68425,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,207.06,68,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 12X2CM PRO3 THIN AMNIOTIC PLACENTAL MEMB",SUP-P01-AMP-0212,CDM,S27800098,LOCAL,0278,RC,,,both,,,12997.88,3899.36,"CIGNA [10200]",Cigna,,5199.15,40,,,,,0,1511.65,11048.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X14MM CLYDESDALE 6D PEEK CAGE INTERBODY",SUP-2968455,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6415.2,27,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 18MM 145CM 3.25MM CORONARY STENT",SUP-1145325-18,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"MULTIPLAN [10600]",Multiplan,,4962.3,85,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 46MM STARDRIVE STAINLESS STEEL T15 CORTEX",SUP-02.206.246,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"FIRST HEALTH [10303]","First Health",,259.19,80,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 10MM 120CM 6FR 2-10-2MM SPACING ELECTROPHYSIOLOGY 10",SUP-D1086784,CDM,C1730,HCPCS,0272,RC,,,both,,,2040.00,612,"UHC [10700]","United Healthcare",,1291.32,63.3,,,,,0,237.25,1734,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insert Cervical Dilator",PX-721000003,CDM,59200,CPT,0721,RC,,,both,,,1079.01,323.7,"PHCS [10601]",PHCS,,755.31,70,,,,,0,125.49,1079.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 12MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240120200,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"BLUE CROSS [10001]","Blue Cross PPO",,2672.34,39.2,,,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAA - AMPLATZ CARDIAC PLUG 2-IDE-018",SUP-9-ACP2-IDE-018,CDM,S62400003,LOCAL,0624,RC,,,both,,,63452.40,19035.72,"CIGNA [10200]","Cigna Local Plus",,33947.03,53.5,,,,,0,7379.51,53934.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 49MM CENTERPULSE LEGACY 12/14 TAPER HIP FEMUR",SUP-451000049,CDM,C1776,HCPCS,0278,RC,,,both,,,2398.65,719.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,284.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,278.96,2038.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VESSEL SEALER EXTENDER",SUP-480422,CDM,S27200284,LOCAL,0272,RC,,,both,,,4528.70,1358.61,"FIRST HEALTH [10303]","First Health",,3622.96,80,,,,,0,526.69,3849.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS SELECT 150CM 4MM 2.1FR .038-.044IN 45D 15MM",SUP-518-093,CDM,C1887,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 30X5IN SAFETY PRECUT FIBERGLASS",SUP-SS-5PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,95.08,28.52,"PHCS [10601]",PHCS,,66.56,70,,,,,0,11.06,80.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 12-12.5IN 2.75IN OSTOMY 2 PIECE SURFIT FLANGE",SUP-020933,CDM,S27000186,LOCAL,0270,RC,,,both,,,241.43,72.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,110.82,45.9,,,,,0,28.08,205.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 24MM LCP STAINLESS STEEL FULL THREAD CANCELLOUS",SUP-206.024,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"KAISER [10500]",Kaiser,,183.33,67,,,,,0,31.82,232.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MERIT LAUREATE VASCULAR .035IN ANGLE 80CM HYDROPHILIC",SUP-LWSTDA3580,CDM,C1769,HCPCS,0272,RC,,,both,,,261.00,78.3,"UHC [10700]","United Healthcare",,165.21,63.3,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 7MM TARGET 3D DETACHABLE CONSISTENT",SUP-M0036157150,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"MULTIPLAN [10600]",Multiplan,,11997.44,85,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 40MM 5MM BALLOON",SUP-U357554,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.818,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"BLUE CROSS [10001]","Blue Cross HMO",,92.76,39.2,,957.42,156.86,7483.26,51,27.52,201.14,"percent of total billed charges",
"CATH SUPER TORQUE 100CM 6FR .051IN .042IN INTERNAL MAMMARY",SUP-532660,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Filter Transfusion Blood",PX-E27200337,CDM,E27200337,LOCAL,0272,RC,,,both,,,52.80,15.84,"CIGNA [10200]","Cigna Open Access",,30.04,56.9,,,,,0,6.14,44.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 150CM 200MM 4MM BALLOON DILATATION PACLITAXEL",SUP-H74939419402010,CDM,C2623,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"FIRST HEALTH [10303]","First Health",,10764,80,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X18X10-17MM RISE-L 10D",SUP-193.335,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9826.68,28.62,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 15MM 2MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG20015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST TRICORTICAL THK24-26MM WEDGE",SUP-450915,CDM,S27800098,LOCAL,0278,RC,,,both,,,7828.74,2348.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,927.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,910.48,6654.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 24CM 6FR .038IN PIGTAIL CURVE",SUP-M006180222120,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,904.58,68,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 18MM OSTEOLOCK TITANIUM HIP ACETABULAR",SUP-5260-5-018,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"FIRST HEALTH [10303]","First Health",,609.12,80,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 96MM 12MM PRESS FIT REUNION SHOULDER",SUP-5567-P-3012,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Local Plus",,5433.75,31.5,,5372.07,4581.20,7242.98,23,2006.18,14662.5,"percent of total billed charges",
"PROBE NERVE STIM 23CM NIM BALL TIP",SUP-9450015,CDM,S27000186,LOCAL,0270,RC,,,both,,,899.10,269.73,"CIGNA [10200]","Cigna Local Plus",,481.02,53.5,,,,,0,104.57,764.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD MARLEX 4X1.8IN GROIN MONOFILAMENT GOLD",SUP-0112710,CDM,C1781,HCPCS,0278,RC,,,both,,,300.00,90,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,137.7,45.9,,,,,0,34.89,255,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 30MM CREO SPINE POLYAXIAL PREASSEMBLE",SUP-5119.1532,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SPINAL CERVICAL 4 LEVEL 74MM ACP 2.1H",SUP-18002474,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"BLADE LARYNGOSCOPE LOPRO 3 GLIDESCOPE",SUP-0270-0938,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"AETNA [10100]","Aetna HMO/PPO",,276.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET GWIRE 18CM 8FR .018IN 6.3FR TROCAR TIP NDL 21GA CURVE 15",SUP-G02906,CDM,C1769,HCPCS,0272,RC,,,both,,,864.76,259.43,"FIRST HEALTH [10303]","First Health",,691.81,80,,,,,0,100.57,735.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 14MM 1.75MM CLEARVIEW INTRACORONARY",SUP-31175,CDM,S27800098,LOCAL,0278,RC,,,both,,,632.53,189.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,290.33,45.9,,,,,0,73.56,537.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 12.5CM 4MM IBUR DISTAL BEND ROUND DIAMOND",SUP-8431-013-040DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,2737.50,821.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1125.11,41.1,,,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM AFFIX II BONE LUMBAR SPINE",SUP-7577045,CDM,S27800098,LOCAL,0278,RC,,,both,,,24141.60,7242.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9656.64,40,,,,,0,2807.67,20520.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC .75CM 13.7CU CM 4.45X5.02CM ESSENTIO",SUP-L101,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"CIGNA [10200]","Cigna Open Access",,13936,33.5,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE DEMINERALIZED BONE MATRIX 5CC",SUP-OCMP5,CDM,C1713,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"BLUE CROSS [10001]","Blue Cross HMO",,1323,39.2,,957.42,156.86,7483.26,51,392.51,2868.75,"percent of total billed charges",
"BEARING 71/75MMX16MM VANGUARD ARCOM KNEE POSTERIOR STABILIZE",SUP-183646,CDM,C1776,HCPCS,0278,RC,,,both,,,8259.30,2477.79,"AETNA [10100]","Aetna HMO/PPO",,6566.14,79.5,,10981.53,8986.79,12413.38,12,960.56,7020.41,"percent of total billed charges",
"HC Mra Pelvis W Cntrst",PX-610000021,CDM,72198,CPT,0610,RC,,,both,,,4406.00,1321.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,649.15,,,,,,,512.42,3745.1,"fee schedule",
"FORCEP BONE CUTTING 5 1/2IN LISTON",SUP-33-2014,CDM,S27200284,LOCAL,0272,RC,,,both,,,694.82,208.45,"NOVANET [10819]",Novanet,,521.12,75,,,,,0,80.81,590.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 15MMX12MMX6CM",SUP-TSB121506A,CDM,C1874,HCPCS,0278,RC,,,both,,,49140.00,14742,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5823.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5714.98,41769,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 13MM 12FR ENDOPROSTHESIS HEPARIN",SUP-VBH130502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18062.10,5418.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5169.37,28.62,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 15MM STAINLESS STEEL T6 CORTEX SELF TAP SELF",SUP-201.365.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,49.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,48.16,352,"percent of total billed charges",
"TRAY TIBIAL 75MM VANGUARD 360 KNEE POROUS REVISION SYSTEM",SUP-185204,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X22X14MM XL PEEK",SUP-6914260,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS [10001]","Blue Cross HMO",,9313.92,39.2,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 48MM TITANIUM CANNULATED",SUP-604648,CDM,C1713,HCPCS,0278,RC,,,both,,,1319.00,395.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,605.42,45.9,,,,,0,153.4,1121.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Incsn Toe Tendon Mult",PX-510000072,CDM,28011,CPT,0761,RC,,,both,,,8374.00,2512.2,"CIGNA [10200]",Cigna,,2606,,"Per diem ($2,606).",,,,0,973.9,8239,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 5-0 FS-2 18IN MONOFILAMENT PLIABILIZED",SUP-661G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 10MM KNEE LEFT E-PLUS EMPOWR 3D KNEE STERILE",SUP-341-10-706,CDM,C1776,HCPCS,0278,RC,,,both,,,12480.24,3744.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3571.84,28.62,,,,,0,1451.45,10608.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPICILLIN-SULBACTAM 1.5 G VIAL",RX-32470,CDM,J0295,HCPCS,0636,RC,71288-0031-91,NDC,both,1,UN,21.20,6.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1.62,,,,,,,1.56,18.02,"fee schedule",
"SCR BONE 3.5MM 13MM DVR TITANIUM CORTICAL ANATOMIC VOLAR",SUP-CS13000,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"BLUE CROSS [10001]","Blue Cross PPO",,428.65,39.2,,957.42,570.23,957.42,28,127.17,929.48,"percent of total billed charges",
"TIP SUCTION POOLE TUBE 6FT ABDOMINAL NONSTERILE",SUP-3505,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.84,20.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.77,56.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 2X1CM AXOGUARD HA+ NERVE PROTCT EXTRACELLULAR",SUP-AGHA12,CDM,C1763,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 24CM 13MM AZUR CX DETACHABLE SOFT SOLID",SUP-45-751324,CDM,S27800098,LOCAL,0278,RC,,,both,,,7672.80,2301.84,"FIRST HEALTH [10303]","First Health",,6138.24,80,,,,,0,892.35,6521.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Infect Agent Nos Ampl Probe",PX-306000147,CDM,87798,CPT,0306,RC,,,both,,,744.80,223.44,"CIGNA [10200]","Cigna Local Plus",,77.2,,,,,,,0.01,633.08,"fee schedule",
"CAGE SPINAL 36X24MM ENDOSKELETON TAS 12D 12MM LARGE TITANIUM",SUP-2312-0212,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Local Plus",,8930.25,31.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 8MM 140CM 2.75MM CORONARY STENT PLATINUM",SUP-H7493927408270,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"NOVANET [10819]",Novanet,,2812.5,75,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Npm1 Gene",PX-309000065,CDM,81310,CPT,0310,RC,,,both,,,1072.50,321.75,"BLUE CROSS [10001]","Blue Cross PPO",,314.95,,"Fee schedule rate ($314.95).",,,,0,0.01,911.63,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL REFLEX ULTRA TURBINATE PLASMA WAND",SUP-EICA4835-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,2166.38,649.91,"FIRST HEALTH [10303]","First Health",,1733.1,80,,,,,0,251.95,1841.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) CATH LITHOPLASTY 110CM 60MM 5MM .064IN ULTRASOUND PER",SUP-M732LPBC5060DX1,CDM,C1725,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SHEATH NAVIGATOR HD 46CM 12-14FR ACCESS STAINLESS STEEL",SUP-M0062502260,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET 8FR PIGTAIL CURVE VTC NEPHRSTMY FIRM DUROMETER LOCK",SUP-M001225140,CDM,C1729,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT ELECTROSURGICAL 50MM 17GA MULTICOOL RADIOFREQUENCY",SUP-MCKA2-17-50-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,9177.00,2753.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"30FR X 3CM OPTILUME DCB, 24FR X 3CM BASIC BALLOON AND INFLAT",SUP-OPTBDL7010B,CDM,C1726,HCPCS,0272,RC,,,both,,,16525.50,4957.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH POWERFLEX P3 135CM 2CM 5FR 7MM 7.5MM BALLOON DILATATION",SUP-4207020X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN RADIOFREQUENCY 5CM 22GA ACCURIAN CURVE SHARP 5MM",SUP-AC0015,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 2.4MM 3.5MM SCR ELLI",SUP-682.104,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 13.7CM NATRELLE BIOCELL P4.5CM MODERATE PLUS",SUP-MSZ15457,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYR INJECTION MEDRAD STELLANT FLEX 2 SPIKE 150ML",SUP-FLEXD-150-SPK,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.18,29.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR 5MM STORZ 2 STEM",SUP-M0068804211,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET INTRO CIAGLIA BLUE RHINO PERCUTANEOUS TRACH",SUP-C-PTIS-100-HC-G-PERC8,CDM,S27200284,LOCAL,0272,RC,,,both,,,2684.48,805.34,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,318.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,312.21,2281.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 30MM 109CM 6MM 75CM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200063070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"MULTIPLAN [10600]",Multiplan,,3519,85,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR STD JL2 CURVE GUIDING NYLON CORONARY",SUP-LA6JL20,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INLAY INTERVERTEBRAL DISC PRODISC-L 10MM MEDIUM SPINE",SUP-PDL-M-PT10S,CDM,C1889,HCPCS,0278,RC,,,both,,,10022.25,3006.67,"KAISER [10500]",Kaiser,,6714.91,67,,,,,0,1165.59,8518.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 80CM 40MM 7MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV07004008P,CDM,C1725,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"UHC [10700]","United Healthcare",,5110.21,63.3,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 3.1X2.4IN XENMATRIX AB RECTANGLE PORCINE",SUP-1150608,CDM,C1781,HCPCS,0278,RC,,,both,,,8599.47,2579.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5847.64,68,,,,,0,1000.12,7309.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135MM 40MM 6FR 5MM .018IN BALLOON DILATATION",SUP-H74939032504010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET SURGICAL 1235MM .016IN STERILE LATEX FREE DISPOSABLE",SUP-INS-5411,CDM,S27200284,LOCAL,0272,RC,,,both,,,733.05,219.91,"CIGNA [10200]",Cigna,,498.47,68,,,,,0,85.25,623.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL CUSHING 1.7MM BAYONET 7.75IN TISSUE 1X2 TEETH",SUP-130421,CDM,S27200284,LOCAL,0272,RC,,,both,,,303.72,91.12,"UHC [10700]","United Healthcare",,192.25,63.3,,,,,0,35.32,258.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +9MM 11/13 STD TAPER 32MM HIP MODULAR ULTAMET",SUP-875956,CDM,C1776,HCPCS,0278,RC,,,both,,,4754.10,1426.23,"PHCS [10601]",PHCS,,3327.87,70,,,,,0,552.9,4040.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 2MM LARGE 210MM VITALLIUM 2 CABLE GRIP DALL-MILES BONE",SUP-6704-3-093,CDM,C1713,HCPCS,0278,RC,,,both,,,10920.00,3276,"BLUE CROSS [10001]","Blue Cross PPO",,4280.64,39.2,,957.42,570.23,957.42,28,1270,9282,"percent of total billed charges",
"SYSTEM MULTI-LINK VISION 15MM 2.75MM CORONARY STENT COCR",SUP-1007847-15,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 3-0 PS-1 SPIRAL 45CM KNOTLESS",SUP-SXMP1B102,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,145.45,68,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PILOT 50 VASCULAR STRAIGHT 190CM 3CM .014IN",SUP-1010480-H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 10MM 2.25MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP22510X,CDM,C1725,HCPCS,0272,RC,,,both,,,534.60,160.38,"FIRST HEALTH [10303]","First Health",,427.68,80,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL CURVE SMALL SUTUREFIX 1.7MM STERILE LATEX",SUP-72204690,CDM,S27200284,LOCAL,0272,RC,,,both,,,1494.45,448.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,614.22,41.1,,,,,0,173.8,1270.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 14MM PRESS FIT REDUCE PROXIMAL PROFILE",SUP-192414,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6796.81,28.62,,,,,0,2761.95,20186.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT GII QUICKANCHOR PLUS ORTHOCORD SHOULDER WITHOUT",SUP-222983,CDM,C1713,HCPCS,0278,RC,,,both,,,6127.20,1838.16,"BLUE CROSS [10001]","Blue Cross PPO",,2401.86,39.2,,957.42,570.23,957.42,28,712.59,5208.12,"percent of total billed charges",
"PARTIAL HIP CONSTRUCT 2",SUP-CAP-SN-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6568.8,68,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOV BP BIOACTIVE GLASS W/ DBM PUTTY 5.0CC SYRINGE - STERILE",SUP-BGP001-05,CDM,C1713,HCPCS,0278,RC,,,both,,,4743.75,1423.12,"CIGNA [10200]",Cigna,,3225.75,68,,1831.33,1831.33,1831.33,16,551.7,4032.19,"percent of total billed charges",
"RELOAD STPLR UNIVERSAL 30X3.5MM ENDO GIA ROTICULATOR",SUP-030452,CDM,S27200284,LOCAL,0272,RC,,,both,,,1085.72,325.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,738.29,68,,,,,0,126.27,922.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 8-11 E-F",SUP-42-5121-008-11,CDM,C1776,HCPCS,0278,RC,,,both,,,9466.80,2840.04,"PHCS [10601]",PHCS,,6626.76,70,,,,,0,1100.99,8046.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP CAUT 5MM SPAT NONSTERILE LATEX FREE DISPOSABLE",SUP-400160,CDM,S27200284,LOCAL,0272,RC,,,both,,,6161.70,1848.51,"CIGNA [10200]","Cigna Open Access",,3506.01,56.9,,,,,0,716.61,5237.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLIER CLIP SUPER INTERLOCK PREMIUM SURGICLIP II 9.75IN RAD",SUP-134051,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 8MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158126108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"NOVANET [10819]",Novanet,,8380.91,75,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 20MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-96-2335,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"PHCS [10601]",PHCS,,10152.66,70,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 1.5IN 18GA 10% PVP IODINE 1% LIDOCAINE CSR",SUP-181058,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.54,41.86,"MULTIPLAN [10600]",Multiplan,,118.61,85,,,,,0,16.23,118.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM NAVITOR TRANSCATHETER SELF EXPAND INTRA",SUP-NVTR-27,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"BLUE CROSS [10001]","Blue Cross PPO",,53625.6,39.2,,,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 4CM 6MM BALLOON DILATATION",SUP-DR13564,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"FIRST HEALTH [10303]","First Health",,1101.6,80,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM SOLERA SPINAL CANNULATED MULTIAXIAL",SUP-54840017545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]",Cigna,,6491.86,68,,1831.33,1831.33,1831.33,16,1110.3,8114.82,"percent of total billed charges",
"STENT ORSIRO MISSION 35MM 140CM 3MM CORONARY STERILE LATEX",SUP-453970,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION 5.8FR 6MM 180CM 2CM RAPID EXCHANGE",SUP-M00545910,CDM,C1900,HCPCS,0278,RC,,,both,,,1849.50,554.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1257.66,68,,,,,0,215.1,1572.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 E-F 17MM KNEE FIX BEARING PROLONG NEXGEN",SUP-00596204017,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5384.54,68,,,,,0,920.91,6730.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT CRUCIATE RETAIN JOURNEY II",SUP-74021157,CDM,C1776,HCPCS,0278,RC,,,both,,,37771.65,11331.49,"BLUE CROSS [10001]","Blue Cross HMO",,14806.49,39.2,,5311.50,4717.44,5388.59,31,4392.84,32105.9,"percent of total billed charges",
"CATH TORCON NB ADVANTAGE BEACON 100CM 5FR MPA CURVE",SUP-G11205,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"UHC [10700]","United Healthcare",,150.33,63.3,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 150MM 3MM BALLOON DILATATION DURALYN",SUP-48003015S,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 15CM 6MM BALLOON DILATATION",SUP-DR135615,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,163.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 10MM2CM 190",SUP-R51010002L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"KAISER [10500]",Kaiser,,1367.81,67,,,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 10MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620410,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PHCS [10601]",PHCS,,7877.73,70,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 2 KNEE LEFT BICRUCIATE STABILIZE",SUP-74022222,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"CIGNA [10200]","Cigna Open Access",,5568.4,33.5,,5302.19,4377.88,6578.61,27,1933.15,14128.79,"percent of total billed charges",
"GWIRE ORTHOPEDIC 220MM 2.8MM",SUP-03.333.004,CDM,C1769,HCPCS,0272,RC,,,both,,,745.20,223.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,88.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.67,633.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE RIGHT MEDIAL LEFT LATERAL RESTORIS",SUP-180515,CDM,C1776,HCPCS,0278,RC,,,both,,,12440.70,3732.21,"CIGNA [10200]","Cigna Open Access",,4167.63,33.5,,5302.19,4377.88,6578.61,27,1446.85,10574.6,"percent of total billed charges",
"WEIGHT REHABILITATION SOFT GREEN THERABAND 4.5IN",SUP-929253,CDM,S27000186,LOCAL,0270,RC,,,both,,,152.25,45.67,"KAISER [10500]",Kaiser,,102.01,67,,,,,0,17.71,129.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 75MM 1.5MM J LATCH NONSTERILE",SUP-310.143,CDM,S27000186,LOCAL,0270,RC,,,both,,,503.50,151.05,"FIRST HEALTH [10303]","First Health",,402.8,80,,,,,0,58.56,427.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 32MM TRI-AD 2 ADAM TRICUSPID VALVE MODEL",SUP-900SFC232,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"NOVANET [10819]",Novanet,,9832.5,75,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH BLACK 150CM RESPONSE ELECTROPHYSIOLOGY HEXAPOLAR",SUP-401972R,CDM,C1769,HCPCS,0272,RC,,,both,,,287.10,86.13,"FIRST HEALTH [10303]","First Health",,229.68,80,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 NARROW KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-42-5000-064-01,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"KAISER [10500]",Kaiser,,15318.01,67,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.0MM X 18.0MM",SUP-493001812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ERAVACYCLINE DIHYDROCHLORIDE 50 MG/5ML IV (WET SOLR VIAL)",RX-415184423,CDM,J0122,HCPCS,0636,RC,71773-0050-05,NDC,both,1,UN,400.04,120.01,"NOVANET [10819]",Novanet,,300.03,75,,,,,0,47.4,340.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28X10X12MM CASCADIA CONVEX TITANIUM POROUS",SUP-6101-2102812NC-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6310.71,28.62,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 19MM 14.8MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-19MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"FIRST HEALTH [10303]","First Health",,23295.38,80,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS THK15MM ALLOGRAFT BLOCK FREEZE DRIED",SUP-400280,CDM,S27800098,LOCAL,0278,RC,,,both,,,6371.46,1911.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1823.51,28.62,,,,,0,741,5415.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INQUIRY 110CM 1MM 4FR 2-5-2MM SPACE MEDIUM CURVE",SUP-81531,CDM,C1730,HCPCS,0272,RC,,,both,,,3750.00,1125,"MULTIPLAN [10600]",Multiplan,,3187.5,85,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION HI-FLO 155CM 2.8-3FR .027IN MICRO INFUSION",SUP-M001195510,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SAPPHIRE 3 CORONARY DILATATION CATHETER 1.0 X 15MM",SUP-54100-150-02,CDM,C1725,HCPCS,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BIOPSY 60CM 7FR 18GA TLAB STRAIGHT CURVE METAL 4 SWAB",SUP-TL-18C,CDM,S27200284,LOCAL,0272,RC,,,both,,,3875.04,1162.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP LAPAROSCOPIC 6MM CADIERE DA VINCI SP",SUP-430009,CDM,S27000186,LOCAL,0270,RC,,,both,,,2063.40,619.02,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cpap Init & Mgmt",PX-410000009,CDM,94660,CPT,0410,RC,,,both,,,1029.95,308.98,"MULTIPLAN [10600]",Multiplan,,875.46,85,,,,,0,119.78,875.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 125CM 6FR .07IN JUDKINS RIGHT",SUP-SM7436,CDM,C1887,HCPCS,0272,RC,,,both,,,1310.50,393.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,155.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,152.41,1113.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 81CM 8FR .032IN SR0 CURVE TRANSSEPTAL SWARTZ",SUP-407404,CDM,C1893,HCPCS,0272,RC,,,both,,,1214.19,364.26,"FIRST HEALTH [10303]","First Health",,971.35,80,,,,,0,141.21,1032.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 75CM 60MM 4MM BALLOON DILATATION DRUG COATED",SUP-LX3575460V,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"UHC [10700]","United Healthcare",,4258.51,63.3,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 28CM 3CM 7FR .035IN PIGTAIL CURVE",SUP-M006180234180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA [10200]","Cigna Local Plus",,781.16,,,,,,,169.81,1241.09,"percent of total billed charges",
"SPACER SPINAL 50X18X12MM COROENT XL PEEK-OPTIMA TLIF",SUP-6912850,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"CIGNA [10200]","Cigna Local Plus",,7484.4,31.5,,16168.95,16168.95,16168.95,"1 through 10",2763.29,20196,"percent of total billed charges",
"INTRO LEAD 23CM 9FR OSCOR PEEL AWAY LUER LOCK KINK",SUP-6663,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"FIRST HEALTH [10303]","First Health",,421.2,80,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLOTRIMAZOLE 2 % VAGINAL CREAM",RX-33986,CDM,,,0250,RC,51672-2062-00,NDC,both,21,GR,66.71,20.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.76,56.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 170MM 2.4MM SCR LCP BONE WRIST STERILE",SUP-242.003S,CDM,C1713,HCPCS,0278,RC,,,both,,,17470.72,5241.22,"CIGNA [10200]","Cigna Open Access",,5852.69,33.5,,1144.80,304.56,2275.09,66,2031.84,14850.11,"percent of total billed charges",
"HC Myelography Lumb Inj >=2 Region Si",PX-361000374,CDM,62305,CPT,0361,RC,,,both,,,6762.75,2028.82,"CIGNA [10200]","Cigna Open Access",,4028,,"Case rate ($4,028). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,786.51,5748.34,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 STD 10MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS4S10R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"UHC [10700]","United Healthcare",,6577.76,63.3,,8601.07,8395.67,8601.07,"1 through 10",1208.52,8832.69,"percent of total billed charges",
"CATH ARCADIA 10MM 16MM BALLOON DILATATION 3CC 2 LUMEN",SUP-ARC10SB,CDM,S27200284,LOCAL,0272,RC,,,both,,,5978.16,1793.45,"MULTIPLAN [10600]",Multiplan,,5081.44,85,,,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 0 BP-1 27IN MONOFILAMENT ABSORBABLE",SUP-47T,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.13,36.94,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.32,104.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ELECTROSURGICAL 20MM BLUNT RIGID SHEATH BONESCALPEL",SUP-MXB-MIS-20LCRS,CDM,S27200284,LOCAL,0272,RC,,,both,,,4220.56,1266.17,"AETNA [10100]","Aetna HMO/PPO",,3355.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,490.85,3587.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIUM CREST ALLOGRAFT WEDGE 24-26MM",SUP-P00208,CDM,S27800098,LOCAL,0278,RC,,,both,,,6660.57,1998.17,"AETNA [10100]","Aetna HMO/PPO",,5295.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,774.62,5661.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER FLEXIVA ID 200UM FLEXSHIELD HIGH POWER NONTAPER",SUP-M006R8403911,CDM,S27200284,LOCAL,0272,RC,,,both,,,2720.04,816.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,322.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,316.34,2312.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS 80CM 4CM 9FR 20MM .035IN BALLOON DILATATION GOLD",SUP-ATG80204,CDM,C1725,HCPCS,0272,RC,,,both,,,4312.50,1293.75,"MULTIPLAN [10600]",Multiplan,,3665.63,85,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13175545,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",348.9,2550,"percent of total billed charges",
"HC Cann Eopa Blunt Nonvent 22f",PX-E27200343,CDM,E27200343,LOCAL,0272,RC,,,both,,,342.10,102.63,"CIGNA [10200]",Cigna,,232.63,68,,,,,0,39.79,290.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 STD KNEE RIGHT CRUCIATE RETAIN PERSONA PPS",SUP-42508605802,CDM,C1776,HCPCS,0278,RC,,,both,,,29326.50,8797.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3475.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3410.67,24927.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SKATER 40CM 8FR PIGTAIL CURVE DRNG BILIARY LOCK ACCEPTS",SUP-755308040,CDM,C1729,HCPCS,0272,RC,,,both,,,651.24,195.37,"FIRST HEALTH [10303]","First Health",,520.99,80,,,,,0,75.74,553.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 24MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-124,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC",499,MS-DRG,,,,,,,inpatient,,,138100.50,41430.15,"BLUE CROSS [10001]","Blue Cross HMO",,46253.34,,,,,,,7561,58824.1,"case rate",
"PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY",RX-11143,CDM,,,0250,RC,45802-0758-00,NDC,both,1,UN,66.93,20.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Xr Femur 2v>",PX-320000210,CDM,73552,CPT,0320,RC,,,both,,,756.51,226.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68.2,,,,,,,42.36,643.03,"fee schedule",
"STEM FEMORAL 165MM 17MM PRESS FIT REDUCE PROXIMAL PROFILE",SUP-192417,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"MULTIPLAN [10600]",Multiplan,,20186.21,85,,,,,0,2761.95,20186.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 155CM 12MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200124020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross HMO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 55MM TSRH OSTEOGRIP THINLINE SPINAL",SUP-83585559,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"NOVANET [10819]",Novanet,,7160.14,75,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 26CM 5FR URETERAL AQ FIRM POS NO GWIRE",SUP-G23398,CDM,C2617,HCPCS,0278,RC,,,both,,,535.41,160.62,"FIRST HEALTH [10303]","First Health",,428.33,80,,,,,0,62.27,455.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Emg 4 Ext",PX-922000004,CDM,95864,CPT,0922,RC,,,both,,,934.00,280.2,"CIGNA [10200]","Cigna Local Plus",,499.69,53.5,,,,,0,108.62,793.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SHEATH GUIDE KINK RESISTANT STOPPER BRUSH",SUP-K-401,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"KAISER [10500]",Kaiser,,1206,67,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 170MM 7MM REVERSE CEMENT AEQUALIS LONG SHOULDER",SUP-DWD931,CDM,C1776,HCPCS,0278,RC,,,both,,,16560.00,4968,"AETNA [10100]","Aetna HMO/PPO",,13165.2,79.5,,10981.53,8986.79,12413.38,12,1925.93,14076,"percent of total billed charges",
"PAROXETINE 10 MG TABLET, IMMEDIATE RELEASE",RX-16632,CDM,,,0637,RC,00904-5676-61,NDC,both,1,UN,14.16,4.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9.63,68,,,,,0,1.65,12.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL FLAT L HOOK 36CM CLEANCOAT COATED",SUP-E3774-36C,CDM,S27200284,LOCAL,0272,RC,,,both,,,251.00,75.3,"MULTIPLAN [10600]",Multiplan,,213.35,85,,,,,0,29.19,213.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BACLOFEN 5 MG/ML ORAL SUSPENSION",RX-408875,CDM,,,0637,RC,08888-8885-91,NDC,both,30,ML,233.23,69.97,"MULTIPLAN [10600]",Multiplan,,198.25,85,,,,,0,27.12,198.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL NDL 2MM STRAIGHT 2.75IN MIDAS TOUCH",SUP-30-1011,CDM,S27200284,LOCAL,0272,RC,,,both,,,169.56,50.87,"NOVANET [10819]",Novanet,,127.17,75,,,,,0,19.72,144.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 22MM 8MM STAINLESS STEEL LONG THREAD HAND",SUP-02.226.322,CDM,C1713,HCPCS,0278,RC,,,both,,,1647.00,494.1,"CIGNA [10200]","Cigna Local Plus",,881.15,53.5,,3978.14,359.25,3978.14,24,191.55,1399.95,"percent of total billed charges",
"COIL EMBOLIZATION 4CM 2MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-02004,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"BLUE CROSS [10001]","Blue Cross HMO",,4054.5,39.2,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 88MM RADIUS J 182X10.2X2.7MM STAINLESS STEEL 3.5MM SCR",SUP-245.934,CDM,C1713,HCPCS,0278,RC,,,both,,,4436.91,1331.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,525.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",516.01,3771.37,"percent of total billed charges",
"COIL EMBOLIZATION 4.5CM 2.5MM GALAXY G3 MINI FREEFORM",SUP-MCR092545,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"KAISER [10500]",Kaiser,,8861.32,67,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 5/32IN STEINMANN SHORT THREAD 1 END TROCAR",SUP-1616-18-000,CDM,C1713,HCPCS,0278,RC,,,both,,,139.20,41.76,"BLUE CROSS [10001]","Blue Cross HMO",,54.57,39.2,,957.42,156.86,7483.26,51,16.19,118.32,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR 3MM OLYMPUS OES PRO",SUP-M0068802641,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"FIRST HEALTH [10303]","First Health",,413.18,80,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 20MM 3MM BALLOON DILATATION DRUG COATED",SUP-H7493960820300,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4524.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 12MM COCR",SUP-VAL-20120-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]","Cigna Open Access",,811.17,56.9,,1144.80,304.56,2275.09,66,165.8,1211.76,"percent of total billed charges",
"CATH JADE 150CM 150MM 6MM BALLOON DILATATION HYDROPHILIC",SUP-586015022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 75CM LEFT VENTRICLE QUARTET",SUP-1458Q/75,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"AETNA [10100]","Aetna HMO/PPO",,4457.57,79.5,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC MEDI-THERM SMALL MEDIUM",SUP-8001061550,CDM,S27000186,LOCAL,0270,RC,,,both,,,1140.48,342.14,"CIGNA [10200]","Cigna Local Plus",,610.16,53.5,,,,,0,132.64,969.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAVER BLADES CURVED 40 DEG 4MM DOUBLE SERRATED CONCAVE STER",SUP-1600550-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,650.63,45.9,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC or IP Robotics 1st Hr",PX-360000012,CDM,9999164,LOCAL,0360,RC,,,both,,,17136.12,5140.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1992.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1992.93,14565.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION 155CM 2.4-3FR .021IN MICRO INFUSION NITINOL",SUP-M001195280,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"AMERIGROUP MEDICAID [20100]",Amerigroup,,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rem/Reins Impl Drug Deliv",PX-761000066,CDM,11983,CPT,0761,RC,,,both,,,4213.65,1264.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1731.81,41.1,,,,,0,490.05,3581.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INNATE IMPLANT 3.6MM X 55MM",SUP-EXINN923655,CDM,C1713,HCPCS,0278,RC,,,both,,,5002.50,1500.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1431.72,28.62,,,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Cannula Hemodialysis",PX-361000125,CDM,36800,CPT,0361,RC,,,both,,,4928.23,1478.47,"UHC [10700]","United Healthcare",,4928.23,,"Case rate ($9,679). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,573.15,4928.23,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Study Ext Artery > 2 Lvls Bi",PX-920000004,CDM,93923,CPT,0921,RC,,,both,,,1568.21,470.46,"AETNA [10100]","Aetna HMO/PPO",,1246.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,182.38,1332.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CILOSTAZOL 100 MG TABLET",RX-24474,CDM,,,0637,RC,50268-0177-11,NDC,both,1,UN,11.32,3.4,"KAISER [10500]",Kaiser,,7.58,67,,,,,0,1.32,9.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 7-0 CC 24IN 2 ARM MONOFILAMENT BLUE",SUP-8704H,CDM,S27200284,LOCAL,0272,RC,,,both,,,198.54,59.56,"AETNA [10100]","Aetna HMO/PPO",,157.84,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.09,168.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cors&Graft Angio W Lt Hrt Cath",PX-481000027,CDM,93459,CPT,0481,RC,,,both,,,20792.02,6237.61,"BLUE CROSS [10001]","Blue Cross PPO",,9637.57,,"Case rate ($9,637.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1566.32,17673.22,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 66-70MM 44MM XLPE",SUP-71331109,CDM,C1776,HCPCS,0278,RC,,,both,,,15193.80,4558.14,"BLUE CROSS [10001]","Blue Cross HMO",,5955.97,39.2,,5311.50,4717.44,5388.59,31,1767.04,12914.73,"percent of total billed charges",
"BINDER ABDOMINAL 10IN SMALL",SUP-U2-710,CDM,S27000186,LOCAL,0270,RC,,,both,,,174.00,52.2,"UHC [10700]","United Healthcare",,110.14,63.3,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 15MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962343,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"NOVANET [10819]",Novanet,,10877.85,75,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL CORTICAL THK3-12MM THIRDS ALLOGRAFT STRUT",SUP-450486,CDM,S27800098,LOCAL,0278,RC,,,both,,,5249.52,1574.86,"CIGNA [10200]",Cigna,,3569.67,68,,,,,0,610.52,4462.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAFCILLIN SODIUM 1 G/4ML IJ (WET SOLR VIAL)",RX-4155333,CDM,J2290,HCPCS,0636,RC,44567-0221-10,NDC,both,1,UN,99.66,29.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,84.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 30CM 150CM 7FR .035IN PIGTAIL CURVE",SUP-M006180235180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,417.88,28.62,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM AXSOS LOCK NONSTERILE",SUP-661040,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,373.7,28.62,,,,,0,151.86,1109.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0348,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,110.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",110.22,805.55,"percent of total billed charges",
"PLATE 14X5MM COALITION AGX BONE SPINE",SUP-1128.1205,CDM,C1713,HCPCS,0278,RC,,,both,,,12420.00,3726,"BLUE CROSS [10001]","Blue Cross PPO",,4868.64,39.2,,957.42,570.23,957.42,28,1444.45,10557,"percent of total billed charges",
"STY LD 58CM .016IN STRG FIRM",SUP-6066,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 2.5MM 3MM 1MM MICRON PORP EAR TITANIUM",SUP-70142028,CDM,S27000186,LOCAL,0270,RC,,,both,,,2235.00,670.5,"FIRST HEALTH [10303]","First Health",,1788,80,,,,,0,259.93,1899.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 22CM 6FR 2.1FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552310,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]","Cigna Open Access",,683.13,,,,,,,139.63,1020.49,"percent of total billed charges",
"HC Myelography Lumb Inj Cerv Si",PX-361000371,CDM,62302,CPT,0361,RC,,,both,,,4612.82,1383.85,"BLUE CROSS [10001]","Blue Cross PPO",,2740.57,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,536.47,4612.82,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 3CM 6FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175264010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"NOVANET [10819]",Novanet,,803.06,75,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Sclp/Ax/Tr/Ext >30.0cm Int",PX-450000036,CDM,12037,CPT,0450,RC,,,both,,,4523.00,1356.9,"UHC [10700]","United Healthcare",,2260,,"Per diem ($2,260).",,,,0,67.13,4523,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE NEEN EDUCATOR EXERCISE PELVIC FLOOR INDCTR SIMPLE",SUP-563972,CDM,S27000186,LOCAL,0270,RC,,,both,,,114.14,34.24,"CIGNA [10200]","Cigna Local Plus",,61.06,53.5,,,,,0,13.27,97.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM 40DEG BIPOLAR CONVEX SERRATED",SUP-BB4040XC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1434.01,430.2,"PHCS [10601]",PHCS,,1003.81,70,,,,,0,166.78,1218.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 100MM 3.8-3.4FR 4MM LOW",SUP-39147-40101,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 75MM 10MM PRESS FIT UNIVERSAL FLUTE KNEE",SUP-867410,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"CIGNA [10200]","Cigna Open Access",,4609.24,56.9,,5302.19,4377.88,6578.61,27,942.1,6885.51,"percent of total billed charges",
"BASEPLT TIBIAL PERSONA F KNEE RIGHT 2 PEG TIVANIUM STERILE",SUP-42530007502,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"MULTIPLAN [10600]",Multiplan,,12057.27,85,,,,,0,1649.72,12057.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 60MM KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-183104,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8666.28,40,,,,,0,2519.72,18415.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 30MM 7MM BALLOON DILATATION DURALYN",SUP-48007003X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"NOVANET [10819]",Novanet,,941.63,75,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS LAPAROSCOPIC 35CM 2 EDGE BLADE ROTATION DIAL",SUP-CB030,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"MULTIPLAN [10600]",Multiplan,,221.85,85,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LEVEL 1 VIP BONE SPINE CERVICAL ANTERIOR",SUP-171.115,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PHCS [10601]",PHCS,,2940,70,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC",868,MS-DRG,,,,,,,inpatient,,,32172.67,9651.8,"BLUE CROSS [10001]","Blue Cross HMO",,23670.75,,,,,,,6395.97,25714.6,"case rate",
"BASEPLT TIBIAL ATTUNE S+ 4 KNEE CEMENT FIX BEARING",SUP-150670004,CDM,C1776,HCPCS,0278,RC,,,both,,,15487.05,4646.11,"CIGNA [10200]","Cigna Local Plus",,4878.42,31.5,,5372.07,4581.20,7242.98,23,1801.14,13163.99,"percent of total billed charges",
"SCR BONE 3MM 18MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0306,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,112.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",110.22,805.55,"percent of total billed charges",
"ELECTRD DEFIB MULTIFUNCTION RADIOTRANSLUCENT LIQUID GEL",SUP-8900-4006,CDM,S27000186,LOCAL,0270,RC,,,both,,,443.56,133.07,"CIGNA [10200]",Cigna,,301.62,68,,,,,0,51.59,377.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UNI-FUSE FLOW-THRU HUB 90CM 2CM 5FR THROMBECTOMY",SUP-H787124018415,CDM,C1757,HCPCS,0272,RC,,,both,,,1417.50,425.25,"FIRST HEALTH [10303]","First Health",,1134,80,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 42MM 26MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-42-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,511.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL TRIATHLON B CONE KNEE RIGHT MEDIAL LEFT LATERAL",SUP-5549-A-222,CDM,C1776,HCPCS,0278,RC,,,both,,,23621.85,7086.55,"BLUE CROSS [10001]","Blue Cross PPO",,9259.77,39.2,,3949.44,3949.44,3949.44,"1 through 10",2747.22,20078.57,"percent of total billed charges",
"CATH APD 25CM 14FR DRNG FLEXIMA METAL HYDROPHILIC REGULAR",SUP-M001271370,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 150MM 3.8FR 2MM BALLOON DILATATION",SUP-39148-20151,CDM,C1725,HCPCS,0272,RC,,,both,,,1762.50,528.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1198.5,68,,,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 170MM 2.4MM SCR LCP BONE WRIST STERILE",SUP-242.003S,CDM,C1713,HCPCS,0278,RC,,,both,,,17470.72,5241.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2070.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2031.84,14850.11,"percent of total billed charges",
"LENS IOL +5.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.055,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]",Cigna,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206050410,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 5FR 4MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-04041,CDM,C1725,HCPCS,0272,RC,,,both,,,972.00,291.6,"UHC [10700]","United Healthcare",,615.28,63.3,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .018IN 5FR 6MM 120CM 10CM PTA OTW",SUP-435600L,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"KAISER [10500]",Kaiser,,841.19,67,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 9IN SPETZLER MALIS 2 IRRIGATE 1.5MM DISPOSABLE",SUP-6770-230-015,CDM,S27200284,LOCAL,0272,RC,,,both,,,3282.98,984.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,381.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,381.81,2790.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +20 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.200,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE ORTHOPEDIC 150MM 1MM CHARLOTTE METATARSOPHALANGEAL",SUP-44112000,CDM,C1713,HCPCS,0278,RC,,,both,,,191.40,57.42,"CIGNA [10200]","Cigna Local Plus",,102.4,53.5,,3978.14,359.25,3978.14,24,22.26,162.69,"percent of total billed charges",
"CATH LUBRI-SIL 20FR SHORT ROUND URETHRAL SILICONE HYDROGEL",SUP-73020L,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.78,26.93,"FIRST HEALTH [10303]","First Health",,71.82,80,,,,,0,10.44,76.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 119MM 14MM ESOPHAGEAL FULL COVER STERILE LATEX",SUP-M00517420,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"NOVANET [10819]",Novanet,,13702.5,75,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIFY ASSURA NEXT GENERATION CRT-D 40",SUP-CD3357-40C,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"MULTIPLAN [10600]",Multiplan,,49062,85,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM PUSHLOCK SHOULDER PEEK 24MM STERILE",SUP-AR-1922PS,CDM,C1713,HCPCS,0278,RC,,,both,,,2835.00,850.5,"KAISER [10500]",Kaiser,,1899.45,67,,,,,0,329.71,2409.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 20MM 144CM 2.5MM CORONARY STENT EVEROLIMUS",SUP-H7493926120250,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"UHC [10700]","United Healthcare",,5459.63,63.3,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Transducer Neonate",PX-E27000131,CDM,E27000131,LOCAL,0270,RC,,,both,,,94.60,28.38,"AETNA [10100]","Aetna HMO/PPO",,75.21,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11,80.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOGRAPHY 5FR L125CM ID0.047IN FL4 CURVE SOFT DIS",SUP-H749163912201,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.17,22.55,"NOVANET [10819]",Novanet,,56.38,75,,,,,0,8.74,63.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEXGEN LPS-FLEX FIXED PROLONG ART SUR EF 3-412MM",SUP-596203212,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,938.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,920.91,6730.67,"percent of total billed charges",
"PLATE 90MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE VARIABLE",SUP-02.107.202,CDM,C1713,HCPCS,0278,RC,,,both,,,5840.44,1752.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3971.5,68,,,,,0,679.24,4964.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 320107 TRICORT BLK 7MM SRVC FEE",SUP-320107,CDM,S27800098,LOCAL,0278,RC,,,both,,,3412.50,1023.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1566.34,45.9,,,,,0,396.87,2900.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR",RX-29858,CDM,,,0637,RC,60687-0390-11,NDC,both,1,UN,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 83MM REGENEREX KNEE PRIMARY CRUCIATE RETAIN",SUP-141276,CDM,C1776,HCPCS,0278,RC,,,both,,,11964.60,3589.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3230.44,27,,,,,0,1391.48,10169.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC VIVA CRT D QUAD S IS-4 DF1 US",SUP-DTBB1Q1,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,23088,40,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIMING GUIDE 2.4MM",SUP-PDG-AIM-24,CDM,S27000186,LOCAL,0270,RC,,,both,,,2392.50,717.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,278.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,278.25,2033.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 6IN CORONARY ARTERY OSTIAL ANTEGRADE SOFT",SUP-30050,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.85,74.35,"UHC [10700]","United Healthcare",,156.89,63.3,,,,,0,28.82,210.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA MEDIAL CONGRUENT 8-11 E-F",SUP-42512100810,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"MULTIPLAN [10600]",Multiplan,,9159.96,85,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE XL BREATHABLE SQUARE TOE OFFLOAD 11.6FT",SUP-VP50201-050,CDM,S27000186,LOCAL,0270,RC,,,both,,,126.15,37.84,"KAISER [10500]",Kaiser,,84.52,67,,,,,0,14.67,107.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS) SUGAR-FREE NO.20 ORAL",RX-172911,CDM,,,0250,RC,00574-0303-16,NDC,both,473,ML,139.83,41.95,"FIRST HEALTH [10303]","First Health",,111.86,80,,,,,0,16.26,118.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 150MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,589.25,41.1,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 7CM WIRE",SUP-49720,CDM,A4648,HCPCS,0278,RC,,,both,,,152.32,45.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.71,129.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DESARA SL SLING SYSTEM SHORT LENGTH STERILE SINGLE USE 5/BOX",SUP-CAL-DS01SL,CDM,C1771,HCPCS,0278,RC,,,both,,,7893.60,2368.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,918.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,918.03,6709.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENDOMAXX 90CM 150CM 23MM 24FR ESOPHAGEAL SILICONE",SUP-MAXX-2315,CDM,C1874,HCPCS,0278,RC,,,both,,,17640.00,5292,"CIGNA [10200]","Cigna Open Access",,5909.4,33.5,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 65MM STERILE",SUP-74013480,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.02,64.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.89,181.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502605802,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"MULTIPLAN [10600]",Multiplan,,19433.3,85,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP CORTICAL CANCELLOUS 20CC 2-4MM ALLOGRAFT",SUP-12710001,CDM,C1713,HCPCS,0278,RC,,,both,,,18160.38,5448.11,"UHC [10700]","United Healthcare",,11495.52,63.3,,5023.51,2672.93,6679.78,18,2112.05,15436.32,"percent of total billed charges",
"CAGE SPINAL 34X24X8MM MODULUS 15D ALIF STERILE LATEX FREE",SUP-1921006P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA [10200]","Cigna Local Plus",,10914.75,31.5,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR XB4 CURVE GUIDING CORONARY SIDEHOLE",SUP-LA8EBU40SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,266.22,68,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"550CC MENTOR CPX4 SILTEX WITH SUTURE TABS TISSUE EXPANDER ME",SUP-354-9214,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1083.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 14.5MM EXCLUDER GORE CONTRALATERAL",SUP-PLC141200,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"CIGNA [10200]","Cigna Open Access",,9379.06,33.5,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL CANNULATED 3.7MM X 80MM",SUP-DRLL-CDC-37080,CDM,S27000186,LOCAL,0270,RC,,,both,,,1905.00,571.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,874.4,45.9,,,,,0,221.55,1619.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Creatine Kinase Total",PX-301000163,CDM,82550,CPT,0301,RC,,,both,,,171.23,51.37,"CIGNA [10200]",Cigna,,14.32,,,,,,,0.17,145.55,"fee schedule",
"ZIDOVUDINE 10 MG/ML ORAL SYRUP",RX-11693,CDM,,,0250,RC,08888-8883-21,NDC,both,10,ML,14.78,4.43,"CIGNA [10200]",Cigna,,10.05,68,,,,,0,1.72,12.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THREADED CAP",SUP-32500-000,CDM,S27800098,LOCAL,0278,RC,,,both,,,2406.60,721.98,"CIGNA [10200]",Cigna,,1636.49,68,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Potassium POC",PX-301000364,CDM,84132,CPT,0301,RC,,,both,,,122.67,36.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.12,.1,,,,,0,0.12,104.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA F KNEE LEFT NONPOROUS REVISION FIXATION",SUP-42542007501,CDM,C1776,HCPCS,0278,RC,,,both,,,16335.06,4900.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1935.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1899.77,13884.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM ARTISAN MRI",SUP-SC-8416-50,CDM,C1778,HCPCS,0278,RC,,,both,,,30240.00,9072,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8654.69,28.62,,,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC XL 24IN 22-26IN KNEE LOOP LOCK CLSR",SUP-79-80038,CDM,S27000186,LOCAL,0270,RC,,,both,,,117.10,35.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,79.63,68,,,,,0,13.62,99.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ERAVACYCLINE DIHYDROCHLORIDE 50 MG/5ML IV (WET SOLR VIAL)",RX-415184423,CDM,J0122,HCPCS,0636,RC,71773-0050-05,NDC,both,1,UN,400.04,120.01,"FIRST HEALTH [10303]","First Health",,320.03,80,,,,,0,47.4,340.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Upr Ext W Cntrst",PX-359000002,CDM,73201,CPT,0352,RC,,,both,,,2120.25,636.07,"MULTIPLAN [10600]",Multiplan,,1802.21,85,,,,,0,246.59,1933,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insitu Hybrid Fish Additional",PX-312000066,CDM,88364,CPT,0312,RC,,,both,,,1473.00,441.9,"KAISER [10500]",Kaiser,,986.91,67,,,,,0,0.01,1252.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Test Car Seat/Bed 60 Min",PX-920000005,CDM,94780,CPT,0920,RC,,,both,,,300.64,90.19,"PHCS [10601]",PHCS,,210.45,70,,,,,0,34.96,255.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Test Car Seat/Bed 60 Min",PX-920000005,CDM,94780,CPT,0920,RC,,,both,,,300.64,90.19,"CIGNA [10200]","Cigna Open Access",,171.06,56.9,,,,,0,34.96,255.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Test Car Seat/Bed 60 Min",PX-920000005,CDM,94780,CPT,0920,RC,,,both,,,300.64,90.19,"AETNA [10100]","Aetna HMO/PPO",,239.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.96,255.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Smoke/Tobacco Asymp >10",PX-510000213,CDM,99407,CPT,0942,RC,,,both,,,85.00,25.5,"MULTIPLAN [10600]",Multiplan,,72.25,85,,,,,0,9.89,85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINACLOTIDE 72 MCG CAPSULE",RX-177659,CDM,,,0637,RC,00456-1203-30,NDC,both,1,UN,85.88,25.76,"CIGNA [10200]","Cigna Local Plus",,45.95,53.5,,,,,0,9.99,73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Levetiracetam",PX-301000075,CDM,80177,CPT,0301,RC,,,both,,,314.93,94.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.18,,"Fee schedule rate ($14.18). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,267.69,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC KAHOOK 2 BLADE DISPOSABLE",SUP-KDB,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1525.84,41.1,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOUND 20FR URETHRAL CURVE VAN BUREN 10.75IN",SUP-51-6320,CDM,S27200284,LOCAL,0272,RC,,,both,,,320.33,96.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.25,272.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 500MM 6MM EVEREST CONTOUR TITANIUM 2 HEXAGONAL",SUP-2901-B660500,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"LOOP 7.7MM 5.2MM MEDIUM OVAL 7IN FLEXIBLE MATTE MIRROR SATIN",SUP-AU5611,CDM,S27200284,LOCAL,0272,RC,,,both,,,402.03,120.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,46.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.76,341.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BIOLOGICAL 3.5X3CM OASIS PORCINE SMALL INTESTINE",SUP-8213-1000-33,CDM,Q4102,HCPCS,0636,RC,,,both,,,894.24,268.27,"NOVANET [10819]",Novanet,,670.68,75,,,,,0,31.95,760.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 16 X 13 X 07MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-161307-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"550CC MENTOR CPX4 SILTEX WITH SUTURE TABS TISSUE EXPANDER ME",SUP-354-9214,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"AETNA [10100]","Aetna HMO/PPO",,7268.29,79.5,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH ADULT 40CM 15.5FR DURATHANE DURAFLOW EMBOSAFE BASIC",SUP-H787103012055,CDM,C1750,HCPCS,0278,RC,,,both,,,1104.50,331.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,130.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,128.45,938.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CERTUS XT LK ABLATION PROBE 15",SUP-LK15XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,14524.50,4357.35,"CIGNA [10200]","Cigna Local Plus",,7770.61,53.5,,,,,0,1689.2,12345.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX21MM FRA 8D NARROW WEDGE SPINE",SUP-10021,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"PHCS [10601]",PHCS,,13230,70,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TEMPO TEMPORARY PACING LEAD",SUP-T1106,CDM,S27200284,LOCAL,0272,RC,,,both,,,3112.50,933.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,368.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Excsn Lesn Tr/Ext 2.1-3.0cm",PX-510000029,CDM,11403,CPT,0761,RC,,,both,,,4138.00,1241.4,"CIGNA [10200]","Cigna Local Plus",,2051,,"Per diem ($2,051).",,,,0,481.25,3517.3,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH TOOL LARGE NONSTERILE",SUP-359.212,CDM,S27200284,LOCAL,0272,RC,,,both,,,7113.21,2133.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,842.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,827.27,6046.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 16 X 13 X 07MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-161307-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1777.3,28.62,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENDOMAXX 90CM 150CM 23MM 24FR ESOPHAGEAL SILICONE",SUP-MAXX-2315,CDM,C1874,HCPCS,0278,RC,,,both,,,17640.00,5292,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5048.57,28.62,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Presumpt ID Ea Isol Urine",PX-306000064,CDM,87088,CPT,0306,RC,,,both,,,17.00,5.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7.28,,,,,,,0.01,17,"fee schedule",
"CATH 130CM 7FR THROMBECTOMY XTORQ TIP",SUP-LITNG7XTORQ130,CDM,C1757,HCPCS,0272,RC,,,both,,,34587.00,10376.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4098.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4022.47,29398.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ENDOSCOPIC LANCET BLADE ROUND HANDLE STAINLESS STEEL",SUP-130916,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.63,31.09,"FIRST HEALTH [10303]","First Health",,82.9,80,,,,,0,12.05,88.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mthfr Gene",PX-309000051,CDM,81291,CPT,0310,RC,,,both,,,1599.80,479.94,"PHCS [10601]",PHCS,,1119.86,70,,,,,0,0.01,1359.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 7IN MOLT 2 END SHARP/SHARP",SUP-DO543R,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.53,83.86,"CIGNA [10200]","Cigna Open Access",,159.05,56.9,,,,,0,32.51,237.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 138MM 13MM PRIMARY PRESSFIT TRABECULAR METAL",SUP-00786401300,CDM,C1776,HCPCS,0278,RC,,,both,,,30164.40,9049.32,"NOVANET [10819]",Novanet,,22623.3,75,,,,,0,3508.12,25639.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEIGHT REHABILITATION SOFT GREEN THERABAND 4.5IN",SUP-929253,CDM,S27000186,LOCAL,0270,RC,,,both,,,152.25,45.67,"CIGNA [10200]","Cigna Local Plus",,81.45,53.5,,,,,0,17.71,129.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO LARGE STYLET SURESIGHT",SUP-321900030,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.00,26.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.290 CLAREON",SUP-SY60WF.290,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Yttrium 90 Ibritumomab Mci",PX-344000005,CDM,A9543,HCPCS,0344,RC,,,both,,,29229.00,8768.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,29229,,,,,,,3399.33,29229,"fee schedule",
"HC Hla Typing a/B/C Sngl Ag",PX-302000177,CDM,86812,CPT,0302,RC,,,both,,,630.42,189.13,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23.23,,,,,,,17.48,535.86,"fee schedule",
"HC Potassium POC",PX-301000364,CDM,84132,CPT,0301,RC,,,both,,,122.67,36.8,"CIGNA [10200]",Cigna,,10.47,,,,,,,0.12,104.27,"fee schedule",
"TROCAR LAPAROSCOPIC 150MM 12MM ENDOPATH XCEL BLADELESS",SUP-B12XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1082.48,324.74,"FIRST HEALTH [10303]","First Health",,865.98,80,,,,,0,125.89,920.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 6MM 6FR ENDOPROSTHESIS HEPARIN",SUP-VBJR060502A,CDM,C1874,HCPCS,0278,RC,,,both,,,19895.40,5968.62,"PHCS [10601]",PHCS,,13926.78,70,,,,,0,2313.84,16911.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14X12.4CM MEMORYSHAPE P5.9CM MODERATE PLUS",SUP-RSZ1407S,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.55,69.16,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 38MM 144CM 4MM",SUP-H7493941238400,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2221.63,28.62,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X7MM 7D LORDOTIC TRAPEZOID SPINE",SUP-7407,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 5MM KII FIOS FIRST ENTRY ADVANCED",SUP-CFF01,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"CIGNA [10200]","Cigna Local Plus",,76.8,53.5,,,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X20X10MM PIVOX 6D LATERAL OLIF25",SUP-2111255,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3135.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 5 % AND 0.45 % NACL IV BOLUS",RX-400295,CDM,,,0258,RC,00338-0085-04,NDC,both,1000,ML,100.65,30.19,"AETNA [10100]","Aetna HMO/PPO",,80.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Cvp Cath Triple",PX-E27200241,CDM,C1751,HCPCS,0272,RC,,,both,,,599.50,179.85,"NOVANET [10819]",Novanet,,449.63,75,,,,,0,69.72,509.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUTURING 10MM 0 ES-9 48IN 1 STITCH LOADING UNIT BRAID",SUP-170056,CDM,S27200284,LOCAL,0272,RC,,,both,,,1010.52,303.16,"PHCS [10601]",PHCS,,707.36,70,,,,,0,117.52,858.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Ish Ea Mult",PX-312000083,CDM,0850T,CPT,0312,RC,,,both,,,104.00,31.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,47.74,45.9,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Ish Ea Mult",PX-312000083,CDM,0850T,CPT,0312,RC,,,both,,,104.00,31.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,70.72,68,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.7MM 2-0 3/8 CIRCLE MINI FULL THREAD TAPER",SUP-AR-1319FT,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"BLUE CROSS [10001]","Blue Cross PPO",,879.8,39.2,,957.42,570.23,957.42,28,261.02,1907.72,"percent of total billed charges",
"INTRO SHEATH 10.5FR .138IN 25CM ROBUST VALVE SPLITTABLE",SUP-PLSX-2510.5,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 6-9 E-F KNEE RIGHT TIBIA",SUP-42521400712,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,956.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,939.21,6864.4,"percent of total billed charges",
"STENT VIABAHN 5CM 120CM 13MM 12FR ENDOPROSTHESIS HEPARIN",SUP-VBH130502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18062.10,5418.63,"CIGNA [10200]","Cigna Local Plus",,5689.56,31.5,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla I Typing Complete Hr",PX-309000088,CDM,81379,CPT,0310,RC,,,both,,,670.76,201.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,192.65,,"Fee schedule rate ($192.65). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.67,670.76,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 22.5 % IN WATER(IV)",RX-410565,CDM,,,0258,RC,08888-8879-96,NDC,both,250,ML,100.65,30.19,"CIGNA [10200]",Cigna,,68.44,68,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK",RX-11359,CDM,,,0250,RC,12870-0001-01,NDC,both,1,UN,12.54,3.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR AL.75 CURVE GUIDING NYLON CORONARY",SUP-LA8AL75SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 40MM 130CM 9MM LONG VASCULAR NITINOL ILIAC",SUP-SC940LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]","Cigna Local Plus",,3876.08,53.5,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5F X 30CM TEARAWAY INTRODUCER",SUP-INT-106-31,CDM,C1894,HCPCS,0272,RC,,,both,,,216.49,64.95,"FIRST HEALTH [10303]","First Health",,173.19,80,,,,,0,25.18,184.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 6MMX15MM 7FR 80CMCATH HEPARIN",SUP-BXB061501A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 13X12.1CM NATRELLE BIOCELL P6.1CM MODERATE HEGHT",SUP-MX-410410,CDM,C1789,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3800.52,45.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOTRACHEAL 10MM 4MM VIVASIGHT 2 LUMEN NONSTERILE LATEX",SUP-412351000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"CIGNA [10200]","Cigna Local Plus",,1043.25,53.5,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEWIRE VASCULAR L60CM 0.018IN TAPER L7.25CM FLOPPY TIP L7",SUP-G08427,CDM,C1769,HCPCS,0272,RC,,,both,,,368.71,110.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.88,313.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA [10200]",Cigna,,6334.2,68,,,,,0,1083.33,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE WATCHMAN FXD CURVE 15FR 12FR CLSR 2 CURVE ACCESS",SUP-M635TU80010,CDM,C1894,HCPCS,0272,RC,,,both,,,6900.00,2070,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4692,68,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE MINI-MONSTER FULL THREAD L38 MM OD4 MM SOLID BLUN",SUP-P20-440-038F,CDM,C1713,HCPCS,0278,RC,,,both,,,1269.68,380.9,"NOVANET [10819]",Novanet,,952.26,75,,,,,0,952.26,952.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINACLOTIDE 72 MCG CAPSULE",RX-177659,CDM,,,0637,RC,00456-1203-30,NDC,both,1,UN,85.88,25.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.99,73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 8MM 140CM 2.25MM",SUP-RSINT22508UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1586.69,28.62,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 8X4IN RESORBABLE REINFORCE",SUP-F10254-0408G,CDM,C1781,HCPCS,0278,RC,,,both,,,1968.00,590.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,563.24,28.62,,,,,0,228.88,1672.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS THK15MM ALLOGRAFT BLOCK FREEZE DRIED",SUP-400280,CDM,S27800098,LOCAL,0278,RC,,,both,,,6371.46,1911.44,"MULTIPLAN [10600]",Multiplan,,5415.74,85,,,,,0,741,5415.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit Level 3 W Proc",PX-450000316,CDM,99283,CPT,0450,RC,,,both,,,1619.02,485.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,694.48,,,,,,,279.7,1619.02,"case rate",
"HC Influenza Virus 1st 2 Types",PX-306000184,CDM,87502,CPT,0306,RC,,,both,,,567.50,170.25,"AETNA [10100]","Aetna HMO/PPO",,451.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,482.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET",RX-9285,CDM,,,0637,RC,00904-7205-46,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL LEGION 6 KNEE LEFT JOURNEY LOCK",SUP-71933572,CDM,C1776,HCPCS,0278,RC,,,both,,,25949.70,7784.91,"PHCS [10601]",PHCS,,18164.79,70,,,,,0,3017.95,22057.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC",750,MS-DRG,,,,,,,inpatient,,,54616.21,16384.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13311.72,,"Fee schedule rate ($13,311.72). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,7561,43087.46,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR BLADDER PROCEDURES WITH CC",654,MS-DRG,,,,,,,inpatient,,,155565.33,46669.6,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,17885.15,,"Case rate ($17,364.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $16,123.86, add-ons for qualifying new technology services are included. If operating cost exceeds $49,163.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,601.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $16,145.19. The transfer operating threshold is the transfer adjustment factor * $16,123.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,219.04. The transfer capital threshold is the transfer adjustment factor * $1,219.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,81728.36,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 5X4IN DURAGEN PLUS CRANIAL DURA BOVINE",SUP-DP1045,CDM,,,0278,RC,,,both,,,6737.85,2021.35,"BLUE CROSS [10001]","Blue Cross HMO",,6.74,.1,,,,,0,6.74,5727.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 8.2MM 2.9MM 65MM STAINLESS STEEL FULL THREAD",SUP-209.665,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,162.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,159.84,1168.25,"percent of total billed charges",
"PLATE STD 68MM STAINLESS STEEL 2.4MM SCR 7 HOLE HEAD 4 HOLE",SUP-02.111.740S,CDM,C1713,HCPCS,0278,RC,,,both,,,4450.50,1335.15,"MULTIPLAN [10600]",Multiplan,,3782.93,85,,,,,0,517.59,3782.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 2-0 CT-2 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z333H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"CIGNA [10200]","Cigna Open Access",,15.36,56.9,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.35IN 18FR HEYMAN PLASTIC DILATION CATH",SUP-021118,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.15,65.14,"CIGNA [10200]","Cigna Local Plus",,116.18,53.5,,,,,0,25.25,184.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Tissue Neck/Thorax",PX-360000051,CDM,21550,CPT,0360,RC,,,both,,,4427.78,1328.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,524.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,514.95,4427.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 8MM CONCERTO DETACHABLE",SUP-NV-8-30-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 3X2IN 2 VELOUR KNITTED WOVEN",SUP-M002000195240,CDM,C1768,HCPCS,0278,RC,,,both,,,1147.37,344.21,"FIRST HEALTH [10303]","First Health",,917.9,80,,,,,0,133.44,975.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 35MM FLEXIBLE REFLECTION STERILE LATEX FREE",SUP-71362935,CDM,S27200284,LOCAL,0272,RC,,,both,,,1538.19,461.46,"CIGNA [10200]","Cigna Open Access",,875.23,56.9,,,,,0,178.89,1307.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER CORD CLAMP UMBILICAL SERRATE",SUP-53-2312,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.97,33.59,"PHCS [10601]",PHCS,,78.38,70,,,,,0,13.02,95.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 32MM HEMASHIELD PLATINUM STRAIGHT TUBE",SUP-M00202175432P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3797.28,1139.18,"MULTIPLAN [10600]",Multiplan,,3227.69,85,,,,,0,441.62,3227.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 445CC P5.5CM MODERATE PLUS PROJECTION TALL",SUP-334-1309,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross HMO",,3583.86,39.2,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALCON SURGICAL STANDARD EYE PACK",SUP-AS2277-19,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.14,30.34,"KAISER [10500]",Kaiser,,67.76,67,,,,,0,11.76,85.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 150MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,169.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enzyme Act Nonrad a-Galacto",PX-301000681,CDM,82657,CPT,0301,RC,,,both,,,820.00,246,"PHCS [10601]",PHCS,,574,70,,,,,0,0.82,697,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.245,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross HMO",,635.04,39.2,,957.42,156.86,7483.26,51,188.41,1377,"percent of total billed charges",
"KIT CIRCUIT 1.5MR EVAQUA 2 4L/MIN 2 LIMB 2 HEAT SYSTEM",SUP-RT265,CDM,S27000186,LOCAL,0270,RC,,,both,,,324.51,97.35,"FIRST HEALTH [10303]","First Health",,259.61,80,,,,,0,37.74,275.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Resection",PX-750000175,CDM,45390,CPT,0750,RC,,,both,,,4291.85,1287.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,499.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,499.14,4291.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH DURAL 3X3IN CLLGN MATRIX DURAMATRIX-ONLAY RESORBABLE",SUP-CDSLM33,CDM,,,0278,RC,,,both,,,6550.03,1965.01,"PHCS [10601]",PHCS,,4585.02,70,,,,,0,6.55,5567.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORQR 65CM 5FR 2-5-2MM SPACING CORONARY SINUS CURVE",SUP-041565CS,CDM,C1730,HCPCS,0272,RC,,,both,,,2250.00,675,"NOVANET [10819]",Novanet,,1687.5,75,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON KPA20 CATHETER 20MM UNIPEDICULAR",SUP-KPA20,CDM,S27200284,LOCAL,0272,RC,,,both,,,20790.00,6237,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2463.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Hip Uni 1v",PX-320000075,CDM,73501,CPT,0320,RC,,,both,,,496.99,149.1,"CIGNA [10200]",Cigna,,52.67,,,,,,,37.66,422.44,"fee schedule",
"HC Respriratory Motion Mgmt Sim",PX-333000056,CDM,77293,CPT,0333,RC,,,both,,,1917.13,575.14,"CIGNA [10200]","Cigna Open Access",,1090.85,56.9,,,,,0,222.96,1917.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9% SOLUTION",SUP-798353,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.68,14.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19.6,41.1,,,,,0,5.55,40.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 20MM MODULAR RESTORATION STRAIGHT CONICAL",SUP-6276-7-120,CDM,C1776,HCPCS,0278,RC,,,both,,,11080.37,3324.11,"FIRST HEALTH [10303]","First Health",,8864.3,80,,,,,0,1288.65,9418.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER ETHIBOND 2-0 MO-7 18IN CONTROL RELEASE BRAID 8",SUP-CX42D,CDM,S27200284,LOCAL,0272,RC,,,both,,,148.17,44.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.23,125.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 20GA 18GA DESIGN OPTIONS CONTINUOUS CATH NDL",SUP-555551,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUETIAPINE 25 MG TABLET, IMMEDIATE RELEASE",RX-21823,CDM,,,0637,RC,00904-6638-61,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION TIGHTROPE ACL RIGHT DELIVERY",SUP-AR-1588RTS,CDM,C1713,HCPCS,0278,RC,,,both,,,3543.75,1063.12,"CIGNA [10200]","Cigna Local Plus",,1895.91,53.5,,3978.14,359.25,3978.14,24,412.14,3012.19,"percent of total billed charges",
"STENT OMNILINK ELITE 19MM 135CM 6MM THIN VASCULAR COCR",SUP-1012629-19,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5712,68,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP BASEPLT TIBIAL ATTUNE CEMENT ROTATE PLATFORM",SUP-OSC372206,CDM,C1776,HCPCS,0278,RC,,,both,,,20790.00,6237,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5950.1,28.62,,,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 6.75IN STRAIGHT 2.5MM LEMPERT SLENDER SURGICAL",SUP-30-7620,CDM,S27200284,LOCAL,0272,RC,,,both,,,769.99,231,"CIGNA [10200]","Cigna Open Access",,438.12,56.9,,,,,0,89.55,654.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 34CM 10MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181034,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"NOVANET [10819]",Novanet,,13948.2,75,,,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG PETROLATUM 3YDX4IN XEROFORM 3% BISMUTH TRIBROMOPHENATE",SUP-SWD432000,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.73,34.12,"UHC [10700]","United Healthcare",,71.99,63.3,,,,,0,13.23,96.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Blastomyces Ab",PX-302000099,CDM,86612,CPT,0302,RC,,,both,,,191.90,57.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,20.29,,,,,,,0.01,163.12,"fee schedule",
"PLATE 116MM STAINLESS STEEL 2.7/3.5MM SCR 4 HOLE TAPER TIP",SUP-02.107.304S,CDM,C1713,HCPCS,0278,RC,,,both,,,6595.85,1978.75,"FIRST HEALTH [10303]","First Health",,5276.68,80,,,,,0,767.1,5606.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN 125 MG CAPSULE",RX-11628,CDM,,,0637,RC,23155-0858-78,NDC,both,1,UN,15.39,4.62,"NOVANET [10819]",Novanet,,11.54,75,,,,,0,1.79,13.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL PERCUFLEX PLUS HYDROPLUS",SUP-M006175198080,CDM,C2617,HCPCS,0278,RC,,,both,,,1205.77,361.73,"NOVANET [10819]",Novanet,,904.33,75,,,,,0,140.23,1024.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 100MM 150CM 8MM VASCULAR NICKEL",SUP-EVD35-08-100-150,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"PHCS [10601]",PHCS,,5071.5,70,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 4 X 10 COMPLEX PICO COIL",SUP-10USC04010,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"CIGNA [10200]","Cigna Local Plus",,4118.78,31.5,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD EMG NEUROVISION M5 15MM NDL MODULE PROBE",SUP-8050015,CDM,S27200284,LOCAL,0272,RC,,,both,,,6210.00,1863,"CIGNA [10200]",Cigna,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE COALITION AGX BONE 16X8MM SPINE",SUP-1128.1408,CDM,C1713,HCPCS,0278,RC,,,both,,,18000.00,5400,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2093.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",2093.4,15300,"percent of total billed charges",
"HC Colonoscopy W Submuc Inj",PX-750000090,CDM,45381,CPT,0750,RC,,,both,,,2559.50,767.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,297.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,297.67,2559.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC PULSED LAVAGE 14MM VERSAJET II 45D EXACT SET NARROWER",SUP-66800041,CDM,S27200284,LOCAL,0272,RC,,,both,,,4278.00,1283.4,"PHCS [10601]",PHCS,,2994.6,70,,,,,0,497.53,3636.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2MM 16MM SMOOTH LOCKING DVR NONSTERILE ANATOMIC",SUP-P16000,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"MULTIPLAN [10600]",Multiplan,,929.48,85,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SILVERSOAKER ON-Q PAINBUSTER 10IN 8IN DRUG DELIVERY",SUP-PM040-A,CDM,S27200305,LOCAL,0272,RC,,,both,,,1108.86,332.66,"KAISER [10500]",Kaiser,,742.94,67,,,,,0,128.96,942.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIGTR ORTHOPEDIC 25YDX2IN COTTON BLACK",SUP-551191,CDM,S27000186,LOCAL,0270,RC,,,both,,,184.70,55.41,"CIGNA [10200]",Cigna,,125.6,68,,,,,0,21.48,157,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thyroid Stimulating Hormone",PX-301000610,CDM,84443,CPT,0301,RC,,,both,,,243.43,73.03,"CIGNA [10200]","Cigna Local Plus",,36.96,,,,,,,0.24,206.92,"fee schedule",
"CATH INTROCAN SAFETY 2.5IN 20GA STRAIGHT IV POLYURETHANE",SUP-4251621-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,55.42,16.63,"PHCS [10601]",PHCS,,38.79,70,,,,,0,6.45,47.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Feeding Ng Levine",PX-E27200224,CDM,E27200224,LOCAL,0272,RC,,,both,,,52.32,15.7,"AETNA [10100]","Aetna HMO/PPO",,41.59,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.08,44.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bone Marrow Smear Interp",PX-305000014,CDM,85097,CPT,0305,RC,,,both,,,988.00,296.4,"AETNA [10100]","Aetna HMO/PPO",,785.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.21,839.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Assay of Haloperidol",PX-301000697,CDM,80173,CPT,0301,RC,,,both,,,70.00,21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.07,.1,,,,,0,0.07,59.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD HEMOSTATIC POLYPROLATE HYDROPHILIC TOPICAL NONWOVEN",SUP-MVP44,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.40,83.52,"KAISER [10500]",Kaiser,,186.53,67,,,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 10CM 27MM 21.5-25MM EXCLUDER",SUP-PLC271000,CDM,C1874,HCPCS,0278,RC,,,both,,,27997.20,8399.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8012.8,28.62,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,inpatient,,,34412.37,10323.71,"CIGNA [10200]","Cigna Local Plus",,9240.66,,"Fee schedule rate ($9,240.66). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,5554.84,22332.87,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 19GA 15CM 9CM ADJUSTABLE COAXIAL TEMNO",SUP-ACT2015,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 52CM .016IN BRADY FIRM",SUP-6584,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SPINAL 5MM SPINEJACK",SUP-0909-000-050,CDM,C1062,HCPCS,0278,RC,,,both,,,24560.17,7368.05,"PHCS [10601]",PHCS,,17192.12,70,,,,,0,2856.35,20876.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 38MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ338,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"BLUE CROSS [10001]","Blue Cross HMO",,377.1,39.2,,5311.50,4717.44,5388.59,31,111.88,817.7,"percent of total billed charges",
"CATH SABERX 150CM 150MM 5MM BALLOON DILATATION RAPID",SUP-47550150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Breast Local Dev Mammo",PX-361000312,CDM,19281,CPT,0361,RC,,,both,,,1681.32,504.4,"CIGNA [10200]","Cigna Local Plus",,1681.32,,"Case rate ($1,965). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,195.54,1681.32,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 12MM 144CM 4MM CORONARY STENT",SUP-H7493911412400,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"AETNA [10100]","Aetna HMO/PPO",,7268.29,79.5,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL CO2 O2 PEDIATRIC SIDESTREAM",SUP-8000-0357,CDM,S27000186,LOCAL,0270,RC,,,both,,,111.29,33.39,"AETNA [10100]","Aetna HMO/PPO",,88.48,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.94,94.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 133MM 15MM PRESSFIT REUNION SHOULDER STERILE",SUP-5569-P-2015,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UHC [10700]","United Healthcare",,7975.8,63.3,,8601.07,8395.67,8601.07,"1 through 10",1465.38,10710,"percent of total billed charges",
"FRAME RTRCTR CHARNLEY INITIAL INCISION",SUP-24-2000F,CDM,S27000186,LOCAL,0270,RC,,,both,,,747.39,224.22,"CIGNA [10200]","Cigna Local Plus",,399.85,53.5,,,,,0,86.92,635.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 108MM ALTIVATE DJO SURGICAL 12 STD SHOULDER",SUP-530-12-108,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"KAISER [10500]",Kaiser,,8442,67,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ERCP TAPER CONTOUR 210CM 5FR BILIARY DISPOSABLE ACCEPTS",SUP-M00530860,CDM,S27200284,LOCAL,0272,RC,,,both,,,407.60,122.28,"CIGNA [10200]","Cigna Local Plus",,218.07,53.5,,,,,0,47.4,346.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14IN 21FR 3/8IN ANGLE TIP VENT CNCT SUT BULB",SUP-5761,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"CIGNA [10200]","Cigna Open Access",,319.4,56.9,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RIFAXIMIN 200 MG TABLET",RX-39063,CDM,,,0637,RC,65649-0301-03,NDC,both,1,UN,53.98,16.19,"CIGNA [10200]","Cigna Open Access",,30.71,56.9,,,,,0,6.28,45.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND MICROPOINT 6-0 TG140-8 18IN MONOFILAMENT",SUP-1732G,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.53,41.26,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,56.52,41.1,,,,,0,15.99,116.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 10.5FR .138IN 25CM ROBUST VALVE SPLITTABLE",SUP-PLS-2510.5,CDM,C1894,HCPCS,0272,RC,,,both,,,319.73,95.92,"NOVANET [10819]",Novanet,,239.8,75,,,,,0,37.18,271.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 5-0 P-1 18IN MONOFILAMENT UNDYED",SUP-Y490G,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.59,20.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,28.6,41.1,,,,,0,8.09,59.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 12IN 4 PANEL HOOK LOOP CLSR 46-62IN MEDIUM",SUP-13652067,CDM,S27000186,LOCAL,0270,RC,,,both,,,88.65,26.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,36.44,41.1,,,,,0,10.31,75.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 20MM 2.5MM .014IN BALLOON DILATATION",SUP-AB14W035150150,CDM,C1725,HCPCS,0272,RC,,,both,,,1577.48,473.24,"PHCS [10601]",PHCS,,1104.24,70,,,,,0,183.46,1340.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 11CM 6MM AVENIR 10 COIL COMPLEX FINISH",SUP-10CFN06011,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3355.15,28.62,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM HYPOCHLORITE 0.125 % SOLUTION",RX-76720,CDM,,,0250,RC,00436-0672-16,NDC,both,473,ML,86.28,25.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,35.46,41.1,,,,,0,10.03,73.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CALCANEUS THK13-15MM ALLOGRAFT FREEZE DRIED CROSS",SUP-400482,CDM,S27800098,LOCAL,0278,RC,,,both,,,4765.14,1429.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,554.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,554.19,4050.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC",320,MS-DRG,,,,,,,inpatient,,,93056.58,27916.97,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mra Pelvis W Cntrst",PX-610000021,CDM,72198,CPT,0610,RC,,,both,,,4406.00,1321.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($936.32). Procedures 2 - 999, Per diem ($468.16).",,,,0,,,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 7/8IN BLADE 15FT 3/8IN PLUMEPEN",SUP-PLPUL2520,CDM,S27200284,LOCAL,0272,RC,,,both,,,277.08,83.12,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP MANIP 6.7MM RUMI II UTERUS ARTICULATE LOCK HANDLE SOFT",SUP-UMG670,CDM,S27200284,LOCAL,0272,RC,,,both,,,602.62,180.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HNDPC BREAST BIOPSY 13CM 9GA 3.7MM EVIVA 20MM SITE LOCALIZER","SUP-EVIVA 0913-20",CDM,S27200284,LOCAL,0272,RC,,,both,,,2000.63,600.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE SUCTION BRONCHOSCOPE STERILE DISPOSABLE",SUP-MAJ-209,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.71,29.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 8MM COCR",SUP-VAL-25080-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,168.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,165.8,1211.76,"percent of total billed charges",
"CLAMP SURGICAL CRYOFLEX 8IN PROBE 60CM1",SUP-60CM1,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11781,68,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 3MM 20MM DCP STAINLESS STEEL MIDDLE PROXIMAL",SUP-200.820,CDM,C1713,HCPCS,0278,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross PPO",,143.24,39.2,,957.42,570.23,957.42,28,42.5,310.59,"percent of total billed charges",
"COIL EMBOLIZATION 40CM 12MM INTERLOCK FIBERED IDC DETACHABLE",SUP-M001363630,CDM,S27800098,LOCAL,0278,RC,,,both,,,5181.90,1554.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1483.06,28.62,,,,,0,602.65,4404.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 95MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355095,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"HC Egd Flex Trnsoral Ablate",PX-750000135,CDM,43270,CPT,0750,RC,,,both,,,3449.38,1034.81,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,401.16,3449.38,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Spinal Punct Lum Dx W/Fluor/CT",PX-320000231,CDM,62328,CPT,0320,RC,,,both,,,2987.01,896.1,"MULTIPLAN [10600]",Multiplan,,2538.96,85,,,,,0,347.39,2740.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,inpatient,,,111735.95,33520.78,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,13801.56,,"Case rate ($12,898.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,977.27, add-ons for qualifying new technology services are included. If operating cost exceeds $45,016.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,287.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $11,993.10. The transfer operating threshold is the transfer adjustment factor * $11,977.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.54. The transfer capital threshold is the transfer adjustment factor * $905.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,60710.16,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAVER BLADES STRAIGHT SHAFT 4MM DOUBLE SERRATED STERILE",SUP-1600540-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"MULTIPLAN [10600]",Multiplan,,1204.88,85,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 6-0 P-3 18IN MONOFILAMENT GREEN NONABSORBABLE",SUP-G696G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"MULTIPLAN [10600]",Multiplan,,21.25,85,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 38MM FREEMAN AREOLA BREAST BIOPSY STAINLESS STEEL",SUP-P464,CDM,S27200284,LOCAL,0272,RC,,,both,,,532.33,159.7,"FIRST HEALTH [10303]","First Health",,425.86,80,,,,,0,61.91,452.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE TIGRIS 80MM 120CM 5MM VASCULAR CBAS NITINOL",SUP-PHA050802A,CDM,C1874,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1199.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Av Grft W Pta Central",PX-361000440,CDM,36907,CPT,0361,RC,,,both,,,23508.64,7052.59,"AETNA [10100]","Aetna HMO/PPO",,18689.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1249,21224.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 1/8IN 1/8IN BARD SILICONE 4 FREE FLOW CHANNEL",SUP-072187,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.45,37.03,"KAISER [10500]",Kaiser,,82.71,67,,,,,0,14.36,104.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBEROS 2CC",SUP-FB020,CDM,C1713,HCPCS,0278,RC,,,both,,,2400.00,720,"CIGNA [10200]","Cigna Local Plus",,1284,53.5,,3978.14,359.25,3978.14,24,279.12,2040,"percent of total billed charges",
"BURR SURGICAL 45MM 1.2MM CARBIDE TAPERED SIDE CUTTING",SUP-1607002105,CDM,S27000186,LOCAL,0270,RC,,,both,,,93.87,28.16,"CIGNA [10200]","Cigna Local Plus",,50.22,53.5,,,,,0,10.92,79.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 40MM 18MM X-CORE 2 0D TITANIUM 18MM",SUP-6184000,CDM,C1713,HCPCS,0278,RC,,,both,,,8257.92,2477.38,"CIGNA [10200]","Cigna Open Access",,4698.76,56.9,,1144.80,304.56,2275.09,66,960.4,7019.23,"percent of total billed charges",
"CATH INFINITI THRULUMEN 100CM 4FR .042IN JUDKINS RIGHT",SUP-538423,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK VITRECTOMY ACCURUS TOTAL PLUS PROBE 2500",SUP-8065741017,CDM,S27200284,LOCAL,0272,RC,,,both,,,2134.13,640.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1451.21,68,,,,,0,248.2,1814.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW CANC PART THRD 4X60MM",SUP-207.06,CDM,S27800098,LOCAL,0278,RC,,,both,,,105.97,31.79,"NOVANET [10819]",Novanet,,79.48,75,,,,,0,12.32,90.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Power Module Combo Vad, Rep",PX-E27400026,CDM,Q0479,HCPCS,0274,RC,,,both,,,35830.15,10749.04,"CIGNA [10200]",Cigna,,14332.06,40,,,,,0,4167.05,30455.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ot Eval High Complex 60 Min",PX-430000037,CDM,97167,CPT,0434,RC,,,both,,,531.81,159.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,426,,"Per diem ($426).",,,,0,61.85,452.04,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rho D Immune Globulin Inj",PX-636000010,CDM,J2790,HCPCS,0636,RC,,,both,,,566.04,169.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,94.62,,"Fee schedule rate ($94.62). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.6,481.13,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHOTREXATE SODIUM 2.5 MG TABLET",RX-4973,CDM,J8610,HCPCS,0637,RC,00054-8550-25,NDC,both,1,UN,17.93,5.38,"AETNA [10100]","Aetna HMO/PPO",,14.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.4,15.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION",RX-5007,CDM,J0616,HCPCS,0636,RC,00143-9873-01,NDC,both,5,ML,24.43,7.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1.15,,,,,,,0.7,20.77,"fee schedule",
"HC Mra Neck WO Cntrst",PX-610000009,CDM,70547,CPT,0615,RC,,,both,,,3270.27,981.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1248,,,,,,,380.33,2816,"per diem",
"HC Assess Aphasia per Hr",PX-740000026,CDM,96105,CPT,0444,RC,,,both,,,1113.00,333.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,129.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,129.44,946.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Onc Lung Mrna Quan Pcr 11&3",PX-310000011,CDM,0288U,CPT,0310,RC,,,both,,,18282.00,5484.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6092.23,,,,,,,2166.42,15539.7,"fee schedule",
"HC Pet Myocardial Metabolic Eval",PX-404000008,CDM,78459,CPT,0404,RC,,,both,,,6429.00,1928.7,"MULTIPLAN [10600]",Multiplan,,5464.65,85,,,,,0,6.43,5464.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENTETATE INDIUM DISODIUM IN-111 INTRATHECAL SOLUTION (1-1.5 MCI)",RX-411849,CDM,A9548,HCPCS,0343,RC,08888-8877-99,NDC,both,1,UN,13114.64,3934.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1525.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1525.23,11147.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mycobacteria TB Dna Ampl Prob",PX-306000140,CDM,87556,CPT,0306,RC,,,both,,,990.85,297.25,"CIGNA [10200]",Cigna,,91.7,,,,,,,0.01,842.22,"fee schedule",
"HC Tavi/Tavr Bypass W Centl Art",PX-361000351,CDM,33369,CPT,0361,RC,,,both,,,45298.00,13589.4,"BLUE CROSS [10001]","Blue Cross HMO",,8667.44,,"Case rate ($8,667.44). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2491,38503.3,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION",RX-88011,CDM,Q2009,HCPCS,0636,RC,00069-5471-01,NDC,both,2,ML,27.69,8.31,"CIGNA [10200]","Cigna Local Plus",,14.81,53.5,,,,,0,3.28,23.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH VASCULAR 8X.8CM TAPER BOVINE PERICARDIAL",SUP-DP08X8,CDM,C1768,HCPCS,0278,RC,,,both,,,1310.50,393.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,601.52,45.9,,,,,0,152.41,1113.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anes Spec Proc Fee Mac",PX-E27200003,CDM,E27200003,LOCAL,0272,RC,,,both,,,1819.33,545.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,211.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,211.59,1546.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ecmo/Ecls Rem Cann Prc 6+",PX-481000121,CDM,33966,CPT,0481,RC,,,both,,,2783.00,834.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,329.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,323.66,2783,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 44MM AXSOS 3 TITANIUM FULL THREAD CANCELLOUS",SUP-607344,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",50.59,369.75,"percent of total billed charges",
"HC Plt Pheresis Lr Ea Unit",PX-390000010,CDM,P9035,HCPCS,0390,RC,,,both,,,3987.10,1196.13,"PHCS [10601]",PHCS,,2790.97,70,,,,,0,463.7,3389.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION",RX-9681,CDM,J0770,HCPCS,0636,RC,42023-0131-01,NDC,both,1,UN,226.52,67.96,"CIGNA [10200]","Cigna Open Access",,32.49,,,,,,,14.19,192.54,"fee schedule",
"HC Block Cmplx",PX-333000019,CDM,77334,CPT,0333,RC,,,both,,,2389.62,716.89,"PHCS [10601]",PHCS,,1672.73,70,,,,,0,277.91,2389.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esoph Imped Func Test>1hr",PX-750000152,CDM,91038,CPT,0750,RC,,,both,,,7093.00,2127.9,"FIRST HEALTH [10303]","First Health",,5674.4,80,,,,,0,824.92,6029.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEIGHT EYELID THK1MM ROUND SPHERE TAPER GOLD CONTOUR 18.8X5",SUP-LL3016,CDM,L8699,HCPCS,0278,RC,,,both,,,2662.50,798.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,315.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,309.65,2263.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Acetaminophen",PX-301000672,CDM,80143,CPT,0301,RC,,,both,,,283.10,84.93,"CIGNA [10200]","Cigna Open Access",,41.01,,,,,,,0.01,240.64,"fee schedule",
"HC Comp Ep Eval Tx Svt",PX-481000093,CDM,93653,CPT,0481,RC,,,both,,,32036.13,9610.84,"PHCS [10601]",PHCS,,22425.29,70,,,,,0,3725.8,27504,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transcath Intraop Microinf",PX-361000641,CDM,C9759,HCPCS,0361,RC,,,both,,,5464.00,1639.2,"AETNA [10100]","Aetna HMO/PPO",,4343.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,635.46,4644.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Inframlr W Pta Sf Init",PX-361000737,CDM,37296,CPT,0361,RC,,,both,,,19230.05,5769.01,"CIGNA [10200]","Cigna Open Access",,6428,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,19.23,16345.54,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC App Rigid Leg Cast",PX-510000074,CDM,29445,CPT,0761,RC,,,both,,,3729.02,1118.71,"CIGNA [10200]","Cigna Local Plus",,2051,,"Per diem ($2,051).",,,,0,433.69,3169.67,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grft a/T/L Add 25scm",PX-510000051,CDM,15272,CPT,0761,RC,,,both,,,344.00,103.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.01,344,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drsg Wound Gel Tegaderm 25gm",PX-E27200127,CDM,E27200127,LOCAL,0272,RC,,,both,,,100.10,30.03,"KAISER [10500]",Kaiser,,67.07,67,,,,,0,11.64,85.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.0MM X 22.0MM",SUP-493002212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM TSRH-3D TITANIUM POSTERIOR PEDICLE",SUP-837-650,CDM,C1713,HCPCS,0278,RC,,,both,,,2361.60,708.48,"CIGNA [10200]","Cigna Local Plus",,1263.46,53.5,,3978.14,359.25,3978.14,24,274.65,2007.36,"percent of total billed charges",
"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC",829,MS-DRG,,,,,,,inpatient,,,127470.32,38241.1,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,20189.72,,"Case rate ($19,601.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $18,201.48, add-ons for qualifying new technology services are included. If operating cost exceeds $51,241.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,758.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $18,225.55. The transfer operating threshold is the transfer adjustment factor * $18,201.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,376.12. The transfer capital threshold is the transfer adjustment factor * $1,376.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,10994,92259.36,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 67MM STAINLESS STEEL 3.5MM SCREWS 3X5 HOLES T RIGHT",SUP-241.15,CDM,C1713,HCPCS,0278,RC,,,both,,,2627.25,788.17,"KAISER [10500]",Kaiser,,1760.26,67,,,,,0,305.55,2233.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23MMX8MM ELEVATE XLORDOTIC PEEK TITANIUM",SUP-8880823,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"CIGNA [10200]","Cigna Open Access",,9648,33.5,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE COMPRESSION SMALL KNEE LENGTH KENDALL SCD SEQUENTIAL",SUP-74021,CDM,S27000186,LOCAL,0270,RC,,,both,,,228.58,68.57,"CIGNA [10200]",Cigna,,155.43,68,,,,,0,26.58,194.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Culture Bronchial",PX-306000035,CDM,87070,CPT,0306,RC,,,both,,,462.65,138.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.05,,"Fee schedule rate ($9.05). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,393.25,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR SMALL WING NAIL SURGICAL NONSTERILE LATEX FREE",SUP-2153-0001,CDM,S27200284,LOCAL,0272,RC,,,both,,,3157.50,947.25,"KAISER [10500]",Kaiser,,2115.53,67,,,,,0,367.22,2683.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM TRIDENT II LOW PROFILE HEXAGONAL STERILE",SUP-7030-6525,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,217.91,28.62,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bld Gases W Calc O2 Sat POC",PX-301000198,CDM,82803,CPT,0301,RC,,,both,,,331.94,99.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,23.22,,"Fee schedule rate ($23.22).",,,,0,13.11,282.15,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 75X12X.8MM LONG STAINLESS STEEL RECIPROCATING 2",SUP-0277096325,CDM,S27200284,LOCAL,0272,RC,,,both,,,303.46,91.04,"CIGNA [10200]","Cigna Local Plus",,162.35,53.5,,,,,0,35.29,257.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21.5 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150U215,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross HMO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUILD-A-BOOT (BARIATRIC SIZE)",SUP-BAB09B,CDM,S27000186,LOCAL,0270,RC,,,both,,,326.25,97.87,"CIGNA [10200]","Cigna Open Access",,185.64,56.9,,,,,0,37.94,277.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 40MM 3.5MM BALLOON DILATATION PEBAX",SUP-H74939032350410,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRD SURGICAL GRAFT",SUP-AR-19007GS,CDM,S27200284,LOCAL,0272,RC,,,both,,,2953.13,885.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2008.13,68,,,,,0,343.45,2510.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPS DIRECT« UPSIZED, STRAIGHT (OC-STR) 54CM-DS2C025",SUP-DS2C025,CDM,C1893,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"AETNA [10100]","Aetna HMO/PPO",,2989.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 FS-2 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8665G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 80MM 8MM 9FR FLUENCY PLUS CARBON EPTFE 2",SUP-FEM08080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM TSRH OSTEOGRIP TITANIUM SHORT POST SPINE",SUP-83565451,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"CIGNA [10200]","Cigna Open Access",,1464.61,56.9,,1144.80,304.56,2275.09,66,299.36,2187.9,"percent of total billed charges",
"TRAY CATHETERIZATION SURESTEP LUBRI-SIL IC COMPLETE CARE",SUP-A303416A,CDM,S27200284,LOCAL,0272,RC,,,both,,,190.70,57.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,78.38,41.1,,,,,0,22.18,162.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 7FR 24CM WITHOUT GWIRE PERCUFLEX PLUS",SUP-M0061755720,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS [10001]","Blue Cross PPO",,353.65,39.2,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC BLUE 76MM THREADED OBTR SEAL CLEAR-TRAC",SUP-014719,CDM,S27200284,LOCAL,0272,RC,,,both,,,215.33,64.6,"UHC [10700]","United Healthcare",,136.3,63.3,,,,,0,25.04,183.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL L HOOK 32CM 5MM UNIVERSAL PLUS",SUP-60-5272-132,CDM,S27200284,LOCAL,0272,RC,,,both,,,176.52,52.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.53,150.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5D MODIFIED C MENISCUS 13MM 6MM POSTERIOR CHMBR",SUP-MN60MA,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE NDL DUAL READY TO USE INDIVIDUALLY STERILE DISPOSABLE",SUP-UA1329-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"CIGNA [10200]","Cigna Open Access",,89.11,56.9,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL ULTRAPRO 11X6CM PARTIAL ABSORBABLE LIGHTWEIGHT",SUP-UMS3,CDM,C1781,HCPCS,0278,RC,,,both,,,826.66,248,"BLUE CROSS [10001]","Blue Cross HMO",,324.05,39.2,,,,,0,96.14,702.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins/Rep Card Sys Atrial",PX-480000084,CDM,0410T,CPT,0480,RC,,,both,,,17015.00,5104.5,"NOVANET [10819]",Novanet,,12761.25,75,,,,,0,1978.84,14462.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 18GA 1.25MM ACCUCATH ACE DOT",SUP-AC1181252,CDM,S27200284,LOCAL,0272,RC,,,both,,,323.03,96.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,37.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.57,274.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 135CM 2CM 5FR 10MM 7.5MM BALLOON",SUP-4200020X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTROLYTE POTASSIUM CHLORIDE/NACL 0.9% 20MEQ/L 1000ML IV",SUP-2B1764X,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"MULTIPLAN [10600]",Multiplan,,68.85,85,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 6MM ENDOWRIST SP NONSTERILE LATEX FREE REUSABLE",SUP-430006,CDM,S27000186,LOCAL,0270,RC,,,both,,,2324.70,697.41,"FIRST HEALTH [10303]","First Health",,1859.76,80,,,,,0,270.36,1976,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW .5IN SIGMA STRYKER LATEX FREE",SUP-562711500,CDM,S27200284,LOCAL,0272,RC,,,both,,,446.16,133.85,"CIGNA [10200]","Cigna Open Access",,253.87,56.9,,,,,0,51.89,379.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT RICKHAM 100MM 2O PRECISION NO CATH PROGRAMMABLE",SUP-NS0568,CDM,S27800098,LOCAL,0278,RC,,,both,,,15669.90,4700.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1856.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1822.41,13319.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM ATS SPINE MULTIAXIAL 4.75MM ROD",SUP-54840046535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"NOVANET [10819]",Novanet,,7160.14,75,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR ANGLE MULTIPURPOSE B CURVE",SUP-H787107349015,CDM,C1887,HCPCS,0272,RC,,,both,,,236.64,70.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,27.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS SELECT 150CM 4MM 3.2FR .052-.059IN 45D 15MM",SUP-518-087,CDM,C1887,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OPTISEAL SIDEPORT  13 CM 6F",SUP-346978,CDM,C1893,HCPCS,0272,RC,,,both,,,486.00,145.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,330.48,68,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 30MM 4.5MM .014IN LOW PROFILE",SUP-1008191-30,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"MULTIPLAN [10600]",Multiplan,,1204.88,85,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +12.5 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150125,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,158.36,45.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH 160MM 2.5MM LONG HANDLE AORTIC",SUP-APU525,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"NOVANET [10819]",Novanet,,217.48,75,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 20CM 11.5FR FULL SILICONE HEMO-CATH SAFETY SCPL",SUP-MCDLTSL20,CDM,C1750,HCPCS,0278,RC,,,both,,,988.20,296.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,117.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SAFETYSPLINT 30X4IN CASTING FIBERGLASS CUSTOM FIT",SUP-SS-430PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,76.67,23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.92,65.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -4 40MM HIP BIOLOX DELTA FMP STERILE LATEX FREE",SUP-400-03-401,CDM,C1776,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Open Access",,2355.66,56.9,,5302.19,4377.88,6578.61,27,481.48,3519,"percent of total billed charges",
"SHELL/LINER BIPOLAR 43MM 28MM TANDEM HIP COCR UHMWPE",SUP-71322043,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"CIGNA [10200]","Cigna Local Plus",,4468.56,53.5,,5372.07,4581.20,7242.98,23,971.39,7099.58,"percent of total billed charges",
"SCRDRVR LARGE HEXAGONAL T HANDLE SURGICAL 4.5MM CORTICAL 6.5",SUP-314.13,CDM,S27200284,LOCAL,0272,RC,,,both,,,3384.45,1015.33,"UHC [10700]","United Healthcare",,2142.36,63.3,,,,,0,393.61,2876.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPANDER TISSUE BREAST 700CC STYLE 133S SMOOTH 3 SUTURE TAB",SUP-133S-MX-15-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"PHCS [10601]",PHCS,,6520.5,70,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URETEROSCOPE FLEXIBLE ASCOPE 5 URETERO REVERSE DEFLECTION",SUP-605101000,CDM,C1747,HCPCS,0272,RC,,,both,,,8581.88,2574.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5835.68,68,,,,,0,998.07,7294.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D MODIFIED L BICONVEX 13MM 6MM POSTERIOR CHMBR 1",SUP-SN60WF,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Culture Screen Only",PX-306000230,CDM,87081,CPT,0306,RC,,,both,,,258.29,77.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,23.52,,,,,,,0.01,219.55,"fee schedule",
"HC Mlh1 Gene Full Seq",PX-309000052,CDM,81292,CPT,0310,RC,,,both,,,2420.00,726,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,610.84,,"Fee schedule rate ($610.84). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.42,2057,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP 39MM 100CM 10MM 75CM ENDOPROSTHESIS METAL",SUP-M001712340,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"FIRST HEALTH [10303]","First Health",,6762,80,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDEAVOR SPRINT 18MM 142CM 2.5MM CORONARY STENT",SUP-ENSP25018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"PHCS [10601]",PHCS,,3880.8,70,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SUT COR-KNOT MINI COMBO STERILE",SUP-031350,CDM,S27200284,LOCAL,0272,RC,,,both,,,5506.20,1651.86,"CIGNA [10200]","Cigna Open Access",,3133.03,56.9,,,,,0,640.37,4680.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX SAFE PERFORMAXX 20MM 80CM 8MM 6FR .035IN",SUP-ZBM08020,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"NOVANET [10819]",Novanet,,7503.75,75,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 0D E X3 TRIDENT STERILE LATEX FREE",SUP-723-00-36E,CDM,C1776,HCPCS,0278,RC,,,both,,,9332.25,2799.67,"CIGNA [10200]",Cigna,,6345.93,68,,5873.17,5873.17,5873.17,"1 through 10",1085.34,7932.41,"percent of total billed charges",
"CATH FOGARTY 40CM 3FR 5MM ROUND EMBOLECTOMY STAINLESS STEEL",SUP-120403F,CDM,C1757,HCPCS,0272,RC,,,both,,,376.01,112.8,"FIRST HEALTH [10303]","First Health",,300.81,80,,,,,0,43.73,319.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL SMALL+ 12.5MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405212,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"FIRST HEALTH [10303]","First Health",,7730.76,80,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 32MM 144CM 2.25MM CORONARY STENT",SUP-H7493952832220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AETNA [10100]","Aetna HMO/PPO",,4424.18,79.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 3 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022213,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"NOVANET [10819]",Novanet,,12466.58,75,,,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE REVERSE REVISION HUMERAL STEM, SZ 8X220MM",SUP-530-08-220,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS [10001]","Blue Cross HMO",,4939.2,39.2,,5311.50,4717.44,5388.59,31,1465.38,10710,"percent of total billed charges",
"GWIRE 2O VASCULAR ANGLE 150CM .035IN HYDROPHILIC FIX CORE",SUP-H2OSTDA35150,CDM,C1769,HCPCS,0272,RC,,,both,,,278.40,83.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,32.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 85MM 16MM STAINLESS STEEL ORTHOPEDIC CANNULATED",SUP-71127085,CDM,C1713,HCPCS,0278,RC,,,both,,,2479.50,743.85,"KAISER [10500]",Kaiser,,1661.27,67,,,,,0,288.37,2107.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cbc W Auto Diff",PX-305000007,CDM,85025,CPT,0305,RC,,,both,,,206.03,61.81,"CIGNA [10200]","Cigna Open Access",,17.09,,,,,,,0.21,175.13,"fee schedule",
"HC Collect Bld Vad Imp",PX-450000232,CDM,36591,CPT,0260,RC,,,both,,,524.59,157.38,"KAISER [10500]",Kaiser,,351.48,67,,,,,0,61.01,524.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND SUTUPAK 0 30IN BRAID TIES 10 STRAND",SUP-SA86G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 CURVE 12.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962062,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"BLUE CROSS [10001]","Blue Cross PPO",,3625.78,39.2,,3949.44,3949.44,3949.44,"1 through 10",1075.71,7862.03,"percent of total billed charges",
"STENT ZILVER FLEX 35 140MM 80CM 7MM 6FR .035IN BILIARY",SUP-G50131,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1742.96,28.62,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 39MM 30MM 7.7MM 20FR ZENITH FLEX Z-TRAK",SUP-G55208,CDM,C1874,HCPCS,0278,RC,,,both,,,14138.10,4241.43,"BLUE CROSS [10001]","Blue Cross HMO",,5542.14,39.2,,9776.84,9776.84,9776.84,"1 through 10",1644.26,12017.39,"percent of total billed charges",
"WAX BONE 2.5GM ABSORBABLE HEMOSTATIC AGENT",SUP-W31G,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.22,15.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,36.19,68,,,,,0,6.19,45.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 18CM 8.5FR DUODENAL BEND BILIARY",SUP-M00534310,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,129.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROPINIROLE 1 MG TABLET, IMMEDIATE RELEASE",RX-21689,CDM,,,0637,RC,00904-6374-61,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]",Cigna,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS SUTUPAK 0 18IN BRAID 6 STRAND ANTIBACTERIAL",SUP-VCP106G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"KAISER [10500]",Kaiser,,16.75,67,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PASSPORT 75CM 73CM 9MM CURVE 70CM 55CM 7FR 3.3MM 2.4",SUP-PSS0705509,CDM,C1887,HCPCS,0272,RC,,,both,,,4485.00,1345.5,"KAISER [10500]",Kaiser,,3004.95,67,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC App Splint Short Arm Static",PX-450000192,CDM,29125,CPT,0361,RC,,,both,,,1115.10,334.53,"UHC [10700]","United Healthcare",,1115.1,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,129.69,1115.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT 3 KNEE CEMENT ROTATE PLATFORM",SUP-129431130,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 12X20 135CM SL",SUP-48012002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"AETNA [10100]","Aetna HMO/PPO",,682.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cta Abd Art Runoff W/WO Cntrst",PX-352000036,CDM,75635,CPT,0352,RC,,,both,,,4639.96,1391.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,405,,"Per diem ($405). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,405,3943.97,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL 8 HOLE LOW PROFILE BONE RIGHT CLAVICLE",SUP-70-0293,CDM,S27800098,LOCAL,0278,RC,,,both,,,6610.20,1983.06,"FIRST HEALTH [10303]","First Health",,5288.16,80,,,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Feeynolm 2.6-5.0cm",PX-450000026,CDM,12013,CPT,0361,RC,,,both,,,909.00,272.7,"BLUE CROSS [10001]","Blue Cross HMO",,909,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,105.72,909,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL IDENTITY IMPRINT 4 NARROW H6 MM KNEE POSTERIOR",SUP-TPS-020-064N,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"NOVANET [10819]",Novanet,,4409.1,75,,,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mra Head WO Cntrst",PX-610000006,CDM,70544,CPT,0615,RC,,,both,,,3956.39,1186.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1248,,,,,,,460.13,3362.93,"per diem",
"STEM FEMORAL 235MM 16MM MODULAR RESTORATION BOWED CONICAL",SUP-6276-7-316,CDM,C1776,HCPCS,0278,RC,,,both,,,12862.80,3858.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1495.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1495.94,10933.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ERTAPENEM 1 G VIAL IV PUSH",RX-408330,CDM,J1335,HCPCS,0636,RC,55150-0282-09,NDC,both,1,UN,301.92,90.58,"CIGNA [10200]","Cigna Open Access",,49.25,,,,,,,21.52,256.63,"fee schedule",
"HOLDER 9.25IN JACOBSON INSRT LOCK HEAVY ROUND HANDLE NDL",SUP-32-471,CDM,S27200284,LOCAL,0272,RC,,,both,,,2245.28,673.58,"CIGNA [10200]","Cigna Local Plus",,1201.22,53.5,,,,,0,261.13,1908.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 9.5CM 20MM 16.5-18.5MM EXCLUDER",SUP-PLC201000,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"CIGNA [10200]",Cigna,,11198.88,40,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 100MM 75CM 9MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200091070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"MULTIPLAN [10600]",Multiplan,,3519,85,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ANGIOGRAPHY AT-P65 HAND CTRL STPCOCK TUBING STERILE",SUP-014645,CDM,S27200284,LOCAL,0272,RC,,,both,,,502.20,150.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,59.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE LISFRANC REMOVAL",SUP-IB200051,CDM,C1713,HCPCS,0278,RC,,,both,,,1044.90,313.47,"NOVANET [10819]",Novanet,,783.68,75,,,,,0,121.52,888.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prosthetic Labor/Consult",PX-E27400099,CDM,L7520,HCPCS,0274,RC,,,both,,,77.00,23.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,52.36,68,,,,,0,8.96,65.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 7.5IN WRIST LEFT ADJUSTABLE",SUP-VP30001-130,CDM,S27000186,LOCAL,0270,RC,,,both,,,92.74,27.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.79,78.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Amiodarone",PX-301000703,CDM,80151,CPT,0301,RC,,,both,,,21.00,6.3,"NOVANET [10819]",Novanet,,15.75,75,,,,,0,0.02,21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 50MM 22GA SONOPLEX II FACET S TIP INJECTION",SUP-001287-74,CDM,C9812,HCPCS,0272,RC,,,both,,,139.20,41.76,"KAISER [10500]",Kaiser,,93.26,67,,,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cytpath Nongyn Liq Base",PX-311000009,CDM,88112,CPT,0311,RC,,,both,,,494.00,148.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,64.81,,,,,,,0.01,419.9,"fee schedule",
"HC TB Test Cell Immunity Measure",PX-302000092,CDM,86480,CPT,0302,RC,,,both,,,553.85,166.15,"CIGNA [10200]","Cigna Local Plus",,136.36,,,,,,,0.55,470.77,"fee schedule",
"HC Immuno Ql Sq Single",PX-301000559,CDM,83518,CPT,0301,RC,,,both,,,377.00,113.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.75,,,,,,,0.38,320.45,"fee schedule",
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 755CC",SUP-SSZ-M755,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"AETNA [10100]","Aetna HMO/PPO",,1184.87,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET",RX-7555,CDM,,,0637,RC,60687-0614-11,NDC,both,1,UN,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Epstein-Barr Viral Capsid Ab",PX-302000129,CDM,86665,CPT,0302,RC,,,both,,,239.40,71.82,"BLUE CROSS [10001]","Blue Cross PPO",,0.24,.1,,,,,0,0.24,203.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Metanephrines",PX-301000313,CDM,83835,CPT,0301,RC,,,both,,,424.03,127.21,"MULTIPLAN [10600]",Multiplan,,360.43,85,,,,,0,0.01,360.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cell Marker Study",PX-311000018,CDM,88182,CPT,0311,RC,,,both,,,586.00,175.8,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,498.1,"per diem",
"STENT CONTOUR 22CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805210,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]","Cigna Open Access",,513.34,,,,,,,104.92,766.85,"percent of total billed charges",
"INSRT ACETABULAR 46/48MM 28MM 0D P2 HIP LINER CONGRUENT",SUP-6352-5-072,CDM,C1776,HCPCS,0278,RC,,,both,,,6837.90,2051.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1957.01,28.62,,,,,0,795.25,5812.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM T10 FULL THREAD LOCK STARDRIVE",SUP-657334,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,172.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",172.92,1263.81,"percent of total billed charges",
"HC Muscle Test Cran Nrv Unil",PX-922000026,CDM,95867,CPT,0922,RC,,,both,,,842.00,252.6,"CIGNA [10200]","Cigna Local Plus",,450.47,53.5,,,,,0,97.92,715.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Who W/O Joints Cf",PX-E27400032,CDM,L3906,HCPCS,0274,RC,,,both,,,1030.48,309.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,122.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,119.84,875.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Crystal Exam Fluid/Tiss",PX-309000105,CDM,89060,CPT,0309,RC,,,both,,,143.44,43.03,"CIGNA [10200]","Cigna Local Plus",,16.13,,,,,,,0.14,121.92,"fee schedule",
"HC Punc Lumb Dx",PX-361000260,CDM,62270,CPT,0361,RC,,,both,,,3257.01,977.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,385.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,378.79,3257.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Connector Y-Type 1/2*1/2*1/2",PX-E27200362,CDM,E27200362,LOCAL,0272,RC,,,both,,,42.90,12.87,"AETNA [10100]","Aetna HMO/PPO",,34.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.99,36.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Sclp/Limb 2.6-7.5cm Cmplx",PX-450000050,CDM,13121,CPT,0450,RC,,,both,,,1861.00,558.3,"BLUE CROSS [10001]","Blue Cross HMO",,1861,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,67.13,1861,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Test Defin 22+ Class",PX-301000669,CDM,G0483,HCPCS,0301,RC,,,both,,,509.83,152.95,"MULTIPLAN [10600]",Multiplan,,433.36,85,,,,,0,0.01,433.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 30CM 150CM 8FR .035IN 3CM BLADDER LOOP",SUP-M006155255190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS [10001]","Blue Cross HMO",,556.77,39.2,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE",RX-165066,CDM,J1447,HCPCS,0636,RC,63459-0912-18,NDC,both,.8,ML,2879.78,863.93,"CIGNA [10200]","Cigna Local Plus",,314.64,,,,,,,140.96,2447.81,"fee schedule",
"KIT TISSUE CLSR PRIMA DUPLOJECT TISSEEL PREFILL SYR FROZEN",SUP-1506079,CDM,S27200284,LOCAL,0272,RC,,,both,,,1280.04,384.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,587.54,45.9,,,,,0,148.87,1088.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 10CM 8.5FR RB AMPLATZ .035IN PIGTAIL CURVE URETER",SUP-G09977,CDM,C2625,HCPCS,0278,RC,,,both,,,1227.07,368.12,"CIGNA [10200]",Cigna,,834.41,68,,,,,0,142.71,1043.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 12IN 4 PANEL HOOK LOOP CLSR 30-45IN SMALL",SUP-13651056,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.17,26.15,"KAISER [10500]",Kaiser,,58.4,67,,,,,0,10.14,74.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX ECHO 2 15CM POSITION SYSTEM STERILE",SUP-1210015,CDM,C1781,HCPCS,0278,RC,,,both,,,27716.85,8315.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3284.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3223.47,23559.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM STAINLESS STEEL T15 CORTEX SELF TAP LOW",SUP-02.206.212,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",37.68,275.39,"percent of total billed charges",
"SYR INFLATION DEVICE BASIXTOUCH 13IN ANALOG DISPLAY",SUP-IN8152,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.44,105.73,"CIGNA [10200]","Cigna Open Access",,200.54,56.9,,,,,0,40.99,299.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3.5MM TARGET HELICAL PLATINUM",SUP-M0035433560,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1085.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 24CM 3CM 7FR .035IN",SUP-M006192142190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CIGNA [10200]","Cigna Local Plus",,746.45,,,,,,,162.27,1185.95,"percent of total billed charges",
"BURR SURGICAL 48MM 1MM E9000 ROUND STAINLESS STEEL 6 FLUTE",SUP-E8210,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXI-TIP 50CM 6/10FR STD URETERAL 2 LUMEN STERILE",SUP-G17145,CDM,C1758,HCPCS,0272,RC,,,both,,,377.58,113.27,"NOVANET [10819]",Novanet,,283.19,75,,,,,0,43.91,320.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC",356,MS-DRG,,,,,,,inpatient,,,161549.45,48464.83,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,29156.22,,"Case rate ($27,248.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $25,302.36, add-ons for qualifying new technology services are included. If operating cost exceeds $58,342.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,294.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $25,335.82. The transfer operating threshold is the transfer adjustment factor * $25,302.36 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,912.98. The transfer capital threshold is the transfer adjustment factor * $1,912.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,128252.19,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 200MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035200M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"AETNA [10100]","Aetna HMO/PPO",,1490.63,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ULTRA FAST-FIX CURVE FIXATION MENISCAL REPAIR SYSTEM",SUP-72201491,CDM,C1713,HCPCS,0278,RC,,,both,,,2338.88,701.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,277.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,272.01,1988.05,"percent of total billed charges",
"SCR BONE 4.5MM 6.5MM 85MM TITANIUM FULL THREAD CORTEX SELF",SUP-414.885,CDM,C1713,HCPCS,0278,RC,,,both,,,453.60,136.08,"BLUE CROSS [10001]","Blue Cross PPO",,177.81,39.2,,957.42,570.23,957.42,28,52.75,385.56,"percent of total billed charges",
"NDL BIOPSY 0-8CM 19GA 4.8FR PROCORE ECHOTIP ULTRASOUND HIGH",SUP-G53585,CDM,S27200284,LOCAL,0272,RC,,,both,,,3195.00,958.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,378.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,371.58,2715.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRAP TRACTION ANKLE ELBOW NYLON DSRCTOR STERILE DISPOSABLE",SUP-AR-1712,CDM,S27200284,LOCAL,0272,RC,,,both,,,411.08,123.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,47.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.81,349.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Feeding Tube W Fl",PX-750000100,CDM,49440,CPT,0750,RC,,,both,,,10162.32,3048.7,"UHC [10700]","United Healthcare",,3833,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1181.88,8637.97,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE S+ 4 KNEE CEMENT FIX BEARING",SUP-150670004,CDM,C1776,HCPCS,0278,RC,,,both,,,15487.05,4646.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1835.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1801.14,13163.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR SKIN CLSR BIOGLUE SPRD TIP STERILE LATEX FREE",SUP-BGST-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 RB-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP713D,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.99,39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,59.67,45.9,,,,,0,15.12,110.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM CEMENTLESS SUMMIT POROCOAT 4 12/14 STD",SUP-157001100,CDM,C1776,HCPCS,0278,RC,,,both,,,14221.44,4266.43,"KAISER [10500]",Kaiser,,9528.36,67,,,,,0,1653.95,12088.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM STAINLESS STEEL T15 TIBIA PROXIMAL SELF",SUP-02.127.120,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"NOVANET [10819]",Novanet,,849.53,75,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 19MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-619,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"CIGNA [10200]",Cigna,,6684.75,68,,5873.17,5873.17,5873.17,"1 through 10",1143.29,8355.94,"percent of total billed charges",
"BLADE SHAVER 13CM 4.2MM MERLIN GATOR 15D 2500-6000 RPM",SUP-C9266M,CDM,S27200284,LOCAL,0272,RC,,,both,,,693.77,208.13,"CIGNA [10200]","Cigna Local Plus",,371.17,53.5,,,,,0,80.69,589.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 5FR INTERNAL MAMMARY CURVE ANGIOGRAPHIC",SUP-H749085262012,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"FIRST HEALTH [10303]","First Health",,61.26,80,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 4.5CM 36MM 30-32MM EXCLUDER GORE-TEX",SUP-PLA360400,CDM,S27800098,LOCAL,0278,RC,,,both,,,19725.30,5917.59,"BLUE CROSS [10001]","Blue Cross PPO",,7732.32,39.2,,,,,0,2294.05,16766.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD SUT ASSISTANT 10MM 3-0 ES-9 7IN 1 STITCH ENDO STITCH",SUP-170070,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,66.17,45.9,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Txcath Embl Si",PX-320000140,CDM,75894,CPT,0320,RC,,,both,,,6838.23,2051.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4650,68,,,,,0,795.29,5812.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM TOTAL HIP PROS PUREFIX HYDROXYAPATITE",SUP-542-11-52E,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"PHCS [10601]",PHCS,,4870.4,70,,,,,0,809.18,5914.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS LIFECARE 5% DEXTROSE QUAD PACK 100ML LATEX",SUP-07923-37,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA [10200]",Cigna,,55.08,68,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 10CM 7FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22355,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS [10001]","Blue Cross PPO",,247.67,39.2,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 19MM 7MM STAINLESS STEEL 1.1MM LONG THREAD",SUP-02.226.119,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"CIGNA [10200]","Cigna Open Access",,936.12,56.9,,1144.80,304.56,2275.09,66,191.34,1398.42,"percent of total billed charges",
"SCR BONE 5.5MM 40MM CREO AMP HA SPINE CANNULATED MODULAR",SUP-1067.4541S,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]",Cigna,,2550,68,,1831.33,1831.33,1831.33,16,436.13,3187.5,"percent of total billed charges",
"CATH CORDIS SABER 90CM 60MM 3MM BALLOON DILATATION DURALYN",SUP-48003006S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PHCS [10601]",PHCS,,878.85,70,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 102MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 2",SUP-71357102,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"UHC [10700]","United Healthcare",,20978.35,63.3,,8601.07,8395.67,8601.07,"1 through 10",3854.32,28169.98,"percent of total billed charges",
"SCR BONE 3.5MM 20MM MINI-MONSTER SHORT THREAD CANNULATED",SUP-P20-135-020S,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 3.75 X 38 MM",SUP-1212375-38,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"MULTIPLAN [10600]",Multiplan,,14662.5,85,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR SURGICAL 40CM 5MM SNAP LOCK RIGID DEHP FREE FIBRIN",SUP-0601139,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.43,194.53,"CIGNA [10200]",Cigna,,440.93,68,,,,,0,75.41,551.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM AVENIR 10 HELICAL FINISH STERILE",SUP-10HFN-04008,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"UHC [10700]","United Healthcare",,6547.18,63.3,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM .91-1.12MM 3MM CORONARY",SUP-RONYX30026W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"CIGNA [10200]","Cigna Local Plus",,2909.87,53.5,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL CANCELLOUS 7D ALLOGRAFT 14MM",SUP-3W5214,CDM,S27800098,LOCAL,0278,RC,,,both,,,21094.92,6328.48,"NOVANET [10819]",Novanet,,15821.19,75,,,,,0,2453.34,17930.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Reposition G-J Tube",PX-750000250,CDM,44799,CPT,0750,RC,,,both,,,7119.00,2135.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,827.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,827.94,7119,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 210MM PERFORM 13 XLONG SHOULDER STERILE LATEX",SUP-PFX13210,CDM,C1776,HCPCS,0278,RC,,,both,,,51351.30,15405.39,"AETNA [10100]","Aetna HMO/PPO",,40824.28,79.5,,10981.53,8986.79,12413.38,12,5972.16,43648.61,"percent of total billed charges",
"ROD REAMER 950MM 3MM TITANIUM SMOOTH TIP DISTAL FEMORAL NAIL",SUP-355.041S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1183.90,355.17,"CIGNA [10200]","Cigna Local Plus",,633.39,53.5,,,,,0,137.69,1006.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-30,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEUROMUSCULAR PASS ELEV",SUP-ACCK2100,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,249.68,41.1,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH GREEN 16CM 13.5FR MAHURKAR ELITE DOUBLE-D LARGE",SUP-8888212316,CDM,C1752,HCPCS,0272,RC,,,both,,,860.01,258,"KAISER [10500]",Kaiser,,576.21,67,,,,,0,100.02,731.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTRA TWINFLEX TCH 69","SUP-392 290",CDM,C1893,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIMPLE SYRUP",RX-7242,CDM,,,0637,RC,31722-0937-47,NDC,both,473,ML,127.93,38.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.88,108.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED DUAL MOBILITY HIP SYSTEM + CER HD + OSS LH",SUP-98000500330,CDM,C1776,HCPCS,0278,RC,,,both,,,31500.00,9450,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3732.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 90CM 8FR FR4 CURVE GUIDING PTFE FEMORAL",SUP-H749343583720,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AETNA [10100]","Aetna HMO/PPO",,291.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 6CM 3MM BALLOON DILATATION HYDROPHILIC",SUP-G50329,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"PHCS [10601]",PHCS,,1653.7,70,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Scrn Low Risk",PX-750000194,CDM,G0121,HCPCS,0750,RC,,,both,,,3920.00,1176,"CIGNA [10200]","Cigna Local Plus",,2587,,"Case rate ($2,587). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",1594.87,1472.36,1669.73,"1 through 10",455.9,3920,"fee schedule",
"SCR BONE 3.5MM 22MM ORTHOLOC",SUP-40233522,CDM,C1713,HCPCS,0278,RC,,,both,,,1474.20,442.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,174.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,171.45,1253.07,"percent of total billed charges",
"CATH CORDIS SABER 150CM 300MM 4MM BALLOON DILATATION DURALYN",SUP-48004030X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 5038-58  LEAD-QUAD SNGL-P A/V 58CM",SUP-5038-58,CDM,C1779,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"MULTIPLAN [10600]",Multiplan,,4765.95,85,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 150MM 7MM BALLOON DILATATION PEBAX",SUP-H74939032701510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEWIRE VASCULAR CORDIS EMERALD HEPARIN PTFE 3 MM RADIUS J",SUP-502587,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"MULTIPLAN [10600]",Multiplan,,81.35,85,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SOLITAIRE 180CM 40MM 4MM THROMBECTOMY SCAFFOLD",SUP-SFR3-4-40-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,40761.00,12228.3,"CIGNA [10200]",Cigna,,27717.48,68,,,,,0,4740.5,34646.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM VARIAX T10 FULL THREAD FOOT ANKLE",SUP-657116,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"FIRST HEALTH [10303]","First Health",,646.96,80,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 5.00 X 20MM",SUP-H7493942820500,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"MULTIPLAN [10600]",Multiplan,,5278.5,85,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 34X24X14IN 12D BRIGADE",SUP-6951434,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"FIRST HEALTH [10303]","First Health",,27420.48,80,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR REGULAR 45MM ECHELON STAINLESS STEEL VASCULAR",SUP-ECR45D,CDM,S27200284,LOCAL,0272,RC,,,both,,,3762.58,1128.77,"FIRST HEALTH [10303]","First Health",,3010.06,80,,,,,0,437.59,3198.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ENDOSCOPIC 3MM 65CM 9CM .025IN STAINLESS STEEL 2 ENDED",SUP-395415,CDM,C1769,HCPCS,0272,RC,,,both,,,282.75,84.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,116.21,41.1,,,,,0,32.88,240.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM CONCERTO DETACHABLE HELIX PERIPHE",SUP-NV-9-30-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 15MM 3.5MM CORONARY STENT EVEROLIMUS",SUP-1550350-15,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METOLAZONE 5 MG TABLET",RX-10588,CDM,,,0637,RC,51079-0024-01,NDC,both,1,UN,18.78,5.63,"AETNA [10100]","Aetna HMO/PPO",,14.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.18,15.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT PHOTOTHERAPY BILISOFT LARGE NEST DISPOSABLE",SUP-M1093123,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.94,25.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,38.53,45.9,,,,,0,9.76,71.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP IDENTITY STEM/AUGMENTED GLENOID/PREMIUM POST/IDENTITY HE",SUP-98000900262,CDM,C1776,HCPCS,0278,RC,,,both,,,33075.00,9922.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3919.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3846.62,28113.75,"percent of total billed charges",
"SIZER IMPL 14X14.5CM NATRELLE P5.2CM MODERATE PROJECTION",SUP-MSZFM500,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"CIGNA [10200]","Cigna Local Plus",,95.2,53.5,,,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55840006555,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM SPINAL",SUP-7835535,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,188.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",188.41,1377,"percent of total billed charges",
"ANCHOR SUT LUPINE LOOP ARTHROSCOPIC",SUP-210711,CDM,C1713,HCPCS,0278,RC,,,both,,,2782.50,834.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,329.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,323.6,2365.13,"percent of total billed charges",
"RESUS MANUAL INFANT TUBE RESVR LATEX FREE DISPOSABLE AMBU",SUP-544212001,CDM,S27000186,LOCAL,0270,RC,,,both,,,65.84,19.75,"FIRST HEALTH [10303]","First Health",,52.67,80,,,,,0,7.66,55.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 9MM KNEE BEARING CRUCIATE RETAIN TRIATHLON",SUP-5530-G-609-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]","Cigna Local Plus",,6105.74,53.5,,5372.07,4581.20,7242.98,23,1327.29,9700.71,"percent of total billed charges",
"CATH ADVANCE 35LP 80CM 10CM 7FR 12MM .035IN BALLOON",SUP-G52381,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AETNA [10100]","Aetna HMO/PPO",,763.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE SUT 18IN MYO/WIRE II 6 CCS-3 .5 CIRCLE MONOFILAMENT 49",SUP-046-082,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.75,50.02,"UHC [10700]","United Healthcare",,105.55,63.3,,,,,0,19.39,141.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 22MM 10D E HIP CONSTRAIN TRIDENT",SUP-690-10-22E,CDM,C1776,HCPCS,0278,RC,,,both,,,17046.45,5113.93,"FIRST HEALTH [10303]","First Health",,13637.16,80,,,,,0,1982.5,14489.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BROWN 50MM 28MM SELF-CENTERING HIP FEMUR",SUP-103550000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,363.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL TLIF 10X11X26MM 20DEG TITANIUM ALLOY SELF EXPAND",SUP-5902026P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM SURGICAL TRITOME 3 EDGE RELEASE STERILE LATEX FREE",SUP-SN21,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"FIRST HEALTH [10303]","First Health",,2970,80,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 20MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158122120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3017.13,27,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT TRIVASCULAR OVATION PRIME PTFE DELIVERY CATH",SUP-TV-AI01-E,CDM,S27200284,LOCAL,0272,RC,,,both,,,801.90,240.57,"MULTIPLAN [10600]",Multiplan,,681.62,85,,,,,0,93.26,681.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +11 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.110,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +10 28MM HIP C TAPER COCR LFIT",SUP-06-2810,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA [10200]","Cigna Local Plus",,1673.32,53.5,,5372.07,4581.20,7242.98,23,363.75,2658.55,"percent of total billed charges",
"AGENT HEMOSTATIC EVITHROM GELATIN TOPICAL NDL FREE VIAL",SUP-2991,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM INCORE TITANIUM T10 COMPRESSION HEXALOBE",SUP-ICLAP3526,CDM,C1713,HCPCS,0278,RC,,,both,,,2402.48,720.74,"KAISER [10500]",Kaiser,,1609.66,67,,,,,0,279.41,2042.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 135CM 80MM 9MM .035IN BALLOON",SUP-AB35W09080135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,460.47,68,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 10CC SELECT FIBER OSTEOAMP",SUP-OASF-10,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM TSRH OSTEOGRIP TITANIUM SHORT POST SPINE",SUP-83565451,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"MULTIPLAN [10600]",Multiplan,,2187.9,85,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 5FR 17.8CM RADIALEASE LATEX FREE VESSEL ACCEPTS",SUP-504505X,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.26,26.18,"MULTIPLAN [10600]",Multiplan,,74.17,85,,,,,0,10.15,74.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 12MM 80CM 6MM 3.6-3.3FR 6FR BILIARY",SUP-1011498-12,CDM,C1876,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 755CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCM-755,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]","Cigna Local Plus",,4042.19,,,,,,,878.7,6422.18,"percent of total billed charges",
"TUBE VENTILATION NUMBER 2 1.14MM BLUE ULTRASIL GROMMET BEVEL",SUP-70245755,CDM,S27800098,LOCAL,0278,RC,,,both,,,104.91,31.47,"NOVANET [10819]",Novanet,,78.68,75,,,,,0,12.2,89.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 36X24MM ENDOSKELETON TAS 12D 12MM LARGE TITANIUM",SUP-2312-0212,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PHCS [10601]",PHCS,,19845,70,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYNX CONTROL 5FR CLSR 10ML 2 MODE BALLOON CATH SEAL",SUP-MX5060,CDM,C1760,HCPCS,0278,RC,,,both,,,1680.00,504,"AMERIGROUP MEDICAID [20100]",Amerigroup,,199.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,195.38,1428,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IV 0.9% SODIUM CHLORIDE 100ML STERILE PRESERVATIVE FREE",SUP-07984-23,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"FIRST HEALTH [10303]","First Health",,64.8,80,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Ctrl Blood",PX-750000041,CDM,43255,CPT,0750,RC,,,both,,,3783.74,1135.12,"CIGNA [10200]","Cigna Local Plus",,2587,,"Case rate ($2,587). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,440.05,3783.74,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BNDG 10YDX4IN CALAMINE ZINC OXIDE PLASTIC LIGHT COMPRESSION",SUP-NONUNNA4,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.98,15.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,24.32,45.9,,,,,0,6.16,45.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR OR3O 56MM 44MM 2 MOBILITY",SUP-71358205,CDM,C1776,HCPCS,0278,RC,,,both,,,16052.85,4815.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6421.14,40,,,,,0,1866.95,13644.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT 17GA 75MM ACTIVE TIP PROBE INTRO TUBE ELECTROTHERAPY",SUP-CRK-17-75-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 30CM 5FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552250,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"FIRST HEALTH [10303]","First Health",,960.46,80,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND VAC VERAFLO LARGE",SUP-ULTVCCO5LG,CDM,S27200284,LOCAL,0272,RC,,,both,,,1846.80,554.04,"KAISER [10500]",Kaiser,,1237.36,67,,,,,0,214.78,1569.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP 2.5MM XL VESSEL CLSR ANASTOCLIP",SUP-4008-08,CDM,S27200284,LOCAL,0272,RC,,,both,,,9791.10,2937.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1138.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1138.7,8322.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG BONE CEMENT 12MM SMALL INTRAMEDULLARY CANAL STERILE",SUP-130609,CDM,C1713,HCPCS,0278,RC,,,both,,,1029.51,308.85,"FIRST HEALTH [10303]","First Health",,823.61,80,,,,,0,119.73,875.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 38.5MM 50.5MM TENDYNE 3SQ CM 39M CONTOUR 156MM","SUP-TENDYNE 39M SYSTEM",CDM,S27800098,LOCAL,0278,RC,,,both,,,319200.00,95760,"BLUE CROSS [10001]","Blue Cross HMO",,125126.4,39.2,,,,,0,37122.96,271320,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 10 X 34 COMPLEX FRAMING COIL",SUP-10CFR-10034,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1363.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 TWINFIX ULTRA SHOULDER LOW PROFILE",SUP-72202595,CDM,C1713,HCPCS,0278,RC,,,both,,,1724.63,517.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,200.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",200.57,1465.94,"percent of total billed charges",
"PLATE 171MM STAINLESS STEEL 3.5MM SCREWS 10 HOLE LCP BONE",SUP-239.961,CDM,C1713,HCPCS,0278,RC,,,both,,,10033.01,3009.9,"BLUE CROSS [10001]","Blue Cross HMO",,3932.94,39.2,,957.42,156.86,7483.26,51,1166.84,8528.06,"percent of total billed charges",
"SCR INTERFERENCE REGENESORB 20MM 6MM SOLID OPEN ARCHITECTURE",SUP-72204391,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,322.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",322.62,2357.93,"percent of total billed charges",
"CABLE CATH IMPELLA CTRL CNCT IMPELLA 2.5 IMPELLA CP IMPELLA",SUP-0042-0002,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRAILBLAZER 90CM 2.6FR 15MM ANGLE SPRT STAINLESS STEEL",SUP-ASC-018-090,CDM,C1887,HCPCS,0272,RC,,,both,,,1377.00,413.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,163.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 20MM MEDLINE UNITE FOOT ANKLE CANNULATED COLOR",SUP-MSL03020,CDM,C1713,HCPCS,0278,RC,,,both,,,1762.50,528.75,"KAISER [10500]",Kaiser,,1180.88,67,,,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK12MM 51X63MM GALLANT IMPLANTABLE 2 CHMBR DF",SUP-CDDRA500Q,CDM,C1721,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"CIGNA [10200]","Cigna Open Access",,19522.13,33.5,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM ORTHOLOC LONG CORTEX ANKLE FOOT 3DI",SUP-58802714,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM CONCERTO DETACHABLE HELIX PERIPHER",SUP-NV-2-4-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 39MM STD COCR CANNULATED",SUP-DWJ1017302,CDM,C1776,HCPCS,0278,RC,,,both,,,18544.68,5563.4,"BLUE CROSS [10001]","Blue Cross PPO",,7269.51,39.2,,3949.44,3949.44,3949.44,"1 through 10",2156.75,15762.98,"percent of total billed charges",
"HC Consult Comprehensive 3",PX-312000035,CDM,88325,CPT,0312,RC,,,both,,,1691.00,507.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,205.91,,,,,,,0.01,1437.35,"fee schedule",
"SCISSOR SURGICAL MAYO DISSECTING HEAVY BLUNT SERRATED STAINL",SUP-80-5017,CDM,S27200284,LOCAL,0272,RC,,,both,,,575.18,172.55,"CIGNA [10200]","Cigna Local Plus",,307.72,53.5,,,,,0,66.89,488.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TIGHTRAIL SUB-C .171IN DIL ROTATE STERILE LATEX FREE",SUP-560-013,CDM,C1773,HCPCS,0272,RC,,,both,,,12385.50,3715.65,"MULTIPLAN [10600]",Multiplan,,10527.68,85,,,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC SURGILAV PLUS SET MULTIORIFICE TIP SPLASH SHIELD",SUP-207-559,CDM,S27200284,LOCAL,0272,RC,,,both,,,337.68,101.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,138.79,41.1,,,,,0,39.27,287.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE KORE FIBER CORTICAL BONE FIBER ALLOGRAFT STRIP",SUP-423305,CDM,C1713,HCPCS,0278,RC,,,both,,,20947.50,6284.25,"MULTIPLAN [10600]",Multiplan,,17805.38,85,,,,,0,2436.19,17805.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 22CM 8FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001274160,CDM,C2617,HCPCS,0278,RC,,,both,,,999.00,299.7,"BLUE CROSS [10001]","Blue Cross HMO",,391.61,39.2,,,,,0,116.18,849.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CROTALIDAE POLYVAL IMMUNE FAB 1 GRAM SOLUTION FOR INJECTION",RX-29313,CDM,J0840,HCPCS,0636,RC,50633-0110-12,NDC,both,1,UN,19303.13,5790.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4910.92,,,,,,,2131.37,16407.66,"fee schedule",
"LINER ACETABULAR PINNACLE 10D +4MM 50MM 32MM ALTRX HIP",SUP-122132150,CDM,C1776,HCPCS,0278,RC,,,both,,,5531.40,1659.42,"NOVANET [10819]",Novanet,,4148.55,75,,,,,0,643.3,4701.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 12MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0280,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"NOVANET [10819]",Novanet,,710.78,75,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM AXSOS STAINLESS STEEL T15 FEMUR HUMERUS",SUP-371538,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"FIRST HEALTH [10303]","First Health",,712.8,80,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMART ABLATE DISPOSABLE CABLES",SUP-M4900633,CDM,S27000186,LOCAL,0270,RC,,,both,,,3052.50,915.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1401.1,45.9,,,,,0,355.01,2594.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 38MM 28MM C VIVACIT-E LUMEN STERILE LATEX FREE",SUP-110031009,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"BLUE CROSS [10001]","Blue Cross PPO",,4059.9,39.2,,3949.44,3949.44,3949.44,"1 through 10",1204.51,8803.37,"percent of total billed charges",
"ELECTRD DEFIB PEDI-PADZ II PEDIATRIC AED PLUS DISPOSABLE",SUP-8900-0810-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,638.60,191.58,"MULTIPLAN [10600]",Multiplan,,542.81,85,,,,,0,74.27,542.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLARED SECUR-FIT HYDROXYAPATITE 6 HIP",SUP-S-2337-HF06,CDM,C1776,HCPCS,0278,RC,,,both,,,16482.96,4944.89,"FIRST HEALTH [10303]","First Health",,13186.37,80,,,,,0,1916.97,14010.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BETHANECHOL CHLORIDE 10 MG TABLET",RX-1043,CDM,,,0637,RC,00832-0511-89,NDC,both,1,UN,10.07,3.02,"MULTIPLAN [10600]",Multiplan,,8.56,85,,,,,0,1.17,8.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 60MM 10MM 8FR BILIARY METAL UNCOVER RAPID",SUP-M00570640,CDM,C1876,HCPCS,0278,RC,,,both,,,11927.41,3578.22,"CIGNA [10200]","Cigna Local Plus",,3757.13,31.5,,,,,0,1387.16,10138.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 30IN BRAID TIE 12 STRAND PRECUT",SUP-A305H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 20MM 4.5FR SEGURA HEMISPHERE",SUP-M0063801190,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,679.11,45.9,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 90CM 40MM 4MM .014IN BALLOON DILATATION",SUP-AB14W040040090,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"MULTIPLAN [10600]",Multiplan,,1177.34,85,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 46MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.536S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"CIGNA [10200]","Cigna Open Access",,851.72,56.9,,1144.80,304.56,2275.09,66,174.09,1272.35,"percent of total billed charges",
"SOL 4.25% DEXTROSE 2L LOW CALCIUM DIANEAL DIALYSIS",SUP-5B9796,CDM,S27200284,LOCAL,0272,RC,,,both,,,340.43,102.13,"PHCS [10601]",PHCS,,238.3,70,,,,,0,39.59,289.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 40MM 3.5MM AXOGUARD PORCINE EXTRACELLULAR",SUP-AG0340,CDM,C1763,HCPCS,0278,RC,,,both,,,19605.60,5881.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2323.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2280.13,16664.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 11MM KNEE POSTERIOR STABILIZE BEARING",SUP-5532P711,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS [10001]","Blue Cross PPO",,3275.51,39.2,,3949.44,3949.44,3949.44,"1 through 10",971.79,7102.52,"percent of total billed charges",
"CATH JADE 150CM 20MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-592502022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 1 POSTERIOR KNEE TOTAL STABILIZED",SUP-5543-A-100,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"CIGNA [10200]",Cigna,,3244.27,68,,5873.17,5873.17,5873.17,"1 through 10",554.87,4055.34,"percent of total billed charges",
"COIL EMBOLIZATION 3CM 7MM MICRUSFRAME 10 COIL",SUP-MFR100730,CDM,S27800098,LOCAL,0278,RC,,,both,,,16974.00,5092.2,"UHC [10700]","United Healthcare",,10744.54,63.3,,,,,0,1974.08,14427.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 4MM 7MM ANGLE SLIGHT 9IN SEMMES SURGICAL SPINAL FUSION",SUP-29-4951,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.98,94.19,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GLIDESHEATH SLENDER SS KIT, 0.021 GW, 5 FR, 10CM",SUP-80-1050,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 135CM 200MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171032010,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 5MM 20MM MONTEREY SPINE LUMBAR ANTERIOR NONSTERILE",SUP-480115020,CDM,S27800098,LOCAL,0278,RC,,,both,,,1620.00,486,"PHCS [10601]",PHCS,,1134,70,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TR BAND LARGE 29CM COMPRESSION RADIAL ARTERY 2",SUP-TRB29-LRG,CDM,S27000186,LOCAL,0270,RC,,,both,,,252.30,75.69,"CIGNA [10200]",Cigna,,171.56,68,,,,,0,29.34,214.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR .09IN LEFT CORONARY BYPASS CURVE",SUP-LA8LCBSH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"KAISER [10500]",Kaiser,,244.82,67,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 11MM 3FR GEMINI HELICAL",SUP-M0063301070,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"AETNA [10100]","Aetna HMO/PPO",,1176.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 220CM 8.5-11MM OTSC 6MM NITINOL STERILE",SUP-100.31,CDM,C1760,HCPCS,0278,RC,,,both,,,4133.10,1239.93,"CIGNA [10200]","Cigna Open Access",,2351.73,56.9,,,,,0,480.68,3513.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TSRH-3D TITANIUM SHORT POST POSTERIOR",SUP-8372640,CDM,C1713,HCPCS,0278,RC,,,both,,,2361.60,708.48,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1083.97,45.9,,,,,0,274.65,2007.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER TORQR 80CM 5FR 2MM SPACING DAO CURVE ELECTROPHYSIOL",SUP-04120DS,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"KAISER [10500]",Kaiser,,209.84,67,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FIXATION ENDOBUTTON CL 25MM ACL PCL",SUP-72200148,CDM,C1713,HCPCS,0278,RC,,,both,,,2157.75,647.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1467.27,68,,,,,0,250.95,1834.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 4MM STD UNIVERSAL VASCULAR ARTICULATING EXTRA",SUP-EGIAUSTND,CDM,S27200284,LOCAL,0272,RC,,,both,,,819.48,245.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,336.81,41.1,,,,,0,95.31,696.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 90CM 5MM 8FR 2-5-2MM SPACE F CURVE",SUP-D8BTF5L252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,576.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC UNIVERSAL SHOULDER",SUP-ORT16000,CDM,S27000186,LOCAL,0270,RC,,,both,,,67.16,20.15,"CIGNA [10200]","Cigna Local Plus",,35.93,53.5,,,,,0,7.81,57.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM TSRH THINLINE OSTEOGRIP",SUP-83565459,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Open Access",,5432.16,56.9,,1144.80,304.56,2275.09,66,1110.3,8114.82,"percent of total billed charges",
"STEM FEMORAL 129MM CEMENT AVENIR PROTASUL-S30 1 38.74MM STD",SUP-01.06010.201,CDM,C1776,HCPCS,0278,RC,,,both,,,18218.34,5465.5,"CIGNA [10200]","Cigna Local Plus",,5738.78,31.5,,5372.07,4581.20,7242.98,23,2118.79,15485.59,"percent of total billed charges",
"DEVICE PERMASORB FIXATION 12 ABSORBABLE FASTENERS",SUP-0113092,CDM,S27200284,LOCAL,0272,RC,,,both,,,3559.32,1067.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,421.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,413.95,3025.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 100MM 3.5MM BALLOON DILATATION RAPID",SUP-47535100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PHCS [10601]",PHCS,,1116.99,70,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XACT 30MM 6-8MM TAPER VASCULAR NITINOL CAROTID ARTERY",SUP-82091-01,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"MULTIPLAN [10600]",Multiplan,,7956,85,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPLR ANASTOMOSIS 3MM FLOW RING PIN ULTRASONIC DOPPLER 20MHZ",SUP-GEM2754-FC,CDM,S27200284,LOCAL,0272,RC,,,both,,,7569.30,2270.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5147.12,68,,,,,0,880.31,6433.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 5.5MM REVOLVE",SUP-185.320,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"FIRST HEALTH [10303]","First Health",,3528,80,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 40MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560040L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 65CM 5FR UNIVERSAL TAPER ANGIOGRAPHIC NYLON NEON",SUP-451504V5,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"KAISER [10500]",Kaiser,,69.95,67,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 11MM 8.2MM 95MM TALON HIP DISTALFIX TECHNOLOGY LAG",SUP-SLN-011-095,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"NOVANET [10819]",Novanet,,3726,75,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATENOLOL 25 MG TABLET",RX-717,CDM,,,0637,RC,51079-0759-01,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GIRAFFE 45D 2MM 5.25IN FRONTAL SINUS 2 ACTION",SUP-63-8840,CDM,S27200284,LOCAL,0272,RC,,,both,,,3430.28,1029.08,"CIGNA [10200]",Cigna,,2332.59,68,,,,,0,398.94,2915.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TORQ-FLEX VASCULAR STRAIGHT 40CM 8CM .018IN STAINLESS",SUP-G07304,CDM,C1769,HCPCS,0272,RC,,,both,,,304.41,91.32,"UHC [10700]","United Healthcare",,192.69,63.3,,,,,0,35.4,258.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Perq Trancath Clsr Mitral Initial",PX-481000113,CDM,93590,CPT,0481,RC,,,both,,,29534.00,8860.2,"KAISER [10500]",Kaiser,,19787.78,67,,,,,0,3434.8,25103.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM RECONSTRUCTION VALVULAR RETRACTION",SUP-680R32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5388.21,41.1,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE POLY L LACTIC ACID 28MM 6.5MM 8MM DELTA",SUP-AR-5028B-08,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,189.34,1383.8,"percent of total billed charges",
"SUT VICRYL 6-0 S-14 8IN 2 ARM BRAID COATED VIOLET ABSORBABLE",SUP-J578G,CDM,S27200284,LOCAL,0272,RC,,,both,,,163.41,49.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,111.12,68,,,,,0,19,138.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT FEMORAL 120MM GMRS KNEE",SUP-64956120,CDM,C1776,HCPCS,0278,RC,,,both,,,16025.25,4807.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1898.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1863.74,13621.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 4-5 C-D KNEE",SUP-42522100311,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"MULTIPLAN [10600]",Multiplan,,9159.96,85,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 59MM STAINLESS STEEL 3.5MM SCREWS SMALL FRAGMENT SET 4",SUP-223.541,CDM,C1713,HCPCS,0278,RC,,,both,,,1726.20,517.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,494.04,28.62,,,,,0,200.76,1467.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL AMPLATZ PTFE COAXIAL STYLET SAFETY WIRE INTRO",SUP-M0062601200,CDM,C1894,HCPCS,0272,RC,,,both,,,365.49,109.65,"FIRST HEALTH [10303]","First Health",,292.39,80,,,,,0,42.51,310.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 46MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ346,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.88,817.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR .09IN LEFT CORONARY BYPASS CURVE",SUP-LA8LCBSH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL CANNULATED 3.5 MM 4 MM SCREWS NONSTERILE",SUP-310.86,CDM,S27000186,LOCAL,0270,RC,,,both,,,2061.00,618.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,946,45.9,,,,,0,239.69,1751.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 3.5/15",SUP-434889,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5332.64,27,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRN6PL,CDM,C1776,HCPCS,0278,RC,,,both,,,13075.50,3922.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5374.03,41.1,,6417.48,6417.48,6417.48,"1 through 10",1520.68,11114.18,"percent of total billed charges",
"HC Hpv Types 16 & 18 Only",PX-306000193,CDM,87625,CPT,0306,RC,,,both,,,249.85,74.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,63.79,,,,,,,0.01,212.37,"fee schedule",
"FLEXIVA PULSE ID 242",SUP-M006L8406910,CDM,S27200284,LOCAL,0272,RC,,,both,,,2856.45,856.93,"CIGNA [10200]","Cigna Local Plus",,1528.2,53.5,,,,,0,332.21,2427.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 52MM 28MM MARATHON HIP",SUP-121928052,CDM,C1776,HCPCS,0278,RC,,,both,,,7631.40,2289.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5189.35,68,,,,,0,887.53,6486.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 11CM MINI GWIRE AVANTI+ STAINLESS STEEL",SUP-504658X,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"UHC [10700]","United Healthcare",,49.56,63.3,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACARBOSE 25 MG TABLET",RX-22148,CDM,,,0637,RC,64380-0758-06,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 50CM 11CM GREEN HUB SNAP FIT DIL TUBING",SUP-PRO-6F-11-035,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"FIRST HEALTH [10303]","First Health",,64.03,80,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 120MM 10.6MM 7MM CUFFED ADJUSTABLE NECK FLANGE WIRE",SUP-75HA70,CDM,S27200284,LOCAL,0272,RC,,,both,,,1619.19,485.76,"CIGNA [10200]",Cigna,,1101.05,68,,,,,0,188.31,1376.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE ABSORBABLE 12.5X8CM PORCINE GELATIN SURGIFOAM THK10MM",SUP-1974,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.54,104.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STYLET PACEMAKER SOFT STRAIGHT 59CM LENGTH",SUP-6521,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACIFIC PLUS 180CM 120MM 4FR 3MM LOW PROFILE COAXIAL",SUP-PCP030120180,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PLEUR-EVAC 10IN 28FR STRAIGHT DRNG PVC THORAX DEPTH",SUP-DTRC-28S,CDM,C1729,HCPCS,0272,RC,,,both,,,187.05,56.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FOOT PROCEDURES WITH CC",504,MS-DRG,,,,,,,inpatient,,,77462.59,23238.78,"BLUE CROSS [10001]","Blue Cross PPO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 20MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MANIP ROTATING HANDLE ENDOSCOPIC CLEARVIEW 7CM UTERINE","SUP-UM 700",CDM,S27200284,LOCAL,0272,RC,,,both,,,1003.83,301.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL TORIC 4.25 D CYLINDER 9.0 DIOPTER",SUP-PPK1704-17,CDM,S27600001,LOCAL,0276,RC,,,both,,,1761.68,528.5,"MULTIPLAN [10600]",Multiplan,,1497.43,85,,,,,0,204.88,1497.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"26 MM EDWARDS SAPIEN 3 ULTRA TRANSCATHETER HEART VALVE (THV)",SUP-S3UCM26A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"PHCS [10601]",PHCS,,129675,70,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000070,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Glucose Bld Quant POC",PX-301000205,CDM,82947,CPT,0301,RC,,,both,,,123.57,37.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4.21,,"Fee schedule rate ($4.21). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",5.91,5.91,5.91,55,2.66,105.03,"fee schedule",
"COIL EMBOLIZATION 3CM 2.5MM AXIUM PRIME HELIX DETACHABLE",SUP-APB-2.5-3-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"MULTIPLAN [10600]",Multiplan,,7595.18,85,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE THINFLAP CRANIOMAXILLOFACIAL TITANIUM 4 HOLE",SUP-191015,CDM,C1713,HCPCS,0278,RC,,,both,,,1822.50,546.75,"CIGNA [10200]","Cigna Open Access",,1037,56.9,,1144.80,304.56,2275.09,66,211.96,1549.13,"percent of total billed charges",
"STENT GORE VIABAHN 79MM 135CM 7MM 11MM 7FR .035IN",SUP-BXA077902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8562.96,40,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 6-7 C-D KNEE",SUP-42-5121-004-11,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1253.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 80MM 80CM 16MM .035IN 3MM VASCULAR VENOUS 3",SUP-VENUM16080,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"KAISER [10500]",Kaiser,,14773.5,67,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARICALCITOL 2 MCG/ML INTRAVENOUS SOLUTION",RX-31688,CDM,J2501,HCPCS,0636,RC,00074-4637-01,NDC,both,1,ML,100.65,30.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5.19,,,,,,,2.21,85.55,"fee schedule",
"STENT ONYX FRONTIER 22MM 2MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG20022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK VITRECTOMY 20GA TOTAL PLUS CONSTELLATION 5000 CPM",SUP-8065751063,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1537.14,41.1,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 50MM BEVEL STERILE LATEX FREE MIS",SUP-SF4050,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"AETNA [10100]","Aetna HMO/PPO",,3949.56,79.5,,1521.93,481.35,16760.95,30,577.78,4222.8,"percent of total billed charges",
"BENCHMARK BMX96 DELIVERY CATHETER 90 CM",SUP-BMX9690,CDM,C1887,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ENTECAVIR 0.5 MG TABLET",RX-41147,CDM,,,0637,RC,60687-0216-95,NDC,both,1,UN,84.26,25.28,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ANTEPARTUM WITHOUT O.R. PROCEDURE,EXTREME",566,APR-DRG,,,,,,,inpatient,,,37533.10,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $8,689.51. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($40,245.97) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"MESALAMINE ER 500 MG CAPSULE,EXTENDED RELEASE",RX-39575,CDM,,,0637,RC,63304-0089-13,NDC,both,1,UN,25.19,7.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER MAMMARY SILICONE 600ML BREAST GEL SMOOTH ROUND",SUP-RSZ-6004,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.91,39.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PENICILLIN G DESENSITIZATION (0.001 MG/ML)",RX-410810,CDM,,,0636,RC,09999-9997-05,NDC,both,250,ML,100.65,30.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 73X25X.89MM MEDIUM WIDE STAINLESS STEEL SAGITTAL",SUP-2108160000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL J HOOK LOCK SHEATH MONOPOLAR LATEX",SUP-5600140,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT MARDIS 26CM 7FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251430,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"NOVANET [10819]",Novanet,,923.22,75,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 10CM 4MM 5FR BALLOON DILATATION",SUP-V1840100,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"NOVANET [10819]",Novanet,,4114.13,75,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 95MM MARS AUXILLARY",SUP-132.195,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"CEMENT BONE STABILIT ER2 SATURATE MIX 1 LEVEL",SUP-3366,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"MULTIPLAN [10600]",Multiplan,,1912.5,85,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER BIPOLAR AQUAMAN 2.3",SUP-23-113-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,2812.50,843.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,327.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUITY WHISPER VIEW ES - EACH",SUP-664640-001,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ARTEMIS 27CM 9.5FT 2.8MM EVACUATION CANN",SUP-AP28,CDM,S27200284,LOCAL,0272,RC,,,both,,,45328.50,13598.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,30823.38,68,,,,,0,5271.7,38529.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER 13CM 3.8MM COOLCUT BONE CUTTING",SUP-AR-8380BC,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"AETNA [10100]","Aetna HMO/PPO",,446.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SLALOM 80CM 20MM 3.7FR 4MM 6.5MM BALLOON",SUP-4384020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 90CM 8FR JR4 CURVE GUIDING PTFE FEMORAL",SUP-H749343587080,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"FIRST HEALTH [10303]","First Health",,293.15,80,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 30MM RELINE C SPINE THORACIC MEDIAL LATERAL",SUP-3985030,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"PHCS [10601]",PHCS,,3381,70,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 54MM SURGICAL 2MM CORTEX SCR NONSTERILE",SUP-311.19,CDM,S27000186,LOCAL,0270,RC,,,both,,,1319.00,395.7,"FIRST HEALTH [10303]","First Health",,1055.2,80,,,,,0,153.4,1121.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LEAD 4.75MM 4.75MM IS-1 DF-1 KIT PPM ACCESS",SUP-6623,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"MULTIPLAN [10600]",Multiplan,,258.83,85,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 28GA SPLITTABLE NDL BREAKAWAY MIDLINE CATH PICC",SUP-384061,CDM,C1892,HCPCS,0272,RC,,,both,,,327.38,98.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,38.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.07,278.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 SQUARE FULL THREAD CORKSCREW TIGERTAIL",SUP-AR-1927BCFT,CDM,C1713,HCPCS,0278,RC,,,both,,,2716.88,815.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1847.48,68,,,,,0,315.97,2309.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 7FR L20CM FIRM TRI LAYER DESIGN RAW COLORANT",SUP-M0061902300,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY",RX-114231,CDM,,,0250,RC,00472-1738-03,NDC,both,1,UN,59.59,17.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,24.49,41.1,,,,,0,6.93,50.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 32MM RESURFACING GENESIS II OXINIUM KNEE",SUP-71420576,CDM,C1776,HCPCS,0278,RC,,,both,,,6344.55,1903.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,737.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,737.87,5392.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Antibody ID Plt Ig",PX-302000010,CDM,86023,CPT,0302,RC,,,both,,,779.95,233.98,"CIGNA [10200]","Cigna Open Access",,27.41,,,,,,,0.01,662.96,"fee schedule",
"STEM FEMORAL 124MM 12.5MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-00771101200,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"MULTIPLAN [10600]",Multiplan,,17764.68,85,,,,,0,2430.63,17764.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH GREEN 16CM 12.5FR MAHURKAR ELITE DOUBLE-D LARGE",SUP-8888231416,CDM,C1752,HCPCS,0272,RC,,,both,,,1178.06,353.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,540.73,45.9,,,,,0,137.01,1001.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM 82MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE",SUP-02.117.805,CDM,C1713,HCPCS,0278,RC,,,both,,,6336.96,1901.09,"MULTIPLAN [10600]",Multiplan,,5386.42,85,,,,,0,736.99,5386.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.300 CLAREON",SUP-SY60WF.300,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 23MM 145CM 2.5MM CORONARY STENT",SUP-1145250-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AETNA [10100]","Aetna HMO/PPO",,4641.21,79.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 120MM 23MM ESOPHAGEAL PARTIAL COVER OTW STERILE",SUP-M00517730,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7508.97,41.1,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENV TISSUE 10.8X8.9CM CANGAROO 2XL SOFT REINFORCE SUPPLE",SUP-CMCV-010-XXL,CDM,S27800098,LOCAL,0278,RC,,,both,,,39375.00,11812.5,"PHCS [10601]",PHCS,,27562.5,70,,,,,0,4579.31,33468.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 12CM MR8 3MM MATCH HEAD TELESCOPE DISSECTING DIAMOND",SUP-MR8-T12MH30D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"NOVANET [10819]",Novanet,,947.7,75,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 10MM KNEE POLYETHYLENE STABILIZE ROTATE",SUP-129416610,CDM,C1776,HCPCS,0278,RC,,,both,,,12447.60,3734.28,"CIGNA [10200]","Cigna Open Access",,4169.95,33.5,,5302.19,4377.88,6578.61,27,1447.66,10580.46,"percent of total billed charges",
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 66MM 36MM MARATHON",SUP-121936466,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6693.14,68,,,,,0,1144.72,8366.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 9MM APTUS TITANIUM 6MM HEAD HAND CORTICAL LOCK",SUP-A-5400.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,579.99,45.9,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 19MM 29MM 26.3MM EPIC TISSUE STENT REDEFINE",SUP-E200-29M,CDM,S27800098,LOCAL,0278,RC,,,both,,,26775.00,8032.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7663.01,28.62,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT SOCKET RSP DJO SURGICAL STD HUMERAL HXE+ STERILE",SUP-509-00-036,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"FIRST HEALTH [10303]","First Health",,7222.18,80,,,,,0,1049.92,7673.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXS CATALYST 7 125CM .082-.0825IN .068IN ASPIRATION",SUP-IC068125,CDM,S27200284,LOCAL,0272,RC,,,both,,,16785.63,5035.69,"AETNA [10100]","Aetna HMO/PPO",,13344.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1952.17,14267.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 RB-1 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP215H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AXIOS 10MM 146MM 15MM 24MM 138MM 10.8FR PANCREATIC",SUP-M00553750,CDM,C1874,HCPCS,0278,RC,,,both,,,24658.20,7397.46,"FIRST HEALTH [10303]","First Health",,19726.56,80,,,,,0,2867.75,20959.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM DYONICS 25 FLUID MANAGEMENT 1 SUCTION INFLOW/OUTFLOW",SUP-7211006,CDM,S27000186,LOCAL,0270,RC,,,both,,,494.10,148.23,"NOVANET [10819]",Novanet,,370.58,75,,,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON PLUS DEMINERALIZED BONE MATRIX 10ML PASTE",SUP-T45010,CDM,C1713,HCPCS,0278,RC,,,both,,,6210.00,1863,"AMERIGROUP MEDICAID [20100]",Amerigroup,,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",722.22,5278.5,"percent of total billed charges",
"CATH TYSHAK II 100CM 5CM 9FR 23MM BALLOON DILATATION",SUP-611941,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"NOVANET [10819]",Novanet,,2850.91,75,,,,,0,442.08,3231.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Programming Device Eval Impl Ccm-D Sys in Person",PX-481000421,CDM,0926T,CPT,0481,RC,,,both,,,58.00,17.4,"AETNA [10100]","Aetna HMO/PPO",,46.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.75,58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 24MM 140CM 4MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927424400,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,1470,39.2,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSOLE SHOE 6.5-8 MEDIUM FEMALE DARCO PEG-ASSIST REMOVABLE",SUP-PTQW2,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.53,30.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,69.04,68,,,,,0,11.81,86.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 100MM 120CM 8MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200091020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE-9 CATHETER",SUP-AFR-00001,CDM,C1733,HCPCS,0272,RC,,,both,,,53550.00,16065,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,22009.05,41.1,,,,,0,6227.87,45517.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 12FR 50CM 12CM 2 DISTAL GWIRE HEMOSTASIS ADPTR",SUP-406306,CDM,C1894,HCPCS,0272,RC,,,both,,,210.98,63.29,"UHC [10700]","United Healthcare",,133.55,63.3,,,,,0,24.54,179.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 16MM HOLLOW CANNULATED PERCUTANEOUS STERILE",SUP-03.037.104S,CDM,S27000186,LOCAL,0270,RC,,,both,,,5415.40,1624.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,629.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.81,4603.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM 1.8MM KIRSCHNER STAINLESS STEEL TROCAR",SUP-02.110.300,CDM,C1713,HCPCS,0278,RC,,,both,,,54.08,16.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,6.29,45.97,"percent of total billed charges",
"SYSTEM XIENCE SIERRA 15MM 3.5MM CORONARY STENT EVEROLIMUS",SUP-1550350-15,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 17MM 135CM 5MM 20MM BILIARY STAINLESS STEEL",SUP-PXB35-05-17-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,517.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 150MM 5FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-06151,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"FIRST HEALTH [10303]","First Health",,1004.4,80,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840004535,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,3978.14,359.25,3978.14,24,441.36,3225.75,"percent of total billed charges",
"LINER ACETABULAR MM ELEVATE 60MM 36MM VIVACIT-E HIP STERILE",SUP-00885201436,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"NOVANET [10819]",Novanet,,7689.02,75,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 8FR .088IN AMPLATZ",SUP-588843,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LASER 25GA ILLUMINATED PIK RADIO FREQUENCY ID",SUP-8065751572,CDM,S27200284,LOCAL,0272,RC,,,both,,,950.62,285.19,"CIGNA [10200]",Cigna,,646.42,68,,,,,0,110.56,808.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 26MM 1 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800126,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 9MM 9FR ENDOPROSTHESIS HEPARIN ILIAC",SUP-VBHR090502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"CIGNA [10200]","Cigna Open Access",,6285.07,33.5,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE .038IN 10CM 2.5CM 5FR GUIDING STAINLESS",SUP-RSS502,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"PHCS [10601]",PHCS,,54.81,70,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION",RX-8120,CDM,J3301,HCPCS,0636,RC,00003-0293-05,NDC,both,1,ML,84.79,25.44,"UHC [10700]","United Healthcare",,5.76,,,,,,,3.48,72.07,"fee schedule",
"COIL EMBOLIZATION 4CM 2MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS02004,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"KAISER [10500]",Kaiser,,7854.48,67,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 8FR L26CM SOFT WITHOUT GUIDEWIRE TRIA",SUP-M0061903430,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CEREBROVASCULAR DISORDERS WITH CC",071,MS-DRG,,,,,,,inpatient,,,34850.13,10455.04,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,6555.27,,"Case rate ($6,364.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,909.72, add-ons for qualifying new technology services are included. If operating cost exceeds $38,949.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,828.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,917.54. The transfer operating threshold is the transfer adjustment factor * $5,909.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $446.80. The transfer capital threshold is the transfer adjustment factor * $446.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",6747.71,6747.71,6747.71,"1 through 10",6364.34,25587.41,other,"IP DRGs"
"CATH ADVANCE 150CM 6CM 4MM BALLOON DILATATION ILIAC",SUP-G34325,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR THUMB OR JOINT PROCEDURES",506,MS-DRG,,,,,,,inpatient,,,65860.45,19758.13,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER MENDER II MENISCAL REPAIR SET SUT STERILE DISPOSABLE",SUP-7209485,CDM,S27200284,LOCAL,0272,RC,,,both,,,1148.18,344.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ERCP RAPID EXCHANGE TAPER TIP 210CM BILIARY ACCEPTS",SUP-M00545770,CDM,S27200284,LOCAL,0272,RC,,,both,,,590.25,177.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SLIP-CATH BEACON 125CM 6FR HEADHUNTER 1 CURVE",SUP-G31134,CDM,S27200284,LOCAL,0272,RC,,,both,,,708.75,212.62,"CIGNA [10200]",Cigna,,481.95,68,,,,,0,82.43,602.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC ELATION 100CM 3CM 24-27-30FR PULMONARY CATH",SUP-P8L30,CDM,C1726,HCPCS,0272,RC,,,both,,,2137.50,641.25,"MULTIPLAN [10600]",Multiplan,,1816.88,85,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP INSRT TIBIAL DOME KNEE ROTATE PLATFORM",SUP-OSC357858,CDM,C1776,HCPCS,0278,RC,,,both,,,19530.00,5859,"NOVANET [10819]",Novanet,,14647.5,75,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 270MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-409-270,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X9MM COLONIAL 7D 12MM LARGE PEEK ACDF",SUP-365.409,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 4MM TITANIUM SPINE CORTEX SELF TAP STARDRIVE",SUP-401.354.99,CDM,C1713,HCPCS,0278,RC,,,both,,,526.50,157.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,61.23,447.53,"percent of total billed charges",
"CATH OMNICURVE 15MM G11 BALLOON VERTEBRAL FRACTURE KIT",SUP-1032-015-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,17883.68,5365.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2119.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2079.87,15201.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 14.5IN 14FR PHILLIPS 1/56IN HOLLOW PLASTIC 1",SUP-346114,CDM,S27200284,LOCAL,0272,RC,,,both,,,146.16,43.85,"CIGNA [10200]","Cigna Open Access",,83.17,56.9,,,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH",RX-27471,CDM,,,0250,RC,00378-9102-16,NDC,both,1,UN,12.54,3.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75446555,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 19MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-819,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"UHC [10700]","United Healthcare",,8519.2,63.3,,8601.07,8395.67,8601.07,"1 through 10",1565.22,11439.68,"percent of total billed charges",
"SCR BONE 1.2MM 12MM APTUS TITANIUM HAND CORTICAL HEXADRIVE 4",SUP-A-5100.12/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,519.34,41.1,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH HEMOSTATIC 4.8X4.8CM ABSORBABLE FIBRIN SEAL TACHOSIL",SUP-1144923,CDM,,,0278,RC,,,both,,,3159.09,947.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1450.02,45.9,,,,,0,3.16,2685.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 300MM 150MM 2.8MM STAINLESS STEEL CALIBRATE",SUP-292.81,CDM,C1769,HCPCS,0272,RC,,,both,,,552.10,165.63,"KAISER [10500]",Kaiser,,369.91,67,,,,,0,64.21,469.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAMP 6IN 10MM SURGICAL STAINLESS STEEL BONE KIENE NONSTERILE",SUP-250-418,CDM,S27100035,LOCAL,0271,RC,,,both,,,257.87,77.36,"CIGNA [10200]","Cigna Local Plus",,137.96,53.5,,,,,0,29.99,219.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 18FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0166SI18,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.21,20.46,"CIGNA [10200]","Cigna Open Access",,38.81,56.9,,,,,0,7.93,57.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 300ML P3.6CM MODERATE PLUS PROFILE HIGH",SUP-350-3001BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL LIGAPAK 2-0 54IN BRAID REEL COATED VIOLET",SUP-J206G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X10MM ADVANCED LORDOTIC TRAPEZOIDAL",SUP-7710,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 2 KNEE DISTAL HINGE",SUP-5612-D-205,CDM,C1776,HCPCS,0278,RC,,,both,,,10143.00,3042.9,"NOVANET [10819]",Novanet,,7607.25,75,,,,,0,1179.63,8621.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE JOURNEY II COCR WITH XR INSERT AND",SUP-71709040,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +3 CYL TORIC ACRYSOF IQ VIVITY",SUP-DFT515,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"KAISER [10500]",Kaiser,,566.15,67,,,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL LONG TEETH",SUP-NF02,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.32,23.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.11,66.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 12FR 20CM HYDROPHILIC RADIOPAQUE STERILE",SUP-G10292,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.78,56.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN EXTRA BACKUP LEFT 4 CURVE",SUP-LA7EBU40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL E-Z CLEAN STERILE PTFE DISPOSABLE",SUP-619,CDM,S27200284,LOCAL,0272,RC,,,both,,,153.99,46.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,104.71,68,,,,,0,17.91,130.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 20MM 109CM 10MM 75CM VASCULAR NITINOL ILIAC",SUP-H74939200102070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,481.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 18GA MAGSEED BREAST BIOPSY 7CM",SUP-SM18107001,CDM,A4648,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1062.52,28.62,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM DARCO TITANIUM FOOT NONLOCK",SUP-DC2820118,CDM,C1713,HCPCS,0278,RC,,,both,,,672.30,201.69,"NOVANET [10819]",Novanet,,504.23,75,,,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE WHOLEY VASCULAR STRAIGHT 145CM .035IN HYDROPHOBIC PTFE",SUP-WWFS35145,CDM,C1769,HCPCS,0272,RC,,,both,,,510.30,153.09,"NOVANET [10819]",Novanet,,382.73,75,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 9IN .5MM SENTINEL ROUNDED ECCENTRIC MONO FLUTED",SUP-S8585,CDM,S27200284,LOCAL,0272,RC,,,both,,,1593.51,478.05,"FIRST HEALTH [10303]","First Health",,1274.81,80,,,,,0,185.33,1354.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 149MM 14MM PRIMARY PRESSFIT TRABECULAR METAL",SUP-00786401400,CDM,C1776,HCPCS,0278,RC,,,both,,,30164.40,9049.32,"BLUE CROSS [10001]","Blue Cross HMO",,11824.44,39.2,,5311.50,4717.44,5388.59,31,3508.12,25639.74,"percent of total billed charges",
"TROCAR LAPAROSCOPIC LOW PROFILE 55MM 5MM KII 2 PACK ACCESS",SUP-CTB23,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"UHC [10700]","United Healthcare",,137.68,63.3,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 8MM 1MM BALLOON DILATATION PERCUTANEOUS",SUP-210-083-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"FIRST HEALTH [10303]","First Health",,1004.4,80,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ULTRABUTTON FIXATION ADJUSTABLE LOOP REDUCTION",SUP-72290003,CDM,C1713,HCPCS,0278,RC,,,both,,,3543.75,1063.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,419.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",412.14,3012.19,"percent of total billed charges",
"STENT COVERA 40MM 80CM 10MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM10040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PHCS [10601]",PHCS,,12789,70,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 6MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120615,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1381.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 30CC 1.7-10MM ALLOGRAFT CHIPS FREEZE",SUP-400150,CDM,C1713,HCPCS,0278,RC,,,both,,,2600.25,780.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,308.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,302.41,2210.21,"percent of total billed charges",
"RELOAD STPLR MEDIUM TRI-STAPLE 2 VASCULAR RADIAL STERILE",SUP-SIGRADVM,CDM,S27200284,LOCAL,0272,RC,,,both,,,2760.15,828.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1266.91,45.9,,,,,0,321.01,2346.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT THR G7 HIP XLPE STEM CUP LINER STD HEAD",SUP-98000100128,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"AETNA [10100]","Aetna HMO/PPO",,19032.3,79.5,,10981.53,8986.79,12413.38,12,2784.22,20349,"percent of total billed charges",
"APPL INTERNAL CLIP MEDIUM 33CM TITANIUM LIGATE PISTOL GRIP",SUP-176619,CDM,S27200284,LOCAL,0272,RC,,,both,,,679.10,203.73,"MULTIPLAN [10600]",Multiplan,,577.24,85,,,,,0,78.98,577.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC INTICA 7 DF-1 CONNECTION MR CONDITIONAL HF-T",SUP-404627,CDM,C1882,HCPCS,0278,RC,,,both,,,78945.00,23683.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9354.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9181.3,67103.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 3 X 8 HELICAL PICO COIL",SUP-10USH03008,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Local Plus",,3692.78,31.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DECA 5-5-5-24-3-3-3-3-3 MPA 120CM",SUP-901828,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE NASOGASTRIC 22IN 5FR PORT ANTICLOG RADIOPAQUE BOW TIP",SUP-20-C1225,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.97,23.99,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MICROCATHETER INFUSION 120CM 2.9FR .025IN TRINAV LV",SUP-TVM-25120-50,CDM,C1982,HCPCS,0272,RC,,,both,,,50292.90,15087.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH ADVANCE 170CM 4CM 2.5MM BALLOON DILATATION HYDROPHILIC",SUP-G50321,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 20MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER DIAGNOSTIC 4FR L100CM GUIDEWIRE 0.038IN NYLON JUDKI",SUP-538417,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"FIRST HEALTH [10303]","First Health",,71.62,80,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 8MM 4MM CORONARY STENT EVEROLIMUS RAPID",SUP-1550400-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"APPL INTERNAL CLIP 20D MEDIUM HEART 8IN TITANIUM LIGATE",SUP-237081,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1147.5,68,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.35IN 20FR HEYMAN PLASTIC COUDE TIP DILATION",SUP-021320,CDM,S27200284,LOCAL,0272,RC,,,both,,,242.30,72.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,99.59,41.1,,,,,0,28.18,205.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9 % 1000 ML PRESSURE BAG",RX-408326,CDM,,,0258,RC,00338-0049-04,NDC,both,1000,ML,100.65,30.19,"CIGNA [10200]","Cigna Local Plus",,53.85,53.5,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 22MM 4.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG45022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2887.50,866.25,"AETNA [10100]","Aetna HMO/PPO",,2295.56,79.5,,,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL LEGION 3 KNEE LEFT JOURNEY LOCK",SUP-71933569,CDM,C1776,HCPCS,0278,RC,,,both,,,25949.70,7784.91,"CIGNA [10200]","Cigna Open Access",,8693.15,33.5,,5302.19,4377.88,6578.61,27,3017.95,22057.25,"percent of total billed charges",
"PLATE LEFT PROXIMAL TIBIAL 118MM STAINLESS STEEL 4.5MM SCR",SUP-240.039,CDM,C1713,HCPCS,0278,RC,,,both,,,8699.80,2609.94,"CIGNA [10200]","Cigna Open Access",,4950.19,56.9,,1144.80,304.56,2275.09,66,1011.79,7394.83,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 12MM 140CM 5MM 2.1-2.7FR CORONARY STENT",SUP-RONYX50012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"AETNA [10100]","Aetna HMO/PPO",,2921.63,79.5,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM  RESOLUTE ONYX OTW CORONARY STENT  2.00 X 30MM",SUP-RONYX20030W,CDM,C1874,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,414.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890005545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 80MM 6FR 4MM 4FR BALLOON DILATATION",SUP-39032-40801,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"PHCS [10601]",PHCS,,1048.95,70,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 23IN 36FR ANGLE RIGHT TAPER DRNG PVC THORAX 5 EYELET",SUP-8136,CDM,C1729,HCPCS,0272,RC,,,both,,,90.25,27.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.5,76.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79MMX10MM VANGUARD ARCOM KNEE ANTERIOR STABILIZE",SUP-189100,CDM,C1776,HCPCS,0278,RC,,,both,,,8154.42,2446.33,"AETNA [10100]","Aetna HMO/PPO",,6482.76,79.5,,10981.53,8986.79,12413.38,12,948.36,6931.26,"percent of total billed charges",
"MARKER SURGICAL MARGINMARKER 6 COLOR STERILE",SUP-MMS6,CDM,S27200284,LOCAL,0272,RC,,,both,,,1437.83,431.35,"FIRST HEALTH [10303]","First Health",,1150.26,80,,,,,0,167.22,1222.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS 135CM 60MM 7MM .035IN BALLOON DILATATION",SUP-AB35W07060135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,460.47,68,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM INFINITY SPINE OCCIPITOCERVICAL UPPER",SUP-3603518,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,3978.14,359.25,3978.14,24,441.36,3225.75,"percent of total billed charges",
"STENT GORE VIABAHN 7.5CM 120CM 5MM 7FR ENDOPROSTHESIS",SUP-VBHR050702A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2473.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS 75CM 6CM 12MM 7FR BALLOON DILATATION PERIPHERAL",SUP-AT75126,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,239.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 14MM PERSONA MEDIAL CONGRUENT 8-9 C-D KNEE",SUP-42522100514,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"FIRST HEALTH [10303]","First Health",,8621.14,80,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 120MM 7MM BALLOON",SUP-U3575712,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR MEDIUM RING SOFT COMPLIANT 7.5CM SOFT TISSUE SURGICAL",SUP-TRM,CDM,S27200284,LOCAL,0272,RC,,,both,,,2453.70,736.11,"AETNA [10100]","Aetna HMO/PPO",,1950.69,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,285.37,2085.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 11MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P311,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,971.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PLASTIBELL 1.1CM CIRCUMCISION PLASTIC PEDIATRIC",SUP-9231,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.65,18.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25.34,41.1,,,,,0,7.17,52.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 4MM 58MM NAIL-EX TITANIUM FULL THREAD HUMERAL TIB",SUP-04.005.448,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"CIGNA [10200]","Cigna Open Access",,658.15,56.9,,1144.80,304.56,2275.09,66,134.52,983.18,"percent of total billed charges",
"SUT VICRYL PLUS 1 OS-6 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP535H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 65MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0276,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]","Cigna Local Plus",,507.02,53.5,,3978.14,359.25,3978.14,24,110.22,805.55,"percent of total billed charges",
"HC Rv Tib/Prneal W Ather Sf Init",PX-361000729,CDM,37288,CPT,0361,RC,,,both,,,23403.71,7021.11,"AETNA [10100]","Aetna HMO/PPO",,18605.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2721.85,19893.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (MR) 10MM X 2.75",SUP-H74939401102750,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 8.5FR 180CM 81CM SUPERSTIFF GUIEWIRE GUIDING",SUP-407454,CDM,C1893,HCPCS,0272,RC,,,both,,,1437.75,431.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC",487,MS-DRG,,,,,,,inpatient,,,80806.34,24241.9,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE EKOS 135CM 2.62MM THROMBECTOMY ENDOVASCULAR STERILE",SUP-H74939605135200,CDM,C1757,HCPCS,0272,RC,,,both,,,37894.50,11368.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH RENEGADE STC-18 150CM 20MM 3-2.4FR .021IN 90D MICRO",SUP-M001181390,CDM,C1887,HCPCS,0272,RC,,,both,,,2325.00,697.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Sn Routine Visit",PX-551000006,CDM,G0299,HCPCS,0551,RC,,,outpatient,,,236.00,70.8,"NOVANET [10819]",Novanet,,177,75,,,,,0,158.12,200.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 40MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75448540,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 38MM CG FUTURE FLEXIBLE LOW PROFILE EYELET",SUP-638BL38,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 5 PRIMARY",SUP-5520-B-500,CDM,C1776,HCPCS,0278,RC,,,both,,,7151.76,2145.53,"BLUE CROSS [10001]","Blue Cross PPO",,2803.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",831.75,6079,"percent of total billed charges",
"GWIRE PLATINUM PLUS VASCULAR 260CM 3CM .018IN MEDIGLIDE",SUP-M001466050,CDM,C1769,HCPCS,0272,RC,,,both,,,1539.00,461.7,"FIRST HEALTH [10303]","First Health",,1231.2,80,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 251MM 10.2MM CANNULATED",SUP-03.168.005,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 100MM 120CM 14MM 3MM VASCULAR VENOUS",SUP-VENUL14100,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHORD-X 2-0 .5 CIRCLE 18MM 2 ARM LOOP PLEDG 3 CHORDAL 20",SUP-CXL-20-1812-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR ADULT LNCS 3FT OXIMETER SPO2 ADHSV SOFT STERILIZABLE",SUP-2653,CDM,S27000186,LOCAL,0270,RC,,,both,,,1490.40,447.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,176.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 19.5MM PRECISION THK.38MM 41MM MICRO STAINLESS",SUP-2296003254,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,32.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 19.5MM PRECISION THK.38MM 41MM MICRO STAINLESS",SUP-2296003254,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"UHC [10700]","United Healthcare",,171.05,63.3,,,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 300MM 6MM BALLOON DILATATION RAPID",SUP-47560300L,CDM,C1725,HCPCS,0272,RC,,,both,,,1890.00,567,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,223.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 30CM 6FR 2.1FR POLARIS ULTRA NAUTILUS .035IN 2",SUP-M006192135050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,142.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE RING BILLARY 25CM",SUP-G03388,CDM,S27200284,LOCAL,0272,RC,,,both,,,413.16,123.95,"CIGNA [10200]","Cigna Open Access",,235.09,56.9,,,,,0,48.05,351.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 80CM 80MM 9MM BALLOON TRANSLUMINAL PACLITAXEL",SUP-IAV09008008P,CDM,C2623,HCPCS,0272,RC,,,both,,,10281.00,3084.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4225.49,41.1,,,,,0,1195.68,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH C-FLEX 70CM 8FR URETERAL TAPER TIP 1 LUMEN RADIOPAQUE",SUP-M0064001530,CDM,C1758,HCPCS,0272,RC,,,both,,,325.47,97.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.85,276.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 3INX8MM OSTEOTOM THIN STERILE DISPOSABLE",SUP-71369208,CDM,S27200284,LOCAL,0272,RC,,,both,,,746.01,223.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,342.42,45.9,,,,,0,86.76,634.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +24 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0240,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,523.91,39.2,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GAUGE MEASURING HEIGHT GAGE KNEE",SUP-66418964,CDM,S27200284,LOCAL,0272,RC,,,both,,,1381.05,414.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,163.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.62,1173.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +24 DIOPTER +3 CYL BICONVEX 13MM 6MM POSTERIOR",SUP-SN6AT5.240,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Local Plus",,184.58,53.5,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE",RX-8880,CDM,,,0637,RC,77333-0983-25,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,3.35,53.5,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE PSI KIT (GLENOID ONLY)",SUP-1235-7152-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,702.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESTRICT CEMENT MEDIUM UNIVERSAL",SUP-B000-0240,CDM,S27800098,LOCAL,0278,RC,,,both,,,620.57,186.17,"CIGNA [10200]","Cigna Open Access",,353.1,56.9,,,,,0,72.17,527.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL E RIGHT CEMENTED POSTERIOR STABILIZED OPTION",SUP-00596401552,CDM,C1776,HCPCS,0278,RC,,,both,,,15346.80,4604.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6138.72,40,,,,,0,1784.83,13044.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL CEMENT HEAD TRABECULAR METAL SHOULDER GLENO",SUP-98000900024,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"MULTIPLAN [10600]",Multiplan,,25436.25,85,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5INX8MM OSTEOTOM LONG MRI STERILE LATEX FREE",SUP-47998602127,CDM,S27200284,LOCAL,0272,RC,,,both,,,996.30,298.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,457.3,45.9,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM TRIDENT",SUP-509-02-58F,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3032.64,27,,,,,0,1306.28,9547.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR .092IN 25CM ROBUST VALVE SPLITTABLE WITHOUT",SUP-PLSX-2507,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"FIRST HEALTH [10303]","First Health",,313.2,80,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR NARROW LORDOTIC 12 DEGRE",SUP-2319,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 20MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405620,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"AETNA [10100]","Aetna HMO/PPO",,7682.44,79.5,,10981.53,8986.79,12413.38,12,1123.86,8213.93,"percent of total billed charges",
"PLATE 60MM 3 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-43F60V,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"SCR BONE 4MM 26MM SPINE PLY NONSTERILE 4MM ROD",SUP-102040126,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 135CM 4CM 5FR 10MM 7.5MM BALLOON DILATATION",SUP-4190040X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502606602,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"KAISER [10500]",Kaiser,,15318.01,67,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175263190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 7MM AXIUM 3D FRAME V01",SUP-FC-7-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,13765.50,4129.65,"BLUE CROSS [10001]","Blue Cross HMO",,5396.08,39.2,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 150MM 4MM XPS ASB 15D CURVED SINUS CUT",SUP-1884075HSE,CDM,S27200284,LOCAL,0272,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Local Plus",,1905.94,53.5,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13176540,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,348.9,2550,"percent of total billed charges",
"BLADE RTRCTR 20MM MARS 3V SYSTEM DOCK PIN",SUP-698.315S,CDM,C1713,HCPCS,0278,RC,,,both,,,2640.00,792,"FIRST HEALTH [10303]","First Health",,2112,80,,,,,0,307.03,2244,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 10 STD KNEE RIGHT CRUCIATE RETAINING PERSONA",SUP-42502806802,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3424.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3360.56,24561.24,"percent of total billed charges",
"FILLER BONE VOID 1.5CC 1-2MM GRANULE MAGNETOS EASYPACK PUTTY",SUP-703-048-US,CDM,C1713,HCPCS,0278,RC,,,both,,,3881.25,1164.37,"PHCS [10601]",PHCS,,2716.88,70,,,,,0,451.39,3299.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 25CM 14FR PIGTAIL CURVE DRNG POLYURETHANE",SUP-RLC-14-038,CDM,C1729,HCPCS,0272,RC,,,both,,,531.36,159.41,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.8,451.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SOLITAIRE 31MM 20MM 6MM 10MM SPACE 4-1 VASCULAR",SUP-SFR4-6-20-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,40761.00,12228.3,"PHCS [10601]",PHCS,,28532.7,70,,,,,0,4740.5,34646.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER SUPPORT L135CM DIA0.0375IN COMPATIBLE GUIDEWIRE 0.0",SUP-P1VC-018STR-135,CDM,C1894,HCPCS,0272,RC,,,both,,,1458.00,437.4,"FIRST HEALTH [10303]","First Health",,1166.4,80,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM 47.8MM HIP 3 SCR HOLE CLUSTER HA",SUP-542-11-46D,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4731.25,68,,,,,0,809.18,5914.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST OP BRA 38D BLACK",SUP-B01G-38D-B,CDM,S27000186,LOCAL,0270,RC,,,both,,,178.18,53.45,"AETNA [10100]","Aetna HMO/PPO",,141.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.72,151.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 150MM 5.5MM CREO STRAIGHT TITANIUM MIS NONSTERILE",SUP-1134.5150,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"SUT SILK PERMA-HAND MULTIPASS 3-0 PS-1 18IN BRAID BLACK",SUP-1684G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"NOVANET [10819]",Novanet,,18.75,75,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 28MM ACUTRAK 2 STD",SUP-AT2-S28-S,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"MULTIPLAN [10600]",Multiplan,,2709.38,85,,,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FLAT CHUCK SKYLINE 12MM",SUP-286820012,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"CIGNA [10200]",Cigna,,2690.35,68,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 12MM 3.75MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012410-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 55MM 18MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113618,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"KAISER [10500]",Kaiser,,8442,67,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 36MM +3MM GLENOSPHERE COLOR CODED",SUP-115313,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3292.11,27,,,,,0,1418.05,10364.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.50MM X 10MM  SCOREFLEX  NC",SUP-625-104-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUE FLOW 110CM 3.5CM 24MM 14FR PERFUSION BALLOON",SUP-TF0243514,CDM,C1725,HCPCS,0272,RC,,,both,,,11730.00,3519,"AETNA [10100]","Aetna HMO/PPO",,9325.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 52CM RVOT KIT MOND STAINLESS STEEL MEDIUM",SUP-4141/52,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,66.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - TIBIAL KIT (PS) - SIZE 1",SUP-5555-2361,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"UHC [10700]","United Healthcare",,640.91,63.3,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZEBRA UROLOGICAL 150CM 3CM .038IN URO-GLIDE NITINOL",SUP-M0066701151,CDM,C1769,HCPCS,0272,RC,,,both,,,447.74,134.32,"MULTIPLAN [10600]",Multiplan,,380.58,85,,,,,0,52.07,380.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 700CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP135RUH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"CIGNA [10200]","Cigna Local Plus",,3749.29,,,,,,,1384.26,10117.13,"percent of total billed charges",
"IMPL BREAST 375CC NATRELLE INSPIRA COHESIVE STERILE LATEX",SUP-SCM-375,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]","Cigna Local Plus",,4042.19,,,,,,,878.7,6422.18,"percent of total billed charges",
"MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION",RX-160048,CDM,,,0250,RC,00121-0945-10,NDC,both,10,ML,31.58,9.47,"FIRST HEALTH [10303]","First Health",,25.26,80,,,,,0,3.67,26.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 9IN CODMAN VERSATRU 1.5MM STD NONSTICK SLEEK",SUP-9009150ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,3198.15,959.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2174.74,68,,,,,0,371.94,2718.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CLEANGUIDE ENDOSCOPIC 19MM ESOPHAGEAL OTW MARK SPRING",SUP-CG-19-3,CDM,C1769,HCPCS,0272,RC,,,both,,,526.50,157.95,"UHC [10700]","United Healthcare",,333.27,63.3,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP SMF WITH UNIPOLAR HEAD",SUP-71705615,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"NOVANET [10819]",Novanet,,7762.5,75,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 95MM 32MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-217.095,CDM,C1713,HCPCS,0278,RC,,,both,,,485.35,145.6,"FIRST HEALTH [10303]","First Health",,388.28,80,,,,,0,56.45,412.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CYPHER 18MM 137CM 2.25MM CORONARY SIROLIMUS ELUTING",SUP-CXS18225,CDM,C1874,HCPCS,0278,RC,,,both,,,13110.00,3933,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3539.7,27,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5CMX12MM FLAT ROUND TIP OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-6-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"FIRST HEALTH [10303]","First Health",,1166.4,80,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 4FR 65CM TRIFORCE FLEXOR PEEL-AWAY CURVE TAPER DOWN",SUP-G56419,CDM,S27200284,LOCAL,0272,RC,,,both,,,2711.18,813.35,"CIGNA [10200]","Cigna Open Access",,1542.66,56.9,,,,,0,315.31,2304.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ 90CM 5FR PULMONARY ARTERY 3 LUMEN BIPOLAR",SUP-D97120F5,CDM,C1730,HCPCS,0272,RC,,,both,,,953.86,286.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,110.93,810.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 22CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175261080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,568.88,45.9,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 30MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206080370,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ONE1STEP CENTESIS CATHETER 5F 10CM19GA INTRODUCER NEEDLE4",SUP-OSC-5F-10LT,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.35,53.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.3MM 65MM CENTRONAIL TITANIUM ANKLE LOCKING",SUP-99-T774065,CDM,C1713,HCPCS,0278,RC,,,both,,,1492.91,447.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,173.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",173.63,1268.97,"percent of total billed charges",
"SCR BONE 4MM 44MM 15MM STAINLESS STEEL PARTIAL THREAD",SUP-121844,CDM,C1713,HCPCS,0278,RC,,,both,,,2006.40,601.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1364.35,68,,,,,0,233.34,1705.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 34MMX8MMX15CM 24FR",SUP-TAC083415A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"BLUE CROSS [10001]","Blue Cross HMO",,71500.8,39.2,,9776.84,9776.84,9776.84,"1 through 10",21213.12,155040,"percent of total billed charges",
"SYSTEM SYNERGY 8MM 144CM 2.75MM CORONARY STENT PEBAX",SUP-H7493926008270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 40MM 120CM 10MM 8FR STRAIGHT VASCULAR",SUP-AVSL10040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7308,40,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOCKING COMPRESSION SCREW 1.8MM X 7.0MM COCR",SUP-CMP-18007-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,508.03,39.2,,957.42,570.23,957.42,28,150.72,1101.6,"percent of total billed charges",
"CATH SLIP-CATH BEACON TIP 40CM 4FR ANGLE KUMPE CURVE",SUP-G31018,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SLIP-CATH BEACON TIP 40CM 4FR ANGLE KUMPE CURVE",SUP-G31018,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 10-11 E-F KNEE RIGHT TIBIA",SUP-42522400810,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3084.21,28.62,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE 79IN .28IN ONE SNARE 1 NITINOL LOOP GOLD PLATED",SUP-ONE701,CDM,S27200284,LOCAL,0272,RC,,,both,,,4278.00,1283.4,"CIGNA [10200]","Cigna Open Access",,2434.18,56.9,,,,,0,497.53,3636.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.5MM X 9MM TI",SUP-VAN-15090-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]",Cigna,,660.96,68,,1831.33,1831.33,1831.33,16,113.04,826.2,"percent of total billed charges",
"BURR SURGICAL 69.9MM 4MM LONG CARBIDE ROUND 8 FLUTED 5092228",SUP-5300020511,CDM,S27000186,LOCAL,0270,RC,,,both,,,271.18,81.35,"NOVANET [10819]",Novanet,,203.39,75,,,,,0,31.54,230.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 80MM 120CM 4.5MM 6FR VASCULAR NITINOL",SUP-S-45-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"KAISER [10500]",Kaiser,,6125.48,67,,,,,0,1063.27,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 110CM 4FR 145D PIGTAIL CURVE",SUP-538453S,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"NOVANET [10819]",Novanet,,67.14,75,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ARTHROSCOPIC ASPIRATE ABLATOR APOLLORF SMALL JOINT 50D",SUP-AR-9845,CDM,S27200284,LOCAL,0272,RC,,,both,,,1968.75,590.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,228.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,228.97,1673.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROLL 24INX6IN VINYL POSITIONING PEDIATRIC TUMBLE FORMS 2",SUP-2794B,CDM,S27000186,LOCAL,0270,RC,,,both,,,806.11,241.83,"CIGNA [10200]","Cigna Local Plus",,431.27,53.5,,,,,0,93.75,685.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARM ENDOSCP 5MM .6MM 1MM RICHARDS STAPES FLUOROPLASTIC",SUP-142138,CDM,S27800098,LOCAL,0278,RC,,,both,,,908.25,272.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,105.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.63,772.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 15MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE32515,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"BLUE CROSS [10001]","Blue Cross PPO",,32796.52,39.2,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOBRAMYCIN 40 MG/ML INJECTION SOLUTION",RX-97790,CDM,J3260,HCPCS,0636,RC,67457-0473-00,NDC,both,2,ML,18.92,5.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5.56,,,,,,,2.43,16.08,"fee schedule",
"STEM FEMORAL 170MM SUMMIT POROCOAT 10 12/14 STD OFFSET TAPER",SUP-157001180,CDM,C1776,HCPCS,0278,RC,,,both,,,25247.25,7574.17,"KAISER [10500]",Kaiser,,16915.66,67,,,,,0,2936.26,21460.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ASCEND FLEX SHOULDER - TOTAL SHOULDER (INCLUSIVE OF ASCE",SUP-CAPFLEXTSA,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"PHCS [10601]",PHCS,,18742.5,70,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT225180,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC New Eval Visit Level 4",PX-510000174,CDM,99204,CPT,0761,RC,,,both,,,512.72,153.82,"BLUE CROSS [10001]","Blue Cross PPO",,0.51,.1,,,,,0,0.51,512.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 4 KNEE RIGHT TOTAL STABILIZE",SUP-5541-A-402,CDM,C1776,HCPCS,0278,RC,,,both,,,6699.90,2009.97,"FIRST HEALTH [10303]","First Health",,5359.92,80,,,,,0,779.2,5694.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC LARGE 38X6IN SHOULDER VELPEAU ELASTIC WRIST",SUP-9008-03,CDM,S27000186,LOCAL,0270,RC,,,both,,,103.62,31.09,"CIGNA [10200]","Cigna Local Plus",,55.44,53.5,,,,,0,12.05,88.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 90MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.085,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 80.6X53.1X4.8MM MBT 5MM KNEE CEMENTED REVISION",SUP-129435150,CDM,C1776,HCPCS,0278,RC,,,both,,,22385.16,6715.55,"NOVANET [10819]",Novanet,,16788.87,75,,,,,0,2603.39,19027.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 76MM 12MM ZENITH HANDL-B ONE-SHOT 2 BRANCH",SUP-G32551,CDM,C1874,HCPCS,0278,RC,,,both,,,24689.70,7406.91,"CIGNA [10200]",Cigna,,9875.88,40,,,,,0,2871.41,20986.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL LARGE+ KNEE LEFT LCS COMPLETE POROCOAT STERILE",SUP-129404070,CDM,C1776,HCPCS,0278,RC,,,both,,,28683.90,8605.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7744.65,27,,,,,0,3335.94,24381.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 20MM 1.5MM BALLOON DILATATION RAPID",SUP-47515020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PHCS [10601]",PHCS,,1116.99,70,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 30MM 6FR 3MM 4FR BALLOON",SUP-H74939031303010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) INTREPID TRANSFEMORAL SUPPORT PLATE",SUP-INTPDTFSPG,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLP LEAD LEAD EXTRACTION STERILE DISPOSABLE",SUP-G20003,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STNT WALLFLEX 60MM 48MM 10MM",SUP-7473,CDM,C1894,HCPCS,0272,RC,,,both,,,261.00,78.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DXTERITY 100CM 5FR .047IN INTERNAL MAMMARY ARTERY CURVE",SUP-DXT5IMA,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTREPIDTM TMVR CRIMPER",SUP-ASM-0014,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 12IN 24FR ARTERIAL ADULT 3/8IN CNCT NONVENTED",SUP-77524,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Manip Knee Joint W/Anes",PX-361000513,CDM,27570,CPT,0361,RC,,,both,,,3992.24,1197.67,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1718,,"Case rate ($1,718). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,464.3,3992.24,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 100CM 3MM BALL NOSE DISPOSABLE VERSANAIL",SUP-281001100,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CIRCULATORY SYSTEM O.R. PROCEDURES",264,MS-DRG,,,,,,,inpatient,,,113503.96,34051.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,66314.25,,"Fee schedule rate ($66,314.25). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,97532.16,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOR BLADDER PROCEDURES WITHOUT CC/MCC",664,MS-DRG,,,,,,,inpatient,,,54205.43,16261.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19867.02,,"Fee schedule rate ($19,867.02). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,6493.99,30565.29,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 35MM ADJUSTABLE FULL FLEXIBLE RADIOPAQUE",SUP-AFR-35,CDM,S27800098,LOCAL,0278,RC,,,both,,,16909.83,5072.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1966.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1966.61,14373.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 13.5CM 16MM 13.5-14.5MM EXCLUDER",SUP-PLC161400,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7559.24,27,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 91MM 16FR ZENITH ABDOMINAL AORTIC",SUP-G32555,CDM,C1874,HCPCS,0278,RC,,,both,,,23565.28,7069.58,"KAISER [10500]",Kaiser,,15788.74,67,,,,,0,2740.64,20030.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 20FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0166SI20,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.21,20.46,"UHC [10700]","United Healthcare",,43.18,63.3,,,,,0,7.93,57.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 7CM MR8 .8MM 4MM TWIST DRILL DISSECTING",SUP-MR8-7TD084,CDM,S27200284,LOCAL,0272,RC,,,both,,,1416.29,424.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,650.08,45.9,,,,,0,164.71,1203.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYDIOXANONE QUILL SRS 2 2XT11 TAPER 1/2 CIRCLE 36X36CM",SUP-RA-1065Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.89,65.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.34,185.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 230MM 4+ MM FLEXIGRAFT GRACILIS TENDON",SUP-FGRACILIS,CDM,S27800098,LOCAL,0278,RC,,,both,,,7607.25,2282.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2177.19,28.62,,,,,0,884.72,6466.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GUIDANCE NAVIGUS EXTERNAL TRAJECTORY KIT",SUP-9733065,CDM,S27200284,LOCAL,0272,RC,,,both,,,8882.92,2664.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6040.39,68,,,,,0,1033.08,7550.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 65CM 5FR ROSCH INFERIOR MESENTRIC CURVE",SUP-H787117334015,CDM,C1887,HCPCS,0272,RC,,,both,,,704.05,211.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,478.75,68,,,,,0,81.88,598.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM SAPIEN 3 ULTRA RESILIA",SUP-S3URCM29A,CDM,S27800098,LOCAL,0278,RC,,,both,,,193800.00,58140,"AMERIGROUP MEDICAID [20100]",Amerigroup,,22965.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22538.94,164730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIG WATER STRL 1000-MSO",SUP-2F7114,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PHCS [10601]",PHCS,,17.5,70,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN SL4 CURVE GUIDING CORONARY",SUP-LA7SL40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL MEDIUM NEUTRAL 65MM KNEE COCRMO UHMWPE MODULAR",SUP-16-2817/35,CDM,C1776,HCPCS,0278,RC,,,both,,,28346.09,8503.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3359.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3296.65,24094.18,"percent of total billed charges",
"SIZER IMPL 14.1CM MEMORYGEL BOOST P4.8CM MODERATE PLUS",SUP-RSZMPB545S,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,121.01,68,,,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET TITANIUM SPINE BREAKOFF",SUP-7340000GR,CDM,C1713,HCPCS,0278,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE CHECKER 130CM 10CM 5MM BALLOON DILATATION",SUP-U8130510,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135CM 100MM 7MM .035IN LOW PROFILE BALLOON",SUP-B2070-100,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL CANNULATED SI-LOK 7.5MM",SUP-639.217,CDM,S27200284,LOCAL,0272,RC,,,both,,,3435.00,1030.5,"CIGNA [10200]","Cigna Open Access",,1954.52,56.9,,,,,0,399.49,2919.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRADYN 14CM 9FR INTRO TEAR AWAY",SUP-612606,CDM,C1892,HCPCS,0272,RC,,,both,,,262.55,78.76,"MULTIPLAN [10600]",Multiplan,,223.17,85,,,,,0,30.53,223.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 100X25MM KINEX THK4MM BIOACTIVE STRIP 10CC",SUP-8115.0110S,CDM,C1713,HCPCS,0278,RC,,,both,,,9867.00,2960.1,"CIGNA [10200]","Cigna Local Plus",,5278.85,53.5,,3978.14,359.25,3978.14,24,1147.53,8386.95,"percent of total billed charges",
"STENT UNIVERSA 22CM 5FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49896,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,89.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT HAND ACCESS LOW PROFILE OBTR BLADELESS OPTICAL TIP",SUP-IAS5-120LP,CDM,S27200284,LOCAL,0272,RC,,,both,,,721.05,216.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,330.96,45.9,,,,,0,83.86,612.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1.5CM 1MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR091015,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"PHCS [10601]",PHCS,,9258.1,70,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 18-14MM 14MM 11FR TRIVASCULAR OVATION",SUP-TV-IL1418100-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"AETNA [10100]","Aetna HMO/PPO",,26545.05,79.5,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Retrograde Gundry 15fr",PX-E27200353,CDM,E27200353,LOCAL,0272,RC,,,both,,,521.40,156.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,239.32,45.9,,,,,0,60.64,443.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 400ML P4CM MODERATE PLUS PROFILE HIGH PROJECTION",SUP-350-4001BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5347.50,1604.25,"BLUE CROSS [10001]","Blue Cross HMO",,2096.22,39.2,,,,,0,621.91,4545.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION",RX-4455,CDM,J2003,HCPCS,0636,RC,00409-4283-11,NDC,both,5,ML,43.79,13.14,"KAISER [10500]",Kaiser,,29.34,67,,,,,0,2.33,37.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 90MM 1.8MM NONSTERILE LATEX FREE DISPOSABLE",SUP-DRILL-1.8/090,CDM,S27000186,LOCAL,0270,RC,,,both,,,1012.50,303.75,"AETNA [10100]","Aetna HMO/PPO",,804.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-04006,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4114.06,45.9,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Cerv/Thorac Sngl W Img",PX-510000204,CDM,62321,CPT,0761,RC,,,both,,,3841.43,1152.43,"PHCS [10601]",PHCS,,2689,70,,,,,0,446.76,3265.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 350CC",SUP-SMPX350,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"MULTIPLAN [10600]",Multiplan,,6334.2,85,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL DEBAKEY 10.5IN 1X2 TEETH 8.5CM AORTIC",SUP-55-6054,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.31,262.29,"CIGNA [10200]",Cigna,,594.53,68,,,,,0,101.68,743.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 149MM 14MM PRIMARY PRESSFIT TRABECULAR METAL",SUP-00786401400,CDM,C1776,HCPCS,0278,RC,,,both,,,30164.40,9049.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12397.57,41.1,,6417.48,6417.48,6417.48,"1 through 10",3508.12,25639.74,"percent of total billed charges",
"RING ANNULOPLASTY 24MM RIGID SADDLE SUT CUFF TITANIUM",SUP-RSAR-24,CDM,S27800098,LOCAL,0278,RC,,,both,,,14801.54,4440.46,"CIGNA [10200]",Cigna,,5920.62,40,,,,,0,1721.42,12581.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 2CM 18FR GUIDING BALLOON LOW PROFILE",SUP-8114,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"UHC [10700]","United Healthcare",,2350.01,63.3,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 250ML GEL SMOOTH ROUND SILICONE P3.4CM","SUP-3502501 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"NOVANET [10819]",Novanet,,2756.25,75,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM ATTUNE 4 KNEE DISTAL CEMENT REVISION STERILE",SUP-154704001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"PHCS [10601]",PHCS,,4250.4,70,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Bone Marrow Multi",PX-341000079,CDM,78103,CPT,0341,RC,,,both,,,1438.69,431.61,"CIGNA [10200]",Cigna,,310.68,,,,,,,167.32,1222.89,"fee schedule",
"INTRO SHEATH 6FR 23CM LUER LOCK HUB WITHOUT GWIRE KIT LONG",SUP-490006,CDM,C1894,HCPCS,0272,RC,,,both,,,737.10,221.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,85.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,85.72,626.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ANTERIOR CHMBR",SUP-MTA5UO,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE 4 % TOPICAL PATCH",RX-112961,CDM,,,0250,RC,46581-0830-06,NDC,both,1,UN,13.62,4.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6.25,45.9,,,,,0,1.58,11.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR FRONTIER II IS-1 CNCT STIMULATION DEVICE TRIGGERED",SUP-5586,CDM,C2621,HCPCS,0275,RC,,,both,,,40540.50,12162.15,"FIRST HEALTH [10303]","First Health",,32432.4,80,,,,,0,4714.86,34459.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE 130CM 80MM 6MM BALLOON DILATATION",SUP-LX181306805F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"NOVANET [10819]",Novanet,,5045.63,75,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enteroscopy W Rmvl Snare",PX-750000229,CDM,44364,CPT,0750,RC,,,both,,,3196.00,958.8,"FIRST HEALTH [10303]","First Health",,2556.8,80,,,,,0,371.69,3196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELIANCE 4 FRONT PASSIVE FIXATION SINGLE COIL 64CM",SUP-0663,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN NAVIGATION 150MM 3MM PRECISION NAVIGATION SYSTEM KNEE",SUP-6007-003-150,CDM,S27200284,LOCAL,0272,RC,,,both,,,669.22,200.77,"UHC [10700]","United Healthcare",,423.62,63.3,,,,,0,77.83,568.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPLANT KITS",SUP-28717,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fondaprainax",PX-301000072,CDM,80299,CPT,0301,RC,,,both,,,546.00,163.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,464.1,"per diem",
"HC Fondaprainax",PX-301000072,CDM,80299,CPT,0301,RC,,,both,,,546.00,163.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.13,,"Fee schedule rate ($18.13). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,464.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.5MM X 13MM TI",SUP-VAN-15130-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,113.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",113.04,826.2,"percent of total billed charges",
"LENS IOL +24.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.245,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT MINI 1 CC PUTTY BIOACTIVE S",SUP-78000010,CDM,C1713,HCPCS,0278,RC,,,both,,,1950.00,585,"KAISER [10500]",Kaiser,,1306.5,67,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE SKYPOINT CORONARY EVEROLIMUS ELUTING CORONARY",SUP-1804250-48,CDM,C1874,HCPCS,0278,RC,,,both,,,4554.00,1366.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,539.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,529.63,3870.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE WHOLEY VASCULAR J 260CM .035IN HYDROPHOBIC",SUP-WWIJ35260,CDM,C1769,HCPCS,0272,RC,,,both,,,558.90,167.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,66.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST 38MM 120CM 10MM VASCULAR STAINLESS STEEL PTFE",SUP-42038,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"CIGNA [10200]","Cigna Local Plus",,5518.89,31.5,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS",RX-9795,CDM,J3480,HCPCS,0258,RC,00338-0803-04,NDC,both,1000,ML,100.65,30.19,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL RAPIDE MULTIPASS 2-0 CT-1 36IN BRAID",SUP-VR945,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ALLODERM (RTU) CONTOUR MEDIUM PERFORATED - THIN",SUP-CM1516P,CDM,Q4116,HCPCS,0636,RC,,,both,,,25263.00,7578.9,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"BENZOCAINE 10 % MUCOSAL GEL",RX-19690,CDM,,,0250,RC,50486-0550-32,NDC,both,7,GR,40.55,12.16,"PHCS [10601]",PHCS,,28.39,70,,,,,0,4.72,34.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM .02IN 16MM PENUMBRA COIL 400 RUBY",SUP-RBY2C1660,CDM,S27800098,LOCAL,0278,RC,,,both,,,7098.00,2129.4,"FIRST HEALTH [10303]","First Health",,5678.4,80,,,,,0,825.5,6033.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 3.3MM 40MM STARDRIVE NAIL-EX TITANIUM 7%",SUP-04.005.430,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,786.54,68,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 10-0 CIF-4 8IN 2 ARM MONOFILAMENT BLUE",SUP-788G,CDM,S27200284,LOCAL,0272,RC,,,both,,,259.79,77.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,176.66,68,,,,,0,30.21,220.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD SUT ASSISTANT 3-0 ES-9 7IN 1 STITCH ENDO STITCH",SUP-170072,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 7-0 BV-1 30IN 2 ARM BLUE NONABSORBABLE",SUP-EP8703H,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.80,68.94,"CIGNA [10200]","Cigna Open Access",,130.76,56.9,,,,,0,26.73,195.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE HEMOSTATIC ERASER STRAIGHT TAPER 20-23GA BIPOLAR FINE",SUP-221265,CDM,S27200284,LOCAL,0272,RC,,,both,,,589.94,176.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,69.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.61,501.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING EXPIRATION LIMB WYE 6FT DISPOSABLE 1.8MR",SUP-29657-001,CDM,S27000186,LOCAL,0270,RC,,,both,,,90.46,27.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.52,76.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM TAPER 36MM HIP MODULAR TYPE 1 BIOLOX DELTA",SUP-12-115122,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"PHCS [10601]",PHCS,,6158.25,70,,,,,0,1023.15,7477.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 5.5MM CARBIDE OVAL",SUP-03-C0905,CDM,S27200284,LOCAL,0272,RC,,,both,,,105.88,31.76,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD SUT ASSISTANT 3-0 ES-9 48IN 1 STITCH ENDO STITCH",SUP-170073,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER BREAST IMPLANT RESTERILIZABLE GEL SMOOTH ROUND MODERAT",SUP-RSZMPB265,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TERAZOSIN 5 MG CAPSULE",RX-14553,CDM,,,0637,RC,50268-0766-11,NDC,both,1,UN,8.08,2.42,"FIRST HEALTH [10303]","First Health",,6.46,80,,,,,0,0.94,6.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16025545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION",RX-33175,CDM,J3486,HCPCS,0636,RC,72266-0160-01,NDC,both,1,UN,247.50,74.25,"UHC [10700]","United Healthcare",,35.68,,,,,,,15.92,210.38,"fee schedule",
"BURR SURGICAL 3MM TPS ELITE OSTEON ROUND FLUTE 5 NOTCH SOFT",SUP-5820-010-130,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"CIGNA [10200]",Cigna,,744.57,68,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION",RX-22560,CDM,,,0250,RC,00121-0853-20,NDC,both,20,ML,128.82,38.65,"MULTIPLAN [10600]",Multiplan,,109.5,85,,,,,0,14.98,109.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 5/64IN STEINMANN 2 END TROCAR POINT",SUP-162438000,CDM,C1713,HCPCS,0278,RC,,,both,,,102.95,30.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",11.97,87.51,"percent of total billed charges",
"PRIMARY TT REVERSE SHOULDER",SUP-SMRTTREV,CDM,C1776,HCPCS,0278,RC,,,both,,,54652.50,16395.75,"PHCS [10601]",PHCS,,38256.75,70,,,,,0,6356.09,46454.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VORTIOXETINE 20 MG TABLET",RX-164867,CDM,,,0250,RC,64764-0750-30,NDC,both,1,UN,81.63,24.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.49,69.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 35MM ATS OPEN PIVOT STD SERIES MECHANICAL",SUP-500DM35,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2799.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cea",PX-301000132,CDM,82378,CPT,0301,RC,,,both,,,331.01,99.3,"UHC [10700]","United Healthcare",,17.06,,,,,,,0.01,281.36,"fee schedule",
"LATERA NASAL IMPLANT",SUP-LATSYS,CDM,S27800098,LOCAL,0278,RC,,,both,,,14262.30,4278.69,"CIGNA [10200]","Cigna Local Plus",,4492.62,31.5,,,,,0,1658.71,12122.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4N NARROW KNEE LEFT POSTERIOR STABILIZE LEGION",SUP-71421264,CDM,C1776,HCPCS,0278,RC,,,both,,,32536.35,9760.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3855.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3783.98,27655.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 7FR MULTIPURPOSE A1",SUP-77827000,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEPPERMINT OIL",RX-6116,CDM,,,0637,RC,00395-2015-91,NDC,both,30,ML,160.96,48.29,"KAISER [10500]",Kaiser,,107.84,67,,,,,0,18.72,136.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHOHEXITAL 500 MG VIAL",RX-70545,CDM,,,0250,RC,42023-0105-01,NDC,both,1,UN,698.41,209.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,81.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.23,593.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X20X5.9MM TITAN NANOLOCK 6D 8MM ANTERALIGN",SUP-46260855,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"NOVANET [10819]",Novanet,,32130,75,,,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 5-0 RB-1 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP213H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET EXT 12IN MIC-KEY SECUR-LOK ENFIT CONTINUOUS FEED DEHP",SUP-0121-12,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.54,20.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRODE BIPOLAR CUTTING LOOP THICK 26 FR SQUARE FITTING",SUP-MV2S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.00,675,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 6.5IN HENLY WEITLANER 3 CENTER BLADE MODIFY BLUNT",SUP-55-9050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1913.63,574.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BOLT SPINAL 50MM 5.5MM DECADE LARGE PLATE EXTREME LATERAL",SUP-7145550,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]",Cigna,,1101.6,68,,1831.33,1831.33,1831.33,16,188.41,1377,"percent of total billed charges",
"DRSG WOUND 4IN .04IN THERAHONEY SQUARE HONEY FOAM STERILE",SUP-MNK1344,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.21,25.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,57.94,68,,,,,0,9.91,72.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR ENDOSCOPIC DIA12MM 100MM NON BLADED STABILITY SLEEVE",SUP-B12LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"KAISER [10500]",Kaiser,,104.92,67,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLDFR FLUID 20L UROLOGY FLUIDRAIN LSS DISPOSABLE",SUP-337220,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,107.27,41.1,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 5MM XLONG 50MM 7.3MM SHILEY PEDIATRIC CUFF TAPE",SUP-5.0PLCF,CDM,S27200284,LOCAL,0272,RC,,,both,,,475.23,142.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,323.16,68,,,,,0,55.27,403.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 15X15.5CM NATRELLE P6.1CM FULL PROJECTION FULL",SUP-MSZFF655,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,81.68,45.9,,,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR AL2 CURVE ANGIOGRAPHIC TRILON PERIPHERAL",SUP-H74908641981,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"CIGNA [10200]","Cigna Open Access",,40.35,56.9,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 3.5 MM HEADLESS SCR",SUP-P20-915-3500,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"CIGNA [10200]","Cigna Local Plus",,537.35,53.5,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 27FR 1 STEM RESECTOSCOPE",SUP-M0068802061,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,351.21,68,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE BRIDLE PRO 16-18FR SECURING PROBE REMOVABLE STYLET",SUP-4-421618,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,84.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR FR3.5 CURVE ANGIOGRAPHIC FEMORAL 2",SUP-H74916391012,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"FIRST HEALTH [10303]","First Health",,61.26,80,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.5MM DART-FIRE",SUP-DSDS0025,CDM,S27200284,LOCAL,0272,RC,,,both,,,1271.70,381.51,"CIGNA [10200]","Cigna Open Access",,723.6,56.9,,,,,0,147.9,1080.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR ARTERY STERILE",SUP-PXVP2X2AT3,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.69,125.31,"PHCS [10601]",PHCS,,292.38,70,,,,,0,48.58,355.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 90MMX4.8MM DST SERIES TA TITANIUM REGULAR",SUP-TA9048L,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.47,98.24,"AETNA [10100]","Aetna HMO/PPO",,260.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.08,278.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER ETHIBOND 2-0 SH-2 36IN 2 ARM BRAID GREEN",SUP-X559H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIOFLON 2/0 1/2KL 25MM DA 75CM PLEDGET TD3X7",SUP-19P30Y,CDM,S27200284,LOCAL,0272,RC,,,both,,,865.35,259.6,"CIGNA [10200]","Cigna Open Access",,492.38,56.9,,,,,0,100.64,735.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER FIRSTPASS MINI LEFT CURVE SUT",SUP-72290129,CDM,S27200284,LOCAL,0272,RC,,,both,,,1856.25,556.87,"AETNA [10100]","Aetna HMO/PPO",,1475.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLANER SURGICAL SP2 LARGE PATELLA BLADE",SUP-976748,CDM,S27200284,LOCAL,0272,RC,,,both,,,978.56,293.57,"CIGNA [10200]",Cigna,,665.42,68,,,,,0,113.81,831.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 5-0 P-1 18IN MONOFILAMENT GREEN NONABSORBABLE",SUP-G695G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"KAISER [10500]",Kaiser,,16.75,67,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH VISISHEATH 33CM 14FR DIL",SUP-501-114,CDM,C1893,HCPCS,0272,RC,,,both,,,1987.50,596.25,"AETNA [10100]","Aetna HMO/PPO",,1580.06,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,231.15,1689.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL WEIL-BLAKESLEY 45D UP 2 5MM 7.5IN NASAL",SUP-66-2813,CDM,S27200284,LOCAL,0272,RC,,,both,,,1913.63,574.09,"UHC [10700]","United Healthcare",,1211.33,63.3,,,,,0,222.56,1626.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL ANGLE SELF CENTERING FORTIFY I",SUP-676.703,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"CIGNA [10200]","Cigna Local Plus",,2116.67,53.5,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 12MM BIOMET STAINLESS STEEL QUICK RELEASE COUPLING",SUP-430054,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISPOSABLE POLYPECTOMY COLD SNARES OUTER DIAMETER 2.4MM WORK",SUP-G61206,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"PHCS [10601]",PHCS,,146.16,70,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM PRECISION ROUND",SUP-5820009040,CDM,S27200284,LOCAL,0272,RC,,,both,,,3587.85,1076.35,"CIGNA [10200]","Cigna Local Plus",,1919.5,53.5,,,,,0,417.27,3049.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 19GA 1.14MM ACQUIRE ULTRASOUND STERILE LATEX FREE",SUP-M00555580,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 8MM CANNULATED ACL LOW PROFILE STERILE",SUP-AR-1408LP,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOLOIST 110CM 6FR 2-5-2MM SPACING JOSEPHSON FLEX CURVE",SUP-FND-019-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CIGNA [10200]",Cigna,,925.34,68,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 3X32+TRAK21 2-PACK - US",SUP-91312,CDM,S27200284,LOCAL,0272,RC,,,both,,,24624.97,7387.49,"AETNA [10100]","Aetna HMO/PPO",,19576.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2863.88,20931.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETAINER VISCERA LARGE PLIABLE MATERIAL GLASSMAN",SUP-RMD3206,CDM,S27200284,LOCAL,0272,RC,,,both,,,272.40,81.72,"FIRST HEALTH [10303]","First Health",,217.92,80,,,,,0,31.68,231.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADHSV SKIN CLSR BSA GLUTARALDEHYDE BIOGLUE PREFILLED SYR",SUP-BG3502-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,4636.80,1391.04,"MULTIPLAN [10600]",Multiplan,,3941.28,85,,,,,0,539.26,3941.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE KIWI PROCUP PALM PUMP VACUUM EXTRACTION RIGID STEM",SUP-VAC-6000S,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,165.65,68,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEK 17 FEMORAL ARTERIAL CANNULA 17FR",SUP-5130-1717,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,103.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 20CM CHIBA ASPIRATION STERILE DISPOSABLE",SUP-G01047,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.31,31.29,"UHC [10700]","United Healthcare",,66.03,63.3,,,,,0,12.13,88.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN AMPLATZ RIGHT",SUP-534648T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"UHC [10700]","United Healthcare",,55.07,63.3,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 34IN 28FR FEMORAL VEIN ADULT TAPER CNCT",SUP-VFEM028,CDM,S27200284,LOCAL,0272,RC,,,both,,,2737.50,821.25,"NOVANET [10819]",Novanet,,2053.13,75,,,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MICROPOINT 8-0 TG175-8 12IN 2 ARM MONOFILAMENT",SUP-1716G,CDM,S27200284,LOCAL,0272,RC,,,both,,,115.14,34.54,"CIGNA [10200]",Cigna,,78.3,68,,,,,0,13.39,97.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLER INTERNAL 25X4.8MM TITANIUM XL CIRCLE STAPLE ENDOSCOP",SUP-EEAXL25,CDM,S27200284,LOCAL,0272,RC,,,both,,,2269.80,680.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1543.46,68,,,,,0,263.98,1929.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIALYZER HEMODIALYSIS 1.8SQ MR REVACLEAR 400 300ML 93ML",SUP-114746L,CDM,S27200284,LOCAL,0272,RC,,,both,,,524.29,157.29,"AETNA [10100]","Aetna HMO/PPO",,416.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.97,445.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE BLUE DIAMOND 30 ATM 13IN INFLATION SYR EXT TUBING 3",SUP-IN7130,CDM,S27200284,LOCAL,0272,RC,,,both,,,399.59,119.88,"FIRST HEALTH [10303]","First Health",,319.67,80,,,,,0,46.47,339.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC RATCHET HANDLE 36CM 10MM ENDOPATH BABCOCK",SUP-10BB,CDM,S27200284,LOCAL,0272,RC,,,both,,,1358.02,407.41,"AETNA [10100]","Aetna HMO/PPO",,1079.63,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,157.94,1154.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 4-0 P-3 18IN MONOFILAMENT BLACK",SUP-699G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE 110CM 6FR .051IN .042IN PIGTAIL CURVE",SUP-532650S,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"UHC [10700]","United Healthcare",,52.32,63.3,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER CURVED TIP RELOAD 60MM PURPLE",SUP-AESC60P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 52CM DEFLECT STEERABLE LOCATOR PLUS ATRIAL 14MM",SUP-1281/52,CDM,S27500001,LOCAL,0275,RC,,,both,,,1972.50,591.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,233.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.4,1676.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PERICARDIOCENTESIS 60CM 6FR .035IN STRAIGHT 7 SPIRAL",SUP-PC201,CDM,C1729,HCPCS,0272,RC,,,both,,,824.18,247.25,"FIRST HEALTH [10303]","First Health",,659.34,80,,,,,0,95.85,700.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 53CM KT MED",SUP-107235,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,45.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX17MM FRA 8D NARROW WEDGE SPINE",SUP-17,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Local Plus",,5953.5,31.5,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO S1 GLIDESCOPE SPECTRUM MILLER DISPOSABLE",SUP-0270-1088,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.40,131.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT MICROINTRODUCER 5FR 50CM GWIRE BEVEL A NDL SMOOTH DIL",SUP-0228950,CDM,C1894,HCPCS,0272,RC,,,both,,,455.54,136.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE CHISEL 2.5INX10MM FLEXIBLE LATEX FREE",SUP-270904019,CDM,S27200284,LOCAL,0272,RC,,,both,,,2362.50,708.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STY LD 52CM .016IN BRADY FIRM",SUP-6584,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 230CM 25-30MM 10FR 270CM COLONIC NITINOL",SUP-6506,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Lymphedema Full Leg",PX-E27000189,CDM,E27000189,LOCAL,0270,RC,,,both,,,1430.87,429.26,"KAISER [10500]",Kaiser,,958.68,67,,,,,0,166.41,1216.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 7MM AXIUM 3D FRAME V01",SUP-FC-7-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,13765.50,4129.65,"KAISER [10500]",Kaiser,,9222.89,67,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC",854,MS-DRG,,,,,,,inpatient,,,64962.71,19488.81,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,12766.16,,"Case rate ($12,394.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,508.98, add-ons for qualifying new technology services are included. If operating cost exceeds $44,548.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,252.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $11,524.20. The transfer operating threshold is the transfer adjustment factor * $11,508.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.13. The transfer capital threshold is the transfer adjustment factor * $870.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",12793.06,12793.06,12793.06,"1 through 10",7561,58336.53,other,"IP DRGs"
"PUMP PERFUSION IMPELLA CARDIOPULMONARY BYPASS NONROLLER",SUP-005082,CDM,S27800098,LOCAL,0278,RC,,,both,,,142500.00,42750,"BLUE CROSS [10001]","Blue Cross PPO",,55860,39.2,,,,,0,16572.75,121125,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE (PF) 20 MG/ML (2%) INJECTION AMP/VIAL SUPERORDERABLE",RX-408650,CDM,J2003,HCPCS,0636,RC,63323-0208-01,NDC,both,5,ML,33.98,10.19,"NOVANET [10819]",Novanet,,25.49,75,,,,,0,1.17,28.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 15X15.5CM 800CC STYLE 133S SMOOTH SUT TAB",SUP-133S-FX-15-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"NOVANET [10819]",Novanet,,6986.25,75,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE GENESIS 23CM 9.5MM TAIL CAP TRIMMABLE",SUP-919509SC,CDM,C2622,HCPCS,0278,RC,,,both,,,55704.60,16711.38,"BLUE CROSS [10001]","Blue Cross PPO",,21836.2,39.2,,,,,0,6478.44,47348.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Asp Bladder W Ndl",PX-361000230,CDM,51100,CPT,0361,RC,,,both,,,11970.82,3591.25,"AETNA [10100]","Aetna HMO/PPO",,9516.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1249,10175.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR ZEPHYR DR DUAL CHMBR BEAT BY BEAT AUTOCAPTURE RATE",SUP-5820,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"AETNA [10100]","Aetna HMO/PPO",,33072,79.5,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RIVASTIGMINE 1.5 MG CAPSULE",RX-28278,CDM,,,0637,RC,00904-7107-61,NDC,both,1,UN,19.82,5.95,"CIGNA [10200]",Cigna,,13.48,68,,,,,0,2.31,16.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alk Phosphatase",PX-301000355,CDM,84075,CPT,0301,RC,,,both,,,114.95,34.48,"NOVANET [10819]",Novanet,,86.21,75,,,,,0,0.01,97.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE SYNTHETIC TISSUE 439012 PG 12X26 SRVC FEE FD",SUP-439012,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 60MM 18MM 75CM ENDOPROSTHESIS VENOUS CATH",SUP-H74912044186070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]",Cigna,,5865,68,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ventil Mgmt IP Init Day",PX-410000002,CDM,94002,CPT,0410,RC,,,both,,,2236.54,670.96,"PHCS [10601]",PHCS,,1565.58,70,,,,,0,254,1901.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE LEAD LOCKING .43-.66MM SLS II 2 .017-.026IN ICD LEAD",SUP-518-019,CDM,C1773,HCPCS,0272,RC,,,both,,,4071.00,1221.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1673.18,41.1,,,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT CEMENTED CRUCIATE RETAINING ATTUNE",SUP-150400106,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"FIRST HEALTH [10303]","First Health",,17914.68,80,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CRYO/CUFF IC LARGE 20-31IN COMPRESSION THERAPY KNEE",SUP-51A11B,CDM,S27000186,LOCAL,0270,RC,,,both,,,649.78,194.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.57,552.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SURGICAL LARGE CIRCLE 3.2IN SPRING OPEN BIORESORBABLE",SUP-5950009,CDM,C1781,HCPCS,0278,RC,,,both,,,2352.00,705.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,278.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,273.54,1999.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL VASCULAR 190",SUP-1009660,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg WO Vid 2-12hr Intmt Mntr",PX-740000041,CDM,95706,CPT,0740,RC,,,both,,,5043.88,1513.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3429.84,68,,,,,0,5.04,4287.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC REAMING 36MM PATELLA DISPOSABLE",SUP-8000-0036,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.00,675,"KAISER [10500]",Kaiser,,1507.5,67,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intrvas Dplr Angio Init",PX-481000044,CDM,93571,CPT,0481,RC,,,both,,,2436.59,730.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,283.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,283.38,2071.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRESSING FOAM MEPILEX TRANSFER SAFETAC SILVER THIN L8 IN X W",SUP-394890,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.61,51.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.07,146.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT INSUFFLATION THERMOFLATOR ADPTR PATIENT CONNECTION TUBE",SUP-20400034,CDM,S27200284,LOCAL,0272,RC,,,both,,,1224.72,367.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,503.36,41.1,,,,,0,142.43,1041.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 24CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006155232010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS [10001]","Blue Cross HMO",,482.54,39.2,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC 7.5MM 52.3X45.4MM ADAPTA DR MVP ATRIUM",SUP-ADDRL1,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4929.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 70MM KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-183112,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"NOVANET [10819]",Novanet,,16249.28,75,,,,,0,2519.72,18415.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bacterium Ab Nos Qual",PX-302000097,CDM,86609,CPT,0302,RC,,,both,,,89.70,26.91,"MULTIPLAN [10600]",Multiplan,,76.25,85,,,,,0,0.01,76.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 26FR 5MM ACMI ELITE",SUP-M0068804121,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,351.21,68,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 255MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-410-255,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"KIT ARTHROSCOPIC FIXATION TOGGLELOC ZIPLOOP MAXBRAID 2 2.4MM",SUP-909874,CDM,C1713,HCPCS,0278,RC,,,both,,,11040.00,3312,"FIRST HEALTH [10303]","First Health",,8832,80,,,,,0,1283.95,9384,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORCLTR SURGICAL ROTOCUT G1 CUTTER 15MM",SUP-091115-05,CDM,S27200284,LOCAL,0272,RC,,,both,,,5157.06,1547.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,599.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,599.77,4383.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ca Ionized",PX-301000124,CDM,82330,CPT,0301,RC,,,both,,,265.61,79.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12.31,,,,,,,0.27,225.77,"fee schedule",
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 17MMX12MMX6CM",SUP-TSB121706A,CDM,C1874,HCPCS,0278,RC,,,both,,,49140.00,14742,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,19656,40,,,,,0,5714.98,41769,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE LP 33S",SUP-TENDV-LP-33S-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,116280,68,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 401322 MDII 22X26 SRVC FEE",SUP-401322,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 220MM 7FR 6MM 5FR BALLOON DILATATION",SUP-39032-60221,CDM,C1725,HCPCS,0272,RC,,,both,,,2137.50,641.25,"MULTIPLAN [10600]",Multiplan,,1816.88,85,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 40MM SIMUPLUS FLEXIBLE LUMEN STERILE LATEX",SUP-7700FB40,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3752.08,28.62,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLATOR AIRWAY ENDOTRACHEAL TUBE STD MANOMETER AIR VENT",SUP-8199,CDM,S27200284,LOCAL,0272,RC,,,both,,,1547.26,464.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,179.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,179.95,1315.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy US Ea 15min (Gp)",PX-420000020,CDM,97035,CPT,0420,RC,,,both,,,163.34,49,"CIGNA [10200]","Cigna Local Plus",,163.34,,"Per diem ($290).",,,,0,19,163.34,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM .02IN 5MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0530,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.00,2003.4,"PHCS [10601]",PHCS,,4674.6,70,,,,,0,776.65,5676.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIPWIRE .035IN STRAIGHT TIP",SUP-M0066802051,CDM,C1769,HCPCS,0272,RC,,,both,,,320.58,96.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.28,272.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 33MMX1MM TITANIUM 2/2.3MM SCR 6 HOLE APTUS",SUP-A-4650.03,CDM,S27200284,LOCAL,0272,RC,,,both,,,5313.00,1593.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2183.64,41.1,,,,,0,617.9,4516.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET HOUSING POS",SUP-AR-1204AF-80,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1174.76,45.9,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Cslt Sld Els",PX-312000071,CDM,0838T,CPT,0311,RC,,,both,,,104.00,31.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VERAPAMIL 80 MG TABLET, IMMEDIATE RELEASE",RX-8530,CDM,,,0637,RC,00591-0343-01,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Kit Nerve Root Block",PX-E27200174,CDM,E27200174,LOCAL,0272,RC,,,both,,,85.80,25.74,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH VIZIGO INTRO STERILE LATEX FREE DISPOSABLE",SUP-D138502,CDM,C1766,HCPCS,0272,RC,,,both,,,6824.10,2047.23,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER PACING LEAD ACUITY 10.5FR LONG",SUP-667474-001,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT EXPEL TWIST-LOC 26CM 8FR URETERAL FLEXITHANE",SUP-H7493936108260,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"CIGNA [10200]",Cigna,,842.72,68,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Sulfr Colloid Up to 20mci",PX-343000028,CDM,A9541,HCPCS,0343,RC,,,both,,,610.00,183,"BLUE CROSS [10001]","Blue Cross HMO",,311.62,,,,,,,70.94,610,"fee schedule",
"HC Cta Neck W/WO Cntrst",PX-351000015,CDM,70498,CPT,0351,RC,,,both,,,4327.01,1298.1,"KAISER [10500]",Kaiser,,2899.1,67,,,,,0,405,3677.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X6MM COALITION MIS 7D 12MM TITANIUM STERILE",SUP-1136.2476,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross PPO",,6762,39.2,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST OP BRA 36C BLACK","SUP-B01G-36 B/C-B",CDM,S27000186,LOCAL,0270,RC,,,both,,,407.16,122.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,186.89,45.9,,,,,0,47.35,346.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 11CM 5FR STRAIGHT PANCREATIC POLYMER DRNG HOLE",SUP-M00536450,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"MULTIPLAN [10600]",Multiplan,,543.36,85,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRESTIGE PLUS HELICAL PACK",SUP-PRES0412HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross HMO",,2569.56,39.2,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 80MM 135CM 6MM 5FR VASCULAR NITINOL LOW",SUP-5F060803CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3357.13,28.62,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 500MM 5.5MM STRAIGHT TITANIUM LINE NONSTERILE",SUP-1554200500,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"DIL VASCULAR 18FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G01328,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"NOVANET [10819]",Novanet,,37,75,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PILOCARPINE 2 % EYE DROPS",RX-6280,CDM,,,0250,RC,61314-0204-15,NDC,both,15,ML,634.13,190.24,"NOVANET [10819]",Novanet,,475.6,75,,,,,0,73.75,539.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET NDL 25MM 15GA ARROW EZ-IO EZ-CONNECT NDL VISE WRIST BAND",SUP-9001P-VC-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1138.86,341.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,132.45,968.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE EVERFLEX 30MM 120CM 5MM .079IN BILIARY NITINOL",SUP-PRB35-05-030-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"FIRST HEALTH [10303]","First Health",,4452,80,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 22-30CM 3CM 4.8FR .035IN",SUP-M006180155090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,904.58,68,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 3MM E9000 ROUND CARBIDE 8 FLUTE LOW SPEED",SUP-E8230LSO,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Ven Thin-Flex 3 Stage",PX-E27200334,CDM,E27200334,LOCAL,0272,RC,,,both,,,198.00,59.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,23.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.03,168.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prolact+6 Qtr Btl",PX-E27000208,CDM,E27000208,LOCAL,0270,RC,,,both,,,268.40,80.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,31.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.21,228.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING CORONARY VENOUS BIPOLAR EASYTRAK 2",SUP-4517,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"FIRST HEALTH [10303]","First Health",,4485.6,80,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vad Holster Vest All Sizes",PX-E27400020,CDM,Q0498,HCPCS,0274,RC,,,both,,,2484.85,745.45,"BLUE CROSS [10001]","Blue Cross HMO",,974.06,39.2,,,,,0,288.99,2112.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intrpul Srf Adm Phys/Qhp Cath Oral Cav No Intub",PX-460000033,CDM,94799,CPT,0460,RC,,,both,,,248.00,74.4,"KAISER [10500]",Kaiser,,166.16,67,,,,,0,28.84,210.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUARTET, WIDE SPACING - 1458QL/75",SUP-1458QL/75,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,664.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEADLESS DR PM 19.5 F 32.2 MM RA",SUP-LSP203A,CDM,C1786,HCPCS,0275,RC,,,both,,,73530.00,22059,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8713.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8551.54,62500.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prcrd Drg 6yr+ WO Cgen Car",PX-450000387,CDM,33017,CPT,0361,RC,,,both,,,3999.64,1199.89,"AETNA [10100]","Aetna HMO/PPO",,3179.71,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,465.16,3999.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thyroid Hormone Uptake",PX-301000421,CDM,84479,CPT,0301,RC,,,both,,,132.11,39.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10.18,,,,,,,0.13,112.29,"fee schedule",
"CATH CEREGLIDE 71 132CM 55CM .082IN .071IN ASPIRATION",SUP-NIC71132U,CDM,C1757,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CEREGLIDE 71 132CM 55CM .082IN .071IN ASPIRATION",SUP-NIC71132U,CDM,C1757,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hdr Ntrstl Icav Brachytx 2-12 Chnl",PX-342000019,CDM,77771,CPT,0342,RC,,,both,,,6630.45,1989.13,"PHCS [10601]",PHCS,,4641.32,70,,,,,0,408.8,5635.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 40MM 120CM 10MM BILIARY VENA CAVA OTW DELIVERY",SUP-G57436,CDM,C1876,HCPCS,0278,RC,,,both,,,12771.83,3831.55,"CIGNA [10200]",Cigna,,5108.73,40,,,,,0,1485.36,10856.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR30,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 345MM TIBIAL TN ADVANCED INTRAMEDULLARY MR",SUP-04.043.135S,CDM,C1713,HCPCS,0278,RC,,,both,,,9579.13,2873.74,"FIRST HEALTH [10303]","First Health",,7663.3,80,,,,,0,1114.05,8142.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 10MM TITANIUM CRANIOFACIAL CORTICAL SELF",SUP-400360,CDM,S27800098,LOCAL,0278,RC,,,both,,,3937.14,1181.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,466.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,457.89,3346.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12IN 22FR ARTERIAL 3/8IN RADIOPAQUE 1 PIECE",SUP-77422,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,184.13,41.1,,,,,0,52.1,380.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS14030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]",Cigna,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 80CM 44MM 10-14FR SEPTAL CATH GORE 23-30",SUP-ASD44A,CDM,C1817,HCPCS,0278,RC,,,both,,,54495.00,16348.5,"BLUE CROSS [10001]","Blue Cross PPO",,21362.04,39.2,,,,,0,6337.77,46320.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 25MM 25MM AEQUALIS REVERSE II",SUP-DWE725,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"AETNA [10100]","Aetna HMO/PPO",,7507.19,79.5,,10981.53,8986.79,12413.38,12,1098.22,8026.55,"percent of total billed charges",
"VALVE AORTIC 27MM NAVITOR TRANSCATHETER SELF EXPAND INTRA",SUP-NVTR-27,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"KAISER [10500]",Kaiser,,91656,67,,,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR TRILOGY 0D STD NEUTRAL 9.9MM 64MM 40MM",SUP-630506440,CDM,C1776,HCPCS,0278,RC,,,both,,,9937.38,2981.21,"FIRST HEALTH [10303]","First Health",,7949.9,80,,,,,0,1155.72,8446.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROFRANCE SATALOFF DISPOSABLE",SUP-MCLS33,CDM,S27200284,LOCAL,0272,RC,,,both,,,533.99,160.2,"KAISER [10500]",Kaiser,,357.77,67,,,,,0,62.1,453.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 19FR SOLID CORE CENTER 4 CHANNEL RADIOPAQUE",SUP-2230,CDM,S27200284,LOCAL,0272,RC,,,both,,,155.21,46.56,"KAISER [10500]",Kaiser,,103.99,67,,,,,0,18.05,131.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 27MM 22.5MM MASTERS PYROLYTIC CARBON PTFE",SUP-27MTJ-503,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3386.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 5% DEXTROSE 20 MEQ POTASSIUM CHLORIDE 0.45%",SUP-07902-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,55.08,68,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE UBER FLEX 40MM 57CM 10MM .078IN VASCULAR",SUP-SR-1040-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 3.1X3.1IN XENMATRIX AQUAPURE SQUARE ACELLULAR",SUP-1160808,CDM,C1781,HCPCS,0278,RC,,,both,,,10750.20,3225.06,"CIGNA [10200]","Cigna Open Access",,6116.86,56.9,,11235.02,819.42,11235.02,"1 through 10",1250.25,9137.67,"percent of total billed charges",
"SCR BONE 6.5MM 30MM TRIDENT SECUR-FIT TITANIUM CANCELLOUS",SUP-2030-6530-1,CDM,C1713,HCPCS,0278,RC,,,both,,,571.90,171.57,"NOVANET [10819]",Novanet,,428.93,75,,,,,0,66.51,486.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 65MM 16MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-216.065,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,305.36,68,,,,,0,52.23,381.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet Myocrd Perf W Metab Dual",PX-404000016,CDM,78432,CPT,0404,RC,,,both,,,6429.00,1928.7,"UHC [10700]","United Healthcare",,4626.25,,,,,,,6.43,5464.65,"fee schedule",
"CATH 80CM 5FR 13MM EMBOLECTOMY 1.5ML OTW",SUP-E1651-88,CDM,C1757,HCPCS,0272,RC,,,both,,,963.90,289.17,"FIRST HEALTH [10303]","First Health",,771.12,80,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 44MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-44-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"KAISER [10500]",Kaiser,,3790.86,67,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 10D E ECCENTRIC HIP X3 TRIDENT",SUP-663-10-36E,CDM,C1776,HCPCS,0278,RC,,,both,,,10008.45,3002.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4593.88,45.9,,,,,0,1163.98,8507.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY THRULUMEN 80CM 4FR 9MM EMBOLECTOMY STAINLESS",SUP-12TLW804F,CDM,C1757,HCPCS,0272,RC,,,both,,,746.58,223.97,"PHCS [10601]",PHCS,,522.61,70,,,,,0,86.83,634.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intrvas Dplr Angio Add",PX-481000045,CDM,93572,CPT,0481,RC,,,both,,,1742.00,522.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH COYOTE 150CM 220MM 4MM BALLOON DILATATION NYBAX",SUP-H74939186402210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE NERVE NIM-RESPONSE FLUSH TIP MONOPOLAR STD 8252053 .5",SUP-8225101,CDM,S27200284,LOCAL,0272,RC,,,both,,,1161.54,348.46,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SINGLE USE INSTRUMENTS - TIBIAL KIT (PS) - SIZE 3",SUP-5555-2363,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP SURGICAL LATIS 6MM .5 FORCE SPRING LATIS/LATIS STERILE",SUP-A1611,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TERUMO 165CM MINI BALLOON OCCLUSION",SUP-BC0210M,CDM,C2628,HCPCS,0272,RC,,,both,,,18585.00,5575.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SET EXT 3.5CM 18FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-18-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CURET 2 FORWARD STRAIGHT OFFSET 9.5IN KARLIN LUMBAR HANDLE",SUP-46-3123,CDM,S27200284,LOCAL,0272,RC,,,both,,,1195.16,358.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PROLENE 3-0 MH 36IN 2 ARM MONOFILAMENT BLUE",SUP-8842H,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.71,19.41,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT EXTERNAL DRNG CSF ASSEMB PATIENT CONNECTION LINE MON",SUP-46126,CDM,S27200284,LOCAL,0272,RC,,,both,,,684.77,205.43,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ELECTROPHYSIOLOGY MEDIUM CURL 7FR DUO DECAPOLAR",SUP-401908R,CDM,C1731,HCPCS,0272,RC,,,both,,,2100.00,630,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL DISSECTING 12CM 2MM LEGEND DIAMOND T12 STERILE",SUP-T12MH20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ION ENDOSCOPIC NONSTERILE LATEX FREE REUSABLE",SUP-490105,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 12.5CM NATRELLE INSPIRA P3.3CM LOW PLUS PROFILE",SUP-MSZ-LP280,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPO 100CM 6FR AL2 CURVE ANGIOGRAPHIC TRILON PERIPHERAL",SUP-H74908641981,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMPULSE 100CM 5FR FR5 CURVE ANGIOGRAPHIC FEMORAL 2 WIRE",SUP-H74916391032,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) TF (-T) LOADING SYSTEM INTPD-TF-LS",SUP-INTPD-TF-LS,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SKIN APLIGRAF HUMAN FIBROBLAST BOVINE CLLGN MATRIX",SUP-APLIGRAF-COM,CDM,Q4101,HCPCS,0636,RC,,,both,,,28192.50,8457.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"ELEV SURGICAL 7.5X1IN SLIGHT CURVE KEY",SUP-26-5625,CDM,S27200284,LOCAL,0272,RC,,,both,,,282.23,84.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 150MM 3.9MM 4.2MM 3 FLUTE QUICK COUPLING 5MM ASLS",SUP-03.025.083,CDM,S27200284,LOCAL,0272,RC,,,both,,,1343.79,403.14,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STEERABLEBALLOON CA",SUP-ARC30SB-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,18270.00,5481,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"START UP KIT, STD TUBING (6FT), CG-500D",SUP-8700-0784-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRUSH CYTOLOGY 1MM 1.7MM 120CM RING HANDLE STERILE",SUP-133R,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.52,22.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.78,64.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MERSILENE 3-0 FS-1 18IN BRAID WHITE NONABSORBABLE",SUP-R647H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Chlamydia Any Source",PX-306000071,CDM,87110,CPT,0306,RC,,,both,,,289.26,86.78,"CIGNA [10200]","Cigna Local Plus",,43.12,,,,,,,0.29,245.87,"fee schedule",
"HC Train for Caregiver Add 15 (Gn)",PX-440000026,CDM,G0540,HCPCS,0440,RC,,,both,,,37.00,11.1,"CIGNA [10200]","Cigna Open Access",,37,,"Per diem ($309).",,,,0,0.04,37,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 57SQ CM 13MM 51X64MM COBALT XT VENTRICULAR",SUP-DVPA2D4,CDM,C1722,HCPCS,0278,RC,,,both,,,56385.00,16915.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,22554,40,,,,,0,6557.58,47927.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DUO-DECA 2-5-2 MPD-H 100CM",SUP-901671,CDM,C1731,HCPCS,0272,RC,,,both,,,4761.00,1428.3,"FIRST HEALTH [10303]","First Health",,3808.8,80,,,,,0,553.7,4046.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 7FR ELECTROPHYSIOLOGY DUO DECAPOLAR",SUP-D139801,CDM,C1731,HCPCS,0272,RC,,,both,,,7086.30,2125.89,"PHCS [10601]",PHCS,,4960.41,70,,,,,0,824.14,6023.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit B Level 2 W Proc",PX-450000328,CDM,G0381,HCPCS,0450,RC,,,both,,,714.00,214.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,694.48,,,,,,,67.13,714,"case rate",
"SUT POLYESTER ETHIBOND 0 CTX 18IN CONTROL RELEASE BRAID 8",SUP-CX31D,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.03,37.51,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.54,106.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 8FR URETHRAL NATURAL RUBBER HYDROGEL 3",SUP-0165PL08,CDM,S27200284,LOCAL,0272,RC,,,both,,,57.33,17.2,"FIRST HEALTH [10303]","First Health",,45.86,80,,,,,0,6.67,48.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PLASTIBELL 1.3CM CIRCUMCISION PLASTIC PEDIATRIC",SUP-9233,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.69,17.61,"MULTIPLAN [10600]",Multiplan,,49.89,85,,,,,0,6.83,49.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMIODARONE 200 MG TABLET",RX-9066,CDM,,,0637,RC,60687-0437-01,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,3.57,56.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUAIFENESIN 100 MG/5 ML ORAL LIQUID",RX-3542,CDM,,,0637,RC,00121-1744-05,NDC,both,5,ML,12.54,3.76,"CIGNA [10200]",Cigna,,8.53,68,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SELENIUM 40 MCG/ML INTRAVENOUS SOLUTION",RX-77308,CDM,,,0250,RC,00517-6510-25,NDC,both,10,ML,167.31,50.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT FOR PREPARATION OF TC 99M-PENTETIC ACID IV SOLUTION (25-50 MCI)",RX-411851,CDM,A9539,HCPCS,0343,RC,08888-8876-00,NDC,both,1,UN,823.05,246.91,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Bx Txcath",PX-361000140,CDM,37200,CPT,0361,RC,,,both,,,3423.00,1026.9,"AETNA [10100]","Aetna HMO/PPO",,2721.29,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,398.09,3423,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Txcath",PX-361000140,CDM,37200,CPT,0361,RC,,,both,,,3423.00,1026.9,"FIRST HEALTH [10303]","First Health",,2738.4,80,,,,,0,398.09,3423,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION",RX-10176,CDM,J1644,HCPCS,0636,RC,63323-0540-07,NDC,both,10,ML,19.40,5.82,"MULTIPLAN [10600]",Multiplan,,16.49,85,,,,,0,2.11,16.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SELENIUM 40 MCG/ML INTRAVENOUS SOLUTION",RX-77308,CDM,,,0250,RC,00517-6510-25,NDC,both,10,ML,167.31,50.19,"FIRST HEALTH [10303]","First Health",,133.85,80,,,,,0,19.46,142.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE DRILL 4.8MM INFINITY INBONE TIBIA BICORTICAL PROXIMAL",SUP-33600048,CDM,S27200284,LOCAL,0272,RC,,,both,,,1603.80,481.14,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT CLAMP 45MM SOFT/TRACTION STERILE LATEX FREE DISPOSABLE",SUP-G-4500,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EUPHORA 142CM 30MM 3MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3030X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) TF (-T) CRADLE ASSEMBLY LHR-0078",SUP-LHR-0078,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MUSTANG 75CM 60MM 10MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171100670,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TAKERU 15MM 3.5MM BALLOON DILATATION PTCA",SUP-DC-RZ3515UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 80CM 8CM 8MM BALLOON DILATATION 2 LUMEN",SUP-G52361,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADMIRAL XTREME 130CM 80MM 6FR 9MM LOW PROFILE BALLOON",SUP-ADM090080130,CDM,C1725,HCPCS,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dressing Sasorb Mextra 9x13in",PX-E27200409,CDM,E27200409,LOCAL,0272,RC,,,both,,,39.81,11.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHOCOLATE 135CM 80MM 3.5MM .014IN BALLOON DILATATION",SUP-CB1413535080OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RASP SURGICAL 18.3MM 3.2MM LONG 3.2MM HELICOIDAL",SUP-5130080030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1035.26,310.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 90CM 200MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530200S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 90CM 200MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025200S,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SINGLE-USE 400 MICRON LASER",SUP-HLFDBX0400C,CDM,S27200284,LOCAL,0272,RC,,,both,,,2546.00,763.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BALLOON DILATATION .018IN 4FR 6MM 135CM 4CM PTA LOW",SUP-G50247,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 40MM 3.5MM BALLOON DILATATION DURALYN",SUP-48003504S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL GRAY 1.4MM SKEETER OTO-FLEX CARBIDE STERILE",SUP-3155634,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOEHENDRA 200CM 3CM 11.5-7FR .035IN BALLOON DILATATION",SUP-G22046,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXCISOR BIOPSY .472X.354IN FISCHER 74D 12MM SMALL CONE",SUP-900-150,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.28,60.98,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 35LP 135CM 8CM 7FR 12MM .035IN BALLOON",SUP-G52300,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE TRACH 8 79MM 12.2MM SHILEY CUFF REUSABLE INNER CANN",SUP-8CN85R,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.92,161.38,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING MONORAIL 80CM 20MM 4MM BALLOON DILATATION",SUP-H74939031402080,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 135CM 60MM 7MM BALLOON DILATATION HYDROPHILIC",SUP-607006022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MINI TREK II 145CM 20MM 2MM ULTRA LOW PROFILE BALLOON",SUP-1012403-20A,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TRANSFORM 15MM 5MM BALLOON OCCLUSION 1 LUMEN COMPLIANT",SUP-M003SRC05150,CDM,C1725,HCPCS,0272,RC,,,both,,,11760.02,3528.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMERGE MONORAIL 144CM 8MM 6FR 4MM .07IN BALLOON",SUP-H7493918908400,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TEMPO 90CM 5FR PIGTAIL CURVE TAPER ANGIOGRAPHIC SLX",SUP-451503F5,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET STENT 75CM 7FR BANDER SOF-FLEX .038IN 5MM URETER PLASTIC",SUP-G14780,CDM,C2625,HCPCS,0272,RC,,,both,,,573.48,172.04,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 120MM 5MM BALLOON DILATATION STERILE LATEX",SUP-595012022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 6FR 4MM .07IN",SUP-H7493926708400,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 150CM 150MM 7FR 5MM BALLOON DILATATION PEBAX",SUP-H74939032501510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC QUANTUM APEX MONORAIL 143CM 20MM 4MM BALLOON",SUP-H7493912420400,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 250MM 6MM BALLOON DILATATION DURALYN",SUP-48006025S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MINI TREK II 145CM 8MM 1.2MM BALLOON DILATATION PEBAX",SUP-1012401-08Z,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 6MM 6FR 2.5MM .07",SUP-H7493926706250,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 3.75MM .017IN",SUP-H7493926708370,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 90CM 40MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT NYLON ETHILON MULTIPASS 6-0 PC-3 18IN MONOFILAMENT BLACK",SUP-1866G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACIFIC XTREME 130CM 250MM 5MM BALLOON DILATATION",SUP-PCU050250130,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACIFIC PLUS 20MM 150MM 4MM BALLOON DILATATION",SUP-PCP040020150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 135CM 40MM 7MM BALLOON DILATATION HYDROPHILIC",SUP-607004022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 135CM 3CM 10MM BALLOON DILATATION 2 LUMEN",SUP-G52292,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 100MM 10MM BALLOON",SUP-U35751010,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEEDLE CHIBA 18 GA X 20CM",SUP-MCN1808,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 80MM 8MM BALLOON DILATATION PEBAX",SUP-H74939032808010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 6MM BALLOON",SUP-U357566,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 100MM 6MM BALLOON DILATATION OTW STERILE",SUP-586010022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1018.98,68,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER/DIVIDER LAPAROSCOPIC 23CM 5MM LIGASURE 180D 17.8MM 2",SUP-LF1823,CDM,S27200284,LOCAL,0272,RC,,,both,,,3213.75,964.12,"MULTIPLAN [10600]",Multiplan,,2731.69,85,,,,,0,373.76,2731.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR IRIS GRIESHABER FLEXIBLE SURGICAL STERILE LATEX FREE",SUP-611.75,CDM,S27200284,LOCAL,0272,RC,,,both,,,746.66,224,"NOVANET [10819]",Novanet,,560,75,,,,,0,86.84,634.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 100MM 9MM BALLOON",SUP-U3575910,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES 145CM 40MM 4MM .014IN BALLOON DILATATION OTW",SUP-39134-40401,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 12MM 6FR 2MM .07IN BALLOON",SUP-H7493918912200,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"NOVANET [10819]",Novanet,,425.25,75,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 15MM 3.25MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP32515X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 2X2IN CUTIMED EPIONA 90% NATIVE CLLGN 10%",SUP-7322700,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.60,26.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.42,76.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 6MM 6FR 2MM .07IN",SUP-H7493926706200,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AETNA [10100]","Aetna HMO/PPO",,450.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 135CM 2CM 5FR 10MM 7.5MM BALLOON",SUP-4200020X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,inpatient,,,40079.48,12023.84,"AMBETTER EXCHANGE  [11102]",Ambetter,,8882.17,,"Case rate ($8,882.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,247.69, add-ons for qualifying new technology services are included. If operating cost exceeds $41,287.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,005.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $8,258.60. The transfer operating threshold is the transfer adjustment factor * $8,247.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $623.57. The transfer capital threshold is the transfer adjustment factor * $623.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,35710.15,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL TWIST 58MM 1.6MM LEIBINGER UNIVERSAL 2 26MM",SUP-6016526,CDM,S27200284,LOCAL,0272,RC,,,both,,,1123.62,337.09,"CIGNA [10200]",Cigna,,764.06,68,,,,,0,130.68,955.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SURGITIE 0 18IN LIGATING LOOP ANCHORED ABSORBABLE",SUP-SGL-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.14,32.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.58,91.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL TWIST 58MM 1.6MM LEIBINGER UNIVERSAL 2 26MM",SUP-6016526,CDM,S27200284,LOCAL,0272,RC,,,both,,,1123.62,337.09,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,130.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,130.68,955.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 200MM 4FR 2.5MM ROUND LOW PROFILE TAPER",SUP-A2025-200,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE VENTRICULAR ASSIST 17.4X13.8IN IMPELLA CP 9.3IN 10-40",SUP-0048-0003,CDM,S27800098,LOCAL,0278,RC,,,both,,,153900.00,46170,"MULTIPLAN [10600]",Multiplan,,130815,85,,,,,0,17898.57,130815,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVOCATE 1500MM 200MM 2MM BALLOON DILATATION SERENE OTW",SUP-A18020200150,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXS CATALYST 6 132CM 6FR GUIDING DISTAL ACCESS STERILE",SUP-M003IC0601320,CDM,S27200284,LOCAL,0272,RC,,,both,,,13688.22,4106.47,"FIRST HEALTH [10303]","First Health",,10950.58,80,,,,,0,1591.94,11634.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 40MM 7MM .035IN BALLOON",SUP-AB35W07040135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,80.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 9.5CM MEMORYGEL P2.9CM MODERATE PLUS PROFILE",SUP-RSZ-1501,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 6-12MM KNEE FLIPCUTTER III STERILE DISPOSABLE",SUP-AR-1204FF,CDM,S27200284,LOCAL,0272,RC,,,both,,,3268.13,980.44,"CIGNA [10200]",Cigna,,2222.33,68,,,,,0,380.08,2777.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DEBAKEY 7.75IN VASCULAR TISSUE TITANIUM 1MM",SUP-55-2005T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1975.58,592.67,"MULTIPLAN [10600]",Multiplan,,1679.24,85,,,,,0,229.76,1679.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH FEMORAL CANAL 32CM 14MM INTRAMEDULLARY STERILE",SUP-6198001514,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.45,22.63,"CIGNA [10200]","Cigna Open Access",,42.93,56.9,,,,,0,8.77,64.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 17.75IN 5MM 15GA ASPIR PUNCTURE",SUP-90-5051L,CDM,S27200284,LOCAL,0272,RC,,,both,,,524.07,157.22,"MULTIPLAN [10600]",Multiplan,,445.46,85,,,,,0,60.95,445.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 20MM 2MM BALLOON DILATATION PEBAX",SUP-1400200-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 150MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP EXTERNAL FIXATION STIMULATION",SUP-675705S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2610.00,783,"FIRST HEALTH [10303]","First Health",,2088,80,,,,,0,303.54,2218.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.3MM SUT GUIDE STERILE",SUP-8757,CDM,S27200284,LOCAL,0272,RC,,,both,,,1058.02,317.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,123.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,123.05,899.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 250MM 2MM .018IN BALLOON",SUP-R51002025L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1694.48,68,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 40MM 4MM BALLOON DILATATION PERCUTANEOUS",SUP-R51004004L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,233.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTAINSTABILITY QUADPOLE LEAD",SUP-479878,CDM,C1900,HCPCS,0278,RC,,,both,,,11626.50,3487.95,"PHCS [10601]",PHCS,,8138.55,70,,,,,0,1352.16,9882.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Distl Fibula W Manip",PX-450000162,CDM,27788,CPT,0450,RC,,,both,,,1879.00,563.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.13,,,,,,,67.13,1879,"case rate",
"SCPL SURGICAL MICRO POINT 128164M",SUP-28164MC-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1500.85,450.25,"MULTIPLAN [10600]",Multiplan,,1275.72,85,,,,,0,174.55,1275.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemoconcentrator Perf",PX-E27200356,CDM,E27200356,LOCAL,0272,RC,,,both,,,498.30,149.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,59.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.95,423.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tryptase",PX-301000282,CDM,83520,CPT,0301,RC,,,both,,,193.70,58.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.19,.1,,,,,0,0.19,164.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC LARGE 24IN KNEE OPEN PATELLA CONTOURED STAY",SUP-7063-03,CDM,L1830,HCPCS,0274,RC,,,both,,,134.24,40.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,38.42,28.62,,,,,0,15.61,114.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERIT MAESTRO 130CM .97MM 2.8FR 64MM 45D MICRO",SUP-28MC2813045,CDM,C1887,HCPCS,0272,RC,,,both,,,2301.00,690.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL SPECIMEN RETRIEVAL 115CM 7MM 3FR STONE CONE NITINOL",SUP-M0063903200,CDM,S27200284,LOCAL,0272,RC,,,both,,,1772.48,531.74,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WOLVERINE CUTTING BALLOON (MR) 15MM X 2.00",SUP-H74939401152000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TREK 145CM 30MM 3.25MM ULTRA LOW PROFILE BALLOON",SUP-1012275-30,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Grft F/N/H/F/G Add 25scm",PX-510000055,CDM,15276,CPT,0761,RC,,,both,,,344.00,103.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.5MM X 10.0MM",SUP-492501012,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL SURGICAL FLAT CHUCK SKYLINE 12MM",SUP-286820012,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"MULTIPLAN [10600]",Multiplan,,3362.94,85,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 1 PREASSEMBLE BLADE MINI HANDLE LED LIGHT",SUP-040-06-0410U,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.42,18.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.26,53.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 30MM 3MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012407-30,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP070200150 PLUS US D7L200UL1500",SUP-PCP070200150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 30MM 3MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012407-30,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOCKWAVE L6 IVL CATHETER 12.0X30 MM",SUP-L6IVL120030,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"FIRST HEALTH [10303]","First Health",,17388,80,,,,,0,2527.78,18474.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED II 100CM 6CM 8FR 20MM .035IN BALLOON DILATATION",SUP-611759,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2185.71,41.1,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 20CM 4MM BALLOON DILATATION ILIAC",SUP-G35527,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.47,41.1,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 200MM 7MM BALLOON DILATATION OTW",SUP-H74939206072010,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 15MM 3.25MM BALLOON DILATATION PTCA",SUP-DC-RZ3215UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MNTR FILTERLINE SMART CAPNOLINE MICROSTREAM ETCO2 PROBE",SUP-989803105531,CDM,S27200284,LOCAL,0272,RC,,,both,,,86.16,25.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,35.41,41.1,,,,,0,10.02,73.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY 6CM ARROW ONCONTROL BONE LESION",SUP-9465-VC-006,CDM,S27200284,LOCAL,0272,RC,,,both,,,3237.50,971.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2201.5,68,,,,,0,376.52,2751.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 40MM 6MM .035IN LOW PROFILE BALLOON",SUP-B1060-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"AETNA [10100]","Aetna HMO/PPO",,611.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 20MM",SUP-SPL20020X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 40MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560040L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL STEALTH LATIS 6MM .25 FORCE LATIS ATRAUMATIC",SUP-A1602,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,103.83,45.9,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 12MM 2MM BALLOON DILATATION",SUP-H7493912412200,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 12.5X7.6MR HALL RECIPROCATE OR STERILE",SUP-505229100,CDM,S27200284,LOCAL,0272,RC,,,both,,,357.74,107.32,"FIRST HEALTH [10303]","First Health",,286.19,80,,,,,0,41.61,304.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PULMONARY EDEMA AND RESPIRATORY FAILURE",189,MS-DRG,,,,,,,inpatient,,,31376.00,9412.8,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,8199.69,,"Case rate ($7,663.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,115.86, add-ons for qualifying new technology services are included. If operating cost exceeds $40,155.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,920.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,125.27. The transfer operating threshold is the transfer adjustment factor * $7,115.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $537.99. The transfer capital threshold is the transfer adjustment factor * $537.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,30809.64,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X100 135CM SL",SUP-48007010R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,584.13,68,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 100MM 6MM .014IN BALLOON DILATATION",SUP-AB14W060100150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP CLUSTER HOLE HA TRIDENT II PSL D",SUP-742-11-50D,CDM,C1776,HCPCS,0278,RC,,,both,,,9502.96,2850.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3905.72,41.1,,6417.48,6417.48,6417.48,"1 through 10",1105.19,8077.52,"percent of total billed charges",
"CATH MINI TREK 145CM 12MM 1.5MM ULTRA LOW PROFILE BALLOON",SUP-1012402-12,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"PHCS [10601]",PHCS,,510.3,70,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 70X25.4X.6MM WIDE STAINLESS STEEL SAGITTAL DUAL",SUP-2108100000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"PHCS [10601]",PHCS,,134.11,70,,,,,0,22.28,162.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUR 12.5CM 2CM ROUND DISTAL BEND DENTAL DIAMOND IBUR",SUP-8431-012-020D,CDM,S27200284,LOCAL,0272,RC,,,both,,,3045.45,913.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,354.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,354.19,2588.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PERIPHERAL L100MM DIA16MM CATHETER L120MM SHEATH 10FR",SUP-VENUL16100,CDM,C1725,HCPCS,0272,RC,,,both,,,22680.00,6804,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2637.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2637.68,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMT BRIDLE PRO- 18 FR",SUP-4-4218,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"FIRST HEALTH [10303]","First Health",,570.24,80,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 6MM 2.25MM BALLOON DILATATION DURATRAC",SUP-NCEUP22506X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 110CM 2CM 5FR 4MM 7.5MM BALLOON DILATATION",SUP-4204020L,CDM,C1725,HCPCS,0272,RC,,,both,,,931.50,279.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,108.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 15MM 3.3-3.6FR 4.5MM BALLOON",SUP-1008191-15,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"UHC [10700]","United Healthcare",,897.28,63.3,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 100MM 9MM BALLOON DILATATION DURALYN",SUP-48009010S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"MULTIPLAN [10600]",Multiplan,,1170.45,85,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 60MM 7FR 7MM 5FR BALLOON",SUP-39031-70601,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,inpatient,,,198611.16,59583.35,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,14208.41,,"Case rate ($13,278.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,330.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,370.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,314.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $12,346.66. The transfer operating threshold is the transfer adjustment factor * $12,330.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.23. The transfer capital threshold is the transfer adjustment factor * $932.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,62499.88,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 6.5MM CYL XCOARSE GRIT DISSECTING DIAMOND",SUP-MR8-14CY65DX,CDM,S27200284,LOCAL,0272,RC,,,both,,,1345.17,403.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,617.43,45.9,,,,,0,156.44,1143.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 20MM 6FR 4MM .07IN BALLOON",SUP-H7493918920400,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 2.5MM BALLOON DILATATION OTW PTCA",SUP-DC-PY2512UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,671.98,68,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE MIC-KEY",SUP-0270-18-2.7-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"CIGNA [10200]","Cigna Local Plus",,1408.55,53.5,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 20MM 6FR 3.75MM",SUP-H7493926720370,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 300MM 3MM BALLOON DILATATION RAPID",SUP-47530300L,CDM,C1725,HCPCS,0272,RC,,,both,,,1890.00,567,"AETNA [10100]","Aetna HMO/PPO",,1502.55,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 80MM 5FR 4MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-04087,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK STRAIGHT 9IN NERVE RETRACTION BLUNT HOEN STAINLESS",SUP-285235,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.01,84.9,"UHC [10700]","United Healthcare",,179.15,63.3,,,,,0,32.91,240.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 4 62MM 9.4MM SHILEY CUFF DISPOSABLE INNER CANN",SUP-4CN65H,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.97,110.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,249.54,68,,,,,0,42.68,311.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.5IN 14FR PHILLIPS PLASTIC DILATION CATH",SUP-021514,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL ASPIRATION 80MM 22GA 1.85MM EZ SHOT 2 ROUND KNOB STYLET",SUP-NA-220H-8022,CDM,S27200284,LOCAL,0272,RC,,,both,,,1467.10,440.13,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NIPPER SURGICAL 1.5MM 5IN 75MM HOUSE-DIETERS MALLEUS",SUP-61-0158,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BAG AUTOTRANSFUSION 400ML CARDIOPAT ORTHOPAT REPLACEMENT RBC",SUP-01200-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.68,40.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 80X25.4MM THK1.3MM LONG WIDE STAINLESS STEEL",SUP-2108118,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATH 5FR 70CM POWERPICC 2 LUMEN GWIRE NITINOL .018IN",SUP-3275355,CDM,C1751,HCPCS,0272,RC,,,both,,,678.94,203.68,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CURET VACUUM 9MM PLASTIC CANN STRAIGHT ROUND TIP SEMIRIGID",SUP-21552,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.34,19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL 7CM MIDAS REX MR8 1.5MM F1 TAPER DISSECTING STERILE",SUP-MR8-F1/7TA15,CDM,S27200284,LOCAL,0272,RC,,,both,,,955.31,286.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 63X32.5MM HALL THK.6MM STAINLESS STEEL OSCILLATE",SUP-507155100,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.86,19.16,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LIGASURE 5MM BLUNT TIP LAP SEALDIVIDER",SUP-LF1637,CDM,S27200284,LOCAL,0272,RC,,,both,,,3384.38,1015.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE STRATAFIX PDS PLUS 1 CT 45CM SUT ABSORBABLE KNOTLESS",SUP-SXPP1A405,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE BEAVER SCLERAL",SUP-375701,CDM,S27200284,LOCAL,0272,RC,,,both,,,896.32,268.9,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"THEOPHYLLINE ER 100 MG CAPSULE,EXTENDED RELEASE 24 HR",RX-27418,CDM,,,0637,RC,52244-0100-10,NDC,both,1,UN,23.36,7.01,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FORCEPS SURGICAL L4.75IN TISSUE 1X2 SERRATED STRAIGHT REUSAB",SUP-77950,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.15,14.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC F5 Gene",PX-309000026,CDM,81241,CPT,0310,RC,,,both,,,769.60,230.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,115.41,,,,,,,0.01,654.16,"fee schedule",
"FRCP ELECTROSURGICAL 8.25INX1.5MM OLSEN BIPOLAR BAYONET",SUP-20-0431R,CDM,S27200284,LOCAL,0272,RC,,,both,,,843.15,252.94,"CIGNA [10200]","Cigna Local Plus",,451.09,53.5,,,,,0,98.06,716.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLOSED WOUND FACIAL DRAINS (TWO) FLAT 4MM SILICONE WITH BIFU",SUP-412ATSX,CDM,S27200284,LOCAL,0272,RC,,,both,,,401.68,120.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,46.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.72,341.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 5FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G00983,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"KAISER [10500]",Kaiser,,33.05,67,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 5FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G00983,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22.64,45.9,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 120MM 12-14MM 13FR 10FR TRIVASCULAR OVATION",SUP-TV-IL1412120-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9015.3,27,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 20CMX10MM 3/8IN SILICONE 4 CHANNEL FULL",SUP-072214,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.62,31.09,"CIGNA [10200]","Cigna Local Plus",,55.44,53.5,,,,,0,12.05,88.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 4-0 PS-2 27IN MONOFILAMENT UNDYED",SUP-Y426H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VXSK-180J RF WIRE 63CM/45DEG/D1 SHEATH",SUP-VXSK0102,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2538.13,41.1,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IDENTITY IMPRINT TKR KNEE POSTERIOR STABILIZE JIG",SUP-TPS-000-D002,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,377.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 145MM 5MM SHORT 3 FLUTE QUICK COUPLING NDL POINT",SUP-03.010.105,CDM,S27200284,LOCAL,0272,RC,,,both,,,1152.14,345.64,"MULTIPLAN [10600]",Multiplan,,979.32,85,,,,,0,133.99,979.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG 35CM PREVENA PEEL AND PLACE VAC PRESSURE INDCTR PATCH",SUP-PRE3255US.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2091.15,627.34,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,959.84,45.9,,,,,0,243.2,1777.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE HEXAGON 240CMX27MM 2.4MM CAPTIVATOR ENDOSCOPIC",SUP-M00562341,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.33,36.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.11,103.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 14MM WRIST VOLAR THREAD LOCK TORX",SUP-TPEG-14,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"CIGNA [10200]","Cigna Open Access",,483.93,56.9,,1144.80,304.56,2275.09,66,98.91,722.93,"percent of total billed charges",
"SHEATH ENDO-SCRUB 2 0D 4MM ENDOSCOPIC CLEANING STORZ",SUP-1912000,CDM,S27200284,LOCAL,0272,RC,,,both,,,605.88,181.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,71.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.46,515,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE QUILL 3-0 3/8 CIRCLE 30X30CM 26MM CLSR MONODERM 2 ARM",SUP-YA-1023Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,202.10,60.63,"KAISER [10500]",Kaiser,,135.41,67,,,,,0,23.5,171.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 1.2MM RAP-PAC B ACL PCL KNEE DRILL",SUP-72202797,CDM,S27200284,LOCAL,0272,RC,,,both,,,1808.25,542.47,"CIGNA [10200]","Cigna Open Access",,1028.89,56.9,,,,,0,210.3,1537.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 12X6CM AXIS TUTOPLAST DERMIS ALLOGRAFT",SUP-939612,CDM,C1762,HCPCS,0278,RC,,,both,,,18402.30,5520.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7563.35,41.1,,,,,0,2140.19,15641.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND COMPRESSION REGULAR ZEPHYR",SUP-190101,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.18,56.45,"NOVANET [10819]",Novanet,,141.14,75,,,,,0,21.89,159.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH 3.5MM AORTIC",SUP-APU535,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,34.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NDL 2.5IN KEITH 2.5 ABDOMINAL STRAIGHT TRIANGULAR POINT","SUP-1827-2 1/2D",CDM,S27200284,LOCAL,0272,RC,,,both,,,81.66,24.5,"PHCS [10601]",PHCS,,57.16,70,,,,,0,9.5,69.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 V-5 30IN 2 ARM BRAID 10 STRAND GREEN",SUP-10X52,CDM,S27200284,LOCAL,0272,RC,,,both,,,879.17,263.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,104.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,102.25,747.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER SUT GREEN 3/8IN SMALL MINI OPEN STRESS RISER",SUP-9894,CDM,S27200284,LOCAL,0272,RC,,,both,,,376.36,112.91,"MULTIPLAN [10600]",Multiplan,,319.91,85,,,,,0,43.77,319.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK INSTR PROSTEP STERILE MIS",SUP-57S1MI07,CDM,S27200284,LOCAL,0272,RC,,,both,,,2077.50,623.25,"CIGNA [10200]","Cigna Local Plus",,1111.46,53.5,,,,,0,241.61,1765.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X8MM COROENT 10D XL+ WIDE PEEK NONSTERILE",SUP-6308250,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL PASSING",SUP-M365SC42300,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"UHC [10700]","United Healthcare",,110.14,63.3,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROXIMATE*RH WIDE SKIN STPLR",SUP-PRW35,CDM,S27200284,LOCAL,0272,RC,,,both,,,152.25,45.67,"MULTIPLAN [10600]",Multiplan,,129.41,85,,,,,0,17.71,129.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP BEIGE 64MM RUSCH EQUIPLITE MILLER 00 SMALL",SUP-004650010,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.98,14.99,"NOVANET [10819]",Novanet,,37.49,75,,,,,0,5.81,42.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 51.2MM 4.8MM ROUND FAST CUTTING STERILE",SUP-1608006139,CDM,S27200284,LOCAL,0272,RC,,,both,,,375.49,112.65,"UHC [10700]","United Healthcare",,237.69,63.3,,,,,0,43.67,319.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN AMPLATZ LEFT 1 CURVE",SUP-DXT5AL10,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"NOVANET [10819]",Novanet,,61.99,75,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL CANNULATED 7.5MM STERILE",SUP-AR-1218-75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP OCCL BALLOON AUDIO INDCTR ALERT ELECTROSURGERY DEVICE",SUP-KC-ARCH-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,470.94,41.1,,,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 330MM 3.2MM QUICK COUPLING 3 FLUTED CALIBRATED 100",SUP-03.010.060,CDM,S27200284,LOCAL,0272,RC,,,both,,,1503.68,451.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1022.5,68,,,,,0,174.88,1278.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 100CM 5FR ANGLE",SUP-G08421,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,27.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GAUGE MEASURING MENDEZ OPHTHALMIC 12MM",SUP-60-7086,CDM,S27000186,LOCAL,0270,RC,,,both,,,870.67,261.2,"CIGNA [10200]","Cigna Open Access",,495.41,56.9,,,,,0,101.26,740.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONCUSSION WITH MCC",088,MS-DRG,,,,,,,inpatient,,,56617.48,19990.48,"BLUE CROSS [10001]","Blue Cross HMO",,31032.99,,,,,,,8385.3,33712.54,"case rate",
"BEARING 63/67MMX12MM VANGUARD ARCOM KNEE POSTERIOR STABILIZE",SUP-183622,CDM,C1776,HCPCS,0278,RC,,,both,,,8259.30,2477.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,978.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,960.56,7020.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-55840015545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2732.31,28.62,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SMALL INTERNAL FILSHIE SILASTIC TITANIUM SOFT LINE",SUP-AVM-851J,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"CIGNA [10200]","Cigna Open Access",,506.98,56.9,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 20MM",SUP-SPL40020X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TL PCMKR REM LD CNCT",SUP-4080,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX ECHO 2 15X10CM POSITION SYSTEM STERILE",SUP-1211015,CDM,C1781,HCPCS,0278,RC,,,both,,,21498.75,6449.62,"CIGNA [10200]","Cigna Open Access",,7202.08,33.5,,11235.02,819.42,11235.02,"1 through 10",2500.3,18273.94,"percent of total billed charges",
"SCR BONE RELINE C SPINE OPEN LOCK NONSTERILE LATEX FREE",SUP-3900240,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"BLUE CROSS [10001]","Blue Cross PPO",,136.42,39.2,,957.42,570.23,957.42,28,40.47,295.8,"percent of total billed charges",
"PORT IMPLANTABLE INFUSION POWERPORT ISP AIRGUARD CHRONOFLEX",SUP-1706060,CDM,C1788,HCPCS,0278,RC,,,both,,,1905.00,571.5,"KAISER [10500]",Kaiser,,1276.35,67,,,,,0,221.55,1619.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 3 OFFSET DOME 9MM UNITY KNEE POLYETHYLENE",SUP-112.018.52,CDM,C1776,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DRILL 75MM 3.2MM 2.5MM NEXGEN TROCAR HEXAGON TROCAR TIP",SUP-00-5901-020-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,797.04,239.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAMP CIRCUMCISION CLEAR 1.3CM PLASTIBELL PLASTIC UNIQUE",SUP-HL9213,CDM,S27200284,LOCAL,0272,RC,,,both,,,57.47,17.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SYNCHRO2 VASCULAR 215CM .014IN HYDROPHILIC PRESHAPE",SUP-S2SPP14215,CDM,C1769,HCPCS,0272,RC,,,both,,,4568.90,1370.67,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MAC-LOC 40CM 16CM 10.2FR DRNG ULTRATHANE HYDROPHILIC",SUP-G13353,CDM,C1729,HCPCS,0272,RC,,,both,,,801.82,240.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARDEX LUBRICATH 24FR STD URETHRAL NATURAL RUBBER",SUP-0119L24,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.52,23.26,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE LARYNSCP SPECTRUM 1 STERILE DISPOSABLE",SUP-0270-0967,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS ADROIT 125CM 6FR JR4 CURVE GUIDING STAINLESS",SUP-67208225,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASKET STONE RETRIEVAL 120CM 11MM 2.4FR GEMINI HELICAL",SUP-M0063303060,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER 4MM 40DEG BIPOLAR CONVEX SERRATED",SUP-BB4040XC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1434.01,430.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 415CC",SUP-SSZ-F415,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT CARDIOVASCULAR 15CM 6MM THORACIC KNIT HEMASHIELD GOLD",SUP-M002020951060,CDM,C1768,HCPCS,0278,RC,,,both,,,2540.03,762.01,"AETNA [10100]","Aetna HMO/PPO",,2019.32,79.5,,,,,0,295.41,2159.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3.5MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-3.5-8-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4678.2,40,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 40MM HIP BIOLOX DELTA FMP SYSTEM",SUP-400-03-403,CDM,S27200284,LOCAL,0272,RC,,,both,,,16953.92,5086.18,"MULTIPLAN [10600]",Multiplan,,14410.83,85,,,,,0,1971.74,14410.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC GREEN 76MM OBTR TROCAR SEAL STERILE",SUP-012421,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,165.65,68,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR 52MM MULTIPOLAR HIP METAL STERILE",SUP-00-5001-052-00,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,434.96,3179,"percent of total billed charges",
"SCR BONE 13MM 1.3MM CORTICAL CRANIOFACIAL TITANIUM SELF",SUP-400.693,CDM,C1713,HCPCS,0278,RC,,,both,,,650.92,195.28,"BLUE CROSS [10001]","Blue Cross PPO",,255.16,39.2,,957.42,570.23,957.42,28,75.7,553.28,"percent of total billed charges",
"INSRT TIBIAL 8 16MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P816,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"MULTIPLAN [10600]",Multiplan,,7102.52,85,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 2-0 CT-2 15CM ANTIBACTERIAL",SUP-SXMP1B415,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.17,68.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.65,194.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 126MM 13.5MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771101300,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2476.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2430.63,17764.68,"percent of total billed charges",
"SYSTEM XIENCE PRIME 33MM 143CM 4MM CORONARY STENT EVEROLIMUS",SUP-1011735-33,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1136.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM COAXIAL HELIX 1 FILAR COIL POSITIVE",SUP-7741,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"AETNA [10100]","Aetna HMO/PPO",,1774.84,79.5,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 37X27X12MM CRESCENT SOVEREIGN 12D MEDIUM PEEK",SUP-7968212,CDM,C1713,HCPCS,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,957.42,570.23,957.42,28,3297.11,24097.5,"percent of total billed charges",
"AIRWAY LARYNGEAL 3 CHILD 30-50KG LMA UNIQUE LATEX FREE",SUP-125030,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.20,15.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,23.96,45.9,,,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET",RX-97463,CDM,,,0637,RC,50268-0866-11,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,3.35,53.5,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM LOW PROFILE LOCK TUBE STERILE RFN-ADVANCED",SUP-04.045.334TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,217.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",217.47,1589.42,"percent of total billed charges",
"HC Plc Cath Ren Arty 1st Ord Bi",PX-361000092,CDM,36252,CPT,0361,RC,,,both,,,14951.46,4485.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1738.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1738.85,12708.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM CREO CREO AMP SPINE TULIP REDUCTION",SUP-1119.0600,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"MULTIPLAN [10600]",Multiplan,,2550,85,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 26MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.726,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"CIGNA [10200]","Cigna Local Plus",,601.14,53.5,,3978.14,359.25,3978.14,24,130.68,955.09,"percent of total billed charges",
"CATH DIREXION HI-FLO 155CM 2.8FR .027IN MICRO BERN INFUSION",SUP-M001195450,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"NOVANET [10819]",Novanet,,2812.5,75,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ASPIRATION 80MM 19GA 1.85MM EZ SHOT 2 ROUND KNOB STYLET",SUP-NA-220H-8019,CDM,S27200284,LOCAL,0272,RC,,,both,,,1467.10,440.13,"FIRST HEALTH [10303]","First Health",,1173.68,80,,,,,0,170.62,1247.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 36MM STD GLENOSPHERE COMPREHENSIVE VERSA-DIAL",SUP-TI-115310,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"CIGNA [10200]","Cigna Open Access",,4084.66,33.5,,5302.19,4377.88,6578.61,27,1418.05,10364.05,"percent of total billed charges",
"STEM FEMORAL CEMENTED EXETER V40 0 44MM OFFSET LONG HIP",SUP-0580-1-044,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,5311.50,4717.44,5388.59,31,2014.9,14726.25,"percent of total billed charges",
"COAG SUCTION 6IN 10FR LECTROVAC VALLEYLAB CORD HAND",SUP-E2505-10FR,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.90,17.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.62,48.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL WHITE 3MM TAPER ROUTER",SUP-5407FA3030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1009.26,302.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.38,857.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FRCP 5.51IN OLSEN ADSON STRAIGHT BIPOLAR INSULATE",SUP-20-1080KI,CDM,S27200284,LOCAL,0272,RC,,,both,,,322.60,96.78,"PHCS [10601]",PHCS,,225.82,70,,,,,0,37.52,274.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD LOOP WHITE 22FR ANGLED CUT NONSTERILE",SUP-26055G,CDM,S27000186,LOCAL,0270,RC,,,both,,,1050.84,315.25,"CIGNA [10200]","Cigna Local Plus",,562.2,53.5,,,,,0,122.21,893.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST OP BRA 36C BLACK","SUP-B01G-36 B/C-B",CDM,S27000186,LOCAL,0270,RC,,,both,,,407.16,122.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,48.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.35,346.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 154MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-240.040S,CDM,C1713,HCPCS,0278,RC,,,both,,,9673.52,2902.06,"BLUE CROSS [10001]","Blue Cross PPO",,3792.02,39.2,,957.42,570.23,957.42,28,1125.03,8222.49,"percent of total billed charges",
"SCR BONE 1.5MM 15MM ALPS TIMAX HAND CORTICAL NONLOCK SQUARE",SUP-131220515,CDM,S27200284,LOCAL,0272,RC,,,both,,,1032.75,309.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,122.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,120.11,877.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Breast Local Dev Stereo Add",PX-361000315,CDM,19284,CPT,0361,RC,,,both,,,2725.49,817.65,"KAISER [10500]",Kaiser,,1826.08,67,,,,,0,316.97,2725.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC T Cell Total Count",PX-302000080,CDM,86359,CPT,0302,RC,,,both,,,244.56,73.37,"BLUE CROSS [10001]","Blue Cross PPO",,48.2,,"Fee schedule rate ($48.20).",,,,0,0.01,207.88,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMEDY SPECTRUM GV FEMORAL LONG STEM MD",SUP-GVLSMD,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX CORE REINFORCED TISSUE MATRIX, LONG-TERM RESORBABLE R",SUP-F10264-1012G,CDM,C1781,HCPCS,0278,RC,,,both,,,6789.60,2036.88,"MULTIPLAN [10600]",Multiplan,,5771.16,85,,,,,0,789.63,5771.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 10.5IN 24FR SILICONE Y PORT GRADUATE SHAFT OPEN DISTAL",SUP-8884720247E,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.71,111.81,"CIGNA [10200]","Cigna Local Plus",,199.4,53.5,,,,,0,43.35,316.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 110MM JOUST MEDIUM THREAD CANNULATED BEAM SHARP",SUP-P26-550-110M,CDM,C1713,HCPCS,0278,RC,,,both,,,7058.70,2117.61,"BLUE CROSS [10001]","Blue Cross PPO",,2767.01,39.2,,957.42,570.23,957.42,28,820.93,5999.9,"percent of total billed charges",
"CATH SOFTOUCH 100CM 5FR .044IN .038IN SIM2 CURVE",SUP-5407-23,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.70,28.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 250MM HUMERUS T2 INTRAMEDULLARY ANTEGRADE",SUP-1830-0925S,CDM,C1713,HCPCS,0278,RC,,,both,,,8702.69,2610.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2490.71,28.62,,,,,0,1012.12,7397.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH PORTEX STERILE LATEX FREE DISPOSABLE",SUP-101/596/090,CDM,S27200284,LOCAL,0272,RC,,,both,,,3247.05,974.11,"MULTIPLAN [10600]",Multiplan,,2759.99,85,,,,,0,377.63,2759.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL CERVICAL THORACIC MA 5MM X 30MM RELINE-C",SUP-3935030,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL HOUSE .6MM 1MM ANGLE LEFT OVAL 5.25IN MIDDLE",SUP-61-0154,CDM,S27200284,LOCAL,0272,RC,,,both,,,1653.90,496.17,"FIRST HEALTH [10303]","First Health",,1323.12,80,,,,,0,192.35,1405.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cytology Concentration",PX-311000006,CDM,88108,CPT,0311,RC,,,both,,,256.50,76.95,"UHC [10700]","United Healthcare",,34.39,,,,,,,0.01,218.03,"fee schedule",
"TROCAR LAPAROSCOPIC 150MM 5MM KII ADVANCE FIXATION RETENTION",SUP-CFR01,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"UHC [10700]","United Healthcare",,90.87,63.3,,,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 18FR SILICONE MIC SECUR-LOK ENFIT FEED TUBE",SUP-8260-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,2567.55,770.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1745.93,68,,,,,0,298.61,2182.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 40MM 140CM 2.5MM CORONARY STERILE LATEX",SUP-453974,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Who W/O Joints Cf",PX-E27400032,CDM,L3906,HCPCS,0274,RC,,,both,,,1030.48,309.14,"MULTIPLAN [10600]",Multiplan,,875.91,85,,,,,0,119.84,875.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REM CLIP ANASTOCLIP UNIVERSAL",SUP-4001-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,2767.50,830.25,"CIGNA [10200]","Cigna Local Plus",,1480.61,53.5,,,,,0,321.86,2352.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 330MM 5MM 3 FLUTE QUICK COUPLING CALIBRATED 100MM",SUP-03.010.062,CDM,S27200284,LOCAL,0272,RC,,,both,,,1617.08,485.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.07,1374.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE 12IN MERITRANS 3 WAY STPCOCK FEMALE LUER",SUP-K11-00280,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"CIGNA [10200]",Cigna,,88.74,68,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 12D ALLOGRAFT 24MM ALIF",SUP-3W4224,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2505.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 4-0 P-3 18IN BRAID BLACK NONABSORBABLE",SUP-641G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TIBIAL NEXGEN OPTION 5 KNEE ZIMALOY CEMENT FLUTE STEM",SUP-591605001,CDM,C1713,HCPCS,0278,RC,,,both,,,11327.04,3398.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3058.3,27,,,,,0,1317.33,9627.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTIGRAFT CORTICAL CANCELLOUS HP6.75MM HA8.22MM",SUP-VG2C-T68P,CDM,S27800098,LOCAL,0278,RC,,,both,,,5865.00,1759.5,"BLUE CROSS [10001]","Blue Cross HMO",,2299.08,39.2,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 11CMX12MM OSTEOTOM CUP NONSTERILE DISPOSABLE",SUP-SBLDCUP-2-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"PHCS [10601]",PHCS,,1020.6,70,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 380MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.058S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1471.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1444.25,10555.59,"percent of total billed charges",
"SHEATH AMPLATZ 17CM 30FR ACCESS PTFE RENAL FIRM TAPER TIP",SUP-M0062601540,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,39.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP040150090 PLUS US D4L150UL900",SUP-PCP040150090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"MULTIPLAN [10600]",Multiplan,,1046.52,85,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 18MM WRIST VOLAR THREAD LOCK TORX",SUP-TPEG-18,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"CIGNA [10200]","Cigna Local Plus",,455.02,53.5,,3978.14,359.25,3978.14,24,98.91,722.93,"percent of total billed charges",
"RULER SURGICAL 30X15X.4MM 1SQ MM SILICONE MICRO-GRID METRIC",SUP-4022805,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.18,41.15,"UHC [10700]","United Healthcare",,86.83,63.3,,,,,0,15.95,116.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM AVENIR 10 COIL STERILE LATEX",SUP-10CFR14030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UHC [10700]","United Healthcare",,7420.72,63.3,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 100MM 6MM XIA 3 TITANIUM",SUP-48238100,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2-0 T-13 18IN BRAID TIES MULTISTRAND LOWER",SUP-AR-7220,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,23.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 18CM TOUCH NARROW BASE PENOSCROTAL NARROW",SUP-EN2918,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"AETNA [10100]","Aetna HMO/PPO",,49846.5,79.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL ZIPWIRE 22-30CM 3CM 4.8FR .035IN PIGTAIL",SUP-M006180155180,CDM,C2617,HCPCS,0278,RC,,,both,,,1466.59,439.98,"KAISER [10500]",Kaiser,,982.62,67,,,,,0,170.56,1246.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 375CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP120RH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"CIGNA [10200]","Cigna Local Plus",,3749.29,,,,,,,1384.26,10117.13,"percent of total billed charges",
"CATH ANGIOSCULPT EVO 6MM 3MM BALLOON DILATATION HYDROPHILIC",SUP-2200-3006-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"UHC [10700]","United Healthcare",,3712.55,63.3,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER TUMARK EVIVA BREAST BIOPSY PROFESSIONAL Q EVIVA STD",SUP-TUMARK-E13-S-Q-02,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,77.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAT TRANSFER 39X49IN HALFMATS HALF MAT AIR WEIGHT LIMIT 500",SUP-3230,CDM,S27100035,LOCAL,0271,RC,,,both,,,526.50,157.95,"AETNA [10100]","Aetna HMO/PPO",,418.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 CTX 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J369H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM 29MM 27MM BIOCOR FLEXFIT LOW PROFILE",SUP-B100-29A-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,30744.00,9223.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12297.6,40,,,,,0,3575.53,26132.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL GOLD 85MM 10.35MM TFN-ADVANCED",SUP-04.038.285S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"MULTIPLAN [10600]",Multiplan,,3384.57,85,,,,,0,463.09,3384.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REGULAR 6FR INTRO NINITOL ECHOGENIC NDL FIXED CORE",SUP-70-6160,CDM,C1894,HCPCS,0272,RC,,,both,,,304.50,91.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,35.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Feeynolm 5.1-7.5cm Int",PX-450000043,CDM,12053,CPT,0450,RC,,,both,,,2140.00,642,"BLUE CROSS [10001]","Blue Cross HMO",,2140,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,67.13,2140,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cor Arty/Grft Angio",PX-481000023,CDM,93455,CPT,0481,RC,,,both,,,11814.88,3544.46,"NOVANET [10819]",Novanet,,8861.16,75,,,,,0,1374.07,11062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL REVERSE ALTIVATE SMALL SHELL 6MM X 220MM",SUP-533-06-220,CDM,C1776,HCPCS,0278,RC,,,both,,,45388.92,13616.68,"AETNA [10100]","Aetna HMO/PPO",,36084.19,79.5,,10981.53,8986.79,12413.38,12,5278.73,38580.58,"percent of total billed charges",
"CANN PERFUSION 20FR CORONARY ARTERY OSTIUM",SUP-30320,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL FIBRA STEALTH 6MM VASCULAR .5 FORCE SPRING",SUP-A1652,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,92.97,41.1,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 18CM 3CM 5FR .035IN STRAIGHT URETERAL",SUP-M006155215180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"KAISER [10500]",Kaiser,,1078.51,67,,,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM 4X1.75IN STEINER-AUVARD VAGINAL STAINLESS STEEL",SUP-500-147,CDM,S27200284,LOCAL,0272,RC,,,both,,,1355.37,406.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,160.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,157.63,1152.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 6-7 C-D KNEE",SUP-42522100411,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PHCS [10601]",PHCS,,7543.49,70,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LATERAL LUMBAR ANCHOR 20MM",SUP-1219.0020,CDM,C1713,HCPCS,0278,RC,,,both,,,3277.50,983.25,"KAISER [10500]",Kaiser,,2195.93,67,,,,,0,381.17,2785.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUROFORM ATLAS STENT SYSTEM 4.5 X 21MM WITHOUT TIP ZERO (PM",SUP-M003UZAS45210,CDM,C1874,HCPCS,0278,RC,,,both,,,52885.22,15865.57,"BLUE CROSS [10001]","Blue Cross HMO",,20731.01,39.2,,9776.84,9776.84,9776.84,"1 through 10",6150.55,44952.44,"percent of total billed charges",
"WIRE FIXATION 150MM 1.1MM KIRSCHNER DART-FIRE",SUP-DSDS1011,CDM,C1713,HCPCS,0278,RC,,,both,,,191.40,57.42,"CIGNA [10200]","Cigna Local Plus",,102.4,53.5,,3978.14,359.25,3978.14,24,22.26,162.69,"percent of total billed charges",
"EXT NEROSTIMLTR 25CM PRECISION PHASE III LEAD",SUP-SC-3138-25,CDM,C1883,HCPCS,0278,RC,,,both,,,3525.00,1057.5,"PHCS [10601]",PHCS,,2467.5,70,,,,,0,409.96,2996.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.3MM 12MM CORTICAL LOCKING ACU-LOC 2 STERILE",SUP-CO-S2312,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA [10200]","Cigna Local Plus",,407.35,53.5,,3978.14,359.25,3978.14,24,88.55,647.19,"percent of total billed charges",
"LOTUS VALVE SYSTEM 23MM REPRISE III",SUP-H749LTVR3CL230,CDM,S62400003,LOCAL,0624,RC,,,both,,,142500.00,42750,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16572.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16572.75,121125,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 155CM 40MM 3MM RECTANGLE HELIX BALLOON",SUP-2155-3040,CDM,C1725,HCPCS,0272,RC,,,both,,,6865.50,2059.65,"PHCS [10601]",PHCS,,4805.85,70,,,,,0,798.46,5835.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 8.25MM 9CM PARTIAL THREAD OBTR TRANSLUCENT",SUP-AR-6575-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"NOVANET [10819]",Novanet,,171.29,75,,,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 450CC SMOOTH SHELL SURFACE NATRELLE INSPIRA FULL",SUP-SRF-450,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"AETNA [10100]","Aetna HMO/PPO",,4360.97,79.5,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 8MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0100800,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"PHCS [10601]",PHCS,,3557.3,70,,,,,0,591.02,4319.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 9.5MM STORZ UNIVERSAL STAINLESS STEEL","SUP-E3096 9.50",CDM,S27200284,LOCAL,0272,RC,,,both,,,575.67,172.7,"AETNA [10100]","Aetna HMO/PPO",,457.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,66.95,489.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV",RX-9807,CDM,J3480,HCPCS,0258,RC,00990-7904-09,NDC,both,1000,ML,100.65,30.19,"FIRST HEALTH [10303]","First Health",,80.52,80,,,,,0,0.02,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 42MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.442TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"MULTIPLAN [10600]",Multiplan,,1718.32,85,,,,,0,235.11,1718.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2.5CM 2MM CEREPAK MICRO UNIFORM DETACHABLE",SUP-FCX100202,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5290.34,40,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT CONTRACTURE DEROYAL MEDIUM ANKLE ANTIROTATION BAR PAD",SUP-4301C,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL STANDARD+ KNEE LEFT CEMENT LCS COMPLETE COCR",SUP-129402050,CDM,C1776,HCPCS,0278,RC,,,both,,,20635.65,6190.69,"PHCS [10601]",PHCS,,14444.96,70,,,,,0,2399.93,17540.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPIDCROSS 170CM 100MM 4MM .014IN BALLOON DILATATION",SUP-A14BX040100170,CDM,S27200284,LOCAL,0272,RC,,,both,,,1385.10,415.53,"MULTIPLAN [10600]",Multiplan,,1177.34,85,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 300CM .014IN",SUP-7913,CDM,C1769,HCPCS,0272,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 70MM ATLANTIS VISION ELITE BONE SPINAL",SUP-7200070,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"BLUE CROSS [10001]","Blue Cross HMO",,2074.46,39.2,,957.42,156.86,7483.26,51,615.46,4498.2,"percent of total billed charges",
"LENS IOL 0 D +26 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.260,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPHENHYDRAMINE 25 MG TABLET",RX-2505,CDM,,,0637,RC,68094-0018-59,NDC,both,1,UN,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL L HOOK 45CM CLEANCOAT WIRE COATED",SUP-E3773-45C,CDM,S27200284,LOCAL,0272,RC,,,both,,,316.07,94.82,"CIGNA [10200]","Cigna Open Access",,179.84,56.9,,,,,0,36.76,268.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0267,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross PPO",,371.5,39.2,,957.42,570.23,957.42,28,110.22,805.55,"percent of total billed charges",
"STENT OMNILINK ELITE 19MM 80CM 8MM THIN VASCULAR COCR",SUP-1012624-19,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"PHCS [10601]",PHCS,,5880,70,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 55MM 4MM STAINLESS STEEL ROUND 8 FLUTED",SUP-1608006137,CDM,S27000186,LOCAL,0270,RC,,,both,,,375.49,112.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,44.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.67,319.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE LEVEL ONE Y CRANIOFACIAL TITANIUM ULTRA LOW",SUP-25-153-07-09,CDM,C1713,HCPCS,0278,RC,,,both,,,2211.60,663.48,"NOVANET [10819]",Novanet,,1658.7,75,,,,,0,257.21,1879.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO BALKIN CURVE 40CM 7FR 2.5MM GUIDING",SUP-G10384,CDM,C1894,HCPCS,0272,RC,,,both,,,405.25,121.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,275.57,68,,,,,0,47.13,344.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEEDING SET MIC FEED ACCESS",SUP-0301-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.69,24.51,"MULTIPLAN [10600]",Multiplan,,69.44,85,,,,,0,9.5,69.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (CR) - SIZE 8",SUP-5555-2208,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"PHCS [10601]",PHCS,,992.25,70,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 5CM 7FR PANCREATIC POLYETHYLENE PUSH CATH DRAIN",SUP-G21374,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hiv-1 Dna Ampl Probe",PX-306000137,CDM,87535,CPT,0306,RC,,,both,,,542.45,162.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,55.2,,,,,,,0.01,461.08,"fee schedule",
"TAP XLONG 125MM SURGICAL 2.7MM CORTEX AND 3.5MM TI SHAFT SCR",SUP-311.28,CDM,S27000186,LOCAL,0270,RC,,,both,,,1550.02,465.01,"UHC [10700]","United Healthcare",,981.16,63.3,,,,,0,180.27,1317.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPICILLIN 2 G IV VIAL",RX-27281,CDM,J0290,HCPCS,0636,RC,00781-3413-15,NDC,both,1,UN,226.52,67.96,"BLUE CROSS [10001]","Blue Cross PPO",,2.56,,,,,,,2.56,192.54,"fee schedule",
"LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK",RX-108119,CDM,J1956,HCPCS,0636,RC,25021-0132-82,NDC,both,100,ML,100.65,30.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68.44,68,,,,,0,5.92,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE ADJUSTMENT UNITRAX +10MM FEMORAL HIP C TAPER",SUP-6942-7-085,CDM,C1713,HCPCS,0278,RC,,,both,,,855.82,256.75,"NOVANET [10819]",Novanet,,641.87,75,,,,,0,99.53,727.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X3 HUMERAL INSERT - 32MM X 8 CONSTRAINED",SUP-5571-C-3208,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"KAISER [10500]",Kaiser,,6753.6,67,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,inpatient,,,126140.57,37842.17,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,19298.44,,"Case rate ($18,736.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $17,397.97, add-ons for qualifying new technology services are included. If operating cost exceeds $50,437.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,697.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $17,420.97. The transfer operating threshold is the transfer adjustment factor * $17,397.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,315.37. The transfer capital threshold is the transfer adjustment factor * $1,315.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,10994,88186.52,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 40MM 80CM 9MM VASCULAR PERIPHERAL SELF",SUP-1012531-40,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross HMO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP LIMIT HOLE COLOR CODED POROUS G7 E",SUP-010000663,CDM,C1776,HCPCS,0278,RC,,,both,,,9256.80,2777.04,"NOVANET [10819]",Novanet,,6942.6,75,,,,,0,1076.57,7868.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK12MM 51X63MM GALLANT IMPLANTABLE 1 CHMBR DF",SUP-CDVRA500Q,CDM,C1722,HCPCS,0278,RC,,,both,,,56385.00,16915.5,"MULTIPLAN [10600]",Multiplan,,47927.25,85,,,,,0,6557.58,47927.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX11MM FRA 8D LORDOTIC NARROW WEDGE",SUP-10011,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"MULTIPLAN [10600]",Multiplan,,16065,85,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 15CM 13FR POWER-TRIALYSIS STRAIGHT 3 LUMEN ACUTE",SUP-5605150,CDM,C1752,HCPCS,0272,RC,,,both,,,1614.33,484.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1097.74,68,,,,,0,187.75,1372.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 11MM KNEE HINGE REVISION TRIATHLON",SUP-5612-P-311,CDM,C1776,HCPCS,0278,RC,,,both,,,16199.82,4859.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1884.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1884.04,13769.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 85MM TITANIUM SELF TAP LOCK NONSTERILE AXSOS 3",SUP-661085,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"CIGNA [10200]","Cigna Local Plus",,698.56,53.5,,3978.14,359.25,3978.14,24,151.86,1109.86,"percent of total billed charges",
"GWIRE CHOICE PT VASCULAR 182CM 35CM .014IN STAINLESS STEEL",SUP-H74912161012,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo Intestine Sm Ilium Bx",PX-750000064,CDM,44377,CPT,0750,RC,,,both,,,4174.00,1252.2,"BLUE CROSS [10001]","Blue Cross PPO",,3634.7,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,485.44,4174,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo Intestine Sm Ilium Bx",PX-750000064,CDM,44377,CPT,0750,RC,,,both,,,4174.00,1252.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,485.44,4174,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 38MM 140CM 3MM CORONARY",SUP-RSINT30038UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"BLUE CROSS [10001]","Blue Cross HMO",,2173.25,39.2,,9776.84,9776.84,9776.84,"1 through 10",644.77,4712.4,"percent of total billed charges",
"PUNCH AORTIC ROTATING 5.0MM X 20CM CLEANCUT STERILE",SUP-RCL50,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"CIGNA [10200]","Cigna Local Plus",,122.18,53.5,,,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X17MM 8D CONVEX LORDOTIC WEDGE",SUP-010617,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3732.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT CYL 30X4IN 1 BLADDER 2 PORT QUICK COLOR CUFF 40IN",SUP-5921-030-235,CDM,S27200284,LOCAL,0272,RC,,,both,,,201.14,60.34,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,92.32,45.9,,,,,0,23.39,170.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rad Tx Del Lvl 3 Sd",PX-333000072,CDM,77412,CPT,0333,RC,,,both,,,3045.45,913.63,"CIGNA [10200]","Cigna Local Plus",,1629.32,53.5,,,,,0,354.19,3045.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 18GA 10CM POWERGLIDE PRO REINFORCE TIP BASIC",SUP-F118100T,CDM,C1751,HCPCS,0272,RC,,,both,,,558.98,167.69,"MULTIPLAN [10600]",Multiplan,,475.13,85,,,,,0,65.01,475.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 34-36MM TITANIUM 5.5MM ROD LOW PROFILE MULTISPAN X10",SUP-8115534,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE",RX-19451,CDM,90700,HCPCS,0636,RC,58160-0810-52,NDC,both,.5,ML,228.78,68.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,111.19,48.6,,,,,0,27.11,194.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BLOOD SAMPLING SAFEDRAW PM",SUP-688496,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"UHC [10700]","United Healthcare",,181.73,63.3,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TMPLT BENDING PELVIC 16 HOLE 3.5 MM LOW PROFILE",SUP-03.100.035,CDM,S27000186,LOCAL,0270,RC,,,both,,,855.04,256.51,"AETNA [10100]","Aetna HMO/PPO",,679.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.44,726.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPHOTERICIN B LIPOSOME 50 MG/12.5ML IV (WET SUSR VIAL)|DISCARDED DRUG NOT ADMINISTE",RX-41521900,CDM,J0289,HCPCS,0636,RC,00469-3051-30,NDC,both,1,UN,1921.31,576.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",JW,278.59,,,,,,,125.17,1633.11,"fee schedule",
"SYSTEM INTEGRITY 12MM 2.75MM CORONARY STENT FULCRUM COCR",SUP-INT27512UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CIGNA [10200]",Cigna,,1642.2,68,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 SH 18IN CONTROL RELEASE BRAID 8",SUP-C012D,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.85,29.95,"CIGNA [10200]","Cigna Open Access",,56.81,56.9,,,,,0,11.61,84.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175274180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,169.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 6FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006145361190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,518.65,45.9,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dilate Urethra Stricture Male",PX-450000379,CDM,53600,CPT,0450,RC,,,both,,,1173.46,352.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1173.46,,,,,,,1.17,1173.46,"case rate",
"HC Dilate Urethra Stricture Male",PX-450000379,CDM,53600,CPT,0450,RC,,,both,,,1173.46,352.04,"CIGNA [10200]",Cigna,,1173.46,,,,,,,1.17,1173.46,"case rate",
"DEFIB CARDIAC THK15MM 51X64MM PROTECTA XT DR ATRIUM",SUP-D314DRG,CDM,C1721,HCPCS,0278,RC,,,both,,,63000.00,18900,"MULTIPLAN [10600]",Multiplan,,53550,85,,,,,0,7326.9,53550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tpmt Gene Com Variants",PX-309000122,CDM,81335,CPT,0310,RC,,,both,,,566.80,170.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,157.33,,,,,,,0.01,502.65,"fee schedule",
"INSRT TIBIAL 3 11MM KNEE HINGE REVISION TRIATHLON",SUP-5612-P-311,CDM,C1776,HCPCS,0278,RC,,,both,,,16199.82,4859.95,"CIGNA [10200]","Cigna Open Access",,5426.94,33.5,,5302.19,4377.88,6578.61,27,1884.04,13769.85,"percent of total billed charges",
"SYSTEM ELUNIR THK90UM 8MM 140CM 4MM CORONARY STENT CARBOSIL",SUP-LUN400R08US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 113MM 30-12MM 7.7MM 20FR ZENITH RENU",SUP-G55382,CDM,C1874,HCPCS,0278,RC,,,both,,,43501.50,13050.45,"BLUE CROSS [10001]","Blue Cross HMO",,17052.59,39.2,,9776.84,9776.84,9776.84,"1 through 10",5059.22,36976.28,"percent of total billed charges",
"CATH CARTO XP THERMOCOOL SF 115CM 8FR 3.5MM FF CURVE",SUP-BNI35FFH,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"FIRST HEALTH [10303]","First Health",,14449.68,80,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE EMERALD VASCULAR 3MM RADIUS 260CM 7CM .035IN PTFE",SUP-502455,CDM,C1769,HCPCS,0272,RC,,,both,,,106.58,31.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,43.8,41.1,,,,,0,12.4,90.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADMIRAL XTREME 130CM 40MM 7MM BALLOON DILATATION",SUP-ADM070040130,CDM,C1725,HCPCS,0272,RC,,,both,,,1134.00,340.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,466.07,41.1,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cholinesterase Serum",PX-301000146,CDM,82480,CPT,0301,RC,,,both,,,289.75,86.92,"NOVANET [10819]",Novanet,,217.31,75,,,,,0,0.01,246.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 8MMX39MM 7FR 80CMCATH HEPARIN",SUP-BXBL083901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]","Cigna Local Plus",,6144.01,31.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DIL VASCULAR",SUP-200-120,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"FIRST HEALTH [10303]","First Health",,1350,80,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 100MM 6MM BALLOON",SUP-U35130610,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 42X30X16MM CRESCENT SOVEREIGN 12D LARGE PEEK",SUP-7969216,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 25MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE50025,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"NOVANET [10819]",Novanet,,62748.45,75,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAPSAICIN 0.075 % TOPICAL CREAM",RX-9399,CDM,,,0637,RC,00536-1118-25,NDC,both,57,GR,35.50,10.65,"CIGNA [10200]",Cigna,,24.14,68,,,,,0,4.13,30.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 30MM TITANIUM CORTICAL 2 LEAD THREAD SELF TAP",SUP-14-405030,CDM,C1713,HCPCS,0278,RC,,,both,,,2475.00,742.5,"BLUE CROSS [10001]","Blue Cross HMO",,970.2,39.2,,957.42,156.86,7483.26,51,287.84,2103.75,"percent of total billed charges",
"SYSTEM ON-Q C SELECT-A-FLOW 2-14ML/HOUR PAIN PUMP 600ML",SUP-CB6004,CDM,C9804,HCPCS,0272,RC,,,both,,,3291.75,987.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2238.39,68,,,,,0,382.83,2797.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 2-0 UCL 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z114H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 30MM 120CM 6MM VASCULAR PERIPHERAL SELF",SUP-PRB35-06-030-120,CDM,C1876,HCPCS,0278,RC,,,both,,,4347.00,1304.1,"PHCS [10601]",PHCS,,3042.9,70,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR PULSE LATITUDE NXT 83.1X69.1MM EMBLEM S-ICD 12.7MM",SUP-A219,CDM,C1722,HCPCS,0278,RC,,,both,,,59280.00,17784,"KAISER [10500]",Kaiser,,39717.6,67,,,,,0,6894.26,50388,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 12MM 144CM 4MM CORONARY STENT",SUP-H7493941812400,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X17MM 8D CONVEX LORDOTIC WEDGE",SUP-010617,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9015.3,28.62,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 28CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155244190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"MULTIPLAN [10600]",Multiplan,,1207.29,85,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 140MM 80CM 8MM 6FR .035IN BILIARY",SUP-G50134,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CIGNA [10200]","Cigna Open Access",,3465.21,56.9,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 48MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.218,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,593.76,68,,,,,0,101.55,742.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 36CM 18MM .021-.027IN AZUR CX HYDROCOIL",SUP-45-781836,CDM,S27800098,LOCAL,0278,RC,,,both,,,5278.50,1583.55,"BLUE CROSS [10001]","Blue Cross PPO",,2069.17,39.2,,,,,0,613.89,4486.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Decalcification Proc",PX-312000019,CDM,88311,CPT,0312,RC,,,both,,,190.00,57,"CIGNA [10200]",Cigna,,19.07,,,,,,,0.01,161.5,"fee schedule",
"SYSTEM PROMUS PREMIER 12MM 144CM 3.5MM CORONARY STENT",SUP-H7493952812350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]",Cigna,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 6MM 1.5MM",SUP-SPL15006X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DAC 044 115CM",SUP-90760,CDM,S27200284,LOCAL,0272,RC,,,both,,,9626.67,2888,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3956.56,41.1,,,,,0,1119.58,8182.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PROC VENACURE EVLT NEVERTOUCH DIRECT NDL SMA 905 CNCT 1",SUP-11403101,CDM,C1888,HCPCS,0272,RC,,,both,,,4532.61,1359.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,537.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,527.14,3852.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Progr Dev Eval Icd Subq Lead",PX-481000106,CDM,93260,CPT,0480,RC,,,both,,,438.70,131.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,201.36,45.9,,,,,0,51.02,438.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RCRD CARDIAC CONFIRM RX SMALL SLIM 1 TOUCH PROGRAM DATA",SUP-DM3500,CDM,C1764,HCPCS,0278,RC,,,both,,,23940.00,7182,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2784.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AICD GENERATOR PROCEDURES",245,MS-DRG,,,,,,,inpatient,,,180041.07,54012.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,90568.2,,"Fee schedule rate ($90,568.20). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,133203.83,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 55CM 6FR .07IN ADULT RENAL CURVE",SUP-67021255,CDM,C1887,HCPCS,0272,RC,,,both,,,304.50,91.35,"MULTIPLAN [10600]",Multiplan,,258.83,85,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 85MM TITANIUM SELF TAP LOCK NONSTERILE AXSOS 3",SUP-661185,CDM,C1713,HCPCS,0278,RC,,,both,,,1377.32,413.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,163.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",160.18,1170.72,"percent of total billed charges",
"CATH JADE 135CM 240MM 6MM BALLOON DILATATION HYDROPHILIC",SUP-606024022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"MULTIPLAN [10600]",Multiplan,,619.65,85,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE EMERALD VASCULAR BENSTON LLT CURVE 150CM 20CM .035IN",SUP-502560,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL PFC SIGMA 4 KNEE TITANIUM NONPOROUS CEMENT FIX",SUP-864182,CDM,C1776,HCPCS,0278,RC,,,both,,,15404.25,4621.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1825.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1791.51,13093.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT FINGER SWANSON 3 METACARPOPHALANGEAL SILICONE GROMMET",SUP-G4700003,CDM,C1776,HCPCS,0278,RC,,,both,,,5733.90,1720.17,"AETNA [10100]","Aetna HMO/PPO",,4558.45,79.5,,10981.53,8986.79,12413.38,12,666.85,4873.82,"percent of total billed charges",
"HC Eval Speech Prod W Comprehension",PX-444000017,CDM,92523,CPT,0444,RC,,,both,,,548.26,164.48,"KAISER [10500]",Kaiser,,367.33,67,,,,,0,63.76,466.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 18MM LOW PROFILE SCREWS STAINLESS STEEL FULL",SUP-AR-8830-18,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vrtplsty Augment Perc Thor Lumb Add",PX-361000380,CDM,22515,CPT,0361,RC,,,both,,,12753.00,3825.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12753,,"Case rate ($23,244). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1249,12753,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 4.3MM 8MM EVOS MINI SMALL BONE SELF TAP LOCK",SUP-72412708,CDM,C1713,HCPCS,0278,RC,,,both,,,1050.98,315.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,482.4,45.9,,,,,0,122.23,893.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 7FR EXTRA BACKUP 3.5",SUP-77805400,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 20MM 6MM BALLOON DILATATION OTW STERILE",SUP-586002022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES,MAJOR",029,APR-DRG,,,,,,,inpatient,,,332256.06,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE ANXIETY AND STRESS SYNDROMES,EXTREME",756,APR-DRG,,,,,,,inpatient,,,60336.89,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $7,223.73. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($43,385.01) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE DREAMWIRE ENDOSCOPIC ROUND STRAIGHT 450CM .035IN",SUP-M00556161,CDM,C1769,HCPCS,0272,RC,,,both,,,1422.36,426.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMERGE MONORAIL 144CM 12MM 6FR 2MM .07IN BALLOON",SUP-H7493918912200,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"APPL INTERNAL CLIP 30D LARGE 13.25IN TITANIUM ENDOSCOPIC",SUP-MCL20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1092.07,327.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHIBOND EXCEL 2-0 CT-2 30IN BRAID GREEN NONABSORBABLE",SUP-X411H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MICROCATHETER EMBOLECTOMY 150CM 2.9FR STRAIGHT ACCEPTS .021",SUP-29MC29150ST,CDM,C1887,HCPCS,0272,RC,,,both,,,2301.00,690.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH APOLLO ONYX 165CM 3CM 1.5-2.7FR .013IN MICRO INFUSION",SUP-105-5096-000,CDM,C1887,HCPCS,0272,RC,,,both,,,11667.90,3500.37,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX RADIANZ 190CM 100MM 8MM .018IN BALLOON",SUP-R51008010L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GLIDECATH XP 65CM 5FR ANGLE ANGIOGRAPHIC STAINLESS",SUP-RF*ZV9510GM,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER SPINAL 50X18X8MM COROENT XL PEEK TLIF RADIOLUCENT",SUP-6908855,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"UHC [10700]","United Healthcare",,15040.08,63.3,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILLSOLID 2.0",SUP-DRLL-STP-20,CDM,S27000186,LOCAL,0270,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 5CM 7FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22455,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"KAISER [10500]",Kaiser,,423.31,67,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 NARROW KNEE LEFT CRUCIATE RETAIN CEMENTLESS",SUP-150401124,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"CIGNA [10200]","Cigna Local Plus",,9064.2,31.5,,5372.07,4581.20,7242.98,23,3346.56,24458.96,"percent of total billed charges",
"PLATE TIBIAL NEXGEN OPTION 5 KNEE ZIMALOY CEMENT FLUTE STEM",SUP-591605001,CDM,C1713,HCPCS,0278,RC,,,both,,,11327.04,3398.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1317.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1317.33,9627.98,"percent of total billed charges",
"CUTTER SURGICAL ACUITY UNIVERSAL SPIRAL",SUP-7060,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 100MM 150CM 6MM VASCULAR NICKEL",SUP-EVD35-06-100-150,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]","Cigna Local Plus",,3876.08,53.5,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUR RND SKEETER OTO-FLEX 0.7MM CARB GRN",SUP-3155637,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR .09IN MP1 CURVE GUIDING CORONARY",SUP-LA8MP1SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US OB Complt Txabd 1st Fetus",PX-402000018,CDM,76811,CPT,0402,RC,,,both,,,815.02,244.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,277,,"Per diem ($277).",,,,0,94.79,692.77,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US OB Complt Txabd 1st Fetus",PX-402000018,CDM,76811,CPT,0402,RC,,,both,,,815.02,244.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,250.96,,,,,,,94.79,692.77,"fee schedule",
"CANN PERFUSION 14IN 21FR AORTA 3/8IN STRAIGHT AUTO DILATE",SUP-EZS21TA,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"NOVANET [10819]",Novanet,,364.5,75,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 24MM DELIVERY SYSTEM WATCHMAN FLX",SUP-M635WU50240,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETHRAL BARDEX IC 22FR FOLEY 2 WAY COUDE TIP 1 EYE",SUP-0168SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.14,33.04,"CIGNA [10200]",Cigna,,74.9,68,,,,,0,12.81,93.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 45CM 18FR SILICONE MIC SECUR-LOK UNIVERSAL",SUP-0250-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"CIGNA [10200]","Cigna Open Access",,997.14,56.9,,,,,0,203.81,1489.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 BB 36IN 2 ARM MONOFILAMENT BLUE",SUP-8581H,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.21,18.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.35,53.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 2-0 UR-6 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP605H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 15.4MM 26.2MM 26.8MM ATS OPEN PIVOT AP360 26MM",SUP-505DM28,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6378.75,27,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X7MM ENDOSKELETON TC 6D 12MM SMALL TITANIUM",SUP-5146-1207-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4750.65,45.9,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC if Herpes Smpx Antigen",PX-306000206,CDM,87290,CPT,0306,RC,,,both,,,251.00,75.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,21.11,,,,,,,0.25,213.35,"fee schedule",
"SUT ORTHOCORD 2 MO-7 36IN BRAIDED BLUE VIOLET NONABSORBABLE",SUP-223114,CDM,S27200284,LOCAL,0272,RC,,,both,,,517.05,155.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,351.59,68,,,,,0,60.13,439.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 28-30MM TITANIUM 5.5MM SCR MULTISPAN X10 XLNK BONE",SUP-8115528,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"AMERIGROUP MEDICAID [20100]",Amerigroup,,572.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",561.73,4105.5,"percent of total billed charges",
"LENS IOL 0 D +26.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.265,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIGTR ORTHOPEDIC 25YDX2IN COTTON BLACK",SUP-551191,CDM,S27000186,LOCAL,0270,RC,,,both,,,184.70,55.41,"FIRST HEALTH [10303]","First Health",,147.76,80,,,,,0,21.48,157,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 8.2MM 150MM 32MM STAINLESS STEEL LARGE BONE",SUP-209.950,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,934.6,68,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.054,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"BLUE CROSS [10001]","Blue Cross HMO",,1898.3,39.2,,957.42,156.86,7483.26,51,563.19,4116.21,"percent of total billed charges",
"CELLULITIS WITHOUT MCC",603,MS-DRG,,,,,,,inpatient,,,27276.67,8183,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,11000.04,,"Case rate ($5,402.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,016.35, add-ons for qualifying new technology services are included. If operating cost exceeds $38,056.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,761.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,022.99. The transfer operating threshold is the transfer adjustment factor * $5,016.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $379.26. The transfer capital threshold is the transfer adjustment factor * $379.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,5402.24,21719.38,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lutetium Lu 177 Vipivotide 1 Mci (Pluvicto)",PX-344000008,CDM,A9607,HCPCS,0344,RC,,,both,,,1609.24,482.77,"MULTIPLAN [10600]",Multiplan,,1367.85,85,,,,,0,187.15,1367.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 40MM 80CM 7MM 6FR VASCULAR NITINOL",SUP-G43851,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,447.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN WOUND 20CMX7MM SILICONE FULL PERFORATION WITHOUT",SUP-SU130-1310,CDM,S27200284,LOCAL,0272,RC,,,both,,,57.68,17.3,"CIGNA [10200]",Cigna,,39.22,68,,,,,0,6.71,49.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 8.5MM PORTEX BLUSELECT CUFF STERILE LATEX FREE",SUP-101/815/085,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.48,103.04,"FIRST HEALTH [10303]","First Health",,274.78,80,,,,,0,39.95,291.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONDUCTR 110CM 7FR 2-5-2MM SPACING ELECTROPHYSIOLOGY",SUP-7856042,CDM,C1733,HCPCS,0272,RC,,,both,,,4554.00,1366.2,"MULTIPLAN [10600]",Multiplan,,3870.9,85,,,,,0,529.63,3870.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CARTO XP THERMOCOOL SF 115CM 8FR 3.5MM FF CURVE",SUP-BNI35FFH,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2140.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 700CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRX-700,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"BLUE CROSS [10001]","Blue Cross PPO",,1555.85,39.2,,16595.83,16595.83,16595.83,"1 through 10",461.59,3373.65,"percent of total billed charges",
"SCR INTERFERENCE TITANIUM 20MM 9MM ORTHOPEDIC CANNULATED",SUP-C8600,CDM,C1713,HCPCS,0278,RC,,,both,,,1016.15,304.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,118.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",118.18,863.73,"percent of total billed charges",
"HEAD BIPOLAR GRAY 44MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103544000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"PHCS [10601]",PHCS,,2145.02,70,,,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 30CM 6FR URETERAL",SUP-M0061456160,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"NOVANET [10819]",Novanet,,468.93,75,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE NONABSORBABLE TAPERCUT POLYESTER 1/2 CIRCLE TAPER L36",SUP-M0068332241,CDM,S27200284,LOCAL,0272,RC,,,both,,,546.75,164.02,"NOVANET [10819]",Novanet,,410.06,75,,,,,0,63.59,464.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-2-2-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"BLUE CROSS [10001]","Blue Cross HMO",,4584.64,39.2,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL 8.5IN CRILE GANGLION STAINLESS STEEL 2 END",SUP-285383,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.39,101.82,"PHCS [10601]",PHCS,,237.57,70,,,,,0,39.47,288.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENCIL SMOKE EVAC TUBING HOLSTER",SUP-CVPLP2000,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INPACT 80CM 60MM 7MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV07006008P,CDM,C1725,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPEL TWIST-LOC APD 45CM 14FR LONG LENGTH DRNG",SUP-H7493931114450,CDM,C1729,HCPCS,0272,RC,,,both,,,712.80,213.84,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER 6250V-EH ATTAIN COMMAND",SUP-6250V-EH,CDM,C1887,HCPCS,0272,RC,,,both,,,2602.50,780.75,"AETNA [10100]","Aetna HMO/PPO",,2068.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,302.67,2212.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL DURAL DURAGEN 5X 7IN SQUARE CALLAGEN DURAMATRIX REPAIR",SUP-DMR57,CDM,,,0278,RC,,,both,,,15122.73,4536.82,"BLUE CROSS [10001]","Blue Cross HMO",,15.12,.1,,,,,0,15.12,12854.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.35MM 14MM CSLP TITANIUM STD SPINE CANCELLOUS",SUP-488.814,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,3978.14,359.25,3978.14,24,117.75,860.63,"percent of total billed charges",
"HEAD FEMORAL +10 28MM HIP C TAPER COCR LFIT",SUP-06-2810,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"NOVANET [10819]",Novanet,,2345.78,75,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE UBER FLEX 30MM 57CM 7MM .065IN VASCULAR",SUP-SR-0730-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 360MM FEMORAL RIGHT EXPERT INTRAMEDULLARY HELICAL",SUP-04.003.452S,CDM,C1713,HCPCS,0278,RC,,,both,,,7849.79,2354.94,"BLUE CROSS [10001]","Blue Cross HMO",,3077.12,39.2,,957.42,156.86,7483.26,51,912.93,6672.32,"percent of total billed charges",
"FILTER PERFUSION PALL .2UM DISPOSABLE",SUP-ELD96LL,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.99,22.5,"KAISER [10500]",Kaiser,,50.24,67,,,,,0,8.72,63.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL VASCULAR 30MM 2.5MM FLO-RESTER VESSEL SILICONE",SUP-60250,CDM,S27200284,LOCAL,0272,RC,,,both,,,634.52,190.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,431.47,68,,,,,0,73.79,539.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 5-0 P-3 18IN MONOFILAMENT PLIABILIZE",SUP-698H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET HEANEY UTERINE TEETH SURGICAL",SUP-500-320,CDM,S27000186,LOCAL,0270,RC,,,both,,,321.64,96.49,"CIGNA [10200]","Cigna Open Access",,183.01,56.9,,,,,0,37.41,273.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 20MM 3.8FR 5MM LOW PROFILE TAPER BALLOON",SUP-H74939032502080,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA3-17-50-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,13179.00,3953.7,"FIRST HEALTH [10303]","First Health",,10543.2,80,,,,,0,1532.72,11202.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASCOPE 5 BROCHNO 4.2/2.2 THIN",SUP-620001000US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2362.50,708.75,"KAISER [10500]",Kaiser,,1582.88,67,,,,,0,274.76,2008.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER AQUA PURPLE 2.9MM BARREL BLADE",SUP-72201520,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 126MM ACCOLADE II V40 PUREFIX TITANIUM 127D 11",SUP-6721-1140,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2786.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC",496,MS-DRG,,,,,,,inpatient,,,94775.27,28432.58,"CIGNA [10200]",Cigna,,23652.74,,"Fee schedule rate ($23,652.74). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,52666.66,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 2 OFFSET DOME 8.5MM CEMENT UNITY KNEE",SUP-112.018.46,CDM,C1776,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.134,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,519.91,45.9,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 10CM 7FR 12MM .035IN BALLOON",SUP-G52381,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PHCS [10601]",PHCS,,671.84,70,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 80CM 125CM 8MM VASCULAR HIWIRE NITINOL",SUP-G43783,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"MULTIPLAN [10600]",Multiplan,,3552.15,85,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 17CM 5MM BALLOON DILATATION",SUP-DR135517,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,163.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL DECOMPRESSION 3.25IN 14GA RUG TUBE OPEN HEX CAP SHOCK",SUP-TM-303,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.43,20.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.84,57.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 106MM STAINLESS STEEL 8 HOLE LOCK BONE ANKLE",SUP-AR-8943C-08,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PROTECTIVE STAINLESS STEEL HOFFMANN XPRESS BLUNT TIP",SUP-5027-1-050,CDM,S27000186,LOCAL,0270,RC,,,both,,,339.82,101.95,"KAISER [10500]",Kaiser,,227.68,67,,,,,0,39.52,288.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.9H 52MM 3 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009352,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,3978.14,359.25,3978.14,24,641.98,4692,"percent of total billed charges",
"HC Cytopath Smear Other Source",PX-311000077,CDM,88160,CPT,0311,RC,,,both,,,183.35,55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.46,,"Fee schedule rate ($26.46). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.18,155.85,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mnt Init Indv Ea 15min",PX-942000004,CDM,97802,CPT,0942,RC,,,both,,,81.83,24.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,81.83,,"Per diem ($213).",,,,0,9.52,81.83,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL 70MM NAIL-EX SPIRAL FEMUR TITANIUM",SUP-04.013.046S,CDM,C1713,HCPCS,0278,RC,,,both,,,3437.70,1031.31,"NOVANET [10819]",Novanet,,2578.28,75,,,,,0,399.8,2922.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 37X29X12MM 6D MEDIUM TITANIUM",SUP-46510612,CDM,S27800098,LOCAL,0278,RC,,,both,,,51660.00,15498,"UHC [10700]","United Healthcare",,32700.78,63.3,,,,,0,6008.06,43911,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X8MM PRECISION 7D TRAPEZOID SPINE",SUP-7408,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mslt / Mwt",PX-740000001,CDM,95805,CPT,0920,RC,,,both,,,3781.68,1134.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1732,,,,,,,439.81,3214.43,"case rate",
"CATH OCCL 100CM 7FR 34FR BALLOON OCCLUSION 1 INFLATION PORT",SUP-M0062201100,CDM,C2628,HCPCS,0272,RC,,,both,,,1155.14,346.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,136.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,134.34,981.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE BIODRESTORE CRYOPRIME MEDIUM HUMAN AMNIOTIC",SUP-AM-010050,CDM,V2790,HCPCS,0278,RC,,,both,,,7590.00,2277,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,899.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PINPOINT PAQ ENDOSCOPIC FLUORESCENCE IMAGE",SUP-PP9036,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC",832,MS-DRG,,,,,,,inpatient,,,22420.49,6726.15,"AMBETTER EXCHANGE  [11102]",Ambetter,,4476.13,,"Case rate ($4,476.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,156.39, add-ons for qualifying new technology services are included. If operating cost exceeds $37,196.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,696.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,161.89. The transfer operating threshold is the transfer adjustment factor * $4,156.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.24. The transfer capital threshold is the transfer adjustment factor * $314.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,4476.13,17995.98,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 NARROW KNEE RIGHT POSTERIOR STABILIZE",SUP-42500206602,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3360.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESPIRATORY NEOPLASMS WITH MCC",180,MS-DRG,,,,,,,inpatient,,,33272.18,9981.65,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,11611.88,,"Case rate ($10,954.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,172.09, add-ons for qualifying new technology services are included. If operating cost exceeds $43,211.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,151.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,185.55. The transfer operating threshold is the transfer adjustment factor * $10,172.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.06. The transfer capital threshold is the transfer adjustment factor * $769.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,33272.18,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X100 135CM SL",SUP-48003010R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,101.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 200MM 2MM ASNIS JONES FRACTURE FIXATION",SUP-705355,CDM,C1769,HCPCS,0272,RC,,,both,,,574.94,172.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,390.96,68,,,,,0,66.87,488.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER NOVOSTITCH 0 MENISCAL MENISCAL SUT REPAIR SYSTEM",SUP-CTXA004,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,1831.33,1831.33,1831.33,16,434.96,3179,"percent of total billed charges",
"GRAFT BONE MAGNIFUSE DEMINERALIZED BONE MATRIX 5X1CM",SUP-7509115,CDM,S27800098,LOCAL,0278,RC,,,both,,,4830.00,1449,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH VASCULAR 16X10CM XENOSURE BOVINE PERICARDIUM STERILE",SUP-E10P16,CDM,C1768,HCPCS,0278,RC,,,both,,,6065.10,1819.53,"KAISER [10500]",Kaiser,,4063.62,67,,,,,0,705.37,5155.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 11MM KNEE CONSTRAIN UHMWPE GENESIS II",SUP-71420538,CDM,C1776,HCPCS,0278,RC,,,both,,,18474.75,5542.42,"AETNA [10100]","Aetna HMO/PPO",,14687.43,79.5,,10981.53,8986.79,12413.38,12,2148.61,15703.54,"percent of total billed charges",
"METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG VIAL",RX-10581,CDM,J2919,HCPCS,0636,RC,43598-0128-11,NDC,both,1,UN,199.32,59.8,"CIGNA [10200]",Cigna,,71.25,,,,,,,23.62,169.42,"fee schedule",
"MEMORYGEL SMOOTH ROUND ULTRA HIGH BREAST IMPLANT 700 CC",SUP-3505700BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"CIGNA [10200]",Cigna,,3565.92,68,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +9MM 12/14 TAPER 32MM HIP CEMENTLESS SLEEVE",SUP-136532730,CDM,C1776,HCPCS,0278,RC,,,both,,,12408.96,3722.69,"CIGNA [10200]","Cigna Local Plus",,3908.82,31.5,,5372.07,4581.20,7242.98,23,1443.16,10547.62,"percent of total billed charges",
"DIL SURGICAL AMPLATZ FIRM KINK RESISTANT GRADUATE TAPER 35CM",SUP-M0062601020,CDM,C1894,HCPCS,0272,RC,,,both,,,362.44,108.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,246.46,68,,,,,0,42.15,308.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 1 GRAM TABLET SUPERORDERABLE",RX-409669,CDM,,,0637,RC,77333-0844-25,NDC,both,1,UN,6.27,1.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM ORTHOLOC FULL THREAD FOOT ANKLE CORTICAL",SUP-58813524,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,523.26,68,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 7CM 8.5FR CENTER BEND THIN WALL",SUP-M00534630,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"CIGNA [10200]","Cigna Local Plus",,582.86,53.5,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 5.5CM AVANTI ENDOVASCULAR GREEN ACCEPTS",SUP-402606R,CDM,C1894,HCPCS,0272,RC,,,both,,,50.03,15.01,"NOVANET [10819]",Novanet,,37.52,75,,,,,0,5.82,42.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABLE 12X26MM 9-16MM 8°",SUP-1172.4113S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"BLUE CROSS [10001]","Blue Cross PPO",,13582.8,39.2,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 TAPER 32MM HIP COCR SPECTRON EF",SUP-71303200,CDM,C1776,HCPCS,0278,RC,,,both,,,8145.45,2443.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3738.76,45.9,,,,,0,947.32,6923.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 100MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939186251010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 14FR 22CM 30CM BALLOON NDL OBTR CONNECT TUBE SYR",SUP-G17320,CDM,C2617,HCPCS,0272,RC,,,both,,,516.05,154.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,61.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.02,438.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 60MM 5MM LCP PROXIMAL FEMORAL STAINLESS STEEL",SUP-02.205.260,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"CIGNA [10200]",Cigna,,1057.98,68,,1831.33,1831.33,1831.33,16,180.95,1322.47,"percent of total billed charges",
"ORTHOLOC? 3DI FOOT RECONSTRUCTION SYSTEM MEDIAL COLUMN PLATE",SUP-58150001,CDM,C1713,HCPCS,0278,RC,,,both,,,14386.50,4315.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1673.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1673.15,12228.53,"percent of total billed charges",
"SPACER SPINAL 45X18X8-15MM RISE-L 6D",SUP-193.323,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CIGNA [10200]","Cigna Open Access",,11502.23,33.5,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR SUREFORM 60 GREEN",SUP-48360G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.25,543.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,210.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,210.65,1539.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 5-0 C-1 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-K895H,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.31,23.19,"KAISER [10500]",Kaiser,,51.8,67,,,,,0,8.99,65.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)MARKER SKIN GREEN 10CM 15GA SMARTCLIP LITE 3-4MM SOFT",SUP-SMARTCLIPLT-GRN-10,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"PHCS [10601]",PHCS,,1890,70,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CITATION TMZF HA 5 SHORT HIP RIGHT",SUP-6265-5215,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"FIRST HEALTH [10303]","First Health",,19537.56,80,,,,,0,2840.27,20758.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eps La/Cs Pacing",PX-481000055,CDM,93621,CPT,0481,RC,,,both,,,11575.72,3472.72,"PHCS [10601]",PHCS,,8103,70,,,,,0,1346.26,11575.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP INSRT TIBIAL KNEE OXINIUM BICRUCIATE STABILIZE CONSTRUCT",SUP-71709010,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9062.55,41.1,,6417.48,6417.48,6417.48,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"HC Lso Boston Overlap Custom",PX-E27400060,CDM,L0631,HCPCS,0274,RC,,,both,,,597.30,179.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,597.3,,,,,,,69.47,597.3,"fee schedule",
"CLIP SURGICAL 12MM 2 SOFT SPRING",SUP-G-1200,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"UHC [10700]","United Healthcare",,143.18,63.3,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD IS4 DF4 STERILE LATEX FREE DISPOSABLE",SUP-412302,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"UHC [10700]","United Healthcare",,258.83,63.3,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 22GA 5.2FR 8- CM ECHOTIP PROCORE HIGH DEFINITION",SUP-G55736,CDM,S27200284,LOCAL,0272,RC,,,both,,,3195.00,958.5,"KAISER [10500]",Kaiser,,2140.65,67,,,,,0,371.58,2715.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 35MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890006035,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"STEM HUMERAL 175MM 8MM SMALL SHELL REVISION ALTIVATE REVERSE",SUP-533-08-175,CDM,C1776,HCPCS,0278,RC,,,both,,,43228.40,12968.52,"MULTIPLAN [10600]",Multiplan,,36744.14,85,,,,,0,5027.46,36744.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM TARGET 3D DETACHABLE CONSISTENT",SUP-M0036154080,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"NOVANET [10819]",Novanet,,10585.98,75,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC THK7.5MM 5MM 6MM 47.9X50.3MM MVP ADAPTA DR",SUP-ADDR06,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4929.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI CHIKAI 10 VASCULAR 3CM STRAIGHT 200CM 9.5CM .26",SUP-WAIN-CKI-10-200,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE",RX-165065,CDM,J1447,HCPCS,0636,RC,63459-0910-17,NDC,both,.5,ML,1808.39,542.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,88.1,,"Fee schedule rate ($88.10). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,88.1,1537.13,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BEACON TIP 65CM 5FR .035IN VANSCHIE4 CURVE ANGIOGRAPHIC",SUP-G13792,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.56,87.17,"AETNA [10100]","Aetna HMO/PPO",,231,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.79,246.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +11 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.110,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 28MM HIP MEDIUM NECK SUPER FINISH COCR",SUP-26000018,CDM,C1776,HCPCS,0278,RC,,,both,,,8887.20,2666.16,"UHC [10700]","United Healthcare",,5625.6,63.3,,8601.07,8395.67,8601.07,"1 through 10",1033.58,7554.12,"percent of total billed charges",
"BASKET SPECIMEN RETRIEVAL 90CM 3FR ODEC16MM 4 WIRE STONE",SUP-M0063901020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1416.61,424.98,"UHC [10700]","United Healthcare",,896.71,63.3,,,,,0,164.75,1204.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 645541 LPINNACLE 5X14X11 SRVC FEE",SUP-645541,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X11MM LUMINARY CC BICONVEX SPINE",SUP-6811,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"CIGNA [10200]",Cigna,,13305.6,40,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 7MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036127200,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2-0 CT-2 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8411H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 24MM 75CM 6MM 100CM",SUP-M001712000,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3879.7,45.9,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 105MM DHS/DCS STAINLESS STEEL CONDYLAR HIP",SUP-280.305,CDM,C1713,HCPCS,0278,RC,,,both,,,2043.30,612.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,242.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",237.64,1736.81,"percent of total billed charges",
"CATH 60CM 10FR TAPER URETERAL 2 LUMEN TORQUE STABLE SHAFT",SUP-608BX,CDM,C1758,HCPCS,0272,RC,,,both,,,374.55,112.36,"PHCS [10601]",PHCS,,262.19,70,,,,,0,43.56,318.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COLONIC WALLFLEX L9 CM OD22 MM SOFT ANCHOR LOCK DELIVE",SUP-M00555770,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEDTRONIC COBALT MRI CRT-D",SUP-DTPB2QQ,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,20776.5,27,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 79MM 12.2MM 7.6MM CUFFLESS FENESTRATE DISPOSABLE INNER",SUP-8DCFN,CDM,S27200284,LOCAL,0272,RC,,,both,,,325.99,97.8,"CIGNA [10200]","Cigna Open Access",,185.49,56.9,,,,,0,34.06,277.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BILIARY 8MM 8.5FR 80MM FULLY COVERED TRANSHEPATIC WALL",SUP-M00574760,CDM,C1874,HCPCS,0278,RC,,,both,,,22050.00,6615,"FIRST HEALTH [10303]","First Health",,17640,80,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 28CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061802240,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,106.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CERES-C SPACER 12X15X6 10 DEG",SUP-SK-08-170-1006,CDM,S27800098,LOCAL,0278,RC,,,both,,,7590.00,2277,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2172.26,28.62,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 60MM TI",SUP-SPL-60600-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",188.41,1377,"percent of total billed charges",
"CATH ELECTROPHYSIOLOGY 95CM 7FR ORBITER ST 20E SMALL CURVE",SUP-M0043200020,CDM,C1731,HCPCS,0272,RC,,,both,,,4111.80,1233.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,478.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,478.2,3495.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR VIVACIT-E OSSEOTI HIP LINER STANDRD HEAD INSR",SUP-98000100039,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"CIGNA [10200]","Cigna Open Access",,9708.3,33.5,,5302.19,4377.88,6578.61,27,3370.37,24633,"percent of total billed charges",
"PLATE 90MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 7",SUP-223.57,CDM,C1713,HCPCS,0278,RC,,,both,,,2041.20,612.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,237.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",237.39,1735.02,"percent of total billed charges",
"CMPNT FEMORAL 8 NARROW KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500006402,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS [10001]","Blue Cross HMO",,8962.18,39.2,,5311.50,4717.44,5388.59,31,2658.93,19433.3,"percent of total billed charges",
"INTRODUCER HEMOSTASIS TEAR AWAY 6FR SAFESHEATH",SUP-6263,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY DRNG 14FR FLEXIBLE STAYFIX LARGE SECUREMENT DEVICE",SUP-RLC-NV-14-SFX,CDM,C1729,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 14 150CM 40MM 1.5MM TAPER BALLOON DILATATION JET",SUP-A2015-040,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 15CM 7.5FR .038IN PIGTAIL CURVE DRNG",SUP-RLC15-7-038MB,CDM,C1729,HCPCS,0272,RC,,,both,,,537.19,161.16,"FIRST HEALTH [10303]","First Health",,429.75,80,,,,,0,62.48,456.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL BIT ASSY, CARBIDE, HUDSON END, 6 MM, SINGLE USE",SUP-SBT005,CDM,S27000186,LOCAL,0270,RC,,,both,,,2212.50,663.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,262.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRODE DEFIBRILLATOR PRO-PADZ TIN ADULT L6.5 IN X W5 IN B",SUP-8900-2303-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,260.46,78.14,"NOVANET [10819]",Novanet,,195.35,75,,,,,0,30.29,221.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sodium Urine",PX-301000399,CDM,84300,CPT,0301,RC,,,both,,,142.50,42.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.25,,,,,,,0.14,121.13,"fee schedule",
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.75MM X 10.0MM",SUP-492751012,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 250MM 190CM 6MM",SUP-R51006025L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1694.48,68,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID UPPER LEG REDUCTION KIT- STANDARD, REGULAR",SUP-25301217,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,853.74,68,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"I-GEL, SINGLE USE SUPRAGLOTTIC AIRWAY, SIZE 5",SUP-8205000,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.19,23.76,"NOVANET [10819]",Novanet,,59.39,75,,,,,0,9.21,67.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP MCGRATH MACINTOSH 4 POLYMER VIDEO FOG FREE",SUP-350-013-000,CDM,S27000186,LOCAL,0270,RC,,,both,,,149.08,44.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.34,126.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LUB INSTR 20ML VIAL VIPERSLIDE DIAMONDBACK 360 ORBITAL",SUP-VPR-SLD2,CDM,S27000186,LOCAL,0270,RC,,,both,,,672.30,201.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,79.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNAP(R) CARTRIDGE - 75 MM HG - 10 IN A CASE",SUP-SNPA075,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"NOVANET [10819]",Novanet,,765.45,75,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 220MM 2MM BALLOON DILATATION PEBAX",SUP-H74939032202210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 100MM 2MM BALLOON DILATATION STERILE LATEX",SUP-592010022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"UHC [10700]","United Healthcare",,846,63.3,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VANSONNENBERG SUMP 35CM 12FR LOOP DRNG FLEXIMA",SUP-M001273030,CDM,C1729,HCPCS,0272,RC,,,both,,,1053.00,315.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,124.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 80MM 3.5MM BALLOON DILATATION PEBAX",SUP-H74939148358010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 6CM 6MM BALLOON DILATATION",SUP-DR8066,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 80MM 3.5MM BALLOON DILATATION PEBAX",SUP-H74939148358010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 8CM 6MM BALLOON",SUP-G52267,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 135CM 30MM 6MM .035IN BALLOON",SUP-AB35W06030135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,78.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 8CM 6MM BALLOON",SUP-G52267,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,111.62,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Drain Thoracic",PX-E27200054,CDM,C1729,HCPCS,0272,RC,,,both,,,182.60,54.78,"UHC [10700]","United Healthcare",,115.59,63.3,,,,,0,21.24,155.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE? NC PLUS BALLOON NON-COMPLIANT 2.25 MM X 18 MM",SUP-222-183-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOPLASTY 5FR L130CM BALLOON L2CM DIA5MM DUAL LAY",SUP-U813052,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE YUEH CATHETER 19GX7CM",SUP-228673,CDM,C1729,HCPCS,0272,RC,,,both,,,147.64,44.29,"KAISER [10500]",Kaiser,,98.92,67,,,,,0,17.17,125.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE YUEH CATHETER 19GX7CM",SUP-228673,CDM,C1729,HCPCS,0272,RC,,,both,,,147.64,44.29,"MULTIPLAN [10600]",Multiplan,,125.49,85,,,,,0,17.17,125.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-08041,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 20MM 145CM 4.5MM BALLOON DILATATION",SUP-1400450-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-08041,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 20MM 3.25MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012408-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE CHECKER 130CM 4CM 6MM BALLOON DILATATION",SUP-U813064,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHOCOLATE 135CM 120MM 4MM 5FR BALLOON DILATATION",SUP-CB1413540120OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3894.36,68,,,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-583515022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE CHECKER 130CM 4CM 6MM BALLOON DILATATION",SUP-U813064,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 250MM 3MM BALLOON DILATATION DURALYN",SUP-48003025X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,881.28,68,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAP TRACTION LARGE FINGER",SUP-AR-1616-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,237.51,71.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,97.62,41.1,,,,,0,27.62,201.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET LIFT 185X90CM HANDYTUBE MEDIUM LONG SLIDE WITHOUT",SUP-3711015,CDM,S27000186,LOCAL,0270,RC,,,both,,,337.13,101.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,229.25,68,,,,,0,39.21,286.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.8MM SHORT CALIBRATED STOP NONSTERILE",SUP-03.112.003,CDM,S27000186,LOCAL,0270,RC,,,both,,,998.57,299.57,"UHC [10700]","United Healthcare",,632.09,63.3,,,,,0,116.13,848.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE MONORAIL 150CM 220MM 4MM BALLOON DILATATION",SUP-H74939185402210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL CPAP 2 CANNULAIDE LATEX FREE DISPOSABLE NONSTERILE",SUP-CA102-0-25,CDM,S27000186,LOCAL,0270,RC,,,both,,,88.81,26.64,"MULTIPLAN [10600]",Multiplan,,75.49,85,,,,,0,10.33,75.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Malaria Ab Plasmodium",PX-302000221,CDM,86750,CPT,0302,RC,,,both,,,380.00,114,"AETNA [10100]","Aetna HMO/PPO",,302.1,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,323,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFIX PRIME 16MM DISC(PLASTIC)",SUP-PS13016,CDM,Q4133,HCPCS,0636,RC,,,both,,,3341.25,1002.37,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT WALLSTENT UNISTEP PLUS 90MM 75CM 14MM 9FR 100CM",SUP-H965403130,CDM,C1876,HCPCS,0278,RC,,,both,,,7140.00,2142,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3277.26,45.9,,,,,0,830.38,6069,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rhd & Rhce Gntyp Rhd1-10 & Rhce5",PX-310000028,CDM,0198U,CPT,0310,RC,,,both,,,600.00,180,"KAISER [10500]",Kaiser,,402,67,,,,,0,71.1,600,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT TRACTION UNIVERSAL LEG OPEN TOE STRAP FOAM VELCRO",SUP-8130-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,156.17,46.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.16,132.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Connecting Drainage Bag",PX-E27200220,CDM,E27200220,LOCAL,0272,RC,,,both,,,79.20,23.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.21,67.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Card MRI Morphlgy W Stress",PX-614000002,CDM,75559,CPT,0614,RC,,,both,,,4887.00,1466.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,579.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,568.36,4153.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR PREPARATION OF TC-99M-BICISATE INTRAVENOUS SOLUTION (0-25 MCI)",RX-184736,CDM,A9557,HCPCS,0343,RC,08888-8877-14,NDC,both,1,UN,9455.04,2836.51,"AETNA [10100]","Aetna HMO/PPO",,7516.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1099.62,8036.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Test Defin 15-21 Class",PX-301000670,CDM,G0482,HCPCS,0301,RC,,,both,,,417.00,125.1,"CIGNA [10200]","Cigna Local Plus",,223.1,53.5,,,,,0,0.01,354.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL TRAY 2 LEFT CEMENTED FIXED PRIMARY GMK",SUP-02.07.1202L,CDM,C1776,HCPCS,0278,RC,,,both,,,6136.20,1840.86,"NOVANET [10819]",Novanet,,4602.15,75,,,,,0,713.64,5215.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER BREAST X-LARGE",SUP-XL/L-BBIND,CDM,S27000186,LOCAL,0270,RC,,,both,,,200.10,60.03,"CIGNA [10200]",Cigna,,136.07,68,,,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 18CM 28.5MM 14.5MM 24-26MM 12-13.5MM GORE",SUP-RLT281418,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,17944.74,28.62,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY ESOPHAGEAL 5 60CM 20 LMA UNIQUE SOFT FLEXIBLE CUFF",SUP-1F8050,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.14,28.84,"MULTIPLAN [10600]",Multiplan,,81.72,85,,,,,0,11.18,81.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN HOCKEY STICK 1 CURVE GUIDING",SUP-LA6HSI,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"KAISER [10500]",Kaiser,,262.31,67,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER BREAST LARGE",SUP-L/L-BBIND,CDM,S27000186,LOCAL,0270,RC,,,both,,,165.30,49.59,"UHC [10700]","United Healthcare",,104.63,63.3,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 2.5MM 3MM 1MM MICRON PORP EAR TITANIUM",SUP-70142028,CDM,S27000186,LOCAL,0270,RC,,,both,,,2235.00,670.5,"UHC [10700]","United Healthcare",,1414.76,63.3,,,,,0,259.93,1899.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Card MRI Morphlgy W Stress",PX-614000002,CDM,75559,CPT,0614,RC,,,both,,,4887.00,1466.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,683,,"Per diem ($683). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,568.36,4153.95,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 194MM 26-34MM 30MM 20FR ZENITH TX2",SUP-G47473,CDM,C1874,HCPCS,0278,RC,,,both,,,98041.65,29412.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,39216.66,40,,,,,0,11402.24,83335.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABLE, 12X26MM, 7-14MM, 15%C2%B0",SUP-1172.4121S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13860,40,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 130MM 4.2MM T2 AO COUPLING CENTER TIPPED",SUP-18064280S,CDM,S27000186,LOCAL,0270,RC,,,both,,,147.00,44.1,"MULTIPLAN [10600]",Multiplan,,124.95,85,,,,,0,17.1,124.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 230MM 2.5MM 3 FLUTED QUICK COUPLING NONSTERILE",SUP-315.92,CDM,S27000186,LOCAL,0270,RC,,,both,,,1181.63,354.49,"NOVANET [10819]",Novanet,,886.22,75,,,,,0,137.42,1004.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 30CM 14FR 22GA FLEXIMA POLYURETHANE 3 WAY STPCOCK 2",SUP-M001273070,CDM,C1729,HCPCS,0272,RC,,,both,,,1950.00,585,"KAISER [10500]",Kaiser,,1306.5,67,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC",857,MS-DRG,,,,,,,inpatient,,,59768.28,17930.48,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,14080.89,,"Case rate ($13,283.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,334.96, add-ons for qualifying new technology services are included. If operating cost exceeds $45,374.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,314.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $12,351.27. The transfer operating threshold is the transfer adjustment factor * $12,334.96 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.58. The transfer capital threshold is the transfer adjustment factor * $932.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,59768.28,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL ADULT MEDIUM O2 RESVR BAG MASK LATEX FREE",SUP-520611000,CDM,S27000186,LOCAL,0270,RC,,,both,,,57.07,17.12,"MULTIPLAN [10600]",Multiplan,,48.51,85,,,,,0,6.64,48.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC",939,MS-DRG,,,,,,,inpatient,,,155639.55,46691.86,"BLUE CROSS [10001]","Blue Cross PPO",,89576.96,,,,,,,7561,105937.69,"case rate",
"INTRO SHEATH 5FR 11CM MINI GWIRE NO OBTR HEXCUSPID VALVE",SUP-504605X,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 5X4IN DURAGEN CRANIAL DURA BOVINE CLLGN",SUP-DURS4591,CDM,,,0278,RC,,,both,,,12684.13,3805.24,"KAISER [10500]",Kaiser,,8498.37,67,,,,,0,12.68,10781.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE 20IN 36FR RIGHT ANGLE DRNG PVC THORACIC 6 EYELET",SUP-8888571067,CDM,C1729,HCPCS,0272,RC,,,both,,,138.54,41.56,"KAISER [10500]",Kaiser,,92.82,67,,,,,0,16.11,117.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 28MM 144CM 2.5MM CORONARY STENT",SUP-H7493941828250,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 135CM 5MM 8MM 7FR .035IN",SUP-BXA057902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5780,27,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ELECTROPHYSIOLOGY 2-8-2MM SPACING CSL CURVE 5FR 65C",SUP-401864R,CDM,C1730,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL SIZE 6 L150MM CEMENTED CONSTRAINED NEXEL",SUP-840004615,CDM,C1776,HCPCS,0278,RC,,,both,,,36662.85,10998.85,"KAISER [10500]",Kaiser,,24564.11,67,,,,,0,4263.89,31163.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATHETER 1.96MR ACHIEVE ADVANCE 10 PIN STERILE LATEX F",SUP-2ACHCR,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION",RX-88011,CDM,Q2009,HCPCS,0636,RC,00069-5471-01,NDC,both,2,ML,27.69,8.31,"BLUE CROSS [10001]","Blue Cross PPO",,5.99,,,,,,,3.28,23.54,"fee schedule",
"HC Hepatitis C Ab",PX-302000172,CDM,86803,CPT,0302,RC,,,both,,,401.85,120.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12.84,,,,,,,0.4,341.57,"fee schedule",
"HC Splint Fiberglass",PX-E27000164,CDM,E27000164,LOCAL,0270,RC,,,both,,,143.00,42.9,"CIGNA [10200]",Cigna,,97.24,68,,,,,0,16.63,121.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Finger(S)>=2v",PX-320000074,CDM,73140,CPT,0320,RC,,,both,,,507.16,152.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,73.38,,,,,,,49.66,431.09,"fee schedule",
"TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET",RX-31684,CDM,,,0637,RC,50268-0758-11,NDC,both,1,UN,25.19,7.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.35,41.1,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Whole Blood L/R Irr Ea",PX-390000018,CDM,P9056,HCPCS,0390,RC,,,both,,,853.00,255.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,101.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.2,725.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 STD 68X62.3MM KNEE RIGHT CRUCIATE RETAIN",SUP-112.001.30,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"BLUE CROSS [10001]","Blue Cross HMO",,3786.72,39.2,,5311.50,4717.44,5388.59,31,1123.46,8211,"percent of total billed charges",
"GRAFT BONE FEMUR HEAD FREEZE DRIED PROXIMAL",SUP-24A001,CDM,S27800098,LOCAL,0278,RC,,,both,,,5733.90,1720.17,"PHCS [10601]",PHCS,,4013.73,70,,,,,0,666.85,4873.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 28MM 5MM CORONARY STENT PLATINUM",SUP-H7493926028500,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"KAISER [10500]",Kaiser,,6241.05,67,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX8-12MM CALIBER",SUP-194122,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7776,27,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tubular Dressing per Linear Yd",PX-E27000285,CDM,A6457,HCPCS,0270,RC,,,both,,,10.00,3,"NOVANET [10819]",Novanet,,7.5,75,,,,,0,1.09,8.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 240CM 5.5CM 7.5FR 15-18MM ESOPHAGEAL",SUP-M00558490,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLUG CARDIOVASCULAR AMPLATZER NITINOL PTFE .038 IN LOW PROFI",SUP-9-AVP038-004,CDM,S27800098,LOCAL,0278,RC,,,both,,,7141.50,2142.45,"CIGNA [10200]",Cigna,,4856.22,68,,,,,0,830.56,6070.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC INTERVERTEBRAL 17X7MM MOBI-C 13MM SPINE CERVICAL COCRMO",SUP-MB3377,CDM,S27800098,LOCAL,0278,RC,,,both,,,33075.00,9922.5,"BLUE CROSS [10001]","Blue Cross HMO",,12965.4,39.2,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X15MM LUMINARY 10/11MM SPINE",SUP-4715,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"BLUE CROSS [10001]","Blue Cross HMO",,12348,39.2,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY CHORDAL GUIDE DURAN ANCORE",SUP-620RG35,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1524.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY CHORDAL GUIDE DURAN ANCORE",SUP-620RG35,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]",Cigna,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"14 X 11 X 6MM 7 DEGREE POROUS COATE",SUP-P21411-706,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA [10200]","Cigna Local Plus",,3572.95,53.5,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 36X24MM ENDOSKELETON TAS 12D 16MM LARGE TITANIUM",SUP-2312-0216,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X11X12MM VERTEX PEEK-OPTIMA ANATOMIC",SUP-6240241,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1911.36,28.62,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X24MM COLOSSEUM 12MM CURVE MESH NONSTERILE",SUP-156.206,CDM,S27800098,LOCAL,0278,RC,,,both,,,28343.70,8503.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3296.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3296.37,24092.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X13X8MM ACIS STD LORDOTIC PEEK RADIOPAQUE",SUP-08.843.008S,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 12CM 31MM 26.1MM 34MM MASTERS 5.18SQ CM CLLGN","SUP-31CAVGJ-514  00",CDM,S27800098,LOCAL,0278,RC,,,both,,,25533.90,7660.17,"KAISER [10500]",Kaiser,,17107.71,67,,,,,0,2969.59,21703.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 12MM AXIUM 3D NEUROVASCULAR FRAME V01",SUP-FC-12-50-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"BLUE CROSS [10001]","Blue Cross PPO",,6478,39.2,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 6MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0615CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,776.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3.5MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035423580,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"PHCS [10601]",PHCS,,9880.25,70,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM ALLOGRAFT STRIP 55X22MM",SUP-T00247,CDM,S27800098,LOCAL,0278,RC,,,both,,,14161.56,4248.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1646.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1646.99,12037.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Protime Mixing Studies",PX-305000058,CDM,85611,CPT,0305,RC,,,both,,,255.55,76.66,"PHCS [10601]",PHCS,,178.89,70,,,,,0,0.01,217.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 54MM",SUP-626-00-54I,CDM,S27800098,LOCAL,0278,RC,,,both,,,9500.40,2850.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6460.27,68,,,,,0,1104.9,8075.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 20X11CM FLEXHD PLIABLE THK1.5-2.2MM MEDIUM THICK",SUP-SF2002,CDM,Q4128,HCPCS,0636,RC,,,both,,,24052.14,7215.64,"CIGNA [10200]","Cigna Local Plus",,80.43,,,,,,,80.43,20444.32,"fee schedule",
"ELECTRD MONOPOLAR 8MM DA VINCI S/SI ENDOWRIST CAUT SPAT",SUP-420184,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS03006,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"NOVANET [10819]",Novanet,,8792.33,75,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM PRESTIGE PLUS HELICAL COMPLEX",SUP-PRES0930CPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,762.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2.5CM 2MM .0135IN MICRUSFRAME MICRO",SUP-MFR140225,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3400.57,28.62,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X14X12MM FORTIFY I 3.5D NO SPIKE FOOTPRINT",SUP-137.311,CDM,S27800098,LOCAL,0278,RC,,,both,,,31320.00,9396,"PHCS [10601]",PHCS,,21924,70,,,,,0,3642.52,26622,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM .0115IN AXIUM PRIME HELIX",SUP-APB-4-8-HX-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,7169.10,2150.73,"BLUE CROSS [10001]","Blue Cross PPO",,2810.29,39.2,,,,,0,833.77,6093.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0930CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,776.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26MMX9MM CAPSTONE PEEK PTC LUMBAR INTERBODY",SUP-3992609,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS [10001]","Blue Cross PPO",,8643.6,39.2,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 24X10X9-5.7MM LUMINARY BULLET NOSE",SUP-15809,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Local Plus",,5953.5,31.5,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE L150MM DIA4-5.5MM SEMITENDINOSUS FROZEN R",SUP-FROPE,CDM,S27800098,LOCAL,0278,RC,,,both,,,6128.93,1838.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1754.1,28.62,,,,,0,712.79,5209.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 12X22X60MM 10DEG INTERBODY FUSION LORDOTIC MODUL",SUP-1221260P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3297.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X7MM COALITION MIS 7D 14MM STERILE",SUP-3136.2107,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5151.6,28.62,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-03004,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3165.24,27,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE 14MM 4MM EMBOLIZATION",SUP-PED2-400-14,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33207.77,41.1,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS14030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1363.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE 14MM 4MM EMBOLIZATION",SUP-PED2-400-14,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9574.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS14030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"NOVANET [10819]",Novanet,,8792.33,75,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE SELF DRILLING SELF RETAINING FIXED ANGLE 4MM 16MM",SUP-04.613.716,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]",Cigna,,688.5,68,,1831.33,1831.33,1831.33,16,117.75,860.63,"percent of total billed charges",
"LEAD ICD 58CM 7FR DURATA ENDOCARDIUM OPTIM TRUE BIPOLAR",SUP-7120Q/58,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4914.63,28.62,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 2X2CM ALLOPATCH THK.4-.8MM ACELLULAR DERMAL",SUP-WC0202,CDM,Q4128,HCPCS,0636,RC,,,both,,,2293.50,688.05,"UHC [10700]","United Healthcare",,247.92,,,,,,,80.43,1949.48,"fee schedule",
"HC Repostn Card Sys Electrode",PX-480000089,CDM,0415T,CPT,0480,RC,,,both,,,1667.00,500.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,197.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,193.87,1667,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repostn Card Sys Electrode",PX-480000089,CDM,0415T,CPT,0480,RC,,,both,,,1667.00,500.1,"CIGNA [10200]",Cigna,,1667,,"Case rate ($4,812). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,193.87,1667,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 6X5CM AMNIOBAND 30SQ CM ALLOGRAFT",SUP-WC3056,CDM,Q4151,HCPCS,0636,RC,,,both,,,35544.60,10663.38,"KAISER [10500]",Kaiser,,23814.88,67,,,,,0,362.66,30212.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD ELLIPSE DR VNTRC 2","SUP-CD2411-36Q CELL",CDM,C1721,HCPCS,0278,RC,,,both,,,35964.00,10789.2,"FIRST HEALTH [10303]","First Health",,28771.2,80,,,,,0,4182.61,30569.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RED 43 REPERFUSION CATHETER 138 CM AND PENUMBRA ASPIRATION T",SUP-RED43KIT138,CDM,C1757,HCPCS,0272,RC,,,both,,,17608.50,5282.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11973.78,68,,,,,0,2047.87,14967.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UNI-FUSE FLOW-THRU HUB 90CM 2CM 5FR THROMBECTOMY",SUP-H787124018415,CDM,C1757,HCPCS,0272,RC,,,both,,,1417.50,425.25,"PHCS [10601]",PHCS,,992.25,70,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mod Sed Oth Phys 1st 15min =>5y",PX-371000011,CDM,99156,CPT,0371,RC,,,both,,,718.00,215.4,"NOVANET [10819]",Novanet,,538.5,75,,,,,0,83.5,610.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Cath Biliary DRN",PX-361000404,CDM,47537,CPT,0361,RC,,,both,,,1329.05,398.71,"FIRST HEALTH [10303]","First Health",,1063.24,80,,,,,0,154.57,1329.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Liver Cyst Ablation",PX-361000181,CDM,47399,CPT,0361,RC,,,both,,,2971.43,891.43,"BLUE CROSS [10001]","Blue Cross HMO",,2971.43,,"Case rate ($4,998.78). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,345.58,2971.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM DESARA 3MM URETHRAL SPRT TRANSVAGINAL INTRO BLUE",SUP-CAL-DS01BTV30,CDM,C1771,HCPCS,0278,RC,,,both,,,6334.20,1900.26,"BLUE CROSS [10001]","Blue Cross PPO",,2483.01,39.2,,,,,0,736.67,5384.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Fungi Pres ID Blood",PX-306000067,CDM,87103,CPT,0306,RC,,,both,,,308.25,92.47,"NOVANET [10819]",Novanet,,231.19,75,,,,,0,0.01,262.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Emg Larynx",PX-922000028,CDM,95865,CPT,0922,RC,,,both,,,670.92,201.28,"UHC [10700]","United Healthcare",,424.69,63.3,,,,,0,78.03,570.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cont Aero Aao 1st Hr",PX-410000007,CDM,94644,CPT,0410,RC,,,both,,,655.80,196.74,"CIGNA [10200]",Cigna,,369,,"Per diem ($369).",,,,0,76.27,557.43,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Swallow Dysphagia",PX-440000005,CDM,92526,CPT,0440,RC,,,both,,,361.52,108.46,"PHCS [10601]",PHCS,,253.06,70,,,,,0,42.04,361.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL INSUFFLATION 150MM 14GA ENDOPATH SPRING LOAD BLUNT",SUP-PN150,CDM,S27200284,LOCAL,0272,RC,,,both,,,273.66,82.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MEDSURG COMMIT BARD VASCULAR ACCESS PICCS AND MIDLINES",SUP-F420088PT,CDM,C1751,HCPCS,0272,RC,,,both,,,955.07,286.52,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DILATOR LACHRYMAL 40X.64MM MNK MN 2MM",SUP-SI-1500,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE CURVE 336MM STAINLESS STEEL 4.5MM SCR 16 HOLE 4 COLUMN",SUP-02.124.416,CDM,C1713,HCPCS,0278,RC,,,both,,,11592.00,3477.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3317.63,28.62,,,,,0,1348.15,9853.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 20CM CENTRAL VENOUS 3 LUMEN OXIMETRY CONTINUOUS SCVO2",SUP-XA3820SAFKT,CDM,C1751,HCPCS,0272,RC,,,both,,,2887.50,866.25,"UHC [10700]","United Healthcare",,1827.79,63.3,,,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVED 94X10X3.6MM STAINLESS STEEL 3.5MM CORTICAL SCR",SUP-245.31,CDM,C1713,HCPCS,0278,RC,,,both,,,4248.47,1274.54,"BLUE CROSS [10001]","Blue Cross HMO",,1665.4,39.2,,957.42,156.86,7483.26,51,494.1,3611.2,"percent of total billed charges",
"SCR BONE 2.3MM 24MM ACU-LOC ACUMED TITANIUM DISTAL RADIAL",SUP-CO-N2324,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,517.75,68,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 25MM 2.50MM BALLOON DILATATION PEBAX",SUP-1400250-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Speech Dev 1st Hr",PX-444000004,CDM,92607,CPT,0444,RC,,,both,,,1042.00,312.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,123.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.18,885.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ptca Mitral Valve",PX-480000046,CDM,92987,CPT,0481,RC,,,both,,,18690.43,5607.13,"CIGNA [10200]","Cigna Open Access",,18690.43,,"Case rate ($21,495). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2173.7,18690.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 10MM 9FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEM10100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP ACETABULAR 56MM PINNACLE 12 DOME SCR MULTIHOLE II HIP",SUP-121730056,CDM,C1776,HCPCS,0278,RC,,,both,,,16778.04,5033.41,"MULTIPLAN [10600]",Multiplan,,14261.33,85,,,,,0,1951.29,14261.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SENSOR DUAL-FLEX UROLOGICAL 10CM 150CM 3CM .035IN",SUP-M0066703011,CDM,C1769,HCPCS,0272,RC,,,both,,,372.19,111.66,"NOVANET [10819]",Novanet,,279.14,75,,,,,0,43.29,316.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 30MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0354,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"KAISER [10500]",Kaiser,,634.96,67,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW 7975525 SOVEREIGN FA 5.5 X 25MM",SUP-7975525,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"CIGNA [10200]","Cigna Open Access",,1672.86,56.9,,1144.80,304.56,2275.09,66,341.92,2499,"percent of total billed charges",
"HC Culture CSF",PX-306000036,CDM,87070,CPT,0306,RC,,,both,,,437.00,131.1,"MULTIPLAN [10600]",Multiplan,,371.45,85,,,,,0,0.01,371.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 16MM TITANIUM LOCK VARIABLE ANGLE",SUP-AR-8933V-16,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"KAISER [10500]",Kaiser,,949.73,67,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 32MM 2 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.232,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Local Plus",,2359.35,53.5,,3978.14,359.25,3978.14,24,512.88,3748.5,"percent of total billed charges",
"SCR BONE 4.5MM 28MM MULTILOC TITANIUM NIOBIUM ALUMINUM 3.8MM",SUP-04.019.028S,CDM,C1713,HCPCS,0278,RC,,,both,,,1747.20,524.16,"NOVANET [10819]",Novanet,,1310.4,75,,,,,0,203.2,1485.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE BREAST BIOPSY 145MM 11GA MAMMOTOME MR LONG BLADELESS",SUP-MRP11X,CDM,S27200284,LOCAL,0272,RC,,,both,,,2043.23,612.97,"FIRST HEALTH [10303]","First Health",,1634.58,80,,,,,0,237.63,1736.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRACCATH, 13W",SUP-4875,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH CRANIAL 76X50X.85MM MTM CRANIOMAXILLOFACIAL TITANIUM",SUP-81020,CDM,C1713,HCPCS,0278,RC,,,both,,,8837.93,2651.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1047.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1027.85,7512.24,"percent of total billed charges",
"DEFIB CARDIAC VIVA S CRT-D ICD DF-1 PHYSIOCURVE DESIGN",SUP-DTBB1D1,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"FIRST HEALTH [10303]","First Health",,46176,80,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPIDCROSS 170CM 120MM 4MM .014IN BALLOON DILATATION",SUP-A14BX040120170,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"MULTIPLAN [10600]",Multiplan,,1177.34,85,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH GORE DRYSEAL FLEX 33CM 9.5MM 26FR INTRO HYDROPHILIC",SUP-GDSF2633,CDM,C1894,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"NOVANET [10819]",Novanet,,3720.83,75,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Deoxyribonuclease Ab",PX-302000035,CDM,86215,CPT,0302,RC,,,both,,,149.50,44.85,"FIRST HEALTH [10303]","First Health",,119.6,80,,,,,0,0.01,127.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC CROME DR 2 CHMBR DF-1 PIN PLUG RADIOPAQUE",SUP-DDPC3D1,CDM,C1882,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6905.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC CROME DR 2 CHMBR DF-1 PIN PLUG RADIOPAQUE",SUP-DDPC3D1,CDM,C1882,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"CIGNA [10200]",Cigna,,23310,40,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 4-5 C-D KNEE",SUP-42522100312,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UHC [10700]","United Healthcare",,6821.47,63.3,,8601.07,8395.67,8601.07,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"LEAD PACING INGEVITY+ STEROID STAINLESS STEEL SILICONE RUBBE",SUP-7840,CDM,C1898,HCPCS,0275,RC,,,both,,,2250.00,675,"CIGNA [10200]","Cigna Local Plus",,1203.75,53.5,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21.5 DIOPTER HAPTIC C BICONVEX 13MM 6MM 1 PIECE",SUP-PCB0000215,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +15.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.155,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vep Test Cns",PX-740000016,CDM,95930,CPT,0740,RC,,,both,,,2256.00,676.8,"CIGNA [10200]","Cigna Open Access",,1283.66,56.9,,,,,0,262.37,1917.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0170,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 72MM STAINLESS STEEL 2.4MM SCR 6X5 HOLES 2",SUP-02.111.551,CDM,C1713,HCPCS,0278,RC,,,both,,,4196.93,1259.08,"CIGNA [10200]","Cigna Open Access",,2388.05,56.9,,1144.80,304.56,2275.09,66,488.1,3567.39,"percent of total billed charges",
"LENS IOL +25.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000255,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 54CM EPICARDIAL UNIPOLAR ACTIVE FIXATION",SUP-4047,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]","Cigna Open Access",,3190.38,56.9,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PRELUDE ROADSTAR STRAIGHT 45CM 55CM 6FR .088IN",SUP-PG6F45S,CDM,C1894,HCPCS,0272,RC,,,both,,,672.30,201.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,79.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 60MM 112CM 6MM 75CM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200066070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross PPO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING TRANSVENOUS STEROID ELUTING",SUP-407458,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1024.72,45.9,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 60MM 75CM 16MM 9FR 100CM",SUP-40332,CDM,C1876,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"CIGNA [10200]","Cigna Open Access",,3827.95,56.9,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC COBALT DR 2 CHMBR DF-1 PIN PLUG RADIOPAQUE",SUP-DDPB3D1,CDM,C1882,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,15734.25,27,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM 6FR ATRIUM VENTRICLE RIGHT IS-1 BIPOLAR",SUP-5076-65,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CIGNA [10200]","Cigna Local Plus",,1194.39,53.5,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.280 CLAREON",SUP-SY60WF.280,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txcath Retrev Intrvas FB",PX-361000295,CDM,37197,CPT,0361,RC,,,both,,,10102.49,3030.75,"CIGNA [10200]",Cigna,,10015,,"Case rate ($10,015). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1174.92,10015,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 5092-58  LEAD BI SIL NOVUS SP PAS 5",SUP-5092-58,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross PPO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL NOYES 8MM FLAT DUCKBILL 5.25IN EAR SERRATE 77",SUP-61-0118,CDM,S27200284,LOCAL,0272,RC,,,both,,,1227.31,368.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,142.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,142.74,1043.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2 38IN BRAID TIES MULTISTRAND LOWER KNOT",SUP-AR-7233,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.84,57.55,"NOVANET [10819]",Novanet,,143.88,75,,,,,0,22.31,163.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 20MM 3.2-2.4-2.6FR 3.5MM BALLOON",SUP-SPR3520W,CDM,C1725,HCPCS,0272,RC,,,both,,,631.80,189.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 120MM 3MM BALLOON",SUP-U3575312,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cholangioscopy W Dirct Vslzn",PX-750000054,CDM,43273,CPT,0750,RC,,,both,,,13893.27,4167.98,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL 3 14MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620314,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7652.65,68,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309012,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10807.54,28.62,,,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Elbow 2v",PX-320000066,CDM,73070,CPT,0320,RC,,,both,,,531.76,159.53,"AETNA [10100]","Aetna HMO/PPO",,422.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.47,452,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Poly Midline",PX-E27200315,CDM,C1751,HCPCS,0272,RC,,,both,,,566.50,169.95,"KAISER [10500]",Kaiser,,379.56,67,,,,,0,65.88,481.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 12MM 2 VELOUR STRAIGHT TUBE",SUP-M002020954120,CDM,C1768,HCPCS,0278,RC,,,both,,,3431.40,1029.42,"BLUE CROSS [10001]","Blue Cross PPO",,1345.11,39.2,,,,,0,399.07,2916.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 10CM 12MM GORE EXCLUDER CONTRALATERAL LEG",SUP-PLC121000,CDM,C1874,HCPCS,0278,RC,,,both,,,27997.20,8399.16,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3256.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 28MM 7MM FULL THREAD STEP",SUP-AR-1370TC,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"CIGNA [10200]",Cigna,,1258.43,68,,1831.33,1831.33,1831.33,16,215.23,1573.04,"percent of total billed charges",
"CATH CORDIS SABER 150CM 150MM 5MM BALLOON DILATATION DURALYN",SUP-48005015X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR THK.36MM ULTRATHIN TAPER 3X1IN KNIT",SUP-M00202019530P0,CDM,C1768,HCPCS,0278,RC,,,both,,,995.73,298.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,457.04,45.9,,,,,0,115.8,846.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC SPRINTER FASTRAC 138CM 21MM 2.4/2.6-1.9FR 2.25MM",SUP-NCSP22521X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH SAFESHEATH HS CURVE 60CM 7FR",SUP-WORLEY/B-60-07-HS,CDM,C1893,HCPCS,0272,RC,,,both,,,3345.00,1003.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,389.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,389.02,2843.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.434,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.21,68,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 111MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 8",SUP-223.581,CDM,C1713,HCPCS,0278,RC,,,both,,,2001.30,600.39,"KAISER [10500]",Kaiser,,1340.87,67,,,,,0,232.75,1701.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIFY ASSURA NEXT GENERATION CRT-D 40 DF4 CONNECTOR",SUP-CD3357-40Q,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,16519.46,28.62,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MEMORY SHAPE 420",SUP-RSZ1305,CDM,S27200284,LOCAL,0272,RC,,,both,,,238.91,71.67,"KAISER [10500]",Kaiser,,160.07,67,,,,,0,27.79,203.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP",RX-70693,CDM,J1815,HCPCS,0637,RC,00002-7511-01,NDC,both,10,ML,773.80,232.14,"NOVANET [10819]",Novanet,,580.35,75,,,,,0,51.7,657.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 45CM 6MM FLIXENE SLIDER GRADUATED WALL",SUP-25050,CDM,C1768,HCPCS,0278,RC,,,both,,,8200.03,2460.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,953.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,953.66,6970.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 60MM 120CM 7MM 8FR STRAIGHT VASCULAR",SUP-AVSL07060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"NOVANET [10819]",Novanet,,13702.5,75,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TFN-ADVANCED ORTHOPEDIC 475MM 3.2MM FEMORAL PROXIMAL",SUP-09.037.010,CDM,C1769,HCPCS,0272,RC,,,both,,,768.93,230.68,"UHC [10700]","United Healthcare",,486.73,63.3,,,,,0,89.43,653.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .035IN 5FR 4MM 110CM 10CM PTA 2",SUP-4204000L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP PROV 35MM CLSR TIP FIRST OPEN END LEFT",SUP-PROV35,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4029.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 44MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-44-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"CIGNA [10200]","Cigna Open Access",,3219.4,56.9,,5302.19,4377.88,6578.61,27,658.03,4809.3,"percent of total billed charges",
"FRCP SURGICAL WEIL-BLAKESLEY 45D UP 0 3.5MM 4.5IN SINUS",SUP-3711040,CDM,S27200284,LOCAL,0272,RC,,,both,,,3720.68,1116.2,"FIRST HEALTH [10303]","First Health",,2976.54,80,,,,,0,432.72,3162.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 20-38CMX3-10MM GRACILIS TENDON ALLOGRAFT",SUP-430300,CDM,C1762,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3990.55,45.9,,,,,0,1011.11,7389.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL MIXTER MICRO ANGLE RIGHT CURVE 9.5IN",SUP-17-0723,CDM,S27200284,LOCAL,0272,RC,,,both,,,340.34,102.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,231.43,68,,,,,0,39.58,289.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BARD INLAY 26CM 4.7FR 2 PIGTAIL CURVE URETERAL",SUP-778426,CDM,C2625,HCPCS,0278,RC,,,both,,,619.16,185.75,"CIGNA [10200]","Cigna Open Access",,352.3,56.9,,,,,0,72.01,526.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lymphocyte Transformation",PX-302000077,CDM,86353,CPT,0302,RC,,,both,,,1470.60,441.18,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,1250.01,"per diem",
"SYSTEM XIENCE ALPINE 23MM 145CM 3.5MM CORONARY STENT",SUP-1145350-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"FIRST HEALTH [10303]","First Health",,4670.4,80,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 16MM 144CM 3.5MM CORONARY STENT",SUP-H7493911416350,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TALUS VANTAGE 2 ANKLE LEFT STERILE LATEX FREE",SUP-350-01-02,CDM,C1776,HCPCS,0278,RC,,,both,,,24790.50,7437.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10188.9,41.1,,6417.48,6417.48,6417.48,"1 through 10",2883.14,21071.93,"percent of total billed charges",
"CATH C-FLEX 70CM 6FR PIGTAIL CURVE URETERAL TAPER TIP 1",SUP-M0064001710,CDM,C1758,HCPCS,0272,RC,,,both,,,499.69,149.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,58.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.11,424.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 15CM 6FR 21GA 4FR APRIMA HYDROPHILIC ACCESS TROCAR",SUP-G52965,CDM,C1894,HCPCS,0272,RC,,,both,,,602.32,180.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,409.58,68,,,,,0,70.05,511.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ VASCULAR 3CM STRAIGHT TAPER 180CM 7CM .035IN",SUP-G03330,CDM,C1769,HCPCS,0272,RC,,,both,,,308.76,92.63,"KAISER [10500]",Kaiser,,206.87,67,,,,,0,35.91,262.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY TORIC AUTONOME",SUP-CNAET5,CDM,V2787,HCPCS,0276,RC,,,both,,,880.00,264,"CIGNA [10200]","Cigna Local Plus",,470.8,53.5,,,,,0,102.34,748,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXCISOR BIOPSY .472X.354IN FISCHER 74D 12MM SMALL CONE",SUP-900-150,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.28,60.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.64,172.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repo Cvc W Fluoro",PX-450000234,CDM,36597,CPT,0361,RC,,,both,,,6675.32,2002.6,"CIGNA [10200]",Cigna,,2497,,"Case rate ($2,497). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,776.34,6675.32,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY PINK 10CM 18GA 17GA BARD MISSION TRUGUIDE 10MM 20",SUP-1810MSK,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,278.05,68,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL 7 18IN MONOFILAMENT TIE 12 STRAND SILVER",SUP-DS18,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.57,22.67,"MULTIPLAN [10600]",Multiplan,,64.23,85,,,,,0,8.79,64.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN STD",SUP-67004100,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"UHC [10700]","United Healthcare",,264.34,63.3,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 15MM 3MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3015X,CDM,C1725,HCPCS,0272,RC,,,both,,,550.80,165.24,"KAISER [10500]",Kaiser,,369.04,67,,,,,0,64.06,468.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Bi (Go)",PX-510000545,CDM,29581,CPT,0430,RC,,,both,,,729.00,218.7,"NOVANET [10819]",Novanet,,546.75,75,,,,,0,84.78,729,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8.5MM 12/14 TAPER 36MM HIP BIOLOX DELTA",SUP-1365-36-330,CDM,C1776,HCPCS,0278,RC,,,both,,,12268.20,3680.46,"UHC [10700]","United Healthcare",,7765.77,63.3,,8601.07,8395.67,8601.07,"1 through 10",1426.79,10427.97,"percent of total billed charges",
"INSRT TIBIAL 2 12.5MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158101112,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UHC [10700]","United Healthcare",,7073.49,63.3,,8601.07,8395.67,8601.07,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"CATH CHRG 135CM 200MM 8MM BALLOON DILATATION OTW",SUP-H74939206082010,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE DESTINATION RENAL DOUBLE CURVE 45CM 5CM 7FR",SUP-RSR15,CDM,C1887,HCPCS,0272,RC,,,both,,,672.30,201.69,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION,MODERATE",046,APR-DRG,,,,,,,inpatient,,,43052.50,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $5,489.30. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($35,199.08) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 40MM 6MM RECTANGLE HELIX BALLOON",SUP-2076-6040,CDM,C1725,HCPCS,0272,RC,,,both,,,6865.50,2059.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MULTI-SNARE 20MMX125CM W/6FRX105CM",SUP-PFM-147320,CDM,C1773,HCPCS,0272,RC,,,both,,,2558.85,767.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ENROUTE ENFLATE TRANSCAROTID RX BALLOON DILATATION CATHETER",SUP-SR-5525-BC,CDM,C1725,HCPCS,0272,RC,,,both,,,2625.00,787.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 135CM 8MM 20MM",SUP-H74938047820130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,580.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 59MM 135CM 7MM THIN VASCULAR COCR",SUP-1012630-59,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"CIGNA [10200]","Cigna Open Access",,4779.6,56.9,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE REFICIO CORTICAL DEMINERALIZED BONE MATRIX",SUP-27800418,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Open Access",,2133.75,56.9,,1144.80,304.56,2275.09,66,436.13,3187.5,"percent of total billed charges",
"HC MRI Brain Perfusion",PX-610000081,CDM,76498,CPT,0610,RC,,,both,,,1755.00,526.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,204.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,204.11,1755,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 25MM 3.5MM VERTEX SELECT PRECUT",SUP-7753725,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,403.54,28.62,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 35MM SECUR-FIT MAX 10",SUP-6052-1035S,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"CIGNA [10200]","Cigna Open Access",,5242.48,33.5,,5302.19,4377.88,6578.61,27,1820,13301.82,"percent of total billed charges",
"KIT MICROINTRODUCER 5FR 50CM GWIRE BEVEL A NDL SMOOTH DIL",SUP-0228950,CDM,C1894,HCPCS,0272,RC,,,both,,,455.54,136.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,309.77,68,,,,,0,50.95,387.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL CURVE TIP NONSTERILE LATEX FREE REUSABLE 12MM",SUP-470530,CDM,S27000186,LOCAL,0270,RC,,,both,,,1224.72,367.42,"PHCS [10601]",PHCS,,857.3,70,,,,,0,142.43,1041.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.5IN ANKLE STERILE",SUP-351-90-21,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"BLUE CROSS [10001]","Blue Cross PPO",,333.4,39.2,,957.42,570.23,957.42,28,98.91,722.93,"percent of total billed charges",
"KIT INTRO 10CM 5FR GLIDESHEATH SLENDER RADIAL NITINOL",SUP-50-1050,CDM,C1894,HCPCS,0272,RC,,,both,,,591.30,177.39,"KAISER [10500]",Kaiser,,396.17,67,,,,,0,68.77,502.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 20MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0102000,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"AETNA [10100]","Aetna HMO/PPO",,4040.07,79.5,,10981.53,8986.79,12413.38,12,591.02,4319.57,"percent of total billed charges",
"HC NM Indium III Wbc",PX-343000032,CDM,A9547,HCPCS,0343,RC,,,both,,,9098.00,2729.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1078.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1058.1,7733.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 80MM 130CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-EX060803CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"CIGNA [10200]","Cigna Local Plus",,3694.95,31.5,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 4.8FR L22CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902110,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 100CM 5FR ANGLE KUMPE",SUP-G11457,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,27.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 11MM 40MM ASYMMETRIC TRIATHLON X3 KNEE",SUP-5551L401,CDM,C1776,HCPCS,0278,RC,,,both,,,4478.10,1343.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,530.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,520.8,3806.39,"percent of total billed charges",
"PACKING COILS XL 30CM",SUP-RBYPCXL30,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 7CM 7FR CENTER BEND BILIARY PLASTIC",SUP-M00534570,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,500.06,45.9,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE PASSER WITH GUIDE SUTURE PASSING PUNCTURE CLOSURE DEV",SUP-RSG-14F,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.80,52.44,"KAISER [10500]",Kaiser,,117.12,67,,,,,0,20.33,148.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 40MM 150CM 7MM VASCULAR NICKEL",SUP-EVD35-07-040-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,744.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG AUTOTRANSFUSION 400ML CARDIOPAT ORTHOPAT REPLACEMENT RBC",SUP-01200-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.68,40.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,61.82,45.9,,,,,0,15.66,114.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUTURE BIOCOMP PUSHLOCK",SUP-AR-1922BCM,CDM,C1713,HCPCS,0278,RC,,,both,,,3268.13,980.44,"FIRST HEALTH [10303]","First Health",,2614.5,80,,,,,0,380.08,2777.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 8.6FR HELIX VENTRICLE 1 COIL ACTIVE",SUP-693552,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"PHCS [10601]",PHCS,,12020.4,70,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PDZ679 SPECIAL ZMED II 22X4.5X110",SUP-611004,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"NOVANET [10819]",Novanet,,3988.53,75,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 100MM 4MM BALLOON DILATATION HYDROPHILIC",SUP-604015022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 35 80CM 40MM 6FR 10MM .035IN LOW PROFILE BALLOON",SUP-B1100-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BTN 1.7CM 18FR REPL GSTRM EVV",SUP-6277,CDM,C1894,HCPCS,0272,RC,,,both,,,139.20,41.76,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RONGEUR 6IN STRAIGHT MINI 3MM RUSKIN 2 ACTION SURGICAL",SUP-31-0403,CDM,S27200284,LOCAL,0272,RC,,,both,,,1521.99,456.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 16CM 12FR 18GA .035IN POLYURETHANE ARROWG+ARD BLUE",SUP-AK-22122-F,CDM,C1752,HCPCS,0272,RC,,,both,,,936.36,280.91,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 24FR URETHRAL NATURAL RUBBER HYDROPHOBIC SILICONE",SUP-265724,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.64,15.79,"NOVANET [10819]",Novanet,,39.48,75,,,,,0,6.12,44.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE IMPELLA 5.5 SMARTASSIST VENTRICULAR ASSIST CATH",SUP-1000100,CDM,S27800098,LOCAL,0278,RC,,,both,,,250800.00,75240,"UHC [10700]","United Healthcare",,158756.4,63.3,,,,,0,29168.04,213180,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR060202A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2223.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .018IN 4FR 6MM 135CM 4CM PTA LOW",SUP-G50247,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 6CM 3MM BALLOON DILATATION",SUP-U815036,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC COBALT HF 2 CHMBR DF-1 PIN PLUG RADIOPAQUE",SUP-DTPB2D1,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"KAISER [10500]",Kaiser,,51556.5,67,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 39MM 135CM 7MM THIN VASCULAR COCR",SUP-1012630-39,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"PHCS [10601]",PHCS,,5880,70,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBTR ENDOSCOPIC VISUAL OES PRO CYSTOURETHROSCOPE 22.5FR",SUP-A20924A,CDM,S27200284,LOCAL,0272,RC,,,both,,,4573.32,1372,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1879.63,41.1,,,,,0,531.88,3887.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC",350,MS-DRG,,,,,,,inpatient,,,102768.93,30830.68,"CIGNA [10200]",Cigna,,32673.79,,"Fee schedule rate ($32,673.79). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,72753.51,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFT TOUCH",SUP-SSM-310,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"KAISER [10500]",Kaiser,,5062.19,67,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cytp Urne 3-5 Probes Ea Spec",PX-311000037,CDM,88120,CPT,0311,RC,,,both,,,3075.00,922.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,287.79,,"Fee schedule rate ($287.79). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,2613.75,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"WATCHMAN TRUSEAL PROCEDURE ACCESS SYSTEM",SUP-WMPERPROTRUACC25,CDM,S27800098,LOCAL,0278,RC,,,both,,,9660.00,2898,"UHC [10700]","United Healthcare",,6114.78,63.3,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 36MM HIP COCR LFIT V40",SUP-6260-9-236,CDM,C1776,HCPCS,0278,RC,,,both,,,6224.40,1867.32,"FIRST HEALTH [10303]","First Health",,4979.52,80,,,,,0,723.9,5290.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP POROCOAT PINNACLE 300 SERIES",SUP-121703054,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"CIGNA [10200]","Cigna Open Access",,3818.42,56.9,,5302.19,4377.88,6578.61,27,780.46,5704.15,"percent of total billed charges",
"STENT ADVANIX NAVIFLEX 12CM 8.5FR DUODENAL BEND BILIARY",SUP-M00534290,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,740.83,68,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X11X9MM ALLOCRAFT 5D LORDOSIS CORTICAL",SUP-6183-7-009,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 300MM 4MM BALLOON",SUP-U3575430,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 25MM 1.3MM 3.9FR AUTOTOME CANNULATE STERILE",SUP-M00584390,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKAGED RADIAL STEM 11MM X -2MM",SUP-ALN-RST-11M2,CDM,C1776,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5688.36,40,,,,,0,1653.89,12087.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE 20X15CM PREPERITONEAL KNIT WEB SYNECOR",SUP-GKWV1520,CDM,C1781,HCPCS,0278,RC,,,both,,,10108.50,3032.55,"FIRST HEALTH [10303]","First Health",,8086.8,80,,,,,0,1175.62,8592.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 62MM 40MM ALTRX HIP",SUP-122140162,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"MULTIPLAN [10600]",Multiplan,,11732.93,85,,,,,0,1605.34,11732.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Orth Device Repair",PX-E27400090,CDM,L4210,HCPCS,0274,RC,,,both,,,95.70,28.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 17.5MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158126117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AETNA [10100]","Aetna HMO/PPO",,8883.77,79.5,,10981.53,8986.79,12413.38,12,1299.6,9498.37,"percent of total billed charges",
"STENT GORE VIABAHN 10CM 120CM 10MM ENDOPROSTHESIS LUMEN CATH",SUP-VBCR101002A,CDM,C1874,HCPCS,0278,RC,,,both,,,17545.50,5263.65,"BLUE CROSS [10001]","Blue Cross HMO",,6877.84,39.2,,9776.84,9776.84,9776.84,"1 through 10",2040.54,14913.68,"percent of total billed charges",
"CAP SYSTEM PERSONA STD TKR PROLONG FEMUR PATELLA TIBIA",SUP-98000900254,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8564.54,28.62,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEARABLE ACCESSORY KIT - INCLUDES WITH IMPLANT KIT - PC NECK",SUP-106129,CDM,Q0508,HCPCS,0274,RC,,,both,,,1377.00,413.1,"PHCS [10601]",PHCS,,963.9,70,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Weighted Prosthesis",PX-E27000249,CDM,L8030,HCPCS,0270,RC,,,both,,,1096.70,329.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,503.39,45.9,,,,,0,127.55,932.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 3CM 5FR STRAIGHT PANCREATIC PLASTIC TEMPORARY",SUP-M00536370,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,75.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ORTHOBLAST II CANCELLOUS DEMINERALIZED BONE",SUP-02-2110-050,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"NOVANET [10819]",Novanet,,2812.5,75,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 2 KNEE REVISION",SUP-5612-B-200,CDM,C1776,HCPCS,0278,RC,,,both,,,26089.56,7826.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3091.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3034.22,22176.13,"percent of total billed charges",
"SCR BONE 2.4MM 14MM LCP STAINLESS STEEL DISTAL VOLAR RADIUS",SUP-02.210.114,CDM,C1713,HCPCS,0278,RC,,,both,,,959.36,287.81,"FIRST HEALTH [10303]","First Health",,767.49,80,,,,,0,111.57,815.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +10MM 36MM HIP C TAPER OFFSET COBALT CHROME",SUP-624718,CDM,C1776,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]",Cigna,,2815.2,68,,5873.17,5873.17,5873.17,"1 through 10",481.48,3519,"percent of total billed charges",
"SUT SILK PERMA-HAND MICROPOINT 6-0 G-6 18IN 2 ARM BRAID",SUP-769G,CDM,S27200284,LOCAL,0272,RC,,,both,,,140.84,42.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FALCON PRECISION CARTRIDGE 90MM",SUP-6725127090,CDM,S27200284,LOCAL,0272,RC,,,both,,,2580.23,774.07,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAMP SURGICAL SATINSKY 42MM 5.5IN CURVED BULLDOG RING",SUP-MB613R,CDM,S27200284,LOCAL,0272,RC,,,both,,,791.86,237.56,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"3.00MM X 15MM  SCOREFLEX  NC",SUP-630-154-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BLAZER II 110CM 4MM 7FR 2.5MM SPACE STD CURVE",SUP-M0045031TH0,CDM,C1733,HCPCS,0272,RC,,,both,,,8107.50,2432.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE EKOSONIC MACH 4 135CM 40CM 5.4FR THROMBECTOMY",SUP-500-56140,CDM,C1887,HCPCS,0272,RC,,,both,,,37894.50,11368.35,"MULTIPLAN [10600]",Multiplan,,32210.33,85,,,,,0,4407.13,32210.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE VASCULAR 1.5MM STD 180CM 3CM .035IN NITINOL",SUP-GR3525,CDM,C1769,HCPCS,0272,RC,,,both,,,361.05,108.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,41.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.99,306.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENZOCAINE 10 % MUCOSAL GEL",RX-19690,CDM,,,0250,RC,50486-0550-32,NDC,both,7,GR,40.55,12.16,"CIGNA [10200]","Cigna Local Plus",,21.69,53.5,,,,,0,4.72,34.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNQT SURGICAL 42IN ATS",SUP-60-7075-157R,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"CIGNA [10200]","Cigna Open Access",,42.08,56.9,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRICATH 16FR STD URETHRAL RUBBER 5CC FOLEY",SUP-119416M,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.53,30.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,41.73,41.1,,,,,0,11.81,86.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 4.5MM BALLOON DILATATION PEBAX",SUP-1012279-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC THK6MM 50X47MM ASSURITY MRI IS-1 CNCT 10.4CC",SUP-PM1272,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"NOVANET [10819]",Novanet,,18630,75,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE TRNSDUC 48IN MERITRANS MALE ROTATE LUER FEMALE FIX",SUP-K11-00392B,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.22,27.67,"CIGNA [10200]","Cigna Local Plus",,49.34,53.5,,,,,0,10.73,78.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR LARGE 40MM AVON KNEE",SUP-6430-0-040,CDM,C1776,HCPCS,0278,RC,,,both,,,5561.40,1668.42,"MULTIPLAN [10600]",Multiplan,,4727.19,85,,,,,0,646.79,4727.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL COMPOSIX L/P 14.2X10.2IN VENTRAL HERNIA PATCH",SUP-0134114,CDM,C1781,HCPCS,0278,RC,,,both,,,6791.40,2037.42,"NOVANET [10819]",Novanet,,5093.55,75,,,,,0,789.84,5772.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR HORNET 14  300CM  STRAIGHT-TIP",SUP-H749393073002,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"KAISER [10500]",Kaiser,,651.24,67,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLGRAFT 50MM 90CM 9MM 10FR 116CM",SUP-M001705950,CDM,C1874,HCPCS,0278,RC,,,both,,,14165.70,4249.71,"CIGNA [10200]",Cigna,,5666.28,40,,,,,0,1647.47,12040.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CEREBROFLO 35CM 10FR 1.9MM LONG EXTERNAL DRNG",SUP-37.550.501,CDM,C1729,HCPCS,0272,RC,,,both,,,6209.21,1862.76,"AETNA [10100]","Aetna HMO/PPO",,4936.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.13,5277.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 54MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.544,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"PHCS [10601]",PHCS,,809.68,70,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 STD KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500606002,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9145.08,40,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 12MM XTEND SPINE VARIABLE ANGLE SELF TAP",SUP-161.312,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]",Cigna,,958.8,68,,1831.33,1831.33,1831.33,16,163.98,1198.5,"percent of total billed charges",
"SYSTEM MULTI-LINK MINI VISION 8MM 2.5MM CORONARY STENT COCR",SUP-1007823-08,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION 14MM TIGHTROPE ROUND CONCAVE ATTACHABLE",SUP-AR-1588TB-4,CDM,C1713,HCPCS,0278,RC,,,both,,,1764.00,529.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1199.52,68,,,,,0,205.15,1499.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE JOURNEY II COCR WITH XR INSERT AND",SUP-71709040,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"PHCS [10601]",PHCS,,13230,70,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 18CM 7FR 2 PIGTAIL CURVE BILIARY POLYETHYLENE",SUP-G21530,CDM,C2617,HCPCS,0278,RC,,,both,,,1328.40,398.52,"CIGNA [10200]","Cigna Local Plus",,710.69,,,,,,,154.49,1129.14,"percent of total billed charges",
"CATH MACH1 55CM 6FR .07IN LIMA CURVE GUIDING PTFE PERIPHERAL",SUP-M001196620,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,406.05,68,,,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GAS INTRAOCULAR ISPAN SULFUR HEXAFLUORIDE 450GM RETINAL",SUP-8065797001,CDM,C1784,HCPCS,0278,RC,,,both,,,28090.76,8427.23,"BLUE CROSS [10001]","Blue Cross PPO",,11011.58,39.2,,,,,0,3266.96,23877.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 2.25MM BALLOON DILATATION RAPID EXCHANGE",SUP-DC-RZ2212UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 10 MICRO RIGHT ANGLE 7.5IN RETRACTION BLUNT 3MM",SUP-RN6210,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 190MM 11MM SHORT CARBON FIBER BRIDGE",SUP-394.796,CDM,S27800098,LOCAL,0278,RC,,,both,,,4945.09,1483.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,585.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,575.11,4203.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 156MM 16-16MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1616C156E,CDM,S27800098,LOCAL,0278,RC,,,both,,,38997.00,11699.1,"BLUE CROSS [10001]","Blue Cross PPO",,15286.82,39.2,,,,,0,4535.35,33147.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 20X10IN RESORBABLE GRID 2",SUP-F10258-1020G,CDM,C1781,HCPCS,0278,RC,,,both,,,25704.00,7711.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6940.08,27,,,,,0,2989.38,21848.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CALCAR 27MM RESTORATION +30MM OFFSET HIP MODULAR",SUP-6276-4-327,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"CIGNA [10200]","Cigna Local Plus",,7309.91,31.5,,5372.07,4581.20,7242.98,23,2698.86,19725.14,"percent of total billed charges",
"LITHO SURGICAL 1 PIECE STONE CATCHER SWISS LITHOCLAST",SUP-M0068407501,CDM,S27200284,LOCAL,0272,RC,,,both,,,578.89,173.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,393.65,68,,,,,0,67.32,492.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 15MM 145CM 4MM CORONARY STENT",SUP-1145400-15,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,678.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 74.9X49.3X25MM MBT 4+ MM KNEE CEMENTED REVISION",SUP-129435425,CDM,C1776,HCPCS,0278,RC,,,both,,,35980.56,10794.17,"NOVANET [10819]",Novanet,,26985.42,75,,,,,0,4184.54,30583.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC",743,MS-DRG,,,,,,,inpatient,,,69872.86,20961.86,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,16546.7,,"Case rate ($7,696.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,146.39, add-ons for qualifying new technology services are included. If operating cost exceeds $40,186.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,922.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $7,155.84. The transfer operating threshold is the transfer adjustment factor * $7,146.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $540.30. The transfer capital threshold is the transfer adjustment factor * $540.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,36223.48,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM 500 MG (AS CARBONATE)-VITAMIN D3 5 MCG (200 UNIT) TABLET",RX-19483,CDM,,,0637,RC,10006-0700-38,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC MEDIUM REGULAR LENGTH 7IN 6.75-7.5IN WRIST",SUP-A60715,CDM,S27000186,LOCAL,0270,RC,,,both,,,141.03,42.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.4,119.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 150MM 1.6MM STAINLESS STEEL THREAD SPADE",SUP-292.72,CDM,C1769,HCPCS,0272,RC,,,both,,,200.45,60.13,"UHC [10700]","United Healthcare",,126.88,63.3,,,,,0,23.31,170.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1.5 KNEE LEFT CRUCIATE RETAIN SIGMA STERILE",SUP-940017,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"MULTIPLAN [10600]",Multiplan,,22006.37,85,,,,,0,3010.99,22006.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8.5FR 71CM STEERABLE SMALL CURL DUAL REACH",SUP-408309,CDM,C1766,HCPCS,0272,RC,,,both,,,3754.80,1126.44,"FIRST HEALTH [10303]","First Health",,3003.84,80,,,,,0,436.68,3191.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) INTREPID MITRAL VALVE 48MM RECOVERABLE CLINICAL IMPLA",SUP-INTPD-V4-48A,CDM,S62400003,LOCAL,0624,RC,,,both,,,256500.00,76950,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,29830.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29830.95,218025,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL HIP 36MM (NECK) INSIGNIA 4 HIP STEM HIGH OFFSET 103MM",SUP-7000-6604,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"PHCS [10601]",PHCS,,21401.73,70,,,,,0,3555.74,25987.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS METAL GWIRE INSRT TOOL TORQUE DEVICE",SUP-MAP102,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.76,40.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.67,114.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 7/8IN BLADE 15FT 3/8IN PLUMEPEN",SUP-PLPUL2520,CDM,S27200284,LOCAL,0272,RC,,,both,,,277.08,83.12,"FIRST HEALTH [10303]","First Health",,221.66,80,,,,,0,32.22,235.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 45MM SOLERA COCR SPINAL MULTIAXIAL CANNULATED",SUP-54840004545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3923.76,41.1,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 23MM 3MM CORONARY STENT EVEROLIMUS",SUP-1550300-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE TITANIUM 25MM 7MM ORTHOPEDIC CANNULATED",SUP-C8710,CDM,C1713,HCPCS,0278,RC,,,both,,,1016.15,304.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,120.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,118.18,863.73,"percent of total billed charges",
"CATH QUICK-CROSS 150CM .018IN STRAIGHT SPRT",SUP-518-092,CDM,C1887,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE HINGE REVISION TRIATHLON",SUP-5612-P-211,CDM,C1776,HCPCS,0278,RC,,,both,,,16199.82,4859.95,"NOVANET [10819]",Novanet,,12149.87,75,,,,,0,1884.04,13769.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH ZURPAZ .032IN MEDIUM SYMMETRIC CURVE 92CM 72CM 8.5FR",SUP-M004USMC85100,CDM,C1894,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,695,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT STD PRECHAMBER MEDIUM HIGH PRESSURE RANGE",SUP-823009,CDM,S27800098,LOCAL,0278,RC,,,both,,,6094.49,1828.35,"PHCS [10601]",PHCS,,4266.14,70,,,,,0,708.79,5180.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 64MM HIP SOLID BACK METAL HA TRIDENT H",SUP-500-11-64H,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.85,2973.55,"FIRST HEALTH [10303]","First Health",,7929.48,80,,,,,0,1152.75,8425.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT TOTAL STBL TRIATHLON COCR",SUP-5512-F-701,CDM,C1776,HCPCS,0278,RC,,,both,,,20599.49,6179.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8466.39,41.1,,6417.48,6417.48,6417.48,"1 through 10",2395.72,17509.57,"percent of total billed charges",
"INSRT TIBIAL 6 17.5MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158106117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]",Cigna,,7598.69,68,,5873.17,5873.17,5873.17,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"SCR BONE 2.7MM 5MM 6MM TITANIUM FULL THREAD RADIUS CORTEX",SUP-402.806,CDM,C1713,HCPCS,0278,RC,,,both,,,380.02,114.01,"BLUE CROSS [10001]","Blue Cross HMO",,148.97,39.2,,957.42,156.86,7483.26,51,44.2,323.02,"percent of total billed charges",
"CURET 4MM 7MM ANGLE SLIGHT 9IN SEMMES SURGICAL SPINAL FUSION",SUP-29-4951,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.98,94.19,"CIGNA [10200]",Cigna,,213.51,68,,,,,0,36.52,266.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC INSPIRIS RESILIA 27MM BOVINE PERICARDIUM",SUP-11500A27,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5375.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 46MM 28MM TANDEM HIP COCR",SUP-71322046,CDM,C1776,HCPCS,0278,RC,,,both,,,7003.50,2101.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,814.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,814.51,5952.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 15CM 2.2MM MR8 MATCH HEAD STERILE DISPOSABLE",SUP-MR8-15MH22,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,138.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,135.93,993.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 155MM 4-5MM FLEXIGRAFT LATERAL ANKLE",SUP-FPSST,CDM,S27800098,LOCAL,0278,RC,,,both,,,9170.10,2751.03,"BLUE CROSS [10001]","Blue Cross PPO",,3594.68,39.2,,,,,0,1066.48,7794.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UROLOGICAL STD 150CM 3CM .038IN LUBRIGLIDE STIFF BODY",SUP-M0066001020,CDM,C1769,HCPCS,0272,RC,,,both,,,254.39,76.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,172.99,68,,,,,0,29.59,216.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640606,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"AETNA [10100]","Aetna HMO/PPO",,8946.85,79.5,,10981.53,8986.79,12413.38,12,1308.83,9565.82,"percent of total billed charges",
"SCR BONE 3.5MM 60MM LCP STAINLESS STEEL PROXIMAL TIBIAL SELF",SUP-212.424,CDM,C1713,HCPCS,0278,RC,,,both,,,1158.79,347.64,"MULTIPLAN [10600]",Multiplan,,984.97,85,,,,,0,134.77,984.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM 49.8MM HIP 3 SCR HOLE CLUSTER RIM",SUP-542-11-48D,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"CIGNA [10200]",Cigna,,4731.25,68,,5873.17,5873.17,5873.17,"1 through 10",809.18,5914.06,"percent of total billed charges",
"SCR BONE 6.5MM 35MM 16MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-216.035,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,53.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,52.23,381.7,"percent of total billed charges",
"GWIRE ZIPWIRE VASCULAR 150CM 3CM .035IN HYDROPHILIC STD",SUP-M00146151B1,CDM,C1769,HCPCS,0272,RC,,,both,,,486.00,145.8,"PHCS [10601]",PHCS,,340.2,70,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 24X10X7-4.6MM LUMINARY BULLET NOSE",SUP-15807,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 40MM 2MM GEMINUS SOLID SIDE CUT NONSTERILE",SUP-DRLL-SSC-20040,CDM,S27200284,LOCAL,0272,RC,,,both,,,753.30,225.99,"CIGNA [10200]","Cigna Local Plus",,403.02,53.5,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 6X37+TRAK21+CAT6 3-PACK - US",SUP-SFP913190,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 8 KNEE PRIMARY BEAD PA",SUP-5526-B-800,CDM,C1776,HCPCS,0278,RC,,,both,,,15783.75,4735.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6313.5,40,,,,,0,1835.65,13416.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 60MM 80CM 6MM VASCULAR PERIPHERAL SELF",SUP-1012528-60,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"MULTIPLAN [10600]",Multiplan,,3519,85,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.4MM KIRSCHNER",SUP-24872018,CDM,C1713,HCPCS,0278,RC,,,both,,,243.60,73.08,"BLUE CROSS [10001]","Blue Cross HMO",,95.49,39.2,,957.42,156.86,7483.26,51,28.33,207.06,"percent of total billed charges",
"CIPROFLOXACIN 0.3 % EYE DROPS",RX-9610,CDM,,,0250,RC,61314-0656-25,NDC,both,2.5,ML,157.44,47.23,"CIGNA [10200]",Cigna,,107.06,68,,,,,0,18.31,133.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.50 X 15 RX US",SUP-1804350-15,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11MM CORNERSTONE PSR 11MM PEEK-OPTIMA LIF",SUP-6287141,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"MULTIPLAN [10600]",Multiplan,,5676.66,85,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM COCR SPINAL MULTIAXIAL CANNULATED",SUP-54840017540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AETNA [10100]","Aetna HMO/PPO",,7589.75,79.5,,1521.93,481.35,16760.95,30,1110.3,8114.82,"percent of total billed charges",
"CATH TORCON NB ADVANTAGE BEACON TIP 80CM 5FR CHG-B CURVE",SUP-G13560,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CIGNA [10200]",Cigna,,161.49,68,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.35MM 100MM TFN-ADVANCED TITANIUM ALUMINUM",SUP-04.038.200S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RX TAKERU 12MM 1.5MM BALLOON DILATATION TIGHT REWRAP",SUP-DC-RY1512UA1,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ALTERATION IN CONSCIOUSNESS,MAJOR",052,APR-DRG,,,,,,,inpatient,,,46145.60,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $6,638.46. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($39,721.68) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BALL 3MM 24/26FR 3MM STERILE YELLOW",SUP-27050N,CDM,S27200284,LOCAL,0272,RC,,,both,,,1113.89,334.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,757.45,68,,,,,0,129.55,946.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PRECISION 12D ALLOGRAFT 14MM",SUP-421466,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 12/14 TAPER 32MM HIP COCR SPECTRON EF",SUP-71303204,CDM,C1776,HCPCS,0278,RC,,,both,,,8145.45,2443.63,"PHCS [10601]",PHCS,,5701.82,70,,,,,0,947.32,6923.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 7MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT074050A,CDM,C1768,HCPCS,0278,RC,,,both,,,12978.90,3893.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1538,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1509.45,11032.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE OPHTHALMIC .9MM MICROSMOOTH SMALL PARTS KIT STERILE",SUP-8065750159,CDM,S27200284,LOCAL,0272,RC,,,both,,,227.94,68.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.51,193.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALENDRONATE 10 MG TABLET",RX-15661,CDM,,,0637,RC,16714-0631-01,NDC,both,1,UN,14.72,4.42,"PHCS [10601]",PHCS,,10.3,70,,,,,0,1.71,12.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Explr Pntrate Wnd Abd/Flnk/Bck",PX-450000063,CDM,20102,CPT,0450,RC,,,both,,,11998.00,3599.4,"NOVANET [10819]",Novanet,,8998.5,75,,,,,0,67.13,10198.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Lumbar Spine W Cntrst",PX-352000015,CDM,72132,CPT,0352,RC,,,both,,,2689.33,806.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,742,,,,,,,312.77,2285.93,"per diem",
"HC Inj Pseudoaneurysm Perc Non Extrem",PX-361000617,CDM,37799,CPT,0361,RC,,,both,,,1745.00,523.5,"KAISER [10500]",Kaiser,,1169.15,67,,,,,0,202.94,1745,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 420MM FEMORAL PROXIMAL TFN-ADVANCED INTRAMEDULLARY",SUP-04.037.262S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"UHC [10700]","United Healthcare",,7860.81,63.3,,5023.51,2672.93,6679.78,18,1444.25,10555.59,"percent of total billed charges",
"STENT AGILE 119MM 18MM ESOPHAGEAL PARTIAL COVER STERILE",SUP-M00517260,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]","Cigna Open Access",,6120.45,33.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1.5 X 4 HELICAL PICO COIL",SUP-10USH01504,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1363.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION MBT TIBIAL TRIAL TRAY",SUP-217830123,CDM,C1713,HCPCS,0278,RC,,,both,,,365.40,109.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,104.58,28.62,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR GRAY 45MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103545000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"BLUE CROSS [10001]","Blue Cross HMO",,1201.21,39.2,,5311.50,4717.44,5388.59,31,356.38,2604.67,"percent of total billed charges",
"CMPNT FEMORAL XS KNEE AVON",SUP-6430-0-050,CDM,C1776,HCPCS,0278,RC,,,both,,,22635.90,6790.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6478.39,28.62,,,,,0,2632.56,19240.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 NARROW KNEE LEFT CRUCIATE RETAIN CEMENT",SUP-42502006001,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"NOVANET [10819]",Novanet,,17147.03,75,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3.33MM LARGE REGULAR PIGTAIL CURVE URETERAL",SUP-M001274050,CDM,C2617,HCPCS,0278,RC,,,both,,,1053.00,315.9,"CIGNA [10200]",Cigna,,716.04,68,,,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE SPINAL 470MM 1MM TITANIUM 1 LEAD CRIMP STERILE",SUP-491.991.01S,CDM,C1713,HCPCS,0278,RC,,,both,,,2433.75,730.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,288.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",283.05,2068.69,"percent of total billed charges",
"STENT ADVANIX 10CM 5FR PIGTAIL CURVE PANCREATIC POLYMER",SUP-M00537180,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,74.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA C KNEE LEFT 2 PEG TIVANIUM STERILE",SUP-42530006401,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1649.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1649.72,12057.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 140MM 80CM 9MM 6FR .035IN BILIARY",SUP-G50137,CDM,C1876,HCPCS,0278,RC,,,both,,,7350.00,2205,"FIRST HEALTH [10303]","First Health",,5880,80,,,,,0,854.81,6247.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 9 STD 36MM PROVOX LIFE LARYTUBE SILICONE",SUP-7413,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"AETNA [10100]","Aetna HMO/PPO",,949.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATTAIN SELECT II GUIDING CORONARY PERCUTANEOUS DELIVERY",SUP-6248DEL130D03,CDM,C1887,HCPCS,0272,RC,,,both,,,1377.00,413.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,163.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THOMASMEDICAL INTRDCR FR10.5 - EACH",SUP-666269-001,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D MODIFIED L BICONVEX 13MM 6MM POSTERIOR CHMBR 1",SUP-SN60WF,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 5.5MM VIPER 2 LORDOTIC TITANIUM MIS",SUP-186788120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 78MM 4 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800478,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"LEAD PACING PASSIVE FIXATION BIPOLAR DUAL COIL 65CM 17CM",SUP-1570,CDM,C1895,HCPCS,0278,RC,,,both,,,20538.00,6161.4,"CIGNA [10200]","Cigna Open Access",,6880.23,33.5,,,,,0,2388.57,17457.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH",RX-27506,CDM,,,0250,RC,52817-0611-04,NDC,both,1,UN,662.97,198.89,"AETNA [10100]","Aetna HMO/PPO",,527.06,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.1,563.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 5MM BALL DISSECTING SYMMETRICAL",SUP-MR8-14BA50T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1495.26,448.58,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,177.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.9,1270.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 340MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.055S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"BLUE CROSS [10001]","Blue Cross HMO",,4867.99,39.2,,957.42,156.86,7483.26,51,1444.25,10555.59,"percent of total billed charges",
"SCR BONE 3.5MM MOUNTAINEER TITANIUM SPINE OCCIPITOCERVICAL",SUP-188362025,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HSE BRTHG 22MM FLRD 40LG VMAX SPEC",SUP-774611-102,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.99,44.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.21,125.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 7MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0750CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"CIGNA [10200]","Cigna Local Plus",,4245.23,53.5,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACCESS THERAPEUTIC POLAR CARE KODIAK REPLACEMENT TRANSFORMER",SUP-10698,CDM,S27000186,LOCAL,0270,RC,,,both,,,129.98,38.99,"KAISER [10500]",Kaiser,,87.09,67,,,,,0,15.12,110.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POLYETHYLENE GLYCOL 3350 ORAL POWDER BOTTLE",RX-24984,CDM,,,0250,RC,45802-0868-02,NDC,both,238,GR,56.89,17.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23.38,41.1,,,,,0,6.62,48.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 STD KNEE RIGHT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB5SR,CDM,C1776,HCPCS,0278,RC,,,both,,,13668.90,4100.67,"NOVANET [10819]",Novanet,,10251.68,75,,,,,0,1589.69,11618.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OMNIWIRE 185 CM J-TIP",SUP-89185J,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"AMERIGROUP MEDICAID [20100]",Amerigroup,,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GERALD STRAIGHT NARROW 7IN TISSUE 1X2 TEETH",SUP-285125,CDM,S27000186,LOCAL,0270,RC,,,both,,,179.48,53.84,"FIRST HEALTH [10303]","First Health",,143.58,80,,,,,0,20.87,152.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.2MM IFUSE IMPL SYSTEM SACROILIAC PUSH",SUP-500090,CDM,S27000186,LOCAL,0270,RC,,,both,,,3326.40,997.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2261.95,68,,,,,0,386.86,2827.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS LAPAROSCOPIC METZENBAUM TIP METZENBAUM MINI 9.4MM",SUP-3122,CDM,S27200284,LOCAL,0272,RC,,,both,,,334.95,100.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE ELECTROSURGICAL 20MM OPTABLATE 1 KIT STERILE LATEX",SUP-9700-020-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,23706.90,7112.07,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SHEATH NAVIGATOR 28CM 13-15FR ACCESS STAINLESS STEEL",SUP-M0062502060,CDM,C1894,HCPCS,0272,RC,,,both,,,895.54,268.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Tube Trach Hyperflex",PX-E27200233,CDM,E27200233,LOCAL,0272,RC,,,both,,,1129.30,338.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 6X4CM CYGNUS DUAL THK.2MM 24SQ CM AMNION",SUP-585-003,CDM,Q4282,HCPCS,0636,RC,,,both,,,64125.00,19237.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH STERLING MONORAIL 135CM 40MM 6FR 4.5MM 4FR BALLOON",SUP-H74939031454010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +16 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.160,CDM,V2632,HCPCS,0276,RC,,,both,,,1085.40,325.62,"BLUE CROSS [10001]","Blue Cross PPO",,425.48,39.2,,,,,0,126.23,922.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT 8MM 4 ARM CAMERA CANN SEAL INSTR DRAPE ACCESS DA VINCI",SUP-420291,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,231.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 20MM 3MM BALLOON",SUP-U357532,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.9H 58MM 3 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009358,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 26CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155233190,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,417.88,28.62,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM CREO ONE HA SPINE MODULAR ROBOTIC",SUP-1134.1646S,CDM,C1713,HCPCS,0278,RC,,,both,,,10336.20,3100.86,"UHC [10700]","United Healthcare",,6542.81,63.3,,5023.51,2672.93,6679.78,18,1202.1,8785.77,"percent of total billed charges",
"INSRT ARTICULAR 3-4 18MM KNEE CONSTRAIN UHMWPE GENESIS II",SUP-71420530,CDM,C1776,HCPCS,0278,RC,,,both,,,17832.15,5349.64,"NOVANET [10819]",Novanet,,13374.11,75,,,,,0,2073.88,15157.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM GORILLA NONSTERILE R3CON NON LOCK PLATE",SUP-P50-453-3512,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,446.15,45.9,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Stent & Ather Sf Init",PX-361000716,CDM,37275,CPT,0361,RC,,,both,,,28914.88,8674.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7883,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,28.91,24577.65,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 13MM 51X74MM CLARIA MRI CRT-D SURESCAN",SUP-DTMA1Q1,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6712.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE INTUITION VASCULAR STRAIGHT 180CM HYDRO-TRACK",SUP-INTU180HS,CDM,C1769,HCPCS,0272,RC,,,both,,,502.20,150.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,58.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE KNIFE 8.25IN 3LA STAINLESS STEEL SATIN FINISH",SUP-110171,CDM,S27000186,LOCAL,0270,RC,,,both,,,174.35,52.3,"AETNA [10100]","Aetna HMO/PPO",,138.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.28,148.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION SLR PTCA DEB 2.5X25MM",SUP-SCA14U-250025D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 3.3MM 38MM TITANIUM T25 FULL THREAD SELF TAP",SUP-04.005.428,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"AMERIGROUP MEDICAID [20100]",Amerigroup,,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",134.52,983.18,"percent of total billed charges",
"PROTEK 15 FEMORAL ARTERIAL CANNULA 15FR",SUP-5130-1715,CDM,S27200284,LOCAL,0272,RC,,,both,,,2962.50,888.75,"NOVANET [10819]",Novanet,,2221.88,75,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR LAPAROSCOPIC 56.7CM 8MM DA VINCI S/SI ENDOWRIST",SUP-420278,CDM,S27000186,LOCAL,0270,RC,,,both,,,1800.00,540,"CIGNA [10200]",Cigna,,1224,68,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 24CM 14.5FR 15FR STRAIGHT POLYURETHANE GLIDEPATH",SUP-5397190,CDM,C1750,HCPCS,0278,RC,,,both,,,1875.00,562.5,"PHCS [10601]",PHCS,,1312.5,70,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHISEL SURGICAL MEDIUM BOX HIP",SUP-6266-5-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,3746.25,1123.87,"AETNA [10100]","Aetna HMO/PPO",,2978.27,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,435.69,3184.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAXCESS-C SCREW, 12MM DISTRACTION",SUP-7670212,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM PK COIL LP STERILE LATEX FREE",SUP-RBYPCLP30,CDM,S27800098,LOCAL,0278,RC,,,both,,,8832.00,2649.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1027.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1027.16,7507.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP5PL,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"CIGNA [10200]","Cigna Local Plus",,6773.1,31.5,,5372.07,4581.20,7242.98,23,2500.67,18276.62,"percent of total billed charges",
"HEAD SCR MATRIX SPINE TITANIUM TOP LOAD POLYAXIAL",SUP-04.632.001,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE REVISION HYBRID CONCELOC WITH JOURNEY 2 C",SUP-71704649,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"CIGNA [10200]",Cigna,,9324,40,,5873.17,5873.17,5873.17,"1 through 10",2710.95,19813.5,"percent of total billed charges",
"STENT EVERFLEX 20MM 120CM 8MM VASCULAR PERIPHERAL SELF",SUP-PRB35-08-020-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"MULTIPLAN [10600]",Multiplan,,4730.25,85,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT OSSEOPERM MENDEC PMMA INJECTOR MIX CNTNR",SUP-OP-0001,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM 8-10MM POD",SUP-RBYPOD10,CDM,S27800098,LOCAL,0278,RC,,,both,,,11661.00,3498.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4664.4,40,,,,,0,1356.17,9911.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 45CM 6FR ATRIUM TRANSVENOUS BIPOLAR TINE IS-1",SUP-5592-45,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,664.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SPINAL 3.5IN 20GA LUMBAR PUNCTURE",SUP-26-LP1CO,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.75,30.82,"CIGNA [10200]",Cigna,,69.87,68,,,,,0,11.95,87.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 12MM MATRIXNEURO CRANIOMAXILLOFACIAL TITANIUM 2",SUP-04.503.062,CDM,C1713,HCPCS,0278,RC,,,both,,,1101.60,330.48,"CIGNA [10200]","Cigna Local Plus",,589.36,53.5,,3978.14,359.25,3978.14,24,128.12,936.36,"percent of total billed charges",
"SHEATH NAVIGATOR HD 36CM 12-14FR ACCESS STAINLESS STEEL",SUP-M0062502250,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"FIRST HEALTH [10303]","First Health",,784.54,80,,,,,0,114.05,833.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 110MM 2MM CALIBRATION QUICK COUPLING 30MM",SUP-03.133.100,CDM,S27200284,LOCAL,0272,RC,,,both,,,879.98,263.99,"MULTIPLAN [10600]",Multiplan,,747.98,85,,,,,0,102.34,747.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVISOR SENSOR ENABLED 15-25MM CIRCULAR MAPPING",SUP-D-AVSE-D20-V1525,CDM,C1732,HCPCS,0272,RC,,,both,,,11730.00,3519,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1390.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Spine Lumbosacral >=4v",PX-320000045,CDM,72110,CPT,0320,RC,,,both,,,1142.39,342.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,261.88,,,,,,,62.2,971.03,"fee schedule",
"HC Ab Elution RBC",PX-302000183,CDM,86860,CPT,0302,RC,,,both,,,538.20,161.46,"NOVANET [10819]",Novanet,,403.65,75,,,,,0,0.01,457.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL CRYOFLEX 8IN 10-S",SUP-60SF3,CDM,S27200284,LOCAL,0272,RC,,,both,,,15870.00,4761,"KAISER [10500]",Kaiser,,10632.9,67,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 12X4IN ANTIMICROBIAL BACK FILM MULTILAYER ABSORBENT",SUP-498600,CDM,S27200284,LOCAL,0272,RC,,,both,,,250.56,75.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.14,212.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 70MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.070,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"CIGNA [10200]","Cigna Local Plus",,110.4,53.5,,3978.14,359.25,3978.14,24,24,175.41,"percent of total billed charges",
"PEG FIXATION 2.7MM 18MM DISTAL VOLAR RADIUS FOSSA HIGH",SUP-HCLP-27180-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD MARLEX 5.4X2.4IN KEYHOLE MONOFILAMENT",SUP-0113710,CDM,C1781,HCPCS,0278,RC,,,both,,,481.14,144.34,"CIGNA [10200]","Cigna Open Access",,273.77,56.9,,11235.02,819.42,11235.02,"1 through 10",55.96,408.97,"percent of total billed charges",
"SPACER ALLOGRAFT 12.5X15X11MM ADVANCED PARALLEL SPINE",SUP-17611,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"AETNA [10100]","Aetna HMO/PPO",,6582.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER ETHIBOND 1 CTX 18IN CONTROL RELEASE BRAID 8",SUP-CX30D,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.13,37.54,"FIRST HEALTH [10303]","First Health",,100.1,80,,,,,0,14.55,106.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 4MM FRMLA 6 FLUTE BARREL F SERIES STERILE",SUP-0375941000,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"KAISER [10500]",Kaiser,,215.67,67,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL 10FR 13.35IN STRAIGHT TIP WOVEN UROLOGICAL HEYMAN",SUP-021110,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.15,65.14,"FIRST HEALTH [10303]","First Health",,173.72,80,,,,,0,25.25,184.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 80CM 20MM 12MM .035IN BALLOON",SUP-AB35W12020080,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"KAISER [10500]",Kaiser,,453.7,67,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH 26FR ENDOSCOPIC FIX INNER TUBE CERAMIC INSULATION",SUP-27040XA,CDM,S27200284,LOCAL,0272,RC,,,both,,,10613.44,3184.03,"KAISER [10500]",Kaiser,,7111,67,,,,,0,1234.34,9021.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 6MM AVENIR 10 COIL STERILE LATEX FREE",SUP-10CFR06030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1389.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAPIPLASTY MINI INCISION SYSTEM",SUP-SK30,CDM,C1713,HCPCS,0278,RC,,,both,,,35248.50,10574.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10088.12,28.62,,,,,0,4099.4,29961.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 35MM 4.75MM CD HORIZON SOLERA COCRMO CAP",SUP-641003035,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 4MM CORONARY STENT",SUP-1145400-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC",498,MS-DRG,,,,,,,inpatient,,,157415.75,47224.72,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,19836.19,,"Case rate ($18,713.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $17,376.65, add-ons for qualifying new technology services are included. If operating cost exceeds $50,416.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,695.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $17,399.63. The transfer operating threshold is the transfer adjustment factor * $17,376.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,313.76. The transfer capital threshold is the transfer adjustment factor * $1,313.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,88078.49,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION",RX-103889,CDM,J2003,HCPCS,0636,RC,63323-0495-07,NDC,both,5,ML,32.54,9.76,"FIRST HEALTH [10303]","First Health",,26.03,80,,,,,0,1.17,27.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL 018 2.0X4",SUP-45-480204,CDM,S27800098,LOCAL,0278,RC,,,both,,,5361.30,1608.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,635.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,623.52,4557.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 140MM 80CM 16MM BILIARY VENOUS DELIVERY",SUP-G57449,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"UHC [10700]","United Healthcare",,9172.17,63.3,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK ANGIOPLSTY ACCESSPLUS HEMOSTASIS VALVE GWIRE INSRT TOOL",SUP-MAP151,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.36,34.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.18,96.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER",RX-81454,CDM,,,0250,RC,00186-0370-28,NDC,both,6,GR,960.93,288.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.76,816.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 34MM STAINLESS STEEL T8 METAPHYSEAL SELF TAP",SUP-02.118.534,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"NOVANET [10819]",Novanet,,392.93,75,,,,,0,60.93,445.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTICROSS 135CM 1.6CM 12MM 30 MHZ ULTRASOUND PERIPHERAL",SUP-H7493932800180,CDM,C1753,HCPCS,0272,RC,,,both,,,10281.00,3084.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1218.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1195.68,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Central Line Dressing Tray",PX-E27000196,CDM,E27000196,LOCAL,0270,RC,,,both,,,80.28,24.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,36.85,45.9,,,,,0,9.34,68.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16016550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"BIT DRILL 250MM 2.8MM QUICK COUPLING STOP CALIBRATED 95MM",SUP-03.113.024,CDM,S27200284,LOCAL,0272,RC,,,both,,,827.82,248.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,562.92,68,,,,,0,96.28,703.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 26X11X7IN TLX 20D STERILE LATEX FREE",SUP-5902731P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 LEFT KNEE POSTERIOR STABILIZED CEMENTED",SUP-5515-F-301,CDM,C1776,HCPCS,0278,RC,,,both,,,16566.90,4970.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6626.76,40,,,,,0,1926.73,14081.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BENTSON 24CM 15CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175252060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"NOVANET [10819]",Novanet,,748.07,75,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myelography Lumb Inj Lumbsac Si",PX-361000373,CDM,62304,CPT,0361,RC,,,both,,,4612.82,1383.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1550,,"Case rate ($1,550). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,536.47,4612.82,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 2.75MM CORONARY STENT EVEROLIMUS",SUP-H7493926132270,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]","Cigna Local Plus",,4614.38,53.5,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +13 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150130,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 20MM 144CM 4MM CORONARY STENT",SUP-H7493952820400,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 12MM 145CM 4.5MM BALLOON DILATATION",SUP-1400450-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Guide Wire Perfusion",PX-E27200262,CDM,E27200262,LOCAL,0272,RC,,,both,,,862.40,258.72,"UHC [10700]","United Healthcare",,545.9,63.3,,,,,0,100.3,733.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nmo/Aqp4 Facs Titer Serum",PX-302000246,CDM,86256,CPT,0302,RC,,,both,,,2216.00,664.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.65,,"Fee schedule rate ($12.65). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1883.6,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTALINK 135CM 2.5MM ATHERECTOMY BURR",SUP-H749393002500,CDM,C1724,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM 11/13 TAPER 40MM HIP M SPECIFICATION METAL",SUP-136543500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"KAISER [10500]",Kaiser,,7422.23,67,,,,,0,1288.37,9416.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT CONTRACTURE XL ANKLE ANTIROTATION BAR PAD TOE PIECE",SUP-4301E,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE 9MM 230CM 2.4MM EXACTO COLD BRAID WIRE CLEAN CUT",SUP-BX00711115,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.70,28.71,"AETNA [10100]","Aetna HMO/PPO",,76.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 6.5IN WEITLANER-BECKMANN 3X4 PRONG HINGE ARM BLUNT",SUP-24-3017,CDM,S27200284,LOCAL,0272,RC,,,both,,,804.98,241.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,369.49,45.9,,,,,0,93.62,684.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID LOWER LEG REDUCTION KIT- STANDARD, REGULAR",SUP-25101217,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"AETNA [10100]","Aetna HMO/PPO",,998.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 8MM 2MM BALLOON DILATATION PEBAX",SUP-1012270-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 16MM VARIAX BLUNT HAND WRIST SELF TAP CROSS",SUP-58-23016E,CDM,C1713,HCPCS,0278,RC,,,both,,,608.96,182.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,279.51,45.9,,,,,0,70.82,517.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD MARLEX 14X10IN GROIN MONOFILAMENT GOLD",SUP-0112660,CDM,C1781,HCPCS,0278,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,428.87,28.62,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 7X11X35MM 12",SUP-5871352,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"MULTIPLAN [10600]",Multiplan,,24480,85,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER SLIMLINE 550UM 1 INCISION SLING",SUP-M0068409250,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION 130CM 2.4FR MICRO J INFUSION NITINOL 1",SUP-M001195270,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 14MM PYRENEES +2.3MM SPINAL",SUP-201-90105,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GEOALIGN 130CM 220MM 4MM 5FR .035IN BALLOON DILATATION",SUP-LX3513042205F,CDM,C2623,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FLUDEOXYGLUCOSE F-18 20 MCI TO 300 MCI/ML INTRAVENOUS SOLUTION",RX-164696,CDM,A9552,HCPCS,0343,RC,08888-8878-25,NDC,both,1,UN,755.00,226.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"URSODIOL 25 MG/ML ORAL SUSPENSION",RX-408889,CDM,,,0637,RC,08888-8884-06,NDC,both,30,ML,120.20,36.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE HUMERUS LEFT DISTAL LATERAL",SUP-629203S,CDM,C1713,HCPCS,0278,RC,,,both,,,6594.74,1978.42,"KAISER [10500]",Kaiser,,4418.48,67,,,,,0,766.97,5605.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 28CM 7FR 2.1FR 2 PIGTAIL CURVE",SUP-M0061921440,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,521.25,45.9,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 100MM STAINLESS STEEL 1.5MM SCREWS 20 HOLE STRAIGHT",SUP-246.19,CDM,C1713,HCPCS,0278,RC,,,both,,,1871.10,561.33,"MULTIPLAN [10600]",Multiplan,,1590.44,85,,,,,0,217.61,1590.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC",959,MS-DRG,,,,,,,inpatient,,,118309.32,35492.8,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,39264.25,,"Case rate ($18,262.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $16,957.91, add-ons for qualifying new technology services are included. If operating cost exceeds $49,997.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,664.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $16,980.33. The transfer operating threshold is the transfer adjustment factor * $16,957.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,282.10. The transfer capital threshold is the transfer adjustment factor * $1,282.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,85955.94,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM FRMLA RESECTOR SERIES F LATEX FREE",SUP-0375542000,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"FIRST HEALTH [10303]","First Health",,257.52,80,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 9MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P809,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]",Cigna,,5682.01,68,,5873.17,5873.17,5873.17,"1 through 10",971.79,7102.52,"percent of total billed charges",
"VIABAHN BX BALLOON EXP ENDO 8MMX29MM 7FR 80CMCATH HEPARIN",SUP-BXB082901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5582.27,28.62,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Ather Sf Ea Add",PX-361000713,CDM,37272,CPT,0361,RC,,,both,,,10249.92,3074.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1214.62,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.25,8712.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB SKIN 20X10CM STRATTICE",SUP-1020002,CDM,Q4130,HCPCS,0636,RC,,,both,,,30561.30,9168.39,"CIGNA [10200]",Cigna,,20781.68,68,,,,,0,3621.51,25977.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 10CM CANN SERRATE EDGE FRANSEEN LUNG STERILE",SUP-G01432,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.10,58.23,"NOVANET [10819]",Novanet,,145.58,75,,,,,0,22.57,164.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 56MM TI",SUP-MTC-37560-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,357.01,28.62,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X-COATED SPECIALTY PACK, 1/CASE",SUP-73331-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.00,513,"UHC [10700]","United Healthcare",,1082.43,63.3,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL HAND 11GA OPTABLATE STERILE LATEX FREE DISPOSABLE",SUP-9700-811-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2970.62,891.19,"UHC [10700]","United Healthcare",,1880.4,63.3,,,,,0,345.48,2525.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 105MM CEMENT EXT PROSTALAC 1 HIGH OFFSET HIP",SUP-1541-06-000,CDM,C1776,HCPCS,0278,RC,,,both,,,18814.32,5644.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2229.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2188.11,15992.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK ELECTROSURGICAL 5MM MONOPOLAR CAUT",SUP-428052,CDM,S27000186,LOCAL,0270,RC,,,both,,,1053.00,315.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,124.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 50MM 4-5MM AVANCE NERVE ALLOGRAFT NATURAL",SUP-411250,CDM,C1762,HCPCS,0278,RC,,,both,,,56586.60,16975.98,"BLUE CROSS [10001]","Blue Cross HMO",,22181.95,39.2,,,,,0,6581.02,48098.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP 2 - SPECIALTY",SUP-CAP-DJO-H-2,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"CIGNA [10200]","Cigna Open Access",,8230.95,33.5,,5302.19,4377.88,6578.61,27,2857.49,20884.5,"percent of total billed charges",
"VALVE AORTIC KONECT 23MM RESILIA AORTIC VALVED CONDUIT",SUP-11060A23,CDM,S27800098,LOCAL,0278,RC,,,both,,,79800.00,23940,"AETNA [10100]","Aetna HMO/PPO",,63441,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9280.74,67830,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM SEPTUM 90MMX7MM KILLIAN SCR JOINT",SUP-OK094R,CDM,S27200284,LOCAL,0272,RC,,,both,,,658.13,197.44,"KAISER [10500]",Kaiser,,440.95,67,,,,,0,76.54,559.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SPECTRUM II 45D ANGLE LEFT HOOK LOCK HANDLE SUT",SUP-C6381,CDM,S27200284,LOCAL,0272,RC,,,both,,,685.50,205.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,79.72,582.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 7MM ALIF LORDOTIC",SUP-365.407,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4541.33,68,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 16MM 140CM 3MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927416300,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"PHCS [10601]",PHCS,,2625,70,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Cerv/Thorac Sngl W Img",PX-510000204,CDM,62321,CPT,0761,RC,,,both,,,3841.43,1152.43,"FIRST HEALTH [10303]","First Health",,3073.14,80,,,,,0,446.76,3265.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 5FR SIDEWINDER 2 CURVE ANGIOGRAPHIC",SUP-10719607,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,89.39,41.1,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HIP HYBRID AND DISP",SUP-98000100224,CDM,C1776,HCPCS,0278,RC,,,both,,,32760.00,9828,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3809.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3809.99,27846,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 7MM 9.5MM 240MM HUMERAL LEFT MULTILOC INTRAMEDULLARY",SUP-04.017.240S,CDM,C1713,HCPCS,0278,RC,,,both,,,11172.76,3351.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4592,41.1,,,,,0,1299.39,9496.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ENDOSCOPIC BLADE SHARP TIP SICKLE CURVE 7.5IN NASAL",SUP-63-7580,CDM,S27200284,LOCAL,0272,RC,,,both,,,539.38,161.81,"CIGNA [10200]",Cigna,,366.78,68,,,,,0,62.73,458.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT CRYOSURGICAL C2 CRYOBALLOON CRTDG CRYOBALLOON ABLATION",SUP-FG-1013,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,363.53,68,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 28CM 8FR LARGE PROXIMAL PIGTAIL CURVE URETERAL",SUP-M001235530,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,103.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE 15X10CM PREPERITONEAL KNIT WEB SYNECOR",SUP-GKWV1015,CDM,C1781,HCPCS,0278,RC,,,both,,,5071.50,1521.45,"NOVANET [10819]",Novanet,,3803.63,75,,,,,0,589.82,4310.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE NOVASURE UTERINE ENDOMETRIUM KIT ABLATION IMPEDANCE",SUP-NS2013US,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"CIGNA [10200]",Cigna,,4692,68,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 52CM .014IN SOFT STIFFNESS KNOB CAP INGEVITY",SUP-5013,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 7.5X1IN SLIGHT CURVE KEY",SUP-26-5625,CDM,S27200284,LOCAL,0272,RC,,,both,,,282.23,84.67,"UHC [10700]","United Healthcare",,178.65,63.3,,,,,0,32.82,239.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 300MM 3.2MM ASNIS III NONSTERILE",SUP-702626,CDM,S27200284,LOCAL,0272,RC,,,both,,,1020.60,306.18,"PHCS [10601]",PHCS,,714.42,70,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135D 48MM MINI TAPER HIGH OFFSET 43.2MM 150MM",SUP-L20312,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"CIGNA [10200]","Cigna Open Access",,5305.44,33.5,,5302.19,4377.88,6578.61,27,1841.86,13461.55,"percent of total billed charges",
"ROD SPINAL GRAY 125MM 5.5MM CONTOUR",SUP-101-655125,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"MULTIPLAN [10600]",Multiplan,,3748.5,85,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 78MM NAIL-EX TITANIUM FEMORAL TIBIAL LOCKING",SUP-04.005.568,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"AMERIGROUP MEDICAID [20100]",Amerigroup,,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",134.52,983.18,"percent of total billed charges",
"STENT WALLFLEX 80MM 75CM 10MM 8.5FR .035IN BILIARY PERMALUME",SUP-M00574790,CDM,C1874,HCPCS,0278,RC,,,both,,,22050.00,6615,"KAISER [10500]",Kaiser,,14773.5,67,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL INFINITY 4 STD TOTAL ANKLE SYSTEM",SUP-33650004,CDM,C1776,HCPCS,0278,RC,,,both,,,29049.30,8714.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8313.91,28.62,,,,,0,3378.43,24691.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST TRICORTICAL THK5MM WEDGE ALLOGRAFT",SUP-400397,CDM,S27800098,LOCAL,0278,RC,,,both,,,3829.50,1148.85,"CIGNA [10200]","Cigna Open Access",,2178.99,56.9,,,,,0,445.37,3255.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Strap Toes",PX-450000206,CDM,29550,CPT,0361,RC,,,both,,,748.02,224.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,748.02,,"Fee schedule rate ($1,729.39).",,,,0,86.99,748.02,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 44CM LEFT TROCHANTERIC INTRAMEDULLARY 130D LONG",SUP-456.365S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1619.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1589.87,11619.86,"percent of total billed charges",
"DEVICE ENDO STITCH V-LOC 180 3-0 8IN CLSR ABSORBABLE RELOAD",SUP-VLOCA308L,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.99,98.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,38.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.15,278.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER GD 100CM 6FR RWY VL4 CRV",SUP-H74938969730,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AETNA [10100]","Aetna HMO/PPO",,291.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL LEGION 6 LEFT KNEE REVISION",SUP-71424006,CDM,C1776,HCPCS,0278,RC,,,both,,,23133.60,6940.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9253.44,40,,,,,0,2690.44,19663.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17CM 5MM MICRUSFRAME 10 COIL",SUP-MFR100517,CDM,S27800098,LOCAL,0278,RC,,,both,,,16974.00,5092.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4582.98,27,,,,,0,1974.08,14427.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXTOME 142CM 10MM 3.75MM BALLOON DILATATION NYLON",SUP-H749CBM3375100,CDM,C1725,HCPCS,0272,RC,,,both,,,5395.80,1618.74,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Barrier Cream",PX-E27000052,CDM,E27000052,LOCAL,0270,RC,,,both,,,28.60,8.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET HOUSING REAMER",SUP-AR-1204AF-75,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHIBOND EXCEL 2 CP-2 30IN BRAID D SPECIAL CUSTOM LIGHT",SUP-D6090,CDM,S27200284,LOCAL,0272,RC,,,both,,,1001.88,300.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,459.86,45.9,,,,,0,116.52,851.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 80CM 5FR CHG-C CURVE",SUP-G13561,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"KAISER [10500]",Kaiser,,159.12,67,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 20MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-593502022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET TITANIUM 5.5-6MM SOLERA SEXTANT CD HORIZON",SUP-5540430,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"FIRST HEALTH [10303]","First Health",,1925.28,80,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 12MM 2.25MM BALLOON DILATATION PEBAX",SUP-1400225-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CILOSTAZOL 100 MG TABLET",RX-24474,CDM,,,0637,RC,50268-0177-11,NDC,both,1,UN,11.32,3.4,"CIGNA [10200]","Cigna Local Plus",,6.06,53.5,,,,,0,1.32,9.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 22MM TARGET XL 360D STD LARGE",SUP-M0036102250,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,,,0637,RC,77333-0938-25,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]",Cigna,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 28MM 144CM 4.5MM CORONARY STENT",SUP-H7493941828450,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALL POLY PAT VE 29 MM DIA",SUP-42-5402-000-29,CDM,C1776,HCPCS,0278,RC,,,both,,,5322.66,1596.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,619.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,619.03,4524.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP GRASPING VERSAGRASP STERILE DISPOSABLE",SUP-M0067802001,CDM,S27200284,LOCAL,0272,RC,,,both,,,704.70,211.41,"NOVANET [10819]",Novanet,,528.53,75,,,,,0,81.96,599,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +9MM OFFSET 36MM HIP TYPE 1 COCR G7",SUP-11363665,CDM,C1776,HCPCS,0278,RC,,,both,,,5296.44,1588.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,627.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,615.98,4501.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 40MM 7FR 12MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206120470,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FARAPOINT PFA CATHETER D-F CURVE",SUP-M004PF81M110,CDM,C1733,HCPCS,0272,RC,,,both,,,24570.00,7371,"PHCS [10601]",PHCS,,17199,70,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 14CM 6MM LEGEND CYL FLUTED LARGE BORE 7.9MM",SUP-14CY60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.28,371.18,"NOVANET [10819]",Novanet,,927.96,75,,,,,0,143.9,1051.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 5IN 3/32IN",SUP-0277-082-085S1,CDM,S27000186,LOCAL,0270,RC,,,both,,,874.80,262.44,"FIRST HEALTH [10303]","First Health",,699.84,80,,,,,0,101.74,743.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 70MM STAINLESS STEEL 2.4MM SCR 7X4 HOLE 2 COLUMN",SUP-02.111.741,CDM,C1713,HCPCS,0278,RC,,,both,,,4046.85,1214.05,"KAISER [10500]",Kaiser,,2711.39,67,,,,,0,470.65,3439.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP LUBRI-SIL STATLOCK 14FR",SUP-A947314,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.06,36.62,"UHC [10700]","United Healthcare",,77.26,63.3,,,,,0,14.2,103.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM STERNALOCK BLU STERNAL CANCELLOUS LOCK",SUP-73-2714,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"FIRST HEALTH [10303]","First Health",,313.2,80,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 70MM STAINLESS STEEL 2.4MM SCR 7X4 HOLE 2 COLUMN",SUP-02.111.741,CDM,C1713,HCPCS,0278,RC,,,both,,,4046.85,1214.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,479.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,470.65,3439.82,"percent of total billed charges",
"BIT DRILL 135MM 2MM AO SCALE",SUP-703896,CDM,S27200284,LOCAL,0272,RC,,,both,,,1068.23,320.47,"CIGNA [10200]","Cigna Open Access",,607.82,56.9,,,,,0,124.24,908,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP GRASPING VERSAGRASP STERILE DISPOSABLE",SUP-M0067802001,CDM,S27200284,LOCAL,0272,RC,,,both,,,704.70,211.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,479.2,68,,,,,0,81.96,599,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC MICROFIBRILLAR CLLGN SPONGE AVITENE",SUP-1050030,CDM,S27200284,LOCAL,0272,RC,,,both,,,272.40,81.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,32.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.68,231.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL MOTOBAND CP DYNAFORCE STERILE LATEX FREE DIS",SUP-7000-16KW,CDM,C1713,HCPCS,0278,RC,,,both,,,583.20,174.96,"KAISER [10500]",Kaiser,,390.74,67,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST LARGE WEDGE FREEZE DRIED",SUP-40A001,CDM,S27800098,LOCAL,0278,RC,,,both,,,3977.85,1193.35,"CIGNA [10200]","Cigna Open Access",,2263.4,56.9,,,,,0,462.62,3381.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502606202,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6172.93,27,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CRYOSURGICAL RED 1.5MM ICEROD CX VISUAL-ICE PRESICE",SUP-FPRPR3533,CDM,C2618,HCPCS,0272,RC,,,both,,,13110.00,3933,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1524.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE NEUROSURGICAL 8IN APEX ARACHNOID KNIVES ULTEM",SUP-AM-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 6MMX79MM 7FR 135CMCATH HEPARIN",SUP-BXB067902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"BLUE CROSS [10001]","Blue Cross HMO",,8391.7,39.2,,9776.84,9776.84,9776.84,"1 through 10",2489.68,18196.29,"percent of total billed charges",
"INSRT TIBIAL 7 STD 10MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS7S10L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4769.65,45.9,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 NARROW KNEE LEFT CEMENTED POSTERIOR",SUP-150410126,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"AETNA [10100]","Aetna HMO/PPO",,17802.71,79.5,,10981.53,8986.79,12413.38,12,2604.35,19034.35,"percent of total billed charges",
"(EVAL) EDWARDS EVOQUE VALVE (EVOQUE VALVE) 48 MM",SUP-9850EV48PCL,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"NOVANET [10819]",Novanet,,149625,75,,,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE WATCHMAN 24MM 75CM 12FR 14FR CLSR PEBAX NITINOL",SUP-M635WU24060,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 22MM TI",SUP-SPL-35220-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,523.91,39.2,,957.42,156.86,7483.26,51,155.43,1136.03,"percent of total billed charges",
"NUT EXTERNAL FIXATION HEX MRI SAFE NONSTERILE",SUP-03.311.061.10,CDM,S27800098,LOCAL,0278,RC,,,both,,,66.83,20.05,"NOVANET [10819]",Novanet,,50.12,75,,,,,0,7.77,56.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VASOVIEW HEMOPRO 2 CONE VESSEL HARVESTING RADIUS",SUP-VH-4000,CDM,S27200284,LOCAL,0272,RC,,,both,,,8211.14,2463.34,"NOVANET [10819]",Novanet,,6158.36,75,,,,,0,954.96,6979.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FARAPOINT PFA CATHETER D-F CURVE",SUP-M004PF81M110,CDM,C1733,HCPCS,0272,RC,,,both,,,24570.00,7371,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2911.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2.5CM 2MM TARGET TETRA DETACHABLE STERILE",SUP-TG5412025,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]","Cigna Open Access",,4728.4,33.5,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +18 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030180,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,460.4,39.2,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO SELECT VASCULAR STRAIGHT 300CM .014IN",SUP-SSUP300STR,CDM,C1769,HCPCS,0272,RC,,,both,,,5686.57,1705.97,"PHCS [10601]",PHCS,,3980.6,70,,,,,0,661.35,4833.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR AEROSOL VAPOTHERM PRECISION FLOW AEROGEN LATEX FREE",SUP-AAA-1,CDM,S27000186,LOCAL,0270,RC,,,both,,,83.52,25.06,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPCOCK ENDOSCOPIC UNIVERSAL LUER LOCK STERILE DISPOSABLE",SUP-00102.1,CDM,S27200284,LOCAL,0272,RC,,,both,,,894.73,268.42,"CIGNA [10200]",Cigna,,608.42,68,,,,,0,104.06,760.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 40MM 80CM 8MM VASCULAR NITINOL PERIPHERAL",SUP-1012530-40,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Open Access",,2355.66,56.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER INDEN 15MM 15DEG SMALL",SUP-3135.0215,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13710.24,40,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 3MM CORONARY STENT",SUP-1125300-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS INTRAOCULAR +17.0 DIOPTER L13.5MM DIA6MM AC D5.2MM 5DEG",SUP-AR40E00170,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"CIGNA [10200]","Cigna Local Plus",,498.35,53.5,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 200MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040200S,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,218.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 6MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620506,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"NOVANET [10819]",Novanet,,8440.43,75,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT AUTOPLEX VERTAPLEX HV M4 MIXER STERILE LATEX",SUP-0707-000-000,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3008.75,45.9,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 75MM KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-183114,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"CIGNA [10200]","Cigna Local Plus",,6824.7,31.5,,5372.07,4581.20,7242.98,23,2519.72,18415.85,"percent of total billed charges",
"HC Ldl Cholesterol",PX-301000306,CDM,83721,CPT,0301,RC,,,both,,,107.90,32.37,"PHCS [10601]",PHCS,,75.53,70,,,,,0,0.01,91.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE PALACOS R+G GENTAMICIN HIGH VISCOSITY ARTHROPLAS",SUP-5036964,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX 20X15CM OPEN POSITION SYSTEM STERILE",SUP-1221520,CDM,C1781,HCPCS,0278,RC,,,both,,,40020.75,12006.22,"PHCS [10601]",PHCS,,28014.53,70,,,,,0,4654.41,34017.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRU PUNCH BIPSY 8MM",SUP-96-1152,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.10,24.63,"MULTIPLAN [10600]",Multiplan,,69.79,85,,,,,0,9.55,69.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 5ML .1-2MM 80% CORTICAL 20% CANCELLOUS",SUP-400061,CDM,C1713,HCPCS,0278,RC,,,both,,,923.40,277.02,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,423.84,45.9,,,,,0,107.39,784.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM .91-1.12MM 3MM CORONARY",SUP-RONYX30022W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"AETNA [10100]","Aetna HMO/PPO",,4324.01,79.5,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM SOLERA CD HORIZON COCR SPINE REDUCTION",SUP-55890006550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM INFINITY SPINE OCCIPITOCERVICAL UPPER",SUP-3603528,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CAROTID SUNDT CONE 30CM TEMPORARY EXTERNAL LOOP FULLY",SUP-NL8505072,CDM,S27800098,LOCAL,0278,RC,,,both,,,4600.44,1380.13,"KAISER [10500]",Kaiser,,3082.29,67,,,,,0,535.03,3910.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 180MM HIP AFFIXUS INTRAMEDULLARY SHORT",SUP-814511180,CDM,C1713,HCPCS,0278,RC,,,both,,,16044.57,4813.37,"FIRST HEALTH [10303]","First Health",,12835.66,80,,,,,0,1865.98,13637.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 12MM 3.5MM EMBOLIZATION",SUP-PED2-350-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9574.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP MEDICAL L235CM L2.8MM 11MM OPENING HEMOSTATIC FIXING RE",SUP-M00522612,CDM,S27200284,LOCAL,0272,RC,,,both,,,1239.81,371.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,146.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.19,1053.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 22CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155231180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309113,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10807.54,28.62,,,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM OBTRYX II PRECISIONBLUE ADVANTAGE THK.66MM 1182UM 22",SUP-M0068505110,CDM,C1788,HCPCS,0278,RC,,,both,,,13183.00,3954.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3772.97,28.62,,,,,0,1533.18,11205.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL ULTRAPRO 12X12IN PARTIAL ABSORBABLE",SUP-UML1,CDM,C1781,HCPCS,0278,RC,,,both,,,1985.63,595.69,"BLUE CROSS [10001]","Blue Cross PPO",,778.37,39.2,,,,,0,230.93,1687.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LASMIDITAN 50 MG TABLET",RX-189200,CDM,,,0637,RC,00002-4312-01,NDC,both,1,UN,400.08,120.02,"NOVANET [10819]",Novanet,,300.06,75,,,,,0,46.53,340.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE STD 25MM BLUNT SCPL BONESCALPEL SURGICAL STERILE LATEX",SUP-MXB-25,CDM,S27200284,LOCAL,0272,RC,,,both,,,3466.88,1040.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2357.48,68,,,,,0,403.2,2946.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM .02IN 3MM RUBY COMPLEX LARGE VOLUME",SUP-RBY4C0305,CDM,S27800098,LOCAL,0278,RC,,,both,,,4158.00,1247.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,492.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,483.58,3534.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 63MM HIP ANTIROTATION FIN EQUATORIAL TEETH",SUP-75100461,CDM,C1776,HCPCS,0278,RC,,,both,,,18389.70,5516.91,"BLUE CROSS [10001]","Blue Cross HMO",,7208.76,39.2,,5311.50,4717.44,5388.59,31,2138.72,15631.25,"percent of total billed charges",
"STENT CONTOUR SENSOR DUAL-FLEX 20CM 3CM 6FR .035IN PIGTAIL",SUP-M006180220090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,157.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 RIGHT MEDIAL LEFT LATERAL PARTIAL KNEE",SUP-5610-F-602,CDM,C1776,HCPCS,0278,RC,,,both,,,13720.65,4116.19,"PHCS [10601]",PHCS,,9604.46,70,,,,,0,1595.71,11662.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GW WHSPR VW VASC J CS JTP X",SUP-4641,CDM,C1769,HCPCS,0272,RC,,,both,,,243.60,73.08,"FIRST HEALTH [10303]","First Health",,194.88,80,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D F KNEE LEFT OSSEOTI KEEL",SUP-42535007501,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"UHC [10700]","United Healthcare",,8713.56,63.3,,8601.07,8395.67,8601.07,"1 through 10",1600.93,11700.68,"percent of total billed charges",
"HC Acquisition Liver Cadaver",PX-812000002,CDM,9999102,LOCAL,0812,RC,,,both,,,225141.00,67542.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,92532.95,41.1,,,,,0,26679.21,191369.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 170MM 4.75MM SOLERA STRAIGHT PERCUTANEOUS COCR",SUP-1476006170,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FAT EMULSION 20 % INTRAVENOUS",RX-10014,CDM,,,0250,RC,00264-4460-30,NDC,both,250,ML,162.22,48.67,"AETNA [10100]","Aetna HMO/PPO",,128.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.87,137.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 3/16IN STEINMANN SHORT THREAD 1 END TROCAR",SUP-161718000,CDM,S27000186,LOCAL,0270,RC,,,both,,,777.60,233.28,"CIGNA [10200]","Cigna Local Plus",,416.02,53.5,,,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 15MM 2.5MM CORONARY STENT COCR",SUP-1007823-15,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYNCHRO .014GUIDE WIRE  35 CM TIP",SUP-M00313010,CDM,C1769,HCPCS,0272,RC,,,both,,,4568.90,1370.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,541.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,531.36,3883.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR PULSE LATITUDE NXT 83.1X69.1MM EMBLEM S-ICD 12.7MM",SUP-A219,CDM,C1722,HCPCS,0278,RC,,,both,,,59280.00,17784,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6894.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6894.26,50388,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 105MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.416,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",160.97,1176.51,"percent of total billed charges",
"PORT IMPLANTABLE INFUSION POWERPORT ISP MRI AIRGUARD",SUP-1809661,CDM,C1788,HCPCS,0278,RC,,,both,,,1471.10,441.33,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,675.23,45.9,,,,,0,171.09,1250.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE LAPIDUS 8D THK10MM RESTORING WEDGE 5-14MM",SUP-PLP-3008,CDM,S27800098,LOCAL,0278,RC,,,both,,,10177.50,3053.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1183.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1183.64,8650.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 21MM 16.7MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-21MECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOVIVE BONE MARROW 2.5CC ALLOGRAFT SCAFFOLD",SUP-203102,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"HC Cath Swan Ganz Alsius",PX-E27200073,CDM,C1751,HCPCS,0272,RC,,,both,,,2820.40,846.12,"NOVANET [10819]",Novanet,,2115.3,75,,,,,0,328.01,2397.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKING COILS XL 30CM",SUP-RBYPCXL30,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 125CM 5FR JR6 CURVE ANGIOGRAPHIC PEBAX",SUP-7523-83,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.74,23.62,"CIGNA [10200]",Cigna,,53.54,68,,,,,0,9.16,66.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE 22-PIN SENSOR ENABLED DIAGNOSTIC CATHETER CABLE",SUP-D-AVSE-CBL22R,CDM,S27000186,LOCAL,0270,RC,,,both,,,1650.00,495,"PHCS [10601]",PHCS,,1155,70,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 55MM EVOLVE STAINLESS STEEL CANCELLOUS ELBOW",SUP-4983555N,CDM,C1713,HCPCS,0278,RC,,,both,,,785.70,235.71,"CIGNA [10200]","Cigna Open Access",,447.06,56.9,,1144.80,304.56,2275.09,66,91.38,667.85,"percent of total billed charges",
"SCR BONE 3.5MM 55MM EVOLVE STAINLESS STEEL CANCELLOUS ELBOW",SUP-4983555N,CDM,C1713,HCPCS,0278,RC,,,both,,,785.70,235.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,93.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,91.38,667.85,"percent of total billed charges",
"CMPNT PATELLAR LARGE 40MM AVON KNEE",SUP-6430-0-040,CDM,C1776,HCPCS,0278,RC,,,both,,,5561.40,1668.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2552.68,45.9,,,,,0,646.79,4727.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 15CM 180CM 20MM 10.5FR ESOPHAGEAL",SUP-G57355,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"AETNA [10100]","Aetna HMO/PPO",,13983.73,79.5,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 24MM 144CM 3MM CORONARY STENT EVEROLIMUS",SUP-H7493926124300,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE DOUBLE DIAMOND 1.2MM X 89MM COCR",SUP-KWCC-DD-12089,CDM,S27000186,LOCAL,0270,RC,,,both,,,400.20,120.06,"FIRST HEALTH [10303]","First Health",,320.16,80,,,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7609,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1974.78,28.62,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 455CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP110RUH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"MULTIPLAN [10600]",Multiplan,,10117.13,85,,,,,0,1384.26,10117.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRN5PL,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,10981.53,8986.79,12413.38,12,2014.9,14726.25,"percent of total billed charges",
"SYSTEM SPEEDBRIDGE FIXATION ACHILLES",SUP-AR-9928BCK-MIS,CDM,C1713,HCPCS,0278,RC,,,both,,,21134.93,6340.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2504.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2457.99,17964.69,"percent of total billed charges",
"ZIPWIRE STIFF .025IN ANGLED TIP BX 5",SUP-M0066802171,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 60MM 6FR 3MM 4FR BALLOON",SUP-H74939031306010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 45MM 2.5MM IJS AXIS",SUP-IJS-EAP-25450,CDM,C1713,HCPCS,0278,RC,,,both,,,2212.50,663.75,"NOVANET [10819]",Novanet,,1659.38,75,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis Be Ab",PX-302000147,CDM,86707,CPT,0302,RC,,,both,,,196.98,59.09,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.15,,"Fee schedule rate ($12.15). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,167.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 850CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP140RUH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"CIGNA [10200]","Cigna Local Plus",,3749.29,,,,,,,1384.26,10117.13,"percent of total billed charges",
"EXTR STONE 115CM 3FR 3.2FR 3 WIRE HELICAL OCCLUSIVE BASKET",SUP-G32733,CDM,S27200284,LOCAL,0272,RC,,,both,,,1662.75,498.82,"KAISER [10500]",Kaiser,,1114.04,67,,,,,0,193.38,1413.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCK AUGMENTATION NEXGEN G 5MM KNEE DISTAL PRECOAT ROTATE",SUP-00599003710,CDM,C1776,HCPCS,0278,RC,,,both,,,7289.16,2186.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3345.72,45.9,,,,,0,847.73,6195.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID COMPREHENSIVE FAST GUIDE VAULT",SUP-110027734,CDM,C1776,HCPCS,0278,RC,,,both,,,93594.00,28078.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,26786.6,28.62,,,,,0,10884.98,79554.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE PT VASCULAR 182CM 35CM .014IN STAINLESS STEEL",SUP-H74912161012,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR NEROSTIMLTR 15CM PRECISION M8",SUP-SC-9218-15,CDM,C1883,HCPCS,0278,RC,,,both,,,3525.00,1057.5,"CIGNA [10200]","Cigna Open Access",,2005.73,56.9,,,,,0,409.96,2996.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER QUICKPASS SUTURELASSO 90D SMALL STRAIGHT 7MM CANN",SUP-AR-6068-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CIGNA [10200]","Cigna Open Access",,774.3,56.9,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 24MM SEMIRIGID OPEN ANTERIOR SEG SEWING",SUP-5300M24,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3726,27,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.135,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETHRAL BARDEX IC 22FR FOLEY 2 WAY COUNCIL TIP 2",SUP-0196SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.25,42.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.54,120.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 14MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-1517-10-714,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"CIGNA [10200]",Cigna,,5917.44,40,,5873.17,5873.17,5873.17,"1 through 10",1720.5,12574.56,"percent of total billed charges",
"SCR BONE 4MM 36MM TITANIUM FULL THREAD CANNULATED",SUP-04.355.436,CDM,C1713,HCPCS,0278,RC,,,both,,,1848.23,554.47,"BLUE CROSS [10001]","Blue Cross HMO",,724.51,39.2,,957.42,156.86,7483.26,51,214.95,1571,"percent of total billed charges",
"SET PLATE 14MM 2.7MM TARSAL METATARSAL LOW PROFILE S1 PLATE",SUP-SK28,CDM,C1713,HCPCS,0278,RC,,,both,,,11730.00,3519,"PHCS [10601]",PHCS,,8211,70,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM TITANIUM STERNAL SELF DRILLING",SUP-04.501.110.01,CDM,C1713,HCPCS,0278,RC,,,both,,,854.96,256.49,"NOVANET [10819]",Novanet,,641.22,75,,,,,0,99.43,726.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 36MM AEQUALIS 12MM SHOULDER LATERALIZE REVERSE",SUP-DWD862,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"NOVANET [10819]",Novanet,,6771,75,,,,,0,1049.96,7673.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SMART 150MM 120CM 7MM LONG BILIARY NITINOL SELF EXPAND",SUP-C07150MB,CDM,C1876,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,919.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 35CM 14.5FR STD STRAIGHT POLYURETHANE PTFE HEMOSTAR",SUP-5833350,CDM,C1750,HCPCS,0278,RC,,,both,,,1633.80,490.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,193.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,190.01,1388.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCOPIC INSTR PUSHLOCK 17GA 2.9MM CANN DRILL NDL",SUP-AR-1923PK,CDM,C1713,HCPCS,0278,RC,,,both,,,1732.50,519.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1178.1,68,,,,,0,201.49,1472.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 8MMX8MMX6CM",SUP-TSB080806A,CDM,C1874,HCPCS,0278,RC,,,both,,,49140.00,14742,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13267.8,27,,,,,0,5714.98,41769,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.6CM NATRELLE BIOCELL P3.8CM MODERATE PROFILE",SUP-MSZ10390,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 20MM AZUR .018IN",SUP-45-482030,CDM,S27800098,LOCAL,0278,RC,,,both,,,7110.45,2133.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3263.7,45.9,,,,,0,826.95,6043.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC",832,MS-DRG,,,,,,,inpatient,,,22420.49,6726.15,"CIGNA [10200]","Cigna Local Plus",,7446.19,,"Fee schedule rate ($7,446.19). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,4476.13,17995.98,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8MM 70MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712870,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,1831.33,1831.33,1831.33,16,441.36,3225.75,"percent of total billed charges",
"EZETIMIBE 10 MG TABLET",RX-34153,CDM,,,0637,RC,60687-0373-11,NDC,both,1,UN,46.86,14.06,"KAISER [10500]",Kaiser,,31.4,67,,,,,0,5.45,39.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 55MM CD HORIZON LEGACY TITANIUM ANGLE REVERSE",SUP-75448555,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 26MM PERSONA VIVACIT-E ALL POLY KNEE STERILE",SUP-42-5402-000-26,CDM,C1776,HCPCS,0278,RC,,,both,,,5322.66,1596.8,"CIGNA [10200]","Cigna Open Access",,3028.59,56.9,,5302.19,4377.88,6578.61,27,619.03,4524.26,"percent of total billed charges",
"SHEATH 20.5IN 9.5MM TNLR POLYMER VASCULAR RADIOPAQUE SMOOTH",SUP-9009-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"PHCS [10601]",PHCS,,408.24,70,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 200MM 5.5MM VIPER 2 STRAIGHT TITANIUM MIS",SUP-186789200,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"SHEATH 27FR ENDOSCOPIC OUTER 2 STPCOCK ROTATE NONSTERILE",SUP-A22021A,CDM,C1894,HCPCS,0272,RC,,,both,,,10209.17,3062.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1209.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1187.33,8677.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TELESCOPE 7FR EXT CORONARY PERIPHERAL COMPATIBLE GUIDE",SUP-TELE7F,CDM,C1887,HCPCS,0272,RC,,,both,,,2767.50,830.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1137.44,41.1,,,,,0,321.86,2352.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 8MM KNEE XLK POSTERIOR LIPPED FIX BEARING PFC",SUP-158103108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"FIRST HEALTH [10303]","First Health",,8939.64,80,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 4X100 40CM SL",SUP-48004010P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"PHCS [10601]",PHCS,,687.49,70,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 60MM 20MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U20060090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Local Plus",,5537.25,53.5,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 9 SLOT LEFT TI",SUP-PHPF-S9L,CDM,C1713,HCPCS,0278,RC,,,both,,,18396.00,5518.8,"MULTIPLAN [10600]",Multiplan,,15636.6,85,,,,,0,2139.45,15636.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +23.5 DIOPTER +3.75 CYL BICONVEX 13MM 6MM",SUP-SN6AT6,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 12MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40012W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"NOVANET [10819]",Novanet,,4079.25,75,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD PLEXA PROMRI SD 65/18",SUP-402263,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS [10001]","Blue Cross HMO",,6731.42,39.2,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN JUDKINS LEFT 5 CURVE GUIDING",SUP-LA6JL50SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 28CM 8.5FR AMPLATZ RB PIGTAIL CURVE URETER AQ",SUP-G09711,CDM,C2625,HCPCS,0272,RC,,,both,,,1227.07,368.12,"FIRST HEALTH [10303]","First Health",,981.66,80,,,,,0,142.71,1043.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemo IV Push Sngl",PX-331000003,CDM,96409,CPT,0331,RC,,,both,,,732.91,219.87,"UHC [10700]","United Healthcare",,732.91,,"Per diem ($1,277).",,,,0,85.24,732.91,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MOTIV SCAFFOLD 3.5MMX60MM","SUP-930035-60 (360)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 80MM 4FR 4MM .018IN BALLOON",SUP-PCP040080130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,837.22,68,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE REFICIO CORTICAL DEMINERALIZED BONE MATRIX",SUP-27800518,CDM,C1713,HCPCS,0278,RC,,,both,,,6194.48,1858.34,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4212.25,68,,,,,0,720.42,5265.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.25 X 38 RX US",SUP-1804225-38,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 100MM 80CM 5MM 6FR .035IN BILIARY",SUP-G50112,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"PHCS [10601]",PHCS,,4263,70,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 7 5MM KNEE AOX CRUCIATE RETAIN ROTATE PLATFORM",SUP-151630705,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]",Cigna,,5250.9,40,,5873.17,5873.17,5873.17,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"COIL EMBOLIZATION 12CM 7MM AXIUM 3D NEUROVASCULAR FRAME V01",SUP-FC-7-12-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,13765.50,4129.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3716.69,27,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE 9MM 230CM 2.4MM EXACTO COLD BRAID WIRE CLEAN CUT",SUP-BX00711115,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.70,28.71,"KAISER [10500]",Kaiser,,64.12,67,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 14MM CANNULATED LARGE QUICK COUPLING FLEXIBLE",SUP-03.033.004,CDM,S27200284,LOCAL,0272,RC,,,both,,,4724.98,1417.49,"AETNA [10100]","Aetna HMO/PPO",,3756.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,549.52,4016.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT GLENOID UNIVERS REVERS POROUS OD30 MM SHOULDER MOD",SUP-AR-9561-30P,CDM,C1776,HCPCS,0278,RC,,,both,,,4029.60,1208.88,"NOVANET [10819]",Novanet,,3022.2,75,,,,,0,468.64,3425.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,inpatient,,,81965.04,24589.51,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,13282.67,,"Case rate ($12,710.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,802.74, add-ons for qualifying new technology services are included. If operating cost exceeds $44,842.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,274.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,818.35. The transfer operating threshold is the transfer adjustment factor * $11,802.74 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $892.34. The transfer capital threshold is the transfer adjustment factor * $892.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,59825.52,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL CHARLOTTE STAINLESS STEEL CANNULATED 4.3 MM SCR",SUP-44112003,CDM,S27200284,LOCAL,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Extractable Nuclear Ag",PX-302000039,CDM,86235,CPT,0302,RC,,,both,,,365.75,109.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,63.66,,,,,,,0.37,310.89,"fee schedule",
"VIABAHN BX BALLOON EXP ENDO 8MMX59MM 7FR 135CMCATH HEPARIN",SUP-BXB085902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"PHCS [10601]",PHCS,,13653.36,70,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL BABCOCK 14IN TISSUE",SUP-50-1026,CDM,S27200284,LOCAL,0272,RC,,,both,,,840.86,252.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,385.95,45.9,,,,,0,97.79,714.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 100CM 4FR 2-5-2MM SPACE STD F CURVE",SUP-112442S,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,952.49,41.1,,,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VERRATA VASCULAR FLAT 300CM 3CM .014IN GLYDX PTFE",SUP-10300,CDM,C1769,HCPCS,0272,RC,,,both,,,4140.00,1242,"MULTIPLAN [10600]",Multiplan,,3519,85,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rheumatoid Factor Quant",PX-302000091,CDM,86431,CPT,0302,RC,,,both,,,250.80,75.24,"BLUE CROSS [10001]","Blue Cross PPO",,0.25,.1,,,,,0,0.25,213.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 7.5CM 5MM LEGEND MIDAS REX SYMMETRICAL",SUP-75BA50T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1326.78,398.03,"CIGNA [10200]","Cigna Open Access",,754.94,56.9,,,,,0,154.3,1127.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER FLEXIVA TRAC TIP 200UM FLEXSHIELD HOLMIUM",SUP-M0068403960,CDM,S27200284,LOCAL,0272,RC,,,both,,,3351.98,1005.59,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1538.56,45.9,,,,,0,389.84,2849.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 111MM COLLAR ACTIS DUOFIX 8 12/14 STANDARD OFFS",SUP-101011080,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"MULTIPLAN [10600]",Multiplan,,25904.81,85,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.6MM 7MM CENTERPIECE TITANIUM SPINE SELF TAP STAB",SUP-853-467,CDM,C1713,HCPCS,0278,RC,,,both,,,443.23,132.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",51.55,376.75,"percent of total billed charges",
"CATH AXS VECTA 46 160CM .046IN ASPIRATION INTERMEDIATE",SUP-INC-11814-160,CDM,S27200284,LOCAL,0272,RC,,,both,,,9911.85,2973.55,"NOVANET [10819]",Novanet,,7433.89,75,,,,,0,1152.75,8425.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 21CM 7MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120721,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAP TRACTION LARGE FINGER",SUP-AR-1616-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,237.51,71.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,161.51,68,,,,,0,27.62,201.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE U -PERSONA STEM EXTENSION",SUP-CAP-U-S,CDM,C1776,HCPCS,0278,RC,,,both,,,4830.00,1449,"FIRST HEALTH [10303]","First Health",,3864,80,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 90CM 100MM 2MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186201090,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 52MM BIO-MOORE II ENDO II HIP ACETABULAR",SUP-12-139028,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"NOVANET [10819]",Novanet,,2094.75,75,,,,,0,324.83,2374.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 16CM 10MM .0135IN MICRUSFRAME MICRO",SUP-MFR141016,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"AETNA [10100]","Aetna HMO/PPO",,9446.03,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 115MM 6MM PRIMARY TURON",SUP-520-01-006,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"BLUE CROSS [10001]","Blue Cross HMO",,3104.64,39.2,,5311.50,4717.44,5388.59,31,921.1,6732,"percent of total billed charges",
"HEAD REAMER 13.5MM RIA 2 STERILE",SUP-03.404.023S,CDM,S27200284,LOCAL,0272,RC,,,both,,,6005.07,1801.52,"CIGNA [10200]","Cigna Open Access",,3416.88,56.9,,,,,0,698.39,5104.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 8CM 5FR PIGTAIL CURVE PANCREATIC",SUP-M00537040,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"NOVANET [10819]",Novanet,,479.44,75,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 106MM STAINLESS STEEL 4.5MM SCR 4 HOLE PRECONTOURED",SUP-239.985,CDM,C1713,HCPCS,0278,RC,,,both,,,10064.75,3019.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1192.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1170.53,8555.04,"percent of total billed charges",
"CATH ARCADIA 20MM 10GA BALLOON DILATATION HIGH PRESSURE",SUP-ARC20ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,5978.16,1793.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,708.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 3.5MM 0-50MM STD THREAD SURGICAL SYMPHONY NONSTERILE",SUP-202033335,CDM,S27200284,LOCAL,0272,RC,,,both,,,1856.25,556.87,"CIGNA [10200]","Cigna Local Plus",,993.09,53.5,,,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 11MM KII FIOS FIRST ENTRY ADVANCE",SUP-CFF34,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA [10200]",Cigna,,124.24,68,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-04010,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"NOVANET [10819]",Novanet,,6722.33,75,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROTHERAPY VITALSTIM",SUP-966240,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.76,34.13,"NOVANET [10819]",Novanet,,85.32,75,,,,,0,13.23,96.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lymph Vessel X-Ray Trunk",PX-323000040,CDM,75805,CPT,0320,RC,,,both,,,6091.05,1827.31,"UHC [10700]","United Healthcare",,6091.05,,,,,,,339.44,6091.05,"fee schedule",
"STEM FEMORAL CITATION TMZF HA 4 SHORT HIP LEFT",SUP-6265-5204,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6593.93,27,,,,,0,2840.27,20758.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 800ML P6CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-8004BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5347.50,1604.25,"AETNA [10100]","Aetna HMO/PPO",,4251.26,79.5,,,,,0,621.91,4545.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 24MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0286,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]",Cigna,,644.44,68,,1831.33,1831.33,1831.33,16,110.22,805.55,"percent of total billed charges",
"TIP BILICHEK CALIBRATION PLASTIC DISPOSABLE ANALZR INFANT",SUP-B800-50,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.91,15.57,"CIGNA [10200]",Cigna,,35.3,68,,,,,0,6.04,44.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 5 KNEE CEMENT REVISION ROTATE PLATFORM",SUP-150660005,CDM,C1776,HCPCS,0278,RC,,,both,,,22629.60,6788.88,"FIRST HEALTH [10303]","First Health",,18103.68,80,,,,,0,2631.82,19235.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRI-SIL 22FR SHORT ROUND STD URETHRAL SILICONE",SUP-70522L,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.74,29.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.25,82.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 12MM DCP STAINLESS STEEL CORTICAL SELF",SUP-200.812,CDM,C1713,HCPCS,0278,RC,,,both,,,365.40,109.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",42.5,310.59,"percent of total billed charges",
"INSRT TIBIAL 5 16MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-1517-10-516,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6080.17,41.1,,6417.48,6417.48,6417.48,"1 through 10",1720.5,12574.56,"percent of total billed charges",
"INSRT ARTICULAR 7-8 18MM KNEE POSTERIOR STABILIZE HIGH",SUP-71421526,CDM,C1776,HCPCS,0278,RC,,,both,,,10774.35,3232.3,"MULTIPLAN [10600]",Multiplan,,9158.2,85,,,,,0,1253.06,9158.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 250ML 20% MANNITOL PLASTIC FLEXIBLE CNTNR",SUP-07715-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.54,39.46,"FIRST HEALTH [10303]","First Health",,105.23,80,,,,,0,15.3,111.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN IRRIGATION 30GA ANTERIOR CHMBR",SUP-110304,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.86,14.36,"FIRST HEALTH [10303]","First Health",,38.29,80,,,,,0,5.57,40.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER ENDOSCOPIC 20MM 3MM TREVO XP PROVUE MICROCATHETER",SUP-80051,CDM,C1757,HCPCS,0272,RC,,,both,,,49249.94,14774.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,20241.73,41.1,,,,,0,5727.77,41862.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 49MM STAINLESS STEEL 2.4MM SCR 7X2 HOLE 2 COLUMN",SUP-02.111.720,CDM,C1713,HCPCS,0278,RC,,,both,,,3748.43,1124.53,"KAISER [10500]",Kaiser,,2511.45,67,,,,,0,435.94,3186.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 3CMX6MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-9-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"CIGNA [10200]","Cigna Open Access",,829.6,56.9,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rem Auton Alg Insln Calc Setup",PX-761000090,CDM,0740T,HCPCS,0761,RC,,,both,,,127.00,38.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,52.2,41.1,,,,,0,14.77,127,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER CHOCOLATE 150CM 80MM 3MM .014IN BALLOON DILATATION",SUP-CB1415030080OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"UHC [10700]","United Healthcare",,3625.19,63.3,,,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 26CM 5FR URETERAL AQ FIRM POS NO GWIRE",SUP-G23398,CDM,C2617,HCPCS,0278,RC,,,both,,,535.41,160.62,"BLUE CROSS [10001]","Blue Cross HMO",,209.88,39.2,,,,,0,62.27,455.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 150CM 6FR .035IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145363190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CIGNA [10200]","Cigna Local Plus",,604.52,,,,,,,131.41,960.46,"percent of total billed charges",
"CAP CONSTRUCT TOTAL SHOULDER/ WITH AUGMENTED GLENOID","SUP-CON ANATOMIC AG",CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"AETNA [10100]","Aetna HMO/PPO",,23790.38,79.5,,10981.53,8986.79,12413.38,12,3480.28,25436.25,"percent of total billed charges",
"BLADE SHAVER 11CM 2.9MM XPS INFERIOR TURBINATE STERILE",SUP-1882940,CDM,S27200284,LOCAL,0272,RC,,,both,,,2349.00,704.7,"KAISER [10500]",Kaiser,,1573.83,67,,,,,0,273.19,1996.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 2-0 UR-6 27IN MONOFILAMENT ABSORBABLE",SUP-N878H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]",Cigna,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FUZEFIX MAX FT OD3 MM CALIBRATE CANNULATED NO",SUP-CD-FT-1030,CDM,S27000186,LOCAL,0270,RC,,,both,,,2130.00,639,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,977.67,45.9,,,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 12D 13CM 4.5MM CURVED RADENOID TONSIL SURGICAL ADULT",SUP-1884008,CDM,S27200284,LOCAL,0272,RC,,,both,,,1782.00,534.6,"CIGNA [10200]","Cigna Open Access",,1013.96,56.9,,,,,0,207.25,1514.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 80MM 75CM 5MM VASCULAR METAL SUPERFICIAL",SUP-H74939293058070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2216.97,45.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006175282190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"MULTIPLAN [10600]",Multiplan,,1075.57,85,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 2-0 4IN ENDO STITCH V-LOC POLYBUTESTER LOAD",SUP-VLOCN204L,CDM,S27200284,LOCAL,0272,RC,,,both,,,275.27,82.58,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,32.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.01,233.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER +3 CYL MODIFIED C BICONVEX 13MM 6MM","SUP-ZCT300 21.0",CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,98.74,28.62,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 48MM 32MM ALTRX HIP",SUP-122132448,CDM,C1776,HCPCS,0278,RC,,,both,,,9241.20,2772.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1095.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1074.75,7855.02,"percent of total billed charges",
"PATELLA: AFFIXIUM ANANTOMIC, AFFIXIUM DOME",SUP-OSC382436,CDM,C1776,HCPCS,0278,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,5302.19,4377.88,6578.61,27,0.01,0.01,"percent of total billed charges",
"GRAFT BONE FEMORAL SHAFT ALLOGRAFT FROZEN 50MM 10+ MM",SUP-450410,CDM,S27800098,LOCAL,0278,RC,,,both,,,4785.84,1435.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,567.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,556.59,4067.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC30ST-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,19530.00,5859,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2314.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 12MM 3MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012407-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVISOR VL SENSOR ENABLED CIRCULAR MAPPING STEERABLE",SUP-D-AVSE-DF10-V1525,CDM,C1732,HCPCS,0272,RC,,,both,,,11730.00,3519,"NOVANET [10819]",Novanet,,8797.5,75,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 67.5MM KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-183110,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"BLUE CROSS [10001]","Blue Cross HMO",,8492.95,39.2,,5311.50,4717.44,5388.59,31,2519.72,18415.85,"percent of total billed charges",
"CAGE SPINAL CERVICAL 7X14X12MM 7DEG LORDOTIC PEEK COHERE",SUP-4071427P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2850.39,45.9,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID LOWER REDUCTION KIT- SHORT, REGULAR",SUP-25101117,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 UR-6 27IN BRAID COATED VIOLET ABSORBABLE",SUP-VCP602H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.28,41.1,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET MULTIAXIAL 4 PK STERILE 559200008",SUP-559200008,CDM,C1713,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross PPO",,1622.88,39.2,,957.42,570.23,957.42,28,481.48,3519,"percent of total billed charges",
"LEAD PACING 78CM 5.3FR 5.1FR .014-.018IN OFFSET S LEFT",SUP-459878,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"PHCS [10601]",PHCS,,3924.9,70,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 57MM TITANIUM 2.4MM SCREW 8 HOLE BONE RIGHT HAND NONST",SUP-449.916,CDM,C1713,HCPCS,0278,RC,,,both,,,3706.50,1111.95,"FIRST HEALTH [10303]","First Health",,2965.2,80,,,,,0,431.07,3150.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT EXTERNAL FIXATION 105MM FEMORAL NECK SYSTEM STERILE",SUP-04.168.305S,CDM,C1713,HCPCS,0278,RC,,,both,,,2435.70,730.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,288.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",283.27,2070.35,"percent of total billed charges",
"BLADE SHAVER YELLOW 4.5MM DYONICS BONECUTTER FULL RADIUS",SUP-7206011,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,213.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ACCLARENT INFLATION SE TUBE PRESSURE GAUGE VACUUM",SUP-SEID,CDM,S27200284,LOCAL,0272,RC,,,both,,,603.86,181.16,"CIGNA [10200]","Cigna Local Plus",,323.07,53.5,,,,,0,70.23,513.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET",RX-28384,CDM,,,0250,RC,27808-0037-01,NDC,both,1,UN,12.54,3.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 30CM 150CM 7FR .038IN 3CM BLADDER LOOP",SUP-M006155245170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,165.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 125CM 5FR .038IN BERN CURVE ANGIOGRAPHIC",SUP-512538BER-H,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,139.45,41.1,,,,,0,39.46,288.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 56MM 32MM MARATHON HIP",SUP-121932056,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"CIGNA [10200]","Cigna Local Plus",,3870.54,53.5,,5372.07,4581.20,7242.98,23,841.39,6149.45,"percent of total billed charges",
"SCR BONE SPINE MODULAR TULIP NONSTERILE MAS PLIF",SUP-7070000,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROPOFOL 10 MG/ML INTRAVENOUS EMULSION",RX-11150,CDM,J2704,HCPCS,0636,RC,43598-0549-52,NDC,both,100,ML,169.01,50.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,114.93,68,,,,,0,10.49,143.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PLUS PROFILE SILICONE",SUP-SCLP-220,CDM,C1789,HCPCS,0278,RC,,,both,,,8004.00,2401.2,"AETNA [10100]","Aetna HMO/PPO",,6363.18,79.5,,,,,0,930.87,6803.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 40MM HIP MODULAR OXINIUM STERILE",SUP-71342340,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,5311.50,4717.44,5388.59,31,2014.9,14726.25,"percent of total billed charges",
"SCISSOR SURGICAL LITTLER SUTURE DELICATE BLUNT SERRATED STAI",SUP-60-1868,CDM,S27200284,LOCAL,0272,RC,,,both,,,233.51,70.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.16,198.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.4 X 3.0 X 30MM TWO-STEP HAMMER TOE IMPLANT",SUP-204-30-030,CDM,C1713,HCPCS,0278,RC,,,both,,,10460.40,3138.12,"KAISER [10500]",Kaiser,,7008.47,67,,,,,0,1216.54,8891.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SIGNAFUSE BIPHASIC CALCIUM PHOSPHATE BIOACTIVE",SUP-SGF-150,CDM,C1713,HCPCS,0278,RC,,,both,,,12972.00,3891.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3502.44,27,,,,,0,1508.64,11026.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTERIAL LINE 4.45CM 20GA ODSEC 22GA .018IN RADIAL",SUP-AK-04020-SPC,CDM,S27200284,LOCAL,0272,RC,,,both,,,221.85,66.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.8,188.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 28MM 145CM 4MM CORONARY STENT",SUP-1145400-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER/DIVIDER LAPAROSCOPIC 44CM 5MM LIGASURE XP MARYLAND",SUP-LXMJ44L,CDM,S27200284,LOCAL,0272,RC,,,both,,,4041.68,1212.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1855.13,45.9,,,,,0,470.05,3435.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC 2XL 27-31IN 19.75-22IN KNEE LEFT COMPACT",SUP-24960,CDM,S27000186,LOCAL,0270,RC,,,both,,,2058.38,617.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1399.7,68,,,,,0,239.39,1749.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 6.5MM 6FR BILIARY NITINOL BRAID SELF",SUP-S-65-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"FIRST HEALTH [10303]","First Health",,7314,80,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH XXL 120CM 40MM 18MM BALLOON DILATATION PERIPHERAL LARGE",SUP-M001145580,CDM,C1725,HCPCS,0272,RC,,,both,,,1709.63,512.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,702.66,41.1,,,,,0,198.83,1453.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 6MM 6FR 2.5MM .07",SUP-H7493926706250,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROPOFOL 10 MG/ML IV EMULSION (ANESTHESIA OSM) 100 ML",RX-408978,CDM,J2704,HCPCS,0636,RC,63323-0269-65,NDC,both,100,ML,181.08,54.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22.8,,,,,,,10.49,153.92,"fee schedule",
"HC Progr Dev Eval Icd Mult Lead",PX-480000055,CDM,93284,CPT,0480,RC,,,both,,,409.40,122.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,48.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.61,409.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE 4X4CM AMNIOFIX AMNIOTIC MEMB DURABLE",SUP-APS-5440,CDM,Q4433,HCPCS,0636,RC,,,both,,,10101.60,3030.48,"FIRST HEALTH [10303]","First Health",,8081.28,80,,,,,0,247.92,8586.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hsg Si",PX-320000126,CDM,74740,CPT,0320,RC,,,both,,,1418.02,425.41,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,168.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.57,1205.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC App Splint Fgr Dynamic",PX-450000195,CDM,29131,CPT,0450,RC,,,both,,,830.00,249,"FIRST HEALTH [10303]","First Health",,664,80,,,,,0,67.13,830,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ptca Pulm Valve",PX-480000047,CDM,92990,CPT,0481,RC,,,both,,,16969.00,5090.7,"NOVANET [10819]",Novanet,,12726.75,75,,,,,0,1973.49,16969,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 STD 10MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS7S10R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"PHCS [10601]",PHCS,,7273.98,70,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transplant Eval Renal Day 1 New Pt",PX-761000011,CDM,99205,CPT,0761,RC,,,both,,,2483.00,744.9,"PHCS [10601]",PHCS,,1738.1,70,,,,,0,2.48,2483,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN READIGRAFT CRYOSKIN 125SQ CM FIBROBLAST",SUP-SK-NM,CDM,Q4433,HCPCS,0636,RC,,,both,,,2925.15,877.54,"CIGNA [10200]",Cigna,,1989.1,68,,,,,0,247.92,2486.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Bn Length Study",PX-320000180,CDM,77073,CPT,0320,RC,,,both,,,383.34,115,"CIGNA [10200]","Cigna Local Plus",,70.93,,,,,,,44.58,325.84,"fee schedule",
"ADPTR CABLE DISPLAY MODE TO POWER",SUP-103871,CDM,Q0486,HCPCS,0274,RC,,,both,,,2025.00,607.5,"KAISER [10500]",Kaiser,,1356.75,67,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +25.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.255,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 4IN .04IN THERAHONEY SQUARE HONEY FOAM STERILE",SUP-MNK1344,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.21,25.56,"CIGNA [10200]","Cigna Open Access",,48.48,56.9,,,,,0,9.91,72.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 26MM SIMUPLUS FLEXIBLE STERILE LATEX FREE",SUP-7700FB26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Open Access",,4391.85,33.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 3CM 1MM GALAXY G3 MINI STRETCH",SUP-GLM910030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]","Cigna Local Plus",,3742.77,31.5,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION SUPERORDERABLE",RX-408816,CDM,,,0250,RC,00143-9506-01,NDC,both,10,ML,36.24,10.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.21,30.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BTTRY SURGICAL DRIVER PACK STERILE DISPOSABLE BTTRY POWERED",SUP-05.000.007.01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3829.50,1148.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,453.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,445.37,3255.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 74MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 3X5",SUP-241.051,CDM,C1713,HCPCS,0278,RC,,,both,,,2270.10,681.03,"AMERIGROUP MEDICAID [20100]",Amerigroup,,269.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",264.01,1929.59,"percent of total billed charges",
"GWIRE ARROW ADVANCER VASCULAR 23 5/8IN .032IN MARK SPRING",SUP-AW-04432,CDM,C1769,HCPCS,0272,RC,,,both,,,100.92,30.28,"KAISER [10500]",Kaiser,,67.62,67,,,,,0,11.74,85.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 4CM 7FR ZIMMON PIGTAIL CURVE PANCREATIC",SUP-G22041,CDM,C2625,HCPCS,0272,RC,,,both,,,1328.40,398.52,"FIRST HEALTH [10303]","First Health",,1062.72,80,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS ACCESSPLUS LARGE BORE",SUP-K12-11413,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.97,31.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.09,88.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 4.75MM LONGITUDE II STRAIGHT CCM",SUP-1475006090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"CAP CONSTRUCT TOTAL KNEE JOURNEY II CRUCIATE RETAINING COCR",SUP-71701672,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS [10001]","Blue Cross PPO",,7408.8,39.2,,3949.44,3949.44,3949.44,"1 through 10",2198.07,16065,"percent of total billed charges",
"MITRACLIP G4 SYSTEM ONE (1) STEERABLE GUIDE CATHETER SGC0701",SUP-CDS0706-NTW,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 80CM 125CM 9MM VASCULAR HIWIRE NITINOL",SUP-G43788,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,495.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PCMKR CRD THK6MM SM 50X47MM","SUP-PM2240 CELL",CDM,C1785,HCPCS,0275,RC,,,both,,,9324.00,2797.2,"BLUE CROSS [10001]","Blue Cross HMO",,3655.01,39.2,,,,,0,1084.38,7925.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE COAGULATION 220CM 2.3MM ARC SMART ARCONNECT QUICK",SUP-G11-400-04,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL BECK COOLEY LARGE MEDIUM CURVE STRAIGHT 6IN",SUP-55-5037,CDM,S27200284,LOCAL,0272,RC,,,both,,,1191.92,357.58,"AETNA [10100]","Aetna HMO/PPO",,947.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,138.62,1013.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 22CM 3.5MM BALLOON DILATATION",SUP-U81503H22,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH SHORT 5MM HANCOCK HANDLE AORTIC",SUP-APU450,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,197.18,68,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MONARCH 13IN INFLATION POLYCARBONATE 20ML DIGITAL",SUP-IN2330,CDM,S27200284,LOCAL,0272,RC,,,both,,,504.14,151.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,231.4,45.9,,,,,0,58.63,428.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK CATH 36CM 14.5FR PALINDROME TAL VENATRAC VASCULAR 2",SUP-8888119364P,CDM,C1750,HCPCS,0278,RC,,,both,,,2649.68,794.9,"CIGNA [10200]","Cigna Open Access",,1507.67,56.9,,,,,0,308.16,2252.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 3CM 4.8FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175254050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,306.45,28.62,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036123060,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 11 STD KNEE LEFT POSTERIOR STABILIZE PERSONA",SUP-42500807001,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"UHC [10700]","United Healthcare",,18290.9,63.3,,8601.07,8395.67,8601.07,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"(EVAL)SAPIEN M3 VALVE EPTFE 29MM",SUP-9880TFX29M,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"NOVANET [10819]",Novanet,,149625,75,,,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIB 69CM 4.7FR OMNIASECURE MRI SURESCAN 1 COIL",SUP-3930M69,CDM,C1777,HCPCS,0278,RC,,,both,,,31468.50,9440.55,"CIGNA [10200]","Cigna Open Access",,10541.95,33.5,,,,,0,3659.79,26748.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SUCTION 10FR 15IN",SUP-50-9845,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.71,33.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,45.91,41.1,,,,,0,12.99,94.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 5-0 S-14 18IN 2 ARM BRAID COATED VIOLET",SUP-J571G,CDM,S27200284,LOCAL,0272,RC,,,both,,,160.62,48.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,19.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.68,136.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BENTSON 26CM 15CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175253060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,116,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 8MM INTERLOCK FIBERED IDC DETACHABLE",SUP-M001361580,CDM,S27800098,LOCAL,0278,RC,,,both,,,2400.00,720,"PHCS [10601]",PHCS,,1680,70,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 5 38IN BRAID TIES MULTISTRAND LOWER KNOT",SUP-AR-7210,CDM,S27200284,LOCAL,0272,RC,,,both,,,347.13,104.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,159.33,45.9,,,,,0,40.37,295.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPLICATIONS OF TREATMENT WITH MCC",919,MS-DRG,,,,,,,inpatient,,,40813.41,12244.02,"AMBETTER EXCHANGE  [11102]",Ambetter,,11356.56,,"Case rate ($11,356.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,545.34, add-ons for qualifying new technology services are included. If operating cost exceeds $43,585.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,179.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,559.28. The transfer operating threshold is the transfer adjustment factor * $10,545.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $797.28. The transfer capital threshold is the transfer adjustment factor * $797.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",20404.31,20404.31,20404.31,"1 through 10",7561,40813.41,other,"INPATIENT DRG"
"IMPL BREAST 335CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-335,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"MULTIPLAN [10600]",Multiplan,,6422.18,85,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 24FR STERILE DISPOSABLE COAGULATE",SUP-27050NP-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1459.48,437.84,"UHC [10700]","United Healthcare",,923.85,63.3,,,,,0,169.74,1240.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 18MM 135CM 7MM 3.3-3.5FR 6FR LOW",SUP-1011505-18,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"AETNA [10100]","Aetna HMO/PPO",,5008.5,79.5,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 30MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75448530,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"CATH ADVANCE PLIAFORM STARCAST 80CM 4CM 12MM BALLOON",SUP-G52379,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PHCS [10601]",PHCS,,671.84,70,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER VASCULAR 80CM 10FR VENA CAVA OPTEASE RETRIEVABLE",SUP-466C220F,CDM,C1880,HCPCS,0278,RC,,,both,,,1134.00,340.2,"NOVANET [10819]",Novanet,,850.5,75,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GERALD 9.25IN TISSUE SERRATE DRSG",SUP-55-9004,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.91,101.97,"MULTIPLAN [10600]",Multiplan,,288.92,85,,,,,0,39.53,288.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 125CM 5FR VTK CURVE ANGIOGRAPHIC",SUP-G47042,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"AETNA [10100]","Aetna HMO/PPO",,167.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"VALVE AORTIC 17.5MM 25MM MOSAIC ULTRA CINCH PORCINE",SUP-305U225,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7843.31,28.62,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 9MM ZERO-P STD LORDOTIC PEEK-OPTIMA STERILE",SUP-04.647.129S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"BLUE CROSS [10001]","Blue Cross PPO",,4868.64,39.2,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELIANCE DF4 NON-GORE, PASSIVE FIXATION SINGLE COIL 59 CM, I",SUP-0262,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"FIRST HEALTH [10303]","First Health",,12144,80,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB PCL SUBST SZ.5X12MM",SUP-2142-1-1212,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,414.32,3028.13,"percent of total billed charges",
"COROENT XL-XW, 1026X55MM 10",SUP-6210155,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,9384.48,39.2,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV",RX-9799,CDM,J3480,HCPCS,0258,RC,00264-7634-00,NDC,both,1000,ML,100.65,30.19,"CIGNA [10200]","Cigna Local Plus",,0.31,,,,,,,0.02,85.55,"fee schedule",
"INSRT TIBIAL 1 11MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530G111,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CIGNA [10200]","Cigna Open Access",,4954.63,56.9,,5302.19,4377.88,6578.61,27,1012.7,7401.47,"percent of total billed charges",
"INTRODUCER PACING LEAD ACUITY 8FR",SUP-667462-001,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CORDIS PALMAZ 30MM 10MM XL BILIARY STAINLESS STEEL",SUP-P3110,CDM,C1876,HCPCS,0278,RC,,,both,,,4278.00,1283.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2909.04,68,,,,,0,497.53,3636.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 44-36MM COMPREHENSIVE +3MM STD SHOULDER E1",SUP-EP-115394,CDM,C1776,HCPCS,0278,RC,,,both,,,8853.60,2656.08,"FIRST HEALTH [10303]","First Health",,7082.88,80,,,,,0,1029.67,7525.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 35MM ACCOLADE TMZF 4.5 HIP",SUP-6021-4535,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"NOVANET [10819]",Novanet,,11736.9,75,,,,,0,1820,13301.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 5.0 MM X 80 MM X 130 CM",SUP-IPU05008013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"UHC [10700]","United Healthcare",,5110.21,63.3,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 94MM STAINLESS STEEL 3.5MM SCR 4 HOLE LCP BONE LEFT",SUP-239.955,CDM,C1713,HCPCS,0278,RC,,,both,,,9233.17,2769.95,"NOVANET [10819]",Novanet,,6924.88,75,,,,,0,1073.82,7848.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 3.5MM OASYS OCCIPITOCERVICOTHORACIC SPINE",SUP-48552050,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2024.19,45.9,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE AUTOCAP RX LOCKING BIOPSY CAP OLYMPUS COMPATIBLE ERCP",SUP-M00545101,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.46,44.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,100.27,68,,,,,0,17.15,125.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 16X6MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2406,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"AETNA [10100]","Aetna HMO/PPO",,7679.7,79.5,,1521.93,481.35,16760.95,30,1123.46,8211,"percent of total billed charges",
"PROTEAN FRAGMENT PLATE CMC",SUP-PRT-CMC-025,CDM,C1713,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,850.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,834.57,6099.6,"percent of total billed charges",
"SET INTRO PEEL-AWAY PERCUTANEOUS STAINLESS STEEL 2 KNOB",SUP-G04495,CDM,C1892,HCPCS,0272,RC,,,both,,,818.10,245.43,"MULTIPLAN [10600]",Multiplan,,695.39,85,,,,,0,95.15,695.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 26GA 1.9FR 50CM FIRST PICC 1 LUMEN SILICONE",SUP-384222,CDM,C1751,HCPCS,0272,RC,,,both,,,665.01,199.5,"FIRST HEALTH [10303]","First Health",,532.01,80,,,,,0,77.34,565.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT GRAFTON DEMINERALIZED BONE MATRIX PUTTY JAR",SUP-T43103,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"CIGNA [10200]",Cigna,,1530,68,,1831.33,1831.33,1831.33,16,261.68,1912.5,"percent of total billed charges",
"SYSTEM SPEEDBRIDGE SWIVELOCK FIBERTAPE 4.75MM FIXATION 2",SUP-AR-2600SBS-8,CDM,C1713,HCPCS,0278,RC,,,both,,,13179.00,3953.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3771.83,28.62,,,,,0,1532.72,11202.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 11MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P411,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,990.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LATERAL LUMBAR ANCHOR 22MM",SUP-1219.0022,CDM,C1713,HCPCS,0278,RC,,,both,,,3277.50,983.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,388.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",381.17,2785.88,"percent of total billed charges",
"STEM FEMORAL 121MM TYPE 1 TAPERLOC MICROPLASTY PPS 133D 18",SUP-51106180,CDM,C1776,HCPCS,0278,RC,,,both,,,28567.35,8570.2,"KAISER [10500]",Kaiser,,19140.12,67,,,,,0,3322.38,24282.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC",244,MS-DRG,,,,,,,inpatient,,,93641.20,28092.36,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,11996.87,,"Case rate ($11,212.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,411.13, add-ons for qualifying new technology services are included. If operating cost exceeds $43,450.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,169.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,424.90. The transfer operating threshold is the transfer adjustment factor * $10,411.13 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.13. The transfer capital threshold is the transfer adjustment factor * $787.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,11212.03,52771.77,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 4.5MM CORONARY STENT",SUP-H7493941820450,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 4-0 SC-1 18IN MONOFILAMENT YELLOWISH TAN",SUP-1824H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTICA NEO HF-T DF1 HIGH ENERGY PROMRI TI AND CLS",SUP-429553,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8949.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE AMNIOBAND PLACENTAL ALLOGRAFT DEHYDRATE",SUP-WC3040,CDM,S27800098,LOCAL,0278,RC,,,both,,,5180.18,1554.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,602.45,4403.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM COCR SPINE MULTIAXIAL CANNULATED",SUP-54840016535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3923.76,41.1,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 4-0 RB-1 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-U203H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP 31.75CM DA VINCI XI ENDOWRIST 8MM SMALL WIDE",SUP-470401,CDM,S27000186,LOCAL,0270,RC,,,both,,,1400.82,420.25,"AETNA [10100]","Aetna HMO/PPO",,1113.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.92,1190.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM TRIATHLON 6 RIGHT MEDIAL LEFT LATERAL TOTAL",SUP-5546-A-602,CDM,C1776,HCPCS,0278,RC,,,both,,,4252.25,1275.67,"NOVANET [10819]",Novanet,,3189.19,75,,,,,0,494.54,3614.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 75MM LCP STAINLESS STEEL MEDIAL PROXIMAL",SUP-212.224,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"CIGNA [10200]","Cigna Local Plus",,467.15,53.5,,3978.14,359.25,3978.14,24,101.55,742.2,"percent of total billed charges",
"SUT POLYSORB SURGIWIP 0 ST-4 48IN BRAID COATED VIOLET",SUP-ELW-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.04,51.91,"PHCS [10601]",PHCS,,121.13,70,,,,,0,20.12,147.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP BARDEX IC COMPLETE CARE 18FR",SUP-A304718A,CDM,S27200284,LOCAL,0272,RC,,,both,,,241.60,72.48,"CIGNA [10200]","Cigna Local Plus",,129.26,53.5,,,,,0,28.1,205.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28MMX12MM X-PAC PARALLEL",SUP-EI2448P,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14IN 28FR VENOUS 90D OPEN LIGHTHOUSE 1 STAGE",SUP-TF028L90,CDM,S27200284,LOCAL,0272,RC,,,both,,,277.18,83.15,"AETNA [10100]","Aetna HMO/PPO",,220.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.24,235.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 64MM HIP MULTIHOLE TRITANIUM TRIDENT II H",SUP-709-04-64H,CDM,C1776,HCPCS,0278,RC,,,both,,,17958.91,5387.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2128.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2088.62,15265.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ON-Q PAINBUSTER SILVERSOAKER 5IN DRUG DELIVERY DEHP",SUP-PM020-A,CDM,S27200305,LOCAL,0272,RC,,,both,,,458.78,137.63,"MULTIPLAN [10600]",Multiplan,,389.96,85,,,,,0,53.36,389.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 24MM 42MM SHOULDER COMPREHENSIVE VERSA-DIAL",SUP-113036,CDM,C1776,HCPCS,0278,RC,,,both,,,9089.00,2726.7,"FIRST HEALTH [10303]","First Health",,7271.2,80,,,,,0,1057.05,7725.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 9MM KNEE LEFT BICRUCIATE STABILIZE XLPE",SUP-74027241,CDM,C1776,HCPCS,0278,RC,,,both,,,20478.15,6143.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8191.26,40,,,,,0,2381.61,17406.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 80CM 5FR SOS OMNI 1 CURVE ANGIOGRAPHIC VISCERAL",SUP-10720401,CDM,C1887,HCPCS,0272,RC,,,both,,,209.32,62.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,142.34,68,,,,,0,24.34,177.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anes Spec Proc Fee General",PX-E27200002,CDM,E27200002,LOCAL,0272,RC,,,both,,,3074.28,922.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,357.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,357.54,2613.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 15ML 1.7-7MM DEMINERALIZED CANCELLOUS",SUP-420035,CDM,C1713,HCPCS,0278,RC,,,both,,,2543.63,763.09,"BLUE CROSS [10001]","Blue Cross HMO",,997.1,39.2,,957.42,156.86,7483.26,51,295.82,2162.09,"percent of total billed charges",
"SCR BONE 32MM 4MM LCP CORTICAL PERIARTICULAR TIBIAL",SUP-02.204.032,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,282.36,28.62,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 66X42X14MM NEXGEN LCCK 3-4 C-D STD KNEE",SUP-00599403014,CDM,C1776,HCPCS,0278,RC,,,both,,,16256.40,4876.92,"MULTIPLAN [10600]",Multiplan,,13817.94,85,,,,,0,1890.62,13817.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING RTRCTR LONE STAR NORYL PLASTIC 2 PEEL POUCH SELF RETAIN",SUP-3308G,CDM,S27200284,LOCAL,0272,RC,,,both,,,642.25,192.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,436.73,68,,,,,0,74.69,545.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X40 40CM SL",SUP-48006004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"PHCS [10601]",PHCS,,687.49,70,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCK AUGMENTATION ASCENT MAXIM 83MMX16MM KNEE TIBIA RIGHT",SUP-141796,CDM,C1776,HCPCS,0278,RC,,,both,,,9255.66,2776.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1096.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1076.43,7867.31,"percent of total billed charges",
"MITRACLIP NTR CDS (CLIP DELIVERY SYSTEM) PRIMARY MR CLINICAL",SUP-CDS0604-NTR,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20263.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 6MM 40MM 14MM LCP STAINLESS STEEL PARTIAL",SUP-206.040,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"BLUE CROSS [10001]","Blue Cross HMO",,107.26,39.2,,957.42,156.86,7483.26,51,31.82,232.58,"percent of total billed charges",
"ZIDOVUDINE 10 MG/ML ORAL SYRUP",RX-11693,CDM,,,0250,RC,08888-8883-21,NDC,both,10,ML,14.78,4.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.72,12.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE MONORAIL 150CM 220MM 3MM BALLOON DILATATION",SUP-H74939185302210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEPTIC ARTHRITIS WITH MCC",548,MS-DRG,,,,,,,inpatient,,,44990.58,13497.17,"CIGNA [10200]","Cigna Local Plus",,19924.96,,"Fee schedule rate ($19,924.96). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,44990.58,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 11CM INFLATABLE NARROW",SUP-EN8911,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,17944.74,28.62,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP070150150 PLUS US D7L150UL1500",SUP-PCP070150150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"NOVANET [10819]",Novanet,,923.4,75,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thyroglobulin Ab",PX-302000171,CDM,86800,CPT,0302,RC,,,both,,,331.47,99.44,"KAISER [10500]",Kaiser,,222.08,67,,,,,0,0.01,281.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32X23X12MM CRESCENT SOVEREIGN 12D SMALL PEEK",SUP-7967212,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"NOVANET [10819]",Novanet,,21262.5,75,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM PYRENEES SPINE CERVICAL SELF STARTING",SUP-201-14014D,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"BLUE CROSS [10001]","Blue Cross HMO",,552.72,39.2,,957.42,156.86,7483.26,51,163.98,1198.5,"percent of total billed charges",
"NDL TRANSEPTAL 71CM 19-22GA NRG CURVE C1 RADIOFREQUENCY",SUP-NRG-E-HF-71-C1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3562.50,1068.75,"FIRST HEALTH [10303]","First Health",,2850,80,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA ARTERIAL SOFT-FLOW 3/8 IN L14 IN OD21 FR ANGLE TIP N",SUP-6384,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,230.71,41.1,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAC-LOC 40CM 16CM 10.2FR DRNG ULTRATHANE HYDROPHILIC",SUP-G13353,CDM,C1729,HCPCS,0272,RC,,,both,,,801.82,240.55,"MULTIPLAN [10600]",Multiplan,,681.55,85,,,,,0,93.25,681.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840006535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"MULTIPLAN [10600]",Multiplan,,8114.82,85,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 1.5IN 18GA 10% PVP IODINE 1% LIDOCAINE CSR",SUP-181027,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.34,39.4,"CIGNA [10200]","Cigna Local Plus",,70.27,53.5,,,,,0,15.27,111.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 60CM 7MM THORAX KNIT SOFT FLEXIBLE SEAL",SUP-M002020952070,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR IMPLANTABLE RESTOREADVANCED SURESCAN RECHRGR",SUP-97754,CDM,C1820,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 12CM 10FR DUODENAL BEND BILIARY",SUP-M00534350,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"BLUE CROSS [10001]","Blue Cross PPO",,427.06,39.2,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 11MM TAS 12D LARGE",SUP-2312-0211,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON DISECT LAPAROSCOPIC PDB SPACEMAKER EXTRA VIEW",SUP-OMS-PDBS2,CDM,C1727,HCPCS,0272,RC,,,both,,,2061.53,618.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1401.84,68,,,,,0,239.76,1752.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP PULSED LAVAGE INTERPULSE IRRIGATION PUMP SUCTION FEMORAL",SUP-210008000,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.44,28.93,"AETNA [10100]","Aetna HMO/PPO",,76.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.22,81.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SPECIMEN RETRIEVAL 120CM 3FR HOOK PRONG GRASP",SUP-M0063701190,CDM,S27200284,LOCAL,0272,RC,,,both,,,1376.11,412.83,"UHC [10700]","United Healthcare",,871.08,63.3,,,,,0,160.04,1169.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT EVEROLIMUS ELUTING CORONARY STENT SYSTEM 4.5",SUP-1804450-12,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"FIBER LASER ACCUTRAC 200UM FLEXSHIELD HOLMIUM FLEXIBLE",SUP-M0068404112,CDM,S27200284,LOCAL,0272,RC,,,both,,,3284.22,985.27,"UHC [10700]","United Healthcare",,2078.91,63.3,,,,,0,381.95,2791.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 38MM TI",SUP-MTC-37380-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,848.23,68,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 50MM 28MM XLPE HIP",SUP-71334950,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"UHC [10700]","United Healthcare",,7056.02,63.3,,8601.07,8395.67,8601.07,"1 through 10",1296.39,9474.91,"percent of total billed charges",
"CATH LAUNCHER 8FR .09IN JUDKINS RIGHT 3.5 CURVE GUIDING",SUP-LA8JR35SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,150.18,41.1,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lithotripsy Bi",PX-360000050,CDM,50590,CPT,0360,RC,,,both,,,31371.91,9411.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4656,,"Case rate ($4,656). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3648.55,26666.12,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ca Ionized POC",PX-301000125,CDM,82330,CPT,0301,RC,,,both,,,202.95,60.88,"PHCS [10601]",PHCS,,142.07,70,,,,,0,0.2,172.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SKIN PURPLE 10CM 15GA SMARTCLIP LITE 3-4MM SOFT",SUP-SMARTCLIPLT-PURP-10,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"AETNA [10100]","Aetna HMO/PPO",,2146.5,79.5,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ORTHOPEDIC 5MM 10MM 5MM END INTERNAL THREAD HEX TALON",SUP-HTN-10-C05,CDM,C1713,HCPCS,0278,RC,,,both,,,1320.30,396.09,"PHCS [10601]",PHCS,,924.21,70,,,,,0,153.55,1122.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE RTI ANTERIOR TIBIALIS TENDON ALLOGRAFT",SUP-453017,CDM,C1762,HCPCS,0278,RC,,,both,,,13800.00,4140,"BLUE CROSS [10001]","Blue Cross PPO",,5409.6,39.2,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM EVOLVE STAINLESS STEEL CORTICAL ELBOW",SUP-4973510N,CDM,C1713,HCPCS,0278,RC,,,both,,,785.70,235.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,93.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",91.38,667.85,"percent of total billed charges",
"INSRT TIBIAL 5 11MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G511,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1109.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 20CM 6FR .038",SUP-M006192130120,CDM,C2617,HCPCS,0278,RC,,,both,,,1528.96,458.69,"MULTIPLAN [10600]",Multiplan,,1299.62,85,,,,,0,177.82,1299.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR 49MM MULTIPOLAR HIP METAL STERILE",SUP-500104900,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 150MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.452,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.21,68,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 140MM 120CM 14MM BILIARY VENA CAVA OTW DELIVERY",SUP-G57452,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1685.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDURANT II AUI 3-PIECE CASE",SUP-ENDURANTIIAUI3,CDM,S27800098,LOCAL,0278,RC,,,both,,,108300.00,32490,"FIRST HEALTH [10303]","First Health",,86640,80,,,,,0,12595.29,92055,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 12MM LCP STAINLESS STEEL CORTEX T6 STARDRIVE",SUP-201.362.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,49.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,48.16,352,"percent of total billed charges",
"CATH PENUMBRA SYSTEM MAX SEPERATOR 139CM 143CM 6-4.3FR .041",SUP-4MAXC,CDM,C1757,HCPCS,0272,RC,,,both,,,11247.00,3374.1,"MULTIPLAN [10600]",Multiplan,,9559.95,85,,,,,0,1308.03,9559.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON THORACIC LEFT TITANIUM ANGLE BLADE",SUP-7541189,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,3978.14,359.25,3978.14,24,348.9,2550,"percent of total billed charges",
"SPACER SPINAL 14X11X5MM CORNERSTONE PSR PEEK LUMBAR",SUP-6277541,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"NOVANET [10819]",Novanet,,5008.82,75,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE SURGICAL 5MM TIP DISECT XRAY DETECTABLE KITTNER",SUP-E7500,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.10,24.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.55,69.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 96L/4D PLA 25MM 9MM FEMUR ACL",SUP-239025M5,CDM,C1713,HCPCS,0272,RC,,,both,,,2563.58,769.07,"UHC [10700]","United Healthcare",,1622.75,63.3,,5023.51,2672.93,6679.78,18,1053.63,1622.75,"percent of total billed charges",
"HEAD HUMERAL 19MM 52MM SHOULDER SIMPLICITI",SUP-7122875,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"CIGNA [10200]",Cigna,,6812.92,68,,5873.17,5873.17,5873.17,"1 through 10",1165.21,8516.15,"percent of total billed charges",
"PATCH DURAL 14X8CM DURA-GUARD CRANIAL BOVINE PERICARDIUM",SUP-DG0814SN,CDM,,,0278,RC,,,both,,,6314.67,1894.4,"BLUE CROSS [10001]","Blue Cross PPO",,6.31,.1,,,,,0,6.31,5367.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM GORILLA NONSTERILE R3CON NON LOCK PLATE",SUP-P50-453-3520,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Local Plus",,520.02,53.5,,3978.14,359.25,3978.14,24,113.04,826.2,"percent of total billed charges",
"PROBE ARTHROSCOPIC MEASUREMENT 60D 220MM",SUP-AR-4070-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP SUCTION DISPOSABLE LUCAS 2",SUP-11576-000046,CDM,S27000186,LOCAL,0270,RC,,,both,,,391.33,117.4,"KAISER [10500]",Kaiser,,262.19,67,,,,,0,45.51,332.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 20X15CM VENTRAL HERNIA OPTIMIZED",SUP-PCO2015X,CDM,C1781,HCPCS,0278,RC,,,both,,,4231.00,1269.3,"CIGNA [10200]","Cigna Open Access",,2407.44,56.9,,11235.02,819.42,11235.02,"1 through 10",492.07,3596.35,"percent of total billed charges",
"LENS IOL +20 DIOPTER UV ABSORBENT CLAREON AUTONOME",SUP-CCA0T0.200,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,345.41,28.62,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 5.5MM DYONICS HIP ABRADER HIGH VISIBILITY",SUP-72203127,CDM,S27200284,LOCAL,0272,RC,,,both,,,550.80,165.24,"NOVANET [10819]",Novanet,,413.1,75,,,,,0,64.06,468.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM VIPER 2 LORDOTIC TITANIUM MIS",SUP-186788040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +24 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.240,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETHRAL LUBRI-SIL IC 14FR FOLEY 2 WAY SILICONE 5ML",SUP-1758SI14,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.35,24.4,"NOVANET [10819]",Novanet,,61.01,75,,,,,0,9.46,69.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.812,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"MULTIPLAN [10600]",Multiplan,,201.14,85,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR SILICONE RADIOPAQUE EXTERNAL RETENTION RING",SUP-8170-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.81,228.54,"KAISER [10500]",Kaiser,,510.41,67,,,,,0,88.6,647.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch Unlstd Proc",PX-750000192,CDM,31899,CPT,0750,RC,,,both,,,3924.00,1177.2,"CIGNA [10200]","Cigna Open Access",,3924,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,456.36,3924,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP LIMIT HOLE POROUS RANAWAT/BURSTEIN",SUP-11-106048,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"PHCS [10601]",PHCS,,4926.6,70,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 1.5MM WIRE PASS STERILE",SUP-1608002059,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 11FR .144IN 25CM ROBUST VALVE SPLITTABLE",SUP-PLSX-2511,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTLINK INTERNALBRACE IMPL",SUP-AR-1588AL-CP2,CDM,C1713,HCPCS,0278,RC,,,both,,,14163.98,4249.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1647.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1647.27,12039.38,"percent of total billed charges",
"LENS IOL 10 D +7.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200075,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"BLUE CROSS [10001]","Blue Cross HMO",,400.08,39.2,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM SAPIEN HEART TRANSCATHETER RETROFLEX 3",SUP-9100RF323A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"BLUE CROSS [10001]","Blue Cross HMO",,72618,39.2,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 5.5MM RELINE LORDOTIC TITANIUM NONSTERILE",SUP-14355060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROMORPHONE (PF) 0.2 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN",RX-123269,CDM,J1171,HCPCS,0636,RC,08888-8884-37,NDC,both,50,ML,1155.80,346.74,"MULTIPLAN [10600]",Multiplan,,982.43,85,,,,,0,11.66,982.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SOAKER CATH ON-Q PAINBUSTER 4ML/HR 2.5IN DRUG",SUP-PM015-A,CDM,C9804,HCPCS,0272,RC,,,both,,,1227.36,368.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,142.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,142.74,1043.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 28MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0311,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,112.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,110.22,805.55,"percent of total billed charges",
"CATH INFINITI THRULUMEN 100CM 4FR .042IN AMPLATZ RIGHT 1",SUP-538441,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"CIGNA [10200]","Cigna Local Plus",,47.89,53.5,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 120MM 2MM BALLOON DILATATION RAPID",SUP-47520120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"MULTIPLAN [10600]",Multiplan,,1356.35,85,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP BILICHEK CALIBRATION PLASTIC DISPOSABLE ANALZR INFANT",SUP-B800-50,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.91,15.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,21.34,41.1,,,,,0,6.04,44.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000065,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1101.6,68,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 58CM .013IN BRADY SFT",SUP-6046,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR 10X5CM ENCAP TECHNOLOGY BIOLINK BOVINE",SUP-C0510,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 35CM INJECTION PROTECTIVE CAP RIGID",SUP-NBI035,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"NOVANET [10819]",Novanet,,455.63,75,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 25MM 5MM 4.4FR AUTOTOME PRO RX 44 CANNULATED",SUP-M00584380,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPN NC 20MM 2.5MM BALLOON DILATATION PLATINUM IRIDIUM",SUP-250-020-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL RUSSIAN 6IN TISSUE",SUP-07-1515,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.21,22.86,"CIGNA [10200]","Cigna Open Access",,43.36,56.9,,,,,0,8.86,64.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR NEROSTIMLTR PRECISION MONTAGE 16 CONTACT MRI",SUP-SC-1200,CDM,C1820,HCPCS,0278,RC,,,both,,,95760.00,28728,"BLUE CROSS [10001]","Blue Cross PPO",,37537.92,39.2,,,,,0,11136.89,81396,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN AL1 CURVE GUIDING CORONARY",SUP-LA6AL10,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"FIRST HEALTH [10303]","First Health",,313.2,80,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nucleotidase 5",PX-301000341,CDM,83915,CPT,0301,RC,,,both,,,134.44,40.33,"CIGNA [10200]","Cigna Open Access",,24.53,,,,,,,0.01,114.27,"fee schedule",
"LENS IOL 0 D +22 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.220,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 50MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.550,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"KAISER [10500]",Kaiser,,734.6,67,,,,,0,127.51,931.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BISACODYL 10 MG RECTAL SUPPOSITORY",RX-1080,CDM,,,0637,RC,00574-7050-12,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,3.35,53.5,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX10MM VANGUARD E1 KNEE CRUCIATE RETAINING",SUP-EP183440,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"BLUE CROSS [10001]","Blue Cross HMO",,5077.45,39.2,,5311.50,4717.44,5388.59,31,1506.4,11009.78,"percent of total billed charges",
"SPACER ALLOGRAFT 14X9X6MM ARCH PARALLEL FREEZE DRY OPEN DOOR",SUP-15114,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Stent & Ather Cmplx Init",PX-361000735,CDM,37294,CPT,0361,RC,,,both,,,21707.51,6512.25,"FIRST HEALTH [10303]","First Health",,17366.01,80,,,,,0,21.71,18451.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22-24X27-32X9MM LUMINARY CC BICONVEX SPINE",SUP-6809,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9520.16,28.62,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM 7MM S-ROM ZTT 18F LARGE HIP POROUS",SUP-550526,CDM,C1776,HCPCS,0278,RC,,,both,,,6466.32,1939.9,"BLUE CROSS [10001]","Blue Cross HMO",,2534.8,39.2,,5311.50,4717.44,5388.59,31,752.03,5496.37,"percent of total billed charges",
"HEAD FEMORAL +10MM 22MM HIP C TAPER COCR LFIT",SUP-06-2210,CDM,C1776,HCPCS,0278,RC,,,both,,,4188.30,1256.49,"FIRST HEALTH [10303]","First Health",,3350.64,80,,,,,0,487.1,3560.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL +0MM 3.5MM HIGH OFFSET SHOULDER REVERSE",SUP-DWF520,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1194.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM 7MM S-ROM ZTT 18F LARGE HIP POROUS",SUP-550526,CDM,C1776,HCPCS,0278,RC,,,both,,,6466.32,1939.9,"CIGNA [10200]","Cigna Open Access",,3679.34,56.9,,5302.19,4377.88,6578.61,27,752.03,5496.37,"percent of total billed charges",
"QUARTET LEAD DOUBLE BEND, 75 C","SUP-CD3369-40C CELL",CDM,C1882,HCPCS,0278,RC,,,both,,,44764.00,13429.2,"CIGNA [10200]",Cigna,,17905.6,40,,,,,0,5206.05,38049.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 6.9FR HELIX ATRIUM VENTRICLE RIGHT BIPOLAR",SUP-5086MRI58,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"KAISER [10500]",Kaiser,,1495.78,67,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE VASCULAR STRAIGHT FLOPPY SPRING COIL 300CM 3CM",SUP-H74912116011,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 10FR 20CM HYDROPHILIC RADIOPAQUE STERILE",SUP-G10207,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET DIL HYDROPLUS GWIRE .038IN 6-16FR URETERAL UD3000",SUP-M0062401000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1200.58,360.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Methylenedioxyamphetamines",PX-301000551,CDM,80359,CPT,0301,RC,,,both,,,90.00,27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.09,90,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 17CM 11CM LOCKING HUB ENHANCED TIP GEOMETRY",SUP-070011,CDM,C1894,HCPCS,0272,RC,,,both,,,69.17,20.75,"NOVANET [10819]",Novanet,,51.88,75,,,,,0,8.04,58.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 10CM 14.5MM EXCLUDER GORE CONTRALATERAL",SUP-PLC141000,CDM,C1874,HCPCS,0278,RC,,,both,,,27997.20,8399.16,"BLUE CROSS [10001]","Blue Cross HMO",,10974.9,39.2,,9776.84,9776.84,9776.84,"1 through 10",3256.07,23797.62,"percent of total billed charges",
"STENT VISI-PRO 27MM 135CM 9MM 30MM BILIARY STAINLESS STEEL",SUP-PXB35-09-27-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2969.56,68,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX79MM 8FR 80CMCATH HEPARIN",SUP-BXB097901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"MULTIPLAN [10600]",Multiplan,,18196.29,85,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER GUIDING ADULT 8FR L100CM CORONARY BLUE NYLON PTFE X",SUP-5888100,CDM,C1725,HCPCS,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 0D F HIP PRIMARY X3 TRIDENT",SUP-623-00-36F,CDM,C1776,HCPCS,0278,RC,,,both,,,6879.60,2063.88,"MULTIPLAN [10600]",Multiplan,,5847.66,85,,,,,0,800.1,5847.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myotomy Lwr Esophgl Transoral",PX-750000220,CDM,43497,CPT,0750,RC,,,both,,,6450.00,1935,"AMERIGROUP MEDICAID [20100]",Amerigroup,,764.33,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,750.14,6450,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 350ML P3.9CM MODERATE PLUS PROFILE HIGH",SUP-350-3501BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1500.83,28.62,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myeloperoxidase Antibody",PX-302000222,CDM,86021,CPT,0302,RC,,,both,,,646.00,193.8,"AETNA [10100]","Aetna HMO/PPO",,513.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,549.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM MITRAL VALVE STIFFNESS COMPOSITE LOW",SUP-638RL32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"NOVANET [10819]",Novanet,,9832.5,75,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 6-9 C-D KNEE RIGHT TIBIA",SUP-42521400512,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"KAISER [10500]",Kaiser,,5410.76,67,,,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 4FR POWERPICC 2 LUMEN PICC LINE LATEX FREE",SUP-S1274108D4,CDM,C1751,HCPCS,0272,RC,,,both,,,1972.95,591.88,"FIRST HEALTH [10303]","First Health",,1578.36,80,,,,,0,229.45,1677.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN IRRIGATION 25MM 19GA BISHOP-HARMON 30D STAINLESS STEEL",SUP-E4922,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.74,53.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,73.87,41.1,,,,,0,20.9,152.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 CURVE PLUS 15MM KNEE XLK FIX BEARING SIGMA",SUP-970473,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"FIRST HEALTH [10303]","First Health",,8939.64,80,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICKSTICK 25CM 10FR LOOP DRNG FLEXIMA HYDROPHILIC",SUP-M001271470,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 1IN 19GA ANGLE DOWN INFUSION 2 LUMEN PORT WITHOUT Y",SUP-0651910,CDM,S27200284,LOCAL,0272,RC,,,both,,,54.64,16.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.35,46.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sensor Pulse Ox Peds",PX-E27000153,CDM,E27000153,LOCAL,0270,RC,,,both,,,110.55,33.16,"KAISER [10500]",Kaiser,,74.07,67,,,,,0,12.86,93.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemiluminescent Assay",PX-301000138,CDM,82397,CPT,0301,RC,,,both,,,222.30,66.69,"NOVANET [10819]",Novanet,,166.73,75,,,,,0,0.01,188.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 40MM 120CM 12MM .079IN LARGE",SUP-SERB65-12-40-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"FIRST HEALTH [10303]","First Health",,4452,80,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTDG ENDOSCOPIC INJECTOR II NDL",SUP-CAT01857,CDM,S27200284,LOCAL,0272,RC,,,both,,,1830.00,549,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1244.4,68,,,,,0,212.83,1555.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Arc Panel",PX-302000185,CDM,86870,CPT,0302,RC,,,both,,,228.80,68.64,"PHCS [10601]",PHCS,,160.16,70,,,,,0,0.01,228.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 2.5CM 10CM GWIRE DIL RADIOPAQUE KINK",SUP-RSB512,CDM,C1894,HCPCS,0272,RC,,,both,,,217.50,65.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET ENDOSCOPIC INSTR MYOSURE SEAL HYSTEROSCOPE OUTFLOW",SUP-40-902,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA2-17-75-5.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,9177.00,2753.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM NAVIFLEX 202.5CM 7FR DELIVERY RAPID EXCHANGE CATH",SUP-M00533560,CDM,C1887,HCPCS,0272,RC,,,both,,,667.20,200.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CESAREAN SECTION WITHOUT STERILIZATION WITH MCC",786,MS-DRG,,,,,,,inpatient,,,52281.03,15684.31,"AETNA [10100]","Aetna HMO/PPO",,,,"Payment is accumulated by procedure count. Procedure 1, Case rate ($14,076). Procedures 2 - 4, Per diem ($0). Procedures 5 - 999, Per diem ($6,063).",,,,0,,,other,"IP CSECTION Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 6FR AR1 CURVE GUIDING NYLON CORONARY",SUP-LA6AR10A,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"UHC [10700]","United Healthcare",,231.3,63.3,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SOAKER CATH ON-Q PAINBUSTER 4ML/HR 2.5IN DRUG",SUP-PM015-A,CDM,C9804,HCPCS,0272,RC,,,both,,,1227.36,368.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,563.36,45.9,,,,,0,142.74,1043.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 440CC",SUP-RSZ-MPX-440S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PENCIL 10FT VALLEYLAB NONSTERILE",SUP-E2515HS-NSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.90,17.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.62,48.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL 11MM 2 KNEE ALL POLYETHYLENE CONDYLAR STABILIZE",SUP-5534-A-211,CDM,C1776,HCPCS,0278,RC,,,both,,,13872.45,4161.73,"KAISER [10500]",Kaiser,,9294.54,67,,,,,0,1613.37,11791.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 15MM 3MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG30015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"NOVANET [10819]",Novanet,,2025,75,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 2.5CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-24-2.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"NOVANET [10819]",Novanet,,584.3,75,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNAP(R) CARTRIDGE - 125 MM HG - 10 IN A CASE",SUP-SNPA125,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"UHC [10700]","United Healthcare",,646.04,63.3,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT-S CERVICAL 5D ALLOGRAFT 11MM",SUP-3W5011,CDM,S27800098,LOCAL,0278,RC,,,both,,,6216.90,1865.07,"CIGNA [10200]",Cigna,,4227.49,68,,,,,0,723.03,5284.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION MRI PLASTIC SILICONE 9.6FR 1 LUMEN",SUP-602640,CDM,C1788,HCPCS,0278,RC,,,both,,,1458.00,437.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,417.28,28.62,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFINITY TOTAL ANKLE SYSTEM TALAR DOME TALAR DOME SZ 4",SUP-33630024,CDM,C1776,HCPCS,0278,RC,,,both,,,30819.60,9245.88,"UHC [10700]","United Healthcare",,19508.81,63.3,,8601.07,8395.67,8601.07,"1 through 10",3584.32,26196.66,"percent of total billed charges",
"GWIRE ASAHI PROWATER VASCULAR STRAIGHT 180CM 3CM .014IN",SUP-AGH146000,CDM,C1769,HCPCS,0272,RC,,,both,,,769.50,230.85,"MULTIPLAN [10600]",Multiplan,,654.08,85,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA NATURAL TIBIA 5D F KNEE RIGHT STEM",SUP-42532007502,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"AETNA [10100]","Aetna HMO/PPO",,8692.32,79.5,,10981.53,8986.79,12413.38,12,1271.59,9293.68,"percent of total billed charges",
"(EVAL) 42MM TF IMPLANT","SUP-INTPDVL42FG APOLLO",CDM,S62400003,LOCAL,0624,RC,,,both,,,256500.00,76950,"CIGNA [10200]","Cigna Open Access",,145948.5,56.9,,,,,0,29830.95,218025,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CITATION TMZF HA 4 SHORT HIP RIGHT",SUP-6265-5214,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"NOVANET [10819]",Novanet,,18316.46,75,,,,,0,2840.27,20758.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 500MM 5.5MM RELINE STRAIGHT TITANIUM NONSTERILE",SUP-15355500,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"INSRT TIBIAL 3-4 9MM KNEE XLPE POSTERIOR STABILIZE LEGION",SUP-71453246,CDM,C1776,HCPCS,0278,RC,,,both,,,14831.55,4449.46,"NOVANET [10819]",Novanet,,11123.66,75,,,,,0,1724.91,12606.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIB 74CM 4.7FR OMNIASECURE MRI SURESCAN 1 COIL",SUP-3930M74,CDM,C1777,HCPCS,0278,RC,,,both,,,31468.50,9440.55,"PHCS [10601]",PHCS,,22027.95,70,,,,,0,3659.79,26748.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 95MM 5.5MM CREO STRAIGHT TITANIUM MIS NONSTERILE",SUP-1134.5095,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"PARICALCITOL 2 MCG/ML INTRAVENOUS SOLUTION",RX-31688,CDM,J2501,HCPCS,0636,RC,00074-4637-01,NDC,both,1,ML,100.65,30.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.76,,,,,,,2.21,85.55,"fee schedule",
"HOLDER 8IN STARDUST CURVE DELICATE JAW ROUND HANDLE",SUP-278103,CDM,S27200284,LOCAL,0272,RC,,,both,,,2069.85,620.95,"UHC [10700]","United Healthcare",,1310.22,63.3,,,,,0,240.72,1759.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SPRAY 100MM COSEAL SEAL 2 SPRAY HEAD 2 LUMEN CNCT HOSE",SUP-0600021,CDM,S25000001,LOCAL,0250,RC,,,both,,,540.38,162.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC",064,MS-DRG,,,,,,,inpatient,,,42920.19,12876.06,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL AMPLATZ PTFE POLYETHYLENE SET RADIOPAQUE 2030CM",SUP-G57459,CDM,C1726,HCPCS,0272,RC,,,both,,,1917.75,575.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.0MM X 12.0MM",SUP-492001212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BUTTON 1.2CM 14FR RADIOPAQUE LOW PROFILE TAPER DISTAL TIP",SUP-0120-14-1.2,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE NC PLUS 15MM 2.25MM BALLOON DILATATION STERILE",SUP-222-153-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT MARDIS 22CM 6FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251310,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS [10001]","Blue Cross PPO",,496.03,39.2,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cannula Inner Trach",PX-E27200045,CDM,E27200045,LOCAL,0272,RC,,,both,,,32.47,9.74,"KAISER [10500]",Kaiser,,21.75,67,,,,,0,3.78,27.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM DELTAXSFT 10 COIL DETACHABLE",SUP-DLX100406,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"KAISER [10500]",Kaiser,,6065.38,67,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Meckel Divert",PX-341000021,CDM,78290,CPT,0341,RC,,,both,,,1730.12,519.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,904.43,,,,,,,201.21,1470.6,"fee schedule",
"LENS IOL +12.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.125,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,197.05,28.62,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SPINAL 6IN 20GA BD QUINCKE ANESTHESIA STERILE LATEX FREE",SUP-405211,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.24,15.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.19,45.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)MARKER SKIN PINK 7.5CM SOFT TISSUE DELIVERY SYSTEM STE",SUP-SMARTCLIPLT-PNK-7.5,CDM,A4648,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA [10200]","Cigna Local Plus",,1404.38,53.5,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 75MM STAINLESS STEEL SELF TAP VARIABLE ANGLE",SUP-42.231.275,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,919.73,68,,,,,0,157.3,1149.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +20.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.205,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BONE VOID FILLER - SYTHETIC 50MM X 10MM X 5MM - 2 STRIPS",SUP-BF2-50X10-05,CDM,C1713,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"PHCS [10601]",PHCS,,3670.8,70,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mcg Interphase Insitu 25",PX-311000072,CDM,88274,CPT,0311,RC,,,both,,,473.00,141.9,"CIGNA [10200]",Cigna,,93.24,,,,,,,0.01,402.05,"fee schedule",
"HC CT Lumbar Spine W/WO Cntrst",PX-352000016,CDM,72133,CPT,0352,RC,,,both,,,4152.30,1245.69,"KAISER [10500]",Kaiser,,2782.04,67,,,,,0,405,3529.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY DIALYSIS 20CM 12FR MAHURKAR 3 LUMEN CURVE EXT HIGH",SUP-8888101003HP,CDM,C1752,HCPCS,0272,RC,,,both,,,995.43,298.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,117.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,115.77,846.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 26MM 2MM DCP SMALL BONE STAINLESS STEEL SELF",SUP-201.896,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"CIGNA [10200]","Cigna Local Plus",,377.36,53.5,,3978.14,359.25,3978.14,24,82.03,599.55,"percent of total billed charges",
"IMPL BREAST 350ML P3.9CM MODERATE PLUS PROFILE HIGH",SUP-350-3501BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,621.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",609.88,4457.4,"percent of total billed charges",
"BURR SURGICAL 7.5CM 3MM LEGEND FLUTE LONG BALL HEAD",SUP-75BA30L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1328.40,398.52,"UHC [10700]","United Healthcare",,840.88,63.3,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16015545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1110.3,8114.82,"percent of total billed charges",
"SCR BONE 5.5MM 20MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.220,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"PHCS [10601]",PHCS,,2058,70,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 20MM 6FR 4MM .07IN BALLOON",SUP-H7493918920400,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,233.04,41.1,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 11CM GREEN HUB HEMOSTASIS VALVE PRELUDE",SUP-PSI-6F-11,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.8,64.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 CURVE PLUS 8MM KNEE XLK FIX BEARING SIGMA",SUP-970480,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3017.13,27,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000095,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 8GA 6IN JAMSHIDI BONE MARROW STERILE LATEX FREE",SUP-EJC6008,CDM,S27200284,LOCAL,0272,RC,,,both,,,377.67,113.3,"MULTIPLAN [10600]",Multiplan,,321.02,85,,,,,0,43.92,321.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Perfusion Ven Fem 28fr",PX-E27200346,CDM,E27200346,LOCAL,0272,RC,,,both,,,1185.80,355.74,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,487.36,41.1,,,,,0,137.91,1007.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 60MM 2MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186200610,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BLUE 53MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103553000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"MULTIPLAN [10600]",Multiplan,,2604.67,85,,,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC PULSED LAVAGE 14MM VERSAJET II PLUS 45D DISPOSABLE",SUP-66800044,CDM,S27200284,LOCAL,0272,RC,,,both,,,4278.00,1283.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1963.6,45.9,,,,,0,497.53,3636.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK HEATING 24X15IN THERMAL-PAK OVER COTTON CANVAS NYLON",SUP-561728,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACCESSORY 6216A003 DLVY SYS LEFT VENTRI",SUP-6216A003,CDM,C1887,HCPCS,0272,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENOBARBITAL SODIUM 130 MG/ML VIAL FOR IM USE",RX-411684,CDM,J2560,HCPCS,0636,RC,00641-0477-21,NDC,both,1,ML,372.40,111.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,70.33,,,,,,,7.76,316.54,"fee schedule",
"SCR BONE 5MM 32MM TAN X25 LOCK STERILE LIGHT GREEN 4.2MM",SUP-04.045.032TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 22.9CM .035IN KIRSCHNER STAINLESS STEEL BOTH",SUP-00018604600,CDM,C1713,HCPCS,0278,RC,,,both,,,119.63,35.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,13.91,101.69,"percent of total billed charges",
"(EVAL) LAMINAR IMPLANT SIZE (10MM)",SUP-FG-6037,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 115CM 7FR 2-8-2MM SPACE D CURVE MAPPING",SUP-D710DRP10RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,441.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 111MM 24MM ZENITH FLEX Z-TRAK 2 BRANCH",SUP-G48409,CDM,C1874,HCPCS,0278,RC,,,both,,,48686.90,14606.07,"MULTIPLAN [10600]",Multiplan,,41383.87,85,,,,,0,5662.29,41383.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 54MM 32MM MARATHON",SUP-121932454,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"FIRST HEALTH [10303]","First Health",,6488.76,80,,,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ICD-DR DDMB1D4 EVERA MRI XT IS-1/DF4 US",SUP-DDMB1D4,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16670.16,41.1,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULE RESUSCITATION RED BROSELOW O2 DELIVERY PEDIATRIC",SUP-7700RAW,CDM,S27200284,LOCAL,0272,RC,,,both,,,160.95,48.28,"CIGNA [10200]","Cigna Local Plus",,86.11,53.5,,,,,0,18.72,136.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 12X3.5IN ATS CYL PORT STERILE DISPOSABLE",SUP-60707510200,CDM,S27200284,LOCAL,0272,RC,,,both,,,150.82,45.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.54,128.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 8.5-10 MEDIUM MALE BEIGE CANVAS RUBBER",SUP-2041-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.42,14.23,"MULTIPLAN [10600]",Multiplan,,40.31,85,,,,,0,5.51,40.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"14MM AMPLATZER MUSCULAR VSD OCCLUDER",SUP-9-VSD-MUSC-014,CDM,C1817,HCPCS,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS [10001]","Blue Cross HMO",,24578.4,39.2,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL X-PAC LORDOTIC TALL L28 MM X H12 MM",SUP-EI2472LT,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Flu Vaccine Quad Split Virus No Prsv .5ml Im",PX-771000023,CDM,90686,CPT,0636,RC,,,both,,,34.10,10.23,"FIRST HEALTH [10303]","First Health",,27.28,80,,,,,0,4.04,28.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 80MM 8MM 9FR FLUENCY PLUS CARBON EPTFE 2",SUP-FEM08080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]","Cigna Open Access",,6120.45,33.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 24CM 5FR .038IN PIGTAIL CURVE",SUP-M006155222120,CDM,C2617,HCPCS,0278,RC,,,both,,,1325.65,397.69,"NOVANET [10819]",Novanet,,994.24,75,,,,,0,154.17,1126.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bndg Comp Comprifore 4 Lyr",PX-HHE27000225,CDM,HHE27000225,LOCAL,0270,RC,,,outpatient,,,61.00,18.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,41.48,68,,,,,0,7.09,51.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION",RX-97343,CDM,J3030,HCPCS,0637,RC,55150-0173-01,NDC,both,.5,ML,99.66,29.9,"NOVANET [10819]",Novanet,,74.75,75,,,,,0,11.59,89.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENCHMARK BMX96 DELIVERY CATHETER 80 CM",SUP-BMX9680,CDM,C1887,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2765,41.1,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 40MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712640,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BIOLOGICAL 5X4IN INTEGRA BOVINE CLLGN GLYCOSAMINOGLYCAN",SUP-BMW4051,CDM,Q4104,HCPCS,0636,RC,,,both,,,41242.26,12372.68,"KAISER [10500]",Kaiser,,27632.31,67,,,,,0,137.14,35055.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 18MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8840-18,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,36.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",35.41,258.83,"percent of total billed charges",
"CMPNT PATELLAR 32MM MEDIALIZE DOME ATTUNE",SUP-151810032,CDM,C1776,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"MULTIPLAN [10600]",Multiplan,,6099.6,85,,,,,0,834.57,6099.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAPAVERINE 30 MG/ML INJECTION SOLUTION",RX-6030,CDM,J2440,HCPCS,0637,RC,00517-4002-25,NDC,both,2,ML,375.18,112.55,"PHCS [10601]",PHCS,,262.63,70,,,,,0,43.63,318.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC",963,MS-DRG,,,,,,,inpatient,,,88505.50,26551.65,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,17975.41,,"Case rate ($16,957.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $15,746.59, add-ons for qualifying new technology services are included. If operating cost exceeds $48,786.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,572.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,767.41. The transfer operating threshold is the transfer adjustment factor * $15,746.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.52. The transfer capital threshold is the transfer adjustment factor * $1,190.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,10994,68178.24,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Histoplasma Capsul Ag Eia",PX-306000105,CDM,87385,CPT,0306,RC,,,both,,,450.30,135.09,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13.91,,"Fee schedule rate ($13.91). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,382.76,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC STD 20IN 25- IN KNEE 1 PANEL FINGER POCKET",SUP-VP40101-050,CDM,L1830,HCPCS,0274,RC,,,both,,,132.94,39.88,"CIGNA [10200]",Cigna,,90.4,68,,,,,0,15.46,113,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 20MM 3.25MM ULTRA LOW PROFILE BALLOON",SUP-1012275-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hrdtry Brst Ca-Rlatd Do 5+",PX-310000040,CDM,81432,CPT,0310,RC,,,both,,,4514.00,1354.2,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,3836.9,"per diem",
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED",SUP-98000200468,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9580.41,41.1,,6417.48,6417.48,6417.48,"1 through 10",2710.95,19813.5,"percent of total billed charges",
"BURR SURGICAL 3MM PRECISION MATCH HEAD LATEX FREE",SUP-8470107530,CDM,S27200284,LOCAL,0272,RC,,,both,,,2033.10,609.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,933.19,45.9,,,,,0,236.45,1728.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACTOR, BROKEN SCREW, 4 MM, 6"" LONG, SINGLE USE",SUP-SXT005-BR3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"FIRST HEALTH [10303]","First Health",,2370,80,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 325ML GEL SMOOTH SILICONE P3.8CM MODERATE PLUS","SUP-3503251 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"NOVANET [10819]",Novanet,,2756.25,75,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC INTERVERTEBRAL 17X7MM MOBI-C 15MM SPINE CERVICAL COCRMO",SUP-MB3577,CDM,S27800098,LOCAL,0278,RC,,,both,,,33075.00,9922.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9466.07,28.62,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM LUMBAR SPINE STERILE",SUP-2140145,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Open Access",,921.78,56.9,,1144.80,304.56,2275.09,66,188.41,1377,"percent of total billed charges",
"DEVICE PIPELINE FLEX 12MM 4MM EMBOLIZATION NEUROVASCULAR 48",SUP-PED-400-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"BLUE CROSS [10001]","Blue Cross PPO",,30164.4,39.2,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 6MM ENDOWRIST SP NONSTERILE LATEX FREE REUSABLE",SUP-430006,CDM,S27000186,LOCAL,0270,RC,,,both,,,2324.70,697.41,"CIGNA [10200]",Cigna,,1580.8,68,,,,,0,270.36,1976,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 6MM",SUP-SPL27506X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 4CM 5.8FR 12FR BALLOON",SUP-M0062251000,CDM,C1726,HCPCS,0272,RC,,,both,,,1670.40,501.12,"MULTIPLAN [10600]",Multiplan,,1419.84,85,,,,,0,194.27,1419.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 28MM CG FUTURE HOLDER EYELET DESIGN CROSS",SUP-638BL28,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"FIRST HEALTH [10303]","First Health",,10488,80,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0204,CDM,S27800098,LOCAL,0278,RC,,,both,,,5451.00,1635.3,"CIGNA [10200]","Cigna Local Plus",,2916.29,53.5,,,,,0,633.95,4633.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING URETHRAL BLUE DESARA TRANSVAGINAL STAINLESS STEEL",SUP-CAL-DS01BTV,CDM,C1771,HCPCS,0278,RC,,,both,,,6203.10,1860.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4218.11,68,,,,,0,721.42,5272.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X22X10MM COROENT XL+ WIDE PEEK NONSTERILE",SUP-6510255,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 3.75MM ARTHROWAND SUPER TURBOVAC 90D",SUP-ASC425001,CDM,S27200284,LOCAL,0272,RC,,,both,,,806.00,241.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,331.27,41.1,,,,,0,93.74,685.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL UNITY KNEE 3 KNEE FIX BEARING",SUP-112.040.06,CDM,C1776,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"AETNA [10100]","Aetna HMO/PPO",,4662.68,79.5,,10981.53,8986.79,12413.38,12,682.1,4985.25,"percent of total billed charges",
"BEARING 87/91MMX12MM VANGUARD ARCOM KNEE POSTERIOR STABILIZE",SUP-183682,CDM,C1776,HCPCS,0278,RC,,,both,,,8259.30,2477.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,978.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,960.56,7020.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL TISSUE CLSR VISTASEAL FIBRIN HUMAN 2ML",SUP-VST02,CDM,S25000001,LOCAL,0250,RC,,,both,,,1459.86,437.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,670.08,45.9,,,,,0,169.78,1240.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT BLUE 34X4IN LONG LEG 2 FILL LINE POSITIVE LOCK",SUP-ASP-564013,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.55,58.66,"CIGNA [10200]",Cigna,,132.97,68,,,,,0,22.74,166.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cryoprecipitate Ea Unit",PX-390000003,CDM,P9012,HCPCS,0390,RC,,,both,,,399.85,119.95,"AETNA [10100]","Aetna HMO/PPO",,317.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.5,339.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 4MM AZUR HYDROCOIL DETACHABLE .018IN",SUP-45-480420,CDM,S27800098,LOCAL,0278,RC,,,both,,,1504.17,451.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,174.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.93,1278.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN JUDKINS",SUP-77800900,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Renal Function Panel",PX-301000011,CDM,80069,CPT,0301,RC,,,both,,,289.75,86.92,"FIRST HEALTH [10303]","First Health",,231.8,80,,,,,0,5.88,246.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 0D E 9.9MM 28MM X3 HIP",SUP-623-00-28E,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"FIRST HEALTH [10303]","First Health",,6836.52,80,,,,,0,993.86,7263.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 29MMX8.5MM 29MM OVAL GENESIS II UHMWPE KNEE",SUP-71421029,CDM,C1776,HCPCS,0278,RC,,,both,,,7162.20,2148.66,"AETNA [10100]","Aetna HMO/PPO",,5693.95,79.5,,10981.53,8986.79,12413.38,12,832.96,6087.87,"percent of total billed charges",
"PROMETHAZINE 25 MG/ML INJECTION SOLUTION",RX-6618,CDM,J2550,HCPCS,0636,RC,00641-0955-21,NDC,both,1,ML,18.92,5.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4.66,,"Fee schedule rate ($4.66). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.96,16.08,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 8IN 13.5MM MODULAR SOL SYSTEM POROUS 12/14",SUP-157201136,CDM,C1776,HCPCS,0278,RC,,,both,,,38107.44,11432.23,"AETNA [10100]","Aetna HMO/PPO",,30295.41,79.5,,10981.53,8986.79,12413.38,12,4431.9,32391.32,"percent of total billed charges",
"SHELL ACETABULAR 58MM HIP MULTIHOLE COLOR CODED OSSEOTI G7 G",SUP-110010267,CDM,C1776,HCPCS,0278,RC,,,both,,,20755.98,6226.79,"CIGNA [10200]",Cigna,,8302.39,40,,5873.17,5873.17,5873.17,"1 through 10",2413.92,17642.58,"percent of total billed charges",
"SET EXT 2.5CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-24-2.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CIGNA [10200]","Cigna Open Access",,443.29,56.9,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION ODYSSEY STERILE",SUP-K0001298,CDM,C1713,HCPCS,0278,RC,,,both,,,2355.00,706.5,"BLUE CROSS [10001]","Blue Cross PPO",,923.16,39.2,,957.42,570.23,957.42,28,273.89,2001.75,"percent of total billed charges",
"FRCP SURGICAL SHEPARD 3 5/8IN CURVED INTRAOCULAR LENS",SUP-355275,CDM,S27200284,LOCAL,0272,RC,,,both,,,2175.83,652.75,"NOVANET [10819]",Novanet,,1631.87,75,,,,,0,253.05,1849.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY LARYNGEAL 4.5 AIR-Q INTUBATING REMOVABLE CNCT MASK",SUP-10-3045,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.25,19.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.59,55.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 30MM 6FR 2.5MM .07IN BALLOON",SUP-H7493918930250,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"KAISER [10500]",Kaiser,,379.89,67,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 21MM RESTORATION +30MM FEMUR MODULAR CMPNT",SUP-6276-1-321,CDM,C1776,HCPCS,0278,RC,,,both,,,14456.02,4336.81,"UHC [10700]","United Healthcare",,9150.66,63.3,,8601.07,8395.67,8601.07,"1 through 10",1681.24,12287.62,"percent of total billed charges",
"CATH DOVER 18FR URETHRAL ULTRAMER HYDROGEL 5ML 2 WAY FOLEY",SUP-1618C,CDM,S27200284,LOCAL,0272,RC,,,both,,,155.93,46.78,"PHCS [10601]",PHCS,,109.15,70,,,,,0,18.13,132.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SHEATH 13FR LEAD EXTRACTION EVOLUTION RL DIL CONTROLLED",SUP-G23747,CDM,C1773,HCPCS,0272,RC,,,both,,,10315.50,3094.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4239.67,41.1,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 20MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530020L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 6MM 3.75MM ULTRA LOW PROFILE BALLOON",SUP-1012277-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CXI 65CM 2.3FR STRAIGHT SPRT STAINLESS STEEL TUNGSTEN",SUP-G18369,CDM,C1887,HCPCS,0272,RC,,,both,,,1522.72,456.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,625.84,41.1,,,,,0,177.09,1294.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest Lesn Premalig 1st Les",PX-361000516,CDM,17000,CPT,0361,RC,,,both,,,474.00,142.2,"BLUE CROSS [10001]","Blue Cross PPO",,474,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,55.13,474,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK 8CM SINUS NASAL ABSORBENT FIRM NASOPORE NONSTERILE LATEX",SUP-5400020008,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNIFE OPHTHALMIC FLUORESCENT PINK 1MM CLEARCUT ANGLE FULL 2",SUP-8065921540,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.96,25.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BAND 24CM REGULAR 2 BALLOON AIR INJECTION PORT TRANSPARENT",SUP-TRB24-REG,CDM,S27000186,LOCAL,0270,RC,,,both,,,252.30,75.69,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CHOLANGIOGRAM 60CM 4FR FRANKLIN .025IN GWIRE 145CM",SUP-G10456,CDM,C1769,HCPCS,0272,RC,,,both,,,486.00,145.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BINDER ABDOMINAL 4 PANELED ELASTIC CONSTRUCTION PLUSH BACK H",SUP-55476301,CDM,S27000186,LOCAL,0270,RC,,,both,,,113.19,33.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT IMPL TITAN INFLATABLE PENILE PROS TUBE STERILE LATEX",SUP-519150,CDM,S27200284,LOCAL,0272,RC,,,both,,,4671.30,1401.39,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE 100MM 12.3MM 7MM CUFF PROXIMAL EXT EXTEND LENGTH",SUP-70XLTCP,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 270MM 3.8MM 3 FLUTE CALIBRATE QUICK COUPLING",SUP-03.019.016S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1629.60,488.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO CATH 13CM 10FR 3.4MM FLEXOR CHECK-FLO LARGE VALVE",SUP-G13031,CDM,C1894,HCPCS,0272,RC,,,both,,,452.22,135.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE NC PLUS 12MM 3.75MM BALLOON DILATATION STERILE",SUP-237-123-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO CATH 13CM 10FR 3.4MM FLEXOR CHECK-FLO LARGE VALVE",SUP-G13031,CDM,C1894,HCPCS,0272,RC,,,both,,,452.22,135.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH AMPHIRION DEEP 150CM 40MM 2.8-3.9FR 4MM BROAD TAPER LOW",SUP-AMP040040152,CDM,C1725,HCPCS,0272,RC,,,both,,,1762.50,528.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 6FR 11CM GREEN HUB HEMOSTASIS VALVE PRELUDE",SUP-PSI-6F-11,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 35LL 135CM 250MM 6MM .035IN LOW PROFILE BALLOON",SUP-B2060-250,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) LOADING INSTRUMENTS",SUP-DWG-0001,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 10.5MM 40MM CREO SPINE PREASSEMBLE THREAD",SUP-5119.1142,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"HC Dup Scan Lwr Ext Arty Bi",PX-921000006,CDM,93925,CPT,0921,RC,,,both,,,1741.69,522.51,"PHCS [10601]",PHCS,,1219.18,70,,,,,0,202.56,1480.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 8MM 12MM WOVEN SIZER ACCESS",SUP-M00202175912P0,CDM,L8670,HCPCS,0278,RC,,,both,,,10847.90,3254.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4458.49,41.1,,,,,0,427.53,9220.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET TISSUE CLSR DUPLOJECT TISSEEL PREFILL SYR 10ML",SUP-1506080,CDM,S27200284,LOCAL,0272,RC,,,both,,,2908.65,872.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,344.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,338.28,2472.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tp53 Gene Trgt Sequence Alys",PX-310000031,CDM,81352,CPT,0310,RC,,,both,,,2891.75,867.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,296.56,,,,,,,0.01,2457.99,"fee schedule",
"INTRO SHEATH 6FR 11CM GREEN HUB HEMOSTASIS VALVE PRELUDE",SUP-PSI-6F-11,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"KAISER [10500]",Kaiser,,50.71,67,,,,,0,8.8,64.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.4MM 25D NANOTACK FLEX INSRT 2 STAGE FIXATION",SUP-CAT01858,CDM,C1713,HCPCS,0278,RC,,,both,,,2655.00,796.5,"FIRST HEALTH [10303]","First Health",,2124,80,,,,,0,308.78,2256.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA NATURAL TIBIA 5D F KNEE RIGHT STEM",SUP-42532007502,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"NOVANET [10819]",Novanet,,8200.31,75,,,,,0,1271.59,9293.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE 40MM 57CM 8-6MM TAPER VASCULAR NITINOL",SUP-SR-080640-TCS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BONE CEMENT AVAFLEX CURVE STERILE LATEX FREE DISPOSABLE",SUP-1025-011-500,CDM,S27200284,LOCAL,0272,RC,,,both,,,2798.33,839.5,"CIGNA [10200]",Cigna,,1902.86,68,,,,,0,325.45,2378.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-3-4-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"BLUE CROSS [10001]","Blue Cross PPO",,4584.64,39.2,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 100CM 8FR 16MM AMPLATZER II .086IN",SUP-9-AVP2-016,CDM,S27800098,LOCAL,0278,RC,,,both,,,6589.50,1976.85,"KAISER [10500]",Kaiser,,4414.97,67,,,,,0,766.36,5601.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD TITANIUM 3 HOLE GEMINUS BONE RIGHT DISTAL VOLAR",SUP-GMN-RTS-3HL,CDM,C1713,HCPCS,0278,RC,,,both,,,5023.20,1506.96,"KAISER [10500]",Kaiser,,3365.54,67,,,,,0,584.2,4269.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 3.5IN 17GA 19GA PERIFIX TUOHY BPA DEHP PVC",SUP-332087,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.01,54.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.05,153.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 7MMX79MM 7FR 135CMCATH HEPARIN",SUP-BXB077902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"CIGNA [10200]","Cigna Open Access",,7171.48,33.5,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 43MM JNOTCH STOP TWIST 5MM 1.1MM",SUP-72-2011,CDM,S27200284,LOCAL,0272,RC,,,both,,,1755.00,526.5,"MULTIPLAN [10600]",Multiplan,,1491.75,85,,,,,0,204.11,1491.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.9MM SHORT PUSHLOCK BIOCOMPOSITE",SUP-AR-8923BC,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.00,945,"AMERIGROUP MEDICAID [20100]",Amerigroup,,373.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",366.35,2677.5,"percent of total billed charges",
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 6MM 4.5MM .017IN",SUP-H7493926706450,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE COALITION AGX 7D ALLOGRAFT 10X16X8MM",SUP-8128.1478S,CDM,S27800098,LOCAL,0278,RC,,,both,,,5002.50,1500.75,"PHCS [10601]",PHCS,,3501.75,70,,,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH SHORT 5MM HANCOCK HANDLE AORTIC",SUP-APU450,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,119.18,41.1,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM LCP STAINLESS STEEL CORTICAL FOREFOOT",SUP-202.872,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"CIGNA [10200]","Cigna Local Plus",,173.33,53.5,,3978.14,359.25,3978.14,24,37.68,275.39,"percent of total billed charges",
"STENT SUPERA 60MM 120CM 6MM 6FR VASCULAR PERIPHERAL",SUP-S-60-060-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"NOVANET [10819]",Novanet,,7546.5,75,,,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM RADIUS DISTAL VOLAR NONLOCK 3 LEAD TAPER",SUP-131227212,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"NOVANET [10819]",Novanet,,637.88,75,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 6CM STD BENTSON 80CM 17CM .035IN FLOPPY TIP",SUP-G01315,CDM,C1769,HCPCS,0272,RC,,,both,,,195.66,58.7,"MULTIPLAN [10600]",Multiplan,,166.31,85,,,,,0,22.76,166.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3IN HEADLESS",SUP-6541-4-003,CDM,C1713,HCPCS,0278,RC,,,both,,,1683.75,505.12,"KAISER [10500]",Kaiser,,1128.11,67,,,,,0,195.82,1431.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SURGICAL SILS ADVANCEMENT CLINCH CHOLECYSTECTOMY 46MM",SUP-SILSCC46,CDM,S27200284,LOCAL,0272,RC,,,both,,,4153.59,1246.08,"FIRST HEALTH [10303]","First Health",,3322.87,80,,,,,0,483.06,3530.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML SUPERORDERABLE ORAL SOLUTION",RX-409531,CDM,,,0250,RC,08888-8879-14,NDC,both,5,ML,25.19,7.56,"NOVANET [10819]",Novanet,,18.89,75,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 8MM 144CM 3MM CORONARY STENT",SUP-H7493911408300,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross PPO",,3583.86,39.2,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 28CM 3CM 6FR .038IN 2 PIGTAIL",SUP-M006192134010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]","Cigna Open Access",,683.13,,,,,,,139.63,1020.49,"percent of total billed charges",
"CATH VISTA BRITE TIP TRUELUMEN 90CM .1IN 8FR .088IN",SUP-588842P,CDM,C1887,HCPCS,0272,RC,,,both,,,304.50,91.35,"MULTIPLAN [10600]",Multiplan,,258.83,85,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM OFFSET 36MM HIP ACETABULAR MODULAR TYPE 1",SUP-650-0660,CDM,C1776,HCPCS,0278,RC,,,both,,,12375.84,3712.75,"PHCS [10601]",PHCS,,8663.09,70,,,,,0,1439.31,10519.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 28MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0353,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,434.99,45.9,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +24.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.245,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Open Access",,391.76,56.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Targeted Genomic Seq Analysis",PX-301000564,CDM,81445,CPT,0310,RC,,,both,,,5525.00,1657.5,"CIGNA [10200]",Cigna,,1315.4,,,,,,,0.01,4696.25,"fee schedule",
"SUT VICRYL PLUS 0 CT 36IN BRAID ANTIBACTERIAL COATED VIOLET",SUP-VCP358H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM STAINLESS STEEL 3.5MM SCR 3 HOLE LCP BONE",SUP-241.901,CDM,C1713,HCPCS,0278,RC,,,both,,,9928.27,2978.48,"CIGNA [10200]","Cigna Local Plus",,5311.62,53.5,,3978.14,359.25,3978.14,24,1154.66,8439.03,"percent of total billed charges",
"GRAFT ENDOVASCULAR 80MM 8MM 9FR FLUENCY PLUS CARBON EPTFE 2",SUP-FEM08080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"NOVANET [10819]",Novanet,,13702.5,75,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805210,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"MULTIPLAN [10600]",Multiplan,,766.85,85,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X8MM CLYDESDALE PTC 6D PEEK TANTALUM",SUP-4986845,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9765.36,41.1,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRESTIGE PLUS HELICAL PACK",SUP-PRES0615HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"FIRST HEALTH [10303]","First Health",,5244,80,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 10MM 2MM BALLOON DILATATION STERILE",SUP-220-103-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT BLUE 34X4IN LONG LEG 1 FILL LINE POSITIVE LOCK",SUP-ASP-564012,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.00,58.5,"UHC [10700]","United Healthcare",,123.44,63.3,,,,,0,22.68,165.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 56MM 28MM XLPE HIP",SUP-71337556,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"UHC [10700]","United Healthcare",,7056.02,63.3,,8601.07,8395.67,8601.07,"1 through 10",1296.39,9474.91,"percent of total billed charges",
"VALVE AORTIC 18MM 27MM 32MM 26MM CARPENTIER-EDWARDS",SUP-3000TFX27MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"NOVANET [10819]",Novanet,,24073.88,75,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 100CM 5FR JL2 CURVE ANGIOGRAPHIC NO",SUP-G47012,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,24.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 8MM 3MM SOFT TISSUE HANDLE",SUP-AR-1530BC,CDM,C1713,HCPCS,0278,RC,,,both,,,3189.38,956.81,"BLUE CROSS [10001]","Blue Cross HMO",,1250.24,39.2,,957.42,156.86,7483.26,51,370.92,2710.97,"percent of total billed charges",
"BODY CONE 29MM RESTORATION +30MM HIP PROXIMAL MODULAR",SUP-6276-1-329,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"BLUE CROSS [10001]","Blue Cross PPO",,8723.86,39.2,,3949.44,3949.44,3949.44,"1 through 10",2588.23,18916.54,"percent of total billed charges",
"HC Hemorrhoid Lig Band",PX-750000099,CDM,46221,CPT,0750,RC,,,both,,,4590.53,1377.16,"PHCS [10601]",PHCS,,3213.37,70,,,,,0,533.88,4590.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EP-XT 110CM 6FR 2-5-2MM SPACE LARGE 4 CURVE",SUP-M0042010070,CDM,C1730,HCPCS,0272,RC,,,both,,,1856.50,556.95,"FIRST HEALTH [10303]","First Health",,1485.2,80,,,,,0,215.91,1578.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 60MM 6FR 5MM BALLOON DILATATION PEBAX",SUP-39032-50601,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 6MM 2MM BALLOON DILATATION PEBAX",SUP-1400200-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY BIOPSY ARROW ONCONTROL BONE MARROW",SUP-9451-VC-006,CDM,C1830,HCPCS,0272,RC,,,both,,,1327.05,398.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACK VITRECTOMY CONSTELLATION PHACO TIPLESS CASSETTE DRNG",SUP-8065751155,CDM,S27200284,LOCAL,0272,RC,,,both,,,1343.39,403.02,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT HANAROSTENT 90MM 22MM DUODENAL NITINOL PYLORUS UNCOVER",SUP-DNJF-22-090-230,CDM,C1876,HCPCS,0278,RC,,,both,,,15104.24,4531.27,"FIRST HEALTH [10303]","First Health",,12083.39,80,,,,,0,1756.62,12838.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 20X12MM 3/32IN COVIDIEN STERILE",SUP-E1561,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.35,27.4,"CIGNA [10200]","Cigna Local Plus",,48.87,53.5,,,,,0,10.62,77.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 5.5MM CURVE NONSTERILE",SUP-1555501060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR30,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Open Access",,4391.85,33.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM PRECEPT SPINE POLYAXIAL NONSTERILE",SUP-8807535A,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SPACER ANTERIOR CERVICAL SPINE FREEZE DRIED BLOCK",SUP-245841,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC",064,MS-DRG,,,,,,,inpatient,,,42920.19,12876.06,"AMBETTER EXCHANGE  [11102]",Ambetter,,12474.35,,"Case rate ($12,474.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,583.28, add-ons for qualifying new technology services are included. If operating cost exceeds $44,622.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,257.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,598.60. The transfer operating threshold is the transfer adjustment factor * $11,583.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $875.75. The transfer capital threshold is the transfer adjustment factor * $875.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",10181.14,10181.14,10181.14,"1 through 10",7561,42920.19,other,"INPATIENT DRG"
"KIT CATH ADULT 24CM 15.5FR POLYURETHANE BIOFLO DURAMAX",SUP-H787103028185,CDM,C1750,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]",Cigna,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC",346,MS-DRG,,,,,,,inpatient,,,51227.92,15368.38,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,7799.56,,"Case rate ($7,358.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,832.47, add-ons for qualifying new technology services are included. If operating cost exceeds $39,872.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,898.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,841.50. The transfer operating threshold is the transfer adjustment factor * $6,832.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $516.57. The transfer capital threshold is the transfer adjustment factor * $516.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7358.08,34632.3,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"AERVIA NEONATAL SUPRAGLOTTIC AIRWAY DEVICE, LARGE, 2000-3500",SUP-AVLARGE,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.47,70.34,"AETNA [10100]","Aetna HMO/PPO",,186.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.27,199.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 2-0 FS SPIRAL 45CM SUT ABSORBABLE",SUP-SXPP1B101,CDM,S27200284,LOCAL,0272,RC,,,both,,,224.03,67.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.05,190.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 14MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650514,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5395.3,41.1,,6417.48,6417.48,6417.48,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"CATH LAUNCHER 100CM 8FR .09IN JUDKINS LEFT 4 CURVE GUIDING",SUP-LA8JL40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL MICRO NDL STRAIGHT 4IN TUNGSTEN",SUP-E16514,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.10,61.83,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INTELLATIP MIFI XP 110CM 8MM 7FR 2.5MM SPACE STD CURVE",SUP-M004PM45000,CDM,C1733,HCPCS,0272,RC,,,both,,,14352.00,4305.6,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 20MM 190CM 5MM",SUP-R51005002L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RETRIEVER ENDOSCOPIC 30MM 4MM TREVO XP PROVUE STERILE LATEX",SUP-90185,CDM,S27200284,LOCAL,0272,RC,,,both,,,47273.94,14182.18,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"NAIL 9MM 210MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-409-210,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 100MM .9MM KIRSCHNER TROCAR 1 END 2-2.5MM SCR",SUP-K100-09S,CDM,C1713,HCPCS,0278,RC,,,both,,,89.18,26.75,"NOVANET [10819]",Novanet,,66.89,75,,,,,0,10.37,75.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ather/Stnt Sngl Maj Cor Art/Br",PX-481000079,CDM,92933,CPT,0481,RC,,,both,,,24747.77,7424.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2795,,"Case rate ($2,795). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2795,24747.77,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 75MM 12MM UNIVERSAL FLUTE KNEE PRESS FIT",SUP-86-7412,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3718.18,45.9,,,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LASSO 115CM 7FR 20MM 6MM SPACE ELECTROPHYSIOLOGY 20",SUP-D7L2020RT,CDM,C1731,HCPCS,0272,RC,,,both,,,10950.30,3285.09,"FIRST HEALTH [10303]","First Health",,8760.24,80,,,,,0,1273.52,9307.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 24MM ARTHREX +4MM SHOULDER MODULAR STERILE",SUP-AR-9560-24-4,CDM,C1776,HCPCS,0278,RC,,,both,,,9335.70,2800.71,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4285.09,45.9,,,,,0,1085.74,7935.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE FIBER OPTIC 8FT RELIEVA LUMA LIGHT GUIDE",SUP-SIS-LGC08,CDM,S27200284,LOCAL,0272,RC,,,both,,,3217.50,965.25,"KAISER [10500]",Kaiser,,2155.73,67,,,,,0,374.2,2734.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X10MM COROENT XL+",SUP-6010855P2,CDM,C1889,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6851.63,28.62,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 24CM 8FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001274170,CDM,C2617,HCPCS,0278,RC,,,both,,,999.00,299.7,"NOVANET [10819]",Novanet,,749.25,75,,,,,0,116.18,849.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX7MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2990722,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"CIGNA [10200]",Cigna,,6359.04,40,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.9MM JUGGERKNOT SUT ANCHOR",SUP-912091,CDM,S27200284,LOCAL,0272,RC,,,both,,,1190.70,357.21,"FIRST HEALTH [10303]","First Health",,952.56,80,,,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 34X15MM MONUMENT 15D LORDOTIC 26MM MEDIUM",SUP-3108.0515,CDM,S27800098,LOCAL,0278,RC,,,both,,,39123.00,11736.9,"CIGNA [10200]",Cigna,,15649.2,40,,,,,0,4550,33254.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC BLUE 2.3MM MAXTORQUE STAINLESS STEEL",SUP-CSS04023,CDM,C1769,HCPCS,0272,RC,,,both,,,234.90,70.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,27.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.32,199.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 36MM ORTHOLOC TITANIUM CORTICAL SELF TAP",SUP-59225536,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"CIGNA [10200]","Cigna Open Access",,566.89,56.9,,1144.80,304.56,2275.09,66,115.87,846.86,"percent of total billed charges",
"CABLE ORTHOPEDIC COCR 1.7MM 750MM TITANIUM CRIMP CERCLAGE",SUP-611.105.01S,CDM,C1713,HCPCS,0278,RC,,,both,,,2845.50,853.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,814.38,28.62,,,,,0,330.93,2418.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AUROUS 100CM 5FR PIGTAIL CURVE ANGIOGRAPHIC NYLON CAVA",SUP-G11916,CDM,S27200284,LOCAL,0272,RC,,,both,,,1025.67,307.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,697.46,68,,,,,0,119.29,871.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SHORT 56MM INTERMEDIATE ANATOMICAL VARIAX BONE RADIUS",SUP-54-25684,CDM,C1713,HCPCS,0278,RC,,,both,,,6820.79,2046.24,"PHCS [10601]",PHCS,,4774.55,70,,,,,0,793.26,5797.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 65CM .035IN ANGLE SPRT",SUP-518-077,CDM,C1887,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 15.9MM THK.38MM THK.69MM 90D OFFSET SAGITTAL 14.3",SUP-2296-003-109S2,CDM,S27200284,LOCAL,0272,RC,,,both,,,667.44,200.23,"NOVANET [10819]",Novanet,,500.58,75,,,,,0,77.62,567.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 20MM 154CM 6MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200062020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross PPO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.3MM STAINLESS STEEL Y BONE NONSTERILE",SUP-221.335,CDM,C1713,HCPCS,0278,RC,,,both,,,2202.90,660.87,"FIRST HEALTH [10303]","First Health",,1762.32,80,,,,,0,256.2,1872.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHIELD RADIOLOGY 16X16IN RADBARRIER LARGE POSITIONAL FREE",SUP-RBFPS101,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.67,83.9,"CIGNA [10200]","Cigna Local Plus",,149.62,53.5,,,,,0,32.53,237.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX TAPER TIP",SUP-M0061455510,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,75.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASE TIB STEM #4 RIGHT PEGLESS",SUP-2586-0-0004,CDM,C1776,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]",Cigna,,4222.8,68,,5873.17,5873.17,5873.17,"1 through 10",722.22,5278.5,"percent of total billed charges",
"NDL INTRAOSSEOUS 15MM 15GA EZ-IO EZ CONNECT WRIST BAND LUER",SUP-9021,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,39.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSPONGE STRIP 50X20X7MM",SUP-109636,CDM,S27800098,LOCAL,0278,RC,,,both,,,13489.50,4046.85,"PHCS [10601]",PHCS,,9442.65,70,,,,,0,1568.83,11466.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER HOLE REFLECTION R3 ACETABULUM THREAD",SUP-71336500,CDM,C1713,HCPCS,0278,RC,,,both,,,989.01,296.7,"BLUE CROSS [10001]","Blue Cross HMO",,387.69,39.2,,957.42,156.86,7483.26,51,115.02,840.66,"percent of total billed charges",
"SUB BONE GRAFT 240X25X4MM BTCP CLLGN VITOSS VOID FILLER FOAM",SUP-2102-1101,CDM,C1713,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Open Access",,6331.5,33.5,,1144.80,304.56,2275.09,66,2198.07,16065,"percent of total billed charges",
"STENT 24CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX TAPER TIP",SUP-M0061453810,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"NOVANET [10819]",Novanet,,474.83,75,,,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 10-12 G-H KNEE LEFT VIVACIT-E",SUP-42512401010,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1253.3,9159.96,"percent of total billed charges",
"SHEATH AMPLATZ 17CM 18FR ACCESS PTFE RENAL FIRM TAPER TIP",SUP-M0062601470,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"NOVANET [10819]",Novanet,,250.95,75,,,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SPINAL 1.5IN 22GA STD SAFETY LUMBAR PUNCTURE PEDIATRIC",SUP-26-LP2SF,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.57,62.57,"FIRST HEALTH [10303]","First Health",,166.86,80,,,,,0,24.26,177.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 18MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8840-18,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"MULTIPLAN [10600]",Multiplan,,258.83,85,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM T10 FULL THREAD LOCK STARDRIVE",SUP-657338,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1011.05,68,,,,,0,172.92,1263.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 10MM THORAX SOFT FLEXIBLE WOVEN",SUP-M00202175210P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Prostate Transrectal US Guided",PX-361000741,CDM,55707,CPT,0361,RC,,,both,,,4814.28,1444.28,"UHC [10700]","United Healthcare",,4814.28,,"Case rate ($5,045). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,559.9,4814.28,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 40CM 14MM 7MM SOFT FLEXIBLE ADHERENT",SUP-M002020851470,CDM,C1768,HCPCS,0278,RC,,,both,,,4778.66,1433.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,566.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,555.76,4061.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 3MM X 10CM",SUP-M0035473100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"MULTIPLAN [10600]",Multiplan,,11997.44,85,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP FULL OSTEOTOM 52MM HEMISPHERE ACETABULAR",SUP-00705305220,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"CIGNA [10200]","Cigna Local Plus",,2421.62,53.5,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 500MM 4.75MM COCR MOLYBDENUM STRAIGHT NONSTERILE",SUP-1475000500,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"FIRST HEALTH [10303]","First Health",,3528,80,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD T .6MM UPPER FACE 7 HOLE 1.2MM SCR BONE LEIBINGER",SUP-55-06270,CDM,C1713,HCPCS,0278,RC,,,both,,,1423.41,427.02,"CIGNA [10200]","Cigna Open Access",,809.92,56.9,,1144.80,304.56,2275.09,66,165.54,1209.9,"percent of total billed charges",
"HEAD BIPOLAR 55MM 26MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-55-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"NOVANET [10819]",Novanet,,3238.33,75,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 20MM 120CM 9MM .079IN LARGE DIAMETER",SUP-SERB65-09-20-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"FIRST HEALTH [10303]","First Health",,4452,80,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE VASCULAR STRAIGHT 190CM 3CM .014IN",SUP-28000,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET CATH 6FR BARD STAINLESS STEEL FOLEY MALLEABLE TIP",SUP-004036,CDM,S27200284,LOCAL,0272,RC,,,both,,,233.16,69.95,"CIGNA [10200]",Cigna,,158.55,68,,,,,0,27.12,198.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTMASTER 19MM 4.5MM CORONARY STENT STAINLESS STEEL",SUP-1012583-19,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"CIGNA [10200]","Cigna Open Access",,5536.04,33.5,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRACTOR 12X55MM 8 1/2 CONCAVE BLADE CURVED DOWN OBWEGESER",SUP-7537,CDM,S27200284,LOCAL,0272,RC,,,both,,,908.58,272.57,"UHC [10700]","United Healthcare",,575.13,63.3,,,,,0,105.67,772.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL FIXATION .75IN TRIATHLON",SUP-6541-4-575,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,50.59,369.75,"percent of total billed charges",
"SUT PROLENE 2-0 KS 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8623H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE ORTHOPEDIC STAINLESS STEEL 2MM HIP CLAMP ACCORD",SUP-71340008,CDM,C1713,HCPCS,0278,RC,,,both,,,3026.25,907.87,"FIRST HEALTH [10303]","First Health",,2421,80,,,,,0,351.95,2572.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 40CM 11CM 12FR 2CM PIGTAIL CURVE DRNG",SUP-RBDC-12-038,CDM,C1729,HCPCS,0272,RC,,,both,,,558.90,167.67,"FIRST HEALTH [10303]","First Health",,447.12,80,,,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 18MM 140CM 4MM 2.1-2.7FR CORONARY STENT",SUP-RONYX40018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1062.52,28.62,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM ALPS TIMAX FULL THREAD ELBOW CORTICAL",SUP-815037028,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"NOVANET [10819]",Novanet,,592.31,75,,,,,0,91.85,671.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 135CM MAMBA STERILE LATEX FREE",SUP-H7493928713500,CDM,C1887,HCPCS,0272,RC,,,both,,,4071.00,1221.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,473.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 27MM STD",SUP-M7-027,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9062.55,41.1,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBJR050202A,CDM,C1874,HCPCS,0278,RC,,,both,,,19895.40,5968.62,"PHCS [10601]",PHCS,,13926.78,70,,,,,0,2313.84,16911.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X6MM COLONIAL 7D LORDOTIC 14MM XL TITANIUM",SUP-365.706CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID PACBAND- LARGE",SUP-38350017,CDM,S27000186,LOCAL,0270,RC,,,both,,,180.96,54.29,"CIGNA [10200]",Cigna,,123.05,68,,,,,0,21.05,153.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 14MM LOW PROFILE SCREWS TITANIUM ANKLE VARIABLE",SUP-AR-8933V-14,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross HMO",,555.66,39.2,,957.42,156.86,7483.26,51,164.86,1204.88,"percent of total billed charges",
"VALVE MITRAL 14.2MM 25MM 23.4MM ON-X 33MM CYLINDRICAL HEART",SUP-ONXM-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10818.36,28.62,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 52MM 32MM ALTRX HIP",SUP-122132052,CDM,C1776,HCPCS,0278,RC,,,both,,,9128.70,2738.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1061.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1061.67,7759.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK LARGE RIGHT ANGLE 7.5IN RETRACTION TIP JANNETTA 4.7MM",SUP-NL3769,CDM,S27200284,LOCAL,0272,RC,,,both,,,789.51,236.85,"PHCS [10601]",PHCS,,552.66,70,,,,,0,91.82,671.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR 5X4CM THK.15-.25MM CARDIAC BOVINE",SUP-C0405,CDM,C1768,HCPCS,0278,RC,,,both,,,2724.75,817.42,"PHCS [10601]",PHCS,,1907.33,70,,,,,0,316.89,2316.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHAMFERED SCREW CALIBRATED DRILL CANNULATED 4.0MM (3.2MM)",SUP-CD-CS-1040,CDM,S27000186,LOCAL,0270,RC,,,both,,,2130.00,639,"MULTIPLAN [10600]",Multiplan,,1810.5,85,,,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 4FR 5MM SPACE STD A CURVE ELECTROPHYSIOLOGY 10 PIN CNCT",SUP-112434RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"UHC [10700]","United Healthcare",,1466.98,63.3,,,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER TORQR 65CM 5FR 2-8-2MM SPACING CORONARY SINUS CURVE",SUP-041865CS,CDM,C1730,HCPCS,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000175,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 STD 12MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS5S12L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4769.65,45.9,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL GLASSMAN RIGHT ANGLE 9.25IN FULLY SERRATED",SUP-SU6128,CDM,S27200284,LOCAL,0272,RC,,,both,,,2764.28,829.28,"CIGNA [10200]","Cigna Local Plus",,1478.89,53.5,,,,,0,321.49,2349.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752740,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"MULTIPLAN [10600]",Multiplan,,766.85,85,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 7CM 10FR DUODENAL BEND BILIARY",SUP-M00534330,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"BLUE CROSS [10001]","Blue Cross HMO",,427.06,39.2,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9FR 13CM HEMOSTASIS VALVE SIDEPORT PACING LEAD",SUP-6709,CDM,C1894,HCPCS,0272,RC,,,both,,,130.50,39.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,88.74,68,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 11MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532-P-811,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"NOVANET [10819]",Novanet,,6266.93,75,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 3/16IN 3/16IN BARD SILICONE 4 FREE FLOW",SUP-072223,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.71,37.11,"FIRST HEALTH [10303]","First Health",,98.97,80,,,,,0,14.39,105.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS TYING L83MM PLATFORM 4MM STAINLESS STEEL STRAIGHT SE","SUP-E1815 S",CDM,S27200284,LOCAL,0272,RC,,,both,,,1307.50,392.25,"UHC [10700]","United Healthcare",,827.65,63.3,,,,,0,152.06,1111.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM ENDOSKELETON TCS TITANIUM STD SPINE",SUP-5301-3516,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,117.75,860.63,"percent of total billed charges",
"GWIRE SYNCHRO VASCULAR STRAIGHT 215CM .014IN HYDROPHILIC",SUP-SSFT215STR,CDM,C1769,HCPCS,0272,RC,,,both,,,4186.64,1255.99,"PHCS [10601]",PHCS,,2930.65,70,,,,,0,486.91,3558.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 240CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRM-240,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2517.84,45.9,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 1 CT-1 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J261H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INFLATION INDEFLATOR .096IN ROTATE HEMOSTATIC VALVE",SUP-1000186,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP POLY POROUS R3 STD",SUP-71331860,CDM,C1776,HCPCS,0278,RC,,,both,,,14334.75,4300.42,"NOVANET [10819]",Novanet,,10751.06,75,,,,,0,1667.13,12184.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 58MM 36MM ALTRX HIP",SUP-122136458,CDM,C1776,HCPCS,0278,RC,,,both,,,6814.08,2044.22,"FIRST HEALTH [10303]","First Health",,5451.26,80,,,,,0,792.48,5791.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL STD OFFSET 32MM HIP TYPE 1 COCR G7",SUP-163669,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"CIGNA [10200]","Cigna Open Access",,2760.05,56.9,,5302.19,4377.88,6578.61,27,564.14,4123.1,"percent of total billed charges",
"STENT URETERAL 8FR L28CM SOFT WITHOUT GUIDEWIRE TRIA",SUP-M0061903440,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.75MM 30MM TITANIUM FULL THREAD SHOULDER GLENOID",SUP-AR-7000-30FT,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 14MM TITANIUM FULL THREAD T10 HEXALOBE FOREFOOT",SUP-AR-8933L-14,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 4CM 16FR MIC-KEY SECUR-LOK ENFIT SILICONE RADIOPAQUE",SUP-8140-16-4.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"PHCS [10601]",PHCS,,545.34,70,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P211,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5682.01,68,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM .91-1.12MM 2.25MM CORONARY",SUP-RONYX22530W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2295,68,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 7MM INTERTAN COMPRESSION SCR STARTER",SUP-71674570,CDM,S27200284,LOCAL,0272,RC,,,both,,,2127.38,638.21,"FIRST HEALTH [10303]","First Health",,1701.9,80,,,,,0,247.41,1808.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 2-0 GS-21 .5 CIRCLE 9IN 37MM CLSR TAPER",SUP-VLOCM0345,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,133.17,68,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EP 5F QUAD 5MM 120CM CRD",SUP-401222R,CDM,S27200284,LOCAL,0272,RC,,,both,,,704.70,211.41,"MULTIPLAN [10600]",Multiplan,,599,85,,,,,0,81.96,599,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 7MM INTERTAN COMPRESSION SCR STARTER",SUP-71674570,CDM,S27200284,LOCAL,0272,RC,,,both,,,2127.38,638.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1446.62,68,,,,,0,247.41,1808.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 14FR SILICONE MIC-KEY SECUR-LOK ENFIT BOLUS",SUP-8200-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"CIGNA [10200]","Cigna Local Plus",,588.28,53.5,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE GRAFT 6CC DEMINERALIZED CORTICAL FIBER ACCELERATE",SUP-T50206,CDM,C1713,HCPCS,0278,RC,,,both,,,9522.00,2856.6,"PHCS [10601]",PHCS,,6665.4,70,,,,,0,1107.41,8093.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 250-355UM 5 VIAL CONTOUR PVA",SUP-M0017600351,CDM,S27800098,LOCAL,0278,RC,,,both,,,1377.00,413.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,936.36,68,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 54MM 32MM ALTRX HIP",SUP-122132054,CDM,C1776,HCPCS,0278,RC,,,both,,,9128.70,2738.61,"FIRST HEALTH [10303]","First Health",,7302.96,80,,,,,0,1061.67,7759.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.2MM STEINMANN BLUNT DISPOSABLE",SUP-500095,CDM,C1713,HCPCS,0278,RC,,,both,,,3326.40,997.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,394.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,386.86,2827.44,"percent of total billed charges",
"DEVICE PIPELINE FLEX 10MM 3MM EMBOLIZATION",SUP-PED2-300-10,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"CIGNA [10200]",Cigna,,32319,40,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 20MM 2.5MM RECTANGLE HELIX BALLOON",SUP-2039-2520,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"NOVANET [10819]",Novanet,,4398.75,75,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN ADULT DORO SKULL STERILE BLUE",SUP-3006-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.92,22.48,"CIGNA [10200]",Cigna,,50.95,68,,,,,0,8.71,63.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 9MM STAINLESS STEEL T4 SELF TAP LOCK VARIABLE",SUP-02.130.209,CDM,C1713,HCPCS,0278,RC,,,both,,,839.16,251.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,97.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",97.59,713.29,"percent of total billed charges",
"SCR BONE 5MM 32.5MM T2 TITANIUM FULL THREAD FEMUR HUMERUS",SUP-1896-5032S,CDM,C1713,HCPCS,0278,RC,,,both,,,1279.15,383.74,"FIRST HEALTH [10303]","First Health",,1023.32,80,,,,,0,148.77,1087.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 75CM 6MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR061001A,CDM,C1874,HCPCS,0278,RC,,,both,,,17545.50,5263.65,"CIGNA [10200]",Cigna,,7018.2,40,,,,,0,2040.54,14913.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 3.5IN 18GA 27GA PERIFIX ESPOCAN SPINOCAN TUOHY",SUP-333182,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.66,74.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.8,210.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 4IN 17GA 19GA TUOHY EPILONG CONTINUOUS CLOSE",SUP-TAL101,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,135.88,41.1,,,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CLOTTRIEVER 115CM 16MM THROMBECTOMY VARIABLE LENGTH",SUP-41-102,CDM,C1757,HCPCS,0272,RC,,,both,,,47250.00,14175,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5599.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5495.18,40162.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE NASOPHARYNX ESOPHAGUS RECTUM GENERAL PURPOSE",SUP-101610-040,CDM,S27000186,LOCAL,0270,RC,,,both,,,63.88,19.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOOK 12MM RETRACTION BLUNT ELASTIC STAY LONE STAR DISPOSABLE",SUP-3350-1G,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.05,27.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 88MM 1.5MM K WIRE ATTACH THREAD HOLE NONSTERILE",SUP-03.130.300,CDM,S27200284,LOCAL,0272,RC,,,both,,,576.07,172.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SUPRAPUBIC 16FR 20- FR 17CM 20CM 1 STEP DIL TROCAR",SUP-G26655,CDM,S27200284,LOCAL,0272,RC,,,both,,,734.67,220.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FIBER LASER 200UM DISPOSABLE",SUP-TFL-FBX200S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2690.00,807,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MAJOR SKIN DISORDERS WITH MCC",595,MS-DRG,,,,,,,inpatient,,,47775.23,14332.57,"AETNA [10100]","Aetna HMO/PPO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PTCA CATHETER 1.75 X 10MM (617-104-1U) SCOREFLEX NC SCORING",SUP-SD36003-01,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ROD SPINAL 35MM 3.5MM VERTEX SELECT PRECUT",SUP-7753735,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"CIRCAID UPPER LEG REDUCTION KIT- STANDARD, REGULAR",SUP-25301217,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 100X14-18MM",SUP-400750,CDM,S27800098,LOCAL,0278,RC,,,both,,,4868.64,1460.59,"KAISER [10500]",Kaiser,,3261.99,67,,,,,0,566.22,4138.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC",485,MS-DRG,,,,,,,inpatient,,,119941.43,35982.43,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,20918.7,,"Case rate ($20,017.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $18,587.97, add-ons for qualifying new technology services are included. If operating cost exceeds $51,627.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,787.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $18,612.56. The transfer operating threshold is the transfer adjustment factor * $18,587.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,405.34. The transfer capital threshold is the transfer adjustment factor * $1,405.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,94218.41,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"TORQR FIXED QUAD",SUP-041005DM,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,212.98,68,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUPERCORE 15CM 9.9CM 18GA 17GA BIOPSY COAXIAL INTRO",SUP-701218150,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.53,140.26,"KAISER [10500]",Kaiser,,313.25,67,,,,,0,54.37,397.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE PACING CNCT DISPOSABLE",SUP-TC-25MB,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"MULTIPLAN [10600]",Multiplan,,177.48,85,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HEAD UNIPOLAR HIP FEMUR HIGH DEMAND",SUP-71701035,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross HMO",,4057.2,39.2,,5311.50,4717.44,5388.59,31,1203.71,8797.5,"percent of total billed charges",
"BASEPLT GLENOID 15MM AEQUALIS 6 SHOULDER HA REVERSED STD",SUP-DWD003,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4334.34,45.9,,,,,0,1098.22,8026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 4 ANGLE 11IN COBB OVAL CUP HOLLOW KNURL HANDLE",SUP-240191,CDM,S27200284,LOCAL,0272,RC,,,both,,,834.79,250.44,"UHC [10700]","United Healthcare",,528.42,63.3,,,,,0,97.09,709.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5N NARROW KNEE RIGHT POSTERIOR STABILIZE",SUP-71421275,CDM,C1776,HCPCS,0278,RC,,,both,,,32536.35,9760.9,"CIGNA [10200]","Cigna Local Plus",,10248.95,31.5,,5372.07,4581.20,7242.98,23,3783.98,27655.9,"percent of total billed charges",
"KIT ARTHROSCOPIC FIXATION FIBER STITCH REVERSE CURVE 2",SUP-AR-4580R,CDM,C1713,HCPCS,0278,RC,,,both,,,3984.75,1195.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1140.44,28.62,,,,,0,463.43,3387.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 75MM 24MM UNIVERSAL FLUTE KNEE PRESS FIT",SUP-867421,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5508.41,68,,,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATRIX-C UNION CERVICAL ALLOGRAFT SPACER 13 X 16 X 8MM 7",SUP-X094-3011,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE REFICIO 100 DEMINERALIZED BONE MATRIX .5CC",SUP-27803518,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 25MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-125,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 6 X 6 HELICAL FINISHING COIL",SUP-10HFN-06006,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1225.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)J VALVE BIOPROSTHESIS 25",SUP-ETF-25,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"NOVANET [10819]",Novanet,,149625,75,,,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 80CM 8MM 16SQ MM 7FR .035IN",SUP-BXAL082901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"MULTIPLAN [10600]",Multiplan,,16579.08,85,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX 3IN MONOFILAMENT SCAFFOLD FULL",SUP-1190100,CDM,C1781,HCPCS,0278,RC,,,both,,,8186.85,2456.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,952.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,952.13,6958.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTROPHYSIOLOGY BLUE 92CM 6FR WEBSTER 2-5-2MM SPACING D",SUP-D6DR252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,1400.60,420.18,"KAISER [10500]",Kaiser,,938.4,67,,,,,0,162.89,1190.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemorrhoid Lig Band",PX-750000099,CDM,46221,CPT,0750,RC,,,both,,,4590.53,1377.16,"FIRST HEALTH [10303]","First Health",,3672.42,80,,,,,0,533.88,4590.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 12X3.5IN ATS CYL PORT STERILE DISPOSABLE",SUP-60707510200,CDM,S27200284,LOCAL,0272,RC,,,both,,,150.82,45.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,69.23,45.9,,,,,0,17.54,128.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 36MM +0MM HIP TRABECULAR METAL POLYETHYLENE",SUP-00434903600,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"AETNA [10100]","Aetna HMO/PPO",,7177.04,79.5,,10981.53,8986.79,12413.38,12,1049.92,7673.56,"percent of total billed charges",
"SABER .035 4X150 80CM SL",SUP-48004015N,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"NOVANET [10819]",Novanet,,747.83,75,,,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE3.5MM 22MM ANKLE FOOT LOCKING",SUP-MFT0213522,CDM,C1713,HCPCS,0278,RC,,,both,,,1547.10,464.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,179.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",179.93,1315.04,"percent of total billed charges",
"BOOT CAST CANVAS LARGE OPEN TOE SHOCK ABSORBENT SOLE ROCKER",SUP-798703,CDM,S27000186,LOCAL,0270,RC,,,both,,,65.69,19.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.64,55.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC FLUORESCENT PINK 1MM CLEARCUT ANGLE FULL 2",SUP-8065921540,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.96,25.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10,73.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 2-0 CT-1 27IN MONOFILAMENT CLEAR ABSORBABLE",SUP-Z259H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 5FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552240,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,343.61,28.62,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 19.3X9.6CM ALLODERM SELECT THK1.6MM 132SQ CM",SUP-CM1518P,CDM,Q4116,HCPCS,0636,RC,,,both,,,24847.20,7454.16,"AETNA [10100]","Aetna HMO/PPO",,19753.52,79.5,,,,,0,247.92,21120.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 50MM TITANIUM SPINE CORTICAL FIX ANGLE 5.5MM",SUP-186731750,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 27.5MM ATLANTIS VISION ELITE BONE SPINE",SUP-7200027,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PHCS [10601]",PHCS,,2940,70,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 80MM 5MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171050810,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UHC [10700]","United Healthcare",,743.46,63.3,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 8MM 16SQ MM 8FR .035IN",SUP-BXAL087901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"FIRST HEALTH [10303]","First Health",,17125.92,80,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 11.5X9X.38MM PRECISION SHORT MEDIUM STAINLESS",SUP-2296003411,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,32.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR POROUS UNIPOLAR PRIMARY INSRT",SUP-98B00100117,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"NOVANET [10819]",Novanet,,7762.5,75,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 80MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"PHCS [10601]",PHCS,,1003.59,70,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 24MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0286,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]","Cigna Open Access",,539.24,56.9,,1144.80,304.56,2275.09,66,110.22,805.55,"percent of total billed charges",
"SYSTEM REGULAR 7FR INTRO NINITOL ECHOGENIC NDL FIXED CORE",SUP-70-7160,CDM,C1894,HCPCS,0272,RC,,,both,,,304.50,91.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,207.06,68,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION",RX-21900,CDM,J0289,HCPCS,0636,RC,00469-3051-30,NDC,both,1,UN,2305.57,691.67,"KAISER [10500]",Kaiser,,1544.73,67,,,,,0,150.21,1959.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 12X19MM FORTIFY 12MM NONSTERILE LATEX FREE",SUP-151.051,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"FIRST HEALTH [10303]","First Health",,25678.8,80,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 137MM 9MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51104090,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9681.34,40,,,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND PURAPLY MZ 500MG",SUP-515-061,CDM,S25000001,LOCAL,0250,RC,,,both,,,8004.00,2401.2,"CIGNA [10200]","Cigna Open Access",,4554.28,56.9,,,,,0,930.87,6803.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 20MM 144CM 2.25MM CORONARY STENT EVEROLIMUS",SUP-H7493926120220,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3544.88,41.1,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 80MM 2.4MM MINI STAINLESS STEEL QUICK COUPLING",SUP-317.871,CDM,S27000186,LOCAL,0270,RC,,,both,,,496.69,149.01,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,204.14,41.1,,,,,0,57.77,422.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG 15L CYCLER PERITONEUM LATEX FREE DIALYSIS",SUP-5C4145NS,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.95,22.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.72,63.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTERNALBRACE IMPL PEEK FOREFOOT STERILE",SUP-AR-1530P-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10106.78,3032.03,"BLUE CROSS [10001]","Blue Cross HMO",,3961.86,39.2,,957.42,156.86,7483.26,51,1175.42,8590.76,"percent of total billed charges",
"(EVAL) VALVE AORTIC 15MM 27MM AVALUS ULTRA 27MM BOVINE PERIC",SUP-400U27,CDM,S27800098,LOCAL,0278,RC,,,both,,,36225.00,10867.5,"KAISER [10500]",Kaiser,,24270.75,67,,,,,0,4212.97,30791.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309016,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4391.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 55MM LCP STAINLESS STEEL FULL THREAD CONDYLAR",SUP-02.207.055,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,1144.80,304.56,2275.09,66,189.34,1383.8,"percent of total billed charges",
"COIL EMBOLIZATION 15CM 4MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0415,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"BLUE CROSS [10001]","Blue Cross HMO",,2650.7,39.2,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Whfo W/O Joints Prefab Ots",PX-E27400049,CDM,L3809,HCPCS,0274,RC,,,both,,,815.10,244.53,"FIRST HEALTH [10303]","First Health",,652.08,80,,,,,0,94.8,692.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC ANATOMIC SOCKET FLIPCUTTER II SHORT KNEE",SUP-AR-1204AS-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"KAISER [10500]",Kaiser,,1714.78,67,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF ENHANCR II 110CM 4MM 7FR 2-5-2MM SPACE 55MM SINGLE",SUP-FND-019-04,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CIGNA [10200]","Cigna Open Access",,774.3,56.9,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.5MM TRIM-IT",SUP-AR-4160-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"KAISER [10500]",Kaiser,,428.73,67,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 35CM 4MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0435CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"BLUE CROSS [10001]","Blue Cross PPO",,2840.04,39.2,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 6-0 S-29 12IN 2 ARM BRAID COATED VIOLET",SUP-J556G,CDM,S27200284,LOCAL,0272,RC,,,both,,,162.65,48.79,"MULTIPLAN [10600]",Multiplan,,138.25,85,,,,,0,18.92,138.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE VENTRICULAR ASSIST STD OUTFLOW GRAFT BEND RELIEF SEAL",SUP-103393,CDM,S27800098,LOCAL,0278,RC,,,both,,,30240.00,9072,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3583.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eo W/Adj Joints Prefabricated",PX-E27400054,CDM,L3760,HCPCS,0274,RC,,,both,,,1647.80,494.34,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,195.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,191.64,1400.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tte Cong W Contr Cmplt",PX-483000019,CDM,C8923,HCPCS,0480,RC,,,both,,,2274.00,682.2,"MULTIPLAN [10600]",Multiplan,,1932.9,85,,,,,0,264.47,2274,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.8MM 350MM KIRSCHNER STAINLESS STEEL SPADE",SUP-29238,CDM,C1713,HCPCS,0278,RC,,,both,,,528.12,158.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,61.42,448.9,"percent of total billed charges",
"CATH SABERX RADIANZ 190CM 150MM 6MM .018IN BALLOON",SUP-R51006015L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACIFIC PLUS 180CM 60MM 4FR 3MM BALLOON DILATATION",SUP-PCP030060180,CDM,C2623,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CELSIUS 115CM 4MM 7FR 2-5-2MM SPACE G CURVE ABLATION 10",SUP-D7BTGL,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WOLVERINE CUTTING BALLOON (OTW)  3.50MM X 10MM",SUP-H74939402103500,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NON-MALIGNANT BREAST DISORDERS WITH CC/MCC",600,MS-DRG,,,,,,,inpatient,,,34178.72,10253.62,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL MEMORYSHAPE MEDIUM HEIGHT MODERATE PLUS PROFILE",SUP-RSZ-1055S,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.90,70.47,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRONCHOSCOPE EXAMINATION BFLEX SLIM 3.8 SINGLE USE X2",SUP-0570-0448,CDM,S27200284,LOCAL,0272,RC,,,both,,,1990.50,597.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEAD FEMORAL +9MM 12/14 TAPER 32MM HIP BIOLOX DELTA",SUP-136532330,CDM,C1776,HCPCS,0278,RC,,,both,,,6844.32,2053.3,"CIGNA [10200]",Cigna,,4654.14,68,,5873.17,5873.17,5873.17,"1 through 10",795.99,5817.67,"percent of total billed charges",
"HOOK SPINAL CD HORIZON LARGE TITANIUM WIDE BLADE TRANSVERSE",SUP-7541114,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,1831.33,1831.33,1831.33,16,348.9,2550,"percent of total billed charges",
"AUG ACETABULAR 25MM 50MM RESTORATION WEDGE HIP",SUP-5096-5025,CDM,C1776,HCPCS,0278,RC,,,both,,,12461.40,3738.42,"BLUE CROSS [10001]","Blue Cross HMO",,4884.87,39.2,,5311.50,4717.44,5388.59,31,1449.26,10592.19,"percent of total billed charges",
"LINER ACETABULAR PINNACLE 10D +4MM 62MM 44MM ALTRX HIP",SUP-122144162,CDM,C1776,HCPCS,0278,RC,,,both,,,14524.50,4357.35,"CIGNA [10200]","Cigna Local Plus",,4575.22,31.5,,5372.07,4581.20,7242.98,23,1689.2,12345.83,"percent of total billed charges",
"PATCH SURGICAL 10.1X6.1IN SPRING OPEN BIORESORBABLE SELF",SUP-5950060,CDM,C1781,HCPCS,0278,RC,,,both,,,6917.40,2075.22,"CIGNA [10200]",Cigna,,4703.83,68,,,,,0,804.49,5879.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 17.5MM S-ROM ZTT 22F 2XL HIP PROXIMAL",SUP-550741,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"BLUE CROSS [10001]","Blue Cross PPO",,4266.82,39.2,,3949.44,3949.44,3949.44,"1 through 10",1265.9,9252.04,"percent of total billed charges",
"SCR BONE 5.5MM 50MM 3DX TSRH OSTEOGRIP THINLINE TITANIUM",SUP-83555501,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,305.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,299.36,2187.9,"percent of total billed charges",
"BALLOON ENDOSCOPIC ULTRAMATRIX LINER EUS NONSTERILE LATEX",SUP-USBOL,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.90,44.37,"MULTIPLAN [10600]",Multiplan,,125.72,85,,,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 23MM STD TITANIUM MECHANICAL ROTATABLE FLEXIBLE",SUP-M7-023,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TOURGUIDE 55CM 9MM 7FR CATH",SUP-TG0705509,CDM,C1766,HCPCS,0272,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD SUT ASSISTANT 2-0 EEN 6IN UNIT ETHIBOND EXCEL STERILE",SUP-SW112,CDM,S27200284,LOCAL,0272,RC,,,both,,,500.19,150.06,"NOVANET [10819]",Novanet,,375.14,75,,,,,0,58.17,425.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 28CM INTERSTIM SURESCAN MRI LEAD KIT 2.16MM",SUP-978A128,CDM,C1778,HCPCS,0278,RC,,,both,,,22050.00,6615,"KAISER [10500]",Kaiser,,14773.5,67,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG 111MM STAINLESS STEEL 2.7/3.5MM SCR 4 HOLE",SUP-02.117.604,CDM,C1713,HCPCS,0278,RC,,,both,,,6541.75,1962.52,"KAISER [10500]",Kaiser,,4382.97,67,,,,,0,760.81,5560.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 12MM .021IN AZUR DETACHABLE .018IN",SUP-45-481215,CDM,S27800098,LOCAL,0278,RC,,,both,,,6037.50,1811.25,"FIRST HEALTH [10303]","First Health",,4830,80,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 90CM 8FR JL4 CURVE GUIDING PTFE FEMORAL",SUP-H749343582010,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"KAISER [10500]",Kaiser,,245.51,67,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 325ML GEL SMOOTH SILICONE P3.8CM MODERATE PLUS","SUP-3503251 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"CIGNA [10200]",Cigna,,2499,68,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 100MM 6MM RECTANGLE HELIX BALLOON",SUP-2237-60100,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"PHCS [10601]",PHCS,,5796,70,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID PACBAND- LARGE",SUP-38350017,CDM,S27000186,LOCAL,0270,RC,,,both,,,180.96,54.29,"PHCS [10601]",PHCS,,126.67,70,,,,,0,21.05,153.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE 10ML INJECTABLE TRAUMACEM V+",SUP-07.702.040S,CDM,C1713,HCPCS,0278,RC,,,both,,,2265.90,679.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,268.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,263.52,1926.02,"percent of total billed charges",
"NDL SCLEROTHERAPY 25GA INJECTION PROJECTION STERILE",SUP-00711811,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"AETNA [10100]","Aetna HMO/PPO",,262.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 24FR SILICONE RADIOPAQUE EXTERNAL RETENTION RING",SUP-8160-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,592.52,177.76,"FIRST HEALTH [10303]","First Health",,474.02,80,,,,,0,68.91,503.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTOLOZANE-TAZOBACTAM 1.5 G/11.4ML IV (WET SOLR VIAL)",RX-415169198,CDM,J0695,HCPCS,0636,RC,67919-0030-01,NDC,both,1,UN,1052.44,315.73,"PHCS [10601]",PHCS,,736.71,70,,,,,0,124.71,894.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins/Rep Card Sys Gen Only",PX-480000083,CDM,0409T,CPT,0480,RC,,,both,,,38311.00,11493.3,"AETNA [10100]","Aetna HMO/PPO",,30457.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2041,32564.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 103MM 14-23MM 18FR ENDURANT IIS 2 BRANCH",SUP-ESBF2314C103E,CDM,S27800098,LOCAL,0278,RC,,,both,,,60782.40,18234.72,"FIRST HEALTH [10303]","First Health",,48625.92,80,,,,,0,7068.99,51665.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 90MM MONSTER SHORT THREAD CANNULATED SHARP",SUP-P20-555-090S,CDM,C1713,HCPCS,0278,RC,,,both,,,2981.25,894.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,353.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",346.72,2534.06,"percent of total billed charges",
"BINDER ABDOMINAL 9IN 3 PANEL ELASTIC CONTACT CLSR PROCARE",SUP-79-89210,CDM,S27000186,LOCAL,0270,RC,,,both,,,74.12,22.24,"UHC [10700]","United Healthcare",,46.92,63.3,,,,,0,8.62,63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE WATERBUG 12FT SUCTION FLOOR QUIET EFFICIENT FLEXIBLE",SUP-90030,CDM,S27200284,LOCAL,0272,RC,,,both,,,119.38,35.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.88,101.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER MARINR 90CM 7FR 2-2-2MM SPACING CORONARY SINUS CURV",SUP-043302M,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL H14MM OD20MM UNIVERSAL COBALT CHROME ANTERIOR DI",SUP-11-210024,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"NOVANET [10819]",Novanet,,10660.5,75,,,,,0,1653.09,12081.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEDG CARDIOVASCULAR WHITE 9.5X4.8MM THK1.5MM Y TFE SOFT",SUP-PCP40,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.95,15.28,"NOVANET [10819]",Novanet,,38.21,75,,,,,0,5.93,43.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 600CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP140RH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"BLUE CROSS [10001]","Blue Cross HMO",,4665.78,39.2,,,,,0,1384.26,10117.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX11MM FRA 12D LORDOTIC NARROW SPINE",SUP-2311,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 4.0/26",SUP-434901,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"NOVANET [10819]",Novanet,,14812.88,75,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX TAPER TIP",SUP-M0061455510,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,181.19,28.62,,,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Exam/Biopsy of Vag W/Scope",PX-761000089,CDM,57421,CPT,0761,RC,,,both,,,2081.70,624.51,"CIGNA [10200]","Cigna Local Plus",,2051,,"Per diem ($2,051).",,,,0,242.1,2081.7,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 95MM 32MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-217.095,CDM,C1713,HCPCS,0278,RC,,,both,,,485.35,145.6,"CIGNA [10200]","Cigna Local Plus",,259.66,53.5,,3978.14,359.25,3978.14,24,56.45,412.55,"percent of total billed charges",
"SIZER IMPL MEMORYSHAPE MEDIUM HEIGHT MODERATE PLUS PROFILE",SUP-RSZ-1255S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"FIRST HEALTH [10303]","First Health",,1560,80,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 103X16X4.8MM STAINLESS STEEL 4.5MM SCR LARGE",SUP-226.06,CDM,C1713,HCPCS,0278,RC,,,both,,,2591.48,777.44,"NOVANET [10819]",Novanet,,1943.61,75,,,,,0,301.39,2202.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM TRIATHLON 2 LEFT MEDIAL RIGHT LATERAL TOTAL",SUP-5545-A-201,CDM,C1776,HCPCS,0278,RC,,,both,,,4327.60,1298.28,"MULTIPLAN [10600]",Multiplan,,3678.46,85,,,,,0,503.3,3678.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ab ID",PX-302000184,CDM,86870,CPT,0302,RC,,,both,,,729.30,218.79,"CIGNA [10200]","Cigna Open Access",,91.26,,,,,,,0.01,619.91,"fee schedule",
"INSRT TIBIAL 5 10MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-510-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"NOVANET [10819]",Novanet,,9025.2,75,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BRONCHOSCOPIC 13MM 22GA WANG TRANSBRONCHIAL MEDIASTINAL",SUP-MW-122,CDM,S27200284,LOCAL,0272,RC,,,both,,,416.12,124.84,"UHC [10700]","United Healthcare",,263.4,63.3,,,,,0,48.39,353.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL VASCULAR 30MM 3MM SYNOVIS FLO-RESTER GLOBAL CORONARY",SUP-60300,CDM,S27200284,LOCAL,0272,RC,,,both,,,741.67,222.5,"KAISER [10500]",Kaiser,,496.92,67,,,,,0,86.26,630.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLITTER CATH CPS UNIVERSAL 4-6FR LEAD COMPATIBLE",SUP-DS2A003,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rho D Immune Globulin Inj",PX-636000010,CDM,J2790,HCPCS,0636,RC,,,both,,,566.04,169.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.6,,"Fee schedule rate ($94.60). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.6,481.13,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 18CM 11MM .0135IN MICRUSFRAME MICRO",SUP-MFR141118,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"MULTIPLAN [10600]",Multiplan,,10099.53,85,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC THK6MM 50X47MM ASSURITY MRI IS-1 CNCT 10.4CC",SUP-PM2272,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4929.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +6 DIOPTER MODIFY L BICONVEX 13MM 6MM POSTERIOR",SUP-CC60WF.060,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 9CM 230CM 22-27MM 10FR COLONIC DELIVERY",SUP-M00565110,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 15MM SECUR-FIT PLUS 11 HIP STERILE",SUP-6054-1115S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"UHC [10700]","United Healthcare",,10232.72,63.3,,8601.07,8395.67,8601.07,"1 through 10",1880.04,13740.62,"percent of total billed charges",
"INSRT TIBIAL 4 25MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-425,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"CIGNA [10200]","Cigna Open Access",,5593.57,56.9,,5302.19,4377.88,6578.61,27,1143.29,8355.94,"percent of total billed charges",
"STPLR INTERNAL 45MM FLEXIBLE ARTICULATING LINEAR CUTTER",SUP-ATS45,CDM,S27200284,LOCAL,0272,RC,,,both,,,4678.94,1403.68,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STNT WALLFLEX 75MM 28MM 10MM",SUP-7472,CDM,C1894,HCPCS,0272,RC,,,both,,,261.00,78.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE NC PLUS 12MM 2.5MM BALLOON DILATATION STERILE",SUP-225-123-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 141CM 4.1FR .041IN THROMBECTOMY REPERFUSION",SUP-PSC041,CDM,C1887,HCPCS,0272,RC,,,both,,,11523.00,3456.9,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FLEXIVA PULSE ID 910",SUP-M006L8406940,CDM,S27200284,LOCAL,0272,RC,,,both,,,4808.75,1442.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VERSACROSS CONNECT LAAC 230P D0",SUP-VXAK0105,CDM,S27200284,LOCAL,0272,RC,,,both,,,6969.00,2090.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Introducer Check Flo",PX-E27200134,CDM,C1894,HCPCS,0272,RC,,,both,,,186.89,56.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GASTROINTESTINAL OBSTRUCTION WITH MCC",388,MS-DRG,,,,,,,inpatient,,,28005.88,8401.76,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 4 ANGLE 11IN COBB OVAL CUP HOLLOW KNURL HANDLE",SUP-240191,CDM,S27200284,LOCAL,0272,RC,,,both,,,834.79,250.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EUPHORA 142CM 8MM 3MM BALLOON DILATATION DURATRAC",SUP-NCEUP3008X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCISSOR SURGICAL MAYO DISSECTING HEAVY BLUNT SERRATED STAINL",SUP-80-5017,CDM,S27200284,LOCAL,0272,RC,,,both,,,575.18,172.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR PAL1 CURVE GUIDING STERILE LATEX",SUP-LA6PAL10,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Sm (Smith) Igg Autoabs",PX-302000046,CDM,86235,CPT,0302,RC,,,both,,,202.35,60.7,"UHC [10700]","United Healthcare",,16.14,,,,,,,0.2,172,"fee schedule",
"STEM FEMORAL 120MM CEMENTLESS OFFSET ACCOLADE TMZF 127D 3 43",SUP-6021-0335,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"PHCS [10601]",PHCS,,10954.44,70,,,,,0,1820,13301.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 30MM TI",SUP-MTLS-37300-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,155.43,1136.03,"percent of total billed charges",
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC",564,MS-DRG,,,,,,,inpatient,,,61272.78,18381.83,"AMBETTER EXCHANGE  [11102]",Ambetter,,9575.04,,"Case rate ($9,575.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,891.08, add-ons for qualifying new technology services are included. If operating cost exceeds $41,930.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,054.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $8,902.84. The transfer operating threshold is the transfer adjustment factor * $8,891.08 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.21. The transfer capital threshold is the transfer adjustment factor * $672.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,38495.84,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Perm Gen Dual Lead",PX-480000022,CDM,33228,CPT,0481,RC,,,both,,,10379.90,3113.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4656,,"Case rate ($4,656). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1207.18,10379.9,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Phlebectomy 1 Ext >20 Incisn",PX-361000553,CDM,37766,CPT,0361,RC,,,both,,,13184.10,3955.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1562.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1533.31,11206.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CHAMPIONIR DES SYSTEM US 6-100",SUP-412601000USRD,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SINGLE COMMERCIAL SYSTEM READER KIT DELIVERY SYSTEM W",SUP-CRDLA005US-TR,CDM,S62400003,LOCAL,0624,RC,,,both,,,116850.00,35055,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SET DIL HYDROPHILIC LONG TAPER TIP .035IN 45CM 20FR 22FR",SUP-G52835,CDM,S27200284,LOCAL,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MASK DISPOSABLE FOR INTEGRATED SHOULDER CHAIRS",SUP-OZ7547575,CDM,S27000186,LOCAL,0270,RC,,,both,,,2055.98,616.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE V-LOC 180 SURGALLOY 3-0 V-20 6IN CLSR ABSORBABLE",SUP-VLOCL0604,CDM,S27200284,LOCAL,0272,RC,,,both,,,406.03,121.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT NEROSTIMLTR 4IN LEAD SCRDRVR ACCESS PAI",SUP-3550-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY BIOPSY BONE MARROW STERILE DISPOSABLE",SUP-BAK4511,CDM,S27200284,LOCAL,0272,RC,,,both,,,320.07,96.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM MULTI-LINK VISION 12MM 3MM CORONARY STENT COCR RAPID",SUP-1007848-12,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIBRILLATOR 52CM 8FR OPTISURE ENDOCARDIUM 1 COIL DF4",SUP-LDA210Q-52,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS [10001]","Blue Cross HMO",,6731.42,39.2,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 5FR 67CM DEFLECTABLE REMOVABLE RADIOPAQUE",SUP-G14178,CDM,S27200284,LOCAL,0272,RC,,,both,,,796.23,238.87,"NOVANET [10819]",Novanet,,597.17,75,,,,,0,92.6,676.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 5FR .058IN EXTRA BACKUP 3.5 LEFT CURVE GUIDING",SUP-LA5EBU35,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"KAISER [10500]",Kaiser,,262.31,67,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15MM INDEPENDENCE 15D NONSTERILE LATEX FREE",SUP-376.515,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"NOVANET [10819]",Novanet,,25706.7,75,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 29MM 24.2MM MASTERS PYROLYTIC CARBON PTFE",SUP-29MTJ-503,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"FIRST HEALTH [10303]","First Health",,23295.38,80,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 100CM 5FR JB1 CURVE URETERAL STAINLESS STEEL",SUP-M0064004041,CDM,C1758,HCPCS,0272,RC,,,both,,,149.15,44.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.35,126.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE STRAIGHT/ROTATION 1.5",SUP-PRT-STR-015,CDM,C1713,HCPCS,0278,RC,,,both,,,6624.00,1987.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3040.42,45.9,,,,,0,770.37,5630.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 2-0 KS 30IN MONOFILAMENT BLACK NONABSORBABLE",SUP-628H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X22X14MM 10D XL WIDE PEEK LORDOTIC",SUP-6921455,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS [10001]","Blue Cross PPO",,9313.92,39.2,,9172.16,8555.87,9172.16,"1 through 10",2763.29,20196,"percent of total billed charges",
"CURET ENDOSCOPIC IVAS LATEX FREE 11GA",SUP-0306-621-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,4372.53,1311.76,"NOVANET [10819]",Novanet,,3279.4,75,,,,,0,508.53,3716.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 57MM 75CM 7MM 60MM",SUP-38046-76075,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"AETNA [10100]","Aetna HMO/PPO",,3839.85,79.5,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPIDCROSS 170CM 100MM 2MM .014IN BALLOON DILATATION",SUP-A14BX020100170,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"FIRST HEALTH [10303]","First Health",,1108.08,80,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 16MM LCP STAINLESS STEEL CORTICAL T6 STARDRIVE",SUP-201.366.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,48.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",48.16,352,"percent of total billed charges",
"SCR BONE 5.5MM 35MM CD HORIZON TITANIUM COCR SPINE",SUP-55890005535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 11.5CM 20MM 16.5-18.5MM GORE EXCLUDER",SUP-PLC201200,CDM,C1874,HCPCS,0278,RC,,,both,,,27997.20,8399.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11506.85,41.1,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 7MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640607,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1308.83,9565.82,"percent of total billed charges",
"TIP MEDIUM SURGILAV SHIELD SPLASH PULSED LAVAGE",SUP-0207068000,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.60,22.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,34.24,45.9,,,,,0,8.68,63.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE",SUP-PCB0000205,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 15CM ACHIEVE COAXIAL INTRO AUTOMATED",SUP-CA2015,CDM,S27200284,LOCAL,0272,RC,,,both,,,967.46,290.24,"MULTIPLAN [10600]",Multiplan,,822.34,85,,,,,0,112.52,822.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC .75CM 4.45X5.02CM ACCOLADE 2 CHMBR RA RV IS1",SUP-L311,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"PHCS [10601]",PHCS,,29120,70,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT CEMENTED CRUCIATE RETAINING ATTUNE",SUP-150400104,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"PHCS [10601]",PHCS,,15675.35,70,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 8MM 144CM 4MM CORONARY STENT",SUP-H7493941808400,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 12FR 54CM HICKMAN 2 LUMEN LOW PROFILE ADPTR PEEL",SUP-0600620,CDM,C1751,HCPCS,0272,RC,,,both,,,1385.10,415.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,161.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Picc WO Port/Img <5yr",PX-361000270,CDM,36568,CPT,0361,RC,,,both,,,7800.82,2340.25,"FIRST HEALTH [10303]","First Health",,6240.66,80,,,,,0,7.8,7800.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COCAINE 4 % SOLUTION SUPERORDERABLE",RX-409212,CDM,,,0250,RC,70839-0362-04,NDC,both,4,ML,1962.17,588.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,232.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,228.2,1667.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 09.0",SUP-DIB00U0090,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,523.91,39.2,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL NDL STRAIGHT 4IN 3/32IN VALLEYLAB",SUP-E1654B,CDM,S27200284,LOCAL,0272,RC,,,both,,,187.40,56.22,"MULTIPLAN [10600]",Multiplan,,159.29,85,,,,,0,21.79,159.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SCRDRVR 80MM 2MM MAXDRIVE 1.5MM SCR",SUP-25-438-97-07,CDM,S27000186,LOCAL,0270,RC,,,both,,,1287.01,386.1,"PHCS [10601]",PHCS,,900.91,70,,,,,0,149.68,1093.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 19MM HELIX R SPINE SELF TAP VARIABLE ANGLE",SUP-7805119,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",117.75,860.63,"percent of total billed charges",
"CATH SLIP-CATH BEACON TIP 65CM 4FR KUMPE CURVE ANGIOGRAPHIC",SUP-G31019,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.55,134.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,205.88,45.9,,,,,0,52.17,381.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 90MM MONSTER SHORT THREAD CANNULATED SHARP",SUP-P20-555-090S,CDM,C1713,HCPCS,0278,RC,,,both,,,2981.25,894.37,"KAISER [10500]",Kaiser,,1997.44,67,,,,,0,346.72,2534.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 40 75CM 2CM 6MM BALLOON DILATATION PERIPHERAL",SUP-CQF7562,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"AETNA [10100]","Aetna HMO/PPO",,1062.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 10IN 22FR FEMORAL ARTERY 3/8IN THIN WALL T",SUP-TFA02225,CDM,S27200284,LOCAL,0272,RC,,,both,,,371.23,111.37,"CIGNA [10200]",Cigna,,252.44,68,,,,,0,43.17,315.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 27MM 80CM 5MM 30MM BILIARY STAINLESS STEEL",SUP-PXB35-05-27-080,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,517.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL AVENIR COMPLETE 9 HIGH OFFSET HIP STERILE LATEX",SUP-574102090,CDM,C1776,HCPCS,0278,RC,,,both,,,26190.36,7857.11,"BLUE CROSS [10001]","Blue Cross PPO",,10266.62,39.2,,3949.44,3949.44,3949.44,"1 through 10",3045.94,22261.81,"percent of total billed charges",
"ALLERGIC REACTIONS WITHOUT MCC",916,MS-DRG,,,,,,,inpatient,,,22697.28,6809.18,"CIGNA [10200]","Cigna Open Access",,7311.98,,"Fee schedule rate ($7,311.98). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,4133.09,16616.86,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY SOFT TISSUE LATEX FREE HAZARDOUS",SUP-32-ST1SF,CDM,S27200284,LOCAL,0272,RC,,,both,,,175.57,52.67,"FIRST HEALTH [10303]","First Health",,140.46,80,,,,,0,20.42,149.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC",940,MS-DRG,,,,,,,inpatient,,,107549.87,32264.96,"AETNA [10100]","Aetna HMO/PPO",,43968.77,,"Fee schedule rate ($43,968.77). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,68228.13,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LIVEWIRE 115CM 2MM 5FR 2-5-2MM SPACING",SUP-401940,CDM,C1730,HCPCS,0272,RC,,,both,,,3375.00,1012.5,"NOVANET [10819]",Novanet,,2531.25,75,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER GD 100CM 6FR RWY HS CRV",SUP-H74938969410,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"MULTIPLAN [10600]",Multiplan,,311.47,85,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 8MM 3MM CORONARY STENT EVEROLIMUS RAPID",SUP-1550300-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 14MM 3FR GEMINI HELICAL URETERAL",SUP-M0063302090,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,172.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFE-T-J VASCULAR 3MM RADIUS 2.5CM J TAPER 260CM 7CM",SUP-G00471,CDM,C1769,HCPCS,0272,RC,,,both,,,156.51,46.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PREVAIL DCB 2.25X20MM",SUP-PRV022520CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VOYANT INTELLIGENT ENERGY SYS 23CM MARYLAND SINGLE STEP ACTI",SUP-EB214,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE EMBOSHIELD NAV6 BAREWIRE WORKHORSE VASCULAR 315CM .014",SUP-22440-31,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC TREK NEO 6MM 145CM 3.5MM BALLOON DILATATION",SUP-1400350-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ROTABLATOR ROTALINK ATHERECTOMY",SUP-H80222782001A0,CDM,C1894,HCPCS,0272,RC,,,both,,,2003.40,601.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TAKERU 12MM 2MM BALLOON DILATATION RAPID EXCHANGE PTCA",SUP-DC-RZ2012UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOOK .25IN STRAIGHT BLUNT TRIANGLE HANDLE 9IN NERVE",SUP-57-5000,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.09,56.43,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC CT Cerv Spine W Cntrst",PX-352000009,CDM,72126,CPT,0352,RC,,,both,,,3423.78,1027.13,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($517.40). Procedures 2 - 999, Per diem ($258.70).",,,,0,,,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE V-18 CONTROLWIRE VASCULAR TAPER 200CM 8CM .018IN",SUP-M001468520,CDM,C1769,HCPCS,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CAP SYSTEM PERSONA TKR VIVACIT-E XLPE FEMUR PATELLA TIBIA CE",SUP-98000200091,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2784.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 5 3/8IN .025IN SPRING TUBE POSITIVE PLACEMENT",SUP-RW-04025,CDM,C1769,HCPCS,0272,RC,,,both,,,60.90,18.27,"FIRST HEALTH [10303]","First Health",,48.72,80,,,,,0,7.08,51.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLODERM (RTU) CONTOUR LARGE PERFORATED - THIN",SUP-CL1516P,CDM,Q4116,HCPCS,0636,RC,,,both,,,31380.30,9414.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3718.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.92,26673.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYMER 13X17CM PERMANENT REINFORCE OVITEX IHR",SUP-F10243-1317I,CDM,C1781,HCPCS,0278,RC,,,both,,,4526.40,1357.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,536.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.2MM X 13MM COCR",SUP-VAN-12013-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 78CM 5.3FR 5.1FR .014-.018IN OFFSET S LEFT",SUP-459878,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"NOVANET [10819]",Novanet,,4205.25,75,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 1MM 3MM EAR FRISBEE",SUP-750-100,CDM,L8613,HCPCS,0278,RC,,,both,,,3074.55,922.36,"AETNA [10100]","Aetna HMO/PPO",,2444.27,79.5,,,,,0,232.31,2613.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 3.25MM ULTRA LOW PROFILE BALLOON",SUP-1012275-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACURATE NE02TM AORTIC VALVE M - CLINICAL",SUP-SYM-SV25-006-C,CDM,S62400003,LOCAL,0624,RC,,,both,,,159600.00,47880,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18561.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18561.48,135660,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRSSZR CEMENT YELLOW SMALL FEMUR CANAL",SUP-0206545000,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.71,37.41,"CIGNA [10200]",Cigna,,84.8,68,,,,,0,14.5,106,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER BIPOLAR 44MM 28MM TANDEM HIP COCR UHMW POLYETHYLENE",SUP-71322044,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"AETNA [10100]","Aetna HMO/PPO",,6640.2,79.5,,10981.53,8986.79,12413.38,12,971.39,7099.58,"percent of total billed charges",
"SYSTEM MULTI-LINK MINI VISION 12MM 2MM CORONARY STENT COCR",SUP-1007821-12,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 45MM ENDOWRIST GREEN",SUP-41445G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,991.44,68,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ESSURE BIRTH CONTROL 2 DEVICE VALVE INTRO CARD",SUP-ESS305,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1512.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X8MM COROENT XL PEEK TLIF NONSTERILE LATEX",SUP-6908845,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNETOS 1CC 1-2MM ALLOGRAFT GRANULE PUTTY GOLD",SUP-703-029-US,CDM,C1713,HCPCS,0278,RC,,,both,,,2550.00,765,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,302.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,296.57,2167.5,"percent of total billed charges",
"CATH EVERCROSS CROSSTEC 135CM 80MM 8MM .035IN BALLOON",SUP-AB35W08080135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"AETNA [10100]","Aetna HMO/PPO",,538.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM PFC SIGMA TC3 2 KNEE POSTERIOR TITANIUM",SUP-960828,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"FIRST HEALTH [10303]","First Health",,4104.67,80,,,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO SD FIRBERSTICK 25D TIGHT RIGHT CURVE 1.8",SUP-AR-4068-25TRF,CDM,S27200284,LOCAL,0272,RC,,,both,,,1513.89,454.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,176.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,176.07,1286.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo Necrosectomy",PX-750000218,CDM,48999,CPT,0750,RC,,,both,,,6476.86,1943.06,"NOVANET [10819]",Novanet,,4857.65,75,,,,,0,753.26,6476.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CXI 135CM 4FR SPRT STAINLESS STEEL HYDROPHILIC LOW",SUP-G52542,CDM,C1887,HCPCS,0272,RC,,,both,,,1522.72,456.82,"PHCS [10601]",PHCS,,1065.9,70,,,,,0,177.09,1294.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 34MM AXSOS LOCK NONSTERILE",SUP-661034,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,887.89,68,,,,,0,151.86,1109.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM ENDOSKELETON TCS TITANIUM STD SPINE",SUP-5301-3516,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 10.8MM 8MM CUFFED HOODED MAGILL CURVE",SUP-18780,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.81,14.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.68,41.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 5FR 1245ML/HR 1 LUMEN MICROINTRODUCER POWER",SUP-0700515,CDM,C1751,HCPCS,0272,RC,,,both,,,1717.50,515.25,"KAISER [10500]",Kaiser,,1150.73,67,,,,,0,199.75,1459.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 100CM 5FR BARNH CURVE ANGIOGRAPHIC CEREBRAL",SUP-M001314041,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"KAISER [10500]",Kaiser,,78.11,67,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET",RX-5604,CDM,,,0250,RC,68462-0639-25,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,3.57,56.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 45MM 2.1MM MICRO CARBIDE CROSS CUT FISSURE 7MM",SUP-0277010421,CDM,S27200284,LOCAL,0272,RC,,,both,,,54.98,16.49,"MULTIPLAN [10600]",Multiplan,,46.73,85,,,,,0,6.39,46.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D +3 CYL BICONVEX TORIC 13MM 6MM POSTERIOR CHMBR 1",SUP-SA25T5,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,213.22,28.62,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE 0.5 % (5 MG/ML) INJECTION SUPERORDERABLE",RX-4081223,CDM,J0665,HCPCS,0636,RC,00409-1162-01,NDC,both,10,ML,25.07,7.52,"CIGNA [10200]","Cigna Local Plus",,2.85,,,,,,,1.17,21.31,"fee schedule",
"SUT VICRYL MULTIPASS 5-0 PS-3 18IN BRAID COATED UNDYED",SUP-J500G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"NOVANET [10819]",Novanet,,18.75,75,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EX 139CM 15MM 2MM LONG RECTANGLE HELIX",SUP-2034-2015,CDM,C1725,HCPCS,0272,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 PC-5 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8631G,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.79,20.34,"FIRST HEALTH [10303]","First Health",,54.23,80,,,,,0,7.88,57.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 25MM 3.75MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP37525X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 20CM 3CM 6FR .035IN PIGTAIL",SUP-M006180220190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS [10001]","Blue Cross PPO",,496.03,39.2,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH LEAD EXTRACTION STEADYSHEATH EVOLUTION 36.5CM 11FR",SUP-LR-TSS-11.0,CDM,C1773,HCPCS,0272,RC,,,both,,,1875.00,562.5,"PHCS [10601]",PHCS,,1312.5,70,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000210,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM CLUSTER HOLE PRIMARY HEMISPHERICAL",SUP-502-03-46B,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1240.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1217.29,8896.8,"percent of total billed charges",
"TUBE JEJUNOSTOMY 12FR BALLOON 2-3ML SILICONE SECURELOK RIGHT",SUP-0200-12LV,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS 1 OS-4 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP695H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT DRNG 35CM 10FR FLEXIMA POLYURETHANE HYDROPHILIC BILIARY",SUP-M001271640,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 55CM .1IN 7FR .078IN RENAL",SUP-77821055,CDM,C1887,HCPCS,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ZELANTEDVT CLOTHUNTER THROMBECTOMY HELICAL ROTATION",SUP-114690-001,CDM,C1757,HCPCS,0272,RC,,,both,,,17640.00,5292,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"GRAFT SOFT TISSUE 3X2CM AMNIOFIX POSTERIOR",SUP-APS-5230,CDM,Q4433,HCPCS,0636,RC,,,both,,,5485.50,1645.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR ACETABULAR TRITANIUM X3 30MM 6.5MM CANCELLOUS HIP TORX",SUP-2080-0030,CDM,C1713,HCPCS,0278,RC,,,both,,,632.74,189.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",73.59,537.83,"percent of total billed charges",
"SCREW SPINAL PEDICLE POLYAXIAL 2FC TITANIUM 4.5MM X 40MM REL",SUP-16214540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 15MM ATLANTIS TITANIUM ANTERIOR CERVICAL",SUP-3125315,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]","Cigna Local Plus",,754.35,53.5,,3978.14,359.25,3978.14,24,163.98,1198.5,"percent of total billed charges",
"CABLE SIGNAL SYSTEM MODULE TO POWER MODULE",SUP-103859,CDM,Q0486,HCPCS,0274,RC,,,both,,,2910.00,873,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1978.8,68,,,,,0,338.43,2473.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 27CM 11MM .0135IN MICRUSFRAME MICRO",SUP-MFR141127,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X7MM 9/11MM SPINE CORTICAL FROZEN DISTAL",SUP-4907,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4471.2,27,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR PREPARATION OF TC-99M-BICISATE INTRAVENOUS SOLUTION (25-50 MCI)",RX-411701,CDM,A9557,HCPCS,0343,RC,08888-8877-41,NDC,both,1,UN,18910.08,5673.02,"KAISER [10500]",Kaiser,,12669.75,67,,,,,0,2199.24,16073.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SEEKER 90CM SPRT HYDROPHILIC PERIPHERAL RADIOPAQUE",SUP-SK9018,CDM,C1887,HCPCS,0272,RC,,,both,,,1498.50,449.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,177.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 32MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661032,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"CIGNA [10200]",Cigna,,887.89,68,,1831.33,1831.33,1831.33,16,151.86,1109.86,"percent of total billed charges",
"HEART VALVE EPIC MITRAL 25MM",SUP-E100-25M-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,24570.00,7371,"UHC [10700]","United Healthcare",,15552.81,63.3,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 16CM 12.7MM SECUR-FIT MAX HA 132D 10 41.7MM 35",SUP-6051-1035S,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"FIRST HEALTH [10303]","First Health",,12519.36,80,,,,,0,1820,13301.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC",261,MS-DRG,,,,,,,inpatient,,,72451.35,21735.4,"BLUE CROSS [10001]","Blue Cross HMO",,43399.81,,,,,,,7561,55195.04,"case rate",
"GRAFT SOFT TISSUE TUTOPLAST PERICARDIUM ALLOGRAFT",SUP-938227,CDM,C1762,HCPCS,0278,RC,,,both,,,6720.60,2016.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,781.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,781.61,5712.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 11MM 3FR GEMINI HELICAL",SUP-M0063301110,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"CIGNA [10200]","Cigna Local Plus",,791.56,53.5,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTOLOZANE-TAZOBACTAM 1.5 G/11.4ML IV (WET SOLR VIAL)",RX-415169198,CDM,J0695,HCPCS,0636,RC,67919-0030-01,NDC,both,1,UN,1052.44,315.73,"MULTIPLAN [10600]",Multiplan,,894.57,85,,,,,0,124.71,894.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 11MM 3FR GEMINI HELICAL",SUP-M0063301110,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,175.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LORAZEPAM 1 MG TABLET",RX-4573,CDM,,,0250,RC,00093-3426-01,NDC,both,1,UN,12.54,3.76,"CIGNA [10200]","Cigna Open Access",,7.14,56.9,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE EXAMINATION BFLEX SLIM 3.8 SINGLE USE X2",SUP-0570-0448,CDM,S27200284,LOCAL,0272,RC,,,both,,,1990.50,597.15,"CIGNA [10200]","Cigna Local Plus",,1064.92,53.5,,,,,0,231.5,1691.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS13030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1363.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 38MM 144CM 2.75MM CORONARY STENT",SUP-H7493911438270,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"NOVANET [10819]",Novanet,,6856.88,75,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN FEMORAL LEFT 3.5 CURVE",SUP-H74908526212,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 40CM 4FR ANGLE KUMPE CURVE ANGIOGRAPHIC",SUP-H787107343015,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - TIBIAL KIT (PS) - SIZE 4",SUP-5555-2364,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"AETNA [10100]","Aetna HMO/PPO",,804.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM G7 STD THR E1 HIP STEM CUP LINER HEAD PREM",SUP-98000100155,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"AETNA [10100]","Aetna HMO/PPO",,20034,79.5,,10981.53,8986.79,12413.38,12,2930.76,21420,"percent of total billed charges",
"HEAD RADIAL 12MM 22MM EXPLOR ELBOW MODULAR",SUP-11-210032,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"KAISER [10500]",Kaiser,,9523.38,67,,,,,0,1653.09,12081.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 95MM 32MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-217.095,CDM,C1713,HCPCS,0278,RC,,,both,,,485.35,145.6,"NOVANET [10819]",Novanet,,364.01,75,,,,,0,56.45,412.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP T CONE UNIVERSAL 12CM 8MM",SUP-60-5180-101,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.76,44.33,"CIGNA [10200]","Cigna Open Access",,84.08,56.9,,,,,0,17.18,125.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN LEFT CORONARY BYPASS CURVE",SUP-LA6LCB,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,266.22,68,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE",RX-11050,CDM,,,0637,RC,63044-0203-61,NDC,both,1,UN,6.27,1.88,"FIRST HEALTH [10303]","First Health",,5.02,80,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA STD TKR VIVACIT-E FEMUR PATELLA TIBIA CEM",SUP-98000647502,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9321.48,41.1,,6417.48,6417.48,6417.48,"1 through 10",2637.68,19278,"percent of total billed charges",
"DRILL SURGICAL SUBTALAR DYNANAIL HELIX 5MM",SUP-3100-01-0005,CDM,S27200284,LOCAL,0272,RC,,,both,,,5037.00,1511.1,"MULTIPLAN [10600]",Multiplan,,4281.45,85,,,,,0,585.8,4281.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH CONE LONG HANDLE 5MM 2 CUT EDGE SHARP STERILE",SUP-APU550,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,197.18,68,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PLEUR-EVAC 19IN 12FR TROCAR DRNG PVC THORAX DEPTH MARK",SUP-DSTC-12S,CDM,C1729,HCPCS,0272,RC,,,both,,,51.33,15.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,34.9,68,,,,,0,5.97,43.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER TUMARK BREAST BIOPSY PROFESSIONAL Q EVIVA PETITE",SUP-TUMARK-E13-P-Q-02,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"CIGNA [10200]",Cigna,,454.14,68,,,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X5MM COLONIAL 7D LORDOTIC 14MM XL TITANIUM",SUP-365.705CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 6-0 P-1 18IN MONOFILAMENT PLIABILIZE BLACK",SUP-697H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.402,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"KAISER [10500]",Kaiser,,927.37,67,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE NONPVC PRISMASOL BGK 2/3.5 STERILE LATEX FREE",SUP-110243S,CDM,S27200284,LOCAL,0272,RC,,,both,,,332.60,99.78,"AETNA [10100]","Aetna HMO/PPO",,264.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.68,282.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +14 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE 13",SUP-PCB0000140,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 98CM 18GA STEEPER PRIMARY BEVEL ANGLE STYLET PROC",SUP-G407212,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC",319,MS-DRG,,,,,,,inpatient,,,109934.38,32980.31,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,29621.51,,"Case rate ($27,683.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $25,706.14, add-ons for qualifying new technology services are included. If operating cost exceeds $58,745.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,325.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $25,740.13. The transfer operating threshold is the transfer adjustment factor * $25,706.14 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,943.51. The transfer capital threshold is the transfer adjustment factor * $1,943.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,7561,109934.38,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP 6IN MINI STRAIGHT LISTON 2 ACTION BONE CUTTING",SUP-33-5015S,CDM,S27200284,LOCAL,0272,RC,,,both,,,947.70,284.31,"FIRST HEALTH [10303]","First Health",,758.16,80,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 5FR 1245ML/HR 1 LUMEN MICROINTRODUCER POWER",SUP-0700515,CDM,C1751,HCPCS,0272,RC,,,both,,,1717.50,515.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,705.89,41.1,,,,,0,199.75,1459.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDURANT II AUI 2-PIECE CASE",SUP-ENDURANTIIAUI2,CDM,S27800098,LOCAL,0278,RC,,,both,,,108300.00,32490,"KAISER [10500]",Kaiser,,72561,67,,,,,0,12595.29,92055,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 20MM 5FR 10MM BALLOON DILATATION PEBAX",SUP-39032-10208,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL VISTA DIAL HEIGHT ADJUSTMENT MOTION",SUP-100071-000,CDM,S27000186,LOCAL,0270,RC,,,both,,,281.88,84.56,"FIRST HEALTH [10303]","First Health",,225.5,80,,,,,0,32.78,239.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP GLIDESCOPE LOPRO S4 TITANIUM VIDEO DISPOSABLE",SUP-0270-0939,CDM,S27200284,LOCAL,0272,RC,,,both,,,328.86,98.66,"CIGNA [10200]","Cigna Local Plus",,175.94,53.5,,,,,0,38.25,279.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH PROFILE BOOST, 190CC",SUP-SMHB190,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,903.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 1.8MM BUTTRESS VARIABLE ANGLE LOCKING T8",SUP-04.210.094,CDM,C1713,HCPCS,0278,RC,,,both,,,872.78,261.83,"MULTIPLAN [10600]",Multiplan,,741.86,85,,,,,0,101.5,741.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR AL2 CURVE GUIDING CORONARY",SUP-LA8AL20D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"FIRST HEALTH [10303]","First Health",,313.2,80,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 40MM 4MM BALLOON DILATATION PEBAX",SUP-H74939032404010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE WIDE TITANIUM 4 HOLE GEMINUS BONE RADIAL LEFT DISTAL",SUP-GMN-LTW-4HL,CDM,C1713,HCPCS,0278,RC,,,both,,,5161.20,1548.36,"BLUE CROSS [10001]","Blue Cross HMO",,2023.19,39.2,,957.42,156.86,7483.26,51,600.25,4387.02,"percent of total billed charges",
"SYSTEM SYNERGY 12MM 144CM 2.5MM CORONARY STENT PEBAX",SUP-H7493926012250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross PPO",,2181.48,39.2,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 4MM COOLCUT 8 FLUTE ROUND STERILE",SUP-AR-8400RBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"UHC [10700]","United Healthcare",,317.64,63.3,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE RIGHT FOOT 19MM STAINLESS STEEL 2MM SCR MINI FRAGMENT",SUP-243.34,CDM,C1713,HCPCS,0278,RC,,,both,,,1053.41,316.02,"CIGNA [10200]","Cigna Local Plus",,563.57,53.5,,3978.14,359.25,3978.14,24,122.51,895.4,"percent of total billed charges",
"WARFARIN 2.5 MG TABLET",RX-8750,CDM,,,0637,RC,68084-0027-11,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL BLACK EFLEX MONOPOLAR ABLATOR SHAFT",SUP-72200683,CDM,S27200284,LOCAL,0272,RC,,,both,,,3465.00,1039.5,"CIGNA [10200]","Cigna Open Access",,1971.59,56.9,,,,,0,402.98,2945.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 235MM 21MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-321,CDM,C1776,HCPCS,0278,RC,,,both,,,18758.25,5627.47,"CIGNA [10200]","Cigna Open Access",,6284.01,33.5,,5302.19,4377.88,6578.61,27,2181.58,15944.51,"percent of total billed charges",
"CATH JADE 135CM 100MM 6MM BALLOON DILATATION HYDROPHILIC",SUP-606010022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,84.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR",RX-70434,CDM,,,0637,RC,50228-0423-60,NDC,both,1,UN,25.19,7.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.56,45.9,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X11X7MM PEEK ANATOMIC",SUP-6240741,CDM,C1776,HCPCS,0278,RC,,,both,,,6678.42,2003.53,"FIRST HEALTH [10303]","First Health",,5342.74,80,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MERIT MAK VASCULAR 60CM .018IN PLATINUM STAINLESS",SUP-MAK005-60,CDM,C1894,HCPCS,0272,RC,,,both,,,255.78,76.73,"NOVANET [10819]",Novanet,,191.84,75,,,,,0,29.75,217.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 8-4MM TORNADO PRELOAD PLATINUM",SUP-G47523,CDM,S27800098,LOCAL,0278,RC,,,both,,,931.42,279.43,"CIGNA [10200]",Cigna,,633.37,68,,,,,0,108.32,791.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REVOLUTION BONE CEMENT FEMUR TOTAL MIXING KIT",SUP-0606593000,CDM,S27200284,LOCAL,0272,RC,,,both,,,963.70,289.11,"AETNA [10100]","Aetna HMO/PPO",,766.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.08,819.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL DURASORB 25X10CM MONOFILAMENT STERILE LATEX",SUP-PTM1025,CDM,C1781,HCPCS,0278,RC,,,both,,,14490.00,4347,"CIGNA [10200]","Cigna Open Access",,4854.15,33.5,,11235.02,819.42,11235.02,"1 through 10",1685.19,12316.5,"percent of total billed charges",
"PLATE CONTOUR MINI INCISION TENSION SIDE PLANTAR POWER BONE",SUP-SD20,CDM,C1713,HCPCS,0278,RC,,,both,,,11385.00,3415.5,"KAISER [10500]",Kaiser,,7627.95,67,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP BIPOLAR HIP Z1 STEM METAL HEAD INSERT",SUP-98000100277,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"UHC [10700]","United Healthcare",,6551.55,63.3,,8601.07,8395.67,8601.07,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"CAP CONSTRUCT TOTAL HIP BIPOLAR TANDEM NON-POROUS FEMUR WITH",SUP-71701460,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"FIRST HEALTH [10303]","First Health",,7728,80,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 4.75IN TROUTMAN DELICATE NDL CURVE ROUND HANDLE 9MM",SUP-60-1899,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL CERVICAL PRE BENT TITANIUM 3.5MM X 70MM RELINE-C",SUP-3943070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"CATH CORDIS INFINITI 100CM 6FR JL4.5 CURVE ANGIOGRAPHIC",SUP-534617T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"CIGNA [10200]",Cigna,,59.16,68,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 1CM UNIVERSAL 12CM 3/32IN STERILE",SUP-R2010,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.17,46.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,71.68,45.9,,,,,0,18.16,132.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 30CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192125010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"KAISER [10500]",Kaiser,,804.39,67,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 250MM 3MM BALLOON DILATATION DURALYN",SUP-48003025X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT SLIM CLEARVUE AIRGUARD",SUP-1618000,CDM,C1788,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1239.3,45.9,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X8MM COUGAR LS PARALLEL",SUP-189145408,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 128MM 13MM PRESS FIT REUNION SHOULDER STERILE",SUP-5569-P-2013,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5178.6,41.1,,6417.48,6417.48,6417.48,"1 through 10",1465.38,10710,"percent of total billed charges",
"SIZER MAMMARY SILICONE 475ML BREAST RESTERILIZABLE GEL",SUP-RSZ-4754,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"AETNA [10100]","Aetna HMO/PPO",,122.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 22MM STAINLESS STEEL 1.1MM ORTHOPEDIC SELF",SUP-S30-22S-11,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 165MM 4.5MM CANNULATED STOP 135MM JACOB CHUCK",SUP-03.010.089S,CDM,S27000186,LOCAL,0270,RC,,,both,,,2549.40,764.82,"CIGNA [10200]","Cigna Local Plus",,1363.93,53.5,,,,,0,296.5,2166.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 20MM 145CM 3.25MM BALLOON DILATATION",SUP-1400325-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR SR4 CURVE GUIDING CORONARY",SUP-LA6SR40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE MARKER 4 X 5 BIOZORB",SUP-F0405,CDM,A4648,HCPCS,0278,RC,,,both,,,7935.00,2380.5,"BLUE CROSS [10001]","Blue Cross PPO",,3110.52,39.2,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 55MM 135CM 5MM 160CM",SUP-M001711050,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"MULTIPLAN [10600]",Multiplan,,7184.63,85,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOLOIST 110CM 6FR 2-5-2MM SPACING CRD2 LONG CURVE",SUP-307F5,CDM,C1733,HCPCS,0272,RC,,,both,,,10005.00,3001.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1163.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VALVE AORTIC 15MM 27MM AVALUS ULTRA 27MM BOVINE PERIC",SUP-400U27,CDM,S27800098,LOCAL,0278,RC,,,both,,,36225.00,10867.5,"NOVANET [10819]",Novanet,,27168.75,75,,,,,0,4212.97,30791.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 12MM 100MM KII ABDOMINAL ADVANCE",SUP-CFS22,CDM,S27200284,LOCAL,0272,RC,,,both,,,119.63,35.89,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION",RX-36576,CDM,,,0250,RC,43598-0326-75,NDC,both,7.5,ML,1353.16,405.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE JAGWIRE ENDOSCOPIC 180CM .035IN PULMONARY DISPOSABLE",SUP-M00515171,CDM,C1769,HCPCS,0272,RC,,,both,,,997.07,299.12,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN NASAL UNOBTRUSIVE PRONG RETENTION OPTIFLOW WAVEFLEX",SUP-OJR412,CDM,S27000186,LOCAL,0270,RC,,,both,,,404.77,121.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET AUTOMATIC GAS VENT LEVEL 1 IRRIGATION 300- MMHG STERILE",SUP-IR-500,CDM,S27200284,LOCAL,0272,RC,,,both,,,273.35,82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT POLARIS 26CM 6FR URETERAL PERCUFLEX PLUS HYDROPLUS 2",SUP-M0061552330,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"FIRST HEALTH [10303]","First Health",,960.46,80,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT FIBERTAK BUTTON KNEE",SUP-AR-3780SP,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,1144.80,304.56,2275.09,66,434.96,3179,"percent of total billed charges",
"DEFIB CARDIAC 75X50X14MM PROMOTE PLUS CRT-D 36J TITANIUM CAN",SUP-CD3211-36Q,CDM,C1882,HCPCS,0278,RC,,,both,,,84445.50,25333.65,"UHC [10700]","United Healthcare",,53454,63.3,,,,,0,9821.01,71778.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 60MM 120CM 7MM 6FR VASCULAR NITINOL PERIPHERAL",SUP-S-70-060-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"PHCS [10601]",PHCS,,6399.75,70,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Femoral Insert Pikv",PX-E27200331,CDM,E27200331,LOCAL,0272,RC,,,both,,,304.70,91.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,139.86,45.9,,,,,0,35.44,259,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 9X20 80CM SL",SUP-48009002N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,353.05,41.1,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0175,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"PHCS [10601]",PHCS,,935.55,70,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 4CM 5MM BALLOON DILATATION",SUP-U815054,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175264070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"NOVANET [10819]",Novanet,,748.07,75,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL 1.5MM 5-8MM GRAFT LAPIDUS 4 HOLE COMPRESSION",SUP-P53-106-L002,CDM,C1713,HCPCS,0278,RC,,,both,,,9848.03,2954.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1166.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1145.33,8370.83,"percent of total billed charges",
"INSRT ARTICULAR 5-6 18MM KNEE CONSTRAIN UHMWPE GENESIS II",SUP-71420544,CDM,C1776,HCPCS,0278,RC,,,both,,,18474.75,5542.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4988.18,27,,,,,0,2148.61,15703.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 5CM CHIBA STERILE DISPOSABLE ASPIRATION",SUP-G02585,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"UHC [10700]","United Healthcare",,52.1,63.3,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 1.5% DEXTROSE 132 MEQ/L SODIUM 95 MEQ/L CHLORIDE 2.5",SUP-044-30321,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.07,15.92,"PHCS [10601]",PHCS,,37.15,70,,,,,0,6.17,45.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 75MM 3.5MM LORDOSIS TITANIUM",SUP-102063075,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 20MM NESTER MICROCOIL PLATINUM .035IN",SUP-G47350,CDM,S27800098,LOCAL,0278,RC,,,both,,,1020.52,306.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,292.07,28.62,,,,,0,118.69,867.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 54MM TITANIUM 2.4MM SCR 6X3 HOLE 2 COLUMN VARIABLE",SUP-04.111.631,CDM,C1713,HCPCS,0278,RC,,,both,,,4217.63,1265.29,"MULTIPLAN [10600]",Multiplan,,3584.99,85,,,,,0,490.51,3584.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 46MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.746,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"CIGNA [10200]","Cigna Open Access",,639.35,56.9,,1144.80,304.56,2275.09,66,130.68,955.09,"percent of total billed charges",
"STPLR INTERNAL 28X4.88MM TITANIUM CIRCULAR LINEAR CUTTER",SUP-EEA28,CDM,S27200284,LOCAL,0272,RC,,,both,,,1880.70,564.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1278.88,68,,,,,0,218.73,1598.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 52MM 26MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-52-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"NOVANET [10819]",Novanet,,3238.33,75,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM MASTER-SERIES PYROLYTIC CARBON PTFE",SUP-23AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY FEMORAL 95MM 20MM RECLAIM 40MM 12/14 OFFSET MINI TAPER",SUP-197520095,CDM,C1776,HCPCS,0278,RC,,,both,,,22082.76,6624.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2616.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2568.22,18770.35,"percent of total billed charges",
"SEPARATOR THROMBECTOMY 200CM .022IN INTRACRANIAL COMPATIBLE",SUP-PSS026,CDM,C1757,HCPCS,0272,RC,,,both,,,16491.00,4947.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11213.88,68,,,,,0,1917.9,14017.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLUE FLEXTIP 8IN 7FR CENTRAL VENOUS POLYURETHANE",SUP-ML-00703,CDM,C1751,HCPCS,0272,RC,,,both,,,285.36,85.61,"AETNA [10100]","Aetna HMO/PPO",,226.86,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.19,242.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE PT VASCULAR J INTERMEDIATE 182CM .014IN",SUP-H7491216101J1,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM SYNERGY 12MM 144CM 3.5MM CORONARY STENT PEBAX",SUP-H7493926012350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,647.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 6MM .0115IN AXIUM PRIME HELICAL",SUP-APB-6-12-HX-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,7169.10,2150.73,"CIGNA [10200]","Cigna Open Access",,4079.22,56.9,,,,,0,833.77,6093.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUARD PIN YELLOW JURGAN PIN BALL .054IN KIRSCHNER WIRE W",SUP-W045-YL,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.50,21.75,"NOVANET [10819]",Novanet,,54.38,75,,,,,0,8.43,61.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK 12X10IN THERAPEUTIC MOIST HEAT THERMAL COLOR CODED TABS",SUP-561725,CDM,S27000186,LOCAL,0270,RC,,,both,,,201.58,60.47,"AETNA [10100]","Aetna HMO/PPO",,160.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.44,171.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COAGULATION DISORDERS",813,MS-DRG,,,,,,,inpatient,,,31920.82,9576.25,"PHCS [10601]",PHCS,,7561,,,,,,,7561,31920.82,"per diem","Estimated amount calculated based on 3 day length of stay."
"NAIL 12MM 320MM FEMORAL PROXIMAL TFN-ADVANCED INTRAMEDULLARY",SUP-04.037.253S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3352.95,27,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"O.R. PROCEDURES FOR OBESITY WITH CC",620,MS-DRG,,,,,,,inpatient,,,95553.19,28665.96,"AETNA [10100]","Aetna HMO/PPO",,43279,,,,,,,7561,46722.36,"case rate",
"4.0 PLY SCRW 4.0X38",SUP-102040138,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,1144.80,304.56,2275.09,66,441.36,3225.75,"percent of total billed charges",
"INSRT TIBIAL 4 13MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G413,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3849.46,41.1,,6417.48,6417.48,6417.48,"1 through 10",1089.28,7961.17,"percent of total billed charges",
"GWIRE HI-TORQUE EXTRA SPORT VASCULAR STRAIGHT 300CM 3CM .014",SUP-22235M,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 755CC",SUP-SSZ-M755,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1013.47,68,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL ALLOGRAFT FROZEN 200-500MM 10+ MM",SUP-450455,CDM,S27800098,LOCAL,0278,RC,,,both,,,13132.08,3939.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5397.28,41.1,,,,,0,1527.26,11162.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP040100150 PLUS US D4L100UL1500",SUP-PCP040100150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,506.02,41.1,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 5MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120515,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"PHCS [10601]",PHCS,,8317.26,70,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 445CC P5.5CM MODERATE PLUS PROJECTION TALL",SUP-334-1309,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2616.58,28.62,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 7/8-5MM 10MM SPACEMAKER BLUNT CONVERTER",SUP-OMS-T10BT,CDM,C1727,HCPCS,0272,RC,,,both,,,1685.25,505.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,195.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,195.99,1432.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X11MM PRECISION 7D TRAPEZOID SPINE",SUP-7411,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 40MM 2.7MM DISPOSABLE",SUP-DRLL-SSC-27040,CDM,S27200284,LOCAL,0272,RC,,,both,,,753.30,225.99,"PHCS [10601]",PHCS,,527.31,70,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 4-0 9IN BRUNS BONE ANGLED TIP OVAL CUP SURGICAL",SUP-240139,CDM,S27100035,LOCAL,0271,RC,,,both,,,337.21,101.16,"CIGNA [10200]","Cigna Open Access",,191.87,56.9,,,,,0,39.22,286.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 4X250 135CM SL",SUP-48004025R,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,123.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.00 X 18 MM  RX FDA",SUP-1203300-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]",Cigna,,6900,40,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 14X13CM BREAST 600ML STYLE 133MX TEXTURED STERILE",SUP-133MX-14,CDM,C1789,HCPCS,0278,RC,,,both,,,5460.00,1638,"BLUE CROSS [10001]","Blue Cross PPO",,2140.32,39.2,,16595.83,16595.83,16595.83,"1 through 10",635,4641,"percent of total billed charges",
"SUT ULTRABRAID 2 38IN COBRAID NDL ASSEMB NONABSORBABLE",SUP-7211081,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"MULTIPLAN [10600]",Multiplan,,155.3,85,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC LARGE 13X3.5-3.75IN HAND LEFT ORTHOSIS",SUP-81096072,CDM,L3807,HCPCS,0274,RC,,,both,,,460.89,138.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,53.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.6,391.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS BLOCK ALLOGRAFT 7MM",SUP-290741,CDM,S27800098,LOCAL,0278,RC,,,both,,,3839.85,1151.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,455.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,446.57,3263.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 270CC P4.7CM MODERATE PLUS PROFILE TALL HEIGHT",SUP-334-1109,CDM,C1789,HCPCS,0278,RC,,,both,,,7583.10,2274.93,"AETNA [10100]","Aetna HMO/PPO",,6028.56,79.5,,,,,0,881.91,6445.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM MANTIS SPINE PEDICLE POLYAXIAL",SUP-48285640,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X7MM LORDOTIC SPINE CERVICAL CORTICAL",SUP-17007,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 CURVE PLUS 10MM KNEE XLK FIX BEARING SIGMA",SUP-970471,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4592.74,41.1,,6417.48,6417.48,6417.48,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 5N 8MM",SUP-TPS-030-085N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 260MM 4MM QUICK COUPLING 3 FLUTED CALIBRATED 65MM",SUP-357.407,CDM,S27200284,LOCAL,0272,RC,,,both,,,1279.15,383.74,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,587.13,45.9,,,,,0,148.77,1087.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 80MM 120CM 5MM LONG BILIARY NITINOL SELF",SUP-SC580L,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"BLUE CROSS [10001]","Blue Cross PPO",,2840.04,39.2,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPEEDBRIDGE SWIVELOCK FIBERTAPE 4.75MM FIXATION 2",SUP-AR-2600SBS-8,CDM,C1713,HCPCS,0278,RC,,,both,,,13179.00,3953.7,"FIRST HEALTH [10303]","First Health",,10543.2,80,,,,,0,1532.72,11202.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM .02IN 6MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0630,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.00,2003.4,"KAISER [10500]",Kaiser,,4474.26,67,,,,,0,776.65,5676.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM 1.7-2.4FR .017IN",SUP-M003C1775ST0,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"KAISER [10500]",Kaiser,,5171.89,67,,,,,0,897.75,6561.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM INTERLOCK IDC 35 COIL OCCLUSION",SUP-M001363520,CDM,S27800098,LOCAL,0278,RC,,,both,,,2827.50,848.25,"CIGNA [10200]",Cigna,,1922.7,68,,,,,0,328.84,2403.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION REUNION NITINOL PILOT STERILE LATEX FREE",SUP-5901-6072,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"BLUE CROSS [10001]","Blue Cross PPO",,298.47,39.2,,957.42,570.23,957.42,28,88.55,647.19,"percent of total billed charges",
"INSERT TIB SUBPCL #5/6X10MM",SUP-2142-1-5610,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"FIRST HEALTH [10303]","First Health",,2850,80,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HIP FEM POROUS OFFSET SZ7",SUP-425-96-007,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"CIGNA [10200]","Cigna Local Plus",,13405.91,31.5,,5372.07,4581.20,7242.98,23,4949.55,36174.68,"percent of total billed charges",
"DEVICE XPRESS ULTRA 1.5MM BALL SUPER SLEEK PROFILE 20MM 2.5",SUP-ULF-105,CDM,C1726,HCPCS,0272,RC,,,both,,,11364.30,3409.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1321.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1321.67,9659.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 56MM ACETABULAR SURGICAL",SUP-6210-0-815,CDM,S27200284,LOCAL,0272,RC,,,both,,,2463.75,739.12,"NOVANET [10819]",Novanet,,1847.81,75,,,,,0,286.53,2094.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ptca Aortic Valve",PX-480000045,CDM,92986,CPT,0481,RC,,,both,,,18690.43,5607.13,"MULTIPLAN [10600]",Multiplan,,15886.87,85,,,,,0,2173.7,18690.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 19MM RESTORATION +20MM HIP MODULAR",SUP-6276-1-219,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"PHCS [10601]",PHCS,,10126.77,70,,,,,0,1682.49,12296.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EMBOLIC PROTECTION 100CM VENA CAVA FILTER INTRO",SUP-352506100E,CDM,C1880,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"BLUE CROSS [10001]","Blue Cross HMO",,3381,39.2,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 12MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192112,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"UHC [10700]","United Healthcare",,15032.79,63.3,,8601.07,8395.67,8601.07,"1 through 10",2761.95,20186.21,"percent of total billed charges",
"BINDER ABDOMINAL 9IN ELASTIC PANEL CONTACT CLSR PROCARE",SUP-79-89071,CDM,S27000186,LOCAL,0270,RC,,,both,,,44.46,13.34,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,30.23,68,,,,,0,5.17,37.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Caregiver Training 1st 30 Min (Go)",PX-430000064,CDM,97550,CPT,0430,RC,,,both,,,90.21,27.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.49,90.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH THERMOCOOL SF 115CM 8FR F CURVE ABLATION",SUP-D131603,CDM,C1732,HCPCS,0272,RC,,,both,,,10149.90,3044.97,"NOVANET [10819]",Novanet,,7612.43,75,,,,,0,1180.43,8627.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS POWERFLEX P3 80CM 40MM 8MM 7.5MM BALLOON",SUP-4208040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPRT 44-46IN 3XL PAD SHOULDER STRAP REMOVABLE DRAIN BULB",SUP-46518-06LF,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RELIEVA SPIN 16MM 6MM M-110 GUIDING MAXILLARY SINUS",SUP-RSM110,CDM,C1726,HCPCS,0272,RC,,,both,,,2400.00,720,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP SURGICAL RANEY INFANT SCALP TEMPORARY GUN KIT PLASTIC",SUP-201037,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.18,38.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEALER/DIVIDER BIPOLAR 37CM LIGASURE MARYLAND 350D 18MM 1",SUP-LF1937,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COMPONENT FEMORAL 4N KNEE LEFT CRUCIATE RETAINING PFC SIGMA",SUP-940019,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"CIGNA [10200]",Cigna,,10355.94,40,,5873.17,5873.17,5873.17,"1 through 10",3010.99,22006.37,"percent of total billed charges",
"STPLR INTERNAL STERILE LATEX FREE DISPOSABLE SUREFORM 45 14",SUP-480445,CDM,S27200284,LOCAL,0272,RC,,,both,,,3622.50,1086.75,"PHCS [10601]",PHCS,,2535.75,70,,,,,0,421.3,3079.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +5.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000055,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 42MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.442TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"CIGNA [10200]","Cigna Local Plus",,1081.53,53.5,,3978.14,359.25,3978.14,24,235.11,1718.32,"percent of total billed charges",
"POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV",RX-9807,CDM,J3480,HCPCS,0258,RC,00990-7904-09,NDC,both,1000,ML,100.65,30.19,"KAISER [10500]",Kaiser,,67.44,67,,,,,0,0.02,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Antiannexin V-Igg",PX-301000261,CDM,83520,CPT,0301,RC,,,both,,,373.00,111.9,"BLUE CROSS [10001]","Blue Cross HMO",,0.37,.1,,,,,0,0.37,317.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy US Ea 15min (Gp)",PX-420000020,CDM,97035,CPT,0420,RC,,,both,,,163.34,49,"BLUE CROSS [10001]","Blue Cross PPO",,163.34,,"Per diem ($371.22).",,,,0,19,163.34,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE REVERSE REVISION HUMERAL STEM, SZ 10X175MM",SUP-530-10-175,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Open Access",,4221,33.5,,5302.19,4377.88,6578.61,27,1465.38,10710,"percent of total billed charges",
"BLADE SAW 18.5X5.5X.4MM HALL MICRO STAINLESS STEEL",SUP-5023-162,CDM,S27200284,LOCAL,0272,RC,,,both,,,220.37,66.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.63,187.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 23MM 145CM 3.5MM CORONARY STENT",SUP-1125350-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"KAISER [10500]",Kaiser,,3911.46,67,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC XL 23.5-26.5IN KNEE WRAP AROUND LONG FLEX",SUP-14012008,CDM,S27000186,LOCAL,0270,RC,,,both,,,737.59,221.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,87.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,85.78,626.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL INFINITY 4 LONG",SUP-33650014,CDM,C1776,HCPCS,0278,RC,,,both,,,29049.30,8714.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8313.91,28.62,,,,,0,3378.43,24691.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SIZE ADJUSTMENT TOOL AND IMPLANT LOCKER",SUP-25100ST,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.7MM 70MM 18MM LOW PROFILE SCREWS TITANIUM 3.5MM",SUP-AR-8967-1870,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,860.63,45.9,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM CORTICAL",SUP-58913516,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"KAISER [10500]",Kaiser,,759.78,67,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERSACROSS SHEATH 63CM 90DEG D1",SUP-VXS0206,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,665.82,41.1,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 30MM 6FR 6MM 4FR BALLOON",SUP-H74939031603010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 44MM GLENOID SCR RSP",SUP-508-44-101,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"UHC [10700]","United Healthcare",,7718.3,63.3,,8601.07,8395.67,8601.07,"1 through 10",1418.07,10364.22,"percent of total billed charges",
"GRAFT BONE OSTEOAMP 10CC 2MM ALLOGRAFT GRANULE",SUP-12600501,CDM,C1713,HCPCS,0278,RC,,,both,,,12431.25,3729.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3356.44,27,,,,,0,1445.75,10566.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 60MM 10MM PRESS FIT REMOVABLE TRUNION SUT HOLE",SUP-AR-9100-10S,CDM,C1776,HCPCS,0278,RC,,,both,,,10713.60,3214.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1245.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1245.99,9106.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION",RX-16169,CDM,,,0250,RC,63323-0418-01,NDC,both,20,ML,1509.40,452.82,"UHC [10700]","United Healthcare",,955.45,63.3,,,,,0,175.54,1282.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 7 UNIVERSAL KNEE TOTAL STABILIZE",SUP-5521-B-700,CDM,C1776,HCPCS,0278,RC,,,both,,,14427.90,4328.37,"CIGNA [10200]",Cigna,,5771.16,40,,5873.17,5873.17,5873.17,"1 through 10",1207.77,12263.72,"percent of total billed charges",
"IMPL BREAST 385CC SMOOTH SHELL SURFACE NATRELLE INSPIRA FULL",SUP-SRF-385,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"KAISER [10500]",Kaiser,,3675.29,67,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 58MM 80CM 6MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU0800658,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"AETNA [10100]","Aetna HMO/PPO",,20785.28,79.5,,,,,0,3040.66,22223.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH XP 135CM 5FR RAVI MG2 CURVE ANGIOGRAPHIC",SUP-RF*ZUF511DJM,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 105MM 32MM LC-DCP STAINLESS STEEL CANCELLOUS",SUP-217.105,CDM,C1713,HCPCS,0278,RC,,,both,,,485.35,145.6,"NOVANET [10819]",Novanet,,364.01,75,,,,,0,56.45,412.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 8 132D",SUP-6720-0837,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"UHC [10700]","United Healthcare",,15167.98,63.3,,8601.07,8395.67,8601.07,"1 through 10",2786.79,20367.74,"percent of total billed charges",
"COIL EMBOLIZATION 25CM .02IN 8MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0825,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.00,2003.4,"CIGNA [10200]",Cigna,,4541.04,68,,,,,0,776.65,5676.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SPINAL 5MM SPINEJACK EXPANSION",SUP-0909-200-050,CDM,S27200284,LOCAL,0272,RC,,,both,,,8966.41,2689.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1062.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1042.79,7621.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 100MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-583510022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1018.98,68,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 5.5MM 6MM SPINE TITANIUM EXT NONSTERILE",SUP-04.633.002,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,414.32,3028.13,"percent of total billed charges",
"FRCP SURGICAL GIRAFFE 45D 2MM 5.25IN FRONTAL SINUS 2 ACTION",SUP-63-8845,CDM,S27200284,LOCAL,0272,RC,,,both,,,3430.28,1029.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,406.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,398.94,2915.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 4CM 4MM BALLOON",SUP-G52252,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"UHC [10700]","United Healthcare",,607.53,63.3,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 5.00 X 20MM",SUP-H7493942820500,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"AMERIGROUP MEDICAID [20100]",Amerigroup,,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PLASTIBELL 1.3CM CIRCUMCISION PLASTIC PEDIATRIC",SUP-9233,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.69,17.61,"KAISER [10500]",Kaiser,,39.32,67,,,,,0,6.83,49.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT TAPERED COMPONENT",SUP-G47480,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"KAISER [10500]",Kaiser,,68761.1,67,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 7FR ELECTROPHYSIOLOGY DUO DECAPOLAR",SUP-D139801,CDM,C1731,HCPCS,0272,RC,,,both,,,7086.30,2125.89,"NOVANET [10819]",Novanet,,5314.73,75,,,,,0,824.14,6023.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC",863,MS-DRG,,,,,,,inpatient,,,38004.56,11401.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,19809.31,,"Fee schedule rate ($19,809.31). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,6190.04,24886.63,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA EZ GLIDE AORTIC 24FR",SUP-EZF24TA,CDM,S27200284,LOCAL,0272,RC,,,both,,,385.15,115.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,45.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.79,327.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT FIRST PASS STERILE",SUP-224036,CDM,S27200284,LOCAL,0272,RC,,,both,,,1523.61,457.08,"FIRST HEALTH [10303]","First Health",,1218.89,80,,,,,0,177.2,1295.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET 5.5/6MM CD HORIZON SOLERAL VOYAGER NONSTERILE LATEX",SUP-6540530,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",40.47,295.8,"percent of total billed charges",
"CATH EVERCROSS CROSSTEC 135CM 40MM 9MM .035IN BALLOON",SUP-AB35W09040135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"MULTIPLAN [10600]",Multiplan,,575.59,85,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 7X 38MM CATH 120CM ENDOVASCULAR",SUP-42738,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"PHCS [10601]",PHCS,,12264.21,70,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP SECTOR POROCOAT PINNACLE STERILE",SUP-121722052,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,780.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,780.46,5704.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREONPANOPTIX PROTORIC(BLF)",SUP-PXYWT5,CDM,V2787,HCPCS,0276,RC,,,both,,,915.00,274.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,108.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 3.5MM OASYS OCCIPITOCERVICOTHORACIC SPINE",SUP-48552050,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Open Access",,2509.29,56.9,,1144.80,304.56,2275.09,66,512.88,3748.5,"percent of total billed charges",
"CAP SYSTEM TKR POROUS FEMUR TIBIA",SUP-98000671001,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"CIGNA [10200]",Cigna,,9324,40,,5873.17,5873.17,5873.17,"1 through 10",2710.95,19813.5,"percent of total billed charges",
"SPACER ALLOGRAFT 22-24X27-32X9MM LUMINARY CC BICONVEX SPINE",SUP-16809,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"MULTIPLAN [10600]",Multiplan,,28274.4,85,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL VANTAGE THK8MM 2 ANKLE LEFT STERILE LATEX FREE",SUP-350-21-22,CDM,C1713,HCPCS,0278,RC,,,both,,,8832.00,2649.6,"NOVANET [10819]",Novanet,,6624,75,,,,,0,1027.16,7507.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 100CM .016IN KT STRG",SUP-6826,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 75CM 7MM 30MM",SUP-38046-73075,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]","Cigna Open Access",,2748.27,56.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 120MM 4FR 3MM .018IN BALLOON",SUP-PCP030120130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,837.22,68,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUETIAPINE 100 MG TABLET, IMMEDIATE RELEASE",RX-21824,CDM,,,0637,RC,00904-6640-61,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MTRL SPLINTING THK1/8IN 24X18IN 19% PERFORATE LATEX FREE",SUP-A963111,CDM,S27000186,LOCAL,0270,RC,,,both,,,707.05,212.11,"AETNA [10100]","Aetna HMO/PPO",,562.1,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,82.23,600.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 140MM 120CM 16MM .035IN VASCULAR VENOUS CATH",SUP-VENUL16140,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2710.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM SPINE POLYAXIAL REVOLVE",SUP-185.454,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1110.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1110.3,8114.82,"percent of total billed charges",
"TUBE JEJUNOSTOMY 57.9CM 24FR TUNGSTEN SILICONE MIC SECUR-LOK",SUP-8210-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"AETNA [10100]","Aetna HMO/PPO",,1147.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X14X6MM PEEK TITANIUM COMPOSITE ANATOMIC",SUP-5030664,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA [10200]","Cigna Local Plus",,3572.95,53.5,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EPIDURAL 3.5IN 17GA 19GA FLEXTIP PLUS SNAPLOCK CATH NDL",SUP-AK-05502,CDM,C1755,HCPCS,0278,RC,,,both,,,191.57,57.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,54.83,28.62,,,,,0,22.28,162.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 3FR 20CM POWERMIDLINE NURSING FULL 1 LUMEN DISTAL",SUP-P4153108,CDM,C1751,HCPCS,0272,RC,,,both,,,941.87,282.56,"AETNA [10100]","Aetna HMO/PPO",,748.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,109.54,800.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH-PROFILE BOOST, 280CC",SUP-SMHB280,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3499.65,45.9,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 40MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.630,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,134.52,983.18,"percent of total billed charges",
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 10MM 1.5MM",SUP-SPL15010X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE BEAVER 6900",SUP-376900,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.37,34.91,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATH 4FR 20CM POWERMIDLINE MICROEZ FLEXURA STATLOCK",SUP-P4154108,CDM,C1751,HCPCS,0272,RC,,,both,,,941.87,282.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 6MM 2.25MM .017IN",SUP-H7493926706220,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAFESHEATH INTRDCR FR11 LONG - EACH",SUP-668005-001,CDM,C1892,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ASAHI VASCULAR J 330CM RG3 PTCA",SUP-AHW10S302S,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BAG SPECIMEN RETRIEVAL 10MM INZII MONARCH UNIVERSAL",SUP-CD001,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PUSHER CUTTER SLOT CANN SET KNOT FAST-FIX 360D STRAIGHT",SUP-72202674,CDM,S27200284,LOCAL,0272,RC,,,both,,,1049.76,314.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,713.84,68,,,,,0,122.09,892.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM CREO SPINE POLYAXIAL NONSTERILE 5.5MM",SUP-5119.1645,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]",Cigna,,6491.86,68,,1831.33,1831.33,1831.33,16,1110.3,8114.82,"percent of total billed charges",
"GRAFT VOID FILLER SYNTHETIC NANOSS 3D PLUS 5CC",SUP-90-400-25504,CDM,C1713,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1023.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1023.15,7477.88,"percent of total billed charges",
"SCR BONE 6.5MM 90MM TITANIUM SHORT THREAD CANNULATED",SUP-04.353.790,CDM,C1713,HCPCS,0278,RC,,,both,,,2240.85,672.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,265.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,260.61,1904.72,"percent of total billed charges",
"STENT EPIC 100MM 120CM 6MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200061020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,481.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR 12X150MM KII FIOS ADV FIX",SUP-CFB71,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"MULTIPLAN [10600]",Multiplan,,155.3,85,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE PACING BEIGE 8FT SMALL LARGE ATRIAL VENTRICULAR SMALL",SUP-S-101-97,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.45,51.13,"AETNA [10100]","Aetna HMO/PPO",,135.51,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.82,144.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 24MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-224,CDM,C1776,HCPCS,0278,RC,,,both,,,17822.70,5346.81,"UHC [10700]","United Healthcare",,11281.77,63.3,,8601.07,8395.67,8601.07,"1 through 10",2072.78,15149.3,"percent of total billed charges",
"SUT CHROMIC 2-0 UR-6 27IN MONOFILAMENT ABSORBABLE",SUP-N878H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM RELINE 2C SPINE POLYAXIAL NONSTERILE",SUP-16016545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1110.3,8114.82,"percent of total billed charges",
"SCR BONE 6.5MM 40MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850016540,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"PHCS [10601]",PHCS,,4588.5,70,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIGESTIVE MALIGNANCY WITH CC",375,MS-DRG,,,,,,,inpatient,,,40215.22,12064.57,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,7728.32,,"Case rate ($7,503.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,967.25, add-ons for qualifying new technology services are included. If operating cost exceeds $40,006.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,908.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $6,976.46. The transfer operating threshold is the transfer adjustment factor * $6,967.25 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $526.76. The transfer capital threshold is the transfer adjustment factor * $526.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7503.22,30166.21,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE PACING BEIGE 8FT SMALL LARGE ATRIAL VENTRICULAR SMALL",SUP-S-101-97,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.45,51.13,"FIRST HEALTH [10303]","First Health",,136.36,80,,,,,0,19.82,144.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 18MM AXSOS STAINLESS STEEL HUMERUS FEMUR TIBIA",SUP-370318,CDM,C1713,HCPCS,0278,RC,,,both,,,1376.51,412.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,393.96,28.62,,,,,0,160.09,1170.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL PEDIATRIC O2 RESVR BAG TODDLER MASK PEEP VALVE",SUP-530213000,CDM,S27000186,LOCAL,0270,RC,,,both,,,60.81,18.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.07,51.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 TAPER 28MM HIP OXINIUM ECHELON",SUP-71342800,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4194.54,27,,,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PROC 1 TRIATHLON PS DISPOSABLE FEMORAL",SUP-5555-2251,CDM,C1776,HCPCS,0278,RC,,,both,,,1417.50,425.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,164.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tumor Immunohistochem Cad",PX-312000046,CDM,88361,CPT,0312,RC,,,both,,,615.33,184.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,282.88,,,,,,,0.01,523.03,"fee schedule",
"CATH WEBSTER 115CM 6FR 10MM SPACE ELECTROPHYSIOLOGY FIX 4",SUP-F6QD010RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"NOVANET [10819]",Novanet,,680.4,75,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 1 CT-1 36IN BRAID ANTIBACTERIAL COATED",SUP-VCP347H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Open Access",,14.23,56.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 116MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 9",SUP-71357009,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3927.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0328,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,110.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",110.22,805.55,"percent of total billed charges",
"SCR BONE 2.6MM 7MM CENTERPIECE TITANIUM SPINE SELF TAP STAB",SUP-853-467,CDM,C1713,HCPCS,0278,RC,,,both,,,443.23,132.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,126.85,28.62,,,,,0,51.55,376.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 20MM 144CM 3MM CORONARY STENT PEBAX",SUP-H7493926020300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross PPO",,2181.48,39.2,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD 5MM BIPOLAR IS-1",SUP-6162,CDM,C1883,HCPCS,0278,RC,,,both,,,2625.00,787.5,"KAISER [10500]",Kaiser,,1758.75,67,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 33CM TIBIAL T2 INTRAMEDULLARY STD LOCK TITANIUM",SUP-1822-0933S,CDM,C1713,HCPCS,0278,RC,,,both,,,8804.12,2641.24,"UHC [10700]","United Healthcare",,5573.01,63.3,,5023.51,2672.93,6679.78,18,1023.92,7483.5,"percent of total billed charges",
"CABLE LIGHT MAXCESS LIGHT GUIDE STERILE DISPOSABLE",SUP-3200220,CDM,S27000186,LOCAL,0270,RC,,,both,,,2973.75,892.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,352.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,345.85,2527.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH SAFESHEATH HO CURVE 60CM 7FR",SUP-WORLEY/B-60-07-HO,CDM,C1893,HCPCS,0272,RC,,,both,,,3345.00,1003.5,"NOVANET [10819]",Novanet,,2508.75,75,,,,,0,389.02,2843.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE RELINE L45 MM OD6.5 MM SPINE POLYAXIAL 2 FULL CAN",SUP-16216545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 16MM LOW PROFILE SCREWS TITANIUM FULL THREAD",SUP-AR-8933-16,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"BLUE CROSS [10001]","Blue Cross HMO",,349.27,39.2,,957.42,156.86,7483.26,51,103.62,757.35,"percent of total billed charges",
"SYSTEM REBEL 12MM 140CM 3MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927412300,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]",Cigna,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UROLOGICAL STD 150CM 3CM .035IN LUBRIGLIDE STRAIGHT",SUP-M0066001250,CDM,C1769,HCPCS,0272,RC,,,both,,,247.43,74.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,28.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.78,210.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 195MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-410-195,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,1144.80,304.56,2275.09,66,2014.9,14726.25,"percent of total billed charges",
"COIL EMBOLIZATION 20CM 6MM TARGET XL LARGE HELICAL",SUP-M0036116200,CDM,S27800098,LOCAL,0278,RC,,,both,,,12419.24,3725.77,"CIGNA [10200]","Cigna Local Plus",,3912.06,31.5,,,,,0,1444.36,10556.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 15CM 18GA SIDEKICK 2 ERGONOMIC HUB",SUP-RFK-C151018S-ZK2-P,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.95,74.38,"CIGNA [10200]","Cigna Open Access",,141.08,56.9,,,,,0,28.84,210.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE COROLENE 3-0 PLEDGETED",SUP-20S20AQ,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.97,17.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.86,50.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 16MM XTEND SPINE VARIABLE ANGLE SELF TAP",SUP-161.316,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 22MM 8MM STAINLESS STEEL LONG THREAD HAND",SUP-02.226.322,CDM,C1713,HCPCS,0278,RC,,,both,,,1647.00,494.1,"FIRST HEALTH [10303]","First Health",,1317.6,80,,,,,0,191.55,1399.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 5MM DELTAFILL 18 COIL",SUP-DLF180520,CDM,S27800098,LOCAL,0278,RC,,,both,,,14145.00,4243.5,"CIGNA [10200]","Cigna Local Plus",,4455.68,31.5,,,,,0,1645.06,12023.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) STERILE TRICUSPID VALVE 180MM",SUP-ES0366-05,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL TRIATHLON X3 3 H16 MM KNEE TOTAL STABILIZE PLU",SUP-5537-G-316-E,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"CIGNA [10200]",Cigna,,5383.38,40,,5873.17,5873.17,5873.17,"1 through 10",1565.22,11439.68,"percent of total billed charges",
"SCR INTERFERENCE 30MM 11MM 60 FULL THREAD COMPOSITCP",SUP-905263,CDM,C1713,HCPCS,0278,RC,,,both,,,3075.00,922.5,"MULTIPLAN [10600]",Multiplan,,2613.75,85,,,,,0,357.62,2613.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED 100CM 6CM 9FR 30MM BALLOON DILATATION RADIOPAQUE",SUP-611560,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,618.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 400ML GEL SMOOTH MEMORYGEL SILICONE P5CM HIGH","SUP-3504004 BC",CDM,S27200284,LOCAL,0272,RC,,,both,,,4823.10,1446.93,"KAISER [10500]",Kaiser,,3231.48,67,,,,,0,560.93,4099.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP BIPOLAR HIP SYSTEM WITH PRESS-FIT STEM",SUP-98000700019,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"FIRST HEALTH [10303]","First Health",,8280,80,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 9IN LAMBOTTE SPINE SURGICAL CURVE .75IN",SUP-28-9470,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.03,72.01,"PHCS [10601]",PHCS,,168.02,70,,,,,0,27.92,204.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX 11CM OPEN POSITION SYSTEM STERILE",SUP-1220011,CDM,C1781,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRONABINOL 2.5 MG CAPSULE",RX-9904,CDM,Q0167,HCPCS,0250,RC,67877-0753-60,NDC,both,1,UN,39.13,11.74,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRAIN INCISION 14FR 12IN DEAVER NATURAL RUBBER 5IN T TUBE",SUP-0099820,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.29,18.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PAD THERAPEUTIC 12X11.34IN COLD WRAP ON REGULAR HOSE XL",SUP-11-0681-9-00000,CDM,S27000187,LOCAL,0270,RC,,,both,,,157.38,47.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 150MM 18GA 10MM",SUP-AC0007,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH AMPLATZ 17CM 14FR ACCESS PTFE RENAL FIRM TAPER TIP",SUP-M0062601450,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ATTAIN GUIDING",SUP-6250MP01,CDM,C1887,HCPCS,0272,RC,,,both,,,1377.00,413.1,"MULTIPLAN [10600]",Multiplan,,1170.45,85,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM VERTEX MAX TITANIUM SPINE MULTIAXIAL",SUP-6958724,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"FIRST HEALTH [10303]","First Health",,3360,80,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DUODENOSCOPE FLEXIBLE EXALT MODEL D DISPOSABLE",SUP-M00542423,CDM,C1748,HCPCS,0272,RC,,,both,,,18459.00,5537.7,"CIGNA [10200]",Cigna,,12552.12,68,,,,,0,2146.78,15690.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 5.5MM CD HORIZON CURVE TITANIUM NONSTERILE",SUP-1553201045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 97MM TRI-LOCK BPS GRIPTION 1 STD OFFSET HIP",SUP-101204010,CDM,C1776,HCPCS,0278,RC,,,both,,,29153.25,8745.97,"FIRST HEALTH [10303]","First Health",,23322.6,80,,,,,0,3390.52,24780.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC HOOK TRIANGLE PACK ENDOTRAC PLANTAR",SUP-3056,CDM,S27200284,LOCAL,0272,RC,,,both,,,2101.05,630.31,"CIGNA [10200]",Cigna,,1428.71,68,,,,,0,244.35,1785.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 9IN LAMBOTTE SYMMETRY SURGICAL CURVE 1.5IN",SUP-28-9490,CDM,S27200284,LOCAL,0272,RC,,,both,,,267.44,80.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,109.92,41.1,,,,,0,31.1,227.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 5MM 58MM NAIL-EX TITANIUM FULL THREAD FEMORAL TIB",SUP-04.005.548,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,134.52,983.18,"percent of total billed charges",
"CATH SABERX 200CM 250MM 4MM BALLOON DILATATION RAPID",SUP-47540250L,CDM,C1725,HCPCS,0272,RC,,,both,,,1890.00,567,"AETNA [10100]","Aetna HMO/PPO",,1502.55,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 5MM 58MM NAIL-EX TITANIUM FULL THREAD FEMORAL TIB",SUP-04.005.548,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,134.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",134.52,983.18,"percent of total billed charges",
"SHEATH GUIDING 62CM 8FR .11IN PREFACE MULTIPURPOSE SHORT",SUP-301803MS,CDM,C1893,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AMPLATZ 30CM 30FR DIL OPAQUE",SUP-G57473,CDM,C1894,HCPCS,0272,RC,,,both,,,284.49,85.35,"PHCS [10601]",PHCS,,199.14,70,,,,,0,33.09,241.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 10X10CM ALLOGRAFT SHEET FORMAT STERILE",SUP-RU-1010,CDM,S27800098,LOCAL,0278,RC,,,both,,,25200.00,7560,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10357.2,41.1,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 6X 22MM CATH 80CM ENDOVASCULAR",SUP-48622,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 26CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155223180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO SD 25D TIGHT RIGHT CURVE 1.8MM 3.8MM",SUP-AR-4068-25TR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1190.70,357.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,141.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14CM NATRELLE INSPIRA P4.6CM MODERATE PROFILE",SUP-MSZ-M485,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PHCS [10601]",PHCS,,110.73,70,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 45MM 135CM 6MM 160CM",SUP-M001711110,CDM,C1876,HCPCS,0278,RC,,,both,,,8728.50,2618.55,"CIGNA [10200]","Cigna Open Access",,4966.52,56.9,,,,,0,1015.12,7419.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDO PDS II MULTIPASS 4-0 PS-2 18IN MONOFILAMENT UNDYED",SUP-Z496G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 1.5MM AXIUM PRIME HELIX DETACHABLE",SUP-APB-1.5-4-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"FIRST HEALTH [10303]","First Health",,7148.4,80,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF CONDUCTR 110CM 4MM 7FR 2-5-2MM SPACE 40-60MM REACH",SUP-0786022,CDM,C1733,HCPCS,0272,RC,,,both,,,3967.50,1190.25,"AETNA [10100]","Aetna HMO/PPO",,3154.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 24CM 3CM 7FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155242050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,837.05,68,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Urinalysis Qual or Semiquant",PX-307000004,CDM,81005,CPT,0307,RC,,,both,,,197.00,59.1,"PHCS [10601]",PHCS,,137.9,70,,,,,0,1.47,167.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aquaporin-4 Antb Cba Each",PX-302000251,CDM,86052,CPT,0302,RC,,,both,,,751.45,225.43,"KAISER [10500]",Kaiser,,503.47,67,,,,,0,0.01,638.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Ctrl Bld",PX-750000079,CDM,45334,CPT,0750,RC,,,both,,,3094.10,928.23,"CIGNA [10200]","Cigna Open Access",,2090,,"Case rate ($2,090). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,359.84,3094.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 35MM 12MM DELTA ACL CANNULATED",SUP-AR-5035TC-12,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"PHCS [10601]",PHCS,,1295.44,70,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 65CM 4FR .041IN STRAIGHT",SUP-CG412,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 5MM MREYE ARTERIAL VENOUS PLATINUM 3.2",SUP-G42460,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,567.27,68,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 22FR URETHRAL HYDROPHILIC 5ML FOLEY 3",SUP-0174L22,CDM,S27200284,LOCAL,0272,RC,,,both,,,854.39,256.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,99.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.37,726.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRANSITION VENTILATOR NASAL INTERFACE HIGH FLOW XL OPTIF",SUP-OJR418VT,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR TRABECULAR METAL CERAMIC XLPE STEM CUP LINER",SUP-98000571502,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"UHC [10700]","United Healthcare",,15154.02,63.3,,8601.07,8395.67,8601.07,"1 through 10",2784.22,20349,"percent of total billed charges",
"NAIL 4.5MM 45MM HAND INNATE INTRAMEDULLARY ANATOMIC",SUP-EXINN924545,CDM,C1713,HCPCS,0278,RC,,,both,,,5002.50,1500.75,"CIGNA [10200]","Cigna Open Access",,2846.42,56.9,,1144.80,304.56,2275.09,66,581.79,4252.13,"percent of total billed charges",
"GRAFT VASCULAR 30CM 8MM HEMASHIELD GOLD STRAIGHT MICROVEL 2",SUP-M002020954080,CDM,C1768,HCPCS,0278,RC,,,both,,,3508.58,1052.57,"CIGNA [10200]","Cigna Open Access",,1996.38,56.9,,,,,0,408.05,2982.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 8MM HEMASHIELD GOLD STRAIGHT MICROVEL 2",SUP-M002020954080,CDM,C1768,HCPCS,0278,RC,,,both,,,3508.58,1052.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1610.44,45.9,,,,,0,408.05,2982.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 16CM NARROW BASE INFRAPUBIC NARROW CORPORA",SUP-EN8816,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]",Cigna,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X22X8MM COROENT WIDE XL",SUP-6908260,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"PHCS [10601]",PHCS,,16632,70,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 15MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50015,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22416.67,27,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ptt Mixng Studies",PX-305000065,CDM,85730,CPT,0305,RC,,,both,,,182.40,54.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.18,.1,,,,,0,0.18,155.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X20MM COLOSSEUM 12MM MESH NONSTERILE LATEX",SUP-156.205,CDM,S27800098,LOCAL,0278,RC,,,both,,,27184.50,8155.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7780.2,28.62,,,,,0,3161.56,23106.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2.5 KNEE RIGHT CEMENTED POSTERIOR STABILIZE",SUP-196050250,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2862,28.62,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2.5 KNEE RIGHT CEMENTED POSTERIOR STABILIZE",SUP-196050250,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"PHCS [10601]",PHCS,,7000,70,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Non Weighted Prosthesis",PX-E27000250,CDM,L8020,HCPCS,0270,RC,,,both,,,705.10,211.53,"CIGNA [10200]",Cigna,,479.47,68,,,,,0,82,599.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 30CC CRUSH FROZEN 1-10MM",SUP-800108,CDM,S27800098,LOCAL,0278,RC,,,both,,,2777.25,833.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1274.76,45.9,,,,,0,322.99,2360.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 15X13.6CM 580ML STYLE 410MF HIGHLY COHESIVE GEL",SUP-MF-410580,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 13.5MM CEMENTLESS MODULAR AML POROUS 45MM",SUP-155402135,CDM,C1776,HCPCS,0278,RC,,,both,,,15374.88,4612.46,"MULTIPLAN [10600]",Multiplan,,13068.65,85,,,,,0,1788.1,13068.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ORTHOPEDIC MEDIUM 18-20.5IN KNEE NEOPRENE SLEEVE OPEN",SUP-NE7702-03,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.70,30.51,"NOVANET [10819]",Novanet,,76.28,75,,,,,0,11.83,86.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 25MM 2MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2025X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"PHCS [10601]",PHCS,,368.55,70,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 4.5FR 3IN TAUT STERILE 20018-M55 18305 18400",SUP-PI-63,CDM,C1894,HCPCS,0272,RC,,,both,,,244.47,73.34,"AETNA [10100]","Aetna HMO/PPO",,194.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.43,207.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 154MM 17MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-104170,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9947.57,41.1,,6417.48,6417.48,6417.48,"1 through 10",2814.85,20572.84,"percent of total billed charges",
"BAND ANNULOPLASTY 27MM DURAN ANCORE CHORDAL GUIDE",SUP-620BG27,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UHC [10700]","United Healthcare",,8298.63,63.3,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM 15MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-015,CDM,C1776,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"MULTIPLAN [10600]",Multiplan,,14892.26,85,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NUCLEUS-X 110CM 4CM 20MM BALLOON DILATATION POLYAMIDE",SUP-612023,CDM,C1725,HCPCS,0272,RC,,,both,,,6566.52,1969.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,778.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,763.69,5581.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTITIS MEDIA AND URI WITH MCC",152,MS-DRG,,,,,,,inpatient,,,34029.10,10208.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,18848.68,,,,,,,7333.27,29482.89,"case rate",
"VANCOMYCIN 500 MG VIAL",RX-8443,CDM,J3373,HCPCS,0636,RC,00409-4332-11,NDC,both,1,UN,73.94,22.18,"MULTIPLAN [10600]",Multiplan,,62.85,85,,,,,0,1.75,62.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 37MM 135CM 9MM 40MM",SUP-38047-94013,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"KAISER [10500]",Kaiser,,2773.8,67,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP ANGLE 24FR 26FR THOMAS CUT",SUP-27050GS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1097.98,329.39,"CIGNA [10200]",Cigna,,746.63,68,,,,,0,127.7,933.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X300 80CM SL",SUP-48003030N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"FIRST HEALTH [10303]","First Health",,832.81,80,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 20MM 7FR 14MM .035IN LOW PROFILE BALLOON",SUP-B1140-020,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 2.5MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-02505,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3355.15,28.62,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 90CM 5FR MHK CURVE ANGIOGRAPHIC POLYURETHANE",SUP-590386MHK-NB,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"UHC [10700]","United Healthcare",,68.84,63.3,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 20CM 8FR .038IN PIGTAIL CURVE TAPER URETER GLIDEX",SUP-M001245620,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"UHC [10700]","United Healthcare",,1091.93,63.3,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE RX BILIARY SYSTEM LOCKING BIOPSY CAP STERILE",SUP-M00545261,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.67,24.8,"AETNA [10100]","Aetna HMO/PPO",,65.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.61,70.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 6MM SPACE MINI 29MM TITANIUM 2MM SCR LOW PROFILE 1",SUP-443.166,CDM,C1713,HCPCS,0278,RC,,,both,,,3487.50,1046.25,"BLUE CROSS [10001]","Blue Cross HMO",,1367.1,39.2,,957.42,156.86,7483.26,51,405.6,2964.38,"percent of total billed charges",
"PACK SUT 1.5MM BROADBAND TAPE BLACK BLUE",SUP-CM0322,CDM,S27200284,LOCAL,0272,RC,,,both,,,631.80,189.54,"AETNA [10100]","Aetna HMO/PPO",,502.28,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 1 CTX 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8455H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LUTONIX 035 130CM 6X60MM1/EACH",SUP-LX35130660,CDM,C1725,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"KAISER [10500]",Kaiser,,7627.95,67,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Intercostal Sngl",PX-510000119,CDM,64420,CPT,0761,RC,,,both,,,3659.03,1097.71,"KAISER [10500]",Kaiser,,2451.55,67,,,,,0,425.55,3659.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 2 LEFT DISTAL KNEE",SUP-5540-A-201,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2085.61,45.9,,,,,0,528.45,3862.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 135CM 5MM 20MM",SUP-H74938047520130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"BLUE CROSS [10001]","Blue Cross PPO",,1956.86,39.2,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH VASCULAR 8X1CM BOVINE PERICARDIAL",SUP-DP1X6,CDM,C1768,HCPCS,0278,RC,,,both,,,1263.68,379.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,361.67,28.62,,,,,0,146.97,1074.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +10.5MM 12/14 TAPER 28MM HIP ZIMALOY VERSYS",SUP-00801802805,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"PHCS [10601]",PHCS,,3395.49,70,,,,,0,564.14,4123.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Femoral Insert Pika",PX-E27200348,CDM,E27200348,LOCAL,0272,RC,,,both,,,304.70,91.41,"CIGNA [10200]","Cigna Local Plus",,163.01,53.5,,,,,0,35.44,259,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 12MM 145CM 3.25MM CORONARY STENT",SUP-1145325-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PHCS [10601]",PHCS,,4086.6,70,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 3CM 4.8FR .035IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145353050,CDM,C2617,HCPCS,0278,RC,,,both,,,940.57,282.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,111.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,109.39,799.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 6.2MM 26MM NCB PROTASUL-64 3.5MM CORTEX SELF",SUP-0203150026,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"CIGNA [10200]","Cigna Open Access",,1056.21,56.9,,1144.80,304.56,2275.09,66,215.88,1577.81,"percent of total billed charges",
"SOL IV 0.9% SODIUM CHLORIDE 500ML PVC FREE DEHP FREE VISIV",SUP-7983-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"NOVANET [10819]",Novanet,,60.75,75,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM TRIFECTA TISSUE ANNULUS",SUP-TF-25A,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross HMO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ICD-VR VISIA MRI AF S US/OUS DF4",SUP-DVFC3D4,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"CIGNA [10200]","Cigna Open Access",,13065,33.5,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CD HORIZON SPINAL FENESTRATE MULTIAXIAL",SUP-55840026540T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 21.6CM 3.2MM RUSH J INTRAMEDULLARY STAINLESS",SUP-00080300111,CDM,C1713,HCPCS,0278,RC,,,both,,,1275.75,382.72,"PHCS [10601]",PHCS,,893.03,70,,,,,0,148.37,1084.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAXX 15CM 10MM NEPHRSTMY PTFE SET",SUP-G47649,CDM,C1726,HCPCS,0272,RC,,,both,,,2279.25,683.77,"MULTIPLAN [10600]",Multiplan,,1937.36,85,,,,,0,265.08,1937.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 12MM OLIF51 DIVERGENCE-L BONE SPINE",SUP-2150012,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2962.17,28.62,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 18MM MICRONAIL TITANIUM BUTTRESS RADIUS",SUP-59412518,CDM,C1713,HCPCS,0278,RC,,,both,,,1328.40,398.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,380.19,28.62,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM MITROFLOW BOVINE PERICARDIUM",SUP-LXA19,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 6-0 PS-6 18IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y510G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"MULTIPLAN [10600]",Multiplan,,21.25,85,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 6-0 PS-6 18IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y510G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]",Cigna,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR CONTRALATERAL 2 CURVE ANGIOGRAPHIC",SUP-M001314581,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 75MM PRECEPT",SUP-8847075,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.50 X 18 MM  RX FDA",SUP-1203350-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross HMO",,6762,39.2,,9776.84,9776.84,9776.84,"1 through 10",2006.18,14662.5,"percent of total billed charges",
"CATH TREK 145CM 15MM 4MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012278-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 105MM CEMENT EXT PROSTALAC 1 HIGH OFFSET HIP",SUP-1541-06-000,CDM,C1776,HCPCS,0278,RC,,,both,,,18814.32,5644.3,"FIRST HEALTH [10303]","First Health",,15051.46,80,,,,,0,2188.11,15992.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 1 CT-1 36IN BRAID COATED UNDYED ABSORBABLE",SUP-J947H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ABLATION STAR POWERCURVE SHORT BLISTER TRAY TUMOR",SUP-RF-0510S-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,22680.00,6804,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2637.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2637.68,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 51MM TITANIUM 2.4MM SCR 6X3 HOLE 2 COLUMN",SUP-04.111.531,CDM,C1713,HCPCS,0278,RC,,,both,,,4217.63,1265.29,"KAISER [10500]",Kaiser,,2825.81,67,,,,,0,490.51,3584.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 CURVE 15MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962063,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"PHCS [10601]",PHCS,,6474.62,70,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 217MM 14MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-414,CDM,C1776,HCPCS,0278,RC,,,both,,,19885.95,5965.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2356.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2312.74,16903.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT 2.5 KNEE CEMENT ROTATE PLATFORM",SUP-129431125,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIRAL ILLNESS WITH MCC",865,MS-DRG,,,,,,,inpatient,,,44127.08,13238.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,23888.49,,,,,,,7561,37366.1,"case rate",
"SCR BONE 6MM 6-5.6MM 260MM 60MM XCALIBER OSTEOTITE HA",SUP-99-612660,CDM,C1713,HCPCS,0278,RC,,,both,,,986.18,295.85,"MULTIPLAN [10600]",Multiplan,,838.25,85,,,,,0,114.69,838.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 40MM 3.8FR 5MM BALLOON DILATATION OTW",SUP-39032-50408,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM 30.7MM 24.9MM MITRAL FLEXIBLE HOLDER",SUP-4450M26,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"PHCS [10601]",PHCS,,7969.5,70,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +12.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200125,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,694.01,68,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM TSRH THINLINE OSTEOGRIP SPINE",SUP-83555459,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"BLUE CROSS [10001]","Blue Cross HMO",,1009.01,39.2,,957.42,156.86,7483.26,51,299.36,2187.9,"percent of total billed charges",
"SCR BONE 6.5MM 7MM 28MM REUNION SHOULDER CENTRAL STERILE",SUP-5573-6528,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"CIGNA [10200]","Cigna Local Plus",,832.3,53.5,,3978.14,359.25,3978.14,24,180.93,1322.35,"percent of total billed charges",
"NAIL 12MM 360MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.256S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1471.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1444.25,10555.59,"percent of total billed charges",
"CEFEPIME 2 G VIAL",RX-16371,CDM,J0692,HCPCS,0636,RC,44567-0241-10,NDC,both,1,UN,88.79,26.64,"BLUE CROSS [10001]","Blue Cross HMO",,5.69,,,,,,,5.69,75.47,"fee schedule",
"ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION",RX-184423,CDM,J0122,HCPCS,0636,RC,71773-0050-05,NDC,both,1,UN,400.04,120.01,"KAISER [10500]",Kaiser,,268.03,67,,,,,0,47.4,340.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Sngl Lumen Power Midline",PX-E27200412,CDM,C1751,HCPCS,0272,RC,,,both,,,771.10,231.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,91.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.68,655.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CARTO XP THERMOCOOL SF 115CM 8FR 3.5MM BF CURVE",SUP-BNI35DFH,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"NOVANET [10819]",Novanet,,13546.58,75,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ORTHOPEDIC 11-12IN NYLON ANKLE ELASTIC CUFF CLSR LOW",SUP-AB2900-12,CDM,S27000186,LOCAL,0270,RC,,,both,,,108.05,32.41,"KAISER [10500]",Kaiser,,72.39,67,,,,,0,12.57,91.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 18CM NARROW BASE INFRAPUBIC NARROW CORPORA",SUP-EN8818,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]","Cigna Local Plus",,19750.5,31.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESVR SHUNT HOLTER RICKHAM PLASTIC",SUP-821615,CDM,S27800098,LOCAL,0278,RC,,,both,,,4123.30,1236.99,"MULTIPLAN [10600]",Multiplan,,3504.81,85,,,,,0,479.54,3504.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT HUMD AEROSOL HIGH FLOW HIGH VELOCITY THERAPY 2.0",SUP-HVT-ADPC-HIGH,CDM,S27000186,LOCAL,0270,RC,,,both,,,1412.10,423.63,"CIGNA [10200]",Cigna,,960.23,68,,,,,0,164.23,1200.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR NEROSTIMLTR INSPIRE 1 TORQUE HEX WRENCH LEAD CNCT",SUP-3150,CDM,C1767,HCPCS,0278,RC,,,both,,,123120.00,36936,"UHC [10700]","United Healthcare",,77934.96,63.3,,,,,0,14318.86,104652,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEEKER SURGICAL 7MM 6MM NUVENT MAXILLARY SINUS",SUP-1830607MAX,CDM,C1726,HCPCS,0272,RC,,,both,,,4298.70,1289.61,"MULTIPLAN [10600]",Multiplan,,3653.9,85,,,,,0,499.94,3653.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Ren Arty >=2nd Ord Bi",PX-361000094,CDM,36254,CPT,0361,RC,,,both,,,18727.81,5618.34,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2178.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2178.04,15918.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Convert Nephrostomy Cath Exist",PX-361000415,CDM,50434,CPT,0361,RC,,,both,,,2658.10,797.43,"MULTIPLAN [10600]",Multiplan,,2259.39,85,,,,,0,309.14,2658.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8MM 90MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704890,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +27.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2750,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 59MM 80CM 7MM 11MM 7FR .035IN",SUP-BXA075901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5582.27,28.62,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH 12IN 9MM TNLR POLYMER VASCULAR RADIOPAQUE SMOOTH",SUP-9009-20,CDM,C1894,HCPCS,0272,RC,,,both,,,583.20,174.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,69.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Nerve Suprascapular",PX-761000048,CDM,64418,CPT,0761,RC,,,both,,,3959.74,1187.92,"BLUE CROSS [10001]","Blue Cross HMO",,2490.09,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,460.52,3365.78,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 150CM .021IN TRINAV 1.5-3.5MM",SUP-TNV-21150-35,CDM,C1982,HCPCS,0272,RC,,,both,,,50292.90,15087.87,"CIGNA [10200]","Cigna Local Plus",,26906.7,53.5,,,,,0,5849.06,42748.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROCKET IPC VALVE REPLACEMENT KIT",SUP-R54410-00-VVH,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"FIRST HEALTH [10303]","First Health",,257.52,80,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC HANDLE AEON LONG STERILE LATEX FREE",SUP-AESH260,CDM,S27200284,LOCAL,0272,RC,,,both,,,1174.50,352.35,"UHC [10700]","United Healthcare",,743.46,63.3,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION",RX-9686,CDM,J0834,HCPCS,0636,RC,00781-3440-71,NDC,both,1,UN,484.09,145.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,40.27,,,,,,,24.26,411.48,"fee schedule",
"SIZER IMPL 11.5CM NATRELLE INSPIRA P3CM LOW PLUS PROFILE",SUP-MSZ-LP220,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"KAISER [10500]",Kaiser,,105.98,67,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT XEMPLIFI DEMINERALIZE BONE MATRIX PLUS 3ML",SUP-8103.0203S,CDM,C1713,HCPCS,0278,RC,,,both,,,3018.75,905.62,"PHCS [10601]",PHCS,,2113.13,70,,,,,0,351.08,2565.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIGNS AND SYMPTOMS WITHOUT MCC",948,MS-DRG,,,,,,,inpatient,,,29162.51,8748.75,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,5114.52,,"Case rate ($4,965.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,610.85, add-ons for qualifying new technology services are included. If operating cost exceeds $37,650.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,730.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,616.95. The transfer operating threshold is the transfer adjustment factor * $4,610.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $348.60. The transfer capital threshold is the transfer adjustment factor * $348.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4965.55,19963.67,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Ather Sf Ea Add",PX-361000730,CDM,37289,CPT,0361,RC,,,both,,,8353.79,2506.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,989.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.35,7883,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 330MM 5MM 3 FLUTE QUICK COUPLING CALIBRATED 100MM",SUP-03.010.062,CDM,S27200284,LOCAL,0272,RC,,,both,,,1617.08,485.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,742.24,45.9,,,,,0,188.07,1374.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 18MM AMNIOBAND PLACENTAL ALLOGRAFT",SUP-WC3018,CDM,Q4151,HCPCS,0636,RC,,,both,,,4395.30,1318.59,"AETNA [10100]","Aetna HMO/PPO",,3494.26,79.5,,,,,0,362.66,3736.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lso Ortholine",PX-E27400064,CDM,L0631,HCPCS,0274,RC,,,both,,,3290.10,987.03,"AMERIGROUP MEDICAID [20100]",Amerigroup,,646.56,,,,,,,382.64,2796.59,"fee schedule",
"STRAP CLAVICLE ADULT XL WATER RESISTANT SERPENTINE STITCH",SUP-3001-05,CDM,S27000186,LOCAL,0270,RC,,,both,,,81.95,24.58,"FIRST HEALTH [10303]","First Health",,65.56,80,,,,,0,9.53,69.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 30MM 6FR 4MM 4FR BALLOON",SUP-H74939031403010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 16X4MM COLOSSEUM 3.5D 14MM NONSTERILE LATEX",SUP-156.564,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,400.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE CAST SMALL CANVAS RUBBER COMFO-EZE NONSLIP ROCKER",SUP-2004-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,72.38,21.71,"NOVANET [10819]",Novanet,,54.29,75,,,,,0,8.42,61.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2 T-5 38IN BRAID TIES MULTISTRAND LOWER KNOT",SUP-AR-7208,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE VERSATURN VASCULAR STRAIGHT 190CM 3CM .014IN",SUP-1013319,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"11 VOLT LITHIUM-ION SYSTEM CONTROLLER (""POCKET CONTROLLER"")",SUP-106128,CDM,Q0506,HCPCS,0274,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,1470,39.2,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 40MM SIMUPLUS FLEXIBLE LUMEN STERILE LATEX",SUP-7700FB40,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"MULTIPLAN [10600]",Multiplan,,11143.5,85,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 20FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0165SI20,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.54,22.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.67,63.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 12MM 144CM 2.25MM CORONARY STENT",SUP-H7493941812220,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION FIBERSTITCH FIBERWIRE 1.5 2-0 CURVE ROTATOR",SUP-AR-19032C,CDM,C1713,HCPCS,0278,RC,,,both,,,3984.75,1195.42,"MULTIPLAN [10600]",Multiplan,,3387.04,85,,,,,0,463.43,3387.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 40MX19.5MMX.4MM STERILE",SUP-KM-3231,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"PHCS [10601]",PHCS,,43.24,70,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 80MM 80CM 9MM 8FR STRAIGHT VASCULAR",SUP-AVSM09080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"KAISER [10500]",Kaiser,,12240.9,67,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 2.7MM STAINLESS STEEL QUICK COUPLING",SUP-310.28,CDM,S27000186,LOCAL,0270,RC,,,both,,,553.39,166.02,"PHCS [10601]",PHCS,,387.37,70,,,,,0,64.36,470.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPTIP APD 25CM 10FR DRNG FLEXIMA METAL POLYURETHANE",SUP-M001281350,CDM,C1729,HCPCS,0272,RC,,,both,,,631.80,189.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) OCCLUDER CARDIOVASCULAR 18MM CARDIAC PLUG AMPLATZER S",SUP-9-ACP2-007-018,CDM,C1817,HCPCS,0278,RC,,,both,,,96900.00,29070,"NOVANET [10819]",Novanet,,72675,75,,,,,0,11269.47,82365,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE RETRIEVE ORTHOPEDIC 350MM 3.2MM",SUP-691.022S,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DUO-DECA 2-8-2 MPD-H 100CM",SUP-901673,CDM,C1731,HCPCS,0272,RC,,,both,,,4761.00,1428.3,"NOVANET [10819]",Novanet,,3570.75,75,,,,,0,553.7,4046.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM LCP STAINLESS STEEL FOREFOOT MIDFOOT",SUP-02.211.014,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,106.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,104.45,763.41,"percent of total billed charges",
"GRAFT BONE CAPSTONE ALLOGRAFT FREEZE DRIED 22MMX10MM",SUP-9441022,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"KAISER [10500]",Kaiser,,11557.5,67,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 4-5 E-F KNEE RIGHT TIBIA FIX",SUP-42522100610,CDM,C1776,HCPCS,0278,RC,,,both,,,9466.80,2840.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6437.42,68,,,,,0,1100.99,8046.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 7.5CM 120CM 7MM 8FR ENDOPROSTHESIS",SUP-VBHR070702A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"KAISER [10500]",Kaiser,,14250.1,67,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 4.75MM STRAIGHT PERCUTANEOUS CCM PLUS",SUP-1476006120,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Local Plus",,2359.35,53.5,,3978.14,359.25,3978.14,24,512.88,3748.5,"percent of total billed charges",
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 135CM 6MM 20MM",SUP-38047-62013,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"KAISER [10500]",Kaiser,,3236.1,67,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT 7INX2MM OLIVECRONA DURA 2 END SURGICAL 3MM",SUP-57-3601,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.16,131.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,179.67,41.1,,,,,0,50.84,371.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 16CM TOUCH NARROW BASE PENOSCROTAL NARROW",SUP-EN2916,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]","Cigna Local Plus",,19750.5,31.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODAFINIL 100 MG TABLET",RX-24702,CDM,,,0637,RC,00904-6791-04,NDC,both,1,UN,48.67,14.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22.34,45.9,,,,,0,5.66,41.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.75CM NATRELLE INSPIRA P5.3CM FULL PROFILE",SUP-SSZ-F450,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,173.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CESAREAN SECTION WITHOUT STERILIZATION,MODERATE",540,APR-DRG,,,,,,,inpatient,,,48377.12,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $5,411.88. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,MINOR",166,APR-DRG,,,,,,,inpatient,,,290342.34,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $21,336.68. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($59,332.57) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8.5MM 12/14 TAPER 28MM HIP CEMENTLESS BIOLOX",SUP-136528330,CDM,C1776,HCPCS,0278,RC,,,both,,,12268.20,3680.46,"FIRST HEALTH [10303]","First Health",,9814.56,80,,,,,0,1426.79,10427.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE SMR TITANIUM L40 MM OD6.5 MM SHOULDER REVISION",SUP-8420.15.050,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"CIGNA [10200]",Cigna,,1057.88,68,,1831.33,1831.33,1831.33,16,180.93,1322.35,"percent of total billed charges",
"CATH CHRG 135CM 150MM 4MM BALLOON DILATATION OTW",SUP-H74939206041510,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 45MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-45,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 130CM 40MM 4MM BALLOON DILATATION",SUP-LX351304405F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2765,41.1,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 66X22MM STAINLESS STEEL 2.4MM SCR 6X4 HOLE 2",SUP-02.111.641,CDM,C1713,HCPCS,0278,RC,,,both,,,4041.68,1212.5,"FIRST HEALTH [10303]","First Health",,3233.34,80,,,,,0,470.05,3435.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT CATH 3FT PKG SOURCING4",SUP-0653,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"KAISER [10500]",Kaiser,,10170.6,67,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS 120CM 4CM 14MM BALLOON DILATATION PERIPHERAL",SUP-AT120144,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"KAISER [10500]",Kaiser,,1381.88,67,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 1.5MM CRANIOFACIAL TITANIUM SELF DRILLING LOW",SUP-400.836,CDM,C1713,HCPCS,0278,RC,,,both,,,708.75,212.62,"KAISER [10500]",Kaiser,,474.86,67,,,,,0,82.43,602.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 4.0/26",SUP-434901,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5652.59,28.62,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 150MM 4MM BALLOON",SUP-U35130415,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 68MM 4 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800468,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"SYSTEM XIENCE SIERRA 8MM 2.25MM CORONARY STENT EVEROLIMUS",SUP-1550225-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM 16MM HIP",SUP-15-2951/08,CDM,C1776,HCPCS,0278,RC,,,both,,,16271.03,4881.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1928.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1892.32,13830.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME PATELLAR 29MM ATTUNE KNEE AOX CEMENTED MEDIALIZE",SUP-151820029,CDM,C1776,HCPCS,0278,RC,,,both,,,6300.00,1890,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1803.06,28.62,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTAREX 135CM 6FR ATHERECTOMY SET GWIRE ROTATIONAL",SUP-80237,CDM,C1724,HCPCS,0272,RC,,,both,,,23625.00,7087.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16065,68,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC",660,MS-DRG,,,,,,,inpatient,,,43786.61,13135.98,"AETNA [10100]","Aetna HMO/PPO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BRONCHOSCOPIC 13MM 22GA WANG TRANSBRONCHIAL MEDIASTINAL",SUP-MW-122,CDM,S27200284,LOCAL,0272,RC,,,both,,,416.12,124.84,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
CABLE,SUP-05001-I,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH HEARTRAIL III 100CM 5FR IL3.75 CURVE GUIDING PTFE",SUP-40-5372,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"KAISER [10500]",Kaiser,,390.74,67,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SUPERORDERABLE",RX-408844,CDM,J1171,HCPCS,0636,RC,76045-0009-05,NDC,both,.5,ML,44.00,13.2,"BLUE CROSS [10001]","Blue Cross HMO",,0.58,,,,,,,0.58,37.4,"fee schedule",
"SUT CHROMIC 2-0 CT 36IN MONOFILAMENT ABSORBABLE",SUP-913H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 50MM 32MM ALTRX HIP",SUP-122132150,CDM,C1776,HCPCS,0278,RC,,,both,,,5531.40,1659.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3761.35,68,,,,,0,643.3,4701.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPEL APD TWIST-LOC 45CM 10FR LONG LENGTH LOOP PIGTAIL",SUP-H7493931110450,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,528.77,68,,,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAPTOPRIL 12.5 MG TABLET",RX-9401,CDM,,,0637,RC,60687-0304-11,NDC,both,1,UN,8.54,2.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3.92,45.9,,,,,0,0.99,7.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 12MM PRESS FIT REDUCE PROXIMAL PROFILE",SUP-192512,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"CIGNA [10200]","Cigna Open Access",,7955.74,33.5,,5302.19,4377.88,6578.61,27,2761.95,20186.21,"percent of total billed charges",
"STENT GEENEN 9CM 7FR PANCREATIC POLYETHYLENE POSITION SLEEVE",SUP-G21480,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,506.02,41.1,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +11.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.115,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 6-9 G-H KNEE LEFT VIVACIT-E",SUP-42512400910,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AETNA [10100]","Aetna HMO/PPO",,8567.25,79.5,,10981.53,8986.79,12413.38,12,1253.3,9159.96,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 12MM 140CM .91-1.12MM 3.5MM CORONARY",SUP-RONYX35012W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"BLUE CROSS [10001]","Blue Cross HMO",,2132.09,39.2,,9776.84,9776.84,9776.84,"1 through 10",632.56,4623.15,"percent of total billed charges",
"CAGE SPINAL TRITANIUM 0 D L23 MM X W11 MM X H9 MM SOLID TIP",SUP-48951090,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]",Cigna,,8820,40,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION LARGE 4 POSITION PIN MR SAFE LARGE",SUP-390.009,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,296.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 167MM 17MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-217,CDM,C1776,HCPCS,0278,RC,,,both,,,19885.95,5965.78,"PHCS [10601]",PHCS,,13920.17,70,,,,,0,2312.74,16903.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 180MM 4.5MM BONECUTTER LONG ARTHROSCOPIC",SUP-7210979,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,67.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 NANO 1.5MM X 4CM",SUP-M0035421540,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENDOTEK 30 ATM INFLATION 20ML 1 HANDED CONTROL ANALOG",SUP-ENDO-AN2030,CDM,S27200284,LOCAL,0272,RC,,,both,,,383.67,115.1,"CIGNA [10200]","Cigna Local Plus",,205.26,53.5,,,,,0,44.62,326.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRECEPT TEMPLATE, 500MM ROD",SUP-8801028,CDM,S27000186,LOCAL,0270,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630512,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]","Cigna Open Access",,4397.63,33.5,,5302.19,4377.88,6578.61,27,1526.7,11158.16,"percent of total billed charges",
"STEM FEMORAL 111MM COLLAR ACTIS DUOFIX 8 12/14 STANDARD OFFS",SUP-101011080,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"FIRST HEALTH [10303]","First Health",,24381,80,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL SHORT NONTOOTH",SUP-NF04,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.32,22.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,30.96,41.1,,,,,0,8.76,64.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C Telopeptide Crosslinks",PX-301000153,CDM,82523,CPT,0301,RC,,,both,,,697.30,209.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,29.38,,,,,,,0.01,592.71,"fee schedule",
"BODY CONE 29MM RESTORATION +10MM HIP MODULAR REVISION",SUP-6276-1-129,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"UHC [10700]","United Healthcare",,14087.26,63.3,,8601.07,8395.67,8601.07,"1 through 10",2588.23,18916.54,"percent of total billed charges",
"SCR BONE 4.5MM 3.9MM 38MM TITANIUM FULL THREAD SELF CUT",SUP-04.019.038,CDM,C1713,HCPCS,0278,RC,,,both,,,1592.14,477.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,455.67,28.62,,,,,0,185.17,1353.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC ANATOMIC SOCKET FLIPCUTTER II SHORT KNEE",SUP-AR-1204AS-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,297.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 0.9% SODIUM CHLORIDE 100ML ADD-VANTAGE LATEX",SUP-710167,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 10MM STAINLESS STEEL CORTICAL LOCK TRIMED",SUP-LCBS2.7-10,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,100.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,98.91,722.93,"percent of total billed charges",
"MIB 2.4MM SCREW CALIBRATED PILOT DRILL BIT",SUP-317-24-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"NOVANET [10819]",Novanet,,1265.63,75,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 24MM 144CM 2.25MM CORONARY STENT PEBAX",SUP-H7493926024220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 40MM LEVEL 2 TRANSLATIONAL BONE SPINE",SUP-201-42D40,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2998.8,68,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRECEPT SCREW, 7.5X35MM POLYAXIAL",SUP-8807535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PHCS [10601]",PHCS,,6682.8,70,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GA-68-GOZETOTIDE INTRAVENOUS SOLUTION (9 MCI)",RX-411559,CDM,A9596,HCPCS,0343,RC,08888-8878-84,NDC,both,1,UN,24796.80,7439.04,"UHC [10700]","United Healthcare",,8397.99,,,,,,,1181,21077.28,"fee schedule",
"MATRIX TISSUE 5X4CM BOVINE PERICARDIUM RESORBABLE SUTURABLE",SUP-BP10405,CDM,Q4432,HCPCS,0636,RC,,,both,,,3501.53,1050.46,"CIGNA [10200]","Cigna Local Plus",,1873.32,53.5,,,,,0,247.92,2976.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 300MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020300S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"NOVANET [10819]",Novanet,,1196.78,75,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0250,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFT TOUCH",SUP-SSM-295,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"MULTIPLAN [10600]",Multiplan,,6422.18,85,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 100MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-05101,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DEX 5    .5 SALINE 1000ML",SUP-792609,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,37.18,45.9,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 20MM 4MM BALLOON DILATATION DURALYN",SUP-48004002S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UHC [10700]","United Healthcare",,794.73,63.3,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 14GA 4.5IN THIN WALL TRU-CUT SPECIMEN NOTCH CUT",SUP-2N2702X,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.11,41.73,"CIGNA [10200]","Cigna Open Access",,79.15,56.9,,,,,0,16.18,118.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 40MM 135CM 7MM 160CM",SUP-M001711190,CDM,C1876,HCPCS,0278,RC,,,both,,,8728.50,2618.55,"BLUE CROSS [10001]","Blue Cross PPO",,3421.57,39.2,,,,,0,1015.12,7419.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 130CM 80MM 6MM BALLOON DILATATION",SUP-ADM06008013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"NOVANET [10819]",Novanet,,6054.75,75,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACCUMAX 200 BOX 5",SUP-M0068404012,CDM,S27200284,LOCAL,0272,RC,,,both,,,2720.04,816.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,322.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,316.34,2312.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 30MM 140CM 3.5MM CORONARY STERILE LATEX",SUP-453965,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 55MM ORTHOLOC LOCK 3DI",SUP-59215555,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"FIRST HEALTH [10303]","First Health",,1758,80,,,,,0,255.57,1867.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 6.5MM 6FR BILIARY NITINOL BRAID SELF",SUP-S-65-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"UHC [10700]","United Healthcare",,5787.2,63.3,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 20MM 5MM .014IN LOW PROFILE",SUP-1008193-20,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIA MATRIX (4 X 4) 16 SQ CM",SUP-585-006,CDM,Q4309,HCPCS,0636,RC,,,both,,,114000.00,34200,"CIGNA [10200]","Cigna Open Access",,2366.1,,,,,,,247.92,96900,"fee schedule",
"HC Rv Inframlr W Pta Cmplx Ea Add",PX-361000740,CDM,37299,CPT,0361,RC,,,both,,,9101.85,2730.55,"CIGNA [10200]","Cigna Open Access",,6428,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,9.1,7883,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 22MM 31MM 41MM 28MM MOSAIC CINCH RING HEART",SUP-310C31,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"FIRST HEALTH [10303]","First Health",,21924,80,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 39MM 80CM 8MM THIN VASCULAR COCR",SUP-1012624-39,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"CIGNA [10200]",Cigna,,5712,68,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC CROME DR 2 CHMBR DF4 INLINE CNCT RADIOPAQUE",SUP-DDPC3D4,CDM,C1882,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"NOVANET [10819]",Novanet,,43706.25,75,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STIM PROXIMATE GENITOURINARY HANDSET NONSTERILE LATEX",SUP-TH90G01,CDM,C1787,HCPCS,0270,RC,,,both,,,12516.60,3754.98,"PHCS [10601]",PHCS,,8761.62,70,,,,,0,1455.68,10639.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 24MM 144CM 2.25MM CORONARY STENT",SUP-H7493952824220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,647.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 80MM 4FR 2.5MM .018IN BALLOON",SUP-PCP025080130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MACH1 90CM 8FR FR4 CURVE GUIDING PTFE FEMORAL",SUP-H749343583720,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS 4-0 PS-2 18IN BRAID COATED UNDYED ABSORBABLE",SUP-VCP496G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.48,45.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 80MM 3.2MM 10MM 8.5FR .035IN BILIARY RAPID",SUP-M00570740,CDM,C1876,HCPCS,0278,RC,,,both,,,9158.00,2747.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3763.94,41.1,,,,,0,1065.08,7784.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) STABILIZER SLIDER",SUP-25100SL,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 39MM STAINLESS STEEL MINI FRAGMENT 4 HOLE .25 TUBULAR",SUP-242.05,CDM,C1713,HCPCS,0278,RC,,,both,,,1077.30,323.19,"NOVANET [10819]",Novanet,,807.98,75,,,,,0,125.29,915.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SURGICAL CEREBRAL RETROGRADE",SUP-3T70R,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"MULTIPLAN [10600]",Multiplan,,88.74,85,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE-USE 600 MICRON LASER",SUP-HLFDBX0600C,CDM,S27200284,LOCAL,0272,RC,,,both,,,2652.88,795.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1090.33,41.1,,,,,0,308.53,2254.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM TITANIUM CORTICAL",SUP-PANL-35200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,899.10,269.73,"CIGNA [10200]",Cigna,,611.39,68,,1831.33,1831.33,1831.33,16,104.57,764.24,"percent of total billed charges",
"SYSTEM PROMUS ELEMENT PLUS 12MM 144CM 3MM CORONARY STENT",SUP-H7493911412300,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA [10200]",Cigna,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 450ML P5.2CM HIGH PROFILE ROUND GEL TEXTURED",SUP-354-4450,CDM,C1789,HCPCS,0278,RC,,,both,,,4823.10,1446.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3279.71,68,,,,,0,560.93,4099.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 56MM 28MM XLPE HIP",SUP-71334956,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"PHCS [10601]",PHCS,,7802.87,70,,,,,0,1296.39,9474.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 CURVE 17.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962064,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1096.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1075.71,7862.03,"percent of total billed charges",
"CAP SYSTEM HEMICAP ARTHROPLASTY SHOULDER",SUP-8HEM-CC,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"CIGNA [10200]","Cigna Open Access",,6859.13,33.5,,5302.19,4377.88,6578.61,27,2381.24,17403.75,"percent of total billed charges",
"KIT PERICARDIOCENTESIS 8.3FR PERIVAC STRAIGHT CATH",SUP-M00443141,CDM,C1729,HCPCS,0272,RC,,,both,,,1242.00,372.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,844.56,68,,,,,0,144.44,1055.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM PRIMARY SOLID BACK HEMISPHERICAL",SUP-500-03-48C,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7117.44,68,,,,,0,1217.29,8896.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER BIPOLAR AQUAMAN MALLEABLE",SUP-23-301-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3607.50,1082.25,"NOVANET [10819]",Novanet,,2705.63,75,,,,,0,419.55,3066.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN JUDKINS LEFT 5 CURVE",SUP-DXT6JL50,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"UHC [10700]","United Healthcare",,52.32,63.3,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM OVAL CARBIDE OVAL STERILE",SUP-ZB-136,CDM,S27200284,LOCAL,0272,RC,,,both,,,258.04,77.41,"CIGNA [10200]",Cigna,,175.47,68,,,,,0,30.01,219.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 80MM 130CM 5MM VASCULAR SELF EXPAND RADIOPAQUE",SUP-H74939293058030,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"MULTIPLAN [10600]",Multiplan,,4105.5,85,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM ORTHOLOC 3DI LOW PROFILE FOOT ANKLE",SUP-58812718,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"BLUE CROSS [10001]","Blue Cross PPO",,333.4,39.2,,957.42,570.23,957.42,28,98.91,722.93,"percent of total billed charges",
"PLEURAL EFFUSION WITH MCC",186,MS-DRG,,,,,,,inpatient,,,52193.67,15658.1,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,10247.52,,"Case rate ($9,667.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,976.90, add-ons for qualifying new technology services are included. If operating cost exceeds $42,016.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,060.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $8,988.77. The transfer operating threshold is the transfer adjustment factor * $8,976.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $678.70. The transfer capital threshold is the transfer adjustment factor * $678.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,38867.43,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHOCKWAVE C2 AERO 138CM 12MM 4MM .047IN LITHOTRIPSY",SUP-C2AIVL4012,CDM,C1761,HCPCS,0272,RC,,,both,,,29610.00,8883,"MULTIPLAN [10600]",Multiplan,,25168.5,85,,,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 30CM SMALL VALVE ASSEMB RADIOPAQUE BAND",SUP-G08867,CDM,C1894,HCPCS,0272,RC,,,both,,,415.08,124.52,"KAISER [10500]",Kaiser,,278.1,67,,,,,0,48.27,352.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 10CM 120CM 13MM ENDOPROSTHESIS HEPARIN",SUP-VBHR131002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"BLUE CROSS [10001]","Blue Cross PPO",,8337.37,39.2,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CHAMPIONIR DES SYSTEM US 5-100",SUP-412501000USRD,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 5 10MM KNEE AOX REVISION CONSTRAIN ROTATE PLAT",SUP-151710510,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4233.93,28.62,,,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP EVERCLIP FOGARTY HYDRAGRIP 61MM ATRAUMATIC",SUP-EVERGRIP61,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.16,41.45,"AETNA [10100]","Aetna HMO/PPO",,109.84,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.07,117.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D +1.5 CYL BICONVEX TORIC 13MM 6MM POSTERIOR CHMBR",SUP-SA25T3,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,341.96,45.9,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 12MM 140CM 2.25MM CORONARY STENT PLATINUM",SUP-H7493927412220,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 4CM 3MM BALLOON DILATATION ILIAC",SUP-G34319,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 7-10 C-H STD 82X51X12MM KNEE PROLONG UHMWPE",SUP-00595205012,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"NOVANET [10819]",Novanet,,5879.84,75,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE LAPIDUS",SUP-AR-8941,CDM,C1713,HCPCS,0278,RC,,,both,,,6175.50,1852.65,"AETNA [10100]","Aetna HMO/PPO",,4909.52,79.5,,1521.93,481.35,16760.95,30,718.21,5249.18,"percent of total billed charges",
"CTRL NEROSTIMLTR INTELLIS PTM PAPER NONSTERILE LATEX FREE",SUP-97745NT,CDM,C1787,HCPCS,0270,RC,,,both,,,5865.00,1759.5,"CIGNA [10200]",Cigna,,3988.2,68,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION",RX-38488,CDM,,,0250,RC,70954-0600-10,NDC,both,120,ML,741.97,222.59,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,86.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.29,630.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X7MM COALITION MIS 7D 14MM TITANIUM STERILE",SUP-1136.4677,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7089.75,41.1,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PLA HYDROXYAPATITE 20MM 8MM ACL PCL",SUP-7209012,CDM,C1713,HCPCS,0278,RC,,,both,,,1839.23,551.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1250.68,68,,,,,0,213.9,1563.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 85MM TITANIUM SELF TAP LOCK NONSTERILE AXSOS 3",SUP-661085,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,151.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",151.86,1109.86,"percent of total billed charges",
"CAGE SPINAL MODULUS 7 D L17 MM X W14 MM X H7 MM CERVICAL STE",SUP-67940037P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"FIRST HEALTH [10303]","First Health",,4968,80,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 60CM 6.8FR 11MM SPACING ENDOCARDIUM INTEGRATED",SUP-7130/60,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]","Cigna Local Plus",,5409.18,31.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEFLUNOMIDE 10 MG TABLET",RX-23872,CDM,,,0637,RC,70748-0129-06,NDC,both,1,UN,62.08,18.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.22,52.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 1.5MM X 15MM COCR",SUP-VAL-15150-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]","Cigna Open Access",,811.17,56.9,,1144.80,304.56,2275.09,66,165.8,1211.76,"percent of total billed charges",
"COIL EMBOLIZATION 15CM 10MM .021IN AZUR DETACHABLE .018IN",SUP-45-481015,CDM,S27800098,LOCAL,0278,RC,,,both,,,6037.50,1811.25,"CIGNA [10200]",Cigna,,4105.5,68,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 3.8-3.4FR 6.5MM LOW",SUP-H74939031654010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8MM 70MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704870,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"TUBE 62MM NONFENESTRATE CUFF DISPOSABLE INNER CANN SMOOTH",SUP-4DCT,CDM,S27200284,LOCAL,0272,RC,,,both,,,325.99,97.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,221.67,68,,,,,0,37.91,277.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS MULTIPASS 3-0 FS-2 27IN BRAID ANTIBACTERIAL",SUP-VCP423H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP MONOPOLAR 33CM 10MM MIXTER DISSECT DIRECT DRIVE",SUP-94-1068,CDM,S27200284,LOCAL,0272,RC,,,both,,,4279.86,1283.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRAIN INCISION 16FR 11IN CATTELL NATURAL RUBBER 12IN T TUBE",SUP-0100180,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.77,19.73,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET CATH LONGER LUKE LAPAROSCOPIC PLACEMENT PERITONEAL",SUP-VP-411,CDM,S27200284,LOCAL,0272,RC,,,both,,,1522.80,456.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 200CM 40MM 1.5MM BALLOON DILATATION RAPID",SUP-47515040L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 3MM LONG STEALTH SYSTEM",SUP-960-524,CDM,S27200284,LOCAL,0272,RC,,,both,,,1466.10,439.83,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRANEXAMIC ACID 1,000 MG/10 ML VIAL TOPICAL SOLUTION",RX-411685,CDM,,,0250,RC,81284-0611-00,NDC,both,10,ML,49.83,14.95,"KAISER [10500]",Kaiser,,33.39,67,,,,,0,5.8,42.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6.7MM 6MM INTERLOCK VORTX FIBERED IDC 18",SUP-M0013822061,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 7FR 90CM .028IN CLOSED TIP URINARY DIVERSION",SUP-5230600,CDM,C2617,HCPCS,0278,RC,,,both,,,2007.23,602.17,"BLUE CROSS [10001]","Blue Cross PPO",,786.83,39.2,,,,,0,233.44,1706.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION HI-FLO 130CM 2.8FR .027IN MICRO J INFUSION",SUP-M001195470,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"UHC [10700]","United Healthcare",,2373.75,63.3,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX11MM FRA 8D LORDOTIC NARROW WEDGE",SUP-11,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY CHORDAL GUIDE DURAN ANCORE",SUP-620RG35,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"NOVANET [10819]",Novanet,,9832.5,75,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY",SUP-F6HF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"UHC [10700]","United Healthcare",,922.91,63.3,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY",SUP-F6HF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"MULTIPLAN [10600]",Multiplan,,1239.3,85,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZEBRA UROLOGICAL 150CM 3CM .032IN URO-GLIDE NITINOL",SUP-M0066701111,CDM,C1769,HCPCS,0272,RC,,,both,,,432.13,129.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.26,367.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X8MM COHERE 10D XL STERILE LATEX FREE",SUP-8180855P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AETNA [10100]","Aetna HMO/PPO",,22538.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME PATELLAR 9MM 38MM KNEE E PLUS 3 PEG STERILE",SUP-130-03-738,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACTOR, BROKEN SCREW, 7 MM, 6"" LONG, SINGLE USE",SUP-SXT008-BR3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1359.79,45.9,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SHILEY BRONCHO-CATH STD CPAP ADJUSTABLE VALVE 2",SUP-85006,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.23,58.57,"MULTIPLAN [10600]",Multiplan,,165.95,85,,,,,0,22.71,165.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP4PR,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"MULTIPLAN [10600]",Multiplan,,18276.62,85,,,,,0,2500.67,18276.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR CHEST PROCEDURES WITH CC",164,MS-DRG,,,,,,,inpatient,,,128677.91,38603.37,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,33661.52,,"Case rate ($15,656.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,538.15, add-ons for qualifying new technology services are included. If operating cost exceeds $47,577.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,481.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $14,557.37. The transfer operating threshold is the transfer adjustment factor * $14,538.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,099.15. The transfer capital threshold is the transfer adjustment factor * $1,099.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,73690.7,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 50CM 11CM ORANGE HUB SNAP FIT DIL TUBING",SUP-PRO-7F-11-035,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ELUVIA 100MM 130CM 6MM VASCULAR DRUG ELUTE DELIVERY",SUP-H74939294601010,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUITY WHISPER VIEW EDS - EACH",SUP-664647-001,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"KAISER [10500]",Kaiser,,759.78,67,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE BENTSON UROLOGICAL STD 150CM .038IN LUBRIGLIDE",SUP-M0066001050,CDM,C1769,HCPCS,0272,RC,,,both,,,247.43,74.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,101.69,41.1,,,,,0,28.78,210.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 3FR 5CM .018IN ARTERIAL STERILE LATEX FREE",SUP-G58405,CDM,S27200284,LOCAL,0272,RC,,,both,,,406.29,121.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,48.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.25,345.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENOL 1.4 % MUCOSAL AEROSOL SPRAY",RX-27889,CDM,,,0250,RC,00904-6305-21,NDC,both,177,ML,80.00,24,"KAISER [10500]",Kaiser,,53.6,67,,,,,0,9.3,68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN SL4 CURVE GUIDING CORONARY",SUP-LA7SL40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FAT EMULSION 20 % IV RATE BASED",RX-40840048,CDM,,,0250,RC,00264-4460-10,NDC,both,500,ML,206.23,61.87,"CIGNA [10200]","Cigna Local Plus",,110.33,53.5,,,,,0,23.98,175.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 CT-1 18IN CONTROL RELEASE BRAIDED 8",SUP-ETVCP738D,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Open Access",,14.23,56.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 36MM +0MM HIP TRABECULAR METAL POLYETHYLENE",SUP-00434903600,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"BLUE CROSS [10001]","Blue Cross PPO",,3538.87,39.2,,3949.44,3949.44,3949.44,"1 through 10",1049.92,7673.56,"percent of total billed charges",
"DIL SURGICAL AMPLATZ PTFE POLYETHYLENE SET RADIOPAQUE 2030CM",SUP-G57459,CDM,C1726,HCPCS,0272,RC,,,both,,,1917.75,575.32,"UHC [10700]","United Healthcare",,1213.94,63.3,,,,,0,223.03,1630.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 70MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.870,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"CIGNA [10200]","Cigna Open Access",,142.77,56.9,,1144.80,304.56,2275.09,66,29.18,213.27,"percent of total billed charges",
"SCR BONE 4.5MM 40MM STAINLESS STEEL FULL THREAD FOOT",SUP-214.740,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,321.58,28.62,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L52 MM OD5 MM LOW PROFILE LOCK TUBE NONSTERILE IN",SUP-04.045.352TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"PHCS [10601]",PHCS,,1308.93,70,,,,,0,217.47,1589.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK VITRECTOMY 20GA 23GA CONSTELLATION ENGAUGE 25GA RUBBER",SUP-8065750957,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.85,175.15,"CIGNA [10200]","Cigna Local Plus",,312.36,53.5,,,,,0,67.9,496.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PLLA HA 35MM 8MM 1.5MM ACL PCL CANNULATED",SUP-7207680,CDM,C1713,HCPCS,0278,RC,,,both,,,1882.13,564.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1279.85,68,,,,,0,218.89,1599.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 6CM 5FR PIGTAIL CURVE PANCREATIC POLYMER DRNG",SUP-M00537140,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"MULTIPLAN [10600]",Multiplan,,543.36,85,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYCLOPENTOLATE 2 % EYE DROPS",RX-9700,CDM,,,0637,RC,00065-0397-02,NDC,both,2,ML,210.31,63.09,"CIGNA [10200]","Cigna Local Plus",,112.52,53.5,,,,,0,24.46,178.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 7MM 11MM 7FR .035IN",SUP-BXA077901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"FIRST HEALTH [10303]","First Health",,17125.92,80,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch W Bronchl Alveolar Lav",PX-750000006,CDM,31624,CPT,0750,RC,,,both,,,4023.02,1206.91,"AMERIGROUP MEDICAID [20100]",Amerigroup,,476.73,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,467.88,4023.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 60MM 36MM XLPE HIP STERILE",SUP-71335760,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"BLUE CROSS [10001]","Blue Cross PPO",,4361.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",1293.98,9457.31,"percent of total billed charges",
"STEM FEMORAL 127MM 13MM CEMENT GMRS COCR STRAIGHT HIP",SUP-6485-3-113,CDM,C1776,HCPCS,0278,RC,,,both,,,14800.50,4440.15,"CIGNA [10200]",Cigna,,5920.2,40,,5873.17,5873.17,5873.17,"1 through 10",1721.3,12580.43,"percent of total billed charges",
"STEM FEMORAL 127MM 13MM CEMENT GMRS COCR STRAIGHT HIP",SUP-6485-3-113,CDM,C1776,HCPCS,0278,RC,,,both,,,14800.50,4440.15,"KAISER [10500]",Kaiser,,9916.34,67,,,,,0,1721.3,12580.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL F 72X65.5MM LEFT SET SCR OPTION NEXGEN LCCK",SUP-00599401691,CDM,C1776,HCPCS,0278,RC,,,both,,,22881.60,6864.48,"KAISER [10500]",Kaiser,,15330.67,67,,,,,0,2661.13,19449.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC INSPIRIS RESILIA 19MM BOVINE PERICARDIUM",SUP-11500A19,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"AETNA [10100]","Aetna HMO/PPO",,36061.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 27MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-027,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"CMPNT FEMORAL LARGE+ KNEE RIGHT LCS COMPLETE POROCOAT",SUP-129403070,CDM,C1776,HCPCS,0278,RC,,,both,,,28683.90,8605.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7744.65,27,,,,,0,3335.94,24381.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 4 HIP",SUP-PRTLE024,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"KAISER [10500]",Kaiser,,12663,67,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR",RX-24470,CDM,,,0637,RC,00904-6570-61,NDC,both,1,UN,11.52,3.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7.83,68,,,,,0,1.34,9.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +21 DIOPTER BICONVEX 13MM 6MM POSTERIOR CHMBR 1",SUP-SY60WF.210,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross PPO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,,,0637,RC,77333-0938-25,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EQUALIZER XXL 100CM 14FR 20MM BALLOON OCCLUSION 4.8ML",SUP-M001171060,CDM,C2628,HCPCS,0272,RC,,,both,,,1336.50,400.95,"PHCS [10601]",PHCS,,935.55,70,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cine/Video Xray",PX-320000170,CDM,76120,CPT,0320,RC,,,both,,,467.00,140.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,55.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.31,396.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 15CM 7FR 2 PIGTAIL CURVE BILIARY POLYETHYLENE",SUP-G21711,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA [10200]","Cigna Local Plus",,338.01,,,,,,,73.48,537.03,"percent of total billed charges",
"HEAD FEMORAL +4MM 26MM HIP PRIMARY TAPER OFFSET COCR LFIT",SUP-6260-9-226,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,370.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,363.75,2658.55,"percent of total billed charges",
"STEM FEMORAL 130MM CEMENTLESS NECK ACCOLADE TMZF 132D 5 44MM",SUP-6020-0537,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"BLUE CROSS [10001]","Blue Cross PPO",,8946.13,39.2,,3949.44,3949.44,3949.44,"1 through 10",2654.17,19398.49,"percent of total billed charges",
"INSRT TIBIAL 2 9MM KNEE X3 BEARING CRUCIATE RETAIN TRIATHLON",SUP-5530-G-209-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]","Cigna Open Access",,6493.77,56.9,,5302.19,4377.88,6578.61,27,1327.29,9700.71,"percent of total billed charges",
"CMPNT GLENOID 46MM PEGGED TURON SHOULDER ALL POLY",SUP-520-01-246,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"CIGNA [10200]","Cigna Open Access",,5214.54,56.9,,5302.19,4377.88,6578.61,27,1065.82,7789.74,"percent of total billed charges",
"ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR",RX-36982,CDM,,,0637,RC,57237-0114-90,NDC,both,1,UN,21.20,6.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.47,18.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG LINGEMAN CYSTOLOGY SEIMENS TABLE",SUP-LG1000,CDM,S27000186,LOCAL,0270,RC,,,both,,,70.99,21.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IMMOB ORTHOPEDIC LARGE 38X6IN SHOULDER VELPEAU ELASTIC WRIST",SUP-9008-03,CDM,S27000186,LOCAL,0270,RC,,,both,,,103.62,31.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SMOKE FLTR SYS SWVL M LL CONN 18IN TUBE W BACT-VIR-SMK FLTR",SUP-301-S400,CDM,S27000186,LOCAL,0270,RC,,,both,,,227.64,68.29,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOOK LAPAROSCOPIC 8MM ENDOWRIST PERMANENT CAUT GRASPING",SUP-470183,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOE CAST LARGE CANVAS RUBBER ROCKER SOLE HOOP LOOP CLSR",SUP-2035-04,CDM,S27000186,LOCAL,0270,RC,,,both,,,48.63,14.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE PEEP 2.5CM 20 22MM ADPTR CNCT THRESHOLD RESISTOR CPAP",SUP-9003B,CDM,S27000186,LOCAL,0270,RC,,,both,,,66.99,20.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TADALAFIL 5 MG TABLET",RX-37400,CDM,,,0637,RC,43547-0049-03,NDC,both,1,UN,46.54,13.96,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PAD STAIN REM BIOFLEX",SUP-1358224,CDM,S27000186,LOCAL,0270,RC,,,both,,,100.22,30.07,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN NASAL VAPOTHERM PROSOFT SMALL NONSTERILE LATEX FREE",SUP-PROSOFT-PED-AS,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.06,33.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP BIPOLAR 9IN SPETZLER MALIS 2 IRRIGATE 1.5MM DISPOSABLE",SUP-6770-230-015,CDM,S27200284,LOCAL,0272,RC,,,both,,,3282.98,984.89,"MULTIPLAN [10600]",Multiplan,,2790.53,85,,,,,0,381.81,2790.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061755740,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]","Cigna Open Access",,513.34,,,,,,,104.92,766.85,"percent of total billed charges",
"ALENDRONATE 10 MG TABLET",RX-15661,CDM,,,0637,RC,16714-0631-01,NDC,both,1,UN,14.72,4.42,"KAISER [10500]",Kaiser,,9.86,67,,,,,0,1.71,12.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ETHAMBUTOL 400 MG TABLET",RX-9983,CDM,,,0637,RC,68084-0280-11,NDC,both,1,UN,8.17,2.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3.36,41.1,,,,,0,0.95,6.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GYNECARE TVT (SINGLE USE DEVICE) LASER CUT MESH",SUP-810041BL,CDM,C1771,HCPCS,0278,RC,,,both,,,7617.67,2285.3,"PHCS [10601]",PHCS,,5332.37,70,,,,,0,885.94,6475.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,inpatient,,,119319.61,35795.88,"AMBETTER EXCHANGE  [11102]",Ambetter,,21632.56,,"Case rate ($21,632.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,087.29, add-ons for qualifying new technology services are included. If operating cost exceeds $53,126.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,900.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $20,113.86. The transfer operating threshold is the transfer adjustment factor * $20,087.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.70. The transfer capital threshold is the transfer adjustment factor * $1,518.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,101818.13,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM AMPLATZER TORQVUE 90D 80CM 195CM 5FR .068IN .059IN",SUP-9-TVLP5F90/080,CDM,S27200284,LOCAL,0272,RC,,,both,,,5754.60,1726.38,"NOVANET [10819]",Novanet,,4315.95,75,,,,,0,669.26,4891.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +11.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000115,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 6X4CM VIALIZE PLACENTAL MEMB ALLOGRAFT",SUP-VL-4060,CDM,,,0278,RC,,,both,,,11040.00,3312,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5067.36,45.9,,,,,0,11.04,9384,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEART FAILURE AND SHOCK WITH MCC",291,MS-DRG,,,,,,,inpatient,,,31504.22,9451.27,"BLUE CROSS [10001]","Blue Cross HMO",,29471.93,,,,,,,7561,31504.22,"case rate",
"REVISION OF HIP OR KNEE REPLACEMENT WITH MCC",466,MS-DRG,,,,,,,inpatient,,,153376.94,46013.08,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,34226.77,,"Case rate ($32,289.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $29,982.91, add-ons for qualifying new technology services are included. If operating cost exceeds $63,022.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,648.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $30,022.56. The transfer operating threshold is the transfer adjustment factor * $29,982.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,266.85. The transfer capital threshold is the transfer adjustment factor * $2,266.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 106%.",,,,0,32289.41,151976.86,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 16.5X11.9CM 750CC STYLE 9100 TEXTURE SURFACE 3",SUP-354-9116,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1083.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 12.5CM 3MM IBUR PROXIMAL BEND MATCH HEAD",SUP-8442-107-530,CDM,S27200284,LOCAL,0272,RC,,,both,,,3045.45,913.63,"CIGNA [10200]",Cigna,,2070.91,68,,,,,0,354.19,2588.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,inpatient,,,82328.55,24698.56,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,10884.66,,"Case rate ($10,268.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,535.04, add-ons for qualifying new technology services are included. If operating cost exceeds $42,574.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,102.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,547.65. The transfer operating threshold is the transfer adjustment factor * $9,535.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.90. The transfer capital threshold is the transfer adjustment factor * $720.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,48331.06,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LONG SURGICAL 8-11MM NAIL STERILE",SUP-03.043.008S,CDM,S27200284,LOCAL,0272,RC,,,both,,,795.02,238.51,"CIGNA [10200]","Cigna Local Plus",,425.34,53.5,,,,,0,92.46,675.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 20MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405620,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4435.52,45.9,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 8MM 145CM 3MM CORONARY STENT EVEROLIMUS",SUP-1125300-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"KAISER [10500]",Kaiser,,3911.46,67,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEVATOR SURGICAL L7 1/2IN TIP 6.5MM PERIOSTEAL SHARP/BLUNT",SUP-55-7026,CDM,S27200284,LOCAL,0272,RC,,,both,,,168.35,50.5,"CIGNA [10200]",Cigna,,114.48,68,,,,,0,19.58,143.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 77MM STAINLESS STEEL 2.7/3.5MM SCR 3 HOLE LCP",SUP-02.112.106,CDM,C1713,HCPCS,0278,RC,,,both,,,3084.38,925.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,882.75,28.62,,,,,0,358.71,2621.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 232SQ CM ALLOGRAFT DRSG NONMESHED FROZEN",SUP-SK-P,CDM,Q4433,HCPCS,0636,RC,,,both,,,4243.02,1272.91,"CIGNA [10200]",Cigna,,2885.25,68,,,,,0,247.92,3606.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 232SQ CM ALLOGRAFT DRSG NONMESHED FROZEN",SUP-SK-P,CDM,Q4433,HCPCS,0636,RC,,,both,,,4243.02,1272.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2885.25,68,,,,,0,247.92,3606.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19 DIOPTER POSTERIOR CHMBR FOLDABLE ASPHERIC UV",SUP-CCA0T0,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Manip Chst Wall Init",PX-410000013,CDM,94667,CPT,0410,RC,,,both,,,504.89,151.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Immuniz Intranasal/Oral 1st",PX-771000025,CDM,90473,CPT,0771,RC,,,both,,,77.10,23.13,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PHENOBARBITAL 32.4 MG TABLET",RX-6217,CDM,,,0637,RC,00904-6575-61,NDC,both,1,UN,12.54,3.76,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP MANIP 5.1MM RUMI UTERUS ARTICULATE LOCK HANDLE SOFT",SUP-UML516,CDM,S27200284,LOCAL,0272,RC,,,both,,,602.62,180.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TISSUE REGENEATION GRAFT 14MM DISK",SUP-GS-5140,CDM,Q4186,HCPCS,0636,RC,,,both,,,2557.50,767.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,406.44,,,,,,,303.06,2173.88,"fee schedule",
"STENT COMPLETE SE 80MM 130CM 6MM LONG VASCULAR NITINOL ILIAC",SUP-SC680LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3325.46,45.9,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM AXSOS STAINLESS STEEL T15 FEMUR HUMERUS",SUP-371526,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,255,28.62,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK12MM 51X63MM GALLANT IMPLANTABLE 1 CHMBR DF",SUP-CDVRA500Q,CDM,C1722,HCPCS,0278,RC,,,both,,,56385.00,16915.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23174.24,41.1,,,,,0,6557.58,47927.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 11MM 3FR GEMINI HELICAL",SUP-M0063301070,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"MULTIPLAN [10600]",Multiplan,,1257.62,85,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 25MMX10MM X-PAC PARALLEL",SUP-EI2510P,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]",Cigna,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brace-Ankle Lace Up",PX-E27400077,CDM,L1902,HCPCS,0274,RC,,,both,,,216.70,65.01,"BLUE CROSS [10001]","Blue Cross HMO",,84.95,39.2,,,,,0,25.2,184.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEPHRSTMY HIGH PRESSURE BALLOON DILATATION CATH",SUP-M0064501140,CDM,C1769,HCPCS,0272,RC,,,both,,,4140.35,1242.1,"KAISER [10500]",Kaiser,,2774.03,67,,,,,0,481.52,3519.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT CRUCIATE RETAIN JOURNEY II",SUP-74021157,CDM,C1776,HCPCS,0278,RC,,,both,,,37771.65,11331.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4475.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4392.84,32105.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM 3 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.345,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"FIRST HEALTH [10303]","First Health",,4233.6,80,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.175,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 100MM 6.35MM TSRH-2D PRECUT BENT",SUP-8371100,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X5CM AMINOEFFECT PURION PLACENTAL MEMB",SUP-LS-5350,CDM,Q4433,HCPCS,0636,RC,,,both,,,13130.70,3939.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8534.96,65,,,,,0,247.92,11161.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 4MM NESTER MICROCOIL PLATINUM ACCEPTS",SUP-G47327,CDM,S27800098,LOCAL,0278,RC,,,both,,,890.92,267.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,605.83,68,,,,,0,103.61,757.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAX BONE HEMOSTATIC AGENT LUKENS",SUP-901,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.75,18.22,"CIGNA [10200]","Cigna Local Plus",,32.5,53.5,,,,,0,7.07,51.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DEMINERALIZED BONE MATRIX FIBER 2.5CC ALLOGRAFT",SUP-MDBM1025,CDM,C1713,HCPCS,0278,RC,,,both,,,2343.75,703.12,"NOVANET [10819]",Novanet,,1757.81,75,,,,,0,272.58,1992.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 11MM KNEE BEARING POSTERIOR STABILIZE",SUP-5532-G-511-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]",Cigna,,7760.57,68,,5873.17,5873.17,5873.17,"1 through 10",1327.29,9700.71,"percent of total billed charges",
"SYSTEM PROMUS ELEMENT PLUS 8MM 144CM 3MM CORONARY STENT",SUP-H7493911408300,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"PHCS [10601]",PHCS,,6399.75,70,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH 1 55CM 7FR .081IN HOCKEY STICK CURVE GUIDING PTFE",SUP-M001197000,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,69.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 3MM 24MM TITANIUM CORTEX HAND SELF TAPPING",SUP-400.824.96,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"NOVANET [10819]",Novanet,,242.99,75,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.25MM X 15.0MM",SUP-492251512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 16MM 4.75MM EMBOLIZATION NEUROVASCULAR",SUP-PED-475-16,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"BLUE CROSS [10001]","Blue Cross PPO",,30164.4,39.2,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 3.5FR UMBILICAL POLYURETHANE DEHP FREE RADIOPAQUE",SUP-P2UVC3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.19,90.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,137.79,45.9,,,,,0,34.91,255.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR SR4 CURVE GUIDING CORONARY",SUP-LA6SR40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 45MM CATHCART BALL HIP FEMUR MODULAR STERILE",SUP-136345000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 3-0 UR-6 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP604H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AETNA [10100]","Aetna HMO/PPO",,19.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER PACING LEAD ACUITY 10FR",SUP-667465-001,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 16MM STAINLESS STEEL T8 SELF TAP LOCK",SUP-02.210.116TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1011.53,303.46,"CIGNA [10200]","Cigna Open Access",,575.56,56.9,,1144.80,304.56,2275.09,66,117.64,859.8,"percent of total billed charges",
"SYSTEM INTEGRITY 12MM 2.75MM CORONARY STENT FULCRUM COCR",SUP-INT27512UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"BLUE CROSS [10001]","Blue Cross HMO",,946.68,39.2,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.7MM 20MM THREAD NONLOCK TITANIUM NONSTERILE",SUP-PANL-27200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.60,379.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,859.25,68,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADMIN 150UM ASSORTED DEHP FREE FILTER SYR ALIQUOT SYSTEM",SUP-0396000F,CDM,S27200284,LOCAL,0272,RC,,,both,,,105.97,31.79,"AETNA [10100]","Aetna HMO/PPO",,84.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.32,90.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP LIMIT HOLE FIN RINGLOC+ 24 STERILE",SUP-16-104154,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"KAISER [10500]",Kaiser,,4715.46,67,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM .91-1.12MM 3MM CORONARY",SUP-RONYX30026W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3698.52,68,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION BARDEX LUBRICATH 18FR 350ML URINE METER",SUP-304918,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.92,54.58,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX 035 GEOALIGN 130CM 100MM 7MM BALLOON DILATATION",SUP-LX3513071005F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SIZE ADJUSTMENT TOOL AND IMPLANT LOCKER",SUP-25100ST,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PERFORMA 100CM 6FR AR MOD CURVE ANGIOGRAPHIC PEBAX",SUP-7506-11,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.74,23.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MONOCRYL 1 CT-1 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Y341H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER ENDOTRAC HOOK STERILE DISPOSABLE",SUP-3055-6,CDM,S27200284,LOCAL,0272,RC,,,both,,,209.50,62.85,"CIGNA [10200]","Cigna Open Access",,119.21,56.9,,,,,0,24.36,178.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL LONG HINDFOOT VALOR 4.3MM SCR IMPL KIT",SUP-415S002352,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"KAISER [10500]",Kaiser,,1155.75,67,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 120MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171031210,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Gel Anasept",PX-E27200092,CDM,E27200092,LOCAL,0272,RC,,,both,,,115.50,34.65,"CIGNA [10200]",Cigna,,78.54,68,,,,,0,13.43,98.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Pg Component Wcs",PX-480000075,CDM,0518T,CPT,0480,RC,,,both,,,6620.00,1986,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5284,,"Case rate ($5,284). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,769.91,6620,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nudt15 Gene Common Variants",PX-310000042,CDM,81306,CPT,0310,RC,,,both,,,425.00,127.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,425,"per diem",
"GWIRE STARTER BENTSON VASCULAR STD TAPER 180CM 15CM .035IN",SUP-M001491471,CDM,C1769,HCPCS,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL TRANSEPTAL 98CM 21GA 18GA NRG C1 CURVED CONVENTIONAL",SUP-NRG-98-C0,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX GEOALIGN 130CM 150MM 6MM BALLOON DILATATION",SUP-LX1813061505F,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TROCAR LAPAROSCOPIC 100MM 15MM KII Z THREAD SLEEVE LATEX",SUP-C0R37,CDM,S27200284,LOCAL,0272,RC,,,both,,,413.25,123.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL DEBAKEY ATRAUMATA 9.5INX2MM DISSECT STERILE",SUP-FB404R,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.96,80.99,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"1.9MM X 341MM TRILOGY PROBE KIT",SUP-M0068403510,CDM,S27200284,LOCAL,0272,RC,,,both,,,5531.45,1659.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 60MM 6MM BALLOON DILATATION STERILE LATEX",SUP-596006022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT URETERAL 5FR 28CM WITHOUT GWIRE POLARIS ULTRA",SUP-M0061921240,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,132.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 140MM 16-14MM 14MM 11FR TRIVASCULAR OVATION",SUP-TV-IL1416140-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3883.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ACCESS AMS 700 PENILE IMPL",SUP-72401850,CDM,C1813,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CIGNA [10200]",Cigna,,5278.5,68,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL X-PAC LORDOTIC TALL L28 MM X H12 MM",SUP-EI2472LT,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"NOVANET [10819]",Novanet,,21262.5,75,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X4CM VIALIZE PLACENTAL MEMB ALLOGRAFT",SUP-VL-4040,CDM,,,0278,RC,,,both,,,10281.00,3084.3,"CIGNA [10200]",Cigna,,6991.08,68,,,,,0,10.28,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 16MM PRESS FIT REDUCE PROXIMAL PROFILE",SUP-192416,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2761.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2761.95,20186.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS CORTICAL RING 10MM",SUP-270100,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 2.50 X 38 MM RX FDA",SUP-1203250-38,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2006.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Collar Aspen",PX-E27400062,CDM,L0172,HCPCS,0274,RC,,,both,,,991.10,297.33,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,454.91,45.9,,,,,0,112.15,842.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONJUGATED ESTROGENS 0.3 MG TABLET",RX-9973,CDM,,,0637,RC,00046-1100-81,NDC,both,1,UN,32.94,9.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.83,28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L19 MM OD3.5 MM SPINE CERVICAL ANTERIOR SELF TAP",SUP-18008419,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,117.75,860.63,"percent of total billed charges",
"SCR BONE 2.7MM 28MM T8 FULL THREAD STARDRIVE NONSTERILE",SUP-656428,CDM,C1713,HCPCS,0278,RC,,,both,,,1107.59,332.28,"KAISER [10500]",Kaiser,,742.09,67,,,,,0,128.81,941.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM VERTEX RECONSTRUCTION SET",SUP-7756010,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"KAISER [10500]",Kaiser,,2650.79,67,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC App Splint Short Leg",PX-450000203,CDM,29515,CPT,0361,RC,,,both,,,1281.63,384.49,"FIRST HEALTH [10303]","First Health",,1025.3,80,,,,,0,149.05,1281.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nfct Ds 22 Trgt Sars-Cov-2",PX-300000414,CDM,0202U,CPT,0300,RC,,,both,,,1106.30,331.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,375.1,,,,,,,1.11,940.36,"fee schedule",
"HC Asp Breast Cyst",PX-361000015,CDM,19000,CPT,0361,RC,,,both,,,1679.93,503.98,"FIRST HEALTH [10303]","First Health",,1343.94,80,,,,,0,195.38,1679.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hgb O2 Affinitiy",PX-300000013,CDM,82820,CPT,0301,RC,,,both,,,147.00,44.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.77,,,,,,,0.01,124.95,"fee schedule",
"HC Hgb O2 Affinitiy",PX-300000013,CDM,82820,CPT,0301,RC,,,both,,,147.00,44.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.28,,"Fee schedule rate ($14.28). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,124.95,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Compr Metabolic Panel (Cmp)",PX-301000008,CDM,80053,CPT,0301,RC,,,both,,,489.25,146.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9.5,,,,,,,0.49,415.86,"fee schedule",
"CEFOXITIN 2 G VIAL IV PUSH",RX-408344,CDM,J0694,HCPCS,0636,RC,00143-9877-01,NDC,both,1,UN,72.48,21.74,"CIGNA [10200]",Cigna,,25.48,,,,,,,11.14,61.61,"fee schedule",
"HC Semen Analysis",PX-301000452,CDM,G0027,HCPCS,0301,RC,,,both,,,257.00,77.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10.22,,,,,,,0.01,218.45,"fee schedule",
"HC MRI Thorac Spine W Cntrst",PX-612000004,CDM,72147,CPT,0612,RC,,,both,,,4257.46,1277.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($683.51). Procedures 2 - 999, Per diem ($341.76).",,,,0,,,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SILVER SULFADIAZINE 1 % TOPICAL CREAM",RX-7224,CDM,,,0250,RC,67877-0124-50,NDC,both,50,GR,130.52,39.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BRACHYTHERAPY 20CM 17GA APPLR SEED ULTRA SHARP TIP",SUP-917205,CDM,C1715,HCPCS,0272,RC,,,both,,,159.04,47.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE R/O II 25CM 2.5CM 7FR INTRO DIL RADIOPAQUE",SUP-RSB703,CDM,C1894,HCPCS,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 8.5MM 40MM RELINE-O 2S SPINE POLYAXIAL NONSTERILE",SUP-13018540,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,441.36,3225.75,"percent of total billed charges",
"DEFIB CARDIAC ATLAS+ DR THK14MM IMPLANTABLE 38ML 78GM",SUP-V-243,CDM,C1721,HCPCS,0278,RC,,,both,,,70537.50,21161.25,"PHCS [10601]",PHCS,,49376.25,70,,,,,0,8203.51,59956.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL THK20MM M2 2 DISTAL BEARING MODULAR ROTATE",SUP-64813320,CDM,C1776,HCPCS,0278,RC,,,both,,,6116.85,1835.05,"BLUE CROSS [10001]","Blue Cross HMO",,2397.81,39.2,,5311.50,4717.44,5388.59,31,711.39,5199.32,"percent of total billed charges",
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL SPACER",SUP-345544,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ON-Q PAINBUSTER T-PEEL 8IN DRUG DELIVERY NDL INTRO",SUP-ACC03,CDM,S27200305,LOCAL,0272,RC,,,both,,,103.64,31.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,47.57,45.9,,,,,0,12.05,88.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE ORTHOTIC 11.5-14 13+ XL PROCARE OFF LOAD SQUARE TOE BOX",SUP-79-81518,CDM,S27000186,LOCAL,0270,RC,,,both,,,237.16,71.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,108.86,45.9,,,,,0,27.58,201.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X2CM ACTISHIELD AMNIOTIC BARR MEMB",SUP-AM202X04,CDM,V2790,HCPCS,0278,RC,,,both,,,9577.20,2873.16,"CIGNA [10200]","Cigna Open Access",,5449.43,56.9,,,,,0,1113.83,8140.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RECTAL RESECTION WITH MCC",332,MS-DRG,,,,,,,inpatient,,,152983.81,45895.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,71874.52,,"Fee schedule rate ($71,874.52). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,105709.96,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13CM NATRELLE CLASSIC P3.6CM MODERATE PROFILE",SUP-MSZ10330,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"NOVANET [10819]",Novanet,,118.64,75,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE 4 MG/ML INJECTION SOLUTION",RX-183096,CDM,J2272,HCPCS,0636,RC,63323-0454-00,NDC,both,1,ML,51.19,15.36,"UHC [10700]","United Healthcare",,13.2,,,,,,,6.07,43.51,"fee schedule",
"PATCH CARDIOVASCULAR THK.36MM 3INX.3INX.36MM KNITTED",SUP-M00202019579P0,CDM,C1768,HCPCS,0278,RC,,,both,,,856.25,256.87,"CIGNA [10200]",Cigna,,582.25,68,,,,,0,99.58,727.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 12.5MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158124112,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1299.6,9498.37,"percent of total billed charges",
"STEM FEMORAL +12MM 44MM STD LATERAL OFFSET 160MM 18MM 13MM",SUP-563618,CDM,C1776,HCPCS,0278,RC,,,both,,,11104.56,3331.37,"MULTIPLAN [10600]",Multiplan,,9438.88,85,,,,,0,1291.46,9438.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT CATH FLEXIBLE KINK RESISTANT FEMALE LUER LOCK FIT DRNG",SUP-M0067401200,CDM,S27200284,LOCAL,0272,RC,,,both,,,55.85,16.75,"KAISER [10500]",Kaiser,,37.42,67,,,,,0,6.5,47.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VICRYL 12X12IN ABSORBABLE WOVEN FLAT HERNIA",SUP-VWML,CDM,C1781,HCPCS,0278,RC,,,both,,,5296.14,1588.84,"MULTIPLAN [10600]",Multiplan,,4501.72,85,,,,,0,615.94,4501.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 6MM CUFFED HOODED MURPHY EYE LOW PRESSURE",SUP-8229506,CDM,S27200284,LOCAL,0272,RC,,,both,,,3487.50,1046.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1433.36,41.1,,,,,0,405.6,2964.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309109,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4391.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING EXTERNAL FIXATION 150MM MAXFRAME 5/8 ALUMINUM",SUP-03.312.650,CDM,C1713,HCPCS,0278,RC,,,both,,,7754.08,2326.22,"BLUE CROSS [10001]","Blue Cross HMO",,3039.6,39.2,,957.42,156.86,7483.26,51,901.8,6590.97,"percent of total billed charges",
"LENS IOL +15.5 DIOPTER HAPTIC C BICONVEX 13MM 6MM POSTERIOR",SUP-ZXR00U0155,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA [10200]","Cigna Open Access",,423.91,56.9,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP LARGE 2 FLAP ADJUSTABLE FOREHEAD HEADSTRAP",SUP-1012572,CDM,S27000186,LOCAL,0270,RC,,,both,,,1822.88,546.86,"CIGNA [10200]","Cigna Open Access",,1037.22,56.9,,,,,0,212,1549.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 3 DISTAL REVISION",SUP-5612-D-310,CDM,C1776,HCPCS,0278,RC,,,both,,,10143.00,3042.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1201.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1179.63,8621.55,"percent of total billed charges",
"SPACER ALLOGRAFT 20X50X13MM ORACLE 8D SPINE LUMBAR FREEZE",SUP-15013,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9839.34,41.1,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURECLIP REPOSITIONABLE 11MM 235CM",SUP-RC30141,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"CIGNA [10200]",Cigna,,605.88,68,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 75CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR070501A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"KAISER [10500]",Kaiser,,12570.14,67,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX ECHO 2 15X10CM POSITION SYSTEM STERILE",SUP-1211015,CDM,C1781,HCPCS,0278,RC,,,both,,,21498.75,6449.62,"MULTIPLAN [10600]",Multiplan,,18273.94,85,,,,,0,2500.3,18273.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT PL SITEMARK 58CM 54CM 9FR 7FR 135D GUIDING",SUP-410183,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"FIRST HEALTH [10303]","First Health",,2970,80,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STREAMER VASCULAR POLYMER CORONARY SINUS EXTRA DISTAL",SUP-363727,CDM,C1769,HCPCS,0272,RC,,,both,,,486.00,145.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,199.75,41.1,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 75X12.5X.8MM .9MM HALL RECIPROCATE STERILE",SUP-00505217900,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.89,65.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.46,186.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 30CM 8.3FR .038IN NEPHRSTMY 6 SIDEPORT PERCUTANEOUS",SUP-G03415,CDM,S27200284,LOCAL,0272,RC,,,both,,,888.08,266.42,"NOVANET [10819]",Novanet,,666.06,75,,,,,0,103.28,754.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 20MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"AETNA [10100]","Aetna HMO/PPO",,1268.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 10 8MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151621008,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4625.35,41.1,,6417.48,6417.48,6417.48,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"CATH GUIDER SOFTIP XF 90CM 5FR 40D GUIDING DURAFORM PTFE",SUP-M003100620,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"NOVANET [10819]",Novanet,,1877.35,75,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 7CM MR8 1.1MM TAPER DISSECTING",SUP-MR8-7TA11,CDM,S27200284,LOCAL,0272,RC,,,both,,,879.26,263.78,"AETNA [10100]","Aetna HMO/PPO",,699.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,102.26,747.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN READIGRAFT CRYOSKIN 387SQ CM FIBROBLAST",SUP-SK-DM,CDM,Q4433,HCPCS,0636,RC,,,both,,,7747.11,2324.13,"NOVANET [10819]",Novanet,,5810.33,75,,,,,0,247.92,6585.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X6MM COLONIAL 7D LORDOTIC 12MM LARGE",SUP-365.406CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP MULTIHOLE TRIDENT D HEMISPHERE",SUP-508-11-50D,CDM,C1776,HCPCS,0278,RC,,,both,,,11233.20,3369.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1331.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1306.42,9548.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0263,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"NOVANET [10819]",Novanet,,710.78,75,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 32MM 144CM 2.25MM CORONARY STENT",SUP-H7493911432220,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross HMO",,3583.86,39.2,,9776.84,9776.84,9776.84,"1 through 10",1063.27,7771.13,"percent of total billed charges",
"VEST COMPRESSION 46-48IN 42IN XL CHEST SHOULDER VELCRO",SUP-2-8003BG-XL,CDM,S27000186,LOCAL,0270,RC,,,both,,,437.40,131.22,"PHCS [10601]",PHCS,,306.18,70,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VIA CANCELLOUS DEMINERALIZE CORTICAL BONE 5CC",SUP-VCAFX-050000,CDM,S27800098,LOCAL,0278,RC,,,both,,,12075.00,3622.5,"NOVANET [10819]",Novanet,,9056.25,75,,,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Lung Ventil&Perfsn Diff",PX-341000034,CDM,78598,CPT,0341,RC,,,both,,,2819.08,845.72,"PHCS [10601]",PHCS,,1973.36,70,,,,,0,327.86,2396.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fna Bx W/Fluor Gdn 1st Les",PX-361000479,CDM,10007,CPT,0361,RC,,,both,,,3171.00,951.3,"UHC [10700]","United Healthcare",,2385,,"Case rate ($2,385). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,368.79,2740.57,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"8MM AMPLATZER MUSCULAR VSD OCCLUDER",SUP-9-VSD-MUSC-008,CDM,C1817,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]",Cigna,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Rmvl FB",PX-750000077,CDM,45332,CPT,0750,RC,,,both,,,2206.73,662.02,"KAISER [10500]",Kaiser,,1478.51,67,,,,,0,256.64,2206.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INLAY OPTIMA 24CM 7FR URETERAL PHREECOAT POLYMER",SUP-788724,CDM,C2617,HCPCS,0278,RC,,,both,,,834.30,250.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,97.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.03,709.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 26MM 140CM 2.25MM CORONARY STERILE",SUP-453955,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 86MM DEGENERATIVE DISC 4 LEVEL ARCHON BONE SPINE",SUP-8787486,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 22MM RSP SHOULDER LOCK GLENOID BASEPLT",SUP-506-03-122,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"PHCS [10601]",PHCS,,1088.99,70,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL UTERINE HEGAR 2 END 11/12MM",SUP-52-3511,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.18,83.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,114.74,41.1,,,,,0,32.47,237.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 52CM .016IN FIRM PCMKR",SUP-6036,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 65CM 1MM 6FR 2-8-2MM SPACING D CURVE ELECTROPHYSIOLOGY",SUP-D6A10DRP10RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,441.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 6MM 45MM VIPER PRIME SPINE POLYAXIAL EXTEND TAB N",SUP-186760245,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE 48IN MERITRANS NONWINGE HOUSING MALE SWIVEL",SUP-K11-00144B,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.22,27.67,"CIGNA [10200]","Cigna Open Access",,52.47,56.9,,,,,0,10.73,78.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 8MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650808,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3606.12,28.62,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fibrinolysis Act Nos Analyte",PX-305000069,CDM,85397,CPT,0305,RC,,,both,,,135.20,40.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,48.54,,,,,,,0.01,114.92,"fee schedule",
"STENT ORSIRO MISSION 26MM 140CM 4MM CORONARY STERILE LATEX",SUP-453960,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PEFORM FX REV LAT BASEPLASTE",SUP-CAP1125,CDM,C1776,HCPCS,0278,RC,,,both,,,61110.00,18333,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25116.21,41.1,,6417.48,6417.48,6417.48,"1 through 10",7107.09,51943.5,"percent of total billed charges",
"SYSTEM CAPSURE STRAIGHT 37CM FIXATION STAINLESS STEEL PEEK",SUP-0113215,CDM,S27200284,LOCAL,0272,RC,,,both,,,1762.50,528.75,"NOVANET [10819]",Novanet,,1321.88,75,,,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 28MM GLENOID LOCK MODULAR",SUP-AR-9563-28,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"NOVANET [10819]",Novanet,,448.04,75,,,,,0,69.48,507.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 29MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-224.661,CDM,C1713,HCPCS,0278,RC,,,both,,,4352.80,1305.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,515.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,506.23,3699.88,"percent of total billed charges",
"CATH GUIDER SOFTIP XF 90CM 7FR 40D GUIDING DURAFORM PTFE",SUP-H965100430,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"CIGNA [10200]",Cigna,,1702.13,68,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM AXSOS 3 TITANIUM CORTICAL NONSTERILE",SUP-661438,CDM,C1713,HCPCS,0278,RC,,,both,,,289.54,86.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,33.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",33.67,246.11,"percent of total billed charges",
"SUT PDS II 0 CT-1 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z340H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE LARGE REGULAR SPIKED 23.22X14.29MM COCR",SUP-128696,CDM,C1713,HCPCS,0278,RC,,,both,,,2300.10,690.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1564.07,68,,,,,0,267.5,1955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 10CM 5MM BALLOON DILATATION PERIPHERAL",SUP-G50243,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 4MM CORONARY STENT",SUP-1125400-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]","Cigna Open Access",,3321.82,56.9,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32X23X10MM SOVEREIGN 8D SMALL",SUP-7967810,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"CIGNA [10200]",Cigna,,13710.24,40,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Neurostim Non Recharge FB",PX-E27800015,CDM,C1767,HCPCS,0278,RC,,,both,,,1.00,0.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.12,0.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 11.9CM 6MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR100611,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"BLUE CROSS [10001]","Blue Cross HMO",,4657.67,39.2,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 4CM 3MM GALAXY G3 MINI STRETCH",SUP-GLM930040,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3208.09,27,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 180CM 120MM 4FR 2MM .018IN BALLOON",SUP-PCP020120180,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"NOVANET [10819]",Novanet,,923.4,75,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 60MM 80CM 10MM VASCULAR PERIPHERAL SELF",SUP-1012532-60,CDM,C1876,HCPCS,0278,RC,,,both,,,8799.00,2639.7,"CIGNA [10200]","Cigna Local Plus",,4707.47,53.5,,,,,0,1023.32,7479.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 8MM 140CM 3MM CORONARY STENT CARBOSIL",SUP-LUN300R08US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PNEUMOTHORAX WITH CC",200,MS-DRG,,,,,,,inpatient,,,21031.99,6309.6,"CIGNA [10200]",Cigna,,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC",965,MS-DRG,,,,,,,inpatient,,,47497.65,14249.29,"AETNA [10100]","Aetna HMO/PPO",,,79.5,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD 25CM 10FR PIGTAIL CURVE DRNG PERCUFLEX GLIDEX METAL",SUP-M001245081,CDM,C1729,HCPCS,0272,RC,,,both,,,850.50,255.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VASCUTRAK 140CM 100MM 7FR 7MM .018IN SHORT BALLOON",SUP-V1870100,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL 9CM MIDAS REX MR8 5MM BALL SYMMETRICAL DISSECTING",SUP-MR8-9BA50T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1444.64,433.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CARTO 3 THERMOCOOL SF 7.5FR D-J CURVE ELECTROPHYSIOLOGY",SUP-BNI35DJCT,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"AETNA [10100]","Aetna HMO/PPO",,14359.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 17X14X7MM COROENT SMALL INTERLOCK 7D PEEK",SUP-6790227,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5104.62,41.1,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NORTRIPTYLINE 10 MG CAPSULE",RX-5674,CDM,,,0637,RC,60687-0900-11,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BONE CEMENT AVAFLEX CURVE STERILE LATEX FREE DISPOSABLE",SUP-1025-011-500,CDM,S27200284,LOCAL,0272,RC,,,both,,,2798.33,839.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1284.43,45.9,,,,,0,325.45,2378.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701056,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"BLUE CROSS [10001]","Blue Cross PPO",,4449.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",1320.06,9647.93,"percent of total billed charges",
"GRAFT BONE ILIAC CREST TRICORTICAL THK5MM WEDGE ALLOGRAFT",SUP-400397,CDM,S27800098,LOCAL,0278,RC,,,both,,,3829.50,1148.85,"NOVANET [10819]",Novanet,,2872.13,75,,,,,0,445.37,3255.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HT COMMAND 14 MT 4G X 25CM 210CM ANG",SUP-1060003A,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"FIRST HEALTH [10303]","First Health",,771.12,80,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 26CM 8FR .035IN URETERAL",SUP-M006155253090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,926.66,68,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ACCESS 63CM VERSACROSS 45D CURVE 1 TRANSSEPTAL DIL",SUP-VXSK0122,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"MULTIPLAN [10600]",Multiplan,,5249.18,85,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 60MM 130CM 7MM LONG VASCULAR NITINOL ILIAC",SUP-SC760LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3325.46,45.9,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL TAPERCUT 5 V-56 30IN MONOFILAMENT 4",SUP-M435G,CDM,S27200284,LOCAL,0272,RC,,,both,,,132.05,39.61,"UHC [10700]","United Healthcare",,83.59,63.3,,,,,0,15.36,112.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 100ML GEL ROUND SMOOTH MEMORYGEL SILICONE P2.7CM","SUP-3501001 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,435.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 18MM INTERLOCK DETACHABLE ARM .018IN",SUP-M001363660,CDM,S27800098,LOCAL,0278,RC,,,both,,,3891.60,1167.48,"FIRST HEALTH [10303]","First Health",,3113.28,80,,,,,0,452.59,3307.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 6MM ELITE ROUND SOFT TOUCH FLUTED STERILE",SUP-5820010160,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"PHCS [10601]",PHCS,,766.47,70,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION 130CM 2.4FR .035IN MICRO SWAN INFUSION NITINOL",SUP-M001195300,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"MULTIPLAN [10600]",Multiplan,,3187.5,85,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 15ML 1.7-10MM ALLOGRAFT CHIPS FREEZE",SUP-T00035,CDM,S27800098,LOCAL,0278,RC,,,both,,,1795.50,538.65,"CIGNA [10200]","Cigna Open Access",,1021.64,56.9,,,,,0,208.82,1526.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.75 X 23 RX US",SUP-1804275-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"STEM FEMORAL 117MM 11MM PRIMARY STD OFFSET PRESS FIT",SUP-00786401100,CDM,S27800098,LOCAL,0278,RC,,,both,,,30164.40,9049.32,"CIGNA [10200]","Cigna Local Plus",,9501.79,31.5,,,,,0,3508.12,25639.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN FULL LENGTH RIGHT CORONARY BYPASS",SUP-H749085261902,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 30.0",SUP-DIB00U0300,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS 75CM 6CM 16MM 8FR BALLOON DILATATION PERIPHERAL",SUP-AT75166,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 20MM 144CM 4.5MM CORONARY STENT",SUP-H7493926020450,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4275.59,45.9,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 5X1CM GAUZE MEROGEL SEPTUM PK STERILE LATEX",SUP-1517100,CDM,S27000186,LOCAL,0270,RC,,,both,,,467.29,140.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ARTHROSCOPIC 75MM 6.5MM DRI-LOK THREAD",SUP-3910075650,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TRUSELECT 105CM 2-2.8FR .021IN MICRO EMBOLIZATION",SUP-M001394101050,CDM,C1887,HCPCS,0272,RC,,,both,,,5102.55,1530.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRAIN INCISION 15FR 3/16IN BARD SILICONE 4 FREE FLOW CHANNEL",SUP-072229,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.71,37.11,"FIRST HEALTH [10303]","First Health",,98.97,80,,,,,0,14.39,105.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +26 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0260,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"PHCS [10601]",PHCS,,935.55,70,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 6X3CM MEMORY BASKET WIRE SOFT",SUP-G57273,CDM,S27200284,LOCAL,0272,RC,,,both,,,2805.00,841.5,"PHCS [10601]",PHCS,,1963.5,70,,,,,0,326.22,2384.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Skin Protectant",PX-E27000156,CDM,E27000156,LOCAL,0270,RC,,,both,,,57.20,17.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.65,48.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION",RX-22185,CDM,J1451,HCPCS,0636,RC,70710-1478-01,NDC,both,1.5,ML,9054.00,2716.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1448.72,,,,,,,1254,7695.9,"fee schedule",
"KIT SHUNT AXIEM CRANIUM NONINVASIVE NAVIGATION SYSTEM",SUP-9733605,CDM,S27200284,LOCAL,0272,RC,,,both,,,4450.50,1335.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,527.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,517.59,3782.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NORIAN SRS 10CM 10GA BONE CEMENT DELIVERY NDL STERILE",SUP-DLS-7103-01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 11MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P411,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2391.46,28.62,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 123MM 10MM PRESS FIT REUNION SHOULDER STERILE",SUP-5569-P-2010,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"MULTIPLAN [10600]",Multiplan,,10710,85,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 19MM 135CM 6MM 8MM 7FR .035IN",SUP-BXA061902A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL 70MM NAIL-EX SPIRAL FEMUR TITANIUM",SUP-04.013.046S,CDM,C1713,HCPCS,0278,RC,,,both,,,3437.70,1031.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1577.9,45.9,,,,,0,399.8,2922.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER HUMERAL INSPACE LARGE",SUP-0132,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4479.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Neur Agent Intercostal Nrv",PX-510000196,CDM,64620,CPT,0761,RC,,,both,,,5254.00,1576.2,"CIGNA [10200]","Cigna Open Access",,2181,,"Per diem ($2,181).",,,,0,611.04,4710,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION LCS SIGMA HIP QUICK DRILL STERILE",SUP-9505-02-300,CDM,S27200284,LOCAL,0272,RC,,,both,,,2043.75,613.12,"UHC [10700]","United Healthcare",,1293.69,63.3,,,,,0,237.69,1737.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 12MM",SUP-SPL35012X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAVVY 150CM 4CM 3.5-3FR 2MM BALLOON DILATATION DURALYN",SUP-435204X,CDM,C1725,HCPCS,0272,RC,,,both,,,2137.50,641.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION VENOUS RETURN 1 PIECE 3 STAGE TUBING CNCT",SUP-RTS-13029,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE TFN-ADVANCED ORTHOPEDIC 475MM 3.2MM FEMORAL PROXIMAL",SUP-09.037.010,CDM,C1769,HCPCS,0272,RC,,,both,,,768.93,230.68,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL 0 D +10 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.100,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM TSRH THINLINE OSTEOGRIP",SUP-83565459,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS [10001]","Blue Cross PPO",,3742.37,39.2,,957.42,570.23,957.42,28,1110.3,8114.82,"percent of total billed charges",
"SHEARS ELECTROSURGICAL 9CM HARMONIC FOCUS CURVED",SUP-FCS9,CDM,S27200284,LOCAL,0272,RC,,,both,,,2314.00,694.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1062.13,45.9,,,,,0,269.12,1966.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 10MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424023,CDM,C1776,HCPCS,0278,RC,,,both,,,11747.25,3524.17,"CIGNA [10200]",Cigna,,4698.9,40,,5873.17,5873.17,5873.17,"1 through 10",1366.21,9985.16,"percent of total billed charges",
"HEAD FEMORAL +3MM 11/13 TAPER 36MM HIP MODULAR BIOLOX DELTA",SUP-136536220,CDM,C1776,HCPCS,0278,RC,,,both,,,7290.36,2187.11,"CIGNA [10200]","Cigna Local Plus",,3900.34,53.5,,5372.07,4581.20,7242.98,23,847.87,6196.81,"percent of total billed charges",
"GRAFT BONE GRAFTECH CANCELLOUS CORTICAL 30ML .5-3MM",SUP-T00070,CDM,S27800098,LOCAL,0278,RC,,,both,,,2840.25,852.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,812.88,28.62,,,,,0,330.32,2414.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER 200UM BALL TIP DISPOSABLE",SUP-TFL-FBX200BS,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 7FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175272070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,118.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG SURGICAL 1.3IN GROIN MONOFILAMENT NONABSORBABLE PERFIX",SUP-0112760,CDM,C1781,HCPCS,0278,RC,,,both,,,740.22,222.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,87.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.09,629.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 10ML PASTE MIX PLUS",SUP-IQSP-PP-110,CDM,C1713,HCPCS,0278,RC,,,both,,,8970.00,2691,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4117.23,45.9,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM ACORN STERILE",SUP-5620030040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1164.29,349.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,137.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,135.41,989.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC",468,MS-DRG,,,,,,,inpatient,,,135034.45,40510.33,"AETNA [10100]","Aetna HMO/PPO",,51703.62,,"Fee schedule rate ($51,703.62). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,17046.01,80230.61,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25.5 DIOPTER +1.5 CYL HAPTIC C BICONVEX 13MM 6MM",SUP-ZXT150U255,CDM,V2788,HCPCS,0276,RC,,,both,,,834.00,250.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,382.81,45.9,,,,,0,96.99,708.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP PROV 50MM CLSR TIP FIRST OPEN END CLIP LEFT",SUP-PROV50,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"UHC [10700]","United Healthcare",,21933.45,63.3,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBTR ENDOSCOPIC 19.8FR OES PRO CYSTOURETHROSCOPE VISUAL",SUP-A20922A,CDM,S27200284,LOCAL,0272,RC,,,both,,,4573.32,1372,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,541.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,531.88,3887.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 38CM FEMUR RIGHT PROXIMAL TALON DISTALFIX",SUP-SLN-125-38R,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1910.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1875.37,13706.51,"percent of total billed charges",
"SCR BONE 4.5MM 50MM TSRH OSTEOGRIP THINLINE TITANIUM SPINE",SUP-83545509,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"CIGNA [10200]",Cigna,,1750.32,68,,1831.33,1831.33,1831.33,16,299.36,2187.9,"percent of total billed charges",
"OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET",RX-5940,CDM,,,0250,RC,00406-0512-23,NDC,both,1,UN,15.95,4.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.85,13.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 39MM UNIVERS REVERS +6MM MEDIUM SHOULDER",SUP-AR-9503M-06,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1999.2,68,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE W8XL12CM THK2-2.79MM READY TO USE ALLODER",SUP-151996,CDM,C1889,HCPCS,0278,RC,,,both,,,17835.30,5350.59,"BLUE CROSS [10001]","Blue Cross PPO",,6991.44,39.2,,9172.16,8555.87,9172.16,"1 through 10",2074.25,15160.01,"percent of total billed charges",
"CATH COYOTE 90CM 150MM 3MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186301590,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL H STD KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-599601851,CDM,C1776,HCPCS,0278,RC,,,both,,,14578.32,4373.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1727.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1695.46,12391.57,"percent of total billed charges",
"SPACER ALLOGRAFT 11X14X5MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7205,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]",Cigna,,4692,68,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 24CM 13.5FR STRAIGHT POLYURETHANE NIAGARA 2 LUMEN",SUP-5575240,CDM,C1752,HCPCS,0272,RC,,,both,,,1031.94,309.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 135CM 150MM 7MM BALLOON DILATATION HYDROPHILIC",SUP-607015022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 3X100 80CM SL",SUP-48003010N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT CARDIOVASCULAR 45CM 4-7MM STD WALLED STEPPED TAPER",SUP-22703,CDM,C1768,HCPCS,0278,RC,,,both,,,2447.18,734.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,289.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,284.61,2080.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT GREEN 5CM 3FR GEENEN PANCREATIC POLYETHYLENE PUSH",SUP-G27181,CDM,C2625,HCPCS,0278,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross HMO",,482.63,39.2,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CREO SPINE CANNULATED NONSTERILE LATEX",SUP-5120.4639,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 16X8MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2408,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"CIGNA [10200]","Cigna Open Access",,5496.54,56.9,,1144.80,304.56,2275.09,66,1123.46,8211,"percent of total billed charges",
"APPL INTERNAL CLIP 5MM ENDOSCOPIC LIGAMAX 5MM STERILE LATEX",SUP-EL5ML,CDM,S27200284,LOCAL,0272,RC,,,both,,,2116.45,634.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1439.19,68,,,,,0,246.14,1798.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 12MM 144CM 2.5MM CORONARY STENT",SUP-H7493941812250,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 28CM 150CM 6FR .038IN STD STRAIGHT URETERAL",SUP-M006180524170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]","Cigna Open Access",,700.42,,,,,,,143.16,1046.32,"percent of total billed charges",
"SPACER SPINAL 34X13MM HEDRON IA 8D 26MM STERILE LATEX FREE",SUP-1212.0613S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"UHC [10700]","United Healthcare",,21933.45,63.3,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 11MM 38MM ASYMMETRIC TRIATHLON POLYETHYLENE",SUP-5551-L-381,CDM,C1776,HCPCS,0278,RC,,,both,,,4478.10,1343.43,"NOVANET [10819]",Novanet,,3358.58,75,,,,,0,520.8,3806.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM MITRAL OPTIMAL ORIFICE AREA RESTORE","SUP-4200 M26",CDM,S27800098,LOCAL,0278,RC,,,both,,,18818.10,5645.43,"AETNA [10100]","Aetna HMO/PPO",,14960.39,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2188.55,15995.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT LAPAROSCOPIC CURVE JAW CORDLESS ULTRASONIC 13CM",SUP-SCDA13,CDM,S27200284,LOCAL,0272,RC,,,both,,,2887.50,866.25,"CIGNA [10200]","Cigna Open Access",,1642.99,56.9,,,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOLTR TRANSCATHETER AORTIC VALVE-23MM - THE 23MM EVOLTR TRA",SUP-EVOLUTR-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]",Cigna,,68400,40,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HYPERGLIDE X-PEDION 150CM 15MM 2.2-2.8FR 4MM .01IN 4MM",SUP-104-4112,CDM,C1725,HCPCS,0272,RC,,,both,,,9232.20,2769.66,"MULTIPLAN [10600]",Multiplan,,7847.37,85,,,,,0,1073.7,7847.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NUCLEUS-X 110CM 4CM 25MM BALLOON DILATATION POLYAMIDE",SUP-612029,CDM,C1725,HCPCS,0272,RC,,,both,,,6566.52,1969.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,763.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,763.69,5581.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 5X5CM NATURALLY POROUS NON-SIDED THIN DURABLE",SUP-DP-25,CDM,Q4122,HCPCS,0636,RC,,,both,,,6900.00,2070,"CIGNA [10200]",Cigna,,4692,68,,,,,0,817.65,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Prox Fib/Shaft WO Manip",PX-450000160,CDM,27780,CPT,0450,RC,,,both,,,1347.00,404.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1347,,"Per diem ($1,469).",,,,0,67.13,1347,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"REG VACUUM 0-300 MMHG CONTINUOUS INTERMITTENT TUBING NIPPLE",SUP-VR-CIUT-OMD,CDM,S27200284,LOCAL,0272,RC,,,both,,,2452.58,735.77,"MULTIPLAN [10600]",Multiplan,,2084.69,85,,,,,0,285.24,2084.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)GWIRE R350 VASCULAR 200CM STRAIGHT 350CM 5CM .013IN NI",SUP-7390,CDM,C1769,HCPCS,0272,RC,,,both,,,1611.90,483.57,"KAISER [10500]",Kaiser,,1079.97,67,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esrd Emergency Dialysis Tx",PX-829000001,CDM,G0257,HCPCS,0829,RC,,,both,,,3128.80,938.64,"KAISER [10500]",Kaiser,,2096.3,67,,,,,0,363.88,2659.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tte Stress W Contr",PX-483000016,CDM,93350,CPT,0483,RC,,,both,,,4038.65,1211.59,"AETNA [10100]","Aetna HMO/PPO",,3210.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,302.63,3432.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tte Stress W Contr",PX-483000016,CDM,93350,CPT,0483,RC,,,both,,,4038.65,1211.59,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,469.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,302.63,3432.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Upgrade Impl Pcmkr Sys",PX-480000009,CDM,33214,CPT,0481,RC,,,both,,,11250.00,3375,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1333.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.38,11250,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHOTREXATE SODIUM 2.5 MG TABLET",RX-4973,CDM,J8610,HCPCS,0637,RC,00054-8550-25,NDC,both,1,UN,17.93,5.38,"MULTIPLAN [10600]",Multiplan,,15.24,85,,,,,0,0.4,15.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Lt Vent/Atrial Angio Si",PX-481000040,CDM,93565,CPT,0481,RC,,,both,,,1503.00,450.9,"PHCS [10601]",PHCS,,1052.1,70,,,,,0,174.8,1503,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Kidney Img Flow WO Drug",PX-341000044,CDM,78707,CPT,0341,RC,,,both,,,2827.57,848.27,"BLUE CROSS [10001]","Blue Cross PPO",,565.02,,"Fee schedule rate ($565.02).",,,,0,269.12,2403.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO S1 GLIDESCOPE SPECTRUM MILLER DISPOSABLE",SUP-0270-1088,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.40,131.22,"NOVANET [10819]",Novanet,,328.05,75,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000100,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 24CM 8FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251520,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS [10001]","Blue Cross HMO",,482.54,39.2,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 24MM STAINLESS STEEL T8 LOCK VARIABLE ANGLE",SUP-02.210.124TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1011.53,303.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.5,28.62,,,,,0,117.64,859.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK",RX-155783,CDM,J1953,HCPCS,0636,RC,43598-0757-52,NDC,both,100,ML,181.08,54.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,123.13,68,,,,,0,4.66,153.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grafix Core per Sq Cm",PX-E63600025,CDM,Q4132,HCPCS,0636,RC,,,both,,,1340.90,402.27,"NOVANET [10819]",Novanet,,1005.68,75,,,,,0,158.9,1139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 82MM PRESS FIT AEQUALIS ASCEND FLEX PTC 137.5D",SUP-DWF605C,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 3-0 RB-1 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-U204H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 2MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES0208CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 3-5 C-D KNEE RIGHT VIVACIT-E",SUP-42522600410,CDM,C1776,HCPCS,0278,RC,,,both,,,12351.00,3705.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5076.26,41.1,,6417.48,6417.48,6417.48,"1 through 10",1436.42,10498.35,"percent of total billed charges",
"LENS IOL 0 D +10 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SA60AT.100,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHYLENE BLUE (ANTIDOTE) 1 % (10 MG/ML) INTRAVENOUS SOLUTION",RX-4985,CDM,Q9968,HCPCS,0636,RC,54288-0147-01,NDC,both,10,ML,1887.50,566.25,"MULTIPLAN [10600]",Multiplan,,1604.38,85,,,,,0,223.67,1887.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 7MM TARGET XL 360D STD LARGE",SUP-M0036107200,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICS IRRIGATION CLIP",SUP-116239,CDM,S27200284,LOCAL,0272,RC,,,both,,,899.10,269.73,"PHCS [10601]",PHCS,,629.37,70,,,,,0,104.57,764.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Co2",PX-301000130,CDM,82374,CPT,0301,RC,,,both,,,70.00,21,"NOVANET [10819]",Novanet,,52.5,75,,,,,0,0.01,59.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR AL2 CURVE ANGIOGRAPHIC TRILON PERIPHERAL",SUP-H74908641981,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"AETNA [10100]","Aetna HMO/PPO",,56.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUAIFENESIN 100 MG/5 ML ORAL LIQUID",RX-3542,CDM,,,0637,RC,00121-1744-05,NDC,both,5,ML,12.54,3.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repositioning Prev Impl Ccm-D Transvns Eltrd/Ld",PX-481000419,CDM,0924T,CPT,0481,RC,,,both,,,953.00,285.9,"NOVANET [10819]",Novanet,,714.75,75,,,,,0,110.83,953,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB LIFEPAK ADULT CONDUCTIVE GEL REDI-PAK",SUP-11996-000042,CDM,S27000186,LOCAL,0270,RC,,,both,,,335.12,100.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,137.73,41.1,,,,,0,38.97,284.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCK DEMINERALIZED 10ML STRIP FORMATS INTERCONNECTED POROSI",SUP-PBF10,CDM,S27800098,LOCAL,0278,RC,,,both,,,6846.53,2053.96,"NOVANET [10819]",Novanet,,5134.9,75,,,,,0,796.25,5819.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PENTARAY 115CM 7FR 3FR 1MM 2-6-2MM SPACING D CURVE STAR",SUP-D128205,CDM,C1732,HCPCS,0272,RC,,,both,,,13634.40,4090.32,"PHCS [10601]",PHCS,,9544.08,70,,,,,0,1585.68,11589.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 43MM BIO-MOORE II ENDO II HIP ACETABULAR",SUP-12-139010,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"MULTIPLAN [10600]",Multiplan,,2374.05,85,,,,,0,324.83,2374.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Elbow Arthgm",PX-361000044,CDM,24220,CPT,0361,RC,,,both,,,979.94,293.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,113.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.97,979.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -4 32MM HIP BIOLOX DELTA FMP SYSTEM",SUP-400-03-321,CDM,C1776,HCPCS,0278,RC,,,both,,,16953.92,5086.18,"CIGNA [10200]",Cigna,,6781.57,40,,5873.17,5873.17,5873.17,"1 through 10",1971.74,14410.83,"percent of total billed charges",
"SCR BONE 8.5MM 45MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75448545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 26CM 6FR KWART RETRO-INJECT STENT INSRT .038IN 2",SUP-G14887,CDM,C2625,HCPCS,0272,RC,,,both,,,1053.00,315.9,"MULTIPLAN [10600]",Multiplan,,895.05,85,,,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 4MM OXFORD ARCOM KNEE LEFT MENISCAL PHASE 3",SUP-159541,CDM,C1776,HCPCS,0278,RC,,,both,,,5270.22,1581.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,624.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,612.93,4479.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPS DIRECT« UPSIZED, X-WIDE 54CM-DS2C029",SUP-DS2C029,CDM,C1893,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"PHCS [10601]",PHCS,,2632.35,70,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS MONOPOLAR 36CM 5MM ENDO MINI-SHEARS MINI RATCHET",SUP-174301,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.92,145.78,"CIGNA [10200]","Cigna Open Access",,276.49,56.9,,,,,0,56.51,413.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC MEDI-THERM SMALL MEDIUM",SUP-8001061550,CDM,S27000186,LOCAL,0270,RC,,,both,,,1140.48,342.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,468.74,41.1,,,,,0,132.64,969.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE HA PLLA 20MM 6MM ACL PCL ABSORBABLE BIOSURE",SUP-72201768,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 80MM 3.5MM 4FR .018IN",SUP-39147-35801,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"PHCS [10601]",PHCS,,1048.95,70,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 11.4MM 8MM SHILEY TAPERGUARD FLEXIBLE CUFF INNER",SUP-7CN80A,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.97,110.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,150.82,41.1,,,,,0,42.68,311.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM STD CABLE TITANIUM COCR TROCHANTER REATTACHMENT",SUP-498.806S,CDM,S27200284,LOCAL,0272,RC,,,both,,,10336.20,3100.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1202.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1202.1,8785.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +27.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZMA00U0275,CDM,V2632,HCPCS,0276,RC,,,both,,,6175.50,1852.65,"NOVANET [10819]",Novanet,,4631.63,75,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 13MM REVISION MODULAR ARCOS STS TITANIUM",SUP-11-300813,CDM,C1776,HCPCS,0278,RC,,,both,,,20372.94,6111.88,"CIGNA [10200]","Cigna Local Plus",,6417.48,31.5,,5372.07,4581.20,7242.98,23,2369.37,17317,"percent of total billed charges",
"SET ADMIN 103IN C11ML INTRAVENOUS LIFESHIELD PLUMSET CLAVE",SUP-12339-12,CDM,S27000186,LOCAL,0270,RC,,,both,,,196.97,59.09,"CIGNA [10200]","Cigna Open Access",,112.08,56.9,,,,,0,22.91,167.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOXIFLOXACIN 0.5 % EYE DROPS",RX-35699,CDM,,,0250,RC,00781-7135-93,NDC,both,3,ML,876.88,263.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,103.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,101.98,745.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 15MM 1-2MM AVANCE NERVE ALLOGRAFT",SUP-111215,CDM,C1762,HCPCS,0278,RC,,,both,,,17734.50,5320.35,"PHCS [10601]",PHCS,,12414.15,70,,,,,0,2062.52,15074.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 16MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-816,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"MULTIPLAN [10600]",Multiplan,,11439.68,85,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM AVENIR 10 COIL FINISH COMPLEX",SUP-10CFN-04006,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"KAISER [10500]",Kaiser,,7854.48,67,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRUTCH WALKING 29-39IN 90D C265LB ADULT ALUMINUM PLASTIC",SUP-609002,CDM,S27000186,LOCAL,0270,RC,,,both,,,769.58,230.87,"KAISER [10500]",Kaiser,,515.62,67,,,,,0,89.5,654.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 360D 7MM TREPHINE RADIAL VACUUM BARRON STAINLESS STEEL",SUP-K20-2054,CDM,S27200284,LOCAL,0272,RC,,,both,,,599.40,179.82,"CIGNA [10200]",Cigna,,407.59,68,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 150MM 120CM 6MM VASCULAR NICKEL",SUP-EVD35-06-150-120,CDM,C1876,HCPCS,0278,RC,,,both,,,8085.00,2425.5,"FIRST HEALTH [10303]","First Health",,6468,80,,,,,0,940.29,6872.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK12MM 51X63MM ENTRANT IMPLANTABLE 1 CHMBR DF",SUP-CDVRA300Q,CDM,C1722,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]",Cigna,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 20MM PRECISION CANNULATED CHAMFER MIS BUNION",SUP-P27-130-0020,CDM,C1713,HCPCS,0278,RC,,,both,,,5492.40,1647.72,"MULTIPLAN [10600]",Multiplan,,4668.54,85,,,,,0,638.77,4668.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 30CM 8.3FR .038IN NEPHRSTMY 6 SIDEPORT PERCUTANEOUS",SUP-G03415,CDM,S27200284,LOCAL,0272,RC,,,both,,,888.08,266.42,"AETNA [10100]","Aetna HMO/PPO",,706.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.28,754.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 36MM SYNAPSE TITANIUM 40D T15 SPINE",SUP-04.614.236,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG SILICONE GENTLE BORDER ADHSV 3 ACTION SHOWERPROOF 30X10",SUP-66800265,CDM,S27200284,LOCAL,0272,RC,,,both,,,45.94,13.78,"CIGNA [10200]","Cigna Open Access",,26.14,56.9,,,,,0,5.34,39.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X8X7MM RISE NONSTERILE",SUP-193.001,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 171226 IMP WG 12X26 SRVC FEE FD",SUP-171226,CDM,S27800098,LOCAL,0278,RC,,,both,,,12572.49,3771.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1489.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1462.18,10686.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 30MM CEMENTLESS ACCOLADE TMZF 1 HIP",SUP-6021-0130,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"MULTIPLAN [10600]",Multiplan,,19398.49,85,,,,,0,2654.17,19398.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 7-12 G-H KNEE RIGHT TIBIA",SUP-42521200610,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,956.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,939.21,6864.4,"percent of total billed charges",
"COMPONENT FEMORAL 4 KNEE LEFT CRUCIATE RETAIN BEAD TRIATHLON",SUP-5517F401,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"CIGNA [10200]",Cigna,,6856.01,40,,5873.17,5873.17,5873.17,"1 through 10",1993.39,14569.03,"percent of total billed charges",
"LINER ACETABULAR PINNACLE 15D 64MM 32MM MARATHON HIP STERILE",SUP-121932264,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,961.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,943.3,6894.31,"percent of total billed charges",
"BASEPLT TIBIAL JOURNEY 5 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022215,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"CIGNA [10200]","Cigna Local Plus",,5235.96,31.5,,5372.07,4581.20,7242.98,23,1933.15,14128.79,"percent of total billed charges",
"PUMP CANSTR LID FILTER TUBING NONSTERILE",SUP-PAPS1,CDM,S27000186,LOCAL,0270,RC,,,both,,,1620.00,486,"FIRST HEALTH [10303]","First Health",,1296,80,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRAP CLAVICLE ADULT LARGE DELUXE ADJUSTABLE CRISSCROSS",SUP-3004-04,CDM,S27000186,LOCAL,0270,RC,,,both,,,59.86,17.96,"PHCS [10601]",PHCS,,41.9,70,,,,,0,6.96,50.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL THUMB CUSTOM FIT UNIQUE",SUP-79-82710,CDM,S27000186,LOCAL,0270,RC,,,both,,,83.43,25.03,"CIGNA [10200]","Cigna Local Plus",,44.64,53.5,,,,,0,9.7,70.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP MEDIUM LEAK 1 ENTRAINMENT NEB ELBOW",SUP-73-1061734,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.58,61.97,"CIGNA [10200]","Cigna Open Access",,117.54,56.9,,,,,0,24.03,175.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Midline Placement W Img",PX-361000537,CDM,36410,CPT,0361,RC,,,both,,,414.95,124.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,48.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.26,352.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT ACM BOWL CEMENT CRTDG FEMORAL NOZZLE MEDIUM",SUP-0306-573-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,732.47,219.74,"PHCS [10601]",PHCS,,512.73,70,,,,,0,85.19,622.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT SPLINT 31X8.25IN 16.5IN ARM SHOWER BAG ADULT",SUP-1710,CDM,S27000186,LOCAL,0270,RC,,,both,,,140.68,42.2,"CIGNA [10200]","Cigna Open Access",,80.05,56.9,,,,,0,16.36,119.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE LARGE XLONG MALE NAVY BLUE BREATHABLE",SUP-100344-040,CDM,S27000186,LOCAL,0270,RC,,,both,,,54.55,16.36,"AETNA [10100]","Aetna HMO/PPO",,43.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.34,46.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT SPLINT 31X8.25IN 16.5IN ARM SHOWER BAG ADULT",SUP-1710,CDM,S27000186,LOCAL,0270,RC,,,both,,,140.68,42.2,"UHC [10700]","United Healthcare",,89.05,63.3,,,,,0,16.36,119.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 62MM 36MM XLPE HIP STERILE",SUP-71335762,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3004.09,27,,,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 13MM KNEE CONSTRAIN UHMWPE GENESIS II",SUP-71420526,CDM,C1776,HCPCS,0278,RC,,,both,,,18474.75,5542.42,"BLUE CROSS [10001]","Blue Cross HMO",,7242.1,39.2,,5311.50,4717.44,5388.59,31,2148.61,15703.54,"percent of total billed charges",
"STEM FEMORAL 103MM TRI-LOCK BPS GRIPTION 4 HIGH OFFSET HIP",SUP-101214040,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"NOVANET [10819]",Novanet,,12080.34,75,,,,,0,1873.26,13691.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT FEMORAL 10MM",SUP-CM2410,CDM,C1776,HCPCS,0278,RC,,,both,,,7341.60,2202.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4992.29,68,,,,,0,853.83,6240.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 30CM 14FR STRAIGHT SILICONE SLX TAPER TIP 2",SUP-MC061405,CDM,C1750,HCPCS,0278,RC,,,both,,,753.30,225.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,89.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Inters Vc for Rad Tx Guid",PX-361000266,CDM,C9728,HCPCS,0361,RC,,,both,,,4000.72,1200.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,465.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,465.28,4000.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Vulva Peri Abscess",PX-450000282,CDM,56405,CPT,0361,RC,,,both,,,1183.72,355.12,"CIGNA [10200]","Cigna Open Access",,1183.72,,"Case rate ($2,751). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,137.67,1183.72,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 74X46X17MM NEXGEN LCCK 5-6 E-F STD KNEE",SUP-00599404017,CDM,C1776,HCPCS,0278,RC,,,both,,,16256.40,4876.92,"BLUE CROSS [10001]","Blue Cross HMO",,6372.51,39.2,,5311.50,4717.44,5388.59,31,1890.62,13817.94,"percent of total billed charges",
"CATH INFINITI THRULUMEN 110CM 5FR .047IN .047IN PIGTAIL",SUP-534550S,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"FIRST HEALTH [10303]","First Health",,74.82,80,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT HAND ACCESS 120MM OBTR OPTICAL TIP AUTOMATIC VENT LOW",SUP-IAS12-120,CDM,S27200284,LOCAL,0272,RC,,,both,,,760.06,228.02,"UHC [10700]","United Healthcare",,481.12,63.3,,,,,0,88.39,646.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5MM HEALICOIL PK KNOTLESS SELF TAP",SUP-72205138,CDM,C1713,HCPCS,0278,RC,,,both,,,3368.25,1010.47,"NOVANET [10819]",Novanet,,2526.19,75,,,,,0,391.73,2863.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vitamin B12 Binding Capacity",PX-301000173,CDM,82608,CPT,0301,RC,,,both,,,164.00,49.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.04,,"Fee schedule rate ($15.04). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.16,139.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"THOMASMEDICAL INTRDCR FR10 - EACH",SUP-666268-001,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE CRANIOFACIAL TITANIUM 6 HOLE STRUT LOW PROFILE",SUP-421.522,CDM,C1713,HCPCS,0278,RC,,,both,,,3127.50,938.25,"CIGNA [10200]",Cigna,,2126.7,68,,1831.33,1831.33,1831.33,16,363.73,2658.38,"percent of total billed charges",
"CATH CELSIUS REDEL 90CM 5MM 8FR 2-5-2MM SPACE D CURVE",SUP-D8BTD5L252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"FIRST HEALTH [10303]","First Health",,3968.88,80,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 6X4IN HERNIA 2D FLAT SHEET RIGID",SUP-VTX1510,CDM,C1781,HCPCS,0278,RC,,,both,,,702.51,210.75,"CIGNA [10200]","Cigna Open Access",,399.73,56.9,,11235.02,819.42,11235.02,"1 through 10",81.7,597.13,"percent of total billed charges",
"PROBE EMG STIMULUS HNDPC NV M5",SUP-2012021,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.00,495,"AETNA [10100]","Aetna HMO/PPO",,1311.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9FR .118IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1009,CDM,C1894,HCPCS,0272,RC,,,both,,,298.32,89.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,35.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.69,253.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-9 CD 10MM KNEE LEFT CRUCIATE RETAINING",SUP-42512000410,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"NOVANET [10819]",Novanet,,8082.32,75,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 1ML DRY BIOCOMPATIBLE INLINE CPLR",SUP-TOR2510,CDM,S27800098,LOCAL,0278,RC,,,both,,,526.50,157.95,"KAISER [10500]",Kaiser,,352.76,67,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 16MM PERSONA 3-5 A-B KNEE RIGHT CONDYLAR",SUP-42522800216,CDM,C1776,HCPCS,0278,RC,,,both,,,16308.84,4892.65,"NOVANET [10819]",Novanet,,12231.63,75,,,,,0,1896.72,13862.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 146MM TYPE 1 PRESS FIT REDUCE TAPERLOC PPS 133D",SUP-51103130,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2814.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE APPROACH VASCULAR STRAIGHT TAPER 300CM .014IN",SUP-G52939,CDM,C1769,HCPCS,0272,RC,,,both,,,1389.07,416.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.55,1180.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN ADULT DORO STRONG PROTECTIVE CAP FURROWED GRIP UNIQUE",SUP-3006-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.04,27.91,"KAISER [10500]",Kaiser,,62.34,67,,,,,0,10.82,79.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Oligoclonal Bands CSF",PX-301000343,CDM,83916,CPT,0301,RC,,,both,,,401.70,120.51,"BLUE CROSS [10001]","Blue Cross PPO",,34.99,,"Fee schedule rate ($34.99).",,,,0,0.01,341.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cpk Isoenzymes",PX-301000164,CDM,82552,CPT,0301,RC,,,both,,,80.75,24.22,"NOVANET [10819]",Novanet,,60.56,75,,,,,0,0.01,68.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMP TIP 35CM 12FR REGULAR DRNG FLEXIMA HYDROPHILIC",SUP-M001281580,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK BONE 230MM BLUNT",SUP-MB418R,CDM,S27200284,LOCAL,0272,RC,,,both,,,357.57,107.27,"CIGNA [10200]","Cigna Local Plus",,191.3,53.5,,,,,0,41.59,303.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.300,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Local Plus",,184.58,53.5,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 6MM 16MM TITANIUM FULL THREAD CANCELLOUS SMALL",SUP-406.016,CDM,C1713,HCPCS,0278,RC,,,both,,,294.76,88.43,"BLUE CROSS [10001]","Blue Cross HMO",,115.55,39.2,,957.42,156.86,7483.26,51,34.28,250.55,"percent of total billed charges",
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX LARGE C9 9.5MM X",SUP-T600309,CDM,S27800098,LOCAL,0278,RC,,,both,,,3150.00,945,"PHCS [10601]",PHCS,,2205,70,,,,,0,366.35,2677.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR HD 46CM 13-15FR ACCESS STAINLESS STEEL",SUP-M0062502290,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"PHCS [10601]",PHCS,,686.47,70,,,,,0,114.05,833.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HALYARD BALLARD 3.5MM 3MM 12IN 7FR 4MM SUCTION",SUP-197,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.21,33.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,74.94,68,,,,,0,12.82,93.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.5/15",SUP-401745,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL GRAY 50MM 5.5MM CURVE CONTOUR",SUP-101-65550,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross HMO",,1728.72,39.2,,957.42,156.86,7483.26,51,512.88,3748.5,"percent of total billed charges",
"CNCT ROD 21-23MM 3.5MM ELLIPSE STRAIGHT TITANIUM SPINE",SUP-182.923,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"KAISER [10500]",Kaiser,,3236.1,67,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 8X8MM JAWS STRAIGHT NITINOL",SUP-P71-008-0808-S,CDM,C1713,HCPCS,0278,RC,,,both,,,8330.03,2499.01,"BLUE CROSS [10001]","Blue Cross HMO",,3265.37,39.2,,957.42,156.86,7483.26,51,968.78,7080.53,"percent of total billed charges",
"SCR BONE 7MM AEQUALIS PERFORM REVERSE STERILE LATEX FREE",SUP-DWJ001,CDM,C1713,HCPCS,0278,RC,,,both,,,3180.00,954,"CIGNA [10200]","Cigna Open Access",,1809.42,56.9,,1144.80,304.56,2275.09,66,369.83,2703,"percent of total billed charges",
"SCR BONE 3.5MM 85MM STAINLESS STEEL T15 TIBIA PROXIMAL SELF",SUP-02.127.185,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"CIGNA [10200]","Cigna Open Access",,644.51,56.9,,1144.80,304.56,2275.09,66,131.73,962.8,"percent of total billed charges",
"STAPLE BONE 8X8MM JAWS STRAIGHT NITINOL",SUP-P71-008-0808-S,CDM,C1713,HCPCS,0278,RC,,,both,,,8330.03,2499.01,"MULTIPLAN [10600]",Multiplan,,7080.53,85,,,,,0,968.78,7080.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.112,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"BLUE CROSS [10001]","Blue Cross HMO",,444.02,39.2,,957.42,156.86,7483.26,51,131.73,962.8,"percent of total billed charges",
"SCR BONE 3.5MM 85MM STAINLESS STEEL T15 TIBIA PROXIMAL SELF",SUP-02.127.185,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,324.18,28.62,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 56MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.556,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,129.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",127.51,931.96,"percent of total billed charges",
"SCR BONE 7MM 60X16MM DARCO FOOT HEADLESS",SUP-DC001660,CDM,C1713,HCPCS,0278,RC,,,both,,,4629.90,1388.97,"CIGNA [10200]","Cigna Local Plus",,2477,53.5,,3978.14,359.25,3978.14,24,538.46,3935.42,"percent of total billed charges",
"SCR BONE 2.4MM 16MM LCP STAINLESS STEEL DISTAL RADIAL",SUP-02.210.116,CDM,C1713,HCPCS,0278,RC,,,both,,,959.36,287.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.36,68,,,,,0,111.57,815.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 100D STD L 5MMX.6MM MIDFACE LEFT 5 HOLE BAR 1.7MM SCR",SUP-55-06762,CDM,C1713,HCPCS,0278,RC,,,both,,,1606.72,482.02,"AMERIGROUP MEDICAID [20100]",Amerigroup,,190.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",186.86,1365.71,"percent of total billed charges",
"SCR BONE 8MM 45MM MATRIX TITANIUM SPINE CANNULATED POLYAXIAL",SUP-04.606.845,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"KIT ARTHROSCOPIC FIXATION TOGGLELOC ZIPLOOP MAXBRAID 2 2.4MM",SUP-909874,CDM,C1713,HCPCS,0278,RC,,,both,,,11040.00,3312,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4537.44,41.1,,,,,0,1283.95,9384,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 6MM 18MM TITANIUM T15 FULL THREAD CORTEX SELF",SUP-04.200.018,CDM,C1713,HCPCS,0278,RC,,,both,,,266.22,79.87,"CIGNA [10200]","Cigna Local Plus",,142.43,53.5,,3978.14,359.25,3978.14,24,30.96,226.29,"percent of total billed charges",
"NAIL 12MM 30CM ANKLE DYNANAIL XL INTRAMEDULLARY NITINOL",SUP-1200-01-1230,CDM,C1713,HCPCS,0278,RC,,,both,,,83106.00,24931.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9848.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",9665.23,70640.1,"percent of total billed charges",
"PLATE SPINAL W32MM ANTERIOR CERVICAL ATLANTIS VISION ELITE",SUP-7200032,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",521.61,3812.25,"percent of total billed charges",
"CATH ARMADA 14 150CM 80MM 4FR 2.5MM ROUND LOW PROFILE TAPER",SUP-A2025-080,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL CANNULATED LARGE QUICK COUPLING 6.5 MM 7.5",SUP-03.333.214,CDM,S27000186,LOCAL,0270,RC,,,both,,,2965.05,889.51,"PHCS [10601]",PHCS,,2075.54,70,,,,,0,344.84,2520.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE 30MM 57CM 8-6MM TAPER VASCULAR NITINOL",SUP-SR-080630-TCS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 43IN 10FR ANTICLOG RADIOPAQUE SMOOTH BOLUS",SUP-20-7431,CDM,S27200284,LOCAL,0272,RC,,,both,,,118.20,35.46,"CIGNA [10200]",Cigna,,80.38,68,,,,,0,13.75,100.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 26-42MM LARGE BALLOON OCCLUSION TAG THORAX TRILOBE",SUP-BCL2645,CDM,C1725,HCPCS,0272,RC,,,both,,,4843.80,1453.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3293.78,68,,,,,0,563.33,4117.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SOF-CURL 26CM 6FR URETERAL TEMPORARY INDWELL CATH",SUP-SSC6026,CDM,C2617,HCPCS,0278,RC,,,both,,,606.45,181.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,173.57,28.62,,,,,0,70.53,515.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +12.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00125,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,460.4,39.2,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSELECT DEMINERALIZED BONE MATRIX 1CC",SUP-309010,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,324.55,28.62,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 40MM 6FR 10MM .035IN LOW PROFILE BALLOON",SUP-B1100-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"PHCS [10601]",PHCS,,538.65,70,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IPG W3DR01 AZURE S DR MRI",SUP-W3DR01,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"PHCS [10601]",PHCS,,29120,70,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 16CM PUMP SET",SUP-ES2916,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7292.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT MONORAIL 22MM 135CM 6MM ENDOPROSTHESIS METAL",SUP-M001719000,CDM,C1876,HCPCS,0278,RC,,,both,,,16615.20,4984.56,"CIGNA [10200]",Cigna,,6646.08,40,,,,,0,1932.35,14122.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 5MM SPACE A CURVE ELECTROPHYSIOLOGY",SUP-F6QRA005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"FIRST HEALTH [10303]","First Health",,725.76,80,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORPLEX 2X3 CM",SUP-CX-2030,CDM,Q4232,HCPCS,0636,RC,,,both,,,9204.60,2761.38,"KAISER [10500]",Kaiser,,6167.08,67,,,,,0,247.92,7823.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Proc Nosebleed",PX-E27000129,CDM,E27000129,LOCAL,0270,RC,,,both,,,177.10,53.13,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Tube Feeding Ng Levine",PX-E27200224,CDM,E27200224,LOCAL,0272,RC,,,both,,,52.32,15.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL 1 CT-1 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J347H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEEDLE YUEH CATHETER 19GX7CM",SUP-228673,CDM,C1729,HCPCS,0272,RC,,,both,,,147.64,44.29,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 6X300 80CM SL",SUP-48006030N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC",462,MS-DRG,,,,,,,inpatient,,,233760.96,70128.29,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GW SUPPORTRAK VASC 100CM IS-1",SUP-6669,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 22FR 20CM RADIOPAQUE STD ACCEPTS .038IN GWIRE",SUP-G01472,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.44,31.03,"NOVANET [10819]",Novanet,,77.58,75,,,,,0,12.03,87.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 1.5MM TARGET NANO HELICAL DETACHABLE",SUP-M0035431530,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"BLUE CROSS [10001]","Blue Cross HMO",,3589.81,39.2,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC",462,MS-DRG,,,,,,,inpatient,,,233760.96,70128.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,52803.66,,"Fee schedule rate ($52,803.66). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,77661.36,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH CRANIAL 76X50X1.5MM MTM CRANIOMAXILLOFACIAL TITANIUM",SUP-81023,CDM,C1713,HCPCS,0278,RC,,,both,,,8837.93,2651.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2529.42,28.62,,,,,0,1027.85,7512.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Iab Sensation+",PX-E27200340,CDM,C1725,HCPCS,0272,RC,,,both,,,5210.70,1563.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,617.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,606,4429.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 200MM 2.5MM BALLOON DILATATION RAPID",SUP-47525200M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"KAISER [10500]",Kaiser,,1356.75,67,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 1.45MM NITINOL BLUNT",SUP-286705320,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM AVENIR 10 COIL FINISH COMPLEX",SUP-10CFN-03004,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Open Access",,3927.24,33.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 74MM FENESTRATE CUFFLESS DISPOSABLE INNER CANN ROUND",SUP-6DCFN,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.84,87.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,134.41,45.9,,,,,0,34.06,248.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 110CM 4FR PIGTAIL CURVE ANGIOGRAPHIC RADIOPAQUE",SUP-H787107140085,CDM,C1887,HCPCS,0272,RC,,,both,,,190.36,57.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.14,161.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID PACBAND- STANDARD",SUP-38340017,CDM,S27000186,LOCAL,0270,RC,,,both,,,180.96,54.29,"CIGNA [10200]","Cigna Open Access",,102.97,56.9,,,,,0,21.05,153.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acapella",PX-E27000029,CDM,E27000029,LOCAL,0270,RC,,,both,,,319.49,95.85,"PHCS [10601]",PHCS,,223.64,70,,,,,0,37.16,271.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION BUTTON DRILL PIN INSRT SCR STERILE",SUP-AR-2260,CDM,S27200284,LOCAL,0272,RC,,,both,,,6158.25,1847.47,"FIRST HEALTH [10303]","First Health",,4926.6,80,,,,,0,716.2,5234.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 67MM 75CM 7MM 100CM",SUP-M001712140,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"BLUE CROSS [10001]","Blue Cross HMO",,3313.38,39.2,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 6MM 8MM 7FR .035IN",SUP-BXA067901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"FIRST HEALTH [10303]","First Health",,17125.92,80,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX11MM CAPSTONE PTC",SUP-3992211,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"AETNA [10100]","Aetna HMO/PPO",,16874.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 15CM 4MM 5FR BALLOON DILATATION",SUP-V1840150,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,650.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 9.5MM S-ROM ZTT 24F SMALL HIP PROXIMAL",SUP-550747,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"UHC [10700]","United Healthcare",,6890.05,63.3,,8601.07,8395.67,8601.07,"1 through 10",1265.9,9252.04,"percent of total billed charges",
"WIRE FIXATION 100MM 1.6MM KIRSCHNER",SUP-WIRE-1.6/100,CDM,S27000186,LOCAL,0270,RC,,,both,,,174.00,52.2,"MULTIPLAN [10600]",Multiplan,,147.9,85,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 170CM 10FR .035IN PUSHING GWIRE STERILE DISPOSABLE",SUP-G21443,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 18MM 135CM 6MM 3.6-3.3FR 6FR LOW",SUP-1011499-18,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"BLUE CROSS [10001]","Blue Cross HMO",,2469.6,39.2,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BIOLOGICAL MICROMATRIX PORCINE EXTRACELLULAR MATRIX",SUP-MM0100,CDM,Q4118,HCPCS,0278,RC,,,both,,,2160.00,648,"KAISER [10500]",Kaiser,,1447.2,67,,,,,0,6.84,1836,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORPLEX 15MM DISC",SUP-CX-0015,CDM,Q4232,HCPCS,0636,RC,,,both,,,4029.60,1208.88,"CIGNA [10200]","Cigna Local Plus",,294.23,,,,,,,247.92,3425.16,"fee schedule",
"SLEEVE SUTURE LATEX FREE",SUP-TV-0700,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"MULTIPLAN [10600]",Multiplan,,140.51,85,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL IDENTITY IMPRINT 3 KNEE POSTERIOR STABILIZE",SUP-TPS-301-T03S,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1042.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1023.15,7477.88,"percent of total billed charges",
"SCR BONE 2MM 36MM LCP DCP STAINLESS STEEL CORTICAL HAND/FOOT",SUP-201.836,CDM,C1713,HCPCS,0278,RC,,,both,,,358.09,107.43,"CIGNA [10200]","Cigna Open Access",,203.75,56.9,,1144.80,304.56,2275.09,66,41.65,304.38,"percent of total billed charges",
"SUB BONE GRAFT 10X8MM GRAFTON DEMINERALIZED BONE MATRIX PLUG",SUP-T42308,CDM,S27800098,LOCAL,0278,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,317.52,39.2,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 7.9X3.9IN XENMATRIX AQUAPURE RECTANGLE",SUP-1161020,CDM,C1781,HCPCS,0278,RC,,,both,,,31593.24,9477.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8530.17,27,,,,,0,3674.29,26854.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 28MM TITANIUM CURVE CIRCLE 2 STAGGER LOW",SUP-111987,CDM,S27200284,LOCAL,0272,RC,,,both,,,2138.85,641.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,253.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,248.75,1818.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 360MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.352S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"CIGNA [10200]","Cigna Local Plus",,4447.15,53.5,,3978.14,359.25,3978.14,24,966.74,7065.57,"percent of total billed charges",
"SCR BONE 6MM 68MM NAIL-EX TITANIUM FEMORAL LOCKING STARDRIVE",SUP-04.005.658,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"FIRST HEALTH [10303]","First Health",,925.34,80,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION TRANSEND 130CM 165CM 2.4FR .014IN MICRO BERN",SUP-M001195840,CDM,C1887,HCPCS,0272,RC,,,both,,,6382.50,1914.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,756.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,742.28,5425.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RE-ENTRY MALECOT AMPLATZ SUPER STIFF 35CM 18CM 24FR 8FR",SUP-M0064101070,CDM,C1729,HCPCS,0272,RC,,,both,,,584.01,175.2,"UHC [10700]","United Healthcare",,369.68,63.3,,,,,0,67.92,496.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E PATELLA CEMENT SURFACE",SUP-98000674130,CDM,C1776,HCPCS,0278,RC,,,both,,,20790.00,6237,"UHC [10700]","United Healthcare",,13160.07,63.3,,8601.07,8395.67,8601.07,"1 through 10",2417.88,17671.5,"percent of total billed charges",
"SPONGE SCLERAL 100MM SILICONE GROOVED SPONGE TYPE 506 BOX OF",SUP-S5.6335,CDM,S27800098,LOCAL,0278,RC,,,both,,,454.25,136.27,"FIRST HEALTH [10303]","First Health",,363.4,80,,,,,0,52.83,386.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +27.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.275,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM 2MM CHARCOT GORILLA GRIP PRECISION GUIDE BONE",SUP-P53-109-R212,CDM,C1713,HCPCS,0278,RC,,,both,,,13263.53,3979.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3796.02,28.62,,,,,0,1542.55,11274,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP INSRT TIBIAL KNEE OXINIUM BICRUCIATE STABILIZE CONSTRUCT",SUP-71709010,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS [10001]","Blue Cross PPO",,8643.6,39.2,,3949.44,3949.44,3949.44,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"SCR BONE 2.4MM 4.5MM 16MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.516.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,70.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",69.37,507.01,"percent of total billed charges",
"ELUVIA US 6X150 130 CM",SUP-H74939294601510,CDM,C1874,HCPCS,0278,RC,,,both,,,25168.50,7550.55,"BLUE CROSS [10001]","Blue Cross PPO",,9866.05,39.2,,,,,0,2927.1,21393.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX SEPRA 12X10IN MONOFILAMENT RESORBABLE",SUP-1202530,CDM,C1781,HCPCS,0278,RC,,,both,,,79297.83,23789.35,"KAISER [10500]",Kaiser,,53129.55,67,,,,,0,9222.34,67403.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIALYZER HEMODIALYSIS 1.8SQ MR OPTIFLUX 102ML HIGH FLUX",SUP-0500318E,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.49,30.75,"NOVANET [10819]",Novanet,,76.87,75,,,,,0,11.92,87.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 2CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE RADIOPAQUE",SUP-8140-24-2.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CIGNA [10200]","Cigna Open Access",,443.29,56.9,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 40CM 32CM 18FR DRNG HYDROPHILIC BILIARY 32 SIDEPORT",SUP-G09829,CDM,C1729,HCPCS,0272,RC,,,both,,,963.82,289.15,"MULTIPLAN [10600]",Multiplan,,819.25,85,,,,,0,112.09,819.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.35MM 125MM TFN-ADVANCED TITANIUM ALUMINUM",SUP-04.038.225S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,1144.80,304.56,2275.09,66,434.96,3179,"percent of total billed charges",
"FIDAXOMICIN 200 MG TABLET",RX-110360,CDM,,,0637,RC,52015-0080-01,NDC,both,1,UN,1180.49,354.15,"FIRST HEALTH [10303]","First Health",,944.39,80,,,,,0,137.29,1003.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 22CM 150CM 7FR .038IN 3CM BLADDER LOOP",SUP-M006155241170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,406.5,28.62,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 32MM 144CM 3.5MM CORONARY STENT",SUP-H7493952832350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]",Cigna,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MULTI-3V 195CM 5.5-7FR 15MM SPECIMEN RETRIEVAL 3 LUMEN",SUP-B-V243Q-A,CDM,C1725,HCPCS,0272,RC,,,both,,,918.62,275.59,"AETNA [10100]","Aetna HMO/PPO",,730.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,106.84,780.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 15CM 28MM TAG THORACIC ACTIVE CONTROL",SUP-TGM282815,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"CIGNA [10200]","Cigna Local Plus",,36531.24,31.5,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 1.5MM X 20MM COCR",SUP-VAL-15200-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"MULTIPLAN [10600]",Multiplan,,1211.76,85,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUSELECT 105CM 2-2.8FR .021IN MICRO EMBOLIZATION",SUP-M001394111050,CDM,C1887,HCPCS,0272,RC,,,both,,,5102.55,1530.76,"KAISER [10500]",Kaiser,,3418.71,67,,,,,0,593.43,4337.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.5MM 24MM RADIUS VOLAR DISTAL THREAD",SUP-131211124,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATALYST HUMERAL STEM SHORT - 36MM X8MM",SUP-1230-7523-001,CDM,C1776,HCPCS,0278,RC,,,both,,,27713.70,8314.11,"CIGNA [10200]","Cigna Local Plus",,8729.82,31.5,,5372.07,4581.20,7242.98,23,3223.1,23556.65,"percent of total billed charges",
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 8FR .088IN EXTRA",SUP-588894,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 32MM DARCO FULL THREAD HEAD",SUP-777453202,CDM,C1713,HCPCS,0278,RC,,,both,,,1740.00,522,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,798.66,45.9,,,,,0,202.36,1479,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG PERITONEAL CATH INSRT TRAY BLUE VALVE STARTER",SUP-4992209,CDM,S27200284,LOCAL,0272,RC,,,both,,,5430.65,1629.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,631.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,631.58,4616.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI CHIKAI VASCULAR STRAIGHT 200CM 30CM .36MM",SUP-WAIN-CKI-200,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1541.25,41.1,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 100MM 5FR 4MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206041010,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH C315H4002 RIGHTSITE",SUP-C315H4002,CDM,C1887,HCPCS,0272,RC,,,both,,,2175.00,652.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,257.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ASAHI TORNUS 135CM 2.1FR .014IN BRAID THREAD GUIDING",SUP-82380-01,CDM,C1887,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2254.54,41.1,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BONE PLATE 105MM LCP ORTHOPEDIC STAINLESS STEEL 9 HOLE 1/3",SUP-241.391,CDM,C1713,HCPCS,0278,RC,,,both,,,1259.96,377.99,"CIGNA [10200]",Cigna,,856.77,68,,1831.33,1831.33,1831.33,16,146.53,1070.97,"percent of total billed charges",
"CATH WORD 60MM 10-12FR DRNG RUBBER BARTHOLIN STERILE LATEX",SUP-53404,CDM,C1758,HCPCS,0272,RC,,,both,,,197.34,59.2,"FIRST HEALTH [10303]","First Health",,157.87,80,,,,,0,22.95,167.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM SPINE MULTIAXIAL STERILE 5.5/6MM ROD",SUP-55720007545,CDM,C1713,HCPCS,0278,RC,,,both,,,10267.20,3080.16,"FIRST HEALTH [10303]","First Health",,8213.76,80,,,,,0,1194.08,8727.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Speech Prod W Comprehension",PX-444000017,CDM,92523,CPT,0444,RC,,,both,,,548.26,164.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,64.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,63.76,466.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Speech Prod W Comprehension",PX-444000017,CDM,92523,CPT,0444,RC,,,both,,,548.26,164.48,"AETNA [10100]","Aetna HMO/PPO",,435.87,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,63.76,466.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC IV Inf Hydrat Add Hr",PX-260000002,CDM,96361,CPT,0260,RC,,,both,,,294.17,88.25,"PHCS [10601]",PHCS,,205.92,70,,,,,0,34.21,294.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD SMALL 5.5MM TSRH-3D OPEN OFFSET TITANIUM POSTERIOR",SUP-8379120,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1635.19,45.9,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD SMALL 5.5MM TSRH-3D OPEN OFFSET TITANIUM POSTERIOR",SUP-8379120,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,414.32,3028.13,"percent of total billed charges",
"SCR BONE 5.5MM 55MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-54840015555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"SCR INTERFERENCE BIOCOMPOSITE 30MM 11MM KNEE FASTTHREAD",SUP-AR-4030C-11,CDM,C1713,HCPCS,0272,RC,,,both,,,2323.13,696.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,954.81,41.1,,,,,0,954.81,1470.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE INSTAFILL SIGNIFY 5CC ALLOGRAFT CRTDG GEL STERILE",SUP-8112.5105S,CDM,C1713,HCPCS,0278,RC,,,both,,,7852.20,2355.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2247.3,28.62,,,,,0,913.21,6674.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 16MM TI",SUP-VAN-25160-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,113.04,826.2,"percent of total billed charges",
"SCR BONE 6.5MM 45MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.431,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"PHCS [10601]",PHCS,,968.89,70,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 16X7MM COALITION AGX BONE SPINE",SUP-1128.1407,CDM,C1713,HCPCS,0278,RC,,,both,,,18000.00,5400,"FIRST HEALTH [10303]","First Health",,14400,80,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 36MM DART-FIRE TITANIUM SMALL PARTIAL THREAD",SUP-D2N30032,CDM,C1713,HCPCS,0278,RC,,,both,,,1657.50,497.25,"PHCS [10601]",PHCS,,1160.25,70,,,,,0,192.77,1408.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 26MM COCR",SUP-VAL-35260-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"NOVANET [10819]",Novanet,,1575,75,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM XIA SERRATO SPINE POLYAXIAL NONSTERILE 3",SUP-482616540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"PLATE BROAD 6.5IN STAINLESS STEEL 4.5MM SCREWS 5 HOLE 6",SUP-3704-3-100,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1032.75,45.9,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM STAINLESS STEEL T25 SELF TAP LOCK VARIABLE",SUP-02.231.234,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,600.29,45.9,,,,,0,152.1,1111.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 5.5MM CREO CURVE TITANIUM NONSTERILE",SUP-1119.7050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"AEON ENDOSTAPLER CURVED TIP RELOAD 45MM PURPLE",SUP-AESC45P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET FIX CLIP HOSE 2 FLOW RATE CHIROPRO 980 IRRIGATION 30-130",SUP-1100037-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN RIGHT",SUP-77808300,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PANTOPRAZOLE SODIUM 40 MG/10ML IV (WET SOLR VIAL)",RX-41526226,CDM,J2470,HCPCS,0636,RC,72603-0128-01,NDC,both,1,UN,52.92,15.88,"NOVANET [10819]",Novanet,,39.69,75,,,,,0,2.2,44.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 40MM 75CM 8MM 8FR .035IN BILIARY METAL",SUP-M00574620,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 35CM MYOCARDIUM VENTRICLE IS-1 CNCT SCR FIXATION",SUP-4058,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross PPO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X2CM VIALIZE PLACENTAL MEMB ALLOGRAFT",SUP-VL-2030,CDM,,,0278,RC,,,both,,,7431.30,2229.39,"CIGNA [10200]","Cigna Open Access",,4228.41,56.9,,,,,0,7.43,6316.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 4.00 X 12MM",SUP-H7493942812400,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,722.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Sinus <3v",PX-320000014,CDM,70210,CPT,0320,RC,,,both,,,552.96,165.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,64.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.66,470.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Type Seq Meth Solate",PX-306000208,CDM,87153,CPT,0306,RC,,,both,,,1009.00,302.7,"CIGNA [10200]","Cigna Open Access",,253.79,,,,,,,0.01,857.65,"fee schedule",
"HC Particle Agglutination Titer",PX-302000242,CDM,86406,CPT,0302,RC,,,both,,,187.00,56.1,"KAISER [10500]",Kaiser,,125.29,67,,,,,0,7.21,158.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR ATHERECTOMY 135CM 1.25MM ROTABLATOR ROTALINK PLUS",SUP-M0011401250,CDM,C1724,HCPCS,0272,RC,,,both,,,16525.50,4957.65,"MULTIPLAN [10600]",Multiplan,,14046.68,85,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 25CM 6FR .087IN .082IN GLIDESHEATH .035IN SPRING J",SUP-RM*BF6M25MA,CDM,C1894,HCPCS,0272,RC,,,both,,,368.01,110.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.8,312.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM TRILOGY TIVANIUM ALLOY CORTICAL",SUP-00625006530,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"BLUE CROSS [10001]","Blue Cross PPO",,390.55,39.2,,957.42,570.23,957.42,28,115.87,846.86,"percent of total billed charges",
"ADPTR FEMORAL VANGUARD 360 5MM OFFSET KNEE REVISION SYSTEM",SUP-185211,CDM,C1776,HCPCS,0278,RC,,,both,,,5978.16,1793.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1710.95,28.62,,,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 5MM 1MM BALLOON DILATATION PERCUTANEOUS",SUP-210-053-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR 2.4MM STEP DRILL GUIDE DISPOSABLE SMALL JOINT",SUP-AR-8934DSC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1233.23,369.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,143.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.42,1048.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Vag Injury",PX-450000287,CDM,57200,CPT,0361,RC,,,both,,,4627.00,1388.1,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,538.12,4627,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 118MM CEMENTLESS OFFSET ACCOLADE TMZF 132D 2.5",SUP-6020-2530,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"CIGNA [10200]",Cigna,,6259.68,40,,5873.17,5873.17,5873.17,"1 through 10",1820,13301.82,"percent of total billed charges",
"SCR BONE 6.5MM 30MM TRIDENT II LOW PROFILE HEXAGONAL STERILE",SUP-7030-6530,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA [10200]","Cigna Local Plus",,407.35,53.5,,3978.14,359.25,3978.14,24,88.55,647.19,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 30CM 10MM THORACIC AORTA WOVEN",SUP-IGW0010-30,CDM,C1768,HCPCS,0278,RC,,,both,,,2894.40,868.32,"BLUE CROSS [10001]","Blue Cross PPO",,1134.6,39.2,,,,,0,336.62,2460.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI FIELDER PTCA GUIDE WIRE W/HYDROPHILIC COATING 180 CM",SUP-AGP140000,CDM,C1769,HCPCS,0272,RC,,,both,,,769.50,230.85,"MULTIPLAN [10600]",Multiplan,,654.08,85,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 12X30X9-16MM 8DEG SABLE",SUP-1172.4213S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4029.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORTICAL SCREW 4MM X 56MM",SUP-HTN-U-4-56,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,445.1,28.62,,,,,0,180.87,1321.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLOTRIMAZOLE 1 % TOPICAL CREAM",RX-1767,CDM,,,0250,RC,45802-0434-11,NDC,both,30,GR,53.97,16.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,22.18,41.1,,,,,0,6.28,45.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 39MM 135CM 7MM THIN VASCULAR COCR",SUP-1012630-39,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"AETNA [10100]","Aetna HMO/PPO",,6678,79.5,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM SYNAPSE TITANIUM 50D T15 SPINE",SUP-04.614.016,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"CLARITHROMYCIN 250 MG TABLET, IMMEDIATE RELEASE",RX-9616,CDM,,,0250,RC,65862-0225-60,NDC,both,1,UN,25.19,7.56,"CIGNA [10200]","Cigna Open Access",,14.33,56.9,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRAPLINER 150CM 13CM 5.1FR 6FR INTERVENTIONAL",SUP-5566,CDM,S27200284,LOCAL,0272,RC,,,both,,,4291.80,1287.54,"UHC [10700]","United Healthcare",,2716.71,63.3,,,,,0,499.14,3648.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE INZII UNIVERSAL 12/15MM 12MM SPECIMEN RETRIEVAL",SUP-CD004,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 12X6CM ALLODERM SELECT THK2-2.8MM THICK",SUP-151972,CDM,Q4116,HCPCS,0636,RC,,,both,,,13496.40,4048.92,"CIGNA [10200]",Cigna,,9177.55,68,,,,,0,247.92,11471.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ercp Cath Pancreatic Si",PX-320000111,CDM,74329,CPT,0320,RC,,,both,,,1592.00,477.6,"NOVANET [10819]",Novanet,,1194,75,,,,,0,96.47,1353.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS BLOCK ALLOGRAFT 6MM",SUP-290641,CDM,S27800098,LOCAL,0278,RC,,,both,,,3839.85,1151.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1762.49,45.9,,,,,0,446.57,3263.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 140MM 5MM VASCULAR DRUG ELUTE ACCEPTS .035",SUP-G38416,CDM,C1874,HCPCS,0278,RC,,,both,,,15906.62,4771.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4294.79,27,,,,,0,1849.94,13520.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL 10.5IN 18MM FLAT TAPER PUTTI 2 END STRAIGHT",SUP-26-1501,CDM,S27200284,LOCAL,0272,RC,,,both,,,449.31,134.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,52.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.25,381.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) INNOVALVE VALVE PROTHESIS FOR TMVR (TRANSCATHETER MIT",SUP-PRO-5813,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR EBU3.25 CURVE GUIDING NYLON CORONARY",SUP-LA6EBU325,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7.5FR 11CM MINI GWIRE AVANTI+ .038IN ORANGE",SUP-504657X,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP LARGE 2 FLAP ADJUSTABLE FOREHEAD HEADSTRAP",SUP-1012572,CDM,S27000186,LOCAL,0270,RC,,,both,,,1822.88,546.86,"UHC [10700]","United Healthcare",,1153.88,63.3,,,,,0,212,1549.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X21MM LUMINARY CC BICONVEX SPINE",SUP-6821,CDM,S27800098,LOCAL,0278,RC,,,both,,,34524.00,10357.2,"CIGNA [10200]","Cigna Open Access",,11565.54,33.5,,,,,0,4015.14,29345.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA CARDIOPLEGIA ANTEGRADE W/VENT",SUP-ANT-2012S,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.72,41.92,"PHCS [10601]",PHCS,,97.8,70,,,,,0,16.25,118.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 40MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040040M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UHC [10700]","United Healthcare",,907.53,63.3,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 1.8MM PILOT",SUP-320-0018,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1074.06,68,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPLR ANASTOMOSIS 3.5MM GEM MICROVASCULAR STERILE DISPOSABLE",SUP-GEM2755,CDM,S27200284,LOCAL,0272,RC,,,both,,,2962.50,888.75,"FIRST HEALTH [10303]","First Health",,2370,80,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 5ML PASTE MIX PLUS",SUP-IQSP-PP-105,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,957.42,156.86,7483.26,51,601.85,4398.75,"percent of total billed charges",
"KIT EPIDURAL 60CM 20GA 18GA STIMUCATH SNAPTEAR PERIPHERAL",SUP-AB-20608-KS,CDM,C1755,HCPCS,0278,RC,,,both,,,537.27,161.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,365.34,68,,,,,0,62.48,456.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 0 GS-21 HALF CIRCLE 6IN 37MM CLSR GLYCOLIC",SUP-VLOCL0306,CDM,S27200284,LOCAL,0272,RC,,,both,,,406.03,121.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,48.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.22,345.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X9MM COLONIAL 7D LORDOTIC 14MM XL TITANIUM",SUP-365.709CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATHETER TURNPIKE 135CM 2.9FR SPIRAL VASCULAR MULTILA",SUP-5640,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 74MM STAINLESS STEEL 3.5MM SCR 3X5 HOLE T OBLIQUE LEFT",SUP-241.951,CDM,S27800098,LOCAL,0278,RC,,,both,,,2274.30,682.29,"BLUE CROSS [10001]","Blue Cross HMO",,891.53,39.2,,,,,0,264.5,1933.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 40MMX12MMX15CM 26FR",SUP-TAC124015A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"NOVANET [10819]",Novanet,,136800,75,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 83MM 6MM COMPREHENSIVE POROUS MINI SHOULDER",SUP-113626,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1465.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 3001021 ZEVO 21MM 1 LVL",SUP-3001021,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PHCS [10601]",PHCS,,2940,70,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 20MM MEDLINE UNITE FOOT ANKLE CANNULATED",SUP-MSL02520,CDM,C1713,HCPCS,0278,RC,,,both,,,1762.50,528.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,208.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",204.98,1498.13,"percent of total billed charges",
"ASAHI PROWATER PTCA GUIDE WIRE J TIP 300 CM",SUP-AGH146300J,CDM,C1769,HCPCS,0272,RC,,,both,,,769.50,230.85,"MULTIPLAN [10600]",Multiplan,,654.08,85,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 12X10CM RESORBABLE GRID 1",SUP-F10256-1012G,CDM,C1781,HCPCS,0278,RC,,,both,,,12966.48,3889.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3500.95,27,,,,,0,1508,11021.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 250MM 3.5MM BALLOON DILATATION RAPID",SUP-47535250S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"PHCS [10601]",PHCS,,1417.5,70,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.810,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"CIGNA [10200]",Cigna,,160.92,68,,1831.33,1831.33,1831.33,16,27.52,201.14,"percent of total billed charges",
"DRILL SURGICAL ANGLE SELF CENTERING FORTIFY I",SUP-676.703,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"CIGNA [10200]",Cigna,,2690.35,68,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING CORONARY VENOUS BIPOLAR EASYTRAK 2",SUP-4517,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3812.76,68,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GALAFLEX 8X6IN SOFT TISSUE MONOFILAMENT",SUP-GP0608,CDM,C1781,HCPCS,0278,RC,,,both,,,12420.00,3726,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1471.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 10MM ITOTAL IPOLY XE POSTERIOR STABILIZE INSRT",SUP-RPS0201000,CDM,C1776,HCPCS,0278,RC,,,both,,,6254.85,1876.45,"FIRST HEALTH [10303]","First Health",,5003.88,80,,,,,0,727.44,5316.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCANNER BARCODE HOLDER",SUP-7000-916HS,CDM,S27000186,LOCAL,0270,RC,,,both,,,3465.00,1039.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,402.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,402.98,2945.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX LOW PROFILE REINFORCED TISSUE MATRIX, LONG-TERM RESOR",SUP-F10264-0606L,CDM,C1781,HCPCS,0278,RC,,,both,,,3547.50,1064.25,"PHCS [10601]",PHCS,,2483.25,70,,,,,0,412.57,3015.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 18MM 2MM CORONARY STENT COCR",SUP-1007821-18,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PERFIX LIGHT 1.5IN 2IN GROIN PLUG MONOFILAMENT",SUP-0117080,CDM,C1781,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 12MM 3MM BALLOON DILATATION STERILE",SUP-230-123-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 53CM KT MED",SUP-107235,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,260.3,68,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 22MM LEFT ELBOW LEFT ANGLE STERILE",SUP-TR-H220L-S,CDM,C1776,HCPCS,0278,RC,,,both,,,13489.50,4046.85,"CIGNA [10200]",Cigna,,5395.8,40,,5873.17,5873.17,5873.17,"1 through 10",1568.83,11466.08,"percent of total billed charges",
"STEM FEMORAL 180MM 18MM COLLAR CEMENTLESS LOW PROFILE NECK",SUP-3L92508,CDM,C1776,HCPCS,0278,RC,,,both,,,30866.40,9259.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3657.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3589.76,26236.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 125CM 6FR .07IN JUDKINS LEFT",SUP-SM7435,CDM,C1887,HCPCS,0272,RC,,,both,,,1310.50,393.15,"AETNA [10100]","Aetna HMO/PPO",,1041.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,152.41,1113.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRIMARY STEMLESS SHOULDER CONSTRUCT",SUP-CONSTEMLESSSHLDR,CDM,C1776,HCPCS,0278,RC,,,both,,,31500.00,9450,"KAISER [10500]",Kaiser,,21105,67,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VICRYL 12X12IN ABSORBABLE WOVEN FLAT HERNIA",SUP-VWML,CDM,C1781,HCPCS,0278,RC,,,both,,,5296.14,1588.84,"KAISER [10500]",Kaiser,,3548.41,67,,,,,0,615.94,4501.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP SMALL LEAK 1 ENTRAINMENT NEB ELBOW",SUP-73-1061733,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.58,61.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,94.82,45.9,,,,,0,24.03,175.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 20MM VLP TITANIUM T6 FOOT CORTICAL SELF TAP",SUP-74402020,CDM,C1713,HCPCS,0278,RC,,,both,,,473.28,141.98,"FIRST HEALTH [10303]","First Health",,378.62,80,,,,,0,55.04,402.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Lactated Ringer",PX-E27200281,CDM,E27200281,LOCAL,0272,RC,,,both,,,122.10,36.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.2,103.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT 2.5 KNEE CEMENT ROTATE PLATFORM",SUP-129431125,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"PLATE SMALL STAINLESS STEEL 3.5/4.5MM SCR 10 HOLE VARIABLE",SUP-02.221.092S,CDM,C1713,HCPCS,0278,RC,,,both,,,18158.87,5447.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2111.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",2111.88,15435.04,"percent of total billed charges",
"ANCHOR SUT 1.45MM 2 1.5MM JUGGERKNOT MAXBRAID 1 LOAD RIGID",SUP-CM-99145BRN,CDM,C1713,HCPCS,0278,RC,,,both,,,3450.00,1035,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,408.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,401.24,2932.5,"percent of total billed charges",
"INTRO LEAD 49CM 9FR SAFESHEATH CSG WORLEY JUMBO CURVE",SUP-CSG/WRLY/BCOR-1-09,CDM,C1892,HCPCS,0272,RC,,,both,,,3345.00,1003.5,"FIRST HEALTH [10303]","First Health",,2676,80,,,,,0,389.02,2843.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE PACING 7MM CHANDLER PACEPORT VENTRICLE TRANSLUMINAL",SUP-D98100,CDM,C1751,HCPCS,0272,RC,,,both,,,1603.80,481.14,"UHC [10700]","United Healthcare",,1015.21,63.3,,,,,0,186.52,1363.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH VERSACROSS 45D 1 LARGE CURVE 63CM 180CM 8.5FR GUIDING",SUP-VXS85-35-63-45-D1,CDM,C1893,HCPCS,0272,RC,,,both,,,1620.00,486,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 30MM 2MM BALLOON DILATATION DURALYN",SUP-48002003X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"MULTIPLAN [10600]",Multiplan,,1067.18,85,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEM POROUS RT SZ12",SUP-427-02-120,CDM,C1776,HCPCS,0278,RC,,,both,,,32703.43,9811.03,"CIGNA [10200]",Cigna,,13081.37,40,,5873.17,5873.17,5873.17,"1 through 10",3803.41,27797.92,"percent of total billed charges",
"CNCT ROD XLNK SMALL SPINE MULTIAXIAL SCR",SUP-7752525,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",414.32,3028.13,"percent of total billed charges",
"SCR BONE 4.5MM 40MM 3DX TSRH OSTEOGRIP THINLINE TITANIUM",SUP-83545409,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"FIRST HEALTH [10303]","First Health",,2059.2,80,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 30MM 9MM .035IN BALLOON DILATATION NYBAX",SUP-39171-09034,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON CERVICAL DILATATION 40CM 18FR COOK SILICONE RIPENING",SUP-G48149,CDM,C1726,HCPCS,0272,RC,,,both,,,527.60,158.28,"PHCS [10601]",PHCS,,369.32,70,,,,,0,61.36,448.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DRAGONFLY OPSTAR DIAGNOSTIC IMAGING STERILE LATEX FREE",SUP-1014651,CDM,S27200284,LOCAL,0272,RC,,,both,,,6472.20,1941.66,"MULTIPLAN [10600]",Multiplan,,5501.37,85,,,,,0,752.72,5501.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 80CM 40MM 6MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV06004008P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"FIRST HEALTH [10303]","First Health",,6458.4,80,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW HEADED THREAD 3.2MM L 50.0MM 46.0TLMM HEXAGON 3.5","SUP-GS905.050.032 STE",CDM,C1713,HCPCS,0278,RC,,,both,,,1579.50,473.85,"KAISER [10500]",Kaiser,,1058.27,67,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL OXFORD B KNEE RIGHT MEDIAL COCRMO",SUP-154721,CDM,C1776,HCPCS,0278,RC,,,both,,,11961.08,3588.32,"PHCS [10601]",PHCS,,8372.76,70,,,,,0,1391.07,10166.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL SYMBOTEX 3.3X2.3MM 9CM 2 SIDE COMPOSITE",SUP-SYM9,CDM,C1781,HCPCS,0278,RC,,,both,,,2354.93,706.48,"BLUE CROSS [10001]","Blue Cross PPO",,923.13,39.2,,,,,0,273.88,2001.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION MICROINTRODUCER KIT 2 LUMEN",SUP-1829570,CDM,C1788,HCPCS,0278,RC,,,both,,,2625.00,787.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,751.28,28.62,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 1.5MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-01503,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4251.01,41.1,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 3/32IN STEINMANN 2 END TROCAR POINT",SUP-1625-38-000,CDM,C1713,HCPCS,0278,RC,,,both,,,102.95,30.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",11.97,87.51,"percent of total billed charges",
"STENT SURPASS ELITE 25MM 5.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE52525,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22589.44,27,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 30MM 2.5MM BALLOON DILATATION",SUP-48002503X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 11 NARROW KNEE LEFT CRUCIATE RETAIN CEMENT",SUP-42502007001,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS [10001]","Blue Cross PPO",,8962.18,39.2,,3949.44,3949.44,3949.44,"1 through 10",2658.93,19433.3,"percent of total billed charges",
"HC Repo Cvc W Fluoro",PX-450000234,CDM,36597,CPT,0361,RC,,,both,,,6675.32,2002.6,"NOVANET [10819]",Novanet,,5006.49,75,,,,,0,776.34,6675.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veeg Ea 12-26hr Cont Mntr",PX-740000051,CDM,95716,CPT,0740,RC,,,both,,,6305.47,1891.64,"CIGNA [10200]","Cigna Local Plus",,3373.43,53.5,,,,,0,733.33,5359.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (4.5-5 MCI)",RX-411878,CDM,A9520,HCPCS,0343,RC,08888-8876-12,NDC,both,1,UN,4614.97,1384.49,"PHCS [10601]",PHCS,,3230.48,70,,,,,0,536.72,4614.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 75CM 8MM 30MM",SUP-38046-83075,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"AETNA [10100]","Aetna HMO/PPO",,3839.85,79.5,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 29MM AEQUALIS SHOULDER HA REVERSE LONG POST",SUP-DWD067,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"KAISER [10500]",Kaiser,,6326.81,67,,,,,0,1098.22,8026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemoglobin Fetal Qual",PX-301000227,CDM,83033,CPT,0301,RC,,,both,,,228.00,68.4,"UHC [10700]","United Healthcare",,7.2,,,,,,,0.23,193.8,"fee schedule",
"TUBE CHEST INSERTION TRAY",SUP-23-9608C,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.11,67.83,"AETNA [10100]","Aetna HMO/PPO",,179.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.3,192.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pvb Thoracic 2nd+ Inj Site",PX-510000200,CDM,64462,CPT,0761,RC,,,both,,,2882.00,864.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,341.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,335.18,2606,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBLIQUE TLIF TI, 8X10X30MM 4",SUP-5480304,CDM,C1889,HCPCS,0278,RC,,,both,,,21225.60,6367.68,"BLUE CROSS [10001]","Blue Cross HMO",,8320.44,39.2,,8555.87,8555.87,8996.26,"1 through 10",2468.54,18041.76,"percent of total billed charges",
"STEM FEMORAL 50MM 15MM CEMENTED TOTAL STABILIZED TRIATHLON",SUP-5560-S-115,CDM,C1776,HCPCS,0278,RC,,,both,,,4271.90,1281.57,"FIRST HEALTH [10303]","First Health",,3417.52,80,,,,,0,496.82,3631.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP",RX-38285,CDM,,,0637,RC,00121-1761-30,NDC,both,30,ML,23.78,7.13,"PHCS [10601]",PHCS,,16.65,70,,,,,0,2.77,20.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM PK COIL LP STERILE LATEX FREE",SUP-RBYPCLP06,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"CIGNA [10200]","Cigna Local Plus",,3617.67,53.5,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 16FR URETHRAL BACTI-GUARD RUBBER HYDROGEL 30",SUP-0167SI16,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.45,32.23,"AETNA [10100]","Aetna HMO/PPO",,85.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.5,91.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM PK COIL LP STERILE LATEX FREE",SUP-RBYPCLP06,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"BLUE CROSS [10001]","Blue Cross HMO",,2650.7,39.2,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC 18IN KNEE 3 PANEL ADJUSTABLE BUCKLE PLASTIC",SUP-VP40105-030,CDM,L1830,HCPCS,0274,RC,,,both,,,160.08,48.02,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,73.48,45.9,,,,,0,18.62,136.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 330MM TIBIAL TN ADVANCED INTRAMEDULLARY MR",SUP-04.043.130S,CDM,C1713,HCPCS,0278,RC,,,both,,,9579.13,2873.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2741.55,28.62,,,,,0,1114.05,8142.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Train for Caregiver Add 15 (Go)",PX-430000069,CDM,G0540,HCPCS,0430,RC,,,both,,,37.00,11.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,37,,"Per diem ($426).",,,,0,0.04,37,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X8MM COUGAR LS PARALLEL LATERAL NONSTERILE",SUP-189150408,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FEVER AND INFLAMMATORY CONDITIONS",864,MS-DRG,,,,,,,inpatient,,,36826.81,11048.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8007.05,,"Fee schedule rate ($8,007.05). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,5506.46,22138.35,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 3.5CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-24-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,92.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachythrpy Grid",PX-E27200042,CDM,E27200042,LOCAL,0272,RC,,,both,,,363.00,108.9,"PHCS [10601]",PHCS,,254.1,70,,,,,0,42.22,308.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL TAPERFILL DJO SURGICAL LATERAL OFFSET HIP",SUP-425-97-008,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"CIGNA [10200]","Cigna Open Access",,14257.08,33.5,,5302.19,4377.88,6578.61,27,4949.55,36174.68,"percent of total billed charges",
"GRAFT BONE CORNERSTONE SR CORTICAL BLOCK 11X11X7MM CERVICAL",SUP-200711,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST FIXATION 30MM 4.5MM LOW PROFILE KNEE BICORTICAL",SUP-AR-1365-30,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"BLUE CROSS [10001]","Blue Cross HMO",,333.4,39.2,,957.42,156.86,7483.26,51,98.91,722.93,"percent of total billed charges",
"RETAINER VISCERA LARGE FISH",SUP-CFUHS32061,CDM,S27200284,LOCAL,0272,RC,,,both,,,512.07,153.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,235.04,45.9,,,,,0,59.55,435.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT BLUE 12CM 5FR COTTON-LEUNG BILIARY POLYETHYLENE",SUP-G22414,CDM,C2625,HCPCS,0278,RC,,,both,,,1328.40,398.52,"BLUE CROSS [10001]","Blue Cross HMO",,520.73,39.2,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 75CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR061001A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"MULTIPLAN [10600]",Multiplan,,18078.48,85,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR MULTIFENESTRATED 2 DISK NITINOL MESH",SUP-9-ASD-MF-018,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8734.08,41.1,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Interrogation Vad in Person",PX-480000001,CDM,93750,CPT,0480,RC,,,both,,,747.18,224.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,88.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.9,635.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 16CM 6MM AVENIR 18 COIL FRAME COMPLEX",SUP-18CFR-06016,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5230.2,40,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 65CM 4FR CB1 CURVE ANGIOGRAPHIC STAINLESS STEEL",SUP-465382CB1,CDM,C1769,HCPCS,0272,RC,,,both,,,108.75,32.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 58-71MM REVERE TRANSVERSE ADJUSTABLE TITANIUM SPINE",SUP-124.916,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2216.97,45.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII CRUCIATE RETAINING POSTE",SUP-71704502,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5409.18,28.62,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 3X32+TRAK21 2-PACK - US",SUP-91312,CDM,S27200284,LOCAL,0272,RC,,,both,,,24624.97,7387.49,"CIGNA [10200]","Cigna Open Access",,14011.61,56.9,,,,,0,2863.88,20931.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 15ML .1-4MM CRUSH",SUP-T20020,CDM,S27800098,LOCAL,0278,RC,,,both,,,2614.50,784.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,309.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,304.07,2222.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CEMENTED EXETER V40 33MM OFFSET HIP",SUP-0580-1-330,CDM,C1776,HCPCS,0278,RC,,,both,,,17001.60,5100.48,"PHCS [10601]",PHCS,,11901.12,70,,,,,0,1977.29,14451.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,inpatient,,,40298.87,12089.66,"CIGNA [10200]",Cigna,,12594.08,,"Fee schedule rate ($12,594.08). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,5958.04,23953.91,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sensor Neurological Bis Quatro",PX-E27000205,CDM,E27000205,LOCAL,0270,RC,,,both,,,194.37,58.31,"KAISER [10500]",Kaiser,,130.23,67,,,,,0,22.61,165.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 75CM .38MM TPR MED",SUP-124301,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,109.56,28.62,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND 4.7X9.4IN SILICONE PORCINE THERAGENESIS 2 LAYER",SUP-TG-M120240,CDM,A2008,HCPCS,0636,RC,,,both,,,36426.60,10927.98,"KAISER [10500]",Kaiser,,24405.82,67,,,,,0,247.92,30962.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anoscopy W Rmvl FB",PX-750000232,CDM,46608,CPT,0750,RC,,,both,,,1561.00,468.3,"BLUE CROSS [10001]","Blue Cross PPO",,1561,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,181.54,1561,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 20CM 3CM 8FR .038IN 2 PIGTAIL",SUP-M006192150010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,343.61,28.62,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X-COATED SPECIALTY PACK, 1/CASE",SUP-73331-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.00,513,"CIGNA [10200]","Cigna Local Plus",,914.85,53.5,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SAFEGUARD RADIAL STD LOW PROFILE 26CM COMPRESSION",SUP-SGR26,CDM,S27000186,LOCAL,0270,RC,,,both,,,261.00,78.3,"UHC [10700]","United Healthcare",,165.21,63.3,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND SILVER CALCIUM PHOSPHATE ANTIMICROBIAL POWDER",SUP-MSC9405,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.98,70.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.33,199.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145362010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"BLUE CROSS [10001]","Blue Cross PPO",,379.02,39.2,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 15MM 140CM 3MM 2.1-2.7FR CORONARY STENT",SUP-RONYX30015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"FIRST HEALTH [10303]","First Health",,2970,80,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 1.27MM PAPARELLA EAR FIRM SILICONE",SUP-24462,CDM,S27800098,LOCAL,0278,RC,,,both,,,65.25,19.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,44.37,68,,,,,0,7.59,55.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT COMPREHENSIVE GLENOID SHOULDER TRABECULA",SUP-98000900027,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"BLUE CROSS [10001]","Blue Cross PPO",,19015.92,39.2,,3949.44,3949.44,3949.44,"1 through 10",5641.71,41233.5,"percent of total billed charges",
"GRAFT BONE MAGNETOS 5CC EASYPACK PUTTY",SUP-703-051-US,CDM,C1713,HCPCS,0278,RC,,,both,,,11488.50,3446.55,"CIGNA [10200]","Cigna Open Access",,3848.65,33.5,,1144.80,304.56,2275.09,66,1336.11,9765.23,"percent of total billed charges",
"DEVICE STATLOCK SECUREMENT IAB STABILIZATION STERILE LATEX",SUP-0684-00-0472,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.58,49.67,"CIGNA [10200]",Cigna,,112.59,68,,,,,0,19.26,140.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE RELINE SPINE MODULAR REDUCTION EXT TULIP NONSTERILE",SUP-16191111,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,957.42,570.23,957.42,28,348.9,2550,"percent of total billed charges",
"HC Thrpy Proc Dirct Ea 15min (Go)",PX-430000014,CDM,97110,CPT,0430,RC,,,both,,,194.83,58.45,"CIGNA [10200]","Cigna Local Plus",,194.83,,"Per diem ($290).",102.32,102.32,102.32,"1 through 10",22.66,194.83,"per diem",
"HEAD FEMORAL STD 36MM HIP ENHANCED STABILITY PROVEN",SUP-6570-0-136,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"BLUE CROSS [10001]","Blue Cross HMO",,3920,39.2,,5311.50,4717.44,5388.59,31,1163,8500,"percent of total billed charges",
"CATH STERLING SL MONORAIL 150CM 150MM 3.5MM BALLOON",SUP-H74939147351510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 6.5MM 26MM TITANIUM FULL THREAD CORTEX SELF",SUP-414.826,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"NOVANET [10819]",Novanet,,206.45,75,,,,,0,32.01,233.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 8X60 80CM SL",SUP-48008006N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,99.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 36MM STAINLESS STEEL T25 SELF TAP VARIABLE",SUP-42.231.236,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,387.1,28.62,,,,,0,157.3,1149.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 9MM 4MM ELBOW TOTAL STERILE",SUP-TR-S0904-S,CDM,C1776,HCPCS,0278,RC,,,both,,,15145.50,4543.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6224.8,41.1,,6417.48,6417.48,6417.48,"1 through 10",1761.42,12873.68,"percent of total billed charges",
"SYSTEM ENTELLUS MEDICAL SHAVER IRRIGATION LINE",SUP-SSA-107,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"CIGNA [10200]",Cigna,,141.98,68,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 40MM 2.5MM BALLOON DILATATION RAPID",SUP-47525040L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUSELECT 105CM 2-2.8FR .021IN MICRO EMBOLIZATION",SUP-M001394101050,CDM,C1887,HCPCS,0272,RC,,,both,,,5102.55,1530.76,"UHC [10700]","United Healthcare",,3229.91,63.3,,,,,0,593.43,4337.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL PTEYE PARATHYROID DETECTION SYSTEM DISPOSABLE",SUP-PTEYE-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3960.60,1188.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,469.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,460.62,3366.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CXI 135CM 4FR DAV CURVE GUIDING TUNGSTEN ACCEPTS .035IN",SUP-G52543,CDM,C1887,HCPCS,0272,RC,,,both,,,1522.72,456.82,"AETNA [10100]","Aetna HMO/PPO",,1210.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,177.09,1294.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STELLAREX 135CM 150MM 5MM BALLOON DILATATION OTW DRUG",SUP-AB35SX050150135,CDM,C2623,HCPCS,0272,RC,,,both,,,11557.50,3467.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4750.13,41.1,,,,,0,1344.14,9823.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155234050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]","Cigna Open Access",,700.42,,,,,,,143.16,1046.32,"percent of total billed charges",
"GWIRE ORTHOPEDIC 150MM 1.1MM STAINLESS STEEL THREAD",SUP-292.622,CDM,C1769,HCPCS,0272,RC,,,both,,,177.48,53.24,"KAISER [10500]",Kaiser,,118.91,67,,,,,0,20.64,150.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL STEALTH 6MM ATRAUMATIC OCCLUSION FIBRA SPRING",SUP-G-6050,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"KAISER [10500]",Kaiser,,151.55,67,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA NASAL ADULT 4M CO2/O2 NOMOLINE LH",SUP-704-4624-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,122.90,36.87,"PHCS [10601]",PHCS,,86.03,70,,,,,0,14.29,104.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 8FR RBU4 CURVE GUIDING CORONARY SIDEHOLE",SUP-LA8RBU40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 58CM .016IN KNOB CAP KT",SUP-6037,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 33MM 2.5MM CORONARY STENT EVEROLIMUS",SUP-1550250-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER FIBERTAPE SMALL CERCLAGE STRAIGHT SUT DISPOSABLE",SUP-AR-7825,CDM,S27200284,LOCAL,0272,RC,,,both,,,1771.88,531.56,"KAISER [10500]",Kaiser,,1187.16,67,,,,,0,206.07,1506.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INLAY OPTIMA 24CM 4.7FR TAPER URETERAL POLYMER",SUP-788424,CDM,C2617,HCPCS,0278,RC,,,both,,,834.30,250.29,"NOVANET [10819]",Novanet,,625.73,75,,,,,0,97.03,709.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP DUAL VENDOR HIP (VENDOR A: LINER, SHELLAND#59; VENDOR B",SUP-98B00100238,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5048.57,28.62,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANGINA PECTORIS",311,MS-DRG,,,,,,,inpatient,,,33115.21,9934.56,"BLUE CROSS [10001]","Blue Cross PPO",,17327.84,,,,,,,4353.92,17504.68,"case rate",
"GWIRE HI-TORQUE IRON MAN VASCULAR 190CM STAINLESS STEEL",SUP-7081,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,771.12,68,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACCESS 6717  FINAL ASSY-PIN-PLUG KIT",SUP-6717,CDM,S27800098,LOCAL,0278,RC,,,both,,,348.00,104.4,"BLUE CROSS [10001]","Blue Cross PPO",,136.42,39.2,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PRECISION 12D ALLOGRAFT 14MM",SUP-421466,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Aerobic Presump ID Bf",PX-306000029,CDM,87070,CPT,0306,RC,,,both,,,365.75,109.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13.56,,,,,,,0.01,310.89,"fee schedule",
"PROS TESTICULAR INFUSION LINE NDL SALINE LARGE 4.9X2.9CM",SUP-450-1329,CDM,L8699,HCPCS,0278,RC,,,both,,,14973.00,4491.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1741.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1741.36,12727.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 87CM LEFT VENTRICULAR QUADRIPOLAR OTW THREAD",SUP-406082,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"KAISER [10500]",Kaiser,,3756.69,67,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 30MM 125CM 5MM 6FR .035IN BILIARY NITINOL",SUP-G32031,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"MULTIPLAN [10600]",Multiplan,,3213,85,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17.5MM 25MM MOSAIC ULTRA CINCH PORCINE",SUP-305U225,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"AETNA [10100]","Aetna HMO/PPO",,21786.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 60MM 120CM 9MM 8FR STRAIGHT VASCULAR",SUP-AVSL09060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"AETNA [10100]","Aetna HMO/PPO",,14524.65,79.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 28MM 10MM BLUNT FULL THREAD",SUP-AR-1400TC,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"BLUE CROSS [10001]","Blue Cross HMO",,725.45,39.2,,957.42,156.86,7483.26,51,215.23,1573.04,"percent of total billed charges",
"CMPNT FEMORAL 10 STD KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-42500606801,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS [10001]","Blue Cross HMO",,8962.18,39.2,,5311.50,4717.44,5388.59,31,2658.93,19433.3,"percent of total billed charges",
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT MONOLITHIC 14MM PLIF",SUP-3W3114,CDM,S27800098,LOCAL,0278,RC,,,both,,,12487.62,3746.29,"MULTIPLAN [10600]",Multiplan,,10614.48,85,,,,,0,1452.31,10614.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH GUIDING 62CM 8FR .11IN PREFACE MULTIPURPOSE SHORT",SUP-301803MS,CDM,C1893,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 30MM 4MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG40030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"NOVANET [10819]",Novanet,,1968.75,75,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 25MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G725,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA [10200]","Cigna Open Access",,5690,56.9,,5302.19,4377.88,6578.61,27,1163,8500,"percent of total billed charges",
"HC Plc Perc Sft Tiss Dev 1st W Img",PX-361000394,CDM,10035,CPT,0361,RC,,,both,,,2117.78,635.33,"BLUE CROSS [10001]","Blue Cross PPO",,2117.78,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,246.3,2117.78,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 30MM LCP STAINLESS STEEL T8 ELBOW METAPHYSEAL",SUP-02.118.530,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"CIGNA [10200]","Cigna Local Plus",,280.29,53.5,,3978.14,359.25,3978.14,24,60.93,445.32,"percent of total billed charges",
"KIT CATH 20GA 8CM POWERGLIDE PRO BIOPATCH FULL RADIOPAQUE",SUP-F320088PT,CDM,C1751,HCPCS,0272,RC,,,both,,,942.76,282.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OSSEOFLEX CONVENIENCE PACKS OSSEOFLEX SB 10GA/4ML STRAIGHT S",SUP-OCP-0114,CDM,S27200284,LOCAL,0272,RC,,,both,,,8211.00,2463.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE WHISPER ES CORONARY SINUS J FOR CORONARY VENOUS LE",SUP-4483,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CBL PCNG DISP",SUP-4043,CDM,S27200284,LOCAL,0272,RC,,,both,,,931.50,279.45,"CIGNA [10200]","Cigna Local Plus",,498.35,53.5,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM 6 HOLE STAR LOCKING BONE STERNAL NONSTERILE",SUP-460.035,CDM,C1713,HCPCS,0278,RC,,,both,,,7471.87,2241.56,"FIRST HEALTH [10303]","First Health",,5977.5,80,,,,,0,868.98,6351.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORTICAL SCREW 4MM X 42MM",SUP-HTN-U-4-42,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,713.84,45.9,,,,,0,180.87,1321.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL LEAD DELIVERY LONG TUNNELING",SUP-SC-4254,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"CIGNA [10200]","Cigna Open Access",,198.01,56.9,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 24X2CM SUSPEND TUTOPLAST FASCIA LATA",SUP-937224,CDM,C1762,HCPCS,0278,RC,,,both,,,17236.20,5170.86,"BLUE CROSS [10001]","Blue Cross HMO",,6756.59,39.2,,,,,0,2004.57,14650.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PROFILE SOFTTOUCH SMOOTH",SUP-SSL-170,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 420MM 4.75MM 3.5MM CCM PLUS",SUP-7753807,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"SHAVER ULTRASONIC MICRO HOOK AND TUBESET NEXUS BONESCALPEL",SUP-110-31-1210,CDM,S27200284,LOCAL,0272,RC,,,both,,,4021.71,1206.51,"AETNA [10100]","Aetna HMO/PPO",,3197.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,467.72,3418.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRIP SCLERAL 100MM SILICONE STRIP TYPE 220 BOX OF 3 STERILE",SUP-S5.2200,CDM,S27800098,LOCAL,0278,RC,,,both,,,174.00,52.2,"CIGNA [10200]",Cigna,,118.32,68,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH INSRT 8FR FIDELITY REINFORCED INTRO VESSEL DIL",SUP-0884-00-0019-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,955.80,286.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.16,812.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOZORB MARKER LP, 2CM X 2CM X 1CM",SUP-F0221,CDM,A4648,HCPCS,0278,RC,,,both,,,5250.00,1575,"BLUE CROSS [10001]","Blue Cross PPO",,2058,39.2,,,,,0,610.58,4462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTERNAL FIX SET BNE STABLELOC EX",SUP-FX40015,CDM,S27200284,LOCAL,0272,RC,,,both,,,11667.90,3500.37,"CIGNA [10200]","Cigna Local Plus",,6242.33,53.5,,,,,0,1356.98,9917.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOCK MULTI -PLY PROSTHETIC",SUP-L8420,CDM,L8420,HCPCS,0274,RC,,,both,,,210.80,63.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,24.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.57,179.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Bn/Jnt Img 3 Phase",PX-341000024,CDM,78315,CPT,0341,RC,,,both,,,3278.75,983.62,"BLUE CROSS [10001]","Blue Cross PPO",,891.22,,"Fee schedule rate ($891.22).",,,,0,381.32,2786.94,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO 940MM .89MM SWISS LITHOCLAST PNEUMATIC FLEXIBLE",SUP-M0068407390,CDM,S27200284,LOCAL,0272,RC,,,both,,,1835.93,550.78,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 150MM 4MM BALLOON DILATATION STERILE LATEX",SUP-594015022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 3.2MM COMPREHENSIVE CENTRAL SCR REVERSE SHOULDER",SUP-405883,CDM,S27200284,LOCAL,0272,RC,,,both,,,1556.00,466.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE JEFFREY VASCULAR 20CM 15CM .018IN 8FR 6.5FR SET TROCAR",SUP-G12016,CDM,C1769,HCPCS,0272,RC,,,both,,,1000.27,300.08,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET CATHETERIZATION ASCEND BALLOON DILATATION INFLATION",SUP-G32842,CDM,C1758,HCPCS,0272,RC,,,both,,,1745.63,523.69,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IPG W1SR01 AZURE XT SR MRI",SUP-W1SR01,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"UHC [10700]","United Healthcare",,15723.72,63.3,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Acutect Up to 20mci",PX-636000002,CDM,A9504,HCPCS,0343,RC,,,both,,,1614.00,484.2,"UHC [10700]","United Healthcare",,1025.17,,,,,,,187.71,1371.9,"fee schedule",
"STENT COTTON-LEUNG 7CM 7FR .035IN GENTLE CURVE BILIARY",SUP-G21683,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 18X8MM HEDRON C 7D 15MM STERILE LATEX FREE",SUP-1211.5818S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]",Cigna,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5-2.8MM 12MM ACUTRAK 2 TITANIUM MICRO FULL THREAD",SUP-AT2-C12,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,377.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,370.71,2709.38,"percent of total billed charges",
"SUT POLYSORB 21IN LOOPED BRAIDED COATED VIOLET ABSORBABLE",SUP-EL21L,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.60,47.58,"MULTIPLAN [10600]",Multiplan,,134.81,85,,,,,0,18.45,134.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORTHOLOC 3DI FOOT RECONSTRUCTION SYSTEM NON-LOCKING SCREW N",SUP-58812724,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"FIRST HEALTH [10303]","First Health",,680.4,80,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 80CM 7FR 14MM ROUND EMBOLECTOMY STAINLESS STEEL",SUP-120807F,CDM,C1757,HCPCS,0272,RC,,,both,,,376.01,112.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,43.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.73,319.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175262080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"KAISER [10500]",Kaiser,,830.38,67,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aspergillus Ab",PX-302000096,CDM,86606,CPT,0302,RC,,,both,,,257.45,77.23,"NOVANET [10819]",Novanet,,193.09,75,,,,,0,0.01,218.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 80CM 27MM 8-15MM GORE CARDIOFORM ATRIAL",SUP-ASD27A,CDM,C1817,HCPCS,0278,RC,,,both,,,54495.00,16348.5,"PHCS [10601]",PHCS,,38146.5,70,,,,,0,6337.77,46320.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPPORTER ATHLETIC XLG",SUP-SA1503-WH-XL,CDM,S27000186,LOCAL,0270,RC,,,both,,,128.24,38.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,14.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.91,109,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 5.00 X 32MM",SUP-H7493942832500,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"FIRST HEALTH [10303]","First Health",,4968,80,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE X-PEDION VASCULAR 200CM 10CM .01IN PLATINUM STAINLESS",SUP-103-0605-200,CDM,C1769,HCPCS,0272,RC,,,both,,,2235.00,670.5,"FIRST HEALTH [10303]","First Health",,1788,80,,,,,0,259.93,1899.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 70CM POWERPICC 2 LUMEN GWIRE INTRO NDL CUFF",SUP-3386355,CDM,C1751,HCPCS,0272,RC,,,both,,,929.88,278.96,"FIRST HEALTH [10303]","First Health",,743.9,80,,,,,0,108.15,790.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET ANGLE 1 OVAL 8IN SURGICAL SPINAL FUSION",SUP-29-4941,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.68,68.9,"NOVANET [10819]",Novanet,,172.26,75,,,,,0,26.71,195.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14CM NATRELLE INSPIRA P3.6CM LOW PLUS PROFILE",SUP-MSZ-LP400,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.69,42.81,"PHCS [10601]",PHCS,,99.88,70,,,,,0,16.59,121.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST EXTERNAL FIXATION MAXFRAME 3 HIGH MOUNT MULTIPARALLEL",SUP-03.313.859,CDM,C1713,HCPCS,0278,RC,,,both,,,1341.85,402.55,"NOVANET [10819]",Novanet,,1006.39,75,,,,,0,156.06,1140.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ANGLE MICRO SPEAR ROUND SURGICAL MYRINGOTOMY STERILE",SUP-70130794,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.66,22.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,33.81,45.9,,,,,0,8.57,62.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 12MM KII FIOS FIRST ENTRY ADVANCE",SUP-CFF73,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"NOVANET [10819]",Novanet,,137.03,75,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 26CM 3CM 8FR .038IN 2",SUP-M006192153170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,165.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 420ML STYLE 10 SMOOTH NATRELLE SILICONE P3.8CM",SUP-10-420,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"CIGNA [10200]","Cigna Open Access",,2031.33,56.9,,5166.00,5166.00,5166.00,"1 through 10",415.19,3034.5,"percent of total billed charges",
"IMPL BREAST SMOOTH HIGH PROFILE XTRA 595CC",SUP-SHPX595,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"CIGNA [10200]",Cigna,,5067.36,68,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 50MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.838,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"FIRST HEALTH [10303]","First Health",,281.05,80,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC",565,MS-DRG,,,,,,,inpatient,,,39169.44,11750.83,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,6225.59,,"Case rate ($6,044.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,612.51, add-ons for qualifying new technology services are included. If operating cost exceeds $38,652.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,806.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,619.93. The transfer operating threshold is the transfer adjustment factor * $5,612.51 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.33. The transfer capital threshold is the transfer adjustment factor * $424.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,6044.26,24300.56,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL GENESIS II 7 LEFT KNEE CEMENT TITANIUM",SUP-71420172,CDM,C1776,HCPCS,0278,RC,,,both,,,14593.50,4378.05,"MULTIPLAN [10600]",Multiplan,,12404.48,85,,,,,0,1697.22,12404.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM VARIAX LOCK NONSTERILE",SUP-657312,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,172.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",172.92,1263.81,"percent of total billed charges",
"HEAD UNIPOLAR 51MM UNITRAX HIP MODULAR ENDOPROSTHESIS",SUP-6942-5-051,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"BLUE CROSS [10001]","Blue Cross PPO",,1226.06,39.2,,3949.44,3949.44,3949.44,"1 through 10",363.75,2658.55,"percent of total billed charges",
"SCR BONE 6.5MM 20MM SMR TITANIUM SHOULDER MODULAR SYSTEM",SUP-8420.15.010,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"FIRST HEALTH [10303]","First Health",,1244.56,80,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER DS NAV 115CM 8MM 7FR 1-7-4MM SPACE J J CURVE",SUP-BN7TCJJ8L,CDM,C1732,HCPCS,0272,RC,,,both,,,16477.20,4943.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1952.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1916.3,14005.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT TRACTION SMALL LEG BUCK FOAM NONSTERILE LATEX FREE",SUP-A155005,CDM,S27000186,LOCAL,0270,RC,,,both,,,99.09,29.73,"KAISER [10500]",Kaiser,,66.39,67,,,,,0,11.52,84.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NEURON 125CM 9CM 6FR 5.6FR .04IN BERENSTEIN CURVE",SUP-PNS6F125BER,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +24 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.240,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X11X7MM ALLOCRAFT 5D LORDOSIS CORTICAL",SUP-6183-7-007,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL GREGORY MEDIUM 7.25IN PROFUNDA",SUP-55-6091,CDM,S27200284,LOCAL,0272,RC,,,both,,,1349.06,404.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,156.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,156.9,1146.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 4MM TWIST STERILE",SUP-KM166-10-06,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12,87.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RUBY XL COIL 40CMX70CM",SUP-RBYXL4070,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7742.01,41.1,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC",345,MS-DRG,,,,,,,inpatient,,,56562.03,16968.61,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,9613.76,,"Case rate ($9,333.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,667.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,706.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,037.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,678.48. The transfer operating threshold is the transfer adjustment factor * $8,667.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.27. The transfer capital threshold is the transfer adjustment factor * $655.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,43931.22,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 100CM 8FR MP2 CURVE GUIDING PTFE FEMORAL",SUP-H74934358390,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AETNA [10100]","Aetna HMO/PPO",,291.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLINICAL TRIAL OF VENAPAX EVH SYSTEM",SUP-VPX3000,CDM,S27200284,LOCAL,0272,RC,,,both,,,4795.50,1438.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3260.94,68,,,,,0,557.72,4076.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON SABRELOC 5-0 RD-1 18IN 2 ARM MONOFILAMENT BLACK",SUP-749G,CDM,S27200284,LOCAL,0272,RC,,,both,,,146.68,44,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SPRINTER FASTRAC 138CM 12MM 3.2-2.4-2.6FR 2.5MM BALLOON",SUP-SPR2512W,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PK 7.5CM ANTERIOR POSTERIOR SINUS NASAL RAPID RHINO ADULT",SUP-RR750,CDM,S27200284,LOCAL,0272,RC,,,both,,,361.92,108.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MAJOR LARGE BOWEL PROCEDURES,MINOR",231,APR-DRG,,,,,,,inpatient,,,105478.15,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 12X40 40CM SL",SUP-48012004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAFESHEATH II SSL10",SUP-398357,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MONOCRYL MULTIPASS 3-0 PS-2 18IN MONOFILAMENT UNDYED",SUP-Y497G,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH FLOWGUARD 14CM 14FR HEMODIALYSIS PEEL AWAY VALVE",SUP-DCVP1400,CDM,C1892,HCPCS,0272,RC,,,both,,,261.00,78.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NANOCROSS 90CM 20MM 3MM .014IN BALLOON DILATATION",SUP-AB14W030020090,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE SECUREMENT CRESCENT TRICOAT SLIDING POST PIGTAIL RETA",SUP-CV0220,CDM,S27200284,LOCAL,0272,RC,,,both,,,46.28,13.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 135CM 40MM 5MM BALLOON DILATATION HYDROPHILIC",SUP-605004022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Pulm Rhb WO Cont Oximetry Mntr",PX-948000002,CDM,94625,CPT,0948,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NEPHROMAX AMPLATZ 55CM 12CM 7FR 30FR 17CM BALLOON",SUP-M0062101420,CDM,C1726,HCPCS,0272,RC,,,both,,,2066.33,619.9,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INPACT 80CM 80MM 6MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV06008008P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT FOR PREPARATION OF TC 99M-PENTETIC ACID IV SOLUTION (0-25 MCI)",RX-124366,CDM,A9539,HCPCS,0343,RC,08888-8878-30,NDC,both,1,UN,823.05,246.91,"PHCS [10601]",PHCS,,576.14,70,,,,,0,56,699.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEPIN ORTHOPEDIC TWIST SUBTALAR",SUP-112-00-004,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL CARDIO-GRIP DEBAKEY 45D 4.75IN BULLDOG RING",SUP-320-185,CDM,S27200284,LOCAL,0272,RC,,,both,,,721.06,216.32,"CIGNA [10200]",Cigna,,490.32,68,,,,,0,83.86,612.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY SPIN PERC",SUP-INS-5600,CDM,S27200284,LOCAL,0272,RC,,,both,,,4936.95,1481.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,585.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,574.17,4196.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 15MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424028,CDM,C1776,HCPCS,0278,RC,,,both,,,11747.25,3524.17,"CIGNA [10200]","Cigna Open Access",,3935.33,33.5,,5302.19,4377.88,6578.61,27,1366.21,9985.16,"percent of total billed charges",
"SOL IRRIGATION 0.9% SODIUM CHLORIDE 3000ML UROMATIC LATEX",SUP-2B7127,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.70,41.01,"MULTIPLAN [10600]",Multiplan,,116.2,85,,,,,0,15.9,116.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM 2.6-2FR .019IN EXCELSIOR",SUP-M0031441910,CDM,S27200284,LOCAL,0272,RC,,,both,,,7801.42,2340.43,"NOVANET [10819]",Novanet,,5851.07,75,,,,,0,907.31,6631.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 150MM 1.25MM THREAD NONSTERILE 3.5MM",SUP-900.722,CDM,C1769,HCPCS,0272,RC,,,both,,,177.48,53.24,"NOVANET [10819]",Novanet,,133.11,75,,,,,0,20.64,150.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 21MM 64MM 54MM SHOULDER COMPREHENSIVE",SUP-113063,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1077.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1057.03,7725.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 C-1 30IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8706,CDM,S27200284,LOCAL,0272,RC,,,both,,,562.13,168.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,66.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.38,477.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 2X1CM AXOGUARD HA+ NERVE PROTCT EXTRACELLULAR",SUP-AGHA12,CDM,C1763,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION",RX-8982,CDM,P9041,HCPCS,0636,RC,44206-0310-50,NDC,both,500,ML,1358.64,407.59,"BLUE CROSS [10001]","Blue Cross PPO",,123.78,,,,,,,123.78,1154.84,"fee schedule",
"GWIRE ZIPWIRE UROLOGICAL ANGLE 150CM 3CM .035IN NITINOL",SUP-M006630223B1,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION BARD LUBRICATH STATLOCK SURESTEP 16FR",SUP-A800361,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.26,25.58,"FIRST HEALTH [10303]","First Health",,68.21,80,,,,,0,9.92,72.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135CM 80MM 6MM .035IN LOW PROFILE BALLOON",SUP-B2060-080,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL CO2 O2 STD DEHUMIDIFICATION LINE SIDESTREAM ADULT",SUP-1149379,CDM,S27000186,LOCAL,0270,RC,,,both,,,172.51,51.75,"FIRST HEALTH [10303]","First Health",,138.01,80,,,,,0,20.06,146.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERIT MAESTRO 150CM 2.4-2.8FR 45D MICRO EMBOLECTOMY",SUP-28MC2415045,CDM,C1887,HCPCS,0272,RC,,,both,,,2301.00,690.3,"KAISER [10500]",Kaiser,,1541.67,67,,,,,0,267.61,1955.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL SABRELOC 6-0 S-14 18IN 2 ARM BRAID COATED UNDYED",SUP-J670G,CDM,S27200284,LOCAL,0272,RC,,,both,,,161.07,48.32,"CIGNA [10200]",Cigna,,109.53,68,,,,,0,18.73,136.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TIGHTROPE BB-TAK FIXATION 2",SUP-AR-8958TDS,CDM,C1713,HCPCS,0278,RC,,,both,,,20736.45,6220.93,"FIRST HEALTH [10303]","First Health",,16589.16,80,,,,,0,2411.65,17625.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 4MM 1.2MM 12MM 4MM STAINLESS STEEL SHORT THREAD",SUP-202.612,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"NOVANET [10819]",Novanet,,832.52,75,,,,,0,129.1,943.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X6MM COALITION MIS 7D 12MM TITANIUM STERILE",SUP-1136.2476,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAFCILLIN 2 GRAM IV VIAL",RX-410100,CDM,J2290,HCPCS,0636,RC,55150-0123-15,NDC,both,1,UN,113.25,33.97,"MULTIPLAN [10600]",Multiplan,,96.26,85,,,,,0,5.83,96.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RTRCTR LEYLA COUPLING NONSTERILE BRAIN",SUP-R2382,CDM,S27200284,LOCAL,0272,RC,,,both,,,7649.13,2294.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5201.41,68,,,,,0,889.59,6501.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UROLOGICAL 150CM 3CM .035IN PTFE STRAIGHT FLEXIBLE TIP",SUP-M0066201200,CDM,C1769,HCPCS,0272,RC,,,both,,,93.35,28,"NOVANET [10819]",Novanet,,70.01,75,,,,,0,10.86,79.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL CUSHING CARB-BITE BAYONET 7.5IN TISSUE SCRP",SUP-130418,CDM,S27200284,LOCAL,0272,RC,,,both,,,631.40,189.42,"AETNA [10100]","Aetna HMO/PPO",,501.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.43,536.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 40MM TITANIUM 2 LEVEL ASSURE BONE SPINE CERVICAL",SUP-110.24,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,3978.14,359.25,3978.14,24,521.61,3812.25,"percent of total billed charges",
"KIT TRAUMA FIXATION 95MM META-TAN INTEGRATE LAG COMPRESSION",SUP-71642695,CDM,C1887,HCPCS,0272,RC,,,both,,,4950.06,1485.02,"UHC [10700]","United Healthcare",,3133.39,63.3,,,,,0,575.69,4207.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC",439,MS-DRG,,,,,,,inpatient,,,25336.85,7601.05,"PHCS [10601]",PHCS,,7561,,,,,,,5218.02,20978.69,"per diem","Estimated amount calculated based on 4 day length of stay."
"SENSOR OXYTIP PLUS TRUSIGNAL .3MR OXIMETER SPO2 ADHSV",SUP-TS-AP-25,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.17,23.15,"NOVANET [10819]",Novanet,,57.88,75,,,,,0,8.97,65.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 12MM STAINLESS STEEL T8 CORTEX TUBE STARDRIVE",SUP-201.762TS,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,323.87,68,,,,,0,55.39,404.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER II HTD 110CM 5MM 7FR 8FR 2.5MM SPACE STD CURVE",SUP-M0045086TH0,CDM,C1733,HCPCS,0272,RC,,,both,,,8107.50,2432.25,"UHC [10700]","United Healthcare",,5132.05,63.3,,,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL 29MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-151111201,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 6 SLOT RIGHT TI",SUP-PHPF-S6R,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,1521.93,481.35,16760.95,30,2014.9,14726.25,"percent of total billed charges",
"SPACER SPINAL 32MMX8MM CAPSTONE PEEK LUMBAR INTERBODY FUSION",SUP-9440832,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Local Plus",,5433.75,31.5,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASTATO 30 VASCULAR 180CM 15CM .33-.45MM SLIP-COAT PTFE",SUP-PAGH18M071,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Voriconazole",PX-301000626,CDM,80285,CPT,0301,RC,,,both,,,314.93,94.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,267.69,"per diem",
"PLATE 19MM TITANIUM 5.5MM ROD LOW PROFILE FIX LEGACY X10",SUP-8115519,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,414.32,3028.13,"percent of total billed charges",
"GWIRE JAGWIRE ENDOSCOPIC STRAIGHT TRIM 260CM .035IN BILIARY",SUP-M00556641,CDM,C1769,HCPCS,0272,RC,,,both,,,811.01,243.3,"FIRST HEALTH [10303]","First Health",,648.81,80,,,,,0,94.32,689.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 8MM 24MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.414S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1017.88,68,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 55MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.055,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"CIGNA [10200]",Cigna,,140.32,68,,1831.33,1831.33,1831.33,16,24,175.41,"percent of total billed charges",
"STENT SURPASS EVOLVE 15MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDS32515,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"FIRST HEALTH [10303]","First Health",,66419.78,80,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 27MM MOSAIC BIOPROSTHESIS HOLDER",SUP-31002701,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8113.77,28.62,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 7.0 MM X 40 MM X 130 CM",SUP-IPU07004013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 150CM 8CM 5MM BALLOON DILATATION ILIAC",SUP-G34331,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR .071IN EXTRA CURVE RIGHT 3.5 GUIDING",SUP-LA6ECR35,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DTECT CARBON DIOXIDE END TIDAL COLORIMETRIC CNCT PORT LATEX",SUP-EASYCAPII,CDM,S27000186,LOCAL,0270,RC,,,both,,,82.22,24.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHIBOND EXCEL 1 XLH 30IN 2 ARM BRAID GREEN",SUP-X190G,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.89,23.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR ALEXIS O 2XL RIGID RETRACTION RING SURGICAL 11-17CM",SUP-C8405,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.80,262.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION",RX-8527,CDM,,,0250,RC,70069-0271-01,NDC,both,2,ML,94.38,28.31,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC",737,MS-DRG,,,,,,,inpatient,,,108598.58,32579.57,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VASCULAR 190CM .014IN HI-TORQUE BALANCE MIDDLEWEIGHT",SUP-1001780J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRUSH CYTOLOGY 46CM COOK STERILE DISPOSABLE LATEX FREE",SUP-G48527,CDM,S27200284,LOCAL,0272,RC,,,both,,,623.70,187.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE MANTA 8FR CLSR DEPTH LOC",SUP-188F,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEUROSES EXCEPT DEPRESSIVE",882,MS-DRG,,,,,,,inpatient,,,20199.19,6059.76,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN AMPLATZ LEFT 1 CURVE ANGIOGRAPHIC",SUP-H74908526962,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LITHIUM CARBONATE 150 MG CAPSULE, IMMEDIATE RELEASE",RX-4528,CDM,,,0637,RC,00054-8526-25,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-FLO RENEGADE FATHOM VASCULAR 105CM 10CM .016IN",SUP-M001184500,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER .035 6MMX300MMX135CM BALLOON DILATATION PTA",SUP-48006030R,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS VISTA BRITE TIP 100CM 6FR JR5 CURVE GUIDING",SUP-67008400,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE RD180 STD 5MM SUTURING 1 PORT AUTORELEASE STERILE",SUP-021100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Mumps Ab",PX-302000154,CDM,86735,CPT,0302,RC,,,both,,,161.00,48.3,"PHCS [10601]",PHCS,,112.7,70,,,,,0,0.01,136.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 55MM VIPER EXPEDIUM TITANIUM SPINE CORTICAL",SUP-186727655,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"NDL BIOPSY 22GA 15CM FINE CHIBA ASPIRATION CM MARK COLOR",SUP-MCN2206,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"CIGNA [10200]","Cigna Local Plus",,66.09,53.5,,,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC FLEXIBLE OVAL BIOPSY CUP 115CM 3.3FR TISSUE",SUP-G15054,CDM,S27200284,LOCAL,0272,RC,,,both,,,2733.75,820.12,"KAISER [10500]",Kaiser,,1831.61,67,,,,,0,317.94,2323.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PINPOINT PAQ ENDOSCOPIC FLUORESCENCE IMAGE",SUP-PP9036,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOTHYROXINE 25 MCG/ML ORAL SUSPENSION",RX-408880,CDM,,,0637,RC,08888-8885-96,NDC,both,8,ML,12.54,3.76,"AETNA [10100]","Aetna HMO/PPO",,9.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Est Eval Visit Level 2",PX-510000177,CDM,99212,CPT,0761,RC,,,both,,,323.05,96.91,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,132.77,41.1,,,,,0,0.32,323.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY",884,MS-DRG,,,,,,,inpatient,,,37940.31,11382.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,31938.27,,"Fee schedule rate ($31,938.27). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,1958,37940.31,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 6.5IN SWEDEN DELICATE INSRT NDL TUNGSTEN CARBIDE 5-0",SUP-32-460,CDM,S27200284,LOCAL,0272,RC,,,both,,,955.64,286.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,438.64,45.9,,,,,0,111.14,812.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AMPLATZ 17CM 22FR ACCESS PTFE RENAL FIRM TAPER TIP",SUP-M0062601490,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,137.52,41.1,,,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 34CM 7FR VENTRICLE BIPOLAR PASSIVE FIXATION",SUP-1646T/34,CDM,C1898,HCPCS,0275,RC,,,both,,,1786.00,535.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1214.48,68,,,,,0,207.71,1518.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXS VECTA 74 125CM .083-.087IN .074IN ASPIRATION SCOUT",SUP-INC-11597-125,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ILLMNTR OPHTHALMIC 23GA CONSTELLATION SAPPHIRE WIDE ANGLE",SUP-8065751184,CDM,S27200284,LOCAL,0272,RC,,,both,,,1033.32,310,"CIGNA [10200]","Cigna Local Plus",,552.83,53.5,,,,,0,120.18,878.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 15CM 120CM 10MM ENDOPROSTHESIS HEPARIN",SUP-VBHR101502A,CDM,C1874,HCPCS,0278,RC,,,both,,,24374.70,7312.41,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2888.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2834.78,20718.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Radionuclide Tc99m With RBC Kit",PX-343000054,CDM,A4641,HCPCS,0343,RC,,,both,,,730.00,219,"AMERIGROUP MEDICAID [20100]",Amerigroup,,86.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.9,620.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SAFEGUARD FOCUS COMPRESSION ADHSV CONTOUR STERILE",SUP-SGF1AC,CDM,S27200284,LOCAL,0272,RC,,,both,,,672.30,201.69,"PHCS [10601]",PHCS,,470.61,70,,,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 30MM 6FR 2MM .07",SUP-H7493926730200,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 NARROW KNEE LEFT POSTERIOR STABILIZE PERSONA",SUP-42500206601,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"PHCS [10601]",PHCS,,20226.91,70,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT PL SITEMARK 51CM 47CM 9FR 7FR 115D GUIDING",SUP-410172,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"MULTIPLAN [10600]",Multiplan,,3155.63,85,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SONOPLEX FIXOCATH 21GA 18GA 20GA INTERVENTIONAL INDWELL",SUP-201285-41E,CDM,C9812,HCPCS,0272,RC,,,both,,,348.00,104.4,"PHCS [10601]",PHCS,,243.6,70,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175264180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"BLUE CROSS [10001]","Blue Cross PPO",,572.36,39.2,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL AMPLATZ FIRM KINK RESISTANT GRADUATE TAPER 35CM",SUP-M0062601110,CDM,C1894,HCPCS,0272,RC,,,both,,,362.44,108.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,246.46,68,,,,,0,42.15,308.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 24MM FUSION ACUTRAK 2.4MM 24MM SCR",SUP-ATF-024,CDM,S27200284,LOCAL,0272,RC,,,both,,,1657.50,497.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,681.23,41.1,,,,,0,192.77,1408.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL CABLATOR PROCIZE EZ VIEW PLASMA 3",SUP-EICA887501,CDM,S27200284,LOCAL,0272,RC,,,both,,,2348.33,704.5,"MULTIPLAN [10600]",Multiplan,,1996.08,85,,,,,0,273.11,1996.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 120MM 16-14MM 14MM 11FR TRIVASCULAR OVATION",SUP-TV-IL1416120-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13356,40,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 7MM SEALGUARD EVAC STERILE",SUP-110870,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.91,99.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,39.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.48,281.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE EKOSONIC MACH 4 106CM 18CM 5.4FR DRUG DELIVERY",SUP-500-55118,CDM,C1887,HCPCS,0272,RC,,,both,,,37894.50,11368.35,"AETNA [10100]","Aetna HMO/PPO",,30126.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4407.13,32210.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR GUIDE 33MM 3.2MM 3.5MM NEXGEN HEXAGON",SUP-590103533,CDM,C1713,HCPCS,0278,RC,,,both,,,880.07,264.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,251.88,28.62,,,,,0,102.35,748.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLORBETABEN F-18 INTRAVENOUS SOLUTION (0-8.1 MCI)",RX-229540,CDM,Q9983,HCPCS,0343,RC,08888-8878-55,NDC,both,1,UN,15094.80,4528.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3090.11,,,,,,,1755.53,12830.58,"fee schedule",
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 40MM 190CM 2.5",SUP-R51002504L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"KAISER [10500]",Kaiser,,1321.07,67,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE FATHOM VASCULAR 10CM 300CM 35CM .014IN STAINLESS STEEL",SUP-M001508140,CDM,C1769,HCPCS,0272,RC,,,both,,,1815.00,544.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,211.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,211.08,1542.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 20MM 4MM BALLOON DILATATION DURALYN",SUP-48004002X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"NOVANET [10819]",Novanet,,941.63,75,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 15MM 3.5MM 1.5MM 1.2MM BALLOON DILATATION RAPID",SUP-DC-RY3515UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,117.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thyroglobulin Ab",PX-302000171,CDM,86800,CPT,0302,RC,,,both,,,331.47,99.44,"PHCS [10601]",PHCS,,232.03,70,,,,,0,0.01,281.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL VASCULAR J",SUP-1009660J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 7FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175270110,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"FIRST HEALTH [10303]","First Health",,991.5,80,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 11CM 4MM XPS DCR 15D 1200 RPM CURVE LONG SINUS",SUP-1884068HS,CDM,S27200284,LOCAL,0272,RC,,,both,,,3060.00,918,"FIRST HEALTH [10303]","First Health",,2448,80,,,,,0,355.88,2601,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Examet Auto Wbc per Study",PX-343000033,CDM,A9569,HCPCS,0343,RC,,,both,,,7642.40,2292.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,888.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,888.81,6496.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BIOEXPAND DEMINERALIZED CANCELLOUS ALLOGRAFT",SUP-77101020,CDM,C1713,HCPCS,0278,RC,,,both,,,8665.02,2599.51,"KAISER [10500]",Kaiser,,5805.56,67,,,,,0,1007.74,7365.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION CURITY ADD-A-CATH 30CC INSRT PREFILL",SUP-5027,CDM,S27200284,LOCAL,0272,RC,,,both,,,45.68,13.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.31,38.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 5MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650605,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3757.02,28.62,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 2MM STEINMANN FOOT ANKLE STAINLESS STEEL",SUP-3811-1-090,CDM,C1713,HCPCS,0278,RC,,,both,,,138.85,41.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,94.42,68,,,,,0,16.15,118.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X2IN DURAGEN PLUS CRANIAL DURA BOVINE",SUP-DP1022,CDM,,,0278,RC,,,both,,,2381.25,714.37,"BLUE CROSS [10001]","Blue Cross HMO",,2.38,.1,,,,,0,2.38,2024.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endovenous Ablation Chem Ext 1",PX-361000554,CDM,36482,CPT,0361,RC,,,both,,,9701.49,2910.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5284,,"Case rate ($5,284). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1128.28,9679,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chlamydia Trach Dna Ampl Prb",PX-306000122,CDM,87491,CPT,0306,RC,,,both,,,292.56,87.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,124.59,,,,,,,0.01,248.68,"fee schedule",
"HC Kit Spinal W/Lidocaine",PX-E27200181,CDM,E27200181,LOCAL,0272,RC,,,both,,,108.17,32.45,"PHCS [10601]",PHCS,,75.72,70,,,,,0,12.58,91.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Pelvis W&WO Cntrst",PX-610000020,CDM,72197,CPT,0610,RC,,,both,,,4971.56,1491.47,"MULTIPLAN [10600]",Multiplan,,4225.83,85,,,,,0,578.19,4225.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Ather Cmplx Ea Add",PX-361000732,CDM,37291,CPT,0361,RC,,,both,,,8353.79,2506.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5284,,"Case rate ($5,284). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,8.35,7883,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Spinal Punct Lum Tx W/Fluor/CT",PX-320000232,CDM,62329,CPT,0361,RC,,,both,,,3308.44,992.53,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1550,,"Case rate ($1,550). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1550,2385,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PROTECTIVE STAINLESS STEEL HOFFMANN XPRESS BLUNT TIP",SUP-5027-1-050,CDM,S27000186,LOCAL,0270,RC,,,both,,,339.82,101.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.52,288.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE RADIUS ULNA SHAFT ALLOGRAFT FREEZE DRIED 60X15-18",SUP-400810,CDM,S27800098,LOCAL,0278,RC,,,both,,,4694.76,1408.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3192.44,68,,,,,0,546,3990.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 42MM STAINLESS STEEL 2.4MM SCR 6 HEAD HOLE 2",SUP-02.111.520S,CDM,C1713,HCPCS,0278,RC,,,both,,,4102.05,1230.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2789.39,68,,,,,0,477.07,3486.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION",RX-8981,CDM,P9047,HCPCS,0636,RC,44206-0251-10,NDC,both,100,ML,1358.64,407.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,123.73,,,,,,,122.58,1154.84,"fee schedule",
"(COMM) CATH GUIDELINER 150CM 25CM 8FR .088IN .071IN INTERVEN",SUP-5573,CDM,C1887,HCPCS,0272,RC,,,both,,,2872.50,861.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,340.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.07,2441.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM REFLECTION TITANIUM FULL THREAD HIP",SUP-71336525,CDM,C1713,HCPCS,0278,RC,,,both,,,1341.36,402.41,"KAISER [10500]",Kaiser,,898.71,67,,,,,0,156,1140.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 6MM CANNULATED REAMER STERILE",SUP-AR-1218-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT CODMAN HAKIM RICKHAM CYL 120CM NONUNITIZE DISTAL",SUP-823855,CDM,S27800098,LOCAL,0278,RC,,,both,,,34085.02,10225.51,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4039.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3964.09,28972.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 12FR 63CM RADIOPAQUE TIP MULLINS DESIGN GWIRE",SUP-G10012,CDM,C1894,HCPCS,0272,RC,,,both,,,890.92,267.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,605.83,68,,,,,0,103.61,757.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 26CM 3CM 6FR .035IN 2 PIGTAIL",SUP-M006192133050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"FIRST HEALTH [10303]","First Health",,960.46,80,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MOTIV SCAFFOLD 3.0MMX48MM","SUP-930030-48 (288)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 40 75CM 4CM 5MM BALLOON DILATATION PERIPHERAL",SUP-CQF7554,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,549.3,41.1,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP HUMERAL 33MM UNIVERS REVERS +2MM SHOULDER LEFT CALCIUM",SUP-AR-9502F-33RCPC,CDM,C1776,HCPCS,0278,RC,,,both,,,7576.20,2272.86,"PHCS [10601]",PHCS,,5303.34,70,,,,,0,881.11,6439.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 4X4CM GRAFTJACKET THK.4-.8MM ACELLULAR DERMAL",SUP-GJ44,CDM,Q4107,HCPCS,0636,RC,,,both,,,9737.42,2921.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6329.32,65,,,,,0,247.92,8276.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT 17GA 75MM ACTIVE TIP COOL RADIOFREQUENCY PROBE TUBE",SUP-CRK-17-75-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES0206CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 22CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006175281170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]","Cigna Open Access",,720,,,,,,,147.16,1075.57,"percent of total billed charges",
"KIT ELBOW JOINT SM REGULAR HUMERAL PIN BUSHING REPLACEMENT C",SUP-32810502501,CDM,C1713,HCPCS,0278,RC,,,both,,,8279.66,2483.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,962.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",962.92,7037.71,"percent of total billed charges",
"LENS IOL 10 D +28 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200280,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"NOVANET [10819]",Novanet,,765.45,75,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 6MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT060080A,CDM,C1768,HCPCS,0278,RC,,,both,,,17056.80,5117.04,"UHC [10700]","United Healthcare",,10796.95,63.3,,,,,0,1983.71,14498.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 92MM STAINLESS STEEL 2.7MM SCR 4 HOLE CONTOUR SHAFT",SUP-02.118.403S,CDM,C1713,HCPCS,0278,RC,,,both,,,4562.97,1368.89,"NOVANET [10819]",Novanet,,3422.23,75,,,,,0,530.67,3878.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 28MM 9MM DELTA TAPER ROUND ACL",SUP-AR-5028P-09,CDM,C1713,HCPCS,0278,RC,,,both,,,1968.75,590.62,"PHCS [10601]",PHCS,,1378.13,70,,,,,0,228.97,1673.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 5FR 25CM RADIOPAQUE GWIRE STERILE DISPOSABLE",SUP-G06587,CDM,S27200284,LOCAL,0272,RC,,,both,,,169.65,50.89,"CIGNA [10200]",Cigna,,115.36,68,,,,,0,19.73,144.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 115CM 5MM 5FR ELECTROPHYSIOLOGY 4 POLE 12 PIN",SUP-D1085413,CDM,C1730,HCPCS,0272,RC,,,both,,,1425.60,427.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,168.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CREO SPINE POLYAXIAL PREASSEMBLE",SUP-5119.1642,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,1831.33,1831.33,1831.33,16,441.36,3225.75,"percent of total billed charges",
"ALPRAZOLAM 0.25 MG TABLET SUPERORDERABLE, IMMEDIATE RELEASE",RX-409585,CDM,,,0637,RC,59762-3719-01,NDC,both,1,UN,12.54,3.76,"FIRST HEALTH [10303]","First Health",,10.03,80,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NIAGARA SINGLE USE GUIDEWIRE  1.7MM SS (QTY 1)",SUP-AC01-90064-G4,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 42.5MM T2 TITANIUM FULL THREAD FEMUR HUMERUS",SUP-1896-5042S,CDM,C1713,HCPCS,0278,RC,,,both,,,1279.15,383.74,"KAISER [10500]",Kaiser,,857.03,67,,,,,0,148.77,1087.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION LIFECARE 0.9% SODIUM CHLORIDE 2L LATEX FREE",SUP-07972-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTW TAKERU PTCA BALLOON 2.25MM X 15MM",SUP-DC-PY2215UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,406.15,41.1,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 51.2MM 4.8MM ROUND FAST CUTTING STERILE",SUP-1608006139,CDM,S27200284,LOCAL,0272,RC,,,both,,,375.49,112.65,"KAISER [10500]",Kaiser,,251.58,67,,,,,0,43.67,319.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 21MM 16.7MM MASTERS SERIES 85D STD HEART",SUP-21AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]","Cigna Local Plus",,9172.56,31.5,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +25.5 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z900200255,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,468.46,45.9,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 15MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015015S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,589.25,41.1,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 122MM STAINLESS STEEL 3.5MM SCREWS 4 HOLE LCP BONE",SUP-02.104.004,CDM,C1713,HCPCS,0278,RC,,,both,,,7481.12,2244.34,"KAISER [10500]",Kaiser,,5012.35,67,,,,,0,870.05,6358.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND W 40CM 20CM POLYURETHANE NOVOSORB MTX SINGLE",SUP-MTX-2040,CDM,A2006,HCPCS,0272,RC,,,both,,,82080.00,24624,"NOVANET [10819]",Novanet,,61560,75,,,,,0,9545.9,69768,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 40CM 3FR 5MM ROUND EMBOLECTOMY STAINLESS STEEL",SUP-120403FP,CDM,C1757,HCPCS,0272,RC,,,both,,,310.76,93.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,36.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.14,264.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT SWIVE TENDON 7X19.5",SUP-AR-1662BC-7,CDM,C1713,HCPCS,0278,RC,,,both,,,3425.63,1027.69,"CIGNA [10200]",Cigna,,2329.43,68,,1831.33,1831.33,1831.33,16,398.4,2911.79,"percent of total billed charges",
"CATH LAUNCHER 90CM 8FR .09IN JUDKINS RIGHT 4 CURVE GUIDING",SUP-LA8JR40D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN AMPLATZ LEFT 1 CURVE ANGIOGRAPHIC",SUP-H74908526962,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 7 SLOT LEFT TI",SUP-PHPF-S7L,CDM,C1713,HCPCS,0278,RC,,,both,,,17388.00,5216.4,"UHC [10700]","United Healthcare",,11006.6,63.3,,5023.51,2672.93,6679.78,18,2022.22,14779.8,"percent of total billed charges",
"DRSG MANUKA HONEY HIGH SUGAR LEVEL TUBE LATEX FREE",SUP-MNK0015,CDM,S27000186,LOCAL,0270,RC,,,both,,,83.69,25.11,"MULTIPLAN [10600]",Multiplan,,71.14,85,,,,,0,9.73,71.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 16CM 35MM 14.5MM EXCLUDER C3 TRUNK",SUP-RLT351416,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"AETNA [10100]","Aetna HMO/PPO",,49846.5,79.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.140 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.140,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH PEDIATRIC 6FR 5.5CM HEXCUSPID VALVE KINK",SUP-504606P,CDM,C1894,HCPCS,0272,RC,,,both,,,200.54,60.16,"FIRST HEALTH [10303]","First Health",,160.43,80,,,,,0,23.32,170.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Laryngeal W Stroboscopy",PX-361000050,CDM,31579,CPT,0440,RC,,,both,,,1236.43,370.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,254,,"Per diem ($254).",,,,0,143.8,1236.43,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Thorac Spine WO Cntrst",PX-352000011,CDM,72128,CPT,0352,RC,,,both,,,2953.08,885.92,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,343.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.88,2510.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 40MM PROFILE 3D STERILE LATEX FREE",SUP-680R40,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]",Cigna,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 16X7MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2407,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"UHC [10700]","United Healthcare",,6114.78,63.3,,5023.51,2672.93,6679.78,18,1123.46,8211,"percent of total billed charges",
"INSRT TIBIAL 9 14MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620914,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1308.83,9565.82,"percent of total billed charges",
"SNARE VASCULAR 94CM 13MM 12FR NEEDLES EYE FEMUR TRANSFEMORAL",SUP-LR-NES001,CDM,C1773,HCPCS,0272,RC,,,both,,,9331.49,2799.45,"KAISER [10500]",Kaiser,,6252.1,67,,,,,0,1085.25,7931.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl&Rplcmt Permanent Ccm-D Pulse Generator Only",PX-481000418,CDM,0923T,CPT,0481,RC,,,both,,,34567.00,10370.1,"MULTIPLAN [10600]",Multiplan,,29381.95,85,,,,,0,4020.14,34567,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 50MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.121,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,99.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",99.7,728.71,"percent of total billed charges",
"SCR BONE 5.5MM 35MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.235,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"CIGNA [10200]","Cigna Local Plus",,1572.9,53.5,,3978.14,359.25,3978.14,24,341.92,2499,"percent of total billed charges",
"INSRT TIBIAL 8 9MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P809,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"UHC [10700]","United Healthcare",,5289.28,63.3,,8601.07,8395.67,8601.07,"1 through 10",971.79,7102.52,"percent of total billed charges",
"STENT CONTOUR 20CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061802300,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]","Cigna Open Access",,513.34,,,,,,,104.92,766.85,"percent of total billed charges",
"CATH BARD LUBRI-SIL IC 20FR URETHRAL BACTI-GUARD SILICONE",SUP-1768SI20,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.26,25.58,"AETNA [10100]","Aetna HMO/PPO",,67.78,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.92,72.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insert Wcs Lv Complt Sys",PX-480000072,CDM,0515T,CPT,0480,RC,,,both,,,51039.00,15311.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2041,,"Per diem ($2,041).",,,,0,2041,43383.15,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +28 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2800,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 11 HOLE SHAFT LCP BONE LEFT DISTAL",SUP-02.110.111,CDM,C1713,HCPCS,0278,RC,,,both,,,9508.75,2852.62,"CIGNA [10200]","Cigna Open Access",,5410.48,56.9,,1144.80,304.56,2275.09,66,1105.87,8082.44,"percent of total billed charges",
"HUMERAL CUP - 40MM DIA X 4MM THK",SUP-5570-4004,CDM,C1776,HCPCS,0278,RC,,,both,,,7980.00,2394,"CIGNA [10200]",Cigna,,5426.4,68,,5873.17,5873.17,5873.17,"1 through 10",928.07,6783,"percent of total billed charges",
"WRAP THERAPEUTIC KNEE GEL FREEZABLE MICROWAVABLE COMPRESSION",SUP-K-24-6-IP,CDM,S27000186,LOCAL,0270,RC,,,both,,,336.69,101.01,"FIRST HEALTH [10303]","First Health",,269.35,80,,,,,0,39.16,286.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PROGREAT 130CM 2.4-2.9FR .022IN .021IN MICRO",SUP-MC*PB2413Y,CDM,C1887,HCPCS,0272,RC,,,both,,,2463.75,739.12,"AETNA [10100]","Aetna HMO/PPO",,1958.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,286.53,2094.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX CORE PERMANENT 4X8CM",SUP-F10244-0408P,CDM,C1781,HCPCS,0278,RC,,,both,,,1968.00,590.4,"BLUE CROSS [10001]","Blue Cross HMO",,771.46,39.2,,,,,0,228.88,1672.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON ULTIMA 9-0 CS140-6 12IN 2 ARM MONOFILAMENT BLACK",SUP-9013G,CDM,S27200284,LOCAL,0272,RC,,,both,,,220.62,66.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.66,187.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.9MM X 350MM TRILOGY PROBE KIT",SUP-M0068403540,CDM,S27200284,LOCAL,0272,RC,,,both,,,5531.45,1659.43,"PHCS [10601]",PHCS,,3872.02,70,,,,,0,643.31,4701.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 2MM TPS ELITE ROUND FLUTED SOFT TOUCH STERILE",SUP-5820010120,CDM,S27000186,LOCAL,0270,RC,,,both,,,1094.96,328.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,450.03,41.1,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 16GA 18GA 16CM .032IN CATH GWIRE NDL SYR DRAPE",SUP-AK-04400,CDM,C1751,HCPCS,0272,RC,,,both,,,188.79,56.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.96,160.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHOCOLATE 135CM 40MM 4MM 5FR BALLOON DILATATION NITINOL",SUP-CB1413540040OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,678.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 4X6CM AMNIOBAND PLACENTAL MEMB ALLOGRAFT",SUP-WC3046,CDM,Q4151,HCPCS,0636,RC,,,both,,,19778.85,5933.65,"FIRST HEALTH [10303]","First Health",,15823.08,80,,,,,0,362.66,16812.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 26CM 6FR .035",SUP-M006192133090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"PHCS [10601]",PHCS,,1044.7,70,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 113MM 12-28MM Z-TRAK ZENITH RENU",SUP-G55376,CDM,C1874,HCPCS,0278,RC,,,both,,,46197.90,13859.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18987.34,41.1,,,,,0,5372.82,39268.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 75CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR061001A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8741.48,41.1,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 6MM CUFFED HOODED MURPHY EYE LOW PRESSURE",SUP-8229506,CDM,S27200284,LOCAL,0272,RC,,,both,,,3487.50,1046.25,"MULTIPLAN [10600]",Multiplan,,2964.38,85,,,,,0,405.6,2964.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP BIPOLAR TANDEM POROUS FEMUR WITH COB",SUP-71701451,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Local Plus",,5537.25,53.5,,5372.07,4581.20,7242.98,23,1203.71,8797.5,"percent of total billed charges",
"PLATE TITANIUM 2 MM SCREW 3X8 HOLE Y BONE HAND NONSTERILE",SUP-447.612,CDM,C1713,HCPCS,0278,RC,,,both,,,3402.00,1020.6,"CIGNA [10200]","Cigna Local Plus",,1820.07,53.5,,3978.14,359.25,3978.14,24,395.65,2891.7,"percent of total billed charges",
"SCR BONE 6.5MM 40MM TSRH OSTEOGRIP THINLINE TITANIUM SHORT",SUP-83565408,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.10,1106.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,429.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",429.04,3135.74,"percent of total billed charges",
"HEAD HUMERAL 48MM SHOULDER REVISION SMR COCR MOLYBDENUM",SUP-1322.09.480,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"PHCS [10601]",PHCS,,5544,70,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 32.77CM 8MM CADIERE DA VINCI XI ENDOWRIST",SUP-470049,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 45MM 6.5MM DECADE LARGE PLATE EXTREME LATERAL",SUP-7146545,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1101.6,68,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Glucagon",PX-301000202,CDM,82943,CPT,0301,RC,,,both,,,293.80,88.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.29,,"Fee schedule rate ($15.29). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,249.73,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SUCTION EVIS OES OSF AMP NONSTERILE REUSABLE",SUP-MB-197,CDM,S27200284,LOCAL,0272,RC,,,both,,,811.86,243.56,"CIGNA [10200]","Cigna Local Plus",,434.35,53.5,,,,,0,94.42,690.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +5 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000050,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Backup Battery Li Ion 11v",PX-E27400055,CDM,Q0506,HCPCS,0274,RC,,,both,,,2513.60,754.08,"CIGNA [10200]",Cigna,,1709.25,68,,,,,0,292.33,2136.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH INTRDCR FR10 - EACH",SUP-667117-002,CDM,C1892,HCPCS,0272,RC,,,both,,,607.50,182.25,"UHC [10700]","United Healthcare",,384.55,63.3,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 75MM STAINLESS STEEL FULL THREAD FEMUR",SUP-208.471,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,164.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,160.97,1176.51,"percent of total billed charges",
"SUT PDS II 6-0 C-1 30IN 2 ARM MONOFILAMENT VIOLET ABSORBABLE",SUP-Z127H,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.74,50.02,"CIGNA [10200]","Cigna Open Access",,94.88,56.9,,,,,0,19.39,141.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 7-0 CC 24IN 2 ARM MONOFILAMENT BLUE",SUP-8704H,CDM,S27200284,LOCAL,0272,RC,,,both,,,198.54,59.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,91.13,45.9,,,,,0,23.09,168.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 35D LARGE AUG CORTILOC SHOULDER RIGHT",SUP-DWK405RA35S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"FIRST HEALTH [10303]","First Health",,8400,80,,,,,0,1221.15,8925,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS LAPAROSCOPIC 31.75CM 8MM DA VINCI XI HOT SHEARS",SUP-470179,CDM,S27000186,LOCAL,0270,RC,,,both,,,2520.00,756,"PHCS [10601]",PHCS,,1764,70,,,,,0,293.08,2142,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL H18MM OD24MM UNIVERSAL COBALT CHROME ANTERIOR DI",SUP-11-210045,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"CIGNA [10200]",Cigna,,5685.6,40,,5873.17,5873.17,5873.17,"1 through 10",1653.09,12081.9,"percent of total billed charges",
"PERIPHERAL VASCULAR DISORDERS WITH MCC",299,MS-DRG,,,,,,,inpatient,,,31488.49,9446.55,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,10431.57,,"Case rate ($10,127.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,404.29, add-ons for qualifying new technology services are included. If operating cost exceeds $42,443.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,093.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,416.73. The transfer operating threshold is the transfer adjustment factor * $9,404.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $711.01. The transfer capital threshold is the transfer adjustment factor * $711.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,31488.49,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 100MM 5.5MM CURVE NONSTERILE",SUP-1555501100,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEERABLE GUIDEWIRE TRITON NITINOL ALLOY .018"""" DIAMETER 260",SUP-CM2010,CDM,C1769,HCPCS,0272,RC,,,both,,,1875.00,562.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Berkeley Lipid Profile",PX-301000009,CDM,80061,CPT,0301,RC,,,both,,,253.00,75.9,"CIGNA [10200]","Cigna Local Plus",,29.46,,,,,,,0.25,215.05,"fee schedule",
"CMPNT FEMORAL F 72X65.4MM KNEE LEFT CEMENT NEXGEN CR-FLEX",SUP-595601601,CDM,C1776,HCPCS,0278,RC,,,both,,,19845.00,5953.5,"NOVANET [10819]",Novanet,,14883.75,75,,,,,0,2307.97,16868.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE HEMSTAT CLLGN ABSRB INSTAT 1 GR",SUP-1985,CDM,S27200284,LOCAL,0272,RC,,,both,,,1046.94,314.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,430.29,41.1,,,,,0,121.76,889.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Potassium Urine",PX-301000366,CDM,84133,CPT,0301,RC,,,both,,,109.25,32.77,"AETNA [10100]","Aetna HMO/PPO",,86.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,92.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AORTIC VALVED GRAFT WITH  MAQUETHEMASHIELDWOVEN DOUBLE VELOU","SUP-19CAVGJ-514 00",CDM,C1768,HCPCS,0278,RC,,,both,,,25533.90,7660.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10494.43,41.1,,,,,0,2969.59,21703.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 12MM 140CM 4MM 2.1-2.7FR CORONARY STENT",SUP-RONYX40012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3628.13,1088.44,"AETNA [10100]","Aetna HMO/PPO",,2884.36,79.5,,,,,0,421.95,3083.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 32MM 80MM MEDLINE UNITE FOOT ANKLE HEAD",SUP-MSD17080,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,305.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",305.29,2231.25,"percent of total billed charges",
"IMPL BREAST NATRELLE INSPIRA LOW PLUS PROFILE SOFTTOUCH",SUP-SSLP-125,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS [10001]","Blue Cross PPO",,2961.76,39.2,,16595.83,16595.83,16595.83,"1 through 10",878.7,6422.18,"percent of total billed charges",
"CATH SUPREME 120CM 5FR 2-8-2MM SPACING CSL CURVE",SUP-401863,CDM,C1730,HCPCS,0272,RC,,,both,,,2587.50,776.25,"PHCS [10601]",PHCS,,1811.25,70,,,,,0,300.93,2199.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 4.75MM SOLERA COCR MOLYBDENUM CURVED",SUP-1475501040,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 30MM 125CM 4MM 5FR .018IN BILIARY NITINOL",SUP-G31438,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"KAISER [10500]",Kaiser,,2799.93,67,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CXI 135CM 4FR DAV CURVE GUIDING TUNGSTEN ACCEPTS .035IN",SUP-G52543,CDM,C1887,HCPCS,0272,RC,,,both,,,1522.72,456.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,177.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,177.09,1294.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 12CM 8MM BALLOON DILATATION OTW LOW",SUP-G30973,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 27MM 46MM SHOULDER COMPREHENSIVE VERSA-DIAL",SUP-113048,CDM,C1776,HCPCS,0278,RC,,,both,,,9089.00,2726.7,"PHCS [10601]",PHCS,,6362.3,70,,,,,0,1057.05,7725.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL HIP 1",SUP-CAP-S-PH-1,CDM,C1776,HCPCS,0278,RC,,,both,,,8280.00,2484,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,962.96,7038,"percent of total billed charges",
"STEM FEMORAL MODULAR REMEDY SPECTRUM GENTAMICIN VANCOMYCIN",SUP-GVHDSM,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5409.18,28.62,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 52CM .014IN SFT J",SUP-6586,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATH GUIDING RDND 1 CURVE 6FR .07IN 55CM CORONARY SOF",SUP-SA6RDND1K,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NUT ORTHOPEDIC MRI SAFE NONSTERILE",SUP-03.311.062,CDM,S27800098,LOCAL,0278,RC,,,both,,,1313.42,394.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,602.86,45.9,,,,,0,140.82,1116.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 20MM 140CM 2.75MM CORONARY STENT PLATINUM",SUP-H7493927420270,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL CINCHLOCK SS ANATOMIC LABRUM RESTORATION SYSTEM",SUP-CAT02463,CDM,S27200284,LOCAL,0272,RC,,,both,,,1279.80,383.94,"CIGNA [10200]","Cigna Open Access",,728.21,56.9,,,,,0,148.84,1087.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 20MM LOCK PERIPHERAL STERILE",SUP-AR-9563-20,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,274.2,45.9,,,,,0,69.48,507.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL SMALL+ KNEE LEFT CEMENT LCS COMPLETE COCR",SUP-129402020,CDM,C1776,HCPCS,0278,RC,,,both,,,20635.65,6190.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2445.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2399.93,17540.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 110MM QUICK CONNECT PERIARTICULAR ZPS 3.5MM",SUP-00480611035,CDM,S27000186,LOCAL,0270,RC,,,both,,,1275.75,382.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ARTHROSCOPIC TRANSLUCENT GRAY 85MM 6MM DRY-DOC ROUND",SUP-C7359,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.63,90.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH AGENT 20MM 2.75MM BALLOON DILATATION PACLITAXEL",SUP-H7493960820270,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH 83CM 19FR AIRWAY EXCHANGE",SUP-G57623,CDM,S27200284,LOCAL,0272,RC,,,both,,,672.30,201.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,308.59,45.9,,,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 400ML P4CM MODERATE PLUS PROFILE HIGH PROJECTION",SUP-350-4001BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5347.50,1604.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,621.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,621.91,4545.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 160MM 2.7MM QUICK COUPLING CANNULATED STERILE",SUP-310.67S,CDM,C1713,HCPCS,0278,RC,,,both,,,2568.60,770.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,304.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",298.73,2183.31,"percent of total billed charges",
"INSRT TIBIAL 3 CURVE PLUS 20MM KNEE XLK FIX BEARING SIGMA",SUP-970455,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]","Cigna Open Access",,6358.32,56.9,,5302.19,4377.88,6578.61,27,1299.6,9498.37,"percent of total billed charges",
"NAIL 3MM ANKLE VALOR INTRAMEDULLARY ENTRY GWIRE SCR KIT",SUP-4150004025,CDM,C1713,HCPCS,0278,RC,,,both,,,1672.50,501.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,194.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",194.51,1421.63,"percent of total billed charges",
"CMPNT FEMORAL 10 STD KNEE RIGHT POSTERIOR STABILIZE PERSONA",SUP-42500806802,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"FIRST HEALTH [10303]","First Health",,23116.46,80,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIFLUFOLASTAT F-18 IV SYRINGE (9-10 MCI)",RX-411826,CDM,A9595,HCPCS,0343,RC,08888-8877-80,NDC,both,1,UN,16868.88,5060.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7168.52,,,,,,,696,14338.55,"fee schedule",
"STAPLE BONE 8X8X2MM FUSEFORCE HAND STERILE",SUP-FFNS-0808,CDM,C1713,HCPCS,0278,RC,,,both,,,6900.00,2070,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4692,68,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 12X14X7MM 6D CERVICAL ANTERIOR TRITANIUM STERILE",SUP-48982076,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"FIRST HEALTH [10303]","First Health",,4968,80,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VOID FILLER SYNTHETIC NANOSS 3D PLUS 5CC",SUP-90-400-25504,CDM,C1713,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1042.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1023.15,7477.88,"percent of total billed charges",
"KIT INTRAMEDULLARY NAIL 360MM 11MM 130D R1.5 LEFT TITANIUM",SUP-3530-1360S,CDM,C1713,HCPCS,0278,RC,,,both,,,13435.13,4030.54,"NOVANET [10819]",Novanet,,10076.35,75,,,,,0,1562.51,11419.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS THERMOCOOL REDEL 115CM 3.5MM 7FR 2-5-2MM SPACE",SUP-DI7TCJLRT,CDM,C2630,HCPCS,0272,RC,,,both,,,9142.50,2742.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1063.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WHOLE PATELLA: FROZEN",SUP-450580,CDM,S27800098,LOCAL,0278,RC,,,both,,,9331.56,2799.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1105.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1085.26,7931.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT LAPAROSCOPIC CURVE JAW CORDLESS ULTRASONIC",SUP-SCD7A39,CDM,S27200284,LOCAL,0272,RC,,,both,,,2887.50,866.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1963.5,68,,,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 60MM 135CM 10MM VASCULAR NITINOL",SUP-1012538-60,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,481.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 4.0X15MM",SUP-PRV040015CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPN NC 20MM 4MM 35 ATM BALLOON DILATATION THIN WALL LOW",SUP-400-020-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"AMERIGROUP MEDICAID [20100]",Amerigroup,,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1",SUP-179715640,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"SCR BONE 6.5MM 40MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1",SUP-179715640,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.464,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"MULTIPLAN [10600]",Multiplan,,4116.21,85,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 90CM 8FR JR4 CURVE GUIDING PTFE FEMORAL",SUP-H749343587080,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"MULTIPLAN [10600]",Multiplan,,311.47,85,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 15.5CM 78CM 23MM 28MM 12CM 18.5FR ESOPHAGEAL",SUP-M00516950,CDM,C1874,HCPCS,0278,RC,,,both,,,16701.45,5010.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1979.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1942.38,14196.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.054,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"MULTIPLAN [10600]",Multiplan,,4116.21,85,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE WEDGE ALLOGRAFT FRESH FROZEN IMPACT 26MMX14MM",SUP-161426,CDM,S27800098,LOCAL,0278,RC,,,both,,,12572.49,3771.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3598.25,28.62,,,,,0,1462.18,10686.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 4FR 20CM RADIOPAQUE GWIRE STERILE DISPOSABLE",SUP-G02366,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.99,22.5,"CIGNA [10200]",Cigna,,50.99,68,,,,,0,8.72,63.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIPOLAR FEMORAL HEAD ADAPTER -4MM",SUP-451010004,CDM,C1776,HCPCS,0278,RC,,,both,,,1539.00,461.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,706.4,45.9,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 154MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-240.040S,CDM,C1713,HCPCS,0278,RC,,,both,,,9673.52,2902.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4440.15,45.9,,,,,0,1125.03,8222.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL CORE TPS STAINLESS STEEL SMALL L11 MM X W5 MM",SUP-5100-037-115,CDM,S27200284,LOCAL,0272,RC,,,both,,,928.26,278.48,"NOVANET [10819]",Novanet,,696.2,75,,,,,0,107.96,789.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Carboxyhemoglobin Quant",PX-301000131,CDM,82375,CPT,0301,RC,,,both,,,202.34,60.7,"FIRST HEALTH [10303]","First Health",,161.87,80,,,,,0,0.01,171.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 2MM LARGE 210MM VITALLIUM 2 CABLE GRIP DALL-MILES BONE",SUP-6704-3-093,CDM,C1713,HCPCS,0278,RC,,,both,,,10920.00,3276,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1270,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1270,9282,"percent of total billed charges",
"RING ANNULOPLASTY 26MM TRI-AD",SUP-900SFC26,CDM,S27800098,LOCAL,0278,RC,,,both,,,14490.00,4347,"BLUE CROSS [10001]","Blue Cross PPO",,5680.08,39.2,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX SEPRA 10X5IN MONOFILAMENT RESORBABLE",SUP-1201325,CDM,C1781,HCPCS,0278,RC,,,both,,,39253.41,11776.02,"CIGNA [10200]",Cigna,,15701.36,40,,,,,0,4565.17,33365.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 20MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962345,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"FIRST HEALTH [10303]","First Health",,11603.04,80,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 4 132D",SUP-6720-0435,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6469.75,27,,,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 31X12-15MM MAGNIFY-S 15D 25MM EXPAND",SUP-1126.0212,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,17607.24,41.1,,,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON 10-O CU-8",SUP-8065202001,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.98,94.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,36.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.52,266.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH UROMAX ULTRA QUADRA-FOLD ENCORE HIGH PRESSURE KINK",SUP-M0062251270,CDM,C1726,HCPCS,0272,RC,,,both,,,1904.70,571.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,782.83,41.1,,,,,0,221.52,1619,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX OTW CORONARY STENT  2.00 X 22MM",SUP-RONYX20022W,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 31MM TITANIUM MINI FRAGMENT SET 4 HOLE .25 TUBULAR",SUP-442.04,CDM,C1713,HCPCS,0278,RC,,,both,,,2546.85,764.05,"MULTIPLAN [10600]",Multiplan,,2164.82,85,,,,,0,296.2,2164.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26MM 8MM CAPSTONE PEEK INTERBODY",SUP-2990826,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"CIGNA [10200]","Cigna Open Access",,7110.58,33.5,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 15MM 145CM 2.75MM CORONARY STENT",SUP-1125275-15,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3969.84,68,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ASSURE TITANIUM SPINE CERVICAL ANTERIOR",SUP-110.032,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]",Cigna,,688.5,68,,1831.33,1831.33,1831.33,16,117.75,860.63,"percent of total billed charges",
"HC Rmvl Tube Obstruction W Fl",PX-750000107,CDM,49460,CPT,0750,RC,,,both,,,3168.00,950.4,"MULTIPLAN [10600]",Multiplan,,2692.8,85,,,,,0,368.44,3168,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC",543,MS-DRG,,,,,,,inpatient,,,27121.19,8136.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,20406.83,,"Fee schedule rate ($20,406.83). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,6376.74,25637.29,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 5MM CENTERPIECE TITANIUM SPINE SELF TAPPING",SUP-853-505,CDM,C1713,HCPCS,0278,RC,,,both,,,443.23,132.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",51.55,376.75,"percent of total billed charges",
"SCREW SNAP-OFF 2.0 X 12MM",SUP-SNAP2012,CDM,C1713,HCPCS,0278,RC,,,both,,,2062.50,618.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,239.87,1753.13,"percent of total billed charges",
"GUIDE PIN ORTHOPEDIC 444MM 3.2MM VERSANAIL HIP THREAD",SUP-281001175,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 3MM I-KNIFE II SATINSLIT ANGLE SCR IN TIP",SUP-8065992962,CDM,S27200284,LOCAL,0272,RC,,,both,,,153.38,46.01,"FIRST HEALTH [10303]","First Health",,122.7,80,,,,,0,17.84,130.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 30MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206050370,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 12D-30D LONG OVAL BUTTON 24FR",SUP-WA22741S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 25X13CM SOMAGEN ACELLULAR DERMAL MATRIX",SUP-WC2325,CDM,Q4433,HCPCS,0636,RC,,,both,,,103307.48,30992.24,"CIGNA [10200]","Cigna Open Access",,58781.96,56.9,,,,,0,247.92,87811.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR .014IN 185CM 2CM STRAIGHT RADIOPAQUE MARKER",SUP-H74938951012,CDM,C1769,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POPE VENT TUBE 1.14MM ID BLUE FLPL",SUP-525-642,CDM,S27800098,LOCAL,0278,RC,,,both,,,214.86,64.46,"BLUE CROSS [10001]","Blue Cross PPO",,84.23,39.2,,,,,0,24.99,182.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insulin Ab",PX-302000073,CDM,86337,CPT,0302,RC,,,both,,,246.05,73.81,"CIGNA [10200]","Cigna Local Plus",,47.1,,,,,,,0.01,209.14,"fee schedule",
"DRIVER NDL 54.5CM 8MM SUTURECUT DA VINCI S/SI ENDOWRIST 30-",SUP-420296,CDM,S27000186,LOCAL,0270,RC,,,both,,,1890.00,567,"AMERIGROUP MEDICAID [20100]",Amerigroup,,223.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 3.6IN VENTRAL HERNIA ROUND RESORBABLE",SUP-PCO9,CDM,C1781,HCPCS,0278,RC,,,both,,,2038.88,611.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,935.85,45.9,,,,,0,237.12,1733.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,inpatient,,,107097.61,32129.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22046.68,,"Fee schedule rate ($22,046.68). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,7561,71360.86,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .079IN .057IN JUDKINS LEFT",SUP-534620T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CAP REVERSE SHOULDER W-LONG STEM",SUP-71701418,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"FIRST HEALTH [10303]","First Health",,36288,80,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .035IN 5FR 10MM 135CM 2CM PERIPHERAL",SUP-4190020X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 RIGHT KNEE CEMENTED POSTERIOR STABILIZED",SUP-5515-F-502,CDM,C1776,HCPCS,0278,RC,,,both,,,16566.90,4970.07,"AETNA [10100]","Aetna HMO/PPO",,13170.69,79.5,,10981.53,8986.79,12413.38,12,1926.73,14081.87,"percent of total billed charges",
"CATH RABINOV 30CM 30GA .012IN SIALOGRAPHY SUBMANDIBULAR DUCT",SUP-G01323,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.91,101.97,"MULTIPLAN [10600]",Multiplan,,288.92,85,,,,,0,39.53,288.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest Nrv Other Periph",PX-510000159,CDM,64640,CPT,0761,RC,,,both,,,8394.00,2518.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,994.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,976.22,7134.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FRONTRUNNER XP CTO 140CM 2.3MM 4.5FR .067IN",SUP-FBP39140,CDM,S27200284,LOCAL,0272,RC,,,both,,,5312.31,1593.69,"CIGNA [10200]","Cigna Open Access",,3022.7,56.9,,,,,0,617.82,4515.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIATORR 8CM 2CM 10MM ENDOPROSTHESIS NITINOL",SUP-PTB108275,CDM,C1874,HCPCS,0278,RC,,,both,,,29206.80,8762.04,"CIGNA [10200]","Cigna Open Access",,9784.28,33.5,,,,,0,3396.75,24825.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HD CUTTING EDGE NEEDLE STAINLESS STEEL",SUP-400-689,CDM,S27200284,LOCAL,0272,RC,,,both,,,2178.00,653.4,"MULTIPLAN [10600]",Multiplan,,1851.3,85,,,,,0,253.3,1851.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMT BRIDLE PRO- 08 FR",SUP-4-4208,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"NOVANET [10819]",Novanet,,534.6,75,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 15MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE40015,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"BLUE CROSS [10001]","Blue Cross HMO",,32796.52,39.2,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP LIGATION RESOLUTION 360 235CM 2.8MM BRAID CATH ROTATION",SUP-M00521232,CDM,S27200284,LOCAL,0272,RC,,,both,,,1449.90,434.97,"KAISER [10500]",Kaiser,,971.43,67,,,,,0,168.62,1232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 20MM 4MM .014IN LOW PROFILE",SUP-1008189-20,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"MULTIPLAN [10600]",Multiplan,,1204.88,85,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP TUBE 16MM CRANIOFIX 2 CRANIAL FLAP TITANIUM SECURE",SUP-FF491T,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.77,401.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,909,68,,,,,0,155.47,1136.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 20MM 135CM 12MM 9FR 160CM",SUP-H965412000,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5747.7,68,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR ZEPHYR SR 52X42MM 10.4ML 23LB IMPLANTABLE 1 CHMBR",SUP-5626,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"UHC [10700]","United Healthcare",,15723.72,63.3,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HSE BRTHG 22MM FLRD 40LG VMAX SPEC",SUP-774611-102,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.99,44.4,"AETNA [10100]","Aetna HMO/PPO",,117.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.21,125.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 15MM 6FR 2MM .07",SUP-H7493926715200,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,233.04,41.1,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 39MM 80CM 10MM 13MM 8FR .035IN",SUP-BXA103901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"AETNA [10100]","Aetna HMO/PPO",,15506.32,79.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 15.8X7.9IN XENMATRIX AQUAPURE RECTANGLE",SUP-1162040,CDM,C1781,HCPCS,0278,RC,,,both,,,107011.23,32103.37,"BLUE CROSS [10001]","Blue Cross PPO",,41948.4,39.2,,,,,0,12445.41,90959.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE VASCULAR 1.5MM STD 180CM 3CM .035IN NITINOL",SUP-GR3525,CDM,C1769,HCPCS,0272,RC,,,both,,,361.05,108.31,"PHCS [10601]",PHCS,,252.74,70,,,,,0,41.99,306.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fast Track/Home",PX-710000001,CDM,9999129,LOCAL,0710,RC,,,both,,,3047.10,914.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2072.03,68,,,,,0,354.38,2590.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON UVA TORIC AUTONOME",SUP-CCA0T4,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"BLUE CROSS [10001]","Blue Cross PPO",,145.04,39.2,,,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sputum Obtn Specimen Aero",PX-300000015,CDM,89220,CPT,0300,RC,,,both,,,189.00,56.7,"AETNA [10100]","Aetna HMO/PPO",,150.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,160.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 28MM T8 FULL THREAD STARDRIVE NONSTERILE",SUP-656428,CDM,C1713,HCPCS,0278,RC,,,both,,,1107.59,332.28,"CIGNA [10200]",Cigna,,753.16,68,,1831.33,1831.33,1831.33,16,128.81,941.45,"percent of total billed charges",
"RING ANNULOPLASTY 36MM SEMIRIGID OPEN ANTERIOR SEG SEWING",SUP-5300M36,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"MULTIPLAN [10600]",Multiplan,,11730,85,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 6CM 2MM GALAXY G3 MINI STRETCH",SUP-GLM920060,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3208.09,27,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAMP 10GA STEERABLE ARTICULATE BALLOON RADIOPAQUE INFLATABLE",SUP-OF-0224,CDM,S27200284,LOCAL,0272,RC,,,both,,,4981.80,1494.54,"UHC [10700]","United Healthcare",,3153.48,63.3,,,,,0,579.38,4234.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 18MM VLP TITANIUM T6 FOOT CORTICAL SELF TAP",SUP-74402018,CDM,C1713,HCPCS,0278,RC,,,both,,,473.28,141.98,"NOVANET [10819]",Novanet,,354.96,75,,,,,0,55.04,402.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 1.27MM 9.5MM GOODE EAR T MODIFIED LARGER",SUP-1026040,CDM,S27800098,LOCAL,0278,RC,,,both,,,264.05,79.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,31.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.71,224.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 30CM 6FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856160,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,503.37,45.9,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP IODINE SSI 6OZ 3 7/16X2",SUP-6G,CDM,S27000186,LOCAL,0270,RC,,,both,,,60.73,18.22,"CIGNA [10200]",Cigna,,41.3,68,,,,,0,7.06,51.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENCIL BIPOLAR 18GA STELLARIS PC CURVE VITREORETINAL 2 PIN",SUP-E7918,CDM,S27200284,LOCAL,0272,RC,,,both,,,835.35,250.6,"PHCS [10601]",PHCS,,584.75,70,,,,,0,97.15,710.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM PRECEPT SPINE POLYAXIAL",SUP-8806545A,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PHCS [10601]",PHCS,,6682.8,70,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTEFILL ALLOGRAFT FREEZE DRIED 20X15-17X15MM",SUP-12015,CDM,S27800098,LOCAL,0278,RC,,,both,,,15456.00,4636.8,"MULTIPLAN [10600]",Multiplan,,13137.6,85,,,,,0,1797.53,13137.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 12MM 144CM 3MM CORONARY STENT",SUP-H7493911412300,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross PPO",,3583.86,39.2,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL MONOFILAMENT ABSORBABLE LOW PROFILE",SUP-5955113,CDM,C1781,HCPCS,0278,RC,,,both,,,8400.00,2520,"AETNA [10100]","Aetna HMO/PPO",,6678,79.5,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 450ML P5.2CM HIGH PROFILE ROUND GEL TEXTURED",SUP-354-4450,CDM,C1789,HCPCS,0278,RC,,,both,,,4823.10,1446.93,"FIRST HEALTH [10303]","First Health",,3858.48,80,,,,,0,560.93,4099.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW 7713515 ZEVO VAR SD 3.5MM X 15MM",SUP-7713515,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"BLUE CROSS [10001]","Blue Cross PPO",,552.72,39.2,,957.42,570.23,957.42,28,163.98,1198.5,"percent of total billed charges",
"PARTICLES EMBOLIZATION 5MM CUBE 3ML PREFILL DRY CARR SOL",SUP-EC5025,CDM,S27800098,LOCAL,0278,RC,,,both,,,526.50,157.95,"CIGNA [10200]",Cigna,,358.02,68,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 80MM SOLERA CD HORIZON OSTEOGRIP TITANIUM",SUP-54840008580,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"FIRST HEALTH [10303]","First Health",,7637.48,80,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT NEUROSURGICAL CSF 87CM LUMBOPERITONEAL CATH T STERILE",SUP-44520,CDM,S27800098,LOCAL,0278,RC,,,both,,,6715.22,2014.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,795.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,780.98,5707.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 8 KNEE LEFT DISTAL TOTAL STABILIZE",SUP-5540-A-801,CDM,C1776,HCPCS,0278,RC,,,both,,,6375.60,1912.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,755.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,741.48,5419.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 2.25X25MM",SUP-PRV022525CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC",066,MS-DRG,,,,,,,inpatient,,,34289.04,10286.71,"BLUE CROSS [10001]","Blue Cross HMO",,15711.63,,,,,,,4245.37,17068.25,"case rate",
"SCR BONE 3.5MM 38MM ARTHREX TITANIUM MINI FULL THREAD",SUP-AR-8730-38H,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA [10200]","Cigna Local Plus",,1404.38,53.5,,3978.14,359.25,3978.14,24,305.29,2231.25,"percent of total billed charges",
"CATH CXI 150CM 4FR SPRT STAINLESS STEEL HYDROPHILIC LOW",SUP-G52544,CDM,C1887,HCPCS,0272,RC,,,both,,,1522.72,456.82,"AETNA [10100]","Aetna HMO/PPO",,1210.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,177.09,1294.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 122MM STAINLESS STEEL 3.5MM SCREWS 4 HOLE LCP BONE",SUP-02.104.004,CDM,C1713,HCPCS,0278,RC,,,both,,,7481.12,2244.34,"AMERIGROUP MEDICAID [20100]",Amerigroup,,886.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",870.05,6358.95,"percent of total billed charges",
"CNCT ROD 4MM SYMPHONY SHORT LATERAL OFFSET SPINE",SUP-102021401,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"AETNA [10100]","Aetna HMO/PPO",,2832.19,79.5,,1521.93,481.35,16760.95,30,414.32,3028.13,"percent of total billed charges",
"CATH MALECOT 36FR NEPHRSTMY NATURAL RUBBER 4 WING DRAIN",SUP-086036,CDM,C1729,HCPCS,0272,RC,,,both,,,105.62,31.69,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 18GA 17GA 11CM 5CM ACHIEVE LIGHTWEIGHT SOFT",SUP-CA1811,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC",001,MS-DRG,,,,,,,inpatient,,,1638727.54,491618.26,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 19FR .25IN BARD SILICONE 4 FREE FLOW CHANNEL",SUP-072230,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.53,31.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SELUTION SLR PTCA DEB 3.5X25MM",SUP-SCA14U-350025D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,inpatient,,,40298.87,12089.66,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT 36-38IN MEDIUM PAD SHOULDER STRAP REMOVABLE DRAIN BULB",SUP-46518-02LF,CDM,S27000186,LOCAL,0270,RC,,,both,,,418.38,125.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT HUMERAL H+0MM 39MM PERFORM .75 SHOULDER REVERSE",SUP-DWP4390,CDM,C1776,HCPCS,0278,RC,,,both,,,17388.00,5216.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4694.76,27,,,,,0,2022.22,14779.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 37MM FULL FLEXIBLE MARKER SIMULUS",SUP-700FF37,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5388.21,41.1,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL STD+ 10MM KNEE GVF POLYETHYLENE ROTATE PLATFORM",SUP-129405510,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"CIGNA [10200]","Cigna Local Plus",,5169.95,53.5,,5372.07,4581.20,7242.98,23,1123.86,8213.93,"percent of total billed charges",
"CMPNT FEMORAL 6 STD KNEE LEFT POSTERIOR STABILIZE PERSONA",SUP-42500806001,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"NOVANET [10819]",Novanet,,21671.69,75,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ATLANTIS TITANIUM ANTERIOR CERVICAL SPINE",SUP-3120212,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,403.54,28.62,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Film Array Gastointestinal Panel",PX-306000197,CDM,87507,CPT,0306,RC,,,both,,,1526.65,457.99,"CIGNA [10200]","Cigna Local Plus",,916.92,,,,,,,1.53,1479.54,"fee schedule",
"COIL EMBOLIZATION 3CM 2MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR092030,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"FIRST HEALTH [10303]","First Health",,10580.68,80,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER FACTORS INFLUENCING HEALTH STATUS",951,MS-DRG,,,,,,,inpatient,,,31435.44,9430.63,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,20260.86,,"Case rate ($9,950.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,239.56, add-ons for qualifying new technology services are included. If operating cost exceeds $42,279.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,080.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,251.77. The transfer operating threshold is the transfer adjustment factor * $9,239.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $698.56. The transfer capital threshold is the transfer adjustment factor * $698.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,31435.44,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 7FR JR4 CURVE GUIDING CORONARY SIDEHOLE",SUP-LA7JR40SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Episiotomy Vag Rpr N-Attend",PX-361000466,CDM,59300,CPT,0361,RC,,,both,,,8459.00,2537.7,"BLUE CROSS [10001]","Blue Cross PPO",,3634.7,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,983.78,7680,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75446525,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX 40MM 135CM 9MM VASCULAR NITINOL CAROTID",SUP-PC0940RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"NOVANET [10819]",Novanet,,5692.5,75,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SIMPLASTIC 16IN 24FR URETHRAL PTFE 30ML 3 WAY FOLEY",SUP-570624,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.43,49.33,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,75.47,45.9,,,,,0,19.12,139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ITOTAL IDENTITY CR 3DP POROUS KIT IPOLY XE INSERTS",SUP-ITCR-3DP-XE-KIT,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"KAISER [10500]",Kaiser,,20049.75,67,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FLUID MANAGEMENT FLUENT FLOPAK BAG TISSUE TRAP",SUP-FLT-112,CDM,S27000186,LOCAL,0270,RC,,,both,,,2125.00,637.5,"FIRST HEALTH [10303]","First Health",,1700,80,,,,,0,247.14,1806.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC 15-16IN AIRMESH 15D LARGE SHOULDER QUICK",SUP-08504,CDM,L3670,HCPCS,0274,RC,,,both,,,389.33,116.8,"NOVANET [10819]",Novanet,,292,75,,,,,0,45.28,330.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 12/14 TAPER 28MM HIP SKIRT COCR",SUP-136514000,CDM,C1776,HCPCS,0278,RC,,,both,,,4457.40,1337.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,518.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,518.4,3788.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.185 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.185,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 15MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-104150,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"AETNA [10100]","Aetna HMO/PPO",,19241.66,79.5,,10981.53,8986.79,12413.38,12,2814.85,20572.84,"percent of total billed charges",
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 3.50MM .017IN",SUP-H7493926708350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AETNA [10100]","Aetna HMO/PPO",,450.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 167MM 12MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-212,CDM,C1776,HCPCS,0278,RC,,,both,,,19885.95,5965.78,"KAISER [10500]",Kaiser,,13323.59,67,,,,,0,2312.74,16903.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT RIB MEDIUM 31X6IN 3 PANEL PREMIUM ELASTIC HOOK LOOP",SUP-13790406,CDM,S27000186,LOCAL,0270,RC,,,both,,,55.59,16.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.47,47.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 12MM 2.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP2512X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"UHC [10700]","United Healthcare",,333.27,63.3,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR RMT HYPERTRONICS 125CM 4MM 7FR 1-7-4MM SPACE",SUP-NR7TCS4Y,CDM,C1732,HCPCS,0272,RC,,,both,,,16256.40,4876.92,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1890.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1890.62,13817.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X6MM HEDRON C 7D 12MM STERILE LATEX FREE",SUP-1211.2416S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Local Plus",,3322.35,53.5,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 62MM 36MM ALTRX HIP",SUP-122136462,CDM,C1776,HCPCS,0278,RC,,,both,,,6814.08,2044.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4633.57,68,,,,,0,792.48,5791.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4F QUAD 10-10-10 MPA 120CM",SUP-901470,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM  RESOLUTE ONYX OTW CORONARY   2.00 X 26MM",SUP-RONYX20026W,CDM,C1874,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1019.59,28.62,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TOGGLELOC ZIPLOOP XL FIXATION",SUP-110005089,CDM,C1713,HCPCS,0278,RC,,,both,,,3864.00,1159.2,"PHCS [10601]",PHCS,,2704.8,70,,,,,0,449.38,3284.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit B Level 3 W Proc",PX-450000330,CDM,G0382,HCPCS,0450,RC,,,both,,,1257.00,377.1,"MULTIPLAN [10600]",Multiplan,,1068.45,85,,,,,0,67.13,1257,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC",577,MS-DRG,,,,,,,inpatient,,,107990.16,32397.05,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,17429,,"Case rate ($16,442.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $15,267.93, add-ons for qualifying new technology services are included. If operating cost exceeds $48,307.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,536.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $15,288.12. The transfer operating threshold is the transfer adjustment factor * $15,267.93 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,154.33. The transfer capital threshold is the transfer adjustment factor * $1,154.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,77389.84,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 12/14 TAPER 28MM HIP COCR ARTICUL/EZE",SUP-136512000,CDM,C1776,HCPCS,0278,RC,,,both,,,2623.32,787,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1204.1,45.9,,,,,0,305.09,2229.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 19MM NIKO LUMBAR INTERBODY FUSION",SUP-342.819,CDM,S27800098,LOCAL,0278,RC,,,both,,,31320.00,9396,"NOVANET [10819]",Novanet,,23490,75,,,,,0,3642.52,26622,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640306,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"AETNA [10100]","Aetna HMO/PPO",,8946.85,79.5,,10981.53,8986.79,12413.38,12,1308.83,9565.82,"percent of total billed charges",
"STENT FLEXSEGMENT PALMAZ GENESIS AVIATOR 11MM 135CM 5MM 4-6",SUP-H739PG1250BAX3,CDM,C1876,HCPCS,0278,RC,,,both,,,6554.03,1966.21,"AETNA [10100]","Aetna HMO/PPO",,5210.45,79.5,,,,,0,762.23,5570.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD TITANIUM 7 HOLE GEMINUS BONE RADIUS RIGHT FOSSA",SUP-GMN-RTS-7HL,CDM,C1713,HCPCS,0278,RC,,,both,,,5768.40,1730.52,"BLUE CROSS [10001]","Blue Cross PPO",,2261.21,39.2,,957.42,570.23,957.42,28,670.86,4903.14,"percent of total billed charges",
"SCR BONE 4MM 16MM ATLANTIS TITANIUM SPINAL CANCELLOUS",SUP-876-816,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 10.5MM CEMENTLESS MODULAR AML POROUS 40MM",SUP-155402106,CDM,C1776,HCPCS,0278,RC,,,both,,,15374.88,4612.46,"CIGNA [10200]",Cigna,,6149.95,40,,5873.17,5873.17,5873.17,"1 through 10",1788.1,13068.65,"percent of total billed charges",
"HC Mod Sedat Add 15min",PX-371000009,CDM,99153,CPT,0371,RC,,,both,,,387.75,116.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,45.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.1,329.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.116,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"CIGNA [10200]","Cigna Local Plus",,458.66,53.5,,3978.14,359.25,3978.14,24,99.7,728.71,"percent of total billed charges",
"STEM HUMERAL 55MM 13MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113613,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UHC [10700]","United Healthcare",,7975.8,63.3,,8601.07,8395.67,8601.07,"1 through 10",1465.38,10710,"percent of total billed charges",
"SCR INTERFERENCE TITANIUM 25MM 7MM ACL PCL CANNULATED",SUP-AR-1371,CDM,C1713,HCPCS,0278,RC,,,both,,,807.98,242.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,370.86,45.9,,,,,0,93.97,686.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR UNIVERSAL 45X3.5MM ENDO GIA TITANIUM ENDOSCOPIC",SUP-030422,CDM,S27200284,LOCAL,0272,RC,,,both,,,697.98,209.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,286.87,41.1,,,,,0,81.18,593.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 12MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-1516-30-712,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"FIRST HEALTH [10303]","First Health",,10501.8,80,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND 10X10CM POLYURETHANE FOAM NOVOSORB BTM SEAL",SUP-BTM-1010,CDM,A2006,HCPCS,0636,RC,,,both,,,8625.00,2587.5,"KAISER [10500]",Kaiser,,5778.75,67,,,,,0,247.92,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 28MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.528,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"PHCS [10601]",PHCS,,767.49,70,,,,,0,127.51,931.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X6MM HEDRON C 7D 12MM STERILE LATEX FREE",SUP-1211.2416S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross HMO",,2434.32,39.2,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 6-9 E-F KNEE RIGHT TIBIA",SUP-42522400712,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1253.3,9159.96,"percent of total billed charges",
"HC Xr Bn Survey Infant",PX-320000182,CDM,77076,CPT,0320,RC,,,both,,,453.73,136.12,"MULTIPLAN [10600]",Multiplan,,385.67,85,,,,,0,52.77,385.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 54MM 3 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.354,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"PHCS [10601]",PHCS,,3704.4,70,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM VERTEX STERILE",SUP-6956010,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1815.99,45.9,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE HUMERAL SHAFT ALLOGRAFT FROZEN 100X20-25MM",SUP-450572,CDM,S27800098,LOCAL,0278,RC,,,both,,,6069.24,1820.77,"BLUE CROSS [10001]","Blue Cross PPO",,2379.14,39.2,,,,,0,705.85,5158.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 8MM VARIAX TITANIUM SMALL BONE LOCK SELF TAP",SUP-53-23008E,CDM,C1713,HCPCS,0278,RC,,,both,,,738.23,221.47,"KAISER [10500]",Kaiser,,494.61,67,,,,,0,85.86,627.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 10MM 11FR ENDOPROSTHESIS HEPARIN",SUP-VBH101502A,CDM,C1874,HCPCS,0278,RC,,,both,,,23102.10,6930.63,"KAISER [10500]",Kaiser,,15478.41,67,,,,,0,2686.77,19636.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO STRAIGHT 45CM 12FR 4.1MM GUIDING",SUP-G56279,CDM,C1894,HCPCS,0272,RC,,,both,,,472.23,141.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,54.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.92,401.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 13MM APTUS TITANIUM TAPER HAND WRIST CORTICAL 2",SUP-A-5400.13/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"PHCS [10601]",PHCS,,884.52,70,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LEAD 40CM 9FR .035IN WORLEY CSG BRAID CORE TIP PEEL",SUP-WOR-CSG-B1-09,CDM,C1892,HCPCS,0272,RC,,,both,,,2730.00,819,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR ENDOSCOPIC HANDLE AEON MEDIUM STERILE LATEX FREE",SUP-AESH160,CDM,S27200284,LOCAL,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PCP070040150 PLUS US D7L40UL1500",SUP-PCP070040150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 5MM ROUND DIAMOND STERILE LATEX FREE",SUP-5820-012-050D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1164.70,349.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,792,68,,,,,0,135.45,990,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.5MM 22MM PARTIAL THREAD RADIUS DISTAL VOLAR",SUP-TP22000,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",127.17,929.48,"percent of total billed charges",
"SUT MERSILENE 5MM CTX 12IN 2 ARM WOVEN WHITE NONABSORBABLE",SUP-RS22,CDM,S27200284,LOCAL,0272,RC,,,both,,,344.74,103.42,"UHC [10700]","United Healthcare",,218.22,63.3,,,,,0,40.09,293.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 16MM 2.4FR SEGURA HEMISPHERE",SUP-M0063801070,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,175.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASC CLLGN ARTEGRAFT 6MMX40CM",SUP-AG740,CDM,C1768,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ASPIRATION 1400MM 2.2MM 22GA WITHOUT SIDEHOLE 80MM",SUP-NA-U200H-8022,CDM,S27200284,LOCAL,0272,RC,,,both,,,2173.50,652.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,252.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,252.78,1847.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 80MM 4.8FR 9MM BALLOON DILATATION OTW",SUP-H74939032908010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 10MM KNEE LEFT MEDIAL PIVOT ADVANCE II",SUP-KIMP210L,CDM,C1776,HCPCS,0278,RC,,,both,,,6141.00,1842.3,"PHCS [10601]",PHCS,,4298.7,70,,,,,0,714.2,5219.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION PIN PAC A WIRE ACL PCL",SUP-7207738,CDM,C1713,HCPCS,0278,RC,,,both,,,1554.23,466.27,"MULTIPLAN [10600]",Multiplan,,1321.1,85,,,,,0,180.76,1321.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL INTRAMEDULLARY L400MM DIA12MM LEFT FEMORAL GREATER TROC",SUP-04.033.271S,CDM,C1713,HCPCS,0278,RC,,,both,,,12217.14,3665.14,"BLUE CROSS [10001]","Blue Cross PPO",,4789.12,39.2,,957.42,570.23,957.42,28,1420.85,10384.57,"percent of total billed charges",
"INSRT TIBIAL 2 10MM KNEE LEFT MEDIAL PIVOT ADVANCE II",SUP-KIMP210L,CDM,C1776,HCPCS,0278,RC,,,both,,,6141.00,1842.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2818.72,45.9,,,,,0,714.2,5219.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH SURGICAL 90MM 22MM DURAPRO 3MM BARREL REMOVAL",SUP-6262.2133S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +7 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-PCB0000070,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.112,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"CIGNA [10200]",Cigna,,582.96,68,,1831.33,1831.33,1831.33,16,99.7,728.71,"percent of total billed charges",
"HC Cold Agglutinin Screen",PX-302000224,CDM,86156,CPT,0302,RC,,,both,,,920.00,276,"MULTIPLAN [10600]",Multiplan,,782,85,,,,,0,0.01,782,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 V-7 36IN 2 ARM BRAID FIRM PLEDG GREEN",SUP-PX62H,CDM,S27200284,LOCAL,0272,RC,,,both,,,90.60,27.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.54,77.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR ENDOSCOPIC HANDLE AEON MEDIUM STERILE LATEX FREE",SUP-AESH160,CDM,S27200284,LOCAL,0272,RC,,,both,,,1134.00,340.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER PROBE ISOSILK 96X5IN L TIP ANGLED TAPE STRIP GEL",SUP-PC1153,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.81,14.64,"UHC [10700]","United Healthcare",,30.9,63.3,,,,,0,5.68,41.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 35X3IN PRECUT FIBERGLASS ORTHO-GLASS",SUP-OG-335PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,115.54,34.66,"PHCS [10601]",PHCS,,80.88,70,,,,,0,13.44,98.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 1 HIP",SUP-PRTLE021,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"MULTIPLAN [10600]",Multiplan,,16065,85,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM INFINITY SPINE MULTIAXIAL NONSTERILE",SUP-3603512,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,1521.93,481.35,16760.95,30,441.36,3225.75,"percent of total billed charges",
"SCR BONE 1.5MM 12MM TITANIUM CORTICAL HAND SELF TAPPING",SUP-400.812,CDM,C1713,HCPCS,0278,RC,,,both,,,401.94,120.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,115.04,28.62,,,,,0,46.75,341.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2 CP 27IN BRAID ANTIBACTERIAL COATED UNDYED",SUP-VCP195H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fondaprainax",PX-301000072,CDM,80299,CPT,0301,RC,,,both,,,546.00,163.8,"PHCS [10601]",PHCS,,382.2,70,,,,,0,0.01,464.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5F DECA 2-8-2 CS 120CM",SUP-901530,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"NOVANET [10819]",Novanet,,2221.88,75,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 34MM DEGENERATIVE DISC 2 LEVEL ARCHON BONE SPINE",SUP-8787234,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 65CM 6FR COBRA CURVE RENAL TORCON STAINLESS STEEL INNER",SUP-G14408,CDM,C1758,HCPCS,0272,RC,,,both,,,274.92,82.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,31.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.97,233.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD SIELLO S 60-J",SUP-106164,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,260.3,68,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL THK20MM S1 S2 PROXIMAL MODULAR ROTATE HINGE",SUP-64813220,CDM,C1776,HCPCS,0278,RC,,,both,,,6061.65,1818.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,718.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,704.97,5152.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM LCP STAINLESS STEEL LONG THREAD FEMORAL",SUP-207.738,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,297.66,28.62,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"I-GEL, SINGLE USE SUPRAGLOTTIC AIRWAY, SIZE 2",SUP-8202000,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.13,23.74,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,36.32,45.9,,,,,0,9.2,67.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 18MM TARGET XL 360D STD LARGE",SUP-M0036101850,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NALOXEGOL 12.5 MG TABLET",RX-169692,CDM,,,0637,RC,82625-8801-01,NDC,both,1,UN,65.98,19.79,"NOVANET [10819]",Novanet,,49.49,75,,,,,0,7.67,56.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 28CM 6FR .038IN PIGTAIL CURVE TAPER URETER GLIDEX",SUP-M001245760,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,708.98,41.1,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 140MM 125CM 5MM 6FR BILIARY",SUP-G50164,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"MULTIPLAN [10600]",Multiplan,,5176.5,85,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR TUOHY-BORST ANL2 CURVE 55CM 7FR 2.5MM GUIDING",SUP-G30000,CDM,C1894,HCPCS,0272,RC,,,both,,,615.52,184.66,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) ZEBRA 7F 95CM ACCESS SYSTEM BER",SUP-AC7087-095-20-B,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TROCAR LAPAROSCOPIC 100MM 12MM ENDOPATH XCEL SMOOTH SLEEVE",SUP-H12LPR,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC PRIMO MRI PHYSIOCURVE SURESCAN SPRINT QUATTRO",SUP-DVMD3D4,CDM,C1722,HCPCS,0278,RC,,,both,,,56385.00,16915.5,"AETNA [10100]","Aetna HMO/PPO",,44826.08,79.5,,,,,0,6557.58,47927.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Artery Line Cutdown",PX-450000237,CDM,36625,CPT,0450,RC,,,both,,,460.00,138,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,460,,,,,,,67.13,460,"case rate",
"MATRIX TISSUE OVITEX 15X15CM OVINE MONOFILAMENT",SUP-F10244-1520L,CDM,C1781,HCPCS,0278,RC,,,both,,,24580.84,7374.25,"CIGNA [10200]","Cigna Local Plus",,7742.96,31.5,,3096.73,1.00,3096.73,"1 through 10",2858.75,20893.71,"percent of total billed charges",
"CATH SOFT-VU 100CM 5FR SIDEWINDER 2 CURVE ANGIOGRAPHIC",SUP-H787107090075,CDM,C1887,HCPCS,0272,RC,,,both,,,190.36,57.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,78.24,41.1,,,,,0,22.14,161.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 5FR 70CM .018IN 2 LUMEN BASIC KIT GWIRE POWER",SUP-3275355F,CDM,C1751,HCPCS,0272,RC,,,both,,,777.11,233.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,92.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.38,660.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM PROFILE 3D",SUP-680R28,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Open Access",,4391.85,33.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA MEDIAL CONGRUENT 8-9 C-D KNEE",SUP-42512100510,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]",Cigna,,7327.97,68,,5873.17,5873.17,5873.17,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"HC Inj Anes Occipital",PX-510000115,CDM,64405,CPT,0761,RC,,,both,,,2896.00,868.8,"FIRST HEALTH [10303]","First Health",,2316.8,80,,,,,0,336.8,2740.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 6.44IN 8FR 22GA PNEUMOTHORAX CATH RADIOPAQUE NDL",SUP-AK-01500,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,105.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 40MM 80CM 8MM 8FR STRAIGHT VASCULAR COVER",SUP-AVSM08040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]",Cigna,,7308,40,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT MASTERGRAFT KIT VOID FILLER PUTTY 1.5ML",SUP-7600702,CDM,C1713,HCPCS,0278,RC,,,both,,,1518.75,455.62,"MULTIPLAN [10600]",Multiplan,,1290.94,85,,,,,0,176.63,1290.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR INFLATION DEVICE BASIXTOUCH 13IN ANALOG DISPLAY",SUP-IN8152,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.44,105.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.99,299.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.0MM X 15.0MM",SUP-493001512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 31X9X.38MM PRECISION MEDIUM LONG THIN STAINLESS",SUP-2296003125,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.45,67.03,"KAISER [10500]",Kaiser,,149.71,67,,,,,0,25.99,189.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CARDIONYL 5-0 12MM MONOFILAMENT NONABSORBABLE",SUP-721202,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.11,20.73,"UHC [10700]","United Healthcare",,43.75,63.3,,,,,0,8.04,58.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PENTARAY 115CM 7FR 3FR 1MM 4-4-4MM SPACE F CURVE",SUP-D128201,CDM,C1732,HCPCS,0272,RC,,,both,,,13634.40,4090.32,"FIRST HEALTH [10303]","First Health",,10907.52,80,,,,,0,1585.68,11589.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLENIC PROCEDURES WITH MCC",799,MS-DRG,,,,,,,inpatient,,,170144.16,51043.25,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,30059.55,,"Case rate ($28,093.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $26,086.29, add-ons for qualifying new technology services are included. If operating cost exceeds $59,125.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,354.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $26,120.79. The transfer operating threshold is the transfer adjustment factor * $26,086.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,972.25. The transfer capital threshold is the transfer adjustment factor * $1,972.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,8593,132225.76,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,inpatient,,,198611.16,59583.35,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,14075.62,,"Case rate ($13,278.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,330.35, add-ons for qualifying new technology services are included. If operating cost exceeds $45,370.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,314.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $12,346.66. The transfer operating threshold is the transfer adjustment factor * $12,330.35 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $932.23. The transfer capital threshold is the transfer adjustment factor * $932.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,62499.88,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 12MM 144CM 4MM CORONARY STENT",SUP-H7493952812400,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 3.2MM 12MM 7% NIOBIUM 6% ALUMINUM TITANIUM",SUP-04.601.112,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"LENS IOL 0 D +19.5 DIOPTER +3 CYL 13MM 6MM POSTERIOR CHMBR 1",SUP-SN6AT5.195,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FROZEN 180MMX5+ MM",SUP-450636,CDM,S27800098,LOCAL,0278,RC,,,both,,,6201.72,1860.52,"CIGNA [10200]",Cigna,,4217.17,68,,,,,0,721.26,5271.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 80MM 5MM .018IN BALLOON DILATATION",SUP-R51005008L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"MULTIPLAN [10600]",Multiplan,,1675.99,85,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X18X10MM COROENT 10D XL PEEK-OPTIMA XLIF",SUP-6981060,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"AETNA [10100]","Aetna HMO/PPO",,18889.2,79.5,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-42500005801,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6543.3,28.62,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUE FLOW 110CM 3.5CM 20MM 11FR PERFUSION VALVULOPLASTY",SUP-TF0203511,CDM,C1725,HCPCS,0272,RC,,,both,,,11730.00,3519,"PHCS [10601]",PHCS,,8211,70,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 50X40X.25MM RECTANGLE POLYDIOXANONE PDS FACE",SUP-ZFP5,CDM,S27800098,LOCAL,0278,RC,,,both,,,2242.50,672.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,260.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,260.8,1906.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 22MM 31MM MOSAIC CINCH PORCINE STENT HOLDER",SUP-310031,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"PHCS [10601]",PHCS,,19183.5,70,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 260MM STAINLESS STEEL 9 HOLE CABLE BMP BONE ORTHOPEDIC",SUP-350819,CDM,C1713,HCPCS,0278,RC,,,both,,,11695.50,3508.65,"PHCS [10601]",PHCS,,8186.85,70,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D E KNEE LEFT CEMENT KEEL",SUP-42536007101,CDM,C1776,HCPCS,0278,RC,,,both,,,10619.10,3185.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1235,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1235,9026.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR061002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"KAISER [10500]",Kaiser,,14250.1,67,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO 45D 1 RIGHT CURVE 10YD 1.5MM ERGONOMIC",SUP-AR-6069-45R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CIGNA [10200]","Cigna Open Access",,774.3,56.9,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 20MM 125CM 9MM VASCULAR NITINOL ILIAC",SUP-G43834,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross PPO",,1481.76,39.2,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 92CM 1MM 6FR 2MM SPACE D CURVE",SUP-D606DR002RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3150.00,945,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,366.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,366.35,2677.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL DARCO ORTHOLOC ANKLE FUSION PLATING SYSTEM",SUP-98230532,CDM,S27200284,LOCAL,0272,RC,,,both,,,1239.30,371.79,"NOVANET [10819]",Novanet,,929.48,75,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTALINK 135CM 2MM ATHERECTOMY BURR EXCHANGE",SUP-H749393002000,CDM,C1724,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 50MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.450TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,927.89,45.9,,,,,0,235.11,1718.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX SEPRA 4X3IN MONOFILAMENT RESORBABLE",SUP-1200710,CDM,C1781,HCPCS,0278,RC,,,both,,,10490.07,3147.02,"BLUE CROSS [10001]","Blue Cross HMO",,4112.11,39.2,,,,,0,1220,8916.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 7.5CM 120CM 6MM 7FR ENDOPROSTHESIS",SUP-VBHR060702A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5742.58,27,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 11MM KNEE BEARING CRUCIATE RETAIN TRIATHLON",SUP-5530-G-311-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"MULTIPLAN [10600]",Multiplan,,9700.71,85,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR FLOW L160CM INFANT NEONATE",SUP-260177,CDM,S27000186,LOCAL,0270,RC,,,both,,,184.94,55.48,"CIGNA [10200]","Cigna Local Plus",,98.94,53.5,,,,,0,21.51,157.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 500MM 5.5MM RELINE STRAIGHT TITANIUM MAS",SUP-12355500,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 45D NDL SHORT 4IN COLORADO STERILE",SUP-E1134,CDM,S27200284,LOCAL,0272,RC,,,both,,,556.15,166.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,255.27,45.9,,,,,0,64.68,472.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Heterophile Ab Screen",PX-302000058,CDM,86308,CPT,0302,RC,,,both,,,185.25,55.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.54,,"Fee schedule rate ($5.54). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",7.80,7.80,7.80,"1 through 10",0.19,157.46,"fee schedule",
"HC Admin Vacc Sngl",PX-771000001,CDM,90471,CPT,0771,RC,,,both,,,112.41,33.72,"CIGNA [10200]","Cigna Open Access",,63.96,56.9,,,,,0,13.07,112.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL TRIATHLON B CONE KNEE LEFT MEDIAL RIGHT LATERAL",SUP-5549-A-221,CDM,C1776,HCPCS,0278,RC,,,both,,,23621.85,7086.55,"CIGNA [10200]","Cigna Open Access",,7913.32,33.5,,5302.19,4377.88,6578.61,27,2747.22,20078.57,"percent of total billed charges",
"CMPNT FEMORAL ATTUNE CEMENTED POSTERIOR STABILIZE STERILE 6",SUP-150410206,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"BLUE CROSS [10001]","Blue Cross PPO",,8778.19,39.2,,3949.44,3949.44,3949.44,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"LINER ACETABULAR PINNACLE 54MM 47MM HIP 2 MOBILITY",SUP-121854047,CDM,C1776,HCPCS,0278,RC,,,both,,,15870.00,4761,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1880.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1845.68,13489.5,"percent of total billed charges",
"HEAD COMPONENT UNITRAX 43MM END",SUP-6942-6-043,CDM,C1776,HCPCS,0278,RC,,,both,,,16025.25,4807.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4326.82,27,,,,,0,1863.74,13621.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 17.5MM KNEE XLK POSTERIOR LIPPED FIX",SUP-158100117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR CERAMIC PRIMARY BIPOLAR STD HEAD",SUP-98B00100101,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"UHC [10700]","United Healthcare",,6114.78,63.3,,8601.07,8395.67,8601.07,"1 through 10",1123.46,8211,"percent of total billed charges",
"COIL EMBOLIZATION 4CM 2MM .0108IN AXIUM PRIME HELICAL",SUP-APB-2-4-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1039.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 17MM ATLANTIS TITANIUM SPINAL CANCELLOUS",SUP-876-817,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT MICRO NONSTERILE DISPOSABLE",SUP-AR-1320BCNF,CDM,C1713,HCPCS,0278,RC,,,both,,,2559.38,767.81,"NOVANET [10819]",Novanet,,1919.54,75,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Mandible <4v",PX-320000186,CDM,70100,CPT,0320,RC,,,both,,,341.78,102.53,"KAISER [10500]",Kaiser,,228.99,67,,,,,0,39.75,290.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BUTTON 8MM 6CM PASSPORT BUTTON SILICONE CURVE HIP 1",SUP-AR-6592-08-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,34.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE TOTAL POROUS NON HA CONCELOC",SUP-71704612,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"MULTIPLAN [10600]",Multiplan,,19813.5,85,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR CEMENTLESS STD Z1 TITANIUM ALLOY 5",SUP-611201050,CDM,C1776,HCPCS,0278,RC,,,both,,,28967.40,8690.22,"UHC [10700]","United Healthcare",,18336.36,63.3,,8601.07,8395.67,8601.07,"1 through 10",3368.91,24622.29,"percent of total billed charges",
"KIT TRANSITION VENTILATOR NASAL INTERFACE HIGH FLOW L OPTIFL",SUP-OJR416VT,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X11X5MM ALLOCRAFT 5D LORDOSIS CORTICAL",SUP-6183-7-005,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC ULTRASOUND ROTATIONAL SHORT TIP LATEX FREE STERILE",SUP-89900,CDM,C1759,HCPCS,0272,RC,,,both,,,5002.50,1500.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,581.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Afb Pres ID",PX-306000072,CDM,87116,CPT,0306,RC,,,both,,,531.05,159.31,"KAISER [10500]",Kaiser,,355.8,67,,,,,0,0.01,451.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE .5MM 22MM LORENZ CRANIOMAXILLOFACIAL TITANIUM",SUP-017309,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.70,405.81,"BLUE CROSS [10001]","Blue Cross PPO",,530.26,39.2,,957.42,570.23,957.42,28,157.32,1149.8,"percent of total billed charges",
"IMPL BREAST 11.5X12CM 290ML STYLE FF HIGHLY COHESIVE GEL",SUP-FF-410290,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2554.34,45.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sirius Marker",PX-E27800024,CDM,A4648,HCPCS,0278,RC,,,both,,,352.00,105.6,"CIGNA [10200]","Cigna Local Plus",,188.32,53.5,,,,,0,40.94,299.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ARTHROSCOPIC .034IN TROCAR TIP LASER LINE",SUP-AR-8737-39,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"FIRST HEALTH [10303]","First Health",,153.12,80,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 7FR 19CM VESSEL ACCEPTS .035IN GWIRE",SUP-504407X,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.86,31.16,"CIGNA [10200]","Cigna Open Access",,59.1,56.9,,,,,0,12.08,88.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 10MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-310-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]","Cigna Local Plus",,3790.58,31.5,,5372.07,4581.20,7242.98,23,1399.51,10228.56,"percent of total billed charges",
"COIL EMBOLIZATION 27CM 10MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-10027,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"NOVANET [10819]",Novanet,,8792.33,75,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 25MM SPINAL",SUP-7976025,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"KAISER [10500]",Kaiser,,1969.8,67,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON KPA25 CATHETER 25MM UNIPEDICULAR",SUP-KPA25,CDM,S27200284,LOCAL,0272,RC,,,both,,,20790.00,6237,"NOVANET [10819]",Novanet,,15592.5,75,,,,,0,2417.88,17671.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR ACTIS DUOFIX 1 STD OFFSET HIP STERILE",SUP-101011010,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3544.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM ELITE ROUND COARSE DIAMOND 5 STEP NOTCH",SUP-5820-013-030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,502.59,45.9,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS RX 135CM 120MM 5.7-3.9FR 6MM BALLOON",SUP-BD-L60120CR,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"MULTIPLAN [10600]",Multiplan,,815.87,85,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION SLR PTCA DEB 4.5X20MM",SUP-SCA14U-450020D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE POWERTURN FLEX VASCULAR STRAIGHT 300CM 3CM",SUP-1044593,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X6MM ADVANCED LORDOTIC CERVICAL",SUP-7706,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross HMO",,3245.76,39.2,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 20MM REVISION 20 GRIT BLAST SURFACE",SUP-197620140,CDM,C1776,HCPCS,0278,RC,,,both,,,17952.48,5385.74,"AETNA [10100]","Aetna HMO/PPO",,14272.22,79.5,,10981.53,8986.79,12413.38,12,2087.87,15259.61,"percent of total billed charges",
"LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION",RX-20954,CDM,J1955,HCPCS,0636,RC,00517-1045-01,NDC,both,5,ML,323.18,96.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,27.52,,,,,,,8.03,274.7,"fee schedule",
"HOOK SMALL BLUNT 7.25IN NERVE VESSEL RETRACTION KRAYENBUEHL",SUP-58-3035,CDM,S27200284,LOCAL,0272,RC,,,both,,,475.47,142.64,"CIGNA [10200]","Cigna Open Access",,270.54,56.9,,,,,0,55.3,404.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X13MM 9/11MM SPINE CORTICAL FREEZE DRY",SUP-14913,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"AETNA [10100]","Aetna HMO/PPO",,13165.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TOURNIQUET W4.125XL24IN SINGLE PORT SINGLE BLADDER CYLI",SUP-60-7075-104R,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.73,54.22,"CIGNA [10200]","Cigna Local Plus",,96.69,53.5,,,,,0,21.02,153.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM 37.1MM 30.9MM MITRAL HOLDER",SUP-4450M32,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"NOVANET [10819]",Novanet,,8538.75,75,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 42MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661042,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,151.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",151.86,1109.86,"percent of total billed charges",
"DEVICE WATCHMAN FLX PRO 27MM CLSR LEFT ATRIAL APPENDAGE",SUP-M635WU60270,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM PRIMARY CEMENT DISTAL BULLET TIP SYNERGY",SUP-71316210,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6085.33,28.62,,,,,0,2472.83,18073.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 28CM 8FR 2.1FR POLARIS ULTRA NAUTILUS .035IN 2",SUP-M006192154050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]","Cigna Open Access",,683.13,,,,,,,139.63,1020.49,"percent of total billed charges",
"CATH PACIFIC PLUS 130CM 80MM 4FR 2MM LOW PROFILE BALLOON",SUP-PCP020080130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 12MM BALLOON",SUP-U3575126,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP MULTIHOLE R3 STD STERILE",SUP-71338669,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"BLUE CROSS [10001]","Blue Cross HMO",,6227.8,39.2,,5311.50,4717.44,5388.59,31,1847.69,13504.16,"percent of total billed charges",
"INSRT TIBIAL 6 8MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650608,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"KAISER [10500]",Kaiser,,8795.26,67,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN .045IN STEINMANN ORTHOPEDIC STAINLESS STEEL",SUP-KM173-29-45,CDM,C1713,HCPCS,0278,RC,,,both,,,59.29,17.79,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,27.21,45.9,,,,,0,6.9,50.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 30IN 21FR FEMUR PERCUTANEOUS ADULT 3/8IN KIT",SUP-96880-021,CDM,S27200284,LOCAL,0272,RC,,,both,,,3022.88,906.86,"MULTIPLAN [10600]",Multiplan,,2569.45,85,,,,,0,351.56,2569.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TIBIAL 75MM 20MM UNIVERSAL KNEE FLUTED",SUP-867419,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5508.41,68,,,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 92CM 4MM 6FR 2-5-2MM SPACE D CURVE",SUP-D6TCDL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,576.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION|DISCARDED DRUG NOT ADMINISTE",RX-3037,CDM,J3010,HCPCS,0636,RC,00641-6247-25,NDC,both,1,ML,17.67,5.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",JW,1.4,,"Fee schedule rate ($1.40). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.28,15.02,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-9 CD 14MM KNEE LEFT CRUCIATE RETAINING",SUP-42512000414,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS [10001]","Blue Cross PPO",,4224.36,39.2,,3949.44,3949.44,3949.44,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION",RX-3497,CDM,J1596,HCPCS,0636,RC,00143-9681-01,NDC,both,2,ML,21.74,6.52,"BLUE CROSS [10001]","Blue Cross HMO",,2.14,,,,,,,1.79,18.48,"fee schedule",
"CAP LOCKING 5.5MM CREO SPINAL NONSTERILE",SUP-1119.0000,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,285.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",279.89,2045.61,"percent of total billed charges",
"SPACER SPINAL 18X6MM HEDRON C 7D 15MM STERILE LATEX FREE",SUP-1211.5816S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"KAISER [10500]",Kaiser,,4160.7,67,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBO-ELITE 150CM 1.4MM .055IN .056IN ATHERECTOMY",SUP-414-151,CDM,C1885,HCPCS,0272,RC,,,both,,,18868.50,5660.55,"NOVANET [10819]",Novanet,,14151.38,75,,,,,0,2194.41,16038.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM TITANIUM T15 FULL THREAD HEXALOBE",SUP-AR-8935-32,CDM,C1713,HCPCS,0278,RC,,,both,,,486.00,145.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,139.09,28.62,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR STRAIGHT 145CM 7CM .035IN",SUP-46-523,CDM,C1769,HCPCS,0272,RC,,,both,,,204.45,61.33,"UHC [10700]","United Healthcare",,129.42,63.3,,,,,0,23.78,173.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 5.5IN CASTROVIEJO SERRATE INSRT LOCK NDL TUNGSTEN",SUP-32-441,CDM,S27200284,LOCAL,0272,RC,,,both,,,1540.46,462.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE FLOPPY II EXTRA SPORT VASCULAR STRAIGHT 300",SUP-22359M-901,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEMOSTAT ABSORBABLE 8X4IN SURGICEL",SUP-1952S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1216.66,365,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN JUDKINS",SUP-77808100,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT FRACTURE STABILIT LONG COMPLETE",SUP-3506,CDM,S27200284,LOCAL,0272,RC,,,both,,,16905.00,5071.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH STERLING SL 150CM 120MM 2MM BALLOON DILATATION PEBAX",SUP-H74939147201210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LASSOSTARNAV,10P,25MM DIA LOOP",SUP-D140403,CDM,C1732,HCPCS,0272,RC,,,both,,,7286.40,2185.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH INTRO GREEN 23CM 6FR BRITE TIP CANN INTERVENTIONAL",SUP-401623M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ANGIOSCULPT XL 155CM 40MM 5FR 3.5MM BALLOON DILATATION",SUP-2155-3540,CDM,C1725,HCPCS,0272,RC,,,both,,,6865.50,2059.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH R2P METACROSS 200CM 80MM 5MM BALLOON DILATATION",SUP-BD-P50080ER,CDM,C1769,HCPCS,0272,RC,,,both,,,2028.75,608.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DISC INTERVERTEBRAL PRESTIGE SPINE",SUP-6972650,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CRYOSURGICAL RED 1.5MM ICEROD CX VISUAL-ICE PRESICE",SUP-FPRPR3533,CDM,C2618,HCPCS,0272,RC,,,both,,,13110.00,3933,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5388.21,41.1,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM STABILIT SHORT BONE CEMENT DELIVERY",SUP-DF-4011S,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT BUMPER GMRS NEUTRAL PROXIMAL BUMPER IMPANT",SUP-6481-2-130,CDM,C1776,HCPCS,0278,RC,,,both,,,3543.75,1063.12,"BLUE CROSS [10001]","Blue Cross PPO",,1389.15,39.2,,3949.44,3949.44,3949.44,"1 through 10",412.14,3012.19,"percent of total billed charges",
"BLADE ANGLE MICRO SPEAR ROUND SURGICAL MYRINGOTOMY STERILE",SUP-70130794,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.66,22.1,"NOVANET [10819]",Novanet,,55.25,75,,,,,0,8.57,62.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IV PLASMA-LYTE A VIAFLEX MULTIPLE ELECTROLYTE 1L LATEX",SUP-2B2544X,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.24,37.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,84.48,68,,,,,0,14.45,105.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 45MM RELINE-O 2S SPINE POLYAXIAL NONSTERILE",SUP-13014545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 5.5MM CURVE NONSTERILE",SUP-1555501090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"GRAFT ENDOVASCULAR 156MM 24-16MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1624C156E,CDM,C1876,HCPCS,0278,RC,,,both,,,40320.00,12096,"UHC [10700]","United Healthcare",,25522.56,63.3,,,,,0,4689.22,34272,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL LARGE 4.25IN NECK 2 PIECE SEMIRIGID",SUP-11344,CDM,S27000186,LOCAL,0270,RC,,,both,,,129.54,38.86,"FIRST HEALTH [10303]","First Health",,103.63,80,,,,,0,15.07,110.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES 145CM 40MM 4MM .014IN BALLOON DILATATION OTW",SUP-39134-40401,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NEW LOCK OVERLAP ATLANTIS VISION BONE SPINAL",SUP-7200167,CDM,C1713,HCPCS,0278,RC,,,both,,,4620.00,1386,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,547.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,537.31,3927,"percent of total billed charges",
"GRAFT VASCULAR 60CM 8MM GORE STD WALL HEPARIN PROPATEN PTFE",SUP-H080060A,CDM,C1768,HCPCS,0278,RC,,,both,,,11378.10,3413.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1323.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1323.27,9671.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN AL.75 CURVE GUIDING CORONARY",SUP-LA7AL75SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,266.22,68,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP OCCL BALLOON AUDIO INDCTR ALERT ELECTROSURGERY DEVICE",SUP-KC-ARCH-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"CIGNA [10200]","Cigna Local Plus",,613.02,53.5,,,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REDUC LAPAROSCOPIC 8-12MM DA VINCI XI ENDOWRIST CANN",SUP-470381,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.10,68.73,"CIGNA [10200]","Cigna Local Plus",,122.57,53.5,,,,,0,26.64,194.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAMINA 1417100 EPIDISC 2PK OTOLOGIC 8MM",SUP-1417100,CDM,C1763,HCPCS,0278,RC,,,both,,,698.10,209.43,"BLUE CROSS [10001]","Blue Cross PPO",,273.66,39.2,,,,,0,81.19,593.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF UROLOGICAL STRAIGHT 145CM 3.5CM",SUP-M0066401081,CDM,C1769,HCPCS,0272,RC,,,both,,,55.76,16.73,"KAISER [10500]",Kaiser,,37.36,67,,,,,0,6.48,47.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPLANT 12.5CM NATRELLE INSPIRA P4.2CM MODERATE PROFIL",SUP-MSZ-M345,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,107.56,68,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 75MM 18MM PRESS FIT UNIVERSAL FLUTE KNEE",SUP-867418,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,959.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 30MM 12MM STAINLESS STEEL 1.1MM LONG THREAD",SUP-02.226.130,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"MULTIPLAN [10600]",Multiplan,,1398.42,85,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE NAVIGATION SYSTEM 5IN TRUDI 70D DISTAL TIP SENSOR LOW",SUP-TDP0705,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"PHCS [10601]",PHCS,,1548.75,70,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X9-6.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-14809,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1757.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION ATTUNE TIBIAL BASE",SUP-254500119,CDM,C1713,HCPCS,0278,RC,,,both,,,430.65,129.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,292.84,68,,,,,0,50.08,366.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vrtplsty Lumb/Sac W Img",PX-361000376,CDM,22511,CPT,0361,RC,,,both,,,9378.00,2813.4,"CIGNA [10200]","Cigna Local Plus",,7882,,"Case rate ($7,882). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1090.66,9378,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 38CM LEFT TROCHANTERIC INTRAMEDULLARY 125D",SUP-456.399S,CDM,C1713,HCPCS,0278,RC,,,both,,,12838.83,3851.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3466.48,27,,,,,0,1493.16,10913.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 5MM SCHANZ STERILE",SUP-20070105,CDM,C1713,HCPCS,0278,RC,,,both,,,599.40,179.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,407.59,68,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM 13MM PRESS FIT REDUCE PROXIMAL PROFILE",SUP-192513,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"BLUE CROSS [10001]","Blue Cross HMO",,9309.4,39.2,,5311.50,4717.44,5388.59,31,2761.95,20186.21,"percent of total billed charges",
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 20MM 6FR 2.75MM",SUP-H7493926720270,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 5IN 2.8MM QUICK RELEASE STERILE",SUP-MS-DC28,CDM,S27200284,LOCAL,0272,RC,,,both,,,696.60,208.98,"NOVANET [10819]",Novanet,,522.45,75,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NOVII FETAL MNTR PATCH",SUP-107-PT-004-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,395.66,118.7,"CIGNA [10200]","Cigna Open Access",,225.13,56.9,,,,,0,46.02,336.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 36MM 14MM STAINLESS STEEL CANNULATED STERILE",SUP-121836,CDM,C1713,HCPCS,0278,RC,,,both,,,2006.40,601.92,"AETNA [10100]","Aetna HMO/PPO",,1595.09,79.5,,1521.93,481.35,16760.95,30,233.34,1705.44,"percent of total billed charges",
"SUT CHROMIC 1 CTX 36IN MONOFILAMENT BROWN ABSORBABLE",SUP-905H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 TWINFIX ULTRABRAID COBRAIDED PEEK-OPTIMA",SUP-72202600,CDM,C1713,HCPCS,0278,RC,,,both,,,1724.63,517.39,"KAISER [10500]",Kaiser,,1155.5,67,,,,,0,200.57,1465.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM ORTHOLOC TITANIUM CORTICAL LOCK",SUP-59215540,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,260.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,255.57,1867.88,"percent of total billed charges",
"SCR BONE 4.5MM 17MM HELIX R SPINE SELF TAP VARIABLE ANGLE",SUP-7805117,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 10MM 1.5MM",SUP-SPL15010X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM ATTUNE 3 KNEE DISTAL CEMENT REVISION STERILE",SUP-154703001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,719.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 65CM 4FR CB1 CURVE ANGIOGRAPHIC STAINLESS STEEL",SUP-465382CB1,CDM,C1769,HCPCS,0272,RC,,,both,,,108.75,32.62,"MULTIPLAN [10600]",Multiplan,,92.44,85,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL PERCUTANEOUS 16CM 18GA NAVIGUIDE ACCESS ADJUSTABLE",SUP-M0067001320,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.70,104.61,"KAISER [10500]",Kaiser,,233.63,67,,,,,0,40.55,296.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.464,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",348.9,2550,"percent of total billed charges",
"SYSTEM IDENTITY IMPRINT TKR KNEE POSTERIOR STABILIZE JIG",SUP-TPS-000-D002,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,370.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4+ 10MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS4P10L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"UHC [10700]","United Healthcare",,6577.76,63.3,,8601.07,8395.67,8601.07,"1 through 10",1208.52,8832.69,"percent of total billed charges",
"CATH SABERX 150CM 300MM 4MM BALLOON DILATATION RAPID",SUP-47540300M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,832.28,41.1,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 90CM 150MM 3.9-4.2FR 5MM BALLOON",SUP-PCU050150090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PHCS [10601]",PHCS,,861.84,70,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLUCAGON (HUMAN RECOMBINANT) 1 MG/ML INJECTION SUPERORDERABLE",RX-408807,CDM,J1611,HCPCS,0636,RC,63323-0594-03,NDC,both,1,UN,905.40,271.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,385.18,,,,,,,107.29,769.59,"fee schedule",
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 8FR .088IN",SUP-588892,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 6MM HIGH VOLUME LOW PRESSURE TAPER CUFF",SUP-5-12612,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,71.51,41.1,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 73.5X12.5MM HALL THK.6MM RECIPROCATE",SUP-5052-334,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.78,26.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.44,76.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mopath Procedure Level 1",PX-309000093,CDM,81400,CPT,0310,RC,,,both,,,1109.85,332.95,"NOVANET [10819]",Novanet,,832.39,75,,,,,0,0.01,943.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT RETRIEVER 20MM 3MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0033PK32021001,CDM,S27200284,LOCAL,0272,RC,,,both,,,20045.55,6013.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2375.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2331.3,17038.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SMART CONTROL MICROMARKER 30MM 120CM 10MM VASCULAR",SUP-C10030ML,CDM,C1876,HCPCS,0278,RC,,,both,,,4657.50,1397.25,"BLUE CROSS [10001]","Blue Cross HMO",,1825.74,39.2,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC",840,MS-DRG,,,,,,,inpatient,,,99834.11,29950.23,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,21470.92,,"Case rate ($20,066.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $18,632.90, add-ons for qualifying new technology services are included. If operating cost exceeds $51,672.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,790.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $18,657.54. The transfer operating threshold is the transfer adjustment factor * $18,632.90 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,408.74. The transfer capital threshold is the transfer adjustment factor * $1,408.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,80675.17,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 8.2MM 135MM 22MM DHS/DCS STAINLESS STEEL",SUP-280.35,CDM,C1713,HCPCS,0278,RC,,,both,,,2264.18,679.25,"CIGNA [10200]","Cigna Open Access",,1288.32,56.9,,1144.80,304.56,2275.09,66,263.32,1924.55,"percent of total billed charges",
"BRACE ORTHOPEDIC 10IN REGULAR ANKLE LOW PROFILE ADJUSTABLE",SUP-11181,CDM,S27000186,LOCAL,0270,RC,,,both,,,115.80,34.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.47,98.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 12MM 12MM RETRACTION BLUNT ELASTIC STAY LONE STAR",SUP-3350-8G,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.91,23.07,"UHC [10700]","United Healthcare",,48.68,63.3,,,,,0,8.94,65.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X10MM PRECISION 7D TRAPEZOID SPINE",SUP-7410,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 25CM 8FR PIGTAIL CURVE NEPHRSTMY FLEXIMA POLYURETHANE",SUP-M001271770,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DRILL PATHWAY PACK QUICK",SUP-217842010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1526.85,458.05,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD EMG I-PAS III DIAMOND DISPOSABLE NONSTERILE LATEX",SUP-2010028,CDM,S27000186,LOCAL,0270,RC,,,both,,,1650.00,495,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CIRCAID UPPER LEG REDUCTION KIT- LONG, WIDE",SUP-25302317,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 100MM 5MM BALLOON DILATATION STERILE LATEX",SUP-595010022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SEEKER 135CM SPRT HYDROPHILIC PERIPHERAL RADIOPAQUE",SUP-SK13514,CDM,C1887,HCPCS,0272,RC,,,both,,,1498.50,449.55,"PHCS [10601]",PHCS,,1048.95,70,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 54MM STAINLESS STEEL 2.4MM SCR 6 HOLE HEAD 3 HOLE",SUP-02.111.631S,CDM,C1713,HCPCS,0278,RC,,,both,,,4217.63,1265.29,"FIRST HEALTH [10303]","First Health",,3374.1,80,,,,,0,490.51,3584.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION MEDIUM COMBINATION SELF HOLDING CLIP",SUP-390.031,CDM,S27000186,LOCAL,0270,RC,,,both,,,3469.20,1040.76,"AETNA [10100]","Aetna HMO/PPO",,2758.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,403.47,2948.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STOCKING COMPRESSION MEDIUM TUBULAR SOFT TENSOGRIP",SUP-13201,CDM,S27000186,LOCAL,0270,RC,,,both,,,274.83,82.45,"AETNA [10100]","Aetna HMO/PPO",,218.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.96,233.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE 2.8CM ROUND 240CM 2.4MM CAPTIVATOR II LOOP SHEATH",SUP-M00561243,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.04,23.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.19,67.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 45X6MM THK.61MM SAGITTAL STERILE LATEX FREE",SUP-SM-4506,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.190 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.190,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM AXSOS 3 TITANIUM CORTICAL NONSTERILE",SUP-661430,CDM,C1713,HCPCS,0278,RC,,,both,,,289.54,86.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,196.89,68,,,,,0,33.67,246.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN EXTRA",SUP-77805600,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Bartholins Gland Abscess",PX-450000283,CDM,56420,CPT,0450,RC,,,both,,,819.50,245.85,"CIGNA [10200]","Cigna Open Access",,819.5,,,,,,,67.13,819.5,"case rate",
"VALVE MITRAL 29MM STD HEART MECHANICAL",SUP-500DM29,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9450,40,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8MM 285MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-408-285,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 8MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT083040A,CDM,C1768,HCPCS,0278,RC,,,both,,,10267.20,3080.16,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1194.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1194.08,8727.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAXCESS MAS TLIF 2 KIT ACCESS",SUP-3500017,CDM,S27200284,LOCAL,0272,RC,,,both,,,8970.00,2691,"MULTIPLAN [10600]",Multiplan,,7624.5,85,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE UNICORTICAL DOWEL ALLOGRAFT FREEZE DRIED 14-40MM",SUP-400201,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"BLUE CROSS [10001]","Blue Cross PPO",,1663.45,39.2,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM OSSEOFLEX CD-H BONE CEMENT HYDRAULIC DELIVERY",SUP-OF-0348,CDM,S27200284,LOCAL,0272,RC,,,both,,,5326.80,1598.04,"PHCS [10601]",PHCS,,3728.76,70,,,,,0,619.51,4527.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC 5MM ENDOWRIST CROCODILE",SUP-428059,CDM,S27000186,LOCAL,0270,RC,,,both,,,963.90,289.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,655.45,68,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD CONTOUR TITANIUM 3 HOLE ANATOMIC GRAFT WINDOW BONE",SUP-AR-8916VSR-03,CDM,C1713,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1569.95,28.62,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 80MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.438,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"NOVANET [10819]",Novanet,,1038.1,75,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE EZDILATE 15 ATM INFLATION 60CC BALLOON SYR LOCK",SUP-MAJ-1740,CDM,S27000186,LOCAL,0270,RC,,,both,,,304.50,91.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,36.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUPHENAZINE 2.5 MG TABLET",RX-3220,CDM,,,0637,RC,24979-0137-01,NDC,both,1,UN,25.70,7.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.56,41.1,,,,,0,2.99,21.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END 5MM TIBIAL T40 STARDRIVE RECESS EXT CANNULATED",SUP-04.004.001,CDM,C1713,HCPCS,0278,RC,,,both,,,1399.36,419.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,165.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,162.75,1189.46,"percent of total billed charges",
"HC C Telopeptide Crosslinks",PX-301000153,CDM,82523,CPT,0301,RC,,,both,,,697.30,209.19,"MULTIPLAN [10600]",Multiplan,,592.71,85,,,,,0,0.01,592.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 2.50 X 28 MM RX FDA",SUP-1203250-28,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]",Cigna,,6900,40,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 8.25MM STORZ UNIVERSAL STAINLESS STEEL","SUP-E3096 8.25",CDM,S27200284,LOCAL,0272,RC,,,both,,,504.23,151.27,"CIGNA [10200]",Cigna,,342.88,68,,,,,0,58.64,428.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 28MM COCR",SUP-VAL-20280-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,969.41,68,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE ROD ORTHOPEDIC 230MM 2.5MM STAINLESS STEEL STOP TROCAR",SUP-03.019.026S,CDM,S27200284,LOCAL,0272,RC,,,both,,,813.89,244.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,96.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.66,691.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 24CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155242180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRANSFORM 10MM 5MM BALLOON OCCLUSION 1 LUMEN COMPLIANT",SUP-M003SRC05100,CDM,C1725,HCPCS,0272,RC,,,both,,,11760.02,3528.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1393.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1367.69,9996.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM PRIMARY ANTHOLOGY POROUS 131D 11 STD",SUP-71356011,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13621.01,41.1,,6417.48,6417.48,6417.48,"1 through 10",3854.32,28169.98,"percent of total billed charges",
"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC",027,MS-DRG,,,,,,,inpatient,,,164317.86,49295.36,"UHC [10700]","United Healthcare",,73658.59,,"Fee schedule rate ($73,658.59). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,15649.71,73658.59,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 2.5MM BALLOON DILATATION STERILE LATEX",SUP-592515022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE 12IN MERITRANS BONDED PIGITAIL CABLE 1 WAY",SUP-K11-00099,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"UHC [10700]","United Healthcare",,49.56,63.3,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 12MM APTUS TRILOCK TITANIUM FOREFOOT MIDFOOT",SUP-A-5450.12/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"CIGNA [10200]",Cigna,,1096.09,68,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 8MM 7FR 1-7-4MM SPACE J CURVE ABLATION",SUP-NS7TCJ8L174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"PHCS [10601]",PHCS,,11109,70,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ANKLE SPORTS LACE UP M",SUP-AB2900-14,CDM,S27000186,LOCAL,0270,RC,,,both,,,108.05,32.41,"CIGNA [10200]","Cigna Open Access",,61.48,56.9,,,,,0,12.57,91.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 24FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0167SI24,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.45,32.23,"AETNA [10100]","Aetna HMO/PPO",,85.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.5,91.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 5 14MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620514,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PHCS [10601]",PHCS,,7877.73,70,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +26 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030260,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,336.14,28.62,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM .02IN 8MM PENUMBRA COIL 400 RUBY",SUP-RBY4C0860,CDM,S27800098,LOCAL,0278,RC,,,both,,,7098.00,2129.4,"BLUE CROSS [10001]","Blue Cross PPO",,2782.42,39.2,,,,,0,825.5,6033.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 95CM 3.9-5.2FR 2.6FR 6CM SPACE LEFT VENTRICULAR",SUP-4675,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]",Cigna,,3812.76,68,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB SKIN 16X6CM STRATTICE PORCINE DERMAL MATRIX FIRM PATCH",SUP-0616002,CDM,Q4130,HCPCS,0636,RC,,,both,,,16063.20,4818.96,"KAISER [10500]",Kaiser,,10762.34,67,,,,,0,1903.49,13653.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG THK3.3CM SMALL 10X7.5CM SENSATRAC PAD DRAPE HYDROPHOBIC",SUP-M8275051/5,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.63,88.39,"CIGNA [10200]","Cigna Local Plus",,157.63,53.5,,,,,0,34.27,250.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 4.75MM CD HORIZON SOLERA PERCUTANEOUS CCM",SUP-641000070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"DEVICE MENISCAL CINCH II SUTURING DEPTH STOP",SUP-AR-4501,CDM,C1713,HCPCS,0278,RC,,,both,,,3110.63,933.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,890.26,28.62,,,,,0,361.77,2644.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM MAXLOCK EXTREME FOOT ANKLE NONLOCK",SUP-MFT-011-35-14,CDM,C1713,HCPCS,0278,RC,,,both,,,1239.30,371.79,"MULTIPLAN [10600]",Multiplan,,1053.41,85,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5INX8MM OSTEOTOM LONG MRI STERILE LATEX FREE",SUP-47998602127,CDM,S27200284,LOCAL,0272,RC,,,both,,,996.30,298.89,"FIRST HEALTH [10303]","First Health",,797.04,80,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 59MM 135CM 6MM 160CM",SUP-M001712070,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2419.11,28.62,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DESOXIMETASONE 0.25 % TOPICAL CREAM",RX-2296,CDM,,,0250,RC,68180-0950-01,NDC,both,15,GR,366.55,109.96,"KAISER [10500]",Kaiser,,245.59,67,,,,,0,42.63,311.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE BIOPSY GI ENDOSCOPY STERILE DISPOSABLE",SUP-MAJ-419,CDM,S27200284,LOCAL,0272,RC,,,both,,,420.91,126.27,"NOVANET [10819]",Novanet,,315.68,75,,,,,0,48.95,357.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X6MM ADVANCED CONVEX SPINE",SUP-17806,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]",Cigna,,5630.4,68,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trichinella Antibody",PX-302000265,CDM,86784,CPT,0302,RC,,,both,,,97.00,29.1,"MULTIPLAN [10600]",Multiplan,,82.45,85,,,,,0,0.1,82.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +14 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.140,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"FIRST HEALTH [10303]","First Health",,276,80,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17.5MM 25MM HANCOCK II ULTRA CINCH PORCINE",SUP-T505U225,CDM,S27800098,LOCAL,0278,RC,,,both,,,21420.00,6426,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5783.4,27,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drsg Sorbion Sorbact 4x8",PX-E27200375,CDM,E27200375,LOCAL,0272,RC,,,both,,,209.00,62.7,"AETNA [10100]","Aetna HMO/PPO",,166.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.31,177.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 120CM 8MM 9FR STRAIGHT VASCULAR",SUP-AVSL08100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]",Cigna,,7308,40,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32MMX12MM X-PAC PARALLEL",SUP-EI2449P,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 5.5CM AVANTI ENDOVASCULAR GREEN ACCEPTS",SUP-402606R,CDM,C1894,HCPCS,0272,RC,,,both,,,50.03,15.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.82,42.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 20MM",SUP-SPL35020X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 15D 58MM 32MM MARATHON HIP STERILE",SUP-121932258,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,961.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,943.3,6894.31,"percent of total billed charges",
"X-C PUMP PACK",SUP-76800-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,4736.85,1421.05,"FIRST HEALTH [10303]","First Health",,3789.48,80,,,,,0,550.9,4026.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SURGICAL 4.7X3.1IN SPRING OPEN BIORESORBABLE SELF",SUP-5950030,CDM,C1781,HCPCS,0278,RC,,,both,,,2250.00,675,"KAISER [10500]",Kaiser,,1507.5,67,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 22GA 15CM CANN SERRATE EDGE FRANSEEN LUNG STERILE",SUP-G01268,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.10,58.23,"PHCS [10601]",PHCS,,135.87,70,,,,,0,22.57,164.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER PACING LEAD ACUITY 6FR LONG",SUP-667469-001,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FROZEN 80MMX5+ MM",SUP-450620,CDM,S27800098,LOCAL,0278,RC,,,both,,,4893.48,1468.04,"CIGNA [10200]","Cigna Local Plus",,2618.01,53.5,,,,,0,569.11,4159.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 33MM 26.1MM MASTERS SERIES 85D STD SUPRA",SUP-33MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"MULTIPLAN [10600]",Multiplan,,24751.35,85,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMVIA EDGE HF-T QP",SUP-460162,CDM,C2621,HCPCS,0275,RC,,,both,,,25200.00,7560,"AETNA [10100]","Aetna HMO/PPO",,20034,79.5,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 70CM 15MM 4FR 6 WIRE STONE UROLOGY",SUP-GU6359,CDM,S27200284,LOCAL,0272,RC,,,both,,,479.36,143.81,"CIGNA [10200]","Cigna Open Access",,272.76,56.9,,,,,0,55.75,407.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD 70CM 6FR URETERAL POLYURETHANE CONE TIP ADPTR KINK",SUP-138010,CDM,C1758,HCPCS,0272,RC,,,both,,,103.05,30.91,"NOVANET [10819]",Novanet,,77.29,75,,,,,0,11.98,87.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP MANIP LARGE CONTOUR TAPER POLYCARBONATE THIMBLE LIKE",SUP-LH-SCOLPO-LRG,CDM,S27200284,LOCAL,0272,RC,,,both,,,1352.70,405.81,"UHC [10700]","United Healthcare",,856.26,63.3,,,,,0,157.32,1149.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 42MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.215,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,103.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,101.55,742.2,"percent of total billed charges",
"INSRT TIBIAL 2 22MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G222,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6800,68,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 56MM 36MM ALTRX HIP",SUP-122136156,CDM,C1776,HCPCS,0278,RC,,,both,,,6814.08,2044.22,"CIGNA [10200]","Cigna Open Access",,3877.21,56.9,,5302.19,4377.88,6578.61,27,792.48,5791.97,"percent of total billed charges",
"CATH TREK 145CM 25MM 3.25MM ULTRA LOW PROFILE BALLOON",SUP-1012275-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP IDENTITY STEM/AUGMENTED GLENOID/PREMIUM POST/IDENTITY TI",SUP-98000900265,CDM,C1776,HCPCS,0278,RC,,,both,,,42525.00,12757.5,"PHCS [10601]",PHCS,,29767.5,70,,,,,0,4945.66,36146.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL RESTORELLE SMARTMESH 27X4CM NONPALPABLE Y FLAT",SUP-501430,CDM,C1781,HCPCS,0278,RC,,,both,,,8645.70,2593.71,"AETNA [10100]","Aetna HMO/PPO",,6873.33,79.5,,,,,0,1005.49,7348.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOCEL PRO CELLULAR BONE MATRIX 1CC SMALL",SUP-5016001,CDM,C1713,HCPCS,0278,RC,,,both,,,3967.50,1190.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2697.9,68,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Scr Mammo Uni Incl Cad",PX-403000007,CDM,77067,CPT,0403,RC,,,both,,,722.12,216.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,83.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,83.98,613.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVETIRACETAM 500 MG TABLET, IMMEDIATE RELEASE",RX-26817,CDM,,,0637,RC,51079-0821-01,NDC,both,1,UN,17.68,5.3,"CIGNA [10200]","Cigna Local Plus",,9.46,53.5,,,,,0,2.06,15.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN INTERNAL MAMMARY ARTERY CURVE",SUP-DXT5IMA,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 10MM 24MM INSET 10D SHOULDER REVERSE STERILE",SUP-2R1T241010,CDM,C1776,HCPCS,0278,RC,,,both,,,15683.01,4704.9,"UHC [10700]","United Healthcare",,9927.35,63.3,,8601.07,8395.67,8601.07,"1 through 10",1823.93,13330.56,"percent of total billed charges",
"GWIRE MERIT MAK VASCULAR 40CM .018IN NITINOL PLATINUM",SUP-MAK001N,CDM,C1894,HCPCS,0272,RC,,,both,,,197.06,59.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,134,68,,,,,0,22.92,167.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +16 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.160,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,345.41,28.62,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 MEDIUM 28MM HIP ACETABULAR BIOLOX",SUP-00877502802,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1168.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1146.57,8379.91,"percent of total billed charges",
"STPLR INTERNAL 30X2.5MM TITANIUM VASCULAR ENDOSCOPIC LINEAR",SUP-TX30V,CDM,S27200284,LOCAL,0272,RC,,,both,,,2001.38,600.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,822.57,41.1,,,,,0,232.76,1701.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY 25CM 18GA BARD MARQUEE CORE ENHANCE TROCAR TIP",SUP-MQ1825,CDM,S27200284,LOCAL,0272,RC,,,both,,,514.35,154.3,"CIGNA [10200]",Cigna,,349.76,68,,,,,0,59.82,437.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 60MM ARCOS A STD OFFSET HIP TITANIUM MODULAR",SUP-11301301,CDM,C1776,HCPCS,0278,RC,,,both,,,39453.12,11835.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16215.23,41.1,,6417.48,6417.48,6417.48,"1 through 10",4588.4,33535.15,"percent of total billed charges",
"PASSER SMARTSTITCH CNCT MAGNUM WIRE ARTHROSCOPIC SUT",SUP-OM-8175,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"PHCS [10601]",PHCS,,1260,70,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8MM 12/14 TAPER 36MM HIP COCR SPECTRON EF",SUP-71303608,CDM,C1776,HCPCS,0278,RC,,,both,,,10236.15,3070.84,"BLUE CROSS [10001]","Blue Cross HMO",,4012.57,39.2,,5311.50,4717.44,5388.59,31,1190.46,8700.73,"percent of total billed charges",
"CAP SYSTEM TKR VIVACIT-E FEMUR PATELLA CMPNT",SUP-98000210020,CDM,C1776,HCPCS,0278,RC,,,both,,,20160.00,6048,"PHCS [10601]",PHCS,,14112,70,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BMT SPLINED KNEE STM V2 13X120",SUP-148316,CDM,C1776,HCPCS,0278,RC,,,both,,,11903.88,3571.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4892.49,41.1,,6417.48,6417.48,6417.48,"1 through 10",1384.42,10118.3,"percent of total billed charges",
"CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET, IMMEDIATE RELEASE",RX-9406,CDM,,,0637,RC,72888-0106-01,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) REPRIEVE SYSTEM URINE COLLECTION SET / STERILE",SUP-AC00002,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE FEEDING 16FR 20ML SILICONE GASTROSTOMY WITH Y PORT KANG",SUP-8884720163,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.27,54.38,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR",276,MS-DRG,,,,,,,inpatient,,,217382.44,65214.73,"CIGNA [10200]","Cigna Open Access",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 46.8%. Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 20MM 4MM BALLOON DILATATION DURATRAC",SUP-NCEUP4020X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 356MM 5MM 126MM 3 FLUTED QUICK COUPLING CALIBRATED",SUP-03.008.008,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 60CM .018IN 6FR MAK-NV 3MM J PLATINUM STAINLESS",SUP-MAK-NV-008,CDM,C1894,HCPCS,0272,RC,,,both,,,592.84,177.85,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PDS PLUS 6-0 RB-2 30IN 2 ARM ANTIBACTERIAL VIOLET",SUP-PDP149H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LINE MNTR ADULT 2 PURPOSE CIRCUIT ETCO2 INTERMEDIATE FILTER",SUP-989803129751,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.32,40.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT CARDIOVASCULAR 60CM 7MM THORAX KNIT SOFT FLEXIBLE SEAL",SUP-M002020952070,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ROUND 9.5CM GELPOINT TRANSVAGINAL ACCESS PLATFORM",SUP-C2A12,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 15MM 3MM BALLOON DILATATION STERILE",SUP-230-153-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 32MM TI",SUP-SPL-35320-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,155.43,1136.03,"percent of total billed charges",
"CATH IMAGER II 65CM 5FR PIGTAIL CURVE ANGIOGRAPHIC BRAID",SUP-31-519,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.04,22.81,"CIGNA [10200]","Cigna Local Plus",,40.68,53.5,,,,,0,8.84,64.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT EDGE STERILE PVC",SUP-E2250H,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.80,1.44,"CIGNA [10200]","Cigna Local Plus",,2.57,53.5,,,,,0,0.56,4.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX 1S REINFORCED TISSUE MATRIX, LONG-TERM RESORBABLE REI",SUP-F10266-2020G,CDM,C1781,HCPCS,0278,RC,,,both,,,39463.20,11838.96,"NOVANET [10819]",Novanet,,29597.4,75,,,,,0,4589.57,33543.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 24MM 144CM 4MM CORONARY STENT",SUP-H7493911424400,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 79MM 8.9MM UNCUFFED FENESTRATED INNER CANN SHILEY TRACH",SUP-10DCFN,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.84,87.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,34.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.06,248.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 34MM 1 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-41F34V,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL SMALL 28MM HIP BIOLOX DELTA",SUP-PHA04402,CDM,C1776,HCPCS,0278,RC,,,both,,,14234.70,4270.41,"CIGNA [10200]","Cigna Open Access",,4768.62,33.5,,5302.19,4377.88,6578.61,27,1655.5,12099.5,"percent of total billed charges",
"MESH SURGICAL GALASHAPE 3D 18.5X6.4CM MONOFILAMENT",SUP-SH3D03,CDM,C1781,HCPCS,0278,RC,,,both,,,7590.00,2277,"BLUE CROSS [10001]","Blue Cross HMO",,2975.28,39.2,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 CC 24IN 2 ARM MONOFILAMENT BLUE",SUP-8807H,CDM,S27200284,LOCAL,0272,RC,,,both,,,196.35,58.9,"PHCS [10601]",PHCS,,137.45,70,,,,,0,22.84,166.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CARDIONYL 5-0 12MM MONOFILAMENT NONABSORBABLE",SUP-721202,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.11,20.73,"CIGNA [10200]","Cigna Open Access",,39.32,56.9,,,,,0,8.04,58.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN MICROPOINT 6-0 G-1 18IN MONOFILAMENT YELLOWISH TAN",SUP-774G,CDM,S27200284,LOCAL,0272,RC,,,both,,,97.49,29.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,44.75,45.9,,,,,0,11.34,82.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 12MM 3.5MM EMBOLIZATION",SUP-PED2-350-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"PHCS [10601]",PHCS,,56558.25,70,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50MM 20MM CONCERTO DETACHABLE 3D SMOOTH VI",SUP-PV-20-50-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 6MM CEREPAK XTRASOFT FREEFORM",SUP-XCR120610,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"NOVANET [10819]",Novanet,,9919.39,75,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pad Grounding Rfl",PX-E27000199,CDM,E27000199,LOCAL,0270,RC,,,both,,,148.50,44.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.27,126.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFT TOUCH",SUP-SSM-310,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3467.97,45.9,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL MEDIUM 6 FLUTE ROUND L50.8 MM OD3 MM STERILE",SUP-5300-010-509,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.08,49.82,"CIGNA [10200]","Cigna Local Plus",,88.85,53.5,,,,,0,19.32,141.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 15CM 6MM BALLOON DILATATION OTW LOW",SUP-G30962,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE SHOULDER",SUP-CAP-S-RS,CDM,C1776,HCPCS,0278,RC,,,both,,,49140.00,14742,"BLUE CROSS [10001]","Blue Cross PPO",,19262.88,39.2,,3949.44,3949.44,3949.44,"1 through 10",5714.98,41769,"percent of total billed charges",
"SET SUCTION 25MM BLUNT BLADE TUBE NEXUS BONE SCPL STERILE",SUP-110-31-1125,CDM,S27200284,LOCAL,0272,RC,,,both,,,4242.67,1272.8,"CIGNA [10200]","Cigna Local Plus",,2269.83,53.5,,,,,0,493.42,3606.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL .7MM ROUND DIAMOND REINFORCE TIP QUICK CONNECT",SUP-5452012007,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 80MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 10",SUP-245.220,CDM,C1713,HCPCS,0278,RC,,,both,,,3664.50,1099.35,"MULTIPLAN [10600]",Multiplan,,3114.83,85,,,,,0,426.18,3114.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla II Typing 1 Allele Hr",PX-309000092,CDM,81383,CPT,0310,RC,,,both,,,424.00,127.2,"CIGNA [10200]",Cigna,,240.09,,,,,,,50.24,387.4,"fee schedule",
"TUBE FEEDING ORANGE 40CM 6.5FR NUTRIO TWISTLOK ENTERAL",SUP-ENSI6065,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.36,32.21,"KAISER [10500]",Kaiser,,71.93,67,,,,,0,12.49,91.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 160MM 14MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424047,CDM,C1776,HCPCS,0278,RC,,,both,,,12181.95,3654.58,"AETNA [10100]","Aetna HMO/PPO",,9684.65,79.5,,10981.53,8986.79,12413.38,12,1416.76,10354.66,"percent of total billed charges",
"LEAD PACING 72CM 8.6FR VENTRICULAR HELIX ELECTRD DF-4 CNCT",SUP-6935M72,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"MULTIPLAN [10600]",Multiplan,,14596.2,85,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX8MM CAPSTONE PEEK INTERBODY",SUP-2990822,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"UHC [10700]","United Healthcare",,13435.8,63.3,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM THIN WALL HYPERINFLATION .5L NO MASK BAG O2 TUBE",SUP-87-HS4051EA,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.24,25.27,"UHC [10700]","United Healthcare",,53.32,63.3,,,,,0,9.8,71.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM AXSOS LOCK NONSTERILE",SUP-661040,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"CIGNA [10200]","Cigna Open Access",,742.95,56.9,,1144.80,304.56,2275.09,66,151.86,1109.86,"percent of total billed charges",
"MARKER TUMARK EVIVA BREAST BIOPSY PROFESSIONAL Q EVIVA STD",SUP-TUMARK-E13-S-Q-02,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,454.14,68,,,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.095 CLAREON",SUP-SY60WF.095,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE WIRE SAW 20IN STAINLESS STEEL GIGLI STILLE NONSTERILE",SUP-260-106,CDM,S27000186,LOCAL,0270,RC,,,both,,,512.41,153.72,"CIGNA [10200]",Cigna,,348.44,68,,,,,0,59.59,435.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUR SURGICAL DIA4MM STAINLESS STEEL EGG 10 FLUTE",SUP-1607002035,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC",578,MS-DRG,,,,,,,inpatient,,,197441.45,59232.43,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,10263.54,,"Case rate ($9,964.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,252.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,292.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,081.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,265.04. The transfer operating threshold is the transfer adjustment factor * $9,252.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $699.56. The transfer capital threshold is the transfer adjustment factor * $699.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,9964.6,46900.45,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 80MM 75CM 7MM VASCULAR METAL SUPERFICIAL",SUP-H74939293078070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"AETNA [10100]","Aetna HMO/PPO",,3839.85,79.5,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MTRL BONDING ROLYAN SOLVENT SELF BRUSH APPLR SOL 237ML",SUP-A3182,CDM,S27000186,LOCAL,0270,RC,,,both,,,80.74,24.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.39,68.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP CLUSTER HOLE HA TRIDENT II PSL D",SUP-742-11-48D,CDM,C1776,HCPCS,0278,RC,,,both,,,9502.96,2850.89,"CIGNA [10200]",Cigna,,6462.01,68,,5873.17,5873.17,5873.17,"1 through 10",1105.19,8077.52,"percent of total billed charges",
"STEM FEMORAL 150MM 14MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192014,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9499.39,40,,,,,0,2761.95,20186.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC IPERIA 7 DR-T IMPLANTABLE HOME MNTR PROMRI",SUP-392409,CDM,C1882,HCPCS,0278,RC,,,both,,,40560.00,12168,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16670.16,41.1,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 6FR 22GA GLIDESHEATH SLENDER .021IN 25MM",SUP-RM*ES6F10HAU,CDM,C1894,HCPCS,0272,RC,,,both,,,761.40,228.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,90.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE INCORE PRECISION POST PLUG GUIDE CORRECTION LAPIDUS",SUP-ICLAP35P,CDM,C1713,HCPCS,0278,RC,,,both,,,3136.35,940.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,371.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,364.76,2665.9,"percent of total billed charges",
"INSRT TIBIAL STD 17.5MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405417,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"CIGNA [10200]",Cigna,,6571.15,68,,5873.17,5873.17,5873.17,"1 through 10",1123.86,8213.93,"percent of total billed charges",
"PARTIAL HIP CONSTRUCT 2",SUP-CAP-MI-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"FIRST HEALTH [10303]","First Health",,7728,80,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 5X4IN DURAMATRIX SUTURABLE",SUP-DMS45,CDM,S27800098,LOCAL,0278,RC,,,both,,,15262.80,4578.84,"CIGNA [10200]",Cigna,,6105.12,40,,,,,0,1775.06,12973.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FIBERTAG FIXATION ACL RIGHT DISPOSABLE",SUP-AR-1588RTT,CDM,C1713,HCPCS,0278,RC,,,both,,,3803.63,1141.09,"BLUE CROSS [10001]","Blue Cross HMO",,1491.02,39.2,,957.42,156.86,7483.26,51,442.36,3233.09,"percent of total billed charges",
"PROBE VITRECTOMY 20GA ULTRAVIT CONSTELLATION ANTERIOR CURVED",SUP-8065751020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1716.68,515,"MULTIPLAN [10600]",Multiplan,,1459.18,85,,,,,0,199.65,1459.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR JR4.5 CURVE GUIDING CORONARY",SUP-LA8JR45,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR ROSCH INFERIOR MESENTRIC CURVE",SUP-H787107333015,CDM,C1887,HCPCS,0272,RC,,,both,,,236.64,70.99,"MULTIPLAN [10600]",Multiplan,,201.14,85,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM TALON DISTALFIX CORTICAL",SUP-HTN-U-4-40,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1057.54,68,,,,,0,180.87,1321.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRD SURGICAL 10IN NARROW INGE LARGE PATTERN LAMINA ADULT 8",SUP-57-5506,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DECOMPRESSION MICROBLADE IO-FLEX L5.5 MM SPINAL PROBE",SUP-IO-MBS5.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,9918.75,2975.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4076.61,41.1,,,,,0,1153.55,8430.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 4FR 5MM SPACE REGULAR D CURVE",SUP-D4S04DR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,269.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOUGIE 26FR OTIS A BOULE SURGICAL",SUP-51-7226,CDM,S27200284,LOCAL,0272,RC,,,both,,,416.82,125.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,48.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.48,354.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE 22-PIN SENSOR ENABLED DIAGNOSTIC CATHETER CABLE",SUP-D-AVSE-CBL22,CDM,S27000186,LOCAL,0270,RC,,,both,,,2362.50,708.75,"AETNA [10100]","Aetna HMO/PPO",,1878.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,274.76,2008.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM SPINE POLYAXIAL REVOLVE",SUP-185.474,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"FIRST HEALTH [10303]","First Health",,7637.48,80,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +14.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.145,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11MM NATURAL STD PARALLEL CERVICAL",SUP-18311,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 34MM CG FUTURE FLEXIBLE LOW PROFILE EYELET",SUP-638BL34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 10MM 2MM BALLOON DILATATION STERILE",SUP-220-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ROCHESTER-OCHSNER 7.25IN MIRROR FINISH CURVED",SUP-105-212,CDM,S27000186,LOCAL,0270,RC,,,both,,,156.34,46.9,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STPLR 3.5MM SUREFORM 45 STERILE LATEX FREE DISPOSABLE",SUP-48345B,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG BIOLOGICAL 10X7CM CYTAL PORCINE EXTRACELLULAR MATRIX 1",SUP-WS0710,CDM,Q4166,HCPCS,0636,RC,,,both,,,2160.00,648,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER 4MM PK DIEGO 40D CURVE CONCAVE SINUS",SUP-7013-8008,CDM,S27200284,LOCAL,0272,RC,,,both,,,912.40,273.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) DELIVERY DEVICE GEN II (50-200MG)",SUP-P-1075,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PRUITT 24CM 12FR OCCLUSION AORTA STERILE LATEX FREE",SUP-E2100-12,CDM,C2628,HCPCS,0272,RC,,,both,,,4478.10,1343.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRANEXAMIC ACID 1,000 MG/10 ML VIAL INHALATION SOLUTION",RX-410363,CDM,,,0250,RC,81284-0611-00,NDC,both,10,ML,49.83,14.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMAGER II 100CM 5FR MULTIPURPOSE SHORT TIP CURVE",SUP-M001314011,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CMPNT FEMORAL 5 KNEE LEFT CEMENTED POSTERIOR STABILIZE SIGMA",SUP-196040500,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4110,41.1,,6417.48,6417.48,6417.48,"1 through 10",1163,8500,"percent of total billed charges",
"CATH NC TREK NEO 12MM 145CM 5MM BALLOON DILATATION HYDROCOAT",SUP-1400500-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 15X15.5CM 750CC STYLE 133S SMOOTH SUT TAB",SUP-133S-FV-15-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1083.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +31 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60AT.310,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM BONE CEMENT 1 2 MIX",SUP-414701,CDM,S27200284,LOCAL,0272,RC,,,both,,,963.90,289.17,"CIGNA [10200]","Cigna Local Plus",,515.69,53.5,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 15MM 5.5MM FOOT ANKLE VENT",SUP-AR-1555PS,CDM,C1713,HCPCS,0278,RC,,,both,,,2480.63,744.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1138.61,45.9,,,,,0,288.5,2108.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC",256,MS-DRG,,,,,,,inpatient,,,66754.53,20026.36,"PHCS [10601]",PHCS,,7561,,,,,,,7561,49571.89,"per diem","Estimated amount calculated based on 4 day length of stay."
"SCR BONE 6.5MM 50MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.405,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,635.32,45.9,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE AUGMENTATION 14MM CORTICAL INTERSPINOUS PROCESS",SUP-4578114,CDM,S27800098,LOCAL,0278,RC,,,both,,,19921.48,5976.44,"PHCS [10601]",PHCS,,13945.04,70,,,,,0,2316.87,16933.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 15ML .1-4MM CRUSH",SUP-T20020,CDM,S27800098,LOCAL,0278,RC,,,both,,,2614.50,784.35,"FIRST HEALTH [10303]","First Health",,2091.6,80,,,,,0,304.07,2222.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP POROUS OR3O WITH COCR HEAD",SUP-71703490,CDM,C1776,HCPCS,0278,RC,,,both,,,30240.00,9072,"CIGNA [10200]","Cigna Local Plus",,9525.6,31.5,,5372.07,4581.20,7242.98,23,3516.91,25704,"percent of total billed charges",
"BALLOON DISECT LAPAROSCOPIC KII 100MM 12MM 1 LATERAL",SUP-C0K18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"CIGNA [10200]",Cigna,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPICILLIN SODIUM 1 G/8ML IJ (WET SOLR VIAL)",RX-415469,CDM,J0290,HCPCS,0636,RC,00781-3404-85,NDC,both,1,UN,65.20,19.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,44.34,68,,,,,0,1.28,55.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE REGENERATION",SUP-345111,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.3MM 230MM KIRSCHNER FLOURO BAND 1 END TROCAR",SUP-P99-194-2323,CDM,C1713,HCPCS,0278,RC,,,both,,,518.40,155.52,"CIGNA [10200]","Cigna Open Access",,294.97,56.9,,1144.80,304.56,2275.09,66,60.29,440.64,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 34MM 140CM .91-1.12MM 3MM CORONARY",SUP-RONYX30034W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"MULTIPLAN [10600]",Multiplan,,4623.15,85,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 12MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620312,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1308.83,9565.82,"percent of total billed charges",
"STEM FEMORAL 130MM 13MM PRIMARY CEMENT SATIN FINISH VERSYS",SUP-785001300,CDM,C1776,HCPCS,0278,RC,,,both,,,18721.08,5616.32,"BLUE CROSS [10001]","Blue Cross PPO",,7338.66,39.2,,3949.44,3949.44,3949.44,"1 through 10",2177.26,15912.92,"percent of total billed charges",
"INSRT TIBIAL 3 17.5MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158123117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PHCS [10601]",PHCS,,7822.19,70,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHALANX CORONAL TRANSFIXION SCREW 1.5MM X 9.0MM COCR",SUP-PTS-15009-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.90,337.77,"BLUE CROSS [10001]","Blue Cross PPO",,441.35,39.2,,957.42,570.23,957.42,28,130.94,957.02,"percent of total billed charges",
"SCREW NON-LOCKING 2.7 X 22MM",SUP-MPSN2722,CDM,C1713,HCPCS,0278,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,336.14,28.62,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM G7 THR XLPE CERAMIC HIP CEMENT STEM CUP LINER HEA",SUP-98000700040,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross HMO",,9384.48,39.2,,5311.50,4717.44,5388.59,31,2784.22,20349,"percent of total billed charges",
"PROBE NAVIGATION SYSTEM SENTIO MMG BALL TIP ADJUSTABLE",SUP-286202200,CDM,S27200284,LOCAL,0272,RC,,,both,,,3290.63,987.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,389.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,382.7,2797.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUTTLE ACCU-PASS 70D UP BEND ERGONOMIC HANDLE THUMB WHEEL",SUP-72200419,CDM,S27200284,LOCAL,0272,RC,,,both,,,961.07,288.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,395,41.1,,,,,0,111.77,816.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SYNTHETIC ETHIBOND EXCEL 2-0 V-7 36IN 2 ARM BRAID FIRM",SUP-PXX79N,CDM,S27200284,LOCAL,0272,RC,,,both,,,745.06,223.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,86.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.65,633.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LEMAITRE 40CM 4FR 10MM EMBOLECTOMY .75ML BALLOON OTW",SUP-1651-44,CDM,C1757,HCPCS,0272,RC,,,both,,,963.90,289.17,"UHC [10700]","United Healthcare",,610.15,63.3,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB ADULT 45MM ADHSV CONDUCTIVE RADIOLUCENT",SUP-8900-4005,CDM,S27000186,LOCAL,0270,RC,,,both,,,228.38,68.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,155.3,68,,,,,0,26.56,334.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT 17GA 150MM COOL RADIOFREQUENCY PROBE ELECTROTHERAPY",SUP-CRK-17-150-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drsg Foam Nonadhesive Rl 4x24",PX-E27200126,CDM,E27200126,LOCAL,0272,RC,,,both,,,144.10,43.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.76,122.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 40X20MM EIKON LT NARROW LOW PROFILE NONCONDUCTIVE",SUP-C40N,CDM,S27200284,LOCAL,0272,RC,,,both,,,7832.88,2349.86,"UHC [10700]","United Healthcare",,4958.21,63.3,,,,,0,910.96,6657.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Triglycerides",PX-301000420,CDM,84478,CPT,0301,RC,,,both,,,132.86,39.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.03,,"Fee schedule rate ($6.03). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,112.93,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 7.5CM 3MM LEGEND BALL TOOL LATEX FREE",SUP-75BA30T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1326.78,398.03,"MULTIPLAN [10600]",Multiplan,,1127.76,85,,,,,0,154.3,1127.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER DARCO ORTHOPEDIC 4/4.5 MM HEAD SCR SYSTEM",SUP-707404501,CDM,C1713,HCPCS,0278,RC,,,both,,,226.20,67.86,"MULTIPLAN [10600]",Multiplan,,192.27,85,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPISTAXIS WITHOUT MCC",151,MS-DRG,,,,,,,inpatient,,,22642.27,6792.68,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,4871.75,,"Case rate ($4,553.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,227.81, add-ons for qualifying new technology services are included. If operating cost exceeds $37,267.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,701.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,233.40. The transfer operating threshold is the transfer adjustment factor * $4,227.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $319.64. The transfer capital threshold is the transfer adjustment factor * $319.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,4553.04,18305.23,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 301MM STAINLESS STEEL 4.5MM SCR 14 HOLE 4 COLUMN",SUP-02.124.415,CDM,C1713,HCPCS,0278,RC,,,both,,,11799.00,3539.7,"CIGNA [10200]",Cigna,,4719.6,40,,1831.33,1831.33,1831.33,16,1372.22,10029.15,"percent of total billed charges",
"SOL IV VIAFLEX 40 MEQ POTASSIUM CHLORIDE 5% DEXTROSE 0.45%",SUP-2B1674X,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.95,24.58,"UHC [10700]","United Healthcare",,51.87,63.3,,,,,0,9.53,69.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 300MM 5MM BALLOON DILATATION RAPID EXCHANGE",SUP-47550300S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"KAISER [10500]",Kaiser,,1356.75,67,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH DURAL 4X4CM DURA-GUARD BOVINE PERICARDIAL RESORBABLE",SUP-DG0404SN,CDM,,,0278,RC,,,both,,,3132.45,939.73,"MULTIPLAN [10600]",Multiplan,,2662.58,85,,,,,0,3.13,2662.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 3.50 X 24MM",SUP-H7493942824350,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"KAISER [10500]",Kaiser,,4160.7,67,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1 KNEE LEFT TOTAL STABILIZE TRIATHLON COCR",SUP-5512-F-101,CDM,C1776,HCPCS,0278,RC,,,both,,,32652.90,9795.87,"AETNA [10100]","Aetna HMO/PPO",,25959.06,79.5,,10981.53,8986.79,12413.38,12,3797.53,27754.97,"percent of total billed charges",
"SCR BONE 7.3MM 75MM LCP STAINLESS STEEL PARTIAL THREAD CONE",SUP-02.207.475,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"FIRST HEALTH [10303]","First Health",,1244.68,80,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Arm/Hnd Rt (Go)",PX-510000546,CDM,29584,CPT,0430,RC,,,both,,,891.00,267.3,"UHC [10700]","United Healthcare",,331,,"Per diem ($331).",,,,0,103.62,891,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 11MM 8.2MM 120MM TALON PROXIMAL FEMUR DISTALFIX",SUP-SLN-011-120,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"MULTIPLAN [10600]",Multiplan,,4222.8,85,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3.5MM 13MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.813.96,CDM,C1713,HCPCS,0278,RC,,,both,,,319.12,95.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,37.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,37.11,271.25,"percent of total billed charges",
"STENT POLARIS 24CM 7FR URETERAL HYDROPLUS 2 DUROMETER",SUP-M0061901420,CDM,C2617,HCPCS,0278,RC,,,both,,,1162.35,348.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,332.66,28.62,,,,,0,135.18,988,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 80MM 4.8FR 7MM BALLOON DILATATION OTW",SUP-39032-70808,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM PRELOAD DISTAL WIREGUIDE STERILE DISPOSABLE",SUP-KD-VC631Q-07203S,CDM,C1769,HCPCS,0272,RC,,,both,,,2817.75,845.32,"PHCS [10601]",PHCS,,1972.43,70,,,,,0,327.7,2395.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION LARGE 4 POSITION PIN MR SAFE LARGE",SUP-390.009,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"CIGNA [10200]",Cigna,,1702.13,68,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 57MM 80CM 8MM 60MM BILIARY STAINLESS STEEL",SUP-PXB35-08-57-080,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"AETNA [10100]","Aetna HMO/PPO",,3471.77,79.5,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 8FR 15CM RADIOPAQUE GWIRE STERILE DISPOSABLE",SUP-G00999,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX16MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183546,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"MULTIPLAN [10600]",Multiplan,,6663.81,85,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 14MM PRIMARY SECUR-FIT PLUS HA 7 35MM HIP",SUP-6070-1035A,CDM,C1776,HCPCS,0278,RC,,,both,,,9473.94,2842.18,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3893.79,41.1,,6417.48,6417.48,6417.48,"1 through 10",1101.82,8052.85,"percent of total billed charges",
"STENT TAEWOONG NITI-S 15CM 180CM 20MM 10.5MM ESOPHAGEAL",SUP-G57357,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"BLUE CROSS [10001]","Blue Cross PPO",,6895.12,39.2,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER ORTHOPEDIC NONSTERILE LATEX FREE",SUP-323.1290,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE TRITIUM STERNAL RESCUE NONSTERILE CABLE PLATE",SUP-86-30-16,CDM,C1713,HCPCS,0278,RC,,,both,,,745.20,223.56,"BLUE CROSS [10001]","Blue Cross PPO",,292.12,39.2,,957.42,570.23,957.42,28,86.67,633.42,"percent of total billed charges",
"CATH SABERX 90CM 200MM 2.5MM BALLOON DILATATION RAPID",SUP-47525200S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE STRATAFIX MONOCRYL PLUS 2-0 CP-1 SPIRAL 70CM SUT",SUP-SXMP1B419,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT FIBERLOOP 4-0 T-22 10IN MULTISTRAND WHITE NONABSORBABLE",SUP-AR-7249-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET",RX-41832,CDM,,,0637,RC,50268-0717-11,NDC,both,1,UN,62.29,18.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PASSER FIBERTAPE STRAIGHT LARGE CERCLAGE SUT DISPOSABLE",SUP-AR-7822,CDM,S27200284,LOCAL,0272,RC,,,both,,,1771.88,531.56,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE VENTILATION BLUE 4.8MM 1.32MM T EAR SILICONE MODIFY",SUP-70245017,CDM,S27200284,LOCAL,0272,RC,,,both,,,152.90,45.87,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EUPHORA 142CM 15MM 3.25MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP32515X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 90X20MM ONETRAC LX 2 SMOKE EVACUATION CHANNEL",SUP-C100240,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 2MM CALIBRATE GRADUATE 2.7/3MM SCR",SUP-AR-8943-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,769.50,230.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 6MM XIA 3 TITANIUM RADIOLUCENT",SUP-48238090,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +10.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.105,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO 70CM 7FR 2.5MM GUIDING RAABE",SUP-G11635,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rf Ablt Nrv Si Joint Bi",PX-510000537,CDM,64625,CPT,0761,RC,,,both,,,4688.00,1406.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,555.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,545.21,3984.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEPHEA PREPARATION KIT",SUP-FG-019,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 15ML FREEZE DRIED CHIP 1-4MM",SUP-100015,CDM,S27800098,LOCAL,0278,RC,,,both,,,2126.25,637.87,"BLUE CROSS [10001]","Blue Cross PPO",,833.49,39.2,,,,,0,247.28,1807.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN AMPLATZ RIGHT 1 CURVE",SUP-H74908641842,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PHCS [10601]",PHCS,,53.61,70,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 17MM 140CM 3.5MM CORONARY STENT",SUP-LUN350R17US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 125CM 5FR FL4 CURVE ANGIOGRAPHIC FEMORAL 2 WIRE",SUP-H749163912202,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]","Cigna Open Access",,43.57,56.9,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM NARROW BLADE LIPPED",SUP-7541223,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",348.9,2550,"percent of total billed charges",
"STENT ORSIRO MISSION 40CM 140CM 3MM CORONARY STERILE LATEX",SUP-453976,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 4-0 SH 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-G121H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X5CM AMINOEFFECT PURION PLACENTAL MEMB",SUP-LS-5350,CDM,Q4433,HCPCS,0636,RC,,,both,,,13130.70,3939.21,"CIGNA [10200]",Cigna,,8928.88,68,,,,,0,247.92,11161.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL 5.25MM 3.75MM SUPER TURBOVAC 90 90D",SUP-ASH4250-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,972.00,291.6,"NOVANET [10819]",Novanet,,729,75,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC",437,MS-DRG,,,,,,,inpatient,,,34098.35,10229.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,13604.78,,,,,,,5293.08,21280.45,"case rate",
"HEAD FEMORAL -2.5MM 32MM HIP C TAPER NECK COCR LFIT",SUP-S-1400-HH31,CDM,C1776,HCPCS,0278,RC,,,both,,,4188.30,1256.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1198.69,28.62,,,,,0,487.1,3560.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIB 70CM 7.3FR RELIANCE 4-FRONT RIGHT VENTRICLE MP35N",SUP-653,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4344.52,28.62,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 24F LARGE HIP PROXIMAL",SUP-550748,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"MULTIPLAN [10600]",Multiplan,,9252.04,85,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 224MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 6",SUP-245.16,CDM,C1713,HCPCS,0278,RC,,,both,,,2851.80,855.54,"PHCS [10601]",PHCS,,1996.26,70,,,,,0,331.66,2424.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 7FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145371010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,276.73,28.62,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT MEGALOADER HD SCORPION",SUP-AR-13999HDN,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAFIRE BLU DUO COMFORTGRIP 110CM 7FR 2-5-2MM SPACE 4MM",SUP-A088107,CDM,C2630,HCPCS,0272,RC,,,both,,,11040.00,3312,"AETNA [10100]","Aetna HMO/PPO",,8776.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1283.95,9384,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID LOWER LEG REDUCTION KIT- LONG, REGULAR",SUP-25101317,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2MM TARGET NANO 360D DETACHABLE",SUP-M0035442030,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"AETNA [10100]","Aetna HMO/PPO",,11221.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB RESUSCITATION COMPLETE AMBULATORY CARE ONESTEP",SUP-8900-0214-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,575.59,172.68,"KAISER [10500]",Kaiser,,385.65,67,,,,,0,65.66,489.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS POWERFLEX P3 80CM 20MM 6MM 7.5MM BALLOON",SUP-4206020S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 36CM FEMUR RIGHT PROXIMAL TALON DISTALFIX",SUP-SLN-125-36R,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"UHC [10700]","United Healthcare",,10207.31,63.3,,5023.51,2672.93,6679.78,18,1875.37,13706.51,"percent of total billed charges",
"SCREW NON-LOCKING 1.2MM X 8MM COCR",SUP-VAN-12008-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STARTER VASCULAR 150CM 15CM .035IN PTFE HEPARIN NEWTON",SUP-49-181,CDM,C1769,HCPCS,0272,RC,,,both,,,83.96,25.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.76,71.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 MEDIUM 32MM HIP ACETABULAR BIOLOX",SUP-877503202,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"PHCS [10601]",PHCS,,6901.1,70,,,,,0,1146.57,8379.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 12MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640612,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"NOVANET [10819]",Novanet,,8440.43,75,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 38MM 144CM 2.5MM CORONARY STENT",SUP-H7493952838250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5-3.6MM 18MM ACUTRAK 2 TITANIUM MINI FULL THREAD",SUP-AT2-M18,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"CIGNA [10200]",Cigna,,2167.5,68,,1831.33,1831.33,1831.33,16,370.71,2709.38,"percent of total billed charges",
"NAIL 9MM 375MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.355S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"CIGNA [10200]",Cigna,,5652.45,68,,1831.33,1831.33,1831.33,16,966.74,7065.57,"percent of total billed charges",
"COIL EMBOLIZATION 30CM 12MM AZUR DETACHABLE HYDROGEL",SUP-45-451230,CDM,S27800098,LOCAL,0278,RC,,,both,,,8832.00,2649.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1027.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1027.16,7507.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 9FR 20CM HYDROPHILIC RADIOPAQUE STERILE",SUP-G10290,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"MULTIPLAN [10600]",Multiplan,,56.87,85,,,,,0,7.78,56.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 7.25X1.25IN TAYLOR 4IN LARGE SPINE SURGICAL",SUP-57-5410,CDM,S27200284,LOCAL,0272,RC,,,both,,,347.39,104.22,"MULTIPLAN [10600]",Multiplan,,295.28,85,,,,,0,40.4,295.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RIGIFLEX II 90CM 10CM 14FR 40MM BALLOON DILATATION",SUP-M00554520,CDM,C1726,HCPCS,0272,RC,,,both,,,4370.81,1311.24,"NOVANET [10819]",Novanet,,3278.11,75,,,,,0,508.33,3715.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM RELINE-O 2S SPINE POLYAXIAL NONSTERILE",SUP-13017535,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"PLATE XLORDOTIC 14MM 1 LEVEL XTEND BONE SPINE CERVICAL",SUP-161.134,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PHCS [10601]",PHCS,,2940,70,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 5.5IN FURST WEITLANER 3X4 BLUNT PRONG SELF RETAIN",SUP-MDS1867113F,CDM,S27200284,LOCAL,0272,RC,,,both,,,260.04,78.01,"PHCS [10601]",PHCS,,182.03,70,,,,,0,30.24,221.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ONE STEP 15CM 5FR DRNG TEFLON 4 SIDEHOLE INTRO NDL SLIP",SUP-OSC-5F-15,CDM,S27200284,LOCAL,0272,RC,,,both,,,160.95,48.28,"CIGNA [10200]","Cigna Open Access",,91.58,56.9,,,,,0,18.72,136.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VTC 25CM 10FR PIGTAIL CURVE NEPHRSTMY METAL",SUP-M001245270,CDM,C1729,HCPCS,0272,RC,,,both,,,729.00,218.7,"FIRST HEALTH [10303]","First Health",,583.2,80,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 DX FIBERTAK NDL",SUP-AR-8991,CDM,C1713,HCPCS,0278,RC,,,both,,,4105.50,1231.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,477.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",477.47,3489.68,"percent of total billed charges",
"MATRIX TISSUE 21.5X10.7CM ALLODERM SELECT 164SQ CM THK1.6-.4",SUP-CL1518P,CDM,Q4116,HCPCS,0636,RC,,,both,,,30870.00,9261,"CIGNA [10200]","Cigna Local Plus",,16515.45,53.5,,,,,0,247.92,26239.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 200MM 120CM 7MM VASCULAR PERIPHERAL SELF",SUP-PRB35-07-200-120,CDM,C1876,HCPCS,0278,RC,,,both,,,11625.00,3487.5,"PHCS [10601]",PHCS,,8137.5,70,,,,,0,1351.99,9881.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 48MM M/G KNEE UNICOMPARTMENTAL",SUP-579104200,CDM,C1713,HCPCS,0278,RC,,,both,,,530.96,159.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",61.75,451.32,"percent of total billed charges",
"TISSUE SYNTHETIC CALCIUM SULFATE 5ML OSTEOSET RESORBABLE",SUP-84000611,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,511.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",501.54,3665.63,"percent of total billed charges",
"MESH HERNIA POLYGLYCOLIC ACID 20X10CM RESORBABLE GRID 1",SUP-F10256-1020G,CDM,C1781,HCPCS,0278,RC,,,both,,,19731.60,5919.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2338.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2294.79,16771.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO 1000093005 OPTISEAL GLBL10FR13CM",SUP-1000093005,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 6X9X6MM ARCH 7.5D SPINE FREEZE DRY NOTCH",SUP-015206,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 65MM LCP STAINLESS STEEL FULL THREAD CONDYLAR",SUP-02.207.065,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,957.42,570.23,957.42,28,189.34,1383.8,"percent of total billed charges",
"CATH BARD 70CM 5FR URETERAL POLYURETHANE WHISTLE TIP ADPTR",SUP-136405,CDM,C1758,HCPCS,0272,RC,,,both,,,116.49,34.95,"KAISER [10500]",Kaiser,,78.05,67,,,,,0,13.55,99.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TNLR SURGICAL 15CM PLASTIC HICKMAN BROVIAC LEONARD CATH",SUP-0601930,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC",353,MS-DRG,,,,,,,inpatient,,,108272.60,32481.78,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,EXTREME",710,APR-DRG,,,,,,,inpatient,,,92820.57,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $37,177.70. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($212,515.67) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"STEINMANN PIN SINGLE DIAMOND 2.4 MM X 229 MM",SUP-SPIN-SD-24229,CDM,S27000186,LOCAL,0270,RC,,,both,,,891.00,267.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE FEEDING 36IN 6FR KANGAROO CORFLO-ULTRA LITE STD Y",SUP-20-9366,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.39,27.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 18GA 20CM CHIBA ASPIRATION STERILE DISPOSABLE",SUP-G01047,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.31,31.29,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 7FR 4CM GWIRE PRELUDE .038IN SHORT STERILE",SUP-PSS-7F-4-038MT,CDM,C1894,HCPCS,0272,RC,,,both,,,208.80,62.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,141.98,68,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 300CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP110RH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"KAISER [10500]",Kaiser,,7974.68,67,,,,,0,1384.26,10117.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 10MM STD WALL GORE-TEX LINE STERILE",SUP-V10080L,CDM,C1768,HCPCS,0278,RC,,,both,,,4926.60,1477.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3350.09,68,,,,,0,572.96,4187.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +18.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.185,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg Extend Monitor 41-60min",PX-740000008,CDM,95812,CPT,0740,RC,,,both,,,1762.04,528.61,"UHC [10700]","United Healthcare",,1762.04,,"Per diem ($1,799).",,,,0,204.93,1762.04,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"REG VACUUM PUSH-TO-SET INTERMITTENT OHMEDA DIAMOND NIPPLE",SUP-8701-1251-901,CDM,S27200284,LOCAL,0272,RC,,,both,,,2674.50,802.35,"MULTIPLAN [10600]",Multiplan,,2273.33,85,,,,,0,311.04,2273.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 80MM 20MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U20080090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1203.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 520CC",SUP-SSZ-M520,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"UHC [10700]","United Healthcare",,943.42,63.3,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM CREO SPINE POLYAXIAL NONSTERILE 5.5MM",SUP-5119.1645,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Open Access",,5432.16,56.9,,1144.80,304.56,2275.09,66,1110.3,8114.82,"percent of total billed charges",
"SHEATH PINNACLE R/O II 10CM 2.5CM 6FR INTRO DIL RADIOPAQUE",SUP-RSB602,CDM,C1894,HCPCS,0272,RC,,,both,,,200.10,60.03,"NOVANET [10819]",Novanet,,150.08,75,,,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 135X30MM ONETRAC LX 2 SMOKE EVACUATION CHANNEL",SUP-C100210,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"FIRST HEALTH [10303]","First Health",,1500,80,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE CURVED 5 SLOT RIGHT TI",SUP-PHPF-C5R,CDM,C1713,HCPCS,0278,RC,,,both,,,17640.00,5292,"UHC [10700]","United Healthcare",,11166.12,63.3,,5023.51,2672.93,6679.78,18,2051.53,14994,"percent of total billed charges",
"SCR BONE 2.7MM 18MM ORTHOLOC 3DI LOW PROFILE FOOT ANKLE",SUP-58812718,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"BLUE CROSS [10001]","Blue Cross HMO",,333.4,39.2,,957.42,156.86,7483.26,51,98.91,722.93,"percent of total billed charges",
"SHEATH FLEXOR CHECK-FLO ANL1 CURVE 55CM 5FR 1.9MM GUIDING",SUP-G56235,CDM,C1894,HCPCS,0272,RC,,,both,,,472.23,141.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,54.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.92,401.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 31MM TITANIUM CURVE CIRCLE 2 STAGGER LOW",SUP-111989,CDM,S27200284,LOCAL,0272,RC,,,both,,,2138.85,641.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,253.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,248.75,1818.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X18MM THK.89MM SAGITTAL SYSTEM 6",SUP-6118089090,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM LOW PROFILE NECK VERTICAL GROOVE CORAIL2",SUP-3L92510,CDM,C1776,HCPCS,0278,RC,,,both,,,28658.70,8597.61,"CIGNA [10200]","Cigna Local Plus",,9027.49,31.5,,5372.07,4581.20,7242.98,23,3333.01,24359.9,"percent of total billed charges",
"OTW TAKERU PTCA BALLOON 2.50MM X 8MM",SUP-DC-PY2508UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"MULTIPLAN [10600]",Multiplan,,839.97,85,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 4FR 50CM 11CM RED HUB SNAP FIT DIL TUBING GWIRE",SUP-PRO-4F-11-035,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"NOVANET [10819]",Novanet,,60.03,75,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 2.4MM INTREPID ANGLE 2 BEVEL MICRO COAXIAL",SUP-8065982465,CDM,S27200284,LOCAL,0272,RC,,,both,,,464.21,139.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,55.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.99,394.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL LEAD DELIVERY EMBLEM STERILE LATEX FREE DISPOSABLE ELEC",SUP-4712,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"MULTIPLAN [10600]",Multiplan,,5865,85,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM CEMENTED OMNIFIT HFX 132D 9 35MM HIP",SUP-6070-0935A,CDM,C1776,HCPCS,0278,RC,,,both,,,7894.95,2368.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,935.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,918.18,6710.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 150MM 6FR 7MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-07151,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XENON-133 IN AIR GAS FOR INHALATION",RX-233854,CDM,A9558,HCPCS,0343,RC,08888-8878-28,NDC,both,1,UN,755.00,226.5,"BLUE CROSS [10001]","Blue Cross PPO",,297.32,,,,,,,87.81,641.75,"fee schedule",
"HC Rmvl FB Ft Cmplx",PX-450000174,CDM,28193,CPT,0450,RC,,,both,,,5935.00,1780.5,"FIRST HEALTH [10303]","First Health",,4748,80,,,,,0,5.94,5935,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cysto Urtroscopy/Pyeloscopy Dx",PX-361000235,CDM,52351,CPT,0361,RC,,,both,,,5209.65,1562.89,"NOVANET [10819]",Novanet,,3907.24,75,,,,,0,605.88,5209.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR DISTRACTION 12MM SPINE CERVICAL ANTERIOR STAINLESS STEEL",SUP-909-12,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.23,67.87,"MULTIPLAN [10600]",Multiplan,,192.3,85,,,,,0,26.31,192.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Fetal Sngl Gestation",PX-610000053,CDM,74712,CPT,0610,RC,,,both,,,1594.00,478.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,188.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.38,1594,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.0 PLY SCRW 4.0X18",SUP-102040118,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",441.36,3225.75,"percent of total billed charges",
"5MM X 3CM BALLOON 4FR SHEATH 142CM SHAFT AVIATOR PLUS PTA BA",SUP-4245030W,CDM,C1769,HCPCS,0272,RC,,,both,,,1438.80,431.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,978.38,68,,,,,0,167.33,1222.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MILNACIPRAN 50 MG TABLET",RX-97089,CDM,,,0637,RC,00456-1550-60,NDC,both,1,UN,38.69,11.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.5,32.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 4FR 2-8-2MM SPACE REGULAR P CURVE",SUP-D4S10PR282RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,441.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sirolimus",PX-301000055,CDM,80195,CPT,0301,RC,,,both,,,425.60,127.68,"NOVANET [10819]",Novanet,,319.2,75,,,,,0,0.01,361.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION",RX-172560,CDM,J2251,HCPCS,0636,RC,44567-0611-01,NDC,both,100,ML,162.97,48.89,"BLUE CROSS [10001]","Blue Cross HMO",,23.31,,,,,,,19.31,138.52,"fee schedule",
"SPLINT NASAL 2.38X1.53IN REGULAR FOAM RUBBER SINGLE EXTERNAL",SUP-1528120,CDM,S27000186,LOCAL,0270,RC,,,both,,,360.88,108.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,42.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.97,306.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 30MM CREO MIS SPINE POLYAXIAL TULIP REDUCTION",SUP-1134.01,CDM,C1713,HCPCS,0278,RC,,,both,,,3555.00,1066.5,"NOVANET [10819]",Novanet,,2666.25,75,,,,,0,413.45,3021.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Androstenedione",PX-301000106,CDM,82157,CPT,0301,RC,,,both,,,217.65,65.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.83,,,,,,,0.01,185,"fee schedule",
"CUTTER PIN 7.5IN 1.6MM CANNULATED END CUT",SUP-14-3030,CDM,S27200284,LOCAL,0272,RC,,,both,,,966.01,289.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,112.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.35,821.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA EXTRA FULL PROFILE SOFT TOUCH",SUP-SSX-445,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"FIRST HEALTH [10303]","First Health",,6044.4,80,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 230MM 2MM STAINLESS STEEL NONTHREADED SPADE",SUP-292.656,CDM,C1769,HCPCS,0272,RC,,,both,,,229.68,68.9,"FIRST HEALTH [10303]","First Health",,183.74,80,,,,,0,26.71,195.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 220CM 11.5-14MM OTSC 3MM NITINOL T CLIP",SUP-100.08,CDM,C1760,HCPCS,0278,RC,,,both,,,4754.10,1426.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,563.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,552.9,4040.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL 0 18IN MONOFILAMENT TIE 12 STRAND SILVER",SUP-DS26,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.87,22.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.82,64.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 750-900ML STYLE 2000 SMOOTH SALINE P5.9-6.8CM",SUP-3502750,CDM,C1789,HCPCS,0278,RC,,,both,,,2350.00,705,"PHCS [10601]",PHCS,,1645,70,,,,,0,273.31,1997.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 65MM LCP STAINLESS STEEL FULL THREAD CONDYLAR",SUP-02.207.065,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"HC Factor X",PX-305000024,CDM,85260,CPT,0305,RC,,,both,,,687.70,206.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.79,,"Fee schedule rate ($18.79). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,584.55,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Factor X",PX-305000024,CDM,85260,CPT,0305,RC,,,both,,,687.70,206.31,"FIRST HEALTH [10303]","First Health",,550.16,80,,,,,0,0.01,584.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN READIGRAFT CRYOSKIN 232SQ CM FIBROBLAST",SUP-SK-M,CDM,Q4433,HCPCS,0636,RC,,,both,,,4809.58,1442.87,"CIGNA [10200]","Cigna Open Access",,2736.65,56.9,,,,,0,247.92,4088.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 16MM PERSONA 3-5+ C-D KNEE RIGHT CONDYLAR",SUP-42522800416,CDM,C1776,HCPCS,0278,RC,,,both,,,16308.84,4892.65,"BLUE CROSS [10001]","Blue Cross PPO",,6393.07,39.2,,3949.44,3949.44,3949.44,"1 through 10",1896.72,13862.51,"percent of total billed charges",
"HC Ihc 1st Antibody per Slide",PX-312000041,CDM,88342,CPT,0312,RC,,,both,,,766.65,229.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,39.08,,"Fee schedule rate ($39.08). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",85.70,85.70,85.70,"1 through 10",0.01,651.65,"fee schedule",
"INSERT TIBIAL 5 16MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620516,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS [10001]","Blue Cross PPO",,4411.53,39.2,,3949.44,3949.44,3949.44,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"VALVE MITRAL 27MM EPIC THV",SUP-E100-27M-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,24570.00,7371,"NOVANET [10819]",Novanet,,18427.5,75,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM 1.25MM PERI-LOC VLP KIRSCHNER STAINLESS",SUP-71161012,CDM,C1713,HCPCS,0278,RC,,,both,,,390.54,117.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,179.26,45.9,,,,,0,45.42,331.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 7MM ZERO-P LARGE LORDOTIC PEEK-OPTIMA ELGILOY",SUP-04.647.227S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"CIGNA [10200]","Cigna Local Plus",,3912.3,31.5,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL FIXATION 1.5IN TRIATHLON HEAD",SUP-6541-4-515,CDM,C1713,HCPCS,0278,RC,,,both,,,595.35,178.6,"MULTIPLAN [10600]",Multiplan,,506.05,85,,,,,0,69.24,506.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARR GRAFT 8X3IN 1.5:1 DERMACARRIER II SKIN PLATEAU GROOVES",SUP-00219501200,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"AETNA [10100]","Aetna HMO/PPO",,331.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 28CM 3CM 8FR .035IN PIGTAIL CURVE",SUP-M006180244170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,147.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 18MM 135CM 5MM 3.3-2.9FR VASCULAR COCR",SUP-1011493-18,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1803.06,28.62,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 5.5MM CD HORIZON SOLERA CCM PLUS",SUP-651000045,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",188.41,1377,"percent of total billed charges",
"BELT SPRT MEDTRONIC SMALL",SUP-FP9000S,CDM,S27000186,LOCAL,0270,RC,,,both,,,408.90,122.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,48.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP 5 SCR HOLE CLUSTER TRITANIUM",SUP-702-04-62G,CDM,C1776,HCPCS,0278,RC,,,both,,,12551.10,3765.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1459.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1459.69,10668.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM LOW PROFILE SCREWS TITANIUM T15 FULL",SUP-AR-8935-18,CDM,C1713,HCPCS,0278,RC,,,both,,,486.00,145.8,"CIGNA [10200]",Cigna,,330.48,68,,1831.33,1831.33,1831.33,16,56.52,413.1,"percent of total billed charges",
"STENT WALLFLEX 80MM 3.2MM 10MM 8.5FR .035IN BILIARY RAPID",SUP-M00570740,CDM,C1876,HCPCS,0278,RC,,,both,,,9158.00,2747.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4203.52,45.9,,,,,0,1065.08,7784.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 40MM 125CM 5MM 5FR BILIARY NITINOL GOLD",SUP-G31352,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2841.72,68,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MYNX CONTROL VCD 6F 7F",SUP-MX6760,CDM,C1760,HCPCS,0278,RC,,,both,,,1680.00,504,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,480.82,28.62,,,,,0,195.38,1428,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rev Skin Pocket Pcmkr",PX-480000016,CDM,33222,CPT,0481,RC,,,both,,,2776.00,832.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,322.85,2776,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD EMG I-PAS III DIAMOND DISPOSABLE NONSTERILE LATEX",SUP-2010028,CDM,S27000186,LOCAL,0270,RC,,,both,,,1650.00,495,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1122,68,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2.5MM DELTAXSFT 10 COIL",SUP-DLX100254,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"AETNA [10100]","Aetna HMO/PPO",,7196.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET RETROGRADE LOW",SUP-AR-1204AF-110,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,303.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 9MM 29MM ASYMMETRIC TRIATHLON X3 KNEE",SUP-5551L299,CDM,C1776,HCPCS,0278,RC,,,both,,,4478.10,1343.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2055.45,45.9,,,,,0,520.8,3806.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 120MM 12MM 10FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEL12120,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]",Cigna,,7308,40,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 10X6IN MEPITEL ONE SAFETAC NONADHERENT LATEX FREE",SUP-289700,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.11,41.73,"CIGNA [10200]","Cigna Open Access",,79.15,56.9,,,,,0,16.18,118.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Sentinel Node",PX-361000169,CDM,38792,CPT,0361,RC,,,both,,,2927.56,878.27,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,346.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,340.48,2927.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 80MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"FIRST HEALTH [10303]","First Health",,1276.56,80,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM EVOLVE STAINLESS STEEL CORTICAL ELBOW",SUP-4973530L,CDM,C1713,HCPCS,0278,RC,,,both,,,1710.00,513,"CIGNA [10200]",Cigna,,1162.8,68,,1831.33,1831.33,1831.33,16,198.87,1453.5,"percent of total billed charges",
"INSRT TIBIAL 5 11MM KNEE BEARING POSTERIOR STABILIZE",SUP-5532-G-511-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"FIRST HEALTH [10303]","First Health",,9130.08,80,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK-175/2,3M STERILE",SUP-128563,CDM,S27500001,LOCAL,0275,RC,,,both,,,408.90,122.67,"CIGNA [10200]","Cigna Local Plus",,218.76,53.5,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Initial Care Training 30 M (Gn)",PX-440000025,CDM,G0539,HCPCS,0440,RC,,,both,,,70.00,21,"PHCS [10601]",PHCS,,49,70,,,,,0,0.07,70,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Central Line Dressing Tray",PX-E27000196,CDM,E27000196,LOCAL,0270,RC,,,both,,,80.28,24.08,"UHC [10700]","United Healthcare",,50.82,63.3,,,,,0,9.34,68.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ptca Ea Addl Br Maj Cor Arty",PX-481000072,CDM,92921,CPT,0481,RC,,,both,,,14045.38,4213.61,"FIRST HEALTH [10303]","First Health",,11236.3,80,,,,,0,1633.48,14045.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 28MM 10D P3 HIP CROSSFIRE SYSTEM 12",SUP-6352-5-073,CDM,C1776,HCPCS,0278,RC,,,both,,,6837.90,2051.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,810.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,795.25,5812.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX ECHO 2 20X15CM POSITION SYSTEM STERILE",SUP-1211520,CDM,C1781,HCPCS,0272,RC,,,both,,,39293.10,11787.93,"UHC [10700]","United Healthcare",,24872.53,63.3,,,,,0,16149.46,24872.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DURASEAL EXACT SPINE SEALANT SYSTEM 3ML US BOX OF 5",SUP-206320,CDM,S27200284,LOCAL,0272,RC,,,both,,,6092.29,1827.69,"PHCS [10601]",PHCS,,4264.6,70,,,,,0,708.53,5178.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cardiovsn Elect Intrnl",PX-480000036,CDM,92961,CPT,0481,RC,,,both,,,986.88,296.06,"FIRST HEALTH [10303]","First Health",,789.5,80,,,,,0,114.77,986.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thromb Crnary Perc Mech",PX-481000013,CDM,92973,CPT,0481,RC,,,both,,,5491.00,1647.3,"KAISER [10500]",Kaiser,,3678.97,67,,,,,0,638.6,4667.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PORTICO FLEXNAV 107CM 6.3MM DELIVERY",SUP-FNAV-DS-LG,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXTR SURGICAL KATZ EXTR FOREIGN BODY REM OTO-RHINO STERILE",SUP-FB5000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1368.96,410.69,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 3X2CM BIODFENCE G3 HUMAN PLACENTAL MEMB",SUP-DF-020203,CDM,Q4140,HCPCS,0636,RC,,,both,,,9239.10,2771.73,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE BUTTRESS TIGHTROPE XP BONE STERILE LATEX FREE",SUP-AR-8959TDS,CDM,C1713,HCPCS,0278,RC,,,both,,,25168.50,7550.55,"BLUE CROSS [10001]","Blue Cross HMO",,9866.05,39.2,,957.42,156.86,7483.26,51,2927.1,21393.23,"percent of total billed charges",
"SHAVER BLADES STRAIGHT SHAFT 3MM SINGLE SERRATED STERILE",SUP-1600541-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"MULTIPLAN [10600]",Multiplan,,1204.88,85,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 140MM 12MM 7FR BILIARY VENOUS SELF EXPAND",SUP-G57435,CDM,C1876,HCPCS,0278,RC,,,both,,,14490.00,4347,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5955.39,41.1,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE CUTTER",SUP-10001-I,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Arm/Hnd Rt (Go)",PX-510000546,CDM,29584,CPT,0430,RC,,,both,,,891.00,267.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,891,,"Case rate ($1,729.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,103.62,891,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETERIZATION 4FR 25GA 2IN .018IN 2 LUMEN SPRING GWIRE",SUP-AK-12402,CDM,C1751,HCPCS,0272,RC,,,both,,,278.40,83.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,32.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JAGWIRE ENDOSCOPIC ANGLE 450CM .035IN HIGH PERFORMANCE",SUP-M00556591,CDM,C1769,HCPCS,0272,RC,,,both,,,932.72,279.82,"UHC [10700]","United Healthcare",,590.41,63.3,,,,,0,108.48,792.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERWIRE 2 38IN BRAID BLACK WHITE NONABSORBABLE",SUP-AR-7203,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.11,63.03,"AETNA [10100]","Aetna HMO/PPO",,167.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.44,178.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.160,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Open Access",,391.76,56.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 10MM APTUS TITANIUM HEXADRIVE 6 TAPER FOOT HAND",SUP-A-5400.10/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"MULTIPLAN [10600]",Multiplan,,1074.06,85,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 8.5INX.5MM HARDY BIPOLAR INSULATE",SUP-US410SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,2487.93,746.38,"CIGNA [10200]","Cigna Open Access",,1415.63,56.9,,,,,0,289.35,2114.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 4MM STOP QUICK COUPLING NONSTERILE",SUP-03.630.905,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELIANCE 4 FRONT PASSIVE FIXATION SINGLE COIL 59CM",SUP-0662,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"NOVANET [10819]",Novanet,,11385,75,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIATHLON PS X3 TIBIAL INSERT",SUP-5532-G-119,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]","Cigna Local Plus",,6105.74,53.5,,5372.07,4581.20,7242.98,23,1327.29,9700.71,"percent of total billed charges",
"CLIP SURGICAL 8MM 8MM STRAIGHT SOFT/SOFT DARK GRAY",SUP-A2201,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ROTAWIRE WIRECLIP TORQUER VASCULAR 330CM 2.2CM .014IN",SUP-H802228240022,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET STENT PURPLE 4CM 10FR ZIMMON .035IN 2 PIGTAIL CURVE",SUP-G21781,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT ORTHOPEDIC 15FTX1IN ROLL FIBERGLASS ORTHO-GLASS LATEX",SUP-OG-1L2,CDM,S27000186,LOCAL,0270,RC,,,both,,,225.50,67.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 80CM 40MM 4.8FR 9MM LOW PROFILE BALLOON",SUP-39032-90408,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cath Swan Ganz Alsius",PX-E27200073,CDM,C1751,HCPCS,0272,RC,,,both,,,2820.40,846.12,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BALLOON CERVICAL DILATATION 40CM 18FR COOK SILICONE RIPENING",SUP-G48149,CDM,C1726,HCPCS,0272,RC,,,both,,,527.60,158.28,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUSTOM PERFUSION FX PACK",SUP-75584,CDM,S27200284,LOCAL,0272,RC,,,both,,,2193.75,658.12,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRIVER NEEDLE DA VINCI XI ENDOWRIST MEGA 38 D L31.75 CM L1.3",SUP-470194,CDM,S27000186,LOCAL,0270,RC,,,both,,,1732.50,519.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 20MM 2.5MM BALLOON DILATATION RAPID",SUP-47525020M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTTER SUT REMOVAL FIBERTAPE ARTHROSCOPY",SUP-AR-13250,CDM,S27200284,LOCAL,0272,RC,,,both,,,7607.25,2282.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WIRE FIXATION .045IN 9IN BUSA KIRSCHNER STAINLESS STEEL FULL",SUP-KM173-39-45,CDM,C1713,HCPCS,0278,RC,,,both,,,59.29,17.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,6.9,50.4,"percent of total billed charges",
"PLATE STAINLESS STEEL 1.3 MM SCREWS 4 HOLE HEAD 8 HOLE SHAFT",SUP-221.334,CDM,C1713,HCPCS,0278,RC,,,both,,,2228.10,668.43,"PHCS [10601]",PHCS,,1559.67,70,,,,,0,259.13,1893.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 5CM 5FR TAPER CONTOUR SPIRAL OFFSET PANCREATIC",SUP-G21803,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,837.22,68,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL ZIPWIRE 22-30CM 3CM 6FR .035IN PIGTAIL",SUP-M006180156170,CDM,C2617,HCPCS,0278,RC,,,both,,,1271.86,381.56,"PHCS [10601]",PHCS,,890.3,70,,,,,0,147.92,1081.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CREO SPINE PREASSEMBLE THREAD",SUP-5119.1652,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Absc Smpl/Sngl",PX-510000002,CDM,10060,CPT,0761,RC,,,both,,,2149.01,644.7,"PHCS [10601]",PHCS,,1504.31,70,,,,,0,249.93,2149.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lymph Vessel X-Ray Arms/Legs",PX-323000039,CDM,75803,CPT,0320,RC,,,both,,,2624.56,787.37,"MULTIPLAN [10600]",Multiplan,,2230.88,85,,,,,0,305.24,2624.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 16CM 3MM BALLOON DILATATION HYDROPHILIC",SUP-G50332,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,279.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-04006,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"BLUE CROSS [10001]","Blue Cross HMO",,3513.54,39.2,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 230CM 25-30MM 10FR 270CM COLONIC NITINOL",SUP-M00565060,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DTECT CARBON DIOXIDE 43IN 12FR KANGAROO DOBBHOFF BELLOWS",SUP-711253CN,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.55,44.26,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.16,125.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY NDL 240CM 2.4MM RADIAL JAW 4 LARGE CAPACITY",SUP-M00513334,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.01,24,"KAISER [10500]",Kaiser,,53.61,67,,,,,0,9.31,68.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 8 5MM KNEE CRUCIATE RETAINING ROTATE PLATFORM",SUP-151630805,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"NOVANET [10819]",Novanet,,9845.44,75,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RX 80MM 194CM 10MM 8FR TAPER BILIARY METAL",SUP-M00569720,CDM,S27200284,LOCAL,0272,RC,,,both,,,11200.98,3360.29,"AETNA [10100]","Aetna HMO/PPO",,8904.78,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1302.67,9520.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.35MM 120MM TFN-ADVANCED TITANIUM ALUMINUM",SUP-04.038.220S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,1466.08,39.2,,957.42,570.23,957.42,28,434.96,3179,"percent of total billed charges",
"INSRT TIBIAL 2.5 17.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962334,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"PHCS [10601]",PHCS,,10152.66,70,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELCA 135CM 6FR .9MM ATHERECTOMY STAINLESS STEEL",SUP-110-004,CDM,C1714,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD BIPOLAR 24FR LOOP CUT STERILE LATEX FREE DISPOSABLE",SUP-27050GP-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1459.48,437.84,"FIRST HEALTH [10303]","First Health",,1167.58,80,,,,,0,169.74,1240.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT PARALLEL ALLOGRAFT 14MM TLIF",SUP-3W3314,CDM,S27800098,LOCAL,0278,RC,,,both,,,17139.60,5141.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7044.38,41.1,,,,,0,1993.34,14568.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 64MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.554S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1017.88,68,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0250,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 26CM 3CM 5FR .035IN",SUP-M006192123190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,948.76,68,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL DUALMESH 24X18CM SOFT TISSUE BIOMATERIAL",SUP-1DLMC06,CDM,C1781,HCPCS,0278,RC,,,both,,,8894.10,2668.23,"BLUE CROSS [10001]","Blue Cross PPO",,3486.49,39.2,,,,,0,1034.38,7559.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM PRIMARY GROUP B BIOFOAM DYNASTY",SUP-DBFPGG62,CDM,C1776,HCPCS,0278,RC,,,both,,,18194.40,5458.32,"CIGNA [10200]",Cigna,,7277.76,40,,5873.17,5873.17,5873.17,"1 through 10",2116.01,15465.24,"percent of total billed charges",
"GRAFT ENDOVASCULAR 7CM 14.5MM 12-13.5MM GORE EXCLUDER ILIAC",SUP-PLL161407,CDM,C1874,HCPCS,0278,RC,,,both,,,19725.30,5917.59,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2337.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2294.05,16766.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL ZIPWIRE 22-30CM 3CM 6FR .035IN PIGTAIL",SUP-M006180156170,CDM,C2617,HCPCS,0278,RC,,,both,,,1271.86,381.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,583.78,45.9,,,,,0,147.92,1081.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROCEED 8X6IN FASCIA FLEXIBLE TISSUE SEPARATE",SUP-PCDG1,CDM,C1781,HCPCS,0278,RC,,,both,,,5269.19,1580.76,"BLUE CROSS [10001]","Blue Cross HMO",,2065.52,39.2,,,,,0,612.81,4478.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 40MM 14MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044144070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3544.88,41.1,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +10 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-AR40E00100,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"CIGNA [10200]","Cigna Open Access",,530.02,56.9,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRAUMA SHEATH GWIRE NDL SYR ARROW-FLEX 3.5IN .035IN",SUP-AK-05801,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.27,57.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,79.02,41.1,,,,,0,22.36,163.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 35MM 35CM KINK RESISTANT CANN RADIOPAQUE 6",SUP-401735M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"KAISER [10500]",Kaiser,,69.95,67,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TIBIAL 6 KNEE TRABECULAR METAL MODULAR FIXED BEARING S",SUP-00595404702,CDM,C1713,HCPCS,0278,RC,,,both,,,9576.00,2872.8,"CIGNA [10200]","Cigna Open Access",,5448.74,56.9,,1144.80,304.56,2275.09,66,1113.69,8139.6,"percent of total billed charges",
"APPL INTERNAL CLIP LARGE 14IN ENDOSCOPIC HORIZON 12MM",SUP-438110,CDM,S27200284,LOCAL,0272,RC,,,both,,,13572.30,4071.69,"CIGNA [10200]","Cigna Open Access",,7722.64,56.9,,,,,0,1578.46,11536.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 18GA 8CM POWERGLIDE PRO REINFORCE TIP BASIC STERILE",SUP-F118080T,CDM,C1751,HCPCS,0272,RC,,,both,,,558.98,167.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,380.11,68,,,,,0,65.01,475.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3.5MM AVENIR COMPLEX 10 COIL FRAME",SUP-10CFR03504,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1389.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR 53MM MULTIPOLAR HIP METAL STERILE",SUP-500105300,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 22MM DCP STAINLESS STEEL CORTICAL HAND/FOOT",SUP-201.822,CDM,C1713,HCPCS,0278,RC,,,both,,,358.09,107.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,102.49,28.62,,,,,0,41.65,304.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 25MM KNEE GVF STABILIZE ROTATE PLATFORM PFC",SUP-962137,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"UHC [10700]","United Healthcare",,6459.83,63.3,,8601.07,8395.67,8601.07,"1 through 10",1186.85,8674.34,"percent of total billed charges",
"STENT PROTEGE EVERFLEX 80MM 80CM 5MM .079IN BILIARY NITINOL",SUP-PRB35-05-080-080,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross HMO",,2181.48,39.2,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3.5MM 24MM TITANIUM CORTEX SELF TAP CRUCIFORM",SUP-401.824,CDM,C1713,HCPCS,0278,RC,,,both,,,397.07,119.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,182.26,45.9,,,,,0,46.18,337.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vep Test Cns",PX-740000016,CDM,95930,CPT,0740,RC,,,both,,,2256.00,676.8,"CIGNA [10200]","Cigna Local Plus",,1206.96,53.5,,,,,0,262.37,1917.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DTECT CARBON DIOXIDE 43IN 12FR KANGAROO DOBBHOFF BELLOWS",SUP-711253CN,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.55,44.26,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,60.64,41.1,,,,,0,17.16,125.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BIO AVS 0D LORDOSIS 12MM ALLOGRAFT C PLUG 14X8MM",SUP-77102080,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2MM AXIUM PRIME HELIX DETACHABLE EXTRA",SUP-APB-2-3-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"BLUE CROSS [10001]","Blue Cross PPO",,3502.72,39.2,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins/Rplc Temp Elec/Pmkr Sngl",PX-480000005,CDM,33210,CPT,0481,RC,,,both,,,9369.81,2810.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9369.81,,"Case rate ($12,174). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1089.71,9369.81,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 19MM 51MM SHOULDER ECLIPSE STERILE ARTHROPLASTY",SUP-AR-9351-19,CDM,C1776,HCPCS,0278,RC,,,both,,,4105.50,1231.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1174.99,28.62,,,,,0,477.47,3489.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 94MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 10",SUP-247.374,CDM,C1713,HCPCS,0278,RC,,,both,,,2429.70,728.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1652.2,68,,,,,0,282.57,2065.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 6.5X55MM POLYAXIAL 4S RELINE-O",SUP-13116555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH UHP-L BREAST IMPLANTS 1135 CC",SUP-350-51135L,CDM,A4648,HCPCS,0278,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYNX CONTROL 5FR CLSR 10ML 2 MODE BALLOON CATH SEAL",SUP-MX5060,CDM,C1760,HCPCS,0272,RC,,,both,,,1680.00,504,"UHC [10700]","United Healthcare",,1063.44,63.3,,,,,0,690.48,1063.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC",728,MS-DRG,,,,,,,inpatient,,,23237.50,6971.25,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,5182.88,,"Case rate ($5,031.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,672.48, add-ons for qualifying new technology services are included. If operating cost exceeds $37,712.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,735.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $4,678.66. The transfer operating threshold is the transfer adjustment factor * $4,672.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $353.26. The transfer capital threshold is the transfer adjustment factor * $353.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,5031.92,20230.52,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 9MM KNEE BEARING POSTERIOR STABILIZE",SUP-5532-G-409-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"UHC [10700]","United Healthcare",,7224.18,63.3,,8601.07,8395.67,8601.07,"1 through 10",1327.29,9700.71,"percent of total billed charges",
"HC Xr Knee >=4v Complt",PX-320000083,CDM,73564,CPT,0320,RC,,,both,,,665.76,199.73,"UHC [10700]","United Healthcare",,261.88,,,,,,,56.97,565.9,"fee schedule",
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 7MM BALLOON",SUP-U357576,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM VENTURE TITANIUM LOW PROFILE SPINE",SUP-9790315,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",117.75,860.63,"percent of total billed charges",
"GWIRE PT2 VASCULAR 185CM 2CM .014IN STAINLESS STEEL NITINOL",SUP-H74938931030,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM TITANIUM 4/5.5MM SCR LOW PROFILE BRIDGE FUSION",SUP-SP02003L,CDM,C1713,HCPCS,0278,RC,,,both,,,17677.80,5303.34,"CIGNA [10200]","Cigna Open Access",,5922.06,33.5,,1144.80,304.56,2275.09,66,2055.93,15026.13,"percent of total billed charges",
"GWIRE TRANSEND VASCULAR 205CM 2CM .014IN SCITANIUM ICE",SUP-M001468070,CDM,C1769,HCPCS,0272,RC,,,both,,,3942.52,1182.76,"NOVANET [10819]",Novanet,,2956.89,75,,,,,0,458.52,3351.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM TSRH OSTEOGRIP TITANIUM SHORT SPINE",SUP-83575358,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.10,1106.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,437.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,429.04,3135.74,"percent of total billed charges",
"CATH PCP040200150 PLUS US D4L200UL1500",SUP-PCP040200150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"FIRST HEALTH [10303]","First Health",,984.96,80,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM MR CONDITIONAL BIPOLAR ULTIPACE STEROID",SUP-LPA1231/52,CDM,C1898,HCPCS,0275,RC,,,both,,,2250.00,675,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,643.95,28.62,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BARR ADHESION 5X3IN BIORESORBABLE 2 SHEET DEHP FREE",SUP-6642-01,CDM,C1765,HCPCS,0278,RC,,,both,,,4258.56,1277.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,495.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,495.27,3619.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER RYDER 7IN SERRATE JAW SURGICAL TUNGSTEN CARBIDE 1MM",SUP-32-467,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.96,105.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ATTAIN CLARITY BALLOON OCCLUSION VENOGRAM",SUP-6225,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) HELO PE THROMBECTOMY SYSTEM",SUP-10001,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 80MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-583508022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 25MM 3.3MM MODULAR STERILE",SUP-21073325,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NANOCROSS 150CM 80MM 2.5MM .014IN BALLOON DILATATION",SUP-AB14W025080150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TYSHAK II 100CM 6CM 8FR 22MM .035IN BALLOON DILATATION",SUP-611938,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 5.5MM FRMLA 6 FLUTE ROUND REPROCESSED F SERIES",SUP-0375950000,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COAG SUCTION 6IN 10FR 3/8IN VALLEYLAB POLYOLEFIN PLASTIC",SUP-E3310NSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.39,24.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAFESHEATH INTRDCR FR8 LONG - EACH",SUP-668001-001,CDM,C1892,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUT 1 DIAMOND POINT SUTURETAK SMALL JOINT 2 NDL",SUP-AR-8934BCNF,CDM,C1713,HCPCS,0278,RC,,,both,,,2559.38,767.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,732.49,28.62,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 150MM 12.5MM LPS BOW KNEE FEMUR POROCOAT COCR",SUP-198716211,CDM,C1776,HCPCS,0278,RC,,,both,,,42547.68,12764.3,"CIGNA [10200]","Cigna Local Plus",,13402.52,31.5,,5372.07,4581.20,7242.98,23,4948.3,36165.53,"percent of total billed charges",
"SPACER SPINAL 7MM CATALYFT PL SHORT",SUP-6068073,CDM,S27800098,LOCAL,0278,RC,,,both,,,39060.00,11718,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16053.66,41.1,,,,,0,4542.68,33201,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INTROCAN SAFETY 1.25IN 24GA STRAIGHT IV POLYURETHANE",SUP-4251623-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.55,16.96,"NOVANET [10819]",Novanet,,42.41,75,,,,,0,6.58,48.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP INTRACK 66MM WHITE INLAY STEP SOFT HIGHLY",SUP-N-10174,CDM,S27200284,LOCAL,0272,RC,,,both,,,267.09,80.13,"CIGNA [10200]",Cigna,,181.62,68,,,,,0,31.06,227.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT XEMPLIFI DEMINERALIZE BONE MATRIX PLUS 3ML",SUP-8103.0203S,CDM,C1713,HCPCS,0278,RC,,,both,,,3018.75,905.62,"BLUE CROSS [10001]","Blue Cross HMO",,1183.35,39.2,,957.42,156.86,7483.26,51,351.08,2565.94,"percent of total billed charges",
"SCR BONE 4.75MM 25MM COMPREHENSIVE 3.5MM SHOULDER FIX ANGLE",SUP-180552,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"MULTIPLAN [10600]",Multiplan,,1322.6,85,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM TITANIUM MIDFOOT CORTICAL LOCK",SUP-AR-8935L-16,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"SCR BONE 6MM 45MM TITANIUM SPINE CORTICAL POLYAXIAL FIX",SUP-186727645,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 15MM 5.5MM FOOT ANKLE VENT",SUP-AR-1555PS,CDM,C1713,HCPCS,0278,RC,,,both,,,2480.63,744.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1686.83,68,,,,,0,288.5,2108.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE CRANIOFACIAL TITANIUM 8 HOLE STRUT LOW PROFILE",SUP-421.523,CDM,C1713,HCPCS,0278,RC,,,both,,,4091.70,1227.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2782.36,68,,,,,0,475.86,3477.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM 4 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800490,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"SCR BONE 5.5MM 50MM SPINE POLYAXIAL REVOLVE",SUP-185.456,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Local Plus",,5107.56,53.5,,3978.14,359.25,3978.14,24,1110.3,8114.82,"percent of total billed charges",
"SCR BONE 3.5MM 16MM TITANIUM MIDFOOT CORTICAL LOCK",SUP-AR-8935L-16,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM CANCELLOUS",SUP-2020-6530-1,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA [10200]",Cigna,,517.75,68,,1831.33,1831.33,1831.33,16,88.55,647.19,"percent of total billed charges",
"SCR BONE 3.5MM 65MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-212.425,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.25,337.57,"KAISER [10500]",Kaiser,,753.92,67,,,,,0,130.87,956.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 ICONIX XBRAID KNOTLESS STERILE LATEX FREE",SUP-3911-723-522,CDM,C1713,HCPCS,0278,RC,,,both,,,3864.00,1159.2,"KAISER [10500]",Kaiser,,2588.88,67,,,,,0,449.38,3284.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.2MM 45MM CLICKX TITANIUM BUTTRESS SPINE PEDICLE",SUP-498.563,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,1470,39.2,,957.42,156.86,7483.26,51,436.13,3187.5,"percent of total billed charges",
"ROD SPINAL 170MM 4.75MM SOLERA STRAIGHT PERCUTANEOUS COCR",SUP-1476006170,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE EZDILATE 15 ATM INFLATION 60CC BALLOON SYR LOCK",SUP-MAJ-1740,CDM,S27000186,LOCAL,0270,RC,,,both,,,304.50,91.35,"CIGNA [10200]",Cigna,,207.06,68,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2 PACK OF DRIVERS ONLY",SUP-NCAAX2U,CDM,S27800098,LOCAL,0278,RC,,,both,,,430.65,129.19,"CIGNA [10200]",Cigna,,292.84,68,,,,,0,50.08,366.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 20MM LOOP ROUND 10MM MEGADYNE",SUP-0440,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.20,28.86,"UHC [10700]","United Healthcare",,60.89,63.3,,,,,0,11.19,81.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD ELECTROSURGICAL GROUNDING CORD DISPERSIVE ELECTRD ADULT",SUP-CRA-SGP,CDM,S27000186,LOCAL,0270,RC,,,both,,,72.58,21.77,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT CHROMIC 2-0 UR-6 27IN MONOFILAMENT ABSORBABLE",SUP-N878H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TENDYNE MITRAL VALVE LP 33M",SUP-TENDV-LP-33M-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"AETNA [10100]","Aetna HMO/PPO",,135945,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 120MM 135CM 5MM 5FR VASCULAR NITINOL LOW",SUP-5F051203CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 60MM 80CM 12MM 3MM VASCULAR ILIOFEMORAL VEIN",SUP-VENUM12060,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"PHCS [10601]",PHCS,,15435,70,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE 80MM 130CM 10MM .035IN LONG BILIARY NITINOL",SUP-SC1080LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"PHCS [10601]",PHCS,,5071.5,70,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 FLEXOR 30MM 125CM 6MM 5FR LOW PROFILE",SUP-G43770,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,495.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM TITANIUM 2.4MM SCR 7X3 HOLE 2 COLUMN VARIABLE",SUP-04.111.731,CDM,C1713,HCPCS,0278,RC,,,both,,,4274.55,1282.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,506.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,497.13,3633.37,"percent of total billed charges",
"CATH VIATRAC 14 PLUS 135CM 40MM 7MM BALLOON DILATATION",SUP-1008201-40,CDM,C1769,HCPCS,0272,RC,,,both,,,1417.50,425.25,"KAISER [10500]",Kaiser,,949.73,67,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH 1 90CM 7FR .081IN MUTLIPURPOSE CURVE GUIDING PTFE",SUP-M001197260,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"UHC [10700]","United Healthcare",,377.98,63.3,,,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE ORTHOPEDIC STAINLESS STEEL 1.8MM 36IN CERCLAGE STERILE",SUP-00223200128,CDM,C1713,HCPCS,0278,RC,,,both,,,4450.50,1335.15,"FIRST HEALTH [10303]","First Health",,3560.4,80,,,,,0,517.59,3782.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN AL.75 CURVE GUIDING CORONARY",SUP-LA7AL75SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X8MM LUMINARY 10-11MM SPINE DEMINERALIZED",SUP-14708,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"AETNA [10100]","Aetna HMO/PPO",,25042.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR RINGLOC 25 +3MM 40MM ARCOMXL HIP STERILE",SUP-XL-108525,CDM,C1776,HCPCS,0278,RC,,,both,,,7249.14,2174.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,843.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,843.07,6161.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD REAMER 15.5MM DEEP FLUTE STAINLESS STEEL CONICAL TIP",SUP-352.257S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2560.05,768.01,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1052.18,41.1,,,,,0,297.73,2176.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 1 MH 30IN BRAID BLACK NONABSORBABLE",SUP-K845H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AXIOS 10MM 146MM 10MM 21MM 138MM 10.8FR PANCREATIC",SUP-M00553740,CDM,C1874,HCPCS,0278,RC,,,both,,,24658.20,7397.46,"UHC [10700]","United Healthcare",,15608.64,63.3,,,,,0,2867.75,20959.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED DUAL MOBILITY HIP SYSTEM + CER HD",SUP-98000500322,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3284.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3223.84,23562,"percent of total billed charges",
"KIT DISPOSABLES CS FIBERTAK",SUP-AR-8991DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,2165.63,649.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,256.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,251.86,1840.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prep Wnd Tr/Ext >100scm",PX-510000047,CDM,15003,CPT,0761,RC,,,both,,,1731.00,519.3,"CIGNA [10200]","Cigna Local Plus",,1731,,"Per diem ($2,051).",,,,0,201.32,1731,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 63MM 33.8MM 25MM DURAN ANCORE 27.8MM 2",SUP-620BG25,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MITRL VAL INTPDMVL54C INTREPID 54MM CLIN",SUP-INTPDMVL54C,CDM,S62400003,LOCAL,0624,RC,,,both,,,256500.00,76950,"CIGNA [10200]","Cigna Local Plus",,137227.5,53.5,,,,,0,29830.95,218025,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENCIL SMOKE EVAC 10FT VALLEYLAB SM EDGE ELECTRD SLIM",SUP-VSMP10,CDM,S27200284,LOCAL,0272,RC,,,both,,,225.24,67.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,103.39,45.9,,,,,0,26.2,191.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X19MM 8D CONVEX LORDOTIC WEDGE",SUP-10619,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12946.5,41.1,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135CM 80MM 6FR 9MM .035IN LOW PROFILE BALLOON",SUP-B2090-080,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"FIRST HEALTH [10303]","First Health",,615.6,80,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8.5FR 60CM HEMOSTASIS GWIRE END HOLE FAST-CATH",SUP-406804,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT DELTA CSF REGULAR PERFORMANCE LEVEL 1.5 CHRONIC",SUP-42823,CDM,S27800098,LOCAL,0278,RC,,,both,,,12602.92,3780.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5179.8,41.1,,,,,0,1465.72,10712.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI 100CM 4FR AMPLATZ RIGHT 2 MODIFY CURVE",SUP-538443,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL STRAIGHT SICKLE",SUP-3722110,CDM,S27200284,LOCAL,0272,RC,,,both,,,922.10,276.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,107.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,107.24,783.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL CERVICAL THORACIC MA 55MM X 30MM RELINE-C",SUP-3935530,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FIX 12MM",SUP-288301112,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"MULTIPLAN [10600]",Multiplan,,3362.94,85,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 24MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.524,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"NOVANET [10819]",Novanet,,822.32,75,,,,,0,127.51,931.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR TRABECULAR METAL STEM STD HEAD",SUP-98786410000,CDM,C1776,HCPCS,0278,RC,,,both,,,15180.00,4554,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1765.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 83MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT SET 4",SUP-240.141,CDM,S27800098,LOCAL,0278,RC,,,both,,,3465.00,1039.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1590.44,45.9,,,,,0,402.98,2945.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRIMP CABLE STERNAL TITANIUM 2 PACK STERILE LATEX FREE",SUP-408-723,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"NOVANET [10819]",Novanet,,228.38,75,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING ORANGE 20IN 5FR ENTERAL POLYURETHANE HUB END",SUP-ENFPU2050LD,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.84,17.65,"CIGNA [10200]",Cigna,,40.01,68,,,,,0,6.84,50.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 300MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.640S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"BLUE CROSS [10001]","Blue Cross HMO",,3258.47,39.2,,957.42,156.86,7483.26,51,966.74,7065.57,"percent of total billed charges",
"CBL PCNG ADPR PAC LOC SF DEV",SUP-344025,CDM,C1893,HCPCS,0272,RC,,,both,,,408.90,122.67,"UHC [10700]","United Healthcare",,258.83,63.3,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 100MM 5.4FR 6MM BALLOON DILATATION 2",SUP-BD-L60100CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"AETNA [10100]","Aetna HMO/PPO",,763.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 60MM 120MM 10MM .035IN 3MM VASCULAR VENOUS",SUP-VENUL10060,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5953.5,27,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 3.5MM 42MM OMEGA3 STAINLESS STEEL FULL THREAD",SUP-340640,CDM,C1713,HCPCS,0278,RC,,,both,,,255.78,76.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,117.4,45.9,,,,,0,29.75,217.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE FIBER OPTIC MAXCESS LIGHT PLIF MAS STERILE",SUP-3400044,CDM,S27200284,LOCAL,0272,RC,,,both,,,2973.75,892.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1222.21,41.1,,,,,0,345.85,2527.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 43IN 10FR SMOOTH BOLUS RADIOPAQUE STYLET",SUP-40-3431,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.04,21.61,"CIGNA [10200]","Cigna Open Access",,40.99,56.9,,,,,0,8.38,61.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM SKYLINE TITANIUM SPINE CERVICAL ANTERIOR",SUP-186852014,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"KAISER [10500]",Kaiser,,944.7,67,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL BLUE 12MM SYNFIX 14D SMALL EVOLUTION 6.7MM 1.9",SUP-08.815.122S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Local Plus",,8930.25,31.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM SKYLINE TITANIUM SPINE CERVICAL ANTERIOR",SUP-186852014,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"AMERIGROUP MEDICAID [20100]",Amerigroup,,167.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",163.98,1198.5,"percent of total billed charges",
"CATH BALLOON DILATATION .018IN 4FR 3MM 150CM 100MM SMALL",SUP-83971-02,CDM,C1725,HCPCS,0272,RC,,,both,,,3037.50,911.25,"AETNA [10100]","Aetna HMO/PPO",,2414.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,353.26,2581.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX MEDIUM C6 8MM X",SUP-T600206,CDM,S27800098,LOCAL,0278,RC,,,both,,,3150.00,945,"CIGNA [10200]","Cigna Local Plus",,1685.25,53.5,,,,,0,366.35,2677.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TISSUE LORDOTIC ALLOGRAFT ANTERIOR SEPTAL",SUP-345844,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 8.5MM TANNE UNIVERSAL TREPHINE UNIQUE HUB","SUP-E3050 8.50",CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"MULTIPLAN [10600]",Multiplan,,469.91,85,,,,,0,64.29,469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC SLIDE LOCK AGGRESSIVE JAW",SUP-95-1048SL,CDM,S27000186,LOCAL,0270,RC,,,both,,,4322.02,1296.61,"CIGNA [10200]","Cigna Local Plus",,2312.28,53.5,,,,,0,502.65,3673.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6' DX CABLE, AUTOCLAVABLE",SUP-C6MRMST8SA,CDM,S27000186,LOCAL,0270,RC,,,both,,,2115.00,634.5,"UHC [10700]","United Healthcare",,1338.8,63.3,,,,,0,245.97,1797.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 22IN 5FR PORT ANTICLOG RADIOPAQUE BOW TIP",SUP-20-C1225,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.97,23.99,"MULTIPLAN [10600]",Multiplan,,67.97,85,,,,,0,9.3,67.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAPROXEN 250 MG TABLET, IMMEDIATE RELEASE",RX-5391,CDM,,,0637,RC,65162-0188-10,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,3.57,56.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT CEMEX FEMORAL PREP",SUP-KIT-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1435.89,430.77,"UHC [10700]","United Healthcare",,908.92,63.3,,,,,0,166.99,1220.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION 16FR SURESTEP BARDEX IC COMPLETE CARE",SUP-A300316A,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.29,41.79,"CIGNA [10200]",Cigna,,94.72,68,,,,,0,16.2,118.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEPHEA MITRAL VALVE TRACK 2 36MM",SUP-23036,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.5MM",SUP-6149.1037,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"CIGNA [10200]","Cigna Local Plus",,2116.67,53.5,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 60MM 120CM 6MM VASCULAR PERIPHERAL SELF",SUP-PRB35-06-060-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Local Plus",,2977.28,53.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL 15X6MM MOBI-C 15MM SPINE CERVICAL TITANIUM COCRMO","SUP-MB 3556",CDM,S27800098,LOCAL,0278,RC,,,both,,,33075.00,9922.5,"BLUE CROSS [10001]","Blue Cross PPO",,12965.4,39.2,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9CM 6MM INTERLOCK FIBERED IDC DETACHABLE",SUP-M001363920,CDM,S27800098,LOCAL,0278,RC,,,both,,,2827.50,848.25,"CIGNA [10200]","Cigna Local Plus",,1512.71,53.5,,,,,0,328.84,2403.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 018 100CM 300MM 5MM BALLOON DILATATION STERILE",SUP-LX1810053005F,CDM,C2623,HCPCS,0272,RC,,,both,,,18270.00,5481,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7508.97,41.1,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT SIGMA 1.5 KNEE POROCOAT",SUP-129434115,CDM,C1776,HCPCS,0278,RC,,,both,,,17561.25,5268.37,"CIGNA [10200]","Cigna Local Plus",,5531.79,31.5,,5372.07,4581.20,7242.98,23,2042.37,14927.06,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS 30CM 3CM 6FR .038IN 2 PIGTAIL",SUP-M006192135010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,142.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 8FR .038IN STRAIGHT PIGTAIL CURVE URETERAL",SUP-M006145379010,CDM,C2617,HCPCS,0278,RC,,,both,,,940.57,282.17,"BLUE CROSS [10001]","Blue Cross HMO",,368.7,39.2,,,,,0,109.39,799.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM ENDOCARDIUM 4 SITE 2 COIL ACTIVE FIXATION",SUP-0276,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4636.44,27,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 CT-3 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP329H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.48,45.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM SYNAPSE TITANIUM 40D SPINE CORTEX",SUP-04.614.334,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX BRITE TIP 30MM 135CM 7MM .065IN",SUP-PC0730RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"BLUE CROSS [10001]","Blue Cross PPO",,2975.28,39.2,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.185,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32MM NCB PROTASUL-64 3.5MM SELF TAP 2 LEAD",SUP-0203150032,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,852.02,45.9,,,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING 2 HEAT PARALLEL Y PORT DRY GAS LINE MDI",SUP-RT210,CDM,S27000186,LOCAL,0270,RC,,,both,,,240.12,72.04,"AETNA [10100]","Aetna HMO/PPO",,190.9,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.93,204.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR POROUS PRIMARY BIPOLAR STD HEAD",SUP-98B00100102,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1226.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1203.71,8797.5,"percent of total billed charges",
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 24MM 144CM 4MM",SUP-H7493941224400,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2221.63,28.62,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR ARTEGRAFT BOVINE CAROTID ARTERY L45 CM OD7 MM",SUP-AG845,CDM,C1768,HCPCS,0278,RC,,,both,,,17759.70,5327.91,"BLUE CROSS [10001]","Blue Cross HMO",,6961.8,39.2,,,,,0,2065.45,15095.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752540,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,414.1,45.9,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 30CM 3CM 7FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006180235050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,123.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.14,885.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 420-500ML STYLE",SUP-3503420,CDM,C1789,HCPCS,0278,RC,,,both,,,2350.00,705,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,672.57,28.62,,,,,0,273.31,1997.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER/DIVIDER LAPAROSCOPIC 37CM LIGASURE BLUNT TIP NONSTICK",SUP-LF1837,CDM,S27200284,LOCAL,0272,RC,,,both,,,3140.63,942.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,372.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,365.26,2669.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HI-FLO RENEGADE 105CM 10CM 3-2.8FR .027IN MICRO",SUP-M001182840,CDM,C1887,HCPCS,0272,RC,,,both,,,2100.00,630,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1428,68,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 262MM STAINLESS STEEL 4.5MM SCR 14 HOLE LCP BONE LEFT",SUP-240.047,CDM,C1713,HCPCS,0278,RC,,,both,,,9088.13,2726.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1056.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1056.95,7724.91,"percent of total billed charges",
"SYSTEM PINPOINT PAQ ENDOSCOPIC FLUORESCENCE IMAGE",SUP-PP9036,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM TSRH OSTEOGRIP TITANIUM SPINE",SUP-83575451,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"NOVANET [10819]",Novanet,,1930.5,75,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL RAPIDE MULTIPASS 5-0 PC-1 18IN BRAID COATED",SUP-VR834,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.27,21.68,"UHC [10700]","United Healthcare",,45.75,63.3,,,,,0,8.41,61.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM TRIATHLON 2 LEFT MEDIAL RIGHT LATERAL",SUP-5612-A-211,CDM,C1776,HCPCS,0278,RC,,,both,,,9878.04,2963.41,"MULTIPLAN [10600]",Multiplan,,8396.33,85,,,,,0,1148.82,8396.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 14FR 70CM PLASTIC NATURAL RUBBER TAPERED",SUP-DMS-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,82.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE WALKING LARGE ANKLE FOOT PNEUMATIC LOW ROCKER SOLE",SUP-01F-L,CDM,L4360,HCPCS,0274,RC,,,both,,,393.41,118.02,"BLUE CROSS [10001]","Blue Cross HMO",,154.22,39.2,,,,,0,45.75,334.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 115MM 6MM UNIVERS II SHOULDER STERILE",SUP-AR-9100-06P,CDM,C1776,HCPCS,0278,RC,,,both,,,10713.60,3214.08,"PHCS [10601]",PHCS,,7499.52,70,,,,,0,1245.99,9106.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 82MM 10MM 14FR ENDURANT II ABDOMINAL",SUP-ETEW1010C82E,CDM,S27800098,LOCAL,0278,RC,,,both,,,28331.10,8499.33,"PHCS [10601]",PHCS,,19831.77,70,,,,,0,3294.91,24081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 700ML GEL SMOOTH ROUND",SUP-3507004BC,CDM,C1789,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Open Access",,3533.49,56.9,,5166.00,5166.00,5166.00,"1 through 10",722.22,5278.5,"percent of total billed charges",
"INSRT ARTICULAR 3-4 C-H STD 66X42X14MM KNEE PROLONG NEXGEN",SUP-00595203014,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,929.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,911.77,6663.81,"percent of total billed charges",
"LINER ACETABULAR G7 FREEDOM H 36MM E1 HIP CONSTRAIN",SUP-010000986,CDM,C1776,HCPCS,0278,RC,,,both,,,19199.88,5759.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5183.97,27,,,,,0,2232.95,16319.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONVEY 5FR .058IN CONTRALATERAL SPRT 3.5 CURVE GUIDING",SUP-H749392285740,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"PHCS [10601]",PHCS,,256.51,70,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 3CM 170CM 7FR 2 PIGTAIL CURVE BILIARY",SUP-G22159,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,180.82,28.62,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR INLINE SENSOR INJECTATE SYR COOL COIL",SUP-680000,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.44,81.43,"CIGNA [10200]","Cigna Local Plus",,145.22,53.5,,,,,0,31.57,230.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRAMIPEXOLE 1 MG TABLET",RX-21288,CDM,,,0637,RC,60687-0592-11,NDC,both,1,UN,6.67,2,"KAISER [10500]",Kaiser,,4.47,67,,,,,0,0.78,5.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 22MM  COCR",SUP-VAL-35220-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"PHCS [10601]",PHCS,,1470,70,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR ENDOSCOPIC FLOSEAL STERILE DISPOSABLE",SUP-110860,CDM,S27200284,LOCAL,0272,RC,,,both,,,624.75,187.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,286.76,45.9,,,,,0,72.66,531.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9CM 3.5MM CEREPAK XTRASOFT FREEFORM",SUP-XCR123509,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"AETNA [10100]","Aetna HMO/PPO",,10514.55,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 20MM SAPIEN 3 ULTRA RESILIA",SUP-S3URCM20A,CDM,S27800098,LOCAL,0278,RC,,,both,,,193800.00,58140,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,55465.56,28.62,,,,,0,22538.94,164730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL G RIGHT KNEE POSTERIOR STABILIZED NEXGEN",SUP-00576401752,CDM,C1776,HCPCS,0278,RC,,,both,,,16934.40,5080.32,"MULTIPLAN [10600]",Multiplan,,14394.24,85,,,,,0,1969.47,14394.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SENSOR 22CM 8FR .038IN 2 FLOPPY URETERAL PERCUFLEX",SUP-M006175281120,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"CIGNA [10200]","Cigna Local Plus",,711.69,,,,,,,154.71,1130.72,"percent of total billed charges",
"SALVATION FLANGE NUT 10MM",SUP-SEF33001,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"FIRST HEALTH [10303]","First Health",,712.8,80,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM .0115IN AXIUM PRIME LATTICEFX 3D",SUP-APB-4-6-3D-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,9591.00,2877.3,"BLUE CROSS [10001]","Blue Cross PPO",,3759.67,39.2,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 22.5MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962346,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"BLUE CROSS [10001]","Blue Cross PPO",,5685.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",1686.79,12328.23,"percent of total billed charges",
"ROD SPINAL 500MM 6MM CREO COCR HEXAGON END",SUP-7120.25,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3.3MM 0 POPLOK HI-FI SECURE FIXATION VERSATILE",SUP-GKP-3302,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT REPAIR SUBSCAPULARIS LARGE",SUP-110046455,CDM,S27200284,LOCAL,0272,RC,,,both,,,4359.42,1307.83,"FIRST HEALTH [10303]","First Health",,3487.54,80,,,,,0,507,3705.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 300MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035300S,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"MULTIPLAN [10600]",Multiplan,,1593.75,85,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPIN ACCESS CATH 90D BRACHYTHERAPY OLYMPUS 190 SCOPE",SUP-INS-5910,CDM,S27200284,LOCAL,0272,RC,,,both,,,7452.00,2235.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5067.36,68,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE PROGRESS 120 VASCULAR STRAIGHT 190CM 3CM",SUP-1011844,CDM,C1769,HCPCS,0272,RC,,,both,,,1036.80,311.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,705.02,68,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 83MM VANGUARD 360 KNEE POROUS PRIMARY REVISION",SUP-185206,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,5372.07,4581.20,7242.98,23,2014.9,14726.25,"percent of total billed charges",
"HC Transplant Eval Liver Day 1",PX-761000001,CDM,99215,CPT,0761,RC,,,both,,,1146.00,343.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1.15,.1,,,,,0,1.15,1146,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 26MM HIP PRIMARY TAPER OFFSET COCR V40",SUP-6260-9-126,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"MULTIPLAN [10600]",Multiplan,,2658.55,85,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 5MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR050502A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"NOVANET [10819]",Novanet,,12678.75,75,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 20CM 3CM 7FR .038IN 2 PIGTAIL",SUP-M006192140010,CDM,C2617,HCPCS,0278,RC,,,both,,,1167.78,350.33,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,536.01,45.9,,,,,0,135.81,992.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 4.75MM STRAIGHT PERCUTANEOUS CCM PLUS",SUP-1476006080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL INTUITIVE DA VINCI XI BLACK 60",SUP-12BSGXI60BK,CDM,S27200284,LOCAL,0272,RC,,,both,,,1323.00,396.9,"UHC [10700]","United Healthcare",,837.46,63.3,,,,,0,153.86,1124.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PANCREATIC 5FR L5CM CATHETER L170CM 0.035IN 2MM ACCESS",SUP-G22209,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PHCS [10601]",PHCS,,861.84,70,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Spinal W/Lidocaine",PX-E27200181,CDM,E27200181,LOCAL,0272,RC,,,both,,,108.17,32.45,"CIGNA [10200]",Cigna,,73.56,68,,,,,0,12.58,91.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 4FR 17.8CM VESSEL ACCEPTS .035IN GWIRE",SUP-504404X,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.26,26.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.15,74.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM MEDLINE UNITE FOOT ANKLE NONLOCK",SUP-MPSN3520,CDM,C1713,HCPCS,0278,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT TOE BLUE SWANSON 6 REGULAR METATARSOPHALANGEAL",SUP-4260006,CDM,C1776,HCPCS,0278,RC,,,both,,,7265.70,2179.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4940.68,68,,,,,0,845,6175.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 150MM 3MM BALLOON DILATATION RAPID",SUP-47530150L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.0MM X 18MM TI",SUP-VAN-20180-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]",Cigna,,660.96,68,,1831.33,1831.33,1831.33,16,113.04,826.2,"percent of total billed charges",
"HC Grad Compression 18-30",PX-E27100005,CDM,S8424,HCPCS,0292,RC,,,both,,,366.00,109.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.88,68,,,,,0,42.57,311.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 9MM 140CM 3MM CORONARY STERILE LATEX",SUP-453928,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17MM 11MM COMPLEX .018IN HELICAL PLATINUM",SUP-M0013120771,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 17MM CHARLOTTE TITANIUM HAND FOOT SELF",SUP-45110006,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"SCR BONE 5.5MM 40MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840045540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Open Access",,5432.16,56.9,,1144.80,304.56,2275.09,66,1110.3,8114.82,"percent of total billed charges",
"EXT STEM 30MM 15MM PFC 46IN KNEE TIBIA CEMENT",SUP-866403,CDM,C1776,HCPCS,0278,RC,,,both,,,5092.20,1527.66,"AETNA [10100]","Aetna HMO/PPO",,4048.3,79.5,,10981.53,8986.79,12413.38,12,592.22,4328.37,"percent of total billed charges",
"FILLER BONE VOID 3.4CC 15X15X15MM DEMINERALIZED CANCELLOUS",SUP-0W1015,CDM,S27800098,LOCAL,0278,RC,,,both,,,5313.00,1593.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,629.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,617.9,4516.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM .91-1.12MM 2.75MM CORONARY",SUP-RONYX27508W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]","Cigna Local Plus",,1805.63,53.5,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL SHOULDER HEMICAPOVO 54MM 50MM OFFSET OVOID",SUP-8H02-5450-W,CDM,S27800098,LOCAL,0278,RC,,,both,,,18585.00,5575.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7638.44,41.1,,,,,0,2161.44,15797.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS 17.0 DIOPTER",SUP-MTA3UO170,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]",Cigna,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE RIGHT CRUCIATE RETAIN PERSONA PPS",SUP-42508606202,CDM,C1776,HCPCS,0278,RC,,,both,,,29326.50,8797.95,"BLUE CROSS [10001]","Blue Cross PPO",,11495.99,39.2,,3949.44,3949.44,3949.44,"1 through 10",3410.67,24927.53,"percent of total billed charges",
"STENT CONTOUR 28CM 150CM 6FR .038IN STD STRAIGHT URETERAL",SUP-M006180524170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,837.05,68,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 13MM 345MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.749S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"NOVANET [10819]",Novanet,,6234.32,75,,,,,0,966.74,7065.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL H+6MM 42MM AEQUALIS ASCEND FLEX 12.5D SHOULDER",SUP-DWF424B,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"MULTIPLAN [10600]",Multiplan,,7673.8,85,,,,,0,1049.96,7673.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC So Gsap Cll Fr Mcrstl Ins",PX-310000022,CDM,81464,CPT,0310,RC,,,both,,,5525.00,1657.5,"KAISER [10500]",Kaiser,,3701.75,67,,,,,0,0.01,4696.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 1300MM 150MM 4MM BALLOON DILATATION",SUP-ADM04015013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,938.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4MM COOLCUT STERILE DISPOSABLE",SUP-AR-8400DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"NOVANET [10819]",Novanet,,376.35,75,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER 6227DEF04 ATTAIN GLOBAL",SUP-6227DEF04,CDM,C1887,HCPCS,0272,RC,,,both,,,4830.00,1449,"NOVANET [10819]",Novanet,,3622.5,75,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 40MMX8MMX20CM 26FR",SUP-TAC084020A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,49248,27,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL EMG NIM XPAK BLUNT",SUP-PK1010,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE S+ 5 KNEE CEMENT FIX BEARING",SUP-150670005,CDM,C1776,HCPCS,0278,RC,,,both,,,15487.05,4646.11,"CIGNA [10200]","Cigna Open Access",,5188.16,33.5,,5302.19,4377.88,6578.61,27,1801.14,13163.99,"percent of total billed charges",
"SPACER SPINAL 45X8-15MM ELSA 6D 20MM",SUP-1122.0145,CDM,S27800098,LOCAL,0278,RC,,,both,,,50400.00,15120,"BLUE CROSS [10001]","Blue Cross PPO",,19756.8,39.2,,,,,0,5861.52,42840,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 15GA 24-48MM ILLINOIS ADJUSTABLE DEPTH STOP T",SUP-DIN1515X,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.20,24.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.44,69.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 194MM 12MM COMPREHENSIVE POROUS SHOULDER",SUP-113672,CDM,C1776,HCPCS,0278,RC,,,both,,,17863.20,5358.96,"BLUE CROSS [10001]","Blue Cross HMO",,7002.37,39.2,,5311.50,4717.44,5388.59,31,2077.49,15183.72,"percent of total billed charges",
"AUG FEMORAL 4MM PFC SIGMA TC3 3 KNEE RIGHT TITANIUM CEMENTED",SUP-960861,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"PHCS [10601]",PHCS,,3591.59,70,,,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 12MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50012,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9838.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 28MM PERIPHERAL STERILE",SUP-AR-9562-28NL,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,69.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",69.48,507.77,"percent of total billed charges",
"GRAFT BONE GRAFTON DEMINERALIZED BONE MATRIX .25CC PUTTY SYR",SUP-T43204,CDM,C1713,HCPCS,0278,RC,,,both,,,432.39,129.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,50.29,367.53,"percent of total billed charges",
"CATH SHOCKWAVE E8 150CM 80MM 4MM LITHOTRIPSY PERIPHERAL",SUP-E8IVL040080,CDM,C1725,HCPCS,0272,RC,,,both,,,29610.00,8883,"NOVANET [10819]",Novanet,,22207.5,75,,,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 40.5MM SAFEDGE THK.025IN STERNUM SAGITTAL CUT EDGE",SUP-2108125000,CDM,S27200284,LOCAL,0272,RC,,,both,,,258.22,77.47,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,106.13,41.1,,,,,0,30.03,219.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 470CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRX-470,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,470.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SLIP-CATH BEACON TIP 90CM 5FR RUC CURVE ANGIOGRAPHIC",SUP-G31234,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"KAISER [10500]",Kaiser,,233.16,67,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 3.25IN 18GA 20GA PAJUNK E-CATH 21GA",SUP-TDL112,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"NOVANET [10819]",Novanet,,400.95,75,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAMIVUDINE 100 MG TABLET",RX-24419,CDM,,,0637,RC,60505-3250-06,NDC,both,1,UN,60.90,18.27,"CIGNA [10200]","Cigna Local Plus",,32.58,53.5,,,,,0,7.08,51.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 32MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-032,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6081.98,28.62,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 6 STD KNEE RIGHT KEEL NONPOROUS",SUP-ETPKN6SR,CDM,C1776,HCPCS,0278,RC,,,both,,,11060.70,3318.21,"KAISER [10500]",Kaiser,,7410.67,67,,,,,0,1286.36,9401.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +11.5 DIOPTER +6 CYL BICONVEX 13MM 6MM",SUP-SN6AT9,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Local Plus",,184.58,53.5,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES 145CM 40MM 4MM .014IN BALLOON DILATATION OTW",SUP-39134-40401,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AIRWAY LARYNGEAL MASK ADULT SIZE 5 OROGASTRIC TUBE 14FR 45ML",SUP-ALBF050SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.97,31.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KWIRE 0.9MM X 127MM DOUBLE TROCAR",SUP-KWIR-DT-09127,CDM,S27000186,LOCAL,0270,RC,,,both,,,234.90,70.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION",RX-7351,CDM,,,0250,RC,63323-0884-01,NDC,both,5,ML,175.84,52.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACING TEMPORARY BIPOLAR BALLOON SHROUD PIN XTW INTRO",SUP-AI-07155-KS,CDM,C1733,HCPCS,0272,RC,,,both,,,1657.50,497.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,MINOR",233,APR-DRG,,,,,,,inpatient,,,70653.22,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488.00. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.20. DRG Reimbursement is equal to $7,505.10. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%.",,,,0,,,other,"SOI-1 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SAFARI GUIDEWIRE",SUP-H74939406XS0,CDM,C1769,HCPCS,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POINTER NAVIGATION AXIEM TRACER STERILE LATEX FREE",SUP-9735317,CDM,S27200284,LOCAL,0272,RC,,,both,,,3919.20,1175.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CIPROFLOXACIN 250 MG TABLET",RX-25118,CDM,,,0250,RC,43547-0688-10,NDC,both,1,UN,22.31,6.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT VASCULAR 30CM 26MM GELWEAVE VASCUTEK STRAIGHT THORACIC",SUP-733026,CDM,C1768,HCPCS,0278,RC,,,both,,,6831.00,2049.3,"BLUE CROSS [10001]","Blue Cross PPO",,2677.75,39.2,,,,,0,794.45,5806.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ACCULINK 40MM 132CM 8MM STRAIGHT VASCULAR NITINOL",SUP-1011340-40,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"BLUE CROSS [10001]","Blue Cross PPO",,3669.12,39.2,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 135CM 200MM 3MM .035IN BALLOON",SUP-AB35W03200135,CDM,C1725,HCPCS,0272,RC,,,both,,,1061.91,318.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,722.1,68,,,,,0,123.5,902.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 7IN ANGLE UP INTERVERTEBRAL DISC 10X2MM CUSHING",SUP-280406,CDM,S27200284,LOCAL,0272,RC,,,both,,,1564.60,469.38,"NOVANET [10819]",Novanet,,1173.45,75,,,,,0,181.96,1329.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPICILLIN SODIUM 2 G/16ML IJ (WET SOLR VIAL)",RX-415472,CDM,J0290,HCPCS,0636,RC,55150-0114-20,NDC,both,1,UN,120.16,36.05,"CIGNA [10200]",Cigna,,6.38,,,,,,,2.56,102.14,"fee schedule",
"SCR BONE 3.5MM 36MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.115,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"FIRST HEALTH [10303]","First Health",,685.84,80,,,,,0,99.7,728.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA MEDIAL CONGRUENT 4-5 C-D KNEE",SUP-42512100313,CDM,C1776,HCPCS,0278,RC,,,both,,,9466.80,2840.04,"BLUE CROSS [10001]","Blue Cross HMO",,3710.99,39.2,,5311.50,4717.44,5388.59,31,1100.99,8046.78,"percent of total billed charges",
"HC Observation Carve-Out Dialysis",PX-762000018,CDM,G0378,HCPCS,0762,RC,,,both,,,66.00,19.8,"CIGNA [10200]","Cigna Local Plus",,66,,,,,,,7.68,66,"case rate",
"SHUTTLE IDEAL STRAIGHT CRESCENT SUT",SUP-251007,CDM,S27200284,LOCAL,0272,RC,,,both,,,2618.78,785.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONQUEST 40 75CM 8CM 4MM BALLOON DILATATION TAPER TIP",SUP-CQF7548,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE CURVED HARMONIC SYNERGY SURGICAL",SUP-SNGCB,CDM,S27200284,LOCAL,0272,RC,,,both,,,1862.06,558.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 9FR .118IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1009,CDM,C1894,HCPCS,0272,RC,,,both,,,298.32,89.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OCCL 65CM 5FR 26FR BALLOON OCCLUSION 1 INFLATION PORT",SUP-M0062201070,CDM,C2628,HCPCS,0272,RC,,,both,,,1155.14,346.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COAGULATION AND PLATELET DISORDERS,MAJOR",661,APR-DRG,,,,,,,inpatient,,,87905.12,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $7,748.92. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($62,284.47) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC",497,MS-DRG,,,,,,,inpatient,,,46072.79,13821.84,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLOBAZAM 10 MG TABLET",RX-155225,CDM,,,0637,RC,60687-0423-11,NDC,both,1,UN,15.69,4.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEAD RADIAL 22MM LEFT ELBOW LEFT ANGLE STERILE",SUP-TR-H220L-S,CDM,C1776,HCPCS,0278,RC,,,both,,,13489.50,4046.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1568.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1568.83,11466.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL INTUITIVE DA VINCI XI BLUE GREEN 60",SUP-1BSGXI60GB,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER 6248V-90P ATTAIN SELECT II",SUP-6248V-90P,CDM,C1887,HCPCS,0272,RC,,,both,,,2272.50,681.75,"NOVANET [10819]",Novanet,,1704.38,75,,,,,0,264.29,1931.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 9MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-609-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"AETNA [10100]","Aetna HMO/PPO",,9566.71,79.5,,10981.53,8986.79,12413.38,12,1399.51,10228.56,"percent of total billed charges",
"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC",099,MS-DRG,,,,,,,inpatient,,,46755.41,14026.62,"AETNA [10100]","Aetna HMO/PPO",,25633.56,,"Fee schedule rate ($25,633.56). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,33976.89,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +19.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.195,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 2MM E9000 FINE ROUND DIAMOND STERILE",SUP-E6220,CDM,S27200284,LOCAL,0272,RC,,,both,,,463.08,138.92,"UHC [10700]","United Healthcare",,293.13,63.3,,,,,0,53.86,393.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4.5CM 2.5MM GALAXY G3 MINI FREEFORM",SUP-MCR092545,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"UHC [10700]","United Healthcare",,8371.96,63.3,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP LIMIT HOLE FIN RINGLOC+ 24 STERILE",SUP-16-104154,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"NOVANET [10819]",Novanet,,5278.5,75,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT TOE LPT 2 REGULAR GREAT TOE",SUP-487S002,CDM,C1776,HCPCS,0278,RC,,,both,,,11585.10,3475.53,"NOVANET [10819]",Novanet,,8688.83,75,,,,,0,1347.35,9847.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 28MM HIP C TAPER COCR LFIT",SUP-06-2800,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"BLUE CROSS [10001]","Blue Cross HMO",,1226.06,39.2,,5311.50,4717.44,5388.59,31,363.75,2658.55,"percent of total billed charges",
"ICD COBALT DR 2 CHAMBER DF4 INLINE CONNECTOR RADIOPAQUE VENT",SUP-DDPB3D4,CDM,C1721,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"BLUE CROSS [10001]","Blue Cross HMO",,22843.8,39.2,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8MM 80MM VIPER TITANIUM SPINE SACRAL ALAR ILIAC",SUP-179704880,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,3978.14,359.25,3978.14,24,641.98,4692,"percent of total billed charges",
"SET GRAFT HARVEST ACL 7MM 6MM COLLAR PIN TUBE OATS",SUP-AR-1980-06S,CDM,S27800098,LOCAL,0278,RC,,,both,,,1871.25,561.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,221.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,217.63,1590.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG VARIABLE ANGLE LOCKING 1.8MM X 20MM",SUP-SPLS-18200-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,969.41,68,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC",809,MS-DRG,,,,,,,inpatient,,,25808.75,7742.62,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,8402.13,,"Case rate ($7,852.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,291.54, add-ons for qualifying new technology services are included. If operating cost exceeds $40,331.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,933.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,301.18. The transfer operating threshold is the transfer adjustment factor * $7,291.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $551.28. The transfer capital threshold is the transfer adjustment factor * $551.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,25808.75,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC",026,MS-DRG,,,,,,,inpatient,,,150443.61,45133.08,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,39271.31,,"Case rate ($19,286.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $17,908.88, add-ons for qualifying new technology services are included. If operating cost exceeds $50,948.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,736.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $17,932.56. The transfer operating threshold is the transfer adjustment factor * $17,908.88 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,354.00. The transfer capital threshold is the transfer adjustment factor * $1,354.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 203.62%.",,,,0,7561,90776.2,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM LCP STAINLESS STEEL SMALL BONE SELF",SUP-202.212,CDM,C1713,HCPCS,0278,RC,,,both,,,748.44,224.53,"KAISER [10500]",Kaiser,,501.45,67,,,,,0,87.04,636.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NEGATIVE PRESSURE 6X6IN PICO DRSG STERILE DISPOSABLE",SUP-66022005,CDM,S27200284,LOCAL,0272,RC,,,both,,,2130.00,639,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1448.4,68,,,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR XTHIN 45MM TRI-STAPLE VASCULAR 2MM GRAY 2",SUP-SIG45AV,CDM,S27200284,LOCAL,0272,RC,,,both,,,1546.45,463.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,709.82,45.9,,,,,0,179.85,1314.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER FIDUCIAL CYL 20CM 17GA 1.2MM SOFT TISSUE PLACEMENT",SUP-MTNW887840,CDM,A4648,HCPCS,0278,RC,,,both,,,595.35,178.6,"KAISER [10500]",Kaiser,,398.88,67,,,,,0,69.24,506.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 15MM 145CM 3.25MM BALLOON DILATATION",SUP-1400325-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLS-2509 CLASSICSHEATH LONG",SUP-398725,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,358.02,68,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD SUT 2/0 8IN LOAD UNIT NONABSORBABLE BARB LOOP 1 HAND",SUP-VLOCN208L,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.99,98.4,"FIRST HEALTH [10303]","First Health",,262.39,80,,,,,0,38.15,278.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POS STENT 45CM 7FR URETERAL RADIOPAQUE",SUP-M0061802021,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.15,26.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,59.94,68,,,,,0,10.25,74.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 27MM MOSAIC BIOPROSTHESIS HOLDER",SUP-31002701,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JEFFREY VASCULAR 20CM 15CM .018IN 8FR 6.5FR SET TROCAR",SUP-G12016,CDM,C1769,HCPCS,0272,RC,,,both,,,1000.27,300.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,116.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.33,850.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 28MM COUNTSINK MAXIMUM TORQUE 4MM",SUP-MSD01040028S,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"NOVANET [10819]",Novanet,,1063.13,75,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25MM THK1.37MM STAINLESS STEEL SAGITTAL 2 CUT",SUP-4125-137-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,393.85,118.15,"MULTIPLAN [10600]",Multiplan,,334.77,85,,,,,0,45.8,334.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION",RX-121669,CDM,J1308,HCPCS,0636,RC,63323-0739-11,NDC,both,2,ML,18.92,5.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1.6,,,,,,,0.93,16.08,"fee schedule",
"SUT VICRYL 9-0 BV100-3 5IN MONOFILAMENT COATED VIOLET",SUP-V402G,CDM,S27200284,LOCAL,0272,RC,,,both,,,199.67,59.9,"CIGNA [10200]",Cigna,,135.78,68,,,,,0,23.22,169.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 10MM 3MM BALLOON DILATATION STERILE",SUP-230-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 55MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.855,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,162.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,159.84,1168.25,"percent of total billed charges",
"CATH DIREXION 130CM 2.4FR MICRO BERN INFUSION NITINOL 2",SUP-M001195340,CDM,C1887,HCPCS,0272,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN READIGRAFT CRYOSKIN 125SQ CM FIBROBLAST",SUP-SK-NM,CDM,Q4433,HCPCS,0636,RC,,,both,,,2925.15,877.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1989.1,68,,,,,0,247.92,2486.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE VENTILATOR 3 WAY INSRT VMAX",SUP-775321,CDM,S27200284,LOCAL,0272,RC,,,both,,,3569.55,1070.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,415.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,415.14,3034.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE HOFFMANN II MRI EXTERNAL FIXATION FRAME 6 PIN YELLOW",SUP-4921-1-100,CDM,S27800098,LOCAL,0278,RC,,,both,,,3638.25,1091.47,"FIRST HEALTH [10303]","First Health",,2910.6,80,,,,,0,423.13,3092.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPICILLIN-SULBACTAM 1.5 G VIAL",RX-32470,CDM,J0295,HCPCS,0636,RC,71288-0031-91,NDC,both,1,UN,21.20,6.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,14.42,68,,,,,0,1.56,18.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 4MM BALLOON DILATATION STERILE LATEX",SUP-584015022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.75MM X 15.0MM",SUP-493751512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 10MM 1.5MM",SUP-SPL15010X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,358.02,68,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER PELLO 2.5MM STRAIGHT",SUP-6290-208-025,CDM,S27200284,LOCAL,0272,RC,,,both,,,1837.50,551.25,"KAISER [10500]",Kaiser,,1231.13,67,,,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ELECTROSURGICAL 23CM LIGASURE MARYLAND 350D OPEN",SUP-LF1923,CDM,S27200284,LOCAL,0272,RC,,,both,,,3441.08,1032.32,"UHC [10700]","United Healthcare",,2178.2,63.3,,,,,0,400.2,2924.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM DCP LC-DCP STAINLESS STEEL PROXIMAL",SUP-204.238,CDM,C1713,HCPCS,0278,RC,,,both,,,177.48,53.24,"KAISER [10500]",Kaiser,,118.91,67,,,,,0,20.64,150.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFTS FOR INJURIES WITH CC/MCC",904,MS-DRG,,,,,,,inpatient,,,175649.32,52694.8,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,23809.77,,"Case rate ($22,784.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $21,156.92, add-ons for qualifying new technology services are included. If operating cost exceeds $54,196.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,981.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $21,184.90. The transfer operating threshold is the transfer adjustment factor * $21,156.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,599.57. The transfer capital threshold is the transfer adjustment factor * $1,599.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,107239.83,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 60MM 3.5MM ANKLE",SUP-58850035,CDM,S27000186,LOCAL,0270,RC,,,both,,,1069.20,320.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,439.44,41.1,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VALVE AORTIC 23MM SAPIEN 3 BOVINE PERICARDIAL TRANSCA",SUP-9600TFX23A,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46170,27,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +14.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.145,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACRANIAL PROCEDURES WITHOUT CC/MCC",039,MS-DRG,,,,,,,inpatient,,,77483.41,23245.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,23334.85,,"Fee schedule rate ($23,334.85). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7291.7,34319.9,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 5% DEXTROSE 0.225% SODIUM CHLORIDE 1L",SUP-792409,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"AETNA [10100]","Aetna HMO/PPO",,64.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC LOW PROFILE 100MM 5MM KII 2 PACK OPTICAL",SUP-CTR24,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,99.83,45.9,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM MINI-MONSTER SHORT THREAD HEAD NONSTERILE",SUP-P20-140-038S,CDM,C1713,HCPCS,0278,RC,,,both,,,1599.75,479.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1087.83,68,,,,,0,186.05,1359.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 15MM 3.5MM CORONARY STENT COCR",SUP-1007849-15,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 SH 18IN CONTROL RELEASE BRAID 8 STRAND COATED",SUP-J775D,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.90,37.17,"PHCS [10601]",PHCS,,86.73,70,,,,,0,14.41,105.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 155CM 100MM 6FR 3.5MM .014IN BALLOON",SUP-2216-35100,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,962.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 3MM TIGERTAPE SUTURELASSO 2MM 2",SUP-AR-2271,CDM,S27800098,LOCAL,0278,RC,,,both,,,8150.63,2445.19,"BLUE CROSS [10001]","Blue Cross HMO",,3195.05,39.2,,,,,0,947.92,6928.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CPR MINI SCORPION DX FIXATION",SUP-AR-8690DS,CDM,C1713,HCPCS,0278,RC,,,both,,,7933.28,2379.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3641.38,45.9,,,,,0,922.64,6743.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 46CM 7FR 10MM SPACING VENTRICLE BIPOLAR PASSIVE",SUP-1948/46,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"AETNA [10100]","Aetna HMO/PPO",,1774.84,79.5,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM 16MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-216.045,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"KAISER [10500]",Kaiser,,300.87,67,,,,,0,52.23,381.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.454,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"BLUE CROSS [10001]","Blue Cross HMO",,1898.3,39.2,,957.42,156.86,7483.26,51,563.19,4116.21,"percent of total billed charges",
"MATRIX TISSUE 4X3CM NATURALLY POROUS NON-SIDED THIN DURABLE",SUP-DP-12,CDM,Q4122,HCPCS,0636,RC,,,both,,,5975.40,1792.62,"MULTIPLAN [10600]",Multiplan,,5079.09,85,,,,,0,708.08,5079.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3 ANTIROTATION",SUP-200178003,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CELSIUS THERMOCOOL REDEL 115CM 3.5MM 7FR 2-5-2MM SPACE",SUP-DI7TCDLRT,CDM,C2630,HCPCS,0272,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT FIBERLINK FIBERWIRE 2 26IN BRAID TIES MULTISTRAND CLOSE",SUP-AR-7235,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE II PRO 20MM 2.75MM BALLOON DILATATION STERILE",SUP-227-203-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC",413,MS-DRG,,,,,,,inpatient,,,155737.30,46721.19,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 30MM 6FR 2.75MM .07IN BALLOON",SUP-H7493918930270,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSERT TIBIAL 10 5MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151621005,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PHCS [10601]",PHCS,,7877.73,70,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 53CM BIPOLAR SOLIA T STERILE LATEX FREE",SUP-377180,CDM,C1898,HCPCS,0275,RC,,,both,,,2250.00,675,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1530,68,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTREPIDTM TMVR CRIMPER",SUP-ASM-0014,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM EDWARDS SAPIEN 3 COMMANDER DELIVERY SYSTEM",SUP-9600CM29A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"UHC [10700]","United Healthcare",,117263.25,63.3,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 3.5MM20CM 190",SUP-R51003520L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,289.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 60MM 18MM REVISION PRESS FIT ATTUNE KNEE STERIL",SUP-151318060,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"AETNA [10100]","Aetna HMO/PPO",,6571.63,79.5,,10981.53,8986.79,12413.38,12,961.36,7026.27,"percent of total billed charges",
"STEM FEMORAL 145MM 11MM COLLAR CEMENTLESS LOW PROFILE NECK",SUP-3L92501,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"BLUE CROSS [10001]","Blue Cross PPO",,6208.15,39.2,,3949.44,3949.44,3949.44,"1 through 10",1841.86,13461.55,"percent of total billed charges",
"INSRT ARTICULAR 7-10 C-H STD 82X51X12MM KNEE PROLONG UHMWPE",SUP-00595205012,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2243.75,28.62,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL 100 MCG/HR TRANSDERMAL PATCH",RX-27908,CDM,,,0250,RC,47781-0428-11,NDC,both,1,UN,408.46,122.54,"CIGNA [10200]","Cigna Open Access",,232.41,56.9,,,,,0,47.5,347.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 18CM 8.5FR DUODENAL BEND BILIARY",SUP-M00534310,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"NOVANET [10819]",Novanet,,817.09,75,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL 50 MCG/ML INJECTION SUPERORDERABLE",RX-4083037,CDM,J3010,HCPCS,0636,RC,70092-1509-35,NDC,both,50,ML,212.43,63.73,"FIRST HEALTH [10303]","First Health",,169.94,80,,,,,0,25.17,180.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 12MM STD WALL GORE-TEX RING 30CM STERILE",SUP-R12030030,CDM,C1768,HCPCS,0278,RC,,,both,,,7969.50,2390.85,"CIGNA [10200]","Cigna Open Access",,4534.65,56.9,,,,,0,926.85,6774.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 C 38MM COCR HIP 2 MOBILITY",SUP-110024461,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1506.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 25D MEDIUM AUG CORTILOC SHOULDER RIGHT",SUP-DWK404RA25S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3005.1,28.62,,,,,0,1221.15,8925,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP CONSTRUCT 4: SHELL AND LINER",SUP-CAP-STY-H4,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"UHC [10700]","United Healthcare",,8735.4,63.3,,8601.07,8395.67,8601.07,"1 through 10",1604.94,11730,"percent of total billed charges",
"CMPNT PATELLAR 9MM 33MM SYMMETRIC TRIATHLON X3 KNEE",SUP-5550-G-339,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,511.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 F 40MM LONGEVITY HIP STERILE LUMEN LATEX",SUP-20104006,CDM,C1776,HCPCS,0278,RC,,,both,,,8101.98,2430.59,"FIRST HEALTH [10303]","First Health",,6481.58,80,,,,,0,942.26,6886.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR CEMENTLESS STD Z1 TITANIUM ALLOY 3",SUP-611201030,CDM,C1776,HCPCS,0278,RC,,,both,,,28967.40,8690.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8290.47,28.62,,,,,0,3368.91,24622.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 STD 12MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS7S12R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4769.65,45.9,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL INBONE 5 STD ANKLE LEFT",SUP-200252905,CDM,C1776,HCPCS,0278,RC,,,both,,,11847.30,3554.19,"BLUE CROSS [10001]","Blue Cross PPO",,4644.14,39.2,,3949.44,3949.44,3949.44,"1 through 10",1377.84,10070.21,"percent of total billed charges",
"CAP BIPOLAR HIP Z1 STEM / CERAMIC HEAD INSERT",SUP-98000100279,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Local Plus",,5537.25,53.5,,5372.07,4581.20,7242.98,23,1203.71,8797.5,"percent of total billed charges",
"ALTIVATE ANATOMIC, NEUTRAL HUMERAL HEAD, 54X18",SUP-520-54-218,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4171.76,45.9,,,,,0,1057.03,7725.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL UNIVERSAL 40MM HIP BIOLOX DELTA TRITANIUM",SUP-6519-1-040,CDM,C1776,HCPCS,0278,RC,,,both,,,10008.84,3002.65,"KAISER [10500]",Kaiser,,6705.92,67,,,,,0,1164.03,8507.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NEURON MAX 100CM .088IN STRAIGHT DELIVERY SYSTEM DIL",SUP-PNML6F0881004,CDM,C1887,HCPCS,0272,RC,,,both,,,3675.00,1102.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH DRYSEAL FLEX 45CM 10FR 4MM 3.3MM INTRO HYDROPHILIC",SUP-GDSF1045,CDM,C1894,HCPCS,0272,RC,,,both,,,5844.30,1753.29,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAFESHEATH II SSL6",SUP-400209,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH HEARTRAIL III 100CM 6FR TIG4 CURVE GUIDING CORONARY",SUP-40-6311,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 90CM 7FR AL1 CURVE GUIDING CORONARY SIDEHOLE",SUP-LA7AL10SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOFT-VU 65CM 1.5CM 4FR STRAIGHT ART CURVE ANGIOGRAPHIC",SUP-H787107314025,CDM,C1887,HCPCS,0272,RC,,,both,,,156.60,46.98,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONCIERGE 100CM 6FR SBS3.5 MOD CURVE GUIDING STAINLESS",SUP-CGC6100SBS35-MSH,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 7FR 65CM GUIDING PINNACLE DESTINATION",SUP-RSP04,CDM,C1887,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER SUPPORT L135CM DIA0.0375IN COMPATIBLE GUIDEWIRE 0.0",SUP-P1VC-014STR-135,CDM,C1894,HCPCS,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TERAZOSIN 1 MG CAPSULE",RX-14550,CDM,,,0637,RC,50268-0764-11,NDC,both,1,UN,8.08,2.42,"PHCS [10601]",PHCS,,5.66,70,,,,,0,0.94,6.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL TLIF 10X11X31MM 20DEG LORDOTIC ALLOY SELF EXPAND",SUP-5902031P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PHCS [10601]",PHCS,,19845,70,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 X-1 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J459H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Redo Endovas Vena Cava Filter",PX-361000137,CDM,37192,CPT,0361,RC,,,both,,,10396.94,3119.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1232.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.4,8837.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 8FR DRNG FLEXIMA METAL BILIARY RADIOPAQUE FIRM",SUP-M001272640,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 40MM 130CM 5MM VASCULAR SUPERFICIAL FEMORAL",SUP-H74939293054030,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"AETNA [10100]","Aetna HMO/PPO",,4006.8,79.5,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONCIERGE 100CM 8FR SBS3.75 MOD CURVE GUIDING STAINLESS",SUP-CGC8100SBS375-M,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,183.1,41.1,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 22-30CM 7FR URETERAL",SUP-M0061456310,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"NOVANET [10819]",Novanet,,468.93,75,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PERFORMER MULLINS CURVE 85CM 12FR 4MM GUIDING FEP",SUP-G09136,CDM,C1894,HCPCS,0272,RC,,,both,,,890.92,267.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,105.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.61,757.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Pilonidal Cyst Cmplx",PX-450000007,CDM,10081,CPT,0450,RC,,,both,,,12300.00,3690,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1261,,,,,,,67.13,10455,"case rate",
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,inpatient,,,42486.88,12746.06,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,7681.68,,"Case rate ($7,457.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,925.20, add-ons for qualifying new technology services are included. If operating cost exceeds $39,964.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,905.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $6,934.36. The transfer operating threshold is the transfer adjustment factor * $6,925.20 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $523.58. The transfer capital threshold is the transfer adjustment factor * $523.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7457.94,35102.35,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 400MM FEMORAL EXPERT INTRAMEDULLARY ROUND",SUP-04.013.460S,CDM,C1713,HCPCS,0278,RC,,,both,,,8319.74,2495.92,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,967.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",967.59,7071.78,"percent of total billed charges",
"DRILL SURGICAL FIX 12MM",SUP-288301112,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"NOVANET [10819]",Novanet,,2967.3,75,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM TRIDENT",SUP-509-02-58F,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"KAISER [10500]",Kaiser,,7525.44,67,,,,,0,1306.28,9547.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 2 RIGHT DISTAL KNEE",SUP-5542-A-202,CDM,C1776,HCPCS,0278,RC,,,both,,,5009.55,1502.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,593.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,582.61,4258.12,"percent of total billed charges",
"CMPNT PATELLAR 38MM ONLAY ADVANCE METAL KNEE STERILE",SUP-KPON38MB,CDM,C1776,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 19MM KNEE X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G819,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA [10200]","Cigna Open Access",,5690,56.9,,5302.19,4377.88,6578.61,27,1163,8500,"percent of total billed charges",
"INSRT HUMERAL 33MM UNIVERS REVERS +6MM SHOULDER LINER",SUP-AR-9503XS-06C,CDM,C1776,HCPCS,0278,RC,,,both,,,4305.60,1291.68,"CIGNA [10200]","Cigna Open Access",,2449.89,56.9,,5302.19,4377.88,6578.61,27,500.74,3659.76,"percent of total billed charges",
"STEM FEMORAL 111MM COLLAR ACTIS DUOFIX 8 12/14 STANDARD OFFS",SUP-101011080,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8722.3,28.62,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 STD 17MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS6S17L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"CIGNA [10200]",Cigna,,7066.15,68,,5873.17,5873.17,5873.17,"1 through 10",1208.52,8832.69,"percent of total billed charges",
"LIDOCAINE 5 % TOPICAL PATCH",RX-28203,CDM,,,0250,RC,00591-3525-11,NDC,both,1,UN,80.00,24,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.88,41.1,,,,,0,9.3,68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 10 6MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151621006,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"MULTIPLAN [10600]",Multiplan,,9565.82,85,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA 5D F KNEE LEFT CEMENTED STEM TIVANIUM",SUP-42532007501,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"CIGNA [10200]","Cigna Local Plus",,5849.55,53.5,,5372.07,4581.20,7242.98,23,1271.59,9293.68,"percent of total billed charges",
"SCR BONE 5MM 28MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.518S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"BLUE CROSS [10001]","Blue Cross PPO",,586.78,39.2,,957.42,570.23,957.42,28,174.09,1272.35,"percent of total billed charges",
"LINER ACETABULAR TRILOGY 0D STD NEUTRAL 8.9MM 62MM 40MM",SUP-630506240,CDM,C1776,HCPCS,0278,RC,,,both,,,9937.38,2981.21,"CIGNA [10200]",Cigna,,6757.42,68,,5873.17,5873.17,5873.17,"1 through 10",1155.72,8446.77,"percent of total billed charges",
"AUG FEMORAL 5MM TRIATHLON 2 KNEE DISTAL HINGE",SUP-5612-D-205,CDM,C1776,HCPCS,0278,RC,,,both,,,10143.00,3042.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1179.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1179.63,8621.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT TOE SWANSON METATARSOPHALANGEAL FLEXIBLE HINGE STERILE",SUP-G4260003,CDM,C1776,HCPCS,0278,RC,,,both,,,7265.70,2179.71,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3334.96,45.9,,,,,0,845,6175.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE JOURNEY II COCR WITH XR INSERT AND",SUP-71709040,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"UHC [10700]","United Healthcare",,11963.7,63.3,,8601.07,8395.67,8601.07,"1 through 10",2198.07,16065,"percent of total billed charges",
"STEM EXT 130MM 16MM NEXGEN FLUTE KNEE FEMUR TIVANIUM",SUP-598801616,CDM,C1776,HCPCS,0278,RC,,,both,,,7446.48,2233.94,"AETNA [10100]","Aetna HMO/PPO",,5919.95,79.5,,10981.53,8986.79,12413.38,12,866.03,6329.51,"percent of total billed charges",
"AUG TIBIAL 15MM MBT 2 KNEE REVISION STEP WEDGE STERILE LATEX",SUP-129456122,CDM,C1776,HCPCS,0278,RC,,,both,,,9889.08,2966.72,"NOVANET [10819]",Novanet,,7416.81,75,,,,,0,1150.1,8405.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT TOE SWANSON METATARSOPHALANGEAL FLEXIBLE HINGE STERILE",SUP-G4260003,CDM,C1776,HCPCS,0278,RC,,,both,,,7265.70,2179.71,"MULTIPLAN [10600]",Multiplan,,6175.85,85,,,,,0,845,6175.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 8-11 E-F KNEE RIGHT TIBIA FIX",SUP-42-5221-008-20,CDM,C1776,HCPCS,0278,RC,,,both,,,12008.76,3602.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4935.6,41.1,,6417.48,6417.48,6417.48,"1 through 10",1396.62,10207.45,"percent of total billed charges",
"STENT ADVANIX NAVIFLEX 12CM 8.5FR DUODENAL BEND BILIARY",SUP-M00534290,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"MULTIPLAN [10600]",Multiplan,,926.03,85,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX14MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183744,CDM,C1776,HCPCS,0278,RC,,,both,,,13241.10,3972.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3789.6,28.62,,,,,0,1539.94,11254.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 56MM 40MM ALTRX HIP",SUP-122140056,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"NOVANET [10819]",Novanet,,10352.59,75,,,,,0,1605.34,11732.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL ATTUNE STERILE 6 KNEE LEFT CEMENTED POSTERIOR",SUP-150410106,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2653.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR WRP CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389696090,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RUBICON 135CM SPRT STRAIGHT TIP ACCEPTS .014IN GWIRE 4",SUP-H74939212014131,CDM,C1887,HCPCS,0272,RC,,,both,,,1449.90,434.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL ENDOSCOPIC CRE 240CM 5.5CM 7.5FR 8-10MM ESOPHAGUS",SUP-M00558670,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MACH1 100CM 8FR JL4 CURVE GUIDING PTFE FEMORAL",SUP-H749343586620,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH NAVIGATOR 28CM 11-13FR ACCESS STAINLESS STEEL",SUP-M0062502011,CDM,C1894,HCPCS,0272,RC,,,both,,,815.04,244.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR .071IN JUDKINS LEFT 4 CURVE GUIDING",SUP-LA6JL40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SHAVER BRICK RED 5.5MM DYONICS ELITE ACROMIOBLASTER",SUP-72200731,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH C315S502",SUP-C315S502,CDM,C1887,HCPCS,0272,RC,,,both,,,2175.00,652.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BALLOON CERVICAL DILATATION 40CM 18FR COOK SILICONE RIPEN",SUP-G19891,CDM,C1726,HCPCS,0272,RC,,,both,,,543.53,163.06,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CPS DIRECT PL SITEMARK 51CM 47CM 9FR 7FR RIGHT SIDE",SUP-410176,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRICLIP XT CLIP DELIVERY SYS CLIN",SUP-TCDS0203-XT,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD 5MM BIPOLAR IS-1",SUP-6162,CDM,C1883,HCPCS,0278,RC,,,both,,,2625.00,787.5,"BLUE CROSS [10001]","Blue Cross PPO",,1029,39.2,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 7 KNEE CEMENTED FIX BEARING STERILE",SUP-150600007,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"PHCS [10601]",PHCS,,10502.84,70,,,,,0,1744.97,12753.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 47MM 26MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-47-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,502.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 5 KNEE RIGHT CRUCIATE RETAINING PFC SIGMA",SUP-940025,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"CIGNA [10200]",Cigna,,10355.94,40,,5873.17,5873.17,5873.17,"1 through 10",3010.99,22006.37,"percent of total billed charges",
"LINER ACETABULAR G7 J 40MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30124010,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1192.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CALCAR 29MM RESTORATION +30MM OFFSET HIP MODULAR",SUP-6276-4-329,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"CIGNA [10200]",Cigna,,9282.42,40,,5873.17,5873.17,5873.17,"1 through 10",2698.86,19725.14,"percent of total billed charges",
"(EVAL) HYDRAULIC LOADER ASSEMBLY",SUP-30-00372,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 130CM 150MM 6MM BALLOON DILATATION",SUP-LX3513061505F,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,983.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR EMPHASYS +4MM NEUTRAL 56-58MM 40MM AOX",SUP-472256440,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AERO 20MM 63CM 10MM 16FR GEOMETRIC TRACHEOBRONCHIAL",SUP-90129-207,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"KAISER [10500]",Kaiser,,11557.5,67,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEMORAL TRIATHLON 4MM KNEE OFFSET TOTAL STABILIZED",SUP-5570-S-040,CDM,C1776,HCPCS,0278,RC,,,both,,,5487.96,1646.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3731.81,68,,,,,0,638.25,4664.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL CARTO 3 115CM 8FR 3.5MM J CURVE",SUP-D133603,CDM,C1732,HCPCS,0272,RC,,,both,,,19845.00,5953.5,"UHC [10700]","United Healthcare",,12561.89,63.3,,,,,0,2307.97,16868.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 7FR ATRIAL VENTRICULAR ACTIVE FIXATION",SUP-1688TC/52,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"NOVANET [10819]",Novanet,,1674.38,75,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP BIPOLAR HIP",SUP-THABIP,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"PHCS [10601]",PHCS,,7245,70,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR NEUROLOGICAL BIS QUATRO CNCT FLEXIBLE 4 ELECTRD",SUP-186-0106,CDM,S27000186,LOCAL,0270,RC,,,both,,,150.64,45.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,102.44,68,,,,,0,17.52,128.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Ganglion Sphenopalat",PX-361000423,CDM,64505,CPT,0361,RC,,,both,,,2996.00,898.8,"PHCS [10601]",PHCS,,2097.2,70,,,,,0,3,2996,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR HD 28CM 12-14FR ACCESS STAINLESS STEEL",SUP-M0062502240,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"PHCS [10601]",PHCS,,686.47,70,,,,,0,114.05,833.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR STD JL2 CURVE GUIDING NYLON CORONARY",SUP-LA6JL20,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"FIRST HEALTH [10303]","First Health",,292.32,80,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 30CM 6FR LONG LENGTH TEARAWAY SMOOTH TRANSITION",SUP-INT-105-57,CDM,C1894,HCPCS,0272,RC,,,both,,,369.75,110.92,"PHCS [10601]",PHCS,,258.83,70,,,,,0,43,314.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 40 75CM 2CM 4MM BALLOON DILATATION TAPER TIP",SUP-CQF7542,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 6FR .07IN KIESZ RIGHT 4 HORIZONTAL CURVE GUIDING",SUP-H749389696520,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"MULTIPLAN [10600]",Multiplan,,311.47,85,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 17MM 6MM STAINLESS STEEL 1.1MM LONG THREAD",SUP-02.226.117,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"NOVANET [10819]",Novanet,,1233.9,75,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 12FR 63CM RADIOPAQUE TIP MULLINS DESIGN GWIRE",SUP-G10012,CDM,C1894,HCPCS,0272,RC,,,both,,,890.92,267.28,"FIRST HEALTH [10303]","First Health",,712.74,80,,,,,0,103.61,757.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN JUDKINS",SUP-CC77801200,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"KAISER [10500]",Kaiser,,279.79,67,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 4FR 21GA MERIT S-MAK .018IN STIFFENED DIL",SUP-S-MAK405,CDM,C1894,HCPCS,0272,RC,,,both,,,321.90,96.57,"MULTIPLAN [10600]",Multiplan,,273.62,85,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACCU-VU 70CM 2CM 5FR PIGTAIL CURVE ANGIOGRAPHIC",SUP-H787137091015,CDM,C1887,HCPCS,0272,RC,,,both,,,376.71,113.01,"AETNA [10100]","Aetna HMO/PPO",,299.48,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.81,320.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 5MM OXFORD ARCOM KNEE RIGHT MENISCAL PHASE 3",SUP-159584,CDM,C1776,HCPCS,0278,RC,,,both,,,5270.22,1581.07,"NOVANET [10819]",Novanet,,3952.67,75,,,,,0,612.93,4479.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC ESOPHAGEAL PYLORIC COLONIC BILIARY INFLATE",SUP-M00558710,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"MULTIPLAN [10600]",Multiplan,,1401.68,85,,,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LEAD 23CM 9FR OSCOR PEEL AWAY LUER LOCK KINK",SUP-6663,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 50CM 23CM GRAY HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-5F-23-038,CDM,C1894,HCPCS,0272,RC,,,both,,,117.45,35.23,"KAISER [10500]",Kaiser,,78.69,67,,,,,0,13.66,99.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN RIGHT",SUP-77818200,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 16MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-416-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]",Cigna,,4813.44,40,,5873.17,5873.17,5873.17,"1 through 10",1399.51,10228.56,"percent of total billed charges",
"AUG FEMORAL 5MM TRIATHLON 7 LEFT DISTAL KNEE",SUP-5540-A-701,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"FIRST HEALTH [10303]","First Health",,3635.05,80,,,,,0,528.45,3862.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 11MM KII ADVANCE FIXATION SLEEVE",SUP-CFB33,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HNDPC ELECTROSURGICAL 9IN ABC BEND-A-BEAM 1 FUNCTION",SUP-134009,CDM,S27200284,LOCAL,0272,RC,,,both,,,921.80,276.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM NAVITOR SMALL LOADING",SUP-NVTR-LS-SM,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE UNIVERSAL FIFTH METATARSAL FRACTURE SYSTEM HOOK BONE",SUP-AR-8956-01,CDM,C1713,HCPCS,0278,RC,,,both,,,9121.80,2736.54,"KAISER [10500]",Kaiser,,6111.61,67,,,,,0,1060.87,7753.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 95MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.895,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"NOVANET [10819]",Novanet,,1030.81,75,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION ENDOBUTTON CL ULTRA 15MM PRELOADED BRAIDED",SUP-72200146,CDM,C1713,HCPCS,0278,RC,,,both,,,2157.75,647.32,"MULTIPLAN [10600]",Multiplan,,1834.09,85,,,,,0,250.95,1834.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LD 26MM 6.4MM 3.4MM SIL SL","SUP-109 185",CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,109.56,28.62,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE TITANIUM 25MM 8MM ACL PCL CANNULATED",SUP-AR-1381,CDM,C1713,HCPCS,0278,RC,,,both,,,807.98,242.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,370.86,45.9,,,,,0,93.97,686.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIPHERAL CUTTING BALLOON 90CM 20MM 7MM BALLOON",SUP-M001PCB7020900,CDM,C1725,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,541.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 45CM .016IN FIRM FNLN",SUP-6064,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER SUPPORT L90CM DIA0.056IN COMPATIBLE GUIDEWIRE 0.035",SUP-P1VC-035ANG-090,CDM,C1894,HCPCS,0272,RC,,,both,,,1458.00,437.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ENDOSCOPIC LINBAR BILIARY ULTRASOUND BALLOON STERILE",SUP-MAJ-249,CDM,C1726,HCPCS,0272,RC,,,both,,,255.57,76.67,"FIRST HEALTH [10303]","First Health",,204.46,80,,,,,0,29.72,217.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 340MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.054S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"BLUE CROSS [10001]","Blue Cross HMO",,4867.99,39.2,,957.42,156.86,7483.26,51,1444.25,10555.59,"percent of total billed charges",
"CATH MERIT MAESTRO 150CM 2.8FR 2.4FR .02IN .018IN MICRO",SUP-28MC24150ST,CDM,C1887,HCPCS,0272,RC,,,both,,,2301.00,690.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,267.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,267.61,1955.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 141MM CEMENT AVENIR PROTASUL-S30 3 39.68MM STD",SUP-01.06010.203,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,5372.07,4581.20,7242.98,23,2014.9,14726.25,"percent of total billed charges",
"SCREW BONE 2.4MM 26MM TITANIUM CORTICAL HAND SELF TAPPING NO",SUP-401.526.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"KAISER [10500]",Kaiser,,399.64,67,,,,,0,69.37,507.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 15MM CLEVERCUT3V PRELOAD DISTAL TIP STERILE",SUP-KD-VC412Q-0215,CDM,C1769,HCPCS,0272,RC,,,both,,,1500.61,450.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,177.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.52,1275.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE WATCHMAN FXD CURVE 15FR 12FR CLSR 2 CURVE ACCESS",SUP-M635TU80020,CDM,C1894,HCPCS,0272,RC,,,both,,,6900.00,2070,"MULTIPLAN [10600]",Multiplan,,5865,85,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH UROMAX ULTRA QUADRA-FOLD ENCORE HIGH PRESSURE KINK",SUP-M0062251240,CDM,C1726,HCPCS,0272,RC,,,both,,,1904.70,571.41,"NOVANET [10819]",Novanet,,1428.53,75,,,,,0,221.52,1619,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 2.5MM 45CM RADIOPAQUE SMALL VALVE FLEXOR",SUP-G09908,CDM,C1894,HCPCS,0272,RC,,,both,,,415.08,124.52,"UHC [10700]","United Healthcare",,262.75,63.3,,,,,0,48.27,352.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP UNISTEP PLUS 90MM 75CM 12MM 8FR 100CM",SUP-H965402130,CDM,C1876,HCPCS,0278,RC,,,both,,,7140.00,2142,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3277.26,45.9,,,,,0,830.38,6069,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 90CM .035IN STRAIGHT SPRT",SUP-518-078,CDM,C1887,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 90CM .035IN STRAIGHT SPRT",SUP-518-078,CDM,C1887,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 55CM 100CM PROGUIDE SIDEHOLE COMPLETE HUB CUFF 50CM",SUP-DC21455550,CDM,C1894,HCPCS,0272,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 55CM 100CM PROGUIDE SIDEHOLE COMPLETE HUB CUFF 50CM",SUP-DC21455550,CDM,C1894,HCPCS,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR AL1.5 CURVE GUIDING NYLON CORONARY",SUP-LA6AL15SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UHC [10700]","United Healthcare",,247.82,63.3,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 7FR L24CM FIRM TRI LAYER DESIGN RAW COLORANT",SUP-M0061902320,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY PRO 69CM 7FR CS-IC 90 CURVE GUIDING CORONARY",SUP-8100,CDM,C1887,HCPCS,0272,RC,,,both,,,1837.50,551.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,213.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MICROSHEATH XL 110CM STRAIGHT GUIDING PERIPHERAL BRAID",SUP-MSXL17110,CDM,C1887,HCPCS,0272,RC,,,both,,,2062.50,618.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5FR X 7CM STIFFEN FLUENT TRANSITIONLESS MICRO-INTRODUCER KIT",SUP-KIT-039-04,CDM,C1887,HCPCS,0272,RC,,,both,,,281.88,84.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,191.68,68,,,,,0,32.78,239.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER SUPPORT L150CM DIA0.0375IN COMPATIBLE GUIDEWIRE 0.0",SUP-P1VC-014STR-150,CDM,C1894,HCPCS,0272,RC,,,both,,,1458.00,437.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 4CM WITHOUT GWIRE DIL RADIOPAQUE MARKER",SUP-RSB705H,CDM,C1894,HCPCS,0272,RC,,,both,,,217.50,65.25,"FIRST HEALTH [10303]","First Health",,174,80,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER 3.5MM CORTICAL LOW PROFILE ALPS ORTHOPEDIC TITANIUM",SUP-131218000,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"CIGNA [10200]","Cigna Local Plus",,455.02,53.5,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 41CM 25CM DIL CHECK-FLO 20FR STERILE DISPOSABLE",SUP-G28999,CDM,C1894,HCPCS,0272,RC,,,both,,,2667.38,800.21,"AETNA [10100]","Aetna HMO/PPO",,2120.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,310.22,2267.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 12CM 1.92MM 1.5MM SONOPET IQ BARRACUDA SOFT TISSUE",SUP-5500-25S-310,CDM,S27200284,LOCAL,0272,RC,,,both,,,6794.31,2038.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3118.59,45.9,,,,,0,790.18,5775.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION HI-FLO TRANSEND-18 130CM 165CM 2.8-3FR .027IN",SUP-M001195910,CDM,C1887,HCPCS,0272,RC,,,both,,,6210.00,1863,"PHCS [10601]",PHCS,,4347,70,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 300MM 2.5MM BALLOON DILATATION",SUP-48002530X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR PAL2 CURVE GUIDING STERILE LATEX",SUP-LA6PAL20,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"MULTIPLAN [10600]",Multiplan,,310.59,85,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 8FR JUDKINS LEFT 4",SUP-588834,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN AMPLATZ",SUP-67004200,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,49.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 125MM 5.5MM CREO STRAIGHT TITANIUM NONSTERILE",SUP-1119.5125,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"GRAFT VASCULAR 80CM 10MM THIN WALL GORE-TEX REMOVABLE RING",SUP-RRT10070080L,CDM,C1768,HCPCS,0278,RC,,,both,,,10108.50,3032.55,"CIGNA [10200]","Cigna Local Plus",,5408.05,53.5,,,,,0,1175.62,8592.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 10MM THIN WALL GORE-TEX REMOVABLE RING",SUP-RRT10070080L,CDM,C1768,HCPCS,0278,RC,,,both,,,10108.50,3032.55,"MULTIPLAN [10600]",Multiplan,,8592.23,85,,,,,0,1175.62,8592.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM AXIUM PRIME HELIX DETACHABLE",SUP-APB-3-10-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1058.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS THK12MM ALLOGRAFT BLOCK FREEZE DRIED",SUP-400293,CDM,S27800098,LOCAL,0278,RC,,,both,,,5547.60,1664.28,"KAISER [10500]",Kaiser,,3716.89,67,,,,,0,645.19,4715.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 20MM QUICKFIX TITANIUM T10 PARTIAL THREAD",SUP-AR-8730-20PT,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"NAIL 15.5-11MM 40CM FEMUR LEFT PROXIMAL TALON DISTALFIX",SUP-SLN-125-40L,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6450.12,40,,,,,0,1875.37,13706.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM STAINLESS STEEL T8 METAPHYSEAL SELF TAP",SUP-02.118.520,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"CIGNA [10200]","Cigna Local Plus",,280.29,53.5,,3978.14,359.25,3978.14,24,60.93,445.32,"percent of total billed charges",
"MESH SURGICAL SYMBOTEX 3.3X2.3MM 12CM 2 SIDE COMPOSITE",SUP-SYM12,CDM,C1781,HCPCS,0278,RC,,,both,,,3229.65,968.89,"FIRST HEALTH [10303]","First Health",,2583.72,80,,,,,0,375.61,2745.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INFLATION INDEFLATOR .096IN ROTATE HEMOSTATIC VALVE",SUP-1000186,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC SMARTVEST WRAP SMALL NONSTERILE LATEX FREE",SUP-SW-15/25-1,CDM,S27000186,LOCAL,0270,RC,,,both,,,437.40,131.22,"FIRST HEALTH [10303]","First Health",,349.92,80,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 23X9X13MM CONCORDE 5D BULLET NOSE CFRP",SUP-187823413,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"NOVANET [10819]",Novanet,,12420,75,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 8MM MREYE 4 LOOP .035IN PLATINUM",SUP-G20452,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"NOVANET [10819]",Novanet,,625.67,75,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 8MM AXIUM 3D FRAME V01",SUP-FC-8-20-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"CIGNA [10200]","Cigna Open Access",,5536.04,33.5,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL 5D ALLOGRAFT 9MM LATEX FREE",SUP-3W3009,CDM,S27800098,LOCAL,0278,RC,,,both,,,5896.74,1769.02,"CIGNA [10200]",Cigna,,4009.78,68,,,,,0,685.79,5012.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30MMX14MM VERTE-STACK CRESCENT LUMBAR",SUP-293014,CDM,S27800098,LOCAL,0278,RC,,,both,,,24290.28,7287.08,"UHC [10700]","United Healthcare",,15375.75,63.3,,,,,0,2824.96,20646.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM CONCERTO DETACHABLE HELIX",SUP-NV-4-8-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM TSRH OSTEOGRIP TITANIUM SHORT SPINE",SUP-83555408,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.10,1106.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,429.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",429.04,3135.74,"percent of total billed charges",
"SUB BONE GRAFT XEMPLIFI DEMINERALIZED BONE MATRIX PLUS 8ML",SUP-8103.0208S,CDM,C1713,HCPCS,0278,RC,,,both,,,7438.20,2231.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,865.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",865.06,6322.47,"percent of total billed charges",
"STENT VISI-PRO 27MM 80CM 9MM 30MM BILIARY STAINLESS STEEL",SUP-PXB35-09-27-080,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"PHCS [10601]",PHCS,,3056.9,70,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 50MM TITANIUM SPINE CORTICAL POLYAXIAL FIX",SUP-186727750,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"CATH ASAHI CORSAIR SHINKA-SHAFT 150CM 2.6-2.8FR .018IN .015",SUP-CSW150-26N,CDM,C1887,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"KAISER [10500]",Kaiser,,3929.55,67,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 50CM 4CM ORANGE HUB STAINLESS STEEL GWIRE",SUP-PSS-8F-4-035MT,CDM,C1894,HCPCS,0272,RC,,,both,,,208.80,62.64,"KAISER [10500]",Kaiser,,139.9,67,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,inpatient,,,46575.25,13972.57,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,7220.03,,"Case rate ($6,747.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,265.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,305.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,855.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,273.97. The transfer operating threshold is the transfer adjustment factor * $6,265.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.72. The transfer capital threshold is the transfer adjustment factor * $473.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,6747.69,27128.64,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ENTEER 150CM 20X2.75X1MM .066IN BALLOON OCCLUSION",SUP-ENB-275-20-150,CDM,C1887,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1430.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.3MM STAINLESS STEEL 2MM SCR 2 HOLE HEAD 6 HOLE SHAFT",SUP-02.130.355S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RETROMAX PLUS 24CM 7-14FR THIN WALL PIGTAIL CURVE",SUP-145-148,CDM,C2617,HCPCS,0278,RC,,,both,,,1677.15,503.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,198.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,195.05,1425.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 57MM 135CM 7MM 60MM BILIARY TANTALUM",SUP-PXB35-07-57-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,507.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT BIORAPTOR HIP KNOTLESS",SUP-72202397,CDM,C1713,HCPCS,0278,RC,,,both,,,2598.75,779.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,307.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,302.23,2208.94,"percent of total billed charges",
"ROD SPINAL 45MM 6MM XIA 3 TITANIUM RADIOLUCENT",SUP-48238045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"SCR BONE 3MM 22MM STAINLESS STEEL 1.1MM ORTHOPEDIC SELF",SUP-S30-22S-11,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 95X19.5X1.27MM OSCILLATING HEAVY DUTY",SUP-2108109000S15,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"CIGNA [10200]","Cigna Local Plus",,476.69,53.5,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 12MM Y 11.8CMX15MM STERILE",SUP-0460,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.20,28.86,"AETNA [10100]","Aetna HMO/PPO",,76.48,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.19,81.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 145MM 28-16MM 18FR ENDURANT II ABDOMEN",SUP-ETBF2816C145E,CDM,S27800098,LOCAL,0278,RC,,,both,,,60782.40,18234.72,"NOVANET [10819]",Novanet,,45586.8,75,,,,,0,7068.99,51665.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PALMAZ 50MM 10MM XL BILIARY STAINLESS STEEL BALLOON",SUP-P5010,CDM,C1877,HCPCS,0278,RC,,,both,,,4278.00,1283.4,"AETNA [10100]","Aetna HMO/PPO",,3401.01,79.5,,,,,0,497.53,3636.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 51X24MM CROSSLOCK LOW PROFILE DVR BONE RADIUS LEFT",SUP-131822050,CDM,C1713,HCPCS,0278,RC,,,both,,,9263.25,2778.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2651.14,28.62,,,,,0,1077.32,7873.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PERMA-HAND SUTUPAK 4-0 24IN BRAID TIES 13 STRAND PRECUT",SUP-SA73H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM OFFSET TAPER 32MM HIP ALUMINA CERAMIC V40",SUP-6565-0-132,CDM,C1776,HCPCS,0278,RC,,,both,,,7383.00,2214.9,"NOVANET [10819]",Novanet,,5537.25,75,,,,,0,858.64,6275.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 5.5MM EXPEDIUM PREBENT TITANIUM LINE",SUP-179771055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"SCR BONE 5MM 26MM NAIL-EX TITANIUM FEMUR TIBIA LOCKING",SUP-04.005.516,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"FIRST HEALTH [10303]","First Health",,925.34,80,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 16CM 1.7MM MIDAS REX LEGEND TAPER BURR",SUP-16TA17,CDM,S27200284,LOCAL,0272,RC,,,both,,,1241.08,372.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,147.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.34,1054.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 360MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.552S,CDM,C1713,HCPCS,0278,RC,,,both,,,8737.47,2621.24,"CIGNA [10200]","Cigna Local Plus",,4674.55,53.5,,3978.14,359.25,3978.14,24,1016.17,7426.85,"percent of total billed charges",
"KIT INTRO 4 1/8IN 8.5FR 18GA ARROW-FLEX TWISTLOCK ARROW",SUP-AK-09803-LF,CDM,C1894,HCPCS,0272,RC,,,both,,,471.95,141.58,"KAISER [10500]",Kaiser,,316.21,67,,,,,0,54.89,401.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 42MM DOT FREEMAN AREOLA BREAST BIOPSY STAINLESS STEEL",SUP-P465,CDM,S27200284,LOCAL,0272,RC,,,both,,,532.33,159.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,244.34,45.9,,,,,0,61.91,452.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 12MM 3MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG30012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAXX 15CM 10MM NEPHRSTMY PTFE SET",SUP-G47649,CDM,C1726,HCPCS,0272,RC,,,both,,,2279.25,683.77,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WOLVERINE CUTTING BALLOON (OTW)  3.50MM X 15MM",SUP-H74939402153500,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SAPPHIRE 3 CORONARY DILATATION CATHETER 1.25 X 8MM",SUP-54125-080-02,CDM,C1725,HCPCS,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE CORNERSTONE L-ASCR CORTICAL LORDOTIC ALLOGRAFT 14",SUP-341241,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 6MM 4MM AMPLATZER NITINOL STAINLESS",SUP-9-AVP2-004,CDM,S27800098,LOCAL,0278,RC,,,both,,,6589.50,1976.85,"FIRST HEALTH [10303]","First Health",,5271.6,80,,,,,0,766.36,5601.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 12MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS12030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1389.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 ULTRA 2.5MM X 4CM",SUP-M0035422540,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"MULTIPLAN [10600]",Multiplan,,11997.44,85,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM 32MM EMBOLD NITINOL FIBER DETACHABLE",SUP-M001394240320600,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"BLUE CROSS [10001]","Blue Cross HMO",,3378.3,39.2,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE L-ASCR CORTICAL 11MM LORDOTIC",SUP-340741,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE L-ASCR CORTICAL 11MM LORDOTIC",SUP-340741,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 160MM FLEXIGRAFT ACHILLES TENDON CALCANEUM",SUP-FATB,CDM,S27800098,LOCAL,0278,RC,,,both,,,12109.50,3632.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3465.74,28.62,,,,,0,1408.33,10293.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 3.5MM CEREPAK XTRASOFT FREEFORM",SUP-XCR123505,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"UHC [10700]","United Healthcare",,8371.96,63.3,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 14 X 12 X 07MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-141207-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1777.3,28.62,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE VENTRICULAR ASSIST TANDEMHEART PROC KIT",SUP-5710-6215,CDM,S27800098,LOCAL,0278,RC,,,both,,,60450.00,18135,"MULTIPLAN [10600]",Multiplan,,51382.5,85,,,,,0,7030.34,51382.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 7MM TITAN 6D MEDIUM CERVICAL",SUP-5166-1407-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"AETNA [10100]","Aetna HMO/PPO",,8228.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 7MM TITAN 6D MEDIUM CERVICAL",SUP-5166-1407-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4253.85,41.1,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 4-0 PS-2 SPIRAL 12IN",SUP-SXMP1B117,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.03,65.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,148.26,68,,,,,0,25.36,185.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 24MM CHARLOTTE STAINLESS STEEL FOOT ANKLE",SUP-44110008,CDM,C1713,HCPCS,0278,RC,,,both,,,1672.50,501.75,"KAISER [10500]",Kaiser,,1120.58,67,,,,,0,194.51,1421.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 45CM 4-7MM STD WALL TAPER PERIPHERAL GORE-TEX",SUP-S47045,CDM,C1768,HCPCS,0278,RC,,,both,,,4692.00,1407.6,"CIGNA [10200]",Cigna,,3190.56,68,,,,,0,545.68,3988.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLUX FIBERS 5CC",SUP-IFLX-CF-05,CDM,S27800098,LOCAL,0278,RC,,,both,,,6037.50,1811.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,702.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 4.5 X 8 COMPLEX PICO COIL",SUP-10USC04508,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"FIRST HEALTH [10303]","First Health",,10460.4,80,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X15-12.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-4815,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"PHCS [10601]",PHCS,,10384.5,70,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 12MM X 30CM",SUP-M0035471230,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS [10001]","Blue Cross PPO",,5532.94,39.2,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNID PATIENT SPECIFIC DATA PLAN AND RODS",SUP-M200000B116,CDM,C1713,HCPCS,0278,RC,,,both,,,25200.00,7560,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7212.24,28.62,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 12CM 29MM MASTERS HEMASHIELD CLLGN MECHANICAL","SUP-29CAVGJ-514  00",CDM,S27800098,LOCAL,0278,RC,,,both,,,25533.90,7660.17,"FIRST HEALTH [10303]","First Health",,20427.12,80,,,,,0,2969.59,21703.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM ADVANCED PARALLEL SPINE",SUP-17612,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"KAISER [10500]",Kaiser,,5547.6,67,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT DELTA CSF REGULAR CONTOURED HIGH PRESSURE",SUP-42326,CDM,S27800098,LOCAL,0278,RC,,,both,,,6782.22,2034.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4611.91,68,,,,,0,788.77,5764.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 7MM ZERO-P PEEK-OPTIMA TITANIUM CERVICAL",SUP-04.617.127S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"MULTIPLAN [10600]",Multiplan,,10557,85,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X21X10MM COUGAR LS LORDOTIC LATERAL NONSTERILE",SUP-189155810,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"NOVANET [10819]",Novanet,,17955,75,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-2-2-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1360.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 2.75MM 1.5MM 1.27MM COLLAR BUTTON LUMEN",SUP-510-131C,CDM,S27800098,LOCAL,0278,RC,,,both,,,178.18,53.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.72,151.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 18MM 4.5MM EMBOLIZATION NEUROVASCULAR",SUP-PED-450-18,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"CIGNA [10200]","Cigna Open Access",,25778.25,33.5,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 11CM 6MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-06011,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PHCS [10601]",PHCS,,8206.17,70,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25X5.5X.38MM MICRO OSCILLATING SAGITTAL STERILE",SUP-2296003524,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,124.03,45.9,,,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 12.5CM 4MM IBUR DISTAL BEND ROUND DIAMOND",SUP-8431-013-040DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,2737.50,821.25,"UHC [10700]","United Healthcare",,1732.84,63.3,,,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X4CM NUSHIELD ALLOGRAFT",SUP-NO-1440,CDM,Q4160,HCPCS,0636,RC,,,both,,,9832.50,2949.75,"NOVANET [10819]",Novanet,,7374.38,75,,,,,0,1165.15,8357.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3.3CM 2.5MM CEREPAK MICRO UNIFORM",SUP-FCX100253,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"AETNA [10100]","Aetna HMO/PPO",,10514.55,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3.3CM 2.5MM CEREPAK MICRO UNIFORM",SUP-FCX100253,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5435.82,41.1,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 8MM TARGET 360D STD PLATINUM",SUP-M0035468300,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"NOVANET [10819]",Novanet,,10585.98,75,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 13CM 4MM .021-.027IN AZUR CX DETACHABLE",SUP-45-780413,CDM,S27800098,LOCAL,0278,RC,,,both,,,5275.05,1582.51,"AETNA [10100]","Aetna HMO/PPO",,4193.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,613.49,4483.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 5MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140512,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"UHC [10700]","United Healthcare",,7521.18,63.3,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 16CM 5MM .021-.027IN AZUR CX DETACHABLE",SUP-45-780516,CDM,S27800098,LOCAL,0278,RC,,,both,,,5275.05,1582.51,"CIGNA [10200]",Cigna,,3587.03,68,,,,,0,613.49,4483.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26MMX10MM VERTE-STACK CAPSTONE PEEK-OPTIMA END",SUP-2961026,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4292.35,27,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X10MM SABLE 15D STERILE LATEX FREE",SUP-1172.2024S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"NOVANET [10819]",Novanet,,25987.5,75,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X9-6.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-4809,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1757.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR MULTIAORTIC 3 CURVE GUIDING STERILE",SUP-LA6MAC3030,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE LARGE 25X14MM IB",SUP-7509014,CDM,S27800098,LOCAL,0278,RC,,,both,,,7728.00,2318.4,"FIRST HEALTH [10303]","First Health",,6182.4,80,,,,,0,898.77,6568.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP COLONOSCOPE BLUE 11MM ENDOCUFF VISION MEDIUM PLASTIC 1",SUP-ARV110,CDM,S27200284,LOCAL,0272,RC,,,both,,,216.11,64.83,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) EYE90 MICROSPHERES UNIT DOSE GEN II",SUP-P-0556,CDM,C1889,HCPCS,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMBOLECTOMY 80CM 4FR 9MM FOGARTY ARTERY BALLOON TUBE",SUP-120804F,CDM,C1757,HCPCS,0272,RC,,,both,,,376.01,112.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT GWIRE INTRO TORQUE DEVICE ROTATABLE HEMOSTATIC VALVE",SUP-22295,CDM,C1894,HCPCS,0272,RC,,,both,,,182.70,54.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MESH SURGICAL MONOFILAMENT ABSORBABLE LOW PROFILE",SUP-5955113,CDM,C1781,HCPCS,0278,RC,,,both,,,8400.00,2520,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2404.08,28.62,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 6MM FIBROUS MATRIX WOVEN CROSS",SUP-AG715,CDM,C1768,HCPCS,0278,RC,,,both,,,14138.10,4241.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3817.29,27,,,,,0,1644.26,12017.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION",RX-2364,CDM,J3490,HCPCS,0258,RC,00264-7510-00,NDC,both,1000,ML,100.65,30.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 6MM FLIXENE SLIDER GRADUATED WALL",SUP-25125,CDM,C1768,HCPCS,0278,RC,,,both,,,7174.62,2152.39,"PHCS [10601]",PHCS,,5022.23,70,,,,,0,834.41,6098.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM QUICKFIX TITANIUM T8 PARTIAL THREAD",SUP-AR-8724-18,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"BLUE CROSS [10001]","Blue Cross PPO",,349.27,39.2,,957.42,570.23,957.42,28,103.62,757.35,"percent of total billed charges",
"STY LD PROMRI SOLIA S UNV KT",SUP-130093,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,109.56,28.62,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD PROMRI SOLIA S UNV KT",SUP-130093,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,175.71,45.9,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOLUTPRO TRANSCATHETER AORTIC VALVE-29MM - THE 29MM EVOLTR",SUP-EVOLUTPRO-29-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS [10001]","Blue Cross HMO",,67032,39.2,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 45CM .014IN SFT FIRM",SUP-6053,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 230CM 25-30MM 10FR 270CM COLONIC NITINOL",SUP-6506,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 52CM .016IN BRADY FIRM",SUP-6584,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 2.6MM COLLARLESS",SUP-521-78-31,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,1831.33,1831.33,1831.33,16,50.59,369.75,"percent of total billed charges",
"BLADE INTRAMEDULLARY NAIL TAN 100MM 10.35MM TFN-ADVANCED",SUP-04.038.400S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"PHCS [10601]",PHCS,,2787.3,70,,,,,0,463.09,3384.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM COMPREHENSIVE 3.5MM SHOULDER CENTRAL",SUP-115396,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"BLUE CROSS [10001]","Blue Cross HMO",,609.95,39.2,,957.42,156.86,7483.26,51,180.96,1322.6,"percent of total billed charges",
"SCREW LOWPROFILE 6.5X20MM",SUP-010-55-020,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,87.15,28.62,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END 10MM TALON DISTALFIX 15.5MM",SUP-SLN-155-010,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"GRAFT STENT 45MM 22MM 14FR 12FR TRIVASCULAR OVATION PRIME",SUP-TV-EX222245-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"AETNA [10100]","Aetna HMO/PPO",,26545.05,79.5,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROCHLORPERAZINE MALEATE 5 MG TABLET",RX-6583,CDM,Q0164,HCPCS,0637,RC,50268-0684-11,NDC,both,1,UN,8.10,2.43,"NOVANET [10819]",Novanet,,6.08,75,,,,,0,0.94,6.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 57MM 135CM 5MM 60MM",SUP-H74938047560130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"MULTIPLAN [10600]",Multiplan,,4243.2,85,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR AMPALTZ RIGHT MODIFIED",SUP-534548T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"KAISER [10500]",Kaiser,,62.67,67,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC LARGE HUB STERLING GATOR 2500-6000 RPM 13",SUP-9263A,CDM,S27200284,LOCAL,0272,RC,,,both,,,293.76,88.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,199.76,68,,,,,0,34.16,249.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIB 59CM 7.3FR RELIANCE 4-FRONT RIGHT VENTRICLE MP35N",SUP-665,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4344.52,28.62,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 180MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-05181,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 12MM 140CM 4MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927412400,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +14.5 DIOPTER HAPTIC C BICONVEX 13MM 6MM 1 PIECE",SUP-PCB0000145,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR L60CM DIA6MM STRAIGHT STRETCH THIN WALLED INT",SUP-IRST06060060L,CDM,C1768,HCPCS,0278,RC,,,both,,,9321.90,2796.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1084.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1084.14,7923.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - TIBIAL KIT (PS) - SIZE 4",SUP-5555-2364,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL WEREWOLF FLOW 90 STERILE LATEX FREE",SUP-72290038,CDM,S27200284,LOCAL,0272,RC,,,both,,,1788.75,536.62,"PHCS [10601]",PHCS,,1252.13,70,,,,,0,208.03,1520.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 SH-1 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J219H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 315MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.343S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2379.02,28.62,,,,,0,966.74,7065.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 122MM 14MM COMPREHENSIVE POROUS STD SHOULDER",SUP-113654,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"KAISER [10500]",Kaiser,,8442,67,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 1 CT 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8435H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUORESCEIN 1 MG EYE STRIPS",RX-27663,CDM,,,0250,RC,51801-0009-01,NDC,both,1,UN,12.54,3.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIBRILLATOR 65CM 8FR OPTISURE ENDOCARDIUM 2 COIL DF4",SUP-LDA230Q-65,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6072,40,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH 1 90CM 8FR AMPLATZ LEFT 1 CURVE GUIDING",SUP-34358-376,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"NOVANET [10819]",Novanet,,274.83,75,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 27MM FLEXIBLE SURE LOCK DELIVERY SYSTEM",SUP-TARP-27,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1434.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 20CM TEMNO EVOLUTION COAXIAL INTRO SOFT",SUP-CTT2020,CDM,S27200284,LOCAL,0272,RC,,,both,,,369.23,110.77,"KAISER [10500]",Kaiser,,247.38,67,,,,,0,42.94,313.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 26MM ACUTRAK 2 TITANIUM MINI SMALL BONE STERILE",SUP-AT2-M26-S,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"AETNA [10100]","Aetna HMO/PPO",,2534.06,79.5,,1521.93,481.35,16760.95,30,370.71,2709.38,"percent of total billed charges",
"SPACER SPINAL 40X18X11MM TRANSCONTINENTAL 6D LORDOTIC XS",SUP-375.911,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6463.8,27,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 24CM 6FR .038IN STRAIGHT URETERAL PERCUFLEX",SUP-M006180222010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CIGNA [10200]",Cigna,,728.1,68,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM OPTIFIX FIXATION PDLLA 30 ABSORBABLE FSTNR SMOOTH",SUP-0113126,CDM,S27200284,LOCAL,0272,RC,,,both,,,741.80,222.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,504.42,68,,,,,0,86.27,630.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 38MM 145CM 2.75MM CORONARY STENT",SUP-1125275-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"FIRST HEALTH [10303]","First Health",,4670.4,80,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS LAPAROSCOPIC 31.75CM 8MM DA VINCI XI HOT SHEARS",SUP-470179,CDM,S27000186,LOCAL,0270,RC,,,both,,,2520.00,756,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1713.6,68,,,,,0,293.08,2142,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.432,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"PHCS [10601]",PHCS,,968.89,70,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE LUNDERQUIST UROLOGICAL STD 150CM 3CM .032IN LUBRIGLIDE",SUP-M0066001060,CDM,C1769,HCPCS,0272,RC,,,both,,,254.39,76.32,"KAISER [10500]",Kaiser,,170.44,67,,,,,0,29.59,216.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TIGHTROPE II FLIPCUTTER III FIBERSTICK FIXATION",SUP-AR-1288RTIB-FC3,CDM,C1713,HCPCS,0278,RC,,,both,,,7643.48,2293.04,"PHCS [10601]",PHCS,,5350.44,70,,,,,0,888.94,6496.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 10 STD KNEE RIGHT POSTERIOR STABILIZE PERSONA",SUP-42500806802,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"AETNA [10100]","Aetna HMO/PPO",,22971.99,79.5,,10981.53,8986.79,12413.38,12,3360.56,24561.24,"percent of total billed charges",
"INSRT TIBIAL 2 8MM RIGHT MEDIAL LEFT LATERAL X3 PARTIAL KNEE",SUP-5630-G-228,CDM,C1776,HCPCS,0278,RC,,,both,,,4514.33,1354.3,"FIRST HEALTH [10303]","First Health",,3611.46,80,,,,,0,525.02,3837.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SURGICAL 3.5MM SPARE HOLLOW REAMER 309.035 NONSTERILE",SUP-309.038,CDM,S27000186,LOCAL,0270,RC,,,both,,,1831.95,549.58,"FIRST HEALTH [10303]","First Health",,1465.56,80,,,,,0,213.06,1557.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 RB-2 30IN 2 ARM MONOFILAMENT BLUE",SUP-8711H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.48,19.94,"NOVANET [10819]",Novanet,,49.86,75,,,,,0,7.73,56.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH THREADER POWERCOIL 105CM 12MM 1.2MM MICRO SMALL THIN",SUP-H7493927012120,CDM,C1725,HCPCS,0272,RC,,,both,,,3300.00,990,"AMERIGROUP MEDICAID [20100]",Amerigroup,,391.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,383.79,2805,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tte Cong W Contr Cmplt",PX-483000019,CDM,C8923,HCPCS,0480,RC,,,both,,,2274.00,682.2,"AETNA [10100]","Aetna HMO/PPO",,1807.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,264.47,2274,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE POWERTURN ULTRAFLEX VASCULAR STRAIGHT 300CM",SUP-1044591,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN POSITIONING ZEVO PLATE NONSTERILE LATEX FREE REUSABLE",SUP-3030003,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOCEL PRO CELLULAR BONE MATRIX, MED",SUP-5016005,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,3978.14,359.25,3978.14,24,2014.9,14726.25,"percent of total billed charges",
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,inpatient,,,2338.83,701.65,"AETNA [10100]","Aetna HMO/PPO",,2338.83,,"Fee schedule rate ($11,268.30). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,2338.83,2338.83,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 380MM FEMORAL EXPERT INTRAMEDULLARY ROUND",SUP-04.013.456S,CDM,C1713,HCPCS,0278,RC,,,both,,,8319.74,2495.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2381.11,28.62,,,,,0,967.59,7071.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 77.5X11.2MM RECIPROCATE SURGICAL STERILE",SUP-KM-325R,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.49,33.15,"PHCS [10601]",PHCS,,77.34,70,,,,,0,12.85,93.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cholesterol Body Fluid",PX-301000145,CDM,82465,CPT,0301,RC,,,both,,,120.00,36,"MULTIPLAN [10600]",Multiplan,,102,85,,,,,0,0.01,102,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRICATH 18FR STD URETHRAL RUBBER 5CC FOLEY",SUP-119418M,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.62,30.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.82,86.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION BLUE 1.27MM 1.5MM COLLAR BUTTON EAR",SUP-240014,CDM,S27800098,LOCAL,0278,RC,,,both,,,97.14,29.14,"KAISER [10500]",Kaiser,,65.08,67,,,,,0,11.3,82.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC INSPIRIS RESILIA 19MM BOVINE PERICARDIUM",SUP-11500A19,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18642.96,41.1,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 16CM PUMP SET",SUP-ES2916,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,17944.74,28.62,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 30MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.730,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,515.75,45.9,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX11MM FRA 8D 30D LORDOTIC NARROW",SUP-211,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE SELF DRILLING RIGID 4MM 14MM ASSURE TITANIUM",SUP-110.014,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,958.8,68,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE FLEXIBLE 600MM 3.8MM 1.2MM AMBU ASCOPE 4 AVIEW",SUP-476101000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"AMERIGROUP MEDICAID [20100]",Amerigroup,,231.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ARTHROSCOPIC 125MM 2MM NANO SCOPE",SUP-AR-3210-0070,CDM,S27200284,LOCAL,0272,RC,,,both,,,4036.50,1210.95,"PHCS [10601]",PHCS,,2825.55,70,,,,,0,469.44,3431.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM INDEPENDENCE SPINE SELF DRILL VARIABLE",SUP-176.740,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"PHCS [10601]",PHCS,,1134,70,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON CABLE BLUE 2.5MM FEMUR TITANIUM ALUMINUM VANADIUM",SUP-47223206001,CDM,C1713,HCPCS,0278,RC,,,both,,,1912.50,573.75,"CIGNA [10200]","Cigna Open Access",,1088.21,56.9,,1144.80,304.56,2275.09,66,222.42,1625.63,"percent of total billed charges",
"GWIRE GLDEWIRE VASCULAR ANGLE 150CM 3CM .035IN HYDROPHILIC",SUP-GS3506,CDM,C1769,HCPCS,0272,RC,,,both,,,413.25,123.97,"NOVANET [10819]",Novanet,,309.94,75,,,,,0,48.06,351.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 5MMX15MM 7FR 135CMCATH HEPARIN",SUP-BXB051502A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM TITANIUM CORTICAL LOCKING NONSTERILE",SUP-CO-2712,CDM,C1713,HCPCS,0278,RC,,,both,,,696.60,208.98,"CIGNA [10200]",Cigna,,473.69,68,,1831.33,1831.33,1831.33,16,81.01,592.11,"percent of total billed charges",
"SCR BONE 5.5MM 35MM LUMBAR SPINE STERILE",SUP-2140135,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]",Cigna,,1101.6,68,,1831.33,1831.33,1831.33,16,188.41,1377,"percent of total billed charges",
"SHELL ACETABULAR 52MM HIP MULTIHOLE TRIDENT E HEMISPHERE",SUP-508-11-52E,CDM,C1776,HCPCS,0278,RC,,,both,,,11233.20,3369.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7638.58,68,,,,,0,1306.42,9548.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LISINOPRIL 10 MG TABLET",RX-10449,CDM,,,0637,RC,60687-0325-11,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 36MM UNIVERS REVERS +3MM SMALL SHOULDER",SUP-AR-9503S-03,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"NOVANET [10819]",Novanet,,2205,75,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 54MM LCP STAINLESS STEEL LONG THREAD SMALL BONE",SUP-207.654,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"NOVANET [10819]",Novanet,,780.03,75,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 3.5IN 17GA 25GA SPROTTE TUOHY EPILONG 8.25%",SUP-TCL901,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 36MM STD SHOULDER COCR CANNULATED",SUP-DWJ1017301,CDM,C1776,HCPCS,0278,RC,,,both,,,18544.68,5563.4,"FIRST HEALTH [10303]","First Health",,14835.74,80,,,,,0,2156.75,15762.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC ELECTROSURGICAL MINERVA 1 STERILE LATEX FREE",SUP-MIN9770,CDM,S27200284,LOCAL,0272,RC,,,both,,,6210.00,1863,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2552.31,41.1,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAMOTRIGINE 100 MG TABLET",RX-13982,CDM,,,0637,RC,68084-0319-11,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT ENDOSCOPIC AGGRESSIVE 13CM 5MM COOLCUT STERILE",SUP-AR-8500DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"KAISER [10500]",Kaiser,,336.21,67,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FAT EMULSION 20 % IV RATE BASED",RX-40840048,CDM,,,0250,RC,00264-4460-10,NDC,both,500,ML,206.23,61.87,"CIGNA [10200]","Cigna Open Access",,117.34,56.9,,,,,0,23.98,175.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RELIEVA SPIN 16MM 6MM M-110 GUIDING MAXILLARY SINUS",SUP-RSM110,CDM,C1726,HCPCS,0272,RC,,,both,,,2400.00,720,"FIRST HEALTH [10303]","First Health",,1920,80,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO 1000093010 OPTISEAL GLBL8FR25CM",SUP-1000093010,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 17.5MM KNEE XLK POSTERIOR LIPPED FIX",SUP-158102117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 91MM 12FR ZENITH ABDOMINAL AORTIC",SUP-G32554,CDM,C1874,HCPCS,0278,RC,,,both,,,23360.40,7008.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6685.75,28.62,,,,,0,2716.81,19856.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60X3.5MM TITANIUM ENDOSCOPIC LINEAR CUTTER",SUP-TA6035S,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.55,176.56,"UHC [10700]","United Healthcare",,372.55,63.3,,,,,0,68.45,500.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 108MM 6MM SMALL SHELL DJO SURGICAL ALTIVATE",SUP-533-06-108,CDM,C1776,HCPCS,0278,RC,,,both,,,43175.16,12952.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5021.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5021.27,36698.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3752.08,28.62,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VISIGI 3D 40FR GASTRIC LAVAGE BULB VENT OFF POSITION",SUP-5240SB,CDM,S27000186,LOCAL,0270,RC,,,both,,,1792.50,537.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1218.9,68,,,,,0,208.47,1523.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI GAIA VASCULAR MICRO J 300CM CORONARY THIRD",SUP-AHW14R311P,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"KAISER [10500]",Kaiser,,759.78,67,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE EVERPOINT 7-0 BV175-6 24IN 2 ARM MONOFILAMENT",SUP-EP8735H,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.23,104.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,237.48,68,,,,,0,40.62,296.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 39MM 28MM +4MM LATERALIZE GLENOSPHERE ARTHREX",SUP-AR-9564-2839-LAT,CDM,C1776,HCPCS,0278,RC,,,both,,,9763.50,2929.05,"CIGNA [10200]","Cigna Local Plus",,5223.47,53.5,,5372.07,4581.20,7242.98,23,1135.5,8298.98,"percent of total billed charges",
"LINER ACETABULAR 10D F 9.9MM 32MM X3 HIP",SUP-623-10-32F,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"BLUE CROSS [10001]","Blue Cross HMO",,3349.89,39.2,,5311.50,4717.44,5388.59,31,993.86,7263.8,"percent of total billed charges",
"INSRT CLAMP 86MM FOGARTY FIBRA ATRAUMATIC OCCLUSION STERILE",SUP-G-8650,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 TWINFIX ULTRABRAID COBRAIDED PEEK-OPTIMA",SUP-72202600,CDM,C1713,HCPCS,0278,RC,,,both,,,1724.63,517.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,200.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",200.57,1465.94,"percent of total billed charges",
"CATH LAUNCHER 100CM 6FR AL2.5 CURVE GUIDING CORONARY",SUP-LA6AL25SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"FIRST HEALTH [10303]","First Health",,292.32,80,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .014IN 6FR 2.5MM 139CM 10MM PTCA",SUP-2034-2510,CDM,C1725,HCPCS,0272,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4.3MM QUADCUT STRAIGHTSHOT M4",SUP-1884380EM,CDM,S27200284,LOCAL,0272,RC,,,both,,,3510.00,1053,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,415.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,408.21,2983.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RECTAL RESECTION WITH CC",333,MS-DRG,,,,,,,inpatient,,,104957.53,31487.26,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,15545.82,,"Case rate ($14,528.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,490.98, add-ons for qualifying new technology services are included. If operating cost exceeds $46,530.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,401.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,508.82. The transfer operating threshold is the transfer adjustment factor * $13,490.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,019.98. The transfer capital threshold is the transfer adjustment factor * $1,019.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,68382.87,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE APPROACH VASCULAR TAPER 300CM .014IN STAINLESS STEEL",SUP-G50792,CDM,C1769,HCPCS,0272,RC,,,both,,,1251.37,375.41,"MULTIPLAN [10600]",Multiplan,,1063.66,85,,,,,0,145.53,1063.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC",577,MS-DRG,,,,,,,inpatient,,,107990.16,32397.05,"PHCS [10601]",PHCS,,7561,,,,,,,7561,77389.84,"per diem","Estimated amount calculated based on 1 day length of stay."
"TUBE NASOGASTRIC 10FR 24 ASPIRATION PORT RADIOPAQUE STRIPE",SUP-AN11,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.70,24.51,"FIRST HEALTH [10303]","First Health",,65.36,80,,,,,0,9.5,69.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SPINAL I-PAS III INSULATED PEDICLE ACCESS SYSTEM BEVELED",SUP-2010029,CDM,S27200284,LOCAL,0272,RC,,,both,,,2342.00,702.6,"CIGNA [10200]",Cigna,,1592.56,68,,,,,0,272.37,1990.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC SMALL 32X6IN SHOULDER WRIST ELASTIC CUFF",SUP-1010159,CDM,S27000186,LOCAL,0270,RC,,,both,,,62.64,18.79,"CIGNA [10200]",Cigna,,42.6,68,,,,,0,7.29,53.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER PORT CLOSOR PRO 14GA SUBCUTANEOUS TISSUE BLUNT STYLET",SUP-PC-120,CDM,S27200284,LOCAL,0272,RC,,,both,,,168.14,50.44,"CIGNA [10200]","Cigna Local Plus",,89.95,53.5,,,,,0,19.55,142.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX OTW CORONARY STENT  2.00 X 15MM",SUP-RONYX20015W,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 32MM ALL POLY",SUP-5972-65-32,CDM,C1776,HCPCS,0278,RC,,,both,,,4623.00,1386.9,"AETNA [10100]","Aetna HMO/PPO",,3675.29,79.5,,10981.53,8986.79,12413.38,12,537.65,3929.55,"percent of total billed charges",
"GWIRE COUGAR XT VASCULAR J 190CM .014IN HYDRO-TRACK EXTRA",SUP-CGRXT190HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,486.00,145.8,"UHC [10700]","United Healthcare",,307.64,63.3,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 8-0 BV130-5 5IN MONOFILAMENT BLUE",SUP-2775G,CDM,S27200284,LOCAL,0272,RC,,,both,,,216.62,64.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,147.3,68,,,,,0,25.19,184.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT PARALLEL ALLOGRAFT 14MM TLIF",SUP-3W3314,CDM,S27800098,LOCAL,0278,RC,,,both,,,17139.60,5141.88,"PHCS [10601]",PHCS,,11997.72,70,,,,,0,1993.34,14568.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 45X20X7MM DEMINERALIZED CANCELLOUS CONFORM",SUP-0W1047,CDM,S27800098,LOCAL,0278,RC,,,both,,,15939.00,4781.7,"FIRST HEALTH [10303]","First Health",,12751.2,80,,,,,0,1853.71,13548.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PALMAZ 50MM 10MM XL BILIARY STAINLESS STEEL BALLOON",SUP-P5010,CDM,C1877,HCPCS,0278,RC,,,both,,,4278.00,1283.4,"MULTIPLAN [10600]",Multiplan,,3636.3,85,,,,,0,497.53,3636.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 144MM 12MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-104120,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"AETNA [10100]","Aetna HMO/PPO",,19241.66,79.5,,10981.53,8986.79,12413.38,12,2814.85,20572.84,"percent of total billed charges",
"CANN PERFUSION 12.5IN 15FR CORONARY SINUS MANUAL INATE CUFF",SUP-94615,CDM,S27200284,LOCAL,0272,RC,,,both,,,793.01,237.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,539.25,68,,,,,0,92.23,674.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL 11MM LORDOTIC",SUP-345641,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION",RX-15706,CDM,,,0250,RC,00121-0595-15,NDC,both,15,ML,36.80,11.04,"CIGNA [10200]",Cigna,,25.02,68,,,,,0,4.28,31.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR LONG 145CM 10CM .018IN",SUP-M001466000,CDM,C1769,HCPCS,0272,RC,,,both,,,486.32,145.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GUIDE PIN ORTHOPEDIC TRUMATCH FEMORAL RIGHT STERILE ATTUNE",SUP-420946,CDM,S27200284,LOCAL,0272,RC,,,both,,,14138.10,4241.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR .035IN RC2",SUP-G08470,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPAT SURGICAL 7X5/8IN DAVIS BRAIN MALLEABLE",SUP-22-0063,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.11,41.13,"FIRST HEALTH [10303]","First Health",,109.69,80,,,,,0,15.95,116.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.2MM 7MM APTUS TITANIUM 4MM HEAD HAND CORTICAL",SUP-A-5100.07/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"AETNA [10100]","Aetna HMO/PPO",,1004.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 80MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520080L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135CM 100MM 7MM .035IN LOW PROFILE BALLOON",SUP-B2070-100,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"PHCS [10601]",PHCS,,538.65,70,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 30MM 5.5MM EXPEDIUM PREBENT TITANIUM LINE",SUP-179771030,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"GWIRE CHOICE VASCULAR FLOPPY 182CM .014IN POLYMER",SUP-H74912132011,CDM,C1769,HCPCS,0272,RC,,,both,,,589.03,176.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,69.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.5,500.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 70CM 5FR 20D .035IN URETERAL FLEXIBLE ANGLED TIP",SUP-G14598,CDM,C1758,HCPCS,0272,RC,,,both,,,367.14,110.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,249.66,68,,,,,0,42.7,312.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIB 70CM 7.3FR RELIANCE 4-FRONT RIGHT VENTRICLE MP35N",SUP-653,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1765.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHLORDIAZEPOXIDE 5 MG CAPSULE",RX-1624,CDM,,,0637,RC,00555-0158-02,NDC,both,1,UN,12.54,3.76,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL NERVE BLOCK 40MM 22GA SONOPLEX II FACET TIP INJECTION",SUP-001285-70,CDM,C9812,HCPCS,0272,RC,,,both,,,119.63,35.89,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,inpatient,,,113902.06,34170.62,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER SHORT TIP RELOAD 60MM PURPLE",SUP-ASR60PS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FILTER PERFUSION PALL .2UM DISPOSABLE",SUP-ELD96LL,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.99,22.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.72,63.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LOW PROFILE RAYHACK BONE ULNA",SUP-40100479,CDM,S27200284,LOCAL,0272,RC,,,both,,,8142.00,2442.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,964.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,946.91,6920.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 40MM 120CM 6MM 8FR STRAIGHT VASCULAR",SUP-AVSL06040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross HMO",,7161.84,39.2,,9776.84,9776.84,9776.84,"1 through 10",2124.8,15529.5,"percent of total billed charges",
"6F DUO-DECA 2-10-2 MPD-H 100CM",SUP-901670,CDM,C1731,HCPCS,0272,RC,,,both,,,4761.00,1428.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,553.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,553.7,4046.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT GREEN 44X4IN XLONG LEG 1 FILL LINE POSITIVE LOCK",SUP-ASP-564014,CDM,S27200284,LOCAL,0272,RC,,,both,,,202.86,60.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.59,172.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT HUMERAL 8IN COONRAD/MORREY SMALL ELBOW TIVANIUM",SUP-32810503508,CDM,C1776,HCPCS,0278,RC,,,both,,,34391.70,10317.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9842.9,28.62,,,,,0,3999.75,29232.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 33MM 26.1MM MASTERS 85D RING ANNULUS PYROLYTIC",SUP-33MECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"PHCS [10601]",PHCS,,20383.46,70,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SURGICAL 60CM CATH STERILE LATEX FREE DISPOSABLE",SUP-8591-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.75MM 34MM TITANIUM PARTIAL THREAD SHOULDER",SUP-AR-7000-34,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSELECT DEMINERALIZED BONE MATRIX 10ML",SUP-359100,CDM,C1713,HCPCS,0278,RC,,,both,,,5602.80,1680.84,"CIGNA [10200]",Cigna,,3809.9,68,,1831.33,1831.33,1831.33,16,651.61,4762.38,"percent of total billed charges",
"SHELL ACETABULAR 56MM 57.8MM HIP 5 SCR HOLE CLUSTER RIM HA",SUP-542-11-56F,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,824.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,809.18,5914.06,"percent of total billed charges",
"SIZER IMPL 11.75CM NATRELLE INSPIRA P3.9CM MODERATE PROFILE",SUP-MSZ-M295,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,72.6,45.9,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 140MM 80CM 10MM 6FR .035IN BILIARY",SUP-G50140,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,721.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 3MM NESTER PLATINUM FIBER 3.2 LOOP",SUP-G47332,CDM,S27800098,LOCAL,0278,RC,,,both,,,842.32,252.7,"KAISER [10500]",Kaiser,,564.35,67,,,,,0,97.96,715.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IVAS ELITE 10MM 11GA DIAGNOSTIC CATH STERILE LATEX",SUP-0808-110-800,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 17GA 6.8CM BIOPINCE COAXIAL INTRO ECHOGENIC TIP",SUP-MCXS1810BP,CDM,S27200284,LOCAL,0272,RC,,,both,,,168.78,50.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.63,143.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL SHAFT ALLOGRAFT FROZEN 100MM 10+ MM",SUP-450430,CDM,S27800098,LOCAL,0278,RC,,,both,,,6785.46,2035.64,"BLUE CROSS [10001]","Blue Cross HMO",,2659.9,39.2,,,,,0,789.15,5767.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLUX PROTEIIIOS GROWTH FACTOR MED",SUP-IFLX-GF-025,CDM,S27800098,LOCAL,0278,RC,,,both,,,8107.50,2432.25,"NOVANET [10819]",Novanet,,6080.63,75,,,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SMART CONTROL MICROMARKER 30MM 80CM 14MM BILIARY",SUP-C14030SB,CDM,C1876,HCPCS,0278,RC,,,both,,,6037.50,1811.25,"KAISER [10500]",Kaiser,,4045.13,67,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 93MM AEQUALIS ASCEND FLEX PTC 132.5D 2B LONG",SUP-DWF612B,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"MULTIPLAN [10600]",Multiplan,,10710,85,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA EXTRA FULL PROFILE SOFT TOUCH",SUP-SSX-615,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]","Cigna Open Access",,4299.08,56.9,,5166.00,5166.00,5166.00,"1 through 10",878.7,6422.18,"percent of total billed charges",
"STENT LIFESTREAM 26MM 80CM 6MM VASCULAR COVER BALLOON EXPAND",SUP-LSMU0800626,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10745.6,41.1,,,,,0,3040.66,22223.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VICI VENOUS STENT 60MM 100CM 12MM ENDOPROSTHESIS CATH",SUP-H74912060100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"MULTIPLAN [10600]",Multiplan,,11143.5,85,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 87MM STAINLESS STEEL 3.5MM SCR 4 HOLE VARIABLE ANGLE",SUP-02.127.211S,CDM,C1713,HCPCS,0278,RC,,,both,,,9729.00,2918.7,"CIGNA [10200]","Cigna Local Plus",,5205.02,53.5,,3978.14,359.25,3978.14,24,1131.48,8269.65,"percent of total billed charges",
"SCR BONE 3.5MM 46MM STARDRIVE STAINLESS STEEL T15 CORTEX",SUP-02.206.246,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,38.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,37.68,275.39,"percent of total billed charges",
"DIL UTERINE HEGAR 2 END 11/12MM",SUP-52-3511,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.18,83.75,"AETNA [10100]","Aetna HMO/PPO",,221.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.47,237.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +28.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030285,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CIGNA [10200]",Cigna,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JETSTREAM 2.4MM ATHERECTOMY EXPANDABLE CUTTER",SUP-112266-001,CDM,C1724,HCPCS,0272,RC,,,both,,,19530.00,5859,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2271.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Home Mgmt Train Ea 15min (Go)",PX-430000021,CDM,97535,CPT,0430,RC,,,both,,,207.28,62.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,207.28,,"Per diem ($254).",,,,0,24.11,207.28,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 3MM NESTER MICROCOIL PLATINUM .018IN",SUP-G47334,CDM,S27800098,LOCAL,0278,RC,,,both,,,842.32,252.7,"CIGNA [10200]",Cigna,,572.78,68,,,,,0,97.96,715.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 12CM 5FR 2.1FR POLARIS ULTRA NAUTILUS ZIPWIRE .035",SUP-M006192112180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"KAISER [10500]",Kaiser,,1065.21,67,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 5CC SELECT FIBER OSTEOAMP",SUP-OASF-05,CDM,C1713,HCPCS,0278,RC,,,both,,,10805.40,3241.62,"BLUE CROSS [10001]","Blue Cross HMO",,4235.72,39.2,,957.42,156.86,7483.26,51,1256.67,9184.59,"percent of total billed charges",
"VALVE HEMOSTASIS FLUORESCENT PINK GREEN DOUBLEPLAY 2Y METAL",SUP-MAP222,CDM,S27200284,LOCAL,0272,RC,,,both,,,185.40,55.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.56,157.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 18MM 143CM 3MM CORONARY EVEROLIMUS ELUTING",SUP-1009541-18,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"MULTIPLAN [10600]",Multiplan,,8152.35,85,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 60MM 9MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171090610,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 116MM 10.5MM MODULAR REMEDY STAINLESS STEEL",SUP-RSHSMD,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"BLUE CROSS [10001]","Blue Cross PPO",,8026.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",2381.24,17403.75,"percent of total billed charges",
"STEM FEMORAL 150MM 20MM CEMENTLESS TOTAL STABILIZE TRIATHLON",SUP-5566-S-010,CDM,C1776,HCPCS,0278,RC,,,both,,,5447.65,1634.29,"CIGNA [10200]","Cigna Open Access",,3099.71,56.9,,5302.19,4377.88,6578.61,27,633.56,4630.5,"percent of total billed charges",
"NORMAL NEWBORN",795,MS-DRG,,,,,,,inpatient,,,5178.32,1553.5,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 150CM 60MM 2MM BALLOON DILATATION",SUP-H74939031206010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CENTRAL LINE DRESSING CHANGE KIT",SUP-78861,CDM,S27200284,LOCAL,0272,RC,,,both,,,235.34,70.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 3INX8MM OSTEOTOM THIN MRI STERILE LATEX FREE",SUP-47998602120,CDM,S27200284,LOCAL,0272,RC,,,both,,,996.30,298.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CPS DIRECT« UPSIZED, RIGHT SIDE 47CM-DS2C023",SUP-DS2C023,CDM,C1893,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET BLOOD WARMING ADMIN LEVEL 1 HOTLINE INTRAVENOUS",SUP-L-70NI,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.48,21.14,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC US OB >1st Trimst Txabd Add",PX-402000017,CDM,76810,CPT,0402,RC,,,both,,,1266.00,379.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure count. Procedure 1, Fee schedule rate ($135.04). Procedures 2 - 999, Fee schedule rate ($67.52).",,,,0,,,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE DESTINATION RENAL DOUBLE CURVE 45CM 5CM 6FR",SUP-RSR13,CDM,C1887,HCPCS,0272,RC,,,both,,,672.30,201.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,78.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS THK12MM ALLOGRAFT BLOCK FREEZE DRIED",SUP-400293,CDM,S27800098,LOCAL,0278,RC,,,both,,,5547.60,1664.28,"BLUE CROSS [10001]","Blue Cross HMO",,2174.66,39.2,,,,,0,645.19,4715.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION LOW PROFILE DETACH CATH INTRO",SUP-CT66LTPD,CDM,C1788,HCPCS,0278,RC,,,both,,,2505.00,751.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1703.4,68,,,,,0,291.33,2129.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VEIN DISTENTION GRAFT TUNNELING",SUP-26050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1278.75,383.62,"PHCS [10601]",PHCS,,895.13,70,,,,,0,148.72,1086.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 20MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158126120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7598.69,68,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Iep Serum",PX-302000070,CDM,86334,CPT,0302,RC,,,both,,,541.50,162.45,"CIGNA [10200]","Cigna Local Plus",,49.15,,,,,,,0.01,460.28,"fee schedule",
"FILLER BONE VOID 25X20X7MM DEMINERALIZED CANCELLOUS CONFORM",SUP-0W1027,CDM,S27800098,LOCAL,0278,RC,,,both,,,9453.00,2835.9,"KAISER [10500]",Kaiser,,6333.51,67,,,,,0,1099.38,8035.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 100MM 6FR 4MM BALLOON DILATATION PEBAX",SUP-H74939032401010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILFRM URETHRAL 13IN 6FR SPIRAL PLASTIC STERILE LATEX FREE",SUP-343106,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.14,31.84,"CIGNA [10200]",Cigna,,72.18,68,,,,,0,12.34,90.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC",958,MS-DRG,,,,,,,inpatient,,,203417.45,61025.23,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,27315.34,,"Case rate ($26,139.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $24,271.91, add-ons for qualifying new technology services are included. If operating cost exceeds $57,311.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,217.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $24,304.00. The transfer operating threshold is the transfer adjustment factor * $24,271.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,835.07. The transfer capital threshold is the transfer adjustment factor * $1,835.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,8593,123029.02,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC",824,MS-DRG,,,,,,,inpatient,,,95382.67,28614.8,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,14896.88,,"Case rate ($14,053.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,049.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,089.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,368.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,067.03. The transfer operating threshold is the transfer adjustment factor * $13,049.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $986.63. The transfer capital threshold is the transfer adjustment factor * $986.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,66146.46,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 3.5CM 20FR RADIOPAQUE LOW PROFILE TAPER DISTAL TIP",SUP-0120-20-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CIGNA [10200]","Cigna Open Access",,443.29,56.9,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND VAC VERAFLO CLEANSE LARGE KIT DISPOSABLE",SUP-ULTVFL05LG.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER TUMARK BREAST BIOPSY VISION EVIVA PETITE",SUP-TUMARK-E13-P-V-02,CDM,A4648,HCPCS,0278,RC,,,both,,,942.84,282.85,"CIGNA [10200]",Cigna,,641.13,68,,,,,0,109.65,801.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK12MM 51X63MM GALLANT IMPLANTABLE 2 CHMBR DF",SUP-CDDRA500Q,CDM,C1721,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6777.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION",317,MS-DRG,,,,,,,inpatient,,,321245.51,96373.65,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,43965.38,,"Case rate ($41,476.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $38,513.99, add-ons for qualifying new technology services are included. If operating cost exceeds $71,553.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $4,293.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $38,564.92. The transfer operating threshold is the transfer adjustment factor * $38,513.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,911.85. The transfer capital threshold is the transfer adjustment factor * $2,911.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,195219.05,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ 110CM 7FR PULMONARY ARTERY AMC THROMBOSHIELD",SUP-D200HF7,CDM,C1751,HCPCS,0272,RC,,,both,,,2625.00,787.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1785,68,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 7 SLOT RIGHT TI",SUP-PHPF-S7R,CDM,C1713,HCPCS,0278,RC,,,both,,,17388.00,5216.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2060.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,2022.22,14779.8,"percent of total billed charges",
"BASKET SPECIMEN RETRIEVAL 120CM 3FR 16MM 4 WIRE STONE",SUP-M0063901030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1416.61,424.98,"UHC [10700]","United Healthcare",,896.71,63.3,,,,,0,164.75,1204.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM STD TWIST",SUP-MFT-072-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,1409.40,422.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,958.39,68,,,,,0,163.91,1197.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 20CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155230190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"MULTIPLAN [10600]",Multiplan,,1207.29,85,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12MM X-CORE MINI TITANIUM SPINE LOCK NONSTERILE",SUP-5960033,CDM,S27800098,LOCAL,0278,RC,,,both,,,1629.00,488.7,"MULTIPLAN [10600]",Multiplan,,1384.65,85,,,,,0,189.45,1384.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD",SUP-98000500306,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM SOLERA SPINAL CANNULATED MULTIAXIAL",SUP-54840017545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Open Access",,5432.16,56.9,,1144.80,304.56,2275.09,66,1110.3,8114.82,"percent of total billed charges",
"SCR BONE 3.5MM 36MM LOW PROFILE SCREWS TITANIUM T15 FULL",SUP-AR-8935L-36,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"DEVICE 7FR CLSR VASCULAR LATEX FREE",SUP-EX700,CDM,C1760,HCPCS,0278,RC,,,both,,,1166.40,349.92,"BLUE CROSS [10001]","Blue Cross PPO",,457.23,39.2,,,,,0,135.65,991.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR ENDOSCOPIC 11MM REPROCESSED 100MM ENDOPATH XCEL",SUP-B11LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,64.36,41.1,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY AND URINARY TRACT INFECTIONS WITH MCC",689,MS-DRG,,,,,,,inpatient,,,29840.22,8952.07,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,7701.23,,"Case rate ($7,197.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,683.28, add-ons for qualifying new technology services are included. If operating cost exceeds $39,722.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,887.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $6,692.12. The transfer operating threshold is the transfer adjustment factor * $6,683.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.29. The transfer capital threshold is the transfer adjustment factor * $505.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7197.41,28936.72,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS MONOPOLAR 31CM 5MM ENDO MINI-SHEARS ROTICULATOR",SUP-174309,CDM,S27200284,LOCAL,0272,RC,,,both,,,619.73,185.92,"CIGNA [10200]","Cigna Local Plus",,331.56,53.5,,,,,0,72.07,526.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 22MM 2.4MM CORTICAL HAND TITANIUM SELF TAPPING",SUP-401.522.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"CIGNA [10200]","Cigna Open Access",,339.4,56.9,,1144.80,304.56,2275.09,66,69.37,507.01,"percent of total billed charges",
"CAGE SPINAL CERVICAL 10X14X12MM 7DEG LORDOTIC PEEK COHERE",SUP-4101427P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Aorta Ivc Ltd",PX-921000016,CDM,93979,CPT,0921,RC,,,both,,,1081.48,324.44,"PHCS [10601]",PHCS,,757.04,70,,,,,0,125.78,919.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP HUMERAL 33MM UNIVERS REVERS +2 RIGHT SUT",SUP-AR-9502F-33LCPC,CDM,C1776,HCPCS,0278,RC,,,both,,,7576.20,2272.86,"NOVANET [10819]",Novanet,,5682.15,75,,,,,0,881.11,6439.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SPINAL SCREW 7.5X50MM 2C MODULAR RELINE MAS",SUP-16187550,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,957.42,156.86,7483.26,51,348.9,2550,"percent of total billed charges",
"KIT BONE GRAFT 6CC DEMINERALIZED CORTICAL FIBER ACCELERATE",SUP-T50206,CDM,C1713,HCPCS,0278,RC,,,both,,,9522.00,2856.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4370.6,45.9,,,,,0,1107.41,8093.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4.5MM FRMLA ANGLED RESECTOR F SERIES",SUP-0380542150,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"NOVANET [10819]",Novanet,,247.95,75,,,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC",271,MS-DRG,,,,,,,inpatient,,,180964.81,54289.44,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,47428.87,,"Case rate ($22,059.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,484.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,523.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,930.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $20,511.24. The transfer operating threshold is the transfer adjustment factor * $20,484.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.70. The transfer capital threshold is the transfer adjustment factor * $1,548.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 215%.",,,,0,10994,103829.73,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PLLA HA 25MM 9MM 1.5MM ACL PCL CANNULATED",SUP-7207681,CDM,C1713,HCPCS,0278,RC,,,both,,,1882.13,564.64,"PHCS [10601]",PHCS,,1317.49,70,,,,,0,218.89,1599.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL ULTRABRIDGE 4MM STERILE LATEX FREE DISPOSABLE",SUP-72205698,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANASTROZOLE 1 MG TABLET",RX-16205,CDM,,,0250,RC,60687-0112-11,NDC,both,1,UN,10.42,3.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.21,8.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX20MM VANGUARD ARCOM KNEE POSTERIOR STABILIZE",SUP-183650,CDM,C1776,HCPCS,0278,RC,,,both,,,8259.30,2477.79,"PHCS [10601]",PHCS,,5781.51,70,,,,,0,960.56,7020.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 40 MEDIUM KEEL AEQUALIS PERFORM SHOULDER",SUP-DWE513,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1103.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1083.45,7918.6,"percent of total billed charges",
"STENT EVERFLEX ENTRUST 60MM 150CM 6MM VASCULAR NICKEL",SUP-EVD35-06-060-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"PHCS [10601]",PHCS,,4399.5,70,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM BIRMINGHAM BICEPS FIXATION STERILE LATEX FREE",SUP-AR-1662S-1,CDM,C1713,HCPCS,0278,RC,,,both,,,5071.50,1521.45,"CIGNA [10200]",Cigna,,3448.62,68,,1831.33,1831.33,1831.33,16,589.82,4310.78,"percent of total billed charges",
"SCR BONE 7.5MM 45MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840007545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",441.36,3225.75,"percent of total billed charges",
"VALVE AIRWAY 4-7MM ENDOBRONCHIAL ZEPHYR",SUP-EBV-TS-4.0,CDM,S27800098,LOCAL,0278,RC,,,both,,,17112.00,5133.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7033.03,41.1,,,,,0,1990.13,14545.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 4MM .6MM SMART STAPES PISTON RECONSTRUCTIVE",SUP-7014-5926,CDM,L8613,HCPCS,0278,RC,,,both,,,1801.20,540.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,209.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,209.48,1531.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25X1.27MM INTREX",SUP-00507132400,CDM,S27200284,LOCAL,0272,RC,,,both,,,323.12,96.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,219.72,68,,,,,0,37.58,274.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TRILOGY HEART VALVE (SIZE 23)",SUP-TRILOGY-THV-S,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"NOVANET [10819]",Novanet,,149625,75,,,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Mscl Perc Ndl",PX-361000027,CDM,20206,CPT,0361,RC,,,both,,,3620.48,1086.14,"NOVANET [10819]",Novanet,,2715.36,75,,,,,0,421.06,3620.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FUSION TITAN 190CM 4CM 24FR 8MM .035IN BALLOON",SUP-G49221,CDM,C1726,HCPCS,0272,RC,,,both,,,2452.50,735.75,"UHC [10700]","United Healthcare",,1552.43,63.3,,,,,0,285.23,2084.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 RIGHT KNEE POSTERIOR STABILIZED CEMENTED",SUP-5515-F-302,CDM,C1776,HCPCS,0278,RC,,,both,,,16566.90,4970.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6809,41.1,,6417.48,6417.48,6417.48,"1 through 10",1926.73,14081.87,"percent of total billed charges",
"BIOLOX DELTA HD 12/14 32X-3.5",SUP-00-8775-032-01,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"CIGNA [10200]","Cigna Local Plus",,5274.42,53.5,,5372.07,4581.20,7242.98,23,1146.57,8379.91,"percent of total billed charges",
"RTRCTR 10 1/8IN C W MAYO ANGLED ABDOMINAL",SUP-SU3450,CDM,S27200284,LOCAL,0272,RC,,,both,,,1314.63,394.39,"CIGNA [10200]","Cigna Local Plus",,703.33,53.5,,,,,0,152.89,1117.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIKING 115CM 5FR 5MM SPACING JOSEPHSON CURVE",SUP-M0044000440,CDM,C1887,HCPCS,0272,RC,,,both,,,1558.44,467.53,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,640.52,41.1,,,,,0,181.25,1324.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURGICAL CURETTES OR LOOPS OR CURETTE SET",SUP-MPN52010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CARTO XP THERMOCOOL SF 7.5FR B-F CURVE",SUP-BNI35BFH,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"MULTIPLAN [10600]",Multiplan,,15352.79,85,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INJECTION 1000ML 5% DEXTROSE USP LIFE FLEXIBLE CNTNR",SUP-792209,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 18MM 145CM 4MM CORONARY STENT",SUP-1145400-18,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]","Cigna Local Plus",,3123.33,53.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 35MM TITANIUM SPIRE BONE SPINAL",SUP-9240200,CDM,C1713,HCPCS,0278,RC,,,both,,,17798.40,5339.52,"UHC [10700]","United Healthcare",,11266.39,63.3,,5023.51,2672.93,6679.78,18,2069.95,15128.64,"percent of total billed charges",
"SCR BONE 5MM 95MM LCP STAINLESS STEEL PERIARTICULAR FEMORAL",SUP-02.205.295,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"BLUE CROSS [10001]","Blue Cross HMO",,609.89,39.2,,957.42,156.86,7483.26,51,180.95,1322.47,"percent of total billed charges",
"STENT CONTOUR SENSOR DUAL-FLEX 24CM 3CM 7FR .035IN PIGTAIL",SUP-M006180232190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC",323,MS-DRG,,,,,,,inpatient,,,222586.62,66775.99,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,28722.14,,"Case rate ($26,843.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $24,925.66, add-ons for qualifying new technology services are included. If operating cost exceeds $57,965.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,266.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $24,958.62. The transfer operating threshold is the transfer adjustment factor * $24,925.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,884.50. The transfer capital threshold is the transfer adjustment factor * $1,884.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,26843.12,126342.77,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR ACCENT SR 52X48MM 1 CHMBR STORED EGMS AUTOCAPTURE",SUP-PM1110,CDM,C1786,HCPCS,0275,RC,,,both,,,9576.00,2872.8,"BLUE CROSS [10001]","Blue Cross HMO",,3753.79,39.2,,,,,0,1113.69,8139.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 30MM RSP SHOULDER LOCK GLENOID BASEPLT",SUP-506-03-130,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,714.07,45.9,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP 135D 230CM ROTATABLE PRELOADED ENDOSCOPIC",SUP-HX-201UR-135LB,CDM,S27200284,LOCAL,0272,RC,,,both,,,513.30,153.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,235.6,45.9,,,,,0,59.7,436.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC",360,MS-DRG,,,,,,,inpatient,,,150519.24,45155.77,"AMBETTER EXCHANGE  [11102]",Ambetter,,14976.05,,"Case rate ($14,976.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,906.28, add-ons for qualifying new technology services are included. If operating cost exceeds $46,945.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,433.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $13,924.67. The transfer operating threshold is the transfer adjustment factor * $13,906.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.38. The transfer capital threshold is the transfer adjustment factor * $1,051.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,14976.05,59601.94,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HARVESTER 5CM EPIDERMIS GRAFT SUCTION MICRODOME CELLUTOME",SUP-CT-H50,CDM,S27200284,LOCAL,0272,RC,,,both,,,3228.75,968.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,375.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,375.5,2744.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 25MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962357,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3916.03,27,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175252090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"PHCS [10601]",PHCS,,931.18,70,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE CONCENTRATE 20 MG/ML ORAL SYRINGE SUPERORDERABLE (FOR ORAL USE ONLY)",RX-410317,CDM,,,0250,RC,68094-0056-01,NDC,both,.5,ML,25.19,7.56,"KAISER [10500]",Kaiser,,16.88,67,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNCOMPLICATED PEPTIC ULCER WITH MCC",383,MS-DRG,,,,,,,inpatient,,,51769.34,15530.8,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,8821.51,,"Case rate ($8,564.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,952.78, add-ons for qualifying new technology services are included. If operating cost exceeds $40,992.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,983.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,963.30. The transfer operating threshold is the transfer adjustment factor * $7,952.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $601.27. The transfer capital threshold is the transfer adjustment factor * $601.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,34433.28,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC",822,MS-DRG,,,,,,,inpatient,,,99189.17,29756.75,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,7692.54,,"Case rate ($7,468.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,934.99, add-ons for qualifying new technology services are included. If operating cost exceeds $39,974.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,906.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $6,944.17. The transfer operating threshold is the transfer adjustment factor * $6,934.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $524.32. The transfer capital threshold is the transfer adjustment factor * $524.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7468.49,35151.98,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 7-0 24IN 2 ARM MONOFILAMENT 4 STRAND",SUP-EPM8704,CDM,S27200284,LOCAL,0272,RC,,,both,,,984.31,295.29,"NOVANET [10819]",Novanet,,738.23,75,,,,,0,114.48,836.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 300MM 10MM TFN-ADVANCED TAPER LARGE QUICK COUPLING",SUP-03.037.021,CDM,S27200284,LOCAL,0272,RC,,,both,,,2801.40,840.42,"UHC [10700]","United Healthcare",,1773.29,63.3,,,,,0,325.8,2381.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION BLUE 4.8MM 1.32MM T EAR ULTRASIL MODIFY",SUP-70241072,CDM,S27800098,LOCAL,0278,RC,,,both,,,201.56,60.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,57.69,28.62,,,,,0,23.44,171.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VISIGLIDE ENDOSCOPIC STRAIGHT 2700MM .035IN .025IN",SUP-G-240-3527S,CDM,C1769,HCPCS,0272,RC,,,both,,,1288.95,386.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,152.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,149.9,1095.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING SINGLE PATIENT USE FOR VOLARA SYSTEM",SUP-M08473,CDM,S27000186,LOCAL,0270,RC,,,both,,,753.79,226.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,87.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.67,640.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 17.5MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158125117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AETNA [10100]","Aetna HMO/PPO",,8883.77,79.5,,10981.53,8986.79,12413.38,12,1299.6,9498.37,"percent of total billed charges",
"DEVICE PIPELINE FLEX 14MM 3.25MM EMBOLIZATION",SUP-PED2-325-14,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,32319,40,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GASTROINTESTINAL HEMORRHAGE WITH MCC",377,MS-DRG,,,,,,,inpatient,,,49461.74,14838.52,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,12019.55,,"Case rate ($11,339.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,529.21, add-ons for qualifying new technology services are included. If operating cost exceeds $43,568.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,178.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,543.14. The transfer operating threshold is the transfer adjustment factor * $10,529.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $796.06. The transfer capital threshold is the transfer adjustment factor * $796.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,45588.49,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL 6MM STD VASCULAR 2 TRACTION SPRING STEALTH",SUP-AVD-6025,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"UHC [10700]","United Healthcare",,99.13,63.3,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 45MM SPINAL POLYAXIAL 5.5MM ROD",SUP-8458545,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"BLUE CROSS [10001]","Blue Cross PPO",,1898.3,39.2,,957.42,570.23,957.42,28,563.19,4116.21,"percent of total billed charges",
"HC Ileoscopy W Polypectomy",PX-750000243,CDM,44799,CPT,0750,RC,,,both,,,3746.37,1123.91,"FIRST HEALTH [10303]","First Health",,2997.1,80,,,,,0,435.7,3746.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 19MM 150CM 5MM BILIARY STAINLESS",SUP-H74937912519150,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"CIGNA [10200]","Cigna Open Access",,2840.45,56.9,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.75MM X 12.0MM",SUP-492751212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC",372,MS-DRG,,,,,,,inpatient,,,26409.63,7922.89,"AMBETTER EXCHANGE  [11102]",Ambetter,,6333.33,,"Case rate ($6,333.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,880.92, add-ons for qualifying new technology services are included. If operating cost exceeds $38,920.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,826.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $5,888.70. The transfer operating threshold is the transfer adjustment factor * $5,880.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $444.63. The transfer capital threshold is the transfer adjustment factor * $444.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",11373.01,11373.01,11373.01,"1 through 10",6333.33,25462.72,other,"INPATIENT DRG"
"CATH SCOUTPRO 55CM 7.3FR 8.7FR MPH CURVE GUIDING HYDROPHILIC","SUP-375 534",CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VENTRALIGHT ST ECHO 2 20CM CIRCLE",SUP-5990020,CDM,C1781,HCPCS,0278,RC,,,both,,,11011.02,3303.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5054.06,45.9,,,,,0,1280.58,9359.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT STEM 25MM TOTAL STABILIZE KNEE FEMUR TRIATHLON",SUP-5571-S-025,CDM,C1776,HCPCS,0278,RC,,,both,,,4495.68,1348.7,"PHCS [10601]",PHCS,,3146.98,70,,,,,0,522.85,3821.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 7MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620207,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Open Access",,6403.47,56.9,,5302.19,4377.88,6578.61,27,1308.83,9565.82,"percent of total billed charges",
"EXERCISER HAND THERABAND STD GREEN MEDIUM RESISTANCE",SUP-527803,CDM,S27000186,LOCAL,0270,RC,,,both,,,60.03,18.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,27.55,45.9,,,,,0,6.98,51.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G211,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"PHCS [10601]",PHCS,,6556.26,70,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z2 100CM 6FR JL4 CURVE GUIDING CORONARY STERILE LATEX",SUP-Z26JL40,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL MODULAR REMEDY SPECTRUM GENTAMICIN VANCOMYCIN",SUP-GVHDSM,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS [10001]","Blue Cross HMO",,7408.8,39.2,,5311.50,4717.44,5388.59,31,2198.07,16065,"percent of total billed charges",
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 60X14-18MM",SUP-400730,CDM,S27800098,LOCAL,0278,RC,,,both,,,4264.20,1279.26,"CIGNA [10200]","Cigna Open Access",,2426.33,56.9,,,,,0,495.93,3624.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD NEROSTIMLTR 100CM INTERSTIM 2.16MM SPACING STERILE",SUP-3560030,CDM,C1883,HCPCS,0278,RC,,,both,,,1747.50,524.25,"CIGNA [10200]","Cigna Open Access",,994.33,56.9,,,,,0,203.23,1485.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP SOLID BACK HA TRIDENT D HEMISPHERE",SUP-500-11-50D,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.85,2973.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1174.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1152.75,8425.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 16 X 13 X 06MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-161306-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"PHCS [10601]",PHCS,,4347,70,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL 92MM TITANIUM 2 HOLE SHAFT 2 COMPRESSION SLOT",SUP-59202010,CDM,C1713,HCPCS,0278,RC,,,both,,,14993.70,4498.11,"KAISER [10500]",Kaiser,,10045.78,67,,,,,0,1743.77,12744.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83X13MM VANGUARD VIVACIT-E KNEE TIBIAL STERILE",SUP-VE183463,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"KAISER [10500]",Kaiser,,8678.3,67,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 55.9CM 8MM DA VINCI S/SI ENDOWRIST 45- D",SUP-420205,CDM,S27000186,LOCAL,0270,RC,,,both,,,2126.25,637.87,"PHCS [10601]",PHCS,,1488.38,70,,,,,0,247.28,1807.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 8MM 3MM 1.5MM 1.2MM BALLOON DILATATION RAPID",SUP-DC-RY3008UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"PHCS [10601]",PHCS,,691.74,70,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 73X40X14IN UNIFY CRT-D 2.5V 500OHM 60 PPM",SUP-CD3231-40Q,CDM,C1882,HCPCS,0278,RC,,,both,,,45926.50,13777.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5442.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5341.25,39037.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VITALYST INTRODUCER SET",SUP-H749396790010,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 30MM 10MM .035IN BALLOON DILATATION NYBAX",SUP-39171-10034,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,853.74,68,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PACING 46CM 4 STRAIGHT STYLET 1J 1 UNIVERSAL CLIP TOOL",SUP-4090/46,CDM,C1898,HCPCS,0275,RC,,,both,,,453.60,136.08,"BLUE CROSS [10001]","Blue Cross PPO",,177.81,39.2,,,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL LONG HINDFOOT VALOR 4.3MM SCR IMPL KIT",SUP-415S002352,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"CIGNA [10200]",Cigna,,1173,68,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 48MM 28MM TANDEM HIP COCR UHMWPE SHELL",SUP-71322048,CDM,C1776,HCPCS,0278,RC,,,both,,,7003.50,2101.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4762.38,68,,,,,0,814.51,5952.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VG2 PRESERVON VERTIGRAFT CORTICAL CANCELLOUS",SUP-VG2C-T46P,CDM,S27800098,LOCAL,0278,RC,,,both,,,5865.00,1759.5,"BLUE CROSS [10001]","Blue Cross HMO",,2299.08,39.2,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE-O MOD SHANK, 5.5X55MM TRACTION",SUP-13175555,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH",RX-28409,CDM,,,0637,RC,00378-3352-99,NDC,both,1,UN,116.74,35.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.58,99.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET",RX-123550,CDM,,,0637,RC,77333-0934-25,NDC,both,1,UN,6.27,1.88,"PHCS [10601]",PHCS,,4.39,70,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE LEAD LOCKING .43-.66MM SLS II 2 .017-.026IN ICD LEAD",SUP-518-019,CDM,C1773,HCPCS,0272,RC,,,both,,,4071.00,1221.3,"KAISER [10500]",Kaiser,,2727.57,67,,,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 20MM 4D RIGHT ELBOW",SUP-TR-H200R-S,CDM,C1776,HCPCS,0278,RC,,,both,,,13489.50,4046.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5395.8,40,,,,,0,1568.83,11466.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 4CM 5MM BALLOON DILATATION",SUP-U815054,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 8X6CM SUSPEND TUTOPLAST FASCIA LATA",SUP-937268,CDM,C1762,HCPCS,0278,RC,,,both,,,3238.30,971.49,"CIGNA [10200]","Cigna Open Access",,1842.59,56.9,,,,,0,376.61,2752.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 33CM 5MM E-Z CLEAN STERILE PTFE",SUP-0021,CDM,S27200284,LOCAL,0272,RC,,,both,,,331.98,99.59,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,152.38,45.9,,,,,0,38.61,282.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM ALLOGRAFT 10MM",SUP-310110,CDM,S27800098,LOCAL,0278,RC,,,both,,,3139.50,941.85,"BLUE CROSS [10001]","Blue Cross HMO",,1230.68,39.2,,,,,0,365.12,2668.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 300CC P3.1CM MODERATE CLASSIC PROFILE STD",SUP-350-7300MC,CDM,C1789,HCPCS,0278,RC,,,both,,,4823.10,1446.93,"FIRST HEALTH [10303]","First Health",,3858.48,80,,,,,0,560.93,4099.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE AMS 700 MS PUMP CONCEAL INFLATABLE RESVR",SUP-720185-01,CDM,C1813,HCPCS,0278,RC,,,both,,,21609.00,6482.7,"UHC [10700]","United Healthcare",,13678.5,63.3,,,,,0,2513.13,18367.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 3-0 PS-2 SPIRAL 45CM SUT",SUP-SXPP1B105,CDM,S27200284,LOCAL,0272,RC,,,both,,,224.03,67.21,"CIGNA [10200]",Cigna,,152.34,68,,,,,0,26.05,190.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 5 1/8IN LAMBOTTE SWISS PATTERN SURGICAL MINI",SUP-27-5706,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.07,43.22,"CIGNA [10200]",Cigna,,97.97,68,,,,,0,16.76,122.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 20MM TI",SUP-MTC-37200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,848.23,68,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 6X38X28MM 10 DEGREE",SUP-1921041P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"NOVANET [10819]",Novanet,,25987.5,75,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM RECONSTRUCTION VALVULAR RETRACTION",SUP-680R32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 2.25MM CORONARY STENT EVEROLIMUS",SUP-H7493926132220,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"AETNA [10100]","Aetna HMO/PPO",,6856.88,79.5,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 10MM ZERO-P PEEK CERVICAL INTERBODY FUSION",SUP-04.617.120S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"MULTIPLAN [10600]",Multiplan,,10557,85,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS13030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PHCS [10601]",PHCS,,8206.17,70,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH ACCESS CLEARPETRA L13 CM OD16 FR ID14 FR NEPHROSTOMY",SUP-90121413,CDM,C1894,HCPCS,0272,RC,,,both,,,1935.00,580.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,229.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,225.04,1644.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASC AORT EXT CUF 28MM",SUP-PLA280300,CDM,C1713,HCPCS,0278,RC,,,both,,,19725.30,5917.59,"AETNA [10100]","Aetna HMO/PPO",,15681.61,79.5,,1521.93,481.35,16760.95,30,2294.05,16766.51,"percent of total billed charges",
"STENT POLYFLEX 30MM 11MM 18MM TRACHEOBRONCHIAL SILICONE SELF",SUP-7020,CDM,C1887,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"AETNA [10100]","Aetna HMO/PPO",,2653.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,388.15,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 56MM 32MM MARATHON HIP",SUP-121932056,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,857.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,841.39,6149.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS SUTUPAK 3-0 18IN BRAID 12 STRAND",SUP-VCP104G,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.32,28.9,"FIRST HEALTH [10303]","First Health",,77.06,80,,,,,0,11.2,81.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7-3MM TORNADO MICROCOIL PLATINUM FIBER",SUP-G47420,CDM,S27800098,LOCAL,0278,RC,,,both,,,931.42,279.43,"MULTIPLAN [10600]",Multiplan,,791.71,85,,,,,0,108.32,791.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM RELINE C MULTIAXIAL NONSTERILE LATEX FREE",SUP-3904016,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL SYMBOTEX 25X20CM 3.3X2.3MM 2 SIDE MONOFILAMENT",SUP-SYM2520OS,CDM,C1781,HCPCS,0278,RC,,,both,,,9718.51,2915.55,"CIGNA [10200]",Cigna,,6608.59,68,,,,,0,1130.26,8260.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 0 4IN ENDO STITCH V-LOC POLYBUTESTER LOAD UNIT",SUP-VLOCN004L,CDM,S27200284,LOCAL,0272,RC,,,both,,,249.43,74.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.01,212.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 8CM 2MM GATOR XTRA SHARP LARGE HUB STERILE",SUP-C9960A,CDM,S27200284,LOCAL,0272,RC,,,both,,,638.28,191.48,"NOVANET [10819]",Novanet,,478.71,75,,,,,0,74.23,542.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X9MM COALITION MIS 7D LORDOTIC 14MM STERILE",SUP-3136.2109,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7089.75,41.1,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 12IN 4 PANEL HOOK LOOP CLSR 30-45IN SMALL",SUP-13651056,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.17,26.15,"NOVANET [10819]",Novanet,,65.38,75,,,,,0,10.14,74.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 120MM 5MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171051210,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135D +0MM 32MM LATERAL OFFSET 36MM 130MM 14MM 9",SUP-523191,CDM,C1776,HCPCS,0278,RC,,,both,,,10761.12,3228.34,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1275.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1251.52,9146.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 45MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.845,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"BLUE CROSS [10001]","Blue Cross PPO",,538.77,39.2,,957.42,570.23,957.42,28,159.84,1168.25,"percent of total billed charges",
"STENT SURPASS EVOLVE 12MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45012,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"MULTIPLAN [10600]",Multiplan,,70571.01,85,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 8X40 40CM SL",SUP-48008004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,116.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE MATRISTEM MICROMATRIX PORCINE URINARY",SUP-MM0500,CDM,Q4118,HCPCS,0278,RC,,,both,,,5699.40,1709.82,"KAISER [10500]",Kaiser,,3818.6,67,,,,,0,6.84,4844.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM 8.6FR HELIX VENTRICLE 1 COIL ACTIVE",SUP-693565,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS [10001]","Blue Cross PPO",,6731.42,39.2,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLITTER KIT  5019  M-4 HV 15-L CE MK",SUP-5019,CDM,S27200284,LOCAL,0272,RC,,,both,,,27090.00,8127,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11133.99,41.1,,,,,0,3150.57,23026.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 5YDX.5IN ALGIDEX SILVER GAUZE PK LATEX FREE",SUP-46-PG12,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.55,19.36,"MULTIPLAN [10600]",Multiplan,,54.87,85,,,,,0,7.51,54.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 60MM 7MM BALLOON DILATATION PEBAX",SUP-H74939032706010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI CHIKAI VASCULAR 3CM 300CM 170CM .014IN SLIP-COAT",SUP-WAIN-CKI-300,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"UHC [10700]","United Healthcare",,2373.75,63.3,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT FIBERGRAFT LARGE BIOACTIVE 12.5CC",SUP-55000125,CDM,C1713,HCPCS,0278,RC,,,both,,,18113.76,5434.13,"FIRST HEALTH [10303]","First Health",,14491.01,80,,,,,0,2106.63,15396.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 40MM 150CM 8MM VASCULAR NICKEL",SUP-EVD35-08-040-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"BLUE CROSS [10001]","Blue Cross PPO",,2463.72,39.2,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER ETHIBOND 0 MO-6 18IN CONTROL RELEASE BRAID 8",SUP-CX45D,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.15,44.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,101.42,68,,,,,0,17.35,126.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 52MM TI",SUP-MTC-37520-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"BLUE CROSS [10001]","Blue Cross HMO",,488.98,39.2,,957.42,156.86,7483.26,51,145.07,1060.29,"percent of total billed charges",
"SCR BONE 4.2MM 44MM GORILLA R3CON LOCK",SUP-P50-353-4244,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,523.91,39.2,,957.42,156.86,7483.26,51,155.43,1136.03,"percent of total billed charges",
"LENS IOL 5 D +31 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-LI61AOR3100,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 250MM 2MM .018IN BALLOON",SUP-R51002025L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"FIRST HEALTH [10303]","First Health",,1993.5,80,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 365CC SMOOTH SHELL SURFACE NATRELLE INSPIRA FULL",SUP-SRF-365,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1569.95,28.62,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL FREEZE DRIED SPACER PLIF WEDGE 26X8MM",SUP-170826,CDM,S27800098,LOCAL,0278,RC,,,both,,,12572.49,3771.75,"BLUE CROSS [10001]","Blue Cross HMO",,4928.42,39.2,,,,,0,1462.18,10686.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X6MM COLONIAL 12MM LARGE PARALLEL TITANIUM",SUP-365.306CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +23.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.235,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 150MM 7MM .035IN BALLOON",SUP-AB35W07150135,CDM,C1725,HCPCS,0272,RC,,,both,,,1061.91,318.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,125.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,123.5,902.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 100CM 5FR STRAIGHT ANGIOGRAPHIC CEREBRUM",SUP-31-403,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"CIGNA [10200]","Cigna Open Access",,66.33,56.9,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 5.5MM CURVE TITANIUM CP4 NONSTERILE",SUP-1553201060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE MARKER 2 X 2 BIOZORB",SUP-F0202,CDM,A4648,HCPCS,0278,RC,,,both,,,8383.50,2515.05,"CIGNA [10200]","Cigna Local Plus",,4485.17,53.5,,,,,0,975,7125.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 51MM 3 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-43F51V,CDM,S27200284,LOCAL,0272,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TRICLIP 4MM 9X17MM DELIVERY 4TH GENERATION STERILE",SUP-TCDS0301-NT,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP SYSTEM WITH METAL HEAD",SUP-55500017,CDM,C1776,HCPCS,0278,RC,,,both,,,21420.00,6426,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8803.62,41.1,,6417.48,6417.48,6417.48,"1 through 10",2491.15,18207,"percent of total billed charges",
"SUT ETHILON MICROPOINT 9-0 TG140-8 12IN 2 ARM MONOFILAMENT",SUP-7717G,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.46,43.64,"CIGNA [10200]","Cigna Open Access",,82.77,56.9,,,,,0,16.92,123.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EASYTRAK 3",SUP-4550,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2573.61,45.9,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM TSRH OSTEOGRIP TITANIUM SPINE",SUP-83575359,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"MULTIPLAN [10600]",Multiplan,,2187.9,85,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 5 KNEE POSTERIOR TOTAL STABILIZE",SUP-5544-A-500,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"FIRST HEALTH [10303]","First Health",,3816.79,80,,,,,0,554.87,4055.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOTUS INTRODUCER SMALL REPRISE III",SUP-H749NTR180,CDM,C1894,HCPCS,0272,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl FB Peritoneal",PX-361000202,CDM,49402,CPT,0361,RC,,,both,,,2339.99,702,"AMERIGROUP MEDICAID [20100]",Amerigroup,,277.29,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.34,2339.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM ENDOSKELETON TCS TITANIUM STD SPINE",SUP-5301-3516,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,396.9,39.2,,957.42,156.86,7483.26,51,117.75,860.63,"percent of total billed charges",
"VALVE AORTIC 19MM 14.8MM MASTER-SERIES PYROLYTIC CARBON PTFE",SUP-19ATJ-503,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"BLUE CROSS [10001]","Blue Cross HMO",,11414.74,39.2,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.25 X 18 RX US",SUP-1804325-18,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIB 64CM 7.3FR RELIANCE 4-FRONT RIGHT VENTRICLE MP35N",SUP-676,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"KAISER [10500]",Kaiser,,10170.6,67,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 9MM BALLOON",SUP-U357598,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH HEARTSPAN 55D FIX CURVE TAPER 101.5CM 8.5FR GUIDING",SUP-FCL-160-10,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 80MM 5FR 10MM BALLOON DILATATION OTW",SUP-39032-10808,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MACH1 100CM 8FR MP2 CURVE GUIDING PTFE FEMORAL",SUP-H74934358390,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC",324,MS-DRG,,,,,,,inpatient,,,199894.76,59968.43,"CIGNA [10200]","Cigna Open Access",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 46.8%. Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 90CM 3FR 11MM STONE 3 WIRE HELICAL",SUP-M0063301090,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL 0 D +29 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.290,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 38CM RIGHT TROCHANTERIC INTRAMEDULLARY 125D",SUP-456.398S,CDM,C1713,HCPCS,0278,RC,,,both,,,12838.83,3851.65,"AETNA [10100]","Aetna HMO/PPO",,10206.87,79.5,,1521.93,481.35,16760.95,30,1493.16,10913.01,"percent of total billed charges",
"CATH NC TREK NEO 20MM 145CM 3.25MM BALLOON DILATATION",SUP-1400325-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL NAVISTAR 115CM 8FR 3.5MM FF CURVE",SUP-D132702,CDM,C1732,HCPCS,0272,RC,,,both,,,19845.00,5953.5,"MULTIPLAN [10600]",Multiplan,,16868.25,85,,,,,0,2307.97,16868.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MILL BNE FN",SUP-5400-702-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2130.15,639.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,875.49,41.1,,,,,0,247.74,1810.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 6FR 3.5MM 4FR BALLOON",SUP-H74939031354010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ROUND 11CM GELPOINT TRANSVAGINAL ACCESS PLATFORM",SUP-C2A11,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 190CM 3CM",SUP-1020013,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE GLIDE TECHNOLOGY VASCULAR STD STRAIGHT 260CM",SUP-GR3504,CDM,C1769,HCPCS,0272,RC,,,both,,,408.90,122.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,48.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acetone Serum Qual",PX-301000084,CDM,82009,CPT,0301,RC,,,both,,,252.00,75.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7.11,,,,,,,0.01,214.2,"fee schedule",
"ANCHOR SUT 2 BIOKNOTLESS PLUS ORTHOCORD ROTATOR CUFF",SUP-212722,CDM,C1713,HCPCS,0278,RC,,,both,,,5664.90,1699.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,658.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",658.83,4815.17,"percent of total billed charges",
"BIT DRILL 170MM 4.5MM STAINLESS STEEL QUICK COUPLING",SUP-310.66,CDM,S27000186,LOCAL,0270,RC,,,both,,,2304.00,691.2,"PHCS [10601]",PHCS,,1612.8,70,,,,,0,267.96,1958.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM ROUND BALL DIAMOND STERILE",SUP-ZB-164,CDM,S27200284,LOCAL,0272,RC,,,both,,,455.06,136.52,"CIGNA [10200]",Cigna,,309.44,68,,,,,0,52.92,386.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X18X11MM TRANSCONTINENTAL 0D CORONAL TAPER",SUP-375.883,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross HMO",,9384.48,39.2,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM PERSONA CD KNEE RIGHT MEDIAL HALF BLOCK",SUP-42555803410,CDM,C1776,HCPCS,0278,RC,,,both,,,7236.72,2171.02,"BLUE CROSS [10001]","Blue Cross HMO",,2836.79,39.2,,5311.50,4717.44,5388.59,31,841.63,6151.21,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 50CM 20MM 10MM KNIT TEXTILE HEMAGARD",SUP-HGK2010,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 10MM 2.75MM BALLOON DILATATION STERILE",SUP-227-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 22CM 8FR .038",SUP-M006192151120,CDM,C2617,HCPCS,0278,RC,,,both,,,1487.32,446.2,"CIGNA [10200]",Cigna,,1011.38,68,,,,,0,172.98,1264.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 6FR 8MM 4FR BALLOON",SUP-H74939031804010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL COALITION AGX 0 D D10.5 MM W18 MM X H7 MM NONS",SUP-3128.1507,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PEN 19CM ISOLATOR TRANSPOLAR",SUP-MAX1,CDM,S27200284,LOCAL,0272,RC,,,both,,,12420.00,3726,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1471.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIGNS AND SYMPTOMS WITHOUT MCC",948,MS-DRG,,,,,,,inpatient,,,29162.51,8748.75,"AMBETTER EXCHANGE  [11102]",Ambetter,,4965.55,,"Case rate ($4,965.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,610.85, add-ons for qualifying new technology services are included. If operating cost exceeds $37,650.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,730.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,616.95. The transfer operating threshold is the transfer adjustment factor * $4,610.85 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $348.60. The transfer capital threshold is the transfer adjustment factor * $348.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,4965.55,19963.67,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,inpatient,,,88435.94,26530.78,"AMBETTER EXCHANGE  [11102]",Ambetter,,10717.03,,"Case rate ($10,717.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,951.49, add-ons for qualifying new technology services are included. If operating cost exceeds $42,991.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,134.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,964.65. The transfer operating threshold is the transfer adjustment factor * $9,951.49 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.38. The transfer capital threshold is the transfer adjustment factor * $752.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,50441.93,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DBF 6CC ALLOGRAFT PUTTY",SUP-T50106,CDM,C1713,HCPCS,0278,RC,,,both,,,8970.00,2691,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4117.23,45.9,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 345841FZ L-ASR 8X14X11 FZ SRVCFEE",SUP-345841FZ,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 108MM 6MM MONOBLOCK RSP",SUP-510-00-006,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5040,40,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50MMX10MM CLYDESDALE 6D PEEK-OPTIMA RADIOPAQUE",SUP-2968050,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Open Access",,8019.9,33.5,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 12CM 180CM 18MM 10.5FR ESOPHAGEAL",SUP-G57326,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"CIGNA [10200]","Cigna Local Plus",,5540.72,31.5,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE LEFT POSTERIOR STABILIZE PERSONA",SUP-42500806201,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"BLUE CROSS [10001]","Blue Cross HMO",,11327.07,39.2,,5311.50,4717.44,5388.59,31,3360.56,24561.24,"percent of total billed charges",
"SCR BONE 4MM 40MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.440TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"PHCS [10601]",PHCS,,1415.09,70,,,,,0,235.11,1718.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL RESTORIS 2 H9 MM KNEE ONLAY MULTICOMPARTMENTAL",SUP-180702-2,CDM,C1776,HCPCS,0278,RC,,,both,,,4046.85,1214.05,"KAISER [10500]",Kaiser,,2711.39,67,,,,,0,470.65,3439.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X18X9MM TRANSCONTINENTAL 0D CORONAL TAPER",SUP-375.492,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"UHC [10700]","United Healthcare",,15154.02,63.3,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 6MM 14MM TITANIUM FULL THREAD CANCELLOUS SMALL",SUP-406.014,CDM,C1713,HCPCS,0278,RC,,,both,,,294.76,88.43,"KAISER [10500]",Kaiser,,197.49,67,,,,,0,34.28,250.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 15MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40015W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"NOVANET [10819]",Novanet,,4079.25,75,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 180MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-05181,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TSRH OSTEOGRIP THINLINE TITANIUM SHORT",SUP-83565408,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.10,1106.73,"FIRST HEALTH [10303]","First Health",,2951.28,80,,,,,0,429.04,3135.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL SHOULDER: HUMERAL HEAD, INSERT GLENOID, HMERAL STE",SUP-SI-TSA,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"CIGNA [10200]",Cigna,,10710,40,,5873.17,5873.17,5873.17,"1 through 10",3113.93,22758.75,"percent of total billed charges",
"SCR BONE 6.5MM 50MM SPINAL POLYAXIAL",SUP-8456550,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"PHCS [10601]",PHCS,,3389.82,70,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Out of or Bedside Procedure",PX-361000431,CDM,361000431,LOCAL,0361,RC,,,both,,,5325.22,1597.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,619.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,619.32,4526.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 38MM 3MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG30038UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2643.75,793.12,"CIGNA [10200]",Cigna,,1797.75,68,,,,,0,307.47,2247.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM VENTURE TITANIUM SPINE CERVICAL ANTERIOR",SUP-9791225,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",117.75,860.63,"percent of total billed charges",
"STENT VIABAHN 10CM 120CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR071002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5742.58,27,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL HEANEY CURVE 8.25IN 2 TOOTH HEAVY JAW",SUP-52-5302,CDM,S27200284,LOCAL,0272,RC,,,both,,,552.02,165.61,"MULTIPLAN [10600]",Multiplan,,469.22,85,,,,,0,64.2,469.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC SUTUPAK 2-0 18IN MONOFILAMENT 12 STRAND PRECUT",SUP-SG13T,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.67,51.8,"CIGNA [10200]","Cigna Open Access",,98.25,56.9,,,,,0,20.08,146.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET LEADWIRE L51IN 5 LEAD MULTI LINK GRABBER INDIVIDUALLY RE",SUP-414556-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,807.98,242.39,"CIGNA [10200]",Cigna,,549.43,68,,,,,0,93.97,686.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL ZIPWIRE 22-30CM 3CM 7FR .035IN PIGTAIL",SUP-M006180157180,CDM,C2617,HCPCS,0278,RC,,,both,,,1466.59,439.98,"BLUE CROSS [10001]","Blue Cross HMO",,574.9,39.2,,,,,0,170.56,1246.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULE ANALZR BD VERITOR PLUS",SUP-256066,CDM,S27000186,LOCAL,0270,RC,,,both,,,1846.28,553.88,"CIGNA [10200]",Cigna,,1255.47,68,,,,,0,214.72,1569.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM OZARK SPINE CERVICAL SELF START VARIABLE",SUP-8801-04016DA,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",117.75,860.63,"percent of total billed charges",
"INTRO SHTH 9FR STD",SUP-7093,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"MULTIPLAN [10600]",Multiplan,,378.68,85,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 10MM KNEE N2VAC POSTERIOR STABILIZE BEARING",SUP-82-3-0710,CDM,C1776,HCPCS,0278,RC,,,both,,,7890.15,2367.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,917.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,917.62,6706.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RASP SURGICAL 13CMX4MM FLAT POWERASP COOLCUT SMOOTH",SUP-AR-8400PR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1233.23,369.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,566.05,45.9,,,,,0,143.42,1048.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 15GA 22CM CENTIMETER MARK ADJUSTABLE STOP COLOR",SUP-MSPN2206,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,84.01,68,,,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION HIP DRILL GUIDE OBTR Q-FIX 1.8MM",SUP-251811,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 12MM RETRACTION BLUNT ELASTIC STAY LONE STAR DISPOSABLE",SUP-3350-1G,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.05,27.31,"UHC [10700]","United Healthcare",,57.63,63.3,,,,,0,10.59,77.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 5 MM X 10 CM",SUP-M0035475100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS [10001]","Blue Cross PPO",,5532.94,39.2,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 13MM 140CM 3MM CORONARY STERILE LATEX",SUP-453934,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 7.25IN CARB-BITE VASCULAR NDL",SUP-121-212,CDM,S27200284,LOCAL,0272,RC,,,both,,,624.51,187.35,"AETNA [10100]","Aetna HMO/PPO",,496.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.63,530.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5+ 10MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS5P10L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1231.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1208.52,8832.69,"percent of total billed charges",
"ANCHOR SUT 3MM 2 SUTURETAK FIBERWIRE BIOCOMPOSITE 14.5MM",SUP-AR-1934BCF,CDM,C1713,HCPCS,0278,RC,,,both,,,2401.88,720.56,"BLUE CROSS [10001]","Blue Cross PPO",,941.54,39.2,,957.42,570.23,957.42,28,279.34,2041.6,"percent of total billed charges",
"BEARING 79MMX12MM VANGUARD E1 KNEE ANTERIOR STABILIZE TIBIAL",SUP-EP189102,CDM,C1776,HCPCS,0278,RC,,,both,,,13372.20,4011.66,"CIGNA [10200]","Cigna Local Plus",,4212.24,31.5,,5372.07,4581.20,7242.98,23,1555.19,11366.37,"percent of total billed charges",
"COIL EMBOLIZATION 20CM 20MM AZUR DETACHABLE HYDROGEL",SUP-45-452020,CDM,S27800098,LOCAL,0278,RC,,,both,,,1974.75,592.42,"BLUE CROSS [10001]","Blue Cross PPO",,774.1,39.2,,,,,0,229.66,1678.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 10MM KNEE RIGHT E-PLUS EMPOWR 3D KNEE STERILE",SUP-342-10-708,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross HMO",,2569.56,39.2,,5311.50,4717.44,5388.59,31,762.35,5571.75,"percent of total billed charges",
"CATH NUCLEUS-X 110CM 4CM 18MM BALLOON DILATATION POLYAMIDE",SUP-612038,CDM,C1725,HCPCS,0272,RC,,,both,,,6566.52,1969.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4465.23,68,,,,,0,763.69,5581.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 21MM 2 STAGGERED TITANIUM STAPLE CIRCULAR ROW",SUP-EEAORVIL21A,CDM,S27200284,LOCAL,0272,RC,,,both,,,685.83,205.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,314.8,45.9,,,,,0,79.76,582.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CARDIOBLATE 300D 304.8CM 7CM ABLATION POROUS POLYMER",SUP-49321,CDM,S27200284,LOCAL,0272,RC,,,both,,,17250.00,5175,"MULTIPLAN [10600]",Multiplan,,14662.5,85,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE RING BILLARY 25CM",SUP-G03388,CDM,S27200284,LOCAL,0272,RC,,,both,,,413.16,123.95,"NOVANET [10819]",Novanet,,309.87,75,,,,,0,48.05,351.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 22CM 6FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251310,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]",Cigna,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 4CM 200CM 2CM 8FR 2 LUMEN",SUP-G22303,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 40MM 6MM 8FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEM06040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PHCS [10601]",PHCS,,12789,70,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM SPINE SHANK NONSTERILE MAS PLIF 3Z",SUP-7096530,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",348.9,2550,"percent of total billed charges",
"LENS IOL SY60WF.265 CLAREON",SUP-SY60WF.265,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross PPO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 45MM 2.5MM IJS AXIS",SUP-IJS-EAP-25450,CDM,C1713,HCPCS,0278,RC,,,both,,,2212.50,663.75,"PHCS [10601]",PHCS,,1548.75,70,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 74MM HIP MULTIHOLE RIM TRITANIUM X3 MDM",SUP-509-02-74J,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE EKOS 106CM 2.62MM THROMBECTOMY ENDOVASCULAR STERILE",SUP-H74939605106200,CDM,C1757,HCPCS,0272,RC,,,both,,,37894.50,11368.35,"KAISER [10500]",Kaiser,,25389.32,67,,,,,0,4407.13,32210.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 3 127D",SUP-6721-0330,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9848.4,41.1,,6417.48,6417.48,6417.48,"1 through 10",2786.79,20367.74,"percent of total billed charges",
"CATH MUSTANG 75CM 40MM 7MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171070470,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL 6MM OFFSET LAMINA LEFT",SUP-7756074L,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,348.9,2550,"percent of total billed charges",
"TISSUE REGENEATIONGRAFT 4CM X 4CM",SUP-GS-5440,CDM,Q4186,HCPCS,0636,RC,,,both,,,19070.10,5721.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12395.57,65,,,,,0,406.44,16209.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 14CM 5FR 5MM .035IN BALLOON",SUP-G52263,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 1 STRAIGHT OVAL 9IN BRUNS SPINE SURGICAL",SUP-29-5351,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.25,71.77,"UHC [10700]","United Healthcare",,151.45,63.3,,,,,0,27.82,203.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 20MM 3MM BALLOON DILATATION DRUG COATED",SUP-H7493960820300,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH METACROSS 135CM 120MM 5.7FR 7MM BALLOON DILATATION 2",SUP-BD-L70120CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTTER ENDARTERECTOMY 12MM 14MM 2 COAXIAL METAL RING",SUP-E4500-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,15835.50,4750.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET EPIDURAL 1.5IN 21GA 25GA EPILONG TUOHY .2UM METAL STEEL",SUP-0131156-51,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.70,80.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE FEEDING ORANGE 40CM 5FR NUTRIO TWISTLOK ENTERAL",SUP-ENSI4050,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.36,32.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 2.5IN 13FR IMPELLA",SUP-0052-0007,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"NOVANET [10819]",Novanet,,3622.5,75,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 12FR 20CM HYDROPHILIC RADIOPAQUE STERILE",SUP-G10292,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"CIGNA [10200]",Cigna,,45.49,68,,,,,0,7.78,56.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVICROSS 150CM 40MM 60MM SPACE SPRT STAINLESS STEEL",SUP-NC18151,CDM,C1887,HCPCS,0272,RC,,,both,,,1462.05,438.61,"UHC [10700]","United Healthcare",,925.48,63.3,,,,,0,170.04,1242.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 60MM STEALTH 3 LATIS STERILE LATEX FREE",SUP-A0C03,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,103.83,45.9,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 7.5IN .75IN SLIGHT CURVE KEY",SUP-26-5620,CDM,S27200284,LOCAL,0272,RC,,,both,,,252.56,75.77,"PHCS [10601]",PHCS,,176.79,70,,,,,0,29.37,214.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NUT SPINAL QUARTEX LOCK HEAD TO HEAD T CNCT",SUP-1149.0003,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER BURR HOLE .4MM 14MM UNIVERSAL NEURO III",SUP-53-34514,CDM,C1713,HCPCS,0278,RC,,,both,,,1858.37,557.51,"BLUE CROSS [10001]","Blue Cross PPO",,728.48,39.2,,957.42,570.23,957.42,28,216.13,1579.61,"percent of total billed charges",
"CAGE SPINAL 17X5MM DIVERGENCE 14MM LORDOTIC NUCLEUS PULPOSUS",SUP-G6626745,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"MULTIPLAN [10600]",Multiplan,,10557,85,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 65MM VALOR HINDFOOT FUSION SYSTEM",SUP-4151150065,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1173,68,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM GRIPTION TF HIP ACETABULAR STERILE",SUP-121740800,CDM,C1713,HCPCS,0278,RC,,,both,,,933.12,279.94,"CIGNA [10200]","Cigna Open Access",,530.95,56.9,,1144.80,304.56,2275.09,66,108.52,793.15,"percent of total billed charges",
"SCR BONE 6MM 35MM MATRIX TITANIUM T25 SPINE PEDICLE",SUP-04.639.635,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"BRA SURG VELC STRP ZIP LG 38-40IN",SUP-958-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,347.48,104.24,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,142.81,41.1,,,,,0,40.41,295.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 82MM PRESS FIT AEQUALIS ASCEND FLEX PTC 127.5D",SUP-DWF605A,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Open Access",,4221,33.5,,5302.19,4377.88,6578.61,27,1465.38,10710,"percent of total billed charges",
"SCR BONE 56MM 5MM NAIL-EX FULL THREAD FEMORAL TIBIAL",SUP-04.005.546,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"BLUE CROSS [10001]","Blue Cross PPO",,453.42,39.2,,957.42,570.23,957.42,28,134.52,983.18,"percent of total billed charges",
"HEAD FEMORAL -3MM OFFSET 32MM HIP MODULAR TYPE 1 SKIRT COCR",SUP-163668,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"NOVANET [10819]",Novanet,,3638.03,75,,,,,0,564.14,4123.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS DS 115CM 8MM 7FR 1-6-2MM SPACING F CURVE",SUP-D7TCF8L162RT,CDM,C1733,HCPCS,0272,RC,,,both,,,7810.80,2343.24,"MULTIPLAN [10600]",Multiplan,,6639.18,85,,,,,0,908.4,6639.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 4FR MERIT MAK COAXIAL PAIR MINI ACCESS",SUP-MAK4F-10,CDM,C1894,HCPCS,0272,RC,,,both,,,152.25,45.67,"PHCS [10601]",PHCS,,106.58,70,,,,,0,17.71,129.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 67MMX15MM VANGUARD 360 KNEE RIGHT MEDIAL LEFT",SUP-185252,CDM,C1776,HCPCS,0278,RC,,,both,,,7577.58,2273.27,"BLUE CROSS [10001]","Blue Cross HMO",,2970.41,39.2,,5311.50,4717.44,5388.59,31,881.27,6440.94,"percent of total billed charges",
"SCR BONE 2.7MM 16MM STAINLESS STEEL FULL THREAD CORTICAL",SUP-349616,CDM,C1713,HCPCS,0278,RC,,,both,,,233.86,70.16,"BLUE CROSS [10001]","Blue Cross HMO",,91.67,39.2,,957.42,156.86,7483.26,51,27.2,198.78,"percent of total billed charges",
"ADPTR TUBING CANN SET INFUSION 4MM ARTHROSCOPE STERILE",SUP-1986,CDM,S27200284,LOCAL,0272,RC,,,both,,,2843.10,852.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1304.98,45.9,,,,,0,330.65,2416.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 55X4.8MM TITANIUM THICK TISSUE ENDOSCOPIC",SUP-AX55G,CDM,S27200284,LOCAL,0272,RC,,,both,,,2834.33,850.3,"KAISER [10500]",Kaiser,,1899,67,,,,,0,329.63,2409.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 CURVE PLUS 15MM KNEE XLK FIX BEARING SIGMA",SUP-970433,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1299.6,9498.37,"percent of total billed charges",
"CAP SYSTEM PERSONA TKR VIVACIT-E FEMUR PATELLA TIBIA INSRT",SUP-98000200118,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"NOVANET [10819]",Novanet,,18427.5,75,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICROINTRODUCER 60CM 4FR VSI NITINOL TUNGSTEN STIFFEN",SUP-9200V,CDM,C1894,HCPCS,0272,RC,,,both,,,265.35,79.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,31.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.86,225.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPEEDBRIDGE SWIVELOCK FIBERWIRE FIXATION ACHILLES",SUP-AR-9929BC-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,18191.25,5457.37,"NOVANET [10819]",Novanet,,13643.44,75,,,,,0,2115.64,15462.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 13IN DEAVER 5 SURGICAL 2IN",SUP-SU3305,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.10,61.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,23.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.97,175.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VENTRICULAR SHUNT PROCEDURES WITH CC",032,MS-DRG,,,,,,,inpatient,,,125683.48,37705.04,"CIGNA [10200]","Cigna Local Plus",,21989.79,,"Fee schedule rate ($21,989.79). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,62216.68,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"METER STATSTRIP BTTRY QUICK REFERENCE GUIDE GLUCOSE",SUP-54790,CDM,S27000186,LOCAL,0270,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 750ML GEL SMOOTH ROUND MEMORYGEL P5CM MODERATE","SUP-350-7501 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"MULTIPLAN [10600]",Multiplan,,3123.75,85,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF THE BILIARY TRACT WITH CC",445,MS-DRG,,,,,,,inpatient,,,26490.58,7947.17,"PHCS [10601]",PHCS,,7561,,,,,,,7561,7561,"per diem","Estimated amount calculated based on 1 day length of stay."
"ROD REAMER 950MM 2.5MM BALL TIP STERILE DISPOSABLE",SUP-351.706S,CDM,S27200284,LOCAL,0272,RC,,,both,,,910.85,273.25,"AETNA [10100]","Aetna HMO/PPO",,724.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.93,774.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 90MM 11MM 14FR ZENITH SPIRAL-Z Z-TRAK",SUP-G55227,CDM,C1874,HCPCS,0278,RC,,,both,,,20160.00,6048,"PHCS [10601]",PHCS,,14112,70,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACURATE NE02TM AORTIC VALVE S - CLINICAL",SUP-SYM-SV23-006-C,CDM,S62400003,LOCAL,0624,RC,,,both,,,159600.00,47880,"MULTIPLAN [10600]",Multiplan,,135660,85,,,,,0,18561.48,135660,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC",179,MS-DRG,,,,,,,inpatient,,,31813.55,9544.06,"BLUE CROSS [10001]","Blue Cross PPO",,18638.72,,,,,,,4683.31,18828.95,"case rate",
"INSRT TIBIAL 3 15MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158103115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]",Cigna,,7598.69,68,,5873.17,5873.17,5873.17,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"SCR BONE 2.4MM 16MM TITANIUM T8 LOCK VARIABLE ANGLE TUBE",SUP-04.210.116TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1056.89,317.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,125.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,122.92,898.36,"percent of total billed charges",
"SCR BONE 2.4MM 16MM TITANIUM T8 LOCK VARIABLE ANGLE TUBE",SUP-04.210.116TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1056.89,317.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,485.11,45.9,,,,,0,122.92,898.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP XL INTERNAL HEM-O-LOK POLYMER LAPAROSCOPIC STERILE",SUP-544250,CDM,S27200284,LOCAL,0272,RC,,,both,,,439.14,131.74,"KAISER [10500]",Kaiser,,294.22,67,,,,,0,51.07,373.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR SURGICAL 22CM COSEAL 2 LUMEN MALLEABLE SEAL EXTEND",SUP-934034,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.79,104.64,"PHCS [10601]",PHCS,,244.15,70,,,,,0,40.56,296.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 2.9MM MAGNUM MINI ABRADER DISPOSABLE",SUP-72201518,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM PRECISION PERCUTANEOUS LINEAR 3-4",SUP-SC-2352-50,CDM,C1778,HCPCS,0278,RC,,,both,,,8914.80,2674.44,"UHC [10700]","United Healthcare",,5643.07,63.3,,,,,0,1036.79,7577.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DOVER 16IN 22FR URETHRAL HYDROGEL 5CC FOLEY 3 WAY LATEX",SUP-2722,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.35,43.6,"MULTIPLAN [10600]",Multiplan,,123.55,85,,,,,0,16.9,123.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 2CM 4MM BALLOON DILATATION HYDROPHILIC",SUP-G50334,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,970.96,41.1,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AERO 30MM 62CM 14MM 16FR GEOMETRIC TRACHEOBRONCHIAL",SUP-90129-214,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"AETNA [10100]","Aetna HMO/PPO",,13713.75,79.5,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 17MM TITANIUM SPINAL SELF TAPPING VARIABLE",SUP-3120317,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"NOVANET [10819]",Novanet,,1057.5,75,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL COMPREHENSIVE +10MM STD SHOULDER REVERSE",SUP-110031401,CDM,C1776,HCPCS,0278,RC,,,both,,,8224.80,2467.44,"CIGNA [10200]","Cigna Open Access",,4679.91,56.9,,5302.19,4377.88,6578.61,27,956.54,6991.08,"percent of total billed charges",
"CATH MAC-LOC 25CM 10.2FR DRNG ULTRATHANE HYDROPHILIC 6",SUP-G09502,CDM,C1729,HCPCS,0272,RC,,,both,,,761.32,228.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,88.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,88.54,647.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM VARIAX TITANIUM T7 FULL THREAD RADIUS",SUP-53-27620E,CDM,C1713,HCPCS,0278,RC,,,both,,,762.05,228.61,"BLUE CROSS [10001]","Blue Cross PPO",,298.72,39.2,,957.42,570.23,957.42,28,88.63,647.74,"percent of total billed charges",
"CATH SUPREME 120CM 5FR 10MM SPACING CRD CURVE",SUP-401957,CDM,C1730,HCPCS,0272,RC,,,both,,,891.00,267.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,105.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28X10X12MM CASCADIA CONVEX TITANIUM POROUS",SUP-6101-2102812NC-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"KAISER [10500]",Kaiser,,14773.5,67,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPLORER ST 100CM 5FR 5MM SPACE COURNAND CURVE",SUP-4542,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,664.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +9 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.090,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT FLITES XL LOOP DISPOSABLE",SUP-MFA2100-XL,CDM,S27000186,LOCAL,0270,RC,,,both,,,231.56,69.47,"PHCS [10601]",PHCS,,162.09,70,,,,,0,26.93,196.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 6 X 10 HELICAL FILLING COIL",SUP-10HFL-06010,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"UHC [10700]","United Healthcare",,5673.64,63.3,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 5.5MM CD HORIZON LEGACY TITANIUM PREBENT CP",SUP-8690090,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]",Cigna,,2998.8,68,,1831.33,1831.33,1831.33,16,512.88,3748.5,"percent of total billed charges",
"SPACER SPINAL 25X10X8MM VERTE-STACK CRESCENT 6D",SUP-9192508,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"NOVANET [10819]",Novanet,,12420,75,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 220CC FULL PROFILE SMOOTH NATRELLE INSPIRA",SUP-SSF-220,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,878.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VASCBAND 27 CM",SUP-3527,CDM,S27000186,LOCAL,0270,RC,,,both,,,174.00,52.2,"KAISER [10500]",Kaiser,,116.58,67,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTRA TWINFLEX TCH 59","SUP-392 289",CDM,C1893,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE KIWI PROCUP PALM PUMP VACUUM EXTRACTION RIGID STEM",SUP-VAC-6000S,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 22MM TITANIUM 1 LEVEL CITADEL BONE SPINE LUMBAR",SUP-130.122,CDM,C1713,HCPCS,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross PPO",,6762,39.2,,957.42,570.23,957.42,28,2006.18,14662.5,"percent of total billed charges",
"SET ACCESS MICROPUNCTURE STIFFENED TRANSITIONLESS CANN",SUP-G35550,CDM,C1769,HCPCS,0272,RC,,,both,,,432.74,129.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.33,367.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 9MM UNIVERS APEX OPTIFIT",SUP-AR-9100-09M,CDM,C1776,HCPCS,0278,RC,,,both,,,26302.50,7890.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3116.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3058.98,22357.13,"percent of total billed charges",
"ROD SPINAL 45MM 3.5MM VERTEX SELECT PRECUT",SUP-7753745,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"SPACER SPINAL 50X22X10MM RISE-L 10D NONSTERILE",SUP-193.434,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CIGNA [10200]","Cigna Open Access",,11502.23,33.5,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +13 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.130,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR SL4 CURVE GUIDING CORONARY SIDEHOLE",SUP-LA6SL40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"UHC [10700]","United Healthcare",,231.3,63.3,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC",740,MS-DRG,,,,,,,inpatient,,,101647.07,30494.12,"AMBETTER EXCHANGE  [11102]",Ambetter,,11225.06,,"Case rate ($11,225.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,423.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,462.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,170.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $10,437.01. The transfer operating threshold is the transfer adjustment factor * $10,423.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.05. The transfer capital threshold is the transfer adjustment factor * $788.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,52833.08,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 13.3MM 19MM 23MM 17.4MM ON-X 19 STD CYLINDRICAL",SUP-ONXAE-19,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"FIRST HEALTH [10303]","First Health",,30240,80,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 12MM 145CM 2.25MM CORONARY STENT",SUP-1125225-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2679.64,45.9,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUARD PIN YELLOW JURGAN PIN BALL .054IN KIRSCHNER WIRE W",SUP-W045-YL,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.50,21.75,"CIGNA [10200]",Cigna,,49.3,68,,,,,0,8.43,61.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC ENDOBLADE GASTROC RECESSION SYSTEM",SUP-AR-8855DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,6484.28,1945.28,"KAISER [10500]",Kaiser,,4344.47,67,,,,,0,754.12,5511.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22 DIOPTER MONOFOCAL UV ABSORBENT CLAREON",SUP-CC60WF.220,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP CERAMIC R3 DELTA POROUS R3 XLPE LINER",SUP-71703415,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2784.22,20349,"percent of total billed charges",
"LEAD PACING 72CM 8.6FR VENTRICULAR HELIX ELECTRD DF-4 CNCT",SUP-6935M72,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1997.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POS SURGICAL STARFISH EVO HEART SILICONE MULTIAPPENDAGE CUP",SUP-HP3000,CDM,S27200284,LOCAL,0272,RC,,,both,,,5266.08,1579.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3580.93,68,,,,,0,612.45,4476.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 52MM 32MM MARATHON HIP",SUP-121932052,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"CIGNA [10200]","Cigna Open Access",,4116.52,56.9,,5302.19,4377.88,6578.61,27,841.39,6149.45,"percent of total billed charges",
"ADPTR CATH 8IN 8FR POLYURETHANE HEMOSTASIS VALVE STPCOCK",SUP-HVA-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.30,22.89,"MULTIPLAN [10600]",Multiplan,,64.86,85,,,,,0,8.87,64.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 3.50 X 18 MM",SUP-1212350-18,CDM,C1874,HCPCS,0272,RC,,,both,,,17250.00,5175,"UHC [10700]","United Healthcare",,10919.25,63.3,,,,,0,7089.75,10919.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10MM CREO MIS SPINE POLYAXIAL TULIP REDUCTION",SUP-1134.0110,CDM,C1713,HCPCS,0278,RC,,,both,,,3555.00,1066.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,421.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",413.45,3021.75,"percent of total billed charges",
"(EVAL) QUALI BRA ADVANCED L",SUP-QADV-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 15MM 3.5MM BALLOON DILATATION PTCA",SUP-DC-RZ3515UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"NOVANET [10819]",Novanet,,741.15,75,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 80MM 120CM 12MM .079IN LARGE",SUP-SERB65-12-80-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Open Access",,3166.49,56.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE EMBOLIZATION BLUE EMBOGOLD 300-500UM GELATIN 2% GOLD",SUP-S420EG,CDM,S27800098,LOCAL,0278,RC,,,both,,,2175.00,652.5,"CIGNA [10200]","Cigna Open Access",,1237.58,56.9,,,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 5FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY",SUP-F5QRF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"NOVANET [10819]",Novanet,,680.4,75,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 115CM 1MM 6FR 10MM SPACE A CURVE",SUP-F6QA010RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,616.9,68,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESPONSE 120CM 6FR 10MM SPACING CRD CURVE",SUP-401210,CDM,C1730,HCPCS,0272,RC,,,both,,,704.70,211.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,81.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.96,599,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nmo/Aqp4 Facs Titer Serum",PX-302000246,CDM,86256,CPT,0302,RC,,,both,,,2216.00,664.8,"CIGNA [10200]","Cigna Local Plus",,26.51,,,,,,,0.01,1883.6,"fee schedule",
"STEM HUMERAL 48MM 14MM STD SHELL DJO SURGICAL ALTIVATE",SUP-530-14-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5523.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5523.6,40370.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 36MM 22MM DHS/DCS STAINLESS STEEL CONDYLAR",SUP-280.990,CDM,C1713,HCPCS,0278,RC,,,both,,,332.78,99.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,152.75,45.9,,,,,0,38.7,282.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MITRACLIP G4 CDS NTW REPAIR-MR CLINICAL",SUP-CDS0704-NTW,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"MULTIPLAN [10600]",Multiplan,,145350,85,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRIP SCLERAL 100MM SILICONE STRIP TYPE 220 BOX OF 3 STERILE",SUP-S5.2200,CDM,S27800098,LOCAL,0278,RC,,,both,,,174.00,52.2,"KAISER [10500]",Kaiser,,116.58,67,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 15MM 145CM 3.5MM CORONARY STENT",SUP-1145350-15,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"KAISER [10500]",Kaiser,,3911.46,67,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB SKIN 10X6CM STRATTICE PORCINE DERMAL MATRIX FIRM PATCH",SUP-0610008,CDM,Q4130,HCPCS,0636,RC,,,both,,,10757.10,3227.13,"MULTIPLAN [10600]",Multiplan,,9143.54,85,,,,,0,1274.72,9143.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLO VIABLE VIAGRAF",SUP-SK-VCA050000,CDM,C1763,HCPCS,0278,RC,,,both,,,17215.50,5164.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7075.57,41.1,,,,,0,2002.16,14633.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TFAT00 AS UVA PANOPTIX",SUP-TFAT00,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,574.6,68,,,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 18GA 8CM POWERGLIDE PRO REINFORCE TIP BASIC STERILE",SUP-F118080T,CDM,C1751,HCPCS,0272,RC,,,both,,,558.98,167.69,"FIRST HEALTH [10303]","First Health",,447.18,80,,,,,0,65.01,475.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 6MM PROPATEN THIN WALL GORE-TEX HEPARIN",SUP-IRTH064040A,CDM,C1768,HCPCS,0278,RC,,,both,,,10929.60,3278.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1271.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1271.11,9290.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 20MM 2 VELOUR STRAIGHT TUBE",SUP-M002020952200,CDM,C1768,HCPCS,0278,RC,,,both,,,3633.53,1090.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,430.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,422.58,3088.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Pta Cmplx Ea Add",PX-361000707,CDM,37266,CPT,0361,RC,,,both,,,7348.26,2204.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,870.77,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.35,7348.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Renal Cyst Study Translumb",PX-320000123,CDM,74470,CPT,0320,RC,,,both,,,1197.00,359.1,"NOVANET [10819]",Novanet,,897.75,75,,,,,0,68.87,1197,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR 75CM 7CM .035IN STAINLESS",SUP-46-563,CDM,C1769,HCPCS,0272,RC,,,both,,,192.13,57.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,130.65,68,,,,,0,22.34,163.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Lymph Node Img",PX-341000010,CDM,78195,CPT,0341,RC,,,both,,,2177.92,653.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,421.71,,,,,,,253.29,1851.23,"fee schedule",
"HC Ins Non-Indwelling Cath Strt",PX-450000271,CDM,51701,CPT,0361,RC,,,both,,,1404.45,421.33,"AETNA [10100]","Aetna HMO/PPO",,1116.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,163.34,1404.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TERBUTALINE 1 MG/ML INFUSION (NICU/PEDS)",RX-408856,CDM,J3105,HCPCS,0636,RC,63323-0665-01,NDC,both,1,ML,178.48,53.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.9,,"Fee schedule rate ($2.90). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.9,151.71,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION",RX-3037,CDM,J3010,HCPCS,0636,RC,00641-6028-01,NDC,both,5,ML,46.03,13.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9.58,,,,,,,3.85,39.13,"fee schedule",
"GRAFT SOFT TISSUE CRYOVALVE PULMONARY VALVE WITHOUT CONDUIT",SUP-SGPV10,CDM,C1768,HCPCS,0278,RC,,,both,,,145293.00,43587.9,"FIRST HEALTH [10303]","First Health",,116234.4,80,,,,,0,16897.58,123499.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hiv 2 Ab",PX-302000223,CDM,86702,CPT,0302,RC,,,both,,,385.70,115.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.47,,"Fee schedule rate ($14.47). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,327.85,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Scr Breast Tomosynthesis Uni",PX-403000008,CDM,77063,CPT,0403,RC,,,both,,,96.68,29,"BLUE CROSS [10001]","Blue Cross HMO",,57.59,,"Fee schedule rate ($57.59).",,,,0,11.24,96.68,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR IMPLANTABLE EON PATIENT OPERABLE",SUP-3851,CDM,C1787,HCPCS,0270,RC,,,both,,,4830.00,1449,"CIGNA [10200]",Cigna,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFAZOLIN 2 G VIAL IV PUSH (1 G VIAL)|DISCARDED DRUG NOT ADMINISTE",RX-408864,CDM,J0690,HCPCS,0636,RC,44567-0707-25,NDC,both,1,UN,14.95,4.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",JW,1.95,,"Fee schedule rate ($1.95). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.41,12.71,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 3 X 10 COMPLEX FINISHING COIL",SUP-10CFN-03010,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS [10001]","Blue Cross PPO",,4595.46,39.2,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Smear Gram Stain",PX-306000084,CDM,87205,CPT,0306,RC,,,both,,,247.00,74.1,"CIGNA [10200]","Cigna Open Access",,9.39,,,,,,,1.59,209.95,"fee schedule",
"HC NM Thy Img",PX-341000060,CDM,78013,CPT,0341,RC,,,both,,,2476.45,742.93,"CIGNA [10200]","Cigna Local Plus",,338.43,,,,,,,241.97,2104.98,"fee schedule",
"INSRT TIBIAL 4 10MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158124110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]","Cigna Open Access",,6358.32,56.9,,5302.19,4377.88,6578.61,27,1299.6,9498.37,"percent of total billed charges",
"HC Tx Cfx Dist Rad WO Manip",PX-450000111,CDM,25600,CPT,0450,RC,,,both,,,1347.00,404.1,"KAISER [10500]",Kaiser,,902.49,67,,,,,0,67.13,1347,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEUROSURGICAL 10MM LASER DIFFUSE",SUP-NEUROKIT-400-T10,CDM,S27200284,LOCAL,0272,RC,,,both,,,68400.00,20520,"CIGNA [10200]",Cigna,,46512,68,,,,,0,7954.92,58140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hfo W/O Joints Prefab Cst",PX-E27400051,CDM,L3923,HCPCS,0274,RC,,,both,,,251.90,75.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,115.62,45.9,,,,,0,27.94,214.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Assay of Galactose",PX-301000615,CDM,82760,CPT,0301,RC,,,both,,,520.00,156,"NOVANET [10819]",Novanet,,390,75,,,,,0,0.52,442,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Speech Production",PX-444000016,CDM,92522,CPT,0444,RC,,,both,,,394.37,118.31,"AETNA [10100]","Aetna HMO/PPO",,313.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.87,394.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg Digital Analysis",PX-740000023,CDM,95957,CPT,0740,RC,,,both,,,364.00,109.2,"CIGNA [10200]","Cigna Open Access",,207.12,56.9,,,,,0,42.33,364,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Apc Resistance",PX-305000036,CDM,85307,CPT,0305,RC,,,both,,,514.80,154.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.09,,"Fee schedule rate ($16.09). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,437.58,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L19 MM OD3.5 MM SPINE CERVICAL ANTERIOR SELF DRIL",SUP-18008119,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 12 G-H KNEE RIGHT TIBIA FIX",SUP-42522101013,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Guide Tiss Ablt",PX-352000037,CDM,77013,CPT,0352,RC,,,both,,,3026.02,907.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,351.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,351.93,2572.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Who Wrist Thumb Benik Lt Sz 1",PX-E27400050,CDM,L3908,HCPCS,0274,RC,,,both,,,91.74,27.52,"BLUE CROSS [10001]","Blue Cross HMO",,35.96,39.2,,,,,0,10.67,77.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO 45D 1 LEFT CURVE 10YD 1.5MM ERGONOMIC",SUP-AR-6069-45L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CIGNA [10200]",Cigna,,925.34,68,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 10IN WRIST 2 PIECE PERFORATE",SUP-79-87020,CDM,S27000186,LOCAL,0270,RC,,,both,,,163.04,48.91,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,67.01,41.1,,,,,0,18.96,138.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTEFILL ALLOGRAFT FREEZE DRIED 20X15-17X17MM",SUP-12017,CDM,S27800098,LOCAL,0278,RC,,,both,,,15456.00,4636.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1797.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1797.53,13137.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-55840016540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUADRA ASSURA NEXT GENERATION CRT-D 40",SUP-CD3365-40C,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"FIRST HEALTH [10303]","First Health",,46176,80,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 3.2MM INTERTAN LAG SCR",SUP-71674540,CDM,S27200284,LOCAL,0272,RC,,,both,,,5071.85,1521.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3448.86,68,,,,,0,589.86,4311.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 20MM 5MM 4.4FR AUTOTOME RX 44 BILIARY HYDRA JAGWIRE",SUP-M00545170,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ROCHESTER-PEAN STRAIGHT 6.25IN ARTERY",SUP-BH442R,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.71,57.81,"MULTIPLAN [10600]",Multiplan,,163.8,85,,,,,0,22.41,163.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE QUILL 2-0 3/8 CIRCLE 14X14CM 26MM CLSR PDO 2 ARM",SUP-RA1020Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.40,39.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.28,111.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE RESTERILIZABLE STERILE LATEX FREE",SUP-MSZFX615,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"CIGNA [10200]","Cigna Local Plus",,95.2,53.5,,,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEART VALVE EPIC MITRAL 25MM",SUP-E100-25M-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,24570.00,7371,"BLUE CROSS [10001]","Blue Cross PPO",,9631.44,39.2,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 12CM MR8 6MM BALL DISSECTING DIAMOND",SUP-MR8-12BA60D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1184.63,355.39,"UHC [10700]","United Healthcare",,749.87,63.3,,,,,0,137.77,1006.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN CHAMP 1 CURVE GUIDING NYLON",SUP-LA6CHAMP10,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM LCP STAINLESS STEEL SHORT THREAD",SUP-207.626,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"CIGNA [10200]","Cigna Open Access",,591.78,56.9,,1144.80,304.56,2275.09,66,120.96,884.03,"percent of total billed charges",
"GRAFT SOFT TISSUE 12X.3CM TUTOPLAST FASCIA LATA SLING",SUP-68028,CDM,C1762,HCPCS,0278,RC,,,both,,,1158.97,347.69,"NOVANET [10819]",Novanet,,869.23,75,,,,,0,134.79,985.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC",690,MS-DRG,,,,,,,inpatient,,,23648.36,7094.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16069.38,,"Fee schedule rate ($16,069.38). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,5021.37,20188.12,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL LIGHT GREEN 28X32X6.9-10.5MM SYNFIX 10D SMALL",SUP-08.815.141S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AETNA [10100]","Aetna HMO/PPO",,22538.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 8MM REINFORCE CUFF MURPHY EYE LOW PRESSURE",SUP-DYNJAARC80,CDM,S27200284,LOCAL,0272,RC,,,both,,,295.80,88.74,"CIGNA [10200]","Cigna Open Access",,168.31,56.9,,,,,0,34.4,251.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET INTUBATION SMALL GLIDERITE DISPOSABLE",SUP-0270-0916,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.38,16.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,25.88,45.9,,,,,0,6.56,47.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 280014 UNCRT DWL 14MM SRVC FEE",SUP-280014,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 135CM 4CM 5FR 4MM 7.5MM BALLOON DILATATION",SUP-4204040X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.5MM JUGGERKNOT SOFT",SUP-912015,CDM,C1713,HCPCS,0278,RC,,,both,,,2430.00,729,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1652.4,68,,,,,0,282.61,2065.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X7MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7107,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"BLUE CROSS [10001]","Blue Cross PPO",,2704.8,39.2,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION .25IN .25IN BARD SILICONE 4 FREE FLOW CHANNEL",SUP-072231,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.37,37.61,"MULTIPLAN [10600]",Multiplan,,106.56,85,,,,,0,14.58,106.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 22CM 7FR .035IN URETERAL",SUP-M006155241090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,625.5,45.9,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 100MM 16MM 3MM VASCULAR VENOUS ILIOFEMORAL VEIN",SUP-VENUM16100,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9062.55,41.1,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLCHICINE 0.3 MG TABLET (PARTIAL OF 0.6 MG TABLET)",RX-409236,CDM,,,0637,RC,08888-8883-77,NDC,both,.5,UN,25.19,7.56,"PHCS [10601]",PHCS,,17.63,70,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 2 3/8IN WIDE RTRCTR 2.7MM MCCULLOCH BLACK FINISH",SUP-57-5730,CDM,S27200284,LOCAL,0272,RC,,,both,,,674.53,202.36,"AETNA [10100]","Aetna HMO/PPO",,536.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.45,573.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 150MM 135CM 6MM 5FR VASCULAR NITINOL LOW",SUP-5F061503CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20128.50,6038.55,"BLUE CROSS [10001]","Blue Cross HMO",,7890.37,39.2,,,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCOPIC 1070MM 2.7MM CATH STERILE LATEX FREE REUSABLE",SUP-ILS-0900-KT,CDM,S27200284,LOCAL,0272,RC,,,both,,,12371.70,3711.51,"NOVANET [10819]",Novanet,,9278.78,75,,,,,0,1438.83,10515.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIANCE TRUELUMEN 150CM .0175IN .038IN STD BALLOON",SUP-VNC-SD-150,CDM,S27200284,LOCAL,0272,RC,,,both,,,8970.00,2691,"CIGNA [10200]","Cigna Open Access",,5103.93,56.9,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3.5MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-3.5-6-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"BLUE CROSS [10001]","Blue Cross HMO",,4584.64,39.2,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 40CM 40MM 7MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV07004004P,CDM,C1725,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,938.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 6MM PRESTIGE PLUS HELICAL PACK ULTRA",SUP-PRES0650HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"KAISER [10500]",Kaiser,,4854.15,67,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN DEBRIDEMENT WITHOUT CC/MCC",572,MS-DRG,,,,,,,inpatient,,,50848.66,15254.6,"CIGNA [10200]","Cigna Local Plus",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CLARK SOCKET MARKED",SUP-50236-001ES,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNIFE SURGICAL 6.25IN SMILLIE RIGHT CURVE MENISCUS",SUP-77-5002,CDM,S27200284,LOCAL,0272,RC,,,both,,,541.65,162.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,MINOR",174,APR-DRG,,,,,,,inpatient,,,124065.12,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEPHRITIS AND NEPHROSIS,MODERATE",462,APR-DRG,,,,,,,inpatient,,,14716.49,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,609.37. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM HOOK SURGICAL STERILE LATEX FREE DISPOSABLE",SUP-SN25,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER HEART ASSIST SYSTEM IMPLANT",215,MS-DRG,,,,,,,inpatient,,,339748.21,101924.46,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 20MM 3MM RECTANGLE HELIX BALLOON",SUP-2039-3020,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT NDL MAYO 3 CATGUT .5 CIRCLE TROCAR POINT CATGUT STERILE",SUP-1826-3DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT POLARIS ZIPWIRE 26CM 150CM 8FR .035IN 3CM BLADDER LOOP",SUP-M006155253190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 8MM .0135IN AXIUM PRIME 3D FRAME",SUP-FC-8-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"NOVANET [10819]",Novanet,,12394.13,75,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3-0 QUICKANCHOR PLUS",SUP-212843,CDM,C1713,HCPCS,0278,RC,,,both,,,4084.80,1225.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1874.92,45.9,,,,,0,475.06,3472.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 40MM 120CM 12MM .079IN LARGE",SUP-SERB65-12-40-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AETNA [10100]","Aetna HMO/PPO",,4424.18,79.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAX NEURON SELECT 105CM 9CM 6FR .04IN .035IN .038IN 1",SUP-PNS6F105H1,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 5-0 P-3 18IN MONOFILAMENT GREEN",SUP-G698G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE STC-18 150CM 20MM 3-2.4FR .021IN 90D MICRO",SUP-M001181390,CDM,C1887,HCPCS,0272,RC,,,both,,,2325.00,697.5,"UHC [10700]","United Healthcare",,1471.73,63.3,,,,,0,270.4,1976.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 MO-6 APOLLO WI-FIBER DELIVERY SYSTEM INTEGRATE",SUP-27-11145,CDM,S27200284,LOCAL,0272,RC,,,both,,,2625.00,787.5,"CIGNA [10200]","Cigna Open Access",,1493.63,56.9,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 20MM 6FR 4MM .07IN BALLOON",SUP-H7493918920400,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 350ML P3.9CM MODERATE PLUS PROFILE HIGH",SUP-350-3501BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"MULTIPLAN [10600]",Multiplan,,4457.4,85,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26MMX9MM CAPSTONE PEEK PTC LUMBAR INTERBODY",SUP-3992609,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"MULTIPLAN [10600]",Multiplan,,18742.5,85,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX ECHO 2 15CM POSITION SYSTEM STERILE",SUP-1210015,CDM,C1781,HCPCS,0278,RC,,,both,,,27716.85,8315.05,"MULTIPLAN [10600]",Multiplan,,23559.32,85,,,,,0,3223.47,23559.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 70MM SECONDARY STOP KIT 2.7MM STERILE LATEX",SUP-2.70K,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"MULTIPLAN [10600]",Multiplan,,3155.63,85,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 80MM 75CM 8MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200088070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,481.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PYRIDOXINE (VITAMIN B6) 50 MG TABLET",RX-6748,CDM,,,0637,RC,77333-0940-25,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 14CM 8FR SHORT LENGTH URETERAL",SUP-H7493936108140,CDM,C2617,HCPCS,0278,RC,,,both,,,1142.10,342.63,"CIGNA [10200]","Cigna Local Plus",,611.02,,,,,,,132.83,970.79,"percent of total billed charges",
"TOOL 12CM MR8 4MM BALL DISSECTING",SUP-MR8-12BA40,CDM,S27200284,LOCAL,0272,RC,,,both,,,1184.63,355.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL HOOK PENCIL 90D RIGHT ANGLE 10FT",SUP-E2510H,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.27,56.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CURET 2 BUCK EAR ANGLED SHARP SURGICAL",SUP-380213,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.07,40.22,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC QUANTUM APEX MONORAIL 143CM 8MM 3.5MM BALLOON",SUP-H7493912408350,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 25CM 10FR PIGTAIL CURVE NEPHRSTMY FLEXIMA POLYURETHANE",SUP-M001271780,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH FLEXOR CHECK-FLO STRAIGHT 55CM 6FR 2.2MM GUIDING HIGH",SUP-G56231,CDM,C1894,HCPCS,0272,RC,,,both,,,472.23,141.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"0.9MM HIGH INFUSION SLEEVE SMALL PARTS KIT",SUP-8065752900,CDM,S27200284,LOCAL,0272,RC,,,both,,,380.97,114.29,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SAPPHIRE 3 CORONARY DILATATION CATHETER 1.0 X 5MM",SUP-54100-050-02,CDM,C1725,HCPCS,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 15CM 15MM MREYE 3.2 LOOP .035IN PLATINUM",SUP-G20055,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"FIRST HEALTH [10303]","First Health",,667.38,80,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 4.8FR .035IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145351050,CDM,C2617,HCPCS,0278,RC,,,both,,,940.57,282.17,"CIGNA [10200]",Cigna,,639.59,68,,,,,0,109.39,799.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 28CM 3CM 5FR .035IN STRAIGHT URETERAL",SUP-M006155224190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,651.94,45.9,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DRNG 15CM 6FR 18GA FUHRMAN PLEURAL PNEUMOPERICARDIAL",SUP-G55714,CDM,C1729,HCPCS,0272,RC,,,both,,,1278.99,383.7,"PHCS [10601]",PHCS,,895.29,70,,,,,0,148.75,1087.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 45MM COMMON ILLIAC SEG 41MM EXTERNAL",SUP-G60344,CDM,C1874,HCPCS,0278,RC,,,both,,,68399.94,20519.98,"UHC [10700]","United Healthcare",,43297.16,63.3,,,,,0,7954.91,58139.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 55MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-54840015555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PULMONARY AERO OTW FULLY COVERED TRACHEOBRONCHIAL STENT 18MM",SUP-90129-201,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"AETNA [10100]","Aetna HMO/PPO",,13713.75,79.5,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 55MM 5MM KII Z THREAD SLEEVE LOW PROFILE",SUP-CTR23,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"UHC [10700]","United Healthcare",,137.68,63.3,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2MM TARGET NANO 360D DETACHABLE",SUP-M0035442030,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE VASCULAR ANGLE LONG TAPER 150CM 5CM .035IN",SUP-GS3507,CDM,C1769,HCPCS,0272,RC,,,both,,,413.25,123.97,"FIRST HEALTH [10303]","First Health",,330.6,80,,,,,0,48.06,351.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 3.50 X 18 MM",SUP-1212350-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"KAISER [10500]",Kaiser,,11557.5,67,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 57.9CM 18FR TUNGSTEN SILICONE MIC SECUR-LOK",SUP-8210-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"MULTIPLAN [10600]",Multiplan,,1226.42,85,,,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR COBRA 1 CURVE ANGIOGRAPHIC BRAID",SUP-M001314641,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.04,22.81,"NOVANET [10819]",Novanet,,57.03,75,,,,,0,8.84,64.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.25/15",SUP-401741,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 9MM THK.43MM 10MM MICRO SMALL BONE SAGITTAL",SUP-KM3-101,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.65,24.19,"CIGNA [10200]",Cigna,,54.84,68,,,,,0,9.38,68.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 140MM 80CM 8MM 6FR .035IN BILIARY",SUP-G50134,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"FIRST HEALTH [10303]","First Health",,4872,80,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPLICATIONS OF TREATMENT WITH MCC",919,MS-DRG,,,,,,,inpatient,,,40813.41,12244.02,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,11867.61,,"Case rate ($11,356.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,545.34, add-ons for qualifying new technology services are included. If operating cost exceeds $43,585.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,179.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,559.28. The transfer operating threshold is the transfer adjustment factor * $10,545.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $797.28. The transfer capital threshold is the transfer adjustment factor * $797.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,40813.41,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 V-5 30IN 2 ARM BRAID 10 STRAND SOFT",SUP-SXP54,CDM,S27200284,LOCAL,0272,RC,,,both,,,746.44,223.93,"PHCS [10601]",PHCS,,522.51,70,,,,,0,86.81,634.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 4MM 7FR 1-7-4MM SPACE F CURVE ABLATION",SUP-118331S,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"AETNA [10100]","Aetna HMO/PPO",,10916.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PELVIC STABILIZATION DEVICE",SUP-T-PODR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1077.30,323.19,"PHCS [10601]",PHCS,,754.11,70,,,,,0,125.29,915.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 22MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-122,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"CIGNA [10200]",Cigna,,5383.38,40,,5873.17,5873.17,5873.17,"1 through 10",1565.22,11439.68,"percent of total billed charges",
"ANCHOR SPINAL 12MM COALITION MIS",SUP-1136.2012,CDM,C1713,HCPCS,0278,RC,,,both,,,18000.00,5400,"PHCS [10601]",PHCS,,12600,70,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175260070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,118.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +15.5 DIOPTER 13MM 6MM POSTERIOR CHMBR 3 PIECE",SUP-Z900200155,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,118.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +22.5 DIOPTER BICONVEX MODIFY L 13MM 6MM",SUP-CC60WF.225,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HALYARD BALLARD 3.5MM 3MM 12IN 7FR 4MM SUCTION",SUP-197,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.21,33.06,"FIRST HEALTH [10303]","First Health",,88.17,80,,,,,0,12.82,93.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AMPHIRION DEEP 150CM 120MM 2.8-3.9FR 3MM TAPER BALLOON",SUP-AMP030120152,CDM,C1725,HCPCS,0272,RC,,,both,,,2422.50,726.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,287.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,281.74,2059.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) RED 72 REPERFUSION CATH W/ THUNDERBOLT ASPIRATION TUB",SUP-THNDRRED72KIT,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP ACETABULAR 52MM PINNACLE BANTAM MULTIHOLE II 10 DOME SCR",SUP-1217-30-052,CDM,C1776,HCPCS,0278,RC,,,both,,,16778.04,5033.41,"PHCS [10601]",PHCS,,11744.63,70,,,,,0,1951.29,14261.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAND ALONE SUCKER",SUP-020-515-900,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.74,58.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,132.42,68,,,,,0,22.65,165.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 6.9FR HELIX ATRIUM VENTRICLE RIGHT BIPOLAR",SUP-5086MRI52,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"BLUE CROSS [10001]","Blue Cross HMO",,875.14,39.2,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAND ALONE SUCKER",SUP-020-515-900,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.74,58.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.65,165.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 12CM OCCL GLDEWIRE NEPHRSTMY INTRO PERCUTANEOUS",SUP-M0067001210,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.79,81.54,"NOVANET [10819]",Novanet,,203.84,75,,,,,0,31.61,231.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 4.1MM CLEARCUT ANGLE 2 BEVEL PHACO SLIT",SUP-8065994140,CDM,S27200284,LOCAL,0272,RC,,,both,,,227.33,68.2,"CIGNA [10200]","Cigna Open Access",,129.35,56.9,,,,,0,26.44,193.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 80MM 3MM BALLOON",SUP-U357538,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 30MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.430TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,239.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,235.11,1718.32,"percent of total billed charges",
"STENT SUPERA 40MM 120CM 7.5MM 6FR VASCULAR NITINOL",SUP-S-75-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"KAISER [10500]",Kaiser,,6125.48,67,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 30CM 14FR TUNGSTEN SILICONE 2CM MIC-KEY",SUP-8270-14-2.0-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,3027.60,908.28,"PHCS [10601]",PHCS,,2119.32,70,,,,,0,352.11,2573.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER BALLOON DILATATION CHOCOLATE NITINOL .014 IN L135 C",SUP-CB1413535040OTW,CDM,C2623,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"MULTIPLAN [10600]",Multiplan,,4867.95,85,,,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-3-8-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"FIRST HEALTH [10303]","First Health",,9356.4,80,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SALIVA SUBSTITUTE COMBO NO.9 MOUTHWASH",RX-166704,CDM,,,0250,RC,48582-0802-20,NDC,both,237,ML,37.27,11.18,"MULTIPLAN [10600]",Multiplan,,31.68,85,,,,,0,4.33,31.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM 20.4MM MASTERS 85D 3.09SQ CM STD RING",SUP-25AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOCKWAVE L6 IVL CATHETER 8.0X30 MM",SUP-L6IVL080030,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"AETNA [10100]","Aetna HMO/PPO",,17279.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2527.78,18474.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Guided Localization Stereo",PX-350000007,CDM,77011,CPT,0350,RC,,,both,,,1410.16,423.05,"KAISER [10500]",Kaiser,,944.81,67,,,,,0,164,1410.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK 21X11IN THERAPEUTIC COLD PLIABLE SOFT OVERSIZE LATEX",SUP-3548D,CDM,S27000186,LOCAL,0270,RC,,,both,,,132.76,39.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.44,112.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 44.5MM 1.6MM CARBIDE 6 FLUTED FAST CUTTING",SUP-0277-010-216,CDM,S27000186,LOCAL,0270,RC,,,both,,,54.98,16.49,"NOVANET [10819]",Novanet,,41.24,75,,,,,0,6.39,46.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR ADULT LNCS ADTX-3 3FT OXIMETER ADHSV LATEX FREE",SUP-2317,CDM,S27000186,LOCAL,0270,RC,,,both,,,64.38,19.31,"AETNA [10100]","Aetna HMO/PPO",,51.18,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.49,54.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANSTR SUCTION .8L WITHOUT SLDFR THOPAZ DISPOSABLE STERILE",SUP-079.0016,CDM,S27000186,LOCAL,0270,RC,,,both,,,324.80,97.44,"NOVANET [10819]",Novanet,,243.6,75,,,,,0,37.77,276.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID UPPER LEG REDUCTION KIT- SHORT, WIDE",SUP-25302117,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"CIGNA [10200]",Cigna,,853.74,68,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER BREAST LARGE",SUP-L/L-BBIND,CDM,S27000186,LOCAL,0270,RC,,,both,,,165.30,49.59,"CIGNA [10200]","Cigna Local Plus",,88.44,53.5,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Somatomedin",PX-301000401,CDM,84305,CPT,0301,RC,,,both,,,236.00,70.8,"PHCS [10601]",PHCS,,165.2,70,,,,,0,0.24,200.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Somatomedin",PX-301000401,CDM,84305,CPT,0301,RC,,,both,,,236.00,70.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.24,.1,,,,,0,0.24,200.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 9FR 19CM RADIALEASE LATEX FREE VESSEL ACCEPTS",SUP-504509X,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.26,26.18,"CIGNA [10200]","Cigna Open Access",,49.65,56.9,,,,,0,10.15,74.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 220MM 4MM BALLOON DILATATION PEBAX",SUP-H74939032402210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 12MM 3.5MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012409-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT VITRECTOMY PERFLUORO-N-OCTANE PROCEDURAL LIQUID PURIFY",SUP-8065900164,CDM,C1784,HCPCS,0278,RC,,,both,,,3845.92,1153.78,"KAISER [10500]",Kaiser,,2576.77,67,,,,,0,447.28,3269.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 8MM 1MM BALLOON DILATATION PERCUTANEOUS",SUP-210-083-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UHC [10700]","United Healthcare",,794.73,63.3,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 20MM 3.5MM BALLOON DILATATION STERILE",SUP-235-203-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 20CM 12FR .035IN MAHURKAR TRIPLE LUMEN HIGH",SUP-8888102003HP,CDM,C1752,HCPCS,0272,RC,,,both,,,995.43,298.63,"CIGNA [10200]","Cigna Open Access",,566.4,56.9,,,,,0,115.77,846.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDING BALLOON",SUP-BVCS6180,CDM,C1725,HCPCS,0272,RC,,,both,,,672.30,201.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,78.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD MONOPOLAR 56.7CM 5MM DA VINCI S/SI ENDOWRIST CAUT",SUP-420142,CDM,S27000186,LOCAL,0270,RC,,,both,,,24381.00,7314.3,"NOVANET [10819]",Novanet,,18285.75,75,,,,,0,2835.51,20723.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Bn Marrow Ndl/Trocar",PX-361000167,CDM,38221,CPT,0361,RC,,,both,,,3910.13,1173.04,"FIRST HEALTH [10303]","First Health",,3128.1,80,,,,,0,454.75,3910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 40MM 2.5MM BALLOON DILATATION RAPID",SUP-47525040L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL PRONG O2 TUBE ADPTR DEHP FREE NEOTECH RAM CANN",SUP-N4905,CDM,S27000186,LOCAL,0270,RC,,,both,,,107.88,32.36,"CIGNA [10200]","Cigna Local Plus",,57.72,53.5,,,,,0,12.55,91.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 12MM 3.75MM BALLOON DILATATION STERILE",SUP-237-123-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UHC [10700]","United Healthcare",,512.73,63.3,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 5.5MM 9CM STERILE",SUP-AR-6532,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE GLDEWIRE GLIDE TECHNOLOGY VASCULAR STD ANGLE 150CM 3CM",SUP-GR3506,CDM,C1769,HCPCS,0272,RC,,,both,,,265.35,79.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMPULSE 100CM 5FR AL2 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916391982,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OBTR ENDOSCOPIC 8MM 120MM AIRSEAL LOW PROFILE ACCESS PORT",SUP-IAS8-120LP,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.95,218.98,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT NUROLON 4-0 TF 18IN BRAID 8 STRAND UNIDIRECTIONAL BLACK",SUP-N104T,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.59,53.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PDS II MULTIPASS 3-0 PC-5 18IN MONOFILAMENT UNDYED",SUP-Z824G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK",RX-116499,CDM,J2020,HCPCS,0636,RC,63323-0713-03,NDC,both,300,ML,274.64,82.39,"CIGNA [10200]","Cigna Local Plus",,22.14,,,,,,,9.66,233.44,"fee schedule",
"HC Infect Agent Nos Ampl Probe",PX-306000147,CDM,87798,CPT,0306,RC,,,both,,,744.80,223.44,"BLUE CROSS [10001]","Blue Cross PPO",,0.74,.1,,,,,0,0.01,633.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR SURGICAL KATZ EXTR FOREIGN BODY REM OTO-RHINO STERILE",SUP-FB5000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1368.96,410.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,159.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,159.21,1163.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chlamydia Trach & Neisseria Gonorr Dna Ampl Prb",PX-306000258,CDM,87494,CPT,0306,RC,,,both,,,566.86,170.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.95,,"Fee schedule rate ($65.95). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,481.83,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAUT 18IN 4.5FR CHOLANGIOGRAM METAL SPRT TUBE LATEX",SUP-20018-M55,CDM,S27200284,LOCAL,0272,RC,,,both,,,455.22,136.57,"CIGNA [10200]",Cigna,,309.55,68,,,,,0,52.94,386.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Central Line",PX-361000004,CDM,9999135,LOCAL,0361,RC,,,both,,,3536.40,1060.92,"PHCS [10601]",PHCS,,2475.48,70,,,,,0,411.28,3005.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 26MM 10MM HEMASHIELD PLATINUM 1 BRANCH",SUP-M00202175826P0,CDM,C1768,HCPCS,0278,RC,,,both,,,8352.73,2505.82,"KAISER [10500]",Kaiser,,5596.33,67,,,,,0,971.42,7099.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Appl on-Body Injector",PX-761000032,CDM,96377,CPT,0761,RC,,,both,,,201.23,60.37,"CIGNA [10200]","Cigna Open Access",,201.23,,"Per diem ($2,181).",,,,0,23.4,201.23,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cmv Dna Ampl Prob Igm/Igg",PX-306000125,CDM,87496,CPT,0306,RC,,,both,,,877.50,263.25,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,745.88,"per diem",
"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION",RX-3037,CDM,J3010,HCPCS,0636,RC,63323-0806-50,NDC,both,50,ML,251.69,75.51,"CIGNA [10200]","Cigna Local Plus",,79.8,,,,,,,29.83,213.94,"fee schedule",
"HC Tiss Cult Bone Marrow",PX-311000028,CDM,88237,CPT,0311,RC,,,both,,,1202.00,360.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,132.92,,"Fee schedule rate ($132.92). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1021.7,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 14GA RIGID NDL RADIOPAQUE GEL MARK ULTRACOR BREAST",SUP-GMUTC005T,CDM,A4648,HCPCS,0278,RC,,,both,,,526.34,157.9,"BLUE CROSS [10001]","Blue Cross PPO",,206.33,39.2,,,,,0,61.21,447.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VITOSS BIMODAL FOAM PACK 5CC",SUP-2102-1905,CDM,C1713,HCPCS,0278,RC,,,both,,,12432.42,3729.73,"NOVANET [10819]",Novanet,,9324.32,75,,,,,0,1445.89,10567.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYNTHETIC TISSUE SCAFFOLD STRIP 0.5CM X 32CM",SUP-31057,CDM,C1763,HCPCS,0278,RC,,,both,,,17215.50,5164.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2040.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2002.16,14633.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESVR PROS 125ML TITAN COLOPLAST LOCK-OUT INFLATABLE SELF",SUP-ER8125,CDM,C1813,HCPCS,0278,RC,,,both,,,15166.20,4549.86,"FIRST HEALTH [10303]","First Health",,12132.96,80,,,,,0,1763.83,12891.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE AMS 700MS 18CM ERECTILE RESTORATION TACTILE PUMP",SUP-72404232-10,CDM,C1813,HCPCS,0278,RC,,,both,,,76351.50,22905.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8879.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8879.68,64898.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRAUMA FIXATION 95MM META-TAN INTEGRATE LAG COMPRESSION",SUP-71642695,CDM,C1887,HCPCS,0272,RC,,,both,,,4950.06,1485.02,"PHCS [10601]",PHCS,,3465.04,70,,,,,0,575.69,4207.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION",RX-9972,CDM,J1410,HCPCS,0636,RC,00046-0749-05,NDC,both,1,UN,2336.29,700.89,"CIGNA [10200]","Cigna Open Access",,1053.33,,,,,,,93.96,1985.85,"fee schedule",
"GYNECARE TVT OBTURATOR SYSTEM (SINGLE USE DEVICE)",SUP-810081,CDM,C1771,HCPCS,0278,RC,,,both,,,8539.72,2561.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1011.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,993.17,7258.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 145MM 36-16MM 20FR ENDURANT II ABDOMEN",SUP-ETBF3616C145E,CDM,S27800098,LOCAL,0278,RC,,,both,,,60782.40,18234.72,"CIGNA [10200]","Cigna Open Access",,20362.1,33.5,,,,,0,7068.99,51665.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 15MM 5FR 1.5MM BALLOON DILATATION PEBAX",SUP-1012402-15,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,84.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D G KNEE LEFT OSSEOTI KEEL",SUP-42535007901,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1631.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX14MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183664,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"BLUE CROSS [10001]","Blue Cross HMO",,5169.95,39.2,,5311.50,4717.44,5388.59,31,1533.84,11210.36,"percent of total billed charges",
"SPACER SPINAL 25X10X9MM 9MM CRESCENT 6D THORACOLUMBAR PEEK 4",SUP-9192509,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS [10001]","Blue Cross HMO",,6491.52,39.2,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SUTURETAPE 2 .5 CIRCLE 36.6MM TAPER NDL BLACK WHITE 1.3",SUP-AR-7506T,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CRE STERI-FLATE INFLATION DISPOSABLE",SUP-M00550630,CDM,S27200284,LOCAL,0272,RC,,,both,,,340.52,102.16,"MULTIPLAN [10600]",Multiplan,,289.44,85,,,,,0,39.6,289.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH 3MM LONG HANDLE AORTIC",SUP-APU530,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,33.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CENTRAL VENOUS PICC",SUP-B9-16350,CDM,C1751,HCPCS,0272,RC,,,both,,,309.51,92.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,36.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36,263.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL FOGARTY SOFTJAW 6MM 2 SPRING ATRAUMATIC",SUP-G-6000,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"AETNA [10100]","Aetna HMO/PPO",,179.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 15CC FINE FROZEN 1-4MM LATEX FREE",SUP-800113,CDM,S27800098,LOCAL,0278,RC,,,both,,,2614.50,784.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,309.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,304.07,2222.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY DRNG 12FR FLEXIBLE REVOLUTION SECUREMENT DEVICE RESOLVE",SUP-RLC-NV-12-REV,CDM,C1729,HCPCS,0272,RC,,,both,,,1255.50,376.65,"MULTIPLAN [10600]",Multiplan,,1067.18,85,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cryptococcal Ag CSF Ref",PX-302000087,CDM,86403,CPT,0302,RC,,,both,,,564.30,169.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.75,,"Fee schedule rate ($11.75). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.91,479.66,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla Class II High Def Qual",PX-302000219,CDM,86833,CPT,0302,RC,,,both,,,845.00,253.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,100.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.85,845,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 5FR ANGLE KUMPE CURVE ANGIOGRAPHIC",SUP-10732703,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"PHCS [10601]",PHCS,,152.25,70,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL SHOULDER ANATOMIC CAP AUGMENTED GLENOID CAP",SUP-TSA3,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,6417.48,6417.48,6417.48,"1 through 10",3297.11,24097.5,"percent of total billed charges",
"FILLER BONE VOID KINEX BIOACTIVE PUTTY 10CC",SUP-8115.0310S,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"MULTIPLAN [10600]",Multiplan,,8211,85,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT VALLEYLAB EDGE",SUP-SEP6000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"CIGNA [10200]","Cigna Open Access",,108.91,56.9,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vitamin D 1 25 Dihydroxy",PX-301000178,CDM,82652,CPT,0301,RC,,,both,,,421.20,126.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.2,,"Fee schedule rate ($41.20). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.42,358.02,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM ALLOGRAFT STRIP 55X22MM",SUP-T00247,CDM,S27800098,LOCAL,0278,RC,,,both,,,14161.56,4248.47,"CIGNA [10200]",Cigna,,5664.62,40,,,,,0,1646.99,12037.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 11MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P311,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,990.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,971.79,7102.52,"percent of total billed charges",
"INSRT TIBIAL 1-2 15MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71934434,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"BLUE CROSS [10001]","Blue Cross PPO",,4771.27,39.2,,3949.44,3949.44,3949.44,"1 through 10",1415.56,10345.86,"percent of total billed charges",
"CLAREONPANOPTIX PRO(UVA)",SUP-PXCWT0,CDM,V2788,HCPCS,0276,RC,,,both,,,915.00,274.5,"CIGNA [10200]",Cigna,,622.2,68,,,,,0,106.41,777.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 10MM 3MM BALLOON DILATATION HYDROPHILIC",SUP-2200-3010-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"MULTIPLAN [10600]",Multiplan,,4985.25,85,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 2.1MM STRAIGHT 2 SERRATE ENTELLUS MEDICAL HNDPC",SUP-SSB-12200-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"NOVANET [10819]",Novanet,,1546.88,75,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest Lumb/Sac Facet Jnt",PX-510000155,CDM,64635,CPT,0761,RC,,,both,,,3281.00,984.3,"FIRST HEALTH [10303]","First Health",,2624.8,80,,,,,0,381.58,3281,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 8MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0301,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross PPO",,371.5,39.2,,957.42,570.23,957.42,28,110.22,805.55,"percent of total billed charges",
"SUT GORE-TEX CV-6 THC-13 30IN 2 ARM MONOFILAMENT WHITE",SUP-6M12A,CDM,S27200284,LOCAL,0272,RC,,,both,,,311.03,93.31,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,127.83,41.1,,,,,0,36.17,264.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 8.5MM TANNE UNIVERSAL TREPHINE UNIQUE HUB","SUP-E3050 8.50",CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"UHC [10700]","United Healthcare",,349.94,63.3,,,,,0,64.29,469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM ATLANTIS TITANIUM ANTERIOR CERVICAL SPINE",SUP-3120415,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,958.8,68,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLATE TIBIAL TRIATHLON 3 UNIVERSAL KNEE TOTAL STABILIZED",SUP-5521-B-300,CDM,C1776,HCPCS,0278,RC,,,both,,,10384.92,3115.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1230.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1207.77,8827.18,"percent of total billed charges",
"KIT THROMBECTOMY 145CM 1.5MM 3-4FR ANGIOJET ULTRA ULTRA",SUP-104834-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"NOVANET [10819]",Novanet,,215.33,75,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE HV-R KYPHX MIXER GRADUATE MARK DISPENSE PLUNGER",SUP-C01B,CDM,C1713,HCPCS,0278,RC,,,both,,,851.76,255.53,"KAISER [10500]",Kaiser,,570.68,67,,,,,0,99.06,724,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 100MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-583510022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"KAISER [10500]",Kaiser,,1004,67,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET QUICK CONNECT PROCESSING",SUP-OPT-P-1000,CDM,S27200284,LOCAL,0272,RC,,,both,,,16560.00,4968,"UHC [10700]","United Healthcare",,10482.48,63.3,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .047IN MULTIPURPOSE A 2",SUP-534542T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"CIGNA [10200]",Cigna,,63.6,68,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 24FR COLLINS STERILE DISPOSABLE",SUP-27050L/6,CDM,S27200284,LOCAL,0272,RC,,,both,,,900.72,270.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,106.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.75,765.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL DUALMESH 15X10CM SOFT TISSUE BIOMATERIAL",SUP-1DLMC200,CDM,C1781,HCPCS,0278,RC,,,both,,,6423.90,1927.17,"CIGNA [10200]","Cigna Local Plus",,3436.79,53.5,,3096.73,1.00,3096.73,"1 through 10",747.1,5460.32,"percent of total billed charges",
"STENT VISI-PRO 27MM 80CM 9MM 30MM BILIARY STAINLESS STEEL",SUP-PXB35-09-27-080,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"FIRST HEALTH [10303]","First Health",,3493.6,80,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENTACAPONE 200 MG TABLET",RX-26547,CDM,,,0637,RC,27241-0049-10,NDC,both,1,UN,22.83,6.85,"FIRST HEALTH [10303]","First Health",,18.26,80,,,,,0,2.66,19.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Lymphedema Arm",PX-E27000186,CDM,E27000186,LOCAL,0270,RC,,,both,,,553.00,165.9,"MULTIPLAN [10600]",Multiplan,,470.05,85,,,,,0,64.31,470.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION",RX-168537,CDM,,,0250,RC,00597-0024-02,NDC,both,4,GR,3133.55,940.06,"UHC [10700]","United Healthcare",,1983.54,63.3,,,,,0,364.43,2663.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP STEM #8",SUP-1601-08127,CDM,C1776,HCPCS,0278,RC,,,both,,,21360.46,6408.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2531.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2484.22,18156.39,"percent of total billed charges",
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 75CM 6MM 30MM",SUP-38046-63075,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM ASNIS III TITANIUM 1/3 THREAD REVERSE CUT",SUP-604640S,CDM,C1713,HCPCS,0278,RC,,,both,,,1929.60,578.88,"NOVANET [10819]",Novanet,,1447.2,75,,,,,0,224.41,1640.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12IN 22FR ARTERIAL ADULT 3/8IN CNCT VENTED",SUP-77622,CDM,C1769,HCPCS,0272,RC,,,both,,,541.37,162.41,"PHCS [10601]",PHCS,,378.96,70,,,,,0,62.96,460.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.6MM 5MM LAMINA CERVICAL",SUP-7650705,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TRUCLEAR INCISOR 357MM 2.9MM REMOVAL TISSUE WINDOW",SUP-72202536,CDM,S27000186,LOCAL,0270,RC,,,both,,,4339.76,1301.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,514.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,504.71,3688.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RAMROD QUADRA-COIL 22-28CM 6FR KIDNEY BLADDER CURL",SUP-5001960,CDM,C2617,HCPCS,0278,RC,,,both,,,721.79,216.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,85.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,83.94,613.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PROC HYSTEROSCOPIC",SUP-7209827,CDM,C1894,HCPCS,0272,RC,,,both,,,2208.00,662.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,261.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,256.79,1876.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL STANDARD+ KNEE LEFT CEMENT LCS COMPLETE COCR",SUP-129402050,CDM,C1776,HCPCS,0278,RC,,,both,,,20635.65,6190.69,"MULTIPLAN [10600]",Multiplan,,17540.3,85,,,,,0,2399.93,17540.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 300CM .014IN",SUP-7913,CDM,C1769,HCPCS,0272,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 2.5% DEXTROSE 132 MEQ/L SODIUM 95 MEQ/L CHLORIDE 2.5",SUP-044-50522,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.45,37.63,"CIGNA [10200]",Cigna,,85.31,68,,,,,0,14.59,106.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 63MM STAINLESS STEEL 2.4MM SCR 6X4 HOLES 2",SUP-02.111.540,CDM,C1713,HCPCS,0278,RC,,,both,,,4041.68,1212.5,"BLUE CROSS [10001]","Blue Cross PPO",,1584.34,39.2,,957.42,570.23,957.42,28,470.05,3435.43,"percent of total billed charges",
"STEM FEMORAL 170MM CEMENTED OMNIFIT HFX 132D 11 46MM OFFSET",SUP-6070-1140A,CDM,C1776,HCPCS,0278,RC,,,both,,,9473.94,2842.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4348.54,45.9,,,,,0,1101.82,8052.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 24/26FR STERILE DISPOSABLE",SUP-27040GP1-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3100.64,930.19,"AETNA [10100]","Aetna HMO/PPO",,2465.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,360.6,2635.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 33MM 9MM ALIGN 15MM TITANIUM SIDE LOAD HYBRID",SUP-ALN-RST-0900,CDM,C1776,HCPCS,0278,RC,,,both,,,14138.10,4241.43,"CIGNA [10200]","Cigna Local Plus",,4453.5,31.5,,5372.07,4581.20,7242.98,23,1644.26,12017.39,"percent of total billed charges",
"EVOQUE TRICUSPID VALVE REPLACEMENT SYSTEM 52MM",SUP-EVQ1US52,CDM,S27800098,LOCAL,0278,RC,,,both,,,245100.00,73530,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,100736.1,41.1,,,,,0,28505.13,208335,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 40MM 125CM 6MM 6FR VASCULAR NITINOL",SUP-G43821,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"AETNA [10100]","Aetna HMO/PPO",,3005.1,79.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUROFORM 3 EZ 4.0 X 30MM",SUP-M003N3EZ40300,CDM,C1874,HCPCS,0278,RC,,,both,,,47878.17,14363.45,"NOVANET [10819]",Novanet,,35908.63,75,,,,,0,5568.23,40696.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC",091,MS-DRG,,,,,,,inpatient,,,55863.17,16758.95,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,11656.38,,"Case rate ($10,893.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,115.65, add-ons for qualifying new technology services are included. If operating cost exceeds $43,155.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,146.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $10,129.02. The transfer operating threshold is the transfer adjustment factor * $10,115.65 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $764.79. The transfer capital threshold is the transfer adjustment factor * $764.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,10893.81,43797.87,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 11MM 16SQ MM 8FR .035IN",SUP-BXA117901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"PHCS [10601]",PHCS,,14985.18,70,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 200MM 6MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171062010,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATH GUIDING RDND 1 CURVE 6FR .07IN 55CM CORONARY SOF",SUP-SA6RDND1K,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"UHC [10700]","United Healthcare",,231.3,63.3,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM 3.5MM 2.1-2.7FR CORONARY",SUP-RONYX35026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1549.13,45.9,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 1.4MM MICROLINK SUT PASS CMC",SUP-ASB-PD,CDM,S27200284,LOCAL,0272,RC,,,both,,,4955.03,1486.51,"FIRST HEALTH [10303]","First Health",,3964.02,80,,,,,0,576.27,4211.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ROCHESTER-OSCHNER STRAIGHT 7.25IN 1X2 TEETH",SUP-16-1218,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.99,22.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.72,63.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IV VIAFLEX 40 MEQ POTASSIUM CHLORIDE 5% DEXTROSE 0.45%",SUP-2B1674X,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.95,24.58,"KAISER [10500]",Kaiser,,54.91,67,,,,,0,9.53,69.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 100MM 130CM 8MM VASCULAR METAL SUPERFICIAL",SUP-H74939293081030,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]","Cigna Open Access",,2748.27,56.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN MULTIPASS 5-0 PC-1 18IN MONOFILAMENT YELLOWISH TAN",SUP-1915G,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.85,21.25,"CIGNA [10200]","Cigna Local Plus",,37.9,53.5,,,,,0,8.24,60.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 1.5MM X 20MM COCR",SUP-VAL-15200-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"FIRST HEALTH [10303]","First Health",,1140.48,80,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRICATH 18FR STD URETHRAL RUBBER 5CC FOLEY",SUP-119418M,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.62,30.49,"AETNA [10100]","Aetna HMO/PPO",,80.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.82,86.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 100CM 60MM 8MM BALLOON DILATATION DRUG COATED",SUP-LX35100860V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"MULTIPLAN [10600]",Multiplan,,7184.63,85,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT FIBERGRAFT MEDIUM 6.25 CC MATRIX BIOAC",SUP-74000063,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]",Cigna,,7038,68,,1831.33,1831.33,1831.33,16,1203.71,8797.5,"percent of total billed charges",
"FRCP SURGICAL TROUTMAN-BARRAQUER 45D .12MM 3IN ANGLED 2X3",SUP-60-1463,CDM,S27200284,LOCAL,0272,RC,,,both,,,1402.60,420.78,"CIGNA [10200]","Cigna Open Access",,798.08,56.9,,,,,0,163.12,1192.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALSARTAN 80 MG TABLET",RX-31209,CDM,,,0637,RC,43547-0368-09,NDC,both,1,UN,24.30,7.29,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9.99,41.1,,,,,0,2.83,20.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOUND 32FR URETHRAL CURVE VAN BUREN 10.75IN",SUP-51-6332,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.21,101.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,40.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.45,288.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL VANTAGE THK8MM 2 ANKLE LEFT STERILE LATEX FREE",SUP-350-21-22,CDM,C1713,HCPCS,0278,RC,,,both,,,8832.00,2649.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4053.89,45.9,,,,,0,1027.16,7507.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 171226 IMP WG 12X26 SRVC FEE FD",SUP-171226,CDM,S27800098,LOCAL,0278,RC,,,both,,,12572.49,3771.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1489.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1462.18,10686.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP BLUE 33MM STAINLESS STEEL 2 SOFT",SUP-A0804,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"MULTIPLAN [10600]",Multiplan,,133.11,85,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.7MM STRAIGHT CANNULATED 3.5MM MINI COMPRESSION",SUP-AR-8737-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"CIGNA [10200]",Cigna,,1074.06,68,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR INJECTION MEDRAD STELLANT FLEX 2 LARGE SALINE SMALL",SUP-FLEXD-200-SCS,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"AETNA [10100]","Aetna HMO/PPO",,86.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER HAPTIC C BICONVEX 13MM 6MM POSTERIOR",SUP-ZXR00U0165,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"BLUE CROSS [10001]","Blue Cross PPO",,292.04,39.2,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX GEOALIGN 130CM 100MM 5MM BALLOON DILATATION",SUP-LX1813051005F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2765,41.1,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EDWARDS SAPIEN M3 MITRAL VALVE REPLACEMENT SYSTEM (29 MM VAL",SUP-SM329US1,CDM,S27800098,LOCAL,0278,RC,,,both,,,307800.00,92340,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,83106,27,,,,,0,35797.14,261630,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRI 2.0 SUL 30 CT ART VSCLR ME",SUP-SIG30CTAVM,CDM,S27200284,LOCAL,0272,RC,,,both,,,1268.54,380.56,"KAISER [10500]",Kaiser,,849.92,67,,,,,0,147.53,1078.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 5FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-06041,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 105MM CEMENTED EXT PROSTALAC 1 HIGH OFFSET HIP",SUP-154106000,CDM,C1776,HCPCS,0278,RC,,,both,,,18814.32,5644.3,"CIGNA [10200]",Cigna,,7525.73,40,,5873.17,5873.17,5873.17,"1 through 10",2188.11,15992.17,"percent of total billed charges",
"SCR BONE 2.7MM 30MM LCP STAINLESS STEEL DISTAL FIBULA T8",SUP-202.230,CDM,C1713,HCPCS,0278,RC,,,both,,,748.44,224.53,"CIGNA [10200]",Cigna,,508.94,68,,1831.33,1831.33,1831.33,16,87.04,636.17,"percent of total billed charges",
"CATH BARDEX IC 22FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0166SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.21,20.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,28.03,41.1,,,,,0,7.93,57.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM DARCO SHORT THREAD HEAD",SUP-777403832,CDM,C1713,HCPCS,0278,RC,,,both,,,1695.00,508.5,"NOVANET [10819]",Novanet,,1271.25,75,,,,,0,197.13,1440.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR LAPAROSCOPIC 45CM VISTASEAL DUAL APPLR FLEXIBLE",SUP-VSTL45,CDM,S27200284,LOCAL,0272,RC,,,both,,,839.46,251.84,"FIRST HEALTH [10303]","First Health",,671.57,80,,,,,0,97.63,713.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X200 135CM SL",SUP-48005020R,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"KAISER [10500]",Kaiser,,668.06,67,,,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE RELINE L45 MM OD5.5 MM SPINE POLYAXIAL 2 FULL CAN",SUP-16215545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"SCR BONE 5.5MM 40MM 6.5MM LEGACY TITANIUM SPINAL MAS",SUP-7576540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Local Plus",,5107.56,53.5,,3978.14,359.25,3978.14,24,1110.3,8114.82,"percent of total billed charges",
"SA60WF.175 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.175,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC",909,MS-DRG,,,,,,,inpatient,,,41193.05,12357.91,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,17506.93,,"Case rate ($8,142.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,561.10, add-ons for qualifying new technology services are included. If operating cost exceeds $40,600.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,953.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $7,571.10. The transfer operating threshold is the transfer adjustment factor * $7,561.10 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.66. The transfer capital threshold is the transfer adjustment factor * $571.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,38325.59,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK VITRECTOMY 20GA STELLARIS ELITE POSTERIOR MIDFIELD",SUP-SE5420M,CDM,S27200284,LOCAL,0272,RC,,,both,,,3570.00,1071,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2427.6,68,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT Y-KNOT PRO RC 2 RIBBON",SUP-YPRC02R,CDM,C1713,HCPCS,0278,RC,,,both,,,3644.70,1093.41,"KAISER [10500]",Kaiser,,2441.95,67,,,,,0,423.88,3098,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED + VE/",SUP-98000200464,CDM,C1776,HCPCS,0278,RC,,,both,,,25830.00,7749,"CIGNA [10200]",Cigna,,10332,40,,5873.17,5873.17,5873.17,"1 through 10",3004.03,21955.5,"percent of total billed charges",
"CANNULA ARTERIAL SOFT-FLOW 3/8 IN L14 IN OD21 FR ANGLE TIP N",SUP-6384,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"CIGNA [10200]","Cigna Local Plus",,300.31,53.5,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 RB-1 36IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8557,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.06,68.72,"PHCS [10601]",PHCS,,160.34,70,,,,,0,26.64,194.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP PERFORMATRAK FOAM LARGE NASAL ORAL 1 ENTRAINMENT E",SUP-73-1019480EA,CDM,S27000186,LOCAL,0270,RC,,,both,,,225.23,67.57,"PHCS [10601]",PHCS,,157.66,70,,,,,0,26.19,191.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE INTUITION VASCULAR STRAIGHT 300CM HYDRO-TRACK",SUP-INTU300HS,CDM,C1769,HCPCS,0272,RC,,,both,,,502.20,150.66,"MULTIPLAN [10600]",Multiplan,,426.87,85,,,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL RIBFIX TITAN NONSTERILE LATEX FREE REUSABLE",SUP-323.8003,CDM,S27000186,LOCAL,0270,RC,,,both,,,4098.60,1229.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,485.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,476.67,3483.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0225,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAVITOR WITH RADIOPAQUE MARKERS 29MM",SUP-NVRO-29,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"FIRST HEALTH [10303]","First Health",,109440,80,,,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HYPERFORM X-PEDION 150CM 15MM 2.2-2.8FR 3MM .01IN 4MM",SUP-104-4315,CDM,C1725,HCPCS,0272,RC,,,both,,,8790.60,2637.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1041.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1022.35,7472.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.3/4F DUO-DECA 18-2-2-2 S 120CM",SUP-904220,CDM,C1731,HCPCS,0272,RC,,,both,,,8970.00,2691,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1062.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Porphobilinogen Urine Quant",PX-301000361,CDM,84110,CPT,0301,RC,,,both,,,456.00,136.8,"UHC [10700]","United Healthcare",,7.6,,,,,,,0.01,387.6,"fee schedule",
"SUT POLYPROPYLENE PROLENE 0 CTX 30IN MONOFILAMENT BLUE",SUP-8454H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ncntc Ifr Spctrsc O/T Pad 1",PX-361000655,CDM,0640T,CPT,0361,RC,,,both,,,61.00,18.3,"NOVANET [10819]",Novanet,,45.75,75,,,,,0,7.09,51.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE TAPE BROADBAND 5 BLACK WHITE CUTTING CORELESS SINGLE",SUP-110045775,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO BALKIN CURVE 40CM 8FR 2.9MM GUIDING",SUP-G32216,CDM,C1894,HCPCS,0272,RC,,,both,,,432.22,129.67,"KAISER [10500]",Kaiser,,289.59,67,,,,,0,50.27,367.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 10MM NCB PROTASUL-64 3.5MM UNICORTICAL SELF TAP",SUP-0203151010,CDM,C1713,HCPCS,0278,RC,,,both,,,1743.75,523.12,"MULTIPLAN [10600]",Multiplan,,1482.19,85,,,,,0,202.8,1482.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE LITHOVUE EMPOWER RETRIEVAL DEPLOYMENT",SUP-M0067919900,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH CHECK-FLO FLEXOR .018/.038IN ANL0 CURVE 45CM 8FR .113",SUP-G49099,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"FIRST HEALTH [10303]","First Health",,421.2,80,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 30MM 3.25MM ULTRA LOW PROFILE BALLOON",SUP-1012275-30,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 SH 36IN 2 ARM MONOFILAMENT BLUE",SUP-8521H,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.78,17.93,"KAISER [10500]",Kaiser,,40.05,67,,,,,0,6.95,50.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM AXSOS STAINLESS STEEL T20 FEMUR HUMERUS",SUP-371340,CDM,C1713,HCPCS,0278,RC,,,both,,,991.44,297.43,"CIGNA [10200]",Cigna,,674.18,68,,1831.33,1831.33,1831.33,16,115.3,842.72,"percent of total billed charges",
"SYSTEM PROMUS ELEMENT PLUS 28MM 144CM 2.75MM CORONARY STENT",SUP-H7493911428270,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DEMINERALIZED BONE MATRIX 1ML PUTTY STERILE",SUP-038010,CDM,C1713,HCPCS,0278,RC,,,both,,,1160.90,348.27,"MULTIPLAN [10600]",Multiplan,,986.77,85,,,,,0,135.01,986.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.3MM 42MM NAIL-EX TITANIUM FULL THREAD HUMERAL",SUP-04.005.532,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"PHCS [10601]",PHCS,,809.68,70,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 10MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036121040,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 95MM TITANIUM T25 SELF TAP TIP SELF RETENTION",SUP-04.003.029S,CDM,C1713,HCPCS,0278,RC,,,both,,,1442.45,432.73,"CIGNA [10200]","Cigna Open Access",,820.75,56.9,,1144.80,304.56,2275.09,66,167.76,1226.08,"percent of total billed charges",
"GRAFT STENT 160MM 18-14MM 13FR 11FR TRIVASCULAR OVATION",SUP-TV-IL1418160-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9556.22,28.62,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM AMPLATZER TORQVUE 90D 80CM 195CM 4FR .055IN .046IN",SUP-9-TVLP4F90/080,CDM,S27200284,LOCAL,0272,RC,,,both,,,5754.60,1726.38,"CIGNA [10200]","Cigna Local Plus",,3078.71,53.5,,,,,0,669.26,4891.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM EVEREST SPINE POLYAXIAL CANNULATED",SUP-M5111-06535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 80MM 8MM BILIARY PARTIAL COVER TRANSHEPATIC",SUP-7471,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT SHOULDER HUMERAL GLENOID TRABECULAR META",SUP-98000972001,CDM,C1776,HCPCS,0278,RC,,,both,,,33075.00,9922.5,"KAISER [10500]",Kaiser,,22160.25,67,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 80MM TITANIUM LOCK ATLANTIS TRANSLATIONAL BONE SPINE",SUP-6190080,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"HC Progesterone",PX-301000373,CDM,84144,CPT,0301,RC,,,both,,,181.45,54.43,"UHC [10700]","United Healthcare",,18.77,,,,,,,0.18,154.23,"fee schedule",
"STENT ORSIRO 3.0/15",SUP-401744,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,9776.84,9776.84,9776.84,"1 through 10",521.61,3812.25,"percent of total billed charges",
"PLATE 2 SMALL VITALLIUM GRIP CABLE BONE TROCHANTER",SUP-6704-3-070,CDM,S27800098,LOCAL,0278,RC,,,both,,,6913.80,2074.14,"NOVANET [10819]",Novanet,,5185.35,75,,,,,0,804.07,5876.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE TIBIAL 10MM LEGION 3-4 HEMI KNEE LEFT MEDIAL RIGHT",SUP-71423034,CDM,C1776,HCPCS,0278,RC,,,both,,,15245.55,4573.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1806.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1773.06,12958.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS BLOCK ALLOGRAFT 7MM",SUP-290741,CDM,S27800098,LOCAL,0278,RC,,,both,,,3839.85,1151.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1762.49,45.9,,,,,0,446.57,3263.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 42.5MM ATLANTIS VISION ELITE BONE SPINE",SUP-7200042,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]",Cigna,,2998.8,68,,1831.33,1831.33,1831.33,16,512.88,3748.5,"percent of total billed charges",
"IMPL BREAST 650ML P5.7CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-6504BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"FIRST HEALTH [10303]","First Health",,4195.2,80,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 7-0 BV175-8 24IN 2 ARM MONOFILAMENT",SUP-8747H,CDM,S27200284,LOCAL,0272,RC,,,both,,,258.69,77.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,106.32,41.1,,,,,0,30.09,219.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-2-4-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1360.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 13MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P113,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS [10001]","Blue Cross HMO",,3275.51,39.2,,5311.50,4717.44,5388.59,31,971.79,7102.52,"percent of total billed charges",
"PERCSSR PNEUMATIC ADULT 43-53IN WRAP LARGE DISPOSABLE THE",SUP-P300632005,CDM,S27000186,LOCAL,0270,RC,,,both,,,548.99,164.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,63.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,63.85,466.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 12MM STAINLESS STEEL T4 CORTEX SELF TAP",SUP-02.214.112,CDM,C1713,HCPCS,0278,RC,,,both,,,418.99,125.7,"NOVANET [10819]",Novanet,,314.24,75,,,,,0,48.73,356.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANDESARTAN 4 MG TABLET",RX-23229,CDM,,,0637,RC,33342-0114-07,NDC,both,1,UN,15.37,4.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10.45,68,,,,,0,1.79,13.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 1CM 1.5CM GALAXY G3 MINI STRETCH",SUP-GLM910015,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]","Cigna Local Plus",,3742.77,31.5,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 125MMX2MM TITANIUM 7 HOLE LOCK LOW PROFILE VARIAX",SUP-40-20907,CDM,C1713,HCPCS,0278,RC,,,both,,,5059.08,1517.72,"FIRST HEALTH [10303]","First Health",,4047.26,80,,,,,0,588.37,4300.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 6CM 7FR PANCREATIC POLYETHYLENE PUSH CATH DRAIN",SUP-G21376,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERSACROSS CONNECT LAAC 180J D0",SUP-VXAK0109,CDM,S27200284,LOCAL,0272,RC,,,both,,,6969.00,2090.7,"CIGNA [10200]","Cigna Open Access",,3965.36,56.9,,,,,0,810.49,5923.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 18FR 20CM 15.5CM PEEL-AWAY LARGE PERCUTANEOUS",SUP-G06444,CDM,C1892,HCPCS,0272,RC,,,both,,,382.71,114.81,"FIRST HEALTH [10303]","First Health",,306.17,80,,,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 5N 7MM",SUP-TPS-030-075N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"CIGNA [10200]","Cigna Open Access",,460.89,56.9,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +18 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z9002180,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CIGNA [10200]",Cigna,,694.01,68,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPEL APD TWIST-LOC 15CM 6FR J SHORT LENGTH DRNG",SUP-H7493931106150,CDM,C1729,HCPCS,0272,RC,,,both,,,712.80,213.84,"FIRST HEALTH [10303]","First Health",,570.24,80,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG FIBER FLUID RETENTION HIGH ABSORPTION NONWOVEN",SUP-603423,CDM,S27200284,LOCAL,0272,RC,,,both,,,118.49,35.55,"MULTIPLAN [10600]",Multiplan,,100.72,85,,,,,0,13.78,100.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 5MM CEREPAK FREEFORM DETACHABLE",SUP-SCR120515,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"UHC [10700]","United Healthcare",,8371.96,63.3,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Ankle Trimall W Manip",PX-450000166,CDM,27818,CPT,0450,RC,,,both,,,2528.88,758.66,"CIGNA [10200]","Cigna Local Plus",,1442,,,,,,,67.13,2528.88,"case rate",
"GRAFT VASCULAR 30CM 12MM STD WALL GORE-TEX RING 30CM STERILE",SUP-R12030030,CDM,C1768,HCPCS,0278,RC,,,both,,,7969.50,2390.85,"NOVANET [10819]",Novanet,,5977.13,75,,,,,0,926.85,6774.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBERFUSE DEMINERALIZED BONE MATRIX 1CC ALLOGRAFT",SUP-420601,CDM,C1713,HCPCS,0278,RC,,,both,,,2174.25,652.27,"NOVANET [10819]",Novanet,,1630.69,75,,,,,0,252.87,1848.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 12MM 3MM BALLOON DILATATION STERILE",SUP-230-123-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM 16MM NECK SECUR-FIT MAX HA 127D 13 53MM",SUP-6052-1340S,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"NOVANET [10819]",Novanet,,17116.31,75,,,,,0,2654.17,19398.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAX BONE 2.5GM ABSORBABLE HEMOSTATIC AGENT",SUP-W31G,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.22,15.97,"CIGNA [10200]","Cigna Local Plus",,28.47,53.5,,,,,0,6.19,45.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIEVER16 CURVE CATHETER, 16F, 110 CM ( ONE TIME INVENTORY I",SUP-25-201-ISO,CDM,C1757,HCPCS,0272,RC,,,both,,,50400.00,15120,"FIRST HEALTH [10303]","First Health",,40320,80,,,,,0,5861.52,42840,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Platelet Antibody",PX-302000009,CDM,86022,CPT,0302,RC,,,both,,,174.20,52.26,"CIGNA [10200]","Cigna Open Access",,40.41,,,,,,,0.01,148.07,"fee schedule",
"STENT 26CM 3CM 6FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175263110,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"CIGNA [10200]",Cigna,,842.78,68,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 100MM 3MM .018IN BALLOON",SUP-R51003010L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"UHC [10700]","United Healthcare",,1292.27,63.3,,,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VANSONNENBERG 25CM 14FR DRNG GLIDEX PERCUFLEX METAL",SUP-M001245140,CDM,C1729,HCPCS,0272,RC,,,both,,,729.00,218.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,299.62,41.1,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 9IN .054IN KIRSCHNER 2 END TROCAR POINT THREAD",SUP-163838000,CDM,C1713,HCPCS,0278,RC,,,both,,,185.60,55.68,"CIGNA [10200]","Cigna Local Plus",,99.3,53.5,,3978.14,359.25,3978.14,24,21.59,157.76,"percent of total billed charges",
"CANN PERFUSION VENOUS RETURN 1 PIECE 3 STAGE TUBING CNCT",SUP-RTS-13029,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,241.66,45.9,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 9CM 5FR GEENEN PANCREATIC POLYETHYLENE PUSH",SUP-G22212,CDM,C2625,HCPCS,0278,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross PPO",,482.63,39.2,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REVEAL LINQ II CARDIAC MNTR",SUP-LNQ22SYS,CDM,C1764,HCPCS,0278,RC,,,both,,,23940.00,7182,"PHCS [10601]",PHCS,,16758,70,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 216MM 3.1MM AXSOS SHORT LOCK NONSTERILE REUSABLE",SUP-705031,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.7MM 18MM THREAD TITANIUM NONSTERILE GEMINUS",SUP-TPNL-27180-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,623.70,187.11,"BLUE CROSS [10001]","Blue Cross HMO",,244.49,39.2,,957.42,156.86,7483.26,51,72.54,530.15,"percent of total billed charges",
"PORT IMPLANTABLE INFUSION DOME GROSHONG TITANIUM SILICONE",SUP-602870,CDM,C1788,HCPCS,0278,RC,,,both,,,1547.10,464.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,183.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",225.81,225.81,225.81,"1 through 10",179.93,1315.04,"percent of total billed charges",
"HC Tobramycin",PX-301000059,CDM,80200,CPT,0301,RC,,,both,,,528.20,158.46,"AETNA [10100]","Aetna HMO/PPO",,419.92,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.15,448.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER FEMORAL 15MM ACCOLADE C RING MEDIUM HIP CEMENT 4 5",SUP-1059-4515,CDM,C1776,HCPCS,0278,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESONATE HF ICD DR",SUP-D533,CDM,C1721,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"NOVANET [10819]",Novanet,,43706.25,75,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 5FR 6FR POWERPICC 3 LUMEN MAXIMAL BARR SHERLOCK",SUP-9385108QD,CDM,C1751,HCPCS,0272,RC,,,both,,,1689.60,506.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,196.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,196.5,1436.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 12MM ROUND 11.8CMX20MM STERILE",SUP-0470,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.20,28.86,"MULTIPLAN [10600]",Multiplan,,81.77,85,,,,,0,11.19,81.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX 1S REINFORCED TISSUE MATRIX, LONG-TERM RESORBABLE REI",SUP-F10266-1012G,CDM,C1781,HCPCS,0278,RC,,,both,,,12966.48,3889.94,"BLUE CROSS [10001]","Blue Cross HMO",,5082.86,39.2,,,,,0,1508,11021.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LUTONIX 035 130CM 6X60MM1/EACH",SUP-LX35130660,CDM,C1725,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OSTEOTOME LAMBOTTE MINI SWISS PATTERN 5 1/8IN 12MM",SUP-27-5712,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.89,39.57,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOUNDSTAR ACUNAV 90CM 10FR ULTRASOUND 2D PHASE ARRAY",SUP-SNDSTR10G,CDM,C1759,HCPCS,0272,RC,,,both,,,6037.50,1811.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 44.5MM .76MM LCP MINI TITANIUM QUICK COUPLING STOP",SUP-316.288,CDM,S27000186,LOCAL,0270,RC,,,both,,,1013.80,304.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EPISTAXIS WITH MCC",150,MS-DRG,,,,,,,inpatient,,,48475.86,14542.76,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 45MM 7.5MM MODULEX OSTEOGRIP SPINE",SUP-55900507545,CDM,C1713,HCPCS,0278,RC,,,both,,,4519.50,1355.85,"PHCS [10601]",PHCS,,3163.65,70,,,,,0,525.62,3841.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET IMPL 68MM KNEE LEFT FUSION NAIL MODULAR STERILE",SUP-15-0028/07,CDM,C1713,HCPCS,0278,RC,,,both,,,43703.48,13111.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5178.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,5082.71,37147.96,"percent of total billed charges",
"SHELL ACETABULAR 74MM HIP MULTIHOLE RIM TRITANIUM X3 MDM",SUP-509-02-74J,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Card MRI Morphlgy WO Cntrst",PX-614000001,CDM,75557,CPT,0614,RC,,,both,,,4812.97,1443.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,583.68,,,,,,,559.75,4091.02,"fee schedule",
"STENT PROTEGE GPS EXPRT 60MM 80CM 9MM .079IN LARGE DIAMETER",SUP-SERB65-09-60-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"MULTIPLAN [10600]",Multiplan,,4730.25,85,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 55MM 20MM 75CM ENDOPROSTHESIS VENOUS CATH",SUP-H74912044205570,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1022.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG NASAL 8CM HEMOPORE SINUS CHITOSAN LACTATE BIORESORBABLE",SUP-5400020208,CDM,S27200284,LOCAL,0272,RC,,,both,,,1775.01,532.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,206.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,206.43,1508.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TOURNIQUET EXPRESSAIRE BROADCLOTH LONG L34 IN X W4 IN L",SUP-A70107010,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR RETRIEVAL CATHETER",SUP-2689,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERLOOP 4-0 T-22 10IN MULTISTRAND WHITE NONABSORBABLE",SUP-AR-7249-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PREDNISONE 10 MG TABLET",RX-6494,CDM,J7512,HCPCS,0636,RC,00603-5338-21,NDC,both,1,UN,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.12,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 8IN 15MM MODULAR SOL SYSTEM POROUS 12/14 LARGE",SUP-157202150,CDM,C1776,HCPCS,0278,RC,,,both,,,38107.44,11432.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10289.01,27,,,,,0,4431.9,32391.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL MEDIUM KNEE REVISION CONCENTRIC CONE ATTUNE",SUP-151404140,CDM,C1776,HCPCS,0278,RC,,,both,,,31812.48,9543.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12724.99,40,,,,,0,3699.79,27040.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND MICROPOINT 4-0 G-3 18IN 2 ARM BRAID",SUP-783G,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.02,40.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.59,113.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PLEATMAN SAC SPECIMEN RETRIEVAL SELF SEAL OBTR",SUP-005326-901,CDM,S27000186,LOCAL,0270,RC,,,both,,,401.94,120.58,"CIGNA [10200]",Cigna,,273.32,68,,,,,0,46.75,341.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 2CM 5FR 3MM .035IN BALLOON DILATATION",SUP-G52325,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"NOVANET [10819]",Novanet,,719.83,75,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 3CM 75CM 8-9-10MM PULMONARY BALLOON",SUP-M00550330,CDM,C1726,HCPCS,0272,RC,,,both,,,2278.65,683.59,"KAISER [10500]",Kaiser,,1526.7,67,,,,,0,265.01,1936.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM OSTEOGRIP",SUP-83565559,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2732.31,28.62,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VITAMINS A,C,E-ZINC-COPPER 2,148 MCG-113 MG-45 MG-17.4 MG TABLET",RX-123640,CDM,,,0250,RC,80681-0052-00,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 5MM 150MM KII ADVANCE FIXATION",SUP-CFS01,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"UHC [10700]","United Healthcare",,44.06,63.3,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Cntrst Tube Check",PX-360000048,CDM,49465,CPT,0361,RC,,,both,,,821.89,246.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,821.89,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,95.59,821.89,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 4MM25CM 190",SUP-R51004025L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"UHC [10700]","United Healthcare",,1577.36,63.3,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC SMALL 8.5IN ANKLE ADJUSTABLE HEEL STRAP AIR",SUP-79-97863,CDM,S27000186,LOCAL,0270,RC,,,both,,,89.78,26.93,"FIRST HEALTH [10303]","First Health",,71.82,80,,,,,0,10.44,76.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHOCARBAMOL 100 MG/ML INJECTION SOLUTION",RX-4970,CDM,J2800,HCPCS,0636,RC,71288-0716-11,NDC,both,10,ML,81.54,24.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.04,,,,,,,5.33,69.31,"fee schedule",
"BLADE MYRINGOTOMY 7IN NARROW NARROW SHAFT STERILE DISPOSABLE",SUP-1458275,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.95,20.98,"KAISER [10500]",Kaiser,,46.87,67,,,,,0,8.14,59.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CORD TUBE FIX LEAD ROTARY PUMP CODMAN IRRIGATION",SUP-9190001RP,CDM,S27200284,LOCAL,0272,RC,,,both,,,4067.00,1220.1,"UHC [10700]","United Healthcare",,2574.41,63.3,,,,,0,472.99,3456.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 23MM CHORDAL GUIDE DURAN ANCORE LATEX FREE",SUP-620RG23,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1524.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X9MM 7D TRAPEZOID SPINE",SUP-017409,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET",RX-41832,CDM,,,0637,RC,50268-0717-11,NDC,both,1,UN,62.29,18.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.24,52.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 2.4MM STEINMANN ORTHOPEDIC STAINLESS STEEL",SUP-3811-2-090,CDM,C1713,HCPCS,0278,RC,,,both,,,138.85,41.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,39.74,28.62,,,,,0,16.15,118.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 8 SLOT LEFT TI",SUP-PHPF-S8L,CDM,C1713,HCPCS,0278,RC,,,both,,,17892.00,5367.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2120.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2080.84,15208.2,"percent of total billed charges",
"SUB BONE GRAFT MASTERGRAFT CALCIUM PHOSPHATE CLLGN VOID",SUP-7600709,CDM,C1713,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3562.99,45.9,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 80MM 7MM .035IN BALLOON",SUP-AB35W07080135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"PHCS [10601]",PHCS,,474.01,70,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HYDRAGLIDE XL 23IN 36FR STRAIGHT TAPER DRNG PVC",SUP-8036,CDM,C1729,HCPCS,0272,RC,,,both,,,58.98,17.69,"FIRST HEALTH [10303]","First Health",,47.18,80,,,,,0,6.86,50.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 80MM 150CM 6MM VASCULAR NICKEL",SUP-EVD35-06-080-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"CIGNA [10200]","Cigna Local Plus",,3362.48,53.5,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"AETNA [10100]","Aetna HMO/PPO",,10422.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 71MM TITANIUM LEVEL 4 ZEVO BONE SPINE CERVICAL",SUP-3004071,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"STENT ZILVER 635 FLEXOR 20MM 80CM 9MM BILIARY NITINOL ILIAC",SUP-G43859,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Local Plus",,2022.3,53.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 11.8X11.8IN XENMATRIX AB SQUARE DERMAL CLLGN",SUP-1153030,CDM,C1781,HCPCS,0278,RC,,,both,,,127400.70,38220.21,"AETNA [10100]","Aetna HMO/PPO",,101283.56,79.5,,,,,0,14816.7,108290.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NAVITOR SMALL LOADING",SUP-NVTR-LS-SM,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"AMERIGROUP MEDICAID [20100]",Amerigroup,,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 44.5MM 1.5MM 4MM STOP J LATCH NONSTERILE",SUP-317.64,CDM,S27000186,LOCAL,0270,RC,,,both,,,1231.20,369.36,"CIGNA [10200]","Cigna Local Plus",,658.69,53.5,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL RANEY INFANT SCALP TEMPORARY GUN KIT PLASTIC",SUP-201037,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.18,38.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,87.16,68,,,,,0,14.91,108.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 40MM 130CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-EX060403CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"BLUE CROSS [10001]","Blue Cross HMO",,4598.16,39.2,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 78MM STAINLESS STEEL 3.5MM SCREWS 4X6 HOLES T RIGHT",SUP-241.161,CDM,S27800098,LOCAL,0278,RC,,,both,,,2450.70,735.21,"KAISER [10500]",Kaiser,,1641.97,67,,,,,0,285.02,2083.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 38MM 2.75MM CORONARY RAPID EXCHANGE",SUP-ONYXNG27538UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"PHCS [10601]",PHCS,,1837.5,70,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY JNS CURVE 5MM SPACING 5FR 120CM",SUP-401443,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"MULTIPLAN [10600]",Multiplan,,266.22,85,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 8.2MM 65MM 22MM DHS/DCS STAINLESS STEEL",SUP-280.65,CDM,C1713,HCPCS,0278,RC,,,both,,,2212.13,663.64,"MULTIPLAN [10600]",Multiplan,,1880.31,85,,,,,0,257.27,1880.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12-15IN 24FR VENOUS ADULT 3/8IN RIGHT ANGLE 1",SUP-67524,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.59,90.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,35.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.07,256.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SCOUT BX 12.3CM 15GA DELIVERY END DEPLOY REFLECTOR",SUP-SSR13B-01,CDM,A4648,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STINGRAY VASCULAR 28D 300CM 20CM .014IN HYDROPHILIC",SUP-H749M3004A0,CDM,C1769,HCPCS,0272,RC,,,both,,,2784.38,835.31,"FIRST HEALTH [10303]","First Health",,2227.5,80,,,,,0,323.82,2366.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN 500 MG VIAL",RX-8443,CDM,J3373,HCPCS,0636,RC,00409-4332-11,NDC,both,1,UN,73.94,22.18,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1.75,,,,,,,1.75,62.85,"fee schedule",
"CMPNT FEMORAL 11 NARROW KNEE LEFT POSTERIOR STABILIZE",SUP-42500207001,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"KAISER [10500]",Kaiser,,19360.04,67,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP SOLID BACK TRITANIUM TRIDENT II D",SUP-700-04-48D,CDM,C1776,HCPCS,0278,RC,,,both,,,12895.96,3868.79,"PHCS [10601]",PHCS,,9027.17,70,,,,,0,1499.8,10961.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 50MM EXPEDIUM TITANIUM SPINE 1 INNIE POLYAXIAL",SUP-179712650,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,573.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",563.19,4116.21,"percent of total billed charges",
"FITMORE HIP STEM B SIZE 8",SUP-01.00551.208,CDM,C1776,HCPCS,0278,RC,,,both,,,28871.64,8661.49,"PHCS [10601]",PHCS,,20210.15,70,,,,,0,3357.77,24540.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 4MM 1.2MM 24MM 10MM STAINLESS STEEL LONG THREAD",SUP-202.724,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,131.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",129.1,943.52,"percent of total billed charges",
"CATHETER C304L6905 SELECTSITE GLOBAL",SUP-C304L6905,CDM,C1887,HCPCS,0272,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY HUMERAL SMR TI6AL4V REVERSE LOCKING SCR ELECTIVE",SUP-1352.15.010,CDM,C1776,HCPCS,0278,RC,,,both,,,10440.00,3132,"BLUE CROSS [10001]","Blue Cross HMO",,4092.48,39.2,,5311.50,4717.44,5388.59,31,1214.17,8874,"percent of total billed charges",
"COIL EMBOLIZATION 16.1CM 8MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR100816,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4883.42,41.1,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 4FR 100CM TRIFORCE FLEXOR PEEL-AWAY STRAIGHT CURVE",SUP-G56418,CDM,S27200284,LOCAL,0272,RC,,,both,,,2711.18,813.35,"UHC [10700]","United Healthcare",,1716.18,63.3,,,,,0,315.31,2304.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL STAND OFFSET SZ10",SUP-425-98-010,CDM,C1776,HCPCS,0278,RC,,,both,,,38695.80,11608.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15478.32,40,,,,,0,4500.32,32891.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 25CM 6.4FR STARBURST TALON SEMI-FLEX",SUP-700-102845,CDM,S27200284,LOCAL,0272,RC,,,both,,,20216.70,6065.01,"AETNA [10100]","Aetna HMO/PPO",,16072.28,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2351.2,17184.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 8MMX39MM 7FR 135CMCATH HEPARIN",SUP-BXBL083902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5582.27,28.62,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 20MM 33MM 30.3MM EPIC TISSUE STENT REDEFINE",SUP-E200-33M,CDM,S27800098,LOCAL,0278,RC,,,both,,,26775.00,8032.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3113.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE V-18 CONTROLWIRE VASCULAR STRAIGHT 150CM 8CM .018IN",SUP-46-850,CDM,C1769,HCPCS,0272,RC,,,both,,,602.64,180.79,"FIRST HEALTH [10303]","First Health",,482.11,80,,,,,0,70.09,512.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 8MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0301,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,112.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,110.22,805.55,"percent of total billed charges",
"SYSTEM ANGIOVAC PERFUSION CIRCUIT BUBBLE TRAP",SUP-H965251880,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"NOVANET [10819]",Novanet,,7762.5,75,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP070100090 PLUS US D7L100UL900",SUP-PCP070100090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8.5MM 31CM TIBIA META-NAIL INTRAMEDULLARY TITANIUM",SUP-71655031,CDM,C1713,HCPCS,0278,RC,,,both,,,15548.46,4664.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1842.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1808.29,13216.19,"percent of total billed charges",
"TIP ASPIRATION DIA1.9MM STANDARD SHORT AND TUBESET",SUP-130-35-1419,CDM,S27200284,LOCAL,0272,RC,,,both,,,5673.19,1701.96,"CIGNA [10200]","Cigna Open Access",,3228.05,56.9,,,,,0,659.79,4822.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE .3MM 47MM UNIVERSAL NEURO III MEDIUM ROUND",SUP-53-00364,CDM,C1713,HCPCS,0278,RC,,,both,,,6240.77,1872.23,"BLUE CROSS [10001]","Blue Cross HMO",,2446.38,39.2,,957.42,156.86,7483.26,51,725.8,5304.65,"percent of total billed charges",
"PIN DISTRACTION 14MM TRIMLINE ANTERIOR CERVICAL",SUP-875-088,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,170.52,39.2,,957.42,156.86,7483.26,51,50.59,369.75,"percent of total billed charges",
"CATHETER ELECTROPHYSIOLOGY 110CM 6FR BARD EP XT 2-5-2MM SPAC",SUP-200794R,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"AETNA [10100]","Aetna HMO/PPO",,804.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 12CM 5FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22363,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,180.82,28.62,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE ROUND SILICONE",SUP-SRF-265,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3730.14,68,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO S3 HYPERANGULATE LOW PROFILE BLADE GLIDESCOPE",SUP-0270-1083,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"MULTIPLAN [10600]",Multiplan,,295.8,85,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 300MM 5.5MM RELINE STRAIGHT TITANIUM MAS",SUP-12355300,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 12MM 5.5MM REVERE SPINE WIDE BLADE PARALLEL CLAMP",SUP-124.965,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2216.97,45.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 15CM NATRELLE INSPIRA P4.9CM MODERATE PROFILE",SUP-SSZ-M600,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1013.47,68,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM TITANIUM CORTICAL",SUP-PANL-35260-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,899.10,269.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,611.39,68,,,,,0,104.57,764.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 27FR CUT STORZ 2 STEM",SUP-M0068802241,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"CIGNA [10200]",Cigna,,325.19,68,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 150CM 6FR .035IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145363190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CIGNA [10200]","Cigna Open Access",,642.94,,,,,,,131.41,960.46,"percent of total billed charges",
"CATH SOFT-VU 65CM 4FR COBRA 3 CURVE ANGIOGRAPHIC VISCERAL",SUP-H787107140125,CDM,C1887,HCPCS,0272,RC,,,both,,,190.36,57.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,78.24,41.1,,,,,0,22.14,161.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 9X60 135CM SL",SUP-48009006R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"FIRST HEALTH [10303]","First Health",,687.21,80,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +7.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.075,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 54MM STAINLESS STEEL T8 METAPHYSEAL SELF TAP",SUP-02.118.554,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"MULTIPLAN [10600]",Multiplan,,445.32,85,,,,,0,60.93,445.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SEEKER 150CM 4FR .014IN GUIDING CROSSING SPRT",SUP-SK15014,CDM,C1887,HCPCS,0272,RC,,,both,,,1498.50,449.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,177.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CEMENTED EXETER V40 4 44MM OFFSET HIP",SUP-0580-1-444,CDM,C1776,HCPCS,0278,RC,,,both,,,17001.60,5100.48,"PHCS [10601]",PHCS,,11901.12,70,,,,,0,1977.29,14451.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) INTREPID TRANSFEMORAL INTRODUCER SHEATH AND DILATOR",SUP-INTPDTFISG,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 645CC",SUP-SMPX645,CDM,C1789,HCPCS,0278,RC,,,both,,,6382.50,1914.75,"PHCS [10601]",PHCS,,4467.75,70,,,,,0,742.28,5425.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 6MM CEREPAK XTRASOFT FREEFORM",SUP-XCR120610,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"PHCS [10601]",PHCS,,9258.1,70,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC",522,MS-DRG,,,,,,,inpatient,,,100547.02,30164.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,40187.59,,"Fee schedule rate ($40,187.59). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,61828.37,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ORTHOPEDIC LARGE CONTOUR ALUMINUM COTTON SUEDE WRIST",SUP-79-87017,CDM,S27000186,LOCAL,0270,RC,,,both,,,50.37,15.11,"KAISER [10500]",Kaiser,,33.75,67,,,,,0,5.86,42.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 37X27X14MM SOVEREIGN 12D",SUP-7968214,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4061.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CEMENTED EXETER V40 4 44MM OFFSET HIP",SUP-0580-1-444,CDM,C1776,HCPCS,0278,RC,,,both,,,17001.60,5100.48,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4590.43,27,,,,,0,1977.29,14451.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOPLASTY L150CM BALLOON L200MM DIA4MM COMPATIBLE",SUP-1013466-200,CDM,S27200284,LOCAL,0272,RC,,,both,,,1255.50,376.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,853.74,68,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FS 40MM UTERINE DISTAL CUP TEXTURE HANDLE SOUND LATCH",SUP-110040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1539.00,461.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,178.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP OCCL BALLOON AUDIO INDCTR ALERT ELECTROSURGERY DEVICE",SUP-KC-ARCH-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,133.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 7 X 30 HELICAL FILLING COIL",SUP-10HFL-07030,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4114.06,45.9,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL TEMP PACING WIRE 2-0 SH SKS-3 24IN 2 ARM",SUP-TPW30,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.32,37.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,85.9,68,,,,,0,14.69,107.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Arthcs Asp/Inj Sm Jt",PX-450000067,CDM,20600,CPT,0361,RC,,,both,,,1275.39,382.62,"KAISER [10500]",Kaiser,,854.51,67,,,,,0,148.33,1275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 28MM 145CM 3MM CORONARY STENT",SUP-1145300-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross PPO",,2288.5,39.2,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL GENESIS II 2 KNEE LEFT CEMENTED",SUP-71420162,CDM,C1776,HCPCS,0278,RC,,,both,,,16725.60,5017.68,"CIGNA [10200]","Cigna Open Access",,5603.08,33.5,,5302.19,4377.88,6578.61,27,1945.19,14216.76,"percent of total billed charges",
"SYSTEM CAPSURE STRAIGHT 37CM FIXATION STAINLESS STEEL PEEK",SUP-0113230,CDM,S27200284,LOCAL,0272,RC,,,both,,,2100.00,630,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,863.1,41.1,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 11MM PERSONA 8-9 C-D KNEE RIGHT TIBIA",SUP-42522100511,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION HI-FLO 130CM 2.8-3FR .027IN MICRO BERN CURVE",SUP-M001195440,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc De Stnt Sngl Maj Cor Arty",PX-481000076,CDM,C9600,HCPCS,0481,RC,,,both,,,31274.02,9382.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3705.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3637.17,26582.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 11CM 2.9MM XPS INFERIOR TURBINATE STERILE",SUP-1882940,CDM,S27200284,LOCAL,0272,RC,,,both,,,2349.00,704.7,"CIGNA [10200]",Cigna,,1597.32,68,,,,,0,273.19,1996.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 80CM 4FR 6MM EMBOLECTOMY ADHERENT CLOT",SUP-140806,CDM,C1757,HCPCS,0272,RC,,,both,,,1763.85,529.15,"NOVANET [10819]",Novanet,,1322.89,75,,,,,0,205.14,1499.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER SMOKE EVAC MEGADYNE MEGA VAC ULTRA LOW PENETRATE AIR",SUP-2211J,CDM,S27000186,LOCAL,0270,RC,,,both,,,327.66,98.3,"CIGNA [10200]","Cigna Open Access",,186.44,56.9,,,,,0,38.11,278.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 16MM 144CM 3MM CORONARY STENT PEBAX",SUP-H7493926016300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"KAISER [10500]",Kaiser,,3728.55,67,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 1.7MM ATRIUM ENDOCARDIUM VENTRICLE BIPOLAR",SUP-4471,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,664.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX CORE REINFORCED TISSUE MATRIX, LONG-TERM RESORBABLE R",SUP-F10264-1012G,CDM,C1781,HCPCS,0278,RC,,,both,,,6789.60,2036.88,"CIGNA [10200]",Cigna,,4616.93,68,,,,,0,789.63,5771.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 38MM 22.2MM D HIP X3 STERILE LATEX FREE MDM",SUP-7236-2-244,CDM,C1776,HCPCS,0278,RC,,,both,,,8711.25,2613.37,"CIGNA [10200]","Cigna Open Access",,4956.7,56.9,,5302.19,4377.88,6578.61,27,1013.12,7404.56,"percent of total billed charges",
"SPLINT ORTHOPEDIC LARGE LEFT WRIST FOREARM PREFORM PAD",SUP-9101-06,CDM,S27000186,LOCAL,0270,RC,,,both,,,72.38,21.71,"NOVANET [10819]",Novanet,,54.29,75,,,,,0,8.42,61.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH AORTIC VASCULAR 4.0MM",SUP-DP-40K,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 12FR 20CM HYDROPHILIC RADIOPAQUE STERILE",SUP-G10292,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEAD FEMORAL +0MM 14/16 OFFSET TAPER 36MM HIP M SPECIFICATIO",SUP-101836500,CDM,C1776,HCPCS,0278,RC,,,both,,,8067.48,2420.24,"KAISER [10500]",Kaiser,,5405.21,67,,,,,0,938.25,6857.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Culture Stool",PX-306000002,CDM,87045,CPT,0306,RC,,,both,,,286.90,86.07,"UHC [10700]","United Healthcare",,8.5,,,,,,,4.26,243.87,"fee schedule",
"STPLR INTERNAL 30MMX4.8MM TITANIUM THICK TISSUE 2 ROW",SUP-TX30G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1810.13,543.04,"NOVANET [10819]",Novanet,,1357.6,75,,,,,0,210.52,1538.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 150MM 5MM BALLOON DILATATION DURALYN",SUP-48005015S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"FIRST HEALTH [10303]","First Health",,1101.6,80,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 14MM PRESS FIT ECHO PF TITANIUM STD OFFSET HIP",SUP-12-150314,CDM,C1776,HCPCS,0278,RC,,,both,,,8336.51,2500.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3826.46,45.9,,,,,0,969.54,7086.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 20FR 20CM RADIOPAQUE STERILE DISPOSABLE STD",SUP-G01471,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.44,31.03,"FIRST HEALTH [10303]","First Health",,82.75,80,,,,,0,12.03,87.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL TSRH-3D TITANIUM SPINE FLUSH BREAK",SUP-8351500,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,236.64,68,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 80CM 15MM 6FR 5MM .018IN BALLOON",SUP-H74939031501580,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX39MM 8FR 135CMCATH HEPARIN",SUP-BXB093902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8016.47,41.1,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 2MM CONCERTO DETACHABLE HELIX PERIPHER",SUP-NV-2-8-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANASTROZOLE 1 MG TABLET",RX-16205,CDM,,,0250,RC,60687-0112-11,NDC,both,1,UN,10.42,3.13,"UHC [10700]","United Healthcare",,6.6,63.3,,,,,0,1.21,8.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 24CM 3CM 7FR .035IN 2 PIGTAIL",SUP-M006192142050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,142.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR HEMI 3HL 52MM",SUP-430-98-052,CDM,C1776,HCPCS,0278,RC,,,both,,,16956.34,5086.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1972.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1972.02,14412.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION",RX-24513,CDM,J0885,HCPCS,0636,RC,59676-0340-01,NDC,both,1,ML,6452.48,1935.74,"PHCS [10601]",PHCS,,4516.74,70,,,,,0,363.69,5484.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 2.8MM TWIST STERILE",SUP-KM166-10-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12,87.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +15.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.155,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,40.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN",RX-174479,CDM,J1815,HCPCS,0637,RC,00002-8824-27,NDC,both,3,ML,1732.94,519.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1178.4,68,,,,,0,77.55,1473,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 24X2CM SUSPEND TUTOPLAST FASCIA LATA",SUP-937224,CDM,C1762,HCPCS,0278,RC,,,both,,,17236.20,5170.86,"MULTIPLAN [10600]",Multiplan,,14650.77,85,,,,,0,2004.57,14650.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP TRUNCATE OSTEOTOM 52MM HEMISPHERE",SUP-00705305210,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2077.62,45.9,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, ALL-POLY PEGGED GLENOID, SIZE 46, E-PLUS",SUP-521-07-246,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"BLUE CROSS [10001]","Blue Cross PPO",,3592.44,39.2,,3949.44,3949.44,3949.44,"1 through 10",1065.82,7789.74,"percent of total billed charges",
"CMPNT PATELLAR 11MM 38MM ASYMMETRIC TRIATHLON X3 KNEE",SUP-5551-G-381,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,511.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,502.16,3670.1,"percent of total billed charges",
"SYSTEM ALEXIS GELPOINT 14CM EXTRACTION 3400ML LARGE SPECIMEN",SUP-GTM14,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,561.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 6FR 4.5MM 4FR BALLOON",SUP-39031-45401,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP FRCP 25 PLUS GRIESHABER REVOLUTION ASYMMETRICAL GRASPING",SUP-705.45P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 560CC",SUP-SMPX560,CDM,C1789,HCPCS,0278,RC,,,both,,,6382.50,1914.75,"FIRST HEALTH [10303]","First Health",,5106,80,,,,,0,742.28,5425.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 52MM TI",SUP-SPL-60520-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross PPO",,635.04,39.2,,957.42,570.23,957.42,28,188.41,1377,"percent of total billed charges",
"SCR BONE 5MM 35MM SPINE POLYAXIAL 1 INNIE NONSTERILE",SUP-179712535,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 60MM 36MM ALTRX HIP",SUP-122136160,CDM,C1776,HCPCS,0278,RC,,,both,,,6814.08,2044.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,807.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,792.48,5791.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 325ML P3.8CM MODERATE PLUS PROFILE HIGH",SUP-350-3251BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"MULTIPLAN [10600]",Multiplan,,4457.4,85,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prostate Ndl Bx",PX-312000058,CDM,88305,CPT,0312,RC,,,both,,,8120.60,2436.18,"CIGNA [10200]","Cigna Local Plus",,420.31,,,,,,,0.01,6902.51,"fee schedule",
"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC",481,MS-DRG,,,,,,,inpatient,,,75942.32,22782.7,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,13771.85,,"Case rate ($12,992.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,064.24, add-ons for qualifying new technology services are included. If operating cost exceeds $45,103.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,294.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,080.20. The transfer operating threshold is the transfer adjustment factor * $12,064.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $912.12. The transfer capital threshold is the transfer adjustment factor * $912.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,61151.02,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTRAZEAL POWDER DRESSING 0.75 GM",SUP-11175-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,1615.87,484.76,"MULTIPLAN [10600]",Multiplan,,1373.49,85,,,,,0,187.93,1373.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC .75CM 4.45X4.81CM ACCOLADE LATITUDE NXT",SUP-L300,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"FIRST HEALTH [10303]","First Health",,19872,80,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X7MM 7D PEEK LUMBAR INTERBODY FUSION",SUP-21411-707,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS [10001]","Blue Cross HMO",,2617.94,39.2,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 10MM INVIS HIP FEMUR DISTAL PMMA RECONSTRUCTION",SUP-71313210,CDM,C1776,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Local Plus",,520.02,53.5,,5372.07,4581.20,7242.98,23,113.04,826.2,"percent of total billed charges",
"STENT PALMAZ BLUE SLALOM FLEXSEGMENT 17MM 80CM 6MM 20MM",SUP-PB1860BSS,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"AETNA [10100]","Aetna HMO/PPO",,3291.3,79.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TBL PST SZ 3-4  LF12MM",SUP-2245-0-3412,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2422.5,68,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM PK COIL LP STERILE LATEX FREE",SUP-RBYPCLP03,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"AETNA [10100]","Aetna HMO/PPO",,5375.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 130D STD BARREL 80MM STAINLESS STEEL 3 HOLE",SUP-121125,CDM,S27800098,LOCAL,0278,RC,,,both,,,5149.13,1544.74,"AETNA [10100]","Aetna HMO/PPO",,4093.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,598.84,4376.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 31.50CM 8MM SUTURECUT ENDOWRIST DA VINCI XI 38D",SUP-471296,CDM,S27000186,LOCAL,0270,RC,,,both,,,1446.12,433.84,"KAISER [10500]",Kaiser,,968.9,67,,,,,0,168.18,1229.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ADVANCE 3 KNEE SCR HOLE BIOFOAM STERILE",SUP-KTSCFM30,CDM,C1776,HCPCS,0278,RC,,,both,,,17063.70,5119.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2022.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1984.51,14504.15,"percent of total billed charges",
"SHELL 60MM ACETABULAR HEMI 3HL",SUP-430-98-060,CDM,C1776,HCPCS,0278,RC,,,both,,,3200.74,960.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,916.05,28.62,,,,,0,372.25,2720.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 42.5MM TRIGEN FEMUR LOW PROFILE",SUP-71645042,CDM,C1713,HCPCS,0278,RC,,,both,,,2314.95,694.48,"CIGNA [10200]","Cigna Open Access",,1317.21,56.9,,1144.80,304.56,2275.09,66,269.23,1967.71,"percent of total billed charges",
"HEAD HUMERAL 17MM 45MM SHOULDER ECLIPSE STERILE ARTHROPLASTY",SUP-AR-9345-17,CDM,C1776,HCPCS,0278,RC,,,both,,,4105.50,1231.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1174.99,28.62,,,,,0,477.47,3489.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR MAC4 CURVE GUIDING CORONARY",SUP-LA7MAC40,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 75CM .4MM FIRM TPR",SUP-124208,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,45.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR XTHIN 45MM TRI-STAPLE VASCULAR 2MM GRAY 2",SUP-SIG45AV,CDM,S27200284,LOCAL,0272,RC,,,both,,,1546.45,463.93,"CIGNA [10200]",Cigna,,1051.59,68,,,,,0,179.85,1314.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION",RX-3037,CDM,J3010,HCPCS,0636,RC,63323-0806-14,NDC,both,20,ML,102.20,30.66,"CIGNA [10200]",Cigna,,31.92,,,,,,,12.11,86.87,"fee schedule",
"SCR BONE 1.7MM 5MM LEIBINGER UNIVERSAL 2 MIDFACE SELF DRILL",SUP-50-17905,CDM,C1713,HCPCS,0278,RC,,,both,,,524.80,157.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",61.03,446.08,"percent of total billed charges",
"PIN FIXATION 15MM 1.1MM MEDLINE UNITE",SUP-MPPF1115,CDM,S27000186,LOCAL,0270,RC,,,both,,,567.00,170.1,"CIGNA [10200]",Cigna,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 1.5IN 18GA 20GA CONTIPLEX TUOHY POLYAMIDE NYLON",SUP-331695,CDM,S27200284,LOCAL,0272,RC,,,both,,,169.77,50.93,"PHCS [10601]",PHCS,,118.84,70,,,,,0,19.74,144.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PERMASORB FIXATION 12 ABSORBABLE FASTENERS",SUP-0113092,CDM,S27200284,LOCAL,0272,RC,,,both,,,3559.32,1067.8,"MULTIPLAN [10600]",Multiplan,,3025.42,85,,,,,0,413.95,3025.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND SUTUPAK 0 30IN BRAID TIES 10 STRAND",SUP-SA86G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 15MM ATLANTIS TITANIUM SPINE CERVICAL",SUP-3125515,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 40MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE50040,CDM,C1876,HCPCS,0278,RC,,,both,,,90839.19,27251.76,"BLUE CROSS [10001]","Blue Cross PPO",,35608.96,39.2,,,,,0,10564.6,77213.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 6MM ROUND DIAMOND STERILE LATEX FREE",SUP-5820-012-060D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1164.70,349.41,"MULTIPLAN [10600]",Multiplan,,990,85,,,,,0,135.45,990,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 7MM 8-6MM 12MM DUCT SELF EXPANDABLE",SUP-9-PDA-005,CDM,C1817,HCPCS,0278,RC,,,both,,,34398.00,10319.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9844.71,28.62,,,,,0,4000.49,29238.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 80MM 120CM 5.5MM 6FR BILIARY NITINOL PERIPHERAL",SUP-S-55-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1192.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 700CC STERILE ARTOURA ULTRA HIGH PROFILE ROUND",SUP-TEXP135RUH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"CIGNA [10200]","Cigna Local Plus",,4336.13,,,,,,,1600.93,11700.68,"percent of total billed charges",
"STENT VISI-PRO 37MM 80CM 8MM 40MM BILIARY STAINLESS STEEL",SUP-PXB35-08-37-080,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"CIGNA [10200]","Cigna Local Plus",,2336.35,53.5,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RUBY XL COIL 24MMX55CM",SUP-RBYXL2455,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"CIGNA [10200]",Cigna,,7534.8,40,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM 2.6-2FR .019IN EXCELSIOR",SUP-M0031441930,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,897.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,897.75,6561.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOX SV 150CM 60MM 4FR 6MM .018IN LARGE CRESCENT LOW",SUP-83981-02,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"MULTIPLAN [10600]",Multiplan,,1593.75,85,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRIMONIDINE 0.1 % EYE DROPS",RX-70262,CDM,,,0250,RC,00023-9321-05,NDC,both,5,ML,1173.65,352.09,"FIRST HEALTH [10303]","First Health",,938.92,80,,,,,0,136.5,997.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX 30MM 135CM 8MM VASCULAR NITINOL CAROTID",SUP-PC0830RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,882.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 64CM ENDOTAK RELIANCE G ENDOCARDIAL STEROID",SUP-175,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4344.52,28.62,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Fetal Echo W/W/O M F/U",PX-402000060,CDM,76826,CPT,0402,RC,,,both,,,1016.95,305.08,"NOVANET [10819]",Novanet,,762.71,75,,,,,0,118.27,864.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CARTIFORM 25X20MM",SUP-ABS-1102-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"MULTIPLAN [10600]",Multiplan,,53295,85,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intra Cor Ffr W 3d Func Map",PX-480000080,CDM,0523T,CPT,0480,RC,,,both,,,3348.00,1004.4,"UHC [10700]","United Healthcare",,3140,,"Per diem ($3,140).",,,,0,389.37,3348,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON 6 6 NUROLON 3-0 SH 18IN CONTROL RELEASE BRAID 8",SUP-C513D,CDM,S27200284,LOCAL,0272,RC,,,both,,,120.76,36.23,"FIRST HEALTH [10303]","First Health",,96.61,80,,,,,0,14.04,102.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 24MM PRESS FIT TRIATHLON TITANIUM KNEE",SUP-5566-S-024,CDM,C1776,HCPCS,0278,RC,,,both,,,7345.05,2203.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,854.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,854.23,6243.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 535CC",SUP-RSZ-SHPX-535S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EXTERNAL DRNG CSF ASSEMB PATIENT CONNECTION LINE MON",SUP-46126,CDM,S27200284,LOCAL,0272,RC,,,both,,,684.77,205.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,281.44,41.1,,,,,0,79.64,582.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 7.5MM CANNULATED SURGICAL",SUP-6134.0075,CDM,C1713,HCPCS,0278,RC,,,both,,,583.20,174.96,"BLUE CROSS [10001]","Blue Cross PPO",,228.61,39.2,,957.42,570.23,957.42,28,67.83,495.72,"percent of total billed charges",
"DEVICE V-LOC 90 2-0 GS-21 12IN CLSR ABSORBABLE VIOLET",SUP-VLOCM0315,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.58,61.67,"MULTIPLAN [10600]",Multiplan,,174.74,85,,,,,0,23.91,174.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 F 36MM LONGEVITY HIP STERILE LUMEN LATEX",SUP-20123606,CDM,C1776,HCPCS,0278,RC,,,both,,,8101.98,2430.59,"AETNA [10100]","Aetna HMO/PPO",,6441.07,79.5,,10981.53,8986.79,12413.38,12,942.26,6886.68,"percent of total billed charges",
"6.0MM X 13MM SENSAR INTRAOCULAR LENS, BICONVEX, 21.0 DIOPTER",SUP-AR40E00210,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"BLUE CROSS [10001]","Blue Cross HMO",,365.15,39.2,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 5MM 12MM LCP TITANIUM FULL THREAD DISTAL",SUP-402.812,CDM,C1713,HCPCS,0278,RC,,,both,,,380.02,114.01,"CIGNA [10200]","Cigna Open Access",,216.23,56.9,,1144.80,304.56,2275.09,66,44.2,323.02,"percent of total billed charges",
"NDL NERVE BLOCK 30MM 24GA SONOPLEX II FACET INJECTION TUBE",SUP-001285-75,CDM,C9812,HCPCS,0272,RC,,,both,,,119.63,35.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM ULNAR 75MM NEXEL 5 ELBOW RIGHT",SUP-840002507,CDM,C1776,HCPCS,0278,RC,,,both,,,31971.49,9591.45,"FIRST HEALTH [10303]","First Health",,25577.19,80,,,,,0,3718.28,27175.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 420MM FEMORAL EXPERT INTRAMEDULLARY FLUTE",SUP-04.013.664S,CDM,C1713,HCPCS,0278,RC,,,both,,,8319.74,2495.92,"FIRST HEALTH [10303]","First Health",,6655.79,80,,,,,0,967.59,7071.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 24CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192122010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS [10001]","Blue Cross PPO",,470.63,39.2,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 9MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-109,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"BLUE CROSS [10001]","Blue Cross HMO",,3853.56,39.2,,5311.50,4717.44,5388.59,31,1143.29,8355.94,"percent of total billed charges",
"CATH NAVISTAR 115CM 7FR 1-7-4MM SPACE J CURVE ABLATION",SUP-NS7TCJL174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9337.08,68,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-02006,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2960.2,28.62,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 210MM CD HORIZON LEGACY TITANIUM PEDICLE",SUP-869-021,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 60CM 10MM 2 VELOUR STRAIGHT TUBE",SUP-95210,CDM,C1768,HCPCS,0278,RC,,,both,,,3748.95,1124.68,"CIGNA [10200]",Cigna,,2549.29,68,,,,,0,436,3186.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 40MM 2.5MM GEMINUS SOLID SIDE CUT NONSTERILE",SUP-DRLL-SSC-25040,CDM,S27200284,LOCAL,0272,RC,,,both,,,753.30,225.99,"CIGNA [10200]",Cigna,,512.24,68,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25022W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"AETNA [10100]","Aetna HMO/PPO",,2683.13,79.5,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROEZ MICROINTRODUCER KIT",SUP-0228960,CDM,C1894,HCPCS,0272,RC,,,both,,,455.54,136.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,187.23,41.1,,,,,0,52.98,387.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 NARROW KNEE LEFT CEMENTED POSTERIOR",SUP-150410126,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"UHC [10700]","United Healthcare",,14174.99,63.3,,8601.07,8395.67,8601.07,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"COIL EMBOLIZATION 2CM 2MM AZUR HYDROCOIL DETACHABLE 18D .018",SUP-45-480202,CDM,S27800098,LOCAL,0278,RC,,,both,,,5361.30,1608.39,"NOVANET [10819]",Novanet,,4020.98,75,,,,,0,623.52,4557.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM STAINLESS STEEL ORTHOPEDIC SELF TAPPING",SUP-S35-16S-11,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,129.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",127.17,929.48,"percent of total billed charges",
"HEAD HUMERAL REUNION STANDARD RADIUS H16 MM OD44 MM SHOULDER",SUP-5552-E-4416,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"FIRST HEALTH [10303]","First Health",,7271.04,80,,,,,0,1057.03,7725.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER TUBE LARGE BLUE NEOBAR NEOBOND HYDROCOLLOID REDUCE",SUP-602-N713-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.08,37.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,56.95,45.9,,,,,0,14.43,105.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VENLAFAXINE 75 MG TABLET, IMMEDIATE RELEASE",RX-12206,CDM,,,0637,RC,68084-0856-11,NDC,both,1,UN,10.99,3.3,"KAISER [10500]",Kaiser,,7.36,67,,,,,0,1.28,9.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM INTERLOCK IDC 18 COIL SOFT 2D",SUP-M0033612020,CDM,S27800098,LOCAL,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 13MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G613,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1089.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE STARDRIVE STAINLESS STEEL 2 PART CONNECT STERILE",SUP-02.120.606S,CDM,C1713,HCPCS,0278,RC,,,both,,,1550.02,465.01,"FIRST HEALTH [10303]","First Health",,1240.02,80,,,,,0,180.27,1317.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 40MM 150CM 6MM VASCULAR NICKEL",SUP-EVD35-06-040-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"KAISER [10500]",Kaiser,,4210.95,67,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EXOFIN FUSION 60CM SKIN CLSR 2-OCTYL CYANOACRYLATE",SUP-EF70466,CDM,S27200284,LOCAL,0272,RC,,,both,,,769.50,230.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14.3CM 7MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR180714,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1381.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBTR LAPAROSCOPIC 8MM DA VINCI S/SI ENDOWRIST LONG STERILE",SUP-420024,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"FIRST HEALTH [10303]","First Health",,182.7,80,,,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 26MM ACU-LOC ACUMED TITANIUM THREADED DISTAL",SUP-CO-N2326,CDM,C1713,HCPCS,0278,RC,,,both,,,720.90,216.27,"CIGNA [10200]",Cigna,,490.21,68,,1831.33,1831.33,1831.33,16,83.84,612.77,"percent of total billed charges",
"LIGHTED SIGMOIDOSCOPE KIT 10 KITS/CS 1 LIGHTED SCOPE RECTO M",SUP-ADKI610,CDM,S27200284,LOCAL,0272,RC,,,both,,,731.43,219.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,300.62,41.1,,,,,0,85.07,621.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC SMALL 7.5IN 5.5-6.5IN WRIST LEFT LOOP LOCK",SUP-79-87293,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.33,14.8,"NOVANET [10819]",Novanet,,37,75,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 50MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0273,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross HMO",,371.5,39.2,,957.42,156.86,7483.26,51,110.22,805.55,"percent of total billed charges",
"CATH CORDIS SUPER TORQUE PLUS 100CM 6FR 3DRC CURVE",SUP-533676,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.83,41.1,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 39MM 135CM 8MM 16SQ MM 7FR .035IN",SUP-BXAL083902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"NOVANET [10819]",Novanet,,14628.6,75,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 20X10IN RESORBABLE GRID 2",SUP-F10258-1020G,CDM,C1781,HCPCS,0278,RC,,,both,,,25704.00,7711.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7356.48,28.62,,,,,0,2989.38,21848.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 79MM ASCENT MAXIM KNEE INTERLOK COCR 1 PIECE",SUP-141235,CDM,C1776,HCPCS,0278,RC,,,both,,,11379.48,3413.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7738.05,68,,,,,0,1323.43,9672.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULTIPACK WITH GUIDES 12-30MM",SUP-NCAGXLU,CDM,S27800098,LOCAL,0278,RC,,,both,,,686.02,205.81,"FIRST HEALTH [10303]","First Health",,548.82,80,,,,,0,79.78,583.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9MM 80MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704980,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TACTICATH 115CM 3.5MM 8FR 2-2-2MM SPACE DAMATO TYPE FIX",SUP-A-TCSE-DF,CDM,C2630,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 12FR Y ADPTR IRRIGATION DECOMPRESSION CORLOCK",SUP-50-6112,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.55,40.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,55.3,41.1,,,,,0,15.65,114.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 C-1 18IN 2 ARM MONOFILAMENT BLUE",SUP-8718H,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.57,52.07,"KAISER [10500]",Kaiser,,116.29,67,,,,,0,20.19,147.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 14MM 3.5MM EMBOLIZATION NEUROVASCULAR",SUP-PED-350-14,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,22023.09,28.62,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 150MM 5.4FR 6MM BALLOON DILATATION 2",SUP-BD-L60150CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.5,41.1,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 46MM TI",SUP-SPL-60460-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross HMO",,635.04,39.2,,957.42,156.86,7483.26,51,188.41,1377,"percent of total billed charges",
"VALVE AORTIC 20-23MM 0-40MM COREVALVE 26MM HEART PORCINE",SUP-MCS-P3-26-AOA-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]",Cigna,,68400,40,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 4CM 7MM BALLOON DILATATION",SUP-DR13574,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 6CM 4MM BALLOON DILATATION",SUP-U815046,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 300MM 5.5MM EXPEDIUM Z TITANIUM NONSTERILE",SUP-179798300,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1635.19,45.9,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 23MM 6MM ACL PCL CANNULATED",SUP-AR-1360C,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"PHCS [10601]",PHCS,,1295.44,70,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32MM X25 LOCK LOW PROFILE STERILE",SUP-04.045.332S,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"CIGNA [10200]",Cigna,,1271.53,68,,1831.33,1831.33,1831.33,16,217.47,1589.42,"percent of total billed charges",
"SET IMPL SUTUREBRIDGE ANCHOR DRILL GUIDE PUNCH TAP ACHILLES",SUP-AR-8928BC-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,12606.30,3781.89,"CIGNA [10200]",Cigna,,5042.52,40,,1831.33,1831.33,1831.33,16,1466.11,10715.36,"percent of total billed charges",
"SUT PLAIN MICROPOINT 6-0 TG140-8 18IN 2 ARM MONOFILAMENT",SUP-1735G,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.81,67.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,152.19,68,,,,,0,26.03,190.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +20 DIOPTER +3 CYL BICONVEX 13MM 6MM POSTERIOR",SUP-SN6AD1U200,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,341.96,45.9,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING AIRVO 2 OPTIFLOW JUNIOR",SUP-900PT531,CDM,S27200284,LOCAL,0272,RC,,,both,,,479.58,143.87,"MULTIPLAN [10600]",Multiplan,,407.64,85,,,,,0,55.78,407.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESPIRATORY NEOPLASMS WITHOUT CC/MCC",182,MS-DRG,,,,,,,inpatient,,,61119.45,18335.83,"CIGNA [10200]","Cigna Local Plus",,7778.46,,"Fee schedule rate ($7,778.46). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,4675.87,18799.02,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 110CM 4FR 145D PIGTAIL CURVE",SUP-538453S,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"KAISER [10500]",Kaiser,,59.98,67,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 22MM 140CM 2.25MM CORONARY STERILE",SUP-453949,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Venous Rv 36f",PX-E27200392,CDM,E27200392,LOCAL,0272,RC,,,both,,,172.70,51.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,70.98,41.1,,,,,0,20.09,146.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM MITROFLOW BOVINE PERICARDIUM",SUP-LXA25,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"MULTIPLAN [10600]",Multiplan,,24097.5,85,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Glucose Postdose",PX-301000206,CDM,82950,CPT,0301,RC,,,both,,,125.00,37.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4.28,,,,,,,0.13,106.25,"fee schedule",
"ROD SPINAL 110MM 4.75MM SOLERA COCR MOLYBDENUM CURVED",SUP-1475501110,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"FIRST HEALTH [10303]","First Health",,3528,80,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACTOR, STRIPPED SCREW, 2 MM, 6"" LONG, SINGLE USE",SUP-SXT009-ST3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1359.79,45.9,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PTCA CATHETER 2.5 X 15MM (625-154-1U) SCOREFLEX NC SCORING",SUP-SD36003-11,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 15MM 3MM BALLOON DILATATION PEBAX",SUP-1400300-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACTOR, STRIPPED SCREW, 2 MM, 6"" LONG, SINGLE USE",SUP-SXT009-ST3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,344.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 80MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,655.83,41.1,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION .054IN 9IN KIRSCHNER STAINLESS STEEL 1 END",SUP-KM173-39-54,CDM,C1713,HCPCS,0278,RC,,,both,,,59.29,17.79,"NOVANET [10819]",Novanet,,44.47,75,,,,,0,6.9,50.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GABAPENTIN 100 MG CAPSULE, IMMEDIATE RELEASE",RX-18309,CDM,,,0637,RC,00904-6665-61,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 30MM 80CM 10MM VASCULAR PERIPHERAL SELF",SUP-1012532-30,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]",Cigna,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 2CM 20FR MIC-KEY SECUR-LOK ENFIT SILICONE RADIOPAQUE",SUP-8140-20-2.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CIGNA [10200]",Cigna,,529.76,68,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 18X7MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2507,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3970.26,41.1,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 CT-1 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J345H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,2.91,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG TRANSPARENT 7X7IN SILICONE ADHSV ISLAND FLEXIBLE BORDER",SUP-MSCOV77EP,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.63,18.79,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,28.75,45.9,,,,,0,7.28,53.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 3-0 V-20 .5 CIRCLE 9IN 26MM CLSR SURGALLOY",SUP-VLOCM2044,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,80.49,41.1,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 36MM 2 MARKER SEMIRIGID WIRE STIFFENER",SUP-800SR36,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"NOVANET [10819]",Novanet,,9832.5,75,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 160MM 28-14MM 13FR TRIVASCULAR OVATION PRIME",SUP-TV-IL1428160-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9015.3,27,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 34MM 2 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.234,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 15MM 19MM 27.5MM 20.8MM EPIC MAX 11MM TISSUE",SUP-EMAX-19,CDM,S27800098,LOCAL,0278,RC,,,both,,,27990.90,8397.27,"PHCS [10601]",PHCS,,19593.63,70,,,,,0,3255.34,23792.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 3MM POD",SUP-RBYPOD3,CDM,S27800098,LOCAL,0278,RC,,,both,,,11661.00,3498.3,"CIGNA [10200]","Cigna Open Access",,3906.44,33.5,,,,,0,1356.17,9911.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER BURR HOLE 7MM MEDPOR LOW PROFILE TITANIUM TAB STERILE",SUP-53-34507,CDM,C1713,HCPCS,0278,RC,,,both,,,1858.35,557.5,"NOVANET [10819]",Novanet,,1393.76,75,,,,,0,216.13,1579.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE",RX-11019,CDM,,,0637,RC,00071-3740-66,NDC,both,1,UN,8.76,2.63,"CIGNA [10200]","Cigna Local Plus",,4.69,53.5,,,,,0,1.02,7.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT SWIVELOCK ANCHOR FIBERLINK SUTURETAPE PUNCH LOOP",SUP-AR-1665BCSL,CDM,C1713,HCPCS,0272,RC,,,both,,,5796.00,1738.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2382.16,41.1,,,,,0,2382.16,3668.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 2.4MM 30MM TITANIUM CORTICAL HAND SELF TAPPING NO",SUP-401.530.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"MULTIPLAN [10600]",Multiplan,,507.01,85,,,,,0,69.37,507.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLASSIC SHEATH KIT CONTAMINATION SLEEVE 80CM PUNCHED SANTOPR",SUP-CON-006-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.80,36.54,"UHC [10700]","United Healthcare",,77.1,63.3,,,,,0,14.17,103.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DEMINERALIZED BONE MATRIX 1ML PUTTY STERILE",SUP-038010,CDM,C1713,HCPCS,0278,RC,,,both,,,1160.90,348.27,"CIGNA [10200]","Cigna Local Plus",,621.08,53.5,,3978.14,359.25,3978.14,24,135.01,986.77,"percent of total billed charges",
"FILLER BONE VOID 50X25MM KINEX THK8MM BIOACTIVE STRIP 10CC",SUP-8115.0010S,CDM,C1713,HCPCS,0278,RC,,,both,,,10251.40,3075.42,"UHC [10700]","United Healthcare",,6489.14,63.3,,5023.51,2672.93,6679.78,18,1192.24,8713.69,"percent of total billed charges",
"CAP STEM HUMERAL REVISION INSRT COMPREHENSIVE XLPE SHORT",SUP-98000900082,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"BLUE CROSS [10001]","Blue Cross PPO",,17781.12,39.2,,3949.44,3949.44,3949.44,"1 through 10",5275.37,38556,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL LOOP 30D .35IN 24FR STERILE",SUP-A22205C,CDM,S27200284,LOCAL,0272,RC,,,both,,,710.34,213.1,"UHC [10700]","United Healthcare",,449.65,63.3,,,,,0,82.61,603.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PINNACLE D THR HIP MODULAR",SUP-OSC378786,CDM,C1776,HCPCS,0278,RC,,,both,,,30240.00,9072,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3583.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ENTEER VASCULAR 28D STD 300CM 1.5MM .014IN HYDROPHILIC",SUP-ENW-SD-014-300,CDM,C1769,HCPCS,0272,RC,,,both,,,1620.00,486,"PHCS [10601]",PHCS,,1134,70,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trichinella Antibody",PX-302000265,CDM,86784,CPT,0302,RC,,,both,,,97.00,29.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,44.6,,,,,,,0.1,82.45,"fee schedule",
"CATH CANTATA 150CM 2.5FR .021IN MICRO INTERVENTIONAL",SUP-G54532,CDM,S27200284,LOCAL,0272,RC,,,both,,,2774.93,832.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,328.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,322.72,2358.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER DS REDEL 115CM 8MM 7FR 1-7-4MM SPACE D-D CURVE",SUP-BD7TCDD8L,CDM,C1733,HCPCS,0272,RC,,,both,,,8700.90,2610.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1031.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1011.91,7395.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Dil Guide Wire",PX-750000037,CDM,43248,CPT,0750,RC,,,both,,,4748.59,1424.58,"NOVANET [10819]",Novanet,,3561.44,75,,,,,0,552.26,4748.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SIZE ADJUSTMENT TOOL AND IMPLANT LOCKER",SUP-25100ST,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intra Cor Ffr W 3d Func Map",PX-480000080,CDM,0523T,CPT,0480,RC,,,both,,,3348.00,1004.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2041,,"Per diem ($2,041).",,,,0,389.37,3348,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Pelvis W&WO Cntrst",PX-352000020,CDM,72194,CPT,0352,RC,,,both,,,3749.84,1124.95,"FIRST HEALTH [10303]","First Health",,2999.87,80,,,,,0,377.28,3187.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY BLACK 54MM 22GA CURVE SHARP ACTIVE TIP",SUP-PMF22-54-10CS,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.83,52.15,"CIGNA [10200]","Cigna Local Plus",,93,53.5,,,,,0,20.22,147.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 40MM 10MM BALLOON DILATATION PEBAX",SUP-H74939032104010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CITATION TMZF HA 5 SHORT HIP LEFT",SUP-6265-5205,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"KAISER [10500]",Kaiser,,16362.71,67,,,,,0,2840.27,20758.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD .99CM 5.37X7.36CM",SUP-D232,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4621.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL STD+ KNEE RIGHT LCS COMPLETE POROCOAT",SUP-129403050,CDM,C1776,HCPCS,0278,RC,,,both,,,28683.90,8605.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3399.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3335.94,24381.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.2MM 9MM APTUS TITANIUM HAND CORTICAL HEXADRIVE 4",SUP-A-5100.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"AETNA [10100]","Aetna HMO/PPO",,1004.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT FIRST PASS STERILE",SUP-224036,CDM,S27200284,LOCAL,0272,RC,,,both,,,1523.61,457.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,626.2,41.1,,,,,0,177.2,1295.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 4MM X 10CM",SUP-M0035474100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"FIRST HEALTH [10303]","First Health",,11291.71,80,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 60MM 120CM 16MM .035IN 3MM VASCULAR ILIOFEMORAL",SUP-VENUL16060,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Open Access",,7386.75,33.5,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORK TUNING 9.5IN HARDY 3 PRONG 3.5IN",SUP-58-3519,CDM,S27000186,LOCAL,0270,RC,,,both,,,1098.36,329.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,451.43,41.1,,,,,0,127.74,933.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5N KNEE LEFT POSTERIOR STABILIZE LEGION",SUP-71421265,CDM,C1776,HCPCS,0278,RC,,,both,,,32536.35,9760.9,"MULTIPLAN [10600]",Multiplan,,27655.9,85,,,,,0,3783.98,27655.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 80MM 15MM FLEXIPATH FLEXIBLE SLEEVE",SUP-FP015,CDM,S27200284,LOCAL,0272,RC,,,both,,,677.30,203.19,"UHC [10700]","United Healthcare",,428.73,63.3,,,,,0,78.77,575.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMOXICILLIN 250 MG CAPSULE, IMMEDIATE RELEASE",RX-450,CDM,,,0637,RC,60687-0776-11,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL BALLENTINE CURVE 8.25IN 1 TEETH LONGITUDINAL",SUP-52-5511,CDM,S27200284,LOCAL,0272,RC,,,both,,,363.14,108.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.23,308.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIBRILLATOR 52CM 8FR OPTISURE ENDOCARDIUM 2 COIL DF4",SUP-LDA220Q-52,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4914.63,28.62,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 750CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP150RH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"CIGNA [10200]","Cigna Open Access",,3987.34,33.5,,5166.00,5166.00,5166.00,"1 through 10",1384.26,10117.13,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 30CM 150CM 6FR .035IN 3CM BLADDER LOOP",SUP-M006155235190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS [10001]","Blue Cross HMO",,556.77,39.2,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3.5MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN03506,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AETNA [10100]","Aetna HMO/PPO",,9319.86,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM ARTHREX TITANIUM T15 LARGE FULL THREAD",SUP-AR-8750-50H,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"FIRST HEALTH [10303]","First Health",,2850,80,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +14 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.140,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL TITAN TUBE",SUP-517770,CDM,C1813,HCPCS,0278,RC,,,both,,,31506.30,9451.89,"KAISER [10500]",Kaiser,,21109.22,67,,,,,0,3664.18,26780.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX 0 CTX 45CM 48MM CLSR PDS PLUS VIOLET",SUP-SXPP1A402,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"NOVANET [10819]",Novanet,,180.23,75,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4PK QUATTRO PREMIUM AND HQ START UP KIT 6FT USA 1 BOX OF 4 CAT",SUP-8700-001043-01,CDM,C1751,HCPCS,0272,RC,,,both,,,34612.70,10383.81,"PHCS [10601]",PHCS,,24228.89,70,,,,,0,4025.46,29420.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ALIMAXX-B 60MM 192CM 8MM BILIARY NITINOL RADIOPAQUE",SUP-70129-205,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"CIGNA [10200]","Cigna Open Access",,4318.71,56.9,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE? NC PLUS BALLOON NON-COMPLIANT 2.0 MM X 18 MM",SUP-220-183-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ON-Q PAINBUSTER 5IN 17GA DELIVERY TNLR SHEATH",SUP-T17X5,CDM,S27200305,LOCAL,0272,RC,,,both,,,250.93,75.28,"CIGNA [10200]","Cigna Local Plus",,134.25,53.5,,,,,0,29.18,213.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 15.2-15.1CM NATRELLE P5.3-5.5CM MODERATE PROFILE",SUP-SZ68650,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"PHCS [10601]",PHCS,,213.15,70,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 0 CT-1 36IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z346H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 32MM AEQUALIS SHOULDER LOCKING",SUP-DWD032,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"FIRST HEALTH [10303]","First Health",,1244.8,80,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET OPHTHALMIC 2.5IN 20GA .8MM SEIFF 3/8IN .08IN LACRIMAL",SUP-585192,CDM,S27200284,LOCAL,0272,RC,,,both,,,383.15,114.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,175.87,45.9,,,,,0,44.56,325.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SIMPLASTIC 16IN 22FR LARGE URETHRAL PVC 30ML 3 WAY",SUP-570622,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.43,49.33,"UHC [10700]","United Healthcare",,104.08,63.3,,,,,0,19.12,139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG BONE CEMENT 16MM MEDIUM INTRAMEDULLARY CANAL STERILE",SUP-130611,CDM,C1713,HCPCS,0278,RC,,,both,,,1029.51,308.85,"KAISER [10500]",Kaiser,,689.77,67,,,,,0,119.73,875.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL RESTORIS 3 KNEE RIGHT MEDIAL LEFT LATERAL",SUP-180613,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"MULTIPLAN [10600]",Multiplan,,5633.33,85,,,,,0,770.77,5633.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 4.5MM FIX THREAD SURGICAL CORTICAL SYMPHONY NONSTERILE",SUP-202033545,CDM,S27200284,LOCAL,0272,RC,,,both,,,1856.25,556.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,219.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 2.66MM LARGE REGULAR PIGTAIL CURVE URETERAL",SUP-M001274040,CDM,C2617,HCPCS,0278,RC,,,both,,,1053.00,315.9,"PHCS [10601]",PHCS,,737.1,70,,,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 38MM 2.75MM CORONARY RAPID EXCHANGE",SUP-ONYXNG27538UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"FIRST HEALTH [10303]","First Health",,2100,80,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 22MM 140CM 2.5MM",SUP-RSINT25022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"BLUE CROSS [10001]","Blue Cross PPO",,2173.25,39.2,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE SHEET 9X9CM DEHYDRATED AMNION CHORION MEM",SUP-APS-5990,CDM,Q4433,HCPCS,0636,RC,,,both,,,36426.60,10927.98,"KAISER [10500]",Kaiser,,24405.82,67,,,,,0,247.92,30962.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 160MM 28-14MM 13FR TRIVASCULAR OVATION PRIME",SUP-TV-IL1428160-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CIGNA [10200]","Cigna Local Plus",,10517.85,31.5,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY TRANSPLANT",652,MS-DRG,,,,,,,inpatient,,,91630.23,27489.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25081.9,,"Fee schedule rate ($25,081.90). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,38588.35,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL STD",SUP-500DM27,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2747.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 13MM 2MM SHANNON RECTA STERILE LATEX FREE",SUP-TM12013,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,257.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Coll/Store Autologous Blood",PX-302000191,CDM,86890,CPT,0302,RC,,,both,,,2077.40,623.22,"MULTIPLAN [10600]",Multiplan,,1765.79,85,,,,,0,0.01,1765.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.50MM X 10MM  SCOREFLEX  NC",SUP-625-104-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION",RX-26226,CDM,J2470,HCPCS,0636,RC,72603-0128-01,NDC,both,1,UN,52.92,15.88,"MULTIPLAN [10600]",Multiplan,,44.98,85,,,,,0,2.2,44.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 154CM 4.1-3.4FR .032IN THROMBECTOMY REPERFUSION",SUP-PSC032,CDM,C1887,HCPCS,0272,RC,,,both,,,8901.00,2670.3,"NOVANET [10819]",Novanet,,6675.75,75,,,,,0,1035.19,7565.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 70MM CD HORIZON SPINE MULTIAXIAL CANNULATED",SUP-25840018570,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER +4 CYL MODIFIED C BICONVEX 13MM 6MM","SUP-ZCT400 20.5",CDM,V2787,HCPCS,0276,RC,,,both,,,495.00,148.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,57.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.57,420.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FUROSEMIDE 40 MG TABLET",RX-3295,CDM,,,0637,RC,00904-7178-61,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXIVA PULSE ID 242 (BOX 5)",SUP-M006L8406911,CDM,S27200284,LOCAL,0272,RC,,,both,,,2823.17,846.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,328.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,328.33,2399.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 100CM 5FR 1 CURVE ANGIOGRAPHIC SLX NYLON CEREBRAL",SUP-451535H0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"NOVANET [10819]",Novanet,,78.3,75,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 1026X55MM 10",SUP-6210155,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross HMO",,9384.48,39.2,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X10MM COROENT XL+ NONSTERILE LATEX FREE",SUP-6010850,CDM,C1889,HCPCS,0278,RC,,,both,,,23940.00,7182,"FIRST HEALTH [10303]","First Health",,19152,80,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30X4.8MM TITANIUM LARGE THICK TISSUE LINEAR",SUP-4901T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1346.54,403.96,"FIRST HEALTH [10303]","First Health",,1077.23,80,,,,,0,156.6,1144.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL MODULAR REMEDY SMALL HIP",SUP-RHSTSM,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Open Access",,5778.75,33.5,,5302.19,4377.88,6578.61,27,2006.18,14662.5,"percent of total billed charges",
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFTTOUCH",SUP-SSM-485,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"KAISER [10500]",Kaiser,,5062.19,67,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +7.5MM 36MM HIP C TAPER BIOLOX DELTA",SUP-183675,CDM,C1776,HCPCS,0278,RC,,,both,,,7340.76,2202.23,"CIGNA [10200]","Cigna Open Access",,4176.89,56.9,,5302.19,4377.88,6578.61,27,853.73,6239.65,"percent of total billed charges",
"GRAFT BONE VIA DEMINERALIZE MINERALIZE CORTICAL CANCELLOUS",SUP-VCAX-050000,CDM,S27800098,LOCAL,0278,RC,,,both,,,12075.00,3622.5,"UHC [10700]","United Healthcare",,7643.48,63.3,,,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOABLATION 10CM STAINLESS STEEL MALLEABLE",SUP-CRYOF,CDM,C9808,HCPCS,0272,RC,,,both,,,15870.00,4761,"MULTIPLAN [10600]",Multiplan,,13489.5,85,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 42MM TI",SUP-SPL-60420-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]",Cigna,,1101.6,68,,1831.33,1831.33,1831.33,16,188.41,1377,"percent of total billed charges",
"STENT POLYFLEX 40MM 12MM 20MM TRACHEOBRONCHIAL SILICONE SELF",SUP-7026,CDM,C1887,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"MULTIPLAN [10600]",Multiplan,,2836.88,85,,,,,0,388.15,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SMALL 2.6MM INTERNAL LIGACLIP EXTRA TITANIUM",SUP-LT100,CDM,S27200284,LOCAL,0272,RC,,,both,,,46.04,13.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.35,39.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 270MM 3.8MM 3 FLUTE CALIBRATE QUICK COUPLING",SUP-03.019.016S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1629.60,488.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,193.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.52,1385.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 20MM ORTHOLOC TITANIUM NITRIDE FOREFOOT",SUP-5201024020,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CIGNA [10200]","Cigna Open Access",,981.53,56.9,,1144.80,304.56,2275.09,66,200.62,1466.25,"percent of total billed charges",
"KIT ARTICULATION NEXEL 4",SUP-00840009400,CDM,S27800098,LOCAL,0278,RC,,,both,,,9239.10,2771.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2644.23,28.62,,,,,0,1074.51,7853.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 1.27MM 1MM TYTAN EAR TAB TITANIUM",SUP-14642,CDM,S27800098,LOCAL,0278,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KT PLSMD PURF ENDFR 10000 TIP",SUP-U226,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6234.41,27,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 34MM STAINLESS STEEL T8 METAPHYSEAL SELF TAP",SUP-02.118.534,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"MULTIPLAN [10600]",Multiplan,,445.32,85,,,,,0,60.93,445.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X11X8MM PTC TANTALUM PEEK ANATOMIC CERVICAL",SUP-5030841,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS [10001]","Blue Cross HMO",,2617.94,39.2,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 330-400ML STYLE 3000 SMOOTH SALINE P4.8-6.2CM",SUP-3503330,CDM,C1789,HCPCS,0278,RC,,,both,,,2350.00,705,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1598,68,,,,,0,273.31,1997.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOLOIST 110CM 6FR 5MM SPACING COURNAND LONG CURVE",SUP-44516U,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,299.62,41.1,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 7.5IN WRIST RIGHT ADJUSTABLE",SUP-VP30001-230,CDM,S27000186,LOCAL,0270,RC,,,both,,,92.74,27.82,"AETNA [10100]","Aetna HMO/PPO",,73.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.79,78.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC IPERIA 7 PROMRI DF4 IMPLANTABLE",SUP-393009,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA [10200]","Cigna Local Plus",,18181.8,31.5,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 92CM 1MM 5FR 10MM SPACE D CURVE",SUP-D508DP10RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3090.00,927,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,366.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,359.37,2626.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC .99IN MINI 5.37X8.18CM DYNAGEN X4 IS-1 DF-4",SUP-G158,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23722.92,41.1,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 95MM TYPE 1 PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51108050,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"PHCS [10601]",PHCS,,19204.67,70,,,,,0,3190.72,23319.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC 2XL STRAIGHT 43-47IN SHOULDER ELASTIC WRIST",SUP-VP10897-060,CDM,L3670,HCPCS,0274,RC,,,both,,,81.87,24.56,"KAISER [10500]",Kaiser,,54.85,67,,,,,0,9.52,81.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Epstein Barr Virus Dna CSF",PX-306000159,CDM,87799,CPT,0306,RC,,,both,,,979.00,293.7,"KAISER [10500]",Kaiser,,655.93,67,,,,,0,0.98,832.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT GLENOID REUNION X3 OD52 MM SHOULDER KEELED STERILE",SUP-5542-P-0052,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"FIRST HEALTH [10303]","First Health",,7222.18,80,,,,,0,1049.92,7673.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM .02IN 4MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0420,CDM,S27800098,LOCAL,0278,RC,,,both,,,6258.00,1877.4,"AETNA [10100]","Aetna HMO/PPO",,4975.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,727.81,5319.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 7FR 10MM SPACE REGULAR STD D CURVE",SUP-D7DR010RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"AETNA [10100]","Aetna HMO/PPO",,1842.41,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 5MM BALLOON DILATATION HYDROPHILIC",SUP-585004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT FIBERTAK SELF PUNCH 3 LOAD STERILE LATEX FREE",SUP-AR-3633SP,CDM,C1713,HCPCS,0278,RC,,,both,,,3228.75,968.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,375.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",375.5,2744.44,"percent of total billed charges",
"CATH TEMPO 65CM 5FR PIGTAIL CURVE ANGIOGRAPHIC SLX NYLON 5",SUP-451503V5,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.91,41.1,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC",970,MS-DRG,,,,,,,inpatient,,,65720.68,18440.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,42049.99,,,,,,,7561,65720.68,"case rate",
"SHELL ACETABULAR 54MM SOLID BACK PRIMARY TRITANIUM E",SUP-500-03-54E,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"CIGNA [10200]",Cigna,,7117.44,68,,5873.17,5873.17,5873.17,"1 through 10",1217.29,8896.8,"percent of total billed charges",
"TIP APPLR 40CM STAINLESS STEEL DUPLOSPRAY",SUP-601130,CDM,S27200284,LOCAL,0272,RC,,,both,,,970.96,291.29,"MULTIPLAN [10600]",Multiplan,,825.32,85,,,,,0,112.92,825.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 40MM 7MM 8FR FLUENCY PLUS CARBON EPTFE 2",SUP-FEM07040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"MULTIPLAN [10600]",Multiplan,,15529.5,85,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachytx Isodose Plan Simple",PX-333000064,CDM,77316,CPT,0333,RC,,,both,,,2249.39,674.82,"UHC [10700]","United Healthcare",,2249.39,,"Per diem ($4,991).",,,,0,261.6,2249.39,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 98CM 18GA STYLET PROC TRANSSEPTAL BRK ADULT",SUP-407206,CDM,S27200284,LOCAL,0272,RC,,,both,,,1539.00,461.7,"MULTIPLAN [10600]",Multiplan,,1308.15,85,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 4-0 PC-5 18IN MONOFILAMENT BLACK",SUP-1894G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PHCS [10601]",PHCS,,17.5,70,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STBL SURGICAL OCTOPUS 3 EVOLUTION TISSUE",SUP-TS2500,CDM,S27200284,LOCAL,0272,RC,,,both,,,9902.88,2970.86,"CIGNA [10200]","Cigna Open Access",,5634.74,56.9,,,,,0,1151.7,8417.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135MM 20MM 7FR 14MM .035IN LOW PROFILE",SUP-B2140-020,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,316.26,41.1,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS LIGAPAK 2-0 54IN BRAID REEL ANTIBACTERIAL",SUP-VCP286G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"NOVANET [10819]",Novanet,,18.75,75,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 0.9% SODIUM CHLORIDE 250ML ADD-VANTAGE LATEX",SUP-07101-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.29,41.1,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX PROGRIP 6X6IN FLAP SELF FIXATE",SUP-TEM1515G,CDM,C1781,HCPCS,0278,RC,,,both,,,1453.00,435.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,168.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.98,1235.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPARIN (PORCINE) 25,000 UNIT/500 ML IN 0.45 % SODIUM CHLORIDE IV SOLN",RX-15848,CDM,J1644,HCPCS,0636,RC,63323-0518-01,NDC,both,500,ML,100.65,30.19,"BLUE CROSS [10001]","Blue Cross PPO",,6.12,,,,,,,5.29,85.55,"fee schedule",
"BURR SURGICAL 13CM 4MM STERLING 10000 RPM OVAL LARGE HUB",SUP-H9101,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 37MM FULL FLEXIBLE MARKER SIMULUS",SUP-700FF37,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3539.7,27,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +26 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.260,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM 3MM 2.1-2.7FR CORONARY STENT",SUP-RONYX30008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,431.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VAN ANDEL 80CM 3CM 6.3FR BALLOON DILATATION ACCEPTS",SUP-G01383,CDM,C1758,HCPCS,0272,RC,,,both,,,502.20,150.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,58.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BIOLOGICAL TISSUE 40X30MM TAPESTRY BIOINTEGRATIVE",SUP-TP-4030-01,CDM,C1781,HCPCS,0278,RC,,,both,,,17633.70,5290.11,"CIGNA [10200]",Cigna,,7053.48,40,,,,,0,2050.8,14988.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE LOCKING SELF TAPPING T25 STARDRIVE RECESS 5MM 85MM",SUP-212.226,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"NOVANET [10819]",Novanet,,654.89,75,,,,,0,101.55,742.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE POWERTURN VASCULAR STRAIGHT 300CM 3CM .014IN",SUP-1044595,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP UNISTEP PLUS 80MM 194CM 10MM 7.5FR",SUP-H965430600,CDM,C1876,HCPCS,0278,RC,,,both,,,9068.53,2720.56,"MULTIPLAN [10600]",Multiplan,,7708.25,85,,,,,0,1054.67,7708.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 490CC",SUP-RSZ-MPX-490S,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"NOVANET [10819]",Novanet,,118.64,75,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 175MM 12MM SMALL SHELL REVISION ALTIVATE",SUP-533-12-175,CDM,C1776,HCPCS,0278,RC,,,both,,,43228.40,12968.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5027.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5027.46,36744.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 12MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640712,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]",Cigna,,7652.65,68,,5873.17,5873.17,5873.17,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"KIT IMPL 10X13MM SPEED NITINOL 1.5X1.5MM",SUP-SE-1310,CDM,C1713,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AETNA [10100]","Aetna HMO/PPO",,6006.62,79.5,,1521.93,481.35,16760.95,30,878.7,6422.18,"percent of total billed charges",
"RING ANNULOPLASTY 28MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR28,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"PHCS [10601]",PHCS,,9177,70,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 360 145CM 30MM .079IN 2MM .014IN",SUP-DBP-CART-200SOL145,CDM,C1724,HCPCS,0272,RC,,,both,,,17250.00,5175,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7089.75,41.1,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT BTCP CLLGN 1.2ML VITOSS FOAM PACK BIOACTIVE",SUP-2102-1601,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"FLUCICLOVINE F-18 INTRAVENOUS SOLUTION (9-10 MCI)|DISCARDED DRUG NOT ADMINISTE",RX-180065,CDM,A9588,HCPCS,0343,RC,08888-8878-27,NDC,both,1,UN,638.44,191.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,JW,434.14,68,,,,,0,74.25,638.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM STAINLESS STEEL SMALL FRAGMENT SET 4 HOLE 1/3",SUP-241.341,CDM,C1713,HCPCS,0278,RC,,,both,,,1149.80,344.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,781.86,68,,,,,0,133.72,977.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HYDRA JAGWIRE DREAM TIP ENDOSCOPIC ROUND ANGLE 450CM",SUP-M00556051,CDM,C1769,HCPCS,0272,RC,,,both,,,1422.36,426.71,"PHCS [10601]",PHCS,,995.65,70,,,,,0,165.42,1209.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 12MM KII FIOS FIRST ENTRY ADVANCED",SUP-CFF71,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"KAISER [10500]",Kaiser,,122.41,67,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 29MM RESTORATION +20MM HIP PROXIMAL MODULAR",SUP-6276-1-229,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6008.78,27,,,,,0,2588.23,18916.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE ENFORM 16X20CM INTRAPERITONEAL",SUP-GBFR1620,CDM,C1781,HCPCS,0278,RC,,,both,,,36477.00,10943.1,"CIGNA [10200]",Cigna,,14590.8,40,,,,,0,4242.28,31005.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Washing Sperm",PX-301000680,CDM,58323,CPT,0301,RC,,,both,,,591.00,177.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,401.88,68,,,,,0,70.03,591,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 60MM 135CM 8MM VASCULAR NITINOL",SUP-1012536-60,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JOURNEY VASCULAR 300CM 2CM .014IN NITINOL HYDROPHILIC",SUP-M001391280,CDM,C1769,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ARROW ARROW ADVANCER VASCULAR J CURVE STRAIGHT 26.75IN",SUP-AW-14725,CDM,C1769,HCPCS,0272,RC,,,both,,,105.79,31.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.3,89.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENCIL SMOKE EVAC TELESCOPIC NOSE PREATTACHED TUBING SWIVEL",SUP-211010,CDM,S27200284,LOCAL,0272,RC,,,both,,,245.36,73.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,166.84,68,,,,,0,28.54,208.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 20MM STAINLESS STEEL T8 CORTEX TUBE STARDRIVE",SUP-201.770TS,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"KAISER [10500]",Kaiser,,319.11,67,,,,,0,55.39,404.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.75 X 28 RX US",SUP-1804275-28,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 18MM 2.75MM CORONARY RAPID EXCHANGE",SUP-ONYXNG27518UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA [10200]","Cigna Open Access",,1536.3,56.9,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL TISSUE CLSR DURASEAL EXACT SPINE 5ML",SUP-206520,CDM,S27200284,LOCAL,0272,RC,,,both,,,6803.15,2040.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2796.09,41.1,,,,,0,791.21,5782.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 65MM LOCK STERILE",SUP-2361-5065S,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.05,506.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,774.36,45.9,,,,,0,196.2,1433.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL 5MM LEGION 6 KNEE SCR",SUP-71421667,CDM,C1776,HCPCS,0278,RC,,,both,,,11995.65,3598.69,"CIGNA [10200]",Cigna,,4798.26,40,,5873.17,5873.17,5873.17,"1 through 10",1395.09,10196.3,"percent of total billed charges",
"SPACER SPINAL 14X11X11MM ALEUTIAN SMALL LORDOTIC ANTERIOR",SUP-403-21411L,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"FIRST HEALTH [10303]","First Health",,5342.74,80,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENZONATATE 100 MG CAPSULE",RX-988,CDM,,,0637,RC,68084-0214-11,NDC,both,1,UN,6.27,1.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUMARK CONIC 18GX10CM 10/BX",SUP-351260,CDM,A4648,HCPCS,0278,RC,,,both,,,961.70,288.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.85,817.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X60 40CM SL",SUP-48003006P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,116.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 7MM 260MM HUMERAL INTRAMEDULLARY UNIVERSAL CANNULATED",SUP-04.001.232S,CDM,C1713,HCPCS,0278,RC,,,both,,,9216.74,2765.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1092.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1071.91,7834.23,"percent of total billed charges",
"525CC MENTOR MEMORYGEL SILICONE BREAST IMPLANT SMOOTH ROUND",SUP-350-5251BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS 2-0 CT-1 27IN MONOFILAMENT ANTIBACTERIAL",SUP-PDP339H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PHCS [10601]",PHCS,,17.5,70,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX SAFE PERFORMAXX 20MM 80CM 8MM 6FR .035IN",SUP-ZBM08020,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2863.43,28.62,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X8MM COROENT 10D XL",SUP-6980845,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"CIGNA [10200]","Cigna Open Access",,7959.6,33.5,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X8MM COROENT 10D XL",SUP-6980845,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"KAISER [10500]",Kaiser,,15919.2,67,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 26CM 3CM 7FR .035IN 2 PIGTAIL",SUP-M006192143050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,551.07,45.9,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM FIBERTAG TIGHTROPE 9MM FIXATION ACL",SUP-AR-1288QT-90,CDM,C1713,HCPCS,0278,RC,,,both,,,7063.88,2119.16,"CIGNA [10200]",Cigna,,4803.44,68,,1831.33,1831.33,1831.33,16,821.53,6004.3,"percent of total billed charges",
"PLATE SPINAL L100MM TITANIUM ANTERIOR CERVICAL QUARTER TURN",SUP-7200100,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN EXTRA",SUP-77806200,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,,,0637,RC,00032-0047-70,NDC,both,1,UN,25.19,7.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARMADA 14 150CM 120MM 2MM BALLOON DILATATION JET",SUP-A2020-120,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION",RX-168537,CDM,,,0250,RC,00597-0024-02,NDC,both,4,GR,3133.55,940.06,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 135CM 6CM 8MM BALLOON DILATATION PERIPHERAL",SUP-G50270,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACK SURGICAL EP LAB STERILE DISPOSABLE LATEX FREE",SUP-DYNJ43533B,CDM,S27000186,LOCAL,0270,RC,,,both,,,597.64,179.29,"KAISER [10500]",Kaiser,,400.42,67,,,,,0,69.51,507.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLP SURGICAL RECHARGEABLE",SUP-5513E,CDM,S27000186,LOCAL,0270,RC,,,both,,,304.50,91.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,125.15,41.1,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DIL STAINLESS STEEL POLYETHYLENE RADIOPAQUE GWIRE SAFETY",SUP-G14185,CDM,C1769,HCPCS,0272,RC,,,both,,,1947.00,584.1,"NOVANET [10819]",Novanet,,1460.25,75,,,,,0,226.44,1654.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN AMPLATZ RIGHT 2 CURVE",SUP-DXT5AR20,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.97,41.1,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 20MM 1.5MM BALLOON DILATATION RAPID",SUP-47515020L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX PDS PLUS 2-0 SH SPIRAL 6IN TAPER POINT",SUP-SXPP1B415,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.96,69.59,"AETNA [10100]","Aetna HMO/PPO",,184.41,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.98,197.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN JUDKINS LEFT 3 CURVE GUIDING",SUP-LA6JL30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +22 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z9002220,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"PHCS [10601]",PHCS,,714.42,70,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR HOCKEY STICK CURVE",SUP-67027800,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"AETNA [10100]","Aetna HMO/PPO",,331.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 80MM 114CM 7MM 75CM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200078070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross PPO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX PROGRIP 5X3IN RIGHT HERNIA PRECUT",SUP-TEM1208GR,CDM,C1781,HCPCS,0278,RC,,,both,,,1892.63,567.79,"CIGNA [10200]",Cigna,,1286.99,68,,,,,0,220.11,1608.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 30ML .1-2MM 80% CORTICAL 20% CANCELLOUS",SUP-400063,CDM,C1713,HCPCS,0278,RC,,,both,,,2842.88,852.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,330.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",330.63,2416.45,"percent of total billed charges",
"HC Ribosomal Abs",PX-301000275,CDM,83516,CPT,0301,RC,,,both,,,146.90,44.07,"CIGNA [10200]","Cigna Open Access",,25.37,,,,,,,0.01,124.87,"fee schedule",
"VALVE MITRAL 27MM 24.2MM MECHANICAL ROTATABLE STD CUFF",SUP-27MHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 75CM 5MM 20MM",SUP-38046-52075,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1184.87,28.62,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 42MM 22MM TANDEM HIP ACETABULAR COCR",SUP-71322042,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,989.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,971.39,7099.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM CARPENTIER-EDWARDS PERIMOUNT MAGNA",SUP-3000TFX23MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"FIRST HEALTH [10303]","First Health",,25678.8,80,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 60MM 80CM 10MM 8FR STRAIGHT VASCULAR COVER",SUP-AVSM10060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"FIRST HEALTH [10303]","First Health",,14616,80,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE",RX-1306,CDM,J0618,HCPCS,0636,RC,76329-3304-01,NDC,both,10,ML,95.13,28.54,"BLUE CROSS [10001]","Blue Cross PPO",,17.48,,,,,,,11.27,80.86,"fee schedule",
"CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE",RX-1306,CDM,J0618,HCPCS,0636,RC,76329-3304-01,NDC,both,10,ML,95.13,28.54,"NOVANET [10819]",Novanet,,71.35,75,,,,,0,11.27,80.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 6-5.6MM 260MM 30MM XCALIBER OSTEOTITE HA",SUP-99-612630,CDM,C1713,HCPCS,0278,RC,,,both,,,986.18,295.85,"CIGNA [10200]","Cigna Open Access",,561.14,56.9,,1144.80,304.56,2275.09,66,114.69,838.25,"percent of total billed charges",
"NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET",RX-5604,CDM,,,0250,RC,68462-0639-25,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X8MM COALITION MIS 7D 14MM TITANIUM STERILE",SUP-1136.4678,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"UHC [10700]","United Healthcare",,10919.25,63.3,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X120 135CM SL",SUP-48006012R,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,115.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 4.75MM CD HORIZON SOLERA COCRMO CAP",SUP-641003050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"VALVE AORTIC 31MM 26.1MM MASTERS SERIES PYROLYTIC CARBON",SUP-29AECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]","Cigna Open Access",,9754.94,33.5,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD QD ASR MP MRLN CLLR","SUP-CD3369-40Q CELL",CDM,C1882,HCPCS,0278,RC,,,both,,,44764.00,13429.2,"FIRST HEALTH [10303]","First Health",,35811.2,80,,,,,0,5206.05,38049.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 92CM 1MM 6FR 5MM SPACE REGULAR D CURVE",SUP-D6DR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1575.9,68,,,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 15MM 135CM 5MM 3.3-2.9FR VASCULAR COCR",SUP-1011493-15,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"PHCS [10601]",PHCS,,4410,70,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIAZEPAM 5 MG TABLET",RX-2405,CDM,,,0250,RC,51079-0285-01,NDC,both,1,UN,12.54,3.76,"AETNA [10100]","Aetna HMO/PPO",,9.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 10MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620710,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Open Access",,6403.47,56.9,,5302.19,4377.88,6578.61,27,1308.83,9565.82,"percent of total billed charges",
"PIN FIXATION 9IN 5/64IN STEINMANN 2 END TROCAR POINT",SUP-162438000,CDM,C1713,HCPCS,0278,RC,,,both,,,102.95,30.88,"BLUE CROSS [10001]","Blue Cross HMO",,40.36,39.2,,957.42,156.86,7483.26,51,11.97,87.51,"percent of total billed charges",
"FILLER BONE VOID 30ML .1-2MM 80% CORTICAL 20% CANCELLOUS",SUP-400063,CDM,C1713,HCPCS,0278,RC,,,both,,,2842.88,852.86,"MULTIPLAN [10600]",Multiplan,,2416.45,85,,,,,0,330.63,2416.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC STRAIGHT 130MM 2.75MM SHUTT MINI-AGGRESSOR",SUP-32.10034,CDM,S27200284,LOCAL,0272,RC,,,both,,,7971.71,2391.51,"UHC [10700]","United Healthcare",,5046.09,63.3,,,,,0,927.11,6775.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION LUBRICATH 16FR 350ML FOLEY URINE METER",SUP-902816,CDM,S27200284,LOCAL,0272,RC,,,both,,,112.06,33.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.03,95.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 3INX8MM OSTEOTOM THIN STERILE DISPOSABLE",SUP-71369208,CDM,S27200284,LOCAL,0272,RC,,,both,,,746.01,223.8,"AETNA [10100]","Aetna HMO/PPO",,593.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.76,634.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 90MM 75CM 14MM 9FR 100CM",SUP-H965403130,CDM,C1876,HCPCS,0278,RC,,,both,,,7140.00,2142,"KAISER [10500]",Kaiser,,4783.8,67,,,,,0,830.38,6069,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT TKR 82 CAP EXTRA",SUP-98000200186,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Open Access",,6331.5,33.5,,5302.19,4377.88,6578.61,27,2198.07,16065,"percent of total billed charges",
"BIT DRILL 1.5MM FAST MINI QUICK CONNECT ALPS HAND FRACTURE",SUP-231220203,CDM,S27200284,LOCAL,0272,RC,,,both,,,668.25,200.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,306.73,45.9,,,,,0,77.72,568.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 2-5-2MM SPACE ELECTROPHYSIOLOGY 10",SUP-D6FR252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,274.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 15MM 3.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP3515X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"KAISER [10500]",Kaiser,,352.76,67,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X17MM LUMINARY CC BICONVEX SPINE",SUP-6817,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"UHC [10700]","United Healthcare",,21056.11,63.3,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -6MM OFFSET 36MM HIP TYPE 1 MODULAR COCR G7",SUP-11107016,CDM,C1776,HCPCS,0278,RC,,,both,,,9570.30,2871.09,"MULTIPLAN [10600]",Multiplan,,8134.76,85,,,,,0,1113.03,8134.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 71CM 21GA 18GA PROC CURVE STERILE BROCKENBROUGH ADULT",SUP-04120DS,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"AETNA [10100]","Aetna HMO/PPO",,804.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBJR070202A,CDM,C1874,HCPCS,0278,RC,,,both,,,19895.40,5968.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2357.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2313.84,16911.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 8MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-708,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UHC [10700]","United Healthcare",,8309.55,63.3,,8601.07,8395.67,8601.07,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"BAND ANNULOPLASTY SIMULUS SEMIRIGID",SUP-800SC30,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"MULTIPLAN [10600]",Multiplan,,11143.5,85,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO S2 LOW PROFILE QUICK CONNECT GLIDESCOPE",SUP-0270-1154,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"NOVANET [10819]",Novanet,,261,75,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25026W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2295,68,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION",RX-6487,CDM,,,0250,RC,70748-0332-02,NDC,both,5,ML,332.11,99.63,"CIGNA [10200]","Cigna Open Access",,188.97,56.9,,,,,0,38.62,282.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LASSO 115CM 7FR 35MM ELECTROPHYSIOLOGY DEFLECTABLE",SUP-122072S,CDM,C1731,HCPCS,0272,RC,,,both,,,10950.30,3285.09,"NOVANET [10819]",Novanet,,8212.73,75,,,,,0,1273.52,9307.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY HOT 240CM 2.2MM RADIAL JAW 4 +2.8MM DISPOSABLE",SUP-M00515033,CDM,S27200284,LOCAL,0272,RC,,,both,,,155.70,46.71,"PHCS [10601]",PHCS,,108.99,70,,,,,0,18.11,132.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 7CM MR8 4MM BALL DISSECTING CARBIDE",SUP-MR8-7BA40C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1089.86,326.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,126.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,126.75,926.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 1.3MM LAPIDUS 3 HOLE COMPRESSION MEDIAL WALL",SUP-P53-106-L101,CDM,C1713,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"BLUE CROSS [10001]","Blue Cross HMO",,3313.38,39.2,,957.42,156.86,7483.26,51,983.03,7184.63,"percent of total billed charges",
"PLATE 14MM 30X16X2.5MM TITANIUM 2 LEVEL PREBENT SKYLINE BONE",SUP-186802030,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"FIRST HEALTH [10303]","First Health",,3528,80,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE CRANIOFACIAL TITANIUM 4 HOLE X LOW PROFILE",SUP-421.510,CDM,C1713,HCPCS,0278,RC,,,both,,,1792.50,537.75,"NOVANET [10819]",Novanet,,1344.38,75,,,,,0,208.47,1523.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 16X8CM ALLODERM THICK REGENERATIVE TISSUE MATRIX",SUP-1520128,CDM,Q4116,HCPCS,0636,RC,,,both,,,23152.50,6945.75,"KAISER [10500]",Kaiser,,15512.18,67,,,,,0,247.92,19679.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALIF SPACER, ANTERIOR: 9MM (H) X 22-24MM (L) X 27-32MM (W):",SUP-10609,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"UHC [10700]","United Healthcare",,19939.5,63.3,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60MM POLYMER ENDOSCOPIC BIOABSORBABLE STERILE",SUP-12BSGEC60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1323.00,396.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,543.75,41.1,,,,,0,153.86,1124.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 20MM 135CM 5MM .018IN BILIARY STAINLESS",SUP-G56624,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"BLUE CROSS [10001]","Blue Cross HMO",,1975.68,39.2,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC GRAFT PROTECTION SCR SEAL CLEAR-TRAC",SUP-7207227,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"FIRST HEALTH [10303]","First Health",,167.04,80,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 3.5MM AXON CURVE TITANIUM NONSTERILE",SUP-498.136,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"CATH URETHRAL BARDEX IC 22FR FOLEY 2 WAY SILVER HYDROGEL 5ML",SUP-0165SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.82,19.45,"CIGNA [10200]","Cigna Open Access",,36.88,56.9,,,,,0,7.54,55.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 RIGHT REVISION TRIATHLON",SUP-5612-F-202,CDM,C1776,HCPCS,0278,RC,,,both,,,48062.70,14418.81,"NOVANET [10819]",Novanet,,36047.03,75,,,,,0,5589.69,40853.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL SURGICAL 132MM 30MM C TAPER NECK",SUP-1100-1330,CDM,C1776,HCPCS,0278,RC,,,both,,,1195.68,358.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,813.06,68,,,,,0,139.06,1016.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE HI-FLO TRANSEND 105CM 10CM 3-2.8FR .027IN 135",SUP-M001182980,CDM,C1887,HCPCS,0272,RC,,,both,,,4726.50,1417.95,"NOVANET [10819]",Novanet,,3544.88,75,,,,,0,549.69,4017.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE SMALL OVAL 240CM 2.4MM SENSATION LOOP SHORT THROW",SUP-M00562693,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.43,23.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,52.65,68,,,,,0,9.01,65.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - TIBIAL KIT (CR) - SIZE 4",SUP-5555-2324,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CAPIO 35CM 12MM SUTURING TRANSVAGINAL SLING OPEN",SUP-M0068321010,CDM,C2631,HCPCS,0278,RC,,,both,,,1841.18,552.35,"CIGNA [10200]","Cigna Local Plus",,985.03,53.5,,,,,0,214.13,1565,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE FROZEN TRIPLE STRAND GRAFTLINK",SUP-FGLTS,CDM,S27800098,LOCAL,0278,RC,,,both,,,15152.40,4545.72,"MULTIPLAN [10600]",Multiplan,,12879.54,85,,,,,0,1762.22,12879.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE CATHETER, SHAPE 20",SUP-4679-01,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 97MM CEMENTED BASIC SUMMIT 2 12/14 TAPER HIP",SUP-157006080,CDM,C1776,HCPCS,0278,RC,,,both,,,8135.10,2440.53,"MULTIPLAN [10600]",Multiplan,,6914.84,85,,,,,0,946.11,6914.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 1.5MM BALLOON DILATATION OTW PTCA",SUP-DC-PY1512UA1,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,117.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 12MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45012,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"PHCS [10601]",PHCS,,58117.3,70,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DRILL 1/8IN VANGUARD QUICK RELEASE STERILE",SUP-32486265,CDM,S27200284,LOCAL,0272,RC,,,both,,,464.94,139.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,55.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.07,395.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .035IN 7FR 27MM 70CM 4.5CM LATEX",SUP-9-SB-024,CDM,S27200284,LOCAL,0272,RC,,,both,,,2445.00,733.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STAPLER 2MM 2.5MM 3MM THK1.5-2.25MM 30MM ENDO GIA MED",SUP-SIG30AVM,CDM,S27200284,LOCAL,0272,RC,,,both,,,1060.37,318.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP BIOPSY NDL MICRO MESH TOOTH STREAMLINE CATH POSITION",SUP-M00513372,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.73,50.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TENDYNE RETRIEVAL SYSTEM",SUP-TENDV-RS-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE CELEROMARK 12GA BREAST BIOPSY INTRO","SUP-CELERO INTRO-12",CDM,S27200284,LOCAL,0272,RC,,,both,,,177.22,53.17,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 7FR 45CM GUIDING PINNACLE DESTINATION",SUP-RSR16,CDM,C1887,HCPCS,0272,RC,,,both,,,672.30,201.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 20MM 6FR 4MM .07",SUP-H7493926720400,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE NASOGASTRIC 36IN 8FR ANTICLOG RADIOPAQUE BOW TIP BOLUS",SUP-40-9368,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.39,27.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW PROPHECY INBONE MICROAIRE WIDE HALL/LINVATEC",SUP-200138104S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1109.70,332.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC F18 Fdg per Study Up to 45mci",PX-343000019,CDM,A9552,HCPCS,0343,RC,,,both,,,755.00,226.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC",033,MS-DRG,,,,,,,inpatient,,,107987.96,32396.39,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER PACING LEAD ACUITY 10FR LONG",SUP-667473-001,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GORE  VIATORR TIPS ENDOPROSTHESIS WITH CONTROLLED EXPANSION,",SUP-PTB6107275,CDM,C1874,HCPCS,0278,RC,,,both,,,33364.80,10009.44,"KAISER [10500]",Kaiser,,22354.42,67,,,,,0,3880.33,28360.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 11MM HELIX R SPINE SELF TAP VARIABLE ANGLE",SUP-7803111,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,117.75,860.63,"percent of total billed charges",
"CATH ADVANCE 150CM 10CM 5MM BALLOON DILATATION ILIAC",SUP-G34332,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PERFORM STEM TSA-PERFORM+",SUP-CAP1185,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10710,40,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 50CM 4CM 7MM BALLOON DILATATION PERIPHERAL",SUP-CQ5074,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL MODULAR REMEDY SMALL HIP",SUP-RHSTSM,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"NOVANET [10819]",Novanet,,12937.5,75,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9 % IV BOLUS 500 ML",RX-400291,CDM,,,0258,RC,00990-7983-55,NDC,both,500,ML,100.65,30.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH METACROSS RX 135CM 20MM 5.7-3.9FR 5MM BALLOON",SUP-BD-L50020CR,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ATENOLOL 25 MG TABLET",RX-717,CDM,,,0637,RC,51079-0759-01,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TREVO NXT 3X32+TRAK21+CAT7 3-PACK - US",SUP-SFP913120,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"BURR SHAVER BLACK 5.5MM DYONICS ELITE STRAIGHT ABRADER",SUP-72200723,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.35,105.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT STRATAFIX PDS PLUS 4-0 SH-1 SPIRAL 9IN KNOTLESS VIOLET",SUP-SXPP1B454,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.35,67.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 34.5X16.5X.4MM 16.5MM PRECISION LONG WIDE",SUP-2296003104,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) ACOLYTE CATHETER","SUP-FG 01412",CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOOK SPINAL 6MM OFFSET LAMINA LEFT",SUP-7756074L,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,3978.14,359.25,3978.14,24,348.9,2550,"percent of total billed charges",
"APPLR SURGICAL 40CM 5MM SNAP LOCK RIGID DEHP FREE FIBRIN",SUP-0601139,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.43,194.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.93,68,,,,,0,75.41,551.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PRIMEWIRE PRESTIGE PLUS VASCULAR STRAIGHT 185CM",SUP-9185,CDM,C1769,HCPCS,0272,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 12.5MM KNEE AOX STABILIZE ROTATE PLATFORM",SUP-196192112,CDM,C1776,HCPCS,0278,RC,,,both,,,13386.00,4015.8,"MULTIPLAN [10600]",Multiplan,,11378.1,85,,,,,0,1556.79,11378.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 19GA 5.2-4.2FR 0-8CM ULTRASOUND CONTOUR",SUP-G31520,CDM,S27200284,LOCAL,0272,RC,,,both,,,2407.50,722.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,285.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,279.99,2046.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER NAV 115CM 4MM 7FR 1-7-4MM SPACE F-F CURVE",SUP-BN7TCFF4L,CDM,C1732,HCPCS,0272,RC,,,both,,,15366.30,4609.89,"UHC [10700]","United Healthcare",,9726.87,63.3,,,,,0,1787.1,13061.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC",219,MS-DRG,,,,,,,inpatient,,,381225.80,114367.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,122420.74,,"Fee schedule rate ($122,420.74). The outlier threshold amount is ($224,410.00),  the outlier percentage is (46.51%).  The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1). Includes an add-on of $2,243.60 when RC 0681-0684 total amount is above $1.",,,,0,47628.97,224175.65,other,"IP STOPLOSS Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 30MM MESENTERY THIN TISSUE ARTICULATE CURVE TIP",SUP-SIG30CTAV,CDM,S27200284,LOCAL,0272,RC,,,both,,,1461.81,438.54,"CIGNA [10200]","Cigna Local Plus",,782.07,53.5,,,,,0,170.01,1242.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRAOCULAR PROCEDURES WITH CC/MCC",116,MS-DRG,,,,,,,inpatient,,,90081.77,27024.53,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER NAV 115CM 4MM 7FR 1-7-4MM SPACE J-J CURVE",SUP-BN7TCJJ4L,CDM,C1732,HCPCS,0272,RC,,,both,,,15366.30,4609.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE GLIDECATH TORQUE .01-.038 IN GWIRE",SUP-TD01,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.20,15.66,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GUIDEZILLA II 150CM 6FR .057IN GUIDING Z-GLIDE EXT",SUP-H7493933515060,CDM,C1769,HCPCS,0272,RC,,,both,,,2956.88,887.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL SURGICAL AMPLATZ FIRM KINK RESISTANT GRADUATE TAPER 35CM",SUP-M0062601080,CDM,C1894,HCPCS,0272,RC,,,both,,,362.44,108.73,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BASEPLATE TIBIAL TRIATHLON 3 UNIVERSAL KNEE TOTAL STABILIZED",SUP-5521-B-300,CDM,C1776,HCPCS,0278,RC,,,both,,,10384.92,3115.48,"CIGNA [10200]","Cigna Open Access",,5909.02,56.9,,5302.19,4377.88,6578.61,27,1207.77,8827.18,"percent of total billed charges",
"CMPNT TIBIAL TRAY 2 LEFT CEMENTED FIXED PRIMARY GMK",SUP-02.07.1202L,CDM,C1776,HCPCS,0278,RC,,,both,,,6136.20,1840.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,727.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,713.64,5215.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 10MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630810,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UHC [10700]","United Healthcare",,8309.55,63.3,,8601.07,8395.67,8601.07,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"PLATE MINI REGULAR L 1MM MID FACE RIGHT 4 HOLE 2MM SCR BONE",SUP-55-08230,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"PLATE 66MM 4 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800466,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL FUZEFIX MINI OD2.5 MM PROXIMAL HEADLESS NONS",SUP-CD-FX-2525,CDM,S27000186,LOCAL,0270,RC,,,both,,,2130.00,639,"FIRST HEALTH [10303]","First Health",,1704,80,,,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP BLUE 33MM STAINLESS STEEL 2 SOFT",SUP-A0804,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"FIRST HEALTH [10303]","First Health",,125.28,80,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +26 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.260,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT 5 KNEE CEMENT ROTATE PLATFORM",SUP-129431150,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,5372.07,4581.20,7242.98,23,2014.9,14726.25,"percent of total billed charges",
"CLINDAMYCIN 150 MG/ML INJECTION SOLUTION",RX-82303,CDM,J0736,HCPCS,0636,RC,00009-0870-26,NDC,both,2,ML,22.53,6.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.24,,"Fee schedule rate ($2.24). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.13,19.15,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXIMA 70CM 7FR 12FR URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002131,CDM,C1758,HCPCS,0272,RC,,,both,,,80.01,24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",11.23,7.03,11.23,"1 through 10",9.31,68.01,"percent of total billed charges",
"STEM FEMORAL ACCOLADE II 8 132D",SUP-6720-0837,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"BLUE CROSS [10001]","Blue Cross PPO",,9393.12,39.2,,3949.44,3949.44,3949.44,"1 through 10",2786.79,20367.74,"percent of total billed charges",
"STENT WALLSTENT 60MM 16MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044166070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"UHC [10700]","United Healthcare",,5459.63,63.3,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 19FR .25IN BLAKE SILICONE 4 CHANNEL .75",SUP-072225,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.15,37.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.44,105.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE TITANIUM 30MM 7MM ACL PCL CANNULATED SHEATH",SUP-AR-1372E,CDM,C1713,HCPCS,0278,RC,,,both,,,978.08,293.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,448.94,45.9,,,,,0,113.75,831.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT RED 18X4IN COLOR CUFF CYLINDRICAL 2 PORT BLADDER",SUP-5921-218-235,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"NOVANET [10819]",Novanet,,55.46,75,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CENTRIFUGAL STERILE DISPOSABLE ARTHREX ANGEL LATEX FREE",SUP-ABS-10061T,CDM,S27200284,LOCAL,0272,RC,,,both,,,3487.50,1046.25,"KAISER [10500]",Kaiser,,2336.63,67,,,,,0,405.6,2964.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X8MM COROENT 10D XL+ PEEK NONSTERILE LATEX",SUP-6308850,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]",Cigna,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 20CM 11.5FR FULL SILICONE HEMO-CATH SAFETY SCPL",SUP-MCDLTSL20,CDM,C1750,HCPCS,0278,RC,,,both,,,988.20,296.46,"MULTIPLAN [10600]",Multiplan,,839.97,85,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR SUREFORM 60 WHITE",SUP-48360W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.25,543.37,"MULTIPLAN [10600]",Multiplan,,1539.56,85,,,,,0,210.65,1539.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 8.5FR 18GA 16CM .032IN 4 LUMEN INDWELL CATH GWIRE",SUP-CDC-42854-1A,CDM,C1751,HCPCS,0272,RC,,,both,,,831.24,249.37,"KAISER [10500]",Kaiser,,556.93,67,,,,,0,96.67,706.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 35MM MAXTORQUE SHORT THREAD ANKLE FOOT",SUP-MSD01040035S,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"CIGNA [10200]",Cigna,,963.9,68,,1831.33,1831.33,1831.33,16,164.86,1204.88,"percent of total billed charges",
"LAMIVUDINE 10 MG/ML ORAL SOLUTION",RX-15881,CDM,,,0250,RC,08888-8887-44,NDC,both,5,ML,17.42,5.23,"CIGNA [10200]",Cigna,,11.85,68,,,,,0,2.03,14.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 11X44MM VERTE-STACK CORNERSTONE PSR 11MM",SUP-6271044,CDM,S27800098,LOCAL,0278,RC,,,both,,,5299.20,1589.76,"NOVANET [10819]",Novanet,,3974.4,75,,,,,0,616.3,4504.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE BONE SIGNATURE ONE ALLIANCE SURGICAL SHOULDER GLENOID",SUP-20-8090-008-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,7562.40,2268.72,"CIGNA [10200]","Cigna Open Access",,4303.01,56.9,,,,,0,879.51,6428.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 20MM 6MM RECTANGLE HELIX BALLOON",SUP-2076-6020,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"FIRST HEALTH [10303]","First Health",,4692,80,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND SABRELOC 6-0 S-14 18IN 2 ARM BRAID BLACK",SUP-1780G,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.66,43.4,"KAISER [10500]",Kaiser,,96.92,67,,,,,0,16.82,122.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X14MM CASCADIA 8D TITANIUM POROUS LATERAL",SUP-6101-2185514LL8-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8113.77,28.62,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +31 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SA60AT.310,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO 330MM 3.8MM PNEUMATIC ULTRASOUND SWISS",SUP-M0068407150,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM CARPENTIER-EDWARDS PHYSIO",SUP-4450M30,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"NOVANET [10819]",Novanet,,8538.75,75,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC 32.51CM 8MM COBRA ENDOWRIST DA VINCI XI 68",SUP-471190,CDM,S27000186,LOCAL,0270,RC,,,both,,,1530.90,459.27,"MULTIPLAN [10600]",Multiplan,,1301.27,85,,,,,0,178.04,1301.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP 16MM OPEN 230CM INTERNAL INSTINCT HEMOCLIP",SUP-G18343,CDM,S27200284,LOCAL,0272,RC,,,both,,,1170.45,351.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,537.24,45.9,,,,,0,136.12,994.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 45CM 4-7MM FLIXENE 2 SLIDER GDS TAPERED",SUP-25138,CDM,C1768,HCPCS,0278,RC,,,both,,,10206.27,3061.88,"CIGNA [10200]","Cigna Local Plus",,5460.35,53.5,,,,,0,1186.99,8675.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE 25CMX4MM POLYESTER SILICONE BARIUM",SUP-PT400000,CDM,C1763,HCPCS,0278,RC,,,both,,,6955.20,2086.56,"KAISER [10500]",Kaiser,,4659.98,67,,,,,0,808.89,5911.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD LUBRI-SIL IC 18FR URETHRAL BACTI-GUARD SILICONE",SUP-1758SI18,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.35,24.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.46,69.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN EXTRA",SUP-77805600,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 10 7MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151621007,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"MULTIPLAN [10600]",Multiplan,,9565.82,85,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAX BONE HEMOSTATIC AGENT LUKENS",SUP-901,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.75,18.22,"MULTIPLAN [10600]",Multiplan,,51.64,85,,,,,0,7.07,51.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR EASY RADIAL RIGHT CURVE GUIDING",SUP-LA6ERADR,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 6FR STRAIGHT RIGHT VENTRICLE MRI PASSIVE",SUP-7731,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1518.1,68,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING 2 HEAT PARALLEL Y PORT DRY GAS LINE MDI",SUP-RT210,CDM,S27000186,LOCAL,0270,RC,,,both,,,240.12,72.04,"UHC [10700]","United Healthcare",,152,63.3,,,,,0,27.93,204.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE 100CM 4FR .0395IN SIDEWINDER SIMMONS",SUP-532415,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"KAISER [10500]",Kaiser,,69.95,67,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 21GA 6.7IN 4.3IN DIL SCPL SYR SPRING COIL",SUP-PHR6F11021SC,CDM,C1894,HCPCS,0272,RC,,,both,,,454.90,136.47,"PHCS [10601]",PHCS,,318.43,70,,,,,0,52.9,386.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM INFINITY SPINE OCCIPITOCERVICAL UPPER",SUP-3603522,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 7FR .081IN JUDKINS LEFT 5 CURVE GUIDING",SUP-LA7JL50,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM STAINLESS STEEL T8 CORTEX TUBE STARDRIVE",SUP-201.768TS,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"BLUE CROSS [10001]","Blue Cross HMO",,186.7,39.2,,957.42,156.86,7483.26,51,55.39,404.84,"percent of total billed charges",
"CATH SABER 150CM 150MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,974.92,68,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTING MODULE",SUP-5041,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 3-0 P-14 18IN CLSR ABSORBABLE PREMIUM",SUP-VLOCL0124,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.73,70.42,"KAISER [10500]",Kaiser,,157.27,67,,,,,0,27.3,199.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X250 135CM SL",SUP-48006025R,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"AETNA [10100]","Aetna HMO/PPO",,827.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM MAXIM ARCOM KNEE POSTERIOR STABILIZE",SUP-11-146572,CDM,C1776,HCPCS,0278,RC,,,both,,,7472.70,2241.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2138.69,28.62,,,,,0,869.08,6351.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 71CM TRANSSEPTAL CARTO VIZIGO ACQCROSS",SUP-900303,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 12D-30D ROLLER 24FR PLASMAROLLER",SUP-WA22751S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3215.54,964.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1475.93,45.9,,,,,0,373.97,2733.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION SCHANZ SCR MR SAFE PIVOT NONSTERILE",SUP-03.311.011,CDM,S27800098,LOCAL,0278,RC,,,both,,,3083.85,925.15,"CIGNA [10200]","Cigna Open Access",,1754.71,56.9,,,,,0,358.65,2621.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VG2 PRESERVON VERTIGRAFT CORTICAL CANCELLOUS",SUP-VG2C-T57P,CDM,S27800098,LOCAL,0278,RC,,,both,,,5865.00,1759.5,"CIGNA [10200]","Cigna Local Plus",,3137.78,53.5,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING ORANGE 16IN 8FR NUTRIO TWISTLOK ENTERAL",SUP-ENPU1680,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.84,17.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH REDEL 115CM 1MM 6FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY",SUP-F6HF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD SUT ASSISTANT 3-0 ES-9 48IN 1 STITCH ENDO STITCH",SUP-170071,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 7.3MM 35MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.835,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CIGNA [10200]","Cigna Open Access",,782.04,56.9,,1144.80,304.56,2275.09,66,159.84,1168.25,"percent of total billed charges",
"OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC",393,MS-DRG,,,,,,,inpatient,,,33120.72,9936.22,"BLUE CROSS [10001]","Blue Cross PPO",,33120.72,,,,,,,7561,33120.72,"case rate",
"KIT DRNG 35CM 12FR 22GA FLEXIMA POLYURETHANE 3 WAY STPCOCK",SUP-M001273090,CDM,C1729,HCPCS,0272,RC,,,both,,,1950.00,585,"NOVANET [10819]",Novanet,,1462.5,75,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 40MM 4MM .014IN LOW PROFILE",SUP-1008189-40,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"FIRST HEALTH [10303]","First Health",,1134,80,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT 7.5IN RHOTON LARGE STRAIGHT SPAT SURGICAL",SUP-58-6022,CDM,S27200284,LOCAL,0272,RC,,,both,,,524.07,157.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,356.37,68,,,,,0,60.95,445.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tlpa Abd Aorta",PX-481000004,CDM,0236T,CPT,0481,RC,,,both,,,18540.00,5562,"BLUE CROSS [10001]","Blue Cross HMO",,18.54,.1,,,,,0,18.54,15759,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY 34MM 140CM 3MM CORONARY STENT",SUP-RSINT30034UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"PHCS [10601]",PHCS,,3880.8,70,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 22MM LCP TITANIUM DISTAL HUMERAL CORTICAL",SUP-401.772,CDM,C1713,HCPCS,0278,RC,,,both,,,455.87,136.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,309.99,68,,,,,0,53.02,387.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +15.5MM 12/14 TAPER 36MM HIP CEMENTLESS M",SUP-136555000,CDM,C1776,HCPCS,0278,RC,,,both,,,6720.60,2016.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,781.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,781.61,5712.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 58X40X33MM NEXGEN LCCK 1-2 C-D MICRO KNEE",SUP-599403010,CDM,C1776,HCPCS,0278,RC,,,both,,,16256.40,4876.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6502.56,40,,,,,0,1890.62,13817.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 80MM 9.6MM 7MM 1 CANN CUFF LOW PRESSURE ROUND TIP OBTR",SUP-7SCT,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.54,64.36,"NOVANET [10819]",Novanet,,160.91,75,,,,,0,24.95,182.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 24MM LOW PROFILE SCREWS TITANIUM FULL THREAD",SUP-AR-8933-24,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,105.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,103.62,757.35,"percent of total billed charges",
"WEDGE TIBIAL 10MM DURACON S1 FULL FLAT KNEE REVISION",SUP-6630-6-510,CDM,C1776,HCPCS,0278,RC,,,both,,,8062.65,2418.79,"CIGNA [10200]","Cigna Open Access",,4587.65,56.9,,5302.19,4377.88,6578.61,27,937.69,6853.25,"percent of total billed charges",
"GWIRE HIWIRE VASCULAR STRAIGHT TAPER 145CM 15CM .035IN PTFE",SUP-TSFNB-35-145,CDM,C1769,HCPCS,0272,RC,,,both,,,121.71,36.51,"KAISER [10500]",Kaiser,,81.55,67,,,,,0,14.15,103.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 15MM 2.25MM CORONARY RAPID EXCHANGE",SUP-ONYXNG22515UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA [10200]",Cigna,,1785,68,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SPEAR JUVENILE ROUND STAINLESS STEEL POLYPROPYLENE",SUP-70130791,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.58,27.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.65,77.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR LOW BEND 102MM STAINLESS STEEL 3.5MM SCR 6",SUP-02.124.204,CDM,C1713,HCPCS,0278,RC,,,both,,,7998.48,2399.54,"CIGNA [10200]","Cigna Open Access",,4551.14,56.9,,1144.80,304.56,2275.09,66,930.22,6798.71,"percent of total billed charges",
"STENT ORSIRO MISSION 9MM 140CM 3MM CORONARY STERILE LATEX",SUP-453928,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SCLEROTHERAPY 25GA 2.3MM BEVEL STRONG PUSHABLE CONTRAST",SUP-M00518361,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.66,81.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 5FR 50CM 11CM GRAY HUB SNAP FIT DIL TUBING",SUP-PRO-5F-11-035,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dgtz Gls Mcrscp Sld Level V / Add on 88307",PX-312000091,CDM,0754T,CPT,0312,RC,,,both,,,100.00,30,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FIBER LASER FLEXIVA 365UM FLEXSHIELD HIGH POWER POLISH",SUP-M0068403921,CDM,S27200284,LOCAL,0272,RC,,,both,,,2258.15,677.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"REAMER SURGICAL MALE 19MM METATARSOPHALANGEAL CONE SPIN",SUP-P01-900-1903,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC",020,MS-DRG,,,,,,,inpatient,,,453478.14,136043.44,"AETNA [10100]","Aetna HMO/PPO",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $208,489. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 79.5%. Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,,,other,"IP STOP LOSS Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL VASCULAR J",SUP-1009663J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUSHG FEMORAL KNEE POLYETHYLENE AUXILIARY",SUP-150477,CDM,C1770,HCPCS,0278,RC,,,both,,,1722.00,516.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1170.96,68,,,,,0,200.27,1463.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veralink Cassette",PX-E27200322,CDM,E27200322,LOCAL,0272,RC,,,both,,,349.80,104.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.68,297.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM 2 MARKER SEMIRIGID WIRE STIFFENER",SUP-800SR26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 11MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-411-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"UHC [10700]","United Healthcare",,7617.27,63.3,,8601.07,8395.67,8601.07,"1 through 10",1399.51,10228.56,"percent of total billed charges",
"EVAC UROLOGY UROVAC BLADDER ADPTR STERILE DISPOSABLE",SUP-M0067301251,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.00,51,"UHC [10700]","United Healthcare",,107.61,63.3,,,,,0,19.77,144.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 24MM 5MM STAINLESS STEEL SHORT THREAD FOOT HAND",SUP-02.226.024,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"CIGNA [10200]","Cigna Local Plus",,880.18,53.5,,3978.14,359.25,3978.14,24,191.34,1398.42,"percent of total billed charges",
"TUBE 74MM 10.8MM 15MM 7.5MM 6.5MM CUFF DISPOSABLE INNER CANN",SUP-6CN75H,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.10,109.83,"PHCS [10601]",PHCS,,256.27,70,,,,,0,42.58,311.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRICLIP NT CLIP DELIVERY SYS CLIN",SUP-TCDS0203-NT,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE SHIELD CONCORD 20GM VCF SYSTEM",SUP-4129.2000S,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,408.97,45.9,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 25MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G325,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1109.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION",RX-93084,CDM,J0282,HCPCS,0636,RC,67457-0153-18,NDC,both,18,ML,155.74,46.72,"CIGNA [10200]",Cigna,,33.35,,,,,,,15.03,132.38,"fee schedule",
"SHEATH HEARTSPAN 120D FIX CURVE TAPER 60CM 8.5FR GUIDING",SUP-FCL-160-04,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 3 STD KNEE RIGHT KEEL NONPOROUS",SUP-ETPKN3SR,CDM,C1776,HCPCS,0278,RC,,,both,,,15193.80,4558.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1767.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1767.04,12914.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL ATTUNE STERILE 7 KNEE RIGHT CEMENTED POSTERIOR",SUP-150410207,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9203.67,41.1,,6417.48,6417.48,6417.48,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"HC RBC Auto",PX-305000009,CDM,85041,CPT,0305,RC,,,both,,,102.60,30.78,"AETNA [10100]","Aetna HMO/PPO",,81.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.04,87.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 50MM STAINLESS STEEL T15 LOW PROFILE CLAVICLE",SUP-02.206.250,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"KAISER [10500]",Kaiser,,217.07,67,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 60CM 6.7FR 10MM SPACE ATRIUM ENDOCARDIUM",SUP-4137,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]",Cigna,,3812.76,68,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA XFULL PROFILE SOFTTOUCH SMOOTH",SUP-SSX-800,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 80CM 10MM 9FR STRAIGHT VASCULAR",SUP-AVSM10100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PHCS [10601]",PHCS,,12789,70,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA MEDIAL CONGRUENT 4-5 E-F KNEE",SUP-42512100613,CDM,C1776,HCPCS,0278,RC,,,both,,,9466.80,2840.04,"BLUE CROSS [10001]","Blue Cross PPO",,3710.99,39.2,,3949.44,3949.44,3949.44,"1 through 10",1100.99,8046.78,"percent of total billed charges",
"COIL EMBOLIZATION 6CM 4.5MM AVENIR COMPLEX 10 COIL FRAME",SUP-10CFR04506,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4818.19,41.1,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 3MM 40D CURVE 2 SERRATE ENTELLUS MEDICAL HNDPC",SUP-SSB-12340-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,847.69,41.1,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM OTHER THAN TRANSVENOUS VDD 1 PASS",SUP-4480,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"KAISER [10500]",Kaiser,,3756.69,67,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALIBRATOR OSMOMETER 100 MOSM/KG 5ML STANDARD AMPULE FOR 325",SUP-3LA011,CDM,S27000186,LOCAL,0270,RC,,,both,,,276.39,82.92,"NOVANET [10819]",Novanet,,207.29,75,,,,,0,32.14,234.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 175MM 10MM SMALL SHELL REVISION ALTIVATE",SUP-533-10-175,CDM,C1776,HCPCS,0278,RC,,,both,,,43228.40,12968.52,"CIGNA [10200]","Cigna Open Access",,14481.51,33.5,,5302.19,4377.88,6578.61,27,5027.46,36744.14,"percent of total billed charges",
"FRCP SURGICAL SHANDON 8IN THUMB BROAD POINT DRSG FINE",SUP-76305,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.56,72.17,"KAISER [10500]",Kaiser,,161.18,67,,,,,0,27.98,204.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOFT TISSUE PROCEDURES WITH CC",501,MS-DRG,,,,,,,inpatient,,,54587.06,16376.12,"BLUE CROSS [10001]","Blue Cross PPO",,43155.43,,,,,,,7561,51037.53,"case rate",
"SYSTEM RESOLUTE ONYX 15MM 140CM 3MM 2.1-2.7FR CORONARY STENT",SUP-RONYX30015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"KAISER [10500]",Kaiser,,2487.38,67,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 56MMX2MM LOCK VARIAX BONE RADIUS LEFT DISTAL",SUP-54-25374,CDM,C1713,HCPCS,0278,RC,,,both,,,6383.05,1914.91,"KAISER [10500]",Kaiser,,4276.64,67,,,,,0,742.35,5425.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 20MM 120CM 10MM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200102020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"AETNA [10100]","Aetna HMO/PPO",,3291.3,79.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 5FR ARTERIAL LINE HEPARIN 4 LUMEN THERMODILUTION",SUP-DTD1504HX5,CDM,S27200284,LOCAL,0272,RC,,,both,,,483.68,145.1,"CIGNA [10200]",Cigna,,328.9,68,,,,,0,56.25,411.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 9MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P409,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"AETNA [10100]","Aetna HMO/PPO",,6642.94,79.5,,10981.53,8986.79,12413.38,12,971.79,7102.52,"percent of total billed charges",
"URETEROSCOPE FLEXIBLE 9.5FR 7.7FR 3.6FR LITHOVUE STD",SUP-M0067913500,CDM,C1747,HCPCS,0272,RC,,,both,,,10350.00,3105,"FIRST HEALTH [10303]","First Health",,8280,80,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 20MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE32520,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,34386.15,41.1,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 80MM 130CM 5MM VASCULAR SELF EXPAND RADIOPAQUE",SUP-H74939293058030,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]","Cigna Open Access",,2748.27,56.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 4CM 10FR ZIMMON .035IN 2 PIGTAIL CURVE",SUP-G21781,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"CIGNA [10200]","Cigna Open Access",,700.55,56.9,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 32MM HIP BIOLOX DELTA V40",SUP-6570-0-232,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"PHCS [10601]",PHCS,,7000,70,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRECISION GUIDE DRILL PIN 3.0 X 320MM PHANTOM? HINDFOOT N",SUP-P31-951-3032,CDM,C1713,HCPCS,0278,RC,,,both,,,2025.00,607.5,"MULTIPLAN [10600]",Multiplan,,1721.25,85,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEOCHORD ARTIFICIAL CHORDAE DELIVERY SYSTEM",SUP-DS1000,CDM,S62400003,LOCAL,0624,RC,,,both,,,63000.00,18900,"AETNA [10100]","Aetna HMO/PPO",,50085,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7326.9,53550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 42MM STAINLESS STEEL 2.4MM SCR 6 HOLE HEAD 2",SUP-02.111.521S,CDM,C1713,HCPCS,0278,RC,,,both,,,4102.05,1230.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,477.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",477.07,3486.74,"percent of total billed charges",
"FILLER BONE VOID 45X20X7MM DEMINERALIZED CANCELLOUS CONFORM",SUP-0W1047,CDM,S27800098,LOCAL,0278,RC,,,both,,,15939.00,4781.7,"UHC [10700]","United Healthcare",,10089.39,63.3,,,,,0,1853.71,13548.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FRACTURE STABILIT POWERCURVE SHORT COMPLETE",SUP-3512-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,15525.00,4657.5,"KAISER [10500]",Kaiser,,10401.75,67,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE WIRE GWR419578 ATTAIN HYBRID 98CM",SUP-GWR419578,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY FEMORAL GREEN 85MM 20MM RECLAIM ARTICUL/EZE 40MM OFFSET",SUP-197520085,CDM,C1776,HCPCS,0278,RC,,,both,,,22082.76,6624.83,"KAISER [10500]",Kaiser,,14795.45,67,,,,,0,2568.22,18770.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 4MM CEREPAK XL HELIFORM DETACHABLE",SUP-SHD180415,CDM,S27800098,LOCAL,0278,RC,,,both,,,13884.25,4165.27,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5706.43,41.1,,,,,0,1614.74,11801.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 34MM THORACIC WOVEN SMOOTH NDL",SUP-M00202175434P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3797.28,1139.18,"BLUE CROSS [10001]","Blue Cross HMO",,1488.53,39.2,,,,,0,441.62,3227.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8MM 40MM HIP PRIMARY TAPER OFFSET COCR LFIT",SUP-6260-9-340,CDM,C1776,HCPCS,0278,RC,,,both,,,6224.40,1867.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,737.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,723.9,5290.74,"percent of total billed charges",
"ROD SPINAL 75MM 5.5MM CREO STRAIGHT TITANIUM",SUP-1119.5075,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS ACCESS PLUS PLASTIC GWIRE INSRT TOOL TORQUE",SUP-MAP154,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.76,40.43,"AETNA [10100]","Aetna HMO/PPO",,107.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.67,114.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE WATCHMAN 30MM 30FR CLSR PEBAX NITINOL PLATINUM",SUP-M635WU30060,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALLET SURGICAL 7 9/16IN 1.5IN STAINLESS STEEL 2LB",SUP-250404,CDM,S27000186,LOCAL,0270,RC,,,both,,,703.16,210.95,"PHCS [10601]",PHCS,,492.21,70,,,,,0,81.78,597.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 80X25.4MM THK1.3MM LONG WIDE STAINLESS STEEL",SUP-2108118,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"AETNA [10100]","Aetna HMO/PPO",,83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE V-18 CONTROLWIRE VASCULAR STRAIGHT 150CM 12CM .018IN",SUP-M001468560,CDM,C1769,HCPCS,0272,RC,,,both,,,602.64,180.79,"KAISER [10500]",Kaiser,,403.77,67,,,,,0,70.09,512.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STELLAREX 135CM 80MM 5MM BALLOON DILATATION ENDURACOAT",SUP-AB35SX050080135,CDM,C2623,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"PHCS [10601]",PHCS,,6520.5,70,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE HA 20MM 8MM ACL BIOSURE",SUP-72201775,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"STENT ORSIRO 3.5/30",SUP-401769,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT EXTERNAL FIXATION TRUELOK UNIVERSAL WIRE",SUP-54-1152,CDM,C1713,HCPCS,0278,RC,,,both,,,683.48,205.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,79.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",79.49,580.96,"percent of total billed charges",
"NDL BIOPSY 11GA 15CM 1 PORT ASPIRATION WITHOUT SIDEHOLE BONE",SUP-710.150.99S,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.80,262.44,"AETNA [10100]","Aetna HMO/PPO",,695.47,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,101.74,743.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 150MM 6MM BALLOON DILATATION RAPID",SUP-47560150L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 175MM 6MM SMALL SHELL REVISION ALTIVATE REVERSE",SUP-533-06-175,CDM,C1776,HCPCS,0278,RC,,,both,,,43228.40,12968.52,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11671.67,27,,,,,0,5027.46,36744.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APEX 143CM 12MM 1.5MM BALLOON DILATATION OPTILEAP",SUP-H7493895912150,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 87.5MM TITANIUM 5 LEVEL ATLANTIS VISION ELITE BONE",SUP-7200087,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"SPACER FEMORAL CATHCART ARTICUL/EZE -3MM 12/14 TAPER HIP",SUP-136308000,CDM,C1776,HCPCS,0278,RC,,,both,,,1650.00,495,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1122,68,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 150MM 2MM .018IN BALLOON",SUP-R51002015L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"MULTIPLAN [10600]",Multiplan,,1735.28,85,,,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THOMASMEDICAL INTRDCR FR6 LONG",SUP-6272,CDM,C1894,HCPCS,0272,RC,,,both,,,139.20,41.76,"PHCS [10601]",PHCS,,97.44,70,,,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +30 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.300,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM 14.8MM MASTER-SERIES PYROLYTIC CARBON",SUP-19AECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"MULTIPLAN [10600]",Multiplan,,24751.35,85,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 18 16 X 50 COMPLEX FRAMING COIL",SUP-18CFR-16050,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5230.2,40,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Swallow Func Incomplt",PX-444000007,CDM,92610,CPT,0444,RC,,,both,,,536.62,160.99,"UHC [10700]","United Healthcare",,331,,"Per diem ($331).",,,,0,62.41,456.13,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION",RX-97253,CDM,J1163,HCPCS,0636,RC,25021-0319-05,NDC,both,5,ML,25.44,7.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.3,68,,,,,0,1.75,21.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 75CM 2CM 12MM 8FR BALLOON DILATATION",SUP-CQ75122,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"UHC [10700]","United Healthcare",,846,63.3,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hiv 2 Ab",PX-302000223,CDM,86702,CPT,0302,RC,,,both,,,385.70,115.71,"CIGNA [10200]",Cigna,,29.74,,,,,,,0.01,327.85,"fee schedule",
"CMPNT FEMORAL 5 CRUCIATE RETAIN CEMENT PERSONA STERILE LATEX",SUP-42572605802,CDM,C1776,HCPCS,0278,RC,,,both,,,26429.76,7928.93,"UHC [10700]","United Healthcare",,16730.04,63.3,,8601.07,8395.67,8601.07,"1 through 10",3073.78,22465.3,"percent of total billed charges",
"COIL EMBOLIZATION 177CM 12MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240120200,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"PHCS [10601]",PHCS,,4772.04,70,,,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 9.75CM NATRELLE INSPIRA P4.1CM FULL PROFILE ROUND",SUP-MSZ-F200,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AETNA [10100]","Aetna HMO/PPO",,125.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 52CM RVOT KIT MOND STAINLESS STEEL WIDE",SUP-4151/52,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"KAISER [10500]",Kaiser,,385.32,67,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL IDENTITY IMPRINT 4 NARROW KNEE POSTERIOR",SUP-TPS-301-T04N,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"AETNA [10100]","Aetna HMO/PPO",,6994.01,79.5,,10981.53,8986.79,12413.38,12,1023.15,7477.88,"percent of total billed charges",
"INTRO SHEATH 8FR 2.5CM 10CM GWIRE DIL RADIOPAQUE MARKER",SUP-RSB802,CDM,C1894,HCPCS,0272,RC,,,both,,,200.10,60.03,"PHCS [10601]",PHCS,,140.07,70,,,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DECA 2-2-2 MPA 120CM",SUP-901537,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"PHCS [10601]",PHCS,,2073.75,70,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Artery Line Cutdown",PX-450000237,CDM,36625,CPT,0450,RC,,,both,,,460.00,138,"NOVANET [10819]",Novanet,,345,75,,,,,0,67.13,460,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pinworm Prep",PX-306000077,CDM,87172,CPT,0306,RC,,,both,,,123.00,36.9,"PHCS [10601]",PHCS,,86.1,70,,,,,0,0.01,104.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Touch Prep Add Site",PX-312000040,CDM,88334,CPT,0312,RC,,,both,,,240.50,72.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.28,,"Fee schedule rate ($14.28). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,204.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ENDOSCOPIC ORANGE 72MM 6.5MM CLEAR-TRAC SHOULDER",SUP-72200428,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,85.82,41.1,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 15MM 19MM 27.5MM 20.8MM EPIC MAX 11MM TISSUE",SUP-EMAX-19,CDM,S27800098,LOCAL,0278,RC,,,both,,,27990.90,8397.27,"NOVANET [10819]",Novanet,,20993.18,75,,,,,0,3255.34,23792.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM EVOLVE STAINLESS STEEL CORTICAL ELBOW",SUP-4973532L,CDM,C1713,HCPCS,0278,RC,,,both,,,1710.00,513,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,198.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",198.87,1453.5,"percent of total billed charges",
"DRSG WOUND VAC VERAFLO LARGE",SUP-ULTVCCO5LG,CDM,S27200284,LOCAL,0272,RC,,,both,,,1846.80,554.04,"FIRST HEALTH [10303]","First Health",,1477.44,80,,,,,0,214.78,1569.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTREPID MITRAL DEL SYS TA CLINICAL",SUP-ASM-0047,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOCUSATE SODIUM 100 MG CAPSULE",RX-2566,CDM,,,0637,RC,60687-0129-11,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPEEDBRIDGE 3.9MM FIXATION ACHILLES",SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,0278,RC,,,both,,,19150.43,5745.13,"MULTIPLAN [10600]",Multiplan,,16277.87,85,,,,,0,2227.2,16277.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 28MM HIP TAPER ORTHINOX V40",SUP-6364-2-228,CDM,C1776,HCPCS,0278,RC,,,both,,,3461.25,1038.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,402.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,402.54,2942.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 60CM 8MM GORE STD WALL HEPARIN PROPATEN PTFE",SUP-H080060A,CDM,C1768,HCPCS,0278,RC,,,both,,,11378.10,3413.43,"CIGNA [10200]",Cigna,,7737.11,68,,,,,0,1323.27,9671.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 6FR 7MM 4FR BALLOON",SUP-39031-70401,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"KAISER [10500]",Kaiser,,1004,67,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X120 40CM SL",SUP-48005012P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,667.85,68,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER TUBE MICRO WHITE NEOBAR ENDOTRACHEAL GENTLE",SUP-N711-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,135.02,40.51,"MULTIPLAN [10600]",Multiplan,,114.77,85,,,,,0,15.7,114.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 55MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16025555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"CATH SUPERTORQUE THRULUMEN 100CM 6FR .079IN .051IN JUDKINS",SUP-532622,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"NOVANET [10819]",Novanet,,61.99,75,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 5MM EMBOLD PLATINUM TUNGSTUN NITINOL",SUP-M001394240050080,CDM,S27800098,LOCAL,0278,RC,,,both,,,6127.20,1838.16,"BLUE CROSS [10001]","Blue Cross HMO",,2401.86,39.2,,,,,0,712.59,5208.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 21MM TRIFECTA TISSUE ANNULUS",SUP-TF-21A,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC",547,MS-DRG,,,,,,,inpatient,,,31107.56,9332.27,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,5550.09,,"Case rate ($5,187). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,816.48, add-ons for qualifying new technology services are included. If operating cost exceeds $37,856.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,746.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,822.85. The transfer operating threshold is the transfer adjustment factor * $4,816.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $364.15. The transfer capital threshold is the transfer adjustment factor * $364.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,5187,20853.99,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CPR MINI SCORPION DX FIXATION",SUP-AR-8690DS,CDM,C1713,HCPCS,0278,RC,,,both,,,7933.28,2379.98,"KAISER [10500]",Kaiser,,5315.3,67,,,,,0,922.64,6743.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR .071IN SHEPHERDS CROOK RIGHT 3.5 CURVE",SUP-LA6SCR35,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MITRACLIP G4 CDS XTW REPAIR-MR CLINICAL",SUP-CDS0704-XTW,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,48940.2,28.62,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE 0.25 % (2.5 MG/ML) INJECTION SUPERORDERABLE",RX-4081222,CDM,J0665,HCPCS,0636,RC,00409-1159-09,NDC,both,30,ML,18.92,5.68,"NOVANET [10819]",Novanet,,14.19,75,,,,,0,1.75,16.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER COMPRESSION XL FOOT IMPAD A-V IMPULSE SYSTEM RIGID",SUP-5107,CDM,S27000186,LOCAL,0270,RC,,,both,,,316.72,95.02,"PHCS [10601]",PHCS,,221.7,70,,,,,0,36.83,269.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LITHO SURGICAL 1950MM 2 SHEATH PREASSEMBLE DISTAL WIRE GUIDE",SUP-BML-V232QR-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2442.00,732.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,289.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,284,2075.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 5X82MM STERILE XL25 RECESS LOCKING TITANIUM RFN A",SUP-04.045.082TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,957.42,570.23,957.42,28,189.34,1383.8,"percent of total billed charges",
"EXP TISSUE 14X13CM BREAST 500ML STYLE 133MV TEXTURE",SUP-133MV-14,CDM,C1789,HCPCS,0278,RC,,,both,,,5460.00,1638,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1562.65,28.62,,,,,0,635,4641,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ARROW ADVANCER VASCULAR 26 13/16IN .035IN 1 END MARK",SUP-AW-14735,CDM,C1769,HCPCS,0272,RC,,,both,,,84.91,25.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.88,72.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 12MM 144CM 3.5MM CORONARY STENT",SUP-H7493952812350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2554.34,45.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINX LAPAROSCOPIC ESOPHAGUS SIZING TOOL",SUP-LST,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 18CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175199180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA [10200]","Cigna Open Access",,830.8,,,,,,,169.81,1241.09,"percent of total billed charges",
"LENS IOL ACRYSOF IQ NATURAL STABLEFORCE ACRYSERT APHAKIA",SUP-SN60WF.155,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 525ML GEL ROUND SMOOTH MEMORYGEL SILICONE P4.4CM","SUP-3505251 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"KAISER [10500]",Kaiser,,2462.25,67,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE STD 24.5CMX2MM POLYESTER SILICONE",SUP-TR200000,CDM,C1763,HCPCS,0278,RC,,,both,,,6955.20,2086.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4729.54,68,,,,,0,808.89,5911.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 60MM 80CM 12MM BILIARY VENOUS DELIVERY",SUP-G57433,CDM,C1876,HCPCS,0278,RC,,,both,,,13800.00,4140,"CIGNA [10200]",Cigna,,5520,40,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cpap Circuit",PX-E27000099,CDM,E27000099,LOCAL,0270,RC,,,both,,,443.98,133.19,"CIGNA [10200]",Cigna,,301.91,68,,,,,0,51.63,377.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSORB GT1 12MM 3MM CORONARY EVEROLIMUS ELUTING POLY L",SUP-1235300-12,CDM,C1874,HCPCS,0278,RC,,,both,,,8280.00,2484,"AMERIGROUP MEDICAID [20100]",Amerigroup,,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT SHOULDER GLENOID TRABECULAR METAL TOTAL",SUP-98000971501,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3480.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 475CC SUT TAB INTEGRAL INJECTION DOME",SUP-SDC-130H,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"CIGNA [10200]","Cigna Local Plus",,3749.29,,,,,,,1384.26,10117.13,"percent of total billed charges",
"STENT RX BILIARY SYSTEM 5CM 8.5FR DUODENAL BEND BILIARY",SUP-M00545650,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"NOVANET [10819]",Novanet,,639.58,75,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2 OS-4 30IN BRAID GREEN NONABSORBABLE",SUP-X519H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 250MM 3MM BALLOON DILATATION DURALYN",SUP-48003025S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,163.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE COROLENE 4-0",SUP-20S15AL,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.89,14.67,"FIRST HEALTH [10303]","First Health",,39.11,80,,,,,0,5.69,41.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 36X24MM ENDOSKELETON TAS 7D 13MM LARGE TITANIUM",SUP-2307-0213,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross HMO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 20MM 6FR 2.5MM .07IN BALLOON",SUP-H7493918920250,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 25X3.5MM TITANIUM ENDOSCOPIC LINEAR CUTTER",SUP-EEAXL2535,CDM,S27200284,LOCAL,0272,RC,,,both,,,2399.55,719.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,279.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,279.07,2039.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135D 47MM MINI TAPER HIGH OFFSET 43.2MM 145MM",SUP-L20311,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"AETNA [10100]","Aetna HMO/PPO",,12590.51,79.5,,10981.53,8986.79,12413.38,12,1841.86,13461.55,"percent of total billed charges",
"(EVAL) CATHETER TURNPIKE 135CM 2.9FR 2.1FR VASCULAR GOLD MUL",SUP-5621,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 3MM DERMAL SURGICAL DISPOSABLE",SUP-33-53,CDM,S27200284,LOCAL,0272,RC,,,both,,,2.41,0.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.28,2.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Proc Resp Othr 1-1 Ea 15min",PX-410000016,CDM,G0238,HCPCS,0410,RC,,,both,,,315.00,94.5,"CIGNA [10200]",Cigna,,315,,"Per diem ($369).",,,,0,36.63,315,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Laryngeal Tube Fenestrated",PX-E27000262,CDM,A7520,HCPCS,0270,RC,,,both,,,661.10,198.33,"FIRST HEALTH [10303]","First Health",,528.88,80,,,,,0,45.47,561.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 11CM TOUCH NARROW BASE",SUP-EN2911,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"AETNA [10100]","Aetna HMO/PPO",,49846.5,79.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET SURGICAL 1235MM .016IN STERILE LATEX FREE DISPOSABLE",SUP-INS-5411,CDM,S27200284,LOCAL,0272,RC,,,both,,,733.05,219.91,"FIRST HEALTH [10303]","First Health",,586.44,80,,,,,0,85.25,623.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT 50X25X8MM SIGNAFUSE GLASS CLLGN TYPE 1",SUP-SGFS-010,CDM,C1713,HCPCS,0278,RC,,,both,,,12972.00,3891.6,"MULTIPLAN [10600]",Multiplan,,11026.2,85,,,,,0,1508.64,11026.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZOOM 45 REPERFUSION CATHETER",SUP-ICRC045144,CDM,S27200284,LOCAL,0272,RC,,,both,,,17146.50,5143.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7870.24,45.9,,,,,0,1994.14,14574.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLIDESHEATH SLENDER SS KIT, 0.021 GW, 5 FR, 16CM",SUP-80-1650,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 30MM 6FR 3.5MM",SUP-H7493926730350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC",307,MS-DRG,,,,,,,inpatient,,,29125.73,8737.72,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,6061.16,,"Case rate ($5,664.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,260, add-ons for qualifying new technology services are included. If operating cost exceeds $38,299.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,779.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,266.95. The transfer operating threshold is the transfer adjustment factor * $5,260.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $397.68. The transfer capital threshold is the transfer adjustment factor * $397.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,5664.64,22774.29,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veno Venous Sinus Jug Si",PX-320000137,CDM,75860,CPT,0320,RC,,,both,,,3756.23,1126.87,"BLUE CROSS [10001]","Blue Cross HMO",,237.49,,"Fee schedule rate ($237.49).",,,,0,114.47,3756.23,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 57CM .02IN 24MM PENUMBRA COIL 400 RUBY",SUP-RBY2C2457,CDM,S27800098,LOCAL,0278,RC,,,both,,,7098.00,2129.4,"NOVANET [10819]",Novanet,,5323.5,75,,,,,0,825.5,6033.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SLIP-CATH BEACON TIP 65CM 5FR ANGLE KUMPE CURVE",SUP-G12156,CDM,S27200284,LOCAL,0272,RC,,,both,,,468.16,140.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,55.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.45,397.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 23MM 2.75MM CORONARY STENT EVEROLIMUS",SUP-1550275-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"INSRT TIBIAL 7 8MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650708,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"MULTIPLAN [10600]",Multiplan,,11158.16,85,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER TEVDEK 2 K-61 30IN BRAIDED GREEN NONABSORBABLE",SUP-79-746,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X18X7MM RISE 3-15D",SUP-193.502,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"NOVANET [10819]",Novanet,,25751.25,75,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.6V 36MM 1 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18006136,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCOUT 5CM DELIVERY NEEDLE AND REFLECTOR",SUP-SSR05-01,CDM,A4648,HCPCS,0278,RC,,,both,,,3300.00,990,"PHCS [10601]",PHCS,,2310,70,,,,,0,383.79,2805,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 9.5CM MEMORYGEL P2.9CM MODERATE PLUS PROFILE",SUP-RSZ-1501,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Open Access",,921.78,56.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 3-0 KS 30IN MONOFILAMENT BLACK NONABSORBABLE",SUP-627H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 40MM 125CM 8MM VASCULAR PERIPHERAL OTW DRUG",SUP-G38495,CDM,C1874,HCPCS,0278,RC,,,both,,,7803.87,2341.16,"FIRST HEALTH [10303]","First Health",,6243.1,80,,,,,0,907.59,6633.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TRANSEND VASCULAR STRAIGHT 135CM 2CM .014IN SCITANIUM",SUP-M001468100,CDM,C1769,HCPCS,0272,RC,,,both,,,2062.50,618.75,"PHCS [10601]",PHCS,,1443.75,70,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC",520,MS-DRG,,,,,,,inpatient,,,88042.13,26412.64,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,9544.76,,"Case rate ($9,266.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,604.81, add-ons for qualifying new technology services are included. If operating cost exceeds $41,644.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,032.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $8,616.19. The transfer operating threshold is the transfer adjustment factor * $8,604.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.57. The transfer capital threshold is the transfer adjustment factor * $650.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,43615.9,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"MICAFUNGIN SODIUM 100 MG/5ML IV (WET SOLR VIAL)",RX-41577685,CDM,J2248,HCPCS,0636,RC,25021-0191-10,NDC,both,1,UN,1128.73,338.62,"UHC [10700]","United Healthcare",,49,,,,,,,29.37,959.42,"fee schedule",
"CUFF TRNQT CYL 12X3.5IN 2 PORT 2 BLADDER POSITIVE LOCK CNCT",SUP-60708010100,CDM,S27200284,LOCAL,0272,RC,,,both,,,284.49,85.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,33.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.09,241.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 40MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0317,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]","Cigna Open Access",,539.24,56.9,,1144.80,304.56,2275.09,66,110.22,805.55,"percent of total billed charges",
"HC Egd W Rmvl FB",PX-750000036,CDM,43247,CPT,0750,RC,,,both,,,4051.68,1215.5,"FIRST HEALTH [10303]","First Health",,3241.34,80,,,,,0,471.21,4051.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRINITY ELITE CANCELLOUS LARGE ALLOGRAFT FROZEN V",SUP-410003,CDM,C1713,HCPCS,0278,RC,,,both,,,20555.64,6166.69,"CIGNA [10200]",Cigna,,8222.26,40,,1831.33,1831.33,1831.33,16,2390.62,17472.29,"percent of total billed charges",
"SCR BONE 3.5MM 44MM T10 FULL THREAD STARDRIVE NONSTERILE",SUP-657444,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"BLUE CROSS [10001]","Blue Cross HMO",,317.01,39.2,,957.42,156.86,7483.26,51,94.05,687.4,"percent of total billed charges",
"CATH SABER 150CM 200MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020200M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,655.83,41.1,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 19MM 135CM 7MM 11MM 7FR .035IN",SUP-BXA071902A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CGUARD PRIME CAROTID STENT SYSTEM 135CM 08MM LENGTH 30MM",SUP-CND0830,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"FIRST HEALTH [10303]","First Health",,16606.8,80,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 10MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0101000,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"MULTIPLAN [10600]",Multiplan,,4319.57,85,,,,,0,591.02,4319.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OXF UNI TIB TRAY SZ E RM PMA",SUP-154727,CDM,C1776,HCPCS,0278,RC,,,both,,,11195.94,3358.78,"FIRST HEALTH [10303]","First Health",,8956.75,80,,,,,0,1302.09,9516.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1 LEFT MEDIAL RIGHT LATERAL PARTIAL KNEE",SUP-5610-F-101,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"NOVANET [10819]",Novanet,,7501.58,75,,,,,0,1163.24,8501.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tlpa Iliac Arty Ea Vssl",PX-481000006,CDM,0238T,CPT,0481,RC,,,both,,,14891.09,4467.33,"UHC [10700]","United Healthcare",,10242,,"Case rate ($10,242). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1731.83,12657.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VIPERWIRE ADVANCE VASCULAR .017IN .014IN PGW",SUP-VPR-GW-17,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 29MM 80CM 8MM LOW PROFILE THIN VASCULAR",SUP-1012624-29,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"CIGNA [10200]",Cigna,,5712,68,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PREVENA PEEL AND PLACE PATCH STRIPS VAC 13CM NEGATIVE",SUP-PRE1101US,CDM,S27200284,LOCAL,0272,RC,,,both,,,3522.60,1056.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,417.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,409.68,2994.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 38MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.038TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"PLATE 25MM TITANIUM 1 LEVEL PRELORDOSED BEND GROOVE VECTRA",SUP-04.613.016,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Mandible <4v",PX-320000186,CDM,70100,CPT,0320,RC,,,both,,,341.78,102.53,"UHC [10700]","United Healthcare",,216.45,,,,,,,39.75,290.51,"fee schedule",
"FOL URETHRAL 13.35IN 22FR HEYMAN PLASTIC COUDE TIP DILATION",SUP-021322,CDM,S27200284,LOCAL,0272,RC,,,both,,,242.30,72.69,"CIGNA [10200]","Cigna Open Access",,137.87,56.9,,,,,0,28.18,205.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC",853,MS-DRG,,,,,,,inpatient,,,95089.08,28526.72,"UHC [10700]","United Healthcare",,95089.08,,"Fee schedule rate ($144,187.37). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,95089.08,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRA-THIN SDS 75CM 40MM 5.8FR 9MM STD BALLOON",SUP-M001177110,CDM,C1725,HCPCS,0272,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 4CM 5.8FR 21FR BALLOON",SUP-M0062251030,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"AETNA [10100]","Aetna HMO/PPO",,1361.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,199.16,1455.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Celiac Plex",PX-510000146,CDM,64530,CPT,0761,RC,,,both,,,3958.01,1187.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,469.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,460.32,3958.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 140MM 80CM 8MM 6FR .035IN BILIARY",SUP-G50134,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"AMERIGROUP MEDICAID [20100]",Amerigroup,,721.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM 4.5MM 2.1-2.7FR CORONARY",SUP-RONYX45026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5754.00,1726.2,"MULTIPLAN [10600]",Multiplan,,4890.9,85,,,,,0,669.19,4890.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D +4.5 CYL MODIFY L 13MM 6MM POSTERIOR CHMBR 1",SUP-CNW0T7,CDM,V2787,HCPCS,0276,RC,,,both,,,355.00,106.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,42.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.29,301.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EVOLUT FX DELIVERY 34 MM",SUP-D-EVOLUTFX-34,CDM,S27200284,LOCAL,0272,RC,,,both,,,14559.00,4367.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1725.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1693.21,12375.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYPROPYLENE PROLENE MULTIPASS 3-0 PC-5 18IN",SUP-8632G,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.12,20.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,45.64,68,,,,,0,7.81,57.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG AUTOTRANSFUSION 400ML CARDIOPAT ORTHOPAT REPLACEMENT RBC",SUP-01200-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.68,40.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.66,114.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Kidney Img Flow W Drug Mult",PX-341000046,CDM,78709,CPT,0341,RC,,,both,,,3154.08,946.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.57,,,,,,,366.82,2680.97,"fee schedule",
"SYSTEM MEDIUM BONE CEMENT FEMUR PROXIMAL PRSSZR SEAL STERILE",SUP-0206546000,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.37,36.71,"MULTIPLAN [10600]",Multiplan,,104.01,85,,,,,0,14.23,104.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 47CM 14MM PRESTIGE PLUS HELICAL COMPLEX 18",SUP-PRES1447COM18,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5395.8,68,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309115,CDM,C1776,HCPCS,0278,RC,,,both,,,37771.65,11331.49,"CIGNA [10200]","Cigna Local Plus",,11898.07,31.5,,5372.07,4581.20,7242.98,23,4392.84,32105.9,"percent of total billed charges",
"SCR BONE 5MM 50MM NAIL-EX TITANIUM FULL THREAD TIBIA 2 CORE",SUP-04.015.540,CDM,C1713,HCPCS,0278,RC,,,both,,,1313.17,393.95,"NOVANET [10819]",Novanet,,984.88,75,,,,,0,152.72,1116.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 15MM 140CM 3MM CORONARY",SUP-RSINT30015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"NOVANET [10819]",Novanet,,4158,75,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC RIVACOR 1 CHMBR DF-4 CNCT LATEX FREE VRT",SUP-429536,CDM,C1722,HCPCS,0278,RC,,,both,,,56385.00,16915.5,"MULTIPLAN [10600]",Multiplan,,47927.25,85,,,,,0,6557.58,47927.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nrv Condct 3-4 Studies",PX-922000020,CDM,95908,CPT,0922,RC,,,both,,,2509.61,752.88,"FIRST HEALTH [10303]","First Health",,2007.69,80,,,,,0,291.87,2133.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT TRACTION UNIVERSAL LEG OPEN TOE STRAP FOAM VELCRO",SUP-8130-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,156.17,46.85,"CIGNA [10200]","Cigna Local Plus",,83.55,53.5,,,,,0,18.16,132.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Fem Art Perc Bio-Med 15f",PX-E27200380,CDM,E27200380,LOCAL,0272,RC,,,both,,,1442.10,432.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,592.7,41.1,,,,,0,167.72,1225.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VXSK-230P RF WIRE 63CM/55DEG/D0 SHEATH",SUP-VXSK0133,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"NOVANET [10819]",Novanet,,4631.63,75,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG VASCULAR 12 MM",SUP-9-PLUG-012,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"MULTIPLAN [10600]",Multiplan,,5249.18,85,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOLOIST 110CM 6FR 2-5-2MM SPACING CRD CURVE",SUP-44216UB,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"PHCS [10601]",PHCS,,510.3,70,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR ANGIOGRAPHY HEMOSTASIS VALVE GWIRE INSRT TOOL MONARCH",SUP-IN2430,CDM,S27200284,LOCAL,0272,RC,,,both,,,504.14,151.24,"NOVANET [10819]",Novanet,,378.11,75,,,,,0,58.63,428.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20GA 2.25IN ACCUCATH ACE BASIC STERILE LATEX FREE",SUP-AC1202250,CDM,S27200284,LOCAL,0272,RC,,,both,,,387.67,116.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,45.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.09,329.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN AMPLATZ",SUP-77803600,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Stent & Ather Cmplx Ea Add",PX-361000719,CDM,37278,CPT,0361,RC,,,both,,,17348.93,5204.68,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,17.35,14746.59,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE EXTRA S-PORT VASCULAR J 190CM 3CM .014IN",SUP-22225MJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET",RX-8958,CDM,,,0637,RC,00904-6938-06,NDC,both,1,UN,10.90,3.27,"CIGNA [10200]","Cigna Local Plus",,5.83,53.5,,,,,0,1.27,9.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR NEROSTIMLTR",SUP-3028,CDM,C1767,HCPCS,0278,RC,,,both,,,103882.50,31164.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12310.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12081.53,88300.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SMALL BLUNT 7.25IN NERVE VESSEL RETRACTION KRAYENBUEHL",SUP-58-3035,CDM,S27200284,LOCAL,0272,RC,,,both,,,475.47,142.64,"NOVANET [10819]",Novanet,,356.6,75,,,,,0,55.3,404.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS LAPAROSCOPIC 35CM 2 EDGE BLADE ROTATION DIAL",SUP-CB030,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,30.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 5FR 4MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-04041,CDM,C1725,HCPCS,0272,RC,,,both,,,972.00,291.6,"FIRST HEALTH [10303]","First Health",,777.6,80,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 383049 SELECTSECURE ACT BI SILI",SUP-383049,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"AETNA [10100]","Aetna HMO/PPO",,1774.84,79.5,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30MM 4MM VORTX 35 COIL PUSHABLE 4MM",SUP-M0013732041,CDM,S27800098,LOCAL,0278,RC,,,both,,,769.50,230.85,"FIRST HEALTH [10303]","First Health",,615.6,80,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL STANDARD+ KNEE RIGHT STABILIZE CEMENT ROTATE",SUP-129411050,CDM,C1776,HCPCS,0278,RC,,,both,,,31285.80,9385.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3707.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3638.54,26592.93,"percent of total billed charges",
"STENT GORE VIABAHN 29MM 135CM 5MM 8MM 7FR .035IN",SUP-BXA052902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UHC [10700]","United Healthcare",,12346.54,63.3,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 26MM COCR",SUP-VAL-35260-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,963.9,45.9,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.5/13",SUP-401736,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 100MM 10MM 7FR BILIARY VENOUS SELF EXPAND",SUP-G57430,CDM,C1876,HCPCS,0278,RC,,,both,,,13109.93,3932.98,"CIGNA [10200]","Cigna Local Plus",,4129.63,31.5,,,,,0,1524.68,11143.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS 5-0 RB-1 30IN 2 ARM ANTIBACTERIAL VIOLET",SUP-PDP320H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 13CM 5.5MM STERLING 12000 RPM SPHERE LARGE HUB",SUP-H9112,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE KYPHON XPEDE SPINAL MIXER",SUP-CX01B,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.75,405.82,"PHCS [10601]",PHCS,,946.93,70,,,,,0,157.32,1149.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 12MM 1.14MM 6MM GOODE T EAR SILICONE FLANGE",SUP-24751,CDM,S27800098,LOCAL,0278,RC,,,both,,,229.87,68.96,"CIGNA [10200]","Cigna Open Access",,130.8,56.9,,,,,0,26.73,195.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 55MM 20-25MM AFX ILIAC LIMB STRATA AAA STERILE","SUP-IS20-25/C55 SA",CDM,C1874,HCPCS,0278,RC,,,both,,,23373.00,7011.9,"FIRST HEALTH [10303]","First Health",,18698.4,80,,,,,0,2718.28,19867.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR NEROSTIMLTR",SUP-3028,CDM,C1767,HCPCS,0278,RC,,,both,,,103882.50,31164.75,"BLUE CROSS [10001]","Blue Cross HMO",,40721.94,39.2,,24070.31,24070.31,24070.31,"1 through 10",12081.53,88300.13,"percent of total billed charges",
"OCTREOTIDE ACETATE 500 MCG/ML INJECTION SUPERORDERABLE",RX-409441,CDM,J2354,HCPCS,0637,RC,00641-6176-01,NDC,both,1,ML,264.18,79.25,"MULTIPLAN [10600]",Multiplan,,224.55,85,,,,,0,15.51,224.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Bn Survey Complete",PX-320000181,CDM,77075,CPT,0320,RC,,,both,,,1478.24,443.47,"PHCS [10601]",PHCS,,1034.77,70,,,,,0,115.51,1256.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPIC VASCULAR 6X80X75",SUP-H74939200068070,CDM,C1725,HCPCS,0272,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 15MM 3.5MM BALLOON DILATATION PACLITAXEL",SUP-H7493960815350,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"CIGNA [10200]",Cigna,,26453.7,68,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 15MM HELIX R SPINE SELF TAP FIX ANGLE",SUP-7806215,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,117.75,860.63,"percent of total billed charges",
"LINER ACETABULAR RINGLOC +3MM 26 40MM ARCOMXL HIP STERILE",SUP-XL-108526,CDM,C1776,HCPCS,0278,RC,,,both,,,7249.14,2174.74,"PHCS [10601]",PHCS,,5074.4,70,,,,,0,843.07,6161.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 14CM 26MM 14.5MM GORE EXCLUDER C3 TRUNK",SUP-RLT261414,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C-Reactive Protein",PX-302000014,CDM,86140,CPT,0302,RC,,,both,,,292.60,87.78,"CIGNA [10200]","Cigna Local Plus",,11.4,,,,,,,0.29,248.71,"fee schedule",
"LENS IOL SY60WF.100 CLAREON",SUP-SY60WF.100,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25X10X7MM VERTE-STACK CRESCENT 6D",SUP-9192507,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1962.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE W8XL12CM THK2-2.79MM READY TO USE ALLODER",SUP-151996,CDM,C1889,HCPCS,0278,RC,,,both,,,17835.30,5350.59,"CIGNA [10200]",Cigna,,7134.12,40,,,,,0,2074.25,15160.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.2MM QUICK RELEASE",SUP-201-78-89,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CRE RX 5.5CM 10-11-12MM BALLOON DILATATION BILIARY",SUP-M00558880,CDM,C1726,HCPCS,0272,RC,,,both,,,2085.75,625.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1418.31,68,,,,,0,242.57,1772.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 16X6MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2406,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1144.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1123.46,8211,"percent of total billed charges",
"CATH TYSHAK II 100CM 6CM 8FR 20MM BALLOON DILATATION DEHP",SUP-611934,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,450.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,442.08,3231.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 76MM 10.8MM 15MM 6.4MM WITHOUT CUFF REUSABLE INNER CANN",SUP-6CFS,CDM,S27200284,LOCAL,0272,RC,,,both,,,700.49,210.15,"NOVANET [10819]",Novanet,,525.37,75,,,,,0,81.47,595.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL RESTORIS 6 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-180606,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,770.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,770.77,5633.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.160 CLAREON",SUP-SY60WF.160,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Combiderm",PX-E27200107,CDM,E27200107,LOCAL,0272,RC,,,both,,,74.80,22.44,"CIGNA [10200]","Cigna Local Plus",,40.02,53.5,,,,,0,8.7,63.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vitamin B6",PX-301000386,CDM,84207,CPT,0301,RC,,,both,,,270.40,81.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,44.2,,,,,,,0.01,229.84,"fee schedule",
"CATH BARDEX IC 14FR URETHRAL BACTI-GUARD RUBBER HYDROGEL 5CC",SUP-0168SI14,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.14,33.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.81,93.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 15MM 1.5MM BALLOON DILATATION RAPID",SUP-47515015S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"FIRST HEALTH [10303]","First Health",,1276.56,80,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 16MM ALPS TIMAX HAND CORTICAL NONLOCK SQUARE",SUP-131220516,CDM,C1713,HCPCS,0278,RC,,,both,,,1032.75,309.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,702.27,68,,,,,0,120.11,877.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 137MM CEMENT ACCOLADE C 132D 4 42MM OFFSET HIP",SUP-6058-0435D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1911.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1911.88,13973.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Creatinine Clearance",PX-301000169,CDM,82575,CPT,0301,RC,,,both,,,353.40,106.02,"FIRST HEALTH [10303]","First Health",,282.72,80,,,,,0,0.35,300.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3.5MM CEREPAK MICRO UNIFORM DETACHABLE",SUP-FCX100356,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"NOVANET [10819]",Novanet,,9919.39,75,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Set Ndl 15mm Ez-Io",PX-E27200302,CDM,E27200302,LOCAL,0272,RC,,,both,,,808.50,242.55,"KAISER [10500]",Kaiser,,541.7,67,,,,,0,94.03,687.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Programming Device Eval Impl Ccm-D Sys in Person",PX-481000421,CDM,0926T,CPT,0481,RC,,,both,,,58.00,17.4,"PHCS [10601]",PHCS,,40.6,70,,,,,0,6.75,58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT THROMBOLYTIC 65CM 5FR 6FR ARROW-TREROTOLA PTD 9MM",SUP-PT-45509,CDM,C1757,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2269.5,68,,,,,0,388.15,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT THROMBOLYTIC 65CM 5FR 6FR ARROW-TREROTOLA PTD 9MM",SUP-PT-45509,CDM,C1757,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,395.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,388.15,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSUFLOW PORT 8MM",SUP-4100-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hzv Vacc Recombinant Im Njx",PX-771000022,CDM,90750,CPT,0636,RC,,,both,,,583.00,174.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,69.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.09,495.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM SPINE POLYAXIAL REVOLVE",SUP-185.456,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"MULTIPLAN [10600]",Multiplan,,8114.82,85,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.8MM 200MM 50MM LCP ANKLE COMPRESSION THREAD",SUP-03.118.050,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,1831.33,1831.33,1831.33,16,50.59,369.75,"percent of total billed charges",
"SPLINT NASAL 2.63INX1.73IN LARGE THERMOPLASTIC THERMASPLINT",SUP-1529020,CDM,S27000186,LOCAL,0270,RC,,,both,,,204.45,61.33,"AETNA [10100]","Aetna HMO/PPO",,162.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.78,173.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 12.5X7.6MR HALL RECIPROCATE OR STERILE",SUP-505229100,CDM,S27200284,LOCAL,0272,RC,,,both,,,357.74,107.32,"PHCS [10601]",PHCS,,250.42,70,,,,,0,41.61,304.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.3/4F DECA 18-2-5-2 S 120CM",SUP-904252,CDM,C1730,HCPCS,0272,RC,,,both,,,6210.00,1863,"AETNA [10100]","Aetna HMO/PPO",,4936.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.75MM X 10.0MM",SUP-493751012,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 80CM 60MM 10MM .035IN BALLOON",SUP-AB35W10060080,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"KAISER [10500]",Kaiser,,453.7,67,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PREMIER THR OSSEOTI E1 CERAMIC HIP STEM CUP LINER",SUP-98000100203,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"KAISER [10500]",Kaiser,,18572.4,67,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA EXTRA FULL PROFILE SOFT TOUCH",SUP-SSX-445,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"MULTIPLAN [10600]",Multiplan,,6422.18,85,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRINITY ELITE MEDIUM ALLOGRAFT",SUP-410002,CDM,C1713,HCPCS,0278,RC,,,both,,,11538.87,3461.66,"CIGNA [10200]","Cigna Open Access",,3865.52,33.5,,1144.80,304.56,2275.09,66,1341.97,9808.04,"percent of total billed charges",
"CATH CORDIS SUPER TORQUE MB 110CM 5FR .0395IN PIGTAIL CURVE",SUP-532598B,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"CIGNA [10200]","Cigna Open Access",,173.26,56.9,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.2MM TWIST STERILE",SUP-KM166-00-04,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.04,24.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 16FR NEPHRSTMY 5CC 2 WAY FOLEY STERILE",SUP-087016,CDM,C1758,HCPCS,0278,RC,,,both,,,343.48,103.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,40.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",11.23,7.03,11.23,"1 through 10",39.95,291.96,"percent of total billed charges",
"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC",497,MS-DRG,,,,,,,inpatient,,,46072.79,13821.84,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,7944.87,,"Case rate ($7,495.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,959.76, add-ons for qualifying new technology services are included. If operating cost exceeds $39,999.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,908.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $6,968.97. The transfer operating threshold is the transfer adjustment factor * $6,959.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $526.19. The transfer capital threshold is the transfer adjustment factor * $526.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7495.16,35277.53,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CERES-C 6MM INTERBODY PLATE",SUP-SK-08-170-06,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross HMO",,2434.32,39.2,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC",761,MS-DRG,,,,,,,inpatient,,,25916.12,7774.84,"CIGNA [10200]",Cigna,,17234.41,,"Fee schedule rate ($17,234.41). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,25916.12,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 12CM LEGEND 3MM 2 FLUTE MATCH HEAD DISSECTING BURR",SUP-T12MH30M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"CIGNA [10200]","Cigna Local Plus",,625.32,53.5,,,,,0,135.93,993.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC T3 Reverse",PX-301000424,CDM,84482,CPT,0301,RC,,,both,,,190.00,57,"NOVANET [10819]",Novanet,,142.5,75,,,,,0,0.01,161.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 20MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560020L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 2-0 CT-1 45CM SUT ABSORBABLE",SUP-ETSXP1A403,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"FIRST HEALTH [10303]","First Health",,192.24,80,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Spinal Cord",PX-361000259,CDM,62269,CPT,0361,RC,,,both,,,1892.03,567.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,224.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.89,1892.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE 9MM 230CM 2.4MM EXACTO COLD BRAID WIRE CLEAN CUT",SUP-BX00711115,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.70,28.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,39.33,41.1,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE 20IN 36FR RIGHT ANGLE DRNG PVC THORACIC 6 EYELET",SUP-8888571067,CDM,C1729,HCPCS,0272,RC,,,both,,,138.54,41.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,94.21,68,,,,,0,16.11,117.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hdr Rdncl Skn Surf Brachytx > 2 Chnl",PX-342000017,CDM,77768,CPT,0333,RC,,,both,,,6814.10,2044.23,"NOVANET [10819]",Novanet,,5110.58,75,,,,,0,408.8,5791.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SWAN NECK CURL CATH 62.5CM 15FR 180D PERITONEAL",SUP-8888413807,CDM,C1750,HCPCS,0278,RC,,,both,,,1188.25,356.47,"KAISER [10500]",Kaiser,,796.13,67,,,,,0,138.19,1010.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR REGULAR 45MM ECHELON THICK TISSUE LINEAR CUTTER",SUP-GST45B,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 10X6IN MEPITEL ONE SAFETAC NONADHERENT LATEX FREE",SUP-289700,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.11,41.73,"CIGNA [10200]",Cigna,,94.59,68,,,,,0,16.18,118.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 66MM 36MM MARATHON HIP",SUP-121936066,CDM,C1776,HCPCS,0278,RC,,,both,,,8942.40,2682.72,"KAISER [10500]",Kaiser,,5991.41,67,,,,,0,1040,7601.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC E-Stim Unattended (Gp)",PX-420000042,CDM,G0282,HCPCS,0420,RC,,,both,,,355.00,106.5,"BLUE CROSS [10001]","Blue Cross HMO",,344.92,,"Per diem ($344.92).",,,,0,41.29,355,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"TMPLT BENDING PELVIC 16 HOLE 3.5 MM LOW PROFILE",SUP-03.100.035,CDM,S27000186,LOCAL,0270,RC,,,both,,,855.04,256.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,101.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.44,726.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 17GA 16.8CM BIOPINCE OPTIONAL COAXIAL FULL CORE",SUP-MCXS1820BP,CDM,S27200284,LOCAL,0272,RC,,,both,,,168.78,50.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.63,143.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 175MM 24MM 19MM STD NECK S-ROM CERAMIC 135D",SUP-523196,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2304.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2262.18,16533.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 4 11MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-411,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"BLUE CROSS [10001]","Blue Cross HMO",,3853.56,39.2,,5311.50,4717.44,5388.59,31,1143.29,8355.94,"percent of total billed charges",
"COIL EMBOLIZATION 8CM 3.5MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-3.5-8-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3347.25,28.62,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 80MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"NOVANET [10819]",Novanet,,1075.28,75,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 10MM 3.2-2.4-2.6FR 1.5MM BALLOON",SUP-SPR1510W,CDM,C1725,HCPCS,0272,RC,,,both,,,607.50,182.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,249.68,41.1,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 16MM 144CM 2.25MM CORONARY STENT PEBAX",SUP-H7493926016220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"NOVANET [10819]",Novanet,,4173.75,75,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 20MM 120CM 7MM 6FR VASCULAR NITINOL PERIPHERAL",SUP-S-70-020-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4196.41,45.9,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC XS 12-15IN LEFT CAWLEY TENSION HINGE",SUP-14191,CDM,S27000186,LOCAL,0270,RC,,,both,,,515.57,154.67,"KAISER [10500]",Kaiser,,345.43,67,,,,,0,59.96,438.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 24FR SILICONE PULL RADIOPAQUE MED PORT MIC SECUR-LOK",SUP-7180-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.81,228.54,"AETNA [10100]","Aetna HMO/PPO",,605.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,88.6,647.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE TIGRIS 80MM 120CM 5MM VASCULAR CBAS NITINOL",SUP-PHA050802A,CDM,C1874,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4239.67,41.1,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 12D-30D BAND STD 24FR PLASMABAND",SUP-WA22723S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3215.54,964.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,381.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,373.97,2733.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET IMPL INTERNALBRACE SWIVELOCK FIBERTAPE 3.5MM 2 2 NDL",SUP-AR-1678-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,7063.88,2119.16,"FIRST HEALTH [10303]","First Health",,5651.1,80,,,,,0,821.53,6004.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 7MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035477200,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3810.95,27,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 13MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G413,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1109.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1089.28,7961.17,"percent of total billed charges",
"SOL DIALYSATE 100 MEQ SODIUM 3 MEQ POTASSIUM 2.25 MEQ",SUP-08-3231-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,44.59,13.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18.33,41.1,,,,,0,5.19,37.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 33MM BOVINE PERICARDIUM LEAFLET COBALT CHROMIUM",SUP-11400M33,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"UHC [10700]","United Healthcare",,28712.88,63.3,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM PRESS FIT BASIC SUMMIT 5 12/14 TAPER HIP",SUP-157005110,CDM,C1776,HCPCS,0278,RC,,,both,,,9090.75,2727.22,"FIRST HEALTH [10303]","First Health",,7272.6,80,,,,,0,1057.25,7727.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR INJECTION MEDRAD STELLANT FLEX 2 LARGE SALINE SMALL",SUP-FLEXD-200-SCS,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"FIRST HEALTH [10303]","First Health",,87,80,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 62MM 36MM ALTRX HIP",SUP-122136162,CDM,C1776,HCPCS,0278,RC,,,both,,,6814.08,2044.22,"PHCS [10601]",PHCS,,4769.86,70,,,,,0,792.48,5791.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 65MM CONDYLAR VARIABLE ANGLE CANNULATED LOCK",SUP-42.231.665,CDM,C1713,HCPCS,0278,RC,,,both,,,1693.95,508.18,"CIGNA [10200]","Cigna Local Plus",,906.26,53.5,,3978.14,359.25,3978.14,24,197.01,1439.86,"percent of total billed charges",
"CAP KIT REPLACEMENT SHOULDER HUMERAL GLENOID TRABECULAR META",SUP-98000972001,CDM,C1776,HCPCS,0278,RC,,,both,,,33075.00,9922.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8930.25,27,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 32MM DCP LC-DCP STAINLESS STEEL PROXIMAL",SUP-204.232,CDM,C1713,HCPCS,0278,RC,,,both,,,177.48,53.24,"CIGNA [10200]","Cigna Local Plus",,94.95,53.5,,3978.14,359.25,3978.14,24,20.64,150.86,"percent of total billed charges",
"PAD 5YDX12INX1/32IN MOLESKIN ADHSV BACK SOFT LINE CAST",SUP-AC3002-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,440.40,132.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,181,41.1,,,,,0,51.22,374.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 20CM 6FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552300,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,816.39,68,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 78MM PRESS FIT AEQUALIS ASCEND FLEX PTC 132.5D",SUP-DWF604B,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UHC [10700]","United Healthcare",,7975.8,63.3,,8601.07,8395.67,8601.07,"1 through 10",1465.38,10710,"percent of total billed charges",
"VIABAHN BX BALLOON EXP ENDO 6MMX79MM 7FR 80CMCATH HEPARIN",SUP-BXB067901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"BLUE CROSS [10001]","Blue Cross HMO",,8391.7,39.2,,9776.84,9776.84,9776.84,"1 through 10",2489.68,18196.29,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 23MM 145CM 2.75MM CORONARY STENT",SUP-1145275-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 5MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-505,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3544.36,27,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Stool Culture Aerobic Bact Ea",PX-306000008,CDM,87046,CPT,0306,RC,,,both,,,324.90,97.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,14.85,,,,,,,0.01,276.17,"fee schedule",
"HC Grft T/a/L >= 100scm Ea Adl 100sq Cm",PX-510000053,CDM,15274,CPT,0761,RC,,,both,,,670.00,201,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,77.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.92,670,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Sld Lvl III / Add on 88304",PX-312000089,CDM,0752T,CPT,0312,RC,,,both,,,100.00,30,"NOVANET [10819]",Novanet,,75,75,,,,,0,11.85,85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT CONTRACTURE DEROYAL MEDIUM ANKLE ANTIROTATION BAR PAD",SUP-4301C,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 73X40X14IN UNIFY CRT-D 2.5V 500OHM 60 PPM",SUP-CD3231-40Q,CDM,C1882,HCPCS,0278,RC,,,both,,,45926.50,13777.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5341.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5341.25,39037.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY PROC 10CM TRU-CLOSE THORACIC VENT STERILE 13FR",SUP-TV13-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.00,513,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Positioning Aid Neonate",PX-E27000146,CDM,E27000146,LOCAL,0270,RC,,,both,,,350.90,105.27,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBING SUCTION 30CM 8FR T SILICONE TRANSLUCENT STERILE LATEX",SUP-SU130-1224,CDM,S27200284,LOCAL,0272,RC,,,both,,,2175.00,652.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHIBOND EXCEL TAPERCUT THK1.5MM 2-0 V-5 30IN 2 ARM",SUP-PXX50,CDM,S27200284,LOCAL,0272,RC,,,both,,,458.91,137.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT ENDOVASCULAR 39MM 20MM 6MM 16FR ZENITH SPIRAL-Z ILIAC",SUP-G55240,CDM,C1874,HCPCS,0278,RC,,,both,,,10643.25,3192.97,"KAISER [10500]",Kaiser,,7130.98,67,,,,,0,1237.81,9046.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 5MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140512,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"PHCS [10601]",PHCS,,8317.26,70,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 CURVE 15MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962033,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6289.63,68,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL FRONT LOAD BUTTON",SUP-786500,CDM,S27200284,LOCAL,0272,RC,,,both,,,3360.38,1008.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1542.41,45.9,,,,,0,390.81,2856.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Combiderm",PX-E27200107,CDM,E27200107,LOCAL,0272,RC,,,both,,,74.80,22.44,"NOVANET [10819]",Novanet,,56.1,75,,,,,0,8.7,63.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 3.5MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES3530CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,858.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cryptococcal Ag Ref",PX-302000088,CDM,86403,CPT,0302,RC,,,both,,,180.75,54.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10.28,,"Fee schedule rate ($10.28).",,,,0,6.91,153.64,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 8MM 14MM STAINLESS STEEL STD CORTEX LARGE",SUP-214.014,CDM,C1713,HCPCS,0278,RC,,,both,,,464.78,139.43,"MULTIPLAN [10600]",Multiplan,,395.06,85,,,,,0,54.05,395.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULAR SEG STRUT 100MM SPINE",SUP-810000,CDM,S27800098,LOCAL,0278,RC,,,both,,,4033.05,1209.91,"KAISER [10500]",Kaiser,,2702.14,67,,,,,0,469.04,3428.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Revise Hepatic Shunt (Tips)",PX-361000130,CDM,37183,CPT,0361,RC,,,both,,,33723.54,10117.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4977.25,,"Case rate ($4,977.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,3922.05,28665.01,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Npwt >50 Sq Cm W/Dme",PX-510000170,CDM,97606,CPT,0761,RC,,,both,,,817.41,245.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,96.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,95.06,817.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM BIO-SWIVELOCK SELF PUNCH 24.5MM STERILE",SUP-AR-2323PSLM,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.00,945,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,373.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,366.35,2677.5,"percent of total billed charges",
"CATH NAVISTAR THERMOCOOL 115CM 3.5MM 7.5FR 2-5-2MM SPACE J",SUP-NI75TCJH,CDM,C1732,HCPCS,0272,RC,,,both,,,16256.40,4876.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6681.38,41.1,,,,,0,1890.62,13817.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 34X12-15MM MAGNIFY-S 15D LORDOTIC 26MM EXPAND",SUP-1126.1212,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,12260.81,28.62,,,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM SKYLINE TITANIUM 20- D SPINE SELF DRILL",SUP-186850016,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]",Cigna,,688.5,68,,1831.33,1831.33,1831.33,16,117.75,860.63,"percent of total billed charges",
"HEAD FEMORAL 28MM HIP TAPERED BIOLOX",SUP-6519-1-028,CDM,C1776,HCPCS,0278,RC,,,both,,,7564.28,2269.28,"AETNA [10100]","Aetna HMO/PPO",,6013.6,79.5,,10981.53,8986.79,12413.38,12,879.73,6429.64,"percent of total billed charges",
"SCR BONE 14MM SKYLINE TITANIUM SPINE SELF DRILL VARIABLE",SUP-186850014,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 NARROW KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500006202,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"AETNA [10100]","Aetna HMO/PPO",,18175.85,79.5,,10981.53,8986.79,12413.38,12,2658.93,19433.3,"percent of total billed charges",
"COIL EMBOLIZATION 190CM 4.5CM 2.5MM GALAXY G3 MINI STRETCH",SUP-GLM925045,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"NOVANET [10819]",Novanet,,8911.35,75,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP 3 HOLE POLY POROUS R3 STD STERILE",SUP-71335552,CDM,C1776,HCPCS,0278,RC,,,both,,,14365.80,4309.74,"PHCS [10601]",PHCS,,10056.06,70,,,,,0,1670.74,12210.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 25CM 10FR PIGTAIL CURVE DRNG POLYURETHANE",SUP-RLC-10-038,CDM,C1729,HCPCS,0272,RC,,,both,,,531.36,159.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PTCA CATHETER 4.0 X 10MM (640-104-1U) SCOREFLEX NC SCORING",SUP-SD36003-22,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 90CM 7FR IMA CURVE GUIDING CORONARY",SUP-LA7IMAD,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Dgtz Gls Mcrscp Fna 1st Ea / Add on 88172",PX-311000086,CDM,0835T,CPT,0311,RC,,,both,,,104.00,31.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MICROFIBRILLAR COLLAGEN HEMOSTAT TOPICAL POWDER IN PACKET",RX-155885,CDM,,,0250,RC,53276-1010-01,NDC,both,1,UN,727.34,218.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 4MM CANNULATED AO COUPLING 4MM SCR NONSTERILE",SUP-702446,CDM,S27200284,LOCAL,0272,RC,,,both,,,2060.10,618.03,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Hepatitis B Core Ab Total",PX-302000144,CDM,86704,CPT,0302,RC,,,both,,,301.15,90.34,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,18.95,,,,,,,0.3,255.98,"fee schedule",
"SCR BONE 7.5MM 80MM CD HORIZON SPINE MULTIAXIAL CANNULATED",SUP-25840017580,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 115CM 1.7FR 8MM MULTIWIRE BASKET KINK RESISTANT",SUP-G48294,CDM,S27200284,LOCAL,0272,RC,,,both,,,2063.25,618.97,"KAISER [10500]",Kaiser,,1382.38,67,,,,,0,239.96,1753.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732048,CDM,C1776,HCPCS,0278,RC,,,both,,,9510.48,2853.14,"AETNA [10100]","Aetna HMO/PPO",,7560.83,79.5,,10981.53,8986.79,12413.38,12,1106.07,8083.91,"percent of total billed charges",
"STEM HUMERAL 39MM TRUNION ARTHREX ECLIPSE",SUP-AR-9301-39CPC,CDM,C1776,HCPCS,0278,RC,,,both,,,9239.10,2771.73,"BLUE CROSS [10001]","Blue Cross PPO",,3621.73,39.2,,3949.44,3949.44,3949.44,"1 through 10",1074.51,7853.24,"percent of total billed charges",
"COVER BURR HOLE 17MM MATRIXNEURO MIDFACE CRANIOFACIAL",SUP-04.503.023,CDM,C1713,HCPCS,0278,RC,,,both,,,3753.60,1126.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1074.28,28.62,,,,,0,436.54,3190.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CLASSIC FLEX-NECK 62CM 5.3CM 3.5CM STD DIALYSIS ADULT 2",SUP-CF-5243,CDM,C1750,HCPCS,0278,RC,,,both,,,1490.40,447.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,684.09,45.9,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 30MM 19MM FREESTYLE ROOT PORCINE BIOPROSTHESIS",SUP-FR995-19,CDM,S27800098,LOCAL,0278,RC,,,both,,,38430.00,11529,"CIGNA [10200]","Cigna Local Plus",,12105.45,31.5,,,,,0,4469.41,32665.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.5MM SOLID STERILE",SUP-829029070,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONCIERGE 100CM 7FR SBS3.5 MOD CURVE GUIDING STAINLESS",SUP-CGC7100SBS35-MSH,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL KNEE 8MM IDENTITY IMPRINT 3 TIBIAL INSRT POSTERIOR",SUP-TPS-030-083S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED II 100CM 4CM 9FR 23MM BALLOON DILATATION",SUP-611765,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXTR STONE 38CM 10FR 2CM BASKET RAPID ATRAUMATIC TIPLESS",SUP-G32862,CDM,S27200284,LOCAL,0272,RC,,,both,,,1266.03,379.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN NASAL CO2 SAMPLE O2 DELIVERY PEDIATRIC CAPNOFLEX DASH",SUP-2013066-005,CDM,S27000186,LOCAL,0270,RC,,,both,,,159.74,47.92,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT THROMBOLYTIC 65CM 5FR 6FR ARROW-TREROTOLA PTD 9MM",SUP-PT-45509,CDM,C1757,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT ARTICULAR 7-8 9MM KNEE CRUCIATE RETAIN DISH UHMWPE",SUP-71420790,CDM,C1776,HCPCS,0278,RC,,,both,,,11550.60,3465.18,"CIGNA [10200]","Cigna Local Plus",,3638.44,31.5,,5372.07,4581.20,7242.98,23,1343.33,9818.01,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 45CM 14/7MM BIFURCATED KNITTED GELSOFT",SUP-631407,CDM,C1768,HCPCS,0278,RC,,,both,,,5103.79,1531.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,604.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,593.57,4338.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tiss Marker Gold Kit",PX-E27800028,CDM,A4648,HCPCS,0278,RC,,,both,,,1630.20,489.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,193.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.59,1385.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP CIRCUMCISION CLEAR 1.3CM PLASTIBELL PLASTIC UNIQUE",SUP-HL9213,CDM,S27200284,LOCAL,0272,RC,,,both,,,57.47,17.24,"NOVANET [10819]",Novanet,,43.1,75,,,,,0,6.68,48.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE FIXED ANGLE SELF TAPPING STERILE 4MM 13MM ATLANTIS",SUP-876-713,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"SYSTEM SYNERGY 12MM 144CM 2.75MM CORONARY STENT EVEROLIMUS",SUP-H7493926112270,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"KAISER [10500]",Kaiser,,5778.75,67,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL PRE BENT TITANIUM 35MM X 110MM RELINE-C",SUP-3943110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 0 CT-1 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J346H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 30MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50030,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"FIRST HEALTH [10303]","First Health",,66419.78,80,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS RMT REDEL 125CM 4MM 7FR 2-5-2MM SPACE ABLATION",SUP-CR7TCS4RTU,CDM,C1733,HCPCS,0272,RC,,,both,,,8142.00,2442.6,"AETNA [10100]","Aetna HMO/PPO",,6472.89,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,946.91,6920.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +8 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-PCB0000080,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD 25CM 8FR PIGTAIL CURVE DRNG GLIDEX PERCUFLEX METAL",SUP-M001245071,CDM,C1729,HCPCS,0272,RC,,,both,,,850.50,255.15,"PHCS [10601]",PHCS,,595.35,70,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VISIGI 3D 40FR GASTRIC LAVAGE BULB",SUP-5240B,CDM,S27000186,LOCAL,0270,RC,,,both,,,1792.50,537.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,212.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,208.47,1523.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 295CC",SUP-RSZ-MPX-295S,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA [10200]","Cigna Local Plus",,84.63,53.5,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 215ML GEL SMOOTH MEMORYGEL SILICONE P2.8CM","SUP-3507215 MC",CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"AMERIGROUP MEDICAID [20100]",Amerigroup,,423.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR 54.5MM CARBIDE 3MM ROUND 6 FLUTE DENTAL",SUP-16-C0107,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.55,40.06,"FIRST HEALTH [10303]","First Health",,106.84,80,,,,,0,15.53,113.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 32MM 1 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-41F32V,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 7.6MM 1.27MM MODIFY T PC SILICONE 6MM",SUP-510-111C,CDM,S27800098,LOCAL,0278,RC,,,both,,,282.38,84.71,"FIRST HEALTH [10303]","First Health",,225.9,80,,,,,0,32.84,240.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 10FT INTERPULSE SUCTION TUBE HNDPC STERILE LATEX FREE",SUP-210100000,CDM,S27000186,LOCAL,0270,RC,,,both,,,249.50,74.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,29.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.02,212.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 30MM 140CM 4MM CORONARY STERILE LATEX",SUP-453966,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 8MM 140CM 4MM CORONARY STENT CARBOSIL",SUP-LUN400R08US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Entire Spine 6v>",PX-320000203,CDM,72084,CPT,0320,RC,,,both,,,892.00,267.6,"BLUE CROSS [10001]","Blue Cross HMO",,258.07,,"Fee schedule rate ($258.07).",,,,0,103.74,758.2,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 11MM COCR",SUP-VAL-20110-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]","Cigna Local Plus",,762.7,53.5,,3978.14,359.25,3978.14,24,165.8,1211.76,"percent of total billed charges",
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 2.5MM CORONARY STENT",SUP-H7493941820250,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Open Access",,1707,56.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT COMPREHENSIVE VIVACIT-E TRABECULAR METAL",SUP-98000900075,CDM,C1776,HCPCS,0278,RC,,,both,,,54810.00,16443,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,15686.62,28.62,,,,,0,6374.4,46588.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS02006,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"NOVANET [10819]",Novanet,,8792.33,75,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 25MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.025,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"FIRST HEALTH [10303]","First Health",,165.09,80,,,,,0,24,175.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO2 VASCULAR 200CM 35CM .014IN NITINOL STAINLESS",SUP-M00326110,CDM,C1769,HCPCS,0272,RC,,,both,,,4186.64,1255.99,"KAISER [10500]",Kaiser,,2805.05,67,,,,,0,486.91,3558.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL LONG 110MM SOLID AO 2MM",SUP-P99-100-2011,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"NOVANET [10819]",Novanet,,753.3,75,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM RELINE-O SPINE POLYAXIAL TRACTION",SUP-13116545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"LEAD DEFIB 79CM 4.7FR OMNIASECURE MRI SURESCAN 1 COIL",SUP-3930M79,CDM,C1777,HCPCS,0278,RC,,,both,,,31468.50,9440.55,"BLUE CROSS [10001]","Blue Cross HMO",,12335.65,39.2,,,,,0,3659.79,26748.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CRE RX 5.5CM 10-11-12MM BALLOON DILATATION BILIARY",SUP-M00558880,CDM,C1726,HCPCS,0272,RC,,,both,,,2085.75,625.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,857.24,41.1,,,,,0,242.57,1772.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER ENDOSCP TIP HOT SHEARS DA VINCI ENDOWRIST 8MM STD CAUT",SUP-400180,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA [10200]","Cigna Open Access",,103.96,56.9,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 118MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 10",SUP-71357110,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"BLUE CROSS [10001]","Blue Cross HMO",,12991.33,39.2,,5311.50,4717.44,5388.59,31,3854.32,28169.98,"percent of total billed charges",
"SCR BONE 4MM 50MM DCP LC-DCP STAINLESS STEEL FULL THREAD",SUP-206.050,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"NOVANET [10819]",Novanet,,205.22,75,,,,,0,31.82,232.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR EEG BIS BILATERAL",SUP-186-0212,CDM,S27000186,LOCAL,0270,RC,,,both,,,263.45,79.03,"MULTIPLAN [10600]",Multiplan,,223.93,85,,,,,0,30.64,223.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 6.35MM TSR2D PRECUT BENT",SUP-8371090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 10.5",SUP-DIB00U0105,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Islet Cell Ab",PX-302000075,CDM,86341,CPT,0302,RC,,,both,,,240.50,72.15,"CIGNA [10200]","Cigna Local Plus",,51.85,,,,,,,0.01,204.43,"fee schedule",
"GRAFT SOFT TISSUE 3X2CM MATRION PLACENTAL MEMB TROPHOBLAST",SUP-PAC06,CDM,Q4201,HCPCS,0636,RC,,,both,,,3300.00,990,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,204.57,,,,,,,204.57,2805,"fee schedule",
"MESH CRANIAL 38X50X1MM MEDPOR TITAN MTB CRANIOMAXILLOFACIAL",SUP-81026,CDM,C1713,HCPCS,0278,RC,,,both,,,8317.26,2495.18,"CIGNA [10200]","Cigna Local Plus",,4449.73,53.5,,3978.14,359.25,3978.14,24,967.3,7069.67,"percent of total billed charges",
"CATH SWAN-GANZ CONTROLCATH 110CM 7FR PULMONARY ARTERY",SUP-C146F7,CDM,C1751,HCPCS,0272,RC,,,both,,,3309.38,992.81,"MULTIPLAN [10600]",Multiplan,,2812.97,85,,,,,0,384.88,2812.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 15MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962343,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5961.06,41.1,,6417.48,6417.48,6417.48,"1 through 10",1686.79,12328.23,"percent of total billed charges",
"SCR BONE 4.75MM TITANIUM SPINAL SET NON BRAKE OFF NONSTERILE",SUP-5440130,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"FIRST HEALTH [10303]","First Health",,1925.28,80,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4.8MM STERLING GATOR LARGE HUB ARTHROSCOPY",SUP-C9262,CDM,S27200284,LOCAL,0272,RC,,,both,,,293.76,88.13,"NOVANET [10819]",Novanet,,220.32,75,,,,,0,34.16,249.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4.8MM STERLING GATOR LARGE HUB ARTHROSCOPY",SUP-C9262,CDM,S27200284,LOCAL,0272,RC,,,both,,,293.76,88.13,"PHCS [10601]",PHCS,,205.63,70,,,,,0,34.16,249.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MILNACIPRAN 25 MG TABLET",RX-97088,CDM,,,0637,RC,00456-1525-60,NDC,both,1,UN,38.69,11.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15.9,41.1,,,,,0,4.5,32.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 54MM CATHCART BALL HIP FEMORAL ORTHOCHROME",SUP-136354000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 9.75CM NATRELLE INSPIRA P4.1CM FULL PROFILE ROUND",SUP-MSZ-F200,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"NOVANET [10819]",Novanet,,118.64,75,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 11MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G711,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1012.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRUGSORB-ATR DEVICE","SUP-DSD 101",CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP CLUSTER HOLE HA TRIDENT D",SUP-502-11-50D,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,824.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,809.18,5914.06,"percent of total billed charges",
"CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR",RX-27633,CDM,,,0637,RC,60505-2807-07,NDC,both,1,UN,9.88,2.96,"PHCS [10601]",PHCS,,6.92,70,,,,,0,1.15,8.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM ORTHOLOC FULL THREAD CORTEX ANKLE FOOT 3",SUP-58813528,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"CIGNA [10200]",Cigna,,523.26,68,,1831.33,1831.33,1831.33,16,89.49,654.08,"percent of total billed charges",
"ANCHOR SUT 1.7MM 5 2 STRAIGHT SUTUREFIX ULTRA SHOULDER 1",SUP-72203853,CDM,C1713,HCPCS,0278,RC,,,both,,,1607.45,482.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,460.05,28.62,,,,,0,186.95,1366.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DRNG 28FR 21IN PLEUR-EVAC STRAIGHT SOFT THERMOSENSITIVE",SUP-DSTC-28S,CDM,C1729,HCPCS,0272,RC,,,both,,,53.94,16.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.27,45.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hep C Ampl Probe",PX-306000132,CDM,87521,CPT,0306,RC,,,both,,,414.20,124.26,"AETNA [10100]","Aetna HMO/PPO",,329.29,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,352.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH VASCULAR 9X2CM VASCU-GUARD PERIPHERAL BOVINE",SUP-VG0209N,CDM,C1768,HCPCS,0278,RC,,,both,,,2482.13,744.64,"FIRST HEALTH [10303]","First Health",,1985.7,80,,,,,0,288.67,2109.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 12/14 TAPER 28MM HIP OXINIUM ECHELON",SUP-71342804,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"BLUE CROSS [10001]","Blue Cross HMO",,6089.86,39.2,,5311.50,4717.44,5388.59,31,1806.76,13205.05,"percent of total billed charges",
"SCR BONE 1.5MM 7MM APTUS TRILOCK TITANIUM PHALANGEAL HAND",SUP-A-5250.07/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC GREEN 76MM OBTR TROCAR SEAL STERILE",SUP-012421,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"CIGNA [10200]",Cigna,,165.65,68,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 8MM DCP STAINLESS STEEL CORTICAL SELF TAPPING",SUP-201.808,CDM,C1713,HCPCS,0278,RC,,,both,,,358.09,107.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,42.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",41.65,304.38,"percent of total billed charges",
"VALVE SHUNT DELTA REGULAR CSF PERFORMANCE LEVEL .5 STERILE",SUP-24048,CDM,S27800098,LOCAL,0278,RC,,,both,,,12630.11,3789.03,"FIRST HEALTH [10303]","First Health",,10104.09,80,,,,,0,1468.88,10735.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3N KNEE RIGHT POSTERIOR STABILIZE LEGION",SUP-71421273,CDM,C1776,HCPCS,0278,RC,,,both,,,32536.35,9760.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8784.81,27,,,,,0,3783.98,27655.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 15ML 1-5MM CANCELLOUS ALLOGRAFT MILLED CHIP",SUP-400115,CDM,C1713,HCPCS,0278,RC,,,both,,,1923.75,577.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,227.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",223.73,1635.19,"percent of total billed charges",
"SUT VICRYL 9-0 BV100-3 5IN MONOFILAMENT COATED VIOLET",SUP-V402G,CDM,S27200284,LOCAL,0272,RC,,,both,,,199.67,59.9,"CIGNA [10200]","Cigna Open Access",,113.61,56.9,,,,,0,23.22,169.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 5.5MM 46MM 7.9MM SHILEY PEDIATRIC UNCUFF TAPE TIE",SUP-5.5PEF,CDM,S27200284,LOCAL,0272,RC,,,both,,,395.85,118.75,"PHCS [10601]",PHCS,,277.1,70,,,,,0,46.04,336.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION",RX-186564,CDM,,,0250,RC,00264-4500-00,NDC,both,1000,ML,241.44,72.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.08,205.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM DARCO SHORT THREAD HEAD",SUP-777403832,CDM,C1713,HCPCS,0278,RC,,,both,,,1695.00,508.5,"BLUE CROSS [10001]","Blue Cross HMO",,664.44,39.2,,957.42,156.86,7483.26,51,197.13,1440.75,"percent of total billed charges",
"DRSG WOUND 4X4IN CUTIMED EPIONA TISSUE 90% NATIVE CLLGN 10%",SUP-7322701,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.04,63.01,"FIRST HEALTH [10303]","First Health",,168.03,80,,,,,0,24.43,178.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 2CM 16FR GUIDING BALLOON LOW PROFILE",SUP-8106,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,431.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) WISE DELIVERY CATHETER","SUP-MODEL 2000",CDM,S62400003,LOCAL,0624,RC,,,both,,,13800.00,4140,"CIGNA [10200]",Cigna,,9384,68,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 121MM 11MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771101120,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"BLUE CROSS [10001]","Blue Cross PPO",,8192.65,39.2,,3949.44,3949.44,3949.44,"1 through 10",2430.63,17764.68,"percent of total billed charges",
"5.5MM CURVED ROD TITANIUM ALLOY 125MM LENGTH",SUP-1119.7125,CDM,C1776,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,5302.19,4377.88,6578.61,27,141.3,1032.75,"percent of total billed charges",
"CATH SABER 90CM 250MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020250S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 15CM 13.5FR STRAIGHT POLYURETHANE NIAGARA BODYSOFT",SUP-5575150,CDM,C1752,HCPCS,0272,RC,,,both,,,1031.94,309.58,"CIGNA [10200]","Cigna Open Access",,587.17,56.9,,,,,0,120.01,877.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 10CM CHIBA STERILE DISPOSABLE ASPIRATION",SUP-G01112,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.31,31.29,"NOVANET [10819]",Novanet,,78.23,75,,,,,0,12.13,88.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 120MM 16MM VASCULAR NITINOL ILIOFEMORAL VEIN SELF",SUP-AB9U16120090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4750.65,45.9,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Fungi Presumpt ID Other",PX-306000066,CDM,87102,CPT,0306,RC,,,both,,,396.15,118.84,"CIGNA [10200]","Cigna Local Plus",,18.5,,,,,,,0.01,336.73,"fee schedule",
"HC Cult Fungi Presumpt ID Other",PX-306000066,CDM,87102,CPT,0306,RC,,,both,,,396.15,118.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7.57,,,,,,,0.01,336.73,"fee schedule",
"STENT POLARIS 22CM 3CM 5FR .038IN BLADDER LOOP STRAIGHT LOW",SUP-M006155221010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"MULTIPLAN [10600]",Multiplan,,1046.32,85,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROGESTERONE MICRONIZED 100 MG CAPSULE",RX-23122,CDM,,,0637,RC,70700-0162-01,NDC,both,1,UN,25.19,7.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.13,68,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 60MM 7MM BALLOON DILATATION HYDROPHILIC",SUP-607006022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 72.5MM KNEE RIGHT CRUCIATE RETAINING CEMENTED",SUP-183013,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"PHCS [10601]",PHCS,,14059.96,70,,,,,0,2335.96,17072.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 250MM 3.5MM BALLOON DILATATION",SUP-48003525X,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,936.36,68,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Central Line",PX-361000004,CDM,9999135,LOCAL,0361,RC,,,both,,,3536.40,1060.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1623.21,45.9,,,,,0,411.28,3005.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL BEND 87MM STAINLESS STEEL 3.5MM SCR 4 HOLE",SUP-02.127.210S,CDM,C1713,HCPCS,0278,RC,,,both,,,9729.00,2918.7,"UHC [10700]","United Healthcare",,6158.46,63.3,,5023.51,2672.93,6679.78,18,1131.48,8269.65,"percent of total billed charges",
"SPACER SPINAL 55X18X14MM COROENT XL",SUP-6914855,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"FIRST HEALTH [10303]","First Health",,19008,80,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) QUALIBREATH",SUP-QB-XS,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"KAISER [10500]",Kaiser,,555.72,67,,,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAVVY 150CM 4CM 3.5-3FR 4MM BALLOON DILATATION DURALYN",SUP-435404X,CDM,C1725,HCPCS,0272,RC,,,both,,,2137.50,641.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,878.51,41.1,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT WALLFLEX 60MM 75CM 10MM 8",SUP-7467,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP CLUSTER HOLE HA TRIDENT D",SUP-502-11-48D,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"CIGNA [10200]","Cigna Local Plus",,3722.38,53.5,,5372.07,4581.20,7242.98,23,809.18,5914.06,"percent of total billed charges",
"SYSTEM SYNERGY 20MM 144CM 2.5MM CORONARY STENT PEBAX",SUP-H7493926020250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2554.34,45.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT AIRGUARD CHRONOFLEX",SUP-1708060,CDM,C1788,HCPCS,0278,RC,,,both,,,1905.00,571.5,"CIGNA [10200]","Cigna Open Access",,1083.95,56.9,,2042.80,1340.96,2042.80,"1 through 10",221.55,1619.25,"percent of total billed charges",
"SCR BONE 30-45MM RELINE C X CNCT ADJ TULIP TULIP",SUP-3903545,CDM,C1713,HCPCS,0278,RC,,,both,,,4657.50,1397.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,551.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",541.67,3958.88,"percent of total billed charges",
"SYSTEM SYNERGY 20MM 144CM 2.5MM CORONARY STENT PEBAX",SUP-H7493926020250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,647.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 12D ALLOGRAFT 22MM ALIF",SUP-3W4222,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5709.24,27,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE",RX-122469,CDM,,,0250,RC,70092-1119-44,NDC,both,5,ML,59.92,17.98,"CIGNA [10200]","Cigna Open Access",,34.09,56.9,,,,,0,6.97,50.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM TIGER CANNULATED",SUP-200-24-018,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"KAISER [10500]",Kaiser,,759.78,67,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 100MM KNEE STEM EXT REMEDY STERILE",SUP-RSK100,CDM,C1776,HCPCS,0278,RC,,,both,,,6210.00,1863,"AETNA [10100]","Aetna HMO/PPO",,4936.95,79.5,,10981.53,8986.79,12413.38,12,722.22,5278.5,"percent of total billed charges",
"LEVOCARNITINE 20 MG/ML INTRAVENOUS SOLUTION (NICU)",RX-408341,CDM,J1955,HCPCS,0636,RC,08888-8887-98,NDC,both,1,ML,66.63,19.99,"UHC [10700]","United Healthcare",,45.38,,,,,,,8.03,62.56,"fee schedule",
"BELT SPRT MEDTRONIC SMALL",SUP-FP9000S,CDM,S27000186,LOCAL,0270,RC,,,both,,,408.90,122.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,278.05,68,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Spectrophotometry",PX-301000403,CDM,84311,CPT,0301,RC,,,both,,,337.25,101.17,"UHC [10700]","United Healthcare",,7.29,,,,,,,0.01,286.66,"fee schedule",
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 4 STD OFFSET HIP",SUP-71935564,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"NOVANET [10819]",Novanet,,27400.28,75,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intro Cath Supr/Infr Ivc/Svc",PX-450000222,CDM,36010,CPT,0361,RC,,,both,,,5075.18,1522.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,601.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,590.24,5075.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 3-0 PS-1 SPIRAL 45CM KNOTLESS",SUP-SXMP1B102,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FUSION 200CM 6FR ENDOSCOPIC STERILE DISPOSABLE ACCEPTS",SUP-G31528,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"KAISER [10500]",Kaiser,,515.57,67,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 180MM 4.2MM T2 AO",SUP-18064270S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1319.98,395.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,605.87,45.9,,,,,0,153.51,1121.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lamotrigine",PX-301000074,CDM,80175,CPT,0301,RC,,,both,,,219.70,65.91,"BLUE CROSS [10001]","Blue Cross PPO",,16.93,,"Fee schedule rate ($16.93).",,,,0,0.01,186.75,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal Uni W Pta Init",PX-361000156,CDM,37228,CPT,0361,RC,,,both,,,14777.16,4433.15,"FIRST HEALTH [10303]","First Health",,11821.73,80,,,,,0,1718.58,12560.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Func Study Laryngeal",PX-440000004,CDM,92520,CPT,0440,RC,,,both,,,836.00,250.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,97.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.23,710.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Func Study Laryngeal",PX-440000004,CDM,92520,CPT,0440,RC,,,both,,,836.00,250.8,"CIGNA [10200]","Cigna Open Access",,309,,"Per diem ($309).",,,,0,97.23,710.6,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Func Study Laryngeal",PX-440000004,CDM,92520,CPT,0440,RC,,,both,,,836.00,250.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,239.55,,"Per diem ($239.55).",,,,0,97.23,710.6,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SURGICAL 6IN AUSTIN INTEGRA 16MM LIGHT CURVE INNER EAR",SUP-3722056,CDM,S27200284,LOCAL,0272,RC,,,both,,,638.36,191.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,74.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.24,542.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732056,CDM,C1776,HCPCS,0278,RC,,,both,,,9510.48,2853.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1126.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1106.07,8083.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 17MM HELIX R SPINE SELF TAP VARIABLE ANGLE",SUP-7805117,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,117.75,860.63,"percent of total billed charges",
"GWIRE SAFE-T-J VASCULAR 180CM 3MM .021IN STAINLESS STEEL TFE",SUP-TSCF-21-180-3-BH,CDM,C1769,HCPCS,0272,RC,,,both,,,163.13,48.94,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.97,138.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PACING 37CM BIPOLAR IS-1",SUP-6984M,CDM,C1883,HCPCS,0278,RC,,,both,,,1069.20,320.76,"CIGNA [10200]","Cigna Local Plus",,572.02,53.5,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hdr Ntrstl Icav Brachytx 2-12 Chnl",PX-342000019,CDM,77771,CPT,0342,RC,,,both,,,6630.45,1989.13,"CIGNA [10200]",Cigna,,4508.71,68,,,,,0,408.8,5635.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION",RX-105634,CDM,,,0250,RC,00409-9045-16,NDC,both,30,ML,36.01,10.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.19,30.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH ALPHA THORACIC ENDOVASCULAR GRAFT PROXIMAL COMPONENTS",SUP-G35343,CDM,C1874,HCPCS,0278,RC,,,both,,,96672.00,29001.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,38668.8,40,,,,,0,11242.95,82171.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT",RX-8117,CDM,,,0637,RC,45802-0054-35,NDC,both,15,GR,38.50,11.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,17.67,45.9,,,,,0,4.48,32.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 28CM 7FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49915,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"KAISER [10500]",Kaiser,,504.71,67,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 36MM TIBIAL METAPHYSEAL META-NAIL INTRAMEDULLARY",SUP-71655136,CDM,C1713,HCPCS,0278,RC,,,both,,,15548.46,4664.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1842.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1808.29,13216.19,"percent of total billed charges",
"ANCHOR SUT 5.5MM HEALICOIL KNOTLESS SELF TAP REGENESORB",SUP-72205136,CDM,C1713,HCPCS,0278,RC,,,both,,,3368.25,1010.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1546.03,45.9,,,,,0,391.73,2863.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 240MM 6MM BALLOON DILATATION STERILE LATEX",SUP-586024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYCLOSPORINE 25 MG CAPSULE",RX-9707,CDM,J7515,HCPCS,0636,RC,68084-0879-95,NDC,both,1,UN,25.19,7.56,"BLUE CROSS [10001]","Blue Cross PPO",,0.93,,,,,,,0.93,21.41,"fee schedule",
"CLAMP SURGICAL VASCU-STATT II PLUS 45D MIDI VASCULAR ANGLED",SUP-1001-573,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW LOWPROFILE 6.5X55MM",SUP-010-55-055,CDM,C1713,HCPCS,0278,RC,,,both,,,2400.01,720,"PHCS [10601]",PHCS,,1680.01,70,,,,,0,279.12,2040.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Dil",PX-750000084,CDM,45340,CPT,0750,RC,,,both,,,2362.42,708.73,"KAISER [10500]",Kaiser,,1582.82,67,,,,,0,274.75,2362.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SUT BROADBAND TAPE 2 BLACK BLUE",SUP-CM0321N,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,390.38,45.9,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MERIT MAK VASCULAR 40CM .018IN STAINLESS STEEL STERILE",SUP-MAK001,CDM,C1894,HCPCS,0272,RC,,,both,,,152.25,45.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.71,129.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM PROFILE 3D",SUP-680R34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3539.7,27,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT ALPHAVENT 3 STRAND HARD BODY PLATFORM PEEK 1.4 MM",SUP-3910-947-031,CDM,C1713,HCPCS,0278,RC,,,both,,,2737.50,821.25,"PHCS [10601]",PHCS,,1916.25,70,,,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 54MM 36MM MARATHON",SUP-121936454,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"AETNA [10100]","Aetna HMO/PPO",,7825.07,79.5,,10981.53,8986.79,12413.38,12,1144.72,8366.42,"percent of total billed charges",
"SABER .035 9X40 135CM SL",SUP-48009004R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"MULTIPLAN [10600]",Multiplan,,730.16,85,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE ANGLE 1.5MM MANDIBLE 4 HOLE BAR 2/2.3MM SCR BONE",SUP-55-15524,CDM,C1713,HCPCS,0278,RC,,,both,,,2846.03,853.81,"NOVANET [10819]",Novanet,,2134.52,75,,,,,0,330.99,2419.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 4IN 21GA PAJUNK SONOPLEX 1 SHOT",SUP-TDL101,CDM,C9812,HCPCS,0272,RC,,,both,,,295.80,88.74,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,121.57,41.1,,,,,0,34.4,251.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA MEDIAL CONGRUENT 8-11 E-F",SUP-42512100813,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AETNA [10100]","Aetna HMO/PPO",,8567.25,79.5,,10981.53,8986.79,12413.38,12,1253.3,9159.96,"percent of total billed charges",
"KIT NEEDLE GUIDE AND COVER DISPOSABLE ULTRPRO3",SUP-610-901,CDM,S27200284,LOCAL,0272,RC,,,both,,,167.62,50.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.49,142.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTOURA BREAST TISSUE EXPANDER HIGH PROJECTION 300CC",SUP-TEXP110RH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"CIGNA [10200]","Cigna Local Plus",,4336.13,,,,,,,1600.93,11700.68,"percent of total billed charges",
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,inpatient,,,81137.52,24247.81,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,12839.94,,"Case rate ($12,287.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,409.33, add-ons for qualifying new technology services are included. If operating cost exceeds $44,449.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,244.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,424.42. The transfer operating threshold is the transfer adjustment factor * $11,409.33 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.60. The transfer capital threshold is the transfer adjustment factor * $862.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,10994,49399.17,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Vad Perc Arterial Access",PX-361000283,CDM,33990,CPT,0361,RC,,,both,,,6158.36,1847.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,729.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,716.22,6158.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175264190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]","Cigna Open Access",,720,,,,,,,147.16,1075.57,"percent of total billed charges",
"BLADE SHAVER 22CM 4MM TRICUT 2 CURVE LARYNGEAL ANGLE TIP",SUP-1884030HRE,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"PHCS [10601]",PHCS,,3168.48,70,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS03008,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Local Plus",,3692.78,31.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Pta Cmplx Init",PX-361000723,CDM,37282,CPT,0361,RC,,,both,,,14777.16,4433.15,"CIGNA [10200]","Cigna Open Access",,6428,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1718.58,12560.59,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 3.5MM 4MM SCR HOLLOW NONSTERILE",SUP-309.035,CDM,S27200284,LOCAL,0272,RC,,,both,,,2918.70,875.61,"MULTIPLAN [10600]",Multiplan,,2480.9,85,,,,,0,339.44,2480.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM LOW PROFILE LOCK TUBE STERILE RFN-ADVANCED",SUP-04.045.334TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"CIGNA [10200]","Cigna Open Access",,1063.97,56.9,,1144.80,304.56,2275.09,66,217.47,1589.42,"percent of total billed charges",
"BLADE SHAVER 4MM 40DEG BIPOLAR CONVEX SERRATED",SUP-BB4040XC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1434.01,430.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,169.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.78,1218.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet/CT Tumor Skull to Thigh",PX-404000004,CDM,78815,CPT,0404,RC,,,both,,,7540.46,2262.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2608,,"Per diem ($2,608). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,876.96,7540.46,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"VASCULAR 190CM .014IN HI-TORQUE BALANCE MIDDLEWEIGHT",SUP-1001780J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 100MM 2MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.19,CDM,S27000186,LOCAL,0270,RC,,,both,,,329.00,98.7,"UHC [10700]","United Healthcare",,208.26,63.3,,,,,0,38.26,279.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CRANIOTOMY 5/8IN 25GA RAZOR BETADINE SWAB NDL SAFETY SYR",SUP-INS-HITH,CDM,S27200284,LOCAL,0272,RC,,,both,,,3373.95,1012.18,"CIGNA [10200]","Cigna Local Plus",,1805.06,53.5,,,,,0,392.39,2867.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID .5CC DBX ALLOGRAFT PASTE FREEZE DRIED",SUP-28005,CDM,C1713,HCPCS,0278,RC,,,both,,,575.91,172.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,68.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,66.98,489.52,"percent of total billed charges",
"BLADE SHAVER 4MM TRUDI 40D CURVE STERILE LATEX FREE",SUP-TSB440,CDM,S27200284,LOCAL,0272,RC,,,both,,,3562.50,1068.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,414.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA ARTERIAL SOFT-FLOW 3/8 IN L14 IN OD21 FR ANGLE TIP N",SUP-6384,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"MULTIPLAN [10600]",Multiplan,,477.13,85,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anoscopy W Biopsy HRA",PX-750000179,CDM,46607,CPT,0750,RC,,,both,,,1398.00,419.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,165.66,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.59,1398,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 36MM FLEX +9MM POLYETHYLENE",SUP-DWF362B,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1069.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1049.96,7673.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 32.77CM 8MM DA VINCI XI MARYLAND ENDOWRIST",SUP-471172,CDM,S27000186,LOCAL,0270,RC,,,both,,,1850.89,555.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,219.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,215.26,1573.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DOVER 16IN 22FR URETHRAL HYDROGEL 5CC FOLEY 3 WAY LATEX",SUP-2722,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.35,43.6,"FIRST HEALTH [10303]","First Health",,116.28,80,,,,,0,16.9,123.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X22X11MM TRANSCONTINENTAL 10D MEDIUM",SUP-375.371CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"UHC [10700]","United Healthcare",,19939.5,63.3,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM MITROFLOW BOVINE PERICARDIUM",SUP-LXA27,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK VITRECTOMY 20GA STELLARIS ELITE POSTERIOR MIDFIELD",SUP-SE5420M,CDM,S27200284,LOCAL,0272,RC,,,both,,,3570.00,1071,"UHC [10700]","United Healthcare",,2259.81,63.3,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"I-GEL, SINGLE USE SUPRAGLOTTIC AIRWAY, SIZE 3",SUP-8203000,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.19,23.76,"FIRST HEALTH [10303]","First Health",,63.35,80,,,,,0,9.21,67.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING UNIPOLAR IS 1 CNCT J+ TINE FIXATION",SUP-4581,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"KAISER [10500]",Kaiser,,759.78,67,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 60MM 36MM MARATHON HIP",SUP-121936160,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2817.02,28.62,,,,,0,1144.72,8366.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SURGICAL SMALL CIRCLE 1.7IN HERNIA REPAIR MONOFILAMENT",SUP-0010301,CDM,C1781,HCPCS,0278,RC,,,both,,,1727.25,518.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,792.81,45.9,,,,,0,200.88,1468.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL USA ELITE SYSTEM USA SERIES 90D .010",SUP-MLE-26-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,450.30,135.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,185.07,41.1,,,,,0,52.37,382.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 59MM 80CM 8MM 16SQ MM 8FR .035IN",SUP-BXAL085901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS [10001]","Blue Cross PPO",,7645.88,39.2,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRI-STAPLE 2.0 RELOAD 60MM VASCULAR/MEDIUM TISSUE TAN",SUP-SIG60AVM,CDM,S27200284,LOCAL,0272,RC,,,both,,,1576.18,472.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1071.8,68,,,,,0,183.31,1339.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 28MM 9MM DELTA TAPER KNEE",SUP-AR-5028C-09,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"CIGNA [10200]","Cigna Local Plus",,990.09,53.5,,3978.14,359.25,3978.14,24,215.23,1573.04,"percent of total billed charges",
"CLAMP SURGICAL EDNA 3.5IN TOWEL BRIGHT FINISH STAINLESS",SUP-37-1010,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.55,15.16,"CIGNA [10200]",Cigna,,34.37,68,,,,,0,5.88,42.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 40MM 18MM X-CORE 2 0D TITANIUM 18MM",SUP-6184000,CDM,C1713,HCPCS,0278,RC,,,both,,,8257.92,2477.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2363.42,28.62,,,,,0,960.4,7019.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 42MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661042,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"BLUE CROSS [10001]","Blue Cross HMO",,511.84,39.2,,957.42,156.86,7483.26,51,151.86,1109.86,"percent of total billed charges",
"CATH NAVICROSS 90CM 40MM 60MM SPACE SPRT STAINLESS STEEL",SUP-NC18900,CDM,C1887,HCPCS,0272,RC,,,both,,,1462.05,438.61,"UHC [10700]","United Healthcare",,925.48,63.3,,,,,0,170.04,1242.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SR CORTICAL BLOCK 14X14X5MM CERVICAL",SUP-200544,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET TPR FIX FRM 70CM",SUP-6769,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 120CM 7.5CM 7MM VASCULAR CATH 7.5CM",SUP-VBJR070702A,CDM,C1874,HCPCS,0278,RC,,,both,,,22163.40,6649.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8865.36,40,,,,,0,2577.6,18838.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 10MM2CM 190",SUP-R51010002L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,241.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 40MM 3.8FR 8MM LOW PROFILE BALLOON",SUP-39032-80408,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 150MM 18GA 20GA SONOLONG SONOLONG SONO",SUP-511187-31C,CDM,C9814,HCPCS,0272,RC,,,both,,,518.40,155.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,61.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.29,440.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 42MM DOT FREEMAN AREOLA BREAST BIOPSY STAINLESS STEEL",SUP-P465,CDM,S27200284,LOCAL,0272,RC,,,both,,,532.33,159.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,361.98,68,,,,,0,61.91,452.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 28CM 6FR URETERAL FLEXITHANE METAL",SUP-H7493936106280,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"CIGNA [10200]",Cigna,,842.72,68,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE GENESIS 23CM 9.5MM TAIL CAP TRIMMABLE",SUP-919509SC,CDM,C2622,HCPCS,0278,RC,,,both,,,55704.60,16711.38,"MULTIPLAN [10600]",Multiplan,,47348.91,85,,,,,0,6478.44,47348.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM TKR POROUS FEMUR PATELLA TIBIA CEMENT HYBRID",SUP-98000670511,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS [10001]","Blue Cross PPO",,8643.6,39.2,,3949.44,3949.44,3949.44,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"MANIP OCCL BALLOON VISUAL AUDIO INDCTR ALERT STABLE CUTTING",SUP-KC-ARCH-25,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"FIRST HEALTH [10303]","First Health",,916.67,80,,,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 100MM 4MM BALLOON DILATATION DURALYN",SUP-48004010S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ONE1STEP CENTESIS CATHETER 5F 10CM19GA INTRODUCER NEEDLE4",SUP-OSC-5F-10LT,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.35,53.5,"MULTIPLAN [10600]",Multiplan,,151.6,85,,,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 28CM INTERSTIM SPINAL CORD TINED",SUP-3889-28,CDM,C1778,HCPCS,0278,RC,,,both,,,20834.10,6250.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2468.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2423.01,17708.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 24CM 10FR NEPHROURETERAL FLEXITHANE",SUP-H7493935110240,CDM,C2617,HCPCS,0278,RC,,,both,,,1069.20,320.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,124.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM CHARLOTTE STAINLESS STEEL",SUP-41122714,CDM,C1713,HCPCS,0278,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDPN ORTHOPEDIC 7.6CM 1/8IN GENESIS II KNEE TROCAR STERILE",SUP-71210002,CDM,C1713,HCPCS,0278,RC,,,both,,,260.35,78.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,30.28,221.3,"percent of total billed charges",
"FORCEPS SURGICAL DISPOSABLE LONG SMOOTH",SUP-NF07,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL 7CM MR8 4MM BALL COARSE GRIT DISSECTING DIAMOND",SUP-MR8-7BA40DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1142.51,342.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DANTROLENE 25 MG CAPSULE",RX-9718,CDM,,,0637,RC,50268-0217-11,NDC,both,1,UN,11.96,3.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 8.25MM HANNA SURGICAL",SUP-17171D825,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INSTR BIOABSORBABLE BIO-TENODESIS DISPOSABLE STERILE",SUP-AR-1676DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,910.00,273,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IOVERA SMART TIP 309 5-PACK (3X8.5-MM NEEDLES PER SMART TIP)",SUP-STT0309-5,CDM,C9809,HCPCS,0272,RC,,,both,,,4105.50,1231.65,"MULTIPLAN [10600]",Multiplan,,3489.68,85,,,,,0,477.47,3489.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE MATRIX ALLOGRAFT STRIP",SUP-T42280,CDM,S27800098,LOCAL,0278,RC,,,both,,,16146.00,4843.8,"AETNA [10100]","Aetna HMO/PPO",,12836.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1877.78,13724.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INFLOW OUTFLOW IRRIGATION STERILE LATEX FREE DISPOSABLE",SUP-AR-6436,CDM,S27200284,LOCAL,0272,RC,,,both,,,799.47,239.84,"CIGNA [10200]",Cigna,,543.64,68,,,,,0,92.98,679.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL STRAIGHT BIPOLAR TAPERED BLUNT POINT",SUP-221266,CDM,S27200284,LOCAL,0272,RC,,,both,,,566.25,169.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.85,481.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL CANNULATED 10.5MM STERILE",SUP-AR-1218-105,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THOMASMEDICAL INTRDCR FR9 LONG - EACH",SUP-666275-001,CDM,C1894,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 230MM 1.6MM KIRSCHNER STAINLESS STEEL 1 END",SUP-3813-3-090,CDM,C1713,HCPCS,0278,RC,,,both,,,211.93,63.58,"MULTIPLAN [10600]",Multiplan,,180.14,85,,,,,0,24.65,180.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT POSITIONING SHOULDER SUSPENSION KIT COBANT WRAP ARM",SUP-72200195,CDM,S27000186,LOCAL,0270,RC,,,both,,,558.90,167.67,"CIGNA [10200]","Cigna Local Plus",,299.01,53.5,,,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Arthgm Ankle Si",PX-322000006,CDM,73615,CPT,0322,RC,,,both,,,712.00,213.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,84.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,82.81,712,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 20MM SYNFIX EVOLUTION FINE TIP STERILE",SUP-04.835.120.02S,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1101.6,68,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPINEPHRINE 1 MG/ML INJECTION SOLUTION",RX-2850,CDM,J0165,HCPCS,0636,RC,42023-0168-01,NDC,both,30,ML,887.88,266.36,"MULTIPLAN [10600]",Multiplan,,754.7,85,,,,,0,105.21,754.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 60MM LOCK STERILE",SUP-2361-5060S,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.05,506.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,199.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",196.2,1433.99,"percent of total billed charges",
"PLATE BONE 32MM LCP ANKLE FOOT STAINLESS STEEL 2X3 HOLE T",SUP-249.685,CDM,C1713,HCPCS,0278,RC,,,both,,,3883.32,1165,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,460.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,451.63,3300.82,"percent of total billed charges",
"DRILL HAND 11GA OPTABLATE STERILE LATEX FREE DISPOSABLE",SUP-9700-811-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2970.62,891.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1220.92,41.1,,,,,0,345.48,2525.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 1-2 15MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934381,CDM,C1776,HCPCS,0278,RC,,,both,,,19429.20,5828.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5560.64,28.62,,,,,0,2259.62,16514.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL VASCULAR 30MM 2MM FLO-RESTER CORONARY ARTERY SILICONE",SUP-60200BIOS,CDM,S27200284,LOCAL,0272,RC,,,both,,,741.67,222.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,87.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.26,630.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD KT NEUROSTIM GAST IMP ENTERRA 35CM",SUP-435135,CDM,C1778,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 44MM INCORE TITANIUM T10 COMPRESSION HEXALOBE",SUP-ICLAP3544,CDM,C1713,HCPCS,0278,RC,,,both,,,2402.48,720.74,"FIRST HEALTH [10303]","First Health",,1921.98,80,,,,,0,279.41,2042.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CARTO 3 THERMOCOOL SF 7.5FR D-D CURVE ELECTROPHYSIOLOGY",SUP-BNI35DDCT,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"UHC [10700]","United Healthcare",,11433.31,63.3,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAUT ELECTROSURGICAL 5/8IN DIAGNOSTICK 2250F HIGH",SUP-65410-181,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.54,35.26,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,48.31,41.1,,,,,0,13.67,99.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25026W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"PHCS [10601]",PHCS,,2362.5,70,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 STD 14MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS5S14R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2974.02,28.62,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 60MM 4MM BALLOON",SUP-LX181304604F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,782.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM CLAW II",SUP-40233524,CDM,C1713,HCPCS,0278,RC,,,both,,,1474.20,442.26,"PHCS [10601]",PHCS,,1031.94,70,,,,,0,171.45,1253.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP PULSED LAVAGE INTERPULSE SOFT TISSUE IRRIGATION FAN",SUP-0210-012-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.99,28.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,38.63,41.1,,,,,0,10.93,79.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 40MM 135CM 9MM VASCULAR NITINOL",SUP-1012537-40,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Open Access",,2355.66,56.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 38MM 140CM 2.5MM 2.1-2.7FR CORONARY",SUP-RONYX25038UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2524.5,68,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WARFARIN 2 MG TABLET",RX-8749,CDM,,,0637,RC,62584-0984-11,NDC,both,1,UN,6.27,1.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2.58,41.1,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM KNEE 100MM 16/13MM ENDO-MODEL SL FEMALE TAPER MODULAR",SUP-15-8517/54,CDM,C1776,HCPCS,0278,RC,,,both,,,16271.03,4881.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1928.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1892.32,13830.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM ACTIVE ARTICULATION THR XLPE POROUS CUP 2 MOBILIT",SUP-98B00100193,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"UHC [10700]","United Healthcare",,11166.12,63.3,,8601.07,8395.67,8601.07,"1 through 10",2051.53,14994,"percent of total billed charges",
"RCRD CARDIAC CONFIRM RX SMALL SLIM 1 TOUCH PROGRAM DATA",SUP-DM3500,CDM,C1764,HCPCS,0278,RC,,,both,,,23940.00,7182,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 36X24MM ENDOSKELETON TAS 7D 13MM LARGE TITANIUM",SUP-2307-0213,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3297.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 30MM 15MM NEXGEN FEMORAL KNEE TIVANIUM ALLOY",SUP-00598801215,CDM,C1776,HCPCS,0278,RC,,,both,,,4909.80,1472.94,"CIGNA [10200]",Cigna,,3338.66,68,,5873.17,5873.17,5873.17,"1 through 10",571.01,4173.33,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR 5MM STORZ 2 STEM",SUP-M0068804211,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,61.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TI 4.0X100 LOR ROD",SUP-102064100,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 8IN 13.5MM MODULAR SOL SYSTEM POROUS 12/14",SUP-157202136,CDM,C1776,HCPCS,0278,RC,,,both,,,38107.44,11432.23,"KAISER [10500]",Kaiser,,25531.98,67,,,,,0,4431.9,32391.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG PRESSURE INFUSION 500ML NYLON INFUSABLE LARGE INFLATION",SUP-IN800012,CDM,S27000186,LOCAL,0270,RC,,,both,,,104.29,31.29,"FIRST HEALTH [10303]","First Health",,83.43,80,,,,,0,12.13,88.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 40MM COMPREHENSIVE TITANIUM SHOULDER FIX",SUP-180505,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"PHCS [10601]",PHCS,,1088.99,70,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 22FR SILICONE MIC RADIOPAQUE FEED TUBE",SUP-8250-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"KAISER [10500]",Kaiser,,1174.14,67,,,,,0,203.81,1489.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL MITRACLIP BUNDLE SGC0301 3 CDS0601 NTR",SUP-MBR0103,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"KAISER [10500]",Kaiser,,114570,67,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 22MM STAINLESS STEEL T8 LOCK VARIABLE ANGLE",SUP-02.210.122TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1011.53,303.46,"FIRST HEALTH [10303]","First Health",,809.22,80,,,,,0,117.64,859.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cognitive Trn Ea Add 15m (Go)",PX-430000053,CDM,97130,CPT,0430,RC,,,both,,,164.80,49.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,164.8,,"Per diem ($239.55).",,,,0,19.17,164.8,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 2CM 7MM BALLOON DILATATION",SUP-DR13572,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"KAISER [10500]",Kaiser,,922.59,67,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PALMAZ GENESIS AVIATOR FLEXSEGMENT 14MM 17MM 7MM 135CM",SUP-H739PG1570BAX3,CDM,C1876,HCPCS,0278,RC,,,both,,,6554.03,1966.21,"NOVANET [10819]",Novanet,,4915.52,75,,,,,0,762.23,5570.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE VASCULAR 182CM .014IN POLYMER HYDROPHILIC EXTRA",SUP-H74912135012,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SIMPLASTIC 16IN 22FR LARGE URETHRAL PVC 30ML 3 WAY",SUP-570622,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.43,49.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,19.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.12,139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 54IN BRAID TIE COATED VIOLET ABSORBABLE",SUP-J614H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT POSTERIOR STABILIZE CEMENT LEGION",SUP-71423223,CDM,C1776,HCPCS,0278,RC,,,both,,,21886.20,6565.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2593.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2545.37,18603.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 38MM 145CM 3MM CORONARY STENT",SUP-1145300-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]",Cigna,,3969.84,68,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBLIQUE TLIF TI, 10X10X25MM 4",SUP-5400254,CDM,C1889,HCPCS,0278,RC,,,both,,,21225.60,6367.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2515.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR .035IN STRAIGHT ANGIOGRAPHIC BRAIDED",SUP-31-402,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT WALLFLEX 60MM 75CM 8MM 8",SUP-7463,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"KAISER [10500]",Kaiser,,58.29,67,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH ADULT 32CM 15.5FR POLYURETHANE BIOFLO DURAMAX",SUP-H787103028205,CDM,C1750,HCPCS,0278,RC,,,both,,,910.00,273,"AMERIGROUP MEDICAID [20100]",Amerigroup,,107.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.83,773.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE INQWIRE AMPLATZ VASCULAR SHORT STRAIGHT 145CM 3.5CM",SUP-IQA527,CDM,S27200284,LOCAL,0272,RC,,,both,,,260.91,78.27,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,107.23,41.1,,,,,0,30.34,221.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +24.5 DIOPTER MODIFIY C BICONVEX 13MM 6MM",SUP-ZMA00U0245,CDM,V2632,HCPCS,0276,RC,,,both,,,6175.50,1852.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4199.34,68,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 90MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.190,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"MULTIPLAN [10600]",Multiplan,,962.8,85,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.00 X 38 RX US",SUP-1804300-38,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN ALIGNMENT 200MM 2.5MM AEQUALIS SHOULDER GLENOID STERILE",SUP-DWD063,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"KAISER [10500]",Kaiser,,1042.52,67,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR AL.75 CURVE GUIDING NYLON CORONARY",SUP-LA8AL75SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INJECTOR BONE CEMENT HYDRAULIC MASTER",SUP-DF-5000A,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.00,675,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1032.75,45.9,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 125ML GEL SMOOTH MEMORYGEL SILICONE P3.5CM ROUND","SUP-3501254 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]",Cigna,,2570.4,68,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY LARYNGEAL MASK CHILD SIZE 4 30ML PVC CUFF STRAIGHT DI",SUP-ALAA040SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.20,15.66,"PHCS [10601]",PHCS,,36.54,70,,,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX21MM FRA 8D NARROW WEDGE SPINE",SUP-10021,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION KIRSCHNER PACK LUMBAR SPINE STERILE",SUP-675.399S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3326.40,997.92,"CIGNA [10200]","Cigna Local Plus",,1779.62,53.5,,,,,0,386.86,2827.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 5YDX.5IN ALGIDEX SILVER GAUZE PK LATEX FREE",SUP-46-PG12,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.55,19.36,"AETNA [10100]","Aetna HMO/PPO",,51.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.51,54.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE WHISPER LS VASCULAR STRAIGHT 190CM 3CM .014",SUP-1005351H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL CRYOABLATION 17.5CM 17GA ICESPHERE 1.5CX 90D NONSTICK",SUP-FPRPR3573,CDM,C2618,HCPCS,0272,RC,,,both,,,13110.00,3933,"FIRST HEALTH [10303]","First Health",,10488,80,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 180CC FULL PROFILE SMOOTH NATRELLE INSPIRA",SUP-SSF-180,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP CEMENTED FEMUR OXINIUM HEAD R3 HIGHL",SUP-71705316,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM BONE CEMENT KIT PREPARATION PLUG INSRT BRUSH CURET",SUP-0206710000,CDM,S27800098,LOCAL,0278,RC,,,both,,,752.88,225.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,87.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.56,639.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE CMC",SUP-PRT-CMC-025,CDM,C1713,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"BLUE CROSS [10001]","Blue Cross PPO",,2812.99,39.2,,957.42,570.23,957.42,28,834.57,6099.6,"percent of total billed charges",
"5F X 30CM TEARAWAY INTRODUCER",SUP-INT-106-31,CDM,C1894,HCPCS,0272,RC,,,both,,,216.49,64.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.18,184.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SURGICAL XLONG FIRST FRACTURE CANN",SUP-2003-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,21432.60,6429.78,"KAISER [10500]",Kaiser,,14359.84,67,,,,,0,2492.61,18217.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL INTUITIVE DA VINCI XI BLACK 60",SUP-12BSGXI60BK,CDM,S27200284,LOCAL,0272,RC,,,both,,,1323.00,396.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,607.26,45.9,,,,,0,153.86,1124.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 159MM STAINLESS STEEL 4.5MM SCR 6 HOLE 4 COLUMN",SUP-02.124.407S,CDM,C1713,HCPCS,0278,RC,,,both,,,13248.28,3974.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1540.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1540.77,11261.04,"percent of total billed charges",
"PIN FIXATION 65MM STERILE",SUP-74013480,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.02,64.21,"CIGNA [10200]","Cigna Local Plus",,114.5,53.5,,,,,0,24.89,181.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 320107 TRICORT BLK 7MM SRVC FEE",SUP-320107,CDM,S27800098,LOCAL,0278,RC,,,both,,,3412.50,1023.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,976.66,28.62,,,,,0,396.87,2900.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 69MM 75CM 10MM 100CM",SUP-M001712380,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1001.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL COMPOSIX 8.2X6.2IN PATCH LOW PROFILE",SUP-0134680,CDM,C1781,HCPCS,0278,RC,,,both,,,3087.00,926.1,"PHCS [10601]",PHCS,,2160.9,70,,,,,0,359.02,2623.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 7FR 12MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-12041,CDM,C1725,HCPCS,0272,RC,,,both,,,972.00,291.6,"FIRST HEALTH [10303]","First Health",,777.6,80,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 235MM 14MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-314,CDM,C1776,HCPCS,0278,RC,,,both,,,18758.25,5627.47,"CIGNA [10200]",Cigna,,7503.3,40,,5873.17,5873.17,5873.17,"1 through 10",2181.58,15944.51,"percent of total billed charges",
"CATH TORCON NB ADVANTAGE BEACON 80CM 5FR C2 CURVE",SUP-G11202,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"UHC [10700]","United Healthcare",,150.33,63.3,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502605802,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2709.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.00 X 38 RX US",SUP-1804300-38,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SPINAL 25GA PENCAN GLASS OB SYR SSK BKG",SUP-560603,CDM,C1755,HCPCS,0278,RC,,,both,,,133.20,39.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,38.12,28.62,,,,,0,15.49,113.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 16FR URETHRAL SILICONE 10ML FOLEY 2 WAY COUDE TIP",SUP-DYND11592,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.03,37.81,"FIRST HEALTH [10303]","First Health",,100.82,80,,,,,0,14.66,107.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9.8FR 8FR 55CM HIGH FLEX DIL RADIOPAQUE CLOSED",SUP-G49045,CDM,C1894,HCPCS,0272,RC,,,both,,,472.23,141.67,"KAISER [10500]",Kaiser,,316.39,67,,,,,0,54.92,401.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 20CM 4MM BALLOON DILATATION OTW LOW",SUP-G30897,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 120CM 6MM 8FR STRAIGHT VASCULAR",SUP-AVSL06100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"AETNA [10100]","Aetna HMO/PPO",,14524.65,79.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH R2P DESTINATION SLENDER 95CM 6FR GUIDING STERILE",SUP-GS-R6ST1C95W,CDM,C1894,HCPCS,0272,RC,,,both,,,2216.25,664.87,"PHCS [10601]",PHCS,,1551.38,70,,,,,0,257.75,1883.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 11MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS11030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3355.15,28.62,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FLAT CHUCK SKYLINE 14MM",SUP-286820014,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,1831.33,1831.33,1831.33,16,50.59,369.75,"percent of total billed charges",
"STENT COPE MAC-LOC 22CM 8.5FR PIGTAIL CURVE",SUP-G48173,CDM,C2617,HCPCS,0278,RC,,,both,,,980.02,294.01,"MULTIPLAN [10600]",Multiplan,,833.02,85,,,,,0,113.98,833.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 22CM 3.33MM LARGE PROXIMAL PIGTAIL CURVE",SUP-M001231400,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,408.97,45.9,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON DISECT LAPAROSCOPIC KII 100MM 12MM 1 LATERAL",SUP-COK12,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"PHCS [10601]",PHCS,,1312.5,70,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG PRESSURE INFUSION 1L NYLON INFUSOR DUAL PRESSURE RELIEF",SUP-PIB1000,CDM,S27000186,LOCAL,0270,RC,,,both,,,95.00,28.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.05,80.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW PROPHECY INBONE MICROAIRE WIDE HALL/LINVATEC",SUP-200138104S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1109.70,332.91,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,456.09,41.1,,,,,0,129.06,943.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION",RX-70536,CDM,,,0250,RC,72888-0141-35,NDC,both,16,GR,587.03,176.11,"FIRST HEALTH [10303]","First Health",,469.62,80,,,,,0,68.27,498.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE AND SUBACUTE ENDOCARDITIS WITH CC",289,MS-DRG,,,,,,,inpatient,,,67175.13,20152.54,"CIGNA [10200]","Cigna Local Plus",,17613.5,,"Fee schedule rate ($17,613.50). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,7561,42568.38,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE UBER FLEX 40MM 57CM 8MM .065IN VASCULAR",SUP-SR-0840-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 2IN 18GA 20GA PAJUNK E-CATH 21GA CONTINUOUS",SUP-TDL103,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PORTICO FLEXNAV 107CM 6MM DELIVERY",SUP-FNAV-DS-SM,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"NOVANET [10819]",Novanet,,7762.5,75,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RATE BASED",RX-409152,CDM,,,0250,RC,00338-0023-02,NDC,both,250,ML,100.65,30.19,"AETNA [10100]","Aetna HMO/PPO",,80.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.2MM KIRSCHNER TEMPORARY",SUP-DC4212,CDM,C1713,HCPCS,0278,RC,,,both,,,550.80,165.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,374.54,68,,,,,0,64.06,468.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-FLO RENEGADE FATHOM VASCULAR 115CM 10CM .016IN",SUP-M001184520,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"KAISER [10500]",Kaiser,,2512.5,67,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOSURGICAL 1.15MM 1.7MM ERBECRYO FLEXIBLE LIGHT PLUG",SUP-20402-410,CDM,C2618,HCPCS,0272,RC,,,both,,,2530.50,759.15,"PHCS [10601]",PHCS,,1771.35,70,,,,,0,294.3,2150.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 45CM SFT",SUP-130091,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,109.56,28.62,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Dialysis Low Ca",PX-E27200287,CDM,E27200287,LOCAL,0272,RC,,,both,,,206.80,62.04,"FIRST HEALTH [10303]","First Health",,165.44,80,,,,,0,24.05,175.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 25MM SIMULUS FULLY FLEXIBLE",SUP-700FC25,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]",Cigna,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORTIVA SILHOUETTE 16X20 CM",SUP-UTD1620,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"PHCS [10601]",PHCS,,43890,70,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VALVE AORTIC 20MM SAPIEN 3 EDWARDS HEART TRANSCATHETE",SUP-9750TFX20A,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"KAISER [10500]",Kaiser,,114570,67,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Tilmanocept Diag 0.5mci",PX-343000030,CDM,A9520,HCPCS,0343,RC,,,both,,,4614.97,1384.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2307.49,50,,,,,0,536.72,3922.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CIRCUIT 1 LIMB 2 SPIRAL HEATER WIRE BREATHING ADULT",SUP-RT202,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.39,61.92,"MULTIPLAN [10600]",Multiplan,,175.43,85,,,,,0,24,175.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME PATELLAR 9MM 35MM KNEE E PLUS 3 PEG STERILE",SUP-130-03-735,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Open Access",,1707,56.9,,5302.19,4377.88,6578.61,27,348.9,2550,"percent of total billed charges",
"HC Cytpath Cerv/Vag Bethesda",PX-311000011,CDM,88164,CPT,0311,RC,,,both,,,101.00,30.3,"KAISER [10500]",Kaiser,,67.67,67,,,,,0,0.01,85.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUARDWIRE 200CM 2.5CM .014IN 3-6IN .070IN .036IN",SUP-GEZ6200US,CDM,C1884,HCPCS,0272,RC,,,both,,,10488.00,3146.4,"CIGNA [10200]",Cigna,,7131.84,68,,,,,0,1219.75,8914.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 50MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-02.207.450,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",180.95,1322.47,"percent of total billed charges",
"BURR SURGICAL 8MM 4MM MICRO100 MICROPOWER 8MM FLUTE ROUND",SUP-00509223600,CDM,S27200284,LOCAL,0272,RC,,,both,,,207.76,62.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,141.28,68,,,,,0,24.16,176.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 36CM 4.8MM SOLID LAPAROSCOPIC",SUP-E2770-36,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.93,90.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,35.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35,255.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 3 POSTERIOR KNEE TOTAL STABILIZED",SUP-5544-A-300,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"BLUE CROSS [10001]","Blue Cross PPO",,1870.23,39.2,,3949.44,3949.44,3949.44,"1 through 10",554.87,4055.34,"percent of total billed charges",
"STEM FEMORAL 140MM PRESS FIT REDUCE TAPERLOC PPS 133D 10 STD",SUP-51103100,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"CIGNA [10200]","Cigna Local Plus",,7624.05,31.5,,5372.07,4581.20,7242.98,23,2814.85,20572.84,"percent of total billed charges",
"SURFACE ARTICULAR 10MM PERSONA 7-12 G-H KNEE LEFT",SUP-42511200610,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3706.77,45.9,,,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL 6.25IN SMILLIE RIGHT CURVE MENISCUS",SUP-77-5002,CDM,S27200284,LOCAL,0272,RC,,,both,,,541.65,162.49,"MULTIPLAN [10600]",Multiplan,,460.4,85,,,,,0,62.99,460.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 13CM 4MM 70D 12000- RPM TAPER FRONTAL SINUS",SUP-1883672HS,CDM,S27200284,LOCAL,0272,RC,,,both,,,3115.00,934.5,"MULTIPLAN [10600]",Multiplan,,2647.75,85,,,,,0,362.27,2647.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN SILICONE POLYMER INCISION FULL PERFORATED FLAT WOUND",SUP-00256900010,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.80,36.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,82.82,68,,,,,0,14.17,103.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablation Renal Tumors Bi Rf",PX-361000227,CDM,50592,CPT,0361,RC,,,both,,,16112.36,4833.71,"PHCS [10601]",PHCS,,11278.65,70,,,,,0,1718,13695.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 15MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934384,CDM,C1776,HCPCS,0278,RC,,,both,,,18947.25,5684.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2245.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2203.57,16105.16,"percent of total billed charges",
"STENT CONTOUR 26CM 6FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-185-614,CDM,C2617,HCPCS,0278,RC,,,both,,,1122.50,336.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,515.23,45.9,,,,,0,130.55,954.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Stent Plc",PX-750000174,CDM,45389,CPT,0750,RC,,,both,,,4000.72,1200.22,"KAISER [10500]",Kaiser,,2680.48,67,,,,,0,465.28,4000.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X8X7MM RISE NONSTERILE",SUP-193.001,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CELERO BREAST BIOPSY VACUUM ASSIST SPRING LOAD CORE",SUP-CELERO-12,CDM,S27200284,LOCAL,0272,RC,,,both,,,1782.38,534.71,"CIGNA [10200]","Cigna Open Access",,1014.17,56.9,,,,,0,207.29,1515.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM TIBIA CORTICAL DISTAL NONLOCK NONSTERILE",SUP-815037016,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,537.03,68,,,,,0,91.85,671.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC 10IN COTTON FOAM SMALL SHOULDER HUMERAL",SUP-79-97953,CDM,S27000186,LOCAL,0270,RC,,,both,,,512.49,153.75,"NOVANET [10819]",Novanet,,384.37,75,,,,,0,59.6,435.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 12MM 6FR 3.25MM .07IN BALLOON",SUP-H7493918912320,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 13.5IN MURPHY-LANE SURGICAL",SUP-FK193R,CDM,S27200284,LOCAL,0272,RC,,,both,,,734.67,220.4,"NOVANET [10819]",Novanet,,551,75,,,,,0,85.44,624.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL IDENTITY IMPRINT 4 NARROW H7 MM KNEE POSTERIOR",SUP-TPS-020-074N,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,683.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 100CM 8FR XB3 CURVE GUIDING STAINLESS",SUP-588875,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KETAMINE 10 MG/ML INJECTION SOLUTION SUPERORDERABLE (STATUS EPILEPTICUS)",RX-410194,CDM,,,0250,RC,55150-0438-01,NDC,both,20,ML,207.45,62.23,"KAISER [10500]",Kaiser,,138.99,67,,,,,0,24.13,176.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 12MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240120300,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5860.31,68,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 110MM 2.9MM TRICUT 360D 5000 RPM SINUS M4",SUP-1882904HRE,CDM,S27200284,LOCAL,0272,RC,,,both,,,2025.00,607.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,239.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM KNEE 130MM 20/16MM ENDO-MODEL SL MALE TAPER MODULAR",SUP-15-8523/58,CDM,C1776,HCPCS,0278,RC,,,both,,,16271.03,4881.31,"AETNA [10100]","Aetna HMO/PPO",,12935.47,79.5,,10981.53,8986.79,12413.38,12,1892.32,13830.38,"percent of total billed charges",
"EPIXL 4X10 CM",SUP-XL-5410,CDM,Q4186,HCPCS,0636,RC,,,both,,,22018.50,6605.55,"CIGNA [10200]",Cigna,,406.44,,,,,,,406.44,18715.73,"fee schedule",
"TOOL INSRT TRANSVALVULAR 7FR",SUP-TVI-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"NOVANET [10819]",Novanet,,123.98,75,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 150MM 12MM TRIATHLON KNEE COCR CEMENT TOTAL",SUP-5560-S-312,CDM,C1776,HCPCS,0278,RC,,,both,,,6448.05,1934.41,"BLUE CROSS [10001]","Blue Cross PPO",,2527.64,39.2,,3949.44,3949.44,3949.44,"1 through 10",749.91,5480.84,"percent of total billed charges",
"PERITONEAL DIALYSIS SOLN DEX 2.5 % LOW CA+ 2.5 MEQ/L&MAG 0.5 MEQ/L",RX-27800,CDM,,,0250,RC,00941-0457-01,NDC,both,6000,ML,362.16,108.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,42.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.12,307.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGSEED PRO 12CM",SUP-MS2-17-1-12,CDM,A4648,HCPCS,0278,RC,,,both,,,3829.50,1148.85,"BLUE CROSS [10001]","Blue Cross HMO",,1501.16,39.2,,,,,0,445.37,3255.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 6.8FR 11MM SPACING ENDOCARDIUM TRUE BIPOLAR",SUP-7122Q/58,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"AETNA [10100]","Aetna HMO/PPO",,13651.74,79.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 12X12.5CM 335CC STYLE 410FF GEL TEXTURE HIGH",SUP-FF-410335,CDM,C1789,HCPCS,0278,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross PPO",,3245.76,39.2,,16595.83,16595.83,16595.83,"1 through 10",962.96,7038,"percent of total billed charges",
"PERIPHERAL VASCULAR DISORDERS WITH MCC",299,MS-DRG,,,,,,,inpatient,,,31488.49,9446.55,"UHC [10700]","United Healthcare",,31488.49,,"Fee schedule rate ($40,717.91). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,31488.49,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"SUMP INTRACARDIAC SUCTION ADULT .25IN SLIP CNCT 15IN 20FR",SUP-12012,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.06,38.72,"CIGNA [10200]","Cigna Local Plus",,69.05,53.5,,,,,0,15.01,109.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 16IN 29FR VENOUS 3/8IN STD OPEN LIGHTHOUSE 3",SUP-TF292902A,CDM,S27200284,LOCAL,0272,RC,,,both,,,377.58,113.27,"CIGNA [10200]",Cigna,,256.75,68,,,,,0,43.91,320.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 100MM STAINLESS STEEL 1.5MM SCREWS 20 HOLE STRAIGHT",SUP-246.19,CDM,C1713,HCPCS,0278,RC,,,both,,,1871.10,561.33,"CIGNA [10200]","Cigna Open Access",,1064.66,56.9,,1144.80,304.56,2275.09,66,217.61,1590.44,"percent of total billed charges",
"MONTEREY AL STAND-ALONE ANTERIOR LUMBAR ANTERIOR LUMBAR CAGE",SUP-480114535,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"AETNA [10100]","Aetna HMO/PPO",,27546.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM RELINE 2C SPINE POLYAXIAL NONSTERILE",SUP-16016540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AETNA [10100]","Aetna HMO/PPO",,7589.75,79.5,,1521.93,481.35,16760.95,30,1110.3,8114.82,"percent of total billed charges",
"CATH GLIDECATH GLIDE TECHNOLOGY 100CM 25CM 5FR .047IN ANGLE",SUP-CG508,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 63CM VERSACROSS 45D TRANSSEPTAL PIGTAIL RF WIRE 1",SUP-VXSK0022,CDM,C1893,HCPCS,0272,RC,,,both,,,6175.50,1852.65,"NOVANET [10819]",Novanet,,4631.63,75,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 8MM 10-8MM 16MM DUCT SELF EXPANDABLE",SUP-9-PDA-006,CDM,C1817,HCPCS,0278,RC,,,both,,,34398.00,10319.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4076.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4000.49,29238.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM GORILLA R3CON LOCK",SUP-P50-353-3522,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"PHCS [10601]",PHCS,,935.55,70,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Connect Perf 3/8in Straight",PX-E27200347,CDM,E27200347,LOCAL,0272,RC,,,both,,,59.40,17.82,"NOVANET [10819]",Novanet,,44.55,75,,,,,0,6.91,50.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Intralesns <=7 Lesns",PX-510000041,CDM,11900,CPT,0761,RC,,,both,,,853.00,255.9,"UHC [10700]","United Healthcare",,539.95,63.3,,,,,0,99.2,853,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD ILINK 2X IMPLANTABLE UNIPOLAR BIPOLAR IS-1",SUP-347481,CDM,S27200284,LOCAL,0272,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 11MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G111,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"PHCS [10601]",PHCS,,6095.33,70,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 32MM SALVATION ORTHOLOC TITANIUM CORTICAL",SUP-59214532,CDM,S27200284,LOCAL,0272,RC,,,both,,,2197.50,659.25,"FIRST HEALTH [10303]","First Health",,1758,80,,,,,0,255.57,1867.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM 10 HOLE X BONE STERNAL NONSTERILE",SUP-460.037,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,1831.33,1831.33,1831.33,16,434.96,3179,"percent of total billed charges",
"STENT WALLFLEX PERMALUME 80MM 194CM 10MM 8.5FR .035IN",SUP-M00570380,CDM,C1874,HCPCS,0278,RC,,,both,,,9360.00,2808,"FIRST HEALTH [10303]","First Health",,7488,80,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4.5MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN04510,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"MULTIPLAN [10600]",Multiplan,,9964.64,85,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY TORIC",SUP-CNWET4,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,247.56,28.62,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 19CM MR8 9MM ACORN DISSECTING",SUP-MR8-9AC90,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,536.49,45.9,,,,,0,135.93,993.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE HUMERAL 10MM COMPREHENSIVE SHOULDER POSITIONING",SUP-113578,CDM,C1776,HCPCS,0278,RC,,,both,,,1518.10,455.43,"CIGNA [10200]",Cigna,,1032.31,68,,5873.17,5873.17,5873.17,"1 through 10",176.56,1290.39,"percent of total billed charges",
"TUBE ENDOTRACHEAL 8.2MM 7MM NASAL ORAL CUFF MURPHY EYE",SUP-86550,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.14,53.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.72,151.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SHORT VARUS NECK PROFEMUR TL CLASSIC 8D 10 HIP",SUP-PRTLE030,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 CURVE PLUS 17.5MM KNEE XLK FIX BEARING",SUP-970444,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross HMO",,4380.42,39.2,,5311.50,4717.44,5388.59,31,1299.6,9498.37,"percent of total billed charges",
"COIL EMBOLIZATION 10CM 5MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0510CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dil Intracranial Vspasm",PX-361000255,CDM,61640,CPT,0361,RC,,,both,,,7679.39,2303.82,"FIRST HEALTH [10303]","First Health",,6143.51,80,,,,,0,7.68,7679.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ORTHOPEDIC LARGE LUMBOSACRAL 2 STRAP COMPRESSION PAD",SUP-79-89357,CDM,S27000186,LOCAL,0270,RC,,,both,,,145.81,43.74,"AETNA [10100]","Aetna HMO/PPO",,115.92,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.96,123.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS",RX-22982,CDM,,,0250,RC,65862-0946-01,NDC,both,10,ML,767.38,230.21,"MULTIPLAN [10600]",Multiplan,,652.27,85,,,,,0,89.25,652.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 170MM FEMORAL PROXIMAL TFN-ADVANCED LATERAL RELIEF",SUP-04.037.212S,CDM,C1713,HCPCS,0278,RC,,,both,,,8273.93,2482.18,"FIRST HEALTH [10303]","First Health",,6619.14,80,,,,,0,962.26,7032.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE MEDPOR SMOOTH PTERIONAL RIGHT LATEX",SUP-929864,CDM,S27800098,LOCAL,0278,RC,,,both,,,14036.26,4210.88,"AETNA [10100]","Aetna HMO/PPO",,11158.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1632.42,11930.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 13MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-613-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]","Cigna Open Access",,4031.26,33.5,,5302.19,4377.88,6578.61,27,1399.51,10228.56,"percent of total billed charges",
"PLATE TIBIAL 7 KNEE TRABECULAR METAL MIS STERILE",SUP-00595405701,CDM,C1713,HCPCS,0278,RC,,,both,,,13555.74,4066.72,"BLUE CROSS [10001]","Blue Cross PPO",,5313.85,39.2,,957.42,570.23,957.42,28,1576.53,11522.38,"percent of total billed charges",
"PACEMKR ZEPHYR XL DR DUAL CHMBR RATE RESPONSIVE EXTENDED",SUP-5826,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"BLUE CROSS [10001]","Blue Cross PPO",,16307.2,39.2,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR EXTRA BACKUP LAD",SUP-67006400,CDM,C1894,HCPCS,0272,RC,,,both,,,417.60,125.28,"FIRST HEALTH [10303]","First Health",,334.08,80,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL URETERAL TAPER NOTTINGHAM ONE-STEP 70CM 4CM 6-10FR",SUP-M0062301000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1005.78,301.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,461.65,45.9,,,,,0,116.97,854.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Perq Right Heart Vad",PX-360000064,CDM,33997,CPT,0360,RC,,,both,,,2344.58,703.37,"CIGNA [10200]",Cigna,,2344.58,,"Case rate ($7,680). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,272.67,2344.58,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENGTHENING SHIM",SUP-6133.0300S,CDM,C1713,HCPCS,0278,RC,,,both,,,2640.00,792,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1795.2,68,,,,,0,307.03,2244,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TRANS-FEMORAL DELIVERY SYSTEM",SUP-TTVR-DS-26113,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GLIDESHEATH SLENDER SS KIT, 0.025 GW, 7 FR, 10CM",SUP-80-1075,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PERFORMER 85CM 9FR 3MM GUIDING ACCEPTS .038IN GWIRE",SUP-G08694,CDM,C1894,HCPCS,0272,RC,,,both,,,680.32,204.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 16CM 11FR SHEATH PEEL AWAY SPLIT",SUP-491110A,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ANGIOSCULPT 137CM 15MM 3.5MM RECTANGLE HELIX TAPER",SUP-2200-3515,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LARYNSCP VIDEO S2.5 HYPERANGULATE LOW PROFILE BLADE GLIDESCO",SUP-0270-1091,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.40,131.22,"MULTIPLAN [10600]",Multiplan,,371.79,85,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 16MM REVISION 20 GRIT BLAST SURFACE",SUP-197616140,CDM,C1776,HCPCS,0278,RC,,,both,,,17952.48,5385.74,"CIGNA [10200]","Cigna Open Access",,6014.08,33.5,,5302.19,4377.88,6578.61,27,2087.87,15259.61,"percent of total billed charges",
"CATH RANGER 135CM 60MM 6MM BALLOON DILATATION PACLITAXEL OTW",SUP-H74939419600610,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1022.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 52MM 2 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800252,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,521.61,3812.25,"percent of total billed charges",
"ACUITY WHISPER VIEW EDS CS-J - EACH",SUP-664648-001,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,466.07,41.1,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SYNTHETIC ETHIBOND EXCEL 2-0 V-5 30IN 2 ARM BRAID FIRM",SUP-PXX52N,CDM,S27200284,LOCAL,0272,RC,,,both,,,681.53,204.46,"UHC [10700]","United Healthcare",,431.41,63.3,,,,,0,79.26,579.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 14MM PRIMARY SECUR-FIT PLUS",SUP-6054-0814S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"PHCS [10601]",PHCS,,11315.81,70,,,,,0,1880.04,13740.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 36IN 8FR ANTICLOG RADIOPAQUE SMOOTH BOLUS",SUP-40-7368,CDM,S27200284,LOCAL,0272,RC,,,both,,,115.84,34.75,"MULTIPLAN [10600]",Multiplan,,98.46,85,,,,,0,13.47,98.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 11.4CM COHESIVE I MEMORYGEL P5.8CM ULTRA HIGH","SUP-3505480 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"BLUE CROSS [10001]","Blue Cross PPO",,2055.65,39.2,,16595.83,16595.83,16595.83,"1 through 10",609.88,4457.4,"percent of total billed charges",
"COIL EMBOLIZATION 30CM 9MM .0135IN AXIUM PRIME 3D FRAME",SUP-FC-9-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1921.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT THROMBO-WELLCOTEST FIBRIN FIBRINOGEN BUFFER CONTROL",SUP-R30852601,CDM,C1757,HCPCS,0272,RC,,,both,,,77.74,23.32,"NOVANET [10819]",Novanet,,58.31,75,,,,,0,9.04,66.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 18GA 50CM 11CM GREEN HUB DIL GWIRE",SUP-PSI-6F-11-038-18G,CDM,C1894,HCPCS,0272,RC,,,both,,,102.23,30.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,69.52,68,,,,,0,11.89,86.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 20MM 135CM 10MM VASCULAR NITINOL",SUP-1012538-20,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross HMO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 LEFT MEDIAL RIGHT LATERAL PARTIAL KNEE",SUP-5610-F-201,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"UHC [10700]","United Healthcare",,6331.33,63.3,,8601.07,8395.67,8601.07,"1 through 10",1163.24,8501.79,"percent of total billed charges",
"KIT ACCESS 2 ATTACHED COLLET PUMP SEG REVISION CATH CNCT",SUP-8784,CDM,C1755,HCPCS,0278,RC,,,both,,,4409.10,1322.73,"AETNA [10100]","Aetna HMO/PPO",,3505.23,79.5,,,,,0,512.78,3747.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEP PIRANHA URET BIOPSY 3FR",SUP-505-160,CDM,S27200284,LOCAL,0272,RC,,,both,,,2308.73,692.62,"MULTIPLAN [10600]",Multiplan,,1962.42,85,,,,,0,268.51,1962.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT CONTRACTURE XL ANKLE ANTIROTATION BAR PAD TOE PIECE",SUP-4301E,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LABETALOL 200 MG TABLET",RX-10374,CDM,,,0637,RC,00904-7452-61,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTENDER LEAD BIS-BIS-17 17CM OSCOR",SUP-BIS-BIS-17,CDM,C1883,HCPCS,0278,RC,,,both,,,1875.00,562.5,"CIGNA [10200]",Cigna,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 30MM 2MM BALLOON DILATATION DURALYN",SUP-48002003S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"MULTIPLAN [10600]",Multiplan,,1067.18,85,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING EXPIRATION LIMB WYE 6FT DISPOSABLE 1.8MR",SUP-29657-001,CDM,S27000186,LOCAL,0270,RC,,,both,,,90.46,27.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,41.52,45.9,,,,,0,10.52,76.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN",RX-14845,CDM,J1265,HCPCS,0636,RC,00409-7809-11,NDC,both,250,ML,119.51,35.85,"UHC [10700]","United Healthcare",,15.6,,,,,,,7.78,101.58,"fee schedule",
"SCR BONE 5.5MM 25MM BRIGADE LUMBAR SPINE",SUP-8595525,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"BLUE CROSS [10001]","Blue Cross HMO",,1152.48,39.2,,957.42,156.86,7483.26,51,341.92,2499,"percent of total billed charges",
"HEAD FEMORAL +1.5 36MM CERAMIC ARTICUL/EZE",SUP-473436015,CDM,C1776,HCPCS,0278,RC,,,both,,,14072.55,4221.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1667.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1636.64,11961.67,"percent of total billed charges",
"MESH SURGICAL SYMBOTEX 3.3X2.3MM 9CM 2 SIDE COMPOSITE",SUP-SYM9,CDM,C1781,HCPCS,0278,RC,,,both,,,2354.93,706.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,279.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,273.88,2001.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 3DEMIN ALLOGRAFT BOAT PLIABLE OSTEOCONDUCTIVE",SUP-109785,CDM,C1713,HCPCS,0278,RC,,,both,,,16422.00,4926.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1909.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1909.88,13958.7,"percent of total billed charges",
"STENT ZILVER 635 20MM 125CM 6MM 6FR VASCULAR ILIAC ARTERY",SUP-G43819,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"MULTIPLAN [10600]",Multiplan,,3213,85,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPRESSION STOCKING ANTI-EMBOLISM 18MMHG KNEE HIGH MEDIUM R",SUP-4279,CDM,S27000186,LOCAL,0270,RC,,,both,,,111.19,33.36,"CIGNA [10200]",Cigna,,75.61,68,,,,,0,12.93,94.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 12MM 135CM 5MM 3.3-2.9FR 6FR LOW",SUP-1011493-12,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"CIGNA [10200]","Cigna Local Plus",,3370.5,53.5,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 3CM 8FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155254050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,352.3,28.62,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 21.5X12.7X.3MM LARGE SAGITTAL STERILE",SUP-1200-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,146.16,43.85,"NOVANET [10819]",Novanet,,109.62,75,,,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 17MM 140CM 3MM CORONARY STENT CARBOSIL",SUP-LUN300R17US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,9776.84,9776.84,9776.84,"1 through 10",601.85,4398.75,"percent of total billed charges",
"SET UNIVERSAL ACC TRANSITIONAL 172 ADULT PAD FOAM PROCARE",SUP-79-83325,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.53,30.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.81,86.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VEST 3 MEDIUM FRONT ZIP ADJUSTABLE SHOULDER STRAP CUP",SUP-111903,CDM,S27000186,LOCAL,0270,RC,,,both,,,403.16,120.95,"CIGNA [10200]",Cigna,,274.15,68,,,,,0,46.89,342.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORPLEX 2X3 CM",SUP-CX-2030,CDM,Q4232,HCPCS,0636,RC,,,both,,,9204.60,2761.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,247.92,,,,,,,247.92,7823.91,"fee schedule",
"HEAD UNIPOLAR 48MM BIO-MOORE II ENDO II HIP ACETABULAR",SUP-12-139020,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,330.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,324.83,2374.05,"percent of total billed charges",
"CATH STERLING MONORAIL 80CM 15MM 6FR 7MM 4FR BALLOON",SUP-H74939031701580,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BONE CEMENT STABILIT VP LONG VERTEBROPLASTY",SUP-VP-1110L,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR 44.5MM CARBIDE 3MM ROUND 6 FLUTE DENTAL",SUP-14-C0107,CDM,S27200284,LOCAL,0272,RC,,,both,,,120.15,36.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH COYOTE 150CM 100MM 2MM BALLOON DILATATION NYBAX",SUP-H74939186201010,CDM,C1725,HCPCS,0272,RC,,,both,,,1974.60,592.38,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT LIFESTREAM 58MM 135CM 6MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU1350658,CDM,C1874,HCPCS,0278,RC,,,both,,,15870.00,4761,"BLUE CROSS [10001]","Blue Cross PPO",,6221.04,39.2,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHIELD SPLASH 4IN SIMPULSE SOLO STERILE LATEX FREE",SUP-0037630,CDM,S27200284,LOCAL,0272,RC,,,both,,,44.81,13.44,"CIGNA [10200]","Cigna Local Plus",,23.97,53.5,,,,,0,5.21,38.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPROXIMATOR SURGICAL 16CM 2.5MM QUICKPASS TENDON SHUTTLE",SUP-AR-8090S,CDM,S27200284,LOCAL,0272,RC,,,both,,,722.93,216.88,"CIGNA [10200]",Cigna,,491.59,68,,,,,0,84.08,614.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +28.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030285,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17CM 5MM PRESTIGE PLUS HELICAL ULTRA",SUP-PRES0517CPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross PPO",,2569.56,39.2,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 20MM 29MM MOSAIC CINCH RING PORCINE STENT",SUP-305C229,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"MULTIPLAN [10600]",Multiplan,,23294.25,85,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL XS KNEE AVON",SUP-6430-0-050,CDM,C1776,HCPCS,0278,RC,,,both,,,22635.90,6790.77,"AETNA [10100]","Aetna HMO/PPO",,17995.54,79.5,,10981.53,8986.79,12413.38,12,2632.56,19240.52,"percent of total billed charges",
"THORECON? DISPOSABLE TENSIONER",SUP-94-TENSIONER-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"CIGNA [10200]","Cigna Open Access",,829.6,56.9,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD 641000075 75MM PERC ROD 4.75MM CCM",SUP-641000075,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 2MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES0208CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX19MM FRA 8D 30D LORDOTIC NARROW",SUP-10219,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS [10001]","Blue Cross HMO",,7408.8,39.2,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.7MM STRAIGHT CANNULATED 3.5MM MINI COMPRESSION",SUP-AR-8737-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"CIGNA [10200]","Cigna Open Access",,898.74,56.9,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GASTRIC LAVAGE TUM-E-VAC SOL BAG PREASSEMBLE CLOSED",SUP-2055,CDM,S27000186,LOCAL,0270,RC,,,both,,,240.94,72.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,28.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.02,204.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAXI LD 80CM 4CM 7FR 18MM LARGE DIAMETER BALLOON",SUP-4171840S,CDM,C1725,HCPCS,0272,RC,,,both,,,1620.00,486,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 145MM 28-16MM 18FR ENDURANT II ABDOMEN",SUP-ETBF2816C145E,CDM,S27800098,LOCAL,0278,RC,,,both,,,60782.40,18234.72,"CIGNA [10200]","Cigna Local Plus",,19146.46,31.5,,,,,0,7068.99,51665.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 15CM 8FR AIRGUARD VALVED HEMODIALYSIS",SUP-5515180,CDM,C1894,HCPCS,0272,RC,,,both,,,752.90,225.87,"NOVANET [10819]",Novanet,,564.68,75,,,,,0,87.56,639.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP LIMIT HOLE POROUS",SUP-11-106052,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4785.84,68,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -4 40MM HIP BIOLOX DELTA FMP STERILE LATEX FREE",SUP-400-03-401,CDM,C1776,HCPCS,0278,RC,,,both,,,4140.00,1242,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE 20/30 INDEFLATOR 30 ATM INFLATION 20CC STERILE LATEX",SUP-1000184,CDM,C1769,HCPCS,0272,RC,,,both,,,321.90,96.57,"KAISER [10500]",Kaiser,,215.67,67,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CALCAR 23MM RESTORATION +10MM OFFSET HIP MODULAR",SUP-6276-4-123,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"FIRST HEALTH [10303]","First Health",,18564.84,80,,,,,0,2698.86,19725.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 20MM 1.2MM ULTRA LOW PROFILE BALLOON",SUP-1012268-20U,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.50 X 23 RX US",SUP-1804350-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 60MM 120CM 6.5MM 6FR VASCULAR NITINOL",SUP-S-65-060-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1083.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ASAHI CORSAIR PRO 150CM .42MM .87-.93MM .38MM .45MM",SUP-CSR150-26P,CDM,C1887,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"KAISER [10500]",Kaiser,,3929.55,67,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 2 CONTOUR 16IN 29- IN KNEE BASIC",SUP-79-96016,CDM,L1830,HCPCS,0274,RC,,,both,,,92.74,27.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.79,79.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 12.5CM 5MM XPS 15D ROUND CURVE DIAMOND HIGH",SUP-1885061HS,CDM,S27200284,LOCAL,0272,RC,,,both,,,3060.00,918,"CIGNA [10200]","Cigna Open Access",,1741.14,56.9,,,,,0,355.88,2601,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SURGICAL CATARACT",SUP-SA60WF.245,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 130MM CANNULATED AO CONNECTION 2.6MM",SUP-P99-110-2613,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE CATH 91.44CM ADPTR QUICK CONNECT 6 POLE TO 9 POLE",SUP-0652,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"MULTIPLAN [10600]",Multiplan,,12903,85,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 16MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P816,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Open Access",,4754.51,56.9,,5302.19,4377.88,6578.61,27,971.79,7102.52,"percent of total billed charges",
"DEVICE ULTRA FAST-FIX AB REVERSE CURVE FIXATION MENISCAL",SUP-72201495,CDM,C1713,HCPCS,0278,RC,,,both,,,2638.13,791.44,"BLUE CROSS [10001]","Blue Cross PPO",,1034.15,39.2,,957.42,570.23,957.42,28,306.81,2242.41,"percent of total billed charges",
"NDL BIOPSY 14GA 4.5IN THIN WALL TRU-CUT SPECIMEN NOTCH CUT",SUP-2N2702X,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.11,41.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.18,118.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 3MM 1.5MM 1.2MM BALLOON DILATATION RAPID",SUP-DC-RY3012UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,406.15,41.1,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"1000 SINGLE USE FLAT TIP HOLMIUM FIBER",SUP-HOL1000SBX,CDM,S27200284,LOCAL,0272,RC,,,both,,,4183.70,1255.11,"UHC [10700]","United Healthcare",,2648.28,63.3,,,,,0,486.56,3556.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 80MM KNEE LEFT POSTERIOR STABILIZE OPEN BOX",SUP-184536,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"MULTIPLAN [10600]",Multiplan,,21101.91,85,,,,,0,2887.24,21101.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins/Rep Card Sys Gen Only",PX-480000083,CDM,0409T,CPT,0480,RC,,,both,,,38311.00,11493.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2795,,"Case rate ($2,795). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2041,32564.35,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 18FR SILICONE MIC RADIOPAQUE FEED TUBE",SUP-8250-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1191.67,68,,,,,0,203.81,1489.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP CLUSTER HOLE RIM TRITANIUM X3 MDM",SUP-502-03-58F,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1240.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1217.29,8896.8,"percent of total billed charges",
"STENT EVOLUTION 8CM 25MM 20MM ESOPHAGEAL SILICONE 2 LASSO",SUP-G52225,CDM,C1874,HCPCS,0278,RC,,,both,,,14283.00,4284.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3856.41,27,,,,,0,1661.11,12140.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +17 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z900200170,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,694.01,68,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Thorac Add >=2nd Ord",PX-361000086,CDM,36218,CPT,0361,RC,,,both,,,931.37,279.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,110.37,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.32,931.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TALAR INBONE 2 DOME ANKLE SULCUS",SUP-220220902,CDM,C1776,HCPCS,0278,RC,,,both,,,23719.50,7115.85,"AETNA [10100]","Aetna HMO/PPO",,18857,79.5,,10981.53,8986.79,12413.38,12,2758.58,20161.58,"percent of total billed charges",
"STAPLE INTERNAL MEDIUM THICK CATRIDGE STERILE GIA TRI-STAPLE",SUP-GIA80MTC,CDM,S27200284,LOCAL,0272,RC,,,both,,,587.66,176.3,"CIGNA [10200]","Cigna Local Plus",,314.4,53.5,,,,,0,68.34,499.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Selct Plc Cath Cca/Innom Neck",PX-361000288,CDM,36222,CPT,0361,RC,,,both,,,9187.29,2756.19,"CIGNA [10200]",Cigna,,7680,,"Case rate ($7,680). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1068.48,7883,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM TSRH OSTEOGRIP THINLINE LONG SPINAL",SUP-83565609,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1110.3,8114.82,"percent of total billed charges",
"TISSUE 330511 ACSR 5X11X11 SRVC FEE",SUP-330511,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 9IN 12FR DRNG",SUP-8888561027,CDM,C1729,HCPCS,0272,RC,,,both,,,219.10,65.73,"PHCS [10601]",PHCS,,153.37,70,,,,,0,25.48,186.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 550ML P5.5CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-5504BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH ARTHROSCOPIC STD KNOTLESS DISPOSABLE CROSSFT 4.75/5.5",SUP-CFK-DBP4755,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 135CM 40MM 6MM BALLOON DILATATION PACLITAXEL OTW",SUP-H74939419600410,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3544.88,41.1,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM T15 LOCK MULTIDIRECTIONAL NONSTERILE",SUP-110018020,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"MULTIPLAN [10600]",Multiplan,,1577.81,85,,,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 CURVE PLUS 12.5MM KNEE XLK FIX BEARING SIGMA",SUP-970452,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP DUAL MOBILITY CEMENTED OR3O WITH OXI HEAD",SUP-71703498,CDM,C1776,HCPCS,0278,RC,,,both,,,30240.00,9072,"BLUE CROSS [10001]","Blue Cross HMO",,11854.08,39.2,,5311.50,4717.44,5388.59,31,3516.91,25704,"percent of total billed charges",
"STENT VIABAHN 15CM 120CM 5MM 6FR ENDOPROSTHESIS HEPARIN",SUP-VBJ051502,CDM,C1874,HCPCS,0278,RC,,,both,,,24462.90,7338.87,"BLUE CROSS [10001]","Blue Cross PPO",,9589.46,39.2,,,,,0,2845.04,20793.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC LARGE 7.75-8.5IN RIGHT WRIST THUMB SPICA",SUP-A6158,CDM,S27000186,LOCAL,0270,RC,,,both,,,224.55,67.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.12,190.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM RELINE-O SPINE POLYAXIAL TRACTION",SUP-13116550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM VARIAX TITANIUM T7 FULL THREAD RADIUS",SUP-53-27218E,CDM,C1713,HCPCS,0278,RC,,,both,,,571.54,171.46,"BLUE CROSS [10001]","Blue Cross HMO",,224.04,39.2,,957.42,156.86,7483.26,51,66.47,485.81,"percent of total billed charges",
"INSRT TIBIAL 7 6MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620706,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1308.83,9565.82,"percent of total billed charges",
"THORECON? X CABLE PLATE KIT",SUP-94-1200-08,CDM,C1713,HCPCS,0278,RC,,,both,,,11488.50,3446.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1361.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1336.11,9765.23,"percent of total billed charges",
"TRAY NERVE BLOCK 2IN 18GA 20GA PAJUNK E-CATH 21GA CONTINUOUS",SUP-TDL103,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"UHC [10700]","United Healthcare",,333.27,63.3,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 30MM 75CM 8MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200083070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SUCTION/IRRIGATION INTREPID 35D POLYMER BENT IA",SUP-8065751511,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.79,32.34,"KAISER [10500]",Kaiser,,72.22,67,,,,,0,12.54,91.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUE FLOW 110CM 3.5CM 20MM 11FR PERFUSION VALVULOPLASTY",SUP-TF0203511,CDM,C1725,HCPCS,0272,RC,,,both,,,11730.00,3519,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7976.4,68,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BROVIAC/HICKMAN/LEONARD CATHETERS HICKMAN TRIPLE LUMEN CATHE",SUP-0606564,CDM,C1751,HCPCS,0272,RC,,,both,,,1611.90,483.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1096.09,68,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X18X8MM COROENT 10D PEEK THORACOLUMBAR",SUP-6980855,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"MULTIPLAN [10600]",Multiplan,,20196,85,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 27MM TRIGEN FEMUR LOW PROFILE",SUP-71645027,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"PHCS [10601]",PHCS,,1448.69,70,,,,,0,240.69,1759.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BARD INLAY 24CM 6FR 2 PIGTAIL CURVE URETERAL",SUP-778624,CDM,C2617,HCPCS,0278,RC,,,both,,,625.73,187.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 28MM LCP STAINLESS STEEL CORTICAL PERIARTICULAR",SUP-02.204.028,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"CIGNA [10200]",Cigna,,670.87,68,,1831.33,1831.33,1831.33,16,114.74,838.59,"percent of total billed charges",
"GRAFT ENDOVASCULAR 199MM 16MM 16FR ENDURANT II ABDOMINAL",SUP-ETLW1616C199E,CDM,C1876,HCPCS,0278,RC,,,both,,,40918.50,12275.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16367.4,40,,,,,0,4758.82,34780.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 13MM CUFF LOW PRESSURE SHILEY TRACH 10 LATEX FREE",SUP-10LPC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1040.12,312.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,123.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,120.97,884.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 6.5IN SWEDEN DELICATE INSRT NDL TUNGSTEN CARBIDE 5-0",SUP-32-460,CDM,S27200284,LOCAL,0272,RC,,,both,,,955.64,286.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,392.77,41.1,,,,,0,111.14,812.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 8MMX59MM 7FR 80CMCATH HEPARIN",SUP-BXB085901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"AETNA [10100]","Aetna HMO/PPO",,15506.32,79.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 0 CTX 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J370H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 36MM 1 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-41F36V,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"NAIL 9MM 345MM TIBIAL TN ADVANCED INTRAMEDULLARY MR",SUP-04.043.135S,CDM,C1713,HCPCS,0278,RC,,,both,,,9579.13,2873.74,"PHCS [10601]",PHCS,,6705.39,70,,,,,0,1114.05,8142.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 7MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0720CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"CIGNA [10200]","Cigna Open Access",,3729.8,56.9,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 10X34X24MM 15 DEGREE",SUP-1921007P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA [10200]","Cigna Local Plus",,10914.75,31.5,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 20MM SAPIEN 3 ULTRA RESILIA",SUP-S3URCM20A,CDM,S27800098,LOCAL,0278,RC,,,both,,,193800.00,58140,"CIGNA [10200]",Cigna,,77520,40,,,,,0,22538.94,164730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 4.75MM SOLERA COCR MOLYBDENUM CURVED",SUP-1475501080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Bone Marrow Img Ltd",PX-341000067,CDM,78102,CPT,0341,RC,,,both,,,1478.24,443.47,"MULTIPLAN [10600]",Multiplan,,1256.5,85,,,,,0,171.92,1256.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SYMPLICITY SPYRAL RENAL",SUP-RDN016,CDM,C1735,HCPCS,0272,RC,,,both,,,91200.00,27360,"KAISER [10500]",Kaiser,,61104,67,,,,,0,10606.56,77520,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN JUDKINS LEFT 4 CURVE GUIDING",SUP-LA7JL40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TELESCOPE 7FR EXT CORONARY PERIPHERAL COMPATIBLE GUIDE",SUP-TELE7F,CDM,C1887,HCPCS,0272,RC,,,both,,,2767.50,830.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MESH SURGICAL PERFIX LIGHT 1.5IN 2IN GROIN PLUG MONOFILAMENT",SUP-0117080,CDM,C1781,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 3.5MM CAPITOL CURVE",SUP-111.855,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT CRUCIATE RETAIN JOURNEY II",SUP-74021157,CDM,C1776,HCPCS,0278,RC,,,both,,,37771.65,11331.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15524.15,41.1,,6417.48,6417.48,6417.48,"1 through 10",4392.84,32105.9,"percent of total billed charges",
"CATH KOALA PRESSURE INTRAUTERINE TRNSDUC TIPPED INTERNAL",SUP-IPC-5000C,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.15,63.94,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.79,181.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,J2004,HCPCS,0636,RC,63323-0482-01,NDC,both,10,ML,35.86,10.76,"UHC [10700]","United Healthcare",,8,,,,,,,1.17,30.48,"fee schedule",
"HEAD UNIPOLAR 46MM CATHCART BALL HIP FEMUR ORTHOCHROME",SUP-136346000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.467,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA [10200]",Cigna,,3292.97,68,,1831.33,1831.33,1831.33,16,563.19,4116.21,"percent of total billed charges",
"BURR 54.5MM STAINLESS STEEL 3.2MM ROUND 6 FLUTE DENTAL",SUP-16-S0107,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.36,33.41,"CIGNA [10200]","Cigna Open Access",,63.36,56.9,,,,,0,12.95,94.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 20MM 5MM 4.9FR DREAMTOME DREAMWIRE BILIARY RAPID",SUP-M00584020,CDM,C1769,HCPCS,0272,RC,,,both,,,3112.43,933.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,368.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,361.98,2645.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"1.1MM X 625MM TRILOGY PROBE KIT",SUP-M0068403490,CDM,S27200284,LOCAL,0272,RC,,,both,,,5531.45,1659.43,"UHC [10700]","United Healthcare",,3501.41,63.3,,,,,0,643.31,4701.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP NANO HUMERUS/AUGMENTED GLENOID/VERSADIAL HEAD",SUP-98000900234,CDM,C1776,HCPCS,0278,RC,,,both,,,34650.00,10395,"BLUE CROSS [10001]","Blue Cross HMO",,13582.8,39.2,,5311.50,4717.44,5388.59,31,4029.8,29452.5,"percent of total billed charges",
"SCR BONE 7.5MM 45MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1",SUP-179712045,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,3978.14,359.25,3978.14,24,441.36,3225.75,"percent of total billed charges",
"BLADE ARTHROSCOPIC ENDOBLADE GASTROC RECESSION SYSTEM",SUP-AR-8855DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,6484.28,1945.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,754.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,754.12,5511.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 28MM 10MM STAINLESS STEEL 1.1MM LONG THREAD",SUP-02.226.128,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,755.15,45.9,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Cath for Cvad",PX-450000226,CDM,36578,CPT,0450,RC,,,both,,,5586.69,1676.01,"BLUE CROSS [10001]","Blue Cross PPO",,4431.65,,"Case rate ($4,431.65). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,67.13,5586.69,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) BRIOVAD IMPLANT KIT",SUP-490022,CDM,S62400003,LOCAL,0624,RC,,,both,,,523630.50,157089.15,"MULTIPLAN [10600]",Multiplan,,445085.93,85,,,,,0,60898.23,445085.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW LOWPROFILE 6.5X30MM",SUP-010-55-030,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"MULTIPLAN [10600]",Multiplan,,258.83,85,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION BARDEX IC 16FR 350ML FOLEY INFECTION",SUP-303316A,CDM,S27200284,LOCAL,0272,RC,,,both,,,155.56,46.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.09,132.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEPERIDINE (PF) 50 MG/ML INJECTION SUPERORDERABLE",RX-408866,CDM,J2175,HCPCS,0636,RC,00641-6053-01,NDC,both,1,ML,49.12,14.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.58,,"Fee schedule rate ($9.58). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.7,41.75,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK LAPAROSCOPIC 55.2CM 8MM DA VINCI S/SI ENDOWRIST CAUT",SUP-420183,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE VOYANT MARYLAND 7MM 18MM 37CM 20MM LAPAROSCOPIC 1",SUP-EB215,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"CIGNA [10200]",Cigna,,2167.5,68,,,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COOK-Z 5CM 15MM 14FR TRACHEOBRONCHIAL STAINLESS STEEL",SUP-G08552,CDM,C1877,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"BLUE CROSS [10001]","Blue Cross PPO",,1638.17,39.2,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE CHECKER 130CM 10CM 5MM BALLOON DILATATION",SUP-U8130510,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.4CM NATRELLE BIOCELL P3.9CM MODERATE PROFILE",SUP-MSZ10450,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PHCS [10601]",PHCS,,110.73,70,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CLSR QUICK LOAD TK 5 STERILE LATEX FREE DISPOSABLE",SUP-030510,CDM,S27200284,LOCAL,0272,RC,,,both,,,391.50,117.45,"AETNA [10100]","Aetna HMO/PPO",,311.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TACTICATH 115CM 3.5MM 7FR 75MM CURVE 2-5-2MM SPACE","SUP-PN-004 075",CDM,C1732,HCPCS,0272,RC,,,both,,,16560.00,4968,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1962.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1 X 3 HELICAL PICO COIL",SUP-10USH01003,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"MULTIPLAN [10600]",Multiplan,,9964.64,85,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 1 SMALL HYPERINFLATION PEDIATRIC .5L 2 PLEAT BAG 1",SUP-HS4151,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.88,30.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EQUIPMENT EXERCISE 21.75X14.5X3-18IN ROLYAN 1.5IN PLASTIC 6",SUP-A4142,CDM,S27000186,LOCAL,0270,RC,,,both,,,1086.94,326.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,498.91,45.9,,,,,0,126.41,923.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 55MM NAIL-EX TITANIUM FULL THREAD TIBIA 2 CORE",SUP-04.015.545,CDM,C1713,HCPCS,0278,RC,,,both,,,1313.17,393.95,"PHCS [10601]",PHCS,,919.22,70,,,,,0,152.72,1116.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol D5 Lactated Ringer",PX-E27200285,CDM,E27200285,LOCAL,0272,RC,,,both,,,122.10,36.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,50.18,41.1,,,,,0,14.2,103.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Ndl Intraosseus Inf",PX-450000239,CDM,36680,CPT,0361,RC,,,both,,,1213.63,364.09,"KAISER [10500]",Kaiser,,813.13,67,,,,,0,141.15,1213.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.75 X 18 MM  RX FDA",SUP-1203375-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Local Plus",,5433.75,31.5,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT ISP AIRGUARD CHRONOFLEX",SUP-1708061,CDM,C1788,HCPCS,0278,RC,,,both,,,1905.00,571.5,"FIRST HEALTH [10303]","First Health",,1524,80,,,,,0,221.55,1619.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SURGICAL EYE CARE POSTOPERATIVE TAPE UV PROTECTIVE",SUP-DYND08000,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.50,15.75,"NOVANET [10819]",Novanet,,39.38,75,,,,,0,6.11,44.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 75CM 6MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200064070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL KNEE 1 PRIMARY - CEMENTED/STRYKER - SCORPIO OR TRIATHL",SUP-CAP-K-1,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7056,40,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL FEMORAL THK3MM HALVE FROZEN TRADITIONAL",SUP-T20675,CDM,S27800098,LOCAL,0278,RC,,,both,,,6109.95,1832.98,"NOVANET [10819]",Novanet,,4582.46,75,,,,,0,710.59,5193.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE JOURNEY UNICOMPARTMENTAL COBALT CHR",SUP-71701805,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2198.07,16065,"percent of total billed charges",
"SCR BONE 5MM 10MM NCB PROTASUL-64 3.5MM UNICORTICAL SELF TAP",SUP-0203151010,CDM,C1713,HCPCS,0278,RC,,,both,,,1743.75,523.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,206.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",202.8,1482.19,"percent of total billed charges",
"LENS IOL +23 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00230,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"KAISER [10500]",Kaiser,,786.92,67,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 42MM AEQUALIS PERFORM +4MM INFERIOR OFFSET",SUP-DWJ034,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"FIRST HEALTH [10303]","First Health",,9754.56,80,,,,,0,1418.07,10364.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM TRICUSPID LOW PROFILE TRI-AD",SUP-900SFC34,CDM,S27800098,LOCAL,0278,RC,,,both,,,14490.00,4347,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5955.39,41.1,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM ATTUNE 5 KNEE DISTAL CEMENT REVISION STERILE",SUP-1547-05-002,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"PHCS [10601]",PHCS,,4250.4,70,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 7CM 12MM GORE EXCLUDER ILIAC INTERNAL",SUP-HGB161207A,CDM,S27800098,LOCAL,0278,RC,,,both,,,19089.00,5726.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7845.58,41.1,,,,,0,2220.05,16225.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 5% DEXTROSE 20 MEQ POTASSIUM CHLORIDE 0.45%",SUP-07902-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,37.18,45.9,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",479,MS-DRG,,,,,,,inpatient,,,74518.26,22355.48,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,12338.03,,"Case rate ($11,530.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,707.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,746.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,191.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,721.35. The transfer operating threshold is the transfer adjustment factor * $10,707.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.52. The transfer capital threshold is the transfer adjustment factor * $809.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,54272.44,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 11 12MM KNEE N2VAC POSTERIOR STABILIZE BEARING",SUP-82-3-1112,CDM,C1776,HCPCS,0278,RC,,,both,,,7890.15,2367.04,"PHCS [10601]",PHCS,,5523.11,70,,,,,0,917.62,6706.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO SMALL STYLET SURESIGHT",SUP-321900010,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.00,26.1,"AETNA [10100]","Aetna HMO/PPO",,69.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 120MM 12MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U12120090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7038,68,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 55MM PROXIMATE TITANIUM ENDOSCOPIC LINEAR",SUP-TCR55,CDM,S27200284,LOCAL,0272,RC,,,both,,,1086.13,325.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,126.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,126.32,923.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 5.5MM CURVE NONSTERILE",SUP-1555501120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"SABER .035 4X40 80CM SL",SUP-48004004N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,353.05,41.1,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 16MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G316,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6368.93,68,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER ACCUMAX 1000UM HOLMIUM FLEXIBLE POLISH OUTPUT",SUP-M0068404040,CDM,S27200284,LOCAL,0272,RC,,,both,,,4633.07,1389.92,"UHC [10700]","United Healthcare",,2932.73,63.3,,,,,0,538.83,3938.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +11 DIOPTER MODIFIED C BICONVEX TECNIS OPTIEDGE",SUP-ZA90030110,CDM,V2632,HCPCS,0276,RC,,,both,,,955.80,286.74,"CIGNA [10200]",Cigna,,649.94,68,,,,,0,111.16,812.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 39MM 30MM 7.7MM 20FR ZENITH FLEX Z-TRAK",SUP-G55208,CDM,C1874,HCPCS,0278,RC,,,both,,,14138.10,4241.43,"CIGNA [10200]","Cigna Open Access",,4736.26,33.5,,,,,0,1644.26,12017.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE 63X38X3MM POLYETHLENE MEDPOR BLOCK",SUP-6338,CDM,C1713,HCPCS,0278,RC,,,both,,,7928.10,2378.43,"BLUE CROSS [10001]","Blue Cross PPO",,3107.82,39.2,,957.42,570.23,957.42,28,922.04,6738.89,"percent of total billed charges",
"TUBE PEG 20FR SILICONE NONBALLOON REPLACEMENT INSRT DEPTH",SUP-00710821,CDM,S27200284,LOCAL,0272,RC,,,both,,,842.40,252.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,99.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.97,716.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 5MM 5MM LUER LOCK SPRING LOAD HANDLE",SUP-BX00711812,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"CIGNA [10200]","Cigna Open Access",,188.11,56.9,,,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 53CM 5.3FR J VENTRICLE BIPOLAR TINE LOW",SUP-457453,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"BLUE CROSS [10001]","Blue Cross PPO",,875.14,39.2,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1.5MM .0108IN AXIUM PRIME HELICAL",SUP-APB-1.5-1-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3672.49,41.1,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 5MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR050202A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"FIRST HEALTH [10303]","First Health",,13524,80,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAWSON-MUELLER MAC-LOC INTRO-TIP 25CM 10.2FR DRNG",SUP-G09706,CDM,C1729,HCPCS,0272,RC,,,both,,,660.07,198.02,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,76.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,76.77,561.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 40MM 18MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044184070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3958.88,45.9,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 16FR 5CM 30CM MULTIPURPOSE PEEL-AWAY",SUP-G02950,CDM,C1894,HCPCS,0272,RC,,,both,,,530.47,159.14,"PHCS [10601]",PHCS,,371.33,70,,,,,0,61.69,450.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 18MM 150CM 6MM BILIARY STAINLESS",SUP-37912-61815,CDM,C1876,HCPCS,0278,RC,,,both,,,6210.00,1863,"PHCS [10601]",PHCS,,4347,70,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 T TIP SURGICAL",SUP-A13A,CDM,S27200284,LOCAL,0272,RC,,,both,,,2437.50,731.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,288.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.75CM NATRELLE INSPIRA P3.3CM LOW PLUS PROFILE",SUP-MSZ-LP300,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,65.01,41.1,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP LARGE 2 FLAP ENTRAINMENT ELBOW FOREHEAD PAD GRAB",SUP-989805610101,CDM,S27000186,LOCAL,0270,RC,,,both,,,208.37,62.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,95.64,45.9,,,,,0,24.23,177.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 4FR 60CM GROSHONG NXT NXT CLEARVUE PICC 1 LUMEN",SUP-7617407,CDM,C1751,HCPCS,0272,RC,,,both,,,737.91,221.37,"PHCS [10601]",PHCS,,516.54,70,,,,,0,85.82,627.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS ELECTROSURGICAL KOAG ALUMINUM SILVER 1 MM L8 IN L12",SUP-DNL8-10S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +2.5MM OFFSET C TAPER 28MM HIP COCR LFIT",SUP-S-1400-HH82,CDM,C1776,HCPCS,0278,RC,,,both,,,4188.30,1256.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,496.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,487.1,3560.06,"percent of total billed charges",
"INSRT TIBIAL 1 16MM KNEE X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G116,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"AETNA [10100]","Aetna HMO/PPO",,7950,79.5,,10981.53,8986.79,12413.38,12,1163,8500,"percent of total billed charges",
"CNCT ROD MEDIUM TSRH TITANIUM SPINAL 3DX",SUP-8351521,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"KAISER [10500]",Kaiser,,6396.39,67,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SCR CD HORIZON SPIRE M4 BREAKOFF",SUP-9240150,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"AETNA [10100]","Aetna HMO/PPO",,1913.25,79.5,,1521.93,481.35,16760.95,30,279.89,2045.61,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 12MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40012W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"AETNA [10100]","Aetna HMO/PPO",,4324.01,79.5,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 1.1MM MICROLINK HI-FI 2 SUT BUTTON",SUP-ASBR-BB,CDM,C1713,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1685.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1653.89,12087.77,"percent of total billed charges",
"HC C Difficile Toxin Amp Probe",PX-306000001,CDM,87493,CPT,0306,RC,,,both,,,294.50,88.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,34.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,250.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 10.6-10.5CM NATRELLE P4.7-5.2CM HIGH PROFILE",SUP-SZHP68280,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"AETNA [10100]","Aetna HMO/PPO",,242.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 130MM 5MM STERLING OVAL LARGE HUB BURR REDUCED",SUP-H9103RH,CDM,S27200284,LOCAL,0272,RC,,,both,,,564.25,169.27,"PHCS [10601]",PHCS,,394.98,70,,,,,0,65.62,479.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL URETERAL 60CM 6-18FR FASCIAL PTFE SET",SUP-G14574,CDM,S27200284,LOCAL,0272,RC,,,both,,,2500.50,750.15,"FIRST HEALTH [10303]","First Health",,2000.4,80,,,,,0,290.81,2125.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PEN 19CM ISOLATOR TRANSPOLAR",SUP-MAX1,CDM,S27200284,LOCAL,0272,RC,,,both,,,12420.00,3726,"FIRST HEALTH [10303]","First Health",,9936,80,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE HEARTMATE 3 VENTRICULAR ASSIST LEFT MODULAR CABLE",SUP-106525US,CDM,Q0508,HCPCS,0274,RC,,,both,,,33679.80,10103.94,"CIGNA [10200]",Cigna,,13471.92,40,,,,,0,3916.96,28627.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 30MM 6.5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ130,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"CIGNA [10200]",Cigna,,6139.04,68,,5873.17,5873.17,5873.17,"1 through 10",1049.96,7673.8,"percent of total billed charges",
"PLATE 154MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT SET 8",SUP-240.041,CDM,C1713,HCPCS,0278,RC,,,both,,,8796.40,2638.92,"BLUE CROSS [10001]","Blue Cross HMO",,3448.19,39.2,,957.42,156.86,7483.26,51,1023.02,7476.94,"percent of total billed charges",
"STEM FEMORAL CEMENTED EXETER V40 0 44MM OFFSET LONG HIP",SUP-0580-1-044,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 3.5MM OASYS OCCIPITOCERVICOTHORACIC SPINE",SUP-48552050,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 4.0MM X 22.0MM",SUP-494002212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 37MM 80CM 8MM VASCULAR BALLOON EXPANDABLE",SUP-LSMU0800837,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"UHC [10700]","United Healthcare",,16549.79,63.3,,,,,0,3040.66,22223.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENZTROPINE 1 MG TABLET",RX-999,CDM,,,0637,RC,68084-0388-11,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL ZIPWIRE 22-30CM 3CM 4.8FR .035IN PIGTAIL",SUP-M006180155180,CDM,C2617,HCPCS,0278,RC,,,both,,,1466.59,439.98,"CIGNA [10200]",Cigna,,997.28,68,,,,,0,170.56,1246.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRECISION MICROWAVE ABLATION PROBE, 17 GUAGE, 20 CM",SUP-PR20,CDM,C2618,HCPCS,0272,RC,,,both,,,14524.50,4357.35,"PHCS [10601]",PHCS,,10167.15,70,,,,,0,1689.2,12345.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SCREW  - TULIP SCREW AND LAMINAR HOOK AND OCCIPITAL TULIP",SUP-8970000,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1636.49,68,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) INTREPID TRANSFEMORAL INTRODUCER SHEATH AND DILATOR L",SUP-INTPDTFISLPG,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 100CM 8FR IM CURVE GUIDING STAINLESS",SUP-588817,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 10MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962341,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1718.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIS CANNULATED X-TAB 6X45MM TI",SUP-186760045,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"MATRIX TISSUE 18MM AMNIOBAND PLACENTAL ALLOGRAFT",SUP-WC3018,CDM,Q4151,HCPCS,0636,RC,,,both,,,4395.30,1318.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,520.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,362.66,3736.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTHER BONE GORE SMOOTHER OD9.5 MM CRUCIAL TOOL STERILE",SUP-014724,CDM,S27200284,LOCAL,0272,RC,,,both,,,2354.63,706.39,"MULTIPLAN [10600]",Multiplan,,2001.44,85,,,,,0,273.84,2001.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 20MM 4FR 6MM .018IN BALLOON",SUP-PCP060020130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,837.22,68,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 4MM BALL COARSE DISSECTING DIAMOND",SUP-MR8-14BA40DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1358.37,407.51,"UHC [10700]","United Healthcare",,859.85,63.3,,,,,0,157.98,1154.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309016,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10807.54,28.62,,,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 10X42X32MM 15 DEGREE",SUP-1921087P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"NOVANET [10819]",Novanet,,25987.5,75,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULTIPACK WITH GUIDES 12-30MM",SUP-NCAGXLU,CDM,S27800098,LOCAL,0278,RC,,,both,,,686.02,205.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,196.34,28.62,,,,,0,79.78,583.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 5",SUP-245.15,CDM,C1713,HCPCS,0278,RC,,,both,,,2467.50,740.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,706.2,28.62,,,,,0,286.97,2097.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIRROR LARYNGEAL 18MM 3 STATIONARY OCTAGONAL HANDLE",SUP-73-4818,CDM,S27000186,LOCAL,0270,RC,,,both,,,65.60,19.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.63,55.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM ORTHOLOC TITANIUM CORTICAL LOCK",SUP-59215540,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"BLUE CROSS [10001]","Blue Cross HMO",,861.42,39.2,,957.42,156.86,7483.26,51,255.57,1867.88,"percent of total billed charges",
"STENT ADVANIX 5CM 4FR STRAIGHT PANCREATIC PLASTIC LEADING",SUP-M00536150,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"MULTIPLAN [10600]",Multiplan,,543.36,85,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM PRIMARY CEMENT DISTAL BULLET TIP SYNERGY",SUP-71316011,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2472.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2472.83,18073.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC XS 8IN LEFT WRIST FOREARM VOLAR/DORSAL",SUP-A124104,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.24,15.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.96,43.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP FOGARTY HYDRAGRIP 86MM SOFTJAW SET ATRAUMATIC",SUP-SOFT86,CDM,S27200284,LOCAL,0272,RC,,,both,,,105.62,31.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.28,89.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURESIGHT BLADE HYPERANGULATED SIZE 3 CHANNELED",SUP-390531000,CDM,S27000186,LOCAL,0270,RC,,,both,,,321.90,96.57,"UHC [10700]","United Healthcare",,203.76,63.3,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 8X100 135CM SL",SUP-48008010R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,101.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25MMX12MM CRESCENT PEEK-OPTIMA VERTEBRAL BODY",SUP-9392512,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6624,40,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 8MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0301,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,271.23,28.62,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 20X16CM ALLODERM SELECT DUO THK2.8-4MM XTHICK",SUP-1522320P,CDM,Q4116,HCPCS,0636,RC,,,both,,,61236.00,18370.8,"UHC [10700]","United Healthcare",,247.92,,,,,,,247.92,52050.6,"fee schedule",
"LEAD ICD 64CM ENDOTAK RELIANCE S ENDOCARDIAL STEROID",SUP-128,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"KAISER [10500]",Kaiser,,10170.6,67,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28MMX12MM X-PAC LORDOTIC",SUP-EI2448L,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 12MM LEGION STRAIGHT KNEE TITANIUM CEMENT",SUP-71424184,CDM,C1776,HCPCS,0278,RC,,,both,,,12357.90,3707.37,"BLUE CROSS [10001]","Blue Cross PPO",,4844.3,39.2,,3949.44,3949.44,3949.44,"1 through 10",1437.22,10504.22,"percent of total billed charges",
"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC",829,MS-DRG,,,,,,,inpatient,,,127470.32,38241.1,"AETNA [10100]","Aetna HMO/PPO",,59455.4,,"Fee schedule rate ($59,455.40). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,10994,92259.36,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X5MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7305,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"BLUE CROSS [10001]","Blue Cross PPO",,2704.8,39.2,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.205,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 4-0 RB-1 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J304H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 15MM 3.5MM BALLOON DILATATION PACLITAXEL",SUP-H7493960815350,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"AETNA [10100]","Aetna HMO/PPO",,30927.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemo IV Inf Add Hr",PX-335000002,CDM,96415,CPT,0335,RC,,,both,,,464.91,139.47,"CIGNA [10200]","Cigna Open Access",,464.91,,"Per diem ($478).",,,,0,54.07,464.91,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 54MM STAINLESS STEEL 2.4MM SCR 6 HOLE HEAD 3 HOLE",SUP-02.111.631S,CDM,C1713,HCPCS,0278,RC,,,both,,,4217.63,1265.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1935.89,45.9,,,,,0,490.51,3584.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 27MM 22.5MM MASTERS PYROLYTIC CARBON PTFE",SUP-27MTJ-503,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"MULTIPLAN [10600]",Multiplan,,24751.35,85,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840005550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 2MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG20008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,858.6,28.62,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 87.5MM 3.1MM STAINLESS STEEL STERILE",SUP-180018000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla II Typing 1 Locus Lr",PX-309000085,CDM,81376,CPT,0310,RC,,,both,,,551.20,165.36,"UHC [10700]","United Healthcare",,110,,,,,,,46.99,468.52,"fee schedule",
"HC Inj Ther Sq/Im",PX-450000310,CDM,96372,CPT,0260,RC,,,both,,,331.68,99.5,"CIGNA [10200]",Cigna,,331.68,,"Per diem ($571).",,,,0,38.57,331.68,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C4",PX-302000027,CDM,86160,CPT,0302,RC,,,both,,,303.50,91.05,"CIGNA [10200]","Cigna Local Plus",,26.4,,,,,,,0.3,257.98,"fee schedule",
"PLATE SHORT NARROW 48.9X21.6MM TITANIUM 3 HOLE LOW PROFILE",SUP-DVRANSL,CDM,C1713,HCPCS,0278,RC,,,both,,,7607.25,2282.17,"KAISER [10500]",Kaiser,,5096.86,67,,,,,0,884.72,6466.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3.5MM 26MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.826.96,CDM,C1713,HCPCS,0278,RC,,,both,,,319.12,95.74,"KAISER [10500]",Kaiser,,213.81,67,,,,,0,37.11,271.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 20CM 5FR CHECK-FLO PERFORMER .018IN PLATINUM",SUP-G12424,CDM,C1894,HCPCS,0272,RC,,,both,,,382.71,114.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,260.24,68,,,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plasminogen Ag",PX-305000047,CDM,85421,CPT,0305,RC,,,both,,,931.00,279.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,36.14,,,,,,,0.93,791.35,"fee schedule",
"MESH SURGICAL VENTRALIGHT ST ECHO 2 11CM CIRCLE",SUP-5990011,CDM,C1781,HCPCS,0278,RC,,,both,,,4734.78,1420.43,"PHCS [10601]",PHCS,,3314.35,70,,,,,0,550.65,4024.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM PEEK-OPTIMA LOCK ROI-A BONE SPINE",SUP-IR2009T,CDM,C1713,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4061.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,3986.25,29134.26,"percent of total billed charges",
"CATH ADMIRAL XTREME 130CM 120MM 5MM BALLOON DILATATION",SUP-ADM050120130,CDM,C1725,HCPCS,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35943,CDM,,,0637,RC,00245-5319-89,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SKIN ULCERS WITH CC",593,MS-DRG,,,,,,,inpatient,,,34769.12,10430.74,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 150CM 40MM 4MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013466-040,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) NUVISION NON?NAV ICE CATHETER",SUP-M60,CDM,C1759,HCPCS,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 10CM 8.5FR 18GA ARROW-FLEX .035IN PERCUTANEOUS",SUP-AK-09803-CDC,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WARFARIN 0.5 MG TABLET (PARTIAL OF 1 MG TABLET)",RX-408647,CDM,,,0637,RC,08888-8886-80,NDC,both,.5,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PRIMIDONE 250 MG TABLET",RX-6544,CDM,,,0637,RC,50268-0687-11,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT PERIPHERAL L80MM DIA14MM CATHETER L80CM GUIDEWIRE 0.03",SUP-VENUM14080,CDM,C1725,HCPCS,0272,RC,,,both,,,22050.00,6615,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH LAUNCHER 5FR .058IN EXTRA BACKUP 3.75 LEFT CURVE",SUP-LA5EBU375,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ALTEPLASE 2 MG INTRA-CATHETER SOLUTION",RX-31310,CDM,J2997,HCPCS,0636,RC,50242-0041-64,NDC,both,1,UN,1117.67,335.3,"FIRST HEALTH [10303]","First Health",,894.14,80,,,,,0,132.44,950.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 5.5MM CREO CURVE TITANIUM NONSTERILE",SUP-1119.7065,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"KAISER [10500]",Kaiser,,2954.7,67,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X11MM PARALLEL SPINE CERVICAL",SUP-17911,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX MONORAIL 143CM 15MM 3MM BALLOON",SUP-H7493912415300,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 45MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4345,CDM,C1713,HCPCS,0278,RC,,,both,,,3112.50,933.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,368.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",361.98,2645.63,"percent of total billed charges",
"VALVE SHUNT 85CM PRESSURE RELATIVE RISK UNITIZE DISTAL CATH",SUP-NS0005,CDM,S27800098,LOCAL,0278,RC,,,both,,,13732.38,4119.71,"CIGNA [10200]","Cigna Local Plus",,4325.7,31.5,,,,,0,1597.08,11672.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 15MM KNEE POSTERIOR STABILIZED",SUP-71420528,CDM,C1776,HCPCS,0278,RC,,,both,,,18474.75,5542.42,"MULTIPLAN [10600]",Multiplan,,15703.54,85,,,,,0,2148.61,15703.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 55MM METATARSOPHALANGEAL JONES FIXATION",SUP-56015555,CDM,C1713,HCPCS,0278,RC,,,both,,,7514.10,2254.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2150.54,28.62,,,,,0,873.89,6386.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FLOSWITCH 1050 PSI FLOW CONTROL 1 WAY HIGH PRESSURE",SUP-M001442011,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.60,17.88,"CIGNA [10200]","Cigna Open Access",,33.91,56.9,,,,,0,6.93,50.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +12 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0120,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txcath Plc Stent Cca W Dp",PX-360000046,CDM,37215,CPT,0361,RC,,,both,,,11807.09,3542.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5284,,"Case rate ($5,284). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1373.16,10036.03,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS CLEAR 7.3FR PHD METAL POLYCARBONATE",SUP-MAP802,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.53,57.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.39,163.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MERSILENE 5MM CTX 12IN 2 ARM WOVEN WHITE NONABSORBABLE",SUP-RS22,CDM,S27200284,LOCAL,0272,RC,,,both,,,344.74,103.42,"CIGNA [10200]","Cigna Local Plus",,184.44,53.5,,,,,0,40.09,293.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Iabp Sensation",PX-E27200329,CDM,C1725,HCPCS,0272,RC,,,both,,,4193.20,1257.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,496.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,487.67,3564.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 25CM ATRIAL VENTRICULAR BIPOLAR SCR IN ELECTRD",SUP-407625,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"MULTIPLAN [10600]",Multiplan,,1897.63,85,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 8MM 26MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.416S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,177.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",174.09,1272.35,"percent of total billed charges",
"IMPLANT BREAST 370CC 11CM 5.4CM PROJECTION HIGH PROFILE SMOO",SUP-SHPB370,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"KAISER [10500]",Kaiser,,5108.42,67,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE 2X1IN SURGICEL FIBRILLAR STERILE",SUP-1961,CDM,S27200284,LOCAL,0272,RC,,,both,,,867.83,260.35,"AETNA [10100]","Aetna HMO/PPO",,689.92,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,100.93,737.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM 22.5MM MASTER-SERIES PYROLYTIC CARBON PTFE",SUP-27ATJ-503,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 5MM BALLOON DILATATION STERILE LATEX",SUP-595012022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT STRETCH VL ZIPWIRE 22-30CM 3CM 4.8FR .035IN PIGTAIL",SUP-M006185155190,CDM,C2617,HCPCS,0278,RC,,,both,,,1199.37,359.81,"MULTIPLAN [10600]",Multiplan,,1019.46,85,,,,,0,139.49,1019.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ALEXIS GELPOINT RTRCTR 6500ML LARGE SPECIMEN",SUP-GTM17,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"FIRST HEALTH [10303]","First Health",,3864,80,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT ALPHAVENT 3 STRAND HARD BODY PLATFORM PEEK 1.4 MM",SUP-3910-947-031,CDM,C1713,HCPCS,0278,RC,,,both,,,2737.50,821.25,"FIRST HEALTH [10303]","First Health",,2190,80,,,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.290 CLAREON",SUP-SY60WF.290,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 7 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022217,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"PHCS [10601]",PHCS,,11635.47,70,,,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK15MM 51X66MM CONSULTA CRT-D ATRIUM",SUP-D204TRM,CDM,C1882,HCPCS,0278,RC,,,both,,,84445.50,25333.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,34707.1,41.1,,,,,0,9821.01,71778.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 25CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBJR052502A,CDM,C1874,HCPCS,0278,RC,,,both,,,41491.80,12447.54,"NOVANET [10819]",Novanet,,31118.85,75,,,,,0,4825.5,35268.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 10MM 22MM EXPLOR ELBOW",SUP-11-210031,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"AETNA [10100]","Aetna HMO/PPO",,11300.13,79.5,,10981.53,8986.79,12413.38,12,1653.09,12081.9,"percent of total billed charges",
"FENTANYL 50 MCG/ML INJECTION SUPERORDERABLE|DISCARDED DRUG NOT ADMINISTE",RX-4083037,CDM,J3010,HCPCS,0636,RC,00409-9094-18,NDC,both,5,ML,30.96,9.29,"MULTIPLAN [10600]",Multiplan,JW,26.32,85,,,,,0,2.56,26.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE RELINE L45 MM OD5.5 MM SPINE POLYAXIAL 2 FULL CAN",SUP-16215545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 25MM TORNIER AEQUALIS PERFORM +6MM SHOULDER",SUP-DWJ503,CDM,C1776,HCPCS,0278,RC,,,both,,,11340.00,3402,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3245.51,28.62,,,,,0,1318.84,9639,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHTH 9.5FR HMSTS VLV",SUP-6267,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION DEB 2.75X15",SUP-SCA14U-275015D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BALLOON DILATATION ARCADIA 15MM STEERABLE LOCK CEMENT",SUP-ARC15SB-LK,CDM,S27200284,LOCAL,0272,RC,,,both,,,17640.00,5292,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"GRAFT STENT 140MM 22-14MM 15MM 12FR TRIVASCULAR OVATION",SUP-TV-IL1422140-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"CIGNA [10200]",Cigna,,13356,40,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 24MM 144CM 2.5MM CORONARY STENT",SUP-H7493952824250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1592.7,28.62,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 3-0 CT-1 27IN MONOFILAMENT ABSORBABLE",SUP-842H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIDOVUDINE 10 MG/ML ORAL SYRUP",RX-11693,CDM,,,0250,RC,99999-0048-24,NDC,both,5,ML,12.54,3.76,"UHC [10700]","United Healthcare",,7.94,63.3,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 28MM TI",SUP-MTC-37280-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"NOVANET [10819]",Novanet,,935.55,75,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 6CM 5MM 6FR BALLOON DILATATION",SUP-V185060,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"PHCS [10601]",PHCS,,3839.85,70,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 109MM 32MM HANDL-B ONE-SHOT ZENITH",SUP-G32539,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,17944.74,28.62,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145361010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"BLUE CROSS [10001]","Blue Cross HMO",,379.02,39.2,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM ELITE ROUND DIAMOND ROUND DIAMOND STERILE",SUP-5820012040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"CIGNA [10200]","Cigna Local Plus",,585.8,53.5,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HYDRA JAGWIRE ENDOSCOPIC STRAIGHT 450CM .035IN PTFE",SUP-M00556041,CDM,C1769,HCPCS,0272,RC,,,both,,,1422.36,426.71,"PHCS [10601]",PHCS,,995.65,70,,,,,0,165.42,1209.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH 160MM 2.5MM LONG HANDLE AORTIC",SUP-APU525,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,197.18,68,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 16MM 43MM SHOULDER AEQUALIS ASCEND FLEX COCR",SUP-DWF143,CDM,C1776,HCPCS,0278,RC,,,both,,,10004.00,3001.2,"NOVANET [10819]",Novanet,,7503,75,,,,,0,1163.47,8503.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 1.5MM FAST MINI QUICK CONNECT ALPS HAND FRACTURE",SUP-231220203,CDM,S27200284,LOCAL,0272,RC,,,both,,,668.25,200.47,"NOVANET [10819]",Novanet,,501.19,75,,,,,0,77.72,568.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 20MM 4.5MM AEQUALIS REVERSED GLENOID TITANIUM",SUP-VDV220,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"KAISER [10500]",Kaiser,,1042.52,67,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4.5MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035424510,CDM,S27800098,LOCAL,0278,RC,,,both,,,13127.94,3938.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1555.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.78,11158.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 130MM 5.5MM REVOLVE XLORDOTIC",SUP-185.930,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 LEFT MEDIAL RIGHT LATERAL PARTIAL KNEE",SUP-5610-F-501,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"KAISER [10500]",Kaiser,,6701.41,67,,,,,0,1163.24,8501.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 80MM 80CM 10MM BILIARY NITINOL ILIAC",SUP-G43868,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Local Plus",,2022.3,53.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAP TRACTION LARGE FINGER",SUP-AR-1616-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,237.51,71.25,"CIGNA [10200]",Cigna,,161.51,68,,,,,0,27.62,201.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1-2 9MM KNEE XLPE POSTERIOR STABILIZE LEGION",SUP-71453241,CDM,C1776,HCPCS,0278,RC,,,both,,,14831.55,4449.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1724.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1724.91,12606.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAVIGATOR CATHETER",SUP-3696,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"175-260MM 9.0 -11.0 MM DIAM FLEXIGRAFT DUALLINK PRESUTURED T",SUP-FDL,CDM,S27800098,LOCAL,0278,RC,,,both,,,16487.14,4946.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4718.62,28.62,,,,,0,1917.45,14014.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 5MM TORPEDO",SUP-AR-8500TD,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.01,257.7,"PHCS [10601]",PHCS,,601.31,70,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOME LAMBOTTE MINI SWISS PATTERN 5 1/8IN 12MM",SUP-27-5712,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.89,39.57,"CIGNA [10200]","Cigna Local Plus",,70.56,53.5,,,,,0,15.34,112.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SRGITLG LP SRGDAC 2/0 21""3""LP",SUP-ED-21-L,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"CIGNA [10200]","Cigna Local Plus",,77.13,53.5,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.431,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,160.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",160.97,1176.51,"percent of total billed charges",
"SPLINT NASAL SILICONE DOYLE II SEPTUM COMPRESSED HOLE IN",SUP-1524050,CDM,S27000186,LOCAL,0270,RC,,,both,,,450.36,135.11,"NOVANET [10819]",Novanet,,337.77,75,,,,,0,52.38,382.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC SMOOTH CUTTER BITE STRYKER STERILE LATEX",SUP-475333000,CDM,S27200284,LOCAL,0272,RC,,,both,,,752.77,225.83,"UHC [10700]","United Healthcare",,476.5,63.3,,,,,0,87.55,639.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30X11MM HEDRON IA 8D 24MM STERILE LATEX FREE",SUP-1212.0111S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"KAISER [10500]",Kaiser,,23215.5,67,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP LARGE LEAK 1 ENTRAINMENT ELBOW CAPSTRAP HEADGEAR",SUP-989805628751,CDM,S27000186,LOCAL,0270,RC,,,both,,,224.74,67.42,"CIGNA [10200]",Cigna,,152.82,68,,,,,0,26.14,191.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 P 19MM KNEE X3 POSTERIOR STABILIZE TRIATHLON",SUP-5532P219,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]",Cigna,,5682.01,68,,5873.17,5873.17,5873.17,"1 through 10",971.79,7102.52,"percent of total billed charges",
"SCR BONE 2.7MM 42MM LCP",SUP-202.242,CDM,C1713,HCPCS,0278,RC,,,both,,,748.44,224.53,"FIRST HEALTH [10303]","First Health",,598.75,80,,,,,0,87.04,636.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ADSON 120MM TISSUE 1X2 TEETH DELICATE SERRATE",SUP-MG275R,CDM,S27200284,LOCAL,0272,RC,,,both,,,309.72,92.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,36.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.02,263.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 8FR .09IN MULTIPURPOSE 1 CURVE GUIDING NYLON",SUP-LA8MP1,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,inpatient,,,561084.65,168325.39,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Belt Gait 72x2in Delrin Polyur",PX-HHE27100028,CDM,HHE27100028,LOCAL,0271,RC,,,outpatient,,,195.00,58.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE NOVASURE ABLATION ENDOMETRIAL STERILE DISPOSABLE",SUP-NS2000,CDM,S27200284,LOCAL,0272,RC,,,both,,,6785.00,2035.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 7FR 20CM AQ DECREASE FRICTION RADIOPAQUE",SUP-G10208,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EUPHORA POWERTRAC 142CM 20MM 2MM BALLOON DILATATION",SUP-NCEUP2020X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH GLIDELIGHT 25-80HZ 50CM 12FR 7.5FR 8.3FR 12.5FR LASER",SUP-500-301,CDM,C2629,HCPCS,0272,RC,,,both,,,19624.50,5887.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"PAD THERAPEUTIC 11.34X10.85IN WRAP ON EXTEND HOSE CONTINUOUS",SUP-11-0680-9-00000,CDM,S27000187,LOCAL,0270,RC,,,both,,,157.38,47.21,"PHCS [10601]",PHCS,,110.17,70,,,,,0,18.3,133.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Arthcs Asp/Inj Mjr Jt Bi",PX-361000033,CDM,20610,CPT,0361,RC,,,both,,,2944.45,883.33,"BLUE CROSS [10001]","Blue Cross HMO",,2490.09,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,342.44,2944.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Breast W Cntrst Bi",PX-610000062,CDM,77049,CPT,0610,RC,,,both,,,5027.00,1508.1,"KAISER [10500]",Kaiser,,3368.09,67,,,,,0,584.64,4272.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esophagoscopy W Eus Exam",PX-750000024,CDM,43231,CPT,0750,RC,,,both,,,3661.48,1098.44,"UHC [10700]","United Healthcare",,3661.48,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,425.83,3661.48,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Spine Entire Antpost Lat",PX-320000033,CDM,72082,CPT,0320,RC,,,both,,,759.90,227.97,"PHCS [10601]",PHCS,,531.93,70,,,,,0,86.74,645.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 5038-58  LEAD-QUAD SNGL-P A/V 58CM",SUP-5038-58,CDM,C1779,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2573.61,45.9,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Perf Bio-Medicus 25f",PX-E27200364,CDM,E27200364,LOCAL,0272,RC,,,both,,,2228.60,668.58,"MULTIPLAN [10600]",Multiplan,,1894.31,85,,,,,0,259.19,1894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cytogen Microarray Copy Nmbr",PX-309000023,CDM,81228,CPT,0310,RC,,,both,,,9903.75,2971.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2587.86,,,,,,,9.9,8418.19,"fee schedule",
"HC Veeg 2-12 Hr Unmonitored",PX-740000046,CDM,95711,CPT,0740,RC,,,both,,,4173.42,1252.03,"PHCS [10601]",PHCS,,2921.39,70,,,,,0,485.37,3547.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Stoma W Rmvl Snare",PX-750000074,CDM,44394,CPT,0750,RC,,,both,,,2975.83,892.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,352.64,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,346.09,2975.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Medihoney",PX-E27200115,CDM,E27200115,LOCAL,0272,RC,,,both,,,109.08,32.72,"MULTIPLAN [10600]",Multiplan,,92.72,85,,,,,0,12.69,92.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transplant Eval Liver Day 1",PX-761000001,CDM,99215,CPT,0510,RC,,,both,,,1146.00,343.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,135.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,135.8,135.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis C Confirm Test",PX-302000173,CDM,86804,CPT,0302,RC,,,both,,,766.00,229.8,"AETNA [10100]","Aetna HMO/PPO",,608.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,651.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Neck/Soft Tiss W/WO Cntrst",PX-351000013,CDM,70492,CPT,0351,RC,,,both,,,3189.70,956.91,"CIGNA [10200]","Cigna Local Plus",,446,,"Per diem ($446). Each unique revenue code and service date combination is paid its own per diem rate.",567.00,567.00,567.00,"1 through 10",370.96,2711.25,"per diem",
"CATH BARDEX LUBRICATH 18FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0196L18,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.32,32.5,"PHCS [10601]",PHCS,,75.82,70,,,,,0,12.6,92.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 8-0 TG140-8 12IN 2 ARM BRAID COATED VIOLET",SUP-J548G,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.98,46.49,"CIGNA [10200]","Cigna Open Access",,88.18,56.9,,,,,0,18.02,131.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 20CM 31MM GORE TAG THORACIC ACTIVE CONTROL",SUP-TGMR313120,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"NOVANET [10819]",Novanet,,86979.15,75,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT GLENOID REVERSE EXT SHOULDER TRABECULAR METAL",SUP-98850090103,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13097.7,27,,,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 80CM 4CM 12MM BALLOON",SUP-G52379,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE UNICORTICAL DOWEL ALLOGRAFT FREEZE DRIED 14-22MM",SUP-400210,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"CIGNA [10200]","Cigna Open Access",,2414.55,56.9,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 60MM 80CM 9MM 8FR STRAIGHT VASCULAR",SUP-AVSM09060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]",Cigna,,7308,40,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 80MM 9.6MM 7MM 1 CANN CUFF LOW PRESSURE ROUND TIP OBTR",SUP-7SCT,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.54,64.36,"PHCS [10601]",PHCS,,150.18,70,,,,,0,24.95,182.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT 36-38IN MEDIUM PAD SHOULDER STRAP REMOVABLE DRAIN BULB",SUP-46518-02LF,CDM,S27000186,LOCAL,0270,RC,,,both,,,418.38,125.51,"PHCS [10601]",PHCS,,292.87,70,,,,,0,48.66,355.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LASMIDITAN 50 MG TABLET",RX-189200,CDM,,,0637,RC,00002-4312-01,NDC,both,1,UN,400.08,120.02,"FIRST HEALTH [10303]","First Health",,320.06,80,,,,,0,46.53,340.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HD CUTTING EDGE NEEDLE STAINLESS STEEL",SUP-400-689,CDM,S27200284,LOCAL,0272,RC,,,both,,,2178.00,653.4,"KAISER [10500]",Kaiser,,1459.26,67,,,,,0,253.3,1851.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH AORTIC VASCULAR 4.0MM",SUP-DP-40K,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 24FR STERILE YELLOW UROLOGICAL LOOP",SUP-27050G.30/6,CDM,S27200284,LOCAL,0272,RC,,,both,,,5370.96,1611.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3652.25,68,,,,,0,624.64,4565.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 15MM COCR",SUP-VAL-25150-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,969.41,68,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.190,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE 25X20CM PREPERITONEAL KNIT WEB SYNECOR",SUP-GKWR2025,CDM,C1781,HCPCS,0278,RC,,,both,,,19435.50,5830.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2303.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2260.35,16520.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NAVIGATION KNEE",SUP-20-8000-000-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,2996.25,898.87,"KAISER [10500]",Kaiser,,2007.49,67,,,,,0,348.46,2546.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL HARRINGTON 12IN THORAX CROSS SERRATE CLAMP",SUP-54-5013,CDM,S27200284,LOCAL,0272,RC,,,both,,,1058.18,317.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,434.91,41.1,,,,,0,123.07,899.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE PEEP 10 CMW 22MM 10CM TRUE THRESHOLD RESISTOR ADPTR",SUP-9010B,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.67,33.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,46.31,41.1,,,,,0,13.1,95.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 1.4MM 20GA A-OK V-LANCE STRAIGHT CORNEAL",SUP-8065912001,CDM,S27200284,LOCAL,0272,RC,,,both,,,202.97,60.89,"MULTIPLAN [10600]",Multiplan,,172.52,85,,,,,0,23.61,172.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60MM TITANIUM XTHICK VASCULAR ARTICULATING",SUP-SIG60AXT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1919.18,575.75,"NOVANET [10819]",Novanet,,1439.39,75,,,,,0,223.2,1631.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 46MM 42.3MM HIP MODULAR REMEDY",SUP-RHHDSM,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2006.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 9X100 135CM SL",SUP-48009010R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"MULTIPLAN [10600]",Multiplan,,730.16,85,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Mphmtrc Ea 1",PX-312000085,CDM,0852T,CPT,0312,RC,,,both,,,104.00,31.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Anes Add 15 Min",PX-370000002,CDM,9999105,LOCAL,0370,RC,,,both,,,578.25,173.47,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Infect Ag Ia Sars/Corona",PX-306000232,CDM,87426,CPT,0306,RC,,,both,,,205.00,61.5,"CIGNA [10200]","Cigna Local Plus",,77.73,,,,,,,19.49,174.25,"fee schedule",
"HC Kit Cath Femoral Artery Arrow",PX-E27200151,CDM,E27200151,LOCAL,0272,RC,,,both,,,287.10,86.13,"CIGNA [10200]","Cigna Open Access",,163.36,56.9,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rotavirus Ag Eia",PX-306000110,CDM,87425,CPT,0306,RC,,,both,,,247.00,74.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.78,,,,,,,0.01,209.95,"fee schedule",
"HC CT Bx Pleura Perc Ndl",PX-361000051,CDM,32400,CPT,0361,RC,,,both,,,2839.44,851.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2839.44,,"Case rate ($4,656). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,330.23,2839.44,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 5CM 7FR DUODENAL BEND BILIARY PLASTIC",SUP-M00534200,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"NOVANET [10819]",Novanet,,817.09,75,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 28CM 14.5FR CARBOTHANE PALINDROME 2 LUMEN SIDE SLOT",SUP-8888145016P,CDM,C1750,HCPCS,0278,RC,,,both,,,2876.79,863.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,334.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.57,2445.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 6X6CM TUTOPLAST THK.3-.5MM PERICARDIUM",SUP-938266,CDM,C1762,HCPCS,0278,RC,,,both,,,16263.30,4878.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1927.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1891.42,13823.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 5 X 10 COMPLEX PICO COIL",SUP-10USC05010,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5230.2,40,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 90CM 150MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939186251590,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immune Cmplx",PX-302000069,CDM,86332,CPT,0302,RC,,,both,,,217.00,65.1,"NOVANET [10819]",Novanet,,162.75,75,,,,,0,0.01,184.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Theophylline",PX-301000058,CDM,80198,CPT,0301,RC,,,both,,,351.25,105.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12.73,,,,,,,9.58,298.56,"fee schedule",
"HC Mgmt Diabetes Indv per 30min",PX-942000007,CDM,G0108,HCPCS,0942,RC,,,both,,,131.07,39.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,131.07,,"Per diem ($213).",,,,0,15.24,131.07,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Catecholamines Blood",PX-301000557,CDM,82383,CPT,0301,RC,,,both,,,401.00,120.3,"BLUE CROSS [10001]","Blue Cross HMO",,0.4,.1,,,,,0,0.4,340.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM LAPIPLASTY BIPLANAR 16X4.3MM 12MM 3MM 3MM INTERNAL",SUP-SK23,CDM,C1713,HCPCS,0278,RC,,,both,,,44068.50,13220.55,"UHC [10700]","United Healthcare",,27895.36,63.3,,5023.51,2672.93,6679.78,18,5125.17,37458.23,"percent of total billed charges",
"TRANEXAMIC ACID 1,000 MG/100 ML(10 MG/ML)IN SOD CHLOR,ISO IV PIGGYBACK",RX-187555,CDM,J3291,HCPCS,0636,RC,51754-0108-01,NDC,both,100,ML,157.30,47.19,"MULTIPLAN [10600]",Multiplan,,133.71,85,,,,,0,18.64,133.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Trach Uncuffed Fen",PX-E27200238,CDM,E27200238,LOCAL,0272,RC,,,both,,,333.30,99.99,"UHC [10700]","United Healthcare",,210.98,63.3,,,,,0,38.76,283.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myd88 Gene Analysis P.Leu265 (L265p) Variant",PX-309000130,CDM,81305,CPT,0310,RC,,,both,,,942.00,282.6,"CIGNA [10200]","Cigna Open Access",,385.88,,,,,,,0.01,800.7,"fee schedule",
"HC Kit Hyperal Plum W/Lavage",PX-E27200166,CDM,E27200166,LOCAL,0272,RC,,,both,,,102.30,30.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.05,41.1,,,,,0,11.9,86.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vasc Embol Occl Arterial Trinav",PX-361000637,CDM,C9797,HCPCS,0361,RC,,,both,,,13815.00,4144.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1637.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1606.68,11835.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Uric Acid Other Source",PX-301000433,CDM,84560,CPT,0301,RC,,,both,,,138.70,41.61,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,117.9,"per diem",
"FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE",RX-244887,CDM,90661,HCPCS,0636,RC,58160-0912-41,NDC,both,.5,ML,226.52,67.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,154.03,68,,,,,0,26.84,192.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Stoma W Stent",PX-750000162,CDM,44402,CPT,0750,RC,,,both,,,4561.00,1368.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3311,,"Case rate ($3,311). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,530.44,4561,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,inpatient,,,61939.99,18582,"CIGNA [10200]","Cigna Open Access",,19062.94,,"Fee schedule rate ($19,062.94). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,50716.37,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prolact Rtf24 Qtr Btl",PX-E27000212,CDM,E27000212,LOCAL,0270,RC,,,both,,,214.50,64.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,145.86,68,,,,,0,24.95,182.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK",RX-32950,CDM,J2260,HCPCS,0636,RC,00143-9719-01,NDC,both,100,ML,114.48,34.34,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,14.48,,,,,,,6.34,97.31,"fee schedule",
"HC Interrogation Vad in Person",PX-480000001,CDM,93750,CPT,0480,RC,,,both,,,747.18,224.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,508.08,68,,,,,0,86.9,635.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Breast Local Dev Mammo Add",PX-361000313,CDM,19282,CPT,0361,RC,,,both,,,1403.07,420.92,"MULTIPLAN [10600]",Multiplan,,1192.61,85,,,,,0,163.18,1403.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Cath for Cvad",PX-450000226,CDM,36578,CPT,0450,RC,,,both,,,5586.69,1676.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2795.56,,"Case rate ($2,795.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,67.13,5586.69,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 6 13MM KNEE POSTERIOR STABILIZED BEARING TRIAT",SUP-5532P613,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"MULTIPLAN [10600]",Multiplan,,7102.52,85,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lyse Chest Fibrin Init Day",PX-361000427,CDM,32561,CPT,0361,RC,,,both,,,2278.07,683.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1718,,"Case rate ($1,718). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,264.94,2278.07,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fo Pip Dip Jnt/Sprng Pre Ots",PX-E27400036,CDM,L3925,HCPCS,0274,RC,,,both,,,119.90,35.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,34.32,28.62,,,,,0,13.94,101.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis a Igm Ab",PX-302000149,CDM,86709,CPT,0302,RC,,,both,,,381.90,114.57,"FIRST HEALTH [10303]","First Health",,305.52,80,,,,,0,0.01,324.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL COCHLEAR 12MM 4MM DERMALOCK BAHA TITANIUM HA 1 STAGE",SUP-93332,CDM,L8690,HCPCS,0278,RC,,,both,,,21042.00,6312.6,"PHCS [10601]",PHCS,,14729.4,70,,,,,0,2447.18,17885.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Right Heart W/Sensor",PX-481000118,CDM,33289,CPT,0481,RC,,,both,,,79638.29,23891.49,"BLUE CROSS [10001]","Blue Cross HMO",,10743.75,,"Case rate ($10,743.75). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2795,67692.55,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR PREPARATION OF TC-99M-EXAMETAZIME INTRAVENOUS KIT (WBC IMAGING)",RX-155751,CDM,A9569,HCPCS,0343,RC,08888-8878-38,NDC,both,1,UN,7642.40,2292.72,"BLUE CROSS [10001]","Blue Cross HMO",,1997.63,,,,,,,888.81,6496.04,"fee schedule",
"CATH HURRICANE 180CM 4CM 5.8FR 4MM 12 ATM BALLOON DILATATION",SUP-M00545900,CDM,C1726,HCPCS,0272,RC,,,both,,,1849.50,554.85,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DULOXETINE 30 MG CAPSULE,DELAYED RELEASE",RX-39276,CDM,,,0637,RC,51991-0747-90,NDC,both,1,UN,28.51,8.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET STENT PURPLE 4CM 7FR ZIMMON PIGTAIL CURVE PANCREATIC",SUP-G22041,CDM,C2625,HCPCS,0272,RC,,,both,,,1328.40,398.52,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EDWARDS EVOQUE VALVE52 MM",SUP-9850EV52,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL 4-0 PS-1 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J935H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIVERTICULITIS AND DIVERTICULOSIS,MODERATE",244,APR-DRG,,,,,,,inpatient,,,35616.16,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,542.35. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 100MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530100S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPLANT 11.5CM NATRELLE INSPIRA P3.9CM MODERATE PROFIL",SUP-MSZ-M275,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NEURON 125CM 9CM 6FR 5.6FR .04IN BERENSTEIN CURVE",SUP-PNS6F125BER,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CMPNT FEMORAL 175MM KNEE STEM EXT REMEDY STERILE",SUP-RSK175,CDM,C1776,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]",Cigna,,4222.8,68,,5873.17,5873.17,5873.17,"1 through 10",722.22,5278.5,"percent of total billed charges",
"TOOL 7CM MR8 .8MM 4MM TWIST DRILL DISSECTING",SUP-MR8-7TD084,CDM,S27200284,LOCAL,0272,RC,,,both,,,1416.29,424.89,"CIGNA [10200]",Cigna,,963.08,68,,,,,0,164.71,1203.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 11MM KNEE BEARING POSTERIOR STABILIZE",SUP-5532-G-711-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7760.57,68,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 9CM 7.5MM LEGEND ACORN STERILE",SUP-9AC75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"CIGNA [10200]",Cigna,,794.8,68,,,,,0,135.93,993.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOLUTION? MP CS INSERT SIZE 6 STANDARD 10MM RIGHT",SUP-EIS6S10R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1231.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1208.52,8832.69,"percent of total billed charges",
"KIT GUIDEWIRE RESTOR3D METATARSOPHALANGEAL STERILE LATEX FRE",SUP-4103-G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 1MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-1-4-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3347.25,28.62,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 11MM TITANIUM SPINAL SELF TAPPING VARIABLE",SUP-3125311,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"PHCS [10601]",PHCS,,987,70,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL 2MR LOW HUMIDITY CO2 WITHOUT O2 TUBE 1 PRONG",SUP-3826,CDM,S27000186,LOCAL,0270,RC,,,both,,,54.98,16.49,"MULTIPLAN [10600]",Multiplan,,46.73,85,,,,,0,6.39,46.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAXI LD 80CM 4CM 7FR 15MM LARGE DIAMETER BALLOON",SUP-4171540S,CDM,C1725,HCPCS,0272,RC,,,both,,,1620.00,486,"NOVANET [10819]",Novanet,,1215,75,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 7MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640807,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"AETNA [10100]","Aetna HMO/PPO",,8946.85,79.5,,10981.53,8986.79,12413.38,12,1308.83,9565.82,"percent of total billed charges",
"GRAFT BONE NEVOS DEMINERALIZED BONE MATRIX 2.5CC ALLOGRAFT",SUP-BNEPP0025,CDM,C1713,HCPCS,0278,RC,,,both,,,2343.75,703.12,"AETNA [10100]","Aetna HMO/PPO",,1863.28,79.5,,1521.93,481.35,16760.95,30,272.58,1992.19,"percent of total billed charges",
"CATH STERLING MONORAIL 80CM 15MM 6FR 7MM 4FR BALLOON",SUP-H74939031701580,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 6.5MM 18MM TITANIUM FULL THREAD CORTEX SELF",SUP-414.818,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"CIGNA [10200]","Cigna Open Access",,156.63,56.9,,1144.80,304.56,2275.09,66,32.01,233.98,"percent of total billed charges",
"HEAD FEMORAL +0MM 12/14 TAPER 26MM HIP COCR VERSYS STERILE",SUP-801802602,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,564.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,564.14,4123.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 30MM 80CM 10MM VASCULAR PERIPHERAL SELF",SUP-1012532-30,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 15D 54MM 32MM MARATHON HIP STERILE",SUP-121932254,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,961.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 10.5MM CANNULATED ACL LOW PROFILE STERILE",SUP-AR-1410LP-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 450-480ML STYLE 68 SMOOTH ANTERIOR DIAPH VALVE",SUP-68-450,CDM,C1789,HCPCS,0278,RC,,,both,,,2250.00,675,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,266.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",261.68,1912.5,"percent of total billed charges",
"(EVAL) FINISHED GOODS INTRODUCER SET (FG IS)",SUP-FG006,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ADDITIONAL LEVEL ACCESS INSTRUMENTS","SUP-FG 0046",CDM,S27200284,LOCAL,0272,RC,,,both,,,4588.50,1376.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) CATHETER TURNPIKE 150CM 2.2-2.9FR 1.6FR GUIDING LOW P",SUP-5639,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INSTR INFERIOR GLENOID HEMICAP DISPOSABLE STERILE HEMI",SUP-G000-0100,CDM,S27200284,LOCAL,0272,RC,,,both,,,3300.00,990,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS 0 CTX 18IN 8 STRAND CONTROL RELEASE BRAID",SUP-VCP724D,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.49,38.55,"FIRST HEALTH [10303]","First Health",,102.79,80,,,,,0,14.94,109.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID XL VAULTLOCK ARTHREX UNIVERS STERILE",SUP-AR-9106-04,CDM,C1776,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]","Cigna Local Plus",,4614.38,53.5,,5372.07,4581.20,7242.98,23,1003.09,7331.25,"percent of total billed charges",
"PACK 21X11IN THERAPEUTIC COLD PLIABLE SOFT OVERSIZE LATEX",SUP-3548D,CDM,S27000186,LOCAL,0270,RC,,,both,,,132.76,39.83,"FIRST HEALTH [10303]","First Health",,106.21,80,,,,,0,15.44,112.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145359010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,443.81,45.9,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE CRANIOFACIAL TITANIUM 6 HOLE STRUT LOW PROFILE",SUP-421.522,CDM,C1713,HCPCS,0278,RC,,,both,,,3127.50,938.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,895.09,28.62,,,,,0,363.73,2658.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS CORTICAL 30ML CRUSH 1-3MM",SUP-110130,CDM,S27800098,LOCAL,0278,RC,,,both,,,2483.25,744.97,"KAISER [10500]",Kaiser,,1663.78,67,,,,,0,288.8,2110.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALLET SURGICAL 11IN 1 3/8IN LARGE BONE STAINLESS STEEL",SUP-250405,CDM,S27200284,LOCAL,0272,RC,,,both,,,646.38,193.91,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.17,549.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 10MM OLIF51 DIVERGENCE-L BONE SPINE",SUP-2150010,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4750.65,45.9,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 5.5MM CREO CURVE TITANIUM NONSTERILE",SUP-1119.7055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"SYSTEM SPEEDBRIDGE SWIVELOCK 4.75MM IMPL BIOCOMPOSITE",SUP-AR-2600SBS-10,CDM,C1713,HCPCS,0278,RC,,,both,,,15576.75,4673.02,"BLUE CROSS [10001]","Blue Cross HMO",,6106.09,39.2,,957.42,156.86,7483.26,51,1811.58,13240.24,"percent of total billed charges",
"TROCAR LAPAROSCOPIC SHIELD BLADE ADVANCE FIXATION SLEEVE",SUP-CFB73,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"FIRST HEALTH [10303]","First Health",,146.16,80,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 21 GAFR 3FR MERIT PAK .018IN 40CM MINI PEDAL",SUP-PAKM5NPD4,CDM,C1894,HCPCS,0272,RC,,,both,,,374.10,112.23,"PHCS [10601]",PHCS,,261.87,70,,,,,0,43.51,317.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 60MM LCP STAINLESS STEEL CORTICAL PERIARTICULAR",SUP-02.204.060,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"MULTIPLAN [10600]",Multiplan,,838.59,85,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 12MM 2MM",SUP-SPL20012X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 46CM 8FR STRAIGHT ENDOCARDIAL IS-1 BIPOLAR CNCT",SUP-LPA1200M/46,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1518.1,68,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL TRIATHLON 3 4 KNEE HINGE BEARING STERILE LATEX",SUP-5612-0-003,CDM,C1776,HCPCS,0278,RC,,,both,,,28659.96,8597.99,"KAISER [10500]",Kaiser,,19202.17,67,,,,,0,3333.15,24360.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 114MM 7.5MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771100700,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2476.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2430.63,17764.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL GOLD 75MM 12.5MM EXPERT SPIRAL",SUP-04.013.047S,CDM,C1713,HCPCS,0278,RC,,,both,,,3676.05,1102.81,"BLUE CROSS [10001]","Blue Cross PPO",,1441.01,39.2,,957.42,570.23,957.42,28,427.52,3124.64,"percent of total billed charges",
"IMPL BREAST 371ML STYLE 15 SMOOTH NATRELLE SILICONE P4.1CM",SUP-15-371,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"KAISER [10500]",Kaiser,,2391.9,67,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP NANO HUMERUS/MODULAR GLENOID/PREMIUM POST/VERSADIAL HEAD",SUP-98000100265,CDM,C1776,HCPCS,0278,RC,,,both,,,34650.00,10395,"AETNA [10100]","Aetna HMO/PPO",,27546.75,79.5,,10981.53,8986.79,12413.38,12,4029.8,29452.5,"percent of total billed charges",
"STENT ASCERTA 24CM 4.8FR URETERAL FIRM STERILE LATEX FREE",SUP-M0061456410,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"BLUE CROSS [10001]","Blue Cross HMO",,245.09,39.2,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL OVITEX PRS LONG TERM RESORBABLE 3 LAYER",SUP-P20163-2020G,CDM,C1781,HCPCS,0278,RC,,,both,,,43738.38,13121.51,"FIRST HEALTH [10303]","First Health",,34990.7,80,,,,,0,5086.77,37177.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 20MM 2.2MM SHANNON RECTA LARGA STERILE LATEX",SUP-TM12220,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"PHCS [10601]",PHCS,,1548.75,70,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX18MM VANGUARD ARCOM KNEE POSTERIOR STABILIZE",SUP-183648,CDM,C1776,HCPCS,0278,RC,,,both,,,8259.30,2477.79,"AETNA [10100]","Aetna HMO/PPO",,6566.14,79.5,,10981.53,8986.79,12413.38,12,960.56,7020.41,"percent of total billed charges",
"SCR BONE 3.5MM 13MM SPINE CERVICAL ANTERIOR SELF DRILL",SUP-18008113,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,3978.14,359.25,3978.14,24,117.75,860.63,"percent of total billed charges",
"NEEDLE CHIBA 18 GA X 20CM",SUP-MCN1808,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"CIGNA [10200]","Cigna Open Access",,70.29,56.9,,,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 80CM 8MM 16SQ MM 7FR .035IN",SUP-BXAL082901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2311.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS 115CM 4MM 7FR 2-5-2MM SPACING D CURVE ABLATION",SUP-D7BTCDL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,576.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 54MM HIP RESURFACING COBALT CHROME BHR",SUP-74121154,CDM,C1776,HCPCS,0278,RC,,,both,,,18360.00,5508,"FIRST HEALTH [10303]","First Health",,14688,80,,,,,0,2135.27,15606,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 12.5MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158123112,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross PPO",,4380.42,39.2,,3949.44,3949.44,3949.44,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"FIXTR EXTERNAL FIXATION MINIRAIL HORIZONTAL AXIS ARTICULATE",SUP-M111,CDM,C1713,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"NOVANET [10819]",Novanet,,5278.5,75,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM CARBO-SEAL ASCENDING AORTA VALSALVA",SUP-CP-029,CDM,S27800098,LOCAL,0278,RC,,,both,,,29408.40,8822.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12086.85,41.1,,,,,0,3420.2,24997.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT CONGR SZ.5X10MM RT",SUP-2042-0-1210,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross HMO",,1396.5,39.2,,5311.50,4717.44,5388.59,31,414.32,3028.13,"percent of total billed charges",
"SPACER ALLOGRAFT 30X8MM LUMINARY 10/11MM SPINE DEMINERALIZED",SUP-4708,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12946.5,41.1,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ROADRUNNER UNIGLIDE VASCULAR ANGLE TAPER 3CM 260CM 20",SUP-G30506,CDM,C1769,HCPCS,0272,RC,,,both,,,383.65,115.09,"FIRST HEALTH [10303]","First Health",,306.92,80,,,,,0,44.62,326.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 8MM BABY GORILLA LOCK",SUP-P50-053-2008,CDM,C1713,HCPCS,0278,RC,,,both,,,1316.25,394.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,604.16,45.9,,,,,0,153.08,1118.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMB LINER 40/41MM 26MM MULTIPOLAR HIP UHMWPE STERILE",SUP-500104026,CDM,C1776,HCPCS,0278,RC,,,both,,,2365.50,709.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1608.54,68,,,,,0,275.11,2010.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 8 STD 27MM 12MM 9.5MM PROVOX LIFE LARYTUBE ADHSV",SUP-7409,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,548.46,45.9,,,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 7MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS07015,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UHC [10700]","United Healthcare",,7420.72,63.3,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE PROTECTION LONG FLEXIBLE 8-11MM NAIL STERILE",SUP-03.043.033S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1633.13,489.94,"CIGNA [10200]","Cigna Open Access",,929.25,56.9,,,,,0,189.93,1388.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 6MM 16MM 6MM TITANIUM PARTIAL THREAD SMALL",SUP-404.216,CDM,C1713,HCPCS,0278,RC,,,both,,,192.27,57.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,130.74,68,,,,,0,22.36,163.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER GRAY 3.5MM INCISOR STRAIGHT STERILE DISPOSABLE",SUP-7205312,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.00,84.9,"NOVANET [10819]",Novanet,,212.25,75,,,,,0,32.91,240.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 100MM 10MM 7FR BILIARY VENOUS SELF EXPAND",SUP-G57430,CDM,C1876,HCPCS,0278,RC,,,both,,,13109.93,3932.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5388.18,41.1,,,,,0,1524.68,11143.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 110MM 2.5MM STAINLESS STEEL QUICK COUPLING",SUP-310.25,CDM,S27000186,LOCAL,0270,RC,,,both,,,310.00,93,"CIGNA [10200]","Cigna Local Plus",,165.85,53.5,,,,,0,36.05,263.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 6MM 36MM STAINLESS STEEL 2.5MM FULL THREAD",SUP-206.036,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"CIGNA [10200]","Cigna Local Plus",,146.39,53.5,,3978.14,359.25,3978.14,24,31.82,232.58,"percent of total billed charges",
"CATH MARINR 90CM 2MM 7FR 2-5-2MM SPACE 2XL CURVE ABLATION",SUP-072302,CDM,C1730,HCPCS,0272,RC,,,both,,,4209.00,1262.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,489.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,489.51,3577.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 5X 22MM CATH 120CM ENDOVASCULAR",SUP-42522,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM STAINLESS STEEL FULL THREAD FOOT",SUP-214.740,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"MULTIPLAN [10600]",Multiplan,,955.09,85,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM EVOLVE STAINLESS STEEL CORTICAL ELBOW",SUP-4973534L,CDM,C1713,HCPCS,0278,RC,,,both,,,1710.00,513,"MULTIPLAN [10600]",Multiplan,,1453.5,85,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.3MM 35MM TITANIUM FOOT TIBIA LOCK LOW PROFILE",SUP-99-T774035,CDM,C1713,HCPCS,0278,RC,,,both,,,1492.91,447.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,176.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",173.63,1268.97,"percent of total billed charges",
"FRCP SURGICAL CARMALT CURVE 9IN ARTERY CROSS SERRATE",SUP-16-3723,CDM,S27200284,LOCAL,0272,RC,,,both,,,643.06,192.92,"UHC [10700]","United Healthcare",,407.06,63.3,,,,,0,74.79,546.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X14MM CLYDESDALE 0D PEEK CAGE INTERBODY",SUP-2969455,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2815.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 4.5 X 6 COMPLEX PICO COIL",SUP-10USC04506,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"KAISER [10500]",Kaiser,,8760.59,67,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +24 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000240,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC",651,MS-DRG,,,,,,,inpatient,,,938005.83,281401.75,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,23676.93,,"Case rate ($22,987.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $21,345.27, add-ons for qualifying new technology services are included. If operating cost exceeds $54,384.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,995.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $21,373.50. The transfer operating threshold is the transfer adjustment factor * $21,345.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,613.81. The transfer capital threshold is the transfer adjustment factor * $1,613.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,22987.31,91485.27,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 2.7CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-24-2.7,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"MULTIPLAN [10600]",Multiplan,,662.2,85,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.3MM 32MM CHARLOTTE STAINLESS STEEL SHORT THREAD",SUP-44110023,CDM,C1713,HCPCS,0278,RC,,,both,,,2055.00,616.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,588.14,28.62,,,,,0,239,1746.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE KYPHON ACTIVOS 10 10% HA",SUP-C10A,CDM,C1713,HCPCS,0278,RC,,,both,,,1118.13,335.44,"CIGNA [10200]",Cigna,,760.33,68,,1831.33,1831.33,1831.33,16,130.04,950.41,"percent of total billed charges",
"SCR BONE 2.7MM 10MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.810,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"FIRST HEALTH [10303]","First Health",,281.05,80,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL GOLD 70MM 3.5MM SYNAPSE CURVE TITANIUM PREBENT",SUP-04.614.770,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 24MM DCP STAINLESS STEEL CORTICAL HAND SELF",SUP-200.824,CDM,C1713,HCPCS,0278,RC,,,both,,,365.40,109.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,42.5,310.59,"percent of total billed charges",
"RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION",RX-2851,CDM,,,0250,RC,00487-2784-01,NDC,both,1,UN,80.00,24,"PHCS [10601]",PHCS,,56,70,,,,,0,9.3,68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 36MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.626,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,134.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",134.52,983.18,"percent of total billed charges",
"PLATE BUTTRESS TIGHTROPE XP BONE STERILE LATEX FREE",SUP-AR-8959TDS,CDM,C1713,HCPCS,0278,RC,,,both,,,25168.50,7550.55,"MULTIPLAN [10600]",Multiplan,,21393.23,85,,,,,0,2927.1,21393.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM CHARLOTTE STAINLESS STEEL FOOT ANKLE",SUP-56015550,CDM,C1713,HCPCS,0278,RC,,,both,,,7514.10,2254.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5109.59,68,,,,,0,873.89,6386.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 94MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 10",SUP-247.374,CDM,C1713,HCPCS,0278,RC,,,both,,,2429.70,728.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,695.38,28.62,,,,,0,282.57,2065.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 12/14 LARGE 36MM BIOLOX DELTA PROCOTYL STERILE",SUP-PHA04418,CDM,C1776,HCPCS,0278,RC,,,both,,,14234.70,4270.41,"KAISER [10500]",Kaiser,,9537.25,67,,,,,0,1655.5,12099.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 3/16IN STEINMANN STAINLESS STEEL 2 END",SUP-KM169-29-31,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,43.25,68,,,,,0,7.4,54.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM SOLERA CD HORIZON OSTEOGRIP TITANIUM COCR",SUP-54840004040,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]",Cigna,,6491.86,68,,1831.33,1831.33,1831.33,16,1110.3,8114.82,"percent of total billed charges",
"SCR BONE 4.5MM 42MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.842,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,170.62,68,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 1.4MM ORTHOLOC TEMPORARY",SUP-5882000014,CDM,C1713,HCPCS,0278,RC,,,both,,,785.70,235.71,"KAISER [10500]",Kaiser,,526.42,67,,,,,0,91.38,667.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 42MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.842,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"NOVANET [10819]",Novanet,,188.18,75,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET SPINE EVEREST GRAY",SUP-2901-10001,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"KAISER [10500]",Kaiser,,1612.42,67,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSPONGE CANCELLOUS DEMINERALIZED BONE MATRIX",SUP-109609,CDM,C1713,HCPCS,0278,RC,,,both,,,8004.00,2401.2,"CIGNA [10200]","Cigna Open Access",,4554.28,56.9,,1144.80,304.56,2275.09,66,930.87,6803.4,"percent of total billed charges",
"WIRE EXTERNAL FIXATION 400MM 1.8MM TRUELOK STAINLESS STEEL",SUP-54-1215,CDM,C1713,HCPCS,0278,RC,,,both,,,1254.93,376.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,145.95,1066.69,"percent of total billed charges",
"SCR BONE 5MM 70MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.070S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREPHINE OPHTHALMIC TRABECULAR STERILE LATEX DISPOSABLE",SUP-AX1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR ENDOSCOPIC L100MM OD5MM DILATING TIP OBTURATOR RADIOL",SUP-D5LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,106.49,68,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L32 MM OD5 MM LOW PROFILE LOCK NONSTERILE RFN-ADV",SUP-04.045.332TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,858.28,45.9,,,,,0,217.47,1589.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE BONE STERILE 11GX4",SUP-RBN114,CDM,S27200284,LOCAL,0272,RC,,,both,,,400.20,120.06,"KAISER [10500]",Kaiser,,268.13,67,,,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 22MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0350,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"MULTIPLAN [10600]",Multiplan,,805.55,85,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 14MM 200MM SUPRACONDYLAR T2 INTRAMEDULLARY",SUP-1826-1420S,CDM,C1713,HCPCS,0278,RC,,,both,,,11554.33,3466.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3119.67,27,,,,,0,1343.77,9821.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 28MM QUICKFIX TITANIUM T10 PARTIAL THREAD",SUP-AR-8730-28PT,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"SCR INTERFERENCE BIOCOMPOSITE 28MM 10MM BLUNT FULL THREAD",SUP-AR-1400TC,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"KAISER [10500]",Kaiser,,1239.92,67,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER PELLO 4MM STRAIGHT",SUP-6290-112-040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1837.50,551.25,"UHC [10700]","United Healthcare",,1163.14,63.3,,,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 10.1CM 23MM ESOPHAGEAL FULL COVER CATH DIAMETER",SUP-M00517760,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"AETNA [10100]","Aetna HMO/PPO",,14524.65,79.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 38MM 144CM 4MM CORONARY STENT",SUP-H7493941838400,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 5/32IN STEINMANN 2 TROCAR POINT",SUP-162938000,CDM,C1713,HCPCS,0278,RC,,,both,,,102.95,30.88,"BLUE CROSS [10001]","Blue Cross HMO",,40.36,39.2,,957.42,156.86,7483.26,51,11.97,87.51,"percent of total billed charges",
"SCREW BONE L58 MM OD5 MM FEMORAL LOW PROFILE STERILE RFN-ADV",SUP-04.045.358TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,858.28,45.9,,,,,0,217.47,1589.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 12MM INDEPENDENCE SPINE FIX ANGLE",SUP-176.12,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.50,506.25,"CIGNA [10200]","Cigna Local Plus",,902.81,53.5,,3978.14,359.25,3978.14,24,196.26,1434.38,"percent of total billed charges",
"SCR BONE 5MM 45MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75445045,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,3978.14,359.25,3978.14,24,441.36,3225.75,"percent of total billed charges",
"CNCT ROD 12MM 5.5-6MM CREO SPINE 2 HEAD LATERAL NONSTERILE",SUP-1175.9933,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1226.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"SCR BONE 6.5MM 40MM EVEREST SPINE POLYAXIAL",SUP-2911-06540,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"PHCS [10601]",PHCS,,3389.82,70,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 10 SLOT LEFT TI",SUP-PHPF-S10L,CDM,C1713,HCPCS,0278,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 26MM TI",SUP-SPL-35260-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 100MM 5.5MM CREO CURVE TITANIUM NONSTERILE",SUP-1119.7100,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ATLANTIS TITANIUM SPINE CERVICAL ANTERIOR",SUP-3120412,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,396.9,39.2,,957.42,156.86,7483.26,51,117.75,860.63,"percent of total billed charges",
"SCR INTERFERENCE REGENESORB 20MM 7MM OPEN ARCHITECTURE",SUP-72204394,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,793.93,28.62,,,,,0,322.62,2357.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840006540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS [10001]","Blue Cross PPO",,3742.37,39.2,,957.42,570.23,957.42,28,1110.3,8114.82,"percent of total billed charges",
"SCR BONE 4.5MM 6.5MM 28MM TITANIUM FULL THREAD CORTEX SELF",SUP-414.828,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"FIRST HEALTH [10303]","First Health",,220.22,80,,,,,0,32.01,233.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9.5MM 90MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840009590,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC",740,MS-DRG,,,,,,,inpatient,,,101647.07,30494.12,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,22856.47,,"Case rate ($11,225.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,423.23, add-ons for qualifying new technology services are included. If operating cost exceeds $43,462.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,170.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $10,437.01. The transfer operating threshold is the transfer adjustment factor * $10,423.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $788.05. The transfer capital threshold is the transfer adjustment factor * $788.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,52833.08,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75445535,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.9MM 1 SUTUREFIX ULTRA ULTRABRAID COBRAID",SUP-72203854,CDM,C1713,HCPCS,0278,RC,,,both,,,3025.28,907.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,358.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",351.84,2571.49,"percent of total billed charges",
"PLATE 63MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 4",SUP-241.041,CDM,C1713,HCPCS,0278,RC,,,both,,,2169.30,650.79,"BLUE CROSS [10001]","Blue Cross HMO",,850.37,39.2,,957.42,156.86,7483.26,51,252.29,1843.91,"percent of total billed charges",
"ROD SPINAL 90MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355090,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 110MM 32MM LCP STAINLESS STEEL CANCELLOUS",SUP-217.110,CDM,C1713,HCPCS,0278,RC,,,both,,,302.06,90.62,"MULTIPLAN [10600]",Multiplan,,256.75,85,,,,,0,35.13,256.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR CHONDRAL DART MULTISHOT OSTEOCHONDRAL",SUP-AR-4095S,CDM,C1713,HCPCS,0278,RC,,,both,,,3767.40,1130.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1078.23,28.62,,,,,0,438.15,3202.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 12MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDS40012,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"PHCS [10601]",PHCS,,58117.3,70,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 24MM 144CM 4.5MM CORONARY STENT",SUP-H7493941824450,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 24MM 144CM 4.5MM CORONARY STENT",SUP-H7493941824450,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL MICROBIAL OMNEX SURGICAL",SUP-4901,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.28,371.18,"FIRST HEALTH [10303]","First Health",,989.82,80,,,,,0,143.9,1051.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM SPINE POLYAXIAL REVOLVE",SUP-185.476,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AETNA [10100]","Aetna HMO/PPO",,7589.75,79.5,,1521.93,481.35,16760.95,30,1110.3,8114.82,"percent of total billed charges",
"SCR BONE 2MM 10MM LCP STAINLESS STEEL SMALL BONE T6",SUP-201.88,CDM,C1713,HCPCS,0278,RC,,,both,,,689.72,206.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,469.01,68,,,,,0,80.21,586.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 91MM STAINLESS STEEL 5 HOLE LOCK MODULAR LOW PROFILE",SUP-AR-8943BR-05,CDM,C1713,HCPCS,0278,RC,,,both,,,6410.10,1923.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4358.87,68,,,,,0,745.49,5448.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840016545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Open Access",,5432.16,56.9,,1144.80,304.56,2275.09,66,1110.3,8114.82,"percent of total billed charges",
"ROD SPINAL 45MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840016545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PHCS [10601]",PHCS,,6682.8,70,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TSRH THINLINE OSTEOGRIP",SUP-83565409,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1110.3,8114.82,"percent of total billed charges",
"PLATE 34MM LEVEL 2 VIP BONE SPINE CERVICAL ANTERIOR",SUP-171.234,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"FIRST HEALTH [10303]","First Health",,3528,80,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 135D SHORT BARREL 78MM STAINLESS STEEL 4 HOLE",SUP-281.540,CDM,C1713,HCPCS,0278,RC,,,both,,,3719.85,1115.95,"BLUE CROSS [10001]","Blue Cross HMO",,1458.18,39.2,,957.42,156.86,7483.26,51,432.62,3161.87,"percent of total billed charges",
"VALVE AORTIC 23MM TRIFECTA TISSUE ANNULUS",SUP-TF-23A,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 11 HOLE SHAFT LCP BONE LEFT DISTAL",SUP-02.110.111,CDM,C1713,HCPCS,0278,RC,,,both,,,9508.75,2852.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1105.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1105.87,8082.44,"percent of total billed charges",
"PROTEAN FRAGMENT PLATE TY 2.0",SUP-PRT-TY-020,CDM,C1713,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4128.96,68,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END 4MM ANKLE INSRT ARTHRODESIS NAIL STERILE T2 8MM",SUP-1826-0003S,CDM,C1713,HCPCS,0278,RC,,,both,,,1316.57,394.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,604.31,45.9,,,,,0,153.12,1119.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 50MM BEVEL STERILE LATEX FREE MIS",SUP-SF4050,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"CIGNA [10200]","Cigna Open Access",,2826.79,56.9,,1144.80,304.56,2275.09,66,577.78,4222.8,"percent of total billed charges",
"SCR BONE 2.7MM 22MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.822,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CIGNA [10200]","Cigna Local Plus",,187.95,53.5,,3978.14,359.25,3978.14,24,40.86,298.61,"percent of total billed charges",
"PLATE 1.9H 66MM 3 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009366,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"SCR BONE 3.5MM 38MM AXSOS 3 TITANIUM CORTICAL NONSTERILE",SUP-661438,CDM,C1713,HCPCS,0278,RC,,,both,,,289.54,86.86,"FIRST HEALTH [10303]","First Health",,231.63,80,,,,,0,33.67,246.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IMPL GLUTEUS MEDIUS",SUP-AR-2941GM-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,9201.15,2760.34,"AETNA [10100]","Aetna HMO/PPO",,7314.91,79.5,,1521.93,481.35,16760.95,30,1070.09,7820.98,"percent of total billed charges",
"SCR BONE 6.5MM 25MM ENDOSKELETON TAS TITANIUM SPINE",SUP-2300-6525,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,405.69,28.62,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTRUMENT SURGICAL RELINE FENESTRATE REPLACEABLE TIP NONSTE",SUP-1729023,CDM,S27000186,LOCAL,0270,RC,,,both,,,1395.23,418.57,"CIGNA [10200]",Cigna,,948.76,68,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 22MM LCP TITANIUM DISTAL VOLAR RADIUS LOCKING",SUP-04.210.122,CDM,C1713,HCPCS,0278,RC,,,both,,,1063.69,319.11,"FIRST HEALTH [10303]","First Health",,850.95,80,,,,,0,123.71,904.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 35MM LOW PROFILE SCREWS STAINLESS STEEL LONG .5",SUP-AR-8840CL-35,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM CD HORIZON LEGACY TITANIUM SPINAL",SUP-75445550,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 55MM AXSOS OMEGA3 STAINLESS STEEL T20 FEMUR",SUP-370355,CDM,C1713,HCPCS,0278,RC,,,both,,,1376.51,412.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,393.96,28.62,,,,,0,160.09,1170.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 24MM LCP",SUP-02.211.024,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"CIGNA [10200]","Cigna Open Access",,511.04,56.9,,1144.80,304.56,2275.09,66,104.45,763.41,"percent of total billed charges",
"KIT INSTR SHOULDER DRILL SPEAR DISPOSABLE STERILE METAL 3.5",SUP-AR-1926DS,CDM,C1713,HCPCS,0278,RC,,,both,,,1488.38,446.51,"KAISER [10500]",Kaiser,,997.21,67,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TIBIAL FREEZE DRIED PLATE",SUP-56A001,CDM,C1713,HCPCS,0278,RC,,,both,,,2771.25,831.37,"CIGNA [10200]",Cigna,,1884.45,68,,1831.33,1831.33,1831.33,16,322.3,2355.56,"percent of total billed charges",
"1.1MM X 425MM TRILOGY PROBE KIT",SUP-M0068403470,CDM,S27200284,LOCAL,0272,RC,,,both,,,5531.45,1659.43,"NOVANET [10819]",Novanet,,4148.59,75,,,,,0,643.31,4701.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM HEALIX ADVANCE PERMATAPE PEEK BLUE",SUP-222363,CDM,C1713,HCPCS,0278,RC,,,both,,,2812.50,843.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,333.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",327.09,2390.63,"percent of total billed charges",
"SCR BONE 4MM 50MM SOLERA CD HORIZON OSTEOGRIP TITANIUM COCR",SUP-54840004050,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS [10001]","Blue Cross HMO",,3742.37,39.2,,957.42,156.86,7483.26,51,1110.3,8114.82,"percent of total billed charges",
"CEMENT BONE SMARTSET 40GM MEDIUM VISCOSITY STERILE",SUP-3122040,CDM,C1713,HCPCS,0278,RC,,,both,,,469.80,140.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,319.46,68,,,,,0,54.64,399.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4 CP-2 ETHIBOND GII QUICKANCHOR PLUS ROTATOR CUFF",SUP-212034,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",434.96,3179,"percent of total billed charges",
"PUTTY 2.5CMX10CM DBM MATRIX PL",SUP-42200,CDM,C1713,HCPCS,0278,RC,,,both,,,14707.35,4412.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3970.98,27,,,,,0,1710.46,12501.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 5-6MM 5-6MM RELINE-O SPINE OFFSET HOOK ROTATE",SUP-11104055,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PHCS [10601]",PHCS,,2493.75,70,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 24MM 1 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-41F24V,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",521.61,3812.25,"percent of total billed charges",
"SCR BONE 2.4MM 16MM 4MM STAINLESS STEEL SHORT THREAD HAND",SUP-02.226.216,CDM,C1713,HCPCS,0278,RC,,,both,,,1647.00,494.1,"CIGNA [10200]","Cigna Local Plus",,881.15,53.5,,3978.14,359.25,3978.14,24,191.55,1399.95,"percent of total billed charges",
"NAIL 9MM 25.5CM TIBIAL NAIL-EX INTRAMEDULLARY CANNULATED",SUP-04.004.331S,CDM,C1713,HCPCS,0278,RC,,,both,,,8593.61,2578.08,"FIRST HEALTH [10303]","First Health",,6874.89,80,,,,,0,999.44,7304.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 54MM TI",SUP-MTC-37540-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"CIGNA [10200]","Cigna Local Plus",,667.36,53.5,,3978.14,359.25,3978.14,24,145.07,1060.29,"percent of total billed charges",
"WIRE FIXATION 150MM 2MM KIRSCHNER VARIAX ELBOW STAINLESS",SUP-390192,CDM,C1713,HCPCS,0278,RC,,,both,,,179.05,53.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",20.82,152.19,"percent of total billed charges",
"ROD SPINAL 55MM 3.5MM VERTEX SELECT PRECUT",SUP-7753755,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"FIXTR EXTERNAL FIXATION MINIRAIL HORIZONTAL AXIS ARTICULATE",SUP-M111,CDM,C1713,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"KAISER [10500]",Kaiser,,4715.46,67,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 3MM 60D CURVE 2 SERRATE ENTELLUS MEDICAL HNDPC",SUP-SSB-12360-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"PHCS [10601]",PHCS,,1443.75,70,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 100CM 5FR JL2 CURVE ANGIOGRAPHIC NO",SUP-G47012,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,86.52,41.1,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM TITANIUM 2.4MM SCR 3X7 HOLE 2 COLUMN VARIABLE",SUP-04.111.730,CDM,C1713,HCPCS,0278,RC,,,both,,,4274.55,1282.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1962.02,45.9,,,,,0,497.13,3633.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L40MM DIA5MM CARBURIZED VARIABLE ANGLE LOCKING SE",SUP-42.231.240,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,157.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",157.3,1149.66,"percent of total billed charges",
"SCR BONE 45MM 6.5MM TORX ACETABULAR CANCELLOUS",SUP-2080-0045,CDM,C1713,HCPCS,0278,RC,,,both,,,632.74,189.82,"BLUE CROSS [10001]","Blue Cross HMO",,248.03,39.2,,957.42,156.86,7483.26,51,73.59,537.83,"percent of total billed charges",
"CNCT ROD 5-6MM 6.35MM RELINE-O SPINE OFFSET HOOK ROTATE",SUP-11104060,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",414.32,3028.13,"percent of total billed charges",
"NAIL 10MM 38CM TIBIAL META-NAIL INTRAMEDULLARY TITANIUM",SUP-71655138,CDM,C1713,HCPCS,0278,RC,,,both,,,15548.46,4664.54,"CIGNA [10200]",Cigna,,6219.38,40,,1831.33,1831.33,1831.33,16,1808.29,13216.19,"percent of total billed charges",
"SCR BONE 2.7MM 18MM VARIAX TITANIUM T7 FULL THREAD RADIUS",SUP-53-27218E,CDM,C1713,HCPCS,0278,RC,,,both,,,571.54,171.46,"FIRST HEALTH [10303]","First Health",,457.23,80,,,,,0,66.47,485.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16015550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"PIN FIXATION 9IN 3/16IN STEINMANN STAINLESS STEEL 2 END",SUP-KM169-29-31,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"CIGNA [10200]",Cigna,,43.25,68,,1831.33,1831.33,1831.33,16,7.4,54.07,"percent of total billed charges",
"IOL RECONSTRUCTION STERILE KIT",SUP-IOL-REC-KIT,CDM,C1713,HCPCS,0278,RC,,,both,,,16284.00,4885.2,"CIGNA [10200]","Cigna Local Plus",,5129.46,31.5,,3978.14,359.25,3978.14,24,1893.83,13841.4,"percent of total billed charges",
"BOLT SPINAL 40MM 5.5MM XL FACET VARIABLE",SUP-5485540,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"AETNA [10100]","Aetna HMO/PPO",,2337.3,79.5,,1521.93,481.35,16760.95,30,341.92,2499,"percent of total billed charges",
"PLATE BEND GROOVE PREBENT 41X11X2.5MM TITANIUM 4/4.5MM SCR 1",SUP-04.613.182,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Initial Care Training 30 M (Go)",PX-430000068,CDM,G0539,HCPCS,0430,RC,,,both,,,70.00,21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.07,.1,,,,,0,0.07,70,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 1.5MM X 10MM COCR",SUP-VAL-15100-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"BLUE CROSS [10001]","Blue Cross PPO",,558.84,39.2,,957.42,570.23,957.42,28,165.8,1211.76,"percent of total billed charges",
"NDL NERVE BLOCK 100MM 19GA 20GA SONOLONG SONOLONG SONO",SUP-531187-31A,CDM,C9814,HCPCS,0272,RC,,,both,,,461.70,138.51,"PHCS [10601]",PHCS,,323.19,70,,,,,0,53.7,392.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 110MM 5.5MM REVOLVE XLORDOTIC",SUP-185.910,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 63MM STAINLESS STEEL 3.5MM SCR 7 HOLE T OBLIQUE RIGHT",SUP-241.941,CDM,C1713,HCPCS,0278,RC,,,both,,,2179.80,653.94,"CIGNA [10200]",Cigna,,1482.26,68,,1831.33,1831.33,1831.33,16,253.51,1852.83,"percent of total billed charges",
"CAP END 0MM RFN-ADVANCED STERILE",SUP-04.233.000S,CDM,C1713,HCPCS,0278,RC,,,both,,,1531.39,459.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,702.91,45.9,,,,,0,178.1,1301.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 16MM TITANIUM COMPRESSION CANNULATED",SUP-04.333.116,CDM,C1713,HCPCS,0278,RC,,,both,,,2518.50,755.55,"BLUE CROSS [10001]","Blue Cross PPO",,987.25,39.2,,957.42,570.23,957.42,28,292.9,2140.73,"percent of total billed charges",
"SMOOTH PEG VARIABLE ANGLE LOCKING 1.8MM X 18MM",SUP-SPLS-18180-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",165.8,1211.76,"percent of total billed charges",
"GRAFT BONE REFICIO 100 DEMINERALIZED BONE MATRIX CORTICAL",SUP-27800218,CDM,C1713,HCPCS,0278,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",94.2,688.5,"percent of total billed charges",
"TUBE TRACH 8 STD 27MM 12MM 9.5MM PROVOX LIFE LARYTUBE ADHSV",SUP-7409,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"AETNA [10100]","Aetna HMO/PPO",,949.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBOHAWK MEC 113CM 9CM 3.5-7MM ATHERECTOMY CALCIUM",SUP-THS-LX-C,CDM,C1714,HCPCS,0272,RC,,,both,,,20128.50,6038.55,"AETNA [10100]","Aetna HMO/PPO",,16002.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TRILOGY TIVANIUM ALLOY HIP CORTICAL",SUP-00625006540,CDM,C1713,HCPCS,0278,RC,,,both,,,691.60,207.48,"CIGNA [10200]",Cigna,,470.29,68,,1831.33,1831.33,1831.33,16,80.43,587.86,"percent of total billed charges",
"SCR BONE 5MM 40MM LCP STAINLESS STEEL T25 CONDYLAR SELF TAP",SUP-02.231.240,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,154.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",152.1,1111.66,"percent of total billed charges",
"SCR BONE 8.5MM 40MM TSRH OSTEOGRIP THINLINE SPINE",SUP-83585409,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"PHCS [10601]",PHCS,,1801.8,70,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OCTARAY 2-3-2-3-2MM SPACE D CURVE ELECTROPHYSIOLOGY",SUP-D160902,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"MULTIPLAN [10600]",Multiplan,,13489.5,85,,,,,0,1791.92,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 4.5MM 11MM EVOS CORTEX T8 DRIVER 2 END DRILL",SUP-72402711,CDM,C1713,HCPCS,0278,RC,,,both,,,363.14,108.94,"MULTIPLAN [10600]",Multiplan,,308.67,85,,,,,0,42.23,308.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM MPA TSRH-3D TITANIUM MINI LONG POST",SUP-8377550,CDM,C1713,HCPCS,0278,RC,,,both,,,3718.80,1115.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1064.32,28.62,,,,,0,432.5,3160.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 30-34MM TITANIUM 5.5MM ROD LOW PROFILE LEGACY",SUP-8115530,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"KAISER [10500]",Kaiser,,2386.88,67,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM LCP TITANIUM DISTAL CORTICAL RADIAL SELF",SUP-402.874,CDM,C1713,HCPCS,0278,RC,,,both,,,358.70,107.61,"MULTIPLAN [10600]",Multiplan,,304.9,85,,,,,0,41.72,304.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 4-0 PS-2 27IN MONOFILAMENT UNDYED",SUP-Y426H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM VARIAX NONSTERILE",SUP-657418,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,371.19,45.9,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE SMARTSET GENTAMICIN 40GM HIGH VISCOSITY",SUP-545035500,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"PHCS [10601]",PHCS,,1134,70,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 25MM 4.75MM SOLERA ILIAC SPINE LATERAL CLOSED",SUP-5444125,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"PHCS [10601]",PHCS,,3381,70,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 2.1H L68 MM SPINE CERVICAL ANTERIOR 4 LEVEL NONST",SUP-18002468,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"PLATE STAINLESS STEEL 1.5 MM SCR MINI FRAGMENT SET 3 HOLE",SUP-246.612,CDM,C1713,HCPCS,0278,RC,,,both,,,2391.90,717.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,684.56,28.62,,,,,0,278.18,2033.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM SECUR-FIT X-TRA TITANIUM T15 CORTICAL",SUP-131218028,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,93.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,91.85,671.29,"percent of total billed charges",
"SCR BONE 4.3MM 50MM CHARLOTTE STAINLESS STEEL LONG THREAD",SUP-44110040,CDM,C1713,HCPCS,0278,RC,,,both,,,2055.00,616.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,243.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,239,1746.75,"percent of total billed charges",
"SCR BONE 3.5MM 50MM LCP STAINLESS STEEL PROXIMAL TIBIAL SELF",SUP-212.421,CDM,C1713,HCPCS,0278,RC,,,both,,,1158.79,347.64,"CIGNA [10200]","Cigna Local Plus",,619.95,53.5,,3978.14,359.25,3978.14,24,134.77,984.97,"percent of total billed charges",
"VALVE AORTIC TRIFECTA GLIDE 25",SUP-TFGT-25A,CDM,S27800098,LOCAL,0278,RC,,,both,,,38367.00,11510.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4462.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4462.08,32611.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Scrn Low Risk",PX-750000194,CDM,G0121,HCPCS,0750,RC,,,both,,,3920.00,1176,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1550,,"Case rate ($1,550). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,455.9,3920,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9MM 65MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712965,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9MM 65MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712965,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"SCR BONE 3.5MM 17MM ZEVO TITANIUM SPINE CERVICAL ANTERIOR",SUP-7723517,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",117.75,860.63,"percent of total billed charges",
"SCR BONE LOW PROFILE SELF DRILLING NONSTERILE 5MM 1.5MM",SUP-400.835,CDM,C1713,HCPCS,0278,RC,,,both,,,1025.46,307.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,293.49,28.62,,,,,0,119.26,871.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP 15CC ALLOGRAFT PUTTY",SUP-14100601,CDM,C1713,HCPCS,0278,RC,,,both,,,16831.31,5049.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6732.52,40,,,,,0,1957.48,14306.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +9 DIOPTER MODIFY L BICONVEX 13MM 6MM POSTERIOR",SUP-CC60WF.090,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BONE SCREW T10 FULL THREAD 2.7MM / L12MM",SUP-657112,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",94.05,687.4,"percent of total billed charges",
"ROD SPINAL 50MM 5.5MM ES2 RADIUS TITANIUM HEXAGONAL",SUP-482806050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH UROMAX ULTRA QUADRA-FOLD ENCORE HIGH PRESSURE KINK",SUP-M0062251260,CDM,C1726,HCPCS,0272,RC,,,both,,,1904.70,571.41,"FIRST HEALTH [10303]","First Health",,1523.76,80,,,,,0,221.52,1619,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL CNCT ACUITY X4 GWIRE FLUSH LEAD",SUP-4604,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,207.06,68,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.7MM 80MM 18MM LOW PROFILE SCREWS TITANIUM 3.5MM",SUP-AR-8967-1880,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 17MM SPINE CERVICAL ANTERIOR SELF TAP VARIABLE",SUP-18008517,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,396.9,39.2,,957.42,156.86,7483.26,51,117.75,860.63,"percent of total billed charges",
"CATH ABLATION 3FR THERMOCOOL SF J CURVE DEFLECTABLE",SUP-D131804,CDM,C1732,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM SPINAL",SUP-8807545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2732.31,28.62,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 44MM TI",SUP-MTLS-37440-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",155.43,1136.03,"percent of total billed charges",
"SCR BONE 4MM 42MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.442TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"BLUE CROSS [10001]","Blue Cross HMO",,792.45,39.2,,957.42,156.86,7483.26,51,235.11,1718.32,"percent of total billed charges",
"TIRE RETINAL 3.5MM GROOVE CONVEX SILICONE 7MM STERILE STYLE",SUP-9223,CDM,S27800098,LOCAL,0278,RC,,,both,,,229.68,68.9,"BLUE CROSS [10001]","Blue Cross PPO",,90.03,39.2,,,,,0,26.71,195.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HEARTSTRING III 3.8MM PROXIMAL SEAL DELIVERY DEVICE",SUP-HSK-3038,CDM,S27200284,LOCAL,0272,RC,,,both,,,3809.28,1142.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,451.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,443.02,3237.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBOHAWK MEC 113CM 9CM 3.5-7MM LOW PROFILE ATHERECTOMY",SUP-TH-LX-M,CDM,C1714,HCPCS,0272,RC,,,both,,,20128.50,6038.55,"AETNA [10100]","Aetna HMO/PPO",,16002.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH XP 65CM 15CM 5FR COBRA 2 CURVE ANGIOGRAPHIC",SUP-RF*ZB5510GM,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ABLATION 7.5FR J CURVE THERMOCOOL SF UNIDIRECTIONAL",SUP-D131504,CDM,C1732,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"KIT CATH BRIDGE PREP GWIRE SYR STPCOCK OCCLUSION BALLOON",SUP-591-001,CDM,C1769,HCPCS,0272,RC,,,both,,,2137.50,641.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,248.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CSL KIT SHORT BUCKLE 2MM MODEL 1036",SUP-100063-212,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE RIGHT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F202,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4905.48,28.62,,,,,0,1993.39,14569.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 99MM TRI-LOCK BPS GRIPTION 2 HIGH OFFSET HIP",SUP-101214020,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"KAISER [10500]",Kaiser,,10791.77,67,,,,,0,1873.26,13691.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 65MM KNEE RIGHT POSTERIOR STABILIZE OPEN BOX",SUP-184508,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10203.4,41.1,,6417.48,6417.48,6417.48,"1 through 10",2887.24,21101.91,"percent of total billed charges",
"GWIRE VASCULAR 185CM PRESSURE VERRATA PLUS STERILE LATEX",SUP-10185P,CDM,C1769,HCPCS,0272,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 7X4CM SUSPEND TUTOPLAST FASCIA LATA",SUP-937201,CDM,C1762,HCPCS,0278,RC,,,both,,,12123.30,3636.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4982.68,41.1,,,,,0,1409.94,10304.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 24FR CIRCON CLASSIC",SUP-M0068802581,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"CIGNA [10200]","Cigna Open Access",,272.11,56.9,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 15MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-015,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,550.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,550.92,4026.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 8MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630508,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1526.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 53MM 28MM TANDEM HIP ACETABULAR COCR",SUP-71322053,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,989.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,971.39,7099.58,"percent of total billed charges",
"HEAD FEMORAL -3MM SHORT 26MM HIP OFFSET TAPER PRIMARY COCR",SUP-6260-9-026,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,370.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,363.75,2658.55,"percent of total billed charges",
"HEAD HUMERAL 27MM 46MM SHOULDER COMPREHENSIVE VERSA-DIAL",SUP-113048,CDM,C1776,HCPCS,0278,RC,,,both,,,9089.00,2726.7,"KAISER [10500]",Kaiser,,6089.63,67,,,,,0,1057.05,7725.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 53MM 28MM TANDEM HIP ACETABULAR COCR",SUP-71322053,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"AETNA [10100]","Aetna HMO/PPO",,6640.2,79.5,,10981.53,8986.79,12413.38,12,971.39,7099.58,"percent of total billed charges",
"STEM FEMORAL 133MM CEMENTLESS NECK ACCOLADE TMZF 132D 5.5 45",SUP-6020-5537,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6531.58,28.62,,,,,0,2654.17,19398.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 101MM TRI-LOCK BPS GRIPTION 3 STD OFFSET HIP",SUP-101204030,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6620.03,41.1,,6417.48,6417.48,6417.48,"1 through 10",1873.26,13691.05,"percent of total billed charges",
"CMPNT FEMORAL SMALL+ KNEE LEFT CEMENT LCS COMPLETE COCR",SUP-129402020,CDM,C1776,HCPCS,0278,RC,,,both,,,20635.65,6190.69,"CIGNA [10200]","Cigna Local Plus",,6500.23,31.5,,5372.07,4581.20,7242.98,23,2399.93,17540.3,"percent of total billed charges",
"CMPNT FEMORAL LARGE KNEE RIGHT LCS COMPLETE POROCOAT",SUP-129403060,CDM,C1776,HCPCS,0278,RC,,,both,,,28683.90,8605.17,"PHCS [10601]",PHCS,,20078.73,70,,,,,0,3335.94,24381.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +23.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.235,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZOOM 45 REPERFUSION CATHETER",SUP-ICRC045144,CDM,S27200284,LOCAL,0272,RC,,,both,,,17146.50,5143.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2031.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1994.14,14574.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 15MM KNEE GVF UHMWPE STABILIZE ROTATE",SUP-972103,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"CIGNA [10200]",Cigna,,6939.47,68,,5873.17,5873.17,5873.17,"1 through 10",1186.85,8674.34,"percent of total billed charges",
"SLEEVE CENTERING G7 +6MM OFFSET TAPER HIP TITANIUM TYPE 1",SUP-650-1068,CDM,C1776,HCPCS,0278,RC,,,both,,,1539.00,461.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,182.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,178.99,1308.15,"percent of total billed charges",
"INSRT TIBIAL 7 9MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G709,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"PHCS [10601]",PHCS,,6095.33,70,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 12.5MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158106112,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"KAISER [10500]",Kaiser,,7486.95,67,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 9.25MM CEMENTRALIZER HIP FEMUR PMMA CEMENT",SUP-137647000,CDM,C1776,HCPCS,0278,RC,,,both,,,846.45,253.93,"BLUE CROSS [10001]","Blue Cross HMO",,331.81,39.2,,5311.50,4717.44,5388.59,31,98.44,719.48,"percent of total billed charges",
"STENT PRECISE 40MM 135CM 8MM VASCULAR NITINOL CAROTID ARTERY",SUP-P08040RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,12178.50,3653.55,"PHCS [10601]",PHCS,,8524.95,70,,,,,0,1416.36,10351.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP 5 SCR HOLE CLUSTER TRITANIUM",SUP-702-04-58F,CDM,C1776,HCPCS,0278,RC,,,both,,,12551.10,3765.33,"UHC [10700]","United Healthcare",,7944.85,63.3,,8601.07,8395.67,8601.07,"1 through 10",1459.69,10668.44,"percent of total billed charges",
"WEDGE TIBIAL 5MM LEGION 5-6 KNEE RIGHT MEDIAL LEFT LATERAL",SUP-71421147,CDM,C1776,HCPCS,0278,RC,,,both,,,15369.75,4610.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6316.97,41.1,,6417.48,6417.48,6417.48,"1 through 10",1787.5,13064.29,"percent of total billed charges",
"STEM HUMERAL 128MM 12MM REUNION SHOULDER STERILE REVERSIBLE",SUP-5568-0012,CDM,C1776,HCPCS,0278,RC,,,both,,,25615.80,7684.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3035.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2979.12,21773.43,"percent of total billed charges",
"CAP SYSTEM INHANCE ARTHROPLASTY SHOULDER HEMI",SUP-OSC382098,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"KAISER [10500]",Kaiser,,13718.25,67,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON PANOPTIX TORIC UVA",SUP-CCWTT4,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,102.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD LINER MP6 GRAY 34MM",SUP-932-34-250,CDM,C1776,HCPCS,0278,RC,,,both,,,12462.02,3738.61,"KAISER [10500]",Kaiser,,8349.55,67,,,,,0,1449.33,10592.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP IDENTITY STEM/AUGMENTED GLENOID/PREMIUM POST/IDENTITY TI",SUP-98000900265,CDM,C1776,HCPCS,0278,RC,,,both,,,42525.00,12757.5,"UHC [10700]","United Healthcare",,26918.33,63.3,,8601.07,8395.67,8601.07,"1 through 10",4945.66,36146.25,"percent of total billed charges",
"PARTIAL HIP HEMIARTHROPLASTY (PARTIAL HIP CONSTRUCT)",SUP-CAP-LB-PH-1,CDM,C1776,HCPCS,0278,RC,,,both,,,6900.00,2070,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4692,68,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 15MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158100115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]",Cigna,,7598.69,68,,5873.17,5873.17,5873.17,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"MESH SURGICAL COMPOSIX L/P 14.2X10.2IN VENTRAL HERNIA PATCH",SUP-0134114,CDM,C1781,HCPCS,0278,RC,,,both,,,6791.40,2037.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4618.15,68,,,,,0,789.84,5772.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC ESOPHAGEAL PYLORIC COLONIC GWIRE BALLOON CATH",SUP-M00558500,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TREVO NXT 6X37+TRAK21 2-PACK - US",SUP-91315,CDM,S27200284,LOCAL,0272,RC,,,both,,,24624.97,7387.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"ACUTE LEUKEMIA WITH OTHER PROCEDURES",850,MS-DRG,,,,,,,inpatient,,,100128.76,30038.63,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID COMPRESSION ANKLET (LG)",SUP-RSANK002,CDM,S27000186,LOCAL,0270,RC,,,both,,,170.52,51.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Vad Holster Battery",PX-E27400019,CDM,Q0498,HCPCS,0274,RC,,,both,,,1438.80,431.64,"MULTIPLAN [10600]",Multiplan,,1222.98,85,,,,,0,167.33,1222.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 5MM DELTAFILL 18 COIL",SUP-DLF180520,CDM,S27800098,LOCAL,0278,RC,,,both,,,14145.00,4243.5,"CIGNA [10200]","Cigna Open Access",,4738.58,33.5,,,,,0,1645.06,12023.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 7MM .0135IN AXIUM PRIME 3D FRAME",SUP-FC-7-20-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,13765.50,4129.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5657.62,41.1,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 12MM ORTHOLOC FOREFOOT NONLOCKING",SUP-5201124012,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA [10200]","Cigna Local Plus",,407.35,53.5,,3978.14,359.25,3978.14,24,88.55,647.19,"percent of total billed charges",
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX LARGE - L 21MM X",SUP-T600612,CDM,S27800098,LOCAL,0278,RC,,,both,,,4347.00,1304.1,"FIRST HEALTH [10303]","First Health",,3477.6,80,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT HUMD HVT PATIENT 2.0 NONSTERILE LATEX FREE",SUP-HVT-DPC,CDM,S27000186,LOCAL,0270,RC,,,both,,,1033.56,310.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,122.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,120.2,878.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER NAV 115CM 4MM 7FR 1-7-4MM SPACE D-D CURVE",SUP-BN7TCDD4L,CDM,C1732,HCPCS,0272,RC,,,both,,,15366.30,4609.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1820.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1787.1,13061.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 17MM 40MM SHOULDER REUNION 4MM STD OFFSET",SUP-5552-E-4017,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"CIGNA [10200]","Cigna Local Plus",,4862.51,53.5,,5372.07,4581.20,7242.98,23,1057.03,7725.48,"percent of total billed charges",
"NAIL 11MM 400MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.160S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"AETNA [10100]","Aetna HMO/PPO",,9872.58,79.5,,1521.93,481.35,16760.95,30,1444.25,10555.59,"percent of total billed charges",
"PIN FIXATION 1.8MM BUTTRESS VARIABLE ANGLE LOCKING T8",SUP-04.210.094,CDM,C1713,HCPCS,0278,RC,,,both,,,872.78,261.83,"CIGNA [10200]","Cigna Open Access",,496.61,56.9,,1144.80,304.56,2275.09,66,101.5,741.86,"percent of total billed charges",
"PLATE 50MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 3",SUP-241.131,CDM,C1713,HCPCS,0278,RC,,,both,,,1852.20,555.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,850.16,45.9,,,,,0,215.41,1574.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 89MM TITANIUM 4 HOLE VARIAX BONE RIGHT OLECRANON ELBOW",SUP-629364,CDM,C1713,HCPCS,0278,RC,,,both,,,7272.88,2181.86,"NOVANET [10819]",Novanet,,5454.66,75,,,,,0,845.84,6181.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE BIOMONITOR CARDIAC IMPLANTABLE STERILE LATEX FREE",SUP-398493,CDM,C1764,HCPCS,0278,RC,,,both,,,40950.00,12285,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4852.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4762.49,34807.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Smear Special Stain",PX-306000086,CDM,87207,CPT,0306,RC,,,both,,,246.00,73.8,"KAISER [10500]",Kaiser,,164.82,67,,,,,0,0.01,209.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ENDOSCOPIC BLUE 76MM OBTR THREADED SEAL CLEAR-TRAC",SUP-7210122,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.98,63.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.54,179.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X10MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7010,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,802.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC",743,MS-DRG,,,,,,,inpatient,,,69872.86,20961.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23544.76,,"Fee schedule rate ($23,544.76). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,36223.48,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG VIAL",RX-10577,CDM,J2919,HCPCS,0636,RC,00143-9851-01,NDC,both,1,UN,316.20,94.86,"BLUE CROSS [10001]","Blue Cross HMO",,48.95,,,,,,,37.47,268.77,"fee schedule",
"STENT INNOVA 40MM 130CM 8MM VASCULAR METAL SUPERFICIAL",SUP-H74939293084030,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,572.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 5.5MM CREO CURVE TITANIUM NONSTERILE",SUP-1119.7050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"PLATE 40MM TITANIUM 2 LEVEL ASSURE BONE SPINE CERVICAL",SUP-110.24,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 3CM 7FR ZIMMON .035IN POLYETHYLENE TAPER",SUP-G22439,CDM,C2625,HCPCS,0278,RC,,,both,,,1328.40,398.52,"BLUE CROSS [10001]","Blue Cross PPO",,520.73,39.2,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 12.5FR 51CM HICKMAN 3 LUMEN LOW PROFILE ADPTR PEEL",SUP-0600650,CDM,C1751,HCPCS,0272,RC,,,both,,,1687.50,506.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 14X14.5CM NATRELLE P5.6CM FULL PROJECTION FULL",SUP-MSZFF535,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts",PX-306000255,CDM,87626,CPT,0306,RC,,,both,,,411.00,123.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COLLAR EXTRICATION GREEN 3.75IN PROCARE TALL FLAT CONTOUR",SUP-79-83027,CDM,S27000186,LOCAL,0270,RC,,,both,,,61.25,18.37,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CMPNT PATELLAR 35MM VIVACIT-E ALL POLY KNEE LATEX FREE",SUP-42540200035,CDM,C1776,HCPCS,0278,RC,,,both,,,5322.66,1596.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1523.35,28.62,,,,,0,619.03,4524.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM SOLERA CD HORIZON SPINE MULTIAXIAL",SUP-54850016555,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3008.75,45.9,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRAMEDULLARY NAIL 340MM 11MM 130D R1.5 LONG LEFT",SUP-3530-1340S,CDM,C1713,HCPCS,0278,RC,,,both,,,13435.13,4030.54,"AETNA [10100]","Aetna HMO/PPO",,10680.93,79.5,,1521.93,481.35,16760.95,30,1562.51,11419.86,"percent of total billed charges",
"SCR BONE 4.5MM 8MM 32MM STAINLESS STEEL STD CORTICAL LARGE",SUP-214.032,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,50.59,369.75,"percent of total billed charges",
"SYSTEM IFUSE IMPL SYSTEM 35MM 7MM SPINAL FIXATION SACROILIAC",SUP-7035M-90,CDM,C1713,HCPCS,0278,RC,,,both,,,21082.95,6324.88,"CIGNA [10200]","Cigna Local Plus",,6641.13,31.5,,3978.14,359.25,3978.14,24,2451.95,17920.51,"percent of total billed charges",
"SCR BONE 3.5MM 14MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.814,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"MULTIPLAN [10600]",Multiplan,,201.14,85,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 106MM STAINLESS STEEL 8 HOLE LOCK BONE ANKLE",SUP-AR-8943C-08,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"DEVICE AIR+ 15D CURVE UP 9D CURVE DOWN 2-0 12-24MM 17GA",SUP-4723,CDM,C1713,HCPCS,0278,RC,,,both,,,3067.50,920.25,"BLUE CROSS [10001]","Blue Cross HMO",,1202.46,39.2,,957.42,156.86,7483.26,51,356.75,2607.38,"percent of total billed charges",
"SCR BONE 6.5MM 20MM G7 DOME HIP ACETABULAR LOW PROFILE",SUP-010000997,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"MULTIPLAN [10600]",Multiplan,,846.86,85,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 240CM 5.5CM 7.5FR 10-12MM ESOPHAGUS",SUP-M00558680,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"KAISER [10500]",Kaiser,,1104.85,67,,,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 10MM BALLOON",SUP-U3575106,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cold Agglutinin Screen",PX-302000224,CDM,86156,CPT,0302,RC,,,both,,,920.00,276,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.54,,,,,,,0.01,782,"fee schedule",
"PLATE SHORT 72MM STAINLESS STEEL 2.7/3.5MM SCR 1 HOLE",SUP-02.117.601,CDM,C1713,HCPCS,0278,RC,,,both,,,6541.75,1962.52,"PHCS [10601]",PHCS,,4579.23,70,,,,,0,760.81,5560.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BRACHYTHERAPY MORGANSTERN STAB PROSTATE",SUP-500118200,CDM,C1715,HCPCS,0272,RC,,,both,,,682.34,204.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,280.44,41.1,,,,,0,79.36,579.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.6MM 150MM KIRSCHNER TROCAR POINT STERILE",SUP-71161016,CDM,C1713,HCPCS,0278,RC,,,both,,,65.09,19.53,"CIGNA [10200]",Cigna,,44.26,68,,1831.33,1831.33,1831.33,16,7.57,55.33,"percent of total billed charges",
"KIT SNARE AMPLATZ GOOSENECK 120CM 35MM 6FR CATH INTRO TORQUE",SUP-GN3500,CDM,C1773,HCPCS,0272,RC,,,both,,,2062.50,618.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 7MM 7CM TWIST-IN 3 DAM SIDEPORT LUER LOCK",SUP-AR-6570TDNV,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,120.14,41.1,,,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUROSTIMULATOR IMPLANTABLE 2INX1.7IN INTERSTIM II 10-14HZ 0",SUP-97800,CDM,C1767,HCPCS,0278,RC,,,both,,,62700.00,18810,"MULTIPLAN [10600]",Multiplan,,53295,85,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUROSTIMULATOR IMPLANTABLE 2INX1.7IN INTERSTIM II 10-14HZ 0",SUP-97800,CDM,C1767,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16929,27,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 9MM 9FR ENDOPROSTHESIS HEPARIN ILIAC",SUP-VBH090502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18566.10,5569.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5313.62,28.62,,,,,0,2159.24,15781.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 18MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40018W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"CIGNA [10200]","Cigna Open Access",,3094.79,56.9,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT STRETCH VL 22-30CM 3CM 6FR .038IN PIGTAIL CURVE",SUP-M006185156010,CDM,C2617,HCPCS,0278,RC,,,both,,,1038.34,311.5,"CIGNA [10200]","Cigna Open Access",,590.82,,,,,,,120.76,882.59,"percent of total billed charges",
"CATH COYOTE ES 143CM 20MM 3MM .014IN BALLOON DILATATION OTW",SUP-39134-30201,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR NEONATAL LNCS OXIMETER ADHESIVE CABLED TAPE MASIMO SE",SUP-1862,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.95,1.48,"KAISER [10500]",Kaiser,,3.32,67,,,,,0,0.58,58.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 196MM 24-32MM 28-29MM 20FR ZENITH TX2",SUP-G47469,CDM,C1874,HCPCS,0278,RC,,,both,,,98041.65,29412.49,"FIRST HEALTH [10303]","First Health",,78433.32,80,,,,,0,11402.24,83335.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH UROPASS 24CM 6-12FR 14FR 12FR ACCESS STAINLESS STEEL",SUP-61224BX,CDM,C1758,HCPCS,0272,RC,,,both,,,903.00,270.9,"KAISER [10500]",Kaiser,,605.01,67,,,,,0,105.02,767.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 28MM COCR",SUP-VAL-35280-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"CIGNA [10200]",Cigna,,1428,68,,1831.33,1831.33,1831.33,16,244.23,1785,"percent of total billed charges",
"GWIRE HI-TORQUE PROGRESS 120 VASCULAR STRAIGHT 300CM 3CM",SUP-1011845,CDM,C1769,HCPCS,0272,RC,,,both,,,1036.80,311.04,"MULTIPLAN [10600]",Multiplan,,881.28,85,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Stent & Ather Add",PX-361000163,CDM,37235,CPT,0361,RC,,,both,,,12161.75,3648.52,"FIRST HEALTH [10303]","First Health",,9729.4,80,,,,,0,12.16,10337.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 9X60 80CM SL",SUP-48009006N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"PHCS [10601]",PHCS,,601.31,70,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55840007535,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",441.36,3225.75,"percent of total billed charges",
"SCR BONE 4MM 12MM ORTHOLOC FULL THREAD CANCELLOUS ANKLE FOOT",SUP-58934012,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,353.2,45.9,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE MATRIX PLIF 5X2.5CM",SUP-42210,CDM,C1713,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA [10200]","Cigna Open Access",,5300.24,56.9,,1144.80,304.56,2275.09,66,1083.33,7917.75,"percent of total billed charges",
"WIRE FIXATION 1.8MM 310MM KIRSCHNER K WIRE INTRAMEDULLARY",SUP-0152-0218S,CDM,C1713,HCPCS,0278,RC,,,both,,,836.89,251.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,99.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,97.33,711.36,"percent of total billed charges",
"SCR BONE 5.5MM 40MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4540,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,1466.08,39.2,,957.42,570.23,957.42,28,434.96,3179,"percent of total billed charges",
"HC Wbc Antibody Identification",PX-302000008,CDM,86021,CPT,0302,RC,,,both,,,608.00,182.4,"KAISER [10500]",Kaiser,,407.36,67,,,,,0,0.01,516.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Wbc Antibody Identification",PX-302000008,CDM,86021,CPT,0302,RC,,,both,,,608.00,182.4,"AETNA [10100]","Aetna HMO/PPO",,483.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,516.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 16MM ALPS COCR SQUARE HAND CORTICAL LOCK SELF",SUP-131220416,CDM,C1713,HCPCS,0278,RC,,,both,,,1032.75,309.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,474.03,45.9,,,,,0,120.11,877.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16025545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"SCR BONE 2.4MM 6MM LCP STAINLESS STEEL DISTAL RADIAL LOCKING",SUP-212.806,CDM,C1713,HCPCS,0278,RC,,,both,,,802.87,240.86,"BLUE CROSS [10001]","Blue Cross PPO",,314.73,39.2,,957.42,570.23,957.42,28,93.37,682.44,"percent of total billed charges",
"SCR BONE 5.5MM 50MM SPINE MULTIAXIAL NONSTERILE 4.75MM ROD",SUP-54840045550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP DUAL MOBILITY HIP",SUP-THAPRE,CDM,C1776,HCPCS,0278,RC,,,both,,,26460.00,7938,"KAISER [10500]",Kaiser,,17728.2,67,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 341111 LACSR 11X11X11 SRVC FEE",SUP-341111,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST OP BRA 34D BLACK",SUP-B01G-34D-B,CDM,S27000186,LOCAL,0270,RC,,,both,,,178.18,53.45,"UHC [10700]","United Healthcare",,112.79,63.3,,,,,0,20.72,151.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VENTRALIGHT ST ECHO 2 25X20CM ELLIPSE",SUP-5992025,CDM,C1781,HCPCS,0278,RC,,,both,,,13069.29,3920.79,"UHC [10700]","United Healthcare",,8272.86,63.3,,,,,0,1519.96,11108.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.431,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",160.97,1176.51,"percent of total billed charges",
"ROD SPINAL 45MM REVERE CURVED",SUP-132.145,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X11MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7311,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"AMERIGROUP MEDICAID [20100]",Amerigroup,,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE MNTR 3FT CO-SET CARDIAC OUTPUT INLINE INJECTATE PORT",SUP-9446-910,CDM,S27000186,LOCAL,0270,RC,,,both,,,2264.40,679.32,"CIGNA [10200]","Cigna Open Access",,1288.44,56.9,,,,,0,263.35,1924.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE GT VASCULAR 45D 180CM 25CM .018IN HYDROPHILIC",SUP-RG*GA1818SP,CDM,C1769,HCPCS,0272,RC,,,both,,,1445.85,433.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,594.24,41.1,,,,,0,168.15,1228.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE 4X2IN NONWOVEN SURGICEL SNOW",SUP-2082,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.79,483.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,662.45,41.1,,,,,0,187.45,1370.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 6MM 16MM TITANIUM 2.5MM FULL THREAD CORTEX",SUP-404.816,CDM,C1713,HCPCS,0278,RC,,,both,,,258.83,77.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,30.1,220.01,"percent of total billed charges",
"SUT VICRYL PLUS 2-0 SH 27IN CONTROL RELEASE BRAIDED 8 STRAND",SUP-VCP785D,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.21,38.76,"UHC [10700]","United Healthcare",,81.79,63.3,,,,,0,15.03,109.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE COROLENE 4-0 3/8X18 MM",SUP-20S15AJ,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.82,14.65,"KAISER [10500]",Kaiser,,32.71,67,,,,,0,5.68,41.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL HEALICOIL REGENESORB PEEK-OPTIMA HIGH TORSIONAL",SUP-72203951,CDM,C1713,HCPCS,0278,RC,,,both,,,1494.45,448.33,"BLUE CROSS [10001]","Blue Cross PPO",,585.82,39.2,,957.42,570.23,957.42,28,173.8,1270.28,"percent of total billed charges",
"RING ANNULOPLASTY 38MM 45.6MM 37.9MM MITRAL TRICUSPID 3D",SUP-460038MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1349.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHASIX UMBILICAL MEDIUM CIRCLE W/ STRAP (6.4CM)",SUP-1230008,CDM,C1781,HCPCS,0278,RC,,,both,,,10701.90,3210.57,"PHCS [10601]",PHCS,,7491.33,70,,,,,0,1244.63,9096.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Occipital Bi",PX-510000116,CDM,64405,CPT,0761,RC,,,both,,,3761.00,1128.3,"MULTIPLAN [10600]",Multiplan,,3196.85,85,,,,,0,437.4,3196.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 20MM 5.5MM EXPEDIUM SPINE ILIAC TITANIUM OPEN",SUP-179797020,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"KAISER [10500]",Kaiser,,2386.88,67,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD VUEPOINT II SPINE EXTRA NONSTERILE",SUP-8976165,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"FIRST HEALTH [10303]","First Health",,2850,80,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM CD HORIZON LEGACY TITANIUM SPINAL",SUP-75447540,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2222.75,45.9,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GIRAFFE 45D 2MM 5.25IN FRONTAL SINUS 2 ACTION",SUP-63-8845,CDM,S27200284,LOCAL,0272,RC,,,both,,,3430.28,1029.08,"CIGNA [10200]","Cigna Local Plus",,1835.2,53.5,,,,,0,398.94,2915.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Caregiver Training 1st 30 Min (Go)",PX-430000064,CDM,97550,CPT,0430,RC,,,both,,,90.21,27.06,"MULTIPLAN [10600]",Multiplan,,76.68,85,,,,,0,10.49,90.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION SIGMA HIGH PERFORMANCE QUICK DRILL",SUP-950502072,CDM,C1713,HCPCS,0278,RC,,,both,,,1526.85,458.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,180.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,177.57,1297.82,"percent of total billed charges",
"SCR BONE 3.5MM 6MM 18MM STAINLESS STEEL T15 FULL THREAD",SUP-02.200.018,CDM,C1713,HCPCS,0278,RC,,,both,,,240.38,72.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,68.8,28.62,,,,,0,27.96,204.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE FIBER 3CC ALLOGRAFT",SUP-T50303,CDM,C1713,HCPCS,0278,RC,,,both,,,4761.00,1428.3,"AETNA [10100]","Aetna HMO/PPO",,3785,79.5,,1521.93,481.35,16760.95,30,553.7,4046.85,"percent of total billed charges",
"SCR BONE 4MM 26MM QUICKFIX TITANIUM SHORT PARTIAL THREAD T15",SUP-AR-8740-26PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM VERTEX MAX TITANIUM PARTIAL THREAD SPINE",SUP-6958726PT,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"SCR BONE 2.7MM 10MM STERNALOCK BLU STERNAL CANCELLOUS LOCK",SUP-73-2710,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM XIA SERRATO SPINE POLYAXIAL REDUCTION",SUP-482626545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 9MM DCP STAINLESS STEEL CORTICAL SELF TAPPING",SUP-200.809,CDM,C1713,HCPCS,0278,RC,,,both,,,365.40,109.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",42.5,310.59,"percent of total billed charges",
"PLATE LOW PROFILE STAINLESS STEEL 3.5MM SCR 3 HOLE SPRING",SUP-02.100.303S,CDM,C1713,HCPCS,0278,RC,,,both,,,1950.00,585,"PHCS [10601]",PHCS,,1365,70,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM CORTEX SELF TAP STARDRIVE",SUP-02.200.016,CDM,C1713,HCPCS,0278,RC,,,both,,,240.38,72.11,"MULTIPLAN [10600]",Multiplan,,204.32,85,,,,,0,27.96,204.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 20MM COMPREHENSIVE 3.5MM SHOULDER CENTRAL",SUP-115394,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,714.2,45.9,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 44MM GORILLA R3CON LOCK",SUP-P50-353-3544,CDM,C1713,HCPCS,0278,RC,,,both,,,1470.15,441.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,174.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,170.98,1249.63,"percent of total billed charges",
"PLATE LOW PROFILE STAINLESS STEEL 3.5MM SCR 3 HOLE SPRING",SUP-02.100.303S,CDM,C1713,HCPCS,0278,RC,,,both,,,1950.00,585,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1326,68,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 2IN 18GA 20GA PAJUNK SONOLONG TUOHY",SUP-TDL106,CDM,C9814,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAPE CERCLAGE LOADER NONABSORBABLE",SUP-AR-7268,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.63,1122.19,"CIGNA [10200]",Cigna,,2543.63,68,,1831.33,1831.33,1831.33,16,435.04,3179.54,"percent of total billed charges",
"WIRE FIXATION 1.4MM KIRSCHNER",SUP-24872018,CDM,C1713,HCPCS,0278,RC,,,both,,,243.60,73.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,69.72,28.62,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 57MM 135CM 5MM 60MM BILIARY STAINLESS STEEL",SUP-PXB35-05-57-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"BLUE CROSS [10001]","Blue Cross HMO",,1711.86,39.2,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM PRIMARY CEMENT DISTAL BULLET TIP SYNERGY",SUP-71316210,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"FIRST HEALTH [10303]","First Health",,17010,80,,,,,0,2472.83,18073.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION TIGHTROPE ACL RIGHT DELIVERY",SUP-AR-1588RTS,CDM,C1713,HCPCS,0278,RC,,,both,,,3543.75,1063.12,"MULTIPLAN [10600]",Multiplan,,3012.19,85,,,,,0,412.14,3012.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 13MM KNEE TOTAL STBL PLUS TRIATHLON STERILE",SUP-5537-G-313-E,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"CIGNA [10200]","Cigna Open Access",,4508.58,33.5,,5302.19,4377.88,6578.61,27,1565.22,11439.68,"percent of total billed charges",
"STENT XIENCE V 8MM 143CM 2.25MM CORONARY EVEROLIMUS ELUTING",SUP-1009544-08,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"CIGNA [10200]","Cigna Local Plus",,5131.19,53.5,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 12MM 144CM 3MM CORONARY STENT EVEROLIMUS",SUP-H7493926112300,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]","Cigna Local Plus",,4614.38,53.5,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.5MM X 9MM TI",SUP-VAN-15090-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Open Access",,553.07,56.9,,1144.80,304.56,2275.09,66,113.04,826.2,"percent of total billed charges",
"CATH POWERGLIDE PRO GUARDIVA 8CM 20GA IV POLYURETHANE 5ML",SUP-F120088PT,CDM,C1751,HCPCS,0272,RC,,,both,,,909.39,272.82,"NOVANET [10819]",Novanet,,682.04,75,,,,,0,105.76,772.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX SMALL - L 11MM X",SUP-T600412,CDM,S27800098,LOCAL,0278,RC,,,both,,,4347.00,1304.1,"MULTIPLAN [10600]",Multiplan,,3694.95,85,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK15MM 51X64MM PROTECTA DR VENTRICLE 2 CHMBR",SUP-D334DRG,CDM,C1721,HCPCS,0278,RC,,,both,,,63000.00,18900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,17010,27,,,,,0,7326.9,53550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE QVS GENTAMICIN HVY",SUP-200-00-002,CDM,C1713,HCPCS,0278,RC,,,both,,,796.50,238.95,"CIGNA [10200]","Cigna Local Plus",,426.13,53.5,,3978.14,359.25,3978.14,24,92.63,677.03,"percent of total billed charges",
"CABLE FIBER OPTIC MAXCESS 4 LIGHT",SUP-3241002,CDM,S27200284,LOCAL,0272,RC,,,both,,,2973.75,892.12,"MULTIPLAN [10600]",Multiplan,,2527.69,85,,,,,0,345.85,2527.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,inpatient,,,37647.37,11294.21,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,24035.17,,"Case rate ($11,179.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,380.60, add-ons for qualifying new technology services are included. If operating cost exceeds $43,420.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,166.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $10,394.33. The transfer operating threshold is the transfer adjustment factor * $10,380.60 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $784.82. The transfer capital threshold is the transfer adjustment factor * $784.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,1476,24035.17,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"ELLIPSE NEXT GENERATION DR 36",SUP-CD2411-36C,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16224,40,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENCIL SMOKE EVAC TUBING HOLSTER",SUP-CVPLP2000,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL DST SERIES TA WHITE 30MM TITANIUM VASCULAR",SUP-TA30V3S,CDM,S27200284,LOCAL,0272,RC,,,both,,,651.48,195.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,267.76,41.1,,,,,0,75.77,553.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM ELITE OSTEON ROUND SOFT TOUCH STERILE",SUP-5820010140,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,129.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 16MM OSS UHMWPE KNEE TIBIAL STD STERILE",SUP-150412,CDM,C1776,HCPCS,0278,RC,,,both,,,8317.26,2495.18,"PHCS [10601]",PHCS,,5822.08,70,,,,,0,967.3,7069.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP UTERINE 2.5CM KOH-EFFICIENT RUMI II CERVIX LOCK HANDLE",SUP-KC-RUMI-25,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,135.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY 16CM 14GA BARD MAX-CORE 2 TRIGGER ULTRA SHARP",SUP-MC1416,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.01,84.9,"NOVANET [10819]",Novanet,,212.26,75,,,,,0,32.91,240.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESPIRATORY NEOPLASMS WITH CC",181,MS-DRG,,,,,,,inpatient,,,44996.45,13498.93,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,14283.48,,"Case rate ($6,643.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,168.92, add-ons for qualifying new technology services are included. If operating cost exceeds $39,208.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,848.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,177.08. The transfer operating threshold is the transfer adjustment factor * $6,168.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $466.40. The transfer capital threshold is the transfer adjustment factor * $466.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,6643.48,26709.67,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 25X13CM SOMAGEN ACELLULAR DERMAL MATRIX",SUP-WC2325,CDM,Q4433,HCPCS,0636,RC,,,both,,,103307.48,30992.24,"KAISER [10500]",Kaiser,,69216.01,67,,,,,0,247.92,87811.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 15MM HELIX R SPINE SELF TAP VARIABLE ANGLE",SUP-7805115,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTNSL CUTLERY SPOON FINGER CONTOUR LIGHTWEIGHT STAINLESS",SUP-AA5551,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.30,21.69,"CIGNA [10200]","Cigna Local Plus",,38.68,53.5,,,,,0,8.41,61.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TRIA 24CM 6FR URETERAL SOFT",SUP-M0061903220,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 20MM 144CM 3.5MM CORONARY STENT",SUP-H7493952820350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 2 KNEE CEMENTED FIX BEARING STERILE",SUP-150600002,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6001.62,40,,,,,0,1744.97,12753.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SURGICAL 4X4IN CHLORAPREP CHEST TUBE PETROLATUM DRSG",SUP-DYND07603,CDM,S27200284,LOCAL,0272,RC,,,both,,,245.92,73.78,"FIRST HEALTH [10303]","First Health",,196.74,80,,,,,0,28.6,209.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP LUBRI-SIL IC COMPLETE CARE",SUP-A300916A,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.87,104.66,"NOVANET [10819]",Novanet,,261.65,75,,,,,0,40.57,296.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DRILL 4MM RETROBUTTON TIGHTROPE KNEE ACL OPEN EYELET",SUP-AR-1595T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1063.13,318.94,"NOVANET [10819]",Novanet,,797.35,75,,,,,0,123.64,903.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X10MM COROENT XL PEEK-OPTIMA LATERAL LUMBAR",SUP-6910850,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"FIRST HEALTH [10303]","First Health",,19008,80,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 100MM 7MM BALLOON",SUP-U35130710,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 83MM REGENEREX KNEE PRIMARY CRUCIATE RETAIN",SUP-141276,CDM,C1776,HCPCS,0278,RC,,,both,,,11964.60,3589.38,"KAISER [10500]",Kaiser,,8016.28,67,,,,,0,1391.48,10169.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ZEBRA 7F 95CM ACCESS SYSTEM BER",SUP-AC7087-095-20-B,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"NOVANET [10819]",Novanet,,6701.63,75,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 7MM OMNIMAX INTERMAXILLARY SELF DRILL TEMPORARY",SUP-915707,CDM,C1713,HCPCS,0278,RC,,,both,,,1377.00,413.1,"CIGNA [10200]","Cigna Local Plus",,736.7,53.5,,3978.14,359.25,3978.14,24,160.15,1170.45,"percent of total billed charges",
"CMPNT GLENOID 15D MEDIUM AUG CORTILOC SHOULDER RIGHT",SUP-DWK404RA15S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"CIGNA [10200]","Cigna Local Plus",,5617.5,53.5,,5372.07,4581.20,7242.98,23,1221.15,8925,"percent of total billed charges",
"CMPNT FEMORAL 5 RIGHT MEDIAL LEFT LATERAL PARTIAL KNEE",SUP-5610-F-502,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1185.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1163.24,8501.79,"percent of total billed charges",
"CAP KIT SURGICAL TANDEM CUSTOM HIP PROC BIPOLAR LOW DEMAND",SUP-71701440,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"FIRST HEALTH [10303]","First Health",,7728,80,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY 12MM 140CM 3.5MM CORONARY STENT",SUP-RSINT35012W,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,656.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BAKRI 54CM 180CM 24FR INTRAUTERINE SILICONE 500ML 60ML",SUP-G24237,CDM,S27200284,LOCAL,0272,RC,,,both,,,2965.28,889.58,"FIRST HEALTH [10303]","First Health",,2372.22,80,,,,,0,344.86,2520.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 18MM 48MM SHOULDER SIMPLICITI",SUP-7122872,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"BLUE CROSS [10001]","Blue Cross HMO",,3927.45,39.2,,5311.50,4717.44,5388.59,31,1165.21,8516.15,"percent of total billed charges",
"COIL EMBOLIZATION 6CM 2MM CONCERTO 3D",SUP-PV-2-6-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 18MM 48MM SHOULDER SIMPLICITI",SUP-7122872,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"MULTIPLAN [10600]",Multiplan,,8516.15,85,,,,,0,1165.21,8516.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 150CM 20MM 6MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013470-020,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"KAISER [10500]",Kaiser,,841.19,67,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2.5MM DELTAXSFT 10 COIL",SUP-DLX100256,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1072.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUADRA ASSURA MP CRT-D",SUP-CD3369-40C,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6839.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENDOPROSTHESIS 5CM 6MM HEPARIN NITINOL EPTFE VIABAHN",SUP-VBHR030501A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 3CM 4.8FR .035IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145350050,CDM,C2617,HCPCS,0278,RC,,,both,,,940.57,282.17,"NOVANET [10819]",Novanet,,705.43,75,,,,,0,109.39,799.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE 8.5-10 LARGE FEMALE BEIGE CANVAS RUBBER",SUP-2041-09,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.42,14.23,"MULTIPLAN [10600]",Multiplan,,40.31,85,,,,,0,5.51,40.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE SMALL SPIKED SHORT LEG FIXATION 15X7.94MM COCR",SUP-12/1/8722,CDM,S27800098,LOCAL,0278,RC,,,both,,,2700.00,810,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,319.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LIVEWIRE 7FR MEDIUM CURL CURVE ELECTROPHYSIOLOGY DUO",SUP-401908,CDM,C1731,HCPCS,0272,RC,,,both,,,6348.00,1904.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,738.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,738.27,5395.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SURGITIE 0 18IN LIGATING LOOP ANCHORED ABSORBABLE",SUP-SGL-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.14,32.44,"MULTIPLAN [10600]",Multiplan,,91.92,85,,,,,0,12.58,91.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 3.5 X 6 HELICAL FINISHING COIL",SUP-10HFN-03506,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"AETNA [10100]","Aetna HMO/PPO",,8222.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +18 DIOPTER BICONVEX 13MM 6MM POSTERIOR CHMBR 1",SUP-CC60WF.180,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X11MM OVAL PARALLEL SPINE CORTICAL",SUP-17111,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAMINAR IMPLANT SIZE (10MM)",SUP-FG-6037,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM INFINITY SPINE MULTIAXIAL",SUP-3603524,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,1521.93,481.35,16760.95,30,441.36,3225.75,"percent of total billed charges",
"SUT VICRYL 1 CTX 36IN BRAID COATED UNDYED ABSORBABLE",SUP-J977H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"MULTIPLAN [10600]",Multiplan,,22.95,85,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR WHITE 53MM 28MM RINGLOC BIO-MOORE II HIP",SUP-11165230,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"PHCS [10601]",PHCS,,4661.92,70,,,,,0,774.54,5660.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 6MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710806,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5917.44,40,,,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TELESCOPE 6FR EXT CORONARY PERIPHERAL COMPATIBLE GUIDE",SUP-TELE6F,CDM,C1887,HCPCS,0272,RC,,,both,,,2775.00,832.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1140.53,41.1,,,,,0,322.73,2358.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 31X9MM THK.051MM LAPIDUS CUT GUIDE SYSTEM",SUP-P99-151-P30M,CDM,S27200284,LOCAL,0272,RC,,,both,,,664.20,199.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,304.87,45.9,,,,,0,77.25,564.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC",824,MS-DRG,,,,,,,inpatient,,,95382.67,28614.8,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,14475.27,,"Case rate ($14,053.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,049.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,089.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,368.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,067.03. The transfer operating threshold is the transfer adjustment factor * $13,049.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $986.63. The transfer capital threshold is the transfer adjustment factor * $986.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,66146.46,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM 6.8FR 11MM SPACING ENDOCARDIUM INTEGRATED",SUP-7131/65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6868.8,40,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT 137CM 10MM 2.5MM RECTANGLE HELIX TAPER",SUP-2200-2510,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"AETNA [10100]","Aetna HMO/PPO",,4662.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 100MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"KAISER [10500]",Kaiser,,960.58,67,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 485MM 4.5-6.5MM LARGE QUICK COUPLING STEPPED",SUP-03.010.078,CDM,S27200284,LOCAL,0272,RC,,,both,,,3166.80,950.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1301.55,41.1,,,,,0,368.3,2691.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 4.0/40",SUP-404677,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4.5MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN04506,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3355.15,28.62,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNFRM OPHTHALMIC MEDIUM ACRYLIC WITHOUT HOLE HARD",SUP-14165,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.40,131.22,"MULTIPLAN [10600]",Multiplan,,371.79,85,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X7-14MM ELSA 20MM",SUP-1122.005,CDM,S27800098,LOCAL,0278,RC,,,both,,,50400.00,15120,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,20714.4,41.1,,,,,0,5861.52,42840,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLEANSER WOUND DEBRISOFT LOLLY POLYPROPYLENE POLYACRYLATE PO",SUP-33224,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.39,25.32,"CIGNA [10200]","Cigna Open Access",,48.02,56.9,,,,,0,9.81,71.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER DRAINGE SYSTEM THORA-PARA DUAL INDICATION CATHETER",SUP-OTP5000,CDM,C1729,HCPCS,0272,RC,,,both,,,445.50,133.65,"PHCS [10601]",PHCS,,311.85,70,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR 10CM SPLIT SURGICAL STERILE DISPOSABLE",SUP-824095,CDM,S27200284,LOCAL,0272,RC,,,both,,,2635.35,790.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,306.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,306.49,2240.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 65CM GUIDING PINNACLE DESTINATION",SUP-RSP04,CDM,C1887,HCPCS,0272,RC,,,both,,,769.50,230.85,"NOVANET [10819]",Novanet,,577.13,75,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM FLUTE ROUND",SUP-5540010030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1288.63,386.59,"FIRST HEALTH [10303]","First Health",,1030.9,80,,,,,0,149.87,1095.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM 11MM COLLAR CEMENTLESS LOW PROFILE NECK",SUP-3L92501,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"KAISER [10500]",Kaiser,,10610.87,67,,,,,0,1841.86,13461.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC LARGE 17X12IN ARM HEAVY DUTY ICE BAG",SUP-8011-03,CDM,S27000186,LOCAL,0270,RC,,,both,,,108.58,32.57,"NOVANET [10819]",Novanet,,81.44,75,,,,,0,12.63,92.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS CT-1 27IN BRAID ANTIBACTERIAL COATED UNDYED",SUP-VCP260H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UHC [10700]","United Healthcare",,15.83,63.3,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 14GA RIGID NDL RADIOPAQUE GEL MARK ULTRACOR BREAST",SUP-GMUTC005T,CDM,A4648,HCPCS,0278,RC,,,both,,,526.34,157.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.21,447.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL CUSHING CARB-BITE BAYONET 7.5IN TISSUE SCRP",SUP-130418,CDM,S27200284,LOCAL,0272,RC,,,both,,,631.40,189.42,"CIGNA [10200]","Cigna Open Access",,359.27,56.9,,,,,0,73.43,536.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 STD 17MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS6S17L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"MULTIPLAN [10600]",Multiplan,,8832.69,85,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE COAGULATION PURPLE 350CM 10FR BRIGHTON",SUP-BP-10F-SP-350,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2.5 X 2 HELICAL PICO COIL",SUP-10USH02502,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"NOVANET [10819]",Novanet,,8792.33,75,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII CRUCIATE RETAINING POROU",SUP-71704545,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2762.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP MONOPOLAR 165X5MM 2.75MM 2.8MM COAGRASPER HEMOSTASIS",SUP-FD-410LR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1506.36,451.91,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,178.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,175.19,1280.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 350MM 5.5MM REVERE PEDICLE TITANIUM STRAIGHT",SUP-124.519,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1262.14,28.62,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X10MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7210,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"PHCS [10601]",PHCS,,4830,70,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Midline",PX-E27200256,CDM,C1751,HCPCS,0272,RC,,,both,,,667.03,200.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,274.15,41.1,,,,,0,77.58,566.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL WHITE 3MM TAPER ROUTER",SUP-5407FA3030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1009.26,302.78,"AETNA [10100]","Aetna HMO/PPO",,802.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.38,857.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5CMX12MM FLAT ROUND TIP OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-6-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"CIGNA [10200]","Cigna Local Plus",,780.03,53.5,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPIDERFX 320CM 190CM 3.2-4.2FR 3MM EMBOLIC PROTECTION",SUP-SPD2-US-030-320,CDM,C1884,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,858.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 24FR URETHRAL SILASTIC 30CC 2 WAY 2 STAGGER DRNG EYE",SUP-33424,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.11,15.03,"MULTIPLAN [10600]",Multiplan,,42.59,85,,,,,0,5.83,42.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X21MM ENDOSKELETON TAS 12D 10MM STD TITANIUM",SUP-2312-0110,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 12MM 144CM 3MM CORONARY STENT",SUP-H7493952812300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PHCS [10601]",PHCS,,3895.5,70,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY DRNG 14FR FLEXIBLE STAYFIX LARGE SECUREMENT DEVICE",SUP-RLC-NV-14-SFX,CDM,C1729,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM EDWARDS SAPIEN 3 COMMANDER DELIVERY SYSTEM",SUP-9600CM29A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"CIGNA [10200]","Cigna Open Access",,62058.75,33.5,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701056,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"UHC [10700]","United Healthcare",,7184.87,63.3,,8601.07,8395.67,8601.07,"1 through 10",1320.06,9647.93,"percent of total billed charges",
"BRA 48-51IN 2XL HOOK LOOP CLSR WIDE ADJUSTABLE SHOULDER",SUP-M5001-XXL,CDM,S27000186,LOCAL,0270,RC,,,both,,,183.57,55.07,"AETNA [10100]","Aetna HMO/PPO",,145.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.35,156.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 2-0 PS-2 18IN MONOFILAMENT BLACK",SUP-593H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 194MM 100MM 8MM 9FR BILIARY PERMALUME",SUP-M00547460,CDM,C1874,HCPCS,0278,RC,,,both,,,17194.52,5158.36,"NOVANET [10819]",Novanet,,12895.89,75,,,,,0,1999.72,14615.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR071002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"UHC [10700]","United Healthcare",,13463.15,63.3,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 12MM 144CM 4.5MM CORONARY STENT",SUP-H7493941812450,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SPINAL 10MM VERTEX LATERAL OFFSET CLOSED",SUP-7756067,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"MULTIPLAN [10600]",Multiplan,,4105.5,85,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM 3MM 2.1-2.7FR CORONARY STENT",SUP-RONYX30022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1549.13,45.9,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 5MM ELITE ROUND DIAMOND 5 STEP NOTCH STERILE",SUP-5820-012-050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"CIGNA [10200]",Cigna,,744.57,68,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE MEDIUM FEMALE METASHANK METASHANK SQUARE",SUP-DS1015-12,CDM,S27000186,LOCAL,0270,RC,,,both,,,90.05,27.01,"CIGNA [10200]",Cigna,,61.23,68,,,,,0,10.47,76.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE REAMER 38MM PILOT HOLE KNEE PATELLA STAINLESS STEEL",SUP-597909538,CDM,S27200284,LOCAL,0272,RC,,,both,,,1129.14,338.74,"MULTIPLAN [10600]",Multiplan,,959.77,85,,,,,0,131.32,959.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-0 THX-36 36IN MONOFILAMENT UNDYED",SUP-0N07A,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.35,88.3,"CIGNA [10200]","Cigna Local Plus",,157.48,53.5,,,,,0,34.23,250.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPIDERFX 320CM 190CM 3.2-4.2FR 4MM EMBOLIC PROTECTION",SUP-SPD2-US-040-320,CDM,C1884,HCPCS,0272,RC,,,both,,,7245.00,2173.5,"FIRST HEALTH [10303]","First Health",,5796,80,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 2.75MM 2.75MM CLEARCUT SATINSLIT ANGLE 1",SUP-8065992745,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.41,88.32,"CIGNA [10200]","Cigna Local Plus",,157.51,53.5,,,,,0,34.24,250.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CRYO/CUFF UNIVERSAL XL 32-48IN COMPRESSION THERAPY",SUP-12A,CDM,S27000186,LOCAL,0270,RC,,,both,,,483.49,145.05,"CIGNA [10200]",Cigna,,328.77,68,,,,,0,56.23,410.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 12MM INTERLOCK FIBERED IDC DETACHABLE",SUP-M001361610,CDM,S27800098,LOCAL,0278,RC,,,both,,,2079.00,623.7,"CIGNA [10200]",Cigna,,1413.72,68,,,,,0,241.79,1767.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 175MM SCHANZ STAINLESS STEEL CONDYLAR HIP SELF",SUP-294.785,CDM,C1713,HCPCS,0278,RC,,,both,,,1042.88,312.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,123.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,121.29,886.45,"percent of total billed charges",
"INTRO SHEATH 4FR 50CM 11CM RED HUB SNAP FIT DIL TUBING GWIRE",SUP-PRO-4F-11-035,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE PEEP 2.5CM 20 22MM ADPTR CNCT THRESHOLD RESISTOR CPAP",SUP-9003B,CDM,S27000186,LOCAL,0270,RC,,,both,,,66.99,20.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PERIPHERAL AND OTHER VASCULAR DISORDERS,MINOR",197,APR-DRG,,,,,,,inpatient,,,32136.70,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,254.62. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE THERAPEP 18IN 22MM PEP MOUTHPC NONSTERILE LATEX FREE",SUP-20-1112,CDM,S27000186,LOCAL,0270,RC,,,both,,,172.03,51.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,78.96,45.9,,,,,0,20.01,146.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 3CM 2MM GALAXY G3 MINI STRETCH",SUP-GLM920030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"NOVANET [10819]",Novanet,,8911.35,75,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CERES-C 6MM INTERBODY PLATE",SUP-SK-08-170-06,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"AETNA [10100]","Aetna HMO/PPO",,4936.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BONE CORT CANC BLK CRNRSTN ASR 11X14X11MM",SUP-245141,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 11X11X7MM CORNERSTONE PSR PEEK LUMBAR",SUP-6276711,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,791.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 11X11X7MM CORNERSTONE PSR PEEK LUMBAR",SUP-6276711,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"NOVANET [10819]",Novanet,,5008.82,75,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL EIT 8 D L28 MM X W10 MM X H8 MM STERILE LATEX FR",SUP-TUI80828,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PHCS [10601]",PHCS,,19845,70,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM MITRAL VALVE PROFILE 3D",SUP-680R26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"NOVANET [10819]",Novanet,,9832.5,75,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 6941041 ANATOMIC 10X14X11 SRVCFEE",SUP-6941041,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 23X9X7MM CONCORDE PARALLEL BULLET NOSE CFRP",SUP-187823107,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA [10200]",Cigna,,6624,40,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PYRAMESH 30MMX13MM CAGE TITANIUM ROUND",SUP-905-133,CDM,S27800098,LOCAL,0278,RC,,,both,,,13135.05,3940.51,"MULTIPLAN [10600]",Multiplan,,11164.79,85,,,,,0,1527.61,11164.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALLET SURGICAL 7.5IN 1.5IN HEATH HEAVYWEIGHT 2LB",SUP-27-0880,CDM,S27200284,LOCAL,0272,RC,,,both,,,920.16,276.05,"FIRST HEALTH [10303]","First Health",,736.13,80,,,,,0,107.01,782.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE WINN VASCULAR TAPER 300CM .014IN DURASTEEL",SUP-1012475,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,112.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CGUARD PRIME CAROTID STENT SYSTEM 135CM 08MM LENGTH 40MM",SUP-CND0840,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"CIGNA [10200]","Cigna Local Plus",,6538.93,31.5,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TELESCOPING SMOKE EVACUATION R",SUP-SEP6015NSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,249.43,74.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,102.52,41.1,,,,,0,29.01,212.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN SX ENDO HEPARIN 35 RO 11MMX10CM 10FR 120CMCATH",SUP-VBHR111002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8741.48,41.1,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL REVERSE REVISION ALTIVATE 12MM X 220MM",SUP-530-12-220,CDM,C1776,HCPCS,0278,RC,,,both,,,56568.96,16970.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,22627.58,40,,,,,0,6578.97,48083.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC",739,MS-DRG,,,,,,,inpatient,,,103309.50,30992.85,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,23224.42,,"Case rate ($22,224.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,636.79, add-ons for qualifying new technology services are included. If operating cost exceeds $53,676.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,942.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $20,664.08. The transfer operating threshold is the transfer adjustment factor * $20,636.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.24. The transfer capital threshold is the transfer adjustment factor * $1,560.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,103309.5,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL COMPREHENSIVE +5MM STD SHOULDER REVERSE",SUP-110031400,CDM,C1776,HCPCS,0278,RC,,,both,,,8473.20,2541.96,"BLUE CROSS [10001]","Blue Cross PPO",,3321.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",985.43,7202.22,"percent of total billed charges",
"VALVE AORTIC KONECT 23MM RESILIA AORTIC VALVED CONDUIT",SUP-11060A23,CDM,S27800098,LOCAL,0278,RC,,,both,,,79800.00,23940,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,21546,27,,,,,0,9280.74,67830,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9.5MM 11MM 160MM HUMERAL RIGHT PROXIMAL MULTILOC",SUP-04.016.038S,CDM,C1713,HCPCS,0278,RC,,,both,,,10722.60,3216.78,"BLUE CROSS [10001]","Blue Cross HMO",,4203.26,39.2,,957.42,156.86,7483.26,51,1247.04,9114.21,"percent of total billed charges",
"CATH TREK 6MM 3.75MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012410-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM NEXGEN LPS-FLEX 5-6 C-D KNEE PROLONG",SUP-596204110,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"CIGNA [10200]","Cigna Local Plus",,4236.37,53.5,,5372.07,4581.20,7242.98,23,920.91,6730.67,"percent of total billed charges",
"FILTER EMBOLIZATION 50MM VENA CAVA FEMORAL 1 PUSH DELIVERY",SUP-G52917,CDM,C1880,HCPCS,0278,RC,,,both,,,3990.00,1197,"BLUE CROSS [10001]","Blue Cross PPO",,1564.08,39.2,,,,,0,464.04,3391.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE OZARK L66 MM SPINE CERVICAL 3 LEVEL NONSTERILE",SUP-AA01-43F66V,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL TRITANIUM 0 D L23 MM X W11 MM X H9 MM SOLID TIP",SUP-48951090,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6310.71,28.62,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X21MM ENDOSKELETON TAS 7D 13MM STD TITANIUM",SUP-2307-0113,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross HMO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG VASCULAR 12 MM",SUP-9-PLUG-012,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"CIGNA [10200]","Cigna Open Access",,3513.86,56.9,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 14MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620214,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"AETNA [10100]","Aetna HMO/PPO",,8946.85,79.5,,10981.53,8986.79,12413.38,12,1308.83,9565.82,"percent of total billed charges",
"VALVE AORTIC 27MM EDWARDS INTUITY ELITE STERILE LATEX FREE",SUP-8300KITB27A,CDM,S27800098,LOCAL,0278,RC,,,both,,,68400.00,20520,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8105.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7954.92,58140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 68MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.768,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,133.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,130.68,955.09,"percent of total billed charges",
"ADHESIVE SKIN CLOSURE SYSTEM MESH EXOFIN FUSION 30CM",SUP-EF70430,CDM,S27200284,LOCAL,0272,RC,,,both,,,615.60,184.68,"CIGNA [10200]",Cigna,,418.61,68,,,,,0,71.59,523.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Shuntogram Nonvasc Shunt Si",PX-323000028,CDM,75809,CPT,0320,RC,,,both,,,668.30,200.49,"PHCS [10601]",PHCS,,467.81,70,,,,,0,77.72,568.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONCUSSION WITH MCC",088,MS-DRG,,,,,,,inpatient,,,56617.48,19990.48,"BLUE CROSS [10001]","Blue Cross PPO",,33371.95,,,,,,,8385.3,33712.54,"case rate",
"SCR SET SPINE LOCKING XLNK MAS CNCT",SUP-7752529,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,41.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",40.47,295.8,"percent of total billed charges",
"CATH DORADO CHECKER 135CM 10CM 6MM BALLOON DILATATION",SUP-DR135610,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"AETNA [10100]","Aetna HMO/PPO",,1094.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1MM STAINLESS STEEL 1.5MM SCR 6 HOLE LOCK VARIABLE",SUP-02.130.266,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,,1521.93,481.35,16760.95,30,434.96,3179,"percent of total billed charges",
"GRAFT STENT 75MM 28MM AFX VELA STRATA AORTIC EXT AAA STERILE",SUP-A28-28/C75V,CDM,C1874,HCPCS,0278,RC,,,both,,,35406.00,10621.8,"BLUE CROSS [10001]","Blue Cross PPO",,13879.15,39.2,,,,,0,4117.72,30095.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 8.2MM 2.9MM 65MM STAINLESS STEEL FULL THREAD",SUP-209.665,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"KAISER [10500]",Kaiser,,920.85,67,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM INFINITY SPINE MULTIAXIAL NONSTANDARD",SUP-G3603510,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATTAIN GUIDING LEFT HEART LEAD DELIVERY SYSTEM LATEX",SUP-6216A,CDM,C1769,HCPCS,0272,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DECA 5-5-5-20-4-4-4-4-4 MPA 120CM",SUP-901829,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"NOVANET [10819]",Novanet,,2221.88,75,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP APPLR 4CM EVICEL CONTROL",SUP-3920,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.97,57.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,78.9,41.1,,,,,0,22.33,163.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP APPLR 4CM EVICEL CONTROL",SUP-3920,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.97,57.59,"KAISER [10500]",Kaiser,,128.62,67,,,,,0,22.33,163.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT LAPAROSCOPIC ROTATION DIAL ERGONOMIC HANDLE CURVE JAW",SUP-CY010,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"CIGNA [10200]","Cigna Open Access",,322.62,56.9,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20GA 10CM POWERGLIDE PRO BIOPATCH BASIC INSRT",SUP-F320107T,CDM,S27200284,LOCAL,0272,RC,,,both,,,575.67,172.7,"PHCS [10601]",PHCS,,402.97,70,,,,,0,66.95,489.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM MEDIUM NECK 32MM BIOLOX DELTA",SUP-PHA04410,CDM,C1776,HCPCS,0278,RC,,,both,,,14234.70,4270.41,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1686.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1655.5,12099.5,"percent of total billed charges",
"CATH SABER 150CM 100MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UHC [10700]","United Healthcare",,907.53,63.3,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX LPR, 12X18 CM",SUP-F10244-1218L,CDM,C1781,HCPCS,0278,RC,,,both,,,17700.98,5310.29,"UHC [10700]","United Healthcare",,11204.72,63.3,,,,,0,2058.62,15045.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 200MM 7MM BALLOON",SUP-U3575720,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYSORB SURGITIE 2-0 21IN BRAID LOOP COATED VIOLET",SUP-EL-22-LN,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.68,42.8,"CIGNA [10200]","Cigna Open Access",,81.18,56.9,,,,,0,16.59,121.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG HYDROCOLLOID 10X3.5IN AQUACEL AG SURGICAL COVER",SUP-412011,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.85,86.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,34.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.48,244.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM EDWARDS SAPIEN NOVAFLEX TRANSFEMORAL",SUP-9355NF23A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"AETNA [10100]","Aetna HMO/PPO",,147273.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 60MM 32MM MARATHON HIP",SUP-121932060,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"CIGNA [10200]","Cigna Local Plus",,3870.54,53.5,,5372.07,4581.20,7242.98,23,841.39,6149.45,"percent of total billed charges",
"STYLET LEAD 59CM .013IN EXTRA SOFT STRAIGHT STERILE LATEX",SUP-5005,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 6MM HIGH VOLUME LOW PRESSURE TAPER CUFF",SUP-5-12612,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,118.32,68,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL KNIFE SHORT LENGTH 230CM 1.7MM .9MM",SUP-KD-612U,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTTER 13CM 3.8MM COOLCUT BONE CUTTING",SUP-AR-8380BC,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER PELLO 3MM STRAIGHT",SUP-6290-112-033,CDM,S27200284,LOCAL,0272,RC,,,both,,,1837.50,551.25,"UHC [10700]","United Healthcare",,1163.14,63.3,,,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 54MM 26MM TURON OFFSET",SUP-520-54-126,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"CIGNA [10200]","Cigna Local Plus",,4862.51,53.5,,5372.07,4581.20,7242.98,23,1057.03,7725.48,"percent of total billed charges",
"VALVE SHUNT DELTA CSF REGULAR CONTOURED MEDIUM PRESSURE",SUP-42324,CDM,S27800098,LOCAL,0278,RC,,,both,,,7576.75,2273.02,"CIGNA [10200]","Cigna Local Plus",,4053.56,53.5,,,,,0,881.18,6440.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 37MM 26.1MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-37MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"BLUE CROSS [10001]","Blue Cross HMO",,11414.74,39.2,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 12MM 144CM 2.75MM CORONARY STENT",SUP-H7493952812270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AETNA [10100]","Aetna HMO/PPO",,4424.18,79.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 300MM 5.5MM REVOLVE",SUP-185.500,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross PPO",,1728.72,39.2,,957.42,570.23,957.42,28,512.88,3748.5,"percent of total billed charges",
"VALVE AORTIC 25MM REDUCED",SUP-R5-025,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Local Plus",,6945.75,31.5,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T 32MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 3",SUP-242.41,CDM,C1713,HCPCS,0278,RC,,,both,,,2328.90,698.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,270.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",270.85,1979.57,"percent of total billed charges",
"SCR BONE 2.4MM 10MM TITANIUM LOW PROFILE FOOT HAND ANKLE",SUP-AR-8724V-10,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,188.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",188.41,1377,"percent of total billed charges",
"KIT PULSE GENRTR WAVEWRITER ALPHA 16 THK10.7MM IMPLANTABLE",SUP-SC-1216,CDM,C1820,HCPCS,0278,RC,,,both,,,95760.00,28728,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,38304,40,,,,,0,11136.89,81396,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION MRI POWERPORT ISP 8FR 1 LUMEN",SUP-1808069,CDM,C1788,HCPCS,0278,RC,,,both,,,1905.00,571.5,"MULTIPLAN [10600]",Multiplan,,1619.25,85,,,,,0,221.55,1619.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT VASCULAR STRAIGHT 300CM",SUP-1001782-HC,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 225-250CC P3.5-4CM MODERATE PROFILE ROUND STYLE",SUP-350-1630,CDM,C1789,HCPCS,0278,RC,,,both,,,2475.00,742.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,708.35,28.62,,,,,0,287.84,2103.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD 70CM 6FR URETERAL POLYURETHANE CONE TIP ADPTR KINK",SUP-138010,CDM,C1758,HCPCS,0272,RC,,,both,,,103.05,30.91,"PHCS [10601]",PHCS,,72.14,70,,,,,0,11.98,87.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 7MM DCP STAINLESS STEEL CORTICAL SELF TAPPING",SUP-200.807,CDM,C1713,HCPCS,0278,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL MICROBIAL OMNEX SURGICAL",SUP-4901,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.28,371.18,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DORADO CHECKER 135CM 15CM 6MM BALLOON DILATATION",SUP-DR135615,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL +18.5 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6",SUP-ZCT225185,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Local Plus",,184.58,53.5,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA TRACHEOSTOMY SIZE 10 SPARE INNER TWIST LOCK CONNECTO",SUP-10SIC,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.12,18.64,"MULTIPLAN [10600]",Multiplan,,52.8,85,,,,,0,7.22,52.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 200MM 7MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171072010,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN ORTHOPEDIC BB-TAK THREAD STERILE DISPOSABLE",SUP-AR-13226TS,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 20CM 13.5FR STRAIGHT POLYURETHANE NIAGARA 2 LUMEN",SUP-5575200,CDM,C1752,HCPCS,0272,RC,,,both,,,1031.94,309.58,"CIGNA [10200]",Cigna,,701.72,68,,,,,0,120.01,877.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN SX ENDO HEPARIN 35 RO 13MMX5CM 10FR 120CMCATH",SUP-VBHR130502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"KAISER [10500]",Kaiser,,12570.14,67,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS GOLD 80CM 6CM 14MM LARGE DIAMETER BALLOON",SUP-ATG80146,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"PHCS [10601]",PHCS,,1443.75,70,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISPOSABLE LOOP LIMB SLING",SUP-VIG22001-L1,CDM,S27000186,LOCAL,0270,RC,,,both,,,145.43,43.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,98.89,68,,,,,0,16.91,123.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEWIRE VASCULAR L145CM DIA0.035IN CURVE RADIUS 3MM TAPER",SUP-G03203,CDM,C1769,HCPCS,0272,RC,,,both,,,260.91,78.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,30.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.34,221.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 30CM 13FR STRAIGHT POLYURETHANE DUOGLIDE 2 LUMEN",SUP-5623300,CDM,C1752,HCPCS,0278,RC,,,both,,,731.03,219.31,"MULTIPLAN [10600]",Multiplan,,621.38,85,,,,,0,85.02,621.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 4MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN04015,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"MULTIPLAN [10600]",Multiplan,,9964.64,85,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 6MM ENDOWRIST SP MARYLAND NONSTERILE LATEX FREE",SUP-431152,CDM,S27000186,LOCAL,0270,RC,,,both,,,2583.00,774.9,"NOVANET [10819]",Novanet,,1937.25,75,,,,,0,300.4,2195.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF PERSONALITY AND IMPULSE CONTROL",883,MS-DRG,,,,,,,inpatient,,,23684.69,7105.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2182.7,,,,,,,1958,3142.79,"per diem","Estimated amount calculated based on 3 day length of stay."
"PASSER SMARTSTITCH CNCT MAGNUM WIRE BRAIDED SUT POLYESTER",SUP-OM-8176,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.18,543.35,"CIGNA [10200]","Cigna Local Plus",,968.98,53.5,,,,,0,210.64,1539.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FROZEN 80MMX5+ MM",SUP-450620,CDM,S27800098,LOCAL,0278,RC,,,both,,,4893.48,1468.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1400.51,28.62,,,,,0,569.11,4159.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE EXAMINATION BFLEX ULTRASLIM 2.8 SINGLE USE X2",SUP-0570-0447,CDM,S27200284,LOCAL,0272,RC,,,both,,,2295.00,688.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1560.6,68,,,,,0,266.91,1950.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 20MM 4MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171040270,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 2.5MM BALLOON DILATATION OTW PTCA",SUP-DC-PY2512UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"AETNA [10100]","Aetna HMO/PPO",,785.62,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Cerv Spine W/WO Cntrst",PX-352000010,CDM,72127,CPT,0352,RC,,,both,,,3543.36,1063.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,742,,,,,,,405,3011.86,"per diem",
"CATH JADE 150CM 80MM 3MM BALLOON DILATATION OTW STERILE",SUP-593008022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"AETNA [10100]","Aetna HMO/PPO",,1159.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 12CM 3.3MM DUODENAL BEND BILIARY PLASTIC",SUP-M00533020,CDM,C2617,HCPCS,0278,RC,,,both,,,447.93,134.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,53.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.09,380.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH",RX-27696,CDM,,,0250,RC,00378-6470-16,NDC,both,1,UN,115.56,34.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 63X49X.9MM HALL OSCILLATING STRAIGHT STERILE",SUP-507155000,CDM,S27200284,LOCAL,0272,RC,,,both,,,221.50,66.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRONCHITIS AND ASTHMA WITHOUT CC/MCC",203,MS-DRG,,,,,,,inpatient,,,17115.06,5134.52,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXTOME 142CM 10MM 2.5MM BALLOON DILATATION NYLON",SUP-H749CBM3250100,CDM,C1725,HCPCS,0272,RC,,,both,,,5395.80,1618.74,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS",029,MS-DRG,,,,,,,inpatient,,,151883.42,45565.03,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 300MM 2.5MM BALLOON DILATATION",SUP-48002530S,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ORTHOPEDIC 12IN .062IN",SUP-AR-8941-12,CDM,S27000186,LOCAL,0270,RC,,,both,,,411.08,123.32,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CPS AIM 65MM 2.46MM 8FR UNIVERSAL GUIDE II SLITTABLE",SUP-DS2N101-65,CDM,C1893,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SURGICEL ORIGINAL ABSORBABLE HEMOSTAT 2X3IN",SUP-1953,CDM,S27200284,LOCAL,0272,RC,,,both,,,307.31,92.19,"UHC [10700]","United Healthcare",,194.53,63.3,,,,,0,35.74,261.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 12/14 OFFSET TAPER 44MM HIP M",SUP-136564000,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"UHC [10700]","United Healthcare",,7012.34,63.3,,8601.07,8395.67,8601.07,"1 through 10",1288.37,9416.26,"percent of total billed charges",
"BLADE STRAIGHT 2.5MM NARROW SHAFT SHARP ALL AROUND BEAVER",SUP-377210,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.70,55.41,"AETNA [10100]","Aetna HMO/PPO",,146.84,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.48,157,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 38.5CM 10FR 16GA HASKAL FLEXOR CHECK-FLO LIVER",SUP-G36126,CDM,C1894,HCPCS,0272,RC,,,both,,,4082.25,1224.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 4FR 11CM GWIRE PRELUDE PRO .035IN STERILE RED",SUP-PRO-4F-11,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 7FR OPTISEAL",SUP-7441,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT MICROINTRODUCER 5FR 50CM GWIRE BEVEL A NDL SMOOTH DIL",SUP-0228950,CDM,C1894,HCPCS,0272,RC,,,both,,,455.54,136.66,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 7FR 50CM 11CM ORANGE HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-7F-11-035,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH HEMOSTASIS VALVE TEAR AWAY SIDEPORT SAFESHEATH",SUP-HLS2510,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP IRRIGATION FORTIFY I COALITION ANGLE 12MM SELF CENTERING",SUP-684.432,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"FIRST HEALTH [10303]","First Health",,427.68,80,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VICI VENOUS STENT 90MM 100MM 16MM ENDOPROSTHESIS",SUP-H74916090100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT THR HIP E1 POROUS CUP 2 MOBILITY AA STD LINER INSRT",SUP-98000100046,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7484.4,27,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5INX10MM OSTEOTOM LONG MRI NONSTERILE LATEX FREE",SUP-998602126,CDM,S27200284,LOCAL,0272,RC,,,both,,,963.09,288.93,"CIGNA [10200]",Cigna,,654.9,68,,,,,0,112.01,818.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 500ML P5.3CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-5004BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,621.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",609.88,4457.4,"percent of total billed charges",
"HC Dressing Wound Allevyn",PX-E27200104,CDM,E27200104,LOCAL,0272,RC,,,both,,,80.68,24.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.38,68.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 196MM 24-32MM 28-29MM 20FR ZENITH TX2",SUP-G47469,CDM,C1874,HCPCS,0278,RC,,,both,,,98041.65,29412.49,"UHC [10700]","United Healthcare",,62060.36,63.3,,,,,0,11402.24,83335.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE PT VASCULAR 300CM .014IN STAINLESS STEEL",SUP-H74912155011,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"FIRST HEALTH [10303]","First Health",,453.6,80,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752610,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"NOVANET [10819]",Novanet,,676.64,75,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 16CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175198090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,157.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 28CM 10FR NEPHROURETERAL METAL",SUP-H7493935110280,CDM,C2617,HCPCS,0278,RC,,,both,,,1069.20,320.76,"BLUE CROSS [10001]","Blue Cross HMO",,419.13,39.2,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABLE, 12X30MM, 7-14MM, 15%C2%B0",SUP-1172.4221S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4106.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR070502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5065.58,27,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER PACING LEAD ACUITY 8FR LONG",SUP-7449,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CMPNT FEMORAL 3 LEFT REVISION TRIATHLON",SUP-5612-F-301,CDM,C1776,HCPCS,0278,RC,,,both,,,48062.70,14418.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5695.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5589.69,40853.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CASSETTE INFUSION PUMP PURGE CTRL IMPELLA",SUP-0043-0003,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"PHCS [10601]",PHCS,,1134,70,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 26CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155233050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"KAISER [10500]",Kaiser,,824.74,67,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPLATZ RENAL SHEATH SET 24-30F",SUP-M0062601500,CDM,C1894,HCPCS,0272,RC,,,both,,,830.57,249.17,"NOVANET [10819]",Novanet,,622.93,75,,,,,0,96.6,705.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Dialysate 106meq/Cl 100meq/L Na 3meq",PX-E25000001,CDM,E25000001,LOCAL,0250,RC,,,both,,,55.24,16.57,"CIGNA [10200]","Cigna Open Access",,31.43,56.9,,,,,0,6.42,46.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK",RX-9627,CDM,J0736,HCPCS,0636,RC,00781-3290-91,NDC,both,50,ML,114.16,34.25,"BLUE CROSS [10001]","Blue Cross PPO",,6.4,,,,,,,6.4,97.04,"fee schedule",
"HANDLE SCOPE RECHARGEABLE UNIVERSAL DESK CHRG NICAD 3.5V",SUP-71670,CDM,S27200284,LOCAL,0272,RC,,,both,,,542.30,162.69,"FIRST HEALTH [10303]","First Health",,433.84,80,,,,,0,63.07,460.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EVOLUT FX DELIVERY 34 MM",SUP-D-EVOLUTFX-34,CDM,S27200284,LOCAL,0272,RC,,,both,,,14559.00,4367.7,"CIGNA [10200]","Cigna Open Access",,8284.07,56.9,,,,,0,1693.21,12375.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 9.5-11.5MM 6 SHOOTER SAEED OPTI-VU 6 BAND NONSTERILE",SUP-G24654,CDM,S27200284,LOCAL,0272,RC,,,both,,,2107.50,632.25,"NOVANET [10819]",Novanet,,1580.63,75,,,,,0,245.1,1791.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 9.5MM S-ROM ZTT 22F SMALL HIP PROXIMAL",SUP-550737,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"UHC [10700]","United Healthcare",,6890.05,63.3,,8601.07,8395.67,8601.07,"1 through 10",1265.9,9252.04,"percent of total billed charges",
"HC Cta Coronaries W Cntrst",PX-352000035,CDM,75574,CPT,0352,RC,,,both,,,1518.10,455.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,405,,"Per diem ($405). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,176.56,1518.1,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 150MM 4MM BALLOON DILATATION",SUP-PCU040150130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM PERSONA 7 7+ KNEE DISTAL STERILE LATEX FREE",SUP-42556606205,CDM,C1776,HCPCS,0278,RC,,,both,,,7236.72,2171.02,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3321.65,45.9,,,,,0,841.63,6151.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR BALKIN CURVE 40CM 7FR GUIDING ACCEPTS .035IN",SUP-G10405,CDM,C1894,HCPCS,0272,RC,,,both,,,1466.10,439.83,"PHCS [10601]",PHCS,,1026.27,70,,,,,0,170.51,1246.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY INTRO EXPRESS KYPHOPAK FIRST FRACTURE 10/2",SUP-KPE1001-CDS,CDM,C1894,HCPCS,0272,RC,,,both,,,13098.00,3929.4,"KAISER [10500]",Kaiser,,8775.66,67,,,,,0,1523.3,11133.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS ZIPWIRE 24CM 3CM 6FR .038IN PIGTAIL CURVE",SUP-M0061265320,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"KAISER [10500]",Kaiser,,978.27,67,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 80MM 194CM 8MM 8.5FR 68MM BILIARY PERMALUME",SUP-M00570710,CDM,C1874,HCPCS,0278,RC,,,both,,,17108.55,5132.56,"NOVANET [10819]",Novanet,,12831.41,75,,,,,0,1989.72,14542.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 615CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRX-615,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2698.92,68,,,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKAGED RADIAL STEM 12MM X -2MM",SUP-ALN-RST-12M2,CDM,C1776,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"PHCS [10601]",PHCS,,9954.63,70,,,,,0,1653.89,12087.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VIPER 2 ORTHOPEDIC 1.37MM BLUNT",SUP-286705200,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS 135CM 60MM 5MM .035IN BALLOON DILATATION",SUP-AB35W05060135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"PHCS [10601]",PHCS,,474.01,70,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +23 DIOPTER +5.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT8,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Open Access",,196.31,56.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Icd Gen Sngl Lead Sys",PX-480000033,CDM,33262,CPT,0481,RC,,,both,,,19976.15,5992.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2367.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2323.23,19976.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH RED 5FT CARTO 3 HYPERTONICS 25 PIN TO LEMO 34 PIN",SUP-D128623,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,399.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG DISSOLVABLE STAMMBERGER SINU-FOAM FOAM SINUS",SUP-RR650,CDM,S27200284,LOCAL,0272,RC,,,both,,,745.04,223.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,88.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.65,633.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN SX ENDO HEPARIN 35 RO 9MMX7.5CM 8FR 120CMCATH",SUP-VBHR090702A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"UHC [10700]","United Healthcare",,13463.15,63.3,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Myelo Cerv Punc",PX-361000248,CDM,61055,CPT,0361,RC,,,both,,,3875.43,1162.63,"CIGNA [10200]","Cigna Open Access",,2090,,"Case rate ($2,090). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,450.71,3875.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 45MM LOW PROFILE SCREWS STAINLESS STEEL LONG .5",SUP-AR-8840CL-45,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Elec Dual",PX-480000012,CDM,33217,CPT,0481,RC,,,both,,,8966.11,2689.83,"FIRST HEALTH [10303]","First Health",,7172.89,80,,,,,0,1042.76,8966.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VXSK-230P RF WIRE 63CM/55DEG/D1 SHEATH",SUP-VXSK0134,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT POLARIS ZIPWIRE 24CM 150CM 7FR .035IN 3CM BLADDER LOOP",SUP-M006155242190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,965.83,68,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 24CM 150CM 7FR .035IN 3CM BLADDER LOOP",SUP-M006155242190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,165.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUADRA ALLURE MP RF CRT-P MRI, MERLIN PKG",SUP-PM3562CELL,CDM,C2621,HCPCS,0275,RC,,,both,,,25200.00,7560,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7212.24,28.62,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 24CM 4.8FR URETERAL FIRM STERILE LATEX FREE",SUP-M0061456410,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"CIGNA [10200]",Cigna,,425.16,68,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL ZIPWIRE 22-30CM 3CM 7FR .035IN PIGTAIL",SUP-M006180157180,CDM,C2617,HCPCS,0278,RC,,,both,,,1466.59,439.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,173.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,170.56,1246.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 24CM 8FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251520,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]","Cigna Open Access",,700.42,,,,,,,143.16,1046.32,"percent of total billed charges",
"SOL IV VIAFLEX 40 MEQ POTASSIUM CHLORIDE 5% DEXTROSE 0.45%",SUP-2B1674X,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.95,24.58,"CIGNA [10200]","Cigna Open Access",,46.63,56.9,,,,,0,9.53,69.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT 50X25X8MM SIGNAFUSE GLASS CLLGN TYPE 1",SUP-SGFS-010,CDM,C1713,HCPCS,0278,RC,,,both,,,12972.00,3891.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3502.44,27,,,,,0,1508.64,11026.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 36MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.526S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"CIGNA [10200]",Cigna,,1017.88,68,,1831.33,1831.33,1831.33,16,174.09,1272.35,"percent of total billed charges",
"PIN FIXATION 5MM CENTRAL THREAD 250MM STEINMANN STAINLESS",SUP-293.840,CDM,C1713,HCPCS,0278,RC,,,both,,,990.79,297.24,"CIGNA [10200]",Cigna,,673.74,68,,1831.33,1831.33,1831.33,16,115.23,842.17,"percent of total billed charges",
"NDL BIOPSY 4IN 8GA ORIGINAL JAMSHIDI BONE MARROW ASPIRATION",SUP-DJ4008X,CDM,S27200284,LOCAL,0272,RC,,,both,,,153.25,45.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,62.99,41.1,,,,,0,17.82,130.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 26FR 5MM ACMI CLASSIC",SUP-M0068804521,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"CIGNA [10200]","Cigna Open Access",,293.88,56.9,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL SHAFT ALLOGRAFT FROZEN 30MM 10+ MM",SUP-450405,CDM,S27800098,LOCAL,0278,RC,,,both,,,4454.64,1336.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,518.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,518.07,3786.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 52CM RVOT KIT MOND STAINLESS STEEL WIDE",SUP-4151/52,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,164.59,28.62,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 45CM .013IN SFT KNOB",SUP-6047,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 4CM 4MM BLNDIL",SUP-6766,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 75CM .36MM SFT TPR",SUP-121197,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,109.56,28.62,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ESOPHAGEAL PYLORIC 6FR 12-15MM 180CM 8CM FIXED WIRE",SUP-M00558360,CDM,C1726,HCPCS,0272,RC,,,both,,,1562.98,468.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,642.38,41.1,,,,,0,181.77,1328.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 8CM 5.5MM TSRH SILO STD PEDICLE TITANIUM PREBENT",SUP-8370080,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",512.88,3748.5,"percent of total billed charges",
"PLATE 5D SMALL FUSION MEDLINE UNITE BONE METATARSOPHALANGEAL",SUP-MPP1002L,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2952.3,28.62,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM STERNALOCK BLU STERNAL CANCELLOUS LOCK",SUP-73-2712,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMB FIXATION MAXFRAME RETENTION BAND",SUP-03.313.886,CDM,C1713,HCPCS,0278,RC,,,both,,,459.76,137.93,"MULTIPLAN [10600]",Multiplan,,390.8,85,,,,,0,53.47,390.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 5/32IN STEINMANN FULL THREAD STAINLESS",SUP-KM169-29-53,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,43.25,68,,,,,0,7.4,54.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32MM TITANIUM T25 SELF TAP LOCK STARDRIVE",SUP-412.210S,CDM,C1713,HCPCS,0278,RC,,,both,,,1220.18,366.05,"KAISER [10500]",Kaiser,,817.52,67,,,,,0,141.91,1037.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL TAPERCUT 5 V-40 18IN MONOFILAMENT 4",SUP-M650G,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.69,44.91,"MULTIPLAN [10600]",Multiplan,,127.24,85,,,,,0,17.41,127.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM STAINLESS STEEL 2.4MM SCR 6X3 HOLE 2 COLUMN",SUP-02.111.630,CDM,C1713,HCPCS,0278,RC,,,both,,,3834.68,1150.4,"CIGNA [10200]","Cigna Open Access",,2181.93,56.9,,1144.80,304.56,2275.09,66,445.97,3259.48,"percent of total billed charges",
"ROD SPINAL 110MM 5.5MM STRAIGHT PERCUTANEOUS CCM",SUP-1555006110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"PLATE SLANT T LISFRANC 3 HOLE COMPRESSION GORILLA BONE LEFT",SUP-P53-110-L000,CDM,C1713,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"NOVANET [10819]",Novanet,,5821.88,75,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 6.2MM 30MM NCB PROTASUL-64 3.5MM CORTEX SELF",SUP-0203150030,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"FIRST HEALTH [10303]","First Health",,1485,80,,,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CREO SPINE PREASSEMBLE THREAD",SUP-5119.1652,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CREO SPINE PREASSEMBLE THREAD",SUP-5119.1652,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 55MM INTERCONTINENTAL HA SPINE VARIABLE ANGLE",SUP-187.255S,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,305.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",305.29,2231.25,"percent of total billed charges",
"PEG FIXATION 2.5MM 12MM FULL THREAD FOOT LOCKING SCR F3",SUP-FP12,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,129.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",127.17,929.48,"percent of total billed charges",
"CEMENT BONE KYPHON XPEDE SPINAL MIXER",SUP-CX01B,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.75,405.82,"BLUE CROSS [10001]","Blue Cross PPO",,530.28,39.2,,957.42,570.23,957.42,28,157.32,1149.84,"percent of total billed charges",
"CAP END FLUSH TALON DISTALFIX 15.5MM",SUP-SLN-155-000,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 40MM TITANIUM 2 LEVEL ASSURE BONE SPINE CERVICAL",SUP-110.24,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 180MM HIP TROCHANTERIC GAMMA3 INTRAMEDULLARY 120D",SUP-3120-1180S,CDM,C1713,HCPCS,0278,RC,,,both,,,8430.28,2529.08,"BLUE CROSS [10001]","Blue Cross HMO",,3304.67,39.2,,957.42,156.86,7483.26,51,980.44,7165.74,"percent of total billed charges",
"SCR BONE 2MM 5MM TRAUMAONE MANDIBLE SELF DRILL CROSS DRIVE",SUP-41-2205,CDM,C1713,HCPCS,0278,RC,,,both,,,664.20,199.26,"BLUE CROSS [10001]","Blue Cross HMO",,260.37,39.2,,957.42,156.86,7483.26,51,77.25,564.57,"percent of total billed charges",
"SCREW NON-LOCKING 2.5MM X 14MM TI",SUP-VAN-25140-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,278.19,28.62,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 8MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0232,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,110.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",110.22,805.55,"percent of total billed charges",
"SCR BONE 2.7MM 4.3MM 8MM EVOS MINI SMALL BONE SELF TAP LOCK",SUP-72412708,CDM,C1713,HCPCS,0278,RC,,,both,,,1050.98,315.29,"CIGNA [10200]",Cigna,,714.67,68,,1831.33,1831.33,1831.33,16,122.23,893.33,"percent of total billed charges",
"PLATE BROAD 6.5IN STAINLESS STEEL 4.5MM SCREWS 5 HOLE 6",SUP-3704-3-100,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"CIGNA [10200]","Cigna Open Access",,1280.25,56.9,,1144.80,304.56,2275.09,66,261.68,1912.5,"percent of total billed charges",
"GRAFT BONE MAGNIFUSE 5CM",SUP-7509145,CDM,C1713,HCPCS,0278,RC,,,both,,,13282.50,3984.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1573.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1544.75,11290.13,"percent of total billed charges",
"HEAD FEMORAL +5MM 12/14 40MM HIP TOTAL STABILIZED TAPER",SUP-136540720,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"AETNA [10100]","Aetna HMO/PPO",,11928.22,79.5,,10981.53,8986.79,12413.38,12,1744.97,12753.44,"percent of total billed charges",
"SCR BONE 3.75MM 30MM TITANIUM PARTIAL THREAD SHOULDER",SUP-AR-7000-30,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 150MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.425,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"NOVANET [10819]",Novanet,,1038.1,75,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 5MM TITANIUM T4 HAND SELF TAP VARIABLE ANGLE",SUP-04.130.205,CDM,C1713,HCPCS,0278,RC,,,both,,,925.34,277.6,"BLUE CROSS [10001]","Blue Cross PPO",,362.73,39.2,,957.42,570.23,957.42,28,107.62,786.54,"percent of total billed charges",
"ANCHOR SUT ALPHAVENT 3 STRAND HARD BODY PLATFORM PEEK 1.4 MM",SUP-3910-947-031,CDM,C1713,HCPCS,0278,RC,,,both,,,2737.50,821.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1256.51,45.9,,,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM INDEPENDENCE SPINE SELF DRILL VARIABLE",SUP-176.745,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,743.58,45.9,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE THINFLAP CRANIOMAXILLOFACIAL TITANIUM 4 HOLE",SUP-191015,CDM,C1713,HCPCS,0278,RC,,,both,,,1822.50,546.75,"MULTIPLAN [10600]",Multiplan,,1549.13,85,,,,,0,211.96,1549.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 38MM PHOENIX TITANIUM CORTICAL SELF TAP 2 LEAD",SUP-14-405038,CDM,C1713,HCPCS,0278,RC,,,both,,,2475.00,742.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,708.35,28.62,,,,,0,287.84,2103.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 158MM STAINLESS STEEL 5MM SCR BASIC FRAGMENT 10 HOLE",SUP-427170S,CDM,C1713,HCPCS,0278,RC,,,both,,,3687.00,1106.1,"BLUE CROSS [10001]","Blue Cross PPO",,1445.3,39.2,,957.42,570.23,957.42,28,428.8,3133.95,"percent of total billed charges",
"PLATE MAXILLOMANDIBULAR HYBRID FIXATION BONE SMARTLOCK",SUP-55-02950,CDM,C1713,HCPCS,0278,RC,,,both,,,2834.40,850.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,811.21,28.62,,,,,0,329.64,2409.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE TITANIUM 25MM 9MM ACL PCL CANNULATED SHEATH",SUP-AR-1391E,CDM,C1713,HCPCS,0278,RC,,,both,,,978.08,293.42,"FIRST HEALTH [10303]","First Health",,782.46,80,,,,,0,113.75,831.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 110MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 75MM ANTIROTATE STERILE FEMORAL NECK SYSTEM",SUP-04.168.475S,CDM,C1713,HCPCS,0278,RC,,,both,,,1642.20,492.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,470,28.62,,,,,0,190.99,1395.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 34MM STAINLESS STEEL T8 METAPHYSEAL SELF TAP",SUP-02.118.534,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"BLUE CROSS [10001]","Blue Cross PPO",,205.37,39.2,,957.42,570.23,957.42,28,60.93,445.32,"percent of total billed charges",
"ROD SPINAL 110MM 5.5MM RELINE-O LORDOTIC TITANIUM NONSTERILE",SUP-14355110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"SCR BONE 2MM 8MM BABY GORILLA LOCK",SUP-P50-053-2008,CDM,C1713,HCPCS,0278,RC,,,both,,,1316.25,394.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,376.71,28.62,,,,,0,153.08,1118.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5-2.8MM 20MM ACUTRAK 2 TITANIUM MICRO FULL THREAD",SUP-AT2-C20-S,CDM,C1713,HCPCS,0278,RC,,,both,,,2460.00,738,"KAISER [10500]",Kaiser,,1648.2,67,,,,,0,286.1,2091,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTICROSS 8FR ULTRASOUND PERIPHERAL STERILE LATEX FREE",SUP-H7493932800350,CDM,C1753,HCPCS,0272,RC,,,both,,,11695.50,3508.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4806.85,41.1,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM STERNALOCK BLU STERNAL CANCELLOUS LOCK",SUP-73-2718,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 65MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.065,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"BLUE CROSS [10001]","Blue Cross HMO",,80.89,39.2,,957.42,156.86,7483.26,51,24,175.41,"percent of total billed charges",
"NAIL 12MM 340MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED",SUP-04.037.254S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1444.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1444.25,10555.59,"percent of total billed charges",
"PLATE T 53MM TITANIUM 2X8 HOLE BONE HAND NONSTERILE",SUP-447.232,CDM,C1713,HCPCS,0278,RC,,,both,,,2461.20,738.36,"AETNA [10100]","Aetna HMO/PPO",,1956.65,79.5,,1521.93,481.35,16760.95,30,286.24,2092.02,"percent of total billed charges",
"SCR BONE 1.5MM 9MM STAINLESS STEEL T4 CORTEX SELF TAP SELF",SUP-02.214.109,CDM,C1713,HCPCS,0278,RC,,,both,,,418.99,125.7,"FIRST HEALTH [10303]","First Health",,335.19,80,,,,,0,48.73,356.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM AXSOS STAINLESS STEEL 2.5MM FULL THREAD",SUP-338622,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",26.77,195.67,"percent of total billed charges",
"NAIL 12MM 440MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.265S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1471.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1444.25,10555.59,"percent of total billed charges",
"SET IMPL INTERNALBRACE SWIVELOCK FIBERTAPE 3.5MM 2 2 NDL",SUP-AR-1678-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,7063.88,2119.16,"KAISER [10500]",Kaiser,,4732.8,67,,,,,0,821.53,6004.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.040S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,189.34,1383.8,"percent of total billed charges",
"SCR BONE 5MM 32MM NCB PROTASUL-64 3.5MM SELF TAP 2 LEAD",SUP-0203150032,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"BLUE CROSS [10001]","Blue Cross PPO",,727.65,39.2,,957.42,570.23,957.42,28,215.88,1577.81,"percent of total billed charges",
"SCR BONE 3.5MM 58MM STAINLESS STEEL T15 VARIABLE ANGLE SELF",SUP-02.127.158,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,770.24,68,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 14MM XTEND SPINE VARIABLE ANGLE SELF DRILL",SUP-161.014,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"NOVANET [10819]",Novanet,,1057.5,75,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 70MM OPTILINK SELF TAP VARIABLE ANGLE STARDRIVE",SUP-42.231.270,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"CIGNA [10200]","Cigna Local Plus",,723.61,53.5,,3978.14,359.25,3978.14,24,157.3,1149.66,"percent of total billed charges",
"GRAFT SYNTHETIC TISSUE OSTEOCONDUCTIVE MATRIX PLUS 10CC",SUP-OCMP10,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 57MM 3 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.357,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"CIGNA [10200]",Cigna,,3598.56,68,,1831.33,1831.33,1831.33,16,615.46,4498.2,"percent of total billed charges",
"SCR BONE 7.5MM 70MM CD HORIZON SPINE MULTIAXIAL CANNULATED",SUP-25840017570,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL WEBSTER 115CM 1MM 6FR 2MM SPACE D CURVE",SUP-F6QD252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"FIRST HEALTH [10303]","First Health",,725.76,80,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 15MM TI",SUP-VAN-25150-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",113.04,826.2,"percent of total billed charges",
"PIN FIXATION 9IN 3.2MM STEINMANN SHARP",SUP-11-1109-FD16,CDM,C1713,HCPCS,0278,RC,,,both,,,3326.40,997.92,"AETNA [10100]","Aetna HMO/PPO",,2644.49,79.5,,1521.93,481.35,16760.95,30,386.86,2827.44,"percent of total billed charges",
"SCR SPINAL 16MM 4MM CODA ANTERIOR CERVICAL SELF TAP VARIABLE",SUP-102254016,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,3978.14,359.25,3978.14,24,117.75,860.63,"percent of total billed charges",
"SCR BONE 5MM 14MM STAINLESS STEEL T25 SELF TAP VARIABLE",SUP-02.231.014S,CDM,C1713,HCPCS,0278,RC,,,both,,,2073.45,622.03,"PHCS [10601]",PHCS,,1451.42,70,,,,,0,241.14,1762.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 10MM LCP STAINLESS STEEL DISTAL FEMUR CONDYLE",SUP-02.221.510S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM CORTICAL LOW PROFILE NONSTERILE ALPS",SUP-131218022,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"CIGNA [10200]","Cigna Local Plus",,422.52,53.5,,3978.14,359.25,3978.14,24,91.85,671.29,"percent of total billed charges",
"SCREW BONE L56MM DIA3.5MM CORTICAL STAINLESS STEEL SELF TAPP",SUP-02.206.256,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"CIGNA [10200]","Cigna Local Plus",,173.33,53.5,,3978.14,359.25,3978.14,24,37.68,275.39,"percent of total billed charges",
"SCR BONE 3.5MM 55MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.855,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"BLUE CROSS [10001]","Blue Cross HMO",,92.76,39.2,,957.42,156.86,7483.26,51,27.52,201.14,"percent of total billed charges",
"CABLE ORTHOPEDIC VITALLIUM 2MM HOMOGENOUS DALL-MILES 2",SUP-6704-0-510,CDM,C1713,HCPCS,0278,RC,,,both,,,1440.74,432.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,170.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,167.56,1224.63,"percent of total billed charges",
"PLATE SMALL STRAIGHT 1MM 1.7MM SCR 16 HOLE LOCKING VARIAX",SUP-57-10316,CDM,C1713,HCPCS,0278,RC,,,both,,,3878.63,1163.59,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,451.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",451.08,3296.84,"percent of total billed charges",
"PLATE 90MM TITANIUM 5 LEVEL ATLANTIS VISION ELITE BONE SPINE",SUP-7200090,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"SCR BONE 6.5MM 60MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.434,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"CIGNA [10200]",Cigna,,941.21,68,,1831.33,1831.33,1831.33,16,160.97,1176.51,"percent of total billed charges",
"GRAFT BONE PRIME HD DBM 5CC ALLOGRAFT LATEX FREE",SUP-421050,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,,1521.93,481.35,16760.95,30,436.13,3187.5,"percent of total billed charges",
"SCR BONE 5MM 75MM TITANIUM SELF TAP LOCK NONSTERILE AXSOS 3",SUP-661175,CDM,C1713,HCPCS,0278,RC,,,both,,,1377.32,413.2,"FIRST HEALTH [10303]","First Health",,1101.86,80,,,,,0,160.18,1170.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 7CM 7FR PIGTAIL CURVE TAPER PANCREATIC",SUP-G22353,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,73.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TRIA 22CM 6FR URETERAL SOFT",SUP-M0061903210,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR 24CM 8FR .038IN BLADDER LOOP LOW",SUP-M006155252120,CDM,C2617,HCPCS,0278,RC,,,both,,,1325.65,397.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,157.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.17,1126.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SPECTRUM MVP 45D RIGHT HOOK SUT STERILE DISPOSABLE",SUP-C6410,CDM,S27200284,LOCAL,0272,RC,,,both,,,1799.93,539.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,739.77,41.1,,,,,0,209.33,1529.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X18X9MM TRANSCONTINENTAL 10D SMALL TITANIUM",SUP-375.069CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"KAISER [10500]",Kaiser,,21105,67,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET PACING 59CM TAPERED",SUP-6543,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 7MM CR VERTEBRAL LORDOTIC NONSTERILE",SUP-889.923,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 57MM 36MM GLADIATOR HIP COCR XLPE UHMWPE",SUP-GLBP3657,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"KAISER [10500]",Kaiser,,9523.38,67,,,,,0,1653.09,12081.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE CHIBA 18GA X 15CM",SUP-MCN1806,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"NOVANET [10819]",Novanet,,92.66,75,,,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2.5CM 2.5MM GALAXY G3 XTRASOFT",SUP-GLX122525,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"PHCS [10601]",PHCS,,8317.26,70,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC ARM ELEV CUTAWAY FOAM ADULT BLUE",SUP-8874-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,86.57,25.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,58.87,68,,,,,0,10.07,73.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 3.5CM 18FR GUIDING BALLOON LOW PROFILE",SUP-8117,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"KAISER [10500]",Kaiser,,2487.38,67,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCOPIC INSTR CANNULATED STEP DRILL DRILL GUIDE OBTR",SUP-AR-8936BC-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10505.25,3151.57,"BLUE CROSS [10001]","Blue Cross PPO",,4118.06,39.2,,957.42,570.23,957.42,28,1221.76,8929.46,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL FLAT L HOOK 36CM CLEANCOAT COATED",SUP-E3774-36C,CDM,S27200284,LOCAL,0272,RC,,,both,,,251.00,75.3,"KAISER [10500]",Kaiser,,168.17,67,,,,,0,29.19,213.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 99MM 9MM FULL PROXIMAL PROFILE ECHO BI-METRIC",SUP-19-3009,CDM,C1776,HCPCS,0278,RC,,,both,,,27578.88,8273.66,"BLUE CROSS [10001]","Blue Cross HMO",,10810.92,39.2,,5311.50,4717.44,5388.59,31,3207.42,23442.05,"percent of total billed charges",
"IMPL BREAST 340ML GEL ROUND TEXTURED MEMORYGEL SILTEX P3.4CM",SUP-3543407MC,CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"MULTIPLAN [10600]",Multiplan,,3213,85,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL HIP 32MM 46MM OR3O 2 MOBILITY LINER STERILE LATEX FREE",SUP-71358252,CDM,C1776,HCPCS,0278,RC,,,both,,,16094.25,4828.27,"CIGNA [10200]",Cigna,,6437.7,40,,5873.17,5873.17,5873.17,"1 through 10",1871.76,13680.11,"percent of total billed charges",
"SUT VICRYL PLUS 0 MO-5 27IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCPP81D,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 6MM BALLOON",SUP-U357566,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Rmvl Pcmkr Gen Only",PX-480000026,CDM,33233,CPT,0481,RC,,,both,,,8960.18,2688.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2262,,"Case rate ($2,262). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1042.07,8960.18,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 32MM AEQUALIS TITANIUM SHOULDER NONLOCKING",SUP-VDV232,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"PHCS [10601]",PHCS,,1089.2,70,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 2 LR 30IN 2 ARM MONOFILAMENT BLACK NONABSORBABLE",SUP-490T,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 28MM 10MM STAINLESS STEEL 1.1MM LONG THREAD",SUP-02.226.128,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"CIGNA [10200]","Cigna Open Access",,936.12,56.9,,1144.80,304.56,2275.09,66,191.34,1398.42,"percent of total billed charges",
"CATH POWERFLEX P3 80CM 10CM 5FR 7MM 7.5MM BALLOON DILATATION",SUP-4207000S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE RIGHT POSTERIOR STABILIZE GENESIS II",SUP-71421206,CDM,C1776,HCPCS,0278,RC,,,both,,,29077.65,8723.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3445.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3381.73,24716,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 12MM MINI-MONSTER SHORT THREAD HEAD NONSTERILE",SUP-P20-120-012S,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"KAISER [10500]",Kaiser,,949.73,67,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR CEMENTLESS STD Z1 TITANIUM ALLOY 4",SUP-611201040,CDM,C1776,HCPCS,0278,RC,,,both,,,28967.40,8690.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3368.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3368.91,24622.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 1.5MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES0153CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM CHARLOTTE MULTIUSE COMPRESSION CANNULATED",SUP-44180015,CDM,C1713,HCPCS,0278,RC,,,both,,,1530.90,459.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,181.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",178.04,1301.27,"percent of total billed charges",
"KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC",686,MS-DRG,,,,,,,inpatient,,,63429.20,19028.76,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,22781.92,,"Case rate ($11,188.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,389.24, add-ons for qualifying new technology services are included. If operating cost exceeds $43,428.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,167.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $10,402.98. The transfer operating threshold is the transfer adjustment factor * $10,389.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $785.48. The transfer capital threshold is the transfer adjustment factor * $785.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,44982.47,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 12 EXTREME LATERAL INTERBODY FUSION 2 HOLE DECADE BONE",SUP-7140212,CDM,C1713,HCPCS,0278,RC,,,both,,,13800.00,4140,"CIGNA [10200]","Cigna Open Access",,4623,33.5,,1144.80,304.56,2275.09,66,1604.94,11730,"percent of total billed charges",
"PLATE 59MM TITANIUM 1.5MM SCREW MODULAR HAND SET 12 HOLE STR",SUP-446.032,CDM,C1713,HCPCS,0278,RC,,,both,,,2373.00,711.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1613.64,68,,,,,0,275.98,2017.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +10MM 36MM HIP MODULAR PCA",SUP-6280-0-336,CDM,C1776,HCPCS,0278,RC,,,both,,,7414.05,2224.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2121.9,28.62,,,,,0,862.25,6301.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PERICARDIOCENTESIS 40CM 8FR STRAIGHT CATH",SUP-PC802,CDM,C1729,HCPCS,0272,RC,,,both,,,1036.80,311.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,122.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM VOLT STAINLESS STEEL T8 CORTEX",SUP-02.527.114,CDM,C1713,HCPCS,0278,RC,,,both,,,1033.56,310.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,120.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",120.2,878.53,"percent of total billed charges",
"HC Rabies Vaccine Titer",PX-302000086,CDM,86382,CPT,0302,RC,,,both,,,387.00,116.1,"NOVANET [10819]",Novanet,,290.25,75,,,,,0,0.01,328.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TITANIUM UHMWPE XBRAID 1.2MM BLUE NONSTERILE LATEX FREE",SUP-3910900017,CDM,S27800098,LOCAL,0278,RC,,,both,,,729.00,218.7,"CIGNA [10200]","Cigna Open Access",,414.8,56.9,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING +10.5MM UNIPOLAR",SUP-411-00-105,CDM,C1776,HCPCS,0278,RC,,,both,,,947.54,284.26,"BLUE CROSS [10001]","Blue Cross HMO",,371.44,39.2,,5311.50,4717.44,5388.59,31,110.2,805.41,"percent of total billed charges",
"PLATE 113MMX2MM TITANIUM 6 HOLE LOCK LOW PROFILE VARIAX",SUP-40-20906,CDM,C1713,HCPCS,0278,RC,,,both,,,4660.81,1398.24,"KAISER [10500]",Kaiser,,3122.74,67,,,,,0,542.05,3961.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER EVERCROSS 135CM 100MM 3MM .035IN BALLOON DILATATION",SUP-AB35W03100135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"AETNA [10100]","Aetna HMO/PPO",,538.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 74MM 10.8MM 6.4MM CUFF DISPOSABLE INNER CANN SMOOTH",SUP-6DCT,CDM,S27200284,LOCAL,0272,RC,,,both,,,325.99,97.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,221.67,68,,,,,0,37.91,277.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYNTHETIC TISSUE SCAFFOLD STRIP .7X16CM",SUP-31056,CDM,C1763,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"AETNA [10100]","Aetna HMO/PPO",,13137.77,79.5,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE DIAMONDTOUCH 35 ATM INFLATION 30ML DIGITAL SYR BARREL",SUP-IN9135,CDM,S27200284,LOCAL,0272,RC,,,both,,,456.19,136.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,54.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.05,387.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +10MM 36MM HIP MODULAR PCA",SUP-6280-0-336,CDM,C1776,HCPCS,0278,RC,,,both,,,7414.05,2224.21,"CIGNA [10200]","Cigna Local Plus",,3966.52,53.5,,5372.07,4581.20,7242.98,23,862.25,6301.94,"percent of total billed charges",
"DIL VASCULAR 6FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G00937,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"MULTIPLAN [10600]",Multiplan,,41.93,85,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG VALU-BAGS BUTT-FLAP 8MM UNIVERSAL U FRAME UROLOGY",SUP-CMS-999,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.10,21.03,"CIGNA [10200]","Cigna Local Plus",,37.5,53.5,,,,,0,8.15,59.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BUTTON 12MM 4CM PASSPORT BUTTON SILICONE CURVE HIP 1",SUP-AR-6592-12-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"CIGNA [10200]","Cigna Local Plus",,273.01,53.5,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO ENDOSCOPIC 8.5FR 5FR 195CM 1 ACTION RADIOPAQUE GUIDE",SUP-G31526,CDM,S27200284,LOCAL,0272,RC,,,both,,,1085.40,325.62,"PHCS [10601]",PHCS,,759.78,70,,,,,0,126.23,922.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTITORQUE 110CM 5FR RADIAL TIGER 4.5 CURVE",SUP-40-5014,CDM,C1713,HCPCS,0278,RC,,,both,,,313.20,93.96,"MULTIPLAN [10600]",Multiplan,,266.22,85,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GEL SURGICAL GREEN BIOFREEZE PUMP 1GL",SUP-81697424,CDM,S27000186,LOCAL,0270,RC,,,both,,,808.54,242.56,"NOVANET [10819]",Novanet,,606.41,75,,,,,0,94.03,687.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FG GATEWAY OTW  US 4.00MM X 15MM",SUP-M0032072215400,CDM,C1725,HCPCS,0272,RC,,,both,,,9423.88,2827.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1116.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1096,8010.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH METAL HEAD + VE",SUP-98000500307,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"FIRST HEALTH [10303]","First Health",,20160,80,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE RIGHT PATELLOFEMORAL JOINT CEMENT",SUP-00592601502,CDM,C1776,HCPCS,0278,RC,,,both,,,15573.60,4672.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4457.16,28.62,,,,,0,1811.21,13237.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Lwr Leg Rt",PX-510000082,CDM,29581,CPT,0761,RC,,,both,,,657.12,197.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,76.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,76.42,657.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZENITH 120MM 36MM 20-30MM 16MM 6FR VASCULAR AORTIC",SUP-G47492,CDM,C1876,HCPCS,0278,RC,,,both,,,87438.00,26231.4,"CIGNA [10200]","Cigna Local Plus",,27542.97,31.5,,,,,0,10169.04,74322.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mitochondrial Antibody Each",PX-302000258,CDM,86381,CPT,0302,RC,,,both,,,175.75,52.72,"NOVANET [10819]",Novanet,,131.81,75,,,,,0,0.01,149.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Pelvis Complete",PX-402000027,CDM,76856,CPT,0402,RC,,,both,,,1238.23,371.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,223.02,,,,,,,114.92,1052.5,"fee schedule",
"CMPNT FEMORAL 4 RIGHT KNEE POSTERIOR STABILIZED CEMENTED",SUP-5515-F-402,CDM,C1776,HCPCS,0278,RC,,,both,,,16566.90,4970.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1963.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1926.73,14081.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tracheostomy Planned",PX-750000193,CDM,31600,CPT,0750,RC,,,both,,,4541.42,1362.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3279,,"Case rate ($3,279). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,4.54,4541.42,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MINAMO VASCULAR 190CM .014IN STERILE LATEX FREE",SUP-AH14R026S,CDM,C1769,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X12X10MM CLYDESDALE PTC 0D PEEK TITANIUM",SUP-4980250,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"MULTIPLAN [10600]",Multiplan,,24097.5,85,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZIPWIRE BENTSON UROLOGICAL STRAIGHT 150CM 5CM .035IN",SUP-M006630224B1,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 16MM OSS UHMWPE KNEE TIBIAL STD STERILE",SUP-150412,CDM,C1776,HCPCS,0278,RC,,,both,,,8317.26,2495.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3817.62,45.9,,,,,0,967.3,7069.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH GORE TIPS NDL GUIDE SHEATH DIL",SUP-TSET1016,CDM,C1887,HCPCS,0272,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 5.5MM TITANIUM PREBENT",SUP-8052060,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross PPO",,1728.72,39.2,,957.42,570.23,957.42,28,512.88,3748.5,"percent of total billed charges",
"PIN ADULT MAYFIELD WING GROOVE PLASTIC CRANIUM SKULL",SUP-A1072,CDM,S27200284,LOCAL,0272,RC,,,both,,,152.81,45.84,"NOVANET [10819]",Novanet,,114.61,75,,,,,0,17.77,129.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE KIT FOR SOFT TISSUE APPROXIMATION LIGATION","SUP-GZL 002",CDM,S27200284,LOCAL,0272,RC,,,both,,,2996.25,898.87,"PHCS [10601]",PHCS,,2097.38,70,,,,,0,348.46,2546.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD MARLEX 5.4X2.4IN KEYHOLE MONOFILAMENT",SUP-0113710,CDM,C1781,HCPCS,0278,RC,,,both,,,481.14,144.34,"NOVANET [10819]",Novanet,,360.86,75,,,,,0,55.96,408.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD MARLEX 5.4X2.4IN KEYHOLE MONOFILAMENT",SUP-0113710,CDM,C1781,HCPCS,0278,RC,,,both,,,481.14,144.34,"CIGNA [10200]",Cigna,,327.18,68,,,,,0,55.96,408.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM POD J-SOFT PACK STERILE LATEX FREE",SUP-RBYPODJ30,CDM,S27800098,LOCAL,0278,RC,,,both,,,8832.00,2649.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1027.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1027.16,7507.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VXSK-230P RF WIRE 81CM/45DEG/D0 SHEATH",SUP-VXSK0137,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"NOVANET [10819]",Novanet,,4631.63,75,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tp53 Gene Full Gene Sequence",PX-310000030,CDM,81351,CPT,0310,RC,,,both,,,2824.50,847.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,334.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,2400.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Line Ext Cardioplegia",PX-E27200368,CDM,E27200368,LOCAL,0272,RC,,,both,,,180.40,54.12,"CIGNA [10200]","Cigna Open Access",,102.65,56.9,,,,,0,20.98,153.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTNR SCR 16MM 3.5MM PRODISC-C SPINE NONSTERILE",SUP-03.820.104,CDM,C1713,HCPCS,0278,RC,,,both,,,1239.30,371.79,"NOVANET [10819]",Novanet,,929.48,75,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE DRILL TAN 3.2MM SURESHOT PIN",SUP-71631436,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 57MM 3 LEVEL XTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.357,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2429.03,45.9,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP LIMIT HOLE FIN RINGLOC+ 24 STERILE",SUP-16-104156,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,818.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 15MM 3MM BALLOON DILATATION STERILE",SUP-230-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Ambu Bag & Mask",PX-E27000040,CDM,E27000040,LOCAL,0270,RC,,,both,,,216.28,64.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GLUCOSAMINE SULFATE 500 MG CAPSULE",RX-15717,CDM,,,0637,RC,43292-0558-57,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM LARGE BONE CEMENT MIX DELIVERY APPLR",SUP-ABS-1000-L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1837.50,551.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE EMBOTRAP II 37MM 5MM THROMBECTOMY",SUP-ET309537,CDM,C1757,HCPCS,0272,RC,,,both,,,40320.00,12096,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH TREK 145CM 25MM 3.5MM BALLOON DILATATION PEBAX",SUP-1012276-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RECTAL RESECTION WITH MCC",332,MS-DRG,,,,,,,inpatient,,,152983.81,45895.14,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYPROPYLENE 22X18IN PERMANENT GRID 2 SMOOTH",SUP-F10248-1822P,CDM,C1781,HCPCS,0278,RC,,,both,,,50891.40,15267.42,"CIGNA [10200]","Cigna Local Plus",,16030.79,31.5,,3096.73,1.00,3096.73,"1 through 10",5918.67,43257.69,"percent of total billed charges",
"PLATE 39X7X1MM TITANIUM 2.7MM SCR MINI FRAGMENT 5 HOLE .25",SUP-442.05,CDM,C1713,HCPCS,0278,RC,,,both,,,3031.80,909.54,"KAISER [10500]",Kaiser,,2031.31,67,,,,,0,352.6,2577.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 51MM STAINLESS STEEL 2.4MM SCR 6X3 HOLE 2",SUP-02.111.531,CDM,C1713,HCPCS,0278,RC,,,both,,,3834.68,1150.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1760.12,45.9,,,,,0,445.97,3259.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 12MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-1516-30-712,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"MULTIPLAN [10600]",Multiplan,,11158.16,85,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR IMPLANTABLE 2INX1.7IN INTERSTIM II 10-14HZ 0-4V",SUP-3058,CDM,C1767,HCPCS,0278,RC,,,both,,,62700.00,18810,"MULTIPLAN [10600]",Multiplan,,53295,85,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 36MM GLENOSPHERE STERILE TRABECULAR METAL",SUP-00434903611,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,696.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SURGICAL HEX IMPACTION 3.5MM DISPOSABLE STERILE LATEX",SUP-111653,CDM,A4648,HCPCS,0278,RC,,,both,,,874.80,262.44,"MULTIPLAN [10600]",Multiplan,,743.58,85,,,,,0,101.74,743.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 65MM KNEE RIGHT CRUCIATE RETAIN CEMENT PRIMARY",SUP-183048,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"FIRST HEALTH [10303]","First Health",,19362.67,80,,,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 16MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620216,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"MULTIPLAN [10600]",Multiplan,,9565.82,85,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.0/13",SUP-401738,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE FUZEFIX MAX FULL THREAD L30 MM OD4.5 MM CANNULATE",SUP-FX-FT-4530,CDM,S27000186,LOCAL,0270,RC,,,both,,,3600.00,1080,"CIGNA [10200]",Cigna,,2448,68,,,,,0,418.68,3060,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPANDER BREAST TISSUE 600CC SUTURE TAB MODERATE HEIGHT EXTR",SUP-133P-MX-14-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9991.20,2997.36,"CIGNA [10200]",Cigna,,6794.02,68,,,,,0,1161.98,8492.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETER 40CM MAHURKAR",SUP-8833074002,CDM,C1752,HCPCS,0272,RC,,,both,,,1666.80,500.04,"CIGNA [10200]","Cigna Open Access",,948.41,56.9,,,,,0,193.85,1416.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E FEMUR PATELLA TIBIA CEMENT",SUP-98000240021,CDM,C1776,HCPCS,0278,RC,,,both,,,20790.00,6237,"BLUE CROSS [10001]","Blue Cross PPO",,8149.68,39.2,,3949.44,3949.44,3949.44,"1 through 10",2417.88,17671.5,"percent of total billed charges",
"CATH ARTERIAL 8FR 110CM THERMODILUTION CARDIAC OUTPUT",SUP-746HF8,CDM,C1751,HCPCS,0272,RC,,,both,,,1541.35,462.4,"KAISER [10500]",Kaiser,,1032.7,67,,,,,0,179.26,1310.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHAIT TRAPDOOR 20CM 6- CM 10.2FR SHORT CECOSTOMY",SUP-G11632,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 10MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620810,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS [10001]","Blue Cross HMO",,4411.53,39.2,,5311.50,4717.44,5388.59,31,1308.83,9565.82,"percent of total billed charges",
"COMPONENT PATELLAR PERSONA OSSEOTI OD38 MM KNEE 3 PEG CEMENT",SUP-42-5405-000-38,CDM,C1776,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"FIRST HEALTH [10303]","First Health",,5961.6,80,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 3DMAX 6.7X4.8IN ABDOMINAL LEFT LIGHTWEIGHT",SUP-0117312,CDM,C1781,HCPCS,0278,RC,,,both,,,1005.80,301.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.97,854.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 20-38CMX3-10MM GRACILIS TENDON ALLOGRAFT",SUP-430300,CDM,C1762,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1030.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1011.11,7389.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM 500 MG (AS CARBONATE)-VITAMIN D3 5 MCG (200 UNIT) TABLET",RX-19483,CDM,,,0637,RC,10006-0700-38,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 300MM 5.5MM REVOLVE",SUP-185.500,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"MULTIPLAN [10600]",Multiplan,,3748.5,85,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM LOW PROFILE SCREWS STAINLESS STEEL",SUP-AR-8827-14,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,153.47,39.2,,957.42,570.23,957.42,28,45.53,332.78,"percent of total billed charges",
"CMPNT FEMORAL 7 STD KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508606201,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10495.3,40,,,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 90CM 5FR RBT CURVE ANGIOGRAPHIC",SUP-G47159,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"CIGNA [10200]",Cigna,,70.99,68,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Anal Tag or Papilla Sngl",PX-750000154,CDM,46220,CPT,0750,RC,,,both,,,7693.27,2307.98,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,894.73,6539.28,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Iliac W Stent Sf Ea Add",PX-361000700,CDM,37259,CPT,0361,RC,,,both,,,9101.85,2730.55,"CIGNA [10200]","Cigna Local Plus",,6044,,"Case rate ($6,044). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,9.1,7883,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 53MM TRUNION ECLIPSE SHOULDER",SUP-AR-9301-53CPC,CDM,C1776,HCPCS,0278,RC,,,both,,,9239.10,2771.73,"BLUE CROSS [10001]","Blue Cross PPO",,3621.73,39.2,,3949.44,3949.44,3949.44,"1 through 10",1074.51,7853.24,"percent of total billed charges",
"SPACER SPINAL DARK BLUE 15MM SYNFIX 18D MEDIUM EVOLUTION 6.9",SUP-08.815.264S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 STD KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500605802,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2709.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2658.93,19433.3,"percent of total billed charges",
"HEAD RADIAL 28MM RIGHT STERILE",SUP-TR-H280R-S,CDM,C1776,HCPCS,0278,RC,,,both,,,13489.50,4046.85,"BLUE CROSS [10001]","Blue Cross HMO",,5287.88,39.2,,5311.50,4717.44,5388.59,31,1568.83,11466.08,"percent of total billed charges",
"CANN OPHTHALMIC 22GA BINKHORST BLUNT IRR SMOOTH FRONT OPEN",SUP-60-1231,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.79,57.84,"CIGNA [10200]",Cigna,,131.1,68,,,,,0,22.42,163.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 4CM 2MM BALLOON DILATATION",SUP-U815024,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSCONN ROD 30-42MM SPINE HEAD TO HEAD",SUP-102023102,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"NOVANET [10819]",Novanet,,2671.88,75,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +27 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.270,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,316.02,45.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET PRESSURE MONITOR QUICK PREFILL SYRINGE DIAPHRAGM CHAMBER",SUP-0295-002-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3 RING SUTURE PASSER KIT",SUP-OS3CDK,CDM,S27200284,LOCAL,0272,RC,,,both,,,421.95,126.58,"PHCS [10601]",PHCS,,295.37,70,,,,,0,49.07,358.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8MM 270MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-408-270,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 5MM 24MM DCP STAINLESS STEEL STD CORTICAL",SUP-202.024,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,161.25,45.9,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 70MM 75CM 22MM 100CM",SUP-H965404520,CDM,C1876,HCPCS,0278,RC,,,both,,,14331.30,4299.39,"NOVANET [10819]",Novanet,,10748.48,75,,,,,0,1666.73,12181.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 2 HOLE STERILE 130DEG TITANIUM FEMORAL NECK SYSTE",SUP-04.268.000S,CDM,C1713,HCPCS,0278,RC,,,both,,,4532.47,1359.74,"NOVANET [10819]",Novanet,,3399.35,75,,,,,0,527.13,3852.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHMBR HUMD 2 FLOAT MECHANISM AUTOFILL CONSISTENT",SUP-MR290HFV,CDM,S27000186,LOCAL,0270,RC,,,both,,,94.72,28.42,"CIGNA [10200]",Cigna,,64.41,68,,,,,0,11.02,80.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.50MM X 15MM  SCOREFLEX  NC",SUP-635-154-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2126.93,41.1,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRGMR NEROSTIMLTR MYSTIM MRI TECHNOLOGY EXT",SUP-97740,CDM,C1787,HCPCS,0270,RC,,,both,,,4830.00,1449,"UHC [10700]","United Healthcare",,3057.39,63.3,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZENITH 120MM 36MM 20-30MM 16MM 6FR VASCULAR AORTIC",SUP-G47492,CDM,C1876,HCPCS,0278,RC,,,both,,,87438.00,26231.4,"BLUE CROSS [10001]","Blue Cross HMO",,34275.7,39.2,,,,,0,10169.04,74322.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 15FTX3IN WRIST IMMOB WRINKLE FREE STRETCH",SUP-OG-3L2,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 12MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640412,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1308.83,9565.82,"percent of total billed charges",
"PLATE 232MM STAINLESS STEEL 2.7/3.5MM SCR 14 HOLE VARIABLE",SUP-02.118.213S,CDM,C1713,HCPCS,0278,RC,,,both,,,13144.50,3943.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5257.8,40,,,,,0,1528.71,11172.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 16MM .0145IN AXIUM PRIME 3D FRAME",SUP-FC-16-40-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"UHC [10700]","United Healthcare",,10460.64,63.3,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE AMS 700 MS PUMP CONCEAL INFLATABLE RESVR",SUP-720185-01,CDM,C1813,HCPCS,0278,RC,,,both,,,21609.00,6482.7,"BLUE CROSS [10001]","Blue Cross HMO",,8470.73,39.2,,,,,0,2513.13,18367.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 1.8MM Q-FIX MINI XL DISPOSABLE",SUP-72290126,CDM,C1713,HCPCS,0278,RC,,,both,,,1385.10,415.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.87,68,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 13MM CENTERPIECE C",SUP-436013C,CDM,S27800098,LOCAL,0278,RC,,,both,,,39060.00,11718,"UHC [10700]","United Healthcare",,24724.98,63.3,,,,,0,4542.68,33201,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 NARROW KNEE LEFT CRUCIATE RETAIN CEMENTLESS",SUP-150401124,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7769.32,27,,,,,0,3346.56,24458.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 14GA RIGID NDL 1 MICROFIBER PAD RADIOPAQUE INTERWOVEN",SUP-SMUC13H,CDM,A4648,HCPCS,0278,RC,,,both,,,630.67,189.2,"CIGNA [10200]","Cigna Local Plus",,337.41,53.5,,,,,0,73.35,536.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTITIS MEDIA AND URI WITHOUT MCC",153,MS-DRG,,,,,,,inpatient,,,22981.45,6894.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6658.56,,"Fee schedule rate ($6,658.56). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,4579.09,18409.97,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2XS UNIVERSAL 12MM KNEE COCR POLYETHYLENE",SUP-198727012,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"BLUE CROSS [10001]","Blue Cross HMO",,11582.18,39.2,,5311.50,4717.44,5388.59,31,3436.24,25114.41,"percent of total billed charges",
"CATH EMERGE MONORAIL 144CM 30MM 6FR 3MM .07IN BALLOON",SUP-H7493918930300,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,inpatient,,,84889.64,25466.89,"AETNA [10100]","Aetna HMO/PPO",,47716.72,,"Fee schedule rate ($47,716.72). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,74043.98,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Lumb/Sac Sngl WO Img",PX-510000205,CDM,62322,CPT,0361,RC,,,both,,,4263.00,1278.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1550,,"Case rate ($1,550). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1550,2385,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemosiderin Qual",PX-301000231,CDM,83070,CPT,0301,RC,,,both,,,229.00,68.7,"CIGNA [10200]","Cigna Local Plus",,10.45,,,,,,,0.01,194.65,"fee schedule",
"HC US OB Complt Txabd Add Fetus",PX-402000019,CDM,76812,CPT,0402,RC,,,both,,,441.01,132.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,277,,"Per diem ($277).",,,,0,51.29,426,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR STD+ CEMENTED 3 PEG LOW PROFILE LCS COMPLETE",SUP-129409450,CDM,C1776,HCPCS,0278,RC,,,both,,,7055.25,2116.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,836.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,820.53,5996.96,"percent of total billed charges",
"SCR BASEPLT 18MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ318,CDM,C1713,HCPCS,0278,RC,,,both,,,962.00,288.6,"NOVANET [10819]",Novanet,,721.5,75,,,,,0,721.5,721.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 6IN 1.6MM KIRSCHNER FEMUR TIBIA SMALL FRAGMENT",SUP-144256,CDM,C1713,HCPCS,0278,RC,,,both,,,810.00,243,"CIGNA [10200]","Cigna Local Plus",,433.35,53.5,,3978.14,359.25,3978.14,24,94.2,688.5,"percent of total billed charges",
"COIL EMBOLIZATION 34CM 10MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181034,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"CIGNA [10200]","Cigna Open Access",,6230.2,33.5,,,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT",RX-856,CDM,,,0250,RC,24208-0555-55,NDC,both,3.5,GR,180.22,54.07,"CIGNA [10200]",Cigna,,122.55,68,,,,,0,20.96,153.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 40MM 5MM .014IN BALLOON DILATATION",SUP-AB14W050040150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"AETNA [10100]","Aetna HMO/PPO",,1101.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +19 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.190,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross PPO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM PROFILE 3D",SUP-680R30,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 CURVE 10MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962051,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1096.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 18MM 140CM 2.5MM CORONARY STERILE LATEX",SUP-453944,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"STEM FEMORAL 109MM TRI-LOCK BPS GRIPTION 7 STD OFFSET HIP",SUP-101204070,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"FIRST HEALTH [10303]","First Health",,12885.7,80,,,,,0,1873.26,13691.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 26CM 150CM 8FR .035IN 3CM BLADDER LOOP",SUP-M006155253180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,738.86,45.9,,,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60X4.8MM TITANIUM THICK TISSUE ENDOSCOPIC",SUP-TA6048S,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.55,176.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,400.21,68,,,,,0,68.45,500.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROCAINAMIDE 100 MG/ML INJECTION SOLUTION",RX-6562,CDM,J2690,HCPCS,0636,RC,14789-0901-07,NDC,both,10,ML,4528.80,1358.64,"BLUE CROSS [10001]","Blue Cross HMO",,343.46,,,,,,,4.25,3849.48,"fee schedule",
"STENT GORE VIABAHN 29MM 135CM 6MM 8MM 7FR .035IN",SUP-BXA062902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5582.27,28.62,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 62MM 3MM SWANSON SHORT PILOT POINT STERILE",SUP-1608-002-133,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EDS II 46CM 1.65MM .76MM DRNG SILICONE LUMBAR LUER LOCK",SUP-821706,CDM,C1729,HCPCS,0272,RC,,,both,,,1553.82,466.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 3.5MM TRIM-IT",SUP-AR-4160-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TORQR FIXED QUAD",SUP-041005DM,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 13MM UCSS CANNULATED STERILE DISPOSABLE",SUP-873-007,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 16MM HOLLOW CANNULATED PERCUTANEOUS STERILE",SUP-03.037.104S,CDM,S27000186,LOCAL,0270,RC,,,both,,,5415.40,1624.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MONOCRYL MULTIPASS 4-0 P-3 18IN MONOFILAMENT VIOLET",SUP-Y464G,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.62,20.59,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ASAHI SION BLUE VASCULAR 190CM .014IN STERILE LATEX",SUP-AHW14R104S,CDM,C1769,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RAPIDCROSS 170CM 210MM 3.5MM .014IN BALLOON DILATATION",SUP-A14BX035210170,CDM,C1725,HCPCS,0272,RC,,,both,,,1638.75,491.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL ASPIRATION 15MM 19GA 1.8MM EXCELON TRANSBRONCHIAL 1 HAND",SUP-M00564101,CDM,S27200284,LOCAL,0272,RC,,,both,,,664.10,199.23,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHELL ACETABULAR 60MM HIP POLY POROUS R3 STD",SUP-71331860,CDM,C1776,HCPCS,0278,RC,,,both,,,14334.75,4300.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5891.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",1667.13,12184.54,"percent of total billed charges",
"CAGE SPINAL 23X9X13MM CONCORDE 5D BULLET NOSE CFRP",SUP-187823413,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1962.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SNARE 120CM 20MM 6FR AMPLATZ GOOSENECK NITINOL CATH",SUP-GN2000,CDM,C1773,HCPCS,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG 10X4IN ADHSV ANTIMICROBIAL BARR PAD POSTOPERATIVE IONIC",SUP-MSC97410,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.65,58.69,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER PACING LEAD ACUITY 11FR",SUP-7445,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TROCAR LAPAROSCOPIC 12MM SPACEMAKER BLUNT TIP BALLOON",SUP-OMS-T12BT,CDM,C1727,HCPCS,0272,RC,,,both,,,1484.97,445.49,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH PASSPORT ENCORE GWIRE LOW PROFILE BALLOON 3FR 12FR",SUP-M0062181200,CDM,C1726,HCPCS,0272,RC,,,both,,,2191.88,657.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE ELECTROSURGICAL STRAIGHT BIPOLAR TAPERED BLUNT POINT",SUP-221266,CDM,S27200284,LOCAL,0272,RC,,,both,,,566.25,169.87,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 240MM 3MM BALLOON DILATATION STERILE LATEX",SUP-583024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PENICILLIN G DESENSITIZATION (0.1 MG/ML)",RX-410811,CDM,,,0636,RC,09999-9997-06,NDC,both,250,ML,100.65,30.19,"MULTIPLAN [10600]",Multiplan,,85.55,85,,,,,0,11.93,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA ARTERIAL BIOLINE L55 CM L20 CM OD25 FR ODSEC3/8 IN V","SUP-BEQ-PVL 2555-USA",CDM,S27200284,LOCAL,0272,RC,,,both,,,3822.60,1146.78,"CIGNA [10200]","Cigna Local Plus",,2045.09,53.5,,,,,0,444.57,3249.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 59MM 135CM 8MM 16SQ MM 8FR .035IN",SUP-BXAL085902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"KAISER [10500]",Kaiser,,13068.22,67,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALLET SURGICAL 10.75IN 1 7/8IN 3LB",SUP-27-0899,CDM,S27200284,LOCAL,0272,RC,,,both,,,539.87,161.96,"MULTIPLAN [10600]",Multiplan,,458.89,85,,,,,0,62.79,458.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 38MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25038W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,392.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR .071IN AMPLATZ LEFT 4 CURVE GUIDING NYLON",SUP-LA6AL40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AORTIC VALVED GRAFT WITH  MAQUETHEMASHIELDWOVEN DOUBLE VELOU","SUP-27CAVGJ-514  00",CDM,C1768,HCPCS,0278,RC,,,both,,,25533.90,7660.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7307.8,28.62,,,,,0,2969.59,21703.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 10X6.8IN MEPITEL ONE NONADHERENT LATEX FREE",SUP-081532332,CDM,S27200284,LOCAL,0272,RC,,,both,,,363.03,108.91,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.22,308.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 75CM 6MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR061001A,CDM,C1874,HCPCS,0278,RC,,,both,,,17545.50,5263.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7018.2,40,,,,,0,2040.54,14913.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FAST-FIX 360D CURVE FIXATION 2 ANCHOR PRETIE SUT",SUP-72202468,CDM,C1713,HCPCS,0278,RC,,,both,,,3300.75,990.22,"CIGNA [10200]","Cigna Local Plus",,1765.9,53.5,,3978.14,359.25,3978.14,24,383.88,2805.64,"percent of total billed charges",
"PLATE SPINAL SACRAL ANTERIOR 3 HOLE/1 HOLE SIDE 27MM VICTORY",SUP-1236.7027,CDM,C1713,HCPCS,0278,RC,,,both,,,29610.00,8883,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11844,40,,,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +9.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.095,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 23IN 36FR ANGLE RIGHT TAPER DRNG PVC THORAX 5 EYELET",SUP-8136,CDM,C1729,HCPCS,0272,RC,,,both,,,90.25,27.07,"PHCS [10601]",PHCS,,63.18,70,,,,,0,10.5,76.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 63MM STAINLESS STEEL 3.5MM SCR 7 HOLE T OBLIQUE RIGHT",SUP-241.941,CDM,C1713,HCPCS,0278,RC,,,both,,,2179.80,653.94,"MULTIPLAN [10600]",Multiplan,,1852.83,85,,,,,0,253.51,1852.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18 DIOPTER HAPTIC C BICONVEX 13MM 6MM 1 PIECE",SUP-PCB0000180,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 22CM 7FR .035IN URETERAL",SUP-M006155241090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"NOVANET [10819]",Novanet,,1022.06,75,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DIVERGENCE-L 15X9.4X6MM ANTERIOR OBLIQUE LUMBAR",SUP-736526,CDM,S27800098,LOCAL,0278,RC,,,both,,,9177.00,2753.1,"NOVANET [10819]",Novanet,,6882.75,75,,,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING UNITRAX V40 +0MM HIP UNIPOLAR",SUP-6942-6-065,CDM,C1776,HCPCS,0278,RC,,,both,,,855.82,256.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,99.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.53,727.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JETSTREAM 1.85MM ATHERECTOMY 1 CUTTER",SUP-112262-001,CDM,C1724,HCPCS,0272,RC,,,both,,,19530.00,5859,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SUT MONOCRYL 3-0 RB-1 27IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y215H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PIN DRILL PATHWAY PACK QUICK",SUP-217842010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1526.85,458.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP PULSED LAVAGE INTERPULSE COAXIAL FAN SPRAY HADNPIECE",SUP-0210014100,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.99,28.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN OPHTHALMIC 4IN 20GA 6MM BD VISITEC 45D LONG BEVEL",SUP-585184,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.59,114.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL PURPLE 11CM LETZ UTAHLOOP LOOP 5X5MM",SUP-DLP-T11,CDM,S27200284,LOCAL,0272,RC,,,both,,,140.07,42.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 7.5MM 40MM COCR SPINAL MULTIAXIAL CANNULATED",SUP-54840017540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]",Cigna,,6491.86,68,,1831.33,1831.33,1831.33,16,1110.3,8114.82,"percent of total billed charges",
"BURR SURGICAL 2MM ROUND CARBIDE EXTEND STERILE LATEX FREE",SUP-5820-110-320C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1910.03,573.01,"CIGNA [10200]","Cigna Local Plus",,1021.87,53.5,,,,,0,222.14,1623.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VLV HMSTS CTHLK",SUP-406298,CDM,C1894,HCPCS,0272,RC,,,both,,,52.20,15.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,21.45,41.1,,,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE HUMERAL SHAFT ALLOGRAFT FROZEN 100X20-25MM",SUP-450572,CDM,S27800098,LOCAL,0278,RC,,,both,,,6069.24,1820.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4127.08,68,,,,,0,705.85,5158.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 350MM 11MM CARBON FIBER MR CONDITIONAL",SUP-394.86,CDM,C1713,HCPCS,0278,RC,,,both,,,1441.80,432.54,"KAISER [10500]",Kaiser,,966.01,67,,,,,0,167.68,1225.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 20MM 144CM 3.5MM CORONARY STENT",SUP-H7493941820350,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 7CM 4FR 1 PIGTAIL CURVE PANCREATIC",SUP-M00537380,CDM,C2625,HCPCS,0278,RC,,,both,,,1411.18,423.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,403.88,28.62,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 82MM 28MM 18FR ENDURANT II ABDOMINAL",SUP-ETEW2828C82E,CDM,S27800098,LOCAL,0278,RC,,,both,,,30315.60,9094.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8185.21,27,,,,,0,3525.7,25768.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM CEMENT ACCOLADE C 132D 5 44MM OFFSET HIP",SUP-6058-0537D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"UHC [10700]","United Healthcare",,10406.05,63.3,,8601.07,8395.67,8601.07,"1 through 10",1911.88,13973.36,"percent of total billed charges",
"COIL EMBOLIZATION 35CM 8MM .01IN DELTAFILL .015IN MICRO 18",SUP-DLF180835,CDM,S27800098,LOCAL,0278,RC,,,both,,,14145.00,4243.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4048.3,28.62,,,,,0,1645.06,12023.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAPIPLASTY MINI INCISION SYSTEM",SUP-SK30,CDM,C1713,HCPCS,0278,RC,,,both,,,35248.50,10574.55,"CIGNA [10200]","Cigna Local Plus",,11103.28,31.5,,3978.14,359.25,3978.14,24,4099.4,29961.23,"percent of total billed charges",
"CMPNT GLENOID 45MM TRUNION ARTHREX ECLIPSE SHOULDER",SUP-AR-9301-45CPC,CDM,C1776,HCPCS,0278,RC,,,both,,,9239.10,2771.73,"BLUE CROSS [10001]","Blue Cross PPO",,3621.73,39.2,,3949.44,3949.44,3949.44,"1 through 10",1074.51,7853.24,"percent of total billed charges",
"PATCH VASCULAR 16X10CM XENOSURE BOVINE PERICARDIUM STERILE",SUP-E10P16,CDM,C1768,HCPCS,0278,RC,,,both,,,6065.10,1819.53,"BLUE CROSS [10001]","Blue Cross PPO",,2377.52,39.2,,,,,0,705.37,5155.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL CAP EXTRA EXTREMITY 417",SUP-98000900249,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"CIGNA [10200]","Cigna Local Plus",,8434.13,31.5,,5372.07,4581.20,7242.98,23,3113.93,22758.75,"percent of total billed charges",
"METHOHEXITAL SODIUM 0.5 G/15ML IV (WET SOLR VIAL)",RX-41570545,CDM,,,0250,RC,42023-0105-01,NDC,both,1,UN,698.41,209.52,"CIGNA [10200]","Cigna Open Access",,397.4,56.9,,,,,0,81.23,593.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 40MM 4FR 4MM ROUND LOW PROFILE TAPER",SUP-A2040-040,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 360 145CM 30MM .079IN 2MM ATHERECTOMY",SUP-DBP-EX-200SOL145,CDM,C1724,HCPCS,0272,RC,,,both,,,23278.50,6983.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2758.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2707.29,19786.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URETEROSCOPE FLEXIBLE LITHOVUE ELITE INTRARENAL DIGITAL",SUP-M0067940000,CDM,C1747,HCPCS,0272,RC,,,both,,,16560.00,4968,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11260.8,68,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 10 SLOT RIGHT TI",SUP-PHPF-S10R,CDM,C1713,HCPCS,0278,RC,,,both,,,18900.00,5670,"PHCS [10601]",PHCS,,13230,70,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM ALLOGRAFT STRIP 45X22MM",SUP-T00245,CDM,S27800098,LOCAL,0278,RC,,,both,,,10833.69,3250.11,"MULTIPLAN [10600]",Multiplan,,9208.64,85,,,,,0,1259.96,9208.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CANNULATION PACK V-1523",SUP-V1523,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.85,70.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT GASTRO 20FR INTRO ANCHOR HEMOSTAT SCPL DIL MIC-KEY",SUP-10240,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.93,543.58,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET HOUSING POS",SUP-AR-1204AF-70,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IMPL INJECTABLE 9CM 20GA CONTIGEN PERIURETHRAL BOVINE CLLGN",SUP-652100,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TOTAL ABSCESSION BLUE SILK 40CM 10FR PIGTAIL CURVE DRNG",SUP-H787140009025,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ZENITH ALPHA THORACIC ENDOVASCULAR GRAFT PROXIMAL COMPONENTS",SUP-G35339,CDM,C1874,HCPCS,0278,RC,,,both,,,96672.00,29001.6,"UHC [10700]","United Healthcare",,61193.38,63.3,,,,,0,11242.95,82171.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTALINK 135CM 2MM ATHERECTOMY BURR EXCHANGE",SUP-H749393002000,CDM,C1724,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11781,68,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 14MM TIGER CANNULATED",SUP-200-24-014,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"CIGNA [10200]","Cigna Local Plus",,606.69,53.5,,3978.14,359.25,3978.14,24,131.88,963.9,"percent of total billed charges",
"PATCH CARDIOVASCULAR THK.6MM RECTANGULAR REGULAR WALL 75X50",SUP-50P7506,CDM,C1768,HCPCS,0278,RC,,,both,,,2172.98,651.89,"CIGNA [10200]",Cigna,,1477.63,68,,,,,0,252.72,1847.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 45CM 6.9FR ATRIUM RIGHT VENTRICLE TRANSVENOUS",SUP-5086MRI45,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CIGNA [10200]","Cigna Local Plus",,1194.39,53.5,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 97MM 18MM ESOPHAGEAL PARTIAL COVER STERILE LATEX",SUP-M00517250,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 7MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640807,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX 20MM 135CM 9MM VASCULAR NITINOL CAROTID",SUP-PC0920RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,9418.50,2825.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1116.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1095.37,8005.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 36MM 24 BASEPLT TAPER",SUP-AR-9564-2436,CDM,C1776,HCPCS,0278,RC,,,both,,,9763.50,2929.05,"BLUE CROSS [10001]","Blue Cross PPO",,3827.29,39.2,,3949.44,3949.44,3949.44,"1 through 10",1135.5,8298.98,"percent of total billed charges",
"CANN ARTHROSCOPIC PUSHLOCK LOW PROFILE SHOULDER OBTR THREAD",SUP-AR-6548,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"CIGNA [10200]","Cigna Open Access",,129.95,56.9,,,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 7CM MR8 4MM BALL DISSECTING CARBIDE",SUP-MR8-7BA40C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1089.86,326.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SUPIRA CATHETER",SUP-FG-03242,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"APPLR ENDOSCOPIC TROCAR NONREFLECTIVE CANN OBTR LATEX FREE",SUP-934055,CDM,S27200284,LOCAL,0272,RC,,,both,,,2242.35,672.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SUPERTORQUE THRULUMEN 100CM 6FR .051IN .042IN SMALL",SUP-532618,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BTTRY SURGICAL DRIVER PACK STERILE DISPOSABLE BTTRY POWERED",SUP-05.000.007.01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3829.50,1148.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT CONTOUR 28CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061802440,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"KAISER [10500]",Kaiser,,604.46,67,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM SEMIRIGID OPEN ANTERIOR SEG SEWING",SUP-5300M32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"UHC [10700]","United Healthcare",,8735.4,63.3,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL DARK BLUE 15MM SYNFIX 18D MEDIUM EVOLUTION 6.9",SUP-08.815.264S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPHEDRINE SULFATE 50 MG/ML INJECTION SOLUTION SUPERORDERABLE",RX-408679,CDM,,,0250,RC,42023-0216-01,NDC,both,1,ML,226.52,67.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.34,192.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL WEIL-BLAKESLEY 45D UP 2 5MM 7.5IN NASAL",SUP-66-2813,CDM,S27200284,LOCAL,0272,RC,,,both,,,1913.63,574.09,"MULTIPLAN [10600]",Multiplan,,1626.59,85,,,,,0,222.56,1626.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC",086,MS-DRG,,,,,,,inpatient,,,43405.93,13021.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25859.9,,"Fee schedule rate ($25,859.90). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,32488.04,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 28.5",SUP-DIB00U0285,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,523.91,39.2,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EVOLUT FX DELIVERY 34 MM",SUP-D-EVOLUTFX-34,CDM,S27200284,LOCAL,0272,RC,,,both,,,14559.00,4367.7,"PHCS [10601]",PHCS,,10191.3,70,,,,,0,1693.21,12375.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 120CM 6MM 8FR STRAIGHT VASCULAR",SUP-AVSL06100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross PPO",,7161.84,39.2,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 95MM 1.6MM CANNULATED QUICK COUPLING",SUP-03.333.100,CDM,S27000186,LOCAL,0270,RC,,,both,,,2684.10,805.23,"KAISER [10500]",Kaiser,,1798.35,67,,,,,0,312.16,2281.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE EZDILATE 15 ATM INFLATION 60CC BALLOON SYR LOCK",SUP-MAJ-1740,CDM,S27000186,LOCAL,0270,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSTR BIOPSY GREEN 10CM 16GA BIOPINCE ULTRA FULL CORE",SUP-370-1080-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"KAISER [10500]",Kaiser,,273.96,67,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION 14MM TIGHTROPE ROUND ACL ATTACHABLE",SUP-AR-1588TB-1,CDM,C1713,HCPCS,0278,RC,,,both,,,1685.25,505.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,199.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,195.99,1432.46,"percent of total billed charges",
"TRAY CATHETERIZATION SURESTEP ADD-A-FOLEY COMPLETE CARE",SUP-A304400A,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.19,33.96,"AETNA [10100]","Aetna HMO/PPO",,89.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.16,96.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 64MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.554S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"PHCS [10601]",PHCS,,1047.82,70,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM ORTHOLOC 3DI LOW PROFILE FOOT ANKLE",SUP-58812718,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,98.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",98.91,722.93,"percent of total billed charges",
"KIT DECOMPRESSION 350CM 7FR MARCON COLONIC SET 5 DRNG",SUP-G21938,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"FIRST HEALTH [10303]","First Health",,1263.6,80,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CESAREAN SECTION WITH STERILIZATION WITH CC",784,MS-DRG,,,,,,,inpatient,,,44261.10,13278.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15694,,,,,,,5464,15694,"case rate",
"DIL VASCULAR 5FR 17.8CM RADIALEASE LATEX FREE VESSEL ACCEPTS",SUP-504505X,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.26,26.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,40.05,45.9,,,,,0,10.15,74.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 340MM 4.2MM T2 AO STERILE",SUP-18064260S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1231.52,369.46,"UHC [10700]","United Healthcare",,779.55,63.3,,,,,0,143.23,1046.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 24FR STD URETHRAL NATURAL RUBBER",SUP-0119L24,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.52,23.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,35.58,45.9,,,,,0,9.02,65.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE 3 WAY STPCOCK 1",SUP-K11-00202,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.22,27.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.73,78.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR EMPHASYS 180D 3MM 64-66MM 52MM METAL HIP 2",SUP-472564052,CDM,C1776,HCPCS,0278,RC,,,both,,,16853.25,5055.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1997.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1960.03,14325.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 6FR 135CM POWERPICC 3 LUMEN PICC GWIRE",SUP-3386135,CDM,C1751,HCPCS,0272,RC,,,both,,,1067.58,320.27,"AETNA [10100]","Aetna HMO/PPO",,848.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.16,907.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 40MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR40,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3752.08,28.62,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT",RX-164210,CDM,,,0250,RC,45802-0188-16,NDC,both,57,GR,31.55,9.46,"KAISER [10500]",Kaiser,,21.14,67,,,,,0,3.67,26.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.165,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,316.02,45.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 4.4MM 18MM TITANIUM T25 FULL THREAD SELF TAP",SUP-412.203,CDM,C1713,HCPCS,0278,RC,,,both,,,959.36,287.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.36,68,,,,,0,111.57,815.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 100CM 15CM 4FR .041IN ANGLE",SUP-CG416,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE NDL 3 ANGLE INSRT LATEX FREE STERILE 10-20GA",SUP-UA1336,CDM,S27200284,LOCAL,0272,RC,,,both,,,263.61,79.08,"NOVANET [10819]",Novanet,,197.71,75,,,,,0,30.66,224.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET NDL 15MM 15GA EZ-IO STAINLESS STEEL 5GM STERILE LATEX",SUP-9018-VC-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1106.46,331.94,"MULTIPLAN [10600]",Multiplan,,940.49,85,,,,,0,128.68,940.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFDINIR 300 MG CAPSULE",RX-22289,CDM,,,0637,RC,60687-0699-11,NDC,both,1,UN,20.37,6.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8.37,41.1,,,,,0,2.37,17.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 16MM SECUR-FIT PLUS 12 HIP STERILE",SUP-6054-1216S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"NOVANET [10819]",Novanet,,12124.08,75,,,,,0,1880.04,13740.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BREAST BIOPSY 145MM 11GA MAMMOTOME UNIVERSAL MR TARGET",SUP-MRU11X,CDM,S27200284,LOCAL,0272,RC,,,both,,,1866.08,559.82,"PHCS [10601]",PHCS,,1306.26,70,,,,,0,217.03,1586.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 22CM 6FR URETERAL AQ FIRM POS NO GWIRE",SUP-G23404,CDM,C2617,HCPCS,0278,RC,,,both,,,535.41,160.62,"NOVANET [10819]",Novanet,,401.56,75,,,,,0,62.27,455.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 5FR CHECK-FLO PERFORMER ACCEPTS .035IN GWIRE",SUP-G57796,CDM,C1894,HCPCS,0272,RC,,,both,,,170.69,51.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.85,145.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X11MM VERTE-STACK CORNERSTONE PSR",SUP-6240141,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"PHCS [10601]",PHCS,,4674.89,70,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS CARDIOBAND FIT GUIDE SHEATH",SUP-25200GS,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BRACHYTHERAPY 20CM 18GA MICK APPLR ULTRA SHARP TIP",SUP-918205,CDM,C1715,HCPCS,0272,RC,,,both,,,80.13,24.04,"PHCS [10601]",PHCS,,56.09,70,,,,,0,9.32,68.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX10MM 10MM CAPSTONE PEEK INTERBODY",SUP-2991022,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"AETNA [10100]","Aetna HMO/PPO",,16874.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 PS-2 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J428H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL 33.5CM 1.98MM (14G) RADIOFREQUENCY","SUP-FG 0060",CDM,S27200284,LOCAL,0272,RC,,,both,,,12420.00,3726,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1471.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 240MM 4MM 110D PREBENT TITANIUM",SUP-04.615.632,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"STENT CONTOUR 20CM 6FR .038IN STRAIGHT URETERAL PERCUFLEX",SUP-M006180220010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"PHCS [10601]",PHCS,,749.52,70,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 9 SLOT LEFT TI",SUP-PHPF-S9L,CDM,C1713,HCPCS,0278,RC,,,both,,,18396.00,5518.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4966.92,27,,,,,0,2139.45,15636.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 60CM HEMOSTASIS GWIRE SWARTZ .032IN SL1",SUP-406849,CDM,C1893,HCPCS,0272,RC,,,both,,,1178.55,353.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,484.38,41.1,,,,,0,137.07,1001.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 2.5MM CORONARY STENT",SUP-1125250-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PHCS [10601]",PHCS,,4086.6,70,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CXI 150CM 2.6FR ANGLE SPRT ACCEPTS .018IN GWIRE",SUP-G56553,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 15MM 21MM BIOCOR FLEXFIT LOW PROFILE SUPRA",SUP-BSP100-21,CDM,S27800098,LOCAL,0278,RC,,,both,,,32715.90,9814.77,"MULTIPLAN [10600]",Multiplan,,27808.52,85,,,,,0,3804.86,27808.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 140MM 16-14MM 14MM 11FR TRIVASCULAR OVATION",SUP-TV-IL1416140-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13356,40,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP FLEXV 45MM CLSR 1 HAND SMALL FOOTPRINT SUT",SUP-ACHV45,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3554.6,28.62,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +12 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200120,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,118.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 3CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175285010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,126.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM PFC SIGMA TC3 2.5 KNEE POSTERIOR TITANIUM",SUP-960846,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,596.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NUROLON 1 CT-1 30IN BRAID BLACK NONABSORBABLE",SUP-5425H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,inpatient,,,32839.80,9851.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,11155.83,,,,,,,4340.29,17449.82,"case rate",
"BASKET SPECIMEN RETRIEVAL 120CM 12MM .8MM AIRWAY ZERO TIP",SUP-M00513200,CDM,S27200284,LOCAL,0272,RC,,,both,,,1932.90,579.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1314.37,68,,,,,0,224.8,1642.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Uc Acid Stph Aureus Amplified",PX-306000219,CDM,87641,CPT,0306,RC,,,both,,,416.00,124.8,"KAISER [10500]",Kaiser,,278.72,67,,,,,0,0.01,353.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Sld Level II / Add on 88302",PX-312000088,CDM,0751T,CPT,0312,RC,,,both,,,100.00,30,"KAISER [10500]",Kaiser,,67,67,,,,,0,11.85,85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sodium Body Fluid",PX-301000525,CDM,84302,CPT,0301,RC,,,both,,,266.95,80.08,"BLUE CROSS [10001]","Blue Cross PPO",,6.21,,"Fee schedule rate ($6.21).",,,,0,0.01,226.91,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sodium Body Fluid",PX-301000525,CDM,84302,CPT,0301,RC,,,both,,,266.95,80.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7.64,,,,,,,0.01,226.91,"fee schedule",
"TRAY TIBIAL 76X51MM PFC SIGMA 4 KNEE CEMENT MODULAR PLUS FIX",SUP-860124,CDM,C1776,HCPCS,0278,RC,,,both,,,16046.64,4813.99,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6418.66,40,,,,,0,1866.22,13639.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 1.75IN 2.1MM CARBIDE 6 FLUTED CROSS CUT",SUP-0277010221,CDM,S27000186,LOCAL,0270,RC,,,both,,,54.98,16.49,"PHCS [10601]",PHCS,,38.49,70,,,,,0,6.39,46.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 28CM 4.8FR URETERAL",SUP-M0061456090,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"CIGNA [10200]","Cigna Local Plus",,334.5,,,,,,,72.72,531.45,"percent of total billed charges",
"SCREW SPINAL 5.5X40MM MIDLINE SYSTEM POLYAXIAL CORTICAL 4S R",SUP-14615540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT THR PREP-IM HIP PLUG BRUSH SPONGE SUCTION LATEX FREE",SUP-121010,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 90CM 8FR FR4 CURVE GUIDING PTFE FEMORAL",SUP-H749343583720,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"FIRST HEALTH [10303]","First Health",,293.15,80,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Galectin-3",PX-301000630,CDM,82777,CPT,0301,RC,,,both,,,165.00,49.5,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,140.25,"per diem",
"KIT INSTR BIOABSORBABLE BIO-TENODESIS DISPOSABLE STERILE",SUP-AR-1676DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,910.00,273,"AETNA [10100]","Aetna HMO/PPO",,723.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.83,773.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 16MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G416,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"NOVANET [10819]",Novanet,,7024.56,75,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 862512 BICRT BLK 12X25 SRVC FEE",SUP-862512,CDM,S27800098,LOCAL,0278,RC,,,both,,,9785.58,2935.67,"NOVANET [10819]",Novanet,,7339.19,75,,,,,0,1138.06,8317.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Capsule Bravo",PX-E27200247,CDM,9999114,LOCAL,0272,RC,,,both,,,2234.10,670.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1025.45,45.9,,,,,0,259.83,1898.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 30CM 3CM 7FR .038IN BLADDER LOOP STRAIGHT LOW",SUP-M006155245010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,352.3,28.62,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING SCR IN ELECTRD ACTIVE FIXATION BIPOLAR IS 1 CNCT",SUP-1688TC/58,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"KAISER [10500]",Kaiser,,1495.78,67,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBERFUSE DEMINERALIZED BONE MATRIX 1CC ALLOGRAFT",SUP-420601,CDM,C1713,HCPCS,0278,RC,,,both,,,2174.25,652.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,622.27,28.62,,,,,0,252.87,1848.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 9 STD 27MM PROVOX LIFE LARYTUBE SOFT SILICONE",SUP-7412,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"UHC [10700]","United Healthcare",,756.38,63.3,,,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL TWIST 1.9MM SMALL",SUP-72203856,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.18,543.35,"PHCS [10601]",PHCS,,1267.83,70,,,,,0,210.64,1539.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OPTIFLOW JUNIOR 2 VENTILATOR TRANSITION KIT - S",SUP-OJR412VT,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 50MM 1800MM 10MM 2.33MM BILIARY NITINOL",SUP-SHS-10-050-180,CDM,C1876,HCPCS,0278,RC,,,both,,,6855.84,2056.75,"BLUE CROSS [10001]","Blue Cross HMO",,2687.49,39.2,,,,,0,797.33,5827.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM KNEE 100MM 14MM GENESIS II LONG TITANIUM",SUP-71420632,CDM,C1776,HCPCS,0278,RC,,,both,,,11540.25,3462.07,"UHC [10700]","United Healthcare",,7304.98,63.3,,8601.07,8395.67,8601.07,"1 through 10",1342.13,9809.21,"percent of total billed charges",
"BEARING 71/75MMX16MM ASCENT ARCOM KNEE PRIMARY DIRECT",SUP-179373,CDM,C1776,HCPCS,0278,RC,,,both,,,9057.91,2717.37,"UHC [10700]","United Healthcare",,5733.66,63.3,,8601.07,8395.67,8601.07,"1 through 10",1053.43,7699.22,"percent of total billed charges",
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 24IN 6FR SUCTION",SUP-8888256545,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.16,19.85,"KAISER [10500]",Kaiser,,44.33,67,,,,,0,7.69,56.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 39MM STAINLESS STEEL MINI FRAGMENT 4 HOLE .25 TUBULAR",SUP-242.05,CDM,C1713,HCPCS,0278,RC,,,both,,,1077.30,323.19,"CIGNA [10200]",Cigna,,732.56,68,,1831.33,1831.33,1831.33,16,125.29,915.71,"percent of total billed charges",
"BUTTON 2.7CM 20FR RADIOPAQUE LOW PROFILE PROXIMAL ANTIREFLUX",SUP-0120-20-2.7,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,529.76,68,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9% SOLUTION",SUP-798353,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.68,14.3,"PHCS [10601]",PHCS,,33.38,70,,,,,0,5.55,40.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 10.5FR .138IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLSX-1010.5,CDM,C1892,HCPCS,0272,RC,,,both,,,304.50,91.35,"KAISER [10500]",Kaiser,,204.02,67,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 28MM 140CM 2.75MM CORONARY STENT PLATINUM",SUP-H7493927428270,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,1470,39.2,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3.5MM CEREPAK MICRO UNIFORM DETACHABLE",SUP-FCX100356,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA [10200]","Cigna Open Access",,4430.66,33.5,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 48MM 28MM 10D HIP CROSSFIRE OMNIFIT STERILE",SUP-2041C-2848,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,834,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,818.52,5982.3,"percent of total billed charges",
"STEM HUMERAL 98MM AEQUALIS ASCEND FLEX PTC 132.5D 3B LONG",SUP-DWF613B,CDM,C1776,HCPCS,0278,RC,,,both,,,12877.00,3863.1,"CIGNA [10200]","Cigna Local Plus",,4056.26,31.5,,5372.07,4581.20,7242.98,23,1497.6,10945.45,"percent of total billed charges",
"TUBE TRACH 7.5MM PORTEX BLUSELECT UNCUFF STERILE LATEX FREE",SUP-101/816/075,CDM,S27200284,LOCAL,0272,RC,,,both,,,311.63,93.49,"NOVANET [10819]",Novanet,,233.72,75,,,,,0,36.24,264.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP LARGE ENTRAINMENT ELBOW LEAK 2 DENSITY FOREHEAD",SUP-73-1018594,CDM,S27000186,LOCAL,0270,RC,,,both,,,212.50,63.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.71,180.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 56MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.456,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3292.97,68,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR OSSEOTI XLPE CUP 2 MOBILITY AA LINER",SUP-98B00102506,CDM,C1776,HCPCS,0278,RC,,,both,,,21420.00,6426,"CIGNA [10200]","Cigna Local Plus",,6747.3,31.5,,5372.07,4581.20,7242.98,23,2491.15,18207,"percent of total billed charges",
"INTRO SHEATH 6FR 23CM NO MINI GWIRE NO OBTR HEXCUSPID VALVE",SUP-504606T,CDM,C1894,HCPCS,0272,RC,,,both,,,200.54,60.16,"FIRST HEALTH [10303]","First Health",,160.43,80,,,,,0,23.32,170.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 5MM LONG CANNULATED LARGE QUICK COUPLING STERILE",SUP-03.333.112S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3257.10,977.13,"KAISER [10500]",Kaiser,,2182.26,67,,,,,0,378.8,2768.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM 2.6-2FR .019IN EXCELSIOR",SUP-M0031441810,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"CIGNA [10200]","Cigna Local Plus",,4129.79,53.5,,,,,0,897.75,6561.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 12MM 10MM LAPIPLASTY TITANIUM METATARSAL SNAP",SUP-SK21,CDM,C1713,HCPCS,0278,RC,,,both,,,3727.50,1118.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1710.92,45.9,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 120MM 3MM BALLOON DILATATION RAPID",SUP-47530120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PHCS [10601]",PHCS,,1116.99,70,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM PRESTIGE PLUS HELICAL HELICAL",SUP-PRES0930HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"KAISER [10500]",Kaiser,,4391.85,67,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON ETHILON 3-0 PS-2 18IN MONOFILAMENT BLACK",SUP-1669H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT WALLFLEX 60MM 48MM 10MM",SUP-7473,CDM,C1894,HCPCS,0272,RC,,,both,,,261.00,78.3,"NOVANET [10819]",Novanet,,195.75,75,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 5FR 70CM RADPICC 1 LUMEN GWIRE MICROINTRODUCER",SUP-3165155,CDM,C1751,HCPCS,0272,RC,,,both,,,399.33,119.8,"KAISER [10500]",Kaiser,,267.55,67,,,,,0,46.44,339.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.433,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,635.32,45.9,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2 CP 27IN BRAID ANTIBACTERIAL COATED UNDYED",SUP-VCP195H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.48,45.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 9.5MM S-ROM ZTT 24F SMALL HIP PROXIMAL",SUP-550747,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1289.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1265.9,9252.04,"percent of total billed charges",
"KIT REPAIR SUBSCAPULARIS SMALL",SUP-110046602,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 6FR POWERPICC SHERLOCK 3 LUMEN MAXIMAL BARR",SUP-9386108D,CDM,C1752,HCPCS,0272,RC,,,both,,,1553.74,466.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,638.59,41.1,,,,,0,180.7,1320.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 7.5CM 3MM LEGEND BALL TOOL LATEX FREE",SUP-75BA30T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1326.78,398.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,545.31,41.1,,,,,0,154.3,1127.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 2.5MM CEREPAK FREEFORM DETACHABLE",SUP-SCR122505,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1567.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Hip Uni W Pelvis 4v>",PX-320000205,CDM,73503,CPT,0320,RC,,,both,,,582.64,174.79,"PHCS [10601]",PHCS,,407.85,70,,,,,0,67.76,495.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL KNEE 1 -  STANDARD",SUP-CAP-DJO-K-1,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7250.04,41.1,,6417.48,6417.48,6417.48,"1 through 10",2051.53,14994,"percent of total billed charges",
"HOOK SPINAL 6MM LAMINA",SUP-7756074,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,1831.33,1831.33,1831.33,16,348.9,2550,"percent of total billed charges",
"FILTER VASCULAR 12FR VENA CAVA GREENFIELD FEMORAL SYSTEM",SUP-M001505010,CDM,C1880,HCPCS,0278,RC,,,both,,,4195.00,1258.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,497.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,487.88,3565.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 14MM NESTER MICROCOIL PLATINUM .035IN",SUP-G47347,CDM,S27800098,LOCAL,0278,RC,,,both,,,1020.52,306.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,468.42,45.9,,,,,0,118.69,867.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 7-9+ C-D KNEE RIGHT CONDYLAR",SUP-42-5228-005-10,CDM,C1776,HCPCS,0278,RC,,,both,,,16308.84,4892.65,"CIGNA [10200]","Cigna Local Plus",,5137.28,31.5,,5372.07,4581.20,7242.98,23,1896.72,13862.51,"percent of total billed charges",
"DOME PATELLAR 35MM ATTUNE KNEE AOX CEMENTED MEDIALIZE",SUP-151820035,CDM,C1776,HCPCS,0278,RC,,,both,,,5409.60,1622.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,641.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.14,4598.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR ITOTAL IDENTITY IPOLY XE POSTERIOR STABILIZE FULL",SUP-ITPS-XE,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"BLUE CROSS [10001]","Blue Cross PPO",,10495.8,39.2,,3949.44,3949.44,3949.44,"1 through 10",3113.93,22758.75,"percent of total billed charges",
"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC",314,MS-DRG,,,,,,,inpatient,,,53260.64,15978.19,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,13516.69,,"Case rate ($12,934.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,010.67, add-ons for qualifying new technology services are included. If operating cost exceeds $45,050.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,290.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,026.56. The transfer operating threshold is the transfer adjustment factor * $12,010.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $908.07. The transfer capital threshold is the transfer adjustment factor * $908.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",8556.89,8556.89,8556.89,"1 through 10",8593,52002.8,other,"IP DRG"
"CAGE SPINAL 50X22X8MM MODULUS 10D XL WIDE STERILE LATEX FREE",SUP-1221850P2,CDM,C1889,HCPCS,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross HMO",,11113.2,39.2,,8555.87,8555.87,8996.26,"1 through 10",3297.11,24097.5,"percent of total billed charges",
"MINOR BLADDER PROCEDURES WITH CC",663,MS-DRG,,,,,,,inpatient,,,75418.74,22625.62,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,19201.14,,"Case rate ($9,429.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,756.29, add-ons for qualifying new technology services are included. If operating cost exceeds $41,795.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,044.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,767.87. The transfer operating threshold is the transfer adjustment factor * $8,756.29 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $662.02. The transfer capital threshold is the transfer adjustment factor * $662.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,9429.89,44383.76,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM 1.1MM LATERAL WALL GORILLA BONE CALCANEUS LEFT",SUP-P53-102-L002,CDM,C1713,HCPCS,0278,RC,,,both,,,8254.13,2476.24,"NOVANET [10819]",Novanet,,6190.6,75,,,,,0,959.96,7016.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 50MM TSRH OSTEOGRIP TITANIUM SPINE NONSTERILE",SUP-83585509,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1750.32,68,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 PS-2 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J497H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18.5 DIOPTER +4 CYL HAPTIC C BICONVEX 13MM 6MM",SUP-ZMB00U0185,CDM,V2632,HCPCS,0276,RC,,,both,,,6175.50,1852.65,"PHCS [10601]",PHCS,,4322.85,70,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LISINOPRIL 2.5 MG TABLET",RX-13089,CDM,,,0637,RC,60687-0656-11,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH XXL 120CM 40MM 5.8FR 14MM 7FR BALLOON DILATATION",SUP-M001145150,CDM,C1725,HCPCS,0272,RC,,,both,,,1709.63,512.89,"MULTIPLAN [10600]",Multiplan,,1453.19,85,,,,,0,198.83,1453.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS",RX-120089,CDM,,,0250,RC,50289-3250-01,NDC,both,1,UN,12.54,3.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5.76,45.9,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 45MM SURGICAL",SUP-G-4555,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]",Cigna,,153.82,68,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DEMINERALIZED BONE MATRIX CANCELLOUS ALLOGRAFT",SUP-7777005,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"NOVANET [10819]",Novanet,,3234.38,75,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL RESTORELLE Y CONTOUR MERIDIAN VPS POLYPROPYLEN",SUP-52081,CDM,C1781,HCPCS,0278,RC,,,both,,,10984.80,3295.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1301.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1277.53,9337.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 4.75MM CD HORIZON COCRMO CAP",SUP-641003045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG ANTIREFLUX TUBING TWIST TYPE VALVE FULLY ADJUSTABLE",SUP-DBAG600H,CDM,S27000186,LOCAL,0270,RC,,,both,,,108.58,32.57,"CIGNA [10200]",Cigna,,73.83,68,,,,,0,12.63,92.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 28CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061802440,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,258.2,28.62,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 85MM ATLANTIS VISION ELITE BONE SPINE",SUP-7200185,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG ANTIREFLUX TUBING TWIST TYPE VALVE FULLY ADJUSTABLE",SUP-DBAG600H,CDM,S27000186,LOCAL,0270,RC,,,both,,,108.58,32.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,49.84,45.9,,,,,0,12.63,92.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 48MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.448TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,239.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,235.11,1718.32,"percent of total billed charges",
"RING ANNULOPLASTY 32MM SEMIRIGID OPEN ANTERIOR SEG SEWING",SUP-5300M32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5671.8,41.1,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 15MM 5MM OVAL",SUP-AR-300-B103,CDM,S27200284,LOCAL,0272,RC,,,both,,,2625.00,787.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1078.88,41.1,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION FIBULINK STAINLESS STEEL",SUP-FGS-1000,CDM,C1713,HCPCS,0278,RC,,,both,,,8125.44,2437.63,"PHCS [10601]",PHCS,,5687.81,70,,,,,0,944.99,6906.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 80CM 4FR RDC1 CURVE ANGIOGRAPHIC NYLON NEON SLX",SUP-451446S0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"FIRST HEALTH [10303]","First Health",,83.52,80,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR STD 31MM 3 PEG KNEE SERIES A",SUP-184764,CDM,C1776,HCPCS,0278,RC,,,both,,,4824.48,1447.34,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3280.65,68,,,,,0,561.09,4100.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER YELLOW 180MM 4.5MM DYONICS LONG STRAIGHT LONG",SUP-7205341,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,67.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 12MM 3.25MM BALLOON DILATATION STERILE",SUP-232-123-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 4.5MM ENDOBUTTON CL CANNULATED ENDOSCOPIC",SUP-7207315,CDM,S27000186,LOCAL,0270,RC,,,both,,,955.23,286.57,"NOVANET [10819]",Novanet,,716.42,75,,,,,0,111.09,811.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN HCL 750 MG/15ML IV (WET SOLR VIAL)",RX-41597371,CDM,J3373,HCPCS,0636,RC,00409-6531-11,NDC,both,1,UN,60.53,18.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6.41,,,,,,,2.62,51.45,"fee schedule",
"CMPNT PATELLAR HIGH DOME 9MM 28MM ADVANCE ALL POLY KNEE",SUP-KPRC28HI,CDM,C1776,HCPCS,0278,RC,,,both,,,3322.50,996.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,950.9,28.62,,,,,0,386.41,2824.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM NEXGEN LPS-FLEX 3-4 E-F KNEE PROLONG",SUP-596203210,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"CIGNA [10200]","Cigna Open Access",,4505.59,56.9,,5302.19,4377.88,6578.61,27,920.91,6730.67,"percent of total billed charges",
"KIT RETRIEVER 25MM 6MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0032PK62510001,CDM,S27200284,LOCAL,0272,RC,,,both,,,29495.34,8848.6,"KAISER [10500]",Kaiser,,19761.88,67,,,,,0,3430.31,25071.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PROFILE SOFTTOUCH SMOOTH",SUP-SSL-125,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2162.38,28.62,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 60MM ARCOS STD OFFSET C HIP FEMUR PROXIMAL",SUP-11-301303,CDM,C1776,HCPCS,0278,RC,,,both,,,39453.12,11835.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10652.34,27,,,,,0,4588.4,33535.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.7MM 40MM 18MM LOW PROFILE SCREWS TITANIUM 3.5MM",SUP-AR-8967-1840,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"KAISER [10500]",Kaiser,,1256.25,67,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE MONORAIL 150CM 100MM 3MM BALLOON DILATATION",SUP-H74939185301010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,881.28,68,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 3MM X 8CM",SUP-M0035473080,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"AETNA [10100]","Aetna HMO/PPO",,11221.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERCI 80CM 8FR GUIDING SILICONE BALLOON STERILE LATEX",SUP-90076,CDM,C1725,HCPCS,0272,RC,,,both,,,9696.36,2908.91,"AETNA [10100]","Aetna HMO/PPO",,7708.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1127.69,8241.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Disco Cerv/Thorac Ea",PX-510000107,CDM,62291,CPT,0761,RC,,,both,,,1524.00,457.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,177.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.52,1524,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 CTX 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J363H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 10MM 2.75MM BALLOON DILATATION STERILE",SUP-227-103-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 76MM 10.8MM 15MM 6.4MM CUFFLESS REUSABLE INNER CANN",SUP-6CFN,CDM,S27200284,LOCAL,0272,RC,,,both,,,312.85,93.85,"FIRST HEALTH [10303]","First Health",,250.28,80,,,,,0,36.38,265.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 46MM TITANIUM T25 SELF TAP LOCK STARDRIVE",SUP-412.217S,CDM,C1713,HCPCS,0278,RC,,,both,,,1220.18,366.05,"NOVANET [10819]",Novanet,,915.14,75,,,,,0,141.91,1037.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE VASCULAR ANGLE TAPER 260CM 1CM .035IN NITINOL",SUP-GR3517,CDM,C1769,HCPCS,0272,RC,,,both,,,408.90,122.67,"UHC [10700]","United Healthcare",,258.83,63.3,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 2.5MM 440MM DIAPHYSIS METAPHYSIS EPIPHYSIS",SUP-475.925,CDM,C1713,HCPCS,0278,RC,,,both,,,1753.50,526.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,501.85,28.62,,,,,0,203.93,1490.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALPRAZOLAM 1 MG TABLET SUPERORDERABLE, IMMEDIATE RELEASE",RX-411296,CDM,,,0637,RC,49884-0213-52,NDC,both,1,UN,19.07,5.72,"AETNA [10100]","Aetna HMO/PPO",,15.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.22,16.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 10D X3 TRIDENT",SUP-623-10-36H,CDM,C1776,HCPCS,0278,RC,,,both,,,6879.60,2063.88,"AETNA [10100]","Aetna HMO/PPO",,5469.28,79.5,,10981.53,8986.79,12413.38,12,800.1,5847.66,"percent of total billed charges",
"COIL EMBOLIZATION 177CM 3MM EMBOLD PLATINUM TUNGSTUN NITINOL",SUP-M001394240030120,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"FIRST HEALTH [10303]","First Health",,5453.76,80,,,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL BIOVER LARGE 3MM 1 NONSLIP OCCLUSION LOW","SUP-GEM TKLV-1",CDM,S27200284,LOCAL,0272,RC,,,both,,,361.05,108.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,42.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.99,306.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 114MM CEMENT SUMMIT 4 12/14 STD OFFSET TAPER",SUP-157003100,CDM,C1776,HCPCS,0278,RC,,,both,,,18219.60,5465.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2159.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2118.94,15486.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE",RX-116491,CDM,,,0250,RC,76329-3302-01,NDC,both,50,ML,183.47,55.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.34,155.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY 115CM 1.8MM PRECISOR BRONCHO OVAL CUP PULMONARY",SUP-100506,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.70,80.91,"FIRST HEALTH [10303]","First Health",,215.76,80,,,,,0,31.37,229.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LISINOPRIL 10 MG TABLET",RX-10449,CDM,,,0637,RC,60687-0325-11,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 20MM 4.5FR SEGURA HEMISPHERE",SUP-M0063801190,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,608.1,41.1,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 50X76X.6MM TITANIUM POLYETHYLENE NONPOROUS MESH EMBED",SUP-81025,CDM,C1713,HCPCS,0278,RC,,,both,,,10082.14,3024.64,"NOVANET [10819]",Novanet,,7561.61,75,,,,,0,1172.55,8569.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 7-12 GH 10MM KNEE RIGHT CRUCIATE RETAINING",SUP-42522000610,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UHC [10700]","United Healthcare",,6821.47,63.3,,8601.07,8395.67,8601.07,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"CATH LUBRICATH 22FR URETHRAL NATURAL RUBBER HYDROGEL 5ML 2",SUP-0168L22,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.78,22.73,"UHC [10700]","United Healthcare",,47.97,63.3,,,,,0,8.81,64.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 26MM COUNTSINK MAXIMUM TORQUE 4MM",SUP-MSD01040026S,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",164.86,1204.88,"percent of total billed charges",
"CATH VISTA BRITE TIP 100CM 7FR .078IN SHORT TIP JUDKINS",SUP-77809100,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"UHC [10700]","United Healthcare",,264.34,63.3,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION HEXAGON KIT",SUP-531-78-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"UHC [10700]","United Healthcare",,512.73,63.3,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 13CM 5FR .038IN CHECK-FLO PERFORMER SIDEARM",SUP-G13212,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 40FR NEPHRSTMY NATURAL RUBBER 4 WING DRAIN",SUP-086040,CDM,C1729,HCPCS,0272,RC,,,both,,,105.62,31.69,"PHCS [10601]",PHCS,,73.93,70,,,,,0,12.28,89.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SUCTION CRTDG TUBE CUSA QUICK CONNECT",SUP-C7300,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 6MM ENDOWRIST SP NONSTERILE LATEX FREE REUSABLE",SUP-431150,CDM,S27000186,LOCAL,0270,RC,,,both,,,3228.75,968.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1482,45.9,,,,,0,375.5,2744.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 3CM 170CM 7FR 2 PIGTAIL CURVE BILIARY",SUP-G22159,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,290,45.9,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR QUADRICEPS TENDON HARVEST GUIDE QUADTRAC",SUP-72205580,CDM,S27200284,LOCAL,0272,RC,,,both,,,2437.50,731.25,"MULTIPLAN [10600]",Multiplan,,2071.88,85,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 20MM 12MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171120270,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"KAISER [10500]",Kaiser,,786.92,67,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM SENSAR INTRAOCULAR LENS, BICONVEX, 22.5 DIOPTER",SUP-AR40E00225,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,427.56,45.9,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRENCH SURGICAL 3IN LONG HEXAGON KIT PRECISION STERILE",SUP-SC-4276,CDM,S27000186,LOCAL,0270,RC,,,both,,,217.50,65.25,"NOVANET [10819]",Novanet,,163.13,75,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 130MM 5MM STERLING OVAL LARGE HUB BURR REDUCED",SUP-H9103RH,CDM,S27200284,LOCAL,0272,RC,,,both,,,564.25,169.27,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT TRACH 7MM PORTEX BLUPERC TUBE STERILE LATEX FREE",SUP-101/563/070,CDM,S27200284,LOCAL,0272,RC,,,both,,,3007.88,902.36,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER TORQR 90CM 5FR 2-5-2MM SPACING CORONARY SINUS CURVE",SUP-041590CS,CDM,C1730,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES,MINOR",364,APR-DRG,,,,,,,inpatient,,,47522.72,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $4,029.30. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%.",,,,0,,,other,"SOI-1 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION,MODERATE",046,APR-DRG,,,,,,,inpatient,,,43052.50,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $5,489.30. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($35,199.08) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 14FR 25CM MAC-LOC NDL OBTR CANN CONNECTING TUBE",SUP-G30405,CDM,C2627,HCPCS,0272,RC,,,both,,,1053.00,315.9,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL FLAT L 28CM VALLEYLAB STERILE ARGON",SUP-E3581-28,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.15,88.24,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TRUE DILATATION 110CM 4.5CM 28MM BALLOON DILATATION OTW",SUP-0284514,CDM,C1725,HCPCS,0272,RC,,,both,,,7590.00,2277,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 6CM 3MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035473060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3810.95,27,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 70MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661070,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"MULTIPLAN [10600]",Multiplan,,1109.86,85,,,,,0,151.86,1109.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM PREBENT 28X16X2.5MM TITANIUM 2 LEVEL SKYLINE BONE",SUP-186802028,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 16MM 8MM STD WALL THIN WALL 2 BRANCH",SUP-SBT1602D,CDM,C1768,HCPCS,0278,RC,,,both,,,8611.20,2583.36,"PHCS [10601]",PHCS,,6027.84,70,,,,,0,1001.48,7319.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE CARDIOFORM ASD OCCLUDER 48MM 14FR",SUP-00733132636525,CDM,C1817,HCPCS,0278,RC,,,both,,,52321.50,15696.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6084.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6084.99,44473.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFE-T-J VASCULAR STD CURVE TAPER 260CM 3CM .035IN",SUP-G00517,CDM,C1769,HCPCS,0272,RC,,,both,,,221.76,66.53,"PHCS [10601]",PHCS,,155.23,70,,,,,0,25.79,188.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 6MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120610,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"MULTIPLAN [10600]",Multiplan,,10099.53,85,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 7 POSTERIOR TOTAL STABILIZE",SUP-5544-A-700,CDM,C1776,HCPCS,0278,RC,,,both,,,6699.90,2009.97,"CIGNA [10200]",Cigna,,4555.93,68,,5873.17,5873.17,5873.17,"1 through 10",779.2,5694.92,"percent of total billed charges",
"GLYCOPYRROLATE 1 MG TABLET",RX-10130,CDM,,,0637,RC,69315-0139-01,NDC,both,1,UN,6.61,1.98,"MULTIPLAN [10600]",Multiplan,,5.62,85,,,,,0,0.77,5.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 1.5MM X 14MM COCR",SUP-VAL-15140-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,408.01,28.62,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 4FR 65CM TRIFORCE FLEXOR PEEL-AWAY CURVE TAPER DOWN",SUP-G56415,CDM,S27200284,LOCAL,0272,RC,,,both,,,2711.18,813.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 6X40 40CM SL",SUP-48006004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"7F DUO-DECA 2-8-2 MPD-L 100CM",SUP-901685,CDM,C1731,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VERAPAMIL 120 MG TABLET, IMMEDIATE RELEASE",RX-8528,CDM,,,0637,RC,00591-0345-01,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE TRACH 7.5MM PORTEX BLUSELECT UNCUFF STERILE LATEX FREE",SUP-101/816/075,CDM,S27200284,LOCAL,0272,RC,,,both,,,311.63,93.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE SPEAKING AQUA RUBBER ADULT 22MM 15MM TRACH LIGHTWEIGHT",SUP-703-007,CDM,S27000186,LOCAL,0270,RC,,,both,,,909.87,272.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACK SUT BROADBAND TAPE 2 BLACK BLUE",SUP-CM0321N,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 2X1CM EPICORD HYALURONIC ACID ALLOGRAFT",SUP-EC-5120,CDM,Q4187,HCPCS,0636,RC,,,both,,,6251.40,1875.42,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ARTHROSCOPIC TRANSLUCENT 9CM 6MM TWIST-IN SHOULDER OBTR",SUP-AR-6545,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Pta Baln Artery Addl",PX-361000444,CDM,37247,CPT,0361,RC,,,both,,,26786.85,8036.05,"KAISER [10500]",Kaiser,,17947.19,67,,,,,0,1249,22768.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Meckel Divert",PX-341000021,CDM,78290,CPT,0341,RC,,,both,,,1730.12,519.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,622.02,,"Fee schedule rate ($622.02).",,,,0,201.21,1470.6,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 605CC",SUP-RSZ-MPX-605S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Local Plus",,866.7,53.5,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEPHRSTMY 8.3FR REPLACEMENT 25CM JINRO PERCUTANEOUS",SUP-M0064202060,CDM,C1729,HCPCS,0272,RC,,,both,,,152.34,45.7,"NOVANET [10819]",Novanet,,114.26,75,,,,,0,17.72,129.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 90MM TITANIUM SELF TAP CANNULATED STERILE",SUP-04.353.890S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,703.88,28.62,,,,,0,286.03,2090.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 40MM VIPER PRIME TITANIUM SPINE EXTEND TAB",SUP-186770240,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 6MM CARBIDE 5-7.3MM SCR STERILE DISPOSABLE",SUP-309.006S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1969.80,590.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,904.14,45.9,,,,,0,229.09,1674.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Upr Ext Nonjnt W Cntrst",PX-610000025,CDM,73219,CPT,0610,RC,,,both,,,4061.00,1218.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,916.05,,,,,,,472.29,3451.85,"fee schedule",
"VXSK-230P RF WIRE 63CM/45DEG/D0 SHEATH",SUP-VXSK0131,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,731.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.5MM CANNULATED AO QUICK CONNECT COLOR CODED",SUP-MSN10004,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 20D DIL FUNNEL TIP RADIOPAQUE COIL REINFORCE",SUP-H965251860,CDM,S27200284,LOCAL,0272,RC,,,both,,,65550.00,19665,"AETNA [10100]","Aetna HMO/PPO",,52112.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7623.47,55717.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-71933654,CDM,C1776,HCPCS,0278,RC,,,both,,,22273.65,6682.09,"PHCS [10601]",PHCS,,15591.56,70,,,,,0,2590.43,18932.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OCTARAY 3-3-3-3-3MM SPCAE F CURVE ELECTROPHYSIOLOGY",SUP-D160906,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"NOVANET [10819]",Novanet,,11902.5,75,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 150MM 16MM STAINLESS STEEL PARTIAL THREAD",SUP-208.425,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"CIGNA [10200]","Cigna Open Access",,787.57,56.9,,1144.80,304.56,2275.09,66,160.97,1176.51,"percent of total billed charges",
"CAP PROTECTIVE 6MM FIXATION PIN NONSTERILE BLUE",SUP-394.994,CDM,S27000186,LOCAL,0270,RC,,,both,,,48.42,14.53,"NOVANET [10819]",Novanet,,36.32,75,,,,,0,5.63,41.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SKIN PURPLE 10CM 15GA SMARTCLIP LITE 3-4MM SOFT",SUP-SMARTCLIPLT-PURP-10,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"KAISER [10500]",Kaiser,,1809,67,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 110CM 5FR AP2 CURVE ANGIOGRAPHIC",SUP-G47035,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"NOVANET [10819]",Novanet,,157.89,75,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ORTHOPEDIC 5MM 10MM 5MM END INTERNAL THREAD HEX TALON",SUP-HTN-10-C05,CDM,C1713,HCPCS,0278,RC,,,both,,,1320.30,396.09,"CIGNA [10200]","Cigna Open Access",,751.25,56.9,,1144.80,304.56,2275.09,66,153.55,1122.26,"percent of total billed charges",
"SYR INFLATION DEVICE BASIXTOUCH 13IN ANALOG DISPLAY",SUP-IN8302,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.44,105.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.99,299.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL TRANSCONTINENTAL BAYONET SPINE ANNULOTOMY",SUP-675.405S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY PINK 25CM 18GA MAX-CORE ANGLE 22MM 2 TRIGGER",SUP-MC1825,CDM,S27200284,LOCAL,0272,RC,,,both,,,254.04,76.21,"PHCS [10601]",PHCS,,177.83,70,,,,,0,29.54,215.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 38MM 80CM 9MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU0800938,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3098.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3040.66,22223.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +21.5 DIOPTER 13MM 6MM 3 PIECE TECNIS ACRYLIC",SUP-ZMA00U0215,CDM,V2632,HCPCS,0276,RC,,,both,,,6175.50,1852.65,"CIGNA [10200]","Cigna Open Access",,3513.86,56.9,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE COONS-BENTSON ENDOSCOPIC 145CM .038IN STAINLESS STEEL",SUP-G14619,CDM,C1769,HCPCS,0272,RC,,,both,,,204.28,61.28,"KAISER [10500]",Kaiser,,136.87,67,,,,,0,23.76,173.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFTS FOR INJURIES WITH CC/MCC",904,MS-DRG,,,,,,,inpatient,,,175649.32,52694.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,58562.91,,,,,,,7561,107239.83,"case rate",
"TIP ASPIR 25KHZ UNIVERSAL ULTRASONIC LARGE DIAMETER SOFT",SUP-5450800306,CDM,S27200284,LOCAL,0272,RC,,,both,,,4359.43,1307.83,"CIGNA [10200]","Cigna Open Access",,2480.52,56.9,,,,,0,507,3705.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR RIGHT CORONARY 3D CURVE",SUP-534576T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,38.44,41.1,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OMEPRAZOLE 2 MG/ML ORAL SUSPENSION",RX-408883,CDM,,,0637,RC,08888-8885-99,NDC,both,50,ML,34.91,10.47,"AETNA [10100]","Aetna HMO/PPO",,27.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.06,29.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 18MM 49MM SHOULDER ECLIPSE STERILE ARTHROPLASTY",SUP-AR-9349-18,CDM,C1776,HCPCS,0278,RC,,,both,,,4105.50,1231.65,"CIGNA [10200]","Cigna Open Access",,2336.03,56.9,,5302.19,4377.88,6578.61,27,477.47,3489.68,"percent of total billed charges",
"CORD ELECTROSURGICAL MONOPOLAR ACTIVE BOVIE STERILE REUSABLE",SUP-C650-129A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1273.89,382.17,"MULTIPLAN [10600]",Multiplan,,1082.81,85,,,,,0,148.15,1082.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Test Pulm Exercise",PX-482000003,CDM,94621,CPT,0460,RC,,,both,,,1260.97,378.29,"PHCS [10601]",PHCS,,882.68,70,,,,,0,146.65,1071.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Test Pulm Exercise",PX-482000003,CDM,94621,CPT,0460,RC,,,both,,,1260.97,378.29,"CIGNA [10200]","Cigna Open Access",,717.49,56.9,,,,,0,146.65,1071.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC",987,MS-DRG,,,,,,,inpatient,,,114651.78,34395.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68057.17,,"Fee schedule rate ($68,057.17). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,8593,100095.57,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE COAGULATION 220CM 2.3MM ARC SMART ARCONNECT QUICK",SUP-G11-400-04,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 9.5MM S-ROM ZTT 20F SMALL HIP PROXIMAL",SUP-550727,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"CIGNA [10200]",Cigna,,7401.63,68,,5873.17,5873.17,5873.17,"1 through 10",1265.9,9252.04,"percent of total billed charges",
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE A CURVE",SUP-D7TCAL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"FIRST HEALTH [10303]","First Health",,3968.88,80,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 80MM 12MM BALLOON",SUP-U35130128,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN LONG",SUP-77800400,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM PRIMARY ANTHOLOGY POROUS 131D 11 STD",SUP-71356011,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8948.11,27,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN JUDKINS LEFT 5 CURVE GUIDING",SUP-LA6JL50,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"FIRST HEALTH [10303]","First Health",,313.2,80,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 9.5MM 4.5MM 9.5MM 1.14MM 9.5MM GOODE EAR T",SUP-1016010,CDM,S27800098,LOCAL,0278,RC,,,both,,,294.06,88.22,"BLUE CROSS [10001]","Blue Cross PPO",,115.27,39.2,,,,,0,34.2,249.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM STAINLESS STEEL T15 CORTEX SELF TAP LOW",SUP-02.206.224,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"MULTIPLAN [10600]",Multiplan,,275.39,85,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRESSURE INJECTABLE ARROWGARD BLUE ADVANCEONE-LUMEN MIDLINE",SUP-CDC-41541-MPKB,CDM,C1751,HCPCS,0272,RC,,,both,,,1477.44,443.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,171.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,171.83,1255.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 20MM CEMENTLESS TOTAL STABILIZE TRIATHLON",SUP-5566-S-010,CDM,C1776,HCPCS,0278,RC,,,both,,,5447.65,1634.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,633.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,633.56,4630.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE PEEP 2.5CM 20 22MM ADPTR CNCT THRESHOLD RESISTOR CPAP",SUP-9003B,CDM,S27000186,LOCAL,0270,RC,,,both,,,66.99,20.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.79,56.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CERVICAL L82.5MM BILATERAL 5 LEVEL TITANIUM ANTERIOR L",SUP-7200182,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL LARGE+ KNEE RIGHT CEMENT LCS COMPLETE COCR",SUP-129401070,CDM,C1776,HCPCS,0278,RC,,,both,,,20635.65,6190.69,"FIRST HEALTH [10303]","First Health",,16508.52,80,,,,,0,2399.93,17540.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 14MM LCP STAINLESS STEEL DISTAL VOLAR RADIUS",SUP-02.210.114,CDM,C1713,HCPCS,0278,RC,,,both,,,959.36,287.81,"MULTIPLAN [10600]",Multiplan,,815.46,85,,,,,0,111.57,815.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER HUMERAL INSPACE MEDIUM",SUP-131,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"CIGNA [10200]","Cigna Local Plus",,11907,31.5,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AXLE FEMORAL GMRS STD KNEE ROTATING HINGE",SUP-6481-2-120,CDM,C1776,HCPCS,0278,RC,,,both,,,3728.09,1118.43,"FIRST HEALTH [10303]","First Health",,2982.47,80,,,,,0,433.58,3168.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 77MM STAINLESS STEEL 2.4MM SCR 5X7 HOLE 2 COLUMN",SUP-02.111.751,CDM,C1713,HCPCS,0278,RC,,,both,,,4198.65,1259.59,"AETNA [10100]","Aetna HMO/PPO",,3337.93,79.5,,1521.93,481.35,16760.95,30,488.3,3568.85,"percent of total billed charges",
"HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET",RX-34505,CDM,,,0250,RC,00406-0123-23,NDC,both,1,UN,12.54,3.76,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM",RX-10434,CDM,,,0250,RC,81033-0025-05,NDC,both,5,GR,61.89,18.57,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNAP LARGE STRAP - CASE - 5 IN A PACK",SUP-STPAL5,CDM,S27000186,LOCAL,0270,RC,,,both,,,182.70,54.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 465MM 13MM LARGE CANNULATED QUICK COUPLING",SUP-03.010.034S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4037.88,1211.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 15CM 10MM .021IN AZUR DETACHABLE .018IN",SUP-45-481015,CDM,S27800098,LOCAL,0278,RC,,,both,,,6037.50,1811.25,"AETNA [10100]","Aetna HMO/PPO",,4799.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WAVELINQ VASCULAR ENDOAVF",SUP-WQ4300,CDM,S27200284,LOCAL,0272,RC,,,both,,,44100.00,13230,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18125.1,41.1,,,,,0,5128.83,37485,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 45MM 75CM 22MM 100CM",SUP-H965404510,CDM,C1876,HCPCS,0278,RC,,,both,,,4410.00,1323,"MULTIPLAN [10600]",Multiplan,,3748.5,85,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 60MM ARCOS A STD OFFSET HIP TITANIUM MODULAR",SUP-11301301,CDM,C1776,HCPCS,0278,RC,,,both,,,39453.12,11835.94,"AETNA [10100]","Aetna HMO/PPO",,31365.23,79.5,,10981.53,8986.79,12413.38,12,4588.4,33535.15,"percent of total billed charges",
"WIRE FIXATION 2MM 150MM KIRSCHNER 1 END TROCAR TIP SMOOTH",SUP-P99-192-2015,CDM,C1713,HCPCS,0278,RC,,,both,,,146.16,43.85,"CIGNA [10200]",Cigna,,99.39,68,,1831.33,1831.33,1831.33,16,17,124.24,"percent of total billed charges",
"LEAD NEROSTIMLTR 50CM INTERSTIM 32 CONTACT PADDLE",SUP-SC-8352-50,CDM,C1778,HCPCS,0278,RC,,,both,,,31500.00,9450,"AETNA [10100]","Aetna HMO/PPO",,25042.5,79.5,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 64MM LCP STAINLESS STEEL LONG THREAD ORTHOPEDIC",SUP-207.764,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,477.38,45.9,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DRNG 15CM 6FR 18GA FUHRMAN PLEURAL PNEUMOPERICARDIAL",SUP-G55714,CDM,C1729,HCPCS,0272,RC,,,both,,,1278.99,383.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,151.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,148.75,1087.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL J HOOK LOCK SHEATH MONOPOLAR LATEX",SUP-5600140,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"UHC [10700]","United Healthcare",,214.78,63.3,,,,,0,39.46,288.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dna Histogram Ploidy S Phase",PX-311000019,CDM,88182,CPT,0311,RC,,,both,,,685.65,205.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,46.47,,,,,,,0.01,582.8,"fee schedule",
"SCR BONE 5MM 8MM 48MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.538,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,786.54,68,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARATHON 165CM 25CM 2.7-1.5FR .015-.013FR MICRO",SUP-105-5056,CDM,C1887,HCPCS,0272,RC,,,both,,,5706.30,1711.89,"UHC [10700]","United Healthcare",,3612.09,63.3,,,,,0,663.64,4850.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT CEMENTED CRUCIATE RETAINING ATTUNE",SUP-150400103,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"PHCS [10601]",PHCS,,15675.35,70,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM .91-1.12MM 2.25MM CORONARY",SUP-RONYX22508W,CDM,C1874,HCPCS,0278,RC,,,both,,,1875.00,562.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,536.63,28.62,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 40MM 120CM 12MM .079IN LARGE",SUP-SERB65-12-40-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC SUTUPAK 0 18IN MONOFILAMENT 12 STRAND PRECUT",SUP-SG14T,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.11,53.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.6,150.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 2-0 CP-1 SPIRAL 70CM SUT",SUP-SXMP1B419,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"CIGNA [10200]","Cigna Local Plus",,114.44,53.5,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 3.5IN 18GA 20GA PERIFIX TUOHY METAL GLASS LOR",SUP-332236,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.73,44.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,60.72,41.1,,,,,0,17.18,125.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR UNIVERSAL 30X3.5MM ENDO GIA ROTICULATOR",SUP-030452,CDM,S27200284,LOCAL,0272,RC,,,both,,,1085.72,325.72,"PHCS [10601]",PHCS,,760,70,,,,,0,126.27,922.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BRONCHOSCOPIC 15MM 21GA WANG TRANSBRONCHIAL CENTRAL",SUP-MW319,CDM,S27200284,LOCAL,0272,RC,,,both,,,411.86,123.56,"FIRST HEALTH [10303]","First Health",,329.49,80,,,,,0,47.9,350.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE L 35MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 2X3",SUP-249.686,CDM,C1713,HCPCS,0278,RC,,,both,,,2305.80,691.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1567.94,68,,,,,0,268.16,1959.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD ILIVIA 7 DR-T",SUP-404623,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"UHC [10700]","United Healthcare",,25674.48,63.3,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EVOLUT FX DELIVERY 23-29 MM",SUP-D-EVOLUTFX-2329,CDM,S27200284,LOCAL,0272,RC,,,both,,,14559.00,4367.7,"PHCS [10601]",PHCS,,10191.3,70,,,,,0,1693.21,12375.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 135CM 4CM 5FR 4MM 7.5MM BALLOON DILATATION",SUP-4204040X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM OFFSET TAPER 40MM HIP ANATOMIC COCR V40",SUP-6260-9-140,CDM,C1776,HCPCS,0278,RC,,,both,,,7469.28,2240.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5079.11,68,,,,,0,868.68,6348.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC CROME 2 CHMBR DF4 INLINE CNCT IS4 INLINE",SUP-DTPC2QQ,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"MULTIPLAN [10600]",Multiplan,,65407.5,85,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM LAVA EMBOLIC",SUP-SLLESMK2,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL CUSHING CARB-BITE BAYONET 7.5IN TISSUE SCRP",SUP-130418,CDM,S27200284,LOCAL,0272,RC,,,both,,,631.40,189.42,"NOVANET [10819]",Novanet,,473.55,75,,,,,0,73.43,536.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 35MM LONG CORTICAL LONG TAP QUICK CPLR",SUP-MS-LTT35,CDM,C1713,HCPCS,0278,RC,,,both,,,1579.50,473.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,452.05,28.62,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 3 ANGLE LEFT RTRCTR 3INX1 1/8IN DAVIS MCGIVOR MOUTH",SUP-45-2141,CDM,S27200284,LOCAL,0272,RC,,,both,,,457.49,137.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,54.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.21,388.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 40CM 12/7MM 2 VELOUR KNITTED BIFURCATED",SUP-M002020851270,CDM,C1768,HCPCS,0278,RC,,,both,,,4673.51,1402.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1337.56,28.62,,,,,0,543.53,3972.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 GEOALIGN 130CM 220MM 7MM BALLOON DILATATION",SUP-LX3513072205F,CDM,C2623,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"KAISER [10500]",Kaiser,,8090.25,67,,,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 26MM RESURFACE GENESIS II KNEE",SUP-71420580,CDM,C1776,HCPCS,0278,RC,,,both,,,6344.55,1903.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2912.15,45.9,,,,,0,737.87,5392.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM AVENIR FITMORE MULTIPOLAR STD THR CERAMIC BIPOLAR",SUP-98000100016,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"NOVANET [10819]",Novanet,,7762.5,75,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM RELINE C SPINE MULTIAXIAL NONSTERILE",SUP-3903514,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HISTOGUIDE WIRE-GUIDED FORCEPS",SUP-BX00711660,CDM,S27200284,LOCAL,0272,RC,,,both,,,1377.00,413.1,"KAISER [10500]",Kaiser,,922.59,67,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 8CM 5MM BALLOON",SUP-G52260,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"KAISER [10500]",Kaiser,,643.05,67,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTEAN FRAGMENT PLATE WEB 2.0",SUP-PRT-WEB-020,CDM,C1713,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"BLUE CROSS [10001]","Blue Cross HMO",,2812.99,39.2,,957.42,156.86,7483.26,51,834.57,6099.6,"percent of total billed charges",
"SYSTEM SYNERGY XD MONORAIL 28MM 144CM 2.25MM CORONARY STENT",SUP-H7493941828220,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE 15X10CM PREPERITONEAL KNIT WEB SYNECOR",SUP-GKWV1015,CDM,C1781,HCPCS,0278,RC,,,both,,,5071.50,1521.45,"AETNA [10100]","Aetna HMO/PPO",,4031.84,79.5,,,,,0,589.82,4310.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM DCP LC-DCP STAINLESS STEEL FULL THREAD",SUP-218.050,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,52.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",52.23,381.7,"percent of total billed charges",
"SCR BONE 3.5MM 48MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.148,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"CIGNA [10200]",Cigna,,770.24,68,,1831.33,1831.33,1831.33,16,131.73,962.8,"percent of total billed charges",
"PLATE STD BONE RIGHT DISTAL VOLAR ULNAR",SUP-70-0046,CDM,C1713,HCPCS,0278,RC,,,both,,,5754.60,1726.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,681.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,669.26,4891.41,"percent of total billed charges",
"ROD SPINAL 55MM 4.75MM CD HORIZON SOLERA COCRMO CAP",SUP-641003055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC",272,MS-DRG,,,,,,,inpatient,,,121931.81,36579.54,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,16944.96,,"Case rate ($15,836.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,705.18, add-ons for qualifying new technology services are included. If operating cost exceeds $47,744.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,493.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $14,724.63. The transfer operating threshold is the transfer adjustment factor * $14,705.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,111.78. The transfer capital threshold is the transfer adjustment factor * $1,111.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,7561,74537.39,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 7X3CM OMEGA3 WOUND FENESTRATE",SUP-50200F02B0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,9170.10,2751.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4103.62,44.75,,,,,0,180.89,7794.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUTTLE ACCU-PASS 70D UP BEND ERGONOMIC HANDLE THUMB WHEEL",SUP-72200419,CDM,S27200284,LOCAL,0272,RC,,,both,,,961.07,288.32,"NOVANET [10819]",Novanet,,720.8,75,,,,,0,111.77,816.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 2MM 120CM HANDLE BRONCHOSCOPIC STERILE",SUP-129,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.00,23.1,"UHC [10700]","United Healthcare",,48.74,63.3,,,,,0,8.96,65.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 4.75MM IMPL FLEXOR DIGITORUM LONGUS",SUP-AR-1547BC-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10831.28,3249.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3099.91,28.62,,,,,0,1259.68,9206.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBTR LAPAROSCOPIC 8MM WECK VISTA LONG BLADELESS STERILE",SUP-470360,CDM,S27200284,LOCAL,0272,RC,,,both,,,274.05,82.21,"UHC [10700]","United Healthcare",,173.47,63.3,,,,,0,31.87,232.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Reticulated Platelet Assay",PX-305000089,CDM,85055,CPT,0305,RC,,,both,,,72.00,21.6,"KAISER [10500]",Kaiser,,48.24,67,,,,,0,0.01,72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 28MM 140CM 4.5MM CORONARY STENT PLATINUM",SUP-H7493927428450,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,1470,39.2,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T OBLIQUE ANGLE 53MM STAINLESS STEEL 3.5MM SCR SMALL",SUP-241.23,CDM,C1713,HCPCS,0278,RC,,,both,,,2594.70,778.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,742.6,28.62,,,,,0,301.76,2205.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 10 12MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151621012,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3220.87,28.62,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE ROUND SILICONE",SUP-SRF-335,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"FIRST HEALTH [10303]","First Health",,4388.4,80,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805210,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,258.2,28.62,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 6MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120615,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"BLUE CROSS [10001]","Blue Cross HMO",,4657.67,39.2,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 7MM CANNULATED",SUP-400146,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,70.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NUT ORTHOPEDIC MRI SAFE NONSTERILE",SUP-03.311.062,CDM,S27800098,LOCAL,0278,RC,,,both,,,1210.87,363.26,"KAISER [10500]",Kaiser,,811.28,67,,,,,0,140.82,1116.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 40MM 125CM 12MM BILIARY NITINOL",SUP-G36239,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"AMERIGROUP MEDICAID [20100]",Amerigroup,,447.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BONE BIOPSY REVOLVE ACCESS TROCAR TIP 8GA",SUP-685.027S,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 8CM 5FR ZIMMON PIGTAIL CURVE PANCREATIC",SUP-G21926,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR PREPARATION OF TC-99M-EXAMETAZIME INTRAVENOUS SOLUTION",RX-186705,CDM,A9521,HCPCS,0343,RC,08888-8878-39,NDC,both,1,UN,9958.79,2987.64,"FIRST HEALTH [10303]","First Health",,7967.03,80,,,,,0,1158.21,8464.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Phencyclidine (PCP)",PX-301000552,CDM,83992,CPT,0301,RC,,,both,,,148.00,44.4,"CIGNA [10200]","Cigna Local Plus",,148,,,,,,,0.15,148,"fee schedule",
"STENT ENROUTE 30MM 57CM 10-8MM TAPER VASCULAR NITINOL",SUP-SR-100830-TCS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Stent & Ather",PX-361000155,CDM,37227,CPT,0361,RC,,,both,,,28914.88,8674.46,"FIRST HEALTH [10303]","First Health",,23131.9,80,,,,,0,3362.8,24577.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Feeding Enteral",PX-E27200222,CDM,E27200222,LOCAL,0272,RC,,,both,,,105.60,31.68,"PHCS [10601]",PHCS,,73.92,70,,,,,0,12.28,89.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Incision Bx Skin Ea Addl",PX-761000064,CDM,11107,CPT,0761,RC,,,both,,,2168.00,650.4,"MULTIPLAN [10600]",Multiplan,,1842.8,85,,,,,0,2.17,2168,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM MEDLINE UNITE FOOT ANKLE NONLOCK",SUP-MPSN2716,CDM,C1713,HCPCS,0278,RC,,,both,,,1174.50,352.35,"CIGNA [10200]",Cigna,,798.66,68,,1831.33,1831.33,1831.33,16,136.59,998.33,"percent of total billed charges",
"STENT EVERFLEX ENTRUST 100MM 150CM 7MM VASCULAR NICKEL",SUP-EVD35-07-100-150,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4926.6,68,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM LCP STAINLESS STEEL FOREFOOT MIDFOOT T8",SUP-02.211.018,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"NOVANET [10819]",Novanet,,673.6,75,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 7IN STRAIGHT BONE LUER SURGICAL",SUP-30-5217,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.40,408.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,158.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.21,1156.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Morpho Anlys in Situ Manual",PX-310000003,CDM,88369,CPT,0310,RC,,,both,,,529.10,158.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,84.87,,,,,,,0.01,449.74,"fee schedule",
"NAIL 11MM 36CM FEMORAL NAIL-EX INTRAMEDULLARY CANNULATED",SUP-04.013.552S,CDM,C1713,HCPCS,0278,RC,,,both,,,8319.74,2495.92,"MULTIPLAN [10600]",Multiplan,,7071.78,85,,,,,0,967.59,7071.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 8 EXTREME LATERAL INTERBODY FUSION 2 HOLE DECADE BONE",SUP-7140208,CDM,C1713,HCPCS,0278,RC,,,both,,,13800.00,4140,"MULTIPLAN [10600]",Multiplan,,11730,85,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP LARGE ALLOGRAFT COMPRESSIBLE SPONGE 50",SUP-13812209,CDM,C1713,HCPCS,0278,RC,,,both,,,15333.74,4600.12,"KAISER [10500]",Kaiser,,10273.61,67,,,,,0,1783.31,13033.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CRANIOTOMY 5.31MM ACCESS DRILL BIT RAZOR SYR NDL HOLDER",SUP-INS-5HND,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"UHC [10700]","United Healthcare",,2367.42,63.3,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY TREK BONE LESION BIOPSY KIT 11GX15CM INTRO",SUP-TKL1115,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"FIRST HEALTH [10303]","First Health",,2700,80,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MTRL STRAPPING PILE LOOP FABRIC NYLON TRICOT THK1/8IN STD 10",SUP-A8097,CDM,S27000186,LOCAL,0270,RC,,,both,,,168.61,50.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.61,143.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY JNS CURVE 5MM SPACING 5FR 120CM",SUP-401443,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"UHC [10700]","United Healthcare",,198.26,63.3,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM .02IN 6MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0630,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.00,2003.4,"CIGNA [10200]","Cigna Local Plus",,3572.73,53.5,,,,,0,776.65,5676.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 92CM 1MM 6FR 10MM SPACE REGULAR D CURVE",SUP-D6DR010RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,274.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 3-0 T-43 18IN BRAID TIES MULTISTRAND LOWER",SUP-AR-7227-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,23.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EPIDURAL EPILONG SOFT CATH",SUP-0431157-51,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.70,80.91,"NOVANET [10819]",Novanet,,202.28,75,,,,,0,31.37,229.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD 20CM 6FR REGULAR DRNG FLEXIMA METAL HYDROPHILIC",SUP-M001271260,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Perc Bile Duct Stent New Int or Ext",PX-361000407,CDM,47540,CPT,0361,RC,,,both,,,13847.00,4154.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1640.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1610.41,11769.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 45CM BIPOLAR ACTIVE FIXATION SOLIA S STEROID",SUP-377176,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CIGNA [10200]","Cigna Open Access",,1270.29,56.9,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR FR4 CURVE ANGIOGRAPHIC VENTRICULAR 2",SUP-H74916599020,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PHCS [10601]",PHCS,,53.61,70,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CITATION TMZF HA 6 SHORT HIP RIGHT",SUP-6265-5216,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"CIGNA [10200]","Cigna Open Access",,8181.35,33.5,,5302.19,4377.88,6578.61,27,2840.27,20758.66,"percent of total billed charges",
"DRAIN INCISION 19FR SOLID CORE CENTER 4 CHANNEL RADIOPAQUE",SUP-2230,CDM,S27200284,LOCAL,0272,RC,,,both,,,155.21,46.56,"UHC [10700]","United Healthcare",,98.25,63.3,,,,,0,18.05,131.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xofigo Radium 223 per Microcurie",PX-344000004,CDM,A9606,HCPCS,0636,RC,,,both,,,620.00,186,"BLUE CROSS [10001]","Blue Cross PPO",,196.99,,,,,,,196.99,421.6,"fee schedule",
"SCR BONE 5MM 175MM 60MM SCHANZ STAINLESS STEEL HA DISTAL",SUP-294.785SHA,CDM,C1713,HCPCS,0278,RC,,,both,,,1933.73,580.12,"BLUE CROSS [10001]","Blue Cross HMO",,758.02,39.2,,957.42,156.86,7483.26,51,224.89,1643.67,"percent of total billed charges",
"CATH JADE 150CM 240MM 4MM BALLOON DILATATION STERILE LATEX",SUP-584024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERCROSS 130CM 80CM 2.4-3.2FR .017-.018IN 120D MICRO",SUP-5306,CDM,C1887,HCPCS,0272,RC,,,both,,,3740.00,1122,"UHC [10700]","United Healthcare",,2367.42,63.3,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VENTRICULAR SHUNT PROCEDURES WITH CC",032,MS-DRG,,,,,,,inpatient,,,125683.48,37705.04,"BLUE CROSS [10001]","Blue Cross PPO",,52608.1,,,,,,,7561,62216.68,"case rate",
"CATH SUPER TORQUE 100CM 5FR .0395IN SIDEWINDER SIM 1 CURVE",SUP-532501,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"MULTIPLAN [10600]",Multiplan,,88.74,85,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840006530,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6491.86,68,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC RATCHET HANDLE 36CM 10MM ENDOPATH BABCOCK",SUP-10BB,CDM,S27200284,LOCAL,0272,RC,,,both,,,1358.02,407.41,"FIRST HEALTH [10303]","First Health",,1086.42,80,,,,,0,157.94,1154.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH C-FLEX 70CM 7FR PIGTAIL CURVE URETERAL TAPER TIP 1",SUP-M0064001720,CDM,C1758,HCPCS,0272,RC,,,both,,,499.69,149.91,"PHCS [10601]",PHCS,,349.78,70,,,,,0,58.11,424.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 12.5MM 4MM SABRETOOTH COOLCUT STERILE",SUP-AR-8400ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,341.22,68,,,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 16MM ALPS TIMAX HAND CORTICAL NONLOCK SQUARE",SUP-131220516,CDM,C1713,HCPCS,0278,RC,,,both,,,1032.75,309.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,295.57,28.62,,,,,0,120.11,877.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW .51IN 1.36IN THK.017IN THIN SMALL BONE OSCILLATING",SUP-KM-3106,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,42,68,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 5MM ACORN STERILE",SUP-5620030050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1066.37,319.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,124.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.02,906.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 8CM 6MM BALLOON DILATATION ILIAC",SUP-G34336,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X16MM COLOSSEUM 12MM MESH NONSTERILE LATEX",SUP-156.204,CDM,S27800098,LOCAL,0278,RC,,,both,,,27184.50,8155.35,"PHCS [10601]",PHCS,,19029.15,70,,,,,0,3161.56,23106.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 23MM 75CM 7MM 100CM",SUP-M001712080,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"CIGNA [10200]","Cigna Open Access",,4809.47,56.9,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIPOLAR UNIPOLAR HIP WITH ANY HIGHLY POROUS CEMENTLESS",SUP-CAP-DS-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,13455.00,4036.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3632.85,27,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL AVENIR COMPLETE 6.5 HIGH OFFSET HIP STERILE",SUP-574102065,CDM,C1776,HCPCS,0278,RC,,,both,,,23461.20,7038.36,"FIRST HEALTH [10303]","First Health",,18768.96,80,,,,,0,2728.54,19942.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR COBRA 1 CURVE ANGIOGRAPHIC VISCERAL",SUP-10719701,CDM,C1887,HCPCS,0272,RC,,,both,,,104.23,31.27,"UHC [10700]","United Healthcare",,65.98,63.3,,,,,0,12.12,88.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL FLUTELESS",SUP-6975150,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE MYRINGOTOMY SPEAR TIP",SUP-60-45070,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.35,18.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DISECT ENDOSCOPIC 2 CUT 4MM COOLCUT CURVE ARTHROSCOPY",SUP-AR-8400CDC,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE ARTHROSCOPIC LARGE HUB STERLING GATOR 2500-6000 RPM 13",SUP-C9266,CDM,S27200284,LOCAL,0272,RC,,,both,,,564.25,169.27,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INFINITI THRULUMEN 100CM 5FR JUDKINS LEFT CORONARY 5",SUP-534522T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 7FR 50CM 11CM GWIRE KINK RESISTANT FLEXIBLE",SUP-PSI-7F-11-038,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL SURGICAL 1.6MM FIBERTAK",SUP-AR-3600D-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.03,267.91,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 8-9 C-D KNEE",SUP-42512100511,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AETNA [10100]","Aetna HMO/PPO",,8567.25,79.5,,10981.53,8986.79,12413.38,12,1253.3,9159.96,"percent of total billed charges",
"GRAFT BONE DEMINERALIZED BONE MATRIX 10ML PUTTY PRETREATED",SUP-T43110,CDM,C1713,HCPCS,0278,RC,,,both,,,4185.00,1255.5,"AETNA [10100]","Aetna HMO/PPO",,3327.08,79.5,,1521.93,481.35,16760.95,30,486.72,3557.25,"percent of total billed charges",
"CATH LAUNCHER 110CM 6FR .071IN MRADIAL CURVE GUIDING NYLON",SUP-LA6MRADIALA,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 16MM 4MM STAINLESS STEEL SHORT THREAD HAND",SUP-02.226.216,CDM,C1713,HCPCS,0278,RC,,,both,,,1647.00,494.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1119.96,68,,,,,0,191.55,1399.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG 17X6CM VAC GRANUFOAM THK1.9CM POLYURETHANE FOAM",SUP-M8275042/10.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,376.72,113.02,"CIGNA [10200]",Cigna,,256.17,68,,,,,0,43.81,320.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 8MM 4MM MICROPOWER MICRO100 MEDIUM ROUND FLUTE",SUP-5091-228,CDM,S27000186,LOCAL,0270,RC,,,both,,,388.11,116.43,"CIGNA [10200]","Cigna Local Plus",,207.64,53.5,,,,,0,45.14,329.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC 24IN KNEE 3 PANEL CANVAS",SUP-23703,CDM,L1830,HCPCS,0274,RC,,,both,,,182.70,54.81,"FIRST HEALTH [10303]","First Health",,146.16,80,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 28CM 3CM 8FR .035IN PIGTAIL CURVE",SUP-M006180244170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,580.81,45.9,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 8CM 5FR PIGTAIL CURVE TAPER PANCREATIC",SUP-G22361,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.5/15",SUP-401745,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 340MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.055S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CIGNA [10200]","Cigna Local Plus",,3911.78,31.5,,3978.14,359.25,3978.14,24,1444.25,10555.59,"percent of total billed charges",
"CATH BALLOON DILATATION .018IN 5FR 6MM 120CM 10CM PTA OTW",SUP-435600L,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1103.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1083.33,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 2-0 CT-1 SPIRAL 30CM SUT",SUP-SXMP1B412,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.03,65.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,148.26,68,,,,,0,25.36,185.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR KT SUT MINI BIO-SUTURETAK 2 FW 2.4X5MM DISP",SUP-AR-1322DSC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1012.1,68,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9CM 6MM INTERLOCK FIBERED IDC DETACHABLE",SUP-M001363920,CDM,S27800098,LOCAL,0278,RC,,,both,,,2827.50,848.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1297.82,45.9,,,,,0,328.84,2403.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 20MM 4FR 4MM .018IN BALLOON",SUP-PCP040020130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"FIRST HEALTH [10303]","First Health",,984.96,80,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 40CM 40MM 8MM BALLOON DILATATION PACLITAXEL UREA",SUP-IAV08004004P,CDM,C1725,HCPCS,0272,RC,,,both,,,10281.00,3084.3,"FIRST HEALTH [10303]","First Health",,8224.8,80,,,,,0,1195.68,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 14MM 4MM STAINLESS STEEL SHORT THREAD HAND",SUP-02.226.214,CDM,C1713,HCPCS,0278,RC,,,both,,,1647.00,494.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,195.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",191.55,1399.95,"percent of total billed charges",
"SHELL ACETABULAR 48MM HIP CLUSTER HOLE 12 SCALLOP SNAP FIT",SUP-00875704801,CDM,C1776,HCPCS,0278,RC,,,both,,,11012.40,3303.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7488.43,68,,,,,0,1280.74,9360.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 8MM 143CM 2.25MM CORONARY EVEROLIMUS ELUTING",SUP-1009544-08,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2744.94,28.62,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 8MM 143CM 2.25MM CORONARY EVEROLIMUS ELUTING",SUP-1009544-08,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1136.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 340MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.955S,CDM,C1713,HCPCS,0278,RC,,,both,,,13031.06,3909.32,"BLUE CROSS [10001]","Blue Cross PPO",,5108.18,39.2,,957.42,570.23,957.42,28,1515.51,11076.4,"percent of total billed charges",
"BLADE SHAVER 4MM TRUDI 60D CURVE STERILE LATEX FREE",SUP-TSB460,CDM,S27200284,LOCAL,0272,RC,,,both,,,3562.50,1068.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 28CM 3CM 7FR .035IN 2",SUP-M006192144180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"BLUE CROSS [10001]","Blue Cross PPO",,623.23,39.2,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP C-MAC S D HYPERANGULATE VIDEO DISPOSABLE",SUP-051216-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,191.40,57.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,87.85,45.9,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH PORTEX PERCUTANEOUS STERILE LATEX FREE DISPOSABLE",SUP-101/596/070,CDM,S27200284,LOCAL,0272,RC,,,both,,,3247.05,974.11,"FIRST HEALTH [10303]","First Health",,2597.64,80,,,,,0,377.63,2759.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Stent Sf Ea Add",PX-361000709,CDM,37268,CPT,0361,RC,,,both,,,13927.30,4178.19,"FIRST HEALTH [10303]","First Health",,11141.84,80,,,,,0,13.93,11838.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT RIB XL 6IN ELASTIC 2 PANEL VELCRO CLSR FEMALE",SUP-13790408,CDM,S27000186,LOCAL,0270,RC,,,both,,,80.56,24.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.11,41.1,,,,,0,9.37,68.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"28.5 DIOPTER, SENSAR IOL, MODEL AR40E, BICONVEX, W/OPTIEDGE,",SUP-AR40E00285,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"CIGNA [10200]","Cigna Open Access",,530.02,56.9,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 9IN NERVE RETRACTION BLUNT ADSON STAINLESS STEEL 5MM",SUP-285230,CDM,S27200284,LOCAL,0272,RC,,,both,,,189.57,56.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,87.01,45.9,,,,,0,22.05,161.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE EXTRA SPORT VASCULAR J CURVE 300CM 3CM .014",SUP-22235MJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE RUNTHROUGH NS VASCULAR STRAIGHT 300CM 3CM .014IN",SUP-25-3013,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,660.96,68,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 7MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620807,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3038.55,27,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN RIGHT CORONARY 3D",SUP-534676T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"UHC [10700]","United Healthcare",,55.07,63.3,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE ROUND 202MM STAINLESS STEEL 12 HOLE 1 THREADED LOCKING",SUP-437112S,CDM,C1713,HCPCS,0278,RC,,,both,,,8594.64,2578.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2459.79,28.62,,,,,0,999.56,7305.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X11X6MM PEEK TITANIUM COMPOSITE ANATOMIC",SUP-5030641,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"AETNA [10100]","Aetna HMO/PPO",,5309.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 4MM CARBIDE OVAL PS STERILE",SUP-2296100026,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.40,83.52,"CIGNA [10200]","Cigna Local Plus",,148.94,53.5,,,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK VITRECTOMY CONSTELLATION PHACO TIPLESS CASSETTE DRNG",SUP-8065751155,CDM,S27200284,LOCAL,0272,RC,,,both,,,1343.39,403.02,"CIGNA [10200]","Cigna Open Access",,764.39,56.9,,,,,0,156.24,1141.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 28MM LCP STAINLESS STEEL DISTAL RADIAL",SUP-02.210.128,CDM,C1713,HCPCS,0278,RC,,,both,,,959.36,287.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",111.57,815.46,"percent of total billed charges",
"CAP END 5MM TIBIA STARDRIVE",SUP-04.004.001S,CDM,C1713,HCPCS,0278,RC,,,both,,,1688.40,506.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,483.22,28.62,,,,,0,196.36,1435.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 55CM 7FR .078IN ADULT RENAL CURVE",SUP-77821255,CDM,C1887,HCPCS,0272,RC,,,both,,,304.50,91.35,"FIRST HEALTH [10303]","First Health",,243.6,80,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLENOSPHERE - 32MM DIA X 2MM THK CONCENTRIC",SUP-5573-C-3202,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"BLUE CROSS [10001]","Blue Cross HMO",,4779.73,39.2,,5311.50,4717.44,5388.59,31,1418.07,10364.22,"percent of total billed charges",
"CATH INFINITI THRULUMEN 125CM 5FR LARGE JR4 CURVE",SUP-SRD6604,CDM,S27200284,LOCAL,0272,RC,,,both,,,314.24,94.27,"UHC [10700]","United Healthcare",,198.91,63.3,,,,,0,36.55,267.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,,,0250,RC,63323-0461-57,NDC,both,50,ML,175.92,52.78,"NOVANET [10819]",Novanet,,131.94,75,,,,,0,20.46,149.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RENAL FAILURE WITH CC",683,MS-DRG,,,,,,,inpatient,,,27646.67,8294,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7899.72,,"Fee schedule rate ($7,899.72). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,5432.64,21841.58,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 15MM APTUS TITANIUM HAND CORTICAL HEXADRIVE 4",SUP-A-5200.15/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,579.99,45.9,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 59MM 135CM 9MM THIN VASCULAR COCR",SUP-1012632-59,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"AETNA [10100]","Aetna HMO/PPO",,6678,79.5,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 500ML P5.3CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-5004BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"BLUE CROSS [10001]","Blue Cross PPO",,2055.65,39.2,,16595.83,16595.83,16595.83,"1 through 10",609.88,4457.4,"percent of total billed charges",
"SCR BONE 3.5MM 22MM PERI-LOC VLP HEXAGON LOW PROFILE FOOT",SUP-71801322,CDM,C1713,HCPCS,0278,RC,,,both,,,254.13,76.24,"CIGNA [10200]","Cigna Local Plus",,135.96,53.5,,3978.14,359.25,3978.14,24,29.56,216.01,"percent of total billed charges",
"INSRT HUMERAL 39MM UNIVERS REVERS +3MM MEDIUM SHOULDER",SUP-AR-9503M-03,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1999.2,68,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 15CM SILICONE SCHON XL BASIC ACUTE HEMODIALYSIS",SUP-H787108007015,CDM,C1752,HCPCS,0278,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY",RX-11143,CDM,,,0250,RC,45802-0758-00,NDC,both,1,UN,66.93,20.08,"FIRST HEALTH [10303]","First Health",,53.54,80,,,,,0,7.78,56.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 10MM 9FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEL10100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX LOW PROFILE REINFORCED TISSUE MATRIX, LONG-TERM RESOR",SUP-F10264-1515L,CDM,C1781,HCPCS,0278,RC,,,both,,,17700.98,5310.29,"BLUE CROSS [10001]","Blue Cross HMO",,6938.78,39.2,,,,,0,2058.62,15045.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 5-0 PS-2 18IN MONOFILAMENT UNDYED",SUP-Y495G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 19MM 150CM 4MM BILIARY STAINLESS",SUP-37912-41915,CDM,C1876,HCPCS,0278,RC,,,both,,,6210.00,1863,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 20MM 1.2MM ULTRA LOW PROFILE BALLOON",SUP-1012268-20U,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE RD180 STD 5MM SUTURING 1 PORT AUTORELEASE STERILE",SUP-021100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,204.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY 10.8CM 13GA 11GA BD TREK AUTOMATIC BRAKE CONTROL",SUP-TKL1106,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,399.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006175274070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"BLUE CROSS [10001]","Blue Cross HMO",,390.99,39.2,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL ADHESIOLYSIS WITH CC",336,MS-DRG,,,,,,,inpatient,,,57144.78,17143.43,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,13996.02,,"Case rate ($13,080.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,146.03, add-ons for qualifying new technology services are included. If operating cost exceeds $45,185.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,300.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,162.09. The transfer operating threshold is the transfer adjustment factor * $12,146.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $918.30. The transfer capital threshold is the transfer adjustment factor * $918.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,57144.78,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 9MM KNEE XLPE POSTERIOR STABILIZE LEGION",SUP-71453246,CDM,C1776,HCPCS,0278,RC,,,both,,,14831.55,4449.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1724.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1724.91,12606.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAUT ELECTROSURGICAL 6MM ENDOWRIST SP MONOPOLAR NONSTERILE",SUP-430101,CDM,S27000186,LOCAL,0270,RC,,,both,,,1669.50,500.85,"AETNA [10100]","Aetna HMO/PPO",,1327.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,194.16,1419.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 34X10-13MM MAGNIFY-S 15D 26MM EXPAND",SUP-1126.1210,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5076.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 325CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-325,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2162.38,28.62,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 12X4IN SILVERLON ISLAND PAD 10X2IN",SUP-ID-412,CDM,S27200284,LOCAL,0272,RC,,,both,,,295.37,88.61,"NOVANET [10819]",Novanet,,221.53,75,,,,,0,34.35,251.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ENDOSCOPIC I TYPE I JET MULTIFUNCTIONAL PROBE",SUP-20150-261,CDM,C1889,HCPCS,0272,RC,,,both,,,4312.50,1293.75,"MULTIPLAN [10600]",Multiplan,,3665.63,85,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 100MM 3.5MM BALLOON",SUP-H74939147351010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULUS ALIF BOLT, 5.0X15MM FIXATION",SUP-1450150,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,188.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",188.41,1377,"percent of total billed charges",
"BIT DRILL 152MM 4.3MM PHOENIX SHORT TWIST CROWE POINT TIBIAL",SUP-27984,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"UHC [10700]","United Healthcare",,1068.19,63.3,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO PERCUTANEOUS CUSTOM SHEATH",SUP-ASK-29804-PH,CDM,S27200284,LOCAL,0272,RC,,,both,,,399.72,119.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,164.28,41.1,,,,,0,46.49,339.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T 25X11X.8MM TITANIUM 1.5MM SCREWS 8 HOLE APTUS",SUP-A-4350.14,CDM,S27200284,LOCAL,0272,RC,,,both,,,6085.80,1825.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,721.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,707.78,5172.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT EDGE ACCUVAC",SUP-E2350HSNSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.17,24.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.44,68.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT POSTERIOR STABILIZE BEAD TRIATHLON",SUP-5516-F-401,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"KAISER [10500]",Kaiser,,11602.35,67,,,,,0,2013.96,14719.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 12CM 5FR .035IN URETERAL",SUP-M006155212090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"KAISER [10500]",Kaiser,,913.04,67,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 5-0 RB-1 30IN 2 ARM BRAID GREEN",SUP-X550H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 2.25MM .017IN",SUP-H7493926708220,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lymph Vessel X-Ray Arms/Legs",PX-323000039,CDM,75803,CPT,0320,RC,,,both,,,2624.56,787.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.24,2624.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RP UNISTEP PLUS 90MM 75CM 12MM 8FR 100CM",SUP-H965402130,CDM,C1876,HCPCS,0278,RC,,,both,,,7140.00,2142,"AETNA [10100]","Aetna HMO/PPO",,5676.3,79.5,,,,,0,830.38,6069,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 7 132D",SUP-6720-0737,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9848.4,41.1,,6417.48,6417.48,6417.48,"1 through 10",2786.79,20367.74,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 15MM 145CM 2.5MM CORONARY STENT",SUP-1145250-15,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 80MM 10MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171100870,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UHC [10700]","United Healthcare",,743.46,63.3,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tiss Cult Solid Tumor",PX-311000029,CDM,88239,CPT,0311,RC,,,both,,,1424.05,427.21,"AETNA [10100]","Aetna HMO/PPO",,1132.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1210.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC",843,MS-DRG,,,,,,,inpatient,,,69733.13,20919.94,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,12745.08,,"Case rate ($12,373.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,489.97, add-ons for qualifying new technology services are included. If operating cost exceeds $44,529.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,250.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $11,505.17. The transfer operating threshold is the transfer adjustment factor * $11,489.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $868.70. The transfer capital threshold is the transfer adjustment factor * $868.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,49748.32,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT CAST CANVAS LARGE OPEN TOE SHOCK ABSORBENT SOLE ROCKER",SUP-798703,CDM,S27000186,LOCAL,0270,RC,,,both,,,65.69,19.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.64,55.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 57MM 135CM 8MM 60MM BILIARY TANTALUM",SUP-PXB35-08-57-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2004.45,45.9,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 18MM 2.5MM CORONARY STENT EVEROLIMUS",SUP-1550250-18,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 31CM E-Z CLEAN LAPAROSCOPIC L HOOK",SUP-0063,CDM,S27200284,LOCAL,0272,RC,,,both,,,421.95,126.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,193.68,45.9,,,,,0,49.07,358.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM PRESS FIT BASIC SUMMIT 4 12/14 TAPER HIP",SUP-157005100,CDM,C1776,HCPCS,0278,RC,,,both,,,9090.75,2727.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1057.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1057.25,7727.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 13MM 51X73MM CLARIA MRI CRT-D SURESCAN",SUP-DTMA1D4,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,23088,40,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18 DIOPTER HAPTIC C BICONVEX 13MM 6MM POSTERIOR",SUP-ZXR00U0180,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,213.22,28.62,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Lwr Ext Arty Bi",PX-921000006,CDM,93925,CPT,0921,RC,,,both,,,1741.69,522.51,"AMERIGROUP MEDICAID [20100]",Amerigroup,,206.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,202.56,1480.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GD CS WORLEY","SUP-361 683",CDM,C1892,HCPCS,0272,RC,,,both,,,2325.00,697.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,275.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,270.4,1976.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 2.4MM INTREPID ANGLE 2 BEVEL MICRO COAXIAL",SUP-8065982465,CDM,S27200284,LOCAL,0272,RC,,,both,,,464.21,139.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,213.07,45.9,,,,,0,53.99,394.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 3.50 X 32MM",SUP-H7493942832350,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 10ML .212-.85MM DEMINERALIZED CORTICAL",SUP-420115,CDM,C1713,HCPCS,0278,RC,,,both,,,1859.63,557.89,"CIGNA [10200]","Cigna Local Plus",,994.9,53.5,,3978.14,359.25,3978.14,24,216.27,1580.69,"percent of total billed charges",
"FRCP SURGICAL 5.5IN TISSUE 1X2 TEETH FLUTED HANDLE MATTE",SUP-130-161,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.69,23.31,"FIRST HEALTH [10303]","First Health",,62.15,80,,,,,0,9.04,66.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90D LEFT 41MM STAINLESS STEEL 2.4MM SCR 2 HOLE HEAD 3",SUP-02.115.630S,CDM,C1713,HCPCS,0278,RC,,,both,,,4045.61,1213.68,"FIRST HEALTH [10303]","First Health",,3236.49,80,,,,,0,470.5,3438.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROLENE 6X3IN HERNIA NONABSORBABLE SOFT",SUP-PMII,CDM,C1781,HCPCS,0278,RC,,,both,,,558.38,167.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,159.81,28.62,,,,,0,64.94,474.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HARVESTER 9MM GRAFT QUADPRO",SUP-AR-2386-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,3346.88,1004.06,"KAISER [10500]",Kaiser,,2242.41,67,,,,,0,389.24,2844.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 60MM 4MM TAPER BALLOON DILATATION JET",SUP-A2040-060,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 520CC",SUP-SSZ-M520,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CIGNA [10200]","Cigna Open Access",,848.04,56.9,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .018IN 4FR 7MM 135CM 4CM PTA LOW",SUP-G50257,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 STD 12MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS7S12R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"MULTIPLAN [10600]",Multiplan,,8832.69,85,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH SMOKE EVAC 10FT VALLEYLAB STERILE LATEX FREE",SUP-E3810,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.80,34.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.23,96.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esophagoscopy Rigid Trnso",PX-750000158,CDM,43180,CPT,0750,RC,,,both,,,4128.00,1238.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3392.46,,"Case rate ($3,392.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,480.09,4128,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Speech Fluency",PX-444000015,CDM,92521,CPT,0444,RC,,,both,,,379.56,113.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,239.55,,"Per diem ($239.55).",,,,0,44.14,379.56,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"GYNECARE TVT OBTURATOR SYSTEM (SINGLE USE DEVICE)",SUP-810081,CDM,C1771,HCPCS,0278,RC,,,both,,,8539.72,2561.92,"BLUE CROSS [10001]","Blue Cross HMO",,3347.57,39.2,,,,,0,993.17,7258.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4.5MM AVENIR COMPLEX 10 COIL FRAME",SUP-10CFR04510,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UHC [10700]","United Healthcare",,7420.72,63.3,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 7FR 12MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206120410,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 24/26FR STERILE DISPOSABLE",SUP-27040GP130-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3100.64,930.19,"CIGNA [10200]","Cigna Local Plus",,1658.84,53.5,,,,,0,360.6,2635.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM SURGICAL SQUARE STERILE LATEX FREE DISPOSABLE",SUP-SN24,CDM,S27200284,LOCAL,0272,RC,,,both,,,3712.50,1113.75,"MULTIPLAN [10600]",Multiplan,,3155.63,85,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 15MM REDAPT LOCK",SUP-71354502,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,1831.33,1831.33,1831.33,16,189.34,1383.8,"percent of total billed charges",
"PASSER SUPER SHUTTLE 3 HIGH STRENGTH EYELET BRAIDED RESIST",SUP-C6005,CDM,S27200284,LOCAL,0272,RC,,,both,,,611.31,183.39,"UHC [10700]","United Healthcare",,386.96,63.3,,,,,0,71.1,519.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE PT VASCULAR 182CM .014IN STAINLESS STEEL",SUP-H74912160011,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"KAISER [10500]",Kaiser,,379.89,67,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH C2 CRYOBALLOON PEAR ABLATION FOCAL STERILE LATEX FREE",SUP-FG-1024,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rev Skin Pocket Pcmkr",PX-480000016,CDM,33222,CPT,0481,RC,,,both,,,2776.00,832.8,"KAISER [10500]",Kaiser,,1859.92,67,,,,,0,322.85,2776,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT POSTERIOR STABILIZE BEAD TRIATHLON",SUP-5516-F-401,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"CIGNA [10200]",Cigna,,6926.78,40,,5873.17,5873.17,5873.17,"1 through 10",2013.96,14719.4,"percent of total billed charges",
"DUMBBELL EXERCISE CAST IRON NEOPRENE 1-10LB",SUP-81513878,CDM,S27000186,LOCAL,0270,RC,,,both,,,725.19,217.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,298.05,41.1,,,,,0,84.34,616.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL MULTIPASS 6-0 PS-3 18IN BRAID COATED UNDYED",SUP-J499G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 45X5IN PRECUT PADDED FIBERGLASS",SUP-OG-545PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,170.00,51,"NOVANET [10819]",Novanet,,127.5,75,,,,,0,19.77,144.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR STD 28MM 3 PEG KNEE SERIES A",SUP-184762,CDM,C1776,HCPCS,0278,RC,,,both,,,4824.48,1447.34,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,561.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.09,4100.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Liver Cyst Ablation",PX-361000181,CDM,47399,CPT,0361,RC,,,both,,,2971.43,891.43,"MULTIPLAN [10600]",Multiplan,,2525.72,85,,,,,0,345.58,2971.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ligation Hemm Intrnl Sngl",PX-450000268,CDM,46945,CPT,0361,RC,,,both,,,11998.00,3599.4,"AETNA [10100]","Aetna HMO/PPO",,9538.41,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1395.37,10198.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GALASHAPE 15.5X5.3CM SOFT TISSUE SCAFFOLD",SUP-FR3D02,CDM,C1781,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 20MM 8MM BALLOON DILATATION DURALYN",SUP-48008002S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 7IN STRAIGHT 1.5MM CUSHING DELICATE SURGICAL",SUP-57-2001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2266.43,679.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1541.17,68,,,,,0,263.59,1926.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS MULTIPASS 5-0 PC-1 18IN BRAID ANTIBACTERIAL",SUP-VCP834G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 3-0 SH-1 18IN CONTROL RELEASE BRAID 8",SUP-C003D,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.00,30.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.75,85.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK PHACOEMULSIFICATION .9MM INFINITI 30D ULTRASOUND",SUP-8065741081,CDM,S27200284,LOCAL,0272,RC,,,both,,,432.39,129.72,"MULTIPLAN [10600]",Multiplan,,367.53,85,,,,,0,50.29,367.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL LONG 140MM OVER SOLID AO CONNECTION 2MM",SUP-P99-100-2014,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG ALGINATE 8X4IN ACTICOAT POLYURETHANE NANOCRYSTALLINE",SUP-66021771,CDM,S27200284,LOCAL,0272,RC,,,both,,,193.33,58,"CIGNA [10200]","Cigna Open Access",,110,56.9,,,,,0,22.48,164.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL DIA10MM HOLLOW FOR MULTILOC HUMERAL NAILING SYSTEM",SUP-03.019.003,CDM,S27200284,LOCAL,0272,RC,,,both,,,2158.80,647.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,887.27,41.1,,,,,0,251.07,1834.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RELIEVA VORTEX 2 IRRIGATION SINUS 1 HAND CONTROL",SUP-RV02,CDM,S27200284,LOCAL,0272,RC,,,both,,,1255.50,376.65,"KAISER [10500]",Kaiser,,841.19,67,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERTORQUE THRULUMEN 100CM 6FR .051IN .042IN RIGHT",SUP-532670,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA [10200]","Cigna Local Plus",,44.22,53.5,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG SQUARE 6X6IN ABSORBENT PAD SELF ADHERENT SILICONE",SUP-294399,CDM,S27200284,LOCAL,0272,RC,,,both,,,46.46,13.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19.1,41.1,,,,,0,5.4,39.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SURGICAL GRAFT STAINLESS STEEL STERILE DISTAL",SUP-AMGM-SD,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.39,26.52,"FIRST HEALTH [10303]","First Health",,70.71,80,,,,,0,10.28,75.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUSHER STENT ADVANIX PANCREATIC RAPID EXCHANGE 4FR 5FR",SUP-M00535010,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 55IN 8FR RADIOPAQUE STRIPE WEIGHT TIP RIGID",SUP-8884720855E,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.09,21.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,47.66,68,,,,,0,8.15,59.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 55IN 8FR RADIOPAQUE STRIPE WEIGHT TIP RIGID",SUP-8884720855E,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.09,21.03,"CIGNA [10200]",Cigna,,47.66,68,,,,,0,8.15,59.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 195MM 4.5MM SPS LONG TWIST AO FITTING STERILE",SUP-700354,CDM,S27200284,LOCAL,0272,RC,,,both,,,1333.58,400.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,612.11,45.9,,,,,0,155.1,1133.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON 80CM 5FR C2 CURVE",SUP-G11202,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"FIRST HEALTH [10303]","First Health",,189.99,80,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2-0 FS 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8685H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 16CM 13.5FR .038IN POLYURETHANE MAHURKAR QPLUS 2",SUP-8888135165,CDM,C1752,HCPCS,0272,RC,,,both,,,860.01,258,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,394.74,45.9,,,,,0,100.02,731.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING DRNG 30CM 12FR SILICONE SOFT PLIABLE T",SUP-SU130-1238,CDM,S27200284,LOCAL,0272,RC,,,both,,,2175.00,652.5,"NOVANET [10819]",Novanet,,1631.25,75,,,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 16GA ACCURIAN CURVE SHARP 10MM",SUP-AC0002,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,47.92,45.9,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC SABRELOC 5-0 S-14 12IN 2 ARM MONOFILAMENT",SUP-1766G,CDM,S27200284,LOCAL,0272,RC,,,both,,,190.36,57.11,"MULTIPLAN [10600]",Multiplan,,161.81,85,,,,,0,22.14,161.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 2-0 CT 27IN MONOFILAMENT ABSORBABLE",SUP-853H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENERAL NEURO PACK (GNUHD)215",SUP-SNE21GNUHE,CDM,S27200284,LOCAL,0272,RC,,,both,,,504.63,151.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,59.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.69,428.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (PS) - SIZE 8",SUP-5555-2258,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"FIRST HEALTH [10303]","First Health",,1134,80,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 35.6X4.3X.6MM MICRO SAGITTAL FINE TOOTH STERILE",SUP-ZS-042,CDM,S27200284,LOCAL,0272,RC,,,both,,,168.61,50.58,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.61,143.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 485CC",SUP-SSZ-M485,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1013.47,68,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER FLEXIVA 200UM FLEXSHIELD HIGH POWER POLISH",SUP-M0068403910,CDM,S27200284,LOCAL,0272,RC,,,both,,,2752.13,825.64,"MULTIPLAN [10600]",Multiplan,,2339.31,85,,,,,0,320.07,2339.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 125CM 5FR BERN1 CURVE ANGIOGRAPHIC PEBAX",SUP-PV512538BERN,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,347,68,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOUND 8-30FR URETHRAL CURVE VAN BUREN 10.75IN",SUP-51-6355,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.02,101.71,"AETNA [10100]","Aetna HMO/PPO",,269.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.43,288.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 130MM 11.7MM 8MM ADJUSTABLE NECK FLANGE CLIP IN OBTR",SUP-75HA80,CDM,S27200284,LOCAL,0272,RC,,,both,,,1619.19,485.76,"MULTIPLAN [10600]",Multiplan,,1376.31,85,,,,,0,188.31,1376.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 6MM PORTEX BLUSELECT UNCUFF STERILE LATEX FREE",SUP-101/816/060,CDM,S27200284,LOCAL,0272,RC,,,both,,,311.63,93.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,143.04,45.9,,,,,0,36.24,264.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR ENDOSCOPIC RECTANGLE RIGID BALLOON RU-75M-R1/RU-12M-R1",SUP-MAJ-864,CDM,S27200284,LOCAL,0272,RC,,,both,,,531.85,159.55,"CIGNA [10200]",Cigna,,361.66,68,,,,,0,61.85,452.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 4FR .042IN LEFT CORONARY",SUP-538472,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"CIGNA [10200]","Cigna Local Plus",,47.89,53.5,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 6MM REINFORCED PROTECTED LEADS NIM EMG",SUP-8229306,CDM,S27200284,LOCAL,0272,RC,,,both,,,3435.00,1030.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1576.67,45.9,,,,,0,399.49,2919.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS",029,MS-DRG,,,,,,,inpatient,,,151883.42,45565.03,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,45499.1,,"Case rate ($21,162.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $19,650.69, add-ons for qualifying new technology services are included. If operating cost exceeds $52,690.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,867.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,676.67. The transfer operating threshold is the transfer adjustment factor * $19,650.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,485.69. The transfer capital threshold is the transfer adjustment factor * $1,485.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,99605.07,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"ASCOPE 5 BROCHNO 2.7/ 1.2 ULTRA THIN",SUP-624001000US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2362.50,708.75,"PHCS [10601]",PHCS,,1653.75,70,,,,,0,274.76,2008.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 3.5CM 14FR RADIOPAQUE LOW PROFILE PROXIMAL ANTIREFLUX",SUP-0120-14-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,529.76,68,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SUT NO5 MAXBRAID CURVED TAPERED NDL NONABSORBABLE 2PK",SUP-CM0225N,CDM,S27200284,LOCAL,0272,RC,,,both,,,737.10,221.13,"CIGNA [10200]","Cigna Open Access",,419.41,56.9,,,,,0,85.72,626.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR INFLATION DEVICE BASIXTOUCH 13IN ANALOG DISPLAY",SUP-IN8403,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.44,105.73,"CIGNA [10200]",Cigna,,239.66,68,,,,,0,40.99,299.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 5FR LCB CURVE GUIDING NYLON CORONARY",SUP-LA5LCB,CDM,S27200284,LOCAL,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13CM NATRELLE INSPIRA P3.4CM LOW PLUS PROFILE",SUP-MSZ-LP320,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AETNA [10100]","Aetna HMO/PPO",,125.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR/ELEV LAPAROSCOPIC STD VCARE CUP CERVICAL UTERINE",SUP-60-6085-201,CDM,S27200284,LOCAL,0272,RC,,,both,,,522.45,156.73,"MULTIPLAN [10600]",Multiplan,,444.08,85,,,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 77.5X11.2MM RECIPROCATE SURGICAL STERILE",SUP-KM-325R,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.49,33.15,"CIGNA [10200]","Cigna Local Plus",,59.11,53.5,,,,,0,12.85,93.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 60CM 8FR EPICARDIUM MYOCARDIUM BIPOLAR SUT",SUP-4968-60,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]","Cigna Local Plus",,2999.75,53.5,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND SUTUPAK 2-0 60IN BRAID 2 STRAND PRECUT",SUP-SA5H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLEANSER WND ANTISEP GEL ANASEPT 3OZ",SUP-5003G,CDM,S27200284,LOCAL,0272,RC,,,both,,,183.80,55.14,"CIGNA [10200]","Cigna Local Plus",,98.33,53.5,,,,,0,21.38,156.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 5MM KII FIOS FIRST ENTRY HANDLED",SUP-CFF04,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,59,41.1,,,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 0-8CM 19GA 4.8FR PROCORE ECHOTIP ULTRASOUND HIGH",SUP-G53585,CDM,S27200284,LOCAL,0272,RC,,,both,,,3195.00,958.5,"CIGNA [10200]","Cigna Open Access",,1817.96,56.9,,,,,0,371.58,2715.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 8.75IN RYDER RING HANDLE NDL TUNGSTEN CARBIDE",SUP-55-2664,CDM,S27200284,LOCAL,0272,RC,,,both,,,2123.25,636.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,974.57,45.9,,,,,0,246.93,1804.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 3-0 RB-1 SPIRAL 6IN KNOTLESS",SUP-SXMP1B424,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.17,68.75,"KAISER [10500]",Kaiser,,153.54,67,,,,,0,26.65,194.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 375CC",SUP-SSZ-M375,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CIGNA [10200]","Cigna Local Plus",,797.36,53.5,,,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT STRAIGHT RETRACTION 80MM MARS 26MM STERILE SPINE",SUP-632.468S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2880.00,864,"AMERIGROUP MEDICAID [20100]",Amerigroup,,341.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.94,2448,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDPN ORTHOPEDIC 300MM 3.2MM THREADED",SUP-71177201,CDM,S27200284,LOCAL,0272,RC,,,both,,,1624.32,487.3,"MULTIPLAN [10600]",Multiplan,,1380.67,85,,,,,0,188.91,1380.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 12MM KII FIOS FIRST ENTRY ADVANCED",SUP-CFF71,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"PHCS [10601]",PHCS,,127.89,70,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 125CM 6FR FR4 CURVE ANGIOGRAPHIC VENTRICULAR 2",SUP-H749165992252,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 4MM E9000 ROUND CARBIDE ROUND HEAD LSO",SUP-E8240LSO,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 4MM E9000 ROUND CARBIDE ROUND HEAD LSO",SUP-E8240LSO,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.3MM SUT GUIDE STERILE",SUP-8757,CDM,S27200284,LOCAL,0272,RC,,,both,,,1058.02,317.41,"MULTIPLAN [10600]",Multiplan,,899.32,85,,,,,0,123.05,899.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY 286CM 1.2MM SPYBITE MAX STERILE LATEX FREE",SUP-M00546470,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1537.14,41.1,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT RX 80MM 194CM 10MM 8FR TAPER ENDOPROSTHESIS",SUP-M00569720,CDM,S27500001,LOCAL,0275,RC,,,both,,,11537.01,3461.1,"UHC [10700]","United Healthcare",,7302.93,63.3,,,,,0,1341.75,9806.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 62.5MM ATLANTIS VISION ELITE BONE ANTERIOR CERVICAL",SUP-7200062,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"PHCS [10601]",PHCS,,3704.4,70,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemostatic Agent",PX-E27200131,CDM,E27200131,LOCAL,0272,RC,,,both,,,320.10,96.03,"CIGNA [10200]","Cigna Open Access",,182.14,56.9,,,,,0,37.23,272.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 405CC",SUP-SMPX405,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"BLUE CROSS [10001]","Blue Cross PPO",,2921.18,39.2,,16595.83,16595.83,16595.83,"1 through 10",866.67,6334.2,"percent of total billed charges",
"LEAD PACING 53CM SOLIA S ENDOCARDIAL STEROID ELUTE BIPOLAR",SUP-377177,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"FIRST HEALTH [10303]","First Health",,1786,80,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STYLET ASSORTED 46CM UNIVERSAL J STRAIGHT REPOSITIONING",SUP-DS06003/46,CDM,S27500001,LOCAL,0275,RC,,,both,,,453.60,136.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,53.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 25X20X7MM DEMINERALIZED CANCELLOUS CONFORM",SUP-0W1027,CDM,S27800098,LOCAL,0278,RC,,,both,,,9453.00,2835.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1120.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1099.38,8035.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEPARATOR SURGICAL 7IN HORSLEY DURA STAINLESS STEEL",SUP-285325,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.34,73,"CIGNA [10200]",Cigna,,165.47,68,,,,,0,28.3,206.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 24CM 150CM 7FR .035IN 3CM BLADDER LOOP",SUP-M006155242190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,406.5,28.62,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE EAGLE INFLATION 20ML UROLOGICAL NITINOL GWIRE",SUP-325130,CDM,C1726,HCPCS,0272,RC,,,both,,,578.18,173.45,"PHCS [10601]",PHCS,,404.73,70,,,,,0,67.24,491.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 40MM 135CM 7MM VASCULAR OTW SELF EXPAND",SUP-1012535-40,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 100MM 2.5MM .018IN BALLOON",SUP-R51002510L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,241.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM SOLERA SPINE CANNULATED MULTIAXIAL",SUP-54840016540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UHC [10700]","United Healthcare",,6043.16,63.3,,5023.51,2672.93,6679.78,18,1110.3,8114.82,"percent of total billed charges",
"AUG FEMORAL 5MM TRIATHLON 7 RIGHT DISTAL KNEE TOTAL",SUP-5540-A-702,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,538.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,528.45,3862.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BRIDGE 90CM 80CM 4MM 20MM .9MM BALLOON OCCLUSION 60CC",SUP-590-001,CDM,C1725,HCPCS,0272,RC,,,both,,,6244.50,1873.35,"FIRST HEALTH [10303]","First Health",,4995.6,80,,,,,0,726.24,5307.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 168MM 21GA 18GA SONOPLEX STIM INDWELL E CATH",SUP-271285-40E,CDM,C9812,HCPCS,0272,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 2 LEFT DISTAL KNEE",SUP-5540-A-201,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"BLUE CROSS [10001]","Blue Cross PPO",,1781.17,39.2,,3949.44,3949.44,3949.44,"1 through 10",528.45,3862.24,"percent of total billed charges",
"SUT NYLON ETHILON MULTIPASS 4-0 FS-2 18IN MONOFILAMENT BLACK",SUP-662H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX11MM CAPSTONE PTC",SUP-3992211,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"BLUE CROSS [10001]","Blue Cross PPO",,8320.44,39.2,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADVISOR SENSOR ENABLED HD GRID X MAPPING BI-DIRECTIONAL CATH",SUP-D-AVHDX-DF16,CDM,C1732,HCPCS,0272,RC,,,both,,,17250.00,5175,"NOVANET [10819]",Novanet,,12937.5,75,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 29MM FLEXIBLE SURE LOCK DELIVERY SYSTEM",SUP-TARP-29,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"CIGNA [10200]","Cigna Local Plus",,3813.52,31.5,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Speech/Hearing Indv",PX-440000002,CDM,92507,CPT,0440,RC,,,both,,,346.95,104.08,"MULTIPLAN [10600]",Multiplan,,294.91,85,,,,,0,40.35,346.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 65CM 5FR BERENSTEIN CURVE ANGIOGRAPHIC DURATION",SUP-H787117221045,CDM,C1887,HCPCS,0272,RC,,,both,,,466.56,139.97,"UHC [10700]","United Healthcare",,295.33,63.3,,,,,0,54.26,396.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS AIM SL 68CM 65CM 7FR 5FR ACUTE CURVE GUIDING PEBAX",SUP-DS2N021-65,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 90MM TITANIUM SELF TAP CANNULATED STERILE",SUP-04.353.890S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"CIGNA [10200]",Cigna,,1672.39,68,,1831.33,1831.33,1831.33,16,286.03,2090.49,"percent of total billed charges",
"DEVICE PIPELINE FLEX 55D 12MM 2.5MM EMBOLIZATION 75% COCR 25",SUP-PED-250-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"PHCS [10601]",PHCS,,53865,70,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACURATE PRIME AORTIC VALVE XL",SUP-SYM-SV29-009-C,CDM,S62400003,LOCAL,0624,RC,,,both,,,127680.00,38304,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH JADE 135CM 150MM 7MM BALLOON DILATATION HYDROPHILIC",SUP-607015022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CAGE SPINAL 9MM XL LORDOTIC",SUP-365.709,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,791.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK",RX-155785,CDM,J1953,HCPCS,0636,RC,43598-0635-52,NDC,both,100,ML,139.64,41.89,"CIGNA [10200]","Cigna Open Access",,5.7,,,,,,,2.33,118.69,"fee schedule",
"TROCAR LAPAROSCOPIC 150MM 5MM KII 2 PACK ACCESS SYSTEM Z",SUP-CTB10,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"KAISER [10500]",Kaiser,,145.73,67,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LASSOSTAR NAV 20MM DIAGNOSTIC CIRCULAR MAPPING CATH",SUP-D140402,CDM,C1732,HCPCS,0272,RC,,,both,,,7286.40,2185.92,"NOVANET [10819]",Novanet,,5464.8,75,,,,,0,847.41,6193.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM STRAIGHT 1.5MM 2.3MM SCR 4 HOLE LOCK VARIAX",SUP-57-15301,CDM,C1713,HCPCS,0278,RC,,,both,,,3123.90,937.17,"CIGNA [10200]","Cigna Local Plus",,1671.29,53.5,,3978.14,359.25,3978.14,24,363.31,2655.32,"percent of total billed charges",
"PLATE MEDIUM STRAIGHT 1.5MM 2.3MM SCR 4 HOLE LOCK VARIAX",SUP-57-15301,CDM,C1713,HCPCS,0278,RC,,,both,,,3123.90,937.17,"NOVANET [10819]",Novanet,,2342.93,75,,,,,0,363.31,2655.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR BICONVEX 26MM GENESIS II KNEE",SUP-71420568,CDM,C1776,HCPCS,0278,RC,,,both,,,6344.55,1903.36,"NOVANET [10819]",Novanet,,4758.41,75,,,,,0,737.87,5392.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION 130CM 2.4-3FR .021IN .035IN MICRO STRAIGHT",SUP-M001195210,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 8FR .09IN MP1 CURVE GUIDING CORONARY",SUP-LA8MP1SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN AMPLATZ",SUP-77803700,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ORTHOCORD 36IN BRAID WITHOUT NDL BLUE VIOLET 2MM",SUP-223113,CDM,S27200284,LOCAL,0272,RC,,,both,,,4029.60,1208.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR EXTRA BACKUP LAD",SUP-67006100,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
SHEATHS,SUP-FCL20100,CDM,C1893,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(COMM) CATHETER WALRUS STRAIGHT BALLOON DILATATION VARIABLE",SUP-BG8087-095,CDM,C1887,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH HI-FLO RENEGADE 135CM 20CM 3-2.8FR .027IN MICRO",SUP-M001183030,CDM,C1887,HCPCS,0272,RC,,,both,,,4726.50,1417.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MACH1 100CM 8FR AL1.5 CURVE GUIDING PTFE FEMORAL",SUP-H74934358850,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY PRESSURE MNTR 2.5FR 5CM .015IN STRAIGHT 1 LUMEN NDL HUB",SUP-G58413,CDM,C1887,HCPCS,0272,RC,,,both,,,891.00,267.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RENEGADE STC-18 150CM 30CM 2.4-3FR .021IN MICRO",SUP-M001181380,CDM,C1887,HCPCS,0272,RC,,,both,,,2287.50,686.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MACH1 55CM 8FR .091IN LIMA CURVE GUIDING PTFE",SUP-M001198620,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT POLYFLEX 60MM 9MM 14MM AIRWAY POLYESTER SILICONE SELF",SUP-7014,CDM,C1887,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 90CM 7FR LCB CURVE GUIDING NYLON CORONARY",SUP-LA7LCBD,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER GD 100CM 6FR RWY JR3.5 CRV",SUP-H749389696910,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RIST 105CM GUIDING STERILE LATEX FREE",SUP-106F-071-105,CDM,C1887,HCPCS,0272,RC,,,both,,,8093.70,2428.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONVEY 100CM 7FR JR4 CURVE GUIDING HYDROPHILIC FEMORAL",SUP-H749392656860,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ACUITY CUT-AWAY 49CM 8FR CS-A6 CURVE GUIDING STERILE",SUP-7024,CDM,C1887,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 90CM 8FR STD JR3.5 CURVE GUIDING NYLON",SUP-LA8JR35D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM RADIAL 7.5MM EVOLVE STD ELBOW PROLINE MODULAR",SUP-496S075,CDM,C1776,HCPCS,0278,RC,,,both,,,14614.20,4384.26,"CIGNA [10200]","Cigna Open Access",,4895.76,33.5,,5302.19,4377.88,6578.61,27,1699.63,12422.07,"percent of total billed charges",
"PROBE LITHO 668MM .8MM SWISS LITHOCLAST PNEUMATIC LATEX FREE",SUP-M0068407310,CDM,S27200284,LOCAL,0272,RC,,,both,,,1680.60,504.18,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET",RX-14825,CDM,,,0637,RC,70700-0268-99,NDC,both,1,UN,379.51,113.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNR SNS PLPCTM HEX SHRTHRW MED",SUP-6034,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 4.8FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175252050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"PHCS [10601]",PHCS,,749.52,70,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 4.8FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175252050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,491.47,45.9,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 28CM 3CM 6FR .035IN 2 PIGTAIL",SUP-M006192134050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]",Cigna,,816.39,68,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 10CM 7FR .035IN GENTLE CURVE BILIARY",SUP-G21979,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ACCUSTICK II .018IN .038IN FLOPPY 60CM 145CM 6FR 4FR",SUP-M001207020,CDM,C1894,HCPCS,0272,RC,,,both,,,769.50,230.85,"PHCS [10601]",PHCS,,538.65,70,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 10X11X30MM 15",SUP-5801305,CDM,C1889,HCPCS,0278,RC,,,both,,,28800.00,8640,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3349.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9FR .118IN 25CM ROBUST VALVE SPLITTABLE",SUP-PLS-2509,CDM,C1894,HCPCS,0272,RC,,,both,,,319.73,95.92,"UHC [10700]","United Healthcare",,202.39,63.3,,,,,0,37.18,271.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS SOLN 2.5% DEXTROSE CA 3.5 MEQ/L-MAG 0.5 MEQ/L",RX-27801,CDM,,,0250,RC,00941-0427-52,NDC,both,2000,ML,241.44,72.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,164.18,68,,,,,0,28.08,205.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 12FR 12CM HEMOSTASIS GWIRE FAST-CATH DUO .038IN",SUP-406301,CDM,C1894,HCPCS,0272,RC,,,both,,,166.00,49.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 5FR 10CM DIL GWIRE PINNACLE TIF TIP .038IN",SUP-10-2531,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH HURRICANE 180CM 4CM 5.8FR 8MM 11 ATM BALLOON DILATATION",SUP-M00545940,CDM,C1726,HCPCS,0272,RC,,,both,,,1849.50,554.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,760.14,41.1,,,,,0,215.1,1572.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH GORE DRYSEAL FLEX 65CM 6.7MM 18FR INTRO HYDROPHILIC",SUP-GDSF1865,CDM,C1894,HCPCS,0272,RC,,,both,,,6858.60,2057.58,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2818.88,41.1,,,,,0,797.66,5829.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN EXTRA BACKUP 5 LEFT CURVE",SUP-LA7EBU50,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AETNA [10100]","Aetna HMO/PPO",,311.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006175284170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER WEBSTER CS 7FR 2-8-2MM SPACE FJ CURVE",SUP-BD710FJ282CT,CDM,C1730,HCPCS,0272,RC,,,both,,,3740.00,1122,"NOVANET [10819]",Novanet,,2805,75,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,inpatient,,,65939.30,19781.79,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Splint Fiberglass",PX-E27000164,CDM,E27000164,LOCAL,0270,RC,,,both,,,143.00,42.9,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT 28CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061755740,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS [10001]","Blue Cross PPO",,353.65,39.2,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 28CM 3CM 6FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006180224050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,298.1,28.62,,,,,0,121.14,885.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POLYETHYLENE GLYCOL 3350 ORAL POWDER BOTTLE",RX-24984,CDM,,,0250,RC,45802-0868-02,NDC,both,238,GR,56.89,17.07,"CIGNA [10200]","Cigna Local Plus",,30.44,53.5,,,,,0,6.62,48.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 RB-1 30IN BRAID GREEN NONABSORBABLE",SUP-X873H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR .09IN LEFT CORONARY BYPASS CURVE",SUP-LA8LCBSH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS LAPAROSCOPIC 54.5CM 8MM DA VINCI S/SI ENDOWRIST",SUP-420007,CDM,S27200284,LOCAL,0272,RC,,,both,,,13455.00,4036.5,"NOVANET [10819]",Novanet,,10091.25,75,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT SL II SITEMARK 50.7CM 47CM 9FR 7FR 135D",SUP-DS2C003,CDM,C1887,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,445.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 8FR .09IN EXTRA BACKUP 3 LEFT CURVE GUIDING",SUP-LA8EBU30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR XB4 CURVE GUIDING CORONARY SIDEHOLE",SUP-LA8EBU40SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR AL.75 CURVE GUIDING NYLON CORONARY",SUP-LA8AL75SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,266.22,68,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER C304XL7405 SELECTSITE GLOBAL",SUP-C304XL7405,CDM,C1887,HCPCS,0272,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLEDG CARDIOVASCULAR WHITE 9.5X4.8MM THK1.5MM Y PTFE FIRM",SUP-PCP30,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN STD",SUP-67011100,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,283.97,68,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CGUARD PRIME CAROTID STENT SYSTEM 135CM 08MM LENGTH 40MM",SUP-CND0840,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"BLUE CROSS [10001]","Blue Cross PPO",,8137.33,39.2,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 135CM 150MM 4MM .035IN BALLOON",SUP-AB35W04150135,CDM,C1725,HCPCS,0272,RC,,,both,,,1061.91,318.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,722.1,68,,,,,0,123.5,902.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 22CM 6FR URETERAL FIRM STERILE LATEX FREE",SUP-M0061456450,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"MULTIPLAN [10600]",Multiplan,,531.45,85,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM PRIMARY CEMENT DISTAL BULLET TIP SYNERGY",SUP-71316011,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8738.89,41.1,,6417.48,6417.48,6417.48,"1 through 10",2472.83,18073.13,"percent of total billed charges",
"STEM HUMERAL 55MM 6MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113606,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]",Cigna,,5040,40,,5873.17,5873.17,5873.17,"1 through 10",1465.38,10710,"percent of total billed charges",
"STENT ASCERTA 28CM 6FR URETERAL FIRM STERILE LATEX FREE",SUP-M0061456480,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"MULTIPLAN [10600]",Multiplan,,531.45,85,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTP W4TR02 SERENA QUAD CRTP MRI US",SUP-W4TR02,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2685.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 10CM 7FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22355,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA [10200]",Cigna,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER RIGHT LOCK ATTACH 10D ORTHOPEDIC STAINLESS STEEL RFNA",SUP-02.233.104S,CDM,C1713,HCPCS,0278,RC,,,both,,,6348.00,1904.4,"BLUE CROSS [10001]","Blue Cross PPO",,2488.42,39.2,,957.42,570.23,957.42,28,738.27,5395.8,"percent of total billed charges",
"LINER ACETABULAR RINGLOC +3MM 26 40MM E-POLY HIP STERILE",SUP-EP-108426,CDM,C1776,HCPCS,0278,RC,,,both,,,14076.00,4222.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5785.24,41.1,,6417.48,6417.48,6417.48,"1 through 10",1637.04,11964.6,"percent of total billed charges",
"CATH BARDEX IC 30FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0165SI30,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.82,19.45,"MULTIPLAN [10600]",Multiplan,,55.1,85,,,,,0,7.54,55.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM YUKON SPINE OCCIPITOCERVICOTHORACIC",SUP-7601-03512,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"1 EACH, REVOLVE FAT PROCESSING SYSTEM",SUP-RV0001,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC MEDIUM 14.5-17IN ARM COMFORT LIGHTWEIGHT",SUP-72819-00062-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,76.21,22.86,"KAISER [10500]",Kaiser,,51.06,67,,,,,0,8.86,64.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORTHOLOC 3DI FOOT RECONSTRUCTION SYSTEM HALLUX PLATES - LAP",SUP-58510000,CDM,C1713,HCPCS,0278,RC,,,both,,,12420.00,3726,"CIGNA [10200]","Cigna Open Access",,4160.7,33.5,,1144.80,304.56,2275.09,66,1444.45,10557,"percent of total billed charges",
"NAIL 7MM 250MM HUMERUS EXPERT INTRAMEDULLARY UNIVERSAL SOLID",SUP-04.001.230S,CDM,C1713,HCPCS,0278,RC,,,both,,,9216.74,2765.02,"PHCS [10601]",PHCS,,6451.72,70,,,,,0,1071.91,7834.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP APPLR 40CM TISSEEL GASLESS SPRAY QUICK CONNECT MIS",SUP-601155,CDM,S27200284,LOCAL,0272,RC,,,both,,,558.17,167.45,"CIGNA [10200]",Cigna,,379.56,68,,,,,0,64.92,474.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) 28MM PERCUTANEOUS CLARITY VALVE",SUP-635000,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 6 8MM",SUP-TPS-030-086S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 330MM TIBIAL EXPERT INTRAMEDULLARY UNIVERSAL ROUND",SUP-04.034.346S,CDM,C1713,HCPCS,0278,RC,,,both,,,8737.47,2621.24,"KAISER [10500]",Kaiser,,5854.1,67,,,,,0,1016.17,7426.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 7-12 GH 10MM KNEE RIGHT CRUCIATE RETAINING",SUP-42522000610,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AETNA [10100]","Aetna HMO/PPO",,8567.25,79.5,,10981.53,8986.79,12413.38,12,1253.3,9159.96,"percent of total billed charges",
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 30MM 140CM 2.75MM",SUP-RSINT27530UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3769.92,68,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Kidney Img Morpohlogy",PX-341000043,CDM,78700,CPT,0341,RC,,,both,,,2034.67,610.4,"MULTIPLAN [10600]",Multiplan,,1729.47,85,,,,,0,2.03,1729.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL",RX-29676,CDM,,,0250,RC,10939-0955-85,NDC,both,44,ML,12.54,3.76,"CIGNA [10200]",Cigna,,8.53,68,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 80MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.880,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"PHCS [10601]",PHCS,,962.09,70,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 5MMX59MM 7FR 135CMCATH HEPARIN",SUP-BXB055902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]","Cigna Local Plus",,6144.01,31.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 4FR 2-8-2MM SPACE REGULAR P CURVE",SUP-D4S10PR282RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1532,41.1,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Powder Stimulen",PX-E27200197,CDM,E27200197,LOCAL,0272,RC,,,both,,,70.40,21.12,"FIRST HEALTH [10303]","First Health",,56.32,80,,,,,0,8.19,59.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X18X12MM COROENT XLIF",SUP-7861245,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"MULTIPLAN [10600]",Multiplan,,29134.26,85,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Varicell Zoster Dna Ultraquant",PX-306000167,CDM,87799,CPT,0306,RC,,,both,,,986.10,295.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.99,.1,,,,,0,0.99,838.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 26CM 3CM 7FR .035IN 2 PIGTAIL",SUP-M006192143050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS [10001]","Blue Cross PPO",,470.63,39.2,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM LOW PROFILE NONSTERILE LATEX FREE",SUP-131227216,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,578.34,68,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER GD EBU4 CRV 8FR 100CM COR",SUP-Z28EBU40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN JUDKINS",SUP-77808000,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 110CM 1MM 5FR 5MM SPACE ELECTROPHYSIOLOGY FIX",SUP-F5QA005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,107.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE DESTINATION STRAIGHT 45CM 35CM 5FR GUIDING",SUP-54-54501,CDM,C1887,HCPCS,0272,RC,,,both,,,672.30,201.69,"AETNA [10100]","Aetna HMO/PPO",,534.48,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC",939,MS-DRG,,,,,,,inpatient,,,155639.55,46691.86,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,23858.27,,"Case rate ($22,507.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,900.02, add-ons for qualifying new technology services are included. If operating cost exceeds $53,939.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,962.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $20,927.66. The transfer operating threshold is the transfer adjustment factor * $20,900.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,580.14. The transfer capital threshold is the transfer adjustment factor * $1,580.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,105937.69,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT PRESS FIT EMPOWR 3D KNEE STERILE",SUP-243-01-107,CDM,C1776,HCPCS,0278,RC,,,both,,,27824.45,8347.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3297.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3235.98,23650.78,"percent of total billed charges",
"HC Ortho Mgmt/Train Ea 15min (Go)",PX-430000030,CDM,97760,CPT,0430,RC,,,both,,,205.82,61.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.94,205.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR .09IN EBU3.75 CURVE GUIDING CORONARY",SUP-LA8EBU375SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT HAND ACCESS 120MM BLUNT TIP AIRSEAL 12MM",SUP-IASB12-120,CDM,S27200284,LOCAL,0272,RC,,,both,,,756.65,226.99,"FIRST HEALTH [10303]","First Health",,605.32,80,,,,,0,88,643.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEARTRAIL III 100CM 5FR IL3.75 CURVE GUIDING PTFE",SUP-40-5372,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"FIRST HEALTH [10303]","First Health",,466.56,80,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET",RX-24559,CDM,,,0250,RC,77333-0948-25,NDC,both,1,UN,6.27,1.88,"FIRST HEALTH [10303]","First Health",,5.02,80,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mask Cpap",PX-E27000134,CDM,E27000134,LOCAL,0270,RC,,,both,,,252.09,75.63,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIDNEY AND URINARY TRACT MALIGNANCY,MAJOR",461,APR-DRG,,,,,,,inpatient,,,71837.60,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $6,411.98. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($55,476.73) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 18CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061751990,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS [10001]","Blue Cross PPO",,353.65,39.2,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 6X 38MM CATH 80CM ENDOVASCULAR",SUP-48638,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"CIGNA [10200]","Cigna Open Access",,5869.3,33.5,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Echoencephgraphy",PX-402000004,CDM,76506,CPT,0402,RC,,,both,,,2508.68,752.6,"KAISER [10500]",Kaiser,,1680.82,67,,,,,0,129.02,2132.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 3-0 RB-1 27IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y215H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 1 OS-8 30IN ARM BRAID GREEN NONABSORBABLE",SUP-X548H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UHC [10700]","United Healthcare",,15.83,63.3,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X21MM ENDOSKELETON TAS 7D 13MM STD TITANIUM",SUP-2307-0113,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"MULTIPLAN [10600]",Multiplan,,24097.5,85,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 46CM 7FR VENTRICLE BIPOLAR TINED PASSIVE",SUP-1646T/46,CDM,C1898,HCPCS,0275,RC,,,both,,,1786.00,535.8,"CIGNA [10200]","Cigna Local Plus",,955.51,53.5,,,,,0,207.71,1518.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mod Sed Oth Phys Add 15min",PX-371000012,CDM,99157,CPT,0371,RC,,,both,,,151.32,45.4,"FIRST HEALTH [10303]","First Health",,121.06,80,,,,,0,17.6,128.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 25MM SOLERA CD HORIZON OSTEOGRIP TITANIUM COCR",SUP-54840004025,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]",Cigna,,6491.86,68,,1831.33,1831.33,1831.33,16,1110.3,8114.82,"percent of total billed charges",
"MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION",RX-160048,CDM,,,0250,RC,00121-0945-10,NDC,both,10,ML,31.58,9.47,"UHC [10700]","United Healthcare",,19.99,63.3,,,,,0,3.67,26.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION",RX-173479,CDM,,,0250,RC,00006-5423-02,NDC,both,2,ML,821.74,246.52,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,377.18,45.9,,,,,0,95.57,698.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 30MM QUICKSET 1 PIECE FLEXIBLE",SUP-227430500,CDM,C1713,HCPCS,0278,RC,,,both,,,3998.55,1199.56,"BLUE CROSS [10001]","Blue Cross PPO",,1567.43,39.2,,957.42,570.23,957.42,28,465.03,3398.77,"percent of total billed charges",
"FILLER BONE VOID 30ML .1-2MM 80% CORTICAL 20% CANCELLOUS",SUP-400063,CDM,C1713,HCPCS,0278,RC,,,both,,,2842.88,852.86,"FIRST HEALTH [10303]","First Health",,2274.3,80,,,,,0,330.63,2416.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 75MM 14MM UNIVERSAL FLUTE KNEE FEMUR PRESS FIT",SUP-867414,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"BLUE CROSS [10001]","Blue Cross HMO",,3175.44,39.2,,5311.50,4717.44,5388.59,31,942.1,6885.51,"percent of total billed charges",
"DIL SURGICAL AMPLATZ FIRM KINK RESISTANT GRADUATE TAPER 35CM",SUP-M0062601110,CDM,C1894,HCPCS,0272,RC,,,both,,,362.44,108.73,"PHCS [10601]",PHCS,,253.71,70,,,,,0,42.15,308.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW STD 57.2X21.6MM TITANIUM 4 HOLE LOW PROFILE FIX",SUP-DVRANL,CDM,C1713,HCPCS,0278,RC,,,both,,,7607.25,2282.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2177.19,28.62,,,,,0,884.72,6466.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP IDNT ST/CMP GLN/VE/INS",SUP-98000900272,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,18144,40,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 116MM STAINLESS STEEL 3.5MM SCREWS SMALL FRAGMENT SET",SUP-223.59,CDM,C1713,HCPCS,0278,RC,,,both,,,2230.20,669.06,"CIGNA [10200]",Cigna,,1516.54,68,,1831.33,1831.33,1831.33,16,259.37,1895.67,"percent of total billed charges",
"LENS IOL +20.5 DIOPTER +3 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT300205,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"FIRST HEALTH [10303]","First Health",,276,80,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 80CM 23CM GRAY HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-5F-23-035,CDM,C1894,HCPCS,0272,RC,,,both,,,117.45,35.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.66,99.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 C-H STD 74X46X17MM KNEE PROLONG NEXGEN",SUP-90595204017,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,929.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CD HORIZON VOYAGER SPINE NONSTERILE",SUP-55850046550,CDM,C1713,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"BLUE CROSS [10001]","Blue Cross HMO",,2907.66,39.2,,957.42,156.86,7483.26,51,862.66,6304.88,"percent of total billed charges",
"GWIRE AMPLATZ SUPER STIFF UROLOGICAL STRAIGHT 145CM 3.5CM",SUP-M0066401091,CDM,C1769,HCPCS,0272,RC,,,both,,,223.05,66.91,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) STERILE TRICUSPID VALVE 160MM",SUP-ES0366-03,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT DRUG DELIVERY 5ML/HR ON-Q 2.25 DAY DELIVERY TIME 270ML",SUP-P270X5,CDM,C9804,HCPCS,0272,RC,,,both,,,1041.14,312.34,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FLEXIMA 70CM 7FR 12FR URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002131,CDM,C1758,HCPCS,0272,RC,,,both,,,80.01,24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRIAL SURGICAL 132MM 30MM C TAPER NECK",SUP-1100-1330,CDM,C1776,HCPCS,0278,RC,,,both,,,1195.68,358.7,"MULTIPLAN [10600]",Multiplan,,1016.33,85,,,,,0,139.06,1016.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 9 5/8IN 30FR POOLE STRAIGHT CHROME CONNECTION",SUP-70-4001,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.10,61.83,"PHCS [10601]",PHCS,,144.27,70,,,,,0,23.97,175.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 14.75CM NATRELLE INSPIRA P4.9CM MODERATE PROFILE",SUP-SRM-560,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"KAISER [10500]",Kaiser,,3675.29,67,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFTOUCH 80CM 4FR PIGTAIL CURVE ANGIOGRAPHIC PEDIATRIC",SUP-4408-2M80SH,CDM,S27200284,LOCAL,0272,RC,,,both,,,518.40,155.52,"CIGNA [10200]","Cigna Local Plus",,277.34,53.5,,,,,0,60.29,440.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 3.5/26",SUP-434900,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5332.64,27,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 205CC P2.9CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-205,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"FIRST HEALTH [10303]","First Health",,6044.4,80,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRI-SIL 60IN 20FR URETHRAL BACTI-GUARD SILICONE",SUP-0172SI20,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.66,57.5,"CIGNA [10200]","Cigna Open Access",,109.05,56.9,,,,,0,22.29,162.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP SNAP-LIGHT 2 FIBER OPTIC BUNDLE SNAP",SUP-2517200,CDM,S27000186,LOCAL,0270,RC,,,both,,,147.81,44.34,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.19,125.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 300MM 3.2MM STAINLESS STEEL CALIBRATED",SUP-292.69,CDM,C1769,HCPCS,0272,RC,,,both,,,759.78,227.93,"PHCS [10601]",PHCS,,531.85,70,,,,,0,88.36,645.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 10MM FLEXIGRAFT DOWEL PATELLAR LIGAMENT",SUP-FPL10,CDM,S27800098,LOCAL,0278,RC,,,both,,,19995.57,5998.67,"NOVANET [10819]",Novanet,,14996.68,75,,,,,0,2325.48,16996.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Exercise Tst Brncspsm WO Ecg",PX-460000022,CDM,94619,CPT,0460,RC,,,both,,,191.00,57.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.21,162.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE 3X2IN ORIGINAL SURGICEL",SUP-1953S,CDM,S27200284,LOCAL,0272,RC,,,both,,,709.63,212.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,84.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,82.53,603.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LANTERN 150CM .025IN MICRO DELIVERY SYSTEM HIGH FLOW",SUP-PXSLIMLAN150STR,CDM,S27200284,LOCAL,0272,RC,,,both,,,4071.00,1221.3,"NOVANET [10819]",Novanet,,3053.25,75,,,,,0,473.46,3460.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 47MM CENTERPULSE LEGACY 12/14 TAPER HIP FEMUR",SUP-451000047,CDM,C1776,HCPCS,0278,RC,,,both,,,2398.65,719.59,"FIRST HEALTH [10303]","First Health",,1918.92,80,,,,,0,278.96,2038.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 11.8X5.9IN XENMATRIX AB RECTANGLE PORCINE",SUP-1151530,CDM,C1781,HCPCS,0278,RC,,,both,,,65285.52,19585.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7736.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7592.71,55492.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTEPLASE 100 MG INTRAVENOUS SOLUTION",RX-9002,CDM,J2997,HCPCS,0636,RC,50242-0085-27,NDC,both,1,UN,53118.96,15935.69,"MULTIPLAN [10600]",Multiplan,,45151.12,85,,,,,0,6294.6,45151.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER BURR HOLE 7MM MEDPOR LOW PROFILE TITANIUM TAB STERILE",SUP-53-34507,CDM,C1713,HCPCS,0278,RC,,,both,,,1858.35,557.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1263.68,68,,,,,0,216.13,1579.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 15CM 2MM BALLOON DILATATION OTW LOW",SUP-G30938,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +23 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.230,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 83MM 42MM 37-38MM 22FR ZENITH TX2",SUP-G47465,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"KAISER [10500]",Kaiser,,68761.1,67,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET IMPL BIOCOMPOSITE SCR DRIVER RECONSTRUCTION SYSTEM",SUP-AR-1675BC-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,12678.75,3803.62,"MULTIPLAN [10600]",Multiplan,,10776.94,85,,,,,0,1474.54,10776.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 3DMAX 7X5IN GROIN LEFT CONTOUR SEAL EDGE",SUP-0115312,CDM,C1781,HCPCS,0278,RC,,,both,,,983.58,295.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,116.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.39,836.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 100CM 6FR BARBEAU CURVE GUIDING",SUP-67017400,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,49.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 35CM EPICARDIUM UNIPOLAR CAPSURE EPI",SUP-4968-35,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross HMO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LUBIPROSTONE 8 MCG CAPSULE",RX-91534,CDM,,,0637,RC,00254-3028-02,NDC,both,1,UN,25.25,7.57,"CIGNA [10200]","Cigna Open Access",,14.37,56.9,,,,,0,2.94,21.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 12X7.5-8.4CM BREAST 200ML STYLE 133LV TEXTURED",SUP-133LV-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,5460.00,1638,"MULTIPLAN [10600]",Multiplan,,4641,85,,,,,0,635,4641,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 20MM 3.8FR 5MM LOW PROFILE TAPER BALLOON",SUP-H74939032502080,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM AXSOS OMEGA3 STAINLESS STEEL T20 FEMUR",SUP-370334,CDM,C1713,HCPCS,0278,RC,,,both,,,1376.51,412.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,160.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",160.09,1170.03,"percent of total billed charges",
"CAP CONSTRUCT TOTAL HIP BIOLOX DELTA HEAD R3 HIGHLY CROSSLIN",SUP-71703600,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"NOVANET [10819]",Novanet,,17955,75,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X6MM COLONIAL 7D LORDOTIC 12MM LARGE",SUP-365.406CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BN 1.2MM 4MM LEIBINGER UNV 2",SUP-50-12904,CDM,C1713,HCPCS,0278,RC,,,both,,,610.82,183.25,"BLUE CROSS [10001]","Blue Cross HMO",,239.44,39.2,,957.42,156.86,7483.26,51,71.04,519.2,"percent of total billed charges",
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 32MM 144CM 2.75MM",SUP-H7493941232270,CDM,C1874,HCPCS,0278,RC,,,both,,,8245.50,2473.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5606.94,68,,,,,0,958.95,7008.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 4MM NESTER MICROCOIL PLATINUM ACCEPTS",SUP-G47372,CDM,S27800098,LOCAL,0278,RC,,,both,,,890.92,267.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,605.83,68,,,,,0,103.61,757.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION FIBULINK STAINLESS STEEL",SUP-FGS-1000,CDM,C1713,HCPCS,0278,RC,,,both,,,8125.44,2437.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2325.5,28.62,,,,,0,944.99,6906.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE NERVE 40MM 2.3MM NEUROTUBE STERILE",SUP-GEM0240NT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"PHCS [10601]",PHCS,,4322.85,70,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 82MM 13MM 14FR ENDURANT II ABDOMEN AORTA",SUP-ETEW1313C82E,CDM,S27800098,LOCAL,0278,RC,,,both,,,28331.10,8499.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3357.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3294.91,24081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BNE CORT CANC 15ML",SUP-07A001,CDM,C1713,HCPCS,0278,RC,,,both,,,1458.00,437.4,"CIGNA [10200]","Cigna Open Access",,829.6,56.9,,1144.80,304.56,2275.09,66,169.57,1239.3,"percent of total billed charges",
"CMPNT FEMORAL 1 LEFT MEDIAL RIGHT LATERAL PARTIAL KNEE",SUP-5610-F-101,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"PHCS [10601]",PHCS,,7001.47,70,,,,,0,1163.24,8501.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PULMONARY AERO OTW FULLY COVERED TRACHEOBRONCHIAL STENT 16MM",SUP-90129-206,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross HMO",,6762,39.2,,9776.84,9776.84,9776.84,"1 through 10",2006.18,14662.5,"percent of total billed charges",
"SUB BONE GRAFT GREEN MASTERGRAFT CALCIUM PHOSPHATE VOID",SUP-7600110,CDM,C1713,HCPCS,0278,RC,,,both,,,4634.39,1390.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3151.39,68,,,,,0,538.98,3939.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 120MM 2MM BALLOON DILATATION RAPID",SUP-47520120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 14.5MM 42X70X10MM GENTAMICIN PMMA REMEDY",SUP-RKINMD,CDM,C1776,HCPCS,0278,RC,,,both,,,4830.00,1449,"AMERIGROUP MEDICAID [20100]",Amerigroup,,572.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 10MM 9FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEM10100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4932.9,27,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Amniocentesis Thpy Reduce Fld",PX-720000004,CDM,59001,CPT,0720,RC,,,both,,,21498.00,6449.4,"CIGNA [10200]","Cigna Open Access",,12232.36,56.9,,,,,0,1729.39,18273.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP060120150 PLUS US D6L120UL1500",SUP-PCP060120150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"KAISER [10500]",Kaiser,,824.9,67,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 15IN 8FR ENTERAL Y PORT RADIOPAQUE MALE",SUP-20-1158AIV,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.03,31.21,"CIGNA [10200]","Cigna Local Plus",,55.66,53.5,,,,,0,12.1,88.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 220MM 2MM BALLOON DILATATION NYBAX",SUP-H74939186202210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON PANOPTIX TORIC",SUP-CNWTT3,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,102.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUBE DEMINERALIZED BONE CANCELLOUS 9MM Q-PACK",SUP-4W0009,CDM,C1713,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"FIRST HEALTH [10303]","First Health",,2700,80,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 109MM COLLAR ACTIS DUOFIX 7 12/14 HIGH OFFSET",SUP-101012070,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"BLUE CROSS [10001]","Blue Cross PPO",,11946.69,39.2,,3949.44,3949.44,3949.44,"1 through 10",3544.39,25904.81,"percent of total billed charges",
"HC Rp Loc Tum Spect W CT 2area",PX-341000074,CDM,78832,CPT,0341,RC,,,both,,,7540.46,2262.14,"FIRST HEALTH [10303]","First Health",,6032.37,80,,,,,0,7.54,6409.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rp Loc Tum Spect W CT 2area",PX-341000074,CDM,78832,CPT,0341,RC,,,both,,,7540.46,2262.14,"BLUE CROSS [10001]","Blue Cross HMO",,7.54,.1,,,,,0,7.54,6409.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 9MM TITANIUM T4 CORTICAL SELF TAP STARDRIVE",SUP-04.214.109,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 14MM T8 FULL THREAD STARDRIVE NONSTERILE",SUP-656114,CDM,C1713,HCPCS,0278,RC,,,both,,,779.22,233.77,"CIGNA [10200]","Cigna Open Access",,443.38,56.9,,1144.80,304.56,2275.09,66,90.62,662.34,"percent of total billed charges",
"HC Xr Fistula/Absc/Sinus Tract Si",PX-320000166,CDM,76080,CPT,0320,RC,,,both,,,936.30,280.89,"MULTIPLAN [10600]",Multiplan,,795.86,85,,,,,0,55.4,936.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Afo Custom Fitted",PX-E27400094,CDM,L4396,HCPCS,0274,RC,,,both,,,338.80,101.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,132.37,,,,,,,39.4,287.98,"fee schedule",
"HC Bronch W Valve Rmvl Ea Add",PX-750000147,CDM,31649,CPT,0750,RC,,,both,,,5006.00,1501.8,"CIGNA [10200]",Cigna,,3951,,"Case rate ($3,951). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,5.01,4617,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE SP 35L",SUP-TENDV-SP-35L-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,116280,68,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Temp Foley Cath Cmplx",PX-450000273,CDM,51703,CPT,0361,RC,,,both,,,782.03,234.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,782.03,,"Case rate ($4,937). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,90.95,782.03,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Varicella-Zoster Ab",PX-302000168,CDM,86787,CPT,0302,RC,,,both,,,337.25,101.17,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,286.66,"per diem",
"CURET 5 10IN SIMS UTERINE SHARP MALLEABLE SURGICAL",SUP-ER415R,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.48,104.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.64,297.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Anal Tag or Papilla Mult",PX-750000156,CDM,46230,CPT,0750,RC,,,both,,,7693.27,2307.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,894.73,6539.28,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION CURITY ADD-A-CATH 30CC INSRT PREFILL",SUP-5027,CDM,S27200284,LOCAL,0272,RC,,,both,,,45.68,13.7,"AETNA [10100]","Aetna HMO/PPO",,36.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.31,38.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSURITY PACEMAKER RF SR",SUP-PM1240,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"FIRST HEALTH [10303]","First Health",,19872,80,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 7CM MR8 2MM BALL FINE GRIT DISSECTING DIAMOND",SUP-MR8-7BA20DF,CDM,S27200284,LOCAL,0272,RC,,,both,,,1142.51,342.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,135.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,132.87,971.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 70MM AXSOS 3 TITANIUM LOCK SELF TAP NONSTERILE",SUP-661070,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"BLUE CROSS [10001]","Blue Cross PPO",,511.84,39.2,,957.42,570.23,957.42,28,151.86,1109.86,"percent of total billed charges",
"PLATE XLORDOTIC 14MM 1 LEVEL XTEND BONE SPINE CERVICAL",SUP-161.134,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1927.8,45.9,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL FLAT L 28CM VALLEYLAB STERILE ARGON",SUP-E3581-28,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.15,88.24,"CIGNA [10200]","Cigna Open Access",,167.37,56.9,,,,,0,34.21,250.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN STERILE LATEX FREE",SUP-519310,CDM,C1813,HCPCS,0278,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM RELINE 2C SPINE MODULAR SHANK NONSTERILE",SUP-16187545,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,957.42,156.86,7483.26,51,348.9,2550,"percent of total billed charges",
"SHEATH INTRO 6FR .087IN 10CM SPRING STRAIGHT TIP GWIRE",SUP-80-1060,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2-0 V-5 36IN 2 ARM MONOFILAMENT BLUE",SUP-8937H,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.29,24.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARD 12FR URETHRAL NATURAL RUBBER SILICONE ELASTOMER 5",SUP-265712,CDM,S27200284,LOCAL,0272,RC,,,both,,,1.84,0.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) ZEBRA 6F  115CM ACCESS SYSTEM SIM2",SUP-AC6074-115-20,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD SUT ASSISTANT 10MM 3-0 ES-9 7IN 1 STITCH ENDO STITCH",SUP-170070,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH",RX-27472,CDM,,,0250,RC,00378-9104-16,NDC,both,1,UN,12.54,3.76,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM EMBOL-X GLIDE XL 11IN 24FR 35-40MM EMBOLIZATION",SUP-EXGF24XLD,CDM,C1884,HCPCS,0272,RC,,,both,,,3007.50,902.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Airway Nasopharyngeal",PX-E27000038,CDM,E27000038,LOCAL,0270,RC,,,both,,,35.48,10.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FOGARTY 80CM 8FR 45MM BALLOON OCCLUSION VASCULAR",SUP-62080822F,CDM,C2628,HCPCS,0272,RC,,,both,,,741.31,222.39,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MATRIX TISSUE 7X3CM ALLODERM SELECT THK1.2-2MM MEDIUM",SUP-141821,CDM,Q4116,HCPCS,0636,RC,,,both,,,5230.20,1569.06,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER SPINAL 14X11X5MM CORNERSTONE PSR PEEK LUMBAR",SUP-6277541,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,776.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 40MM 130CM 8MM LONG VASCULAR NITINOL ILIAC",SUP-SC840LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]",Cigna,,4926.6,68,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acetylcholn Rcptr Blckg Antb",PX-301000692,CDM,86042,CPT,0301,RC,,,both,,,398.05,119.41,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,338.34,"per diem",
"HC Rmvl Cath Tunneled IP",PX-361000205,CDM,49422,CPT,0361,RC,,,both,,,7443.33,2233,"BLUE CROSS [10001]","Blue Cross HMO",,4025.22,,"Case rate ($4,025.22). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,865.66,7311,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AMPHIRION DEEP 150CM 80MM 3.5MM BROAD TAPER BALLOON",SUP-AMP035080152,CDM,C1725,HCPCS,0272,RC,,,both,,,2422.50,726.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,287.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,281.74,2059.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC CROME VR 1 CHMBR DF-1 PIN PLUG RADIOPAQUE",SUP-DVPC3D1,CDM,C1882,HCPCS,0278,RC,,,both,,,56385.00,16915.5,"CIGNA [10200]","Cigna Local Plus",,17761.28,31.5,,,,,0,6557.58,47927.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D G KNEE RIGHT CEMENT KEEL",SUP-42536007902,CDM,C1776,HCPCS,0278,RC,,,both,,,10619.10,3185.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4364.45,41.1,,6417.48,6417.48,6417.48,"1 through 10",1235,9026.24,"percent of total billed charges",
"SHELL ACETABULAR 46MM 3 HOLE EMPHASYS",SUP-471046300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4847.85,27,,,,,0,2088.17,15261.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOLD CEMENT SURESPACE SMALL FEMORAL SPACER",SUP-SSF1060,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"UHC [10700]","United Healthcare",,8997.46,63.3,,8601.07,8395.67,8601.07,"1 through 10",1653.09,12081.9,"percent of total billed charges",
"CATH CPS AIM SL 62CM 59CM 7FR 5FR ACUTE CURVE GUIDING PEBAX",SUP-DS2N021-59,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC BLUE MINI-BLADE 180D STRAIGHT 2 BEVEL SHARP",SUP-6900,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.08,14.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.59,40.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +19.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.195,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 5-0 PS-2 18IN MONOFILAMENT UNDYED",SUP-Y495G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ACCULINK 40MM 132CM 6-8MM TAPER VASCULAR NITINOL",SUP-1011343-40,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"CIGNA [10200]",Cigna,,6364.8,68,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ffp Sngl Donor Within 8 Hr",PX-390000005,CDM,P9017,HCPCS,0390,RC,,,both,,,907.20,272.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,107.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (PS) - SIZE 5",SUP-5555-2255,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"CIGNA [10200]","Cigna Open Access",,806.56,56.9,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR ARTERY STERILE",SUP-PXVP2X2AT3,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.69,125.31,"NOVANET [10819]",Novanet,,313.27,75,,,,,0,48.58,355.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BT-CATH HEMOSTATIC BALLOON SILICONE TAMPONADE LUMEN",SUP-BTC-ESY,CDM,S27200284,LOCAL,0272,RC,,,both,,,604.26,181.28,"KAISER [10500]",Kaiser,,404.85,67,,,,,0,70.28,513.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 9MM4CM 190",SUP-R51009004L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"FIRST HEALTH [10303]","First Health",,1633.2,80,,,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 5MM 1X8 ELECTRD KIT",SUP-977D260,CDM,C1897,HCPCS,0278,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR PAL2 CURVE GUIDING STERILE LATEX",SUP-LA6PAL20,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X18X1.19MM SAGITTAL SYSTEM 6",SUP-6118-119-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 5-0 RB-1 30IN 2 ARM MONOFILAMENT VIOLET",SUP-Z320H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.00,19.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,30.29,45.9,,,,,0,7.68,56.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 STD KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-42500605801,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"MULTIPLAN [10600]",Multiplan,,19433.3,85,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAXCESS MAS TLIF 2 KIT ACCESS",SUP-3500017,CDM,S27200284,LOCAL,0272,RC,,,both,,,8970.00,2691,"NOVANET [10819]",Novanet,,6727.5,75,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echovirus Abs",PX-302000124,CDM,86658,CPT,0302,RC,,,both,,,77.00,23.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.82,,,,,,,0.01,65.45,"fee schedule",
"INSRT TIBIAL 7 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640706,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4625.35,41.1,,6417.48,6417.48,6417.48,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"TROCAR LAPAROSCOPIC 130MM 12MM KII BALLOON BLUNT TIP LATEX",SUP-C0R50,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,83.86,45.9,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 5.5MM TSRH-2D CONTOUR PEDICLE TITANIUM",SUP-8370065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 9 STD 36MM PROVOX LIFE LARYTUBE SILICONE",SUP-7413,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,812.54,68,,,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE FATHOM VASCULAR STRAIGHT 140CM 25CM .016IN PERIPHERAL",SUP-M001509000,CDM,C1769,HCPCS,0272,RC,,,both,,,1792.50,537.75,"KAISER [10500]",Kaiser,,1200.98,67,,,,,0,208.47,1523.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 12CM 10FR CENTER BEND THIN WALL",SUP-M00534710,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"CIGNA [10200]","Cigna Open Access",,619.9,56.9,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 4.75MM 3.5MM INTERNALBRACE",SUP-AR-1788J-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"NOVANET [10819]",Novanet,,7736.63,75,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SERFAS 90-S CRUISE ENERGY ENDOSCOPIC",SUP-0279401200,CDM,S27200284,LOCAL,0272,RC,,,both,,,1174.50,352.35,"KAISER [10500]",Kaiser,,786.92,67,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 4.00 X 12MM",SUP-H7493942812400,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1777.3,28.62,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .057IN JUDKINS RIGHT 5",SUP-534623T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.5MM 24MM RADIUS VOLAR DISTAL THREAD",SUP-131211124,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,189.34,1383.8,"percent of total billed charges",
"HC Dlyd Plcmnt Dist Ext Prosth Lsa to Celiac",PX-360000030,CDM,33886,CPT,0361,RC,,,both,,,5378.50,1613.55,"UHC [10700]","United Healthcare",,3833,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,625.52,5378.5,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.215,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"NOVANET [10819]",Novanet,,258.75,75,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pretreat RBC Ab ID Enzyme",PX-302000210,CDM,86971,CPT,0302,RC,,,both,,,75.40,22.62,"BLUE CROSS [10001]","Blue Cross PPO",,28.95,,"Fee schedule rate ($28.95).",,,,0,0.01,75.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 150MM 4MM BALLOON DILATATION DURALYN",SUP-48004015S,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 80CM 8FR 45MM BALLOON OCCLUSION VASCULAR",SUP-62080822F,CDM,C2628,HCPCS,0272,RC,,,both,,,741.31,222.39,"KAISER [10500]",Kaiser,,496.68,67,,,,,0,86.21,630.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Actvty Dirct 15min (Gp)",PX-420000027,CDM,97530,CPT,0420,RC,,,both,,,183.84,55.15,"NOVANET [10819]",Novanet,,137.88,75,,,,,0,21.38,183.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mod Sed Oth Phys 1st 15min < 5y",PX-371000010,CDM,99155,CPT,0371,RC,,,both,,,718.00,215.4,"CIGNA [10200]",Cigna,,488.24,68,,,,,0,0.72,610.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immunoassy Tumor Ca 19-9",PX-302000056,CDM,86301,CPT,0302,RC,,,both,,,320.15,96.04,"BLUE CROSS [10001]","Blue Cross PPO",,26.59,,"Fee schedule rate ($26.59).",,,,0,0.01,272.13,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Homocysteine",PX-301000234,CDM,83090,CPT,0301,RC,,,both,,,343.90,103.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.82,,"Fee schedule rate ($18.82). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,292.32,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 8.25MM 7CM TWIST-IN SHOULDER OBTR THREAD",SUP-AR-6530,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"PHCS [10601]",PHCS,,159.87,70,,,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND SUTUPAK 4-0 18IN BRAID TIES 17 STRAND",SUP-SA63H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK12MM 51X74MM GALLANT HF IS-1 IS-4 DF-4 CNCT",SUP-CDHFA500Q,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"FIRST HEALTH [10303]","First Health",,61560,80,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX BRITE TIP 30MM 135CM 7MM .065IN",SUP-PC0730RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"BLUE CROSS [10001]","Blue Cross HMO",,2975.28,39.2,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 5.75IN 16FR URETHRAL STAINLESS STEEL FEMALE NONSTERILE",SUP-475-636,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.39,103.02,"FIRST HEALTH [10303]","First Health",,274.71,80,,,,,0,39.94,291.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPREME EXTENSION CABLE BLUE  150 CM",SUP-401981R,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"CIGNA [10200]",Cigna,,195.23,68,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 95MM 90MM INTERTAN TROCHANTERIC LAG COMPRESSION KIT",SUP-7167-7095,CDM,C1713,HCPCS,0278,RC,,,both,,,6986.94,2096.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4751.12,68,,,,,0,812.58,5938.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 67MM VANGUARD 360 KNEE POROUS REVISION SYSTEM",SUP-185202,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,10981.53,8986.79,12413.38,12,2014.9,14726.25,"percent of total billed charges",
"GRAFT BONE 5CC SELECT FIBER OSTEOAMP",SUP-OASF-05,CDM,C1713,HCPCS,0278,RC,,,both,,,10805.40,3241.62,"NOVANET [10819]",Novanet,,8104.05,75,,,,,0,1256.67,9184.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Screening Oxycodone",PX-301000555,CDM,80365,CPT,0301,RC,,,both,,,159.60,47.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,159.6,,,,,,,0.01,159.6,"fee schedule",
"CATH ENVOY 105CM 6FR MPD CURVE GUIDING DISTAL ACCESS",SUP-67125805D,CDM,C1887,HCPCS,0272,RC,,,both,,,5198.32,1559.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,616,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,604.56,4418.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 13MM KNEE BEARING CRUCIATE RETAIN TRIATHLON",SUP-5530-G-513-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"PHCS [10601]",PHCS,,7988.82,70,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 12MM 144CM 4MM CORONARY STENT EVEROLIMUS",SUP-H7493926112400,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1103.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 14MM VARIAX SMARTLOCK TITANIUM RADIUS DISTAL",SUP-52-23614,CDM,C1713,HCPCS,0278,RC,,,both,,,1513.32,454,"AMERIGROUP MEDICAID [20100]",Amerigroup,,179.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",176,1286.32,"percent of total billed charges",
"NAIL 14MM 200MM SUPRACONDYLAR T2 INTRAMEDULLARY",SUP-1826-1420S,CDM,C1713,HCPCS,0278,RC,,,both,,,11554.33,3466.3,"AETNA [10100]","Aetna HMO/PPO",,9185.69,79.5,,1521.93,481.35,16760.95,30,1343.77,9821.18,"percent of total billed charges",
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 135CM 6MM 20MM",SUP-38047-62013,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]","Cigna Local Plus",,2584.05,53.5,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL AMPLATZ FIRM KINK RESISTANT GRADUATE TAPER 35CM",SUP-M0062601020,CDM,C1894,HCPCS,0272,RC,,,both,,,362.44,108.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,42.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.15,308.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 75CM 40MM 9MM BALLOON DILATATION DRUG COATED",SUP-LX3575940V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"KAISER [10500]",Kaiser,,5663.18,67,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR GRAY 43MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103543000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"MULTIPLAN [10600]",Multiplan,,2604.67,85,,,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Ablt ABN Tissue",PX-750000173,CDM,45388,CPT,0750,RC,,,both,,,4944.35,1483.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3311,,"Case rate ($3,311). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,575.03,4812,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 99MM STAINLESS STEEL 2.7/3.5MM SCR 5 HOLE ANATOMICALLY",SUP-02.112.141,CDM,C1713,HCPCS,0278,RC,,,both,,,3076.50,922.95,"BLUE CROSS [10001]","Blue Cross HMO",,1205.99,39.2,,957.42,156.86,7483.26,51,357.8,2615.03,"percent of total billed charges",
"HC Pacing Hrt Rhythm",PX-481000052,CDM,93618,CPT,0480,RC,,,both,,,4831.00,1449.3,"FIRST HEALTH [10303]","First Health",,3864.8,80,,,,,0,561.85,4831,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Meds Intravitreal",PX-761000067,CDM,67028,CPT,0761,RC,,,both,,,1439.46,431.84,"CIGNA [10200]",Cigna,,1439.46,,"Per diem ($2,606).",,,,0,1.44,1439.46,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC 2 POUCH PACK 1 POWDER STD APPLR TIP PVC",SUP-PCUS003,CDM,A6250,HCPCS,0272,RC,,,both,,,1348.71,404.61,"KAISER [10500]",Kaiser,,903.64,67,,,,,0,156.85,1146.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 3.4CM 24FR LOW PROFILE REPLACEMENT GASTRO ENDOVIVE",SUP-M00509430,CDM,S27000186,LOCAL,0270,RC,,,both,,,972.00,291.6,"NOVANET [10819]",Novanet,,729,75,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 26CM 3CM 8FR .038IN PIGTAIL CURVE",SUP-M006180543170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,352.3,28.62,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 8MM TRANSPORT 7 POLYMER PROXIMAL",SUP-CAT00224,CDM,S27200284,LOCAL,0272,RC,,,both,,,743.90,223.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,88.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.52,632.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 3INX12MM OSTEOTOM THIN MRI NONSTERILE LATEX FREE",SUP-998602122,CDM,S27200284,LOCAL,0272,RC,,,both,,,963.09,288.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,114.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.01,818.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Bn Length Study",PX-320000180,CDM,77073,CPT,0320,RC,,,both,,,383.34,115,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,45.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",45.44,45.44,45.44,"1 through 10",44.58,325.84,"percent of total billed charges",
"HC Eval Speech Dev 1st Hr",PX-444000004,CDM,92607,CPT,0444,RC,,,both,,,1042.00,312.6,"FIRST HEALTH [10303]","First Health",,833.6,80,,,,,0,121.18,885.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 131MM CEMENT ACCOLADE C 132D 3 39MM OFFSET HIP",SUP-6058-0335D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"PHCS [10601]",PHCS,,11507.48,70,,,,,0,1911.88,13973.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 8MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620308,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]",Cigna,,7652.65,68,,5873.17,5873.17,5873.17,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"GRAFT SOFT TISSUE 2X2CM VIASHIELD AMNION 2 LAYER PATCH",SUP-8155.2002S,CDM,V2790,HCPCS,0278,RC,,,both,,,8970.00,2691,"FIRST HEALTH [10303]","First Health",,7176,80,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 37CM XL CIRCULAR 2 ROW SEAL 5.2MMX1.5-2.2MM",SUP-ECS29B,CDM,S27200284,LOCAL,0272,RC,,,both,,,6267.91,1880.37,"PHCS [10601]",PHCS,,4387.54,70,,,,,0,728.96,5327.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 0 CT-1 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z340H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 22GA 20CM FRANSEEN CLEAR LUER LOCK HUB CROWN",SUP-FRA2220,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"FIRST HEALTH [10303]","First Health",,160.08,80,,,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 99MM TRI-LOCK BPS GRIPTION 2 HIGH OFFSET HIP",SUP-101214020,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6620.03,41.1,,6417.48,6417.48,6417.48,"1 through 10",1873.26,13691.05,"percent of total billed charges",
"HC Xr Bn Survey Complete",PX-320000181,CDM,77075,CPT,0320,RC,,,both,,,1478.24,443.47,"NOVANET [10819]",Novanet,,1108.68,75,,,,,0,115.51,1256.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 8IN DUROGRIP HEANEY CURVED SERRATED NDL TUNGSTEN",SUP-BM081R,CDM,S27200284,LOCAL,0272,RC,,,both,,,477.58,143.27,"MULTIPLAN [10600]",Multiplan,,405.94,85,,,,,0,55.54,405.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POUCH 34.5CM 10MM ENDO CATCH GOLD MINIMIZE SPILLAGE",SUP-173050G,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,143.03,41.1,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA STD TKR FEMUR PATELLA TIBIA CEMENT STEM",SUP-98000600084,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"PHCS [10601]",PHCS,,15435,70,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW MULTI-THREAD LOCKING 3.5MM X 14MM TI",SUP-MTLS-35140-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1320.30,396.09,"CIGNA [10200]",Cigna,,897.8,68,,1831.33,1831.33,1831.33,16,153.55,1122.26,"percent of total billed charges",
"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC",802,MS-DRG,,,,,,,inpatient,,,92999.44,27899.83,"BLUE CROSS [10001]","Blue Cross PPO",,92999.44,,,,,,,7561,92999.44,"case rate",
"HC Dlyd Plcmnt Dist Ext Prosth Lsa to Celiac",PX-360000030,CDM,33886,CPT,0361,RC,,,both,,,5378.50,1613.55,"CIGNA [10200]","Cigna Open Access",,5378.5,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,625.52,5378.5,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM POLYAXIAL 5.5MM ROD",SUP-8456555,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"BLUE CROSS [10001]","Blue Cross PPO",,1898.3,39.2,,957.42,570.23,957.42,28,563.19,4116.21,"percent of total billed charges",
"TRNSDUC FLOW RATE BIO-PROBE 3/8IN TRILLIUM PROBE ADULT",SUP-DP38T,CDM,S27000186,LOCAL,0270,RC,,,both,,,170.52,51.16,"MULTIPLAN [10600]",Multiplan,,144.94,85,,,,,0,19.83,144.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS AIM SL 62CM 59CM 7FR 5FR 90D GUIDING PEBAX",SUP-DS2N022-59,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND MULTIPASS 2-0 PSL 18IN BRAID BLACK",SUP-673H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS TRABECULAR 5ML 4-10MM FREEZE DRIED",SUP-08A024,CDM,C1713,HCPCS,0278,RC,,,both,,,486.00,145.8,"KAISER [10500]",Kaiser,,325.62,67,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Emg Ltd",PX-922000029,CDM,95870,CPT,0922,RC,,,both,,,495.00,148.5,"FIRST HEALTH [10303]","First Health",,396,80,,,,,0,57.57,420.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM CEMENT SUMMIT 6 12/14 HIGH OFFSET TAPER",SUP-157013120,CDM,C1776,HCPCS,0278,RC,,,both,,,18219.60,5465.88,"BLUE CROSS [10001]","Blue Cross PPO",,7142.08,39.2,,3949.44,3949.44,3949.44,"1 through 10",2118.94,15486.66,"percent of total billed charges",
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,inpatient,,,46575.25,13972.57,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,7220.03,,"Case rate ($6,747.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,265.69, add-ons for qualifying new technology services are included. If operating cost exceeds $39,305.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,855.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,273.97. The transfer operating threshold is the transfer adjustment factor * $6,265.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.72. The transfer capital threshold is the transfer adjustment factor * $473.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,6747.69,27128.64,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.9H 50MM 3 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009350,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16MMX8MM ANATOMIC 14MM PTC RADIOPAQUE CERVICAL",SUP-5030864,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 14MM MINI-MONSTER SHORT THREAD CANNULATED",SUP-P20-125-014S,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross HMO",,555.66,39.2,,957.42,156.86,7483.26,51,164.86,1204.88,"percent of total billed charges",
"PROMETHAZINE 25 MG TABLET",RX-6622,CDM,Q0169,HCPCS,0250,RC,68084-0155-11,NDC,both,1,UN,6.27,1.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2.58,41.1,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 5FR 7MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206070410,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 12MM ENDOPATH XCEL BLUNT TIP",SUP-H12LP,CDM,S27200284,LOCAL,0272,RC,,,both,,,1189.82,356.95,"CIGNA [10200]","Cigna Local Plus",,636.55,53.5,,,,,0,138.38,1011.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOPROSTHESIS STENT AORTOILIAC L59MM DIA8MM VIABAHN V",SUP-BXBL085902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"MULTIPLAN [10600]",Multiplan,,16579.08,85,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL INFINITY 2 STD",SUP-33650002,CDM,S27200284,LOCAL,0272,RC,,,both,,,29049.30,8714.79,"PHCS [10601]",PHCS,,20334.51,70,,,,,0,3378.43,24691.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 32MM CENTER",SUP-5573-6532,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",180.93,1322.35,"percent of total billed charges",
"STEM FEMORAL 127MM CEMENT BASIC SUMMIT 6 12/14 TAPER HIP",SUP-1570-06-120,CDM,C1776,HCPCS,0278,RC,,,both,,,8135.10,2440.53,"FIRST HEALTH [10303]","First Health",,6508.08,80,,,,,0,946.11,6914.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 4.5MM 75MM EVOS MINI T8 LONG BONE SMALL BONE",SUP-72402775,CDM,C1713,HCPCS,0278,RC,,,both,,,456.52,136.96,"MULTIPLAN [10600]",Multiplan,,388.04,85,,,,,0,53.09,388.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORTHOSIS SMALL 11IN THERMOPLASTIC FOAM HAND RIGHT BREATHABLE",SUP-55460406,CDM,L3807,HCPCS,0274,RC,,,both,,,460.89,138.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,179.46,,,,,,,53.6,391.76,"fee schedule",
"PILLOW POSITIONING 7IN GENTLETOUCH HDRST RIGHT INTUB SLOT NO",SUP-1927DZ,CDM,S27000186,LOCAL,0270,RC,,,both,,,54.30,16.29,"NOVANET [10819]",Novanet,,40.73,75,,,,,0,6.32,46.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Ankle >=3v Complt",PX-320000088,CDM,73610,CPT,0320,RC,,,both,,,696.21,208.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,44.44,,,,,,,44.44,591.78,"fee schedule",
"30ATM INFLATION DEVICES AND ANGIOPLASTY PACKSBASIXCOMPAK30 INF",SUP-IN4530,CDM,S27200284,LOCAL,0272,RC,,,both,,,264.13,79.24,"MULTIPLAN [10600]",Multiplan,,224.51,85,,,,,0,30.72,224.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN SUCTION PAL LONG 3MM 30CM PORT 8MM DISPOSABLE",SUP-PAL-300-LL,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,263,41.1,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +23 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.230,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG PROC PACK BLUE WRAPPING ALCOHOL PAD VALVE CAP SELF",SUP-50-7290A,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"NOVANET [10819]",Novanet,,306.68,75,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 15.5CM 9FR PEEL-AWAY PERCUTANEOUS STERILE",SUP-G01697,CDM,C1894,HCPCS,0272,RC,,,both,,,382.71,114.81,"KAISER [10500]",Kaiser,,256.42,67,,,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DTECT CARBON DIOXIDE 43IN 12FR KANGAROO DOBBHOFF BELLOWS",SUP-711253CN,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.55,44.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.16,125.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 111MM 13MM PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51107130,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10974.1,40,,,,,0,3190.72,23319.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HALOPERIDOL 5 MG TABLET",RX-3583,CDM,,,0637,RC,70756-0004-11,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Abdomen WO Cntrst",PX-610000040,CDM,74181,CPT,0610,RC,,,both,,,3907.20,1172.16,"KAISER [10500]",Kaiser,,2617.82,67,,,,,0,436.01,3321.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM .9IN KIRSCHNER 1 END TROCAR POINT SMOOTH",SUP-P99-192-0915,CDM,C1713,HCPCS,0278,RC,,,both,,,146.16,43.85,"MULTIPLAN [10600]",Multiplan,,124.24,85,,,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 18MM 143CM 2.25MM CORONARY EVEROLIMUS ELUTING",SUP-1009544-18,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"CIGNA [10200]",Cigna,,6521.88,68,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEED THERA-BAND IODINE-125 BRACHYTHERAPY",SUP-TG726IL,CDM,C2638,HCPCS,0278,RC,,,both,,,139.20,41.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILFRM URETHRAL 13IN 5FR STRAIGHT PLASTIC STERILE LATEX FREE",SUP-342105,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.96,28.19,"MULTIPLAN [10600]",Multiplan,,79.87,85,,,,,0,10.93,79.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 50MM SPINAL FENESTRATE MULTIAXIAL 5.5/6MM ROD",SUP-55840024550T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,3978.14,359.25,3978.14,24,641.98,4692,"percent of total billed charges",
"CANN PERFUSION 36FR VENOUS 1 STAGE DLP STERILE LATEX FREE",SUP-66136,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.63,85.69,"CIGNA [10200]","Cigna Local Plus",,152.81,53.5,,,,,0,33.22,242.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MAXI 8-11.5IN OSTOMY FISTULA 2 LAYER 2 SPOUT OUTLET",SUP-14070,CDM,S27200284,LOCAL,0272,RC,,,both,,,303.20,90.96,"PHCS [10601]",PHCS,,212.24,70,,,,,0,35.26,257.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8- KNEE RIGHT PRESS FIT EMPOWR KNEE STERILE BP",SUP-353-04-108,CDM,C1776,HCPCS,0278,RC,,,both,,,15979.64,4793.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1893.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1858.43,13582.69,"percent of total billed charges",
"SUT ETHILON MULTIPASS 5-0 FS-2 18IN MONOFILAMENT PLIABILIZED",SUP-661H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 28MM 8MM BLUNT FULL THREAD",SUP-AR-1380TC,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"NOVANET [10819]",Novanet,,1387.97,75,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC CURRENT DR 36J DS-1/IS-1 CNCT DUAL CHMBR",SUP-2207-36,CDM,C1721,HCPCS,0278,RC,,,both,,,70537.50,21161.25,"BLUE CROSS [10001]","Blue Cross HMO",,27650.7,39.2,,,,,0,8203.51,59956.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 CT 36IN BRAID ANTIBACTERIAL COATED",SUP-VCP956H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"KAISER [10500]",Kaiser,,16.75,67,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 13MM ZEVO TITANIUM SPINE CERVICAL ANTERIOR",SUP-7723513,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 12MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25012W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1549.13,45.9,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL KNIFE 24FR STERILE DISPOSABLE TUIP",SUP-M0068802371,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"CIGNA [10200]","Cigna Open Access",,293.88,56.9,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX PDS PLUS 1 CT-2 6IN UNIDIRECTIONAL SYMMETRIC",SUP-SXPP1A419,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"NOVANET [10819]",Novanet,,180.23,75,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chrom Add Cell Count",PX-311000074,CDM,88285,CPT,0311,RC,,,both,,,128.70,38.61,"CIGNA [10200]",Cigna,,59.2,,,,,,,0.01,109.4,"fee schedule",
"INSRT TIBIAL 2 16MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532G216,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"MULTIPLAN [10600]",Multiplan,,7401.47,85,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +18 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.180,CDM,V2632,HCPCS,0276,RC,,,both,,,3292.50,987.75,"BLUE CROSS [10001]","Blue Cross HMO",,1290.66,39.2,,,,,0,382.92,2798.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 52MM COCR",SUP-VAL-35520-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"AMERIGROUP MEDICAID [20100]",Amerigroup,,248.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",244.23,1785,"percent of total billed charges",
"STEM HUMERAL 122MM 7MM COMPREHENSIVE POROUS STD SHOULDER",SUP-113647,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5178.6,41.1,,6417.48,6417.48,6417.48,"1 through 10",1465.38,10710,"percent of total billed charges",
"BAND ANNULOPLASTY 27MM SIMULUS FULLY FLEXIBLE",SUP-700FC27,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]",Cigna,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 40MM 75CM 10MM 8.5FR .035IN 48MM BILIARY",SUP-M00574730,CDM,C1874,HCPCS,0278,RC,,,both,,,19530.00,5859,"MULTIPLAN [10600]",Multiplan,,16600.5,85,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 34X24X12MM BRIGADE 8D NONSTERILE LATEX FREE",SUP-6941234,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"BLUE CROSS [10001]","Blue Cross HMO",,13436.04,39.2,,8555.87,8555.87,8996.26,"1 through 10",3986.25,29134.26,"percent of total billed charges",
"CATH PACIFIC XTREME 90CM 150MM 3.9-4.2FR 5MM BALLOON",SUP-PCU050150090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UHC [10700]","United Healthcare",,779.35,63.3,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FRONTRUNNER XP CTO 140CM 2.3MM 4.5FR .067IN",SUP-FBP39140,CDM,S27200284,LOCAL,0272,RC,,,both,,,5312.31,1593.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,629.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,617.82,4515.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.165,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]",Cigna,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABRE VENOUS SELF-EXPADING STENT16X120X90",SUP-AB9T16120090,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X9X9MM COROENT 4D PEEK LARGE IMPACT NONSTERILE",SUP-6709932,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA [10200]",Cigna,,6624,40,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 8MMX39MM 7FR 80CMCATH HEPARIN",SUP-BXB083901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"AETNA [10100]","Aetna HMO/PPO",,15506.32,79.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SLINGSHOT 70D UP SUTURING 1 PORT BRAID VARIABLE TIP",SUP-CAT02590,CDM,S27200284,LOCAL,0272,RC,,,both,,,2280.00,684,"MULTIPLAN [10600]",Multiplan,,1938,85,,,,,0,265.16,1938,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 25MM TITANIUM LOCK TRANSLATIONAL ATLANTIS BONE SPINE",SUP-6190025,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,957.42,570.23,957.42,28,521.61,3812.25,"percent of total billed charges",
"SCR BONE 2.7MM 12MM LOW PROFILE SCREWS STAINLESS STEEL FULL",SUP-AR-8827L-12,CDM,C1713,HCPCS,0278,RC,,,both,,,931.50,279.45,"CIGNA [10200]",Cigna,,633.42,68,,1831.33,1831.33,1831.33,16,108.33,791.78,"percent of total billed charges",
"CATH REDEL 110CM 1MM 5FR 5MM SPACE D CURVE ELECTROPHYSIOLOGY",SUP-F5QD005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"PHCS [10601]",PHCS,,635.04,70,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 6MM 60MM 2.5MM PELVIC CORTEX SELF TAP SMALL",SUP-204.66,CDM,C1713,HCPCS,0278,RC,,,both,,,179.48,53.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,20.87,152.56,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL L HOOK STD 32CM 5MM STERILE",SUP-60-5163-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,251.69,75.51,"KAISER [10500]",Kaiser,,168.63,67,,,,,0,29.27,213.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH 1 55CM 6FR .07IN RENAL 2 CURVE GUIDING PTFE",SUP-M001196660,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"PHCS [10601]",PHCS,,417.99,70,,,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE LARGE XLONG FEMALE NAVY BLUE BREATHABLE",SUP-100347-040,CDM,S27000186,LOCAL,0270,RC,,,both,,,54.55,16.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.34,46.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.4MM 2 SUTURETAK FIBERWIRE BIOCOMPOSITE 12MM",SUP-AR-1934BCF-24-2,CDM,C1713,HCPCS,0278,RC,,,both,,,2520.00,756,"FIRST HEALTH [10303]","First Health",,2016,80,,,,,0,293.08,2142,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR EMPHASYS 48MM 36MM AOX ELEVATE",SUP-472248236,CDM,C1776,HCPCS,0278,RC,,,both,,,14038.05,4211.41,"CIGNA [10200]",Cigna,,5615.22,40,,5873.17,5873.17,5873.17,"1 through 10",1632.63,11932.34,"percent of total billed charges",
"SCR BONE 3.5MM 13MM GEMINUS TITANIUM DISTAL CORTEX VOLAR",SUP-COLS-35130-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA [10200]","Cigna Local Plus",,338.01,53.5,,3978.14,359.25,3978.14,24,73.48,537.03,"percent of total billed charges",
"WIRE FIXATION 100MM 1.6MM KIRSCHNER",SUP-WIRE-1.6/100,CDM,S27000186,LOCAL,0270,RC,,,both,,,174.00,52.2,"NOVANET [10819]",Novanet,,130.5,75,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGSEED 7CM",SUP-SM18-1-07,CDM,A4648,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CIGNA [10200]","Cigna Local Plus",,1986.19,53.5,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HT COMMAND 14 ST 6G X 10CM 300CM ANG",SUP-1060002A,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,396.16,41.1,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 15CM 18MM 2 VELOUR KNIT HEMASHIELD GOLD",SUP-M002020951180,CDM,C1768,HCPCS,0278,RC,,,both,,,2698.73,809.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1238.72,45.9,,,,,0,313.86,2293.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ VASCULAR STRAIGHT 260CM .035IN STAINLESS STEEL",SUP-G03562,CDM,C1769,HCPCS,0272,RC,,,both,,,247.86,74.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.83,210.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rt&Lt Hrt Cath Si",PX-481000021,CDM,93453,CPT,0481,RC,,,both,,,14177.69,4253.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6079.88,,"Case rate ($6,079.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,1566.32,12051.04,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 6.7IN SEWALL 1 ORBITAL SURGICAL 52X7MM",SUP-N3321,CDM,S27200284,LOCAL,0272,RC,,,both,,,1320.30,396.09,"CIGNA [10200]",Cigna,,897.8,68,,,,,0,153.55,1122.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STATION DOCKING FOUR POSITION VERSION FOR NOVA STATSTRIP GLU",SUP-53402,CDM,S27000186,LOCAL,0270,RC,,,both,,,8280.00,2484,"AMERIGROUP MEDICAID [20100]",Amerigroup,,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT GLENOID SHORT STEM INSRT VERSA-DIAL",SUP-98B00900110,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5859.95,28.62,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET FEEDING 18FR L3.5CM TUBE JEJUNAL EXTENSION MIC-KEY ENFIT",SUP-8230-18-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"CIGNA [10200]","Cigna Open Access",,820.98,56.9,,,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 180CM 40MM 4FR 2MM .018IN BALLOON",SUP-PCP020040180,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UHC [10700]","United Healthcare",,779.35,63.3,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tte 2d Fu/Ltd",PX-483000006,CDM,93308,CPT,0483,RC,,,both,,,1015.18,304.55,"CIGNA [10200]",Cigna,,690.32,68,,,,,0,118.07,862.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 CURVE 17.5MM KNEE GVF ROTATE PLATFORM PFC",SUP-972004,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1096.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1075.71,7862.03,"percent of total billed charges",
"AVENIR 18 7 X 19 COMPLEX FRAMING COIL",SUP-18CFR-07019,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1549.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET KIT W/UNIV CLIP-ON TOOL AND IMPLANT TOOL, 58CM-DS0600",SUP-DS06002/58,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,334.61,45.9,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) CATH LITHOPLASTY 110CM 60MM 6MM .064IN ULTRASOUND PER",SUP-M732LPBC6060DX1,CDM,C1725,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 44MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.544,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"BLUE CROSS [10001]","Blue Cross HMO",,429.8,39.2,,957.42,156.86,7483.26,51,127.51,931.96,"percent of total billed charges",
"SHEATH INTRO ORANGE 11CM 7FR BRITE TIP CANN INTERVENTIONAL",SUP-401711M,CDM,C1894,HCPCS,0272,RC,,,both,,,60.90,18.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.08,51.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 10-11X30X11MM LUMINARY SPINE LUMBAR FREEZE",SUP-14711,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3663.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW LAPIPLASTY",SUP-ZMS-4011,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"UHC [10700]","United Healthcare",,384.55,63.3,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00160,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,743.58,68,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.6CM MEMORYGEL P3.3CM MODERATE CLASSIC PROFILE",SUP-RSZ-7360MC,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"FIRST HEALTH [10303]","First Health",,123.38,80,,,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Carbamazepine Total",PX-301000036,CDM,80156,CPT,0301,RC,,,both,,,329.70,98.91,"CIGNA [10200]","Cigna Open Access",,32.05,,,,,,,0.01,280.25,"fee schedule",
"HC TB Test Cell Immunity Measure",PX-302000092,CDM,86480,CPT,0302,RC,,,both,,,553.85,166.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,66.33,,"Fee schedule rate ($66.33). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.55,470.77,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Protein Electrophoresis Other",PX-301000382,CDM,84166,CPT,0301,RC,,,both,,,289.50,86.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16.05,,,,,,,0.29,246.08,"fee schedule",
"HC Colorectal Scrn Flex Sig",PX-750000196,CDM,G0104,HCPCS,0750,RC,,,both,,,2890.63,867.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,336.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,336.18,2890.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR DEFIB CROME PIN PLUG MRI HIGH FREQUENCY CRT-D",SUP-DTPC2D1,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"NOVANET [10819]",Novanet,,57712.5,75,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +20 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SA60WF.200,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOXYLAMINE SUCCINATE 25 MG TABLET",RX-14847,CDM,,,0637,RC,70677-1129-01,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER ABLATION 7FR CORONARY SINUS 2-8-2MM SPACING D-F CUR",SUP-BD710DF282RTSR,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP",RX-38285,CDM,,,0637,RC,00121-1761-30,NDC,both,30,ML,23.78,7.13,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLING ORTHOPEDIC LARGE 13+ IN ARM ABDUCTION PILLOW COOL",SUP-11-0138-4-13130,CDM,S27000186,LOCAL,0270,RC,,,both,,,373.06,111.92,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL +17.5 DIOPTER HAPTIC C BICONVEX 13MM 6MM POSTERIOR",SUP-ZXR00U0175,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,88.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 9CM 3MM LEGEND MATCH HEAD STERILE",SUP-9MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1184.63,355.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,543.75,45.9,,,,,0,137.77,1006.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER BURR HOLE .4MM 14MM UNIVERSAL NEURO III",SUP-53-34514,CDM,C1713,HCPCS,0278,RC,,,both,,,1858.37,557.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,220.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,216.13,1579.61,"percent of total billed charges",
"SCREW CORTEX 4.5X28MM SYN",SUP-214.028,CDM,S27800098,LOCAL,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25MMX10MM CRESCENT PEEK-OPTIMA VERTEBRAL BODY",SUP-9392510,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"KAISER [10500]",Kaiser,,11095.2,67,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 9X40 80CM SL",SUP-48009004N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,99.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 13X1IN DEAVER 2 STD HANDLE HANDHELD STAINLESS STEEL",SUP-50-4304,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.91,23.07,"FIRST HEALTH [10303]","First Health",,61.53,80,,,,,0,8.94,65.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 23MM BRIDGE LOCK POST ADVANTAGERIB BONE NONSTERILE",SUP-323.1013,CDM,C1713,HCPCS,0278,RC,,,both,,,23221.80,6966.54,"UHC [10700]","United Healthcare",,14699.4,63.3,,5023.51,2672.93,6679.78,18,2700.7,19738.53,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 24CM 3CM 7FR .035IN",SUP-M006192142190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"NOVANET [10819]",Novanet,,1046.42,75,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER VASCULAR 80CM 10FR VENA CAVA OPTEASE RETRIEVABLE",SUP-466C220F,CDM,C1880,HCPCS,0278,RC,,,both,,,1134.00,340.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN STD",SUP-67008300M,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"UHC [10700]","United Healthcare",,264.34,63.3,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +19 DIOPTER MODIFIED C BICONVEX 13MM 6MM POSTE",SUP-Z900200190,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,694.01,68,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLEANSER WND ANTISEP GEL ANASEPT 3OZ",SUP-5003G,CDM,S27200284,LOCAL,0272,RC,,,both,,,183.80,55.14,"KAISER [10500]",Kaiser,,123.15,67,,,,,0,21.38,156.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14CM NATRELLE BIOCELL P3.8CM MODERATE PROFILE",SUP-MSZ10420,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SND1T6 AS SP ASPHER RESTOR REFERENCE",SUP-SND1T6,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"NOVANET [10819]",Novanet,,558.75,75,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 17MM NEXGEN LPS-FLEX 1-2 C-D KNEE PROLONG",SUP-596202217,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"CIGNA [10200]","Cigna Open Access",,4505.59,56.9,,5302.19,4377.88,6578.61,27,920.91,6730.67,"percent of total billed charges",
"CAGE SPINAL 60X22X10MM MODULUS 10D XL WIDE STERILE LATEX",SUP-1221060P2,CDM,C1889,HCPCS,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Local Plus",,8930.25,31.5,,16168.95,16168.95,16168.95,"1 through 10",3297.11,24097.5,"percent of total billed charges",
"SHEATH HEARTSPAN 120D FIX CURVE TAPER 79.4CM 8.5FR GUIDING",SUP-FCL-160-09,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 20MM CLEVERCUT3V PRELOAD DISTAL TIP STERILE",SUP-KD-VC411Q-0720,CDM,S27200284,LOCAL,0272,RC,,,both,,,1500.61,450.18,"UHC [10700]","United Healthcare",,949.89,63.3,,,,,0,174.52,1275.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 110CM 6FR ULT4T-40 CURVE ANGIOGRAPHIC PEBAX",SUP-6110381ULT4-T40,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.84,61.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC",688,MS-DRG,,,,,,,inpatient,,,11552.53,3465.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 135CM 80MM 4MM BALLOON DILATATION PACLITAXEL OTW",SUP-H74939419400810,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE COMET II VASCULAR 185CM .014IN PRESSURE STERILE LATEX",SUP-H74939359110,CDM,C1769,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) AGENT DCB MR 3.00MM X 30MM",SUP-H74939436303010,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH R2P DESTINATION SLENDER 105CM 6FR GUIDING STERILE",SUP-GS-R6ST1C10W,CDM,C1894,HCPCS,0272,RC,,,both,,,2216.25,664.87,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MTRL SPLINTING HAND THERMOPLASTIC THK1/8IN 36X24IN 1%",SUP-A297012,CDM,S27000186,LOCAL,0270,RC,,,both,,,623.13,186.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INFINITI 100CM 6FR JL6 CURVE ANGIOGRAPHIC VESTAN",SUP-534624T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,inpatient,,,31163.00,9348.9,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 4FR 15CM RADIOPAQUE GWIRE STERILE DISPOSABLE",SUP-G02551,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.61,28.68,"FIRST HEALTH [10303]","First Health",,76.49,80,,,,,0,11.12,81.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25.4MM THK1.3MM 99MM XLONG WIDE STAINLESS STEEL",SUP-2108218000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"CIGNA [10200]","Cigna Open Access",,109.01,56.9,,,,,0,22.28,162.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL SHILEY EVAC TAPERGUARD OD11.8 MM ID8.0 MM",SUP-18880S,CDM,S27200284,LOCAL,0272,RC,,,both,,,159.85,47.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,73.37,45.9,,,,,0,18.59,135.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 480MM 6MM XIA 3 TITANIUM NONSTERILE",SUP-48232480,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"CATH CPS LOC MEDIUM CARDIAC PERCUTANEOUS 3D STERILE",SUP-DS2C200-42,CDM,C1893,HCPCS,0272,RC,,,both,,,2250.00,675,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,266.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 12IN MULTIPANEL PROCARE 36-65IN MEDIUM",SUP-79-89386,CDM,S27000186,LOCAL,0270,RC,,,both,,,61.60,18.48,"MULTIPLAN [10600]",Multiplan,,52.36,85,,,,,0,7.16,52.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XACT 40MM 7-9MM TAPER VASCULAR NITINOL CAROTID ARTERY",SUP-82086-01,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3846.96,41.1,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 18MM 140CM 3MM 2.1-2.7FR CORONARY STENT",SUP-RONYX30018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3309.38,992.81,"CIGNA [10200]","Cigna Local Plus",,1770.52,53.5,,,,,0,384.88,2812.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR WRP CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389696090,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,249.18,68,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 33MM STEALTH SOFT TRACTION STERILE LATEX FREE",SUP-G-3300,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"KAISER [10500]",Kaiser,,151.55,67,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest Cerv/Thor Facet Jnt Bi",PX-510000152,CDM,64633,CPT,0761,RC,,,both,,,5726.64,1717.99,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,666.01,4867.64,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION",RX-121811,CDM,J3475,HCPCS,0636,RC,63323-0106-15,NDC,both,500,ML,100.65,30.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32,,,,,,,2.39,85.55,"fee schedule",
"HC Surg Path Gross Micro Level 5",PX-312000016,CDM,88307,CPT,0312,RC,,,both,,,777.40,233.22,"FIRST HEALTH [10303]","First Health",,621.92,80,,,,,0,0.01,660.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS MULTIPASS 3-0 PS-2 27IN BRAID COATED UNDYED",SUP-VCP427H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.28,41.1,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM 20MM PRESS FIT UNIVERSAL FLUTE KNEE",SUP-867433,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"CIGNA [10200]","Cigna Open Access",,4609.24,56.9,,5302.19,4377.88,6578.61,27,942.1,6885.51,"percent of total billed charges",
"NAIL 8MM 180MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-408-180,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,1831.33,1831.33,1831.33,16,2014.9,14726.25,"percent of total billed charges",
"SCR BONE 4MM 42MM LCP STAINLESS STEEL CORTICAL PERIARTICULAR",SUP-02.204.042,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"CIGNA [10200]",Cigna,,670.87,68,,1831.33,1831.33,1831.33,16,114.74,838.59,"percent of total billed charges",
"SCR BONE 5MM 65MM LCP STAINLESS STEEL PROXIMAL FEMORAL",SUP-02.205.065,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,579.85,45.9,,,,,0,146.92,1073.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17CM 5MM MICRUSFRAME 10 COIL",SUP-MFR100517,CDM,S27800098,LOCAL,0278,RC,,,both,,,16974.00,5092.2,"FIRST HEALTH [10303]","First Health",,13579.2,80,,,,,0,1974.08,14427.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX16MM VANGUARD POROUS KNEE POSTERIOR",SUP-183746,CDM,C1776,HCPCS,0278,RC,,,both,,,8757.48,2627.24,"BLUE CROSS [10001]","Blue Cross PPO",,3432.93,39.2,,3949.44,3949.44,3949.44,"1 through 10",1018.49,7443.86,"percent of total billed charges",
"HC Xr Arthgm Elbow Si",PX-322000002,CDM,73085,CPT,0322,RC,,,both,,,1259.43,377.83,"CIGNA [10200]",Cigna,,163.64,,,,,,,117,1070.52,"fee schedule",
"SCR BONE 4MM 22MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.422,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"AETNA [10100]","Aetna HMO/PPO",,3339,79.5,,1521.93,481.35,16760.95,30,488.46,3570,"percent of total billed charges",
"INSERT SURGICAL SCREWDRIVER TORX SCREW",SUP-80083,CDM,S27200284,LOCAL,0272,RC,,,both,,,6326.27,1897.88,"NOVANET [10819]",Novanet,,4744.7,75,,,,,0,735.75,5377.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 120CM 6FR 5MM SPACE JOSEPHSON CURVE ELECTROPHYSIOLOGY",SUP-200624S,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"PHCS [10601]",PHCS,,219.24,70,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUITY PRO LEAD DELIVERY SYSTEM",SUP-PLDS,CDM,S27200284,LOCAL,0272,RC,,,both,,,3339.00,1001.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2270.52,68,,,,,0,388.33,2838.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"27 MM LOTUS EDGE AORTIC VALVE SYSTEM AND LARGE LOTUS INTRODU",SUP-B0M27EDGELGIS,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,50017.5,27,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Fna I&R / Add on 88173",PX-311000088,CDM,0837T,CPT,0311,RC,,,both,,,104.00,31.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,47.74,45.9,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 24MM 4.5MM CORONARY STENT PLATINUM",SUP-H7493926024450,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"BLUE CROSS [10001]","Blue Cross PPO",,3651.48,39.2,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 50 % IN WATER (D50W) SUPERORDERABLE - GLUCOMMANDER",RX-409649,CDM,,,0250,RC,06937-4953-50,NDC,both,50,ML,100.65,30.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68.44,68,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE LORDOTIC ALLOGRAFT 14X14X6MM",SUP-645644,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM 13MM PRESS FIT REDUCE PROXIMAL PROFILE",SUP-192513,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"UHC [10700]","United Healthcare",,15032.79,63.3,,8601.07,8395.67,8601.07,"1 through 10",2761.95,20186.21,"percent of total billed charges",
"FRCP BIOPSY FORMABLE SHAFT UNIQUE CUTTING EDGE SUPERIOR",SUP-190051,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"UHC [10700]","United Healthcare",,1068.19,63.3,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bandage Viscopaste",PX-E27000051,CDM,E27000051,LOCAL,0270,RC,,,both,,,61.43,18.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25.25,41.1,,,,,0,7.14,52.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 108MM RADIUS CURVE 104X10.2X2.7MM STAINLESS STEEL 3.5",SUP-245.878,CDM,C1713,HCPCS,0278,RC,,,both,,,4488.04,1346.41,"PHCS [10601]",PHCS,,3141.63,70,,,,,0,521.96,3814.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 45MM LCP STAINLESS STEEL FULL THREAD CANCELLOUS",SUP-206.045,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"BLUE CROSS [10001]","Blue Cross HMO",,107.26,39.2,,957.42,156.86,7483.26,51,31.82,232.58,"percent of total billed charges",
"SLEEVE ORTHOPEDIC THK1/8IN SMALL 13IN NEOPRENE KNEE EXTRA",SUP-79-82003,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.72,17.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 150CM 300MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035300M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"PHCS [10601]",PHCS,,1312.5,70,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PLATE 4 66X46MM CEMENTED STEMMED MODULAR NEXGEN",SUP-00598003702,CDM,C1776,HCPCS,0278,RC,,,both,,,8643.60,2593.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1005.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1005.25,7347.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 30MM 75CM 7MM .035IN VASCULAR NITINOL ILIAC",SUP-H74939200073070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"AMERIGROUP MEDICAID [20100]",Amerigroup,,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 2.75MM CLEARCUT ANGLE 2 BEVEL EYE CELOS",SUP-8065992747,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.76,61.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.93,174.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 14.5MM 42X70X10MM GENTAMICIN PMMA REMEDY",SUP-RKINMD,CDM,C1776,HCPCS,0278,RC,,,both,,,4830.00,1449,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,561.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 8.5FR PUSHING BILIARY STERILE LATEX FREE DISPOSABLE",SUP-G21623,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH C-FLEX 70CM 8FR PIGTAIL CURVE URETERAL TAPER TIP 1",SUP-M0064001730,CDM,C1758,HCPCS,0272,RC,,,both,,,499.69,149.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,58.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.11,424.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER COMPLI REDEL 115CM 1MM 6FR 2-5-2MM SPACE A",SUP-F6CQA252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"KAISER [10500]",Kaiser,,1552.73,67,,,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 3.5MM PRECUT",SUP-3603770,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 9/64IN STEINMANN STAINLESS STEEL 2 END",SUP-KM169-29-96,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,7.4,54.07,"percent of total billed charges",
"NDL NERVE BLOCK 80MM 22GA SONOPLEX II FACET S TIP INJECTION",SUP-001287-71,CDM,C9812,HCPCS,0272,RC,,,both,,,139.20,41.76,"CIGNA [10200]","Cigna Open Access",,79.2,56.9,,,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,inpatient,,,113902.06,34170.62,"BLUE CROSS [10001]","Blue Cross HMO",,81707.81,,,,,,,7561,103914.4,"case rate",
"RTRCTR 14.5IN HARRINGTON LARGE WIDE BLADE SURGICAL 7.5X4.5IN",SUP-CH1008,CDM,S27200284,LOCAL,0272,RC,,,both,,,2128.43,638.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,247.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.54,1809.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT PARALLEL ALLOGRAFT 16MM TLIF",SUP-3W3316,CDM,S27800098,LOCAL,0278,RC,,,both,,,17139.60,5141.88,"KAISER [10500]",Kaiser,,11483.53,67,,,,,0,1993.34,14568.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 15MM 145CM 3.5MM BALLOON DILATATION",SUP-1400350-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 120MM 3.8FR 3MM BALLOON DILATATION",SUP-H74939148301210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE UNIVERSAL NEURO III LARGE LOW PROFILE",SUP-53-34240,CDM,C1713,HCPCS,0278,RC,,,both,,,2289.90,686.97,"PHCS [10601]",PHCS,,1602.93,70,,,,,0,266.32,1946.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MITRACLIP DELIVERY KIT SGC0101 CDS0201",SUP-MSK0101,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46170,27,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Proc Unlisted",PX-402000044,CDM,76999,CPT,0402,RC,,,both,,,837.00,251.1,"AETNA [10100]","Aetna HMO/PPO",,665.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.34,711.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG ROUND DRAPE SENSATRAC PAD CNCT POLYURETHANE VAC",SUP-M8275075/10.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,337.70,101.31,"PHCS [10601]",PHCS,,236.39,70,,,,,0,39.27,287.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 30ML .5-5MM 80% CORTICAL 20% CANCELLOUS",SUP-400051,CDM,C1713,HCPCS,0278,RC,,,both,,,2842.88,852.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1304.88,45.9,,,,,0,330.63,2416.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC",025,MS-DRG,,,,,,,inpatient,,,200885.48,60265.64,"UHC [10700]","United Healthcare",,132745.45,,"Fee schedule rate ($132,745.45). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,28203.45,132745.45,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT C-ACS 11MMX14MM 6DEG 7MM",SUP-4W7407,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Local Plus",,3691.5,53.5,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 180CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-200,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"MULTIPLAN [10600]",Multiplan,,6422.18,85,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hydroxycorticosteroids",PX-301000237,CDM,83491,CPT,0301,RC,,,both,,,178.00,53.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,62.22,,,,,,,0.01,151.3,"fee schedule",
"PLATE 12MM TITANIUM MULTIPLE HOLE OPEN DOOR PRECUT INTRINSIC",SUP-853-012,CDM,C1713,HCPCS,0278,RC,,,both,,,2624.40,787.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,310.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,305.22,2230.74,"percent of total billed charges",
"STENT CONTOUR 24CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006180242010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CIGNA [10200]","Cigna Local Plus",,572.85,,,,,,,124.53,910.13,"percent of total billed charges",
"CATH ACCUCATH ACCUTIP 2.25IN 22GA ULTRASOUND 6ML",SUP-AC0222250,CDM,C1753,HCPCS,0272,RC,,,both,,,365.40,109.62,"FIRST HEALTH [10303]","First Health",,292.32,80,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 150MM 2MM .018IN BALLOON",SUP-R51002015L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1388.22,68,,,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 10MM MREYE PLATINUM 1.6 LOOP ACCEPTS",SUP-G19908,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"NOVANET [10819]",Novanet,,625.67,75,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON DISECT LAPAROSCOPIC KII 100MM 12MM 2 LATERAL LOW",SUP-C0K15,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BIOPSY 10CM 20GA BARD MARQUEE CORE DISPOSABLE",SUP-MQK2010,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH UNI-FUSE FLOW-THRU HUB 90CM 50CM 5FR THROMBECTOMY",SUP-12401810,CDM,C1757,HCPCS,0272,RC,,,both,,,1641.75,492.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Kit Cath Impella",PX-E27200152,CDM,E27200152,LOCAL,0272,RC,,,both,,,3185.60,955.68,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORODYN P1 ANGIO VNGR BLN",SUP-336074,CDM,C1893,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Xr Spine Cerv Complt",PX-320000037,CDM,72052,CPT,0320,RC,,,both,,,1013.48,304.04,"FIRST HEALTH [10303]","First Health",,810.78,80,,,,,0,75.77,861.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ercp Ablation",PX-750000143,CDM,43278,CPT,0750,RC,,,both,,,3239.00,971.7,"KAISER [10500]",Kaiser,,2170.13,67,,,,,0,376.7,3239,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tumor Immunohistochem Cad",PX-312000046,CDM,88361,CPT,0312,RC,,,both,,,615.33,184.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,89.87,,"Fee schedule rate ($89.87). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,523.03,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Splint Ankle",PX-E27000162,CDM,E27000162,LOCAL,0270,RC,,,both,,,756.80,227.04,"AETNA [10100]","Aetna HMO/PPO",,601.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,88.02,643.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rem Impl Drug Deliv Non-Biodeg",PX-361000515,CDM,11982,CPT,0361,RC,,,both,,,4282.83,1284.85,"MULTIPLAN [10600]",Multiplan,,3640.41,85,,,,,0,498.09,4282.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRICATH 16FR STD URETHRAL NATURAL RUBBER HYDROGEL 5ML",SUP-0119L16,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.52,23.26,"MULTIPLAN [10600]",Multiplan,,65.89,85,,,,,0,9.02,65.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT UNDYED VICRYL 2-0 CT-1 18IN CONTROL RELEASE BRAID 8",SUP-J839D,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.65,37.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.61,106.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Human Epididymis Protein 4",PX-301000545,CDM,86305,CPT,0302,RC,,,both,,,840.00,252,"KAISER [10500]",Kaiser,,562.8,67,,,,,0,0.01,714,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET FEEDING KANGAROO EPUMP ANTIFREE FLOW DEHP FREE PUMP 1000",SUP-041865CS,CDM,C1730,HCPCS,0272,RC,,,both,,,2250.00,675,"AMERIGROUP MEDICAID [20100]",Amerigroup,,266.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED II 110CM 4.5CM 10FR 20MM 5 ATM BALLOON DILATATION",SUP-611003,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"MULTIPLAN [10600]",Multiplan,,4520.33,85,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRAUMA FIXATION 80MM META-TAN INTEGRATE LAG COMPRESSION",SUP-71642680,CDM,C1713,HCPCS,0278,RC,,,both,,,4950.06,1485.02,"NOVANET [10819]",Novanet,,3712.55,75,,,,,0,575.69,4207.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EAGLE EYE 150CM 5FR 20MM 20MHZ SHORT TAPER ULTRASOUND",SUP-85900PST,CDM,C1753,HCPCS,0272,RC,,,both,,,5002.50,1500.75,"AETNA [10100]","Aetna HMO/PPO",,3976.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LARGE 121X11MM TITANIUM 10 HOLE LOW PROFILE LOCKING",SUP-70-0294,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"AETNA [10100]","Aetna HMO/PPO",,5255.11,79.5,,1521.93,481.35,16760.95,30,768.77,5618.67,"percent of total billed charges",
"SYSTEM SYNERGY 32MM 144CM 2.75MM CORONARY STENT PEBAX",SUP-H7493926032270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"KAISER [10500]",Kaiser,,3728.55,67,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GYNECARE ABBREVO",SUP-TVTOML,CDM,C1771,HCPCS,0278,RC,,,both,,,7836.40,2350.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,928.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,911.37,6660.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SORBAFIX 36CM FIXATION 15 SHOT ABSORBABLE THREAD",SUP-0113115,CDM,S27200284,LOCAL,0272,RC,,,both,,,502.20,150.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,206.4,41.1,,,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60MM POLYMER ENDOSCOPIC BIOABSORBABLE STERILE",SUP-12BSGEC60,CDM,S27200284,LOCAL,0272,RC,,,both,,,1323.00,396.9,"CIGNA [10200]",Cigna,,899.64,68,,,,,0,153.86,1124.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"26.0MM HEAD, RIGHT",SUP-TR-H260R-S,CDM,C1776,HCPCS,0278,RC,,,both,,,13489.50,4046.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5544.18,41.1,,6417.48,6417.48,6417.48,"1 through 10",1568.83,11466.08,"percent of total billed charges",
"WRAP THERAPEUTIC KNEE GEL FREEZABLE MICROWAVABLE COMPRESSION",SUP-K-24-6-IP,CDM,S27000186,LOCAL,0270,RC,,,both,,,336.69,101.01,"KAISER [10500]",Kaiser,,225.58,67,,,,,0,39.16,286.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 115MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.915,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"FIRST HEALTH [10303]","First Health",,1099.53,80,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT AV 80CM 40MM 6MM BALLOON DILATATION PACLITAXEL",SUP-IAV05004008P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,956.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE EVERPOINT 6-0 RB-2 30IN 2 ARM MONOFILAMENT BLUE",SUP-EP8711H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Local Plus",,13.38,53.5,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 13MM ZEVO TITANIUM SPINE CERVICAL ANTERIOR",SUP-7724013,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 55CM 7FR .081IN LEFT INTERNAL MAMMARY ARTER CURVE",SUP-M001197620,CDM,C1725,HCPCS,0272,RC,,,both,,,597.13,179.14,"KAISER [10500]",Kaiser,,400.08,67,,,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE MEDIUM MALE PATIENT POSTOPERATIVE SHORT WEDGE HEELWEDGE",SUP-92732603,CDM,S27000186,LOCAL,0270,RC,,,both,,,256.65,76.99,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT POLARIS ULTRA NAUTILUS 26CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192123010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]",Cigna,,816.39,68,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 47MM UNITRAX HIP MODULAR ENDOPROSTHESIS",SUP-6942-5-047,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"MULTIPLAN [10600]",Multiplan,,2658.55,85,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 110CM 6CM 5FR 8MM 7.5MM BALLOON DILATATION",SUP-4198060L,CDM,C1725,HCPCS,0272,RC,,,both,,,931.50,279.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,110.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM TSRH THINLINE OSTEOGRIP SPINE",SUP-83555459,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"NOVANET [10819]",Novanet,,1930.5,75,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 26MM 3MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT30026UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"AETNA [10100]","Aetna HMO/PPO",,1919.93,79.5,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM SUMMIT DUOFIX 3 12/14 STD OFFSET TAPER",SUP-157002090,CDM,C1776,HCPCS,0278,RC,,,both,,,27946.80,8384.04,"CIGNA [10200]",Cigna,,11178.72,40,,5873.17,5873.17,5873.17,"1 through 10",3250.21,23754.78,"percent of total billed charges",
"SCR BONE 6.5MM 90MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.413,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"CIGNA [10200]","Cigna Open Access",,787.57,56.9,,1144.80,304.56,2275.09,66,160.97,1176.51,"percent of total billed charges",
"SPACER ALLOGRAFT 8MM NATURAL LARGE LORDOTIC",SUP-19408,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOURNIQUET DSP CUF SPSB STL34",SUP-60707510600,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.84,63.25,"CIGNA [10200]","Cigna Local Plus",,112.8,53.5,,,,,0,24.52,179.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 10FT CARTO 3 HYPERTONICS 20 PIN TO LEMO 25 PIN",SUP-CG2025CT,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2289.9,68,,,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM MITRAL CARPENTIER-EDWARDS PHYSIO II",SUP-520026MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,15180.00,4554,"UHC [10700]","United Healthcare",,9608.94,63.3,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP CLUSTER HOLE HA TRIDENT II PSL F",SUP-742-11-56F,CDM,C1776,HCPCS,0278,RC,,,both,,,9502.96,2850.89,"UHC [10700]","United Healthcare",,6015.37,63.3,,8601.07,8395.67,8601.07,"1 through 10",1105.19,8077.52,"percent of total billed charges",
"HC Insj Perm Ccm-D Sys Dual Transvns Leads Only",PX-481000413,CDM,0918T,CPT,0481,RC,,,both,,,12746.00,3823.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1510.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1482.36,12746,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ot Eval Low Complex 30 Min",PX-430000035,CDM,97165,CPT,0434,RC,,,both,,,449.84,134.95,"FIRST HEALTH [10303]","First Health",,359.87,80,,,,,0,52.32,426,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 50 % IN WATER (D50W) SUPERORDERABLE",RX-4082365,CDM,,,0250,RC,06937-4953-50,NDC,both,50,ML,100.65,30.19,"MULTIPLAN [10600]",Multiplan,,85.55,85,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 65MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"IMPL BREAST 250ML GEL SMOOTH ROUND SILICONE P3.4CM","SUP-3502501 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"CIGNA [10200]","Cigna Local Plus",,1966.13,,,,,,,427.4,3123.75,"percent of total billed charges",
"PROBE LITHO 940MM .89MM SWISS LITHOCLAST PNEUMATIC FLEXIBLE",SUP-M0068407390,CDM,S27200284,LOCAL,0272,RC,,,both,,,1835.93,550.78,"CIGNA [10200]","Cigna Local Plus",,982.22,53.5,,,,,0,213.52,1560.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPAT ELECTROSURGICAL 33CM PKS PLASMASPATULA LAPAROSCOPIC",SUP-952005PK,CDM,S27200284,LOCAL,0272,RC,,,both,,,2400.00,720,"NOVANET [10819]",Novanet,,1800,75,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL CSTM MERIT",SUP-K12T-02235B,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.68,71.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUTURE SLINGSHOT ZIPLINE 2 COBRAID WHITE BLACK NONABSORBABLE",SUP-CAT01586,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.13,54.34,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 12MM SPINE",SUP-610.712,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STY LD 85CM OTW FIRM K",SUP-346980,CDM,C1893,HCPCS,0272,RC,,,both,,,486.00,145.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT HUMAN TISSUE 15CC DEMINERALIZED CORTICAL PUREBONE FIBE",SUP-PBF-15,CDM,S27800098,LOCAL,0278,RC,,,both,,,9984.30,2995.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1183.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1161.17,8486.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII 16MM 20MM",SUP-401116,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TYSHAK NUCLEUS 100CM 4CM 11FR 22MM .035IN 9FR 2 TAPER",SUP-612112,CDM,C1725,HCPCS,0272,RC,,,both,,,5345.43,1603.63,"PHCS [10601]",PHCS,,3741.8,70,,,,,0,621.67,4543.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X11MM RISE 15D NONSTERILE",SUP-193.141,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anoscopy W Rmvl FB",PX-750000232,CDM,46608,CPT,0750,RC,,,both,,,1561.00,468.3,"CIGNA [10200]","Cigna Open Access",,1561,,"Case rate ($2,090). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,181.54,1561,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SURGICAL PETITE NEW","SUP-TRIMARK EVIVA-2S-10",CDM,A4648,HCPCS,0278,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 4FR 5MM SPACE REGULAR F CURVE",SUP-D4S04FR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,269.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 2MM BALLOON DILATATION STERILE LATEX",SUP-582012022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 90MM 135CM 7MM 160CM",SUP-M001711230,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1001.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX LARGE CYLINDER",SUP-T600822,CDM,S27800098,LOCAL,0278,RC,,,both,,,4347.00,1304.1,"PHCS [10601]",PHCS,,3042.9,70,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TRUCLEAR ULTRA PLUS 10MM 4MM REMOVAL TISSUE WINDOW",SUP-72203012,CDM,C1782,HCPCS,0272,RC,,,both,,,5788.76,1736.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2379.18,41.1,,,,,0,673.23,4920.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL CANCELLOUS 7D ALLOGRAFT 14MM",SUP-3W5214,CDM,S27800098,LOCAL,0278,RC,,,both,,,21094.92,6328.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2453.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2453.34,17930.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 FORCE FIBER PRECUT WITHOUT TIP UHMWPE 36IN BLUE",SUP-SMK100101,CDM,C1713,HCPCS,0278,RC,,,both,,,117.45,35.23,"CIGNA [10200]","Cigna Open Access",,66.83,56.9,,1144.80,304.56,2275.09,66,13.66,99.83,"percent of total billed charges",
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT MONOLITHIC 10MM PLIF",SUP-3W3110,CDM,S27800098,LOCAL,0278,RC,,,both,,,12487.62,3746.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1452.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1452.31,10614.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD INSULATION CARDIAC ADULT",SUP-ACIP,CDM,S27200284,LOCAL,0272,RC,,,both,,,148.38,44.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,60.98,41.1,,,,,0,17.26,126.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 12CM SONOPET IQ BONE MICRO CLAW 1.6X2MM STERILE",SUP-5500-25B-315,CDM,S27200284,LOCAL,0272,RC,,,both,,,7162.61,2148.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4870.57,68,,,,,0,833.01,6088.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE NITREX VASCULAR 15D 180CM 5CM .018IN TUNGSTEN NITINOL",SUP-N181805,CDM,C1769,HCPCS,0272,RC,,,both,,,540.00,162,"KAISER [10500]",Kaiser,,361.8,67,,,,,0,62.8,459,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE FEMORAL ANTHOLOGY +0 12/14 TAPER HIP TITANIUM MODULAR",SUP-71344247,CDM,C1776,HCPCS,0278,RC,,,both,,,1885.50,565.65,"CIGNA [10200]","Cigna Open Access",,1072.85,56.9,,5302.19,4377.88,6578.61,27,219.28,1602.68,"percent of total billed charges",
"GRAFT ENDOPROSTHESIS STENT AORTOILIAC L29MM DIA7MM VIABAHN V",SUP-BXB072902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"BLUE CROSS [10001]","Blue Cross HMO",,7645.88,39.2,,9776.84,9776.84,9776.84,"1 through 10",2268.41,16579.08,"percent of total billed charges",
"STENT GORE VIABAHN 79MM 135CM 11MM 16SQ MM 8FR .035IN",SUP-BXA117902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"CIGNA [10200]","Cigna Open Access",,7171.48,33.5,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORPLEX 2X3 CM",SUP-CX-2030,CDM,Q4232,HCPCS,0636,RC,,,both,,,9204.60,2761.38,"CIGNA [10200]","Cigna Open Access",,294.23,,,,,,,247.92,7823.91,"fee schedule",
"BASEPLT TIBIAL TRIATHLON 4 UNIVERSAL KNEE TOTAL STABILIZED",SUP-5521-B-400,CDM,C1776,HCPCS,0278,RC,,,both,,,10384.92,3115.48,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4766.68,45.9,,,,,0,1207.77,8827.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM MASTER-SERIES PYROLYTIC CARBON PTFE",SUP-19AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AETNA [10100]","Aetna HMO/PPO",,23149.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Cerv Spine WO Cntrst",PX-612000001,CDM,72141,CPT,0612,RC,,,both,,,3910.59,1173.18,"PHCS [10601]",PHCS,,2737.41,70,,,,,0,360.71,3324,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCHLOROTHIAZIDE 25 MG TABLET",RX-3720,CDM,,,0637,RC,60687-0593-11,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 3-0 RB-1 SPIRAL 16CM SUT",SUP-SXMP2B402,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.02,66.91,"MULTIPLAN [10600]",Multiplan,,189.57,85,,,,,0,25.94,189.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT ENDOSCOPIC 2 ACTION MONOPOLAR SERRATE JAW WIDE SPREAD",SUP-625124,CDM,S27200284,LOCAL,0272,RC,,,both,,,3935.42,1180.63,"KAISER [10500]",Kaiser,,2636.73,67,,,,,0,457.69,3345.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Creatinine Blood",PX-301000166,CDM,82565,CPT,0301,RC,,,both,,,67.60,20.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,18.2,,,,,,,0.07,57.46,"fee schedule",
"INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP",RX-10286,CDM,J1815,HCPCS,0637,RC,00002-8715-01,NDC,both,10,ML,404.15,121.24,"PHCS [10601]",PHCS,,282.91,70,,,,,0,47,343.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X8MM COLONIAL 7D LORDOTIC 14MM XL TITANIUM",SUP-365.708CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 STD KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508606601,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7509.38,28.62,,,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 80MM 5MM .018IN BALLOON DILATATION",SUP-R51005008L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,810.39,41.1,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X10X10-14MM ALTERA 15D",SUP-1124.1033,CDM,S27800098,LOCAL,0278,RC,,,both,,,29925.00,8977.5,"CIGNA [10200]","Cigna Open Access",,10024.88,33.5,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 28CM 7FR .035",SUP-M006192144090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,427.13,28.62,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LACTULOSE 10 GRAM/15 ML ORAL SOLUTION",RX-38245,CDM,,,0250,RC,45963-0439-65,NDC,both,946,ML,422.48,126.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,50.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,49.13,359.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURETTE SPINAL FUSION 203MM LENGTH OVAL",SUP-29-5035,CDM,S27200284,LOCAL,0272,RC,,,both,,,235.51,70.65,"MULTIPLAN [10600]",Multiplan,,200.18,85,,,,,0,27.39,200.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 9MM 29MM ASYMMETRIC TRIATHLON X3 KNEE",SUP-5551L299,CDM,C1776,HCPCS,0278,RC,,,both,,,4478.10,1343.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,530.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,520.8,3806.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 8MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT083040A,CDM,C1768,HCPCS,0278,RC,,,both,,,10267.20,3080.16,"NOVANET [10819]",Novanet,,7700.4,75,,,,,0,1194.08,8727.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 7MM AXIUM 3D NEUROVASCULAR FRAME V01",SUP-FC-7-12-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,13765.50,4129.65,"KAISER [10500]",Kaiser,,9222.89,67,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12MM X-CORE MINI TITANIUM SPINE LOCK NONSTERILE",SUP-5960033,CDM,S27800098,LOCAL,0278,RC,,,both,,,1629.00,488.7,"PHCS [10601]",PHCS,,1140.3,70,,,,,0,189.45,1384.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X5MM LORDOTIC SPINE CERVICAL CORTICAL",SUP-17005,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL LARGE KNEE STEM REMEDY STERILE",SUP-RSKFLG,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"PHCS [10601]",PHCS,,12075,70,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PRELUDESYNC 29CM COMPRESSION 20ML RADIAL BAND SOFT",SUP-SRB29MED,CDM,S27000186,LOCAL,0270,RC,,,both,,,217.50,65.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +7.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.075,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6-2MM TORNADO MICROCOIL PLATINUM FIBER",SUP-G47419,CDM,S27800098,LOCAL,0278,RC,,,both,,,931.42,279.43,"CIGNA [10200]","Cigna Local Plus",,498.31,53.5,,,,,0,108.32,791.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.034S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 6FT 18FR URETHRAL BACTI-GUARD HYDROGEL 5CC",SUP-129418,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.68,42.8,"CIGNA [10200]","Cigna Local Plus",,76.33,53.5,,,,,0,16.59,121.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 4CM 3MM GALAXY G3 MINI STRETCH",SUP-GLM930040,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1407.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO ORTHOPEDIC 3.6MM DFINE LONG BEVEL TIP",SUP-1467,CDM,S27200284,LOCAL,0272,RC,,,both,,,1312.20,393.66,"PHCS [10601]",PHCS,,918.54,70,,,,,0,152.61,1115.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION VECTRA TEMPORARY",SUP-324.101,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Rt (Gp)",PX-510000084,CDM,29581,CPT,0761,RC,,,both,,,729.00,218.7,"KAISER [10500]",Kaiser,,488.43,67,,,,,0,84.78,729,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 55MM TSRH-3D TITANIUM SPINE PEDICLE POSTERIOR",SUP-837-755,CDM,C1713,HCPCS,0278,RC,,,both,,,2361.60,708.48,"FIRST HEALTH [10303]","First Health",,1889.28,80,,,,,0,274.65,2007.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 2-0 P-14 12IN CLSR ABSORBABLE UNDYED",SUP-VLOCM0115,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"NOVANET [10819]",Novanet,,146.88,75,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5CMX8MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-1-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"AETNA [10100]","Aetna HMO/PPO",,1159.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 40MM 5MM VASCULAR DRUG ELUTE ACCEPTS .035IN",SUP-G38404,CDM,C1874,HCPCS,0278,RC,,,both,,,8114.33,2434.3,"CIGNA [10200]","Cigna Open Access",,4617.05,56.9,,,,,0,943.7,6897.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 550ML GEL ROUND SMOOTH SILICONE P4.5CM","SUP-3505501 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"CIGNA [10200]",Cigna,,2499,68,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM ROUND STERILE LATEX FREE DISPOSABLE",SUP-5820110030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1164.70,349.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,135.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,135.45,990,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 32CM RIGHT TROCHANTERIC INTRAMEDULLARY 125D LONG",SUP-456.392S,CDM,C1713,HCPCS,0278,RC,,,both,,,12838.83,3851.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3466.48,27,,,,,0,1493.16,10913.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 52MM QUICKFIX TITANIUM T15 SHORT THREAD",SUP-AR-8740-52PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross PPO",,523.91,39.2,,957.42,570.23,957.42,28,155.43,1136.03,"percent of total billed charges",
"KIT CATH 48CM 15FR 1.9ML PALINDROME REVERSE TUNNEL HUB SNAP",SUP-8888541028P,CDM,C1750,HCPCS,0278,RC,,,both,,,2669.19,800.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,310.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,310.43,2268.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 2MM STEINMANN STAINLESS STEEL TROCAR POINT",SUP-3593-1-090,CDM,C1713,HCPCS,0278,RC,,,both,,,179.05,53.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",20.82,152.19,"percent of total billed charges",
"SPACER ALLOGRAFT 6MM NATURAL STD PARALLEL CERVICAL",SUP-18306,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS BLOCK THK18MM ALLOGRAFT FREEZE DRIED",SUP-400288,CDM,S27800098,LOCAL,0278,RC,,,both,,,6739.92,2021.98,"NOVANET [10819]",Novanet,,5054.94,75,,,,,0,783.85,5728.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHIELD WOUND IRRIGATION ROUND FISH SKIN SILICONE CONTACT",SUP-50215I52B0D,CDM,A2019,HCPCS,0636,RC,,,both,,,37195.20,11158.56,"CIGNA [10200]",Cigna,,25292.74,68,,,,,0,247.92,31615.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 10MM KNEE GVF POLYETHYLENE ROTATE",SUP-129405610,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"NOVANET [10819]",Novanet,,7247.59,75,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 7MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0720CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3008.75,45.9,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 46CM 28MM STEERABLE SMOOTHLY EXTEND LOC PLUS",SUP-1281/46,CDM,S27500001,LOCAL,0275,RC,,,both,,,1972.50,591.75,"BLUE CROSS [10001]","Blue Cross PPO",,773.22,39.2,,,,,0,229.4,1676.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 135CM 30MM 9MM .035IN BALLOON",SUP-AB35W09030135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,80.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 CURVE PLUS 10MM KNEE XLK FIX BEARING SIGMA",SUP-970461,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"FIRST HEALTH [10303]","First Health",,8939.64,80,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 14MM BABY GORILLA LOCK",SUP-P50-053-2514,CDM,C1713,HCPCS,0278,RC,,,both,,,1316.25,394.87,"KAISER [10500]",Kaiser,,881.89,67,,,,,0,153.08,1118.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9.5FR 14CM HEMOSTASIS PEEL AWAY .038IN",SUP-405148,CDM,C1892,HCPCS,0272,RC,,,both,,,356.70,107.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,41.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.48,303.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE TOTAL ROBOTIC",SUP-71704632,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"CIGNA [10200]",Cigna,,9324,40,,5873.17,5873.17,5873.17,"1 through 10",2710.95,19813.5,"percent of total billed charges",
"NAVITOR WITH RADIOPAQUE MARKERS 35MM",SUP-NVRO-35,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"AETNA [10100]","Aetna HMO/PPO",,108756,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKAGED RADIAL STEM 6MM X -2MM",SUP-ALN-RST-06M2,CDM,C1776,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5844.79,41.1,,6417.48,6417.48,6417.48,"1 through 10",1653.89,12087.77,"percent of total billed charges",
"SYSTEM PROMUS ELEMENT PLUS 32MM 144CM 3MM CORONARY STENT",SUP-H7493911432300,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross PPO",,3583.86,39.2,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8MM 180MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-408-180,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"GW WHSPR VW VASC XSUPP GD CATH",SUP-4640,CDM,C1769,HCPCS,0272,RC,,,both,,,243.60,73.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL 6MM LAMINA RIGHT OFFSET",SUP-7756074R,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM SPINAL POLYAXIAL",SUP-8456545,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"MULTIPLAN [10600]",Multiplan,,4116.21,85,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL SYMBOTEX 25X20CM 3.3X2.3MM 2 SIDE MONOFILAMENT",SUP-SYM2520OS,CDM,C1781,HCPCS,0278,RC,,,both,,,9718.51,2915.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6608.59,68,,,,,0,1130.26,8260.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM 32MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-217.060,CDM,C1713,HCPCS,0278,RC,,,both,,,485.43,145.63,"CIGNA [10200]","Cigna Open Access",,276.21,56.9,,1144.80,304.56,2275.09,66,56.46,412.62,"percent of total billed charges",
"SCR BONE 3MM 14MM DART-FIRE TITANIUM SMALL PARTIAL THREAD",SUP-D1N30014S,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,382.51,28.62,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 14MM VARIAX SMARTLOCK TITANIUM RADIUS DISTAL",SUP-52-23614,CDM,C1713,HCPCS,0278,RC,,,both,,,1513.32,454,"PHCS [10601]",PHCS,,1059.32,70,,,,,0,176,1286.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL MAGNESIUM SULFATE WATER 20GM PER 500ML 500ML INJECTION",SUP-06729-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"AETNA [10100]","Aetna HMO/PPO",,64.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPLATZER TALISMAN PFO OCCLUDER 25-18MM",SUP-9-PFO-2518,CDM,C1817,HCPCS,0278,RC,,,both,,,56668.50,17000.55,"PHCS [10601]",PHCS,,39667.95,70,,,,,0,6590.55,48168.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 146MM 13MM 16FR ENDURANT II 2 BRANCH",SUP-ETLW1613C146E,CDM,S27800098,LOCAL,0278,RC,,,both,,,40320.00,12096,"KAISER [10500]",Kaiser,,27014.4,67,,,,,0,4689.22,34272,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 119MM TRI-LOCK BPS GRIPTION 12 STANDARD OFFSET",SUP-101204120,CDM,C1776,HCPCS,0278,RC,,,both,,,29153.25,8745.97,"PHCS [10601]",PHCS,,20407.28,70,,,,,0,3390.52,24780.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12-15IN 28FR VENOUS 3/8IN ANGLE RIGHT SMALL",SUP-67528,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.59,90.48,"FIRST HEALTH [10303]","First Health",,241.27,80,,,,,0,35.07,256.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000185,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 4MM DRNG SILICONE 100ML CENTER HOLE FLAT BULB",SUP-6649,CDM,S27200284,LOCAL,0272,RC,,,both,,,329.12,98.74,"AETNA [10100]","Aetna HMO/PPO",,261.65,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.28,279.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAL LENS",SUP-60005-3,CDM,V2787,HCPCS,0276,RC,,,both,,,730.00,219,"FIRST HEALTH [10303]","First Health",,584,80,,,,,0,84.9,620.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR CIRCON CLASSIC",SUP-M0068802551,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,237.06,45.9,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM HEALICOIL KNOTLESS SELF TAP REGENESORB",SUP-72205136,CDM,C1713,HCPCS,0278,RC,,,both,,,3368.25,1010.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,391.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",391.73,2863.01,"percent of total billed charges",
"COIL EMBOLIZATION 3CM 2MM TARGET HELICAL PLATINUM DETACHABLE",SUP-M0035432030,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"MULTIPLAN [10600]",Multiplan,,7784.03,85,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CHOICE PT VASCULAR J 300CM .014IN STAINLESS STEEL",SUP-H7491215501J2,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE SMALL SPIKED SHORT LEG FIXATION 15X7.94MM COCR",SUP-12/1/8722,CDM,S27800098,LOCAL,0278,RC,,,both,,,2700.00,810,"CIGNA [10200]","Cigna Open Access",,1536.3,56.9,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA WEDGE ALLOGRAFT STRUT 70MM",SUP-817000,CDM,S27800098,LOCAL,0278,RC,,,both,,,3864.00,1159.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,457.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,449.38,3284.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 13.5X12.7CM 475CC MEMORYGEL COHESIVE III CPG 322",SUP-3341355,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"MULTIPLAN [10600]",Multiplan,,7771.13,85,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX 20X15CM OPEN POSITION SYSTEM STERILE",SUP-1221520,CDM,C1781,HCPCS,0272,RC,,,both,,,40020.75,12006.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16448.53,41.1,,,,,0,16448.53,25333.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC INSPIRIS RESILIA 25MM BOVINE PERICARDIUM",SUP-11500A25,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5275.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR SKIN DISORDERS WITHOUT MCC",596,MS-DRG,,,,,,,inpatient,,,27875.69,8362.71,"BLUE CROSS [10001]","Blue Cross PPO",,26723.73,,,,,,,6714.82,26996.47,"case rate",
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,inpatient,,,92799.83,27839.95,"CIGNA [10200]","Cigna Open Access",,23910.15,,"Fee schedule rate ($23,910.15). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,63612.24,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 6-0 P-1 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J489G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 30MM 120CM 10MM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200103020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP STEALTH SMALL LATIS SIDE BITE STERILE LATEX FREE",SUP-A0C05,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"UHC [10700]","United Healthcare",,143.18,63.3,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NORTRIPTYLINE 10 MG CAPSULE",RX-5674,CDM,,,0637,RC,60687-0900-11,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,3.57,56.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 50X40X.25MM RECTANGLE POLYDIOXANONE PDS FACE",SUP-ZFP5,CDM,S27800098,LOCAL,0278,RC,,,both,,,2242.50,672.75,"NOVANET [10819]",Novanet,,1681.88,75,,,,,0,260.8,1906.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +13 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.130,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Open Access",,196.31,56.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19.5 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150195,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 34MM TRI-AD 2 ADAM TRICUSPID VALVE MODEL",SUP-900SFC234,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UHC [10700]","United Healthcare",,8298.63,63.3,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +14 DIOPTER +3 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT300140,CDM,V2787,HCPCS,0276,RC,,,both,,,495.00,148.5,"CIGNA [10200]","Cigna Open Access",,281.66,56.9,,,,,0,57.57,420.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII ALLOGRAFT 20MM 20MM",SUP-401120A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC GREEN BEAVER OPTIMUM 15D STRAIGHT STAB",SUP-374891,CDM,S27200284,LOCAL,0272,RC,,,both,,,175.09,52.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.36,148.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRI-SIL 16FR URETHRAL SILICONE 30ML 3 WAY FOLEY",SUP-73016L,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.78,26.93,"MULTIPLAN [10600]",Multiplan,,76.31,85,,,,,0,10.44,76.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 60MM SOLERA CD HORIZON OSTEOGRIP TITANIUM",SUP-54840005560,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 20MM 145CM 3.75MM BALLOON DILATATION",SUP-1400375-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 80MM 16MM STAINLESS STEEL ORTHOPEDIC CANNULATED",SUP-71127080,CDM,C1713,HCPCS,0278,RC,,,both,,,2479.50,743.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,293.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",288.37,2107.58,"percent of total billed charges",
"DEVICE 30IN INFLATION EXT TUBING",SUP-K05-01172,CDM,S27200284,LOCAL,0272,RC,,,both,,,256.65,76.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.85,218.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 20IN 36FR STRAIGHT",SUP-8888572578,CDM,C1729,HCPCS,0272,RC,,,both,,,104.57,31.37,"PHCS [10601]",PHCS,,73.2,70,,,,,0,12.16,88.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 535CC",SUP-RSZ-SHPX-535S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"CIGNA [10200]","Cigna Open Access",,94.51,56.9,,,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 46MM TITANIUM LOCK SELF TAP AXSOS 3",SUP-661046,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"FIRST HEALTH [10303]","First Health",,1044.58,80,,,,,0,151.86,1109.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR STD CEMENT 3 PEG ROTATE PLATFORM MOBILE",SUP-129409640,CDM,C1776,HCPCS,0278,RC,,,both,,,11978.40,3593.52,"CIGNA [10200]","Cigna Local Plus",,3773.2,31.5,,5372.07,4581.20,7242.98,23,1393.09,10181.64,"percent of total billed charges",
"SCR BONE 4MM 3.3MM 40MM STARDRIVE NAIL-EX TITANIUM 7%",SUP-04.005.430,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"MULTIPLAN [10600]",Multiplan,,983.18,85,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 4MM DRNG SILICONE 100ML CENTER HOLE FLAT BULB",SUP-6649,CDM,S27200284,LOCAL,0272,RC,,,both,,,329.12,98.74,"NOVANET [10819]",Novanet,,246.84,75,,,,,0,38.28,279.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SOLITAIRE X 200CM 40MM 47MM 6MM .021-.027IN",SUP-SFR4-6-40-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,40761.00,12228.3,"UHC [10700]","United Healthcare",,25801.71,63.3,,,,,0,4740.5,34646.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM LAVA-34 EMBOLIC 2ML LIQUID",SUP-SLLES342,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS [10001]","Blue Cross PPO",,6491.52,39.2,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) OCCL CARDIOVASCULAR 10X28-31MM 34MM 41MM HEMOSTASIS",SUP-9-ACP2-010-034,CDM,C1817,HCPCS,0278,RC,,,both,,,102600.00,30780,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12158.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11932.38,87210,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79MMX10MM VANGUARD E1 KNEE ANTERIOR STABILIZE TIBIAL",SUP-EP189100,CDM,C1776,HCPCS,0278,RC,,,both,,,13372.20,4011.66,"CIGNA [10200]","Cigna Open Access",,4479.69,33.5,,5302.19,4377.88,6578.61,27,1555.19,11366.37,"percent of total billed charges",
"SUT SYNTHETIC ETHIBOND EXCEL 2-0 V-5 30IN 2 ARM BRAID FIRM",SUP-PXX50N,CDM,S27200284,LOCAL,0272,RC,,,both,,,632.96,189.89,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SEEKER 150CM 4FR .018IN GUIDING CROSSING SPRT",SUP-SK15018,CDM,C1887,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER ATHERECTOMY DIAMONDBACK L145 CM OD2 MM MAX CROWN EX",SUP-DBP-EX-200MAX145,CDM,C1724,HCPCS,0272,RC,,,both,,,23278.50,6983.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"GWIRE JAGWIRE DREAM TIP ENDOSCOPIC 260CM 5CM .025IN",SUP-M00556481,CDM,C1769,HCPCS,0272,RC,,,both,,,811.01,243.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ORTHOPEDIC 230MM 2MM STAINLESS STEEL NONTHREADED SPADE",SUP-292.656,CDM,C1769,HCPCS,0272,RC,,,both,,,229.68,68.9,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPAT SURGICAL 7X.5IN DAVIS BRAIN MALLEABLE",SUP-22-0060,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.76,36.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL DEBAKEY ANGLE 7.75IN VASCULAR TISSUE STAINLESS",SUP-320106,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.09,191.73,"CIGNA [10200]","Cigna Open Access",,363.64,56.9,,,,,0,74.33,543.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 20X20MM RETRACTION 3 FINGER RAKE SPIRA BLUNT END",SUP-3335-4G,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.15,51.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,71.16,41.1,,,,,0,20.14,147.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"Debrider Sinus 4mm Straight Bipolar Type A Blade All In One",SUP-DSD4000BA,CDM,S27200284,LOCAL,0272,RC,,,both,,,2025.00,607.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1377,68,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VENLAFAXINE 75 MG TABLET, IMMEDIATE RELEASE",RX-12206,CDM,,,0637,RC,68084-0856-11,NDC,both,1,UN,10.99,3.3,"FIRST HEALTH [10303]","First Health",,8.79,80,,,,,0,1.28,9.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT OSSEOPERM MENDEC PMMA INJECTOR MIX CNTNR",SUP-OP-0001,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,3978.14,359.25,3978.14,24,434.96,3179,"percent of total billed charges",
"NAIL 11MM 345MM TIBIAL TN ADVANCED INTRAMEDULLARY MR",SUP-04.043.335S,CDM,C1713,HCPCS,0278,RC,,,both,,,9579.13,2873.74,"MULTIPLAN [10600]",Multiplan,,8142.26,85,,,,,0,1114.05,8142.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR ALEXIS O 2XL RIGID RETRACTION RING SURGICAL 11-17CM",SUP-C8405,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.80,262.44,"UHC [10700]","United Healthcare",,553.75,63.3,,,,,0,101.74,743.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 7MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620807,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"UHC [10700]","United Healthcare",,7123.72,63.3,,8601.07,8395.67,8601.07,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"HEMOSTAT ABSORBABLE 8X4IN SURGICEL",SUP-1952S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1216.66,365,"KAISER [10500]",Kaiser,,815.16,67,,,,,0,141.5,1034.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR IMC CURVE ANGIOGRAPHIC TRILON BRACHIAL",SUP-H749085262032,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"MULTIPLAN [10600]",Multiplan,,65.09,85,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LEAD 23CM 9FR OSCOR PEEL AWAY LUER LOCK KINK",SUP-6663,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"AETNA [10100]","Aetna HMO/PPO",,418.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 12D ALLOGRAFT 20MM",SUP-3W4220,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2505.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MONARCH INFLATION 3 WAY STPCOCK SYR EXT TUBE DIGITAL",SUP-K05-L3-L4B,CDM,S27200284,LOCAL,0272,RC,,,both,,,720.90,216.27,"CIGNA [10200]","Cigna Open Access",,410.19,56.9,,,,,0,83.84,612.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM MULTIFIX S ULTRA KNOTLESS PEEK",SUP-72290001,CDM,C1713,HCPCS,0278,RC,,,both,,,3138.75,941.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1440.69,45.9,,,,,0,365.04,2667.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TRICLIP NTW DELIVERY 4TH GENERATION TEER",SUP-TCDS0301-NTW,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 17MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50017,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA [10200]","Cigna Open Access",,27813.28,33.5,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 20MM 2.5MM .014IN BALLOON DILATATION",SUP-AB14W035150150,CDM,C1725,HCPCS,0272,RC,,,both,,,1577.48,473.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,186.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.46,1340.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 40MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050040M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"MULTIPLAN [10600]",Multiplan,,1218.65,85,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY TORIC AUTONOME",SUP-CNAET5,CDM,V2787,HCPCS,0276,RC,,,both,,,880.00,264,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,251.86,28.62,,,,,0,102.34,748,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 42MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.842,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",27.52,201.14,"percent of total billed charges",
"SPLINT ORTHOPEDIC LARGE 8IN WRIST LEFT BLACK",SUP-A120107,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.46,17.54,"KAISER [10500]",Kaiser,,39.17,67,,,,,0,6.8,49.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUCICLOVINE F-18 INTRAVENOUS SOLUTION (9-10 MCI)",RX-180065,CDM,A9588,HCPCS,0343,RC,08888-8878-27,NDC,both,1,UN,755.00,226.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,755,,,,,,,87.81,755,"fee schedule",
"PLATE TITANIUM 12 HOLE LOCKING BONE STERNAL NONSTERILE",SUP-460.019,CDM,C1713,HCPCS,0278,RC,,,both,,,7688.81,2306.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2200.54,28.62,,,,,0,894.21,6535.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 115CM 6FR 5MM SPACE ELECTROPHYSIOLOGY FIX 4",SUP-F6QD005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,372.86,41.1,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM EVOLVE STAINLESS STEEL CORTICAL ELBOW",SUP-4973534L,CDM,C1713,HCPCS,0278,RC,,,both,,,1710.00,513,"BLUE CROSS [10001]","Blue Cross PPO",,670.32,39.2,,957.42,570.23,957.42,28,198.87,1453.5,"percent of total billed charges",
"STEM FEMORAL 30MM CEMENTLESS ACCOLADE TMZF 1 HIP",SUP-6021-0130,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9128.7,40,,,,,0,2654.17,19398.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NUCLEUS-X 110CM 4CM 20MM BALLOON DILATATION POLYAMIDE",SUP-612023,CDM,C1725,HCPCS,0272,RC,,,both,,,6566.52,1969.96,"KAISER [10500]",Kaiser,,4399.57,67,,,,,0,763.69,5581.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE LEVEL ONE LONG CRANIOFACIAL TITANIUM 2 HOLE ULTRA",SUP-25-153-12-09,CDM,C1713,HCPCS,0278,RC,,,both,,,927.13,278.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,630.45,68,,,,,0,107.83,788.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION DISTAL FEMORAL KNEE MODULAR TRIATHLON",SUP-5575-X-000,CDM,C1776,HCPCS,0278,RC,,,both,,,1891.66,567.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1286.33,68,,,,,0,220,1607.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT RESECTOSCOPE OES PRO 9MM 8FR WORKING ANTIBLOCKING",SUP-A42091A,CDM,S27800098,LOCAL,0278,RC,,,both,,,4515.00,1354.5,"CIGNA [10200]","Cigna Local Plus",,2415.53,53.5,,,,,0,525.09,3837.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX BILIARY RAPID EXCHANGE FULL COVER STERILE",SUP-M00547480,CDM,C1874,HCPCS,0278,RC,,,both,,,17194.52,5158.36,"AETNA [10100]","Aetna HMO/PPO",,13669.64,79.5,,,,,0,1999.72,14615.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE 11MM SPINE TISSUE",SUP-331141,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC ON OFF SWITCH RATCHET HANDLE 31CM 5MM ENDO",SUP-174317,CDM,S27200284,LOCAL,0272,RC,,,both,,,504.63,151.39,"CIGNA [10200]",Cigna,,343.15,68,,,,,0,58.69,428.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MIDAS REX LEGEND 2.5MM BALL FLUTED DISSECTING BURR",SUP-14BA25,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"CIGNA [10200]",Cigna,,859.25,68,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 5MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-05015,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4114.06,45.9,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 6.9FR HELIX ATRIUM VENTRICLE RIGHT BIPOLAR",SUP-5086MRI58,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CIGNA [10200]","Cigna Open Access",,1270.29,56.9,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL NASAL INTERFACE BLENDER TRANSITION KIT OPTIFLOW",SUP-OJR416B,CDM,S27000186,LOCAL,0270,RC,,,both,,,520.02,156.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,353.61,68,,,,,0,60.48,442.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 8.6CM PATCH SELF CENTER COMPOSITE",SUP-PCO8VP,CDM,C1781,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5MM 6MM VORTX 35 COIL PUSHABLE OCCLUSION",SUP-M0013733061,CDM,S27800098,LOCAL,0278,RC,,,both,,,769.50,230.85,"KAISER [10500]",Kaiser,,515.57,67,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 26CM 8FR NEPHROURETERAL FLEXITHANE",SUP-H7493935108260,CDM,C2617,HCPCS,0278,RC,,,both,,,1069.20,320.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,727.06,68,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 12MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0280,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]",Cigna,,644.44,68,,1831.33,1831.33,1831.33,16,110.22,805.55,"percent of total billed charges",
"STENT ONYX FRONTIER 38MM 2.25MM CORONARY RAPID EXCHANGE",SUP-ONYXNG22538UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"MULTIPLAN [10600]",Multiplan,,2231.25,85,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C-Reactive Protein Sensitive",PX-302000015,CDM,86141,CPT,0302,RC,,,both,,,292.60,87.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,248.71,"per diem",
"HC Bx Brst Ndl Perc WO Guide",PX-361000563,CDM,19100,CPT,0361,RC,,,both,,,2480.00,744,"FIRST HEALTH [10303]","First Health",,1984,80,,,,,0,288.42,2480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYSORB SURGITIE 0 21IN BRAID LOOP COATED VIOLET",SUP-EL-23-LN,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.24,40.87,"UHC [10700]","United Healthcare",,86.24,63.3,,,,,0,15.84,115.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SUCTION FLEXIBLE INTUB SCOPE DISPOSABLE",SUP-11301CE1/20,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.02,42.61,"CIGNA [10200]","Cigna Local Plus",,75.98,53.5,,,,,0,16.52,120.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 30GA 5MM AIR INJECTION",SUP-60-1149,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.13,24.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.76,41.1,,,,,0,9.55,69.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 99MM 9MM FULL PROXIMAL PROFILE ECHO BI-METRIC",SUP-19-3009,CDM,C1776,HCPCS,0278,RC,,,both,,,27578.88,8273.66,"KAISER [10500]",Kaiser,,18477.85,67,,,,,0,3207.42,23442.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM LCP STAINLESS STEEL T25 CONDYLAR SELF TAP",SUP-02.231.240,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"MULTIPLAN [10600]",Multiplan,,1111.66,85,,,,,0,152.1,1111.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 22CM 3CM 6FR .035IN PIGTAIL CURVE",SUP-M006180221170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,147.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trichomonas Vag Dirct Probe",PX-306000145,CDM,87660,CPT,0306,RC,,,both,,,607.05,182.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,71.19,,,,,,,0.61,515.99,"fee schedule",
"PLATE 20MM NONBIOABSORBABLE CLAW CHARLOTTE BONE NONSTERILE",SUP-40120020,CDM,C1713,HCPCS,0278,RC,,,both,,,6948.30,2084.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,823.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,808.09,5906.06,"percent of total billed charges",
"HC Ldl Cholesterol",PX-301000306,CDM,83721,CPT,0301,RC,,,both,,,107.90,32.37,"CIGNA [10200]","Cigna Open Access",,23.1,,,,,,,0.01,91.72,"fee schedule",
"INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION",RX-179659,CDM,Q5104,HCPCS,0636,RC,78206-0162-01,NDC,both,1,UN,4547.47,1364.24,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,541.1,,,,,,,314.69,3865.35,"fee schedule",
"HC Egd Flex Trnsoral W Dil",PX-750000136,CDM,43233,CPT,0750,RC,,,both,,,5806.00,1741.8,"CIGNA [10200]",Cigna,,5806,,"Case rate ($5,859). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,675.24,5806,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP HEMOSTATIC ENDOSCOPIC INSTINCT PLUS",SUP-G58010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"CIGNA [10200]","Cigna Local Plus",,922.88,53.5,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP SURESIGHT 2 HYPERANGULATED NONSTERILE",SUP-390521000,CDM,S27000186,LOCAL,0270,RC,,,both,,,445.50,133.65,"NOVANET [10819]",Novanet,,334.13,75,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL TORIC 4.25 D CYLINDER 9.0 DIOPTER",SUP-PPK1704-17,CDM,S27600001,LOCAL,0276,RC,,,both,,,1761.68,528.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,208.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,204.88,1497.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intro Cath Renal DRN Perc",PX-361000221,CDM,50432,CPT,0361,RC,,,both,,,4242.74,1272.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4242.74,,"Case rate ($4,937). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,493.43,4242.74,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 34X24X12MM BRIGADE 8D NONSTERILE LATEX FREE",SUP-6941234,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"UHC [10700]","United Healthcare",,21696.45,63.3,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRT C4TR01 CONSULTA CRT-P",SUP-C4TR01,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"CIGNA [10200]",Cigna,,9236.16,40,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC INTERVERTEBRAL 14MM 7MM PRESTIGE LP CERVICAL SPINE",SUP-6972470,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",3297.11,24097.5,"percent of total billed charges",
"PROBE VITRECTOMY 20GA ULTRAVIT CONSTELLATION ANTERIOR CURVED",SUP-8065751020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1716.68,515,"KAISER [10500]",Kaiser,,1150.18,67,,,,,0,199.65,1459.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30X3.5MM TITANIUM REGULAR ENDOSCOPIC LINEAR",SUP-TA3035S,CDM,S27200284,LOCAL,0272,RC,,,both,,,568.94,170.68,"FIRST HEALTH [10303]","First Health",,455.15,80,,,,,0,66.17,483.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 55MM RELINE-O SPINE POLYAXIAL TRACTION",SUP-13115555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,957.42,156.86,7483.26,51,641.98,4692,"percent of total billed charges",
"STY LD 52CM .016IN STRG FIRM",SUP-6065,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 3 X 10 HELICAL FILLING COIL",SUP-10HFL-03010,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"FIRST HEALTH [10303]","First Health",,7170.48,80,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS POWERFLEX P3 80CM 40MM 12MM 7.5MM BALLOON",SUP-4202040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION",RX-1222,CDM,J0665,HCPCS,0636,RC,00409-1559-19,NDC,both,30,ML,46.21,13.86,"NOVANET [10819]",Novanet,,34.66,75,,,,,0,1.75,39.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.25/18",SUP-401747,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 8IN SPETZLER MALIS .5MM SLIM DISPOSABLE",SUP-6780-200-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,3208.53,962.56,"AETNA [10100]","Aetna HMO/PPO",,2550.78,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,373.15,2727.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM EVOLVE STAINLESS STEEL CORTICAL ELBOW",SUP-4973510N,CDM,C1713,HCPCS,0278,RC,,,both,,,785.70,235.71,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,360.64,45.9,,,,,0,91.38,667.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 24MM 144CM 2.5MM CORONARY STENT",SUP-H7493911424250,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"KAISER [10500]",Kaiser,,6125.48,67,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 66MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 7",SUP-249.684,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH PERCUTANEOUS PASSIVE TIP",SUP-9731115,CDM,S27200284,LOCAL,0272,RC,,,both,,,3939.90,1181.97,"NOVANET [10819]",Novanet,,2954.93,75,,,,,0,458.21,3348.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 30MM STAINLESS STEEL CORTICAL SELF TAPPING",SUP-18235130,CDM,C1713,HCPCS,0278,RC,,,both,,,546.75,164.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,371.79,68,,,,,0,63.59,464.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 50X27MM STD OSCILLATE ERGONOMIC LIGHTWEIGHT THK.6",SUP-519.100S,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"CIGNA [10200]",Cigna,,347,68,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 80MM 114CM 9MM 75CM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200098070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 6MM SMALL SHELL DJO SURGICAL ALTIVATE",SUP-533-06-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,13592.91,28.62,,,,,0,5523.6,40370.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 3-0 RB-1 SPIRAL 16CM SUT",SUP-SXMP2B402,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.02,66.91,"KAISER [10500]",Kaiser,,149.42,67,,,,,0,25.94,189.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 100CM 6FR 12MM AMPLATZER .086IN TYPE II",SUP-9-AVP2-012,CDM,S27800098,LOCAL,0278,RC,,,both,,,6589.50,1976.85,"CIGNA [10200]","Cigna Local Plus",,3525.38,53.5,,,,,0,766.36,5601.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE VASCULAR 175CM 4-8MM 3.2FR EN SNARE MINI CATH 150CM",SUP-EN1003008,CDM,C1773,HCPCS,0272,RC,,,both,,,4554.00,1366.2,"NOVANET [10819]",Novanet,,3415.5,75,,,,,0,529.63,3870.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 15MM 6FR 2.25MM .07IN BALLOON",SUP-H7493918915220,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 30MM 12/10/8/8MM HEMASHIELD PLATINUM 60D",SUP-M00202175730AP0,CDM,L8670,HCPCS,0278,RC,,,both,,,13387.59,4016.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3831.53,28.62,,,,,0,427.53,11379.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X3CM PRO3 THICK AMNIOTIC MEMB UMBILICAL",SUP-P01-AMC-0203,CDM,V2790,HCPCS,0278,RC,,,both,,,11022.75,3306.82,"CIGNA [10200]","Cigna Local Plus",,5897.17,53.5,,,,,0,1281.95,9369.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 14MM OSTEOLOCK RESTORATION CANCELLOUS HEXAGON",SUP-5260-5-014,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,88.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",88.55,647.19,"percent of total billed charges",
"GALLANT DR ICD DF1 CONNECTOR",SUP-CDDRA500T,CDM,C1721,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"CIGNA [10200]","Cigna Local Plus",,18356.63,31.5,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 2MM PK DIEGO STRAIGHT TURBINATE SINUS SERRATE",SUP-7013-8033,CDM,S27200284,LOCAL,0272,RC,,,both,,,897.05,269.11,"FIRST HEALTH [10303]","First Health",,717.64,80,,,,,0,104.33,762.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 20MM REFLECTION R3 CONTOUR HIP ACETABULAR",SUP-71332520,CDM,C1713,HCPCS,0278,RC,,,both,,,1287.90,386.37,"PHCS [10601]",PHCS,,901.53,70,,,,,0,149.78,1094.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 1.6MM FIBERTAK",SUP-AR-3600D-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.03,267.91,"AETNA [10100]","Aetna HMO/PPO",,709.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.86,759.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3.5MM BIO-PUSHLOCK 19.5MM STERILE DISPOSABLE",SUP-AR-1926B,CDM,C1713,HCPCS,0278,RC,,,both,,,2835.00,850.5,"KAISER [10500]",Kaiser,,1899.45,67,,,,,0,329.71,2409.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL SYMMETRY 45D .3MM MICRO 5.75INX9MM FLAT HANDLE",SUP-78-0065,CDM,S27200284,LOCAL,0272,RC,,,both,,,539.54,161.86,"KAISER [10500]",Kaiser,,361.49,67,,,,,0,62.75,458.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 14CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155213180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"KAISER [10500]",Kaiser,,1078.51,67,,,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER STRAIGHT STAR 20 SURGICAL",SUP-59250095,CDM,S27200284,LOCAL,0272,RC,,,both,,,1845.00,553.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,218.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,214.57,1568.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 1.5MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES0156CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL STANDARD+ KNEE LEFT STABILIZE CEMENT ROTATE",SUP-129412050,CDM,C1776,HCPCS,0278,RC,,,both,,,31285.80,9385.74,"KAISER [10500]",Kaiser,,20961.49,67,,,,,0,3638.54,26592.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 10MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158124110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1299.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45MM STAINLESS STEEL INSTR SURGIDAC SUT",SUP-020730,CDM,S27200284,LOCAL,0272,RC,,,both,,,544.40,163.32,"PHCS [10601]",PHCS,,381.08,70,,,,,0,63.31,462.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 775CC P6.6CM HIGH PROFILE COHESIVE GEL SOFT",SUP-SHPB775,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"BLUE CROSS [10001]","Blue Cross HMO",,2988.8,39.2,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 214MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-226.62,CDM,C1713,HCPCS,0278,RC,,,both,,,1837.88,551.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,213.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",213.75,1562.2,"percent of total billed charges",
"CATH TRINAV 150CM INNER DIA 0.025 FR 2.9 INFUSION 5MM",SUP-TVM-25150-50,CDM,C1982,HCPCS,0272,RC,,,both,,,50292.90,15087.87,"PHCS [10601]",PHCS,,35205.03,70,,,,,0,5849.06,42748.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Irr Water Sterile 1000ml",PX-E27200207,CDM,E27200207,LOCAL,0272,RC,,,both,,,39.81,11.94,"UHC [10700]","United Healthcare",,25.2,63.3,,,,,0,4.63,33.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MR DRILL BIT 7.5 X 1.5MM BALL FLTD",SUP-75BA15L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1441.80,432.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,592.58,41.1,,,,,0,167.68,1225.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 3MM 1.8MM 160CM 3 RING HANDLE BRISTLE CATH",SUP-60314,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.41,38.82,"UHC [10700]","United Healthcare",,81.92,63.3,,,,,0,15.05,110,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150220,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,158.36,45.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 5.5MM CD HORIZON CURVE COCRMO NONSTERILE",SUP-1555501040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"STEM FEMORAL CEMENTED EXETER V40 0 44MM OFFSET LONG HIP",SUP-0580-1-044,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BMT SPLINED KNEE STM V2 11X80",SUP-148301,CDM,C1776,HCPCS,0278,RC,,,both,,,11903.88,3571.16,"AETNA [10100]","Aetna HMO/PPO",,9463.58,79.5,,10981.53,8986.79,12413.38,12,1384.42,10118.3,"percent of total billed charges",
"BASEPLT TIBIAL RESTORIS 5 KNEE RIGHT MEDIAL LEFT LATERAL",SUP-180615,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"CIGNA [10200]","Cigna Open Access",,3771.02,56.9,,5302.19,4377.88,6578.61,27,770.77,5633.33,"percent of total billed charges",
"GWIRE ASAHI MIRACLEBROS 12 VASCULAR STRAIGHT 300CM 11CM .014",SUP-AG14M370,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,466.07,41.1,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR SPARE TUNE STERILE DISPOSABLE",SUP-SC-4252,CDM,S27000186,LOCAL,0270,RC,,,both,,,348.00,104.4,"CIGNA [10200]","Cigna Open Access",,198.01,56.9,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 4IN 5FR 21GA MAK .018IN PLATINUM COIL TIP NITINOL",SUP-MAK501NBT,CDM,C1894,HCPCS,0272,RC,,,both,,,250.56,75.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.14,212.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 LEFT MEDIAL RIGHT LATERAL PARTIAL KNEE",SUP-5610-F-401,CDM,C1776,HCPCS,0278,RC,,,both,,,12002.52,3600.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4933.04,41.1,,6417.48,6417.48,6417.48,"1 through 10",1395.89,10202.14,"percent of total billed charges",
"SCR BONE 6.5MM 45MM REFLECTION R3 CONTOUR HIP ACETABULAR",SUP-71332545,CDM,C1713,HCPCS,0278,RC,,,both,,,1287.90,386.37,"MULTIPLAN [10600]",Multiplan,,1094.72,85,,,,,0,149.78,1094.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION",RX-122253,CDM,J1212,HCPCS,0636,RC,67457-0177-50,NDC,both,50,ML,6611.54,1983.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,872.78,,,,,,,1.28,5619.81,"fee schedule",
"SPACER SPINAL 37X27X10MM CRESCENT SOVEREIGN 8D MEDIUM PEEK",SUP-7968810,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 6.5MM 48MM TITANIUM FULL THREAD CORTEX SELF",SUP-414.848,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"BLUE CROSS [10001]","Blue Cross HMO",,107.91,39.2,,957.42,156.86,7483.26,51,32.01,233.98,"percent of total billed charges",
"SPACER SPINAL 14X16MM VERTE-STACK CORNERSTONE PSR 8MM",SUP-6240864,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FIXATION ATTACHABLE OPEN",SUP-AR-1588TN-1,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,1144.80,304.56,2275.09,66,189.34,1383.8,"percent of total billed charges",
"SODIUM POLYSTYRENE SULFONATE 15 GRAM ORAL POWDER",RX-7356,CDM,,,0250,RC,10702-0036-15,NDC,both,15,GR,85.01,25.5,"CIGNA [10200]",Cigna,,57.81,68,,,,,0,9.89,72.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CARDIONYL 5-0 1 STRAND NONABSORBABLE",SUP-721222,CDM,S27200284,LOCAL,0272,RC,,,both,,,55.34,16.6,"CIGNA [10200]","Cigna Local Plus",,29.61,53.5,,,,,0,6.44,47.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 D 36MM LONGEVITY HIP STERILE LUMEN LATEX",SUP-20103604,CDM,C1776,HCPCS,0278,RC,,,both,,,8101.98,2430.59,"CIGNA [10200]","Cigna Local Plus",,4334.56,53.5,,5372.07,4581.20,7242.98,23,942.26,6886.68,"percent of total billed charges",
"STENT AERO 30MM 62CM 12MM 16FR GEOMETRIC TRACHEOBRONCHIAL",SUP-90129-211,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Open Access",,5778.75,33.5,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 130CM 60MM 4MM BALLOON DILATATION",SUP-LX351304605F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"MULTIPLAN [10600]",Multiplan,,5718.38,85,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD BARDEX 16FR URETHRAL SILICONE ELASTOMER NATURAL",SUP-0166V16S,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.59,28.08,"FIRST HEALTH [10303]","First Health",,74.87,80,,,,,0,10.88,79.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 8FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0165SI08,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.82,19.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,29.75,45.9,,,,,0,7.54,55.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 7 9MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-709,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4040.34,41.1,,6417.48,6417.48,6417.48,"1 through 10",1143.29,8355.94,"percent of total billed charges",
"GRAFT ENDOVASCULAR 56MM 16MM 5.4MM 14FR ZENITH SPIRAL-Z",SUP-G55237,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2462.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 12MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640212,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4625.35,41.1,,6417.48,6417.48,6417.48,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"CATH LAUNCHER 100CM 8FR .09IN AMPLATZ RIGHT 1 CURVE GUIDING",SUP-LA8AR10,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AETNA [10100]","Aetna HMO/PPO",,311.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 110MM 5.5MM REVOLVE",SUP-185.310,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASIC EVALUATION KIT",SUP-309201,CDM,C1897,HCPCS,0278,RC,,,both,,,648.00,194.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,297.43,45.9,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 58MM X25 LOCK INTRAMEDULLARY NAIL",SUP-04.045.058S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 120MM 125CM 10MM 6FR .035IN BILIARY",SUP-G50178,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"AMERIGROUP MEDICAID [20100]",Amerigroup,,721.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 10MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424023,CDM,C1776,HCPCS,0278,RC,,,both,,,11747.25,3524.17,"NOVANET [10819]",Novanet,,8810.44,75,,,,,0,1366.21,9985.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 10MM OCCIPITAL",SUP-7750510,CDM,C1713,HCPCS,0278,RC,,,both,,,1931.70,579.51,"NOVANET [10819]",Novanet,,1448.78,75,,,,,0,224.66,1641.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 75X12X.8MM LONG STAINLESS STEEL RECIPROCATING 2",SUP-0277096325,CDM,S27200284,LOCAL,0272,RC,,,both,,,303.46,91.04,"MULTIPLAN [10600]",Multiplan,,257.94,85,,,,,0,35.29,257.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 3.9MM 38MM TITANIUM FULL THREAD SELF CUT",SUP-04.019.038,CDM,C1713,HCPCS,0278,RC,,,both,,,1592.14,477.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,188.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",185.17,1353.32,"percent of total billed charges",
"CMPNT FEMORAL 5 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502605802,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"CIGNA [10200]","Cigna Open Access",,7659,33.5,,5302.19,4377.88,6578.61,27,2658.93,19433.3,"percent of total billed charges",
"VIABAHN BX BALLOON EXP ENDO 6MMX15MM 7FR 80CMCATH HEPARIN",SUP-BXB061501A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM ACETABULAR CUP SURGICAL 56MM",SUP-6210-0-820,CDM,C1776,HCPCS,0278,RC,,,both,,,1852.74,555.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,219.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,215.47,1574.83,"percent of total billed charges",
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 20MM",SUP-SPL40020X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE CONNECT VASCULAR 195CM .018IN DURASTEEL",SUP-1012588,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"FIRST HEALTH [10303]","First Health",,771.12,80,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Haemophilus Influenza Ab Igg",PX-302000241,CDM,86684,CPT,0302,RC,,,both,,,83.00,24.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,56.24,,,,,,,0.01,70.55,"fee schedule",
"HEAD FEMORAL C TAPER HIP INTERLOCK COCR LFIT",SUP-S-1400-HH84,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1435.61,45.9,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL MEDIUM NEUTRAL KNEE COCRMO UHMWPE CONNECTION",SUP-16-2840/05,CDM,C1776,HCPCS,0278,RC,,,both,,,10553.00,3165.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1250.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1227.31,8970.05,"percent of total billed charges",
"CMPNT PATELLAR 38MM ONLAY ADVANCE METAL KNEE STERILE",SUP-KPON38MB,CDM,C1776,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,601.85,4398.75,"percent of total billed charges",
"STENT SUPERA 120MM 120CM 5MM 6FR VASCULAR PERIPHERAL",SUP-S-50-120-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10782.00,3234.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1253.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1253.95,9164.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE REVERSE REVISION HUMERAL STEM, SZ 6X220MM",SUP-530-06-220,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Local Plus",,3969,31.5,,5372.07,4581.20,7242.98,23,1465.38,10710,"percent of total billed charges",
"SCR BONE 4MM 3.3MM 46MM TITANIUM T25 FULL THREAD HUMERAL",SUP-04.005.436S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"PHCS [10601]",PHCS,,1047.82,70,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 80MM 6FR 5MM 4FR BALLOON DILATATION",SUP-39032-50801,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD RVOT KIT MOND",SUP-4150/58,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"FIRST HEALTH [10303]","First Health",,460.08,80,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE SIMPLEX P TOBRAMYCIN FULL DOSE",SUP-6197-9-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,1620.00,486,"FIRST HEALTH [10303]","First Health",,1296,80,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDEAVOR SPRINT 18MM 142CM 3MM CORONARY STENT",SUP-ENSP30018W,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"AETNA [10100]","Aetna HMO/PPO",,4407.48,79.5,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fetal Fibronectin",PX-301000190,CDM,82731,CPT,0301,RC,,,both,,,729.60,218.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,67.63,,"Fee schedule rate ($67.63). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,620.16,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Perq Njx Algc CT Lmbr Ea",PX-361000550,CDM,0630T,CPT,0361,RC,,,both,,,2677.00,803.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1249,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,311.34,2275.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 23GA SHORT SOFT TIP STERILE DISPOSABLE",SUP-8065149527,CDM,S27200284,LOCAL,0272,RC,,,both,,,199.75,59.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,135.83,68,,,,,0,23.23,169.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 80CM 9MM 9FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM09100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"UHC [10700]","United Healthcare",,11564.91,63.3,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL MEMORYSHAPE MEDIUM HEIGHT MODERATE PLUS PROFILE",SUP-RSZ-0905S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1987.50,596.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,231.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,231.15,1689.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERTAPE FIBERWIRE 2-0 T-5 18IN BRAID TIES MULTISTRAND",SUP-AR-7242,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"MULTIPLAN [10600]",Multiplan,,170.82,85,,,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 2.4 MM SCR 8 HOLE STERNALOCK BLU BONE STERNAL",SUP-73-2623,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"CIGNA [10200]","Cigna Local Plus",,1705.31,53.5,,3978.14,359.25,3978.14,24,370.71,2709.38,"percent of total billed charges",
"SABER .035 10X100 40CM SL",SUP-48010010P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"FIRST HEALTH [10303]","First Health",,785.7,80,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 29MM SIMULUS FULLY FLEXIBLE",SUP-700FC29,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3539.7,27,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP 45D 40MM 6CM CLSR NITINOL POLYESTER FLEXIBLE",SUP-ACH240,CDM,S27800098,LOCAL,0278,RC,,,both,,,8245.50,2473.65,"CIGNA [10200]","Cigna Local Plus",,4411.34,53.5,,,,,0,958.95,7008.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 19MM 50MM SHOULDER SIMPLICITI",SUP-7122874,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"NOVANET [10819]",Novanet,,7514.25,75,,,,,0,1165.21,8516.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4645,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM POLYCARBOPHIL 625 MG TABLET",RX-11046,CDM,,,0637,RC,00904-2500-91,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,3.35,53.5,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CHOLANGIOGRAM JAGTOME RAPID EXCHANGE",SUP-7612,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"MULTIPLAN [10600]",Multiplan,,133.11,85,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP CEMENTED FEMUR COCR HEAD ANTEVERTED LINER",SUP-71703322,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6851.63,28.62,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 8MM 145CM 3.25MM CORONARY STENT",SUP-1145325-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AETNA [10100]","Aetna HMO/PPO",,4641.21,79.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 14CM 7.5MM MIDAS REX LEGEND ACORN FLUTE BURR",SUP-14AC75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1184.63,355.39,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,543.75,45.9,,,,,0,137.77,1006.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 135CM 4CM 5FR 10MM 7.5MM BALLOON DILATATION",SUP-4190040X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII CRUCIATE RETAINING POROU",SUP-71704545,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6671.32,28.62,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pet/CT Tumor Ltd",PX-404000003,CDM,78814,CPT,0404,RC,,,both,,,7540.46,2262.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4768,,,,,,,876.96,7540.46,"per diem",
"STEM FEMORAL 160MM 12MM CEMENTLESS MODULAR AML POROUS 40MM",SUP-155402121,CDM,C1776,HCPCS,0278,RC,,,both,,,15374.88,4612.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4151.22,27,,,,,0,1788.1,13068.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEARTRAIL III 100CM 6FR IL3.5 CURVE GUIDING PTFE",SUP-40-6371,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,69.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH C-FLEX 70CM 6FR URETERAL TAPER TIP 1 LUMEN FLEXIBLE",SUP-M0064001400,CDM,C1758,HCPCS,0272,RC,,,both,,,339.04,101.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,39.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.43,288.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REVOLUTION BONE CEMENT MIX BREAKAWAY FEMORAL NOZZLE",SUP-0606573000,CDM,S27200284,LOCAL,0272,RC,,,both,,,911.44,273.43,"FIRST HEALTH [10303]","First Health",,729.15,80,,,,,0,106,774.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 STD 10MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS7S10L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"PHCS [10601]",PHCS,,7273.98,70,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 34MM VUEPOINT II SPINE MULTIAXIAL NONSTERILE",SUP-8975734,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 5X150 80CM SL",SUP-48005015N,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,115.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 1.5MM 140CM ERGONOMIC HANDLE AUTOMATIC STOP",SUP-M00516011,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.01,40.5,"PHCS [10601]",PHCS,,94.51,70,,,,,0,15.7,114.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 23CM ORANGE HUB HEMOSTASIS VALVE PRELUDE",SUP-PSI-7F-23,CDM,C1894,HCPCS,0272,RC,,,both,,,110.93,33.28,"MULTIPLAN [10600]",Multiplan,,94.29,85,,,,,0,12.9,94.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit App Fibrijet W Dual Spr",PX-E27200263,CDM,E27200263,LOCAL,0272,RC,,,both,,,248.60,74.58,"MULTIPLAN [10600]",Multiplan,,211.31,85,,,,,0,28.91,211.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL MINI 2.75MM CANNULATED OPEN REPAIR .066IN",SUP-AR-7000-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,2756.25,826.87,"CIGNA [10200]",Cigna,,1874.25,68,,,,,0,320.55,2342.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELIANCE DF4 NON-GORE ACTIVE FIXATION SINGLE COIL 64 CM, IRO",SUP-0273,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"FIRST HEALTH [10303]","First Health",,12144,80,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 12.5IN 2.5IN HARRINGTON LAMB HANDLE STAINLESS STEEL",SUP-200-176,CDM,S27000186,LOCAL,0270,RC,,,both,,,814.54,244.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,94.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.73,692.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 26MM GORILLA R3CON LOCK",SUP-P50-353-4226,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"PHCS [10601]",PHCS,,935.55,70,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 20MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"FIRST HEALTH [10303]","First Health",,1276.56,80,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STATLOCK UNIVERSAL PLUS LARGE 12-14FR SECUREMENT FOAM",SUP-VUPD1214,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.96,25.79,"CIGNA [10200]",Cigna,,58.45,68,,,,,0,10,73.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 40MM 75CM 10MM 8.5FR .035IN 48MM BILIARY",SUP-M00574730,CDM,C1874,HCPCS,0278,RC,,,both,,,19530.00,5859,"CIGNA [10200]","Cigna Local Plus",,6151.95,31.5,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 8.2MM 2.9MM 65MM STAINLESS STEEL FULL THREAD",SUP-209.665,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"MULTIPLAN [10600]",Multiplan,,1168.25,85,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM DCP LC-DCP STAINLESS STEEL FULL THREAD",SUP-218.045,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"CIGNA [10200]","Cigna Local Plus",,240.25,53.5,,3978.14,359.25,3978.14,24,52.23,381.7,"percent of total billed charges",
"SCR BONE 4MM 52MM LCP STAINLESS STEEL LONG THREAD CANNULATED",SUP-207.652,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"KAISER [10500]",Kaiser,,696.83,67,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM EXCELSIOR XT-27 1 TIP",SUP-M003XT2750920,CDM,S27200284,LOCAL,0272,RC,,,both,,,8474.58,2542.37,"CIGNA [10200]","Cigna Open Access",,4822.04,56.9,,,,,0,985.59,7203.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 STD KNEE RIGHT CRUCIATE RETAIN PERSONA PPS",SUP-42508606602,CDM,C1776,HCPCS,0278,RC,,,both,,,29326.50,8797.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11730.6,40,,,,,0,3410.67,24927.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mod Sed Oth Phys Add 15min",PX-371000012,CDM,99157,CPT,0371,RC,,,both,,,151.32,45.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.6,128.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Spine Lumbosacral 2-3v",PX-320000044,CDM,72100,CPT,0320,RC,,,both,,,915.10,274.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,69.24,,,,,,,46.01,777.84,"fee schedule",
"GWIRE HIWIRE SAFE-T-J VASCULAR CURVE TAPER 145CM 3CM .035IN",SUP-G00561,CDM,C1769,HCPCS,0272,RC,,,both,,,121.71,36.51,"PHCS [10601]",PHCS,,85.2,70,,,,,0,14.15,103.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 CURVE PLUS 12.5MM KNEE XLK FIX BEARING",SUP-970422,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4592.74,41.1,,6417.48,6417.48,6417.48,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"SA60WF.155 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.155,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 19MM LOTUS LARGE NITINOL BOVINE PERICARDIAL BRAID",SUP-H749NTR200,CDM,C1894,HCPCS,0272,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 33MM 140CM 3.5MM CORONARY STENT",SUP-LUN350R33US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 270MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.334S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"PHCS [10601]",PHCS,,5818.7,70,,,,,0,966.74,7065.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT VENTRICULOSTOMY EUROPEAN VERSION",SUP-46154,CDM,S27200284,LOCAL,0272,RC,,,both,,,2803.43,841.03,"CIGNA [10200]","Cigna Open Access",,1595.15,56.9,,,,,0,326.04,2382.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM DELTAXSFT 10 COIL",SUP-DLX100202,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3720.7,41.1,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 NARROW KNEE RIGHT POSTERIOR STABILIZE",SUP-42500206002,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11876.08,41.1,,6417.48,6417.48,6417.48,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"TOOL 9CM MR8 7.5MM ACORN DISSECTING",SUP-MR8-9AC75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"UHC [10700]","United Healthcare",,739.87,63.3,,,,,0,135.93,993.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 2X2CM AMNIOBAND PLACENTAL ALLOGRAFT",SUP-WC3022,CDM,Q4151,HCPCS,0636,RC,,,both,,,6749.93,2024.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4387.45,65,,,,,0,362.66,5737.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IVAS ELITE 20MM 10GA DIAGNOSTIC CATH STERILE LATEX",SUP-0808-020-800,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOME 5INX10MM FLEXIBLE THIN SHAFT SURGICAL",SUP-270904011,CDM,S27200284,LOCAL,0272,RC,,,both,,,842.40,252.72,"CIGNA [10200]",Cigna,,572.83,68,,,,,0,97.97,716.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,inpatient,,,32839.80,9851.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6311.29,,"Fee schedule rate ($6,311.29). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,4340.29,17449.82,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pvb Thoracic Cont Infusion",PX-510000201,CDM,64463,CPT,0761,RC,,,both,,,2882.00,864.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1184.5,41.1,,,,,0,335.18,2740.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6X20X75/ 6F UNISTEP PLUS",SUP-M001711080,CDM,C1725,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3473.98,41.1,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE TRUWAVE 1 BOND 1 WAY SHUTOFF STPCOCK",SUP-PX600,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.31,27.69,"MULTIPLAN [10600]",Multiplan,,78.46,85,,,,,0,10.74,78.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR LAPAROSCOPIC 35CM VISTASEAL DUAL APPLR RIGID",SUP-VSTL35,CDM,S27200284,LOCAL,0272,RC,,,both,,,839.46,251.84,"KAISER [10500]",Kaiser,,562.44,67,,,,,0,97.63,713.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CONNECTING 8FT SHROUDED 4 PIN TORQR MEDTRONIC VG REPRO",SUP-05508SPR,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.20,93.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 1.6MM TWIST STERILE",SUP-KM166-00-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.04,24.01,"PHCS [10601]",PHCS,,56.03,70,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM FEMORAL ANTHOLOGY HIP",SUP-71703330,CDM,C1776,HCPCS,0278,RC,,,both,,,25515.00,7654.5,"FIRST HEALTH [10303]","First Health",,20412,80,,,,,0,2967.39,21687.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Scr Breast Tomosynthesis Uni",PX-403000008,CDM,77063,CPT,0403,RC,,,both,,,96.68,29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.24,96.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 390MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.358S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,985.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,966.74,7065.57,"percent of total billed charges",
"SCR BONE 4.5MM 35MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4335,CDM,C1713,HCPCS,0278,RC,,,both,,,3112.50,933.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,368.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",361.98,2645.63,"percent of total billed charges",
"3.0MM PHALANX LNTRAMEDULLARY NAIL 3MM X 42.5MM TI",SUP-IHFN-PHX-30042,CDM,C1713,HCPCS,0278,RC,,,both,,,8052.30,2415.69,"CIGNA [10200]","Cigna Open Access",,4581.76,56.9,,1144.80,304.56,2275.09,66,936.48,6844.46,"percent of total billed charges",
"SA60WF.175 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.175,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH XP 100CM 5FR ANGLE ANGIOGRAPHIC STAINLESS",SUP-RF*ZV95110M,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 3.1CC DARK BLUE 15MM SYNFIX 18D SMALL",SUP-08.815.174S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"NOVANET [10819]",Novanet,,21262.5,75,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 30MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50030,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"MULTIPLAN [10600]",Multiplan,,70571.01,85,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY DIALYSIS 20CM 12FR MAHURKAR 3 LUMEN CURVE EXT HIGH",SUP-8888101003HP,CDM,C1752,HCPCS,0272,RC,,,both,,,995.43,298.63,"KAISER [10500]",Kaiser,,666.94,67,,,,,0,115.77,846.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 3CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175283110,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,354.71,28.62,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 7X7CM AMNIOBAND ALLOGRAFT MEMB",SUP-WC3077,CDM,Q4151,HCPCS,0636,RC,,,both,,,57330.00,17199,"AETNA [10100]","Aetna HMO/PPO",,45577.35,79.5,,,,,0,362.66,48730.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.0MM PHALANX LNTRAMEDULLARY NAIL 3MM X 32.5MM TI",SUP-IHFN-PHX-30032,CDM,C1713,HCPCS,0278,RC,,,both,,,8052.30,2415.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2304.57,28.62,,,,,0,936.48,6844.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL H+6MM 36MM 39MM SHOULDER CONSTRAIN COMBINATION",SUP-AR-9503-3639-3C,CDM,C1776,HCPCS,0278,RC,,,both,,,4305.60,1291.68,"CIGNA [10200]","Cigna Local Plus",,2303.5,53.5,,5372.07,4581.20,7242.98,23,500.74,3659.76,"percent of total billed charges",
"HANDLE SIZER",SUP-720530301,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 4MM MATCH HEAD DISSECTING",SUP-MR8-14MH40,CDM,S27200284,LOCAL,0272,RC,,,both,,,1416.29,424.89,"KAISER [10500]",Kaiser,,948.91,67,,,,,0,164.71,1203.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLF TORIC AUTONOME",SUP-CNA0T3,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,43.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 51MM 2MM SHORT CARBIDE ROUND STERILE",SUP-04-C0105,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.21,18.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PTCA CATHETER 2.25 X 15MM (622-154-1U) SCOREFLEX NC SCORING",SUP-SD36003-08,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PASSER SUTURELASSO 90D STRAIGHT CURVE REELPASS SUT",SUP-AR-6069-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"URSODIOL 300 MG CAPSULE",RX-11624,CDM,,,0637,RC,59651-0421-01,NDC,both,1,UN,27.79,8.34,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PREVAIL DCB 2.00X15MM",SUP-PRV020015CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VEST 4 LARGE FRONT ZIP ADJUSTABLE SHOULDER STRAP CUP",SUP-111904,CDM,S27000186,LOCAL,0270,RC,,,both,,,403.16,120.95,"MULTIPLAN [10600]",Multiplan,,342.69,85,,,,,0,46.89,342.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy US Ea 15min (Gp)",PX-420000020,CDM,97035,CPT,0420,RC,,,both,,,163.34,49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,163.34,,"Per diem ($254).",,,,0,19,163.34,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Transperi Pros Inters",PX-361000240,CDM,55875,CPT,0361,RC,,,both,,,7679.62,2303.89,"UHC [10700]","United Healthcare",,7679.62,,"Case rate ($15,045). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,893.14,7679.62,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET SILASTIC 8X6IN THK.02IN SILICONE REINFORCE STERILE",SUP-PR72034-02R,CDM,S27800098,LOCAL,0278,RC,,,both,,,2130.00,639,"FIRST HEALTH [10303]","First Health",,1704,80,,,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW FREEFIX COMPRESSION 3.5MM X 26MM TI",SUP-FFC-35260-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1061.10,318.33,"FIRST HEALTH [10303]","First Health",,848.88,80,,,,,0,123.41,901.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 310115 ILBL TRCT 15X15 SRVC FEE",SUP-310115,CDM,S27800098,LOCAL,0278,RC,,,both,,,4858.98,1457.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1390.64,28.62,,,,,0,565.1,4130.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CARDIOBLATE 300D 304.8CM 7CM ABLATION POROUS POLYMER",SUP-49321,CDM,S27200284,LOCAL,0272,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Open Access",,9815.25,56.9,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 194MM STAINLESS STEEL 3.5MM SCR 8 HOLE LCP BONE RIGHT",SUP-02.104.008S,CDM,C1713,HCPCS,0278,RC,,,both,,,9988.58,2996.57,"FIRST HEALTH [10303]","First Health",,7990.86,80,,,,,0,1161.67,8490.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 5 V-37 30IN BRAID 4 STRAND GREEN NONABSORBABLE",SUP-MB66G,CDM,S27200284,LOCAL,0272,RC,,,both,,,155.74,46.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,71.48,45.9,,,,,0,18.11,132.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET",RX-2009,CDM,,,0637,RC,77333-0938-25,NDC,both,1,UN,6.27,1.88,"FIRST HEALTH [10303]","First Health",,5.02,80,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 12MM EXCLUDER C3 CONTRALATERAL LEG",SUP-PXC121200,CDM,S27800098,LOCAL,0278,RC,,,both,,,27720.00,8316,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11392.92,41.1,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION L4 1/8IN OD18GA STRAIGHT WITH OBTURATOR HOUSE",SUP-68-1007,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 NARROW KNEE LEFT CEMENTED CRUCIATE RETAINING",SUP-150400126,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6046.2,27,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 250MM 5MM BALLOON DILATATION RAPID",SUP-47550250M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,239.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD 4X1.8IN PRESHAPE ROUND EDGE MONOFILAMENT",SUP-0112700,CDM,C1781,HCPCS,0278,RC,,,both,,,159.50,47.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.55,135.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SHORT STRAIGHT NECK PROFEMUR TL CLASSIC 8 HIP",SUP-PRTLS028,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"AETNA [10100]","Aetna HMO/PPO",,15025.5,79.5,,10981.53,8986.79,12413.38,12,2198.07,16065,"percent of total billed charges",
"IMPL BREAST 750CC COHESIVE NATRELLE INSPIRA STERILE",SUP-SCX-750,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]",Cigna,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 16X8CM ALLODERM THK1.04-2.28MM IMPL REGENERATIVE",SUP-102128,CDM,Q4116,HCPCS,0636,RC,,,both,,,23347.80,7004.34,"NOVANET [10819]",Novanet,,17510.85,75,,,,,0,247.92,19845.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 50MM 28MM UHR UNIVERSAL HIP UHMWPE PRIMARY",SUP-UH1-50-28,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1235.75,28.62,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL AVENIR COMPLETE 5 STD HIP STERILE LATEX FREE",SUP-574101050,CDM,C1776,HCPCS,0278,RC,,,both,,,23461.20,7038.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2780.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2728.54,19942.02,"percent of total billed charges",
"TELESCOPING SMOKE EVACUATION R",SUP-SEP6015NSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,249.43,74.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,29.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.01,212.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 40MM EXPEDIUM TITANIUM SPINE CORTICAL FIX 5.5MM",SUP-186731740,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH ARTHROSCOPIC STRAIGHT LOW PROFILE SERIES 1 DESIGN",SUP-AR-11040XL,CDM,S27200284,LOCAL,0272,RC,,,both,,,7933.28,2379.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3260.58,41.1,,,,,0,922.64,6743.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GS 90, 90 CM, STRAIGHT, DISTAL",SUP-GS9090SD,CDM,C1887,HCPCS,0272,RC,,,both,,,3573.98,1072.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1468.91,41.1,,,,,0,415.65,3037.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 9MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-309-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"UHC [10700]","United Healthcare",,7617.27,63.3,,8601.07,8395.67,8601.07,"1 through 10",1399.51,10228.56,"percent of total billed charges",
"STEM FEMORAL 17MM CEMENT FEMUR",SUP-71316017,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"CIGNA [10200]",Cigna,,8505,40,,5873.17,5873.17,5873.17,"1 through 10",2472.83,18073.13,"percent of total billed charges",
"WIRE FIXATION 15.2CM .045IN KIRSCHNER STAINLESS STEEL BOTH",SUP-00018607400,CDM,C1713,HCPCS,0278,RC,,,both,,,119.63,35.89,"FIRST HEALTH [10303]","First Health",,95.7,80,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT 10-0 CU-1 12IN 2 ARM MONOFILAMENT BLACK NONABSORBABLE",SUP-8065198001,CDM,S27200284,LOCAL,0272,RC,,,both,,,280.40,84.12,"FIRST HEALTH [10303]","First Health",,224.32,80,,,,,0,32.61,238.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS ELECTROSURGICAL 9CM HARMONIC FOCUS+ CURVE TAPER 2",SUP-HAR9F,CDM,S27200284,LOCAL,0272,RC,,,both,,,2362.50,708.75,"MULTIPLAN [10600]",Multiplan,,2008.13,85,,,,,0,274.76,2696.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 9 SLOT LEFT TI",SUP-PHPF-S9L,CDM,C1713,HCPCS,0278,RC,,,both,,,18396.00,5518.8,"PHCS [10601]",PHCS,,12877.2,70,,,,,0,2139.45,15636.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL UTERINE HEGAR 2 END 9/10MM",SUP-52-3509,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL CANCELLOUS 7D ALLOGRAFT 16MM",SUP-3W5216,CDM,S27800098,LOCAL,0278,RC,,,both,,,21094.92,6328.48,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8670.01,41.1,,,,,0,2453.34,17930.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR FR4 CURVE ANGIOGRAPHIC VENTRICULAR 2",SUP-H74916391021,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 82MM 20MM 16FR ENDURANT II ABDOMEN AORTA",SUP-ETEW2020C82E,CDM,S27800098,LOCAL,0278,RC,,,both,,,29553.30,8865.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3502.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3437.05,25120.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR .079IN .057IN JUDKINS LEFT",SUP-534620T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"UHC [10700]","United Healthcare",,55.07,63.3,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 22CM 3CM 8FR .035IN PIGTAIL CURVE",SUP-M006180241170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,580.81,45.9,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER 2.6MR FLEXIVA PULSE TRACTIP 910UM HIGH POWER",SUP-M006L8405940,CDM,S27200284,LOCAL,0272,RC,,,both,,,4808.75,1442.62,"AETNA [10100]","Aetna HMO/PPO",,3822.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,559.26,4087.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 20MM 6MM BALLOON DILATATION OTW STERILE",SUP-586002022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"MULTIPLAN [10600]",Multiplan,,1273.73,85,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17.5 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE",SUP-PCB0000175,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR .071IN AMPLATZ LEFT 3 CURVE GUIDING NYLON",SUP-LA6AL30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +10 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-MN60AC,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LOW PROFILE STAINLESS STEEL 3.5MM SCR 3 HOLE SPRING",SUP-02.100.303S,CDM,C1713,HCPCS,0278,RC,,,both,,,1950.00,585,"FIRST HEALTH [10303]","First Health",,1560,80,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT SL II SITEMARK 50.7CM 47CM 9FR 7FR 135D",SUP-DS2C003,CDM,C1887,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,445.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 170MM 14.7MM NECK SECUR-FIT MAX HA 127D 12 52MM",SUP-6052-1240S,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2704.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2654.17,19398.49,"percent of total billed charges",
"CMPNT FEMORAL 5 NARROW KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-71933650,CDM,C1776,HCPCS,0278,RC,,,both,,,22273.65,6682.09,"FIRST HEALTH [10303]","First Health",,17818.92,80,,,,,0,2590.43,18932.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 1.5CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-24-1.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"NOVANET [10819]",Novanet,,584.3,75,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 10X7CM SYNTHETIC BIO-A BIOABSORBABLE",SUP-HH0710,CDM,C1763,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"BLUE CROSS [10001]","Blue Cross PPO",,1455.3,39.2,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 10MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158122110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"KAISER [10500]",Kaiser,,7486.95,67,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ENDOSCOPIC ORANGE 72MM 6.5MM CLEAR-TRAC SHOULDER",SUP-72200428,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"CIGNA [10200]","Cigna Open Access",,118.81,56.9,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE NUCEL MEDIUM HUMAN AMNIOTIC PLACENTAL MEMB",SUP-NC-1001,CDM,S27800098,LOCAL,0278,RC,,,both,,,13593.00,4077.9,"AETNA [10100]","Aetna HMO/PPO",,10806.44,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1580.87,11554.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 117MM STAINLESS STEEL 3.5MM SCR 6 HOLE VARIABLE ANGLE",SUP-02.127.220S,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"AETNA [10100]","Aetna HMO/PPO",,8228.25,79.5,,1521.93,481.35,16760.95,30,1203.71,8797.5,"percent of total billed charges",
"TENDYNE MITRAL VALVE LP 37S",SUP-TENDV-LP-37S-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20263.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 20MM NESTER MICROCOIL PLATINUM .035IN",SUP-G47361,CDM,S27800098,LOCAL,0278,RC,,,both,,,1113.67,334.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,757.3,68,,,,,0,129.52,946.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS 0 CT-2 27IN ANTIBACTERIAL VIOLET ABSORBABLE",SUP-PDP334H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 70CM PRECISION PERCUTANEOUS LINEAR 3-4",SUP-SC-2352-70,CDM,C1778,HCPCS,0278,RC,,,both,,,8914.80,2674.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1036.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1036.79,7577.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 69.6X45.8X4.8MM MBT 3MM KNEE CEMENTED REVISION",SUP-129435130,CDM,C1776,HCPCS,0278,RC,,,both,,,22385.16,6715.55,"KAISER [10500]",Kaiser,,14998.06,67,,,,,0,2603.39,19027.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 10MM 2.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2510X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +26.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200265,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CIGNA [10200]","Cigna Open Access",,580.72,56.9,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LG DOME NON-T 4 POLE NON-BRAID",SUP-D7CL252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,5326.80,1598.04,"FIRST HEALTH [10303]","First Health",,4261.44,80,,,,,0,619.51,4527.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC",857,MS-DRG,,,,,,,inpatient,,,59768.28,17930.48,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT WALLFLEX 60MM 75CM 8MM 8",SUP-7463,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL BIT ASSY, CARBIDE, HUDSON END, 3 MM, SINGLE USE",SUP-SBT002,CDM,S27000186,LOCAL,0270,RC,,,both,,,2212.50,663.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE JEJUNOSTOMY 18FR SILICONE MIC-KEY SECUR-LOK ENFIT BOLUS",SUP-8200-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TROCAR LAPAROSCOPIC LOW PROFILE 55MM 5MM KII 2 PACK ACCESS",SUP-CTB23,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT ZILVER PTX 40MM 5MM VASCULAR DRUG ELUTE ACCEPTS .035IN",SUP-G38404,CDM,C1874,HCPCS,0278,RC,,,both,,,8114.33,2434.3,"BLUE CROSS [10001]","Blue Cross HMO",,3180.82,39.2,,9776.84,9776.84,9776.84,"1 through 10",943.7,6897.18,"percent of total billed charges",
"BLADE SAW 15X7X.38MM PRECISION SHORT NARROW THIN STAINLESS",SUP-2296003103,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,111.06,41.1,,,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 535CC",SUP-RSZ-SHPX-535S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"KAISER [10500]",Kaiser,,111.28,67,,,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE SINGLE DIAMOND TIP WITH STOP 1.5MM X 229MM",SUP-KWIR-SD-15229,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 45D HOOK 8.5IN 3/32IN STERILE EDGE",SUP-E1511,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.38,44.21,"MULTIPLAN [10600]",Multiplan,,125.27,85,,,,,0,17.14,125.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 189MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 14",SUP-223.641,CDM,C1713,HCPCS,0278,RC,,,both,,,3645.60,1093.68,"NOVANET [10819]",Novanet,,2734.2,75,,,,,0,423.98,3098.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Mastoid<3v per Side",PX-320000006,CDM,70120,CPT,0320,RC,,,both,,,348.00,104.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 22CM FEMUR PROXIMAL TALON DISTALFIX",SUP-SLN-130-220,CDM,C1713,HCPCS,0278,RC,,,both,,,13227.30,3968.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1567.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1538.33,11243.21,"percent of total billed charges",
"AVENIR 10, 1 X 4 HELICAL PICO COIL",SUP-10USH01004,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1389.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE FEMORAL 30MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-151101202,CDM,C1776,HCPCS,0278,RC,,,both,,,16151.52,4845.46,"BLUE CROSS [10001]","Blue Cross HMO",,6331.4,39.2,,5311.50,4717.44,5388.59,31,1878.42,13728.79,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 28MM 145CM 4MM CORONARY STENT",SUP-1145400-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross HMO",,2288.5,39.2,,9776.84,9776.84,9776.84,"1 through 10",678.96,4962.3,"percent of total billed charges",
"PASSER WECK EFX CONE 9.82IN SUT STERILE LATEX FREE",SUP-EFXCT1,CDM,S27200284,LOCAL,0272,RC,,,both,,,644.76,193.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.99,548.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR SURGICAL KATZ EXTR FOREIGN BODY REM OTO-RHINO STERILE",SUP-FB5000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1368.96,410.69,"AETNA [10100]","Aetna HMO/PPO",,1088.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,159.21,1163.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT 2-0 ABSORBABLE",SUP-021030,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"KAISER [10500]",Kaiser,,192.36,67,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 36MM TI",SUP-SPL-35360-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,1144.80,304.56,2275.09,66,155.43,1136.03,"percent of total billed charges",
"EXP OPHTHALMIC MALYUGIN 7MM RING",SUP-MAL-0002-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1147.50,344.25,"AETNA [10100]","Aetna HMO/PPO",,912.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,133.45,975.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 40MM 140CM 2.5MM CORONARY STERILE LATEX",SUP-453974,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 163MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 12",SUP-223.621,CDM,C1713,HCPCS,0278,RC,,,both,,,2423.40,727.02,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1112.34,45.9,,,,,0,281.84,2059.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 15MM MREYE .038IN ARTERIAL VENOUS",SUP-G42487,CDM,S27800098,LOCAL,0278,RC,,,both,,,766.50,229.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.14,651.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX LOW PROFILE REINFORCED TISSUE MATRIX, LONG-TERM RESOR",SUP-F10264-1515L,CDM,C1781,HCPCS,0278,RC,,,both,,,17700.98,5310.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2097.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2058.62,15045.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 60MM TI",SUP-SPL-35600-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,523.91,39.2,,957.42,156.86,7483.26,51,155.43,1136.03,"percent of total billed charges",
"ACC INTRDCR VALV FR7",SUP-7461,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"AETNA [10100]","Aetna HMO/PPO",,69.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOXCROSS 135CM 40MM 10MM BALLOON DILATATION JETCOAT",SUP-10340-40,CDM,C1725,HCPCS,0272,RC,,,both,,,1539.00,461.7,"KAISER [10500]",Kaiser,,1031.13,67,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 7IN MOLT 2 END SHARP/SHARP",SUP-DO543R,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.53,83.86,"AETNA [10100]","Aetna HMO/PPO",,222.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.51,237.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 3MM OXFORD ARCOM KNEE LEFT MENISCAL PHASE 3",SUP-159547,CDM,C1776,HCPCS,0278,RC,,,both,,,5270.22,1581.07,"KAISER [10500]",Kaiser,,3531.05,67,,,,,0,612.93,4479.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 16MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P316,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS [10001]","Blue Cross PPO",,3275.51,39.2,,3949.44,3949.44,3949.44,"1 through 10",971.79,7102.52,"percent of total billed charges",
"LENS IOL +5.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.055,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAVITOR WITH RADIOPAQUE MARKERS 29MM",SUP-NVRO-29,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,54720,40,,,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7607,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX 4-0 TH-18 36IN 2 ARM MONOFILAMENT UNDYED",SUP-4N02A,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.28,86.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,34.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.64,245.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM DELTAXSFT 10 COIL",SUP-DLX100304,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2590.91,28.62,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 60X22X8MM RISE-L 6D NONSTERILE",SUP-193.426,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4068.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDEAVOR SPRINT 12MM 142CM 2.5MM CORONARY STENT",SUP-ENSP25012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1586.69,28.62,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701062,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"BLUE CROSS [10001]","Blue Cross PPO",,4449.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",1320.06,9647.93,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 22CM 150CM 5FR .038IN 3CM BLADDER LOOP",SUP-M006155221170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 560CC NATRELLE INSPIRA COHESIVE STERILE",SUP-TCM-560,CDM,C1789,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]",Cigna,,5630.4,68,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 40MM 1.5MM BALLOON DILATATION NYBAX",SUP-H74939186150410,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM MITRAL OPTIMAL ORIFICE AREA RESTORE",SUP-4200-M30,CDM,S27800098,LOCAL,0278,RC,,,both,,,18818.10,5645.43,"PHCS [10601]",PHCS,,13172.67,70,,,,,0,2188.55,15995.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP SOLID BACK METAL HA TRIDENT D",SUP-500-11-48D,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.85,2973.55,"PHCS [10601]",PHCS,,6938.3,70,,,,,0,1152.75,8425.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 28MM 144CM 2.75MM CORONARY STENT",SUP-H7493952828270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross PPO",,2181.48,39.2,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX INGUINAL REINFORCED TISSUE MATRIX, LONG-TERM RESORBAB",SUP-F10263-1317I,CDM,C1781,HCPCS,0278,RC,,,both,,,4526.40,1357.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2077.62,45.9,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL HIP INSIGNIA 11 HIGHT COLLAR",SUP-7000-6611,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"UHC [10700]","United Healthcare",,19353.28,63.3,,8601.07,8395.67,8601.07,"1 through 10",3555.74,25987.82,"percent of total billed charges",
"PARTIAL HIP 1",SUP-CAP-S-PH-1,CDM,C1776,HCPCS,0278,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross HMO",,3245.76,39.2,,5311.50,4717.44,5388.59,31,962.96,7038,"percent of total billed charges",
"KIT ARTHROSCOPIC FIXATION RAP-PAC ACL PCL DRILL GUIDE",SUP-014725,CDM,S27200284,LOCAL,0272,RC,,,both,,,1976.78,593.03,"CIGNA [10200]","Cigna Local Plus",,1057.58,53.5,,,,,0,229.9,1680.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 80CM 6FR 10MM EMBOLECTOMY ADHERENT CLOT",SUP-1408010,CDM,C1757,HCPCS,0272,RC,,,both,,,1763.85,529.15,"PHCS [10601]",PHCS,,1234.7,70,,,,,0,205.14,1499.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE REGENESORB 25MM 6MM BIOSURE",SUP-72204392,CDM,C1713,HCPCS,0278,RC,,,both,,,2774.03,832.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1273.28,45.9,,,,,0,322.62,2357.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 20F LARGE HIP PROXIMAL",SUP-550728,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"BLUE CROSS [10001]","Blue Cross PPO",,4266.82,39.2,,3949.44,3949.44,3949.44,"1 through 10",1265.9,9252.04,"percent of total billed charges",
"TOOL DISSECTING 140MM 5MM LEGEND LONG CYL STERILE",SUP-14CY50L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.28,371.18,"UHC [10700]","United Healthcare",,783.2,63.3,,,,,0,143.9,1051.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 35MM ACCOLADE TMZF 4.5 HIP",SUP-6021-4535,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6431.82,41.1,,6417.48,6417.48,6417.48,"1 through 10",1820,13301.82,"percent of total billed charges",
"STENT 26CM 150CM 8FR .035IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145381170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,133.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2.5CM 2MM CEREPAK MICRO UNIFORM DETACHABLE",SUP-FCX100202,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3570.98,27,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ILLMNTR ENDOSCOPIC 8FR PHOTONSABER FRAZIER STD TEARDROP",SUP-PSF08ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,1991.25,597.37,"CIGNA [10200]",Cigna,,1354.05,68,,,,,0,231.58,1692.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON ETHILON MULTIPASS 4-0 FS-2 18IN MONOFILAMENT BLACK",SUP-662H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 4-0 SH 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J315H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 3.33MM LARGE REGULAR PIGTAIL CURVE URETERAL",SUP-M001274060,CDM,C2617,HCPCS,0278,RC,,,both,,,1053.00,315.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,122.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCK DEMINERALIZED 10ML STRIP FORMATS INTERCONNECTED POROSI",SUP-PBF10,CDM,S27800098,LOCAL,0278,RC,,,both,,,6846.53,2053.96,"AETNA [10100]","Aetna HMO/PPO",,5442.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,796.25,5819.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bat Clps Elec/Comb Vad, Rep",PX-E27400015,CDM,Q0497,HCPCS,0274,RC,,,both,,,3419.68,1025.9,"MULTIPLAN [10600]",Multiplan,,2906.73,85,,,,,0,397.71,2906.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID UPPER LEG REDUCTION KIT- LONG, WIDE",SUP-25302317,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"MULTIPLAN [10600]",Multiplan,,1067.18,85,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 3003059 ZEVO 59MM 3 LVL",SUP-3003059,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,627.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,615.46,4498.2,"percent of total billed charges",
"(EVAL) CATHETER GUIDELINER 150CM 25CM 8FR .088IN .071IN INTE",SUP-5573,CDM,C1887,HCPCS,0272,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 330541 ACSR 5X14X11 SRVC FEE",SUP-330541,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 13MM COROENT INTERLOCK II SPINE SELF TAP",SUP-1903013,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,396.9,39.2,,957.42,156.86,7483.26,51,117.75,860.63,"percent of total billed charges",
"PACK SURGICAL CEREBRAL RETROGRADE",SUP-3T70R,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.91,41.1,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 10-0 CS160-6 12IN 2 ARM MONOFILAMENT BLACK",SUP-9000G,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.29,68.79,"MULTIPLAN [10600]",Multiplan,,194.9,85,,,,,0,26.67,194.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE MEDIUM BREATHABLE SQUARE TOE OFFLOAD 10FT",SUP-VP50201-030,CDM,S27000186,LOCAL,0270,RC,,,both,,,114.67,34.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,47.13,41.1,,,,,0,13.34,97.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR CATH 9FR CHECK-FLO SELF ADJUSTING SEAL SIDE CONNECTION",SUP-G06002,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.87,25.76,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TAKERU 12MM 2.5MM BALLOON DILATATION OTW PTCA",SUP-DC-PY2512UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOE POSTOPERATIVE XL FEMALE SUEDE RUBBER BOTTOM WOOD SOLE",SUP-2007-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,77.43,23.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.01,65.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 6.5MM 15MM CANCELLOUS STERILE",SUP-117215000,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,133.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",133.3,974.23,"percent of total billed charges",
"HEAD FEMORAL +9MM 12/14 STD 32MM HIP CEMENTLESS COCR",SUP-136523000,CDM,C1776,HCPCS,0278,RC,,,both,,,2701.44,810.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1836.98,68,,,,,0,314.18,2296.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL O2 DELIVERY TUBE INTERMEDIATE INFANT 7L/MIN RT329",SUP-BC2755-20,CDM,S27000186,LOCAL,0270,RC,,,both,,,70.91,21.27,"CIGNA [10200]",Cigna,,48.22,68,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDPLATE SPINAL 14X6MM SECURE-C 6D 13MM SPHERICAL",SUP-714.266S,CDM,C1713,HCPCS,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,1144.80,304.56,2275.09,66,3297.11,24097.5,"percent of total billed charges",
"HC Osteocalcin",PX-301000519,CDM,83937,CPT,0301,RC,,,both,,,191.00,57.3,"NOVANET [10819]",Novanet,,143.25,75,,,,,0,0.01,162.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET TRANSFER 77X30IN MAXISLIDE FLITES LATEX FREE",SUP-NPA0500,CDM,S27000186,LOCAL,0270,RC,,,both,,,96.35,28.9,"PHCS [10601]",PHCS,,67.45,70,,,,,0,11.21,81.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSCONN ROD 60-70MM ADJUSTABLE ARCH",SUP-8450260,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK 7.5CM NASAL INFLATABLE UNILATERAL AIRWAY RAPID RHINO",SUP-RR751,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT FINGER SWANSON 4 METACARPOPHALANGEAL GROMMET HIGH",SUP-G4700004,CDM,C1776,HCPCS,0278,RC,,,both,,,4170.60,1251.18,"PHCS [10601]",PHCS,,2919.42,70,,,,,0,485.04,3545.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC ENDOBLADE GASTROC RECESSION SYSTEM",SUP-AR-8855DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,6484.28,1945.28,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OCTARAY 2-2-2-2-2MM SPACE D CURVE ELECTROPHYSIOLOGY",SUP-D160901,CDM,C1732,HCPCS,0272,RC,,,both,,,15407.70,4622.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH MALECOT 14FR NEPHRSTMY NATURAL RUBBER 4 WING DRAIN",SUP-086014,CDM,C1729,HCPCS,0272,RC,,,both,,,105.65,31.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT ARTHROSCOPIC FIXATION STRAIGHT SPEAR DISPOSABLE",SUP-AR-3638DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC",698,MS-DRG,,,,,,,inpatient,,,42098.63,12629.59,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 60MM 4MM BALLOON DILATATION PEBAX",SUP-H74939032406010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX MONORAIL 143CM 15MM 3MM BALLOON",SUP-H7493912415300,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LOCKING 5.5MM MATRIX FLAT SPINE COCR TITANIUM STEP",SUP-09.632.099,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",40.47,295.8,"percent of total billed charges",
"PLATE CONTOUR 142MM STAINLESS STEEL 4.5MM SCR 6 HOLE LIMIT",SUP-239.986S,CDM,C1713,HCPCS,0278,RC,,,both,,,11207.39,3362.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1328.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1303.42,9526.28,"percent of total billed charges",
"SYSTEM PROMUS PREMIER 12MM 144CM 3MM CORONARY STENT",SUP-H7493952812300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"KAISER [10500]",Kaiser,,3728.55,67,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FLEXIGRAFT CANCELLOUS XLONG ALLOGRAFT FULL",SUP-PCDXL11,CDM,S27800098,LOCAL,0278,RC,,,both,,,7917.75,2375.32,"CIGNA [10200]","Cigna Open Access",,4505.2,56.9,,,,,0,920.83,6730.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRAPLINER 150CM 13CM 5.7FR INTERVENTIONAL HYDROPHILIC",SUP-5567,CDM,S27200284,LOCAL,0272,RC,,,both,,,4291.80,1287.54,"CIGNA [10200]","Cigna Local Plus",,2296.11,53.5,,,,,0,499.14,3648.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION .062IN 9IN KIRSCHNER DUAL TROCAR POINT BOTH",SUP-1600-1962T,CDM,C1713,HCPCS,0278,RC,,,both,,,200.22,60.07,"CIGNA [10200]","Cigna Open Access",,113.93,56.9,,1144.80,304.56,2275.09,66,23.29,170.19,"percent of total billed charges",
"PACK PHACOEMULSIFICATION .9MM CENTURION INTREPID 30D BEVEL",SUP-8065752200,CDM,S27200284,LOCAL,0272,RC,,,both,,,833.00,249.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,566.44,68,,,,,0,96.88,708.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH CUSTOM PICC",SUP-K12T-01916,CDM,C1751,HCPCS,0272,RC,,,both,,,450.36,135.11,"PHCS [10601]",PHCS,,315.25,70,,,,,0,52.38,382.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 6",SUP-249.682,CDM,C1713,HCPCS,0278,RC,,,both,,,2429.70,728.91,"MULTIPLAN [10600]",Multiplan,,2065.25,85,,,,,0,282.57,2065.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 13MM ALPS COCR SQUARE HAND CORTICAL LOCK SELF",SUP-131220413,CDM,S27200284,LOCAL,0272,RC,,,both,,,1032.75,309.82,"MULTIPLAN [10600]",Multiplan,,877.84,85,,,,,0,120.11,877.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 150CM .025IN STD TIP FIXED CORE J 3CM EMERALD",SUP-502524,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 0 CT-1 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z340H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP FLEX-MINI 35MM CLSR LEFT ATRIAL APPENDAGE",SUP-ACHM35,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4191.75,27,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 STANDARD 3MMX6CM",SUP-M0035463060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"NOVANET [10819]",Novanet,,10585.98,75,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 6MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120615,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"KAISER [10500]",Kaiser,,7960.81,67,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL SHAFT 200MM",SUP-T20658,CDM,S27800098,LOCAL,0278,RC,,,both,,,7472.01,2241.6,"CIGNA [10200]",Cigna,,5080.97,68,,,,,0,868.99,6351.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 5 UNIVERSAL KNEE TOTAL STABILIZED",SUP-5521-B-500,CDM,C1776,HCPCS,0278,RC,,,both,,,10384.92,3115.48,"CIGNA [10200]","Cigna Open Access",,5909.02,56.9,,5302.19,4377.88,6578.61,27,1207.77,8827.18,"percent of total billed charges",
"SPACER SPINAL 14X7MM COLONIAL 7D LORDOTIC 12MM LARGE",SUP-365.407CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 20MM EMBOLD NITINOL FIBER DETACHABLE",SUP-M001394240200500,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"CIGNA [10200]","Cigna Local Plus",,4610.68,53.5,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 33X30MM ROI-A 14D SIZING TABLE LORDOSIS ALIF","SUP-IR 2645 P",CDM,S27800098,LOCAL,0278,RC,,,both,,,39060.00,11718,"PHCS [10601]",PHCS,,27342,70,,,,,0,4542.68,33201,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 100415 CNCHP 4-10MM 15CC SRVC FEE",SUP-100415,CDM,S27800098,LOCAL,0278,RC,,,both,,,2126.25,637.87,"CIGNA [10200]",Cigna,,1445.85,68,,,,,0,247.28,1807.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VALVE AORTIC 23MM SAPIEN 3 BOVINE PERICARDIAL TRANSCA",SUP-9600TFX23A,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,70281,41.1,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 95MM MARS AUXILLARY",SUP-132.195,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"GRAFT BONE CORTICAL CANCELLOUS THK8MM ALLOGRAFT STRUT FREEZE",SUP-400605,CDM,S27800098,LOCAL,0278,RC,,,both,,,6412.86,1923.86,"CIGNA [10200]","Cigna Local Plus",,3430.88,53.5,,,,,0,745.82,5450.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT CSF PROGRAMMABLE SIPHONGUARD RIGHT ANGLE STERILE",SUP-823182,CDM,S27800098,LOCAL,0278,RC,,,both,,,44384.89,13315.47,"BLUE CROSS [10001]","Blue Cross PPO",,17398.88,39.2,,,,,0,5161.96,37727.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 42MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR42,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Local Plus",,4129.65,31.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X14X7MM PTC PEEK TANTALUM TITANIUM CERVICAL",SUP-5030764,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA [10200]","Cigna Local Plus",,3572.95,53.5,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM REGENT FLEXCUFF 85D SUPRA ANNULAR",SUP-25AGFN-756,CDM,S27800098,LOCAL,0278,RC,,,both,,,31229.42,9368.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8431.94,27,,,,,0,3631.98,26545.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL GOLD 13.5MM SYNFIX 18D MEDIUM EVOLUTION 5.4MM",SUP-08.815.263S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PHCS [10601]",PHCS,,19845,70,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL L8 MM PLATE 2 SIDE STERILE LATEX FREE XLIF",SUP-1910208P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"UHC [10700]","United Healthcare",,8735.4,63.3,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 26X9X13MM 12D PLIF",SUP-PUI31306,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7654.5,27,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 31MM 26.1MM MASTER-SERIES PYROLYTIC CARBON PTFE",SUP-29ATJ-503,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7862.19,27,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS03010,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Open Access",,3927.24,33.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL ORBITAL MEDPOR POLYETHYLENE 16MM CRANIOMAXILLOFACIAL",SUP-6326,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NUT ORTHOPEDIC MRI SAFE NONSTERILE",SUP-03.311.062,CDM,S27800098,LOCAL,0278,RC,,,both,,,1210.87,363.26,"MULTIPLAN [10600]",Multiplan,,1029.24,85,,,,,0,140.82,1116.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 60X12-13MM",SUP-400731,CDM,S27800098,LOCAL,0278,RC,,,both,,,4264.20,1279.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2899.66,68,,,,,0,495.93,3624.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL IO-FLEX MICROBLADE SHAVER SPINE CANN FLEXIBLE",SUP-IO-IP,CDM,S27200284,LOCAL,0272,RC,,,both,,,1599.75,479.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACEL 110CM 2MM 5FR 10CM 1CM SPACE RIGHT HEART CURVE",SUP-401763,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYR ANGIOGRAPHY 30ML INFLATION LATEX FREE MONARCH",SUP-IN2530,CDM,S27200284,LOCAL,0272,RC,,,both,,,504.14,151.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT FIBERSTICK TIGERSTICK 2 50IN 1 END STIFFEN BRAID",SUP-AR-7209,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE 24FR REPLACEMENT STRAIGHT ANGLE BOLST GASTRO ENDOVIVE",SUP-M00509941,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.82,72.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LEAD PACING 45CM 5.7FR ATRIUM VENTRICLE TRANSVENOUS BIPOLAR",SUP-407645,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"FIRST HEALTH [10303]","First Health",,1786,80,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 15MM MBT 2.5 KNEE REVISION STEP WEDGE STERILE",SUP-129456127,CDM,C1776,HCPCS,0278,RC,,,both,,,9889.08,2966.72,"CIGNA [10200]","Cigna Open Access",,5626.89,56.9,,5302.19,4377.88,6578.61,27,1150.1,8405.72,"percent of total billed charges",
"PLATE 8 LEVEL NEW LOCK ATLANTIS VISION BONE SPINAL",SUP-7200082,CDM,C1713,HCPCS,0278,RC,,,both,,,4620.00,1386,"PHCS [10601]",PHCS,,3234,70,,,,,0,537.31,3927,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOPLASTY L150CM BALLOON L60MM DIA6MM COMPATIBLE",SUP-1013470-060,CDM,S27200284,LOCAL,0272,RC,,,both,,,1255.50,376.65,"UHC [10700]","United Healthcare",,794.73,63.3,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AZITHROMYCIN 600 MG TABLET",RX-17387,CDM,,,0637,RC,69452-0173-13,NDC,both,1,UN,70.62,21.19,"KAISER [10500]",Kaiser,,47.32,67,,,,,0,8.21,60.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +6MM 11/13 TAPER 32MM HIP MODULAR BIOLOX DELTA",SUP-136532230,CDM,C1776,HCPCS,0278,RC,,,both,,,12385.50,3715.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1467.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1440.43,10527.68,"percent of total billed charges",
"HC Critical Care 30-74min W Proc",PX-450000322,CDM,99291,CPT,0450,RC,,,both,,,4692.00,1407.6,"PHCS [10601]",PHCS,,3284.4,70,,,,,0,559.4,3988.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 82MM PRESS FIT AEQUALIS ASCEND FLEX PTC 127.5D",SUP-DWF605A,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"FIRST HEALTH [10303]","First Health",,10080,80,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP FEM N/POROUS SIZE 5 RIGHT",SUP-2154-0-0005,CDM,C1776,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3800.52,45.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 73X25X.89MM MEDIUM WIDE STAINLESS STEEL 2 CUT",SUP-2108-105,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,27.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 12MM 100MM KII ABDOMINAL ADVANCE",SUP-CFS22,CDM,S27200284,LOCAL,0272,RC,,,both,,,119.63,35.89,"CIGNA [10200]",Cigna,,81.35,68,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.5/13",SUP-401739,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE COAGULATION PURPLE 350CM 7FR BRIGHTON GASTROINTESTINAL",SUP-BP-7F-DP-350,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END 10MM TALON DISTALFIX 15.5MM",SUP-SLN-155-010,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"COIL EMBOLIZATION 12CM .02IN 3MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0312,CDM,S27800098,LOCAL,0278,RC,,,both,,,5838.00,1751.4,"KAISER [10500]",Kaiser,,3911.46,67,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23-26MM 0-43MM COREVALVE 29MM HEART PORCINE",SUP-MCS-P3-29-AOA-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]",Cigna,,68400,40,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL ORBITAL BIO-EYE HA 18MM LIGHTWEIGHT POROSITY",SUP-I00018S,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT 85CM PRESSURE RELATIVE RISK UNITIZE DISTAL CATH",SUP-NS0005,CDM,S27800098,LOCAL,0278,RC,,,both,,,13732.38,4119.71,"BLUE CROSS [10001]","Blue Cross PPO",,5383.09,39.2,,,,,0,1597.08,11672.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 12MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS12030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PHCS [10601]",PHCS,,8206.17,70,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 12MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS12030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"NOVANET [10819]",Novanet,,8792.33,75,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 7CM 10MM GORE EXCLUDER ILIAC INTERNAL",SUP-HGB161007A,CDM,S27800098,LOCAL,0278,RC,,,both,,,19089.00,5726.7,"PHCS [10601]",PHCS,,13362.3,70,,,,,0,2220.05,16225.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 93MM 16MM 14FR",SUP-ETLW1616C93E,CDM,S27800098,LOCAL,0278,RC,,,both,,,16740.00,5022,"CIGNA [10200]",Cigna,,6696,40,,,,,0,1946.86,14229,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 21MM 16.7MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-21MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AETNA [10100]","Aetna HMO/PPO",,23149.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 25MM SUPRA STENTED LOW PROFILE FLEXFIT",SUP-BSP100-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,32715.90,9814.77,"KAISER [10500]",Kaiser,,21919.65,67,,,,,0,3804.86,27808.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOLUTPRO TRANSCATHETER AORTIC VALVE-29MM - THE 29MM EVOLTR",SUP-EVOLUTPRO-29-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,48940.2,28.62,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X6MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7006,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"NOVANET [10819]",Novanet,,5175,75,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 3.5 X 4 HELICAL FINISHING COIL",SUP-10HFN-03504,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"FIRST HEALTH [10303]","First Health",,8274.48,80,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ON-X AORTIC PROSTHETIC HEART VALVE 27/29MM WITH CONFORM-XSEW",SUP-ONXACE-27/29,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4479.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 3.5MM 1.14MM 3.5MM ARMSTRONG EAR GROMMET",SUP-1010030,CDM,S27800098,LOCAL,0278,RC,,,both,,,236.64,70.99,"MULTIPLAN [10600]",Multiplan,,201.14,85,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 38MM MITRAL CARPENTIER-EDWARDS PHYSIO II",SUP-520038MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"CIGNA [10200]","Cigna Local Plus",,4347,31.5,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X13MM LUMINARY CC BICONVEX SPINE",SUP-16813,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3941.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X10MM ADVANCED LORDOTIC TRAPEZOIDAL",SUP-7710,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"KAISER [10500]",Kaiser,,5547.6,67,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X28MM BENGAL 12MM STD LORDOTIC THORACOLUMBAR",SUP-177306128,CDM,S27800098,LOCAL,0278,RC,,,both,,,15950.04,4785.01,"FIRST HEALTH [10303]","First Health",,12760.03,80,,,,,0,1854.99,13557.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 122MM 3.5MM AO OVER",SUP-703694,CDM,S27200284,LOCAL,0272,RC,,,both,,,1068.23,320.47,"FIRST HEALTH [10303]","First Health",,854.58,80,,,,,0,124.24,908,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM AXIUM PRIME HELIX DETACHABLE",SUP-APB-3-10-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"PHCS [10601]",PHCS,,6254.85,70,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA ALLOGRAFT STRUT FROZEN 110X5MM",SUP-450655,CDM,S27800098,LOCAL,0278,RC,,,both,,,6172.74,1851.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,731.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,717.89,5246.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT 5 KNEE CEMENT ROTATE PLATFORM",SUP-129431150,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETERIZATION 14GA 18GA 8IN SHARPSAWAY 2.5IN .032IN",SUP-AK-04700,CDM,C1751,HCPCS,0272,RC,,,both,,,161.82,48.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.82,137.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING FULL CARBON FIBER 180MM",SUP-4933-5-180,CDM,S27800098,LOCAL,0278,RC,,,both,,,11248.79,3374.64,"NOVANET [10819]",Novanet,,8436.59,75,,,,,0,1308.23,9561.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE AVIVE SOFT 3CM X 6CM",SUP-CA0306,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2198.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)VALVE AORTIC 23MM SAPIEN RETROFLEX 3 HEART COCR BOVINE",SUP-9600TFX23,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"AETNA [10100]","Aetna HMO/PPO",,135945,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 40MM SEMIRIGID OPEN ANTERIOR SEG SEWING",SUP-5300M40,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3949.56,28.62,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM MITRAL OPTIMAL ORIFICE AREA RESTORE",SUP-4200-M30,CDM,S27800098,LOCAL,0278,RC,,,both,,,18818.10,5645.43,"BLUE CROSS [10001]","Blue Cross PPO",,7376.7,39.2,,,,,0,2188.55,15995.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17.8MM 25MM 32MM 23.4MM ON-X 25 STD CYLINDRICAL",SUP-ONXAE-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"PHCS [10601]",PHCS,,26460,70,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR NARROW LORDOTIC 12 DEGRE",SUP-12311,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"PHCS [10601]",PHCS,,13230,70,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM FOOTPRINT SELF LOCK NONABSORBABLE",SUP-72203783,CDM,C1713,HCPCS,0278,RC,,,both,,,2548.20,764.46,"NOVANET [10819]",Novanet,,1911.15,75,,,,,0,296.36,2165.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO 28CM 14FR SENTRANT .035IN HYDROPHILIC GWIRE",SUP-SENSH1428W,CDM,C1894,HCPCS,0272,RC,,,both,,,1620.00,486,"NOVANET [10819]",Novanet,,1215,75,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE PRIME 33MM 143CM 4MM CORONARY STENT EVEROLIMUS",SUP-1011735-33,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"CIGNA [10200]","Cigna Local Plus",,5131.19,53.5,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 44MM TI",SUP-MTLS-37440-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR 8X6CM PERI-GUARD BOVINE PERICARDIAL",SUP-PC0608NBIO,CDM,S27800098,LOCAL,0278,RC,,,both,,,4544.00,1363.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,538.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,528.47,3862.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB CONGRU 10MM LFT 1-2",SUP-2041-0-1210,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Open Access",,2027.06,56.9,,5302.19,4377.88,6578.61,27,414.32,3028.13,"percent of total billed charges",
"CATH 115CM 1MM 6FR 2MM SPACE A CURVE ELECTROPHYSIOLOGY 10",SUP-F6QA002RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"AETNA [10100]","Aetna HMO/PPO",,721.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNGOSCOPE SPECTRUM LOPRO 2 TITANIUM GLIDESCOPE DISP",SUP-0270-0877,CDM,S27200284,LOCAL,0272,RC,,,both,,,414.99,124.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,49.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.26,352.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 7CM 10FR 2 PIGTAIL CURVE THIN WALL BILIARY",SUP-M00532270,CDM,C2617,HCPCS,0278,RC,,,both,,,447.93,134.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,53.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.09,380.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 11MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424024,CDM,C1776,HCPCS,0278,RC,,,both,,,11747.25,3524.17,"NOVANET [10819]",Novanet,,8810.44,75,,,,,0,1366.21,9985.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 12MM 3.2-2.4-2.6FR 2.5MM BALLOON",SUP-SPR2512W,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE DESTINATION TUOHY-BORST STRAIGHT 90CM 15CM 6",SUP-RSC01,CDM,C1887,HCPCS,0272,RC,,,both,,,785.70,235.71,"UHC [10700]","United Healthcare",,497.35,63.3,,,,,0,91.38,667.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE RUNTHROUGH NS VASCULAR STRAIGHT 300CM 3CM .014IN",SUP-25-3013,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR TEGT CURVE",SUP-G11377,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"UHC [10700]","United Healthcare",,150.33,63.3,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM CONCERTO 3D",SUP-PV-2-2-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 120MM 150CM 8MM VASCULAR NICKEL",SUP-EVD35-08-120-150,CDM,C1876,HCPCS,0278,RC,,,both,,,7665.00,2299.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,908.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,891.44,6515.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DIALYSIS EASY-LOCK INTRAVENOUS ADPTR",SUP-5C4137,CDM,S27000186,LOCAL,0270,RC,,,both,,,111.27,33.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.94,94.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 7-9+ C-D KNEE RIGHT CONDYLAR",SUP-42-5228-005-10,CDM,C1776,HCPCS,0278,RC,,,both,,,16308.84,4892.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4403.39,27,,,,,0,1896.72,13862.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 100CM 8FR IM CURVE GUIDING STAINLESS",SUP-588817,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 50MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0250,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"NOVANET [10819]",Novanet,,710.78,75,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175252180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"FIRST HEALTH [10303]","First Health",,1168.09,80,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HALYARD BALLARD 21.3IN 14FR 22MM 15MM SUCTION",SUP-2210,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.78,22.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,50.85,68,,,,,0,8.7,63.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE PACING 135CM 2.4FR CHANDLER V AMC THROMBOSHIELD",SUP-D98100H,CDM,S27200284,LOCAL,0272,RC,,,both,,,917.73,275.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,106.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,106.73,780.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 25X14-18MM",SUP-400716,CDM,S27800098,LOCAL,0278,RC,,,both,,,3783.96,1135.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,448.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,440.07,3216.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM PERSONA 7 7+ KNEE DISTAL STERILE LATEX FREE",SUP-42556606205,CDM,C1776,HCPCS,0278,RC,,,both,,,7236.72,2171.02,"CIGNA [10200]",Cigna,,4920.97,68,,5873.17,5873.17,5873.17,"1 through 10",841.63,6151.21,"percent of total billed charges",
"GWIRE ASNIS III ORTHOPEDIC 300MM 3.2MM THREAD CANNULATED SCR",SUP-702462,CDM,C1769,HCPCS,0272,RC,,,both,,,365.40,109.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,150.18,41.1,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 12 G-H KNEE RIGHT TIBIA FIX",SUP-42522101012,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7327.97,68,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 15MM 41MM SHOULDER SIMPLICITI",SUP-7122869,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1187.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1165.21,8516.15,"percent of total billed charges",
"HEAD UNIPOLAR 41MM BIO-MOORE II ENDO II HIP ACETABULAR",SUP-12-139006,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"BLUE CROSS [10001]","Blue Cross HMO",,1094.86,39.2,,5311.50,4717.44,5388.59,31,324.83,2374.05,"percent of total billed charges",
"BASEPLT TIBIAL ATTUNE 9 KNEE CEMENTED FIX BEARING STERILE",SUP-150600009,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6166.66,41.1,,6417.48,6417.48,6417.48,"1 through 10",1744.97,12753.44,"percent of total billed charges",
"SYSTEM LINX 14 BEAD 1.5 TESLA IMPL GASTROINTESTINAL GERD",SUP-LXMC14,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"MULTIPLAN [10600]",Multiplan,,29452.5,85,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 55MM LCP DHHS STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.220,CDM,C1713,HCPCS,0278,RC,,,both,,,939.84,281.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,111.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,109.3,798.86,"percent of total billed charges",
"PUSHER STENT ADVANIX PANCREATIC RAPID EXCHANGE 4FR 5FR",SUP-M00535010,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12MM NATURAL STD LORDOTIC CORTICOCANCELLOUS",SUP-18412,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 64CM .016IN FIRM STERILE LATEX FREE DISPOSABLE",SUP-6971,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 15IN 34-38FR VENOUS ATRIAL CAVAL ADULT 3/8IN",SUP-93463,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.70,87.81,"FIRST HEALTH [10303]","First Health",,234.16,80,,,,,0,34.04,248.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cea",PX-301000132,CDM,82378,CPT,0301,RC,,,both,,,331.01,99.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,29.82,,,,,,,0.01,281.36,"fee schedule",
"SUT PROLENE 0 CT-1 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8424H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC",056,MS-DRG,,,,,,,inpatient,,,32875.68,9862.7,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,15274.96,,"Case rate ($14,410.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,380.97, add-ons for qualifying new technology services are included. If operating cost exceeds $46,420.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,393.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $13,398.66. The transfer operating threshold is the transfer adjustment factor * $13,380.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,011.67. The transfer capital threshold is the transfer adjustment factor * $1,011.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,32875.68,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 9MM CEMENT COLLAR FOUNDATION HIP SERIES 460",SUP-460-01-090,CDM,C1776,HCPCS,0278,RC,,,both,,,18958.40,5687.52,"NOVANET [10819]",Novanet,,14218.8,75,,,,,0,2204.86,16114.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION",RX-11567,CDM,,,0250,RC,24208-0295-25,NDC,both,2.5,ML,305.22,91.57,"CIGNA [10200]","Cigna Local Plus",,163.29,53.5,,,,,0,35.5,259.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS HIGHFLOW 100CM 7FR AL2 CURVE ANGIOGRAPHIC DUCOR",SUP-527741,CDM,C1887,HCPCS,0272,RC,,,both,,,137.11,41.13,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP BIPOLAR 9IN SPETZLER-MALIS SLIM 1MM DISPOSABLE",SUP-6780-230-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,3208.53,962.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"APPENDIX PROCEDURES WITHOUT CC/MCC",399,MS-DRG,,,,,,,inpatient,,,57452.94,17235.88,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBTR LAPAROSCOPIC 8MM WECK VISTA LONG BLADELESS STERILE",SUP-470360,CDM,S27200284,LOCAL,0272,RC,,,both,,,274.05,82.21,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ICP CENTRIFUGAL PUMP XC STERILE",SUP-3CXCP8,CDM,S27200284,LOCAL,0272,RC,,,both,,,1087.43,326.23,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PERFORMA 100CM 4FR .041IN .035IN PIGTAIL ANGIOGRAPHIC",SUP-7742-20M100SH,CDM,S27200284,LOCAL,0272,RC,,,both,,,733.13,219.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE VASCULAR J ROSEN CURVE 145CM 1.5CM .035IN PTFE",SUP-G01261,CDM,C1769,HCPCS,0272,RC,,,both,,,118.23,35.47,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP ELECTROSURGICAL 7.5INX1.5MM HARDY IRRIGATE 3.5IN LATEX",SUP-US416SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,2487.93,746.38,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cath Midline",PX-E27200256,CDM,C1751,HCPCS,0272,RC,,,both,,,667.03,200.11,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 135CM 200MM 6MM BALLOON DILATATION OTW",SUP-H74939206062010,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT DRNG 25CM 8FR .018IN FLEXITHANE HYDROPHILIC LOCK LOOP",SUP-H749393110825K1,CDM,C1729,HCPCS,0272,RC,,,both,,,1474.20,442.26,"KAISER [10500]",Kaiser,,987.71,67,,,,,0,171.45,1253.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 23MM 145CM 2.5MM CORONARY STENT",SUP-1145250-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"MULTIPLAN [10600]",Multiplan,,4962.3,85,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM CHARLOTTE CLAW FOOT HEXAGONAL LOCKING",SUP-40133524,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,189.34,1383.8,"percent of total billed charges",
"REFERENCE TOE DISPOSABLE INSTRUMENT SET SIZE 3-4","SUP-M03 S0003",CDM,S27200284,LOCAL,0272,RC,,,both,,,3337.50,1001.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,388.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,388.15,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 3DMAX 5.3X3.1IN ABDOMINAL RIGHT MONOFILAMENT",SUP-0117320,CDM,C1781,HCPCS,0278,RC,,,both,,,951.60,285.48,"BLUE CROSS [10001]","Blue Cross HMO",,373.03,39.2,,,,,0,110.67,808.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X12MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7112,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"KAISER [10500]",Kaiser,,4623,67,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM CD HORIZON VOYAGER SPINE NONSTERILE",SUP-55850044535,CDM,C1713,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,878.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",862.66,6304.88,"percent of total billed charges",
"GRAFT SOFT TISSUE 160MM FLEXIGRAFT ACHILLES TENDON CALCANEUM",SUP-FATB,CDM,S27800098,LOCAL,0278,RC,,,both,,,12109.50,3632.85,"BLUE CROSS [10001]","Blue Cross HMO",,4746.92,39.2,,,,,0,1408.33,10293.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 28MM 145CM 2.75MM CORONARY STENT",SUP-1145275-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross HMO",,2288.5,39.2,,9776.84,9776.84,9776.84,"1 through 10",678.96,4962.3,"percent of total billed charges",
"NEUROFORM ATLAS STENT SYSTEM 4.5 X 30MM WITHOUT TIP ZERO (PM",SUP-M003UZAS45300,CDM,C1874,HCPCS,0278,RC,,,both,,,52885.22,15865.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,21154.09,40,,,,,0,6150.55,44952.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 2 BRANCH 3 WAY STPCOCK TRNSDUC FLUSH",SUP-PX2X2,CDM,S27200284,LOCAL,0272,RC,,,both,,,256.13,76.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,174.17,68,,,,,0,29.79,217.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 FLEXOR 30MM 125CM 9MM 5FR LOW PROFILE",SUP-G43785,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"KAISER [10500]",Kaiser,,2799.93,67,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CBL PCNG DISP",SUP-4042,CDM,S27200284,LOCAL,0272,RC,,,both,,,696.60,208.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,82.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE PRIME 38MM 143CM 3MM CORONARY STENT EVEROLIMUS",SUP-1011733-38,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1136.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP LOCKING REAMER IRR ASPIR INTRAMEDULLARY BONE HARVEST",SUP-352.260S,CDM,S27200284,LOCAL,0272,RC,,,both,,,557.69,167.31,"PHCS [10601]",PHCS,,390.38,70,,,,,0,64.86,474.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 CRUCIATE RETAIN CEMENT PERSONA STERILE LATEX",SUP-42572605802,CDM,C1776,HCPCS,0278,RC,,,both,,,26429.76,7928.93,"PHCS [10601]",PHCS,,18500.83,70,,,,,0,3073.78,22465.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI 24MM TITANIUM 1 LEVEL HELIX BONE SPINE CERVICAL",SUP-7740124,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",521.61,3812.25,"percent of total billed charges",
"STEM FEMORAL 155MM 17MM MODULAR RESTORATION HA CONICAL",SUP-6276-7-017,CDM,C1776,HCPCS,0278,RC,,,both,,,10468.22,3140.47,"CIGNA [10200]",Cigna,,7118.39,68,,5873.17,5873.17,5873.17,"1 through 10",1217.45,8897.99,"percent of total billed charges",
"CIR STPLR TRIEEAXL33XT BLK EXT",SUP-TRIEEAXL33XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,3083.78,925.13,"MULTIPLAN [10600]",Multiplan,,2621.21,85,,,,,0,358.64,2621.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 2.5CM 10CM WITHOUT MINI GWIRE DIL PINNACLE",SUP-RSS604,CDM,C1894,HCPCS,0272,RC,,,both,,,73.95,22.18,"PHCS [10601]",PHCS,,51.77,70,,,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 8FR PIGTAIL NEPHROURETERAL PERCUFLEX METAL",SUP-M001221380,CDM,C2617,HCPCS,0278,RC,,,both,,,811.20,243.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,372.34,45.9,,,,,0,94.34,689.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH ENDOSCP 4MM 15MM STRAIGHT ROUND SOFT SIDEHOLE STERILE",SUP-D-201-14304,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.26,63.08,"MULTIPLAN [10600]",Multiplan,,178.72,85,,,,,0,24.45,178.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP SMALL ALLOGRAFT COMPRESSIBLE SPONGE",SUP-13810809,CDM,C1713,HCPCS,0278,RC,,,both,,,7197.47,2159.24,"MULTIPLAN [10600]",Multiplan,,6117.85,85,,,,,0,837.07,6117.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 20MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,169.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CORDIS EXOSEAL 6FR CLSR FEMORAL ARTERY ABSORBABLE",SUP-EX600,CDM,C1760,HCPCS,0272,RC,,,both,,,1166.40,349.92,"UHC [10700]","United Healthcare",,738.33,63.3,,,,,0,479.39,738.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LOW PROFILE STAINLESS STEEL 8 HOLE LOCK MODULAR BONE",SUP-AR-8943BL-08,CDM,C1713,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"FIRST HEALTH [10303]","First Health",,4388.4,80,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 25MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G425,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1089.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LARGE 33.4MMX1.5MM TITANIUM 2.7MM SCR 4 HOLE",SUP-DC2805115,CDM,C1713,HCPCS,0278,RC,,,both,,,7286.40,2185.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,863.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",847.41,6193.44,"percent of total billed charges",
"CATH LAUNCHER 100CM 6FR EBU3.25 CURVE GUIDING NYLON CORONARY",SUP-LA6EBU325,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER SKIN PURPLE 5CM SOFT TISSUE DELIVERY SYSTEM STERILE",SUP-SMARTCLIPLT-PURP-5,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"FIRST HEALTH [10303]","First Health",,2160,80,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 26X9X12MM 8D EIT PLIF STERILE LATEX FREE",SUP-PUI81206,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTD DTMC1D1 COMPIA MRI US DF1",SUP-DTMC1D1,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,23088,40,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE MIC-KEY",SUP-0270-18-2.0-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,311.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE NDL 1.6MM BIOPSY BIPLANE STERILE DISPOSABLE LATEX FREE",SUP-UA1322-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.15,37.84,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXT NEROSTIMLTR 10CM INTERSTIM 13L SPINAL CORD LEAD TNLR",SUP-3095-10,CDM,C1883,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"KAISER [10500]",Kaiser,,2487.38,67,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 15.2-15.1CM NATRELLE P5.3-5.5CM MODERATE PROFILE",SUP-SZ68650,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"UHC [10700]","United Healthcare",,192.75,63.3,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 62MM 23MM ESOPHAGEAL PARTIAL COVER OTW STERILE",SUP-M00517710,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]","Cigna Open Access",,6120.45,33.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL SPINAL SPROTTE CLOSE TIP NDL CATH",SUP-TCL101,CDM,S27200284,LOCAL,0272,RC,,,both,,,445.50,133.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 15MM 3MM BALLOON DILATATION PTCA",SUP-DC-RZ3015UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"AETNA [10100]","Aetna HMO/PPO",,785.62,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 20CM 10FR LARGE PROXIMAL PIGTAIL CURVE",SUP-M001235570,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA [10200]",Cigna,,605.88,68,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTRUMENT CLAMP EM SPHERE  - MAXIMUM 10 USES",SUP-8000060020,CDM,S27200284,LOCAL,0272,RC,,,both,,,16242.60,4872.78,"MULTIPLAN [10600]",Multiplan,,13806.21,85,,,,,0,1889.01,13806.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR HD 46CM 11-13FR ACCESS STAINLESS STEEL",SUP-M0062502230,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"PHCS [10601]",PHCS,,686.47,70,,,,,0,114.05,833.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 8MMX59MM 7FR 80CMCATH HEPARIN",SUP-BXB085901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UHC [10700]","United Healthcare",,12346.54,63.3,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? DISPOSABLE POWER DRIVER BIT",SUP-94-DRIVERBIT-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,84.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 230CM 22-27MM 10FR DUODENAL NITINOL",SUP-M00565030,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP CLUSTER HOLE SNAP FIT INTEGRATED",SUP-00875705401,CDM,C1776,HCPCS,0278,RC,,,both,,,9319.80,2795.94,"PHCS [10601]",PHCS,,6523.86,70,,,,,0,1083.89,7921.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 70MM LCP STAINLESS STEEL FULL THREAD PROXIMAL",SUP-02.207.070,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 11MM KII FIOS ADVANCE FIXATION",SUP-CFF33,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"MULTIPLAN [10600]",Multiplan,,155.3,85,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING 2 HEAT PARALLEL Y PORT DRY GAS LINE MDI",SUP-RT210,CDM,S27000186,LOCAL,0270,RC,,,both,,,240.12,72.04,"KAISER [10500]",Kaiser,,160.88,67,,,,,0,27.93,204.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR SKIN 20MM WIDE ENDOSCOPIC LINEAR CUTTER RELOADABLE",SUP-070614,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.01,84.3,"MULTIPLAN [10600]",Multiplan,,238.86,85,,,,,0,32.68,238.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL ZIPWIRE 22-30CM 3CM 7FR .035IN PIGTAIL",SUP-M006180157180,CDM,C2617,HCPCS,0278,RC,,,both,,,1466.59,439.98,"FIRST HEALTH [10303]","First Health",,1173.27,80,,,,,0,170.56,1246.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 10-0 BV100-3 5CM MONOFILAMENT BLUE NONABSORBABLE",SUP-2794G,CDM,S27200284,LOCAL,0272,RC,,,both,,,250.46,75.14,"KAISER [10500]",Kaiser,,167.81,67,,,,,0,29.13,212.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.2MM 14MM APTUS TITANIUM HAND ELBOW HEXADRIVE 4",SUP-A-5100.14/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,579.99,45.9,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 15CM 20GA ACCURIAN STRAIGHT SHARP 10MM",SUP-AC0013,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"CIGNA [10200]",Cigna,,70.99,68,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 5.75MM 7CM CRYSTAL BARREL SHOULDER DISTAL",SUP-AR-6560,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"NOVANET [10819]",Novanet,,171.29,75,,,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,inpatient,,,46072.65,13821.79,"AMBETTER EXCHANGE  [11102]",Ambetter,,5332.77,,"Case rate ($5,332.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,951.84, add-ons for qualifying new technology services are included. If operating cost exceeds $37,991.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,756.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $4,958.39. The transfer operating threshold is the transfer adjustment factor * $4,951.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.38. The transfer capital threshold is the transfer adjustment factor * $374.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,5332.77,25099.8,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"GENTAMICIN 0.3 % EYE DROPS",RX-3428,CDM,,,0250,RC,24208-0580-60,NDC,both,5,ML,269.53,80.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,123.71,45.9,,,,,0,31.35,229.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOR SKIN DISORDERS WITH MCC",606,MS-DRG,,,,,,,inpatient,,,37704.84,11311.45,"CIGNA [10200]",Cigna,,19841.08,,"Fee schedule rate ($19,841.08). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,37704.84,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 6MM .0115IN AXIUM PRIME 3D",SUP-APB-6-15-3D-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,9591.00,2877.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1136.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE PROBE 10GA MAMMOTOME REVOLVE FORK DISPOSABLE",SUP-MG10A,CDM,S27200284,LOCAL,0272,RC,,,both,,,51.97,15.59,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.04,44.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR JUDKINS LEFT 4",SUP-67000500,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,283.97,68,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX PERMALUME 80MM 194CM 8MM 8.5FR .035IN BILIARY",SUP-M00570350,CDM,C1874,HCPCS,0278,RC,,,both,,,9360.00,2808,"NOVANET [10819]",Novanet,,7020,75,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 75MMX18MM VANGUARD E1 KNEE ANTERIOR STABILIZE TIBIAL",SUP-EP189088,CDM,C1713,HCPCS,0278,RC,,,both,,,13372.20,4011.66,"CIGNA [10200]",Cigna,,5348.88,40,,1831.33,1831.33,1831.33,16,1555.19,11366.37,"percent of total billed charges",
"STENT BENTSON 20CM 15CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175270060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,457.82,45.9,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE COROLENE TAPER",SUP-20S05B,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.98,30.59,"PHCS [10601]",PHCS,,71.39,70,,,,,0,11.86,86.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 4.5MM 42MM 6.7MM SHILEY PEDIATRIC UNCUFF TAPE TIE",SUP-4.5PEF,CDM,S27200284,LOCAL,0272,RC,,,both,,,395.85,118.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.04,336.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 20MM MODULAR RESTORATION STRAIGHT CONICAL",SUP-6276-7-120,CDM,C1776,HCPCS,0278,RC,,,both,,,11080.37,3324.11,"CIGNA [10200]","Cigna Open Access",,6304.73,56.9,,5302.19,4377.88,6578.61,27,1288.65,9418.31,"percent of total billed charges",
"INSRT TIBIAL 6 10MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650610,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"AETNA [10100]","Aetna HMO/PPO",,10436.16,79.5,,10981.53,8986.79,12413.38,12,1526.7,11158.16,"percent of total billed charges",
"MALIGNANT BREAST DISORDERS WITHOUT CC/MCC",599,MS-DRG,,,,,,,inpatient,,,49345.54,14803.66,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,9718.05,,"Case rate ($4,772.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,431.72, add-ons for qualifying new technology services are included. If operating cost exceeds $37,471.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,717.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,437.58. The transfer operating threshold is the transfer adjustment factor * $4,431.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $335.06. The transfer capital threshold is the transfer adjustment factor * $335.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,4772.64,19188.07,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"FORTIFY ASSURA NEXT GENERATION DR 40 DF4 CONNECTOR",SUP-CD2357-40Q,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,11608.27,28.62,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Irr Water Sterile 1000ml",PX-E27200207,CDM,E27200207,LOCAL,0272,RC,,,both,,,39.81,11.94,"CIGNA [10200]",Cigna,,27.07,68,,,,,0,4.63,33.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP POROCOAT PINNACLE 300 SERIES",SUP-121703052,CDM,C1776,HCPCS,0278,RC,,,both,,,6710.76,2013.23,"BLUE CROSS [10001]","Blue Cross HMO",,2630.62,39.2,,5311.50,4717.44,5388.59,31,780.46,5704.15,"percent of total billed charges",
"LENS IOL 5 D +28 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2800,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,396.9,39.2,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 22CM 150CM 7FR .038IN 3CM BLADDER LOOP",SUP-M006155241170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR REGULAR 45X3.5MM DST SERIES TA TITANIUM",SUP-TA4535L,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.89,114.87,"CIGNA [10200]","Cigna Open Access",,217.86,56.9,,,,,0,44.53,325.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 12MM CEMENTRALIZER HIP FEMUR PMMA CEMENT SUMMIT",SUP-137621000,CDM,C1776,HCPCS,0278,RC,,,both,,,846.45,253.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,100.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,98.44,719.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DISTRACTION 14MM CASPAR STERILE",SUP-73-2592-S5,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X7MM HEDRON C 7D 14MM STERILE LATEX FREE",SUP-1211.4617S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross PPO",,2434.32,39.2,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X6MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7306,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"MULTIPLAN [10600]",Multiplan,,5865,85,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 79MM STAINLESS STEEL 2.7MM SCR 3 HOLE CONTOUR SHAFT",SUP-02.118.400S,CDM,C1713,HCPCS,0278,RC,,,both,,,4398.75,1319.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2019.03,45.9,,,,,0,511.57,3738.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 45CM .014IN SFT FIRM",SUP-6053,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC HEAD",SUP-600,CDM,S27000186,LOCAL,0270,RC,,,both,,,728.19,218.46,"PHCS [10601]",PHCS,,509.73,70,,,,,0,84.69,618.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP IRRIGATION ELITE MEDIUM ATTACH",SUP-5100010270,CDM,S27200284,LOCAL,0272,RC,,,both,,,2434.05,730.21,"CIGNA [10200]","Cigna Local Plus",,1302.22,53.5,,,,,0,283.08,2068.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7-3MM TORNADO MICROCOIL PLATINUM FIBER",SUP-G47420,CDM,S27800098,LOCAL,0278,RC,,,both,,,931.42,279.43,"CIGNA [10200]",Cigna,,633.37,68,,,,,0,108.32,791.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 32MM LCP ANKLE FOOT STAINLESS STEEL 2X3 HOLE T",SUP-249.685,CDM,C1713,HCPCS,0278,RC,,,both,,,3883.32,1165,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2640.66,68,,,,,0,451.63,3300.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 60MM 5MM NAIL-EX FULL THREAD FEMORAL TIBIAL",SUP-04.005.550,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,331.04,28.62,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 30MM DCP LC-DCP STAINLESS STEEL DISTAL CORTICAL",SUP-204.830,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,27.52,201.14,"percent of total billed charges",
"STEM FEMORAL 105MM CEMENT EXT PROSTALAC 1 HIGH OFFSET HIP",SUP-1541-06-000,CDM,C1776,HCPCS,0278,RC,,,both,,,18814.32,5644.3,"CIGNA [10200]","Cigna Open Access",,6302.8,33.5,,5302.19,4377.88,6578.61,27,2188.11,15992.17,"percent of total billed charges",
"VALVE AORTIC 11CM 24MM 33MM 21.4MM GELWEAVE VALSALVA ON-X",SUP-ONXAAP-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,51187.50,15356.25,"CIGNA [10200]","Cigna Open Access",,17147.81,33.5,,,,,0,5953.11,43509.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035424060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4039.61,28.62,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 7MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS07030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3165.24,27,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3MM AVENIR HELICAL 10 COIL FILL",SUP-10HFL-03008,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"KAISER [10500]",Kaiser,,6005.28,67,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TIBIAL SHAFT THK10+ MM ALLOGRAFT FROZEN 100MMX10+",SUP-450520,CDM,S27800098,LOCAL,0278,RC,,,both,,,6963.48,2089.04,"BLUE CROSS [10001]","Blue Cross HMO",,2729.68,39.2,,,,,0,809.85,5918.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM CONCERTO 3D",SUP-PV-4-10-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM CONCERTO 3D",SUP-PV-4-10-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 11.9MM 21MM 19.4MM ON-X 30MM CYLINDRICAL HEART",SUP-ONXANE-21,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"FIRST HEALTH [10303]","First Health",,30240,80,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 80% CANCELLOUS 20% CORTICAL 90CC 1-4MM LATEX FREE",SUP-800122,CDM,S27800098,LOCAL,0278,RC,,,both,,,6365.94,1909.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2921.97,45.9,,,,,0,740.36,5411.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"14 X 11 X 6MM 7 DEGREE POROUS COATE",SUP-P21411-706,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"NOVANET [10819]",Novanet,,5008.82,75,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30MM 4MM 35 COIL PUSHABLE 2D HELICAL",SUP-M0013724031,CDM,S27800098,LOCAL,0278,RC,,,both,,,769.50,230.85,"CIGNA [10200]","Cigna Open Access",,437.85,56.9,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 11.5CM 4MM CEREPAK MICRO UNIFORM",SUP-FCX100412,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"FIRST HEALTH [10303]","First Health",,10580.68,80,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X11MM ADVANCED PARALLEL SPINE",SUP-17611,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3800.52,45.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X11MM ADVANCED PARALLEL SPINE",SUP-17611,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"KAISER [10500]",Kaiser,,5547.6,67,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM AXIUM PRIME HELIX DETACHABLE EXTRA",SUP-APB-1-1-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3672.49,41.1,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE 15CC DEMINERALIZED CORTICAL PUREBONE FIBE",SUP-PBF-15,CDM,S27800098,LOCAL,0278,RC,,,both,,,9984.30,2995.29,"MULTIPLAN [10600]",Multiplan,,8486.66,85,,,,,0,1161.17,8486.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM BOVINE PERICARDIUM LEAFLET COBALT CHROMIUM",SUP-11400M25,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5375.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM TARGET 3D DETACHABLE CONSISTENT",SUP-M0036153060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"NOVANET [10819]",Novanet,,10585.98,75,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 27MM 22.5MM MASTERS 85D STD RING ANNULUS",SUP-27MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"FIRST HEALTH [10303]","First Health",,23295.38,80,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X20X8MM PIVOX 0D LATERAL OLIF25",SUP-2110150,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7144.2,27,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT 14MM ALIF",SUP-3W3214,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"MULTIPLAN [10600]",Multiplan,,17973.52,85,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 12X26X50MM 10",SUP-6212150,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]",Cigna,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 5MM TARGET XL LARGE HELICAL",SUP-M0036115150,CDM,S27800098,LOCAL,0278,RC,,,both,,,12419.24,3725.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5104.31,41.1,,,,,0,1444.36,10556.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14X7MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2207,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"BLUE CROSS [10001]","Blue Cross HMO",,3786.72,39.2,,957.42,156.86,7483.26,51,1123.46,8211,"percent of total billed charges",
"STPLR INTERNAL INTUITIVE DA VINCI XI BLUE GREEN 60",SUP-12BSGXI60GB,CDM,S27200284,LOCAL,0272,RC,,,both,,,1323.00,396.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,607.26,45.9,,,,,0,153.86,1124.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 5-0 P-1 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J490G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 11X14MM VERTE-STACK CORNERSTONE PSR 6MM",SUP-6277006,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"KAISER [10500]",Kaiser,,4474.54,67,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL LORDOTIC",SUP-345541,CDM,S27800098,LOCAL,0278,RC,,,both,,,4975.00,1492.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2283.53,45.9,,,,,0,578.59,4228.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 13.6CM 8MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR180813,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"KAISER [10500]",Kaiser,,7960.81,67,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 7 X 20 HELICAL FILLING COIL",SUP-10HFL-07020,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4114.06,45.9,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFARI2 EXTRA SPRT VASCULAR LARGE CURVE 275X4.9X5CM",SUP-H74939598ESL0,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM .02IN 14MM PENUMBRA COIL 400 RUBY",SUP-RBY2C1460,CDM,S27800098,LOCAL,0278,RC,,,both,,,7098.00,2129.4,"BLUE CROSS [10001]","Blue Cross HMO",,2782.42,39.2,,,,,0,825.5,6033.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 34X17MM HEDRON IA 15D 26MM STERILE LATEX FREE",SUP-1212.0717S,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3663.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X11MM RISE 15D NONSTERILE",SUP-193.141,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X6MM ENDOSKELETON TC 6D 14MM MEDIUM CERVICAL",SUP-5166-1406-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2962.17,28.62,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3.5MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-3.5-10-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"CIGNA [10200]","Cigna Open Access",,3917.99,33.5,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 4 X 6 COMPLEX PICO COIL",SUP-10USC04006,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5374.03,41.1,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL CORTICAL THK3-12MM HALVED ALLOGRAFT STRUT",SUP-450481,CDM,S27800098,LOCAL,0278,RC,,,both,,,7973.64,2392.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5422.08,68,,,,,0,927.33,6777.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 4 X 6 COMPLEX PICO COIL",SUP-10USC04006,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"BLUE CROSS [10001]","Blue Cross PPO",,5125.6,39.2,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM",RX-5754,CDM,,,0250,RC,45802-0880-14,NDC,both,15,GR,158.13,47.44,"CIGNA [10200]",Cigna,,107.53,68,,,,,0,18.39,134.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 30ML .212-.85MM DEMINERALIZED CORTICAL",SUP-420118,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 55CM RIGHT VENTRICLE DF-4 TRIPOLAR SCR DEFIB",SUP-6935M55,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"NOVANET [10819]",Novanet,,12879,75,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM .02IN 12MM RUBY COMPLEX LARGE VOLUME",SUP-RBY2C1240,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.00,2003.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4541.04,68,,,,,0,776.65,5676.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CALCANEUS THK13-15MM ALLOGRAFT FREEZE DRIED CROSS",SUP-400482,CDM,S27800098,LOCAL,0278,RC,,,both,,,4765.14,1429.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1363.78,28.62,,,,,0,554.19,4050.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL 53MM ATTUNE KNEE POROCOAT REVISION PARTIAL COA",SUP-151111104,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 19GA PREMARKED",SUP-SDAN2000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1294.38,388.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.54,1100.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC UNIVERSAL 18.5X9.5IN SHOULDER ULTRASOFT",SUP-VP20106-000,CDM,L3670,HCPCS,0274,RC,,,both,,,63.51,19.05,"MULTIPLAN [10600]",Multiplan,,53.98,85,,,,,0,7.39,63.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX12MM VANGUARD POROUS KNEE POSTERIOR",SUP-183722,CDM,C1776,HCPCS,0278,RC,,,both,,,8757.48,2627.24,"UHC [10700]","United Healthcare",,5543.48,63.3,,8601.07,8395.67,8601.07,"1 through 10",1018.49,7443.86,"percent of total billed charges",
"INTRO SHTH 12FR HMSTS EP",SUP-6271,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,35.76,41.1,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL FIXATION ELOX TORQUE DH-ELOX DISPOSABLE",SUP-331668,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.80,114.84,"AETNA [10100]","Aetna HMO/PPO",,304.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION .8MM 70MM KIRSCHNER STAINLESS STEEL TROCAR",SUP-292.08,CDM,C1713,HCPCS,0278,RC,,,both,,,52.86,15.86,"BLUE CROSS [10001]","Blue Cross PPO",,20.72,39.2,,957.42,570.23,957.42,28,6.15,44.93,"percent of total billed charges",
"TIP CAUT 5MM SPAT NONSTERILE LATEX FREE DISPOSABLE",SUP-400160,CDM,S27200284,LOCAL,0272,RC,,,both,,,6161.70,1848.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2828.22,45.9,,,,,0,716.61,5237.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL FIXATION ELOX TORQUE DH-ELOX DISPOSABLE",SUP-331668,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.80,114.84,"KAISER [10500]",Kaiser,,256.48,67,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PSN FEM CR CMT CCR STD SZ 7 L",SUP-42-5026-062-01,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6172.93,27,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER PELLO 60D 4MM",SUP-6290-112-040-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,2137.50,641.25,"FIRST HEALTH [10303]","First Health",,1710,80,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 25CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR052502A,CDM,C1874,HCPCS,0278,RC,,,both,,,40635.00,12190.5,"CIGNA [10200]",Cigna,,16254,40,,,,,0,4725.85,34539.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT EVEROLIMUS ELUTING CORONARY STENT SYSTEM 5.0",SUP-1804500-28,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.50MM X 15MM  SCOREFLEX  NC",SUP-625-154-1U,CDM,C1725,HCPCS,0272,RC,,,both,,,5175.00,1552.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2126.93,41.1,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 10MM 3.2-2.4-2.6FR 3.5MM BALLOON",SUP-SPR3510W,CDM,C1725,HCPCS,0272,RC,,,both,,,643.95,193.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,437.89,68,,,,,0,74.89,547.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE HEMO-SEAL 4-0 C-1 30IN 2 ARM MONOFILAMENT BLUE",SUP-9706H,CDM,S27200284,LOCAL,0272,RC,,,both,,,432.46,129.74,"CIGNA [10200]","Cigna Open Access",,246.07,56.9,,,,,0,50.3,367.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 15MM 19MM 27.5MM 20.8MM EPIC MAX 11MM TISSUE",SUP-EMAX-19,CDM,S27800098,LOCAL,0278,RC,,,both,,,27990.90,8397.27,"BLUE CROSS [10001]","Blue Cross HMO",,10972.43,39.2,,,,,0,3255.34,23792.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60MM COROENT XL",SUP-6910860,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"KAISER [10500]",Kaiser,,15919.2,67,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +19.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-AR40E00195,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,110.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CUP ACETABULAR BI-MENTUM PRESS FIT HIP CERAMIC ON",SUP-OSC371182,CDM,C1776,HCPCS,0278,RC,,,both,,,26460.00,7938,"CIGNA [10200]","Cigna Local Plus",,8334.9,31.5,,5372.07,4581.20,7242.98,23,3077.3,22491,"percent of total billed charges",
"DRILL SURGICAL 35MM FLEXIBLE REFLECTION STERILE LATEX FREE",SUP-71362935,CDM,S27200284,LOCAL,0272,RC,,,both,,,1538.19,461.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1045.97,68,,,,,0,178.89,1307.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDER 8MM 1.5MM .014IN BALLOON DILATATION LOW PROFILE",SUP-4100A-1508,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.50,708.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1606.5,68,,,,,0,274.76,2008.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE PLUS 100CM 6FR .044IN .042IN AMPLATZ RIGHT",SUP-533641,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,55.96,68,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 20MM 75CM 6MM VASCULAR METAL SUPERFICIAL",SUP-H74939293060270,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"AETNA [10100]","Aetna HMO/PPO",,3839.85,79.5,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 70MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.870,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"FIRST HEALTH [10303]","First Health",,200.73,80,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 40MM 120CM 6MM VASCULAR NICKEL",SUP-EVD35-06-040-120,CDM,C1876,HCPCS,0278,RC,,,both,,,6203.00,1860.9,"CIGNA [10200]","Cigna Open Access",,3529.51,56.9,,,,,0,721.41,5272.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL MITRACLIP VALVE SYSTEM EVALVE",SUP-MSK01ST,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF GALLBLADDER AND BILIARY TRACT,MODERATE",284,APR-DRG,,,,,,,inpatient,,,38592.57,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,418.71. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTIVE HIP JOINT REPLACEMENT,MODERATE",324,APR-DRG,,,,,,,inpatient,,,98757.24,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $10,603.63. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($32,878.75) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 30MM 9MM .035IN BALLOON DILATATION NYBAX",SUP-39171-09034,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE NC PLUS 8MM 2MM BALLOON DILATATION STERILE",SUP-220-083-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE JEJUNOSTOMY 45CM 16FR SILICONE MIC SECUR-LOK UNIVERSAL",SUP-0250-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"MULTIPLAN [10600]",Multiplan,,1489.58,85,,,,,0,203.81,1489.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 21MM FREESTYLE PORCINE BIOPROSTHESIS COMPLETE",SUP-995CS-21MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,38430.00,11529,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4469.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4469.41,32665.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX21MM FRA 8D NARROW WEDGE SPINE",SUP-10021,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"UHC [10700]","United Healthcare",,11963.7,63.3,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 35MM FLEXIBLE SURE LOCK DELIVERY SYSTEM",SUP-TARP-35,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3464.85,28.62,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1.5MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR091520,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"PHCS [10601]",PHCS,,9258.1,70,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PRECISION ALLOGRAFT 26MMX20MM",SUP-452066A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE PIN ORTHOPEDIC 2MM HEMICAP SHOULDER 25/30MM",SUP-6007-1200,CDM,S27800098,LOCAL,0278,RC,,,both,,,461.70,138.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,54.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.7,392.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 12X26X6-12MM 8DEG SABLE",SUP-1172.4110S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"KAISER [10500]",Kaiser,,23215.5,67,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 24MM 33.6MM 25.9MM MITRAL TRICUSPID FLEXIB",SUP-460024MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"CIGNA [10200]","Cigna Local Plus",,6090.98,53.5,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM ALLOGRAFT 12MM",SUP-310112,CDM,S27800098,LOCAL,0278,RC,,,both,,,3139.50,941.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2134.86,68,,,,,0,365.12,2668.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LAPIDUS NO STEP BONE TARSOMETATARSAL NONSTERILE",SUP-MPP2000U,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"UHC [10700]","United Healthcare",,6529.71,63.3,,5023.51,2672.93,6679.78,18,1199.69,8768.18,"percent of total billed charges",
"COIL EMBOLIZATION 35CM AZUR HYDROPACK .018IN PERIPHERAL",SUP-45-880035,CDM,S27800098,LOCAL,0278,RC,,,both,,,9473.70,2842.11,"CIGNA [10200]","Cigna Open Access",,5390.54,56.9,,,,,0,1101.79,8052.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X7MM CORNERSTONE PSR PEEK-OPTIMA LATERAL",SUP-6287741,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"MULTIPLAN [10600]",Multiplan,,5676.66,85,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 6MM NATURAL LARGE LORDOTIC CORTICOCANCELLOUS",SUP-19406,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2 X 1 HELICAL PICO COIL",SUP-10USH02001,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Local Plus",,3692.78,31.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM CONCERTO DETACHABLE HELIX",SUP-NV-4-8-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X11MM VERTE-STACK CORNERSTONE PSR",SUP-6240141,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS [10001]","Blue Cross PPO",,2617.94,39.2,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X20X10MM PIVOX 6D LATERAL OLIF25",SUP-2111255,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7144.2,27,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR CANCELLOUS CORTICAL LORDOTIC",SUP-345841,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT DELTA CSF REGULAR CONTOURED HIGH PRESSURE",SUP-42326,CDM,S27800098,LOCAL,0278,RC,,,both,,,6782.22,2034.67,"AETNA [10100]","Aetna HMO/PPO",,5391.86,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,788.77,5764.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3.5MM TARGET TETRA DETACHABLE STERILE",SUP-TG5413560,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"MULTIPLAN [10600]",Multiplan,,11997.44,85,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 82MM 16-16MM 14FR ENDURANT II ABDOMEN",SUP-ETLW1616C82E,CDM,S27800098,LOCAL,0278,RC,,,both,,,29553.30,8865.99,"BLUE CROSS [10001]","Blue Cross PPO",,11584.89,39.2,,,,,0,3437.05,25120.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 25X14-18MM",SUP-400716,CDM,S27800098,LOCAL,0278,RC,,,both,,,3783.96,1135.19,"CIGNA [10200]","Cigna Open Access",,2153.07,56.9,,,,,0,440.07,3216.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUBE DEMINERALIZED BONE 13MM Q-PACK CONFORM",SUP-4W0013,CDM,S27800098,LOCAL,0278,RC,,,both,,,4462.92,1338.88,"CIGNA [10200]","Cigna Open Access",,2539.4,56.9,,,,,0,519.04,3793.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIRE RETINAL 2.5MM GROOVE CONCAVE SILICONE 7MM ASYMMETRICAL",SUP-9218,CDM,S27800098,LOCAL,0278,RC,,,both,,,207.06,62.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,95.04,45.9,,,,,0,24.08,176,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 16X14X7MM SPINE CERVICAL",SUP-6940764,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2.5MM AXIUM PRIME HELIX DETACHABLE",SUP-APB-2.5-3-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1058.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX23MM FRA 8D NARROW SPINE ANTERIOR",SUP-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 16X3MM COLOSSEUM 3.5D 14MM NONSTERILE LATEX",SUP-156.563,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"BLUE CROSS [10001]","Blue Cross PPO",,1349.46,39.2,,,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP FLEX-V 40CM CLSR 1 HAND SUT LESS CLIP SMALL",SUP-ACHV40,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1471.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VIA DEMINERALIZE MINERALIZE CORTICAL CANCELLOUS",SUP-VCAMX-025000,CDM,S27800098,LOCAL,0278,RC,,,both,,,6037.50,1811.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,715.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE PULMONARY 27MM CRYOVALVE SG HEART CONDUIT",SUP-SGPV00-27-99,CDM,S27800098,LOCAL,0278,RC,,,both,,,145293.00,43587.9,"NOVANET [10819]",Novanet,,108969.75,75,,,,,0,16897.58,123499.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX13MM FRA 12D LORDOTIC NARROW SPINE",SUP-2313,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"KAISER [10500]",Kaiser,,12663,67,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL COLONIAL 2XL ANTERIOR CERVICAL DISCECTOMY AND",SUP-365.068,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"FIRST HEALTH [10303]","First Health",,5342.74,80,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX13MM FRA 12D LORDOTIC NARROW SPINE",SUP-2313,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X12X7MM RISE NONSTERILE",SUP-193.202,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1 X 3 COMPLEX PICO COIL",SUP-10USC01003,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"BLUE CROSS [10001]","Blue Cross PPO",,5125.6,39.2,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 174MM 8MM HOFFMANN II MRI CARBON SEMI",SUP-5028-7-030,CDM,S27800098,LOCAL,0278,RC,,,both,,,3150.60,945.18,"PHCS [10601]",PHCS,,2205.42,70,,,,,0,366.41,2678.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1.5MM DELTAXSFT 10 COIL",SUP-DLX100152,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1072.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM CEMENTLESS ACCOLADE TMZF 2 30MM HIP",SUP-6021-0230,CDM,S27800098,LOCAL,0278,RC,,,both,,,15649.20,4694.76,"PHCS [10601]",PHCS,,10954.44,70,,,,,0,1820,13301.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X12X8MM RISE 10D LORDOTIC NONSTERILE",SUP-193.222,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X12X10MM CLYDESDALE PTC 0D PEEK TITANIUM",SUP-4980250,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 8MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036128300,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 10MM 3.75MM EMBOLIZATION",SUP-PED2-375-10,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"NOVANET [10819]",Novanet,,60598.13,75,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT ENDURANT II CUSTOM KIT 4 PIECE",SUP-ENDURANTII4,CDM,S27800098,LOCAL,0278,RC,,,both,,,108300.00,32490,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12833.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12595.29,92055,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR BROAD LORDOTIC 12 DEGREE",SUP-012415,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]",Cigna,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32MMX12MM VERTE-STACK CAPSTONE PEEK-OPTIMA END",SUP-2961232,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"BLUE CROSS [10001]","Blue Cross PPO",,6231.86,39.2,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 15MM MASTERS HP SERIES LATEX FREE",SUP-15MHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,60064.20,18019.26,"NOVANET [10819]",Novanet,,45048.15,75,,,,,0,6985.47,51054.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPELLA RP PUMP SET",SUP-004334,CDM,S27800098,LOCAL,0278,RC,,,both,,,142500.00,42750,"CIGNA [10200]",Cigna,,57000,40,,,,,0,16572.75,121125,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM TARGET XL LARGE HELICAL",SUP-M0036116200,CDM,S27800098,LOCAL,0278,RC,,,both,,,12419.24,3725.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3353.19,27,,,,,0,1444.36,10556.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 103MM 14-36MM 20FR ENDURANT IIS 2 BRANCH",SUP-ESBF3614C103E,CDM,S27800098,LOCAL,0278,RC,,,both,,,60782.40,18234.72,"PHCS [10601]",PHCS,,42547.68,70,,,,,0,7068.99,51665.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17CM 6MM AZUR CX DETACHABLE CROSS",SUP-45-750617,CDM,S27800098,LOCAL,0278,RC,,,both,,,7672.80,2301.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,909.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,892.35,6521.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X18X9MM TRANSCONTINENTAL 10D MEDIUM TITANIUM",SUP-375.269CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12600,40,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X9MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7009,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Local Plus",,3691.5,53.5,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM MASTERS HEMODYNAMIC PLUS MECHANICAL STD",SUP-27AHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11968,41.1,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST TRICORTICAL THK16-18MM WEDGE",SUP-400412,CDM,S27800098,LOCAL,0278,RC,,,both,,,6023.70,1807.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,713.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,700.56,5120.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM MASTERS HEMODYNAMIC PLUS MECHANICAL STD",SUP-27AHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"BLUE CROSS [10001]","Blue Cross HMO",,11414.74,39.2,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 BV-1 18IN 2 ARM MONOFILAMENT BLUE",SUP-8806H,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.57,52.07,"CIGNA [10200]",Cigna,,118.03,68,,,,,0,20.19,147.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 18 25 X 60 COMPLEX FRAMING COIL",SUP-18CFR-25060,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3742.21,28.62,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 2.2CC 13X13X13MM DEMINERALIZED CANCELLOUS",SUP-0W1013,CDM,S27800098,LOCAL,0278,RC,,,both,,,4968.00,1490.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3378.24,68,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175274090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,610.59,45.9,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 60CM RVOT KIT MOND STAINLESS STEEL MEDIUM",SUP-4141/60,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,68.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPEL APD TWIST-LOC 45CM 10FR LONG LENGTH LOOP PIGTAIL",SUP-H7493931110450,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"KAISER [10500]",Kaiser,,520.99,67,,,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 12MM 145CM 2.75MM CORONARY STENT",SUP-1145275-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"KAISER [10500]",Kaiser,,3911.46,67,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC",409,MS-DRG,,,,,,,inpatient,,,121020.17,36306.05,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,14316.28,,"Case rate ($13,505.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,541.17, add-ons for qualifying new technology services are included. If operating cost exceeds $45,580.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,330.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,557.75. The transfer operating threshold is the transfer adjustment factor * $12,541.17 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.17. The transfer capital threshold is the transfer adjustment factor * $948.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,63568.45,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D F KNEE LEFT CEMENT KEEL",SUP-42536007501,CDM,C1776,HCPCS,0278,RC,,,both,,,10619.10,3185.73,"KAISER [10500]",Kaiser,,7114.8,67,,,,,0,1235,9026.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENESTROMETER EAR 6.5IN 4MM PAPARELLA",SUP-61-0438,CDM,S27000186,LOCAL,0270,RC,,,both,,,776.47,232.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,319.13,41.1,,,,,0,90.3,660,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC",166,MS-DRG,,,,,,,inpatient,,,100065.18,30019.55,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,24576.29,,"Case rate ($23,185.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $21,529.01, add-ons for qualifying new technology services are included. If operating cost exceeds $54,568.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,009.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $21,557.48. The transfer operating threshold is the transfer adjustment factor * $21,529.01 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,627.70. The transfer capital threshold is the transfer adjustment factor * $1,627.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,100065.18,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 15MM 1.25MM BALLOON DILATATION RAPID",SUP-47512015L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 7MMX15MM 7FR 135CMCATH HEPARIN",SUP-BXB071502A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 58MM 32MM ZENITH LOW PROFILE MAIN BODY",SUP-G50993,CDM,C1874,HCPCS,0624,RC,,,both,,,6510.15,1953.04,"KAISER [10500]",Kaiser,,4361.8,67,,,,,0,757.13,5533.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 8MM 143CM 2.25MM CORONARY EVEROLIMUS ELUTING",SUP-1009544-08,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"FIRST HEALTH [10303]","First Health",,7672.8,80,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 4.00 X 20MM",SUP-H7493942820400,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"AMERIGROUP MEDICAID [20100]",Amerigroup,,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYOSURE 1.8MM 54MM 140ML/MIN 300 MMHG 14MM 32CM 3MM",SUP-10-401,CDM,S27200284,LOCAL,0272,RC,,,both,,,5692.50,1707.75,"CIGNA [10200]",Cigna,,3870.9,68,,,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,inpatient,,,50738.54,15221.56,"PHCS [10601]",PHCS,,7561,,,,,,,7561,37081.8,"per diem","Estimated amount calculated based on 4 day length of stay."
"PACK SUT NO5 MAXBRAID CURVED TAPERED NDL NONABSORBABLE 2PK",SUP-CM0225N,CDM,S27200284,LOCAL,0272,RC,,,both,,,737.10,221.13,"CIGNA [10200]","Cigna Local Plus",,394.35,53.5,,,,,0,85.72,626.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SND1T6 AS SP ASPHER RESTOR REFERENCE",SUP-SND1T6,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,86.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 90MM 13MM AEQUALIS FLEX REVIVE SHOULDER DISTAL",SUP-ARS741803,CDM,C1776,HCPCS,0278,RC,,,both,,,16704.00,5011.2,"AETNA [10100]","Aetna HMO/PPO",,13279.68,79.5,,10981.53,8986.79,12413.38,12,1942.68,14198.4,"percent of total billed charges",
"STEM HIP FEM P2 POROUS OFFSZ14",SUP-425-97-014,CDM,C1776,HCPCS,0278,RC,,,both,,,42558.45,12767.53,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,17491.52,41.1,,6417.48,6417.48,6417.48,"1 through 10",4949.55,36174.68,"percent of total billed charges",
"SCR BASEPLT 22MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ322,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,114,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.88,817.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 4 8.75IN BARNHILL ADENOID SURGICAL 18MM",SUP-71-3618,CDM,S27200284,LOCAL,0272,RC,,,both,,,299.98,89.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,35.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.89,254.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 30CC 1.7-10MM ALLOGRAFT CHIPS FREEZE",SUP-400150,CDM,C1713,HCPCS,0278,RC,,,both,,,2600.25,780.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,744.19,28.62,,,,,0,302.41,2210.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 12.5MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962342,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4150.99,28.62,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 16MM PRESSFIT TRIATHLON TITANIUM FLUTE",SUP-5566-S-016,CDM,C1776,HCPCS,0278,RC,,,both,,,5447.65,1634.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3704.4,68,,,,,0,633.56,4630.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 16MM PRESSFIT TRIATHLON TITANIUM FLUTE",SUP-5566-S-016,CDM,C1776,HCPCS,0278,RC,,,both,,,5447.65,1634.29,"NOVANET [10819]",Novanet,,4085.74,75,,,,,0,633.56,4630.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12.5MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158105112,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UHC [10700]","United Healthcare",,7073.49,63.3,,8601.07,8395.67,8601.07,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"TOTAL SHOULDER: HUMERAL HEAD, INSERT GLENOID, HMERAL STE",SUP-SI-TSA,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"BLUE CROSS [10001]","Blue Cross PPO",,10495.8,39.2,,3949.44,3949.44,3949.44,"1 through 10",3113.93,22758.75,"percent of total billed charges",
"STEM FEMORAL 165MM CEMENTLESS SUMMIT POROCOAT 9 12/14 STANDA",SUP-157001165,CDM,C1776,HCPCS,0278,RC,,,both,,,25247.25,7574.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10098.9,40,,,,,0,2936.26,21460.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROCEED 6X4IN HERNIA TISSUE SEPARATING",SUP-PCDN1,CDM,C1781,HCPCS,0278,RC,,,both,,,2882.42,864.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,341.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,335.23,2450.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TITAN TOUCH INFRAPUBIC ZERO ANGLE 24CM",SUP-ES2824,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,17944.74,28.62,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 24B LARGE HIP PROXIMAL",SUP-550562,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1265.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C3",PX-302000025,CDM,86160,CPT,0302,RC,,,both,,,303.50,91.05,"FIRST HEALTH [10303]","First Health",,242.8,80,,,,,0,0.3,257.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Parvovirus B19 Detector",PX-306000148,CDM,87798,CPT,0306,RC,,,both,,,811.30,243.39,"PHCS [10601]",PHCS,,567.91,70,,,,,0,0.01,689.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 7CM 10FR PROXIMAL BEND BILIARY 2 LAYER STERILE",SUP-PBD-421-1007,CDM,C2625,HCPCS,0278,RC,,,both,,,1387.85,416.35,"MULTIPLAN [10600]",Multiplan,,1179.67,85,,,,,0,161.41,1179.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HYPERFORM X-PEDION 150CM 15MM 2.5-2.8MM 4MM .01IN 2MM",SUP-104-4415,CDM,C1725,HCPCS,0272,RC,,,both,,,10425.90,3127.77,"MULTIPLAN [10600]",Multiplan,,8862.02,85,,,,,0,1212.53,8862.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pulm Func Test Lung Plethy",PX-460000010,CDM,94726,CPT,0460,RC,,,both,,,661.52,198.46,"PHCS [10601]",PHCS,,463.06,70,,,,,0,76.93,562.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE HI-FLO 150CM 10CM 3-2.8FR .027IN MICRO",SUP-18-290,CDM,C1751,HCPCS,0272,RC,,,both,,,2100.00,630,"FIRST HEALTH [10303]","First Health",,1680,80,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 7MM ADVANTA SST SLIDER STRAIGHT HP3 PTFE",SUP-25019,CDM,C1768,HCPCS,0278,RC,,,both,,,9948.28,2984.48,"NOVANET [10819]",Novanet,,7461.21,75,,,,,0,1156.98,8456.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM OTHER THAN TRANSVENOUS VDD 1 PASS",SUP-4480,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"FIRST HEALTH [10303]","First Health",,4485.6,80,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM CHLORIDE 100 MG/ML (10 %) IV VIAL",RX-113687,CDM,J0618,HCPCS,0636,RC,00517-6710-01,NDC,both,10,ML,183.16,54.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,124.55,68,,,,,0,17.48,155.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM CHLORIDE 100 MG/ML (10 %) IV VIAL",RX-113687,CDM,J0618,HCPCS,0636,RC,00517-6710-01,NDC,both,10,ML,183.16,54.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,17.48,,,,,,,17.48,155.69,"fee schedule",
"SYNTHETIC TISSUE SCAFFOLD STRIP .7X8CM",SUP-31055,CDM,C1763,HCPCS,0278,RC,,,both,,,11557.50,3467.25,"NOVANET [10819]",Novanet,,8668.13,75,,,,,0,1344.14,9823.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAYONET 8IN STR TIP DN6214",SUP-DN6214,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Local Plus",,866.7,53.5,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 10.5IN 20FR SILICONE Y PORT GRADUATE SHAFT OPEN DISTAL",SUP-8884720205E,CDM,S27200284,LOCAL,0272,RC,,,both,,,416.36,124.91,"UHC [10700]","United Healthcare",,263.56,63.3,,,,,0,48.42,353.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDING CATH 5FR JR 50 SH",SUP-LA5JR50SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 32CM 14.5FR STRAIGHT DURATHANE EVENMORE BASIC",SUP-H787103035035,CDM,C1750,HCPCS,0278,RC,,,both,,,1385.10,415.53,"CIGNA [10200]","Cigna Open Access",,788.12,56.9,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC App Traction Mech (Gp)",PX-420000013,CDM,97012,CPT,0420,RC,,,both,,,164.07,49.22,"CIGNA [10200]","Cigna Open Access",,164.07,,"Per diem ($309).",,,,0,19.08,164.07,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE REVERSED FX STEM",SUP-CAP-T-1058,CDM,C1776,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross PPO",,1470,39.2,,3949.44,3949.44,3949.44,"1 through 10",436.13,3187.5,"percent of total billed charges",
"SCREW NON-LOCKING 1.5MM X 7MM TI",SUP-VAN-15070-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"BLUE CROSS [10001]","Blue Cross HMO",,381.02,39.2,,957.42,156.86,7483.26,51,113.04,826.2,"percent of total billed charges",
"HC Programming Device Eval Impl Ccm-D Sys in Person",PX-481000421,CDM,0926T,CPT,0481,RC,,,both,,,58.00,17.4,"CIGNA [10200]","Cigna Open Access",,58,,"Case rate ($6,428). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,6.75,58,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.0MM X 8MM TI",SUP-VAN-20080-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,113.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",113.04,826.2,"percent of total billed charges",
"NAIL 8MM 255MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-408-255,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,3978.14,359.25,3978.14,24,2014.9,14726.25,"percent of total billed charges",
"LEAD PACING 59CM 2.4MM ATRIAL VENTRICULAR BIPOLAR ACTIVE",SUP-4088,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"PHCS [10601]",PHCS,,3924.9,70,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR E1 CERAMIC POROUS LINER HEAD",SUP-98B00100125,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6804,27,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Sl Imm Ea M / Add on 88344",PX-312000099,CDM,0762T,CPT,0312,RC,,,both,,,100.00,30,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,45.9,45.9,,,,,0,11.85,85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0195,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Psg >4 Param Incomplt",PX-740000005,CDM,95810,CPT,0920,RC,,,both,,,3284.00,985.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1725,,"Per diem ($1,725).",,,,0,381.93,2791.4,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM PFC SIGMA TC3 2 KNEE RIGHT TITANIUM CEMENTED",SUP-960821,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"BLUE CROSS [10001]","Blue Cross PPO",,2011.29,39.2,,3949.44,3949.44,3949.44,"1 through 10",596.72,4361.21,"percent of total billed charges",
"HC Arthrocent Jt Inter W/US",PX-361000388,CDM,20606,CPT,0361,RC,,,both,,,2748.54,824.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2748.54,,"Case rate ($30,606). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,319.66,2748.54,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Arthrocent Jt Inter W/US",PX-361000388,CDM,20606,CPT,0361,RC,,,both,,,2748.54,824.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,325.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,319.66,2748.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 100MM 75CM 6MM VASCULAR METAL SUPERFICIAL",SUP-H74939293061070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]",Cigna,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 59CM ENDOTAK RELIANCE G 4 SITE ENDOCARDIAL GORE",SUP-295,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"AETNA [10100]","Aetna HMO/PPO",,12068.1,79.5,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 100MM 16MM 3MM VASCULAR VENOUS ILIOFEMORAL VEIN",SUP-VENUM16100,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"UHC [10700]","United Healthcare",,13957.65,63.3,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ercp Stent Change W Dilate",PX-750000141,CDM,43276,CPT,0750,RC,,,both,,,6232.49,1869.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4937,,"Case rate ($4,937). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,724.84,6232.49,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE 25CM 2.5CM 5FR INTRO STAINLESS STEEL",SUP-RSS506,CDM,C1894,HCPCS,0272,RC,,,both,,,156.60,46.98,"FIRST HEALTH [10303]","First Health",,125.28,80,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 5.0 MM X 120 MM X 130 CM",SUP-IPU05012013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,938.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 53CM 5.3FR J VENTRICLE BIPOLAR TINE LOW",SUP-457453,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,259.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5-6 11MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71933737,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"FIRST HEALTH [10303]","First Health",,9737.28,80,,,,,0,1415.56,10345.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Dil",PX-750000084,CDM,45340,CPT,0750,RC,,,both,,,2362.42,708.73,"FIRST HEALTH [10303]","First Health",,1889.94,80,,,,,0,274.75,2362.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 43MM 28MM TANDEM HIP COCR UHMWPE",SUP-71322043,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"BLUE CROSS [10001]","Blue Cross PPO",,3274.16,39.2,,3949.44,3949.44,3949.44,"1 through 10",971.39,7099.58,"percent of total billed charges",
"INSERT TIBIAL 7 9MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-709,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"BLUE CROSS [10001]","Blue Cross PPO",,3853.56,39.2,,3949.44,3949.44,3949.44,"1 through 10",1143.29,8355.94,"percent of total billed charges",
"VALVE HEMOSTASIS ACCESS PLUS VALUELINK LARGE BORE",SUP-MAP150,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.10,32.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Nrv Condct 11-12 Studies",PX-959000024,CDM,95912,CPT,0922,RC,,,both,,,8234.00,2470.2,"UHC [10700]","United Healthcare",,5212.12,63.3,,,,,0,957.61,6998.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 4FR 135CM POWERPICC 1 LUMEN MAXIMAL BARR NURSING",SUP-3174335,CDM,C1751,HCPCS,0272,RC,,,both,,,792.67,237.8,"NOVANET [10819]",Novanet,,594.5,75,,,,,0,92.19,673.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE",RX-11639,CDM,,,0637,RC,68462-0292-01,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX 1S REINFORCED TISSUE MATRIX, LONG-TERM RESORBABLE REI",SUP-F10266-0408G,CDM,C1781,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYNCHRO 2/14 200 CM STANDARD PRESHAPED",SUP-M00326420,CDM,C1769,HCPCS,0272,RC,,,both,,,4186.64,1255.99,"UHC [10700]","United Healthcare",,2650.14,63.3,,,,,0,486.91,3558.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CM 7MM CLLGN",SUP-AG750,CDM,C1768,HCPCS,0278,RC,,,both,,,26327.70,7898.31,"MULTIPLAN [10600]",Multiplan,,22378.55,85,,,,,0,3061.91,22378.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX MONORAIL 143CM 8MM 4MM BALLOON",SUP-H7493912408400,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL IDENTITY IMPRINT 3 H10 MM KNEE POSTERIOR STABI",SUP-TPS-020-103S,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,683.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SELECT CORTICAL FIBULA WEDGE 6MM",SUP-210600,CDM,S27800098,LOCAL,0278,RC,,,both,,,3018.75,905.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2052.75,68,,,,,0,351.08,2565.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR ROSCH INFERIOR MESENTRIC CURVE",SUP-10733401,CDM,C1887,HCPCS,0272,RC,,,both,,,108.75,32.62,"FIRST HEALTH [10303]","First Health",,87,80,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 250ML GEL SMOOTH ROUND SILICONE P3.4CM","SUP-3502501 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,435.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",427.4,3123.75,"percent of total billed charges",
"KIT REPAIR MESH UPSYLON Y",SUP-M0068318220,CDM,C1763,HCPCS,0278,RC,,,both,,,11217.61,3365.28,"FIRST HEALTH [10303]","First Health",,8974.09,80,,,,,0,1304.61,9534.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET IMPL INTERNALBRACE SWIVELOCK FIBERTAPE 3.5MM 2 2 NDL",SUP-AR-1678-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,7063.88,2119.16,"CIGNA [10200]",Cigna,,4803.44,68,,1831.33,1831.33,1831.33,16,821.53,6004.3,"percent of total billed charges",
"DRILL 3.5 X 160MM CANNULATED 3/16 SQ. CONNECTION",SUP-P99-110-3516,CDM,S27000186,LOCAL,0270,RC,,,both,,,1004.40,301.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,682.99,68,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C-Reactive Protein Sensitive",PX-302000015,CDM,86141,CPT,0302,RC,,,both,,,292.60,87.78,"CIGNA [10200]","Cigna Local Plus",,28.49,,,,,,,0.01,248.71,"fee schedule",
"HC Xr Elbow 1v",PX-320000274,CDM,73070,CPT,0320,RC,,,both,,,508.01,152.4,"CIGNA [10200]","Cigna Open Access",,46.82,,,,,,,33.47,431.81,"fee schedule",
"STENT POLYFLEX 30MM 11MM 18MM TRACHEOBRONCHIAL SILICONE SELF",SUP-7020,CDM,C1887,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"FIRST HEALTH [10303]","First Health",,2670,80,,,,,0,388.15,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 0 V-34 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J518H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE PREBENT 23X18X2.5MM TITANIUM 1 LEVEL CAUDAL HOLE",SUP-450.151,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,957.42,156.86,7483.26,51,521.61,3812.25,"percent of total billed charges",
"WIRE FIXATION 2.8MM 200MM 10MM LCP ANKLE COMPRESSION THREAD",SUP-03.118.010,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",50.59,369.75,"percent of total billed charges",
"SCR BONE 2.4MM 16MM TIGER CANNULATED",SUP-200-24-016,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"CIGNA [10200]","Cigna Local Plus",,606.69,53.5,,3978.14,359.25,3978.14,24,131.88,963.9,"percent of total billed charges",
"AUG FEMORAL 5MM NEXGEN F DISTAL KNEE TRABECULAR METAL",SUP-00549003610,CDM,C1776,HCPCS,0278,RC,,,both,,,7761.60,2328.48,"CIGNA [10200]","Cigna Open Access",,4416.35,56.9,,5302.19,4377.88,6578.61,27,902.67,6597.36,"percent of total billed charges",
"CATH STERLING 150CM 200MM 6MM BALLOON DILATATION PEBAX",SUP-H74939032602110,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR KNEE FEMUR PATELLA TIBIA BEARING INSR",SUP-98000200143,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7933.46,28.62,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 9MM APTUS TITANIUM HEXADRIVE 4 HAND CORTICAL",SUP-A-5200.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP POROUS OR3O WITH OXINIUM HEAD",SUP-71703495,CDM,C1776,HCPCS,0278,RC,,,both,,,30240.00,9072,"KAISER [10500]",Kaiser,,20260.8,67,,,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM 13MM PRESS FIT REDUCE PROXIMAL PROFILE",SUP-192513,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"AETNA [10100]","Aetna HMO/PPO",,18880.04,79.5,,10981.53,8986.79,12413.38,12,2761.95,20186.21,"percent of total billed charges",
"INSRT TIBIAL 2 15MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158101115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1299.6,9498.37,"percent of total billed charges",
"CAP CONSTRUCT HIP POROUS OR3O WITH OXINIUM HEAD",SUP-71703495,CDM,C1776,HCPCS,0278,RC,,,both,,,30240.00,9072,"CIGNA [10200]","Cigna Local Plus",,9525.6,31.5,,5372.07,4581.20,7242.98,23,3516.91,25704,"percent of total billed charges",
"MESH SURGICAL VENTRALIGHT ST ECHO 2 20X15CM ELLIPSE",SUP-5991520,CDM,C1781,HCPCS,0278,RC,,,both,,,8155.80,2446.74,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3743.51,45.9,,,,,0,948.52,6932.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST ALLOGRAFT WEDGE 10-12MM",SUP-P00204,CDM,S27800098,LOCAL,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross HMO",,1893.36,39.2,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Int/Ext Hem 1 Group",PX-750000240,CDM,46255,CPT,0750,RC,,,both,,,7114.00,2134.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3279,,"Case rate ($3,279). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,827.36,7114,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER REDEL 115CM 4MM 7FR 1-7-4MM SPACE J-J CURVE",SUP-BD7TJJ4L,CDM,C1733,HCPCS,0272,RC,,,both,,,6113.40,1834.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2512.61,41.1,,,,,0,710.99,5196.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER REDEL 115CM 4MM 7FR 1-7-4MM SPACE J-J CURVE",SUP-BD7TJJ4L,CDM,C1733,HCPCS,0272,RC,,,both,,,6113.40,1834.02,"AMERIGROUP MEDICAID [20100]",Amerigroup,,724.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,710.99,5196.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg Extend Mntr 61-119 Min",PX-740000009,CDM,95813,CPT,0740,RC,,,both,,,1944.46,583.34,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,230.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,226.14,1799,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 3CM 7FR BILIARY POLYETHYLENE TAPERED TIP",SUP-G21679,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,180.82,28.62,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE GLENOID EQUINOXE SHOULDER SMALL REVERSE",SUP-320-35-01,CDM,C1713,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"PHCS [10601]",PHCS,,6037.5,70,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 42MM FEMORAL LOW PROFILE STERILE RFN-ADVANCED",SUP-04.045.342TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,535.17,28.62,,,,,0,217.47,1589.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 100CM INTERSTIM PERCUTANEOUS ELECTRD",SUP-3560022,CDM,C1883,HCPCS,0278,RC,,,both,,,1747.50,524.25,"PHCS [10601]",PHCS,,1223.25,70,,,,,0,203.23,1485.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM LIMITED HOLE PPS G7 F HEMISPHERE",SUP-010000665,CDM,C1776,HCPCS,0278,RC,,,both,,,9256.80,2777.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1076.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1076.57,7868.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED + VE",SUP-98000200467,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"NOVANET [10819]",Novanet,,18427.5,75,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +1.5MM 12/14 TAPER 36MM HIP CEMENTLESS BIOLOX",SUP-136536310,CDM,C1776,HCPCS,0278,RC,,,both,,,7222.32,2166.7,"BLUE CROSS [10001]","Blue Cross HMO",,2831.15,39.2,,5311.50,4717.44,5388.59,31,839.96,6138.97,"percent of total billed charges",
"CMPNT FEMORAL 7 NARROW KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-42500006201,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2709.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 22MM LEFT ELBOW LEFT ANGLE STERILE",SUP-TR-H220L-S,CDM,C1776,HCPCS,0278,RC,,,both,,,13489.50,4046.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3642.17,27,,,,,0,1568.83,11466.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 14MM 9MM STD NECK S-ROM CERAMIC 135D",SUP-523251,CDM,C1776,HCPCS,0278,RC,,,both,,,19451.25,5835.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7780.5,40,,,,,0,2262.18,16533.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 56MM UNITRAX HIP FEMORAL MODULAR EXETER V40",SUP-6942-5-056,CDM,C1776,HCPCS,0278,RC,,,both,,,4291.80,1287.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,508.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,499.14,3648.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP SOLID BACK METAL HA TRIDENT F",SUP-500-11-58F,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.85,2973.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2836.77,28.62,,,,,0,1152.75,8425.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 RIGHT KNEE POSTERIOR STABILIZED BEADED",SUP-5516F302,CDM,C1776,HCPCS,0278,RC,,,both,,,17316.94,5195.08,"NOVANET [10819]",Novanet,,12987.71,75,,,,,0,2013.96,14719.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 12 STD KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508607401,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3109.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3051.51,22302.5,"percent of total billed charges",
"CAP KIT THR G7 HIP XLPE CERAMIC STEM CUP LINER HEAD",SUP-98000100131,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6463.8,27,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD FLEXIMA 25CM 8FR LOOP DRNG METAL HYDROPHILIC",SUP-M001271340,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 58MM 49MM HIP 2 MOBILITY",SUP-121858049,CDM,C1776,HCPCS,0278,RC,,,both,,,15870.00,4761,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6348,40,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE REVISION HYBRID CONCELOC HYBRID WITH NON",SUP-71704638,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"PHCS [10601]",PHCS,,16317,70,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR RINGLOC MAX-ROM 24 32MM E-POLY HIP",SUP-EP-105934,CDM,C1776,HCPCS,0278,RC,,,both,,,14076.00,4222.8,"MULTIPLAN [10600]",Multiplan,,11964.6,85,,,,,0,1637.04,11964.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM 14.8MM MASTER-SERIES PYROLYTIC CARBON",SUP-19AECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]",Cigna,,11647.69,40,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X3 HUMERAL INSERT - 36MM X 10MM STANDARD",SUP-5571-S-3610,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6854.4,68,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL COMPREHENSIVE +6MM +10MM SHOULDER REVERSE",SUP-110031407,CDM,C1776,HCPCS,0278,RC,,,both,,,8473.20,2541.96,"CIGNA [10200]","Cigna Local Plus",,4533.16,53.5,,5372.07,4581.20,7242.98,23,985.43,7202.22,"percent of total billed charges",
"HEAD UNIPOLAR 49MM CATHCART BALL HIP FEMUR MODULAR",SUP-136349000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,5311.50,4717.44,5388.59,31,434.96,3179,"percent of total billed charges",
"X3 HUMERAL INSERT - 36MM X 10MM STANDARD",SUP-5571-S-3610,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1172.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT SHOULDER GLENOID TRABECULAR METAL TOTAL",SUP-98000971501,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3546.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 23MM MODULAR RESTORATION HA STRAIGHT CONE",SUP-6276-7-023,CDM,C1776,HCPCS,0278,RC,,,both,,,10468.22,3140.47,"PHCS [10601]",PHCS,,7327.75,70,,,,,0,1217.45,8897.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 50MM BIO-MOORE II ENDO II HIP ACETABULAR",SUP-12-139024,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"CIGNA [10200]","Cigna Open Access",,1589.22,56.9,,5302.19,4377.88,6578.61,27,324.83,2374.05,"percent of total billed charges",
"CUP ACETABULAR 56MM MODULAR MULTIHOLE REVISION HIP",SUP-00620205620,CDM,C1776,HCPCS,0278,RC,,,both,,,17500.14,5250.04,"UHC [10700]","United Healthcare",,11077.59,63.3,,8601.07,8395.67,8601.07,"1 through 10",2035.27,14875.12,"percent of total billed charges",
"WEDGE TIBIAL 10MM LEGION 5-6 FULL KNEE SCR STEP",SUP-71423059,CDM,C1776,HCPCS,0278,RC,,,both,,,16601.40,4980.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1930.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1930.74,14111.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 32MM PERSONA ALL POLY KNEE LATEX FREE",SUP-42540000032,CDM,C1776,HCPCS,0278,RC,,,both,,,4667.16,1400.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,542.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,542.79,3967.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NEURON 125CM 9CM 6FR 5.6FR .04IN 1 CURVE THROMBECTOMY",SUP-PNS6F125H1,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE BREAST BIOPSY 115MM 11GA MAMMOTOME MR SHORT BLADELESS",SUP-MRP11S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2043.23,612.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC",322,MS-DRG,,,,,,,inpatient,,,128524.42,38557.33,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48.3MM 4MM MEDIUM CARBIDE ROUND STERILE",SUP-5300010511,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.08,49.82,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH UMBILI-CATH 34CM 5FR UMBILICAL POLYURETHANE NEONATE 1",SUP-4185005,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.36,31.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL IV PLASMA-LYTE A VIAFLEX MULTIPLE ELECTROLYTE 1L LATEX",SUP-2B2544X,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.24,37.27,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG TRANSPARENT 9X9IN HYDROGEL SILICONE ADHSV FLEXIBLE",SUP-MSCOV99EP,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.70,28.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 14.75CM NATRELLE INSPIRA P4.9CM MODERATE PROFILE",SUP-MSZ-M560,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE QUILL 3-0 3/8 CIRCLE 14X14CM 18MM CLSR MONODERM 2 ARM",SUP-YA-1016Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,159.70,47.91,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OSTEOTOM 56MM ACETABULAR SURGICAL",SUP-6210-0-815,CDM,S27200284,LOCAL,0272,RC,,,both,,,2463.75,739.12,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EUPHORA 142CM 20MM 3MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3020X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CAP HANDLE IMPL INHANCE TOTAL SH",SUP-OSC382035,CDM,S27200284,LOCAL,0272,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CLIP 235CM INTERNAL MANTIS CLOSE DEFECTS GI WORKING CHANNEL",SUP-M00521421,CDM,S27200284,LOCAL,0272,RC,,,both,,,2835.00,850.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VENLAFAXINE 25 MG TABLET, IMMEDIATE RELEASE",RX-12203,CDM,,,0637,RC,57237-0172-01,NDC,both,1,UN,9.77,2.93,"KAISER [10500]",Kaiser,,6.55,67,,,,,0,1.14,8.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 22FR STD URETHRAL NATURAL RUBBER",SUP-0118L22,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.96,26.39,"CIGNA [10200]","Cigna Local Plus",,47.06,53.5,,,,,0,10.23,74.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.145 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.145,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 23CM .5MM SPETZLER-MALIS STD DISPOSABLE",SUP-6760-230-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,2848.10,854.43,"NOVANET [10819]",Novanet,,2136.08,75,,,,,0,331.23,2420.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 5MM KII LOW PROFILE Z THREADED",SUP-CTR22,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.90,44.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO S2.5 HYPERANGULATE LOW PROFILE BLADE GLIDESCO",SUP-0270-1091,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.40,131.22,"CIGNA [10200]",Cigna,,297.43,68,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM BD NEXIVA MAXZERO 1.25IN 20GA 1.066-1.143MM .787-.863",SUP-383557,CDM,S27200284,LOCAL,0272,RC,,,both,,,45.15,13.54,"FIRST HEALTH [10303]","First Health",,36.12,80,,,,,0,5.25,38.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT VALLEYLAB EDGE",SUP-SEP6000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"NOVANET [10819]",Novanet,,143.55,75,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET NDL .75IN 2X2IN 20GA PORT ACCESS SYR PAD Y SITE 10ML",SUP-PA0031YN,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.87,28.76,"CIGNA [10200]","Cigna Local Plus",,51.29,53.5,,,,,0,11.15,81.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 4-0 SH 27IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y415H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS MULTIPASS 6-0 P-3 18IN MONOFILAMENT",SUP-MCP492G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AETNA [10100]","Aetna HMO/PPO",,19.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 8IN 40D UP CERVICAL 9X5MM MICRO-KERRISON EJECTOR",SUP-57-0695,CDM,S27200284,LOCAL,0272,RC,,,both,,,2535.15,760.54,"NOVANET [10819]",Novanet,,1901.36,75,,,,,0,294.84,2154.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 8-0 BV130-5 24IN 2 ARM MONOFILAMENT 4 STRAND",SUP-M8731,CDM,S27200284,LOCAL,0272,RC,,,both,,,940.08,282.02,"UHC [10700]","United Healthcare",,595.07,63.3,,,,,0,109.33,799.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 90MM STEALTH 5 FIBRA STERILE LATEX FREE",SUP-A0G14,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"AETNA [10100]","Aetna HMO/PPO",,179.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH METAL HEAD + VE",SUP-98000500307,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"BLUE CROSS [10001]","Blue Cross HMO",,9878.4,39.2,,5311.50,4717.44,5388.59,31,2930.76,21420,"percent of total billed charges",
"PENCIL BIPOLAR 18GA STELLARIS PC CURVE VITREORETINAL 2 PIN",SUP-E7918,CDM,S27200284,LOCAL,0272,RC,,,both,,,835.35,250.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,97.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.15,710.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP LUBRICATH STATLOCK 16FR 2",SUP-A119416M,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.94,69.58,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,95.33,41.1,,,,,0,26.97,197.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 340CC P4.1CM MODERATE PLUS PROFILE COHESIVE GEL",SUP-SMPB340,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2182.13,28.62,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 26CM 8FR NEPHROURETERAL FLEXITHANE",SUP-H7493935108260,CDM,C2617,HCPCS,0278,RC,,,both,,,1069.20,320.76,"CIGNA [10200]","Cigna Local Plus",,572.02,,,,,,,124.35,908.82,"percent of total billed charges",
"BLADE SHAVER 4MM FRMLA STRAIGHT CUTTER AGGRESSIVE PLUS",SUP-0375544000,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,218.89,68,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER 505UM TFL DISPOSABLE SOLTIVE",SUP-TFL-FBX550S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3801.07,1140.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2584.73,68,,,,,0,442.06,3230.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TEMPO TEMPORARY PACING LEAD",SUP-T1106,CDM,S27200284,LOCAL,0272,RC,,,both,,,3112.50,933.75,"AETNA [10100]","Aetna HMO/PPO",,2474.44,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 12.5CM 3MM IBUR DISTAL BEND MATCH HEAD",SUP-8431-107-530,CDM,S27200284,LOCAL,0272,RC,,,both,,,3045.45,913.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,354.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,354.19,2588.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL 220CM 2.3MM FIAPC FLEXIBLE SIDEFIRE",SUP-20132-217,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY LARYNGEAL MASK CHILD SIZE 4 30ML PVC CUFF STRAIGHT DI",SUP-ALAA040SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.20,15.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,21.45,41.1,,,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY TREK BONE LESION BIOPSY KIT 11GX15CM INTRO",SUP-TKL1115,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]",Cigna,,2295,68,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENCIL SMOKE EVAC 10FT VALLEYLAB SM EDGE ELECTRD SLIM",SUP-VSMP10,CDM,S27200284,LOCAL,0272,RC,,,both,,,225.24,67.57,"NOVANET [10819]",Novanet,,168.93,75,,,,,0,26.2,191.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CASSETTE INFUSION PUMP GEN 2 PURGE",SUP-1000200,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3167.1,45.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CASSETTE WOUND DRNG VAC VERALINK 5 PACK VAC ULTA VAC VERAFLO",SUP-ULTLNK0500,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE STRPR 9MM QUADRICEPS TENDON GRAFT CUT DISPOSABLE",SUP-AR-2385-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,611.72,41.1,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY PRECISIONPOINT TRANSPERINEAL ACC SYS BX",SUP-P1002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1777.50,533.25,"CIGNA [10200]",Cigna,,1208.7,68,,,,,0,206.72,1510.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE DOPPLER DISPOSABLE 8MM",SUP-108260,CDM,S27200284,LOCAL,0272,RC,,,both,,,1061.10,318.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,436.11,41.1,,,,,0,123.41,901.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 8MM 144CM 3MM CORONARY STENT PEBAX EVEROLIMUS",SUP-H7493926008300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 1.1MM 24MM STAINLESS STEEL PARTIAL THREAD LOW",SUP-S30-24S-11,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE PIRANHA L14 MM OD4.25 MM SPINE CERVICAL FIX",SUP-CSF-425-14,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"KAISER [10500]",Kaiser,,944.7,67,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER SURGICAL 7IN TUNGSTEN CARBIDE FLUSH WIRE CABLE",SUP-32-129,CDM,S27200284,LOCAL,0272,RC,,,both,,,2739.45,821.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1125.91,41.1,,,,,0,318.6,2328.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL SYMMETRY .4-1MM VESSEL 1",SUP-B-1VB,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.30,176.49,"AETNA [10100]","Aetna HMO/PPO",,467.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.42,500.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 4-0 PS-2 SPIRAL 12IN",SUP-SXMP1B117,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.03,65.41,"UHC [10700]","United Healthcare",,138.01,63.3,,,,,0,25.36,185.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 4-0 PS-2 SPIRAL 12IN",SUP-SXMP1B117,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.03,65.41,"CIGNA [10200]","Cigna Local Plus",,116.65,53.5,,,,,0,25.36,185.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 26CM 5FR .038",SUP-M006192123120,CDM,C2617,HCPCS,0278,RC,,,both,,,1528.96,458.69,"MULTIPLAN [10600]",Multiplan,,1299.62,85,,,,,0,177.82,1299.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 37MM 135CM 9MM 40MM BILIARY STAINLESS STEEL",SUP-PXB35-09-37-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"NOVANET [10819]",Novanet,,3275.25,75,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTRA TWINFLEX TCH 59","SUP-392 289",CDM,C1893,HCPCS,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COPE MAC-LOC 22CM 10.2FR PIGTAIL CURVE",SUP-G48162,CDM,C2617,HCPCS,0278,RC,,,both,,,996.22,298.87,"NOVANET [10819]",Novanet,,747.17,75,,,,,0,115.86,846.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR WHITE 56MM 28MM RINGLOC ECCENTRIC HIP",SUP-11-165236,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"KAISER [10500]",Kaiser,,4462.12,67,,,,,0,774.54,5660.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 450ML GEL ROUND SMOOTH SILICONE P5.1CM","SUP-3504504 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"PHCS [10601]",PHCS,,2646,70,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACRANIAL PROCEDURES WITH CC",038,MS-DRG,,,,,,,inpatient,,,85170.73,25551.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,14635.85,,"Fee schedule rate ($14,635.85). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,7561,47373.43,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACRANIAL PROCEDURES WITH CC",038,MS-DRG,,,,,,,inpatient,,,85170.73,25551.22,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,10367.03,,"Case rate ($10,065.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,346.11, add-ons for qualifying new technology services are included. If operating cost exceeds $42,385.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,088.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,358.47. The transfer operating threshold is the transfer adjustment factor * $9,346.11 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $706.61. The transfer capital threshold is the transfer adjustment factor * $706.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,47373.43,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175273190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS [10001]","Blue Cross PPO",,496.03,39.2,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 7FR .081IN JUDKINS RIGHT 4 CURVE GUIDING",SUP-LA7JR40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR EBU3.25 CURVE GUIDING NYLON CORONARY",SUP-LA6EBU325,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 15CM 5FR .035IN GENTLE CURVE BILIARY",SUP-G22399,CDM,C2617,HCPCS,0278,RC,,,both,,,729.00,218.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 10CM 10FR DUODENAL BEND BILIARY FLEXIMA PLASTIC",SUP-M00539320,CDM,C2625,HCPCS,0278,RC,,,both,,,755.24,226.57,"MULTIPLAN [10600]",Multiplan,,641.95,85,,,,,0,87.83,641.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X2IN DURAGEN CRANIAL DURA BOVINE CLLGN",SUP-DURS2291,CDM,,,0278,RC,,,both,,,4166.57,1249.97,"BLUE CROSS [10001]","Blue Cross HMO",,4.17,.1,,,,,0,4.17,3541.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 5CM 5FR PIGTAIL PANCREATIC POLYMER RADIOPAQUE",SUP-M00537130,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"FIRST HEALTH [10303]","First Health",,511.4,80,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 5CM 5FR PIGTAIL PANCREATIC POLYMER RADIOPAQUE",SUP-M00537130,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"CIGNA [10200]","Cigna Open Access",,363.73,,,,,,,74.34,543.36,"percent of total billed charges",
"NDL ENDOSCOPIC 8- CM 25GA 1.52MM NITINOL 2.4MM 1 WAY STPCOCK",SUP-M00555521,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INLAY OPTIMA 22CM 6FR URETERAL PHREECOAT POLYMER",SUP-788622,CDM,C2617,HCPCS,0278,RC,,,both,,,729.00,218.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,84.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 240CC NATRELLE INSPIRA COHESIVE STERILE LATEX",SUP-SCM-240,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"KAISER [10500]",Kaiser,,5062.19,67,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 30CM 8FR UNIVERSA 2 PIGTAIL CURVE URETER AQ",SUP-G49924,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"CIGNA [10200]",Cigna,,512.24,68,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 22CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006175271170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACC INTRDCR VALV FR6",SUP-667460-001,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 22CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006175281170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 22CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006175271170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]",Cigna,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR CHEST TRAUMA WITHOUT CC/MCC",185,MS-DRG,,,,,,,inpatient,,,37292.38,11187.71,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,5220.22,,"Case rate ($4,878.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,530.21, add-ons for qualifying new technology services are included. If operating cost exceeds $37,569.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,724.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,536.20. The transfer operating threshold is the transfer adjustment factor * $4,530.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.51. The transfer capital threshold is the transfer adjustment factor * $342.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,4878.71,19614.52,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"NEUROLOGICAL EYE DISORDERS",123,MS-DRG,,,,,,,inpatient,,,43843.81,13153.14,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,5176.69,,"Case rate ($4,953.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,599.91, add-ons for qualifying new technology services are included. If operating cost exceeds $37,639.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,729.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,605.99. The transfer operating threshold is the transfer adjustment factor * $4,599.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $347.78. The transfer capital threshold is the transfer adjustment factor * $347.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,4953.77,19916.29,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"VERSACROSS SHEATH 63CM 55DEG D1",SUP-VXS0204,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"AETNA [10100]","Aetna HMO/PPO",,1287.9,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC",461,MS-DRG,,,,,,,inpatient,,,226474.50,67942.35,"BLUE CROSS [10001]","Blue Cross PPO",,136346.58,,"Fee schedule rate ($136,346.58). The outlier threshold amount is ($224,410.00),  the outlier percentage is (63.7%).  The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1). Includes an add-on of $3,218.50 when RC 0681-0684 total amount is above $1.",,,,0,7561,161249.51,other,"IP STOPLOSS Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 465CC",SUP-SMPX465,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5067.36,68,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOBRONCHIAL ARNDT PEDIATRIC 65CM 7FR STD 1 LUMEN CATH",SUP-G44114,CDM,S27200284,LOCAL,0272,RC,,,both,,,1942.50,582.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,230.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,225.91,1651.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN IRRIGATION 9/64IN 20GA BD VISITEC 55D ANTERIOR CHMBR",SUP-585061,CDM,S27200284,LOCAL,0272,RC,,,both,,,962.60,288.78,"PHCS [10601]",PHCS,,673.82,70,,,,,0,111.95,818.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG OCCLUSION 12X5.3MM 3MM MVP PTFE MECHANICALLY DETACHABLE",SUP-MVP-3Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,10695.00,3208.5,"AETNA [10100]","Aetna HMO/PPO",,8502.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1243.83,9090.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 80MM 15MM FLEXIPATH FLEXIBLE SLEEVE",SUP-FP015,CDM,S27200284,LOCAL,0272,RC,,,both,,,677.30,203.19,"CIGNA [10200]",Cigna,,460.56,68,,,,,0,78.77,575.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BRACHYTHERAPY INTERFACE CONTROL SYSTEM BRACHYBALLOON",SUP-610-898,CDM,S27200284,LOCAL,0272,RC,,,both,,,584.62,175.39,"CIGNA [10200]","Cigna Local Plus",,312.77,53.5,,,,,0,67.99,496.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP840D,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.36,38.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.04,109.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAC 136CM 3.9FR .038IN GUIDING DISTAL ACCESS STERILE",SUP-90721,CDM,S27200284,LOCAL,0272,RC,,,both,,,9626.67,2888,"MULTIPLAN [10600]",Multiplan,,8182.67,85,,,,,0,1119.58,8182.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE SURGICAL KNIFE 9.5IN HARDY SYMMETRY BAYONET STAINLESS",SUP-58-7578,CDM,S27200284,LOCAL,0272,RC,,,both,,,680.72,204.22,"MULTIPLAN [10600]",Multiplan,,578.61,85,,,,,0,79.17,578.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 21FR 3/8IN AORTA CURVE NONVENTED STRAIGHT",SUP-EZC21A,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"MULTIPLAN [10600]",Multiplan,,413.1,85,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 125CM 5FR VERT CURVE ANGIOGRAPHIC",SUP-G47180,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"PHCS [10601]",PHCS,,147.36,70,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ENDOSCOPIC ORANGE 72MM 6.5MM CLEAR-TRAC SHOULDER",SUP-72200428,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"UHC [10700]","United Healthcare",,132.17,63.3,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 24MM 140CM 4MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927424400,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2MM 1MM 14 MICRO ANGLE 7.5IN SURGICAL NONSTERILE",SUP-RN6214,CDM,S27200284,LOCAL,0272,RC,,,both,,,686.88,206.06,"MULTIPLAN [10600]",Multiplan,,583.85,85,,,,,0,79.88,583.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD IS4 DF4 STERILE LATEX FREE DISPOSABLE",SUP-412302,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"KAISER [10500]",Kaiser,,273.96,67,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 3.5IN 17GA EPILONG TUOHYSONO GRADUATE METAL",SUP-0431187-48,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.10,86.13,"AETNA [10100]","Aetna HMO/PPO",,228.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 6.5IN TUNGSTEN 15X12MM NONHEX",SUP-E15606,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.49,30.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46.12,45.9,,,,,0,11.69,85.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY LARYNGEAL MASK ADULT SIZE 4 ELONGATED CUFF 45ML CLEAR",SUP-ALBF040SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.97,31.19,"PHCS [10601]",PHCS,,72.78,70,,,,,0,12.09,88.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMB VENTILATOR VMAX D PLUS DIRECTION TUBE V62J",SUP-769524-102,CDM,S27200284,LOCAL,0272,RC,,,both,,,676.51,202.95,"AETNA [10100]","Aetna HMO/PPO",,537.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.68,575.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN MICROPOINT 6-0 TG140-8 18IN 2 ARM MONOFILAMENT",SUP-1735G,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.81,67.14,"CIGNA [10200]",Cigna,,152.19,68,,,,,0,26.03,190.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MITRACLIP G4 CDS NTW REPAIR-MR CLINICAL",SUP-CDS0704-NTW,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS [10001]","Blue Cross HMO",,67032,39.2,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X9X9MM COROENT 4D PEEK LARGE IMPACT NONSTERILE",SUP-6709932,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA [10200]","Cigna Open Access",,5547.6,33.5,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GALASHAPE 3D 18.5X6.4CM SOFT TISSUE SCAFFOLD",SUP-SH3D04,CDM,C1781,HCPCS,0278,RC,,,both,,,15180.00,4554,"FIRST HEALTH [10303]","First Health",,12144,80,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG VASCULAR 8MM",SUP-9-PLUG-008,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"BLUE CROSS [10001]","Blue Cross PPO",,2420.8,39.2,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL 37X27X40MM MBT KNEE METAPHYSEAL POROUS",SUP-129454100,CDM,C1776,HCPCS,0278,RC,,,both,,,15133.08,4539.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6219.7,41.1,,6417.48,6417.48,6417.48,"1 through 10",1759.98,12863.12,"percent of total billed charges",
"RETRACTOR SURGICAL L6 1/4IN SHARP PREMIUM GRADE SENN",SUP-20-0508,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.99,22.5,"CIGNA [10200]","Cigna Open Access",,42.67,56.9,,,,,0,8.72,63.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY",SUP-CNWET0,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,247.56,28.62,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 1/8IN 1 PIECE HEADLESS FLUTED SQUARE END 3.5IN",SUP-BMA-S90010S,CDM,S27200284,LOCAL,0272,RC,,,both,,,603.61,181.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,70.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.2,513.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 6FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856140,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,745.73,68,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 3.1MM T HANDLE ROD SYSTEM WRIST HAND 300MM",SUP-RMT3130,CDM,S27200284,LOCAL,0272,RC,,,both,,,1287.90,386.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,529.33,41.1,,,,,0,149.78,1094.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD IS4 DF4 STERILE LATEX FREE DISPOSABLE",SUP-412302,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,48.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.165,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TABS BED PAD PRESSURE",SUP-26300,CDM,S27000186,LOCAL,0270,RC,,,both,,,165.30,49.59,"KAISER [10500]",Kaiser,,110.75,67,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MFLD INJECTION ACIST CVI SALINE CONTRAST PORT SPIKE TUBE",SUP-014613,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.25,71.77,"PHCS [10601]",PHCS,,167.48,70,,,,,0,27.82,203.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DANTROLENE 20 MG INTRAVENOUS SOLUTION",RX-9716,CDM,,,0250,RC,78670-0003-67,NDC,both,1,UN,471.91,141.57,"CIGNA [10200]","Cigna Open Access",,268.52,56.9,,,,,0,54.88,401.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS LOC MEDIUM CARDIAC PERCUTANEOUS 3D STERILE",SUP-DS2C200-42,CDM,C1893,HCPCS,0272,RC,,,both,,,2250.00,675,"MULTIPLAN [10600]",Multiplan,,1912.5,85,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 12MM 6MM STD WALL THIN WALL 2 BRANCH",SUP-SBT1202D,CDM,C1768,HCPCS,0278,RC,,,both,,,8611.20,2583.36,"CIGNA [10200]",Cigna,,5855.62,68,,,,,0,1001.48,7319.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 2.63INX1.73IN LARGE THERMOPLASTIC THERMASPLINT",SUP-1529020,CDM,S27000186,LOCAL,0270,RC,,,both,,,204.45,61.33,"UHC [10700]","United Healthcare",,129.42,63.3,,,,,0,23.78,173.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 82MM PRESS FIT AEQUALIS ASCEND FLEX PTC 132.5D",SUP-DWF605B,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UHC [10700]","United Healthcare",,7975.8,63.3,,8601.07,8395.67,8601.07,"1 through 10",1465.38,10710,"percent of total billed charges",
"LEAD NEROSTIMLTR INSPIRE 3 ELECTRD CUFF TUNNEL ROD STERILE",SUP-4063,CDM,C1778,HCPCS,0278,RC,,,both,,,13455.00,4036.5,"AETNA [10100]","Aetna HMO/PPO",,10696.73,79.5,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 7MM ENDOPROSTHESIS HEPARIN",SUP-VBJR070502A,CDM,C1874,HCPCS,0278,RC,,,both,,,19895.40,5968.62,"NOVANET [10819]",Novanet,,14921.55,75,,,,,0,2313.84,16911.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatobiliary Sys Img W Drug",PX-341000018,CDM,78227,CPT,0341,RC,,,both,,,3290.63,987.19,"NOVANET [10819]",Novanet,,2467.97,75,,,,,0,382.7,2797.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 18MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-018,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"CIGNA [10200]","Cigna Open Access",,2695.41,56.9,,5302.19,4377.88,6578.61,27,550.92,4026.54,"percent of total billed charges",
"SCR BONE 6.5MM 40MM CREO CREO AMP SPINE MODULAR",SUP-1067.1640,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3923.76,41.1,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYSORB 3-0 C-16 30IN BRAID COATED UNDYED ABSORBABLE",SUP-USUSL696,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.44,51.73,"FIRST HEALTH [10303]","First Health",,137.95,80,,,,,0,20.05,146.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 170ML GEL ROUND TEXTURED MEMORYGEL SILTEX P2.",SUP-3541707MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY NDL STEPPED 230CM 2.8MM ENDOJAW LOWER",SUP-FB-220U.A,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.82,18.25,"FIRST HEALTH [10303]","First Health",,48.66,80,,,,,0,7.07,51.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 23GA SHORT SOFT TIP STERILE DISPOSABLE",SUP-8065149527,CDM,S27200284,LOCAL,0272,RC,,,both,,,199.75,59.92,"NOVANET [10819]",Novanet,,149.81,75,,,,,0,23.23,169.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VXSK-230J RF WIRE 63CM/45DEG/D1 SHEATH",SUP-VXSK0112,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"CIGNA [10200]","Cigna Local Plus",,3303.89,53.5,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN LOCK-OUT 22CM PUMP SET INFLATABLE FLUID",SUP-ES8922,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"NOVANET [10819]",Novanet,,47025,75,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5F DECA 2-5-2 MPD-SL. 110CM",SUP-901707,CDM,C1730,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"AETNA [10100]","Aetna HMO/PPO",,4360.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO S2 LOW PROFILE QUICK CONNECT GLIDESCOPE",SUP-0270-1152,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.26,129.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,294.62,68,,,,,0,50.39,368.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trypsin Fecal Qual",PX-301000427,CDM,84311,CPT,0301,RC,,,both,,,338.00,101.4,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,287.3,"per diem",
"SUT VICRYL 2-0 RB-1 27IN BRAID COATED VIOLET ABSORBABLE",SUP-J306H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 47MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-47-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"FIRST HEALTH [10303]","First Health",,4526.4,80,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FRACTURE OMNICURVE 11G 15MM",SUP-1032-115-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 13MM KNEE CONSTRAIN UHMWPE GENESIS II",SUP-71420526,CDM,C1776,HCPCS,0278,RC,,,both,,,18474.75,5542.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2189.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2148.61,15703.54,"percent of total billed charges",
"BASEPLT TIBIAL ATTUNE 10 KNEE CEMENT ROTATE PLATFORM STERILE",SUP-150680010,CDM,C1776,HCPCS,0278,RC,,,both,,,17225.85,5167.75,"PHCS [10601]",PHCS,,12058.1,70,,,,,0,2003.37,14641.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 5CC .5-5MM 80% CORTICAL 20% CANCELLOUS",SUP-400053,CDM,C1713,HCPCS,0278,RC,,,both,,,923.40,277.02,"CIGNA [10200]","Cigna Open Access",,525.41,56.9,,1144.80,304.56,2275.09,66,107.39,784.89,"percent of total billed charges",
"GWIRE TRANSEND VASCULAR STRAIGHT 135CM 2CM .018IN SCITANIUM",SUP-M001468120,CDM,C1769,HCPCS,0272,RC,,,both,,,2062.50,618.75,"FIRST HEALTH [10303]","First Health",,1650,80,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11.75CM NATRELLE INSPIRA P4.8CM FULL PROFILE",SUP-MSZ-F345,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMAKER CARDIAC THK6MM 59X56MM ALLURE QUADRA RF IS4-LLLL C",SUP-PM3242,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"CIGNA [10200]","Cigna Open Access",,7735.28,33.5,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR VIVACIT-E LL 58MM 36MM HIP NEUTRAL",SUP-00885101336,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"UHC [10700]","United Healthcare",,6489.53,63.3,,8601.07,8395.67,8601.07,"1 through 10",1192.31,8714.22,"percent of total billed charges",
"PATCH SOFT TISSUE 20X15CM SOFT CONFORMABLE TRIM STRONG",SUP-1315020020,CDM,C1781,HCPCS,0278,RC,,,both,,,16008.00,4802.4,"CIGNA [10200]","Cigna Local Plus",,5042.52,31.5,,3096.73,1.00,3096.73,"1 through 10",1861.73,13606.8,"percent of total billed charges",
"TUBE 79MM 13.8MM 8.9MM CUFF DISPOSABLE INNER CANN OBTR",SUP-10DFEN,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.46,95.84,"FIRST HEALTH [10303]","First Health",,255.57,80,,,,,0,37.15,271.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 4MM 7FR 2-5-2MM SPACE A CURVE ABLATION 10",SUP-D7AL252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,5326.80,1598.04,"UHC [10700]","United Healthcare",,3371.86,63.3,,,,,0,619.51,4527.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL CRYOABLATION 17.5CM 14GA ICEPEARL 2.1CX STRAIGHT IMAGE",SUP-FPRPR3603,CDM,C2618,HCPCS,0272,RC,,,both,,,13110.00,3933,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1524.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 15MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158125115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PHCS [10601]",PHCS,,7822.19,70,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 130MM 4.5MM RADENOID 40D ADENOID CURVED",SUP-1884507,CDM,S27200284,LOCAL,0272,RC,,,both,,,1941.00,582.3,"FIRST HEALTH [10303]","First Health",,1552.8,80,,,,,0,225.74,1649.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 217MM 16MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-416,CDM,C1776,HCPCS,0278,RC,,,both,,,19885.95,5965.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5691.36,28.62,,,,,0,2312.74,16903.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON SUT PERCHIK STERILE DISPOSABLE",SUP-H787138002015,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.12,19.84,"PHCS [10601]",PHCS,,46.28,70,,,,,0,7.69,56.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION ENDOBUTTON 1.2MM ACCESS PACK GUIDE",SUP-72202799,CDM,C1713,HCPCS,0278,RC,,,both,,,2488.50,746.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,294.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",289.41,2115.23,"percent of total billed charges",
"SCR BONE 2.7MM 16MM LOW PROFILE SCREWS STAINLESS STEEL FULL",SUP-AR-8827L-16,CDM,C1713,HCPCS,0278,RC,,,both,,,931.50,279.45,"MULTIPLAN [10600]",Multiplan,,791.78,85,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 8MM 70MM EXPERT TITANIUM 3.5MM FULL THREAD",SUP-450.866,CDM,C1713,HCPCS,0278,RC,,,both,,,1576.91,473.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,451.31,28.62,,,,,0,183.39,1340.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 44MM 2 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-42F44V,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 48MM LCP STAINLESS STEEL FULL THREAD PROXIMAL",SUP-212.12,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"FIRST HEALTH [10303]","First Health",,685.84,80,,,,,0,99.7,728.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ALIMAXX-B 80MM 194CM 10MM BILIARY NITINOL UNCOVERED",SUP-70129-210,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"BLUE CROSS [10001]","Blue Cross PPO",,2975.28,39.2,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 150CM 6FR .038IN STD STRAIGHT LOW PROFILE",SUP-M006180523170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,143.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT STEM 30MM 15MM PFC 46IN KNEE TIBIA CEMENT",SUP-866403,CDM,C1776,HCPCS,0278,RC,,,both,,,5092.20,1527.66,"BLUE CROSS [10001]","Blue Cross HMO",,1996.14,39.2,,5311.50,4717.44,5388.59,31,592.22,4328.37,"percent of total billed charges",
"SUT STRATAFIX MONOCRYL PLUS 2-0 SH SPIRAL 30CM KNOTLESS",SUP-SXMP1B410,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.03,65.41,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.36,185.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ACCUSTICK II .018IN .038IN 60CM 145CM 6FR 4FR INTRO",SUP-M001207100,CDM,C1894,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SENTAI SAMURAI RC VASCULAR 190CM 24CM .014IN STAINLESS",SUP-H749393061902,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"MULTIPLAN [10600]",Multiplan,,826.2,85,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ADVANCE 3 KNEE SCR HOLE BIOFOAM STERILE",SUP-KTSCFM30,CDM,C1776,HCPCS,0278,RC,,,both,,,17063.70,5119.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6825.48,40,,,,,0,1984.51,14504.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 15MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"MULTIPLAN [10600]",Multiplan,,2295,85,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORNUS 135CM .028IN .024IN .018IN .014IN .016IN MICRO",SUP-AT24135,CDM,C1887,HCPCS,0272,RC,,,both,,,4795.50,1438.65,"PHCS [10601]",PHCS,,3356.85,70,,,,,0,557.72,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30MMX11MM VERTE-STACK CRESCENT THORACOLUMBAR",SUP-9193011,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"NOVANET [10819]",Novanet,,12420,75,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE EKOS 106CM 2.62MM THROMBECTOMY ENDOVASCULAR STERILE",SUP-H74939605106080,CDM,C1757,HCPCS,0272,RC,,,both,,,37894.50,11368.35,"AETNA [10100]","Aetna HMO/PPO",,30126.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4407.13,32210.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH DURAL 7X5IN THK3.5MM CRANIOMAXILLOFACIAL",SUP-DMOP57,CDM,S27800098,LOCAL,0278,RC,,,both,,,15989.99,4797,"CIGNA [10200]","Cigna Local Plus",,5036.85,31.5,,,,,0,1859.64,13591.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 4MM RETRACTA 5.6 LOOP DETACHABLE",SUP-G34187,CDM,S27800098,LOCAL,0278,RC,,,both,,,4308.98,1292.69,"AETNA [10100]","Aetna HMO/PPO",,3425.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,501.13,3662.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE D CURVE",SUP-D7BTDL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 8MM CALIBRATE DEPTH MARK CANNULATED STERILE",SUP-AR-1218-80,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Xtra Bowl Set 225ml",PX-E27200339,CDM,E27200339,LOCAL,0272,RC,,,both,,,354.20,106.26,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Connector Y-Type 1/4*1/4*1/4",PX-E27200366,CDM,E27200366,LOCAL,0272,RC,,,both,,,40.70,12.21,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE NC PLUS 12MM 2.75MM BALLOON DILATATION STERILE",SUP-227-123-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DIREXION 155CM 2.4-3FR .021IN MICRO INFUSION NITINOL",SUP-M001195310,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 45CM 5FR 21GA .018IN MICRO STAINLESS STEEL NITINOL",SUP-H787065970535,CDM,C1769,HCPCS,0272,RC,,,both,,,294.93,88.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HYDROCORTISONE 5 MG TABLET",RX-10209,CDM,,,0637,RC,59762-0073-01,NDC,both,1,UN,6.27,1.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH METACROSS 135CM 40MM 5.4FR 5MM BALLOON DILATATION 2",SUP-BD-L50040CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONCIERGE 100CM 5FR SBS4.5 MOD CURVE GUIDING STAINLESS",SUP-CGC5100SBS45SH-M,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"AETNA [10100]","Aetna HMO/PPO",,354.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CELLULITIS WITH MCC",602,MS-DRG,,,,,,,inpatient,,,41110.48,12333.14,"BLUE CROSS [10001]","Blue Cross HMO",,32628.49,,,,,,,7561,35445.8,"case rate",
"SPHERE GLENOID 42MM AEQUALIS PERFORM +4MM INFERIOR OFFSET",SUP-DWJ034,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5011.41,41.1,,6417.48,6417.48,6417.48,"1 through 10",1418.07,10364.22,"percent of total billed charges",
"CMPNT FEMORAL MEDIUM KNEE RIGHT STABILIZE CEMENT ROTATE",SUP-129411030,CDM,C1776,HCPCS,0278,RC,,,both,,,31285.80,9385.74,"FIRST HEALTH [10303]","First Health",,25028.64,80,,,,,0,3638.54,26592.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.5MM CORTEX SCREW 50MM",SUP-214.05,CDM,C1713,HCPCS,0278,RC,,,both,,,345.22,103.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,158.46,45.9,,,,,0,40.15,293.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 2MM 3.5MM CORTEX 4MM CANCELLOUS SCR",SUP-310.89,CDM,S27200284,LOCAL,0272,RC,,,both,,,1828.50,548.55,"CIGNA [10200]",Cigna,,1243.38,68,,,,,0,212.65,1554.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CAPIO VICRYL W/NEEDLE",SUP-M0068332451,CDM,S27200284,LOCAL,0272,RC,,,both,,,492.27,147.68,"KAISER [10500]",Kaiser,,329.82,67,,,,,0,57.25,418.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 80CM 4CM 5FR 6MM 7.5MM BALLOON DILATATION",SUP-4196040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 22MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ322,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.88,817.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 3MM 1.5MM 1.2MM BALLOON DILATATION RAPID",SUP-DC-RY3012UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"AETNA [10100]","Aetna HMO/PPO",,785.62,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATFORM ACCESS GELPOINT INSUFFLATION STABILIZATION BAG",SUP-CNB11,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"CIGNA [10200]",Cigna,,4105.5,68,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ZEBRA 7F 95CM ACCESS SYSTEM SIM2",SUP-AC7087-095-20-S,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1058.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25X5.5X.38MM PRECISION MICRO THIN STAINLESS STEEL",SUP-2296-003-414,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"CIGNA [10200]",Cigna,,183.75,68,,,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SPINAL W32.5MM ANTERIOR CERVICAL ATLANTIS VISION ELITE",SUP-7200132,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 12MM KII Z THREAD SLEEVE SHIELD",SUP-CTB73,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"KAISER [10500]",Kaiser,,163.21,67,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL LEGION 4 5D 5P L KNEE DISTAL SCR",SUP-71421731,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL PERCUFLEX PLUS HYDROPLUS",SUP-M006175198080,CDM,C2617,HCPCS,0278,RC,,,both,,,1205.77,361.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.23,1024.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 CURVE PLUS 8MM KNEE XLK FIX BEARING SIGMA",SUP-970460,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]","Cigna Open Access",,6358.32,56.9,,5302.19,4377.88,6578.61,27,1299.6,9498.37,"percent of total billed charges",
"S MEGATRON US MR 4.00 X 20MM",SUP-H7493942820400,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Open Access",,3533.49,56.9,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND 288SQ CM 9.4X4.7IN CLLGN SILICONE PORCINE",SUP-TG-B120240,CDM,A2008,HCPCS,0636,RC,,,both,,,30962.61,9288.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,15047.83,48.6,,,,,0,247.92,26318.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY TRICUSPID 28MM",SUP-900SFC28,CDM,S27800098,LOCAL,0278,RC,,,both,,,14490.00,4347,"CIGNA [10200]","Cigna Local Plus",,4564.35,31.5,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPORT ASPIRATION CATHETER 6FR",SUP-ADVANCE,CDM,C1757,HCPCS,0272,RC,,,both,,,2250.00,675,"UHC [10700]","United Healthcare",,1424.25,63.3,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Td Vaccine No Prsrv >/= 7 Im",PX-771000017,CDM,90714,CPT,0636,RC,,,both,,,99.03,29.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.97,,,,,,,11.97,99.03,"fee schedule",
"HC Compres Band Tubigrip per Linear Yd",PX-E27000091,CDM,A6457,HCPCS,0270,RC,,,both,,,47.30,14.19,"KAISER [10500]",Kaiser,,31.69,67,,,,,0,1.09,40.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 3MM MREYE 5.3 LOOPS CATH END HOLE",SUP-G42419,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,567.27,68,,,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +15.5 DIOPTER TORIC BLUE LIGHT FILTER CLAREON",SUP-CNW0T4,CDM,V2787,HCPCS,0276,RC,,,both,,,355.00,106.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,41.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.29,301.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Foramen Epi Lumb Add",PX-510000130,CDM,64484,CPT,0761,RC,,,both,,,3392.48,1017.74,"MULTIPLAN [10600]",Multiplan,,2883.61,85,,,,,0,394.55,3392.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,inpatient,,,71618.94,21485.68,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,17944.37,,"Case rate ($8,346.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,750.03, add-ons for qualifying new technology services are included. If operating cost exceeds $40,789.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,967.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $7,760.28. The transfer operating threshold is the transfer adjustment factor * $7,750.03 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.94. The transfer capital threshold is the transfer adjustment factor * $585.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,39283.22,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lgh Gene Rearrange Amp Meth",PX-309000037,CDM,81261,CPT,0310,RC,,,both,,,1046.90,314.07,"BLUE CROSS [10001]","Blue Cross PPO",,252.95,,"Fee schedule rate ($252.95).",,,,0,0.01,889.87,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE ER 30 MG TABLET,EXTENDED RELEASE",RX-20921,CDM,,,0250,RC,00406-8330-23,NDC,both,1,UN,24.91,7.47,"AETNA [10100]","Aetna HMO/PPO",,19.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.9,21.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL CO2 O2 SAMPLE HUMD ADULT LOFLO NAFION LATEX FREE",SUP-989805628041,CDM,S27000186,LOCAL,0270,RC,,,both,,,152.50,45.75,"UHC [10700]","United Healthcare",,96.53,63.3,,,,,0,17.74,129.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT BBTRAUMA BONE BRIDGING TECHNOLOGIES VITOSS",SUP-2102-2201,CDM,C1713,HCPCS,0278,RC,,,both,,,3868.83,1160.65,"CIGNA [10200]",Cigna,,2630.8,68,,1831.33,1831.33,1831.33,16,449.94,3288.51,"percent of total billed charges",
"(EVAL) PREVAIL DCB 2.00X30MM",SUP-PRV020030CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TREVO NXT 4MM X 28MM - US",SUP-90313,CDM,S27200284,LOCAL,0272,RC,,,both,,,35649.18,10694.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"GUIDE WIRE GWR419588 ATTAIN HYBRID 108CM",SUP-GWR419588,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC",002,MS-DRG,,,,,,,inpatient,,,337005.87,101101.76,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Umbilical Neonate",PX-E27200076,CDM,E27200076,LOCAL,0272,RC,,,both,,,359.70,107.91,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PUNCH CONE LONG HANDLE 5MM 2 CUT EDGE SHARP STERILE",SUP-APU550,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC",279,MS-DRG,,,,,,,inpatient,,,156972.67,47091.8,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID UPPER LEG REDUCTION KIT- LONG, REGULAR",SUP-25301317,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"CIGNA [10200]",Cigna,,853.74,68,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 32MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.832,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CIGNA [10200]","Cigna Local Plus",,187.95,53.5,,3978.14,359.25,3978.14,24,40.86,298.61,"percent of total billed charges",
"STPLR INTERNAL 57X.17MM TITANIUM UNIVERSAL ABSORBABLE LINEAR",SUP-015170,CDM,S27200284,LOCAL,0272,RC,,,both,,,10786.91,3236.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7335.1,68,,,,,0,1254.52,9168.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.0/35",SUP-404669,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE",RX-18386,CDM,,,0637,RC,68084-0708-95,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 15MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE40015,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"MULTIPLAN [10600]",Multiplan,,71114.91,85,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT QUILL SRS PDS 2 CT-1 T-8 36X36CM ABSORBABLE",SUP-RX-1062Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.81,62.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,141.99,68,,,,,0,24.28,177.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 6FT 16FR URETHRAL BACTI-GUARD HYDROGEL 5CC",SUP-129416,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.68,42.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 20MM MATRION PLACENTAL MEMB TROPHOBLAST",SUP-PAC20MM,CDM,Q4201,HCPCS,0636,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT ORTHOPEDIC 18X.75IN FINGER 4 PRONG XRAY LUCENT STRIP",SUP-9115-03,CDM,S27000186,LOCAL,0270,RC,,,both,,,75.73,22.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYR TOOMEY ADPTR IRRIGATION",SUP-242,CDM,S27200284,LOCAL,0272,RC,,,both,,,650.75,195.22,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAFIRE TX COMFORTGRIP QUADRIPOLAR 110CM 8MM 7FR 2-5-2MM",SUP-402839,CDM,C1733,HCPCS,0272,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ANAL AND STOMAL PROCEDURES WITH MCC",347,MS-DRG,,,,,,,inpatient,,,73588.86,22076.66,"PHCS [10601]",PHCS,,7561,,,,,,,7561,67022.34,"per diem","Estimated amount calculated based on 8 day length of stay."
"INSRT TIBIAL 9 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640906,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Local Plus",,6020.84,53.5,,5372.07,4581.20,7242.98,23,1308.83,9565.82,"percent of total billed charges",
"CATH 23IN 40FR RIGHT ANGLED DRNG PVC ADULT THORACIC 5 EYELET",SUP-8140,CDM,C1729,HCPCS,0272,RC,,,both,,,91.16,27.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.6,77.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Flow Meter",PX-E27000111,CDM,E27000111,LOCAL,0270,RC,,,both,,,91.15,27.34,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.6,77.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY HUMERAL 17MM AEQUALIS FLEX REVIVE SHOULDER",SUP-ARS741705,CDM,C1776,HCPCS,0278,RC,,,both,,,18558.00,5567.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5010.66,27,,,,,0,2158.3,15774.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BIOLOGICAL 7X3CM CYTAL PORCINE EXTRACELLULAR MATRIX 1",SUP-WS0307,CDM,Q4166,HCPCS,0636,RC,,,both,,,1289.52,386.86,"PHCS [10601]",PHCS,,902.66,70,,,,,0,53.69,1096.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 11MM KII ABDOMEN ADVANCE FIXATION",SUP-CFR33,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"AETNA [10100]","Aetna HMO/PPO",,145.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 49MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 5",SUP-249.681,CDM,C1713,HCPCS,0278,RC,,,both,,,2429.70,728.91,"KAISER [10500]",Kaiser,,1627.9,67,,,,,0,282.57,2065.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 75MM 5.5MM CONTOUR",SUP-101-65570,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1262.14,28.62,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 135CM 60MM 4MM BALLOON DILATATION PACLITAXEL OTW",SUP-H74939419400610,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"NOVANET [10819]",Novanet,,6468.75,75,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM 1.1MM KIRSCHNER DART-FIRE",SUP-DSDS1011,CDM,C1713,HCPCS,0278,RC,,,both,,,191.40,57.42,"CIGNA [10200]",Cigna,,130.15,68,,1831.33,1831.33,1831.33,16,22.26,162.69,"percent of total billed charges",
"CATH DIAMONDBACK 360 145CM 30MM .079IN 2MM .014IN",SUP-DBP-CART-200SOL145,CDM,C1724,HCPCS,0272,RC,,,both,,,17250.00,5175,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC MICRA AV2 LEADLESS BUNDLE",SUP-MICRAAV2SYSTEM,CDM,C1786,HCPCS,0275,RC,,,both,,,69654.00,20896.2,"PHCS [10601]",PHCS,,48757.8,70,,,,,0,8100.76,59205.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 30CM 150CM 7FR .038IN 3CM BLADDER LOOP",SUP-M006155245170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS [10001]","Blue Cross PPO",,556.77,39.2,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LEAD 75CM 5FR .046IN WORLEY ERGONOMIC WING HUB BRAID",SUP-57538CSHK-WOR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1010.88,303.26,"MULTIPLAN [10600]",Multiplan,,859.25,85,,,,,0,117.57,859.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 7FR EXTRA BACKUP 3",SUP-77805200,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 8MM ZERO-P LARGE LORDOTIC PEEK-OPTIMA TITANIUM",SUP-04.617.228S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"NOVANET [10819]",Novanet,,9315,75,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 15CM 37MM TAG THORACIC ACTIVE CONTROL",SUP-TGMR373715,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"NOVANET [10819]",Novanet,,86979.15,75,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE GT VASCULAR 90D 60D 180CM 25CM .018IN",SUP-RG*GW1818SP,CDM,C1769,HCPCS,0272,RC,,,both,,,1445.85,433.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,594.24,41.1,,,,,0,168.15,1228.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-207.040,CDM,C1713,HCPCS,0278,RC,,,both,,,280.05,84.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,33.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",32.57,238.04,"percent of total billed charges",
"COIL EMBOLIZATION 190CM 3CM 1MM GALAXY G3 MINI STRETCH",SUP-GLM910030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"MULTIPLAN [10600]",Multiplan,,10099.53,85,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 20MM LOW PROFILE SCREWS TITANIUM VARIABLE",SUP-AR-8724V-20,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross PPO",,635.04,39.2,,957.42,570.23,957.42,28,188.41,1377,"percent of total billed charges",
"NDL ASPIRATION 130CM 20GA 1.8MM EXCELON TRANSBRONCHIAL",SUP-M00564111,CDM,S27200284,LOCAL,0272,RC,,,both,,,664.10,199.23,"NOVANET [10819]",Novanet,,498.08,75,,,,,0,77.23,564.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE (RSP) MONOBLOCK REVISION HUMERAL STEM, 175MM, 12X175",SUP-510-12-175,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"NOVANET [10819]",Novanet,,9450,75,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR AVENIR COMPLETE 5 STD HIP STERILE LATEX",SUP-574201050,CDM,C1776,HCPCS,0278,RC,,,both,,,23461.20,7038.36,"AETNA [10100]","Aetna HMO/PPO",,18651.65,79.5,,10981.53,8986.79,12413.38,12,2728.54,19942.02,"percent of total billed charges",
"CATH BARRX 135CM 15.7X7.5MM",SUP-TTS-1100,CDM,C1886,HCPCS,0272,RC,,,both,,,14959.20,4487.76,"KAISER [10500]",Kaiser,,10022.66,67,,,,,0,1739.75,12715.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IV VIAFLEX 10 MEQ POTASSIUM CHLORIDE 5% DEXTROSE 0.45%",SUP-2B1644X,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,55.08,68,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.75/30",SUP-401767,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Massage Ea 15min (Gp)",PX-420000025,CDM,97124,CPT,0420,RC,,,both,,,163.34,49,"NOVANET [10819]",Novanet,,122.51,75,,,,,0,19,163.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 155MM 3.5MM PERI-LOC SHORT QUICK CONNECT STERILE",SUP-71173504,CDM,S27200284,LOCAL,0272,RC,,,both,,,1354.73,406.42,"KAISER [10500]",Kaiser,,907.67,67,,,,,0,157.56,1151.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X14X8MM ENDOSKELETON TC 6D MEDIUM TITANIUM",SUP-5166-1408-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1203.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ASPIRATION 1400MM 2.2MM 22GA WITHOUT SIDEHOLE 80MM",SUP-NA-U200H-8022,CDM,S27200284,LOCAL,0272,RC,,,both,,,2173.50,652.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,893.31,41.1,,,,,0,252.78,1847.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION 11MM TIGHTROPE ROUND CONCAVE INTERNALBRACE",SUP-AR-1588TB-3IB,CDM,C1713,HCPCS,0278,RC,,,both,,,2165.63,649.69,"MULTIPLAN [10600]",Multiplan,,1840.79,85,,,,,0,251.86,1840.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 13CM 4MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-04013,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UHC [10700]","United Healthcare",,7420.72,63.3,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Gastric Emptying W Sm Bowel",PX-341000068,CDM,78265,CPT,0341,RC,,,both,,,2606.75,782.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1065.54,,,,,,,303.17,2215.74,"fee schedule",
"INSRT TIBIAL XS UNIVERSAL 23MM KNEE HINGE LPS",SUP-198727123,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7977.52,27,,,,,0,3436.24,25114.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6215  BALLOON CATHETER-80CM X 10MM BALL",SUP-6215,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"NOVANET [10819]",Novanet,,546.75,75,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 41MM CATHCART BALL HIP FEMUR ORTHOCHROME",SUP-136341000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,434.96,3179,"percent of total billed charges",
"SHELL ACETABULAR 52MM HIP CLUSTER HOLE HA TRIDENT II PSL E",SUP-742-11-52E,CDM,C1776,HCPCS,0278,RC,,,both,,,9502.96,2850.89,"BLUE CROSS [10001]","Blue Cross HMO",,3725.16,39.2,,5311.50,4717.44,5388.59,31,1105.19,8077.52,"percent of total billed charges",
"INSRT HUMERAL 36MM UNIVERS REVERS +6MM SMALL SHOULDER",SUP-AR-9503S-06C,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"PHCS [10601]",PHCS,,2058,70,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 24FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0118L24,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.96,26.39,"KAISER [10500]",Kaiser,,58.93,67,,,,,0,10.23,74.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD LAPAROSCOPIC VALLEYLAB L HOOK RETRACTABLE ASPIRATION",SUP-E3784R-28ASP,CDM,S27200284,LOCAL,0272,RC,,,both,,,254.91,76.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,29.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.65,216.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS INTRAOCULAR ADULT +21.0 DIOPTER L13MM DIA6MM AC D5.4MM",SUP-ZCB0000210,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,336.14,28.62,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 54MM TI",SUP-MTLS-37540-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 11/13 TAPER 44MM HIP M SPECIFICATION METAL",SUP-136562500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"NOVANET [10819]",Novanet,,8308.46,75,,,,,0,1288.37,9416.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 6MM 2.25MM ULTRA LOW PROFILE BALLOON",SUP-1012404-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 100CM 6FR RB CURVE GUIDING STAINLESS",SUP-67017200,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 8FR 63CM SUPERSTIFF GWIRE GUIDING HEMOSTASIS",SUP-407436,CDM,C1893,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TROCAR LAPAROSCOPIC 150MM 5MM KII ADVANCED FIXATION SLEEVE",SUP-CFB01,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAMP SURGICAL GEMINI 9IN",SUP-54-7258,CDM,S27200284,LOCAL,0272,RC,,,both,,,215.76,64.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 8FR 85CM MULLINS DESIGN RADIOPAQUE TIP SIDEARM",SUP-G08600,CDM,C1894,HCPCS,0272,RC,,,both,,,680.32,204.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION SUPERORDERABLE",RX-409572,CDM,J1160,HCPCS,0636,RC,00641-1410-31,NDC,both,2,ML,49.83,14.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.6,,,,,,,1.6,42.36,"fee schedule",
"IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION",RX-27737,CDM,Q9967,HCPCS,0255,RC,00270-1315-35,NDC,both,100,ML,200.00,60,"FIRST HEALTH [10303]","First Health",,160,80,,,,,0,23.26,170,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 26CM 150CM 8FR .035IN 3CM BLADDER LOOP",SUP-M006155253190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,965.83,68,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BALL 37CM 8FR NONSTERILE REUSABLE",SUP-257F8,CDM,S27000186,LOCAL,0270,RC,,,both,,,833.98,250.19,"AETNA [10100]","Aetna HMO/PPO",,663.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,96.99,708.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X22X10MM COROENT 10D XL PEEK-OPTIMA LORDOTIC",SUP-6921055,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"KAISER [10500]",Kaiser,,15919.2,67,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mastectomy Bra",PX-E27000251,CDM,L8000,HCPCS,0270,RC,,,both,,,146.30,43.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,60.13,41.1,,,,,0,17.01,124.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Bone Marrow",PX-610000055,CDM,77084,CPT,0610,RC,,,both,,,3916.00,1174.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,455.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,455.43,3328.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 7MM LONG ROUND HEAD DIAMOND POINT STERILE",SUP-5130012070,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.07,262.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,594.37,68,,,,,0,101.65,742.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALIBRATOR OSMOMETER 100 MOSM/KG 5ML STANDARD AMPULE FOR 325",SUP-3LA011,CDM,S27000186,LOCAL,0270,RC,,,both,,,276.39,82.92,"CIGNA [10200]","Cigna Open Access",,157.27,56.9,,,,,0,32.14,234.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 8.75IN MIDDLETON PEDIATRIC ADENOID SURGICAL 8MM",SUP-71-3209,CDM,S27200284,LOCAL,0272,RC,,,both,,,825.07,247.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 5FR 50CM 4CM 2 ENDED GWIRE PRELUDE STAINLESS",SUP-PSS-5F-4-038MT,CDM,C1894,HCPCS,0272,RC,,,both,,,208.80,62.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 135CM 40MM 6FR 9MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-09041,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONQUEST 40 75CM 8CM 10MM BALLOON DILATATION PERIPHERAL",SUP-CQF75108,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 14.6CM MEMORYGEL COHESIVE I P4.5CM MODERATE PLUS",SUP-RSZ-5501S,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 55MM OPTILINK SELF TAP VARIABLE ANGLE STARDRIVE",SUP-42.231.255,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"CIGNA [10200]","Cigna Local Plus",,723.61,53.5,,3978.14,359.25,3978.14,24,157.3,1149.66,"percent of total billed charges",
"SUT MONOCRYL PLUS 4-0 PC-3 18IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP845G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]",Cigna,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 80MM 20MM FINNED CEMENTLESS SMR TITANIUM",SUP-1304.15.200,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"AETNA [10100]","Aetna HMO/PPO",,6296.4,79.5,,10981.53,8986.79,12413.38,12,921.1,6732,"percent of total billed charges",
"PIN FIXATION 225MM 6MM STEINMANN STAINLESS STEEL",SUP-294.950,CDM,C1713,HCPCS,0278,RC,,,both,,,793.80,238.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,92.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",92.32,674.73,"percent of total billed charges",
"SODIUM CHLORIDE 0.9 % IVPB-ADDV/MBP",RX-120160,CDM,J3490,HCPCS,0258,RC,00409-7101-04,NDC,both,250,ML,100.65,30.19,"PHCS [10601]",PHCS,,70.46,70,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL TAN 75MM 10.35MM TFN-ADVANCED",SUP-04.038.375S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"AETNA [10100]","Aetna HMO/PPO",,3165.57,79.5,,1521.93,481.35,16760.95,30,463.09,3384.57,"percent of total billed charges",
"TRIAL KNEE IDENTITY IMPRINT THK6MM 5 TIBIAL INSRT POSTERIOR",SUP-TPS-030-065S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Stoma Bx",PX-750000069,CDM,44389,CPT,0750,RC,,,both,,,2060.19,618.06,"PHCS [10601]",PHCS,,2060.19,,"Case rate ($4,710). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,239.6,2060.19,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 3-0 SH-1 27IN MONOFILAMENT BROWN ABSORBABLE",SUP-G182H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"KAISER [10500]",Kaiser,,16.75,67,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 100MM 6FR 7MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-07101,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEED THERA-BAND IODINE-125 BRACHYTHERAPY",SUP-TG726IL,CDM,C2638,HCPCS,0278,RC,,,both,,,139.20,41.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,94.66,68,,,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG FIBER FLUID RETENTION NONWOVEN 6X6IN BEIGE STERILE",SUP-709903,CDM,S27200284,LOCAL,0272,RC,,,both,,,46.33,13.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.39,39.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cush WC 17x17in Waffle Preinfl",PX-E27000270,CDM,E27000270,LOCAL,0270,RC,,,both,,,94.60,28.38,"MULTIPLAN [10600]",Multiplan,,80.41,85,,,,,0,11,80.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DRILL 1/8IN VANGUARD QUICK RELEASE STERILE",SUP-32486265,CDM,S27200284,LOCAL,0272,RC,,,both,,,464.94,139.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,54.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.07,395.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 80CM 8MM EXTERNALLY SUPPORTED REVOLUTIO",SUP-503087B,CDM,L8670,HCPCS,0278,RC,,,both,,,16537.92,4961.38,"CIGNA [10200]","Cigna Open Access",,5540.2,33.5,,,,,0,427.53,14057.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 44MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.844,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"BLUE CROSS [10001]","Blue Cross HMO",,92.76,39.2,,957.42,156.86,7483.26,51,27.52,201.14,"percent of total billed charges",
"PROBE LASER 20GA STRAIGHT ENDOPHOTOCOAGULATION",SUP-10562,CDM,S27000186,LOCAL,0270,RC,,,both,,,1363.50,409.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,927.18,68,,,,,0,158.58,1158.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SUPER TORQUE PLUS 125CM 6FR MPA1 CURVE",SUP-533667,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"FIRST HEALTH [10303]","First Health",,65.84,80,,,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT HUMERAL 42MM AEQUALIS SHOULDER METAPHYSIS REVERSE",SUP-DWB961,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2884.9,28.62,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8.5MM 5MM OFFSET CONTOUR KNEE TROCHLEA",SUP-PX02-0855-W,CDM,C1776,HCPCS,0278,RC,,,both,,,27216.00,8164.8,"CIGNA [10200]","Cigna Open Access",,9117.36,33.5,,5302.19,4377.88,6578.61,27,3165.22,23133.6,"percent of total billed charges",
"CAP SYSTEM THR OSSEOTI E1 CERAMIC HIP CEMENT FIX STEM CUP LI",SUP-98000100193,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7484.4,27,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR OVAL 32MMX9MM GENESIS II UHMWPE KNEE",SUP-71421032,CDM,C1776,HCPCS,0278,RC,,,both,,,7162.20,2148.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,848.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,832.96,6087.87,"percent of total billed charges",
"LENS IOL +12.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.125,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE SPINE MODULAR TULIP NONSTERILE MAS PLIF",SUP-7070000,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 13MM 345MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.749S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"BLUE CROSS [10001]","Blue Cross HMO",,3258.47,39.2,,957.42,156.86,7483.26,51,966.74,7065.57,"percent of total billed charges",
"INSRT TIBIAL 3 CURVE PLUS 20MM KNEE XLK FIX BEARING SIGMA",SUP-970455,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AETNA [10100]","Aetna HMO/PPO",,8883.77,79.5,,10981.53,8986.79,12413.38,12,1299.6,9498.37,"percent of total billed charges",
"INSRT TIBIAL 3 CURVE PLUS 20MM KNEE XLK FIX BEARING SIGMA",SUP-970455,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 5MM BALLOON",SUP-U357556,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOGRAPHIC RADIALTIGER CURVE 6FR 4.5MM 100CM CORONARY",SUP-40-6012,CDM,C1713,HCPCS,0278,RC,,,both,,,313.20,93.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,37.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,36.43,266.22,"percent of total billed charges",
"TRAY CATHETERIZATION SLIM-LINE 15FR 1000ML PREATTACHED COLL",SUP-771215,CDM,S27200284,LOCAL,0272,RC,,,both,,,1.83,0.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,0.75,41.1,,,,,0,0.21,1.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM PRIMARY HEMISPHERICAL CLUSTER HOLE",SUP-502-03-52D,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4804.27,45.9,,,,,0,1217.29,8896.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSOLE SHOE 6-8 SMALL MALE DARCO PEG-ASSIST REMOVABLE PEG",SUP-PTQM1,CDM,S27000186,LOCAL,0270,RC,,,both,,,100.92,30.28,"CIGNA [10200]","Cigna Open Access",,57.42,56.9,,,,,0,11.74,85.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 28MM 9MM BLUNT FULL THREAD",SUP-AR-1390TC,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,219.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",215.23,1573.04,"percent of total billed charges",
"SUT SUTURETAPE 40IN X 2 STRAND BLACK BLUE WHITE 1.3MM",SUP-AR-7501,CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"UHC [10700]","United Healthcare",,349.94,63.3,,,,,0,64.29,469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LASSO NAVISTAR 7FR 20MM SPACING D CURVE",SUP-D134909,CDM,C1732,HCPCS,0272,RC,,,both,,,11350.50,3405.15,"FIRST HEALTH [10303]","First Health",,9080.4,80,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 14CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175197190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"PHCS [10601]",PHCS,,885.77,70,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 10MM NATURAL LORDOTIC CORTICOCANCELLOUS",SUP-18410,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drain Absc Peritoneal Open",PX-361000506,CDM,49020,CPT,0361,RC,,,both,,,1769.00,530.7,"FIRST HEALTH [10303]","First Health",,1415.2,80,,,,,0,205.73,1769,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 3.5X10MM",SUP-PRV035010CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE DIA11MM PRESHAPED PATELLAR LIGAMENT DOWEL",SUP-FPL11,CDM,S27800098,LOCAL,0278,RC,,,both,,,19995.57,5998.67,"PHCS [10601]",PHCS,,13996.9,70,,,,,0,2325.48,16996.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS SHEET 45MMX20MMX7MM",SUP-4W0047,CDM,C1713,HCPCS,0278,RC,,,both,,,15559.50,4667.85,"KAISER [10500]",Kaiser,,10424.87,67,,,,,0,1809.57,13225.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 200MM 4MM TAPER BALLOON DILATATION JET",SUP-A2040-200,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANAKINRA 100 MG/0.67 ML SUBCUTANEOUS SYRINGE",RX-31784,CDM,,,0637,RC,66658-0234-01,NDC,both,.67,ML,935.63,280.69,"UHC [10700]","United Healthcare",,592.25,63.3,,,,,0,108.81,795.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Not Feeynolm<=2.5cm",PX-450000019,CDM,12001,CPT,0361,RC,,,both,,,738.00,221.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,738,,"Fee schedule rate ($1,729.39).",,,,0,85.83,738,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"TI LOW PROFILE TRANSCONNECTOR 42MM-55MM FOR 6.0MM RODS",SUP-497.798,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"MULTIPLAN [10600]",Multiplan,,3187.5,85,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 5MM 100MM KII ABDOMINAL ADVANCE FIXATION",SUP-CFS02,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM TRICUSPID 1 SEAM 2 WRAP ANATOMIC",SUP-4900T26,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5246.42,41.1,,,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 44MM CAYMAN SPINE SELF START NONSTERILE",SUP-4501-15544,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,188.41,1377,"percent of total billed charges",
"LENS IOL +15.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000155,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 6.5MM 6FR BILIARY NITINOL BRAID SELF",SUP-S-65-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1083.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 10FT ABC THERMOGARD PLUS STERILE",SUP-7-382,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.94,15.88,"AETNA [10100]","Aetna HMO/PPO",,42.09,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.16,45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.8MM 2 20MM TRUSHOT HI-FI NDL",SUP-Y18TN,CDM,C1713,HCPCS,0278,RC,,,both,,,6944.85,2083.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4722.5,68,,,,,0,807.69,5903.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 11CM 5FR GEENEN PANCREATIC POLYETHYLENE",SUP-G27151,CDM,C2625,HCPCS,0278,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross HMO",,482.63,39.2,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE 13",SUP-PCB0000250,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL OXFORD C KNEE RIGHT MEDIAL COCRMO",SUP-154723,CDM,C1776,HCPCS,0278,RC,,,both,,,11195.94,3358.78,"CIGNA [10200]","Cigna Open Access",,6370.49,56.9,,5302.19,4377.88,6578.61,27,1302.09,9516.55,"percent of total billed charges",
"SCR BONE 3.5MM 42MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.342TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"CIGNA [10200]","Cigna Local Plus",,1081.53,53.5,,3978.14,359.25,3978.14,24,235.11,1718.32,"percent of total billed charges",
"CYCLOSPORINE MODIFIED 25 MG CAPSULE",RX-28842,CDM,J7515,HCPCS,0636,RC,23155-0837-11,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.74,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL LEGION 5 5D 5P L KNEE SCR",SUP-71421741,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 10MM KNEE RIGHT E-PLUS EMPOWR 3D KNEE STERILE",SUP-342-10-707,CDM,C1776,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"CIGNA [10200]","Cigna Open Access",,3729.8,56.9,,5302.19,4377.88,6578.61,27,762.35,5571.75,"percent of total billed charges",
"CATH SHOCKWAVE E8 150CM 80MM 3MM LITHOTRIPSY PERIPHERAL",SUP-E8IVL030080,CDM,C1725,HCPCS,0272,RC,,,both,,,29610.00,8883,"AETNA [10100]","Aetna HMO/PPO",,23539.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN",RX-163725,CDM,,,0250,RC,00942-0641-04,NDC,both,1000,ML,100.65,30.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSOLE SHOE 6.5-8 MEDIUM FEMALE DARCO PEG-ASSIST REMOVABLE",SUP-PTQW2,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.53,30.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.81,86.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.5MM LCP SUP ANT CLAVICLE PL W/LAT EXTN 5H/LT/94MM-STER",SUP-02.112.013S,CDM,C1713,HCPCS,0278,RC,,,both,,,6058.75,1817.62,"MULTIPLAN [10600]",Multiplan,,5149.94,85,,,,,0,704.63,5149.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 25MM 3.75MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012410-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 14CM 5FR 4MM .035IN BALLOON",SUP-G52336,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP MULTIHOLE TRITANIUM TRIDENT II E",SUP-709-04-52E,CDM,C1776,HCPCS,0278,RC,,,both,,,17958.91,5387.67,"AETNA [10100]","Aetna HMO/PPO",,14277.33,79.5,,10981.53,8986.79,12413.38,12,2088.62,15265.07,"percent of total billed charges",
"CATH EXTERNAL DRNG SUBDURAL CSF EVACUATION SPECIALTY",SUP-951315,CDM,C1729,HCPCS,0272,RC,,,both,,,2349.38,704.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,278.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,273.23,1996.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN 2 GRAM INTRAVENOUS SOLUTION",RX-240676,CDM,J3374,HCPCS,0636,RC,72078-0066-50,NDC,both,1,UN,323.07,96.92,"CIGNA [10200]","Cigna Local Plus",,57,,,,,,,23.49,274.61,"fee schedule",
"KIT INTRAMEDULLARY NAIL 420MM 11MM GAMMA 125D LONG R1.5",SUP-3525-1420S,CDM,C1713,HCPCS,0278,RC,,,both,,,13435.13,4030.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5374.05,40,,,,,0,1562.51,11419.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 4FR 18GA 20CM 1 LUMEN MIDLINE MAXIMAL BARR",SUP-4154108D,CDM,C1752,HCPCS,0272,RC,,,both,,,899.10,269.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,369.53,41.1,,,,,0,104.57,764.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 12.5MM KNEE AOX STABILIZE ROTATE PLATFORM",SUP-196192132,CDM,C1776,HCPCS,0278,RC,,,both,,,13386.00,4015.8,"CIGNA [10200]",Cigna,,5354.4,40,,5873.17,5873.17,5873.17,"1 through 10",1556.79,11378.1,"percent of total billed charges",
"SCR BONE 4.5MM 45MM COCR SPINE MULTIAXIAL 5.5MM ROD",SUP-55840004545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM DARCO LONG THREAD FOOT ANKLE HEAD",SUP-777403822,CDM,C1713,HCPCS,0278,RC,,,both,,,1695.00,508.5,"CIGNA [10200]","Cigna Open Access",,964.46,56.9,,1144.80,304.56,2275.09,66,197.13,1440.75,"percent of total billed charges",
"SUT PROLENE 4-0 V-7 36IN 2 ARM MONOFILAMENT BLUE",SUP-8975H,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.96,25.19,"CIGNA [10200]","Cigna Local Plus",,44.92,53.5,,,,,0,9.76,71.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6-2MM TORNADO MICROCOIL PLATINUM FIBER",SUP-G47419,CDM,S27800098,LOCAL,0278,RC,,,both,,,931.42,279.43,"CIGNA [10200]",Cigna,,633.37,68,,,,,0,108.32,791.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAFLEX 15CM 66CM 7.5FR .025IN IAB CARDIOTHANE II",SUP-IAB-06840-U,CDM,S27200284,LOCAL,0272,RC,,,both,,,12385.50,3715.65,"NOVANET [10819]",Novanet,,9289.13,75,,,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Cvp Cath Triple",PX-E27200241,CDM,C1751,HCPCS,0272,RC,,,both,,,599.50,179.85,"AETNA [10100]","Aetna HMO/PPO",,476.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.72,509.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 5.5MM STRAIGHT SHAFT SURGICAL INTERCONTINENTAL FORTIFY I",SUP-687.526,CDM,S27000186,LOCAL,0270,RC,,,both,,,3120.00,936,"UHC [10700]","United Healthcare",,1974.96,63.3,,,,,0,362.86,2652,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY NDL 240CM 2.4MM RADIAL JAW 4 LARGE CAPACITY",SUP-M00513334,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.01,24,"CIGNA [10200]","Cigna Local Plus",,42.81,53.5,,,,,0,9.31,68.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 22MM E HIP CONSTRAINED X3 TRIDENT",SUP-690-00-22E,CDM,C1776,HCPCS,0278,RC,,,both,,,17046.45,5113.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6818.58,40,,,,,0,1982.5,14489.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X22X14MM COROENT XL WIDE FIRST LATERAL",SUP-6161450,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4061.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX18MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183668,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1562.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1533.84,11210.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE COCR WITH LEGION INSERT PATELLA JOU",SUP-71704624,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"MULTIPLAN [10600]",Multiplan,,16065,85,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 100MM 1800MM 8MM 2.33MM BILIARY METAL",SUP-SHS-08-100-180,CDM,C1874,HCPCS,0278,RC,,,both,,,6855.84,2056.75,"KAISER [10500]",Kaiser,,4593.41,67,,,,,0,797.33,5827.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 110MM 3.5MM STAINLESS STEEL QUICK COUPLING STERILE",SUP-310.35S,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.57,257.87,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) WARRIOR GUIDEWIRE (200 CM)",SUP-7388,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL 34CM 5MM ENDOPATH PROBE PLUS II 5MM",SUP-EPH02,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.63,267.49,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ISAVUCONAZONIUM SULFATE 186 MG CAPSULE",RX-170071,CDM,,,0250,RC,00469-0520-01,NDC,both,1,UN,525.03,157.51,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE UROLOGICAL 150CM .038IN LUBRIGLIDE STRAIGHT TIP",SUP-M0066001000,CDM,C1769,HCPCS,0272,RC,,,both,,,247.43,74.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEFIB CARDIAC 73X40X14IN FORTIFY 2.5V 500OHM 60 PPM TITANIUM",SUP-CD1231-40,CDM,C1722,HCPCS,0278,RC,,,both,,,35000.00,10500,"CIGNA [10200]","Cigna Open Access",,11725,33.5,,,,,0,4070.5,29750,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"12MM AMPLATZER MUSCULAR VSD OCCLUDER",SUP-9-VSD-MUSC-012,CDM,C1817,HCPCS,0278,RC,,,both,,,62700.00,18810,"PHCS [10601]",PHCS,,43890,70,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Arthrocent Jt Inter W/US",PX-361000388,CDM,20606,CPT,0361,RC,,,both,,,2748.54,824.56,"MULTIPLAN [10600]",Multiplan,,2336.26,85,,,,,0,319.66,2748.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP BEIGE 64MM RUSCH EQUIPLITE MILLER 00 SMALL",SUP-004650010,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.98,14.99,"CIGNA [10200]",Cigna,,33.99,68,,,,,0,5.81,42.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP HEMOSTATIC 30 CRTDG SUPERFINE BLUE GEM TITANIUM",SUP-GEM1521,CDM,S27200284,LOCAL,0272,RC,,,both,,,101.50,30.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.8,86.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC 3d Render W Postprocess",PX-350000002,CDM,76377,CPT,0350,RC,,,both,,,5088.60,1526.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,190.76,,,,,,,190.76,4325.31,"fee schedule",
"LENS IOL +10 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000100,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 15MM ALPS TIMAX HAND CORTICAL NONLOCK SQUARE",SUP-131220515,CDM,S27200284,LOCAL,0272,RC,,,both,,,1032.75,309.82,"CIGNA [10200]","Cigna Open Access",,587.63,56.9,,,,,0,120.11,877.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repo Cannula Ecmo Perc Peripheral>=6",PX-361000366,CDM,33958,CPT,0481,RC,,,both,,,7589.00,2276.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4656,,"Case rate ($4,656). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,882.6,7589,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP SMF WITH COBALT CHROME HEAD AND R3 H",SUP-71705511,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2836.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2784.22,20349,"percent of total billed charges",
"HEAD HUMERAL 16MM 43MM SHOULDER SIMPLICITI",SUP-7122870,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"BLUE CROSS [10001]","Blue Cross HMO",,3927.45,39.2,,5311.50,4717.44,5388.59,31,1165.21,8516.15,"percent of total billed charges",
"STEM HUMERAL 108MM ALTIVATE DJO SURGICAL 6 STD SHOULDER",SUP-530-06-108,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Open Access",,4221,33.5,,5302.19,4377.88,6578.61,27,1465.38,10710,"percent of total billed charges",
"BAND COMPRESSION REGULAR ZEPHYR",SUP-190101,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.18,56.45,"CIGNA [10200]","Cigna Open Access",,107.07,56.9,,,,,0,21.89,159.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 4-0 PC-3 18IN MONOFILAMENT BLUE",SUP-8634G,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.79,20.34,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,46.1,68,,,,,0,7.88,57.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK LAPAROSCOPIC 8MM ENDOWRIST PERMANENT CAUT GRASPING",SUP-470183,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,468.46,45.9,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 70MM 4.75MM CD HORIZON SOLERA COCRMO CAP",SUP-641003070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"LINER ACETABULAR G7 C NEUTRAL 32MM ARCOMXL HIP",SUP-010000730,CDM,C1776,HCPCS,0278,RC,,,both,,,8101.98,2430.59,"BLUE CROSS [10001]","Blue Cross PPO",,3175.98,39.2,,3949.44,3949.44,3949.44,"1 through 10",942.26,6886.68,"percent of total billed charges",
"STENT GORE VIABAHN 7.5CM 120CM 5MM 7FR ENDOPROSTHESIS",SUP-VBHR050702A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"AETNA [10100]","Aetna HMO/PPO",,16908.7,79.5,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BNDG COBAN 5.1YDX4IN COMPRESSION 2 LAYER SYSTEM COMFORTABLE",SUP-081572445,CDM,S27000186,LOCAL,0270,RC,,,both,,,207.11,62.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,95.06,45.9,,,,,0,24.09,176.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 6 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022216,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"UHC [10700]","United Healthcare",,10521.79,63.3,,8601.07,8395.67,8601.07,"1 through 10",1933.15,14128.79,"percent of total billed charges",
"SYSTEM MULTI-LINK VISION 18MM 4MM CORONARY STENT COCR RAPID",SUP-1007850-18,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X19.5X1.27MM INTREX",SUP-507130400,CDM,S27200284,LOCAL,0272,RC,,,both,,,323.12,96.94,"CIGNA [10200]","Cigna Local Plus",,172.87,53.5,,,,,0,37.58,274.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFDINIR 125 MG/5 ML ORAL SUSPENSION",RX-22290,CDM,,,0250,RC,68180-0722-04,NDC,both,60,ML,320.79,96.24,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN SUCTION PAL LONG 3MM 30CM PORT 8MM DISPOSABLE",SUP-PAL-300-LL,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HT COMMAND 14 ST 6G X 10CM 300CM ANG",SUP-1060002A,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INSTR 2-0 .041IN 2.5MM NDL CANNULATED DRILL SUT PASS",SUP-AR-1530DS,CDM,S27000186,LOCAL,0270,RC,,,both,,,2323.13,696.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE LARYNSCP SPECTRUM 0 STERILE DISPOSABLE",SUP-0270-0966,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 6 1/8IN 14FR URETHRAL FEMALE",SUP-51-7114,CDM,C1887,HCPCS,0272,RC,,,both,,,199.32,59.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE AORTIC 26-30MM EVOLUT FX+ 34MM ANNULUS",SUP-EVFXPLUS-34,CDM,S27800098,LOCAL,0278,RC,,,both,,,182400.00,54720,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21614.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 55MM CD HORIZON LEGACY TITANIUM ANGLE REVERSE",SUP-75448555,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 11CM 4MM TRICUT XPS 5000 RPM ETHMOID",SUP-1884004,CDM,S27200284,LOCAL,0272,RC,,,both,,,2050.50,615.15,"KAISER [10500]",Kaiser,,1373.84,67,,,,,0,238.47,1742.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 20MM 75CM 7MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200072070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross HMO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD REAMER 17MM STAINLESS STEEL RIA STERILE DISPOSABLE",SUP-352.261S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2533.80,760.14,"CIGNA [10200]",Cigna,,1722.98,68,,,,,0,294.68,2153.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHARGER 12.0 X60  75CM",SUP-H74939206120670,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GLIDECATH GLIDE TECHNOLOGY 65CM 4FR .041IN STRAIGHT",SUP-CG412,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 100CM 15MM 14FR 3MM AIRWAY EXCHANGE 2 LUMEN XFIRM BLUNT",SUP-G36402,CDM,S27200284,LOCAL,0272,RC,,,both,,,622.08,186.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BLAZER DX-20 100CM 7FR 2-10-2MM SPACE SUPER LARGE CURVE",SUP-M00420SL21020,CDM,C1731,HCPCS,0272,RC,,,both,,,11557.50,3467.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR ENDOSCOPIC RELOAD AEON 60MMX2.5MM STERILE LATEX FREE",SUP-AESR60W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPECLM GRAVES VAGINAL 105X33MM",SUP-EL196R,CDM,S27200284,LOCAL,0272,RC,,,both,,,183.74,55.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) PREVAIL DCB 2.50X15MM",SUP-PRV025015CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AZTREONAM 500 MG IV PUSH",RX-408855,CDM,J0457,HCPCS,0636,RC,00003-2560-16,NDC,both,1,UN,226.52,67.96,"CIGNA [10200]","Cigna Open Access",,30.07,,,,,,,14.74,192.54,"fee schedule",
"PLATE LONG TITANIUM ACU-LOC BONE RIGHT DISTAL VOLAR ULNAR",SUP-70-0048,CDM,C1713,HCPCS,0278,RC,,,both,,,5754.60,1726.38,"KAISER [10500]",Kaiser,,3855.58,67,,,,,0,669.26,4891.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 17GA 25GA 3.5IN 5IN 5ML LOR SPRINGWOUND CLOSED",SUP-333196,CDM,C1755,HCPCS,0278,RC,,,both,,,306.26,91.88,"BLUE CROSS [10001]","Blue Cross PPO",,120.05,39.2,,,,,0,35.62,260.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ZEBRA 6F 95CM ACCESS SYSTEM BER",SUP-AC6074-095-20,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1058.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE NITREX VASCULAR 45D 260CM 4CM .035IN NITINOL TUNGSTEN",SUP-N352603,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,881.28,68,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 170CM 5FR .035IN PUSHING GWIRE STERILE DISPOSABLE",SUP-G21771,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY THORACENTESIS 3.5IN 8FR TURKEL ARGYLE MONOJECT 11 SYR",SUP-566059,CDM,C1729,HCPCS,0272,RC,,,both,,,1908.65,572.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,784.46,41.1,,,,,0,221.98,1622.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL ADULT SHORT 2IN PROCARE XTEND 174 CHIN REST",SUP-79-83203,CDM,S27000186,LOCAL,0270,RC,,,both,,,362.70,108.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,149.07,41.1,,,,,0,42.18,308.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOQUE TRICUSPID VALVE REPLACEMENT SYSTEM 44MM",SUP-EVQ1US44,CDM,S27800098,LOCAL,0278,RC,,,both,,,245100.00,73530,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,70147.62,28.62,,,,,0,28505.13,208335,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR CATH GATEWAY PLUS Y",SUP-M001153223,CDM,S27200284,LOCAL,0272,RC,,,both,,,346.83,104.05,"UHC [10700]","United Healthcare",,219.54,63.3,,,,,0,40.34,294.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM THK5-30MM ALLOGRAFT STRIP",SUP-400520,CDM,S27800098,LOCAL,0278,RC,,,both,,,13417.74,4025.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5367.1,40,,,,,0,1560.48,11405.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WASHER 6.6MM CANNULATED ASNIS III ORTHOPEDIC STAINLESS STEEL",SUP-390016,CDM,C1713,HCPCS,0278,RC,,,both,,,328.16,98.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,38.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",38.17,278.94,"percent of total billed charges",
"CATH GLIDECATH RADIFOCUS 100CM 4FR 1 CURVE ANGIOGRAPHIC",SUP-CG404,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOXYCYCLINE HYCLATE 100 MG VIAL",RX-2622,CDM,J1271,HCPCS,0636,RC,16714-0644-01,NDC,both,1,UN,211.17,63.35,"CIGNA [10200]","Cigna Open Access",,28.5,,,,,,,12.82,179.49,"fee schedule",
"CATH GLIDECATH GLIDE TECHNOLOGY 65CM 25CM 5FR .047IN ANGLE",SUP-CG507,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 21GA 45CM 11CM SPRING COIL WIRE STRAIGHT",SUP-PID5F11021SSC,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CLSR 14GA 15CM SUT 1 HND",SUP-RSG-14F-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.80,52.44,"CIGNA [10200]","Cigna Local Plus",,93.52,53.5,,,,,0,20.33,148.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X30X14MM 12D LARGE",SUP-7969814,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13710.24,40,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BD NEXIVA DIFFUSICS 1IN 22GA 1.65MM 6.5ML/SEC 325 PSI",SUP-383591,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.16,17.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.88,50.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM EXCELSIOR XT-27 STRAIGHT",SUP-M003XT2750810,CDM,S27200284,LOCAL,0272,RC,,,both,,,8474.58,2542.37,"CIGNA [10200]","Cigna Open Access",,4822.04,56.9,,,,,0,985.59,7203.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 5FR RBU3.5 CURVE GUIDING NYLON CORONARY",SUP-LA5RBU35,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT SURGICAL OD.3 MM SCREWDRIVER CRUCIFORM RECESS",SUP-80055,CDM,S27200284,LOCAL,0272,RC,,,both,,,4428.77,1328.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BD NEXIVA DIFFUSICS 1IN 22GA 1.65MM 6.5ML/SEC 325 PSI",SUP-383591,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.16,17.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROSTATECTOMY WITH MCC",665,MS-DRG,,,,,,,inpatient,,,84968.66,25490.6,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,inpatient,,,198611.16,59583.35,"CIGNA [10200]",Cigna,,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 55.9%. Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO SD 25D TIGHT LEFT CURVE 1.8MM 3.8MM SUT",SUP-AR-4068-25TL,CDM,S27200284,LOCAL,0272,RC,,,both,,,1190.70,357.21,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE D CURVE",SUP-D7TCDG252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC",337,MS-DRG,,,,,,,inpatient,,,68639.21,20591.76,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,9807.34,,"Case rate ($9,521.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,841.54, add-ons for qualifying new technology services are included. If operating cost exceeds $41,881.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,050.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,853.23. The transfer operating threshold is the transfer adjustment factor * $8,841.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.46. The transfer capital threshold is the transfer adjustment factor * $668.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,44815.86,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 TAPER 28MM HIP M SPECIFICATION METAL",SUP-136516500,CDM,C1776,HCPCS,0278,RC,,,both,,,5716.65,1714.99,"CIGNA [10200]","Cigna Open Access",,3252.77,56.9,,5302.19,4377.88,6578.61,27,664.85,4859.15,"percent of total billed charges",
"STENT POLARIS 22CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155241050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]",Cigna,,837.05,68,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 1 CT-1 36IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y947H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRESSURE SENSING ACCESS SYSTEM (PSAS) 6F 12CM",SUP-PSS-30-0612200-SCN,CDM,S27200284,LOCAL,0272,RC,,,both,,,25200.00,7560,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2930.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT 137CM 6MM 3MM RECTANGLE HELIX TAPER BALLOON",SUP-2200-3006,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOLDER 5 1/8IN DUROGRIP HALSEY SERRATE NDL TUNGSTEN CARBIDE",SUP-BM012R,CDM,S27000186,LOCAL,0270,RC,,,both,,,323.21,96.96,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH QUICK-CROSS 90CM 3.1FR .05-.063IN 50MM SPACE SPRT",SUP-518-036,CDM,C1887,HCPCS,0272,RC,,,both,,,972.00,291.6,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC TREK 12MM 1.5MM ROUND BALLOON DILATATION CROSSFLEX2",SUP-1012432-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNIFE SURGICAL 8.5IN CRILE GANGLION STAINLESS STEEL 2 END",SUP-285383,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.39,101.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VEST 5 XL FRONT ZIP ADJUSTABLE SHOULDER STRAP CUP",SUP-111905,CDM,S27000186,LOCAL,0270,RC,,,both,,,990.87,297.26,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC",395,MS-DRG,,,,,,,inpatient,,,26460.98,7938.29,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER RED 7CM 2.9MM MINI FULL RADIUS STERILE",SUP-3419,CDM,S27200284,LOCAL,0272,RC,,,both,,,2105.18,631.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL DISSECTING 14CM 5MM MIDAS REX LEGEND CYL FLUTE 7.9MM",SUP-14CY50,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.28,371.18,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS INFINITI 100CM 4FR AR MOD CURVE ANGIOGRAPHIC",SUP-538448,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD DEFIB LIFEPAK ADULT CONDUCTIVE GEL REDI-PAK",SUP-11996-000042,CDM,S27000186,LOCAL,0270,RC,,,both,,,335.12,100.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INSTR JOINT PREPARATION ORTHOLOC 2 STERILE",SUP-9914PK01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1093.50,328.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LASSO REDEL 115CM 7FR 25MM 8MM SPACE ELECTROPHYSIOLOGY",SUP-D7L2025RT,CDM,C1731,HCPCS,0272,RC,,,both,,,10950.30,3285.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 15MM 3.2MM RINGLOC+ ACETABULAR STERILE DISPOSABLE",SUP-31-323215,CDM,S27000186,LOCAL,0270,RC,,,both,,,896.67,269,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RETRIEVER SUT GREEN 3/8IN SMALL MINI OPEN STRESS RISER",SUP-9894,CDM,S27200284,LOCAL,0272,RC,,,both,,,376.36,112.91,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM XIENCE ALPINE 12MM 145CM 2.75MM CORONARY STENT",SUP-1125275-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Gel Iodosorb",PX-E27200094,CDM,E27200094,LOCAL,0272,RC,,,both,,,39.23,11.77,"FIRST HEALTH [10303]","First Health",,31.38,80,,,,,0,4.56,33.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZOLPIDEM 5 MG TABLET, IMMEDIATE RELEASE",RX-11701,CDM,,,0637,RC,60687-0838-11,NDC,both,1,UN,12.54,3.76,"CIGNA [10200]","Cigna Local Plus",,6.71,53.5,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 6 6MM",SUP-TPS-030-066S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"UHC [10700]","United Healthcare",,512.73,63.3,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VICI VENOUS STENT 60MM 100MM 16MM ENDOPROSTHESIS",SUP-H74916060100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"AETNA [10100]","Aetna HMO/PPO",,10422.45,79.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY DRNG 12FR FLEXIBLE RESOLVE",SUP-RLC-NV-12,CDM,C1729,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL 9CM MR8 3MM TAPER DISSECTING",SUP-MR8-9TA30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.28,371.18,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MATRIX TISSUE 20X16CM STRATTICE LIFECELL 320SQ CM",SUP-1620002P,CDM,Q4130,HCPCS,0636,RC,,,both,,,50362.20,15108.66,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"PRECISION MICROWAVE ABLATION PROBE, 17 GUAGE, 20 CM",SUP-PR20,CDM,C2618,HCPCS,0272,RC,,,both,,,14524.50,4357.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Tte W/Wwo Cntrst Complt 2d",PX-483000018,CDM,C8929,HCPCS,0480,RC,,,both,,,3690.00,1107,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SYNCHRO VASCULAR 300CM .014IN HYDROPHILIC PRESHAPE",SUP-SSFT300PRE,CDM,C1769,HCPCS,0272,RC,,,both,,,5686.57,1705.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE POWERTURN VASCULAR J CURVE 300CM .014IN",SUP-1044593J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ADHSV SKIN CLSR 2 OCTYL CYANOACRYLATE DERMABOND MINI LIQUID",SUP-DHVM12,CDM,S27200284,LOCAL,0272,RC,,,both,,,308.17,92.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE SUCTION FLEXIBLE INTUB SCOPE DISPOSABLE",SUP-11301CE1/20,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.02,42.61,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RESUS MANUAL ADULT MEDIUM TUBE RESVR MASK PEEP VALVE LATEX",SUP-521611001,CDM,S27000186,LOCAL,0270,RC,,,both,,,71.56,21.47,"FIRST HEALTH [10303]","First Health",,57.25,80,,,,,0,8.32,60.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 4X100 80CM SL",SUP-48004010N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"NOVANET [10819]",Novanet,,644.26,75,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ph Impedance Catheter",PX-E27200295,CDM,E27200295,LOCAL,0272,RC,,,both,,,715.00,214.5,"PHCS [10601]",PHCS,,500.5,70,,,,,0,83.15,607.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 7MM 7CM TWIST-IN 3 DAM SIDEPORT LUER LOCK",SUP-AR-6570TD,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,134.17,45.9,,,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 200MM 2.5MM BALLOON DILATATION RAPID",SUP-47525200S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,832.28,41.1,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 11MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-411-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]","Cigna Open Access",,4031.26,33.5,,5302.19,4377.88,6578.61,27,1399.51,10228.56,"percent of total billed charges",
"BIT DRILL 14MM 2.5MM ACCS STOP NONSTERILE",SUP-324.153,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 4CM 10MM BALLOON DILATATION",SUP-DR80104,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 5.0MM X 26.0MM",SUP-495002612,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PASSPORT 150CM 2CM 3FR 12FR BALLOON DILATATION",SUP-M0062181000,CDM,C1726,HCPCS,0272,RC,,,both,,,1928.85,578.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AEQUALIS PERFORM GLENOID (CORTILOC)- M30",SUP-DWE411,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1103.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1083.45,7918.6,"percent of total billed charges",
"SCR BONE 4.5MM 28MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.828,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"MULTIPLAN [10600]",Multiplan,,213.27,85,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT TOTAL STBL TRIATHLON COCR",SUP-5512-F-301,CDM,C1776,HCPCS,0278,RC,,,both,,,20599.49,6179.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2395.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2395.72,17509.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL SYMBOTEX 25X20CM 3.3X2.3MM 2 SIDE MONOFILAMENT",SUP-SYM2520OS,CDM,C1781,HCPCS,0278,RC,,,both,,,9718.51,2915.55,"FIRST HEALTH [10303]","First Health",,7774.81,80,,,,,0,1130.26,8260.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 8MM THORACIC 2 VELOUR STRAIGHT",SUP-M00202175208P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"K-WIRE DOUBLE DIAMOND 1.2MM X 89MM COCR",SUP-KWCC-DD-12089,CDM,S27000186,LOCAL,0270,RC,,,both,,,400.20,120.06,"KAISER [10500]",Kaiser,,268.13,67,,,,,0,46.54,340.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP INTRACK 66MM WHITE INLAY STEP SOFT HIGHLY",SUP-N-10174,CDM,S27200284,LOCAL,0272,RC,,,both,,,267.09,80.13,"MULTIPLAN [10600]",Multiplan,,227.03,85,,,,,0,31.06,227.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM TKR CEMENT FLEX",SUP-98000670100,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"MULTIPLAN [10600]",Multiplan,,16065,85,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 75CM 2CM 8MM 6FR BALLOON DILATATION PERIPHERAL",SUP-CQ7582,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 20GA 15CM CHIBA COLOR CODED HUB FNA ADJUSTABLE",SUP-MCN2006,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM SAFETYSPLINT 30X4IN CASTING FIBERGLASS CUSTOM FIT",SUP-SS-430PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,76.67,23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR",RX-3781,CDM,,,0250,RC,09999-9998-62,NDC,both,5,ML,12.54,3.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) ZEBRA 7F 105CM ACCESS SYSTEM BER",SUP-AC7087-105-20-B,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION",RX-25246,CDM,,,0637,RC,65862-0071-50,NDC,both,50,ML,30.51,9.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 150CM 150MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE SQUARE 2.4MM SCR 12 HOLE LOW PROFILE 2 SIDE STERNALOCK",SUP-73-2632,CDM,C1713,HCPCS,0278,RC,,,both,,,4754.10,1426.23,"FIRST HEALTH [10303]","First Health",,3803.28,80,,,,,0,552.9,4040.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC THK3/32IN MEDIUM 4.25X3.5IN CMC PRECUT",SUP-556005,CDM,S27000186,LOCAL,0270,RC,,,both,,,55.25,16.57,"NOVANET [10819]",Novanet,,41.44,75,,,,,0,6.43,46.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 7MM ALIF LORDOTIC",SUP-365.407,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1911.36,28.62,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RELIEVA SPIN PLUS 16MM 6MM BALLOON DILATATION",SUP-RSP0616MFS,CDM,S27200284,LOCAL,0272,RC,,,both,,,13455.00,4036.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1564.82,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SMOKE EVAC 24IN 1.25IN TUBE HOSE VACUUM FILTER WAND",SUP-VT10510,CDM,S27000186,LOCAL,0270,RC,,,both,,,75.22,22.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,30.92,41.1,,,,,0,8.75,63.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM EVEREST SPINE CANNULATED POLYAXIAL MIS",SUP-M5111-05535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"CATH LUBRI-SIL 60IN 22FR URETHRAL BACTI-GUARD SILICONE",SUP-0172SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.66,57.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,130.33,68,,,,,0,22.29,162.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 5X3CM AMNIOCORD PURION PLUS AMNIOTIC",SUP-AC-5350,CDM,Q4433,HCPCS,0636,RC,,,both,,,14821.20,4446.36,"KAISER [10500]",Kaiser,,9930.2,67,,,,,0,247.92,12598.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE EMERALD VASCULAR BENSTON LLT CURVE 150CM 20CM .035IN",SUP-502560,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,65.08,68,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL ARTHREX UNIVERS REVERS 8 SHOULDER STERILE",SUP-AR-9501-08P,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7178.76,68,,,,,0,1227.78,8973.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 170MM 130CM 7MM 6FR .035IN VASCULAR NITINOL",SUP-EX071703CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"BLUE CROSS [10001]","Blue Cross PPO",,8137.33,39.2,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER SMOKE EVACUATION ULPA MULTIPORT TELEVAC 2",SUP-5000746,CDM,S27000186,LOCAL,0270,RC,,,both,,,3997.79,1199.34,"CIGNA [10200]",Cigna,,2718.5,68,,,,,0,464.94,3398.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 5.5MM 6FR VASCULAR NITINOL",SUP-S-55-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"KAISER [10500]",Kaiser,,6741.54,67,,,,,0,1083.33,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER 115CM 4MM 7FR 1-7-4MM SPACING D-F CURVE",SUP-BD7TDF4L,CDM,C1733,HCPCS,0272,RC,,,both,,,6113.40,1834.02,"FIRST HEALTH [10303]","First Health",,4890.72,80,,,,,0,710.99,5196.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 21MM ON-X CARBON MECHANICAL CONFORM-X SEWING",SUP-ONXACE/21,CDM,S27800098,LOCAL,0278,RC,,,both,,,21780.00,6534,"BLUE CROSS [10001]","Blue Cross PPO",,8537.76,39.2,,,,,0,2533.01,18513,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 4.75MM STRAIGHT PERCUTANEOUS CCM PLUS",SUP-1476006080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"STENT GORE VIABAHN 79MM 80CM 10MM 13MM 8FR .035IN",SUP-BXA107901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"BLUE CROSS [10001]","Blue Cross HMO",,8391.7,39.2,,9776.84,9776.84,9776.84,"1 through 10",2489.68,18196.29,"percent of total billed charges",
"SCR BONE 7.3MM 95MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.895,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"FIRST HEALTH [10303]","First Health",,1099.53,80,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK 6MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-101244506,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,299.62,41.1,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LACTATED RINGERS IV BOLUS",RX-400296,CDM,J3490,HCPCS,0258,RC,00338-0117-04,NDC,both,1000,ML,100.65,30.19,"PHCS [10601]",PHCS,,70.46,70,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ENDOSCOPIC AGGRESSIVE SMALL JOINT STERILE 3.5MM",SUP-0275638000,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE CORDIS EMERALD VASCULAR STRAIGHT 150CM 7CM .025IN PTFE",SUP-502549,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 150CM 250MM 3.5MM BALLOON DILATATION",SUP-48003525X,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RANGER 150CM 120MM 5MM BALLOON DILATATION PACLITAXEL",SUP-H74939419501210,CDM,C2623,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHAFT T8 STARDRIVE SELF RETAINING QUICK COUPLING SCRDRVR",SUP-314.467,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEALER/DIVIDER LAPAROSCOPIC 18CM 13.5MM LIGASURE IMPACT 14D",SUP-LF4418,CDM,S27200284,LOCAL,0272,RC,,,both,,,3337.50,1001.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 48MM 5MM MEDIUM CARBIDE ROUND ZIMMER RSC",SUP-5300-10-513,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.08,49.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CNCT SHUNT ACCU-FLO STRAIGHT CSF RADIOPAQUE CATH PLASTIC",SUP-45103,CDM,S27800098,LOCAL,0278,RC,,,both,,,755.57,226.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,216.24,28.62,,,,,0,87.87,642.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE SMALL PROTEIOS",SUP-IFLX-GF-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,5761.50,1728.45,"CIGNA [10200]","Cigna Local Plus",,3082.4,53.5,,,,,0,670.06,4897.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BRACHYTHERAPY 20CM 18GA MICK APPLR ULTRA SHARP TIP",SUP-918205,CDM,C1715,HCPCS,0272,RC,,,both,,,80.13,24.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.93,41.1,,,,,0,9.32,68.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1.5 X 2 COMPLEX PICO COIL",SUP-10USC01502,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1549.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT-S CERVICAL 5D ALLOGRAFT 6MM",SUP-3W5006,CDM,S27800098,LOCAL,0278,RC,,,both,,,6216.90,1865.07,"KAISER [10500]",Kaiser,,4165.32,67,,,,,0,723.03,5284.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 54MM 26MM UHR UNIVERSAL ACETABULAR HIP COCR",SUP-UH1-54-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,511.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,502.16,3670.1,"percent of total billed charges",
"SCR BONE 2.4MM 20MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656020,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,907.94,68,,,,,0,155.28,1134.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH KOALA PRESSURE INTRAUTERINE TRNSDUC TIPPED INTERNAL",SUP-IPC-5000C,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.15,63.94,"UHC [10700]","United Healthcare",,134.92,63.3,,,,,0,24.79,181.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 7X11X35MM 12",SUP-5871352,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"AETNA [10100]","Aetna HMO/PPO",,22896,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 360D 7MM TREPHINE RADIAL VACUUM BARRON STAINLESS STEEL",SUP-K20-2054,CDM,S27200284,LOCAL,0272,RC,,,both,,,599.40,179.82,"KAISER [10500]",Kaiser,,401.6,67,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 20X20MM FORTIFY 0D 20MM FOOTPRINT LOWER",SUP-151.451,CDM,S27800098,LOCAL,0278,RC,,,both,,,3172.50,951.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,375.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,368.96,2696.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 18GA MAGSEED BREAST BIOPSY 7CM",SUP-SM18107001,CDM,A4648,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CIGNA [10200]","Cigna Open Access",,2112.41,56.9,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA F KNEE LEFT 2 PEG TIVANIUM STERILE",SUP-42530007501,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4059.75,28.62,,,,,0,1649.72,12057.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHOCKWAVE E8 150CM 80MM 4MM LITHOTRIPSY PERIPHERAL",SUP-E8IVL040080,CDM,C1725,HCPCS,0272,RC,,,both,,,29610.00,8883,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3508.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 60 LARGE KEEL AEQUALIS PERFORM SHOULDER",SUP-DWE523,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6334.88,68,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DIVERGENCE-L 15X9.4X5MM ANTERIOR OBLIQUE LUMBAR",SUP-736525,CDM,S27800098,LOCAL,0278,RC,,,both,,,9177.00,2753.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1067.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1067.29,7800.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 18MM 145CM 4MM CORONARY STENT",SUP-1145400-18,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AETNA [10100]","Aetna HMO/PPO",,4641.21,79.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 12MM 144CM 3.5MM CORONARY STENT",SUP-H7493911412350,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA [10200]","Cigna Open Access",,5202.08,56.9,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROXYUREA 500 MG CAPSULE",RX-10236,CDM,,,0637,RC,00904-6939-61,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Local Plus",,3.35,53.5,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Protek Solo",PX-E27200440,CDM,E27200440,LOCAL,0272,RC,,,both,,,38695.80,11608.74,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"THIOGUANINE 20 MG/ML ORAL SUSPENSION",RX-408888,CDM,,,0637,RC,08888-8884-05,NDC,both,30,ML,36235.62,10870.69,"PHCS [10601]",PHCS,,25364.93,70,,,,,0,4214.2,30800.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 18MM RESTORATION HA STRAIGHT CONICAL HIP",SUP-6276-7-118,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2014.9,14726.25,"percent of total billed charges",
"HC Plc Cath Ren Arty 1st Ord Bi",PX-361000092,CDM,36252,CPT,0361,RC,,,both,,,14951.46,4485.44,"KAISER [10500]",Kaiser,,10017.48,67,,,,,0,1738.85,12708.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 19GA 5.2-4.2FR 0-8CM ULTRASOUND CONTOUR",SUP-G31520,CDM,S27200284,LOCAL,0272,RC,,,both,,,2407.50,722.25,"CIGNA [10200]",Cigna,,1637.1,68,,,,,0,279.99,2046.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 4-0 P-3 18IN BRAID BLACK NONABSORBABLE",SUP-641G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 11/13 TAPER 32MM HIP COCR S-ROM STERILE",SUP-522032,CDM,S27800098,LOCAL,0278,RC,,,both,,,2882.88,864.86,"FIRST HEALTH [10303]","First Health",,2306.3,80,,,,,0,335.28,2450.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM COAXIAL HELIX 1 FILAR COIL POSITIVE",SUP-7741,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"NOVANET [10819]",Novanet,,1674.38,75,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 42X13.3X.61MM PRECISION THK.38MM XLONG WIDE THIN",SUP-2296-003-515,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"NOVANET [10819]",Novanet,,202.67,75,,,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 105CM 2FR BUGBEE SHORT TIP STERILE",SUP-BE-202,CDM,S27200284,LOCAL,0272,RC,,,both,,,745.97,223.79,"AETNA [10100]","Aetna HMO/PPO",,593.05,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.76,634.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDURANT II AUI 3-PIECE CASE",SUP-ENDURANTIIAUI3,CDM,S27800098,LOCAL,0278,RC,,,both,,,108300.00,32490,"CIGNA [10200]","Cigna Local Plus",,34114.5,31.5,,,,,0,12595.29,92055,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 57.5MM T2 TITANIUM FULL THREAD FEMUR HUMERUS",SUP-1896-5057S,CDM,C1713,HCPCS,0278,RC,,,both,,,1279.15,383.74,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,587.13,45.9,,,,,0,148.77,1087.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY LARYNGEAL MASK SIZE 2.5 SILICONE DISPOSABLE SOURCEMAR",SUP-SOUM0372,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.85,14.35,"CIGNA [10200]",Cigna,,32.54,68,,,,,0,5.56,40.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 60MM 125CM 6MM 6FR VASCULAR NITINOL",SUP-G43822,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"AMERIGROUP MEDICAID [20100]",Amerigroup,,447.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 20MM 144CM 2.5MM CORONARY STENT",SUP-H7493911420250,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1083.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 107MM 13MM 5.4MM 14FR SPIRAL-Z ZENITH",SUP-G55234,CDM,C1874,HCPCS,0278,RC,,,both,,,19435.50,5830.65,"KAISER [10500]",Kaiser,,13021.79,67,,,,,0,2260.35,16520.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mra Abdomen WO Cntrst",PX-610000044,CDM,74185,CPT,0610,RC,,,both,,,4010.00,1203,"PHCS [10601]",PHCS,,2807,70,,,,,0,466.36,3408.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM CEREPAK XTRASOFT FREEFORM",SUP-XCR120406,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1538.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.6MM 14MM VIP SPINE CERVICAL ANTERIOR VARIABLE",SUP-171.314,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CIGNA [10200]",Cigna,,958.8,68,,1831.33,1831.33,1831.33,16,163.98,1198.5,"percent of total billed charges",
"HC Bronchodil Responsiveness",PX-460000002,CDM,94060,CPT,0460,RC,,,both,,,977.84,293.35,"CIGNA [10200]","Cigna Local Plus",,523.14,53.5,,,,,0,113.72,831.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Meckel Divert",PX-341000021,CDM,78290,CPT,0341,RC,,,both,,,1730.12,519.04,"KAISER [10500]",Kaiser,,1159.18,67,,,,,0,201.21,1470.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPIDERFX .014IN 190CM 5MM EMBOLIC PROTECTION NITINOL",SUP-SPDRX-US-050,CDM,C1884,HCPCS,0272,RC,,,both,,,5859.00,1757.7,"MULTIPLAN [10600]",Multiplan,,4980.15,85,,,,,0,681.4,4980.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE RX BILIARY SYSTEM LOCKING BIOPSY CAP STERILE",SUP-4527,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross PPO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR",RX-29031,CDM,J0165,HCPCS,0636,RC,49502-0101-01,NDC,both,1,UN,943.13,282.94,"BLUE CROSS [10001]","Blue Cross HMO",,1.12,,,,,,,1.01,801.66,"fee schedule",
"CATH STERLING SL 150CM 150MM 2MM BALLOON DILATATION PEBAX",SUP-H74939147201510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 14MM TITANIUM LOW PROFILE FOOT HAND ANKLE",SUP-AR-8724V-14,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]",Cigna,,1101.6,68,,1831.33,1831.33,1831.33,16,188.41,1377,"percent of total billed charges",
"SCR BONE 3.5MM 26MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-26,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,170.52,39.2,,957.42,156.86,7483.26,51,50.59,369.75,"percent of total billed charges",
"IMPL BREAST 770CC SMOOTH SHELL SURFACE NATRELLE INSPIRA FULL",SUP-SRF-770,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"MULTIPLAN [10600]",Multiplan,,3373.65,85,,,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT225200,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"FIRST HEALTH [10303]","First Health",,276,80,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656320,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"MULTIPLAN [10600]",Multiplan,,1134.92,85,,,,,0,155.28,1134.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 16CM TRU-CORE II AUTOMATIC BIOPSY INSTR",SUP-763120160X,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.54,86.86,"PHCS [10601]",PHCS,,202.68,70,,,,,0,33.67,246.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM AVS ANCHOR-C TITANIUM SPINE SELF DRILL",SUP-48335312,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"BLUE CROSS [10001]","Blue Cross PPO",,368.48,39.2,,957.42,570.23,957.42,28,109.32,799,"percent of total billed charges",
"ARTOURA BREAST TISSUE EXPANDER HIGH PROJECTION 300CC",SUP-TEXP110RH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3939.69,28.62,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 4.8IN VENTRAL HERNIA COMPOSITE 3D",SUP-PCO12X,CDM,C1781,HCPCS,0278,RC,,,both,,,2638.00,791.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1210.84,45.9,,,,,0,306.8,2242.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 18FR URETHRAL BACTI-GUARD RUBBER HYDROGEL 5CC",SUP-0102SI18,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.46,38.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.06,110.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 10FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0165PL10,CDM,S27200284,LOCAL,0272,RC,,,both,,,57.33,17.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,26.31,45.9,,,,,0,6.67,48.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APOLLO ONYX 165CM 3CM 1.5-2.7FR .013IN MICRO INFUSION",SUP-105-5096-000,CDM,C1887,HCPCS,0272,RC,,,both,,,11667.90,3500.37,"PHCS [10601]",PHCS,,8167.53,70,,,,,0,1356.98,9917.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 150MM SCHANZ STAINLESS STEEL CONDYLAR HIP SELF",SUP-294.778,CDM,C1713,HCPCS,0278,RC,,,both,,,1094.39,328.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,129.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,127.28,930.23,"percent of total billed charges",
"CATH WEBSTER 115CM 6FR 10MM SPACE ELECTROPHYSIOLOGY FIX 4",SUP-F6QD010RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"FIRST HEALTH [10303]","First Health",,725.76,80,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM ORTHOLOC LONG CORTEX ANKLE FOOT 3DI",SUP-58802714,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 15IN 34-38FR VENOUS ATRIAL CAVAL ADULT 3/8IN",SUP-93463,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.70,87.81,"CIGNA [10200]","Cigna Open Access",,166.55,56.9,,,,,0,34.04,248.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 115MM 1.5MM TWIST J NOTCH 2MM SCR",SUP-25-469-11-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,1270.49,381.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,150.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.76,1079.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 4-0 P-12 12IN CLSR ABSORBABLE UNDYED",SUP-VLOCM0013,CDM,S27200284,LOCAL,0272,RC,,,both,,,381.15,114.34,"PHCS [10601]",PHCS,,266.81,70,,,,,0,44.33,323.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit Level 1",PX-450000311,CDM,99281,CPT,0450,RC,,,both,,,770.92,231.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,725,,,,,,,55.94,770.92,"case rate",
"LINER ACETABULAR PINNACLE 10D +4MM 56MM 40MM ALTRX HIP",SUP-122140156,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5521.38,40,,,,,0,1605.34,11732.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DRAGONFLY OPSTAR DIAGNOSTIC IMAGING STERILE LATEX FREE",SUP-1014651,CDM,S27200284,LOCAL,0272,RC,,,both,,,6472.20,1941.66,"CIGNA [10200]","Cigna Local Plus",,3462.63,53.5,,,,,0,752.72,5501.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 8MM 4MM MICRO100 MICROPOWER 8MM FLUTE ROUND",SUP-00509223600,CDM,S27200284,LOCAL,0272,RC,,,both,,,207.76,62.33,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,95.36,45.9,,,,,0,24.16,176.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM OFFSET TAPER 32MM HIP ALUMINA CERAMIC V40",SUP-6565-0-132,CDM,C1776,HCPCS,0278,RC,,,both,,,7383.00,2214.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,874.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,858.64,6275.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO S4 HYPERANGULATE LOW PROFILE BLADE GLIDESCOPE",SUP-0270-1084,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"CIGNA [10200]",Cigna,,236.64,68,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.5MM 100MM AFFIXUS 6.5MM HIP CANNULATED SELF TAP",SUP-814510100,CDM,C1713,HCPCS,0278,RC,,,both,,,6417.00,1925.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1836.55,28.62,,,,,0,746.3,5454.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 5X5CM GENTRIX PORCINE URINARY BLADDER",SUP-PSMX0505,CDM,C1781,HCPCS,0278,RC,,,both,,,2028.60,608.58,"CIGNA [10200]","Cigna Open Access",,1154.27,56.9,,11235.02,819.42,11235.02,"1 through 10",235.93,1724.31,"percent of total billed charges",
"CATH CPS DIRECT 10.06FR 135D GUIDING NONSTEERABLE",SUP-DS2C020,CDM,C1893,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"MULTIPLAN [10600]",Multiplan,,3196.43,85,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL PEDIATRIC MEDIUM O2 RESVR BAG MASK TUBE LATEX",SUP-530613000,CDM,S27000186,LOCAL,0270,RC,,,both,,,57.00,17.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SUPER TORQUE PLUS 100CM 6FR .044IN .042IN AMPLATZ RIGHT",SUP-533641,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Needle Cath Yueh",PX-E27200195,CDM,E27200195,LOCAL,0272,RC,,,both,,,166.10,49.83,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTTER ARTHROSCOPIC ANATOMIC SOCKET FLIPCUTTER II SHORT KNEE",SUP-AR-1204AS-105,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4MM 12MM SAPPHIRE SPINE SELF DRILL VARIABLE ANGLE",SUP-27240-012,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,958.8,68,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 14MM 3FR GEMINI HELICAL",SUP-M0063302060,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"AETNA [10100]","Aetna HMO/PPO",,1176.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TM REVERSE 36MM POLY LINER +3MM",SUP-00434903603,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"CIGNA [10200]","Cigna Local Plus",,4829.83,53.5,,5372.07,4581.20,7242.98,23,1049.92,7673.56,"percent of total billed charges",
"ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET",RX-14087,CDM,,,0637,RC,00406-0484-23,NDC,both,1,UN,12.78,3.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8.69,68,,,,,0,1.49,10.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE KIT FOR SOFT TISSUE APPROXIMATION LIGATION","SUP-GZL 002",CDM,S27200284,LOCAL,0272,RC,,,both,,,2996.25,898.87,"NOVANET [10819]",Novanet,,2247.19,75,,,,,0,348.46,2546.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.75/30",SUP-401767,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 4.5MM 45MM HAND INNATE INTRAMEDULLARY ANATOMIC",SUP-EXINN924545,CDM,C1713,HCPCS,0278,RC,,,both,,,5002.50,1500.75,"CIGNA [10200]",Cigna,,3401.7,68,,1831.33,1831.33,1831.33,16,581.79,4252.13,"percent of total billed charges",
"SUT PROLENE 6-0 BV-1 30IN 2 ARM MONOFILAMENT BLUE",SUP-8709H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZIPWIRE UROLOGICAL 150CM 3CM .035IN NITINOL",SUP-M006630222B1,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 40MM TSRH OSTEOGRIP THINLINE SPINE",SUP-83585409,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1750.32,68,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 6X4IN RIGHT HERNIA ANATOMICAL",SUP-TECT1510AR,CDM,C1781,HCPCS,0278,RC,,,both,,,1003.02,300.91,"MULTIPLAN [10600]",Multiplan,,852.57,85,,,,,0,116.65,852.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 82MM 10MM 14FR ENDURANT II ABDOMINAL",SUP-ETEW1010C82E,CDM,S27800098,LOCAL,0278,RC,,,both,,,28331.10,8499.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3357.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3294.91,24081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 65CM 5FR HK MOD CURVE ANGIOGRAPHIC PEBAX",SUP-7603-20M65SH,CDM,S27200284,LOCAL,0272,RC,,,both,,,733.13,219.94,"MULTIPLAN [10600]",Multiplan,,623.16,85,,,,,0,85.26,623.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISPOSABLE POLYPECTOMY COLD SNARES OUTER DIAMETER 2.4MM WORK",SUP-G61206,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"NOVANET [10819]",Novanet,,156.6,75,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIPASE-PROTEASE-AMYLASE (PORK) 3,000-9,500-15,000 UNIT CAPSULE,DEL REL",RX-111147,CDM,,,0637,RC,00032-0045-70,NDC,both,1,UN,10.94,3.28,"CIGNA [10200]","Cigna Local Plus",,5.85,53.5,,,,,0,1.27,9.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 9MM 140CM 3MM CORONARY STERILE LATEX",SUP-453928,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM ATTUNE 7 KNEE DISTAL CEMENT REVISION STERILE",SUP-154707001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4128.96,68,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cr West Nile Virus Igm-Expl832",PX-300000032,CDM,86788,CPT,0302,RC,,,both,,,358.00,107.4,"NOVANET [10819]",Novanet,,268.5,75,,,,,0,0.01,304.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT CYL 24X4IN 2 PORT TUBING LIMB PROTECTION SLEEVE",SUP-5921-024-235,CDM,S27200284,LOCAL,0272,RC,,,both,,,185.29,55.59,"UHC [10700]","United Healthcare",,117.29,63.3,,,,,0,21.55,157.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 125MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.447,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"FIRST HEALTH [10303]","First Health",,1107.3,80,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X11MM VERTE-STACK CORNERSTONE PSR",SUP-6240141,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA [10200]","Cigna Open Access",,3800.02,56.9,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRA-THIN SDS 90CM 40MM 5.3FR 7MM STD BALLOON",SUP-M001176570,CDM,C1725,HCPCS,0272,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colposcopy W/ Bx Cervix",PX-510000542,CDM,57455,CPT,0361,RC,,,both,,,1459.50,437.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1249,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1249,1459.5,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN DEBRIDEMENT WITH MCC",570,MS-DRG,,,,,,,inpatient,,,87589.05,26276.71,"PHCS [10601]",PHCS,,7561,,,,,,,7561,85868.36,"per diem","Estimated amount calculated based on 8 day length of stay."
"KIT TRACH 8MM PORTEX PREFIT PERCUTANEOUS STERILE LATEX FREE",SUP-101/815/080,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.48,103.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,233.57,68,,,,,0,39.95,291.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 30MM 14MM ATTUNE KNEE CEMENT REVISION STERILE",SUP-1512-14-030,CDM,C1776,HCPCS,0278,RC,,,both,,,5230.20,1569.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,619.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,608.27,4445.67,"percent of total billed charges",
"HC Reservoir Cardiotomy",PX-E27200266,CDM,E27200266,LOCAL,0272,RC,,,both,,,506.92,152.08,"CIGNA [10200]","Cigna Local Plus",,271.2,53.5,,,,,0,58.95,430.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Antidepressant Tricyclic 1 or 2",PX-301000494,CDM,80335,CPT,0301,RC,,,both,,,194.75,58.42,"UHC [10700]","United Healthcare",,102.99,,,,,,,0.01,194.75,"fee schedule",
"CRTDG STAPLE 60MM STERILE GIA LATEX FREE DISPOSABLE BLACK",SUP-GIA60XTC,CDM,S27200284,LOCAL,0272,RC,,,both,,,432.65,129.79,"MULTIPLAN [10600]",Multiplan,,367.75,85,,,,,0,50.32,367.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 6.5MM 7MM SCR HOLLOW NONSTERILE",SUP-309.065,CDM,S27200284,LOCAL,0272,RC,,,both,,,2918.70,875.61,"AETNA [10100]","Aetna HMO/PPO",,2320.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,339.44,2480.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 130MM 5.5MM STRAIGHT PERCUTANEOUS CCM",SUP-1555006130,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 4 KNEE CEMENT REVISION ROTATE PLATFORM",SUP-1506-60-004,CDM,C1776,HCPCS,0278,RC,,,both,,,22629.60,6788.88,"KAISER [10500]",Kaiser,,15161.83,67,,,,,0,2631.82,19235.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Admin Hyperbaric O2 per 30min",PX-413000001,CDM,G0277,HCPCS,0413,RC,,,both,,,1849.00,554.7,"FIRST HEALTH [10303]","First Health",,1479.2,80,,,,,0,215.04,1849,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE IRRIGATION",SUP-111613,CDM,S27200284,LOCAL,0272,RC,,,both,,,899.10,269.73,"AETNA [10100]","Aetna HMO/PPO",,714.78,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.57,764.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 46MM 15MM STAINLESS STEEL CANNULATED STERILE",SUP-121846,CDM,C1713,HCPCS,0278,RC,,,both,,,2006.40,601.92,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,233.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",233.34,1705.44,"percent of total billed charges",
"SET EXT 3.5CM 20FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-20-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"KAISER [10500]",Kaiser,,521.97,67,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 50MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.486,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA [10200]","Cigna Open Access",,2755.44,56.9,,1144.80,304.56,2275.09,66,563.19,4116.21,"percent of total billed charges",
"CANN ARTHROSCOPIC 5.2MM 120MM DRAGONWING LARGE AUTOGRAFT",SUP-AD5CH52120,CDM,S27200284,LOCAL,0272,RC,,,both,,,8273.10,2481.93,"UHC [10700]","United Healthcare",,5236.87,63.3,,,,,0,962.16,7032.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Ferguson Vent Lt",PX-E27200352,CDM,E27200352,LOCAL,0272,RC,,,both,,,155.10,46.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,105.47,68,,,,,0,18.04,131.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 8FR L22CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902410,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CELECOXIB 200 MG CAPSULE",RX-24501,CDM,,,0637,RC,50268-0169-11,NDC,both,1,UN,12.21,3.66,"MULTIPLAN [10600]",Multiplan,,10.38,85,,,,,0,1.42,10.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 45MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75448545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"GRAFT BONE RIGHT LATERAL FEMORAL CORTICAL THK3-15MM THIRD",SUP-450974,CDM,S27800098,LOCAL,0278,RC,,,both,,,5775.30,1732.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3927.2,68,,,,,0,671.67,4909.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 5CM CHIBA STERILE DISPOSABLE ASPIRATION",SUP-G02585,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO BREAST BIOPSY 14GA SERTERA NONSTERILE LATEX FREE","SUP-SERTERA INTRO-14",CDM,S27200284,LOCAL,0272,RC,,,both,,,177.22,53.17,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL TUNNELING 338MM 3.1MM STAINLESS STEEL 6996SQ LEAD",SUP-6996T,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL INTRAVENOUS 0.45% SODIUM CHLORIDE 500ML LIFECARE LATEX",SUP-798503,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO LD WORLEY JMB CRV CS",SUP-361684,CDM,C1892,HCPCS,0272,RC,,,both,,,3339.00,1001.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX ULTRAVERSE 130CM 300MM 5MM BALLOON DILATATION",SUP-LX1813053005F,CDM,C2623,HCPCS,0272,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH NC TREK NEO 20MM 145CM 3.25MM BALLOON DILATATION",SUP-1400325-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC",087,MS-DRG,,,,,,,inpatient,,,41061.01,12318.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,,68,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH ENDOSCP 4MM 13.4MM STRAIGHT ROUND SOFT SIDEHOLE",SUP-D-201-12704,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.26,63.08,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cryptosporidium Ag Eia",PX-306000100,CDM,87328,CPT,0306,RC,,,both,,,66.30,19.89,"KAISER [10500]",Kaiser,,44.42,67,,,,,0,0.01,56.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Upr Ext Jnt W Cntrst",PX-610000028,CDM,73222,CPT,0610,RC,,,both,,,3889.39,1166.82,"NOVANET [10819]",Novanet,,2917.04,75,,,,,0,452.34,3305.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Spine Lumb/Thor 2+ V",PX-320000042,CDM,72080,CPT,0320,RC,,,both,,,686.11,205.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,38.7,,,,,,,38.7,583.19,"fee schedule",
"DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION",RX-9815,CDM,J7042,HCPCS,0636,RC,00990-7941-09,NDC,both,1000,ML,100.65,30.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.08,,"Fee schedule rate ($3.08). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.74,85.55,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Pulse Gen Mult Leads",PX-480000015,CDM,33221,CPT,0481,RC,,,both,,,7603.22,2280.97,"AETNA [10100]","Aetna HMO/PPO",,6044.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,884.25,7603.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Del Placenta",PX-720000002,CDM,59414,CPT,0720,RC,,,both,,,3611.29,1083.39,"FIRST HEALTH [10303]","First Health",,2889.03,80,,,,,0,419.99,3611.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL EMPHASYS POLYETHYLENE LINER EXTR SCR",SUP-481500092,CDM,S27200284,LOCAL,0272,RC,,,both,,,3742.91,1122.87,"FIRST HEALTH [10303]","First Health",,2994.33,80,,,,,0,435.3,3181.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC RBC Ag Not Abo/Rh(D) Ea",PX-302000196,CDM,86905,CPT,0302,RC,,,both,,,92.30,27.69,"NOVANET [10819]",Novanet,,69.23,75,,,,,0,0.01,78.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla I Typing Complete Lr",PX-309000081,CDM,81372,CPT,0310,RC,,,both,,,1427.00,428.1,"FIRST HEALTH [10303]","First Health",,1141.6,80,,,,,0,1.43,1212.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vrtplsty Cerv/Thor Lumb/Sac W Img Add",PX-361000377,CDM,22512,CPT,0361,RC,,,both,,,8890.00,2667,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1053.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1033.91,8890,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE FLEXIBLE 600MM 5MM 2.2MM AMBU ASCOPE STERILE",SUP-621001000US,CDM,C1601,HCPCS,0272,RC,,,both,,,2362.50,708.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1606.5,68,,,,,0,274.76,2008.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR SHUNT CDI HEPARIN 1.2ML SYSTEM 500 STERILE DISPOSABLE",SUP-CDI510H,CDM,S27200284,LOCAL,0272,RC,,,both,,,15414.60,4624.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1792.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1792.72,13102.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 70MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.870,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"MULTIPLAN [10600]",Multiplan,,213.27,85,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 5 1/8IN LAMBOTTE SWISS PATTERN SURGICAL MINI",SUP-27-5704,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.07,40.82,"FIRST HEALTH [10303]","First Health",,108.86,80,,,,,0,15.82,115.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL WEREWOLF FLOW 90 STERILE LATEX FREE",SUP-72290038,CDM,S27200284,LOCAL,0272,RC,,,both,,,1788.75,536.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,211.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,208.03,1520.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL VASCU-STATT II 75-80GM CLAMPING PRESSURE MIDI",SUP-1001-532,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.36,32.81,"CIGNA [10200]","Cigna Open Access",,62.23,56.9,,,,,0,12.72,92.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 15MM 2.25MM BALLOON DILATATION PACLITAXEL",SUP-H7493960815220,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"AETNA [10100]","Aetna HMO/PPO",,30927.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 60MM 4MM .014IN BALLOON DILATATION",SUP-AB14W040060150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"AETNA [10100]","Aetna HMO/PPO",,1101.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 60MM 120CM 6MM 6FR VASCULAR PERIPHERAL",SUP-S-60-060-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2879.74,28.62,,,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 9MM CANNULATED ACL LOW PROFILE STERILE",SUP-AR-1409LP,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 100CM 5FR BARNH CURVE ANGIOGRAPHIC CEREBRAL",SUP-M001314041,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"NOVANET [10819]",Novanet,,87.44,75,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 26CM 3CM 5FR .038IN STRAIGHT URETERAL",SUP-M006155223010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]","Cigna Local Plus",,658.56,,,,,,,143.16,1046.32,"percent of total billed charges",
"STENT ADVANIX 18CM 10FR STRAIGHT PANCREATIC POLYMER DRNG",SUP-M00536730,CDM,C2617,HCPCS,0278,RC,,,both,,,722.28,216.68,"BLUE CROSS [10001]","Blue Cross PPO",,283.13,39.2,,,,,0,84,613.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 445CC NATRELLE INSPIRA COHESIVE STERILE LATEX",SUP-SCM-445,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DANTROLENE 25 MG CAPSULE",RX-9718,CDM,,,0637,RC,50268-0217-11,NDC,both,1,UN,11.96,3.59,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC US OB >1st Trimst Txabd Add",PX-402000017,CDM,76810,CPT,0402,RC,,,both,,,1266.00,379.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure count. Procedure 1, Fee schedule rate ($94.14). Procedures 2 - 999, Fee schedule rate ($47.07).",,,,0,,,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT GREEN 44X4IN XLONG LEG 1 FILL LINE POSITIVE LOCK",SUP-ASP-564014,CDM,S27200284,LOCAL,0272,RC,,,both,,,202.86,60.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUFF TRNQT WHITE 30X4IN MEDIUM LEG 1 FILL LINE POSITIVE LOCK",SUP-ASP-564010,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.01,53.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FORCEPS ELECSURG BPLR SHRP 1.5MMX7.75IN DISP",SUP-191003C,CDM,S27200284,LOCAL,0272,RC,,,both,,,369.75,110.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MICROCATHETER CEREBROVASCULAR 150CM 2.4-1.7FR .0165IN",SUP-M0031681920,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE V-LOC 90 2-0 GS-22 .5 CIRCLE 9IN 27MM CLSR TAPER",SUP-VLOCM2245,CDM,S27200284,LOCAL,0272,RC,,,both,,,405.94,121.78,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 13CM 4MM 70D 12000- RPM TAPER FRONTAL SINUS",SUP-1883672HS,CDM,S27200284,LOCAL,0272,RC,,,both,,,3115.00,934.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,362.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,362.27,2647.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 90MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE TAPER TIP",SUP-02.107.302,CDM,C1713,HCPCS,0278,RC,,,both,,,5840.44,1752.13,"CIGNA [10200]","Cigna Open Access",,3323.21,56.9,,1144.80,304.56,2275.09,66,679.24,4964.37,"percent of total billed charges",
"CATH EUPHORA 142CM 12MM 3MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3012X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 30MM 6FR 2.5MM",SUP-H7493926730250,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 20MM 29MM MOSAIC ULTRA CINCH RING PORCINE STENT",SUP-305U229,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"UHC [10700]","United Healthcare",,17347.37,63.3,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 47.5MM TITANIUM 3 LEVEL ATLANTIS VISION ELITE BONE",SUP-7200147,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1514.57,28.62,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 68MM STAINLESS STEEL T8 ELBOW METAPHYSEAL",SUP-02.118.568,CDM,C1713,HCPCS,0278,RC,,,both,,,547.40,164.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,63.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",63.66,465.29,"percent of total billed charges",
"FLUCYTOSINE 500 MG CAPSULE",RX-10052,CDM,,,0637,RC,43386-0770-01,NDC,both,1,UN,600.28,180.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,246.72,41.1,,,,,0,69.81,510.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRACTOR ABDOMINAL RIBBON TISSUE HAND HELD MALLEABLE 8IN LE",SUP-22-0017,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.04,24.61,"KAISER [10500]",Kaiser,,54.97,67,,,,,0,9.54,69.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE HEXAGONAL 4.5CM 3CM 7FR ACUSNARE 1 PIECE GRADUATED",SUP-G22700,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.43,49.33,"PHCS [10601]",PHCS,,115.1,70,,,,,0,19.12,139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 5-7MM LEVEL 2 LOCK ROI-C BONE SPINE",SUP-MC1005T,CDM,C1713,HCPCS,0278,RC,,,both,,,18000.00,5400,"UHC [10700]","United Healthcare",,11394,63.3,,5023.51,2672.93,6679.78,18,2093.4,15300,"percent of total billed charges",
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL TITANIUM LOW",SUP-AR-8719MXDS-1515,CDM,C1713,HCPCS,0278,RC,,,both,,,17215.50,5164.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4927.08,28.62,,,,,0,2002.16,14633.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 7.5% IN WATER INFUSION",RX-410561,CDM,,,0258,RC,08888-8879-92,NDC,both,250,ML,100.65,30.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 6.5MM CANNULATED REVOLVE SURGICAL SPINE GLOB",SUP-685.065,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"UHC [10700]","United Healthcare",,2504.4,63.3,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 2.4MM 26MM TITANIUM CORTICAL HAND SELF TAPPING NO",SUP-401.526.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"MULTIPLAN [10600]",Multiplan,,507.01,85,,,,,0,69.37,507.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL MEMORYSHAPE MEDIUM HEIGHT MODERATE PLUS PROFILE",SUP-RSZ-1005S,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.55,69.16,"CIGNA [10200]","Cigna Open Access",,131.18,56.9,,,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14FR CORONARY SINUS RETROGRADE MANUAL INFLATE",SUP-PLD014MIBH,CDM,S27200284,LOCAL,0272,RC,,,both,,,653.75,196.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,77.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,76.03,555.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23.5 DIOPTER UV ABSORBENT CLAREON AUTONOME",SUP-CCA0T0.235,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR INSTR HUMERAL CUP TRIAL REUNION STERILE LATEX FREE",SUP-5901-6056,CDM,C1776,HCPCS,0278,RC,,,both,,,2073.00,621.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,593.29,28.62,,,,,0,241.09,1762.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 545CC 12.5CM 6.1CM PROJECTION HIGH PROFILE SM",SUP-SHPB545,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"CIGNA [10200]","Cigna Open Access",,4338.34,56.9,,5166.00,5166.00,5166.00,"1 through 10",886.73,6480.83,"percent of total billed charges",
"HC Colposcopy W/ Bx Cervix",PX-510000542,CDM,57455,CPT,0761,RC,,,both,,,1459.50,437.85,"CIGNA [10200]","Cigna Open Access",,1459.5,,"Per diem ($2,181).",,,,0,169.74,1459.5,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC MEDIUM 20IN 16-18IN KNEE CONTOUR POSTERIOR",SUP-4462-03,CDM,L1830,HCPCS,0274,RC,,,both,,,140.77,42.23,"BLUE CROSS [10001]","Blue Cross PPO",,55.18,39.2,,,,,0,16.37,119.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 8MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR081502A,CDM,C1874,HCPCS,0278,RC,,,both,,,24374.70,7312.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10018,41.1,,,,,0,2834.78,20718.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR NEONATE LNCS NEO-3 3FT OXIMETER ADHSV SPO2 STERILE",SUP-2604,CDM,S27000186,LOCAL,0270,RC,,,both,,,148.77,44.63,"PHCS [10601]",PHCS,,104.14,70,,,,,0,17.3,126.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 16MM STERNALOCK BLU STERNAL CANCELLOUS SELF",SUP-73-2416,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,153.47,39.2,,957.42,156.86,7483.26,51,45.53,332.78,"percent of total billed charges",
"PLUG BONE CEMENT 18.5MM SMALL INTRAMEDULLARY CANAL STERILE",SUP-6215-5-001,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,517.75,68,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 6-0 P-1 18IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y489G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 10X80 80CM SL",SUP-48010008N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"PHCS [10601]",PHCS,,601.31,70,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 60MM 16MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-1513-16-060,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"MULTIPLAN [10600]",Multiplan,,7026.27,85,,,,,0,961.36,7026.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP NANO HUM/MD GLD/PLY PST/VSDL HD/INS",SUP-98000900235,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,8601.07,8395.67,8601.07,"1 through 10",3297.11,24097.5,"percent of total billed charges",
"ROD SPINAL 50MM",SUP-8847050,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 80X6.4X.6MM LONG STAINLESS STEEL RECIPROCATE",SUP-0277-096-300,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.85,90.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,34.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.99,255.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ATTAIN HYBRID VASCULAR STRAIGHT 108CM .018IN STABILITY",SUP-GWR419688,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 38MM PHOENIX TITANIUM CORTICAL SELF TAP 2 LEAD",SUP-14-405038,CDM,C1713,HCPCS,0278,RC,,,both,,,2475.00,742.5,"NOVANET [10819]",Novanet,,1856.25,75,,,,,0,287.84,2103.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CELL SAVER VACUUM LINE AUTOTRANSFUSION TUBING NONSTERILE",SUP-HAR-A-1000,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.79,29.94,"CIGNA [10200]",Cigna,,67.86,68,,,,,0,11.61,84.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE TIBIAL 14.5MM PFC SIGMA 20D 3 HEMI KNEE TITANIUM",SUP-860179,CDM,C1776,HCPCS,0278,RC,,,both,,,8260.68,2478.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2364.21,28.62,,,,,0,960.72,7021.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 6CM 10MM BALLOON DILATATION OTW LOW",SUP-G30929,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 157CM 2.4-2FR .017IN TREVO XP",SUP-90231,CDM,S27200284,LOCAL,0272,RC,,,both,,,7221.82,2166.55,"CIGNA [10200]",Cigna,,4910.84,68,,,,,0,839.9,6138.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 2CM 5MM 6FR BALLOON DILATATION",SUP-V185020,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"AETNA [10100]","Aetna HMO/PPO",,4360.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 12MM 6MM STD WALL THIN WALL 2 BRANCH",SUP-SBT1202D,CDM,C1768,HCPCS,0278,RC,,,both,,,8611.20,2583.36,"BLUE CROSS [10001]","Blue Cross PPO",,3375.59,39.2,,,,,0,1001.48,7319.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO FUCHSIA 11CM 10FR BRITE TIP SILICONE KINK",SUP-401011M,CDM,C1894,HCPCS,0272,RC,,,both,,,60.90,18.27,"PHCS [10601]",PHCS,,42.63,70,,,,,0,7.08,51.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUPERCORE ECHOGENIC 9CM 4.2CM 20GA 19GA BIOPSY",SUP-701220090,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.53,140.26,"CIGNA [10200]",Cigna,,317.92,68,,,,,0,54.37,397.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 60-75MM 9-11MM KNEE QUADLINK PRESUTURED",SUP-FQL,CDM,S27800098,LOCAL,0278,RC,,,both,,,17043.00,5112.9,"CIGNA [10200]","Cigna Open Access",,5709.41,33.5,,,,,0,1982.1,14486.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SUCTION BF-20 ENF-T3 NONSTERILE LATEX FREE REUSABLE",SUP-MD-493,CDM,S27200284,LOCAL,0272,RC,,,both,,,1173.61,352.08,"AETNA [10100]","Aetna HMO/PPO",,933.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.49,997.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE INFILTRAC VASCULAR 190CM TIP .014IN",SUP-1030001J,CDM,C1769,HCPCS,0272,RC,,,both,,,1036.80,311.04,"KAISER [10500]",Kaiser,,694.66,67,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLIDE HER 2 PATHWAY 4 IN 1 PARAFFIN EMBED CONTROL",SUP-781-2991,CDM,S27000186,LOCAL,0270,RC,,,both,,,226.46,67.94,"MULTIPLAN [10600]",Multiplan,,192.49,85,,,,,0,26.34,192.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 23X16.5X2.5MM TITANIUM 4/4.5MM SCR 1 LEVEL INTEGRATED",SUP-04.613.014,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,957.42,570.23,957.42,28,521.61,3812.25,"percent of total billed charges",
"ABRE VENOUS SELF-EXPADING STENT18X120X90",SUP-AB9T18120090,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER 19CM 4.2MM CURVE HIP LENGTH ADAPTEUR POWER SYSTEM",SUP-AR-6420CBC,CDM,S27200284,LOCAL,0272,RC,,,both,,,654.89,196.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,77.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,76.16,556.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTNR STRLZTN 23.25X10.75X5.25IN SOLID BOTTOM",SUP-JK442,CDM,S27200284,LOCAL,0272,RC,,,both,,,2055.83,616.75,"FIRST HEALTH [10303]","First Health",,1644.66,80,,,,,0,239.09,1747.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO FUCHSIA 11CM 10FR BRITE TIP SILICONE KINK",SUP-401011M,CDM,C1894,HCPCS,0272,RC,,,both,,,60.90,18.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.08,51.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDO 2-0 CT-1 SPIRAL 30CM SUT ABSORBABLE",SUP-SXPD1B401,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.13,55.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,84.52,45.9,,,,,0,21.41,156.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION|DISCARDED DRUG NOT ADMINISTE",RX-3037,CDM,J3010,HCPCS,0636,RC,00641-6028-01,NDC,both,5,ML,20.84,6.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",JW,4.64,,,,,,,2.47,17.71,"fee schedule",
"SCR BONE 4MM 22MM QUARTEX SPINE POLYAXIAL NONSTERILE LATEX",SUP-1149.4022,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"KIT INTRO 4 1/8IN 8.5FR 7-7.5FR ARROWG+ARD BLUE ARROW-FLEX",SUP-AK-29803-CDC,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 22CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155241050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]","Cigna Local Plus",,658.56,,,,,,,143.16,1046.32,"percent of total billed charges",
"HC Total Tau",PX-301000702,CDM,84394,CPT,0301,RC,,,both,,,630.00,189,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,428.4,68,,,,,0,0.01,535.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 3MM25CM 190",SUP-R51003025L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1694.48,68,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 5X4IN DURAGEN CRANIUM BOVINE CLLGN MATRIX",SUP-ID4501,CDM,,,0278,RC,,,both,,,10871.57,3261.47,"BLUE CROSS [10001]","Blue Cross HMO",,10.87,.1,,,,,0,10.87,9240.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRECEPT TI ROD, 95MM PREBENT LORDOTIC",SUP-8847095,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EPIDURAL CLEAR 30X26IN 19GA FLEXBLOCK SNAPTEAR STATLOCK",SUP-FB-19608-KU,CDM,S27200284,LOCAL,0272,RC,,,both,,,491.30,147.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,57.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.14,417.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 22CM 3CM 7FR .035IN 2",SUP-M006192141180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,188.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 11MM SURGICAL PARALLEL GRAFT KNIFE STERILE",SUP-AR-2285-11,CDM,S27200284,LOCAL,0272,RC,,,both,,,429.35,128.8,"PHCS [10601]",PHCS,,300.55,70,,,,,0,49.93,364.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM CREO SPINE PREASSEMBLE THREAD",SUP-5119.1742,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 80MM 7FR 6MM 5FR BALLOON DILATATION",SUP-39032-60801,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AICD LEAD PROCEDURES",265,MS-DRG,,,,,,,inpatient,,,82933.12,24879.94,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,23790.56,,"Case rate ($22,443.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,840.70, add-ons for qualifying new technology services are included. If operating cost exceeds $53,880.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,957.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $20,868.26. The transfer operating threshold is the transfer adjustment factor * $20,840.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,575.66. The transfer capital threshold is the transfer adjustment factor * $1,575.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 106%.",,,,0,6245,82933.12,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 102MM 2.7MM STAINLESS STEEL QUICK CONNECT 76MM",SUP-KM166-310-26,CDM,S27200284,LOCAL,0272,RC,,,both,,,198.53,59.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.09,168.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMIKACIN 1,000 MG/4 ML VIAL",RX-123478,CDM,J0278,HCPCS,0636,RC,23155-0290-32,NDC,both,4,ML,129.56,38.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7.34,,,,,,,6.34,110.13,"fee schedule",
"BASEPLT TIBIAL EVOLUTION MP 5 STD KNEE LEFT KEEL NONPOROUS",SUP-ETPKN5SL,CDM,C1776,HCPCS,0278,RC,,,both,,,15193.80,4558.14,"BLUE CROSS [10001]","Blue Cross PPO",,5955.97,39.2,,3949.44,3949.44,3949.44,"1 through 10",1767.04,12914.73,"percent of total billed charges",
"CMPNT FEMORAL 4 RIGHT KNEE CRUCIATE RETAINING CEMENTED",SUP-5510-F-402,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6739.52,41.1,,6417.48,6417.48,6417.48,"1 through 10",1907.07,13938.17,"percent of total billed charges",
"TOOL 9CM MR8 7.5MM BALL DISSECTING",SUP-MR8-9BA75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1187.46,356.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,140.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,138.1,1009.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 19MM 90CM 4MM BILIARY STAINLESS",SUP-H74937912419900,CDM,C1876,HCPCS,0278,RC,,,both,,,3967.50,1190.25,"MULTIPLAN [10600]",Multiplan,,3372.38,85,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 70MM KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-183112,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"CIGNA [10200]","Cigna Local Plus",,6824.7,31.5,,5372.07,4581.20,7242.98,23,2519.72,18415.85,"percent of total billed charges",
"HEAD FEMORAL -2MM 12/14 TAPER 22MM HIP COCR VERSYS STERILE",SUP-00801802220,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3298.48,68,,,,,0,564.14,4123.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 14MM FOOT ANKLE NONLOCKING",SUP-5201124014,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,90.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",88.55,647.19,"percent of total billed charges",
"STENT ZIPWIRE 24CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT",SUP-M006145361170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"PHCS [10601]",PHCS,,790.97,70,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SCLEROTHERAPY 25GA INJECTION PROJECTION STERILE",SUP-00711811,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"MULTIPLAN [10600]",Multiplan,,281.01,85,,,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 17.5MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158104117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3198.16,28.62,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUNAV 90CM 10FR ULTRASOUND INTRACARDIAC 4 WAY STEERING",SUP-10043342,CDM,C1759,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 32MM 144CM 3.5MM CORONARY STENT",SUP-H7493911432350,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE NDL 9GA DISPOSABLE EVIVA","SUP-EVIVA NG09L",CDM,S27200284,LOCAL,0272,RC,,,both,,,90.31,27.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,61.41,68,,,,,0,10.5,76.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 65MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.065,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"MULTIPLAN [10600]",Multiplan,,175.41,85,,,,,0,24,175.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI L 8MMX1MM MID FACE RIGHT 4 HOLE BAR 2MM SCR BONE",SUP-55-08232,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,1831.33,1831.33,1831.33,16,189.34,1383.8,"percent of total billed charges",
"CATHETER MARINR 90CM 7FR 2-2-2MM SPACING CORONARY SINUS CURV",SUP-043302M,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 25D SMALL AUG CORTILOC SHOULDER RIGHT",SUP-DWK403RA25S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"BLUE CROSS [10001]","Blue Cross HMO",,4116,39.2,,5311.50,4717.44,5388.59,31,1221.15,8925,"percent of total billed charges",
"SCR BONE 5.5MM 25MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.25,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.50,506.25,"FIRST HEALTH [10303]","First Health",,1350,80,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR AR1 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916599842,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"AETNA [10100]","Aetna HMO/PPO",,60.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC",409,MS-DRG,,,,,,,inpatient,,,121020.17,36306.05,"AETNA [10100]","Aetna HMO/PPO",,40965.9,,"Fee schedule rate ($40,965.90). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,63568.45,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25X9MM THK.51MM THK.56MM SMALL BONE OSCILLATE",SUP-KM33-111,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.65,24.19,"NOVANET [10819]",Novanet,,60.49,75,,,,,0,9.38,68.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 8CM 5FR 7MM .035IN BALLOON",SUP-G52274,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"MULTIPLAN [10600]",Multiplan,,815.8,85,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 80MM 125CM 8MM 6FR .035IN VASCULAR NITINOL",SUP-G43833,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"AMERIGROUP MEDICAID [20100]",Amerigroup,,447.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 62X56MM KNEE LEFT POSTERIOR STABILIZE",SUP-81-4405L,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4378.98,27,,,,,0,1886.21,13785.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 54MM 36MM ALTRX HIP",SUP-1221-36-154,CDM,C1776,HCPCS,0278,RC,,,both,,,11405.70,3421.71,"PHCS [10601]",PHCS,,7983.99,70,,,,,0,1326.48,9694.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP CONSTRUCT 2 W TRITANTIUM",SUP-CAP-STY-H2,CDM,C1776,HCPCS,0278,RC,,,both,,,25830.00,7749,"KAISER [10500]",Kaiser,,17306.1,67,,,,,0,3004.03,21955.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0205,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"NOVANET [10819]",Novanet,,1002.38,75,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Vad Tunl W Port Age 5 Yr/>",PX-361000111,CDM,36561,CPT,0361,RC,,,both,,,8433.66,2530.1,"AETNA [10100]","Aetna HMO/PPO",,6704.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",10026.54,10026.54,10026.54,"1 through 10",980.83,8239,"percent of total billed charges",
"FIBER LASER FLEXIVA 200UM FLEXSHIELD HIGH POWER POLISH",SUP-M0068403911,CDM,S27200284,LOCAL,0272,RC,,,both,,,2720.04,816.01,"CIGNA [10200]",Cigna,,1849.63,68,,,,,0,316.34,2312.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STONETOME 30MM 200CM 20MM 11.5MM 5.5FR STONE REMOVAL",SUP-M00535130,CDM,S27200284,LOCAL,0272,RC,,,both,,,2611.73,783.52,"FIRST HEALTH [10303]","First Health",,2089.38,80,,,,,0,303.74,2219.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 365CC",SUP-SSZ-F365,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,173.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.33,1266.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DISTAL FEMUR 5D KIDNEY BEAN ANATOMIC BIPLANAR",SUP-PLP-3005,CDM,S27800098,LOCAL,0278,RC,,,both,,,10177.50,3053.25,"MULTIPLAN [10600]",Multiplan,,8650.88,85,,,,,0,1183.64,8650.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.2MM 230MM PRECISION KIRSCHNER SMOOTH",SUP-P27-192-3023,CDM,S27000186,LOCAL,0270,RC,,,both,,,237.51,71.25,"CIGNA [10200]",Cigna,,161.51,68,,,,,0,27.62,201.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 12MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE45012,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"PHCS [10601]",PHCS,,58565.22,70,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-1-2-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"BLUE CROSS [10001]","Blue Cross PPO",,4584.64,39.2,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOBRAMYCIN 40 MG/ML INJECTION SOLUTION",RX-97790,CDM,J3260,HCPCS,0636,RC,67457-0428-00,NDC,both,30,ML,197.28,59.18,"BLUE CROSS [10001]","Blue Cross HMO",,41.43,,,,,,,36.47,167.69,"fee schedule",
"EPIFIX 18 MM DISK",SUP-GS-5180-10,CDM,Q4186,HCPCS,0636,RC,,,both,,,4278.69,1283.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2909.51,68,,,,,0,406.44,3636.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 8 EXTREME LATERAL INTERBODY FUSION 2 HOLE DECADE BONE",SUP-7140208,CDM,C1713,HCPCS,0278,RC,,,both,,,13800.00,4140,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3726,27,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP SURGICAL 3CM ADVINCULA DELINEATOR KOH-EFFICIENT KOH",SUP-AD750-KE30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 20MM 8MM .035IN BALLOON",SUP-AB35W08020135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS HIGHFLOW 100CM 7FR JL5 CURVE ANGIOGRAPHIC DUCOR",SUP-527722,CDM,C1887,HCPCS,0272,RC,,,both,,,137.11,41.13,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM EVOLUT FX DELIVERY 34 MM",SUP-D-EVOLUTFX-34,CDM,S27200284,LOCAL,0272,RC,,,both,,,14559.00,4367.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 240MM 6MM BALLOON DILATATION STERILE LATEX",SUP-586024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC",959,MS-DRG,,,,,,,inpatient,,,118309.32,35492.8,"CIGNA [10200]","Cigna Open Access",,,56.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG 14CM C125ML 8MM ANCHOR TISSUE RETRIEVAL SYSTEM SPECIMEN",SUP-TRS-ROBO-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,780.14,234.04,"AETNA [10100]","Aetna HMO/PPO",,620.21,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.73,663.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM .0108IN AXIUM PRIME HELICAL EXTRA",SUP-APB-3-4-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"PHCS [10601]",PHCS,,6254.85,70,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 25MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G325,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"UHC [10700]","United Healthcare",,5928.73,63.3,,8601.07,8395.67,8601.07,"1 through 10",1089.28,7961.17,"percent of total billed charges",
"SCR BONE 2.4MM 12MM STAINLESS STEEL T8 CORTEX TUBE STARDRIVE",SUP-201.762TS,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"MULTIPLAN [10600]",Multiplan,,404.84,85,,,,,0,55.39,404.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Non Weighted Prosthesis",PX-E27000250,CDM,L8020,HCPCS,0270,RC,,,both,,,705.10,211.53,"CIGNA [10200]","Cigna Local Plus",,377.23,53.5,,,,,0,82,599.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP SOLID BACK METAL HA TRIDENT D",SUP-500-11-48D,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.85,2973.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2836.77,28.62,,,,,0,1152.75,8425.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMALL PERIPHERAL CUTTING BALLOON 142CM 1.5CM 2MM",SUP-M001PCB02015140F0,CDM,C1725,HCPCS,0272,RC,,,both,,,4854.15,1456.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3300.82,68,,,,,0,564.54,4126.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 52MM 28MM 10D HIP CROSSFIRE OMNIFIT STERILE",SUP-2041C-2852,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"KAISER [10500]",Kaiser,,4715.46,67,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 30MM CEMENTLESS ACCOLADE TMZF 1 HIP",SUP-6021-0130,CDM,C1776,HCPCS,0278,RC,,,both,,,22821.75,6846.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2704.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2654.17,19398.49,"percent of total billed charges",
"INSRT TIBIAL 2 19MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-219,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"BLUE CROSS [10001]","Blue Cross HMO",,3853.56,39.2,,5311.50,4717.44,5388.59,31,1143.29,8355.94,"percent of total billed charges",
"CATH ACUITY PRO 7FR 130D CS-IC CURVE GUIDING INNER",SUP-8103,CDM,C1887,HCPCS,0272,RC,,,both,,,1386.50,415.95,"NOVANET [10819]",Novanet,,1039.88,75,,,,,0,161.25,1178.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 39MM TORNIER AEQUALIS PERFORM +3MM SHOULDER",SUP-DWJ023,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"KAISER [10500]",Kaiser,,8169.31,67,,,,,0,1418.05,10364.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD + VE",SUP-98000700015,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7212.24,28.62,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13-12.8CM NATRELLE P5.7-6.3CM HIGH PROFILE ROUND",SUP-SZHP68500,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,35.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST GEL SMOOTH ROUND MODERATE PLUS PROFILE 290CC",SUP-SMPB290,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2182.13,28.62,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS ETHIGUARD 0 CTX-B 36IN BRAID ANTIBACTERIAL",SUP-VCPB978H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Local Plus",,13.38,53.5,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT BLACK 22CM 8.5FR 2 PIGTAIL CURVE STRAIGHT URETERAL",SUP-G46434,CDM,C2617,HCPCS,0278,RC,,,both,,,1194.75,358.42,"FIRST HEALTH [10303]","First Health",,955.8,80,,,,,0,138.95,1015.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy US Ea 15min (Gp)",PX-420000020,CDM,97035,CPT,0420,RC,,,both,,,163.34,49,"UHC [10700]","United Healthcare",,163.34,,"Per diem ($331).",,,,0,19,163.34,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 10MM XLIF MODULAR MODULUS BONE SPINE NONSTERILE LATEX",SUP-1759451P2,CDM,C1713,HCPCS,0278,RC,,,both,,,13800.00,4140,"AETNA [10100]","Aetna HMO/PPO",,10971,79.5,,1521.93,481.35,16760.95,30,1604.94,11730,"percent of total billed charges",
"DISORDERS OF THE BILIARY TRACT WITH MCC",444,MS-DRG,,,,,,,inpatient,,,43316.06,12994.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,26640.38,,,,,,,7561,41670.58,"case rate",
"KIT NEROSTIMLTR PRECISION CHARGE",SUP-SC-6412-3,CDM,C1820,HCPCS,0278,RC,,,both,,,6900.00,2070,"BLUE CROSS [10001]","Blue Cross PPO",,2704.8,39.2,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 150MM 16MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U16150090,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4692,40,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 6CM 7MM BALLOON",SUP-M0062251090,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,199.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,199.16,1455.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX TAPER TIP",SUP-M0061453600,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,181.19,28.62,,,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 39MM 135CM 8MM 11MM 7FR .035IN",SUP-BXA083902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"FIRST HEALTH [10303]","First Health",,15603.84,80,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-FLO RENEGADE FATHOM VASCULAR 105CM 20CM .016IN",SUP-M001184510,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"UHC [10700]","United Healthcare",,2373.75,63.3,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 10MM 3.5MM EMBOLIZATION BRAID SOFT",SUP-PED-350-10,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"MULTIPLAN [10600]",Multiplan,,65407.5,85,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Hrt Morphology",PX-352000033,CDM,75572,CPT,0352,RC,,,both,,,1739.45,521.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,202.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,202.3,1739.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCALE SPRING C5KG 8X2X1IN .01ML",SUP-5K3582Z,CDM,S27000186,LOCAL,0270,RC,,,both,,,241.43,72.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,164.17,68,,,,,0,28.08,205.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS GRSP ENDOSCP NDL NOSE GRANDEE OPN LP 16G",SUP-10165,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.40,131.22,"NOVANET [10819]",Novanet,,328.05,75,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 6-9 E-F KNEE RIGHT VIVACIT-E",SUP-42522600712,CDM,C1776,HCPCS,0278,RC,,,both,,,13634.40,4090.32,"MULTIPLAN [10600]",Multiplan,,11589.24,85,,,,,0,1585.68,11589.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SYNTHETIC TISSUE OSTEOCONDUCTIVE MATRIX DEMINERALIZED",SUP-OCMP2,CDM,C1713,HCPCS,0278,RC,,,both,,,1458.00,437.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,991.44,68,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Iliac W Stent Add",PX-361000151,CDM,37223,CPT,0361,RC,,,both,,,9101.85,2730.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1078.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1058.55,7883,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 6-9 E-F KNEE RIGHT VIVACIT-E",SUP-42522600712,CDM,C1776,HCPCS,0278,RC,,,both,,,13634.40,4090.32,"CIGNA [10200]","Cigna Local Plus",,4294.84,31.5,,5372.07,4581.20,7242.98,23,1585.68,11589.24,"percent of total billed charges",
"GWIRE TRANSEND VASCULAR 300CM 2CM .014IN SCITANIUM ICE",SUP-M003468140,CDM,C1769,HCPCS,0272,RC,,,both,,,4599.61,1379.88,"KAISER [10500]",Kaiser,,3081.74,67,,,,,0,534.93,3909.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 15CM 20GA KOPANS BEVEL TIP MODIFIED",SUP-G02850,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.89,64.47,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,88.32,41.1,,,,,0,24.99,182.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 20MM 2.75MM BALLOON DILATATION STERILE",SUP-227-203-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL .5MM STRAIGHT MICRO 7IN 1X2 TEETH PLATFORM",SUP-277041,CDM,S27200284,LOCAL,0272,RC,,,both,,,1439.05,431.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,978.55,68,,,,,0,167.36,1223.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 0 UR-4 27IN MONOFILAMENT ABSORBABLE",SUP-U256H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM",SUP-8847050,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"KAISER [10500]",Kaiser,,2954.7,67,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cell Marker Study",PX-311000018,CDM,88182,CPT,0311,RC,,,both,,,586.00,175.8,"MULTIPLAN [10600]",Multiplan,,498.1,85,,,,,0,0.01,498.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 5MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035425150,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]","Cigna Local Plus",,4446.11,31.5,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 22.5MM KNEE GVF STABILIZE ROTATE PLATFORM PFC",SUP-962136,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4684.14,45.9,,,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE 3MM TAPERED ELITE SURGICAL",SUP-5820-071-030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,129.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 120MM 80CM 7MM 6FR .035IN BILIARY",SUP-G50130,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4141.2,68,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X3CM DERMACELL THK.2-1MM DERMIS ALLOGRAFT",SUP-DCELL111,CDM,Q4122,HCPCS,0636,RC,,,both,,,6334.96,1900.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 90CM 8FR XB4 CURVE GUIDING CORONARY SIDEHOLE",SUP-LA8EBU40SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP 55CM 7FR .078IN HOCKEY STICK CURVE",SUP-77827855,CDM,C1887,HCPCS,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT EDGE ACCUVAC",SUP-E2450HSNSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.17,24.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Rpr Eynoel Add<=5cm Cmplx",PX-450000058,CDM,13153,CPT,0361,RC,,,both,,,1347.00,404.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 14GA 16CM BARD MAGNUM ULTRA SHARP TIP POLISH",SUP-MN1416,CDM,S27200284,LOCAL,0272,RC,,,both,,,176.96,53.09,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LEAD PACING MYOCARDIAL 2 DISCRETE ELECTRD BIPOLAR CURVE NDL",SUP-6495,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LEAD PACING MYOCARDIAL 2 DISCRETE ELECTRD BIPOLAR CURVE NDL",SUP-6495,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"CIGNA [10200]","Cigna Local Plus",,303.35,53.5,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL 15X6MM MOBI-C 15MM SPINE CERVICAL TITANIUM COCRMO","SUP-MB 3556",CDM,S27800098,LOCAL,0278,RC,,,both,,,33075.00,9922.5,"AETNA [10100]","Aetna HMO/PPO",,26294.63,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL DELTA XTEND POROUS SHOULDER",SUP-OSC368700,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"NOVANET [10819]",Novanet,,34020,75,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 20CM 31MM GORE TAG THORACIC ACTIVE CONTROL",SUP-TGMR313120,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"CIGNA [10200]",Cigna,,46388.88,40,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 155CM 40MM 2.5MM RECTANGLE HELIX BALLOON",SUP-2155-2540,CDM,C1725,HCPCS,0272,RC,,,both,,,6865.50,2059.65,"NOVANET [10819]",Novanet,,5149.13,75,,,,,0,798.46,5835.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 3-4 21MM KNEE RIGHT BICRUCIATE STABILIZE",SUP-74027235,CDM,C1776,HCPCS,0278,RC,,,both,,,20478.15,6143.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2426.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2381.61,17406.43,"percent of total billed charges",
"CAUT ELECTROSURGICAL 5/8IN DIAGNOSTICK 2250F HIGH",SUP-65410-181,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.54,35.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,53.95,45.9,,,,,0,13.67,99.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM HIP MULTIHOLE TRIDENT C HEMISPHERE",SUP-508-11-46C,CDM,C1776,HCPCS,0278,RC,,,both,,,11233.20,3369.96,"PHCS [10601]",PHCS,,7863.24,70,,,,,0,1306.42,9548.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM STAINLESS STEEL T15 CORTEX SELF TAP LOW",SUP-02.206.212S,CDM,C1713,HCPCS,0278,RC,,,both,,,725.76,217.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,84.41,616.9,"percent of total billed charges",
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 6-7 C-D KNEE",SUP-42-5121-004-11,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Local Plus",,5765.38,53.5,,5372.07,4581.20,7242.98,23,1253.3,9159.96,"percent of total billed charges",
"HC Inj Indwl Lumb/Sac W Img",PX-510000210,CDM,62327,CPT,0761,RC,,,both,,,5968.00,1790.4,"FIRST HEALTH [10303]","First Health",,4774.4,80,,,,,0,5.97,5072.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS AIM 59MM 2.46MM 8FR UNIVERSAL GUIDE II SLITTABLE",SUP-DS2N101-59,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 200CM 60MM 5MM BALLOON DILATATION STERILE",SUP-H74939031506020,CDM,C1725,HCPCS,0272,RC,,,both,,,3740.00,1122,"UHC [10700]","United Healthcare",,2367.42,63.3,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM 32MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-217.055,CDM,C1713,HCPCS,0278,RC,,,both,,,449.06,134.72,"CIGNA [10200]",Cigna,,305.36,68,,1831.33,1831.33,1831.33,16,52.23,381.7,"percent of total billed charges",
"INSRT TIBIAL 4 22MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-422,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1352.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165CM 8.5-11MM OTSC 7MM",SUP-100.5,CDM,C1760,HCPCS,0272,RC,,,both,,,4478.10,1343.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1840.5,41.1,,,,,0,1840.5,2834.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25.5X4.5X.024MM MICROCHOICE SAGITTAL OSCILLATE",SUP-KM-3102,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"FIRST HEALTH [10303]","First Health",,49.42,80,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE REAMER 35MM PILOT HOLE KNEE PATELLA STAINLESS STEEL",SUP-597909535,CDM,S27200284,LOCAL,0272,RC,,,both,,,1129.14,338.74,"AETNA [10100]","Aetna HMO/PPO",,897.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.32,959.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 4.50 X 8MM",SUP-H7493942808450,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 40 75CM 8CM 10MM BALLOON DILATATION PERIPHERAL",SUP-CQF75108,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"FIRST HEALTH [10303]","First Health",,1069.2,80,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +28 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2800,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPR LD 5MM UNPLR",SUP-501203,CDM,C1883,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE COOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-CRKA-17-75-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 100CM 15MM 14FR 3MM AIRWAY EXCHANGE 2 LUMEN XFIRM BLUNT",SUP-G36402,CDM,S27200284,LOCAL,0272,RC,,,both,,,622.08,186.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,255.67,41.1,,,,,0,72.35,528.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GARM COMPRESSION 50-60HZ 25VA STD UNIVERSAL CALF VELCRO SCD",SUP-DVT10,CDM,S27000186,LOCAL,0270,RC,,,both,,,71.08,21.32,"KAISER [10500]",Kaiser,,47.62,67,,,,,0,8.27,60.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2 X 1 HELICAL PICO COIL",SUP-10USH02001,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"NOVANET [10819]",Novanet,,8792.33,75,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 118CM 6FR EBU4 CURVE GUIDING STERILE LATEX",SUP-LA6EBU40Y,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X12X8MM RISE 10D LORDOTIC NONSTERILE",SUP-193.222,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Local Plus",,8930.25,31.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 115MM 6MM PRIMARY TURON",SUP-520-01-006,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2266.7,28.62,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 20CM 11.5FR FULL SILICONE HEMO-CATH SAFETY SCPL",SUP-MCDLTSL20,CDM,C1750,HCPCS,0278,RC,,,both,,,988.20,296.46,"CIGNA [10200]","Cigna Local Plus",,528.69,53.5,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CITATION TMZF HA 5 SHORT HIP RIGHT",SUP-6265-5215,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10037.42,41.1,,6417.48,6417.48,6417.48,"1 through 10",2840.27,20758.66,"percent of total billed charges",
"HEAD FEMORAL +0MM 12/14 MEDIUM 40MM HIP ACETABULAR BIOLOX",SUP-00877504002,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1168.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1146.57,8379.91,"percent of total billed charges",
"TRAY THORACENTESIS/PARACENTESIS 8FR THORA-PARA POLYURETHANE",SUP-TPT1000,CDM,C1729,HCPCS,0272,RC,,,both,,,210.80,63.24,"AETNA [10100]","Aetna HMO/PPO",,167.59,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.52,179.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 61CM TRANSSEPTAL AGILIS NXT ACQCROSS",SUP-900300,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 195MM 3.5MM STAINLESS STEEL QUICK COUPLING",SUP-310.37,CDM,S27200284,LOCAL,0272,RC,,,both,,,519.37,155.81,"CIGNA [10200]","Cigna Open Access",,295.52,56.9,,,,,0,60.4,441.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH GORE DRYSEAL FLEX 33CM 9.5MM 26FR INTRO HYDROPHILIC",SUP-GDSF2633,CDM,C1894,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,587.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 15MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962363,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"CIGNA [10200]",Cigna,,5801.52,40,,5873.17,5873.17,5873.17,"1 through 10",1686.79,12328.23,"percent of total billed charges",
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 20MM TI",SUP-MTC-37200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"KAISER [10500]",Kaiser,,835.76,67,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 8MM4CM 190",SUP-R51008004L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,233.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 12D 30D LARGE LOOP 24FR PLASMALOOP",SUP-WA22607S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3236.00,970.8,"KAISER [10500]",Kaiser,,2168.12,67,,,,,0,376.35,2750.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 32MM 144CM 2.5MM",SUP-H7493941232250,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,919.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR AMPALTZ RIGHT MODIFIED",SUP-534548T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,42.93,45.9,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Urogram Inf/Bolus W Nephrotom",PX-320000117,CDM,74415,CPT,0320,RC,,,both,,,1220.00,366,"CIGNA [10200]","Cigna Local Plus",,281.29,,,,,,,141.89,1037,"fee schedule",
"LENS IOL +15.5 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6",SUP-ZCT225155,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM STARDRIVE STAINLESS STEEL TI5 CORTEX",SUP-02.206.238,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"KAISER [10500]",Kaiser,,217.07,67,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BONE SCREW T10 FULL THREAD 2.7MM / L12MM",SUP-657112,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,231.45,28.62,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 8MM 22MM EXPERT TITANIUM FULL THREAD TIBIA 2",SUP-04.005.412S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,687.07,45.9,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE 8.5-10 MEDIUM MALE PATIENT 2 PADDED POSTOPERATIVE",SUP-MQM2B,CDM,S27000186,LOCAL,0270,RC,,,both,,,79.43,23.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.65,41.1,,,,,0,9.24,67.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 38MM 144CM 2.5MM CORONARY STENT EVEROLIMUS",SUP-H7493926138250,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"NOVANET [10819]",Novanet,,6468.75,75,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD BIPOLAR 5FR VERSAPOINT SPRING TIP HYSTEROSCOPIC",SUP-WA47783A,CDM,S27200284,LOCAL,0272,RC,,,both,,,3439.80,1031.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,407.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,400.05,2923.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION TIGHTROPE ACL REPAIR STERILE",SUP-AR-1588T,CDM,C1713,HCPCS,0278,RC,,,both,,,2756.25,826.87,"CIGNA [10200]","Cigna Local Plus",,1474.59,53.5,,3978.14,359.25,3978.14,24,320.55,2342.81,"percent of total billed charges",
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 24IN 8FR SUCTION",SUP-8888256529,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.16,19.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.69,56.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 18MM 53MM 46MM SHOULDER COMPREHENSIVE",SUP-113042,CDM,C1776,HCPCS,0278,RC,,,both,,,9089.00,2726.7,"CIGNA [10200]",Cigna,,6180.52,68,,5873.17,5873.17,5873.17,"1 through 10",1057.05,7725.65,"percent of total billed charges",
"BMT SPLINED KNEE STM V2 11X80",SUP-148301,CDM,C1776,HCPCS,0278,RC,,,both,,,11903.88,3571.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3406.89,28.62,,,,,0,1384.42,10118.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL ADULT TALL 3.75IN PROCARE TRANSITIONAL 172",SUP-79-83367,CDM,S27000186,LOCAL,0270,RC,,,both,,,316.16,94.85,"AETNA [10100]","Aetna HMO/PPO",,251.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.77,268.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD 5YDX12INX1/32IN MOLESKIN ADHSV BACK SOFT LINE CAST",SUP-AC3002-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,440.40,132.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,52.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.22,374.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX11MM FRA 8D LORDOTIC NARROW WEDGE",SUP-11,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 CURVE PLUS 17.5MM KNEE XLK FIX BEARING",SUP-970424,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]","Cigna Open Access",,6358.32,56.9,,5302.19,4377.88,6578.61,27,1299.6,9498.37,"percent of total billed charges",
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 70MM COCR",SUP-VAL-35700-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"PHCS [10601]",PHCS,,1470,70,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 14X14.5CM 500ML STYLE FM HIGHLY COHESIVE GEL",SUP-FM-410500,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross HMO",,2181.48,39.2,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL 195MM 3MM MULTIVAC 50D XL HIP PLATINUM",SUP-ASC473001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2558.25,767.47,"NOVANET [10819]",Novanet,,1918.69,75,,,,,0,297.52,2174.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR HYPERTRONICS 115CM 4MM 7FR 1-7-4MM SPACE D",SUP-NS7TCDM174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9337.08,68,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM .0125IN AXIUM DETACHABLE HELIX SM",SUP-NV-6-20-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM CREO SPINE PREASSEMBLE THREAD",SUP-5119.1537,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40MM 3MM .035IN 2D HELIX PLATINUM FIBER",SUP-M0013723041,CDM,S27800098,LOCAL,0278,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross HMO",,301.64,39.2,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT SURGICAL 12MM PLASTIC DILAMEZINSERT 12MM PENILE PROS",SUP-DMI-12G,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENT BUR 2MM FLUTED BALL TS SHORT EXTENDED ANSPACH",SUP-SA-FB2L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"PHCS [10601]",PHCS,,1207.5,70,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thromblys Crbrl",PX-361000139,CDM,37195,CPT,0361,RC,,,both,,,3799.10,1139.73,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,3.8,3799.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alcohol Assay Except UR&Breath Ia",PX-301000674,CDM,82077,CPT,0301,RC,,,both,,,280.25,84.07,"UHC [10700]","United Healthcare",,15.54,,,,,,,0.01,238.21,"fee schedule",
"HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION",RX-3769,CDM,J3410,HCPCS,0636,RC,00517-4201-01,NDC,both,1,ML,230.74,69.22,"FIRST HEALTH [10303]","First Health",,184.59,80,,,,,0,0.3,196.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 24MM CHARLOTTE STAINLESS STEEL FOOT ANKLE",SUP-44110008,CDM,C1713,HCPCS,0278,RC,,,both,,,1672.50,501.75,"PHCS [10601]",PHCS,,1170.75,70,,,,,0,194.51,1421.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 39MM 135CM 11MM 16SQ MM 8FR .035IN",SUP-BXA113902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8016.47,41.1,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ph Study Mcus Tele",PX-750000113,CDM,91035,CPT,0750,RC,,,both,,,6579.56,1973.87,"KAISER [10500]",Kaiser,,4408.31,67,,,,,0,765.2,5592.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 8X34X24MM 10DEG",SUP-1921002P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"AETNA [10100]","Aetna HMO/PPO",,27546.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 23MM +20MM HIP MODULAR REVISION BOLT",SUP-6276-1-223,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5786.73,40,,,,,0,1682.49,12296.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 9X11X30MM 15",SUP-5891305,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"CIGNA [10200]","Cigna Local Plus",,9072,31.5,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 0MM 36MM HIP COCR LFIT V40",SUP-6260-9-136,CDM,C1776,HCPCS,0278,RC,,,both,,,6224.40,1867.32,"BLUE CROSS [10001]","Blue Cross PPO",,2439.96,39.2,,3949.44,3949.44,3949.44,"1 through 10",723.9,5290.74,"percent of total billed charges",
"CANN PERFUSION 35CM 26FR VENOUS 90D OPEN LIGHTHOUSE 1 STAGE",SUP-TF026L90,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.54,58.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,132.29,68,,,,,0,22.63,165.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 18-14MM 14MM 11FR TRIVASCULAR OVATION",SUP-TV-IL1418100-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"BLUE CROSS [10001]","Blue Cross HMO",,13088.88,39.2,,9776.84,9776.84,9776.84,"1 through 10",3883.26,28381.5,"percent of total billed charges",
"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC",329,MS-DRG,,,,,,,inpatient,,,104361.22,31308.37,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,58056.89,,"Case rate ($28,512.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $26,475.67, add-ons for qualifying new technology services are included. If operating cost exceeds $59,515.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,383.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $26,510.68. The transfer operating threshold is the transfer adjustment factor * $26,475.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,001.69. The transfer capital threshold is the transfer adjustment factor * $2,001.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,104361.22,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000175,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL REUNION STANDARD RADIUS H19 MM OD44 MM SHOULDER",SUP-5552-E-4419,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"CIGNA [10200]","Cigna Local Plus",,4862.51,53.5,,5372.07,4581.20,7242.98,23,1057.03,7725.48,"percent of total billed charges",
"GIRDLE COMPRESSION XL ABOVE KNEE LENGTH POWERKNIT 12.75X7.25",SUP-4-4012B-XL,CDM,S27000186,LOCAL,0270,RC,,,both,,,672.30,201.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,457.16,68,,,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 103MM 14-28MM 18FR ENDURANT IIS 2 BRANCH",SUP-ESBF2814C103E,CDM,S27800098,LOCAL,0278,RC,,,both,,,60782.40,18234.72,"MULTIPLAN [10600]",Multiplan,,51665.04,85,,,,,0,7068.99,51665.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM TRICUSPID RIGID EDWARDS MC3 3D ANGLE",SUP-4900T32,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"BLUE CROSS [10001]","Blue Cross HMO",,5003.88,39.2,,,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY T-LOK STD BONE MARROW",SUP-BMT1104BTL,CDM,S27200284,LOCAL,0272,RC,,,both,,,434.30,130.29,"AETNA [10100]","Aetna HMO/PPO",,345.27,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.51,369.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 13CM 4.2MM DISTAL TIP STEALTH FRR DIAMOND LIKE CARBON",SUP-S9247A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1044.90,313.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,123.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.52,888.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14X8MM COALITION AGX BONE SPINE",SUP-1128.1208,CDM,C1713,HCPCS,0278,RC,,,both,,,18000.00,5400,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7200,40,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DECA 5-5-5-24-3-3-3-3-3 MPA 120CM",SUP-901828,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"AETNA [10100]","Aetna HMO/PPO",,2355.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 100MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025100S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"KAISER [10500]",Kaiser,,960.58,67,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TI 4.0X110 LOR ROD",SUP-102064110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 55MM 5MM KII LOW PROFILE Z THREAD BLADED",SUP-CTB21,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.90,44.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,100.57,68,,,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 16FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0196L16,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.32,32.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.6,92.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 6MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBH060502,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARM ENDOSCP 5MM .6MM 1MM RICHARDS STAPES FLUOROPLASTIC",SUP-142138,CDM,S27800098,LOCAL,0278,RC,,,both,,,908.25,272.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,259.94,28.62,,,,,0,105.63,772.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC",476,MS-DRG,,,,,,,inpatient,,,58758.08,17627.42,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,7833.31,,"Case rate ($7,320.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,797.91, add-ons for qualifying new technology services are included. If operating cost exceeds $39,837.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,895.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,806.90. The transfer operating threshold is the transfer adjustment factor * $6,797.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $513.95. The transfer capital threshold is the transfer adjustment factor * $513.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7320.85,34457.12,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLIABILIZE MONOFILAMENT ETHILON MULTIPASS 4-0 P-3 18IN",SUP-699H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR SILICONE PUSH RADIOPAQUE MED PORT MIC SECUR-LOK",SUP-7170-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.81,228.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,90.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,88.6,647.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM ASNIS III TITANIUM PARTIAL THREAD REVERSE",SUP-604640,CDM,C1713,HCPCS,0278,RC,,,both,,,1319.00,395.7,"PHCS [10601]",PHCS,,923.3,70,,,,,0,153.4,1121.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 20CM 2MM BALLOON DILATATION HYDROPHILIC",SUP-G50319,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"UHC [10700]","United Healthcare",,1495.42,63.3,,,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENZONATATE 100 MG CAPSULE",RX-988,CDM,,,0637,RC,68084-0214-11,NDC,both,1,UN,6.27,1.88,"FIRST HEALTH [10303]","First Health",,5.02,80,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 30MMX8MM SUREFORM STERILE LATEX FREE DISPOSABLE",SUP-48230M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS ILM 25GA",SUP-705.44,CDM,S27200284,LOCAL,0272,RC,,,both,,,984.07,295.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,404.45,41.1,,,,,0,114.45,836.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 30MM TI",SUP-MTC-37300-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"PHCS [10601]",PHCS,,873.18,70,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR 75CM 7CM .035IN STAINLESS",SUP-46-563,CDM,C1769,HCPCS,0272,RC,,,both,,,192.13,57.64,"NOVANET [10819]",Novanet,,144.1,75,,,,,0,22.34,163.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 12/14 TAPER 28MM HIP OXINIUM ECHELON",SUP-71342800,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"BLUE CROSS [10001]","Blue Cross HMO",,6089.86,39.2,,5311.50,4717.44,5388.59,31,1806.76,13205.05,"percent of total billed charges",
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 50MM 32MM MARATHON",SUP-121932450,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3722.93,45.9,,,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 29/37FR MC2X",SUP-91437,CDM,S27200284,LOCAL,0272,RC,,,both,,,374.15,112.24,"UHC [10700]","United Healthcare",,236.84,63.3,,,,,0,43.51,318.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 1.3MM 7MM TITANIUM CORTICAL CRANIOFACIAL SELF TAP",SUP-400.687,CDM,C1713,HCPCS,0278,RC,,,both,,,650.92,195.28,"CIGNA [10200]","Cigna Open Access",,370.37,56.9,,1144.80,304.56,2275.09,66,75.7,553.28,"percent of total billed charges",
"OSTEOTOM 9IN LAMBOTTE SPINE SURGICAL CURVE .5IN",SUP-28-9462,CDM,S27200284,LOCAL,0272,RC,,,both,,,232.99,69.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,95.76,41.1,,,,,0,27.1,198.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TRITIUM 4 HOLE CABLE AUXILIARY BONE STERNAL NONSTERILE",SUP-86-500,CDM,C1713,HCPCS,0278,RC,,,both,,,4926.60,1477.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2261.31,45.9,,,,,0,572.96,4187.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 6FR 19CM RADIALEASE LATEX FREE VESSEL ACCEPTS",SUP-504506X,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.26,26.18,"AETNA [10100]","Aetna HMO/PPO",,69.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.15,74.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY 12CM 10GA AVAMAX LOW PROFILE UNIVERSAL HANDLE",SUP-VPH0010,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"KAISER [10500]",Kaiser,,379.89,67,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 24MMX10MM WAVE D 6D PEEK STERILE",SUP-2661024,CDM,S27800098,LOCAL,0278,RC,,,both,,,24192.00,7257.6,"UHC [10700]","United Healthcare",,15313.54,63.3,,,,,0,2813.53,20563.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY 100CM 1.8MM RADIAL JAW STD PULMONARY DISPOSABLE",SUP-M00515181,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.48,104.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,160.41,45.9,,,,,0,40.64,297.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ATRICLIP FLEX-MINI 45MM CLSR POLYESTER LOW PROFILE",SUP-ACHM45,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"MULTIPLAN [10600]",Multiplan,,13196.25,85,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 10FR 1/8IN BARD SILICONE 4 FREE FLOW CHANNEL",SUP-072186,CDM,S27200284,LOCAL,0272,RC,,,both,,,105.10,31.53,"MULTIPLAN [10600]",Multiplan,,89.34,85,,,,,0,12.22,89.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006155234010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,352.3,28.62,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 36-44MM COMPREHENSIVE STD SHOULDER ARCOMXL",SUP-XL115363,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"MULTIPLAN [10600]",Multiplan,,7673.8,85,,,,,0,1049.96,7673.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL HIP CONSTRUCT 2",SUP-CAP-MI-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"MULTIPLAN [10600]",Multiplan,,8211,85,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2.5MM TARGET NANO HELICAL DETACHABLE",SUP-M0035452540,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1065.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 100MM 22MM DHS/DCS STAINLESS STEEL LARGE",SUP-280,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,520.42,28.62,,,,,0,211.48,1545.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBOHAWK MEC 110CM 6CM 3.5-7MM ATHERECTOMY PERIPHERAL",SUP-THS-LS-C,CDM,C1714,HCPCS,0272,RC,,,both,,,18900.00,5670,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM LOW PROFILE NECK VERTICAL GROOVE CORAIL2",SUP-L20309,CDM,C1776,HCPCS,0278,RC,,,both,,,28658.70,8597.61,"NOVANET [10819]",Novanet,,21494.03,75,,,,,0,3333.01,24359.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0239,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,271.23,28.62,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 26MM SIMUPLUS FLEXIBLE STERILE LATEX FREE",SUP-7700FB26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross PPO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE REVERSE REVISION HUMERAL STEM, SZ 8X175MM",SUP-530-08-175,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Open Access",,4221,33.5,,5302.19,4377.88,6578.61,27,1465.38,10710,"percent of total billed charges",
"CATH LAUNCHER 90CM 7FR IMA CURVE GUIDING CORONARY",SUP-LA7IMAD,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 130CM 80MM 4MM BALLOON DILATATION",SUP-ADM04008013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"MULTIPLAN [10600]",Multiplan,,6862.05,85,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL O2 LOW FLOW PEDIATRIC SMALL VAPOTHERM .073-.11IN",SUP-MPS1500,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.76,14.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,20.45,41.1,,,,,0,5.79,42.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 65MM KNEE RIGHT CRUCIATE RETAINING CEMENTED",SUP-183008,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5748.52,28.62,,,,,0,2335.96,17072.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SKATER CHOICE LOCK 25CM 12FR PIGTAIL CURVE DRNG",SUP-756612025,CDM,C1729,HCPCS,0272,RC,,,both,,,651.24,195.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,442.84,68,,,,,0,75.74,553.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 11MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-511-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]","Cigna Open Access",,4031.26,33.5,,5302.19,4377.88,6578.61,27,1399.51,10228.56,"percent of total billed charges",
"CANN PERFUSION 12GA AORTIC ROOT MIAR FLOW-GUARD",SUP-11012L,CDM,S27200284,LOCAL,0272,RC,,,both,,,310.30,93.09,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,36.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.09,263.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL IDENTITY IMPRINT 4 NARROW H7 MM KNEE POSTERIOR",SUP-TPS-020-074N,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"CIGNA [10200]",Cigna,,3997.58,68,,5873.17,5873.17,5873.17,"1 through 10",683.7,4996.98,"percent of total billed charges",
"SHEATH VERSACROSS SMALL CURL 72CM 180CM 8.5FR GUIDING",SUP-VSTK0018,CDM,C1766,HCPCS,0272,RC,,,both,,,11212.50,3363.75,"MULTIPLAN [10600]",Multiplan,,9530.63,85,,,,,0,1304.01,9530.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP CONSTRUCT 1",SUP-CAP-Z-H-1,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"CIGNA [10200]","Cigna Open Access",,7597.8,33.5,,5302.19,4377.88,6578.61,27,2637.68,19278,"percent of total billed charges",
"SPACER SPINAL 23MMX11MM ELEVATE XLORDOTIC PEEK TITANIUM",SUP-8881123,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Local Plus",,8930.25,31.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 46CM 18MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181846,CDM,S27800098,LOCAL,0278,RC,,,both,,,18597.60,5579.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7643.61,41.1,,,,,0,2162.9,15807.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAC-LOC 40CM 16CM 8.5FR DRNG ULTRATHANE HYDROPHILIC",SUP-G13359,CDM,C1729,HCPCS,0272,RC,,,both,,,801.82,240.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,545.24,68,,,,,0,93.25,681.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 37X27X16MM 12D MEDIUM",SUP-7968216,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4061.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT HAND ACCESS 120MM OBTR OPTICAL TIP AUTOMATIC VENT LOW",SUP-IAS12-120,CDM,S27200284,LOCAL,0272,RC,,,both,,,760.06,228.02,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,348.87,45.9,,,,,0,88.39,646.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 195CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCM-195,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"FIRST HEALTH [10303]","First Health",,6044.4,80,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 10.2CM .4MM JEWELERS IRIS CURVED STRAIGHT",SUP-14-1080,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA [10200]","Cigna Local Plus",,97.74,53.5,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 10CM DIL GWIRE PINNACLE TIF TIP .035IN",SUP-10-2533,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,inpatient,,,145350.75,43605.22,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,25627.85,,"Case rate ($23,951.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $22,240.37, add-ons for qualifying new technology services are included. If operating cost exceeds $55,280.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,063.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,269.78. The transfer operating threshold is the transfer adjustment factor * $22,240.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,681.48. The transfer capital threshold is the transfer adjustment factor * $1,681.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,7561,112731.6,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL CRUCIATE STABILIZE CEMENTED PFC SIGMA TC3 2 60",SUP-960087,CDM,C1776,HCPCS,0278,RC,,,both,,,27588.96,8276.69,"PHCS [10601]",PHCS,,19312.27,70,,,,,0,3208.6,23450.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X10MM MODULUS 10D XL WIDE STERILE LATEX",SUP-1221050P2,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2815.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN JUDKINS LEFT 3.5 CURVE",SUP-DXT5JL35,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,56.2,68,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT 10X1CM GRAFTON DEMINERALIZED BONE MATRIX",SUP-T42275,CDM,S27800098,LOCAL,0278,RC,,,both,,,8073.00,2421.9,"PHCS [10601]",PHCS,,5651.1,70,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INFUSION CATH ACCESS PORT SYNCHROMED II NONSTERILE LATEX",SUP-8540,CDM,A4220,HCPCS,0272,RC,,,both,,,278.40,83.52,"PHCS [10601]",PHCS,,194.88,70,,,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 93MM 20-16MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1620C93E,CDM,S27800098,LOCAL,0278,RC,,,both,,,30006.90,9002.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12002.76,40,,,,,0,3489.8,25505.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL MEMORYSHAPE MEDIUM HEIGHT MODERATE PLUS PROFILE",SUP-RSZ-1205S,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.90,70.47,"KAISER [10500]",Kaiser,,157.38,67,,,,,0,27.32,199.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 13MM PRIMARY SECUR-FIT PLUS HA 7 30MM HIP",SUP-6054-0713S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"AETNA [10100]","Aetna HMO/PPO",,12851.52,79.5,,10981.53,8986.79,12413.38,12,1880.04,13740.62,"percent of total billed charges",
"BLADE CAST CUTTER 2.5IN NITRIDE CAST SAW LATEX FREE",SUP-31-0168,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"KAISER [10500]",Kaiser,,134.65,67,,,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.3MM STAINLESS STEEL Y BONE NONSTERILE",SUP-221.335,CDM,C1713,HCPCS,0278,RC,,,both,,,2202.90,660.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1497.97,68,,,,,0,256.2,1872.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nucleic Acid Amp Mycobact Ai",PX-306000252,CDM,87561,CPT,0306,RC,,,both,,,392.00,117.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,55.2,,,,,,,0.01,333.2,"fee schedule",
"GWIRE HI-TORQUE WINN VASCULAR TAPER 190CM .014IN DURASTEEL",SUP-1012474,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"NOVANET [10819]",Novanet,,722.93,75,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 130MM 32MM STAINLESS STEEL PARTIAL THREAD",SUP-208.448,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"PHCS [10601]",PHCS,,968.89,70,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 10MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424023,CDM,C1776,HCPCS,0278,RC,,,both,,,11747.25,3524.17,"BLUE CROSS [10001]","Blue Cross PPO",,4604.92,39.2,,3949.44,3949.44,3949.44,"1 through 10",1366.21,9985.16,"percent of total billed charges",
"STENT ZIMMON 4CM 10FR .035IN 2 PIGTAIL CURVE BILIARY",SUP-G21974,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,180.82,28.62,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STIM SPRINT EXTENSA NERVE NONSTERILE LATEX FREE DISPOSABLE",SUP-9288-6002,CDM,C1778,HCPCS,0278,RC,,,both,,,51030.00,15309,"CIGNA [10200]",Cigna,,20412,40,,6217.33,6217.33,6217.33,"1 through 10",5934.79,43375.5,"percent of total billed charges",
"XIENCE SKYPOINT DES 2.75 X 23 RX US",SUP-1804275-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 100MM DHS/DCS STAINLESS STEEL CONDYLAR HIP",SUP-280.301S,CDM,C1713,HCPCS,0278,RC,,,both,,,2333.10,699.93,"BLUE CROSS [10001]","Blue Cross HMO",,914.58,39.2,,957.42,156.86,7483.26,51,271.34,1983.14,"percent of total billed charges",
"ELECTRD DEFIB ADULT 45MM ADHSV CONDUCTIVE RADIOLUCENT",SUP-8900-4005,CDM,S27000186,LOCAL,0270,RC,,,both,,,392.95,117.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,161.5,41.1,,,,,0,26.56,334.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - TIBIAL KIT (CR) - SIZE 6",SUP-5555-2326,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY 10CM 10GA 12GA ARROW ONCONTROL BONE LESION 14CM",SUP-9463-VC-006,CDM,C1830,HCPCS,0272,RC,,,both,,,3237.50,971.25,"KAISER [10500]",Kaiser,,2169.13,67,,,,,0,376.52,2751.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM OZARK SPINE CERVICAL SELF START VARIABLE",SUP-8801-04016DA,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 8MM 7FR 1-7-4MM SPACE LARGE F CURVE",SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10791.6,68,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM 1.5 MM SCREW 3X8 HOLE T BONE HAND NONSTERILE",SUP-446.233,CDM,C1713,HCPCS,0278,RC,,,both,,,2736.30,820.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,324.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",318.23,2325.86,"percent of total billed charges",
"FERRIC CITRATE 210 MG IRON TABLET",RX-168253,CDM,,,0637,RC,00378-2895-20,NDC,both,1,UN,33.36,10.01,"CIGNA [10200]","Cigna Local Plus",,17.85,53.5,,,,,0,3.88,28.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL INTERTAN 10X24X130DG",SUP-71934480,CDM,C1713,HCPCS,0278,RC,,,both,,,12096.00,3628.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4971.46,41.1,,,,,0,1406.76,10281.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC",497,MS-DRG,,,,,,,inpatient,,,46072.79,13821.84,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,7944.87,,"Case rate ($7,495.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,959.76, add-ons for qualifying new technology services are included. If operating cost exceeds $39,999.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,908.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $6,968.97. The transfer operating threshold is the transfer adjustment factor * $6,959.76 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $526.19. The transfer capital threshold is the transfer adjustment factor * $526.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7495.16,35277.53,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 65CM PAMIRA SD 18CM",SUP-428773,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS [10001]","Blue Cross HMO",,5950.56,39.2,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Touch Prep Add Site",PX-312000040,CDM,88334,CPT,0312,RC,,,both,,,240.50,72.15,"CIGNA [10200]",Cigna,,42.35,,,,,,,0.01,204.43,"fee schedule",
"SUT VICRYL PLUS MULTIPASS 4-0 PC-1 18IN BRAID ANTIBACTERIAL",SUP-VCP835G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"KAISER [10500]",Kaiser,,16.75,67,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PENCIL 10FT VALLEYLAB NONSTERILE",SUP-E2515HS-NSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.90,17.07,"PHCS [10601]",PHCS,,39.83,70,,,,,0,6.62,48.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG EQUIPMENT HEARTMATE II TRAVEL LEFT VENTRICULAR ASSIST",SUP-1260,CDM,Q0508,HCPCS,0274,RC,,,both,,,1259.71,377.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,856.6,68,,,,,0,146.5,1070.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 16MM 144CM 2.75MM CORONARY STENT",SUP-H7493911416270,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"NOVANET [10819]",Novanet,,6856.88,75,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TALAR INBONE 2 DOME ANKLE SULCUS",SUP-220220902,CDM,C1776,HCPCS,0278,RC,,,both,,,23719.50,7115.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6404.27,27,,,,,0,2758.58,20161.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 55MM REVOLVE SPINE POLYAXIAL NONSTERILE",SUP-185.477,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PHCS [10601]",PHCS,,6682.8,70,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 23MM 10MM STEP TAPER ACL PCL",SUP-AR-1400C,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1258.43,68,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 59CM ENDOTAK RELIANCE ENDOCARDIAL STEROID SILICONE",SUP-157,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"KAISER [10500]",Kaiser,,10170.6,67,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ACCULINK 30MM 132CM 7-10MM TAPER VASCULAR NITINOL",SUP-1011344-30,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"CIGNA [10200]",Cigna,,6364.8,68,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP 15CC ALLOGRAFT PUTTY",SUP-14100601,CDM,C1713,HCPCS,0278,RC,,,both,,,16831.31,5049.39,"FIRST HEALTH [10303]","First Health",,13465.05,80,,,,,0,1957.48,14306.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 28CM 10FR NEPHROURETERAL METAL",SUP-H7493935110280,CDM,C2617,HCPCS,0278,RC,,,both,,,1069.20,320.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,490.76,45.9,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 43MM 26MM UHR UNIVERSAL HIP UHMWPE",SUP-UH1-43-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"BLUE CROSS [10001]","Blue Cross PPO",,1692.57,39.2,,3949.44,3949.44,3949.44,"1 through 10",502.16,3670.1,"percent of total billed charges",
"ROD SPINAL 45MM",SUP-8847045,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"FIRST HEALTH [10303]","First Health",,3528,80,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 45MM 22MM 14FR 12FR TRIVASCULAR OVATION PRIME",SUP-TV-EX222245-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"MULTIPLAN [10600]",Multiplan,,28381.5,85,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PLUMEPORT UNIVERSAL SMOKE EVAC LAPAROSCOPIC PLUME",SUP-PP010,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.11,42.93,"FIRST HEALTH [10303]","First Health",,114.49,80,,,,,0,16.64,121.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Smear Special Stain",PX-306000086,CDM,87207,CPT,0306,RC,,,both,,,246.00,73.8,"MULTIPLAN [10600]",Multiplan,,209.1,85,,,,,0,0.01,209.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RELIEVA SPIN RELIEVA VORTEX 2 F-70 16MM 6MM",SUP-RS0616F,CDM,S27200284,LOCAL,0272,RC,,,both,,,11557.50,3467.25,"UHC [10700]","United Healthcare",,7315.9,63.3,,,,,0,1344.14,9823.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELIANCE 4 FRONT ACTIVE FIXATION SINGLE COIL 59CM",SUP-0672,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4344.52,28.62,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE C TI ROD, 3.5X60MM PRE BENT",SUP-3943060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN EXTRA",SUP-77806200,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 90MM 5 HOLE LOW PROFILE BONE LEFT OLECRANON ELBOW",SUP-70-0304,CDM,C1713,HCPCS,0278,RC,,,both,,,7051.80,2115.54,"CIGNA [10200]","Cigna Open Access",,4012.47,56.9,,1144.80,304.56,2275.09,66,820.12,5994.03,"percent of total billed charges",
"BASEPLT TIBIAL TRIATHLON 7 KNEE PRIMARY BEAD PA",SUP-5526-B-700,CDM,C1776,HCPCS,0278,RC,,,both,,,15783.75,4735.12,"UHC [10700]","United Healthcare",,9991.11,63.3,,8601.07,8395.67,8601.07,"1 through 10",1835.65,13416.19,"percent of total billed charges",
"INSRT TIBIAL 7 10MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-1516-30-710,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]","Cigna Open Access",,4397.63,33.5,,5302.19,4377.88,6578.61,27,1526.7,11158.16,"percent of total billed charges",
"SCR BONE 2.6MM 5MM CENTERPIECE TITANIUM SPINAL SELF TAPPING",SUP-853-465,CDM,C1713,HCPCS,0278,RC,,,both,,,443.23,132.97,"BLUE CROSS [10001]","Blue Cross HMO",,173.75,39.2,,957.42,156.86,7483.26,51,51.55,376.75,"percent of total billed charges",
"BLADE SAW 15X10MM THK.4MM SMOOTH FINE TEETH SAGITTAL SLOTTED",SUP-532.042S,CDM,S27200284,LOCAL,0272,RC,,,both,,,605.07,181.52,"CIGNA [10200]","Cigna Open Access",,344.28,56.9,,,,,0,70.37,514.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 16MM APTUS TRILOCK TITANIUM MIDFOOT HEXADRIVE 6",SUP-A-5450.16/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,739.86,45.9,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH DURAL 8X6CM DURA-GUARD BOVINE PERICARDIUM",SUP-DG0608SN,CDM,S27800098,LOCAL,0278,RC,,,both,,,4835.93,1450.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1384.04,28.62,,,,,0,562.42,4110.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP040250150 PLUS US D4L250UL1500",SUP-PCP040250150,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"KAISER [10500]",Kaiser,,850.69,67,,,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 80MM 7MM BALLOON DILATATION DURALYN",SUP-48007008S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"NOVANET [10819]",Novanet,,941.63,75,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 4FR 20CM PROVENA 2 LUMEN MIDLINE FULL STERILE LATEX",SUP-S4254108,CDM,C1751,HCPCS,0272,RC,,,both,,,1206.25,361.87,"FIRST HEALTH [10303]","First Health",,965,80,,,,,0,140.29,1025.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYRINGE CONTROL 10ML 3 RING",SUP-70085007,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.07,15.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,20.58,41.1,,,,,0,5.82,42.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 11MM FLEXIGRAFT KNEE ACHILLES TENDON",SUP-FATB11,CDM,S27800098,LOCAL,0278,RC,,,both,,,16918.80,5075.64,"CIGNA [10200]","Cigna Local Plus",,5329.42,31.5,,,,,0,1967.66,14380.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM CREO AMP HA SPINE CANNULATED MODULAR",SUP-1067.4541S,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"NOVANET [10819]",Novanet,,2812.5,75,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.5MM 90MM AFFIXUS 6.5MM HIP SELF TAP LAG SQUARE",SUP-814510090,CDM,C1713,HCPCS,0278,RC,,,both,,,6417.00,1925.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1836.55,28.62,,,,,0,746.3,5454.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 38MM 145CM 3.5MM CORONARY STENT",SUP-1125350-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"MULTIPLAN [10600]",Multiplan,,4962.3,85,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 14MM RETRACTA DETACHABLE .035IN",SUP-G34192,CDM,S27800098,LOCAL,0278,RC,,,both,,,4308.98,1292.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1977.82,45.9,,,,,0,501.13,3662.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 16GA CURVE SILICONIZE SHARP 10MM",SUP-RFK-C101016VZ-P,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"UHC [10700]","United Healthcare",,104.63,63.3,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR 3MM OLYMPUS OES",SUP-M0068802351,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"MULTIPLAN [10600]",Multiplan,,439.01,85,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DECOMPRESSION 350CM 10FR MARCON .035IN COLON DISPOSABLE",SUP-G22218,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,724.99,45.9,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 79MM 12.2MM 7.6MM UNCUFFED NONFENESTRATED INNER CANN",SUP-8DCFS,CDM,S27200284,LOCAL,0272,RC,,,both,,,407.77,122.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,277.28,68,,,,,0,47.42,346.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER FLEXIVA 200UM FLEXSHIELD HIGH POWER POLISH",SUP-M0068403910,CDM,S27200284,LOCAL,0272,RC,,,both,,,2752.13,825.64,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,320.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,320.07,2339.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 7IN STRAIGHT 1.5MM CUSHING DELICATE SURGICAL",SUP-57-2001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2266.43,679.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,268.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,263.59,1926.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET NDL .75IN 2X2IN 20GA PORT ACCESS SYR PAD Y SITE 10ML",SUP-PA0031YN,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.87,28.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.15,81.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL ADULT UNIVERSAL VISTA PROCARE 2 PIECE",SUP-79-83380,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POD XL 6MMX55CM",SUP-RBYPODXL0655,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"UHC [10700]","United Healthcare",,11923.82,63.3,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"Y-KNOT RC ALL-SUTURE ANCHOR, WITH THREE #2 (5 METRIC) HI-FI",SUP-YRC03,CDM,C1713,HCPCS,0278,RC,,,both,,,4626.31,1387.89,"AETNA [10100]","Aetna HMO/PPO",,3677.92,79.5,,1521.93,481.35,16760.95,30,538.04,3932.36,"percent of total billed charges",
"JOINT FINGER SWANSON 4 METACARPOPHALANGEAL GROMMET HIGH",SUP-G4700004,CDM,C1776,HCPCS,0278,RC,,,both,,,4170.60,1251.18,"CIGNA [10200]",Cigna,,2836.01,68,,5873.17,5873.17,5873.17,"1 through 10",485.04,3545.01,"percent of total billed charges",
"CATH PERFORMA 110CM 7.5CM 6FR .054IN .038IN PIGTAIL 155",SUP-7509-33,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"FIRST HEALTH [10303]","First Health",,65.5,80,,,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 3MM CEREPAK XTRASOFT FREEFORM",SUP-XCR120304,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3785.24,28.62,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 15MM 3MM BALLOON DILATATION STERILE",SUP-230-153-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 2X4CM PURAPLY 8SQ CM","SUP-PURAPLY-COM 2X4",CDM,Q4195,HCPCS,0636,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Local Plus",,263.34,,,,,,,263.34,5278.5,"fee schedule",
"SURFACE ARTICULAR 10MM PERSONA 3-5 E-F KNEE RIGHT TIBIA",SUP-42521400610,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"BLUE CROSS [10001]","Blue Cross PPO",,3165.7,39.2,,3949.44,3949.44,3949.44,"1 through 10",939.21,6864.4,"percent of total billed charges",
"STENT ELUVIA 120MM 130CM 7MM VASCULAR DRUG ELUTE DELIVERY",SUP-H74939294701210,CDM,C1874,HCPCS,0278,RC,,,both,,,18238.50,5471.55,"MULTIPLAN [10600]",Multiplan,,15502.73,85,,,,,0,2121.14,15502.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bone Survey",PX-320000199,CDM,77074,CPT,0320,RC,,,both,,,954.96,286.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,70.03,,,,,,,70.03,811.72,"fee schedule",
"CATH PACIFIC PLUS 130CM 120MM 4FR 4MM .018IN BALLOON",SUP-PCP040120130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UHC [10700]","United Healthcare",,779.35,63.3,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SEROSAFUSE IMPLANTABLE FASTNER",SUP-R2275,CDM,S27800098,LOCAL,0278,RC,,,both,,,34618.50,10385.55,"CIGNA [10200]","Cigna Open Access",,11597.2,33.5,,,,,0,4026.13,29425.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP TRABECULAR METAL REVERSE STEM/TITANIUM GLENOID/TRABECULA",SUP-98000900071,CDM,C1776,HCPCS,0278,RC,,,both,,,57960.00,17388,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,16588.15,28.62,,,,,0,6740.75,49266,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CASSETTE INFUSION PUMP GEN 2 PURGE",SUP-1000200,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"AETNA [10100]","Aetna HMO/PPO",,5485.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END LOCK TITANIUM ALUMINUM VANADIUM NCB 8MM 3.5MM",SUP-0203150300,CDM,C1713,HCPCS,0278,RC,,,both,,,1631.25,489.37,"CIGNA [10200]",Cigna,,1109.25,68,,1831.33,1831.33,1831.33,16,189.71,1386.56,"percent of total billed charges",
"SCR BONE 3.5MM 12MM VARIAX TORX TITANIUM FULL THREAD T10",SUP-40-35612,CDM,C1713,HCPCS,0278,RC,,,both,,,1211.11,363.33,"CIGNA [10200]",Cigna,,823.55,68,,1831.33,1831.33,1831.33,16,140.85,1029.44,"percent of total billed charges",
"OVITEX INGUINAL REINFORCED TISSUE MATRIX, LONG-TERM RESORBAB",SUP-F10263-1317I,CDM,C1781,HCPCS,0278,RC,,,both,,,4526.40,1357.92,"BLUE CROSS [10001]","Blue Cross HMO",,1774.35,39.2,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 145MM 4.2MM QUICK COUPLING NDL POINT 3 FLUTED",SUP-03.010.104,CDM,S27000186,LOCAL,0270,RC,,,both,,,1077.30,323.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,127.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,125.29,915.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.00 X 15 RX US",SUP-1804300-15,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION",RX-11634,CDM,,,0250,RC,25021-0685-10,NDC,both,1,UN,39.86,11.96,"NOVANET [10819]",Novanet,,29.9,75,,,,,0,4.64,33.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 30MM QUARTEX SPINE POLYAXIAL NONSTERILE LATEX",SUP-1149.453,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"CAP IDENTITY STEM/COMPREHENSIVE GLENOID/XLPE POLY/AUGMENTED",SUP-98000900275,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"AETNA [10100]","Aetna HMO/PPO",,38565.45,79.5,,10981.53,8986.79,12413.38,12,5641.71,41233.5,"percent of total billed charges",
"HC Dest L/S Facet Jnt Add Bi",PX-510000158,CDM,64636,CPT,0761,RC,,,both,,,1990.72,597.22,"FIRST HEALTH [10303]","First Health",,1592.58,80,,,,,0,231.52,1990.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC",337,MS-DRG,,,,,,,inpatient,,,68639.21,20591.76,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,10188.21,,"Case rate ($9,521.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,841.54, add-ons for qualifying new technology services are included. If operating cost exceeds $41,881.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,050.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,853.23. The transfer operating threshold is the transfer adjustment factor * $8,841.54 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.46. The transfer capital threshold is the transfer adjustment factor * $668.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,44815.86,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC",198,MS-DRG,,,,,,,inpatient,,,43483.37,13045.01,"CIGNA [10200]",Cigna,,9390.81,,"Fee schedule rate ($9,390.81). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,4442.64,17861.31,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 42MM AEQUALIS PERFORM +3MM SHOULDER",SUP-DWJ024,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"CIGNA [10200]","Cigna Open Access",,4084.66,33.5,,5302.19,4377.88,6578.61,27,1418.05,10364.05,"percent of total billed charges",
"(EVAL) SELUTION DEB 3.0X40",SUP-SCA14U-300040D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN ORTHOPEDIC BB-TAK THREAD STERILE DISPOSABLE",SUP-AR-13226TS,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 135CM 4CM 5FR 7MM 7.5MM BALLOON DILATATION",SUP-4197040X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL KNEE 1 PRIMARY - CEMENTED/MEDACTA - CEMENTED KNEE",SUP-CAP-K-1,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"NOVANET [10819]",Novanet,,13230,75,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATALYST 6.5 CENTER SCREW IMPLANT TRIPACK - 35MM",SUP-1230-7532-003,CDM,C1713,HCPCS,0278,RC,,,both,,,3219.00,965.7,"MULTIPLAN [10600]",Multiplan,,2736.15,85,,,,,0,374.37,2736.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 5X3CM AMNIOCORD PURION PLUS AMNIOTIC",SUP-AC-5350,CDM,Q4433,HCPCS,0636,RC,,,both,,,14821.20,4446.36,"NOVANET [10819]",Novanet,,11115.9,75,,,,,0,247.92,12598.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 130CM 4CM 7MM BALLOON DILATATION",SUP-U813074,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC LOW PROFILE 100MM 5MM KII 2 PACK OPTICAL",SUP-CTR12,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,147.9,68,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL SMALL+ KNEE LEFT LCS COMPLETE POROCOAT STERILE",SUP-129404020,CDM,C1776,HCPCS,0278,RC,,,both,,,28683.90,8605.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11473.56,40,,,,,0,3335.94,24381.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +24.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.245,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 7MM 8FR ENDOPROSTHESIS HEPARIN",SUP-VBH070502,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 32MM 140CM 2.75MM CORONARY STENT PLATINUM",SUP-H7493927432270,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross PPO",,1470,39.2,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 7.2INX1MM OLSEN STRAIGHT BAYONET",SUP-20-1440I,CDM,S27200284,LOCAL,0272,RC,,,both,,,332.16,99.65,"NOVANET [10819]",Novanet,,249.12,75,,,,,0,38.63,282.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 4CM 7MM BALLOON DILATATION",SUP-DR8074,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"MULTIPLAN [10600]",Multiplan,,1170.45,85,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 44-41MM COMPREHENSIVE STD SHOULDER E1",SUP-EP-115396,CDM,C1776,HCPCS,0278,RC,,,both,,,8854.00,2656.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4063.99,45.9,,,,,0,1029.72,7525.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL TRIATHLON X3 3 H11 MM KNEE TOTAL STABILIZE PLU",SUP-5537-G-311-E,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"FIRST HEALTH [10303]","First Health",,10766.76,80,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHARKCORE LG FNB BIOPSY SYSTEM WITH NEEDLE - 19 GUAGE",SUP-DSL-19-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,4933.50,1480.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,573.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,573.77,4193.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BNDG TUBIGRIP 10MR COMPRESSION LATEX REUSABLE MULTIPURPOSE",SUP-1443,CDM,S27000186,LOCAL,0270,RC,,,both,,,189.83,56.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,78.02,41.1,,,,,0,22.08,161.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 100MM 116CM 6MM 75CM VASCULAR NITINOL ILIAC",SUP-H74939200061070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX15MM FRA 8D LORDOTIC NARROW WEDGE",SUP-10015,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Local Plus",,5953.5,31.5,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL PERCUFLEX PLUS HYDROPLUS",SUP-M006175255090,CDM,C2617,HCPCS,0278,RC,,,both,,,1294.14,388.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.51,1100.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SHUNT ACCU-FLO RIGHT ANGLE CSF CATH PLASTIC STERILE",SUP-45104,CDM,S27800098,LOCAL,0278,RC,,,both,,,762.78,228.83,"MULTIPLAN [10600]",Multiplan,,648.36,85,,,,,0,88.71,648.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 250MM 11MM CARBON FIBER MR CONDITIONAL",SUP-394.84,CDM,C1713,HCPCS,0278,RC,,,both,,,1441.80,432.54,"KAISER [10500]",Kaiser,,966.01,67,,,,,0,167.68,1225.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE COAGULATION PURPLE 350CM 7FR BRIGHTON GASTROINTESTINAL",SUP-BP-7F-SP-350,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATORVASTATIN 10 MG TABLET",RX-19176,CDM,,,0637,RC,68084-0097-11,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 26CM 6FR .038IN PIGTAIL CURVE",SUP-M006155233120,CDM,C2617,HCPCS,0278,RC,,,both,,,1385.67,415.7,"CIGNA [10200]",Cigna,,942.26,68,,,,,0,161.15,1177.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAVITOR WITH RADIOPAQUE MARKERS 23MM",SUP-NVRO-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"KAISER [10500]",Kaiser,,91656,67,,,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 58CM DEFLECT STEERABLE LOCATOR PLUS ATRIAL 16MM",SUP-1292/58,CDM,S27500001,LOCAL,0275,RC,,,both,,,1972.50,591.75,"CIGNA [10200]","Cigna Open Access",,1122.35,56.9,,,,,0,229.4,1676.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR LONG 145CM 10CM .018IN",SUP-M001466000,CDM,C1769,HCPCS,0272,RC,,,both,,,486.32,145.9,"NOVANET [10819]",Novanet,,364.74,75,,,,,0,56.56,413.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM EVEREST SPINE POLYAXIAL",SUP-2911-06545,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA [10200]","Cigna Open Access",,2755.44,56.9,,1144.80,304.56,2275.09,66,563.19,4116.21,"percent of total billed charges",
"INTRO SHEATH 5FR 21GA 40CM 4CM GRAY HUB GWIRE NDL RADIOPAQUE",SUP-PSS-5F-4-018MT,CDM,C1894,HCPCS,0272,RC,,,both,,,286.67,86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,194.94,68,,,,,0,33.34,243.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 15MM 3MM BALLOON DILATATION PACLITAXEL RADIOPAQUE",SUP-H7493960815300,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"AETNA [10100]","Aetna HMO/PPO",,30927.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 28MM 145CM 2.5MM CORONARY STENT",SUP-1125250-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1670.84,28.62,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM ALPS T15 TIBIA CORTICAL DISTAL LOCK SELF",SUP-816135010,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,957.42,570.23,957.42,28,189.34,1383.8,"percent of total billed charges",
"STPLR INTERNAL XL XTHICK CIRCULAR STERILE LATEX FREE EEA",SUP-TRIEEAXL25XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2678.40,803.52,"CIGNA [10200]",Cigna,,1821.31,68,,,,,0,311.5,2276.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION 14MM LAPIPLASTY MICRO-QUAD RAPID COMPRESSION",SUP-SK61,CDM,C1713,HCPCS,0278,RC,,,both,,,24406.20,7321.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2892.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,2838.44,20745.27,"percent of total billed charges",
"COIL EMBOLIZATION 28CM 8MM .021-.027IN AZUR CX HYDROCOIL",SUP-45-780828,CDM,S27800098,LOCAL,0278,RC,,,both,,,5278.50,1583.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2422.83,45.9,,,,,0,613.89,4486.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 3N 8MM",SUP-TPS-030-083N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER ACCUTRAC 200UM FLEXSHIELD HOLMIUM FLEXIBLE",SUP-M0068404110,CDM,S27200284,LOCAL,0272,RC,,,both,,,3351.98,1005.59,"NOVANET [10819]",Novanet,,2513.99,75,,,,,0,389.84,2849.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 32MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.732,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"CIGNA [10200]","Cigna Open Access",,639.35,56.9,,1144.80,304.56,2275.09,66,130.68,955.09,"percent of total billed charges",
"TI 4.0-4.0X220 ADJ ROD",SUP-102074220,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1073.25,28.62,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH THERMOCOOL SF 115CM 8FR 2-5-2MM SPACE D-F CURVE",SUP-BDI35DFRT,CDM,C2630,HCPCS,0272,RC,,,both,,,11350.50,3405.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1345.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.110,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"BLUE CROSS [10001]","Blue Cross PPO",,336.06,39.2,,957.42,570.23,957.42,28,99.7,728.71,"percent of total billed charges",
"WIRE FIXATION 150MM 1.6MM KIRSCHNER STAINLESS STEEL GUIDE",SUP-GP540CE,CDM,C1713,HCPCS,0278,RC,,,both,,,316.07,94.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,36.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",36.76,268.66,"percent of total billed charges",
"KIT CATHETERIZATION 14GA 18GA 8IN SHARPSAWAY 2.5IN .032IN",SUP-AK-04700,CDM,C1751,HCPCS,0272,RC,,,both,,,161.82,48.55,"PHCS [10601]",PHCS,,113.27,70,,,,,0,18.82,137.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 36MM RECONSTRUCTION VALVULAR RETRACTION",SUP-680R36,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 5MM ELITE ROUND DIAMOND 5 STEP NOTCH STERILE",SUP-5820-012-050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"MULTIPLAN [10600]",Multiplan,,930.72,85,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 600CC NATRELLE INSPIRA COHESIVE STERILE LATEX",SUP-SCM-600,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]",Cigna,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 1MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR091030,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA [10200]",Cigna,,5290.34,40,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 15MM 145CM 3.75MM BALLOON DILATATION",SUP-1400375-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE 2X.5IN FLEXIBLE SHEER WEAVE SURGICEL",SUP-1955,CDM,S27200284,LOCAL,0272,RC,,,both,,,159.75,47.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,65.66,41.1,,,,,0,18.58,135.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 55MM STAINLESS STEEL 2.4MM SCR 7 HOLE HEAD 3 HOLE",SUP-02.111.731S,CDM,C1713,HCPCS,0278,RC,,,both,,,4274.55,1282.36,"KAISER [10500]",Kaiser,,2863.95,67,,,,,0,497.13,3633.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR WOLF RESECTOSCOPE",SUP-M0068802451,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"CIGNA [10200]","Cigna Local Plus",,276.32,53.5,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR LARGE 2.5X2X1.2MM 1MM APPLEBAUM",SUP-14-0957,CDM,L8613,HCPCS,0278,RC,,,both,,,2652.68,795.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,308.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,232.31,2254.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM RADIUS DISTAL VOLAR LOCK 3 LEAD TAPER",SUP-131227118,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,1144.80,304.56,2275.09,66,155.43,1136.03,"percent of total billed charges",
"BIT DRILL NONSTERILE",SUP-357.405,CDM,C1713,HCPCS,0278,RC,,,both,,,2213.25,663.97,"CIGNA [10200]","Cigna Open Access",,1259.34,56.9,,1144.80,304.56,2275.09,66,257.4,1881.26,"percent of total billed charges",
"STENT MICROMARKER SMART CONTROL 30MM 120CM 12MM .035IN",SUP-C12030MB,CDM,C1876,HCPCS,0278,RC,,,both,,,6037.50,1811.25,"CIGNA [10200]",Cigna,,4105.5,68,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR LONG 145CM 10CM .018IN",SUP-M001466000,CDM,C1769,HCPCS,0272,RC,,,both,,,486.32,145.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,56.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.56,413.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 5CM 120CM 9MM ENDOPROSTHESIS LUMEN CATH",SUP-VBCR090502A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4564.35,27,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 12MM 2.25MM BALLOON DILATATION RAPID EXCHANGE",SUP-DC-RY2212UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"NOVANET [10819]",Novanet,,741.15,75,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM EVEREST SPINE POLYAXIAL",SUP-2911-06545,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"AETNA [10100]","Aetna HMO/PPO",,3849.87,79.5,,1521.93,481.35,16760.95,30,563.19,4116.21,"percent of total billed charges",
"LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION",RX-14868,CDM,J2002,HCPCS,0636,RC,00264-9594-10,NDC,both,500,ML,83.05,24.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,57,,,,,,,9.84,70.59,"fee schedule",
"GRAFT BONE BLOCK 50X12X10MM ENTANGLE CLLGN MATRIX 6CC ATTRAX",SUP-5015104,CDM,S27800098,LOCAL,0278,RC,,,both,,,7072.50,2121.75,"MULTIPLAN [10600]",Multiplan,,6011.63,85,,,,,0,822.53,6011.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 100CM 60MM 9MM BALLOON DILATATION DRUG COATED",SUP-LX35100960V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3473.98,41.1,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 150MM 5.4FR 5MM BALLOON DILATATION 2",SUP-BD-L50150CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"UHC [10700]","United Healthcare",,607.59,63.3,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRODE ELECTROTHERAPY VITALSTIM ADULT",SUP-966032,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.34,40.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ATB ADVANCE 80CM 4CM 5.9FR 10MM BALLOON DILATATION",SUP-G26890,CDM,C1725,HCPCS,0272,RC,,,both,,,654.48,196.34,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHAFT 2.5MM SMALL HEXAGONAL SCRDRVR",SUP-314.03,CDM,S27000186,LOCAL,0270,RC,,,both,,,730.30,219.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG 12.7X3.2CM ROUND PRECUT DRAPE SENSATRAC POLYURETHANE",SUP-M8275075/5.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,441.46,132.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPRT ORTHOPEDIC XL 23-25.5IN KNEE NEOPRENE SLEEVE OPEN",SUP-NE7702-05,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.70,30.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOOK LARGE RIGHT ANGLE 7.5IN RETRACTION TIP JANNETTA 4.7MM",SUP-NL3769,CDM,S27200284,LOCAL,0272,RC,,,both,,,789.51,236.85,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL)INTRODUCER SYSTEM STEERABLE SHEATH AND DILATOR",SUP-TR1TF-45-02/02,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC App Rigid Leg Cast",PX-510000074,CDM,29445,CPT,0761,RC,,,both,,,3729.02,1118.71,"MULTIPLAN [10600]",Multiplan,,3169.67,85,,,,,0,433.69,3169.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR WOLF RESECTOSCOPE",SUP-M0068802451,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) NAVCATH",SUP-5320,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL HARMONIC SCPL DISSECTING HOOK",SUP-SNGHK,CDM,S27200284,LOCAL,0272,RC,,,both,,,1862.06,558.62,"PHCS [10601]",PHCS,,1303.44,70,,,,,0,216.56,1582.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX MONORAIL 143CM 15MM 3MM BALLOON",SUP-H7493912415300,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 10MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424023,CDM,C1776,HCPCS,0278,RC,,,both,,,11747.25,3524.17,"CIGNA [10200]","Cigna Local Plus",,3700.38,31.5,,5372.07,4581.20,7242.98,23,1366.21,9985.16,"percent of total billed charges",
"GRAFT BONE CANCELLOUS ALLOGRAFT BLOCK 30X13X13MM",SUP-T00150,CDM,S27800098,LOCAL,0278,RC,,,both,,,4805.85,1441.75,"CIGNA [10200]",Cigna,,3267.98,68,,,,,0,558.92,4084.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL OVITEX 22X18IN PERMANENT GRID 1 SMOOTH SIDE",SUP-F10246-1822P,CDM,C1781,HCPCS,0278,RC,,,both,,,39068.57,11720.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4629.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4543.67,33208.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA 6-9 E-F KNEE LEFT",SUP-42511400713,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5491.52,68,,,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUTNER 70CM 4FR 8FR UNIVERSAL URETERAL ADULT WEDGE",SUP-G14056,CDM,C1758,HCPCS,0272,RC,,,both,,,117.45,35.23,"UHC [10700]","United Healthcare",,74.35,63.3,,,,,0,13.66,99.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAGTRACE 10 VIAL CARTON",SUP-MTVC10,CDM,A9697,HCPCS,0255,RC,,,both,,,5416.50,1624.95,"AETNA [10100]","Aetna HMO/PPO",,4306.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +1.5MM 12/14 TAPER 44MM HIP TOTAL STABILIZE",SUP-136544710,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"AETNA [10100]","Aetna HMO/PPO",,11928.22,79.5,,10981.53,8986.79,12413.38,12,1744.97,12753.44,"percent of total billed charges",
"NAIL 10MM 340MM RIGHT TROCHANTERIC INTRAMEDULLARY 130D LONG",SUP-456.354S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5468.17,40,,,,,0,1589.87,11619.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 3N 8MM",SUP-TPS-030-083N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CM 6MM 5CM HYBRID REINFORCED COATED",SUP-0650HYB0905A,CDM,C1768,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"UHC [10700]","United Healthcare",,10700.87,63.3,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +1.5MM 12/14 TAPER 44MM HIP TOTAL STABILIZE",SUP-136544710,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"CIGNA [10200]","Cigna Local Plus",,4726.28,31.5,,5372.07,4581.20,7242.98,23,1744.97,12753.44,"percent of total billed charges",
"CNCT SHUNT ACCU-FLO RIGHT ANGLE CSF CATH PLASTIC STERILE",SUP-45104,CDM,S27800098,LOCAL,0278,RC,,,both,,,762.78,228.83,"BLUE CROSS [10001]","Blue Cross PPO",,299.01,39.2,,,,,0,88.71,648.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 150CM 8FR .038IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006175280170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,580.81,45.9,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 340MM RIGHT TROCHANTERIC INTRAMEDULLARY 130D LONG",SUP-456.354S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1619.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1589.87,11619.86,"percent of total billed charges",
"INSRT TIBIAL 2.5 CURVE PLUS 20MM KNEE XLK FIX BEARING SIGMA",SUP-970445,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"KAISER [10500]",Kaiser,,7486.95,67,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE TRUWAVE 1 BOND 1 WAY SHUTOFF STPCOCK",SUP-PX600,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.31,27.69,"NOVANET [10819]",Novanet,,69.23,75,,,,,0,10.74,78.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SURGITIE 0 21IN LIGATE LOOP ABSORBABLE",SUP-SGL-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PENTARAY 7FR 2-6-2MM F CURVE ELECTROPHYSIOLOGY",SUP-D128208,CDM,C1732,HCPCS,0272,RC,,,both,,,13634.40,4090.32,"MULTIPLAN [10600]",Multiplan,,11589.24,85,,,,,0,1585.68,11589.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2MM FAST ULNA ANATOMIC ANATOMIC VOLAR PLATING",SUP-FDB20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 15MM 3MM BALLOON DILATATION PACLITAXEL RADIOPAQUE",SUP-H7493960815300,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4609.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 20MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.720,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.61,466.68,"BLUE CROSS [10001]","Blue Cross PPO",,609.8,39.2,,957.42,570.23,957.42,28,180.92,1322.27,"percent of total billed charges",
"STEM FEMORAL 17MM CEMENT FEMUR",SUP-71316017,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2519.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2472.83,18073.13,"percent of total billed charges",
"STENT 20CM 150CM 8FR .038IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006175280170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"NOVANET [10819]",Novanet,,949.04,75,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 26MM AXSOS LOCK NONSTERILE",SUP-661026,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"CIGNA [10200]",Cigna,,887.89,68,,1831.33,1831.33,1831.33,16,151.86,1109.86,"percent of total billed charges",
"MODULE SPINAL MAXCESS 4",SUP-8240060,CDM,S27200284,LOCAL,0272,RC,,,both,,,12551.10,3765.33,"FIRST HEALTH [10303]","First Health",,10040.88,80,,,,,0,1459.69,10668.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 28.3CM 10FR NEPHRSTMY PERCUFLEX LOCK LOOP STERILE LATEX",SUP-M0064101120,CDM,C1729,HCPCS,0272,RC,,,both,,,616.49,184.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INFLAMMATORY BOWEL DISEASE WITH CC",386,MS-DRG,,,,,,,inpatient,,,34543.87,10363.16,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RADPICC 250MM 70CM 5FR 10UM CENTRAL VENOUS POLYURETHANE",SUP-3265155,CDM,C1751,HCPCS,0272,RC,,,both,,,475.47,142.64,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET VENTRICULAR ASSIST IMPELLA AXILLARY LATEX FREE",SUP-0052-0011,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,inpatient,,,128797.44,38639.23,"BLUE CROSS [10001]","Blue Cross PPO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 8MM DA VINCI S/SI ENDOWRIST CADIERE",SUP-420049,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LEAD PACING 86CM 3.9-5.2FR 2.6FR 75CM SPACE LEFT VENTRICULAR",SUP-4677,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"AETNA [10100]","Aetna HMO/PPO",,4457.57,79.5,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kerecis Omega3, per Sq Cm",PX-E63600047,CDM,Q4158,HCPCS,0636,RC,,,both,,,655.17,196.55,"FIRST HEALTH [10303]","First Health",,524.14,80,,,,,0,77.64,556.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 5.5MM 72MM CLEAR-TRAC SHOULDER OBTR",SUP-72200429,CDM,S27200284,LOCAL,0272,RC,,,both,,,317.90,95.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,216.17,68,,,,,0,36.97,270.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,inpatient,,,78138.17,23441.45,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,33952.23,,"of the excess amount. Final payment is multiplied by 103%.",,,,0,2462,70871.16,"case rate","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VISIGI 3D 32FR GASTRIC LAVAGE BULB VENT OFF POSITION",SUP-5232SB,CDM,S27000186,LOCAL,0270,RC,,,both,,,1792.50,537.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,736.72,41.1,,,,,0,208.47,1523.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER SOLOIST 110CM 6FR 2-5-2MM SPACING JOSEPHSON CURVE E",SUP-44216J,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"UHC [10700]","United Healthcare",,198.26,63.3,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 5-0 P-1 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J490G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRUG DELIVERY 5ML/HR ON-Q 2.25 DAY DELIVERY TIME 270ML",SUP-P270X5,CDM,C9804,HCPCS,0272,RC,,,both,,,1041.14,312.34,"CIGNA [10200]","Cigna Local Plus",,557.01,53.5,,,,,0,121.08,884.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (MR) 10MM X 3.75",SUP-H74939401103750,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,641.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRSSZR CEMENT MEDIUM FEMUR ADVANCE",SUP-0206-566-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,222.66,66.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.9,189.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pad Level Sensor Sarns",PX-E27200270,CDM,E27200270,LOCAL,0272,RC,,,both,,,53.22,15.97,"CIGNA [10200]",Cigna,,36.19,68,,,,,0,6.19,45.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,inpatient,,,64156.26,19246.88,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,18593.6,,"Case rate ($9,131.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,479.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,518.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,023.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $8,490.45. The transfer operating threshold is the transfer adjustment factor * $8,479.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $641.07. The transfer capital threshold is the transfer adjustment factor * $641.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,36712.7,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 20MM TI",SUP-MTC-37200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"CIGNA [10200]","Cigna Local Plus",,667.36,53.5,,3978.14,359.25,3978.14,24,145.07,1060.29,"percent of total billed charges",
"CATH EXTR PRO RX-S 200CM 7-6FR 9-12MM SPECIMEN RETRIEVAL",SUP-M00547300,CDM,C1769,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 55MM ATLANTIS VISION ELITE BONE ANTERIOR CERVICAL",SUP-7200055,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"BLUE CROSS [10001]","Blue Cross HMO",,2074.46,39.2,,957.42,156.86,7483.26,51,615.46,4498.2,"percent of total billed charges",
"SCR BONE 5MM 65MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.222,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,249.9,28.62,,,,,0,101.55,742.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH KODAMA ULTRASOUND",SUP-017788,CDM,C1753,HCPCS,0272,RC,,,both,,,4140.00,1242,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17 DIOPTER +1.5 CYL MODIFY C BICONVEX 13MM 6MM",SUP-ZCT150U170,CDM,V2632,HCPCS,0276,RC,,,both,,,3712.50,1113.75,"CIGNA [10200]",Cigna,,2524.5,68,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORTHOLOC 3DI ANKLE FUSION SYSTEM NON-LOCKING SCREW 5.5MM NON",SUP-59225540,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"BLUE CROSS [10001]","Blue Cross HMO",,390.55,39.2,,957.42,156.86,7483.26,51,115.87,846.86,"percent of total billed charges",
"COIL EMBOLIZATION 20CM 6MM CEREPAK FREEFORM DETACHABLE",SUP-SCR120620,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA [10200]","Cigna Open Access",,4430.66,33.5,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 9 5/8IN 30FR POOLE STRAIGHT CHROME CONNECTION",SUP-70-4001,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.10,61.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,140.15,68,,,,,0,23.97,175.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 30MM 80CM 6MM VASCULAR NITINOL PERIPHERAL",SUP-1012528-30,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR STRAIGHT 180CM .025IN HYDROPHILIC FIX CORE",SUP-H2OSTDS25180,CDM,C1769,HCPCS,0272,RC,,,both,,,408.47,122.54,"KAISER [10500]",Kaiser,,273.67,67,,,,,0,47.51,347.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 2X1CM ALLODERM SELECT THK.2-1MM 2SQ CM THIN",SUP-141602,CDM,Q4116,HCPCS,0636,RC,,,both,,,1239.30,371.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,842.72,68,,,,,0,146.86,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL OVITEX 22X18IN PERMANENT GRID 1 SMOOTH SIDE",SUP-F10246-1822P,CDM,C1781,HCPCS,0278,RC,,,both,,,39068.57,11720.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4543.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4543.67,33208.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 240MM 8MM DISTAL RADIAL CARBON FIBER",SUP-395.786,CDM,C1713,HCPCS,0278,RC,,,both,,,600.00,180,"AMERIGROUP MEDICAID [20100]",Amerigroup,,71.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",69.78,510,"percent of total billed charges",
"LENS IOL SQUARE EDGE 1 PIECE ANTERIOR ASPHERIC UV BLOCK",SUP-ZCB0000110,CDM,C1780,HCPCS,0276,RC,,,both,,,1174.50,352.35,"PHCS [10601]",PHCS,,822.15,70,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 240CM 5.5CM 7.5FR 15-18MM ESOPHAGUS",SUP-M00558700,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOLOIST 110CM 6FR 2-5-2MM SPACING JOSEPHSON FLEX CURVE",SUP-44216JF,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC US Elastogrp Ea Add Target",PX-402000057,CDM,76983,CPT,0402,RC,,,both,,,1560.00,468,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure count. Procedure 1, Fee schedule rate ($117.76). Procedures 2 - 999, Fee schedule rate ($58.88).",,,,0,,,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 90X20MM ONETRAC LX 2 SMOKE EVACUATION CHANNEL",SUP-C100240,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"FIRST HEALTH [10303]","First Health",,1500,80,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM TRABECULAR METAL REVERSE PLUS ORTHOPEDIC SHOULDER",SUP-98000900084,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"AETNA [10100]","Aetna HMO/PPO",,38565.45,79.5,,10981.53,8986.79,12413.38,12,5641.71,41233.5,"percent of total billed charges",
"INTRO SHEATH 6FR 80CM 23CM GREEN HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-6F-23-035,CDM,C1894,HCPCS,0272,RC,,,both,,,117.45,35.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,48.27,41.1,,,,,0,13.66,99.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Perq Tcat US Abltj Nrv P-Art",PX-361000551,CDM,0632T,CPT,0361,RC,,,both,,,3208.00,962.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3208,,"Case rate ($6,657). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,373.09,3208,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 7.5IN RYDER IMPREGNATE NDL TITANIUM TUNGSTEN CARBIDE",SUP-55-0468T,CDM,S27200284,LOCAL,0272,RC,,,both,,,3385.13,1015.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,401.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,393.69,2877.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X12X8MM ENDOSKELETON TC 6D LORDOTIC SMALL",SUP-5146-1208-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"FIRST HEALTH [10303]","First Health",,8280,80,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLICATOR TIP EXT FLX 2 LUMN F SEAL SYS 8CM W 3 SPRY TIP",SUP-205108,CDM,S27200284,LOCAL,0272,RC,,,both,,,1096.08,328.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,503.1,45.9,,,,,0,127.47,931.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 70MM TI",SUP-SPL-60700-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X17MM LUMINARY CC BICONVEX SPINE",SUP-6817,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"CIGNA [10200]","Cigna Local Plus",,10478.16,31.5,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Needle Nerve Stimuplex",PX-E27200254,CDM,E27200254,LOCAL,0272,RC,,,both,,,118.80,35.64,"CIGNA [10200]","Cigna Local Plus",,63.56,53.5,,,,,0,13.82,100.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 15X14CM BREAST 700ML STYLE 133MX STERILE NATRELLE",SUP-133MX-15-T,CDM,C1789,HCPCS,0278,RC,,,both,,,6510.00,1953,"BLUE CROSS [10001]","Blue Cross PPO",,2551.92,39.2,,16595.83,16595.83,16595.83,"1 through 10",757.11,5533.5,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL 2.84IN 3/32IN EDGE STD PTFE ELECTRD",SUP-E1465B,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.24,14.77,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 135CM 40MM 6MM BALLOON DILATATION HYDROPHILIC",SUP-606004022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUB TISSUE 8X6CM STRATTICE PORCINE DERMAL MATRIX PLIABLE",SUP-0608001,CDM,Q4130,HCPCS,0636,RC,,,both,,,8031.60,2409.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT POLYPROPYLENE PROLENE HS 5-0 RB-2 30IN 2 ARM",SUP-EPH8710H,CDM,S27200284,LOCAL,0272,RC,,,both,,,168.43,50.53,"FIRST HEALTH [10303]","First Health",,134.74,80,,,,,0,19.59,143.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Tilmanocept Diag 0.5mci",PX-343000030,CDM,A9520,HCPCS,0343,RC,,,both,,,4614.97,1384.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3138.18,68,,,,,0,536.72,3922.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X4CM VIALIZE PLACENTAL MEMB ALLOGRAFT",SUP-VL-4040,CDM,,,0278,RC,,,both,,,10281.00,3084.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1218.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.28,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 3MM BALLOON DILATATION OTW STERILE",SUP-593004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"FIRST HEALTH [10303]","First Health",,1166.4,80,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX16MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183566,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5181.07,40,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BISACODYL 10 MG RECTAL SUPPOSITORY",RX-1080,CDM,,,0637,RC,00574-7050-12,NDC,both,1,UN,6.27,1.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X14X12MM FORTIFY I 3.5D NO SPIKE FOOTPRINT",SUP-137.311,CDM,S27800098,LOCAL,0278,RC,,,both,,,31320.00,9396,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12528,40,,,,,0,3642.52,26622,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 18X4IN 1 TUBE 2 PORT WITHOUT SLEEVE ATS STERILE",SUP-60707010300,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.22,52.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,118.47,68,,,,,0,20.26,148.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD STIMULATOR SPINE 70CM 4X8",SUP-SC-8336-70,CDM,C1778,HCPCS,0278,RC,,,both,,,31500.00,9450,"CIGNA [10200]","Cigna Open Access",,10552.5,33.5,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 90MM 6MM DISTAFLO SMALL BEAD MINI CUFF",SUP-DFX9006SC,CDM,C1768,HCPCS,0278,RC,,,both,,,10339.63,3101.89,"PHCS [10601]",PHCS,,7237.74,70,,,,,0,1202.5,8788.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 86MM STAINLESS STEEL 2.7/3.5MM SCR 4 HOLE LCP BONE",SUP-02.112.139,CDM,C1713,HCPCS,0278,RC,,,both,,,3031.88,909.56,"CIGNA [10200]","Cigna Open Access",,1725.14,56.9,,1144.80,304.56,2275.09,66,352.61,2577.1,"percent of total billed charges",
"CATHETER GUIDING ADULT 8FR L100CM CORONARY BLUE NYLON PTFE X",SUP-5888100,CDM,C1725,HCPCS,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING IRRIGATION FMS SOLO ARTHROSCOPIC FLUID MANAGEMENT EXT",SUP-281103,CDM,S27200284,LOCAL,0272,RC,,,both,,,201.91,60.57,"CIGNA [10200]","Cigna Open Access",,114.89,56.9,,,,,0,23.48,171.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE PRO3 AMNIOTIC PLACENTAL MEMBRANE THIN L4 C",SUP-P01-AMP-0404,CDM,S27800098,LOCAL,0278,RC,,,both,,,8918.25,2675.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1056.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1037.19,7580.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN AMPLATZ RIGHT 1 CURVE",SUP-08526-84,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]",Cigna,,52.07,68,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TRAPEZOID 45MMX1MM TITANIUM 2/2.3MM SCR 6X2 HOLE GRID",SUP-A-4650.67,CDM,S27200284,LOCAL,0272,RC,,,both,,,7245.00,2173.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2977.7,41.1,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 9FR RIGHT VENTRICLE ENDOCARDIUM BIPOLAR",SUP-4458,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"PHCS [10601]",PHCS,,3924.9,70,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 18GA 20GA 3.5IN 1.5IN 5ML LOR CLOSED END CATH",SUP-332220,CDM,S27200284,LOCAL,0272,RC,,,both,,,151.89,45.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,69.72,45.9,,,,,0,17.66,129.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE DRILL 26-30MM 3-4MM PONTO REMOVABLE SPACER PILOT",SUP-M50287,CDM,S27200284,LOCAL,0272,RC,,,both,,,1708.88,512.66,"FIRST HEALTH [10303]","First Health",,1367.1,80,,,,,0,198.74,1452.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 30X11X13MM ENDOSKELETON TT 4D LORDOTIC LARGE",SUP-4114-3013-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,28980.00,8694,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11910.78,41.1,,,,,0,3370.37,24633,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE AUG 3CC",SUP-K20003010,CDM,C1734,HCPCS,0278,RC,,,both,,,23052.69,6915.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2681.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2681.03,19594.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 42MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.742,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,133.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",130.68,955.09,"percent of total billed charges",
"CATH CORDIS SABER 90CM 80MM 3MM BALLOON DILATATION DURALYN",SUP-48003008S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PHCS [10601]",PHCS,,878.85,70,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPANDER TISSUE BREAST 850CC STYLE 133S SMOOTH 3 SUTURE TAB",SUP-133S-MX-16-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA [10200]","Cigna Open Access",,5300.24,56.9,,5166.00,5166.00,5166.00,"1 through 10",1083.33,7917.75,"percent of total billed charges",
"CAP KIT REPLACEMENT GLENOID SHOULDER TRABECULAR METAL VIVACI",SUP-98000900026,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"AETNA [10100]","Aetna HMO/PPO",,38565.45,79.5,,10981.53,8986.79,12413.38,12,5641.71,41233.5,"percent of total billed charges",
"INSRT TIBIAL 5 CURVE PLUS 20MM KNEE XLK FIX BEARING SIGMA",SUP-970475,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4592.74,41.1,,6417.48,6417.48,6417.48,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"SURFACE ARTICULAR 10MM PERSONA 3-7 C-D KNEE LEFT",SUP-42511200410,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"FIRST HEALTH [10303]","First Health",,6460.61,80,,,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cystoscopy",PX-361000355,CDM,52000,CPT,0361,RC,,,both,,,4285.99,1285.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,507.89,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,498.46,4285.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE VOYANT MARYLAND 7MM 18MM 23CM 20MM LAPAROSCOPIC 1",SUP-EB217,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 8MM BALLOON",SUP-U357586,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH THERMOCOOL SF 115CM 8FR 2-5-2MM SPACE D-F CURVE",SUP-BDI35DFRT,CDM,C2630,HCPCS,0272,RC,,,both,,,11350.50,3405.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS INFINITI 100CM 6FR JL4.5 CURVE ANGIOGRAPHIC",SUP-534617T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 150CM 150MM 7MM BALLOON DILATATION PEBAX",SUP-H74939032701510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 16GA 18GA 6IN .032IN GWIRE NDL SYR CENTRAL VENOUS",SUP-AK-04306,CDM,C1751,HCPCS,0272,RC,,,both,,,145.48,43.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Grft F/N/H/F/G Add 25scm",PX-510000055,CDM,15276,CPT,0761,RC,,,both,,,344.00,103.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER ALLOGRAFT 21-26X27-32X15MM LUMINARY CC BICONVEX SPINE",SUP-16815,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"NOVANET [10819]",Novanet,,24948,75,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 60MM 120MM 12MM .035IN 3MM VASCULAR VENOUS",SUP-VENUL12060,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS [10001]","Blue Cross PPO",,8643.6,39.2,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"E-CATH TRAY 18G X 4'' (100MM) INDWELLING CATHETER SONOPLEX 2",SUP-TDL135,CDM,S27200284,LOCAL,0272,RC,,,both,,,603.45,181.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,71.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.18,512.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT BLUE GRAY SURGISLEEVE ALEXIS 3X FILM ELASTIC",SUP-WPSM256,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.71,57.81,"CIGNA [10200]",Cigna,,131.04,68,,,,,0,22.41,163.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 22X8X11-8.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-4811,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"BLUE CROSS [10001]","Blue Cross PPO",,5815.32,39.2,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 4.5MM 16MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.516.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"BLUE CROSS [10001]","Blue Cross HMO",,233.82,39.2,,957.42,156.86,7483.26,51,69.37,507.01,"percent of total billed charges",
"RELOAD SUT ASSISTANT 2-0 ES-9 7IN 1 STITCH BRAID COATED ENDO",SUP-170002,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"KAISER [10500]",Kaiser,,96.59,67,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVISOR VL SENSOR ENABLED CIRCULAR MAPPING STEERABLE",SUP-D-AVSE-DF10-V1525,CDM,C1732,HCPCS,0272,RC,,,both,,,11730.00,3519,"FIRST HEALTH [10303]","First Health",,9384,80,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 STD KNEE RIGHT BIOFOAM SCR EVOLUTION MP",SUP-ETPSB8SR,CDM,C1776,HCPCS,0278,RC,,,both,,,13668.90,4100.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5467.56,40,,,,,0,1589.69,11618.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 55MM XIA SERRATO SPINE POLYAXIAL NONSTERILE 3",SUP-482617555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Spectrophotometry",PX-301000403,CDM,84311,CPT,0301,RC,,,both,,,337.25,101.17,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,286.66,"per diem",
"SCR BONE 2.7MM 26MM RADIUS DISTAL VOLAR 3 LEAD THREAD",SUP-131227326,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8.5FR 180CM 81CM GWIRE BRAID HEMOSTASIS VALVE",SUP-407456,CDM,C1893,HCPCS,0272,RC,,,both,,,1409.40,422.82,"KAISER [10500]",Kaiser,,944.3,67,,,,,0,163.91,1197.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRI-STAPLE 2.0 RELOAD 60MM MEDIUM/THICK TISSUE PURPLE",SUP-SIG60AMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 4CM 2MM GALAXY G3 MINI STRETCH",SUP-GLM920040,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]",Cigna,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 38CM RIGHT TROCHANTERIC INTRAMEDULLARY 130D LONG",SUP-456.478S,CDM,C1713,HCPCS,0278,RC,,,both,,,12838.83,3851.65,"UHC [10700]","United Healthcare",,8126.98,63.3,,5023.51,2672.93,6679.78,18,1493.16,10913.01,"percent of total billed charges",
"CAGE SPINAL 60X10MM STD XL PEEK PLATE FUSION",SUP-7861060,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"NOVANET [10819]",Novanet,,25706.7,75,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL SHEPARD 3 5/8IN CURVED INTRAOCULAR LENS",SUP-355275,CDM,S27200284,LOCAL,0272,RC,,,both,,,2175.83,652.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,253.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,253.05,1849.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 18 12 X 40 COMPLEX FRAMING COIL",SUP-18CFR-12040,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1520.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 36MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0292,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"KAISER [10500]",Kaiser,,634.96,67,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +10 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.100,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VIA DEMINERALIZE MINERALIZE CORTICAL CANCELLOUS",SUP-VCAMX-025000,CDM,S27800098,LOCAL,0278,RC,,,both,,,6037.50,1811.25,"FIRST HEALTH [10303]","First Health",,4830,80,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 9IN CODMAN VERSATRU 1.5MM STD NONSTICK SLEEK",SUP-9009150ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,3198.15,959.44,"MULTIPLAN [10600]",Multiplan,,2718.43,85,,,,,0,371.94,2718.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 5 MM X 10 CM",SUP-M0035475100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4039.61,28.62,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA PERFUSION ADULT PEDIATRIC 34FR L12-15IN CONNECTION S",SUP-67534,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.59,90.48,"CIGNA [10200]","Cigna Local Plus",,161.35,53.5,,,,,0,35.07,256.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER VASCULAR PROCEDURES WITH CC",253,MS-DRG,,,,,,,inpatient,,,132400.34,39720.1,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,32784.18,,"Case rate ($16,100.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,950.56, add-ons for qualifying new technology services are included. If operating cost exceeds $47,990.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,512.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $14,970.33. The transfer operating threshold is the transfer adjustment factor * $14,950.56 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.34. The transfer capital threshold is the transfer adjustment factor * $1,130.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,75781.14,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM SOLERA COCR TITANIUM SPINE MULTIAXIAL",SUP-54840007550,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6491.86,68,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS INFINITI 100CM 6FR JL4.5 CURVE ANGIOGRAPHIC",SUP-534617T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"NOVANET [10819]",Novanet,,65.25,75,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 20MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.720,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.61,466.68,"PHCS [10601]",PHCS,,1088.93,70,,,,,0,180.92,1322.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC RBC Lr Irrad Ea Unit",PX-390000013,CDM,P9040,HCPCS,0390,RC,,,both,,,1892.80,567.84,"MULTIPLAN [10600]",Multiplan,,1608.88,85,,,,,0,220.13,1608.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH X-FORCE U30 4CM 6FR 5MM BALLOON DILATATION PERCUTANEOUS",SUP-997504,CDM,C1726,HCPCS,0272,RC,,,both,,,1909.58,572.87,"UHC [10700]","United Healthcare",,1208.76,63.3,,,,,0,222.08,1623.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ELECTROSURGICAL 18.8CM LIGASURE FORCETRIAD 3.4V SMALL",SUP-LF1212A,CDM,S27200284,LOCAL,0272,RC,,,both,,,2797.50,839.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1284.05,45.9,,,,,0,325.35,2377.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 3.8-3.4FR 5.5MM LOW",SUP-H74939031554010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 18MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0101800,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"AETNA [10100]","Aetna HMO/PPO",,4040.07,79.5,,10981.53,8986.79,12413.38,12,591.02,4319.57,"percent of total billed charges",
"PROBE ELECTROSURGICAL BLACK ABLATOR 90D KNEE SHOULDER",SUP-7209659,CDM,S27200284,LOCAL,0272,RC,,,both,,,1105.65,331.69,"UHC [10700]","United Healthcare",,699.88,63.3,,,,,0,128.59,939.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 17.5MM KNEE GVF STABILIZE ROTATE PLATFORM PFC",SUP-962114,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"CIGNA [10200]","Cigna Open Access",,5806.7,56.9,,5302.19,4377.88,6578.61,27,1186.85,8674.34,"percent of total billed charges",
"CATH RADPICC 250MM 70CM 5FR 10UM CENTRAL VENOUS POLYURETHANE",SUP-3265155,CDM,C1751,HCPCS,0272,RC,,,both,,,475.47,142.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,323.32,68,,,,,0,55.3,404.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ELECTROSURGICAL 8.25IN OLSEN BAYONET BIPOLAR FRCP SMOOTH",SUP-20-1400KI,CDM,S27200284,LOCAL,0272,RC,,,both,,,402.18,120.65,"PHCS [10601]",PHCS,,281.53,70,,,,,0,46.77,341.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW ACU-LOC 2 BONE RIGHT DISTAL VOLAR RADIAL",SUP-70-0359,CDM,C1713,HCPCS,0278,RC,,,both,,,6654.91,1996.47,"NOVANET [10819]",Novanet,,4991.18,75,,,,,0,773.97,5656.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 FS-2 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8665G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 28MM AEQUALIS TITANIUM HUMERAL PROXIMAL",SUP-7425028,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"CIGNA [10200]",Cigna,,848.23,68,,1831.33,1831.33,1831.33,16,145.07,1060.29,"percent of total billed charges",
"CATH XXL 120CM 40MM 18MM BALLOON DILATATION PERIPHERAL LARGE",SUP-M001145580,CDM,C1725,HCPCS,0272,RC,,,both,,,1709.63,512.89,"UHC [10700]","United Healthcare",,1082.2,63.3,,,,,0,198.83,1453.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP SYSTEM WITH METAL HEAD",SUP-55500017,CDM,C1776,HCPCS,0278,RC,,,both,,,21420.00,6426,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6130.4,28.62,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH X-FORCE U30 4CM 6FR 5MM BALLOON DILATATION PERCUTANEOUS",SUP-997504,CDM,C1726,HCPCS,0272,RC,,,both,,,1909.58,572.87,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,inpatient,,,111735.95,33520.78,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 4.75MM CD HORIZON SOLERA CURVE COCRMO",SUP-1475001120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12MM 8MM COMPLEX .018IN HELICAL PLATINUM",SUP-M0013120551,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KT GSTRM 24FR GTB BLN",SUP-6223,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"KAISER [10500]",Kaiser,,204.02,67,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE3.5MM 22MM ANKLE FOOT LOCKING",SUP-MFT0213522,CDM,C1713,HCPCS,0278,RC,,,both,,,1547.10,464.13,"BLUE CROSS [10001]","Blue Cross HMO",,606.46,39.2,,957.42,156.86,7483.26,51,179.93,1315.04,"percent of total billed charges",
"BOOT CAST CANVAS LARGE OPEN TOE SHOCK ABSORBENT SOLE ROCKER",SUP-798703,CDM,S27000186,LOCAL,0270,RC,,,both,,,65.69,19.71,"FIRST HEALTH [10303]","First Health",,52.55,80,,,,,0,7.64,55.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL LOCK HOLE COMPRESSION SLOT PRECONTOUR",SUP-AR-2652CR,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"16MM AMPLATZER MUSCULAR VSD OCCLUDER",SUP-9-VSD-MUSC-016,CDM,C1817,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]","Cigna Open Access",,21004.5,33.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX14MM MAXIM ARCOM KNEE POSTERIOR STABILIZE",SUP-11146534,CDM,C1776,HCPCS,0278,RC,,,both,,,7472.70,2241.81,"NOVANET [10819]",Novanet,,5604.53,75,,,,,0,869.08,6351.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 9CM 7FR DUODENAL BEND BILIARY PLASTIC",SUP-M00534220,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"FIRST HEALTH [10303]","First Health",,871.56,80,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 7IN SMITH SUCTION NERVE",SUP-58-5000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1207.63,362.29,"MULTIPLAN [10600]",Multiplan,,1026.49,85,,,,,0,140.45,1026.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION",RX-123154,CDM,J2919,HCPCS,0636,RC,00009-0047-27,NDC,both,1,UN,77.41,23.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6.12,,,,,,,6.12,65.8,"fee schedule",
"PATCH CARDIOVASCULAR 5X2CM ENCAP TECHNOLOGY PERICARDIAL",SUP-C0205,CDM,C1768,HCPCS,0278,RC,,,both,,,2874.38,862.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1954.58,68,,,,,0,334.29,2443.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 CURVE 10MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962031,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1096.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION X-PORT DUO SILICONE POLYURETHANE",SUP-0607675,CDM,C1788,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1204.88,45.9,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 28CM 150CM 5FR .038IN 3CM BLADDER LOOP",SUP-M006155224170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS [10001]","Blue Cross PPO",,556.77,39.2,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 40MM TI",SUP-SPL-35400-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,1144.80,304.56,2275.09,66,155.43,1136.03,"percent of total billed charges",
"SHEARS MONOPOLAR 31CM 5MM ENDO MINI-SHEARS ROTICULATOR",SUP-174309,CDM,S27200284,LOCAL,0272,RC,,,both,,,619.73,185.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,421.42,68,,,,,0,72.07,526.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDER 4MM 1.5MM .014IN BALLOON DILATATION LOW PROFILE",SUP-4100A-1504,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.50,708.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,279.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,274.76,2008.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 20MM CHESAPEAKE SPINE SELF TAPPING",SUP-2001-15520,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,341.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",341.92,2499,"percent of total billed charges",
"COIL EMBOLIZATION 40MM 6MM 35 COIL PUSHABLE 2D HELICAL",SUP-M0013726041,CDM,S27800098,LOCAL,0278,RC,,,both,,,769.50,230.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752620,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,104.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 27MM STD",SUP-M7-027,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6310.71,28.62,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +21.5 DIOPTER MODIFIED C BICONVEX MULTIPIECE",SUP-MA60AC.215,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75445050,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,3978.14,359.25,3978.14,24,441.36,3225.75,"percent of total billed charges",
"SUT PLAIN 3-0 CT-1 27IN MONOFILAMENT ABSORBABLE",SUP-842H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 36IN 8FR ANTICLOG RADIOPAQUE SMOOTH BOLUS",SUP-40-7368,CDM,S27200284,LOCAL,0272,RC,,,both,,,115.84,34.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.47,98.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 600CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRM-600,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"PHCS [10601]",PHCS,,2778.3,70,,,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 16MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532-P-116,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]",Cigna,,5682.01,68,,5873.17,5873.17,5873.17,"1 through 10",971.79,7102.52,"percent of total billed charges",
"CAGE SPINAL 8MM XL COLONIAL",SUP-365.708,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3065.39,45.9,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC",843,MS-DRG,,,,,,,inpatient,,,69733.13,20919.94,"CIGNA [10200]",Cigna,,26155.82,,"Fee schedule rate ($26,155.82). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,49748.32,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 30X5IN PRECUT ROLL FIBERGLASS ORTHO-GLASS",SUP-OG-5PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,126.93,38.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 10CM 4FR 21GA MERIT MAK .018IN STD STAINLESS STEEL",SUP-MAK405,CDM,C1894,HCPCS,0272,RC,,,both,,,225.77,67.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL MICROPOINT 6-0 G-6 18IN 2 ARM BRAID COATED VIOLET",SUP-J551G,CDM,S27200284,LOCAL,0272,RC,,,both,,,155.31,46.59,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,inpatient,,,37647.37,11294.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,,"Includes a variable per diem for the first 99999 days: RC 0170:0171 @ $1,091; RC 0179 @ $1,091; RC 0172 @ $2,586; RC 0173 @ $3,714; RC 0174 @ $4,240. Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,,,other,"IP NURSERY Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW .36IN TPS THK.017IN .73IN THIN SMALL BONE SAGITTAL",SUP-KM-3105,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE STBL XS VASCULAR 180CM 3CM .014IN STEERABLE SUPER SOFT",SUP-527914,CDM,C1769,HCPCS,0272,RC,,,both,,,613.25,183.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS 3-0 SH 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP864D,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.64,38.89,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EUPHORA 142CM 27MM 3MM BALLOON DILATATION DURATRAC",SUP-NCEUP3027X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE LUNDERQUIST VASCULAR STRAIGHT 300CM 4CM .035IN PTFE",SUP-G45352,CDM,C1769,HCPCS,0272,RC,,,both,,,937.98,281.39,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 6-32MM SYNERGRAFT CRYOVALVE SG PULMONARY",SUP-SGPV00,CDM,S27800098,LOCAL,0278,RC,,,both,,,145293.00,43587.9,"BLUE CROSS [10001]","Blue Cross HMO",,56954.86,39.2,,,,,0,16897.58,123499.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORPLEX 3X5 CM",SUP-CX-3050,CDM,Q4232,HCPCS,0636,RC,,,both,,,14966.10,4489.83,"PHCS [10601]",PHCS,,10476.27,70,,,,,0,247.92,12721.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 66MM STAINLESS STEEL T8 ELBOW METAPHYSEAL",SUP-02.118.566,CDM,C1713,HCPCS,0278,RC,,,both,,,547.40,164.22,"CIGNA [10200]","Cigna Open Access",,311.47,56.9,,1144.80,304.56,2275.09,66,63.66,465.29,"percent of total billed charges",
"STENT ZILVER 635 20MM 80CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-G43844,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"MULTIPLAN [10600]",Multiplan,,3213,85,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 300MM 2.5MM DRILL TIP NONSTERILE",SUP-03.120.026,CDM,C1769,HCPCS,0272,RC,,,both,,,437.72,131.32,"KAISER [10500]",Kaiser,,293.27,67,,,,,0,50.91,372.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE EVERPOINT 8-0 BV175-6 24IN 2 ARM MONOFILAMENT",SUP-EP8741H,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.23,104.77,"KAISER [10500]",Kaiser,,233.98,67,,,,,0,40.62,296.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 16MM 144CM 5MM CORONARY STENT",SUP-H7493926016500,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"AETNA [10100]","Aetna HMO/PPO",,7405.43,79.5,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SPINAL I-PAS III INSULATED PEDICLE ACCESS SYSTEM BEVELED",SUP-2010029,CDM,S27200284,LOCAL,0272,RC,,,both,,,2342.00,702.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,962.56,41.1,,,,,0,272.37,1990.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 40MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR40,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UHC [10700]","United Healthcare",,8298.63,63.3,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ASPIRATION 15MM 19GA 1.8MM EXCELON TRANSBRONCHIAL 1 HAND",SUP-M00564101,CDM,S27200284,LOCAL,0272,RC,,,both,,,664.10,199.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,304.82,45.9,,,,,0,77.23,564.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP BILICHEK CALIBRATION PLASTIC DISPOSABLE ANALZR INFANT",SUP-B800-50,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.91,15.57,"CIGNA [10200]","Cigna Local Plus",,27.77,53.5,,,,,0,6.04,44.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 22MM HIP C TAPER COCR LFIT",SUP-06-2200,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,370.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Spirometry Breathing Capacity",PX-460000001,CDM,94010,CPT,0460,RC,,,both,,,630.76,189.23,"CIGNA [10200]","Cigna Open Access",,358.9,56.9,,,,,0,73.36,536.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 30MM 80CM 10MM 8FR STRAIGHT VASCULAR",SUP-AVSM10030,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross HMO",,7161.84,39.2,,9776.84,9776.84,9776.84,"1 through 10",2124.8,15529.5,"percent of total billed charges",
"CATH SAPPHIRE NC PLUS 8MM 2.75MM BALLOON DILATATION STERILE",SUP-227-083-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 30MM 125CM 8MM 6FR .035IN VASCULAR NITINOL",SUP-G43830,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"KAISER [10500]",Kaiser,,2532.6,67,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 105MM 11MM INSIGNIA 5 40 STD OFFSET 35MM HIP",SUP-7000-5505,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"UHC [10700]","United Healthcare",,19353.28,63.3,,8601.07,8395.67,8601.07,"1 through 10",3555.74,25987.82,"percent of total billed charges",
"STEM FEMORAL 117MM TRI-LOCK BPS GRIPTION 11 12/14 STD OFFSET",SUP-101204110,CDM,C1776,HCPCS,0278,RC,,,both,,,29153.25,8745.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3454.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3390.52,24780.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 4.0 MM X 120 MM X 130 CM",SUP-IPU04012013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,956.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.3MM 50MM CHARLOTTE STAINLESS STEEL LONG THREAD",SUP-44110040,CDM,C1713,HCPCS,0278,RC,,,both,,,2055.00,616.5,"KAISER [10500]",Kaiser,,1376.85,67,,,,,0,239,1746.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.9MM JUGGERKNOT SUT ANCHOR",SUP-912091,CDM,S27200284,LOCAL,0272,RC,,,both,,,1190.70,357.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,546.53,45.9,,,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC MRI SURESCAN VENTRICULAR 1 CHMBR EV4 LATEX",SUP-DVEA3E4,CDM,C1722,HCPCS,0278,RC,,,both,,,118275.00,35482.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,48611.03,41.1,,,,,0,13755.38,100533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acylcarnitine Quant,Plasma Aru",PX-300000025,CDM,82017,CPT,0301,RC,,,both,,,304.95,91.48,"UHC [10700]","United Healthcare",,15.18,,,,,,,0.01,259.21,"fee schedule",
"WEDGE SCLERAL 2.5MM GROOVED SILICONE STERILE",SUP-92-28,CDM,S27800098,LOCAL,0278,RC,,,both,,,241.95,72.58,"KAISER [10500]",Kaiser,,162.11,67,,,,,0,28.14,205.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH ARTHROSCOPIC 4.5 MM CORKSCREW 4.5 MM PUSHLOCK FULL",SUP-AR-1922P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1615.95,484.78,"PHCS [10601]",PHCS,,1131.17,70,,,,,0,187.93,1373.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR DISPOSABLE STERILE 2.9MM PUSHLOCK",SUP-AR-1923DHS,CDM,C1713,HCPCS,0278,RC,,,both,,,1488.38,446.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,683.17,45.9,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 132D 10 HIP",SUP-6720-1040,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"BLUE CROSS [10001]","Blue Cross PPO",,9393.12,39.2,,3949.44,3949.44,3949.44,"1 through 10",2786.79,20367.74,"percent of total billed charges",
"BLADE LARYNGOSCOPE GLIDESCOPE 2.5 STAT VIDEO BATON COBALT AV",SUP-0270-0709,CDM,S27200284,LOCAL,0272,RC,,,both,,,216.11,64.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.13,183.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 16MM 144CM 3.5MM CORONARY STENT PEBAX",SUP-H7493926016350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CREO ONE ROBOTIC MODULAR NONSTERILE",SUP-1134.1640,CDM,C1713,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5621.02,68,,,,,0,961.36,7026.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 24CM 6FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856130,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"CIGNA [10200]","Cigna Local Plus",,586.71,,,,,,,127.54,932.16,"percent of total billed charges",
"INTRO SUPRAPUBIC 16FR 20- FR 17CM 20CM 1 STEP DIL TROCAR",SUP-G26655,CDM,S27200284,LOCAL,0272,RC,,,both,,,734.67,220.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,87.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,85.44,624.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AORTIC VALVED GRAFT WITH  MAQUETHEMASHIELDWOVEN DOUBLE VELOU","SUP-27CAVGJ-514  00",CDM,C1768,HCPCS,0278,RC,,,both,,,25533.90,7660.17,"CIGNA [10200]","Cigna Local Plus",,8043.18,31.5,,,,,0,2969.59,21703.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ANGLE STRAIGHT HANDLE 9.5IN ZEP ATRAUMATIC",SUP-52-9994,CDM,S27200284,LOCAL,0272,RC,,,both,,,1426.98,428.09,"CIGNA [10200]","Cigna Open Access",,811.95,56.9,,,,,0,165.96,1212.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 4MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012411-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELCA 130CM .9MM .038IN ATHERECTOMY OTW ADJUSTABLE LASER",SUP-110-002,CDM,C1885,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 100MM 135CM 6MM 5FR VASCULAR NITINOL LOW",SUP-5F061003CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"KAISER [10500]",Kaiser,,10170.6,67,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 8MM 3.25MM ULTRA LOW PROFILE BALLOON",SUP-1012275-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLECAINIDE 100 MG TABLET",RX-10041,CDM,,,0637,RC,00054-0011-20,NDC,both,1,UN,18.01,5.4,"KAISER [10500]",Kaiser,,12.07,67,,,,,0,2.09,15.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH CONE LONG HANDLE 5MM 2 CUT EDGE SHARP STERILE",SUP-APU550,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,33.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING URETHRAL BLUE DESARA TRANSVAGINAL STAINLESS STEEL",SUP-CAL-DS01BTV,CDM,C1771,HCPCS,0278,RC,,,both,,,6203.10,1860.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,721.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,721.42,5272.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 5092-58  LEAD BI SIL NOVUS SP PAS 5",SUP-5092-58,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,664.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC L100MM DIA5MM BLADELESS WITH STABILITY S",SUP-B5LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"MULTIPLAN [10600]",Multiplan,,133.11,85,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM PRIMARY HEMISPHERICAL CLUSTER HOLE",SUP-5020362G,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"NOVANET [10819]",Novanet,,7850.12,75,,,,,0,1217.29,8896.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH ARTHROSCOPIC STRAIGHT 130MM NANO BITER",SUP-AR-10911D-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,2086.88,626.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,957.88,45.9,,,,,0,242.7,1773.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY ESOPHAGEAL 2.5 STD 5MM 4MM PEDIATRIC LMA UNIQUE",SUP-125025,CDM,S27000186,LOCAL,0270,RC,,,both,,,52.20,15.66,"CIGNA [10200]","Cigna Local Plus",,27.93,53.5,,,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nucleic Acid Trichomon Amp",PX-306000195,CDM,87661,CPT,0306,RC,,,both,,,304.00,91.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.16,,"Fee schedule rate ($25.16). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.3,258.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"Bien-Air 40deg Curved Adenoid, Double Serrated, Convex, 4.0m",SUP-1600572,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,164.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE NDL 9GA DISPOSABLE EVIVA","SUP-EVIVA NG09L",CDM,S27200284,LOCAL,0272,RC,,,both,,,90.31,27.09,"FIRST HEALTH [10303]","First Health",,72.25,80,,,,,0,10.5,76.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 12MM 6FR 2.25MM .07IN BALLOON",SUP-H7493918912220,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX18MM VANGUARD POROUS KNEE POSTERIOR",SUP-183748,CDM,C1776,HCPCS,0278,RC,,,both,,,8757.48,2627.24,"PHCS [10601]",PHCS,,6130.24,70,,,,,0,1018.49,7443.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Consult Rad Physics/Weeksd",PX-333000059,CDM,77336,CPT,0333,RC,,,both,,,1181.32,354.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,139.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,137.39,1181.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HRA HUMERAL RESURFACING",SUP-71701416,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,8601.07,8395.67,8601.07,"1 through 10",3297.11,24097.5,"percent of total billed charges",
"HEAD FEMORAL 54MM HIP RESURFACING COBALT CHROME BHR",SUP-74121154,CDM,C1776,HCPCS,0278,RC,,,both,,,18360.00,5508,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7344,40,,,,,0,2135.27,15606,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 22FR SILICONE RADIOPAQUE BOLUS ENTERAL FEED INTERNAL",SUP-0110-22,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,33.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNGOSCOPE LOPRO 3 GLIDESCOPE",SUP-0270-0938,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"MULTIPLAN [10600]",Multiplan,,295.8,85,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 60MM 120CM 6MM 6FR VASCULAR PERIPHERAL",SUP-S-60-060-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"KAISER [10500]",Kaiser,,6741.54,67,,,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 24FR SILICONE TROCAR CANN ROUND EXTERNAL BOLST",SUP-M00509061,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"AETNA [10100]","Aetna HMO/PPO",,386.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 25MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G225,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA [10200]","Cigna Local Plus",,5350,53.5,,5372.07,4581.20,7242.98,23,1163,8500,"percent of total billed charges",
"SET INTRO CIAGLIA BLUE RHINO PERCUTANEOUS TRACH",SUP-C-PTIS-100-HC-G-PERC8,CDM,S27200284,LOCAL,0272,RC,,,both,,,2684.48,805.34,"CIGNA [10200]","Cigna Open Access",,1527.47,56.9,,,,,0,312.21,2281.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 16FR 14FR 22CM 30CM BALLOON NDL OBTR CONNECT TUBE",SUP-G14920,CDM,C2627,HCPCS,0272,RC,,,both,,,516.05,154.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,61.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.02,438.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT SPRT MEDTRONIC MEDIUM",SUP-FP9000M,CDM,S27000186,LOCAL,0270,RC,,,both,,,408.90,122.67,"CIGNA [10200]",Cigna,,278.05,68,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED II 100CM 6CM 9FR 22MM .035IN BALLOON DILATATION",SUP-611763,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"AETNA [10100]","Aetna HMO/PPO",,4227.84,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX14MM MAXIM ARCOM KNEE POSTERIOR STABILIZE",SUP-11146534,CDM,C1776,HCPCS,0278,RC,,,both,,,7472.70,2241.81,"FIRST HEALTH [10303]","First Health",,5978.16,80,,,,,0,869.08,6351.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 9 1/5INX9 1/5IN SELF ADHERENT ABSORBENT PAD MOISTURE",SUP-282400,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.52,26.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,40.17,45.9,,,,,0,10.18,74.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25.5X9.5X.38MM HALL MICRO STAINLESS STEAL SAGITTAL",SUP-5301025038,CDM,S27200284,LOCAL,0272,RC,,,both,,,157.73,47.32,"KAISER [10500]",Kaiser,,105.68,67,,,,,0,18.34,134.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTNR 9 1/8INX5 7/8IN MEDIUM VISCERAL STERILE LATEX FREE",SUP-3204,CDM,S27200284,LOCAL,0272,RC,,,both,,,413.25,123.97,"PHCS [10601]",PHCS,,289.28,70,,,,,0,48.06,351.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 29MM EPIC THV",SUP-E100-29M-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,24570.00,7371,"AETNA [10100]","Aetna HMO/PPO",,19533.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 4-0 SC-1 18IN 2 ARM MONOFILAMENT PLIABILIZE",SUP-1828H,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.77,21.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,29.09,41.1,,,,,0,8.23,60.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR 14X9MM ENCAP TECHNOLOGY",SUP-C0914,CDM,C1768,HCPCS,0278,RC,,,both,,,4767.21,1430.16,"CIGNA [10200]",Cigna,,3241.7,68,,,,,0,554.43,4052.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 50CM 11CM ORANGE HUB SNAP FIT DIL TUBING",SUP-PRO-7F-11-035,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X8MM COROENT 10D XL+ PEEK NONSTERILE LATEX",SUP-6308845,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"PHCS [10601]",PHCS,,16758,70,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 80CM 4CM 5FR 4MM 7.5MM BALLOON DILATATION",SUP-4194040S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALLOON RETRIEVAL EXTR PRO RX 200CM 6-7FR 12-15MM BILIARY 3",SUP-M00547040,CDM,C1889,HCPCS,0278,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 42CM FEMUR RIGHT PROXIMAL TALON DISTALFIX",SUP-SLN-125-42R,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"MULTIPLAN [10600]",Multiplan,,13706.51,85,,,,,0,1875.37,13706.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 6MM 4MM BALLOON DILATATION DURATRAC",SUP-NCEUP4006X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"FIRST HEALTH [10303]","First Health",,453.6,80,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SYR STELLANT 2 SPIKE DUAL T CNCT LOW PRESSURE TUBING 200",SUP-SDS-CTP-SCS,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.53,35.26,"CIGNA [10200]","Cigna Open Access",,66.87,56.9,,,,,0,13.67,99.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sodium Urine",PX-301000399,CDM,84300,CPT,0301,RC,,,both,,,142.50,42.75,"UHC [10700]","United Healthcare",,4.55,,,,,,,0.14,121.13,"fee schedule",
"BURR SURGICAL RED WHITE 2.3MM OTO-FLEX DIAMOND STERILE",SUP-3155642,CDM,S27200284,LOCAL,0272,RC,,,both,,,1972.50,591.75,"PHCS [10601]",PHCS,,1380.75,70,,,,,0,229.4,1676.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LOWER ROD",SUP-5680,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL GRAY WHITE 1.4MM OTO-FLEX DIAMOND STERILE",SUP-3155643,CDM,S27200284,LOCAL,0272,RC,,,both,,,1927.50,578.25,"UHC [10700]","United Healthcare",,1220.11,63.3,,,,,0,224.17,1638.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE BARRX RFA ENDOSCOPIC STRAIGHT 260CM .038IN STAINLESS",SUP-GW-002B,CDM,C1769,HCPCS,0272,RC,,,both,,,1466.10,439.83,"NOVANET [10819]",Novanet,,1099.58,75,,,,,0,170.51,1246.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE II DEMINERALIZED BONE MATRIX",SUP-7509505,CDM,S27800098,LOCAL,0278,RC,,,both,,,16715.25,5014.57,"CIGNA [10200]","Cigna Open Access",,5599.61,33.5,,,,,0,1943.98,14207.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVOLUTION SUTURE PASSER",SUP-FG0008,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,909.34,41.1,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THD SLIDE PATIENT KIT DISPOSABLE",SUP-800070,CDM,S27200284,LOCAL,0272,RC,,,both,,,4260.06,1278.02,"CIGNA [10200]","Cigna Local Plus",,2279.13,53.5,,,,,0,495.44,3621.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 62CM RIGHT VENTRICLE TRIPOLAR SCR IN EXTENDABLE",SUP-6935M62,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4636.44,27,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ekg Event Recording 30 Day",PX-730000005,CDM,93270,CPT,0730,RC,,,both,,,586.04,175.81,"FIRST HEALTH [10303]","First Health",,468.83,80,,,,,0,68.16,498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH-PROFILE BOOST, 170CC",SUP-SMHB170,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"AETNA [10100]","Aetna HMO/PPO",,6061.48,79.5,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Proc Dirct Ea 15min (Gp)",PX-420000021,CDM,97110,CPT,0420,RC,,,both,,,194.83,58.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.66,194.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 22CM 3CM 5FR .038IN 2",SUP-M006192121170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CIGNA [10200]","Cigna Open Access",,793.89,,,,,,,162.27,1185.95,"percent of total billed charges",
"SOL INTRAVENOUS FIRSTCHOICE 5% DEXTROSE 40 MEQ POTASSIUM",SUP-07904-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"UHC [10700]","United Healthcare",,51.27,63.3,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP MULTIHOLE R3 STD STERILE",SUP-71338665,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"CIGNA [10200]","Cigna Local Plus",,5004.48,31.5,,5372.07,4581.20,7242.98,23,1847.69,13504.16,"percent of total billed charges",
"STENT SUPERA 80MM 120CM 7.5MM 6FR VASCULAR NITINOL",SUP-S-75-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA [10200]",Cigna,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SR CORTICAL BLOCK 11X11X9MM",SUP-200911,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 22MM HIP C TAPER COCR LFIT",SUP-06-2200,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA [10200]","Cigna Local Plus",,1673.32,53.5,,5372.07,4581.20,7242.98,23,363.75,2658.55,"percent of total billed charges",
"COIL EMBOLIZATION 40CM 8MM INTERLOCK FIBERED IDC 35 COIL",SUP-M001363590,CDM,S27800098,LOCAL,0278,RC,,,both,,,5181.90,1554.57,"FIRST HEALTH [10303]","First Health",,4145.52,80,,,,,0,602.65,4404.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE CATH RELIEVA SIDEKICK SINUS GUIDE",SUP-SDKKLP,CDM,S27200284,LOCAL,0272,RC,,,both,,,445.50,133.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,204.48,45.9,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 40MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,166.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 401322 MDII 22X26 SRVC FEE",SUP-401322,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 60MM 6FR 5MM BALLOON DILATATION PEBAX",SUP-39032-50601,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eo W/Adj Joints Prefabricated",PX-E27400054,CDM,L3760,HCPCS,0274,RC,,,both,,,1647.80,494.34,"CIGNA [10200]","Cigna Local Plus",,881.57,53.5,,,,,0,191.64,1400.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12IN 18FR 3/18IN ARTERY THIN 1 PIECE",SUP-77418,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"AETNA [10100]","Aetna HMO/PPO",,356.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.1,380.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS AIM SL 7.62FR OBTUSE GUIDING STERILE LATEX FREE",SUP-DS2N028-65,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 29MM EPIC THV",SUP-E100-29M-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,24570.00,7371,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10098.27,41.1,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM 1.5 MM SCREW 7 HOLE BONE RIGHT CONDYLAR NONST",SUP-446.64.96,CDM,C1713,HCPCS,0278,RC,,,both,,,3271.80,981.54,"NOVANET [10819]",Novanet,,2453.85,75,,,,,0,380.51,2781.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE MONORAIL 150CM 220MM 2MM BALLOON DILATATION",SUP-H74939185202210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC",824,MS-DRG,,,,,,,inpatient,,,95382.67,28614.8,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,28616.06,,"Case rate ($14,053.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,049.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,089.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,368.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,067.03. The transfer operating threshold is the transfer adjustment factor * $13,049.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $986.63. The transfer capital threshold is the transfer adjustment factor * $986.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,66146.46,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL BROWN WHITE 1.8MM OTO-FLEX DIAMOND STERILE",SUP-3155645,CDM,S27200284,LOCAL,0272,RC,,,both,,,1482.30,444.69,"CIGNA [10200]",Cigna,,1007.96,68,,,,,0,172.39,1259.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT LEAD CAP STERILE LATEX FREE DISPOSABLE",SUP-7007,CDM,S27800098,LOCAL,0278,RC,,,both,,,1174.50,352.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON DEMINERALIZED BONE MATRIX DEMINERALIZED",SUP-T50101,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"MULTIPLAN [10600]",Multiplan,,1785,85,,,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT PRO+ 34MM",SUP-EVPROPLUS-34US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"AETNA [10100]","Aetna HMO/PPO",,135945,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM",RX-9969,CDM,,,0637,RC,00093-3541-43,NDC,both,42.5,GR,2257.83,677.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,267.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,262.59,1919.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM PFC SIGMA TC3 2 KNEE POSTERIOR TITANIUM",SUP-960826,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2355.06,45.9,,,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE THINFLAP LONG CRANIOMAXILLOFACIAL TITANIUM 4 HOLE",SUP-191045,CDM,C1713,HCPCS,0278,RC,,,both,,,1020.60,306.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,120.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",118.7,867.51,"percent of total billed charges",
"DIL SURGICAL AMPLATZ PTFE POLYETHYLENE SET RADIOPAQUE 2030CM",SUP-G57459,CDM,C1726,HCPCS,0272,RC,,,both,,,1917.75,575.32,"FIRST HEALTH [10303]","First Health",,1534.2,80,,,,,0,223.03,1630.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM FIBERTAK SPEEDBRIDGE SWIVELOCK SUTURETAPE IMPL SELF",SUP-AR-2600FSB-1,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25.5X9.5X.38MM HALL MICRO STAINLESS STEAL SAGITTAL",SUP-5301025038,CDM,S27200284,LOCAL,0272,RC,,,both,,,157.73,47.32,"PHCS [10601]",PHCS,,110.41,70,,,,,0,18.34,134.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIFLUFOLASTAT F-18 IV SYRINGE (8-9 MCI)",RX-411825,CDM,A9595,HCPCS,0343,RC,08888-8877-79,NDC,both,1,UN,16868.88,5060.66,"BLUE CROSS [10001]","Blue Cross PPO",,6451.67,,,,,,,696,14338.55,"fee schedule",
"SPACER SPINAL 22MMX9MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2990922,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1883.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 79MM 12.2MM 7.6MM TAPER DISTAL TIP DISPOSABLE INNER",SUP-8PERC,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.62,111.79,"NOVANET [10819]",Novanet,,279.47,75,,,,,0,43.34,316.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 1026X60MM 10",SUP-6210160,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross HMO",,9384.48,39.2,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,inpatient,,,355598.71,106679.61,"CIGNA [10200]",Cigna,,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 55.9%. Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES,MINOR",220,APR-DRG,,,,,,,inpatient,,,85344.12,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $8,791.20. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($32,550.17) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES,EXTREME",115,APR-DRG,,,,,,,inpatient,,,135241.37,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $10,601.32. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($118,927.55) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SYRINGE CONTROL 10ML 3 RING",SUP-70085007,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.07,15.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE",RX-11050,CDM,,,0637,RC,63044-0203-61,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PLAIN 3-0 CT-1 27IN MONOFILAMENT ABSORBABLE",SUP-842H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT PORCINE 5.9X3.9IN XENMATRIX AB RECTANGLE DERMAL CLLGN",SUP-1151015,CDM,C1781,HCPCS,0278,RC,,,both,,,25080.30,7524.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10308,41.1,,,,,0,2916.84,21318.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.2CM MEMORYGEL BOOST P4.5CM MODERATE PLUS",SUP-RSZMPB450S,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT 14MM ALIF",SUP-3W3214,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"BLUE CROSS [10001]","Blue Cross HMO",,8288.97,39.2,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esophagosc Rem Lesion by Snare",PX-750000203,CDM,43217,CPT,0750,RC,,,both,,,2075.00,622.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2075,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,241.32,2075,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 4IN 17GA 19GA TUOHY EPILONG CONTINUOUS CLOSE",SUP-TAL101,CDM,S27200284,LOCAL,0272,RC,,,both,,,330.60,99.18,"UHC [10700]","United Healthcare",,209.27,63.3,,,,,0,38.45,281.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 10CM 7FR 12MM .035IN BALLOON",SUP-G52301,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"FIRST HEALTH [10303]","First Health",,767.82,80,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPREME 120CM 4FR 5MM SPACING CRD CURVE",SUP-401891,CDM,C1730,HCPCS,0272,RC,,,both,,,1239.30,371.79,"UHC [10700]","United Healthcare",,784.48,63.3,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER IMPL SPINE TEMPORARY FIXATION SCR",SUP-650.012,CDM,S27800098,LOCAL,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,124.5,28.62,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR 5X2CM ENCAP TECHNOLOGY PERICARDIAL",SUP-C0205,CDM,C1768,HCPCS,0278,RC,,,both,,,2874.38,862.31,"CIGNA [10200]","Cigna Local Plus",,1537.79,53.5,,,,,0,334.29,2443.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +24 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.240,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X6MM ANATOMIC 14MM PEEK RADIOPAQUE CERVICAL",SUP-4240664,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +27 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.270,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 39MM MITRAL TRICUSPID FULL FLEXIBLE BAND",SUP-700FF39,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 150MM 6MM .018IN BALLOON",SUP-R51006015L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,237.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 3-0 CV-23 9IN CLSR ABSORBABLE UNDYED",SUP-VLOCM1944,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,89.89,45.9,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UNI-FUSE FLOW-THRU HUB 135CM 20CM 5FR THROMBECTOMY",SUP-12401813,CDM,C1757,HCPCS,0272,RC,,,both,,,3112.50,933.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1279.24,41.1,,,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 71CM TRANSSEPTAL CARTO VIZIGO ACQCROSS",SUP-900303,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Spine Lumb/Thor 2+ V",PX-320000042,CDM,72080,CPT,0320,RC,,,both,,,686.11,205.83,"FIRST HEALTH [10303]","First Health",,548.89,80,,,,,0,38.7,583.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX9MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2990922,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6533.91,41.1,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-0 TH-50 48IN NONABSORBABLE",SUP-0U01A,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.35,88.3,"AETNA [10100]","Aetna HMO/PPO",,234.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.23,250.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER ENDOSCOPIC 30MM 4MM TREVO XP PROVUE STERILE LATEX",SUP-90185,CDM,S27200284,LOCAL,0272,RC,,,both,,,47273.94,14182.18,"PHCS [10601]",PHCS,,33091.76,70,,,,,0,5497.96,40182.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM CROSSFT HI-FI KNOTLESS VENT PEEK BLUE",SUP-CFK-475STA,CDM,C1713,HCPCS,0278,RC,,,both,,,4444.57,1333.37,"PHCS [10601]",PHCS,,3111.2,70,,,,,0,516.9,3777.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL BENDING FIBERSTITCH 1.5",SUP-AR-4585,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"CIGNA [10200]","Cigna Open Access",,266.17,56.9,,,,,0,54.4,397.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENTOLAMINE 5 MG INJECTION SOLUTION",RX-10947,CDM,J2760,HCPCS,0636,RC,68094-0101-20,NDC,both,1,UN,2533.91,760.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.29,,,,,,,37.29,2153.82,"fee schedule",
"RTRCTR 7IN WYLIE LONG BLADE RENAL VEIN SURGICAL 1IN",SUP-54-1797,CDM,S27200284,LOCAL,0272,RC,,,both,,,1009.75,302.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,463.48,45.9,,,,,0,117.43,858.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TF DELIVERY SYSTEM (42MM) INTPD-TF-42DS",SUP-INTPDTF42DSG,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ASPIRATION NEEDLE, 5MMX42CM, 15 GAUGE NEEDLE 10/BOX",SUP-MY3015,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD DEFIB ADULT 42IN PREATTACHED WIRE RADIOTRANSPARENT",SUP-22550R,CDM,S27200284,LOCAL,0272,RC,,,both,,,86.77,26.03,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ROD SPINAL 90MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000090,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross HMO",,635.04,39.2,,957.42,156.86,7483.26,51,188.41,1377,"percent of total billed charges",
"MELOXICAM 7.5 MG TABLET",RX-20566,CDM,,,0637,RC,50268-0525-11,NDC,both,1,UN,15.58,4.67,"PHCS [10601]",PHCS,,10.91,70,,,,,0,1.81,13.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT OMEGA 2 KNOTLESS PEEK STERILE LATEX FREE",SUP-3910500472,CDM,C1713,HCPCS,0278,RC,,,both,,,4836.90,1451.07,"PHCS [10601]",PHCS,,3385.83,70,,,,,0,562.53,4111.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX PDS PLUS 3-0 PS SPIRAL 5IN ABSORBABLE",SUP-SXPP2B417,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.38,69.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,106.2,45.9,,,,,0,26.91,196.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 150MM 5.7FR 7MM BALLOON DILATATION 2",SUP-BD-L70150CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,394.5,41.1,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 16FR SILICONE STD J MIC SECUR-LOK TRIMMABLE",SUP-0200-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"AETNA [10100]","Aetna HMO/PPO",,874.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 00 8IN EPSTEIN SURGICAL",SUP-57-4621,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.74,104.92,"CIGNA [10200]","Cigna Local Plus",,187.11,53.5,,,,,0,40.67,297.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR OXIMETER ADULT CABLE L3FT BLACK SPO2 FLEX WITH FLEXIW",SUP-8000J,CDM,S27000186,LOCAL,0270,RC,,,both,,,2670.00,801,"PHCS [10601]",PHCS,,1869,70,,,,,0,310.52,2269.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB CONGR SZ3/4X10MM RT",SUP-2042-0-3410,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,414.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 18X1.2IN MELGISORB SILVER CALCIUM ALGINATE HIGH",SUP-255600,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.08,19.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.57,55.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD THK12MM 36J 51X68MM","SUP-CD1411-36C CELL",CDM,C1722,HCPCS,0278,RC,,,both,,,35964.00,10789.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,14385.6,40,,,,,0,4182.61,30569.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP CEMENTED FEMUR WITH OXINIUM HEAD XLPE CUP",SUP-71701003,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6463.8,27,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 SH 30IN BRAID BLACK NONABSORBABLE",SUP-K833H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAVITOR WITH RADIOPAQUE MARKERS 27MM",SUP-NVRO-27,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"UHC [10700]","United Healthcare",,86594.4,63.3,,,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Del Placenta",PX-720000002,CDM,59414,CPT,0720,RC,,,both,,,3611.29,1083.39,"CIGNA [10200]","Cigna Local Plus",,1932.04,53.5,,,,,0,419.99,3611.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ACCESS ASCENDA 2 ATTACHED COLLET CATH CNCT ANCHOR",SUP-8785,CDM,C1755,HCPCS,0278,RC,,,both,,,1912.50,573.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,226.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,222.42,1625.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Breast Uni W/WO Cntrst",PX-610000061,CDM,77048,CPT,0610,RC,,,both,,,5158.14,1547.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1248,,,,,,,599.89,4384.42,"per diem",
"HC Est Eval Visit Level 4",PX-510000179,CDM,99214,CPT,0761,RC,,,both,,,444.10,133.23,"PHCS [10601]",PHCS,,310.87,70,,,,,0,0.44,444.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 12X18X55MM 10DEG LORDOTIC MODULUS XL",SUP-1181255P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]",Cigna,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 00 8IN EPSTEIN SURGICAL",SUP-57-4621,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.74,104.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,160.53,45.9,,,,,0,40.67,297.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 16IN 29FR VEIN STD OPEN LIGHTHOUSE 3 STAGE 2",SUP-TF292902,CDM,S27200284,LOCAL,0272,RC,,,both,,,356.18,106.85,"NOVANET [10819]",Novanet,,267.14,75,,,,,0,41.42,302.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)CORONARY IVL CATHETER, 3.5MM X 12MM, RX IDE",SUP-501050-003,CDM,C1761,HCPCS,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 16MM 144CM 3.5MM CORONARY STENT PEBAX",SUP-H7493926016350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]","Cigna Local Plus",,2977.28,53.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 6+ MM 36MM AEQUALIS ASCEND FLEX B 12.5D",SUP-DWF361B,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"KAISER [10500]",Kaiser,,6048.76,67,,,,,0,1049.96,7673.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST MODERATE PROFILE 255CC SMOOTH SHELL SURFACE",SUP-SRM-255,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"CIGNA [10200]","Cigna Local Plus",,2934.74,,,,,,,637.96,4662.68,"percent of total billed charges",
"AEQUALIS PERFORM GLENOID (CORTILOC)- XL40",SUP-DWE431,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"CIGNA [10200]","Cigna Local Plus",,4984.06,53.5,,5372.07,4581.20,7242.98,23,1083.45,7918.6,"percent of total billed charges",
"STENT SUPERA 80MM 120CM 7.5MM 6FR VASCULAR NITINOL",SUP-S-75-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"PHCS [10601]",PHCS,,6399.75,70,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM VANGUARD TKR E1 FEMUR PATELLA TIBIA CEMENT STEM B",SUP-98000800027,CDM,C1776,HCPCS,0278,RC,,,both,,,19530.00,5859,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5589.49,28.62,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.75MM 30MM TITANIUM FULL THREAD SHOULDER GLENOID",SUP-AR-7000-30FT,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,1144.80,304.56,2275.09,66,189.34,1383.8,"percent of total billed charges",
"INSERT TIBIAL 4 20MM KNEE POSTERIOR STABILIZE ROTATE PLATFOR",SUP-151650420,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"PHCS [10601]",PHCS,,9189.08,70,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 8MM 270MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-408-270,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,1521.93,481.35,16760.95,30,2014.9,14726.25,"percent of total billed charges",
"TIP ASPIR SPETZLER BARRACUDA SONOPET 25KHZ SOFT TISSUE",SUP-5450800310,CDM,S27200284,LOCAL,0272,RC,,,both,,,4228.67,1268.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,501.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,491.79,3594.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X-CORE MINI CORE 12MM 22-34MM",SUP-5962223,CDM,S27800098,LOCAL,0278,RC,,,both,,,27720.00,8316,"MULTIPLAN [10600]",Multiplan,,23562,85,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 3CM 5FR 1 PIGTAIL CURVE PANCREATIC",SUP-M00537390,CDM,S27800098,LOCAL,0278,RC,,,both,,,1411.18,423.35,"BLUE CROSS [10001]","Blue Cross HMO",,553.18,39.2,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 16MM 144CM 5MM CORONARY STENT",SUP-H7493941816500,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,9776.84,9776.84,9776.84,"1 through 10",348.9,2550,"percent of total billed charges",
"HC Dgtz Gls Mcrscp Cslt Sld Els",PX-312000071,CDM,0838T,CPT,0311,RC,,,both,,,104.00,31.2,"MULTIPLAN [10600]",Multiplan,,88.4,85,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING UNITRAX V40 EXETER +8MM TAPER HIP UNIPOLAR",SUP-6942-6-075,CDM,C1776,HCPCS,0278,RC,,,both,,,1085.40,325.62,"KAISER [10500]",Kaiser,,727.22,67,,,,,0,126.23,922.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXENATIDE 10 MCG/DOSE(250 MCG/ML)2.4 ML SUBCUTANEOUS PEN INJECTOR",RX-105629,CDM,,,0637,RC,70121-1686-01,NDC,both,2.4,ML,4873.77,1462.13,"MULTIPLAN [10600]",Multiplan,,4142.7,85,,,,,0,566.82,4142.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM HIP LIMIT HOLE COLOR CODED OSSEOTI G7",SUP-110010241,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 3DMAX 6X4IN GROIN LEFT CONTOUR SEAL EDGE",SUP-0115311,CDM,C1781,HCPCS,0278,RC,,,both,,,887.28,266.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,105.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.19,754.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPARIN 25,000 UNIT/500 ML IN 1/2 NS INFUSION (USE ONLY FOR HIGH INTENSITY PROTOCOL)",RX-408257,CDM,J1644,HCPCS,0636,RC,00409-3150-05,NDC,both,500,ML,119.51,35.85,"BLUE CROSS [10001]","Blue Cross HMO",,6.12,,,,,,,5.29,101.58,"fee schedule",
"ITOTAL PS IPOLY IMPLANT KIT",SUP-TPS1111111,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10710,40,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL BIT ASSY, CARBIDE, HUDSON END, 6 MM, SINGLE USE",SUP-SBT005,CDM,S27000186,LOCAL,0270,RC,,,both,,,2212.50,663.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,909.34,41.1,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 17MM MODULAR RESTORATION HA CONICAL",SUP-6276-7-017,CDM,C1776,HCPCS,0278,RC,,,both,,,10468.22,3140.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4804.91,45.9,,,,,0,1217.45,8897.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 4 1/8IN 8.5FR 18GA ARROW-FLEX .035IN PERCUTANEOUS",SUP-CDC-09803-1A,CDM,C1894,HCPCS,0272,RC,,,both,,,638.28,191.48,"FIRST HEALTH [10303]","First Health",,510.62,80,,,,,0,74.23,542.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION",RX-9476,CDM,J0713,HCPCS,0636,RC,25021-0128-50,NDC,both,1,UN,99.66,29.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,15.73,,,,,,,6.91,84.71,"fee schedule",
"MALLET SURGICAL 10.75IN 1 7/8IN 3LB",SUP-27-0899,CDM,S27200284,LOCAL,0272,RC,,,both,,,539.87,161.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,62.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.79,458.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR MRESS CURVE GUIDING NYLON CORONARY",SUP-LA6MRESS,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM TRILOGY TIVANIUM HIP CORTICAL ACETABULAR",SUP-00625006535,CDM,C1713,HCPCS,0278,RC,,,both,,,691.60,207.48,"NOVANET [10819]",Novanet,,518.7,75,,,,,0,80.43,587.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT T-5 .5 CIRCLE TAPER 26.5MM LOOP BIO-TENODESIS",SUP-AR-7281,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.57,52.07,"MULTIPLAN [10600]",Multiplan,,147.53,85,,,,,0,20.19,147.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOR SKIN DISORDERS WITH MCC",606,MS-DRG,,,,,,,inpatient,,,37704.84,11311.45,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,9949.66,,"Case rate ($9,386.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,715.98, add-ons for qualifying new technology services are included. If operating cost exceeds $41,755.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,040.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $8,727.50. The transfer operating threshold is the transfer adjustment factor * $8,715.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $658.97. The transfer capital threshold is the transfer adjustment factor * $658.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,37704.84,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X12MM ADVANCED LORDOTIC SPINE",SUP-017712,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,962.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 45MM LCP STAINLESS STEEL PROXIMAL FEMORAL",SUP-02.205.045,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"CIGNA [10200]",Cigna,,859.03,68,,1831.33,1831.33,1831.33,16,146.92,1073.79,"percent of total billed charges",
"VALVE AORTIC 21MM 18.6MM MASTERS HP PYROLYTIC CARBON",SUP-21AEHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"NOVANET [10819]",Novanet,,21839.42,75,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 700ML P5.8CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-7004BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"KAISER [10500]",Kaiser,,3513.48,67,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Collar Cervical Malibu",PX-E27400058,CDM,L0172,HCPCS,0274,RC,,,both,,,702.90,210.87,"CIGNA [10200]",Cigna,,477.97,68,,,,,0,81.75,597.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION DEB 3.0X35",SUP-SCA14U-300035D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR EXTERNAL FIXATION 250MM 5MM SCHANZ STAINLESS STEEL HA",SUP-294.788SHA,CDM,C1713,HCPCS,0278,RC,,,both,,,1933.73,580.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,229.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,224.89,1643.67,"percent of total billed charges",
"KIT SUT DISPOSABLE STERILE LATEX DX KNOTLESS FIBERTAK",SUP-AR-8991CP,CDM,C1713,HCPCS,0278,RC,,,both,,,12678.75,3803.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3423.26,27,,,,,0,1474.54,10776.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 35MM 10MM DELTA ACL CANNULATED",SUP-AR-5035TC-10,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,219.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,215.23,1573.04,"percent of total billed charges",
"TROCHLEAR COMPRESSION SCREW LOCKING CAP",SUP-TCS-LC,CDM,C1713,HCPCS,0278,RC,,,both,,,1815.00,544.5,"KAISER [10500]",Kaiser,,1216.05,67,,,,,0,211.08,1542.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS VOICE PROLARYN VOCAL CORD INJECTABLE CALCIUM HA",SUP-8044M0K5,CDM,C1878,HCPCS,0278,RC,,,both,,,4692.00,1407.6,"MULTIPLAN [10600]",Multiplan,,3988.2,85,,,,,0,545.68,3988.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT GRAFTON PLUS DEMINERALIZED BONE MATRIX PASTE",SUP-T45001,CDM,C1713,HCPCS,0278,RC,,,both,,,844.00,253.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,98.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",98.16,717.4,"percent of total billed charges",
"INSRT TIBIAL 6 14MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-614-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"AETNA [10100]","Aetna HMO/PPO",,9566.71,79.5,,10981.53,8986.79,12413.38,12,1399.51,10228.56,"percent of total billed charges",
"ROD SPINAL 50MM 3.5MM VUEPOINT II TITANIUM NONSTERILE LATEX",SUP-8976105,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"TOOL INSRT 9/11FR TRANSVALVULAR LATEX FREE",SUP-7600,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"UHC [10700]","United Healthcare",,110.14,63.3,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 2IN 19GA 21GA EPILONG TUOHY .2UM METAL PLASTIC",SUP-0131153-51,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.70,80.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,183.4,68,,,,,0,31.37,229.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND MULTIPASS 3-0 FS-1 18IN BRAID BLACK",SUP-684G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 4-0 PC-3 18IN MONOFILAMENT BLACK",SUP-1864G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE E CURVE",SUP-D7TEL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"KAISER [10500]",Kaiser,,3323.94,67,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPI-FIT 83CM 14FR 3MM AIRWAY EXCHANGE ADPTR LUER LOCK",SUP-G57622,CDM,S27200284,LOCAL,0272,RC,,,both,,,672.30,201.69,"PHCS [10601]",PHCS,,470.61,70,,,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENROUTE TRANSCAROTID STENT SYSTEM 9 X 30",SUP-SR-0930-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX SEPRA 10X8IN MONOFILAMENT RESORBABLE",SUP-1202025,CDM,C1781,HCPCS,0278,RC,,,both,,,59022.18,17706.65,"BLUE CROSS [10001]","Blue Cross PPO",,23136.69,39.2,,,,,0,6864.28,50168.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 21MM REVISION MODULAR ARCOS STS TITANIUM",SUP-11-300821,CDM,C1776,HCPCS,0278,RC,,,both,,,20372.94,6111.88,"CIGNA [10200]","Cigna Open Access",,6824.93,33.5,,5302.19,4377.88,6578.61,27,2369.37,17317,"percent of total billed charges",
"CATH OPTA PRO 80CM 2CM 5FR 7MM 7.5MM BALLOON DILATATION",SUP-4197020S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR 50CM LINEAR PERCUTANEOUS 3-6 LEAD TRIAL SUT",SUP-SC-2366-50E,CDM,C1778,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 PC-5 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8631G,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.79,20.34,"KAISER [10500]",Kaiser,,45.42,67,,,,,0,7.88,57.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 25D SMALL AUG CORTILOC SHOULDER RIGHT",SUP-DWK403RA25S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"PHCS [10601]",PHCS,,7350,70,,,,,0,1221.15,8925,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET AUTOMATIC GAS VENT LEVEL 1 IRRIGATION 300- MMHG STERILE",SUP-IR-500,CDM,S27200284,LOCAL,0272,RC,,,both,,,273.35,82,"NOVANET [10819]",Novanet,,205.01,75,,,,,0,31.79,232.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC RBC Irrad Ea Unit",PX-390000023,CDM,P9038,HCPCS,0390,RC,,,both,,,455.00,136.5,"CIGNA [10200]",Cigna,,309.4,68,,,,,0,52.92,386.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 80MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560080L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +15.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.155,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 20CM 8FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251500,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]","Cigna Local Plus",,658.56,,,,,,,143.16,1046.32,"percent of total billed charges",
"SYSTEM SYNERGY 8MM 144CM 3MM CORONARY STENT PEBAX EVEROLIMUS",SUP-H7493926008300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"MULTIPLAN [10600]",Multiplan,,4730.25,85,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 12CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175196180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,670.19,45.9,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM ORTHOLOC FULL THREAD LOW PROFILE FOOT",SUP-58813520,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross PPO",,301.64,39.2,,957.42,570.23,957.42,28,89.49,654.08,"percent of total billed charges",
"HC App Rigid Leg Cast",PX-510000074,CDM,29445,CPT,0761,RC,,,both,,,3729.02,1118.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,441.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,433.69,3169.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 11FR .144IN 25CM ROBUST VALVE SPLITTABLE",SUP-PLSX-2511,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUBRICATH 24FR URETHRAL NATURAL RUBBER NYLON 30CC 3 WAY",SUP-2551H24,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.57,57.47,"CIGNA [10200]","Cigna Local Plus",,102.49,53.5,,,,,0,22.28,162.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 14MM MODULAR RESTORATION HA STRAIGHT CONE",SUP-6276-7-014,CDM,C1776,HCPCS,0278,RC,,,both,,,10468.22,3140.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1217.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1217.45,8897.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165MM 8.5-9.8MM OTSC 3MM MINI NITINOL T",SUP-100.02,CDM,C1760,HCPCS,0278,RC,,,both,,,3667.50,1100.25,"NOVANET [10819]",Novanet,,2750.63,75,,,,,0,426.53,3117.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE TUTOPLAST PERICARDIUM ALLOGRAFT",SUP-938227,CDM,C1762,HCPCS,0278,RC,,,both,,,6720.60,2016.18,"CIGNA [10200]","Cigna Open Access",,3824.02,56.9,,,,,0,781.61,5712.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE GENESIS 27CM 13MM 3 PAIR TAIL CAP TRIMMABLE",SUP-919513SC,CDM,C2622,HCPCS,0278,RC,,,both,,,55704.60,16711.38,"KAISER [10500]",Kaiser,,37322.08,67,,,,,0,6478.44,47348.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 9.5MM 3MM S-ROM ZTT 14B SMALL HIP POROUS",SUP-550501,CDM,C1776,HCPCS,0278,RC,,,both,,,6466.32,1939.9,"NOVANET [10819]",Novanet,,4849.74,75,,,,,0,752.03,5496.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 19MM 7MM STAINLESS STEEL 1.1MM LONG THREAD",SUP-02.226.119,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,755.15,45.9,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X4MM VERTE-STACK CORNERSTONE PSR 11MM",SUP-6277441,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE ENDOSCOPIC BNX SHARKCORE",SUP-DSC-25-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,2865.00,859.5,"UHC [10700]","United Healthcare",,1813.55,63.3,,,,,0,333.2,2435.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 60MM 80CM 9MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM09060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 20CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155220180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"CIGNA [10200]",Cigna,,1094.6,68,,,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL MEDIUM KNEE AVON",SUP-6430-0-200,CDM,C1776,HCPCS,0278,RC,,,both,,,22635.90,6790.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2632.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2632.56,19240.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 7MM TITAN 6D MEDIUM CERVICAL",SUP-5166-1407-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Local Plus",,5537.25,53.5,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE BONE SAGITTAL L 90X25MM",SUP-BR4125-127-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,225.50,67.65,"FIRST HEALTH [10303]","First Health",,180.4,80,,,,,0,26.23,191.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE BONE SIGNATURE ONE ALLIANCE SURGICAL SHOULDER GLENOID",SUP-20-8090-008-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,7562.40,2268.72,"PHCS [10601]",PHCS,,5293.68,70,,,,,0,879.51,6428.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X3 HUMERAL INSERT - 32MM X 10MM STANDARD",SUP-5571-S-3210,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"CIGNA [10200]",Cigna,,6854.4,68,,5873.17,5873.17,5873.17,"1 through 10",1172.3,8568,"percent of total billed charges",
"SOL 2.5% DEXTROSE 6000ML LOW CALCIUM 1 BAG LUER DIANEAL",SUP-L5B9771,CDM,S27200284,LOCAL,0272,RC,,,both,,,425.43,127.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,50.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,49.48,361.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 7MM TITAN 6D MEDIUM CERVICAL",SUP-5166-1407-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1226.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 30CM PRECISION 2X8 SPLITTER",SUP-SC-3400-30,CDM,C1883,HCPCS,0278,RC,,,both,,,7590.00,2277,"NOVANET [10819]",Novanet,,5692.5,75,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 60MM 80CM 9MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM09060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"FIRST HEALTH [10303]","First Health",,14616,80,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tte Complt",PX-483000004,CDM,93307,CPT,0483,RC,,,both,,,1105.92,331.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,752.03,68,,,,,0,128.62,940.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC LARGE HUB PREBENT EXTEND LENGTH STERLING",SUP-C9255,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 150MM 7MM BALLOON DILATATION OTW",SUP-H74939206071510,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY FIXATION NONSTERILE GOLD 105MM 11MM",SUP-456.306,CDM,C1713,HCPCS,0278,RC,,,both,,,3964.33,1189.3,"BLUE CROSS [10001]","Blue Cross HMO",,1554.02,39.2,,957.42,156.86,7483.26,51,461.05,3369.68,"percent of total billed charges",
"COIL EMBOLIZATION 3.5CM 2.5MM CEREPAK MINI FREEFORM",SUP-MCR092535,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS [10001]","Blue Cross PPO",,5184.53,39.2,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM NEXGEN LPS-FLEX 5-6MM GH KNEE UHMWPE",SUP-00596404210,CDM,C1776,HCPCS,0278,RC,,,both,,,6291.60,1887.48,"AETNA [10100]","Aetna HMO/PPO",,5001.82,79.5,,10981.53,8986.79,12413.38,12,731.71,5347.86,"percent of total billed charges",
"PHALANX CORONAL TRANSFIXION SCREW 1.5MM X 11.0MM COCR",SUP-PTS-15011-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.90,337.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,130.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",130.94,957.02,"percent of total billed charges",
"BURR SURGICAL 4MM MEDIUM ROUND FLUTED STERILE",SUP-5120010040,CDM,S27200284,LOCAL,0272,RC,,,both,,,668.25,200.47,"CIGNA [10200]",Cigna,,454.41,68,,,,,0,77.72,568.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VIPERWIRE ADVANCE VASCULAR 475CM .014IN PERIPHERAL",SUP-VPR-GW-EL14,CDM,C1769,HCPCS,0272,RC,,,both,,,1539.00,461.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,178.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 30MM 14MM ATTUNE KNEE CEMENT REVISION STERILE",SUP-1512-14-030,CDM,C1776,HCPCS,0278,RC,,,both,,,5230.20,1569.06,"BLUE CROSS [10001]","Blue Cross HMO",,2050.24,39.2,,5311.50,4717.44,5388.59,31,608.27,4445.67,"percent of total billed charges",
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED + VE",SUP-98B00200541,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"FIRST HEALTH [10303]","First Health",,19656,80,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 15MM TI",SUP-VAN-25150-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Open Access",,553.07,56.9,,1144.80,304.56,2275.09,66,113.04,826.2,"percent of total billed charges",
"CATH PCP040250150 PLUS US D4L250UL1500",SUP-PCP040250150,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"UHC [10700]","United Healthcare",,803.71,63.3,,,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE NONABSORBABLE ULTRABRAID UHMWPE 2 L38 IN BRAIDED PREC",SUP-72202965,CDM,C1713,HCPCS,0278,RC,,,both,,,176.18,52.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,20.49,149.75,"percent of total billed charges",
"PLATE 36MM 2 LEVEL ARCHON BONE SPINE NONSTERILE",SUP-8787236,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",512.88,3748.5,"percent of total billed charges",
"HC Ventil Mgmt IP Init Day",PX-410000002,CDM,94002,CPT,0410,RC,,,both,,,2236.54,670.96,"CIGNA [10200]","Cigna Open Access",,309,,"Per diem ($309).",,,,0,254,1901.06,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL 4.6 X 300MM SOLID TROCAR TIP 3/16  SQ. CONNECTION",SUP-P99-100-4630,CDM,S27200284,LOCAL,0272,RC,,,both,,,2085.00,625.5,"CIGNA [10200]","Cigna Local Plus",,1115.48,53.5,,,,,0,242.49,1772.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP MEDIUM 3.2MM INTERNAL LIGACLIP EXTRA TITANIUM",SUP-LT200,CDM,S27200284,LOCAL,0272,RC,,,both,,,55.53,16.66,"PHCS [10601]",PHCS,,38.87,70,,,,,0,6.46,47.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR INJECTION MEDRAD STELLANT FLEX 1 SPIKE 150ML",SUP-FLEXS-150-SPK,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.73,20.02,"PHCS [10601]",PHCS,,46.71,70,,,,,0,7.76,56.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE SPEARMINT GREEN RALLY MEDIUM VISCOSITY 40GM",SUP-71271590,CDM,C1713,HCPCS,0278,RC,,,both,,,1458.00,437.4,"KAISER [10500]",Kaiser,,976.86,67,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC West Nile Blood",PX-306000149,CDM,87798,CPT,0306,RC,,,both,,,854.00,256.2,"FIRST HEALTH [10303]","First Health",,683.2,80,,,,,0,0.01,725.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL STEALTH FIBRA 2 45MM INSRT SOFT STEALTH",SUP-A0G02,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,92.97,41.1,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 150MM 2MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.221,CDM,S27000186,LOCAL,0270,RC,,,both,,,1969.20,590.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,233.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.02,1673.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 80MM 80CM 7MM BILIARY NITINOL ILIAC",SUP-G43853,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross HMO",,1481.76,39.2,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EX 139CM 15MM 2MM LONG RECTANGLE HELIX",SUP-2034-2015,CDM,C1725,HCPCS,0272,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL MEDIUM KNEE AVON",SUP-6430-0-200,CDM,C1776,HCPCS,0278,RC,,,both,,,22635.90,6790.77,"AETNA [10100]","Aetna HMO/PPO",,17995.54,79.5,,10981.53,8986.79,12413.38,12,2632.56,19240.52,"percent of total billed charges",
"GRAFT SOFT TISSUE TUTOPLAST THK.3-.5MM PERICARDIUM ALLOGRAFT",SUP-938212,CDM,C1762,HCPCS,0278,RC,,,both,,,11709.30,3512.79,"MULTIPLAN [10600]",Multiplan,,9952.91,85,,,,,0,1361.79,9952.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 6.5MM FRACTURE EQUINOXE RIGHT SHOULDER",SUP-304-22-07,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5520,40,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR PULL ENDOVIVE ENFIT STD",SUP-M00509041,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"CIGNA [10200]","Cigna Local Plus",,260.01,53.5,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 38MM 3.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG35038UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS ELECTROSURGICAL 20CM 5MM HARMONIC HD CURVE TIP 1000I",SUP-HARHD20,CDM,S27200284,LOCAL,0272,RC,,,both,,,5082.89,1524.87,"UHC [10700]","United Healthcare",,3217.47,63.3,,,,,0,591.14,4320.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 52MM ATLANTIS VISION ELITE BONE ANTERIOR CERVICAL",SUP-7200152,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"COIL EMBOLIZATION 8CM 4MM CONCERTO 3D",SUP-PV-4-8-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL METRX BAYONET STERILE DISPOSABLE",SUP-9560659,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.60,562.68,"FIRST HEALTH [10303]","First Health",,1500.48,80,,,,,0,218.13,1594.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTHER BONE 7.9MM CRUCIAL TOOL GORE SMOOTHER STERILE",SUP-014723,CDM,S27200284,LOCAL,0272,RC,,,both,,,2354.63,706.39,"UHC [10700]","United Healthcare",,1490.48,63.3,,,,,0,273.84,2001.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 140MM TIMAX 7 HOLE HIGH ALPS BONE HUMERUS LEFT",SUP-110030302,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,1831.33,1831.33,1831.33,16,2014.9,14726.25,"percent of total billed charges",
"CLAMP SURGICAL STEALTH FIBRA 2 45MM INSRT SOFT STEALTH",SUP-A0G02,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25MM M-CLASS HALL THK1.47MM STAINLESS STEEL",SUP-T250-147-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,521.80,156.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,214.46,41.1,,,,,0,60.69,443.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP 3 HOLE POLY POROUS R3 STD STERILE",SUP-71335550,CDM,C1776,HCPCS,0278,RC,,,both,,,14345.10,4303.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4105.57,28.62,,,,,0,1668.34,12193.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE 15CC FIBER OSTEOAMP SELECT",SUP-OASF-15,CDM,C1713,HCPCS,0278,RC,,,both,,,22268.61,6680.58,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2638.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,2589.84,18928.32,"percent of total billed charges",
"ANCHOR SUT SWIVELOCK SPEEDBRIDGE 5.5 KNOTLESS",SUP-AR-2600FSB-4,CDM,C1713,HCPCS,0278,RC,,,both,,,18356.63,5506.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2175.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2134.88,15603.14,"percent of total billed charges",
"SCREW NON-LOCKING 1.2MM X 9MM COCR",SUP-VAN-12009-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"CIGNA [10200]","Cigna Open Access",,737.42,56.9,,1144.80,304.56,2275.09,66,150.72,1101.6,"percent of total billed charges",
"MATRIX TISSUE 20X20CM STRATTICE LIFECELL 400SQ CM",SUP-2020002P,CDM,Q4130,HCPCS,0636,RC,,,both,,,62949.60,18884.88,"PHCS [10601]",PHCS,,44064.72,70,,,,,0,7459.53,53507.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 19GA 15CM 9CM ADJUSTABLE COAXIAL TEMNO",SUP-ACT2015,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Orbit MRI Screen",PX-351000017,CDM,70480,CPT,0351,RC,,,both,,,2767.89,830.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($377.70). Procedures 2 - 999, Per diem ($188.85).",,,,0,,,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 5 1/8IN LAMBOTTE SWISS PATTERN SURGICAL MINI",SUP-27-5704,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.07,40.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM PLUMEPORT UNIVERSAL SMOKE EVAC LAPAROSCOPIC PLUME",SUP-PP010,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.11,42.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Perq Trancath Clsr Mitr/Aort Addl",PX-481000115,CDM,93592,CPT,0481,RC,,,both,,,29534.00,8860.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"SHELL ACETABULAR 60MM HIP 3 HOLE PUREFIX HYDROXYAPATITE",SUP-542-11-60G,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"NOVANET [10819]",Novanet,,5218.29,75,,,,,0,809.18,5914.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW FREEFIX LOCKING 3.5MM X 16MM TI",SUP-FFL-35160-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1223.10,366.93,"CIGNA [10200]","Cigna Local Plus",,654.36,53.5,,3978.14,359.25,3978.14,24,142.25,1039.64,"percent of total billed charges",
"ANCHOR SUT 5.5MM 2 FULL THREAD BIO-CORKSCREW FIBERWIRE",SUP-AR-1927BF,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"FIRST HEALTH [10303]","First Health",,1795.5,80,,,,,0,261.02,1907.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 OS-6 18IN CONTROL RELEASE BRAID 3 STRAND",SUP-VCP754T,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.62,22.09,"FIRST HEALTH [10303]","First Health",,58.9,80,,,,,0,8.56,62.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ucg Retro Si",PX-320000121,CDM,74450,CPT,0320,RC,,,both,,,893.90,268.17,"BLUE CROSS [10001]","Blue Cross HMO",,747.04,,"Fee schedule rate ($747.04).",,,,0,80.95,759.82,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC D-Dimer",PX-305000041,CDM,85378,CPT,0305,RC,,,both,,,360.00,108,"FIRST HEALTH [10303]","First Health",,288,80,,,,,0,0.01,306,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1.5MM TARGET NANO HELICAL DETACHABLE",SUP-M0035431520,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"BLUE CROSS [10001]","Blue Cross PPO",,3589.81,39.2,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 4CM 5MM BALLOON DILATATION",SUP-U815054,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VAC PREVENA PEEL AND PLACE 13CM 13CM NEGATIVE PRESSURE",SUP-PRE1121US,CDM,S27200284,LOCAL,0272,RC,,,both,,,4536.27,1360.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1864.41,41.1,,,,,0,527.57,3855.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION SUB-Q TITANIUM SILICONE 9.6FR 1",SUP-0602230,CDM,C1788,HCPCS,0278,RC,,,both,,,928.72,278.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,631.53,68,,,,,0,108.01,789.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 9MM KNEE X3 CONDYLAR STABILIZED PRIMARY",SUP-5531-G-609,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"MULTIPLAN [10600]",Multiplan,,7961.17,85,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 15MM AEQUALIS 6 SHOULDER HA REVERSED STD",SUP-DWD003,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1119,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1098.22,8026.55,"percent of total billed charges",
"HC Xr Esophagus W Cntrst",PX-320000097,CDM,74220,CPT,0320,RC,,,both,,,882.87,264.86,"UHC [10700]","United Healthcare",,437.65,,,,,,,102.68,750.44,"fee schedule",
"TIP ASPIR 25KHZ LARGE DIAMETER ULTRASONIC STRAIGHT SONOPET",SUP-5450800308,CDM,S27200284,LOCAL,0272,RC,,,both,,,4264.19,1279.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1957.26,45.9,,,,,0,495.93,3624.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUETIAPINE 200 MG TABLET, IMMEDIATE RELEASE",RX-21825,CDM,,,0637,RC,50268-0633-11,NDC,both,1,UN,46.01,13.8,"NOVANET [10819]",Novanet,,34.51,75,,,,,0,5.35,39.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC 12IN KNEE 3 PANEL ADJUSTABLE BUCKLE PLASTIC",SUP-VP40105-005,CDM,L1830,HCPCS,0274,RC,,,both,,,160.08,48.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.62,136.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Valve Suction Flex Endo",PX-E27000198,CDM,E27000198,LOCAL,0270,RC,,,both,,,141.61,42.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.47,120.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TERBINAFINE HCL 250 MG TABLET",RX-12724,CDM,,,0637,RC,16714-0795-01,NDC,both,1,UN,47.89,14.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.57,40.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 150MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UHC [10700]","United Healthcare",,907.53,63.3,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 80MM 80CM 7MM BILIARY NITINOL ILIAC",SUP-G43853,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Local Plus",,2022.3,53.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 65CM 5FR STRAIGHT ANGIOGRAPHIC POLYURETHANE",SUP-5653510STF-NB,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"AETNA [10100]","Aetna HMO/PPO",,86.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIAL LABORATORY SPY ELITE 1 PACK",SUP-LC3006,CDM,S27200284,LOCAL,0272,RC,,,both,,,4457.45,1337.23,"KAISER [10500]",Kaiser,,2986.49,67,,,,,0,518.4,3788.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE POLYOLEFIN 5000ML PRISMASOL BGK 0/2.5 STERILE",SUP-110240S,CDM,S27200284,LOCAL,0272,RC,,,both,,,332.60,99.78,"UHC [10700]","United Healthcare",,210.54,63.3,,,,,0,38.68,282.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 80MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.880,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"BLUE CROSS [10001]","Blue Cross HMO",,92.76,39.2,,957.42,156.86,7483.26,51,27.52,201.14,"percent of total billed charges",
"DEVICE PERCLOSE 6FR CLSR VASCULAR SUT MEDIATE KNOT PUSH",SUP-12673-03,CDM,C1760,HCPCS,0278,RC,,,both,,,983.00,294.9,"CIGNA [10200]","Cigna Open Access",,559.33,56.9,,,,,0,114.32,835.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ABLATION 115CM 7.5FR 3.5MM 2-5-2MM SPACING D-F CURVE EZ",SUP-BNI75TCDFH,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"FIRST HEALTH [10303]","First Health",,14449.68,80,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ONDANSETRON 8 MG DISINTEGRATING TABLET",RX-27698,CDM,Q0162,HCPCS,0250,RC,57237-0078-10,NDC,both,1,UN,140.36,42.11,"KAISER [10500]",Kaiser,,94.04,67,,,,,0,16.32,119.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT 120MM SCP ACCUPORT 11GA END DELIVERY CANN",SUP-414.503,CDM,C1713,HCPCS,0278,RC,,,both,,,23486.40,7045.92,"UHC [10700]","United Healthcare",,14866.89,63.3,,5023.51,2672.93,6679.78,18,2731.47,19963.44,"percent of total billed charges",
"LINER ACETABULAR G7 D NEUTRAL 36MM E1 HIP",SUP-010000856,CDM,C1776,HCPCS,0278,RC,,,both,,,12282.00,3684.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1455.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1428.4,10439.7,"percent of total billed charges",
"VALVE AORTIC 17MM MASTERS HEMODYNAMIC PLUS STD MECHANICAL",SUP-17AHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11968,41.1,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 5D MEDIUM 47MM 3DI FUSION LOW PROFILE COMPRESSION SLOT",SUP-587225LT,CDM,S27200284,LOCAL,0272,RC,,,both,,,12420.00,3726,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1444.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +8.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000085,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM COMPREHENSIVE 3.5MM SHOULDER CENTRAL",SUP-115396,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"PHCS [10601]",PHCS,,1089.2,70,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (PS) - SIZE 2",SUP-5555-2252,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"UHC [10700]","United Healthcare",,897.28,63.3,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STOCKING COMPRESSION SMALL TUBULAR SOFT TENSOGRIP",SUP-13200,CDM,S27000186,LOCAL,0270,RC,,,both,,,165.30,49.59,"CIGNA [10200]",Cigna,,112.4,68,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 60CM 8MM STRAIGHT FUSION BIOLINE POLYESTER 2",SUP-M00201503068B0,CDM,C1768,HCPCS,0278,RC,,,both,,,10631.52,3189.46,"CIGNA [10200]",Cigna,,7229.43,68,,,,,0,1236.45,9036.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE ORTHOPEDIC STAINLESS STEEL 1.7MM 750MM HIP CRIMP",SUP-298.801.01S,CDM,C1713,HCPCS,0278,RC,,,both,,,2843.40,853.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1933.51,68,,,,,0,330.69,2416.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 5.0/20",SUP-434898,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"CIGNA [10200]",Cigna,,7900.2,40,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL STEALTH FIBRA 2 45MM INSRT SOFT STEALTH",SUP-A0G02,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"FIRST HEALTH [10303]","First Health",,180.96,80,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 30MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25030W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"AETNA [10100]","Aetna HMO/PPO",,2683.13,79.5,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 39X15MM HEDRON IA 15D 29MM STERILE LATEX FREE",SUP-1212.1215S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13860,40,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 235MM 28MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-328,CDM,C1776,HCPCS,0278,RC,,,both,,,18758.25,5627.47,"KAISER [10500]",Kaiser,,12568.03,67,,,,,0,2181.58,15944.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28X10X10MM COALESCE LORDOTIC STRAIGHT STERILE",SUP-2000-00-101008,CDM,C1889,HCPCS,0278,RC,,,both,,,21420.00,6426,"MULTIPLAN [10600]",Multiplan,,18207,85,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 49MM TRUNION ARTHREX ECLIPSE",SUP-AR-9301-49CPC,CDM,C1776,HCPCS,0278,RC,,,both,,,9239.10,2771.73,"CIGNA [10200]","Cigna Open Access",,5257.05,56.9,,5302.19,4377.88,6578.61,27,1074.51,7853.24,"percent of total billed charges",
"CATH TREK 145CM 12MM 2.25MM BALLOON DILATATION PEBAX",SUP-1012404-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES 143CM 20MM 3MM BALLOON DILATATION NYBAX",SUP-H74939134302010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17.5 DIOPTER UV ABSORBENT CLAREON AUTONOME",SUP-CCA0T0.175,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 19.1MM 3.1MM LONG STRAIGHT STERILE",SUP-5130-070-031,CDM,S27200284,LOCAL,0272,RC,,,both,,,747.95,224.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,343.31,45.9,,,,,0,86.99,635.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIOGLITAZONE 15 MG TABLET",RX-25528,CDM,,,0637,RC,16729-0020-15,NDC,both,1,UN,26.49,7.95,"FIRST HEALTH [10303]","First Health",,21.19,80,,,,,0,3.08,22.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 200MM 5MM BALLOON DILATATION RAPID",SUP-47550200L,CDM,C1725,HCPCS,0272,RC,,,both,,,1890.00,567,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1285.2,68,,,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT EXTERNAL FIXATION 100MM FEMORAL NECK SYSTEM STERILE",SUP-04.168.300S,CDM,C1713,HCPCS,0278,RC,,,both,,,2435.70,730.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,288.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,283.27,2070.35,"percent of total billed charges",
"SUT STRATAFIX MONOCRYL PLUS 3-0 SH SPIRAL 70CM KNOTLESS",SUP-SXMP1B428,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"MULTIPLAN [10600]",Multiplan,,181.82,85,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 16MM 50MM SHOULDER SIMPLICITI",SUP-7122873,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6812.92,68,,,,,0,1165.21,8516.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.265,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Open Access",,196.31,56.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOVIVE PLUS 2.5CC SYRINGE",SUP-203225,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 9MM KNEE ONLAY MULTICOMPARTMENTAL RESTORIS",SUP-180705-2,CDM,C1776,HCPCS,0278,RC,,,both,,,4046.85,1214.05,"NOVANET [10819]",Novanet,,3035.14,75,,,,,0,470.65,3439.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE CROSS-IT 100XT VASCULAR J TAPER 190CM 3CM",SUP-1003309HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 4.75MM SOLERA COCR MOLYBDENUM CURVED",SUP-1475501090,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross PPO",,1728.72,39.2,,957.42,570.23,957.42,28,512.88,3748.5,"percent of total billed charges",
"TLX IMPLANT, 9X11X30MM 15",SUP-5891305,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"CIGNA [10200]",Cigna,,11520,40,,,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC STATSEAL XL DISC POTASSIUM FERRATE",SUP-DX617,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"AETNA [10100]","Aetna HMO/PPO",,207.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 54MM STARDRIVE STAINLESS STEEL T15 SELF TAP",SUP-02.127.154,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"BLUE CROSS [10001]","Blue Cross HMO",,444.02,39.2,,957.42,156.86,7483.26,51,131.73,962.8,"percent of total billed charges",
"SCR BONE 1.5MM 14MM STAINLESS STEEL T4 SELF TAP LOCK",SUP-02.130.214,CDM,C1713,HCPCS,0278,RC,,,both,,,839.16,251.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,385.17,45.9,,,,,0,97.59,713.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 14MM STAINLESS STEEL T4 SELF TAP LOCK",SUP-02.130.214,CDM,C1713,HCPCS,0278,RC,,,both,,,839.16,251.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,99.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,97.59,713.29,"percent of total billed charges",
"ROD SPINAL 45MM 5.5MM REVERE PEDICLE TITANIUM CURVED",SUP-124.645,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"MESH SURGICAL GALAFORM 3D 20.3X7.6CM MONOFILAMENT",SUP-FR3D07,CDM,C1781,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4750.65,45.9,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Asp Bladder W Trocar",PX-361000231,CDM,51101,CPT,0361,RC,,,both,,,11400.78,3420.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2491,,"Case rate ($2,491). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1325.91,9690.66,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 4MM X 41MM - US",SUP-90314,CDM,S27200284,LOCAL,0272,RC,,,both,,,35649.18,10694.75,"KAISER [10500]",Kaiser,,23884.95,67,,,,,0,4146,30301.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 35CM INJECTION CYSTOSCOPY WILLIAMS 8MM 23GA 5",SUP-G14220,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,99.83,45.9,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW STAINLESS STEEL THK.05 IN L3.543 IN X W.709 IN 2 C",SUP-4118127090,CDM,S27200284,LOCAL,0272,RC,,,both,,,383.76,115.13,"KAISER [10500]",Kaiser,,257.12,67,,,,,0,44.63,326.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 24CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006155232010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,352.3,28.62,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION",RX-28282,CDM,,,0637,RC,00088-2220-33,NDC,both,10,ML,582.18,174.65,"AETNA [10100]","Aetna HMO/PPO",,462.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.71,494.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH MIFI XP 9 PIN INTELLA TIP QUICK CNCT FILTER",SUP-M0046200,CDM,S27200284,LOCAL,0272,RC,,,both,,,3408.75,1022.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1564.62,45.9,,,,,0,396.44,2897.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH URETHRAL BARDEX IC 20FR FOLEY 2 WAY COUNCIL TIP 2",SUP-0196SI20,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.25,42.67,"NOVANET [10819]",Novanet,,106.69,75,,,,,0,16.54,120.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 8-4MM TORNADO PRELOAD PLATINUM",SUP-G47523,CDM,S27800098,LOCAL,0278,RC,,,both,,,931.42,279.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,266.57,28.62,,,,,0,108.32,791.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC ELECTROSURGICAL MINERVA 1 STERILE LATEX FREE",SUP-MIN9770,CDM,S27200284,LOCAL,0272,RC,,,both,,,6210.00,1863,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER BIPOLAR 44MM 28MM TANDEM HIP COCR UHMW POLYETHYLENE",SUP-71322044,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,989.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,971.39,7099.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8.5FR 145CM 60CM GUIDING GWIRE HEMOSTASIS VALVE",SUP-406854,CDM,C1893,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO BALKIN CURVE 40CM 7FR 2.5MM GUIDING",SUP-G32225,CDM,C1894,HCPCS,0272,RC,,,both,,,432.22,129.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,177.64,41.1,,,,,0,50.27,367.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM AZUR .018IN",SUP-45-480310,CDM,S27800098,LOCAL,0278,RC,,,both,,,5678.70,1703.61,"PHCS [10601]",PHCS,,3975.09,70,,,,,0,660.43,4826.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE +90D LEFT 49MM STAINLESS STEEL 2.4MM SCR 2 HOLE HEAD 4",SUP-02.115.640S,CDM,C1713,HCPCS,0278,RC,,,both,,,4196.30,1258.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1200.98,28.62,,,,,0,488.03,3566.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG DEFIB IS4/DF4 PORT",SUP-AC-IS4PP,CDM,C1883,HCPCS,0278,RC,,,both,,,453.60,136.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,53.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC LARGE HUB PREBENT EXTEND LENGTH STERLING",SUP-C9255,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY EPIDURAL 20GA 18GA DESIGN OPTIONS CONTINUOUS CATH NDL",SUP-555551,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GUIDE DRILL 26-30MM 3-4MM PONTO REMOVABLE SPACER PILOT",SUP-M50287,CDM,S27200284,LOCAL,0272,RC,,,both,,,1708.88,512.66,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 100MM 6MM BALLOON",SUP-LX1813061005F,CDM,C2623,HCPCS,0272,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PARICALCITOL 1 MCG CAPSULE",RX-41497,CDM,,,0637,RC,49483-0687-03,NDC,both,1,UN,30.24,9.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12.43,41.1,,,,,0,3.52,25.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 0 CT-1 36IN MONOFILAMENT ABSORBABLE",SUP-924H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM VUEPOINT II SPINE FAVORED ANGLE NONSTERILE",SUP-8975612,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,1144.80,304.56,2275.09,66,441.36,3225.75,"percent of total billed charges",
"GUIDE DRILL 26-30MM 3-4MM PONTO REMOVABLE SPACER PILOT",SUP-M50287,CDM,S27200284,LOCAL,0272,RC,,,both,,,1708.88,512.66,"PHCS [10601]",PHCS,,1196.22,70,,,,,0,198.74,1452.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +10MM OFFSET C TAPER 36MM HIP COCR LFIT",SUP-06-3610,CDM,C1776,HCPCS,0278,RC,,,both,,,7962.60,2388.78,"CIGNA [10200]","Cigna Local Plus",,4259.99,53.5,,5372.07,4581.20,7242.98,23,926.05,6768.21,"percent of total billed charges",
"TRAY EPIDURAL 20GA 18GA DESIGN OPTIONS CONTINUOUS CATH NDL",SUP-555551,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE",SUP-PCB0000205,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Direct Adm Observation Care",PX-762000003,CDM,G0379,HCPCS,0762,RC,,,both,,,359.00,107.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,359,,,,,,,41.75,359,"case rate",
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,inpatient,,,32919.14,9875.74,"CIGNA [10200]",Cigna,,5967.27,,"Fee schedule rate ($5,967.27). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,2823.02,11349.74,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER SOLOIST 110CM 6FR 2-5-2MM SPACING JOSEPHSON FLEX CU",SUP-44216JF,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"UHC [10700]","United Healthcare",,198.26,63.3,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE INCISION ACMI CLASSIC",SUP-M0068805511,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"CIGNA [10200]","Cigna Local Plus",,276.32,53.5,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 60MM 32MM XLPE HIP",SUP-71337660,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4572.89,41.1,,6417.48,6417.48,6417.48,"1 through 10",1293.98,9457.31,"percent of total billed charges",
"ELECTRD EMG NIM-RESPONSE 18MM NDL PROTECTED LEAD DISPOSABLE",SUP-8227304,CDM,S27200284,LOCAL,0272,RC,,,both,,,1451.52,435.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.81,1233.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 275CC P3CM MODERATE CLASSIC PROFILE STD",SUP-350-7275MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,16595.83,16595.83,16595.83,"1 through 10",601.85,4398.75,"percent of total billed charges",
"ENV ABSORBABLE MEDIUM 2.7X2.5IN POLYARYLATE MINOCYCLINE",SUP-NMRM6122,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"MULTIPLAN [10600]",Multiplan,,5249.18,85,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 90CM 8FR STRAIGHT GUIDING DURAFORM",SUP-H965100520,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1028.79,41.1,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 400MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.160S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1444.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1444.25,10555.59,"percent of total billed charges",
"RELOAD STPLR 0 6IN ENDO STITCH V-LOC POLYBUTESTER LOAD UNIT",SUP-VLOCN006L,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.01,84.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,191.09,68,,,,,0,32.68,238.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE WIDE TITANIUM 4 HOLE GEMINUS BONE RADIAL LEFT DISTAL",SUP-GMN-LTW-4HL,CDM,C1713,HCPCS,0278,RC,,,both,,,5161.20,1548.36,"CIGNA [10200]",Cigna,,3509.62,68,,1831.33,1831.33,1831.33,16,600.25,4387.02,"percent of total billed charges",
"DRSG TRANSPARENT 6X6IN MULTISITE ADHSV OPTIVIEW LATEX FREE",SUP-MSCOVM6EP,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.56,14.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,32.34,68,,,,,0,5.53,40.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ 110CM 7FR STD ARTERIAL LINE 4 LUMEN",SUP-131F7P,CDM,C1751,HCPCS,0272,RC,,,both,,,654.08,196.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,444.77,68,,,,,0,76.07,555.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 0D HIP X3 TRIDENT",SUP-623-00-32D,CDM,C1776,HCPCS,0278,RC,,,both,,,6242.04,1872.61,"BLUE CROSS [10001]","Blue Cross HMO",,2446.88,39.2,,5311.50,4717.44,5388.59,31,725.95,5305.73,"percent of total billed charges",
"CATH SYMMETRY 135CM 20MM 4FR 2MM 4T CURVE LOW PROFILE",SUP-M001103400,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"NOVANET [10819]",Novanet,,1546.88,75,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC SMALL 20X8IN LEG FEMUR POSTERIOR MALLEABLE",SUP-79-72293,CDM,S27000186,LOCAL,0270,RC,,,both,,,215.76,64.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.09,183.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS",RX-87834,CDM,,,0250,RC,70069-0651-01,NDC,both,5,ML,1232.15,369.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,506.41,41.1,,,,,0,143.3,1047.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRIP SCLERAL 2.5MM GROOVE SILICONE STYLE 219",SUP-92-06,CDM,C1784,HCPCS,0278,RC,,,both,,,136.21,40.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,38.98,28.62,,,,,0,15.84,115.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH ENDOSCP 2MM 12.1MM ROUND EDGE STERILE LATEX FREE",SUP-D-201-11802,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.26,63.08,"PHCS [10601]",PHCS,,147.18,70,,,,,0,24.45,178.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLODERM (RTU) CONTOUR LARGE PERFORATED - THIN",SUP-CL1516P,CDM,Q4116,HCPCS,0636,RC,,,both,,,31380.30,9414.09,"FIRST HEALTH [10303]","First Health",,25104.24,80,,,,,0,247.92,26673.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM EVOLVE STAINLESS STEEL CORTICAL ELBOW",SUP-4973510N,CDM,C1713,HCPCS,0278,RC,,,both,,,785.70,235.71,"KAISER [10500]",Kaiser,,526.42,67,,,,,0,91.38,667.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPINAL DISORDERS AND INJURIES WITH CC/MCC",052,MS-DRG,,,,,,,inpatient,,,60679.82,18203.95,"BLUE CROSS [10001]","Blue Cross HMO",,41581.63,,,,,,,7561,45172.01,"case rate",
"ELECTRD ELECTROSURGICAL BLADE PENCIL 15FT 3/8IN PLUMEPEN",SUP-PLP2520,CDM,S27200284,LOCAL,0272,RC,,,both,,,287.25,86.17,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND 0 CT-1 30IN BRAID BLACK NONABSORBABLE",SUP-424H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RETRIEVER ENDOSCOPIC 20MM 4MM TREVO XP PROVUE STERILE LATEX",SUP-90182,CDM,S27200284,LOCAL,0272,RC,,,both,,,47273.94,14182.18,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"4.0MM X 60MM M5+ CATHETER",SUP-FG63502-4060,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,,41.1,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WIRE FIXATION FUZEFIX MAX FT STANDARD OD1.4 MM NONSTERILE",SUP-CD-FX-0014,CDM,S27000186,LOCAL,0270,RC,,,both,,,261.00,78.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 1.5MM 10MM TITANIUM CORTEX SELF TAPPING NONSTERILE",SUP-400.010,CDM,C1713,HCPCS,0278,RC,,,both,,,330.34,99.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,39.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",38.42,280.79,"percent of total billed charges",
"SCR BONE 4MM 48MM AXSOS STAINLESS STEEL T15 FEMUR HUMERUS",SUP-371548,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"BLUE CROSS [10001]","Blue Cross PPO",,349.27,39.2,,957.42,570.23,957.42,28,103.62,757.35,"percent of total billed charges",
"TRAY TIBIAL IDENTITY IMPRINT 6 NARROW KNEE POSTERIOR",SUP-TPS-301-T06N,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"BLUE CROSS [10001]","Blue Cross HMO",,3448.62,39.2,,5311.50,4717.44,5388.59,31,1023.15,7477.88,"percent of total billed charges",
"SCR BONE 5MM 65MM NAIL-EX TITANIUM FULL THREAD TIBIAL SELF",SUP-04.015.555,CDM,C1713,HCPCS,0278,RC,,,both,,,1313.17,393.95,"CIGNA [10200]","Cigna Local Plus",,702.55,53.5,,3978.14,359.25,3978.14,24,152.72,1116.19,"percent of total billed charges",
"CAGE SPINAL 55X12X10MM CLYDESDALE PTC 0D PEEK TITANIUM",SUP-4980255,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LD WORLEY JMB CRV CS",SUP-361684,CDM,C1892,HCPCS,0272,RC,,,both,,,3339.00,1001.7,"KAISER [10500]",Kaiser,,2237.13,67,,,,,0,388.33,2838.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 64CM ENDOTAK RELIANCE S ENDOCARDIAL STEROID",SUP-128,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6072,40,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM TARGET TETRA DETACHABLE STERILE",SUP-TG5414060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5801.12,41.1,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.2MM STEINMANN BLUNT DISPOSABLE",SUP-500095,CDM,C1713,HCPCS,0278,RC,,,both,,,3326.40,997.92,"NOVANET [10819]",Novanet,,2494.8,75,,,,,0,386.86,2827.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 2 CONTOUR 20IN 36- IN KNEE 2",SUP-79-96019,CDM,L1830,HCPCS,0274,RC,,,both,,,121.54,36.46,"BLUE CROSS [10001]","Blue Cross PPO",,47.64,39.2,,,,,0,14.14,103.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 6.75IN GOLDMAN ANGLE RIGHT KNIFE GUIDE SURGICAL",SUP-63-4008,CDM,S27200284,LOCAL,0272,RC,,,both,,,753.95,226.18,"NOVANET [10819]",Novanet,,565.46,75,,,,,0,87.68,640.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM LCP STAINLESS STEEL CORTEX PERIARTICULAR",SUP-02.204.040,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"NOVANET [10819]",Novanet,,739.94,75,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 300MM 5MM BALLOON DILATATION DURALYN",SUP-48005030S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 18GA 1.25MM ACCUCATH ACE DOT",SUP-AC1181252,CDM,S27200284,LOCAL,0272,RC,,,both,,,323.03,96.91,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,132.77,41.1,,,,,0,37.57,274.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PRECISION ACCESS SYSTEM PINNACLE TAPER 45CM 10CM 8FR",SUP-70-8160,CDM,C1894,HCPCS,0272,RC,,,both,,,304.50,91.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,35.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 80MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SUBSTITUTE 50X20X5MM DEMINERALIZED CANCELLOUS STR",SUP-PBS-50,CDM,S27800098,LOCAL,0278,RC,,,both,,,13693.05,4107.91,"FIRST HEALTH [10303]","First Health",,10954.44,80,,,,,0,1592.5,11639.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SOFT TISSUE 15X10CM SOFT CONFORMABLE TRIM STRONG",SUP-1305015020,CDM,C1781,HCPCS,0278,RC,,,both,,,4347.00,1304.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,515.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ACETABULAR 58MM DURALOC DYNAMIC HIP LOCK STERILE LATEX",SUP-124958000,CDM,C1776,HCPCS,0278,RC,,,both,,,1878.00,563.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1277.04,68,,,,,0,218.41,1596.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 25CM 10FR .018IN FLEXITHANE HYDROPHILIC LOCK LOOP",SUP-H749393111025K1,CDM,C1729,HCPCS,0272,RC,,,both,,,1474.20,442.26,"NOVANET [10819]",Novanet,,1105.65,75,,,,,0,171.45,1253.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ATTUNE FB WITH REVISION TRAY",SUP-OSC366808,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"CIGNA [10200]","Cigna Open Access",,7597.8,33.5,,5302.19,4377.88,6578.61,27,2637.68,19278,"percent of total billed charges",
"CNCT ROD 33-39MM QUARTEX T SPINE 2 HEAD",SUP-1149.8302,CDM,C1713,HCPCS,0278,RC,,,both,,,3277.50,983.25,"CIGNA [10200]","Cigna Open Access",,1864.9,56.9,,1144.80,304.56,2275.09,66,381.17,2785.88,"percent of total billed charges",
"HC Donath-Landsteiner Abs",PX-301000264,CDM,83520,CPT,0301,RC,,,both,,,325.00,97.5,"PHCS [10601]",PHCS,,227.5,70,,,,,0,0.33,276.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIMOLOL MALEATE 0.5 % EYE DROPS",RX-11562,CDM,,,0250,RC,61314-0227-05,NDC,both,5,ML,106.93,32.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,43.95,41.1,,,,,0,12.44,90.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH CHECK-FLO FLEXOR .018-.038IN ANL0 CURVE 45CM 5FR .074",SUP-G44153,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Perq Njx Algc Fluor Lmbr Ea",PX-361000548,CDM,0628T,CPT,0361,RC,,,both,,,2677.00,803.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Rhd & Rhce Gntyp Rhd1-10 & Rhce5",PX-310000028,CDM,0198U,CPT,0310,RC,,,both,,,600.00,180,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Rom Measurement Hnd (Gp)",PX-420000011,CDM,95852,CPT,0420,RC,,,both,,,252.89,75.87,"PHCS [10601]",PHCS,,177.02,70,,,,,0,29.41,252.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150220,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 3.5MM 36MM AXSOS STAINLESS STEEL HEXAGON",SUP-340636,CDM,C1713,HCPCS,0278,RC,,,both,,,255.78,76.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,73.2,28.62,,,,,0,29.75,217.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 76MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.076TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM 40DEG BIPOLAR CONVEX SERRATED",SUP-BB4040XC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1434.01,430.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,166.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.78,1218.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.0MM X 8.0MM",SUP-493000812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SHAVER 13CM 5MM COOLCUT 8 FLUTE OVAL STERILE DISPOSABLE",SUP-AR-8500OBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cath Sterling MR",PX-E27200406,CDM,C1725,HCPCS,0272,RC,,,both,,,1163.80,349.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WEBSTER 115CM 6FR 2-5-2MM SPACE F CURVE MAPPING STERILE",SUP-F6QF252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GUIDER SOFTIP XF 90CM 5FR STRAIGHT GUIDING DURAFORM",SUP-M003100640,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH AMPLATZ 20CM 30FR ACCESS PTFE RENAL KINK RESISTANT",SUP-M0069001230,CDM,S27200284,LOCAL,0272,RC,,,both,,,325.03,97.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX 035 GEOALIGN 130CM 220MM 7MM BALLOON DILATATION",SUP-LX3513072205F,CDM,C2623,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION TRANSSEPTAL",SUP-5140-6217,CDM,S27200284,LOCAL,0272,RC,,,both,,,13455.00,4036.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 50X27MM STD OSCILLATE ERGONOMIC LIGHTWEIGHT THK.6",SUP-519.100S,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRUSH CYTOLOGY 2.4MM 3MM 230CM COLONOSCOPE STERILE",SUP-00711499,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"CIGNA [10200]","Cigna Open Access",,148.51,56.9,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFAZOLIN 1 G VIAL IV PUSH|DISCARDED DRUG NOT ADMINISTE",RX-408310,CDM,J0690,HCPCS,0636,RC,44567-0707-25,NDC,both,1,UN,14.95,4.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",JW,1.86,,,,,,,1.41,12.71,"fee schedule",
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 14CM 3CM 5FR .035IN 2",SUP-M006192113180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,188.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLESEVELAM 625 MG TABLET",RX-28372,CDM,,,0637,RC,00713-0936-81,NDC,both,1,UN,19.90,5.97,"MULTIPLAN [10600]",Multiplan,,16.92,85,,,,,0,2.31,16.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM .062IN KIRSCHNER 2MM TROCAR SMOOTH 4MM",SUP-AR-8945K,CDM,C1713,HCPCS,0278,RC,,,both,,,87.00,26.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,10.12,73.95,"percent of total billed charges",
"KIT RETRIEVER 25MM 6MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0032PK62510001,CDM,S27200284,LOCAL,0272,RC,,,both,,,29495.34,8848.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3495.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3430.31,25071.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 36MM TITANIUM LOCK SELF TAP AXSOS 3",SUP-661036,CDM,C1713,HCPCS,0278,RC,,,both,,,1305.72,391.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,373.7,28.62,,,,,0,151.86,1109.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE 1X10",SUP-7509211,CDM,S27800098,LOCAL,0278,RC,,,both,,,12696.00,3808.8,"CIGNA [10200]","Cigna Local Plus",,3999.24,31.5,,,,,0,1476.54,10791.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2 .5 CIRCLE STRAIGHT DIAMOND POINT 38IN BRAID",SUP-AR-7201,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.73,95.92,"CIGNA [10200]",Cigna,,217.42,68,,,,,0,37.18,271.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 3.5MM PRECUT",SUP-3603750,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 2CM 6MM BALLOON DILATATION",SUP-DR13562,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"PHCS [10601]",PHCS,,963.9,70,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE THINFLAP CRANIOMAXILLOFACIAL TITANIUM 4 HOLE",SUP-191015,CDM,C1713,HCPCS,0278,RC,,,both,,,1822.50,546.75,"CIGNA [10200]",Cigna,,1239.3,68,,1831.33,1831.33,1831.33,16,211.96,1549.13,"percent of total billed charges",
"CAGE SPINAL 28MMX10MM X-PAC LORDOTIC",SUP-EI2502L,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 40CM 7FR .038IN CHECK-FLO PERFORMER BALKIN UP AND",SUP-RCFW703840RBBLKN,CDM,C1894,HCPCS,0272,RC,,,both,,,509.49,152.85,"AETNA [10100]","Aetna HMO/PPO",,405.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.25,433.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0930CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"AETNA [10100]","Aetna HMO/PPO",,5211.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 9MM KNEE XLPE POSTERIOR STABILIZE LEGION",SUP-71453246,CDM,C1776,HCPCS,0278,RC,,,both,,,14831.55,4449.46,"FIRST HEALTH [10303]","First Health",,11865.24,80,,,,,0,1724.91,12606.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 80MM 7MM BALLOON DILATATION DURALYN",SUP-48007008S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AETNA [10100]","Aetna HMO/PPO",,998.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-1504-40-107,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"PHCS [10601]",PHCS,,21079.8,70,,,,,0,3502.26,25596.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 18MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-018,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"KAISER [10500]",Kaiser,,3173.86,67,,,,,0,550.92,4026.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 CURVE PLUS 15MM KNEE XLK FIX BEARING SIGMA",SUP-970463,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]","Cigna Open Access",,6358.32,56.9,,5302.19,4377.88,6578.61,27,1299.6,9498.37,"percent of total billed charges",
"HEAD FEMORAL +0MM 11/13 TAPER 40MM HIP M SPECIFICATION METAL",SUP-136542500,CDM,C1776,HCPCS,0278,RC,,,both,,,11077.95,3323.38,"PHCS [10601]",PHCS,,7754.57,70,,,,,0,1288.37,9416.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 2CM 5MM 6FR BALLOON DILATATION",SUP-V185020,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"FIRST HEALTH [10303]","First Health",,4388.4,80,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 75CM 60MM 5MM BALLOON DILATATION DRUG COATED",SUP-LX3575560V,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,797.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 17.5% IN WATER INFUSION",RX-410564,CDM,,,0258,RC,08888-8879-94,NDC,both,250,ML,100.65,30.19,"UHC [10700]","United Healthcare",,63.71,63.3,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC",575,MS-DRG,,,,,,,inpatient,,,47798.08,14339.42,"CIGNA [10200]","Cigna Open Access",,19720.28,,"Fee schedule rate ($19,720.28). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,47798.08,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM VARIAX TITANIUM T7 FULL THREAD RADIUS",SUP-53-27620E,CDM,C1713,HCPCS,0278,RC,,,both,,,762.05,228.61,"CIGNA [10200]","Cigna Local Plus",,407.7,53.5,,3978.14,359.25,3978.14,24,88.63,647.74,"percent of total billed charges",
"TUBE ENDOTRACHEAL 9.5MM 7MM STD LOW PROFILE DEPH FREE",SUP-8229707,CDM,S27200284,LOCAL,0272,RC,,,both,,,2895.00,868.5,"KAISER [10500]",Kaiser,,1939.65,67,,,,,0,336.69,2460.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 80MM 6FR 9MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206090870,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA D KNEE RIGHT NONPOROUS REVISION",SUP-42542006702,CDM,C1776,HCPCS,0278,RC,,,both,,,16335.06,4900.52,"NOVANET [10819]",Novanet,,12251.3,75,,,,,0,1899.77,13884.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PCMKR CRD THK6MM 50X47MM","SUP-PM1272 CELL",CDM,C1786,HCPCS,0275,RC,,,both,,,9324.00,2797.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1104.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1084.38,7925.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 9IN .062IN KIRSCHNER 2 END TROCAR POINT SMOOTH",SUP-164910000,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"BLUE CROSS [10001]","Blue Cross PPO",,444.53,39.2,,957.42,570.23,957.42,28,131.88,963.9,"percent of total billed charges",
"COIL EMBOLIZATION 3CM 1MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN01003,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"KAISER [10500]",Kaiser,,7854.48,67,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 44MM MODULAR TOTAL OXINIUM",SUP-71342344,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,5873.17,5873.17,5873.17,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"BINDER BREAST 3XL 50-54""""",SUP-XXXL-BIND,CDM,S27000186,LOCAL,0270,RC,,,both,,,191.40,57.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,22.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 20GA 10CM PERIPHERAL POWERGLIDE PRO BIOPATCH FULL",SUP-F320108PT,CDM,C1751,HCPCS,0272,RC,,,both,,,942.76,282.83,"UHC [10700]","United Healthcare",,596.77,63.3,,,,,0,109.64,801.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502605802,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS [10001]","Blue Cross HMO",,8962.18,39.2,,5311.50,4717.44,5388.59,31,2658.93,19433.3,"percent of total billed charges",
"IRR SUCTION 8MM ENDOWRIST STERILE LATEX FREE DISPOSABLE",SUP-480299,CDM,S27200284,LOCAL,0272,RC,,,both,,,2087.50,626.25,"KAISER [10500]",Kaiser,,1398.63,67,,,,,0,242.78,1774.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rem Impl Drug Deliv Non-Biodeg",PX-361000515,CDM,11982,CPT,0361,RC,,,both,,,4282.83,1284.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,507.52,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,498.09,4282.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 4.0MM X 26.0MM",SUP-494002612,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SPINAL AXONICS FORAMEN LONG STERILE LATEX FREE",SUP-9001-L,CDM,S27200284,LOCAL,0272,RC,,,both,,,621.00,186.3,"UHC [10700]","United Healthcare",,393.09,63.3,,,,,0,72.22,527.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Detect Agent Nos Dna Quant",PX-306000164,CDM,87799,CPT,0306,RC,,,both,,,831.25,249.37,"BLUE CROSS [10001]","Blue Cross PPO",,0.83,.1,,,,,0,0.83,706.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER 7969812 L 42 X 30 X 12MM 8 DEG",SUP-7969812,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4061.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS SELECT 135CM 4MM 2.1FR .038-.044IN 45D 15MM",SUP-518-091,CDM,C1887,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRATHECAL REVISION SEG SPINE DISTAL",SUP-8598A,CDM,C1755,HCPCS,0278,RC,,,both,,,2880.00,864,"NOVANET [10819]",Novanet,,2160,75,,,,,0,334.94,2448,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL LEAD DELIVERY 36.1CM EPSILA EV POLYCARBONATE",SUP-EAZ201,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1701.54,41.1,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 15CM CHIBA COLOR CODED HUB FNA ADJUSTABLE",SUP-MCN2006,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"MULTIPLAN [10600]",Multiplan,,105.01,85,,,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM ELITE ROUND DIAMOND ROUND DIAMOND STERILE",SUP-5820012040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INQUIRY 110CM 1MM 5FR 2-5-2MM SPACE LARGE CURVE",SUP-IBI-81174,CDM,C1730,HCPCS,0272,RC,,,both,,,2343.75,703.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,277.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,272.58,1992.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 6 HOLE LOW PROFILE BONE RIGHT CLAVICLE",SUP-70-0297,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"NOVANET [10819]",Novanet,,4957.65,75,,,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 60MM 7FR 7MM 5FR BALLOON",SUP-39031-70601,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL BONE VERTECOR",SUP-2224,CDM,S27200284,LOCAL,0272,RC,,,both,,,1607.45,482.23,"MULTIPLAN [10600]",Multiplan,,1366.33,85,,,,,0,186.95,1366.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 7CM 8.5FR .035IN GENTLE CURVE BILIARY",SUP-G21620,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CIGNA [10200]",Cigna,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL MEDIUM VENOUS 2","SUP-GEM TKMV-2",CDM,S27200284,LOCAL,0272,RC,,,both,,,582.39,174.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,69.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.73,495.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 40MM 7MM .035IN BALLOON",SUP-AB35W07040135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,278.31,41.1,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG CARDIOVASCULAR 8MM 14MM AMPLATZER NITINOL 1 LOBE SELF",SUP-9-PLUG-014,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,731.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 28MM TRI-AD 2 ADAM TRICUSPID VALVE MODEL",SUP-900SFC228,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UHC [10700]","United Healthcare",,8298.63,63.3,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 10.5MM THORACOPORT THREAD BLUNT TIP OBTR",SUP-179301,CDM,S27200284,LOCAL,0272,RC,,,both,,,615.28,184.58,"KAISER [10500]",Kaiser,,412.24,67,,,,,0,71.56,522.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 77X11X3.3MM TITANIUM 3.5MM SCR SMALL FRAGMENT 6 HOLE",SUP-423.56,CDM,C1713,HCPCS,0278,RC,,,both,,,905.58,271.67,"KAISER [10500]",Kaiser,,606.74,67,,,,,0,105.32,769.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 75CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR061501A,CDM,C1874,HCPCS,0278,RC,,,both,,,24374.70,7312.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6581.17,27,,,,,0,2834.78,20718.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 55MM TSRH-3D TITANIUM POSTERIOR PEDICLE",SUP-837-655,CDM,C1713,HCPCS,0278,RC,,,both,,,2361.60,708.48,"FIRST HEALTH [10303]","First Health",,1889.28,80,,,,,0,274.65,2007.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 30MM 1 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800130,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,1144.80,304.56,2275.09,66,521.61,3812.25,"percent of total billed charges",
"SUT PROLENE SABRELOC 10-0 STC-6 8IN 2 ARM MONOFILAMENT",SUP-1713G,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.75,65.32,"CIGNA [10200]","Cigna Open Access",,123.9,56.9,,,,,0,25.32,185.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 13MM KNEE CRUCIATE RETAIN TRIATHLON",SUP-5530P713,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,990.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,971.79,7102.52,"percent of total billed charges",
"INTRO SHEATH 1.9FR LOW PROFILE PEEL-AWAY",SUP-SHEATH1.9,CDM,S27200284,LOCAL,0272,RC,,,both,,,385.32,115.6,"CIGNA [10200]",Cigna,,262.02,68,,,,,0,44.81,327.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 1.5CM 4FR STRAIGHT ART CURVE ANGIOGRAPHIC",SUP-H787107140225,CDM,C1887,HCPCS,0272,RC,,,both,,,156.60,46.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 121MM 20FR ZENITH ABDOMINAL AORTIC",SUP-G32560,CDM,C1874,HCPCS,0278,RC,,,both,,,23565.28,7069.58,"KAISER [10500]",Kaiser,,15788.74,67,,,,,0,2740.64,20030.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATHETERIZATION 1.75IN 20GA 23GA .015IN RADIAL ARTERY",SUP-RA-04122,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.00,28.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.05,80.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 8MM 144CM 3.5MM CORONARY STENT EVEROLIMUS",SUP-H7493926108350,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"PHCS [10601]",PHCS,,6037.5,70,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mycardial Ab If1",PX-302000053,CDM,86255,CPT,0302,RC,,,both,,,199.00,59.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.65,,"Fee schedule rate ($12.65). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.2,169.15,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 STD 10MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS2S10L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"CIGNA [10200]","Cigna Open Access",,5912.71,56.9,,5302.19,4377.88,6578.61,27,1208.52,8832.69,"percent of total billed charges",
"NDL 71CM 18GA STYLET PROC TRANSSEPTAL BRK ADULT",SUP-407200,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"AETNA [10100]","Aetna HMO/PPO",,1126.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 5CM 20GA HAWKINS III FLEXSTRAND",SUP-253050,CDM,A4648,HCPCS,0278,RC,,,both,,,310.59,93.18,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,88.89,28.62,,,,,0,36.12,264,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AXIOS 10MM 146MM 15MM 24MM 138MM 10.8FR PANCREATIC",SUP-M00553650,CDM,C1874,HCPCS,0278,RC,,,both,,,28551.60,8565.48,"MULTIPLAN [10600]",Multiplan,,24268.86,85,,,,,0,3320.55,24268.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE HANDPIECE INFUSION MCINTYRE",SUP-61-1060,CDM,S27000186,LOCAL,0270,RC,,,both,,,144.86,43.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,98.5,68,,,,,0,16.85,123.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER SMOKE EVACUATION ULPA MULTIPORT TELEVAC 2",SUP-5000746,CDM,S27000186,LOCAL,0270,RC,,,both,,,3997.79,1199.34,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,464.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,464.94,3398.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 122MM 13MM 5.4MM 4.7MM ZENITH SPIRAL-Z",SUP-G55235,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6060.08,28.62,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 20MM 144CM 3.5MM CORONARY STENT",SUP-H7493952820350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"FIRST HEALTH [10303]","First Health",,4452,80,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM",SUP-8847040,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2998.8,68,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 15MM HELIX R SPINE SELF TAP VARIABLE ANGLE",SUP-7805115,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 12.5MM KNEE GVF STABILIZE ROTATE PLATFORM PFC",SUP-962162,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1186.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE 100 MEQ SODIUM 2 MEQ POTASSIUM 3.5 MEQ CALCIUM",SUP-08-2351-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.29,15.99,"NOVANET [10819]",Novanet,,39.97,75,,,,,0,6.2,45.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 30MM COCR",SUP-VAL-35300-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,244.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",244.23,1785,"percent of total billed charges",
"SYSTEM INTEGRITY 26MM 4MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT40026UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"MULTIPLAN [10600]",Multiplan,,2052.75,85,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 800ML STYLE 7200 MEDIUM HEIGHT CENTERSCOPE",SUP-354-7216,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Local Plus",,5537.25,53.5,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP MACINTOSH 4 STAINLESS STEEL FIBER OPTIC",SUP-040-914U,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 19CM 14.5FR PALINDROME 2 LUMEN LATEX FREE",SUP-8888145014P,CDM,C1750,HCPCS,0278,RC,,,both,,,2876.79,863.04,"CIGNA [10200]",Cigna,,1956.22,68,,,,,0,334.57,2445.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 150MM 130CM 6MM 6FR .035IN HELICAL VASCULAR",SUP-EX061503CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20128.50,6038.55,"AETNA [10100]","Aetna HMO/PPO",,16002.16,79.5,,,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL INTERTAN 11.5X24X125DG",SUP-71934481,CDM,C1713,HCPCS,0278,RC,,,both,,,12096.00,3628.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3265.92,27,,,,,0,1406.76,10281.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 34MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40034W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"BLUE CROSS [10001]","Blue Cross HMO",,2132.09,39.2,,9776.84,9776.84,9776.84,"1 through 10",632.56,4623.15,"percent of total billed charges",
"AUG TIBIAL TRIATHLON A CONE KNEE TRITANIUM SYMMETRIC STERILE",SUP-5549-A-110,CDM,C1776,HCPCS,0278,RC,,,both,,,22087.80,6626.34,"KAISER [10500]",Kaiser,,14798.83,67,,,,,0,2568.81,18774.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM INFINITY SPINE MULTIAXIAL",SUP-3603524,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 12MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620712,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7652.65,68,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 50MM BIO-MOORE II ENDO II HIP ACETABULAR",SUP-12-139024,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"CIGNA [10200]",Cigna,,1899.24,68,,5873.17,5873.17,5873.17,"1 through 10",324.83,2374.05,"percent of total billed charges",
"INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP",RX-70693,CDM,J1815,HCPCS,0637,RC,00002-7511-01,NDC,both,10,ML,773.80,232.14,"KAISER [10500]",Kaiser,,518.45,67,,,,,0,51.7,657.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 10MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620610,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]",Cigna,,7652.65,68,,5873.17,5873.17,5873.17,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"OSTEOTOM 7.5IN RHOTON SURGICAL 4MM",SUP-NL3785-148,CDM,S27200284,LOCAL,0272,RC,,,both,,,921.13,276.34,"CIGNA [10200]","Cigna Local Plus",,492.8,53.5,,,,,0,107.13,782.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 70MM KNEE LEFT POSTERIOR STABILIZE CEMENT OPEN",SUP-183132,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8666.28,40,,,,,0,2519.72,18415.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 150MM 4MM BALLOON DILATATION NYBAX",SUP-H74939186401510,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE RX 30MM 135CM 8/6MM 6FR TAPER VASCULAR NITINOL",SUP-SECX-8-6-30-135,CDM,C1876,HCPCS,0278,RC,,,both,,,12420.00,3726,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3353.4,27,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC CLEAR 5MM SPACEMAKER PRO BLUNT TIP OVAL",SUP-SMBTTOVLX,CDM,C1727,HCPCS,0272,RC,,,both,,,3323.48,997.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,393.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,386.52,2824.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 125CM 6FR .07IN JUDKINS LEFT",SUP-SM7435,CDM,C1887,HCPCS,0272,RC,,,both,,,1310.50,393.15,"FIRST HEALTH [10303]","First Health",,1048.4,80,,,,,0,152.41,1113.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prosthetic Labor/Consult",PX-E27400099,CDM,L7520,HCPCS,0274,RC,,,both,,,77.00,23.1,"MULTIPLAN [10600]",Multiplan,,65.45,85,,,,,0,8.96,65.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Group Caregiver Training (Gn)",PX-443000002,CDM,97552,CPT,0443,RC,,,both,,,22.00,6.6,"PHCS [10601]",PHCS,,15.4,70,,,,,0,0.02,22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 4MM NESTER MICROCOIL PLATINUM ACCEPTS",SUP-G47372,CDM,S27800098,LOCAL,0278,RC,,,both,,,890.92,267.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,408.93,45.9,,,,,0,103.61,757.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEMORAL VANGUARD 360 2.5MM OFFSET KNEE REVISION SYSTEM",SUP-185210,CDM,C1776,HCPCS,0278,RC,,,both,,,5978.16,1793.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4065.15,68,,,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 150MM 120CM 7MM VASCULAR NICKEL",SUP-EVD35-07-150-120,CDM,C1876,HCPCS,0278,RC,,,both,,,8085.00,2425.5,"AETNA [10100]","Aetna HMO/PPO",,6427.58,79.5,,,,,0,940.29,6872.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 0 CT-1 18IN CONTROL RELEASE BRAID 8",SUP-C021D,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.49,30.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,69.69,68,,,,,0,11.92,87.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CLOTTRIEVER 105CM 16MM THROMBECTOMY",SUP-42-102,CDM,C1757,HCPCS,0272,RC,,,both,,,44100.00,13230,"PHCS [10601]",PHCS,,30870,70,,,,,0,5128.83,37485,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 11CM ROTATE SUT COLLAR KINK RESISTANT CANN",SUP-504608A,CDM,C1894,HCPCS,0272,RC,,,both,,,72.65,21.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.45,61.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 6FR 4.5MM 4FR BALLOON",SUP-H74939031454010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7.5CM 3.5MM CEREPAK FREEFORM DETACHABLE",SUP-SCR123575,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1538.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRANSFORM 15MM 4MM BALLOON OCCLUSION 1 LUMEN COMPLIANT",SUP-M003SRC04150,CDM,C1725,HCPCS,0272,RC,,,both,,,11760.02,3528.01,"FIRST HEALTH [10303]","First Health",,9408.02,80,,,,,0,1367.69,9996.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE LAPAROSCOPIC 12MM 100MM KII ABDOMINAL ADVANCE",SUP-CFS22,CDM,S27200284,LOCAL,0272,RC,,,both,,,119.63,35.89,"KAISER [10500]",Kaiser,,80.15,67,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 4-5 C-D KNEE RIGHT TIBIA FIX",SUP-42522100316,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AETNA [10100]","Aetna HMO/PPO",,8567.25,79.5,,10981.53,8986.79,12413.38,12,1253.3,9159.96,"percent of total billed charges",
"SPECLM EAR 4MM ROUND EBONY FINISH STAINLESS STEEL",SUP-130640,CDM,S27200284,LOCAL,0272,RC,,,both,,,525.29,157.59,"FIRST HEALTH [10303]","First Health",,420.23,80,,,,,0,61.09,446.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035423100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1672.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 3.3MM 50MM TITANIUM T25 FULL THREAD TIBIAL LOCK",SUP-04.005.440,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"AMERIGROUP MEDICAID [20100]",Amerigroup,,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",134.52,983.18,"percent of total billed charges",
"CATH STERLING SL 150CM 80MM 2MM BALLOON DILATATION PEBAX",SUP-H74939147208010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 8MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-008,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"AETNA [10100]","Aetna HMO/PPO",,16894.39,79.5,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 165MM 17MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192117,CDM,C1776,HCPCS,0278,RC,,,both,,,955.80,286.74,"CIGNA [10200]",Cigna,,649.94,68,,5873.17,5873.17,5873.17,"1 through 10",111.16,812.43,"percent of total billed charges",
"TOOL 14CM MR8 3MM TAPER DISSECTING",SUP-MR8-14TA30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.19,388.56,"MULTIPLAN [10600]",Multiplan,,1100.91,85,,,,,0,150.63,1100.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 24FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0119SI24,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.53,33.46,"KAISER [10500]",Kaiser,,74.73,67,,,,,0,12.97,94.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 390MM 16MM TFN-ADVANCED LARGE LONG PERCUTANEOUS",SUP-03.037.102,CDM,S27200284,LOCAL,0272,RC,,,both,,,4797.16,1439.15,"AETNA [10100]","Aetna HMO/PPO",,3813.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,557.91,4077.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR MDM X3 TRITANIUM E HEMISPHERE OD54 MM CLUST",SUP-502-03-54E,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"CIGNA [10200]","Cigna Local Plus",,5599.75,53.5,,5372.07,4581.20,7242.98,23,1217.29,8896.8,"percent of total billed charges",
"CATH BALLOON DILATATION .035IN 14MM 135CM 40MM PERIPHERAL",SUP-10343-40,CDM,C1725,HCPCS,0272,RC,,,both,,,1539.00,461.7,"MULTIPLAN [10600]",Multiplan,,1308.15,85,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GASTROJEJUNOSTOMY TUBE 18FR STOMA L2.7CM JEJUNAL L30CM S",SUP-8270-18-2.7-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"PHCS [10601]",PHCS,,1842.96,70,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 40MM 3MM .035IN BALLOON",SUP-AB35W03040135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,278.31,41.1,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MICROSHEATH XL 110CM 7FR .083IN .067IN VERTEBRAL",SUP-MSXL17110V,CDM,C1887,HCPCS,0272,RC,,,both,,,2062.50,618.75,"UHC [10700]","United Healthcare",,1305.56,63.3,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL CEMENTED POSTERIOR STABILIZE ATTUNE STERILE 3",SUP-150410223,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"UHC [10700]","United Healthcare",,14174.99,63.3,,8601.07,8395.67,8601.07,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"SET ENDOSCOPIC INSTR 1.2MM RAP-PAC KNEE GWIRE STERILE LATEX",SUP-72202798,CDM,S27200284,LOCAL,0272,RC,,,both,,,1883.25,564.97,"CIGNA [10200]","Cigna Open Access",,1071.57,56.9,,,,,0,219.02,1600.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM AZUR HYDROPACK .018IN PERIPHERAL",SUP-45-880020,CDM,S27800098,LOCAL,0278,RC,,,both,,,6768.90,2030.67,"PHCS [10601]",PHCS,,4738.23,70,,,,,0,787.22,5753.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 12CM 3MM MIDAS REX MR8 MATCH HEAD SD STERILE",SUP-MR8-SD12MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,326.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LEFT FOOT 19MM STAINLESS STEEL 2MM SCR MINI FRAGMENT",SUP-243.33,CDM,C1713,HCPCS,0278,RC,,,both,,,1053.41,316.02,"FIRST HEALTH [10303]","First Health",,842.73,80,,,,,0,122.51,895.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 135CM 5MM 30MM",SUP-H74938047530130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"AETNA [10100]","Aetna HMO/PPO",,3968.64,79.5,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM TPS MEDIUM EGG STERILE",SUP-5120015040,CDM,S27200284,LOCAL,0272,RC,,,both,,,727.62,218.29,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,299.05,41.1,,,,,0,84.62,618.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 300MM 2.8MM THREAD",SUP-03.333.015,CDM,S27200284,LOCAL,0272,RC,,,both,,,1125.33,337.6,"CIGNA [10200]","Cigna Local Plus",,602.05,53.5,,,,,0,130.88,956.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 46MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.746,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"KAISER [10500]",Kaiser,,752.83,67,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER SURGICAL 203MM MAXFIRE DISPOSABLE",SUP-905732,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL 89CM 18GA PROC TRANSSEPTAL 50D HEARTSPAN",SUP-FND01903,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EZ STEER THERMOCOOL 115CM 3.5MM 7.5FR 2-5-2MM SPACING",SUP-BNI75TCDDH,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"VALVE HEMOSTASIS CLEAR 7.3FR PHD POLYCARBONATE SILICONE",SUP-MAP800,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.61,52.38,"FIRST HEALTH [10303]","First Health",,139.69,80,,,,,0,20.31,148.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 115MM STAINLESS STEEL 3.5MM SCR 8 HOLE PRECONTOUR",SUP-02.112.084S,CDM,C1713,HCPCS,0278,RC,,,both,,,6443.22,1932.97,"NOVANET [10819]",Novanet,,4832.42,75,,,,,0,749.35,5476.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 93MM 28-16MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1628C93E,CDM,S27800098,LOCAL,0278,RC,,,both,,,30006.90,9002.07,"BLUE CROSS [10001]","Blue Cross HMO",,11762.7,39.2,,,,,0,3489.8,25505.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR THUMB OR JOINT PROCEDURES",506,MS-DRG,,,,,,,inpatient,,,65860.45,19758.13,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,8620.25,,"Case rate ($8,369.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,771.34, add-ons for qualifying new technology services are included. If operating cost exceeds $40,811.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,969.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $7,781.62. The transfer operating threshold is the transfer adjustment factor * $7,771.34 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.55. The transfer capital threshold is the transfer adjustment factor * $587.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,39391.24,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 12CM 180CM 20MM 10.5FR ESOPHAGEAL",SUP-G57348,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"CIGNA [10200]","Cigna Local Plus",,5540.72,31.5,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) IMPLANT DELIVERY SYSTEM WITH IMPLANT LOADING TOOL",SUP-FG-1001-01,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 401322 MDII 22X26 SRVC FEE",SUP-401322,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2014.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 4MM LORDOSIS TITANIUM",SUP-102064040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13177535,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"MULTIPLAN [10600]",Multiplan,,2550,85,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE SCLERAL 2.5MM GROOVED SILICONE STERILE",SUP-92-28,CDM,S27800098,LOCAL,0278,RC,,,both,,,241.95,72.58,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.14,205.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X8MM CLYDESDALE PTC 6D PEEK TANTALUM",SUP-4986845,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6415.2,27,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 SH 30IN BRAID BLACK NONABSORBABLE",SUP-K833H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX14MM MAXIM ARCOM KNEE POSTERIOR STABILIZE",SUP-11146534,CDM,C1776,HCPCS,0278,RC,,,both,,,7472.70,2241.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,869.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,869.08,6351.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 9CM 20GA GHIATAS BARBED WIRE STIFFENED",SUP-49920,CDM,A4648,HCPCS,0278,RC,,,both,,,182.79,54.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,52.31,28.62,,,,,0,21.26,155.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLUE FLEXTIP 16CM 7FR CENTRAL VENOUS POLYURETHANE 3",SUP-SS-14703,CDM,C1751,HCPCS,0272,RC,,,both,,,288.84,86.65,"UHC [10700]","United Healthcare",,182.84,63.3,,,,,0,33.59,245.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION 10MM INBONE 4+ ANKLE EVERLAST",SUP-22025410,CDM,C1776,HCPCS,0278,RC,,,both,,,13530.90,4059.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1573.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1573.64,11501.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-707,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1555.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 STD KNEE RIGHT CRUCIATE RETAIN PERSONA PPS",SUP-42508606402,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10783.92,41.1,,6417.48,6417.48,6417.48,"1 through 10",3051.51,22302.5,"percent of total billed charges",
"BLADE 16CMX12MM HIP MEDIAL OSTEOTOM CURVE NONSTERILE",SUP-SBLDCURVE-4-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TALUS VANTAGE 3 ANKLE LEFT STERILE LATEX FREE",SUP-350-01-03,CDM,C1776,HCPCS,0278,RC,,,both,,,24790.50,7437.15,"AETNA [10100]","Aetna HMO/PPO",,19708.45,79.5,,10981.53,8986.79,12413.38,12,2883.14,21071.93,"percent of total billed charges",
"HC Wheelchair Mgmt 15min (Gp)",PX-420000031,CDM,97542,CPT,0420,RC,,,both,,,87.20,26.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.14,87.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 80MM 120CM 4.5MM 6FR VASCULAR NITINOL",SUP-S-45-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"AETNA [10100]","Aetna HMO/PPO",,7999.29,79.5,,,,,0,1063.27,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 80MM 10MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171100870,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC PERCLOT STANDARD L9 CM 1 GM STERILE LATEX F",SUP-PCUS001,CDM,A6250,HCPCS,0272,RC,,,both,,,715.83,214.75,"AETNA [10100]","Aetna HMO/PPO",,569.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,83.25,608.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rem Auton Alg Insln 30d Data",PX-761000091,CDM,0741T,HCPCS,0761,RC,,,both,,,289.00,86.7,"FIRST HEALTH [10303]","First Health",,231.2,80,,,,,0,33.61,289,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BIOABSORBABLE REGENETEN LARGE ROTATOR CUFF BOVINE",SUP-4566,CDM,S27800098,LOCAL,0278,RC,,,both,,,14490.00,4347,"NOVANET [10819]",Novanet,,10867.5,75,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FABRIC CARDIOVASCULAR 6X2IN HEMASHIELD THK.46MM CLLGN",SUP-M002000196270,CDM,L8670,HCPCS,0278,RC,,,both,,,2687.48,806.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,312.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,312.55,2284.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOXEPIN 10 MG CAPSULE",RX-2608,CDM,,,0637,RC,00904-7052-61,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE",RX-105903,CDM,J1650,HCPCS,0636,RC,63323-0586-63,NDC,both,1,ML,84.44,25.33,"UHC [10700]","United Healthcare",,10.3,,,,,,,6.88,71.77,"fee schedule",
"GRAFT SYNTHETIC TISSUE DEMINERALIZED BONE MATRIX 5CC",SUP-OCMP5,CDM,C1713,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"MULTIPLAN [10600]",Multiplan,,2868.75,85,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LOCKING ELLIPSE SPINE OCCIPITOCERVICOTHORACIC POSTERIOR",SUP-182.500,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"CIGNA [10200]","Cigna Local Plus",,1287.53,53.5,,3978.14,359.25,3978.14,24,279.89,2045.61,"percent of total billed charges",
"BODY CALCAR 25MM RESTORATION +30MM OFFSET HIP MODULAR",SUP-6276-4-325,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2698.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2698.86,19725.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR 5X2CM ENCAP TECHNOLOGY PERICARDIAL",SUP-C0205,CDM,C1768,HCPCS,0278,RC,,,both,,,2874.38,862.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1319.34,45.9,,,,,0,334.29,2443.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.225,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,197.05,28.62,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 41-49MM 5.5MM EXPEDIUM SFX A5 SPINE MEDIAL TITANIUM",SUP-189401405,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"MULTIPLAN [10600]",Multiplan,,3028.13,85,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 16MM 4.25MM EMBOLIZATION NEUROVASCULAR",SUP-PED-425-16,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"BLUE CROSS [10001]","Blue Cross HMO",,30164.4,39.2,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 27CM 8MM AVENIR 10 COIL COMPLEX FINISH",SUP-10CFN08027,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PHCS [10601]",PHCS,,8206.17,70,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 7FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175270110,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,354.71,28.62,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CLEARVIEW BLOWER/MISTER TUBE SET STERILE LATEX FREE N",SUP-22150,CDM,S27200284,LOCAL,0272,RC,,,both,,,445.50,133.65,"MULTIPLAN [10600]",Multiplan,,378.68,85,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Train for Caregiver Add 15 (Gn)",PX-440000026,CDM,G0540,HCPCS,0440,RC,,,both,,,37.00,11.1,"CIGNA [10200]",Cigna,,37,,"Per diem ($369).",,,,0,0.04,37,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 270ML STYLE 10 GEL SMOOTH NATRELLE SILICONE P3.3",SUP-10-270,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"CIGNA [10200]",Cigna,,2427.6,68,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 80MM 120CM 10MM .079IN LARGE",SUP-SERB65-10-80-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross HMO",,2181.48,39.2,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X10X10-17MM RISE 15D",SUP-193.142,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ITOTAL IDENTITY CR 3DP POROUS KIT IPOLY XE INSERTS",SUP-ITCR-3DP-XE-KIT,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"MULTIPLAN [10600]",Multiplan,,25436.25,85,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 80CM 5MM 8MM 7FR .035IN",SUP-BXA052901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UHC [10700]","United Healthcare",,12346.54,63.3,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.3MM 2 CURVED OSTEORAPTOR 1 ULTRABRAID COBRAID",SUP-72203291,CDM,C1713,HCPCS,0278,RC,,,both,,,2504.25,751.27,"NOVANET [10819]",Novanet,,1878.19,75,,,,,0,291.24,2128.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 42MM AXSOS STAINLESS STEEL T15 FEMUR HUMERUS",SUP-371542,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA [10200]","Cigna Local Plus",,476.69,53.5,,3978.14,359.25,3978.14,24,103.62,757.35,"percent of total billed charges",
"AVENIR 10, 3 X 6 HELICAL PICO COIL",SUP-10USH03006,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PHCS [10601]",PHCS,,8206.17,70,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION KIRSCHNER PACK LUMBAR SPINE STERILE",SUP-675.399S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3326.40,997.92,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,386.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,386.86,2827.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM 6.5MM LEGACY TITANIUM SPINAL MAS",SUP-7576545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1110.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1110.3,8114.82,"percent of total billed charges",
"SHELL ACETABULAR 50MM 51.8MM HIP 5 HOLE CLUSTER PUREFIX",SUP-542-11-50E,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,824.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,809.18,5914.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X5MM ADVANCED CONVEX SPINE",SUP-17805,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]",Cigna,,5630.4,68,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 4MM MICRO CARBIDE OVAL STERILE",SUP-00509123600,CDM,S27200284,LOCAL,0272,RC,,,both,,,207.76,62.33,"KAISER [10500]",Kaiser,,139.2,67,,,,,0,24.16,176.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 29MM 24.2MM MASTERS 85D RING ANNULUS PYROLYTIC",SUP-29MECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"BLUE CROSS [10001]","Blue Cross PPO",,11414.74,39.2,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT BONE 10X115MM STERILE TITANIUM FEMORAL NECK SYSTEM",SUP-04.168.315S,CDM,C1713,HCPCS,0278,RC,,,both,,,2435.70,730.71,"CIGNA [10200]","Cigna Local Plus",,1303.1,53.5,,3978.14,359.25,3978.14,24,283.27,2070.35,"percent of total billed charges",
"DEVICE TENDER TOUCH ULTRA 60MM VACUUM EXTRACTION SILICONE",SUP-505TT,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.75,58.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,80.45,41.1,,,,,0,22.77,166.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 100CM 3CM 6FR .54IN .038IN AR1 CURVE",SUP-7508-13,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"AETNA [10100]","Aetna HMO/PPO",,65.09,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH 1 90CM 8FR .091IN STRAIGHT TIP CURVE GUIDING PTFE",SUP-M001198480,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,245.42,41.1,,,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 20MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.220,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"CIGNA [10200]","Cigna Local Plus",,1572.9,53.5,,3978.14,359.25,3978.14,24,341.92,2499,"percent of total billed charges",
"COIL EMBOLIZATION 6CM 2MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036122060,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 13MM INDEPENDENCE 8D PLATE DISK ALIF",SUP-376.413,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"MULTIPLAN [10600]",Multiplan,,29134.26,85,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 20CM 8MM BALLOON DILATATION OTW LOW",SUP-G30921,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR SURGICAL 230CM SPARE DELIVERY ENDOCLOT 2.8CM",SUP-EA230,CDM,S27200284,LOCAL,0272,RC,,,both,,,431.52,129.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION",RX-14983,CDM,,,0250,RC,63323-0461-57,NDC,both,50,ML,175.92,52.78,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO BIOPSY 10CM 19GA 20GA ACHIEVE UNIVERSAL COAXIAL",SUP-PP1910,CDM,S27200284,LOCAL,0272,RC,,,both,,,114.41,34.32,"AETNA [10100]","Aetna HMO/PPO",,90.96,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.31,97.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 26FR STD URETHRAL NATURAL RUBBER",SUP-0167L26,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.13,23.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.09,66.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BLOCK 16X14X10MM",SUP-345644,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X2CM ALLOPATCH DERMAL MATRIX ALLOGRAFT",SUP-WC0222,CDM,Q4128,HCPCS,0636,RC,,,both,,,3166.80,950.04,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH RED WHITE 9.5FR GROSHONG CENTRAL VENOUS 2 LUMEN",SUP-7742000,CDM,C1751,HCPCS,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 48MM 3MM E9000 ROUND CARBIDE 8 FLUTE LOW SPEED",SUP-E8230LSO,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP IRRIGATION FORTIFY I COALITION ANGLE 12MM SELF CENTERING",SUP-684.432,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,62.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9.5MM 80MM RELINE-O 2S SPINE ILIAC POLYAXIAL",SUP-13019580,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 44.5MM 1.5MM 4MM STOP J LATCH NONSTERILE",SUP-317.64,CDM,S27000186,LOCAL,0270,RC,,,both,,,1231.20,369.36,"CIGNA [10200]","Cigna Open Access",,700.55,56.9,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 5MM PRECEPT PREBENT LORDOTIC",SUP-8847085,CDM,S27800098,LOCAL,0278,RC,,,both,,,4410.00,1323,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,512.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 60CM STRG SOLIA S",SUP-106162,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"CIGNA [10200]","Cigna Open Access",,217.81,56.9,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXTR PRO XL 200CM 7-6FR 9-12MM SPECIMEN RETRIEVAL",SUP-M00547100,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 17MM 6MM STAINLESS STEEL 1.1MM LONG THREAD",SUP-02.226.117,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1118.74,68,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR IMPLANTABLE 40CM STRETCH-COIL 1X8 EXT BOOT",SUP-3708140,CDM,C1883,HCPCS,0278,RC,,,both,,,6127.20,1838.16,"KAISER [10500]",Kaiser,,4105.22,67,,,,,0,712.59,5208.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26MMX13MM CAPSTONE PEEK PTC LUMBAR INTERBODY",SUP-3992613,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2564.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 16MM 144CM 4MM CORONARY STENT",SUP-H7493941816400,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID UPPER LEG REDUCTION KIT- LONG, WIDE",SUP-25302317,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"KAISER [10500]",Kaiser,,841.19,67,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 360 145CM 30MM .079IN 2MM .014IN",SUP-DBP-CART-200SOL145,CDM,C1724,HCPCS,0272,RC,,,both,,,17250.00,5175,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11730,68,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 7X 22MM CATH 120CM ENDOVASCULAR",SUP-42722,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL AMPLATZ FIRM KINK RESISTANT GRADUATE TAPER 35CM",SUP-M0062601080,CDM,C1894,HCPCS,0272,RC,,,both,,,362.44,108.73,"AETNA [10100]","Aetna HMO/PPO",,288.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.15,308.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR28,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Open Access",,4391.85,33.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 10CM 12MM GORE EXCLUDER CONTRALATERAL LEG",SUP-PLC121000,CDM,C1874,HCPCS,0278,RC,,,both,,,27997.20,8399.16,"PHCS [10601]",PHCS,,19598.04,70,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM FULL THREAD HEALICOIL ULTRABRAID SHOULDER",SUP-72203704,CDM,C1713,HCPCS,0278,RC,,,both,,,2868.75,860.62,"MULTIPLAN [10600]",Multiplan,,2438.44,85,,,,,0,333.64,2438.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 345541FZ L-ASR 5X14X11 FZ SRVCFEE",SUP-345541FZ,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 35CM ENDOCARDIUM MYOCARDIUM RIGHT VENTRICLE IS-1",SUP-4046,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"NOVANET [10819]",Novanet,,4205.25,75,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VISIGI 3D 36FR GASTRIC LAVAGE BULB",SUP-5236B,CDM,S27000186,LOCAL,0270,RC,,,both,,,1792.50,537.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,822.76,45.9,,,,,0,208.47,1523.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 150MM 5.5MM CREO STRAIGHT TITANIUM MIS NONSTERILE",SUP-1134.5150,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,957.42,570.23,957.42,28,141.3,1032.75,"percent of total billed charges",
"SCR BONE 4MM 15MM SPINE CERVICAL ANTERIOR SELF TAP VARIABLE",SUP-18008515,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.50 X 33 RX US",SUP-1804250-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 105MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.701S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"CIGNA [10200]","Cigna Local Plus",,1315.78,53.5,,3978.14,359.25,3978.14,24,286.03,2090.49,"percent of total billed charges",
"(EVAL) WISE PULSE GENERATOR TRANSMITTER","SUP-MODEL 4100",CDM,S62400003,LOCAL,0624,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,42636,68,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 8MM 16MM STAINLESS STEEL STD CORTEX LARGE",SUP-214.016,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,3978.14,359.25,3978.14,24,50.59,369.75,"percent of total billed charges",
"NAIL 12MM 420MM FEMORAL LEFT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.263S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5103.94,41.1,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCORTISONE 5 MG TABLET",RX-10209,CDM,,,0637,RC,59762-0073-01,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MINI TREK 145CM 8MM 1.2MM ULTRA LOW PROFILE BALLOON",SUP-1012268-08U,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL 105CM 2FR BUGBEE SHORT TIP STERILE",SUP-BE-202,CDM,S27200284,LOCAL,0272,RC,,,both,,,745.97,223.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,88.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.76,634.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +7.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.075,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 7FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552440,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]",Cigna,,816.39,68,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX17MM FRA 8D NARROW WEDGE SPINE",SUP-17,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"BLUE CROSS [10001]","Blue Cross PPO",,7408.8,39.2,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BICALUTAMIDE 50 MG TABLET",RX-15746,CDM,,,0637,RC,16714-0816-01,NDC,both,1,UN,68.99,20.7,"UHC [10700]","United Healthcare",,43.67,63.3,,,,,0,8.02,58.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM SPINE PLY NONSTERILE 4MM ROD",SUP-102035112,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,441.36,3225.75,"percent of total billed charges",
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 50MM 32MM MARATHON",SUP-121932450,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"BLUE CROSS [10001]","Blue Cross PPO",,3179.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",943.3,6894.31,"percent of total billed charges",
"SUT ARTHREX TIGERLINK SUTURETAPE .9MM BLACK WHITE",SUP-AR-7559T,CDM,S27200284,LOCAL,0272,RC,,,both,,,807.98,242.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,93.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,93.97,686.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 52.5MM ATLANTIS VISION ELITE BONE SPINAL",SUP-7200052,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"CIGNA [10200]","Cigna Open Access",,3011.15,56.9,,1144.80,304.56,2275.09,66,615.46,4498.2,"percent of total billed charges",
"MESH SURGICAL RESTORELLE SMARTMESH 30X30CM ULTRA LIGHTWEIGHT",SUP-501330,CDM,C1781,HCPCS,0278,RC,,,both,,,11812.80,3543.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1399.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1373.83,10040.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE VASCULAR HIGH SENSITIVITY 5MHZ",SUP-VP5XS-USA,CDM,S27000186,LOCAL,0270,RC,,,both,,,1843.28,552.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1253.43,68,,,,,0,214.37,1566.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL CRYOFLEX 8IN PROBE 60CM1",SUP-60CM1,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 2 KNEE LEFT TOTAL STABILIZE",SUP-5541-A-201,CDM,C1776,HCPCS,0278,RC,,,both,,,6699.90,2009.97,"CIGNA [10200]","Cigna Open Access",,3812.24,56.9,,5302.19,4377.88,6578.61,27,779.2,5694.92,"percent of total billed charges",
"PORT IMPLANTABLE INFUSION 9.6FR 10FR 1.6MM TITANIUM SILICONE",SUP-CT96STSD,CDM,C1788,HCPCS,0278,RC,,,both,,,2505.00,751.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,716.93,28.62,,,,,0,291.33,2129.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 40MM COCR SPINE MULTIAXIAL CANNULATED 5.5 ROD",SUP-55840014540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Local Plus",,5107.56,53.5,,3978.14,359.25,3978.14,24,1110.3,8114.82,"percent of total billed charges",
"SPLINT ORTHOPEDIC LARGE 8IN WRIST LEFT BLACK",SUP-A120107,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.46,17.54,"PHCS [10601]",PHCS,,40.92,70,,,,,0,6.8,49.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32X23X12MM CRESCENT SOVEREIGN 12D SMALL PEEK",SUP-7967212,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 34MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ334,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,114,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.88,817.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.5MM KIRSCHNER SMOOTH TIP",SUP-707092502,CDM,C1713,HCPCS,0278,RC,,,both,,,191.40,57.42,"KAISER [10500]",Kaiser,,128.24,67,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP CEMENTED FEMUR COCR HEAD ANTEVERTED LINER",SUP-71703322,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"UHC [10700]","United Healthcare",,15154.02,63.3,,8601.07,8395.67,8601.07,"1 through 10",2784.22,20349,"percent of total billed charges",
"HC Dgtz Gls Mcrscp Cytp Slctv / Add on 88112",PX-311000081,CDM,0830T,CPT,0311,RC,,,both,,,104.00,31.2,"CIGNA [10200]","Cigna Open Access",,59.18,56.9,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MIXEVAC III UNIVERSAL BONE CEMENT HIGH VACUUM SPAT",SUP-0206-015-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,394.59,118.38,"KAISER [10500]",Kaiser,,264.38,67,,,,,0,45.89,335.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SYVEK NT CLSR PATCH HEMOSTATIC STERILE LATEX FREE",SUP-400-09-NT,CDM,S27200284,LOCAL,0272,RC,,,both,,,623.70,187.11,"CIGNA [10200]","Cigna Local Plus",,333.68,53.5,,,,,0,72.54,530.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 30MM 190CM 3MM",SUP-R51003003L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"MULTIPLAN [10600]",Multiplan,,1675.99,85,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC",847,MS-DRG,,,,,,,inpatient,,,63157.72,18947.32,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,8601.74,,"Case rate ($8,114.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,535.18, add-ons for qualifying new technology services are included. If operating cost exceeds $40,574.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,951.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,545.15. The transfer operating threshold is the transfer adjustment factor * $7,535.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.70. The transfer capital threshold is the transfer adjustment factor * $569.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,32625.2,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 7MM 7CM TWIST-IN 3 DAM SIDEPORT LUER LOCK",SUP-AR-6570TDNV,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"UHC [10700]","United Healthcare",,185.04,63.3,,,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 20MM 120CM 7MM VASCULAR PERIPHERAL SELF",SUP-PRB35-07-020-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1592.7,28.62,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO 70CM 8FR 2.9MM GUIDING RAABE",SUP-G11637,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"KAISER [10500]",Kaiser,,298.49,67,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 2-0 CT-1 45CM SUT ABSORBABLE",SUP-ETSXP1A403,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,110.3,45.9,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 3CM 4FR STRAIGHT PANCREATIC PLASTIC TRAIL",SUP-M00536130,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"NOVANET [10819]",Novanet,,479.44,75,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 19MM STRAIGHT CONICAL MODULAR RESTORATION",SUP-6276-7-119,CDM,C1776,HCPCS,0278,RC,,,both,,,11080.37,3324.11,"AETNA [10100]","Aetna HMO/PPO",,8808.89,79.5,,10981.53,8986.79,12413.38,12,1288.65,9418.31,"percent of total billed charges",
"KIT BALLOON DILATATION ARCADIA 15MM STEERABLE LOCK CEMENT",SUP-ARC15SB-LK,CDM,S27200284,LOCAL,0272,RC,,,both,,,17640.00,5292,"AETNA [10100]","Aetna HMO/PPO",,14023.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LOCKING REVOLVE SPINE LUMBAR",SUP-185.000,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"MULTIPLAN [10600]",Multiplan,,2045.61,85,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MELATONIN 3 MG TABLET",RX-16830,CDM,,,0637,RC,20555-0036-00,NDC,both,1,UN,6.27,1.88,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND MICROPOINT 4-0 G-3 18IN 2 ARM BRAID",SUP-783G,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.02,40.21,"FIRST HEALTH [10303]","First Health",,107.22,80,,,,,0,15.59,113.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rh Phenotyping Complete",PX-302000197,CDM,86906,CPT,0302,RC,,,both,,,354.90,106.47,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6.98,,,,,,,0.01,301.67,"fee schedule",
"BOOT CONTRACTURE LARGE ANKLE ANTIROTATION BAR PAD TOE PIECE",SUP-4301D,CDM,L4396,HCPCS,0274,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,132.37,,,,,,,50.59,369.75,"fee schedule",
"SCR BONE 3.5MM 30MM CLAW II ORTHOLOC CORTICAL ANKLE FOOT",SUP-40233530,CDM,C1713,HCPCS,0278,RC,,,both,,,1474.20,442.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,174.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",171.45,1253.07,"percent of total billed charges",
"INTRO SHEATH 9FR .118IN 25CM ROBUST VALVE SPLITTABLE WITHOUT",SUP-PLSX-2509,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR COBRA 2 CURVE ANGIOGRAPHIC VISCERAL",SUP-H787107091085,CDM,C1887,HCPCS,0272,RC,,,both,,,236.64,70.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,97.26,41.1,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR JL6 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389696650,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AETNA [10100]","Aetna HMO/PPO",,291.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINR 90CM 55MM 7FR 2-8-2MM SPACING ELECTROPHYSIOLOGY",SUP-043328M,CDM,C1730,HCPCS,0272,RC,,,both,,,3187.50,956.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1310.06,41.1,,,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.2MM 5MM CORTICAL 4 HANDLE",SUP-A-5100.05/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"UHC [10700]","United Healthcare",,799.86,63.3,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 20MM 7MM BALLOON",SUP-U357572,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE RSP MONOBLOCK REVISION HUMERAL STEM, 220MM, 8X220MM",SUP-510-08-220,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]",Cigna,,5040,40,,5873.17,5873.17,5873.17,"1 through 10",1465.38,10710,"percent of total billed charges",
"PLATE XSHORT 49MM 10 HOLE INTERMEDIATE VARIAX BONE RADIUS",SUP-54-25673,CDM,C1713,HCPCS,0278,RC,,,both,,,6820.79,2046.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3130.74,45.9,,,,,0,793.26,5797.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP GRIPTION PINNACLE STERILE LATEX",SUP-121731048,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1921.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1886.21,13785.68,"percent of total billed charges",
"CATH COYOTE 150CM 80MM 4MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186400810,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 8MM GORE STD WALL HEPARIN PROPATEN PTFE",SUP-H080040A,CDM,C1768,HCPCS,0278,RC,,,both,,,7562.40,2268.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,896.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,879.51,6428.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING PASSIVE FIXATION BIPOLAR DUAL COIL 65CM 17CM",SUP-1570,CDM,C1895,HCPCS,0278,RC,,,both,,,20538.00,6161.4,"BLUE CROSS [10001]","Blue Cross PPO",,8050.9,39.2,,,,,0,2388.57,17457.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM TITANIUM T7 FULL THREAD SELF TAP LOCK",SUP-40-27614,CDM,C1713,HCPCS,0278,RC,,,both,,,1211.11,363.33,"BLUE CROSS [10001]","Blue Cross HMO",,474.76,39.2,,957.42,156.86,7483.26,51,140.85,1029.44,"percent of total billed charges",
"NAIL 10MM 300MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-410-300,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4958.42,28.62,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E FEMUR PATELLA TIBIA INSRT",SUP-98000200118,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"MULTIPLAN [10600]",Multiplan,,20884.5,85,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELUVIA US 6X150 130 CM",SUP-H74939294601510,CDM,C1874,HCPCS,0278,RC,,,both,,,25168.50,7550.55,"BLUE CROSS [10001]","Blue Cross HMO",,9866.05,39.2,,9776.84,9776.84,9776.84,"1 through 10",2927.1,21393.23,"percent of total billed charges",
"BEARING 71/75MMX12MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183642,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1533.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1533.84,11210.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 6MM 18MM TITANIUM FULL THREAD CANCELLOUS SMALL",SUP-406.018,CDM,C1713,HCPCS,0278,RC,,,both,,,294.76,88.43,"KAISER [10500]",Kaiser,,197.49,67,,,,,0,34.28,250.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 45MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.845,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,162.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",159.84,1168.25,"percent of total billed charges",
"CMPNT GLENOID SMALL-R CNCT SCR REVISION SMR TITANIUM",SUP-1374.15.305,CDM,C1776,HCPCS,0278,RC,,,both,,,1555.70,466.71,"MULTIPLAN [10600]",Multiplan,,1322.35,85,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK RETRACTION SHARP NONSTERILE",SUP-319.39,CDM,S27200284,LOCAL,0272,RC,,,both,,,1147.61,344.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 125MM 2MM STAINLESS STEEL QUICK COUPLING",SUP-310.21,CDM,S27000186,LOCAL,0270,RC,,,both,,,519.37,155.81,"AETNA [10100]","Aetna HMO/PPO",,412.9,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.4,441.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 10CM 16GA CURVE SILICONIZE SHARP 10MM",SUP-RFK-C101016VZ-P,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"CIGNA [10200]","Cigna Open Access",,94.06,56.9,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STARTER BENTSON VASCULAR STD TAPER 260CM 15CM .035IN",SUP-M001491481,CDM,C1769,HCPCS,0272,RC,,,both,,,304.50,91.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,125.15,41.1,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM VARIAX T10 FULL THREAD FOOT ANKLE LOCK",SUP-657326,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,176.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,172.92,1263.81,"percent of total billed charges",
"STEM FEMORAL 128MM 12MM PRIMARY PRESS FIT STD OFFSET TAPERED",SUP-00786401200,CDM,C1776,HCPCS,0278,RC,,,both,,,30164.40,9049.32,"PHCS [10601]",PHCS,,21115.08,70,,,,,0,3508.12,25639.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 6.4MM 1.6MM MIDAS REX LEGEND CARBIDE WHEEL",SUP-MC16,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 10X10MM FUSEFORCE HAND STERILE",SUP-FFNS1010,CDM,C1713,HCPCS,0278,RC,,,both,,,5582.10,1674.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1597.6,28.62,,,,,0,649.2,4744.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 8FR .09IN AMPLATZ LEFT .75 CURVE GUIDING NYLON",SUP-LA8AL75,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"FIRST HEALTH [10303]","First Health",,313.2,80,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC 7.5MM MODIFIED ELLIPSE 44.5X47MM ADVANTIO DR",SUP-K063,CDM,C1785,HCPCS,0275,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Open Access",,5778.75,33.5,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X12MM CLYDESDALE PTC 6D PEEK TITANIUM",SUP-4986245,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +20.5 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.205,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross PPO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175263090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"CIGNA [10200]","Cigna Open Access",,756.92,,,,,,,154.71,1130.72,"percent of total billed charges",
"PLATE 101MMX2MM 5 HOLE VARIAX BONE FOOT FIBULA DISTAL",SUP-40-20905,CDM,C1713,HCPCS,0278,RC,,,both,,,4488.59,1346.58,"BLUE CROSS [10001]","Blue Cross HMO",,1759.53,39.2,,957.42,156.86,7483.26,51,522.02,3815.3,"percent of total billed charges",
"NAIL 11MM 36CM RIGHT TROCHANTERIC INTRAMEDULLARY 125D",SUP-456.396S,CDM,C1713,HCPCS,0278,RC,,,both,,,12838.83,3851.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3674.47,28.62,,,,,0,1493.16,10913.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 16CM 11.5FR MAHURKAR 2 LUMEN CURVED EXT",SUP-8830415003,CDM,C1752,HCPCS,0272,RC,,,both,,,651.84,195.55,"MULTIPLAN [10600]",Multiplan,,554.06,85,,,,,0,75.81,554.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L48MM DIA5MM CARBURIZED VARIABLE ANGLE LOCKING SE",SUP-42.231.248,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,160.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",157.3,1149.66,"percent of total billed charges",
"VALVE MITRAL 14.2MM 27/29MM 23.4MM ON-X 34MM CYLINDRICAL",SUP-ONXM-27/29,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"BLUE CROSS [10001]","Blue Cross HMO",,14817.6,39.2,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 NARROW KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502006402,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2709.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 7MMX59MM 7FR 80CMCATH HEPARIN",SUP-BXB075901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"KAISER [10500]",Kaiser,,13068.22,67,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 125CM 5FR JR6 CURVE ANGIOGRAPHIC PEBAX",SUP-7523-83,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.74,23.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ASAHI PROWATERFLEX PTCA GUIDE WIRE 180 CM",SUP-AGH147000,CDM,C1769,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"APPROXIMATOR SURGICAL 16CM 2.5MM QUICKPASS TENDON SHUTTLE",SUP-AR-8090S,CDM,S27200284,LOCAL,0272,RC,,,both,,,722.93,216.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Bk Virus Qpcr CSF 2500",PX-306000154,CDM,87799,CPT,0306,RC,,,both,,,986.10,295.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,38.56,,,,,,,0.99,838.19,"fee schedule",
"PLATE 11MM 1 LEVEL SAPPHIRE BONE SPINE CERVICAL ANTERIOR",SUP-26001-011,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"FIRST HEALTH [10303]","First Health",,3360,80,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN READIGRAFT CRYOSKIN 125SQ CM FIBROBLAST",SUP-SK-NM,CDM,Q4433,HCPCS,0636,RC,,,both,,,2925.15,877.54,"UHC [10700]","United Healthcare",,247.92,,,,,,,247.92,2486.38,"fee schedule",
"BURR SURGICAL 12MM 2MM MICA STERILE",SUP-57SR0212,CDM,S27200284,LOCAL,0272,RC,,,both,,,2580.00,774,"PHCS [10601]",PHCS,,1806,70,,,,,0,300.05,2193,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 26CM 11FR SHORT LENGTH URETERAL",SUP-H7493936110260,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"CIGNA [10200]","Cigna Local Plus",,663.03,,,,,,,144.13,1053.41,"percent of total billed charges",
"SCR BONE 2.5MM 18MM COMPRESSION FT TITANIUM 1.5MM MICRO FULL",SUP-AR-8725-18H,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,751.28,28.62,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 2MM BALLOON DILATATION STERILE LATEX",SUP-582015022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN SCREW 3.2MMX89MM FLUTED DISP",SUP-GS901.089.032-4P,CDM,C1713,HCPCS,0278,RC,,,both,,,605.48,181.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,71.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,70.42,514.66,"percent of total billed charges",
"PLATE XLONG TITANIUM 14 HOLE BONE RIGHT LATERAL EPICONDYLAR",SUP-PL-LEL14R,CDM,C1713,HCPCS,0278,RC,,,both,,,6755.10,2026.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4593.47,68,,,,,0,785.62,5741.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2.5MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-02504,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7033.31,68,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 11MM BABY GORILLA LOCK",SUP-P50-053-2511,CDM,C1713,HCPCS,0278,RC,,,both,,,1316.25,394.87,"BLUE CROSS [10001]","Blue Cross HMO",,515.97,39.2,,957.42,156.86,7483.26,51,153.08,1118.81,"percent of total billed charges",
"SCR BONE EQUINOXE SHOULDER GLENOSPHERE LOCK REVERSE",SUP-320-15-05,CDM,C1713,HCPCS,0278,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 200MM 5MM BALLOON DILATATION DURALYN",SUP-48005020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"FIRST HEALTH [10303]","First Health",,1101.6,80,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Lumb/Thorac",PX-510000145,CDM,64520,CPT,0761,RC,,,both,,,4745.00,1423.5,"AETNA [10100]","Aetna HMO/PPO",,3772.28,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,551.84,4710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ANGIOGRAPHY 65IN 2 LINE TUBING MULTIGUARD CNCT WASTE","SUP-AVA 500 SPAT",CDM,S27000186,LOCAL,0270,RC,,,both,,,309.86,92.96,"KAISER [10500]",Kaiser,,207.61,67,,,,,0,36.04,263.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nrv Condct 7-8 Studies",PX-922000022,CDM,95910,CPT,0922,RC,,,both,,,5376.18,1612.85,"PHCS [10601]",PHCS,,3763.33,70,,,,,0,625.25,4569.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 5FR SAR1 CURVE GUIDING NYLON CORONARY",SUP-LA5SAR10,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ILLMNTR ENDOSCOPIC 8FR PHOTONSABER FRAZIER STD TEARDROP",SUP-PSF08ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,1991.25,597.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1354.05,68,,,,,0,231.58,1692.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 26FR CUT ACMI CLASSIC",SUP-M0068802541,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"CIGNA [10200]","Cigna Local Plus",,255.85,53.5,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 24CM 7FR .035",SUP-M006192142090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"NOVANET [10819]",Novanet,,1119.32,75,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 20MM .038IN AZUR FRAMING ELECTRICAL",SUP-45-652050,CDM,S27800098,LOCAL,0278,RC,,,both,,,9149.40,2744.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1064.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1064.08,7776.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL KNEE 7MM EMPOWR 3D KNEE FEMUR RIGHT PRESS FIT STERILE",SUP-243-02-107,CDM,C1776,HCPCS,0278,RC,,,both,,,27824.45,8347.33,"CIGNA [10200]",Cigna,,11129.78,40,,5873.17,5873.17,5873.17,"1 through 10",3235.98,23650.78,"percent of total billed charges",
"SCR BONE 3MM 20MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0307,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,110.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",110.22,805.55,"percent of total billed charges",
"BAND ANNULOPLASTY 38MM CG FUTURE FLEXIBLE LOW PROFILE EYELET",SUP-638BL38,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH DURAL 3X3IN CLLGN MATRIX DURAMATRIX-ONLAY RESORBABLE",SUP-CDSLM33,CDM,,,0278,RC,,,both,,,6550.03,1965.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,776.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.55,5567.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL DELTA XTEND POROUS SHOULDER",SUP-OSC368700,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"PHCS [10601]",PHCS,,31752,70,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP MONOPOLAR 12.5IN 5MM ULTRA BOTTLE NOSE 2 ACTION DISSECT",SUP-90-1030I,CDM,S27200284,LOCAL,0272,RC,,,both,,,2909.63,872.89,"CIGNA [10200]",Cigna,,1978.55,68,,,,,0,338.39,2473.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 7X 38MM CATH 120CM ENDOVASCULAR",SUP-42738,CDM,C1874,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"NOVANET [10819]",Novanet,,13140.23,75,,,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 CT-2 30IN BRAID GREEN NONABSORBABLE",SUP-X411H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2/0 CARDIOXYL NO PLEDGET 18MM",SUP-73P30T,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"CIGNA [10200]","Cigna Local Plus",,250.26,53.5,,,,,0,54.4,397.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MIXEVAC III SMALL BONE CEMENT SPAT MIXER STERILE",SUP-0206-020-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X18X11MM TRANSCONTINENTAL 10D LORDOTIC",SUP-375.793,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"FIRST HEALTH [10303]","First Health",,19152,80,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 37MMX12MMX20CM 24FR",SUP-TAC123720A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"MULTIPLAN [10600]",Multiplan,,155040,85,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 20MM 120CM 4MM LONG BILIARY NITINOL SELF",SUP-SC420LV,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Local Plus",,2022.3,53.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION SIGMA HIGH PERFORMANCE QUICK DRILL",SUP-950502072,CDM,C1713,HCPCS,0278,RC,,,both,,,1526.85,458.05,"BLUE CROSS [10001]","Blue Cross PPO",,598.53,39.2,,957.42,570.23,957.42,28,177.57,1297.82,"percent of total billed charges",
"PLATE SPINAL 10MM CODA ANTERIOR CERVICAL LEVEL 1 NONSTERILE",SUP-102201010,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,1831.33,1831.33,1831.33,16,521.61,3812.25,"percent of total billed charges",
"CATH RUNWAY 100CM 6FR LEFTBU3.5 CURVE GUIDING PTFE FEMORAL",SUP-H749389697140,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEV TRQ TIP INTRO",SUP-4071,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.30,49.59,"KAISER [10500]",Kaiser,,110.75,67,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +24 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.240,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.00 X 33 RX US",SUP-1804300-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1086.13,28.62,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IRR ENDOSCOPIC 10IN PATHFINDER PLUS BULB UROLOGICAL TUBE",SUP-PA701,CDM,S27200284,LOCAL,0272,RC,,,both,,,344.96,103.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Filter Gas Cobe",PX-E27000110,CDM,E27000110,LOCAL,0270,RC,,,both,,,58.30,17.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL DEBAKEY ANGLE 7.75IN VASCULAR TISSUE 2MM",SUP-55-2015,CDM,S27200284,LOCAL,0272,RC,,,both,,,523.18,156.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL MIDAS REX MR8 2.3MM 7CM TAPER DISSECTING STERILE LATEX",SUP-MR8-F2/7TA23,CDM,S27200284,LOCAL,0272,RC,,,both,,,974.03,292.21,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Topical Skin Adhesive",PX-E27200218,CDM,E27200218,LOCAL,0272,RC,,,both,,,222.42,66.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,102.09,45.9,,,,,0,25.87,189.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM 41.6MM 34MM MITRAL TRICUSPID FLEXIBLE",SUP-460034MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"CIGNA [10200]",Cigna,,7741.8,68,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 28MM 144CM 3.5MM",SUP-H7493941228350,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"KAISER [10500]",Kaiser,,5200.88,67,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840045540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1110.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1110.3,8114.82,"percent of total billed charges",
"STEM FEMORAL 140MM CEMENTLESS SUMMIT DUOFIX 4 12/14 STD",SUP-157002100,CDM,C1776,HCPCS,0278,RC,,,both,,,15590.88,4677.26,"AETNA [10100]","Aetna HMO/PPO",,12394.75,79.5,,10981.53,8986.79,12413.38,12,1813.22,13252.25,"percent of total billed charges",
"ALLOGRAFT FLOWABLE 2.5CC OSTEOAMP SELECT",SUP-OAFL-025,CDM,C1713,HCPCS,0278,RC,,,both,,,7427.64,2228.29,"FIRST HEALTH [10303]","First Health",,5942.11,80,,,,,0,863.83,6313.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR NEROSTIMLTR 46X50MM PRECISION SPECTRA 10.8MM TITANIUM",SUP-SC-1132,CDM,C1820,HCPCS,0278,RC,,,both,,,95760.00,28728,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,38304,40,,,,,0,11136.89,81396,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE 25CM 2.5CM 7FR INTRO STAINLESS STEEL",SUP-RSS705,CDM,C1894,HCPCS,0272,RC,,,both,,,178.35,53.5,"PHCS [10601]",PHCS,,124.85,70,,,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SKATER CHOICE LOCK 20CM 6FR DRNG SLIP-COAT POLYURETHANE",SUP-756606020,CDM,C1729,HCPCS,0272,RC,,,both,,,651.24,195.37,"KAISER [10500]",Kaiser,,436.33,67,,,,,0,75.74,553.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL EIT 8 D L28 MM X W10 MM X H8 MM STERILE LATEX FR",SUP-TUI80828,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X20MM BENGAL 12MM STD LORDOTIC THORACOLUMBAR",SUP-177306120,CDM,S27800098,LOCAL,0278,RC,,,both,,,15950.04,4785.01,"FIRST HEALTH [10303]","First Health",,12760.03,80,,,,,0,1854.99,13557.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 65MM LOW PROFILE SCREWS TITANIUM PARTIAL",SUP-AR-8945-65PT,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 14MM DCP STAINLESS STEEL CORTICAL SELF TAPPING",SUP-201.814,CDM,C1713,HCPCS,0278,RC,,,both,,,358.09,107.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,42.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,41.65,304.38,"percent of total billed charges",
"INSRT TIBIAL 6 19MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P619,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2391.46,28.62,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM STAINLESS STEEL 2MM SCR MINI FRAGMENT SET 6 HOLE",SUP-247.346,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"SCR BONE 4MM 12MM ATLANTIS TITANIUM SPINAL CANCELLOUS",SUP-876-812,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"PATCH SURGICAL 10.1X6.1IN VENTRAL 2 LAYER MONOFILAMENT SELF",SUP-0010219,CDM,C1781,HCPCS,0278,RC,,,both,,,6453.30,1935.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,764.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,750.52,5485.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM",RX-16299,CDM,,,0637,RC,00904-5354-31,NDC,both,28,GR,27.30,8.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,18.56,68,,,,,0,3.17,23.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS SMALL PLUG CRUSHED 10MM",SUP-291086,CDM,S27800098,LOCAL,0278,RC,,,both,,,4805.85,1441.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1375.43,28.62,,,,,0,558.92,4084.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBJR050502A,CDM,C1874,HCPCS,0278,RC,,,both,,,19895.40,5968.62,"CIGNA [10200]","Cigna Local Plus",,6267.05,31.5,,,,,0,2313.84,16911.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ESOPHAGEAL PYLORIC 6FR 18-20MM 180CM 8CM FIXED WIRE",SUP-M00558380,CDM,C1726,HCPCS,0272,RC,,,both,,,1562.98,468.89,"FIRST HEALTH [10303]","First Health",,1250.38,80,,,,,0,181.77,1328.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL CLEAR 2.8MM CLEARCUT HP2 CUT ANGLED SLIT HP2",SUP-8065982865,CDM,S27200284,LOCAL,0272,RC,,,both,,,288.93,86.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,34.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.6,245.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 8FR L28CM FIRM TRI LAYER DESIGN RAW COLORANT",SUP-M0061902440,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE IRRIGATION ELITE 12CM",SUP-5407-010-470,CDM,S27200284,LOCAL,0272,RC,,,both,,,585.74,175.72,"MULTIPLAN [10600]",Multiplan,,497.88,85,,,,,0,68.12,497.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 20MM 144CM 3MM CORONARY STENT",SUP-H7493952820300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"NOVANET [10819]",Novanet,,4173.75,75,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 10X42X32MM 15 DEGREE",SUP-1921087P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13860,40,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM TARGET NANO HELICAL DETACHABLE",SUP-M0035431010,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"CIGNA [10200]",Cigna,,6227.22,68,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drsg Wound Mextra Hydro",PX-HHE27200400,CDM,HHE27200400,LOCAL,0272,RC,,,outpatient,,,35.00,10.5,"NOVANET [10819]",Novanet,,26.25,75,,,,,0,4.07,29.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 300MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020300S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"PHCS [10601]",PHCS,,1116.99,70,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE",RX-27631,CDM,,,0637,RC,68084-0313-11,NDC,both,1,UN,7.14,2.14,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEET TRANSFER 77X60IN MAXISLIDE FLITES PREMIUM LATEX FREE",SUP-NPAV5000,CDM,S27000186,LOCAL,0270,RC,,,both,,,203.06,60.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BNDG PASTE LATEX FREE E MOTION",SUP-60648,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.92,28.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TAP 6.5MM CANNULATED REVOLVE SURGICAL SPINE GLOB",SUP-685.065,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 1.5MM 4MM APTUS TITANIUM 4 CORTICAL HEXADRIVE",SUP-A-5200.04/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL LOOP 27FR CUT STORZ 2 STEM",SUP-M0068802241,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL URETERAL HYDROPLUS 70CM 16FR STERILE",SUP-M0062401150,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.52,130.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LAMOTRIGINE 25 MG TABLET",RX-13981,CDM,,,0637,RC,00904-7007-61,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 100CM 5FR STRAIGHT ANGIOGRAPHIC POLYETHYLENE PERIPHERAL",SUP-G00159,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.19,73.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT SURGICAL OSTEOCOOL BONE ACCESS 8GA",SUP-OCN003,CDM,S27200284,LOCAL,0272,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BASEPLT 38MM 4.5MM AEQUALIS SHOULDER TITANIUM LOCK",SUP-DWD038,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1058.08,68,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE COROLENE 6-0 3/8X10 MM",SUP-20S07B,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.94,20.08,"CIGNA [10200]",Cigna,,45.52,68,,,,,0,7.79,56.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM LOW PROFILE NONLOCK HEXALOBE",SUP-3025-35022,CDM,C1713,HCPCS,0278,RC,,,both,,,988.20,296.46,"FIRST HEALTH [10303]","First Health",,790.56,80,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JEIL POWER DRIVER, SINGLE USE",SUP-111-ED-050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL GREEN 4.7MM SQUARE CANNULATED",SUP-CSS07247SQ,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC RIVACOR 1 CHMBR DF-4 CNCT LATEX FREE VRT",SUP-429536,CDM,C1722,HCPCS,0278,RC,,,both,,,56385.00,16915.5,"UHC [10700]","United Healthcare",,35691.71,63.3,,,,,0,6557.58,47927.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SENTAI SAMURAI RC VASCULAR 190CM 24CM .014IN STAINLESS",SUP-H749393061902,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Arm/Hnd Rt",PX-510000099,CDM,29584,CPT,0761,RC,,,both,,,891.00,267.3,"AETNA [10100]","Aetna HMO/PPO",,708.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,891,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 100MM 14MM NEXGEN FEMORAL KNEE TIVANIUM EXT",SUP-00598801014,CDM,C1776,HCPCS,0278,RC,,,both,,,4909.80,1472.94,"BLUE CROSS [10001]","Blue Cross PPO",,1924.64,39.2,,3949.44,3949.44,3949.44,"1 through 10",571.01,4173.33,"percent of total billed charges",
"CMPNT PATELLAR BICONVEX 26MM GENESIS II KNEE",SUP-71420568,CDM,C1776,HCPCS,0278,RC,,,both,,,6344.55,1903.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,751.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,737.87,5392.87,"percent of total billed charges",
"STENT CONTOUR 26CM 150CM 6FR .038IN STD STRAIGHT LOW PROFILE",SUP-M006180523170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]",Cigna,,837.05,68,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 7CM 5FR PIGTAIL CURVE PANCREATIC",SUP-M00537420,CDM,C2625,HCPCS,0278,RC,,,both,,,1411.18,423.35,"PHCS [10601]",PHCS,,987.83,70,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 6MM CEREPAK XTRASOFT FREEFORM",SUP-XCR120610,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS [10001]","Blue Cross PPO",,5184.53,39.2,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 34MM 17FR AFX ACTIVESEAL STRATA STRAIGHT",SUP-A34-34/C80-O20,CDM,C1874,HCPCS,0278,RC,,,both,,,28721.70,8616.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3403.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3340.33,24413.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS SOLN 4.25 % DEX LOW CA+ 2.5 MEQ/L-MG 0.5 MEQ/L",RX-27804,CDM,,,0250,RC,00941-0459-01,NDC,both,6000,ML,301.80,90.54,"AETNA [10100]","Aetna HMO/PPO",,239.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.1,256.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX10MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183640,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1533.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1533.84,11210.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 20MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDS32520,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA [10200]",Cigna,,33209.89,40,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB SKIN 20X20CM STRATTICE PORCINE DERMAL MATRIX FIRM PATCH",SUP-2020000,CDM,Q4130,HCPCS,0636,RC,,,both,,,60309.90,18092.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26988.68,44.75,,,,,0,7146.72,51263.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 26MM TRI-AD 2 ADAM TRICUSPID VALVE MODEL",SUP-900SFC226,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UHC [10700]","United Healthcare",,8298.63,63.3,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 6.5MM CANNULATED BONE CREO MIS",SUP-6134.0065,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,267.69,45.9,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS HIGHFLOW 100CM 7FR JL3.5 CURVE ANGIOGRAPHIC",SUP-527718,CDM,C1887,HCPCS,0272,RC,,,both,,,137.11,41.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,93.23,68,,,,,0,15.95,116.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP070120150 PLUS US D7L120UL1500",SUP-PCP070120150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) QUALIBREATH  SIZE M",SUP-QB-M,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) BOOSTER AND SUPPORT PLATE (BOOSTER KIT)",SUP-VSU05803,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTW TAKERU PTCA BALLOON 1.50MM X 15MM",SUP-DC-PY1515UA1,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL 6 19MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P619,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"NOVANET [10819]",Novanet,,6266.93,75,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650607,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"MULTIPLAN [10600]",Multiplan,,11158.16,85,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RCRD CARDIAC REVEAL DX INSERTABLE AUTOMATICALLY ACTIVATED",SUP-9529,CDM,C1764,HCPCS,0278,RC,,,both,,,20884.50,6265.35,"CIGNA [10200]","Cigna Open Access",,6996.31,33.5,,,,,0,2428.87,17751.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Angio Iliac Arty W Cath",PX-323000037,CDM,G0278,HCPCS,0323,RC,,,both,,,3229.72,968.92,"PHCS [10601]",PHCS,,2260.8,70,,,,,0,375.62,2745.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRA DP 2.5MM STD 110CM 15CM 8FR 6.4MM SHUNT",SUP-907122,CDM,S27800098,LOCAL,0278,RC,,,both,,,7886.70,2366.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,917.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,917.22,6703.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION",RX-175466,CDM,,,0250,RC,00781-3269-71,NDC,both,1,ML,371.82,111.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,170.67,45.9,,,,,0,43.24,316.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION",RX-111437,CDM,J3424,HCPCS,0636,RC,50633-0310-11,NDC,both,1,UN,6325.73,1897.72,"PHCS [10601]",PHCS,,4428.01,70,,,,,0,749.6,5376.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Splint Leg Full Pneu Prefb Ots",PX-E27400061,CDM,L4370,HCPCS,0274,RC,,,both,,,1683.00,504.9,"CIGNA [10200]","Cigna Open Access",,957.63,56.9,,,,,0,138.46,1430.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE BREAST STYLE 410 690CC STERILE LATEX",SUP-MSZFX690,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNR SNS PLPCTM HEX SHRTHRW MED",SUP-6034,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,170.52,39.2,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS ZIPWIRE 30CM 3CM 7FR .038IN PIGTAIL CURVE",SUP-M0061265450,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,165.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SCR 32MM 6.35MM TSRH-3D SHORT POST POSTERIOR PEDICLE",SUP-8281246,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"KAISER [10500]",Kaiser,,233.16,67,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 11MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P311,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"PHCS [10601]",PHCS,,5849.13,70,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH 1 55CM 6FR .07IN HOCKEY STICK CURVE GUIDING PTFE",SUP-M001196000,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"AETNA [10100]","Aetna HMO/PPO",,474.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)MARKER SKIN PINK 10CM 15GA SMARTCLIP LITE 3-4MM SOFT T",SUP-SMARTCLIPLT-PNK-10,CDM,A4648,HCPCS,0278,RC,,,both,,,2625.00,787.5,"BLUE CROSS [10001]","Blue Cross PPO",,1029,39.2,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +28 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-AR40E00280,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"MULTIPLAN [10600]",Multiplan,,791.78,85,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 140MM 120CM 16MM .035IN VASCULAR VENOUS CATH",SUP-VENUL16140,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"MULTIPLAN [10600]",Multiplan,,19813.5,85,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 3.5MM STEALTH FRR SURGICAL STERILE LATEX FREE",SUP-SC9248,CDM,S27200284,LOCAL,0272,RC,,,both,,,1044.90,313.47,"MULTIPLAN [10600]",Multiplan,,888.17,85,,,,,0,121.52,888.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Multlayer Comprsn Arm/Hnd Lt (Go)",PX-510000096,CDM,29584,CPT,0761,RC,,,both,,,891.00,267.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,891,,"Case rate ($1,729.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,103.62,891,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION COMPLETE CARE ADD-A-FOLEY STATLOCK 2L",SUP-399400A,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.39,22.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,51.95,68,,,,,0,8.88,64.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE LEFT POSTERIOR STABILIZE CEMENT ATTUNE",SUP-150410102,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"PHCS [10601]",PHCS,,15675.35,70,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 13MM CUFF LOW PRESSURE SHILEY TRACH 10 LATEX FREE",SUP-10LPC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1040.12,312.04,"CIGNA [10200]","Cigna Open Access",,591.83,56.9,,,,,0,120.97,884.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 28MM GLENOID LOCK MODULAR",SUP-AR-9563-28,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"FIRST HEALTH [10303]","First Health",,477.9,80,,,,,0,69.48,507.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE RELINE C SPINE OPEN LOCK NONSTERILE LATEX FREE",SUP-3900240,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"BLUE CROSS [10001]","Blue Cross HMO",,136.42,39.2,,957.42,156.86,7483.26,51,40.47,295.8,"percent of total billed charges",
"STAPLE BONE 20X20MM JAWS STRAIGHT NITINOL",SUP-P71-020-2020-S,CDM,C1713,HCPCS,0278,RC,,,both,,,8952.75,2685.82,"CIGNA [10200]","Cigna Local Plus",,4789.72,53.5,,3978.14,359.25,3978.14,24,1041.2,7609.84,"percent of total billed charges",
"FILLER BONE VOID 50X25MM KINEX THK4MM BIOACTIVE STRIP 5CC",SUP-8115.0005S,CDM,C1713,HCPCS,0278,RC,,,both,,,5589.00,1676.7,"AETNA [10100]","Aetna HMO/PPO",,4443.26,79.5,,1521.93,481.35,16760.95,30,650,4750.65,"percent of total billed charges",
"CATH EXPEL TWIST-LOC 25CM 12FR NEPHRSTMY FLEXITHANE METAL",SUP-H7493934112250,CDM,C1729,HCPCS,0272,RC,,,both,,,826.20,247.86,"FIRST HEALTH [10303]","First Health",,660.96,80,,,,,0,96.09,702.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.9MM VERTEX STERILE DISPOSABLE",SUP-NAV2076,CDM,S27200284,LOCAL,0272,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,2846.25,2846.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 6.5IN HENLY WEITLANER 3 CENTER BLADE MODIFY BLUNT",SUP-55-9050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1913.63,574.09,"AETNA [10100]","Aetna HMO/PPO",,1521.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,222.56,1626.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD .99CM 5.37X8.08CM",SUP-G138,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6839.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71MMX12MM VANGUARD E1 KNEE ANTERIOR STABILIZE TIBIAL",SUP-EP189062,CDM,C1776,HCPCS,0278,RC,,,both,,,13372.20,4011.66,"UHC [10700]","United Healthcare",,8464.6,63.3,,8601.07,8395.67,8601.07,"1 through 10",1555.19,11366.37,"percent of total billed charges",
"CATH SPYSCOPE DSII DIGITAL ACCESS",SUP-M00546610,CDM,S27200284,LOCAL,0272,RC,,,both,,,16905.00,5071.5,"UHC [10700]","United Healthcare",,10700.87,63.3,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BIO DBM PUTTY DEMINERALIZED BONE MATRIX 5CC",SUP-7775005,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECT 125CM 90CM 6FR BERENSTEIN CURVE DELIVERY SYSTEM",SUP-BMX9690BER125,CDM,S27200284,LOCAL,0272,RC,,,both,,,6727.50,2018.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3087.92,45.9,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14 EXTREME LATERAL INTERBODY FUSION 4 HOLE DECADE BONE",SUP-7140414,CDM,C1713,HCPCS,0278,RC,,,both,,,13800.00,4140,"BLUE CROSS [10001]","Blue Cross PPO",,5409.6,39.2,,957.42,570.23,957.42,28,1604.94,11730,"percent of total billed charges",
"PLATE 75MM STAINLESS STEEL 2.4MM SCREWS 6X2 HOLE 2 COLUMN",SUP-02.111.651,CDM,C1713,HCPCS,0278,RC,,,both,,,4196.93,1259.08,"CIGNA [10200]","Cigna Local Plus",,2245.36,53.5,,3978.14,359.25,3978.14,24,488.1,3567.39,"percent of total billed charges",
"SCR BONE 3MM 34MM QUICKFIX TITANIUM T10 PARTIAL THREAD",SUP-AR-8730-34PT,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL SPINAL 34X24X8MM BASE 10 TITANIUM NONSTERILE",SUP-6951810,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13710.24,40,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LOCKING REVOLVE SPINE LUMBAR",SUP-185.000,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"KAISER [10500]",Kaiser,,1612.42,67,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR WHITE 50MM 28MM RINGLOC BIO-MOORE II HIP",SUP-11165224,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"CIGNA [10200]",Cigna,,4528.72,68,,5873.17,5873.17,5873.17,"1 through 10",774.54,5660.9,"percent of total billed charges",
"FRCP ELECTROSURGICAL 8.25INX1.5MM OLSEN BIPOLAR BAYONET",SUP-20-0431R,CDM,S27200284,LOCAL,0272,RC,,,both,,,843.15,252.94,"MULTIPLAN [10600]",Multiplan,,716.68,85,,,,,0,98.06,716.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA MEDIAL CONGRUENT 8-11 G-H",SUP-42512100913,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Local Plus",,5765.38,53.5,,5372.07,4581.20,7242.98,23,1253.3,9159.96,"percent of total billed charges",
"CATH VISTA BRITE TIP IG 55CM 8FR RENAL CURVE GUIDING",SUP-4038553A,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.35,161.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,220.85,41.1,,,,,0,62.49,456.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 7MMX39MM 7FR 80CMCATH HEPARIN",SUP-BXB073901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"AETNA [10100]","Aetna HMO/PPO",,15506.32,79.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 11X11X7MM CORNERSTONE PSR PEEK LUMBAR",SUP-6276711,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA [10200]",Cigna,,4541.33,68,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 26MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-126,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,6417.48,6417.48,6417.48,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"SCR BONE 2.7MM 18MM VARIAX T8 FULL THREAD NONSTERILE",SUP-656418,CDM,C1713,HCPCS,0278,RC,,,both,,,779.22,233.77,"NOVANET [10819]",Novanet,,584.42,75,,,,,0,90.62,662.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ 110CM 5FR PULMONARY ARTERY 2 LUMEN MNTR",SUP-110F5,CDM,C1751,HCPCS,0272,RC,,,both,,,731.84,219.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,300.79,41.1,,,,,0,85.11,622.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Foramen Sngl Bi",PX-510000125,CDM,64479,CPT,0761,RC,,,both,,,7036.15,2110.84,"PHCS [10601]",PHCS,,4710,,"Case rate ($4,710). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,818.3,5980.73,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH SAFESHEATH HO CURVE 60CM 7FR",SUP-WORLEY/B-60-07-HO,CDM,C1893,HCPCS,0272,RC,,,both,,,3345.00,1003.5,"AETNA [10100]","Aetna HMO/PPO",,2659.28,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,389.02,2843.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CM 6MM HEMODIALYSIS ACCESS VECTRA THK",SUP-T6050001,CDM,C1768,HCPCS,0278,RC,,,both,,,4684.26,1405.28,"FIRST HEALTH [10303]","First Health",,3747.41,80,,,,,0,544.78,3981.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 15X8IN OVITEX PRS CONTOUR OVINE POLYGLYCOLIC",SUP-R20252-0815G,CDM,C1781,HCPCS,0278,RC,,,both,,,13524.00,4057.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1572.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1572.84,11495.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE RTRCTR 77MM RIBBON MALLEABLE FLAT",SUP-MB947R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1639.28,491.78,"PHCS [10601]",PHCS,,1147.5,70,,,,,0,190.65,1393.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AIRWAY 4-7MM ENDOBRONCHIAL ZEPHYR",SUP-EBV-TS-4.0,CDM,S27800098,LOCAL,0278,RC,,,both,,,17112.00,5133.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4897.45,28.62,,,,,0,1990.13,14545.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE STAINLESS STEEL T15 2 PART CONNECT STARDRIVE",SUP-02.120.606,CDM,C1713,HCPCS,0278,RC,,,both,,,1192.32,357.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,547.27,45.9,,,,,0,138.67,1013.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 100CM 25CM 5FR .047IN",SUP-CG511,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rubeola Ab",PX-302000162,CDM,86765,CPT,0302,RC,,,both,,,265.05,79.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,225.29,"per diem",
"GRAFT BONE CARTIFORM 25X20MM",SUP-ABS-1102-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS [10001]","Blue Cross HMO",,24578.4,39.2,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL IHF 1.4MM",SUP-DRLL-IHF-14,CDM,S27000186,LOCAL,0270,RC,,,both,,,996.30,298.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,677.48,68,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 20CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061802400,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"KAISER [10500]",Kaiser,,604.46,67,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTIGRAFT CERVICAL LARGE PARALLEL 14X14.5X8MM",SUP-VG2C-DR8P,CDM,S27800098,LOCAL,0278,RC,,,both,,,6077.73,1823.32,"NOVANET [10819]",Novanet,,4558.3,75,,,,,0,706.84,5166.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X10MM COROENT 10D XL+ PEEK NONSTERILE LATEX",SUP-6310855,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALL THERAPEUTIC SMALL SPHERE HAND FOREARM WRIST METAL",SUP-A83720,CDM,S27000186,LOCAL,0270,RC,,,both,,,151.90,45.57,"NOVANET [10819]",Novanet,,113.93,75,,,,,0,17.67,129.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 15CM FINE ASPIRATION CM MARK COLOR CODED HUB",SUP-MSPN2006,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"CIGNA [10200]","Cigna Local Plus",,66.09,53.5,,,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RANGER 135CM 40MM 4MM BALLOON DILATATION PACLITAXEL OTW",SUP-H74939419400410,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3544.88,41.1,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest Lumb/Sac Facet Jnt",PX-510000155,CDM,64635,CPT,0761,RC,,,both,,,3281.00,984.3,"PHCS [10601]",PHCS,,2296.7,70,,,,,0,381.58,3281,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 75MM 8MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR081501A,CDM,C1874,HCPCS,0278,RC,,,both,,,21577.50,6473.25,"FIRST HEALTH [10303]","First Health",,17262,80,,,,,0,2509.46,18340.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 27MM CARPENTIER-EDWARDS PERIMOUNT MAGNA HEART",SUP-7300TFX27MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,62370.00,18711,"FIRST HEALTH [10303]","First Health",,49896,80,,,,,0,7253.63,53014.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 4CM WITHOUT GWIRE DIL RADIOPAQUE MARKER",SUP-RSB605H,CDM,C1894,HCPCS,0272,RC,,,both,,,217.50,65.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 44MM GLENOID SCR RSP",SUP-508-44-101,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"KAISER [10500]",Kaiser,,8169.44,67,,,,,0,1418.07,10364.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANSTR WOUND DRNG ABTHERA 1X LARGE NEGATIVE PRESSURE",SUP-370620.S,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.00,26.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,39.93,45.9,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.225 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.225,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 12MM STAINLESS STEEL T4 CORTEX SELF TAP",SUP-02.214.112,CDM,C1713,HCPCS,0278,RC,,,both,,,418.99,125.7,"CIGNA [10200]",Cigna,,284.91,68,,1831.33,1831.33,1831.33,16,48.73,356.14,"percent of total billed charges",
"IN.PACT 018 5.0 MM X 80 MM X 130 CM",SUP-IPU05008013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"KAISER [10500]",Kaiser,,5408.91,67,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SURGICAL XLONG FIRST FRACTURE CANN",SUP-2003,CDM,S27200284,LOCAL,0272,RC,,,both,,,21105.00,6331.5,"MULTIPLAN [10600]",Multiplan,,17939.25,85,,,,,0,2454.51,17939.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE 1%-EPI 1:100,000 BUFFERED WITH SOD BICARB (3 ML) INJ SYRINGE",RX-124329,CDM,,,0250,RC,70092-1663-43,NDC,both,3,ML,77.92,23.38,"NOVANET [10819]",Novanet,,58.44,75,,,,,0,9.06,66.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB SUBPCL #5/6X10MM",SUP-2142-1-5610,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2422.5,68,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE FLOPPY II VASCULAR STRAIGHT 190CM 2CM .014IN",SUP-22339H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Neck/Soft Tiss W/WO Cntrst",PX-351000013,CDM,70492,CPT,0351,RC,,,both,,,3189.70,956.91,"CIGNA [10200]",Cigna,,567,,"Per diem ($567). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,370.96,2711.25,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SAPIEN M3 VALVE 29MM",SUP-9680TFX29M,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"KAISER [10500]",Kaiser,,133665,67,,,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOPPLER FETAL DOPPLEX 2MHZ PROBE",SUP-FD1-P-USA,CDM,S27200284,LOCAL,0272,RC,,,both,,,3684.75,1105.42,"CIGNA [10200]","Cigna Local Plus",,1971.34,53.5,,,,,0,428.54,3132.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM RELINE-O SPINE POLYAXIAL TRACTION",SUP-13117535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 195MM STAINLESS STEEL 4.5MM SCR 8 HOLE 4 COLUMN",SUP-02.124.408,CDM,C1713,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"UHC [10700]","United Healthcare",,6333.17,63.3,,5023.51,2672.93,6679.78,18,1163.58,8504.25,"percent of total billed charges",
"OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC",316,MS-DRG,,,,,,,inpatient,,,30036.29,9010.89,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,4358.04,,"Case rate ($4,231.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,928.87, add-ons for qualifying new technology services are included. If operating cost exceeds $36,968.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,679.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,934.07. The transfer operating threshold is the transfer adjustment factor * $3,928.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.04. The transfer capital threshold is the transfer adjustment factor * $297.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4231.11,17010.89,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.115,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL CRYOABLATION 17.5CM 14GA ICEFORCE 2.1CX 90D DISTAL SHAFT",SUP-FPRPR3602,CDM,C2618,HCPCS,0272,RC,,,both,,,13110.00,3933,"PHCS [10601]",PHCS,,9177,70,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 100MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015100S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,166.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE FIBER OPTIC 8FT RELIEVA LUMA LIGHT GUIDE",SUP-SIS-LGC08,CDM,S27200284,LOCAL,0272,RC,,,both,,,3217.50,965.25,"CIGNA [10200]",Cigna,,2187.9,68,,,,,0,374.2,2734.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORONARY BYPASS WITH PTCA WITH MCC",231,MS-DRG,,,,,,,inpatient,,,498969.17,149690.75,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,55428.65,,"Case rate ($52,291.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $48,555.91, add-ons for qualifying new technology services are included. If operating cost exceeds $81,595.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $5,053.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $48,620.12. The transfer operating threshold is the transfer adjustment factor * $48,555.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,671.06. The transfer capital threshold is the transfer adjustment factor * $3,671.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,52291.18,246119.36,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL 8 MHZ ADPTR STERILE DISPOSABLE",SUP-VDP-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,963.90,289.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,114.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 12MM ANKLE CORTICAL NONSTERILE",SUP-TRX2.3-12,CDM,C1713,HCPCS,0278,RC,,,both,,,729.00,218.7,"MULTIPLAN [10600]",Multiplan,,619.65,85,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENTETATE INDIUM DISODIUM IN-111 INTRATHECAL SOLUTION (1-1.5 MCI)",RX-411849,CDM,A9548,HCPCS,0343,RC,08888-8877-99,NDC,both,1,UN,13114.64,3934.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3096.15,,,,,,,1525.23,11147.44,"fee schedule",
"ESPRIT BTK 3.00 X 38 MM  RX FDA",SUP-1203300-38,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Open Access",,5778.75,33.5,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 2CM 7FR .035IN BILIARY POLYETHYLENE TAPER",SUP-G22392,CDM,C2617,HCPCS,0278,RC,,,both,,,729.00,218.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEMLESS SHOULDER",SUP-PHC-CONV,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8113.77,28.62,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 23MM 2.75MM CORONARY STENT COCR",SUP-1007847-23,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 18MM 48MM SHOULDER SIMPLICITI",SUP-7122872,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4117.81,41.1,,6417.48,6417.48,6417.48,"1 through 10",1165.21,8516.15,"percent of total billed charges",
"CATH CHRG 135CM 150MM 5FR 4MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-04151,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 FLEXOR 80MM 125CM 4MM 7FR BILIARY NITINOL",SUP-G36047,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"PHCS [10601]",PHCS,,2925.3,70,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC",963,MS-DRG,,,,,,,inpatient,,,88505.50,26551.65,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,17721.04,,"Case rate ($16,957.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $15,746.59, add-ons for qualifying new technology services are included. If operating cost exceeds $48,786.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,572.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,767.41. The transfer operating threshold is the transfer adjustment factor * $15,746.59 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,190.52. The transfer capital threshold is the transfer adjustment factor * $1,190.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,10994,68178.24,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 32X6.3MM THK.8MM STERNUM STERILE LATEX FREE",SUP-0298-097-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,184.70,55.41,"MULTIPLAN [10600]",Multiplan,,157,85,,,,,0,21.48,157,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOR SKIN DISORDERS WITHOUT MCC",607,MS-DRG,,,,,,,inpatient,,,26723.16,8016.95,"BLUE CROSS [10001]","Blue Cross HMO",,20808.03,,,,,,,5622.45,22604.71,"case rate",
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 6MM",SUP-SPL40006X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PREGABALIN 50 MG CAPSULE",RX-42163,CDM,,,0637,RC,60687-0484-11,NDC,both,1,UN,14.51,4.35,"FIRST HEALTH [10303]","First Health",,11.61,80,,,,,0,1.69,12.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X11X10MM ALLOCRAFT 5D LORDOSIS CORTICAL",SUP-6183-7-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 3DEMIN ALLOGRAFT BOAT PLIABLE OSTEOCONDUCTIVE",SUP-109785,CDM,C1713,HCPCS,0278,RC,,,both,,,16422.00,4926.6,"CIGNA [10200]",Cigna,,6568.8,40,,1831.33,1831.33,1831.33,16,1909.88,13958.7,"percent of total billed charges",
"CATH CORDIS SABER 90CM 20MM 4MM BALLOON DILATATION DURALYN",SUP-48004002S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +24.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030245,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Analysis Antitachy Pcmkr Sys",PX-480000064,CDM,93724,CPT,0480,RC,,,both,,,367.00,110.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.68,367,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 40MM 9MM BALLOON",SUP-U357594,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER DELIVERY MULTIPURPOSE SSPC",SUP-9182,CDM,C1887,HCPCS,0272,RC,,,both,,,3375.00,1012.5,"NOVANET [10819]",Novanet,,2531.25,75,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 90CM 220MM 3MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186302290,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM VARIAX TITANIUM ELBOW SELF TAPPING",SUP-614716,CDM,C1713,HCPCS,0278,RC,,,both,,,1023.92,307.18,"BLUE CROSS [10001]","Blue Cross PPO",,401.38,39.2,,957.42,570.23,957.42,28,119.08,870.33,"percent of total billed charges",
"VALVE AORTIC 11.3MM 23.5MM ATS OPEN PIVOT AP360 STD TITANIUM",SUP-500FA23,CDM,S27800098,LOCAL,0278,RC,,,both,,,25011.00,7503.3,"NOVANET [10819]",Novanet,,18758.25,75,,,,,0,2908.78,21259.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 15MM 135CM 6MM 3.6-3.3FR 6FR LOW",SUP-1011499-15,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"AMERIGROUP MEDICAID [20100]",Amerigroup,,746.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 4-0 RB-1 27IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y214H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIPHERAL CUTTING BALLOON 135CM 20MM 5MM BALLOON",SUP-M001PCB50201350,CDM,C1725,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"KAISER [10500]",Kaiser,,3120.53,67,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE SURGICEL NU-KNIT LATEX FREE STERILE",SUP-1943S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1487.17,446.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,172.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,172.96,1264.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP INSRT TIBIAL KNEE OXINIUM BICRUCIATE STABILIZE CONSTRUCT",SUP-71709010,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]",Cigna,,8820,40,,5873.17,5873.17,5873.17,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"PLATE 25MM TITANIUM LOCK TRANSLATIONAL ATLANTIS BONE SPINE",SUP-6190025,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,1831.33,1831.33,1831.33,16,521.61,3812.25,"percent of total billed charges",
"SCR BONE 8.5MM 50MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75448550,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COHERE XL 8X18X60MM 10°",SUP-8180860P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63/67MMX10MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183520,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3707.06,28.62,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 13MM CONDYLAR STABILIZE BEARING TRIATHLON",SUP-5531-G-313-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"BLUE CROSS [10001]","Blue Cross PPO",,4717.17,39.2,,3949.44,3949.44,3949.44,"1 through 10",1399.51,10228.56,"percent of total billed charges",
"METOPROLOL TARTRATE (10 MG/ML) ORAL SUSPENSION",RX-408544,CDM,,,0637,RC,08888-8886-43,NDC,both,1,ML,12.54,3.76,"KAISER [10500]",Kaiser,,8.4,67,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60MM TITANIUM XTHICK VASCULAR ARTICULATING",SUP-SIG60AXT,CDM,S27200284,LOCAL,0272,RC,,,both,,,1919.18,575.75,"FIRST HEALTH [10303]","First Health",,1535.34,80,,,,,0,223.2,1631.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTAPRO 135CM .58IN 2.38MM ATHERECTOMY PRECONNECT BURR",SUP-H749394672380,CDM,C1724,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"FIRST HEALTH [10303]","First Health",,10764,80,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 10MM .0135IN AXIUM PRIME 3D FRAME",SUP-FC-10-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"CIGNA [10200]","Cigna Open Access",,5536.04,33.5,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MICROPOINT 9-0 TG140-8 6IN 2 ARM MONOFILAMENT",SUP-1754G,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.81,61.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,83.77,41.1,,,,,0,23.7,173.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG LEAD BLIND BS IS4",SUP-403724,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"CIGNA [10200]","Cigna Open Access",,198.01,56.9,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR VIVACIT-E KK 56MM 40MM HIP NEUTRAL",SUP-00885101240,CDM,C1776,HCPCS,0278,RC,,,both,,,7996.80,2399.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,947.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,930.03,6797.28,"percent of total billed charges",
"CATH MUSTANG 75CM 20MM 4MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171040270,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 20X16CM GENTRIX THICK PORCINE",SUP-PSMT1620,CDM,C1781,HCPCS,0278,RC,,,both,,,57153.60,17146.08,"CIGNA [10200]","Cigna Local Plus",,18003.38,31.5,,3096.73,1.00,3096.73,"1 through 10",6646.96,48580.56,"percent of total billed charges",
"CATH EMERGE MONORAIL 144CM 15MM 6FR 4MM .07IN BALLOON",SUP-H7493918915400,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 SH 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP864D,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.64,38.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.08,110.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 60MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.060,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,24.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,24,175.41,"percent of total billed charges",
"COIL EMBOLIZATION 15CM 7MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS07015,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]",Cigna,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL TAKAHASHI STRAIGHT 7.25IN 2.5-8MM NASAL SHAFT",SUP-63-2020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1132.54,339.76,"FIRST HEALTH [10303]","First Health",,906.03,80,,,,,0,131.71,962.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM 1.7-2.4FR .017IN",SUP-M003C1715900,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,914.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,897.75,6561.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 40MM 7MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171070410,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,482.72,41.1,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 100MM 2MM BALLOON DILATATION STERILE LATEX",SUP-592010022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"PHCS [10601]",PHCS,,935.55,70,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 24CM 3CM 7FR .035IN 2",SUP-M006192142180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"FIRST HEALTH [10303]","First Health",,1271.9,80,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 100MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171081010,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AETNA [10100]","Aetna HMO/PPO",,933.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PLASMABUTTON RESECTION LOOP NDL",SUP-WA22657S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3062.33,918.7,"AETNA [10100]","Aetna HMO/PPO",,2434.55,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,356.15,2602.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE VASCULAR STRAIGHT 180CM 3CM .018IN",SUP-GR1803,CDM,C1769,HCPCS,0272,RC,,,both,,,461.70,138.51,"NOVANET [10819]",Novanet,,346.28,75,,,,,0,53.7,392.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 10MM VUEPOINT II SPINE MULTIAXIAL NONSTERILE",SUP-8975410,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AETNA [10100]","Aetna HMO/PPO",,3017.03,79.5,,1521.93,481.35,16760.95,30,441.36,3225.75,"percent of total billed charges",
"CATH JADE 150CM 80MM 4MM BALLOON DILATATION STERILE LATEX",SUP-584008022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,615.88,41.1,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"NOVANET [10819]",Novanet,,9832.5,75,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8MM 50MM MATRIX TITANIUM SPINE CANNULATED POLYAXIAL",SUP-04.606.850,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC",033,MS-DRG,,,,,,,inpatient,,,107987.96,32396.39,"UHC [10700]","United Healthcare",,48550.03,,"Fee schedule rate ($48,550.03). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,48550.03,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC",167,MS-DRG,,,,,,,inpatient,,,80029.55,24008.86,"AETNA [10100]","Aetna HMO/PPO",,33930.97,,"Fee schedule rate ($33,930.97). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,52652.07,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 16MM 140CM 4MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927416400,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 110MM 3.5MM RAD 90 90D FRONTAL SINUS RADIAL",SUP-1883519HR,CDM,S27200284,LOCAL,0272,RC,,,both,,,2615.00,784.5,"CIGNA [10200]",Cigna,,1778.2,68,,,,,0,304.12,2222.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 23MM 8MM STEP TAPER ACL PCL",SUP-AR-1380C,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,219.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",215.23,1573.04,"percent of total billed charges",
"COIL EMBOLIZATION 50CM 14MM EMBOLD NITINOL FIBER DETACHABLE",SUP-M001394240140500,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3955.71,45.9,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA PERFUSION BIO-MEDICUS OD19 FR",SUP-96570-019,CDM,S27200284,LOCAL,0272,RC,,,both,,,2120.63,636.19,"MULTIPLAN [10600]",Multiplan,,1802.54,85,,,,,0,246.63,1802.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 80CM 4FR RDC1 CURVE ANGIOGRAPHIC NYLON NEON SLX",SUP-451446S0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SENSOR UROLOGICAL 150CM 3CM .038IN NITINOL STAINLESS",SUP-M0066703101,CDM,C1769,HCPCS,0272,RC,,,both,,,355.45,106.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,41.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.34,302.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAUTERY ESURG RAM AARON 593D FN LO",SUP-AA04,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.82,20.65,"CIGNA [10200]","Cigna Open Access",,39.16,56.9,,,,,0,8,58.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 100MM 18MM VASCULAR NITINOL VENOUS ILIOFEMORAL",SUP-AB9U18100090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross PPO",,4057.2,39.2,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tmvi W/Pros Vlv Perc Approach",PX-480000070,CDM,0483T,CPT,0481,RC,,,both,,,48360.36,14508.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,32885.04,68,,,,,0,2491,41106.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 1.5X1.5CM ALLOPATCH THK.4-.8MM THIN ACELLULAR",SUP-WC1515,CDM,Q4128,HCPCS,0636,RC,,,both,,,1226.83,368.05,"FIRST HEALTH [10303]","First Health",,981.46,80,,,,,0,80.43,1042.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM 20.4MM MASTERS-SERIES 85D STD PYROLYTIC",SUP-25MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AETNA [10100]","Aetna HMO/PPO",,23149.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST TRICORTICAL THK10-12MM WEDGE",SUP-400402,CDM,S27800098,LOCAL,0278,RC,,,both,,,4719.60,1415.88,"BLUE CROSS [10001]","Blue Cross PPO",,1850.08,39.2,,,,,0,548.89,4011.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL DUALMESH PLUS 24CMX18CMX1MM HERNIA PATCH",SUP-1DLMCP06,CDM,C1781,HCPCS,0278,RC,,,both,,,9273.60,2782.08,"AETNA [10100]","Aetna HMO/PPO",,7372.51,79.5,,,,,0,1078.52,7882.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP 55.6CM 8MM DA VINCI S/SI ENDOWRIST 35- D MEDIUM",SUP-420327,CDM,S27000186,LOCAL,0270,RC,,,both,,,700.41,210.12,"CIGNA [10200]","Cigna Local Plus",,374.72,53.5,,,,,0,81.46,595.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Voltage-Gtd Ca Chnl Antb Ea",PX-302000259,CDM,86596,CPT,0302,RC,,,both,,,492.10,147.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,18.95,,,,,,,0.01,418.29,"fee schedule",
"GRAFT ENDOVASCULAR 10CM 12MM GORE EXCLUDER CONTRALATERAL LEG",SUP-PLC121000,CDM,C1874,HCPCS,0278,RC,,,both,,,27997.20,8399.16,"CIGNA [10200]","Cigna Open Access",,9379.06,33.5,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 40MMX8MMX15CM 26FR",SUP-TAC084015A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"MULTIPLAN [10600]",Multiplan,,155040,85,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM 5.5MM PREBENT CURVED AUXILLARY",SUP-132.155,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"KIT FOR THE PREPARATION OF TC-99M-TETROFOSMIN 1.38 MG IV SOLUTION",RX-169822,CDM,A9502,HCPCS,0343,RC,08888-8878-17,NDC,both,1,UN,206.95,62.08,"BLUE CROSS [10001]","Blue Cross HMO",,99.38,,,,,,,24.07,206.95,"fee schedule",
"SCR BONE 5MM 50MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.050TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,957.42,570.23,957.42,28,189.34,1383.8,"percent of total billed charges",
"INTRO SHEATH 8FR 11CM GWIRE PRELUDE .035IN STERILE BLUE",SUP-PRO-8F-11,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"MULTIPLAN [10600]",Multiplan,,64.34,85,,,,,0,8.8,64.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9FR .118IN 13CM ROBUST VALVE SPLITTABLE WITHOUT",SUP-PLSX-1009,CDM,C1892,HCPCS,0272,RC,,,both,,,304.50,91.35,"UHC [10700]","United Healthcare",,192.75,63.3,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH VASCULAR 9X2CM XENOSURE BOVINE PERICARDIAL",SUP-E2P9,CDM,C1768,HCPCS,0278,RC,,,both,,,2917.50,875.25,"CIGNA [10200]",Cigna,,1983.9,68,,,,,0,339.31,2479.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VEST, CUP LARGE","SUP-16V LARGE",CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 8CM 5FR 3MM .035IN BALLOON DILATATION",SUP-G52327,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP POLAR STEM POLAR CUP DELTA HEAD",SUP-71703511,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"NOVANET [10819]",Novanet,,17955,75,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 6MM 2.25MM BALLOON DILATATION DURATRAC",SUP-NCEUP22506X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,358.02,68,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 2 RIGHT MEDIAL LEFT LATERAL PARTIAL",SUP-5620-B-202,CDM,C1776,HCPCS,0278,RC,,,both,,,6899.21,2069.76,"MULTIPLAN [10600]",Multiplan,,5864.33,85,,,,,0,802.38,5864.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 80MM 4FR 5MM .018IN BALLOON",SUP-PCP050080130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"MULTIPLAN [10600]",Multiplan,,1046.52,85,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 18MM 4MM EMBOLIZATION NEUROVASCULAR 48",SUP-PED-400-18,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"BLUE CROSS [10001]","Blue Cross PPO",,30164.4,39.2,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 130CM 120MM 5MM BALLOON DILATATION",SUP-ADM05012013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"FIRST HEALTH [10303]","First Health",,6458.4,80,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ENDOSCP SEALING 9.8-11.1MM MEDIUM RADIOFREQUENCY",SUP-CP-002A,CDM,S27200284,LOCAL,0272,RC,,,both,,,341.04,102.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,231.91,68,,,,,0,39.66,289.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPEEDBRIDGE JUMPSTART FIXATION BIOCOMPOSITE ACHILLES",SUP-AR-8928BCJ-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5506.2,40,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TANDEM BIPOLAR COCR 55OD 28ID",SUP-71322055,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"AETNA [10100]","Aetna HMO/PPO",,6640.2,79.5,,10981.53,8986.79,12413.38,12,971.39,7099.58,"percent of total billed charges",
"LENS IOL APODIZE DIFFRACTIVE ASPHERIC OPTIC 1 PIECE FOLDABLE",SUP-SN6AD1U220,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,86.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON SUT 20X5MM TIGHTROPE LARGE EXT FOOTPRINT",SUP-AR-1589RT,CDM,C1713,HCPCS,0278,RC,,,both,,,1771.88,531.56,"PHCS [10601]",PHCS,,1240.32,70,,,,,0,206.07,1506.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE FLOPPY II VASCULAR J CURVE 300CM 2CM .014IN",SUP-22359MJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 15MM 1.5MM BALLOON DILATATION RAPID",SUP-47515015M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"KAISER [10500]",Kaiser,,1069.12,67,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 60MM 112CM 10MM 75CM VASCULAR NITINOL ILIAC",SUP-H74939200106070,CDM,C1876,HCPCS,0278,RC,,,both,,,4515.00,1354.5,"NOVANET [10819]",Novanet,,3386.25,75,,,,,0,525.09,3837.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX SEPRA 6IN MONOFILAMENT RESORBABLE",SUP-1200015,CDM,C1781,HCPCS,0278,RC,,,both,,,25529.49,7658.85,"KAISER [10500]",Kaiser,,17104.76,67,,,,,0,2969.08,21700.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 2.75MM X 12.0MM",SUP-492751212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 7MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620207,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"UHC [10700]","United Healthcare",,7123.72,63.3,,8601.07,8395.67,8601.07,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"CATH CHRG 75CM 80MM 5FR 4MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-04087,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 14MM 2.25MM CLEARVIEW INTRACORONARY",SUP-31225,CDM,S27800098,LOCAL,0278,RC,,,both,,,632.53,189.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,290.33,45.9,,,,,0,73.56,537.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 16MM 144CM 4.5MM CORONARY STENT",SUP-H7493941816450,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 82MM 32MM 28-29MM 20FR ZENITH TX2",SUP-G47450,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12161.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 20MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,589.25,41.1,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 12FR 30CM STRAIGHT KELLER-TIMMERMANS STERILE",SUP-G09346,CDM,C1894,HCPCS,0272,RC,,,both,,,522.45,156.73,"PHCS [10601]",PHCS,,365.72,70,,,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X17MM LUMINARY CC 30D BICONVEX",SUP-6917,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13305.6,40,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 5.5MM SURGICAL SPINE REVERE",SUP-624.215,CDM,S27000186,LOCAL,0270,RC,,,both,,,3956.40,1186.92,"NOVANET [10819]",Novanet,,2967.3,75,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX SAFE PERFORMAXX 20MM 80CM 7MM 6FR .035IN",SUP-ZBM07020,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6803.4,68,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM 12/14 TAPER 32MM HIP OXINIUM ECHELON",SUP-71343203,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1806.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 50CM 11CM GWIRE KINK RESISTANT FLEXIBLE",SUP-PSI-8F-11-038,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 28CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192124010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"KAISER [10500]",Kaiser,,804.39,67,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH HIGH PROFILE XTRA 465CC",SUP-SHPX465,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"CIGNA [10200]","Cigna Local Plus",,3986.82,,,,,,,866.67,6334.2,"percent of total billed charges",
"INTRO SHEATH 5FR 50CM 11CM GRAY HUB SNAP FIT DIL TUBING",SUP-PRO-5F-11-035,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"PHCS [10601]",PHCS,,56.03,70,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY 30MM 140CM 4MM CORONARY STENT",SUP-RSINT40030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"KAISER [10500]",Kaiser,,3714.48,67,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BICORTICAL ILIUM THK3+ MM ALLOGRAFT FREEZE DRIED",SUP-400345,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INNATE IMPLANT 3.6MM X 40MM",SUP-EXINN923640,CDM,C1713,HCPCS,0278,RC,,,both,,,5347.50,1604.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,633.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,621.91,4545.38,"percent of total billed charges",
"INSRT TIBIAL 6 CURVE 10MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962061,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"KAISER [10500]",Kaiser,,6197.13,67,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) INNOVALVE STAGE FOR TMVR TRANSCATHETER MITRAL VALVE R",SUP-PRO-17582,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PRELUDESYNC EZ SLIP-N-LOCK 29CM COMPRESSION RADIAL",SUP-EZ-REG,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.77,71.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.89,203.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 18MM SECUR-FIT X-TRA TITANIUM T15 CORTICAL",SUP-131218018,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,537.03,68,,,,,0,91.85,671.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM TITANIUM T8 LOCK VARIABLE ANGLE TUBE",SUP-04.210.118TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1056.89,317.07,"BLUE CROSS [10001]","Blue Cross HMO",,414.3,39.2,,957.42,156.86,7483.26,51,122.92,898.36,"percent of total billed charges",
"AXLE FEMORAL GMRS SMALL KNEE",SUP-6495-2-115,CDM,C1776,HCPCS,0278,RC,,,both,,,3698.60,1109.58,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,430.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,430.15,3143.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +27.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.275,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,197.05,28.62,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP COMPREHENSIVE SHORT STEM/TITANIUM GLENOID/TITANIUM HEAD",SUP-98B00900136,CDM,C1776,HCPCS,0278,RC,,,both,,,39375.00,11812.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4665.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4579.31,33468.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +10MM 36MM HIP C TAPER OFFSET COBALT CHROME",SUP-624718,CDM,C1776,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Open Access",,2355.66,56.9,,5302.19,4377.88,6578.61,27,481.48,3519,"percent of total billed charges",
"STENT WALLSTENT UNISTEP PLUS 55MM 75CM 20MM 100CM",SUP-H965404310,CDM,C1876,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 STD KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508605801,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"FIRST HEALTH [10303]","First Health",,20990.59,80,,,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +11.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.115,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14IN 28FR VENOUS 90D OPEN LIGHTHOUSE SHORTER",SUP-SPC207428,CDM,S27200284,LOCAL,0272,RC,,,both,,,115.28,34.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,52.91,45.9,,,,,0,13.41,97.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lgh Gene Rearrange Dir Probe",PX-309000038,CDM,81262,CPT,0310,RC,,,both,,,241.00,72.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,71.98,,"Fee schedule rate ($71.98). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,204.85,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 G 36MM LONGEVITY HIP STERILE LUMEN LATEX",SUP-20123607,CDM,C1776,HCPCS,0278,RC,,,both,,,8101.98,2430.59,"AETNA [10100]","Aetna HMO/PPO",,6441.07,79.5,,10981.53,8986.79,12413.38,12,942.26,6886.68,"percent of total billed charges",
"SCR BONE 6.5MM 50MM TSRH OSTEOGRIP TITANIUM SPINE",SUP-83565501,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,305.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",299.36,2187.9,"percent of total billed charges",
"SHEATH ZURPAZ .032IN MEDIUM SYMMETRIC CURVE 92CM 72CM 8.5FR",SUP-M004USMC85100,CDM,C1894,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,682.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL 7 18IN MONOFILAMENT TIE 12 STRAND SILVER",SUP-DS18,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.57,22.67,"NOVANET [10819]",Novanet,,56.68,75,,,,,0,8.79,64.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ORTHOPEDIC 15MM INDEPENDENCE 15D SPINE",SUP-376.815,CDM,C1776,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"CIGNA [10200]",Cigna,,13710.24,40,,5873.17,5873.17,5873.17,"1 through 10",3986.25,29134.26,"percent of total billed charges",
"DRILL SURGICAL FIX 12MM",SUP-288301112,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"UHC [10700]","United Healthcare",,2504.4,63.3,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 100CM 5FR STRAIGHT ANGIOGRAPHIC POLYETHYLENE PERIPHERAL",SUP-G00159,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.19,73.86,"CIGNA [10200]","Cigna Open Access",,140.08,56.9,,,,,0,28.63,209.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 3FR 20CM PROVENA BIOPATCH 1 LUMEN MIDLINE MAXIMUM",SUP-S4153108BD,CDM,C1752,HCPCS,0272,RC,,,both,,,1214.51,364.35,"FIRST HEALTH [10303]","First Health",,971.61,80,,,,,0,141.25,1032.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 9MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530-G-409,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"FIRST HEALTH [10303]","First Health",,6966.09,80,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN ORTHOPEDIC BB-TAK THREAD STERILE DISPOSABLE",SUP-AR-13226TS,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 4.5MM 6FR BILIARY NITINOL BRAID SELF",SUP-S-45-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross PPO",,3583.86,39.2,,,,,0,1063.27,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 45MM 5.5MM ARMADA SPINE TITANIUM FIX CROSS",SUP-8450145,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2422.5,68,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Evasc Rpr Taa Incl Subcl",PX-360000026,CDM,33880,CPT,0361,RC,,,both,,,12936.00,3880.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6019.63,,"Fee schedule rate ($6,019.63).",,,,0,1504.46,10995.6,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 8 HOLE BONE LEFT CLAVICLE",SUP-70-0300,CDM,S27800098,LOCAL,0278,RC,,,both,,,6610.20,1983.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,783.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 38MM UNITRAX HIP FEMORAL MODULAR EXETER V40",SUP-6942-5-038,CDM,C1776,HCPCS,0278,RC,,,both,,,3753.24,1125.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,444.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.5,3190.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTMASTER 26MM 3.5MM CORONARY STENT STAINLESS STEEL",SUP-1012581-26,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"UHC [10700]","United Healthcare",,10460.64,63.3,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 20MM 29MM HANCOCK II ULTRA CINCH PORCINE",SUP-T505U229,CDM,S27800098,LOCAL,0278,RC,,,both,,,21420.00,6426,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2538.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ext Ecg>48hr<7d Recording",PX-731000005,CDM,93242,CPT,0731,RC,,,both,,,383.00,114.9,"KAISER [10500]",Kaiser,,256.61,67,,,,,0,30.87,383,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 24CM 4.8FR .035IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856070,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"CIGNA [10200]",Cigna,,745.73,68,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 32MM 140CM 2.75MM CORONARY STENT PLATINUM",SUP-H7493927432270,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1721.25,45.9,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 4FR ANGLE BERENSTEIN CURVE ANGIOGRAPHIC",SUP-H787107140165,CDM,C1887,HCPCS,0272,RC,,,both,,,181.31,54.39,"PHCS [10601]",PHCS,,126.92,70,,,,,0,21.09,154.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 22MM 2.5MM CORONARY STENT FULCRUM COCR",SUP-INT25022UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"BLUE CROSS [10001]","Blue Cross HMO",,946.68,39.2,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2MM HALF CIRCLE 32MM",SUP-3910900024,CDM,C1713,HCPCS,0278,RC,,,both,,,252.30,75.69,"KAISER [10500]",Kaiser,,169.04,67,,,,,0,29.34,214.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 53MM 26MM UHR UNIVERSAL ACETABULAR HIP COCR",SUP-UH1-53-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"CIGNA [10200]",Cigna,,2936.08,68,,5873.17,5873.17,5873.17,"1 through 10",502.16,3670.1,"percent of total billed charges",
"STEM RADIAL 4MM 8MM ELBOW TITANIUM HEAD STERILE",SUP-TR-S0804-S,CDM,C1776,HCPCS,0278,RC,,,both,,,15145.50,4543.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6058.2,40,,,,,0,1761.42,12873.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 21MM 4MM BALLOON DILATATION PTCA",SUP-DC-RZ4021UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 54MM 36MM MARATHON",SUP-121936454,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"CIGNA [10200]","Cigna Local Plus",,5265.92,53.5,,5372.07,4581.20,7242.98,23,1144.72,8366.42,"percent of total billed charges",
"POSITIONER PATIENT XPOSE ACCESS DEVICE ACROBAT-I",SUP-XP-5000Z,CDM,S27200284,LOCAL,0272,RC,,,both,,,6011.69,1803.51,"CIGNA [10200]","Cigna Local Plus",,3216.25,53.5,,,,,0,699.16,5109.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER 150UM BALL TIP SOLTIVE",SUP-TFL-FBX150S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2690.00,807,"FIRST HEALTH [10303]","First Health",,2152,80,,,,,0,312.85,2286.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR NEROSTIMLTR 46X50MM PRECISION SPECTRA 10.8MM TITANIUM",SUP-SC-1132,CDM,C1820,HCPCS,0278,RC,,,both,,,95760.00,28728,"UHC [10700]","United Healthcare",,60616.08,63.3,,,,,0,11136.89,81396,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR INJECTION FAST-LOAD EMPOWER CTA SPIKE PACK",SUP-017345,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.89,19.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.55,55.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOSCP RIGID CENTERLINE CARPAL TUNNEL RELEASE SYSTEM",SUP-AR-8850S,CDM,S27200284,LOCAL,0272,RC,,,both,,,13403.25,4020.97,"MULTIPLAN [10600]",Multiplan,,11392.76,85,,,,,0,1558.8,11392.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT EDGE STERILE PVC",SUP-E2250HNSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.80,1.44,"PHCS [10601]",PHCS,,3.36,70,,,,,0,0.56,4.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 43IN 10FR ANTICLOG RADIOPAQUE SMOOTH BOLUS",SUP-20-7431,CDM,S27200284,LOCAL,0272,RC,,,both,,,118.20,35.46,"AETNA [10100]","Aetna HMO/PPO",,93.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.75,100.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 4.75MM 3.5MM INTERNALBRACE",SUP-AR-1788J-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"PHCS [10601]",PHCS,,7220.85,70,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTAROLINE FOSAMIL 600 MG VIAL",RX-107671,CDM,J0712,HCPCS,0636,RC,00456-0600-01,NDC,both,1,UN,1554.03,466.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,695.43,44.75,,,,,0,184.15,1320.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC",316,MS-DRG,,,,,,,inpatient,,,30036.29,9010.89,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,4484.98,,"Case rate ($4,231.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,928.87, add-ons for qualifying new technology services are included. If operating cost exceeds $36,968.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,679.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,934.07. The transfer operating threshold is the transfer adjustment factor * $3,928.87 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $297.04. The transfer capital threshold is the transfer adjustment factor * $297.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,4231.11,17010.89,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE SMALL PATIENT POSTOPERATIVE SHORT WEDGE HEELWEDGE",SUP-92732602,CDM,S27000186,LOCAL,0270,RC,,,both,,,256.65,76.99,"KAISER [10500]",Kaiser,,171.96,67,,,,,0,29.85,218.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMINO ACID 4.25 % NO.1 IN DEXTROSE 5 % INTRAVENOUS SOLUTION",RX-27927,CDM,J3490,HCPCS,0258,RC,00338-1089-04,NDC,both,2000,ML,452.70,135.81,"PHCS [10601]",PHCS,,316.89,70,,,,,0,52.65,384.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Swallow Func Incomplt",PX-444000007,CDM,92610,CPT,0444,RC,,,both,,,536.62,160.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,254,,"Per diem ($254).",,,,0,62.41,456.13,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP OSTEOTOM 46MM HEMISPHERE ACETABULAR CUP",SUP-705304620,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,536.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SYRINGE (FOR ORAL USE ONLY)",RX-186013,CDM,,,0250,RC,68094-0045-01,NDC,both,.5,ML,25.19,7.56,"MULTIPLAN [10600]",Multiplan,,21.41,85,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 13MM KNEE POSTERIOR STABILIZED PRIMARY",SUP-5532P313,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Open Access",,4754.51,56.9,,5302.19,4377.88,6578.61,27,971.79,7102.52,"percent of total billed charges",
"DEVICE MANTA 14FR CLSR VASCULAR",SUP-2156,CDM,C1760,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1704.04,45.9,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL CINCHLOCK FLEX STERILE DISPOSABLE",SUP-CAT02644,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 3.5 X 8 COMPLEX PICO COIL",SUP-10USC03508,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1520.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON ULTIMA 10-0 CS140-6 12IN 2 ARM MONOFILAMENT",SUP-9003G,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.29,68.79,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,105.24,45.9,,,,,0,26.67,194.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM ANGLED NECK SYSTEM OMNIFIT EON 132D 7 35",SUP-6098-0735,CDM,C1776,HCPCS,0278,RC,,,both,,,10292.40,3087.72,"BLUE CROSS [10001]","Blue Cross HMO",,4034.62,39.2,,5311.50,4717.44,5388.59,31,1197.01,8748.54,"percent of total billed charges",
"CATH RF ENHANCR II 110CM 4MM 7FR 2-5-2MM SPACE 45MM SINGLE",SUP-31744523,CDM,C1733,HCPCS,0272,RC,,,both,,,3375.00,1012.5,"MULTIPLAN [10600]",Multiplan,,2868.75,85,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER/DIVIDER LAPAROSCOPIC 30CM LIGASURE MARYLAND THORACIC",SUP-LF1930T,CDM,S27200284,LOCAL,0272,RC,,,both,,,4551.65,1365.49,"CIGNA [10200]","Cigna Local Plus",,2435.13,53.5,,,,,0,529.36,3868.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC",832,MS-DRG,,,,,,,inpatient,,,22420.49,6726.15,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,4677.56,,"Case rate ($4,476.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,156.39, add-ons for qualifying new technology services are included. If operating cost exceeds $37,196.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,696.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,161.89. The transfer operating threshold is the transfer adjustment factor * $4,156.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.24. The transfer capital threshold is the transfer adjustment factor * $314.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,4476.13,17995.98,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 44MM UNITRAX FEMORAL HIP MODULAR",SUP-6942-5-044,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"FIRST HEALTH [10303]","First Health",,2502.16,80,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 20-30MM SPINE CROSS HEAD TO HEAD NONSTERILE",SUP-102023101,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"NOVANET [10819]",Novanet,,2671.88,75,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 20MM 1.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP1520X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL COMPOSIX 8.2X6.2IN PATCH LOW PROFILE",SUP-0134680,CDM,C1781,HCPCS,0278,RC,,,both,,,3087.00,926.1,"NOVANET [10819]",Novanet,,2315.25,75,,,,,0,359.02,2623.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 53CM 5.3FR J VENTRICLE BIPOLAR TINE LOW",SUP-457453,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1024.72,45.9,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO SD 90D LEFT CURVE 1.8MM 3.8MM THUMB PAD",SUP-AR-4068-90L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1190.70,357.21,"KAISER [10500]",Kaiser,,797.77,67,,,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE STC-18 105CM 20CM 2.4-3FR .021IN MICRO GUIDING",SUP-M001181270,CDM,C1887,HCPCS,0272,RC,,,both,,,2325.00,697.5,"UHC [10700]","United Healthcare",,1471.73,63.3,,,,,0,270.4,1976.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM LOW PROFILE SCREWS TITANIUM VARIABLE",SUP-AR-8724V-18,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"KAISER [10500]",Kaiser,,1085.4,67,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 5FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552240,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA [10200]","Cigna Open Access",,683.13,,,,,,,139.63,1020.49,"percent of total billed charges",
"PLATE LOCK COVER TCS BONE",SUP-5303-1405-S,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 20CM 6MM BALLOON DILATATION OTW LOW",SUP-G30909,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 14X26X55MM 10",SUP-6214155,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Local Plus",,7541.1,31.5,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 64MM HIP MULTIHOLE R3 STD STERILE",SUP-71338672,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1882.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1847.69,13504.16,"percent of total billed charges",
"INSRT TIBIAL 8 6MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710806,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"PHCS [10601]",PHCS,,10355.52,70,,,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) GUIDEWIRE RAIDER VASCULAR STRAIGHT 190CM .014IN STAIN",SUP-7448,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"UHC [10700]","United Healthcare",,0.01,63.3,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG SPECIMEN RETRIEVAL 9.9IN 5.5IN ANCHOR TISSUE SYSTEM",SUP-TRS-VATS-15,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"FIRST HEALTH [10303]","First Health",,1650,80,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER SUPPORT CXI ANGLE L65 CM OD2.6 FR ACCEPTS .018 IN G",SUP-G18377,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 4MM 36MM REUNION X3 STD SHOULDER STERILE LATEX",SUP-5571-S-3604,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"CIGNA [10200]","Cigna Open Access",,5735.52,56.9,,5302.19,4377.88,6578.61,27,1172.3,8568,"percent of total billed charges",
"HEAD FEMORAL +2.5 MMM 36MM HIP BIOLOX DELTA V40",SUP-6570-0-536,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4110,41.1,,6417.48,6417.48,6417.48,"1 through 10",1163,8500,"percent of total billed charges",
"BAG SPECIMEN RETRIEVAL 9.9IN 5.5IN ANCHOR TISSUE SYSTEM",SUP-TRS-VATS-15,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"NOVANET [10819]",Novanet,,1546.88,75,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 25MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE50025,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"BLUE CROSS [10001]","Blue Cross PPO",,32796.52,39.2,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 3.9X3.9IN XENMATRIX AQUAPURE SQUARE ACELLULAR",SUP-1161010,CDM,C1781,HCPCS,0278,RC,,,both,,,16797.36,5039.21,"NOVANET [10819]",Novanet,,12598.02,75,,,,,0,1953.53,14277.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 29MM VIVACIT-E ALL POLY KNEE LATEX FREE",SUP-42540200029,CDM,C1776,HCPCS,0278,RC,,,both,,,5322.66,1596.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,630.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,619.03,4524.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Umbilical Neonate",PX-E27200076,CDM,E27200076,LOCAL,0272,RC,,,both,,,359.70,107.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,41.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.83,305.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 64MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.864,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"CIGNA [10200]","Cigna Local Plus",,134.24,53.5,,3978.14,359.25,3978.14,24,29.18,213.27,"percent of total billed charges",
"INSRT TIBIAL 5 25MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G525,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"AETNA [10100]","Aetna HMO/PPO",,7950,79.5,,10981.53,8986.79,12413.38,12,1163,8500,"percent of total billed charges",
"NAIL 10MM 440MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.064S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"AETNA [10100]","Aetna HMO/PPO",,9872.58,79.5,,1521.93,481.35,16760.95,30,1444.25,10555.59,"percent of total billed charges",
"STENT GORE VIABAHN 39MM 135CM 6MM 8MM 7FR .035IN",SUP-BXA063902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UHC [10700]","United Healthcare",,12346.54,63.3,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 12MM 140CM 4MM CORONARY STENT CARBOSIL",SUP-LUN400R12US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 5.5MM CANNULATED SPINAL CREO MIS",SUP-6134.0055,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,267.69,45.9,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE ENDOSCOPIC 45D 400CM .035IN HYDROPHILIC STIFF",SUP-GS3540,CDM,C1769,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 15MM 3.25MM BALLOON DILATATION",SUP-NCEUP32515X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 18MM 145CM 3.25MM CORONARY STENT",SUP-1125325-18,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AETNA [10100]","Aetna HMO/PPO",,4641.21,79.5,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT 10X1CM GRAFTON DEMINERALIZED BONE MATRIX",SUP-T42275,CDM,S27800098,LOCAL,0278,RC,,,both,,,8073.00,2421.9,"CIGNA [10200]","Cigna Open Access",,4593.54,56.9,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE HA 30MM 11MM ACL BIOSURE",SUP-72201789,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,957.42,570.23,957.42,28,189.34,1383.8,"percent of total billed charges",
"GRAFT ENDOVASCULAR 199MM 28-36MM 31-32MM 22FR ZENITH TX2",SUP-G47477,CDM,C1874,HCPCS,0278,RC,,,both,,,98041.65,29412.49,"FIRST HEALTH [10303]","First Health",,78433.32,80,,,,,0,11402.24,83335.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4.8MM PK DIEGO 15D CURVE CONVEX SINUS TONSIL",SUP-70139010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1349.60,404.88,"PHCS [10601]",PHCS,,944.72,70,,,,,0,156.96,1147.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHOLESTYRAMINE 4 GRAM ORAL POWDER FOR SUSPENSION IN A PACKET",RX-243327,CDM,,,0637,RC,68382-0529-60,NDC,both,1,UN,21.08,6.32,"MULTIPLAN [10600]",Multiplan,,17.92,85,,,,,0,2.45,17.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP POROCOAT PINNACLE 300 SERIES",SUP-121703062,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1345.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SPINAL SPACER W14.5XH8XL12MM 7DEG CERVICAL LORDOSIS PR",SUP-VG1C-T68P,CDM,S27800098,LOCAL,0278,RC,,,both,,,5865.00,1759.5,"BLUE CROSS [10001]","Blue Cross PPO",,2299.08,39.2,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLOTRIMAZOLE 2 % VAGINAL CREAM",RX-33986,CDM,,,0250,RC,51672-2062-00,NDC,both,21,GR,66.71,20.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,30.62,45.9,,,,,0,7.76,56.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ACHILLES SPEEDBRIDGE ARTHREX FIXATION BIOCOMPOSITE",SUP-AR-8929BC-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,7063.88,2119.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4803.44,68,,,,,0,821.53,6004.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PSN REV CCK VE 12MM R 7-9+ EF",SUP-42-5228-007-12,CDM,C1776,HCPCS,0278,RC,,,both,,,16308.84,4892.65,"AETNA [10100]","Aetna HMO/PPO",,12965.53,79.5,,10981.53,8986.79,12413.38,12,1896.72,13862.51,"percent of total billed charges",
"STENT EXPEL TWIST-LOC 26CM 8FR URETERAL FLEXITHANE",SUP-H7493936108260,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"MULTIPLAN [10600]",Multiplan,,1053.41,85,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION",RX-11403,CDM,,,0250,RC,00264-2201-00,NDC,both,1000,ML,100.65,30.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL 45X3.5MM TITANIUM REGULAR ENDOSCOPIC LINEAR",SUP-TA4535S,CDM,S27200284,LOCAL,0272,RC,,,both,,,860.30,258.09,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT ABSOLUTE PRO 80MM 135CM 6MM VASCULAR OTW SELF EXPAND",SUP-1012534-80,CDM,C1876,HCPCS,0278,RC,,,both,,,8799.00,2639.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3616.39,41.1,,,,,0,1023.32,7479.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 15MM REFLECTION FULL THREAD HIP ACETABULAR",SUP-71336515,CDM,C1713,HCPCS,0278,RC,,,both,,,1341.36,402.41,"CIGNA [10200]","Cigna Local Plus",,717.63,53.5,,3978.14,359.25,3978.14,24,156,1140.16,"percent of total billed charges",
"CATH TYSHAK II 100CM 5CM 8FR 22MM BALLOON DILATATION",SUP-611937,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,450.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,442.08,3231.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL C-FLEX DOYLE BIVALVE SET",SUP-1524075,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.95,74.38,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.84,210.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 20MM EMBOLD NITINOL FIBER DETACHABLE",SUP-M001394240200500,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"MULTIPLAN [10600]",Multiplan,,7325.39,85,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ZEBRA 6F 95CM ACCESS SYSTEM SIM2",SUP-AC6074-095-30,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3672.49,41.1,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD 74X68.6MM KNEE RIGHT CRUCIATE RETAIN",SUP-112.001.34,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1123.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 14FR 3 PORT REPLACEMENT STRAIGHT BOLST GASTRO ENDOVIVE",SUP-M00509891,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.82,72.25,"CIGNA [10200]",Cigna,,163.76,68,,,,,0,28.01,204.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE ENDOSCOPIC DISECT BRUSH FINISH RADIOPAQUE TIP 38CM 5",SUP-KT-9101,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.21,36.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.33,104.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVICROSS 90CM 40MM 60MM SPACE SPRT STAINLESS STEEL",SUP-NC18901,CDM,C1887,HCPCS,0272,RC,,,both,,,1462.05,438.61,"AETNA [10100]","Aetna HMO/PPO",,1162.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,170.04,1242.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 81MM 41.8MM 33MM DURAN ANCORE 35.8MM 2",SUP-620BG33,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER HUMERAL ARTHREX XS LINER 33+6MM STERILE",SUP-AR-9503XS-06,CDM,C1776,HCPCS,0278,RC,,,both,,,4305.60,1291.68,"PHCS [10601]",PHCS,,3013.92,70,,,,,0,500.74,3659.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 1 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022211,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"PHCS [10601]",PHCS,,11635.47,70,,,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 59CM ENDOTAK RELIANCE G ENDOCARDIAL STEROID",SUP-174,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]",Cigna,,6072,40,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 8MM 2.75MM CORONARY STENT FULCRUM COCR",SUP-INT27508UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"NOVANET [10819]",Novanet,,1811.25,75,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890007540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2-2.4MM CANNULATED DISPOSABLE",SUP-212-24-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1650.00,495,"UHC [10700]","United Healthcare",,1044.45,63.3,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 28MM 143CM 3MM CORONARY EVEROLIMUS ELUTING",SUP-1009541-28,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"BLUE CROSS [10001]","Blue Cross PPO",,3759.67,39.2,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 100MM 4MM BALLOON DILATATION STERILE LATEX",SUP-584010022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 150MM 5MM BALLOON DILATATION RAPID",SUP-47550150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZINGER VASCULAR J CURVE 180CM .014IN HYDRO-TRACK",SUP-ZNGRLS180HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,502.20,150.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,341.5,68,,,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM TARGET 3D DETACHABLE CONSISTENT",SUP-M0036154080,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"KAISER [10500]",Kaiser,,9456.81,67,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTELLISYSTEM25 13IN INFLATION POLYCARBONATE 20ML",SUP-IN1425,CDM,S27200284,LOCAL,0272,RC,,,both,,,464.13,139.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.98,394.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION ENDOBUTTON CL ULTRA 35MM ACL PCL",SUP-72200150,CDM,C1713,HCPCS,0278,RC,,,both,,,2157.75,647.32,"FIRST HEALTH [10303]","First Health",,1726.2,80,,,,,0,250.95,1834.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 45CM HELIX ENDOCARDIUM ATRIUM VENTRICLE BIPOLAR",SUP-4086,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross HMO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 42MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.542,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,313.8,28.62,,,,,0,127.51,931.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW .36IN CORE PRECISION THK.015IN .98IN THIN OFFSET",SUP-2296003511,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"NOVANET [10819]",Novanet,,202.67,75,,,,,0,31.43,229.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 12MM LCP STAINLESS STEEL DISTAL RADIAL",SUP-02.210.112,CDM,C1713,HCPCS,0278,RC,,,both,,,959.36,287.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,274.57,28.62,,,,,0,111.57,815.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL REVERSE ALTIVATE SMALL SHELL 8MM X 220MM",SUP-533-08-220,CDM,C1776,HCPCS,0278,RC,,,both,,,45388.92,13616.68,"KAISER [10500]",Kaiser,,30410.58,67,,,,,0,5278.73,38580.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION .035IN 9IN KIRSCHNER STAINLESS STEEL 1 END",SUP-KM173-39-35,CDM,C1713,HCPCS,0278,RC,,,both,,,59.29,17.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",6.9,50.4,"percent of total billed charges",
"HEMOSTAT ABSORBABLE 2X1IN NONWOVEN SURGICEL SNOW STERILE",SUP-2081,CDM,S27200284,LOCAL,0272,RC,,,both,,,892.99,267.9,"UHC [10700]","United Healthcare",,565.26,63.3,,,,,0,103.85,759.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX 80MM 80CM 12MM 6FR .035IN BILIARY CATH",SUP-ZBM12080,CDM,C1874,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1185.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTRA 42CM 7FR 130D GUIDING STERILE LATEX FREE",SUP-451790,CDM,C1893,HCPCS,0272,RC,,,both,,,1800.00,540,"PHCS [10601]",PHCS,,1260,70,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIPOLAR 33CM 5MM ENDOPATH MACRO JAW STERILE",SUP-EBF01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1088.49,326.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,126.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,126.59,925.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 220MM 4.6MM 3/16IN SQUARE CANNULATED 7MM MONSTER",SUP-P99-110-4622,CDM,S27200284,LOCAL,0272,RC,,,both,,,1279.80,383.94,"KAISER [10500]",Kaiser,,857.47,67,,,,,0,148.84,1087.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT FEMORAL DOME FIX BEARING CEMENT ATTUNE",SUP-OSC379572,CDM,C1776,HCPCS,0278,RC,,,both,,,19530.00,5859,"NOVANET [10819]",Novanet,,14647.5,75,,,,,0,2271.34,16600.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 120MM 150CM 8MM VASCULAR NICKEL",SUP-EVD35-08-120-150,CDM,C1876,HCPCS,0278,RC,,,both,,,7665.00,2299.5,"CIGNA [10200]","Cigna Local Plus",,4100.78,53.5,,,,,0,891.44,6515.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AMPLATZ 17CM 16FR ACCESS PTFE RENAL FIRM TAPER TIP",SUP-M0062601460,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"FIRST HEALTH [10303]","First Health",,267.68,80,,,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL FLAT L 28CM VALLEYLAB STERILE ARGON",SUP-E3581-28,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.15,88.24,"CIGNA [10200]",Cigna,,200.02,68,,,,,0,34.21,250.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 FSL 18IN BRAID BLACK NONABSORBABLE",SUP-677G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brca1&2 Gen Full Seq Dup/Del",PX-310000039,CDM,81162,CPT,0310,RC,,,both,,,4300.00,1290,"AMERIGROUP MEDICAID [20100]",Amerigroup,,509.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,4300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135CM 20MM 6FR 12MM .035IN LOW PROFILE",SUP-B2120-020,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"AETNA [10100]","Aetna HMO/PPO",,611.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.5MM X 40MM S4 CATHETER",SUP-FG63091-2540,CDM,C1725,HCPCS,0272,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE SELF DRILLING RIGID 4MM 14MM ASSURE TITANIUM",SUP-110.014,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,163.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",163.98,1198.5,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 12MM 145CM 2.25MM CORONARY STENT",SUP-1145225-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2679.64,45.9,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Picc Line",PX-450000229,CDM,36584,CPT,0361,RC,,,both,,,7009.87,2102.96,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,815.25,7009.87,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 7IN 40D FORWARD 1MM KERRISON STAINLESS STEEL",SUP-280041,CDM,S27200284,LOCAL,0272,RC,,,both,,,3584.70,1075.41,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,424.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,416.9,3047,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET TUBE KAIRISON HIGH PRESSURE DISPOSABLE",SUP-FK888SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,1402.56,420.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,953.74,68,,,,,0,163.12,1192.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) OPTIMAP CATHETER GEN 1A",SUP-OPTI-CATH-50,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 18CM 5FR 2 PIGTAIL CURVE",SUP-M0061921150,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"BLUE CROSS [10001]","Blue Cross HMO",,445.16,39.2,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 65CM 5FR CB2 CURVE ANGIOGRAPHIC LEGATO",SUP-56538CB2-H,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"CIGNA [10200]","Cigna Open Access",,193.06,56.9,,,,,0,39.46,288.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN AMPLATZ RIGHT 2 CURVE GUIDING",SUP-LA6AR20SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 20MM 135CM 4MM .018IN BILIARY STAINLESS",SUP-G56620,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"BLUE CROSS [10001]","Blue Cross PPO",,1975.68,39.2,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 20MM 135CM 4MM .018IN BILIARY STAINLESS",SUP-G56620,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"CIGNA [10200]",Cigna,,3427.2,68,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL LEGION 4 5D 5P L KNEE DISTAL SCR",SUP-71421731,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,2014.9,14726.25,"percent of total billed charges",
"SLEEVE TIBIAL 37MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-1511-11-202,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 20MM COMPREHENSIVE 3.5MM HEXAGON SHOULDER",SUP-180558,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,714.2,45.9,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135CM 40MM 7MM .035IN LOW PROFILE BALLOON",SUP-B2070-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"FIRST HEALTH [10303]","First Health",,615.6,80,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 85MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-02.207.485,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"MULTIPLAN [10600]",Multiplan,,1322.47,85,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE LP 37M",SUP-TENDV-LP-37M-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"KAISER [10500]",Kaiser,,114570,67,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOTHYROXINE 100 MCG TABLET",RX-4423,CDM,,,0637,RC,00904-6953-61,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 23MM 145CM 3MM CORONARY STENT",SUP-1145300-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PHCS [10601]",PHCS,,4086.6,70,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRSG 17.5X14.7X3.3CM VAC SIMPLACE GRANUFOAM MEDIUM 1",SUP-M8275045/5.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,389.71,116.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,265,68,,,,,0,45.32,331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT HUMERAL SHOULDER TOTAL PATIENT SPECIFIC",SUP-98000900003,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3546.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3480.28,25436.25,"percent of total billed charges",
"SUT MONODERM 2-0 14X14 BRB",SUP-YA-1012Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,148.13,44.44,"NOVANET [10819]",Novanet,,111.1,75,,,,,0,17.23,125.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SUCTION BIG YANK 11/32IN 10IN OPEN NONVENTED TUBE 10FT",SUP-0034970U,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.66,30.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.19,41.1,,,,,0,11.94,87.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 10 KNEE RIGHT CEMENTED POSTERIOR STABILIZE",SUP-150410210,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"FIRST HEALTH [10303]","First Health",,17914.68,80,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 19MM 150CM 4MM BILIARY STAINLESS",SUP-H74937912419150,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,580.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X80 135CM SL",SUP-48006008R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"FIRST HEALTH [10303]","First Health",,687.21,80,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 60MM 12MM KII Z THREAD SLEEVE LATEX FREE",SUP-C0R83,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"NOVANET [10819]",Novanet,,182.7,75,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 80CM 1MM 5FR 2-5-2MM SPACE A CURVE",SUP-D5SAL252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3150.00,945,"PHCS [10601]",PHCS,,2205,70,,,,,0,366.35,2677.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX19MM FRA 12D NARROW LORDOTIC SPINE",SUP-12319,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 40 75CM 2CM 6MM BALLOON DILATATION PERIPHERAL",SUP-CQF7562,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"UHC [10700]","United Healthcare",,846,63.3,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC ATLAS+ HF THK1.4CM IMPLANTABLE 2 CHMBR",SUP-V-343,CDM,C1882,HCPCS,0278,RC,,,both,,,101944.50,30583.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,29176.52,28.62,,,,,0,11856.15,86652.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE LCP ANKLE FOOT STAINLESS STEEL 8 HOLE 2.4 MM SCR",SUP-249.678,CDM,C1713,HCPCS,0278,RC,,,both,,,2299.50,689.85,"NOVANET [10819]",Novanet,,1724.63,75,,,,,0,267.43,1954.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X14X7MM ANCHOR-C 4D HOLLOW CERVICAL ANTERIOR",SUP-48323074,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"CIGNA [10200]","Cigna Open Access",,6030,33.5,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARVEDILOL 0.5 MG/ML ORAL SUSPENSION",RX-408876,CDM,,,0637,RC,08888-8885-92,NDC,both,100,ML,53.47,16.04,"MULTIPLAN [10600]",Multiplan,,45.45,85,,,,,0,6.22,45.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR GG ELEVATE 48MM 32MM VIVACIT-E HIP STERILE",SUP-885200832,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"MULTIPLAN [10600]",Multiplan,,8714.22,85,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUMARK VISION 12CM",SUP-351232,CDM,A4648,HCPCS,0278,RC,,,both,,,942.84,282.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,432.76,45.9,,,,,0,109.65,801.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 15MM 145CM 3.5MM CORONARY STENT",SUP-1125350-15,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PHCS [10601]",PHCS,,4086.6,70,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 4MM 38MM LCP STAINLESS STEEL CORTICAL PERIARTICUL",SUP-02.204.038,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"CIGNA [10200]","Cigna Open Access",,561.36,56.9,,1144.80,304.56,2275.09,66,114.74,838.59,"percent of total billed charges",
"OCCL CARDIOVASCULAR 38MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-038,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"BLUE CROSS [10001]","Blue Cross PPO",,8330.31,39.2,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NIPPER NAIL 4.5IN TISSUE",SUP-43-7592,CDM,S27200284,LOCAL,0272,RC,,,both,,,245.51,73.65,"CIGNA [10200]",Cigna,,166.95,68,,,,,0,28.55,208.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE OFFSET NEUTRAL ENCORE",SUP-411-00-000,CDM,C1776,HCPCS,0278,RC,,,both,,,947.54,284.26,"MULTIPLAN [10600]",Multiplan,,805.41,85,,,,,0,110.2,805.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 6MM LEIBINGER UNIVERSAL TITANIUM MANDIBULAR",SUP-5020406,CDM,C1713,HCPCS,0278,RC,,,both,,,458.02,137.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,210.23,45.9,,,,,0,53.27,389.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 60MM 120MM 12MM .035IN 3MM VASCULAR VENOUS",SUP-VENUL12060,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9062.55,41.1,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 26CM 3CM 8FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155253050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"NOVANET [10819]",Novanet,,923.22,75,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOCKWAVE L6 IVL CATHETER 10.0X30 MM",SUP-L6IVL100030,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"MULTIPLAN [10600]",Multiplan,,18474.75,85,,,,,0,2527.78,18474.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM EVEREST SPINE CANNULATED POLYAXIAL MIS",SUP-M5111-05535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"SNARE ROUND 240CM 2.4MM CAPTIVATOR COLD STIFF THIN WIRE",SUP-M00561101,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.90,44.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 11MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P711,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]",Cigna,,5682.01,68,,5873.17,5873.17,5873.17,"1 through 10",971.79,7102.52,"percent of total billed charges",
"INSERT TIBIAL 6 16MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620616,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1308.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 15MM 3.75MM BALLOON DILATATION",SUP-NCEUP37515X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"UHC [10700]","United Healthcare",,333.27,63.3,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS ENDOSCOPIC L230CM DIA2.4MM OPENING 9MM LONG GRIPPER",SUP-M00527551,CDM,S27200284,LOCAL,0272,RC,,,both,,,625.73,187.72,"MULTIPLAN [10600]",Multiplan,,531.87,85,,,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 CURVE 12.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962042,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"BLUE CROSS [10001]","Blue Cross HMO",,3625.78,39.2,,5311.50,4717.44,5388.59,31,1075.71,7862.03,"percent of total billed charges",
"POD XL 5MMX10CM",SUP-RBYPODXL0510,CDM,S27800098,LOCAL,0278,RC,,,both,,,13731.00,4119.3,"BLUE CROSS [10001]","Blue Cross HMO",,5382.55,39.2,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 8X100 40CM SL",SUP-48008010P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"FIRST HEALTH [10303]","First Health",,785.7,80,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +19 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1900,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD SUT ASSISTANT 4-0 ES-9 48IN 1 STITCH ENDO STITCH",SUP-170096,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"AETNA [10100]","Aetna HMO/PPO",,114.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +28 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000280,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 25MM RESTORATION +30MM HIP MODULAR",SUP-6276-1-325,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1714.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1682.49,12296.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NAVITOR LARGE LOADING STENT GUIDE LEAFLET LOADING",SUP-NVTR-LS-LG+,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Local Plus",,2006.25,53.5,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 15.8MM 7.75MM BEAVER CORNEAL STAINLESS",SUP-9722,CDM,S27200284,LOCAL,0272,RC,,,both,,,456.35,136.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,54.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.07,387.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TIBIA FROZEN PLATE 150X20MM",SUP-56B002,CDM,C1713,HCPCS,0278,RC,,,both,,,2771.25,831.37,"FIRST HEALTH [10303]","First Health",,2217,80,,,,,0,322.3,2355.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,inpatient,,,53571.02,16071.31,"AETNA [10100]","Aetna HMO/PPO",,34651.59,,"Fee schedule rate ($34,651.59). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,7561,45930.16,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Ankle Arthgm",PX-361000049,CDM,27648,CPT,0361,RC,,,both,,,893.00,267.9,"KAISER [10500]",Kaiser,,598.31,67,,,,,0,103.86,893,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X80 40CM SL",SUP-48003008P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"MULTIPLAN [10600]",Multiplan,,834.81,85,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL FIXATION GREEN 400MM 11MM 130D RIGHT DISTAL",SUP-456.420S,CDM,C1713,HCPCS,0278,RC,,,both,,,12838.83,3851.65,"FIRST HEALTH [10303]","First Health",,10271.06,80,,,,,0,1493.16,10913.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 13MM THK.64MM 50MM MICRO OFFSET SAGITTAL STERILE",SUP-2296-003-108S5,CDM,S27200284,LOCAL,0272,RC,,,both,,,659.10,197.73,"PHCS [10601]",PHCS,,461.37,70,,,,,0,76.65,560.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 70CM INFINION PERCUTANEOUS 16 LEAD",SUP-SC-2316-70,CDM,C1897,HCPCS,0278,RC,,,both,,,17640.00,5292,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2090.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD BIPOLAR HEMISPHERICAL VAPOR ENUCLEATION STERILE",SUP-27040VE-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3439.15,1031.74,"UHC [10700]","United Healthcare",,2176.98,63.3,,,,,0,399.97,2923.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM HAWKONE ATHERECTOMY H1-M",SUP-H1-M,CDM,C1714,HCPCS,0272,RC,,,both,,,20128.50,6038.55,"KAISER [10500]",Kaiser,,13486.1,67,,,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEARABLE ACCESSORY KIT - INCLUDES WITH IMPLANT KIT - PC NECK",SUP-106129,CDM,Q0508,HCPCS,0274,RC,,,both,,,1377.00,413.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,632.04,45.9,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? BONE SCREW, 2.7MM X 14MM, 4 PACK",SUP-94-27-14-4S,CDM,C1713,HCPCS,0278,RC,,,both,,,2947.50,884.25,"FIRST HEALTH [10303]","First Health",,2358,80,,,,,0,342.79,2505.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM 4MM 2.1-2.7FR CORONARY STENT",SUP-RONYX40022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1704.04,45.9,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 90MM 32MM STAINLESS STEEL ORTHOPEDIC CANNULATED",SUP-71128090,CDM,C1713,HCPCS,0278,RC,,,both,,,2479.50,743.85,"BLUE CROSS [10001]","Blue Cross HMO",,971.96,39.2,,957.42,156.86,7483.26,51,288.37,2107.58,"percent of total billed charges",
"HOLDER PLATE BB-TAK LARGE TITANIUM",SUP-AR-8970-09,CDM,S27000186,LOCAL,0270,RC,,,both,,,1093.50,328.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 3CM 7FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22454,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS [10001]","Blue Cross PPO",,247.67,39.2,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 96MM 1.5MM NONSTERILE",SUP-310.507,CDM,S27000186,LOCAL,0270,RC,,,both,,,945.76,283.73,"UHC [10700]","United Healthcare",,598.67,63.3,,,,,0,109.99,803.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL STD OFFSET 40MM HIP ACETABULAR TYPE 1 COCR G7",SUP-10001035,CDM,C1776,HCPCS,0278,RC,,,both,,,7734.90,2320.47,"BLUE CROSS [10001]","Blue Cross PPO",,3032.08,39.2,,3949.44,3949.44,3949.44,"1 through 10",899.57,6574.67,"percent of total billed charges",
"HC NM Tum Loc Planar Wb Sngl",PX-341000049,CDM,78802,CPT,0341,RC,,,both,,,2226.26,667.88,"BLUE CROSS [10001]","Blue Cross HMO",,817.57,,"Fee schedule rate ($817.57).",,,,0,258.91,2226.26,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 20MM 6FR 4MM .07",SUP-H7493926720400,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"NOVANET [10819]",Novanet,,425.25,75,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMORAL SHAFT ALLOGRAFT FROZEN 150MM 10+ MM",SUP-450440,CDM,S27800098,LOCAL,0278,RC,,,both,,,9509.58,2852.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1105.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1105.96,8083.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 7.5MM 32MM GENESIS II",SUP-71932636,CDM,C1776,HCPCS,0278,RC,,,both,,,6882.75,2064.82,"PHCS [10601]",PHCS,,4817.93,70,,,,,0,800.46,5850.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 40MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,974.92,68,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 124MM 28-16MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1628C124E,CDM,C1876,HCPCS,0278,RC,,,both,,,31342.50,9402.75,"CIGNA [10200]","Cigna Local Plus",,9872.89,31.5,,,,,0,3645.13,26641.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM CREO CREO AMP SPINE MODULAR",SUP-1067.1545,CDM,C1713,HCPCS,0278,RC,,,both,,,2437.50,731.25,"MULTIPLAN [10600]",Multiplan,,2071.88,85,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE-USE 1000 MICRON LASER",SUP-HLFDBX1000C,CDM,S27200284,LOCAL,0272,RC,,,both,,,5276.02,1582.81,"FIRST HEALTH [10303]","First Health",,4220.82,80,,,,,0,613.6,4484.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 0MM 26MM HIP C TAPER COCR LFIT",SUP-06-2600,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"NOVANET [10819]",Novanet,,2345.78,75,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET DIL RING 8-26FR RADIOPAQUE PTFE TORQUE GWIRE SHEATH",SUP-G14893,CDM,C1894,HCPCS,0272,RC,,,both,,,1806.75,542.02,"AMERIGROUP MEDICAID [20100]",Amerigroup,,214.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,210.13,1535.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WINGSPAN 20MM 3MM INTRACRANIAL HYDROPHILIC SELF EXPAND",SUP-M003WS0300200,CDM,C1874,HCPCS,0278,RC,,,both,,,51979.47,15593.84,"BLUE CROSS [10001]","Blue Cross HMO",,20375.95,39.2,,9776.84,9776.84,9776.84,"1 through 10",6045.21,44182.55,"percent of total billed charges",
"HC Cath Bactiseal Evd",PX-E27200052,CDM,C1729,HCPCS,0272,RC,,,both,,,3671.80,1101.54,"PHCS [10601]",PHCS,,2570.26,70,,,,,0,427.03,3121.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNGOSCOPE SPECTRUM LOPRO 4 GLIDESCOPE DISPOSABLE",SUP-0270-0939,CDM,S27200284,LOCAL,0272,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0D +3 CYL BICONVEX TORIC 13MM 6MM POSTERIOR CHMBR 1",SUP-SA25T5,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"NOVANET [10819]",Novanet,,558.75,75,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 THK17MM FIXED ULTRACONGRUENT PRIMARY GMK",SUP-02.07.0317FUC,CDM,C1776,HCPCS,0278,RC,,,both,,,4271.40,1281.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,506.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,496.76,3630.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION REFERENCE 150MM PERCUTANEOUS STERILE",SUP-9733236,CDM,S27200284,LOCAL,0272,RC,,,both,,,1988.48,596.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,817.27,41.1,,,,,0,231.26,1690.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 55CM 8FR .091IN RENAL DOUBLE CURVE GUIDING PTFE",SUP-M001198660,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"AETNA [10100]","Aetna HMO/PPO",,474.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +8 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR 1",SUP-MTA4U0.080,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]",Cigna,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 20MM 2.75MM BALLOON DILATATION PACLITAXEL",SUP-H7493960820270,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"CIGNA [10200]","Cigna Open Access",,22135.52,56.9,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 149MM TITANIUM 8 HOLE AXSOS 3 BONE TIBIAL RIGHT DISTAL",SUP-627438,CDM,C1713,HCPCS,0278,RC,,,both,,,11452.90,3435.87,"MULTIPLAN [10600]",Multiplan,,9734.97,85,,,,,0,1331.97,9734.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 195CC SMOOTH SHELL SURFACE SOFT TOUCH NATRELLE",SUP-SSM-195,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2162.38,28.62,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM SPINE POLYAXIAL REVOLVE",SUP-185.456,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4382,45.9,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM E HIP ELEVATE RIM X3 TRIDENT",SUP-643-00-36E,CDM,C1776,HCPCS,0278,RC,,,both,,,9915.30,2974.59,"BLUE CROSS [10001]","Blue Cross HMO",,3886.8,39.2,,5311.50,4717.44,5388.59,31,1153.15,8428.01,"percent of total billed charges",
"COIL EMBOLIZATION 10CM 5MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS05010,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UHC [10700]","United Healthcare",,7420.72,63.3,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X12MM ALEUTIAN 7D SMALL PEEK ACDF",SUP-403-21412L,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"KAISER [10500]",Kaiser,,3004.95,67,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP TRUNCATE OSTEOTOM 54MM HEMISPHERE",SUP-00705305410,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"CIGNA [10200]","Cigna Open Access",,2575.52,56.9,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.75MM X 8.0MM",SUP-493750812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET TITANIUM SPINE BLOCKER XIA 3",SUP-48230000,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"CIGNA [10200]","Cigna Local Plus",,186.18,53.5,,3978.14,359.25,3978.14,24,40.47,295.8,"percent of total billed charges",
"IMPL FIXATION FIBERTAG TIGHTROPE II ATTACHABLE BUTTON SYSTEM",SUP-AR-1588TNT2,CDM,C1713,HCPCS,0278,RC,,,both,,,3189.38,956.81,"AETNA [10100]","Aetna HMO/PPO",,2535.56,79.5,,1521.93,481.35,16760.95,30,370.92,2710.97,"percent of total billed charges",
"IMPL BREAST SMOOTH MOD + PROF XTRA 405CC",SUP-SMPX405,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2132.76,28.62,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD SAFIO S 45 J",SUP-113395,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"BLUE CROSS [10001]","Blue Cross HMO",,150.06,39.2,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR AXONICS LEAD STERILE LATEX FREE",SUP-1801,CDM,C1894,HCPCS,0272,RC,,,both,,,2497.50,749.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1026.47,41.1,,,,,0,290.46,2122.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 17MM ATLANTIS TITANIUM SPINE CERVICAL",SUP-3125217,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYR ANGIOGRAPHY LATEX FREE MARK 7 ARTERION","SUP-ART 700 SYR",CDM,S27200284,LOCAL,0272,RC,,,both,,,73.29,21.99,"FIRST HEALTH [10303]","First Health",,58.63,80,,,,,0,8.52,62.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0250,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +15.5 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE",SUP-PCB0000155,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 38-47MM 5.5/6MM MATRIX 6 SPINE TITANIUM TRANSVERSE",SUP-04.633.338,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Local Plus",,1905.94,53.5,,3978.14,359.25,3978.14,24,414.32,3028.13,"percent of total billed charges",
"FRCP BIPOLAR 34CM KLEPPINGER CABLE",SUP-BC3310,CDM,S27200284,LOCAL,0272,RC,,,both,,,961.88,288.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,113.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.87,817.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER FEMORAL CATHCART ARTICUL/EZE -3MM 12/14 TAPER HIP",SUP-136308000,CDM,C1776,HCPCS,0278,RC,,,both,,,1650.00,495,"FIRST HEALTH [10303]","First Health",,1320,80,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 37MMX4.2MMX5CM 24FR",SUP-TE3742A,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25769.7,41.1,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 29MM BOVINE PERICARDIUM LEAFLET COBALT CHROMIUM",SUP-11400M29,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"FIRST HEALTH [10303]","First Health",,36288,80,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 80MM 7MM .035IN BALLOON",SUP-AB35W07080135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"NOVANET [10819]",Novanet,,507.87,75,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 12MM 144CM 4MM CORONARY STENT EVEROLIMUS",SUP-H7493926112400,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4275.59,45.9,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 10MM LCP STAINLESS STEEL DISTAL RADIAL SELF",SUP-212.810,CDM,C1713,HCPCS,0278,RC,,,both,,,802.87,240.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,229.78,28.62,,,,,0,93.37,682.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 6.2CM 23MM ESOPHAGEAL FULL COVER CATH DIAMETER",SUP-M00517750,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 5.5MM LONG 8 FLUTE ROUND F SERIES",SUP-385950008,CDM,S27200284,LOCAL,0272,RC,,,both,,,494.10,148.23,"FIRST HEALTH [10303]","First Health",,395.28,80,,,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BD ANGIOCATH 1.88IN 18GA STD INTRAVENOUS FEP PERIPHERAL",SUP-381147,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.83,15.85,"NOVANET [10819]",Novanet,,39.62,75,,,,,0,6.14,44.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8.5MM 12/14 TAPER 36MM HIP BIOLOX DELTA",SUP-1365-36-330,CDM,C1776,HCPCS,0278,RC,,,both,,,12268.20,3680.46,"NOVANET [10819]",Novanet,,9201.15,75,,,,,0,1426.79,10427.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 28CM 6FR URETERAL",SUP-M0061456150,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER EMBOLIZATION 50MM VENA CAVA JUGULAR INTRO SHEATH",SUP-G52916,CDM,C1880,HCPCS,0278,RC,,,both,,,3990.00,1197,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,464.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,464.04,3391.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.5 X 18MM ESPRIT BTK IDE",SUP-1202350-18,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL INBONE II 3 LONG KNEE RIGHT",SUP-220222903,CDM,C1776,HCPCS,0278,RC,,,both,,,10212.00,3063.6,"FIRST HEALTH [10303]","First Health",,8169.6,80,,,,,0,1187.66,8680.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 2MM 45MM ENDO GIA MEDIUM THICK TISSUE REINFORCE",SUP-SIGTRSB45AMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2325.23,697.57,"NOVANET [10819]",Novanet,,1743.92,75,,,,,0,270.42,1976.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM CD HORIZON VOYAGER SPINE NONSTERILE",SUP-55850047545,CDM,C1713,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3404.63,45.9,,,,,0,862.66,6304.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULTI-ARRAY SEPTAL CATHETER (MASC)",SUP-990001,CDM,S62400003,LOCAL,0624,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 40MM 4FR 7MM .018IN BALLOON",SUP-PCP070040130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,506.02,41.1,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR AVENIR COMPLETE 5 STD HIP STERILE LATEX",SUP-574201050,CDM,C1776,HCPCS,0278,RC,,,both,,,23461.20,7038.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2780.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2728.54,19942.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL CANN 8MM DA VINCI ENDOWRIST DISPOSABLE",SUP-400077,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.46,41.24,"KAISER [10500]",Kaiser,,92.1,67,,,,,0,15.99,116.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW STRAIGHT 126MM MINI FRAGMENT 10 HOLE",SUP-629510,CDM,C1713,HCPCS,0278,RC,,,both,,,4459.88,1337.96,"FIRST HEALTH [10303]","First Health",,3567.9,80,,,,,0,518.68,3790.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 20MM 7MM BALLOON DILATATION PEBAX",SUP-H74939032702010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 4MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-04007,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4818.19,41.1,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL TROUTMAN-BARRAQUER 45D .12MM 3IN ANGLED 2X3",SUP-60-1463,CDM,S27200284,LOCAL,0272,RC,,,both,,,1402.60,420.78,"PHCS [10601]",PHCS,,981.82,70,,,,,0,163.12,1192.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 18LP 150CM 4CM 7MM BALLOON DILATATION 2 LUMEN",SUP-G34339,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INTELLANAV STABLEPOINT 4MM 8FR ABLATION RING ELECTRD",SUP-M004RFSDS96200,CDM,C2630,HCPCS,0272,RC,,,both,,,20160.00,6048,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8285.76,41.1,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS ENDOSCOPIC GRASPING DISSECTING ATRAUMATIC TIP STRAIG",SUP-97-1051RC,CDM,S27100035,LOCAL,0271,RC,,,both,,,3525.60,1057.68,"CIGNA [10200]","Cigna Local Plus",,1886.2,53.5,,,,,0,410.03,2996.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) CATH TURNPIKE 135CM 2.2-2.9FR 1.6FR GUIDING LOW PROF",SUP-5638,CDM,S27200284,LOCAL,0272,RC,,,both,,,3967.50,1190.25,"KAISER [10500]",Kaiser,,2658.23,67,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 91MM 16FR ZENITH ABDOMINAL AORTIC",SUP-G32555,CDM,C1874,HCPCS,0278,RC,,,both,,,23565.28,7069.58,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2740.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2740.64,20030.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP CLUSTER HOLE 12 SCALLOP SNAP FIT",SUP-00875706001,CDM,C1776,HCPCS,0278,RC,,,both,,,11012.40,3303.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1304.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1280.74,9360.54,"percent of total billed charges",
"CATH TAKERU 20MM 2.25MM BALLOON DILATATION RAPID EXCHANGE",SUP-DC-RY2220UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,117.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBERFUSE DEMINERALIZED BONE MATRIX ALLOGRAFT",SUP-420705,CDM,C1713,HCPCS,0278,RC,,,both,,,14983.35,4495,"FIRST HEALTH [10303]","First Health",,11986.68,80,,,,,0,1742.56,12735.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,inpatient,,,149949.56,44984.87,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,14732.09,,"Case rate ($13,768.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $12,784.81, add-ons for qualifying new technology services are included. If operating cost exceeds $45,824.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,348.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $12,801.72. The transfer operating threshold is the transfer adjustment factor * $12,784.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $966.59. The transfer capital threshold is the transfer adjustment factor * $966.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7561,64803.44,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE THINFLAP STD CRANIOFACIAL TITANIUM 6 HOLE CURVED",SUP-191050,CDM,C1713,HCPCS,0278,RC,,,both,,,1912.50,573.75,"MULTIPLAN [10600]",Multiplan,,1625.63,85,,,,,0,222.42,1625.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .014IN 4FR 4MM 142CM 1.5CM",SUP-4244015W,CDM,C1725,HCPCS,0272,RC,,,both,,,1438.80,431.64,"AETNA [10100]","Aetna HMO/PPO",,1143.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.33,1222.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 80MM 2.2MM MIDAS REX LEGEND MATCH HEAD",SUP-8MH22,CDM,S27200284,LOCAL,0272,RC,,,both,,,974.03,292.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,447.08,45.9,,,,,0,113.28,827.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 4.50 X 16MM",SUP-H7493942816450,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross HMO",,2434.32,39.2,,9776.84,9776.84,9776.84,"1 through 10",722.22,5278.5,"percent of total billed charges",
"PORT IMPLANTABLE INFUSION SILICONE FILL SUT PLUG 1 LUMEN",SUP-1716000,CDM,C1788,HCPCS,0278,RC,,,both,,,1905.00,571.5,"CIGNA [10200]","Cigna Local Plus",,1019.18,53.5,,,,,0,221.55,1619.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Cong Card Ltd",PX-483000002,CDM,93304,CPT,0483,RC,,,both,,,3662.94,1098.88,"CIGNA [10200]","Cigna Local Plus",,1959.67,53.5,,,,,0,307.78,3113.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 KNEE RIGHT CEMENTED POSTERIOR STABILIZE",SUP-150410209,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2653.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2604.35,19034.35,"percent of total billed charges",
"CATH MUSTANG 40CM 20MM 9MM .035IN BALLOON DILATATION NYBAX",SUP-39171-09024,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,136.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOFT TISSUE PROCEDURES WITHOUT CC/MCC",502,MS-DRG,,,,,,,inpatient,,,89001.64,26700.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,21458.67,,,,,,,7561,39294.9,"case rate",
"CLAREON VIVITY TORIC UVA",SUP-CCWET4,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"FIRST HEALTH [10303]","First Health",,692,80,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP050020150 PLUS US D5L20UL1500",SUP-PCP050020150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ELUNIR THK90UM 33MM 140CM 3.5MM CORONARY STENT",SUP-LUN350R33US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM OPHTHALMIC EYE BARRAQUER 5MM PEDIATRIC",SUP-60-1962,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.10,83.73,"FIRST HEALTH [10303]","First Health",,223.28,80,,,,,0,32.46,237.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 24FR SILICONE INTERNAL RETENTION BALLOON RECESS DISTAL",SUP-8100-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,33.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC",067,MS-DRG,,,,,,,inpatient,,,51686.11,15505.83,"UHC [10700]","United Healthcare",,36627.91,,"Fee schedule rate ($36,627.91). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,36627.91,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFARI2 275CM SMALL CURVE SGL REPRISE III",SUP-H74939407S0,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D F KNEE LEFT OSSEOTI KEEL",SUP-42535007501,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5506.2,40,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 6-0 S-14 18IN 2 ARM BRAID COATED VIOLET",SUP-J570G,CDM,S27200284,LOCAL,0272,RC,,,both,,,161.82,48.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,19.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.82,137.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TEVDEK 5-0 T-3 30IN 2 ARM BRAIDED COATED GREEN",SUP-7-796,CDM,S27200284,LOCAL,0272,RC,,,both,,,273.14,81.94,"CIGNA [10200]","Cigna Local Plus",,146.13,53.5,,,,,0,31.77,232.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZIPWIRE BENTSON UROLOGICAL STRAIGHT 150CM 8CM .038IN",SUP-M0066802271,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 19MM 80CM 6MM 8MM 7FR .035IN",SUP-BXA061901A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP LIMIT HOLE MODULAR TITANIUM POROUS",SUP-PT-116050,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"BLUE CROSS [10001]","Blue Cross PPO",,4000.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",1186.85,8674.34,"percent of total billed charges",
"LENS IOL +15.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.155,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Open Access",,391.76,56.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12.5CM 78CM 23MM 18.5FR 28MM FLARE ESOPHAGEAL",SUP-M00516740,CDM,C1874,HCPCS,0278,RC,,,both,,,10076.00,3022.8,"AETNA [10100]","Aetna HMO/PPO",,8010.42,79.5,,,,,0,1171.84,8564.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X21MM ENDOSKELETON TAS 12D 13MM STD TITANIUM",SUP-2312-0113,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PHCS [10601]",PHCS,,19845,70,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 8-0 BV130-4 5IN BRAID COATED VIOLET ABSORBABLE",SUP-J405G,CDM,S27200284,LOCAL,0272,RC,,,both,,,190.22,57.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,129.35,68,,,,,0,22.12,161.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GALLANT HF CRT-D DF1 CONNECTOR",SUP-CDHFA500T,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,20776.5,27,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE MNTR .3MR M-NMT MECHANOSENSOR",SUP-888418,CDM,S27000186,LOCAL,0270,RC,,,both,,,2622.90,786.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,305.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.04,2229.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL MEDIUM 6 FLUTE ROUND L50.8 MM OD3 MM STERILE",SUP-5300-010-509,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.08,49.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,76.23,45.9,,,,,0,19.32,141.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT GRAFTON LARGE DEFECT DEMINERALIZED BON",SUP-T44150,CDM,C1713,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Open Access",,3533.49,56.9,,1144.80,304.56,2275.09,66,722.22,5278.5,"percent of total billed charges",
"CATHETER ANGIOPLASTY L150CM BALLOON L200MM DIA4MM COMPATIBLE",SUP-1013466-200,CDM,S27200284,LOCAL,0272,RC,,,both,,,1255.50,376.65,"CIGNA [10200]","Cigna Local Plus",,671.69,53.5,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROMORPHONE 2 MG TABLET",RX-3760,CDM,,,0250,RC,60687-0579-11,NDC,both,1,UN,12.54,3.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8.53,68,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 3-0 CV-23 .5 CIRCLE 12IN 17MM CLSR TAPER",SUP-VLOCL0814,CDM,S27200284,LOCAL,0272,RC,,,both,,,426.30,127.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,195.67,45.9,,,,,0,49.58,362.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 240CM 5.5CM 7.5FR 15-18MM ESOPHAGEAL",SUP-M00558490,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,195.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE LARYNSCP ROUND 3 SPRUNG BALL ADVANCE LED LIGHT BLADE",SUP-040-310U,CDM,S27000186,LOCAL,0270,RC,,,both,,,44.00,13.2,"MULTIPLAN [10600]",Multiplan,,37.4,85,,,,,0,5.12,37.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX16MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183546,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,929.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE RIGHT MEDIAL LEFT LATERAL RESTORIS",SUP-180513,CDM,C1776,HCPCS,0278,RC,,,both,,,12440.70,3732.21,"KAISER [10500]",Kaiser,,8335.27,67,,,,,0,1446.85,10574.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 70MM 4 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800470,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 25MM TRIGEN FEMUR LOW PROFILE",SUP-71645025,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"CIGNA [10200]","Cigna Local Plus",,1107.21,53.5,,3978.14,359.25,3978.14,24,240.69,1759.12,"percent of total billed charges",
"IMPL BREAST 14.4-14.8CM P5.6-6.5CM MODERATE PLUS PROFILE",SUP-3502650,CDM,C1789,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 4FR RIGHT CORONARY BYPASS",SUP-538470,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RECTAL RESECTION WITH CC",333,MS-DRG,,,,,,,inpatient,,,104957.53,31487.26,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN LONG",SUP-77805500,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCREW FREEFIX COMPRESSION 3.5MM X 22MM TI",SUP-FFC-35220-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1061.10,318.33,"BLUE CROSS [10001]","Blue Cross HMO",,415.95,39.2,,957.42,156.86,7483.26,51,123.41,901.94,"percent of total billed charges",
"EXTR STONE 115CM 1.7FR 11MM NGAGE KIDNEY URETER NITINOL",SUP-G48295,CDM,S27200284,LOCAL,0272,RC,,,both,,,2063.25,618.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,239.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.96,1753.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 4IN TUNGSTEN 20X12MM NONHEX",SUP-E15614,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.49,30.15,"CIGNA [10200]","Cigna Open Access",,57.18,56.9,,,,,0,11.69,85.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VASCULAR 9MM 29MM 135CM OTW BALLOON EXPANDABLE",SUP-1012632-29,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 12X4IN ABSORBENT SELF ADHERENT SHOWER PROOF",SUP-395990,CDM,S27200284,LOCAL,0272,RC,,,both,,,225.59,67.68,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,103.55,45.9,,,,,0,26.24,191.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CROSSWALK 90CM 2.5FR 1.7FR .021FR .019FR 2.7FR MICRO",SUP-PSC18090A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1498.50,449.55,"CIGNA [10200]",Cigna,,1018.98,68,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEPHEA MITRAL VALVE TRACK 2 40MM",SUP-23040,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT WALKING GENESIS MEDIUM MID CALF FOREFOOT ANKLE FULL",SUP-BL525005,CDM,S27000186,LOCAL,0270,RC,,,both,,,434.91,130.47,"CIGNA [10200]",Cigna,,295.74,68,,,,,0,50.58,369.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD SENTUS PROMRI LEFT VENTRICULAR OTW QUADRIPOLAR",SUP-408718,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1604.72,28.62,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACCU-VU 100CM 20CM 5FR PIGTAIL CURVE ANGIOGRAPHIC",SUP-H787137098035,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.98,329.99,"FIRST HEALTH [10303]","First Health",,879.98,80,,,,,0,127.93,934.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL WEIL-BLAKESLEY 0 3.5MM 7.5IN NASAL FENESTRATE",SUP-63-2009,CDM,S27200284,LOCAL,0272,RC,,,both,,,1920.45,576.13,"CIGNA [10200]",Cigna,,1305.91,68,,,,,0,223.35,1632.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2MM 2MM .018IN HELICAL STRAIGHT PLATINUM",SUP-M0013120021,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.085 CLAREON",SUP-SY60WF.085,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 60CM 6MM 2 VELOUR KNITTED STRAIGHT TUBE",SUP-M002020952060,CDM,C1768,HCPCS,0278,RC,,,both,,,3748.95,1124.68,"KAISER [10500]",Kaiser,,2511.8,67,,,,,0,436,3186.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 44MM 2 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-42F44V,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",521.61,3812.25,"percent of total billed charges",
"STENT ABSOLUTE PRO 40MM 80CM 8MM VASCULAR NITINOL PERIPHERAL",SUP-1012530-40,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,481.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POD XL 8MMX55CM",SUP-RBYPODXL0855,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"BLUE CROSS [10001]","Blue Cross HMO",,7384.1,39.2,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL ABDOMEN 12IN CIRCUMFERENCE 45IN-62IN M",SUP-55476302,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.33,38.5,"FIRST HEALTH [10303]","First Health",,102.66,80,,,,,0,14.92,109.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 15CM 180CM 20MM 10.5FR ESOPHAGEAL",SUP-G57355,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"BLUE CROSS [10001]","Blue Cross PPO",,6895.12,39.2,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PATCH KIT",SUP-900-00031,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKING COILS XL 30CM",SUP-RBYPCXL30,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO BLACK 23CM 9FR BRITE TIP CANN INTERVENTIONAL",SUP-401923M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"PHCS [10601]",PHCS,,73.08,70,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C1 Complement Esterase Inhib",PX-302000031,CDM,86161,CPT,0302,RC,,,both,,,237.90,71.37,"CIGNA [10200]","Cigna Local Plus",,26.4,,,,,,,0.01,202.22,"fee schedule",
"CIRCAID COMPRESSION ANKLET (LG)",SUP-RSANK002,CDM,S27000186,LOCAL,0270,RC,,,both,,,170.52,51.16,"KAISER [10500]",Kaiser,,114.25,67,,,,,0,19.83,144.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50MM 2MM 18 COIL STRAIGHT PLATINUM FIBER 5",SUP-M0013120051,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 0 CT-1 SPIRAL 70CM SUT ABSORBABLE",SUP-SXPP1B408,CDM,S27200284,LOCAL,0272,RC,,,both,,,224.03,67.21,"MULTIPLAN [10600]",Multiplan,,190.43,85,,,,,0,26.05,190.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REGULAR 5FR INTRO STAINLESS STEEL ECHOGENIC NDL GWIRE",SUP-70-5130,CDM,C1894,HCPCS,0272,RC,,,both,,,295.80,88.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,35.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.4,251.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +28.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.285,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM STAINLESS STEEL STD CORTEX SPHERICAL",SUP-202.012,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"BLUE CROSS [10001]","Blue Cross PPO",,137.71,39.2,,957.42,570.23,957.42,28,40.86,298.61,"percent of total billed charges",
"SCR BONE CONICAL CANNULATED 5MM 85MM LCP STAINLESS STEEL",SUP-02.205.285,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"FIRST HEALTH [10303]","First Health",,1244.68,80,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 65MM TITANIUM LEVEL 3 ZEVO BONE SPINE CERVICAL",SUP-3003065,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 16X18MM FUSEFORCE HAND 2MM REAMER STERILE",SUP-FFNS1816,CDM,S27200284,LOCAL,0272,RC,,,both,,,7755.60,2326.68,"PHCS [10601]",PHCS,,5428.92,70,,,,,0,901.98,6592.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 50MM CREO SPINE PREASSEMBLE THREAD",SUP-5119.1552,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL STRAIGHT SICKLE",SUP-3722110,CDM,S27200284,LOCAL,0272,RC,,,both,,,922.10,276.63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,109.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,107.24,783.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ALUMI-HAND XL 13X10.5IN POSITIONING ALUMINUM HAND",SUP-761,CDM,S27200284,LOCAL,0272,RC,,,both,,,427.39,128.22,"MULTIPLAN [10600]",Multiplan,,363.28,85,,,,,0,49.71,363.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL XL XTHICK CIRCLE TISSUE ANVIL EEA TILT-TOP",SUP-TRIEEAXL31XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2678.40,803.52,"UHC [10700]","United Healthcare",,1695.43,63.3,,,,,0,311.5,2276.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL BONE VERTECOR",SUP-2224,CDM,S27200284,LOCAL,0272,RC,,,both,,,1607.45,482.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1093.07,68,,,,,0,186.95,1366.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CEMENTED EXETER V40 4 44MM OFFSET HIP",SUP-0580-1-444,CDM,C1776,HCPCS,0278,RC,,,both,,,17001.60,5100.48,"BLUE CROSS [10001]","Blue Cross HMO",,6664.63,39.2,,5311.50,4717.44,5388.59,31,1977.29,14451.36,"percent of total billed charges",
"SCR BASEPLT 38MM 4.5MM AEQUALIS SHOULDER TITANIUM LOCK",SUP-DWD038,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"PHCS [10601]",PHCS,,1089.2,70,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) SYSTEM AVEIR PACEMKR LEADLESS VR RET CATH TRI LOOP",SUP-LSCR111,CDM,S27200284,LOCAL,0272,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 300CC SMOOTH SUT TAB INTEGRAL INJECTION",SUP-SMXP110RH,CDM,C1789,HCPCS,0278,RC,,,both,,,11902.50,3570.75,"CIGNA [10200]","Cigna Open Access",,3987.34,33.5,,5166.00,5166.00,5166.00,"1 through 10",1384.26,10117.13,"percent of total billed charges",
"SYR ANGIOGRAPHY LATEX FREE MARK 7 ARTERION",SUP-60729385,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.29,21.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.52,62.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ortho/Pros Mgmt Sub 15min (Gp)",PX-420000162,CDM,97763,CPT,0420,RC,,,both,,,133.00,39.9,"KAISER [10500]",Kaiser,,89.11,67,,,,,0,15.47,133,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE TIBIAL LEGACY 7D 4 CONE KNEE CONDYLE CONSTRAIN",SUP-544605431,CDM,C1776,HCPCS,0278,RC,,,both,,,38828.22,11648.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4601.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,4515.72,33003.99,"percent of total billed charges",
"SCR BONE 3.5MM 18MM VUEPOINT II SPINE MULTIAXIAL NONSTERILE",SUP-8975318,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"VXSK-230J RF WIRE 63CM/45DEG/D0 SHEATH",SUP-VXSK0111,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,731.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 35MM 75CM 9MM 100CM",SUP-M001712260,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1001.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 14.5X15CM 595ML STYLE FF HIGHLY COHESIVE GEL",SUP-FF-410595,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TALON ORTHOPEDIC BALL TIP SHEATHED",SUP-SLN-T41,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UHC [10700]","United Healthcare",,769.1,63.3,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER TEVDEK 2-0 C-2 30IN 2 ARM BRAIDED GREEN",SUP-7-420,CDM,S27200284,LOCAL,0272,RC,,,both,,,215.31,64.59,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AMPUTATION OF LOWER LIMB EXCEPT TOES,MAJOR",305,APR-DRG,,,,,,,inpatient,,,134519.07,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $18,005.89. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($125,411.26) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,MODERATE",651,APR-DRG,,,,,,,inpatient,,,78771.99,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $7,392.44. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($57,620.77) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAUT 18IN 4.5FR 7.5FR CHOLANGIOGRAM SPRT TUBE MAXIMUM",SUP-20018-010,CDM,S27200284,LOCAL,0272,RC,,,both,,,455.22,136.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSOLE SHOE 6-8 SMALL MALE DARCO PEG-ASSIST REMOVABLE PEG",SUP-PTQM1,CDM,S27000186,LOCAL,0270,RC,,,both,,,100.92,30.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 25.4MM THK1.3MM 99MM XLONG WIDE STAINLESS STEEL",SUP-2108218000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.58,57.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOOD SURGEON FLYTE ZIPPER PEEL AWAY LENS STERILE LATEX FREE",SUP-0408-800-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.71,111.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR JUDKINS RIGHT 4",SUP-67009000,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PLAIN 2-0 CT 27IN MONOFILAMENT ABSORBABLE",SUP-853H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEART FAILURE,EXTREME",194,APR-DRG,,,,,,,inpatient,,,26805.20,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $14,238.90. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($106,536.53) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 535CC",SUP-RSZ-SHPX-535S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 10CM 4FR 21GA MERIT MAK .018IN STD STAINLESS STEEL",SUP-MAK401,CDM,C1894,HCPCS,0272,RC,,,both,,,197.06,59.12,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER MAMMARY SILICONE 300ML BREAST GEL SMOOTH ROUND",SUP-RSZ3004,CDM,S27200284,LOCAL,0272,RC,,,both,,,127.64,38.29,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 1.5MM 8MM TITANIUM CORTICAL HAND SELF TAPPING",SUP-400.808,CDM,C1713,HCPCS,0278,RC,,,both,,,421.52,126.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,49.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",49.02,358.29,"percent of total billed charges",
"GRAFT STENT 60MM 6MM 8FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEM06060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR AXONICS PERCUTANEOUS NERVE EVALUATION",SUP-1901,CDM,C1897,HCPCS,0278,RC,,,both,,,348.00,104.4,"CIGNA [10200]",Cigna,,236.64,68,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 140MM 120CM 10MM BILIARY VENA CAVA OTW DELIVERY",SUP-G57439,CDM,C1876,HCPCS,0278,RC,,,both,,,13109.93,3932.98,"CIGNA [10200]","Cigna Open Access",,4391.83,33.5,,,,,0,1524.68,11143.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT MEGALOADER HD SCORPION",SUP-AR-13999HDN,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E KNEE FEMUR TIBIA CEMENT",SUP-98000600010,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,9384.48,39.2,,3949.44,3949.44,3949.44,"1 through 10",2784.22,20349,"percent of total billed charges",
"GRAFT BONE CANCELLOUS 60ML 1.7-10MM ALLOGRAFT CHIPS FREEZE",SUP-T00045,CDM,S27800098,LOCAL,0278,RC,,,both,,,5105.31,1531.59,"MULTIPLAN [10600]",Multiplan,,4339.51,85,,,,,0,593.75,4339.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 10X9X6MM ARCH PARALLEL SPINE FREEZE DRIED",SUP-15110,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE3.5MM 32.5MM MAXLOCK EXTREME ANKLE FOOT NONLOCKING",SUP-MFT01135325,CDM,C1713,HCPCS,0278,RC,,,both,,,1239.30,371.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,146.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",144.13,1053.41,"percent of total billed charges",
"GRAFT SOFT TISSUE 8X6CM AXIS TUTOPLAST DERMIS ALLOGRAFT",SUP-939268,CDM,C1762,HCPCS,0278,RC,,,both,,,16629.00,4988.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1933.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1933.95,14134.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA MIV 110CM 5FR PIGTAIL LT CURVE ANGIOGRAPHIC",SUP-5RPL110,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.84,61.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,94.48,45.9,,,,,0,23.94,174.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 2-0 CT-1 SPIRAL 45CM CLSR",SUP-SXMP1B413,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"NOVANET [10819]",Novanet,,160.43,75,,,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL 2.8 X 160MM SOLID MEASURING LONG AO",SUP-P99-100-2816,CDM,S27000186,LOCAL,0270,RC,,,both,,,1004.40,301.32,"CIGNA [10200]",Cigna,,682.99,68,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK",RX-32950,CDM,J2260,HCPCS,0636,RC,00143-9719-01,NDC,both,100,ML,114.48,34.34,"UHC [10700]","United Healthcare",,10.52,,,,,,,6.34,97.31,"fee schedule",
"AVENIR 10, 4 X 10 COMPLEX PICO COIL",SUP-10USC04010,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1549.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THORECON? BONE SCREW, 2.7MM X 14MM, 4 PACK",SUP-94-27-14-4S,CDM,C1713,HCPCS,0278,RC,,,both,,,2947.50,884.25,"BLUE CROSS [10001]","Blue Cross HMO",,1155.42,39.2,,957.42,156.86,7483.26,51,342.79,2505.38,"percent of total billed charges",
"SCR BONE 1.5MM 9MM TITANIUM T4 CORTICAL SELF TAP STARDRIVE",SUP-04.214.109,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,1831.33,1831.33,1831.33,16,50.59,369.75,"percent of total billed charges",
"LEAD DEFIB 52CM 7.5FR SPRINT QUATTRO TRANSVENE VENTRICLE",SUP-6937A-52,CDM,C1896,HCPCS,0278,RC,,,both,,,6900.00,2070,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Aerob Presump ID Wound",PX-306000026,CDM,87070,CPT,0306,RC,,,both,,,362.90,108.87,"UHC [10700]","United Healthcare",,7.76,,,,,,,0.01,308.47,"fee schedule",
"CATH BD ANGIOCATH 3.25IN 14GA INTRAVENOUS FEP PERIPHERAL",SUP-382268,CDM,S27200284,LOCAL,0272,RC,,,both,,,115.88,34.76,"FIRST HEALTH [10303]","First Health",,92.7,80,,,,,0,13.48,98.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tte Stress W Contr",PX-483000016,CDM,93350,CPT,0483,RC,,,both,,,4038.65,1211.59,"CIGNA [10200]","Cigna Open Access",,2297.99,56.9,,,,,0,302.63,3432.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 5 X 6 HELICAL FINISHING COIL",SUP-10HFN-05006,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA [10200]",Cigna,,7033.31,68,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 12/14 TAPER 36MM HIP CEMENTLESS M",SUP-136552000,CDM,C1776,HCPCS,0278,RC,,,both,,,3991.68,1197.5,"BLUE CROSS [10001]","Blue Cross HMO",,1564.74,39.2,,5311.50,4717.44,5388.59,31,464.23,3392.93,"percent of total billed charges",
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 15MM COCR",SUP-VAL-20150-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]","Cigna Local Plus",,762.7,53.5,,3978.14,359.25,3978.14,24,165.8,1211.76,"percent of total billed charges",
"SYSTEM MULTI-LINK VISION 28MM 3MM CORONARY STENT COCR RAPID",SUP-1007848-28,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Open Access",,1707,56.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 20CM 3CM 6FR .035IN 2",SUP-M006192130180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"KAISER [10500]",Kaiser,,1065.21,67,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TELESCOPE 7FR EXT CORONARY PERIPHERAL COMPATIBLE GUIDE",SUP-TELE7F,CDM,C1887,HCPCS,0272,RC,,,both,,,2767.50,830.25,"UHC [10700]","United Healthcare",,1751.83,63.3,,,,,0,321.86,2352.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .018IN 4FR 7MM 135CM 4CM PTA LOW",SUP-G50257,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 100MM 1800MM 18MM ESOPHAGEAL METAL NITINOL",SUP-ECBA-18-100-180,CDM,C1874,HCPCS,0278,RC,,,both,,,16425.45,4927.63,"AETNA [10100]","Aetna HMO/PPO",,13058.23,79.5,,,,,0,1910.28,13961.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX PROGRIP 30X15CM SELF GRIP FLAT SHEET",SUP-TEM3015G,CDM,C1781,HCPCS,0278,RC,,,both,,,3099.38,929.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,360.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,360.46,2634.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175263090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"PHCS [10601]",PHCS,,931.18,70,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST LARGE WEDGE FREEZE DRIED",SUP-40A001,CDM,S27800098,LOCAL,0278,RC,,,both,,,3977.85,1193.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,471.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,462.62,3381.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE PENCIL STD 2.75IN 3/32IN EDGE",SUP-E1455B,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.24,14.77,"UHC [10700]","United Healthcare",,31.17,63.3,,,,,0,5.73,41.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 RIGHT MEDIAL LEFT LATERAL PARTIAL KNEE",SUP-5610-F-202,CDM,C1776,HCPCS,0278,RC,,,both,,,10002.10,3000.63,"NOVANET [10819]",Novanet,,7501.58,75,,,,,0,1163.24,8501.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +16.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM POST",SUP-ZA90030165,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross PPO",,460.4,39.2,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 550ML STYLE 7200 MEDIUM HEIGHT CENTERSCOPE",SUP-3547214,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"KAISER [10500]",Kaiser,,6125.48,67,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SAPPHIRE 3 CORONARY DILATATION CATHETER 1.25 X 5MM",SUP-54125-050-02,CDM,C1725,HCPCS,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 90CM 6FR STRAIGHT GUIDING DURAFORM",SUP-H965100500,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"MULTIPLAN [10600]",Multiplan,,2127.66,85,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR",RX-9773,CDM,,,0637,RC,08888-8887-37,NDC,both,5,ML,80.00,24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.3,68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 4.5MM 10MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.510.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"BLUE CROSS [10001]","Blue Cross HMO",,233.82,39.2,,957.42,156.86,7483.26,51,69.37,507.01,"percent of total billed charges",
"ADPR LD 6MM",SUP-501204,CDM,C1883,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cholesterol Ldl",PX-301000549,CDM,83721,CPT,0301,RC,,,both,,,116.00,34.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16.52,,,,,,,0.01,98.6,"fee schedule",
"RELINE C SCREW, 4.5X35MM MA THORACIC",SUP-3934535,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR CANCELLOUS CORTICAL LORDOTIC",SUP-345841,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE URETHROTOME CORRUGATE",SUP-A3557,CDM,S27200284,LOCAL,0272,RC,,,both,,,2004.75,601.42,"CIGNA [10200]","Cigna Local Plus",,1072.54,53.5,,,,,0,233.15,1704.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.215,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"FIRST HEALTH [10303]","First Health",,276,80,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 32MM 144CM 5MM CORONARY STENT",SUP-H7493941832500,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC",229,MS-DRG,,,,,,,inpatient,,,185247.33,55574.2,"CIGNA [10200]",Cigna,,41296.24,,"Fee schedule rate ($41,296.24). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,19536.54,91952.8,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 19MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-619,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1352.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1327.29,9700.71,"percent of total billed charges",
"CATH DIREXION 105CM 2.4-3FR .021IN MICRO INFUSION NITINOL",SUP-M001195260,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 8X80 80CM SL",SUP-48008008N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"AETNA [10100]","Aetna HMO/PPO",,682.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL JACOBSON MOSQUITO MICRO CURVE 5IN VERY SLENDER",SUP-15-4182,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.39,53.82,"CIGNA [10200]",Cigna,,121.99,68,,,,,0,20.86,152.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SR LORDOTIC ALLOGRAFT 14X11X4MM",SUP-400441,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 15MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158106115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1299.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 28CM 150CM 5FR .038IN 3CM BLADDER LOOP",SUP-M006155224170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"MULTIPLAN [10600]",Multiplan,,1207.29,85,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR VANSCHIE 4",SUP-G13783,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.56,87.17,"KAISER [10500]",Kaiser,,194.68,67,,,,,0,33.79,246.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL STD OFFSET 36MM HIP TYPE 1 COCR G7",SUP-11363662,CDM,C1776,HCPCS,0278,RC,,,both,,,5296.44,1588.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3601.58,68,,,,,0,615.98,4501.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 100MM 2MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.19,CDM,S27000186,LOCAL,0270,RC,,,both,,,329.00,98.7,"CIGNA [10200]","Cigna Open Access",,187.2,56.9,,,,,0,38.26,279.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP 3 HOLE POLY POROUS R3 STD STERILE",SUP-71335562,CDM,C1776,HCPCS,0278,RC,,,both,,,14614.20,4384.26,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6006.44,41.1,,6417.48,6417.48,6417.48,"1 through 10",1699.63,12422.07,"percent of total billed charges",
"SCR BONE 4.5MM 56MM STAINLESS STEEL PARTIAL THREAD LONG BONE",SUP-214.556,CDM,C1713,HCPCS,0278,RC,,,both,,,1096.42,328.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",127.51,931.96,"percent of total billed charges",
"CMPNT FEMORAL KNEE LEFT 2.5 63X59MM CEMENTED CRUCIATE",SUP-960086,CDM,C1776,HCPCS,0278,RC,,,both,,,27588.96,8276.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11339.06,41.1,,6417.48,6417.48,6417.48,"1 through 10",3208.6,23450.62,"percent of total billed charges",
"CAP SIDUS ANCHOR (HUMERUS)/MODULAR GLENOID/PREMIUM POST/VERS",SUP-98000900331,CDM,C1776,HCPCS,0278,RC,,,both,,,34650.00,10395,"FIRST HEALTH [10303]","First Health",,27720,80,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 3 KNEE REVISION",SUP-5612-B-300,CDM,C1776,HCPCS,0278,RC,,,both,,,26089.56,7826.87,"AETNA [10100]","Aetna HMO/PPO",,20741.2,79.5,,10981.53,8986.79,12413.38,12,3034.22,22176.13,"percent of total billed charges",
"CATH OPTICROSS 6 6FR ULTRASOUND INTRAVASCULAR",SUP-H7495181160,CDM,C1753,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3167.1,68,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.5/9",SUP-401730,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 15MM 90CM 7MM BILIARY STAINLESS",SUP-H74937911715900,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"MULTIPLAN [10600]",Multiplan,,4243.2,85,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 120MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,589.25,41.1,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 000 ANGLE OVAL 9IN BRUNS SPINE SURGICAL",SUP-29-5373,CDM,S27200284,LOCAL,0272,RC,,,both,,,253.00,75.9,"MULTIPLAN [10600]",Multiplan,,215.05,85,,,,,0,29.42,215.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION LARGE 6 POSITION PIN MR CONDITIONAL",SUP-390.01,CDM,S27800098,LOCAL,0278,RC,,,both,,,2793.00,837.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1899.24,68,,,,,0,324.83,2374.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 11MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS11030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PHCS [10601]",PHCS,,8206.17,70,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 CC 24IN 2 ARM MONOFILAMENT BLUE",SUP-8807H,CDM,S27200284,LOCAL,0272,RC,,,both,,,196.35,58.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,90.12,45.9,,,,,0,22.84,166.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 STRAIGHT OVAL 8IN SURGICAL SPINAL FUSION",SUP-29-5032,CDM,S27200284,LOCAL,0272,RC,,,both,,,353.39,106.02,"FIRST HEALTH [10303]","First Health",,282.71,80,,,,,0,41.1,300.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640512,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"MULTIPLAN [10600]",Multiplan,,9565.82,85,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 26MM 10MM HEMASHIELD PLATINUM 1 BRANCH",SUP-M00202175826P0,CDM,C1768,HCPCS,0278,RC,,,both,,,8352.73,2505.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,989.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,971.42,7099.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT 4 .5 CIRCLE TROCAR POINT MAYO CATGUT STERILE LATEX",SUP-1826-4DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 146MM CANNULATED SURGICAL 3.5MM CANNULATED SCR",SUP-311.39,CDM,S27000186,LOCAL,0270,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM TSRH OSTEOGRIP TITANIUM SHORT SPINE",SUP-83575408,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.10,1106.73,"NOVANET [10819]",Novanet,,2766.83,75,,,,,0,429.04,3135.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY CHORDAL GUIDE DURAN ANCORE",SUP-620RG31,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Open Access",,4391.85,33.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 13X13.5CM BREAST 500ML STYLE 133FV TEXTURE",SUP-133FV-13,CDM,C1789,HCPCS,0278,RC,,,both,,,5460.00,1638,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3712.8,68,,,,,0,635,4641,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 12MM TITANIUM LOW PROFILE FOOT HAND ANKLE",SUP-AR-8724V-12,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"PHCS [10601]",PHCS,,1134,70,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 4.5MM .6MM RICHARDS EAR PISTON RIBBON LOOP",SUP-140785,CDM,L8613,HCPCS,0278,RC,,,both,,,1209.90,362.97,"CIGNA [10200]",Cigna,,822.73,68,,,,,0,140.71,1028.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEFIX V",SUP-ZV-181E10,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.46,25.04,"CIGNA [10200]","Cigna Local Plus",,44.65,53.5,,,,,0,9.71,70.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC .062IN TROCAR TIP DISPOSABLE 5MM SCR",SUP-AR-8750K,CDM,C1713,HCPCS,0278,RC,,,both,,,130.50,39.15,"BLUE CROSS [10001]","Blue Cross HMO",,51.16,39.2,,957.42,156.86,7483.26,51,15.18,110.93,"percent of total billed charges",
"TRAY CATHETERIZATION SURESTEP BARDEX IC COMPLETE CARE 18FR",SUP-A304718A,CDM,S27200284,LOCAL,0272,RC,,,both,,,241.60,72.48,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,110.89,45.9,,,,,0,28.1,205.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 26MM SAPIEN 3 COMMANDER EDWARDS TRANSCATHETER",SUP-S3UCM226A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,74100,40,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCITRIOL 0.5 MCG CAPSULE",RX-9351,CDM,,,0637,RC,64380-0724-06,NDC,both,1,UN,9.73,2.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.13,8.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP BARDEX IC COMPLETE CARE",SUP-A300416A,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.07,41.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.06,117.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING HEMODIALYSIS 14IN 8MM 82ML 60ML COMBISET SPLIT SEPTUM",SUP-03-2622-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,566.76,170.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,232.94,41.1,,,,,0,65.91,481.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CREO CREO AMP HA SPINE MODULAR STERILE",SUP-1067.1651S,CDM,S27800098,LOCAL,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 36MM LEVEL 2 VIP BONE SPINE CERVICAL ANTERIOR",SUP-171.236,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION LIFECARE 0.9% SODIUM CHLORIDE 2L LATEX FREE",SUP-07972-07,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 22GA BINKHORST STRAIGHT BLUNT IRR SMOOTH",SUP-60-1229,CDM,S27200284,LOCAL,0272,RC,,,both,,,196.71,59.01,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,80.85,41.1,,,,,0,22.88,167.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 20GA 45CM 10CM FLEXIBLE MINI WIRE SLENDER",SUP-80-1065,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"MULTIPLAN [10600]",Multiplan,,378.68,85,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 0 18IN BRAID 12 STRAND COATED VIOLET ABSORBABLE",SUP-J906G,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.08,26.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.36,75.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 150CM 200MM 5MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013468-200,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PHCS [10601]",PHCS,,878.85,70,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR 75CM 7CM .035IN STAINLESS",SUP-M001465631,CDM,C1769,HCPCS,0272,RC,,,both,,,494.10,148.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,203.08,41.1,,,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM TITANIUM T7 FULL THREAD SELF TAP LOCK",SUP-40-27614,CDM,C1713,HCPCS,0278,RC,,,both,,,1211.11,363.33,"KAISER [10500]",Kaiser,,811.44,67,,,,,0,140.85,1029.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 31-44MM 20MM FORTIFY",SUP-151.152,CDM,S27800098,LOCAL,0278,RC,,,both,,,31320.00,9396,"CIGNA [10200]",Cigna,,12528,40,,,,,0,3642.52,26622,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC THK6MM 57X59MM SYNCRA ATRIUM VENTRICLE 2",SUP-C2TR01,CDM,C2621,HCPCS,0275,RC,,,both,,,23090.40,6927.12,"MULTIPLAN [10600]",Multiplan,,19626.84,85,,,,,0,2685.41,19626.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 3MM CORONARY STENT",SUP-1145300-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 120MM 80CM 5MM 6FR .035IN BILIARY",SUP-G50113,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,721.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE OFFSET +7.0MM ENCORE",SUP-411-00-700,CDM,C1776,HCPCS,0278,RC,,,both,,,947.54,284.26,"BLUE CROSS [10001]","Blue Cross PPO",,371.44,39.2,,3949.44,3949.44,3949.44,"1 through 10",110.2,805.41,"percent of total billed charges",
"GO2VENT (100% FIO2 ONLY, NO ENTRAINMENT) WITH MANOMETER AND 10",SUP-64-6001,CDM,S27200284,LOCAL,0272,RC,,,both,,,469.80,140.94,"UHC [10700]","United Healthcare",,297.38,63.3,,,,,0,54.64,399.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 200MM 4MM BALLOON",SUP-U3575420,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 590ML GEL SMOOTH MEMORYGEL COHESIVE I P6.3CM","SUP-3505590 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3885.00,1165.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,460.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,451.83,3302.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ACCUSTICK II VASCULAR 60CM 7.5CM .018IN 21GA STAINLESS",SUP-M001201081,CDM,C1769,HCPCS,0272,RC,,,both,,,287.10,86.13,"NOVANET [10819]",Novanet,,215.33,75,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Admin Hyperbaric O2 per 30min",PX-413000001,CDM,G0277,HCPCS,0413,RC,,,both,,,1849.00,554.7,"BLUE CROSS [10001]","Blue Cross HMO",,1412.77,,"Per diem ($1,412.77).",,,,0,215.04,1849,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 40MM 80CM 10MM BILIARY VENOUS DELIVERY",SUP-G57428,CDM,C1876,HCPCS,0278,RC,,,both,,,12771.83,3831.55,"NOVANET [10819]",Novanet,,9578.87,75,,,,,0,1485.36,10856.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 7.9MM 5.5MM MAGILL CURVE NASAL ORAL 2 CUFF",SUP-86395,CDM,S27200284,LOCAL,0272,RC,,,both,,,8390.91,2517.27,"NOVANET [10819]",Novanet,,6293.18,75,,,,,0,975.86,7132.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE BREAST 650CC SUT TAB INTEGRAL INJECTION DOME",SUP-SDC130UH,CDM,C1789,HCPCS,0278,RC,,,both,,,12730.50,3819.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3643.47,28.62,,,,,0,1480.56,10820.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 40MM 125CM 6MM 5FR .018IN VASCULAR NITINOL",SUP-G43771,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1196.03,28.62,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB SKIN 16X6CM STRATTICE PORCINE DERMAL MATRIX FIRM PATCH",SUP-0616002,CDM,Q4130,HCPCS,0636,RC,,,both,,,16063.20,4818.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7373.01,45.9,,,,,0,1903.49,13653.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 40MM 125CM 8MM VASCULAR PERIPHERAL OTW DRUG",SUP-G38495,CDM,C1874,HCPCS,0278,RC,,,both,,,7803.87,2341.16,"PHCS [10601]",PHCS,,5462.71,70,,,,,0,907.59,6633.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REINFORCEMENT STAPLE LINE BIOABSORBABLE STERILE SEAMGUARD",SUP-12BSGTRI60P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1323.00,396.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,156.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,153.86,1124.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 16MM TITANIUM SPINAL SELF TAPPING",SUP-3120316,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"KAISER [10500]",Kaiser,,944.7,67,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 STD KNEE RIGHT POSTERIOR STABILIZE PERSONA",SUP-42500806402,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11558.23,40,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 40MM 8MM BALLOON DILATATION PEBAX",SUP-H74939032804010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 45CM 4-7MM GORE INTERING STD WALL TAPER PTFE",SUP-IRS47045L,CDM,C1768,HCPCS,0278,RC,,,both,,,4774.80,1432.44,"CIGNA [10200]","Cigna Open Access",,2716.86,56.9,,,,,0,555.31,4058.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 12.5MM KNEE AOX STABILIZE ROTATE PLATFORM",SUP-196192132,CDM,C1776,HCPCS,0278,RC,,,both,,,13386.00,4015.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5354.4,40,,,,,0,1556.79,11378.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM ACTIVE ARTICULATION STD THR E1 OSSEOTI HIP 2 MOBI",SUP-98000100160,CDM,C1776,HCPCS,0278,RC,,,both,,,31500.00,9450,"MULTIPLAN [10600]",Multiplan,,26775,85,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 10MM SMALL SHELL DJO SURGICAL ALTIVATE",SUP-533-10-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"CIGNA [10200]",Cigna,,18997.78,40,,5873.17,5873.17,5873.17,"1 through 10",5523.6,40370.27,"percent of total billed charges",
"PLATE SMALL OLIF25 2 HOLE BONE SPINE STERILE",SUP-2140001,CDM,C1713,HCPCS,0278,RC,,,both,,,17250.00,5175,"PHCS [10601]",PHCS,,12075,70,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 6MM .038IN AZUR DETACHABLE .035IN",SUP-45-450615,CDM,S27800098,LOCAL,0278,RC,,,both,,,1851.00,555.3,"BLUE CROSS [10001]","Blue Cross HMO",,725.59,39.2,,,,,0,215.27,1573.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 10CC SELECT FIBER OSTEOAMP",SUP-OASF-10,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,1144.80,304.56,2275.09,66,2014.9,14726.25,"percent of total billed charges",
"SCR BONE 6.5MM 35MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-55840016535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"STENT WALLFLEX 40MM 10MM 8.5FR .035IN BILIARY RAPID EXCHANGE",SUP-M00570890,CDM,C1876,HCPCS,0278,RC,,,both,,,11927.41,3578.22,"FIRST HEALTH [10303]","First Health",,9541.93,80,,,,,0,1387.16,10138.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 3-0 PC-5 18IN MONOFILAMENT BLACK",SUP-1893G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 19FR JACKSON-PRATT SILICONE ROUND HUBLESS",SUP-JP-2230,CDM,S27200284,LOCAL,0272,RC,,,both,,,207.54,62.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,141.13,68,,,,,0,24.14,176.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 160MM 2.6MM CANNULATED 4MM LPS PARTIAL THREAD SCR",SUP-AR-8943-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 8FR 19CM VESSEL ACCEPTS .035IN GWIRE",SUP-504408X,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.26,26.18,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG WOUND 9X13IN MEXTRA HYDROPHILIC ABSORBENT 4 LAYER FLUID",SUP-610500,CDM,S27200284,LOCAL,0272,RC,,,both,,,45.24,13.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER YELLOW 180MM 4.5MM DYONICS LONG STRAIGHT LONG",SUP-7205341,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DTECT CARBON DIOXIDE VISUAL INDCTR ANTIFOGGING AGENT LATEX",SUP-172713,CDM,S27000186,LOCAL,0270,RC,,,both,,,65.51,19.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH AGENT 30MM 2MM BALLOON DILATATION PACLITAXEL RADIOPAQUE",SUP-H7493960830200,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"(EVAL) SUPIRA CATHETER",SUP-FG-04444,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DOVER 16IN 18FR URETHRAL SILICONE NONPOROUS 30CC FOLEY",SUP-8887630187,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.36,43.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL DISSECTING 9CM 3MM MR8 METAL CUTTER METAL CUT STERILE",SUP-MR8-9MC30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FLOSWITCH 1050 PSI FLOW CONTROL 1 WAY HIGH PRESSURE",SUP-M001442011,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.60,17.88,"CIGNA [10200]","Cigna Local Plus",,31.89,53.5,,,,,0,6.93,50.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE COMPRESSION 15X15MM STAINLESS STEEL FOOT ANKLE",SUP-43110005,CDM,C1713,HCPCS,0278,RC,,,both,,,3682.50,1104.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,436.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",428.27,3130.13,"percent of total billed charges",
"SPACER SPINAL 7MM COLONIAL XL LORDOTIC ACDF",SUP-365.707,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"NOVANET [10819]",Novanet,,5008.82,75,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500606202,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9145.08,40,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX39MM 8FR 135CMCATH HEPARIN",SUP-BXB093902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"FIRST HEALTH [10303]","First Health",,15603.84,80,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR NEONATAL LNCS 36IN FINGER OXIMETER ADHESIVE LOW NOISE",SUP-2329,CDM,S27000186,LOCAL,0270,RC,,,both,,,71.00,21.3,"CIGNA [10200]","Cigna Open Access",,40.4,56.9,,,,,0,8.26,60.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 45-150UM 5 VIAL CONTOUR PVA",SUP-M0017600151,CDM,S27800098,LOCAL,0278,RC,,,both,,,1377.00,413.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,163.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 100MM 1.5MM BALLOON DILATATION RAPID",SUP-47515100S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,655.83,41.1,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 4MM 7FR 1-7-4MM SPACING D CURVE ABLATION",SUP-NS7TCDL174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5643.44,41.1,,,,,0,1596.92,11671.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.8MM 3.5MM STERILETRAC TRAUMAONE TITANIUM",SUP-91-1803,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"CIGNA [10200]","Cigna Local Plus",,209.45,53.5,,3978.14,359.25,3978.14,24,45.53,332.78,"percent of total billed charges",
"HOOK 9IN RETRACTION CUSHING GANGLION",SUP-20-2240,CDM,S27200284,LOCAL,0272,RC,,,both,,,297.80,89.34,"NOVANET [10819]",Novanet,,223.35,75,,,,,0,34.63,253.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MONARQ TTVR SYSTEM LARGE IMPLANT",SUP-DWG-4710,CDM,S62400003,LOCAL,0624,RC,,,both,,,182400.00,54720,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21213.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SUPERORDERABLE",RX-40814984,CDM,,,0250,RC,06332-3462-04,NDC,both,10,ML,26.12,7.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.04,22.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 550ML STYLE 9300 TEXTURED SELF SEALING PATCH",SUP-3549314,CDM,C1789,HCPCS,0278,RC,,,both,,,6720.00,2016,"CIGNA [10200]","Cigna Local Plus",,3595.2,,,,,,,781.54,5712,"percent of total billed charges",
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 8 STD OFFSET HIP",SUP-71935568,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10455.94,28.62,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 47MM 26MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-47-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"CIGNA [10200]","Cigna Local Plus",,2310.01,53.5,,5372.07,4581.20,7242.98,23,502.16,3670.1,"percent of total billed charges",
"SCR BONE 5MM 44MM TITANIUM T25 SELF TAP LOCK STARDRIVE",SUP-412.216S,CDM,C1713,HCPCS,0278,RC,,,both,,,1220.18,366.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,560.06,45.9,,,,,0,141.91,1037.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 22GA 15CM CANN SERRATE EDGE FRANSEEN LUNG STERILE",SUP-G01268,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.10,58.23,"CIGNA [10200]",Cigna,,131.99,68,,,,,0,22.57,164.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM CD HORIZON REDUCTION MULTIAXIAL",SUP-55890007550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AMERIGROUP MEDICAID [20100]",Amerigroup,,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",641.98,4692,"percent of total billed charges",
"PROBE LACRIMAL 5IN BOWMAN STAINLESS STEEL 2 ENDED SET",SUP-360-270,CDM,S27000186,LOCAL,0270,RC,,,both,,,751.52,225.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,87.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.4,638.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 4-0 P-3 18IN MONOFILAMENT VIOLET",SUP-Y464G,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.62,20.59,"CIGNA [10200]","Cigna Open Access",,39.04,56.9,,,,,0,7.98,58.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 20CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006175270070,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"BLUE CROSS [10001]","Blue Cross HMO",,390.99,39.2,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE ANALZR 8X2IN CAPTURE-R READY-ID EXTEND II D NEGATIVE",SUP-0006457,CDM,C1713,HCPCS,0278,RC,,,both,,,110.20,33.06,"KAISER [10500]",Kaiser,,73.83,67,,,,,0,12.82,93.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 450-480ML STYLE 68 SMOOTH ANTERIOR DIAPH VALVE",SUP-68-450,CDM,C1789,HCPCS,0278,RC,,,both,,,2250.00,675,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1032.75,45.9,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP APPLR FIBRIJET DUAL SPRAY STERILE DISPOSABLE",SUP-SA-3660,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"CIGNA [10200]",Cigna,,165.65,68,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE 336MM STAINLESS STEEL 4.5MM SCR 16 HOLE 4 COLUMN",SUP-02.124.417,CDM,C1713,HCPCS,0278,RC,,,both,,,14200.48,4260.14,"FIRST HEALTH [10303]","First Health",,11360.38,80,,,,,0,1651.52,12070.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ELUVIA 120MM 130CM 6MM VASCULAR DRUG ELUTE DELIVERY",SUP-H74939294601210,CDM,C1874,HCPCS,0278,RC,,,both,,,18238.50,5471.55,"CIGNA [10200]","Cigna Local Plus",,5745.13,31.5,,,,,0,2121.14,15502.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM AXSOS TITANIUM CORTEX NONSTERILE",SUP-661422,CDM,C1713,HCPCS,0278,RC,,,both,,,289.54,86.86,"BLUE CROSS [10001]","Blue Cross PPO",,113.5,39.2,,957.42,570.23,957.42,28,33.67,246.11,"percent of total billed charges",
"INSRT ACETABULAR 48MM 28MM NEUTRAL HIP CERAMIC STERILE LATEX",SUP-121889650,CDM,C1776,HCPCS,0278,RC,,,both,,,14690.10,4407.03,"BLUE CROSS [10001]","Blue Cross HMO",,5758.52,39.2,,5311.50,4717.44,5388.59,31,1708.46,12486.59,"percent of total billed charges",
"SIZER MAMMARY SILICONE 300ML BREAST RESTERILIZABLE GEL",SUP-RSZ-7300MC,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 100CM 220MM 5MM BALLOON",SUP-LX1810052205F,CDM,C2623,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"FIRST HEALTH [10303]","First Health",,9660,80,,,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 35MM 3.5MM VERTEX SELECT PRECUT",SUP-7753735,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM EAR FARRIOR 1 6MM ROUND OBLIQUE END",SUP-61-0924,CDM,S27200284,LOCAL,0272,RC,,,both,,,416.90,125.07,"CIGNA [10200]","Cigna Local Plus",,223.04,53.5,,,,,0,48.49,354.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 12MM SPINE",SUP-610.712,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,396.58,68,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 150MM 4MM BALLOON DILATATION NYBAX",SUP-H74939186401510,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CHAMPIONIR DES SYSTEM US 6-100",SUP-412601000USRD,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 FIBERTAK SWIVELOCK C TIGERTAIL 2 LOAD",SUP-AR-2323BCT-2,CDM,C1713,HCPCS,0278,RC,,,both,,,3346.88,1004.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2275.88,68,,,,,0,389.24,2844.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE BALLOON DILATATION 6FR LIQUID FOGARTY BILIARY 1.25ML",SUP-410236FP,CDM,C1757,HCPCS,0272,RC,,,both,,,510.14,153.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,209.67,41.1,,,,,0,59.33,433.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 28MM 4.5MM CORONARY STENT PLATINUM",SUP-H7493926028450,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"NOVANET [10819]",Novanet,,6986.25,75,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIC PEG REPLACEMENT FEEDING ADAPTER  20FR",SUP-0135-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.86,20.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,46.14,68,,,,,0,7.89,57.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 16MM STAINLESS STEEL T8 CORTEX TUBE STARDRIVE",SUP-201.766TS,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,323.87,68,,,,,0,55.39,404.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX10MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183640,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5275.46,40,,,,,0,1533.84,11210.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIPWIRE .038IN ANGLED TIP BX 5",SUP-M0066802091,CDM,C1769,HCPCS,0272,RC,,,both,,,320.58,96.17,"UHC [10700]","United Healthcare",,202.93,63.3,,,,,0,37.28,272.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 60CM 6.8FR 11MM SPACING ENDOCARDIAL 1 COIL DEFIB",SUP-7122/60,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"KAISER [10500]",Kaiser,,11505.24,67,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.5MM 110MM GAMMA3 TITANIUM HIP TROCHANTERIC LAG",SUP-3060-0110S,CDM,C1713,HCPCS,0278,RC,,,both,,,3471.30,1041.39,"KAISER [10500]",Kaiser,,2325.77,67,,,,,0,403.71,2950.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND SUTUPAK 0 30IN BRAID TIES 10 STRAND",SUP-SA86G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 200MM CEMENT EXT PROSTALAC 3 HIP LEFT LATEX",SUP-154123000,CDM,C1776,HCPCS,0278,RC,,,both,,,18814.32,5644.3,"CIGNA [10200]","Cigna Open Access",,6302.8,33.5,,5302.19,4377.88,6578.61,27,2188.11,15992.17,"percent of total billed charges",
"LUTONIX 035 130CM 4X60MM1/EACH",SUP-LX35130460,CDM,C2623,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"KAISER [10500]",Kaiser,,7627.95,67,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WINGSPAN GATEWAY 9MM 3.5MM 3.5FR INTRACRANIAL",SUP-M003WS0350090,CDM,C1874,HCPCS,0278,RC,,,both,,,51979.47,15593.84,"PHCS [10601]",PHCS,,36385.63,70,,,,,0,6045.21,44182.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 5-0 BB 36IN 2 ARM MONOFILAMENT BLUE",SUP-8580H,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.19,20.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,28.44,41.1,,,,,0,8.05,58.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR",RX-28824,CDM,,,0250,RC,64980-0324-30,NDC,both,30,GR,549.31,164.79,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,252.13,45.9,,,,,0,63.88,466.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAMINAR IMPLANT SIZE (16MM)",SUP-FG-6032,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 26MM TI",SUP-MTC-37260-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"BLUE CROSS [10001]","Blue Cross HMO",,488.98,39.2,,957.42,156.86,7483.26,51,145.07,1060.29,"percent of total billed charges",
"VIABAHN SX ENDO HEPARIN 35 RO 10MMX5CM 8FR 120CMCATH",SUP-VBHR100502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"PHCS [10601]",PHCS,,13132.98,70,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 2-0 CT 27IN MONOFILAMENT ABSORBABLE",SUP-853H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAMP 20MM 4.2MM 14MM 400 PSI LOW PROFILE UNIQUE INFLATABLE",SUP-K09A,CDM,S27200284,LOCAL,0272,RC,,,both,,,6494.00,1948.2,"PHCS [10601]",PHCS,,4545.8,70,,,,,0,755.25,5519.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM NASAL 6IN MEDIUM HARTMANN-HALLE BLADE 30MM",SUP-66-0302,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.21,140.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,55.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.34,397.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX RADIOPAQUE",SUP-M0061453740,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,290.59,45.9,,,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.7MM 11MM VARIAX T5 LOCK NONSTERILE",SUP-662511,CDM,C1713,HCPCS,0278,RC,,,both,,,1075.03,322.51,"BLUE CROSS [10001]","Blue Cross PPO",,421.41,39.2,,957.42,570.23,957.42,28,125.03,913.78,"percent of total billed charges",
"STENT SURPASS ELITE 40MM 5.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE52540,CDM,C1876,HCPCS,0278,RC,,,both,,,90839.19,27251.76,"KAISER [10500]",Kaiser,,60862.26,67,,,,,0,10564.6,77213.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 59MM 135CM 11MM 16SQ MM 8FR .035IN",SUP-BXA115902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2311.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR SLIDER GDS VGTS",SUP-25129,CDM,C1768,HCPCS,0278,RC,,,both,,,9982.09,2994.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1160.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1160.92,8484.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 24FR 5MM ACMI CLASSIC",SUP-M0068804511,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"FIRST HEALTH [10303]","First Health",,413.18,80,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR FR4 CURVE ANGIOGRAPHIC VENTRICULAR 2",SUP-H74916599020,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]",Cigna,,52.07,68,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STATION DOCKING ONE POSITION WITH AC ADAPTER FOR NOVA STATST",SUP-53400,CDM,S27000186,LOCAL,0270,RC,,,both,,,729.00,218.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,84.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 4FR 23CM AVANTI+ MID LENGTH DISPOSABLE RED",SUP-504604T,CDM,C1894,HCPCS,0272,RC,,,both,,,200.54,60.16,"KAISER [10500]",Kaiser,,134.36,67,,,,,0,23.32,170.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 36MM REVISION MEDIUM LONG SHOULDER",SUP-520003036,CDM,C1776,HCPCS,0278,RC,,,both,,,29116.08,8734.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3386.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.2,24748.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 25MM SYNFIX EVOLUTION STERILE",SUP-04.835.225.02S,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,188.41,1377,"percent of total billed charges",
"SUT VICRYL RAPIDE 3-0 SH 27IN BRAID COATED UNDYED ABSORBABLE",SUP-VR416,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 48MM ORTHOLOC FULL THREAD CORTICAL ANKLE FOOT",SUP-58813548,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"MULTIPLAN [10600]",Multiplan,,654.08,85,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYPERTENSION WITHOUT MCC",305,MS-DRG,,,,,,,inpatient,,,26912.14,8073.64,"CIGNA [10200]","Cigna Local Plus",,7791.88,,"Fee schedule rate ($7,791.88). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,4683.93,18831.44,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"ENROUTE TRANSCAROTID STENT SYSTEM 6 X 40",SUP-SR-0640-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOSARTAN 25 MG TABLET",RX-14823,CDM,,,0637,RC,50268-0504-11,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONCIERGE 5FR SBS3.75 MOD CURVE GUIDING BACKUP SPRT",SUP-CGC5100SBS375-M,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 20MM 2.5MM",SUP-SPL25020X,CDM,C1725,HCPCS,0272,RC,,,both,,,546.75,164.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIZACT OPEN SEALER DIVIDER",SUP-BZ4212A,CDM,S27200284,LOCAL,0272,RC,,,both,,,2212.50,663.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PNEUMOTHORAX WITH MCC",199,MS-DRG,,,,,,,inpatient,,,54927.12,16478.14,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC",476,MS-DRG,,,,,,,inpatient,,,58758.08,17627.42,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LASSO REDEL 115CM 7FR 25MM 8MM SPACE ELECTROPHYSIOLOGY",SUP-D7L1025RT,CDM,C1730,HCPCS,0272,RC,,,both,,,7507.20,2252.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5104.9,68,,,,,0,873.09,6381.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT STRAIGHT RETRACTION 50MM MARS 26MM",SUP-632.465S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2880.00,864,"AMERIGROUP MEDICAID [20100]",Amerigroup,,341.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.94,2448,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 STD 14MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS7S14L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"KAISER [10500]",Kaiser,,6962.24,67,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM TITANIUM LEVEL 3 ASSURE BONE SPINE CERVICAL",SUP-110.345,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,615.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",615.46,4498.2,"percent of total billed charges",
"LENS IOL 5 D +16 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1600,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA [10200]",Cigna,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO 453MM 1.6MM SWISS LITHOCLAST PNEUMATIC LATEX",SUP-M0068407350,CDM,S27200284,LOCAL,0272,RC,,,both,,,1680.60,504.18,"AETNA [10100]","Aetna HMO/PPO",,1336.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,195.45,1428.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ETHOSUXIMIDE 250 MG CAPSULE",RX-9989,CDM,,,0637,RC,69452-0152-20,NDC,both,1,UN,10.78,3.23,"UHC [10700]","United Healthcare",,6.82,63.3,,,,,0,1.25,9.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 330541 ACSR 5X14X11 SRVC FEE",SUP-330541,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 FULL THREAD CORKSCREW FIBERWIRE 2 BRAID 4",SUP-AR-1927PNF,CDM,C1713,HCPCS,0278,RC,,,both,,,2323.13,696.94,"NOVANET [10819]",Novanet,,1742.35,75,,,,,0,270.18,1974.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 355CC",SUP-RSZ-SHPX-355S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"KAISER [10500]",Kaiser,,111.28,67,,,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 220MM 6MM BALLOON",SUP-LX1813062205F,CDM,C2623,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"NOVANET [10819]",Novanet,,9056.25,75,,,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"175-260MM 9.0 -11.0 MM DIAM FLEXIGRAFT DUALLINK PRESUTURED T",SUP-FDL,CDM,S27800098,LOCAL,0278,RC,,,both,,,16487.14,4946.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6594.86,40,,,,,0,1917.45,14014.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 50MM 32MM MARATHON HIP",SUP-121932150,CDM,C1776,HCPCS,0278,RC,,,both,,,4845.96,1453.79,"CIGNA [10200]","Cigna Local Plus",,2592.59,53.5,,5372.07,4581.20,7242.98,23,563.59,4119.07,"percent of total billed charges",
"STENT GORE VIABAHN 39MM 135CM 11MM 16SQ MM 8FR .035IN",SUP-BXA113902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]",Cigna,,7801.92,40,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 1L NORMOSOL-R LIFECARE MULTIPLE ELECTROLYTES",SUP-07670-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"NOVANET [10819]",Novanet,,60.75,75,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 4FR RIGHT CORONARY BYPASS",SUP-538470,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"CIGNA [10200]","Cigna Open Access",,50.94,56.9,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X13MM 8D CONVEX LORDOTIC WEDGE",SUP-010613,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CIGNA [10200]",Cigna,,12600,40,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR 20CM 3CM 7FR .035IN 2 FLOPPY PIGTAIL",SUP-M006180230090,CDM,C2617,HCPCS,0278,RC,,,both,,,1294.14,388.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,370.38,28.62,,,,,0,150.51,1100.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE 23MM 7MM MILAGRO ACL PLGA TCP RESORBABLE",SUP-231800,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",434.96,3179,"percent of total billed charges",
"SUT ULTRAGLIDE 9-0 CS160-6 6IN MONOFILAMENT BLUE",SUP-J2625N,CDM,S27200284,LOCAL,0272,RC,,,both,,,235.62,70.69,"KAISER [10500]",Kaiser,,157.87,67,,,,,0,27.4,200.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW FREEFIX LOCKING 3.5MM X 20MM TI",SUP-FFL-35200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1223.10,366.93,"FIRST HEALTH [10303]","First Health",,978.48,80,,,,,0,142.25,1039.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 60MM 5MM BALLOON DILATATION DURALYN",SUP-48005006S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AETNA [10100]","Aetna HMO/PPO",,998.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE SMALL MALE",SUP-100611-020,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.99,17.7,"CIGNA [10200]",Cigna,,40.11,68,,,,,0,6.86,50.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 32MM UNIVERS REVERS GLENOID PERIPHERAL LOCK",SUP-AR-9563-32,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"CIGNA [10200]","Cigna Local Plus",,319.6,53.5,,3978.14,359.25,3978.14,24,69.48,507.77,"percent of total billed charges",
"CAP SYSTEM THR TRABECULAR METAL VIVACIT-E CERAMIC STEM CUP L",SUP-98000571504,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10357.2,41.1,,6417.48,6417.48,6417.48,"1 through 10",2930.76,21420,"percent of total billed charges",
"CATH NC EUPHORA 142CM 15MM 2MM BALLOON DILATATION DURATRAC",SUP-NCEUP2015X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET SILASTIC 8X6IN THK.02IN SILICONE REINFORCE STERILE",SUP-PR72034-02R,CDM,S27800098,LOCAL,0278,RC,,,both,,,2130.00,639,"BLUE CROSS [10001]","Blue Cross PPO",,834.96,39.2,,,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF ENHANCR II 110CM 4MM 7FR 2-5-2MM SPACE 55MM MEDIUM",SUP-FND-019-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,624.61,45.9,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE RIGHT CEMENTED CRUCIATE RETAINING",SUP-150400204,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9203.67,41.1,,6417.48,6417.48,6417.48,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"STENT UNISTEP PLUS WALLSTENT RP 47MM 135CM 8MM 160CM",SUP-M001712210,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"AETNA [10100]","Aetna HMO/PPO",,6719.74,79.5,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 85MM 5.5MM CREO LATERAL HEAD LEFT NONSTERILE",SUP-1175.5527,CDM,C1713,HCPCS,0278,RC,,,both,,,12061.20,3618.36,"NOVANET [10819]",Novanet,,9045.9,75,,,,,0,1402.72,10252.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Ather Sf Init",PX-361000729,CDM,37288,CPT,0361,RC,,,both,,,23403.71,7021.11,"PHCS [10601]",PHCS,,16382.6,70,,,,,0,2721.85,19893.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000170,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 14MM 3FR GEMINI HELICAL",SUP-M0063302110,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,679.11,45.9,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE INTERNAL MEDIUM THICK CATRIDGE STERILE GIA TRI-STAPLE",SUP-GIA80XTC,CDM,S27200284,LOCAL,0272,RC,,,both,,,597.46,179.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,70.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.48,507.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 2-0 CT-2 SPIRAL 15CM CLSR",SUP-SXPP1B413,CDM,S27200284,LOCAL,0272,RC,,,both,,,231.96,69.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,27.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.98,197.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X13X7MM ACIS STD LORDOTIC PEEK RADIOPAQUE",SUP-08.843.007S,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"KAISER [10500]",Kaiser,,3004.95,67,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 56MM 40MM ALTRX HIP",SUP-122140456,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"KAISER [10500]",Kaiser,,9248.31,67,,,,,0,1605.34,11732.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRAP CLAVICLE SMALL CONTOUR 2 WAY CONTACT CLSR LIGTR",SUP-79-98674,CDM,S27000186,LOCAL,0270,RC,,,both,,,53.59,16.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,22.03,41.1,,,,,0,6.23,45.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 15MM 140CM 2.25MM CORONARY STERILE",SUP-453937,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 39FR LEFT ANGLE ADJUSTABLE VALVE STYLET 2",SUP-125039,CDM,S27200284,LOCAL,0272,RC,,,both,,,439.99,132,"AETNA [10100]","Aetna HMO/PPO",,349.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.17,373.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.75/9",SUP-401731,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBTR LAPAROSCOPIC 8MM WECK VISTA LONG BLADELESS STERILE",SUP-470360,CDM,S27200284,LOCAL,0272,RC,,,both,,,274.05,82.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,31.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.87,232.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE CANNULATED STERILE 7MM 75MM 16MM STAINLESS STEEL",SUP-71127075,CDM,C1713,HCPCS,0278,RC,,,both,,,2479.50,743.85,"NOVANET [10819]",Novanet,,1859.63,75,,,,,0,288.37,2107.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 93MM TYPE 1 PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51108040,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"MULTIPLAN [10600]",Multiplan,,23319.95,85,,,,,0,3190.72,23319.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 22-30CM 3CM 7FR .035IN",SUP-M006180157190,CDM,C2617,HCPCS,0278,RC,,,both,,,1271.86,381.56,"BLUE CROSS [10001]","Blue Cross HMO",,498.57,39.2,,,,,0,147.92,1081.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 25CM 9MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120925,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3208.09,27,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 8 40MM HIP BIOLOX DELTA FMP SYSTEM",SUP-400-03-404,CDM,S27200284,LOCAL,0272,RC,,,both,,,16953.92,5086.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7781.85,45.9,,,,,0,1971.74,14410.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM MASTERS HEMODYNAMIC PLUS MECHANICAL STD",SUP-27AHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"NOVANET [10819]",Novanet,,21839.42,75,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 6MM 6FR ENDOPROSTHESIS HEPARIN",SUP-VBJR061002A,CDM,C1874,HCPCS,0278,RC,,,both,,,22163.40,6649.02,"CIGNA [10200]","Cigna Open Access",,7424.74,33.5,,,,,0,2577.6,18838.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 27MM TRIGEN FEMUR LOW PROFILE",SUP-71645027,CDM,C1713,HCPCS,0278,RC,,,both,,,2069.55,620.86,"AETNA [10100]","Aetna HMO/PPO",,1645.29,79.5,,1521.93,481.35,16760.95,30,240.69,1759.12,"percent of total billed charges",
"MESH SURGICAL PHASIX ECHO 2 25X20CM POSITION SYSTEM STERILE",SUP-1212025,CDM,C1781,HCPCS,0278,RC,,,both,,,61916.40,18574.92,"MULTIPLAN [10600]",Multiplan,,52628.94,85,,,,,0,7200.88,52628.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 4-0 TF 27IN BRAID COATED UNDYED ABSORBABLE",SUP-VCP434H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 35MM ARTHREX SHOULDER CENTRAL MODULAR STERILE",SUP-AR-9561-35S,CDM,C1713,HCPCS,0278,RC,,,both,,,4029.60,1208.88,"PHCS [10601]",PHCS,,2820.72,70,,,,,0,468.64,3425.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 80MM 18MM FINNED CEMENTLESS SMR SHOULDER",SUP-1304.15.180,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"MULTIPLAN [10600]",Multiplan,,6732,85,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 14MM 7MM STD WALL THIN WALL 2 BRANCH",SUP-SBT1402D,CDM,C1768,HCPCS,0278,RC,,,both,,,8611.20,2583.36,"CIGNA [10200]","Cigna Local Plus",,4606.99,53.5,,,,,0,1001.48,7319.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 28CM 7FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251440,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE VASCULAR 120CM 27-45MM 7FR EN SNARE STD PLATINUM",SUP-EN2007045,CDM,C1773,HCPCS,0272,RC,,,both,,,2520.00,756,"UHC [10700]","United Healthcare",,1595.16,63.3,,,,,0,293.08,2964.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SIMPLICITI W PERFORM+ GLENOID",SUP-CAP1112,CDM,C1776,HCPCS,0278,RC,,,both,,,31500.00,9450,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3732.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 95MM STAINLESS STEEL 2.4/3.5MM SCR 5 HOLE SHAFT LCP",SUP-02.110.105,CDM,C1713,HCPCS,0278,RC,,,both,,,8550.14,2565.04,"PHCS [10601]",PHCS,,5985.1,70,,,,,0,994.38,7267.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 4.00 X 23 RX US",SUP-1804400-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 40MM 150CM 7MM VASCULAR NICKEL",SUP-EVD35-07-040-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"FIRST HEALTH [10303]","First Health",,5028,80,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTOURA BREAST TISSUE EXPANDER ULTRA HIGH PROJECTION 850 CC",SUP-TEXP140RUH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"CIGNA [10200]","Cigna Local Plus",,4336.13,,,,,,,1600.93,11700.68,"percent of total billed charges",
"SCR BONE 10.35MM 75MM TFN-ADVANCED TITANIUM NIOBIUM ALUMINUM",SUP-04.038.175S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 94MM 10MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044109470,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5865,68,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 17MM ZEVO TITANIUM SPINE CERVICAL ANTERIOR",SUP-7713517,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 26CM 8FR POLARIS ULTRA .035IN STRAIGHT URETERAL",SUP-M006192153190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"KAISER [10500]",Kaiser,,934.8,67,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE COUGAR XT VASCULAR STRAIGHT 300CM .014IN PRO PEL EXTRA",SUP-CGRXT300S,CDM,C1769,HCPCS,0272,RC,,,both,,,502.20,150.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,206.4,41.1,,,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) 6F TRAPLINER CATHETER",SUP-5566,CDM,C1887,HCPCS,0272,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPO 100CM 5FR SIM2 CURVE ANGIOGRAPHIC SLX CEREBRAL",SUP-451531H0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UHC [10700]","United Healthcare",,66.09,63.3,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 86MM FOGARTY FIBRA ATRAUMATIC OCCLUSION STERILE",SUP-G-8650,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 57MM TITANIUM 2.4MM SCREW 8 HOLE BONE RIGHT HAND NONST",SUP-449.916,CDM,C1713,HCPCS,0278,RC,,,both,,,3706.50,1111.95,"CIGNA [10200]",Cigna,,2520.42,68,,1831.33,1831.33,1831.33,16,431.07,3150.53,"percent of total billed charges",
"BURR SURGICAL 70MM 5.5MM OVAL CARBIDE STERILE",SUP-09-C0905,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.49,33.15,"PHCS [10601]",PHCS,,77.34,70,,,,,0,12.85,93.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 12MM 2MM BALLOON DILATATION PACLITAXEL RADIOPAQUE",SUP-H7493960812200,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"KAISER [10500]",Kaiser,,26064.68,67,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMR GLENOSPHERE 40MM",SUP-1374.09.121,CDM,C1776,HCPCS,0278,RC,,,both,,,9183.90,2755.17,"FIRST HEALTH [10303]","First Health",,7347.12,80,,,,,0,1068.09,7806.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SURGICAL AVAFLEX PLUS 11GA",SUP-1025-011-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,3275.40,982.62,"MULTIPLAN [10600]",Multiplan,,2784.09,85,,,,,0,380.93,2784.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grft F/N/H/F/G Add 25scm",PX-510000055,CDM,15276,CPT,0761,RC,,,both,,,344.00,103.2,"CIGNA [10200]","Cigna Local Plus",,344,,"Per diem ($2,051).",,,,0,40.01,344,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 15MM 3MM BALLOON DILATATION PACLITAXEL RADIOPAQUE",SUP-H7493960815300,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"CIGNA [10200]",Cigna,,26453.7,68,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26MMX8MM CAPSTONE PEEK PTC LUMBAR INTERBODY",SUP-3992608,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5953.5,27,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +7 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-PCB0000070,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 9X20 40CM SL",SUP-48009002P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,116.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-71422344,CDM,C1776,HCPCS,0278,RC,,,both,,,29720.25,8916.07,"NOVANET [10819]",Novanet,,22290.19,75,,,,,0,3456.47,25262.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP DUAL MOBILITY CEMENTED OR3O WITH OXI HEAD",SUP-71703498,CDM,C1776,HCPCS,0278,RC,,,both,,,30240.00,9072,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3516.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 25MM SHOULDER CENTRAL",SUP-550025600,CDM,C1713,HCPCS,0278,RC,,,both,,,2796.00,838.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1283.36,45.9,,,,,0,325.17,2376.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI STRAIGHT 8MMX1MM MANDIBLE 4 HOLE 2MM SCR BONE",SUP-55-10503,CDM,C1713,HCPCS,0278,RC,,,both,,,1085.16,325.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,128.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,126.2,922.39,"percent of total billed charges",
"GWIRE ORTHOPEDIC 450MM 2.8MM FLUTE TIP STERILE",SUP-03.333.006S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1347.19,404.16,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,156.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,156.68,1145.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXTR PRO XL 200CM 7-6FR 9-12MM SPECIMEN RETRIEVAL",SUP-M00547100,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET OBLONG 7.5IN ANTRUM SURGICAL STAINLESS STEEL 9.5X3.7MM",SUP-440402,CDM,S27200284,LOCAL,0272,RC,,,both,,,675.95,202.78,"FIRST HEALTH [10303]","First Health",,540.76,80,,,,,0,78.61,574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 30MM SEPTAL 2 DISK NITINOL MESH SELF",SUP-9-ASD-MF-030,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"FIRST HEALTH [10303]","First Health",,17000.64,80,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 40X18X9MM TRANSCONTINENTAL 0D CORONAL TAPER",SUP-375.492,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Local Plus",,7541.1,31.5,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 12CM OCCL GLDEWIRE NEPHRSTMY INTRO PERCUTANEOUS",SUP-M0067001210,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.79,81.54,"CIGNA [10200]","Cigna Local Plus",,145.41,53.5,,,,,0,31.61,231.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 80MM 3MM BALLOON DILATATION DURALYN",SUP-48003008X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"NOVANET [10819]",Novanet,,941.63,75,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM FREESTYLE ROOT PORCINE PHYSIOLOGIC",SUP-FR995-29,CDM,S27800098,LOCAL,0278,RC,,,both,,,38430.00,11529,"AETNA [10100]","Aetna HMO/PPO",,30551.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4469.41,32665.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 20MM 190CM 3.5",SUP-R51003502L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"KAISER [10500]",Kaiser,,1321.07,67,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 3-0 RB-1 36IN 2 ARM BRAID GREEN NONABSORBABLE",SUP-X558H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 80MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.780S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"PHCS [10601]",PHCS,,1721.58,70,,,,,0,286.03,2090.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEARTRAIL III 100CM 6FR IKARI LEFT 4 CURVE GUIDING",SUP-40-6373,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"MULTIPLAN [10600]",Multiplan,,495.72,85,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER TORQR 110CM 6FR 2-5-2MM SPACING COURNAND CURVE ELEC",SUP-041002UMR,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"FIRST HEALTH [10303]","First Health",,250.56,80,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mpl Gene Common Variants",PX-310000012,CDM,81338,HCPCS,0310,RC,,,both,,,836.00,250.8,"UHC [10700]","United Healthcare",,135.3,,,,,,,0.01,710.6,"fee schedule",
"SYSTEM INSPIRA AIR 40MM 10MM BALLOON DILATATION HIGH",SUP-BC1040A,CDM,C1726,HCPCS,0272,RC,,,both,,,4795.50,1438.65,"NOVANET [10819]",Novanet,,3596.63,75,,,,,0,557.72,4076.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GASTRO 16FR 18GA NDL SCPL INTRO SYR HEMOSTAT MIC-KEY 11",SUP-98437,CDM,S27200284,LOCAL,0272,RC,,,both,,,1649.78,494.93,"CIGNA [10200]","Cigna Local Plus",,882.63,53.5,,,,,0,191.87,1402.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1.5MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-1.5-2-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"BLUE CROSS [10001]","Blue Cross HMO",,4584.64,39.2,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 2.5CM 1.5MM GALAXY G3 MINI STRETCH",SUP-GLM915025,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1381.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 5MM SELF DRILL NEW HEAD",SUP-92-15905,CDM,C1713,HCPCS,0278,RC,,,both,,,563.03,168.91,"MULTIPLAN [10600]",Multiplan,,478.58,85,,,,,0,65.48,478.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOABLATION 17IN 8MM CRYOICE CRYOSPHERE STERILE LATEX",SUP-CRYOSP-L,CDM,C9808,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 150MM 4MM BALLOON DILATATION OTW",SUP-H74939206041510,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +7.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.075,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 15MM 7MM BICEPTOR BIOSURE SCR",SUP-72202299,CDM,C1713,HCPCS,0278,RC,,,both,,,2895.75,868.72,"NOVANET [10819]",Novanet,,2171.81,75,,,,,0,336.78,2461.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL BARD ONFLEX 5.6X3.4IN INGUINAL POCKET STRAP",SUP-0115610,CDM,C1781,HCPCS,0278,RC,,,both,,,1620.00,486,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1101.6,68,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE RELINE C HEX SPINE LOCK CROSS CONNECT NONSTERILE",SUP-3900200,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"BLUE CROSS [10001]","Blue Cross HMO",,136.42,39.2,,957.42,156.86,7483.26,51,40.47,295.8,"percent of total billed charges",
"CATH MAHURKAR 16CM 11.5FR HEMODIALYSIS 2 LUMEN STRAIGHT EXT",SUP-8830414001,CDM,C1752,HCPCS,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 30MM 3MM BALLOON DILATATION DRUG COATED",SUP-H7493960830300,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,17856.25,45.9,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 110MM 10 HOLE BONE CLAVICLE LEFT SUPERIOR NONSTERILE",SUP-133525110,CDM,C1713,HCPCS,0278,RC,,,both,,,14334.75,4300.42,"PHCS [10601]",PHCS,,10034.33,70,,,,,0,1667.13,12184.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Potassium Body Fluid",PX-301000363,CDM,84132,CPT,0301,RC,,,both,,,107.00,32.1,"KAISER [10500]",Kaiser,,71.69,67,,,,,0,0.11,90.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM AVENIR 10 COIL STERILE LATEX",SUP-10CFR14030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1389.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER 1628-017M MERIT MED VRT",SUP-1628-017M,CDM,C1887,HCPCS,0272,RC,,,both,,,1044.90,313.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,710.53,68,,,,,0,121.52,888.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 10 X 30 HELICAL FILLING COIL",SUP-10HFL-10030,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"CIGNA [10200]","Cigna Local Plus",,4795.26,53.5,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cath Clsr Asd W Imp",PX-481000046,CDM,93580,CPT,0481,RC,,,both,,,25493.04,7647.91,"PHCS [10601]",PHCS,,17845.13,70,,,,,0,2964.84,25493.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC TRANSLUCENT 7CM 5.75MM CRYSTAL BARREL",SUP-AR-6562,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,155.3,68,,,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 26CM 3CM 8FR .038IN PIGTAIL CURVE",SUP-M006180543170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"MULTIPLAN [10600]",Multiplan,,1046.32,85,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE ENDOSCOPIC DISECT BRUSH FINISH RADIOPAQUE TIP 38CM 5",SUP-KT-9101,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.21,36.96,"NOVANET [10819]",Novanet,,92.41,75,,,,,0,14.33,104.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 30MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0335,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,112.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",110.22,805.55,"percent of total billed charges",
"XIENCE SKYPOINT DES 2.75 X 23 RX US",SUP-1804275-23,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG GERMICIDAL DISK .75IN 1.5MM BIOPATCH CHG ANTIMICROBIAL",SUP-4151,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.49,14.85,"FIRST HEALTH [10303]","First Health",,39.59,80,,,,,0,5.76,42.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP MULTIHOLE PRIMARY MODULAR STERILE",SUP-620206220,CDM,C1776,HCPCS,0278,RC,,,both,,,17500.14,5250.04,"BLUE CROSS [10001]","Blue Cross HMO",,6860.05,39.2,,5311.50,4717.44,5388.59,31,2035.27,14875.12,"percent of total billed charges",
"INTRO SHEATH 9FR 35MM 35CM KINK RESISTANT CANN",SUP-401935M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"KAISER [10500]",Kaiser,,69.95,67,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNETOS MATRIX .25-1MM LARGE ALLOGRAFT FLEX",SUP-703-058-US,CDM,C1713,HCPCS,0278,RC,,,both,,,20997.90,6299.37,"BLUE CROSS [10001]","Blue Cross HMO",,8231.18,39.2,,957.42,156.86,7483.26,51,2442.06,17848.22,"percent of total billed charges",
"KIT NEPHRSTMY 12FR LOCK REGULAR DUROMETER 25CM FLEXIMA",SUP-M001271880,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,881.28,68,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PLUS PROFILE SOFTTOUCH",SUP-SSLP-125,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3467.97,45.9,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LIVEWIRE 95CM 2MM 7FR 2-5-2MM SPACE SUPER LARGE CURL",SUP-401914,CDM,C1731,HCPCS,0272,RC,,,both,,,4149.60,1244.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1705.49,41.1,,,,,0,482.6,3527.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 125CM 6FR .057IN STD JUDKINS RIGHT",SUP-534615T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE UBER FLEX 40MM 57CM 7MM .065IN VASCULAR",SUP-SR-0740-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 3MM .01IN DELTAFILL .015IN MICRO 18",SUP-DLF180312,CDM,S27800098,LOCAL,0278,RC,,,both,,,14145.00,4243.5,"CIGNA [10200]","Cigna Open Access",,4738.58,33.5,,,,,0,1645.06,12023.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X8MM COUGAR LS PARALLEL LATERAL NONSTERILE",SUP-189150408,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2784.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PENTARAY 7FR 1-8-1MM D CURVE ELECTROPHYSIOLOGY",SUP-D128212,CDM,C1732,HCPCS,0272,RC,,,both,,,13634.40,4090.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1615.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1585.68,11589.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32MMX8MM CAPSTONE PEEK LUMBAR INTERBODY FUSION",SUP-9440832,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"KAISER [10500]",Kaiser,,11557.5,67,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Intermediate Procedure",PX-450000382,CDM,450000382,LOCAL,0361,RC,,,both,,,1687.35,506.2,"KAISER [10500]",Kaiser,,1130.52,67,,,,,0,196.24,1434.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Foley W/O Catheter",PX-E27000125,CDM,E27000125,LOCAL,0270,RC,,,both,,,58.30,17.49,"FIRST HEALTH [10303]","First Health",,46.64,80,,,,,0,6.78,49.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 30MM 140CM 3MM CORONARY STERILE LATEX",SUP-453964,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X12MM 5D LORDOTIC OVAL SPINE CORTICAL",SUP-017212,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE",RX-11050,CDM,,,0637,RC,63044-0203-61,NDC,both,1,UN,6.27,1.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,0.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM FIBERTAG TIGHTROPE 9MM FIXATION ACL",SUP-AR-1288QT-90,CDM,C1713,HCPCS,0278,RC,,,both,,,7063.88,2119.16,"FIRST HEALTH [10303]","First Health",,5651.1,80,,,,,0,821.53,6004.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 150MM 1.4MM TROCAR TIP STERILE",SUP-03.333.002.01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,577.37,173.21,"CIGNA [10200]","Cigna Open Access",,328.52,56.9,,,,,0,67.15,490.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 STD KNEE RIGHT CRUCIATE RETAIN PERSONA COCR",SUP-42502805402,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"UHC [10700]","United Healthcare",,18290.9,63.3,,8601.07,8395.67,8601.07,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC",408,MS-DRG,,,,,,,inpatient,,,123008.73,36902.62,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,23112.91,,"Case rate ($22,117.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,537.72, add-ons for qualifying new technology services are included. If operating cost exceeds $53,577.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,934.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $20,564.88. The transfer operating threshold is the transfer adjustment factor * $20,537.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,552.75. The transfer capital threshold is the transfer adjustment factor * $1,552.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,104101.26,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE ULTIMA 10-0 CS160-6 CTC-6 4IN 2 ARM MONOFILAMENT",SUP-9090G,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.32,85.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,194.02,68,,,,,0,33.18,242.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 16MM CORE ALLOGRAFT CM2",SUP-PS60014,CDM,C1713,HCPCS,0278,RC,,,both,,,3341.25,1002.37,"CIGNA [10200]","Cigna Local Plus",,1787.57,53.5,,3978.14,359.25,3978.14,24,388.59,2840.06,"percent of total billed charges",
"SCR BONE 3.5MM 20MM VUEPOINT II SPINE FAVORED ANGLE",SUP-8975520,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"CIGNA [10200]","Cigna Open Access",,2389.8,56.9,,1144.80,304.56,2275.09,66,488.46,3570,"percent of total billed charges",
"PUNCH SURGICAL STAINLESS STEEL ADENOID SCHMEDEN 5.5IN 0 6MM",SUP-430210,CDM,S27200284,LOCAL,0272,RC,,,both,,,1993.73,598.12,"CIGNA [10200]","Cigna Open Access",,1134.43,56.9,,,,,0,231.87,1694.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN JUDKINS LEFT 6 CURVE",SUP-DXT6JL60,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATH GREEN 20CM 12FR MAHURKAR ELITE DOUBLE-D LARGE",SUP-8888222320,CDM,C1752,HCPCS,0272,RC,,,both,,,860.01,258,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PIN FIXATION REFERENCE 150MM PERCUTANEOUS STERILE",SUP-9733236,CDM,S27200284,LOCAL,0272,RC,,,both,,,1988.48,596.54,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FLEXIVA PULSE ID 365 (BOX 5)",SUP-M006L8406921,CDM,S27200284,LOCAL,0272,RC,,,both,,,2343.77,703.13,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL STD 200MM SERRATE",SUP-BD051R,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.35,26.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STYLET INTUBATION SMALL GLIDERITE DISPOSABLE",SUP-0270-0916,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.38,16.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP MEDIUM SURGILAV SHIELD SPLASH PULSED LAVAGE",SUP-0207068000,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.60,22.38,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EUPHORA 142CM 6MM 2.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP2506X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 180MM 4.3MM QUICK COUPLING 5MM LOCKING SCR",SUP-310.431,CDM,S27200284,LOCAL,0272,RC,,,both,,,476.58,142.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,195.87,41.1,,,,,0,55.43,405.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 13MM STAINLESS STEEL T6 SELF TAP LOCK VARIABLE",SUP-02.130.313,CDM,C1713,HCPCS,0278,RC,,,both,,,841.43,252.43,"BLUE CROSS [10001]","Blue Cross PPO",,329.84,39.2,,957.42,570.23,957.42,28,97.86,715.22,"percent of total billed charges",
"STENT ADVANIX 5CM 4FR PIGTAIL CURVE PANCREATIC POLYMER",SUP-M00537370,CDM,C2625,HCPCS,0278,RC,,,both,,,1411.18,423.35,"BLUE CROSS [10001]","Blue Cross PPO",,553.18,39.2,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 19FR JACKSON-PRATT SILICONE ROUND HUBLESS",SUP-JP-2230,CDM,S27200284,LOCAL,0272,RC,,,both,,,207.54,62.26,"KAISER [10500]",Kaiser,,139.05,67,,,,,0,24.14,176.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 13.5X11.7CM BREAST 550CC STYLE 8200 SUT TAB CPX4",SUP-3548214,CDM,C1789,HCPCS,0278,RC,,,both,,,9694.50,2908.35,"CIGNA [10200]","Cigna Open Access",,5516.17,56.9,,5166.00,5166.00,5166.00,"1 through 10",1127.47,8240.33,"percent of total billed charges",
"SHELL ACETABULAR 62MM PRIMARY HEMISPHERICAL CLUSTER HOLE",SUP-5020362G,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"BLUE CROSS [10001]","Blue Cross HMO",,4102.99,39.2,,5311.50,4717.44,5388.59,31,1217.29,8896.8,"percent of total billed charges",
"FRCP SURGICAL NOYES 8MM FLAT DUCKBILL 5.25IN EAR SERRATE 77",SUP-61-0118,CDM,S27200284,LOCAL,0272,RC,,,both,,,1227.31,368.19,"UHC [10700]","United Healthcare",,776.89,63.3,,,,,0,142.74,1043.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10MM 5MM TARGET DETACHABLE FRAME 3D",SUP-M0036155100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1672.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CEMENTED EXETER V40 0 35.5MM OFFSET HIP",SUP-0580-1-352,CDM,C1776,HCPCS,0278,RC,,,both,,,17001.60,5100.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2014.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1977.29,14451.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 30CM 3CM 5FR .035IN 2",SUP-M006192125180,CDM,C2617,HCPCS,0278,RC,,,both,,,1589.87,476.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1081.11,68,,,,,0,184.9,1351.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR PULSE WAVEWRITER ALPHA 32",SUP-SC-1232,CDM,C1820,HCPCS,0278,RC,,,both,,,99750.00,29925,"FIRST HEALTH [10303]","First Health",,79800,80,,,,,0,11600.93,84787.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 8MM REINFORCE CUFF MURPHY EYE LOW PRESSURE",SUP-DYNJAARC80,CDM,S27200284,LOCAL,0272,RC,,,both,,,295.80,88.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,201.14,68,,,,,0,34.4,251.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 19.5CM 11.5FR MAHURKAR 2 LUMEN STRAIGHT EXT",SUP-8813793009,CDM,C1752,HCPCS,0272,RC,,,both,,,651.84,195.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,443.25,68,,,,,0,75.81,554.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 19MM 44MM SHOULDER ANATOMIC RESTORATION",SUP-AR-9144-19P,CDM,C1776,HCPCS,0278,RC,,,both,,,7231.20,2169.36,"PHCS [10601]",PHCS,,5061.84,70,,,,,0,840.99,6146.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 100MM 6MM .035IN BALLOON",SUP-AB35W06100135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"MULTIPLAN [10600]",Multiplan,,575.59,85,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 21GA 4CM TUBE RADIOPAQUE REMOVABLE STPCOCK",SUP-PSS-7F-4MT,CDM,C1894,HCPCS,0272,RC,,,both,,,165.30,49.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,67.94,41.1,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL CEMENT HEAD STD SHOULDER GLENOID",SUP-98000900023,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"UHC [10700]","United Healthcare",,16948.58,63.3,,8601.07,8395.67,8601.07,"1 through 10",3113.93,22758.75,"percent of total billed charges",
"IMPL BREAST 650ML GEL ROUND SMOOTH MEMORYGEL SILICONE P4.7CM","SUP-3506501 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"NOVANET [10819]",Novanet,,2756.25,75,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.0MM X 15.0MM",SUP-493001512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 8 KNEE LEFT DISTAL TOTAL",SUP-5542-A-801,CDM,C1776,HCPCS,0278,RC,,,both,,,7027.65,2108.29,"AETNA [10100]","Aetna HMO/PPO",,5586.98,79.5,,10981.53,8986.79,12413.38,12,817.32,5973.5,"percent of total billed charges",
"BURR SURGICAL 4MM FRMLA ROUND 6 FLUTED ARTHROSCOPIC STERILE",SUP-0375940000,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,218.89,68,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 30MM SIMUPLUS FLEXIBLE LUMEN STERILE LATEX",SUP-7700FB30,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SPINAL 12MM 3.5MM CODA ANTERIOR CERVICAL SELF DRILL",SUP-102250012,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Open Access",,576.11,56.9,,1144.80,304.56,2275.09,66,117.75,860.63,"percent of total billed charges",
"SPACER ALLOGRAFT 23-27MMX23MM FRA 8D NARROW SPINE ANTERIOR",SUP-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]",Cigna,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG GERMICIDAL 6X6IN AQUACEL AG",SUP-422298,CDM,S27200284,LOCAL,0272,RC,,,both,,,157.45,47.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,72.27,45.9,,,,,0,18.31,133.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MNTR CARDIAC BIOMONITOR III SILICONE IRIDIUM INSERTABLE",SUP-436066,CDM,C1764,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]",Cigna,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DISTAL FEMUR 5D KIDNEY BEAN ANATOMIC BIPLANAR",SUP-PLP-3005,CDM,S27800098,LOCAL,0278,RC,,,both,,,10177.50,3053.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6920.7,68,,,,,0,1183.64,8650.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE EKOS 135CM 2.62MM THROMBECTOMY ENDOVASCULAR STERILE",SUP-H74939605135160,CDM,C1757,HCPCS,0272,RC,,,both,,,37894.50,11368.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25768.26,68,,,,,0,4407.13,32210.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 TWINFIX ULTRABRAID COBRAIDED PEEK-OPTIMA",SUP-72202625,CDM,C1713,HCPCS,0278,RC,,,both,,,1724.63,517.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,204.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",200.57,1465.94,"percent of total billed charges",
"DRILL CANNULATED 3.7MM X 80MM",SUP-DRLL-CDC-37080,CDM,S27000186,LOCAL,0270,RC,,,both,,,1905.00,571.5,"CIGNA [10200]","Cigna Open Access",,1083.95,56.9,,,,,0,221.55,1619.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 12MM PFC SIGMA 2 KNEE RIGHT TITANIUM COMBO",SUP-960830,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"FIRST HEALTH [10303]","First Health",,4104.67,80,,,,,0,596.72,4361.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP TRAY HUMERAL ASCEND FLEX REVERSE",SUP-CAPFLEXREV,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"NOVANET [10819]",Novanet,,34020,75,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 10CM 7FR 12MM .035IN BALLOON",SUP-G52301,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"KAISER [10500]",Kaiser,,643.05,67,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 45MM CREO AMP SPINE CANNULATED MODULAR",SUP-1067.4345,CDM,C1713,HCPCS,0278,RC,,,both,,,3112.50,933.75,"FIRST HEALTH [10303]","First Health",,2490,80,,,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODULAR CUP NEUTRAL LINER LONGEVITY 60X36",SUP-630506036,CDM,C1776,HCPCS,0278,RC,,,both,,,9937.38,2981.21,"CIGNA [10200]","Cigna Open Access",,5654.37,56.9,,5302.19,4377.88,6578.61,27,1155.72,8446.77,"percent of total billed charges",
"HC Observation Careve-Out - Respiratory",PX-762000015,CDM,G0378,HCPCS,0762,RC,,,both,,,66.00,19.8,"FIRST HEALTH [10303]","First Health",,52.8,80,,,,,0,7.68,66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 4.5MM STAINLESS STEEL 3.5MM SCR 4 HOLE LOCK ATTACH LCP",SUP-02.120.601S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,1144.80,304.56,2275.09,66,434.96,3179,"percent of total billed charges",
"BIT DRILL 1.1MM 1.1MM MEDIUM WIRE PASS STERILE",SUP-5300010059,CDM,S27200284,LOCAL,0272,RC,,,both,,,293.10,87.93,"CIGNA [10200]","Cigna Open Access",,166.77,56.9,,,,,0,34.09,249.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER FASTRAC 138CM 20MM 3.2-2.4-2.6FR 2MM BALLOON",SUP-SPR2020W,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LITHO SURGICAL 1950MM 2 SHEATH PREASSEMBLE DISTAL WIRE GUIDE",SUP-BML-V232QR-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2442.00,732.6,"UHC [10700]","United Healthcare",,1545.79,63.3,,,,,0,284,2075.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 5MM CEREPAK FREEFORM DETACHABLE",SUP-SCR120515,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1567.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM TIGER CANNULATED",SUP-200-24-018,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,131.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",131.88,963.9,"percent of total billed charges",
"INSRT ACETABULAR 36MM 0D D HIP X3 TRIDENT STERILE LATEX FREE",SUP-723-00-36D,CDM,C1776,HCPCS,0278,RC,,,both,,,9332.25,2799.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1105.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1085.34,7932.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL ATTUNE CEMENTED POSTERIOR STABILIZE STERILE 5",SUP-150410105,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"CIGNA [10200]",Cigna,,8957.34,40,,5873.17,5873.17,5873.17,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"SCR BONE 7MM 75X16MM DARCO FOOT HEADLESS",SUP-DC001675,CDM,C1713,HCPCS,0278,RC,,,both,,,4629.90,1388.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,538.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",538.46,3935.42,"percent of total billed charges",
"TRAY CATHETERIZATION SURESTEP LUBRI-SIL IC COMPLETE CARE",SUP-A303416A,CDM,S27200284,LOCAL,0272,RC,,,both,,,190.70,57.21,"KAISER [10500]",Kaiser,,127.77,67,,,,,0,22.18,162.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM HYPOCHLORITE 0.5 % SOLUTION",RX-2110,CDM,,,0250,RC,00436-0946-16,NDC,both,473,ML,86.28,25.88,"KAISER [10500]",Kaiser,,57.81,67,,,,,0,10.03,73.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZIPWIRE UROLOGICAL 150CM 3CM .035IN NITINOL",SUP-M006630206B1,CDM,S27200284,LOCAL,0272,RC,,,both,,,311.88,93.56,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,128.18,41.1,,,,,0,36.27,265.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 78MM NAIL-EX TITANIUM FEMORAL TIBIAL LOCKING",SUP-04.005.568,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"CIGNA [10200]","Cigna Local Plus",,618.82,53.5,,3978.14,359.25,3978.14,24,134.52,983.18,"percent of total billed charges",
"MICONAZOLE NITRATE 2 % TOPICAL OINTMENT",RX-13651,CDM,,,0250,RC,84389-0135-51,NDC,both,71,GR,364.42,109.33,"CIGNA [10200]","Cigna Open Access",,207.35,56.9,,,,,0,42.38,309.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT",SUP-G47439,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"KAISER [10500]",Kaiser,,68761.1,67,,,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 15MM INDEPENDENCE 8D LARGE PEEK ALIF PLATE",SUP-376.715,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"MULTIPLAN [10600]",Multiplan,,29134.26,85,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 6CM 230CM 22-27MM 10FR 270CM DUODENAL NITINOL",SUP-M00565010,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICROINTRODUCER 7CM 5FR MICROEZ STAINLESS STEEL GWIRE",SUP-0828950,CDM,C1894,HCPCS,0272,RC,,,both,,,455.54,136.66,"FIRST HEALTH [10303]","First Health",,364.43,80,,,,,0,52.98,387.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 109MM 30MM 26-27MM 16FR ZENITH ALPHA",SUP-G35341,CDM,C1874,HCPCS,0278,RC,,,both,,,89041.07,26712.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,36595.88,41.1,,,,,0,10355.48,75684.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 40CM 5FR KUMPE CURVE ANGIOGRAPHIC DURATION",SUP-H787117327025,CDM,C1887,HCPCS,0272,RC,,,both,,,466.56,139.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,191.76,41.1,,,,,0,54.26,396.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 6.5MM CONICAL STOP NONSTERILE",SUP-03.019.018,CDM,S27200284,LOCAL,0272,RC,,,both,,,1982.40,594.72,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HARVESTER 9MM GRAFT QUADPRO",SUP-AR-2386-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,3346.88,1004.06,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT ORTHOPEDIC SMALL 8IN WRIST RIGHT 4 WAY STRETCH",SUP-351SR,CDM,S27000186,LOCAL,0270,RC,,,both,,,121.28,36.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 18GA 20CM ACHIEVE LIGHTWEIGHT AUTOMATE",SUP-A1820,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.39,103.02,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL ENDOSCOPIC HERCULES PET FLEX 5.5CM 240CM 8-9-10MM 8FR",SUP-G51799,CDM,C1726,HCPCS,0272,RC,,,both,,,1965.00,589.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH GUIDER SOFTIP XF 90CM 8FR STRAIGHT GUIDING DURAFORM",SUP-H965100520,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS,MINOR",385,APR-DRG,,,,,,,inpatient,,,25620.39,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $3,237.19. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE 30ML THORACIC DRNG 1 WAY STEPPED CNCT AIR LEAK WELL",SUP-16100,CDM,S27200284,LOCAL,0272,RC,,,both,,,613.59,184.08,"AETNA [10100]","Aetna HMO/PPO",,487.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,71.36,521.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Bn Survey Complete",PX-320000181,CDM,77075,CPT,0320,RC,,,both,,,1478.24,443.47,"UHC [10700]","United Healthcare",,261.88,,,,,,,115.51,1256.5,"fee schedule",
"HC Prgrmg Evl Ldls Pm 1chmbr IP",PX-481000393,CDM,0826T,CPT,0481,RC,,,both,,,58.00,17.4,"FIRST HEALTH [10303]","First Health",,46.4,80,,,,,0,6.75,58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SUCTION BIG YANK 11/32IN 10IN OPEN NONVENTED TUBE 10FT",SUP-0034970U,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.66,30.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,47.12,45.9,,,,,0,11.94,87.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 170MM PERFORM 15 LONG SHOULDER STERILE LATEX",SUP-PFX15170,CDM,C1776,HCPCS,0278,RC,,,both,,,42493.50,12748.05,"AETNA [10100]","Aetna HMO/PPO",,33782.33,79.5,,10981.53,8986.79,12413.38,12,4941.99,36119.48,"percent of total billed charges",
"PLATE 30MM TITANIUM LEVEL 2 ASSURE BONE SPINE CERVICAL",SUP-110.230,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1262.14,28.62,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X22X12MM MODULUS 10D XL WIDE STERILE LATEX",SUP-1221245P2,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9765.36,41.1,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE LEGACY DBM 5CC ALLOGRAFT NONSTERILE LATEX FREE",SUP-420805,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1073.25,28.62,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2-0 T-13 18IN BRAID TIES MULTISTRAND LOWER",SUP-AR-7220,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 4CM GLIDESHEATH SLENDER TIBIAL PEDAL",SUP-52-1050,CDM,C1894,HCPCS,0272,RC,,,both,,,607.50,182.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ROTAWIRE WIRECLIP TORQUER VASCULAR 330CM 2.2CM .014IN",SUP-H802228240022,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ANGIOSCULPT EVO 6MM 3.5MM BALLOON DILATATION",SUP-2200-3506-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2410.52,41.1,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 58MM STAINLESS STEEL 2.4MM SCR 7X3 HOLE 2 COLUMN",SUP-02.111.731,CDM,C1713,HCPCS,0278,RC,,,both,,,3884.70,1165.41,"CIGNA [10200]",Cigna,,2641.6,68,,1831.33,1831.33,1831.33,16,451.79,3302,"percent of total billed charges",
"HC Cult Fungi Defin ID Yeast",PX-306000068,CDM,87106,CPT,0306,RC,,,both,,,206.15,61.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16.23,,,,,,,0.21,175.23,"fee schedule",
"HC Sigmoid Flex W Eus Exam",PX-750000085,CDM,45341,CPT,0750,RC,,,both,,,4726.85,1418.05,"MULTIPLAN [10600]",Multiplan,,4017.82,85,,,,,0,549.73,4710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bordetella Ab",PX-302000100,CDM,86615,CPT,0302,RC,,,both,,,175.00,52.5,"PHCS [10601]",PHCS,,122.5,70,,,,,0,0.01,148.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Ather Sf Ea Add",PX-361000730,CDM,37289,CPT,0361,RC,,,both,,,8353.79,2506.14,"BLUE CROSS [10001]","Blue Cross HMO",,8.35,.1,,,,,0,8.35,7883,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR VL3.5 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H74938969720,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"NOVANET [10819]",Novanet,,274.83,75,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PLATE 5 74X46MM CEMENTED STEMMED MODULAR NEXGEN",SUP-00598004701,CDM,C1776,HCPCS,0278,RC,,,both,,,8643.60,2593.08,"MULTIPLAN [10600]",Multiplan,,7347.06,85,,,,,0,1005.25,7347.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM CORTICAL RAYHACK GENERATION II",SUP-40100912,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"FIRST HEALTH [10303]","First Health",,609.12,80,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 250MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530250S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,239.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BK ULTRASOUND N/L STERILE COVERS",SUP-UA0068,CDM,S27200284,LOCAL,0272,RC,,,both,,,1020.60,306.18,"CIGNA [10200]","Cigna Local Plus",,546.02,53.5,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAP POSITIONING DIGIT TRAP SMALL FINGER ATRAUMATIC HOOK",SUP-9906,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.72,38.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.09,110.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH UROMAX ULTRA QUADRA-FOLD ENCORE HIGH PRESSURE KINK",SUP-M0062251280,CDM,C1726,HCPCS,0272,RC,,,both,,,1892.70,567.81,"UHC [10700]","United Healthcare",,1198.08,63.3,,,,,0,220.12,1608.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VOYAGER NC 15MM 2.75MM SHORT ROUND TAPER BALLOON",SUP-1011753-15,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"NOVANET [10819]",Novanet,,546.75,75,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC RBC Irrad Ea Unit",PX-390000023,CDM,P9038,HCPCS,0390,RC,,,both,,,455.00,136.5,"PHCS [10601]",PHCS,,318.5,70,,,,,0,52.92,386.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prosth Ext Train Ea 15min (Gp)",PX-420000039,CDM,97761,CPT,0420,RC,,,both,,,152.35,45.7,"MULTIPLAN [10600]",Multiplan,,129.5,85,,,,,0,17.72,152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE KORE FIBER CORTICAL BONE FIBER 1CC ALLOGRAFT",SUP-423201,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"MULTIPLAN [10600]",Multiplan,,1466.25,85,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PROGENIX PLUS DEMINERALIZED BONE MATRIX BOVINE",SUP-6001,CDM,C1713,HCPCS,0278,RC,,,both,,,1394.82,418.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,399.2,28.62,,,,,0,162.22,1185.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 CURVE PLUS 10MM KNEE XLK FIX BEARING SIGMA",SUP-970471,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]","Cigna Local Plus",,5978.38,53.5,,5372.07,4581.20,7242.98,23,1299.6,9498.37,"percent of total billed charges",
"BLADE ARTHROSCOPIC LARGE HUB STERLING GREAT WHITE 2500-6000",SUP-9399A,CDM,S27200284,LOCAL,0272,RC,,,both,,,503.82,151.15,"AETNA [10100]","Aetna HMO/PPO",,400.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.59,428.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 12/14 STD TAPER 22.225MM HIP COCR",SUP-136529000,CDM,C1776,HCPCS,0278,RC,,,both,,,4457.40,1337.22,"PHCS [10601]",PHCS,,3120.18,70,,,,,0,518.4,3788.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 6FR AR1 CURVE GUIDING NYLON CORONARY",SUP-LA6AR10A,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE,MODERATE",252,APR-DRG,,,,,,,inpatient,,,31363.46,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $6,221.90. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($31,922.76) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X2CM MATRION PLACENTAL MEMB TROPHOBLAST",SUP-PAC06,CDM,Q4201,HCPCS,0636,RC,,,both,,,3300.00,990,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ARTHROSCOPIC TRANSLUCENT GRAY 85MM 6MM DRY-DOC ROUND",SUP-C7359,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.63,90.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,35.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.08,256.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE MERITRANS 3 WAY STPCOCK ROTATING MALE ADPTR",SUP-K11-00392,CDM,S27200284,LOCAL,0272,RC,,,both,,,92.22,27.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.73,78.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR CEMENTLESS STD Z1 TITANIUM ALLOY 6",SUP-611201060,CDM,C1776,HCPCS,0278,RC,,,both,,,28967.40,8690.22,"CIGNA [10200]","Cigna Open Access",,9704.08,33.5,,5302.19,4377.88,6578.61,27,3368.91,24622.29,"percent of total billed charges",
"CATH STERLING SL 150CM 100MM 4MM BALLOON DILATATION PEBAX",SUP-H74939148401010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FRACTURE OMNICURVE 11G 15MM",SUP-1032-115-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 13MM STAINLESS STEEL T6 SELF TAP LOCK VARIABLE",SUP-02.130.313,CDM,C1713,HCPCS,0278,RC,,,both,,,841.43,252.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,386.22,45.9,,,,,0,97.86,715.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERSACROSS SHEATH 63CM 55DEG D1",SUP-VXS0204,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,188.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI MIRACLEBROS 6 VASCULAR 300CM 11CM .014IN",SUP-AG14M360,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT VESSEL HARVESTING HEMPRO ENDOSCOPIC","SUP-VH - 3000",CDM,S27200284,LOCAL,0272,RC,,,both,,,7590.00,2277,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,882.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 125CM 5FR 10MM SPACING L CURVE ELECTROPHYSIOLOGY FIXED",SUP-F5QL010ST,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"UHC [10700]","United Healthcare",,574.26,63.3,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8MM 45MM MATRIX TITANIUM SPINE CANNULATED POLYAXIAL",SUP-04.606.845,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"STEMLESS ANATOMIC PSI KIT (HUMERAL ONLY)",SUP-1235-7151-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2481.41,41.1,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309010,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"CIGNA [10200]",Cigna,,15104.88,40,,5873.17,5873.17,5873.17,"1 through 10",4391.74,32097.87,"percent of total billed charges",
"ALTIVATE REVERSE PRIMARY HUMERAL STEM, SZ 18X108MM",SUP-530-18-108,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"FIRST HEALTH [10303]","First Health",,10080,80,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 75MM VIPER 2 LORDOTIC",SUP-186788075,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"FOL URETHRAL 13.35IN 14FR HEYMAN PLASTIC DILATION CATH",SUP-021114,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.13,65.14,"CIGNA [10200]","Cigna Open Access",,123.55,56.9,,,,,0,25.25,184.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE ALL STAR VASCULAR STRAIGHT 190CM 3CM .014IN",SUP-1001740,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 28CM 3CM 7FR .038IN PIGTAIL CURVE",SUP-M006180534170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"NOVANET [10819]",Novanet,,923.22,75,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 22MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-422,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"MULTIPLAN [10600]",Multiplan,,9700.71,85,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 8FR .088IN AMPLATZ",SUP-588847,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 20MM STAINLESS STEEL CORTICAL HAND FOOT SELF",SUP-201.650,CDM,C1713,HCPCS,0278,RC,,,both,,,391.94,117.58,"BLUE CROSS [10001]","Blue Cross PPO",,153.64,39.2,,957.42,570.23,957.42,28,45.58,333.15,"percent of total billed charges",
"TRAY SURGICAL 19 1/8INX12 5/8INX5/8IN MAYO STAINLESS STEEL",SUP-19,CDM,S27200284,LOCAL,0272,RC,,,both,,,511.43,153.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,210.2,41.1,,,,,0,59.48,434.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 5MM CEREPAK XL UNIFORM DETACHABLE",SUP-FCX180510,CDM,S27800098,LOCAL,0278,RC,,,both,,,15872.28,4761.68,"KAISER [10500]",Kaiser,,10634.43,67,,,,,0,1845.95,13491.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER PELLO 2.5MM STRAIGHT",SUP-6290-208-025,CDM,S27200284,LOCAL,0272,RC,,,both,,,1837.50,551.25,"NOVANET [10819]",Novanet,,1378.13,75,,,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Rmvl Hot Bx",PX-750000078,CDM,45333,CPT,0750,RC,,,both,,,2142.07,642.62,"BLUE CROSS [10001]","Blue Cross PPO",,2142.07,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,249.12,2142.07,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Encephalitiss West Equine Ab",PX-302000117,CDM,86654,CPT,0302,RC,,,both,,,216.60,64.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,184.11,"per diem",
"HC Midline Placement WO Img",PX-361000536,CDM,36410,CPT,0361,RC,,,both,,,414.95,124.48,"KAISER [10500]",Kaiser,,278.02,67,,,,,0,48.26,352.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg WO Vid 2-12hr Intmt Mntr",PX-740000041,CDM,95706,CPT,0740,RC,,,both,,,5043.88,1513.16,"BLUE CROSS [10001]","Blue Cross PPO",,5.04,.1,,,,,0,5.04,4287.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Obstruction Intraluminal",PX-361000123,CDM,36596,CPT,0361,RC,,,both,,,6510.86,1953.26,"CIGNA [10200]","Cigna Local Plus",,1965,,"Case rate ($1,965). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,757.21,6510.86,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 20MM 140CM 3MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927420300,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Open Access",,2133.75,56.9,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X40 80CM SL",SUP-48006004N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,101.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL POSTERIOR STABILIZED IPOLY ITOTAL 22MM",SUP-RPS0102200,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,602.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,591.02,4319.57,"percent of total billed charges",
"INTRO SHEATH 6FR 11CM MINI GWIRE NO OBTR HEXCUSPID VALVE",SUP-504606X,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"AETNA [10100]","Aetna HMO/PPO",,62.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 40CM FEMUR LEFT PROXIMAL TALON DISTALFIX",SUP-SLN-125-40L,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"CIGNA [10200]","Cigna Local Plus",,5079.47,31.5,,3978.14,359.25,3978.14,24,1875.37,13706.51,"percent of total billed charges",
"SCR BONE 5MM 66MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.066S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 56MM TI",SUP-MTC-37560-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"CIGNA [10200]","Cigna Open Access",,709.77,56.9,,1144.80,304.56,2275.09,66,145.07,1060.29,"percent of total billed charges",
"HC Pregnancy Test Urine",PX-307000008,CDM,81025,CPT,0307,RC,,,both,,,383.80,115.14,"UHC [10700]","United Healthcare",,7.75,,,,,,,4.29,326.23,"fee schedule",
"HC Progesterone",PX-301000373,CDM,84144,CPT,0301,RC,,,both,,,181.45,54.43,"BLUE CROSS [10001]","Blue Cross HMO",,26.75,,"Fee schedule rate ($26.75).",,,,0,0.18,154.23,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 12CM WIRE MANDREL HEMOSTASIS VALVE MICRO",SUP-CLI-101-15,CDM,C1894,HCPCS,0272,RC,,,both,,,295.80,88.74,"UHC [10700]","United Healthcare",,187.24,63.3,,,,,0,34.4,251.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 X-1 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J458H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ext Ecg>48hr<7d Recording",PX-731000005,CDM,93242,CPT,0731,RC,,,both,,,383.00,114.9,"AETNA [10100]","Aetna HMO/PPO",,304.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.87,383,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 17.5MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158122117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross PPO",,4380.42,39.2,,3949.44,3949.44,3949.44,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"CATH OPTA PRO 80CM 2CM 5FR 7MM 7.5MM BALLOON DILATATION",SUP-4197020S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nrv Condct 9-10 Studies",PX-922000023,CDM,95911,CPT,0922,RC,,,both,,,6810.24,2043.07,"MULTIPLAN [10600]",Multiplan,,5788.7,85,,,,,0,792.03,5788.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 356MM 5MM 126MM 3 FLUTED QUICK COUPLING CALIBRATED",SUP-03.008.008,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +22 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z9002220,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,468.46,45.9,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON ULTIMA 10-0 CS140-6 12IN 2 ARM MONOFILAMENT",SUP-9003G,CDM,S27200284,LOCAL,0272,RC,,,both,,,229.29,68.79,"MULTIPLAN [10600]",Multiplan,,194.9,85,,,,,0,26.67,194.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X21MM LUMINARY CC 30D BICONVEX",SUP-6921,CDM,S27800098,LOCAL,0278,RC,,,both,,,34524.00,10357.2,"NOVANET [10819]",Novanet,,25893,75,,,,,0,4015.14,29345.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FREEFIX PROXIMAL HUMERUS PLATE STRAIGHT 9 SLOT RIGHT TI",SUP-PHPF-S9R,CDM,C1713,HCPCS,0278,RC,,,both,,,18396.00,5518.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2179.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",2139.45,15636.6,"percent of total billed charges",
"CMPNT FEMORAL 10 STD KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-42500606801,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"KAISER [10500]",Kaiser,,15318.01,67,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Epididymis Testis",PX-450000280,CDM,54700,CPT,0361,RC,,,both,,,9333.00,2799.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3279,,"Case rate ($3,279). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,9.33,7933.05,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 3.5MM VUEPOINT II TITANIUM NONSTERILE LATEX",SUP-8976112,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VALVE AORTIC 20MM SAPIEN 3 BOVINE TRANSCATHETER STERI",SUP-9600TFX20A,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,48940.2,28.62,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP POROCOAT PINNACLE 300 SERIES",SUP-121703062,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3248.51,28.62,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 1.5MM 140CM ERGONOMIC HANDLE AUTOMATIC STOP",SUP-M00516011,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.01,40.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,61.97,45.9,,,,,0,15.7,114.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ATLANTIS TITANIUM SPINAL SELF TAPPING",SUP-876-710,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"CATH SPRINTER FASTRAC 138CM 6MM 3.2-2.4-2.6FR 2.25MM BALLOON",SUP-SPR22506W,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VOYANT INTELLIGENT ENERGY SYS 23CM MARYLAND SINGLE STEP ACTI",SUP-EB214,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"AETNA [10100]","Aetna HMO/PPO",,2534.06,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 6.5MM 64MM TITANIUM FULL THREAD CORTEX SELF",SUP-414.864,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"CIGNA [10200]","Cigna Open Access",,156.63,56.9,,1144.80,304.56,2275.09,66,32.01,233.98,"percent of total billed charges",
"MTRL SPLINTING THK1/8IN 24X18IN 19% PERFORATE OPTIPERF",SUP-A963101,CDM,S27000186,LOCAL,0270,RC,,,both,,,707.05,212.11,"UHC [10700]","United Healthcare",,447.56,63.3,,,,,0,82.23,600.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.5/22",SUP-401754,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 8FR .088IN EXTRA",SUP-5888103,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 20CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061802200,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,106.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Glucose Bld Quant",PX-301000204,CDM,82947,CPT,0301,RC,,,both,,,130.15,39.04,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.66,,,,,,,2.66,110.63,"fee schedule",
"HC Ins Picc WO Port/Img >=5yr",PX-361000115,CDM,36569,CPT,0361,RC,,,both,,,7818.16,2345.45,"PHCS [10601]",PHCS,,4710,,"Case rate ($4,710). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,909.25,7818.16,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC",718,MS-DRG,,,,,,,inpatient,,,45243.20,13572.96,"CIGNA [10200]",Cigna,,17610.73,,"Fee schedule rate ($17,610.73). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,39213.15,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM HIP ACETABULAR CANCELLOUS PRIMARY",SUP-2020-6540-1,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"BLUE CROSS [10001]","Blue Cross HMO",,298.47,39.2,,957.42,156.86,7483.26,51,88.55,647.19,"percent of total billed charges",
"HEAD UNIPOLAR 52MM CATHCART BALL HIP FEMORAL ORTHOCHROME",SUP-136352000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X40 40CM SL",SUP-48006004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,403.66,41.1,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROTEGE GPS EXPRT 30MM 80CM 14MM .079IN LARGE DIAMETER",SUP-SERB65-14-30-80,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"MULTIPLAN [10600]",Multiplan,,4730.25,85,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD SUT ASSISTANT 0 ES-9 7IN COATED ENDO STITCH BRALON",SUP-170010,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"KAISER [10500]",Kaiser,,96.59,67,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 545CC NATRELLE INSPIRA COHESIVE STERILE",SUP-SCX-545,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]","Cigna Open Access",,4299.08,56.9,,5166.00,5166.00,5166.00,"1 through 10",878.7,6422.18,"percent of total billed charges",
"INSRT TIBIAL 6 17.5MM KNEE GVF STABILIZE ROTATE PLATFORM PFC",SUP-962164,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2920.7,28.62,,,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.075 CLAREON",SUP-SY60WF.075,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +19.5 DIOPTER MODIFIED C BICONVEX 12.5MM 7MM",SUP-CZ70BD.195,CDM,V2632,HCPCS,0276,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE INSPIRA MODERATE PROFILE SILICONE 640CC",SUP-SSZ-M640,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHELL ACETABULAR 48MM HIP CLUSTER HOLE 12 SCALLOP SNAP FIT",SUP-00875704801,CDM,C1776,HCPCS,0278,RC,,,both,,,11012.40,3303.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1304.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1280.74,9360.54,"percent of total billed charges",
"DIL SURGICAL .038IN 18CM 7FR VESSEL",SUP-DIL-600-07,CDM,C1894,HCPCS,0272,RC,,,both,,,95.23,28.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,64.76,68,,,,,0,11.08,80.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL IN 0.9 % NACL 10 MCG/ML IV SUPERORDERABLE|DISCARDED DRUG NOT ADMINISTE",RX-40830807,CDM,J3010,HCPCS,0636,RC,70004-0202-40,NDC,both,250,ML,151.00,45.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",JW,34.95,,"Fee schedule rate ($34.95). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.89,128.35,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X22X10MM RISE-L 10D NONSTERILE",SUP-193.433,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"AETNA [10100]","Aetna HMO/PPO",,27296.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR CHMBR",SUP-MTA3U0.050,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN REGULAR",SUP-67018100,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,283.97,68,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE APICAL PAD - SMALL",SUP-TENDV-SPAD-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOTUS INTRODUCER SMALL REPRISE III",SUP-H749NTR180,CDM,C1894,HCPCS,0272,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 103MM 14-36MM 20FR ENDURANT IIS 2 BRANCH",SUP-ESBF3614C103E,CDM,S27800098,LOCAL,0278,RC,,,both,,,60782.40,18234.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16411.25,27,,,,,0,7068.99,51665.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX 11CM OPEN POSITION SYSTEM STERILE",SUP-1220011,CDM,C1781,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.25CM NATRELLE INSPIRA P4.1CM MODERATE PROFILE",SUP-MSZ-M330,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"KAISER [10500]",Kaiser,,105.98,67,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL 15X5MM MOBI-C 13MM CERVICAL TITANIUM COCRMO UHMWPE","SUP-MB 3355",CDM,S27800098,LOCAL,0278,RC,,,both,,,33075.00,9922.5,"NOVANET [10819]",Novanet,,24806.25,75,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM INDEPENDENCE SPINE SELF DRILL VARIABLE",SUP-176.745,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross PPO",,635.04,39.2,,957.42,570.23,957.42,28,188.41,1377,"percent of total billed charges",
"GWIRE PLATINUM PLUS VASCULAR STRAIGHT 180CM .018IN STAINLESS",SUP-H74917531,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN AMPLATZ RIGHT 2 CURVE",SUP-DXT6AR20,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"PHCS [10601]",PHCS,,57.86,70,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 18MM AXSOS STAINLESS STEEL HUMERUS FEMUR TIBIA",SUP-370318,CDM,C1713,HCPCS,0278,RC,,,both,,,1376.51,412.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,936.03,68,,,,,0,160.09,1170.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRGMR NEROSTIMLTR ACTIVA PATIENT ANTENNA DETERMINED DEEP",SUP-37092,CDM,C1787,HCPCS,0270,RC,,,both,,,607.50,182.25,"NOVANET [10819]",Novanet,,455.63,75,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TIGHTROPE II FLIPCUTTER III FIBERSTICK FIXATION BONE",SUP-AR-1288BTBIB-FC3,CDM,C1713,HCPCS,0278,RC,,,both,,,8223.08,2466.92,"BLUE CROSS [10001]","Blue Cross HMO",,3223.45,39.2,,957.42,156.86,7483.26,51,956.34,6989.62,"percent of total billed charges",
"STENT ZIMMON 15CM 5FR 2 PIGTAIL CURVE BILIARY POLYETHYLENE",SUP-G22128,CDM,C2625,HCPCS,0278,RC,,,both,,,1328.40,398.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,380.19,28.62,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +27.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000275,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 15MM 3.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP3515X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,358.02,68,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 53CM 6.6FR MYOCARDIUM UNIPOLAR FIXED SCR IS-1",SUP-5071-53,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"NOVANET [10819]",Novanet,,4205.25,75,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"1000 SINGLE USE FLAT TIP HOLMIUM FIBER",SUP-HOL1000SBX,CDM,S27200284,LOCAL,0272,RC,,,both,,,4183.70,1255.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1719.5,41.1,,,,,0,486.56,3556.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION SURESTEP ADD-A-FOLEY COMPLETE CARE",SUP-A399400A,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.70,27.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,37.69,41.1,,,,,0,10.66,77.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG 232X12X3.7MM STAINLESS STEEL 3.5MM SCR SMALL",SUP-241.923S,CDM,C1713,HCPCS,0278,RC,,,both,,,10695.00,3208.5,"CIGNA [10200]",Cigna,,7272.6,68,,1831.33,1831.33,1831.33,16,1243.83,9090.75,"percent of total billed charges",
"SULFACETAMIDE SODIUM 10 % EYE DROPS",RX-7359,CDM,,,0250,RC,24208-0670-04,NDC,both,15,ML,383.72,115.12,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,157.71,41.1,,,,,0,44.63,326.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT IMPL 20X5.5MM BME ELITE 1.5MM BRIDGE 2 LEG CONTINUOUS",SUP-EL-2020S2,CDM,C1713,HCPCS,0278,RC,,,both,,,8435.25,2530.57,"MULTIPLAN [10600]",Multiplan,,7169.96,85,,,,,0,981.02,7169.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 13MM KNEE X3 BEARING POSTERIOR STABILIZE",SUP-5532-G-313,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"FIRST HEALTH [10303]","First Health",,6966.09,80,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 0MM 28MM HIP MODULAR TYPE 1 CERAMIC BIOLOX",SUP-650-1158,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1168.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1146.57,8379.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 93MM TYPE 1 PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51108040,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3190.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3190.72,23319.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endovenous Ablat Chem Ext Subq",PX-361000555,CDM,36483,CPT,0361,RC,,,both,,,9689.00,2906.7,"NOVANET [10819]",Novanet,,7266.75,75,,,,,0,1126.83,8235.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 75X25MM 3 TONGUE DAVIS",SUP-45-5113,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.96,81.59,"AETNA [10100]","Aetna HMO/PPO",,216.21,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.63,231.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cellular Function W/Stim",PX-302000076,CDM,86352,CPT,0302,RC,,,both,,,1484.85,445.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,1262.12,"per diem",
"GRAFT ENDOVASCULAR 45MM 10MM ZENITH ILIAC BRANCH 41MM",SUP-G60340,CDM,C1874,HCPCS,0278,RC,,,both,,,68399.94,20519.98,"CIGNA [10200]",Cigna,,27359.98,40,,,,,0,7954.91,58139.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1/3 TUBE 123MM STAINLESS STEEL 10 HOLE LOCK BONE ANKLE",SUP-AR-8943T-10,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMDESIVIR 100 MG/20ML IV (WET SOLR VIAL)",RX-415225383,CDM,J0248,HCPCS,0636,RC,61958-2901-02,NDC,both,1,UN,2615.60,784.68,"MULTIPLAN [10600]",Multiplan,,2223.26,85,,,,,0,622.5,2223.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS",RX-15981,CDM,J1250,HCPCS,0636,RC,00409-2346-31,NDC,both,250,ML,157.30,47.19,"MULTIPLAN [10600]",Multiplan,,133.71,85,,,,,0,6.7,133.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 5-0 P-1 18IN MONOFILAMENT UNDYED",SUP-Y490G,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.59,20.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,47.32,68,,,,,0,8.09,59.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 300MM 3MM BALLOON DILATATION DURALYN",SUP-48003030X,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SELUTION SLR PTCA DEB 3.5X20MM",SUP-SCA14U-350020D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 30IN 23FR FEMUR VEIN ADULT .5IN CNCT 1 PIECE",SUP-96370-023,CDM,S27200284,LOCAL,0272,RC,,,both,,,2120.63,636.19,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PUTTY EXERCISE ROLYAN 50/50 MIX ELASTOMER CUSTOM GRIP",SUP-A9582,CDM,S27000186,LOCAL,0270,RC,,,both,,,593.00,177.9,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,MAJOR",049,APR-DRG,,,,,,,inpatient,,,113786.70,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $11,922.08. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($84,203.55) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X10X7MM SABLE 15D STERILE LATEX FREE",SUP-1172.2121S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14241.15,41.1,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEMOSTAR XK 28CM 16FR ALPHACURVE STD HEMODIALYSIS",SUP-5885230,CDM,C1750,HCPCS,0278,RC,,,both,,,1563.30,468.99,"NOVANET [10819]",Novanet,,1172.48,75,,,,,0,181.81,1328.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE CARDIOFORM ASD OCCLUDER 37MM 11FR",SUP-00733132636501,CDM,C1817,HCPCS,0278,RC,,,both,,,52321.50,15696.45,"MULTIPLAN [10600]",Multiplan,,44473.28,85,,,,,0,6084.99,44473.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 100MM 2.7MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.26,CDM,S27000186,LOCAL,0270,RC,,,both,,,496.69,149.01,"NOVANET [10819]",Novanet,,372.52,75,,,,,0,57.77,422.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 38MM MITRAL CARPENTIER-EDWARDS PHYSIO II",SUP-5200M38,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3726,27,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL 195MM 3MM MULTIVAC 50D XL HIP PLATINUM",SUP-ASC473001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2558.25,767.47,"CIGNA [10200]","Cigna Open Access",,1455.64,56.9,,,,,0,297.52,2174.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +21.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.215,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM RELINE-O 4S SPINE MODULAR SHANK TRACTION",SUP-13176535,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,,1521.93,481.35,16760.95,30,348.9,2550,"percent of total billed charges",
"STENT ZIPWIRE 28CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175274190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]",Cigna,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN AMPLATZ",SUP-67011300,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"AETNA [10100]","Aetna HMO/PPO",,331.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 21.5X12.7X.3MM LARGE SAGITTAL STERILE",SUP-1200-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,146.16,43.85,"KAISER [10500]",Kaiser,,97.93,67,,,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SCISSORS MONOPOLAR CURVE STERILE LATEX FREE DISPOSABLE",SUP-430035,CDM,S27200284,LOCAL,0272,RC,,,both,,,1020.60,306.18,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP BIOPSY MICROMESH TEETH STREAMLINE CATH 240CM 2.4MM",SUP-M00513321,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.37,38.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUFF TRNQT GREEN 44X4IN XLONG LEG 1 FILL LINE POSITIVE LOCK",SUP-ASP-564014,CDM,S27200284,LOCAL,0272,RC,,,both,,,202.86,60.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OCCL CARDIOVASCULAR 27MM DELIVERY SYSTEM WATCHMAN FLX",SUP-M635WU50270,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE 51MM 3 LEVEL OZARK BONE SPINE CERVICAL NONSTERILE",SUP-AA01-43F51V,CDM,S27200284,LOCAL,0272,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT PLAIN 4-0 SC-1 18IN 2 ARM MONOFILAMENT PLIABILIZE",SUP-1828H,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.77,21.23,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE TENDER TOUCH ULTRA 65MM 65MM VACUUM EXTRACTION",SUP-505TTL,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.75,58.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH AXS CATALYST 6 132CM 6FR GUIDING DISTAL ACCESS STERILE",SUP-M003IC0601320,CDM,S27200284,LOCAL,0272,RC,,,both,,,13688.22,4106.47,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE LAPAROSCOPIC 11MM OPTICAL ACCESS SYSTEM 100MM KII",SUP-CTS12,CDM,S27200284,LOCAL,0272,RC,,,both,,,119.63,35.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCISSORS LAPAROSCOPIC MONOPOLAR CAUT ADPTR HOOK CURVE JAW",SUP-176605,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHILON MULTIPASS 3-0 PS-1 18IN MONOFILAMENT PLIABILIZE",SUP-1663H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRAIN INCISION JACKSON-PRATT SILICONE OD19 FR T TUBE CROSSBA",SUP-SU130-1334,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.55,28.66,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 18.5X5.5X.38MM HALL MICRO STAINLESS STEEL",SUP-5301030062,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.29,43.59,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.9,123.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE S-101 - EACH",SUP-666697-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,177.48,68,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP LIGATION RESOLUTION 360 ULTRA 235CM BRAID ROTATION",SUP-M00521401,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,739.86,45.9,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIR STPLR TRIEEA33XT BLK EXTHK",SUP-TRIEEA33XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2254.95,676.48,"MULTIPLAN [10600]",Multiplan,,1916.71,85,,,,,0,262.25,1916.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER SURGICAL 30X12MM",SUP-691.004S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"CIGNA [10200]","Cigna Local Plus",,902.81,53.5,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM POLAR CARE GLACIER LONG THERAPEUTIC KNEE WRAP ON",SUP-10906,CDM,S27200284,LOCAL,0272,RC,,,both,,,1035.10,310.53,"CIGNA [10200]",Cigna,,703.87,68,,,,,0,120.38,879.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR SKIN 3.9X6.9MM WIDE RECTANGULAR 35 COUNT",SUP-PXW35,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.12,19.84,"CIGNA [10200]","Cigna Open Access",,37.62,56.9,,,,,0,7.69,56.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tavi/Tavr Bypassperc per Art",PX-361000349,CDM,33367,CPT,0361,RC,,,both,,,45298.00,13589.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6019.63,,"Fee schedule rate ($6,019.63).",,,,0,2491,38503.3,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Admin Dialysis Hf1000",PX-E27200139,CDM,E27200139,LOCAL,0272,RC,,,both,,,942.70,282.81,"CIGNA [10200]","Cigna Open Access",,536.4,56.9,,,,,0,109.64,801.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CARDIOMEMS CARDIAC MNTR DELIVERY PULMONARY ARTERY",SUP-CM2000,CDM,C2624,HCPCS,0278,RC,,,both,,,102600.00,30780,"KAISER [10500]",Kaiser,,68742,67,,,,,0,11932.38,87210,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SCLEROTHERAPY 23GA 2.3MM .32MM BEVEL STRONG PUSHABLE",SUP-M00518350,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.66,81.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,32.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.48,230.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 27.5CM 3.5MM SKIMMER 15D SUBGLOTTIC 2 CURVED",SUP-1883523,CDM,S27200284,LOCAL,0272,RC,,,both,,,4429.80,1328.94,"CIGNA [10200]","Cigna Local Plus",,2369.94,53.5,,,,,0,515.19,3765.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 5-0 PC-3 18IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP844G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR ELECTROSURGICAL 4FT 3/8IN 7/8IN PENADAPT 45D PENCIL",SUP-PA2010,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.57,43.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.93,123.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 3.5MM SUREFORM 45 STERILE LATEX FREE DISPOSABLE",SUP-48345B,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 2-0 SH 30IN BRAID GREEN NONABSORBABLE",SUP-X833H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OLANZAPINE 2.5 MG TABLET",RX-21057,CDM,,,0637,RC,60505-3110-00,NDC,both,1,UN,42.33,12.7,"CIGNA [10200]","Cigna Open Access",,24.09,56.9,,,,,0,4.92,35.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE DAKOTA OPENSURE 120CM 1.9FR 8MM STONE RETRIEVAL",SUP-M0063905000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXIVA PULSE ID 242",SUP-M006L8406910,CDM,S27200284,LOCAL,0272,RC,,,both,,,2856.45,856.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1174,41.1,,,,,0,332.21,2427.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,,,0637,RC,00032-0047-70,NDC,both,1,UN,25.19,7.56,"KAISER [10500]",Kaiser,,16.88,67,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD LUBRI-SIL IC 20FR URETHRAL BACTI-GUARD SILICONE",SUP-1758SI20,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.35,24.4,"AETNA [10100]","Aetna HMO/PPO",,64.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.46,69.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enteroscopy W Rmvl FB",PX-750000228,CDM,44363,CPT,0750,RC,,,both,,,3196.00,958.8,"PHCS [10601]",PHCS,,3196,,"Case rate ($6,277). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,371.69,3196,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE VASCULAR 18-30MM EN SNARE SYSTEM RETRIEVAL",SUP-EN2007030,CDM,C1773,HCPCS,0272,RC,,,both,,,2520.00,756,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,293.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,293.08,2142,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 24IN MIC-KEY SECUR-LOK ENFIT LOW PROFILE CONTINUOUS",SUP-0141-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.50,22.05,"AETNA [10100]","Aetna HMO/PPO",,58.43,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.55,62.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP OCCL BALLOON AUDIO INDCTR ALERT ELECTROSURGERY DEVICE",SUP-KC-ARCH-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"MULTIPLAN [10600]",Multiplan,,973.96,85,,,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VIVIGEN MIS CELLULAR BONE MATRIX ALLOGRAFT",SUP-BL-1900-GUN,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,436.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOCUSATE SODIUM 100 MG CAPSULE",RX-2566,CDM,,,0637,RC,60687-0129-11,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,3.57,56.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 6.5IN 9MM 5MM SAYRE 2 END BLUNT PERIOSTEAL",SUP-26-3751,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.92,53.98,"KAISER [10500]",Kaiser,,120.55,67,,,,,0,20.92,152.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL ROLLER BALL 27FR 5MM STORZ 1 STEM",SUP-M0068804021,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,351.21,68,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DTECT CARBON DIOXIDE END TIDAL COLORIMETRIC LATEX FREE","SUP-PEDICAP 6",CDM,S27200284,LOCAL,0272,RC,,,both,,,82.22,24.67,"FIRST HEALTH [10303]","First Health",,65.78,80,,,,,0,9.56,69.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 100MM 10.8MM 6.4MM CUFFED LOW PRESSURE SHILEY TRACH 6",SUP-6PERC,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.62,111.79,"KAISER [10500]",Kaiser,,249.66,67,,,,,0,43.34,316.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 55MM R3CON NONSTERILE GORILLA PLATE SYSTEM",SUP-P50-453-4255,CDM,C1713,HCPCS,0278,RC,,,both,,,1113.75,334.12,"CIGNA [10200]",Cigna,,757.35,68,,1831.33,1831.33,1831.33,16,129.53,946.69,"percent of total billed charges",
"CATH STERLING 150CM 200MM 7MM BALLOON DILATATION PEBAX",SUP-H74939032702110,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM GORILLA R3CON LOCK",SUP-P50-353-3510,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bat Clps Elec/Comb Vad, Rep",PX-E27400015,CDM,Q0497,HCPCS,0274,RC,,,both,,,3419.68,1025.9,"CIGNA [10200]","Cigna Open Access",,1945.8,56.9,,,,,0,397.71,2906.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anoscopy W Ctrl Bld",PX-750000233,CDM,46614,CPT,0750,RC,,,both,,,2042.00,612.6,"PHCS [10601]",PHCS,,1429.4,70,,,,,0,237.48,2042,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anoscopy W Ctrl Bld",PX-750000233,CDM,46614,CPT,0750,RC,,,both,,,2042.00,612.6,"NOVANET [10819]",Novanet,,1531.5,75,,,,,0,237.48,2042,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE SP 37L",SUP-TENDV-SP-37L-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,78489,45.9,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BD NEXIVA DIFFUSICS 1.25IN 18GA INTRAVENOUS BD VIALON",SUP-383594,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.16,17.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.88,50.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER 19CM 4.2MM HIP LENGTH ADAPTEUR POWER SYSTEM RESECTOR",SUP-AR-6420BC,CDM,S27200284,LOCAL,0272,RC,,,both,,,654.89,196.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,445.33,68,,,,,0,76.16,556.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS PLUS 2-0 CT-1 27IN MONOFILAMENT ANTIBACTERIAL",SUP-PDP339H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY 14.8CM 12GA 10GA BD TREK AUTOMATIC BRAKE CONTROL",SUP-TKL1010,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,399.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 6.5MM PILOT HEAD STERILE",SUP-AR-1451,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROCKET IPC VALVE REPLACEMENT KIT",SUP-R54410-00-VVH,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,218.89,68,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 4MM SABRETOOTH COOLCUT CURVE STAINLESS",SUP-AR-8400CST,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"NOVANET [10819]",Novanet,,421,75,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN MICROPOINT 5-0 G-3 18IN 2 ARM MONOFILAMENT",SUP-772G,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.58,54.17,"AETNA [10100]","Aetna HMO/PPO",,143.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21,153.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 16FR URETHRAL BACTI-GUARD RUBBER HYDROGEL 30",SUP-0167SI16,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.45,32.23,"CIGNA [10200]","Cigna Open Access",,61.14,56.9,,,,,0,12.5,91.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STERIS OLY BRONCH 2-PC KIT",SUP-10034100,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.80,36.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,82.82,68,,,,,0,14.17,103.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SMARTABLATE IRRIGATION",SUP-SAT001,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,435.13,68,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUSA CLARITY 36KHZ TORQUE WRENCH (5-PACK)",SUP-C7602,CDM,S27200284,LOCAL,0272,RC,,,both,,,1022.79,306.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,695.5,68,,,,,0,118.95,869.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 24FR SILICONE TROCAR CANN ROUND EXTERNAL BOLST",SUP-M00509061,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"PHCS [10601]",PHCS,,340.2,70,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 125CM 6FR .052IN PIGTAIL CURVE ANGIOGRAPHIC TRILON",SUP-H749086412152,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]","Cigna Open Access",,43.57,56.9,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC20ST-LK,CDM,S27200284,LOCAL,0272,RC,,,both,,,17640.00,5292,"FIRST HEALTH [10303]","First Health",,14112,80,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 28MM HEMASHIELD PLATINUM STRAIGHT TUBE",SUP-M00202175428P0,CDM,L8670,HCPCS,0278,RC,,,both,,,2271.36,681.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,264.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,264.16,1930.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARBAMAZEPINE 200 MG TABLET, IMMEDIATE RELEASE",RX-1357,CDM,,,0637,RC,68084-0444-11,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 45MM ECHELON ENDOSCOPIC LINEAR CUTTER",SUP-ECR45M,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"UHC [10700]","United Healthcare",,2367.42,63.3,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILFRM URETHRAL 13IN 6FR SPIRAL PLASTIC STERILE LATEX FREE",SUP-343106,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.14,31.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.34,90.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RIFAXIMIN 550 MG TABLET",RX-104604,CDM,,,0637,RC,65649-0303-03,NDC,both,1,UN,277.53,83.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,32.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.28,235.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRESSURE SENSING ACCESS SYSTEM (PSAS) 8F 25CM",SUP-PSS-10-0825200-SCN,CDM,S27200284,LOCAL,0272,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRESSING IV SILVERLON LIFESAVER SILVER 8.5 MM OD1.5 IN ANTIM",SUP-IVCD-15-85,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.49,25.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,39.24,45.9,,,,,0,9.94,72.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 6 FIRING 3 GEL TUBE OPEN LINEAR STERILE LATEX",SUP-PSD7506EN,CDM,S27200284,LOCAL,0272,RC,,,both,,,1301.40,390.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,151.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,151.35,1106.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE",RX-19146,CDM,,,0637,RC,60687-0683-11,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 25MM 1.7MM ROUTER TAPERED STERILE",SUP-5120071059,CDM,S27200284,LOCAL,0272,RC,,,both,,,667.12,200.14,"UHC [10700]","United Healthcare",,422.29,63.3,,,,,0,77.59,567.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 3.5CM 14FR RADIOPAQUE LOW PROFILE PROXIMAL ANTIREFLUX",SUP-0120-14-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,90.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM OPTIFIX FIXATION PDLLA 30 ABSORBABLE FSTNR SMOOTH",SUP-0113126,CDM,S27200284,LOCAL,0272,RC,,,both,,,741.80,222.54,"KAISER [10500]",Kaiser,,497.01,67,,,,,0,86.27,630.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lipoprotein A",PX-301000299,CDM,83695,CPT,0301,RC,,,both,,,164.75,49.42,"UHC [10700]","United Healthcare",,12.89,,,,,,,0.16,140.04,"fee schedule",
"TNLR SURGICAL BULLET TIP KELLY-WICK 4MM VASCULAR STERILE",SUP-KWT004,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,167.72,45.9,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG PROC PACK BLUE WRAPPING ALCOHOL PAD VALVE CAP SELF",SUP-50-7290A,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,278.05,68,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 14MM 3FR GEMINI HELICAL",SUP-M0063302080,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,175.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.4MM X 340MM TRILOGY PROBE KIT",SUP-M0068403520,CDM,S27200284,LOCAL,0272,RC,,,both,,,5531.45,1659.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2273.43,41.1,,,,,0,643.31,4701.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MANTA 18FR CLSR VASCULAR",SUP-2115,CDM,C1760,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1704.04,45.9,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 8IN 40D UP CERVICAL 9X4MM MICRO-KERRISON EJECTOR",SUP-57-0694,CDM,S27200284,LOCAL,0272,RC,,,both,,,2535.15,760.54,"CIGNA [10200]",Cigna,,1723.9,68,,,,,0,294.84,2154.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE MULTICOOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-MCKA3-17-50-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,13179.00,3953.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5416.57,41.1,,,,,0,1532.72,11202.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOPHARYNGEAL 67MM 32FR ADJUSTABLE FLANGE SOFT RED",SUP-125200-000320,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.91,23.07,"KAISER [10500]",Kaiser,,51.53,67,,,,,0,8.94,65.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 155MM 3.5MM PERI-LOC SHORT QUICK CONNECT STERILE",SUP-71173504,CDM,S27200284,LOCAL,0272,RC,,,both,,,1354.73,406.42,"CIGNA [10200]","Cigna Open Access",,770.84,56.9,,,,,0,157.56,1151.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"**DO NOT REUSE ITEM # - PS GO LIVE ISSUE**TROCAR LAPAROSCOPI",SUP-C0R47,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"FIRST HEALTH [10303]","First Health",,146.16,80,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SMALL 235CMX11MM INTERNAL DURACLIP REPOSITIONABLE",SUP-DC0235,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL DAICOFF 7.75IN VASCULAR NDL PULL",SUP-30-8015,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP MONOPOLAR 32CM 5MM ACCU-SPIN MARYLAND 23MM CURVE",SUP-97-1067RC,CDM,S27200284,LOCAL,0272,RC,,,both,,,3590.03,1077.01,"UHC [10700]","United Healthcare",,2272.49,63.3,,,,,0,417.52,3051.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET RETROGRADE LOW",SUP-AR-1204AF-110,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"MULTIPLAN [10600]",Multiplan,,2175.47,85,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 SH-1 30IN 2 ARM MONOFILAMENT BLUE",SUP-8526H,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.76,19.13,"NOVANET [10819]",Novanet,,47.82,75,,,,,0,7.42,54.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DONEPEZIL 5 MG TABLET",RX-18786,CDM,,,0637,RC,00904-6477-61,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 1MM E9000 ROUND STAINLESS STEEL 6 FLUTE",SUP-E8210,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 7.5MM ACORN DISSECTING",SUP-MR8-14AC75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1184.63,355.39,"MULTIPLAN [10600]",Multiplan,,1006.94,85,,,,,0,137.77,1006.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 80CM 5FR NEFF CURVE ANGIOGRAPHIC",SUP-G47078,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"UHC [10700]","United Healthcare",,133.26,63.3,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 100CM 5FR AL1 CURVE ANGIOGRAPHIC PEBAX",SUP-7527-13,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.74,23.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,53.54,68,,,,,0,9.16,66.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOTHYROXINE 75 MCG TABLET",RX-4422,CDM,,,0637,RC,00904-6951-61,NDC,both,1,UN,6.27,1.88,"UHC [10700]","United Healthcare",,3.97,63.3,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH ARTHROSCOPIC DISPOSABLE 4.5MM CORKSCREW 4.5MM PUSHLOCK",SUP-AR-1922PBS,CDM,S27200284,LOCAL,0272,RC,,,both,,,637.88,191.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,262.17,41.1,,,,,0,74.19,542.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER SURGIDAC 2-0 21IN LOOPED BRAIDED COATED GREEN",SUP-ED-20-L,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,59.25,41.1,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH ARTHROSCOPIC DISPOSABLE 4.5MM CORKSCREW 4.5MM PUSHLOCK",SUP-AR-1922PBS,CDM,S27200284,LOCAL,0272,RC,,,both,,,637.88,191.36,"CIGNA [10200]","Cigna Local Plus",,341.27,53.5,,,,,0,74.19,542.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROLENE 7/0 3/8R 10MM DA 60CM",SUP-20S05C,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.47,30.74,"CIGNA [10200]","Cigna Local Plus",,54.82,53.5,,,,,0,11.92,87.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL ULTRA STRONG CURVE 3CM VEIN LIGHTWEIGHT",SUP-15-0730,CDM,S27200284,LOCAL,0272,RC,,,both,,,1659.75,497.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,682.16,41.1,,,,,0,193.03,1410.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC 160CM 2.8MM RADIAL JAW 4 LARGE CAPACITY",SUP-M00513301,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.37,38.51,"NOVANET [10819]",Novanet,,96.28,75,,,,,0,14.93,109.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NICARDIPINE 30 MG CAPSULE",RX-10713,CDM,,,0637,RC,42806-0502-09,NDC,both,1,UN,83.88,25.16,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.76,71.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 21MMX3.5MM TITANIUM STD CIRCULAR LINEAR",SUP-EEA2135,CDM,S27200284,LOCAL,0272,RC,,,both,,,1978.05,593.41,"CIGNA [10200]","Cigna Open Access",,1125.51,56.9,,,,,0,230.05,1681.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VXSK-180J RF WIRE 63CM/45DEG/D1 SHEATH",SUP-VXSK0102,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4199.34,68,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 5MM DERMAL SURGICAL DISPOSABLE",SUP-33-55,CDM,S27200284,LOCAL,0272,RC,,,both,,,877.55,263.26,"AMERIGROUP MEDICAID [20100]",Amerigroup,,103.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,102.06,745.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE HEXAGONAL 4.5CM 3CM 7FR SOFT ACUSNARE 1 PIECE BRAID",SUP-G22702,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.43,49.33,"CIGNA [10200]","Cigna Open Access",,93.56,56.9,,,,,0,19.12,139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 18GA 20CM 19MM ECHOGENIC PRO-MAG ULTRA COAXIAL",SUP-765018200,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.10,62.43,"UHC [10700]","United Healthcare",,131.73,63.3,,,,,0,24.2,176.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 47CM 8/10/32MM ABDOMINAL THORACIC WOVEN",SUP-M00202175432T0,CDM,L8670,HCPCS,0278,RC,,,both,,,13481.36,4044.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5540.84,41.1,,,,,0,427.53,11459.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 4-0 PS-2 18IN MONOFILAMENT UNDYED",SUP-Y496G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BNDG PASTE LATEX FREE E MOTION",SUP-60648,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.92,28.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,39.42,41.1,,,,,0,11.16,81.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION BARDEX COMPLETE CARE 16FR COUDE TIP",SUP-A304416A,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.60,47.58,"MULTIPLAN [10600]",Multiplan,,134.81,85,,,,,0,18.45,134.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablation Renal Tumors Uni Cryo",PX-361000352,CDM,50593,CPT,0361,RC,,,both,,,14539.29,4361.79,"CIGNA [10200]","Cigna Open Access",,8383,,"Case rate ($8,383). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1690.92,12358.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE ROUND 240CM 2.4MM 2.8MM CAPTIVATOR COLD STIFF",SUP-M00561102,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,59.9,45.9,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULTIVITAMIN WITH FOLIC ACID 400 MCG TABLET",RX-155943,CDM,,,0637,RC,00904-0530-61,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE RING BILLARY 25CM",SUP-G03388,CDM,S27200284,LOCAL,0272,RC,,,both,,,413.16,123.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,48.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.05,351.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE 11IN VALLEYLAB STERILE ARGON",SUP-E3580-28,CDM,S27200284,LOCAL,0272,RC,,,both,,,294.15,88.24,"AETNA [10100]","Aetna HMO/PPO",,233.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,34.21,250.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR",RX-91073,CDM,,,0637,RC,51991-0311-90,NDC,both,1,UN,43.35,13,"CIGNA [10200]","Cigna Local Plus",,23.19,53.5,,,,,0,5.04,36.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT ACM BREAK-AWAY MIX BOWL BASE CRTDG FEMORAL",SUP-0306-563-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,630.00,189,"KAISER [10500]",Kaiser,,422.1,67,,,,,0,73.27,535.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK VITRECTOMY 25GA STELLARIS ELITE POSTERIOR MID FIELD",SUP-SE5425MV,CDM,S27200284,LOCAL,0272,RC,,,both,,,4126.20,1237.86,"AETNA [10100]","Aetna HMO/PPO",,3280.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,479.88,3507.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL INJECTABLE 9CM 20GA CONTIGEN PERIURETHRAL BOVINE CLLGN",SUP-652100,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.91,41.1,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 5FR INTERNAL MAMMARY CURVE ANGIOGRAPHIC",SUP-H749085262012,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 2MM TPS ELITE ROUND COARSE DIAMOND 5 STEP",SUP-5820013020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.4CM MEMORYGEL BOOST P6.6CM HIGH PROFILE",SUP-RSZHPB775S,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.95,53.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.7,151.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 5MM XLONG 50MM 7.3MM SHILEY PEDIATRIC CUFF TAPE",SUP-5.0PLCF,CDM,S27200284,LOCAL,0272,RC,,,both,,,475.23,142.57,"PHCS [10601]",PHCS,,332.66,70,,,,,0,55.27,403.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL NDL STRAIGHT 2.13IN 3/32IN VALLEYLAB",SUP-E1651,CDM,S27200284,LOCAL,0272,RC,,,both,,,187.40,56.22,"KAISER [10500]",Kaiser,,125.56,67,,,,,0,21.79,159.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 5CM 22GA ACCURIAN CURVE SHARP 5MM",SUP-AC0015,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"FIRST HEALTH [10303]","First Health",,83.52,80,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SNARE AMPLATZ GOOSENECK 120CM 35MM 6FR CATH INTRO TORQUE",SUP-GN3500,CDM,C1773,HCPCS,0272,RC,,,both,,,2062.50,618.75,"NOVANET [10819]",Novanet,,1546.88,75,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON 100CM 5FR SIM3 CURVE",SUP-G08597,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"FIRST HEALTH [10303]","First Health",,189.99,80,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYSTEROSCOPE RIGID MYOSURE XL ROD LENS OUTFLOW CHANNEL",SUP-50-250XL,CDM,S27200284,LOCAL,0272,RC,,,both,,,31468.50,9440.55,"NOVANET [10819]",Novanet,,23601.38,75,,,,,0,3659.79,26748.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SNARE AMPLATZ GOOSENECK 90D 200CM 2.3-3FR 7MM",SUP-SK701,CDM,C1773,HCPCS,0272,RC,,,both,,,4140.00,1242,"MULTIPLAN [10600]",Multiplan,,3519,85,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM STRAIGHT 2 SERRATE ENTELLUS MEDICAL HNDPC",SUP-SSB-12400-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FLUID TRANSFER 122CM NATRELLE UNIVERSAL 2 WAY CHECK",SUP-30-00033,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"CIGNA [10200]","Cigna Open Access",,44.55,56.9,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 4FR 1200 PSI 3D RIGHT CORONARY",SUP-538476,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,60.87,68,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC PULSED LAVAGE INTERPULSE COAXIAL MULTIORIFICE TIP",SUP-0210158000,CDM,S27200284,LOCAL,0272,RC,,,both,,,337.28,101.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,154.81,45.9,,,,,0,39.23,286.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INDOMETHACIN 100 MG RECTAL SUPPOSITORY",RX-233460,CDM,,,0637,RC,73702-0140-71,NDC,both,1,UN,1134.00,340.2,"UHC [10700]","United Healthcare",,717.82,63.3,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plasminogen Activator Inihibit",PX-305000044,CDM,85400,CPT,0305,RC,,,both,,,402.80,120.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.4,.1,,,,,0,0.4,342.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 72CM 8.6FR TENSI-LOCK SPRINT QUATTRO HELIX STD",SUP-6947M72,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"PHCS [10601]",PHCS,,12020.4,70,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC",352,MS-DRG,,,,,,,inpatient,,,73673.29,22101.99,"BLUE CROSS [10001]","Blue Cross PPO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT MICROINTRODUCER 45CM 4FR .018IN TUNGSTEN NITINOL GWIRE",SUP-H787065970525,CDM,C1894,HCPCS,0272,RC,,,both,,,281.01,84.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 9FR 11CM MINI GWIRE NO OBTR HEXCUSPID VALVE",SUP-504609X,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LOTUS INTRODUCER SMALL REPRISE III",SUP-H749NTR180,CDM,C1894,HCPCS,0272,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ARCADIA 36MM 30MM 20MM BALLOON DILATATION 8CC STEERABLE",SUP-ARC30SB,CDM,S27200284,LOCAL,0272,RC,,,both,,,5978.16,1793.45,"NOVANET [10819]",Novanet,,4483.62,75,,,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 35FR LEFT ANGLE ADJUSTABLE VALVE STYLET 2",SUP-125035,CDM,S27200284,LOCAL,0272,RC,,,both,,,439.99,132,"FIRST HEALTH [10303]","First Health",,351.99,80,,,,,0,51.17,373.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 5MMX79MM 7FR 80CMCATH HEPARIN",SUP-BXB057901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"NOVANET [10819]",Novanet,,16055.55,75,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR NARROW LORDOTIC 12 DEGRE",SUP-12311,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]",Cigna,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 330544 ACSR 5X14X14 SRVC FEE",SUP-330544,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING STEROID ELUTING 65CM 7FR ENDOCARDIAL DF4 CNCT",SUP-7120Q/65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"NOVANET [10819]",Novanet,,12879,75,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY",SUP-F6QRF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"NOVANET [10819]",Novanet,,680.4,75,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SPINAL 5IN 20GA INTERSTIM FORAMEN OPAQUE HUB LOCK STYLET",SUP-041829,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"PHCS [10601]",PHCS,,1260,70,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDO 0 MH SPIRAL 30CM SUT ABSORBABLE",SUP-SXPD2B411,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.43,54.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,123.37,68,,,,,0,21.1,154.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ANGLE STRAIGHT HANDLE 9.5IN ZEP ATRAUMATIC",SUP-52-9994,CDM,S27200284,LOCAL,0272,RC,,,both,,,1426.98,428.09,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,165.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.96,1212.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT T-5 .5 CIRCLE TAPER 26.5MM LOOP BIO-TENODESIS",SUP-AR-7281,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.57,52.07,"UHC [10700]","United Healthcare",,109.87,63.3,,,,,0,20.19,147.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 80CM 5FR .046IN .038IN MIK CURVE ANGIOGRAPHIC",SUP-58038MIK,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"CIGNA [10200]","Cigna Local Plus",,58.18,53.5,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR SPETZLER BARRACUDA SONOPET 25KHZ SOFT TISSUE",SUP-5450800310,CDM,S27200284,LOCAL,0272,RC,,,both,,,4228.67,1268.6,"NOVANET [10819]",Novanet,,3171.5,75,,,,,0,491.79,3594.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL BUIE 6.25IN FISTULA STERLING SILVER",SUP-50-9420,CDM,S27200284,LOCAL,0272,RC,,,both,,,391.76,117.53,"KAISER [10500]",Kaiser,,262.48,67,,,,,0,45.56,333,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM SAPIEN 3 ULTRA RESILIA",SUP-S3URCM23A,CDM,S27800098,LOCAL,0278,RC,,,both,,,193800.00,58140,"CIGNA [10200]",Cigna,,77520,40,,,,,0,22538.94,164730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAPE RADIOPAQUE 270MM LEMAITRE 20 STRIP STENT GUIDE",SUP-1102-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,502.20,150.66,"UHC [10700]","United Healthcare",,317.89,63.3,,,,,0,58.41,426.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 3 WAY STPCOCK 3 FLUSH DEVICE TRNSDUC",SUP-PX3X3,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GS SPECTRUM QC, MAC S1, BOX-10",SUP-0270-1140,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.26,129.98,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.07,41.1,,,,,0,50.39,368.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 98CM 22-19GA RADIOFREQUENCY ENERGY PUNCTURE STEERABLE",SUP-NRG-E-HF-98-C0,CDM,S27200284,LOCAL,0272,RC,,,both,,,3562.50,1068.75,"FIRST HEALTH [10303]","First Health",,2850,80,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 1 CT-2 27IN MONOFILAMENT ABSORBABLE",SUP-885H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT LAVAGE 6IN 9FR LAZARUS-NELSON MINI PERITONEAL GWIRE",SUP-MLNK9001,CDM,S27200284,LOCAL,0272,RC,,,both,,,150.72,45.22,"FIRST HEALTH [10303]","First Health",,120.58,80,,,,,0,17.53,128.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE SMALL OVAL 240CM 2.4MM CAPTIFLEX LOOP FLEXIBLE",SUP-M00562422,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.00,22.5,"CIGNA [10200]",Cigna,,51,68,,,,,0,8.72,63.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAPAROSCOPIC KIT",SUP-SBA21LGUH4,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCORTISONE 5 MG TABLET",RX-10209,CDM,,,0637,RC,59762-0073-01,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR ENDOSCOPIC FLOSEAL STERILE DISPOSABLE",SUP-110860,CDM,S27200284,LOCAL,0272,RC,,,both,,,624.75,187.42,"MULTIPLAN [10600]",Multiplan,,531.04,85,,,,,0,72.66,531.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNAL FEEDING 18FR STOMA L4CM JEJUNAL L45CM TRANSGAST",SUP-0270-18-4.0-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,306.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2.5MM 18MM PARTIAL THREAD DISTAL VOLAR RADIUS",SUP-TP18000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1093.50,328.05,"PHCS [10601]",PHCS,,765.45,70,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL MEDIUM 6 FLUTE ROUND L50.8 MM OD3 MM STERILE",SUP-5300-010-509,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.08,49.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,112.93,68,,,,,0,19.32,141.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLITTER SURGICAL FACIAL BLADE RELINE",SUP-10000795,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"AMERIGROUP MEDICAID [20100]",Amerigroup,,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 4.75IN SNAGFREE SATIN FINISH NDL FINE STERILE",SUP-66355,CDM,S27200284,LOCAL,0272,RC,,,both,,,58.53,17.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,26.87,45.9,,,,,0,6.81,49.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENCIL BIPOLAR 5.9IN 25GA 2 PIN CNCT TAPER TIP SHAFT RETINAL",SUP-E7924,CDM,S27200284,LOCAL,0272,RC,,,both,,,722.93,216.88,"CIGNA [10200]",Cigna,,491.59,68,,,,,0,84.08,614.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SUCTION RUBBER LEAFLET INSTR CHANNEL STERILE",SUP-11301CA/20,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.50,23.85,"CIGNA [10200]","Cigna Open Access",,45.24,56.9,,,,,0,9.25,67.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Electrode Fetal Scalp",PX-E27000203,CDM,E27000203,LOCAL,0270,RC,,,both,,,28.60,8.58,"AETNA [10100]","Aetna HMO/PPO",,22.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.33,24.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN LIGAPAK 2-0 54IN MONOFILAMENT REEL YELLOWISH TAN",SUP-L103G,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11.1,41.1,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TRACH CIAGLIA BLUE RHINO SHILEY PERCUTANEOUS STERILE",SUP-CPTISY100HCPERC6,CDM,S27200284,LOCAL,0272,RC,,,both,,,3288.30,986.49,"AETNA [10100]","Aetna HMO/PPO",,2614.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,382.43,2795.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GIRAFFE 45D 2MM 5.25IN FRONTAL SINUS 2 ACTION",SUP-63-8840,CDM,S27200284,LOCAL,0272,RC,,,both,,,3430.28,1029.08,"CIGNA [10200]","Cigna Local Plus",,1835.2,53.5,,,,,0,398.94,2915.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL CANN 10MM 10MM SINGLE-SITE STERILE LATEX FREE",SUP-478161,CDM,S27200284,LOCAL,0272,RC,,,both,,,137.46,41.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.99,116.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 5-0 PC-3 18IN MONOFILAMENT BLACK",SUP-1865G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 4-0 FSL 30IN MONOFILAMENT BLACK NONABSORBABLE",SUP-1670H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VASCADE 6/7FR COMPRESSION CLLGN VASCULAR",SUP-700-580I-05U,CDM,C1760,HCPCS,0278,RC,,,both,,,1539.00,461.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,182.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ELECTROSURGICAL 45CM 5MM ENSEAL TRIO 3MM CURVED TIP",SUP-ETRIO345H,CDM,S27200284,LOCAL,0272,RC,,,both,,,3657.00,1097.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,433.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,425.31,3108.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SMARTSTITCH PERFECTPASSER MAGNUMWIRE SUT COBRAID",SUP-OM8177,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.18,543.35,"CIGNA [10200]",Cigna,,1231.6,68,,,,,0,210.64,1539.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ENDOSCOPIC ORANGE 72MM 6.5MM CLEAR-TRAC SHOULDER",SUP-72200427,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,85.82,41.1,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 36IN 8FR ANTICLOG RADIOPAQUE SMOOTH BOLUS",SUP-40-8368,CDM,S27200284,LOCAL,0272,RC,,,both,,,115.84,34.75,"PHCS [10601]",PHCS,,81.09,70,,,,,0,13.47,98.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE VOYANT MARYLAND 44CM 5MM LAPAROSCOPIC FUSION",SUP-EB216,CDM,S27200284,LOCAL,0272,RC,,,both,,,3187.50,956.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2167.5,68,,,,,0,370.71,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL UTERINE HEGAR 2 END .75MM",SUP-52-3503,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.73,21.22,"KAISER [10500]",Kaiser,,47.39,67,,,,,0,8.23,60.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 BUCK EAR ANGLED SHARP SURGICAL",SUP-380213,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.07,40.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.59,113.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR EMG PATHWAY STIM VAGINAL RECTAL",SUP-2959,CDM,S27200284,LOCAL,0272,RC,,,both,,,333.47,100.04,"CIGNA [10200]","Cigna Open Access",,189.74,56.9,,,,,0,38.78,283.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 80MM 2.5MM QUICK CONNECT NONSTERILE",SUP-03.133.103,CDM,S27200284,LOCAL,0272,RC,,,both,,,927.61,278.28,"KAISER [10500]",Kaiser,,621.5,67,,,,,0,107.88,788.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 5 CCS 30IN BRAID 4 STRAND GREEN NONABSORBABLE",SUP-MB47G,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.84,61.75,"MULTIPLAN [10600]",Multiplan,,174.96,85,,,,,0,23.94,174.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOOP AV SUPPLEMENT CUSTOM",SUP-20151703,CDM,S27200284,LOCAL,0272,RC,,,both,,,765.45,229.63,"UHC [10700]","United Healthcare",,484.53,63.3,,,,,0,89.02,650.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LACTOBACILLUS RHAMNOSUS GG 10 BILLION CELL CAPSULE",RX-27974,CDM,,,0637,RC,49100-0381-64,NDC,both,1,UN,7.76,2.33,"KAISER [10500]",Kaiser,,5.2,67,,,,,0,0.9,6.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL URETERAL HYDROPLUS 70CM 10FR STERILE",SUP-M0062401120,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.52,130.06,"FIRST HEALTH [10303]","First Health",,346.82,80,,,,,0,50.42,368.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 155MM 2.7MM CANNULATED DISPOSABLE",SUP-71173581,CDM,S27200284,LOCAL,0272,RC,,,both,,,3744.90,1123.47,"UHC [10700]","United Healthcare",,2370.52,63.3,,,,,0,435.53,3183.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 CT 36IN BRAID ANTIBACTERIAL COATED",SUP-VCP956H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.48,45.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hme Cartridge Classicflow",PX-E27000259,CDM,A7504,HCPCS,0270,RC,,,both,,,636.24,190.87,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH REDEL 115CM 1MM 6FR 10MM SPACE F CURVE",SUP-F6QRF010RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 15MM 3.2MM DISPOSABLE",SUP-31-323220,CDM,S27000186,LOCAL,0270,RC,,,both,,,896.67,269,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SOFT TISSUE 3X3CM AMINOFIX",SUP-AAS-5330,CDM,Q4433,HCPCS,0636,RC,,,both,,,7396.80,2219.04,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH REDEL 110CM 5MM SPACE REGULAR P CURVE ELECTROPHYSIOLOGY",SUP-D510PR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 100CM 1MM 4FR 5MM SPACE A CURVE ELECTROPHYSIOLOGY 10",SUP-F4QA005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC",785,MS-DRG,,,,,,,inpatient,,,39001.45,11700.43,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF CONDUCTR 110CM 7FR 2-5-2MM SPACING 55-75MM REACH",SUP-041005JM,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LIVEWIRE 115CM 2MM 6FR 2-8-2MM SPACING",SUP-401926,CDM,C1730,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,551.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DECA 4-4-34-4-4-4-4-4-50 MPA 120CM",SUP-950824,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"FIRST HEALTH [10303]","First Health",,2370,80,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLP LEAD LEAD EXTRACTION STERILE DISPOSABLE",SUP-G20003,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"CIGNA [10200]",Cigna,,484.7,68,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCPOINT PULMONARY NEEDLE 21GA",SUP-ILS-2100-PN,CDM,S27200284,LOCAL,0272,RC,,,both,,,1857.00,557.1,"AETNA [10100]","Aetna HMO/PPO",,1476.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,215.97,1578.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 30CM 6FR URETERAL FIRM STERILE LATEX FREE",SUP-M0061456490,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,74.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 20CM 3CM 6FR .038IN 2 PIGTAIL",SUP-M006192130010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,142.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 30CM 6FR .035IN URETERAL",SUP-M006155235090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"AMERIGROUP MEDICAID [20100]",Amerigroup,,161.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 5.0MM X 18.0MM",SUP-495001812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR JR3.5 CURVE GUIDING CORONARY",SUP-LA7JR35SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ABSORBER CARBON DIOXIDE PREFILL SEAL CANSTR MEDISORB EF EX",SUP-2079797-001,CDM,S27000186,LOCAL,0270,RC,,,both,,,169.74,50.92,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 150CM 150MM 4MM BALLOON DILATATION DURALYN",SUP-48004015X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 50.8MM 1.5MM MEDIUM CARBIDE TAPERED STERILE",SUP-5300-010-708,CDM,S27200284,LOCAL,0272,RC,,,both,,,153.38,46.01,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET",RX-14087,CDM,,,0637,RC,00406-0484-23,NDC,both,1,UN,12.78,3.83,"UHC [10700]","United Healthcare",,8.09,63.3,,,,,0,1.49,10.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 40MM 3.5MM BALLOON DILATATION DURALYN",SUP-48003504S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT SCRDRVR 25MM 3.5MM AEQUALIS HEXAGONAL",SUP-DWD167,CDM,S27200284,LOCAL,0272,RC,,,both,,,780.00,234,"PHCS [10601]",PHCS,,546,70,,,,,0,90.71,663,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 22CM 8FR 2 PIGTAIL CURVE",SUP-M0061921510,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"BLUE CROSS [10001]","Blue Cross PPO",,445.16,39.2,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 4.8FR L30CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902150,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155234050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,143.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS ELECTROSURGICAL 45CM 5MM HARMONIC ACE +7 CURVE",SUP-HARH45,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 295CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-295,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"FIRST HEALTH [10303]","First Health",,6044.4,80,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 24CM 6FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001274120,CDM,C2617,HCPCS,0278,RC,,,both,,,999.00,299.7,"PHCS [10601]",PHCS,,699.3,70,,,,,0,116.18,849.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 26CM 6FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001245750,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"MULTIPLAN [10600]",Multiplan,,1466.25,85,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 26CM 6FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001245750,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"UHC [10700]","United Healthcare",,1091.93,63.3,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 45-150UM 5 VIAL CONTOUR PVA",SUP-M0017600151,CDM,S27800098,LOCAL,0278,RC,,,both,,,1377.00,413.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,632.04,45.9,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 8FR PIGTAIL NEPHROURETERAL PERCUFLEX METAL",SUP-M001221370,CDM,C2617,HCPCS,0278,RC,,,both,,,811.20,243.36,"KAISER [10500]",Kaiser,,543.5,67,,,,,0,94.34,689.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 19.3X9.6CM ALLODERM SELECT THK.4-2.4MM THICK",SUP-CM1519P,CDM,Q4116,HCPCS,0636,RC,,,both,,,24847.20,7454.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11119.12,44.75,,,,,0,247.92,21120.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION",RX-7351,CDM,,,0250,RC,63323-0884-01,NDC,both,5,ML,175.84,52.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.45,149.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING EXPIRATION LIMB WYE 6FT DISPOSABLE 1.8MR",SUP-29657-001,CDM,S27000186,LOCAL,0270,RC,,,both,,,90.46,27.14,"CIGNA [10200]",Cigna,,61.51,68,,,,,0,10.52,76.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR SKIN 20MM WIDE ENDOSCOPIC LINEAR CUTTER RELOADABLE",SUP-070614,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.01,84.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,128.98,45.9,,,,,0,32.68,238.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OXYCHLOROSENE SODIUM TOPICAL POWDER FOR SOLUTION",RX-168152,CDM,,,0250,RC,00327-0001-10,NDC,both,2,GR,45.14,13.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.25,38.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM ARTISAN MRI",SUP-SC-8416-50,CDM,C1778,HCPCS,0278,RC,,,both,,,30240.00,9072,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3516.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDEAVOR SPRINT 15MM 142CM 3.5MM CORONARY STENT",SUP-ENSP35015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"PHCS [10601]",PHCS,,3880.8,70,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM PRECISION PERCUTANEOUS PHASE III",SUP-SC-2158-50,CDM,C1778,HCPCS,0278,RC,,,both,,,8914.80,2674.44,"MULTIPLAN [10600]",Multiplan,,7577.58,85,,,,,0,1036.79,7577.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 60MM 4FR 2MM .018IN BALLOON",SUP-PCP020060130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CREO SPINE PREASSEMBLE POLYAXIAL",SUP-5119.164,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"NOVANET [10819]",Novanet,,7160.14,75,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 90CM 4MM 8FR 2-5-2MM SPACE E CURVE",SUP-D8BTCEL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"UHC [10700]","United Healthcare",,3140.38,63.3,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP SMALL LEAK 1 ENTRAINMENT NEB ELBOW",SUP-73-1061733,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.58,61.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 6.5MM 45MM CREO CREO AMP SPINE MODULAR",SUP-1067.1645,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"MULTIPLAN [10600]",Multiplan,,8114.82,85,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 20MM 4MM .035IN BALLOON",SUP-AB35W04020135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,80.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Valproic Acid",PX-301000041,CDM,80164,CPT,0301,RC,,,both,,,341.05,102.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.69,,,,,,,0.01,289.89,"fee schedule",
"HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR",RX-28824,CDM,,,0250,RC,64980-0324-30,NDC,both,30,GR,549.31,164.79,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,63.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,63.88,466.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI 110CM 5FR PIGTAIL 155D CURVE ANGIOGRAPHIC",SUP-534554S,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,38.44,41.1,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 590CC P4.2CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-590,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT FLAT FIBERTAK FIBERWIRE ROTATOR CUFF TAPE BRAID",SUP-AR-3632,CDM,C1713,HCPCS,0278,RC,,,both,,,2913.75,874.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,338.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",338.87,2476.69,"percent of total billed charges",
"BURR SURGICAL 45MM 1.2MM TAPER CARBIDE SIDE CUT STERILE",SUP-1607-002-105,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.18,26.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO CATH 90CM 5FR 1.9MM FLEXOR SHUTTLE TUOHY BORST CHECK",SUP-G31133,CDM,C1894,HCPCS,0272,RC,,,both,,,1173.69,352.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET INTRO 25 5/8IN 7FR 8FR SUPER ARROW-FLEX PERCUTANEOUS 3",SUP-CL-07765,CDM,C1894,HCPCS,0272,RC,,,both,,,875.61,262.68,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 330MM 4.2MM QUICK COUPLING 3 FLUTED CALIBRATED 100",SUP-03.010.061,CDM,S27000186,LOCAL,0270,RC,,,both,,,1503.68,451.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL SPACER",SUP-345544,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO ELECTROSURGICAL 10CM STARBURST XL SOFT COAXIAL ACCESS",SUP-700-102636,CDM,C1894,HCPCS,0272,RC,,,both,,,882.90,264.87,"AETNA [10100]","Aetna HMO/PPO",,701.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,102.68,750.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 7MM TARGET XL LARGE HELICAL",SUP-M0036117200,CDM,S27800098,LOCAL,0278,RC,,,both,,,12419.24,3725.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4967.7,40,,,,,0,1444.36,10556.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 70CM 10MM THIN WALL GORE-TEX REMOVABLE RING",SUP-RRT10070070L,CDM,C1768,HCPCS,0278,RC,,,both,,,9204.60,2761.38,"FIRST HEALTH [10303]","First Health",,7363.68,80,,,,,0,1070.49,7823.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT ENDOSCOPIC 12MM 36CM SILS CLINCH",SUP-SILS12CH36,CDM,S27200284,LOCAL,0272,RC,,,both,,,3310.80,993.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1519.66,45.9,,,,,0,385.05,2814.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"475CC 13CM X 5.3CM MENTOR MEMORYGEL BREAST IMPLANT SMOOTH RO",SUP-350-4754BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"PHCS [10601]",PHCS,,3670.8,70,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 375ML GEL SMOOTH","SUP-3505375 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3885.00,1165.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,451.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,451.83,3302.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIASSIST 24IN 36IN DRUG DELIVERY 60ML GAS",SUP-AA0608,CDM,S27000186,LOCAL,0270,RC,,,both,,,769.50,230.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,316.26,41.1,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PSN MC VE ASF L 14MM 6-7/EF",SUP-42-5121-007-14,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1253.3,9159.96,"percent of total billed charges",
"CATH CELSIUS THERMOCOOL REDEL 115CM 3.5MM 7FR 2-5-2MM SPACE",SUP-DI7TCBLRT,CDM,C2630,HCPCS,0272,RC,,,both,,,9142.50,2742.75,"UHC [10700]","United Healthcare",,5787.2,63.3,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFT TOUCH",SUP-SSM-275,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PHCS [10601]",PHCS,,5288.85,70,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VAN ANDEL 80CM 3CM 6.3FR BALLOON DILATATION ACCEPTS",SUP-G01383,CDM,C1758,HCPCS,0272,RC,,,both,,,502.20,150.66,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FIBER LASER 200UM FLEXIVA TRACTIP HOLMIUM HIGH POWER POLISH",SUP-M006R8403961,CDM,S27200284,LOCAL,0272,RC,,,both,,,3284.22,985.27,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET CATHETERIZATION ASCEND BALLOON DILATATION INFLATION",SUP-G32842,CDM,C1758,HCPCS,0272,RC,,,both,,,1745.63,523.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL DISSECTING 12CM 3MM MIDAS REX MR8 MATCH HEAD SD STERILE",SUP-MR8-SD12MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLUG DOME HOLE CONTINUUM ACETABULAR LATEX FREE",SUP-875700001,CDM,C1713,HCPCS,0278,RC,,,both,,,597.78,179.33,"NOVANET [10819]",Novanet,,448.34,75,,,,,0,69.52,508.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH C-FLEX 70CM 6FR PIGTAIL CURVE URETERAL TAPER TIP 1",SUP-M0064001710,CDM,C1758,HCPCS,0272,RC,,,both,,,499.69,149.91,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,205.37,41.1,,,,,0,58.11,424.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR BLUE 50CM NEVRO 5MM SPACING LEAD STERILE",SUP-LEAD1058-50B,CDM,C1778,HCPCS,0278,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT 25MMX100MMX4MM BTCP CLLGN VITOSS VOID FILLER",SUP-2102-1100,CDM,C1713,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"UHC [10700]","United Healthcare",,5459.63,63.3,,5023.51,2672.93,6679.78,18,1003.09,7331.25,"percent of total billed charges",
"IMMOB ORTHOPEDIC 12IN 30- IN KNEE 3 PANEL TERRYCLOTH",SUP-VP40106-005,CDM,L1830,HCPCS,0274,RC,,,both,,,152.42,45.73,"BLUE CROSS [10001]","Blue Cross HMO",,59.75,39.2,,,,,0,17.73,129.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER SUTURELASSO 45D 1 LEFT CURVE 10YD 1.5MM ERGONOMIC",SUP-AR-6069-45L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"NOVANET [10819]",Novanet,,1020.6,75,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.2MM LONG CALIBRATED STERILE",SUP-03.313.700S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 30CM PRECISION PERCUTANEOUS PHASE III",SUP-SC-2158-30,CDM,C1778,HCPCS,0278,RC,,,both,,,8914.80,2674.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6062.06,68,,,,,0,1036.79,7577.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE LIFEGUARD SAFETY 20X3/4",SUP-LG-20-75,CDM,S27200284,LOCAL,0272,RC,,,both,,,83.09,24.93,"CIGNA [10200]","Cigna Local Plus",,44.45,53.5,,,,,0,9.66,70.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM ATRIUM RIGHT VENTRICLE TRANSVENOUS 4 TINE",SUP-407452,CDM,C1898,HCPCS,0275,RC,,,both,,,2250.00,675,"AMERIGROUP MEDICAID [20100]",Amerigroup,,266.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 13.5X12.7CM 475CC MEMORYGEL COHESIVE III CPG 322",SUP-3341355,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1083.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,inpatient,,,159017.83,47705.35,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,38145.89,,"Case rate ($18,733.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $17,395.66, add-ons for qualifying new technology services are included. If operating cost exceeds $50,435.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,697.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,418.67. The transfer operating threshold is the transfer adjustment factor * $17,395.66 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,315.20. The transfer capital threshold is the transfer adjustment factor * $1,315.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,10994,88174.84,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.814,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CIGNA [10200]",Cigna,,238.89,68,,1831.33,1831.33,1831.33,16,40.86,298.61,"percent of total billed charges",
"IMPL BREAST 600CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRM-600,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,461.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LASER G-PROBE ILLUMINATE BOX STERILE LATEX FREE",SUP-16200,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SUTURETAPE .5 CIRCLE 38IN CONVENTIONAL CUT NDL BLUE",SUP-AR-7511,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 16MM PRESS FIT UNIVERSAL FLUTE KNEE",SUP-867444,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,959.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,942.1,6885.51,"percent of total billed charges",
"GRAFT SOFT TISSUE 7X4CM VERITAS BOVINE CLLGN MATRIX",SUP-RM0407,CDM,C9354,HCPCS,0278,RC,,,both,,,7492.52,2247.76,"NOVANET [10819]",Novanet,,5619.39,75,,,,,0,871.38,6368.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS ZIPWIRE 28CM 3CM 7FR .038IN PIGTAIL CURVE",SUP-M0061265440,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"FIRST HEALTH [10303]","First Health",,1136.27,80,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX TAPER TIP",SUP-M0061453510,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,181.19,28.62,,,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 26CM 3CM 5FR .038IN STRAIGHT URETERAL",SUP-M006155223170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS [10001]","Blue Cross PPO",,556.77,39.2,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 30CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175255180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,670.19,45.9,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pulse Ox O2 Sat Sngl",PX-460000015,CDM,94760,CPT,0460,RC,,,both,,,70.94,21.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.25,60.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 4CM 170CM 7FR 2 PIGTAIL CURVE BILIARY",SUP-G22161,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,73.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 67.5MM TITANIUM LOCK TRANSLATIONAL ATLANTIS BONE SPINE",SUP-6190067,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 2MM LARGE 110MM VITALLIUM 2 CABLE GRIP RECONSTRUCTION",SUP-6704-3-091,CDM,C1713,HCPCS,0278,RC,,,both,,,6913.80,2074.14,"KAISER [10500]",Kaiser,,4632.25,67,,,,,0,804.07,5876.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER 13MM 5.5MM ANTERIOR CHMBR CONVEXOPLANO",SUP-MTA4U0.210,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Stoma W Rmvl FB",PX-750000070,CDM,44390,CPT,0750,RC,,,both,,,2289.10,686.73,"FIRST HEALTH [10303]","First Health",,1831.28,80,,,,,0,266.22,2289.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH BIOFLO DURAMAX VASCPAK ENDEXO 2 VALVE ADULT 28CM",SUP-H787103028195,CDM,C1750,HCPCS,0278,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SUPRAPUBIC 18FR 22FR 17CM 20CM ONE STEP DRNG CATH DIL",SUP-G26666,CDM,C1894,HCPCS,0272,RC,,,both,,,734.67,220.4,"NOVANET [10819]",Novanet,,551,75,,,,,0,85.44,624.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH CHECK-FLO FLEXOR .018-.038IN ANL0 CURVE 45CM 5FR .074",SUP-G44153,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"AETNA [10100]","Aetna HMO/PPO",,418.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO FUCHSIA 11CM 10FR BRITE TIP SILICONE KINK",SUP-401011M,CDM,C1894,HCPCS,0272,RC,,,both,,,60.90,18.27,"KAISER [10500]",Kaiser,,40.8,67,,,,,0,7.08,51.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL BLUE 28X36X7.9-12MM SYNFIX 10D MEDIUM PEEK",SUP-08.815.212S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WHITE PETROLATUM TOPICAL SUPERORDERABLE",RX-40828809,CDM,,,0637,RC,72140-0452-31,NDC,both,50,GR,34.60,10.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.02,29.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BONE CEMENT 120MM 11GA ACCUPORT END DELIVERY STERILE",SUP-307.034,CDM,S27200284,LOCAL,0272,RC,,,both,,,3360.00,1008,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,390.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,390.77,2856,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING IS-1 BIPOLAR PASSIVE FIXATION INSULATION 2",SUP-4548,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"AETNA [10100]","Aetna HMO/PPO",,4457.57,79.5,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DICLOFENAC 1 % TOPICAL GEL",RX-100611,CDM,,,0250,RC,00067-8152-03,NDC,both,100,GR,157.25,47.17,"NOVANET [10819]",Novanet,,117.94,75,,,,,0,18.29,133.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PLA HA 20MM 7MM ACL TAPERED BIOCOMPATIBLE",SUP-72201771,CDM,C1713,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,669.11,1030.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tavi/Tavr Transapical Exposure",PX-361000348,CDM,33366,CPT,0361,RC,,,both,,,45298.00,13589.4,"PHCS [10601]",PHCS,,31708.6,70,,,,,0,2491,38503.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 64CM ENDOTAK RELIANCE 4 SITE ENDOCARDIAL STEROID",SUP-276,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS [10001]","Blue Cross HMO",,5950.56,39.2,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 11CM WITHOUT GWIRE PRELUDE ACT GREEN",SUP-PSI-6F-11ACT,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"FIRST HEALTH [10303]","First Health",,60.55,80,,,,,0,8.8,64.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 17.75IN 10FR 8FR SUPER ARROW-FLEX PERCUTANEOUS",SUP-CL-07045,CDM,C1894,HCPCS,0272,RC,,,both,,,767.88,230.36,"FIRST HEALTH [10303]","First Health",,614.3,80,,,,,0,89.3,652.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING DEFIB TRUE BIPOLAR PASSIVE FIXATION DURATA SJ4",SUP-7170/65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]","Cigna Open Access",,5752.62,33.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC",314,MS-DRG,,,,,,,inpatient,,,53260.64,15978.19,"CIGNA [10200]","Cigna Open Access",,22882.98,,"Fee schedule rate ($22,882.98). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,8593,52002.8,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE VASCULAR 94CM 13MM 12FR NEEDLES EYE FEMUR TRANSFEMORAL",SUP-LR-NES001,CDM,C1773,HCPCS,0272,RC,,,both,,,9331.49,2799.45,"FIRST HEALTH [10303]","First Health",,7465.19,80,,,,,0,1085.25,7931.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AMPLATZER TORQVUE 80CM 8FR .136IN .106IN 45D DELIVERY",SUP-9-ITV08F45/80,CDM,C1773,HCPCS,0272,RC,,,both,,,4912.80,1473.84,"AMERIGROUP MEDICAID [20100]",Amerigroup,,582.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,571.36,4175.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 3MM 12MM TITANIUM CORTEX HAND SELF TAPPING",SUP-400.812.96,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"CIGNA [10200]","Cigna Open Access",,184.35,56.9,,1144.80,304.56,2275.09,66,37.68,275.39,"percent of total billed charges",
"STOP DRILL 3.5MM X 70MM",SUP-DRLL-35070,CDM,S27000186,LOCAL,0270,RC,,,both,,,3781.20,1134.36,"AETNA [10100]","Aetna HMO/PPO",,3006.05,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.75,3214.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP CLUSTER HOLE RIM TRITANIUM X3 MDM",SUP-502-03-58F,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"AETNA [10100]","Aetna HMO/PPO",,8321.12,79.5,,10981.53,8986.79,12413.38,12,1217.29,8896.8,"percent of total billed charges",
"SCR BONE 105MM 3.5MM DCP LC-DCP CORTEX PELVIC STAINLESS",SUP-204.705,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"MULTIPLAN [10600]",Multiplan,,233.98,85,,,,,0,32.01,233.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 24CM 3CM 7FR .035IN STRAIGHT PIGTAIL CURVE",SUP-M006180232050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"KAISER [10500]",Kaiser,,697.86,67,,,,,0,121.14,885.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 90MM LCP STAINLESS STEEL FULL THREAD PROXIMAL",SUP-02.205.090,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",146.92,1073.79,"percent of total billed charges",
"HC Legionella Direct Ifa",PX-302000052,CDM,86255,CPT,0302,RC,,,both,,,228.00,68.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.9,,"Fee schedule rate ($12.90). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.23,193.8,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 286ML STYLE 15 SMOOTH NATRELLE SILICONE P3.8CM",SUP-15-286,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"KAISER [10500]",Kaiser,,2391.9,67,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM TRIATHLON 2 LEFT MEDIAL RIGHT LATERAL",SUP-5612-A-211,CDM,C1776,HCPCS,0278,RC,,,both,,,9878.04,2963.41,"KAISER [10500]",Kaiser,,6618.29,67,,,,,0,1148.82,8396.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP740D,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.09,38.73,"NOVANET [10819]",Novanet,,96.82,75,,,,,0,15.01,109.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP VESOLOCK X-LARGE",SUP-71114V,CDM,S27200284,LOCAL,0272,RC,,,both,,,323.76,97.13,"UHC [10700]","United Healthcare",,204.94,63.3,,,,,0,37.65,275.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +8 DIOPTER MODIFY L BICONVEX 13MM 6MM POSTERIOR",SUP-CCA0T0.080,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM REVOLVE SPINE PEDICLE POLYAXIAL",SUP-185.453,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AETNA [10100]","Aetna HMO/PPO",,7589.75,79.5,,1521.93,481.35,16760.95,30,1110.3,8114.82,"percent of total billed charges",
"TUBE SUCTION 5 1/8IN 3FR BARON REGULAR THUMB PLATE CUT OFF 3",SUP-62-2210,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.28,38.78,"KAISER [10500]",Kaiser,,86.62,67,,,,,0,15.04,109.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 350ML GEL TEXTURED SILTEX SILICONE P4.9CM HIGH",SUP-3544350,CDM,C1789,HCPCS,0278,RC,,,both,,,3885.00,1165.5,"KAISER [10500]",Kaiser,,2602.95,67,,,,,0,451.83,3302.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 385CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-385,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"MULTIPLAN [10600]",Multiplan,,6422.18,85,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 44.8MM 1.6MM TAPER CARBIDE SIDE CUTTING",SUP-1607002107,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.87,28.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.92,79.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 240CM 5.5CM 7.5FR 15-18MM ESOPHAGUS",SUP-M00558700,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"PHCS [10601]",PHCS,,1154.32,70,,,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 10X9.4CM 195ML GEL TEXTURE ORIENTATION MARK",SUP-3341005,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3757.57,41.1,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY",RX-11138,CDM,,,0637,RC,00574-7226-12,NDC,both,1,UN,47.56,14.27,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19.55,41.1,,,,,0,5.53,40.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP ENDOSCOPIC 2 ACTION ATRAUMATIC JAW SLIDE LOCK HANDLE",SUP-8360-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,6499.94,1949.98,"CIGNA [10200]",Cigna,,4419.96,68,,,,,0,755.94,5524.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17.5 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6",SUP-ZCT225175,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIGESTIVE MALIGNANCY WITHOUT CC/MCC",376,MS-DRG,,,,,,,inpatient,,,50803.21,15240.96,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,10752.3,,"Case rate ($10,439.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,693.44, add-ons for qualifying new technology services are included. If operating cost exceeds $42,733.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,114.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $9,706.26. The transfer operating threshold is the transfer adjustment factor * $9,693.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $732.87. The transfer capital threshold is the transfer adjustment factor * $732.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,49133.95,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PRIMARY HIP (HIP CONSTRUCT)",SUP-CAP-LB-H-1,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"NOVANET [10819]",Novanet,,17010,75,,,,,0,2637.68,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +11 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.110,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY PINK 20CM 18GA 17GA BARD MISSION TRUGUIDE 10MM 20",SUP-1820MSK,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"AETNA [10100]","Aetna HMO/PPO",,325.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNCOMPLICATED PEPTIC ULCER WITHOUT MCC",384,MS-DRG,,,,,,,inpatient,,,39295.03,11788.51,"CIGNA [10200]","Cigna Local Plus",,8820.68,,"Fee schedule rate ($8,820.68). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,5302.38,21317.86,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ENDOSCOPIC AGGRESSIVE SMALL JOINT STERILE 2.5MM",SUP-0275628000,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,147.75,45.9,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OMNIWIRE 185 CM J-TIP",SUP-89185J,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"PHCS [10601]",PHCS,,2898,70,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 5MM AVENIR 10 COIL FINISH COMPLEX",SUP-10CFN-05008,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Open Access",,3927.24,33.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURESIGHT BLADE MAC SIZE 3",SUP-390331000,CDM,S27000186,LOCAL,0270,RC,,,both,,,321.90,96.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH SAFESHEATH MP CURVE 60CM 7FR",SUP-WORLEY/B-60-07-MP,CDM,C1893,HCPCS,0272,RC,,,both,,,3345.00,1003.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 150CM 40MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025040M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARDEX LUBRICATH 18FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0118L18,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.96,26.39,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLING ORTHOPEDIC AIRMESH 15D UNIVERSAL SHOULDER BREATHABLE",SUP-00052,CDM,S27000186,LOCAL,0270,RC,,,both,,,321.03,96.31,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE ENDO STITCH V-LOC 180 2-0 8IN CLSR ABSORBABLE RELOAD",SUP-VLOCA208L,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.99,98.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS AVIATOR PLUS 142CM 30MM 4.5MM .014IN BALLOON",SUP-4244530W,CDM,C1725,HCPCS,0272,RC,,,both,,,1438.80,431.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION",RX-14953,CDM,,,0250,RC,81033-0104-05,NDC,both,5,ML,143.41,43.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,58.94,41.1,,,,,0,16.68,121.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR .045IN FEMORAL RIGHT 3.5 CURVE",SUP-H75908526012,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 685CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCM-685,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"FIRST HEALTH [10303]","First Health",,6044.4,80,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 42MM FEMORAL LOW PROFILE STERILE RFN-ADVANCED",SUP-04.045.342TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"CIGNA [10200]","Cigna Open Access",,1063.97,56.9,,1144.80,304.56,2275.09,66,217.47,1589.42,"percent of total billed charges",
"LENS IOL 0 D +8 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.080,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 120MM 125CM 6MM 6FR BILIARY",SUP-G50166,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"BLUE CROSS [10001]","Blue Cross PPO",,2387.28,39.2,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX OTW CORONARY STENT  2.00 X 15MM",SUP-RONYX20015W,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,9776.84,9776.84,9776.84,"1 through 10",434.96,3179,"percent of total billed charges",
"FORCEPS SURGICAL L5 1/2IN TISSUE HEMOSTATIC STANDARD LINE SE",SUP-32-4031,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.81,14.64,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE ELECTROSURGICAL 220CM 2.3MM FIAPC FLEXIBLE SIDEFIRE",SUP-20132-217,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CAUTERY, LO-TEMP OPTHALMIC",SUP-03-AA00,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.04,18.01,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 130CM 100MM 7MM BALLOON",SUP-U35130710,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE DOC VASCULAR 145CM .014IN CORONARY EXT",SUP-22260,CDM,C1769,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX 035 130CM 60MM 6MM BALLOON DILATATION",SUP-LX351306605F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WASHER 8MM ASNIS III ORTHOPEDIC STAINLESS STEEL 7MM",SUP-390018,CDM,C1713,HCPCS,0278,RC,,,both,,,236.12,70.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,160.56,68,,,,,0,27.46,200.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM VERTEX MAX TITANIUM SPINE MULTIAXIAL",SUP-6958716,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"FIRST HEALTH [10303]","First Health",,3360,80,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,inpatient,,,83832.58,25149.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16180.98,,"Fee schedule rate ($16,180.98). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,7561,52374.7,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4/3MM 80MM 20MM SCHANZ STAINLESS STEEL DISTAL",SUP-294.30,CDM,C1713,HCPCS,0278,RC,,,both,,,563.92,169.18,"NOVANET [10819]",Novanet,,422.94,75,,,,,0,65.58,479.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE SMALL HEXAGON CAPTIVATOR STIFF ENDOSCOPIC POLYPECTOMY",SUP-M00562450,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.33,36.4,"CIGNA [10200]",Cigna,,82.5,68,,,,,0,14.11,103.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILFRM URETHRAL 13IN 3FR SPIRAL PVC PLASTIC STERILE LATEX",SUP-343103,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.14,31.84,"CIGNA [10200]","Cigna Local Plus",,56.78,53.5,,,,,0,12.34,90.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 450ML GEL ROUND SMOOTH COHESIVE I SILICONE P4.2",SUP-3504501BC,CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"BLUE CROSS [10001]","Blue Cross HMO",,1440.6,39.2,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRIMARY METAL BACK GLENOID TOTAL SHOULDER (CONVERITIBLE)",SUP-SMRMBTS,CDM,C1776,HCPCS,0278,RC,,,both,,,33232.50,9969.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9511.14,28.62,,,,,0,3864.94,28247.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 6MM 2MM",SUP-SPL20006X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 22CM 6FR URETERAL",SUP-M0061456120,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,74.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TRANSITION HA SPINE PEDICLE POLYAXIAL",SUP-152.764S,CDM,C1713,HCPCS,0278,RC,,,both,,,10791.60,3237.48,"NOVANET [10819]",Novanet,,8093.7,75,,,,,0,1255.06,9172.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drsg Endoform Templt 4x5in",PX-E27200327,CDM,E27200327,LOCAL,0272,RC,,,both,,,325.60,97.68,"PHCS [10601]",PHCS,,227.92,70,,,,,0,37.87,276.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 5.00 X 8MM",SUP-H7493942808500,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Local Plus",,3322.35,53.5,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKAGED RADIAL STEM 10MM X -2MM",SUP-ALN-RST-10M2,CDM,C1776,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"UHC [10700]","United Healthcare",,9001.83,63.3,,8601.07,8395.67,8601.07,"1 through 10",1653.89,12087.77,"percent of total billed charges",
"CATH TRANSFORM 15MM 4MM BALLOON OCCLUSION 1 LUMEN COMPLIANT",SUP-M003SRC04150,CDM,C1725,HCPCS,0272,RC,,,both,,,11760.02,3528.01,"KAISER [10500]",Kaiser,,7879.21,67,,,,,0,1367.69,9996.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 135D STD BARREL 38MM STAINLESS STEEL 1 STEP SYSTEM 4",SUP-281.140,CDM,C1713,HCPCS,0278,RC,,,both,,,3719.85,1115.95,"MULTIPLAN [10600]",Multiplan,,3161.87,85,,,,,0,432.62,3161.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION LOW PROFILE DETACH CATH INTRO",SUP-CT66LTPD,CDM,C1788,HCPCS,0278,RC,,,both,,,2505.00,751.5,"AETNA [10100]","Aetna HMO/PPO",,1991.48,79.5,,1729.13,1729.13,1729.13,"1 through 10",291.33,2129.25,"percent of total billed charges",
"SCR BONE 5MM 16MM STAINLESS STEEL T25 CONDYLAR SELF TAP LOCK",SUP-02.231.016,CDM,C1713,HCPCS,0278,RC,,,both,,,1738.80,521.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,497.64,28.62,,,,,0,202.22,1477.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachytx Isodose Complx",PX-333000066,CDM,77318,CPT,0333,RC,,,both,,,4264.02,1279.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1957.19,45.9,,,,,0,408.8,4264.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 3.50 X 12MM",SUP-H7493942812350,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"AETNA [10100]","Aetna HMO/PPO",,4936.95,79.5,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145364010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"CIGNA [10200]","Cigna Open Access",,550.17,,,,,,,112.45,821.87,"percent of total billed charges",
"GRAFT SOFT TISSUE 50CMX.49MM 16/8MM HEMAGARD VASCULAR BOVINE",SUP-HGK1608,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TIBIAL VANTAGE 3 ANKLE LEFT STERILE LATEX FREE",SUP-350-11-03,CDM,C1713,HCPCS,0278,RC,,,both,,,29389.50,8816.85,"PHCS [10601]",PHCS,,20572.65,70,,,,,0,3418,24981.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 26MM 4MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT40026UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,286.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Not Feeynolm 2.6-7.5cm",PX-450000020,CDM,12002,CPT,0361,RC,,,both,,,1025.43,307.63,"UHC [10700]","United Healthcare",,1025.43,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,119.26,1025.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 16CM 5FR 2.1FR POLARIS ULTRA NAUTILUS ZIPWIRE .038",SUP-M006192114170,CDM,C2617,HCPCS,0278,RC,,,both,,,1357.24,407.17,"CIGNA [10200]","Cigna Local Plus",,726.12,,,,,,,157.85,1153.65,"percent of total billed charges",
"PENICILLIN V POTASSIUM 250 MG TABLET",RX-6092,CDM,,,0250,RC,57237-0040-01,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 6MM INFINITY SPINE OCCIPITOCERVICAL",SUP-3600406,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX20MM VANGUARD ARCOM KNEE POSTERIOR STABILIZE",SUP-183650,CDM,C1776,HCPCS,0278,RC,,,both,,,8259.30,2477.79,"NOVANET [10819]",Novanet,,6194.48,75,,,,,0,960.56,7020.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (7.5-8 MCI)",RX-411884,CDM,A9520,HCPCS,0343,RC,08888-8876-18,NDC,both,1,UN,4614.97,1384.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,546.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,536.72,4614.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 5.5MM CD HORIZON LEGACY TITANIUM PREBENT",SUP-8690040,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1262.14,28.62,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 6.2MM 26MM NCB PROTASUL-64 3.5MM CORTEX SELF",SUP-0203150026,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"MULTIPLAN [10600]",Multiplan,,1577.81,85,,,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 12MM 6FR 3.5MM",SUP-H7493926712350,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CD HORIZON MODULEX SPINE CORTICAL",SUP-55900106540,CDM,C1713,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"NOVANET [10819]",Novanet,,4398.75,75,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 90CM 8FR JL4 CURVE GUIDING PTFE FEMORAL",SUP-H749343582010,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"FIRST HEALTH [10303]","First Health",,293.15,80,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ileoscopy Stoma W Bal Dil",PX-750000159,CDM,44381,CPT,0750,RC,,,both,,,4055.00,1216.5,"UHC [10700]","United Healthcare",,3833,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,471.6,4055,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 23MM 7MM STERILE",SUP-AR-1370P,CDM,C1713,HCPCS,0278,RC,,,both,,,1968.75,590.62,"MULTIPLAN [10600]",Multiplan,,1673.44,85,,,,,0,228.97,1673.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXIMA 25CM 24CM 8FR NEPHRSTMY PERCUFLEX COMBINATION",SUP-M0064101260,CDM,C1729,HCPCS,0272,RC,,,both,,,648.89,194.67,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 7X80 80CM SL",SUP-48007008N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 60MM 3.5MM BALLOON DILATATION DURALYN",SUP-48003506S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FARAWAVE 4MM ABLATION PULSED FIELD STERILE LATEX FREE",SUP-M004PF41M402,CDM,C1733,HCPCS,0272,RC,,,both,,,53235.00,15970.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6191.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6191.23,45249.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL RADIOLOGY 20CM 17GA 1.2MM GOLD PLACEMENT KNURL MARKER 3",SUP-MTNW887830,CDM,A4648,HCPCS,0278,RC,,,both,,,696.60,208.98,"MULTIPLAN [10600]",Multiplan,,592.11,85,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 17.7X.8IN EXUFIBER FIBER FLUID RETENTION HIGH",SUP-603420,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.86,19.46,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 2.1H L68 MM SPINE CERVICAL ANTERIOR 4 LEVEL NONST",SUP-18002468,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMT BRIDLE PRO- 16 FR",SUP-4-4216,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"MULTIPLAN [10600]",Multiplan,,605.88,85,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 87MM STAINLESS STEEL 3.5MM SCREWS 3X7 HOLES T RIGHT",SUP-241.171,CDM,C1713,HCPCS,0278,RC,,,both,,,3068.10,920.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2086.31,68,,,,,0,356.82,2607.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIDODRINE 5 MG TABLET",RX-10610,CDM,,,0637,RC,63739-0145-10,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 12X3.5IN ATS CYL PORT STERILE DISPOSABLE",SUP-60707510200,CDM,S27200284,LOCAL,0272,RC,,,both,,,150.82,45.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.54,128.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 180CM 60MM 4FR 3MM BALLOON DILATATION",SUP-PCP030060180,CDM,C2623,HCPCS,0272,RC,,,both,,,1231.20,369.36,"FIRST HEALTH [10303]","First Health",,984.96,80,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 18MM 1.75MM FLO-THRU INTRALUMINAL",SUP-FT12175,CDM,S27200284,LOCAL,0272,RC,,,both,,,763.91,229.17,"FIRST HEALTH [10303]","First Health",,611.13,80,,,,,0,88.84,649.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUADRA ASSURA NEXT GENERATION CRT-D 40",SUP-CD3365-40C,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23722.92,41.1,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 6MM 1.5MM BALLOON DILATATION OTW PTCA",SUP-DC-PY1506UA1,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO MEDIUM STYLET SURESIGHT",SUP-321900020,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.00,26.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LIVEWIRE 7FR MEDIUM CURL CURVE ELECTROPHYSIOLOGY DUO",SUP-401908,CDM,C1731,HCPCS,0272,RC,,,both,,,6348.00,1904.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,752.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,738.27,5395.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL LOCALIZATION 3CM 20GA HAWKINS III FLEXSTRAND HARDWIRE",SUP-253030,CDM,A4648,HCPCS,0278,RC,,,both,,,310.59,93.18,"CIGNA [10200]","Cigna Local Plus",,166.17,53.5,,,,,0,36.12,264,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 25MM 5.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE52525,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9730.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 8MM 140CM .91-1.12MM 2.75MM CORONARY",SUP-RONYX27508W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]","Cigna Open Access",,1920.38,56.9,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 4.9CC 17X17X17MM DEMINERALIZED CANCELLOUS",SUP-0W1017,CDM,S27800098,LOCAL,0278,RC,,,both,,,5658.00,1697.4,"PHCS [10601]",PHCS,,3960.6,70,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP LIMIT HOLE FIN RINGLOC+ 23 STERILE",SUP-16-104152,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"CIGNA [10200]","Cigna Local Plus",,3765.33,53.5,,5372.07,4581.20,7242.98,23,818.52,5982.3,"percent of total billed charges",
"STENT ZIPWIRE 10CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175195190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 95X25MM 4 TONGUE DAVIS",SUP-45-5114,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.96,81.59,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,111.78,41.1,,,,,0,31.63,231.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 5CM 5FR PIGTAIL CURVE PANCREATIC",SUP-M00537410,CDM,C2625,HCPCS,0278,RC,,,both,,,1411.18,423.35,"PHCS [10601]",PHCS,,987.83,70,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACURATE PRIME LOADING KIT XL",SUP-SYM-AC-009-C,CDM,S62400003,LOCAL,0624,RC,,,both,,,9660.00,2898,"AETNA [10100]","Aetna HMO/PPO",,7679.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STIM 70CM SURPASS LEAD STERILE LATEX FREE DISPOSABLE",SUP-LEAD3005-70B,CDM,C1778,HCPCS,0278,RC,,,both,,,8970.00,2691,"CIGNA [10200]","Cigna Local Plus",,4798.95,53.5,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL CERVICAL 6X16X14MM 7DEG LORDOTIC PEEK COHERE",SUP-4061647P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"FIRST HEALTH [10303]","First Health",,4968,80,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 90CM KIT DELIVERY SYSTEM FIRM STD",SUP-6491,CDM,S27500001,LOCAL,0275,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,317.52,39.2,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL 8 MHZ ADPTR STERILE DISPOSABLE",SUP-VDP-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,963.90,289.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,442.43,45.9,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 70MM TITANIUM FULL THREAD CANCELLOUS NONSTERILE",SUP-607370,CDM,C1713,HCPCS,0278,RC,,,both,,,316.68,95,"FIRST HEALTH [10303]","First Health",,253.34,80,,,,,0,36.83,269.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS MONOPOLAR MONOPOLAR ENDOWRIST SP CURVE NONSTERILE",SUP-430004,CDM,S27000186,LOCAL,0270,RC,,,both,,,2772.00,831.6,"KAISER [10500]",Kaiser,,1857.24,67,,,,,0,322.38,2356.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.250,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY 25CM 18GA BARD MARQUEE CORE ENHANCE TROCAR TIP",SUP-MQ1825,CDM,S27200284,LOCAL,0272,RC,,,both,,,514.35,154.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,60.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.82,437.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION",RX-3037,CDM,J3010,HCPCS,0636,RC,63323-0806-50,NDC,both,50,ML,251.69,75.51,"CIGNA [10200]",Cigna,,79.8,,,,,,,29.83,213.94,"fee schedule",
"HC Anoscopy W Dilation",PX-750000214,CDM,46604,CPT,0750,RC,,,both,,,4285.22,1285.57,"BLUE CROSS [10001]","Blue Cross PPO",,3634.7,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,498.37,4285.22,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anoscopy W Dilation",PX-750000214,CDM,46604,CPT,0750,RC,,,both,,,4285.22,1285.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4285.22,,"Case rate ($5,284). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,498.37,4285.22,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Deoxyribonuclease Ab",PX-302000035,CDM,86215,CPT,0302,RC,,,both,,,149.50,44.85,"AETNA [10100]","Aetna HMO/PPO",,118.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,127.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 32MM TI",SUP-MTC-37320-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,145.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",145.07,1060.29,"percent of total billed charges",
"HC Chemo Horm Anti-Neo Sq/Im",PX-331000002,CDM,96402,CPT,0331,RC,,,both,,,428.21,128.46,"CIGNA [10200]",Cigna,,428.21,,"Per diem ($571).",,,,0,49.8,428.21,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 20FTX3IN ROLL 15 LAYER REINFORCE OPEN CELL",SUP-SR315,CDM,S27000186,LOCAL,0270,RC,,,both,,,449.15,134.74,"MULTIPLAN [10600]",Multiplan,,381.78,85,,,,,0,52.24,381.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPISPIN LOCK SOFT TRAY 17G X 3 1/2'' (90MM) TUOHY NEEDLE WIT",SUP-TCL121,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 39MM MITRAL TRICUSPID FULL FLEXIBLE BAND",SUP-700FF39,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross PPO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)CORONARY IVL CATHETER, 3.5MM X 12MM, RX IDE",SUP-501050-003,CDM,C1761,HCPCS,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 11CM 2MM XPS 360D 60-3000 RPM INFERIOR",SUP-1882040HR,CDM,S27200284,LOCAL,0272,RC,,,both,,,2412.00,723.6,"CIGNA [10200]","Cigna Open Access",,1372.43,56.9,,,,,0,280.52,2050.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 22CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175251080,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"BLUE CROSS [10001]","Blue Cross HMO",,485.84,39.2,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 5D MEDIUM 52MM STAINLESS STEEL 2.4/2.7MM SCR LOW",SUP-02.211.238S,CDM,C1713,HCPCS,0278,RC,,,both,,,6404.58,1921.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4355.11,68,,,,,0,744.85,5443.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC .75CM 4.45X4.81CM ACCOLADE 1 CHMBR RA RV IS1",SUP-L310,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6706.8,27,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pt Eval Low Complex 20 Min",PX-420000153,CDM,97161,CPT,0424,RC,,,both,,,449.84,134.95,"BLUE CROSS [10001]","Blue Cross PPO",,371.22,,"Per diem ($371.22).",,,,0,52.32,426,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM GORILLA R3CON LOCK",SUP-P50-353-3526,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ventil Mgmt IP Subq Day",PX-410000003,CDM,94003,CPT,0410,RC,,,both,,,2236.54,670.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,260.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,254,1901.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ventil Mgmt IP Subq Day",PX-410000003,CDM,94003,CPT,0410,RC,,,both,,,2236.54,670.96,"CIGNA [10200]",Cigna,,369,,"Per diem ($369).",,,,0,254,1901.06,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Propoxyphene",PX-301000571,CDM,80367,CPT,0301,RC,,,both,,,83.00,24.9,"FIRST HEALTH [10303]","First Health",,66.4,80,,,,,0,0.01,83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Antinuclear Antibodies Titer",PX-302000012,CDM,86039,CPT,0302,RC,,,both,,,261.25,78.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.04,,,,,,,0.26,222.06,"fee schedule",
"HC Albumin Other Source",PX-301000089,CDM,82042,CPT,0301,RC,,,both,,,184.30,55.29,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,12.24,,,,,,,0.01,156.66,"fee schedule",
"HC Sars-Cov-2",PX-300000408,CDM,U0001,HCPCS,0300,RC,,,both,,,212.00,63.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.33,,,,,,,0.21,180.2,"fee schedule",
"LEAD DEFIB 74CM 4.7FR OMNIASECURE MRI SURESCAN 1 COIL",SUP-3930M74,CDM,C1777,HCPCS,0278,RC,,,both,,,31468.50,9440.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3659.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3659.79,26748.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tumor Immunohistochem Manual",PX-312000045,CDM,88360,CPT,0312,RC,,,both,,,545.15,163.54,"NOVANET [10819]",Novanet,,408.86,75,,,,,0,0.01,463.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tumor Immunohistochem Manual",PX-312000045,CDM,88360,CPT,0312,RC,,,both,,,545.15,163.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,146.47,,,,,,,0.01,463.38,"fee schedule",
"HC Tumor Immunohistochem Manual",PX-312000045,CDM,88360,CPT,0312,RC,,,both,,,545.15,163.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.72,,"Fee schedule rate ($51.72). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,463.38,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Dplr Complt",PX-483000012,CDM,93320,CPT,0483,RC,,,both,,,1268.76,380.63,"KAISER [10500]",Kaiser,,850.07,67,,,,,0,84.89,1078.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Dplr Complt",PX-483000012,CDM,93320,CPT,0483,RC,,,both,,,1268.76,380.63,"BLUE CROSS [10001]","Blue Cross HMO",,122.23,,"Fee schedule rate ($122.23).",,,,0,84.89,1078.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC New Eval Visit Level 4",PX-510000174,CDM,99204,CPT,0761,RC,,,both,,,512.72,153.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,59.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.51,512.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC New Eval Visit Level 4",PX-510000174,CDM,99204,CPT,0761,RC,,,both,,,512.72,153.82,"NOVANET [10819]",Novanet,,384.54,75,,,,,0,0.51,512.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Natural Killer Total Count",PX-302000079,CDM,86357,CPT,0302,RC,,,both,,,333.45,100.03,"UHC [10700]","United Healthcare",,33.96,,,,,,,0.01,283.43,"fee schedule",
"HC Natural Killer Total Count",PX-302000079,CDM,86357,CPT,0302,RC,,,both,,,333.45,100.03,"PHCS [10601]",PHCS,,233.42,70,,,,,0,0.01,283.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Proinsulin",PX-301000385,CDM,84206,CPT,0301,RC,,,both,,,425.10,127.53,"BLUE CROSS [10001]","Blue Cross PPO",,34.1,,"Fee schedule rate ($34.10).",,,,0,0.01,361.34,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lead",PX-301000296,CDM,83655,CPT,0301,RC,,,both,,,226.00,67.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.97,,"Fee schedule rate ($11.97). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",11.97,11.97,11.97,"1 through 10",0.01,192.1,"fee schedule",
"STENT UNISTEP PLUS WALLSTENT RP 55MM 135CM 5MM 160CM",SUP-M001711050,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5747.7,68,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL XLIF 10MM X 18MM X 55MM 10 DEGREE LORDOTIC TITAN",SUP-1181055P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7654.5,27,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH II SSL8",SUP-398355,CDM,C1894,HCPCS,0272,RC,,,both,,,3339.00,1001.7,"MULTIPLAN [10600]",Multiplan,,2838.15,85,,,,,0,388.33,2838.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X20 40CM SL",SUP-48003002P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"AETNA [10100]","Aetna HMO/PPO",,780.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 5-0 FS-2 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J421H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GOLD PROBE 300CM 7FR ELECTROHEMOSTASIS HEMOGLIDE",SUP-M00560071,CDM,S27200284,LOCAL,0272,RC,,,both,,,1017.42,305.23,"MULTIPLAN [10600]",Multiplan,,864.81,85,,,,,0,118.33,864.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT AORTIC 3.3CM 23MM",SUP-PLA230300,CDM,S27800098,LOCAL,0278,RC,,,both,,,19725.30,5917.59,"CIGNA [10200]",Cigna,,7890.12,40,,,,,0,2294.05,16766.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAWSON-MUELLER MAC-LOC INTRO-TIP 25CM 10.2FR DRNG",SUP-G09706,CDM,C1729,HCPCS,0272,RC,,,both,,,660.07,198.02,"PHCS [10601]",PHCS,,462.05,70,,,,,0,76.77,561.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,inpatient,,,40079.48,12023.84,"CIGNA [10200]",Cigna,,18775.07,,"Fee schedule rate ($18,775.07). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7561,35710.15,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 20CM OCCL GLDEWIRE NEPHRSTMY INTRO PERCUTANEOUS",SUP-M0067001220,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.79,81.54,"FIRST HEALTH [10303]","First Health",,217.43,80,,,,,0,31.61,231.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL CONTOUR TIMAX 10 HOLE LOW PROFILE ALPS BONE",SUP-131218600,CDM,S27200284,LOCAL,0272,RC,,,both,,,9987.75,2996.32,"NOVANET [10819]",Novanet,,7490.81,75,,,,,0,1161.58,8489.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 12 G-H KNEE",SUP-42522101011,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1253.3,9159.96,"percent of total billed charges",
"NDL ANESTHESIA 17GA 4.5IN HUB WING DEHP FREE STERILE PERIFIX",SUP-332181,CDM,S27200284,LOCAL,0272,RC,,,both,,,54.95,16.48,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,25.22,45.9,,,,,0,6.39,46.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SELUTION SLR PTCA DEB 4.5X30MM",SUP-SCA14U-450030D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC INVENTRA 7 VR-T DX IMPLANTABLE HOME MNTR",SUP-399436,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"CIGNA [10200]","Cigna Local Plus",,12285,31.5,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 25.5CM TIBIAL NAIL-EX INTRAMEDULLARY CANNULATED",SUP-04.004.331S,CDM,C1713,HCPCS,0278,RC,,,both,,,8593.61,2578.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3531.97,41.1,,,,,0,999.44,7304.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 32MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 2X4",SUP-249.697,CDM,C1713,HCPCS,0278,RC,,,both,,,3883.32,1165,"AETNA [10100]","Aetna HMO/PPO",,3087.24,79.5,,1521.93,481.35,16760.95,30,451.63,3300.82,"percent of total billed charges",
"CATH 70CM 4.8FR 8FR URETERAL CONE TIP OPEN END",SUP-G14663,CDM,C1758,HCPCS,0272,RC,,,both,,,117.80,35.34,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",11.23,7.03,11.23,"1 through 10",13.7,100.13,"percent of total billed charges",
"STENT WALLSTENT 40MM 18MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044184070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"KAISER [10500]",Kaiser,,5778.75,67,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 16CM 26MM 12MM 22-23MM 10-11MM GORE",SUP-RLT261216,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25080,40,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM .0135IN AXIUM PRIME 3D FRAME",SUP-FC-9-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"PHCS [10601]",PHCS,,11567.85,70,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL IDENTITY IMPRINT 6 NARROW KNEE POSTERIOR",SUP-TPS-301-T06N,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"CIGNA [10200]",Cigna,,5982.3,68,,5873.17,5873.17,5873.17,"1 through 10",1023.15,7477.88,"percent of total billed charges",
"TUBE CALIBRATION NONSTERILE",SUP-B-2017,CDM,S27000186,LOCAL,0270,RC,,,both,,,1474.20,442.26,"CIGNA [10200]","Cigna Local Plus",,788.7,53.5,,,,,0,171.45,1253.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 75CM 8MM 20MM",SUP-H74938046820750,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X22X12MM COROENT WIDE XL",SUP-6912260,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"MULTIPLAN [10600]",Multiplan,,20196,85,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 45MM FREEMAN AREOLA BREAST BIOPSY STAINLESS STEEL",SUP-P467,CDM,S27200284,LOCAL,0272,RC,,,both,,,507.79,152.34,"AMERIGROUP MEDICAID [20100]",Amerigroup,,60.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.06,431.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xm Archive Tiss Mole Anal",PX-310000002,CDM,88363,CPT,0310,RC,,,both,,,230.85,69.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.47,,"Fee schedule rate ($27.47). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,196.22,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insert Picc With S&I >= 5yr",PX-361000486,CDM,36573,CPT,0361,RC,,,both,,,4198.10,1259.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,497.47,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,488.24,4198.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 24FR 26FR CIAGLIA BLUE RHINO EZ PASS HYDROPHILIC J",SUP-G12115,CDM,C1894,HCPCS,0272,RC,,,both,,,2910.90,873.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1979.41,68,,,,,0,338.54,2474.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT 3 .5 CIRCLE REGULAR .984IN .024IN TAPER POINT FREE",SUP-212903,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.09,21.63,"KAISER [10500]",Kaiser,,48.3,67,,,,,0,8.38,61.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 13CM 6FR 21GA 2MM .018IN PERFORMER NITINOL",SUP-G12423,CDM,C1894,HCPCS,0272,RC,,,both,,,382.71,114.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,45.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.51,325.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR TRABECULAR METAL VIVACIT-E STEM CUP LINER STD",SUP-98000571503,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"NOVANET [10819]",Novanet,,18900,75,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 54MM 28MM XLPE HIP",SUP-71334954,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"CIGNA [10200]","Cigna Local Plus",,5963.62,53.5,,5372.07,4581.20,7242.98,23,1296.39,9474.91,"percent of total billed charges",
"STENT EXPRESS LD TANDEM ARCHITECTURE 57MM 135CM 6MM 60MM",SUP-38047-66013,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTIGRAFT CERVICAL LARGE PARALLEL 14X14.5X6MM",SUP-VG2C-DR6P,CDM,S27800098,LOCAL,0278,RC,,,both,,,6077.73,1823.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2789.68,45.9,,,,,0,706.84,5166.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 16.5CM NATRELLE INSPIRA P5CM MODERATE PROFILE",SUP-MSZ-M755,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PHCS [10601]",PHCS,,110.73,70,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL TOE JOINT 2.75MM HAMMERTUBE 10D PEEK CANNULATED KIT",SUP-P40-002-0275-SK,CDM,C1713,HCPCS,0278,RC,,,both,,,8607.75,2582.32,"BLUE CROSS [10001]","Blue Cross PPO",,3374.24,39.2,,957.42,570.23,957.42,28,1001.08,7316.59,"percent of total billed charges",
"PIN FIXATION 457MM 3.2MM STEINMANN LONG BLUNT",SUP-11-1109-FD21,CDM,C1713,HCPCS,0278,RC,,,both,,,3326.40,997.92,"CIGNA [10200]","Cigna Open Access",,1892.72,56.9,,1144.80,304.56,2275.09,66,386.86,2827.44,"percent of total billed charges",
"GWIRE 2O VASCULAR ANGLE 80CM .035IN HYDROPHILIC FIXED CORE",SUP-H2OSTDA3580,CDM,C1769,HCPCS,0272,RC,,,both,,,278.40,83.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,114.42,41.1,,,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X80 80CM SL",SUP-48007008N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,584.13,68,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP FEM N/POROUS SIZE 2 RIGHT",SUP-2154-0-0002,CDM,C1776,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3800.52,45.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPR LD BFUR BP CNCT TO BP",SUP-501205,CDM,C1883,HCPCS,0278,RC,,,both,,,1830.00,549,"CIGNA [10200]","Cigna Local Plus",,979.05,53.5,,,,,0,212.83,1555.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL MONORAIL 150CM 120MM 3.5MM BALLOON",SUP-H74939147351210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TORCON NB ADVANTAGE 100CM 5FR JL2 CURVE ANGIOGRAPHIC NO",SUP-G47012,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-FLO RENEGADE FATHOM VASCULAR 115CM 20CM .016IN",SUP-M001184530,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATHETERIZATION BARDEX LUBRICATH 18FR 350ML URINE METER",SUP-304918,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.92,54.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE NARROW SAGITTAL MICS SURGICAL DISPOSABLE",SUP-116171,CDM,S27200284,LOCAL,0272,RC,,,both,,,2287.50,686.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL VERITAS 6 FIRING GEL TUBE LINEAR POUCH",SUP-PSD4506UV,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE STREAMER VASCULAR STERILE LATEX FREE DISPOSABLE",SUP-363724,CDM,C1769,HCPCS,0272,RC,,,both,,,486.00,145.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AWL SURGICAL FORTIFY I SELF CENTER BENT",SUP-676.705,CDM,S27000186,LOCAL,0270,RC,,,both,,,2010.00,603,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VASCUTRAK 140CM 100MM 7FR 7MM .018IN SHORT BALLOON",SUP-V1870100,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TROCAR LAPAROSCOPIC 100MM 12MM KII HASSON",SUP-C0R85,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA [10200]",Cigna,,124.24,68,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 80MM 20MM SCHANZ STAINLESS STEEL ORTHOPEDIC",SUP-294.775,CDM,C1713,HCPCS,0278,RC,,,both,,,1094.39,328.32,"CIGNA [10200]",Cigna,,744.19,68,,1831.33,1831.33,1831.33,16,127.28,930.23,"percent of total billed charges",
"SCR BONE 4MM 30MM CREO CREO AMP SPINE MODULAR NONSTERILE",SUP-1067.1230,CDM,C1713,HCPCS,0278,RC,,,both,,,2812.50,843.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,333.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",327.09,2390.63,"percent of total billed charges",
"CATH CHRG 135CM 100MM 6FR 7MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206071010,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 20MM 6FR 12MM .035IN LOW PROFILE BALLOON",SUP-B1120-020,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"MULTIPLAN [10600]",Multiplan,,654.08,85,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 345141FZ L-ASR 11X14X11 FZ SRVCFE",SUP-345141FZ,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANSTR WOUND DRNG PREVENA PLUS 150ML",SUP-PRE4095.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.63,64.39,"AETNA [10100]","Aetna HMO/PPO",,170.63,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.96,182.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 60MM 10MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U10060090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Local Plus",,5537.25,53.5,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 550ML STYLE 20 SMOOTH NATRELLE SILICONE P5.6CM",SUP-20-550,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"MULTIPLAN [10600]",Multiplan,,3034.5,85,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CREO SPINE PREASSEMBLE POLYAXIAL",SUP-5119.164,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4382,45.9,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insert Picc With S&I >= 5yr",PX-361000486,CDM,36573,CPT,0361,RC,,,both,,,4198.10,1259.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4198.1,,"Case rate ($4,750). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,488.24,4198.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 90MM STAINLESS STEEL FULL THREAD FEMUR",SUP-208.474,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"FIRST HEALTH [10303]","First Health",,1107.3,80,,,,,0,160.97,1176.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 38MM PERSONA VIVACIT-E ALL POLY KNEE STERILE",SUP-42540200038,CDM,C1776,HCPCS,0278,RC,,,both,,,4919.70,1475.91,"BLUE CROSS [10001]","Blue Cross PPO",,1928.52,39.2,,3949.44,3949.44,3949.44,"1 through 10",572.16,4181.75,"percent of total billed charges",
"SCR BONE 3MM 24MM TIGER CANNULATED SCR SYSTEM",SUP-200-30-024,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,324.55,28.62,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 20MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-02008,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1202.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTNR 9 1/8INX5 7/8IN MEDIUM VISCERAL STERILE LATEX FREE",SUP-3204,CDM,S27200284,LOCAL,0272,RC,,,both,,,413.25,123.97,"FIRST HEALTH [10303]","First Health",,330.6,80,,,,,0,48.06,351.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOCKWAVE L6 IVL CATHETER 9.0X30 MM",SUP-L6IVL090030,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"KAISER [10500]",Kaiser,,14562.45,67,,,,,0,2527.78,18474.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE II DEMINERALIZED BONE MATRIX",SUP-7509505,CDM,S27800098,LOCAL,0278,RC,,,both,,,16715.25,5014.57,"BLUE CROSS [10001]","Blue Cross HMO",,6552.38,39.2,,,,,0,1943.98,14207.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AXS OFFSET 150CM .05IN GUIDING STERILE LATEX FREE",SUP-M003DC050150A0,CDM,S27200284,LOCAL,0272,RC,,,both,,,7523.76,2257.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3453.41,45.9,,,,,0,875.01,6395.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Wnd Dehis W Packing",PX-510000044,CDM,12021,CPT,0761,RC,,,both,,,5428.00,1628.4,"CIGNA [10200]","Cigna Local Plus",,2051,,"Per diem ($2,051).",,,,0,631.28,4710,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .048IN .047IN AMPLATZ LEFT",SUP-534546T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"FIRST HEALTH [10303]","First Health",,74.82,80,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 20MM 100CM 14MM 75CM",SUP-H965403100,CDM,C1876,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Local Plus",,2359.35,53.5,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 38MM 4.5MM AEQUALIS REVERSED GLENOID TITANIUM",SUP-VDV238,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"BLUE CROSS [10001]","Blue Cross PPO",,609.95,39.2,,3949.44,3949.44,3949.44,"1 through 10",180.96,1322.6,"percent of total billed charges",
"LINER ACETABULAR G7 D OFFSET 36MM E1 HIP HIGH WALL",SUP-010000934,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"BLUE CROSS [10001]","Blue Cross PPO",,4018.79,39.2,,3949.44,3949.44,3949.44,"1 through 10",1192.31,8714.22,"percent of total billed charges",
"HC Dilatation Ureter",PX-361000237,CDM,53899,CPT,0361,RC,,,both,,,3053.01,915.9,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,355.07,3053.01,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LACRIMAL 5IN BOWMAN STAINLESS STEEL 2 ENDED SET",SUP-360-270,CDM,S27000186,LOCAL,0270,RC,,,both,,,751.52,225.46,"FIRST HEALTH [10303]","First Health",,601.22,80,,,,,0,87.4,638.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX13MM 12D BROAD LORDOTIC SPINE",SUP-2413,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM 1.8MM KIRSCHNER STAINLESS STEEL TROCAR",SUP-02.110.300,CDM,C1713,HCPCS,0278,RC,,,both,,,54.08,16.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,15.48,28.62,,,,,0,6.29,45.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUPERCORE 15CM 9.9CM 18GA 17GA BIOPSY COAXIAL INTRO",SUP-701218150,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.53,140.26,"NOVANET [10819]",Novanet,,350.65,75,,,,,0,54.37,397.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC MATRIX RECOTHROM FLOSEAL",SUP-ADS202110,CDM,S27200284,LOCAL,0272,RC,,,both,,,1994.35,598.3,"CIGNA [10200]","Cigna Local Plus",,1066.98,53.5,,,,,0,231.94,1695.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT RIB LARGE 36X6IN KNIT ELASTIC 2 PANEL CONTACT CLSR",SUP-13790307,CDM,S27000186,LOCAL,0270,RC,,,both,,,59.25,17.77,"NOVANET [10819]",Novanet,,44.44,75,,,,,0,6.89,50.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 18MM 3MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT30018UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CIGNA [10200]","Cigna Open Access",,1374.14,56.9,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 25CM ATRIAL VENTRICULAR BIPOLAR SCR IN ELECTRD",SUP-407625,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"BLUE CROSS [10001]","Blue Cross HMO",,875.14,39.2,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EPIDURAL 8.89CM 17GA 19GA FLEXTIP PLUS CATH SYR DRAPE 3",SUP-AK-05560,CDM,S27200284,LOCAL,0272,RC,,,both,,,320.16,96.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,131.59,41.1,,,,,0,37.23,272.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD HEEL FOOTPEDAL",SUP-401320,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 10MM 2MM BALLOON DILATATION HYDROPHILIC",SUP-2200-2010-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,682.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM STAINLESS STEEL T15 CORTEX SELF TAP LOW",SUP-02.206.230S,CDM,C1713,HCPCS,0278,RC,,,both,,,725.76,217.73,"BLUE CROSS [10001]","Blue Cross PPO",,284.5,39.2,,957.42,570.23,957.42,28,84.41,616.9,"percent of total billed charges",
"KIT CRYOSURGICAL TRUFREEZE PASSIVE VENT CATH",SUP-CO8407030501,CDM,C2618,HCPCS,0272,RC,,,both,,,13765.50,4129.65,"MULTIPLAN [10600]",Multiplan,,11700.68,85,,,,,0,1520.68,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12IN 24FR ARTERIAL ADULT 3/8IN CNCT BLUNT TIP",SUP-77424,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"AETNA [10100]","Aetna HMO/PPO",,356.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,52.1,380.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER 1 INCISION SUT STERILE DISPOSABLE",SUP-520250,CDM,S27200284,LOCAL,0272,RC,,,both,,,3382.50,1014.75,"PHCS [10601]",PHCS,,2367.75,70,,,,,0,393.38,2875.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB VOICE RECORDING GRAPHICAL COVER AED PLUS",SUP-20100001101011010,CDM,S27200284,LOCAL,0272,RC,,,both,,,12000.07,3600.02,"NOVANET [10819]",Novanet,,9000.05,75,,,,,0,1395.61,10200.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 6MM .0115IN AXIUM PRIME 3D",SUP-APB-6-15-3D-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,9591.00,2877.3,"BLUE CROSS [10001]","Blue Cross PPO",,3759.67,39.2,,,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE GRAFT 6CC DEMINERALIZED CORTICAL FIBER ACCELERATE",SUP-T50206,CDM,C1713,HCPCS,0278,RC,,,both,,,9522.00,2856.6,"AETNA [10100]","Aetna HMO/PPO",,7569.99,79.5,,1521.93,481.35,16760.95,30,1107.41,8093.7,"percent of total billed charges",
"ANCHOR SUT 4.75MM ARTHREX CORKSCREW FT SUTURETAPE PEEK",SUP-AR-1927PST-475,CDM,C1713,HCPCS,0278,RC,,,both,,,2480.63,744.19,"KAISER [10500]",Kaiser,,1662.02,67,,,,,0,288.5,2108.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE MICRO 150CM 10CM 2.5MM BALLOON DILATATION",SUP-G26678,CDM,C1725,HCPCS,0272,RC,,,both,,,3112.43,933.73,"UHC [10700]","United Healthcare",,1970.17,63.3,,,,,0,361.98,2645.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 20FR NEPHRSTMY NATURAL RUBBER 4 WING DRAIN",SUP-086020,CDM,C1729,HCPCS,0272,RC,,,both,,,105.62,31.69,"FIRST HEALTH [10303]","First Health",,84.5,80,,,,,0,12.28,89.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X10X8-12MM ALTERA 8D",SUP-1124.1011,CDM,S27800098,LOCAL,0278,RC,,,both,,,29925.00,8977.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3546.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLACK 11CM 3MM UTAHBALL SHAFT",SUP-DBL-311,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"CIGNA [10200]","Cigna Local Plus",,69.82,53.5,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL STRAIGHT 90MM TITANIUM 3X1 HOLE COMPRESSION 3DI",SUP-5920601L,CDM,C1713,HCPCS,0278,RC,,,both,,,14848.80,4454.64,"FIRST HEALTH [10303]","First Health",,11879.04,80,,,,,0,1726.92,12621.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT JUGGERKNOT SOFT TISSUE",SUP-912076,CDM,C1713,HCPCS,0278,RC,,,both,,,2835.00,850.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,335.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",329.71,2409.75,"percent of total billed charges",
"STEM FEMORAL 195MM 19MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-219,CDM,C1776,HCPCS,0278,RC,,,both,,,17822.70,5346.81,"BLUE CROSS [10001]","Blue Cross PPO",,6986.5,39.2,,3949.44,3949.44,3949.44,"1 through 10",2072.78,15149.3,"percent of total billed charges",
"NAIL 11MM 315MM TIBIAL TN ADVANCED INTRAMEDULLARY MR",SUP-04.043.325S,CDM,C1713,HCPCS,0278,RC,,,both,,,9579.13,2873.74,"AETNA [10100]","Aetna HMO/PPO",,7615.41,79.5,,1521.93,481.35,16760.95,30,1114.05,8142.26,"percent of total billed charges",
"VALVE HEMOSTASIS 20CM HONOR METAL GWIRE INSRT TOOL BONDED",SUP-MAP352,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.63,63.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,143.23,68,,,,,0,24.5,179.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 80MM 3.5MM BALLOON DILATATION",SUP-48003508X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 200MM 6MM BALLOON DILATATION OTW",SUP-H74939206062010,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUPERCORE 15CM 9.9CM 18GA 17GA BIOPSY COAXIAL INTRO",SUP-701218150,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.53,140.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,55.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.37,397.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Intrauterine",PX-E27200253,CDM,E27200253,LOCAL,0272,RC,,,both,,,1333.20,399.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,157.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.05,1133.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM SPINAL POLYAXIAL",SUP-8807540,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS [10001]","Blue Cross PPO",,3742.37,39.2,,957.42,570.23,957.42,28,1110.3,8114.82,"percent of total billed charges",
"GRAFT BONE SIGNAFUSE BIPHASIC CALCIUM PHOSPHATE BIOACTIVE",SUP-SGF-037,CDM,C1713,HCPCS,0278,RC,,,both,,,3891.60,1167.48,"CIGNA [10200]","Cigna Local Plus",,2082.01,53.5,,3978.14,359.25,3978.14,24,452.59,3307.86,"percent of total billed charges",
"RELOAD SUT ASSISTANT 2-0 EEN 6IN UNIT ETHIBOND EXCEL STERILE",SUP-SW112,CDM,S27200284,LOCAL,0272,RC,,,both,,,500.19,150.06,"CIGNA [10200]","Cigna Open Access",,284.61,56.9,,,,,0,58.17,425.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 16MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0101600,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"FIRST HEALTH [10303]","First Health",,4065.48,80,,,,,0,591.02,4319.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 90CM 20MM 5MM BALLOON DILATATION",SUP-PCP050020090,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AETNA [10100]","Aetna HMO/PPO",,978.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEP PIRANHA URET BIOPSY 3FR",SUP-505-160,CDM,S27200284,LOCAL,0272,RC,,,both,,,2308.73,692.62,"AETNA [10100]","Aetna HMO/PPO",,1835.44,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,268.51,1962.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 37X29X12MM DIVERGENCE-L 6D MEDIUM ANTERIOR OLIF",SUP-2151212,CDM,S27800098,LOCAL,0278,RC,,,both,,,26460.00,7938,"MULTIPLAN [10600]",Multiplan,,22491,85,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.5 X 18MM ESPRIT BTK IDE",SUP-1202250-18,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR PREPARATION OF TC 99M-ALBUMIN INTRAVENOUS SOLUTION",RX-124310,CDM,A9540,HCPCS,0343,RC,08888-8878-32,NDC,both,1,UN,885.51,265.65,"KAISER [10500]",Kaiser,,593.29,67,,,,,0,34.97,752.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 56CM 19GA PROC TRANSSEPTAL 50D HEARTSPAN",SUP-FND01900,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM SPINE MULTIAXIAL REDUCTION 5.5/6MM ROD",SUP-55890007545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +6MM OFFSET 36MM HIP TYPE 1 COCR G7",SUP-11363664,CDM,C1776,HCPCS,0278,RC,,,both,,,5296.44,1588.93,"CIGNA [10200]","Cigna Open Access",,3013.67,56.9,,5302.19,4377.88,6578.61,27,615.98,4501.97,"percent of total billed charges",
"HC Npwt <=50 Sq Cm",PX-510000169,CDM,97605,CPT,0761,RC,,,both,,,980.25,294.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114,980.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 25.4IN 6MM DA VINCI SP 9.8MM",SUP-430200,CDM,S27000186,LOCAL,0270,RC,,,both,,,2324.70,697.41,"PHCS [10601]",PHCS,,1627.29,70,,,,,0,270.36,1976,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR DISPOSABLE STERILE 2.9MM PUSHLOCK",SUP-AR-1923DHS,CDM,C1713,HCPCS,0278,RC,,,both,,,1488.38,446.51,"CIGNA [10200]","Cigna Open Access",,846.89,56.9,,1144.80,304.56,2275.09,66,173.1,1265.12,"percent of total billed charges",
"CATH VASCUTRAK 140CM 8CM 2MM BALLOON DILATATION HYDROPHILIC",SUP-V142080,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"FIRST HEALTH [10303]","First Health",,4388.4,80,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X15MM LUMINARY 10-11MM SPINE",SUP-14715,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"KAISER [10500]",Kaiser,,21105,67,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 132D 10 HIP",SUP-6720-1040,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9584.82,40,,,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARCADIA 10MM BALLOON DILATATION 3CC ROBUST DURABLE HIGH",SUP-ARC10ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,5978.16,1793.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,708.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,695.26,5081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 24CM 13.5FR STRAIGHT POLYURETHANE MAHURKAR QPLUS 2",SUP-8888135241,CDM,C1752,HCPCS,0272,RC,,,both,,,564.86,169.46,"PHCS [10601]",PHCS,,395.4,70,,,,,0,65.69,480.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERIT MAESTRO 150CM 2.9FR .027IN MICRO 45D .021IN .042",SUP-29MC2915045,CDM,C1887,HCPCS,0272,RC,,,both,,,2301.00,690.3,"PHCS [10601]",PHCS,,1610.7,70,,,,,0,267.61,1955.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23MMX9MM ELEVATE XLORDOTIC PEEK TITANIUM",SUP-8880923,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 38MM 145CM 2.5MM CORONARY STENT",SUP-1125250-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3969.84,68,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION 10MM INBONE 4+ ANKLE EVERLAST",SUP-22025410,CDM,C1776,HCPCS,0278,RC,,,both,,,13530.90,4059.27,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1603.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1573.64,11501.27,"percent of total billed charges",
"CATH SABERX 200CM 150MM 4MM BALLOON DILATATION RAPID",SUP-47540150L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 3 HEALICOIL PK ULTRABRAID SHOULDER COBRAID",SUP-72203380,CDM,C1713,HCPCS,0278,RC,,,both,,,2835.00,850.5,"FIRST HEALTH [10303]","First Health",,2268,80,,,,,0,329.71,2409.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 0 8IN ENDO STITCH V-LOC POLYBUTESTER LOAD UNIT",SUP-VLOCN008L,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.99,98.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,223.03,68,,,,,0,38.15,278.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X22X12MM COROENT WIDE XL",SUP-6912260,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2763.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES 145CM 40MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939134254010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHIBOND 2-0 SH 30IN BRAID GREEN NONABSORBABLE",SUP-X833H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL DISSECTING 16CM 1.7MM MIDAS REX LEGEND TAPER BURR",SUP-16TA17,CDM,S27200284,LOCAL,0272,RC,,,both,,,1241.08,372.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP ASPIR 12CM 2.49MM 2MM SONOPET IQ LARGE SOFT TISSUE",SUP-5500-25S-308,CDM,S27200284,LOCAL,0272,RC,,,both,,,6269.10,1880.73,"CIGNA [10200]",Cigna,,4262.99,68,,,,,0,729.1,5328.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 1.5MM AXIUM PRIME HELIX DETACHABLE",SUP-APB-1.5-3-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"MULTIPLAN [10600]",Multiplan,,7595.18,85,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC UNIVERSAL 22IN 25IN 19IN KNEE THIGH 3 PANEL",SUP-ORT2411022,CDM,S27000186,LOCAL,0270,RC,,,both,,,141.38,42.41,"MULTIPLAN [10600]",Multiplan,,120.17,85,,,,,0,16.44,120.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
PSYCHOSES,885,MS-DRG,,,,,,,inpatient,,,32205.02,9661.51,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,8924.37,,"Case rate ($8,664.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,045.52, add-ons for qualifying new technology services are included. If operating cost exceeds $41,085.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,990.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $8,056.16. The transfer operating threshold is the transfer adjustment factor * $8,045.52 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $608.28. The transfer capital threshold is the transfer adjustment factor * $608.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,1958,32205.02,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 6FR .07IN STD",SUP-67008300M,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,49.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 8MM 144CM 3MM CORONARY STENT EVEROLIMUS",SUP-H7493926108300,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2468.48,28.62,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ACROBAT ENDOSCOPIC 450CM 4CM .035IN HYDROPHILIC",SUP-G34266,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INDIGO CATHETER 6X 132CM STRAIGHT + TRAX",SUP-LITNGBT6XTX,CDM,C1757,HCPCS,0272,RC,,,both,,,48132.00,14439.6,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CANN ARTHROSCOPIC 7CM 8.25MM TWIST-IN 3 DAM TRANSLUCENT",SUP-AR-6530TD,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Echo Stress W Contrast Add On",PX-483000020,CDM,93352,CPT,0483,RC,,,both,,,672.00,201.6,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CRYOPRESERVED SKIN 115.52 SQ CM 7.6CM X 15.2CM CRYOPRESER",SUP-104TSXLR,CDM,Q4121,HCPCS,0636,RC,,,both,,,21690.90,6507.27,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"KIT TKR ITOTAL IDENTITY IPOLY XE POSTERIOR STABILIZE FULL",SUP-ITPS-XE,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"CIGNA [10200]","Cigna Open Access",,8969.63,33.5,,5302.19,4377.88,6578.61,27,3113.93,22758.75,"percent of total billed charges",
"CATH RANGER 135CM 40MM 6MM BALLOON DILATATION PACLITAXEL OTW",SUP-H74939419600410,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"MULTIPLAN [10600]",Multiplan,,7331.25,85,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 2.5CM 10CM GWIRE DIL RADIOPAQUE MARKER",SUP-RSB802,CDM,C1894,HCPCS,0272,RC,,,both,,,200.10,60.03,"UHC [10700]","United Healthcare",,126.66,63.3,,,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 25MM LCP STAINLESS STEEL PROXIMAL FEMORAL",SUP-02.205.025,CDM,C1713,HCPCS,0278,RC,,,both,,,1263.28,378.98,"FIRST HEALTH [10303]","First Health",,1010.62,80,,,,,0,146.92,1073.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL COMPREHENSIVE +6MM +10MM SHOULDER REVERSE",SUP-110031407,CDM,C1776,HCPCS,0278,RC,,,both,,,8473.20,2541.96,"CIGNA [10200]",Cigna,,5761.78,68,,5873.17,5873.17,5873.17,"1 through 10",985.43,7202.22,"percent of total billed charges",
"TUBE 24FR SILICONE INTERNAL RETENTION BALLOON RECESS DISTAL",SUP-8100-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"UHC [10700]","United Healthcare",,177.16,63.3,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETAB HXL 44MM",SUP-932-44-260,CDM,C1776,HCPCS,0278,RC,,,both,,,12462.02,3738.61,"CIGNA [10200]","Cigna Local Plus",,3925.54,31.5,,5372.07,4581.20,7242.98,23,1449.33,10592.72,"percent of total billed charges",
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.25MM X 12.0MM",SUP-493251212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AETNA [10100]","Aetna HMO/PPO",,643.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST GEL SMOOTH ROUND MODERATE PLUS PROFILE 320CC",SUP-SMPB320,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"AETNA [10100]","Aetna HMO/PPO",,6061.48,79.5,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 55MM 11MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113611,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"PHCS [10601]",PHCS,,8820,70,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 65MM KNEE LEFT POSTERIOR STABILIZE OPEN BOX",SUP-184528,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"FIRST HEALTH [10303]","First Health",,19860.62,80,,,,,0,2887.24,21101.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 755CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCM-755,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS [10001]","Blue Cross PPO",,2961.76,39.2,,16595.83,16595.83,16595.83,"1 through 10",878.7,6422.18,"percent of total billed charges",
"DRSG WOUND WHITE 10X7.5CM WHITEFOAM VAC THK1CM SMALL",SUP-M6275033/10,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.61,23.28,"KAISER [10500]",Kaiser,,52,67,,,,,0,9.03,65.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY INSTR 446X49X88MM 2 TELESCOPE",SUP-WA05990A,CDM,S27000186,LOCAL,0270,RC,,,both,,,1913.03,573.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1300.86,68,,,,,0,222.49,1626.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 65CM 8MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0865CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"PHCS [10601]",PHCS,,5554.5,70,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Progesterone",PX-301000373,CDM,84144,CPT,0301,RC,,,both,,,181.45,54.43,"NOVANET [10819]",Novanet,,136.09,75,,,,,0,0.18,154.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG BODY SHROUD",SUP-SP3160,CDM,S27000186,LOCAL,0270,RC,,,both,,,168.22,50.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,77.21,45.9,,,,,0,19.56,142.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO 1000093010 OPTISEAL GLBL8FR25CM",SUP-1000093010,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 13MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-813,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"CIGNA [10200]","Cigna Open Access",,4508.58,33.5,,5302.19,4377.88,6578.61,27,1565.22,11439.68,"percent of total billed charges",
"CATH BALLOON DILATATION .014IN 4FR 6MM 142CM 2CM PERIPHERAL",SUP-4246020W,CDM,C1725,HCPCS,0272,RC,,,both,,,1438.80,431.64,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,591.35,41.1,,,,,0,167.33,1222.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC ELIM PET 230CM 4CM 15MM PYLORIC BALLOON",SUP-848,CDM,C1726,HCPCS,0272,RC,,,both,,,607.50,182.25,"UHC [10700]","United Healthcare",,384.55,63.3,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 4.0X30MM",SUP-PRV040030CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 30MM 7MM STAINLESS STEEL 1.1MM SHORT THREAD",SUP-02.226.030,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,194.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",191.34,1398.42,"percent of total billed charges",
"HC Rmvl Pcmkr Gen Only",PX-480000026,CDM,33233,CPT,0481,RC,,,both,,,8960.18,2688.05,"FIRST HEALTH [10303]","First Health",,7168.14,80,,,,,0,1042.07,8960.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE 12IN MERITRANS WINGED HOUSING MALE SWIVEL",SUP-K11-00096B,CDM,S27200284,LOCAL,0272,RC,,,both,,,94.13,28.24,"CIGNA [10200]","Cigna Local Plus",,50.36,53.5,,,,,0,10.95,80.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 5MM",SUP-SB080050,CDM,S27200284,LOCAL,0272,RC,,,both,,,2355.00,706.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1601.4,68,,,,,0,273.89,2001.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 10MM 11FR ENDOPROSTHESIS HEPARIN",SUP-VBH101502A,CDM,C1874,HCPCS,0278,RC,,,both,,,23102.10,6930.63,"BLUE CROSS [10001]","Blue Cross HMO",,9056.02,39.2,,9776.84,9776.84,9776.84,"1 through 10",2686.77,19636.79,"percent of total billed charges",
"LENS IOL +12 DIOPTER +2.25 CYLINDER HAPTIC C BICONVEX 13MM 6",SUP-ZXT225U120,CDM,V2788,HCPCS,0276,RC,,,both,,,834.00,250.2,"MULTIPLAN [10600]",Multiplan,,708.9,85,,,,,0,96.99,708.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE KNIFE 4IN KARLIN MICRO 2MM",SUP-46-3177,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.05,39.31,"CIGNA [10200]",Cigna,,89.11,68,,,,,0,15.24,111.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 30ML 1.7-10MM CHIPS",SUP-T20040,CDM,S27800098,LOCAL,0278,RC,,,both,,,2940.00,882,"BLUE CROSS [10001]","Blue Cross PPO",,1152.48,39.2,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIEWFLEX X ICE CATHETER SENSOR ENABLED",SUP-ICE-VF-SE-2D-01,CDM,C1759,HCPCS,0272,RC,,,both,,,16905.00,5071.5,"MULTIPLAN [10600]",Multiplan,,14369.25,85,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR FLOW OFFSET BCG TRNSDUC ENHANCE MALE TO FEMALE",SUP-1503-3858-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1287.90,386.37,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL 4 15MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962353,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1686.79,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC",846,MS-DRG,,,,,,,inpatient,,,75361.88,22608.56,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,16563.88,,"Case rate ($16,081.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,932.70, add-ons for qualifying new technology services are included. If operating cost exceeds $47,972.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,511.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $14,952.45. The transfer operating threshold is the transfer adjustment factor * $14,932.70 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,128.99. The transfer capital threshold is the transfer adjustment factor * $1,128.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,64654.36,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH PERITONEUM STARTER PERITX 1000ML",SUP-158432,CDM,C1729,HCPCS,0272,RC,,,both,,,6900.00,2070,"AMERIGROUP MEDICAID [20100]",Amerigroup,,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION LUBRICATH 16FR 350ML FOLEY URINE METER",SUP-902816,CDM,S27200284,LOCAL,0272,RC,,,both,,,112.06,33.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,76.2,68,,,,,0,13.03,95.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT CONSTRAIN LEGION OXINIUM",SUP-71421163,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"BLUE CROSS [10001]","Blue Cross PPO",,22670.93,39.2,,3949.44,3949.44,3949.44,"1 through 10",6726.09,49158.9,"percent of total billed charges",
"WASHER ORTHOPEDIC 6.5 MM CANNULATED SCR",SUP-04.353.907.05,CDM,C1713,HCPCS,0278,RC,,,both,,,251.05,75.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,71.85,28.62,,,,,0,29.2,213.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 50MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-50,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,1144.80,304.56,2275.09,66,50.59,369.75,"percent of total billed charges",
"STENT 30CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752650,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,613.48,68,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 75MM KNEE LEFT CRUCIATE RETAIN CEMENT PRIMARY",SUP-183034,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"BLUE CROSS [10001]","Blue Cross PPO",,7873.58,39.2,,3949.44,3949.44,3949.44,"1 through 10",2335.96,17072.81,"percent of total billed charges",
"MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION",RX-113697,CDM,,,0250,RC,00121-0431-30,NDC,both,30,ML,14.72,4.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6.76,45.9,,,,,0,1.71,12.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE VISI-BLACK 7-0 BV-1 24IN 2 ARM MONOFILAMENT BLUE",SUP-8304H,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.86,53.36,"KAISER [10500]",Kaiser,,119.17,67,,,,,0,20.69,151.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 50MM DYNANAIL HELIX HEADLESS STERILE LATEX FREE",SUP-3200-01-7050,CDM,S27200284,LOCAL,0272,RC,,,both,,,30208.50,9062.55,"CIGNA [10200]","Cigna Open Access",,17188.64,56.9,,,,,0,3513.25,25677.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTW TAKERU PTCA BALLOON 1.50MM X 15MM",SUP-DC-PY1515UA1,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,406.15,41.1,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 190CM 3CM",SUP-1020014,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,inpatient,,,34647.33,10394.2,"AETNA [10100]","Aetna HMO/PPO",,16805.56,,"Fee schedule rate ($16,805.56). Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",10199.90,10199.90,10199.90,"1 through 10",5540.57,22275.51,other,"IP DRG - Acute"
"ELEMENT 17 F VASCULAR ACCESS SYSTEM 45CM",SUP-ELMNT17F45,CDM,C1887,HCPCS,0272,RC,,,both,,,6210.00,1863,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2552.31,41.1,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20CM 18G BIOPINCE ULTRA CO AXIAL INTRO NDL",SUP-360-2080-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.84,161.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,62.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.55,457.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 65CM 22MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES2265CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5395.8,68,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 11CM TOUCH NARROW BASE",SUP-EN2811,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"KAISER [10500]",Kaiser,,42009,67,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 16.1CM 8MM CEREPAK MICRO UNIFORM",SUP-FCX100816,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5290.34,40,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 73X18.5X.76MM MEDIUM STAINLESS STEEL SAGITTAL",SUP-2108-115-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"MULTIPLAN [10600]",Multiplan,,203.22,85,,,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM STAINLESS STEEL T15 CORTEX SELF TAP LOW",SUP-02.206.212,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"BLUE CROSS [10001]","Blue Cross HMO",,127,39.2,,957.42,156.86,7483.26,51,37.68,275.39,"percent of total billed charges",
"CATH LUTONIX 035 130CM 150MM 6MM BALLOON DILATATION",SUP-LX3513061505F,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"KAISER [10500]",Kaiser,,5663.18,67,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ENDOSCOPIC INSTR TIGHTROPE CANNULATED STERILE",SUP-AR-8926SS,CDM,C1713,HCPCS,0278,RC,,,both,,,8107.50,2432.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3721.34,45.9,,,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3530,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"BLUE CROSS [10001]","Blue Cross PPO",,587.41,39.2,,957.42,570.23,957.42,28,174.28,1273.73,"percent of total billed charges",
"INSRT TIBIAL 5 CURVE 12.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962052,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"BLUE CROSS [10001]","Blue Cross HMO",,3625.78,39.2,,5311.50,4717.44,5388.59,31,1075.71,7862.03,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL 3IN 5MM ARGONPLUS FLEXIBLE ACTIVE",SUP-E2530-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.83,54.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.15,154.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY LARYNGEAL MASK CHILD SIZE 4 30ML PVC CUFF STRAIGHT DI",SUP-ALAA040SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.20,15.66,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PYRAZINAMIDE 500 MG TABLET",RX-6738,CDM,,,0637,RC,33342-0447-11,NDC,both,1,UN,25.19,7.56,"FIRST HEALTH [10303]","First Health",,20.15,80,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 14CM 5FR 3MM .035IN BALLOON",SUP-G52330,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,652.64,68,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 70MM TITANIUM LOCKING ATLANTIS VISION BONE ANTERIOR",SUP-976-170,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1876.04,28.62,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SP RD180 SUTURING 1 PORT STERILE",SUP-021450,CDM,S27200284,LOCAL,0272,RC,,,both,,,2490.00,747,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,289.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,289.59,2116.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAT TISS ELVATN SURG MIC MICROMAT 5FR SIL W 5FR SUC GRD",SUP-3103-5G,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM GALAXY G3 XTRASOFT NEUROVASCULAR",SUP-GLX120410,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"PHCS [10601]",PHCS,,8317.26,70,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION",RX-187806,CDM,,,0637,RC,00338-0126-12,NDC,both,100,ML,317.10,95.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,215.63,68,,,,,0,36.88,269.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH 1 90CM 7FR .081IN MUTLIPURPOSE CURVE GUIDING PTFE",SUP-M001197260,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,69.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CAROTID BARD JAVID TAPER 27.5CM TYPE 1852 KINK",SUP-007714,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"CIGNA [10200]","Cigna Local Plus",,390.02,53.5,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 3CM 4.8FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175253050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,491.47,45.9,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 1MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR091040,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"AETNA [10100]","Aetna HMO/PPO",,10514.55,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE LEFT TOTAL STABILIZE TRIATHLON COCR",SUP-5512-F-801,CDM,C1776,HCPCS,0278,RC,,,both,,,32652.90,9795.87,"AETNA [10100]","Aetna HMO/PPO",,25959.06,79.5,,10981.53,8986.79,12413.38,12,3797.53,27754.97,"percent of total billed charges",
"STENT ZIPWIRE 24CM 3CM 6FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006145361190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,133.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM CONCERTO DETACHABLE",SUP-PV-14-30-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 90CM CORONARY VENOUS IS-1 EASYTRAK 2",SUP-4543,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1604.72,28.62,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 1MM E9000 ROUND DIAMOND COARSE STERILE",SUP-E5210,CDM,S27200284,LOCAL,0272,RC,,,both,,,472.88,141.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,321.56,68,,,,,0,55,401.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LD 35MM 5.3MM BK-N",SUP-109224,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.80,114.84,"AETNA [10100]","Aetna HMO/PPO",,304.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 5 KNEE CEMENT ROTATE PLATFORM STERILE",SUP-150680005,CDM,C1776,HCPCS,0278,RC,,,both,,,17225.85,5167.75,"AETNA [10100]","Aetna HMO/PPO",,13694.55,79.5,,10981.53,8986.79,12413.38,12,2003.37,14641.97,"percent of total billed charges",
"SIZER IMPL 14.9CM MEMORYGEL COHESIVE I P4.6CM MODERATE PLUS",SUP-RSZ-5751S,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,104.88,68,,,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SURGICAL BARIATRIC RUNNING",SUP-021021,CDM,S27200284,LOCAL,0272,RC,,,both,,,1530.90,459.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,178.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,178.04,1301.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL SOFT TISSUE 4X1X1CM MOIST TOUGH FLEXIBLE SHEET",SUP-89223,CDM,C1763,HCPCS,0278,RC,,,both,,,2692.80,807.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1831.1,68,,,,,0,313.17,2288.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 20IN 24FR STRAIGHT",SUP-8888570531,CDM,C1729,HCPCS,0272,RC,,,both,,,94.09,28.23,"AETNA [10100]","Aetna HMO/PPO",,74.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.94,79.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 9MM ECHO FX COCR STD OFFSET HIP STERILE",SUP-12-151309,CDM,C1776,HCPCS,0278,RC,,,both,,,8941.02,2682.31,"BLUE CROSS [10001]","Blue Cross PPO",,3504.88,39.2,,3949.44,3949.44,3949.44,"1 through 10",1039.84,7599.87,"percent of total billed charges",
"LENS IOL +22.5 DIOPTER MODIFY C BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB0000225,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,798.66,68,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 5592-53  LEAD CAP SP BI SIL DWNSIZE",SUP-5592-53,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"NOVANET [10819]",Novanet,,4205.25,75,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 5X4IN THERAHONEY RECTANGLE MANUKA HONEY POROUS",SUP-MNK0077,CDM,S27200284,LOCAL,0272,RC,,,both,,,51.23,15.37,"CIGNA [10200]","Cigna Open Access",,29.15,56.9,,,,,0,5.96,43.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 18IN ENDOLOOP VICRYL ABSORBABLE SUT BRAID ENDOSCOPIC",SUP-EJ10G,CDM,S27200284,LOCAL,0272,RC,,,both,,,822.04,246.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,97.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,95.6,698.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METRONIDAZOLE 500 MG TABLET",RX-5016,CDM,,,0637,RC,50268-0535-11,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 25MM 3.75MM ULTRA LOW PROFILE BALLOON DILATATION",SUP-1012410-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 14CM 5FR 4MM .035IN BALLOON",SUP-G52336,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 25GA GRIESHABER DSP 45D STERILE DISPOSABLE",SUP-337.92,CDM,S27200284,LOCAL,0272,RC,,,both,,,368.97,110.69,"MULTIPLAN [10600]",Multiplan,,313.62,85,,,,,0,42.91,313.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOGARTY 80CM 8FR 13MM THROMBECTOMY VENOUS BALLOON",SUP-320808F,CDM,C1757,HCPCS,0272,RC,,,both,,,708.99,212.7,"KAISER [10500]",Kaiser,,475.02,67,,,,,0,82.46,602.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IFUSE IMPL SYSTEM 40MM 7MM SPINAL FIXATION SACROILIAC",SUP-7040M-90,CDM,C1713,HCPCS,0278,RC,,,both,,,21082.95,6324.88,"MULTIPLAN [10600]",Multiplan,,17920.51,85,,,,,0,2451.95,17920.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 90CM .1IN 6FR .07IN JUDKINS",SUP-67008290,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"UHC [10700]","United Healthcare",,264.34,63.3,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 28MM 144CM 4.5MM CORONARY STENT",SUP-H7493941828450,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRD SURGICAL GRAFT",SUP-AR-19007GS,CDM,S27200284,LOCAL,0272,RC,,,both,,,2953.13,885.94,"CIGNA [10200]","Cigna Open Access",,1680.33,56.9,,,,,0,343.45,2510.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM MASTERS HEMODYNAMIC PLUS MECHANICAL STD",SUP-25AHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"UHC [10700]","United Healthcare",,18432.47,63.3,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +10MM 36MM HIP MODULAR PCA",SUP-6280-0-336,CDM,C1776,HCPCS,0278,RC,,,both,,,7414.05,2224.21,"NOVANET [10819]",Novanet,,5560.54,75,,,,,0,862.25,6301.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VOLT, HD GRID X, AGILIS 13F MED, ICE SE",SUP-K-VOLT-HDI-M,CDM,C1732,HCPCS,0272,RC,,,both,,,74100.00,22230,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8780.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8617.83,62985,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRILL 2MM",SUP-DK-200C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1660.50,498.15,"NOVANET [10819]",Novanet,,1245.38,75,,,,,0,193.12,1411.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 13X13.5CM BREAST 500ML STYLE 133FV TEXTURE",SUP-133FV-13,CDM,C1789,HCPCS,0278,RC,,,both,,,5460.00,1638,"AETNA [10100]","Aetna HMO/PPO",,4340.7,79.5,,,,,0,635,4641,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 560CC NATRELLE INSPIRA COHESIVE STERILE",SUP-TCM-560,CDM,C1789,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3800.52,45.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM FEMORAL POROUS HIP",SUP-OSC366414,CDM,C1776,HCPCS,0278,RC,,,both,,,6210.00,1863,"FIRST HEALTH [10303]","First Health",,4968,80,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM ATS OPEN PIVOT MECHANICAL STD SERIES",SUP-500DM25,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6378.75,27,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 40MM 5MM BALLOON DILATATION RAPID EXCHANGE",SUP-47550040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"UHC [10700]","United Healthcare",,1010.08,63.3,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 40CM 32FR VENOUS 90D 1 STAGE WIRE REINFORCE",SUP-TF032L90,CDM,S27200284,LOCAL,0272,RC,,,both,,,277.18,83.15,"CIGNA [10200]",Cigna,,188.48,68,,,,,0,32.24,235.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER ENDOSCOPIC 20MM 3MM TREVO XP PROVUE MICROCATHETER",SUP-80051,CDM,C1757,HCPCS,0272,RC,,,both,,,49249.94,14774.98,"AETNA [10100]","Aetna HMO/PPO",,39153.7,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5727.77,41862.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEMOSTAT ABSORBABLE POWDER KIT SYR TIP SURGIFOAM PORCINE",SUP-1979,CDM,S27200284,LOCAL,0272,RC,,,both,,,1743.17,522.95,"UHC [10700]","United Healthcare",,1103.43,63.3,,,,,0,202.73,1481.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 25MM AEQUALIS PERFORM 15D SHOULDER WEDGE AUG",SUP-DWJ505,CDM,C1776,HCPCS,0278,RC,,,both,,,11340.00,3402,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3061.8,27,,,,,0,1318.84,9639,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BISECTED PAT.LIGAMENT; FROZEN",SUP-FBPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,15573.30,4671.99,"BLUE CROSS [10001]","Blue Cross HMO",,6104.73,39.2,,,,,0,1811.17,13237.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT OMNILINK ELITE 29MM 80CM 9MM THIN VASCULAR COCR",SUP-1012625-29,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"BLUE CROSS [10001]","Blue Cross HMO",,3292.8,39.2,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 28MM HIP BIOLOX DELTA BIOLOX OPTION G7",SUP-650-1055,CDM,C1776,HCPCS,0278,RC,,,both,,,13896.60,4168.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1616.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1616.17,11812.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIB 70CM 7.3FR RELIANCE 4-FRONT RIGHT VENTRICLE MP35N",SUP-652,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA [10200]","Cigna Open Access",,5085.3,33.5,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI GAIA FIRST VASCULAR MICRO 300CM CORONARY J TIP",SUP-AHW14R307P,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,131.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 6CM SHORT UNIVERSAL VASCULAR ARTICULATING",SUP-EGIAUSHORT,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 27MM 135CM 8MM 30MM BILIARY STAINLESS STEEL",SUP-PXB35-08-27-135,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1249.84,28.62,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 90CM .1IN 8FR .088IN",SUP-588842P,CDM,C1887,HCPCS,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT STRATAFIX SYMMETRIC PDS PLUS 0 CT-1 24IN VIOLET",SUP-SXPP1A440,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"5F QUAD 10-10-10 CS 120CM",SUP-901423,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 16-34MM SMALL BALLOON OCCLUSION TRILOBE STENT PLACEMENT",SUP-BCM1634,CDM,C1725,HCPCS,0272,RC,,,both,,,4843.80,1453.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STAPLER INTERNAL 33MM TITANIUM 4.8MM XL ANVIL ENDOSCOPIC LIN",SUP-EEAXL33,CDM,S27200284,LOCAL,0272,RC,,,both,,,2546.25,763.87,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC",826,MS-DRG,,,,,,,inpatient,,,278940.49,83682.15,"AETNA [10100]","Aetna HMO/PPO",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $208,489. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 79.5%. Includes an add-on of 79.5% of RC 0274 if total amount is above $2,000, 79.5% of RC 0275 if total amount is above $2,000, 79.5% of RC 0276 if total amount is above $2,000, 79.5% of RC 0001-0999 if total amount is above $2,000, 79.5% of RC 0343 if total amount is above $2,000, 79.5% of RC 0344 if total amount is above $2,000, 79.5% of RC 0636 if total amount is above $2,000.",,,,0,,,other,"IP STOP LOSS Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 7FR 2-8-2MM SPACE ELECTROPHYSIOLOGY DEFLECT",SUP-D728260RT,CDM,C1731,HCPCS,0272,RC,,,both,,,7086.30,2125.89,"MULTIPLAN [10600]",Multiplan,,6023.36,85,,,,,0,824.14,6023.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY LARYNGEAL 3 PEDIATRIC SILICONE LMA UNIQUE MASK CUFF",SUP-105300-000030,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.85,14.35,"UHC [10700]","United Healthcare",,30.29,63.3,,,,,0,5.56,40.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS BLOCK ALLOGRAFT 10MM",SUP-291041,CDM,S27800098,LOCAL,0278,RC,,,both,,,3839.85,1151.95,"AETNA [10100]","Aetna HMO/PPO",,3052.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,446.57,3263.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 100MM 28MM 20MM AFX2 2 BRANCH 40MM",SUP-BEA28-100/I20-40,CDM,C1874,HCPCS,0278,RC,,,both,,,84559.50,25367.85,"BLUE CROSS [10001]","Blue Cross HMO",,33147.32,39.2,,9776.84,9776.84,9776.84,"1 through 10",9834.27,71875.58,"percent of total billed charges",
"CHMBR HUMD AEROCHAMBER PLUS Z STAT FLOWSIGNAL ANTISTATIC",SUP-58-79710EA,CDM,S27200284,LOCAL,0272,RC,,,both,,,51.32,15.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.97,43.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 38MM QUICKFIX TITANIUM T15 SHORT THREAD",SUP-AR-8740-38PTS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Local Plus",,715.03,53.5,,3978.14,359.25,3978.14,24,155.43,1136.03,"percent of total billed charges",
"COIL EMBOLIZATION 15CM 3MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0315,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"BLUE CROSS [10001]","Blue Cross PPO",,2650.7,39.2,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR PIGTAIL CURVE ANGIOGRAPHIC RADIOPAQUE",SUP-10708501,CDM,C1887,HCPCS,0272,RC,,,both,,,218.37,65.51,"PHCS [10601]",PHCS,,152.86,70,,,,,0,25.4,185.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REINFORCEMENT STAPLE LINE BIOABSORBABLE CIRCULAR STPLR",SUP-1BSGC2829,CDM,S27200284,LOCAL,0272,RC,,,both,,,2145.00,643.5,"CIGNA [10200]",Cigna,,1458.6,68,,,,,0,249.46,1823.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHOCOLATE 135CM 120MM 3.5MM .014IN BALLOON DILATATION",SUP-CB1413535120OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,678.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC",219,MS-DRG,,,,,,,inpatient,,,381225.80,114367.74,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,49772.27,,"Case rate ($47,628.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $44,226.72, add-ons for qualifying new technology services are included. If operating cost exceeds $77,266.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $4,725.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $44,285.21. The transfer operating threshold is the transfer adjustment factor * $44,226.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,343.76. The transfer capital threshold is the transfer adjustment factor * $3,343.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 104.5%.",,,,0,47628.97,224175.65,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 12MM 8MM FOOT ANKLE VENT",SUP-AR-1680PS,CDM,C1713,HCPCS,0278,RC,,,both,,,2480.63,744.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1138.61,45.9,,,,,0,288.5,2108.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 30MM 125CM 8MM 6FR .035IN VASCULAR NITINOL",SUP-G43830,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"AETNA [10100]","Aetna HMO/PPO",,3005.1,79.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL PFC SIGMA TC3 2 60X56MM KNEE LEFT CEMENTED",SUP-960081,CDM,C1776,HCPCS,0278,RC,,,both,,,27588.96,8276.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3269.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3208.6,23450.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 40MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,655.83,41.1,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myelography Lumb Inj Thorac Si",PX-361000372,CDM,62303,CPT,0361,RC,,,both,,,4095.47,1228.64,"CIGNA [10200]","Cigna Local Plus",,3787,,"Case rate ($3,787). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,476.3,4095.47,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM STAINLESS STEEL 2.4MM SCR 6 HOLE HEAD 2 HOLE",SUP-02.111.621S,CDM,C1713,HCPCS,0278,RC,,,both,,,4102.05,1230.61,"CIGNA [10200]",Cigna,,2789.39,68,,1831.33,1831.33,1831.33,16,477.07,3486.74,"percent of total billed charges",
"CMPNT FEMORAL 5 STD KNEE RIGHT CRUCIATE RETAIN PERSONA PPS",SUP-42508605802,CDM,C1776,HCPCS,0278,RC,,,both,,,29326.50,8797.95,"CIGNA [10200]","Cigna Local Plus",,9237.85,31.5,,5372.07,4581.20,7242.98,23,3410.67,24927.53,"percent of total billed charges",
"LINER ACETABULAR R3 0D 58MM 28MM XLPE HIP",SUP-71337558,CDM,C1776,HCPCS,0278,RC,,,both,,,11146.95,3344.08,"CIGNA [10200]",Cigna,,7579.93,68,,5873.17,5873.17,5873.17,"1 through 10",1296.39,9474.91,"percent of total billed charges",
"SCR BONE 3.5MM 14MM ALPS T15 TIBIA CORTICAL DISTAL LOCK SELF",SUP-816135014,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"ROD SPINAL 110MM 5.5MM CURVE NONSTERILE",SUP-1555501110,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"STY LD 90CM KT DLV SYS",SUP-6691,CDM,S27500001,LOCAL,0275,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CW003, 5MMX42CM EPIX ES SMK EVAC ANG NDL",SUP-CW003,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PELVIC STABILIZATION DEVICE",SUP-T-PODR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1077.30,323.19,"MULTIPLAN [10600]",Multiplan,,915.71,85,,,,,0,125.29,915.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM LOW PROFILE SCREWS STAINLESS STEEL FULL",SUP-AR-8827L-16,CDM,C1713,HCPCS,0278,RC,,,both,,,931.50,279.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,108.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",108.33,791.78,"percent of total billed charges",
"SCR BONE 4MM 10MM ATLANTIS TITANIUM ANTERIOR CERVICAL SPINE",SUP-876-810,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (5.5-6 MCI)",RX-411880,CDM,A9520,HCPCS,0343,RC,08888-8876-14,NDC,both,1,UN,4614.97,1384.49,"NOVANET [10819]",Novanet,,3461.23,75,,,,,0,536.72,4614.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502606002,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"AETNA [10100]","Aetna HMO/PPO",,18175.85,79.5,,10981.53,8986.79,12413.38,12,2658.93,19433.3,"percent of total billed charges",
"SHEATH AMPLATZ 17CM 16FR ACCESS PTFE RENAL FIRM TAPER TIP",SUP-M0062601460,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,227.53,68,,,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 80CM 125CM 9MM VASCULAR HIWIRE NITINOL",SUP-G43788,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"MULTIPLAN [10600]",Multiplan,,3552.15,85,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INFUSION PORT WITHOUT Y SITE ACCESS 20GA POWERLOC 1IN",SUP-2652010,CDM,C1788,HCPCS,0278,RC,,,both,,,102.14,30.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,69.46,68,,,,,0,11.88,86.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 24MM 144CM 2.5MM CORONARY STENT PEBAX",SUP-H7493926024250,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2554.34,45.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 100MM 21GA 20GA E-CATH PLUS SONOPLEX 18GA",SUP-261285-41E,CDM,C9812,HCPCS,0272,RC,,,both,,,382.80,114.84,"KAISER [10500]",Kaiser,,256.48,67,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL GREEN 330MM 4.2MM 3 FLUTE TIBIAL QUICK COUPLING",SUP-03.010.061S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1682.10,504.63,"FIRST HEALTH [10303]","First Health",,1345.68,80,,,,,0,195.63,1429.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 GEOALIGN 130CM 80MM 7MM BALLOON DILATATION",SUP-LX351307805F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"FIRST HEALTH [10303]","First Health",,5382,80,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM EAR 7MM ROUND EBONY FINISH STAINLESS STEEL",SUP-130670,CDM,S27200284,LOCAL,0272,RC,,,both,,,535.98,160.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,364.47,68,,,,,0,62.33,455.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING SCR IN ELECTRD ACTIVE FIXATION BIPOLAR IS 1 CNCT",SUP-1688T/58,CDM,C1898,HCPCS,0275,RC,,,both,,,3375.00,1012.5,"AETNA [10100]","Aetna HMO/PPO",,2683.13,79.5,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MOTIV SCAFFOLD 2.5MMX48MM","SUP-930025-48 (280)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 34X15MM MONUMENT 8D 26MM MEDIUM NONSTERILE",SUP-3108.0415,CDM,S27800098,LOCAL,0278,RC,,,both,,,39123.00,11736.9,"FIRST HEALTH [10303]","First Health",,31298.4,80,,,,,0,4550,33254.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC .99IN MINI 5.37X8.08CM DYNAGEN X4 IS-1 DF-1",SUP-G156,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"NOVANET [10819]",Novanet,,43290,75,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN 2.8MM 8.6-11.5MM SPEEDBAND SUPERVIEW SUPER 7",SUP-M00542253,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.47,350.54,"UHC [10700]","United Healthcare",,739.64,63.3,,,,,0,135.89,993.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE BARD PRESSURE MNTR INTRAABDOMINAL KIT FOLEY CATH",SUP-IAP001,CDM,S27200284,LOCAL,0272,RC,,,both,,,589.28,176.78,"AETNA [10100]","Aetna HMO/PPO",,468.48,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.53,500.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 14MM TITANIUM DISTAL RADIAL CORTICAL WRIST",SUP-CO-T2314,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"KAISER [10500]",Kaiser,,510.14,67,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26MMX9MM CAPSTONE PEEK PTC LUMBAR INTERBODY",SUP-3992609,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9062.55,41.1,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"Y-KNOT RC ALL-SUTURE ANCHOR, WITH TWO #2 ( 5 METRIC) HI-FI S",SUP-YRC02,CDM,C1713,HCPCS,0278,RC,,,both,,,4552.69,1365.81,"AETNA [10100]","Aetna HMO/PPO",,3619.39,79.5,,1521.93,481.35,16760.95,30,529.48,3869.79,"percent of total billed charges",
"SYSTEM TIGHTROPE II FIBERTAPE FIXATION BONE TENDON BONE",SUP-AR-1588BTB-IB,CDM,C1713,HCPCS,0278,RC,,,both,,,4673.03,1401.91,"FIRST HEALTH [10303]","First Health",,3738.42,80,,,,,0,543.47,3972.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Aerob Presump ID Tissue",PX-306000023,CDM,87070,CPT,0306,RC,,,both,,,377.15,113.14,"NOVANET [10819]",Novanet,,282.86,75,,,,,0,0.01,320.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12IN 24FR ARTERIAL ADULT 3/8IN CNCT VENTED",SUP-77624,CDM,C1769,HCPCS,0272,RC,,,both,,,541.37,162.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,222.5,41.1,,,,,0,62.96,460.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 14MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710414,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5917.44,40,,,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ethosuximide",PX-301000043,CDM,80168,CPT,0301,RC,,,both,,,245.00,73.5,"KAISER [10500]",Kaiser,,164.15,67,,,,,0,0.01,208.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR INFINION CX",SUP-SC-2317-50,CDM,C1897,HCPCS,0278,RC,,,both,,,17640.00,5292,"BLUE CROSS [10001]","Blue Cross HMO",,6914.88,39.2,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 4IN 4FR 21GA MAK .018IN PLATINUM COIL TIP NITINOL",SUP-MAK401NEBT,CDM,C1894,HCPCS,0272,RC,,,both,,,250.56,75.17,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM OPTIFIX FIXATION POLY-DL-LACTIDE 15 ABSORBABLE SMOOTH",SUP-0113127,CDM,S27200284,LOCAL,0272,RC,,,both,,,524.88,157.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER VASCULAR PROCEDURES WITHOUT CC/MCC",254,MS-DRG,,,,,,,inpatient,,,94164.32,28249.3,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR EBU3.25 CURVE GUIDING NYLON CORONARY",SUP-LA6EBU325,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE NC PLUS 10MM 3.75MM BALLOON DILATATION STERILE",SUP-237-103-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 13MM 2MM STRAIGHT",SUP-AR-300-B001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2625.00,787.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY EPIDURAL 3.5IN 18GA 27GA PERIFIX ESPOCAN SPINOCAN TUOHY",SUP-333182,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.66,74.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOUNDSTAR 90CM 10FR 3D ULTRASOUND NAVIGATION SENSOR",SUP-SNDSTR10R,CDM,C1759,HCPCS,0272,RC,,,both,,,9996.00,2998.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL 8 16MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532P816,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"FIRST HEALTH [10303]","First Health",,6684.72,80,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIA MATRIX (4 X 6) 24 SQ CM",SUP-585-007,CDM,Q4309,HCPCS,0636,RC,,,both,,,171000.00,51300,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,111150,65,,,,,0,247.92,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 10MM 1.9FR BAGLEY HELICAL 3",SUP-M0063401220,CDM,S27200284,LOCAL,0272,RC,,,both,,,1247.08,374.12,"CIGNA [10200]",Cigna,,848.01,68,,,,,0,145.04,1060.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL BIT COUNTSINK 26-30MM 4.5MM PONTO 4MM GUIDE WIDE IMPL",SUP-M51122,CDM,S27200284,LOCAL,0272,RC,,,both,,,1708.88,512.66,"KAISER [10500]",Kaiser,,1144.95,67,,,,,0,198.74,1452.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD 37MM 135CM 9MM 7MM 6FR BILIARY METAL",SUP-H74938047740130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"MULTIPLAN [10600]",Multiplan,,4243.2,85,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 2 KNEE PRIMARY BEAD PA",SUP-5526-B-200,CDM,C1776,HCPCS,0278,RC,,,both,,,15783.75,4735.12,"PHCS [10601]",PHCS,,11048.63,70,,,,,0,1835.65,13416.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 21.5X10.7CM ALLODERM SELECT THK2-2.8MM CONTOUR",SUP-CL1519P,CDM,Q4116,HCPCS,0636,RC,,,both,,,31380.30,9414.09,"AETNA [10100]","Aetna HMO/PPO",,24947.34,79.5,,,,,0,247.92,26673.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH",RX-27472,CDM,,,0250,RC,00378-9104-16,NDC,both,1,UN,12.54,3.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5.15,41.1,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM 32.9MM 26.9MM MITRAL FLEXIBLE HOLDER",SUP-4450M28,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"NOVANET [10819]",Novanet,,8538.75,75,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.2MM 18MM ACUTRAK 2 MINI HINDFOOT ANKLE STD",SUP-AT2-L2515,CDM,C1713,HCPCS,0278,RC,,,both,,,1702.50,510.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,487.26,28.62,,,,,0,198,1447.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 36MM PERIPHERAL STERILE",SUP-AR-9562-36NL,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,70.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",69.48,507.77,"percent of total billed charges",
"CATH EMERGE MONORAIL 144CM 12MM 6FR 2.25MM .07IN BALLOON",SUP-H7493918912220,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 54MM 32MM MARATHON",SUP-121932454,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"CIGNA [10200]","Cigna Local Plus",,4339.36,53.5,,5372.07,4581.20,7242.98,23,943.3,6894.31,"percent of total billed charges",
"DEVICE FAST-FIX 360D CURVE FIXATION 2 ANCHOR PRETIE SUT",SUP-72202468,CDM,C1713,HCPCS,0278,RC,,,both,,,3300.75,990.22,"CIGNA [10200]",Cigna,,2244.51,68,,1831.33,1831.33,1831.33,16,383.88,2805.64,"percent of total billed charges",
"SHELL ACETABULAR 62MM PRIMARY HEMISPHERICAL CLUSTER HOLE",SUP-5020362G,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1217.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1217.29,8896.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE-9 CATHETER",SUP-AFR-00001,CDM,C1733,HCPCS,0272,RC,,,both,,,53550.00,16065,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6345.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6227.87,45517.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sjogrens Abs",PX-302000045,CDM,86235,CPT,0302,RC,,,both,,,411.35,123.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,28.2,,,,,,,0.41,349.65,"fee schedule",
"CAP SYSTEM PERSONA STD TKR VIVACIT-E KNEE FEMUR PATELLA TIBI",SUP-98000200166,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9321.48,41.1,,6417.48,6417.48,6417.48,"1 through 10",2637.68,19278,"percent of total billed charges",
"VALVE MITRAL 29MM 24.2MM MASTERS SERIES 85D STD SUPRA",SUP-29MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11647.69,40,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN2BONES DONATED HUMAN TISSUE ALLOGRAFT",SUP-BGP001-02,CDM,V2790,HCPCS,0278,RC,,,both,,,1875.00,562.5,"NOVANET [10819]",Novanet,,1406.25,75,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL MEDIUM PEDICLE 5.5/6MM ROD",SUP-5541103,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"MULTIPLAN [10600]",Multiplan,,2550,85,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PENTARAY 7FR 2-6-2MM D CURVE ELECTROPHYSIOLOGY",SUP-D128211,CDM,C1732,HCPCS,0272,RC,,,both,,,13634.40,4090.32,"MULTIPLAN [10600]",Multiplan,,11589.24,85,,,,,0,1585.68,11589.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER II 110CM 4MM 7FR 2.5MM SPACE STD CURVE ABLATION",SUP-M0045031TL0,CDM,C1733,HCPCS,0272,RC,,,both,,,8107.50,2432.25,"KAISER [10500]",Kaiser,,5432.03,67,,,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JAGWIRE ENDOSCOPIC STRAIGHT TRIM 260CM .035IN BILIARY",SUP-5664,CDM,C1769,HCPCS,0272,RC,,,both,,,811.01,243.3,"FIRST HEALTH [10303]","First Health",,648.81,80,,,,,0,94.32,689.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 40MM 4FR 2.5MM LOW PROFILE COAXIAL",SUP-PCP025040130,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 27MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-227,CDM,C1776,HCPCS,0278,RC,,,both,,,17822.70,5346.81,"KAISER [10500]",Kaiser,,11941.21,67,,,,,0,2072.78,15149.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 2X2IN DURAGEN PLUS CRANIAL DURA BOVINE",SUP-DP1022,CDM,,,0278,RC,,,both,,,2381.25,714.37,"CIGNA [10200]","Cigna Open Access",,1354.93,56.9,,,,,0,2.38,2024.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 4-0 PS-2 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP426H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.17,19.85,"AETNA [10100]","Aetna HMO/PPO",,52.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.7,56.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 4-0 PS-2 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP426H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.17,19.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,30.37,45.9,,,,,0,7.7,56.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 20MM 5MM RECTANGLE HELIX BALLOON",SUP-2076-5020,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FIBER LASER 365UM FLEXIVA FLEXSHIELD HIGH POWER POLISH",SUP-M006R8403921,CDM,S27200284,LOCAL,0272,RC,,,both,,,2258.15,677.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 7FR .081IN CHAMP 1.5 CURVE GUIDING NYLON",SUP-LA7CHAMP15,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PASSER SPECTRUM MVP 45D RIGHT HOOK SUT STERILE DISPOSABLE",SUP-C6410,CDM,S27200284,LOCAL,0272,RC,,,both,,,1799.93,539.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ZEPHYR 2.8MM 4 DELIVERY SYSTEM FLEXIBLE EMPHASYS",SUP-EDC-TS-4.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,3898.50,1169.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 18LP 80CM 10CM 4FR 6MM .018IN BALLOON",SUP-G50252,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 1.2MM 9MM APTUS TITANIUM HAND CORTICAL HEXADRIVE 4",SUP-A-5100.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 48MM 3MM E9000 ROUND CARBIDE 8 FLUTE LOW SPEED",SUP-E8230LSO,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH HEARTSPAN 55D FIX CURVE TAPER 60CM 8.5FR GUIDING",SUP-FCL-160-02,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 135CM 150MM 5FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-06151,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 7MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBJR071002A,CDM,C1874,HCPCS,0278,RC,,,both,,,22163.40,6649.02,"FIRST HEALTH [10303]","First Health",,17730.72,80,,,,,0,2577.6,18838.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 15MM 2.25MM BALLOON DILATATION STERILE",SUP-222-153-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 15MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962323,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1718.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.5MM TRIM-IT",SUP-AR-4160-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"CIGNA [10200]","Cigna Open Access",,364.1,56.9,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 4FR .042IN AMPLATZ LEFT 1",SUP-538445,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"AETNA [10100]","Aetna HMO/PPO",,71.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE AUGMENTATION THK8MM 20MM 20MM BIOFOAM EVANS FOOTPRINT",SUP-46S52008,CDM,C1776,HCPCS,0278,RC,,,both,,,12489.00,3746.7,"MULTIPLAN [10600]",Multiplan,,10615.65,85,,,,,0,1452.47,10615.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE BONE SAGITTAL L 90X25MM",SUP-BR4125-127-090,CDM,S27200284,LOCAL,0272,RC,,,both,,,225.50,67.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,103.5,45.9,,,,,0,26.23,191.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP SMF WITH UNIPOLAR HEAD",SUP-71705615,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"PHCS [10601]",PHCS,,7245,70,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 9MM 0MM STERILE",SUP-TR-S0900-S,CDM,C1776,HCPCS,0278,RC,,,both,,,15145.50,4543.65,"UHC [10700]","United Healthcare",,9587.1,63.3,,8601.07,8395.67,8601.07,"1 through 10",1761.42,12873.68,"percent of total billed charges",
"BAND ANNULOPLASTY 34MM SIMUPLUS FLEXIBLE LUMEN STERILE LATEX",SUP-7700FB34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Open Access",,4391.85,33.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 103MM 14-23MM 18FR ENDURANT IIS 2 BRANCH",SUP-ESBF2314C103E,CDM,S27800098,LOCAL,0278,RC,,,both,,,60782.40,18234.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7202.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7068.99,51665.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC XL 8.5IN 8.5+ IN WRIST RIGHT PREFORM STAY",SUP-79-87288,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.33,14.8,"CIGNA [10200]","Cigna Local Plus",,26.39,53.5,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 64MM LCP STAINLESS STEEL LONG THREAD ORTHOPEDIC",SUP-207.764,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,707.23,68,,,,,0,120.96,884.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 22MM DCP STAINLESS STEEL CORTICAL HAND SELF",SUP-200.822,CDM,C1713,HCPCS,0278,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross HMO",,143.24,39.2,,957.42,156.86,7483.26,51,42.5,310.59,"percent of total billed charges",
"BIT DRILL 2MM CALIBRATE GRADUATE 2.7/3MM SCR",SUP-AR-8943-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,769.50,230.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 7MM 8-6MM 12MM DUCT SELF EXPANDABLE",SUP-9-PDA-005,CDM,C1817,HCPCS,0278,RC,,,both,,,34398.00,10319.4,"UHC [10700]","United Healthcare",,21773.93,63.3,,,,,0,4000.49,29238.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MODAFINIL 100 MG TABLET",RX-24702,CDM,,,0637,RC,00904-6791-04,NDC,both,1,UN,48.67,14.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.66,41.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chromo Analyss 15-20 Cell Band",PX-311000035,CDM,88262,CPT,0311,RC,,,both,,,1561.30,468.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,112.94,,,,,,,0.01,1327.11,"fee schedule",
"TUBE TRACH 12.7MM 9MM 8MM SHILEY ADULT FLEXIBLE CUFFLESS",SUP-9UN90A,CDM,S27200284,LOCAL,0272,RC,,,both,,,335.47,100.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNARE VASCULAR EN SNARE MINI L175 CM L150 CM OD2-4 MM ODSEC3",SUP-EN1003004,CDM,C1773,HCPCS,0272,RC,,,both,,,4554.00,1366.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE HEMOSTASIS 20CM HONOR METAL GWIRE INSRT TOOL BONDED",SUP-MAP352,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.63,63.19,"KAISER [10500]",Kaiser,,141.12,67,,,,,0,24.5,179.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 4X3CM PLACENTAL ALLOGRAFT",SUP-WC4034,CDM,S27800098,LOCAL,0278,RC,,,both,,,11178.00,3353.4,"NOVANET [10819]",Novanet,,8383.5,75,,,,,0,1300,9501.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ORTHOLOC 3DI FOOT RECONSTRUCTION SYSTEM HALLUX PLATES - MTP",SUP-587110RT,CDM,C1713,HCPCS,0278,RC,,,both,,,12420.00,3726,"BLUE CROSS [10001]","Blue Cross HMO",,4868.64,39.2,,957.42,156.86,7483.26,51,1444.45,10557,"percent of total billed charges",
"STEM FEMORAL 100MM 12MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-012,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"AETNA [10100]","Aetna HMO/PPO",,3765.99,79.5,,10981.53,8986.79,12413.38,12,550.92,4026.54,"percent of total billed charges",
"STENT PALMAZ GENESIS AVIATOR FLEXSEGMENT 17MM 135CM 5MM 20MM",SUP-H739PG1850BAX3,CDM,C1876,HCPCS,0278,RC,,,both,,,6554.03,1966.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3008.3,45.9,,,,,0,762.23,5570.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM KNEE 160MM 10MM 16MM ENDO-MODEL-M CONICAL TILASTAN",SUP-15-2952/06,CDM,C1776,HCPCS,0278,RC,,,both,,,17756.24,5326.87,"PHCS [10601]",PHCS,,12429.37,70,,,,,0,2065.05,15092.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +16.5 DIOPTER BICONVEX 13MM 6MM POSTERIOR CHMBR",SUP-CC60WF.165,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 35MM 3.5MM VERTEX SELECT PRECUT",SUP-7753735,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 2.5CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR050202A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"PHCS [10601]",PHCS,,13132.98,70,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XACT 30MM 6-8MM TAPER VASCULAR NITINOL CAROTID ARTERY",SUP-82091-01,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1109.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 110MM 16MM STAINLESS STEEL FEMUR CANNULATED",SUP-208.910,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,630.85,45.9,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 28MM 145CM 3MM CORONARY STENT",SUP-1145300-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1670.84,28.62,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER ACCUMAX 365UM HOLMIUM POLISH OUTPUT TIP NONTAPER",SUP-M0068404022,CDM,S27200284,LOCAL,0272,RC,,,both,,,2258.15,677.44,"CIGNA [10200]","Cigna Local Plus",,1208.11,53.5,,,,,0,262.62,1919.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEPHRSTMY 10FR 21GA INTRO CATH CUFF GWIRE CONNECT TUBE",SUP-M001281660,CDM,C1729,HCPCS,0272,RC,,,both,,,1296.00,388.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GW SUPPORTRAK VASC 80CM LVL 1",SUP-6683,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"NOVANET [10819]",Novanet,,850.5,75,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRD SURGICAL GRAFT",SUP-AR-19007GS,CDM,S27200284,LOCAL,0272,RC,,,both,,,2953.13,885.94,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,349.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,343.45,2510.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3.5MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN03510,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"NOVANET [10819]",Novanet,,7757.33,75,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CANTATA 135CM 2.8FR .025IN MICRO INTERVENTIONAL",SUP-G54535,CDM,S27200284,LOCAL,0272,RC,,,both,,,3142.43,942.73,"KAISER [10500]",Kaiser,,2105.43,67,,,,,0,365.46,2671.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 15MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-104150,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"BLUE CROSS [10001]","Blue Cross PPO",,9487.71,39.2,,3949.44,3949.44,3949.44,"1 through 10",2814.85,20572.84,"percent of total billed charges",
"RELOAD STPLR 30MMX2.5MM PROXIMATE TX TITANIUM VASCULAR",SUP-XR30V,CDM,S27200284,LOCAL,0272,RC,,,both,,,964.78,289.43,"MULTIPLAN [10600]",Multiplan,,820.06,85,,,,,0,112.2,820.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUE FLOW 110CM 3.5CM 26MM 16FR PERFUSION BALLOON",SUP-TF0263516,CDM,C1725,HCPCS,0272,RC,,,both,,,11730.00,3519,"MULTIPLAN [10600]",Multiplan,,9970.5,85,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 300CM 3CM",SUP-1020011,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla I Typing 1 Allele Hr",PX-309000090,CDM,81381,CPT,0310,RC,,,both,,,1057.35,317.2,"MULTIPLAN [10600]",Multiplan,,898.75,85,,,,,0,46.99,898.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION",RX-11565,CDM,J3260,HCPCS,0636,RC,39822-0412-06,NDC,both,1,UN,471.91,141.57,"CIGNA [10200]",Cigna,,83.36,,,,,,,36.47,401.12,"fee schedule",
"HC Aquaporin-4 Antb Elisa",PX-302000250,CDM,86051,CPT,0302,RC,,,both,,,791.00,237.3,"UHC [10700]","United Healthcare",,10.38,,,,,,,0.01,672.35,"fee schedule",
"HC Lipase",PX-301000298,CDM,83690,CPT,0301,RC,,,both,,,256.11,76.83,"PHCS [10601]",PHCS,,179.28,70,,,,,0,0.26,217.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL SOFT TISSUE 4X1X1CM MOIST TOUGH FLEXIBLE SHEET",SUP-89223,CDM,C1763,HCPCS,0278,RC,,,both,,,2692.80,807.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,313.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,313.17,2288.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Cardiopleg Retrograde 14",PX-E27200358,CDM,E27200358,LOCAL,0272,RC,,,both,,,437.80,131.34,"NOVANET [10819]",Novanet,,328.35,75,,,,,0,50.92,372.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFEPIME 2 G VIAL IV PUSH",RX-408309,CDM,J0692,HCPCS,0636,RC,44567-0241-10,NDC,both,1,UN,88.79,26.64,"MULTIPLAN [10600]",Multiplan,,75.47,85,,,,,0,5.69,75.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echovirus Abs",PX-302000124,CDM,86658,CPT,0302,RC,,,both,,,77.00,23.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,46.24,,,,,,,0.01,65.45,"fee schedule",
"CATH TEMPTIP APD 25CM 14FR DRNG FLEXIMA METAL POLYURETHANE",SUP-M001281390,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Anal Tag or Papilla Mult",PX-750000156,CDM,46230,CPT,0750,RC,,,both,,,7693.27,2307.98,"UHC [10700]","United Healthcare",,3833,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,894.73,6539.28,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL GOLD 75MM 12.5MM EXPERT SPIRAL",SUP-04.013.047S,CDM,C1713,HCPCS,0278,RC,,,both,,,3676.05,1102.81,"CIGNA [10200]","Cigna Open Access",,2091.67,56.9,,1144.80,304.56,2275.09,66,427.52,3124.64,"percent of total billed charges",
"HC Angio Pulm Uni Sel Si",PX-323000021,CDM,75741,CPT,0323,RC,,,both,,,5688.05,1706.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,661.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,110.82,5688.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 15FTX2IN WRIST WRINKLE FREE STRETCH PAD",SUP-OG-2L2,CDM,S27000186,LOCAL,0270,RC,,,both,,,317.20,95.16,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,36.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.89,269.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Brain Scan Static <4v",PX-341000058,CDM,78600,CPT,0341,RC,,,both,,,1166.52,349.96,"KAISER [10500]",Kaiser,,781.57,67,,,,,0,1.17,991.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 240CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRM-240,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,650.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",637.96,4662.68,"percent of total billed charges",
"22MM X 45MM X 15MM 12 LLIF CAGE POROUS COATED",SUP-P12245-215,CDM,S27800098,LOCAL,0278,RC,,,both,,,25200.00,7560,"UHC [10700]","United Healthcare",,15951.6,63.3,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lso Flex Surg Support",PX-E27400071,CDM,L0628,HCPCS,0274,RC,,,both,,,575.30,172.59,"CIGNA [10200]","Cigna Open Access",,327.35,56.9,,,,,0,52.83,489.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cftr Gene Intron Poly T",PX-309000019,CDM,81224,CPT,0310,RC,,,both,,,627.00,188.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,485.22,,,,,,,0.63,532.95,"fee schedule",
"HC Av Grft W Stent Central",PX-361000441,CDM,36908,CPT,0361,RC,,,both,,,31048.56,9314.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1249,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1249,26391.28,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cellular Function W/Stim",PX-302000076,CDM,86352,CPT,0302,RC,,,both,,,1484.85,445.45,"AETNA [10100]","Aetna HMO/PPO",,1180.46,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1262.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 82MM 13MM 14FR ENDURANT II ABDOMEN AORTA",SUP-ETEW1313C82E,CDM,S27800098,LOCAL,0278,RC,,,both,,,28331.10,8499.33,"CIGNA [10200]","Cigna Open Access",,9490.92,33.5,,,,,0,3294.91,24081.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"F/G WINGSPAN STENT SYSTEM  4.0 X 20MM",SUP-M003WS0400200,CDM,C1874,HCPCS,0278,RC,,,both,,,51979.47,15593.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6159.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6045.21,44182.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inf Nuc Acid Virus 3-5 Targets",PX-306000199,CDM,87631,CPT,0306,RC,,,both,,,269.00,80.7,"CIGNA [10200]","Cigna Open Access",,269,,,,,,,0.01,269,"fee schedule",
"HC Egd W Dil Schatzki Ring W Bx Forceps",PX-750000241,CDM,43499,CPT,0750,RC,,,both,,,5311.00,1593.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5311,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,617.67,5311,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 7FR 3MM 240CM BRISTLE STERILE DISPOSABLE RED",SUP-G22108,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"NOVANET [10819]",Novanet,,137.03,75,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE TOTAL POROUS HA CONCELOC",SUP-71704614,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"BLUE CROSS [10001]","Blue Cross PPO",,9137.52,39.2,,3949.44,3949.44,3949.44,"1 through 10",2710.95,19813.5,"percent of total billed charges",
"GRAFT SOFT TISSUE 2X1.5IN AMNIOGRAFT B THK50-100UM AMNIOTIC",SUP-AG-2015,CDM,V2790,HCPCS,0278,RC,,,both,,,5589.00,1676.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1599.57,28.62,,,,,0,650,4750.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)MARKER SKIN GREEN 5CM SOFT TISSUE DELIVERY SYSTEM STER",SUP-SMARTCLIPLT-GRN-5,CDM,A4648,HCPCS,0278,RC,,,both,,,2700.00,810,"BLUE CROSS [10001]","Blue Cross HMO",,1058.4,39.2,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASC HEMA PLATINUM 26X30",SUP-175426P,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chromo Brkg 100 Cells",PX-311000033,CDM,88248,CPT,0311,RC,,,both,,,1763.00,528.9,"BLUE CROSS [10001]","Blue Cross PPO",,221.24,,"Fee schedule rate ($221.24).",,,,0,0.01,1498.55,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION",RX-109034,CDM,J0706,HCPCS,0636,RC,25021-0601-03,NDC,both,3,ML,181.20,54.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,16.92,,,,,,,16.92,154.02,"fee schedule",
"IOPAMIDOL 300 MG IODINE/ML (61 %) INTRATHECAL SOLUTION",RX-10327,CDM,Q9967,HCPCS,0255,RC,00270-1412-15,NDC,both,15,ML,225.00,67.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",29.09,29.09,29.09,15,26.17,191.25,"percent of total billed charges",
"HC Xr Ankle 1v",PX-320000192,CDM,73600,CPT,0320,RC,,,both,,,598.76,179.63,"CIGNA [10200]","Cigna Open Access",,54.12,,,,,,,38.7,508.95,"fee schedule",
"CLINDAMYCIN 150 MG/ML INJECTION SOLUTION",RX-82303,CDM,J0736,HCPCS,0636,RC,25021-0115-04,NDC,both,4,ML,36.54,10.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,24.85,68,,,,,0,4.27,31.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Test Prsmv Chem Anlyzr",PX-301000548,CDM,80307,CPT,0301,RC,,,both,,,474.83,142.45,"CIGNA [10200]","Cigna Open Access",,136.71,,,,,,,0.01,403.61,"fee schedule",
"DEVICE TOGGLELOC ZIPLOOP XL FIXATION",SUP-110005089,CDM,C1713,HCPCS,0278,RC,,,both,,,3864.00,1159.2,"CIGNA [10200]","Cigna Open Access",,2198.62,56.9,,1144.80,304.56,2275.09,66,449.38,3284.4,"percent of total billed charges",
"INSRT TIBIAL 7 9MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530-G-709,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3996.79,45.9,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Critical Care Add 30min Wproc",PX-450000324,CDM,99292,CPT,0450,RC,,,both,,,3116.00,934.8,"CIGNA [10200]","Cigna Open Access",,1534,,,,,,,559.4,2648.6,"case rate",
"GRAFT VASCULAR 80CM 6MM STRAIGHT FUSION BIOLINE POLYESTER 2",SUP-M00201503086B0,CDM,C1768,HCPCS,0278,RC,,,both,,,16537.92,4961.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6615.17,40,,,,,0,1923.36,14057.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 80MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.880,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",27.52,201.14,"percent of total billed charges",
"CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK",RX-9627,CDM,J0736,HCPCS,0636,RC,00781-3290-91,NDC,both,50,ML,114.16,34.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6.4,,,,,,,6.4,97.04,"fee schedule",
"SUT POLYSORB SURGIWIP 0 ST-4 48IN BRAID COATED VIOLET",SUP-ELW-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,173.04,51.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ENDOSCOPIC 6.5MM 90MM DRI-LOK DISTAL THREAD STERILE",SUP-3910090800,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT FRCP OLSEN DISPOSABLE",SUP-20-1415KI,CDM,S27200284,LOCAL,0272,RC,,,both,,,404.70,121.41,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMERGE MONORAIL 144CM 8MM 6FR 3.25MM .07IN BALLOON",SUP-H7493918908320,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHIBOND EXCEL 2-0 SH 30IN 2 ARM BRAID 10 STRAND SOFT",SUP-SXP76N,CDM,S27200284,LOCAL,0272,RC,,,both,,,586.26,175.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE TRACH 3.5MM 40MM 5.4MM SHILEY PEDIATRIC UNCUFF TAPE TIE",SUP-3.5PEF,CDM,S27200284,LOCAL,0272,RC,,,both,,,395.85,118.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VERSACROSS CONNECT LAAC 230P D0",SUP-VXAK0105,CDM,S27200284,LOCAL,0272,RC,,,both,,,6969.00,2090.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC",718,MS-DRG,,,,,,,inpatient,,,45243.20,13572.96,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 12X4IN ABSORBENT SELF ADHERENT SHOWER PROOF",SUP-395990,CDM,S27200284,LOCAL,0272,RC,,,both,,,225.59,67.68,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC",373,MS-DRG,,,,,,,inpatient,,,31337.66,9401.3,"UHC [10700]","United Healthcare",,18140.63,,"Fee schedule rate ($18,140.63). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,4512.11,18140.63,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLYFLEX 60MM 11MM 18MM AIRWAY POLYESTER SILICONE SELF",SUP-7023,CDM,C1887,HCPCS,0272,RC,,,both,,,3337.50,1001.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,395.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,388.15,2836.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pad Level Sensor Sarns",PX-E27200270,CDM,E27200270,LOCAL,0272,RC,,,both,,,53.22,15.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,24.43,45.9,,,,,0,6.19,45.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM BONE CEMENT NOZZLE HUMERAL",SUP-0206509000,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.71,37.41,"CIGNA [10200]","Cigna Local Plus",,66.72,53.5,,,,,0,14.5,106,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 20CM 6FR .038",SUP-M006192130120,CDM,C2617,HCPCS,0278,RC,,,both,,,1528.96,458.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,701.79,45.9,,,,,0,177.82,1299.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 20CM 6FR .038",SUP-M006192130120,CDM,C2617,HCPCS,0278,RC,,,both,,,1528.96,458.69,"CIGNA [10200]","Cigna Local Plus",,817.99,,,,,,,177.82,1299.62,"percent of total billed charges",
"STENT CONTOUR ZIPWIRE 30CM 150CM 7FR .038IN STD PIGTAIL",SUP-M006180235170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"NOVANET [10819]",Novanet,,949.04,75,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN SX ENDO HEPARIN 35 RO 11MMX10CM 10FR 120CMCATH",SUP-VBHR111002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"MULTIPLAN [10600]",Multiplan,,18078.48,85,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH SILVERHAWK 4.5CM 8FR ENDOSCOPIC KINK RESISTANT",SUP-P9104,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"NOVANET [10819]",Novanet,,334.13,75,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ENVOY 95CM 6FR MPD CURVE GUIDING DISTAL ACCESS",SUP-67125895D,CDM,C1887,HCPCS,0272,RC,,,both,,,5198.32,1559.5,"UHC [10700]","United Healthcare",,3290.54,63.3,,,,,0,604.56,4418.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REPAGLINIDE 0.5 MG TABLET",RX-22584,CDM,,,0637,RC,65862-0670-01,NDC,both,1,UN,16.75,5.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.95,14.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL TAPERCUT 5-0 V-5 30IN 2 ARM BRAID GREEN",SUP-X934H,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.71,18.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,42.64,68,,,,,0,7.29,53.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUMP INTRACARDIAC SUCTION 15IN 20FR DLP .25IN PERICARDIAL",SUP-12010,CDM,S27200284,LOCAL,0272,RC,,,both,,,126.52,37.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.71,107.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL E-R RIGHT KNEE OPTION LPS-FLEX GSF STERILE",SUP-00576401552,CDM,C1776,HCPCS,0278,RC,,,both,,,16934.40,5080.32,"BLUE CROSS [10001]","Blue Cross PPO",,6638.28,39.2,,3949.44,3949.44,3949.44,"1 through 10",1969.47,14394.24,"percent of total billed charges",
"CABLE CATH YELLOW 152.4CM 6FR POLARIS X CABLE DECAPOLAR",SUP-M0045454S0,CDM,S27200284,LOCAL,0272,RC,,,both,,,2196.75,659.02,"AETNA [10100]","Aetna HMO/PPO",,1746.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,255.48,1867.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 30CM 3CM 5FR .035IN",SUP-M006192125190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"NOVANET [10819]",Novanet,,1046.42,75,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT PL SITEMARK 58CM 54CM 9FR 7FR 135D GUIDING",SUP-410183,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,431.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 5FR 21GA MERIT MAK .018IN STAINLESS STEEL",SUP-MAK501-PED,CDM,C1894,HCPCS,0272,RC,,,both,,,197.06,59.12,"PHCS [10601]",PHCS,,137.94,70,,,,,0,22.92,167.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 4.00 X 24MM",SUP-H7493942824400,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRT-D DTBA1D1 VIVA XT IS1/DF1 US",SUP-DTBA1D1,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CIGNA [10200]",Cigna,,23088,40,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-207.040,CDM,C1713,HCPCS,0278,RC,,,both,,,280.05,84.01,"NOVANET [10819]",Novanet,,210.04,75,,,,,0,32.57,238.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMUR HEAD FREEZE DRIED PROXIMAL",SUP-24A001,CDM,S27800098,LOCAL,0278,RC,,,both,,,5733.90,1720.17,"KAISER [10500]",Kaiser,,3841.71,67,,,,,0,666.85,4873.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 20CM 7FR 2.1FR POLARIS ULTRA NAUTILUS ZIPWIRE .038",SUP-M006192140170,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"KAISER [10500]",Kaiser,,934.8,67,,,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRAILBLAZER 65CM .056IN 50MM ANGLE SPRT STAINLESS STEEL",SUP-ASC-035-065,CDM,C1887,HCPCS,0272,RC,,,both,,,1377.00,413.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,163.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 0 8IN EPSTEIN SPINE SURGICAL",SUP-57-4622,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.74,104.92,"CIGNA [10200]",Cigna,,237.82,68,,,,,0,40.67,297.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 6FR L24CM FIRM TRI LAYER DESIGN RAW COLORANT",SUP-M0061902220,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 24CM 3CM 5FR .035IN STRAIGHT URETERAL",SUP-M006155222050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS [10001]","Blue Cross HMO",,482.54,39.2,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VEIN DISTENTION GRAFT TUNNELING",SUP-26050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1278.75,383.62,"CIGNA [10200]","Cigna Open Access",,727.61,56.9,,,,,0,148.72,1086.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RAMROD QUADRA-COIL 22-28CM 6FR KIDNEY BLADDER CURL",SUP-5001960,CDM,C2617,HCPCS,0278,RC,,,both,,,721.79,216.54,"FIRST HEALTH [10303]","First Health",,577.43,80,,,,,0,83.94,613.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 39MM 135CM 8MM 11MM 7FR .035IN",SUP-BXA083902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2268.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 80MM 5MM BALLOON DILATATION OTW NONCOMPLIANT",SUP-H74939206050870,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIV WITH MAJOR RELATED CONDITION WITH CC",975,MS-DRG,,,,,,,inpatient,,,47370.52,14211.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,25707.05,,"Fee schedule rate ($25,707.05). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,32296.01,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 22CM 7FR .038IN STRAIGHT URETERAL PERCUFLEX",SUP-M006180231010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"FIRST HEALTH [10303]","First Health",,856.59,80,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 286CMX15MM SPYGLASS STERILE LATEX",SUP-M00546550,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LONG SURGICAL 8-13MM NAIL STERILE",SUP-03.043.012S,CDM,S27200284,LOCAL,0272,RC,,,both,,,800.28,240.08,"CIGNA [10200]","Cigna Open Access",,455.36,56.9,,,,,0,93.07,680.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC LARGE 7.75-8.5IN RIGHT WRIST THUMB SPICA",SUP-A6158,CDM,S27000186,LOCAL,0270,RC,,,both,,,224.55,67.36,"KAISER [10500]",Kaiser,,150.45,67,,,,,0,26.12,190.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 80MM 120CM 8MM VASCULAR PERIPHERAL SELF",SUP-PRB35-08-080-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"NOVANET [10819]",Novanet,,4173.75,75,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH DURAL 3X1IN DUREPAIR CRANIAL BOVINE CLLGN MATRIX",SUP-62106,CDM,S27800098,LOCAL,0278,RC,,,both,,,3418.95,1025.68,"CIGNA [10200]","Cigna Open Access",,1945.38,56.9,,,,,0,397.62,2906.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8MM 44MM HIP BIOLOX DELTA FMP",SUP-400-03-444,CDM,C1776,HCPCS,0278,RC,,,both,,,16953.92,5086.18,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6968.06,41.1,,6417.48,6417.48,6417.48,"1 through 10",1971.74,14410.83,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 30CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155245180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2MM 19MM FOSSA RADIUS DISTAL VOLAR SMOOTH LOCK",SUP-SPLS-20190-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,639.90,191.97,"FIRST HEALTH [10303]","First Health",,511.92,80,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 150D STD BARREL 78MM STAINLESS STEEL 8 HOLE",SUP-281.440,CDM,C1713,HCPCS,0278,RC,,,both,,,2156.11,646.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,255.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,250.76,1832.69,"percent of total billed charges",
"STENT CONTOUR BENTSON 26CM 15CM 6FR .035IN STRAIGHT URETERAL",SUP-M006180223060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"BLUE CROSS [10001]","Blue Cross PPO",,390.99,39.2,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 150CM 120MM 6MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013470-120,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UHC [10700]","United Healthcare",,794.73,63.3,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METER URINE BARD EZ-LOK INFECTION CONTROL SAMPLE PORT DRNG",SUP-153214A,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.29,19.29,"NOVANET [10819]",Novanet,,48.22,75,,,,,0,7.48,54.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER RED 7CM 2.9MM DYONICS POWERMINI SMALL JOINT",SUP-72201509,CDM,S27200284,LOCAL,0272,RC,,,both,,,2565.00,769.5,"PHCS [10601]",PHCS,,1795.5,70,,,,,0,298.31,2180.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.6MM 5MM LAMINA CERVICAL",SUP-7650705,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",155.43,1136.03,"percent of total billed charges",
"IDENTITY IMPRINT PS INSERT SIZE 4, 7MM",SUP-TPS-020-074S,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1682.51,28.62,,,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE ADPTR -2.5MM UNIVERSAL C TAPER TITANIUM",SUP-19-0325T,CDM,C1776,HCPCS,0278,RC,,,both,,,1304.10,391.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,373.23,28.62,,,,,0,151.67,1108.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 40X14-18MM",SUP-400720,CDM,S27800098,LOCAL,0278,RC,,,both,,,3978.54,1193.56,"PHCS [10601]",PHCS,,2784.98,70,,,,,0,462.7,3381.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARD 22FR URETHRAL SILICONE ELASTOMER 30CC 3 WAY 2",SUP-0167V22S,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.47,21.14,"FIRST HEALTH [10303]","First Health",,56.38,80,,,,,0,8.2,59.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 24CM 6FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001274120,CDM,C2617,HCPCS,0278,RC,,,both,,,999.00,299.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,116.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.18,849.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Iliac W Pta Cmplx Ea Add",PX-361000698,CDM,37257,CPT,0361,RC,,,both,,,7309.72,2192.92,"NOVANET [10819]",Novanet,,5482.29,75,,,,,0,7.31,7309.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM ORTHOLOC LONG CORTICAL ANKLE FOOT 3DI",SUP-58803530,CDM,C1713,HCPCS,0278,RC,,,both,,,1506.60,451.98,"CIGNA [10200]",Cigna,,1024.49,68,,1831.33,1831.33,1831.33,16,175.22,1280.61,"percent of total billed charges",
"HC Cult Tubercle Pres ID",PX-306000073,CDM,87116,CPT,0306,RC,,,both,,,464.55,139.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,55.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,394.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Ankle Trimal WO Manip",PX-450000165,CDM,27816,CPT,0450,RC,,,both,,,1347.00,404.1,"CIGNA [10200]","Cigna Local Plus",,1347,,,,,,,67.13,1347,"case rate",
"HC B Cell Total Count",PX-302000078,CDM,86355,CPT,0302,RC,,,both,,,360.05,108.01,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,35.46,,"Fee schedule rate ($35.46). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,306.04,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 12CM 1.92MM 1.5MM SONOPET IQ BARRACUDA SOFT TISSUE",SUP-5500-25S-310,CDM,S27200284,LOCAL,0272,RC,,,both,,,6794.31,2038.29,"AETNA [10100]","Aetna HMO/PPO",,5401.48,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,790.18,5775.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Strap Toes",PX-450000206,CDM,29550,CPT,0361,RC,,,both,,,748.02,224.41,"BLUE CROSS [10001]","Blue Cross HMO",,748.02,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,86.99,748.02,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 116SQ CM THERASKIN ALLOGRAFT CRYOPRESERVE",SUP-103TSXL,CDM,Q4121,HCPCS,0636,RC,,,both,,,21690.90,6507.27,"CIGNA [10200]","Cigna Open Access",,141.84,,,,,,,141.84,18437.27,"fee schedule",
"HC Hla I Typing 1 Allele Hr",PX-309000090,CDM,81381,CPT,0310,RC,,,both,,,1057.35,317.2,"PHCS [10601]",PHCS,,740.15,70,,,,,0,46.99,898.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC ACTICOR 7 HF-T QP",SUP-429522,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"NOVANET [10819]",Novanet,,57712.5,75,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 4CM 5FR 2 PIGTAIL CURVE TAPER BILIARY",SUP-G22137,CDM,C2625,HCPCS,0278,RC,,,both,,,1231.20,369.36,"NOVANET [10819]",Novanet,,923.4,75,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR .09IN LEFT CORONARY BYPASS CURVE",SUP-LA8LCBSH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"PHCS [10601]",PHCS,,255.78,70,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL BLUE 18GA 1% LIDOCAINE 0.9% SODIUM CHLORIDE",SUP-555077,CDM,C1751,HCPCS,0272,RC,,,both,,,99.26,29.78,"MULTIPLAN [10600]",Multiplan,,84.37,85,,,,,0,11.54,84.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 7-0 P-6 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8648G,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.81,21.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,8.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.47,61.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650707,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"NOVANET [10819]",Novanet,,9845.44,75,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 320110 TRICORT BLK 10MM SRVC FEE",SUP-320110,CDM,S27800098,LOCAL,0278,RC,,,both,,,3412.50,1023.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,976.66,28.62,,,,,0,396.87,2900.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM IFUSE IMPL SYSTEM 35MM 7MM SPINAL FIXATION SACROILIAC",SUP-7035M-90,CDM,C1713,HCPCS,0278,RC,,,both,,,21082.95,6324.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8665.09,41.1,,,,,0,2451.95,17920.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE COALITION AGX 7D ALLOGRAFT 10X16X6MM",SUP-8128.1476S,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 12MM 140CM 2.75MM 2.1-2.7FR CORONARY",SUP-RONYX27512UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"BLUE CROSS [10001]","Blue Cross PPO",,1323,39.2,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 8MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR081002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6087.13,28.62,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STOPPER EXTERNAL FIXATION TRUELOK RUBBER WIRE",SUP-54-1133,CDM,C1713,HCPCS,0278,RC,,,both,,,54.20,16.26,"FIRST HEALTH [10303]","First Health",,43.36,80,,,,,0,6.3,46.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP PULSED LAVAGE INTERPULSE COAXIAL FAN SPRAY HADNPIECE",SUP-0210014100,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.99,28.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 15CM 13FR POLYURETHANE POWER-TRIALYSIS 3 LUMEN",SUP-5613150,CDM,C1752,HCPCS,0272,RC,,,both,,,1321.11,396.33,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2MM 12MM ORTHOLOC TITANIUM NITRIDE FOREFOOT LOCKING",SUP-5201020012,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,200.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",200.62,1466.25,"percent of total billed charges",
"INSRT TIBIAL 5 6MM KNEE POSTERIOR STABILIZE IDENTITY IMPRINT",SUP-TPS-020-065S,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"KAISER [10500]",Kaiser,,3938.8,67,,,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 24CM 7FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G23415,CDM,C2617,HCPCS,0278,RC,,,both,,,535.41,160.62,"FIRST HEALTH [10303]","First Health",,428.33,80,,,,,0,62.27,455.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE MONORAIL 150CM 220MM 2MM BALLOON DILATATION",SUP-H74939185202210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR AVENIR COMPLETE 6.5 HIGH OFFSET HIP",SUP-574202065,CDM,C1776,HCPCS,0278,RC,,,both,,,23461.20,7038.36,"BLUE CROSS [10001]","Blue Cross HMO",,9196.79,39.2,,5311.50,4717.44,5388.59,31,2728.54,19942.02,"percent of total billed charges",
"RING ANNULOPLASTY SIZE 36 OD43MM ID36MM MITRAL VALVE SEMI RI",SUP-SARP-36,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4842.56,40,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +15.5 DIOPTER 13MM 6MM POSTERIOR CHMBR 3 PIECE",SUP-Z900200155,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"KAISER [10500]",Kaiser,,683.8,67,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ELECTROSURGICAL 8.25IN OLSEN BAYONET BIPOLAR FRCP SMOOTH",SUP-20-1440KI,CDM,S27200284,LOCAL,0272,RC,,,both,,,388.65,116.59,"CIGNA [10200]",Cigna,,264.28,68,,,,,0,45.2,330.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC LARGE 8IN WRIST LEFT 4 WAY STRETCH",SUP-351LL,CDM,S27000186,LOCAL,0270,RC,,,both,,,121.28,36.38,"FIRST HEALTH [10303]","First Health",,97.02,80,,,,,0,14.1,103.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM ARTISAN MRI",SUP-SC-8416-50,CDM,C1778,HCPCS,0278,RC,,,both,,,30240.00,9072,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12096,40,,,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC",543,MS-DRG,,,,,,,inpatient,,,27121.19,8136.36,"CIGNA [10200]","Cigna Open Access",,11281.27,,"Fee schedule rate ($11,281.27). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,6376.74,25637.29,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 125MM CEMENTLESS OFFSET ACCOLADE TMZF 132D 4 +0",SUP-6020-0435,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"CIGNA [10200]",Cigna,,6259.68,40,,5873.17,5873.17,5873.17,"1 through 10",1820,13301.82,"percent of total billed charges",
"BURR 44.5MM CARBIDE 7.9MM 4MM OVAL 8 FLUTE DENTAL",SUP-14-C0901,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.29,44.19,"CIGNA [10200]","Cigna Open Access",,83.81,56.9,,,,,0,17.13,125.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET",RX-1300,CDM,,,0637,RC,00904-1883-61,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 53CM 5.3FR J ATRIAL TRANSVENOUS BIPOLAR TINED",SUP-4592-53,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]",Cigna,,3812.76,68,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 CURVE 12.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962052,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"PHCS [10601]",PHCS,,6474.62,70,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 1MM 3MM EAR HA FRISBEE PARTIAL",SUP-749-100,CDM,L8613,HCPCS,0278,RC,,,both,,,3221.33,966.4,"AETNA [10100]","Aetna HMO/PPO",,2560.96,79.5,,,,,0,232.31,2738.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT ELECTROSURGICAL PROC SET GENESYS HTA PROCERVA",SUP-M006580211,CDM,S27200284,LOCAL,0272,RC,,,both,,,10151.28,3045.38,"CIGNA [10200]",Cigna,,6902.87,68,,,,,0,1180.59,8628.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SPINAL 5/6-6MM CD HORIZON 25MM LATERAL TOP",SUP-5564325,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PHCS [10601]",PHCS,,2493.75,70,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 STD KNEE LEFT CRUCIATE RETAIN PERSONA COCR",SUP-42502806001,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"CIGNA [10200]","Cigna Open Access",,9680.02,33.5,,5302.19,4377.88,6578.61,27,3360.56,24561.24,"percent of total billed charges",
"ROD SPINAL 190MM 5.5MM RELINE STRAIGHT TITANIUM MAS",SUP-12355190,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"SCR BONE 60MM 5MM NAIL-EX FULL THREAD FEMORAL TIBIAL",SUP-04.005.550,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"MULTIPLAN [10600]",Multiplan,,983.18,85,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 18MM 40MM SHOULDER SOFT TISSUE BALANCE",SUP-7122878,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,921.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 3CM 170CM 5FR CONTOUR PANCREATIC POLYETHYLENE",SUP-G22206,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,506.02,41.1,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE HA 25MM 11MM ACL BIOSURE",SUP-72201788,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,957.42,570.23,957.42,28,189.34,1383.8,"percent of total billed charges",
"SHOE POSTOPERATIVE 8.5-10 7.5-9 MEDIUM FEMALE MALE SQUARED",SUP-79-81235,CDM,S27000186,LOCAL,0270,RC,,,both,,,53.07,15.92,"FIRST HEALTH [10303]","First Health",,42.46,80,,,,,0,6.17,45.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM SPINAL POLYAXIAL",SUP-8456545,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA [10200]","Cigna Open Access",,2755.44,56.9,,1144.80,304.56,2275.09,66,563.19,4116.21,"percent of total billed charges",
"RELOAD SUT ASSISTANT 0 ES-9 48IN COATED ENDO STITCH BRALON",SUP-170012,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 90X25MM THK1.27MM STAINLESS STEEL SAGITTAL 2 CUT",SUP-4125127090,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.02,114.61,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMERGE MONORAIL 144CM 15MM 6FR 3.25MM .07IN BALLOON",SUP-H7493918915320,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 150CM 100MM 2.5MM BALLOON DILATATION OTW STERILE",SUP-47025100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 150CM 100MM 2MM BALLOON DILATATION DURALYN",SUP-48002010X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TREVO NXT 3X32+PRO14 2-PACK - US",SUP-91316,CDM,S27200284,LOCAL,0272,RC,,,both,,,24624.97,7387.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"AUG FEMORAL 5MM TRIATHLON 2 POSTERIOR KNEE TOTAL STABILIZED",SUP-5543-A-200,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3244.27,68,,,,,0,554.87,4055.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 16MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-516-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]","Cigna Local Plus",,6105.74,53.5,,5372.07,4581.20,7242.98,23,1327.29,9700.71,"percent of total billed charges",
"CMPNT FEMORAL 4 KNEE LEFT CONSTRAIN LEGION OXINIUM",SUP-71421164,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"CIGNA [10200]","Cigna Local Plus",,18217.71,31.5,,5372.07,4581.20,7242.98,23,6726.09,49158.9,"percent of total billed charges",
"TRAY CATHETERIZATION COMPLETE CARE BARDEX IC STATLOCK",SUP-301216A,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.57,83.57,"NOVANET [10819]",Novanet,,208.93,75,,,,,0,32.4,236.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 16MM 144CM 5MM CORONARY STENT",SUP-H7493941816500,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE 1X10",SUP-7509211,CDM,S27800098,LOCAL,0278,RC,,,both,,,12696.00,3808.8,"BLUE CROSS [10001]","Blue Cross HMO",,4976.83,39.2,,,,,0,1476.54,10791.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 30CM 14FR TUNGSTEN SILICONE 2.7CM MIC-KEY",SUP-0270-14-2.7-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,3027.60,908.28,"MULTIPLAN [10600]",Multiplan,,2573.46,85,,,,,0,352.11,2573.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ENVOY XB BRITE TIP 100CM 6FR .07IN STRAIGHT GUIDING",SUP-67026000B,CDM,C1887,HCPCS,0272,RC,,,both,,,3390.23,1017.07,"NOVANET [10819]",Novanet,,2542.67,75,,,,,0,394.28,2881.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KT PG 20FR XLCN SIL PUL METH",SUP-6646,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 46MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.746,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,130.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",130.68,955.09,"percent of total billed charges",
"HANDLE LARYNSCP BRITEPRO SOLO MILLER 1 METAL BLADE OVERMOULD",SUP-040-341U,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.63,21.79,"AETNA [10100]","Aetna HMO/PPO",,57.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.45,61.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 7.5FR VENTRICLE CS SVC COIL TRANSVENE",SUP-6937A-58,CDM,C1896,HCPCS,0278,RC,,,both,,,6900.00,2070,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP 3 HOLE POLY POROUS R3 STD STERILE",SUP-71335556,CDM,C1776,HCPCS,0278,RC,,,both,,,14386.50,4315.95,"CIGNA [10200]","Cigna Local Plus",,4531.75,31.5,,5372.07,4581.20,7242.98,23,1673.15,12228.53,"percent of total billed charges",
"SHOCKWAVE C2+ IVL CATHETER 4.0X12 MM",SUP-C2PIVL4012,CDM,C1761,HCPCS,0272,RC,,,both,,,29610.00,8883,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3508.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 120MM 125CM 7MM 6FR BILIARY NITINOL",SUP-G50169,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,721.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIOMESSENGER SMART",SUP-64765319,CDM,S27000186,LOCAL,0270,RC,,,both,,,6210.00,1863,"NOVANET [10819]",Novanet,,4657.5,75,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR AL2 CURVE GUIDING CORONARY",SUP-LA8AL20D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE MONORAIL 150CM 220MM 4MM BALLOON DILATATION",SUP-H74939185402210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GARM COMPRESSION 50-60HZ 25VA LARGE UNIVERSAL CALF VELCRO",SUP-DVT20,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.58,33.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,46.27,41.1,,,,,0,6.55,95.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ICAST STENT DIAMETER 5X 16MM CATH 120CM ENDOVASCULAR",SUP-42516,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTHER BONE 7.9MM CRUCIAL TOOL GORE SMOOTHER STERILE",SUP-014723,CDM,S27200284,LOCAL,0272,RC,,,both,,,2354.63,706.39,"MULTIPLAN [10600]",Multiplan,,2001.44,85,,,,,0,273.84,2001.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 51MM 4MM MEDIUM CARBIDE ROUND 8 FLUTED STERILE",SUP-04-C0108,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.66,29,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,39.73,41.1,,,,,0,11.24,82.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 39MM TRUNION ARTHREX ECLIPSE",SUP-AR-9301-39CPC,CDM,C1776,HCPCS,0278,RC,,,both,,,9239.10,2771.73,"AETNA [10100]","Aetna HMO/PPO",,7345.08,79.5,,10981.53,8986.79,12413.38,12,1074.51,7853.24,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 18MM 140CM 2MM CORONARY STENT BIOLINX",SUP-RONYX20018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"MULTIPLAN [10600]",Multiplan,,3028.13,85,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 30MM ORTHOLOC TITANIUM CORTICAL NONLOCK",SUP-59224530,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"NOVANET [10819]",Novanet,,747.23,75,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING G7 -3MM OFFSET TAPER HIP TITANIUM TYPE 1",SUP-650-1065,CDM,C1776,HCPCS,0278,RC,,,both,,,1539.00,461.7,"CIGNA [10200]","Cigna Open Access",,875.69,56.9,,5302.19,4377.88,6578.61,27,178.99,1308.15,"percent of total billed charges",
"STENT ONYX FRONTIER 22MM 3.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG35022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,314.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 3.5MM PRECUT",SUP-3603760,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"IMPL BREAST 475CC P5.4CM HIGH PROFILE ROUND TEXTURE",SUP-354-4475,CDM,C1789,HCPCS,0278,RC,,,both,,,4823.10,1446.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,571.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,560.93,4099.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 80MM 17MM FINNED CEMENTLESS SMR TITANIUM",SUP-1304.15.170,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"NOVANET [10819]",Novanet,,5940,75,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 8.5FR 18GA 16CM ARROWG+ARD BLUE PLUS BLUE FLEXTIP",SUP-CDC-42854-P1A,CDM,C1751,HCPCS,0272,RC,,,both,,,1062.72,318.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,125.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,123.59,903.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC IPERIA 7 PROMRI DF4 IMPLANTABLE",SUP-393009,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6712.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFTTOUCH",SUP-SSM-140,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 100MM 2.5MM BALLOON DILATATION PEBAX",SUP-H74939148251010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING HME FILTER MASK BAG SAMPLE ELBOW PORT 70IN",SUP-NCF375-6121Z,CDM,S27000186,LOCAL,0270,RC,,,both,,,88.04,26.41,"UHC [10700]","United Healthcare",,55.73,63.3,,,,,0,10.24,74.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00200,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"NOVANET [10819]",Novanet,,820.13,75,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 60MM 12MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-151312060,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,961.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,961.36,7026.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 50MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.486,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"CIGNA [10200]",Cigna,,3292.97,68,,1831.33,1831.33,1831.33,16,563.19,4116.21,"percent of total billed charges",
"CATH EXPO 125CM 5FR .045IN MPA2 CURVE ANGIOGRAPHIC",SUP-8526122,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"FIRST HEALTH [10303]","First Health",,61.26,80,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE, 2.1MM REUSABLE",SUP-SSB-222-0,CDM,S27200284,LOCAL,0272,RC,,,both,,,7590.00,2277,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3119.49,41.1,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL COBLATOR REFLEX ULTRA 45 WAND",SUP-EICA4845-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,2001.00,600.3,"AETNA [10100]","Aetna HMO/PPO",,1590.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,232.72,1700.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE SYNTHETIC 4.8MM OSTEOSET CALCIUM SULFATE PELLET 10ML",SUP-84000102,CDM,C1713,HCPCS,0278,RC,,,both,,,3339.00,1001.7,"AETNA [10100]","Aetna HMO/PPO",,2654.51,79.5,,1521.93,481.35,16760.95,30,388.33,2838.15,"percent of total billed charges",
"SYSTEM FIBERLOCK INTERNAL FIXATION FIBERLOCK SUSPENSION",SUP-AR-8988-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,11555.78,3466.73,"PHCS [10601]",PHCS,,8089.05,70,,,,,0,1343.94,9822.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 5% DEXTROSE EXCEL 1L LATEX FREE",SUP-L5100,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 25KHZ UNIVERSAL STRAIGHT SONOPET DISPOSABLE",SUP-5450800307,CDM,S27200284,LOCAL,0272,RC,,,both,,,4262.78,1278.83,"MULTIPLAN [10600]",Multiplan,,3623.36,85,,,,,0,495.76,3623.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 20X20MM FORTIFY 0D 20MM FOOTPRINT LOWER",SUP-151.451,CDM,S27800098,LOCAL,0278,RC,,,both,,,3172.50,951.75,"CIGNA [10200]","Cigna Local Plus",,1697.29,53.5,,,,,0,368.96,2696.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE ELECTROSURGICAL ENPOWER CONTROL CABLE DETACHMENT",SUP-ECB00018200,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"PHCS [10601]",PHCS,,1260,70,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 18FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0196L18,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.32,32.5,"MULTIPLAN [10600]",Multiplan,,92.07,85,,,,,0,12.6,92.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 6MM 8MM 7FR .035IN",SUP-BXA067901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2489.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFTS FOR INJURIES WITH CC/MCC",904,MS-DRG,,,,,,,inpatient,,,175649.32,52694.8,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,48986.61,,"Case rate ($22,784.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $21,156.92, add-ons for qualifying new technology services are included. If operating cost exceeds $54,196.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,981.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $21,184.90. The transfer operating threshold is the transfer adjustment factor * $21,156.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,599.57. The transfer capital threshold is the transfer adjustment factor * $1,599.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,107239.83,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 1.6MM TWIST STERILE",SUP-KM166-00-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.04,24.01,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.9,41.1,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X10MM COROENT 10D XL+ WIDE PEEK NONSTERILE",SUP-6310250,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Open Access",,8019.9,33.5,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1 X 4 COMPLEX PICO COIL",SUP-10USC01004,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"CIGNA [10200]",Cigna,,5230.2,40,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOBRAMYCIN 0.3 % EYE DROPS",RX-7995,CDM,,,0250,RC,70069-0131-01,NDC,both,5,ML,80.00,24,"KAISER [10500]",Kaiser,,53.6,67,,,,,0,9.3,68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX SAFE PERFORMAXX 20MM 80CM 8MM 6FR .035IN",SUP-ZBM08020,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"PHCS [10601]",PHCS,,7003.5,70,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP MEDICINE 14OZ IODINE 4 3/8IN 2IN",SUP-14G,CDM,S27000186,LOCAL,0270,RC,,,both,,,128.24,38.47,"FIRST HEALTH [10303]","First Health",,102.59,80,,,,,0,14.91,109,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXTOME 142CM 10MM 2.25MM BALLOON DILATATION NYLON",SUP-H749CBM3225100,CDM,C1725,HCPCS,0272,RC,,,both,,,5395.80,1618.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,639.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,627.53,4586.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER MOSES 80HZ 120W 6J 550UM D/F/L LITHOTRIPSY",SUP-AC-10030120,CDM,S27200284,LOCAL,0272,RC,,,both,,,3759.05,1127.71,"KAISER [10500]",Kaiser,,2518.56,67,,,,,0,437.18,3195.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 10CM 8MM BALLOON DILATATION 2 LUMEN",SUP-G52282,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 21MM 54MM SOFT TISSUE BALANCE AEQUALIS ASCEND",SUP-DWG055,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"KAISER [10500]",Kaiser,,5306.4,67,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 12X6CM REPLIFORM PELVIC FLOOR ACELLULAR DERMAL",SUP-M0068202460,CDM,C1762,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +12.5 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.125,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ALLOGRAFT BLOCK 6MM",SUP-320106,CDM,S27800098,LOCAL,0278,RC,,,both,,,3412.50,1023.75,"CIGNA [10200]","Cigna Local Plus",,1825.69,53.5,,,,,0,396.87,2900.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.8MM 200MM 30MM LCP ANKLE COMPRESSION THREAD",SUP-03.118.030,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM .02IN 8MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0840,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.00,2003.4,"BLUE CROSS [10001]","Blue Cross HMO",,2617.78,39.2,,,,,0,776.65,5676.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE 15CC DEMINERALIZED CORTICAL PUREBONE FIBE",SUP-PBF-15,CDM,S27800098,LOCAL,0278,RC,,,both,,,9984.30,2995.29,"BLUE CROSS [10001]","Blue Cross HMO",,3913.85,39.2,,,,,0,1161.17,8486.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT SHOULDER TOTAL",SUP-98000971500,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"PHCS [10601]",PHCS,,18742.5,70,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 28CM 150CM 8FR .035IN 3CM BLADDER LOOP",SUP-M006155254190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,406.5,28.62,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 160CM 2.8-3.2FR .027IN MARKSMAN",SUP-FA-55160-1030,CDM,S27200284,LOCAL,0272,RC,,,both,,,7741.80,2322.54,"NOVANET [10819]",Novanet,,5806.35,75,,,,,0,900.37,6580.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.25CM NATRELLE INSPIRA P3.5CM LOW PLUS PROFILE",SUP-MSZ-LP340,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"KAISER [10500]",Kaiser,,105.98,67,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 2-0 GS-22 9IN CLSR ABSORBABLE VIOLET",SUP-VLOCM2145,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"CIGNA [10200]","Cigna Open Access",,111.43,56.9,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 18LP 80CM 6CM 4FR 6MM .018IN BALLOON DILATATION",SUP-G50248,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASPIRA HOME DRAINAGE SYSTEM ASPIRA REPAIR KIT",SUP-4992306,CDM,S27200284,LOCAL,0272,RC,,,both,,,426.30,127.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,175.21,41.1,,,,,0,49.58,362.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 70MM STAINLESS STEEL 2.4MM SCR 7X4 HOLE 2 COLUMN",SUP-02.111.740,CDM,C1713,HCPCS,0278,RC,,,both,,,4046.85,1214.05,"KAISER [10500]",Kaiser,,2711.39,67,,,,,0,470.65,3439.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25X9MM TPS PRECISION MEDIUM OSCILLATING SAGITTAL",SUP-2296003111,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.45,67.03,"MULTIPLAN [10600]",Multiplan,,189.93,85,,,,,0,25.99,189.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.00 X 18 RX US",SUP-1804300-18,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE DRILL 1.8MM 2MM SPYROMITE MINITAC SUT ANCHOR",SUP-72202040,CDM,S27200284,LOCAL,0272,RC,,,both,,,680.40,204.12,"MULTIPLAN [10600]",Multiplan,,578.34,85,,,,,0,79.13,578.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM TITANIUM T25 SELF TAP LOCK STARDRIVE",SUP-412.219S,CDM,C1713,HCPCS,0278,RC,,,both,,,1220.18,366.05,"BLUE CROSS [10001]","Blue Cross PPO",,478.31,39.2,,957.42,570.23,957.42,28,141.91,1037.15,"percent of total billed charges",
"ROD SPINAL 120MM 4MM LORDOSIS TITANIUM",SUP-102064120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,inpatient,,,303597.46,91079.24,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,38099.15,,"Case rate ($36,989.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $34,347.23, add-ons for qualifying new technology services are included. If operating cost exceeds $67,386.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,978.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $34,392.65. The transfer operating threshold is the transfer adjustment factor * $34,347.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,596.82. The transfer capital threshold is the transfer adjustment factor * $2,596.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,174098.67,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.9H 40MM 2 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009240,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,957.42,156.86,7483.26,51,521.61,3812.25,"percent of total billed charges",
"JOINT FINGER SWANSON 4 METACARPOPHALANGEAL GROMMET HIGH",SUP-G4700004,CDM,C1776,HCPCS,0278,RC,,,both,,,4170.60,1251.18,"BLUE CROSS [10001]","Blue Cross HMO",,1634.88,39.2,,5311.50,4717.44,5388.59,31,485.04,3545.01,"percent of total billed charges",
"SPACER ALLOGRAFT 12.5X15X12MM ADVANCED LORDOTIC TRAPEZOIDAL",SUP-7712,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]",Cigna,,5630.4,68,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 100MM 125CM 9MM 6FR BILIARY",SUP-G50174,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"AETNA [10100]","Aetna HMO/PPO",,4841.55,79.5,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHIELD CONTAMINATION BLUE CATH-GARD 7-7.5FR CATH",SUP-ST-09880,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.14,31.84,"CIGNA [10200]","Cigna Open Access",,60.39,56.9,,,,,0,12.34,90.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VIPERWIRE ADVANCE VASCULAR 335CM .014IN PERIPHERAL",SUP-VPR-GW-FLEX14,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ABLATION RADIOFREQUENCY",SUP-64082,CDM,C1886,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT ADMIRAL 130CM 60MM 5MM BALLOON DILATATION",SUP-ADM05006013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"FIRST HEALTH [10303]","First Health",,6458.4,80,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 24MM 144CM 2.5MM",SUP-H7493941224250,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,919.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 4-0 PS-4 18IN MONOFILAMENT PLIABILIZE",SUP-1662G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 90MM 16MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044169070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"BLUE CROSS [10001]","Blue Cross PPO",,3381,39.2,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)DEVICE CELT ACD 5FR CLOSURE VASCULAR STERILE LATEX FRE",SUP-CLT-05,CDM,C1760,HCPCS,0278,RC,,,both,,,1611.90,483.57,"CIGNA [10200]",Cigna,,1096.09,68,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET M6 SPINE OCCIPITOCERVICAL UPPER THORACIC INFINITY",SUP-3600215,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"KAISER [10500]",Kaiser,,233.16,67,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHOCOLATE 120CM 40MM 5MM 6FR BALLOON DILATATION NITINOL",SUP-CB1812050040OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5520.00,1656,"NOVANET [10819]",Novanet,,4140,75,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 124MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 9",SUP-223.591,CDM,C1713,HCPCS,0278,RC,,,both,,,2129.40,638.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,609.43,28.62,,,,,0,247.65,1809.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL XS-XL LEFT KNEE MODULAR ROTATING HINGE",SUP-6481-2-100,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"UHC [10700]","United Healthcare",,6625.5,63.3,,8601.07,8395.67,8601.07,"1 through 10",1217.29,8896.8,"percent of total billed charges",
"LENS IOL SY60WF.185 CLAREON",SUP-SY60WF.185,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX12MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2991222,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"NOVANET [10819]",Novanet,,11923.2,75,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 CT-1 27IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCPP42D,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UHC [10700]","United Healthcare",,15.83,63.3,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM .062IN KIRSCHNER 2MM TROCAR SMOOTH 4MM",SUP-AR-8945K,CDM,C1713,HCPCS,0278,RC,,,both,,,87.00,26.1,"KAISER [10500]",Kaiser,,58.29,67,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 110CM 5FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY",SUP-F5CQF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"PHCS [10601]",PHCS,,635.04,70,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL HIP HEMIARTHROPLASTY (PARTIAL HIP CONSTRUCT)",SUP-CAP-LB-PH-1,CDM,C1776,HCPCS,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]",Cigna,,4692,68,,5873.17,5873.17,5873.17,"1 through 10",802.47,5865,"percent of total billed charges",
"STENT COMPLETE SE 100MM 5MM BILIARY SELF EXPANDING",SUP-SC5100L,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"BLUE CROSS [10001]","Blue Cross HMO",,3516.24,39.2,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 116MM 10.5MM MODULAR REMEDY STAINLESS STEEL",SUP-RSHSMD,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"UHC [10700]","United Healthcare",,12960.68,63.3,,8601.07,8395.67,8601.07,"1 through 10",2381.24,17403.75,"percent of total billed charges",
"DEVICE STRATAFIX PDS PLUS 3-0 PS-2 SPIRAL 45CM SUT",SUP-SXPP1B105,CDM,S27200284,LOCAL,0272,RC,,,both,,,224.03,67.21,"MULTIPLAN [10600]",Multiplan,,190.43,85,,,,,0,26.05,190.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 13MM 360MM HIP RIGHT FEMUR AFFIXUS INTRAMEDULLARY 125D",SUP-814313360,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2458.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,2412.38,17631.34,"percent of total billed charges",
"PLATE SMALL BEND 207MM STAINLESS STEEL 3.5MM SCR 12 HOLE",SUP-02.127.250S,CDM,C1713,HCPCS,0278,RC,,,both,,,12592.50,3777.75,"MULTIPLAN [10600]",Multiplan,,10703.63,85,,,,,0,1464.51,10703.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FREEZOR MAX 90CM 8MM 9FR 3-5-2MM SPACE 66MM LONG",SUP-209F5,CDM,C1733,HCPCS,0272,RC,,,both,,,11730.00,3519,"FIRST HEALTH [10303]","First Health",,9384,80,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BIOLOGICAL TISSUE 40X30MM TAPESTRY BIOINTEGRATIVE",SUP-TP-4030-01,CDM,C1781,HCPCS,0278,RC,,,both,,,17633.70,5290.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2089.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2050.8,14988.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE SP 33S",SUP-TENDV-SP-33S-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"CIGNA [10200]","Cigna Local Plus",,91485,53.5,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAPIPLASTY SAW BLADE (40MM X 11MM)-STRYKER",SUP-SM-4011,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SPECIMEN RETRIEVAL 120CM 2.6FR 8MM URETERAL STONE 2",SUP-M0063204010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION BARDEX LUBRICATH 18FR 350ML URINE METER",SUP-304918,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.92,54.58,"FIRST HEALTH [10303]","First Health",,145.54,80,,,,,0,21.16,154.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 42MM SHOULDER REVISION SMR COCR MOLYBDENUM",SUP-1322.09.420,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CIGNA [10200]","Cigna Local Plus",,4237.2,53.5,,5372.07,4581.20,7242.98,23,921.1,6732,"percent of total billed charges",
"(EVAL) NUVISION NON?NAV ICE CATHETER",SUP-M60,CDM,C1759,HCPCS,0272,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE POSTERIOR STABILIZED TRIATHLON",SUP-5532P211,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"FIRST HEALTH [10303]","First Health",,6684.72,80,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE QUILL 2-0 3/8 CIRCLE 14X14CM 26MM CLSR PDO 2 ARM",SUP-RA1020Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.40,39.42,"CIGNA [10200]","Cigna Local Plus",,70.3,53.5,,,,,0,15.28,111.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 24CM PROXIMAL HUMERAL NAIL-EX INTRAMEDULLARY",SUP-04.001.428S,CDM,C1713,HCPCS,0278,RC,,,both,,,9216.74,2765.02,"AETNA [10100]","Aetna HMO/PPO",,7327.31,79.5,,1521.93,481.35,16760.95,30,1071.91,7834.23,"percent of total billed charges",
"GRAFT BONE TRICORTICAL ILIUM THK7MM ALLOGRAFT",SUP-310107,CDM,S27800098,LOCAL,0278,RC,,,both,,,3139.50,941.85,"KAISER [10500]",Kaiser,,2103.47,67,,,,,0,365.12,2668.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TISSUE LORDOTIC ALLOGRAFT ANTERIOR SEPTAL",SUP-345844,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 18MM 140CM 2.5MM 2.1-2.7FR CORONARY",SUP-RONYX25018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"BLUE CROSS [10001]","Blue Cross PPO",,1455.3,39.2,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYNXGRIP GRIP 6-7FR CLSR 10ML VASCULAR BALLOON CATH",SUP-MX6721,CDM,C1760,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 100CM 25CM 5FR .047IN",SUP-CG510,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BAG PRESSURE INFUSER 1000ML WITH HOOK INFU-SURG REPROCESSED",SUP-4010HR,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.59,15.48,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROS OSSICULAR 3.5X2.5MM APPLEBAUM INCUS HA PARTIAL",SUP-140974,CDM,L8613,HCPCS,0278,RC,,,both,,,2680.88,804.26,"KAISER [10500]",Kaiser,,1796.19,67,,,,,0,232.31,2278.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 20MM STAINLESS STEEL T8 LOCK VARIABLE ANGLE",SUP-02.210.120TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1011.53,303.46,"BLUE CROSS [10001]","Blue Cross PPO",,396.52,39.2,,957.42,570.23,957.42,28,117.64,859.8,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 28MM 145CM 2.75MM CORONARY STENT",SUP-1145275-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PHCS [10601]",PHCS,,4086.6,70,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 22MM LCP STAINLESS STEEL SHORT THREAD SMALL",SUP-207.622,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"CIGNA [10200]","Cigna Open Access",,591.78,56.9,,1144.80,304.56,2275.09,66,120.96,884.03,"percent of total billed charges",
"(EVAL) LAPLACE TTVR TRICUSPID VALVE LARGE",SUP-TTVR-L-85X53,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X12MM COROENT XL FIXATION",SUP-7861250,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"KAISER [10500]",Kaiser,,22964.65,67,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC ARTIFICIAL 15X6MM M6-C 15MM MEDIUM LONG SPINE CERVICAL",SUP-CDM-635L,CDM,C1776,HCPCS,0278,RC,,,both,,,37800.00,11340,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10818.36,28.62,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 26CM 10FR LARGE PROXIMAL PIGTAIL CURVE",SUP-M001235600,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"MULTIPLAN [10600]",Multiplan,,757.35,85,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .018IN 4FR 3MM 135CM 4CM PTA LOW",SUP-G50218,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 20MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962365,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5801.52,40,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABRE VENOUS SELF-EXPADING STENT16X100X90",SUP-AB9T16100090,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL COMPREHENSIVE +10MM STD SHOULDER REVERSE",SUP-110031401,CDM,C1776,HCPCS,0278,RC,,,both,,,8224.80,2467.44,"BLUE CROSS [10001]","Blue Cross PPO",,3224.12,39.2,,3949.44,3949.44,3949.44,"1 through 10",956.54,6991.08,"percent of total billed charges",
"STENT URETERAL 8FR L20CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902400,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 60MM TI",SUP-MTC-37600-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,848.23,68,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Orbit/Face/Nck W/WO Cntrst",PX-610000005,CDM,70543,CPT,0610,RC,,,both,,,5059.76,1517.93,"FIRST HEALTH [10303]","First Health",,4047.81,80,,,,,0,588.45,4300.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELIANCE 4 FRONT ACTIVE FIXATION SINGLE COIL 64CM",SUP-0673,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"NOVANET [10819]",Novanet,,11385,75,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X13X6MM COROENT SMALL LORDOTIC PLUS PEEK",SUP-6806815,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS SOLN 4.25 % DEX LOW CA+ 2.5 MEQ/L-MG 0.5 MEQ/L",RX-27804,CDM,,,0250,RC,00941-0459-01,NDC,both,6000,ML,301.80,90.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,35.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.1,256.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 66MM HIP CLUSTER HOLE PRIMARY RIM TRITANIUM",SUP-502-03-66H,CDM,C1776,HCPCS,0278,RC,,,both,,,12551.10,3765.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1459.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1459.69,10668.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 10MM DCP STAINLESS STEEL CORTICAL SELF TAPPING",SUP-201.810,CDM,C1713,HCPCS,0278,RC,,,both,,,358.09,107.43,"FIRST HEALTH [10303]","First Health",,286.47,80,,,,,0,41.65,304.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 6-0 S-14 8IN 2 ARM BRAID COATED VIOLET ABSORBABLE",SUP-J578G,CDM,S27200284,LOCAL,0272,RC,,,both,,,163.41,49.02,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19,138.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 10FR 60CM HEMOSTASIS MULLINS DESIGN GWIRE",SUP-406901,CDM,C1894,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HIWIRE VASCULAR STRAIGHT TAPER 145CM .035IN PTFE",SUP-G01057,CDM,C1769,HCPCS,0272,RC,,,both,,,191.31,57.39,"PHCS [10601]",PHCS,,133.92,70,,,,,0,22.25,162.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 100D L 12MMX.8MM MIDFACE LEFT 6 HOLE BAR 1.7MM SCR",SUP-55-07766,CDM,C1713,HCPCS,0278,RC,,,both,,,1659.08,497.72,"BLUE CROSS [10001]","Blue Cross PPO",,650.36,39.2,,957.42,570.23,957.42,28,192.95,1410.22,"percent of total billed charges",
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN JUDKINS",SUP-77808500,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOLD CEMENT SURESPACE SMALL FEMORAL SPACER",SUP-SSF1060,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"FIRST HEALTH [10303]","First Health",,11371.2,80,,,,,0,1653.09,12081.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL PERSONA COCR 4 NARROW KNEE LEFT CRUCIATE R",SUP-42502005601,CDM,C1776,HCPCS,0278,RC,,,both,,,21420.00,6426,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2491.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL HIP STEM 96MM NK 33.5MM INSIGNIA 1 HIGH STEM HIGH",SUP-7000-6601,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"BLUE CROSS [10001]","Blue Cross HMO",,11984.97,39.2,,5311.50,4717.44,5388.59,31,3555.74,25987.82,"percent of total billed charges",
"PROBE ELECTROSURGICAL APOLLORF 90D MULTIPORT",SUP-AR-9811,CDM,S27200284,LOCAL,0272,RC,,,both,,,1615.95,484.78,"PHCS [10601]",PHCS,,1131.17,70,,,,,0,187.93,1373.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.2MM 80MM STERILE",SUP-143080,CDM,C1713,HCPCS,0278,RC,,,both,,,1010.88,303.26,"BLUE CROSS [10001]","Blue Cross HMO",,396.26,39.2,,957.42,156.86,7483.26,51,117.57,859.25,"percent of total billed charges",
"PK 8X1.5X2CM LARGE NASAL 2 COMPRESS BACTERIOSTATIC AIRWAY",SUP-7089-0837,CDM,S27200284,LOCAL,0272,RC,,,both,,,869.54,260.86,"CIGNA [10200]","Cigna Open Access",,494.77,56.9,,,,,0,101.13,739.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 23MM 14.5MM 19-21MM 12-13.5MM GORE",SUP-RLT231412,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]","Cigna Open Access",,21004.5,33.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 2.9MM 45CM RADIOPAQUE SMALL VALVE FLEXOR",SUP-G09601,CDM,C1894,HCPCS,0272,RC,,,both,,,468.67,140.6,"NOVANET [10819]",Novanet,,351.5,75,,,,,0,54.51,398.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 7.5CM 8.25MM EXPANULA ROTATOR CUFF OBTR",SUP-AR-6569,CDM,S27200284,LOCAL,0272,RC,,,both,,,356.27,106.88,"MULTIPLAN [10600]",Multiplan,,302.83,85,,,,,0,41.43,302.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ON-Q PAINBUSTER SILVERSOAKER 4ML/HR 5IN DRUG DELIVERY",SUP-PM028-A,CDM,C9804,HCPCS,0272,RC,,,both,,,2199.21,659.76,"AETNA [10100]","Aetna HMO/PPO",,1748.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,255.77,1869.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.00 X 18 MM  RX FDA",SUP-1203300-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X20 40CM SL",SUP-48007002P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,667.85,68,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC",522,MS-DRG,,,,,,,inpatient,,,100547.02,30164.11,"BLUE CROSS [10001]","Blue Cross PPO",,52279.77,,,,,,,7561,61828.37,"case rate",
"Siegel TAVR Transcatheter Aortic Valve   29 mm",SUP-30-1-0129,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"AMERIGROUP MEDICAID [20100]",Amerigroup,,23640.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 20X50X11MM ORACLE 0D PARALLEL SPINE LUMBAR",SUP-15041,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6851.63,28.62,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 44CM LONG 12 FIRINGS ECHELON FLEX GST POWERED",SUP-PLEE60A,CDM,S27200284,LOCAL,0272,RC,,,both,,,8028.50,2408.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,951.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,933.71,6824.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701052,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1345.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LASER CYCLO G6 G-PROBE WEDGE TIP GLAUCOMA DISPOSABLE",SUP-15980,CDM,S27200284,LOCAL,0272,RC,,,both,,,1812.50,543.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,831.94,45.9,,,,,0,210.79,1540.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 10GA HYDROMARK BREAST BIOPSY OPEN COIL TITANIUM",SUP-4010-05-10-T3,CDM,A4648,HCPCS,0278,RC,,,both,,,640.49,192.15,"KAISER [10500]",Kaiser,,429.13,67,,,,,0,74.49,544.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +17 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.170,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS 28 AND ICODEXTRIN 7.5 % CA 3.5 MEQ/L-MAG 0.5 MEQ/L",RX-120693,CDM,,,0250,RC,00941-0679-53,NDC,both,2500,ML,892.83,267.85,"UHC [10700]","United Healthcare",,565.16,63.3,,,,,0,103.84,758.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR 5MM PREPARATION SPINEJACK STERILE LATEX FREE",SUP-0909-100-050,CDM,S27200284,LOCAL,0272,RC,,,both,,,8966.41,2689.92,"PHCS [10601]",PHCS,,6276.49,70,,,,,0,1042.79,7621.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 66MM 32MM 10D HIP CROSSFIRE OMNIFIT STERILE",SUP-2041C-3266,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,834,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 25D MEDIUM AUG CORTILOC SHOULDER LEFT",SUP-DWK404LA25S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"UHC [10700]","United Healthcare",,6646.5,63.3,,8601.07,8395.67,8601.07,"1 through 10",1221.15,8925,"percent of total billed charges",
"SCR BONE 3.5MM 26MM SPINE PLY SHAFT NONSTERILE 4MM ROD",SUP-102035726,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"CATH NC QUANTUM APEX 143CM 12MM 3MM BALLOON DILATATION",SUP-H7493912412300,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXTOME 142CM 10MM 4MM BALLOON DILATATION NYLON",SUP-H749CBM3400100,CDM,C1725,HCPCS,0272,RC,,,both,,,5395.80,1618.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3669.14,68,,,,,0,627.53,4586.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM TARGET 3D DETACHABLE CONSISTENT",SUP-M0036154080,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"PHCS [10601]",PHCS,,9880.25,70,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 331344 ACSR 13X14X14 SRVC FEE",SUP-331344,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Open Access",,2944.58,56.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRESSING IV SILVERLON LIFESAVER SILVER 8.5 MM OD1.5 IN ANTIM",SUP-IVCD-15-85,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.49,25.65,"CIGNA [10200]","Cigna Open Access",,48.64,56.9,,,,,0,9.94,72.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THROMBIN (BOVINE) 5,000 UNIT TOPICAL SOLUTION",RX-121612,CDM,,,0250,RC,60793-0215-05,NDC,both,1,UN,457.43,137.23,"CIGNA [10200]","Cigna Open Access",,260.28,56.9,,,,,0,53.2,388.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL LEGION 3 KNEE LEFT REVISION",SUP-71424003,CDM,C1776,HCPCS,0278,RC,,,both,,,23133.60,6940.08,"PHCS [10601]",PHCS,,16193.52,70,,,,,0,2690.44,19663.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE MONORAIL 150CM 100MM 3MM BALLOON DILATATION",SUP-H74939185301010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"AETNA [10100]","Aetna HMO/PPO",,1030.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VITOSS BIMODAL FOAM PACK 5CC",SUP-2102-1905,CDM,C1713,HCPCS,0278,RC,,,both,,,12432.42,3729.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3356.75,27,,,,,0,1445.89,10567.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SURGICAL PROC 40CM WELCH ALLYN CATH EXT TUBE SET",SUP-660005000,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.40,131.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,179.77,41.1,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP SURGICAL 3CM ADVINCULA DELINEATOR KOH-EFFICIENT KOH",SUP-AD750-KE30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP CONSTRUCT 2",SUP-CAP-Z-H-2,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"PHCS [10601]",PHCS,,17199,70,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 120MM STAINLESS STEEL LARGE FRAGMENT SET 6 HOLE SPOON",SUP-240.06,CDM,C1713,HCPCS,0278,RC,,,both,,,1945.13,583.54,"BLUE CROSS [10001]","Blue Cross PPO",,762.49,39.2,,957.42,570.23,957.42,28,226.22,1653.36,"percent of total billed charges",
"PARTICLES EMBOLIZATION 1ML DRY BIOCOMPATIBLE INLINE CPLR",SUP-TOR2520,CDM,S27800098,LOCAL,0278,RC,,,both,,,526.50,157.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 16MM .0145IN AXIUM PRIME 3D FRAME",SUP-FC-16-40-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"PHCS [10601]",PHCS,,11567.85,70,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LASER 20GA STRAIGHT ENDOPHOTOCOAGULATION",SUP-10562,CDM,S27000186,LOCAL,0270,RC,,,both,,,1363.50,409.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,161.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.58,1158.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.2MM 20MM CORTICAL HEXAGONAL NONSTERILE",SUP-HEX3.2-20,CDM,C1713,HCPCS,0278,RC,,,both,,,729.00,218.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,495.72,68,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 12/14 TAPER 28MM HIP SKIRT COCR",SUP-136514000,CDM,C1776,HCPCS,0278,RC,,,both,,,4457.40,1337.22,"AETNA [10100]","Aetna HMO/PPO",,3543.63,79.5,,10981.53,8986.79,12413.38,12,518.4,3788.79,"percent of total billed charges",
"CMPNT PATELLAR 26MM RESURFACE GENESIS II KNEE",SUP-71420580,CDM,C1776,HCPCS,0278,RC,,,both,,,6344.55,1903.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,751.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,737.87,5392.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tlso Tripl Mod Rigid Shell 4pc",PX-E27400057,CDM,L0464,HCPCS,0274,RC,,,both,,,5230.50,1569.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1496.97,28.62,,,,,0,608.31,4445.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE XL BREATHABLE SQUARE TOE OFFLOAD 11.6FT",SUP-VP50201-050,CDM,S27000186,LOCAL,0270,RC,,,both,,,126.15,37.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,57.9,45.9,,,,,0,14.67,107.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 650ML STYLE 9200 TEXTURED SELF SEALING PATCH",SUP-3549215,CDM,C1789,HCPCS,0278,RC,,,both,,,6720.00,2016,"AETNA [10100]","Aetna HMO/PPO",,5342.4,79.5,,,,,0,781.54,5712,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO LEAD 75CM 5FR .046IN WORLEY ERGONOMIC WING HUB BRAID",SUP-57538CSHK-WOR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1010.88,303.26,"KAISER [10500]",Kaiser,,677.29,67,,,,,0,117.57,859.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 4-11 E-F KNEE RIGHT TIBIA",SUP-42521200512,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"CIGNA [10200]","Cigna Local Plus",,4320.53,53.5,,5372.07,4581.20,7242.98,23,939.21,6864.4,"percent of total billed charges",
"SABER .035 4X60 40CM SL",SUP-48004006P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"UHC [10700]","United Healthcare",,621.69,63.3,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH HEARTSPAN MR0 CURVE 81CM 8.5FR GUIDING PEBAX STEEL",SUP-FCB8581MR0,CDM,C1894,HCPCS,0272,RC,,,both,,,1432.08,429.62,"KAISER [10500]",Kaiser,,959.49,67,,,,,0,166.55,1217.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC MEDIUM 11.5X3-3.5IN HAND RIGHT ORTHOSIS",SUP-55460408,CDM,L3807,HCPCS,0274,RC,,,both,,,460.89,138.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,179.46,,,,,,,53.6,391.76,"fee schedule",
"HC Dbrd Skin & Sq Tiss Add 20scm",PX-510000010,CDM,11045,CPT,0761,RC,,,both,,,4681.74,1404.52,"CIGNA [10200]","Cigna Local Plus",,2051,,"Per diem ($2,051).",,,,0,544.49,3979.48,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"COPPER CU-64 DOTATATE INTRAVENOUS SOLUTION (4-5 MCI)",RX-411823,CDM,A9592,HCPCS,0343,RC,08888-8877-78,NDC,both,1,UN,20412.00,6123.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13267.8,65,,,,,0,1155,17350.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GA-68-GOZETOTIDE INTRAVENOUS SOLUTION (4 MCI)",RX-411539,CDM,A9596,HCPCS,0343,RC,08888-8878-70,NDC,both,1,UN,24796.80,7439.04,"AETNA [10100]","Aetna HMO/PPO",,19713.46,79.5,,,,,0,1181,21077.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repo Impl Lv Elect",PX-480000020,CDM,33226,CPT,0481,RC,,,both,,,6653.00,1995.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,788.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,773.74,6653,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cholinesterase Serum",PX-301000146,CDM,82480,CPT,0301,RC,,,both,,,289.75,86.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7.08,,,,,,,0.01,246.29,"fee schedule",
"LEAD PACING 53CM BIPOLAR SOLIA T STERILE LATEX FREE",SUP-377180,CDM,C1898,HCPCS,0275,RC,,,both,,,2250.00,675,"CIGNA [10200]","Cigna Open Access",,1280.25,56.9,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FRACTURE STABILIT MX SHORT FULL VERTEBROPLASTY SYSTEM",SUP-MX-2100S,CDM,S27200284,LOCAL,0272,RC,,,both,,,15870.00,4761,"UHC [10700]","United Healthcare",,10045.71,63.3,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN HOLDING QUICK CONNECT TROCAR TIP NONLOCK 3IN STERILE",SUP-201-78-81,CDM,C1713,HCPCS,0278,RC,,,both,,,261.00,78.3,"NOVANET [10819]",Novanet,,195.75,75,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 46MM 2 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800246,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]",Cigna,,3049.8,68,,1831.33,1831.33,1831.33,16,521.61,3812.25,"percent of total billed charges",
"CATH 110CM 7FR PRESSURE MNTR PULMONARY WEDGE",SUP-150075,CDM,C1713,HCPCS,0278,RC,,,both,,,118.32,35.5,"BLUE CROSS [10001]","Blue Cross PPO",,46.38,39.2,,957.42,570.23,957.42,28,13.76,100.57,"percent of total billed charges",
"CATH 22IN 20FR STRAIGHT DRNG PVC THORACIC 4 EYELET",SUP-8020,CDM,C1729,HCPCS,0272,RC,,,both,,,59.96,17.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.97,50.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD 37MM 135CM 9MM 7MM 6FR BILIARY METAL",SUP-H74938047740130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"KAISER [10500]",Kaiser,,3344.64,67,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 12CM 2MM BALLOON DILATATION OTW LOW",SUP-G30937,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEMMED ANATOMIC PSI KIT (GLENOID ONLY)",SUP-1235-7153-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"AETNA [10100]","Aetna HMO/PPO",,4799.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STATION DOCKING FOUR POSITION VERSION FOR NOVA STATSTRIP GLU",SUP-53402,CDM,S27000186,LOCAL,0270,RC,,,both,,,8280.00,2484,"KAISER [10500]",Kaiser,,5547.6,67,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC NDL 240CM RADIAL JAW 4 STD CAPACITY BX40",SUP-M00513412,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.56,19.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.39,54.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 35X3IN PRECUT FIBERGLASS ORTHO-GLASS",SUP-OG-335PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,115.54,34.66,"CIGNA [10200]","Cigna Local Plus",,61.81,53.5,,,,,0,13.44,98.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 8MM VARIAX TITANIUM SMALL BONE LOCK SELF TAP",SUP-53-23008E,CDM,C1713,HCPCS,0278,RC,,,both,,,738.23,221.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,87.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,85.86,627.5,"percent of total billed charges",
"EXERCISER HAND C10-100 LB 3 SPRING RESISTIVE LATEX FREE",SUP-A8461,CDM,S27000186,LOCAL,0270,RC,,,both,,,151.03,45.31,"AETNA [10100]","Aetna HMO/PPO",,120.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.56,128.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBTALAR DISTRACTION ARTHRODESIS WEDGE, 12 MM",SUP-PSBT-1206,CDM,S27800098,LOCAL,0278,RC,,,both,,,12851.25,3855.37,"BLUE CROSS [10001]","Blue Cross HMO",,5037.69,39.2,,,,,0,1494.6,10923.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 24MM ARTHREX SHOULDER MODULAR STERILE LATEX",SUP-AR-9560-24,CDM,C1776,HCPCS,0278,RC,,,both,,,9335.70,2800.71,"UHC [10700]","United Healthcare",,5909.5,63.3,,8601.07,8395.67,8601.07,"1 through 10",1085.74,7935.35,"percent of total billed charges",
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 3MM .017IN",SUP-H7493926708300,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +19.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.195,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 20MM 2.25MM BALLOON DILATATION",SUP-NCEUP22520X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"AETNA [10100]","Aetna HMO/PPO",,418.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 75MM 14MM UNIVERSAL FLUTE KNEE PRESS FIT",SUP-86-7414,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"CIGNA [10200]","Cigna Open Access",,4609.24,56.9,,5302.19,4377.88,6578.61,27,942.1,6885.51,"percent of total billed charges",
"COIL EMBOLIZATION 190CM 3CM 1.5MM GALAXY G3 MINI STRETCH",SUP-GLM915030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3208.09,27,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MAILMAN VASCULAR 182CM 3CM .014IN STAINLESS STEEL",SUP-H74912136012,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 8 KNEE LEFT DISTAL TOTAL",SUP-5541-A-801,CDM,C1776,HCPCS,0278,RC,,,both,,,6699.90,2009.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1917.51,28.62,,,,,0,779.2,5694.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 4CM 4MM BALLOON DILATATION",SUP-U815044,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL H+0MM 36MM PERFORM .75 SHOULDER REVERSE",SUP-DWP4360,CDM,C1776,HCPCS,0278,RC,,,both,,,17388.00,5216.4,"CIGNA [10200]","Cigna Local Plus",,5477.22,31.5,,5372.07,4581.20,7242.98,23,2022.22,14779.8,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 8MM 145CM 3MM CORONARY STENT EVEROLIMUS",SUP-1145300-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 350ML P4.8CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-3504BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,609.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X20 135CM SL",SUP-48007002R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE MAMMOSITE BRACHYTHERAPY BREAST CAVITY EVALUATION",SUP-9031,CDM,C1728,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SYNCHRO-14 VASCULAR 200CM 35CM .014IN NITINOL",SUP-M00313410,CDM,C1769,HCPCS,0272,RC,,,both,,,4568.90,1370.67,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,inpatient,,,162263.37,48679.01,"CIGNA [10200]","Cigna Open Access",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 46.8%. Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"MINERAL OIL ORAL",RX-5086,CDM,,,0250,RC,48433-0202-30,NDC,both,30,ML,15.10,4.53,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS 3-0 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP838D,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT ONYX FRONTIER 30MM 4MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG40030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"7F DUO-DECA 2.5-2.5-2.5 PV21 110CM",SUP-903953,CDM,C1731,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"FIRST HEALTH [10303]","First Health",,5382,80,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP APPLR PROGEL SPRAY EXTEND 29CM",SUP-PGEN005-11,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Stool Culture Aerobic Bact Ea",PX-306000008,CDM,87046,CPT,0306,RC,,,both,,,324.90,97.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.6,,,,,,,0.01,276.17,"fee schedule",
"STENT SURPASS STREAMLINE 40MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-M003SFD040400,CDM,C1874,HCPCS,0278,RC,,,both,,,93183.77,27955.13,"AETNA [10100]","Aetna HMO/PPO",,74081.1,79.5,,,,,0,10837.27,79206.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR HD 28CM 11-13FR ACCESS STAINLESS STEEL",SUP-M0062502210,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"KAISER [10500]",Kaiser,,657.05,67,,,,,0,114.05,833.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trach Em Proc Transtrach",PX-450000218,CDM,31603,CPT,0450,RC,,,both,,,2017.00,605.1,"MULTIPLAN [10600]",Multiplan,,1714.45,85,,,,,0,2.02,2017,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 11MM 8.2MM 100MM TALON HIP DISTALFIX TECHNOLOGY LAG",SUP-SLN-011-100,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2280.31,45.9,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP HEMOSTATIC ENDOSCOPIC INSTINCT PLUS",SUP-G58010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"PHCS [10601]",PHCS,,1207.5,70,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.190,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 5 LEFT DISTAL KNEE",SUP-5540-A-501,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"KAISER [10500]",Kaiser,,3044.35,67,,,,,0,528.45,3862.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW MARK SPRING TIP",SUP-CG-05-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"KAISER [10500]",Kaiser,,352.76,67,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC",308,MS-DRG,,,,,,,inpatient,,,44304.97,13291.49,"UHC [10700]","United Healthcare",,30026.56,,"Fee schedule rate ($30,026.56). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7468.49,30026.56,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG 1.5L ANGIOFLUSH III COLL CO2",SUP-16100602,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.20,15.66,"NOVANET [10819]",Novanet,,39.15,75,,,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 35X3IN PRECUT FIBERGLASS ORTHO-GLASS",SUP-OG-335PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,115.54,34.66,"CIGNA [10200]","Cigna Open Access",,65.74,56.9,,,,,0,13.44,98.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 126MM ACCOLADE II V40 PUREFIX TITANIUM 127D 11",SUP-6721-1140,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"AETNA [10100]","Aetna HMO/PPO",,19049.83,79.5,,10981.53,8986.79,12413.38,12,2786.79,20367.74,"percent of total billed charges",
"GRAFT BONE CORNERSTONE MASR CANCELLOUS CORTICAL LORDOTIC",SUP-645511,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC MEDIUM RIGHT WRIST FOREARM PREFORM PAD",SUP-9101-02,CDM,S27000186,LOCAL,0270,RC,,,both,,,72.38,21.71,"CIGNA [10200]","Cigna Open Access",,41.18,56.9,,,,,0,8.42,61.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXIVA PULSE ID 550",SUP-M006L8406930,CDM,S27200284,LOCAL,0272,RC,,,both,,,3122.85,936.85,"CIGNA [10200]","Cigna Local Plus",,1670.72,53.5,,,,,0,363.19,2654.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 2-0 PS 18IN MONOFILAMENT BLACK NONABSORBABLE",SUP-585H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Local Plus",,13.38,53.5,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TENFUSE PIP ANGLED ALLOGRAFT 15X2MM STERILE",SUP-TFF2015A,CDM,C1762,HCPCS,0278,RC,,,both,,,8763.00,2628.9,"CIGNA [10200]","Cigna Local Plus",,4688.21,53.5,,,,,0,1019.14,7448.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUSA CLARITY 36KHZ TORQUE WRENCH (5-PACK)",SUP-C7602,CDM,S27200284,LOCAL,0272,RC,,,both,,,1022.79,306.84,"NOVANET [10819]",Novanet,,767.09,75,,,,,0,118.95,869.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARROW EPIDURAL CATHETERIZATION KIT",SUP-AK-05502D,CDM,C1755,HCPCS,0278,RC,,,both,,,346.26,103.88,"FIRST HEALTH [10303]","First Health",,277.01,80,,,,,0,40.27,294.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 110MM 5.5MM MATRIX 200MM RADIUS CURVE BULLET NOSE",SUP-04.651.310,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"SIZER IMPL 13CM NATRELLE INSPIRA P2.6CM LOW PROFILE ROUND",SUP-MSZ-L290,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.69,42.81,"CIGNA [10200]","Cigna Local Plus",,76.34,53.5,,,,,0,16.59,121.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 30CM 150CM 7FR .038IN 3CM BLADDER LOOP",SUP-M006155245170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"KAISER [10500]",Kaiser,,951.63,67,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 V-7 48IN 2 ARM MONOFILAMENT BLUE",SUP-D6175,CDM,S27200284,LOCAL,0272,RC,,,both,,,720.72,216.22,"NOVANET [10819]",Novanet,,540.54,75,,,,,0,83.82,612.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835L-12,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,523.91,39.2,,957.42,156.86,7483.26,51,155.43,1136.03,"percent of total billed charges",
"CMPNT FEMORAL 4 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRN4PL,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,5873.17,5873.17,5873.17,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL BLADE INCISION STORZ 2 STEM",SUP-M0068805211,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"FIRST HEALTH [10303]","First Health",,413.18,80,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 15IN 30FR VENOUS ADULT 3/8IN CONNECTION SITE",SUP-66130,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.63,85.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,33.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.22,242.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 22MM 10D E HIP CONSTRAIN TRIDENT",SUP-690-10-22E,CDM,C1776,HCPCS,0278,RC,,,both,,,17046.45,5113.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2020,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1982.5,14489.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 10MM TITANIUM T4 CORTEX SELF TAP STARDRIVE",SUP-04.214.110,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION ATTUNE THREAD PACK HEAD HEADLESS DISPOSABLE",SUP-254400111,CDM,C1713,HCPCS,0278,RC,,,both,,,2043.75,613.12,"PHCS [10601]",PHCS,,1430.63,70,,,,,0,237.69,1737.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11.7CM MEMORYGEL P3.5CM MODERATE PLUS PROFILE",SUP-RSZ-2751S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"CIGNA [10200]",Cigna,,1074.06,68,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vasoactive Intestinal Peptide",PX-301000436,CDM,84586,CPT,0301,RC,,,both,,,209.30,62.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,125.42,,,,,,,0.01,177.91,"fee schedule",
"HC Washing Sperm",PX-301000680,CDM,58323,CPT,0301,RC,,,both,,,591.00,177.3,"CIGNA [10200]",Cigna,,401.88,68,,,,,0,70.03,591,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Hip Bil 2v",PX-320000206,CDM,73521,CPT,0320,RC,,,both,,,589.43,176.83,"PHCS [10601]",PHCS,,412.6,70,,,,,0,48.1,501.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE FUZEFIX TITANIUM T7 MINI L12 MM OD2 MM COMPRESSIO",SUP-FX-HL-2012,CDM,C1713,HCPCS,0278,RC,,,both,,,2287.50,686.25,"AETNA [10100]","Aetna HMO/PPO",,1818.56,79.5,,1521.93,481.35,16760.95,30,266.04,1944.38,"percent of total billed charges",
"HC Pulse Ox O2 Sat Sngl",PX-460000015,CDM,94760,CPT,0460,RC,,,both,,,70.94,21.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,32.56,45.9,,,,,0,8.25,60.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Special Dosimetry",PX-333000016,CDM,77331,CPT,0333,RC,,,both,,,1139.76,341.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1139.76,,"Per diem ($3,244).",,,,0,132.55,1139.76,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 5FR .047IN 3D RIGHT CURVE DIAGNOSTIC",SUP-DXT53DRC,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"CIGNA [10200]","Cigna Local Plus",,44.22,53.5,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW LOWPROFILE 6.5X30MM",SUP-010-55-030,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"CIGNA [10200]","Cigna Local Plus",,162.91,53.5,,3978.14,359.25,3978.14,24,35.41,258.83,"percent of total billed charges",
"LEAD ICD 70CM ENDOTAK RELIANCE G ENDOCARDIAL STEROID",SUP-186,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS [10001]","Blue Cross HMO",,5950.56,39.2,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM GALAXY G3 XTRASOFT NEUROVASCULAR",SUP-GLX120306,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4752.72,40,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM CORKSCREW FT 3 PLAY PEEK STERILE LATEX",SUP-AR-1927PSF-475,CDM,C1713,HCPCS,0278,RC,,,both,,,2480.63,744.19,"BLUE CROSS [10001]","Blue Cross PPO",,972.41,39.2,,957.42,570.23,957.42,28,288.5,2108.54,"percent of total billed charges",
"SCR BONE 3.5MM 26MM NONSTERILE GORILLA R3CON",SUP-P50-453-3526,CDM,C1713,HCPCS,0278,RC,,,both,,,1069.20,320.76,"MULTIPLAN [10600]",Multiplan,,908.82,85,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 0 CT-1 36IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z346H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG VASCULAR  10MM",SUP-9-PLUG-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4199.34,68,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Swallowing Study W Video",PX-320000098,CDM,74230,CPT,0320,RC,,,both,,,837.92,251.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,99.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.45,712.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM 3DX TSRH OSTEOGRIP THINLINE TITANIUM",SUP-83555359,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1110.3,8114.82,"percent of total billed charges",
"ANCHOR SUT MICRO NONSTERILE DISPOSABLE",SUP-AR-1320BCNF,CDM,C1713,HCPCS,0278,RC,,,both,,,2559.38,767.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,732.49,28.62,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISPOSABLE POLYPECTOMY COLD SNARES OUTER DIAMETER 2.4MM WORK",SUP-G61206,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"AETNA [10100]","Aetna HMO/PPO",,166,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 190ML GEL ROUND SMOOTH MEMORYGEL COHESIVE I","SUP-3507190 MC",CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"PHCS [10601]",PHCS,,2499,70,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25MM BR2000 THK1.19MM LARGE BONE OSCILLATE",SUP-BR1-2590-47,CDM,S27200284,LOCAL,0272,RC,,,both,,,245.25,73.57,"AETNA [10100]","Aetna HMO/PPO",,194.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.52,208.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXERCISER HAND C10-100 LB 3 SPRING RESISTIVE LATEX FREE",SUP-A8461,CDM,S27000186,LOCAL,0270,RC,,,both,,,151.03,45.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,102.7,68,,,,,0,17.56,128.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 14MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-214-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3444.02,28.62,,,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 45CM 12MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES1245CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,858.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pacing Ivent",PX-481000050,CDM,93612,CPT,0480,RC,,,both,,,6134.00,1840.2,"FIRST HEALTH [10303]","First Health",,4907.2,80,,,,,0,713.38,6134,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBOHAWK MEC 135CM 5.9CM 2-4MM ATHERECTOMY CALCIUM",SUP-THS-SX-C,CDM,C1714,HCPCS,0272,RC,,,both,,,20128.50,6038.55,"PHCS [10601]",PHCS,,14089.95,70,,,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM GALAXY G3 XTRASOFT NEUROVASCULAR",SUP-GLX120410,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"NOVANET [10819]",Novanet,,8911.35,75,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC M Environment/Sterility Cultur",PX-300000017,CDM,87999,CPT,0300,RC,,,both,,,58.00,17.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,39.44,68,,,,,0,0.06,49.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY NDL STREAMLINE CATH POSITION MARKER 100CM 1.8MM",SUP-M00515191,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.48,104.84,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OSTEOTOM 5 1/8IN LAMBOTTE SWISS PATTERN SURGICAL MINI",SUP-27-5704,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.07,40.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH METACROSS 135CM 100MM 5.4FR 5MM BALLOON DILATATION 2",SUP-BD-L50100CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,MINOR",613,APR-DRG,,,,,,,inpatient,,,40987.10,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $8,405.83. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to (Final Base Payment plus Newborn Screen Add-on Amount $63.00) multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($49,131.52) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-1 Newborn; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 300MM 6MM .018IN BALLOON",SUP-R51006030L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUT 4.5MM TWINFIX ULTRA COBRAID HA STERILE BLUE WHITE",SUP-72202597,CDM,C1713,HCPCS,0278,RC,,,both,,,1945.13,583.54,"CIGNA [10200]","Cigna Open Access",,1106.78,56.9,,1144.80,304.56,2275.09,66,226.22,1653.36,"percent of total billed charges",
"GRAFT BONE FIBERFUSE CANCELLOUS DEMINERALIZE CORTICAL BONE",SUP-420710,CDM,C1713,HCPCS,0278,RC,,,both,,,25755.98,7726.79,"NOVANET [10819]",Novanet,,19316.99,75,,,,,0,2995.42,21892.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 13MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530G213,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"BLUE CROSS [10001]","Blue Cross HMO",,3413.38,39.2,,5311.50,4717.44,5388.59,31,1012.7,7401.47,"percent of total billed charges",
"CLIP MEDIUM INTERNAL HEMOCLIP TITANIUM ENDOSCOPIC LIGATING",SUP-523100,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"CIGNA [10200]","Cigna Open Access",,114.35,56.9,,,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GARM COMPRESSION CALF NONSTERILE LATEX FREE DISPOSABLE 18-",SUP-VP501MG,CDM,S27000186,LOCAL,0270,RC,,,both,,,65.25,19.57,"NOVANET [10819]",Novanet,,48.94,75,,,,,0,7.59,55.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 12MM KII THREAD SLEEVE HANDLED",SUP-CTR74,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"NOVANET [10819]",Novanet,,182.7,75,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 20MM CLEVERCUT3V PRELOAD DISTAL TIP STERILE",SUP-KD-VC611Q-07201S,CDM,C1769,HCPCS,0272,RC,,,both,,,2817.75,845.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,333.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,327.7,2395.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNITY - TIBIAL INSERT MC #6 Th9 R",SUP-1127609,CDM,C1776,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1184.87,28.62,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 110CM 1MM 5FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY FIX",SUP-F5QF005CT,CDM,C1730,HCPCS,0272,RC,,,both,,,551.20,165.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,65.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.1,468.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 60CM 6.7FR 10MM SPACE ATRIUM ENDOCARDIUM",SUP-4137,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"NOVANET [10819]",Novanet,,4205.25,75,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 6MM 70MM DCP LC-DCP STAINLESS STEEL CORTEX",SUP-204.67,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"FIRST HEALTH [10303]","First Health",,220.22,80,,,,,0,32.01,233.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PROFILE SILICONE SMOOTH",SUP-SCL-290,CDM,C1789,HCPCS,0278,RC,,,both,,,8004.00,2401.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,948.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,930.87,6803.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 13.5MM 19MM MOSAIC CINCH PORCINE BIOPROSTHESIS",SUP-305C219,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7399.35,27,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SILICONE 600ML BREAST GEL SMOOTH ROUND",SUP-RSZ-6004,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.91,39.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.22,111.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 15MM 3MM BALLOON DILATATION DURATRAC",SUP-NCEUP3015X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE FATHOM VASCULAR STRAIGHT 140CM 35CM .016IN PERIPHERAL",SUP-M001509010,CDM,C1769,HCPCS,0272,RC,,,both,,,1792.50,537.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE ANGIO-SEAL VIP BONDEK-PLUS 70CM 6FR .035IN CLSR",SUP-610130,CDM,C1760,HCPCS,0278,RC,,,both,,,988.00,296.4,"KAISER [10500]",Kaiser,,661.96,67,,,,,0,114.9,839.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY NAIL TAN 85MM 10.35MM TFN-ADVANCED",SUP-04.038.385,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",434.96,3179,"percent of total billed charges",
"SCR BONE 5MM 85MM CONDYLAR VARIABLE ANGLE CANNULATED LOCK",SUP-42.231.685,CDM,C1713,HCPCS,0278,RC,,,both,,,1693.95,508.18,"MULTIPLAN [10600]",Multiplan,,1439.86,85,,,,,0,197.01,1439.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM TRICUSPID 3 RADIAL MARKER POLISH WIRE",SUP-900SFC32,CDM,S27800098,LOCAL,0278,RC,,,both,,,14490.00,4347,"UHC [10700]","United Healthcare",,9172.17,63.3,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 3CM 5FR STRAIGHT PANCREATIC PLASTIC",SUP-M00537540,CDM,C2617,HCPCS,0278,RC,,,both,,,1411.18,423.35,"NOVANET [10819]",Novanet,,1058.39,75,,,,,0,164.12,1199.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 55CM 6FR .07IN ADULT RENAL CURVE",SUP-67021255,CDM,C1887,HCPCS,0272,RC,,,both,,,304.50,91.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,35.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC",191,MS-DRG,,,,,,,inpatient,,,24567.48,7370.24,"PHCS [10601]",PHCS,,7561,,,,,,,5229.18,21023.58,"per diem","Estimated amount calculated based on 1 day length of stay."
"STENT ORSIRO 2.75/18",SUP-401749,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 3CM 75CM 10-11-12MM PULMONARY BALLOON",SUP-M00550340,CDM,C1726,HCPCS,0272,RC,,,both,,,2278.65,683.59,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1549.48,68,,,,,0,265.01,1936.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 135CM 10CM 5FR 3MM .035IN BALLOON",SUP-G52248,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ORTHOCORD OS-6 MONOFILAMENT VIOLET NONABSORBABLE",SUP-223103,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.13,40.24,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Selct Plc Cath Cca/Innom Neck",PX-361000288,CDM,36222,CPT,0361,RC,,,both,,,9187.29,2756.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4752,,"Case rate ($4,752). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1068.48,7883,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 7MM TARGET 3D DETACHABLE CONSISTENT",SUP-M0036157150,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"CIGNA [10200]","Cigna Open Access",,4728.4,33.5,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE WINN VASCULAR TAPER 300CM .014IN DURASTEEL",SUP-1012475,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,655.45,68,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 69MM COLONIAL 2XL PEEK ANTERIOR CERVICAL",SUP-365.069,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"NOVANET [10819]",Novanet,,5008.82,75,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.476,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1385.95,28.62,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 4MM CONCERTO 3D",SUP-PV-4-12-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"AETNA [10100]","Aetna HMO/PPO",,3565.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 40MM COMPREHENSIVE +3MM SHOULDER PROLONG",SUP-110031423,CDM,C1776,HCPCS,0278,RC,,,both,,,5354.40,1606.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,634.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,622.72,4551.24,"percent of total billed charges",
"EXT BONE GRAFT INQU HYALURONIC ACID POLY",SUP-IQSP-PP-102,CDM,C1713,HCPCS,0278,RC,,,both,,,2812.50,843.75,"BLUE CROSS [10001]","Blue Cross PPO",,1102.5,39.2,,957.42,570.23,957.42,28,327.09,2390.63,"percent of total billed charges",
"GORE CARDIOFORM ASD OCCLUDER 32MM 10FR",SUP-00733132636495,CDM,C1817,HCPCS,0278,RC,,,both,,,52321.50,15696.45,"NOVANET [10819]",Novanet,,39241.13,75,,,,,0,6084.99,44473.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 7MMX19MM 7FR 135CMCATH HEPARIN",SUP-BXB071902A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT VASCULAR 300CM .014IN",SUP-1001782J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 42.5-67MM 6MM CREO LONG SPINE CROSS LOW PROFILE",SUP-1119.0267,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"KAISER [10500]",Kaiser,,2386.88,67,,,,,0,414.32,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 10MM RELIANCE HIP FEMUR FRACTURE PRODUCTS F R",SUP-6259-8-100,CDM,C1776,HCPCS,0278,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,231.82,28.62,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +30 DIOPTER POSTERIOR CHMBR 1 PIECE FOLDABLE UV",SUP-ACU0T0,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR GREEN 46MM 28MM RINGLOC BIO-MOORE II HIP",SUP-11165216,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1906.06,28.62,,,,,0,774.54,5660.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 10MM NATURAL LORDOTIC CORTICOCANCELLOUS",SUP-18410,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 6MM AZUR HYDROCOIL PUSHABLE .018IN",SUP-45-280610,CDM,S27800098,LOCAL,0278,RC,,,both,,,1416.69,425.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,164.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.76,1204.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GELFOAM PLUS THROMBIN SALINE HEMOSTASIS SPONGE SYR NDL",SUP-1501341,CDM,S27200284,LOCAL,0272,RC,,,both,,,611.39,183.42,"UHC [10700]","United Healthcare",,387.01,63.3,,,,,0,71.1,519.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG NASAL WHITE 4CM NASOPORE OTOPORE STD SINUS FOAM FIRM",SUP-5400020004,CDM,S27200284,LOCAL,0272,RC,,,both,,,1124.90,337.47,"FIRST HEALTH [10303]","First Health",,899.92,80,,,,,0,130.83,956.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X10MM ADVANCED LORDOTIC SPINE",SUP-017710,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]","Cigna Local Plus",,4429.8,53.5,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 5 KNEE LEFT BICRUCIATE STABILIZE",SUP-74022225,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1933.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 4.75MM SOLERA COCR MOLYBDENUM CURVED",SUP-1475501090,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Local Plus",,2359.35,53.5,,3978.14,359.25,3978.14,24,512.88,3748.5,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL 12D 30D LARGE LOOP 24FR PLASMALOOP",SUP-WA22607S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3236.00,970.8,"CIGNA [10200]",Cigna,,2200.48,68,,,,,0,376.35,2750.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 48MM PERIPHERAL",SUP-5572-4548,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"CIGNA [10200]","Cigna Open Access",,885.19,56.9,,1144.80,304.56,2275.09,66,180.93,1322.35,"percent of total billed charges",
"SODIUM CHLORIDE 0.9 % IVPB-ADDV/MBP",RX-120160,CDM,J3490,HCPCS,0258,RC,00338-0553-18,NDC,both,100,ML,100.65,30.19,"FIRST HEALTH [10303]","First Health",,80.52,80,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 345041FZ L-ASR 10X14X11 FZ SRVCFE",SUP-345041FZ,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 5MM INTERLOCK IDC 18 COIL SOFT 2D",SUP-M0013615120,CDM,S27800098,LOCAL,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE SURGICAL SACHSE COLD STRAIGHT WITHOUT HF CURRENT",SUP-27069K,CDM,S27200284,LOCAL,0272,RC,,,both,,,1470.42,441.13,"CIGNA [10200]","Cigna Open Access",,836.67,56.9,,,,,0,171.01,1249.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VENTRALIGHT ST SEPRA 6IN UNCOATED MONOFILAMENT",SUP-5954600,CDM,C1781,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"MULTIPLAN [10600]",Multiplan,,3665.63,85,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 4X2CM ALLODERM THIN ACELLULAR DERMAL MATRIX",SUP-102010,CDM,Q4116,HCPCS,0636,RC,,,both,,,3187.50,956.25,"CIGNA [10200]","Cigna Open Access",,1813.69,56.9,,,,,0,247.92,2709.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 1.6IN WING SARNS",SUP-824370,CDM,S27200284,LOCAL,0272,RC,,,both,,,147.90,44.37,"KAISER [10500]",Kaiser,,99.09,67,,,,,0,17.2,125.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 14MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650614,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1555.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1526.7,11158.16,"percent of total billed charges",
"BINDER ABDOMINAL 60-75X12IN 4 PANEL MEDIUM",SUP-818,CDM,S27000186,LOCAL,0270,RC,,,both,,,316.85,95.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.4,269.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM TKR PATELLOFEMORAL",SUP-98000661000,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7767.9,41.1,,6417.48,6417.48,6417.48,"1 through 10",2198.07,16065,"percent of total billed charges",
"DIL VASCULAR 5MM 8.25IN STAINLESS STEEL GARRETT MALLEABLE",SUP-25-8024,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.12,22.24,"UHC [10700]","United Healthcare",,46.92,63.3,,,,,0,8.62,63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW PHTHALATE FREE",SUP-CG-15-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"CIGNA [10200]",Cigna,,358.02,68,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP LOCKING REAMER IRR ASPIR INTRAMEDULLARY BONE HARVEST",SUP-352.260S,CDM,S27200284,LOCAL,0272,RC,,,both,,,557.69,167.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,255.98,45.9,,,,,0,64.86,474.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 340MM 4.2MM T2 AO STERILE",SUP-18064260S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1231.52,369.46,"CIGNA [10200]",Cigna,,837.43,68,,,,,0,143.23,1046.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"112 (284 CM) 15 DROP PRIMARY SET W/2 CLAVE?, REMV 3-PORT NAN",SUP-041890CS,CDM,C1730,HCPCS,0272,RC,,,both,,,2250.00,675,"NOVANET [10819]",Novanet,,1687.5,75,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXIVA PULSE ID 365",SUP-M006L8406920,CDM,S27200284,LOCAL,0272,RC,,,both,,,2303.10,690.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC",821,MS-DRG,,,,,,,inpatient,,,127030.23,38109.07,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 8.25IN YANKAUER PEDIATRIC",SUP-170-118,CDM,S27000186,LOCAL,0270,RC,,,both,,,332.43,99.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS,MAJOR",721,APR-DRG,,,,,,,inpatient,,,58698.04,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $11,456.40. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($51,480.13) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) MOTIV SCAFFOLD 3.0MMX18MM","SUP-930030-18 (115)",CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIDNEY AND URINARY TRACT INFECTIONS,MINOR",463,APR-DRG,,,,,,,inpatient,,,17455.42,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $3,126.84. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR LCB CURVE ANGIOGRAPHIC CORONARY 2",SUP-H749163911952,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SAVION DLVR VASCULAR ANGLE 300CM 3CM .014IN ICE",SUP-H749394203001J0,CDM,C1769,HCPCS,0272,RC,,,both,,,1265.54,379.66,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VIABAHN BX BALLOON EXP ENDO 6MMX29MM 7FR 135CMCATH HEPARIN",SUP-BXB062902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"PHCS [10601]",PHCS,,13653.36,70,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE FEMORAL TANDEM +0MM 12/14 TAPER HIP UNIPOLAR",SUP-71326600,CDM,C1776,HCPCS,0278,RC,,,both,,,1212.57,363.77,"NOVANET [10819]",Novanet,,909.43,75,,,,,0,141.02,1030.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC",082,MS-DRG,,,,,,,inpatient,,,77613.92,23284.18,"BLUE CROSS [10001]","Blue Cross PPO",,56424.72,,,,,,,7561,57000.58,"case rate",
"STEM HUMERAL 55MM 9MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113609,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Local Plus",,3969,31.5,,5372.07,4581.20,7242.98,23,1465.38,10710,"percent of total billed charges",
"SCR BONE 6.5MM 30MM ATS SPINE MULTIAXIAL 4.75MM ROD",SUP-54840046530,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UHC [10700]","United Healthcare",,6043.16,63.3,,5023.51,2672.93,6679.78,18,1110.3,8114.82,"percent of total billed charges",
"SUB BONE GRAFT KINEX PLUS BIOACTIVE PUTTY 2CC",SUP-8115.5302S,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2422.5,68,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BMA NEEDLE 74285-01M 11 GAUGE X 11CM",SUP-7428501M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.00,513,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1162.8,68,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 150CM 7FR .035IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145372190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"NOVANET [10819]",Novanet,,847.46,75,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX RADIOPAQUE",SUP-M0061453640,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"KAISER [10500]",Kaiser,,424.18,67,,,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) PLATE V 4 HOLE BONE NONSTERILE LATEX FREE",SUP-115.101.04,CDM,C1713,HCPCS,0278,RC,,,both,,,2527.50,758.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,299.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,293.95,2148.38,"percent of total billed charges",
"GRAFT BONE TIBIAL CORTICAL THK3-15MM THIRD ALLOGRAFT FROZEN",SUP-450571,CDM,S27800098,LOCAL,0278,RC,,,both,,,4765.14,1429.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,564.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,554.19,4050.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL GENESIS II 4 LEFT KNEE CEMENT TITANIUM",SUP-71420166,CDM,C1776,HCPCS,0278,RC,,,both,,,14593.50,4378.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3940.25,27,,,,,0,1697.22,12404.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER AQUA 4MM DYONICS ELITE STRAIGHT ABRADER STERILE",SUP-72200722,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.35,105.7,"CIGNA [10200]","Cigna Local Plus",,188.51,53.5,,,,,0,40.98,299.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 60 LARGE PEG AEQUALIS PERFORM CORTILOC",SUP-DWE423,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"KAISER [10500]",Kaiser,,6241.72,67,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 37MM 135CM 9MM 40MM BILIARY STAINLESS STEEL",SUP-PXB35-09-37-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"BLUE CROSS [10001]","Blue Cross HMO",,1711.86,39.2,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLIER INTERNAL CLIP 5MM ENDOSCOPIC HEM-O-LOK 5MM",SUP-544965,CDM,S27200284,LOCAL,0272,RC,,,both,,,16387.50,4916.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1905.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1905.87,13929.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.7MM 7MM VARIAX T5 LOCK NONSTERILE",SUP-662507,CDM,C1713,HCPCS,0278,RC,,,both,,,1075.03,322.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,493.44,45.9,,,,,0,125.03,913.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 45CM 12MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036121240,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 14.5",SUP-DIB00U0145,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"BLUE CROSS [10001]","Blue Cross HMO",,523.91,39.2,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NEURON 120CM THROMBECTOMY",SUP-PNS5F120BER,CDM,C1757,HCPCS,0272,RC,,,both,,,1012.50,303.75,"AETNA [10100]","Aetna HMO/PPO",,804.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT HUMERAL STANDARD OD32 MM GLENOSPHERE",SUP-1230-7512-001,CDM,C1776,HCPCS,0278,RC,,,both,,,16684.20,5005.26,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4775.02,28.62,,,,,0,1940.37,14181.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG 2L COMPLETE CARE ADD-A-FOLEY CONTROL-FIT TRAY ANTI",SUP-399100A,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.95,22.18,"AETNA [10100]","Aetna HMO/PPO",,58.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.6,62.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 300MM 6MM BALLOON DILATATION",SUP-PCU060300130,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,863.38,68,,,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM DIGNISHIELD FECAL MANAGEMENT 60CC CATH SYR COLL BAG",SUP-SMS002,CDM,S27000186,LOCAL,0270,RC,,,both,,,1093.50,328.05,"NOVANET [10819]",Novanet,,820.13,75,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BARD INLAY 28CM 7FR 2 PIGTAIL CURVE URETERAL",SUP-778728,CDM,C2617,HCPCS,0278,RC,,,both,,,625.73,187.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,287.21,45.9,,,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3.5MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN03510,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"FIRST HEALTH [10303]","First Health",,8274.48,80,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL NDL 4IN 3/32IN EDGE SAFETY SLEEVE",SUP-E1465B-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,54.81,16.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 175X30MM ONETRAC LX 2 SMOKE EVACUATION CHANNEL",SUP-C100220,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 120MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-583512022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT RETRIEVER 20MM 4MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0033PK42022001,CDM,S27200284,LOCAL,0272,RC,,,both,,,20045.55,6013.66,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"RESPIRATORY SIGNS AND SYMPTOMS",204,MS-DRG,,,,,,,inpatient,,,33982.74,10194.82,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH 3FT THERMISTOR",SUP-M0046510,CDM,S27200284,LOCAL,0272,RC,,,both,,,2537.63,761.29,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHELL ACETABULAR 46MM 47.8MM HIP 3 SCR HOLE CLUSTER HA",SUP-542-11-46D,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,824.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,809.18,5914.06,"percent of total billed charges",
"CAGE SPINAL 17X7MM DIVERGENCE 14MM LORDOTIC NUCLEUS PULPOSUS",SUP-G6626747,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"NOVANET [10819]",Novanet,,9315,75,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 49CM 8.6FR HELIX VENTRICLE 1 COIL ACTIVE",SUP-6935M49,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]","Cigna Open Access",,5752.62,33.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 8MM 3.5MM CORONARY STENT COCR RAPID",SUP-1007849-08,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 5.00 X 20MM",SUP-H7493942820500,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"PHCS [10601]",PHCS,,4347,70,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH MOD + PROF XTRA 525CC",SUP-RSZ-MPX-525S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL STERILE LATEX FREE DISPOSABLE SUREFORM 45 14",SUP-480445,CDM,S27200284,LOCAL,0272,RC,,,both,,,3622.50,1086.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,429.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,421.3,3079.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE KORE FIBER CORTICAL BONE FIBER 1CC ALLOGRAFT",SUP-423201,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CIGNA [10200]","Cigna Open Access",,981.53,56.9,,1144.80,304.56,2275.09,66,200.62,1466.25,"percent of total billed charges",
"BIT DRILL 100MM 2.7MM LONG QUICK COUPLING 50MM 2.7MM CORTEX",SUP-311.26,CDM,S27000186,LOCAL,0270,RC,,,both,,,1550.02,465.01,"KAISER [10500]",Kaiser,,1038.51,67,,,,,0,180.27,1317.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT MONORAIL 31MM 135CM 10MM ENDOPROSTHESIS",SUP-M001719050,CDM,C1876,HCPCS,0278,RC,,,both,,,16615.20,4984.56,"CIGNA [10200]","Cigna Local Plus",,5233.79,31.5,,,,,0,1932.35,14122.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 37MM 80CM 10MM 40MM BILIARY STAINLESS STEEL",SUP-PXB35-10-37-080,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"FIRST HEALTH [10303]","First Health",,3493.6,80,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR NDL SURGICAL",SUP-PK1011,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 45D JJ ELEVATED 54MM 36MM LONGEVITY HIP",SUP-00875201136,CDM,C1776,HCPCS,0278,RC,,,both,,,6497.40,1949.22,"CIGNA [10200]","Cigna Local Plus",,3476.11,53.5,,5372.07,4581.20,7242.98,23,755.65,5522.79,"percent of total billed charges",
"SCR BONE 6.5MM 40MM SPINAL POLYAXIAL 5.5MM ROD",SUP-8456540,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1385.95,28.62,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 9MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P509,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3434.27,41.1,,6417.48,6417.48,6417.48,"1 through 10",971.79,7102.52,"percent of total billed charges",
"KIT ADVANCE COOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-CRKA-17-75-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 6MM XIA 3 TITANIUM RADIOLUCENT",SUP-48238040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPEL APD TWIST-LOC 15CM 10FR SHORT LENGTH PIGTAIL",SUP-H7493931110150,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,90.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,90.43,660.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 12MM X 30CM",SUP-M0035471230,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4039.61,28.62,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 15MM DVR TITANIUM CORTICAL DISTAL RADIUS",SUP-CS15000,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"BLUE CROSS [10001]","Blue Cross PPO",,428.65,39.2,,957.42,570.23,957.42,28,127.17,929.48,"percent of total billed charges",
"GWIRE COONS-BENTSON ENDOSCOPIC 145CM .038IN STAINLESS STEEL",SUP-G14619,CDM,C1769,HCPCS,0272,RC,,,both,,,204.28,61.28,"PHCS [10601]",PHCS,,143,70,,,,,0,23.76,173.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Muga Bld Pool Mult",PX-341000030,CDM,78473,CPT,0341,RC,,,both,,,2635.28,790.58,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2.64,.1,,,,,0,2.64,2239.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURESIGHT BLADE HYPERANGULATED SIZE 3",SUP-390231000,CDM,S27000186,LOCAL,0270,RC,,,both,,,321.90,96.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,147.75,45.9,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK II 145CM 6MM 5FR 1.2MM BALLOON DILATATION",SUP-1012401-06Z,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 110MM 6MM XIA TITANIUM",SUP-48238110,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC .99CM 5.37X7.79CM MOMENTUM HEARTLOGIC RIGHT",SUP-D121,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"KAISER [10500]",Kaiser,,27175.2,67,,,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR E1 CERAMIC POROUS HIP CEMENT FIX STEM CUP",SUP-98B00100157,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10357.2,41.1,,6417.48,6417.48,6417.48,"1 through 10",2930.76,21420,"percent of total billed charges",
"SCR BONE 5MM 46MM X25 LOCK STERILE LATEX FREE INTRAMEDULLARY",SUP-04.045.046TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 92CM 1MM 6FR 52-8-2MM SPACE REGULAR D CURVE",SUP-D6-10DR-P10-RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2096.20,628.86,"NOVANET [10819]",Novanet,,1572.15,75,,,,,0,243.79,1781.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL UNITY KNEE 6 KNEE FIX BEARING",SUP-112.040.12,CDM,C1776,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1678.56,28.62,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-150440108,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8130.78,27,,,,,0,3502.26,25596.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 15MM 44MM SHOULDER SOFT TISSUE BALANCE",SUP-7122880,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CIGNA [10200]","Cigna Local Plus",,4237.2,53.5,,5372.07,4581.20,7242.98,23,921.1,6732,"percent of total billed charges",
"ADPTR FEMORAL PFC SIGMA NEUTRAL KNEE BOLT STERILE",SUP-960783,CDM,C1776,HCPCS,0278,RC,,,both,,,1671.00,501.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,478.24,28.62,,,,,0,194.34,1420.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM THR XLPE POROUS CUP LINER INSRT",SUP-98B00100190,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1635.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1604.94,11730,"percent of total billed charges",
"CMPNT FEMORAL 3 STD KNEE RIGHT CRUCIATE RETAIN PERSONA COCR",SUP-42502805402,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"CIGNA [10200]",Cigna,,11558.23,40,,5873.17,5873.17,5873.17,"1 through 10",3360.56,24561.24,"percent of total billed charges",
"SET STENT 22CM 8FR 2.1FR POLARIS ULTRA NAUTILUS ZIPWIRE .038",SUP-M006192151170,CDM,C2617,HCPCS,0278,RC,,,both,,,1357.24,407.17,"CIGNA [10200]","Cigna Open Access",,772.27,,,,,,,157.85,1153.65,"percent of total billed charges",
"SURFACE ARTICULAR 10MM PERSONA 6-9 E-F KNEE LEFT",SUP-42511400710,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"AETNA [10100]","Aetna HMO/PPO",,6420.23,79.5,,10981.53,8986.79,12413.38,12,939.21,6864.4,"percent of total billed charges",
"SCR BONE 5.5MM 90MM MONSTER SHORT THREAD CANNULATED SHARP",SUP-P20-555-090S,CDM,C1713,HCPCS,0278,RC,,,both,,,2981.25,894.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,353.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,346.72,2534.06,"percent of total billed charges",
"HEAD BIPOLAR BROWN 48MM 28MM SELF-CENTERING HIP FEMUR",SUP-103548000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"CIGNA [10200]","Cigna Open Access",,1743.6,56.9,,5302.19,4377.88,6578.61,27,356.38,2604.67,"percent of total billed charges",
"CATH INFINITI THRULUMEN 100CM 5FR .047IN JUDKINS RIGHT",SUP-534523T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,63.6,68,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 24FR SILICONE RADIOPAQUE EXTERNAL RETENTION RING",SUP-8160-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,592.52,177.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,70.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.91,503.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 25MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-425,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"CIGNA [10200]",Cigna,,6684.75,68,,5873.17,5873.17,5873.17,"1 through 10",1143.29,8355.94,"percent of total billed charges",
"SURFACE ARTICULAR PERSONA 4-5 C-D KNEE RIGHT TIBIA FIX",SUP-42522100316,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"FIRST HEALTH [10303]","First Health",,8621.14,80,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 B NEUTRAL 32MM E1 HIP",SUP-010000846,CDM,C1776,HCPCS,0278,RC,,,both,,,12282.00,3684.6,"KAISER [10500]",Kaiser,,8228.94,67,,,,,0,1428.4,10439.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY FEMORAL 95MM 20MM RECLAIM 40MM 12/14 OFFSET MINI TAPER",SUP-197520095,CDM,C1776,HCPCS,0278,RC,,,both,,,22082.76,6624.83,"KAISER [10500]",Kaiser,,14795.45,67,,,,,0,2568.22,18770.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5 36MM ARTICUL/EZE",SUP-473436050,CDM,C1776,HCPCS,0278,RC,,,both,,,14072.55,4221.76,"BLUE CROSS [10001]","Blue Cross HMO",,5516.44,39.2,,5311.50,4717.44,5388.59,31,1636.64,11961.67,"percent of total billed charges",
"LENS IOL 0 D +15 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.150,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL HOLLOW COMPLETE 2.7 MM SCR NONSTERILE",SUP-309.250,CDM,S27200284,LOCAL,0272,RC,,,both,,,2173.50,652.05,"FIRST HEALTH [10303]","First Health",,1738.8,80,,,,,0,252.78,1847.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5 36MM ARTICUL/EZE",SUP-473436050,CDM,C1776,HCPCS,0278,RC,,,both,,,14072.55,4221.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1667.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1636.64,11961.67,"percent of total billed charges",
"STEM FEMORAL 195MM 21MM MODULAR RESTORATION BOWED CONICAL",SUP-6276-7-221,CDM,C1776,HCPCS,0278,RC,,,both,,,11695.32,3508.6,"CIGNA [10200]",Cigna,,4678.13,40,,5873.17,5873.17,5873.17,"1 through 10",1360.17,9941.02,"percent of total billed charges",
"HEAD FEMORAL -3MM 36MM HIP MODULAR BIOLOX DELTA",SUP-12-115120,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"CIGNA [10200]",Cigna,,5982.3,68,,5873.17,5873.17,5873.17,"1 through 10",1023.15,7477.88,"percent of total billed charges",
"BIPOLAR UNIPOLAR HIP WITH ANY HIGHLY POROUS CEMENTLESS",SUP-CAP-DS-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,13455.00,4036.5,"CIGNA [10200]",Cigna,,5382,40,,5873.17,5873.17,5873.17,"1 through 10",1564.82,11436.75,"percent of total billed charges",
"STEM FEMORAL 114MM CEMENT SUMMIT 4 12/14 STD OFFSET TAPER",SUP-157003100,CDM,C1776,HCPCS,0278,RC,,,both,,,18219.60,5465.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2118.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2118.94,15486.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII POSTERIOR STABILIZED HYB",SUP-71704530,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"FIRST HEALTH [10303]","First Health",,17640,80,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VENTRALIGHT ST ECHO 2 35X30CM ELLIPSE",SUP-5993035,CDM,C1781,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,3096.73,1.00,3096.73,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"LENS IOL 0 D +18.5 DIOPTER BICONVEX 13MM 6MM POSTERIOR CHMBR",SUP-CC60WF.185,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 75MM KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-183114,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5849.74,27,,,,,0,2519.72,18415.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PRIMARY HYBRID KNEE",SUP-TKASTND-HYB,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"UHC [10700]","United Healthcare",,13957.65,63.3,,8601.07,8395.67,8601.07,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"MATRIX TISSUE BIODRESTORE CRYOPRIME MEDIUM HUMAN AMNIOTIC",SUP-AM-010050,CDM,V2790,HCPCS,0278,RC,,,both,,,7590.00,2277,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3483.81,45.9,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 7MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT076080A,CDM,C1768,HCPCS,0278,RC,,,both,,,18225.90,5467.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7290.36,40,,,,,0,2119.67,15492.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUMP CYLNDER PENILE 15CM 700MS",SUP-72404231,CDM,C1813,HCPCS,0278,RC,,,both,,,76351.50,22905.45,"BLUE CROSS [10001]","Blue Cross HMO",,29929.79,39.2,,,,,0,8879.68,64898.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUMP CYLNDER PENILE 15CM 700MS",SUP-72404231,CDM,C1813,HCPCS,0278,RC,,,both,,,76351.50,22905.45,"CIGNA [10200]",Cigna,,30540.6,40,,,,,0,8879.68,64898.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL LEAD TUNNLR",SUP-6888,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"AMERIGROUP MEDICAID [20100]",Amerigroup,,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 103MM TRI-LOCK BPS GRIPTION 4 STD OFFSET HIP",SUP-101204040,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"BLUE CROSS [10001]","Blue Cross PPO",,6313.99,39.2,,3949.44,3949.44,3949.44,"1 through 10",1873.26,13691.05,"percent of total billed charges",
"LINER ACETABULAR PINNACLE NEUTRAL 64MM 36MM MARATHON HIP",SUP-121936064,CDM,C1776,HCPCS,0278,RC,,,both,,,8942.40,2682.72,"CIGNA [10200]","Cigna Local Plus",,4784.18,53.5,,5372.07,4581.20,7242.98,23,1040,7601.04,"percent of total billed charges",
"BEARING 79/83MMX10MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183560,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"BLUE CROSS [10001]","Blue Cross HMO",,5077.45,39.2,,5311.50,4717.44,5388.59,31,1506.4,11009.78,"percent of total billed charges",
"CMPNT FEMORAL E LEFT KNEE CEMENTED POSTERIOR STABILIZED",SUP-00596401551,CDM,C1776,HCPCS,0278,RC,,,both,,,15346.80,4604.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1818.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1784.83,13044.78,"percent of total billed charges",
"BEARING 79/83MMX10MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183560,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1534.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1506.4,11009.78,"percent of total billed charges",
"SURFACE ARTICULAR 12MM PERSONA 3-5 C-D KNEE LEFT",SUP-42511400412,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,956.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 64MM 36MM MARATHON HIP",SUP-121936064,CDM,C1776,HCPCS,0278,RC,,,both,,,8942.40,2682.72,"MULTIPLAN [10600]",Multiplan,,7601.04,85,,,,,0,1040,7601.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 3-5 C-D KNEE LEFT",SUP-42511400412,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5491.52,68,,,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 6 13MM KNEE POSTERIOR STABILIZED BEARING TRIAT",SUP-5532P613,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS [10001]","Blue Cross PPO",,3275.51,39.2,,3949.44,3949.44,3949.44,"1 through 10",971.79,7102.52,"percent of total billed charges",
"STEM FEMORAL 150MM 16MM REVISION MODULAR ARCOS STS TITANIUM",SUP-11-300816,CDM,C1776,HCPCS,0278,RC,,,both,,,20372.94,6111.88,"CIGNA [10200]","Cigna Open Access",,6824.93,33.5,,5302.19,4377.88,6578.61,27,2369.37,17317,"percent of total billed charges",
"INSRT TIBIAL 5 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650507,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1555.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 8MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158102108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7598.69,68,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +27.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.275,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTERED TC 99M-SODIUM THIOSULFATE SOLUTION (20-40 MCI)",RX-411855,CDM,A9541,HCPCS,0343,RC,08888-8876-02,NDC,both,1,UN,746.77,224.03,"NOVANET [10819]",Novanet,,560.08,75,,,,,0,86.85,746.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM ATTUNE 4 KNEE POSTERIOR CEMENT REVISION",SUP-154904001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"PHCS [10601]",PHCS,,4250.4,70,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE U - CB CUTTING BLOCK",SUP-CAP-U-CB,CDM,C1776,HCPCS,0278,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D H KNEE LEFT OSSEOTI KEEL",SUP-42535008301,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3939.69,28.62,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BROWN 47MM 28MM SELF-CENTERING HIP FEMUR",SUP-103547000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,877.01,28.62,,,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D H KNEE LEFT OSSEOTI KEEL",SUP-42535008301,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"FIRST HEALTH [10303]","First Health",,11012.4,80,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 6MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620306,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"NOVANET [10819]",Novanet,,8440.43,75,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 49MM 28MM TANDEM HIP ACETABULAR COCR",SUP-71322049,CDM,C1776,HCPCS,0278,RC,,,both,,,8352.45,2505.73,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2390.47,28.62,,,,,0,971.39,7099.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE WALKING LARGE ANKLE FOOT PNEUMATIC LOW ROCKER SOLE",SUP-01F-L,CDM,L4360,HCPCS,0274,RC,,,both,,,393.41,118.02,"KAISER [10500]",Kaiser,,263.58,67,,,,,0,45.75,334.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 70CM 145CM 5FR 20D .035IN URETERAL ANGLED TIP BEVELED",SUP-G14600,CDM,C1758,HCPCS,0272,RC,,,both,,,272.75,81.82,"FIRST HEALTH [10303]","First Health",,218.2,80,,,,,0,31.72,231.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC LARGE 1 PIECE AUTOSTOP BUCKLE 2 PRONG",SUP-563499,CDM,S27000186,LOCAL,0270,RC,,,both,,,668.90,200.67,"KAISER [10500]",Kaiser,,448.16,67,,,,,0,77.79,568.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT BREATHING T PIECE PEEP VALVE DEHP FREE NEONATE LATEX",SUP-M1091335VS,CDM,S27000186,LOCAL,0270,RC,,,both,,,84.19,25.26,"MULTIPLAN [10600]",Multiplan,,71.56,85,,,,,0,9.79,71.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAP TISSUE BERKELEY SAFETOUCH SPECIMEN ASPIRATION SYSTEM",SUP-003853-902,CDM,S27000186,LOCAL,0270,RC,,,both,,,74.12,22.24,"KAISER [10500]",Kaiser,,49.66,67,,,,,0,8.62,63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cardioassist Intrnl",PX-481000011,CDM,92970,CPT,0481,RC,,,both,,,5701.00,1710.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2616.76,45.9,,,,,0,663.03,4845.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIRWAY LARYNGEAL MASK SIZE 2.5 SILICONE DISPOSABLE SOURCEMAR",SUP-SOUM0372,CDM,S27000186,LOCAL,0270,RC,,,both,,,47.85,14.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.56,40.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STOCKING COMPRESSION MEDIUM TUBULAR SOFT TENSOGRIP",SUP-13201,CDM,S27000186,LOCAL,0270,RC,,,both,,,274.83,82.45,"MULTIPLAN [10600]",Multiplan,,233.61,85,,,,,0,31.96,233.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL O2 DELIVERY TUBE INTERMEDIATE INFANT 7L/MIN RT329",SUP-BC2755-20,CDM,S27000186,LOCAL,0270,RC,,,both,,,70.91,21.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,32.55,45.9,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL BLOCK 14X13",SUP-245341,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR EMPHASYS NEUTRAL 54MM 40MM AOX HIP",SUP-472254040,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 52MM 32MM MARATHON HIP",SUP-121932152,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3722.93,45.9,,,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA NATURAL TIBIA 5D G KNEE RIGHT STEM",SUP-42532007902,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"BLUE CROSS [10001]","Blue Cross PPO",,4286.03,39.2,,3949.44,3949.44,3949.44,"1 through 10",1271.59,9293.68,"percent of total billed charges",
"BASEPLT TIBIAL PERSONA NATURAL TIBIA 5D G KNEE RIGHT STEM",SUP-42532007902,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"NOVANET [10819]",Novanet,,8200.31,75,,,,,0,1271.59,9293.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 62MM 32MM XLPE HIP",SUP-71337662,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"NOVANET [10819]",Novanet,,8344.69,75,,,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE REVERSE HYBRID WITH CEMENTED PATELLA CONC",SUP-71704620,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2762.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2710.95,19813.5,"percent of total billed charges",
"INSRT TIBIAL 6 15MM KNEE GVF STABILIZE ROTATE PLATFORM PFC",SUP-962163,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"UHC [10700]","United Healthcare",,6459.83,63.3,,8601.07,8395.67,8601.07,"1 through 10",1186.85,8674.34,"percent of total billed charges",
"STEM HUMERAL 7MM UNIVERS APEX OPTIFIT",SUP-AR-9100-07M,CDM,C1776,HCPCS,0278,RC,,,both,,,26302.50,7890.75,"CIGNA [10200]","Cigna Open Access",,8811.34,33.5,,5302.19,4377.88,6578.61,27,3058.98,22357.13,"percent of total billed charges",
"AUG FEMORAL 5MM TRIATHLON 5 LEFT DISTAL KNEE",SUP-5540-A-501,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,538.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,528.45,3862.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 10 12MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151621012,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"AETNA [10100]","Aetna HMO/PPO",,8946.85,79.5,,10981.53,8986.79,12413.38,12,1308.83,9565.82,"percent of total billed charges",
"CMPNT FEMORAL 5 KNEE RIGHT CEMENTED CRUCIATE RETAINING",SUP-150400205,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2653.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +15 DIOPTER MODIFY C BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB0000150,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"BLUE CROSS [10001]","Blue Cross PPO",,460.4,39.2,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 CURVE PLUS 20MM KNEE XLK FIX BEARING SIGMA",SUP-970455,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"PHCS [10601]",PHCS,,7822.19,70,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 8-11 E-F KNEE RIGHT TIBIA FIX",SUP-42522100810,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1253.3,9159.96,"percent of total billed charges",
"SHELL ACETABULAR 52MM PRIMARY HEMISPHERICAL CLUSTER HOLE",SUP-502-03-52D,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"CIGNA [10200]","Cigna Local Plus",,5599.75,53.5,,5372.07,4581.20,7242.98,23,1217.29,8896.8,"percent of total billed charges",
"CMPNT PATELLAR STD 31MM 3 PEG KNEE SERIES A",SUP-184764,CDM,C1776,HCPCS,0278,RC,,,both,,,4824.48,1447.34,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1380.77,28.62,,,,,0,561.09,4100.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL F KNEE RIGHT LPS-FLEX GENDER SOLUTIONS OPT",SUP-00576401652,CDM,C1776,HCPCS,0278,RC,,,both,,,21833.28,6549.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8733.31,40,,,,,0,2539.21,18558.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 32MM VIVACIT-E ALL POLY KNEE",SUP-42540200032,CDM,C1776,HCPCS,0278,RC,,,both,,,5322.66,1596.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,630.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,619.03,4524.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM TRIATHLON 3 RIGHT MEDIAL LEFT LATERAL TOAL",SUP-5546-A-302,CDM,C1776,HCPCS,0278,RC,,,both,,,4766.58,1429.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2187.86,45.9,,,,,0,554.35,4051.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 19MM KNEE X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G219,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"MULTIPLAN [10600]",Multiplan,,7961.17,85,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 22MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-122,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"UHC [10700]","United Healthcare",,8519.2,63.3,,8601.07,8395.67,8601.07,"1 through 10",1565.22,11439.68,"percent of total billed charges",
"INSRT TIBIAL 1 22MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-122,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3633.78,27,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYPROPYLENE 20X20IN PERMANENT REINFORCE LOCK",SUP-F10244-2020P,CDM,C1781,HCPCS,0278,RC,,,both,,,20664.00,6199.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8492.9,41.1,,,,,0,2403.22,17564.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TMPLT SIZING MEDIAL PATELLOFEMORAL LIGAMENT NONSTERILE",SUP-AR-13211,CDM,S27200284,LOCAL,0272,RC,,,both,,,3110.63,933.19,"KAISER [10500]",Kaiser,,2084.12,67,,,,,0,361.77,2644.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP 6 UNIPOLAR/BIPOLAR - FX STEM/STRYKER",SUP-CAP-H-6,CDM,C1776,HCPCS,0278,RC,,,both,,,6720.00,2016,"MULTIPLAN [10600]",Multiplan,,5712,85,,,,,0,781.54,5712,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-150440106,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"BLUE CROSS [10001]","Blue Cross PPO",,11804.69,39.2,,3949.44,3949.44,3949.44,"1 through 10",3502.26,25596.9,"percent of total billed charges",
"TOTAL HIP 6 UNIPOLAR/BIPOLAR - FX STEM/STRYKER",SUP-CAP-H-6,CDM,C1776,HCPCS,0278,RC,,,both,,,6720.00,2016,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4569.6,68,,,,,0,781.54,5712,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 48MM 16MM STD SHELL DJO SURGICAL ALTIVATE",SUP-530-16-048,CDM,C1776,HCPCS,0278,RC,,,both,,,47494.44,14248.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5628.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,5523.6,40370.27,"percent of total billed charges",
"LINER ACETABULAR R3 20D 62MM 36MM XLPE HIP STERILE",SUP-71335762,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"AETNA [10100]","Aetna HMO/PPO",,8845.37,79.5,,10981.53,8986.79,12413.38,12,1293.98,9457.31,"percent of total billed charges",
"GRAFT SYNTHETIC TISSUE 8X8CM BIO-A BIOABSORBABLE",SUP-FS0808,CDM,C1781,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,858.6,28.62,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ANTERIOR ASPHERIC SURFACE ABERRATION FREE ADVANCED",SUP-LI61AOR2850,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,396.9,39.2,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 18CM 5FR .035",SUP-M006192115090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"BLUE CROSS [10001]","Blue Cross HMO",,585.03,39.2,,,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-71422345,CDM,C1776,HCPCS,0278,RC,,,both,,,29720.25,8916.07,"MULTIPLAN [10600]",Multiplan,,25262.21,85,,,,,0,3456.47,25262.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE RIGHT MEDIAL LEFT LATERAL RESTORIS",SUP-180513,CDM,C1776,HCPCS,0278,RC,,,both,,,12440.70,3732.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1474.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1446.85,10574.6,"percent of total billed charges",
"CMPNT FEMORAL 5 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-71422345,CDM,C1776,HCPCS,0278,RC,,,both,,,29720.25,8916.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11888.1,40,,,,,0,3456.47,25262.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 20MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405620,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"BLUE CROSS [10001]","Blue Cross HMO",,3788.07,39.2,,5311.50,4717.44,5388.59,31,1123.86,8213.93,"percent of total billed charges",
"HC Cann Fem Art Perc Bio-Med 15f",PX-E27200380,CDM,E27200380,LOCAL,0272,RC,,,both,,,1442.10,432.63,"CIGNA [10200]","Cigna Local Plus",,771.52,53.5,,,,,0,167.72,1225.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ACCESS MICROPUNCTURE STIFFENED TRANSITIONLESS CANN",SUP-G35550,CDM,C1769,HCPCS,0272,RC,,,both,,,432.74,129.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,177.86,41.1,,,,,0,50.33,367.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH ADULT 24CM 15.5FR DURATHANE DURAFLOW EMBOSAFE BASIC",SUP-H787103012015,CDM,C1750,HCPCS,0278,RC,,,both,,,1104.50,331.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,130.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,128.45,938.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +4MM 26MM HIP PRIMARY TAPER OFFSET COCR LFIT",SUP-6260-9-226,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,895.15,28.62,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 115MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.915,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"PHCS [10601]",PHCS,,962.09,70,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 19MM RESTORATION +30MM HIP MODULAR",SUP-6276-1-319,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3906.04,27,,,,,0,1682.49,12296.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 13MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G113,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1163,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE 13",SUP-PCB0000210,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT GLENOID UNIVERS REVERS POROUS OD30 MM SHOULDER MOD",SUP-AR-9561-30P,CDM,C1776,HCPCS,0278,RC,,,both,,,4029.60,1208.88,"BLUE CROSS [10001]","Blue Cross HMO",,1579.6,39.2,,5311.50,4717.44,5388.59,31,468.64,3425.16,"percent of total billed charges",
"STEM FEMORAL 120MM CEMENT SUMMIT 5 12/14 HIGH OFFSET TAPER",SUP-157013110,CDM,C1776,HCPCS,0278,RC,,,both,,,18219.60,5465.88,"CIGNA [10200]","Cigna Local Plus",,5739.17,31.5,,5372.07,4581.20,7242.98,23,2118.94,15486.66,"percent of total billed charges",
"BLOCK AUGMENTATION OSS 71/75MMX20MM KNEE TIBIA RIGHT MEDIAL",SUP-150431,CDM,C1776,HCPCS,0278,RC,,,both,,,8232.39,2469.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2356.11,28.62,,,,,0,957.43,6997.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +12.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.125,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00180,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"BLUE CROSS [10001]","Blue Cross PPO",,428.65,39.2,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 4.5MM 45MM HAND INNATE INTRAMEDULLARY ANATOMIC",SUP-EXINN924545,CDM,C1713,HCPCS,0278,RC,,,both,,,5002.50,1500.75,"BLUE CROSS [10001]","Blue Cross HMO",,1960.98,39.2,,957.42,156.86,7483.26,51,581.79,4252.13,"percent of total billed charges",
"LINER ACETABULAR G7 D 40MM COCR HIP 2 MOBILITY",SUP-110024462,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1534.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1506.4,11009.78,"percent of total billed charges",
"CMPNT FEMORAL 72.5MM KNEE LEFT POSTERIOR STABILIZE CEMENT",SUP-183133,CDM,C1776,HCPCS,0278,RC,,,both,,,21665.70,6499.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8904.6,41.1,,6417.48,6417.48,6417.48,"1 through 10",2519.72,18415.85,"percent of total billed charges",
"HT COMMAND 14 MT 4G X 25CM 210CM",SUP-1060003,CDM,C1769,HCPCS,0272,RC,,,both,,,963.90,289.17,"MULTIPLAN [10600]",Multiplan,,819.32,85,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM TARGET TETRA DETACHABLE STERILE",SUP-TG5413060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS [10001]","Blue Cross HMO",,5532.94,39.2,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 36MM 22.2MM ACTIVE ARTICULATION E1 B G7 2",SUP-010000991,CDM,C1776,HCPCS,0278,RC,,,both,,,2700.00,810,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,314.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +22 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.220,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 9MM KNEE XLPE POSTERIOR STABILIZE LEGION",SUP-71453247,CDM,C1776,HCPCS,0278,RC,,,both,,,14831.55,4449.46,"CIGNA [10200]","Cigna Open Access",,4968.57,33.5,,5302.19,4377.88,6578.61,27,1724.91,12606.82,"percent of total billed charges",
"HEAD FEMORAL +0MM 11/13 32MM HIP ALUMINA S-ROM",SUP-528323,CDM,C1776,HCPCS,0278,RC,,,both,,,8956.20,2686.86,"KAISER [10500]",Kaiser,,6000.65,67,,,,,0,1041.61,7612.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 9MM KNEE XLPE POSTERIOR STABILIZE LEGION",SUP-71453247,CDM,C1776,HCPCS,0278,RC,,,both,,,14831.55,4449.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6095.77,41.1,,6417.48,6417.48,6417.48,"1 through 10",1724.91,12606.82,"percent of total billed charges",
"INSRT TIBIAL 7 16MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710716,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"CIGNA [10200]","Cigna Local Plus",,4659.98,31.5,,5372.07,4581.20,7242.98,23,1720.5,12574.56,"percent of total billed charges",
"PATCH SURGICAL SMALL CIRCLE 1.7IN HERNIA REPAIR MONOFILAMENT",SUP-0010301,CDM,C1781,HCPCS,0278,RC,,,both,,,1727.25,518.17,"PHCS [10601]",PHCS,,1209.08,70,,,,,0,200.88,1468.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +8 DIOPTER MODIFY L BICONVEX 13MM 6MM POSTERIOR",SUP-CCA0T0.080,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 50MM SPINAL FENESTRATE MULTIAXIAL 5.5/6MM ROD",SUP-55840024550T,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"GWIRE ORTHOPEDIC 150MM 1.4MM STERILE",SUP-03.333.002S,CDM,C1769,HCPCS,0272,RC,,,both,,,473.20,141.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,55.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,55.03,402.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 4MM 7FR 1-7-4MM SPACE F CURVE ABLATION",SUP-118331S,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 120MM 3MM BALLOON DILATATION RAPID",SUP-47530120M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Factor VIII 1 Stage",PX-305000018,CDM,85240,CPT,0305,RC,,,both,,,563.11,168.93,"PHCS [10601]",PHCS,,394.18,70,,,,,0,0.01,478.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repositioning Prev Impl Ccm-D Transvns Eltrd/Ld",PX-481000419,CDM,0924T,CPT,0481,RC,,,both,,,953.00,285.9,"CIGNA [10200]","Cigna Local Plus",,953,,"Case rate ($29,596). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,110.83,953,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRGMR NEROSTIMLTR MYSTIM MRI TECHNOLOGY EXT",SUP-97740,CDM,C1787,HCPCS,0270,RC,,,both,,,4830.00,1449,"CIGNA [10200]",Cigna,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP MULTIHOLE TRITANIUM TRIDENT II F",SUP-709-04-58F,CDM,C1776,HCPCS,0278,RC,,,both,,,17958.91,5387.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7183.56,40,,,,,0,2088.62,15265.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PALINDROME 45CM 28CM 14.5FR CENTRAL VENOUS CARBOTHANE",SUP-8888128450P,CDM,C1750,HCPCS,0278,RC,,,both,,,2142.00,642.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,249.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,249.11,1820.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL OXFORD D KNEE RIGHT MEDIAL UNICOMPARTMENTAL",SUP-154725,CDM,C1776,HCPCS,0278,RC,,,both,,,11195.94,3358.78,"CIGNA [10200]","Cigna Open Access",,6370.49,56.9,,5302.19,4377.88,6578.61,27,1302.09,9516.55,"percent of total billed charges",
"ADPTR HEAD TITANIUM STD TAPER COMPREHENSIVE VERSA-DIAL",SUP-118001,CDM,C1776,HCPCS,0278,RC,,,both,,,9089.00,2726.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1057.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1057.05,7725.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM 15MM CEMENT GMRS COCR STRAIGHT HIP",SUP-6485-3-115,CDM,C1776,HCPCS,0278,RC,,,both,,,14800.50,4440.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1753.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1721.3,12580.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CALCAR 29MM RESTORATION +30MM OFFSET HIP MODULAR",SUP-6276-4-329,CDM,C1776,HCPCS,0278,RC,,,both,,,23206.05,6961.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2698.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2698.86,19725.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL DUALMESH PLUS 10X7.5CM SOFT TISSUE BIOMATERIAL",SUP-1DLMCP05,CDM,C1781,HCPCS,0278,RC,,,both,,,2655.00,796.5,"CIGNA [10200]",Cigna,,1805.4,68,,,,,0,308.78,2256.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +15.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.155,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,345.41,28.62,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SURGICAL OSTEOCOOL BONE ACCESS 8GA",SUP-OCN003,CDM,S27200284,LOCAL,0272,RC,,,both,,,3000.00,900,"MULTIPLAN [10600]",Multiplan,,2550,85,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOLOX DELTA HEAD 12/14 36X0",SUP-00-8775-036-02,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"FIRST HEALTH [10303]","First Health",,7886.98,80,,,,,0,1146.57,8379.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 14/16 OFFSET TAPER 36MM HIP M SPECIFICATIO",SUP-101836500,CDM,C1776,HCPCS,0278,RC,,,both,,,8067.48,2420.24,"AETNA [10100]","Aetna HMO/PPO",,6413.65,79.5,,10981.53,8986.79,12413.38,12,938.25,6857.36,"percent of total billed charges",
"STEM HUMERAL 108MM 6MM MONOBLOCK RSP",SUP-510-00-006,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"AETNA [10100]","Aetna HMO/PPO",,10017,79.5,,10981.53,8986.79,12413.38,12,1465.38,10710,"percent of total billed charges",
"INSRT TIBIAL 4 CURVE 10MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962041,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1096.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1075.71,7862.03,"percent of total billed charges",
"CAP KIT REPLACEMENT SHOULDER TRABECULAR METAL REVERSE",SUP-98000971000,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5748.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +2.5MM 26MM HIP C TAPER INTERLOK COCR LFIT",SUP-S-1400-HH62,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,363.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 5CM 5FR TAPER CONTOUR SPIRAL OFFSET PANCREATIC",SUP-G21803,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUINTON 42CM DIALYSIS PEDIATRIC PERITONEAL 2 CUFF",SUP-8810888003,CDM,C1750,HCPCS,0278,RC,,,both,,,410.29,123.09,"FIRST HEALTH [10303]","First Health",,328.23,80,,,,,0,47.72,348.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Arthgm Elbow Si",PX-322000002,CDM,73085,CPT,0322,RC,,,both,,,1259.43,377.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,149.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117,1070.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 25MM X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-325,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"FIRST HEALTH [10303]","First Health",,10766.76,80,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 16CM TOUCH NARROW BASE INFRAPUBIC NARROW",SUP-EN2816,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS [10001]","Blue Cross HMO",,24578.4,39.2,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CARDIAC MNTR REVEAL LINQ INSERTABLE",SUP-LNQ11,CDM,C1764,HCPCS,0278,RC,,,both,,,17982.00,5394.6,"NOVANET [10819]",Novanet,,13486.5,75,,,,,0,2091.31,15284.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Heavy Metal Qual Any Numbr",PX-301000218,CDM,83015,CPT,0301,RC,,,both,,,534.00,160.2,"NOVANET [10819]",Novanet,,400.5,75,,,,,0,0.53,453.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Heavy Metal Qual Any Numbr",PX-301000218,CDM,83015,CPT,0301,RC,,,both,,,534.00,160.2,"CIGNA [10200]",Cigna,,46.07,,,,,,,0.53,453.9,"fee schedule",
"CMPNT FEMORAL 100MM KNEE STEM EXT REMEDY STERILE",SUP-RSK100,CDM,C1776,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2850.39,45.9,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Thorac Add >=2nd Ord",PX-361000086,CDM,36218,CPT,0361,RC,,,both,,,931.37,279.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,931.37,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,108.32,931.37,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDEPIN ORTHOPEDIC TWIST SUBTALAR",SUP-112-00-004,CDM,S27200284,LOCAL,0272,RC,,,both,,,729.00,218.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 63MMX10MM VANGUARD E1 KNEE ANTERIOR STABILIZE TIBIAL",SUP-EP189020,CDM,C1776,HCPCS,0278,RC,,,both,,,13372.20,4011.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3610.49,27,,,,,0,1555.19,11366.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19.5 DIOPTER HAPTIC C BICONVEX 13MM 6MM POSTERIOR",SUP-ZXR00U0195,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA [10200]","Cigna Open Access",,423.91,56.9,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pta Pulmonary Arty Add Vssl",PX-481000018,CDM,92998,CPT,0481,RC,,,both,,,24116.00,7234.8,"MULTIPLAN [10600]",Multiplan,,20498.6,85,,,,,0,2795,24116,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pta Pulmonary Arty Add Vssl",PX-481000018,CDM,92998,CPT,0481,RC,,,both,,,24116.00,7234.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,17669,,"Case rate ($17,669). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2795,24116,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Npwt <=50 Sq Cm (Go)",PX-430000027,CDM,97605,CPT,0430,RC,,,both,,,753.00,225.9,"KAISER [10500]",Kaiser,,504.51,67,,,,,0,87.57,640.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP MULTIHOLE R3 STD STERILE",SUP-71338666,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"CIGNA [10200]",Cigna,,6354.9,40,,5873.17,5873.17,5873.17,"1 through 10",1847.69,13504.16,"percent of total billed charges",
"ALTIVATE ANATOMIC, NEUTRAL HUMERAL HEAD, 54X18",SUP-520-54-218,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"CIGNA [10200]","Cigna Local Plus",,4862.51,53.5,,5372.07,4581.20,7242.98,23,1057.03,7725.48,"percent of total billed charges",
"VALVE SUCTION BRONCHOSCOPE STERILE DISPOSABLE",SUP-MAJ-209,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.71,29.91,"CIGNA [10200]","Cigna Open Access",,56.73,56.9,,,,,0,11.6,84.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hfe Gene",PX-309000034,CDM,81256,CPT,0310,RC,,,both,,,854.25,256.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,726.11,"per diem",
"VIA MATRIX (2 X 3) 6 SQ CM",SUP-585-005,CDM,Q4309,HCPCS,0636,RC,,,both,,,47250.00,14175,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"HC Drsg Wound Normlgel Ag 1.5oz",PX-E27200317,CDM,E27200317,LOCAL,0272,RC,,,both,,,123.42,37.03,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FLEXIVA PULSE ID 910",SUP-M006L8406940,CDM,S27200284,LOCAL,0272,RC,,,both,,,4808.75,1442.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL +7.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.075,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENTOLAMINE 5 MG INJECTION SOLUTION",RX-10947,CDM,J2760,HCPCS,0636,RC,68094-0101-20,NDC,both,1,UN,2533.91,760.17,"AETNA [10100]","Aetna HMO/PPO",,2014.46,79.5,,,,,0,37.29,2153.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY TORIC AUTONOME",SUP-CNAET4,CDM,V2787,HCPCS,0276,RC,,,both,,,880.00,264,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,598.4,68,,,,,0,102.34,748,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 9MM 33MM SYMMETRIC TRIATHLON X3 KNEE SUPERIOR",SUP-5550L339,CDM,C1776,HCPCS,0278,RC,,,both,,,4478.10,1343.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3045.11,68,,,,,0,520.8,3806.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM 11MM MRS KNEE",SUP-6485-3-111,CDM,C1776,HCPCS,0278,RC,,,both,,,14800.50,4440.15,"MULTIPLAN [10600]",Multiplan,,12580.43,85,,,,,0,1721.3,12580.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE 2 MG/ML INTRAVENOUS SYRINGE",RX-166018,CDM,J2270,HCPCS,0636,RC,00409-1890-01,NDC,both,1,ML,115.79,34.74,"CIGNA [10200]",Cigna,,8.15,,,,,,,2.54,98.42,"fee schedule",
"AUG TIBIAL 67MMX15MM VANGUARD 360 KNEE RIGHT MEDIAL LEFT",SUP-185252,CDM,C1776,HCPCS,0278,RC,,,both,,,7577.58,2273.27,"MULTIPLAN [10600]",Multiplan,,6440.94,85,,,,,0,881.27,6440.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 67MMX15MM VANGUARD 360 KNEE RIGHT MEDIAL LEFT",SUP-185252,CDM,C1776,HCPCS,0278,RC,,,both,,,7577.58,2273.27,"FIRST HEALTH [10303]","First Health",,6062.06,80,,,,,0,881.27,6440.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 24MM RIGHT STERILE",SUP-TR-H240R-S,CDM,C1776,HCPCS,0278,RC,,,both,,,13489.50,4046.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5395.8,40,,,,,0,1568.83,11466.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 42MM 28MM E HIP X3 ADM STERILE LATEX FREE",SUP-7236-2-848,CDM,C1776,HCPCS,0278,RC,,,both,,,8711.25,2613.37,"BLUE CROSS [10001]","Blue Cross PPO",,3414.81,39.2,,3949.44,3949.44,3949.44,"1 through 10",1013.12,7404.56,"percent of total billed charges",
"INSRT TIBIAL 6 11MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P611,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"FIRST HEALTH [10303]","First Health",,6684.72,80,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIPOLAR HIP 1 PRESS FIT",SUP-CAP-STY-BP1,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"UHC [10700]","United Healthcare",,6551.55,63.3,,8601.07,8395.67,8601.07,"1 through 10",1203.71,8797.5,"percent of total billed charges",
"HEAD FEMORAL +0MM 11/13 TAPER 36MM HIP MODULAR BIOLOX DELTA",SUP-136536210,CDM,C1776,HCPCS,0278,RC,,,both,,,7290.36,2187.11,"NOVANET [10819]",Novanet,,5467.77,75,,,,,0,847.87,6196.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 24MM RIGHT STERILE",SUP-TR-H240R-S,CDM,C1776,HCPCS,0278,RC,,,both,,,13489.50,4046.85,"MULTIPLAN [10600]",Multiplan,,11466.08,85,,,,,0,1568.83,11466.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP 12 SCALLOP CLUSTER HOLE SNAP FIT",SUP-00875705001,CDM,C1776,HCPCS,0278,RC,,,both,,,11012.40,3303.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7488.43,68,,,,,0,1280.74,9360.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 85MM TFN-ADVANCED STERILE",SUP-04.038.185S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,1466.08,39.2,,957.42,570.23,957.42,28,434.96,3179,"percent of total billed charges",
"STENT CONTOUR 30CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061805250,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,414.1,45.9,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.814,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",40.86,298.61,"percent of total billed charges",
"FRCP SURGICAL JANSEN-MIDDLETON 8.25IN",SUP-OK405R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1917.83,575.35,"PHCS [10601]",PHCS,,1342.48,70,,,,,0,223.04,1630.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA G KNEE RIGHT 2 PEG TIVANIUM STERILE",SUP-42530007902,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3829.96,27,,,,,0,1649.72,12057.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 2 POSTERIOR KNEE TOTAL STABILIZED",SUP-5543-A-200,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"AETNA [10100]","Aetna HMO/PPO",,3792.94,79.5,,10981.53,8986.79,12413.38,12,554.87,4055.34,"percent of total billed charges",
"INSRT TIBIAL 5-6 9MM KNEE XLPE POSTERIOR STABILIZE LEGION",SUP-71453252,CDM,C1776,HCPCS,0278,RC,,,both,,,14831.55,4449.46,"AETNA [10100]","Aetna HMO/PPO",,11791.08,79.5,,10981.53,8986.79,12413.38,12,1724.91,12606.82,"percent of total billed charges",
"INSRT TIBIAL 4 22.5MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962356,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"KAISER [10500]",Kaiser,,9717.55,67,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD LINER MP7 ORANGE/BRN 36MM",SUP-932-36-252,CDM,C1776,HCPCS,0278,RC,,,both,,,12462.02,3738.61,"CIGNA [10200]","Cigna Open Access",,4174.78,33.5,,5302.19,4377.88,6578.61,27,1449.33,10592.72,"percent of total billed charges",
"MESH SURGICAL 5.4X2.4IN HERNIA SOFT PRESHAPED KEYHOLE LARGE",SUP-0117015,CDM,C1781,HCPCS,0278,RC,,,both,,,209.96,62.99,"KAISER [10500]",Kaiser,,140.67,67,,,,,0,24.42,178.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +21.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SA60WF.215,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +11MM 14/16 OFFSET TAPER 36MM HIP M",SUP-101836511,CDM,C1776,HCPCS,0278,RC,,,both,,,5239.08,1571.72,"AETNA [10100]","Aetna HMO/PPO",,4165.07,79.5,,10981.53,8986.79,12413.38,12,609.31,4453.22,"percent of total billed charges",
"BEARING 71/75MMX12MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183742,CDM,C1776,HCPCS,0278,RC,,,both,,,13241.10,3972.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1569.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1539.94,11254.94,"percent of total billed charges",
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET HOUSING REAMER",SUP-AR-1204AF-75,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"CIGNA [10200]",Cigna,,1740.38,68,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLLGN POLYLOOP PRELOADED DEVICE DISPOSABLE ENDOSCOPIC NYLON",SUP-HX-400U-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,642.86,192.86,"CIGNA [10200]","Cigna Open Access",,365.79,56.9,,,,,0,74.76,546.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LOCKING REVERE SPINE",SUP-124.000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2406.60,721.98,"FIRST HEALTH [10303]","First Health",,1925.28,80,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Parva B19 Qpcr Plasma 1500",PX-306000162,CDM,87799,CPT,0306,RC,,,both,,,907.25,272.17,"UHC [10700]","United Healthcare",,38.56,,,,,,,0.91,771.16,"fee schedule",
"CMPNT FEMORAL SMALL 65X55MM KNEE LEFT MODULAR ROTATE HINGE",SUP-64811110,CDM,C1776,HCPCS,0278,RC,,,both,,,25203.15,7560.94,"FIRST HEALTH [10303]","First Health",,20162.52,80,,,,,0,2931.13,21422.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL LCS COMPLETE MBT 1.5 KNEE CEMENT ROTATE PLATFORM",SUP-129431115,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,8601.07,8395.67,8601.07,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"TRAY TIBIAL LCS COMPLETE MBT 1.5 KNEE CEMENT ROTATE PLATFORM",SUP-129431115,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP 3 HOLE EMPHASYS",SUP-471054300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4847.85,27,,,,,0,2088.17,15261.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 19MM 52MM SHOULDER AEQUALIS ASCEND FLEX COCR 4",SUP-DWF152,CDM,C1776,HCPCS,0278,RC,,,both,,,10004.00,3001.2,"BLUE CROSS [10001]","Blue Cross HMO",,3921.57,39.2,,5311.50,4717.44,5388.59,31,1163.47,8503.4,"percent of total billed charges",
"MESH SURGICAL PROLENE 6X3IN HERNIA NONABSORBABLE SOFT",SUP-PMII,CDM,C1781,HCPCS,0278,RC,,,both,,,558.38,167.51,"MULTIPLAN [10600]",Multiplan,,474.62,85,,,,,0,64.94,474.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX PRS LONG-TERM RESORBABLE, 25X30 CM OVAL",SUP-P20363-2530G,CDM,C1781,HCPCS,0278,RC,,,both,,,86776.80,26033.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,35665.26,41.1,,,,,0,10092.14,73760.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +23.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.235,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000195,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 150MM 12MM TRIATHLON KNEE COCR CEMENT TOTAL",SUP-5560-S-312,CDM,C1776,HCPCS,0278,RC,,,both,,,6448.05,1934.41,"PHCS [10601]",PHCS,,4513.64,70,,,,,0,749.91,5480.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR -6MM TAPER HIP ADPTR ENDO II",SUP-139249,CDM,C1776,HCPCS,0278,RC,,,both,,,1157.25,347.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,137.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,134.59,983.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 11MM 40MM ASYMMETRIC TRIATHLON X3 KNEE",SUP-5551L401,CDM,C1776,HCPCS,0278,RC,,,both,,,4478.10,1343.43,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1281.63,28.62,,,,,0,520.8,3806.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 20MM 2MM BALLOON DILATATION PACLITAXEL RADIOPAQUE",SUP-H7493960820200,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"CIGNA [10200]",Cigna,,26453.7,68,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 22MM E HIP CONSTRAINED X3 TRIDENT",SUP-690-00-22E,CDM,C1776,HCPCS,0278,RC,,,both,,,17046.45,5113.93,"KAISER [10500]",Kaiser,,11421.12,67,,,,,0,1982.5,14489.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 5 KNEE CEMENTED ROTATE PLATFORM",SUP-150610005,CDM,C1776,HCPCS,0278,RC,,,both,,,16694.55,5008.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1978.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1941.58,14190.37,"percent of total billed charges",
"CMPNT FEMORAL 5 CRUCIATE RETAIN CEMENT PERSONA STERILE LATEX",SUP-42572605802,CDM,C1776,HCPCS,0278,RC,,,both,,,26429.76,7928.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3131.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3073.78,22465.3,"percent of total billed charges",
"CMPNT GLENOID MEDIUM 4MM BASE MODULAR COMPREHENSIVE HYBRID",SUP-113954,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"PHCS [10601]",PHCS,,6415.08,70,,,,,0,1065.77,7789.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 10MM 32MM PRIMARY NEXGEN TRABECULAR METAL",SUP-00587806532,CDM,C1776,HCPCS,0278,RC,,,both,,,7350.00,2205,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,870.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,854.81,6247.5,"percent of total billed charges",
"INSRT TIBIAL 6 13MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P613,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"MULTIPLAN [10600]",Multiplan,,7102.52,85,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 0MM 12/14 STRAIGHT 28MM HIP ZIMALOY LEGACY VERS",SUP-00801802802,CDM,C1776,HCPCS,0278,RC,,,both,,,3322.20,996.66,"PHCS [10601]",PHCS,,2325.54,70,,,,,0,386.37,2823.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640506,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS [10001]","Blue Cross PPO",,4411.53,39.2,,3949.44,3949.44,3949.44,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"LINER ACETABULAR G7 B 32MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30103202,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"CIGNA [10200]","Cigna Open Access",,5833.4,56.9,,5302.19,4377.88,6578.61,27,1192.31,8714.22,"percent of total billed charges",
"CMPNT FEMORAL 9 STD KNEE LEFT CRUCIATE RETAIN CEMENT PERSONA",SUP-42572606601,CDM,C1776,HCPCS,0278,RC,,,both,,,20837.25,6251.17,"KAISER [10500]",Kaiser,,13960.96,67,,,,,0,2423.37,17711.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 14MM ITOTAL IPOLY XE POSTERIOR STABILIZE INSRT",SUP-RPS0201400,CDM,C1776,HCPCS,0278,RC,,,both,,,6254.85,1876.45,"FIRST HEALTH [10303]","First Health",,5003.88,80,,,,,0,727.44,5316.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 8MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650408,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1555.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH ADULT 24CM 15.5FR POLYURETHANE BIOFLO DURAMAX",SUP-H965103028031,CDM,C1750,HCPCS,0278,RC,,,both,,,2137.50,641.25,"CIGNA [10200]","Cigna Open Access",,1216.24,56.9,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 10CM 3CM 5FR .038IN 2 PIGTAIL",SUP-M006192111010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,139.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE CORTICAL 4.5 MM DIAMETER 58 MM LENGTH CANNULATED",SUP-214.76,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.61,466.68,"NOVANET [10819]",Novanet,,1166.71,75,,,,,0,180.92,1322.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT GLENOID UNIVERS REVERS POROUS OD30 MM MODULAR POST",SUP-AR-9582-30,CDM,C1776,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"MULTIPLAN [10600]",Multiplan,,4457.4,85,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR 48MM MULTIPOLAR HIP METAL STERILE",SUP-500104800,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1716.66,45.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA F KNEE RIGHT 2 PEG TIVANIUM STERILE",SUP-42530007502,CDM,C1776,HCPCS,0278,RC,,,both,,,14185.02,4255.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5830.04,41.1,,6417.48,6417.48,6417.48,"1 through 10",1649.72,12057.27,"percent of total billed charges",
"STEM EXT 120MM 14MM LEGION STRAIGHT KNEE TITANIUM CEMENT",SUP-71424186,CDM,C1776,HCPCS,0278,RC,,,both,,,12357.90,3707.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3536.83,28.62,,,,,0,1437.22,10504.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +16.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM POST",SUP-ZA90030165,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"FIRST HEALTH [10303]","First Health",,939.6,80,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Actin Antibody Each",PX-302000247,CDM,86015,CPT,0302,RC,,,both,,,304.00,91.2,"UHC [10700]","United Healthcare",,10.85,,,,,,,0.01,258.4,"fee schedule",
"CATH SABERX RADIANZ 190CM 80MM 7MM .018IN BALLOON DILATATION",SUP-R51007008L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"KAISER [10500]",Kaiser,,1367.81,67,,,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 10MM PRESS FIT FULL PROXIMAL PROFILE ECHO",SUP-192010,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"CIGNA [10200]",Cigna,,9499.39,40,,5873.17,5873.17,5873.17,"1 through 10",2761.95,20186.21,"percent of total billed charges",
"STEM FEMORAL 190MM 15MM REVISION MODULAR ARCOS STS TITANIUM",SUP-11-300915,CDM,C1776,HCPCS,0278,RC,,,both,,,20372.94,6111.88,"UHC [10700]","United Healthcare",,12896.07,63.3,,8601.07,8395.67,8601.07,"1 through 10",2369.37,17317,"percent of total billed charges",
"TRIATHLON CR TIBIAL INSERT",SUP-5530-P-519,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2391.46,28.62,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 124MM CEMENTLESS OFFSET ACCOLADE TMZF 127D +0",SUP-6021-3535,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"UHC [10700]","United Healthcare",,9905.94,63.3,,8601.07,8395.67,8601.07,"1 through 10",1820,13301.82,"percent of total billed charges",
"LINER ACE E-PLUS NEUT 10D HD40",SUP-932-40-756,CDM,C1776,HCPCS,0278,RC,,,both,,,16186.99,4856.1,"BLUE CROSS [10001]","Blue Cross HMO",,6345.3,39.2,,5311.50,4717.44,5388.59,31,1882.55,13758.94,"percent of total billed charges",
"SURFACE ARTICULAR 14MM PERSONA MEDIAL CONGRUENT 8-9 C-D KNEE",SUP-42522100514,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Local Plus",,5765.38,53.5,,5372.07,4581.20,7242.98,23,1253.3,9159.96,"percent of total billed charges",
"REVERSE (RSP) MONOBLOCK REVISION HUMERAL STEM, 220MM, 6X220M",SUP-510-06-220,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]",Cigna,,5040,40,,5873.17,5873.17,5873.17,"1 through 10",1465.38,10710,"percent of total billed charges",
"STEM FEMORAL 124MM CEMENTED NECK ACCOLADE 127D 2 39MM OFFSET",SUP-6057-0230D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"FIRST HEALTH [10303]","First Health",,13151.4,80,,,,,0,1911.88,13973.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 10D TILTED",SUP-DWD191,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"PHCS [10601]",PHCS,,8535.1,70,,,,,0,1418.05,10364.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID MEDIUM 35MM PEG PERFORM CORTILOC SHOULDER",SUP-DWE412,CDM,C1776,HCPCS,0278,RC,,,both,,,9315.60,2794.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1103.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1083.4,7918.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 10D TILTED",SUP-DWD191,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"MULTIPLAN [10600]",Multiplan,,10364.05,85,,,,,0,1418.05,10364.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP STEM OR3O WITH COCR HEAD R3 CATALYST",SUP-71703331,CDM,C1776,HCPCS,0278,RC,,,both,,,31815.00,9544.5,"FIRST HEALTH [10303]","First Health",,25452,80,,,,,0,3700.08,27042.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 64MM 36MM XLPE HIP STERILE",SUP-71332764,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1293.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT CONSTRAIN LEGION OXINIUM",SUP-71421177,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,15615.18,27,,,,,0,6726.09,49158.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thromblys Crbrl",PX-361000139,CDM,37195,CPT,0361,RC,,,both,,,3799.10,1139.73,"CIGNA [10200]","Cigna Open Access",,2090,,"Case rate ($2,090). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,3.8,3799.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 13MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G513,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1089.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 20MM STAINLESS STEEL T8 LOCK VARIABLE ANGLE",SUP-02.210.120TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1011.53,303.46,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.5,28.62,,,,,0,117.64,859.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN OMEGA3 MARIGEN 19SQ CM MICRO FISH SKIN STERILE",SUP-50200P02D0D,CDM,Q4158,HCPCS,0636,RC,,,both,,,7969.50,2390.85,"MULTIPLAN [10600]",Multiplan,,6774.08,85,,,,,0,180.89,6774.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ICY 38CM 9.3FR CENTRAL VENOUS INFERIOR VENA CAVA",SUP-8700-0782-01,CDM,C1751,HCPCS,0272,RC,,,both,,,6231.11,1869.33,"MULTIPLAN [10600]",Multiplan,,5296.44,85,,,,,0,724.68,5296.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ICY 38CM 9.3FR CENTRAL VENOUS INFERIOR VENA CAVA",SUP-8700-0782-01,CDM,C1751,HCPCS,0272,RC,,,both,,,6231.11,1869.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,738.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,724.68,5296.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 120MM 20GA SONOPLEX II FACET TIP INJECTION",SUP-001287-72,CDM,C9812,HCPCS,0272,RC,,,both,,,153.12,45.94,"CIGNA [10200]","Cigna Local Plus",,81.92,53.5,,,,,0,17.81,130.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER HYDROMARK BREAST BIOPSY OPEN COIL TITANIUM 18GA",SUP-4010-02-18-T3,CDM,A4648,HCPCS,0278,RC,,,both,,,640.49,192.15,"NOVANET [10819]",Novanet,,480.37,75,,,,,0,74.49,544.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB TISSUE 25X20CM STRATTICE PORCINE DERMAL MATRIX FIRM",SUP-2025002,CDM,Q4130,HCPCS,0636,RC,,,both,,,69129.60,20738.88,"AETNA [10100]","Aetna HMO/PPO",,54958.03,79.5,,,,,0,8191.86,58760.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION",RX-9413,CDM,J0675,HCPCS,0636,RC,00009-0856-05,NDC,both,1,ML,845.04,253.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,410.69,48.6,,,,,0,80.16,718.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 14MM HEMASHIELD PLATINUM STRAIGHT",SUP-M00202175414P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEOSTIGMINE METHYLSULFATE 0.5 MG/ML INTRAVENOUS SOLUTION",RX-163545,CDM,J2710,HCPCS,0636,RC,00641-6150-01,NDC,both,10,ML,72.48,21.74,"MULTIPLAN [10600]",Multiplan,,61.61,85,,,,,0,1.2,61.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER BUCKLE MRI GUIDED RIGID DEPLOYMENT DEVICE SECURMARK",SUP-SMARK-M-SS1,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"BLUE CROSS [10001]","Blue Cross PPO",,261.8,39.2,,,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRUG DELIVERY 5ML/HR ON-Q 2.25 DAY DELIVERY TIME 270ML",SUP-P270X5,CDM,C9804,HCPCS,0272,RC,,,both,,,1041.14,312.34,"NOVANET [10819]",Novanet,,780.86,75,,,,,0,121.08,884.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 16MM TIGER CANNULATED NONSTERILE",SUP-200-30-016,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,131.88,963.9,"percent of total billed charges",
"TFAT50 UVA PANOPTIX TORIC",SUP-TFAT50,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"MULTIPLAN [10600]",Multiplan,,718.25,85,,,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 16CM PUMP SET",SUP-ES2816,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]","Cigna Local Plus",,19750.5,31.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 6MM GORE STD WALL HEPARIN PROPATEN PTFE",SUP-H060040A,CDM,C1768,HCPCS,0278,RC,,,both,,,7562.40,2268.72,"MULTIPLAN [10600]",Multiplan,,6428.04,85,,,,,0,879.51,6428.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemodialysis I/P 1 Eval",PX-801000004,CDM,90935,CPT,0801,RC,,,both,,,2636.00,790.8,"UHC [10700]","United Healthcare",,1668.59,63.3,,,,,0,58.62,2240.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RCRD CARDIAC 56.3X8X18.5MM SJM CONFIRM 128HZ SENSEABILITY",SUP-DM2102,CDM,C1764,HCPCS,0278,RC,,,both,,,26460.00,7938,"CIGNA [10200]","Cigna Open Access",,8864.1,33.5,,,,,0,3077.3,22491,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 18GA MAGSEED BREAST BIOPSY 12CM",SUP-SM18112001,CDM,A4648,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CIGNA [10200]","Cigna Open Access",,2112.41,56.9,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER TOP HAT TITANIUM RIGID END DEPLOYMENT DELIVERY SYSTEM",SUP-SMARK-EVIVA-2S-13,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,77.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 23MM 8MM STEP TAPER ACL PCL",SUP-AR-1380C,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"FIRST HEALTH [10303]","First Health",,1480.5,80,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transcatheter Biopsy Si",PX-320000198,CDM,75970,CPT,0320,RC,,,both,,,3127.00,938.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1435.29,45.9,,,,,0,363.67,2657.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN COLOPLAST LOCK-OUT 20CM PUMP INFRAPUBIC",SUP-ES8820,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7429.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Upgrade Impl Pcmkr Sys",PX-480000009,CDM,33214,CPT,0481,RC,,,both,,,11250.00,3375,"PHCS [10601]",PHCS,,7875,70,,,,,0,1308.38,11250,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 8FR 12GA 20CM .032IN CURVE 2 LUMEN IMPREGNATE",SUP-G50820,CDM,C1751,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esoph Capsule",PX-750000115,CDM,91111,CPT,0750,RC,,,both,,,7900.00,2370,"AETNA [10100]","Aetna HMO/PPO",,6280.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,918.77,6715,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 KNEE RIGHT CEMENTED CRUCIATE RETAINING",SUP-150400208,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"BLUE CROSS [10001]","Blue Cross PPO",,8778.19,39.2,,3949.44,3949.44,3949.44,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"INSRT TIBIAL 8 14MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620814,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"FIRST HEALTH [10303]","First Health",,9003.12,80,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP GRIPTION PINNACLE STERILE LATEX",SUP-121731060,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"BLUE CROSS [10001]","Blue Cross PPO",,6357.63,39.2,,3949.44,3949.44,3949.44,"1 through 10",1886.21,13785.68,"percent of total billed charges",
"STEM FEMORAL 107MM TRI-LOCK BPS GRIPTION 6 STD OFFSET HIP",SUP-101204060,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1908.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1873.26,13691.05,"percent of total billed charges",
"STEM FEMORAL 105MM CEMENTED EXT PROSTALAC 1 HIGH OFFSET HIP",SUP-154106000,CDM,C1776,HCPCS,0278,RC,,,both,,,18814.32,5644.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5384.66,28.62,,,,,0,2188.11,15992.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640406,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1333.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1308.83,9565.82,"percent of total billed charges",
"LINER/10 DEGREE HOODED-NEUTRAL MP10",SUP-932-44-760,CDM,C1776,HCPCS,0278,RC,,,both,,,16186.99,4856.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6474.8,40,,,,,0,1882.55,13758.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 4 KNEE CEMENTED FIX BEARING STERILE",SUP-150600004,CDM,C1776,HCPCS,0278,RC,,,both,,,15004.05,4501.21,"CIGNA [10200]","Cigna Open Access",,5026.36,33.5,,5302.19,4377.88,6578.61,27,1744.97,12753.44,"percent of total billed charges",
"INSRT TIBIAL 5 8MM KNEE ONLAY MULTICOMPARTMENTAL RESTORIS",SUP-180705-1,CDM,C1776,HCPCS,0278,RC,,,both,,,4046.85,1214.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,470.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,470.65,3439.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 12/14 TAPER 28MM HIP OXINIUM",SUP-71342812,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4194.54,27,,,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 5 KNEE CEMENT ROTATE PLATFORM STERILE",SUP-150680005,CDM,C1776,HCPCS,0278,RC,,,both,,,17225.85,5167.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7079.82,41.1,,6417.48,6417.48,6417.48,"1 through 10",2003.37,14641.97,"percent of total billed charges",
"SABER .035 7X120 135CM SL",SUP-48007012R,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"UHC [10700]","United Healthcare",,658.96,63.3,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chromo Analyss 15-20 Cell Band",PX-311000035,CDM,88262,CPT,0311,RC,,,both,,,1561.30,468.39,"CIGNA [10200]","Cigna Open Access",,276.08,,,,,,,0.01,1327.11,"fee schedule",
"INSRT TIBIAL 1.5 CURVE 15MM KNEE GVF ROTATE PLATFORM PFC",SUP-972003,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"CIGNA [10200]","Cigna Local Plus",,4948.46,53.5,,5372.07,4581.20,7242.98,23,1075.71,7862.03,"percent of total billed charges",
"INSRT TIBIAL 1.5 CURVE 15MM KNEE GVF ROTATE PLATFORM PFC",SUP-972003,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"AETNA [10100]","Aetna HMO/PPO",,7353.31,79.5,,10981.53,8986.79,12413.38,12,1075.71,7862.03,"percent of total billed charges",
"CATH CHRG 135CM 200MM 7MM BALLOON DILATATION OTW",SUP-H74939206072010,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 415CC",SUP-RSZ-SHPX-415S,CDM,S27200284,LOCAL,0272,RC,,,both,,,170.05,51.01,"FIRST HEALTH [10303]","First Health",,136.04,80,,,,,0,19.78,144.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL FEMUR LATERAL DISTAL STAINLESS STEEL LOCK AXSOS",SUP-370003,CDM,C1776,HCPCS,0278,RC,,,both,,,456.27,136.88,"NOVANET [10819]",Novanet,,342.2,75,,,,,0,53.06,387.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 62MM KNEE STRAIGHT TRIATHLON",SUP-5630-G-620,CDM,C1776,HCPCS,0278,RC,,,both,,,5309.55,1592.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,629.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,617.5,4513.12,"percent of total billed charges",
"LINER ACETABULAR DYNASTY A-CLASS 15D 36MM POLY BIOFOAM HIP",SUP-DLXPLD36,CDM,C1776,HCPCS,0278,RC,,,both,,,7507.20,2252.16,"CIGNA [10200]","Cigna Local Plus",,4016.35,53.5,,5372.07,4581.20,7242.98,23,873.09,6381.12,"percent of total billed charges",
"STEM FEMORAL 105MM CEMENT EXT PROSTALAC 1 HIGH OFFSET HIP",SUP-1541-06-000,CDM,C1776,HCPCS,0278,RC,,,both,,,18814.32,5644.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7525.73,40,,,,,0,2188.11,15992.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ITOTAL IDENTITY CR 3DP POROUS KIT IPOLY XE INSERTS",SUP-ITCR-3DP-XE-KIT,CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"AETNA [10100]","Aetna HMO/PPO",,23790.38,79.5,,10981.53,8986.79,12413.38,12,3480.28,25436.25,"percent of total billed charges",
"LENS IOL 0 D +20 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-SY60WF.200,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 65MM TITANIUM LEVEL 3 ZEVO BONE SPINE CERVICAL",SUP-3003065,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"ADPTR FEMORAL TRIATHLON 2MM OFFSET KNEE TOTAL STABILIZE",SUP-5570-S-020,CDM,C1776,HCPCS,0278,RC,,,both,,,4573.30,1371.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2099.14,45.9,,,,,0,531.87,3887.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XIENCE V 23MM 143CM 4MM CORONARY EVEROLIMUS ELUTING",SUP-1009543-23,CDM,C1874,HCPCS,0278,RC,,,both,,,9591.00,2877.3,"BLUE CROSS [10001]","Blue Cross HMO",,3759.67,39.2,,9776.84,9776.84,9776.84,"1 through 10",1115.43,8152.35,"percent of total billed charges",
"CMPNT GLENOID 39MM 24MM +4MM LATERALIZE GLENOSPHERE ARTHREX",SUP-AR-9564-2439-LAT,CDM,C1776,HCPCS,0278,RC,,,both,,,9763.50,2929.05,"CIGNA [10200]","Cigna Local Plus",,5223.47,53.5,,5372.07,4581.20,7242.98,23,1135.5,8298.98,"percent of total billed charges",
"CMPNT FEMORAL G KNEE LEFT CEMENT LPS-FLEX NEXGEN TIVANIUM",SUP-596801751,CDM,C1776,HCPCS,0278,RC,,,both,,,26214.30,7864.29,"CIGNA [10200]","Cigna Local Plus",,8257.5,31.5,,5372.07,4581.20,7242.98,23,3048.72,22282.16,"percent of total billed charges",
"CMPNT FEMORAL 7 KNEE RIGHT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F702,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"FIRST HEALTH [10303]","First Health",,13712.02,80,,,,,0,1993.39,14569.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOME LAMBOTTE MINI SWISS PATTERN 5 1/8IN 12MM",SUP-27-5712,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.89,39.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,60.54,45.9,,,,,0,15.34,112.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 23MM 52MM OFFSET 4MM TOTAL SHOULDER REPLACEMENT",SUP-5552-E-5223,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4171.76,45.9,,,,,0,1057.03,7725.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 36CM CARBOTHANE PALINDROME TAL VENATRAC 2 LUMEN",SUP-8888145039P,CDM,C1750,HCPCS,0278,RC,,,both,,,2876.79,863.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,823.34,28.62,,,,,0,334.57,2445.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TIBIAL 75+ MM 14MM PERSONA STRAIGHT KNEE SMOOTH",SUP-42560007514,CDM,C1776,HCPCS,0278,RC,,,both,,,10540.44,3162.13,"UHC [10700]","United Healthcare",,6672.1,63.3,,8601.07,8395.67,8601.07,"1 through 10",1225.85,8959.37,"percent of total billed charges",
"STEM FEMORAL CITATION TMZF HA 3 SHORT HIP RIGHT",SUP-6265-5213,CDM,C1776,HCPCS,0278,RC,,,both,,,24421.95,7326.58,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2894,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2840.27,20758.66,"percent of total billed charges",
"CAP PRIMARY TIN KNEE",SUP-TKAPREM-TIN,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Local Plus",,5953.5,31.5,,5372.07,4581.20,7242.98,23,2198.07,16065,"percent of total billed charges",
"LENS IOL 0 D +10 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.100,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 8.2MM 100MM TITANIUM T25 SELF TAP TIP",SUP-04.003.030S,CDM,C1713,HCPCS,0278,RC,,,both,,,1442.45,432.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,662.08,45.9,,,,,0,167.76,1226.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 30MM ENDOSKELETON TAS SPINE ALIF",SUP-2300-5530,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"NOVANET [10819]",Novanet,,1063.13,75,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL STD 12.5MM KNEE REVISION ROTATE PLATFORM LCS",SUP-129424412,CDM,C1776,HCPCS,0278,RC,,,both,,,12858.84,3857.65,"CIGNA [10200]","Cigna Local Plus",,4050.53,31.5,,5372.07,4581.20,7242.98,23,1495.48,10930.01,"percent of total billed charges",
"KIT TKR 40MM LPS TITANIUM MALE TO FEMALE TAPER ANTIROTATION",SUP-198707040,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,5311.50,4717.44,5388.59,31,2014.9,14726.25,"percent of total billed charges",
"INSRT ACETABULAR 40MM 0D G HIP EXPANDED X3 TRIDENT 7.4MM",SUP-623-00-40G,CDM,C1776,HCPCS,0278,RC,,,both,,,6879.60,2063.88,"AETNA [10100]","Aetna HMO/PPO",,5469.28,79.5,,10981.53,8986.79,12413.38,12,800.1,5847.66,"percent of total billed charges",
"HC Cult Yersinia",PX-306000009,CDM,87046,CPT,0306,RC,,,both,,,294.00,88.2,"FIRST HEALTH [10303]","First Health",,235.2,80,,,,,0,0.01,249.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TIBIAL 135+ MM 16MM PERSONA STRAIGHT KNEE SPLINE",SUP-42560113516,CDM,C1776,HCPCS,0278,RC,,,both,,,11300.82,3390.25,"KAISER [10500]",Kaiser,,7571.55,67,,,,,0,1314.29,9605.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON PANOPTIX TORIC UVA",SUP-CCWTT5,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"NOVANET [10819]",Novanet,,648.75,75,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.6MM KIRSCHNER STAINLESS STEEL NONSTERILE",SUP-KW062SS,CDM,C1713,HCPCS,0278,RC,,,both,,,486.00,145.8,"CIGNA [10200]","Cigna Local Plus",,260.01,53.5,,3978.14,359.25,3978.14,24,56.52,413.1,"percent of total billed charges",
"HEAD BIPOLAR 44MM 26MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-44-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"CIGNA [10200]","Cigna Open Access",,2456.81,56.9,,5302.19,4377.88,6578.61,27,502.16,3670.1,"percent of total billed charges",
"INSRT TIBIAL 4 CURVE PLUS 12.5MM KNEE XLK FIX BEARING SIGMA",SUP-970462,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7598.69,68,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 44MM 26MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-44-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"CIGNA [10200]",Cigna,,2936.08,68,,5873.17,5873.17,5873.17,"1 through 10",502.16,3670.1,"percent of total billed charges",
"CATH AGENT 15MM 3MM BALLOON DILATATION PACLITAXEL RADIOPAQUE",SUP-H7493960815300,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"FILTER SMOKE EVAC .25IN STACKHOUSE .3-.5UM 65% ASHRAE MEDIA",SUP-BILF100,CDM,S27000186,LOCAL,0270,RC,,,both,,,64.42,19.33,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 150CM 60MM 8MM BALLOON DILATATION DURALYN",SUP-48008006X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WIRE FIXATION 1.4MM 203MM KIRSCHNER 1 TROCAR NONSTERILE",SUP-KWIR-ST-14203,CDM,S27000186,LOCAL,0270,RC,,,both,,,374.10,112.23,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT ORTHOPEDIC SMALL 8IN THUMB LEFT WRIST D RING CLSR",SUP-A125105,CDM,S27000186,LOCAL,0270,RC,,,both,,,115.80,34.74,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COLLAR EXTRICATION 4.25IN 13-16IN CALIFORNIA PROCARE MEDIUM",SUP-79-83145,CDM,S27000186,LOCAL,0270,RC,,,both,,,82.74,24.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 2MM",SUP-0277082085S4,CDM,S27000186,LOCAL,0270,RC,,,both,,,528.20,158.46,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BOOT ORTHOPEDIC PROCARE PODOUS REGULAR FOOT LIGHTWEIGHT",SUP-79-90550,CDM,S27000186,LOCAL,0270,RC,,,both,,,291.54,87.46,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM HUMERAL 78MM PRESS FIT AEQUALIS ASCEND FLEX PTC 127.5D",SUP-DWF604A,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3402,27,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL REUNION OD9 MM PRESS FIT TOTAL SHOULDER ARTHROP",SUP-5569-C-2009,CDM,C1776,HCPCS,0278,RC,,,both,,,10440.00,3132,"CIGNA [10200]","Cigna Open Access",,5940.36,56.9,,5302.19,4377.88,6578.61,27,1214.17,8874,"percent of total billed charges",
"INSRT TIBIAL 5-6 18MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71933740,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"BLUE CROSS [10001]","Blue Cross HMO",,4771.27,39.2,,5311.50,4717.44,5388.59,31,1415.56,10345.86,"percent of total billed charges",
"STEM FEMORAL 96MM ACCOLADE II V40 PUREFIX TITANIUM PLASMA",SUP-6720-0127,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"PHCS [10601]",PHCS,,16773.44,70,,,,,0,2786.79,20367.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACTOR, BROKEN SCREW, 6 MM, 6"" LONG, SINGLE USE",SUP-SXT007-BR3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"AETNA [10100]","Aetna HMO/PPO",,2355.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ehrlichia Antibody",PX-302000130,CDM,86666,CPT,0302,RC,,,both,,,162.50,48.75,"CIGNA [10200]","Cigna Local Plus",,22.4,,,,,,,0.01,138.13,"fee schedule",
"HC Insert Wcs Lv Pg Component",PX-480000074,CDM,0517T,CPT,0480,RC,,,both,,,17015.00,5104.5,"PHCS [10601]",PHCS,,11910.5,70,,,,,0,1978.84,14462.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insert Wcs Lv Pg Component",PX-480000074,CDM,0517T,CPT,0480,RC,,,both,,,17015.00,5104.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2016.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1978.84,14462.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 6-9 E-F KNEE RIGHT TIBIA",SUP-42521400712,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,956.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 6-9 E-F KNEE RIGHT TIBIA",SUP-42521400712,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5491.52,68,,,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP TSS TOTAL SHOULDER ARTHROPLASTY W-LONG STEM",SUP-71701420,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"CIGNA [10200]","Cigna Open Access",,8969.63,33.5,,5302.19,4377.88,6578.61,27,3113.93,22758.75,"percent of total billed charges",
"EXT STEM 80MM 10MM 1 AXIS PRESS FIT CEMENTED KNEE VITALLIUM",SUP-6478-6-395,CDM,C1776,HCPCS,0278,RC,,,both,,,3364.45,1009.33,"CIGNA [10200]","Cigna Local Plus",,1799.98,53.5,,5372.07,4581.20,7242.98,23,391.29,2859.78,"percent of total billed charges",
"HC Echo Dplr Complt",PX-483000012,CDM,93320,CPT,0483,RC,,,both,,,1268.76,380.63,"AETNA [10100]","Aetna HMO/PPO",,1008.66,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.89,1078.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Dplr Complt",PX-483000012,CDM,93320,CPT,0483,RC,,,both,,,1268.76,380.63,"MULTIPLAN [10600]",Multiplan,,1078.45,85,,,,,0,84.89,1078.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Spectrophotometry",PX-301000403,CDM,84311,CPT,0301,RC,,,both,,,337.25,101.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.74,,,,,,,0.01,286.66,"fee schedule",
"(EVAL) BELT SPRT LARGE STERNUM",SUP-QB-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,380.71,45.9,,,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCRDRVR SMALL HEXAGON LCP HOLDING SLEEVE SURGICAL NONSTERILE",SUP-314.02,CDM,S27000186,LOCAL,0270,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION",RX-2508,CDM,J1200,HCPCS,0636,RC,63323-0664-01,NDC,both,1,ML,27.27,8.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.87,,,,,,,0.83,23.18,"fee schedule",
"PUTTY THERAPY THERAPUTTY PUTTYCISE 5 PIECE TOOL SET CARRY",SUP-562946,CDM,S27000186,LOCAL,0270,RC,,,both,,,841.67,252.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,99.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.89,715.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Factor VIII Vw Ristocetin",PX-305000020,CDM,85245,CPT,0305,RC,,,both,,,387.60,116.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,20.65,,,,,,,0.01,329.46,"fee schedule",
"HC Tobramycin",PX-301000059,CDM,80200,CPT,0301,RC,,,both,,,528.20,158.46,"UHC [10700]","United Healthcare",,14.52,,,,,,,10.15,448.97,"fee schedule",
"ELECTRD ELECTROSURGICAL BARREL 22FR 3MM STERILE DISPOSABLE",SUP-26055RK,CDM,S27000186,LOCAL,0270,RC,,,both,,,1123.40,337.02,"KAISER [10500]",Kaiser,,752.68,67,,,,,0,130.65,954.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOARD REHABILITATION 13X9IN E-Z-EXER 2 HOOK LOOP STRIP 4",SUP-A7251,CDM,S27000186,LOCAL,0270,RC,,,both,,,971.19,291.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,660.41,68,,,,,0,112.95,825.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOARD REHABILITATION 13X9IN E-Z-EXER 2 HOOK LOOP STRIP 4",SUP-A7251,CDM,S27000186,LOCAL,0270,RC,,,both,,,971.19,291.36,"CIGNA [10200]",Cigna,,660.41,68,,,,,0,112.95,825.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACTOR, BROKEN SCREW, 5 MM, 6"" LONG, SINGLE USE",SUP-SXT006-BR3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,351.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL O2 THERAPY NEONATE LATEX FREE",SUP-BC2425-20,CDM,S27000186,LOCAL,0270,RC,,,both,,,70.91,21.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,48.22,68,,,,,0,8.25,60.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALIBRATOR OSMOMETER 100 MOSM/KG 5ML STANDARD AMPULE FOR 325",SUP-3LA011,CDM,S27000186,LOCAL,0270,RC,,,both,,,276.39,82.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,113.6,41.1,,,,,0,32.14,234.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 250MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040250M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"PHCS [10601]",PHCS,,1312.5,70,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 8CM 3.5MM 5FR BALLOON DILATATION",SUP-V143580,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"AETNA [10100]","Aetna HMO/PPO",,4360.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SAPPHIRE 3 CORONARY DILATATION CATHETER 1.0 X 5MM",SUP-54100-050-02,CDM,C1725,HCPCS,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ARM 24IN TO 28IN L HEMI II LEFT LONG ACROMION ELASTIC",SUP-A653-7,CDM,S27000186,LOCAL,0270,RC,,,both,,,388.89,116.67,"MULTIPLAN [10600]",Multiplan,,330.56,85,,,,,0,45.23,330.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Assay Infliximab",PX-301000623,CDM,80230,CPT,0301,RC,,,both,,,223.25,66.97,"UHC [10700]","United Healthcare",,34.71,,,,,,,0.01,189.76,"fee schedule",
"HC Drug Assay Infliximab",PX-301000623,CDM,80230,CPT,0301,RC,,,both,,,223.25,66.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.22,.1,,,,,0,0.01,189.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 60-75X12IN 4 PANEL MEDIUM",SUP-818,CDM,S27000186,LOCAL,0270,RC,,,both,,,316.85,95.05,"FIRST HEALTH [10303]","First Health",,253.48,80,,,,,0,0.4,269.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Triact",PX-E27200124,CDM,E27200124,LOCAL,0272,RC,,,both,,,152.90,45.87,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 200CM 200MM 3MM BALLOON DILATATION RAPID",SUP-47530200L,CDM,C1725,HCPCS,0272,RC,,,both,,,1890.00,567,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CORDIS SABER 90CM 20MM 6MM BALLOON DILATATION DURALYN",SUP-48006002S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEAD BIPOLAR 43MM 26MM UHR UNIVERSAL HIP UHMWPE",SUP-UH1-43-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"MULTIPLAN [10600]",Multiplan,,3670.1,85,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nucleotidase 5",PX-301000341,CDM,83915,CPT,0301,RC,,,both,,,134.44,40.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.04,,,,,,,0.01,114.27,"fee schedule",
"SURFACE ARTICULAR 10MM PERSONA 6-9 G-H KNEE LEFT VIVACIT-E",SUP-42512400910,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Open Access",,6131.78,56.9,,5302.19,4377.88,6578.61,27,1253.3,9159.96,"percent of total billed charges",
"DOXYCYCLINE HYCLATE 100 MG VIAL",RX-2622,CDM,J1271,HCPCS,0636,RC,16714-0644-01,NDC,both,1,UN,211.17,63.35,"FIRST HEALTH [10303]","First Health",,168.94,80,,,,,0,12.82,179.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Homovanillic Acid",PX-301000236,CDM,83150,CPT,0301,RC,,,both,,,253.00,75.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,23.98,,"Fee schedule rate ($23.98). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,215.05,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Psa Free",PX-301000377,CDM,84154,CPT,0301,RC,,,both,,,205.20,61.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,65.3,,,,,,,0.21,174.42,"fee schedule",
"HC Gamma Glutamyl Transferase",PX-301000212,CDM,82977,CPT,0301,RC,,,both,,,141.73,42.52,"CIGNA [10200]","Cigna Local Plus",,15.84,,,,,,,0.14,120.47,"fee schedule",
"LENS IOL TORIC UV ABSORBENT CLAREON",SUP-CCW0T6,CDM,V2787,HCPCS,0276,RC,,,both,,,355.00,106.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,101.6,28.62,,,,,0,41.29,301.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +23.5 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6",SUP-ZCT225235,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Open Access",,196.31,56.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PIONEER PLUS 120CM 6FR .014IN CURVE ULTRASOUND REENTRY",SUP-PPLUS120,CDM,C1753,HCPCS,0272,RC,,,both,,,20128.50,6038.55,"UHC [10700]","United Healthcare",,12741.34,63.3,,,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enterovirus Dna Ampl Probe",PX-306000129,CDM,87498,CPT,0306,RC,,,both,,,473.10,141.93,"NOVANET [10819]",Novanet,,354.83,75,,,,,0,0.01,402.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULTI-ARRAY ABLATION CATHETER (MAAC)",SUP-990000,CDM,S62400003,LOCAL,0624,RC,,,both,,,7245.00,2173.5,"MULTIPLAN [10600]",Multiplan,,6158.25,85,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT INTRAMUSCULAR SOLUTION",RX-11257,CDM,90675,HCPCS,0636,RC,49281-0250-51,NDC,both,1,UN,2326.28,697.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1041.01,44.75,,,,,0,178.05,1977.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Bone Marrow Wb",PX-341000071,CDM,78104,CPT,0341,RC,,,both,,,1531.98,459.59,"FIRST HEALTH [10303]","First Health",,1225.58,80,,,,,0,178.17,1302.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 3 2/3IN 21GA 18GA SONOPLEX CORNERSTONE 20GA",SUP-241285-40E,CDM,C9812,HCPCS,0272,RC,,,both,,,356.70,107.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,42.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.48,303.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 5MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650605,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3544.36,27,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640606,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS [10001]","Blue Cross PPO",,4411.53,39.2,,3949.44,3949.44,3949.44,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"PROS PENILE TITAN 22CM PUMP SET INFLATABLE FLUID FILL SOFT",SUP-ES8822,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS [10001]","Blue Cross PPO",,24578.4,39.2,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NUCLEUS-X 110CM 4CM 25MM BALLOON DILATATION POLYAMIDE",SUP-612029,CDM,C1725,HCPCS,0272,RC,,,both,,,6566.52,1969.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,778.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,763.69,5581.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 360 145CM 2MM ATHERECTOMY DIAMOND",SUP-DBP-200SOLID145,CDM,C1724,HCPCS,0272,RC,,,both,,,21388.50,6416.55,"KAISER [10500]",Kaiser,,14330.3,67,,,,,0,2487.48,18180.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT SL II SITEMARK 50.7CM 47CM 9FR 7FR RIGHT",SUP-DS2C006,CDM,C1887,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"PHCS [10601]",PHCS,,2632.35,70,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 52MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.452TS,CDM,C1713,HCPCS,0278,RC,,,both,,,2021.55,606.46,"NOVANET [10819]",Novanet,,1516.16,75,,,,,0,235.11,1718.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR BERENSTEIN CURVE URETERAL STAINLESS",SUP-M0064003031,CDM,C1758,HCPCS,0272,RC,,,both,,,153.35,46,"KAISER [10500]",Kaiser,,102.74,67,,,,,0,17.83,130.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC SMALL 22IN 14-16IN KNEE CONTACT CLSR",SUP-79-80053,CDM,S27000186,LOCAL,0270,RC,,,both,,,111.80,33.54,"AETNA [10100]","Aetna HMO/PPO",,88.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13,95.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablt Thrpy Vein Init",PX-361000102,CDM,36478,CPT,0361,RC,,,both,,,10361.47,3108.44,"FIRST HEALTH [10303]","First Health",,8289.18,80,,,,,0,1205.04,10015,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORPLEX 15MM DISC",SUP-CX-0015,CDM,Q4232,HCPCS,0636,RC,,,both,,,4029.60,1208.88,"AETNA [10100]","Aetna HMO/PPO",,3203.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.92,3425.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Procalcitonin",PX-301000374,CDM,84145,CPT,0301,RC,,,both,,,444.60,133.38,"FIRST HEALTH [10303]","First Health",,355.68,80,,,,,0,0.01,377.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA ARTHROSCOPIC L90 MM OD5.5 MM THREAD STERILE CLEAR",SUP-214110,CDM,S27200284,LOCAL,0272,RC,,,both,,,759.78,227.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,312.27,41.1,,,,,0,88.36,645.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR WEITLANER TESSA SELF RETAIN SURGICAL DISPOSABLE",SUP-NF08,CDM,S27200284,LOCAL,0272,RC,,,both,,,426.30,127.89,"PHCS [10601]",PHCS,,298.41,70,,,,,0,49.58,362.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADHSV BONDING LATEX FREE MESH TAPE EASY REMOVE DERMABOND 42",SUP-CLR422US,CDM,S27200284,LOCAL,0272,RC,,,both,,,6207.45,1862.23,"CIGNA [10200]","Cigna Open Access",,3532.04,56.9,,,,,0,721.93,5276.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERLINK SUTURETAPE CLOSE LOOP BLACK WHITE 1.7MM",SUP-AR-7538T,CDM,S27200284,LOCAL,0272,RC,,,both,,,807.98,242.39,"CIGNA [10200]","Cigna Open Access",,459.74,56.9,,,,,0,93.97,686.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 4-0 PS-1 27IN MONOFILAMENT UNDYED",SUP-Y935H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYSORB SURGITIE 0 21IN BRAID LOOP COATED VIOLET",SUP-EL-23-LN,CDM,S27200284,LOCAL,0272,RC,,,both,,,136.24,40.87,"KAISER [10500]",Kaiser,,91.28,67,,,,,0,15.84,115.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE DRILL 3.2MM THREADED 4MM LOCKING SCR SELF TAPPING",SUP-312.445,CDM,S27200284,LOCAL,0272,RC,,,both,,,1773.30,531.99,"MULTIPLAN [10600]",Multiplan,,1507.31,85,,,,,0,206.23,1507.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 2MM 120CM HANDLE BRONCHOSCOPIC STERILE",SUP-129,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.00,23.1,"PHCS [10601]",PHCS,,53.9,70,,,,,0,8.96,65.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRENCH TORQ ULTRSNC SURG ASPIR CUSA 23 KHZ DISP",SUP-C5601,CDM,S27200284,LOCAL,0272,RC,,,both,,,1124.39,337.32,"CIGNA [10200]",Cigna,,764.59,68,,,,,0,130.77,955.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 74X50X14MM CURRENT PLUS DR 36J TITANIUM IS-1",SUP-CD2211-36Q,CDM,C1721,HCPCS,0278,RC,,,both,,,64712.10,19413.63,"UHC [10700]","United Healthcare",,40962.76,63.3,,,,,0,7526.02,55005.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 SURGALLOY 3-0 P-12 18IN CLSR ABSORBABLE",SUP-VLOCM0024,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.73,70.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,27.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.3,199.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROCKER LRG SHOE PAIR EXFIX 180-210",SUP-4934-8-180,CDM,S27800098,LOCAL,0278,RC,,,both,,,9620.53,2886.16,"MULTIPLAN [10600]",Multiplan,,8177.45,85,,,,,0,1118.87,8177.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER DS NAV 115CM 8MM 7FR 1-7-4MM SPACE D-F CURVE",SUP-BN7TCDF8L,CDM,C1732,HCPCS,0272,RC,,,both,,,16477.20,4943.16,"PHCS [10601]",PHCS,,11534.04,70,,,,,0,1916.3,14005.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS CARDIOBAND FIT SIZE ADJUSTMENT TOOL AND LOCKE",SUP-25200ST,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 73X5.8MM THK.64MM SHORT NARROW STAINLESS STEEL",SUP-2108144000,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR XHALE ASSURANCE NASAL ALAR SPO2 OXIMETER LOW",SUP-301-11214,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.34,67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,91.79,41.1,,,,,0,25.97,189.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 30MM TI",SUP-SPL-35300-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 20MM 125CM 10MM 6FR .035IN VASCULAR NITINOL",SUP-G43839,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"MULTIPLAN [10600]",Multiplan,,3213,85,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER DS NAV 115CM 8MM 7FR 1-7-4MM SPACING F-J CURVE",SUP-BN7TCFJ8L,CDM,C1732,HCPCS,0272,RC,,,both,,,16477.20,4943.16,"FIRST HEALTH [10303]","First Health",,13181.76,80,,,,,0,1916.3,14005.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CARTO THERMOCOOL 115CM 3.5MM 8FR 2-5-2MM SPACE B CURVE",SUP-NI75TCBH,CDM,C1732,HCPCS,0272,RC,,,both,,,16256.40,4876.92,"PHCS [10601]",PHCS,,11379.48,70,,,,,0,1890.62,13817.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) VALVE AORTIC 26MM SAPIEN 3 EDWARDS HEART TRANSCATHETE",SUP-9750TFX26A,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"MULTIPLAN [10600]",Multiplan,,145350,85,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE VERSACORE VASCULAR MODIFIED J 175CM .035IN",SUP-1012068-05,CDM,C1769,HCPCS,0272,RC,,,both,,,631.80,189.54,"UHC [10700]","United Healthcare",,399.93,63.3,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION",RX-20472,CDM,,,0250,RC,72485-0508-01,NDC,both,10,ML,41.00,12.3,"KAISER [10500]",Kaiser,,27.47,67,,,,,0,4.77,34.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION PIN PAC A WIRE ACL PCL",SUP-7207738,CDM,C1713,HCPCS,0278,RC,,,both,,,1554.23,466.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,713.39,45.9,,,,,0,180.76,1321.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LASSO NAVISTAR 7FR 25MM 8MM SPACING D CURVE ABLATION 22",SUP-D134906,CDM,C1732,HCPCS,0272,RC,,,both,,,12889.20,3866.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5297.46,41.1,,,,,0,1499.01,10955.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 18GA 50CM 11CM BLUE HUB DIL GWIRE",SUP-PSI-8F-11-035-18G,CDM,C1894,HCPCS,0272,RC,,,both,,,102.23,30.67,"PHCS [10601]",PHCS,,71.56,70,,,,,0,11.89,86.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP SURESIGHT 0 MILLER NONSTERILE DISPOSABLE",SUP-390101000,CDM,S27000186,LOCAL,0270,RC,,,both,,,445.50,133.65,"KAISER [10500]",Kaiser,,298.49,67,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST GEL SMOOTH ROUND MODERATE PLUS PROFILE 320CC",SUP-SMPB320,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"NOVANET [10819]",Novanet,,5718.38,75,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 24CM 13.5FR STRAIGHT POLYURETHANE MAHURKAR QPLUS 2",SUP-8888135241,CDM,C1752,HCPCS,0272,RC,,,both,,,564.86,169.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,65.69,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.69,480.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 160MM 5.5MM STRAIGHT CCM PERCUTANEOUS APPROACH",SUP-1555006160,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST GEL SMOOTH ROUND MODERATE PLUS PROFILE 320CC",SUP-SMPB320,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"CIGNA [10200]","Cigna Local Plus",,4079.11,,,,,,,886.73,6480.83,"percent of total billed charges",
"SET EPIDURAL 2IN 19GA 21GA EPILONG TUOHY .2UM METAL PLASTIC",SUP-0131153-51,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.70,80.91,"UHC [10700]","United Healthcare",,170.72,63.3,,,,,0,31.37,229.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Vad Complt Tunl W Pump",PX-361000119,CDM,36583,CPT,0361,RC,,,both,,,9864.48,2959.34,"NOVANET [10819]",Novanet,,7398.36,75,,,,,0,1147.24,9679,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AZTREONAM 1 G VIAL IV PUSH",RX-408306,CDM,J0457,HCPCS,0636,RC,63323-0401-01,NDC,both,1,UN,272.33,81.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,32.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.49,231.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 12MM 144CM 3MM CORONARY STENT PEBAX",SUP-H7493926012300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"BLUE CROSS [10001]","Blue Cross HMO",,2181.48,39.2,,9776.84,9776.84,9776.84,"1 through 10",647.21,4730.25,"percent of total billed charges",
"HEAD FEMORAL +4MM 28MM HIP OFFSET TAPERED PRESSFIT COCR LFIT",SUP-6260-9-228,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1435.61,45.9,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.25 X 12 RX US",SUP-1804225-12,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ortho Mgmt/Train Ea 15min (Gp)",PX-420000038,CDM,97760,CPT,0420,RC,,,both,,,205.82,61.75,"UHC [10700]","United Healthcare",,205.82,,"Per diem ($331).",,,,0,23.94,205.82,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Assess Aphasia per Hr",PX-740000026,CDM,96105,CPT,0444,RC,,,both,,,1113.00,333.9,"AETNA [10100]","Aetna HMO/PPO",,884.84,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,129.44,946.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 0 SH 30IN BRAID GREEN NONABSORBABLE",SUP-X834H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OCTARAY 2-2-2-2-2MM SPACE D CURVE ELECTROPHYSIOLOGY",SUP-D160901,CDM,C1732,HCPCS,0272,RC,,,both,,,15407.70,4622.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1825.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1791.92,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP",RX-123703,CDM,,,0250,RC,60687-0576-40,NDC,both,5,ML,59.09,17.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,40.18,68,,,,,0,6.87,50.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 15MM MODULAR RESTORATION BOW CONE HIP",SUP-6276-7-215,CDM,C1776,HCPCS,0278,RC,,,both,,,17822.70,5346.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7325.13,41.1,,6417.48,6417.48,6417.48,"1 through 10",2072.78,15149.3,"percent of total billed charges",
"HC Immuno Optical Org",PX-306000173,CDM,87899,CPT,0306,RC,,,both,,,343.90,103.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,46.21,,,,,,,0.01,292.32,"fee schedule",
"HC Inj Indwl Lumb/Sac W Img",PX-510000210,CDM,62327,CPT,0761,RC,,,both,,,5968.00,1790.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5.97,.1,,,,,0,5.97,5072.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Copper",PX-301000156,CDM,82525,CPT,0301,RC,,,both,,,237.05,71.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.24,.1,,,,,0,0.24,201.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL THK.25MM STD THIN FLUOROPLASTIC REUTER SEPTUM",SUP-1527000,CDM,S27000186,LOCAL,0270,RC,,,both,,,281.01,84.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,33.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.68,238.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immuno Tumr Ag Other Ag Qn",PX-302000060,CDM,86316,CPT,0302,RC,,,both,,,358.15,107.44,"CIGNA [10200]","Cigna Local Plus",,45.78,,,,,,,0.01,304.43,"fee schedule",
"INSRT TIBIAL 5 CURVE PLUS 17.5MM KNEE XLK FIX BEARING SIGMA",SUP-970474,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"NOVANET [10819]",Novanet,,8380.91,75,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Angio Baln Perc Intracranial",PX-361000253,CDM,61630,CPT,0361,RC,,,both,,,7464.98,2239.49,"MULTIPLAN [10600]",Multiplan,,6345.23,85,,,,,0,7.46,6345.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRACKER NAVIGATION VPAD",SUP-INS-0050,CDM,S27200284,LOCAL,0272,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Small Bowel Feed Tube W Fl",PX-750000101,CDM,49441,CPT,0750,RC,,,both,,,8277.00,2483.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2292.95,,"Case rate ($2,292.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,962.62,7035.45,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 11MM 38MM ASYMMETRIC TRIATHLON POLYETHYLENE",SUP-5551-L-381,CDM,C1776,HCPCS,0278,RC,,,both,,,4478.10,1343.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,530.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,520.8,3806.39,"percent of total billed charges",
"SCR BONE 2MM 3.5MM 30MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.830.96,CDM,C1713,HCPCS,0278,RC,,,both,,,319.12,95.74,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,146.48,45.9,,,,,0,37.11,271.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS 30ML .1-4MM ALLOGRAFT CRUSH FROZEN",SUP-T20025,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL ANGLE SELF CENTERING FORTIFY I",SUP-676.703,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"KAISER [10500]",Kaiser,,2650.79,67,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cytopath Smear Other Source",PX-311000077,CDM,88160,CPT,0311,RC,,,both,,,183.35,55,"CIGNA [10200]","Cigna Local Plus",,120.67,,,,,,,0.18,155.85,"fee schedule",
"HC Xr Sm Bowel",PX-320000103,CDM,74250,CPT,0320,RC,,,both,,,1287.42,386.23,"MULTIPLAN [10600]",Multiplan,,1094.31,85,,,,,0,131.63,1094.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC 6.25MM FLEXOR HALLUCIS LONGUS",SUP-AR-1562BC-CP,CDM,S27200284,LOCAL,0272,RC,,,both,,,10831.28,3249.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1283.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1259.68,9206.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 24MM ARTHREX SHOULDER MODULAR STERILE LATEX",SUP-AR-9560-24,CDM,C1776,HCPCS,0278,RC,,,both,,,9335.70,2800.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2671.88,28.62,,,,,0,1085.74,7935.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL PLIF HL 22 DEGREE 11MM X 9MM X 28MM MOD-EX",SUP-1931928P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4106.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE WHISPER LS VASCULAR J CURVE 190CM 3CM .014IN",SUP-1005351HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 4.8FR L28CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902140,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 30MM GRIPTION TF HIP ACETABULAR POLYAXIAL",SUP-121730800,CDM,C1713,HCPCS,0278,RC,,,both,,,933.12,279.94,"NOVANET [10819]",Novanet,,699.84,75,,,,,0,108.52,793.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING SCR IN ELECTRD ACTIVE FIXATION BIPOLAR IS 1 CNCT",SUP-1688T/58,CDM,C1898,HCPCS,0275,RC,,,both,,,3375.00,1012.5,"MULTIPLAN [10600]",Multiplan,,2868.75,85,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE REAMER 19MM SPIN GUARD PROTCT FEMALE",SUP-P01-911-1902,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"CIGNA [10200]","Cigna Local Plus",,676.03,53.5,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH YELLOW 10FT CARTO 3 HYPERTONICS 12 PIN TO REDEL",SUP-CY1210CT,CDM,S27000186,LOCAL,0270,RC,,,both,,,3367.50,1010.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2289.9,68,,,,,0,391.64,2862.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUSH ENDOSCOPY ELEVIEW METHYLENE BLUE 10ML STERILE",SUP-9000020,CDM,S27200284,LOCAL,0272,RC,,,both,,,677.16,203.15,"CIGNA [10200]",Cigna,,460.47,68,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FITMORE HIP STEM B SIZE 8",SUP-01.00551.208,CDM,C1776,HCPCS,0278,RC,,,both,,,28871.64,8661.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11548.66,40,,,,,0,3357.77,24540.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 6MM AZUR HYDROCOIL PUSHABLE .035IN",SUP-45-250610,CDM,S27800098,LOCAL,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM CROSSFT 2 THREAD PEEK",SUP-CFK-475DT,CDM,C1713,HCPCS,0278,RC,,,both,,,2936.55,880.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,347.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,341.52,2496.07,"percent of total billed charges",
"CATH SAPPHIRE II PRO 20MM 2MM BALLOON DILATATION STERILE",SUP-220-203-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM 14.8MM MASTER-SERIES PYROLYTIC CARBON PTFE",SUP-19ATJ-503,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"MULTIPLAN [10600]",Multiplan,,24751.35,85,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 12D ALLOGRAFT 22MM ALIF",SUP-3W4222,CDM,S27800098,LOCAL,0278,RC,,,both,,,21145.32,6343.6,"BLUE CROSS [10001]","Blue Cross HMO",,8288.97,39.2,,,,,0,2459.2,17973.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 100CM 5FR 1 CURVE ANGIOGRAPHIC",SUP-G47001,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.52,63.16,"KAISER [10500]",Kaiser,,141.05,67,,,,,0,24.48,178.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE II PRO 15MM 3.5MM BALLOON DILATATION STERILE",SUP-235-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SIMPLICITI TOTAL SHOULDER SYSTEM",SUP-CAP1072,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross HMO",,11113.2,39.2,,5311.50,4717.44,5388.59,31,3297.11,24097.5,"percent of total billed charges",
"VALVE MITRAL 17.8MM 31-33MM 36MM 23.4MM ON-X 31/33 STD",SUP-ONXM-31/33,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"BLUE CROSS [10001]","Blue Cross PPO",,14817.6,39.2,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 9MM SEPTAL DELIVERY SYSTEM AMPLATZER",SUP-9-ASD-009,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2518.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 2.5MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES2512CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"MULTIPLAN [10600]",Multiplan,,5571.75,85,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 30MMX4.8MM PI TITANIUM LARGE THICK TISSUE",SUP-4908T,CDM,S27200284,LOCAL,0272,RC,,,both,,,392.20,117.66,"FIRST HEALTH [10303]","First Health",,313.76,80,,,,,0,45.61,333.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nephelometry",PX-301000321,CDM,83883,CPT,0301,RC,,,both,,,393.30,117.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,334.31,"per diem",
"STENT TEMPTIP 22CM 8FR LARGE PROXIMAL PIGTAIL CURVE URETERAL",SUP-M001235500,CDM,C2617,HCPCS,0278,RC,,,both,,,1093.50,328.05,"BLUE CROSS [10001]","Blue Cross HMO",,428.65,39.2,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 13MM PRESSFIT LEGION KNEE",SUP-71424046,CDM,C1776,HCPCS,0278,RC,,,both,,,12181.95,3654.58,"CIGNA [10200]","Cigna Open Access",,4080.95,33.5,,5302.19,4377.88,6578.61,27,1416.76,10354.66,"percent of total billed charges",
"BODY CONE 19MM RESTORATION +10MM HIP MODULAR",SUP-6276-1-119,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1714.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1682.49,12296.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 80MM 135CM 9MM VASCULAR NITINOL",SUP-1012537-80,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross HMO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL CARMALT CURVE 9IN ARTERY CROSS SERRATE",SUP-16-3723,CDM,S27200284,LOCAL,0272,RC,,,both,,,643.06,192.92,"PHCS [10601]",PHCS,,450.14,70,,,,,0,74.79,546.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL ORBITAL HA 20MM I O I",SUP-I00020S,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 200MM 2MM ASNIS JONES FRACTURE FIXATION",SUP-705355,CDM,C1769,HCPCS,0272,RC,,,both,,,574.94,172.48,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,236.3,41.1,,,,,0,66.87,488.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT CEMENTED CRUCIATE RETAINING ATTUNE",SUP-150400107,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"AETNA [10100]","Aetna HMO/PPO",,17802.71,79.5,,10981.53,8986.79,12413.38,12,2604.35,19034.35,"percent of total billed charges",
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 52MM 32MM MARATHON",SUP-121932452,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"FIRST HEALTH [10303]","First Health",,6488.76,80,,,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 9.5CM 16MM 13.5-14.5MM EXCLUDER",SUP-PLC161000,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"UHC [10700]","United Healthcare",,17722.23,63.3,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 10CM 5.8FR 12FR BALLOON",SUP-M0062251150,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1164.49,68,,,,,0,199.16,1455.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BRACE UNIVERSE AIR-STIRRUP UNIVERSAL ANKLE COLD PACK",SUP-02EK,CDM,S27000186,LOCAL,0270,RC,,,both,,,159.12,47.74,"PHCS [10601]",PHCS,,111.38,70,,,,,0,18.51,135.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOOT PROCEDURES WITH CC",504,MS-DRG,,,,,,,inpatient,,,77462.59,23238.78,"AETNA [10100]","Aetna HMO/PPO",,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 9IN LAMBOTTE SYMMETRY SURGICAL CURVE 1.25IN",SUP-28-9480,CDM,S27200284,LOCAL,0272,RC,,,both,,,252.56,75.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 3INX8MM OSTEOTOM THIN MRI NONSTERILE LATEX FREE",SUP-998602120,CDM,S27200284,LOCAL,0272,RC,,,both,,,963.09,288.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LEAD PACING 52CM 5.3FR VENTRICLE IS-1 BIPOLAR TINE CAPSURE",SUP-4092-52,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,664.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 21MM RESTORATION +0MM STD HIP MODULAR REVISION",SUP-6276-1-021,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1714.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1682.49,12296.8,"percent of total billed charges",
"TUBE 89MM 10.9MM 8MM 1 CANN CUFF SMOOTH ROUND TIP OBTR",SUP-8SCT,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.54,64.36,"FIRST HEALTH [10303]","First Health",,171.63,80,,,,,0,24.95,182.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 60MM 80CM 5MM 6FR .035IN BILIARY NITINOL",SUP-G32009,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Local Plus",,2022.3,53.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 13MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P613,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Open Access",,4754.51,56.9,,5302.19,4377.88,6578.61,27,971.79,7102.52,"percent of total billed charges",
"SCR BONE 3MM 2MM 40MM 10MM STAINLESS STEEL 1.1MM SHORT",SUP-02.226.040,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"FIRST HEALTH [10303]","First Health",,1316.16,80,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Re-ED Neuromscl Ea 15min (Gp)",PX-420000022,CDM,97112,CPT,0420,RC,,,both,,,167.73,50.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,167.73,,"Per diem ($215).",,,,0,19.51,167.73,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 15MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA [10200]","Cigna Open Access",,1536.3,56.9,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 5MMX79MM 7FR 135CMCATH HEPARIN",SUP-BXB057902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6126.8,28.62,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE PROTECTION RIGID 8-13 MM NAIL STERILE",SUP-03.043.036S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1633.13,489.94,"FIRST HEALTH [10303]","First Health",,1306.5,80,,,,,0,189.93,1388.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 17CM 31MM 14.5MM EXCLUDER C3 TRUNK",SUP-RLT311417,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7292.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT WHITE 30X4IN MEDIUM LEG 2 FILL LINE POSITIVE LOCK",SUP-ASP-564011,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.12,54.34,"PHCS [10601]",PHCS,,126.78,70,,,,,0,21.06,153.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 50X18X8-15MM RISE-L 6D",SUP-193.324,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CIGNA [10200]",Cigna,,13734,40,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URETEROSCOPE FLEXIBLE LITHOVUE STD EMPOWER",SUP-M00679135SB,CDM,C1747,HCPCS,0272,RC,,,both,,,10350.00,3105,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7038,68,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URETEROSCOPE FLEXIBLE LITHOVUE STD EMPOWER",SUP-M00679135SB,CDM,C1747,HCPCS,0272,RC,,,both,,,10350.00,3105,"CIGNA [10200]",Cigna,,7038,68,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 12MM TITANIUM UNIVERSAL VASCULAR HANDLE INSTR",SUP-030403,CDM,S27200284,LOCAL,0272,RC,,,both,,,604.10,181.23,"UHC [10700]","United Healthcare",,382.4,63.3,,,,,0,70.26,513.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 80MM DYNANAIL HELIX HEADLESS STERILE LATEX FREE",SUP-3200-01-7080,CDM,S27200284,LOCAL,0272,RC,,,both,,,30208.50,9062.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13865.7,45.9,,,,,0,3513.25,25677.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYGNUS MATRIX (4 X 4) 16 SQ CM",SUP-585-010,CDM,Q4199,HCPCS,0636,RC,,,both,,,9832.50,2949.75,"CIGNA [10200]",Cigna,,298.85,,,,,,,298.85,8357.63,"fee schedule",
"SUT VICRYL PLUS MULTIPASS 4-0 PS-2 27IN BRAID COATED UNDYED",SUP-VCP426H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"NOVANET [10819]",Novanet,,18.75,75,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION LCS SIGMA HIP QUICK DRILL STERILE",SUP-9505-02-300,CDM,S27200284,LOCAL,0272,RC,,,both,,,2043.75,613.12,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1389.75,68,,,,,0,237.69,1737.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE EXAMINATION BFLEX SLIM 3.8 SINGLE USE X2",SUP-0570-0448,CDM,S27200284,LOCAL,0272,RC,,,both,,,1990.50,597.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,235.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,231.5,1691.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM THK5-30MM ALLOGRAFT FROZEN",SUP-450910,CDM,S27800098,LOCAL,0278,RC,,,both,,,14899.86,4469.96,"PHCS [10601]",PHCS,,10429.9,70,,,,,0,1732.85,12664.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SALINE 225-250ML 2 WAY CHECK VALVE SMOOTH",SUP-351-225SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"MULTIPLAN [10600]",Multiplan,,722.93,85,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 80MM 2.5MM QUICK CONNECT NONSTERILE",SUP-03.133.103,CDM,S27200284,LOCAL,0272,RC,,,both,,,927.61,278.28,"CIGNA [10200]",Cigna,,630.77,68,,,,,0,107.88,788.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ECHELON CONTOUR GST RELOAD (BLUE)",SUP-GCR40B,CDM,S27200284,LOCAL,0272,RC,,,both,,,2994.05,898.21,"MULTIPLAN [10600]",Multiplan,,2544.94,85,,,,,0,348.21,2544.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BACTISEAL 120CM 14CM DRNG VENTRICLE DISTAL KIT SHUNT",SUP-823072,CDM,S27800098,LOCAL,0278,RC,,,both,,,4862.22,1458.67,"CIGNA [10200]","Cigna Open Access",,2766.6,56.9,,,,,0,565.48,4132.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 35MM TSRH OSTEOGRIP THINLINE TITANIUM SPINE",SUP-83545359,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,736.68,28.62,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 16MM 144CM 3MM CORONARY STENT EVEROLIMUS",SUP-H7493926116300,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"UHC [10700]","United Healthcare",,5896.4,63.3,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CREO SPINE PREASSEMBLE 5.5MM ROD",SUP-5119.165,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross PPO",,1893.36,39.2,,957.42,570.23,957.42,28,561.73,4105.5,"percent of total billed charges",
"TRAY CATHETERIZATION COMPLETE CARE 16FR FOLEY DRNG BAG",SUP-300016A,CDM,S27200284,LOCAL,0272,RC,,,both,,,122.36,36.71,"KAISER [10500]",Kaiser,,81.98,67,,,,,0,14.23,104.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDEAVOR SPRINT 12MM 142CM 3.5MM CORONARY STENT",SUP-ENSP35012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5817.00,1745.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2670,45.9,,,,,0,676.52,4944.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Ankle Arthgm",PX-361000049,CDM,27648,CPT,0361,RC,,,both,,,893.00,267.9,"PHCS [10601]",PHCS,,625.1,70,,,,,0,103.86,893,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.25 X 28 RX US",SUP-1804225-28,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 7MM 9.5MM 240MM HUMERAL LEFT MULTILOC INTRAMEDULLARY",SUP-04.017.240S,CDM,C1713,HCPCS,0278,RC,,,both,,,11172.76,3351.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3016.65,27,,,,,0,1299.39,9496.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prolact Rtf24 Qtr Btl",PX-E27000212,CDM,E27000212,LOCAL,0270,RC,,,both,,,214.50,64.35,"PHCS [10601]",PHCS,,150.15,70,,,,,0,24.95,182.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL STRAIGHT SPAT 36CM CLEANCOAT",SUP-E3770-36C,CDM,S27200284,LOCAL,0272,RC,,,both,,,251.00,75.3,"CIGNA [10200]",Cigna,,170.68,68,,,,,0,29.19,213.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Somatomedin",PX-301000401,CDM,84305,CPT,0301,RC,,,both,,,236.00,70.8,"CIGNA [10200]","Cigna Local Plus",,46.77,,,,,,,0.24,200.6,"fee schedule",
"CANN ARTHROSCOPIC 75MM 6.5MM DRI-LOK THREAD",SUP-3910075650,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"KAISER [10500]",Kaiser,,116.58,67,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VISTA BRITE TIP GUIDE CATHETER 6F .070 XB 3.5 ECO PK",SUP-6700540E,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL NATRELLE INSPIRA FULL PROFILE SILICONE 520CC",SUP-SSZ-F520,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL 3-0 PS-2 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J497G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 5MM CANNULATED LARGE QUICK COUPLING",SUP-03.333.112,CDM,S27000186,LOCAL,0270,RC,,,both,,,3111.08,933.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,368.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,361.82,2644.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOABLATION 11IN 8MM CRYOSPHERE 180D UP BALL TIP",SUP-CRYOS,CDM,C9808,HCPCS,0272,RC,,,both,,,17250.00,5175,"PHCS [10601]",PHCS,,12075,70,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE TIBIAL 14.5MM PFC SIGMA 20D 3 HEMI KNEE TITANIUM",SUP-860179,CDM,C1776,HCPCS,0278,RC,,,both,,,8260.68,2478.2,"KAISER [10500]",Kaiser,,5534.66,67,,,,,0,960.72,7021.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 52.5MM TITANIUM LOCK TRANSLATIONAL ATLANTIS BONE SPINE",SUP-6190052,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1514.57,28.62,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 14CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175197190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS [10001]","Blue Cross HMO",,496.03,39.2,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 18MM 9MM STD WALL THIN WALL 2 BRANCH",SUP-SBT1802D,CDM,C1768,HCPCS,0278,RC,,,both,,,8611.20,2583.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3952.54,45.9,,,,,0,1001.48,7319.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 3.5-4MM PARALLEL SPINE S ROD",SUP-102015081,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"KAISER [10500]",Kaiser,,2386.88,67,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 400MM HIP RIGHT FEMUR AFFIXUS INTRAMEDULLARY 130D",SUP-814509400,CDM,C1713,HCPCS,0278,RC,,,both,,,20742.75,6222.82,"FIRST HEALTH [10303]","First Health",,16594.2,80,,,,,0,2412.38,17631.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP GLOBAL UNITE REVER",SUP-OSC368944,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5275.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 29MM 24.2MM MASTERS SERIES 85D STD SUPRA",SUP-29AJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]","Cigna Open Access",,9754.94,33.5,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 32MM 14MM STAINLESS STEEL ORTHOPEDIC CANNULATED",SUP-121832,CDM,C1713,HCPCS,0278,RC,,,both,,,2006.40,601.92,"FIRST HEALTH [10303]","First Health",,1605.12,80,,,,,0,233.34,1705.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATRIAL LIFT",SUP-MI-ALS-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,3018.75,905.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,351.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,351.08,2565.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO2 VASCULAR 200CM 35CM .014IN NITINOL STAINLESS",SUP-M00326410,CDM,C1769,HCPCS,0272,RC,,,both,,,4186.64,1255.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,496.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,486.91,3558.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOJET ULTRA CROSS-STREAM SPIROFLEX VG 60ML/MIN",SUP-106608-001,CDM,C1757,HCPCS,0272,RC,,,both,,,12891.96,3867.59,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1499.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1499.33,10958.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL STEALTH 11MM 11MM VASCULAR SOFT WHITE",SUP-G-1100,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"PHCS [10601]",PHCS,,109.62,70,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X3CM GRAFIX PRIME PLACENTAL MEMBRANE ALLO",SUP-PS13034,CDM,Q4133,HCPCS,0636,RC,,,both,,,8383.50,2515.05,"CIGNA [10200]","Cigna Local Plus",,373.04,,,,,,,373.04,7125.98,"fee schedule",
"STENT 20CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX TAPER TIP",SUP-M0061453790,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"CIGNA [10200]",Cigna,,430.51,68,,,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 24CM 3CM 8FR .035IN PIGTAIL CURVE",SUP-M006180242180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,670.19,45.9,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 30ML 1.7-7MM DEMINERALIZED CANCELLOUS",SUP-420037,CDM,C1713,HCPCS,0278,RC,,,both,,,3874.01,1162.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2634.33,68,,,,,0,450.55,3292.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM VARIAX TITANIUM T7 FULL THREAD RADIUS",SUP-53-27620E,CDM,C1713,HCPCS,0278,RC,,,both,,,762.05,228.61,"CIGNA [10200]","Cigna Open Access",,433.61,56.9,,1144.80,304.56,2275.09,66,88.63,647.74,"percent of total billed charges",
"SCR BONE 5MM 38MM PHOENIX TITANIUM CORTICAL SELF TAP 2 LEAD",SUP-14-405038,CDM,C1713,HCPCS,0278,RC,,,both,,,2475.00,742.5,"CIGNA [10200]","Cigna Open Access",,1408.28,56.9,,1144.80,304.56,2275.09,66,287.84,2103.75,"percent of total billed charges",
"SYSTEM SPEEDBRIDGE JUMPSTART FIXATION PEEK ACHILLES STERILE",SUP-AR-8928PJ-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,14453.78,4336.13,"CIGNA [10200]","Cigna Open Access",,4842.02,33.5,,1144.80,304.56,2275.09,66,1680.97,12285.71,"percent of total billed charges",
"SCR BONE 2.4MM 12MM QUICKFIX TITANIUM T8 PARTIAL THREAD",SUP-AR-8724-12,CDM,C1713,HCPCS,0278,RC,,,both,,,1028.70,308.61,"MULTIPLAN [10600]",Multiplan,,874.4,85,,,,,0,119.64,874.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 9IN .035IN KIRSCHNER 2 TROCAR POINT BOTH END",SUP-163834000,CDM,C1713,HCPCS,0278,RC,,,both,,,185.60,55.68,"CIGNA [10200]","Cigna Open Access",,105.61,56.9,,1144.80,304.56,2275.09,66,21.59,157.76,"percent of total billed charges",
"PLATE SMALL BEND 117MM STAINLESS STEEL 3.5MM SCR 6 HOLE",SUP-02.127.221S,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"UHC [10700]","United Healthcare",,6551.55,63.3,,5023.51,2672.93,6679.78,18,1203.71,8797.5,"percent of total billed charges",
"SCR BONE 3.5MM 24MM SECUR-FIT X-TRA TITANIUM T15 CORTICAL",SUP-131218024,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"NOVANET [10819]",Novanet,,592.31,75,,,,,0,91.85,671.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.0MM X 14MM TI",SUP-VAN-20140-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"BLUE CROSS [10001]","Blue Cross HMO",,381.02,39.2,,957.42,156.86,7483.26,51,113.04,826.2,"percent of total billed charges",
"PEG FIXATION 2MM 23MM FOSSA RADIUS DISTAL VOLAR SMOOTH LOCK",SUP-SPLS-20230-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,639.90,191.97,"BLUE CROSS [10001]","Blue Cross PPO",,250.84,39.2,,957.42,570.23,957.42,28,74.42,543.92,"percent of total billed charges",
"PLATE BONE .5MM 22MM LORENZ CRANIOMAXILLOFACIAL TITANIUM",SUP-017309,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.70,405.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,919.84,68,,,,,0,157.32,1149.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 14MM OSTEOLOCK RESTORATION CANCELLOUS HEXAGON",SUP-5260-5-014,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,349.48,45.9,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 36MM NAIL-EX TITANIUM FULL THREAD FEMORAL",SUP-04.005.526S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"BLUE CROSS [10001]","Blue Cross HMO",,586.78,39.2,,957.42,156.86,7483.26,51,174.09,1272.35,"percent of total billed charges",
"PLATE NARROW TITANIUM ALUMINUM VANADIUM PERIPROSTHETIC NCB",SUP-0202263301,CDM,C1713,HCPCS,0278,RC,,,both,,,9729.00,2918.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3998.62,41.1,,,,,0,1131.48,8269.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 4MM 1.2MM 18MM 8MM STAINLESS STEEL LONG THREAD",SUP-202.718,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"BLUE CROSS [10001]","Blue Cross HMO",,435.13,39.2,,957.42,156.86,7483.26,51,129.1,943.52,"percent of total billed charges",
"PLATE 20MM TITANIUM 1 LEVEL CITADEL BONE SPINE LUMBAR",SUP-130.120,CDM,C1713,HCPCS,0278,RC,,,both,,,17250.00,5175,"KAISER [10500]",Kaiser,,11557.5,67,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 20MM TITANIUM 1 LEVEL CITADEL BONE SPINE LUMBAR",SUP-130.120,CDM,C1713,HCPCS,0278,RC,,,both,,,17250.00,5175,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,2006.18,14662.5,"percent of total billed charges",
"SCR BONE 2.4MM 10MM LCP STAINLESS STEEL DISTAL CORTICAL",SUP-201.760,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADAPTA  SR  IS-1  213",SUP-ADSR01,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"CIGNA [10200]","Cigna Open Access",,8321.4,33.5,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SPEEDSTITCH SUTURING CASSETTE NDL STERILE DISPOSABLE",SUP-OM8850,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT EMG STIM PATHWAY VAGINA",SUP-2949,CDM,S27200284,LOCAL,0272,RC,,,both,,,329.38,98.81,"KAISER [10500]",Kaiser,,220.68,67,,,,,0,38.31,279.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 152MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-226.581,CDM,C1713,HCPCS,0278,RC,,,both,,,3099.60,929.88,"MULTIPLAN [10600]",Multiplan,,2634.66,85,,,,,0,360.48,2634.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC",816,MS-DRG,,,,,,,inpatient,,,21595.68,6478.7,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,4155.55,,"Case rate ($3,920.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,640.30, add-ons for qualifying new technology services are included. If operating cost exceeds $36,679.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,657.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,645.11. The transfer operating threshold is the transfer adjustment factor * $3,640.30 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $275.22. The transfer capital threshold is the transfer adjustment factor * $275.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,3920.33,15761.45,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 36IN 8FR TEFLON POLYURETHANE SILICONE",SUP-50-7368,CDM,S27200284,LOCAL,0272,RC,,,both,,,396.39,118.92,"AETNA [10100]","Aetna HMO/PPO",,315.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.1,336.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175263190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS [10001]","Blue Cross PPO",,496.03,39.2,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM ORTHOLOC TITANIUM CORTICAL LOCK",SUP-59215540,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,260.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",255.57,1867.88,"percent of total billed charges",
"HC Block Smpl",PX-333000017,CDM,77332,CPT,0333,RC,,,both,,,1229.94,368.98,"BLUE CROSS [10001]","Blue Cross PPO",,617.85,,"Per diem ($617.85).",,,,0,143.04,1229.94,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 7FR L26CM SOFT WITHOUT GUIDEWIRE TRIA",SUP-M0061903330,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 75CM 60MM 5MM BALLOON DILATATION DRUG COATED",SUP-LX3575560V,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL 12CM MR8 3MM MATCH HEAD DISSECTING",SUP-MR8-12MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1089.86,326.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"WALKER PATIENT C300LB 25-32IN DAYS 5IN ALUMINUM PVC 17IN 2",SUP-081561737,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MONOCRYL 1 CT-1 36IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Y947H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HNDPC PULSED LAVAGE 8MM 8MM VERSAJET II 45D EXACT NARROWER",SUP-66800042,CDM,S27200284,LOCAL,0272,RC,,,both,,,4278.00,1283.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL LOOP 6.5IN TUNGSTEN 20X12MM NONHEX",SUP-E15616,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.49,30.15,"CIGNA [10200]","Cigna Open Access",,57.18,56.9,,,,,0,11.69,85.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE PRO3 AMNIOTIC PLACENTAL MEMBRANE THIN L8 C",SUP-P01-AMP-0408,CDM,S27800098,LOCAL,0278,RC,,,both,,,13886.25,4165.87,"CIGNA [10200]","Cigna Local Plus",,4374.17,31.5,,,,,0,1614.97,11803.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 1MM ELITE ROUND DIAMOND 5 STEP NOTCH STERILE",SUP-5820012010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1119.18,335.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,513.7,45.9,,,,,0,130.16,951.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 50MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT SET 3X3",SUP-241.13,CDM,C1713,HCPCS,0278,RC,,,both,,,2315.70,694.71,"CIGNA [10200]","Cigna Open Access",,1317.63,56.9,,1144.80,304.56,2275.09,66,269.32,1968.35,"percent of total billed charges",
"SHELL ACETABULAR HEMI 3HL 58M",SUP-430-98-058,CDM,C1776,HCPCS,0278,RC,,,both,,,5341.60,1602.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,621.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,621.23,4540.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SHUNT MULTAVAC 3 WAY CATH PORT CSF STERILE",SUP-20033,CDM,S27800098,LOCAL,0278,RC,,,both,,,2163.68,649.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1471.3,68,,,,,0,251.64,1839.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PX 400 VELOCITY 160CM 2.6-2.95FR .025IN MICRO 3D",SUP-VEL160STR,CDM,C1887,HCPCS,0272,RC,,,both,,,7293.30,2187.99,"KAISER [10500]",Kaiser,,4886.51,67,,,,,0,848.21,6199.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD 10CM OSCOR UNIVERSAL IMPLANTABLE BIPOLAR IS-1","SUP-355 914",CDM,S27200284,LOCAL,0272,RC,,,both,,,4947.30,1484.19,"MULTIPLAN [10600]",Multiplan,,4205.21,85,,,,,0,575.37,4205.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 13CM 3.4MM QUADCUT M4 STRAIGHTSHOT M4 LATEX",SUP-1883480EM,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPIFIX 3X4 CM ""Q"" CODED",SUP-GS-5340,CDM,Q4186,HCPCS,0636,RC,,,both,,,16511.70,4953.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7388.99,44.75,,,,,0,406.44,14034.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NEURON 130CM 9CM 5FR .04IN .038IN SIMS CURVE DELIVERY",SUP-PNS5F130SIM,CDM,C1887,HCPCS,0272,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 6MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0100600,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"AETNA [10100]","Aetna HMO/PPO",,4040.07,79.5,,10981.53,8986.79,12413.38,12,591.02,4319.57,"percent of total billed charges",
"CATH RELIEVA SPIN 16MM 6MM 0D S-0 GUIDING SPHENOID SINUS",SUP-RSS0,CDM,S27200284,LOCAL,0272,RC,,,both,,,2400.00,720,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,986.4,41.1,,,,,0,279.12,2040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alloderm per Sq Cm",PX-E63600016,CDM,Q4116,HCPCS,0636,RC,,,both,,,149.60,44.88,"CIGNA [10200]","Cigna Local Plus",,80.04,53.5,,,,,0,17.73,149.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 55MM AXSOS OMEGA3 STAINLESS STEEL T20 FEMUR",SUP-370355,CDM,C1713,HCPCS,0278,RC,,,both,,,1376.51,412.95,"FIRST HEALTH [10303]","First Health",,1101.21,80,,,,,0,160.09,1170.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +6.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.065,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BROWN 51MM 28MM SELF-CENTERING HIP FEMUR",SUP-103551000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,877.01,28.62,,,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 13X11CM 400CC STYLE 133S SMOOTH SUT TAB NATRELLE",SUP-133S-SX-13-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4275.59,45.9,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND PLUS 10CMX15CM ACELL GENTRIX 150 CM2 8 LAYER",SUP-MSPL1015,CDM,C1781,HCPCS,0278,RC,,,both,,,26790.75,8037.22,"KAISER [10500]",Kaiser,,17949.8,67,,,,,0,3115.76,22772.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 24MM TARGET XL 360D STD LARGE",SUP-M0036102450,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BROWN 51MM 28MM SELF-CENTERING HIP FEMUR",SUP-103551000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"NOVANET [10819]",Novanet,,2298.24,75,,,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 8-0 BV175-6 24IN 2 ARM MONOFILAMENT BLUE",SUP-8741H,CDM,S27200284,LOCAL,0272,RC,,,both,,,258.69,77.61,"FIRST HEALTH [10303]","First Health",,206.95,80,,,,,0,30.09,219.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 2MM PK DIEGO STRAIGHT TURBINATE SINUS SERRATE",SUP-7013-8033,CDM,S27200284,LOCAL,0272,RC,,,both,,,897.05,269.11,"CIGNA [10200]","Cigna Local Plus",,479.92,53.5,,,,,0,104.33,762.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 97MM CEMENTED BASIC SUMMIT 2 12/14 TAPER HIP",SUP-157006080,CDM,C1776,HCPCS,0278,RC,,,both,,,8135.10,2440.53,"CIGNA [10200]","Cigna Open Access",,4628.87,56.9,,5302.19,4377.88,6578.61,27,946.11,6914.84,"percent of total billed charges",
"SA60WF.180 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.180,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 6CM 5.5MM TSRH SILO STD PEDICLE TITANIUM PREBENT",SUP-8370060,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,512.88,3748.5,"percent of total billed charges",
"CATH CHRG 135CM 40MM 7FR 12MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206120410,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 2.1MM STRAIGHT 2 SERRATE ENTELLUS MEDICAL HNDPC",SUP-SSB-12200-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENDO STITCH V LOC 180 3-0 6IN CLSR ABSORBABLE RELOAD",SUP-VLOCA306L,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.01,84.3,"KAISER [10500]",Kaiser,,188.28,67,,,,,0,32.68,238.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CENTRAL VENOUS PICC",SUP-B9-16350,CDM,C1751,HCPCS,0272,RC,,,both,,,309.51,92.85,"MULTIPLAN [10600]",Multiplan,,263.08,85,,,,,0,36,263.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 52MM 28MM 10D HIP CROSSFIRE OMNIFIT STERILE",SUP-2041C-2852,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"PHCS [10601]",PHCS,,4926.6,70,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 6CM 5.5MM TSRH SILO STD PEDICLE TITANIUM PREBENT",SUP-8370060,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"NOVANET [10819]",Novanet,,3307.5,75,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 11GA 4IN JAMSHIDI TAPER DISTAL ADPTR SHARP BEVEL",SUP-DJ4011X,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.05,42.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,65.66,45.9,,,,,0,16.64,121.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP 1CC 2-4MM ALLOGRAFT GRANULE",SUP-12700201,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 12MM 135CM 6MM 3.6-3.3FR 6FR BILIARY",SUP-1011499-12,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,746.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP 6MM 165CM INTERNAL OTSC GRSP 12MM",SUP-100.11,CDM,C1760,HCPCS,0278,RC,,,both,,,4133.10,1239.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,489.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,480.68,3513.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INQUIRY 6FR ELECTROPHYSIOLOGY STERILE DISPOSABLE",SUP-IBI-81404,CDM,C1725,HCPCS,0272,RC,,,both,,,2325.00,697.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOOK OPHTHALMIC LARGE REGULAR 5 1/8IN JAMESON MUSCLE",SUP-60-1339,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT SPINAL SPINEJACK 4.2MM EXPANSION",SUP-0909-200-042,CDM,S27200284,LOCAL,0272,RC,,,both,,,8966.41,2689.92,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT EDGE ACCUVAC",SUP-E2450HS,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.66,32,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GYNECOLOGIC PROCEDURES WITHOUT MALIGNANCY,MODERATE",513,APR-DRG,,,,,,,inpatient,,,86194.53,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $6,575.49. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,607.14) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 7FR .081IN RIGHT BACKUP 3.5 CURVE",SUP-LA7RBU35,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE SUCTION RUBBER LEAFLET INSTR CHANNEL STERILE",SUP-11301CA/20,CDM,S27200284,LOCAL,0272,RC,,,both,,,79.50,23.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING SL MONORAIL 150CM 120MM 4MM BALLOON DILATATION",SUP-H74939147401210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BRUSH CYTOLOGY 3MM 5FR 120CM BRISTLE STERILE DISPOSABLE BLUE",SUP-G21386,CDM,S27200284,LOCAL,0272,RC,,,both,,,167.91,50.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATH 20CM 11FR .052IN PERITONEUM 90 SIDEPORT DIL GWIRE",SUP-CPDSY1101T20,CDM,C1894,HCPCS,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) CATHETER THE RINGER PERFUSION 20MM OD 4.5MM PERFUSION",SUP-5890,CDM,C1725,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"PROS OSSICULAR 4MM .6MM SMART STAPES PISTON RECONSTRUCTIVE",SUP-7014-5926,CDM,L8613,HCPCS,0278,RC,,,both,,,1801.20,540.36,"PHCS [10601]",PHCS,,1260.84,70,,,,,0,209.48,1531.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 3 HOLE PIN DORSAL ULNAR PIN PLATE BONE",SUP-DUP3,CDM,C1713,HCPCS,0278,RC,,,both,,,4278.00,1283.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,506.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,497.53,3636.3,"percent of total billed charges",
"SCR BONE 4.75MM 35MM COMPREHENSIVE 3.5MM SHOULDER FIX ANGLE",SUP-180554,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,180.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",180.96,1322.6,"percent of total billed charges",
"CATH RANGER 150CM 200MM 6MM BALLOON DILATATION PACLITAXEL",SUP-H74939419602010,CDM,C2623,HCPCS,0272,RC,,,both,,,13455.00,4036.5,"MULTIPLAN [10600]",Multiplan,,11436.75,85,,,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fibrin Plasminogen Activator",PX-305000045,CDM,85415,CPT,0305,RC,,,both,,,1107.70,332.31,"PHCS [10601]",PHCS,,775.39,70,,,,,0,0.01,941.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT FLITES C600LB LARGE GENERAL PURPOSE CLIP",SUP-MFA1000M-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,268.70,80.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,31.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.25,228.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC",846,MS-DRG,,,,,,,inpatient,,,75361.88,22608.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,41334.12,,,,,,,7561,64654.36,"case rate",
"INSRT TIBIAL 3 13MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P313,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3434.27,41.1,,6417.48,6417.48,6417.48,"1 through 10",971.79,7102.52,"percent of total billed charges",
"INSRT TIBIAL 8 19MM KNEE X3 BEARING CRUCIATE RETAIN",SUP-5530-G-819,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"MULTIPLAN [10600]",Multiplan,,9700.71,85,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLIDE HER 2 PATHWAY 4 IN 1 PARAFFIN EMBED CONTROL",SUP-781-2991,CDM,S27000186,LOCAL,0270,RC,,,both,,,226.46,67.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN RIGHT",SUP-77808300,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 45MM 2.5MM QUICK CONNECT NONSTERILE",SUP-03.133.102,CDM,S27200284,LOCAL,0272,RC,,,both,,,787.00,236.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SUPERTORQUE 100CM 6FR JUDKINS LEFT CORONARY 4.5 CURVE",SUP-532627,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 90CM 200MM 2MM BALLOON DILATATION OTW STERILE",SUP-47020200S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUBE DEMINERALIZED BONE 11MM Q-PACK CONFORM",SUP-4W0011,CDM,S27800098,LOCAL,0278,RC,,,both,,,4462.92,1338.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,519.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,519.04,3793.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 60MM 32MM MARATHON HIP",SUP-121932060,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,841.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,841.39,6149.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 50X40MM THK.5MM POLYDIOXANONE PDS FLEXIBLE",SUP-ZFP6,CDM,S27800098,LOCAL,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Shave Ext Lesn >2.0cm",PX-510000021,CDM,11303,CPT,0761,RC,,,both,,,1076.00,322.8,"AETNA [10100]","Aetna HMO/PPO",,855.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,125.14,1076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transferrin",PX-301000419,CDM,84466,CPT,0301,RC,,,both,,,293.80,88.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11.48,,,,,,,0.29,249.73,"fee schedule",
"SCR BONE 6MM 40MM MATRIX TITANIUM T25 SPINE PEDICLE",SUP-04.639.640,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"FORCEPS ILM 25+SHARKSKIN DSP",SUP-705.88P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1171.10,351.33,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,537.53,45.9,,,,,0,136.2,995.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET",RX-39255,CDM,J0750,HCPCS,0636,RC,00904-7172-07,NDC,both,1,UN,11.75,3.52,"BLUE CROSS [10001]","Blue Cross PPO",,2.02,,,,,,,1.39,9.99,"fee schedule",
"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC",098,MS-DRG,,,,,,,inpatient,,,88819.60,26645.88,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COR KNOT MIS DEVICE HANDLED",SUP-030800,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATHETERIZATION SURESTEP LUBRICATH STATLOCK 16FR 2L",SUP-A899916,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.36,32.21,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SNARE 79IN .28IN ONE SNARE 1 NITINOL LOOP GOLD PLATED",SUP-ONE701,CDM,S27200284,LOCAL,0272,RC,,,both,,,4278.00,1283.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM FEMORAL 93MM TYPE 1 PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51108040,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"CIGNA [10200]","Cigna Open Access",,9190.81,33.5,,5302.19,4377.88,6578.61,27,3190.72,23319.95,"percent of total billed charges",
"BURR SHAVER AQUA 4MM DYONICS ELITE STRAIGHT ABRADER STERILE",SUP-72200722,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.35,105.7,"MULTIPLAN [10600]",Multiplan,,299.5,85,,,,,0,40.98,299.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 155MM 32MM ZENITH ALPHA 7.1MM CYLINDRICAL",SUP-G35347,CDM,C1874,HCPCS,0278,RC,,,both,,,89041.07,26712.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,25483.55,28.62,,,,,0,10355.48,75684.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP FOGARTY LARGE 86MM SOFT/TRACTION STERILE",SUP-A0803,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"KAISER [10500]",Kaiser,,104.92,67,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE U - CB CUTTING BLOCK",SUP-CAP-U-CB,CDM,C1776,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,463.64,28.62,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 24CM 8FR .038",SUP-M006192152120,CDM,C2617,HCPCS,0278,RC,,,both,,,1528.96,458.69,"CIGNA [10200]","Cigna Open Access",,869.98,,,,,,,177.82,1299.62,"percent of total billed charges",
"HC Vasc Embol Occl Venous",PX-361000320,CDM,37241,CPT,0361,RC,,,both,,,13861.00,4158.3,"NOVANET [10819]",Novanet,,10395.75,75,,,,,0,1612.03,11781.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE 2.8CM ROUND 240CM 15MM 2.4MM CAPTIVATOR II LOOP STIFF",SUP-M00561231,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.70,40.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.78,115.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ELECTRODE KIT (ENSITE X PATCH)",SUP-ENSITE-SEK-5-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,7526.18,2257.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5117.8,68,,,,,0,875.29,6397.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grad Compression Thigh 30-40",PX-E27100013,CDM,A6534,HCPCS,0292,RC,,,both,,,191.40,57.42,"UHC [10700]","United Healthcare",,121.16,63.3,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop Uni W Pta",PX-361000152,CDM,37224,CPT,0361,RC,,,both,,,12247.10,3674.13,"BLUE CROSS [10001]","Blue Cross HMO",,7166.56,,"Case rate ($7,166.56). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1424.34,10410.04,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONJUGATED ESTROGENS 0.625 MG TABLET",RX-9974,CDM,,,0637,RC,50742-0389-01,NDC,both,1,UN,30.47,9.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12.52,41.1,,,,,0,3.54,25.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 18FR SILICONE BOLUS FEED INTERNAL RETENTION BALLOON",SUP-8110-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"KAISER [10500]",Kaiser,,187.52,67,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 40MM 3MM BALLOON DILATATION DURALYN",SUP-48003004S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"FIRST HEALTH [10303]","First Health",,1004.4,80,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TORSEMIDE 5 MG TABLET",RX-18295,CDM,,,0637,RC,50268-0754-11,NDC,both,1,UN,6.27,1.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2.58,41.1,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Duoderm",PX-E27200109,CDM,E27200109,LOCAL,0272,RC,,,both,,,123.87,37.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.41,105.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 8MM KII OPTICAL ACCESS SYSTEM Z",SUP-C0Q19,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,71.88,45.9,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Creatinine Other Source",PX-301000168,CDM,82570,CPT,0301,RC,,,both,,,88.67,26.6,"KAISER [10500]",Kaiser,,59.41,67,,,,,0,0.09,75.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 18CM 5.5MM DYONICS LONG ABRADER ARTHROSCOPIC",SUP-72200082,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"FIRST HEALTH [10303]","First Health",,466.56,80,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR/ELEV LAPAROSCOPIC 34MM VCARE PLUS CUP CERVICAL",SUP-60-6085-201A,CDM,S27200284,LOCAL,0272,RC,,,both,,,522.45,156.73,"UHC [10700]","United Healthcare",,330.71,63.3,,,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 17MM 4MM INTRACRANIAL BARE METAL FLOW",SUP-FDS40017,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"AETNA [10100]","Aetna HMO/PPO",,66004.65,79.5,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE LEFT POSTERIOR STABILIZE CEMENT ATTUNE",SUP-150410102,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"AETNA [10100]","Aetna HMO/PPO",,17802.71,79.5,,10981.53,8986.79,12413.38,12,2604.35,19034.35,"percent of total billed charges",
"CMPNT FEMORAL E-R RIGHT KNEE OPTION LPS-FLEX GSF STERILE",SUP-00576401552,CDM,C1776,HCPCS,0278,RC,,,both,,,16934.40,5080.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6773.76,40,,,,,0,1969.47,14394.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 135CM 4CM 4MM BALLOON",SUP-G52252,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"AETNA [10100]","Aetna HMO/PPO",,763.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 137MM CEMENT ACCOLADE C 127D 4 46MM OFFSET HIP",SUP-6057-0435D,CDM,C1776,HCPCS,0278,RC,,,both,,,16439.25,4931.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4438.6,27,,,,,0,1911.88,13973.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 10GA HYDROMARK BREAST BIOPSY OPEN COIL TITANIUM",SUP-4010-05-10-T3,CDM,A4648,HCPCS,0278,RC,,,both,,,640.49,192.15,"CIGNA [10200]","Cigna Open Access",,364.44,56.9,,,,,0,74.49,544.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM LAPIPLASTY BIPLANAR 14X3.9MM 12MM 2.7MM 2.7MM",SUP-SK14,CDM,C1713,HCPCS,0278,RC,,,both,,,29521.80,8856.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12133.46,41.1,,,,,0,3433.39,25093.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 18MM 145CM 3.5MM CORONARY STENT",SUP-1145350-18,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PHCS [10601]",PHCS,,4086.6,70,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 1-2 C-H STD 58X40X10MM KNEE PROLONG NEXGEN",SUP-00595202110,CDM,C1776,HCPCS,0278,RC,,,both,,,8757.48,2627.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1037.76,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1018.49,7443.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 100MM 150CM 6MM VASCULAR NICKEL",SUP-EVD35-06-100-150,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3325.46,45.9,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X12MM COROENT PEEK THORACOLUMBAR INTERBODY",SUP-6981255,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"PHCS [10601]",PHCS,,16632,70,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING SL 150CM 100MM 2.5MM BALLOON DILATATION PEBAX",SUP-H74939147251010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 10FR PIGTAIL URETERAL PERCUFLEX METAL",SUP-M001221410,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,105.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 4X2CM ALLODERM SELECT THK.3-.8MM THIN",SUP-141408,CDM,Q4116,HCPCS,0636,RC,,,both,,,3337.50,1001.25,"UHC [10700]","United Healthcare",,247.92,,,,,,,247.92,2836.88,"fee schedule",
"SHAVER BLADES STRAIGHT SHAFT 3MM SINGLE SERRATED STERILE",SUP-1600541-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"UHC [10700]","United Healthcare",,897.28,63.3,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Sl Sp Grpiii / Add on 88319",PX-312000096,CDM,0759T,CPT,0312,RC,,,both,,,100.00,30,"MULTIPLAN [10600]",Multiplan,,85,85,,,,,0,11.85,85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP070100150 PLUS US D7L100UL1500",SUP-PCP070100150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLS-2507 CLASSICSHEATH LONG",SUP-398723,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PORT HAND ACCESS LOW PROFILE OBTR BLADELESS OPTICAL TIP",SUP-IAS5-120LP,CDM,S27200284,LOCAL,0272,RC,,,both,,,721.05,216.31,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 7FR 75CM MULLINS DESIGN RADIOPAQUE TIP SIDEARM",SUP-G08756,CDM,C1894,HCPCS,0272,RC,,,both,,,680.32,204.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,inpatient,,,33328.69,9998.61,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION",RX-1649,CDM,J3230,HCPCS,0636,RC,00641-1397-31,NDC,both,1,ML,226.52,67.96,"BLUE CROSS [10001]","Blue Cross PPO",,29.45,,,,,,,9.53,192.54,"fee schedule",
"PLATE 77MM STAINLESS STEEL 2.4MM SCR 5X7 HOLE 2 COLUMN",SUP-02.111.750,CDM,C1713,HCPCS,0278,RC,,,both,,,4198.65,1259.59,"KAISER [10500]",Kaiser,,2813.1,67,,,,,0,488.3,3568.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 5MM BALL DISSECTING STERILE DISPOSABLE",SUP-MR8-14BA50,CDM,S27200284,LOCAL,0272,RC,,,both,,,1326.78,398.03,"AMERIGROUP MEDICAID [20100]",Amerigroup,,157.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.3,1127.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 17MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE40017,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,23944.81,28.62,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L15 MM OD3.5 MM SPINE CERVICAL ANTERIOR SELF TAP",SUP-18008415,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER DIAGNOSTIC 4FR 110CM 145DEG GUIDEWIRE 0.035IN NYLON",SUP-538457V,CDM,C1769,HCPCS,0272,RC,,,both,,,89.52,26.86,"FIRST HEALTH [10303]","First Health",,71.62,80,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 150MM 1.4MM TROCAR TIP STERILE",SUP-03.333.002.01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,577.37,173.21,"MULTIPLAN [10600]",Multiplan,,490.76,85,,,,,0,67.15,490.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLASH 8MM 4.5MM MINI BALLOON DILATATION 2 BALLOON",SUP-OCB4508BA,CDM,C1725,HCPCS,0272,RC,,,both,,,6762.00,2028.6,"AETNA [10100]","Aetna HMO/PPO",,5375.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP MEDIUM FULL 2 FLAP FOREHEAD SPRT HEADSTRAP CLIP",SUP-1012624,CDM,S27000186,LOCAL,0270,RC,,,both,,,1822.88,546.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,749.2,41.1,,,,,0,212,1549.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +12 DIOPTER MODIFIED C BICONVEX 12.5MM 7MM",SUP-CZ70BD.120,CDM,V2632,HCPCS,0276,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL IHF 1.4MM",SUP-DRLL-IHF-14,CDM,S27000186,LOCAL,0270,RC,,,both,,,996.30,298.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,118.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 60MM 75CM 6MM VASCULAR METAL SUPERFICIAL",SUP-H74939293066070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"KAISER [10500]",Kaiser,,3236.1,67,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 22F LARGE HIP PROXIMAL",SUP-550546,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1289.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION 1000-1180UM 5 VIAL CONTOUR PVA",SUP-M0017601151,CDM,S27800098,LOCAL,0278,RC,,,both,,,1377.00,413.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,936.36,68,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 20MM DCP STAINLESS STEEL CORTICAL SELF",SUP-202.820,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"CIGNA [10200]","Cigna Local Plus",,187.95,53.5,,3978.14,359.25,3978.14,24,40.86,298.61,"percent of total billed charges",
"DEVICE PIPELINE FLEX 10MM 3.5MM EMBOLIZATION BRAID SOFT",SUP-PED-350-10,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"FIRST HEALTH [10303]","First Health",,61560,80,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3/32IN THREADED DIAMOND POINT ONE END 9IN",SUP-KM169-39-33,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"NOVANET [10819]",Novanet,,47.71,75,,,,,0,7.4,54.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE MALLEABLE CONTOURABLE MESH LOW PROFILE 100X100MM",SUP-421.533S,CDM,C1713,HCPCS,0278,RC,,,both,,,15000.60,4500.18,"CIGNA [10200]","Cigna Open Access",,5025.2,33.5,,1144.80,304.56,2275.09,66,1744.57,12750.51,"percent of total billed charges",
"GRAFT BONE OSTEOSPONGE CANCELLOUS DEMINERALIZED BONE MATRIX",SUP-109530,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Local Plus",,5537.25,53.5,,3978.14,359.25,3978.14,24,1203.71,8797.5,"percent of total billed charges",
"O.R. PROCEDURES FOR OBESITY WITH MCC",619,MS-DRG,,,,,,,inpatient,,,114444.88,34333.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,57317.78,,"Fee schedule rate ($57,317.78). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,10994,84300.53,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI REGULAR L 1MM MID FACE RIGHT 4 HOLE 2MM SCR BONE",SUP-55-08230,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC MEDIUM 24IN 16-19IN KNEE CONTACT CLSR",SUP-79-80035,CDM,S27000186,LOCAL,0270,RC,,,both,,,117.10,35.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.62,99.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 15MM 2.75MM BALLOON DILATATION PEBAX",SUP-1400275-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 22MM GELWEAVE VASCUTEK STRAIGHT THORACIC",SUP-733022,CDM,C1768,HCPCS,0278,RC,,,both,,,6831.00,2049.3,"CIGNA [10200]",Cigna,,4645.08,68,,,,,0,794.45,5806.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE SMOOTH SHELL",SUP-SRF-220,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"NOVANET [10819]",Novanet,,4114.13,75,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT 2.8-8CM ALEXIS ATRAUMATIC FLEXIBLE RETRACTION RING",SUP-HR105,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"UHC [10700]","United Healthcare",,1234.35,63.3,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 100MM 75CM 7MM VASCULAR METAL SUPERFICIAL",SUP-H74939293071070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]",Cigna,,3284.4,68,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +20 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SA60WF.200,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 94MM PRESS FIT AEQUALIS ASCEND FLEX PTC 132.5D",SUP-DWF608B,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3606.12,28.62,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14X6MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2206,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"CIGNA [10200]","Cigna Local Plus",,5168.1,53.5,,3978.14,359.25,3978.14,24,1123.46,8211,"percent of total billed charges",
"NEUROFORM 3 EZ 4.0 X 30MM",SUP-M003N3EZ40300,CDM,C1874,HCPCS,0278,RC,,,both,,,47878.17,14363.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,19677.93,41.1,,,,,0,5568.23,40696.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175263180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,173.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOLOIST 110CM 6FR 5MM SPACING COURNAND LONG CURVE",SUP-44516U,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"NOVANET [10819]",Novanet,,546.75,75,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBERFUSE DEMINERALIZED BONE MATRIX 1CC ALLOGRAFT",SUP-420601,CDM,C1713,HCPCS,0278,RC,,,both,,,2174.25,652.27,"KAISER [10500]",Kaiser,,1456.75,67,,,,,0,252.87,1848.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 22MM 140CM 2.5MM",SUP-RSINT25022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"MULTIPLAN [10600]",Multiplan,,4712.4,85,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 64MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732064,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"BLUE CROSS [10001]","Blue Cross HMO",,6357.63,39.2,,5311.50,4717.44,5388.59,31,1886.21,13785.68,"percent of total billed charges",
"BIT DRILL 145MM 3.2MM QUICK COUPLING STERILE",SUP-310.31S,CDM,S27000186,LOCAL,0270,RC,,,both,,,825.55,247.66,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,97.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,96.01,701.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Retroperitoneal Complete",PX-402000010,CDM,76770,CPT,0402,RC,,,both,,,1285.72,385.72,"CIGNA [10200]","Cigna Local Plus",,161.46,,,,,,,115.44,1092.86,"fee schedule",
"CATH SABER 150CM 40MM 4MM BALLOON DILATATION DURALYN",SUP-48004004X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE SYNTHETIC CALCIUM PHOSPHATE CALCIUM SULFATE 10ML",SUP-87SR0410,CDM,C1713,HCPCS,0278,RC,,,both,,,18062.10,5418.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4876.77,27,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 100MM 16MM LCP STAINLESS STEEL CANCELLOUS",SUP-216.100,CDM,C1713,HCPCS,0278,RC,,,both,,,302.06,90.62,"BLUE CROSS [10001]","Blue Cross HMO",,118.41,39.2,,957.42,156.86,7483.26,51,35.13,256.75,"percent of total billed charges",
"SHEATH HEARTSPAN MP28 CURVE 60CM 8.5FR GUIDING TRANSSEPTAL",SUP-FCB8560MP28,CDM,C1894,HCPCS,0272,RC,,,both,,,1432.08,429.62,"PHCS [10601]",PHCS,,1002.46,70,,,,,0,166.55,1217.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL DURAL DURAGEN 1X 3IN SQUARE CALLAGEN DURAMATRIX REPAIR",SUP-DMR13,CDM,,,0278,RC,,,both,,,5221.92,1566.58,"CIGNA [10200]","Cigna Open Access",,2971.27,56.9,,,,,0,5.22,4438.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT TAPERED COMPONENT",SUP-G47480,CDM,C1874,HCPCS,0278,RC,,,both,,,102628.50,30788.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12161.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11935.69,87234.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 11 NARROW KNEE LEFT POSTERIOR STABILIZE",SUP-42500207001,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"FIRST HEALTH [10303]","First Health",,23116.46,80,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 1 CP 27IN BRAID COATED UNDYED ABSORBABLE",SUP-J196H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Impacted Cerumen",PX-450000304,CDM,69210,CPT,0361,RC,,,both,,,1527.04,458.11,"NOVANET [10819]",Novanet,,1145.28,75,,,,,0,177.59,1527.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AWL SURGICAL 3.8MM TAPER DISPOSABLE",SUP-72202621,CDM,S27200284,LOCAL,0272,RC,,,both,,,546.75,164.02,"CIGNA [10200]",Cigna,,371.79,68,,,,,0,63.59,464.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOPLASTY L150CM BALLOON L120MM DIA4MM COMPATIBLE",SUP-1013466-120,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAVITOR WITH RADIOPAQUE MARKERS 25MM",SUP-NVRO-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,16210.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENV DEFIB AIGISRX R MINOCYCLINE RIFAMPIN RESORBABLE",SUP-CMRM-6133-B,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1767.43,28.62,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 60MM LCP STAINLESS STEEL CORTICAL PERIARTICULAR",SUP-02.204.060,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"BLUE CROSS [10001]","Blue Cross HMO",,386.74,39.2,,957.42,156.86,7483.26,51,114.74,838.59,"percent of total billed charges",
"HC Shuntogram Nonvasc Shunt Si",PX-323000028,CDM,75809,CPT,0320,RC,,,both,,,668.30,200.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,93,,,,,,,77.72,568.06,"fee schedule",
"HC Braf Gene",PX-309000007,CDM,81210,CPT,0310,RC,,,both,,,1532.30,459.69,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,1302.46,"per diem",
"HC Prolact+4 10ml Qtr Btl",PX-E27000206,CDM,E27000206,LOCAL,0270,RC,,,both,,,89.10,26.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.36,75.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Irrig Imp Vad",PX-510000165,CDM,96523,CPT,0761,RC,,,both,,,261.60,78.48,"FIRST HEALTH [10303]","First Health",,209.28,80,,,,,0,30.42,261.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASPIRIN 81 MG CHEWABLE TABLET",RX-679,CDM,,,0250,RC,00904-7509-30,NDC,both,1,UN,6.27,1.88,"PHCS [10601]",PHCS,,4.39,70,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 25MM INDEPENDENCE SPINE SELF DRILL VARIABLE",SUP-176.725,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,348.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,341.92,2499,"percent of total billed charges",
"POSACONAZOLE 100 MG TABLET,DELAYED RELEASE",RX-164981,CDM,,,0250,RC,00527-2133-35,NDC,both,1,UN,279.75,83.92,"KAISER [10500]",Kaiser,,187.43,67,,,,,0,32.53,237.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mastotomy W Explr/Drainage",PX-450000061,CDM,19020,CPT,0361,RC,,,both,,,11998.00,3599.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1421.76,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1395.37,11998,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Absc Cmplx/Mult",PX-450000005,CDM,10061,CPT,0361,RC,,,both,,,3501.42,1050.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,414.92,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,407.22,3501.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 15MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDS32515,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,23761.67,28.62,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS ZIPWIRE 26CM 3CM 6FR .035IN PIGTAIL CURVE",SUP-M0061265730,CDM,C2617,HCPCS,0278,RC,,,both,,,1483.43,445.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,680.89,45.9,,,,,0,172.52,1260.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 0MM OFFSET 36MM HIP ACETABULAR MODULAR TYPE 1",SUP-650-0661,CDM,C1776,HCPCS,0278,RC,,,both,,,12375.84,3712.75,"FIRST HEALTH [10303]","First Health",,9900.67,80,,,,,0,1439.31,10519.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE MAS-R SCREW,8.5X90MM POLYILIAC 2C",SUP-16028590,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Labor Room 1st Hour",PX-721000001,CDM,9999138,LOCAL,0721,RC,,,both,,,1638.30,491.49,"CIGNA [10200]",Cigna,,1114.04,68,,,,,0,190.53,1392.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 28MM 144CM 3MM CORONARY STENT",SUP-H7493952828300,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"NOVANET [10819]",Novanet,,4173.75,75,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER TUBE MINI PURPLE NEOBAR ENDOTRACHEAL GENTLE",SUP-N709-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,135.02,40.51,"NOVANET [10819]",Novanet,,101.27,75,,,,,0,15.7,114.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BROWN 51MM 28MM SELF-CENTERING HIP FEMUR",SUP-103551000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"KAISER [10500]",Kaiser,,2053.09,67,,,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 60MM 5.5MM XL",SUP-5485560,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1349.46,45.9,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG 14CM C125ML 8MM ANCHOR TISSUE RETRIEVAL SYSTEM SPECIMEN",SUP-TRS-ROBO-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,780.14,234.04,"MULTIPLAN [10600]",Multiplan,,663.12,85,,,,,0,90.73,663.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 16MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620216,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Open Access",,6403.47,56.9,,5302.19,4377.88,6578.61,27,1308.83,9565.82,"percent of total billed charges",
"HC Dgtz Gls Mcrscp Sld Lvl III / Add on 88304",PX-312000089,CDM,0752T,CPT,0312,RC,,,both,,,100.00,30,"UHC [10700]","United Healthcare",,63.3,63.3,,,,,0,11.85,85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Dil Guide Wire",PX-750000037,CDM,43248,CPT,0750,RC,,,both,,,4748.59,1424.58,"CIGNA [10200]","Cigna Open Access",,2751,,"Case rate ($2,751). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,552.26,4748.59,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 40MM 150CM 5MM BALLOON DILATATION",SUP-PCP050040150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH FLEXOR RAABE 90CM 6FR 2.2MM GUIDING AQ CHECK-FLO",SUP-G12266,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VISTA BRITE TIP GUIDE CATHETER 6F .070 XB 3.5 ECO PK",SUP-6700540E,CDM,C1887,HCPCS,0272,RC,,,both,,,417.60,125.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COLLAR CERVICAL SMALL 4.25IN PHILADELPHIA CHIN REST TRACH",SUP-TX9916-11,CDM,S27000186,LOCAL,0270,RC,,,both,,,155.21,46.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER SPINAL 55X22X10MM RISE-L 10D LORDOTIC NONSTERILE",SUP-193.435,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CIGNA [10200]","Cigna Open Access",,11502.23,33.5,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 8MM 40MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.530,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"BLUE CROSS [10001]","Blue Cross PPO",,453.42,39.2,,957.42,570.23,957.42,28,134.52,983.18,"percent of total billed charges",
"INSRT CLAMP 33MM STEALTH SOFT TRACTION STERILE LATEX FREE",SUP-G-3300,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"UHC [10700]","United Healthcare",,143.18,63.3,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 12IN MULTIPANEL PROCARE 36-65IN MEDIUM",SUP-79-89386,CDM,S27000186,LOCAL,0270,RC,,,both,,,61.60,18.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,41.89,68,,,,,0,7.16,52.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 100MM 3.5MM BALLOON DILATATION NYBAX",SUP-H74939186351010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"KAISER [10500]",Kaiser,,868.32,67,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT FX 23MM",SUP-EVOLUTFX-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"NOVANET [10819]",Novanet,,128250,75,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 31MM ADJUSTABLE FULL FLEXIBLE RADIOPAQUE",SUP-AFR-31,CDM,S27800098,LOCAL,0278,RC,,,both,,,16909.83,5072.95,"BLUE CROSS [10001]","Blue Cross PPO",,6628.65,39.2,,,,,0,1966.61,14373.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE SP 39M",SUP-TENDV-SP-39M-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"CIGNA [10200]",Cigna,,116280,68,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL2712,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"KAISER [10500]",Kaiser,,1004,67,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
PROTEKDUO-31FR,SUP-5820-3118,CDM,S27200284,LOCAL,0272,RC,,,both,,,105450.00,31635,"MULTIPLAN [10600]",Multiplan,,89632.5,85,,,,,0,12263.84,89632.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Stoma W Stent",PX-750000162,CDM,44402,CPT,0750,RC,,,both,,,4561.00,1368.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,540.48,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,530.44,4561,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VISI-PRO 37MM 135CM 6MM 40MM BILIARY STAINLESS STEEL",SUP-PXB35-06-37-135,CDM,C1876,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"BLUE CROSS [10001]","Blue Cross PPO",,1711.86,39.2,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 35CM 22FR MALECOT NEPHRSTMY CATH STYLET RETENTION DISK",SUP-G14437,CDM,C1729,HCPCS,0272,RC,,,both,,,836.73,251.02,"KAISER [10500]",Kaiser,,560.61,67,,,,,0,97.31,711.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 180CM 30MM 1.75MM ATHERECTOMY PERIPHERAL",SUP-DBP-175SOLID180,CDM,C1724,HCPCS,0272,RC,,,both,,,22648.50,6794.55,"NOVANET [10819]",Novanet,,16986.38,75,,,,,0,2634.02,19251.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG VACUUM BOTTLE PLEURX 1000ML",SUP-50-7510,CDM,C1729,HCPCS,0272,RC,,,both,,,558.90,167.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,380.05,68,,,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 57X.14MM LACTOMER TITANIUM UNIVERSAL",SUP-015140,CDM,S27200284,LOCAL,0272,RC,,,both,,,60570.47,18171.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,27801.85,45.9,,,,,0,7044.35,51484.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL CERVICAL MA 35MM X 16MM RELINE-C",SUP-3903516,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,521.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",521.61,3812.25,"percent of total billed charges",
"NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION",RX-5751,CDM,,,0250,RC,00904-7276-41,NDC,both,5,ML,12.54,3.76,"UHC [10700]","United Healthcare",,7.94,63.3,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Coronary Sinus 13f",PX-E27200383,CDM,E27200383,LOCAL,0272,RC,,,both,,,62.70,18.81,"MULTIPLAN [10600]",Multiplan,,53.3,85,,,,,0,7.29,53.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR AR1 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916391842,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL ENDOSCOPIC 8CM ECHOTIP INSIGHT 25GA 5.2FR",SUP-G46560,CDM,S27200284,LOCAL,0272,RC,,,both,,,13558.50,4067.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE STREAMER VASCULAR POLYMER CORONARY SINUS EXTRA DISTAL",SUP-363726,CDM,C1769,HCPCS,0272,RC,,,both,,,486.00,145.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TURNPIKE 135CM 2.6-3.1FR 1.6FR VASCULAR MULTILAYER",SUP-5642,CDM,C1887,HCPCS,0272,RC,,,both,,,3285.00,985.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LIPASE-PROTEASE-AMYLASE(PORK)12,000-38,000-60,000 UNIT CAPSULE,DEL REL",RX-98035,CDM,,,0637,RC,00032-0047-70,NDC,both,1,UN,25.19,7.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL SCLEROTHERAPY 25GA 2.3MM BEVEL STRONG PUSHABLE CONTRAST",SUP-M00518361,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.66,81.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VALVE MITRAL 25MM 22.5MM MASTERS HP MECHANICAL ROTATABLE STD",SUP-25MHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11647.69,40,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TRAPEZOID 27MMX.8MM TITANIUM 1.5MM SCR 5X2 HOLE GRID",SUP-A-4350.66,CDM,S27200284,LOCAL,0272,RC,,,both,,,7631.40,2289.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,887.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,887.53,6486.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM 9FR ENDOCARDIAL DF4-LLHO CNCT 1 COIL STYLET",SUP-273,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 125MM 1.6MM TWIST STERILE",SUP-KM166-10-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"KAISER [10500]",Kaiser,,69.13,67,,,,,0,12,87.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 12CM 5MM BALLOON DILATATION OTW LOW",SUP-G30955,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SPINAL W32.5MM ANTERIOR CERVICAL ATLANTIS VISION ELITE",SUP-7200132,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3049.8,68,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO ORANGE 11CM 7FR BRITE TIP CANN INTERVENTIONAL",SUP-401711M,CDM,C1894,HCPCS,0272,RC,,,both,,,60.90,18.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,41.41,68,,,,,0,7.08,51.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION 17MM TIGHTROPE ROUND CONCAVE",SUP-AR-1588TB-17,CDM,C1713,HCPCS,0278,RC,,,both,,,2165.63,649.69,"FIRST HEALTH [10303]","First Health",,1732.5,80,,,,,0,251.86,1840.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 10 KNEE RIGHT CEMENTED POSTERIOR STABILIZE",SUP-150410210,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"NOVANET [10819]",Novanet,,16795.01,75,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BLUE 53MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-1035-53-000,CDM,C1776,HCPCS,0278,RC,,,both,,,6372.15,1911.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,755.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,741.08,5416.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 60MM 75CM 14MM 9FR 100CM",SUP-H965403120,CDM,C1876,HCPCS,0278,RC,,,both,,,4410.00,1323,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL ARTHREX UNIVERS REVERS 10 SHOULDER STERILE",SUP-AR-9501-10S,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1227.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1227.78,8973.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 30MM 80CM 10MM 6FR VASCULAR NITINOL",SUP-G43865,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2570.4,68,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM 11/13 TAPER 32MM HIP MODULAR BIOLOX DELTA",SUP-136532220,CDM,C1776,HCPCS,0278,RC,,,both,,,12385.50,3715.65,"AETNA [10100]","Aetna HMO/PPO",,9846.47,79.5,,10981.53,8986.79,12413.38,12,1440.43,10527.68,"percent of total billed charges",
"HEAD FEMORAL +15.5MM 12/14 TAPER 36MM HIP CEMENTLESS M",SUP-136555000,CDM,C1776,HCPCS,0278,RC,,,both,,,6720.60,2016.18,"BLUE CROSS [10001]","Blue Cross PPO",,2634.48,39.2,,3949.44,3949.44,3949.44,"1 through 10",781.61,5712.51,"percent of total billed charges",
"COMPONENT FEMORAL 3 NARROW KNEE RIGHT CEMENTED CRUCIATE RETA",SUP-150400223,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8957.34,40,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30MMX7MM CRESCENT LORDOTIC",SUP-293007,CDM,S27800098,LOCAL,0278,RC,,,both,,,24290.28,7287.08,"FIRST HEALTH [10303]","First Health",,19432.22,80,,,,,0,2824.96,20646.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 40MM 3.5MM BALLOON DILATATION PEBAX",SUP-H74939032350410,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 20X16IN RESORBABLE GRID 2",SUP-F10258-1620G,CDM,C1781,HCPCS,0278,RC,,,both,,,41126.40,12337.92,"FIRST HEALTH [10303]","First Health",,32901.12,80,,,,,0,4783,34957.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOXCROSS 135CM 40MM 6MM BALLOON DILATATION JETCOAT",SUP-10336-40,CDM,C1725,HCPCS,0272,RC,,,both,,,1539.00,461.7,"UHC [10700]","United Healthcare",,974.19,63.3,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 32MM 140CM 2.75MM CORONARY STENT PLATINUM",SUP-H7493927432270,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Local Plus",,2006.25,53.5,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PEEK-OPTIMA 15MM 5MM RADIOLUCENT G-FORCE",SUP-86PS0515,CDM,C1713,HCPCS,0278,RC,,,both,,,3037.50,911.25,"AETNA [10100]","Aetna HMO/PPO",,2414.81,79.5,,1521.93,481.35,16760.95,30,353.26,2581.88,"percent of total billed charges",
"CATH BALLOON DILATATION .018IN 3.5-3FR 4MM 120CM 6CM",SUP-435406L,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE WIGGLE VASCULAR STRAIGHT RIBBON 190CM 30CM",SUP-22299M-W30,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 30MM CREO SPINE TULIP REDUCTION FENESTRATE",SUP-1192.0200,CDM,C1713,HCPCS,0278,RC,,,both,,,4140.00,1242,"AMERIGROUP MEDICAID [20100]",Amerigroup,,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",481.48,3519,"percent of total billed charges",
"PLATE 262MM STAINLESS STEEL 4.5MM SCR 14 HOLE LCP BONE LEFT",SUP-240.047,CDM,C1713,HCPCS,0278,RC,,,both,,,9088.13,2726.44,"MULTIPLAN [10600]",Multiplan,,7724.91,85,,,,,0,1056.95,7724.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Spinal W/Lidocaine",PX-E27200181,CDM,E27200181,LOCAL,0272,RC,,,both,,,108.17,32.45,"KAISER [10500]",Kaiser,,72.47,67,,,,,0,12.58,91.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +18.5 DIOPTER BICONVEX 13MM 6MM POSTERIOR CHMBR",SUP-CC60WF.185,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 38MM 145CM 3MM CORONARY STENT",SUP-1145300-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"FIRST HEALTH [10303]","First Health",,4670.4,80,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERTORQUE PLUS 100CM 6FR AMPLATZ RIGHT 2 MODIFIED",SUP-533643,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.30,24.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.57,69.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE ABSORBABLE 6X2CM HEMOSTATIC AGENT GELATIN SURGIFOAM",SUP-1972,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.25,19.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,26.82,41.1,,,,,0,7.59,55.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SA60WF.190 SP AS ASPHERIC UV ABSORB",SUP-SA60WF.190,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]",Cigna,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 45MM 12MM ZENITH ILIAC BRANCH 58MM",SUP-G60346,CDM,C1874,HCPCS,0278,RC,,,both,,,68399.94,20519.98,"BLUE CROSS [10001]","Blue Cross PPO",,26812.78,39.2,,,,,0,7954.91,58139.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR INLINE SENSOR INJECTATE SYR COOL COIL",SUP-680000,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.44,81.43,"MULTIPLAN [10600]",Multiplan,,230.72,85,,,,,0,31.57,230.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 6 STRAIGHT OVAL 9IN BRUNS SPINE SURGICAL",SUP-29-5356,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.25,71.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,109.82,45.9,,,,,0,27.82,203.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX 40MM 135CM 9MM VASCULAR NITINOL CAROTID",SUP-PC0940RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"CIGNA [10200]","Cigna Local Plus",,4060.65,53.5,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE HUMERUS LEFT DISTAL LATERAL",SUP-629203S,CDM,C1713,HCPCS,0278,RC,,,both,,,6594.74,1978.42,"AETNA [10100]","Aetna HMO/PPO",,5242.82,79.5,,1521.93,481.35,16760.95,30,766.97,5605.53,"percent of total billed charges",
"SPACER SPINAL 14X11X7MM 7D PEEK LUMBAR INTERBODY FUSION",SUP-21411-707,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA [10200]",Cigna,,4541.33,68,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM ALPS T15 TIBIA CORTICAL DISTAL LOCK SELF",SUP-816135026,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"CAP GLOBAL UNITE SHORT",SUP-OSC378959,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2426.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2381.24,17403.75,"percent of total billed charges",
"IMPL BREAST 330-400ML STYLE 3000 SMOOTH SALINE P4.8-6.2CM",SUP-3503330,CDM,C1789,HCPCS,0278,RC,,,both,,,2350.00,705,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1078.65,45.9,,,,,0,273.31,1997.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 6 FIRING 3 GEL TUBE OPEN LINEAR STERILE LATEX",SUP-PSD7506EN,CDM,S27200284,LOCAL,0272,RC,,,both,,,1301.40,390.42,"CIGNA [10200]","Cigna Open Access",,740.5,56.9,,,,,0,151.35,1106.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7611,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1974.78,28.62,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL 6.5X45MM MIDLINE SYSTEM POLYAXIAL CORTICAL 4S R",SUP-14616545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"HC Mitochondrial Antibody Each",PX-302000258,CDM,86381,CPT,0302,RC,,,both,,,175.75,52.72,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,149.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 58-70MM 5.5MM CREO SPINE CROSS NONSTERILE",SUP-1119.0062,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1019.59,28.62,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PICK SURGICAL 6.5IN 30D .33MM STRAIGHT OVAL WINDOW HOUSE",SUP-61-0383,CDM,S27200284,LOCAL,0272,RC,,,both,,,358.88,107.66,"NOVANET [10819]",Novanet,,269.16,75,,,,,0,41.74,305.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FEEDING SNS SUPPLEMENTAL NURSING SYSTEM CNTNR COVER",SUP-00901S,CDM,S27200284,LOCAL,0272,RC,,,both,,,175.65,52.69,"MULTIPLAN [10600]",Multiplan,,149.3,85,,,,,0,20.43,149.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 28CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006175274170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,362.15,28.62,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL LEGION 3 KNEE LEFT REVISION",SUP-71424003,CDM,C1776,HCPCS,0278,RC,,,both,,,23133.60,6940.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2690.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2690.44,19663.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 331311 ACSR 13X11X11 SRVC FEE",SUP-331311,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY PERF W/FEET SM 1/2 242X252X110MM",SUP-920300,CDM,S27000186,LOCAL,0270,RC,,,both,,,838.03,251.41,"UHC [10700]","United Healthcare",,530.47,63.3,,,,,0,97.46,712.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE",RX-105902,CDM,J1650,HCPCS,0636,RC,25021-0410-78,NDC,both,.8,ML,71.30,21.39,"FIRST HEALTH [10303]","First Health",,57.04,80,,,,,0,5.5,60.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2.5MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN02502,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"MULTIPLAN [10600]",Multiplan,,8791.64,85,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 12/14 TAPER 36MM HIP CEMENTLESS BIOLOX",SUP-136536320,CDM,C1776,HCPCS,0278,RC,,,both,,,7222.32,2166.7,"CIGNA [10200]","Cigna Open Access",,4109.5,56.9,,5302.19,4377.88,6578.61,27,839.96,6138.97,"percent of total billed charges",
"PACEMKR CARDIAC .75CM 4.45X6.13CM VISIONIST X4 IS-1 CNCT",SUP-U225,CDM,C2621,HCPCS,0275,RC,,,both,,,25200.00,7560,"MULTIPLAN [10600]",Multiplan,,21420,85,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 60X22X10MM COROENT XL WIDE 100",SUP-6921060,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"MULTIPLAN [10600]",Multiplan,,20196,85,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TRANSFEMORAL GUIDE SHEATH AND INTRODUCER",SUP-TTVR-AC-2672,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR LAPAROSCOPIC 56.7CM 8MM DA VINCI S/SI ENDOWRIST",SUP-420278,CDM,S27000186,LOCAL,0270,RC,,,both,,,1800.00,540,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,213.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Stent & Ather Add",PX-361000163,CDM,37235,CPT,0361,RC,,,both,,,12161.75,3648.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,12.16,.1,,,,,0,12.16,10337.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 8MM GORE PROPATEN EPTFE HEPARIN STRETCH",SUP-HT087080A,CDM,C1768,HCPCS,0278,RC,,,both,,,18559.80,5567.94,"CIGNA [10200]","Cigna Local Plus",,5846.34,31.5,,,,,0,2158.5,15775.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 7.9MM 5.5MM MAGILL CURVE NASAL ORAL 2 CUFF",SUP-86395,CDM,S27200284,LOCAL,0272,RC,,,both,,,8390.91,2517.27,"CIGNA [10200]",Cigna,,5705.82,68,,,,,0,975.86,7132.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL V MUELLER GERALD 7IN 1X2 TEETH DELICATE SATIN",SUP-NL1440,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.94,67.18,"UHC [10700]","United Healthcare",,141.75,63.3,,,,,0,26.04,190.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.2MM DVR CROSSLOCK TRAY",SUP-231200200,CDM,S27200284,LOCAL,0272,RC,,,both,,,1154.25,346.27,"FIRST HEALTH [10303]","First Health",,923.4,80,,,,,0,134.24,981.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) BELT SPRT LARGE STERNUM",SUP-QB-L,CDM,S27000186,LOCAL,0270,RC,,,both,,,829.44,248.83,"MULTIPLAN [10600]",Multiplan,,705.02,85,,,,,0,96.46,705.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 37MM SIMULUS C FULL FLEXIBLE STERILE",SUP-700FC37,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"MULTIPLAN [10600]",Multiplan,,11143.5,85,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC",498,MS-DRG,,,,,,,inpatient,,,157415.75,47224.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,57249.81,,"Fee schedule rate ($57,249.81). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,88078.49,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR EMPHASYS NEUTRAL 54MM 40MM AOX HIP",SUP-472254040,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 21MM 3.5MM BALLOON DILATATION PTCA",SUP-DC-RZ3521UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"NOVANET [10819]",Novanet,,741.15,75,,,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC AVALUS 25MM 400 SERIES LATEX FREE",SUP-40025,CDM,S27800098,LOCAL,0278,RC,,,both,,,33390.00,10017,"KAISER [10500]",Kaiser,,22371.3,67,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL 50 MCG/ML INJECTION SUPERORDERABLE (IV PREP ONLY)|DISCARDED DRUG NOT ADMINISTE",RX-409368,CDM,J3010,HCPCS,0636,RC,08888-8879-66,NDC,both,100,ML,422.80,126.84,"BLUE CROSS [10001]","Blue Cross HMO",JW,64.1,,,,,,,50.1,359.38,"fee schedule",
"SPACER SPINAL 34X17MM HEDRON IA 15D 26MM STERILE LATEX FREE",SUP-1212.0717S,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,12600,40,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER SAGE GREEN 7CM 3.5MM DYONICS POWERMINI INCISOR",SUP-72201514,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 6MM 40MM 14MM LCP STAINLESS STEEL PARTIAL",SUP-206.040,CDM,C1713,HCPCS,0278,RC,,,both,,,273.62,82.09,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,186.06,68,,,,,0,31.82,232.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTERIAL LINE 4.45CM 20GA ODSEC 22GA .018IN RADIAL",SUP-AK-04020-SPC,CDM,S27200284,LOCAL,0272,RC,,,both,,,221.85,66.55,"PHCS [10601]",PHCS,,155.3,70,,,,,0,25.8,188.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC",073,MS-DRG,,,,,,,inpatient,,,54588.84,16376.65,"BLUE CROSS [10001]","Blue Cross HMO",,36829.58,,,,,,,7561,40009.64,"case rate",
"STENT HANAROSTENT LOWAX 120MM 22MM COLONIC NITINOL RECTAL",SUP-CNJF-22-120-230,CDM,C1876,HCPCS,0278,RC,,,both,,,15104.24,4531.27,"PHCS [10601]",PHCS,,10572.97,70,,,,,0,1756.62,12838.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP 2A - ACTIS STEM AND STANDARD CUP",SUP-CAP-DS-H-2A,CDM,C1776,HCPCS,0278,RC,,,both,,,24885.00,7465.5,"PHCS [10601]",PHCS,,17419.5,70,,,,,0,2894.13,21152.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR SPEAR TROCAR TIP DISPOSABLE 2.6 FIBERTAK",SUP-AR-3650DS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSELECT DEMINERALIZED BONE MATRIX 1CC",SUP-359010,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"KAISER [10500]",Kaiser,,759.78,67,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CORDIS EMERALD VASCULAR STRAIGHT 220CM 7CM .035IN PTFE",SUP-502558,CDM,C1769,HCPCS,0272,RC,,,both,,,134.42,40.33,"FIRST HEALTH [10303]","First Health",,107.54,80,,,,,0,15.63,114.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER SURGICAL 24-38MM GRAFT",SUP-M002363200211,CDM,S27200284,LOCAL,0272,RC,,,both,,,90.75,27.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.55,77.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 10CM DIL GWIRE PINNACLE TIF TIP .038IN",SUP-10-2532,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"UHC [10700]","United Healthcare",,55.07,63.3,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID UPPER LEG REDUCTION KIT- SHORT, REGULAR",SUP-25301117,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"CIGNA [10200]",Cigna,,853.74,68,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 150MM 5.4FR 3MM BALLOON DILATATION 2",SUP-BD-L30150CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"FIRST HEALTH [10303]","First Health",,767.88,80,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 90CM 5MM 8FR 2-5-2MM SPACE G CURVE",SUP-D8BTCG5L,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,587.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STABLEMAPR SM 110CM 7FR 2-10-2MM SPACING",SUP-04125UM,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THIN LOOP, 7CM LONGER THAN STANDARD",SUP-VXRU1L,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.00,675,"PHCS [10601]",PHCS,,1575,70,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIGASURE 5MM BLUNT TIP LAP SEALDIVIDER",SUP-LF1637,CDM,S27200284,LOCAL,0272,RC,,,both,,,3384.38,1015.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,401.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,393.6,2876.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM GEMINUS TITANIUM CORTEX LOCK NONSTERILE",SUP-COLS-35160-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,631.80,189.54,"FIRST HEALTH [10303]","First Health",,505.44,80,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM GEMINUS TITANIUM CORTEX LOCK NONSTERILE",SUP-COLS-35160-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS [10001]","Blue Cross HMO",,247.67,39.2,,957.42,156.86,7483.26,51,73.48,537.03,"percent of total billed charges",
"COIL EMBOLIZATION 14CM 16MM NESTER MICROCOIL PLATINUM .035IN",SUP-G47348,CDM,S27800098,LOCAL,0278,RC,,,both,,,1020.52,306.16,"FIRST HEALTH [10303]","First Health",,816.42,80,,,,,0,118.69,867.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 15CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR051502A,CDM,C1874,HCPCS,0278,RC,,,both,,,24374.70,7312.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6581.17,27,,,,,0,2834.78,20718.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFT TOUCH",SUP-SSM-600,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS [10001]","Blue Cross HMO",,2961.76,39.2,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM SWIVELOCK C CLOSED EYELET VENT",SUP-AR-2324BCCTT,CDM,C1713,HCPCS,0278,RC,,,both,,,3701.25,1110.37,"PHCS [10601]",PHCS,,2590.88,70,,,,,0,430.46,3146.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSOLE SHOE 4-6 SMALL FEMALE DARCO PEG-ASSIST REMOVABLE PEG",SUP-PTQW1,CDM,S27000186,LOCAL,0270,RC,,,both,,,100.92,30.28,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.74,85.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,inpatient,,,40298.87,12089.66,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,6315.52,,"Case rate ($5,958.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,532.44, add-ons for qualifying new technology services are included. If operating cost exceeds $38,572.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,800.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,539.76. The transfer operating threshold is the transfer adjustment factor * $5,532.44 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.28. The transfer capital threshold is the transfer adjustment factor * $418.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,5958.04,23953.91,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +33 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000330,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +30 DIOPTER 0 D 13MM 6MM POSTERIOR CHMBR 1 PIECE",SUP-SN60WF.300,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 20IN 28FR STRAIGHT",SUP-8888570549,CDM,C1729,HCPCS,0272,RC,,,both,,,94.36,28.31,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.97,80.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 75CM 60MM 9MM BALLOON DILATATION DRUG COATED",SUP-LX3575960V,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"PHCS [10601]",PHCS,,5916.75,70,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2.3CM 3MM INTERLOCK FIBERED IDC VORTX 18",SUP-M001361740,CDM,S27800098,LOCAL,0278,RC,,,both,,,1984.50,595.35,"BLUE CROSS [10001]","Blue Cross HMO",,777.92,39.2,,,,,0,230.8,1686.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HYBRID TOTAL KNEE SYSTEM (EITHER POROUS FEMUR OR TIBIA)",SUP-98000600209,CDM,C1776,HCPCS,0278,RC,,,both,,,26460.00,7938,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10875.06,41.1,,6417.48,6417.48,6417.48,"1 through 10",3077.3,22491,"percent of total billed charges",
"SCR BONE TALAR STERILE",SUP-351-90-24,CDM,C1713,HCPCS,0278,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE RIGHT POSTERIOR STABILIZE CEMENT LEGION",SUP-71423235,CDM,C1776,HCPCS,0278,RC,,,both,,,21886.20,6565.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8995.23,41.1,,6417.48,6417.48,6417.48,"1 through 10",2545.37,18603.27,"percent of total billed charges",
"AUG TIBIAL TRIATHLON B CONE KNEE LEFT MEDIAL RIGHT LATERAL",SUP-5549-A-221,CDM,C1776,HCPCS,0278,RC,,,both,,,23621.85,7086.55,"BLUE CROSS [10001]","Blue Cross PPO",,9259.77,39.2,,3949.44,3949.44,3949.44,"1 through 10",2747.22,20078.57,"percent of total billed charges",
"CANN NASAL VAPOTHERM PROSOFT SMALL NONSTERILE LATEX FREE",SUP-PROSOFT-PED-AS,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.06,33.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.03,95.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CENTER",SUP-5573-6540,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"FIRST HEALTH [10303]","First Health",,1244.56,80,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 36MM HIP C TAPER HIGH PERFORMANCE OFFSET",SUP-18-3605,CDM,C1776,HCPCS,0278,RC,,,both,,,7340.76,2202.23,"BLUE CROSS [10001]","Blue Cross PPO",,2877.58,39.2,,3949.44,3949.44,3949.44,"1 through 10",853.73,6239.65,"percent of total billed charges",
"CAGE SPINAL 15X10MM DIVERGENCE 12MM LORDOTIC NUCLEUS",SUP-G6626520,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"KAISER [10500]",Kaiser,,8321.4,67,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY IMPROVE MICROMESH TEETH STREAMLINE CATH 100CM",SUP-M00515201,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.48,104.84,"CIGNA [10200]","Cigna Local Plus",,186.97,53.5,,,,,0,40.64,297.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 6MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620406,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"MULTIPLAN [10600]",Multiplan,,9565.82,85,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 12MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650412,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1555.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1526.7,11158.16,"percent of total billed charges",
"CATH TREK 145CM 15MM 5MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012280-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 190MM 21MM REVISION MODULAR ARCOS STS TITANIUM",SUP-11-300921,CDM,C1776,HCPCS,0278,RC,,,both,,,20372.94,6111.88,"CIGNA [10200]",Cigna,,8149.18,40,,5873.17,5873.17,5873.17,"1 through 10",2369.37,17317,"percent of total billed charges",
"OCCL CARDIOVASCULAR 30MM SEPTAL 2 DISK NITINOL MESH SELF",SUP-9-ASD-MF-030,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"KAISER [10500]",Kaiser,,14238.04,67,,,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 NARROW 10MM KNEE POSTERIOR STABILIZE IDENTITY",SUP-TPS-020-103N,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"AETNA [10100]","Aetna HMO/PPO",,4673.65,79.5,,10981.53,8986.79,12413.38,12,683.7,4996.98,"percent of total billed charges",
"HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC",001,MS-DRG,,,,,,,inpatient,,,1638727.54,491618.26,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,186002.33,,"Case rate ($173,833.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $161,416.61, add-ons for qualifying new technology services are included. If operating cost exceeds $194,456.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $13,585.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $161,630.07. The transfer operating threshold is the transfer adjustment factor * $161,416.61 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $12,203.88. The transfer capital threshold is the transfer adjustment factor * $12,203.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 107%.",,,,0,173833.95,691827.42,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 6X4CM CYGNUS DUAL THK.2MM 24SQ CM AMNION",SUP-585-003,CDM,Q4282,HCPCS,0636,RC,,,both,,,64125.00,19237.5,"FIRST HEALTH [10303]","First Health",,51300,80,,,,,0,247.92,54506.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESPONSE 120CM 6FR 10MM SPACING CRD CURVE",SUP-401210,CDM,C1730,HCPCS,0272,RC,,,both,,,704.70,211.41,"AETNA [10100]","Aetna HMO/PPO",,560.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.96,599,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM STARDRIVE STAINLESS STEEL T15 SELF TAP",SUP-02.127.124,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"CIGNA [10200]","Cigna Local Plus",,605.99,53.5,,3978.14,359.25,3978.14,24,131.73,962.8,"percent of total billed charges",
"LINER ACETABULAR PINNACLE ESC 10D +4MM 50MM 28MM GVF",SUP-121828750,CDM,C1776,HCPCS,0278,RC,,,both,,,19449.36,5834.81,"CIGNA [10200]","Cigna Local Plus",,6126.55,31.5,,5372.07,4581.20,7242.98,23,2261.96,16531.96,"percent of total billed charges",
"IMPL BREAST 485CC NATRELLE INSPIRA COHESIVE STERILE LATEX",SUP-SCM-485,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",878.7,6422.18,"percent of total billed charges",
"SCR BONE 7.5MM 45MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16017545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AETNA [10100]","Aetna HMO/PPO",,7589.75,79.5,,1521.93,481.35,16760.95,30,1110.3,8114.82,"percent of total billed charges",
"HOOK SPINAL CD HORIZON MEDIUM PEDICLE TITANIUM LIPPED 5.5MM",SUP-7541203,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 20GA 2.25IN ACCUCATH ACE BASIC STERILE LATEX FREE",SUP-AC1202250,CDM,S27200284,LOCAL,0272,RC,,,both,,,387.67,116.3,"KAISER [10500]",Kaiser,,259.74,67,,,,,0,45.09,329.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPLANT 14.5CM NATRELLE INSPIRA P5.9CM FULL PROFILE RO",SUP-MSZ-F650,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"UHC [10700]","United Healthcare",,100.13,63.3,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PATELLAR THK13-15MM WEDGE ALLOGRAFT FREEZE DRIED",SUP-400580,CDM,S27800098,LOCAL,0278,RC,,,both,,,5870.52,1761.16,"BLUE CROSS [10001]","Blue Cross PPO",,2301.24,39.2,,,,,0,682.74,4989.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL CUSHING 1.7MM BAYONET 7.75IN TISSUE 1X2 TEETH",SUP-130421,CDM,S27200284,LOCAL,0272,RC,,,both,,,303.72,91.12,"CIGNA [10200]","Cigna Local Plus",,162.49,53.5,,,,,0,35.32,258.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL UTERINE HEGAR 2 END 11/12MM",SUP-52-3511,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.18,83.75,"FIRST HEALTH [10303]","First Health",,223.34,80,,,,,0,32.47,237.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 100MM 11MM NEXGEN OFFSET KNEE FEMUR 145MM STERILE",SUP-00598802011,CDM,C1776,HCPCS,0278,RC,,,both,,,10435.56,3130.67,"CIGNA [10200]","Cigna Local Plus",,5583.02,53.5,,5372.07,4581.20,7242.98,23,1213.66,8870.23,"percent of total billed charges",
"STAPLE BONE 15X12MM NITINOL ASYMMETRICAL",SUP-ES-15X12,CDM,C1713,HCPCS,0278,RC,,,both,,,8590.50,2577.15,"FIRST HEALTH [10303]","First Health",,6872.4,80,,,,,0,999.08,7301.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL BIT, CANNULATED, 3.0MM",SUP-MSN10005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT SL II SITEMARK 50.7CM 47CM 9FR 7FR 115D",SUP-DS2C002,CDM,C1887,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2557.14,68,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR ANGLE 150CM .035IN HYDROPHILIC FIX CORE",SUP-H2OSTFA35150,CDM,C1769,HCPCS,0272,RC,,,both,,,278.40,83.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,189.31,68,,,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 12MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424025,CDM,C1776,HCPCS,0278,RC,,,both,,,11747.25,3524.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1392.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1366.21,9985.16,"percent of total billed charges",
"SET STENT 12CM 6FR SOF-FLEX SMALL 2 PIGTAIL CURVE COUDE",SUP-G14867,CDM,C2617,HCPCS,0278,RC,,,both,,,1028.70,308.61,"MULTIPLAN [10600]",Multiplan,,874.4,85,,,,,0,119.64,874.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM AZUR DETACHABLE HYDROGEL",SUP-45-450410,CDM,S27800098,LOCAL,0278,RC,,,both,,,1702.50,510.75,"CIGNA [10200]","Cigna Local Plus",,910.84,53.5,,,,,0,198,1447.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 70MM 75CM 24MM 100CM",SUP-40512,CDM,C1876,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3087.92,45.9,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Feeding Enteral",PX-E27200222,CDM,E27200222,LOCAL,0272,RC,,,both,,,105.60,31.68,"FIRST HEALTH [10303]","First Health",,84.48,80,,,,,0,12.28,89.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 90CM 80MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939186250890,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"NOVANET [10819]",Novanet,,972,75,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Rmvl Hot Bx",PX-750000039,CDM,43250,CPT,0750,RC,,,both,,,2848.46,854.54,"FIRST HEALTH [10303]","First Health",,2278.77,80,,,,,0,331.28,2848.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMBLED FREEFIX DISTAL HUMERUS PLATE LATERAL CAPITELLAR 10",SUP-DHPF-LCR-5HL,CDM,C1713,HCPCS,0278,RC,,,both,,,13655.10,4096.53,"NOVANET [10819]",Novanet,,10241.33,75,,,,,0,1588.09,11606.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 2 OFFSET DOME 8.5MM CEMENT UNITY KNEE",SUP-112.018.46,CDM,C1776,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 6MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT060040A,CDM,C1768,HCPCS,0278,RC,,,both,,,8763.00,2628.9,"PHCS [10601]",PHCS,,6134.1,70,,,,,0,1019.14,7448.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 4.8FR .035IN STRAIGHT URETERAL",SUP-M006175253180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,417.88,28.62,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHROMIUM CHLORIDE 0.4 MCG/ML INTRAVENOUS SOLUTION",RX-408352,CDM,,,0250,RC,08888-8886-05,NDC,both,1,ML,18.92,5.68,"MULTIPLAN [10600]",Multiplan,,16.08,85,,,,,0,2.2,16.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 13CM 16FR PERFORMER ACCEPTS .038IN GWIRE",SUP-G28322,CDM,C1894,HCPCS,0272,RC,,,both,,,378.19,113.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,155.44,41.1,,,,,0,43.98,321.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 95MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.895,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"BLUE CROSS [10001]","Blue Cross HMO",,538.77,39.2,,957.42,156.86,7483.26,51,159.84,1168.25,"percent of total billed charges",
"DRILL SURGICAL PROFILE MICRO COMPRESSION FT SCR",SUP-AR-8737-46,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 5FR 5MM SPACE P CURVE ELECTROPHYSIOLOGY",SUP-D5S10PR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"PHCS [10601]",PHCS,,2609.25,70,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Q Fever (Coxiella) Ab",PX-302000109,CDM,86638,CPT,0302,RC,,,both,,,320.15,96.04,"CIGNA [10200]","Cigna Open Access",,26.66,,,,,,,0.01,272.13,"fee schedule",
"STENT EVERFLEX 150MM 120CM 6MM VASCULAR PERIPHERAL SELF",SUP-PRB35-06-150-120,CDM,C1876,HCPCS,0278,RC,,,both,,,7560.00,2268,"KAISER [10500]",Kaiser,,5065.2,67,,,,,0,879.23,6426,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 NARROW KNEE RIGHT CRUCIATE RETAIN PERSONA",SUP-42502206602,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3424.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 55D 12MM 2.5MM EMBOLIZATION 75% COCR 25",SUP-PED-250-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,20776.5,27,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cholesterol Ldl",PX-301000549,CDM,83721,CPT,0301,RC,,,both,,,116.00,34.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.46,,,,,,,0.01,98.6,"fee schedule",
"STENT 30CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX RADIOPAQUE",SUP-M0061453640,CDM,C2617,HCPCS,0278,RC,,,both,,,633.10,189.93,"NOVANET [10819]",Novanet,,474.83,75,,,,,0,73.63,538.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"330CC MENTOR MEMORYGEL CPG BREAST IMPLANT MEDIUM HEIGHT MODE",SUP-334-1205,CDM,C1789,HCPCS,0278,RC,,,both,,,8107.50,2432.25,"MULTIPLAN [10600]",Multiplan,,6891.38,85,,,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX16MM VANGUARD ARCOM KNEE POSTERIOR STABILIZE",SUP-183666,CDM,C1776,HCPCS,0278,RC,,,both,,,8259.30,2477.79,"CIGNA [10200]","Cigna Open Access",,4699.54,56.9,,5302.19,4377.88,6578.61,27,960.56,7020.41,"percent of total billed charges",
"HC Cr Thiopurine Methyl Transfera",PX-300000026,CDM,82657,CPT,0301,RC,,,both,,,276.00,82.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,34.87,,,,,,,0.28,234.6,"fee schedule",
"STEM KNEE 130MM 20/16MM ENDO-MODEL SL MALE TAPER MODULAR",SUP-15-8523/58,CDM,C1776,HCPCS,0278,RC,,,both,,,16271.03,4881.31,"NOVANET [10819]",Novanet,,12203.27,75,,,,,0,1892.32,13830.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Powder Stimulen",PX-E27200197,CDM,E27200197,LOCAL,0272,RC,,,both,,,70.40,21.12,"MULTIPLAN [10600]",Multiplan,,59.84,85,,,,,0,8.19,59.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ostomy Pouch",PX-E27000139,CDM,E27000139,LOCAL,0270,RC,,,both,,,92.40,27.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.75,78.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Gastric Emptying W Sm Bowel",PX-341000068,CDM,78265,CPT,0341,RC,,,both,,,2606.75,782.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,719.94,,"Fee schedule rate ($719.94).",,,,0,303.17,2215.74,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CBL PCNG MRLN THRSH MDTRNC",SUP-4051,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,119.8,45.9,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION 4.75MM SWIVELOCK FIBERTAPE DX KNOTLESS CLLGN",SUP-AR-8981BCTJ-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,7208.78,2162.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3308.83,45.9,,,,,0,838.38,6127.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.4MM KIRSCHNER VARIAX OLIVE DISTAL RADIUS",SUP-56-40281,CDM,C1713,HCPCS,0278,RC,,,both,,,237.51,71.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,161.51,68,,,,,0,27.62,201.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5.5MM TI CURVED ROD 65MM",SUP-04.636.065,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR FR5 CURVE ANGIOGRAPHIC FEMORAL 2 WIRE",SUP-H74916599032,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,52.07,68,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 5MM 8.25IN STAINLESS STEEL GARRETT MALLEABLE",SUP-25-8024,CDM,S27200284,LOCAL,0272,RC,,,both,,,74.12,22.24,"CIGNA [10200]","Cigna Open Access",,42.17,56.9,,,,,0,8.62,63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 10MM KNEE GVF POLYETHYLENE ROTATE",SUP-129405610,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"FIRST HEALTH [10303]","First Health",,7730.76,80,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAFIRE COMFORTGRIP 115CM 4MM 7FR 2-5-2MM SPACE 1MM",SUP-402811,CDM,C1733,HCPCS,0272,RC,,,both,,,4140.00,1242,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM NARROW BLADE LIPPED",SUP-7541223,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Open Access",,1707,56.9,,1144.80,304.56,2275.09,66,348.9,2550,"percent of total billed charges",
"GRAFT STENT 120MM 10-14MM 13FR 10FR TRIVASCULAR OVATION",SUP-TV-IL1410120-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"KAISER [10500]",Kaiser,,22371.3,67,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM VARIAX T10 FULL THREAD FOOT ANKLE LOCK",SUP-657326,CDM,C1713,HCPCS,0278,RC,,,both,,,1486.84,446.05,"PHCS [10601]",PHCS,,1040.79,70,,,,,0,172.92,1263.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ESOPHAGUS 50CM 12 INTEGRATED SENSOR 2 PLANE RADIOPAQUE",SUP-CS-2001,CDM,S27200284,LOCAL,0272,RC,,,both,,,3967.50,1190.25,"CIGNA [10200]",Cigna,,2697.9,68,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 11MM KNEE X3 POSTERIOR STABILIZED TRIATHLON",SUP-5532-G-411,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5921.17,68,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 150MM 5MM SCHANZ SELF DRILL CALCANEAL FRACTURE",SUP-AR-8954-01,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"MULTIPLAN [10600]",Multiplan,,1912.5,85,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Nose to Rectum Child",PX-320000165,CDM,76010,CPT,0320,RC,,,both,,,381.65,114.49,"BLUE CROSS [10001]","Blue Cross PPO",,69.15,,"Fee schedule rate ($69.15).",,,,0,32.95,324.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"2.8MM ANGLED SLIT KNIFE",SUP-MSL28,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.20,24.36,"KAISER [10500]",Kaiser,,54.4,67,,,,,0,9.44,69.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 27MM 22.5MM MASTERS 85D STD RING ANNULUS",SUP-27MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"NOVANET [10819]",Novanet,,21839.42,75,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FIXATION 2.8MM MAGNUM2 KNOTLESS",SUP-OM1502,CDM,C1713,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"NOVANET [10819]",Novanet,,2531.25,75,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AERO 40MM 61CM 12MM 16FR GEOMETRIC TRACHEOBRONCHIAL",SUP-90129-212,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]",Cigna,,6900,40,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3.5X3.5CM AMNIOGRAFT THK50-100UM C",SUP-AG-3535,CDM,V2790,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"PHCS [10601]",PHCS,,5916.75,70,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X14MM CAPSTONE PEEK INTERBODY GHX",SUP-2991426,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"NOVANET [10819]",Novanet,,11923.2,75,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 14MM TARGET 360D 2XL DETACHABLE",SUP-M0036181450,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 10X10MM FUSEFORCE HAND STERILE",SUP-FFNS1010,CDM,C1713,HCPCS,0278,RC,,,both,,,5582.10,1674.63,"CIGNA [10200]","Cigna Open Access",,3176.21,56.9,,1144.80,304.56,2275.09,66,649.2,4744.79,"percent of total billed charges",
"SCR BASEPLT 14MM 5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ314,CDM,C1776,HCPCS,0278,RC,,,both,,,962.00,288.6,"CIGNA [10200]","Cigna Open Access",,547.38,56.9,,5302.19,4377.88,6578.61,27,111.88,817.7,"percent of total billed charges",
"STENT TRIA 22CM 6FR URETERAL SOFT",SUP-M0061903210,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM TSRH OSTEOGRIP TITANIUM SHORT SPINE",SUP-83575508,CDM,C1713,HCPCS,0278,RC,,,both,,,3689.10,1106.73,"MULTIPLAN [10600]",Multiplan,,3135.74,85,,,,,0,429.04,3135.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx/Exc Lymph Node Super Open",PX-361000504,CDM,38500,CPT,0361,RC,,,both,,,7566.00,2269.8,"BLUE CROSS [10001]","Blue Cross HMO",,7.57,.1,,,,,0,7.57,7566,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABORTION WITHOUT D&C",779,MS-DRG,,,,,,,inpatient,,,24578.27,7373.48,"PHCS [10601]",PHCS,,7561,,,,,,,7561,7561,"per diem","Estimated amount calculated based on 1 day length of stay."
"DRIVER HEX QUICK CONNECT 3.2MM SURGICAL",SUP-8361025,CDM,S27000186,LOCAL,0270,RC,,,both,,,4930.05,1479.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,573.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,573.36,4190.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAUT BTTRY 5IN BOVIE HIGH TEMPERATURE LOOP TIP EXTEND SHAFT",SUP-AA09,CDM,S27200284,LOCAL,0272,RC,,,both,,,120.79,36.24,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,49.64,41.1,,,,,0,14.05,102.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENT BUR 6.0MM FLUTED TS SHORT ANSPACH",SUP-SA-FB6,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"AETNA [10100]","Aetna HMO/PPO",,1371.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 300MM 2.8MM",SUP-03.333.005,CDM,S27000186,LOCAL,0270,RC,,,both,,,684.29,205.29,"AETNA [10100]","Aetna HMO/PPO",,544.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,79.58,581.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD SAFIO S 45 J",SUP-113395,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"FIRST HEALTH [10303]","First Health",,306.24,80,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +24.5 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z900200245,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"MULTIPLAN [10600]",Multiplan,,867.51,85,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 40MM 130CM 8MM LONG VASCULAR NITINOL ILIAC",SUP-SC840LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"NOVANET [10819]",Novanet,,5433.75,75,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 31MM MASTERS ROTATABLE HEMASHIELD TECHNOLOGY",SUP-23AECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]","Cigna Open Access",,9754.94,33.5,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 32MM 140CM 4.5MM CORONARY STENT PLATINUM",SUP-H7493927432450,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,436.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X6MM AVS AS 4D 12MM PEEK CERVICAL INTERBODY",SUP-48322064,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross HMO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 20MM 4FR 2MM .018IN BALLOON",SUP-PCP020020130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"FIRST HEALTH [10303]","First Health",,984.96,80,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE LAPIDUS",SUP-AR-8941,CDM,C1713,HCPCS,0278,RC,,,both,,,6175.50,1852.65,"BLUE CROSS [10001]","Blue Cross PPO",,2420.8,39.2,,957.42,570.23,957.42,28,718.21,5249.18,"percent of total billed charges",
"FILFRM URETHRAL 13IN 4FR 1/56IN PLASTIC POLYMER SPIRAL TIP",SUP-343104,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.89,49.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.29,141.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REFERENCE TOE 1ST MTP IMPLANT WITH GROMMETS  SIZE 1","SUP-M30 SE010",CDM,C1776,HCPCS,0278,RC,,,both,,,11937.00,3581.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4906.11,41.1,,6417.48,6417.48,6417.48,"1 through 10",1388.27,10146.45,"percent of total billed charges",
"BASKET STONE RETRIEVAL 90CM 11MM 2.4FR GEMINI HELICAL",SUP-M0063303040,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"MULTIPLAN [10600]",Multiplan,,1257.62,85,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 12MM 3.75MM BALLOON DILATATION",SUP-H7493912412370,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOMATRIX C CANCELLOUS 5ML PUTTY MOLDABLE",SUP-860C0500,CDM,C1713,HCPCS,0278,RC,,,both,,,4968.00,1490.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3378.24,68,,,,,0,577.78,4222.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 19MM KNEE X3 BEARING CRUCIATE RETAIN",SUP-5530-G-119,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3266.29,28.62,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYPROHEPTADINE 4 MG TABLET",RX-2033,CDM,,,0637,RC,10135-0638-01,NDC,both,1,UN,6.27,1.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 35MM ATS OPEN PIVOT STD SERIES MECHANICAL",SUP-500DM35,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"UHC [10700]","United Healthcare",,14954.63,63.3,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER SMOKE EVAC 7/8IN VIROSAFE 1 PORT FEMALE PORT TUBE",SUP-VS06004,CDM,S27000186,LOCAL,0270,RC,,,both,,,1008.45,302.53,"PHCS [10601]",PHCS,,705.92,70,,,,,0,117.28,857.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 22-38CMX6-12MM 6-12MM PERONEUS LONGUS",SUP-430345,CDM,C1762,HCPCS,0278,RC,,,both,,,9735.90,2920.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4001.45,41.1,,,,,0,1132.29,8275.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD POSITIONING JACKSON SET TABLE",SUP-5808,CDM,S27000186,LOCAL,0270,RC,,,both,,,231.77,69.53,"MULTIPLAN [10600]",Multiplan,,197,85,,,,,0,26.95,197,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTMASTER 16MM 4MM CORONARY STENT STAINLESS STEEL",SUP-1012582-16,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1921.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM MITRAL VALVE BAND CG FUTURE",SUP-638RL28,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 10MM KNEE LEFT MEDIAL PIVOT ADVANCE II",SUP-KIMP210L,CDM,C1776,HCPCS,0278,RC,,,both,,,6141.00,1842.3,"CIGNA [10200]","Cigna Local Plus",,3285.44,53.5,,5372.07,4581.20,7242.98,23,714.2,5219.85,"percent of total billed charges",
"SABERX RADIANZ 3MM30CM 190",SUP-R51003030L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"PHCS [10601]",PHCS,,1744.32,70,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD EMG NIM-RESPONSE 2 CHANNEL PAIRED SUBDERMAL",SUP-8227410,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 4CM WITHOUT GWIRE DIL RADIOPAQUE MARKER",SUP-RSB705H,CDM,C1894,HCPCS,0272,RC,,,both,,,217.50,65.25,"KAISER [10500]",Kaiser,,145.73,67,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 22MM TI",SUP-SPL-35220-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,613.45,45.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP LIMIT HOLE TITANIUM POROUS",SUP-PT-116060,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1209.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1186.85,8674.34,"percent of total billed charges",
"BURR SURGICAL 4MM MEDIUM BARREL",SUP-5120017040,CDM,S27200284,LOCAL,0272,RC,,,both,,,765.94,229.78,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,314.8,41.1,,,,,0,89.08,651.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 9X11X30MM 15",SUP-5891305,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3412.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1 X 3 COMPLEX PICO COIL",SUP-10USC01003,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"PHCS [10601]",PHCS,,9152.85,70,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 2.6MM COLLARLESS",SUP-521-78-31,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,50.59,369.75,"percent of total billed charges",
"WIRE FIXATION FUZEFIX MAX FT STANDARD OD1.4 MM NONSTERILE",SUP-CD-FX-0014,CDM,S27000186,LOCAL,0270,RC,,,both,,,261.00,78.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 25MM 4MM NONSTERILE REUSABLE",SUP-7005-4025,CDM,S27200284,LOCAL,0272,RC,,,both,,,476.93,143.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,196.02,41.1,,,,,0,55.47,405.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 30MM MITRAL CARPENTIER-EDWARDS PHYSIO II",SUP-520030MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,13800.00,4140,"KAISER [10500]",Kaiser,,9246,67,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TIGHTROPE II RT FIXATION FLIP SUT",SUP-AR-1588RT-2J,CDM,C1713,HCPCS,0278,RC,,,both,,,3661.88,1098.56,"NOVANET [10819]",Novanet,,2746.41,75,,,,,0,425.88,3112.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 40MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.117,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"FIRST HEALTH [10303]","First Health",,685.84,80,,,,,0,99.7,728.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 20MM TIGER CANNULATED",SUP-200-30-020,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",131.88,963.9,"percent of total billed charges",
"SPACER ALLOGRAFT 22X8X15-12.6MM CONTOUR WEDGE SPINE CORTICAL",SUP-4815,CDM,S27800098,LOCAL,0278,RC,,,both,,,14835.00,4450.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5934,40,,,,,0,1725.31,12609.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Charger Elec/Combo Vad, Rep",PX-E27400014,CDM,Q0495,HCPCS,0274,RC,,,both,,,31785.72,9535.72,"CIGNA [10200]","Cigna Local Plus",,10012.5,31.5,,,,,0,3696.68,27017.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 0 CT-2 30IN BRAID GREEN NONABSORBABLE",SUP-X412H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP LIMIT HOLE TITANIUM POROUS",SUP-PT-116052,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4684.14,45.9,,,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 14CM 14.5MM 32MM EXCLUDER TRUNK",SUP-CXT321414,CDM,C1874,HCPCS,0278,RC,,,both,,,71175.90,21352.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8277.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8277.76,60499.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM SEMIRIGID FLEXIBLE LUMEN SIMUFORM",SUP-7800RR34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INBORN AND OTHER DISORDERS OF METABOLISM",642,MS-DRG,,,,,,,inpatient,,,39926.25,11977.87,"CIGNA [10200]","Cigna Open Access",,15606.13,,"Fee schedule rate ($15,606.13). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,35465.75,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ab ID",PX-302000184,CDM,86870,CPT,0302,RC,,,both,,,729.30,218.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,308.23,,,,,,,0.01,619.91,"fee schedule",
"SIZER MAMMARY SILICONE 475ML BREAST RESTERILIZABLE GEL",SUP-RSZ-4754,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"NOVANET [10819]",Novanet,,115.67,75,,,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL NEONATE PROSOFT NONSTERILE LATEX FREE DISPOSABLE",SUP-PROSOFT-NEO,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.06,33.62,"MULTIPLAN [10600]",Multiplan,,95.25,85,,,,,0,13.03,95.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 100CM 6FR MP CURVE GUIDING DURAFORM",SUP-M003101460,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER 12.5MM 4MM SABRETOOTH COOLCUT STERILE",SUP-AR-8400ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL +20.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0205,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 10.5",SUP-DIB00U0105,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DECA 2-2-2 MPA 120CM",SUP-901537,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,351.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) DILATOR KIT LHR-0105",SUP-LHR-0105,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 30MM TSRH OSTEOGRIP THINLINE TITANIUM SPINE",SUP-83575309,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"CIGNA [10200]","Cigna Open Access",,1464.61,56.9,,1144.80,304.56,2275.09,66,299.36,2187.9,"percent of total billed charges",
"ALTIVATE ANATOMIC, ALL-POLY PEGGED GLENOID, SIZE 46, E-PLUS",SUP-521-07-246,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"FIRST HEALTH [10303]","First Health",,7331.52,80,,,,,0,1065.82,7789.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE",RX-8121,CDM,,,0250,RC,00713-0655-40,NDC,both,5,GR,417.64,125.29,"CIGNA [10200]",Cigna,,284,68,,,,,0,48.57,354.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CM 32MM 12/10/10/10MM THORAX 2",SUP-M00202175732P0,CDM,C1768,HCPCS,0278,RC,,,both,,,12361.21,3708.36,"UHC [10700]","United Healthcare",,7824.65,63.3,,,,,0,1437.61,10507.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS LIGAPAK 1 54IN BRAID REEL ANTIBACTERIAL",SUP-VCP208G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PROTECTIVE 6MM FIXATION PIN NONSTERILE BLUE",SUP-394.994,CDM,S27000186,LOCAL,0270,RC,,,both,,,48.42,14.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.63,41.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MICROMARKER SMART CONTROL 30MM 80CM 12MM .035IN",SUP-C12030SB,CDM,C1876,HCPCS,0278,RC,,,both,,,2812.50,843.75,"FIRST HEALTH [10303]","First Health",,2250,80,,,,,0,327.09,2390.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE HA 20MM 9MM ACL BIOSURE",SUP-72201780,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 60MM CATHCART BALL HIP FEMORAL ORTHOCHROME",SUP-136360000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Skull>=4v",PX-320000018,CDM,70260,CPT,0320,RC,,,both,,,768.38,230.51,"BLUE CROSS [10001]","Blue Cross HMO",,101.95,,"Fee schedule rate ($101.95).",,,,0,49.14,653.12,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 40 MEDIUM PEG AEQUALIS PERFORM SHOULDER",SUP-DWE313,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"KAISER [10500]",Kaiser,,6241.72,67,,,,,0,1083.45,7918.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 6-0 P-1 18IN MONOFILAMENT UNDYED ABSORBABLE",SUP-Z489G,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL 2.8 X 160MM SOLID MEASURING LONG AO",SUP-P99-100-2816,CDM,S27000186,LOCAL,0270,RC,,,both,,,1004.40,301.32,"KAISER [10500]",Kaiser,,672.95,67,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLSTER VENTRICULAR ASSIST HEARTMATE GOGEAR 14V SMALL",SUP-104229,CDM,Q0498,HCPCS,0274,RC,,,both,,,2883.60,865.08,"BLUE CROSS [10001]","Blue Cross HMO",,1130.37,39.2,,,,,0,335.36,2451.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 23MMX10MM ELEVATE XLORDOTIC PEEK TITANIUM",SUP-8881023,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AETNA [10100]","Aetna HMO/PPO",,22538.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT ENDURANT II CUSTOM KIT 4 PIECE",SUP-ENDURANTII4,CDM,S27800098,LOCAL,0278,RC,,,both,,,108300.00,32490,"CIGNA [10200]",Cigna,,43320,40,,,,,0,12595.29,92055,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 60MM 120CM 7MM VASCULAR PERIPHERAL SELF",SUP-PRB35-07-060-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]",Cigna,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 5.5MM CORE THK.51MM 25MM LONG NARROW SAGITTAL",SUP-2296-033-414,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.84,87.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL ENDOSCOPIC CRE 240CM 5.5CM 7.5FR 8-10MM ESOPHAGEAL",SUP-M00558460,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SMOOTH UHP-L BREAST IMPLANTS 1445 CC",SUP-350-51445L,CDM,A4648,HCPCS,0278,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,39.2,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPO 100CM 5FR .045IN AMPLATZ LEFT 2 CURVE ANGIOGRAPHIC",SUP-H74908526982,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE RUNTHROUGH NS VASCULAR STRAIGHT 180CM 3CM .014IN",SUP-25-1011,CDM,C1769,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PUNCH SHORT 4.8MM STD HANDLE STERILE DISPOSABLE AORTIC",SUP-APU448,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABER 90CM 150MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EXPEL APD TWIST-LOC 20CM 6FR DRNG FLEXITHANE METAL",SUP-H7493931006200,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOUNDSTAR 90CM 8FR ULTRASOUND GREEN SIEMENS SEQUOIA",SUP-10439011R,CDM,C1759,HCPCS,0272,RC,,,both,,,7590.00,2277,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR JCR3.5 CURVE GUIDING NYLON CORONARY",SUP-LA6JCR35,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)",RX-35943,CDM,,,0637,RC,00245-5319-89,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LEVETIRACETAM 500 MG TABLET, IMMEDIATE RELEASE",RX-26817,CDM,,,0637,RC,51079-0821-01,NDC,both,1,UN,17.68,5.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7.27,41.1,,,,,0,2.06,15.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 40MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171030470,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UHC [10700]","United Healthcare",,743.46,63.3,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 20CM 150CM 7FR .035IN PIGTAIL CURVE",SUP-M006180230180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA [10200]","Cigna Open Access",,830.8,,,,,,,169.81,1241.09,"percent of total billed charges",
"CATH EMERGE MONORAIL 144CM 20MM 6FR 2.5MM .07IN BALLOON",SUP-H7493918920250,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,233.04,41.1,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 40MM GORILLA R3CON LOCK",SUP-P50-353-4240,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",155.43,1136.03,"percent of total billed charges",
"CATH PACIFIC PLUS 130CM 40MM 4FR 6MM .018IN BALLOON",SUP-PCP060040130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,143.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ILIAC CREST TRICORTICAL THK16-18MM WEDGE",SUP-400408,CDM,S27800098,LOCAL,0278,RC,,,both,,,5717.34,1715.2,"FIRST HEALTH [10303]","First Health",,4573.87,80,,,,,0,664.93,4859.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 4MM INFUSION STERILE DISPOSABLE",SUP-8065820101,CDM,S27200284,LOCAL,0272,RC,,,both,,,204.71,61.41,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE STBL VASCULAR STRAIGHT 300CM 3CM .014IN SUPER SOFT TIP",SUP-507914X,CDM,C1769,HCPCS,0272,RC,,,both,,,636.58,190.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Sol D5 Nacl",PX-E27200282,CDM,E27200282,LOCAL,0272,RC,,,both,,,119.90,35.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE COAGULATION 220CM 2.3MM ARC SMART ARCONNECT QUICK",SUP-G11-400-04,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Tc99m Acutect Up to 20mci",PX-636000002,CDM,A9504,HCPCS,0343,RC,,,both,,,1614.00,484.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT CATH 24CM 13FR STRAIGHT POWER-TRIALYSIS 3 LUMEN SHORT",SUP-5603240,CDM,C1752,HCPCS,0272,RC,,,both,,,1245.78,373.73,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL BIT ASSY, CARBIDE, HUDSON END, 5 MM, SINGLE USE",SUP-SBT004,CDM,S27000186,LOCAL,0270,RC,,,both,,,2212.50,663.75,"UHC [10700]","United Healthcare",,1400.51,63.3,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9MM 100MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704999,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Eus Fna/Bx Esoph Only",PX-750000029,CDM,43238,CPT,0750,RC,,,both,,,6242.31,1872.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,739.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,725.98,6242.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Npwt <=50 Sq Cm Disp (Gp)",PX-420000043,CDM,97607,CPT,0420,RC,,,both,,,934.00,280.2,"AETNA [10100]","Aetna HMO/PPO",,742.53,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.62,793.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Virus Inoculation Add Study",PX-306000094,CDM,87253,CPT,0306,RC,,,both,,,345.00,103.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.03,,,,,,,0.35,293.25,"fee schedule",
"HC Ugt1a1 Gene",PX-309000077,CDM,81350,CPT,0310,RC,,,both,,,322.40,96.72,"CIGNA [10200]","Cigna Open Access",,322.4,,,,,,,0.01,322.4,"fee schedule",
"HC Cytp Urne 3-5 Probes Ea Spec",PX-311000037,CDM,88120,CPT,0311,RC,,,both,,,3075.00,922.5,"KAISER [10500]",Kaiser,,2060.25,67,,,,,0,0.01,2613.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Neu Prksn Msfl Î±-Syncln Prtn",PX-310000034,CDM,0393U,CPT,0310,RC,,,both,,,3000.00,900,"MULTIPLAN [10600]",Multiplan,,2550,85,,,,,0,355.5,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES,MINOR",115,APR-DRG,,,,,,,inpatient,,,19879.51,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $3,397.81. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SURGICAL EZ-IO SOFT SIDE INTRAOSSEOUS VASCULAR ACCESS",SUP-9065,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CURET 3MM 1 STRAIGHT 5.75IN BUCK EAR SHARP SURGICAL",SUP-380202,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.07,40.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPLINT ORTHOPEDIC SMALL 22IN 14-16IN KNEE CONTACT CLSR",SUP-79-80053,CDM,S27000186,LOCAL,0270,RC,,,both,,,111.80,33.54,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS 0 CT-2 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP727D,CDM,S27200284,LOCAL,0272,RC,,,both,,,128.80,38.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SUPERTORQUE 100CM 6FR .051IN .042IN JUDKINS LEFT",SUP-532624,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.97,41.1,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 60MM 112CM 9MM 75CM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200096070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL SHANK MODULAR TRACTION TITANIUM 5.5MM X 50MM RE",SUP-13175550,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,957.42,156.86,7483.26,51,348.9,2550,"percent of total billed charges",
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STEERABLEBALLOON CA",SUP-ARC30SB-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,18270.00,5481,"NOVANET [10819]",Novanet,,13702.5,75,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SURGICAL PROC 40CM WELCH ALLYN CATH EXT TUBE SET",SUP-660005000,CDM,S27200284,LOCAL,0272,RC,,,both,,,437.40,131.22,"CIGNA [10200]","Cigna Open Access",,248.88,56.9,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL HIP UNIPOLAR LOW END CEMENTED FEMORAL CO",SUP-71700025,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2764.69,28.62,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 51MM CATHCART BALL HIP FEMORAL ORTHOCHROME",SUP-136351000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross PPO",,1466.08,39.2,,3949.44,3949.44,3949.44,"1 through 10",434.96,3179,"percent of total billed charges",
"BINDER ABDOMINAL 12IN LARGE 4 PANEL ELASTIC HOOK LOOP CLSR",SUP-55476303,CDM,S27000186,LOCAL,0270,RC,,,both,,,137.81,41.34,"NOVANET [10819]",Novanet,,103.36,75,,,,,0,16.03,117.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 58MM 26MM UHR UNIVERSAL ACETABULAR HIP COCR",SUP-UH1-58-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"MULTIPLAN [10600]",Multiplan,,3670.1,85,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 6MM NATURAL LARGE LORDOTIC CORTICOCANCELLOUS",SUP-19406,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 20MM 10MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171100210,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AETNA [10100]","Aetna HMO/PPO",,933.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 119MM 18MM ESOPHAGEAL PARTIAL COVER STERILE",SUP-M00517260,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross HMO",,7161.84,39.2,,9776.84,9776.84,9776.84,"1 through 10",2124.8,15529.5,"percent of total billed charges",
"CATH IMPULSE 125CM 6FR FR4 CURVE ANGIOGRAPHIC VENTRICULAR 2",SUP-H749165992252,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"UHC [10700]","United Healthcare",,48.48,63.3,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI SUOH3 190 STRAIGHT",SUP-AHW14R013S,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,131.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT BUMPER GMRS 3D KNEE PROXIMAL MODULAR ROTATE HINGE",SUP-6481-2-133,CDM,C1776,HCPCS,0278,RC,,,both,,,3543.75,1063.12,"KAISER [10500]",Kaiser,,2374.31,67,,,,,0,412.14,3012.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD SENTUS PROMRI LEFT VENTRICULAR OTW QUADRIPOLAR",SUP-408718,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CIGNA [10200]","Cigna Local Plus",,2999.75,53.5,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 34CM FEMUR LEFT PROXIMAL TALON DISTALFIX",SUP-SLN-125-34L,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"AETNA [10100]","Aetna HMO/PPO",,12819.61,79.5,,1521.93,481.35,16760.95,30,1875.37,13706.51,"percent of total billed charges",
"CATH BARDEX LUBRICATH 10FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0165PL10,CDM,S27200284,LOCAL,0272,RC,,,both,,,57.33,17.2,"AETNA [10100]","Aetna HMO/PPO",,45.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.67,48.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.190 CLAREON",SUP-SY60WF.190,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Local Plus",,645.69,53.5,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY FEMORAL 75MM 20MM RECLAIM 40MM 12/14 OFFSET MINI TAPER",SUP-1975-20-075,CDM,C1776,HCPCS,0278,RC,,,both,,,22082.76,6624.83,"KAISER [10500]",Kaiser,,14795.45,67,,,,,0,2568.22,18770.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 31X14-17MM MAGNIFY-S 15D LORDOTIC 25MM EXPAND",SUP-1126.0214,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4982.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 6CM 6MM BALLOON DILATATION ILIAC",SUP-G34335,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 22MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532-P-722,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"PHCS [10601]",PHCS,,5849.13,70,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 10CM 8.5FR RB AMPLATZ .035IN PIGTAIL CURVE URETER",SUP-G09977,CDM,C2625,HCPCS,0278,RC,,,both,,,1227.07,368.12,"CIGNA [10200]","Cigna Local Plus",,656.48,53.5,,,,,0,142.71,1043.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PYRIDOXINE (VITAMIN B6) 50 MG TABLET",RX-6748,CDM,,,0637,RC,77333-0940-25,NDC,both,1,UN,6.27,1.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Tumor Loc Wb>=2 Days",PX-341000051,CDM,78804,CPT,0341,RC,,,both,,,3193.94,958.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,378.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,371.46,3193.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION",RX-26226,CDM,J2470,HCPCS,0636,RC,72603-0128-01,NDC,both,1,UN,52.92,15.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,35.99,68,,,,,0,2.2,44.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 240MM SEMITENDINOSUS",SUP-81B003,CDM,C1762,HCPCS,0278,RC,,,both,,,6537.75,1961.32,"CIGNA [10200]","Cigna Open Access",,3719.98,56.9,,,,,0,760.34,5557.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 24MM 144CM 3MM",SUP-H7493941224300,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"MULTIPLAN [10600]",Multiplan,,6598.13,85,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CHOLANGIOGRAM JAGTOME RAPID EXCHANGE",SUP-7612,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"FIRST HEALTH [10303]","First Health",,125.28,80,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ROADRUNNER NIMBLE VASCULAR ANGLE TAPER 145CM 9CM .035",SUP-G07914,CDM,C1769,HCPCS,0272,RC,,,both,,,313.11,93.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.41,266.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POUCH SURGICAL TISSUE 10X8IN LAPSAC INNER LINER DRAWSTRING",SUP-G16497,CDM,S27200284,LOCAL,0272,RC,,,both,,,877.54,263.26,"KAISER [10500]",Kaiser,,587.95,67,,,,,0,102.06,745.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STAPLER 2MM 2.5MM 3MM THK1.5-2.25MM 30MM ENDO GIA MED",SUP-SIG30AVM,CDM,S27200284,LOCAL,0272,RC,,,both,,,1060.37,318.11,"CIGNA [10200]","Cigna Open Access",,603.35,56.9,,,,,0,123.32,901.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 30X27X14MM ROI-A 10D PEEK-OPTIMA ALIF","SUP-IR 2534 P",CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4061.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 10CM 6MM BALLOON DILATATION",SUP-DR80610,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,565.95,41.1,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HANAROSTENT 120MM 2300MM 20MM 3.5MM ESOPHAGEAL NITINOL",SUP-ECBA-20-120-230,CDM,C1874,HCPCS,0278,RC,,,both,,,16425.45,4927.63,"MULTIPLAN [10600]",Multiplan,,13961.63,85,,,,,0,1910.28,13961.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 FULL THREAD CROSSFT BC HI-FI CANNULATED",SUP-CFBC-5503,CDM,C1713,HCPCS,0278,RC,,,both,,,3471.30,1041.39,"KAISER [10500]",Kaiser,,2325.77,67,,,,,0,403.71,2950.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL 3MM ARTHROWAND TRISTAR 50D INTEGRATE","SUP-ASC 463001",CDM,S27200284,LOCAL,0272,RC,,,both,,,1255.50,376.65,"CIGNA [10200]","Cigna Open Access",,714.38,56.9,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pathogen Test Platelets",PX-300000416,CDM,P9100,HCPCS,0300,RC,,,both,,,313.00,93.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,36.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.31,266.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AZITHROMYCIN 500 MG/5ML IV (WET SOLR VIAL)",RX-41521063,CDM,J0456,HCPCS,0636,RC,70860-0125-41,NDC,both,1,UN,26.52,7.96,"CIGNA [10200]","Cigna Open Access",,5.5,,,,,,,2.38,22.54,"fee schedule",
"SCR BONE 4MM 32.5MM MAXTORQUE SHORT THREAD",SUP-MSD01040325S,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"PHCS [10601]",PHCS,,992.25,70,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 47MM 75CM 8MM 100CM",SUP-M001712200,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1001.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 175MM SCHANZ STAINLESS STEEL CONDYLAR HIP SELF",SUP-294.785,CDM,C1713,HCPCS,0278,RC,,,both,,,1042.88,312.86,"FIRST HEALTH [10303]","First Health",,834.3,80,,,,,0,121.29,886.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOLD CEMENT 75MM STAGEONE UNIVERSAL FEMUR KNEE SILICONE AGC",SUP-432175,CDM,S27200284,LOCAL,0272,RC,,,both,,,12867.12,3860.14,"MULTIPLAN [10600]",Multiplan,,10937.05,85,,,,,0,1496.45,10937.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR EXTERNAL FIXATION 190MM 6MM SCHANZ SPADE POINT 50MM",SUP-294.68,CDM,C1713,HCPCS,0278,RC,,,both,,,550.80,165.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,252.82,45.9,,,,,0,64.06,468.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR BIOPSY 9CM 18GA SUPERCORE STERILE LATEX FREE",SUP-701118090,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.65,103.09,"KAISER [10500]",Kaiser,,230.25,67,,,,,0,39.97,292.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 15.5X16CM 775CC STYLE 410FX HIGHLY COHESIVE",SUP-FX-410775,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"MULTIPLAN [10600]",Multiplan,,4730.25,85,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0200,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,382.51,28.62,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 5CC .5-5MM 80% CORTICAL 20% CANCELLOUS",SUP-400053,CDM,C1713,HCPCS,0278,RC,,,both,,,923.40,277.02,"MULTIPLAN [10600]",Multiplan,,784.89,85,,,,,0,107.39,784.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RX BILIARY SYSTEM 12CM 8.5FR DUODENAL BEND BILIARY",SUP-M00545680,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"BLUE CROSS [10001]","Blue Cross PPO",,334.29,39.2,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR ATHERECTOMY 135CM 2.25MM ROTABLATOR ROTALINK PLUS",SUP-M0011402250,CDM,C1724,HCPCS,0272,RC,,,both,,,16525.50,4957.65,"KAISER [10500]",Kaiser,,11072.09,67,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIEVER16 CURVE CATHETER, 16F, 110 CM ( ONE TIME INVENTORY I",SUP-25-201-ISO,CDM,C1757,HCPCS,0272,RC,,,both,,,50400.00,15120,"NOVANET [10819]",Novanet,,37800,75,,,,,0,5861.52,42840,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM ASSEMB",SUP-11-4745*,CDM,C1713,HCPCS,0278,RC,,,both,,,6210.00,1863,"PHCS [10601]",PHCS,,4347,70,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 1.27MM SHEEHY COLLAR BUTTON EAR",SUP-70145971,CDM,S27800098,LOCAL,0278,RC,,,both,,,65.57,19.67,"FIRST HEALTH [10303]","First Health",,52.46,80,,,,,0,7.63,55.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 200MM 6MM COCR HEXAGONAL END",SUP-7120.22,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 20MM 3MM",SUP-SPL30020X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 18IN BRAID TIE 12 STRAND PRECUT",SUP-A185H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE CHOICE PT VASCULAR J 185CM 35CM .014IN FLOPPY",SUP-H7491216001J1,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY",884,MS-DRG,,,,,,,inpatient,,,37940.31,11382.09,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC KNEE GEL FREEZABLE MICROWAVABLE COMPRESSION",SUP-K-24-6-IP,CDM,S27000186,LOCAL,0270,RC,,,both,,,336.69,101.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRAOCULAR PROCEDURES WITH CC/MCC",116,MS-DRG,,,,,,,inpatient,,,90081.77,27024.53,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE WATCHMAN FLX PRO 31MM CLSR LEFT ATRIAL APPENDAGE",SUP-M635WU60310,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NEEDLE EZ-IO 15MM STABILIZER",SUP-9018P-VC-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1138.86,341.66,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT GORE VIABAHN 79MM 135CM 9MM 13MM 8FR .035IN",SUP-BXA097902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"CIGNA [10200]","Cigna Open Access",,7171.48,33.5,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1 CP-2 ETHIBOND GII QUICKANCHOR PLUS ROTATOR CUFF",SUP-212031,CDM,C1713,HCPCS,0278,RC,,,both,,,5782.20,1734.66,"FIRST HEALTH [10303]","First Health",,4625.76,80,,,,,0,672.47,4914.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 550ML STYLE 20 SMOOTH NATRELLE SILICONE P5.6CM",SUP-20-550,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"KAISER [10500]",Kaiser,,2391.9,67,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 28CM 8FR NEPHROURETERAL FLEXITHANE",SUP-H7493935108280,CDM,C2617,HCPCS,0278,RC,,,both,,,1069.20,320.76,"NOVANET [10819]",Novanet,,801.9,75,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 68MM STAINLESS STEEL 2.4MM SCR 7 HOLE HEAD 4 HOLE",SUP-02.111.740S,CDM,C1713,HCPCS,0278,RC,,,both,,,4450.50,1335.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2042.78,45.9,,,,,0,517.59,3782.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 250CM 7.5FR BILIARY FLEXIMA TEFLON NASAL TUBE",SUP-M00540130,CDM,C2617,HCPCS,0272,RC,,,both,,,859.33,257.8,"CIGNA [10200]","Cigna Open Access",,488.96,,,,,,,99.94,730.43,"percent of total billed charges",
"BASEPLT TIBIAL ATTUNE 3 KNEE CEMENT FIX BEARING STERILE",SUP-150670003,CDM,C1776,HCPCS,0278,RC,,,both,,,15487.05,4646.11,"PHCS [10601]",PHCS,,10840.94,70,,,,,0,1801.14,13163.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION",RX-113561,CDM,90377,HCPCS,0636,RC,76125-0150-02,NDC,both,2,ML,4500.54,1350.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2013.99,44.75,,,,,0,518.06,3825.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cine/Video Xray",PX-320000170,CDM,76120,CPT,0320,RC,,,both,,,467.00,140.1,"BLUE CROSS [10001]","Blue Cross PPO",,318.67,,"Fee schedule rate ($318.67).",,,,0,54.31,396.95,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL 2-0 RB-1 30IN BRAID GREEN NONABSORBABLE",SUP-X873H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Fna I&R / Add on 88173",PX-311000088,CDM,0837T,CPT,0311,RC,,,both,,,104.00,31.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC ED Simple Procedure",PX-450000381,CDM,450000381,LOCAL,0361,RC,,,both,,,281.40,84.42,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Bronch Unlstd Proc",PX-750000192,CDM,31899,CPT,0750,RC,,,both,,,3924.00,1177.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,464.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,456.36,3924,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Alpha-Fetoprotein Serum",PX-301000097,CDM,82105,CPT,0301,RC,,,both,,,293.00,87.9,"CIGNA [10200]","Cigna Local Plus",,36.89,,,,,,,0.01,249.05,"fee schedule",
"HC Ph Probe",PX-E27200296,CDM,E27200296,LOCAL,0272,RC,,,both,,,760.10,228.03,"FIRST HEALTH [10303]","First Health",,608.08,80,,,,,0,88.4,646.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Trach Hyperflex",PX-E27200233,CDM,E27200233,LOCAL,0272,RC,,,both,,,1129.30,338.79,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CONVEY 100CM 5FR CLS3 CURVE GUIDING HYDROPHILIC FEMORAL",SUP-H749392285730,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAFIRE TX COMFORTGRIP 110CM 8MM 7FR 1MM 2-5-2MM SPACE",SUP-402841,CDM,C1733,HCPCS,0272,RC,,,both,,,6555.00,1966.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ANGIOSCULPT XL 137CM 200MM 6FR 6MM .014IN BALLOON",SUP-2249-60200,CDM,C1725,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 8FR 19CM LATEX FREE VESSEL ACCEPTS .038IN GWIRE",SUP-504508X,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.26,26.18,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHIELD SPIRAL, 30 MM DIAMETER",SUP-50215K52B0D,CDM,A2019,HCPCS,0636,RC,,,both,,,37195.20,11158.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"HC Plt Lr Ea Unit",PX-390000022,CDM,P9031,HCPCS,0390,RC,,,both,,,1023.00,306.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE LOOPTIP FUSION ENDOSCOPIC 480CM 4X2MM .035IN NITINOL",SUP-G50977,CDM,C1769,HCPCS,0272,RC,,,both,,,1360.80,408.24,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PHENYLEPHRINE 0.1 MG/ML INTRAVENOUS SOLUTION",RX-188414,CDM,J2373,HCPCS,0636,RC,00641-6245-01,NDC,both,5,ML,45.30,13.59,"NOVANET [10819]",Novanet,,33.98,75,,,,,0,4.08,38.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM MITRAL EDWARDS GEOFORM",SUP-420028MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA [10200]",Cigna,,6624,40,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plt Lr Ea Unit",PX-390000022,CDM,P9031,HCPCS,0390,RC,,,both,,,1023.00,306.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,469.56,45.9,,,,,0,118.97,869.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Porphobilinogen Urine Quant",PX-301000361,CDM,84110,CPT,0301,RC,,,both,,,456.00,136.8,"KAISER [10500]",Kaiser,,305.52,67,,,,,0,0.01,387.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOANCHOR AORTIC HELI-FX W/AP",SUP-SA-85,CDM,S27800098,LOCAL,0278,RC,,,both,,,27197.10,8159.13,"MULTIPLAN [10600]",Multiplan,,23117.54,85,,,,,0,3163.02,23117.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK POPE EPSTX",SUP-22-60406,CDM,S27000186,LOCAL,0270,RC,,,both,,,67.86,20.36,"AETNA [10100]","Aetna HMO/PPO",,53.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.89,57.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Train for Caregiver Add 15 (Gn)",PX-440000026,CDM,G0540,HCPCS,0440,RC,,,both,,,37.00,11.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.04,37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPIFIX MESH 2X3 CM",SUP-ES-2300,CDM,Q4186,HCPCS,0636,RC,,,both,,,6693.00,2007.9,"CIGNA [10200]","Cigna Open Access",,406.44,,,,,,,406.44,5689.05,"fee schedule",
"CAP IDNT ST/CMP GLN/XL/INS",SUP-98000900268,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"MULTIPLAN [10600]",Multiplan,,38556,85,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Tmj",PX-610000002,CDM,70336,CPT,0610,RC,,,both,,,3403.00,1020.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,583.68,,,,,,,395.77,2892.55,"fee schedule",
"CATH EMERGE MONORAIL 144CM 15MM 6FR 1.25MM .07IN ULTRA LOW",SUP-H7493918915120,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 100MM 10MM BILIARY STERILE LATEX FREE DISPOSABLE",SUP-M00572340,CDM,C1876,HCPCS,0278,RC,,,both,,,10624.97,3187.49,"BLUE CROSS [10001]","Blue Cross HMO",,4164.99,39.2,,,,,0,1235.68,9031.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CRE STERI-FLATE INFLATION DISPOSABLE",SUP-M00550630,CDM,S27200284,LOCAL,0272,RC,,,both,,,340.52,102.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,139.95,41.1,,,,,0,39.6,289.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION CURVE SPEAR DISPOSABLE",SUP-AR-3638DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL GAMMA3 CLOSED TUBE STERILE",SUP-13200125S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1041.01,312.3,"KAISER [10500]",Kaiser,,697.48,67,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN AMPLATZ",SUP-77804800,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EXTRACTION OUTAKE CATH SYR GLOVE TRANSPORT TUBE",SUP-CET300,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"CIGNA [10200]",Cigna,,207.06,68,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachythrpy Stranded I-125",PX-E27800013,CDM,C2638,HCPCS,0278,RC,,,both,,,363.00,108.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.22,308.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 25MM X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-325,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5383.38,40,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM TITANIUM SELF TAP LOCK NONSTERILE AXSOS 3",SUP-661134,CDM,C1713,HCPCS,0278,RC,,,both,,,1377.32,413.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,163.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,160.18,1170.72,"percent of total billed charges",
"INSRT TIBIAL 5 19MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-519,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3266.29,28.62,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 100MM 6MM .014IN BALLOON DILATATION",SUP-AB14W060100150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"FIRST HEALTH [10303]","First Health",,1108.08,80,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE 25MMX10CM",SUP-7509010,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"NOVANET [10819]",Novanet,,5071.5,75,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL TWIST 1.9MM SMALL",SUP-72203856,CDM,S27200284,LOCAL,0272,RC,,,both,,,1811.18,543.35,"CIGNA [10200]","Cigna Open Access",,1030.56,56.9,,,,,0,210.64,1539.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON VIVITY TORIC UVA",SUP-CCWET5,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,397.04,45.9,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN SMOOTH TIP GUIDE 2.5MM x 200MM",SUP-DWD168,CDM,S27200284,LOCAL,0272,RC,,,both,,,1556.00,466.8,"PHCS [10601]",PHCS,,1089.2,70,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 54MM LCP STAINLESS STEEL CORTICAL CONDYLAR",SUP-214.854,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"FIRST HEALTH [10303]","First Health",,200.73,80,,,,,0,29.18,213.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 7-8 13MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934389,CDM,C1776,HCPCS,0278,RC,,,both,,,19089.00,5726.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2262.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2220.05,16225.65,"percent of total billed charges",
"STENT PROTEGE GPS 30MM 80CM 8MM BILIARY ACCEPTS .035IN GWIRE",SUP-SERB65-08-30-80,CDM,C1876,HCPCS,0278,RC,,,both,,,6037.50,1811.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,702.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM ORTHOLOC FULL THREAD LOW PROFILE FOOT",SUP-58813520,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"BLUE CROSS [10001]","Blue Cross HMO",,301.64,39.2,,957.42,156.86,7483.26,51,89.49,654.08,"percent of total billed charges",
"PLATE 57MM TITANIUM 2.4MM SCREW 8 HOLE BONE RIGHT HAND NONST",SUP-449.916,CDM,C1713,HCPCS,0278,RC,,,both,,,3706.50,1111.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,439.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",431.07,3150.53,"percent of total billed charges",
"SLEEVE HUMERAL 10MM COMPREHENSIVE SHOULDER POSITIONING",SUP-113578,CDM,C1776,HCPCS,0278,RC,,,both,,,1518.10,455.43,"CIGNA [10200]","Cigna Local Plus",,812.18,53.5,,5372.07,4581.20,7242.98,23,176.56,1290.39,"percent of total billed charges",
"WAND ELECTROSURGICAL EVAC 70 70D TONSIL ADENOID PLASMA",SUP-EICA587401,CDM,S27200284,LOCAL,0272,RC,,,both,,,2158.13,647.44,"NOVANET [10819]",Novanet,,1618.6,75,,,,,0,250.99,1834.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM 14MM PRIMARY CEMENT SATIN FINISH VERSYS",SUP-785001400,CDM,C1776,HCPCS,0278,RC,,,both,,,18721.08,5616.32,"CIGNA [10200]","Cigna Local Plus",,5897.14,31.5,,5372.07,4581.20,7242.98,23,2177.26,15912.92,"percent of total billed charges",
"CATH BALLOON DILATATION .018IN 4FR 5MM 150CM 30MM SMALL",SUP-83171-02,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC TRANSLUCENT GRAY 85MM 6MM DRY-DOC ROUND",SUP-C7359,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.63,90.49,"NOVANET [10819]",Novanet,,226.22,75,,,,,0,35.08,256.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 45CM 14/7MM GELSOFT PLUS VASCUTEK 2 BRANCH",SUP-631407P,CDM,C1768,HCPCS,0278,RC,,,both,,,5103.79,1531.14,"PHCS [10601]",PHCS,,3572.65,70,,,,,0,593.57,4338.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 4IN TUNGSTEN 20X15MM NONHEX",SUP-E15624,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.49,30.15,"PHCS [10601]",PHCS,,70.34,70,,,,,0,11.69,85.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 12MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240120200,CDM,S27800098,LOCAL,0278,RC,,,both,,,6817.20,2045.16,"NOVANET [10819]",Novanet,,5112.9,75,,,,,0,792.84,5794.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE VASCULAR STRAIGHT 190CM 3CM .014IN",SUP-28000,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE TUTOPLAST THK.3-.5MM PERICARDIUM ALLOGRAFT",SUP-938212,CDM,C1762,HCPCS,0278,RC,,,both,,,11709.30,3512.79,"PHCS [10601]",PHCS,,8196.51,70,,,,,0,1361.79,9952.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH DRYSEAL FLEX 33CM 12FR 4.7MM 4MM INTRO HYDROPHILIC",SUP-GDSF1233,CDM,C1894,HCPCS,0272,RC,,,both,,,3760.50,1128.15,"UHC [10700]","United Healthcare",,2380.4,63.3,,,,,0,437.35,3196.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO 6207BTK-5  LEAD INTRODUCER  7 FR",SUP-6207BTK-5,CDM,C1894,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 7.5MM TANNE UNIVERSAL TREPHINE UNIQUE HUB","SUP-E3050 7.50",CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"NOVANET [10819]",Novanet,,414.62,75,,,,,0,64.29,469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 22X10X10MM CASCADIA CONVEX NARROW TITANIUM",SUP-6101-2102210NC-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"CIGNA [10200]","Cigna Open Access",,7110.58,33.5,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,inpatient,,,32839.80,9851.94,"BLUE CROSS [10001]","Blue Cross PPO",,17273.53,,,,,,,4340.29,17449.82,"case rate",
"ELECTRD ELECTROSURGICAL 10IN EVAC 70 XTRA 70D TONSIL ADENOID",SUP-EICA5872-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1835.63,550.69,"PHCS [10601]",PHCS,,1284.94,70,,,,,0,213.48,1560.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE VERSATURN VASCULAR STRAIGHT 190CM 3CM .014IN",SUP-1013319,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER RADIOLOGY 4MM 17GA ULTRACLIP II 3MM TISSUE COIL",SUP-864017,CDM,A4648,HCPCS,0278,RC,,,both,,,640.63,192.19,"CIGNA [10200]",Cigna,,435.63,68,,,,,0,74.51,544.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 20MM OSTEOLOCK TITANIUM CANCELLOUS HIP",SUP-5260-5-020,CDM,C1713,HCPCS,0278,RC,,,both,,,580.01,174,"FIRST HEALTH [10303]","First Health",,464.01,80,,,,,0,67.46,493.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +21 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.210,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,158.36,45.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 95MM LCP STAINLESS STEEL PERIARTICULAR FEMORAL",SUP-02.205.295,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"MULTIPLAN [10600]",Multiplan,,1322.47,85,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 5.5MM CURVE TITANIUM CP4 NONSTERILE",SUP-1553201060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"LEAD 5568-53 CAPSUREFIX LEAD-CAPFIX ATR",SUP-5568-53,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"PHCS [10601]",PHCS,,3924.9,70,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 5568-53 CAPSUREFIX LEAD-CAPFIX ATR",SUP-5568-53,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,664.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X19MM M-CLASS HALL THK1.27MM STAINLESS STEEL",SUP-T190-127-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,553.72,166.12,"UHC [10700]","United Healthcare",,350.5,63.3,,,,,0,64.4,470.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER EMBOLIZATION 48MM FEMORAL VENA CAVA 3 WAY STPCOCK",SUP-G48373,CDM,C1880,HCPCS,0278,RC,,,both,,,7621.05,2286.31,"CIGNA [10200]",Cigna,,5182.31,68,,,,,0,886.33,6477.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER DS NAV 115CM 8MM 7FR 1-7-4MM SPACE D-F CURVE",SUP-BN7TCDF8L,CDM,C1732,HCPCS,0272,RC,,,both,,,16477.20,4943.16,"KAISER [10500]",Kaiser,,11039.72,67,,,,,0,1916.3,14005.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN",RX-163725,CDM,,,0250,RC,00942-0641-04,NDC,both,1000,ML,100.65,30.19,"CIGNA [10200]","Cigna Local Plus",,53.85,53.5,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intro Sheath",PX-E27200305,CDM,C1894,HCPCS,0272,RC,,,both,,,123.20,36.96,"PHCS [10601]",PHCS,,86.24,70,,,,,0,14.33,104.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 2.5MM 13CM SMALL VALVE RADIOPAQUE FLEXOR",SUP-G11211,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR TUOHY-BORST ANL2 CURVE 55CM 6FR 2.2MM GUIDING",SUP-G29997,CDM,C1894,HCPCS,0272,RC,,,both,,,615.52,184.66,"UHC [10700]","United Healthcare",,389.62,63.3,,,,,0,71.58,523.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 150CM 4.8FR .035IN 3CM STD STRAIGHT URETERAL",SUP-M006145350190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CIGNA [10200]","Cigna Local Plus",,604.52,,,,,,,131.41,960.46,"percent of total billed charges",
"LENS IOL 0 D +23 DIOPTER +5.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT8,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"FIRST HEALTH [10303]","First Health",,276,80,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAFCILLIN 1 GRAM IV VIAL",RX-410099,CDM,J2290,HCPCS,0636,RC,25021-0139-10,NDC,both,1,UN,86.07,25.82,"BLUE CROSS [10001]","Blue Cross PPO",,2.91,,,,,,,2.91,73.16,"fee schedule",
"CMPNT FEMORAL 72.5MM KNEE LEFT POSTERIOR STABILIZE OPEN BOX",SUP-184533,CDM,C1776,HCPCS,0278,RC,,,both,,,24825.78,7447.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2941.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2887.24,21101.91,"percent of total billed charges",
"CATH ULTRAVERSE 035 GEOALIGN 130CM 100MM 7MM BALLOON",SUP-U35130710,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 3 2/3IN 21GA 18GA SONOPLEX CORNERSTONE 20GA",SUP-211285-40E,CDM,C9812,HCPCS,0272,RC,,,both,,,321.90,96.57,"PHCS [10601]",PHCS,,225.33,70,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,inpatient,,,82328.55,24698.56,"AMBETTER EXCHANGE  [11102]",Ambetter,,10268.55,,"Case rate ($10,268.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,535.04, add-ons for qualifying new technology services are included. If operating cost exceeds $42,574.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,102.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,547.65. The transfer operating threshold is the transfer adjustment factor * $9,535.04 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.90. The transfer capital threshold is the transfer adjustment factor * $720.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,48331.06,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR RMT THERMOCOOL 125CM 7FR 1-7-4MM SPACING",SUP-NR7TCSIY,CDM,C1732,HCPCS,0272,RC,,,both,,,17690.40,5307.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2057.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2057.39,15036.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER URETHRAL DOVER ULTRAMER RUBBER L16 IN OD22 FR 30 ML",SUP-1422,CDM,S27200284,LOCAL,0272,RC,,,both,,,45.33,13.6,"CIGNA [10200]",Cigna,,30.82,68,,,,,0,5.27,38.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 16CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155214180,CDM,C2617,HCPCS,0278,RC,,,both,,,1609.71,482.91,"KAISER [10500]",Kaiser,,1078.51,67,,,,,0,187.21,1368.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16.5 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150165,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"FIRST HEALTH [10303]","First Health",,276,80,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 140MM 2MM QUICK COUPLING DEPTH MARK NONSTERILE",SUP-323.062,CDM,S27000186,LOCAL,0270,RC,,,both,,,945.76,283.73,"CIGNA [10200]",Cigna,,643.12,68,,,,,0,109.99,803.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCALE SPRING C5KG 8X2X1IN .01ML",SUP-5K3582Z,CDM,S27000186,LOCAL,0270,RC,,,both,,,241.43,72.43,"CIGNA [10200]",Cigna,,164.17,68,,,,,0,28.08,205.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LIVEWIRE 115CM 4MM 6FR 1MM 2-5-2MM SPACE MEDIUM SWEEP",SUP-401600,CDM,C1730,HCPCS,0272,RC,,,both,,,2625.00,787.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,305.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 39X15MM HEDRON IA 15D 29MM STERILE LATEX FREE",SUP-1212.1215S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"AETNA [10100]","Aetna HMO/PPO",,27546.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 18CM 26MM 14.5MM 22-23MM 12-13.5MM GORE",SUP-RLT261418,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"MULTIPLAN [10600]",Multiplan,,53295,85,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 8CM 3MM GALAXY G3 MINI STRETCH",SUP-GLM930080,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"PHCS [10601]",PHCS,,8317.26,70,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 20CM 8FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251500,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,352.3,28.62,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE VENTRICULAR ASSIST TANDEMHEART PROC KIT",SUP-5710-6215,CDM,S27800098,LOCAL,0278,RC,,,both,,,60450.00,18135,"AETNA [10100]","Aetna HMO/PPO",,48057.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7030.34,51382.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X18X8MM COROENT XL+ PEEK NONSTERILE LATEX FREE",SUP-6008855,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EVOLUTPRO TRANSCATHETER AORTIC VALVE-29MM - THE 29MM EVOLTR",SUP-EVOLUTPRO-29-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"AETNA [10100]","Aetna HMO/PPO",,135945,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 18MM RETRACTA DETACHABLE .035IN",SUP-G34194,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,502.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 16MM 25MM BIOCOR FLEXFIT 25MM TISSUE ANNULUS",SUP-B100-25M-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,30744.00,9223.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12635.78,41.1,,,,,0,3575.53,26132.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 3.5MM CEREPAK XTRASOFT FREEFORM",SUP-XCR123505,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA [10200]","Cigna Open Access",,4430.66,33.5,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 2MM .064MM 115CM THIN BRISTLE INTEGRAL HANDLE",SUP-BC-205D-2010,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER MDI FLOW-VU AEROCHAMBER MAX LARGE VALVE HOLD CHMBR",SUP-80810,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.85,40.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.68,114.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Teeth 1v",PX-320000276,CDM,70300,CPT,0320,RC,,,both,,,137.00,41.1,"CIGNA [10200]","Cigna Local Plus",,17.62,,,,,,,12.6,137,"fee schedule",
"SCR BONE 1.5MM 6MM TITANIUM T4 HAND SELF TAP VARIABLE ANGLE",SUP-04.130.206,CDM,C1713,HCPCS,0278,RC,,,both,,,925.34,277.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,424.73,45.9,,,,,0,107.62,786.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 20MM 144CM 2.5MM CORONARY STENT EVEROLIMUS",SUP-H7493926120250,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2468.48,28.62,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) CATH NUVISION ICE 10FR ULTRASOUND",SUP-FG10593,CDM,C1759,HCPCS,0272,RC,,,both,,,20160.00,6048,"MULTIPLAN [10600]",Multiplan,,17136,85,,,,,0,2344.61,17136,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR STD STRAIGHT TAPER 145CM 6CM .038IN STAINLESS",SUP-G00671,CDM,C1769,HCPCS,0272,RC,,,both,,,133.81,40.14,"FIRST HEALTH [10303]","First Health",,107.05,80,,,,,0,15.56,113.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 41MM CEMENTED MEDIALIZE ATTUNE AOX KNEE",SUP-151810041,CDM,C1776,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,834.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,834.57,6099.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPN NC 15MM 4MM 35 ATM BALLOON DILATATION THIN WALL LOW",SUP-400-015-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"KAISER [10500]",Kaiser,,5547.6,67,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 50X25MM KINEX THK8MM BIOACTIVE STRIP 10CC",SUP-8115.0010S,CDM,C1713,HCPCS,0278,RC,,,both,,,10251.40,3075.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2933.95,28.62,,,,,0,1192.24,8713.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC SMALL 20IN 14-16IN KNEE T BAR CONTOUR",SUP-A142005,CDM,L1830,HCPCS,0274,RC,,,both,,,117.71,35.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,54.03,45.9,,,,,0,13.69,100.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MEMORY SHAPE 420",SUP-RSZ1305,CDM,S27200284,LOCAL,0272,RC,,,both,,,238.91,71.67,"CIGNA [10200]",Cigna,,162.46,68,,,,,0,27.79,203.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL BIPOLAR-I OD51 MM ID28 MM HIP STERILE LATEX FRE",SUP-1110951,CDM,C1776,HCPCS,0278,RC,,,both,,,2250.00,675,"CIGNA [10200]","Cigna Open Access",,1280.25,56.9,,5302.19,4377.88,6578.61,27,261.68,1912.5,"percent of total billed charges",
"SUT NDL 2.5IN KEITH 2.5 ABDOMINAL STRAIGHT TRIANGULAR POINT","SUP-1827-2 1/2D",CDM,S27200284,LOCAL,0272,RC,,,both,,,81.66,24.5,"CIGNA [10200]","Cigna Local Plus",,43.69,53.5,,,,,0,9.5,69.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER 92CM 1MM 6FR 5MM SPACE REGULAR D CURVE",SUP-D6DR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"KAISER [10500]",Kaiser,,1552.73,67,,,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM RADIUS DISTAL VOLAR 3 LEAD THREAD",SUP-131227318,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TSRH TITANIUM SPINE SHORT POST",SUP-83565401,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,299.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",299.36,2187.9,"percent of total billed charges",
"SHELL ACETABULAR 60MM HIP 3 HOLE EMPHASYS",SUP-471060300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"MULTIPLAN [10600]",Multiplan,,15261.75,85,,,,,0,2088.17,15261.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING ORTHOPEDIC 30D MEDIUM 11-13IN ARM LEFT DEROTATIONAL",SUP-11-1346-3,CDM,L3670,HCPCS,0274,RC,,,both,,,495.23,148.57,"CIGNA [10200]","Cigna Open Access",,281.79,56.9,,,,,0,57.6,420.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Paravrt Jt C/T 1 Lvl",PX-510000132,CDM,64490,CPT,0761,RC,,,both,,,6149.00,1844.7,"CIGNA [10200]","Cigna Local Plus",,2051,,"Per diem ($2,051).",,,,0,715.13,5226.65,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 20MM 6MM FASTTHREAD",SUP-AR-4020C-06,CDM,C1713,HCPCS,0272,RC,,,both,,,2323.13,696.94,"UHC [10700]","United Healthcare",,1470.54,63.3,,5023.51,2672.93,6679.78,18,954.81,1470.54,"percent of total billed charges",
"SCR BONE 7.3MM 55MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.855,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"FIRST HEALTH [10303]","First Health",,1099.53,80,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 10 79MM 13.8MM SHILEY UNCUFF REUSABLE INNER CANN",SUP-10CN10R,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.92,161.38,"MULTIPLAN [10600]",Multiplan,,457.23,85,,,,,0,62.56,457.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 110MM 2.9MM STRAIGHTSHOT STRAIGHT INFERIOR TURB",SUP-1882940HRE,CDM,S27200284,LOCAL,0272,RC,,,both,,,1720.80,516.24,"UHC [10700]","United Healthcare",,1089.27,63.3,,,,,0,200.13,1462.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPL 7F DEC 2/5 2M 115 MEDSWP",SUP-401582R,CDM,S27200284,LOCAL,0272,RC,,,both,,,2625.00,787.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,311.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ASP 130CM 20GA 1.8MM",SUP-6411,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,131.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 39MM 13MM 5.4MM 14FR ZENITH SPIRAL-Z",SUP-G55230,CDM,C1874,HCPCS,0278,RC,,,both,,,19435.50,5830.65,"PHCS [10601]",PHCS,,13604.85,70,,,,,0,2260.35,16520.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 87.5MM 4.2MM STAINLESS STEEL STERILE",SUP-180023000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"KAISER [10500]",Kaiser,,1090.76,67,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 24MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.724,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"CIGNA [10200]",Cigna,,764.07,68,,1831.33,1831.33,1831.33,16,130.68,955.09,"percent of total billed charges",
"GRAFT BONE KORE FIBER CORTICAL BONE FIBER ALLOGRAFT STRIP",SUP-423310,CDM,C1713,HCPCS,0278,RC,,,both,,,20947.50,6284.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2436.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",2436.19,17805.38,"percent of total billed charges",
"LEAD KT NEUROSTIM GAST IMP ENTERRA 35CM",SUP-435135,CDM,C1778,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 52MM 32MM XLPE HIP STERILE",SUP-71339552,CDM,C1776,HCPCS,0278,RC,,,both,,,11457.45,3437.23,"NOVANET [10819]",Novanet,,8593.09,75,,,,,0,1332.5,9738.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN LAPAROSCOPIC 100MM Z THREADED KII STERILE 5MM LATEX",SUP-CTS02,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.00,20.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.91,57.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 7.5CM 5MM LEGEND MIDAS REX SYMMETRICAL",SUP-75BA50T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1326.78,398.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,608.99,45.9,,,,,0,154.3,1127.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS PASSAGE PLASTIC GWIRE INSRT TOOL",SUP-MAP103,CDM,S27200284,LOCAL,0272,RC,,,both,,,117.89,35.37,"CIGNA [10200]","Cigna Open Access",,67.08,56.9,,,,,0,13.71,100.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM PK DIEGO STRAIGHT SINUS SERRATE",SUP-7013-8000,CDM,S27200284,LOCAL,0272,RC,,,both,,,897.05,269.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,368.69,41.1,,,,,0,104.33,762.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC MRI SURESCAN VENTRICULAR 1 CHMBR EV4 LATEX",SUP-DVEA3E4,CDM,C1722,HCPCS,0278,RC,,,both,,,118275.00,35482.5,"UHC [10700]","United Healthcare",,74868.08,63.3,,,,,0,13755.38,100533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 4.0/20",SUP-434896,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5332.64,27,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 12MM 144CM 5MM CORONARY STENT",SUP-H7493926012500,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1083.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 3.25 X 12 RX US",SUP-1804325-12,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SLIP-CATH 40CM 5FR ANGLE KMP CURVE ANGIOGRAPHIC NYLON",SUP-G11993,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE? II PRO SZ PTCA BALLOON SEMI-COMPLIANT 1.75 MM X 15",SUP-217-153-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 60MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-05067,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 16.5CM NATRELLE INSPIRA P5CM MODERATE PROFILE",SUP-MSZ-M755,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPN NC 20MM 3.5MM BALLOON DILATATION CORONARY ACCEPTS 6",SUP-350-020-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5630.4,68,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 13MM 140CM 3.5MM CORONARY STERILE LATEX",SUP-453935,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 120MM 28-14MM 13FR TRIVASCULAR OVATION PRIME",SUP-TV-IL1428120-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13356,40,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 18FR URETHRAL NATURAL RUBBER HYDROGEL",SUP-0168L18,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.78,22.73,"UHC [10700]","United Healthcare",,47.97,63.3,,,,,0,8.81,64.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL MICRO NDL STRAIGHT 4IN TUNGSTEN",SUP-E16514,CDM,S27200284,LOCAL,0272,RC,,,both,,,206.10,61.83,"CIGNA [10200]","Cigna Open Access",,117.27,56.9,,,,,0,23.97,175.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 98CM 3MM BEAD TIP DISPOSABLE RETROGRADE",SUP-27922,CDM,S27200284,LOCAL,0272,RC,,,both,,,1743.75,523.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,206.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,202.8,1482.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPIC VASCULAR 6X60X120",SUP-H74939200066020,CDM,C1725,HCPCS,0272,RC,,,both,,,4140.00,1242,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,481.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 80MM 7MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171070810,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PHCS [10601]",PHCS,,822.15,70,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPIC VASCULAR 6X60X120",SUP-H74939200066020,CDM,C1725,HCPCS,0272,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 3.8-3.4FR 6MM LOW PROFILE",SUP-H74939031604010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 22MM 3MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG30022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"AETNA [10100]","Aetna HMO/PPO",,2146.5,79.5,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AERO 20MM 63CM 12MM 16FR GEOMETRIC TRACHEOBRONCHIAL",SUP-90129-210,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"PHCS [10601]",PHCS,,12075,70,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 26MM 80CM 6MM VASCULAR COVER BALLOON EXPAND",SUP-LSMU0800626,CDM,C1874,HCPCS,0278,RC,,,both,,,26145.00,7843.5,"BLUE CROSS [10001]","Blue Cross PPO",,10248.84,39.2,,,,,0,3040.66,22223.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE RAPTOR 230CM 2.4MM SPECIMEN RETRIEVAL HYBRID JAW",SUP-00711177,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 26CM 3CM 8FR .035IN PIGTAIL",SUP-M006180243190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F HEXA 5-5-5-5-5 MPA 120CM",SUP-901130,CDM,C1730,HCPCS,0272,RC,,,both,,,1255.50,376.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 10MM CANNULATED COLLAR PIN SET CORING",SUP-AR-1224S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 40MM 7MM 8FR FLUENCY PLUS CARBON EPTFE 2",SUP-FEM07040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"FIRST HEALTH [10303]","First Health",,14616,80,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22 DIOPTER +3 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT300220,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 20MM PRESS FIT LEGION KNEE",SUP-71424053,CDM,C1776,HCPCS,0278,RC,,,both,,,12181.95,3654.58,"CIGNA [10200]","Cigna Local Plus",,3837.31,31.5,,5372.07,4581.20,7242.98,23,1416.76,10354.66,"percent of total billed charges",
"HEAD BIPOLAR 47MM 26MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-47-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"KAISER [10500]",Kaiser,,2892.91,67,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE PENCIL 10FT EDGE ACCUVAC",SUP-E2350HSNSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.17,24.35,"UHC [10700]","United Healthcare",,51.38,63.3,,,,,0,9.44,68.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN SCREW 3.2MMX89MM FLUTED DISP",SUP-GS901.089.032-4P,CDM,C1713,HCPCS,0278,RC,,,both,,,605.48,181.64,"CIGNA [10200]",Cigna,,411.73,68,,1831.33,1831.33,1831.33,16,70.42,514.66,"percent of total billed charges",
"HC Semen Analysis",PX-301000452,CDM,G0027,HCPCS,0301,RC,,,both,,,257.00,77.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,218.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 4MM APTUS TITANIUM 4 CORTICAL HEXADRIVE",SUP-A-5200.04/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT TRACTION UNIVERSAL SPRD BAR MEDIAL LATERAL STAY FULL",SUP-8140-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,205.06,61.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,24.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.85,174.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM AVENIR 10 COIL FINISH COMPLEX",SUP-10CFN-03006,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS [10001]","Blue Cross HMO",,4595.46,39.2,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 G 36MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30123607,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1192.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP ASCEND FLEX REV W PERF REV AUG BASEPLATE",SUP-CAP1133,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"PHCS [10601]",PHCS,,33957,70,,,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 32CM 10MM .021-.027IN AZUR CX HYDROCOIL",SUP-45-781032,CDM,S27800098,LOCAL,0278,RC,,,both,,,5278.50,1583.55,"PHCS [10601]",PHCS,,3694.95,70,,,,,0,613.89,4486.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 19MM 27MM 24MM HANCOCK II CINCH 35MM",SUP-T510C27,CDM,S27800098,LOCAL,0278,RC,,,both,,,21420.00,6426,"CIGNA [10200]","Cigna Local Plus",,6747.3,31.5,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII ALLOGRAFT 18MM 26MM",SUP-401318,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG REPAIR ASPIRA PLEURAL EFFUSION",SUP-4992306,CDM,S27000186,LOCAL,0270,RC,,,both,,,200.97,60.29,"AETNA [10100]","Aetna HMO/PPO",,159.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDING NONSTERILE LATEX FREE",SUP-490107,CDM,S27000186,LOCAL,0270,RC,,,both,,,348.00,104.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,41.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"14 X 11 X 6MM 7 DEGREE POROUS COATE",SUP-P21411-706,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"MULTIPLAN [10600]",Multiplan,,5676.66,85,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 26CM 6FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001274130,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 26CM 6FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49906,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"CIGNA [10200]","Cigna Open Access",,428.63,,,,,,,87.61,640.31,"percent of total billed charges",
"COIL EMBOLIZATION 20CM 14MM INTERLOCK IDC 18 COIL OCCLUSION",SUP-M001361630,CDM,S27800098,LOCAL,0278,RC,,,both,,,2079.00,623.7,"AETNA [10100]","Aetna HMO/PPO",,1652.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,241.79,1767.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM BLOCK 15MMX14MM",SUP-310114,CDM,S27800098,LOCAL,0278,RC,,,both,,,3139.50,941.85,"FIRST HEALTH [10303]","First Health",,2511.6,80,,,,,0,365.12,2668.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 4.8FR L22CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902110,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX 7CM 10FR DUODENAL BEND BILIARY PLASTIC 1",SUP-M00533000,CDM,C2617,HCPCS,0278,RC,,,both,,,447.93,134.38,"CIGNA [10200]","Cigna Local Plus",,239.64,,,,,,,52.09,380.74,"percent of total billed charges",
"INDCTR CLEANING VERIFY BASKET",SUP-U505,CDM,S27000186,LOCAL,0270,RC,,,both,,,203.86,61.16,"UHC [10700]","United Healthcare",,129.04,63.3,,,,,0,23.71,173.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE NERVE STIM RIGHT LATERAL MECHANOMYOGRAPHIC",SUP-286202208,CDM,S27000186,LOCAL,0270,RC,,,both,,,6727.50,2018.25,"CIGNA [10200]","Cigna Open Access",,3827.95,56.9,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM TRIFECTA TISSUE ANNULUS",SUP-TF-27A,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 156MM 16-10MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1610C156E,CDM,S27800098,LOCAL,0278,RC,,,both,,,38997.00,11699.1,"PHCS [10601]",PHCS,,27297.9,70,,,,,0,4535.35,33147.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SHUNT ACCU-FLO STRAIGHT CSF RADIOPAQUE CATH PLASTIC",SUP-45103,CDM,S27800098,LOCAL,0278,RC,,,both,,,755.57,226.67,"FIRST HEALTH [10303]","First Health",,604.46,80,,,,,0,87.87,642.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 13.6CM 8MM CEREPAK XL UNIFORM DETACHABLE",SUP-FCX180813,CDM,S27800098,LOCAL,0278,RC,,,both,,,15872.28,4761.68,"PHCS [10601]",PHCS,,11110.6,70,,,,,0,1845.95,13491.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 4.5 X 10 COMPLEX PICO COIL",SUP-10USC04510,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3530.39,27,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SHUNT ACCU-FLO STRAIGHT CSF RADIOPAQUE CATH PLASTIC",SUP-45103,CDM,S27800098,LOCAL,0278,RC,,,both,,,755.57,226.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,87.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.87,642.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CAPSTONE CORTICAL IMPACTED 32MMX10MM",SUP-9441032,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6900,40,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30X10X7-14MM RISE",SUP-193.103,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11651.85,41.1,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CAPSTONE CORTICAL IMPACTED 32MMX10MM",SUP-9441032,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X14X8MM ENDOSKELETON TC 6D MEDIUM TITANIUM",SUP-5166-1408-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"FIRST HEALTH [10303]","First Health",,8280,80,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X14X8MM ENDOSKELETON TC 6D MEDIUM TITANIUM",SUP-5166-1408-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS [10001]","Blue Cross HMO",,4057.2,39.2,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 22CM 150CM 5FR .038IN 3CM BLADDER LOOP",SUP-M006155221170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"MULTIPLAN [10600]",Multiplan,,1207.29,85,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28MMX10MM X-PAC LORDOTIC",SUP-EI2502L,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FREEZE DRIED DOWEL ALLOGRAFT TAPERED 13MM",SUP-400206,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"MULTIPLAN [10600]",Multiplan,,3606.98,85,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 24X10X13-9.7MM LUMINARY BULLET NOSE",SUP-15813,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"AETNA [10100]","Aetna HMO/PPO",,15025.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 30CM 150CM 8FR .035IN PIGTAIL CURVE",SUP-M006180245180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA [10200]","Cigna Open Access",,830.8,,,,,,,169.81,1241.09,"percent of total billed charges",
"COIL EMBOLIZATION 37CM 11MM AVENIR 18 COIL COMPLEX FRAME",SUP-18CFR-11037,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1549.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X18X10-17MM RISE-L 10D",SUP-193.335,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"MULTIPLAN [10600]",Multiplan,,29184.75,85,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752720,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"MULTIPLAN [10600]",Multiplan,,766.85,85,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 16MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532G116,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1352.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1327.29,9700.71,"percent of total billed charges",
"AVENIR 10, 5 X 10 COMPLEX PICO COIL",SUP-10USC05010,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"AETNA [10100]","Aetna HMO/PPO",,10395.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9CM 6MM .0135IN MICRUSFRAME MICRO COMPLEX",SUP-MFR140609,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1407.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FEMUR SHAFT 70MM",SUP-800140,CDM,S27800098,LOCAL,0278,RC,,,both,,,5602.80,1680.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2571.69,45.9,,,,,0,651.61,4762.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 5-2MM TORNADO MICROCOILS PLATINUM",SUP-G08356,CDM,S27800098,LOCAL,0278,RC,,,both,,,696.60,208.98,"NOVANET [10819]",Novanet,,522.45,75,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 4 X 10 COMPLEX FRAMING COIL",SUP-10CFR04010,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1363.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 4 X 10 COMPLEX FRAMING COIL",SUP-10CFR04010,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UHC [10700]","United Healthcare",,7420.72,63.3,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X18X10MM COROENT 10 XL PEEK",SUP-6981050,CDM,S27800098,LOCAL,0278,RC,,,both,,,23760.00,7128,"CIGNA [10200]","Cigna Open Access",,7959.6,33.5,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X9MM ADVANCED CONVEX SPINE",SUP-17809,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]","Cigna Open Access",,4711.32,56.9,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN",SUP-77819000,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 55CM 6FR .07IN LIMA CURVE GUIDING PTFE PERIPHERAL",SUP-M001196620,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,69.45,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 21MM FREESTYLE PORCINE BIOPROSTHESIS COMPLETE",SUP-995CS-21MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,38430.00,11529,"AETNA [10100]","Aetna HMO/PPO",,30551.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4469.41,32665.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT NEUROSURGICAL ULTRA SMALL 90CM CSF SNAP ASSEMB DOME",SUP-46560,CDM,S27800098,LOCAL,0278,RC,,,both,,,10727.02,3218.11,"MULTIPLAN [10600]",Multiplan,,9117.97,85,,,,,0,1247.55,9117.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 14X26X55MM",SUP-6214055,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 6FR .038IN STRAIGHT URETERAL",SUP-M006175262170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"MULTIPLAN [10600]",Multiplan,,1075.57,85,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 30CM 6FR 2.1FR POLARIS ULTRA NAUTILUS .035IN 2",SUP-M006192135050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS [10001]","Blue Cross HMO",,470.63,39.2,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION HI-FLO 130CM 2.8FR .027IN MICRO J INFUSION",SUP-M001195470,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM 40MM RUBY STD",SUP-RBY2C4060,CDM,S27800098,LOCAL,0278,RC,,,both,,,8625.00,2587.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5865,68,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 34CM 10MM AVENIR 18 COIL COMPLEX FRAME",SUP-18CFR-10034,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5230.2,40,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR CANCELLOUS CORTICAL LORDOTIC",SUP-345611,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COOK-Z 5CM 20MM 16FR TRACHEOBRONCHIAL STAINLESS STEEL",SUP-G08553,CDM,C1877,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"KAISER [10500]",Kaiser,,2799.93,67,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X9MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7209,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"NOVANET [10819]",Novanet,,5175,75,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONTOUR 150-250 2 VIALS BX/2",SUP-M0017600221,CDM,S27800098,LOCAL,0278,RC,,,both,,,1458.00,437.4,"NOVANET [10819]",Novanet,,1093.5,75,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 67MM 7MM VORTX 35 COIL PUSHABLE 5.5MM",SUP-M0013733071,CDM,S27800098,LOCAL,0278,RC,,,both,,,769.50,230.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,91.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X10MM ADVANCED PARALLEL SPINE",SUP-17610,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE LEFT MEDIAL FEMORAL CORTICAL THK3-15MM THIRD",SUP-450970,CDM,S27800098,LOCAL,0278,RC,,,both,,,5775.30,1732.59,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2650.86,45.9,,,,,0,671.67,4909.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 36MM TRICUSPID CONTOUR 3D TITANIUM",SUP-690R36,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"MULTIPLAN [10600]",Multiplan,,11143.5,85,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE SYNTHETIC 24X5MM SILASTIC SWANSON HUNTER ROD BARIUM",SUP-24270005,CDM,S27800098,LOCAL,0278,RC,,,both,,,6955.20,2086.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1990.58,28.62,,,,,0,808.89,5911.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE UNICORTICAL DOWEL ALLOGRAFT FREEZE DRIED 16-40MM",SUP-400230,CDM,S27800098,LOCAL,0278,RC,,,both,,,4413.24,1323.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,522.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,513.26,3751.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVED 94X10X3.6MM STAINLESS STEEL 3.5MM CORTICAL SCR",SUP-245.31,CDM,C1713,HCPCS,0278,RC,,,both,,,4248.47,1274.54,"CIGNA [10200]","Cigna Open Access",,2417.38,56.9,,1144.80,304.56,2275.09,66,494.1,3611.2,"percent of total billed charges",
"KIT CATH 20GA 20GA 12CM .025IN GWIRE NDL SYR DRAPE CENTRAL",SUP-AK-04550-S,CDM,C1751,HCPCS,0272,RC,,,both,,,217.50,65.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X10MM LUMINARY 10/11MM SPINE",SUP-4710,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"FIRST HEALTH [10303]","First Health",,25200,80,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Asy Hydroxychloroquine",PX-301000682,CDM,80220,CPT,0301,RC,,,both,,,163.00,48.9,"CIGNA [10200]","Cigna Open Access",,41.01,,,,,,,0.01,138.55,"fee schedule",
"GRAFT SOFT TISSUE 50CMX.49MM 18/9MM HEMAGARD 2 BRANCH",SUP-HGK1809,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUMARK PROFESSIONAL Q SHAPE 12CM",SUP-351222,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"CIGNA [10200]",Cigna,,454.14,68,,,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 58CM STREAMLINE MOND RIGHT VENTRICULAR OUTFLOW",SUP-4140/58,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"NOVANET [10819]",Novanet,,431.33,75,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +27.5 DIOPTER 13MM 5.5MM ANTERIOR CHMBR 1 PIECE",SUP-MTA4U0.275,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Open Access",,391.76,56.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONTROL CHEMISTRY 1ML LEVEL 1 ASSAYED LIQUID HUMAN WHOLE",SUP-171,CDM,C1895,HCPCS,0278,RC,,,both,,,362.79,108.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,166.52,45.9,,,,,0,42.19,308.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.210,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VIPERWIRE ADVANCE VASCULAR 335CM .014IN PERIPHERAL",SUP-VPR-GW-14,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UROLOGICAL STD 150CM 3CM .035IN LUBRIGLIDE STRAIGHT",SUP-M0066001250,CDM,C1769,HCPCS,0272,RC,,,both,,,247.43,74.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.78,210.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sars-Cov-2/2019-Ncov (Covid-19)",PX-300000409,CDM,U0002,HCPCS,0300,RC,,,both,,,315.90,94.77,"CIGNA [10200]","Cigna Open Access",,112.88,,,,,,,27.64,268.52,"fee schedule",
"GWIRE ROSEN VASCULAR J CURVE 260CM 1.5CM .035IN STAINLESS",SUP-G01253,CDM,C1769,HCPCS,0272,RC,,,both,,,252.21,75.66,"MULTIPLAN [10600]",Multiplan,,214.38,85,,,,,0,27.07,214.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Foley W/O Catheter",PX-E27000125,CDM,E27000125,LOCAL,0270,RC,,,both,,,58.30,17.49,"AETNA [10100]","Aetna HMO/PPO",,46.35,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.78,49.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +18.5 DIOPTER BICONVEX 13MM 6MM POSTERIOR CHMBR",SUP-CC60WF.185,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIAGON GUIDEWIRE 0.6MM SINGLE USE","SUP-FGW-E 01 3913",CDM,C1769,HCPCS,0272,RC,,,both,,,2062.50,618.75,"PHCS [10601]",PHCS,,1443.75,70,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI FIELDER PTCA GUIDE WIRE W/HYDROPHILIC COATING 180 CM",SUP-AGP140000,CDM,C1769,HCPCS,0272,RC,,,both,,,769.50,230.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 20MM CLEVERCUT3V PRELOAD DISTAL TIP STERILE",SUP-KD-VC611Q-07201S,CDM,C1769,HCPCS,0272,RC,,,both,,,2817.75,845.32,"UHC [10700]","United Healthcare",,1783.64,63.3,,,,,0,327.7,2395.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) GUIDEWIRE VASCULAR .014INX200CM ZOOM WIRE 14 X-SUPPOR",SUP-Z14-200-003,CDM,C1769,HCPCS,0272,RC,,,both,,,4140.00,1242,"KAISER [10500]",Kaiser,,2773.8,67,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RAMIPRIL 2.5 MG CAPSULE",RX-11260,CDM,,,0637,RC,65862-0475-01,NDC,both,1,UN,9.09,2.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6.18,68,,,,,0,1.06,7.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ARROW ADVANCER VASCULAR 26 13/16IN .035IN 1 END MARK",SUP-AW-14735,CDM,C1769,HCPCS,0272,RC,,,both,,,84.91,25.47,"MULTIPLAN [10600]",Multiplan,,72.17,85,,,,,0,9.88,72.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 16MM PERSONA 6-9 C-D KNEE RIGHT VIVACIT-E",SUP-42522600516,CDM,C1776,HCPCS,0278,RC,,,both,,,13634.40,4090.32,"NOVANET [10819]",Novanet,,10225.8,75,,,,,0,1585.68,11589.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 60CM MIC-KEY SECUR-LOK LOW PROFILE BOLUS FEED CNCT",SUP-0143-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.50,22.05,"MULTIPLAN [10600]",Multiplan,,62.48,85,,,,,0,8.55,62.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 80CM 60MM 9MM .035IN BALLOON",SUP-AB35W09060080,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"KAISER [10500]",Kaiser,,453.7,67,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +10 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000100,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +20 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR2000,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +9 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.090,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"E-CATH TRAY 18G X 4'' (100MM) INDWELLING CATHETER SONOPLEX 2",SUP-TDL135,CDM,S27200284,LOCAL,0272,RC,,,both,,,603.45,181.03,"FIRST HEALTH [10303]","First Health",,482.76,80,,,,,0,70.18,512.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP ACETABULAR 50MM CLUSTER HOLE MODULAR HIP",SUP-620205022,CDM,C1776,HCPCS,0278,RC,,,both,,,13372.20,4011.66,"UHC [10700]","United Healthcare",,8464.6,63.3,,8601.07,8395.67,8601.07,"1 through 10",1555.19,11366.37,"percent of total billed charges",
"LENS IOL 0 D +23 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.230,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SOFT TISSUE 20X15CM SOFT CONFORMABLE TRIM STRONG",SUP-1315020020,CDM,C1781,HCPCS,0278,RC,,,both,,,16008.00,4802.4,"NOVANET [10819]",Novanet,,12006,75,,,,,0,1861.73,13606.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl FB Peritoneal",PX-361000202,CDM,49402,CPT,0361,RC,,,both,,,2339.99,702,"BLUE CROSS [10001]","Blue Cross PPO",,2.34,.1,,,,,0,2.34,2339.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETER 14.5FR L40CM INSERTION L23CM POLYURETHANE DOUBL",SUP-8888145040P,CDM,C1750,HCPCS,0278,RC,,,both,,,2876.79,863.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,340.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.57,2445.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC ELATION 100CM 3CM 12-13.5-15MM PULMONARY 3",SUP-P12L30,CDM,C1726,HCPCS,0272,RC,,,both,,,2137.50,641.25,"PHCS [10601]",PHCS,,1496.25,70,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK12MM 51X74MM GALLANT HF IS-1 IS-4 DF-4 CNCT",SUP-CDHFA500Q,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"BLUE CROSS [10001]","Blue Cross PPO",,30164.4,39.2,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH 1 55CM 7FR .081IN HOCKEY STICK CURVE GUIDING PTFE",SUP-M001197000,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,245.42,41.1,,,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SILICONE 300ML BREAST RESTERILIZABLE GEL",SUP-RSZ-7300MC,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"NOVANET [10819]",Novanet,,115.67,75,,,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 6MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS06030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Local Plus",,3692.78,31.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 38MM 145CM 2.5MM CORONARY STENT",SUP-1145250-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"MULTIPLAN [10600]",Multiplan,,4962.3,85,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR IDUO IPOLY PATIENT SPECIFIC BICOMPARTMENTAL STERILE",SUP-BKA1111111,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Local Plus",,7541.1,31.5,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 33CM 5MM LYONS CORD",SUP-942005PK,CDM,S27200284,LOCAL,0272,RC,,,both,,,2466.60,739.98,"NOVANET [10819]",Novanet,,1849.95,75,,,,,0,286.87,2096.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC 3.5MM LARGE HUB STERLING GATOR 2500-6000",SUP-C9264,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II MULTIPASS 4-0 PS-2 18IN MONOFILAMENT VIOLET",SUP-Z513G,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.55,19.96,"CIGNA [10200]","Cigna Local Plus",,35.6,53.5,,,,,0,7.74,56.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3.8MM 1.6MM 7 MICRO MEDIUM",SUP-00-5091-272-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.03,41.71,"CIGNA [10200]","Cigna Open Access",,79.11,56.9,,,,,0,16.17,118.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.250,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 5CM MIDAS REX MR8 3MM BALL DISSECTING DIAMOND LP",SUP-MR8-LP05BA30D,CDM,S27200284,LOCAL,0272,RC,,,both,,,2179.13,653.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,258.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,253.43,1852.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LOOP ENDOSCOPIC MONOPOLAR CABLE ESU CNCT LINA GOLD LOOP 240",SUP-EL-240-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,2981.25,894.37,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,346.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,346.72,2534.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYPROPYLENE PROLENE 0 CTX 30IN MONOFILAMENT BLUE",SUP-8454H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD PACING 100CM 6FR BARD NBIH 1CM PROXIMAL BIPOLAR",SUP-007152P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1822.50,546.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,215.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,211.96,1549.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 8 79MM 12.2MM SHILEY UNCUFF DISPOSABLE INNER CANN",SUP-8UN85H,CDM,S27200284,LOCAL,0272,RC,,,both,,,327.56,98.27,"CIGNA [10200]","Cigna Open Access",,186.38,56.9,,,,,0,38.1,278.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 21MMX3.5MM TITANIUM STD CIRCULAR LINEAR",SUP-EEA2135,CDM,S27200284,LOCAL,0272,RC,,,both,,,1978.05,593.41,"FIRST HEALTH [10303]","First Health",,1582.44,80,,,,,0,230.05,1681.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR GUIDE SPEAR STEP DRILL TROCAR DISPOSABLE STERILE 3",SUP-AR-1934DS-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,925.34,68,,,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER QUICKPASS SUTURELASSO 25D 1.5MM CURVE RIGHT PRELOAD",SUP-AR-6068-25R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1445.85,433.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,983.18,68,,,,,0,168.15,1228.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOWL BONE CEMENT SMARTMIX CTS MIX SYSTEM LATEX FREE",SUP-540176501,CDM,S27200284,LOCAL,0272,RC,,,both,,,1762.50,528.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1198.5,68,,,,,0,204.98,1498.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 285CC",SUP-RSZ-SHPX-285S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,112.94,68,,,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 2-0 CT 36IN MONOFILAMENT ABSORBABLE",SUP-913H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"AETNA [10100]","Aetna HMO/PPO",,21.47,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 19CM 10MM AZUR CX DETACHABLE SOFT SOLID",SUP-45-751019,CDM,S27800098,LOCAL,0278,RC,,,both,,,7672.80,2301.84,"FIRST HEALTH [10303]","First Health",,6138.24,80,,,,,0,892.35,6521.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 24CM 8FR .035IN URETERAL",SUP-M006155252090,CDM,C2617,HCPCS,0278,RC,,,both,,,1362.74,408.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,625.5,45.9,,,,,0,158.49,1158.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM SOLERA SPINAL MULTIAXIAL CANNULATED",SUP-54840045545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6491.86,68,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OPEN CRANIOTOMY EXCEPT TRAUMA,EXTREME",021,APR-DRG,,,,,,,inpatient,,,363992.99,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $48,368.33. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($219,588.30) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,MODERATE",174,APR-DRG,,,,,,,inpatient,,,134039.80,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $11,825.59. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($43,600.31) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS,MAJOR",861,APR-DRG,,,,,,,inpatient,,,45383.24,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0111-0219. Covered Room Charges are equal to the number of bed days reimbursed at the following rate per revenue code per day 0111:0219@$1,488. Private Room Differential is equal to Bed Charges minus Covered Room Charges. Covered Charges are equal to Total Charges minus Private Room Differential. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 0.21. DRG Reimbursement is equal to $8,119.26. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%.",,,,0,,,other,"SOI-3 Short Stay; Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL KNEE IDENTITY IMPRINT THK8MM 4 TIBIAL INSRT POSTERIOR",SUP-TPS-030-084S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 3.7MM CANNULATED",SUP-CSS07237SQ,CDM,S27200284,LOCAL,0272,RC,,,both,,,1506.60,451.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,178.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,175.22,1280.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INJECTION 5% DEXTROSE LACTATED RINGERS USP LIFE 1000ML",SUP-792909,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.29,41.1,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 14.5IN INJECTABLE HUB WING SHAFT DISPOSABLE",SUP-MRN-420,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 22MM 10D E HIP CONSTRAIN TRIDENT",SUP-690-10-22E,CDM,C1776,HCPCS,0278,RC,,,both,,,17046.45,5113.93,"CIGNA [10200]","Cigna Local Plus",,5369.63,31.5,,5372.07,4581.20,7242.98,23,1982.5,14489.48,"percent of total billed charges",
"SHEATH AXS INFINITY LS PLUS LONG 70CM 8FR .091IN INTRO",SUP-INC-11196-70,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL INFUSION 700MM 21GA 1.9MM ECHOGENIC DIMPLED TIP STOPPING",SUP-NA-201SX-4021,CDM,S27200284,LOCAL,0272,RC,,,both,,,946.08,283.82,"CIGNA [10200]","Cigna Open Access",,538.32,56.9,,,,,0,110.03,804.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 V-7 48IN 2 ARM MONOFILAMENT BLUE",SUP-D6175,CDM,S27200284,LOCAL,0272,RC,,,both,,,720.72,216.22,"AETNA [10100]","Aetna HMO/PPO",,572.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,83.82,612.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR FL3.5 CURVE ANGIOGRAPHIC FEMORAL 2",SUP-H74916599210,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PHCS [10601]",PHCS,,53.61,70,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW CORE INTRAORAL",SUP-5400031054,CDM,S27200284,LOCAL,0272,RC,,,both,,,857.06,257.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,393.39,45.9,,,,,0,99.68,728.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE CR OXI FEMUR ALL POLY TIBIA LEGION GENESI",SUP-71701265,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"NOVANET [10819]",Novanet,,16537.5,75,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 5MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630305,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"PHCS [10601]",PHCS,,9189.08,70,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6D SMALL 66X62MM KNEE LEFT ROTATE HINGE PIN",SUP-623411L,CDM,C1776,HCPCS,0278,RC,,,both,,,30350.88,9105.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8194.74,27,,,,,0,3529.81,25798.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 NARROW KNEE LEFT CEMENTED CRUCIATE RETAINING",SUP-150400126,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"CIGNA [10200]",Cigna,,8957.34,40,,5873.17,5873.17,5873.17,"1 through 10",2604.35,19034.35,"percent of total billed charges",
"CLAREON IQ NATURAL",SUP-SY60WF,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON PANOPTIX",SUP-CNWTT0,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"CIGNA [10200]",Cigna,,588.2,68,,,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL GENESIS II 4 KNEE RIGHT CEMENTED TITANIUM",SUP-71420184,CDM,C1776,HCPCS,0278,RC,,,both,,,14593.50,4378.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1697.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1697.22,12404.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 9MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-609-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]",Cigna,,4813.44,40,,5873.17,5873.17,5873.17,"1 through 10",1399.51,10228.56,"percent of total billed charges",
"CAP CONSTRUCT TOTAL SHOULDER/ WITH AUGMENTED GLENOID","SUP-CON ANATOMIC AG",CDM,C1776,HCPCS,0278,RC,,,both,,,29925.00,8977.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11970,40,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM NEXGEN LPS-FLEX 3-4 E-F KNEE UHMWPE",SUP-00596403210,CDM,C1776,HCPCS,0278,RC,,,both,,,6291.60,1887.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,731.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,731.71,5347.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL GENESIS II 4 KNEE RIGHT CEMENTED TITANIUM",SUP-71420184,CDM,C1776,HCPCS,0278,RC,,,both,,,14593.50,4378.05,"BLUE CROSS [10001]","Blue Cross HMO",,5720.65,39.2,,5311.50,4717.44,5388.59,31,1697.22,12404.48,"percent of total billed charges",
"BASEPLT TIBIAL ATTUNE 9 KNEE CEMENTED ROTATE PLATFORM",SUP-150610009,CDM,C1776,HCPCS,0278,RC,,,both,,,16694.55,5008.36,"CIGNA [10200]",Cigna,,6677.82,40,,5873.17,5873.17,5873.17,"1 through 10",1941.58,14190.37,"percent of total billed charges",
"KIT BIOPSY 10CM 18GA BARD MARQUEE CORE DISPOSABLE",SUP-MQK1810,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"CIGNA [10200]","Cigna Local Plus",,312.01,53.5,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 15MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158104115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"MULTIPLAN [10600]",Multiplan,,9498.37,85,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKAGED RADIAL STEM 8MM X -2MM",SUP-ALN-RST-08M2,CDM,C1776,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"CIGNA [10200]","Cigna Local Plus",,4479.58,31.5,,5372.07,4581.20,7242.98,23,1653.89,12087.77,"percent of total billed charges",
"STEM EXT 110MM 16MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-1513-16-110,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"MULTIPLAN [10600]",Multiplan,,7026.27,85,,,,,0,961.36,7026.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 125MM ACCOLADE HFX 127D 4 44MM OFFSET HIP",SUP-6077-0435,CDM,C1776,HCPCS,0278,RC,,,both,,,8983.80,2695.14,"PHCS [10601]",PHCS,,6288.66,70,,,,,0,1044.82,7636.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 11MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G511,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"CIGNA [10200]","Cigna Local Plus",,5010.85,53.5,,5372.07,4581.20,7242.98,23,1089.28,7961.17,"percent of total billed charges",
"AUG FEMORAL 12MM PFC SIGMA TC3 2.5 KNEE LEFT TITANIUM COMBO",SUP-960849,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,608,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,596.72,4361.21,"percent of total billed charges",
"INSRT TIBIAL 1 11MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-111,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"KAISER [10500]",Kaiser,,6586.45,67,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 56MM 32MM MARATHON HIP",SUP-121932156,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"CIGNA [10200]","Cigna Open Access",,4615.13,56.9,,5302.19,4377.88,6578.61,27,943.3,6894.31,"percent of total billed charges",
"CMPNT GLENOID 39MM 28MM +4MM LATERALIZE GLENOSPHERE ARTHREX",SUP-AR-9564-2839-LAT,CDM,C1776,HCPCS,0278,RC,,,both,,,9763.50,2929.05,"BLUE CROSS [10001]","Blue Cross PPO",,3827.29,39.2,,3949.44,3949.44,3949.44,"1 through 10",1135.5,8298.98,"percent of total billed charges",
"STEM FEMORAL 112MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 7",SUP-71357007,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"NOVANET [10819]",Novanet,,24855.86,75,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Fetal Addl Gestation",PX-610000054,CDM,74713,CPT,0610,RC,,,both,,,1846.00,553.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($970.52). Procedures 2 - 999, Per diem ($485.26).",,,,0,,,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON MONORAIL 10CM 2.5MM BALLOON",SUP-H74939401102500,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TENDYNE MITRAL VALVE SP 33B",SUP-TENDV-SP-33B-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"PRGMR NEROSTIMLTR MYSTIM MRI TECHNOLOGY EXT",SUP-97740,CDM,C1787,HCPCS,0270,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MERCI 150CM 3-2.4FR .017IN THROMBECTOMY HYDROPHILIC 1",SUP-90044,CDM,C1887,HCPCS,0272,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH ENDO-SCRUB 2 0D 4MM ENDOSCOPIC CLEANING SINUS SET",SUP-1912030,CDM,S27200284,LOCAL,0272,RC,,,both,,,481.14,144.34,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT NEROSTIMLTR NEVRO REMOTE NONSTERILE LATEX FREE REUSABLE",SUP-PTRC1000,CDM,C1787,HCPCS,0270,RC,,,both,,,6900.00,2070,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MATRIX WOUND 3.2X2.4IN SILICONE PORCINE THERAGENESIS 2 LAYER",SUP-TG-M8260,CDM,A2008,HCPCS,0636,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH ADVANCE 35LP 80CM 14CM 5FR 3MM .035IN BALLOON",SUP-G52330,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BODY HUMERAL 17MM AEQUALIS FLEX REVIVE SHOULDER",SUP-ARS741705,CDM,C1776,HCPCS,0278,RC,,,both,,,18558.00,5567.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2199.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2158.3,15774.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE AUGMENTATION THK6MM LONG 14X25MM COTTON PRESERVE",SUP-PCOT-181406,CDM,C1776,HCPCS,0278,RC,,,both,,,8538.75,2561.62,"CIGNA [10200]","Cigna Local Plus",,4568.23,53.5,,5372.07,4581.20,7242.98,23,993.06,7257.94,"percent of total billed charges",
"STEM FEMORAL 155MM 19MM MODULAR RESTORATION HA CONICAL",SUP-6276-7-019,CDM,C1776,HCPCS,0278,RC,,,both,,,10468.22,3140.47,"UHC [10700]","United Healthcare",,6626.38,63.3,,8601.07,8395.67,8601.07,"1 through 10",1217.45,8897.99,"percent of total billed charges",
"BASEPLT GLENOID 24MM 20D OBLIQUE FULL AUG STERILE LATEX FREE",SUP-AR-9580-2420,CDM,C1776,HCPCS,0278,RC,,,both,,,11571.30,3471.39,"NOVANET [10819]",Novanet,,8678.48,75,,,,,0,1345.74,9835.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 51MM BIO-MOORE II ENDO II HIP ACETABULAR",SUP-12-139026,CDM,C1776,HCPCS,0278,RC,,,both,,,2793.00,837.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,799.36,28.62,,,,,0,324.83,2374.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 10MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-310,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"MULTIPLAN [10600]",Multiplan,,11158.16,85,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP PARTIAL ANTHOLOGY AFIT WITH OXINIUM HEAD A",SUP-71703320,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"PHCS [10601]",PHCS,,16758,70,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20 DIOPTER +1.5 CYL HAPTIC C BICONVEX 13MM 6MM",SUP-ZXT150U200,CDM,V2788,HCPCS,0276,RC,,,both,,,834.00,250.2,"NOVANET [10819]",Novanet,,625.5,75,,,,,0,96.99,708.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 60MM 10MM PRESS FIT REMOVABLE TRUNION SUT HOLE",SUP-AR-9100-10S,CDM,C1776,HCPCS,0278,RC,,,both,,,10713.60,3214.08,"CIGNA [10200]","Cigna Open Access",,6096.04,56.9,,5302.19,4377.88,6578.61,27,1245.99,9106.56,"percent of total billed charges",
"CMPNT FEMORAL 9 NARROW KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502006602,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS [10001]","Blue Cross HMO",,8962.18,39.2,,5311.50,4717.44,5388.59,31,2658.93,19433.3,"percent of total billed charges",
"INSRT ACETABULAR 36MM 10D G HIP X3 TRIDENT",SUP-723-10-36G,CDM,C1776,HCPCS,0278,RC,,,both,,,9332.25,2799.67,"BLUE CROSS [10001]","Blue Cross HMO",,3658.24,39.2,,5311.50,4717.44,5388.59,31,1085.34,7932.41,"percent of total billed charges",
"STEM HUMERAL 170MM PERFORM 13 LONG SHOULDER STERILE LATEX",SUP-PFX13170,CDM,C1776,HCPCS,0278,RC,,,both,,,42493.50,12748.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11473.25,27,,,,,0,4941.99,36119.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP BIOLOX DELTA HEAD WITH R3 XLPE LINER",SUP-71703605,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]",Cigna,,9576,40,,5873.17,5873.17,5873.17,"1 through 10",2784.22,20349,"percent of total billed charges",
"STEM FEMORAL 160MM 13.5MM CEMENTLESS MODULAR AML POROUS 45MM",SUP-155402135,CDM,C1776,HCPCS,0278,RC,,,both,,,15374.88,4612.46,"UHC [10700]","United Healthcare",,9732.3,63.3,,8601.07,8395.67,8601.07,"1 through 10",1788.1,13068.65,"percent of total billed charges",
"STEM FEMORAL 129MM 15MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-771101500,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"MULTIPLAN [10600]",Multiplan,,17764.68,85,,,,,0,2430.63,17764.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 53MM 26MM UHR UNIVERSAL ACETABULAR HIP COCR",SUP-UH1-53-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"FIRST HEALTH [10303]","First Health",,3454.22,80,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRUMATCH PIN GUIDES UPCHARGE",SUP-CAP-DS-UP-1,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAS 54850016545 4.75 EXT TAB CANN 6.5X45",SUP-54850016545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4382,45.9,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 6MM GORE PROPATEN EPTFE HEPARIN THIN",SUP-HT066080A,CDM,C1768,HCPCS,0278,RC,,,both,,,18011.70,5403.51,"NOVANET [10819]",Novanet,,13508.78,75,,,,,0,2094.76,15309.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Flow Cytometry Tc Add Marker",PX-311000021,CDM,88185,CPT,0311,RC,,,both,,,199.50,59.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.63,,"Fee schedule rate ($26.63). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,169.58,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 40CM 22/11MM BIFURCATED KNITTED SOFT",SUP-M002020852210,CDM,C1768,HCPCS,0278,RC,,,both,,,4673.51,1402.05,"BLUE CROSS [10001]","Blue Cross PPO",,1832.02,39.2,,,,,0,543.53,3972.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 45CM 4-7MM STD WALLED STEPPED TAPER",SUP-22703,CDM,C1768,HCPCS,0278,RC,,,both,,,2447.18,734.15,"CIGNA [10200]","Cigna Local Plus",,1309.24,53.5,,,,,0,284.61,2080.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Evasc Stnt Rpr Thrc/Aa X Crsg Br",PX-481000136,CDM,33895,CPT,0481,RC,,,both,,,45298.00,13589.4,"MULTIPLAN [10600]",Multiplan,,38503.3,85,,,,,0,2491,38503.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BROVIAC PEEL-APART SURECUFF 90CM 6.6FR 2.2MM 1MM 2",SUP-0600540,CDM,C1751,HCPCS,0272,RC,,,both,,,988.20,296.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,117.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl/Bivalv Cast Arm/Leg",PX-450000208,CDM,29705,CPT,0361,RC,,,both,,,1142.16,342.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1142.16,,"Case rate ($7,066). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,132.83,1142.16,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Stereo Body Rad Ther 1+ Lesion",PX-333000055,CDM,77373,CPT,0333,RC,,,both,,,23438.21,7031.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2725.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,408.8,20711,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE 1 - VITAMIN E POLY LINERS/INSERTS",SUP-CAP-U-E-PLUS,CDM,C1776,HCPCS,0278,RC,,,both,,,1875.00,562.5,"BLUE CROSS [10001]","Blue Cross PPO",,735,39.2,,3949.44,3949.44,3949.44,"1 through 10",218.06,1593.75,"percent of total billed charges",
"HEAD FEMORAL +0MM 28MM HIP BIOLOX DELTA V40",SUP-6570-0-128,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA [10200]","Cigna Local Plus",,5350,53.5,,5372.07,4581.20,7242.98,23,1163,8500,"percent of total billed charges",
"LINER ACETABULAR G7 F NEUTRAL 40MM E1 HIP",SUP-010000864,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"KAISER [10500]",Kaiser,,6868.85,67,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 25MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-825,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1594.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1565.22,11439.68,"percent of total billed charges",
"SLEEVE CENTERING V40 2.5MM UNIVERSAL KNEE ADPTR",SUP-6519-T-025,CDM,C1776,HCPCS,0278,RC,,,both,,,1000.82,300.25,"BLUE CROSS [10001]","Blue Cross PPO",,392.32,39.2,,3949.44,3949.44,3949.44,"1 through 10",116.4,850.7,"percent of total billed charges",
"TACTIFLEX SE BID CURVE D-F",SUP-A-TFSE-DF,CDM,C2630,HCPCS,0272,RC,,,both,,,23940.00,7182,"NOVANET [10819]",Novanet,,17955,75,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL C-STEM AMT 5 12/14 STANDARD OFFSET TAPER L124 M",SUP-157004110,CDM,C1776,HCPCS,0278,RC,,,both,,,20317.50,6095.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2407.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2362.93,17269.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 CURVE PLUS 8MM KNEE XLK FIX BEARING SIGMA",SUP-970430,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"MULTIPLAN [10600]",Multiplan,,9498.37,85,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 8MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158121108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1324.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 10 NARROW KNEE LEFT CRUCIATE RETAIN CEMENT",SUP-42502006801,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"BLUE CROSS [10001]","Blue Cross HMO",,8962.18,39.2,,5311.50,4717.44,5388.59,31,2658.93,19433.3,"percent of total billed charges",
"INSRT TIBIAL STD 15MM KNEE GVF ROTATE PLATFORM LCS COMPLETE",SUP-129405415,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1145.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1123.86,8213.93,"percent of total billed charges",
"STENT INNOVA 20MM 130CM 7MM VASCULAR SELF EXPAND RADIOPAQUE",SUP-H74939293070230,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2216.97,45.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSELECT PLUS DEMINERALIZED BONE MATRIX 5CC",SUP-359450,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,511.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",501.54,3665.63,"percent of total billed charges",
"CATH NC EUPHORA 142CM 27MM 3.75MM BALLOON DILATATION",SUP-NCEUP37527X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.4MM 170MM KIRSCHNER 6.5MM HEADLESS",SUP-AR-8610K-65,CDM,C1713,HCPCS,0278,RC,,,both,,,130.50,39.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,15.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",15.18,110.93,"percent of total billed charges",
"CATH EVD 33CM 1.5FR EXTERNAL DRNG CSF VENTRICULAR HERMETIC",SUP-50318,CDM,C1729,HCPCS,0272,RC,,,both,,,2604.38,781.31,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1070.4,41.1,,,,,0,302.89,2213.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL SYMBOTEX 3.3X2.3MM 12CM 2 SIDE COMPOSITE",SUP-SYM12,CDM,C1781,HCPCS,0278,RC,,,both,,,3229.65,968.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,382.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,375.61,2745.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 60MM 40CM 8MM 6FR BILIARY NITINOL SELF",SUP-G31495,CDM,C1876,HCPCS,0278,RC,,,both,,,4588.50,1376.55,"FIRST HEALTH [10303]","First Health",,3670.8,80,,,,,0,533.64,3900.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD MONOPOLAR 36CM OPTI2 CURVED SPAT TIP LAPAROSCOPIC",SUP-E2771-36,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.69,101.91,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.51,288.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 98MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT",SUP-224.551,CDM,C1713,HCPCS,0278,RC,,,both,,,2116.80,635.04,"BLUE CROSS [10001]","Blue Cross PPO",,829.79,39.2,,957.42,570.23,957.42,28,246.18,1799.28,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 18CM 150CM 5FR .038IN 3CM BLADDER LOOP",SUP-M006155215170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"NOVANET [10819]",Novanet,,1065.26,75,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER 13CM 3.8MM COOLCUT BONE CUTTING",SUP-AR-8380BC,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"CIGNA [10200]","Cigna Local Plus",,300.31,53.5,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPT CATH URETH 2IN LF",SUP-UCA5-95,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.50,56.55,"AETNA [10100]","Aetna HMO/PPO",,149.86,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.92,160.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM WIDE BLADE RAMP 5.5MM",SUP-7541133,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,3978.14,359.25,3978.14,24,348.9,2550,"percent of total billed charges",
"CAGE SPINAL XLIF 10MM X 18MM X 55MM 10 DEGREE LORDOTIC TITAN",SUP-1181055P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8113.77,28.62,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH GREEN 24CM 12FR MAHURKAR ELITE POLYURETHANE 2",SUP-8888221324,CDM,C1752,HCPCS,0272,RC,,,both,,,860.01,258,"UHC [10700]","United Healthcare",,544.39,63.3,,,,,0,100.02,731.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL STEALTH 11MM 11MM VASCULAR SOFT WHITE",SUP-G-1100,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"AETNA [10100]","Aetna HMO/PPO",,124.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC 7.5MM MODIFIED ELLIPSE 44.5X47MM INGENIO",SUP-K173,CDM,C1785,HCPCS,0275,RC,,,both,,,17250.00,5175,"MULTIPLAN [10600]",Multiplan,,14662.5,85,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPT CATH URETH 2IN LF",SUP-UCA5-95,CDM,S27200284,LOCAL,0272,RC,,,both,,,188.50,56.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,128.18,68,,,,,0,21.92,160.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILFRM URETHRAL 13IN 6FR SPIRAL PLASTIC STERILE LATEX FREE",SUP-343106,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.14,31.84,"AETNA [10100]","Aetna HMO/PPO",,84.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.34,90.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +21 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.210,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 4.0 MM X 150 MM X 130 CM",SUP-IPU04015013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"UHC [10700]","United Healthcare",,5110.21,63.3,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 86CM 3.9-5.2FR 2.6FR 6CM 20.5-7.5-7.5MM SPACE",SUP-4674,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"MULTIPLAN [10600]",Multiplan,,4765.95,85,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 445CC NATRELLE INSPIRA COHESIVE STERILE LATEX",SUP-SCM-445,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,878.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 80CM 4CM 7MM BALLOON",SUP-G52352,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 80MM 120CM 7MM 8FR STRAIGHT VASCULAR",SUP-AVSL07080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"KAISER [10500]",Kaiser,,12240.9,67,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX 40MM 135CM 8MM VASCULAR NITINOL CAROTID",SUP-PC0840RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"BLUE CROSS [10001]","Blue Cross HMO",,2975.28,39.2,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARM RTRCTR 16.75IN LEYLA FLEXIBLE SNAKE SELF RETAIN",SUP-R2400,CDM,S27200284,LOCAL,0272,RC,,,both,,,5653.10,1695.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,669.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,657.46,4805.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 11MM HELIX R SPINE SELF TAP FIX ANGLE",SUP-7806211,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA [10200]","Cigna Local Plus",,541.69,53.5,,3978.14,359.25,3978.14,24,117.75,860.63,"percent of total billed charges",
"CATH SAPPHIRE NC PLUS 15MM 2.5MM BALLOON DILATATION STERILE",SUP-225-153-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 212MM 40MM 24FR VALIANT CAPTIVIA SINUSOIDAL",SUP-VAMF4040C200TU,CDM,C1874,HCPCS,0278,RC,,,both,,,102229.50,30668.85,"MULTIPLAN [10600]",Multiplan,,86895.08,85,,,,,0,11889.29,86895.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE OPHTHALMIC .9MM ALCON FMS ABS INTREPID 45D BALANCE",SUP-8065752918,CDM,S27200284,LOCAL,0272,RC,,,both,,,833.00,249.9,"AETNA [10100]","Aetna HMO/PPO",,662.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,96.88,708.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 99MM STAINLESS STEEL 2.7/3.5MM SCR 5 HOLE LCP BONE",SUP-02.112.140,CDM,C1713,HCPCS,0278,RC,,,both,,,3076.50,922.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,364.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,357.8,2615.03,"percent of total billed charges",
"SPACER SPINAL 26X10X7-14MM RISE",SUP-193.102,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUITY WHISPER VIEW EDS - EACH",SUP-664647-001,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,771.12,68,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL CERVICAL 8X14X12MM 7DEG LORDOTIC PEEK COHERE",SUP-4081427P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"NOVANET [10819]",Novanet,,4657.5,75,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) FLOW REVERSER (42MM) INTPDDS42A",SUP-INTPDDS42A,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 20MM 5.5MM SPINE LATERAL TITANIUM FIX OPEN",SUP-179793020,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1635.19,45.9,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17.5 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6",SUP-ZCT225175,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"BLUE CROSS [10001]","Blue Cross HMO",,135.24,39.2,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3.8MM 2.9MM MATCH HEAD",SUP-KM-AM8U,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Ext Vein Uni",PX-921000012,CDM,93971,CPT,0921,RC,,,both,,,1421.25,426.37,"FIRST HEALTH [10303]","First Health",,1137,80,,,,,0,165.29,1208.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 26CM 3CM 8FR .035IN PIGTAIL CURVE",SUP-M006180243170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]",Cigna,,860.46,68,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-5 TH-26 36IN 2 ARM MONOFILAMENT WHITE",SUP-5N20B,CDM,S27200284,LOCAL,0272,RC,,,both,,,233.69,70.11,"PHCS [10601]",PHCS,,163.58,70,,,,,0,27.18,198.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 90CM 4MM 8FR 2-5-2MM SPACE D CURVE",SUP-D8BRDL252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,5326.80,1598.04,"AETNA [10100]","Aetna HMO/PPO",,4234.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,619.51,4527.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9.5FR .125IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLSX-1009.5,CDM,C1892,HCPCS,0272,RC,,,both,,,304.50,91.35,"UHC [10700]","United Healthcare",,192.75,63.3,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TNLR SURGICAL BULLET TIP 8MM",SUP-BTT08,CDM,S27200284,LOCAL,0272,RC,,,both,,,785.70,235.71,"KAISER [10500]",Kaiser,,526.42,67,,,,,0,91.38,667.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla Class I & II Ab Qual",PX-302000220,CDM,86828,CPT,0302,RC,,,both,,,929.10,278.73,"PHCS [10601]",PHCS,,650.37,70,,,,,0,57.17,789.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis B Surface Antigen (Hbsag) Neutralization",PX-306000194,CDM,87341,CPT,0306,RC,,,both,,,250.80,75.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7,,,,,,,0.01,213.18,"fee schedule",
"LENS IOL 0 D +21 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.210,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 4CM 6MM BALLOON DILATATION",SUP-DR13564,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UHC [10700]","United Healthcare",,871.64,63.3,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT PATIENT L15FT 22MM WITHOUT PEEP DISPOSABLE",SUP-29665-001,CDM,S27000186,LOCAL,0270,RC,,,both,,,219.36,65.81,"KAISER [10500]",Kaiser,,146.97,67,,,,,0,25.51,186.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intro Ndl/Cath Ext Arty",PX-361000076,CDM,36140,CPT,0361,RC,,,both,,,2075.76,622.73,"MULTIPLAN [10600]",Multiplan,,1764.4,85,,,,,0,241.41,2075.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 58CM 7FR DURATA ENDOCARDIUM OPTIM TRUE BIPOLAR",SUP-7121Q/58,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4914.63,28.62,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 13MM TITANIUM T4 HAND SELF TAP VARIABLE ANGLE",SUP-04.130.213,CDM,C1713,HCPCS,0278,RC,,,both,,,925.34,277.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,424.73,45.9,,,,,0,107.62,786.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ELECTROPHYSIOLOGY 6FR L120CM 5MM SPACING 1.5MM PROX",SUP-H301200624S1,CDM,C1730,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 13MM 12FR ENDOPROSTHESIS HEPARIN",SUP-VBH130502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18062.10,5418.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2100.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM YUKON SPINE OCCIPITOCERVICOTHORACIC",SUP-7601-03514,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,1144.80,304.56,2275.09,66,441.36,3225.75,"percent of total billed charges",
"NEROSTIMLTR IMPLANTABLE INTERSTIM MICRO SURESCAN RECHARGABLE",SUP-97810,CDM,C1820,HCPCS,0278,RC,,,both,,,60662.70,18198.81,"MULTIPLAN [10600]",Multiplan,,51563.3,85,,,,,0,7055.07,51563.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 24MM FUSION ACUTRAK 2.4MM 24MM SCR",SUP-ATF-024,CDM,S27200284,LOCAL,0272,RC,,,both,,,1657.50,497.25,"CIGNA [10200]","Cigna Open Access",,943.12,56.9,,,,,0,192.77,1408.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.66-10MM 360MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED",SUP-04.037.056S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"KAISER [10500]",Kaiser,,8320.29,67,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 60MM 157CM 12MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200126020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Gastric Band Adjustment",PX-361000268,CDM,S2083,HCPCS,0361,RC,,,both,,,899.29,269.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,611.52,68,,,,,0,104.59,764.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR IMC CURVE ANGIOGRAPHIC TRILON BRACHIAL",SUP-H749085262032,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PHCS [10601]",PHCS,,53.61,70,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 CTX 36IN BRAID ANTIBACTERIAL COATED UNDYED",SUP-VCP978H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2 LR 20IN MONOFILAMENT 3 STRAND BLUE",SUP-3846T,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.63,32.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.75,93.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CEREBROVASCULAR DISORDERS WITH CC",071,MS-DRG,,,,,,,inpatient,,,34850.13,10455.04,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,16631.46,,"Fee schedule rate ($16,631.46). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,6364.34,25587.41,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP SMALL 9IN TITANIUM ENDOSCOPIC LIGATING",SUP-133650,CDM,S27200284,LOCAL,0272,RC,,,both,,,379.23,113.77,"NOVANET [10819]",Novanet,,284.42,75,,,,,0,44.1,322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT VERTECEM II POWDER MONOMER GLASS AMPOULE",SUP-08.702.017S,CDM,C1713,HCPCS,0278,RC,,,both,,,1650.00,495,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1122,68,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON MULTIPASS 4-0 PS-4 18IN MONOFILAMENT PLIABILIZE",SUP-1662G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.69,41.1,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL HEAD SHORT DHS NONSTERILE",SUP-338.44,CDM,S27200284,LOCAL,0272,RC,,,both,,,6520.50,1956.15,"AETNA [10100]","Aetna HMO/PPO",,5183.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,758.33,5542.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MAGNIFUSE II DEMINERALIZED BONE MATRIX",SUP-7509505,CDM,S27800098,LOCAL,0278,RC,,,both,,,16715.25,5014.57,"BLUE CROSS [10001]","Blue Cross PPO",,6552.38,39.2,,,,,0,1943.98,14207.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +28 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.280,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 20MM 2.5MM RECTANGLE HELIX BALLOON",SUP-2039-2520,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2410.52,41.1,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 50MM 12.6MM 7.6MM CUFFLESS INNER CANN LOW PROFILE ROUND",SUP-8LGT,CDM,S27200284,LOCAL,0272,RC,,,both,,,346.09,103.83,"PHCS [10601]",PHCS,,242.26,70,,,,,0,40.25,294.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 11MM KNEE POSTERIOR STABILIZE UHMWPE",SUP-71420832,CDM,C1776,HCPCS,0278,RC,,,both,,,9998.10,2999.43,"NOVANET [10819]",Novanet,,7498.58,75,,,,,0,1162.78,8498.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 14MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650514,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]","Cigna Open Access",,4397.63,33.5,,5302.19,4377.88,6578.61,27,1526.7,11158.16,"percent of total billed charges",
"CATH SHERPA NX BALANCED 55CM 6FR RDND1 CURVE GUIDING HDPE",SUP-SB6RDND1K,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC TREK NEO 145CM 6MM 3.25MM BALLOON DILATATION PEBAX",SUP-1400325-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,inpatient,,,154147.97,46244.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,,68,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myelin Basic Protein CSF",PX-301000317,CDM,83873,CPT,0301,RC,,,both,,,478.40,143.52,"CIGNA [10200]",Cigna,,37.84,,,,,,,0.01,406.64,"fee schedule",
"OCCL CARDIOVASCULAR 80CM 44MM 10-14FR SEPTAL CATH GORE 23-30",SUP-ASD44A,CDM,C1817,HCPCS,0278,RC,,,both,,,54495.00,16348.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,21798,40,,,,,0,6337.77,46320.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIPERACILLIN-TAZOBACTAM 3.375 G VIAL",RX-18303,CDM,J2543,HCPCS,0636,RC,55150-0120-30,NDC,both,1,UN,49.83,14.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.84,,"Fee schedule rate ($3.84). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $7,524.08, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",22.30,22.30,22.30,12,3.74,42.36,"fee schedule",
"HANDLE PADDLE INTERNAL WITH DISCHARGE CONTROL LIFEPAK 15",SUP-11131-000001,CDM,S27200284,LOCAL,0272,RC,,,both,,,9846.30,2953.89,"CIGNA [10200]","Cigna Local Plus",,5267.77,53.5,,,,,0,1145.12,8369.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE POLY L LACTIC ACID 28MM 6.5MM 8MM DELTA",SUP-AR-5028B-08,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,3978.14,359.25,3978.14,24,189.34,1383.8,"percent of total billed charges",
"TUBE JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE MIC-KEY",SUP-0270-18-2.7-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,306.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 42MM AEQUALIS PERFORM +3MM SHOULDER",SUP-DWJ024,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4877.2,40,,,,,0,1418.05,10364.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 40MM 125CM 8MM 5FR .018IN VASCULAR NITINOL",SUP-G43781,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"KAISER [10500]",Kaiser,,2799.93,67,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 5-0 TF 24IN 2 ARM MONOFILAMENT BLUE",SUP-8205H,CDM,S27200284,LOCAL,0272,RC,,,both,,,110.60,33.18,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,75.21,68,,,,,0,12.86,94.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 41MM PERSONA ALL POLY KNEE STERILE LATEX FREE",SUP-42540000041,CDM,C1776,HCPCS,0278,RC,,,both,,,4667.16,1400.15,"NOVANET [10819]",Novanet,,3500.37,75,,,,,0,542.79,3967.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 80MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,589.25,41.1,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 22X9X11MM 12D EIT PLIF STERILE LATEX FREE",SUP-PUI31102,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7654.5,27,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES",212,MS-DRG,,,,,,,inpatient,,,544847.10,163454.13,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,137347.21,,"Case rate ($67,452.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $62,634.41, add-ons for qualifying new technology services are included. If operating cost exceeds $95,674.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $6,117.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $62,717.24. The transfer operating threshold is the transfer adjustment factor * $62,634.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,735.47. The transfer capital threshold is the transfer adjustment factor * $4,735.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,67452.71,317480.22,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM 9FR ENDOCARDIUM 2 COIL ACTIVE FIXATION",SUP-0185,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"MULTIPLAN [10600]",Multiplan,,14596.2,85,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLAMMATORY BOWEL DISEASE WITH CC",386,MS-DRG,,,,,,,inpatient,,,34543.87,10363.16,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,12331.33,,"Case rate ($6,056.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,623.45, add-ons for qualifying new technology services are included. If operating cost exceeds $38,663.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,807.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $5,630.89. The transfer operating threshold is the transfer adjustment factor * $5,623.45 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.16. The transfer capital threshold is the transfer adjustment factor * $425.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,6056.05,24347.95,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 6X4IN RIGHT HERNIA 3D LIGHTWEIGHT",SUP-TECT1510ADPR,CDM,C1781,HCPCS,0278,RC,,,both,,,1047.00,314.1,"CIGNA [10200]",Cigna,,711.96,68,,,,,0,121.77,889.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 30MM 4MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012278-30,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SUTURETAPE 1.7MM BLACK WHITE NONABSORBABLE",SUP-AR-7511T,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Open Access",,247.52,56.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MINI STRAIGHT 1MM MANDIBLE 16 HOLE 2/2.3MM SCR BONE",SUP-55-10516,CDM,C1713,HCPCS,0278,RC,,,both,,,1289.68,386.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,876.98,68,,,,,0,149.99,1096.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Grft T/a/L >= 100scm Ea Adl 100sq Cm",PX-510000053,CDM,15274,CPT,0761,RC,,,both,,,670.00,201,"CIGNA [10200]",Cigna,,670,,"Per diem ($2,606).",,,,0,77.92,670,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 26CM 7FR URETERAL",SUP-M0061456200,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"CIGNA [10200]","Cigna Open Access",,355.76,,,,,,,72.72,531.45,"percent of total billed charges",
"SUT SUTURETAPE 1.7MM BLACK WHITE NONABSORBABLE",SUP-AR-7511T,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL2714,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"FIRST HEALTH [10303]","First Health",,1198.8,80,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL 3.5MM CANNULATED IOL",SUP-DRLL-CDC-35,CDM,S27000186,LOCAL,0270,RC,,,both,,,2362.50,708.75,"FIRST HEALTH [10303]","First Health",,1890,80,,,,,0,274.76,2008.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 20MM 80CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-G43844,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"AMERIGROUP MEDICAID [20100]",Amerigroup,,447.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 2.5MM CEREPAK XTRASOFT FREEFORM",SUP-XCR122505,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"KAISER [10500]",Kaiser,,8861.32,67,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,inpatient,,,36356.65,10906.99,"CIGNA [10200]",Cigna,,14983.08,,"Fee schedule rate ($14,983.08). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,7088.24,28497.8,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCADIA? VERTEBRAL AUGMENTATION BALLOONS STRAIGHTBALLOON CAT",SUP-ARC20ST-LK,CDM,S27200284,LOCAL,0272,RC,,,both,,,17640.00,5292,"UHC [10700]","United Healthcare",,11166.12,63.3,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +10.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.105,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,396.9,39.2,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC FIXATION 15MM 7MM BICEPTOR BIOSURE SCR",SUP-72202299,CDM,C1713,HCPCS,0278,RC,,,both,,,2895.75,868.72,"CIGNA [10200]",Cigna,,1969.11,68,,1831.33,1831.33,1831.33,16,336.78,2461.39,"percent of total billed charges",
"SNARE 10MM ROUND 240CM 2.4MM CAPTIVATOR COLD THIN WIRE",SUP-M00561103,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.10,33.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,51.91,45.9,,,,,0,13.15,96.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL YELLOW .8MM OTO-FLEX CARBIDE MALLEABLE",SUP-3155638,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 3MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035423060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1672.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUTTY PROGENIX DBM 1ML",SUP-005001,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",117.75,860.63,"percent of total billed charges",
"HC Ins Picc With S&I < 5 Yr",PX-361000485,CDM,36572,CPT,0361,RC,,,both,,,5574.10,1672.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,660.53,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.57,4737.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 8CM 180CM 18MM 10.5FR ESOPHAGEAL",SUP-G57310,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"UHC [10700]","United Healthcare",,11134.22,63.3,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Calcitonin",PX-301000122,CDM,82308,CPT,0301,RC,,,both,,,328.70,98.61,"AETNA [10100]","Aetna HMO/PPO",,261.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,279.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Iadna Borrelia Miyamotoi Amp Prb",PX-306000249,CDM,87478,CPT,0306,RC,,,both,,,784.00,235.2,"CIGNA [10200]",Cigna,,77.2,,,,,,,0.01,666.4,"fee schedule",
"NDL TRANSSEPTAL 98CM 86D",SUP-FND01906,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 20MM QUICKFIX TITANIUM T10 PARTIAL THREAD",SUP-AR-8730-20PT,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 80CM 20MM 6MM BALLOON DILATATION PEBAX NYLON",SUP-48006002N,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"NOVANET [10819]",Novanet,,644.26,75,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 58MM 36MM ALTRX HIP",SUP-122136158,CDM,C1776,HCPCS,0278,RC,,,both,,,6814.08,2044.22,"PHCS [10601]",PHCS,,4769.86,70,,,,,0,792.48,5791.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 4.5MM CANNULATED",SUP-AR-1204.5L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1564.92,469.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,185.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,182,1330.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"**DO NOT REUSE ITEM # - PS GO LIVE ISSUE**ELECTRD DEFIB RESU",SUP-8900-0214-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,585.23,175.57,"AETNA [10100]","Aetna HMO/PPO",,465.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.06,497.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HRA HUMERAL RESURFACING",SUP-71701416,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,5302.19,4377.88,6578.61,27,3297.11,24097.5,"percent of total billed charges",
"LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION",RX-96972,CDM,C9254,HCPCS,0636,RC,00131-1810-67,NDC,both,20,ML,922.89,276.87,"NOVANET [10819]",Novanet,,692.17,75,,,,,0,46.62,784.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.170,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 2IN 19GA 21GA EPILONG TUOHY .2UM METAL PLASTIC",SUP-0131153-51,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.70,80.91,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,31.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.37,229.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM DCP LC-DCP STAINLESS STEEL PROXIMAL",SUP-204.216,CDM,C1713,HCPCS,0278,RC,,,both,,,117.28,35.18,"CIGNA [10200]","Cigna Local Plus",,62.74,53.5,,3978.14,359.25,3978.14,24,13.64,99.69,"percent of total billed charges",
"TUBE JEJUNOSTOMY 16FR SILICONE STD J MIC SECUR-LOK TRIMMABLE",SUP-0200-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"NOVANET [10819]",Novanet,,824.69,75,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 30MM 9.5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ230,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6139.04,68,,,,,0,1049.96,7673.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ca Ionized POC",PX-301000125,CDM,82330,CPT,0301,RC,,,both,,,202.95,60.88,"FIRST HEALTH [10303]","First Health",,162.36,80,,,,,0,0.2,172.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNAP(R) CARTRIDGE - 125 MM HG - 10 IN A CASE",SUP-SNPA125,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH HYPERFORM 150CM 7MM 2.5-2.8FR 4MM .01IN 2MM BALLOON",SUP-104-4470,CDM,C1725,HCPCS,0272,RC,,,both,,,10425.90,3127.77,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BAG IV 5000ML TOTAL PARENTAL NUTRITION LARGE BORE THREAD",SUP-H938743,CDM,S27200284,LOCAL,0272,RC,,,both,,,140.85,42.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ARTHROSCOPIC GRAFT PROTECTION SCR SEAL CLEAR-TRAC",SUP-7207227,CDM,S27200284,LOCAL,0272,RC,,,both,,,208.80,62.64,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC CT Guide Ndl Plc",PX-350000004,CDM,77012,CPT,0352,RC,,,both,,,2394.19,718.26,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,278.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.67,2035.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Guide Ndl Plc",PX-350000004,CDM,77012,CPT,0352,RC,,,both,,,2394.19,718.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,405,,"Per diem ($405). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,162.67,2035.06,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Guide Ndl Plc",PX-350000004,CDM,77012,CPT,0352,RC,,,both,,,2394.19,718.26,"BLUE CROSS [10001]","Blue Cross HMO",,234.22,,"Fee schedule rate ($234.22).",,,,0,162.67,2035.06,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immunoassy Infect Ab Qual/Sq",PX-302000065,CDM,86318,CPT,0302,RC,,,both,,,261.00,78.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,52.02,,,,,,,0.26,221.85,"fee schedule",
"HC Venous Sampling Add Si",PX-323000034,CDM,75893,CPT,0320,RC,,,both,,,6056.28,1816.88,"MULTIPLAN [10600]",Multiplan,,5147.84,85,,,,,0,125.43,6056.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acc Av Grft W Stent Periph",PX-361000436,CDM,36903,CPT,0361,RC,,,both,,,35030.85,10509.25,"FIRST HEALTH [10303]","First Health",,28024.68,80,,,,,0,4074.09,29776.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acc Av Grft W Stent Periph",PX-361000436,CDM,36903,CPT,0361,RC,,,both,,,35030.85,10509.25,"BLUE CROSS [10001]","Blue Cross HMO",,8667.44,,"Case rate ($8,667.44). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,4074.09,29776.22,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 25MM ATLANTIS VISION ELITE BONE ANTERIOR CERVICAL",SUP-7200025,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"AETNA [10100]","Aetna HMO/PPO",,3339,79.5,,1521.93,481.35,16760.95,30,488.46,3570,"percent of total billed charges",
"COIL EMBOLIZATION 4CM 1.5MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-1.5-4-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"NOVANET [10819]",Novanet,,8771.63,75,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Breast W Cntrst Bi",PX-610000062,CDM,77049,CPT,0610,RC,,,both,,,5027.00,1508.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,584.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,584.64,4272.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 4 KNEE CEMENT ROTATE PLATFORM STERILE",SUP-150680004,CDM,C1776,HCPCS,0278,RC,,,both,,,17225.85,5167.75,"CIGNA [10200]","Cigna Open Access",,5770.66,33.5,,5302.19,4377.88,6578.61,27,2003.37,14641.97,"percent of total billed charges",
"CATH IMAGER II 100CM 5FR BARNH CURVE ANGIOGRAPHIC CEREBRAL",SUP-M001314041,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,53.51,45.9,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Cath Biliary DRN",PX-361000404,CDM,47537,CPT,0361,RC,,,both,,,1329.05,398.71,"BLUE CROSS [10001]","Blue Cross HMO",,1329.05,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,154.57,1329.05,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUARTET LEAD DOUBLE BEND, 75 C","SUP-CD3369-40C CELL",CDM,C1882,HCPCS,0278,RC,,,both,,,44764.00,13429.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18398,41.1,,,,,0,5206.05,38049.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Txhep Port Perc W Hemo Eval Si",PX-323000029,CDM,75885,CPT,0320,RC,,,both,,,3213.00,963.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,380.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.41,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intrinsic Factor Ab",PX-302000074,CDM,86340,CPT,0302,RC,,,both,,,279.50,83.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,23.72,,,,,,,0.01,237.58,"fee schedule",
"DRSG WOUND 2X4CM PURAPLY 8SQ CM","SUP-PURAPLY-COM 2X4",CDM,Q4195,HCPCS,0636,RC,,,both,,,6210.00,1863,"KAISER [10500]",Kaiser,,4160.7,67,,,,,0,263.34,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG WOUND 2X4CM PURAPLY 8SQ CM","SUP-PURAPLY-COM 2X4",CDM,Q4195,HCPCS,0636,RC,,,both,,,6210.00,1863,"CIGNA [10200]",Cigna,,263.34,,,,,,,263.34,5278.5,"fee schedule",
"HC Mnt Group Ea 30min Reassess",PX-942000010,CDM,G0271,HCPCS,0942,RC,,,both,,,43.00,12.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5,43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chlamydia Ab",PX-302000106,CDM,86631,CPT,0302,RC,,,both,,,148.20,44.46,"AETNA [10100]","Aetna HMO/PPO",,117.82,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,125.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AXLE TIBIAL OSS KNEE LOW FRICTION INTERFACE",SUP-150480,CDM,C1776,HCPCS,0278,RC,,,both,,,3690.00,1107,"KAISER [10500]",Kaiser,,2472.3,67,,,,,0,429.15,3136.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 12MM DCP STAINLESS STEEL CORTICAL SELF TAPPING",SUP-201.812,CDM,C1713,HCPCS,0278,RC,,,both,,,358.09,107.43,"CIGNA [10200]",Cigna,,243.5,68,,1831.33,1831.33,1831.33,16,41.65,304.38,"percent of total billed charges",
"SCR BONE 3MM 22MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0285,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]","Cigna Open Access",,539.24,56.9,,1144.80,304.56,2275.09,66,110.22,805.55,"percent of total billed charges",
"RESVR DRNG SILICONE JACKSON-PRATT BULB 400CC STERILE LATEX",SUP-SU130-1000,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.53,54.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21,153.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP MULTIHOLE COLOR CODED OSSEOTI G7 G",SUP-110010267,CDM,C1776,HCPCS,0278,RC,,,both,,,20755.98,6226.79,"UHC [10700]","United Healthcare",,13138.54,63.3,,8601.07,8395.67,8601.07,"1 through 10",2413.92,17642.58,"percent of total billed charges",
"PROGESTERONE MICRONIZED 100 MG CAPSULE",RX-23122,CDM,,,0637,RC,70700-0162-01,NDC,both,1,UN,25.19,7.56,"UHC [10700]","United Healthcare",,15.95,63.3,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 15MM 3MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG30015UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"FIRST HEALTH [10303]","First Health",,2160,80,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.5MM X 22MM TI",SUP-VAN-25220-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"KAISER [10500]",Kaiser,,651.24,67,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HELIOS STELLAR IDE UPDATED HANDLE DESIGN",SUP-D1389-04-SI,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET TPR .016 45CM",SUP-6035,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 380MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.958S,CDM,C1713,HCPCS,0278,RC,,,both,,,13031.06,3909.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1544.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1515.51,11076.4,"percent of total billed charges",
"HC Human Epididymis Protein 4",PX-301000545,CDM,86305,CPT,0302,RC,,,both,,,840.00,252,"CIGNA [10200]","Cigna Local Plus",,45.78,,,,,,,0.01,714,"fee schedule",
"CARDIOFLON 2/0 1/2KL 20MM DA 75CM",SUP-19P30U,CDM,S27200284,LOCAL,0272,RC,,,both,,,604.80,181.44,"CIGNA [10200]",Cigna,,411.26,68,,,,,0,70.34,514.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 10.1CM 23MM ESOPHAGEAL FULL COVER CATH DIAMETER",SUP-M00517760,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4932.9,27,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL ULTRAPRO 6X3IN PARTIAL ABSORBABLE LIGHTWEIGHT",SUP-UMR3,CDM,C1781,HCPCS,0278,RC,,,both,,,840.92,252.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,240.67,28.62,,,,,0,97.8,714.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 35MM 5.5MM DECADE LARGE PLATE EXTREME LATERAL",SUP-7145535,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"KAISER [10500]",Kaiser,,1085.4,67,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOZORB MARKER LP, 2CM X 3CM X 1CM",SUP-F0231,CDM,A4648,HCPCS,0278,RC,,,both,,,5250.00,1575,"AMERIGROUP MEDICAID [20100]",Amerigroup,,622.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,610.58,4462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 14CM 7.5MM LEGEND BALL BURR STERILE",SUP-14BA75,CDM,S27200284,LOCAL,0272,RC,,,both,,,1295.19,388.56,"NOVANET [10819]",Novanet,,971.39,75,,,,,0,150.63,1100.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM TITANIUM PARTIAL THREAD LOW PROFILE",SUP-AR-8916VNC-18,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"CIGNA [10200]","Cigna Open Access",,645.25,56.9,,1144.80,304.56,2275.09,66,131.88,963.9,"percent of total billed charges",
"COIL EMBOLIZATION 50CM 10MM INTERLOCK FIBERED IDC 18 COIL",SUP-M001361920,CDM,S27800098,LOCAL,0278,RC,,,both,,,4843.80,1453.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2223.3,45.9,,,,,0,563.33,4117.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE OD43MM FEMORAL HEAD OSTEOARTICULAR ALLOGR",SUP-FFH,CDM,Q4433,HCPCS,0636,RC,,,both,,,7988.82,2396.65,"FIRST HEALTH [10303]","First Health",,6391.06,80,,,,,0,247.92,6790.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 12MM 3.75MM BALLOON DILATATION STERILE",SUP-237-123-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 27X10MM THK.6MM SAGITTAL COARSE TEETH",SUP-532.062S,CDM,S27200284,LOCAL,0272,RC,,,both,,,605.07,181.52,"CIGNA [10200]",Cigna,,411.45,68,,,,,0,70.37,514.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR .071IN MULTIPURPOSE 1 CURVE GUIDING NYLON",SUP-LA6MP1SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,150.18,41.1,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 135D SHORT BARREL 94X19X5.8MM STAINLESS STEEL 4.5MM",SUP-281.55,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,3978.14,359.25,3978.14,24,434.96,3179,"percent of total billed charges",
"CERENOVUS ASPIRATION TUBING SE",SUP-EVT110,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"CIGNA [10200]",Cigna,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 130MM 1.35MM TROCAR TIP DISPOSABLE 4MM",SUP-AR-8943-01,CDM,C1769,HCPCS,0272,RC,,,both,,,174.00,52.2,"FIRST HEALTH [10303]","First Health",,139.2,80,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NUROLON 0 CT-1 18IN BRAIDED CONTROL RELEASE MULTIPACK",SUP-C521D,CDM,S27200284,LOCAL,0272,RC,,,both,,,120.76,36.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,82.12,68,,,,,0,14.04,102.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 5MM 48MM STAINLESS STEEL CORTICAL SELF TAP",SUP-202.848,CDM,C1713,HCPCS,0278,RC,,,both,,,351.31,105.39,"FIRST HEALTH [10303]","First Health",,281.05,80,,,,,0,40.86,298.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 69.9MM 5MM LONG CARBIDE ROUND ZIMMER RSC",SUP-5300020513,CDM,S27000186,LOCAL,0270,RC,,,both,,,271.18,81.35,"CIGNA [10200]",Cigna,,184.4,68,,,,,0,31.54,230.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 5.5IN 5MM ROUND",SUP-KM-AM35U,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 22CM 6.3FR COPE",SUP-G03407,CDM,C1769,HCPCS,0272,RC,,,both,,,761.32,228.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,88.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,88.54,647.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT STEM 80MM 14MM 1 AXIS PRESS FIT CEMENT KNEE VITALLIUM",SUP-6478-6-399,CDM,C1776,HCPCS,0278,RC,,,both,,,3364.45,1009.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,398.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,391.29,2859.78,"percent of total billed charges",
"IMPL BREAST 650CC COHESIVE NATRELLE INSPIRA STERILE LATEX",SUP-SCF-650,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS [10001]","Blue Cross PPO",,2961.76,39.2,,16595.83,16595.83,16595.83,"1 through 10",878.7,6422.18,"percent of total billed charges",
"KIT CATH 20GA 8CM POWERGLIDE 1.3IN .014IN 5ML/SEC FULL",SUP-M020081,CDM,C1751,HCPCS,0272,RC,,,both,,,607.50,182.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,249.68,41.1,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INTELLANAV ST 110CM 7FR 4MM 2.5MM SPACE STD CURVE",SUP-M004R5031TH0,CDM,C1733,HCPCS,0272,RC,,,both,,,14145.00,4243.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1645.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1645.06,12023.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL URETHRAL S-CURVE HYDROPHILIC SIDEPORT 37CM 24FR",SUP-G46250,CDM,S27200284,LOCAL,0272,RC,,,both,,,309.72,92.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,210.61,68,,,,,0,36.02,263.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS RX 135CM 80MM 5.7-3.9FR 8MM BALLOON",SUP-BD-L80080CR,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,111.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 56MM 40MM ALTRX HIP",SUP-122140456,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"CIGNA [10200]","Cigna Local Plus",,4348.09,31.5,,5372.07,4581.20,7242.98,23,1605.34,11732.93,"percent of total billed charges",
"INSRT CLAMP STEALTH 2 45MM VASCULAR SOFT TRACTION",SUP-A0A02,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.70,28.71,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,39.33,41.1,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM 18MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-018,CDM,C1776,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"CIGNA [10200]",Cigna,,7008.12,40,,5873.17,5873.17,5873.17,"1 through 10",2037.61,14892.26,"percent of total billed charges",
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET HOUSING POS",SUP-AR-1204AF-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"AETNA [10100]","Aetna HMO/PPO",,2034.71,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNGOSCOPE SPECTRUM LOPRO 2 TITANIUM GLIDESCOPE DISP",SUP-0270-0877,CDM,S27200284,LOCAL,0272,RC,,,both,,,414.99,124.5,"CIGNA [10200]","Cigna Local Plus",,222.02,53.5,,,,,0,48.26,352.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED 100CM 9CM 9FR 28MM .035IN BALLOON DILATATION",SUP-611683,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"AETNA [10100]","Aetna HMO/PPO",,4227.84,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 1.6MM TPS ELITE 5 STEP NOTCH CROSS CUT FISSURE",SUP-5820-066-216,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"NOVANET [10819]",Novanet,,821.22,75,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG GERMICIDAL 6X6IN AQUACEL AG",SUP-422298,CDM,S27200284,LOCAL,0272,RC,,,both,,,157.45,47.23,"MULTIPLAN [10600]",Multiplan,,133.83,85,,,,,0,18.31,133.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS FIRSTCHOICE 5% DEXTROSE 40 MEQ POTASSIUM",SUP-07904-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,55.08,68,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 100MM 80CM 10MM VASCULAR NITINOL",SUP-1012532-100,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"AETNA [10100]","Aetna HMO/PPO",,3291.3,79.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC FLUORESCENT PINK 1MM CLEARCUT ANGLE FULL 2",SUP-8065921540,CDM,S27200284,LOCAL,0272,RC,,,both,,,85.96,25.79,"CIGNA [10200]","Cigna Open Access",,48.91,56.9,,,,,0,10,73.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP CEMENTED FEMUR WITH OXINIUM HEAD XLPE CUP",SUP-71701003,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Local Plus",,7541.1,31.5,,5372.07,4581.20,7242.98,23,2784.22,20349,"percent of total billed charges",
"UROLIFT 2 IMPLANT CARTRIDGE HANDLE KIT",SUP-UL2-CHK,CDM,L8699,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"FIRST HEALTH [10303]","First Health",,5796,80,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 2-0 V-20 12IN CLSR ABSORBABLE TAPER POINT",SUP-VLOCL0615,CDM,S27200284,LOCAL,0272,RC,,,both,,,426.30,127.89,"PHCS [10601]",PHCS,,298.41,70,,,,,0,49.58,362.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 48MM 28MM NEUTRAL HIP CERAMIC STERILE LATEX",SUP-121889650,CDM,C1776,HCPCS,0278,RC,,,both,,,14690.10,4407.03,"CIGNA [10200]","Cigna Local Plus",,4627.38,31.5,,5372.07,4581.20,7242.98,23,1708.46,12486.59,"percent of total billed charges",
"10MM X 11MM TITANIUM COMPRESSION STAPLE","SUP-C03 013",CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"TUBE 65MM 9.4MM 15MM 5MM CUFFLESS REUSABLE INNER CANN CNCT",SUP-4CFS,CDM,S27200284,LOCAL,0272,RC,,,both,,,352.61,105.78,"CIGNA [10200]",Cigna,,239.77,68,,,,,0,41.01,299.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 120MM 12MM LEGION STRAIGHT KNEE TITANIUM CEMENT",SUP-71424184,CDM,C1776,HCPCS,0278,RC,,,both,,,12357.90,3707.37,"FIRST HEALTH [10303]","First Health",,9886.32,80,,,,,0,1437.22,10504.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PRUITT 27CM 3FR 7MM C.5ML BALLOON OCCLUSION SYR STERILE",SUP-E2103-36,CDM,C2628,HCPCS,0272,RC,,,both,,,3742.50,1122.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1538.17,41.1,,,,,0,435.25,3181.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMEDY SPECTRUM GV FEMORAL HEAD - 54MM",SUP-GVHDMD,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE TITANIUM",SUP-CAP-T-1071,CDM,C1776,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Open Access",,2133.75,56.9,,5302.19,4377.88,6578.61,27,436.13,3187.5,"percent of total billed charges",
"HC Tc99m Tilmanocept Diag 0.5mci",PX-343000030,CDM,A9520,HCPCS,0343,RC,,,both,,,4614.97,1384.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,546.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,536.72,3922.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 22MM 52MM SHOULDER ANATOMIC RESTORATION",SUP-AR-9152-22P,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"PHCS [10601]",PHCS,,5544,70,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 13MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-613,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"FIRST HEALTH [10303]","First Health",,7864.42,80,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 44-41MM COMPREHENSIVE STD SHOULDER E1",SUP-EP-115396,CDM,C1776,HCPCS,0278,RC,,,both,,,8854.00,2656.2,"BLUE CROSS [10001]","Blue Cross PPO",,3470.77,39.2,,3949.44,3949.44,3949.44,"1 through 10",1029.72,7525.9,"percent of total billed charges",
"INSERT TIBIAL 6 12MM KNEE AOX REVISION CRUCIATE SUBSTITUTE R",SUP-151710612,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"MULTIPLAN [10600]",Multiplan,,12574.56,85,,,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT BIORAPTOR SHOULDER KNOTLESS INNER LOCK PLUG",SUP-72202403,CDM,C1713,HCPCS,0278,RC,,,both,,,2212.88,663.86,"KAISER [10500]",Kaiser,,1482.63,67,,,,,0,257.36,1880.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS RX 135CM 20MM 5.7-3.9FR 5MM BALLOON",SUP-BD-L50020CR,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET RETRIEVAL 125CM 20MM 20-30MM MULTI-SNARE SNARE CATH",SUP-612975,CDM,C1773,HCPCS,0272,RC,,,both,,,2310.83,693.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL 24FR POWERBALL UROLOGY ACMI CLASSIC",SUP-M0068802511,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHIBOND EXCEL 2-0 V-5 36IN 2 ARM BRAID 1 STRAND FIRM",SUP-PX17H,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.67,73.1,"FIRST HEALTH [10303]","First Health",,194.94,80,,,,,0,28.34,207.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM ENDOSCOPIC BLACK 25MM 4-5FR UTS ULTRA TAPER",SUP-G22489,CDM,S27200284,LOCAL,0272,RC,,,both,,,1642.50,492.75,"NOVANET [10819]",Novanet,,1231.88,75,,,,,0,191.02,1396.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 20FR DRN SF PG PUL",SUP-6772,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Meckel Divert",PX-341000021,CDM,78290,CPT,0341,RC,,,both,,,1730.12,519.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,422.22,,,,,,,201.21,1470.6,"fee schedule",
"PLATE 14MM 51X16X2.5MM TITANIUM 3 LEVEL PREBENT SKYLINE BONE",SUP-186803051,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"BLUE CROSS [10001]","Blue Cross PPO",,2074.46,39.2,,957.42,570.23,957.42,28,615.46,4498.2,"percent of total billed charges",
"SIZER MAMMARY SILICONE 235ML BREAST RESTERILIZABLE GEL",SUP-RSZ-7235MC,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,65.01,41.1,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC L100MM DIA5MM BLADELESS WITH STABILITY S",SUP-B5LTR,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"CIGNA [10200]","Cigna Open Access",,89.11,56.9,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH CRANIAL 85X53X.3MM LORENZ NEURO PANEL 1.5MM SCR",SUP-1/1/7185,CDM,C1713,HCPCS,0278,RC,,,both,,,5934.00,1780.2,"BLUE CROSS [10001]","Blue Cross PPO",,2326.13,39.2,,957.42,570.23,957.42,28,690.12,5043.9,"percent of total billed charges",
"SUT ABSORBABLE 30X30CM QUILL 2",SUP-RA-1058Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,185.29,55.59,"UHC [10700]","United Healthcare",,117.29,63.3,,,,,0,21.55,157.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12IN 18FR 3/18IN ARTERY THIN 1 PIECE",SUP-77418,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"NOVANET [10819]",Novanet,,336,75,,,,,0,52.1,380.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 58MM TI",SUP-SPL-35580-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,382.51,28.62,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 20MM INSET SHOULDER LOCK REVERSE",SUP-2R1PT45020,CDM,C1713,HCPCS,0278,RC,,,both,,,865.08,259.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,247.59,28.62,,,,,0,100.61,735.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 3D LOCK VARIAX BONE RIGHT FOOT",SUP-40-15062,CDM,C1713,HCPCS,0278,RC,,,both,,,5435.82,1630.75,"BLUE CROSS [10001]","Blue Cross HMO",,2130.84,39.2,,957.42,156.86,7483.26,51,632.19,4620.45,"percent of total billed charges",
"HC Ercp Biliary&Pancreas Si",PX-320000112,CDM,74330,CPT,0320,RC,,,both,,,2002.00,600.6,"BLUE CROSS [10001]","Blue Cross HMO",,240.92,,"Fee schedule rate ($240.92).",,,,0,167.32,1701.7,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X22X10MM MODULUS 15D XL WIDE STERILE LATEX",SUP-1225055P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,29925.00,8977.5,"BLUE CROSS [10001]","Blue Cross HMO",,11730.6,39.2,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM ENDOSKELETON TAS TITANIUM SPINE",SUP-2300-6525,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"CIGNA [10200]","Cigna Local Plus",,758.36,53.5,,3978.14,359.25,3978.14,24,164.86,1204.88,"percent of total billed charges",
"BLADE SAW 85X12.7MM THK1.2MM LONG NARROW STAINLESS STEEL",SUP-2108352000,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"KAISER [10500]",Kaiser,,160.18,67,,,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 5MM KII 2 PACK ACCESS SYSTEM Z",SUP-CTB10,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,99.83,45.9,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 75MM 5MM KII FIOS FIRST ENTRY ADVANCE",SUP-CFF05,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"AETNA [10100]","Aetna HMO/PPO",,114.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 3.5MM CORONARY STENT",SUP-1145350-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross HMO",,2288.5,39.2,,9776.84,9776.84,9776.84,"1 through 10",678.96,4962.3,"percent of total billed charges",
"STEM EXT 160MM 16MM LEGION STRAIGHT KNEE TITANIUM PRESS FIT",SUP-71424049,CDM,C1776,HCPCS,0278,RC,,,both,,,12181.95,3654.58,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5006.78,41.1,,6417.48,6417.48,6417.48,"1 through 10",1416.76,10354.66,"percent of total billed charges",
"AVENIR 10, 1 X 2.5 COMPLEX PICO COIL",SUP-10USC0102H,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"CIGNA [10200]","Cigna Open Access",,4380.29,33.5,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 14CM 5FR 3MM .035IN BALLOON",SUP-G52330,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"PHCS [10601]",PHCS,,671.84,70,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30X10X7-14MM RISE",SUP-193.103,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 CURVE 10MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962011,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"CIGNA [10200]","Cigna Local Plus",,4948.46,53.5,,5372.07,4581.20,7242.98,23,1075.71,7862.03,"percent of total billed charges",
"PROS PENILE TITAN COLOPLAST LOCK-OUT 20CM PUMP SET",SUP-ES2820,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA [10200]","Cigna Open Access",,21004.5,33.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 60MM 36MM MARATHON",SUP-121936460,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1144.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1144.72,8366.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US OB > 1st Trimst Txabd Sngl",PX-402000016,CDM,76805,CPT,0402,RC,,,both,,,1394.28,418.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,277,,"Per diem ($277).",,,,0,139.53,1185.14,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 18MM 25MM MOSAIC CINCH PORCINE BIOPROSTHESIS",SUP-310-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ANGIO-SEAL EVOLUTION 6FR .035IN CLSR VASCULAR GWIRE",SUP-C610134,CDM,C1760,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,200.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 64CM ENDOTAK RELIANCE S ENDOCARDIAL STEROID",SUP-128,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4098.6,27,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 56MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.156,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,131.73,962.8,"percent of total billed charges",
"BURR SURGICAL GRAY WHITE 1.4MM OTO-FLEX DIAMOND STERILE",SUP-3155643,CDM,S27200284,LOCAL,0272,RC,,,both,,,1927.50,578.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,884.72,45.9,,,,,0,224.17,1638.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE 12MM 4MM EMBOLIZATION",SUP-PED2-400-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9396.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 16FR SILICONE STD J MIC SECUR-LOK TRIMMABLE",SUP-0200-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"FIRST HEALTH [10303]","First Health",,879.66,80,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 7 9MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-709,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1164.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 10MM 1.9FR BAGLEY HELICAL 3 WIRE",SUP-M0063401210,CDM,S27200284,LOCAL,0272,RC,,,both,,,1247.08,374.12,"CIGNA [10200]",Cigna,,848.01,68,,,,,0,145.04,1060.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT XACT 40MM 8-10MM TAPER VASCULAR NITINOL CAROTID ARTERY",SUP-82096-01,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"BLUE CROSS [10001]","Blue Cross HMO",,3669.12,39.2,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl FB Ft Sq",PX-450000172,CDM,28190,CPT,0361,RC,,,both,,,3198.00,959.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3198,,"Case rate ($4,617). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,371.93,3198,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +21.5 DIOPTER MODIFIED C BICONVEX MULTIPIECE",SUP-MA60AC.215,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 62MM 3MM SWANSON SHORT PILOT POINT STERILE",SUP-1608-002-133,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transferase Alanine Amino",PX-301000418,CDM,84460,CPT,0301,RC,,,both,,,106.50,31.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5.67,,"Fee schedule rate ($5.67). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",7.60,7.60,7.60,"1 through 10",0.11,90.53,"fee schedule",
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,inpatient,,,106136.80,31841.04,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,20992.61,,"Case rate ($20,088.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $18,653.64, add-ons for qualifying new technology services are included. If operating cost exceeds $51,693.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,792.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $18,678.31. The transfer operating threshold is the transfer adjustment factor * $18,653.64 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.31. The transfer capital threshold is the transfer adjustment factor * $1,410.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,94551.25,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER CHOCOLATE 120MM 2.5MM .014IN BALLOON DILATATION GUI",SUP-CB1415025120OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2353.8,41.1,,,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPEEDBRIDGE SWIVELOCK 4.75/5.5MM IMPL BIOCOMPOSITE",SUP-AR-2600SBS-11,CDM,C1713,HCPCS,0278,RC,,,both,,,15576.75,4673.02,"BLUE CROSS [10001]","Blue Cross PPO",,6106.09,39.2,,957.42,570.23,957.42,28,1811.58,13240.24,"percent of total billed charges",
"CATH 35CM 10FR PIGTAIL CURVE DRNG FLEXIMA BILIARY FLEXIBLE",SUP-M001271600,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD BIPOLAR CELONPROBREATH STERILE LATEX FREE DISPOSABLE",SUP-WB990310,CDM,S27200284,LOCAL,0272,RC,,,both,,,1406.44,421.93,"PHCS [10601]",PHCS,,984.51,70,,,,,0,163.57,1195.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNAP(R) CARTRIDGE - 75 MM HG - 10 IN A CASE",SUP-SNPA075,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,120.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER CHOCOLATE 120MM 2.5MM .014IN BALLOON DILATATION GUI",SUP-CB1415025120OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"AETNA [10100]","Aetna HMO/PPO",,4552.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 4CM 1.5MM GALAXY G3 MINI STRETCH",SUP-GLM915040,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"FIRST HEALTH [10303]","First Health",,9505.44,80,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repo Gastrostmy Tube",PX-750000061,CDM,43761,CPT,0750,RC,,,both,,,3401.50,1020.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1249,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,395.59,3401.5,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 20MM 2.5MM BALLOON DILATATION PEBAX",SUP-H74939032250210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 OS-6 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP533H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.48,45.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 7FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175272010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"BLUE CROSS [10001]","Blue Cross PPO",,419.73,39.2,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE COATED VICRYL PLUS 0 27IN ABSORBABLE VIOLET ANTIBACTE",SUP-VCP340H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]",Cigna,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM GORILLA R3CON LOCK",SUP-P50-353-3526,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Local Plus",,715.03,53.5,,3978.14,359.25,3978.14,24,155.43,1136.03,"percent of total billed charges",
"NDL BIOPSY 17GA 17.8CM TRUGUIDE BARD COAXIAL ULTRA THIN WALL",SUP-C1820A,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.96,27.59,"CIGNA [10200]",Cigna,,62.53,68,,,,,0,10.69,78.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL CERVICAL 6X16X14MM 7DEG LORDOTIC PEEK COHERE",SUP-4061647P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"AMERIGROUP MEDICAID [20100]",Amerigroup,,735.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Igh@/Bcl2 Translocation Alys",PX-310000050,CDM,81278,CPT,0310,RC,,,both,,,336.00,100.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,326.1,,,,,,,0.01,336,"fee schedule",
"CATH LAUNCHER 100CM 8FR .09IN JUDKINS LEFT 4.5 CURVE GUIDING",SUP-LA8JL45,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,266.22,68,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET",RX-10384,CDM,,,0637,RC,64980-0146-98,NDC,both,1,UN,10.22,3.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.19,8.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 90MM 16MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044169070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"KAISER [10500]",Kaiser,,5778.75,67,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 320MM LEFT TROCHANTER INTRAMEDULLARY 130D LONG",SUP-456.353S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"CIGNA [10200]",Cigna,,5468.17,40,,1831.33,1831.33,1831.33,16,1589.87,11619.86,"percent of total billed charges",
"RING ANNULOPLASTY 39MM MITRAL TRICUSPID FULL FLEXIBLE BAND",SUP-700FF39,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"FIRST HEALTH [10303]","First Health",,10488,80,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL GRAY WHITE 1.4MM OTO-FLEX DIAMOND STERILE",SUP-3155643,CDM,S27200284,LOCAL,0272,RC,,,both,,,1927.50,578.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,792.2,41.1,,,,,0,224.17,1638.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 7 X 15 HELICAL FILLING COIL",SUP-10HFL-07015,CDM,S27800098,LOCAL,0278,RC,,,both,,,8963.10,2688.93,"KAISER [10500]",Kaiser,,6005.28,67,,,,,0,1042.41,7618.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC",824,MS-DRG,,,,,,,inpatient,,,95382.67,28614.8,"AMBETTER EXCHANGE  [11102]",Ambetter,,14053.66,,"Case rate ($14,053.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,049.77, add-ons for qualifying new technology services are included. If operating cost exceeds $46,089.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,368.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,067.03. The transfer operating threshold is the transfer adjustment factor * $13,049.77 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $986.63. The transfer capital threshold is the transfer adjustment factor * $986.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,66146.46,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM SPINAL",SUP-8807550,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UHC [10700]","United Healthcare",,6043.16,63.3,,5023.51,2672.93,6679.78,18,1110.3,8114.82,"percent of total billed charges",
"SCR BONE 2.7MM 60MM LCP STAINLESS STEEL CORTEX FOREFOOT",SUP-202.969,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",37.68,275.39,"percent of total billed charges",
"PLATE 93MM STAINLESS STEEL 3.5MM SCR 4 HOLE LCP BONE RIGHT",SUP-239.954,CDM,C1713,HCPCS,0278,RC,,,both,,,9233.17,2769.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3794.83,41.1,,,,,0,1073.82,7848.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR JUDKINS LEFT 3.5 CURVE",SUP-534518T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"NOVANET [10819]",Novanet,,70.15,75,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 13.3MM 24.2MM 22.8MM ATS OPEN PIVOT AP360 24MM",SUP-505DM24,CDM,S27800098,LOCAL,0278,RC,,,both,,,23625.00,7087.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9450,40,,,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 65CM 5FR .046IN .035IN C2 CURVE ANGIOGRAPHIC",SUP-5584-E3,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"CIGNA [10200]","Cigna Local Plus",,55.2,53.5,,,,,0,12,87.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM DIAMONDBACK .014IN .063 200CM 10MM 1.50MM 5FR",SUP-DBP-150SOLID200,CDM,C1724,HCPCS,0272,RC,,,both,,,22648.50,6794.55,"AETNA [10100]","Aetna HMO/PPO",,18005.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2634.02,19251.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL MIXTER-CRAFOORD 90D 10IN ARTERY DISSECT",SUP-17-0775,CDM,S27200284,LOCAL,0272,RC,,,both,,,953.61,286.08,"NOVANET [10819]",Novanet,,715.21,75,,,,,0,110.9,810.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 110CM 6FR 145D PIGTAIL CURVE ANGIOGRAPHIC",SUP-7777-33,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"CIGNA [10200]","Cigna Local Plus",,43.8,53.5,,,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CONTOUR 64X10.7X2.4MM TIMAX 3.5MM SCR 7 HOLE LOW",SUP-131218202,CDM,C1713,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"NOVANET [10819]",Novanet,,7917.75,75,,,,,0,1227.78,8973.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 5X1CM GAUZE MEROGEL SEPTUM PK STERILE LATEX",SUP-1517100,CDM,S27000186,LOCAL,0270,RC,,,both,,,467.29,140.19,"FIRST HEALTH [10303]","First Health",,373.83,80,,,,,0,54.35,397.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE-EPINEPHRINE (PF) 2%-1:200,000 INJECTION SOLUTION",RX-10431,CDM,J2004,HCPCS,0636,RC,63323-0489-17,NDC,both,10,ML,106.08,31.82,"BLUE CROSS [10001]","Blue Cross PPO",,2.33,,,,,,,2.33,90.17,"fee schedule",
"SCR BONE 7.5MM 50MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840007550,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 24MM ARTHREX +4MM SHOULDER MODULAR STERILE",SUP-AR-9560-24-4,CDM,C1776,HCPCS,0278,RC,,,both,,,9335.70,2800.71,"UHC [10700]","United Healthcare",,5909.5,63.3,,8601.07,8395.67,8601.07,"1 through 10",1085.74,7935.35,"percent of total billed charges",
"FRCP ARTHROSCOPIC SUT RETRIEVAL",SUP-16.1018,CDM,S27200284,LOCAL,0272,RC,,,both,,,6652.15,1995.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,788.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,773.65,5654.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM OFFSET 36MM HIP ACETABULAR MODULAR TYPE 1",SUP-650-0660,CDM,C1776,HCPCS,0278,RC,,,both,,,12375.84,3712.75,"MULTIPLAN [10600]",Multiplan,,10519.46,85,,,,,0,1439.31,10519.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIXTR EXTERNAL FIXATION MINIRAIL HORIZONTAL AXIS ARTICULATE",SUP-M111,CDM,C1713,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"MULTIPLAN [10600]",Multiplan,,5982.3,85,,,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 34MM 140CM 4MM CORONARY",SUP-RSINT40034UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"AETNA [10100]","Aetna HMO/PPO",,4407.48,79.5,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE VITRECTOMY 23GA EDGEPLUS 4MM 1 COUNT VALVED ENTRY",SUP-8065751585,CDM,S27200284,LOCAL,0272,RC,,,both,,,450.44,135.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,206.75,45.9,,,,,0,52.39,382.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA MEDIAL CONGRUENT 6-7 E-F KNEE",SUP-42522100713,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"FIRST HEALTH [10303]","First Health",,8621.14,80,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 26MM 2.25MM CORONARY STENT FULCRUM COCR",SUP-INT22526UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,280.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE CORNEAL 8.25MM CORNEAL STAINLESS STEEL TREPHINE",SUP-K20-2159,CDM,S27200284,LOCAL,0272,RC,,,both,,,430.65,129.19,"CIGNA [10200]","Cigna Local Plus",,230.4,53.5,,,,,0,50.08,366.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC",271,MS-DRG,,,,,,,inpatient,,,180964.81,54289.44,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,22721.74,,"Case rate ($22,059.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,484.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,523.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,930.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $20,511.24. The transfer operating threshold is the transfer adjustment factor * $20,484.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,548.70. The transfer capital threshold is the transfer adjustment factor * $1,548.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.",,,,0,10994,103829.73,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOCRINE DISORDERS WITH MCC",643,MS-DRG,,,,,,,inpatient,,,41516.82,12455.05,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,10517.19,,"Case rate ($10,210.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,481.47, add-ons for qualifying new technology services are included. If operating cost exceeds $42,521.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,098.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $9,494.01. The transfer operating threshold is the transfer adjustment factor * $9,481.47 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.85. The transfer capital threshold is the transfer adjustment factor * $716.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,41052.09,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 30CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX",SUP-M0061802450,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"NOVANET [10819]",Novanet,,676.64,75,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD BIPOLAR 24FR 26FR LOOP CUT STERILE LATEX FREE",SUP-27040GP140-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3100.64,930.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"6725  KIT-PIN PLUG IS-1 FOR DUAL CHAMBE",SUP-6725,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP BIOPSY HOT 240CM 2.2MM RADIAL JAW 4 +2.8MM DISPOSABLE",SUP-M00515031,CDM,S27200284,LOCAL,0272,RC,,,both,,,322.60,96.78,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL NERVE BLOCK 80MM 22GA SONOPLEX II FACET TIP INJECTION",SUP-001285-71,CDM,C9812,HCPCS,0272,RC,,,both,,,119.63,35.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL NERVE BLOCK 80MM 22GA SONOPLEX II FACET TIP INJECTION",SUP-001285-71,CDM,C9812,HCPCS,0272,RC,,,both,,,119.63,35.89,"FIRST HEALTH [10303]","First Health",,95.7,80,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 18MM SKYLINE TITANIUM 0-5D SPINE CERVICAL",SUP-186862018,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross HMO",,396.9,39.2,,957.42,156.86,7483.26,51,117.75,860.63,"percent of total billed charges",
"SCR BONE 2MM 38MM LCP STAINLESS STEEL CORTEX WRIST HAND FOOT",SUP-201.381.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"CIGNA [10200]","Cigna Local Plus",,221.55,53.5,,3978.14,359.25,3978.14,24,48.16,352,"percent of total billed charges",
"DEXTROSE 50 % IN WATER (D50W) SUPERORDERABLE - GLUCOMMANDER",RX-409649,CDM,,,0250,RC,06937-4953-50,NDC,both,50,ML,100.65,30.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46.2,45.9,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 12X10IN RESORBABLE REINFORCE",SUP-F10254-1012G,CDM,C1781,HCPCS,0278,RC,,,both,,,6789.60,2036.88,"PHCS [10601]",PHCS,,4752.72,70,,,,,0,789.63,5771.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 9IN 7/64IN STEINMANN THREAD 2 TROCAR POINT",SUP-KM169-29-76,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",7.4,54.07,"percent of total billed charges",
"WIRE FIXATION OLIVE STERILE",SUP-7000-LVWR,CDM,S27200284,LOCAL,0272,RC,,,both,,,480.17,144.05,"NOVANET [10819]",Novanet,,360.13,75,,,,,0,55.84,408.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM 2MM CORONARY STENT BIOLINX",SUP-RONYX20022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 8FR JUDKINS RIGHT 4",SUP-588831,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER TENDON 25CMX4MM SWANSON HUNTER SILICONE",SUP-24270004,CDM,C1713,HCPCS,0278,RC,,,both,,,6955.20,2086.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,824.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,808.89,5911.92,"percent of total billed charges",
"LEAD ICD INTICA 7 DF-1 CONNECTION HF-T QP",SUP-404629,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"AETNA [10100]","Aetna HMO/PPO",,45887.4,79.5,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 10MM 4MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP4010X,CDM,C1725,HCPCS,0272,RC,,,both,,,558.90,167.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,66.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 8MMX39MM 7FR 135CMCATH HEPARIN",SUP-BXB083902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8016.47,41.1,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 014 150CM 8CM 2.5MM BALLOON DILATATION",SUP-U41502H8,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 80MM 40CM 8MM BILIARY SELF EXPAND",SUP-G36011,CDM,C1876,HCPCS,0278,RC,,,both,,,4653.98,1396.19,"CIGNA [10200]","Cigna Local Plus",,2489.88,53.5,,,,,0,541.26,3955.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"27 MM LOTUS EDGE AORTIC VALVE SYSTEM AND LARGE LOTUS INTRODU",SUP-B0M27EDGELGIS,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,76137.75,41.1,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 137CM 20MM 3MM RECTANGLE HELIX BALLOON",SUP-2039-3020,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"AETNA [10100]","Aetna HMO/PPO",,4662.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY HUMERAL 13MM AEQUALIS FLEX REVIVE SHOULDER",SUP-ARS741703,CDM,C1776,HCPCS,0278,RC,,,both,,,18558.00,5567.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2199.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2158.3,15774.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE RIGHT PROXIMAL TIBIAL 82MM STAINLESS STEEL 4.5MM SCR",SUP-240.036,CDM,C1713,HCPCS,0278,RC,,,both,,,8587.74,2576.32,"MULTIPLAN [10600]",Multiplan,,7299.58,85,,,,,0,998.75,7299.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sensor Pulse Ox Peds",PX-E27000153,CDM,E27000153,LOCAL,0270,RC,,,both,,,110.55,33.16,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,50.74,45.9,,,,,0,12.86,93.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT POSITIONING KNEE",SUP-FP-KNEEPOS,CDM,S27200284,LOCAL,0272,RC,,,both,,,151.41,45.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,69.5,45.9,,,,,0,17.61,128.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 12MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0303,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,112.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,110.22,805.55,"percent of total billed charges",
"GRAFT ENDOVASCULAR 56MM 9MM 5.4MM 4.7MM ZENITH SPIRAL-Z",SUP-G55219,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6060.08,28.62,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL LIGAPAK 3-0 144IN BRAID COATED UNDYED ABSORBABLE",SUP-J885G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UHC [10700]","United Healthcare",,15.83,63.3,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 4FR ANGLE KUMPE CURVE ANGIOGRAPHIC",SUP-H787107140145,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,89.39,41.1,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE NERVE STIM 23CM NIM BALL TIP",SUP-9450015,CDM,S27000186,LOCAL,0270,RC,,,both,,,899.10,269.73,"FIRST HEALTH [10303]","First Health",,719.28,80,,,,,0,104.57,764.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERIT MAESTRO 150CM 2.9FR .027IN MICRO 45D .021IN .042",SUP-29MC2915045,CDM,C1887,HCPCS,0272,RC,,,both,,,2301.00,690.3,"MULTIPLAN [10600]",Multiplan,,1955.85,85,,,,,0,267.61,1955.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL CERVICAL 10X14X12MM 7DEG LORDOTIC PEEK COHERE",SUP-4101427P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"KAISER [10500]",Kaiser,,4160.7,67,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 25.5CM TIBIAL NAIL-EX INTRAMEDULLARY CANNULATED",SUP-04.004.331S,CDM,C1713,HCPCS,0278,RC,,,both,,,8593.61,2578.08,"CIGNA [10200]","Cigna Open Access",,4889.76,56.9,,1144.80,304.56,2275.09,66,999.44,7304.57,"percent of total billed charges",
"ANCHOR SUT 2.3MM 2 OSTEORAPTOR ULTRABRAID COBRAID WHITE",SUP-72201991,CDM,C1713,HCPCS,0278,RC,,,both,,,2531.25,759.37,"FIRST HEALTH [10303]","First Health",,2025,80,,,,,0,294.38,2151.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SMALL INTERNAL FILSHIE SILASTIC TITANIUM SOFT LINE",SUP-AVM-851,CDM,S27800098,LOCAL,0278,RC,,,both,,,465.82,139.75,"MULTIPLAN [10600]",Multiplan,,395.95,85,,,,,0,54.17,395.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 7X11X30MM 15",SUP-5871305,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3412.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .048IN .047IN AMPLATZ LEFT",SUP-534546T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,42.93,45.9,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 2.5MM CEREPAK XTRASOFT FREEFORM",SUP-XCR122505,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"NOVANET [10819]",Novanet,,9919.39,75,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH AMPLATZ 24CM 30FR DIL RENAL OPAQUE",SUP-G17980,CDM,C1894,HCPCS,0272,RC,,,both,,,275.09,82.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,32.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.99,233.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 12.5CM 4MM IBUR DISTAL BEND ROUND DIAMOND",SUP-8431-013-040DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,2737.50,821.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1861.5,68,,,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CRE 5.5CM 6-7-8MM 18-21-24FR BALLOON DILATATION BILIARY",SUP-M00558860,CDM,C1726,HCPCS,0272,RC,,,both,,,2085.75,625.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1418.31,68,,,,,0,242.57,1772.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1",SUP-179715645,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 20CM 13.5FR STRAIGHT POLYURETHANE NIAGARA 2 LUMEN",SUP-5575200,CDM,C1752,HCPCS,0272,RC,,,both,,,1031.94,309.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,473.66,45.9,,,,,0,120.01,877.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 014 150CM 8CM 2.5MM BALLOON DILATATION",SUP-U41502H8,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT POSITIONING KNEE",SUP-FP-KNEEPOS,CDM,S27200284,LOCAL,0272,RC,,,both,,,151.41,45.42,"MULTIPLAN [10600]",Multiplan,,128.7,85,,,,,0,17.61,128.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARR GRAFT 8IN SKIN PVC BOARD CARR STERILE LATEX FREE",SUP-00-7708-000-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L58 MM OD5 MM FEMORAL LOW PROFILE STERILE RFN-ADV",SUP-04.045.358TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"BLUE CROSS [10001]","Blue Cross PPO",,733,39.2,,957.42,570.23,957.42,28,217.47,1589.42,"percent of total billed charges",
"LARYNGOSCOPE VIDEO I-VIEW DISPOSABLE",SUP-441-8008000EA,CDM,S27000186,LOCAL,0270,RC,,,both,,,706.23,211.87,"FIRST HEALTH [10303]","First Health",,564.98,80,,,,,0,82.13,600.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X9MM ADVANCED LORDOTIC TRAPEZOIDAL",SUP-7709,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"AMERIGROUP MEDICAID [20100]",Amerigroup,,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICKSTICK 25CM 10FR LOOP DRNG FLEXIMA HYDROPHILIC",SUP-M001271470,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 45MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0318,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"FIRST HEALTH [10303]","First Health",,758.16,80,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 STD KNEE LEFT CRUCIATE RETAIN CEMENT PERSONA",SUP-42502606001,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"MULTIPLAN [10600]",Multiplan,,19433.3,85,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 23MM TITANIUM LOCKING ATLANTIS VISION BONE ANTERIOR",SUP-976-123,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,,1521.93,481.35,16760.95,30,601.85,4398.75,"percent of total billed charges",
"CATH ANGIOSCULPT XL 137CM 20MM 3MM RECTANGLE HELIX BALLOON",SUP-2039-3020,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,695,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER HUMERAL 33MM UNIVERS REVERS +6MM SHOULDER",SUP-AR-9504-06,CDM,C1776,HCPCS,0278,RC,,,both,,,2257.50,677.25,"BLUE CROSS [10001]","Blue Cross HMO",,884.94,39.2,,5311.50,4717.44,5388.59,31,262.55,1918.88,"percent of total billed charges",
"PORT IMPLANTABLE INFUSION MRI SILICONE PLASTIC 6.6FR 1 LUMEN",SUP-602690,CDM,C1788,HCPCS,0278,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BILIARY 10MM 8.5FR 40MM FULLY COVERED TRANSHEPATIC WAL",SUP-M00574770,CDM,C1874,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]",Cigna,,8820,40,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP PARTIAL WITH XLPE LINER AND OXI HEAD R3",SUP-71703368,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1635.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1604.94,11730,"percent of total billed charges",
"ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC",615,MS-DRG,,,,,,,inpatient,,,86871.33,26061.4,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,9200.75,,"Case rate ($8,679.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,059.92, add-ons for qualifying new technology services are included. If operating cost exceeds $41,099.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,991.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $8,070.57. The transfer operating threshold is the transfer adjustment factor * $8,059.92 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $609.37. The transfer capital threshold is the transfer adjustment factor * $609.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,40853.96,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 12.5CM 4MM IBUR DISTAL BEND ROUND DIAMOND",SUP-8431-013-040DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,2737.50,821.25,"CIGNA [10200]","Cigna Open Access",,1557.64,56.9,,,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENTETATE INDIUM DISODIUM IN-111 INTRATHECAL SOLUTION (0.5-1 MCI)",RX-411848,CDM,A9548,HCPCS,0343,RC,08888-8877-98,NDC,both,1,UN,13114.64,3934.39,"UHC [10700]","United Healthcare",,2907.92,,,,,,,1525.23,11147.44,"fee schedule",
"DEVICE SUTURING 9MM 2-0 48IN LOADING UNIT ENDO STITCH",SUP-170053,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 80MM 120CM 6.5MM 6FR VASCULAR NITINOL",SUP-S-65-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA [10200]","Cigna Open Access",,5202.08,56.9,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Perc Bile Duct Stent New Access",PX-361000406,CDM,47539,CPT,0361,RC,,,both,,,13746.00,4123.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7883,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1598.66,11684.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN IRRIGATION 18GA 50MM 10MM",SUP-AC0004,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 50CM 6MM 5CM HYBRID REINFORCED COATED",SUP-0650HYB0705A,CDM,C1768,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"NOVANET [10819]",Novanet,,12678.75,75,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE 60CC 1-4MM CANCELLOUS CHIP PUREBONE",SUP-PBC-1460,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 9X100 135CM SL",SUP-48009010R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"NOVANET [10819]",Novanet,,644.26,75,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 60MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.060,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"KAISER [10500]",Kaiser,,138.26,67,,,,,0,24,175.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH-PROFILE BOOST, 170CC",SUP-SMHB170,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3499.65,45.9,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS FIRSTCHOICE 5% DEXTROSE 40 MEQ POTASSIUM",SUP-07904-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA [10200]","Cigna Open Access",,46.09,56.9,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP 3 HOLE CEMENTLESS EMPHASYS",SUP-471048300,CDM,C1776,HCPCS,0278,RC,,,both,,,17955.00,5386.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2088.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2088.17,15261.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 4-0 SC-1 18IN 2 ARM MONOFILAMENT PLIABILIZE",SUP-1828H,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.77,21.23,"MULTIPLAN [10600]",Multiplan,,60.15,85,,,,,0,8.23,60.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SMOOTH SHELL",SUP-SCM-310,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"KAISER [10500]",Kaiser,,5062.19,67,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR ROUND 7.5MM 32MM RESURFACE JOURNEY",SUP-71932912,CDM,C1776,HCPCS,0278,RC,,,both,,,6768.90,2030.67,"PHCS [10601]",PHCS,,4738.23,70,,,,,0,787.22,5753.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 5FR IMC CURVE ANGIOGRAPHIC TRILON BRACHIAL",SUP-H749085262031,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.91,21.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IMMOB ORTHOPEDIC SMALL 32-36IN 32-36IN SHOULDER ELASTIC RIB",SUP-79-84033,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.42,14.83,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PUNCH ARTHROSCOPIC DISPOSABLE 5.5 CORKSCREW FULL THREAD",SUP-AR-1927PBS,CDM,S27200284,LOCAL,0272,RC,,,both,,,637.88,191.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL TAKAHASHI STRAIGHT 7.25IN 2.5-8MM NASAL SHAFT",SUP-63-2020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1132.54,339.76,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RESPIRATORY MALIGNANCY,EXTREME",136,APR-DRG,,,,,,,inpatient,,,94788.68,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $13,131.33. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($62,661.69) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-HYPOVOLEMIC SODIUM DISORDERS,MAJOR",426,APR-DRG,,,,,,,inpatient,,,47858.23,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $8,529.47. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($46,360.17) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 25MM CHESAPEAKE SPINE SELF TAP",SUP-2001-15525,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,841.43,28.62,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR DISPOSABLE 4.5/14MM BIOCOMPOSITE CORKSCREW",SUP-AR-8927DSC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"CIGNA [10200]",Cigna,,1012.1,68,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 4X.7X.05IN SYSTEM 6 SAGITTAL HEAVY DUTY BEVELED",SUP-6118127100,CDM,S27200284,LOCAL,0272,RC,,,both,,,313.30,93.99,"CIGNA [10200]",Cigna,,213.04,68,,,,,0,36.44,266.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 130CM 80MM 5MM BALLOON",SUP-LX181305805F,CDM,C2623,HCPCS,0272,RC,,,both,,,13110.00,3933,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1553.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,782.41,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 22CM 6FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251310,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]","Cigna Open Access",,720,,,,,,,147.16,1075.57,"percent of total billed charges",
"HC Occult Bld Othr Than Screening",PX-301000118,CDM,82272,CPT,0301,RC,,,both,,,70.45,21.13,"CIGNA [10200]","Cigna Open Access",,9.31,,,,,,,2.18,59.88,"fee schedule",
"HC Basic Metabolic Panel Calcium",PX-301000556,CDM,80047,CPT,0301,RC,,,both,,,511.10,153.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,12.23,,"Fee schedule rate ($12.23).",,,,0,12.23,434.44,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANISTER SUCTION ENGN NS",SUP-PAPS3,CDM,S27200284,LOCAL,0272,RC,,,both,,,2737.50,821.25,"NOVANET [10819]",Novanet,,2053.13,75,,,,,0,318.37,2326.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 6MM X 37MM - US",SUP-90315,CDM,S27200284,LOCAL,0272,RC,,,both,,,35649.18,10694.75,"KAISER [10500]",Kaiser,,23884.95,67,,,,,0,4146,30301.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 1.3 MM SCREWS 6 HOLE STRAIGHT BONE",SUP-221.306,CDM,C1713,HCPCS,0278,RC,,,both,,,2007.60,602.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,237.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,233.48,1706.46,"percent of total billed charges",
"STEM HUMERAL 66MM PRESS FIT AEQUALIS ASCEND FLEX PTC 137.5D",SUP-DWF601C,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]",Cigna,,5040,40,,5873.17,5873.17,5873.17,"1 through 10",1465.38,10710,"percent of total billed charges",
"GWIRE PROSTREAM VASCULAR 175CM 12CM .035IN TEFLON STAINLESS",SUP-41278-01,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASC HEMA PLATINUM 26X30",SUP-175426P,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK 8CM SINUS NASAL ABSORBENT FIRM NASOPORE NONSTERILE LATEX",SUP-5400020008,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 16MM 140CM 2.25MM CORONARY STENT PLATINUM",SUP-H7493927416220,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"FIRST HEALTH [10303]","First Health",,3000,80,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 28MM NAIL-EX TITANIUM HUMERAL TIBIAL LOCKING",SUP-04.005.418,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"NOVANET [10819]",Novanet,,867.51,75,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 5 38IN BRAID TIES MULTISTRAND LOWER KNOT",SUP-AR-7210,CDM,S27200284,LOCAL,0272,RC,,,both,,,347.13,104.14,"CIGNA [10200]","Cigna Open Access",,197.52,56.9,,,,,0,40.37,295.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 25MM PRESS FIT FLUTED TRIATHLON KNEE",SUP-5565-S-025,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1355.76,28.62,,,,,0,550.92,4026.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRESSURE SENSING ACCESS SYSTEM (PSAS) 8F 25CM",SUP-PSS-10-0825200-SCN,CDM,S27200284,LOCAL,0272,RC,,,both,,,28350.00,8505,"PHCS [10601]",PHCS,,19845,70,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESTRICT CEMENT MEDIUM UNIVERSAL DISTAL DISPOSABLE INSRT",SUP-B000-1240,CDM,S27800098,LOCAL,0278,RC,,,both,,,810.00,243,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,371.79,45.9,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 65CM PAMIRA S DX 17CM",SUP-428776,CDM,C1777,HCPCS,0278,RC,,,both,,,15180.00,4554,"PHCS [10601]",PHCS,,10626,70,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LITHO SURGICAL 1950MM 2 SHEATH PREASSEMBLE DISTAL WIRE GUIDE",SUP-BML-V232QR-26,CDM,S27200284,LOCAL,0272,RC,,,both,,,2442.00,732.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,289.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,284,2075.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repl Trach Puncture Dilator",PX-E27400047,CDM,L8514,HCPCS,0274,RC,,,both,,,234.30,70.29,"BLUE CROSS [10001]","Blue Cross HMO",,91.85,39.2,,,,,0,27.25,199.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOSCOPIC DISSECTOR STICK, BULLET, 5MM X 400MM",SUP-698.135S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4112.40,1233.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1690.2,41.1,,,,,0,478.27,3495.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 71CM 21GA 18GA PROC CURVE STERILE BROCKENBROUGH ADULT",SUP-EP003994S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 42MM TI",SUP-SPL-35420-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",155.43,1136.03,"percent of total billed charges",
"LENS IOL CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR 1 PIECE UV",SUP-MTA4UO,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Open Access",,391.76,56.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 BV-1 24IN 2 ARM MONOFILAMENT BLUE",SUP-8805H,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.60,58.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,79.98,41.1,,,,,0,22.63,165.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 62MM 3MM SWANSON SHORT PILOT POINT STERILE",SUP-1608-002-133,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 21MM RESTORATION +10MM STD HIP MODULAR REVISION",SUP-6276-1-121,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"CIGNA [10200]","Cigna Open Access",,4846.38,33.5,,5302.19,4377.88,6578.61,27,1682.49,12296.8,"percent of total billed charges",
"GWIRE VASCULAR 6CM STD BENTSON 80CM 17CM .035IN FLOPPY TIP",SUP-G01315,CDM,C1769,HCPCS,0272,RC,,,both,,,195.66,58.7,"FIRST HEALTH [10303]","First Health",,156.53,80,,,,,0,22.76,166.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Scrn Low Risk",PX-750000194,CDM,G0121,HCPCS,0750,RC,,,both,,,3920.00,1176,"BLUE CROSS [10001]","Blue Cross HMO",,2490.09,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",2490.09,2369.03,2490.09,23,455.9,3920,"fee schedule",
"DIL ENDOSCOPIC QUANTUM TTC 320CM 3CM 10MM 6.8-4.5FR BILIARY",SUP-G22767,CDM,C1726,HCPCS,0272,RC,,,both,,,3045.00,913.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,360.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,354.13,2588.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Susceptibility Disk",PX-306000081,CDM,87184,CPT,0306,RC,,,both,,,131.10,39.33,"MULTIPLAN [10600]",Multiplan,,111.44,85,,,,,0,0.01,111.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TAEWOONG NITI-S 15CM 180CM 18MM 10.5FR ESOPHAGEAL",SUP-G57330,CDM,C1874,HCPCS,0278,RC,,,both,,,17589.60,5276.88,"KAISER [10500]",Kaiser,,11785.03,67,,,,,0,2045.67,14951.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Igh@/Bcl2 Translocation Alys",PX-310000050,CDM,81278,CPT,0310,RC,,,both,,,336.00,100.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,336,"per diem",
"CATH CXI 65CM 2.6FR ANGLE SPRT STAINLESS STEEL TUNGSTEN",SUP-G18368,CDM,C1887,HCPCS,0272,RC,,,both,,,1255.50,376.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,853.74,68,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOOTPRINT PEEL-AWAY 1.9FR IV POLYURETHANE PERIPHERAL 2",SUP-P2PIC1.9-C,CDM,C1751,HCPCS,0272,RC,,,both,,,704.70,211.41,"AETNA [10100]","Aetna HMO/PPO",,560.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.96,599,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUMP INFUSION 34MM INTERA 3000 HEPATIC ARTERY HIGH FLOW 30ML",SUP-AP03000H,CDM,C1891,HCPCS,0278,RC,,,both,,,82023.00,24606.9,"NOVANET [10819]",Novanet,,61517.25,75,,,,,0,9539.27,69719.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 5.2MMX1.5-2.2MM 31MM 30 3D GRIP SURFACE POWER",SUP-CDH31P,CDM,S27200284,LOCAL,0272,RC,,,both,,,8613.48,2584.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3953.59,45.9,,,,,0,1001.75,7321.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732050,CDM,C1776,HCPCS,0278,RC,,,both,,,9510.48,2853.14,"BLUE CROSS [10001]","Blue Cross PPO",,3728.11,39.2,,3949.44,3949.44,3949.44,"1 through 10",1106.07,8083.91,"percent of total billed charges",
"CAGE SPINAL 8MM XL COLONIAL",SUP-365.708,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"FIRST HEALTH [10303]","First Health",,5342.74,80,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 30X5IN PRECUT ROLL FIBERGLASS ORTHO-GLASS",SUP-OG-5PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,126.93,38.08,"PHCS [10601]",PHCS,,88.85,70,,,,,0,14.76,107.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOME HOKE 5 1/2IN 5/16IN",SUP-28-4958,CDM,S27200284,LOCAL,0272,RC,,,both,,,190.36,57.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,22.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.14,161.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 73MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE TAPER TIP",SUP-02.107.102S,CDM,C1713,HCPCS,0278,RC,,,both,,,5743.84,1723.15,"MULTIPLAN [10600]",Multiplan,,4882.26,85,,,,,0,668.01,4882.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Spine Lumb/Thor 2+ V",PX-320000042,CDM,72080,CPT,0320,RC,,,both,,,686.11,205.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,65.1,,,,,,,38.7,583.19,"fee schedule",
"SIZER IMPL 13.25CM NATRELLE INSPIRA P6.3CM EXTRA FULL",SUP-MSZ-X560,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA [10200]","Cigna Open Access",,90,56.9,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER HYDROMARK BREAST BIOPSY OPEN COIL TITANIUM 18GA",SUP-4010-02-18-T3,CDM,A4648,HCPCS,0278,RC,,,both,,,640.49,192.15,"BLUE CROSS [10001]","Blue Cross HMO",,251.07,39.2,,,,,0,74.49,544.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 3 WAY STPCOCK TRNSDUC FLUSH DEVICE",SUP-PX260,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.53,31.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,70.4,68,,,,,0,12.04,88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 21-26X27-32X17MM 8D LORDOTIC RING WEDGE",SUP-617,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"CIGNA [10200]","Cigna Open Access",,10552.5,33.5,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EPIDURAL 2IN 19GA 21GA EPILONG TUOHY .2UM METAL PLASTIC",SUP-0131153-51,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.70,80.91,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,31.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.37,229.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STRAIGHT 38MMX1.3MM TITANIUM 2/2.3MM SCREWS 6 HOLE",SUP-A-4655.03,CDM,S27200284,LOCAL,0272,RC,,,both,,,7728.00,2318.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5255.04,68,,,,,0,898.77,6568.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INFLUX SPARC 1CC",SUP-IFLX-CM-01,CDM,S27800098,LOCAL,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND MULTIPASS 3-0 FS-1 18IN BRAID BLACK",SUP-684G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4.0MM CROSSBLADE BURSECTOR",SUP-0475541000,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"PHCS [10601]",PHCS,,425.25,70,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AXLE TIBIAL OSS KNEE LOW FRICTION INTERFACE",SUP-150480,CDM,C1776,HCPCS,0278,RC,,,both,,,3690.00,1107,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1693.71,45.9,,,,,0,429.15,3136.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 195MM 3.2MM STAINLESS STEEL QUICK COUPLING",SUP-310.29,CDM,S27000186,LOCAL,0270,RC,,,both,,,814.21,244.26,"CIGNA [10200]","Cigna Local Plus",,435.6,53.5,,,,,0,94.69,692.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 34MMX12MMX15CM 24FR",SUP-TAC123415A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"NOVANET [10819]",Novanet,,136800,75,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR SURGICAL CONICAL 2.7 MM 3.5 MM 4 MM CORTICAL CONICAL",SUP-309.520,CDM,S27000186,LOCAL,0270,RC,,,both,,,901.69,270.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,613.15,68,,,,,0,104.87,766.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-4 TT-17 36IN 2 ARM MONOFILAMENT WHITE",SUP-4N04A,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.85,83.95,"FIRST HEALTH [10303]","First Health",,223.88,80,,,,,0,32.55,237.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL LONG POST BASEPLT TRABECULAR METAL SHOULDER",SUP-98000961000,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5748.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 8.5INX1MM HARDY BIPOLAR INSULATE",SUP-US411SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,2487.93,746.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,289.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,289.35,2114.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14.75CM NATRELLE INSPIRA P6CM FULL PROFILE ROUND",SUP-MSZ-F695,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"KAISER [10500]",Kaiser,,105.98,67,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EXOFIN FUSION 22CM SKIN CLSR 2-OCTYL CYANOACRYLATE",SUP-EF70401,CDM,S27200284,LOCAL,0272,RC,,,both,,,518.40,155.52,"KAISER [10500]",Kaiser,,347.33,67,,,,,0,60.29,440.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 135CM 150MM 5.7FR 7MM BALLOON DILATATION 2",SUP-BD-L70150CW,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"MULTIPLAN [10600]",Multiplan,,815.87,85,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ADENOID 5/BX",SUP-MM4000SS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1327.95,398.38,"CIGNA [10200]",Cigna,,903.01,68,,,,,0,154.44,1128.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNGOSCOPE GLIDESCOPE 2.5 STAT VIDEO BATON COBALT AV",SUP-0270-0709,CDM,S27200284,LOCAL,0272,RC,,,both,,,216.11,64.83,"KAISER [10500]",Kaiser,,144.79,67,,,,,0,25.13,183.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 5.2MMX1.5-2.2MM 29MM 26 3D GRIP SURFACE POWER",SUP-CDH29P,CDM,S27200284,LOCAL,0272,RC,,,both,,,8613.48,2584.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1020.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1001.75,7321.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SUBSTITUTE 15CC 4-10MM CANCELLOUS CHIPS PUREBONE",SUP-PBC-41015,CDM,S27800098,LOCAL,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 135CM 100MM 4MM .035IN BALLOON",SUP-AB35W04100135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,78.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 20CM 18GA 8FR PEEL-AWAY .038IN STD STAINLESS STEEL",SUP-G01922,CDM,C1892,HCPCS,0272,RC,,,both,,,818.10,245.43,"UHC [10700]","United Healthcare",,517.86,63.3,,,,,0,95.15,695.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BANDAGE ISOBAND 5MRX15CM STERILE WHITE COMPRESSION LATEX FRE",SUP-01958,CDM,S27200284,LOCAL,0272,RC,,,both,,,3096.60,928.98,"MULTIPLAN [10600]",Multiplan,,2632.11,85,,,,,0,360.13,2632.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X7MM 9/11MM SPINE CORTICAL FREEZE DRIED",SUP-14907,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"AETNA [10100]","Aetna HMO/PPO",,13165.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 8MM 16SQ MM 8FR .035IN",SUP-BXAL087901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8562.96,40,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 20MM 75CM 7MM 100CM",SUP-M001711160,CDM,C1876,HCPCS,0278,RC,,,both,,,7417.50,2225.25,"AETNA [10100]","Aetna HMO/PPO",,5896.91,79.5,,,,,0,862.66,6304.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 20MM 8MM BALLOON",SUP-U357582,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656316,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"BLUE CROSS [10001]","Blue Cross PPO",,523.4,39.2,,957.42,570.23,957.42,28,155.28,1134.92,"percent of total billed charges",
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 6-7 E-F KNEE",SUP-42522100712,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS [10001]","Blue Cross PPO",,4224.36,39.2,,3949.44,3949.44,3949.44,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"GRAFT SOFT TISSUE 20X16CM GENTRIX THICK PORCINE",SUP-PSMT1620,CDM,C1781,HCPCS,0278,RC,,,both,,,57153.60,17146.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,15431.47,27,,,,,0,6646.96,48580.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GARMENT CMPR CALF SEQ REPROC",SUP-MSALP1R,CDM,S27000186,LOCAL,0270,RC,,,both,,,75.26,22.58,"NOVANET [10819]",Novanet,,56.45,75,,,,,0,8.75,63.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 4CM 1.5MM GALAXY G3 MINI STRETCH",SUP-GLM915040,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1407.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 1.3 MM SCREWS 6 HOLE STRAIGHT BONE",SUP-221.306,CDM,C1713,HCPCS,0278,RC,,,both,,,2007.60,602.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1365.17,68,,,,,0,233.48,1706.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LASSOSTAR NAV 20MM DIAGNOSTIC CIRCULAR MAPPING CATH",SUP-D140402,CDM,C1732,HCPCS,0272,RC,,,both,,,7286.40,2185.92,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) EDWARDS PASCAL PRECISION TRANSCATHETER VALVE REPAIR S",SUP-20000STCL,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 110MM 2.8MM QUICK CONNECT STERILE",SUP-03.133.108S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1084.10,325.23,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cautery High Temp Fine Tip",PX-E27000077,CDM,E27000077,LOCAL,0270,RC,,,both,,,85.80,25.74,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 35LP 135CM 8CM 5FR 3MM .035IN BALLOON",SUP-G52247,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 8CM 3.5MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN03508,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"MULTIPLAN [10600]",Multiplan,,9964.64,85,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 18MM 50MM SHOULDER DJO SURGICAL ALTIVATE",SUP-520-50-218,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1077.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1057.03,7725.48,"percent of total billed charges",
"SCR BONE 7.3MM 8.2MM 110MM 32MM STAINLESS STEEL 4MM PARTIAL",SUP-209.910,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,630.85,45.9,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 100MM 2MM BALLOON DILATATION STERILE LATEX",SUP-592010022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 80CM SFT STD",SUP-6490,CDM,S27500001,LOCAL,0275,RC,,,both,,,810.00,243,"BLUE CROSS [10001]","Blue Cross HMO",,317.52,39.2,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 152CM 6MM 1.25MM",SUP-SPL12506WL,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 58MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-58-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"NOVANET [10819]",Novanet,,4243.5,75,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 75MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000075,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Local Plus",,866.7,53.5,,3978.14,359.25,3978.14,24,188.41,1377,"percent of total billed charges",
"GENRTR PULSE ATTESTA SR MRI IMPLANTABLE",SUP-ATSR01,CDM,C1786,HCPCS,0275,RC,,,both,,,14490.00,4347,"FIRST HEALTH [10303]","First Health",,11592,80,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR OTSC MINI NITINOL BLUNT TEETH WALL CLSR",SUP-100.01,CDM,C1760,HCPCS,0278,RC,,,both,,,3667.50,1100.25,"MULTIPLAN [10600]",Multiplan,,3117.38,85,,,,,0,426.53,3117.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL BLUE 12MM SYNFIX 14D SMALL EVOLUTION 6.7MM 1.9",SUP-08.815.122S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22MMX9MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2990922,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1883.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MITRACLIP DELIVERY G5",SUP-MCG50100,CDM,S27800098,LOCAL,0278,RC,,,both,,,188100.00,56430,"BLUE CROSS [10001]","Blue Cross HMO",,73735.2,39.2,,,,,0,21876.03,159885,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 1 BP-1 27IN BRAID COATED VIOLET ABSORBABLE",SUP-D6160,CDM,S27200284,LOCAL,0272,RC,,,both,,,305.28,91.58,"AMERIGROUP MEDICAID [20100]",Amerigroup,,36.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.5,259.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 80CM 5FR .046IN .038IN MIK CURVE ANGIOGRAPHIC",SUP-58038MIK,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 6IN 16MM BITE SLIGHT CURVE 3MM KLEINERT-KUTZ",SUP-31-0553,CDM,S27200284,LOCAL,0272,RC,,,both,,,1715.18,514.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PULMONARY EMBOLISM,MODERATE",134,APR-DRG,,,,,,,inpatient,,,39203.61,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $4,712.21. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL RUSSIAN 14IN TISSUE",SUP-07-1535,CDM,S27200284,LOCAL,0272,RC,,,both,,,874.31,262.29,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH XXL 75CM 20MM 5.8FR 12MM 7FR BALLOON DILATATION",SUP-M001145080,CDM,C1725,HCPCS,0272,RC,,,both,,,1709.63,512.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC",423,MS-DRG,,,,,,,inpatient,,,137138.63,41141.59,"CIGNA [10200]","Cigna Local Plus",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $123,159. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 44%. Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 3.5 MM SCR",SUP-P20-910-3500,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIOZORB MARKER LP, 2CM X 3CM X 1CM",SUP-F0231,CDM,A4648,HCPCS,0278,RC,,,both,,,5250.00,1575,"NOVANET [10819]",Novanet,,3937.5,75,,,,,0,610.58,4462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-211-E,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"MULTIPLAN [10600]",Multiplan,,11439.68,85,,,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNEE CONSTRUCT 3 UNICONDYLAR KNEE SYSTEM",SUP-CAP-STY-K3,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"NOVANET [10819]",Novanet,,14175,75,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 170CM 4CM 2.5MM BALLOON DILATATION HYDROPHILIC",SUP-G50321,CDM,C1725,HCPCS,0272,RC,,,both,,,2362.43,708.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,279.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,274.75,2008.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 97MM TRI-LOCK BPS GRIPTION 1 HIGH OFFSET HIP",SUP-101214010,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"KAISER [10500]",Kaiser,,10791.77,67,,,,,0,1873.26,13691.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 10MM LCP STAINLESS STEEL DISTAL FEMUR CONDYLE",SUP-02.221.510S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 12MM 4MM BALLOON DILATATION PACLITAXEL RADIOPAQUE",SUP-H7493960812400,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4609.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT 240X25X4MM BTCP CLLGN VITOSS VOID FILLER FOAM",SUP-2102-1101,CDM,C1713,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Local Plus",,5953.5,31.5,,3978.14,359.25,3978.14,24,2198.07,16065,"percent of total billed charges",
"COIL EMBOLIZATION 8CM 5MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-05008,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PHCS [10601]",PHCS,,8206.17,70,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHAIR COMD 23.5X27-31IN C1000LB 18IN BARIATRIC STEEL DROP",SUP-559247,CDM,S27000186,LOCAL,0270,RC,,,both,,,1298.92,389.68,"UHC [10700]","United Healthcare",,822.22,63.3,,,,,0,151.06,1104.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP HEAD UNIPOLAR HIP FEMUR HIGH DEMAND",SUP-71701035,CDM,C1776,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2962.17,28.62,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 2.5MM15CM 190",SUP-R51002515L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,237.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO MULTIPURPOSE CURVE 45CM 5FR 1.9MM",SUP-G29981,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL BLUE WHITE .6MM OTO-FLEX DIAMOND DIAMOND",SUP-3155646,CDM,S27200284,LOCAL,0272,RC,,,both,,,1972.50,591.75,"PHCS [10601]",PHCS,,1380.75,70,,,,,0,229.4,1676.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Jak2 Gene",PX-309000045,CDM,81270,CPT,0310,RC,,,both,,,1442.10,432.63,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86.21,,"Fee schedule rate ($86.21). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1225.79,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR NONABSORBABLE SAFFRON FIXATION STERILE LATEX FREE",SUP-520340,CDM,S27200284,LOCAL,0272,RC,,,both,,,3898.50,1169.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1602.28,41.1,,,,,0,453.4,3313.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 18FR SILICONE MIC RADIOPAQUE FEED TUBE",SUP-8250-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1752.45,525.73,"CIGNA [10200]","Cigna Open Access",,997.14,56.9,,,,,0,203.81,1489.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120620,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"KAISER [10500]",Kaiser,,7960.81,67,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEEDLE SPINAL FENESTRATED RELINE MAS",SUP-10001117,CDM,S27000186,LOCAL,0270,RC,,,both,,,1008.45,302.53,"CIGNA [10200]","Cigna Local Plus",,539.52,53.5,,,,,0,117.28,857.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000175,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 6.25MM SWIVELOCK TENODESIS SHOULDER BICEPS CLOSED",SUP-AR-1662BC,CDM,C1713,HCPCS,0278,RC,,,both,,,3228.75,968.62,"CIGNA [10200]","Cigna Local Plus",,1727.38,53.5,,3978.14,359.25,3978.14,24,375.5,2744.44,"percent of total billed charges",
"SPACER ALLOGRAFT 7X12MM CORTICAL INTERSPINOUS PROCESS",SUP-4578712,CDM,S27800098,LOCAL,0278,RC,,,both,,,9832.50,2949.75,"NOVANET [10819]",Novanet,,7374.38,75,,,,,0,1143.52,8357.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL COMFORT FLO PLUS LARGE HEAT HUMD WITH CONCHASMART",SUP-2412-11,CDM,S27000186,LOCAL,0270,RC,,,both,,,166.39,49.92,"CIGNA [10200]","Cigna Local Plus",,89.02,53.5,,,,,0,19.35,141.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 8MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-708,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]",Cigna,,5250.9,40,,5873.17,5873.17,5873.17,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"STENT EVERFLEX ENTRUST 60MM 120CM 8MM VASCULAR NICKEL",SUP-EVD35-08-060-120,CDM,C1876,HCPCS,0278,RC,,,both,,,6079.00,1823.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,720.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,706.99,5167.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 4.8FR 20CM WITHOUT GWIRE PERCUFLEX PLUS",SUP-M0061752500,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]","Cigna Local Plus",,482.67,,,,,,,104.92,766.85,"percent of total billed charges",
"GRAFT VASC AORT EXT CUF 28MM",SUP-PLA280300,CDM,C1713,HCPCS,0278,RC,,,both,,,19725.30,5917.59,"KAISER [10500]",Kaiser,,13215.95,67,,,,,0,2294.05,16766.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 24CM 5FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552220,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"NOVANET [10819]",Novanet,,900.44,75,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 16MM 144CM 4MM CORONARY STENT PEBAX",SUP-H7493926016400,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"KAISER [10500]",Kaiser,,3728.55,67,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 3/16IN 3/16IN BARD SILICONE 4 FREE FLOW",SUP-072223,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.71,37.11,"KAISER [10500]",Kaiser,,82.89,67,,,,,0,14.39,105.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +11.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000115,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 15MM 2.5MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP2515X,CDM,C1725,HCPCS,0272,RC,,,both,,,558.90,167.67,"AETNA [10100]","Aetna HMO/PPO",,444.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 8X9X6MM ARCH PARALLEL SPINE FREEZE DRIED",SUP-15108,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 80CM 20MM 5FR 10MM BALLOON DILATATION PEBAX",SUP-39032-10208,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 150MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"FIRST HEALTH [10303]","First Health",,1146.96,80,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ARTHROSCOPIC L7 MM FLEXOR HALLUCIS LONGUS",SUP-AR-1570BC-CP,CDM,C1713,HCPCS,0278,RC,,,both,,,10831.28,3249.38,"PHCS [10601]",PHCS,,7581.9,70,,,,,0,1259.68,9206.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE",RX-6257,CDM,,,0637,RC,60687-0841-11,NDC,both,1,UN,9.42,2.83,"KAISER [10500]",Kaiser,,6.31,67,,,,,0,1.1,8.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER DS 115CM 8MM 7FR 1-7-4MM SPACE F F CURVE",SUP-BD7TCFF8L,CDM,C1733,HCPCS,0272,RC,,,both,,,8700.90,2610.27,"KAISER [10500]",Kaiser,,5829.6,67,,,,,0,1011.91,7395.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH QUICK-CROSS 135CM 1.5FR .026-.039IN 15MM SPACE SPRT",SUP-518-032,CDM,C1887,HCPCS,0272,RC,,,both,,,972.00,291.6,"AETNA [10100]","Aetna HMO/PPO",,772.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REVOLUTION BONE CEMENT FEMUR TOTAL MIXING KIT",SUP-0606593000,CDM,S27200284,LOCAL,0272,RC,,,both,,,963.70,289.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,442.34,45.9,,,,,0,112.08,819.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 730CC P5.1CM MODERATE PLUS PROFILE COHESIVE GEL",SUP-SMPB730,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,903.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",886.73,6480.83,"percent of total billed charges",
"SCR BONE 4MM 8MM 26MM NAIL-EX TITANIUM FULL THREAD HUMERUS",SUP-04.005.416S,CDM,C1713,HCPCS,0278,RC,,,both,,,1496.88,449.06,"NOVANET [10819]",Novanet,,1122.66,75,,,,,0,174.09,1272.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3MM 2 SUTURETAK FIBERWIRE BIOCOMPOSITE 14.5MM",SUP-AR-1934BCF,CDM,C1713,HCPCS,0278,RC,,,both,,,2401.88,720.56,"CIGNA [10200]","Cigna Local Plus",,1285.01,53.5,,3978.14,359.25,3978.14,24,279.34,2041.6,"percent of total billed charges",
"MESH HERNIA POLYGLYCOLIC ACID 20X20IN RESORBABLE GRID 2",SUP-F10258-2020G,CDM,C1781,HCPCS,0272,RC,,,both,,,49593.60,14878.08,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,20382.97,41.1,,,,,0,20382.97,31392.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXIVA PULSE ID 910",SUP-M006L8406940,CDM,S27200284,LOCAL,0272,RC,,,both,,,4808.75,1442.62,"FIRST HEALTH [10303]","First Health",,3847,80,,,,,0,559.26,4087.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL LIGHT GREEN 28X32X6.9-10.5MM SYNFIX 10D SMALL",SUP-08.815.141S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ 110CM 7FR STD ARTERIAL LINE 4 LUMEN",SUP-131F7P,CDM,C1751,HCPCS,0272,RC,,,both,,,654.08,196.22,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,268.83,41.1,,,,,0,76.07,555.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM CD HORIZON SOLERA VOYAGER SPINE",SUP-55850015545,CDM,C1713,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"AETNA [10100]","Aetna HMO/PPO",,5211.23,79.5,,1521.93,481.35,16760.95,30,762.35,5571.75,"percent of total billed charges",
"STENT LIFESTENT 170MM 135CM 5MM 5FR VASCULAR NITINOL LOW",SUP-5F051703CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"BLUE CROSS [10001]","Blue Cross PPO",,8137.33,39.2,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBING PRESSURE MON SEPARATOR MALE TO FEMALE LUER 7/64X3/64",SUP-029456000,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,118.32,68,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 95MM 11MM 6MM CUFF DISTAL EXT EXTEND LENGTH DISPOSABLE",SUP-60XLTCD,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"CIGNA [10200]","Cigna Local Plus",,259.62,53.5,,,,,0,56.44,412.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ATHERECTOMY DIAMONDBACK L145 CM OD2 MM PERIPHERAL M",SUP-DBP-200MAX145,CDM,C1724,HCPCS,0272,RC,,,both,,,21388.50,6416.55,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH INFINITI THRULUMEN 100CM 5FR .047IN JUDKINS RIGHT",SUP-534523T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ANGIOSCULPT XL 137CM 20MM 6MM RECTANGLE HELIX BALLOON",SUP-2076-6020,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EMBOLECTOMY 80CM 4FR 9MM STAINLESS STEEL SILICONE",SUP-NL4EMB80,CDM,C1757,HCPCS,0272,RC,,,both,,,376.01,112.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET RTRCTR REDDICK-SAYE SCR KIT NDL",SUP-E2504-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,2617.22,785.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH QUICK-CROSS 65CM .035IN ANGLE SPRT",SUP-518-077,CDM,C1887,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SHEATH 10.5FR 18GA 17.7IN 25CM SPLITTABLE HEMOSTA",SUP-CLS-2510.5,CDM,C1892,HCPCS,0272,RC,,,both,,,1417.50,425.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,164.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE MERIT LAUREATE VASCULAR ANGLE STD 180CM 3CM .035IN",SUP-LWSTDA35180,CDM,C1769,HCPCS,0272,RC,,,both,,,278.40,83.52,"MULTIPLAN [10600]",Multiplan,,236.64,85,,,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 61MM 28MM UHR UNIVERSAL HIP FEMUR COCR UHMWPE",SUP-UH1-61-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"PHCS [10601]",PHCS,,3960.6,70,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Cerv Spine W Cntrst",PX-352000009,CDM,72126,CPT,0352,RC,,,both,,,3423.78,1027.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,405.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,398.19,2910.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC",918,MS-DRG,,,,,,,inpatient,,,19632.20,5889.66,"UHC [10700]","United Healthcare",,19632.2,,"Fee schedule rate ($21,375.22). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,5316.64,19632.2,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE SMALL OVAL 240CM 2.4MM SENSATION LOOP SHORT THROW",SUP-M00562693,CDM,S27200284,LOCAL,0272,RC,,,both,,,77.43,23.23,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.01,65.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ENDARTERECTOMY 11MM 13MM 2 COAXIAL METAL RING",SUP-E4500-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,17633.70,5290.11,"CIGNA [10200]","Cigna Local Plus",,9434.03,53.5,,,,,0,2050.8,14988.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 100MM 120CM 6.5MM 6FR VASCULAR NITINOL",SUP-S-65-100-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1192.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TENDER TOUCH ULTRA 60MM VACUUM EXTRACTION SILICONE",SUP-505TT,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.75,58.72,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,133.11,68,,,,,0,22.77,166.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anoscopy Diagnostic",PX-750000178,CDM,46601,CPT,0750,RC,,,both,,,711.00,213.3,"KAISER [10500]",Kaiser,,476.37,67,,,,,0,82.69,711,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 6MMX15MM 7FR 135CMCATH HEPARIN",SUP-BXB061502A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG DOME HOLE ACETABULAR DOME",SUP-2060-0000-1,CDM,S27800098,LOCAL,0278,RC,,,both,,,571.90,171.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,163.68,28.62,,,,,0,66.51,486.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS",RX-87834,CDM,,,0250,RC,70069-0651-01,NDC,both,5,ML,1232.15,369.64,"CIGNA [10200]","Cigna Open Access",,701.09,56.9,,,,,0,143.3,1047.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3.5MM 12/14 LARGE 32MM HIP ACETABULAR BIOLOX",SUP-877503203,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"UHC [10700]","United Healthcare",,6240.57,63.3,,8601.07,8395.67,8601.07,"1 through 10",1146.57,8379.91,"percent of total billed charges",
"SCR BONE 2MM 12MM CHARLOTTE SNAP OFF",SUP-45110002,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 36MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR36,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UHC [10700]","United Healthcare",,8298.63,63.3,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 24MMX11MM WAVE D 6D PEEK STERILE",SUP-2661124,CDM,S27800098,LOCAL,0278,RC,,,both,,,24192.00,7257.6,"PHCS [10601]",PHCS,,16934.4,70,,,,,0,2813.53,20563.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WATCHDOG ACCESSORY KIT (20-PACK)",SUP-H74939343A021,CDM,C1725,HCPCS,0272,RC,,,both,,,437.40,131.22,"FIRST HEALTH [10303]","First Health",,349.92,80,,,,,0,50.87,371.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 7MM 220MM HUMERAL NAIL-EX INTRAMEDULLARY CANNULATED",SUP-04.001.224S,CDM,C1713,HCPCS,0278,RC,,,both,,,9216.74,2765.02,"PHCS [10601]",PHCS,,6451.72,70,,,,,0,1071.91,7834.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 124MM CEMENTLESS OFFSET ACCOLADE TMZF 127D +0",SUP-6021-3535,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"FIRST HEALTH [10303]","First Health",,12519.36,80,,,,,0,1820,13301.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 6.5MM FRACTURE EQUINOXE RIGHT SHOULDER",SUP-304-22-07,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"BLUE CROSS [10001]","Blue Cross HMO",,5409.6,39.2,,5311.50,4717.44,5388.59,31,1604.94,11730,"percent of total billed charges",
"COROENT XL-XW, 12X26X45MM 10",SUP-6212145,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 14.2MM 25MM 23.4MM ON-X 33MM CYLINDRICAL HEART",SUP-ONXM-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4396.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 9MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G109,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4590,45.9,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 11X44MM VERTE-STACK CORNERSTONE PSR 11MM",SUP-6271044,CDM,S27800098,LOCAL,0278,RC,,,both,,,5299.20,1589.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3603.46,68,,,,,0,616.3,4504.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 28CM 6FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001274140,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 16MM 135CM 7MM VASCULAR BALLOON EXPANDABLE",SUP-LSMU1350716,CDM,C1874,HCPCS,0278,RC,,,both,,,15870.00,4761,"AETNA [10100]","Aetna HMO/PPO",,12616.65,79.5,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 30CM 7FR .035",SUP-M006192145090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,173.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP APPLR PROGEL SPRAY EXTEND 29CM",SUP-PGEN005-11,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,159.73,45.9,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 32MM VUEPOINT II SPINE MULTIAXIAL NONSTERILE",SUP-8975732,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Open Access",,2159.36,56.9,,1144.80,304.56,2275.09,66,441.36,3225.75,"percent of total billed charges",
"NDL BIOPSY 25GA 5.2FR 0-8CM ECHOTIP PROCORE CONTOUR HANDLE",SUP-G55738,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]","Cigna Open Access",,1920.38,56.9,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 35CM INJECTION CYSTOSCOPY WILLIAMS 8MM 23GA 5",SUP-G14220,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"UHC [10700]","United Healthcare",,137.68,63.3,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX12MM MAXIM KNEE PRIMARY CRUCIATE RETAIN",SUP-11-146352,CDM,C1776,HCPCS,0278,RC,,,both,,,7472.70,2241.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3429.97,45.9,,,,,0,869.08,6351.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 28CM 8FR SHORT LENGTH URETERAL",SUP-H7493936108280,CDM,C2617,HCPCS,0278,RC,,,both,,,1142.10,342.63,"KAISER [10500]",Kaiser,,765.21,67,,,,,0,132.83,970.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM 20.4MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-25MECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11647.69,40,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 30CM 6FR .038",SUP-M006192135120,CDM,C2617,HCPCS,0278,RC,,,both,,,1528.96,458.69,"NOVANET [10819]",Novanet,,1146.72,75,,,,,0,177.82,1299.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 10 STD KNEE LEFT CRUCIATE RETAINING PERSONA",SUP-42502806801,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11558.23,40,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 40MM TI",SUP-MTC-37400-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"MULTIPLAN [10600]",Multiplan,,1060.29,85,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL MULTIPASS 5-0 PS-3 18IN BRAID COATED UNDYED",SUP-J500G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"MULTIPLAN [10600]",Multiplan,,21.25,85,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER 200UM BALL TIP DISPOSABLE",SUP-TFL-FBX200BS,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROLIFT PL EXPANDABLE INTERBODY 10X28X8-13 MM 0",SUP-58-1028-0813K,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"NOVANET [10819]",Novanet,,21262.5,75,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 17X10CM FLEXHD PLIABLE THK.7-1.4MM SMALL THIN",SUP-SF1500,CDM,Q4128,HCPCS,0636,RC,,,both,,,18741.62,5622.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2220.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.43,15930.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL BLUE WHITE .6MM OTO-FLEX DIAMOND DIAMOND",SUP-3155646,CDM,S27200284,LOCAL,0272,RC,,,both,,,1972.50,591.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,905.38,45.9,,,,,0,229.4,1676.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLUE FLEXTIP 8IN 7FR CENTRAL VENOUS POLYURETHANE",SUP-ML-00703,CDM,C1751,HCPCS,0272,RC,,,both,,,285.36,85.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,33.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.19,242.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 25GA 5.2FR 0-8CM ECHOTIP PROCORE CONTOUR HANDLE",SUP-G55738,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"AETNA [10100]","Aetna HMO/PPO",,2683.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET SILASTIC 2X2X.04IN TRIMMABLE STERILE LATEX FREE",SUP-1532520,CDM,S27800098,LOCAL,0278,RC,,,both,,,237.51,71.25,"FIRST HEALTH [10303]","First Health",,190.01,80,,,,,0,27.62,201.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 13MM CEMENTLESS TOTAL STABILIZED",SUP-5566-S-013,CDM,C1776,HCPCS,0278,RC,,,both,,,5447.65,1634.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,633.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,633.56,4630.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAPPHIRE NC PLUS 8MM 3.75MM BALLOON DILATATION",SUP-237-083-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BAKRI 54CM 180CM 24FR INTRAUTERINE SILICONE 500ML 60ML",SUP-G24237,CDM,S27200284,LOCAL,0272,RC,,,both,,,2965.28,889.58,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,351.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.86,2520.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH SUPER SHEATH SHORT 11CM 7FR INTRO SILICONE TWIST LOCK",SUP-H7491603507B1,CDM,C1894,HCPCS,0272,RC,,,both,,,79.31,23.79,"UHC [10700]","United Healthcare",,50.2,63.3,,,,,0,9.22,67.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE 3-5 CUSTOM MODEL SET SIGNATURE SURGICAL TOTAL KNEE",SUP-42-422551,CDM,S27200284,LOCAL,0272,RC,,,both,,,7468.56,2240.57,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5078.62,68,,,,,0,868.59,6348.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EXOFIN FUSION 22CM SKIN CLSR 2-OCTYL CYANOACRYLATE",SUP-EF70401,CDM,S27200284,LOCAL,0272,RC,,,both,,,518.40,155.52,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,61.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.29,440.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX 3IN MONOFILAMENT SCAFFOLD FULL",SUP-1190100,CDM,C1781,HCPCS,0278,RC,,,both,,,8186.85,2456.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5567.06,68,,,,,0,952.13,6958.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 100MM 135CM 6MM 5FR VASCULAR NITINOL LOW",SUP-5F061003CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"AETNA [10100]","Aetna HMO/PPO",,12068.1,79.5,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 24CM 7MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-07024,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"FIRST HEALTH [10303]","First Health",,9378.48,80,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 28MM 144CM 2.75MM",SUP-H7493941228270,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,919.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 60MM 80CM 8MM 8FR STRAIGHT VASCULAR COVER",SUP-AVSM08060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5228.87,28.62,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INBORN AND OTHER DISORDERS OF METABOLISM",642,MS-DRG,,,,,,,inpatient,,,39926.25,11977.87,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,9086.01,,"Case rate ($8,821.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,191.24, add-ons for qualifying new technology services are included. If operating cost exceeds $41,230.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,001.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,202.07. The transfer operating threshold is the transfer adjustment factor * $8,191.24 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.30. The transfer capital threshold is the transfer adjustment factor * $619.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,35465.75,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 12/14 TAPER 36MM HIP M SPECIFICATION COCR",SUP-136554000,CDM,C1776,HCPCS,0278,RC,,,both,,,6720.60,2016.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,796.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,781.61,5712.51,"percent of total billed charges",
"INSRT TIBIAL 3 11MM KNEE X3 POSTERIOR STABILIZED PRIMARY",SUP-5532-G-311,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CIGNA [10200]","Cigna Local Plus",,4658.57,53.5,,5372.07,4581.20,7242.98,23,1012.7,7401.47,"percent of total billed charges",
"BLADE SAW 100X25X1.37MM SAGITTAL",SUP-6125-137-100,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 235MM 28MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-328,CDM,C1776,HCPCS,0278,RC,,,both,,,18758.25,5627.47,"CIGNA [10200]",Cigna,,7503.3,40,,5873.17,5873.17,5873.17,"1 through 10",2181.58,15944.51,"percent of total billed charges",
"HOOK ENDOSCOPIC HARMONIC SYNERGY COMBINATION BLADE",SUP-SNGHK2,CDM,S27200284,LOCAL,0272,RC,,,both,,,1862.06,558.62,"CIGNA [10200]","Cigna Local Plus",,996.2,53.5,,,,,0,216.56,1582.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X6MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7306,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"PHCS [10601]",PHCS,,4830,70,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 10FR DRNG FLEXIMA BILIARY METAL AND FLEXIBLE",SUP-M001271550,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR .035IN RC2",SUP-G08470,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"PHCS [10601]",PHCS,,166.24,70,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dbrd Wnd Rmvl Tis Non-Sel",PX-510000168,CDM,97602,CPT,0761,RC,,,both,,,563.45,169.03,"KAISER [10500]",Kaiser,,377.51,67,,,,,0,65.53,563.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 100CM 5FR BARNH CURVE ANGIOGRAPHIC CEREBRAL",SUP-M001314041,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"AETNA [10100]","Aetna HMO/PPO",,92.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemdnrv Larynx Perc",PX-361000329,CDM,64617,CPT,0761,RC,,,both,,,2984.00,895.2,"KAISER [10500]",Kaiser,,1999.28,67,,,,,0,347.04,2740.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plt Count Auto",PX-305000013,CDM,85049,CPT,0305,RC,,,both,,,123.50,37.05,"FIRST HEALTH [10303]","First Health",,98.8,80,,,,,0,0.01,104.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000105,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM G7 STD THR E1 HIP STEM CUP LINER HEAD PREM",SUP-98000100155,CDM,C1776,HCPCS,0278,RC,,,both,,,25200.00,7560,"NOVANET [10819]",Novanet,,18900,75,,,,,0,2930.76,21420,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 73X25X.89MM MEDIUM WIDE STAINLESS STEEL 2 CUT",SUP-2108-105,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"PHCS [10601]",PHCS,,167.36,70,,,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 30ML 1.7-10MM 50% CORTICAL 50% CANCELLOUS",SUP-400045,CDM,C1713,HCPCS,0278,RC,,,both,,,2842.88,852.86,"CIGNA [10200]",Cigna,,1933.16,68,,1831.33,1831.33,1831.33,16,330.63,2416.45,"percent of total billed charges",
"BLADE INTRAMEDULLARY NAIL TAN 105MM 10.35MM TFN-ADVANCED",SUP-04.038.405S,CDM,C1713,HCPCS,0278,RC,,,both,,,3981.85,1194.55,"CIGNA [10200]","Cigna Open Access",,2265.67,56.9,,1144.80,304.56,2275.09,66,463.09,3384.57,"percent of total billed charges",
"RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR",RX-70434,CDM,,,0637,RC,50228-0423-60,NDC,both,1,UN,25.19,7.56,"PHCS [10601]",PHCS,,17.63,70,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER ENDOSCOPIC 20MM 3MM TREVO XP PROVUE STERILE LATEX",SUP-90183,CDM,S27200284,LOCAL,0272,RC,,,both,,,47273.94,14182.18,"FIRST HEALTH [10303]","First Health",,37819.15,80,,,,,0,5497.96,40182.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDEAVOR SPRINT 18MM 142CM 3MM CORONARY STENT",SUP-ENSP30018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1586.69,28.62,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 8IN DURAL RETRACTION BLUNT ADSON",SUP-285227,CDM,S27200284,LOCAL,0272,RC,,,both,,,203.41,61.02,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,93.37,45.9,,,,,0,23.66,172.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ITOTAL PS IPOLY IMPLANT KIT",SUP-TPS1111111,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"AETNA [10100]","Aetna HMO/PPO",,21286.13,79.5,,10981.53,8986.79,12413.38,12,3113.93,22758.75,"percent of total billed charges",
"LEAD PACING DEFIB TRUE BIPOLAR PASSIVE FIXATION DURATA SJ4",SUP-7170/65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"FIRST HEALTH [10303]","First Health",,13737.6,80,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 65MM NAIL-EX TITANIUM FULL THREAD TIBIAL SELF",SUP-04.015.555,CDM,C1713,HCPCS,0278,RC,,,both,,,1313.17,393.95,"CIGNA [10200]","Cigna Open Access",,747.19,56.9,,1144.80,304.56,2275.09,66,152.72,1116.19,"percent of total billed charges",
"HC CT Upr Ext WO Cntrst",PX-359000001,CDM,73200,CPT,0352,RC,,,both,,,2018.48,605.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,405,,"Per diem ($405). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,234.75,1933,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 2.75MM BALLOON DILATATION PEBAX",SUP-1012273-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Actinomyces Antibody",PX-302000262,CDM,86602,CPT,0302,RC,,,both,,,50.00,15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16.01,,,,,,,0.01,42.5,"fee schedule",
"COLCHICINE 0.6 MG TABLET",RX-1821,CDM,,,0637,RC,50268-0187-11,NDC,both,1,UN,27.21,8.16,"CIGNA [10200]","Cigna Open Access",,15.48,56.9,,,,,0,3.16,23.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP RIM CLUSTER HOLE TRITANIUM X3 MDM",SUP-502-03-56E,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7117.44,68,,,,,0,1217.29,8896.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR OMNI CURVE ANGIOGRAPHIC VISCERAL",SUP-10732201,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.62,32.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,74.54,68,,,,,0,12.75,93.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 11MM HELIX R SPINE SELF TAP VARIABLE ANGLE",SUP-7805111,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",117.75,860.63,"percent of total billed charges",
"CATH SOFT-VU 65CM 5FR OMNI CURVE ANGIOGRAPHIC VISCERAL",SUP-10732201,CDM,S27200284,LOCAL,0272,RC,,,both,,,109.62,32.89,"UHC [10700]","United Healthcare",,69.39,63.3,,,,,0,12.75,93.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR RINGLOC +3MM 23 36MM ARCOMXL HIP HIGH WALL",SUP-XL-108323,CDM,C1776,HCPCS,0278,RC,,,both,,,9937.38,2981.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1177.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1155.72,8446.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SPECIMEN RETRIEVAL 240CM 5.5FR 3 PRONG HOOKED GRASPING",SUP-G25080,CDM,S27200284,LOCAL,0272,RC,,,both,,,1239.30,371.79,"FIRST HEALTH [10303]","First Health",,991.44,80,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 10MM 27MM SYMMETRIC DURACON DURATION KNEE",SUP-6642-2-627,CDM,C1776,HCPCS,0278,RC,,,both,,,3506.63,1051.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1003.6,28.62,,,,,0,407.82,2980.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 20MM 7MM BALLOON",SUP-U3513072,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR REGULAR 30MM PROXIMATE TX TITANIUM ENDOSCOPIC",SUP-XR30B,CDM,S27200284,LOCAL,0272,RC,,,both,,,938.45,281.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GARM COMPRESSION LARGE UNIVERSAL THIGH FABRIC FLOWTRON 10.6",SUP-DVT40,CDM,S27000186,LOCAL,0270,RC,,,both,,,180.70,54.21,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MARINR 80CM 5FR 2-5-2MM SPACING 65MM REACH ABLATION",SUP-76586,CDM,C1733,HCPCS,0272,RC,,,both,,,3562.50,1068.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PASSER ACCU-PASS 45D RIGHT CURVE RIGHT SHUTTLE ERGONOMIC",SUP-7210424,CDM,S27200284,LOCAL,0272,RC,,,both,,,1129.95,338.98,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EZ STEER NAV 115CM 4MM 7FR 1-7-4MM SPACE D-D CURVE",SUP-BN7TCDD4L,CDM,C1732,HCPCS,0272,RC,,,both,,,15366.30,4609.89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EQUALIZER 100CM 7FR 110.5MM STD BALLOON OCCLUSION NYLON",SUP-M001171030,CDM,C2628,HCPCS,0272,RC,,,both,,,1912.50,573.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 165MM 4.5MM CANNULATED STOP 135MM JACOB CHUCK",SUP-03.010.089S,CDM,S27000186,LOCAL,0270,RC,,,both,,,2549.40,764.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LIVEWIRE 115CM 4MM 6FR 1MM 2-5-2MM SPACE MEDIUM SWEEP",SUP-401600,CDM,C1730,HCPCS,0272,RC,,,both,,,2625.00,787.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TIP SCISSORS MONOPOLAR CURVE STERILE LATEX FREE DISPOSABLE",SUP-430035,CDM,S27200284,LOCAL,0272,RC,,,both,,,1020.60,306.18,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CRM PROBE COVER 6X96",SUP-451524,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.80,114.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 200CM 80MM 6MM BALLOON DILATATION RAPID EXCHANGE",SUP-47560080L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PRESSURE INJECTABLE ARROWGARD BLUE ADVANCEONE-LUMEN PICC PR",SUP-DLX-45541-VPSB,CDM,C1751,HCPCS,0272,RC,,,both,,,2577.50,773.25,"FIRST HEALTH [10303]","First Health",,2062,80,,,,,0,299.76,2190.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 100MM 120CM 10MM 161CM VASCULAR NITINOL ILIAC",SUP-H74939200101020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross PPO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 3 LEFT DISTAL KNEE TOTAL",SUP-5540-A-301,CDM,C1776,HCPCS,0278,RC,,,both,,,4543.81,1363.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3089.79,68,,,,,0,528.45,3862.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 16MM STAINLESS STEEL T6 SELF TAP LOCK VARIABLE",SUP-02.130.316,CDM,C1713,HCPCS,0278,RC,,,both,,,841.43,252.43,"MULTIPLAN [10600]",Multiplan,,715.22,85,,,,,0,97.86,715.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE INCISION ACMI CLASSIC",SUP-M0068805511,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,237.06,45.9,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION PAPARELLA NOTCH TAB",SUP-1025001,CDM,S27800098,LOCAL,0278,RC,,,both,,,220.98,66.29,"MULTIPLAN [10600]",Multiplan,,187.83,85,,,,,0,25.7,187.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEARS ELECTROSURGICAL 20CM 5MM HARMONIC HD CURVE TIP 1000I",SUP-HARHD20,CDM,S27200284,LOCAL,0272,RC,,,both,,,5082.89,1524.87,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2333.05,45.9,,,,,0,591.14,4320.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 16MM 144CM 3MM CORONARY STENT",SUP-H7493941816300,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 10MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-510-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"UHC [10700]","United Healthcare",,7617.27,63.3,,8601.07,8395.67,8601.07,"1 through 10",1399.51,10228.56,"percent of total billed charges",
"COIL EMBOLIZATION 15CM 4MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0415,CDM,S27800098,LOCAL,0278,RC,,,both,,,6762.00,2028.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1935.28,28.62,,,,,0,786.42,5747.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Ish Ea Adl 1",PX-312000082,CDM,0849T,CPT,0312,RC,,,both,,,104.00,31.2,"NOVANET [10819]",Novanet,,78,75,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIAGNOSTIC ELECTROPHYSIOLOGY CABLE 6F FEMORAL ONLY SINGLE US",SUP-DEX-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ACROBAT ENDOSCOPIC 25CM SPRING COIL 260CM 4CM .025IN",SUP-G32758,CDM,C1769,HCPCS,0272,RC,,,both,,,1441.80,432.54,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN ENDOSCOPIC FLEXIBLE EFLEX STERILE DISPOSABLE 5.7MM HIP",SUP-7205360,CDM,S27200284,LOCAL,0272,RC,,,both,,,198.45,59.53,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SPRINTER FASTRAC 138CM 15MM 3.2-2.4-2.6FR 3MM BALLOON",SUP-SPR3015W,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE VENTILATION BLUE 7.6MM 1.14MM ARMSTRONG EAR SILICONE",SUP-240052,CDM,S27200284,LOCAL,0272,RC,,,both,,,135.01,40.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MACH1 55CM 7FR .081IN MULTIPURPOSE CURVE GUIDING PTFE",SUP-M001197230,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH COYOTE MONORAIL 150CM 220MM 4MM BALLOON DILATATION",SUP-H74939185402210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT CONTOUR SENSOR DUAL-FLEX 22-30CM 3CM 4.8FR .035IN",SUP-M006180155090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,157.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH UROMAX ULTRA QUADRA-FOLD ENCORE HIGH PRESSURE KINK",SUP-M0062251280,CDM,C1726,HCPCS,0272,RC,,,both,,,1892.70,567.81,"KAISER [10500]",Kaiser,,1268.11,67,,,,,0,220.12,1608.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT CEMENTED CRUCIATE RETAINING ATTUNE",SUP-150400106,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"PHCS [10601]",PHCS,,15675.35,70,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROLIFT PL EXPANDABLE INTERBODY 10X28X8-13 MM 0",SUP-58-1028-0813K,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 5MM BALLOON DILATATION STERILE LATEX",SUP-585012022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"UHC [10700]","United Healthcare",,948.55,63.3,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 20MM 9MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171090270,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 5FR 21GA MERIT MAK .018IN STAINLESS STEEL",SUP-MAK505-PED,CDM,C1894,HCPCS,0272,RC,,,both,,,230.55,69.16,"NOVANET [10819]",Novanet,,172.91,75,,,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM ORTHOLOC TITANIUM NITRIDE FOREFOOT ANKLE",SUP-5201024018,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,791.78,45.9,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 5MM SPACE STD F CURVE",SUP-F6QF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"KAISER [10500]",Kaiser,,607.82,67,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 30CM 6FR 2.2MM FLEXOR CHECK-FLO SMALL VALVE",SUP-G08969,CDM,C1894,HCPCS,0272,RC,,,both,,,415.08,124.52,"FIRST HEALTH [10303]","First Health",,332.06,80,,,,,0,48.27,352.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752740,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,414.1,45.9,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE 8.5-10 LARGE FEMALE PATIENT 2 PADDED POSTOPERATIVE",SUP-MQW3B,CDM,S27000186,LOCAL,0270,RC,,,both,,,78.91,23.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.18,67.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANSURETHRAL PROCEDURES WITH CC",669,MS-DRG,,,,,,,inpatient,,,63375.59,19012.68,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,9915.96,,"Case rate ($9,627.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,939.46, add-ons for qualifying new technology services are included. If operating cost exceeds $41,979.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,057.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,951.28. The transfer operating threshold is the transfer adjustment factor * $8,939.46 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $675.87. The transfer capital threshold is the transfer adjustment factor * $675.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,45312.19,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 25MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-425,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1164.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1143.29,8355.94,"percent of total billed charges",
"SCR INTERFERENCE TITANIUM 20MM 7MM ACL PCL CANNULATED SHEATH",SUP-AR-1370E,CDM,C1713,HCPCS,0278,RC,,,both,,,978.08,293.42,"BLUE CROSS [10001]","Blue Cross PPO",,383.41,39.2,,957.42,570.23,957.42,28,113.75,831.37,"percent of total billed charges",
"LENS IOL MONOFOCAL 1 PIECE ANTERIOR ASPHERIC UV BLOCK TECNIS",SUP-PCB0000105,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 8- CM 22GA 5.2FR ULTRASOUND SHEATH BALL",SUP-G31521,CDM,S27200284,LOCAL,0272,RC,,,both,,,2340.00,702,"CIGNA [10200]","Cigna Local Plus",,1251.9,53.5,,,,,0,272.14,1989,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUP ACETABULAR 66MM PINNACLE HIP POROCOAT SECTOR SERIES",SUP-121722066,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"CIGNA [10200]","Cigna Local Plus",,6072.52,53.5,,5372.07,4581.20,7242.98,23,1320.06,9647.93,"percent of total billed charges",
"GRAFT BONE CANCELLOUS 60ML .1-4MM ALLOGRAFT CRUSH FREEZE",SUP-T20027,CDM,S27800098,LOCAL,0278,RC,,,both,,,6399.75,1919.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2937.49,45.9,,,,,0,744.29,5439.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METRONIDAZOLE 50 MG/ML ORAL SUSPENSION",RX-408882,CDM,,,0637,RC,08888-8885-98,NDC,both,83,ML,48.03,14.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22.05,45.9,,,,,0,5.59,40.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TYSHAK II 100CM 5CM 8FR 18MM BALLOON DILATATION",SUP-611929,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"FIRST HEALTH [10303]","First Health",,3040.97,80,,,,,0,442.08,3231.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GARM COMPRESSION 50-60HZ 25VA LARGE UNIVERSAL CALF VELCRO",SUP-DVT20,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.58,33.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.55,95.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17MM MASTERS HEMODYNAMIC PLUS STD MECHANICAL",SUP-17AHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7862.19,27,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 12MM AXIUM 3D FRAME V01",SUP-FC-12-40-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"NOVANET [10819]",Novanet,,12394.13,75,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 0D HIP X3 TRIDENT",SUP-623-00-32D,CDM,C1776,HCPCS,0278,RC,,,both,,,6242.04,1872.61,"CIGNA [10200]","Cigna Local Plus",,3339.49,53.5,,5372.07,4581.20,7242.98,23,725.95,5305.73,"percent of total billed charges",
"SCR BONE 1.5MM 13MM ALPS COCR SQUARE HAND CORTICAL LOCK SELF",SUP-131220413,CDM,S27200284,LOCAL,0272,RC,,,both,,,1032.75,309.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,424.46,41.1,,,,,0,120.11,877.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 28MM 144CM 4MM CORONARY STENT",SUP-H7493911428400,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"MULTIPLAN [10600]",Multiplan,,7771.13,85,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PRECISION ALIF 14MM",SUP-451466A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 120MM 120CM 6MM VASCULAR PERIPHERAL SELF",SUP-PRB35-06-120-120,CDM,C1876,HCPCS,0278,RC,,,both,,,6930.00,2079,"AETNA [10100]","Aetna HMO/PPO",,5509.35,79.5,,,,,0,805.96,5890.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 14.5IN 14FR PHILLIPS 1/56IN HOLLOW PLASTIC 1",SUP-346114,CDM,S27200284,LOCAL,0272,RC,,,both,,,146.16,43.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +24 DIOPTER +2.25 CYL BICONVEX 13MM 6MM",SUP-SN6AT4.240,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"KAISER [10500]",Kaiser,,231.15,67,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW CPRTEX 4.5X54MM",SUP-214.054,CDM,S27800098,LOCAL,0278,RC,,,both,,,464.78,139.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,54.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.05,395.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 60X14-18MM",SUP-400730,CDM,S27800098,LOCAL,0278,RC,,,both,,,4264.20,1279.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,505.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,495.93,3624.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 15MM AEQUALIS 6 SHOULDER HA REVERSED STD",SUP-DWD003,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"BLUE CROSS [10001]","Blue Cross PPO",,3701.66,39.2,,3949.44,3949.44,3949.44,"1 through 10",1098.22,8026.55,"percent of total billed charges",
"PCMKR CRD THK6MM 50X47MM","SUP-PM1272 CELL",CDM,C1786,HCPCS,0275,RC,,,both,,,9324.00,2797.2,"CIGNA [10200]","Cigna Open Access",,5305.36,56.9,,,,,0,1084.38,7925.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LOCKING CREO SPINAL MIS NONSTERILE",SUP-1134.0010,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",50.59,369.75,"percent of total billed charges",
"OCCL CARDIOVASCULAR 6MM 11MM 5MM DUCT TYPE II SELF EXPANDING",SUP-9-PDA2-05-06,CDM,C1817,HCPCS,0278,RC,,,both,,,15444.00,4633.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4420.07,28.62,,,,,0,1796.14,13127.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)CORONARY IVL CATHETER, 3.5MM X 20MM, RX IDE",SUP-501050-007,CDM,C1761,HCPCS,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE PLUS REVOLUTION 25CM 8.5FR DRNG HYDROPHILIC",SUP-RLCMB-8-REV,CDM,C1729,HCPCS,0272,RC,,,both,,,595.35,178.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,244.69,41.1,,,,,0,69.24,506.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HYDRA JAGWIRE ENDOSCOPIC STRAIGHT 260CM .035IN",SUP-M00556021,CDM,C1769,HCPCS,0272,RC,,,both,,,1422.36,426.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) CHAMPIONIR DES SYSTEM US 6-100",SUP-412601000USRD,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 8.5-7MM 35MM CREO SPINE 2 OUTER DIAMETER",SUP-5119.2837,CDM,C1713,HCPCS,0278,RC,,,both,,,6900.00,2070,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4692,68,,,,,0,601.85,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 110MM 18 HOLE RESORBABLE BIOBRIDGE BONE RIB NONSTERILE",SUP-RRP1501,CDM,C1713,HCPCS,0272,RC,,,both,,,9204.60,2761.38,"UHC [10700]","United Healthcare",,5826.51,63.3,,5023.51,2672.93,6679.78,18,3783.09,5826.51,"percent of total billed charges",
"RESPIRATORY SIGNS AND SYMPTOMS",204,MS-DRG,,,,,,,inpatient,,,33982.74,10194.82,"PHCS [10601]",PHCS,,7561,,,,,,,5008.35,20135.75,"per diem","Estimated amount calculated based on 2 day length of stay."
"ELECTRD ELECTROSURGICAL WHITE 11CM UTAHLOOP SAFE-T-GAUGE",SUP-DLP-W11,CDM,S27200284,LOCAL,0272,RC,,,both,,,140.07,42.02,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,95.25,68,,,,,0,16.29,119.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.320,CDM,C1713,HCPCS,0278,RC,,,both,,,4140.00,1242,"AETNA [10100]","Aetna HMO/PPO",,3291.3,79.5,,1521.93,481.35,16760.95,30,481.48,3519,"percent of total billed charges",
"BROADBAND INTERNET KIT MODEL EX1170, US",SUP-EX1170,CDM,S27000186,LOCAL,0270,RC,,,both,,,2062.50,618.75,"CIGNA [10200]",Cigna,,1402.5,68,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL TRABECULAR METAL SHOULDER REVERSE SYSTEM",SUP-98000900053,CDM,C1776,HCPCS,0278,RC,,,both,,,51660.00,15498,"BLUE CROSS [10001]","Blue Cross PPO",,20250.72,39.2,,3949.44,3949.44,3949.44,"1 through 10",6008.06,43911,"percent of total billed charges",
"TRAY BIOPSY JAMSHIDI SAFE-T PLUS BONE MARROW STERILE",SUP-BCTM3411SP,CDM,S27200284,LOCAL,0272,RC,,,both,,,386.91,116.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,177.59,45.9,,,,,0,45,328.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TNLR SURGICAL SHEATH ON-Q 12IN 11GA DISPOSABLE",SUP-T11X12,CDM,S27200305,LOCAL,0272,RC,,,both,,,250.93,75.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,170.63,68,,,,,0,29.18,213.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 25MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962327,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"BLUE CROSS [10001]","Blue Cross PPO",,5685.49,39.2,,3949.44,3949.44,3949.44,"1 through 10",1686.79,12328.23,"percent of total billed charges",
"KIT TEMPERATURE 6FT THERMOGARD HQTM INTRAVASCULAR START UP",SUP-8700-001027-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,2423.25,726.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,995.96,41.1,,,,,0,281.82,2059.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION DETACHMENT HANDLE",SUP-DH1,CDM,S27800098,LOCAL,0278,RC,,,both,,,1822.50,546.75,"MULTIPLAN [10600]",Multiplan,,1549.13,85,,,,,0,211.96,1549.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GALASHAPE 3D 18.5X6.4CM MONOFILAMENT",SUP-SH3D03,CDM,C1781,HCPCS,0278,RC,,,both,,,7590.00,2277,"CIGNA [10200]",Cigna,,5161.2,68,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SPEED PIN 45MM FIXATION",SUP-74013471,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"PHCS [10601]",PHCS,,140.68,70,,,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON ETHILON MULTIPASS 6-0 PC-3 18IN MONOFILAMENT BLACK",SUP-1866G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 50MM SOLERA CD HORIZON OSTEOGRIP TITANIUM COCR",SUP-54840004050,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3923.76,41.1,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BLUE 53MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103553000,CDM,C1776,HCPCS,0278,RC,,,both,,,3064.32,919.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1406.52,45.9,,,,,0,356.38,2604.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 CURVE PLUS 8MM KNEE XLK FIX BEARING SIGMA",SUP-970480,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7598.69,68,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 14MM T8 FULL THREAD LOCK STARDRIVE NONSTERILE",SUP-656014,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"PHCS [10601]",PHCS,,934.64,70,,,,,0,155.28,1134.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8MM 60MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712860,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM NAVITOR TRANSCATHETER SELF EXPAND INTRA",SUP-NVTR-27,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"CIGNA [10200]","Cigna Local Plus",,43092,31.5,,,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 0 TIP STONE 3 WIRE HELICAL PAIRED",SUP-M0063301080,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"CIGNA [10200]","Cigna Local Plus",,791.56,53.5,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR EXTRICATION ORANGE 3IN PROCARE REGULAR FLAT CONTOUR",SUP-79-83025,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.12,17.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,26.68,45.9,,,,,0,6.76,49.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 100MM 75CM 8MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200081070,CDM,C1876,HCPCS,0278,RC,,,both,,,4515.00,1354.5,"BLUE CROSS [10001]","Blue Cross HMO",,1769.88,39.2,,,,,0,525.09,3837.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SCR EQUINOXE SQUARE SHOULDER TORQUE DEFINE",SUP-300-20-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"FIRST HEALTH [10303]","First Health",,1296,80,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 200-240ML STYLE 2000 ROUND SMOOTH SALINE",SUP-3502200,CDM,C1789,HCPCS,0278,RC,,,both,,,2350.00,705,"AMERIGROUP MEDICAID [20100]",Amerigroup,,278.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,273.31,1997.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 3DMAX 5X3IN RIGHT GROIN HERNIA NONABSORBABLE",SUP-0115322,CDM,C1781,HCPCS,0278,RC,,,both,,,983.58,295.07,"CIGNA [10200]",Cigna,,668.83,68,,,,,0,114.39,836.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 80MM 6MM BALLOON DILATATION STERILE LATEX",SUP-596008022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cytpath Fna Immediate Eval",PX-311000012,CDM,88172,CPT,0311,RC,,,both,,,370.50,111.15,"BLUE CROSS [10001]","Blue Cross PPO",,26.79,,"Fee schedule rate ($26.79).",,,,0,13.37,314.93,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL HEADSTRAP CLIP SOFT CHEEK PAD 2 CNCT OPTIFLOW",SUP-OPT946,CDM,S27000186,LOCAL,0270,RC,,,both,,,190.75,57.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.18,162.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUARD PIN GREEN JURGAN PIN BALL .054-.062IN WIRE W SERIES",SUP-W062-GN,CDM,S27200284,LOCAL,0272,RC,,,both,,,417.60,125.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,171.63,41.1,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT PATIENT L15FT 22MM WITHOUT PEEP DISPOSABLE",SUP-29665-001,CDM,S27000186,LOCAL,0270,RC,,,both,,,219.36,65.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,25.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.51,186.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS EVOQUE STABILIZER PLATE",SUP-9850PTCL,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WOLVERINE CUTTING BALLOON (MR) 6MM X 3.00",SUP-H74939401063000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 8FR 75CM MULLINS DESIGN RADIOPAQUE BAND",SUP-G08759,CDM,C1894,HCPCS,0272,RC,,,both,,,680.32,204.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 20MM 190CM 3MM",SUP-R51003002L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ONYX 18 EMBOLIZATION DIMETHYL SULFOXIDE 1.5ML 1ML SYR",SUP-105-7100-060,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHANK SCR 50MM 6.5MM MODULEX OSTEOGRIP SPINE",SUP-55900506550,CDM,C1713,HCPCS,0278,RC,,,both,,,4519.50,1355.85,"NOVANET [10819]",Novanet,,3389.63,75,,,,,0,525.62,3841.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 45MMX4.6MMX6.5CM 26F",SUP-TE4546A,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS [10001]","Blue Cross PPO",,24578.4,39.2,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 10CM 5FR 21GA MICROPUNCTURE PUSH-PLUS .018IN",SUP-G48007,CDM,C1769,HCPCS,0272,RC,,,both,,,208.80,62.64,"NOVANET [10819]",Novanet,,156.6,75,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL FIXATION GREEN 400MM 11MM 130D RIGHT DISTAL",SUP-456.420S,CDM,C1713,HCPCS,0278,RC,,,both,,,12838.83,3851.65,"AETNA [10100]","Aetna HMO/PPO",,10206.87,79.5,,1521.93,481.35,16760.95,30,1493.16,10913.01,"percent of total billed charges",
"GRAFT BONE MAGNIFUSE 5CM",SUP-7509145,CDM,C1713,HCPCS,0278,RC,,,both,,,13282.50,3984.75,"PHCS [10601]",PHCS,,9297.75,70,,,,,0,1544.75,11290.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION SUPERORDERABLE",RX-409183,CDM,,,0250,RC,67157-0101-51,NDC,both,50,ML,2421.66,726.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,286.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,281.64,2058.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TLX IMPLANT, 11X11X30MM 15",SUP-5811305,CDM,S27800098,LOCAL,0278,RC,,,both,,,28800.00,8640,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3349.44,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3349.44,24480,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP IRRIGATION XMAX MICROMAX EMAX 2 PLUS SHORT ATTACH",SUP-IRR-CLIP-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 4.25% DEXTROSE 3L LOW CALCIUM ULTRABAG DIANEAL DIALYSIS",SUP-5B9759,CDM,S27200284,LOCAL,0272,RC,,,both,,,355.14,106.54,"CIGNA [10200]","Cigna Local Plus",,190,53.5,,,,,0,41.3,301.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 6-7 C-D KNEE",SUP-42-5121-004-11,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS [10001]","Blue Cross PPO",,4224.36,39.2,,3949.44,3949.44,3949.44,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"SLDFR FLUID 20L UROLOGY FLUIDRAIN LSS DISPOSABLE",SUP-337220,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,30.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 40MM TSRH OSTEOGRIP THINLINE SPINAL",SUP-83575409,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Open Access",,5432.16,56.9,,1144.80,304.56,2275.09,66,1110.3,8114.82,"percent of total billed charges",
"14.0 DIOPTER, TECNIS EYHANCE 1-PIECE IOL W/ SIMPLICITY DELIV",SUP-DIB00U0140,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 16MM 144CM 3MM CORONARY STENT EVEROLIMUS",SUP-H7493926116300,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2665.95,28.62,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.50 X 08 RX US",SUP-1804250-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 80MM 4.8FR 9MM BALLOON DILATATION OTW",SUP-H74939032908010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAPE SLUSH MACH EQUIPMENT",SUP-29-33009,CDM,S27000186,LOCAL,0270,RC,,,both,,,93.15,27.94,"CIGNA [10200]","Cigna Open Access",,53,56.9,,,,,0,10.83,79.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 36MM TRICUSPID 1 SEAM 2 WRAP ANATOMIC",SUP-4900T36,CDM,S27800098,LOCAL,0278,RC,,,both,,,12765.00,3829.5,"KAISER [10500]",Kaiser,,8552.55,67,,,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC",275,MS-DRG,,,,,,,inpatient,,,257110.34,77133.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,135313.6,,"Fee schedule rate ($135,313.60). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,6245,208179.16,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.464,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"AETNA [10100]","Aetna HMO/PPO",,3849.87,79.5,,1521.93,481.35,16760.95,30,563.19,4116.21,"percent of total billed charges",
"TRAY CATH 3FR 8CM CENTRAL VENOUS 1 LUMEN GWIRE PRESSURE MNTR",SUP-G58927,CDM,C1751,HCPCS,0272,RC,,,both,,,473.12,141.94,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,321.72,68,,,,,0,55.02,402.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR TRNSDUC 2 SAMPLE SITE RESVR POLE MOUNT",SUP-PXVP2272,CDM,S27200284,LOCAL,0272,RC,,,both,,,238.47,71.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,162.16,68,,,,,0,27.73,202.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 12MM MATRIXNEURO CRANIOMAXILLOFACIAL TITANIUM 2",SUP-04.503.062,CDM,C1713,HCPCS,0278,RC,,,both,,,1101.60,330.48,"BLUE CROSS [10001]","Blue Cross PPO",,431.83,39.2,,957.42,570.23,957.42,28,128.12,936.36,"percent of total billed charges",
"SCR BONE 2.7MM 68MM STAINLESS STEEL T8 ELBOW METAPHYSEAL",SUP-02.118.568,CDM,C1713,HCPCS,0278,RC,,,both,,,547.40,164.22,"CIGNA [10200]",Cigna,,372.23,68,,1831.33,1831.33,1831.33,16,63.66,465.29,"percent of total billed charges",
"SCR BONE 2.7MM 68MM STAINLESS STEEL T8 ELBOW METAPHYSEAL",SUP-02.118.568,CDM,C1713,HCPCS,0278,RC,,,both,,,547.40,164.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,156.67,28.62,,,,,0,63.66,465.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 49MM CENTERPULSE LEGACY 12/14 TAPER HIP FEMUR",SUP-451000049,CDM,C1776,HCPCS,0278,RC,,,both,,,2398.65,719.59,"BLUE CROSS [10001]","Blue Cross HMO",,940.27,39.2,,5311.50,4717.44,5388.59,31,278.96,2038.85,"percent of total billed charges",
"INSRT TIBIAL 3 15MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158103115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4592.74,41.1,,6417.48,6417.48,6417.48,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"COIL EMBOLIZATION 12CM 7MM AXIUM 3D NEUROVASCULAR FRAME V01",SUP-FC-7-12-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,13765.50,4129.65,"BLUE CROSS [10001]","Blue Cross PPO",,5396.08,39.2,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM VARIAX T8 FULL THREAD NONSTERILE",SUP-656416,CDM,C1713,HCPCS,0278,RC,,,both,,,779.22,233.77,"CIGNA [10200]",Cigna,,529.87,68,,1831.33,1831.33,1831.33,16,90.62,662.34,"percent of total billed charges",
"LEAD PACING 25CM 7FR ATRIUM VENTRICLE BIPOLAR ACTIVE",SUP-1688TC/25,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,264.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 12.7X3.2CM ROUND PRECUT DRAPE SENSATRAC POLYURETHANE",SUP-M8275075/5.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,441.46,132.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,181.44,41.1,,,,,0,51.34,375.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 22MM LCP STAINLESS STEEL FULL THREAD CORTEX",SUP-02.204.022,CDM,C1713,HCPCS,0278,RC,,,both,,,986.58,295.97,"NOVANET [10819]",Novanet,,739.94,75,,,,,0,114.74,838.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING URETHRAL VIRTUE ALEXIS MALE",SUP-50020,CDM,C1771,HCPCS,0278,RC,,,both,,,33604.20,10081.26,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13811.33,41.1,,,,,0,3908.17,28563.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 11MM KII FIOS FIRST ENTRY Z THREAD",SUP-CTF33,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,21.25,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORPLEX 3X5 CM",SUP-CX-3050,CDM,Q4232,HCPCS,0636,RC,,,both,,,14966.10,4489.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9727.97,65,,,,,0,247.92,12721.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 12MM 144CM 5MM CORONARY STENT",SUP-H7493926012500,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"AETNA [10100]","Aetna HMO/PPO",,7405.43,79.5,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL 5X1CM GAUZE MEROGEL SEPTUM PK STERILE LATEX",SUP-1517100,CDM,S27000186,LOCAL,0270,RC,,,both,,,467.29,140.19,"PHCS [10601]",PHCS,,327.1,70,,,,,0,54.35,397.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION .045IN 9IN KIRSCHNER STAINLESS STEEL 2 END",SUP-KM173-49-45,CDM,C1713,HCPCS,0278,RC,,,both,,,355.74,106.72,"FIRST HEALTH [10303]","First Health",,284.59,80,,,,,0,41.37,302.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 20MM INSET SHOULDER LOCK REVERSE",SUP-2R1PT45020,CDM,C1713,HCPCS,0278,RC,,,both,,,865.08,259.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,588.25,68,,,,,0,100.61,735.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +21.5 DIOPTER MODIFIED C BICONVEX MULTIPIECE",SUP-MA60AC.215,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 70MM 75CM 22MM 100CM",SUP-H965404520,CDM,C1876,HCPCS,0278,RC,,,both,,,14331.30,4299.39,"CIGNA [10200]","Cigna Local Plus",,4514.36,31.5,,,,,0,1666.73,12181.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTAROLINE FOSAMIL 600 MG/20ML IV (WET SOLR VIAL)",RX-415107671,CDM,J0712,HCPCS,0636,RC,00456-0600-01,NDC,both,1,UN,1554.03,466.21,"NOVANET [10819]",Novanet,,1165.52,75,,,,,0,184.15,1320.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AORTIC VALVED GRAFT WITH  MAQUETHEMASHIELDWOVEN DOUBLE VELOU","SUP-27CAVGJ-514  00",CDM,C1768,HCPCS,0278,RC,,,both,,,25533.90,7660.17,"NOVANET [10819]",Novanet,,19150.43,75,,,,,0,2969.59,21703.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 11MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530-G-611,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CIGNA [10200]",Cigna,,5921.17,68,,5873.17,5873.17,5873.17,"1 through 10",1012.7,7401.47,"percent of total billed charges",
"DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION",RX-9814,CDM,J3490,HCPCS,0258,RC,00990-7926-09,NDC,both,1000,ML,100.65,30.19,"PHCS [10601]",PHCS,,70.46,70,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSORB GT1 8MM 3MM CORONARY EVEROLIMUS ELUTING POLY L",SUP-1235300-08,CDM,C1874,HCPCS,0278,RC,,,both,,,8280.00,2484,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25 DIOPTER UV ABSORBENT CLAREON AUTONOME",SUP-CCA0T0.250,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN 0 54IN MONOFILAMENT TIES YELLOWISH TAN ABSORBABLE",SUP-S104H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM 6FR AMPLATZ RIGHT 2",SUP-67011200,CDM,C1887,HCPCS,0272,RC,,,both,,,83.52,25.06,"NOVANET [10819]",Novanet,,62.64,75,,,,,0,9.71,70.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRACH 9MM PORTEX BLUPERC TUBE STERILE LATEX FREE",SUP-101/561/090,CDM,S27200284,LOCAL,0272,RC,,,both,,,2872.20,861.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1180.47,41.1,,,,,0,334.04,2441.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Gad-65",PX-301000252,CDM,83519,CPT,0301,RC,,,both,,,244.00,73.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,9.15,,,,,,,0.01,207.4,"fee schedule",
"CATH ARMADA 150CM 150MM 5MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013468-150,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PHCS [10601]",PHCS,,878.85,70,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH SURGICAL LARGE CIRCLE 3.2IN UMBILICAL HERNIA REPAIR",SUP-0010303,CDM,C1781,HCPCS,0278,RC,,,both,,,2370.82,711.25,"CIGNA [10200]","Cigna Local Plus",,1268.39,53.5,,3096.73,1.00,3096.73,"1 through 10",275.73,2015.2,"percent of total billed charges",
"ROD SPINAL 80MM 4.75MM SOLERA COCR MOLYBDENUM CURVED",SUP-1475501080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",141.3,1032.75,"percent of total billed charges",
"INSRT TIBIAL 2 P 19MM KNEE X3 POSTERIOR STABILIZE TRIATHLON",SUP-5532P219,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,990.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035424100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5801.12,41.1,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN SL4.5 CURVE GUIDING CORONARY",SUP-LA7SL45SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER 3MR FLEXIVA PULSE TRACTIP 242UM HIGH POWER",SUP-M006L8405910,CDM,S27200284,LOCAL,0272,RC,,,both,,,2856.45,856.93,"CIGNA [10200]","Cigna Open Access",,1625.32,56.9,,,,,0,332.21,2427.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM VARIAX T10 FULL THREAD NONSTERILE LOCK",SUP-657426,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"CIGNA [10200]",Cigna,,549.92,68,,1831.33,1831.33,1831.33,16,94.05,687.4,"percent of total billed charges",
"CATH DXTERITY 100CM 5FR .047IN LEFT CORONARY BYPASS CURVE",SUP-DXT5LCB,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"NOVANET [10819]",Novanet,,52.2,75,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12MM 2MM 3.5MM CORTEX",SUP-401.812.96,CDM,C1713,HCPCS,0278,RC,,,both,,,319.12,95.74,"BLUE CROSS [10001]","Blue Cross PPO",,125.1,39.2,,957.42,570.23,957.42,28,37.11,271.25,"percent of total billed charges",
"ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY",884,MS-DRG,,,,,,,inpatient,,,37940.31,11382.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,14512.28,,"Fee schedule rate ($14,512.28). Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,1958,37940.31,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC SURGILAV PLUS SET MULTIORIFICE TIP SPLASH SHIELD",SUP-207-559,CDM,S27200284,LOCAL,0272,RC,,,both,,,337.68,101.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,155,45.9,,,,,0,39.27,287.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 3MM OXFORD ARCOM KNEE LEFT MENISCAL PHASE 3",SUP-159547,CDM,C1776,HCPCS,0278,RC,,,both,,,5270.22,1581.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2419.03,45.9,,,,,0,612.93,4479.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COTTON-LEUNG 15CM 5FR .035IN GENTLE CURVE BILIARY",SUP-G22399,CDM,C2617,HCPCS,0278,RC,,,both,,,729.00,218.7,"CIGNA [10200]","Cigna Local Plus",,390.02,,,,,,,84.78,619.65,"percent of total billed charges",
"STENT ORSIRO MISSION 26MM 140CM 2.25MM CORONARY STERILE",SUP-453955,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNGOSCOPE VIDEO I-VIEW DISPOSABLE",SUP-441-8008000EA,CDM,S27000186,LOCAL,0270,RC,,,both,,,706.23,211.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,290.26,41.1,,,,,0,82.13,600.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 3X250 80CM SL",SUP-48003025N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"KAISER [10500]",Kaiser,,697.48,67,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEUCOVORIN CALCIUM 5 MG TABLET",RX-4398,CDM,,,0637,RC,00555-0484-02,NDC,both,1,UN,11.83,3.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4.86,41.1,,,,,0,1.38,10.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER TENDON 25CMX4MM SWANSON HUNTER SILICONE",SUP-24270004,CDM,C1713,HCPCS,0278,RC,,,both,,,6955.20,2086.56,"AETNA [10100]","Aetna HMO/PPO",,5529.38,79.5,,1521.93,481.35,16760.95,30,808.89,5911.92,"percent of total billed charges",
"STENT TEMPTIP 28CM 8FR LARGE PROXIMAL PIGTAIL CURVE URETERAL",SUP-M001231390,CDM,C2617,HCPCS,0278,RC,,,both,,,931.50,279.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,110.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL RAPIDE 5-0 P-1 18IN BRAID COATED UNDYED",SUP-VR490,CDM,S27200284,LOCAL,0272,RC,,,both,,,71.48,21.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,48.61,68,,,,,0,8.31,60.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STY LD 59CM .016IN FIRM KNOB",SUP-6604,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOME PATELLAR 9MM 35MM KNEE E PLUS 3 PEG STERILE",SUP-130-03-735,CDM,C1776,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,858.6,28.62,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR STRAIGHT 180CM .035IN HYDROPHILIC FIX CORE",SUP-H2OSTFS35180,CDM,C1769,HCPCS,0272,RC,,,both,,,348.00,104.4,"FIRST HEALTH [10303]","First Health",,278.4,80,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM PFC SIGMA TC3 4 KNEE LEFT TITANIUM CEMENTED",SUP-960880,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"CIGNA [10200]",Cigna,,3488.97,68,,5873.17,5873.17,5873.17,"1 through 10",596.72,4361.21,"percent of total billed charges",
"CATH STERLING MONORAIL 150CM 220MM 2.5MM BALLOON DILATATION",SUP-H74939031252210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 30MM 120CM 7MM VASCULAR PERIPHERAL SELF",SUP-PRB35-07-030-120,CDM,C1876,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 21GA 40CM 4CM BLUE HUB TUBING STAINLESS",SUP-PSS-8F-4-018MT,CDM,C1894,HCPCS,0272,RC,,,both,,,286.67,86,"PHCS [10601]",PHCS,,200.67,70,,,,,0,33.34,243.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 33MM EVERCLIP FOGARTY HYDRAGRIP ATRAUMATIC",SUP-EVERGRIP33,CDM,S27200284,LOCAL,0272,RC,,,both,,,138.16,41.45,"NOVANET [10819]",Novanet,,103.62,75,,,,,0,16.07,117.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (MR) 10MM X 2.25",SUP-H74939401102250,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"KAISER [10500]",Kaiser,,3629.06,67,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN AMPLATZ RIGHT 1 CURVE",SUP-H74908641842,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SMOOTH SHELL",SUP-SRM-405,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"BLUE CROSS [10001]","Blue Cross PPO",,2150.32,39.2,,16595.83,16595.83,16595.83,"1 through 10",637.96,4662.68,"percent of total billed charges",
"AUG FEMORAL 4MM ATTUNE 7 KNEE DISTAL CEMENT REVISION STERILE",SUP-154707001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"CIGNA [10200]","Cigna Local Plus",,3248.52,53.5,,5372.07,4581.20,7242.98,23,706.17,5161.2,"percent of total billed charges",
"HC Esoph Flex Trnsnasl W Bx",PX-750000125,CDM,43198,CPT,0750,RC,,,both,,,4531.00,1359.3,"NOVANET [10819]",Novanet,,3398.25,75,,,,,0,526.96,4531,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC 7.5MM MODIFIED ELLIPSE 44.5X47MM ADVANTIO DR",SUP-K063,CDM,C1785,HCPCS,0275,RC,,,both,,,17250.00,5175,"MULTIPLAN [10600]",Multiplan,,14662.5,85,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 85MM 16MM STAINLESS STEEL ORTHOPEDIC CANNULATED",SUP-71127085,CDM,C1713,HCPCS,0278,RC,,,both,,,2479.50,743.85,"BLUE CROSS [10001]","Blue Cross PPO",,971.96,39.2,,957.42,570.23,957.42,28,288.37,2107.58,"percent of total billed charges",
"GRAFT STENT 120MM 13.5MM 10FR FLUENCY PLUS ENDOVASCULAR",SUP-FEL14120,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PHCS [10601]",PHCS,,12789,70,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +25 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00250,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 5MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0540CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2073.52,28.62,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 11MM 1 LEVEL SAPPHIRE BONE SPINE CERVICAL ANTERIOR",SUP-26001-011,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PHCS [10601]",PHCS,,2940,70,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET HELICAL ULTRA 3 MM X 4 CM",SUP-M0035433040,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6227.22,68,,,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 5CM 2.5MM CEREPAK FREEFORM DETACHABLE",SUP-SCR122505,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS [10001]","Blue Cross PPO",,5184.53,39.2,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immunoassy Tumor Ca 19-9",PX-302000056,CDM,86301,CPT,0302,RC,,,both,,,320.15,96.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.27,,"Fee schedule rate ($22.27). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,272.13,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 ULTRA 5MM X 10CM",SUP-M0035425100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"FIRST HEALTH [10303]","First Health",,11291.71,80,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.210,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Open Access",,391.76,56.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG SILVER CELOS ETHYL SULPHONATE FIBER ANTIMICROBIAL",SUP-66800571,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.97,20.99,"NOVANET [10819]",Novanet,,52.48,75,,,,,0,8.14,59.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INOUE 70CM 2.5CM 12FR 22-26MM BALLOON DILATATION PVC",SUP-PTMC-26,CDM,C1725,HCPCS,0272,RC,,,both,,,17250.00,5175,"AETNA [10100]","Aetna HMO/PPO",,13713.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 15MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158105115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1299.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 75MM 32MM NCB TITANIUM ALUMINUM VANADIUM",SUP-0203152075,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"GWIRE HI-TORQUE WHISPER MS VASCULAR J 300CM 3CM .014IN",SUP-1005359HJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 150CM 6FR .035IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145361180,CDM,C2617,HCPCS,0278,RC,,,both,,,1422.52,426.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,407.13,28.62,,,,,0,165.44,1209.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH SURGICAL 25MM 180MM DURAPRO 5MM BRUSH",SUP-6262.4351S,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 23MM 2MM CORONARY STENT COCR",SUP-1007821-23,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT 137CM 10MM 2MM RECTANGLE HELIX TAPER",SUP-2200-2010,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"AETNA [10100]","Aetna HMO/PPO",,4662.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 3.2MM INTERTAN LAG SCR",SUP-71674540,CDM,S27200284,LOCAL,0272,RC,,,both,,,5071.85,1521.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,601.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,589.86,4311.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 14MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620414,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7652.65,68,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 22X9X11MM 12D EIT PLIF STERILE LATEX FREE",SUP-PUI31102,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 55CM 14FR STRAIGHT TRINIFLEX SPLIT CATH III BASIC",SUP-ASPC55-3,CDM,C1750,HCPCS,0278,RC,,,both,,,2437.50,731.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1657.5,68,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 21MM 18.6MM MASTERS HP PYROLYTIC CARBON",SUP-21AEHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"FIRST HEALTH [10303]","First Health",,23295.38,80,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 100MM 1.3MM AO CNCT",SUP-P99-100-1310,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,682.99,68,,,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 35CM 8FR DRNG FLEXIMA BILIARY REGULAR DUROMETER",SUP-M001272600,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 3D LOCK VARIAX BONE RIGHT FOOT",SUP-40-15062,CDM,C1713,HCPCS,0278,RC,,,both,,,5435.82,1630.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2495.04,45.9,,,,,0,632.19,4620.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 700ML STYLE 20 GEL SMOOTH NATRELLE SILICONE P6.2",SUP-20-700,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"AETNA [10100]","Aetna HMO/PPO",,2838.15,79.5,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 125CM 6FR JL4 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389696620,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 15X7X.38MM PRECISION SHORT NARROW THIN STAINLESS",SUP-2296003103,CDM,S27200284,LOCAL,0272,RC,,,both,,,270.22,81.07,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EUPHORA 142CM 8MM 4.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP4508X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPHINTOM CLEVERCUT3V PRELOAD STERILE DISPOSABLE ENDOSCOPIC",SUP-KD-V631M-07201S,CDM,C1769,HCPCS,0272,RC,,,both,,,2433.53,730.06,"KAISER [10500]",Kaiser,,1630.47,67,,,,,0,283.02,2068.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 135CM 2CM 5MM BALLOON DILATATION PERIPHERAL",SUP-G50235,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 40CM 12FR DRNG BILIARY",SUP-G13355,CDM,C1729,HCPCS,0272,RC,,,both,,,801.82,240.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,93.25,681.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HURRICANE 180CM 4CM 5.8FR 8MM 11 ATM BALLOON DILATATION",SUP-M00545940,CDM,C1726,HCPCS,0272,RC,,,both,,,1849.50,554.85,"FIRST HEALTH [10303]","First Health",,1479.6,80,,,,,0,215.1,1572.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 38MM 144CM 2.25MM CORONARY STENT PEBAX",SUP-H7493926038220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AETNA [10100]","Aetna HMO/PPO",,4424.18,79.5,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS",998,MS-DRG,,,,,,,inpatient,,,36599.36,10979.81,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,8991.54,,"Case rate ($4,182.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $3,883.37, add-ons for qualifying new technology services are included. If operating cost exceeds $36,923.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,675.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $3,888.50. The transfer operating threshold is the transfer adjustment factor * $3,883.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $293.60. The transfer capital threshold is the transfer adjustment factor * $293.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,4182.11,11132.13,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER RP 360 DEGREE FLEXIBLE NDL SUT DISPOSABLE",SUP-3910900091,CDM,S27200284,LOCAL,0272,RC,,,both,,,1125.90,337.77,"FIRST HEALTH [10303]","First Health",,900.72,80,,,,,0,130.94,957.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 FSL 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP588H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 38MM 144CM 2.25MM CORONARY STENT EVEROLIMUS",SUP-H7493926138220,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1022.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 80CM 5FR SOS OMNI 1 CURVE ANGIOGRAPHIC VISCERAL",SUP-10720401,CDM,C1887,HCPCS,0272,RC,,,both,,,209.32,62.8,"FIRST HEALTH [10303]","First Health",,167.46,80,,,,,0,24.34,177.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECTRUM DVM S3",SUP-0270-0932,CDM,S27200284,LOCAL,0272,RC,,,both,,,328.86,98.66,"MULTIPLAN [10600]",Multiplan,,279.53,85,,,,,0,38.25,279.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMOVAL KIT",SUP-R540000RKH,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.80,114.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,44.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE RIGHT CRUCIATE RETAIN GENESIS II LEGION",SUP-71421224,CDM,C1776,HCPCS,0278,RC,,,both,,,28831.95,8649.58,"FIRST HEALTH [10303]","First Health",,23065.56,80,,,,,0,3353.16,24507.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 60MM SOLERA CD HORIZON OSTEOGRIP TITANIUM",SUP-54840005560,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175272180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA [10200]","Cigna Open Access",,830.8,,,,,,,169.81,1241.09,"percent of total billed charges",
"CATH SAPPHIRE NC PLUS 10MM 3MM BALLOON DILATATION STERILE",SUP-230-103-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PHCS [10601]",PHCS,,567,70,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE REVERSE REVISION HUMERAL STEM, SZ 16X175MM",SUP-530-16-175,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"NOVANET [10819]",Novanet,,9450,75,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BICORTICAL ILIUM ALLOGRAFT STRIP FREEZE DRIED",SUP-P00257,CDM,S27800098,LOCAL,0278,RC,,,both,,,5197.08,1559.12,"BLUE CROSS [10001]","Blue Cross HMO",,2037.26,39.2,,,,,0,604.42,4417.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 STRAIGHT OVAL 8IN SURGICAL SPINAL FUSION",SUP-29-5032,CDM,S27200284,LOCAL,0272,RC,,,both,,,353.39,106.02,"KAISER [10500]",Kaiser,,236.77,67,,,,,0,41.1,300.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 22MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710322,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"UHC [10700]","United Healthcare",,9364.35,63.3,,8601.07,8395.67,8601.07,"1 through 10",1720.5,12574.56,"percent of total billed charges",
"CATH APD 25CM 6FR LOOP DRNG FLEXIMA METAL HYDROPHILIC",SUP-M001271330,CDM,C1729,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR BLUE 5/8IN 25GA INTERSTIM REGULAR WALL",SUP-305901,CDM,C1778,HCPCS,0278,RC,,,both,,,321.90,96.57,"CIGNA [10200]","Cigna Open Access",,183.16,56.9,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR FL3.5 CURVE ANGIOGRAPHIC FEMORAL 2",SUP-H74916599212,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Ceretec Up to 25mci",PX-343000008,CDM,A9521,HCPCS,0343,RC,,,both,,,8220.00,2466,"BLUE CROSS [10001]","Blue Cross HMO",,1997.63,,,,,,,955.99,6987,"fee schedule",
"COMPLICATED PEPTIC ULCER WITHOUT CC/MCC",382,MS-DRG,,,,,,,inpatient,,,34920.90,10476.27,"CIGNA [10200]",Cigna,,10497.47,,"Fee schedule rate ($10,497.47). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,4966.18,19966.16,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL URETERAL 60CM 6-18FR FASCIAL PTFE SET",SUP-G14574,CDM,S27200284,LOCAL,0272,RC,,,both,,,2500.50,750.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1027.71,41.1,,,,,0,290.81,2125.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URSODIOL 300 MG CAPSULE",RX-11624,CDM,,,0637,RC,59651-0421-01,NDC,both,1,UN,27.79,8.34,"UHC [10700]","United Healthcare",,17.59,63.3,,,,,0,3.23,23.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Troponin Quant POC",PX-301000426,CDM,84484,CPT,0301,RC,,,both,,,403.00,120.9,"CIGNA [10200]",Cigna,,27.43,,,,,,,6.67,342.55,"fee schedule",
"STEM HUMERAL 122MM 17MM COMPREHENSIVE POROUS STD SHOULDER",SUP-113657,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"NOVANET [10819]",Novanet,,9450,75,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 4.5CM 2.5MM GALAXY G3 MINI STRETCH",SUP-GLM925045,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]","Cigna Local Plus",,3742.77,31.5,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUANFACINE 1 MG TABLET, IMMEDIATE RELEASE",RX-10149,CDM,,,0637,RC,00591-0444-01,NDC,both,1,UN,6.27,1.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE TRACER METRO DIRECT ENDOSCOPIC STRAIGHT 600CM 5CM .035",SUP-G50660,CDM,C1769,HCPCS,0272,RC,,,both,,,2610.00,783,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STY LD S 60-C",SUP-359223,CDM,C1893,HCPCS,0272,RC,,,both,,,382.80,114.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH ZURPAZ .032IN MEDIUM ASYMMETRIC CURVE 92CM 72CM 8.5FR",SUP-M004USMCA85200,CDM,C1894,HCPCS,0272,RC,,,both,,,7714.20,2314.26,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH DORADO CHECKER 80CM 2CM 8MM BALLOON DILATATION",SUP-DR8082,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BLAZER II XP 110CM 10MM 7FR 8FR 8MM SPACE LARGE CURVE",SUP-M0044790THK20,CDM,C1733,HCPCS,0272,RC,,,both,,,12199.20,3659.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE PERMASORB FIXATION 12 ABSORBABLE FASTENERS",SUP-0113092,CDM,S27200284,LOCAL,0272,RC,,,both,,,3559.32,1067.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AMINO ACID 10 % INTRAVENOUS SOLUTION",RX-112907,CDM,,,0258,RC,00264-1933-10,NDC,both,500,ML,269.11,80.73,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE 7 TITANIUM ZERO-P BONE SPINE STERILE NATURAL",SUP-04.617.707S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"BLUE CROSS [10001]","Blue Cross HMO",,4868.64,39.2,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 535CC",SUP-RSZ-SHPX-535S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"UHC [10700]","United Healthcare",,105.13,63.3,,,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SUCTION ORCAPOD ORCA SEAL AIR WATER SILICONE FREE",SUP-SUV-629-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.20,24.06,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.96,41.1,,,,,0,9.33,68.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 10MM AZUR HYDROCOIL 18 COILS",SUP-45-481020,CDM,S27800098,LOCAL,0278,RC,,,both,,,6406.65,1921.99,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2940.65,45.9,,,,,0,745.09,5445.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR KNEE FEMUR PATELLA TIBIA BEARING INSR",SUP-98000200143,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"NOVANET [10819]",Novanet,,20790,75,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .62IN 5FR .056IN AR2",SUP-5561120L,CDM,C1713,HCPCS,0278,RC,,,both,,,417.60,125.28,"NOVANET [10819]",Novanet,,313.2,75,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X6MM VERTE-STACK CORNERSTONE PSR",SUP-6240641,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA [10200]",Cigna,,4541.33,68,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mech Thromb Venous Init",PX-361000134,CDM,37187,CPT,0361,RC,,,both,,,8934.60,2680.38,"PHCS [10601]",PHCS,,6254.22,70,,,,,0,1039.09,8934.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 30MM 5.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE52530,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"AETNA [10100]","Aetna HMO/PPO",,66513.36,79.5,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 30MM REFLECTION FULL THREAD HIP ACETABULAR",SUP-71336530,CDM,C1713,HCPCS,0278,RC,,,both,,,1341.36,402.41,"PHCS [10601]",PHCS,,938.95,70,,,,,0,156,1140.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATHETERIZATION 10.8CM 20GA 22GA .018IN ARTERY",SUP-FA-04020,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.80,36.54,"CIGNA [10200]",Cigna,,82.82,68,,,,,0,14.17,103.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 15MM 3.2MM RINGLOC+ ACETABULAR STERILE DISPOSABLE",SUP-31-323215,CDM,S27000186,LOCAL,0270,RC,,,both,,,896.67,269,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,368.53,41.1,,,,,0,104.28,762.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER BREAST MEDIUM",SUP-M/L-BBIND,CDM,S27000186,LOCAL,0270,RC,,,both,,,191.40,57.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,22.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"QUARTET, SMALL-S - 1456Q/86",SUP-1456Q/86,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"KAISER [10500]",Kaiser,,3756.69,67,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 95MM TRI-LOCK BPS GRIPTION 0 STD OFFSET HIP",SUP-101204005,CDM,C1776,HCPCS,0278,RC,,,both,,,16107.12,4832.14,"CIGNA [10200]","Cigna Local Plus",,5073.74,31.5,,5372.07,4581.20,7242.98,23,1873.26,13691.05,"percent of total billed charges",
"CATH ULTRAVERSE CHECKER 130CM 4CM 5MM BALLOON DILATATION",SUP-U813054,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BIOLOGICAL 2.22X2IN PURACOL PLUS SQUARE SILVER CLLGN",SUP-MSC8722EP,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.94,19.18,"NOVANET [10819]",Novanet,,47.96,75,,,,,0,7.44,54.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL PERSONA NATURAL TIBIA 5D G KNEE RIGHT STEM",SUP-42532007902,CDM,C1776,HCPCS,0278,RC,,,both,,,10933.74,3280.12,"CIGNA [10200]","Cigna Open Access",,6221.3,56.9,,5302.19,4377.88,6578.61,27,1271.59,9293.68,"percent of total billed charges",
"HC Nrv Condct =>13 Studies",PX-922000025,CDM,95913,CPT,0922,RC,,,both,,,10036.11,3010.83,"KAISER [10500]",Kaiser,,6724.19,67,,,,,0,1167.2,8530.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORTICAL BONE FIBER 2.5CC ALLOGRAFT MOLDABLE",SUP-423202,CDM,C1713,HCPCS,0278,RC,,,both,,,3967.50,1190.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1821.08,45.9,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 58MM 36MM XLPE HIP STERILE",SUP-71335758,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"KAISER [10500]",Kaiser,,7454.59,67,,,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 10FR PIGTAIL URETERAL PERCUFLEX METAL",SUP-M001221410,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"MULTIPLAN [10600]",Multiplan,,757.35,85,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHIELD ADHESIVE, 15 MM DIAMETER",SUP-50215H50B0D,CDM,A2019,HCPCS,0636,RC,,,both,,,6216.90,1865.07,"CIGNA [10200]",Cigna,,4227.49,68,,,,,0,247.92,5284.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LOCKING CREO SPINAL MIS NONSTERILE",SUP-1134.001,CDM,C1713,HCPCS,0278,RC,,,both,,,707.94,212.38,"FIRST HEALTH [10303]","First Health",,566.35,80,,,,,0,50.59,601.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 12D 30D SMALL 24FR PLASMALOOP",SUP-WA22705S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3181.82,954.55,"CIGNA [10200]","Cigna Open Access",,1810.46,56.9,,,,,0,370.05,2704.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 3.5V HALOGEN COAXIAL POWER HANDLE UNIVERSAL DESK CHRG",SUP-71641-M,CDM,S27200284,LOCAL,0272,RC,,,both,,,3523.73,1057.12,"CIGNA [10200]","Cigna Open Access",,2005,56.9,,,,,0,409.81,2995.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 15MM INTERLOCK OCCLUSION SYSTEM",SUP-M001363650,CDM,S27800098,LOCAL,0278,RC,,,both,,,5181.90,1554.57,"PHCS [10601]",PHCS,,3627.33,70,,,,,0,602.65,4404.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ffp Sngl Donor Within 8 Hr",PX-390000005,CDM,P9017,HCPCS,0390,RC,,,both,,,907.20,272.16,"CIGNA [10200]","Cigna Local Plus",,485.35,53.5,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Venipuncture",PX-300000010,CDM,36415,CPT,0300,RC,,,both,,,44.65,13.39,"MULTIPLAN [10600]",Multiplan,,37.95,85,,,,,0,2.15,37.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Fluoro Guide Spine Inj",PX-320000175,CDM,77003,CPT,0320,RC,,,both,,,1421.42,426.43,"AETNA [10100]","Aetna HMO/PPO",,1130.03,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.31,1208.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Powder Stimulen",PX-E27200197,CDM,E27200197,LOCAL,0272,RC,,,both,,,70.40,21.12,"PHCS [10601]",PHCS,,49.28,70,,,,,0,8.19,59.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fna Bx W/US Gdn 1st Les",PX-361000477,CDM,10005,CPT,0361,RC,,,both,,,2651.08,795.32,"CIGNA [10200]","Cigna Local Plus",,1965,,"Case rate ($1,965). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,308.32,2651.08,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 19.3X9.6CM ALLODERM SELECT THK.4-2.4MM THICK",SUP-CM1519P,CDM,Q4116,HCPCS,0636,RC,,,both,,,24847.20,7454.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16150.68,65,,,,,0,247.92,21120.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 14MM 3FR GEMINI HELICAL",SUP-M0063302100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"NOVANET [10819]",Novanet,,1109.66,75,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachythrpy Balloon",PX-E27200041,CDM,E27200041,LOCAL,0272,RC,,,both,,,231.00,69.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,106.03,45.9,,,,,0,26.87,196.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US Head&Neck Soft Tiss",PX-402000005,CDM,76536,CPT,0402,RC,,,both,,,1579.16,473.75,"FIRST HEALTH [10303]","First Health",,1263.33,80,,,,,0,131.63,1342.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Inframlr W Pta Cmplx Init",PX-361000739,CDM,37298,CPT,0361,RC,,,both,,,19230.05,5769.01,"NOVANET [10819]",Novanet,,14422.54,75,,,,,0,19.23,16345.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrombin Time",PX-305000063,CDM,85670,CPT,0305,RC,,,both,,,137.75,41.32,"FIRST HEALTH [10303]","First Health",,110.2,80,,,,,0,0.01,117.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 110MM 7 HOLE LOW PROFILE BONE LEFT OLECRANON ELBOW",SUP-70-0306,CDM,C1713,HCPCS,0278,RC,,,both,,,7051.80,2115.54,"AETNA [10100]","Aetna HMO/PPO",,5606.18,79.5,,1521.93,481.35,16760.95,30,820.12,5994.03,"percent of total billed charges",
"CATH VISTA BRITE TIP IG 55CM 8FR RENAL CURVE GUIDING",SUP-4038553A,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.35,161.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,63.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.49,456.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDON ANCHOR",SUP-2504-1,CDM,C1713,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,695,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,682.1,4985.25,"percent of total billed charges",
"ANCHOR SUTURE BONE ARTHROSCOPIC DELIVERY",SUP-4403,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE CONCENTRATE 20 MG/ML ORAL SYRINGE SUPERORDERABLE (FOR ORAL USE ONLY)",RX-410317,CDM,,,0250,RC,68094-0056-01,NDC,both,.5,ML,25.19,7.56,"CIGNA [10200]","Cigna Local Plus",,13.48,53.5,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 55CM 7FR .078IN HOCKEY STICK CURVE",SUP-77827855,CDM,C1887,HCPCS,0272,RC,,,both,,,304.50,91.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,207.06,68,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X13MM VERTE-STACK CORNERSTONE PSR 14MM PEEK-",SUP-6240364,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 12IN ATS 1 PORT 1 BLADDER LUER LOCK CNCT STERILE",SUP-60707505200,CDM,S27200284,LOCAL,0272,RC,,,both,,,198.36,59.51,"KAISER [10500]",Kaiser,,132.9,67,,,,,0,23.07,168.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.9MM 2 JUGGERKNOT",SUP-912529,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"FIRST HEALTH [10303]","First Health",,2400,80,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 7FR 24CM WITHOUT GWIRE PERCUFLEX PLUS",SUP-M0061755720,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS [10001]","Blue Cross HMO",,353.65,39.2,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 4-0 FS-2 18IN BRAID COATED VIOLET ABSORBABLE",SUP-J392H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT RETRIEVER 20MM 3MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0033PK32021001,CDM,S27200284,LOCAL,0272,RC,,,both,,,20045.55,6013.66,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2331.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2331.3,17038.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 2MM 14MM DCP STAINLESS STEEL SMALL BONE SELF TAPP",SUP-201.884,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"BLUE CROSS [10001]","Blue Cross HMO",,276.5,39.2,,957.42,156.86,7483.26,51,82.03,599.55,"percent of total billed charges",
"STPLR INTERNAL XL MEDIUM THICK CIRCLE EEA TRI-STAPLE PURPLE",SUP-TRIEEAXL28MT,CDM,S27200284,LOCAL,0272,RC,,,both,,,2610.30,783.09,"UHC [10700]","United Healthcare",,1652.32,63.3,,,,,0,303.58,2218.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 70X8X2CM PRECISION ARTISAN PLATNALOCK",SUP-SC-8216-70,CDM,C1778,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Local Plus",,6945.75,31.5,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 90CM 60MM 3.5MM BALLOON DILATATION PEBAX",SUP-H74939032350690,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE ORTHOPEDIC COCR 2MM 75MM HIP CLAMP ACCORD",SUP-71340020,CDM,C1713,HCPCS,0278,RC,,,both,,,1991.25,597.37,"BLUE CROSS [10001]","Blue Cross HMO",,780.57,39.2,,957.42,156.86,7483.26,51,231.58,1692.56,"percent of total billed charges",
"REAMER SURGICAL 7.5MM CANNULATED ACL LOW PROFILE STERILE",SUP-AR-1407LP-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 40MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530040M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"UHC [10700]","United Healthcare",,1010.08,63.3,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 12MM 144CM 3.5MM CORONARY STENT",SUP-H7493941812350,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"AETNA [10100]","Aetna HMO/PPO",,2385,79.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 12MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-612-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"BLUE CROSS [10001]","Blue Cross HMO",,4717.17,39.2,,5311.50,4717.44,5388.59,31,1399.51,10228.56,"percent of total billed charges",
"VALVE MITRAL MITRACLIP BUNDLE SGC0301 2 CDS0601 NTR 1",SUP-MBR0302,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"PHCS [10601]",PHCS,,119700,70,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 140MM 80CM 7MM 6FR .035IN BILIARY",SUP-G50131,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4141.2,68,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SKYPOINT MULTI-LINK 8MM 145CM 2.25MM CORONARY",SUP-1804225-08,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE WALKING LARGE ANKLE FOOT PNEUMATIC LOW ROCKER SOLE",SUP-01F-L,CDM,L4360,HCPCS,0274,RC,,,both,,,393.41,118.02,"BLUE CROSS [10001]","Blue Cross PPO",,154.22,39.2,,,,,0,45.75,334.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 28MM 10D P3 HIP CROSSFIRE SYSTEM 12",SUP-6352-5-073,CDM,C1776,HCPCS,0278,RC,,,both,,,6837.90,2051.37,"FIRST HEALTH [10303]","First Health",,5470.32,80,,,,,0,795.25,5812.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOXYCYCLINE HYCLATE 100 MG VIAL",RX-2622,CDM,J1271,HCPCS,0636,RC,16714-0644-01,NDC,both,1,UN,211.17,63.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,25.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.82,179.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NUT EXTERNAL FIXATION SQUARE MRI SAFE",SUP-03.311.060,CDM,S27800098,LOCAL,0278,RC,,,both,,,666.95,200.08,"KAISER [10500]",Kaiser,,446.86,67,,,,,0,77.57,566.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 152MM 16MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-104160,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"NOVANET [10819]",Novanet,,18152.51,75,,,,,0,2814.85,20572.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 46MM 42.3MM HIP MODULAR REMEDY",SUP-RHHDSM,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2006.18,14662.5,"percent of total billed charges",
"CATH PERFORMA 125CM 5FR JR4 CURVE ANGIOGRAPHIC PEBAX",SUP-7523-63,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"PHCS [10601]",PHCS,,57.31,70,,,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 014 150CM 15CM 3MM BALLOON DILATATION",SUP-U4150315,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELATION 180CM 8CM 7.5FR 36-40.5-45FR BALLOON DILATATION",SUP-E12,CDM,C1726,HCPCS,0272,RC,,,both,,,1458.00,437.4,"MULTIPLAN [10600]",Multiplan,,1239.3,85,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +13 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1300,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,396.9,39.2,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TACTICATH 115CM 3.5MM 8FR 2-2-2MM SPACE DAMATO TYPE FIX",SUP-A-TCSE-DF,CDM,C2630,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 6FR .038IN STRAIGHT URETERAL PERCUFLEX",SUP-M006180223010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,728.1,68,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 70MM STAINLESS STEEL 3.5MM SCR 5 HOLE RECONSTRUCTION",SUP-245.051,CDM,C1713,HCPCS,0278,RC,,,both,,,2534.70,760.41,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,300.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,294.79,2154.5,"percent of total billed charges",
"GRAFT BONE NEVOS DEMINERALIZED BONE MATRIX 5CC ALLOGRAFT",SUP-BNEPP0005,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"FIRST HEALTH [10303]","First Health",,3450,80,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 20FTX3IN ROLL 15 LAYER REINFORCE OPEN CELL",SUP-SR315,CDM,S27000186,LOCAL,0270,RC,,,both,,,449.15,134.74,"UHC [10700]","United Healthcare",,284.31,63.3,,,,,0,52.24,381.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS FIRSTCHOICE 5% DEXTROSE 40 MEQ POTASSIUM",SUP-07904-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA [10200]",Cigna,,55.08,68,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 4 1/8IN 8.5FR 18GA ARROW-FLEX .035IN PERCUTANEOUS",SUP-CDC-09803-1A,CDM,C1894,HCPCS,0272,RC,,,both,,,638.28,191.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,75.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.23,542.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 120MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.419,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,164.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,160.97,1176.51,"percent of total billed charges",
"SOL INTRAVENOUS 10% DEXTROSE INJECTION 500ML LATEX",SUP-07938-19,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"PHCS [10601]",PHCS,,56.7,70,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 6MM 6FR ENDOPROSTHESIS HEPARIN",SUP-VBJR061002A,CDM,C1874,HCPCS,0278,RC,,,both,,,22163.40,6649.02,"BLUE CROSS [10001]","Blue Cross HMO",,8688.05,39.2,,9776.84,9776.84,9776.84,"1 through 10",2577.6,18838.89,"percent of total billed charges",
"TUBE JEJUNOSTOMY 3CM 18FR SILICONE MIC-KEY SECUR-LOK",SUP-0230-18-3.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"PHCS [10601]",PHCS,,1010,70,,,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TRICLIP XT DELIVERY 4TH GENERATION TEER",SUP-TCDS0301-XT,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM ALPS TIMAX FULL THREAD HEXAGON ELBOW",SUP-815037014,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"BLUE CROSS [10001]","Blue Cross HMO",,309.58,39.2,,957.42,156.86,7483.26,51,91.85,671.29,"percent of total billed charges",
"LENS IOL +15.5 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6",SUP-ZCT225155,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Open Access",,196.31,56.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 25CM 8FR .018IN FLEXITHANE HYDROPHILIC LOCK LOOP",SUP-H749393110825K1,CDM,C1729,HCPCS,0272,RC,,,both,,,1474.20,442.26,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,605.9,41.1,,,,,0,171.45,1253.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PLLA HA 35MM 8MM 1.5MM ACL PCL CANNULATED",SUP-7207680,CDM,C1713,HCPCS,0278,RC,,,both,,,1882.13,564.64,"PHCS [10601]",PHCS,,1317.49,70,,,,,0,218.89,1599.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 26X7MM 9/11MM SPINE CORTICAL FROZEN DISTAL",SUP-4907,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"FIRST HEALTH [10303]","First Health",,13248,80,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 22CM 3CM 6FR .038IN 2 PIGTAIL",SUP-M006192131010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"NOVANET [10819]",Novanet,,900.44,75,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM FLUTE ROUND",SUP-5540010030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1288.63,386.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,152.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,149.87,1095.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 20MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE40020,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,34386.15,41.1,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 14CM 26MM 12MM 22-23MM 10-11MM GORE",SUP-RLT261214,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"MULTIPLAN [10600]",Multiplan,,53295,85,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOPROSTHESIS STENT AORTOILIAC L59MM DIA7MM VIABAHN V",SUP-BXB075902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]","Cigna Local Plus",,6144.01,31.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER RIGID SHARP DELIVERY SYSTEM HYDROMARK BREAST BIOPSY",SUP-4010-02-15-T3,CDM,A4648,HCPCS,0278,RC,,,both,,,640.49,192.15,"KAISER [10500]",Kaiser,,429.13,67,,,,,0,74.49,544.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MARINER 130CM 5FR VERTEBRAL CURVE ANGIOGRAPHIC DURATION",SUP-H787117193035,CDM,C1887,HCPCS,0272,RC,,,both,,,398.81,119.64,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT ENDOSCOPIC INSTR 1.35-1.6MM DRILL GUIDE GWIRE DISPOSABLE",SUP-AR-8990DS,CDM,C1769,HCPCS,0272,RC,,,both,,,2165.63,649.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT ELITE VASCULAR STRAIGHT",SUP-1011882,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MAJOR CHEST AND RESPIRATORY TRAUMA,EXTREME",135,APR-DRG,,,,,,,inpatient,,,152715.49,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $10,797.76. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($80,042.18) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE NUSHIELD 1.6CM DISC",SUP-NO-1160C,CDM,Q4160,HCPCS,0636,RC,,,both,,,2962.50,888.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 8FR 23CM BLUE HUB HEMOSTASIS VALVE PRELUDE",SUP-PSI-8F-23,CDM,C1894,HCPCS,0272,RC,,,both,,,110.93,33.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR 2.5X15/16IN V MUELLER HILL-FERGUSON MIRROR SATIN",SUP-SU181,CDM,S27200284,LOCAL,0272,RC,,,both,,,1070.09,321.03,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE V-LOC 180 2-0 GS-21 12IN CLSR ABSORBABLE GREEN",SUP-VLOCL0315,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,23.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERTAPE BLUNT NDL CLSR STERNAL NONABSORBABLE",SUP-AR-7289,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"PHCS [10601]",PHCS,,1041.87,70,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET 130D 3M/C 4M/C 5M/C HD LENS 2 DRIVE BELT OPHTHALMOSCOPE",SUP-54411,CDM,S27200284,LOCAL,0272,RC,,,both,,,818.10,245.43,"MULTIPLAN [10600]",Multiplan,,695.39,85,,,,,0,95.15,695.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +20.5 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.205,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MITRACLIP DELIVERY G5",SUP-MCG50100,CDM,S27800098,LOCAL,0278,RC,,,both,,,188100.00,56430,"CIGNA [10200]","Cigna Open Access",,63013.5,33.5,,,,,0,21876.03,159885,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 15MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962323,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3916.03,27,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 60X3.8MM TITANIUM REGULAR KNIFELESS",SUP-SGIA6038S,CDM,S27200284,LOCAL,0272,RC,,,both,,,657.15,197.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,77.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,76.43,558.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FIXATION ACL RIGHT 2 LOAD PASS SUT",SUP-AR-1588RT-J,CDM,C1713,HCPCS,0278,RC,,,both,,,2913.75,874.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1337.41,45.9,,,,,0,338.87,2476.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT FIXATION 6MM 3.4MM 3MM TOE 2 STEP HAMMER",SUP-204-30-006,CDM,C1713,HCPCS,0278,RC,,,both,,,6141.00,1842.3,"CIGNA [10200]",Cigna,,4175.88,68,,1831.33,1831.33,1831.33,16,714.2,5219.85,"percent of total billed charges",
"SCR BONE 4.5MM 40MM PERIPHERAL",SUP-5572-4540,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,184.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,180.93,1322.35,"percent of total billed charges",
"CATH SABERX 200CM 40MM 5MM BALLOON DILATATION RAPID EXCHANGE",SUP-47550040L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL LOCKING 3.7MM X 46MM TI",SUP-MTLS-37460-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 60MM 80CM 10MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM10060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross HMO",,7161.84,39.2,,9776.84,9776.84,9776.84,"1 through 10",2124.8,15529.5,"percent of total billed charges",
"INTRO LEAD 23CM 10FR OSCOR PEEL AWAY LUER LOCK KINK",SUP-6664,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,358.02,68,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STEALTH 145CM 10MM .07IN 1.25MM .014IN ATHERECTOMY",SUP-PRD-SC30-125,CDM,C1724,HCPCS,0272,RC,,,both,,,21388.50,6416.55,"AETNA [10100]","Aetna HMO/PPO",,17003.86,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2487.48,18180.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY REFSTAR PLUS QWIKPATCH",SUP-XRPP8Y,CDM,S27000186,LOCAL,0270,RC,,,both,,,3142.50,942.75,"CIGNA [10200]",Cigna,,2136.9,68,,,,,0,365.47,2671.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BUSH URETERAL 5 FR",SUP-84120,CDM,C1758,HCPCS,0272,RC,,,both,,,1385.10,415.53,"NOVANET [10819]",Novanet,,1038.83,75,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 C-H STD 74X46X14MM KNEE PROLONG UHMWPE",SUP-00595204014,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,929.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,911.77,6663.81,"percent of total billed charges",
"FRCP ELECTROSURGICAL 8.25IN OLSEN MIDAS TOUCH BAYONET",SUP-20-1440IMT,CDM,S27200284,LOCAL,0272,RC,,,both,,,919.32,275.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,108.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,106.92,781.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE, 2.1MM REUSABLE",SUP-SSB-222-0,CDM,S27200284,LOCAL,0272,RC,,,both,,,7590.00,2277,"NOVANET [10819]",Novanet,,5692.5,75,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 30CM 13FR POWER-TRIALYSIS STRAIGHT 3 LUMEN SHORT",SUP-5605300,CDM,C1752,HCPCS,0272,RC,,,both,,,1614.33,484.3,"NOVANET [10819]",Novanet,,1210.75,75,,,,,0,187.75,1372.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMNIOFIX INJECTABLE 160MG",SUP-AI-5200,CDM,Q4433,HCPCS,0636,RC,,,both,,,13765.50,4129.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8947.58,65,,,,,0,247.92,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 6 6MM KNEE AOX CRUCIATE RETAINING ROTATE PLATF",SUP-151630606,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"MULTIPLAN [10600]",Multiplan,,11158.16,85,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 4.5CM 2.5MM GALAXY G3 MINI STRETCH",SUP-GLM925045,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"UHC [10700]","United Healthcare",,7521.18,63.3,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Trigger Pnt<=2 Mscl",PX-510000062,CDM,20552,CPT,0761,RC,,,both,,,3291.17,987.35,"FIRST HEALTH [10303]","First Health",,2632.94,80,,,,,0,382.76,2797.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER ABDOMINAL 9IN 3 PANEL ELASTIC HOOK LOOP CLSR 46-62IN",SUP-13662067,CDM,S27000186,LOCAL,0270,RC,,,both,,,76.91,23.07,"CIGNA [10200]","Cigna Local Plus",,41.15,53.5,,,,,0,8.94,65.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 12MM STERNALOCK BLU STERNAL CANCELLOUS SELF",SUP-73-2412,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,266.22,68,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 66MM PRESS FIT AEQUALIS ASCEND FLEX PTC 127.5D",SUP-DWF601A,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"MULTIPLAN [10600]",Multiplan,,10710,85,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 22MM COLONIC ENTERAL ANCHOR LOCK",SUP-M00555780,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 100MM 11MM NEXGEN OFFSET KNEE FEMUR 145MM STERILE",SUP-00598802011,CDM,C1776,HCPCS,0278,RC,,,both,,,10435.56,3130.67,"UHC [10700]","United Healthcare",,6605.71,63.3,,8601.07,8395.67,8601.07,"1 through 10",1213.66,8870.23,"percent of total billed charges",
"STEM FEMORAL 135D 38.5MM STD OFFSET 38.5MM 130MM 9MM COLLAR",SUP-3L92499,CDM,C1776,HCPCS,0278,RC,,,both,,,30866.40,9259.92,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3657.67,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3589.76,26236.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 120MM 6MM 8FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEM06120,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4932.9,27,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 150MM 11MM OSS STRAIGHT KNEE SCR STERILE LATEX FREE",SUP-CP111649,CDM,C1776,HCPCS,0278,RC,,,both,,,11287.71,3386.31,"KAISER [10500]",Kaiser,,7562.77,67,,,,,0,1312.76,9594.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP 8IN OPEN LIGATE SMALL CURVE WIDE HORIZON",SUP-137082,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"CIGNA [10200]","Cigna Local Plus",,902.81,53.5,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CROWN FISTULA WOUND",SUP-00860013000301.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"UHC [10700]","United Healthcare",,338.4,63.3,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) GUIDEWIRE VASCULAR .018INX200CM ARISTOTLE 18 STANDARD",SUP-A18-200-002,CDM,C1769,HCPCS,0272,RC,,,both,,,4830.00,1449,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,561.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 1 KNEE LEFT DISTAL TOTAL",SUP-5541-A-101,CDM,C1776,HCPCS,0278,RC,,,both,,,6699.90,2009.97,"CIGNA [10200]","Cigna Local Plus",,3584.45,53.5,,5372.07,4581.20,7242.98,23,779.2,5694.92,"percent of total billed charges",
"GRAFT ENDOVASCULAR 124MM 28-16MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1628C124E,CDM,C1876,HCPCS,0278,RC,,,both,,,31342.50,9402.75,"FIRST HEALTH [10303]","First Health",,25074,80,,,,,0,3645.13,26641.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 20MM GEMINUS COCR DISTAL VOLAR RADIUS",SUP-PALS-25200-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1036.80,311.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,705.02,68,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC SMALL 20IN 14-16IN KNEE T BAR CONTOUR",SUP-A142005,CDM,L1830,HCPCS,0274,RC,,,both,,,117.71,35.31,"CIGNA [10200]",Cigna,,80.04,68,,,,,0,13.69,100.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COAG SUCTION 6IN 8FR 3/8IN VALLEYLAB PLASTIC POLYOLEFIN",SUP-E2608-6,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.69,20.91,"FIRST HEALTH [10303]","First Health",,55.75,80,,,,,0,8.1,59.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 44MM 28MM MARATHON HIP",SUP-121928044,CDM,C1776,HCPCS,0278,RC,,,both,,,8328.30,2498.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5663.24,68,,,,,0,968.58,7079.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM MEDIUM NECK 32MM BIOLOX DELTA",SUP-PHA04410,CDM,C1776,HCPCS,0278,RC,,,both,,,14234.70,4270.41,"MULTIPLAN [10600]",Multiplan,,12099.5,85,,,,,0,1655.5,12099.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER 13CM 3.8MM COOLCUT BONE CUTTING",SUP-AR-8380BC,CDM,S27200284,LOCAL,0272,RC,,,both,,,561.33,168.4,"PHCS [10601]",PHCS,,392.93,70,,,,,0,65.28,477.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 12MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620912,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS [10001]","Blue Cross PPO",,4411.53,39.2,,3949.44,3949.44,3949.44,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"LENS IOL +15 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE 13",SUP-PCB0000150,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X3IN DURAGEN CRANIUM BOVINE CLLGN MATRIX",SUP-DURS3391,CDM,,,0278,RC,,,both,,,7552.19,2265.66,"MULTIPLAN [10600]",Multiplan,,6419.36,85,,,,,0,7.55,6419.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR 45CM 12FR ACCESS URETERAL CONTINUOUS WORK",SUP-G46168,CDM,C1894,HCPCS,0272,RC,,,both,,,1244.97,373.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,147.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.79,1058.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 80MM 9.6MM 7MM 1 CANN CUFF LOW PRESSURE ROUND TIP OBTR",SUP-7SCT,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.54,64.36,"FIRST HEALTH [10303]","First Health",,171.63,80,,,,,0,24.95,182.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1 KNEE LEFT TOTAL STABILIZE TRIATHLON COCR",SUP-5512-F-101,CDM,C1776,HCPCS,0278,RC,,,both,,,32652.90,9795.87,"CIGNA [10200]","Cigna Open Access",,10938.72,33.5,,5302.19,4377.88,6578.61,27,3797.53,27754.97,"percent of total billed charges",
"VALVE AORTIC INSPIRIS RESILIA 21MM BOVINE PERICARDIUM",SUP-11500A21,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18642.96,41.1,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBO ELITE 150CM 2MM .080IN ATHERECTOMY PERIPHERAL",SUP-420-159,CDM,C1885,HCPCS,0272,RC,,,both,,,18868.50,5660.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2235.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2194.41,16038.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 14MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240140300,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3542.04,41.1,,,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 8MM 144CM 3MM CORONARY STENT",SUP-H7493941808300,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 35MM ATS SPINE MULTIAXIAL 4.75MM ROD",SUP-54840046535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1131.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",1110.3,8114.82,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL BALL UNIVERSAL 12CM 3MM STERILE",SUP-B0312,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.17,46.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,71.68,45.9,,,,,0,18.16,132.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inf Agent Zika Amp",PX-306000233,CDM,87662,CPT,0306,RC,,,both,,,997.50,299.25,"NOVANET [10819]",Novanet,,748.13,75,,,,,0,0.01,847.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acth",PX-301000086,CDM,82024,CPT,0301,RC,,,both,,,401.85,120.55,"PHCS [10601]",PHCS,,281.3,70,,,,,0,0.01,341.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acth",PX-301000086,CDM,82024,CPT,0301,RC,,,both,,,401.85,120.55,"CIGNA [10200]",Cigna,,84.96,,,,,,,0.01,341.57,"fee schedule",
"HC Acth",PX-301000086,CDM,82024,CPT,0301,RC,,,both,,,401.85,120.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,341.57,"per diem",
"HC Phenytoin Total",PX-301000049,CDM,80185,CPT,0301,RC,,,both,,,295.10,88.53,"CIGNA [10200]","Cigna Open Access",,29.15,,,,,,,0.01,250.84,"fee schedule",
"STENT CONTOUR ZIPWIRE 22CM 3CM 7FR .035IN PIGTAIL CURVE",SUP-M006180231170,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,362.15,28.62,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVERSTITCH NXT ENDOSCOPIC SUTURE SYSTEM",SUP-M00505430,CDM,S27200284,LOCAL,0272,RC,,,both,,,21712.32,6513.7,"CIGNA [10200]","Cigna Local Plus",,11616.09,53.5,,,,,0,2525.14,18455.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ORTHOPEDIC WRIST WRISTWIDGET LATEX FREE",SUP-564743,CDM,S27000186,LOCAL,0270,RC,,,both,,,340.78,102.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.63,289.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 20FR SILICONE MIC-KEY SECUR-LOK ENFIT BOLUS",SUP-8200-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"UHC [10700]","United Healthcare",,696.03,63.3,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM PRESTIGE PLUS HELICAL ULTRA",SUP-PRES0620CPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"CIGNA [10200]",Cigna,,4457.4,68,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 20MM 6MM BALLOON",SUP-U3513062,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE STC-18 150CM 30CM 2.4-3FR .021IN MICRO",SUP-M001181380,CDM,C1887,HCPCS,0272,RC,,,both,,,2287.50,686.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,940.16,41.1,,,,,0,266.04,1944.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM VALOR HINDFOOT FUSION SYSTEM",SUP-4151150040,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"CIGNA [10200]",Cigna,,1173,68,,1831.33,1831.33,1831.33,16,200.62,1466.25,"percent of total billed charges",
"STENT CONTOUR VL ZIPWIRE 22-30CM 3CM 6FR .035IN PIGTAIL",SUP-M006180156180,CDM,C2617,HCPCS,0278,RC,,,both,,,1466.59,439.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,170.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,170.56,1246.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 13MM HELIX R SPINE SELF TAP FIX ANGLE",SUP-7804213,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TEMPTIP 28CM 10FR LARGE PROXIMAL PIGTAIL CURVE",SUP-M001235610,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA [10200]",Cigna,,605.88,68,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 125CM 5FR JR4 CURVE ANGIOGRAPHIC PEBAX",SUP-7523-63,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.87,24.56,"CIGNA [10200]","Cigna Local Plus",,43.8,53.5,,,,,0,9.52,69.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 15MM 2MM BALLOON DILATATION",SUP-H7493912415200,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 75MM STAINLESS STEEL 2.4MM SCR 6 HOLE HEAD 5 HOLE",SUP-02.111.651S,CDM,C1713,HCPCS,0278,RC,,,both,,,4617.83,1385.35,"MULTIPLAN [10600]",Multiplan,,3925.16,85,,,,,0,537.05,3925.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ CONTROLCATH 110CM 6FR C PULMONARY ARTERY",SUP-C145F6N,CDM,C1751,HCPCS,0272,RC,,,both,,,926.07,277.82,"AETNA [10100]","Aetna HMO/PPO",,736.23,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,107.7,787.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 32MM ALL POLY",SUP-5972-65-32,CDM,C1776,HCPCS,0278,RC,,,both,,,4623.00,1386.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,547.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,537.65,3929.55,"percent of total billed charges",
"CUFF TRNQT BLUE 34X4IN LONG LEG 1 FILL LINE POSITIVE LOCK",SUP-ASP-564012,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.00,58.5,"CIGNA [10200]","Cigna Open Access",,110.96,56.9,,,,,0,22.68,165.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 13MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530G213,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"FIRST HEALTH [10303]","First Health",,6966.09,80,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH CARDIOVASCULAR 5X2CM ENCAP TECHNOLOGY PERICARDIAL",SUP-C0205,CDM,C1768,HCPCS,0278,RC,,,both,,,2874.38,862.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,340.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,334.29,2443.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF TRNQT 12X3.5IN ATS CYL PORT STERILE DISPOSABLE",SUP-60707510200,CDM,S27200284,LOCAL,0272,RC,,,both,,,150.82,45.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.54,128.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 130CM 8CM 6MM BALLOON DILATATION",SUP-U813068,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UHC [10700]","United Healthcare",,820.37,63.3,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD + OSS LH + VE",SUP-98000500316,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"MULTIPLAN [10600]",Multiplan,,24633,85,,,,,0,3370.37,24633,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 6MM X 37MM - US",SUP-90315,CDM,S27200284,LOCAL,0272,RC,,,both,,,35649.18,10694.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4146,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4146,30301.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ileoscopy Stoma W Bal Dil",PX-750000159,CDM,44381,CPT,0750,RC,,,both,,,4055.00,1216.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2795,,"Case rate ($2,795). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,471.6,4055,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Microbe Suscept Macrobroth",PX-306000217,CDM,87188,CPT,0306,RC,,,both,,,199.00,59.7,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,169.15,"per diem",
"STY LD 65CM SFT KNTRX",SUP-117464,CDM,S27500001,LOCAL,0275,RC,,,both,,,382.80,114.84,"KAISER [10500]",Kaiser,,256.48,67,,,,,0,44.52,325.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 24X10X11-7.7MM LUMINARY BULLET NOSE SPINE",SUP-15811,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7767.9,41.1,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE GRAFT 6CC DEMINERALIZED CORTICAL FIBER ACCELERATE",SUP-T50206,CDM,C1713,HCPCS,0278,RC,,,both,,,9522.00,2856.6,"BLUE CROSS [10001]","Blue Cross PPO",,3732.62,39.2,,957.42,570.23,957.42,28,1107.41,8093.7,"percent of total billed charges",
"SURFACE ARTICULAR 10MM PERSONA 3-11 E-F KNEE LEFT VIVACIT-E",SUP-42512000510,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PHCS [10601]",PHCS,,7543.49,70,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 24CM 7FR .038IN PIGTAIL CURVE",SUP-M006155242120,CDM,C2617,HCPCS,0278,RC,,,both,,,1325.65,397.69,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,154.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,154.17,1126.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS SENSOR DUAL-FLEX 24CM 7FR .038IN PIGTAIL CURVE",SUP-M006155242120,CDM,C2617,HCPCS,0278,RC,,,both,,,1325.65,397.69,"CIGNA [10200]","Cigna Open Access",,754.29,,,,,,,154.17,1126.8,"percent of total billed charges",
"CLIP HEMOSTATIC 2.8MM REPOSITIONABLE DURACLIP 235CM 16MM",SUP-DC0235W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1053.00,315.9,"CIGNA [10200]","Cigna Open Access",,599.16,56.9,,,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 75CM 8MM 20MM",SUP-H74938046820750,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"KAISER [10500]",Kaiser,,2773.8,67,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 150MM 5FR 4MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-04151,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA MEDIAL CONGRUENT 6-7 E-F KNEE",SUP-42522100712,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"AETNA [10100]","Aetna HMO/PPO",,8567.25,79.5,,10981.53,8986.79,12413.38,12,1253.3,9159.96,"percent of total billed charges",
"STENT ABSOLUTE PRO 80MM 135CM 9MM VASCULAR NITINOL",SUP-1012537-80,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR ANGLE 150CM .025IN HYDROPHILIC FIX CORE",SUP-H2OSTDA25150,CDM,C1769,HCPCS,0272,RC,,,both,,,408.47,122.54,"MULTIPLAN [10600]",Multiplan,,347.2,85,,,,,0,47.51,347.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LORAZEPAM 1 MG TABLET",RX-4573,CDM,,,0250,RC,00093-3426-01,NDC,both,1,UN,12.54,3.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET",RX-184098,CDM,,,0637,RC,00310-1105-01,NDC,both,1,UN,173.34,52,"KAISER [10500]",Kaiser,,116.14,67,,,,,0,20.16,147.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 12MM NONCOLLAR REDUCE PROXIMAL PROFILE",SUP-192412,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"AETNA [10100]","Aetna HMO/PPO",,18880.04,79.5,,10981.53,8986.79,12413.38,12,2761.95,20186.21,"percent of total billed charges",
"CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION",RX-4294,CDM,,,0250,RC,51754-1007-01,NDC,both,10,ML,857.98,257.39,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,352.63,41.1,,,,,0,99.78,729.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 5.6MM 32MM NCB TITANIUM ALUMINUM VANADIUM",SUP-00236903235,CDM,C1713,HCPCS,0278,RC,,,both,,,1275.75,382.72,"MULTIPLAN [10600]",Multiplan,,1084.39,85,,,,,0,148.37,1084.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASK CPAP SMALL 1 CLICK DESIGN SOFT SEAL GEL CUSH",SUP-1090401,CDM,S27000186,LOCAL,0270,RC,,,both,,,165.30,49.59,"MULTIPLAN [10600]",Multiplan,,140.51,85,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 10IN FOREARM LEFT WRIST D RING",SUP-5066-81,CDM,S27000186,LOCAL,0270,RC,,,both,,,72.91,21.87,"CIGNA [10200]",Cigna,,49.58,68,,,,,0,8.48,61.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 150CM 15CM 2MM BALLOON DILATATION",SUP-U8150215,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CTRL ANGIOGRAPHY 3 CLOCKWISE COUNT ROTATION SPINR .014-.038",SUP-3X-GW,CDM,S27200284,LOCAL,0272,RC,,,both,,,1987.50,596.25,"KAISER [10500]",Kaiser,,1331.63,67,,,,,0,231.15,1689.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 650CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRX-650,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"BLUE CROSS [10001]","Blue Cross HMO",,1555.85,39.2,,,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 2-0 GS-21 .5 CIRCLE 9IN 37MM CLSR TAPER",SUP-VLOCM0345,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,80.49,41.1,,,,,0,22.78,166.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 440MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.164S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"UHC [10700]","United Healthcare",,7860.81,63.3,,5023.51,2672.93,6679.78,18,1444.25,10555.59,"percent of total billed charges",
"INSRT TIBIAL 6 18MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650618,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA [10200]",Cigna,,5250.9,40,,5873.17,5873.17,5873.17,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC",698,MS-DRG,,,,,,,inpatient,,,42098.63,12629.59,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,10878.08,,"Case rate ($10,262.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,529.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,568.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,102.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,541.88. The transfer operating threshold is the transfer adjustment factor * $9,529.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.46. The transfer capital threshold is the transfer adjustment factor * $720.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,41259.08,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"VLV SHNT CERTAS INLN SPHGRD",SUP-828804PL,CDM,S27800098,LOCAL,0278,RC,,,both,,,38643.57,11593.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10433.76,27,,,,,0,4494.25,32847.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVOCATE 130CM 60MM 7FR BALLOON DILATATION SERENE OTW",SUP-A35120060130,CDM,C1725,HCPCS,0272,RC,,,both,,,1093.50,328.05,"NOVANET [10819]",Novanet,,820.13,75,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 8.2MM 135MM 22MM DHS/DCS STAINLESS STEEL",SUP-280.35,CDM,C1713,HCPCS,0278,RC,,,both,,,2264.18,679.25,"CIGNA [10200]","Cigna Local Plus",,1211.34,53.5,,3978.14,359.25,3978.14,24,263.32,1924.55,"percent of total billed charges",
"CATH MACH1 90CM 8FR AL2 CURVE GUIDING PTFE FEMORAL",SUP-H749343583990,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"UHC [10700]","United Healthcare",,231.96,63.3,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE GOLD VASCULAR 70D 180CM 8CM .014IN",SUP-GM1402,CDM,C1769,HCPCS,0272,RC,,,both,,,2175.00,652.5,"UHC [10700]","United Healthcare",,1376.78,63.3,,,,,0,252.95,1848.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BINDER QUEEN ZIPPER BRA RECOVERY MAMMARY",SUP-958-QUEEN,CDM,S27000186,LOCAL,0270,RC,,,both,,,449.39,134.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,206.27,45.9,,,,,0,52.26,381.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE ROUND SILICONE",SUP-SRF-335,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"BLUE CROSS [10001]","Blue Cross HMO",,2150.32,39.2,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFE-T-J VASCULAR TAPER STD 180CM 3CM .035IN PTFE",SUP-G00902,CDM,C1769,HCPCS,0272,RC,,,both,,,121.71,36.51,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.15,103.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN RADIAL CURVE GUIDING NYLON",SUP-LA6MRADIAL,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 25MM 40MM SHOULDER MODULAR REMEDY PMMA",SUP-RSHHSM,CDM,C1776,HCPCS,0278,RC,,,both,,,20475.00,6142.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5528.25,27,,,,,0,2381.24,17403.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 4X4CM VIALIZE PLACENTAL MEMB ALLOGRAFT",SUP-VL-4040,CDM,,,0278,RC,,,both,,,10281.00,3084.3,"CIGNA [10200]","Cigna Local Plus",,5500.34,53.5,,,,,0,10.28,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT CONSTRAIN LEGION OXINIUM",SUP-71421166,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,15615.18,27,,,,,0,6726.09,49158.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.7MM 12MM VARIAX TITANIUM LOW PROFILE HAND WRIST",SUP-53-17012E,CDM,C1713,HCPCS,0278,RC,,,both,,,734.83,220.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,85.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",85.46,624.61,"percent of total billed charges",
"(EVAL) 35MM CLAAS (LARGE) IMPLANT WITH DELIVERY SYSTEM",SUP-30-00269,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR .071IN 3 DIMENSIONAL RIGHT CURVE",SUP-LA63DRCSH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OBTR ENDOSCOPIC 24FR RESECTOSCOPY DEFLECTABLE TIP",SUP-A22085A,CDM,S27200284,LOCAL,0272,RC,,,both,,,4234.67,1270.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT MONOCRYL PLUS 4-0 P-3 18IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP494G,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.78,20.63,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL BIOPSY 21GA ALWAYS-ON TIP TRACKED ANSO CYTOLOGY",SUP-INS-0392,CDM,S27200284,LOCAL,0272,RC,,,both,,,3912.30,1173.69,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 2.7MM COMPREHENSIVE PERIPHERAL SCR REVERSE",SUP-405889,CDM,S27200284,LOCAL,0272,RC,,,both,,,1556.00,466.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 5MM CARBIDE ROUND STERILE",SUP-0277010250,CDM,S27200284,LOCAL,0272,RC,,,both,,,262.31,78.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT THROMBECTOMY PENUMBRA SYSTEM REPERFUSION CATH TUBE",SUP-3MAXCKIT,CDM,C1757,HCPCS,0272,RC,,,both,,,13765.50,4129.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5657.62,41.1,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 57MM 135CM 10MM 60MM",SUP-H74938047160130,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT PORCINE 3.1X3.1IN XENMATRIX AQUAPURE SQUARE ACELLULAR",SUP-1160808,CDM,C1781,HCPCS,0278,RC,,,both,,,10750.20,3225.06,"UHC [10700]","United Healthcare",,6804.88,63.3,,,,,0,1250.25,9137.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 100MM 2.4MM STAINLESS STEEL QUICK COUPLING",SUP-310.53,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4+ 10MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS4P10R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2974.02,28.62,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND 3.2X2.4IN SILICONE PORCINE THERAGENESIS 2 LAYER",SUP-TG-M8260,CDM,A2008,HCPCS,0636,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,247.92,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 14GA RIGID NDL RADIOPAQUE GEL MARK ULTRACOR BREAST",SUP-GMUTC005SS,CDM,A4648,HCPCS,0278,RC,,,both,,,526.34,157.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,241.59,45.9,,,,,0,61.21,447.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 100CM 5FR ANGLE",SUP-G08421,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"PHCS [10601]",PHCS,,166.24,70,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 30MM 2MM QUICK CONNECT STERILE",SUP-03.133.100S,CDM,S27200284,LOCAL,0272,RC,,,both,,,959.36,287.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,440.35,45.9,,,,,0,111.57,815.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX GEOALIGN 130CM 150MM 6MM BALLOON DILATATION",SUP-LX1813061505F,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"NOVANET [10819]",Novanet,,6339.38,75,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 40MM LOW PROFILE SCREWS STAINLESS STEEL SHORT",SUP-AR-8840C-40,CDM,C1713,HCPCS,0278,RC,,,both,,,1770.00,531,"AMERIGROUP MEDICAID [20100]",Amerigroup,,209.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",205.85,1504.5,"percent of total billed charges",
"LENS IOL 10 D +11 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.110,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH GREEN 16CM 12.5FR MAHURKAR ELITE DOUBLE-D LARGE",SUP-8888231416,CDM,C1752,HCPCS,0272,RC,,,both,,,1178.06,353.42,"KAISER [10500]",Kaiser,,789.3,67,,,,,0,137.01,1001.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TEMPTIP APD 20CM 8FR DRNG FLEXIMA METAL POLYURETHANE",SUP-M001281290,CDM,C1729,HCPCS,0272,RC,,,both,,,631.80,189.54,"MULTIPLAN [10600]",Multiplan,,537.03,85,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 2X2CM AXOGUARD HA+ NERVE PROTCT EXTRACELLULAR",SUP-AGHA22,CDM,C1763,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 42MM TI",SUP-SPL-35420-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,1144.80,304.56,2275.09,66,155.43,1136.03,"percent of total billed charges",
"HC Ligation Hemm Intrnl Sngl",PX-450000268,CDM,46945,CPT,0361,RC,,,both,,,11998.00,3599.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1395.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1395.37,10198.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 33MM UNIVERS REVERS +3MM LINER",SUP-AR-9503XS-03,CDM,C1776,HCPCS,0278,RC,,,both,,,4305.60,1291.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,500.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,500.74,3659.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUARD SUCTION CUSA CLARITY CONTAMINATION",SUP-C7005,CDM,S27200284,LOCAL,0272,RC,,,both,,,3821.84,1146.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1754.22,45.9,,,,,0,444.48,3248.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) OCCL CARDIOVASCULAR 10X22-25MM 28MM 35MM HEMOSTASIS",SUP-9-ACP2-010-028,CDM,C1817,HCPCS,0278,RC,,,both,,,102600.00,30780,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12158.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11932.38,87210,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIR STPLR TRIEEAXL33XT BLK EXT",SUP-TRIEEAXL33XT,CDM,S27200284,LOCAL,0272,RC,,,both,,,3083.78,925.13,"PHCS [10601]",PHCS,,2158.65,70,,,,,0,358.64,2621.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 51MM TITANIUM 3 LEVEL ZEVO BONE SPINE CERVICAL",SUP-3003051,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 10CC DBX ALLOGRAFT FREEZE DRIED PASTE",SUP-28100,CDM,C1713,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]",Cigna,,4222.8,68,,1831.33,1831.33,1831.33,16,722.22,5278.5,"percent of total billed charges",
"STENT COMPLETE SE 100MM 130CM 7MM LONG VASCULAR NITINOL",SUP-SC7100LV,CDM,C1876,HCPCS,0278,RC,,,both,,,8970.00,2691,"CIGNA [10200]","Cigna Open Access",,5103.93,56.9,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 83MM 19MM COMPREHENSIVE POROUS MINI SHOULDER",SUP-113639,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1465.38,10710,"percent of total billed charges",
"HEAD UNIPOLAR 50MM CENTERPULSE LEGACY 12/14 TAPER HIP FEMUR",SUP-451000050,CDM,C1776,HCPCS,0278,RC,,,both,,,2328.75,698.62,"FIRST HEALTH [10303]","First Health",,1863,80,,,,,0,270.83,1979.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SR CORTICAL BLOCK 11X11X9MM",SUP-200911,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 158MM STAINLESS STEEL 3.5MM SCREWS 6 HOLE LCP BONE",SUP-02.104.026S,CDM,C1713,HCPCS,0278,RC,,,both,,,9414.08,2824.22,"CIGNA [10200]","Cigna Open Access",,5356.61,56.9,,1144.80,304.56,2275.09,66,1094.86,8001.97,"percent of total billed charges",
"PIN FIXATION 9IN 5/64IN STEINMANN BRASSELER USA STAINLESS",SUP-KM169-29-56,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"NOVANET [10819]",Novanet,,47.71,75,,,,,0,7.4,54.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL REMEDY MEDIUM KNEE STEM STERILE",SUP-RSKTMD,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4657.5,27,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR INSIGNIA 10 HIGH",SUP-7000-6610,CDM,C1776,HCPCS,0278,RC,,,both,,,30573.90,9172.17,"CIGNA [10200]","Cigna Local Plus",,9630.78,31.5,,5372.07,4581.20,7242.98,23,3555.74,25987.82,"percent of total billed charges",
"HC Hbb Full Gene Sequence",PX-309000140,CDM,81364,CPT,0310,RC,,,both,,,1536.00,460.8,"CIGNA [10200]","Cigna Local Plus",,714.08,,,,,,,0.01,1305.6,"fee schedule",
"SUT MONOCRYL PLUS 2-0 CP-1 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP266H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]",Cigna,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 14MM TITANIUM FULL THREAD T10 HEXALOBE FOREFOOT",SUP-AR-8933L-14,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,1144.80,304.56,2275.09,66,141.3,1032.75,"percent of total billed charges",
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 6-7 E-F KNEE",SUP-42522100711,CDM,C1776,HCPCS,0278,RC,,,both,,,9466.80,2840.04,"MULTIPLAN [10600]",Multiplan,,8046.78,85,,,,,0,1100.99,8046.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL STD 65MM KNEE RIGHT GMRS COCR",SUP-64952040,CDM,C1776,HCPCS,0278,RC,,,both,,,34568.10,10370.43,"CIGNA [10200]","Cigna Open Access",,11580.31,33.5,,5302.19,4377.88,6578.61,27,4020.27,29382.89,"percent of total billed charges",
"INSRT TIBIAL 2.5 20MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962335,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4150.99,28.62,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 135D STD BARREL 62X19X5.8MM STAINLESS STEEL 4.5MM",SUP-281.131S,CDM,C1713,HCPCS,0278,RC,,,both,,,3765.33,1129.6,"CIGNA [10200]","Cigna Open Access",,2142.47,56.9,,1144.80,304.56,2275.09,66,437.91,3200.53,"percent of total billed charges",
"CATH BARDEX IC 16FR URETHRAL BACTI-GUARD RUBBER HYDROGEL 5CC",SUP-0196SI16,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.25,42.67,"KAISER [10500]",Kaiser,,95.31,67,,,,,0,16.54,120.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ENDEAVOR SPRINT 8MM 142CM 2.5MM CORONARY STENT",SUP-ENSP25008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"FIRST HEALTH [10303]","First Health",,4435.2,80,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 73MM STAINLESS STEEL 2.7/3.5MM SCR 2 HOLE VARIABLE",SUP-02.107.002S,CDM,C1713,HCPCS,0278,RC,,,both,,,5743.84,1723.15,"BLUE CROSS [10001]","Blue Cross HMO",,2251.59,39.2,,957.42,156.86,7483.26,51,668.01,4882.26,"percent of total billed charges",
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC",698,MS-DRG,,,,,,,inpatient,,,42098.63,12629.59,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,10724.15,,"Case rate ($10,262.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,529.28, add-ons for qualifying new technology services are included. If operating cost exceeds $42,568.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,102.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $9,541.88. The transfer operating threshold is the transfer adjustment factor * $9,529.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.46. The transfer capital threshold is the transfer adjustment factor * $720.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",10918.89,8936.40,10918.89,"1 through 10",7561,41259.08,other,"IP DRG"
"INTRO SHEATH 4.5FR 11CM RED HUB TUBING ROTATING SUT RING",SUP-PSI-4F-11ACT,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"AETNA [10100]","Aetna HMO/PPO",,63.63,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ESURG 195MM 3MM MULTIVAC 50D",SUP-72290004,CDM,S27200284,LOCAL,0272,RC,,,both,,,3476.25,1042.87,"KAISER [10500]",Kaiser,,2329.09,67,,,,,0,404.29,2954.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE BENTSON UROLOGICAL 150CM 15CM .035IN PTFE STRAIGHT TIP",SUP-M0066201250,CDM,C1769,HCPCS,0272,RC,,,both,,,128.93,38.68,"KAISER [10500]",Kaiser,,86.38,67,,,,,0,14.99,109.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +25.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.255,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 28.5CM TIBIAL NAIL-EX INTRAMEDULLARY CANNULATED",SUP-04.004.537S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"CIGNA [10200]","Cigna Local Plus",,4447.15,53.5,,3978.14,359.25,3978.14,24,966.74,7065.57,"percent of total billed charges",
"INTRO SHEATH 4.5FR 11CM RED HUB TUBING ROTATING SUT RING",SUP-PSI-4F-11ACT,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"NOVANET [10819]",Novanet,,60.03,75,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE INTRAMEDULLARY FIXATION NONSTERILE GOLD 90MM 11MM",SUP-456.303,CDM,C1713,HCPCS,0278,RC,,,both,,,3964.33,1189.3,"BLUE CROSS [10001]","Blue Cross PPO",,1554.02,39.2,,957.42,570.23,957.42,28,461.05,3369.68,"percent of total billed charges",
"STENT FRMLA 418 20MM 135CM 6MM .018IN BILIARY STAINLESS",SUP-G56627,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"CIGNA [10200]",Cigna,,3427.2,68,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE RIGHT CRUCIATE RETAIN JOURNEY II",SUP-74021157,CDM,C1776,HCPCS,0278,RC,,,both,,,37771.65,11331.49,"NOVANET [10819]",Novanet,,28328.74,75,,,,,0,4392.84,32105.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 32.51CM 8MM DA VINCI XI ENDOWRIST 30D LONG",SUP-470048,CDM,S27000186,LOCAL,0270,RC,,,both,,,2100.00,630,"AMERIGROUP MEDICAID [20100]",Amerigroup,,248.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE STEELCORE VASCULAR STRAIGHT 190CM 3CM .018IN",SUP-1007709,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 32MM CORTICAL",SUP-HTN-U-4-32,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,713.84,45.9,,,,,0,180.87,1321.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X7MM ADVANCED CONVEX SPINE",SUP-17807,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"MULTIPLAN [10600]",Multiplan,,7038,85,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14MM 51X16X2.5MM TITANIUM 3 LEVEL PREBENT SKYLINE BONE",SUP-186803051,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,627.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",615.46,4498.2,"percent of total billed charges",
"AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET, IMMEDIATE RELEASE",RX-33227,CDM,,,0250,RC,42571-0161-01,NDC,both,1,UN,19.04,5.71,"NOVANET [10819]",Novanet,,14.28,75,,,,,0,2.21,16.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SET BANDER URETER  LF 7F",SUP-25707,CDM,S27200284,LOCAL,0272,RC,,,both,,,523.26,156.98,"AETNA [10100]","Aetna HMO/PPO",,415.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.86,444.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 640CC P4.3CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-640,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT CONSTRAIN LEGION OXINIUM",SUP-71421166,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23769.77,41.1,,6417.48,6417.48,6417.48,"1 through 10",6726.09,49158.9,"percent of total billed charges",
"TRAY TIBIAL MBT LCS COMPLETE 3 KNEE POROUS CEMENTED KEEL",SUP-129434130,CDM,C1776,HCPCS,0278,RC,,,both,,,17561.25,5268.37,"NOVANET [10819]",Novanet,,13170.94,75,,,,,0,2042.37,14927.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L15 MM OD3.5 MM SPINE CERVICAL ANTERIOR SELF DRIL",SUP-18008215,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",117.75,860.63,"percent of total billed charges",
"FOL URETHRAL 13.35IN 12FR HEYMAN PLASTIC DILATION CATH",SUP-021112,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.15,65.14,"MULTIPLAN [10600]",Multiplan,,184.58,85,,,,,0,25.25,184.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 25MM TORNIER AEQUALIS PERFORM STD SHOULDER",SUP-DWJ401,CDM,C1776,HCPCS,0278,RC,,,both,,,9443.00,2832.9,"NOVANET [10819]",Novanet,,7082.25,75,,,,,0,1098.22,8026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 22CM PUMP SET INFLATABLE FLUID FILL SOFT",SUP-ES8822,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"MULTIPLAN [10600]",Multiplan,,53295,85,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL VANTAGE THK6MM 3 ANKLE LEFT STERILE LATEX FREE",SUP-350-21-03,CDM,C1713,HCPCS,0278,RC,,,both,,,8832.00,2649.6,"CIGNA [10200]","Cigna Local Plus",,4725.12,53.5,,3978.14,359.25,3978.14,24,1027.16,7507.2,"percent of total billed charges",
"CANN RADIOFREQUENCY 100MM 20GA 10MM",SUP-AC0009,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"MULTIPLAN [10600]",Multiplan,,88.74,85,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 14MM TITANIUM T10 FULL THREAD CORTEX SELF TAP",SUP-AR-8933-14,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"BLUE CROSS [10001]","Blue Cross HMO",,349.27,39.2,,957.42,156.86,7483.26,51,103.62,757.35,"percent of total billed charges",
"SCR BONE 3MM 2MM 18MM 6MM STAINLESS STEEL 1.1MM LONG THREAD",SUP-02.226.118,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"CIGNA [10200]","Cigna Local Plus",,880.18,53.5,,3978.14,359.25,3978.14,24,191.34,1398.42,"percent of total billed charges",
"DEVICE RIALTO 40X12MM FUSION THREAD STERILE LATEX FREE",SUP-74200001240,CDM,C1713,HCPCS,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS [10001]","Blue Cross PPO",,6491.52,39.2,,957.42,570.23,957.42,28,1925.93,14076,"percent of total billed charges",
"GRAFT SOFT TISSUE 16MM AMNIOGRAFT PROKERA THK50-100UM",SUP-PK-16,CDM,V2790,HCPCS,0278,RC,,,both,,,6548.10,1964.43,"NOVANET [10819]",Novanet,,4911.08,75,,,,,0,761.54,5565.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 23MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.230,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"BLUE CROSS [10001]","Blue Cross PPO",,1152.48,39.2,,957.42,570.23,957.42,28,341.92,2499,"percent of total billed charges",
"SUT ETHIBOND EXCEL 2-0 V-7 36IN 2 ARM BRAID FIRM PLEDG WHITE",SUP-PX64H,CDM,S27200284,LOCAL,0272,RC,,,both,,,90.60,27.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.54,77.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Set Rad Ther Field Cmplx",PX-333000006,CDM,77290,CPT,0333,RC,,,both,,,3279.64,983.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,388.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,381.42,3279.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE SELF TAPPING RIGID 4MM 14MM ASSURE TITANIUM",SUP-110.034,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"BLUE CROSS [10001]","Blue Cross HMO",,552.72,39.2,,957.42,156.86,7483.26,51,163.98,1198.5,"percent of total billed charges",
"BASEPLT TIBIAL ATTUNE S+ 8 KNEE CEMENT FIX BEARING",SUP-150670008,CDM,C1776,HCPCS,0278,RC,,,both,,,15487.05,4646.11,"CIGNA [10200]","Cigna Open Access",,5188.16,33.5,,5302.19,4377.88,6578.61,27,1801.14,13163.99,"percent of total billed charges",
"HC Dgtz Gls Mcrscp Electron Mic",PX-312000087,CDM,0856T,CPT,0312,RC,,,both,,,104.00,31.2,"CIGNA [10200]","Cigna Local Plus",,55.64,53.5,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X22X14MM 10D XL WIDE PEEK LORDOTIC",SUP-6921455,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6800.11,28.62,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TORQ-FLEX VASCULAR STRAIGHT 60CM 8CM .018IN STAINLESS",SUP-G07303,CDM,C1769,HCPCS,0272,RC,,,both,,,304.41,91.32,"PHCS [10601]",PHCS,,213.09,70,,,,,0,35.4,258.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 10CM 27MM 36MM 28MM GELWEAVE VALSALVA MASTERS",SUP-27VAVGJ-515,CDM,S27800098,LOCAL,0278,RC,,,both,,,36805.86,11041.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15127.21,41.1,,,,,0,4280.52,31284.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 41-44MM TITANIUM 4.75MM SCR MULTISPAN XLNK BONE SPINE",SUP-5442141,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"AMERIGROUP MEDICAID [20100]",Amerigroup,,572.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",561.73,4105.5,"percent of total billed charges",
"LINER ACETABULAR R3 20D 60MM 32MM XLPE HIP",SUP-71337660,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1318.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1293.98,9457.31,"percent of total billed charges",
"LENS IOL 10 D +13 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.130,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC LARGE HUB PREBENT EXTEND LENGTH STERLING",SUP-C9255,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 50MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.850,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"BLUE CROSS [10001]","Blue Cross PPO",,538.77,39.2,,957.42,570.23,957.42,28,159.84,1168.25,"percent of total billed charges",
"DEVICE BIOPINCE ULTRA 20CM 18GA BIOPSY FULL CORE INDCTR",SUP-360-2080-02,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"KAISER [10500]",Kaiser,,273.96,67,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Est Eval Visit Level 4",PX-510000179,CDM,99214,CPT,0761,RC,,,both,,,444.10,133.23,"AETNA [10100]","Aetna HMO/PPO",,353.06,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.44,444.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 22CM 3CM 6FR .035IN PIGTAIL CURVE",SUP-M006180521170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"MULTIPLAN [10600]",Multiplan,,1046.32,85,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Renin",PX-301000391,CDM,84244,CPT,0301,RC,,,both,,,297.70,89.31,"MULTIPLAN [10600]",Multiplan,,253.05,85,,,,,0,0.01,253.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 10 10MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151621010,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS [10001]","Blue Cross PPO",,4411.53,39.2,,3949.44,3949.44,3949.44,"1 through 10",1308.83,9565.82,"percent of total billed charges",
"MARKER 45MM FREEMAN AREOLA BREAST BIOPSY STAINLESS STEEL",SUP-P467,CDM,S27200284,LOCAL,0272,RC,,,both,,,507.79,152.34,"KAISER [10500]",Kaiser,,340.22,67,,,,,0,59.06,431.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BIOABSORBABLE REGENETEN LARGE ROTATOR CUFF BOVINE",SUP-4566,CDM,S27800098,LOCAL,0278,RC,,,both,,,14490.00,4347,"BLUE CROSS [10001]","Blue Cross PPO",,5680.08,39.2,,,,,0,1685.19,12316.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SELENIUM 40 MCG/ML INTRAVENOUS SOLUTION",RX-77308,CDM,,,0250,RC,00517-6510-25,NDC,both,10,ML,167.31,50.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.46,142.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE SMALL 35MM SPIRE Z BONE SPINAL",SUP-9240535,CDM,C1713,HCPCS,0278,RC,,,both,,,17798.40,5339.52,"BLUE CROSS [10001]","Blue Cross HMO",,6976.97,39.2,,957.42,156.86,7483.26,51,2069.95,15128.64,"percent of total billed charges",
"CATH LUTONIX GEOALIGN 130CM 150MM 5MM BALLOON DILATATION",SUP-LX1813051505F,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"UHC [10700]","United Healthcare",,5350.43,63.3,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 60MM DCP LC-DCP STAINLESS STEEL MALLEOLAR",SUP-215.060,CDM,C1713,HCPCS,0278,RC,,,both,,,206.36,61.91,"CIGNA [10200]","Cigna Local Plus",,110.4,53.5,,3978.14,359.25,3978.14,24,24,175.41,"percent of total billed charges",
"GRAFT CARDIOVASCULAR 15CM 24MM KNITTED VASCUTEK GELWEAVE",SUP-733036,CDM,C1768,HCPCS,0278,RC,,,both,,,7104.24,2131.27,"CIGNA [10200]","Cigna Local Plus",,3800.77,53.5,,,,,0,826.22,6038.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acquisition Pancreas Cadaver",PX-812000003,CDM,9999103,LOCAL,0812,RC,,,both,,,216655.00,64996.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,147325.4,68,,,,,0,25673.62,184156.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO 28CM 12FR SENTRANT HYDROPHILIC STERILE LATEX",SUP-SENSH1228W,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT TRANSPORT LIGHTWEIGHT CARRY CASE FOR STAT STRIP HOSPITAL",SUP-53425,CDM,S27000186,LOCAL,0270,RC,,,both,,,891.00,267.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 190CM 3CM",SUP-1020010,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"URETEROSCOPE FLEXIBLE ASCOPE 5 URETERO STD DEFLECTION",SUP-604101000,CDM,C1747,HCPCS,0272,RC,,,both,,,8581.88,2574.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 4-2MM TORNADO MICROCOIL PLATINUM FIBER",SUP-G47417,CDM,S27800098,LOCAL,0278,RC,,,both,,,931.42,279.43,"BLUE CROSS [10001]","Blue Cross PPO",,365.12,39.2,,,,,0,108.32,791.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE EXAMINATION BFLEX SLIM 3.8 SINGLE USE X2",SUP-0570-0448,CDM,S27200284,LOCAL,0272,RC,,,both,,,1990.50,597.15,"AETNA [10100]","Aetna HMO/PPO",,1582.45,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,231.5,1691.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 8 HOLE BONE LEFT CLAVICLE",SUP-70-0290,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4494.94,68,,,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO NEPHRSTMY 12CM 18FR OBRIEN PEEL-AWAY SUPRAPUBIC ACCESS",SUP-G16120,CDM,C1769,HCPCS,0272,RC,,,both,,,908.82,272.65,"KAISER [10500]",Kaiser,,608.91,67,,,,,0,105.7,772.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 8MMX29MM 7FR 80CMCATH HEPARIN",SUP-BXBL082901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5266.3,27,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SUCTION DLP .25IN CNCT 6FR 6IN SOFT DISPOSABLE",SUP-10052,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.36,33.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,45.77,41.1,,,,,0,12.95,94.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 FLEXOR 80MM 125CM 4MM 7FR BILIARY NITINOL",SUP-G36047,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"CIGNA [10200]","Cigna Open Access",,2377.85,56.9,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICROBRITE 142CM 6MM",SUP-SPL27506X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ileoscopy Stoma W Bal Dil",PX-750000159,CDM,44381,CPT,0750,RC,,,both,,,4055.00,1216.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3311,,"Case rate ($3,311). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,471.6,4055,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM THK5-30MM ALLOGRAFT FROZEN",SUP-450910,CDM,S27800098,LOCAL,0278,RC,,,both,,,14899.86,4469.96,"CIGNA [10200]",Cigna,,5959.94,40,,,,,0,1732.85,12664.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 60MM TSRH OSTEOGRIP TITANIUM THIN SPINE",SUP-83555609,CDM,C1713,HCPCS,0278,RC,,,both,,,2574.00,772.2,"PHCS [10601]",PHCS,,1801.8,70,,,,,0,299.36,2187.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH PLEURA STARTER PLEURX 1000ML",SUP-158431,CDM,C1729,HCPCS,0272,RC,,,both,,,8280.00,2484,"AETNA [10100]","Aetna HMO/PPO",,6582.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 2.3 MM SCR 13 HOLE LOCKING BONE RIGHT DISTAL",SUP-70-0125,CDM,C1713,HCPCS,0278,RC,,,both,,,6651.60,1995.48,"BLUE CROSS [10001]","Blue Cross HMO",,2607.43,39.2,,957.42,156.86,7483.26,51,773.58,5653.86,"percent of total billed charges",
"KIT INSTR DISPOSABLE 4.5/14MM BIOCOMPOSITE CORKSCREW",SUP-AR-8927DSC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"UHC [10700]","United Healthcare",,942.14,63.3,,,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP 1CC ALLOGRAFT PUTTY",SUP-14100201,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Open Access",,1707,56.9,,1144.80,304.56,2275.09,66,348.9,2550,"percent of total billed charges",
"AGENT HEMOSTATIC PRO QR BIOSEAL ADVANCED POWDER TOP STERILE",SUP-LP607,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.52,74.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,29.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,28.79,210.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM)DEVICE CELT ACD 6FR CLOSURE VASCULAR STERILE LATEX FRE",SUP-CLT-06,CDM,C1760,HCPCS,0278,RC,,,both,,,1611.90,483.57,"KAISER [10500]",Kaiser,,1079.97,67,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 20MM 8MM BALLOON",SUP-U357582,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL PRONG O2 TUBE ADPTR DEHP FREE NEOTECH RAM CANN",SUP-N4904,CDM,S27000186,LOCAL,0270,RC,,,both,,,107.88,32.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.55,91.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 14MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0281,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross HMO",,371.5,39.2,,957.42,156.86,7483.26,51,110.22,805.55,"percent of total billed charges",
"INSRT ACETABULAR 48MM 28MM NEUTRAL HIP CERAMIC STERILE LATEX",SUP-121889650,CDM,C1776,HCPCS,0278,RC,,,both,,,14690.10,4407.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1740.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1708.46,12486.59,"percent of total billed charges",
"CATH CPS DIRECT PL SITEMARK 51CM 47CM 9FR 7FR WIDE CURVE",SUP-410174,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"PHCS [10601]",PHCS,,2598.75,70,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR IDUO IPOLY PATIENT SPECIFIC BICOMPARTMENTAL STERILE",SUP-BKA1111111,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE GEOALIGN 100CM 220MM 5MM BALLOON",SUP-LX1810052205F,CDM,C2623,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUTTER ARTHROSCOPIC DRILL PIN FEMORAL SOCKET HOUSING POS",SUP-AR-1204AF-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ADVANCE 18LP 80CM 4CM 4FR 7MM .018IN BALLOON DILATATION",SUP-G50256,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TEMPO 100CM 5FR SIM1 CURVE ANGIOGRAPHIC SLX NYLON",SUP-451530H0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tracheostoma Smp W/O Rotat",PX-361000451,CDM,31613,CPT,0360,RC,,,both,,,6941.00,2082.3,"PHCS [10601]",PHCS,,6277,,"Case rate ($6,277). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,6.94,6941,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cannula Inner Trach Fen",PX-E27200046,CDM,E27200046,LOCAL,0272,RC,,,both,,,588.04,176.41,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,68.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,68.39,499.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS AIM 71CM 5FR 90D GUIDING CORONARY SINUS",SUP-410148,CDM,C1887,HCPCS,0272,RC,,,both,,,2212.50,663.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1504.5,68,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK SURGICAL CATARACT",SUP-SA60WF.170,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC",178,MS-DRG,,,,,,,inpatient,,,35718.36,10715.51,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,6477.97,,"Case rate ($6,054.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,621.72, add-ons for qualifying new technology services are included. If operating cost exceeds $38,661.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,807.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $5,629.16. The transfer operating threshold is the transfer adjustment factor * $5,621.72 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.03. The transfer capital threshold is the transfer adjustment factor * $425.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,6054.18,24340.46,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Burn Triact",PX-E27200090,CDM,E27200090,LOCAL,0272,RC,,,both,,,73.70,22.11,"MULTIPLAN [10600]",Multiplan,,62.65,85,,,,,0,8.57,62.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 275CC P3CM MODERATE CLASSIC PROFILE STD",SUP-350-7275MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 3.5CM 16FR RADIOPAQUE LOW PROFILE PROXIMAL ANTIREFLUX",SUP-0120-16-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"KAISER [10500]",Kaiser,,521.97,67,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH ARTHROSCOPIC DISPOSABLE 5.5 CORKSCREW FULL THREAD",SUP-AR-1927PBS,CDM,S27200284,LOCAL,0272,RC,,,both,,,637.88,191.36,"NOVANET [10819]",Novanet,,478.41,75,,,,,0,74.19,542.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST MODERATE PROFILE 255CC SMOOTH SHELL SURFACE",SUP-SRM-255,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"KAISER [10500]",Kaiser,,3675.29,67,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 93MM STAINLESS STEEL 3.5MM SCR 4 HOLE LCP BONE RIGHT",SUP-239.954,CDM,C1713,HCPCS,0278,RC,,,both,,,9233.17,2769.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6278.56,68,,,,,0,1073.82,7848.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 40MM 130CM 7MM 6FR .035IN HELICAL VASCULAR",SUP-EX070403CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"NOVANET [10819]",Novanet,,8797.5,75,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT COMPREHENSIVE TRABECULAR METAL XLPE REVE",SUP-98000900077,CDM,C1776,HCPCS,0278,RC,,,both,,,51660.00,15498,"BLUE CROSS [10001]","Blue Cross PPO",,20250.72,39.2,,3949.44,3949.44,3949.44,"1 through 10",6008.06,43911,"percent of total billed charges",
"GWIRE ORTHOPEDIC 8IN .094IN TROCAR TIP THREAD DISPOSABLE",SUP-AR-8967KT,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"FIRST HEALTH [10303]","First Health",,208.8,80,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XTRA ASPIRATION AND ANTICOAGULATION LINE (AAL) 1/4",SUP-4373,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"UHC [10700]","United Healthcare",,121.16,63.3,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 10MM 27MM SYMMETRIC DURACON DURATION KNEE",SUP-6642-2-627,CDM,C1776,HCPCS,0278,RC,,,both,,,3506.63,1051.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,415.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,407.82,2980.64,"percent of total billed charges",
"LD PCNG VNTRC UNPLR TN VS-1",SUP-4023,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"UHC [10700]","United Healthcare",,538.37,63.3,,,,,0,98.91,722.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM STAINLESS STEEL T8 METAPHYSEAL SELF TAP",SUP-02.118.516,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"BLUE CROSS [10001]","Blue Cross PPO",,205.37,39.2,,957.42,570.23,957.42,28,60.93,445.32,"percent of total billed charges",
"PIN FIXATION 9IN 5/64IN STEINMANN BRASSELER USA STAINLESS",SUP-KM169-29-56,CDM,C1713,HCPCS,0278,RC,,,both,,,63.61,19.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",7.4,54.07,"percent of total billed charges",
"CMPNT FEMORAL 7 KNEE LEFT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F701,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"CIGNA [10200]","Cigna Local Plus",,5399.11,31.5,,5372.07,4581.20,7242.98,23,1993.39,14569.03,"percent of total billed charges",
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 20MM COCR",SUP-VAL-25200-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"MULTIPLAN [10600]",Multiplan,,1211.76,85,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL 22-30CM 3CM 7FR .035IN PIGTAIL CURVE",SUP-M006180157050,CDM,C2617,HCPCS,0278,RC,,,both,,,1047.90,314.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,299.91,28.62,,,,,0,121.87,890.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 100MM 120CM 6MM VASCULAR NICKEL",SUP-EVD35-06-100-120,CDM,C1876,HCPCS,0278,RC,,,both,,,7035.00,2110.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3229.07,45.9,,,,,0,818.17,5979.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 5MM CEREPAK XTRASOFT FREEFORM",SUP-XCR120510,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"MULTIPLAN [10600]",Multiplan,,11241.97,85,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 13MM CENTERPIECE E",SUP-436013E,CDM,S27800098,LOCAL,0278,RC,,,both,,,39060.00,11718,"CIGNA [10200]",Cigna,,15624,40,,,,,0,4542.68,33201,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Salmonella Ab",PX-302000163,CDM,86768,CPT,0302,RC,,,both,,,297.35,89.2,"CIGNA [10200]","Cigna Local Plus",,29.02,,,,,,,0.01,252.75,"fee schedule",
"ROD SPINAL 40MM 4MM LORDOSIS TITANIUM",SUP-102064040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"LENS IOL 0 D +11.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.115,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross PPO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 167MM 16MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-116,CDM,C1776,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"CIGNA [10200]","Cigna Open Access",,5869.3,33.5,,5302.19,4377.88,6578.61,27,2037.61,14892.26,"percent of total billed charges",
"KIT STIM 70CM SURPASS LEAD STERILE LATEX FREE DISPOSABLE",SUP-LEAD3005-70B,CDM,C1778,HCPCS,0278,RC,,,both,,,8970.00,2691,"AETNA [10100]","Aetna HMO/PPO",,7131.15,79.5,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION MRI SILICONE PLASTIC 9.6FR 1 LUMEN",SUP-602680,CDM,C1788,HCPCS,0278,RC,,,both,,,1417.50,425.25,"CIGNA [10200]","Cigna Open Access",,806.56,56.9,,2042.80,1340.96,2042.80,"1 through 10",164.86,1204.88,"percent of total billed charges",
"HC NM Pulm Img Perfsn",PX-341000031,CDM,78580,CPT,0341,RC,,,both,,,1836.14,550.84,"PHCS [10601]",PHCS,,1285.3,70,,,,,0,213.54,1560.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER THERMOCOOL 115CM 3.5MM 7.5FR 2-5-2MM SPACING",SUP-BNI75TCDDH,CDM,C1732,HCPCS,0272,RC,,,both,,,18062.10,5418.63,"PHCS [10601]",PHCS,,12643.47,70,,,,,0,2100.62,15352.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL BABCOCK RATCHET",SUP-NF05,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.44,26.23,"CIGNA [10200]",Cigna,,59.46,68,,,,,0,10.17,74.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ADMIN 250UM UNIVERSAL INTRAVENOUS THE BELMONT 3 BAG",SUP-903-00006,CDM,S27200284,LOCAL,0272,RC,,,both,,,1507.27,452.18,"KAISER [10500]",Kaiser,,1009.87,67,,,,,0,175.3,1281.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 150MM 2.5MM .014IN BALLOON DILATATION",SUP-39186-25151,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 28MM 144CM 3MM CORONARY STENT",SUP-H7493941828300,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1377,45.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMB LINER 40/41MM 26MM MULTIPOLAR HIP UHMWPE STERILE",SUP-500104026,CDM,C1776,HCPCS,0278,RC,,,both,,,2365.50,709.65,"BLUE CROSS [10001]","Blue Cross PPO",,927.28,39.2,,3949.44,3949.44,3949.44,"1 through 10",275.11,2010.68,"percent of total billed charges",
"PRIMARY METAL BACK GLENOID TOTAL SHOULDER (CONVERITIBLE)",SUP-SMRMBTS,CDM,C1776,HCPCS,0278,RC,,,both,,,33232.50,9969.75,"CIGNA [10200]","Cigna Local Plus",,10468.24,31.5,,5372.07,4581.20,7242.98,23,3864.94,28247.63,"percent of total billed charges",
"STENT STRETCH VL SENSOR 22-30CM 5CM 4.8FR .035IN PIGTAIL",SUP-M006185155180,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.01,426,"KAISER [10500]",Kaiser,,951.41,67,,,,,0,165.15,1207.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 8MM NASAL ORAL CUFF REINFORCE MURPHY EYE",SUP-86552,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.14,53.44,"FIRST HEALTH [10303]","First Health",,142.51,80,,,,,0,20.72,151.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE LITHO 403MM 3.8MM PNEUMATIC ULTRASOUND SELECT SWISS",SUP-M0068407170,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"KAISER [10500]",Kaiser,,2505.8,67,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 46MM 42.3MM HIP MODULAR REMEDY",SUP-RHHDSM,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Open Access",,5778.75,33.5,,5302.19,4377.88,6578.61,27,2006.18,14662.5,"percent of total billed charges",
"STENT ORSIRO 4.0/30",SUP-401770,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PHCS [10601]",PHCS,,3139.5,70,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP MODIFIER TITANIUM",SUP-CAP1071,CDM,C1776,HCPCS,0278,RC,,,both,,,3750.00,1125,"PHCS [10601]",PHCS,,2625,70,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 6.5MM 28MM TITANIUM FULL THREAD CORTEX SELF",SUP-414.828,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"MULTIPLAN [10600]",Multiplan,,233.98,85,,,,,0,32.01,233.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOMETASONE 0.1 % TOPICAL CREAM",RX-10646,CDM,,,0250,RC,45802-0257-35,NDC,both,15,GR,183.42,55.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,124.73,68,,,,,0,21.33,155.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 26MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0333,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA [10200]","Cigna Open Access",,539.24,56.9,,1144.80,304.56,2275.09,66,110.22,805.55,"percent of total billed charges",
"SUT VICRYL 4-0 P-3 18IN BRAID COATED VIOLET ABSORBABLE",SUP-J464G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 15D 60MM 32MM MARATHON HIP STERILE",SUP-121932260,CDM,C1776,HCPCS,0278,RC,,,both,,,8110.95,2433.28,"PHCS [10601]",PHCS,,5677.67,70,,,,,0,943.3,6894.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET TRANSFER 77X45IN 29IN MAXITUBE FLITES",SUP-NPA0750,CDM,S27000186,LOCAL,0270,RC,,,both,,,144.56,43.37,"KAISER [10500]",Kaiser,,96.86,67,,,,,0,16.81,122.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM DCP LC-DCP STAINLESS STEEL PROXIMAL",SUP-204.222,CDM,C1713,HCPCS,0278,RC,,,both,,,117.28,35.18,"CIGNA [10200]","Cigna Local Plus",,62.74,53.5,,3978.14,359.25,3978.14,24,13.64,99.69,"percent of total billed charges",
"LINER ACETABULAR DYNASTY A-CLASS STD 36MM BIOFOAM POLY HIP",SUP-DLXPGG36,CDM,C1776,HCPCS,0278,RC,,,both,,,12771.90,3831.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3448.41,27,,,,,0,1485.37,10856.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X5MM PRECISION CONVEX SPINE",SUP-17505,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL PURPLE 17MM SYNFIX 14D MEDIUM EVOLUTION 10.9MM",SUP-08.815.225S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPIDERFX .014IN 190CM 5MM EMBOLIC PROTECTION NITINOL",SUP-SPDRX-US-050,CDM,C1884,HCPCS,0272,RC,,,both,,,5859.00,1757.7,"CIGNA [10200]",Cigna,,3984.12,68,,,,,0,681.4,4980.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 14MM PYRENEES SPINE CERVICAL SELF STARTING",SUP-201-14014D,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"BLUE CROSS [10001]","Blue Cross PPO",,552.72,39.2,,957.42,570.23,957.42,28,163.98,1198.5,"percent of total billed charges",
"CATHETER CHOCOLATE 150CM 80MM 2.5MM .014IN BALLOON DILATATIO",SUP-CB1415025080OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"FIRST HEALTH [10303]","First Health",,4581.6,80,,,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUSHG FEMORAL TRIATHLON STD KNEE HINGE AXLE STERILE LATEX",SUP-5612-3-000,CDM,C1776,HCPCS,0278,RC,,,both,,,15657.48,4697.24,"BLUE CROSS [10001]","Blue Cross HMO",,6137.73,39.2,,5311.50,4717.44,5388.59,31,1820.96,13308.86,"percent of total billed charges",
"BARD SKYLITE 1.9FR NITINOL SPECIMEN RETRIEVAL BASKET",SUP-041900,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER PELLO 3MM STRAIGHT",SUP-6290-112-033,CDM,S27200284,LOCAL,0272,RC,,,both,,,1837.50,551.25,"NOVANET [10819]",Novanet,,1378.13,75,,,,,0,213.7,1561.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 5ML PASTE MIX PLUS",SUP-IQSP-PP-105,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",601.85,4398.75,"percent of total billed charges",
"STYLET LEAD 45CM .013IN EXTRA SOFT STIFFNESS KNOB CAP",SUP-5003,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER O.R. PROCEDURES FOR INJURIES WITH MCC",907,MS-DRG,,,,,,,inpatient,,,102004.75,30601.42,"PHCS [10601]",PHCS,,7561,,,,,,,7561,102004.75,"per diem","Estimated amount calculated based on 9 day length of stay."
"HC Dbrd Sel Opn Wnd<=20scm",PX-510000166,CDM,97597,CPT,0761,RC,,,both,,,1190.27,357.08,"CIGNA [10200]",Cigna,,1190.27,,"Per diem ($2,606).",,,,0,138.43,1190.27,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 80MM 16-14MM 14MM 11FR TRIVASCULAR OVATION PRIME",SUP-TV-IL141680-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"MULTIPLAN [10600]",Multiplan,,28381.5,85,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MAXTACK FIXATION 30 TACK ABSORBABLE MOTORIZE",SUP-MAXTACK30,CDM,S27200284,LOCAL,0272,RC,,,both,,,3907.88,1172.36,"CIGNA [10200]","Cigna Open Access",,2223.58,56.9,,,,,0,454.49,3321.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3.5MM 20MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.820.96,CDM,C1713,HCPCS,0278,RC,,,both,,,319.12,95.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",37.11,271.25,"percent of total billed charges",
"CATH WOLVERINE CUTTING BALLOON (OTW)  3.00MM X 10MM",SUP-H74939402103000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"KAISER [10500]",Kaiser,,3629.06,67,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT CONTRACTURE DEROYAL MEDIUM ANKLE ANTIROTATION BAR PAD",SUP-4301C,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL WHITE 3MM TAPER ROUTER",SUP-5407FA3030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1009.26,302.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 16MM",SUP-650.116,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SOLOIST 110CM 6FR 2-5-2MM SPACING JOSEPHSON CURVE",SUP-44216J,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD DEFIB PEDI-PADZ II PEDIATRIC AED PLUS DISPOSABLE",SUP-8900-0810-01,CDM,S27000186,LOCAL,0270,RC,,,both,,,638.60,191.58,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC",058,MS-DRG,,,,,,,inpatient,,,60669.63,18200.89,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION SIGMA HIGH PERFORMANCE QUICK DRILL",SUP-950502072,CDM,C1713,HCPCS,0278,RC,,,both,,,1526.85,458.05,"CIGNA [10200]",Cigna,,1038.26,68,,1831.33,1831.33,1831.33,16,177.57,1297.82,"percent of total billed charges",
"DEVICE ATRICLIP FLEX-MINI 45MM CLSR POLYESTER LOW PROFILE",SUP-ACHM45,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"NOVANET [10819]",Novanet,,11643.75,75,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Amputation Toe Mtp Joint",PX-761000028,CDM,28820,CPT,0761,RC,,,both,,,9740.00,2922,"BLUE CROSS [10001]","Blue Cross PPO",,4431.65,,"Case rate ($4,431.65). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1132.76,8279,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 13MM CUFF LOW PRESSURE SHILEY TRACH 10 LATEX FREE",SUP-10LPC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1040.12,312.04,"MULTIPLAN [10600]",Multiplan,,884.1,85,,,,,0,120.97,884.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC",578,MS-DRG,,,,,,,inpatient,,,197441.45,59232.43,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,21423.89,,"Case rate ($9,964.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,252.80, add-ons for qualifying new technology services are included. If operating cost exceeds $42,292.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,081.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $9,265.04. The transfer operating threshold is the transfer adjustment factor * $9,252.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $699.56. The transfer capital threshold is the transfer adjustment factor * $699.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,9964.6,46900.45,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM TITANIUM TIBIA CANCELLOUS OPENING WEDGE",SUP-AR-13280-60,CDM,C1713,HCPCS,0278,RC,,,both,,,1968.75,590.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,233.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,228.97,1673.44,"percent of total billed charges",
"TUBE JEJUNOSTOMY 30CM 18FR TUNGSTEN SILICONE MIC-KEY",SUP-0270-18-2.0-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"CIGNA [10200]","Cigna Open Access",,1498.06,56.9,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EXTRACTION OUTAKE CATH SYR GLOVE TRANSPORT TUBE",SUP-CET300,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,207.06,68,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309009,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"BLUE CROSS [10001]","Blue Cross PPO",,14802.78,39.2,,3949.44,3949.44,3949.44,"1 through 10",4391.74,32097.87,"percent of total billed charges",
"STENT PALMAZ 40MM 10MM XL BILIARY STAINLESS STEEL BALLOON",SUP-H739P40103,CDM,C1877,HCPCS,0278,RC,,,both,,,4278.00,1283.4,"CIGNA [10200]","Cigna Local Plus",,2288.73,53.5,,,,,0,497.53,3636.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY PRO 54CM 9FR GUIDING STERILE LATEX FREE",SUP-8104,CDM,C1887,HCPCS,0272,RC,,,both,,,1386.50,415.95,"AETNA [10100]","Aetna HMO/PPO",,1102.27,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.25,1178.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNIVERSA 26CM 6FR 2 PIGTAIL CURVE URETERAL AQ",SUP-G49906,CDM,C2617,HCPCS,0278,RC,,,both,,,753.30,225.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,89.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER O.R. PROCEDURES FOR INJURIES WITH MCC",907,MS-DRG,,,,,,,inpatient,,,102004.75,30601.42,"UHC [10700]","United Healthcare",,102004.75,,"Fee schedule rate ($112,092.20). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,102004.75,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Yersinia Ab",PX-302000170,CDM,86793,CPT,0302,RC,,,both,,,385.00,115.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11.87,,,,,,,0.01,327.25,"fee schedule",
"STENT VIABAHN 15CM 75MM 8MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR081501A,CDM,C1874,HCPCS,0278,RC,,,both,,,21577.50,6473.25,"PHCS [10601]",PHCS,,15104.25,70,,,,,0,2509.46,18340.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR .045GA",SUP-210-40-004,CDM,C1713,HCPCS,0278,RC,,,both,,,113.10,33.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,51.91,45.9,,,,,0,13.15,96.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC ILESTO VR-T DX",SUP-383594,CDM,C1722,HCPCS,0278,RC,,,both,,,63000.00,18900,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,18030.6,28.62,,,,,0,7326.9,53550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BD NEXIVA 1.75IN 20GA IV BD VIALON PERIPHERAL CLOSED",SUP-383538,CDM,S27200284,LOCAL,0272,RC,,,both,,,45.33,13.6,"FIRST HEALTH [10303]","First Health",,36.26,80,,,,,0,5.27,38.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DAT415 AS UVA VIVITY",SUP-DAT415,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,387.86,45.9,,,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ARTHROSCOPIC ANATOMIC SOCKET FLIPCUTTER II SHORT KNEE",SUP-AR-1204AS-95,CDM,S27200284,LOCAL,0272,RC,,,both,,,2559.38,767.81,"KAISER [10500]",Kaiser,,1714.78,67,,,,,0,297.66,2175.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 035 130CM 150MM 5MM BALLOON DILATATION",SUP-LX3513051505F,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5747.7,68,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FREEHAND HINDFOOT VALOR 4.3MM SCR IMPL KIT",SUP-415S002350,CDM,S27200284,LOCAL,0272,RC,,,both,,,1972.50,591.75,"KAISER [10500]",Kaiser,,1321.58,67,,,,,0,229.4,1676.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 TF 36IN BRAID MONOFILAMENT BLUE",SUP-D4295,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.68,18.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25.76,41.1,,,,,0,7.29,53.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT FIBERGRAFT LARGE BIOACTIVE 12.5CC",SUP-55000125,CDM,C1713,HCPCS,0278,RC,,,both,,,18113.76,5434.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7245.5,40,,,,,0,2106.63,15396.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 5FR 3MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206030410,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,266.33,41.1,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONDUIT VALVE 29MM KONECT AORTIC RESILIA",SUP-11060A29,CDM,S27800098,LOCAL,0278,RC,,,both,,,79800.00,23940,"AETNA [10100]","Aetna HMO/PPO",,63441,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9280.74,67830,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 16MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530-G-616,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CIGNA [10200]",Cigna,,5921.17,68,,5873.17,5873.17,5873.17,"1 through 10",1012.7,7401.47,"percent of total billed charges",
"INSRT CLAMP 60MM STEALTH 3 FIBRA STERILE LATEX FREE",SUP-A0G13,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,153.82,68,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 28MM 12MM BLUNT FULL THREAD",SUP-AR-1404TC,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1258.43,68,,,,,0,215.23,1573.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .035IN 6MM 135CM 20MM PERIPHERAL",SUP-10336-20,CDM,C1725,HCPCS,0272,RC,,,both,,,1539.00,461.7,"MULTIPLAN [10600]",Multiplan,,1308.15,85,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 80MM 5MM BALLOON",SUP-U3513058,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X8MM VERTE-STACK CORNERSTONE PSR 11MM",SUP-6287841,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS [10001]","Blue Cross PPO",,1758.12,39.2,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLIDESHEATH SLENDER SS KIT, 0.021 GW, 7 FR, 16CM",SUP-80-1670,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"FIRST HEALTH [10303]","First Health",,356.4,80,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 16X10CM STRATTICE LIFECELL 160SQ CM",SUP-1016002P,CDM,Q4130,HCPCS,0636,RC,,,both,,,25181.10,7554.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2983.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2983.96,21403.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 120MM 120CM 4.5MM 6FR VASCULAR NITINOL",SUP-S-45-120-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA [10200]","Cigna Local Plus",,4891.24,53.5,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE FLOPPY II VASCULAR STRAIGHT 190CM 2CM .014IN",SUP-22339H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX EXTREME 80CM 2CM 5FR 4MM LOW PROFILE TAPER",SUP-4154020S,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PHCS [10601]",PHCS,,481.95,70,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 60MM 10MM PRESS FIT REMOVABLE TRUNION SUT HOLE",SUP-AR-9100-10S,CDM,C1776,HCPCS,0278,RC,,,both,,,10713.60,3214.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4917.54,45.9,,,,,0,1245.99,9106.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19.5 DIOPTER +2.25 CYL MODIFIED C BICONVEX 13MM 6",SUP-ZCT225195,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX PERMALUME 60MM 194CM 10MM 8.5FR .035IN",SUP-M00570370,CDM,C1874,HCPCS,0278,RC,,,both,,,9360.00,2808,"PHCS [10601]",PHCS,,6552,70,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE HA 30MM 8MM ACL BIOSURE",SUP-72201778,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,1144.80,304.56,2275.09,66,189.34,1383.8,"percent of total billed charges",
"NAIL 15.5-11MM 22CM FEMUR PROXIMAL TALON DISTALFIX",SUP-SLN-120-220,CDM,C1713,HCPCS,0278,RC,,,both,,,13227.30,3968.19,"KAISER [10500]",Kaiser,,8862.29,67,,,,,0,1538.33,11243.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 40MM 5MM .035IN LOW PROFILE BALLOON",SUP-B1050-040,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 24IN COVERS SHUNT POLYPROPYLENE PERITONEUM",SUP-901124,CDM,C1894,HCPCS,0272,RC,,,both,,,439.99,132,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH REDEL 110CM 1MM 5FR 2-5-2MM SPACE F CURVE",SUP-F5QRF252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HANDLE SUCTION/IRRIGATION 10FT UNIVERSAL PLUS HI FLO PISTOL",SUP-60-6010-002,CDM,S27200284,LOCAL,0272,RC,,,both,,,825.82,247.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH REDEL 92CM 1MM 6FR 10MM SPACE REGULAR D CURVE",SUP-D6DR010RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Yo Immunoreactivity",PX-301000283,CDM,86255,CPT,0301,RC,,,both,,,258.70,77.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.65,,"Fee schedule rate ($12.65). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.26,219.9,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Trach Uncuffed Fen",PX-E27200238,CDM,E27200238,LOCAL,0272,RC,,,both,,,333.30,99.99,"FIRST HEALTH [10303]","First Health",,266.64,80,,,,,0,38.76,283.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 150MM 1.6MM LCP THREAD COMPRESSION 15MM",SUP-03.211.415,CDM,C1713,HCPCS,0278,RC,,,both,,,316.68,95,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,145.36,45.9,,,,,0,36.83,269.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL SHOULDER WITH NECK ANATOMIC ALTIVATE CS SIZE 1",SUP-520-08-018,CDM,C1776,HCPCS,0278,RC,,,both,,,34907.04,10472.11,"KAISER [10500]",Kaiser,,23387.72,67,,,,,0,4059.69,29670.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 2 KNEE LOW PROFILE",SUP-5520-M-200,CDM,C1776,HCPCS,0278,RC,,,both,,,7998.48,2399.54,"AETNA [10100]","Aetna HMO/PPO",,6358.79,79.5,,10981.53,8986.79,12413.38,12,930.22,6798.71,"percent of total billed charges",
"HC Tilt Table Eval W/WO Drug",PX-481000065,CDM,93660,CPT,0481,RC,,,both,,,2814.00,844.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1913.52,68,,,,,0,327.27,2391.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE EVERPOINT 6-0 C-1 30IN 2 ARM MONOFILAMENT 4",SUP-EPM8706,CDM,S27200284,LOCAL,0272,RC,,,both,,,734.16,220.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,85.38,624.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 290MM 3.2MM NONSTERILE",SUP-03.010.115,CDM,C1769,HCPCS,0272,RC,,,both,,,601.02,180.31,"KAISER [10500]",Kaiser,,402.68,67,,,,,0,69.9,510.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Balloon Nasal Epistaxis",PX-E27000050,CDM,E27000050,LOCAL,0270,RC,,,both,,,363.00,108.9,"MULTIPLAN [10600]",Multiplan,,308.55,85,,,,,0,42.22,308.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.7MM 14MM ZERO-P TITANIUM SPINE CERVICAL VARIABLE",SUP-04.647.834,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,289.78,28.62,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM 7MM S-ROM ZTT 20F LARGE HIP POROUS",SUP-550536,CDM,C1776,HCPCS,0278,RC,,,both,,,6466.32,1939.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2968.04,45.9,,,,,0,752.03,5496.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK 10X1.5X2.5CM THK1.5CM SEPTUM NASAL WITHOUT STRING STRONG",SUP-400406,CDM,S27200284,LOCAL,0272,RC,,,both,,,296.67,89,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) DILATOR KIT LHR-0105",SUP-LHR-0105,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Rem Auton Alg Insln Calc Setup",PX-761000090,CDM,0740T,HCPCS,0761,RC,,,both,,,127.00,38.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX RADIANZ 190CM 20MM 6MM .018IN BALLOON DILATATION",SUP-R51006002L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL UTERINE HEGAR 2 END 5/6MM",SUP-52-3505,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DICLOFENAC 0.1 % EYE DROPS",RX-19714,CDM,,,0637,RC,61314-0014-25,NDC,both,2.5,ML,225.19,67.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRIVER NDL 8MM 23- D MEGA 49.7CM ROBOTIC SUTURECUT ENDOWRIST",SUP-420309,CDM,S27000186,LOCAL,0270,RC,,,both,,,1890.00,567,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH VISTA BRITE TIP TRUELUMEN 55CM .1IN 7FR .078IN",SUP-77827055,CDM,C1887,HCPCS,0272,RC,,,both,,,304.50,91.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE DERMATOME INTEGRA PADGETT STERILE DISPOSABLE",SUP-3539252,CDM,S27200284,LOCAL,0272,RC,,,both,,,855.36,256.61,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TEMPO 100CM 5FR 1 CURVE ANGIOGRAPHIC SLX NYLON CEREBRAL",SUP-451535H0,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRAIN INCISION 20FR 11IN CATTELL NATURAL RUBBER 12IN T TUBE",SUP-0100200,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.77,19.73,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL IV PLASMA-LYTE A VIAFLEX MULTIPLE ELECTROLYTE 1L LATEX",SUP-2B2544X,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.24,37.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,14.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.45,105.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135D 41.5MM STD OFFSET 38.5MM STERILE 155MM 13",SUP-3L92513,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"NOVANET [10819]",Novanet,,11877.84,75,,,,,0,1841.86,13461.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR NARROW LORDOTIC 12 DEGRE",SUP-2319,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"KAISER [10500]",Kaiser,,12663,67,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AZELASTINE 137 MCG (0.1 %) NASAL SPRAY",RX-19179,CDM,,,0250,RC,42291-0094-30,NDC,both,30,ML,915.57,274.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,106.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,106.48,778.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 30MM CD HORIZON TITANIUM COCR SPINE",SUP-55890005530,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,641.98,4692,"percent of total billed charges",
"SCR BONE 35MM REDAPT LOCK",SUP-71354506,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,957.42,156.86,7483.26,51,189.34,1383.8,"percent of total billed charges",
"WIRE REDUCTION 150MM 1.25MM STAINLESS STEEL THREAD TIP SMALL",SUP-02.111.500.01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,384.98,115.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,158.23,41.1,,,,,0,44.77,327.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION DOME GROSHONG TITANIUM SILICONE",SUP-602870,CDM,C1788,HCPCS,0278,RC,,,both,,,1547.10,464.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,179.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,179.93,1315.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 93MM 28-16MM 16FR ENDURANT II ABDOMEN",SUP-ETLW1628C93E,CDM,S27800098,LOCAL,0278,RC,,,both,,,30006.90,9002.07,"PHCS [10601]",PHCS,,21004.83,70,,,,,0,3489.8,25505.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 E NEUTRAL 36MM E1 HIP",SUP-010000857,CDM,C1776,HCPCS,0278,RC,,,both,,,12282.00,3684.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4912.8,40,,,,,0,1428.4,10439.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER ACCUMAX 1000UM HOLMIUM FLEXIBLE POLISH OUTPUT",SUP-M0068404042,CDM,S27200284,LOCAL,0272,RC,,,both,,,4603.54,1381.06,"KAISER [10500]",Kaiser,,3084.37,67,,,,,0,535.39,3913.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 5FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY",SUP-F5QRF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"PHCS [10601]",PHCS,,635.04,70,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASCEND FLEX HEMI",SUP-CAP-T-FLEXHEM,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA [10200]","Cigna Open Access",,7386.75,33.5,,5302.19,4377.88,6578.61,27,2564.42,18742.5,"percent of total billed charges",
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 8MM 140CM 2.5MM CORONARY",SUP-RSINT25008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA [10200]","Cigna Local Plus",,2966.04,53.5,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BILIARY L14MM BALLOON L17MM DIA6MM CATHETER L80CM 14/1",SUP-PB1560BSS,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1900.26,45.9,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 8MM 2.75MM CORONARY STENT COCR",SUP-1007847-08,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross HMO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL CANCELLOUS 7D ALLOGRAFT 12MM",SUP-3W5212,CDM,S27800098,LOCAL,0278,RC,,,both,,,21094.92,6328.48,"MULTIPLAN [10600]",Multiplan,,17930.68,85,,,,,0,2453.34,17930.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 1.5% DEXTROSE 2000ML 1 BAG SPIKE CNTNR AMBU-FLEX II",SUP-L5B5166,CDM,S27200284,LOCAL,0272,RC,,,both,,,114.29,34.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,77.72,68,,,,,0,13.29,97.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 5MM AZUR HYDROCOIL PUSHABLE .018IN 18",SUP-45-280506,CDM,S27800098,LOCAL,0278,RC,,,both,,,5030.10,1509.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,596.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,585,4275.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 420CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRX-420,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"PHCS [10601]",PHCS,,2778.3,70,,,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 15-20MM DIA12MM X-CORE",SUP-5962152,CDM,S27800098,LOCAL,0278,RC,,,both,,,27720.00,8316,"CIGNA [10200]",Cigna,,11088,40,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 7CM 14.5MM GORE EXCLUDER ILIAC INTERNAL",SUP-HGB161407A,CDM,S27800098,LOCAL,0278,RC,,,both,,,19089.00,5726.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2262.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2220.05,16225.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 40MM HIP BIOLOX DELTA BIOLOX OPTION G7",SUP-650-1058,CDM,C1776,HCPCS,0278,RC,,,both,,,13896.60,4168.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1616.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1616.17,11812.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 12CM 10FR SHORT LENGTH URETERAL",SUP-H7493936110120,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.30,371.79,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,146.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 40MM 3MM BALLOON DILATATION OTW STERILE",SUP-583004022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120MM 8MM ENDOPROSTHESIS NITINOL EPTFE",SUP-VBCR080502A,CDM,C1874,HCPCS,0278,RC,,,both,,,16905.00,5071.5,"CIGNA [10200]","Cigna Open Access",,5663.18,33.5,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LARGE 33.4MMX1.5MM TITANIUM 2.7MM SCR 4 HOLE",SUP-DC2805115,CDM,C1713,HCPCS,0278,RC,,,both,,,7286.40,2185.92,"NOVANET [10819]",Novanet,,5464.8,75,,,,,0,847.41,6193.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC New Eval Visit Level 5",PX-510000175,CDM,99205,CPT,0761,RC,,,both,,,553.58,166.07,"CIGNA [10200]","Cigna Local Plus",,553.58,,"Per diem ($2,051).",,,,0,0.55,553.58,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEAL DURAL DURAGEN 3X 3IN SQUARE CALLAGEN DURAMATRIX REPAIR",SUP-DMR33,CDM,,,0278,RC,,,both,,,7742.49,2322.75,"NOVANET [10819]",Novanet,,5806.87,75,,,,,0,7.74,6581.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640906,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3220.87,28.62,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION",RX-1090,CDM,,,0250,RC,01490-0039-08,NDC,both,236,ML,19.30,5.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.24,16.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION 11MM HOFFMANN 3 30D 5 HOLE PIN 2",SUP-4922-2-240,CDM,S27200284,LOCAL,0272,RC,,,both,,,5954.98,1786.49,"UHC [10700]","United Healthcare",,3769.5,63.3,,,,,0,692.56,5061.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 6FR .035IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145361050,CDM,C2617,HCPCS,0278,RC,,,both,,,940.57,282.17,"KAISER [10500]",Kaiser,,630.18,67,,,,,0,109.39,799.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX12MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183542,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"BLUE CROSS [10001]","Blue Cross HMO",,3073.19,39.2,,5311.50,4717.44,5388.59,31,911.77,6663.81,"percent of total billed charges",
"FOL URETHRAL 13.35IN 12FR HEYMAN PLASTIC DILATION CATH",SUP-021112,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.15,65.14,"CIGNA [10200]",Cigna,,147.66,68,,,,,0,25.25,184.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 74.9X49.3X15MM MBT 4+ MM KNEE CEMENTED REVISION",SUP-129435415,CDM,C1776,HCPCS,0278,RC,,,both,,,35980.56,10794.17,"KAISER [10500]",Kaiser,,24106.98,67,,,,,0,4184.54,30583.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +18.5 DIOPTER 12.5MM 5.5MM ANTERIOR CHMBR 1 PIECE",SUP-MTA3U0.185,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Open Access",,391.76,56.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 80MM 16MM FINNED CEMENTLESS SMR TITANIUM",SUP-1304.15.160,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"AETNA [10100]","Aetna HMO/PPO",,6296.4,79.5,,10981.53,8986.79,12413.38,12,921.1,6732,"percent of total billed charges",
"BLADE CHISEL 40X10MM THK1MM STRAIGHT SMALL",SUP-75100517,CDM,S27200284,LOCAL,0272,RC,,,both,,,1489.59,446.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,176.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.24,1266.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 6MM .0115IN AXIUM PRIME HELICAL",SUP-APB-6-12-HX-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,7169.10,2150.73,"CIGNA [10200]",Cigna,,4874.99,68,,,,,0,833.77,6093.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROLAMINE SALICYLATE 10 % TOPICAL CREAM",RX-27680,CDM,,,0637,RC,41167-0057-23,NDC,both,85,GR,25.66,7.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.98,21.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 8FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145381010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"NOVANET [10819]",Novanet,,725.18,75,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ABLATION 20CM 14GA CERTUS",SUP-LN20,CDM,C2618,HCPCS,0272,RC,,,both,,,14524.50,4357.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1689.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1689.2,12345.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 TF 36IN BRAID MONOFILAMENT BLUE",SUP-D4295,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.68,18.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.29,53.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +7 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR CHMBR",SUP-MTA5U0.070,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 40MM 80CM 12MM 6FR .035IN BILIARY NITINOL",SUP-G36229,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross PPO",,1481.76,39.2,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 6FR 20CM HYDROPHILIC RADIOPAQUE STERILE",SUP-G10285,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.90,20.07,"UHC [10700]","United Healthcare",,42.35,63.3,,,,,0,7.78,56.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE FATHOM VASCULAR 10CM STRAIGHT 200CM 25CM .016IN",SUP-M001509200,CDM,C1769,HCPCS,0272,RC,,,both,,,1815.00,544.5,"KAISER [10500]",Kaiser,,1216.05,67,,,,,0,211.08,1542.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 1.3MM FIBERTAK SUTURETAPE 2 LOAD BLUE WHITE",SUP-AR-3602-2,CDM,C1713,HCPCS,0278,RC,,,both,,,2913.75,874.12,"BLUE CROSS [10001]","Blue Cross PPO",,1142.19,39.2,,957.42,570.23,957.42,28,338.87,2476.69,"percent of total billed charges",
"STEM FEMORAL 100MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 1",SUP-71357001,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"FIRST HEALTH [10303]","First Health",,26512.92,80,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Hemodialysis Temp",PX-E27200058,CDM,C1752,HCPCS,0272,RC,,,both,,,941.16,282.35,"CIGNA [10200]",Cigna,,639.99,68,,,,,0,109.46,799.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colorectal Scrn Flex Sig",PX-750000196,CDM,G0104,HCPCS,0750,RC,,,both,,,2890.63,867.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,342.54,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,336.18,2890.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE RX BILIARY SYSTEM LOCKING BIOPSY CAP STERILE",SUP-M00545261,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.67,24.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.98,41.1,,,,,0,9.61,70.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL PEDIATRIC O2 RESVR BAG TODDLER MASK PEEP VALVE",SUP-530213000,CDM,S27000186,LOCAL,0270,RC,,,both,,,60.81,18.24,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AEON ENDOSTAPLER CURVED TIP RELOAD 30MM PURPLE",SUP-ASR30PC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT CLAMP 45MM STEALTH 2 FIBRA STERILE LATEX FREE",SUP-A0G12,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 10CM 6FR GLIDESHEATH .035IN HYDROPHILIC SPRING J",SUP-RM*BF6M10MA,CDM,C1894,HCPCS,0272,RC,,,both,,,368.01,110.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER ALLOGRAFT 12X14X13MM PARALLEL SPINE CERVICAL",SUP-17913,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PHCS [10601]",PHCS,,3622.5,70,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000050,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]",Cigna,,1101.6,68,,1831.33,1831.33,1831.33,16,188.41,1377,"percent of total billed charges",
"SOUND 26FR URETHRAL CURVE VAN BUREN 10.75IN",SUP-51-6326,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.21,101.76,"MULTIPLAN [10600]",Multiplan,,288.33,85,,,,,0,39.45,288.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC UNIVERSAL SHOULDER",SUP-ORT16000,CDM,S27000186,LOCAL,0270,RC,,,both,,,67.16,20.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.81,57.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 12MMX.4MM UNIVERSAL NEURO III STRAIGHT",SUP-53-34212,CDM,C1713,HCPCS,0278,RC,,,both,,,1068.80,320.64,"BLUE CROSS [10001]","Blue Cross HMO",,418.97,39.2,,957.42,156.86,7483.26,51,124.3,908.48,"percent of total billed charges",
"SCR BONE 2.7MM 14MM RADIUS DISTAL VOLAR LOCK 3 LEAD TAPER",SUP-131227114,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",155.43,1136.03,"percent of total billed charges",
"SUB BONE GRAFT OSTEOMATRIX+ 2 STRIP 18CC STERILE",SUP-OMP-18,CDM,C1713,HCPCS,0278,RC,,,both,,,6776.66,2033,"MULTIPLAN [10600]",Multiplan,,5760.16,85,,,,,0,788.13,5760.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOPPLER FETAL DOPPLEX 2MHZ PROBE",SUP-FD1-P-USA,CDM,S27200284,LOCAL,0272,RC,,,both,,,3684.75,1105.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1514.43,41.1,,,,,0,428.54,3132.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC",036,MS-DRG,,,,,,,inpatient,,,107434.48,32230.34,"BLUE CROSS [10001]","Blue Cross HMO",,44600.45,,,,,,,10994,56721.99,"case rate",
"DEVICE MYOSURE XL TISSUE REMOVAL FLUID MANAGEMENT SYSTEM",SUP-50-601XL,CDM,S27200284,LOCAL,0272,RC,,,both,,,5692.50,1707.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,662.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Protein Electrophoresis Other",PX-301000382,CDM,84166,CPT,0301,RC,,,both,,,289.50,86.85,"CIGNA [10200]",Cigna,,39.23,,,,,,,0.29,246.08,"fee schedule",
"LEAD NEROSTIMLTR 70CM PRECISION PERCUTANEOUS LINEAR 3-4",SUP-SC-2352-70,CDM,C1778,HCPCS,0278,RC,,,both,,,8914.80,2674.44,"MULTIPLAN [10600]",Multiplan,,7577.58,85,,,,,0,1036.79,7577.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR AL2 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916599982,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"AETNA [10100]","Aetna HMO/PPO",,60.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 6CM 7FR PANCREATIC POLYETHYLENE PUSH CATH DRAIN",SUP-G21376,CDM,C2617,HCPCS,0278,RC,,,both,,,631.80,189.54,"BLUE CROSS [10001]","Blue Cross HMO",,247.67,39.2,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 50CM 11CM HUB SNAP FIT DIL TUBE GWIRE",SUP-PRO-7F-11-038,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"NOVANET [10819]",Novanet,,60.03,75,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENDO STITCH V-LOC 180 0 4IN CLSR ABSORBABLE RELOAD",SUP-VLOCA004L,CDM,S27200284,LOCAL,0272,RC,,,both,,,282.40,84.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,116.07,41.1,,,,,0,32.84,240.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT GRAFTON DEMINERALIZED BONE MATRIX PUTTY JAR",SUP-T43103,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1530,68,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 9IN LAMBOTTE SPINE SURGICAL CURVE .25IN",SUP-28-9456,CDM,S27200284,LOCAL,0272,RC,,,both,,,225.16,67.55,"MULTIPLAN [10600]",Multiplan,,191.39,85,,,,,0,26.19,191.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT LEAD SPLICE 6.1FR 8.3FR CAPSURE 10.7FR TRANSVENOUS",SUP-5867-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,174.00,52.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TORSEMIDE 5 MG TABLET",RX-18295,CDM,,,0637,RC,50268-0754-11,NDC,both,1,UN,6.27,1.88,"PHCS [10601]",PHCS,,4.39,70,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 20MM 144CM 2.75MM CORONARY STENT EVEROLIMUS",SUP-H7493926120270,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"PHCS [10601]",PHCS,,6037.5,70,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE RX BILIARY SYSTEM LOCKING BIOPSY CAP STERILE",SUP-M00545261,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.67,24.8,"FIRST HEALTH [10303]","First Health",,66.14,80,,,,,0,9.61,70.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VERSACROSS SHEATH 63CM 90DEG D1",SUP-VXS0206,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"MULTIPLAN [10600]",Multiplan,,1377,85,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 6FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552340,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,816.39,68,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR 66.7MM STAINLESS STEEL 24.3MM 2.2MM LINDEMANN 4 FLUTE",SUP-19-S1802,CDM,S27200284,LOCAL,0272,RC,,,both,,,220.98,66.29,"CIGNA [10200]","Cigna Open Access",,125.74,56.9,,,,,0,25.7,187.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +7 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR CHMBR",SUP-MTA5U0.070,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 64MM HIP SECTOR GRIPTION PINNACLE STERILE",SUP-121732064,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6487.38,40,,,,,0,1886.21,13785.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 5X5CM MATRION ALLOGRAFT FENESTRATE SHEET",SUP-PAC25M,CDM,Q4201,HCPCS,0636,RC,,,both,,,7521.00,2256.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,204.57,,,,,,,204.57,6392.85,"fee schedule",
"SECONDARY DELIVERY CATHETER, PROXIMAL",SUP-4850-04,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DICLOXACILLIN 250 MG CAPSULE",RX-2414,CDM,,,0637,RC,00093-3123-01,NDC,both,1,UN,7.56,2.27,"PHCS [10601]",PHCS,,5.29,70,,,,,0,0.88,6.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Duoderm",PX-E27200109,CDM,E27200109,LOCAL,0272,RC,,,both,,,123.87,37.16,"CIGNA [10200]","Cigna Local Plus",,66.27,53.5,,,,,0,14.41,105.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 2 STRAIGHT OVAL 9IN BRUNS SPINE SURGICAL",SUP-29-5352,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.25,71.77,"CIGNA [10200]","Cigna Open Access",,136.13,56.9,,,,,0,27.82,203.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON 6 6 NUROLON 3-0 SH 18IN CONTROL RELEASE BRAID 8",SUP-C513D,CDM,S27200284,LOCAL,0272,RC,,,both,,,120.76,36.23,"NOVANET [10819]",Novanet,,90.57,75,,,,,0,14.04,102.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9.5MM 90MM CD HORIZON SPINE MULTIAXIAL CANNULATED",SUP-25630019590,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]",Cigna,,3753.6,68,,1831.33,1831.33,1831.33,16,641.98,4692,"percent of total billed charges",
"SYSTEM PROMUS PREMIER 12MM 144CM 2.75MM CORONARY STENT",SUP-H7493952812270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]",Cigna,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 7MM KIT EMG",SUP-2010470,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"KAISER [10500]",Kaiser,,1155.75,67,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY SHARP JAW RADIOPAQUE 104CM 7FR 2.3MM STAINLESS",SUP-504300L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,963.9,68,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Chest 2v",PX-324000010,CDM,71046,CPT,0324,RC,,,both,,,397.84,119.35,"BLUE CROSS [10001]","Blue Cross PPO",,75.63,,"Fee schedule rate ($75.63).",75.62,75.62,75.91,"1 through 10",36.6,338.16,"fee schedule",
"ELECTRD ELECTROSURGICAL 24FR COLLINS STERILE DISPOSABLE",SUP-27050L/6,CDM,S27200284,LOCAL,0272,RC,,,both,,,900.72,270.22,"AETNA [10100]","Aetna HMO/PPO",,716.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.75,765.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VG2 PRESERVON VERTIGRAFT CORTICAL CANCELLOUS",SUP-VG2C-T911,CDM,S27800098,LOCAL,0278,RC,,,both,,,8109.23,2432.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3722.14,45.9,,,,,0,943.1,6892.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 4.5MM 13MM EVOS CORTEX T8 DRIVER 2 END DRILL",SUP-72402713,CDM,C1713,HCPCS,0278,RC,,,both,,,363.14,108.94,"CIGNA [10200]","Cigna Local Plus",,194.28,53.5,,3978.14,359.25,3978.14,24,42.23,308.67,"percent of total billed charges",
"WEDGE POSITIONING 22X20X4IN TUMBLE FORMS 2 VINYL STRIP TRUNK",SUP-2795A,CDM,S27000186,LOCAL,0270,RC,,,both,,,918.78,275.63,"CIGNA [10200]","Cigna Local Plus",,491.55,53.5,,,,,0,106.85,780.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 250MM 5MM BALLOON DILATATION RAPID EXCHANGE",SUP-47550250S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"PHCS [10601]",PHCS,,1417.5,70,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 40MM 80CM 8MM 6FR VASCULAR NITINOL",SUP-G43856,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross PPO",,1481.76,39.2,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3MM TARGET HELICAL PLATINUM DETACHABLE",SUP-M0035433080,CDM,S27800098,LOCAL,0278,RC,,,both,,,9157.68,2747.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1085.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1065.04,7784.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 14.5IN HARRINGTON LARGE WIDE BLADE SURGICAL 7.5X4.5IN",SUP-CH1008,CDM,S27200284,LOCAL,0272,RC,,,both,,,2128.43,638.53,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,874.78,41.1,,,,,0,247.54,1809.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIVIGEN CELLULAR BONE MATRIX 1CC CRYO",SUP-BL-1500-001,CDM,C1713,HCPCS,0278,RC,,,both,,,3315.00,994.5,"CIGNA [10200]",Cigna,,2254.2,68,,1831.33,1831.33,1831.33,16,385.53,2817.75,"percent of total billed charges",
"BLADE LARYNSCP GRAY PURPLE INTUBRITE MILLER 00 METAL 2 LED",SUP-1039.C,CDM,S27000186,LOCAL,0270,RC,,,both,,,3.85,1.15,"MULTIPLAN [10600]",Multiplan,,3.27,85,,,,,0,0.45,3.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 20CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155240190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,168.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 8MM 144CM 2.25MM CORONARY STENT PEBAX",SUP-H7493926008220,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2554.34,45.9,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 200MM 6MM BALLOON DILATATION RAPID",SUP-47560200M,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,235.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC",058,MS-DRG,,,,,,,inpatient,,,58833.28,18200.89,"CIGNA [10200]","Cigna Open Access",,18760.05,,"Fee schedule rate ($18,760.05). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,42633.22,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPREME 120CM 5FR 1MM 5MM SPACE COURNAND-2 CURVE",SUP-401860,CDM,C1730,HCPCS,0272,RC,,,both,,,572.00,171.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,67.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,66.52,486.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP PERFORM STEM TSA-PERFORM GLENOID",SUP-CAP1182,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"NOVANET [10819]",Novanet,,20081.25,75,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 119MM STAINLESS STEEL 3.5MM SCREWS 6 HOLE LCP BONE",SUP-239.956,CDM,C1713,HCPCS,0278,RC,,,both,,,9506.13,2851.84,"FIRST HEALTH [10303]","First Health",,7604.9,80,,,,,0,1105.56,8080.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25.5X9.5X.4MM MICRO 100 MICROPOWER SAGITTAL FINE",SUP-507112300,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.42,71.83,"FIRST HEALTH [10303]","First Health",,191.54,80,,,,,0,27.84,203.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUMARK PROFESSIONAL Q SHAPE 12CM",SUP-351222,CDM,A4648,HCPCS,0278,RC,,,both,,,667.85,200.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,79.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.67,567.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Duoderm",PX-E27200109,CDM,E27200109,LOCAL,0272,RC,,,both,,,123.87,37.16,"KAISER [10500]",Kaiser,,82.99,67,,,,,0,14.41,105.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM DYONICS 25 FLUID MANAGEMENT 1 SUCTION INFLOW/OUTFLOW",SUP-7211006,CDM,S27000186,LOCAL,0270,RC,,,both,,,494.10,148.23,"KAISER [10500]",Kaiser,,331.05,67,,,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 NARROW KNEE LEFT CRUCIATE RETAIN CEMENT",SUP-42-5020-064-01,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9396.57,41.1,,6417.48,6417.48,6417.48,"1 through 10",2658.93,19433.3,"percent of total billed charges",
"INSRT TIBIAL 2 CURVE 15MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962013,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"KAISER [10500]",Kaiser,,6197.13,67,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKING COILS XL 45CM",SUP-RBYPCXL45,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 25MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962347,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5801.52,40,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 5MM TRIATHLON 4 POSTERIOR KNEE TOTAL STABILIZED",SUP-5543-A-400,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"CIGNA [10200]","Cigna Local Plus",,2552.48,53.5,,5372.07,4581.20,7242.98,23,554.87,4055.34,"percent of total billed charges",
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 7 6MM",SUP-TPS-030-067S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GAUGE MEASURING MENDEZ OPHTHALMIC 12MM",SUP-60-7086,CDM,S27000186,LOCAL,0270,RC,,,both,,,870.67,261.2,"NOVANET [10819]",Novanet,,653,75,,,,,0,101.26,740.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PENCIL 10FT VALLEYLAB EDGE SMOKE",SUP-SEP5000,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"CIGNA [10200]","Cigna Open Access",,108.91,56.9,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL MEDIUM 70X61MM KNEE RIGHT MODULAR ROTATE HINGE",SUP-64811121,CDM,C1776,HCPCS,0278,RC,,,both,,,25203.15,7560.94,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2986.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2931.13,21422.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 92CM 1MM 6FR 2-5-2MM SPACE D CURVE ELECTROPHYSIOLOGY",SUP-D608DR252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3090.00,927,"MULTIPLAN [10600]",Multiplan,,2626.5,85,,,,,0,359.37,2626.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP PURPLE 75MM RUSCH EQUIPLITE MILLER 0",SUP-004650000,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.98,14.99,"CIGNA [10200]","Cigna Open Access",,28.44,56.9,,,,,0,5.81,42.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX LPR 15 CM CIRCLE",SUP-F10244-1515L,CDM,C1781,HCPCS,0278,RC,,,both,,,18437.08,5531.12,"FIRST HEALTH [10303]","First Health",,14749.66,80,,,,,0,2144.23,15671.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 12X5.5X.4MM HALL MICROPOWER MICRO100 THK.6MM SMALL",SUP-5023-160,CDM,S27200284,LOCAL,0272,RC,,,both,,,153.03,45.91,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,70.24,45.9,,,,,0,17.8,130.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 1.8MM PILOT",SUP-320-0018,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,187.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 27MM DURAN ANCORE CHORDAL GUIDE",SUP-620BG27,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 380MM FEMORAL EXPERT INTRAMEDULLARY ROUND",SUP-04.013.456S,CDM,C1713,HCPCS,0278,RC,,,both,,,8319.74,2495.92,"KAISER [10500]",Kaiser,,5574.23,67,,,,,0,967.59,7071.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 18LP 80CM 8CM 4FR 8MM .018IN BALLOON DILATATION",SUP-G50271,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL +20.5 DIOPTER +3 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT300205,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,40.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +5MM 26MM HIP C TAPER COCR LFIT",SUP-06-2605,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA [10200]",Cigna,,2126.84,68,,5873.17,5873.17,5873.17,"1 through 10",363.75,2658.55,"percent of total billed charges",
"WIRE FIXATION DIAMOND POINT STYLE BOTH END 15.2CM .035IN",SUP-00018605800,CDM,C1713,HCPCS,0278,RC,,,both,,,119.63,35.89,"NOVANET [10819]",Novanet,,89.72,75,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM LINX 13 BEAD 1.5 TESLA IMPL GASTROINTESTINAL GERD",SUP-LXMC13,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4106.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS PNEUMATIC LIFEBAND CHEST COMPRESSION STRAP LATEX FREE",SUP-8700-0706-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1202.12,360.64,"FIRST HEALTH [10303]","First Health",,961.7,80,,,,,0,139.81,1021.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL MALLEABLE CURVED GRADUATED SIMS 13IN 4MM",SUP-EO012R,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.38,43.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,65.81,45.9,,,,,0,16.68,121.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASE TIB STEM #3 RIGHT PEGLESS",SUP-2586-0-0003,CDM,C1776,HCPCS,0278,RC,,,both,,,6210.00,1863,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,722.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC",190,MS-DRG,,,,,,,inpatient,,,33113.82,9934.15,"CIGNA [10200]",Cigna,,14524.16,,"Fee schedule rate ($14,524.16). Includes an add-on of 40% of RC 0274 if total amount is above $24,380, 40% of RC 0275 if total amount is above $24,380, 40% of RC 0001-0999 if total amount is above $24,380, 40% of RC 0276 if total amount is above $24,380, 65% of RC 0636 if total amount is above $7,171.",,,,0,6871.13,27624.93,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET",RX-34544,CDM,,,0637,RC,00406-0124-23,NDC,both,1,UN,12.57,3.77,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5.17,41.1,,,,,0,1.46,10.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 6MM 6FR 3MM .07IN",SUP-H7493926706300,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 RIGHT KNEE POSTERIOR STABILIZED CEMENTED",SUP-5515-F-702,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6800,68,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 20IN 32FR STRAIGHT",SUP-8888570556,CDM,C1729,HCPCS,0272,RC,,,both,,,88.90,26.67,"FIRST HEALTH [10303]","First Health",,71.12,80,,,,,0,10.34,75.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 60MM 75CM 18MM 10FR 100CM",SUP-40412,CDM,C1876,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"MULTIPLAN [10600]",Multiplan,,5718.38,85,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION",RX-2007,CDM,J3420,HCPCS,0636,RC,63323-0044-00,NDC,both,1,ML,30.80,9.24,"KAISER [10500]",Kaiser,,20.64,67,,,,,0,0.31,26.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 30MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0266,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"FIRST HEALTH [10303]","First Health",,758.16,80,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY PREP ON-Q T-BLOC STERILE",SUP-TBT02,CDM,S27200305,LOCAL,0272,RC,,,both,,,250.02,75.01,"NOVANET [10819]",Novanet,,187.52,75,,,,,0,29.08,212.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 5.5MM RELINE LORDOTIC TITANIUM MULTIAXIAL",SUP-11355080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 10 STD 36MM PROVOX LIFE LARYTUBE",SUP-7416,CDM,S27000186,LOCAL,0270,RC,,,both,,,1194.91,358.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,812.54,68,,,,,0,138.97,1015.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 8MM 3.5MM BALLOON DILATATION PTCA",SUP-DC-RZ3508UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,114.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAVIGO STEERABLE INTRACARDIAC CATHETER INTRODUCER KIT, LARGE",SUP-S08574LL,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2216.97,45.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 69.6X45.8X25MM MBT 3+ MM KNEE CEMENT REVISION",SUP-1294-35-325,CDM,C1776,HCPCS,0278,RC,,,both,,,35980.56,10794.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14788.01,41.1,,6417.48,6417.48,6417.48,"1 through 10",4184.54,30583.48,"percent of total billed charges",
"SET 20-30CM 7-18FR MALECOT NEPHRSTMY CATH STENT FLEXIBLE",SUP-G14431,CDM,C1729,HCPCS,0272,RC,,,both,,,824.58,247.37,"MULTIPLAN [10600]",Multiplan,,700.89,85,,,,,0,95.9,700.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM 25MM 6-5FR COTTON CANNULATOME II BILIARY PANCREATIC",SUP-G22241,CDM,S27200284,LOCAL,0272,RC,,,both,,,1642.50,492.75,"PHCS [10601]",PHCS,,1149.75,70,,,,,0,191.02,1396.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 7.5IN WIDE CUSHING JARIT CONVEX EDGE WIDE",SUP-285-375,CDM,S27200284,LOCAL,0272,RC,,,both,,,269.96,80.99,"FIRST HEALTH [10303]","First Health",,215.97,80,,,,,0,31.4,229.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 18.5X10MM MICRO 100 MICROPOWER THK.4MM STRAIGHT",SUP-502316300,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.65,53.29,"CIGNA [10200]","Cigna Local Plus",,95.04,53.5,,,,,0,20.66,151,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 31MM 26.1MM MASTERS SERIES PYROLYTIC CARBON",SUP-29AECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"NOVANET [10819]",Novanet,,21839.42,75,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE SHOULDER AUGMENTED BASEPLATE CAP",SUP-RSA2,CDM,C1776,HCPCS,0278,RC,,,both,,,47880.00,14364,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,12927.6,27,,,,,0,5568.44,40698,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 14IN 24FR AORTA 3/8IN STRAIGHT AUTODILATE TIP",SUP-EZS24TA,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"FIRST HEALTH [10303]","First Health",,388.8,80,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP 2.5CC 2-4MM ALLOGRAFT GRANULE",SUP-12710101,CDM,C1713,HCPCS,0278,RC,,,both,,,4588.50,1376.55,"PHCS [10601]",PHCS,,3211.95,70,,,,,0,533.64,3900.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT PROSERIES 170MM 80MM 5MM 5FR .014-.035IN",SUP-5F051701CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"FIRST HEALTH [10303]","First Health",,16606.8,80,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM FRMLA LONG ANGLED AGGRESSIVE PLUS",SUP-0385544100,CDM,S27200284,LOCAL,0272,RC,,,both,,,494.10,148.23,"KAISER [10500]",Kaiser,,331.05,67,,,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM AXSOS STAINLESS STEEL 2.5MM FULL THREAD",SUP-338622,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"CIGNA [10200]","Cigna Open Access",,130.98,56.9,,1144.80,304.56,2275.09,66,26.77,195.67,"percent of total billed charges",
"COIL EMBOLIZATION 20CM 7MM PRESTIGE PLUS HELICAL HELICAL",SUP-PRES0720HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"CIGNA [10200]","Cigna Local Plus",,3506.93,53.5,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRELUDE SNAP SPLITTABLE SHEAT",SUP-PLS-1006,CDM,C1892,HCPCS,0272,RC,,,both,,,518.40,155.52,"AMERIGROUP MEDICAID [20100]",Amerigroup,,61.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.29,440.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 18X7MM COALITION AGX 7D 10.5MM NONSTERILE",SUP-3128.1577,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"FIRST HEALTH [10303]","First Health",,4416,80,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM SEMIRIGID BAND SIMULUS POLYESTER",SUP-800SR32,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"KAISER [10500]",Kaiser,,8783.7,67,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC MEDIUM 7IN 6.75-7.5IN LEFT WRIST D RING",SUP-A611LM,CDM,S27000186,LOCAL,0270,RC,,,both,,,136.16,40.85,"KAISER [10500]",Kaiser,,91.23,67,,,,,0,15.84,115.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR STD 100MM PROXIMATE TITANIUM ENDOSCOPIC LINEAR",SUP-TCR10,CDM,S27200284,LOCAL,0272,RC,,,both,,,2272.61,681.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1043.13,45.9,,,,,0,264.3,1931.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eps WO Arryth",PX-481000053,CDM,93619,CPT,0481,RC,,,both,,,24234.00,7270.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16234,,"Case rate ($16,234). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2818.41,23595,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 180MM HIP RIGHT FEMORAL AFFIXUS GOAL POST",SUP-814311180,CDM,C1713,HCPCS,0278,RC,,,both,,,16042.50,4812.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4591.36,28.62,,,,,0,1865.74,13636.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS SOLN DEX 2.5 % LOW CA+ 2.5 MEQ/L&MAG 0.5 MEQ/L",RX-27800,CDM,,,0250,RC,00941-0430-52,NDC,both,2000,ML,241.44,72.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,99.23,41.1,,,,,0,28.08,205.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 34CM 7FR ATRIUM VENTRICLE BIPOLAR ACTIVE",SUP-1688TC/34,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"AETNA [10100]","Aetna HMO/PPO",,1774.84,79.5,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 34CM 7FR ATRIUM VENTRICLE BIPOLAR ACTIVE",SUP-1688TC/34,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"MULTIPLAN [10600]",Multiplan,,1897.63,85,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 12MM MATRIXNEURO CRANIOMAXILLOFACIAL TITANIUM 2",SUP-04.503.062,CDM,C1713,HCPCS,0278,RC,,,both,,,1101.60,330.48,"MULTIPLAN [10600]",Multiplan,,936.36,85,,,,,0,128.12,936.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 45CM 4-7MM FLIXENE 2 SLIDER GDS TAPERED",SUP-25138,CDM,C1768,HCPCS,0278,RC,,,both,,,10206.27,3061.88,"NOVANET [10819]",Novanet,,7654.7,75,,,,,0,1186.99,8675.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEDIA XYLENE SHANDON EZ MOUNT 500ML HIGH VISCOSITY MOUNTING",SUP-9999120,CDM,S27000186,LOCAL,0270,RC,,,both,,,403.38,121.01,"CIGNA [10200]","Cigna Open Access",,229.52,56.9,,,,,0,46.91,342.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FUZEFIX MINI OD1.9 MM CALIBRATE CANNULATED NO",SUP-CD-FX-1019,CDM,S27000186,LOCAL,0270,RC,,,both,,,2130.00,639,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,875.43,41.1,,,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 45MM LOW PROFILE SCREWS TITANIUM PARTIAL",SUP-AR-9045-45PT,CDM,C1713,HCPCS,0278,RC,,,both,,,7838.40,2351.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2243.35,28.62,,,,,0,911.61,6662.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP LIMIT HOLE COLOR CODED POROUS G7 G",SUP-010000667,CDM,C1776,HCPCS,0278,RC,,,both,,,10120.92,3036.28,"UHC [10700]","United Healthcare",,6406.54,63.3,,8601.07,8395.67,8601.07,"1 through 10",1177.06,8602.78,"percent of total billed charges",
"TUBE ENDOTRACHEAL 6.5MM REINFORCE CUFF MURPHY EYE LOW",SUP-DYNJAARC65,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.86,46.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,63.65,41.1,,,,,0,18.01,131.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8.5MM 45MM RELINE 2C SPINE POLYAXIAL REDUCTION",SUP-16028545,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP VESOLOCK MED-LARGE",SUP-51114V,CDM,S27200284,LOCAL,0272,RC,,,both,,,267.21,80.16,"CIGNA [10200]","Cigna Open Access",,152.04,56.9,,,,,0,31.08,227.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CXI SPRT",SUP-G18378,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEARTRAIL III 100CM 5FR IR1 CURVE GUIDING PTFE CORONARY",SUP-40-5380,CDM,C1887,HCPCS,0272,RC,,,both,,,583.20,174.96,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CEFUROXIME AXETIL 250 MG TABLET",RX-9495,CDM,,,0637,RC,67877-0215-60,NDC,both,1,UN,25.19,7.56,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAMP SURGICAL CLASSIC REUL 5/8IN 10IN AORTA VASCULAR 1X2",SUP-37-1026,CDM,S27200284,LOCAL,0272,RC,,,both,,,627.02,188.11,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DISECT ENDOSCOPIC RIGHT ANGLED TIP 5MM DISPOSABLE",SUP-3332,CDM,S27200284,LOCAL,0272,RC,,,both,,,334.95,100.48,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ACHIEVE 20MM 6CM 5CM 11CM 14GA 13.5GA BIOPSY SOFT",SUP-CA1411,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.05,130.51,"KAISER [10500]",Kaiser,,291.48,67,,,,,0,50.6,369.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 25KHZ UNIVERSAL STRAIGHT SONOPET DISPOSABLE",SUP-5450800307,CDM,S27200284,LOCAL,0272,RC,,,both,,,4262.78,1278.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1752,41.1,,,,,0,495.76,3623.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT AORTIC VALVE 18FR CERTITUDE SAPIEN 3 ATRION 20MM",SUP-9600CT20A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21952.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM INTERLOCK FIBERED IDC DETACHABLE",SUP-M001361640,CDM,S27800098,LOCAL,0278,RC,,,both,,,2079.00,623.7,"BLUE CROSS [10001]","Blue Cross PPO",,814.97,39.2,,,,,0,241.79,1767.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM 30.7MM 24.9MM MITRAL FLEXIBLE HOLDER",SUP-4450M26,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"NOVANET [10819]",Novanet,,8538.75,75,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 90CM 16MM 3FR SEGURA HEMISPHERE",SUP-M0063801020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"UHC [10700]","United Healthcare",,936.56,63.3,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE RETINAL ROUND SILICONE STYLE 270",SUP-92-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,95.70,28.71,"CIGNA [10200]","Cigna Open Access",,54.45,56.9,,,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TIBIAL 18MM INBONE ANKLE PLASMA BASE",SUP-200009902,CDM,C1776,HCPCS,0278,RC,,,both,,,2743.00,822.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,785.05,28.62,,,,,0,319.01,2331.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE LARGE SQUARE TOE",SUP-100614-040,CDM,S27000186,LOCAL,0270,RC,,,both,,,68.82,20.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,28.29,41.1,,,,,0,8,58.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SUT 0 FIBERLOOP SUTURETAPE GRAFT TENDON SIZER TENODESIS",SUP-AR-1676ST,CDM,S27200284,LOCAL,0272,RC,,,both,,,2323.13,696.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1066.32,45.9,,,,,0,270.18,1974.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM EVEREST SPINE CANNULATED POLYAXIAL MIS",SUP-M5111-05535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,1144.80,304.56,2275.09,66,641.98,4692,"percent of total billed charges",
"CATH SHOCKWAVE M5 60MM 110CM 8MM 7MM BALLOON DILATATION",SUP-M5PIVL8060,CDM,C1725,HCPCS,0272,RC,,,both,,,21735.00,6520.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2575.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2527.78,18474.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 180MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-410-180,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XPANSE EXPANDABLE DEMINERALIZED BONE MATRIX LARGE - L 21MM X",SUP-T600612,CDM,S27800098,LOCAL,0278,RC,,,both,,,4347.00,1304.1,"BLUE CROSS [10001]","Blue Cross HMO",,1704.02,39.2,,,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL 22-30CM 6FR .038IN STRAIGHT URETERAL",SUP-M006180156010,CDM,C2617,HCPCS,0278,RC,,,both,,,1077.22,323.17,"BLUE CROSS [10001]","Blue Cross PPO",,422.27,39.2,,,,,0,125.28,915.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8.5MM 12/14 TAPER 36MM HIP CEMENTLESS M",SUP-136553000,CDM,C1776,HCPCS,0278,RC,,,both,,,3991.68,1197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2714.34,68,,,,,0,464.23,3392.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 3 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022213,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1933.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1933.15,14128.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135CM 100MM 6MM .035IN LOW PROFILE BALLOON",SUP-B2060-100,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,316.26,41.1,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD SENTUS PROMRI LEFT VENTRICULAR OTW QUADRIPOLAR",SUP-408719,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3812.76,68,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 1 11MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530-P-111,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,990.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,971.79,7102.52,"percent of total billed charges",
"STENT WALLFLEX 12CM 230CM 25-30MM 10FR 270CM COLONIC NITINOL",SUP-M00565060,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Open Access",,5803.88,33.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR NEUROSURGICAL MAXCESS 4 DISPOSABLE",SUP-3240060,CDM,S27000186,LOCAL,0270,RC,,,both,,,11730.00,3519,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7976.4,68,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla Xm Flow Cyto 1st Smpl/Dil",PX-302000180,CDM,86825,CPT,0302,RC,,,both,,,850.00,255,"NOVANET [10819]",Novanet,,637.5,75,,,,,0,97.51,722.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUDEOXYGLUCOSE F-18 20 MCI TO 500 MCI/ML INTRAVENOUS SOLUTION",RX-164698,CDM,A9552,HCPCS,0343,RC,08888-8878-26,NDC,both,1,UN,755.00,226.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,755,,,,,,,87.81,755,"fee schedule",
"GRAFT ENDOVASCULAR 160MM 36-40MM 35-36MM 22FR ZENITH TX2",SUP-G47482,CDM,C1874,HCPCS,0278,RC,,,both,,,98041.65,29412.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,39216.66,40,,,,,0,11402.24,83335.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL SPIN GUARD FEMORAL METATARSOPHALANGEAL",SUP-P01-900-1902,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"MULTIPLAN [10600]",Multiplan,,1657.5,85,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trauma Response Lvl II W Pre-Notification",PX-682000001,CDM,G0390,HCPCS,0682,RC,,,both,,,8607.00,2582.1,"CIGNA [10200]",Cigna,,5852.76,68,,,,,0,1019.93,7315.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 2 KNEE LOW PROFILE",SUP-5520-M-200,CDM,C1776,HCPCS,0278,RC,,,both,,,7998.48,2399.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,947.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,930.22,6798.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNAP(R) LONG DRESSING KIT - 10 KIT CASE",SUP-SKTF14X34,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,371.79,45.9,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 92CM 1MM 6FR 12MM SPACE ISMUS CATH CURVE",SUP-D6R20P12RT,CDM,C1731,HCPCS,0272,RC,,,both,,,7086.30,2125.89,"NOVANET [10819]",Novanet,,5314.73,75,,,,,0,824.14,6023.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE URETHROTOME STRAIGHT COLD SACHSE DISPOSABLE",SUP-27069K-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1558.63,467.59,"PHCS [10601]",PHCS,,1091.04,70,,,,,0,181.27,1324.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AEROMINI 115MM 15MM 8MM 12.5FR TRACHEOBRONCHIAL TAPER",SUP-AERO815,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PHCS [10601]",PHCS,,12127.5,70,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NIFEDIPINE ER 30 MG TABLET EXTENDED RELEASE SUPERORDERABLE",RX-408831,CDM,,,0637,RC,50268-0597-11,NDC,both,1,UN,6.60,1.98,"CIGNA [10200]","Cigna Local Plus",,3.53,53.5,,,,,0,0.77,5.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 10MM 1.9FR BAGLEY HELICAL 3",SUP-M0063401220,CDM,S27200284,LOCAL,0272,RC,,,both,,,1247.08,374.12,"AETNA [10100]","Aetna HMO/PPO",,991.43,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,145.04,1060.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 30-35MM RELINE C X CNCT ADJ ROD-ROD",SUP-3900353,CDM,C1713,HCPCS,0278,RC,,,both,,,4657.50,1397.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,551.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",541.67,3958.88,"percent of total billed charges",
"CATH PERFORMA 110CM 6FR ULT4T-40 CURVE ANGIOGRAPHIC PEBAX",SUP-6110381ULT4-T40,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.84,61.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,23.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.94,174.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER HUMERAL 36MM UNIVERS REVERS +9MM SHOULDER TITANIUM",SUP-AR-9555-09,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,348.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,341.92,2499,"percent of total billed charges",
"BASKET SPECIMEN RETRIEVAL 220CM 2.5CM 7FR MEMORY BASKET",SUP-G57270,CDM,S27200284,LOCAL,0272,RC,,,both,,,2805.00,841.5,"CIGNA [10200]","Cigna Open Access",,1596.05,56.9,,,,,0,326.22,2384.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 57MM 75CM 6MM 60MM",SUP-38046-66075,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross PPO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE SIGNAFUSE BIPHASIC CALCIUM PHOSPHATE BIOACTIVE",SUP-SGF-075,CDM,C1713,HCPCS,0278,RC,,,both,,,7783.20,2334.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3572.49,45.9,,,,,0,905.19,6615.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LARGE BEND 177MM STAINLESS STEEL 3.5MM SCR 10 HOLE",SUP-02.127.341S,CDM,C1713,HCPCS,0278,RC,,,both,,,11799.00,3539.7,"AETNA [10100]","Aetna HMO/PPO",,9380.21,79.5,,1521.93,481.35,16760.95,30,1372.22,10029.15,"percent of total billed charges",
"CATH PERFORMA 125CM 5FR JR6 CURVE ANGIOGRAPHIC PEBAX",SUP-7523-83,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.74,23.62,"MULTIPLAN [10600]",Multiplan,,66.93,85,,,,,0,9.16,66.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 60MM STEALTH 3 SOFT STERILE LATEX FREE",SUP-A0A13,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,71.88,45.9,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CENTERPIECE CORTICAL ALLOGRAFT FREEZE DRIED STRUT",SUP-853910,CDM,S27800098,LOCAL,0278,RC,,,both,,,3412.50,1023.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,404.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,396.87,2900.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VISIGI 36FR STD W/BULB 25 PER CARTON",SUP-5536B,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 80MM 130MM 5MM LONG VASCULAR NITINOL",SUP-SC580LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3325.46,45.9,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 5MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0540CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7245.00,2173.5,"CIGNA [10200]",Cigna,,4926.6,68,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablt Perc Liver Tmr Rf",PX-361000179,CDM,47382,CPT,0361,RC,,,both,,,7662.58,2298.77,"BLUE CROSS [10001]","Blue Cross HMO",,6134.53,,"Case rate ($6,134.53). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,891.16,7662.58,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUSTOM PERFUSION FX PACK",SUP-75584,CDM,S27200284,LOCAL,0272,RC,,,both,,,2193.75,658.12,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ROTAREX 110CM 8FR ATHERECTOMY SET GWIRE STERILE",SUP-80239,CDM,C1724,HCPCS,0272,RC,,,both,,,23625.00,7087.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"STENT COMPLETE SE 30MM 130CM 4MM LONG BILIARY NITINOL SELF",SUP-SC430LV,CDM,C1876,HCPCS,0278,RC,,,both,,,6210.00,1863,"MULTIPLAN [10600]",Multiplan,,5278.5,85,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 250MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530250S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1377,68,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.5MM 95MM GAMMA3 TITANIUM HIP TROCHANTER LAG",SUP-3060-0095S,CDM,C1713,HCPCS,0278,RC,,,both,,,3906.00,1171.8,"CIGNA [10200]","Cigna Local Plus",,2089.71,53.5,,3978.14,359.25,3978.14,24,454.27,3320.1,"percent of total billed charges",
"BLADE SAW LAPIPLASTY",SUP-ZMS-4011,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"CIGNA [10200]","Cigna Open Access",,345.67,56.9,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELCA 135CM 6FR .9MM ATHERECTOMY STAINLESS STEEL",SUP-110-004,CDM,C1714,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11781,68,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRECISION GUIDE DRILL PIN 3.0 X 320MM PHANTOM? HINDFOOT N",SUP-P31-951-3032,CDM,C1713,HCPCS,0278,RC,,,both,,,2025.00,607.5,"CIGNA [10200]","Cigna Open Access",,1152.23,56.9,,1144.80,304.56,2275.09,66,235.51,1721.25,"percent of total billed charges",
"COPPER CU-64 DOTATATE INTRAVENOUS SOLUTION (2-3 MCI)",RX-411821,CDM,A9592,HCPCS,0343,RC,08888-8877-76,NDC,both,1,UN,20412.00,6123.6,"CIGNA [10200]","Cigna Local Plus",,1155,,"Per diem ($1,155). Each quantity on the visit service is paid its own per diem rate. Each eligible service on a given day will be paid its own per diem rate.",,,,0,1155,17350.2,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM TRIATHLON 3 LEFT MEDIAL RIGHT LATERAL",SUP-5612-A-351,CDM,C1776,HCPCS,0278,RC,,,both,,,9878.04,2963.41,"AETNA [10100]","Aetna HMO/PPO",,7853.04,79.5,,10981.53,8986.79,12413.38,12,1148.82,8396.33,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 30MM 140CM 2.5MM 2.1-2.7FR CORONARY",SUP-RONYX25030UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"PHCS [10601]",PHCS,,2572.5,70,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY 14.8CM 13GA 11GA BD TREK AUTOMATIC BRAKE CONTROL",SUP-TKL1110,CDM,S27200284,LOCAL,0272,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]","Cigna Local Plus",,1805.63,53.5,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Chest W/WO Cntrst",PX-610000014,CDM,71552,CPT,0610,RC,,,both,,,5765.38,1729.61,"CIGNA [10200]","Cigna Local Plus",,752,,"Per diem ($752). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,670.51,4900.57,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Cerv Spine W/WO Cntrst",PX-352000010,CDM,72127,CPT,0352,RC,,,both,,,3543.36,1063.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,412.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,405,3011.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 2MM MEDIUM 200MM VITALLIUM 2 CABLE GRIP DALL-MILES",SUP-6704-3-083,CDM,C1713,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA [10200]","Cigna Open Access",,5690,56.9,,1144.80,304.56,2275.09,66,1163,8500,"percent of total billed charges",
"HC Guidance Radiation Tx",PX-333000060,CDM,77387,CPT,0333,RC,,,both,,,3171.03,951.31,"FIRST HEALTH [10303]","First Health",,2536.82,80,,,,,0,368.79,3171.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Abd Ea 3rd Ord",PX-361000089,CDM,36247,CPT,0361,RC,,,both,,,3507.05,1052.11,"PHCS [10601]",PHCS,,2454.94,70,,,,,0,407.87,3507.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Abd Ea 3rd Ord",PX-361000089,CDM,36247,CPT,0361,RC,,,both,,,3507.05,1052.11,"KAISER [10500]",Kaiser,,2349.72,67,,,,,0,407.87,3507.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 360MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.256S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4967.34,40,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 22CM 3CM 7FR .035IN PIGTAIL",SUP-M006180231090,CDM,C2617,HCPCS,0278,RC,,,both,,,1294.14,388.24,"FIRST HEALTH [10303]","First Health",,1035.31,80,,,,,0,150.51,1100.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752540,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]","Cigna Open Access",,513.34,,,,,,,104.92,766.85,"percent of total billed charges",
"GWIRE ZIPWIRE VASCULAR TAPER 180CM 3CM .035IN NITINOL",SUP-M00146308B1,CDM,C1769,HCPCS,0272,RC,,,both,,,583.20,174.96,"MULTIPLAN [10600]",Multiplan,,495.72,85,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 8FR 18GA 20CM .032IN 2 LUMEN INDWELL CATH GWIRE NDL",SUP-CDC-45802-XP1A,CDM,C1752,HCPCS,0272,RC,,,both,,,1028.70,308.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,472.17,45.9,,,,,0,119.64,874.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CRYO/CUFF LARGE 20-31IN COMPRESSION THERAPY KNEE",SUP-11B,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DX DEFL 8 POLE",SUP-D708DR002RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3090.00,927,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2101.2,68,,,,,0,359.37,2626.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 4965-50  PKG ASSY-LEAD UNIPOLAR 50C",SUP-4965-50,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"FIRST HEALTH [10303]","First Health",,4485.6,80,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT PRO+ 29MM",SUP-EVPROPLUS-29US,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"AETNA [10100]","Aetna HMO/PPO",,135945,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 4.5CM 18FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-18-4.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"PHCS [10601]",PHCS,,545.34,70,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175273190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 24CM 4.8FR URETERAL",SUP-M0061456070,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,72.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC 9IN UNIVERSAL ANKLE LOW PROFILE ADJUSTABLE",SUP-11180,CDM,S27000186,LOCAL,0270,RC,,,both,,,121.97,36.59,"CIGNA [10200]",Cigna,,82.94,68,,,,,0,14.19,103.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM CD HORIZON LEGACY TITANIUM SPINAL",SUP-75447545,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"MULTIPLAN [10600]",Multiplan,,4116.21,85,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRAMEDULLARY NAIL .062IN SLOTTED AWL LOCKING DEVICE",SUP-SBFS062,CDM,C1713,HCPCS,0278,RC,,,both,,,4347.00,1304.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,505.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",505.56,3694.95,"percent of total billed charges",
"LINER ACETABULAR PINNACLE NEUTRAL 62MM 36MM ALTRX HIP",SUP-122136062,CDM,C1776,HCPCS,0278,RC,,,both,,,6186.60,1855.98,"FIRST HEALTH [10303]","First Health",,4949.28,80,,,,,0,719.5,5258.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 400ML GEL ROUND SMOOTH SILICONE P4CM","SUP-3504001 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,435.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE CORDIS STORQ VASCULAR ANGLE 300CM 10CM .035IN SLX",SUP-503456Y,CDM,C1769,HCPCS,0272,RC,,,both,,,434.30,130.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.32,68,,,,,0,50.51,369.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VEIN DISTENTION GRAFT TUNNELING",SUP-26050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1278.75,383.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,148.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,148.72,1086.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 24CM 150CM 5FR .035IN 3CM BLADDER LOOP",SUP-M006155222180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 10.35MM 120MM TFN-ADVANCED TITANIUM ALUMINUM",SUP-04.038.220S,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,1831.33,1831.33,1831.33,16,434.96,3179,"percent of total billed charges",
"BRACE ORTHOPEDIC 10IN COTTON FOAM SMALL SHOULDER HUMERAL",SUP-79-97953,CDM,S27000186,LOCAL,0270,RC,,,both,,,512.49,153.75,"CIGNA [10200]","Cigna Local Plus",,274.18,53.5,,,,,0,59.6,435.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30MMX4.8MM TITANIUM THICK TISSUE 2 ROW",SUP-TX30G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1810.13,543.04,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,210.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,210.52,1538.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX10MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183660,CDM,C1776,HCPCS,0278,RC,,,both,,,13188.66,3956.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1533.84,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1533.84,11210.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 80MM 159CM 8MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200088020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +1.5MM 12/14 TAPER 36MM HIP BIOLOX DELTA",SUP-1365-36-310,CDM,C1776,HCPCS,0278,RC,,,both,,,12268.20,3680.46,"AETNA [10100]","Aetna HMO/PPO",,9753.22,79.5,,10981.53,8986.79,12413.38,12,1426.79,10427.97,"percent of total billed charges",
"COLLAR CERVICAL PEDIATRIC 1.5-2IN PATRIOT PROCARE SPINE 1",SUP-79-83130,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.33,15.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,23.56,45.9,,,,,0,5.97,43.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM 7FR ENDOCARDIAL TRUE BIPOLAR ACTIVE",SUP-7121/65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]",Cigna,,6868.8,40,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 7.5MM EVOLVE +2MM ELBOW PROLINE MODULAR",SUP-496S275,CDM,C1776,HCPCS,0278,RC,,,both,,,14614.20,4384.26,"BLUE CROSS [10001]","Blue Cross PPO",,5728.77,39.2,,3949.44,3949.44,3949.44,"1 through 10",1699.63,12422.07,"percent of total billed charges",
"SYSTEM REBEL 8MM 140CM 2.75MM CORONARY STENT PLATINUM",SUP-H7493927408270,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,436.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFEPIME 1 G VIAL IV PUSH",RX-408308,CDM,J0692,HCPCS,0636,RC,60505-6144-00,NDC,both,1,UN,153.52,46.06,"KAISER [10500]",Kaiser,,102.86,67,,,,,0,2.84,130.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 90MM LCP STAINLESS STEEL FULL THREAD CONDYLAR",SUP-02.207.090,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL MONOFILAMENT ABSORBABLE LOW PROFILE",SUP-5954790,CDM,C1781,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"CIGNA [10200]",Cigna,,2841.72,68,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veeg 2-12 Hr Intmt Mntr",PX-740000047,CDM,95712,CPT,0740,RC,,,both,,,5043.88,1513.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3429.84,68,,,,,0,5.04,4287.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 24CM LEFT HINDFOOT NAIL-EX INTRAMEDULLARY",SUP-04.008.078S,CDM,C1713,HCPCS,0278,RC,,,both,,,10019.35,3005.8,"CIGNA [10200]","Cigna Open Access",,5701.01,56.9,,1144.80,304.56,2275.09,66,1165.25,8516.45,"percent of total billed charges",
"MEDICAL BACK PROBLEMS WITHOUT MCC",552,MS-DRG,,,,,,,inpatient,,,28175.88,8452.76,"PHCS [10601]",PHCS,,7561,,,,,,,5963.01,23973.86,"per diem","Estimated amount calculated based on 2 day length of stay."
"(EVAL) 4MM CATHETER",SUP-AVSPV4060,CDM,C1761,HCPCS,0624,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 15MM 2.25MM BALLOON DILATATION",SUP-NCEUP22515X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,358.02,68,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Epstein Barr Virus Pcr",PX-306000160,CDM,87799,CPT,0306,RC,,,both,,,954.75,286.42,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,38.56,,,,,,,0.95,811.54,"fee schedule",
"CATH BENCHMARK 105CM .07IN STRAIGHT DELIVERY SYSTEM LATEX",SUP-BMK6F105,CDM,S27200284,LOCAL,0272,RC,,,both,,,6727.50,2018.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4574.7,68,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 11MM 16SQ MM 8FR .035IN",SUP-BXA117901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5780,27,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL INFINITY 4 STD TOTAL ANKLE SYSTEM",SUP-33650004,CDM,C1776,HCPCS,0278,RC,,,both,,,29049.30,8714.79,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7843.31,27,,,,,0,3378.43,24691.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 175MM 10MM SMALL SHELL REVISION ALTIVATE",SUP-533-10-175,CDM,C1776,HCPCS,0278,RC,,,both,,,43228.40,12968.52,"CIGNA [10200]",Cigna,,17291.36,40,,5873.17,5873.17,5873.17,"1 through 10",5027.46,36744.14,"percent of total billed charges",
"BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL",RX-230392,CDM,,,0250,RC,10310-0283-13,NDC,both,11.9,GR,32.94,9.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 12MM 6FR 6MM .07",SUP-H7493926712600,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"NOVANET [10819]",Novanet,,425.25,75,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SRGITLG LP SRGDAC 2/0 21""3""LP",SUP-ED-21-L,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP SMALL INTERNAL FILSHIE SILASTIC TITANIUM SOFT LINE",SUP-AVM-851J,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 5FR 2.5CM 10CM WITHOUT MINI GWIRE DIL PINNACLE",SUP-RSS504,CDM,C1894,HCPCS,0272,RC,,,both,,,73.95,22.18,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRNQT SURGICAL 36IN 1 HOSE CPC CNCT STERILE DISPOSABLE",SUP-60400910100,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.27,15.68,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL VASCULAR 22FR 20CM DISTAL COONS TAPER STERILE DISPOSABLE",SUP-G04443,CDM,S27200284,LOCAL,0272,RC,,,both,,,150.25,45.07,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 200CM 80MM 2.5MM BALLOON DILATATION RAPID",SUP-47525080L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 90CM 20MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PACK VITRECTOMY INFINITI ANTERIOR STERILE DISPOSABLE",SUP-8065750157,CDM,S27200284,LOCAL,0272,RC,,,both,,,1232.09,369.63,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STENT ZILVER FLEX 35 140MM 80CM 9MM 6FR .035IN BILIARY",SUP-G50137,CDM,C1876,HCPCS,0278,RC,,,both,,,7350.00,2205,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,870.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,854.81,6247.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 15CM 34MM TAG THORACIC ACTIVE CONTROL",SUP-TGM343415,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"CIGNA [10200]","Cigna Local Plus",,36531.24,31.5,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PNEUMOCLEAR HIGH FLOW TUBE SET",SUP-0620050100,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.90,32.67,"MULTIPLAN [10600]",Multiplan,,92.57,85,,,,,0,12.67,92.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 65MM TI",SUP-MTC-37650-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,147.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",145.07,1060.29,"percent of total billed charges",
"SUT VICRYL PLUS 3-0 KS 27IN BRAIDED COATED ANTIBACTERIAL",SUP-VCP663H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10.28,41.1,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 8MM 3MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG30008UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"FIRST HEALTH [10303]","First Health",,2100,80,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM G7 ACTIVE ARTICULATION THR E1 CERAMIC HIP CEMENT",SUP-98000100187,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"BLUE CROSS [10001]","Blue Cross PPO",,11360.16,39.2,,3949.44,3949.44,3949.44,"1 through 10",3370.37,24633,"percent of total billed charges",
"VALVE AORTIC 20MM 29MM MOSAIC ULTRA CINCH RING PORCINE STENT",SUP-305U229,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"CIGNA [10200]","Cigna Open Access",,9180.68,33.5,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 15CM 5FR 2 PIGTAIL CURVE BILIARY POLYETHYLENE",SUP-G22128,CDM,C2625,HCPCS,0278,RC,,,both,,,1328.40,398.52,"BLUE CROSS [10001]","Blue Cross HMO",,520.73,39.2,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 26MM SIMULUS ANNULUS POSTERIOR POLYESTER",SUP-800SC26,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]",Cigna,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CMPNT GLENOID REVERSE SHOULDER",SUP-98B00901601,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13097.7,27,,,,,0,5641.71,41233.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH ARTHROSCOPIC 15D UP TIP XL STRAIGHT SERIES 1 DESIGN",SUP-AR-11240XL,CDM,S27200284,LOCAL,0272,RC,,,both,,,7933.28,2379.98,"MULTIPLAN [10600]",Multiplan,,6743.29,85,,,,,0,922.64,6743.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 18MM 4MM NAIL-EX FULL THREAD HUMERAL TIBIAL",SUP-04.005.408,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,137.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,134.52,983.18,"percent of total billed charges",
"STEM FEMORAL 107.5MM TYPE 1 TAPERLOC MICROPLASTY PPS 133D 11",SUP-51106110,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3190.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3190.72,23319.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN SX ENDO HEPARIN 35 RO 9MMX10CM 8FR 120CMCATH",SUP-VBHR091002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2520.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 100MM 32MM LC-DCP LCP STAINLESS STEEL PARTIAL",SUP-217.100,CDM,C1713,HCPCS,0278,RC,,,both,,,485.35,145.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,222.78,45.9,,,,,0,56.45,412.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP 16MM OPEN 230CM INTERNAL INSTINCT HEMOCLIP",SUP-G18343,CDM,S27200284,LOCAL,0272,RC,,,both,,,1170.45,351.13,"NOVANET [10819]",Novanet,,877.84,75,,,,,0,136.12,994.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 340MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.154S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3554.13,28.62,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 285MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.337S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"BLUE CROSS [10001]","Blue Cross PPO",,3258.47,39.2,,957.42,570.23,957.42,28,966.74,7065.57,"percent of total billed charges",
"HC Emg 4 Ext",PX-922000004,CDM,95864,CPT,0922,RC,,,both,,,934.00,280.2,"NOVANET [10819]",Novanet,,700.5,75,,,,,0,108.62,793.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 650-780CC P5.6-6.5CM MODERATE PLUS PROFILE ROUND",SUP-3502650,CDM,C1789,HCPCS,0278,RC,,,both,,,3487.50,1046.25,"FIRST HEALTH [10303]","First Health",,2790,80,,,,,0,405.6,2964.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PREVAIL DCB 2.75X10MM",SUP-PRV027510CX,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LATERA ABSORBABLE NASAL IMPLANTS",SUP-LATSYS01,CDM,C1713,HCPCS,0278,RC,,,both,,,13330.80,3999.24,"KAISER [10500]",Kaiser,,8931.64,67,,,,,0,1550.37,11331.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC",301,MS-DRG,,,,,,,inpatient,,,31559.65,9467.89,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,14286.76,,"Fee schedule rate ($14,286.76). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,4464.34,17948.6,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION",RX-10181,CDM,J1644,HCPCS,0636,RC,63323-0262-03,NDC,both,1,ML,37.69,11.31,"BLUE CROSS [10001]","Blue Cross PPO",,1.22,,,,,,,1.06,32.04,"fee schedule",
"SCR BONE 4MM 14MM STALIF C NO-PROFILE ABO TITANIUM STD SPINE",SUP-ABS1440,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"KAISER [10500]",Kaiser,,629.8,67,,,,,0,109.32,799,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)CORONARY IVL CATHETER, 3.0MM X 12MM, RX IDE",SUP-501050-002,CDM,C1761,HCPCS,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL CO2 O2 STD DEHUMIDIFICATION LINE SIDESTREAM ADULT",SUP-1149379,CDM,S27000186,LOCAL,0270,RC,,,both,,,172.51,51.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,70.9,41.1,,,,,0,20.06,146.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 6MM 3.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP3506X,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 40CM 6MM GORE INTERING STD WALL PTFE RADIAL",SUP-IRS06040L,CDM,C1768,HCPCS,0278,RC,,,both,,,3974.40,1192.32,"CIGNA [10200]","Cigna Local Plus",,2126.3,53.5,,,,,0,462.22,3378.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 15MM 145CM 4.5MM BALLOON DILATATION",SUP-1400450-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR .071IN MULTIPURPOSE 2 CURVE GUIDING NYLON",SUP-LA6MP2,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,266.22,68,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC",344,MS-DRG,,,,,,,inpatient,,,85073.72,25522.12,"BLUE CROSS [10001]","Blue Cross PPO",,63761.71,,,,,,,7561,75407.43,"case rate",
"SIZER IMPL 11CM NATRELLE INSPIRA P5.4CM EXTRA FULL PROFILE",SUP-MSZ-X340,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 40MM 0D I HIP X3 TRIDENT 10.6MM",SUP-623-00-40I,CDM,C1776,HCPCS,0278,RC,,,both,,,9332.25,2799.67,"CIGNA [10200]","Cigna Open Access",,5310.05,56.9,,5302.19,4377.88,6578.61,27,1085.34,7932.41,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL LOOP 27FR CUT STORZ 2 STEM",SUP-M0068802241,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"KAISER [10500]",Kaiser,,320.41,67,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32MMX12MM CAPSTONE PEEK-OPTIMA SELF DISTRACT",SUP-2991232,CDM,S27800098,LOCAL,0278,RC,,,both,,,15897.60,4769.28,"CIGNA [10200]",Cigna,,6359.04,40,,,,,0,1848.89,13512.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 9IN OLLIER BLUNT 4 PRONG STAINLESS STEEL SURGICAL 42",SUP-200318,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.10,114.63,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,157.04,41.1,,,,,0,44.44,324.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAYONET 8IN CURVE TIP DN6216",SUP-DN6216,CDM,S27200284,LOCAL,0272,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Local Plus",,866.7,53.5,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRELUDE ACT SHEATHS 8 FR 11CM 50CM LENGTH .038 GUIDEWIRE",SUP-PSI-8F-11-038ACT,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"MULTIPLAN [10600]",Multiplan,,68.03,85,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 80MM 3MM BALLOON DILATATION HYDROPHILIC",SUP-603008022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"AETNA [10100]","Aetna HMO/PPO",,579.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 15MM 2.75MM BALLOON DILATATION PACLITAXEL",SUP-H7493960815270,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"PHCS [10601]",PHCS,,27231.75,70,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM PRIMARY CEMENT DISTAL BULLET TIP SYNERGY",SUP-71316216,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"PHCS [10601]",PHCS,,14883.75,70,,,,,0,2472.83,18073.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plasminogen Not Ag",PX-305000046,CDM,85420,CPT,0305,RC,,,both,,,255.00,76.5,"NOVANET [10819]",Novanet,,191.25,75,,,,,0,0.01,216.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 18.5X7X.38MM 5MM PRECISION MEDIUM NARROW THIN",SUP-2296003114,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.45,67.03,"MULTIPLAN [10600]",Multiplan,,189.93,85,,,,,0,25.99,189.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 500MM 5.5MM CD HORIZON STRAIGHT COCRMO NONSTERILE",SUP-1555000500,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",164.86,1204.88,"percent of total billed charges",
"LENS IOL 10 D +19 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.190,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RONGEUR 7IN STRAIGHT 1.5MM CUSHING DELICATE SURGICAL",SUP-57-2001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2266.43,679.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 5X20 40CM SL",SUP-48005002P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX 035 GEOALIGN 130CM 80MM 7MM BALLOON DILATATION",SUP-LX351307805F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 12.75CM NATRELLE INSPIRA P5.3CM FULL PROFILE",SUP-SSZ-F450,CDM,S27200284,LOCAL,0272,RC,,,both,,,1490.40,447.12,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUT Q-FIX MINITAPE 2 PRELOAD BLUE COBRAID WHITE",SUP-72205860,CDM,C1713,HCPCS,0278,RC,,,both,,,3150.00,945,"FIRST HEALTH [10303]","First Health",,2520,80,,,,,0,366.35,2677.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCRDRVR LARGE HEXAGONAL T HANDLE SURGICAL 4.5MM CORTICAL 6.5",SUP-314.13,CDM,S27200284,LOCAL,0272,RC,,,both,,,3384.45,1015.33,"CIGNA [10200]","Cigna Open Access",,1925.75,56.9,,,,,0,393.61,2876.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.434,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,164.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,160.97,1176.51,"percent of total billed charges",
"STENT SURPASS STREAMLINE 50MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-M003SFD050500,CDM,C1874,HCPCS,0278,RC,,,both,,,93183.77,27955.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10837.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10837.27,79206.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 450ML STYLE 10 SMOOTH NATRELLE SILICONE P3.9CM",SUP-10-450,CDM,C1789,HCPCS,0278,RC,,,both,,,4933.50,1480.05,"CIGNA [10200]","Cigna Open Access",,2807.16,56.9,,5166.00,5166.00,5166.00,"1 through 10",573.77,4193.48,"percent of total billed charges",
"TRNSDUC PRESSURE MNTR CENTURION STERILE LATEX FREE",SUP-CUHG1-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,553.73,166.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,64.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.4,470.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 16FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0166SI16,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.21,20.46,"CIGNA [10200]",Cigna,,46.38,68,,,,,0,7.93,57.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 54MM HIP GRIPTION PINNACLE SECTOR SERIES",SUP-1217-32-054,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"CIGNA [10200]",Cigna,,6487.38,40,,5873.17,5873.17,5873.17,"1 through 10",1886.21,13785.68,"percent of total billed charges",
"HEAD LINER XLT MP9 40MM",SUP-932-40-256,CDM,C1776,HCPCS,0278,RC,,,both,,,12462.02,3738.61,"MULTIPLAN [10600]",Multiplan,,10592.72,85,,,,,0,1449.33,10592.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM CREO CREO AMP QUAD SPINE 2 RIGHT HEAD",SUP-1119.0160,CDM,C1713,HCPCS,0278,RC,,,both,,,18314.10,5494.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7325.64,40,,,,,0,2129.93,15566.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD STAIN REM BIOFLEX",SUP-1358224,CDM,S27000186,LOCAL,0270,RC,,,both,,,100.22,30.07,"NOVANET [10819]",Novanet,,75.17,75,,,,,0,11.66,85.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 10X22X60MM 5DEG LORDOTIC TITANIUM ALLOY MODULUS",SUP-1223060P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"NOVANET [10819]",Novanet,,21262.5,75,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM TITANIUM T15 CORTICAL LOW PROFILE",SUP-110017714,CDM,C1713,HCPCS,0278,RC,,,both,,,668.25,200.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,306.73,45.9,,,,,0,77.72,568.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR S 31X9MM TRITANIUM STERILE LATEX FREE",SUP-5556-L-319,CDM,C1776,HCPCS,0278,RC,,,both,,,4410.00,1323,"CIGNA [10200]","Cigna Local Plus",,2359.35,53.5,,5372.07,4581.20,7242.98,23,512.88,3748.5,"percent of total billed charges",
"HC Inj Disco Cerv/Thorac Ea",PX-510000107,CDM,62291,CPT,0761,RC,,,both,,,1524.00,457.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1.52,.1,,,,,0,1.52,1524,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PULMONARY AERO OTW FULLY COVERED TRACHEOBRONCHIAL STENT 18MM",SUP-90129-201,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"KAISER [10500]",Kaiser,,11557.5,67,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETENE DS 15X10CM 2.4MM COMPOSITE",SUP-PPDS1510,CDM,C1781,HCPCS,0278,RC,,,both,,,2936.03,880.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,341.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,341.46,2495.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM DVR TITANIUM RADIUS CORTICAL DISTAL",SUP-CS14000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1093.50,328.05,"FIRST HEALTH [10303]","First Health",,874.8,80,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH C-FLEX 70CM 4.8FR URETERAL TAPER TIP 1 LUMEN RADIOPAQUE",SUP-M0064001500,CDM,C1758,HCPCS,0272,RC,,,both,,,334.60,100.38,"NOVANET [10819]",Novanet,,250.95,75,,,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ST CLAIR 7.25IN ADENOID RING JAW 10X5MM",SUP-71-5018,CDM,S27200284,LOCAL,0272,RC,,,both,,,1750.20,525.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,203.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,203.55,1487.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immune Cmplx",PX-302000069,CDM,86332,CPT,0302,RC,,,both,,,217.00,65.1,"MULTIPLAN [10600]",Multiplan,,184.45,85,,,,,0,0.01,184.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 120CM 6MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR061002A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"BLUE CROSS [10001]","Blue Cross PPO",,8337.37,39.2,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 200MM 6MM BALLOON DILATATION",SUP-PCU060200130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AETNA [10100]","Aetna HMO/PPO",,978.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAFIRE BLU DUO COMFORTGRIP 110CM 7FR 2-5-2MM SPACE 4MM",SUP-A088107,CDM,C2630,HCPCS,0272,RC,,,both,,,11040.00,3312,"PHCS [10601]",PHCS,,7728,70,,,,,0,1283.95,9384,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEALER BIPOLAR AQUAMAN 9.5XL",SUP-23-313-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVOLUTION 4CM 10MM 11MM BILIARY PLATINUM RADIOPACITY",SUP-G23127,CDM,C1876,HCPCS,0278,RC,,,both,,,8820.00,2646,"UHC [10700]","United Healthcare",,5583.06,63.3,,,,,0,1025.77,7497,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 6MM MAGILL CURVE NASAL ORAL CUFFED MURPHY",SUP-86398,CDM,S27200284,LOCAL,0272,RC,,,both,,,413.34,124,"MULTIPLAN [10600]",Multiplan,,351.34,85,,,,,0,48.07,351.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 530CC P4.7CM MODERATE PLUS PROFILE COHESIVE GEL",SUP-SMPB530,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5184.66,68,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT BIPOLAR HIP OSTEO",SUP-CAP-H-B-O,CDM,C1776,HCPCS,0278,RC,,,both,,,10660.50,3198.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1263.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1239.82,9061.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPRT ORTHOPEDIC 11-12IN NYLON ANKLE ELASTIC CUFF CLSR LOW",SUP-AB2900-12,CDM,S27000186,LOCAL,0270,RC,,,both,,,108.05,32.41,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Tx Inhal Aero Sputum Rpeat",PX-410000005,CDM,94640,CPT,0410,RC,,,both,,,298.34,89.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE OPHTHALMIC BLUE BEAVER MICRO-SHARP 15D 3MM STAB",SUP-377513,CDM,S27200284,LOCAL,0272,RC,,,both,,,152.02,45.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP SURGICAL NELSON 6IN TISSUE 6X7 TEETH STAINLESS STEEL",SUP-130370,CDM,S27200284,LOCAL,0272,RC,,,both,,,393.15,117.94,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"APPL INTERNAL CLIP LARGE 13IN TITANIUM ENDOSCOPIC LIGATING",SUP-134048,CDM,S27200284,LOCAL,0272,RC,,,both,,,379.23,113.77,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM",RX-5749,CDM,,,0250,RC,45802-0059-35,NDC,both,15,GR,110.11,33.03,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT FIBERWIRE 2 C-13 38IN BRAID TIES MULTISTRAND LOWER KNOT",SUP-AR-7202,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.97,60.29,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH HEMOSPRAY 220CM 7FR ENDOSCOPIC HEMOSTAT 2.8MM MINIMUM",SUP-G56572,CDM,C1052,HCPCS,0272,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"IMMOB ORTHOPEDIC UNIVERSAL SHOULDER DELUXE SLING SWATHE OPEN",SUP-9007-00,CDM,S27000186,LOCAL,0270,RC,,,both,,,83.35,25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 8FR 10CM DIL GWIRE PINNACLE TIF TIP .038IN",SUP-10-2534,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) AGENT DCB MR 3.00MM X 30MM",SUP-H74939436303010,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE CENTERING 9.5MM S-ROM ZTT 22B SMALL HIP PROXIMAL",SUP-521423,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"AETNA [10100]","Aetna HMO/PPO",,8653.38,79.5,,10981.53,8986.79,12413.38,12,1265.9,9252.04,"percent of total billed charges",
"SPACER SPINAL COALITION ANTERIOR CERVICAL DISCECTOMY AND",SUP-384.106,CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7200,40,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MENISCAL CINCH CURVE SUTURING STERILE DISPOSABLE",SUP-AR-4500,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"MULTIPLAN [10600]",Multiplan,,1907.72,85,,,,,0,261.02,1907.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD XLNK SMALL SPINE MULTIAXIAL SCR",SUP-7752525,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2422.5,68,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FEMORAL IDENTITY IMPRINT 3 NARROW KNEE POSTERIOR",SUP-TPS-101-F03N,CDM,C1776,HCPCS,0278,RC,,,both,,,11716.20,3514.86,"MULTIPLAN [10600]",Multiplan,,9958.77,85,,,,,0,1362.59,9958.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR LARGE 40MM AVON KNEE",SUP-6430-0-040,CDM,C1776,HCPCS,0278,RC,,,both,,,5561.40,1668.42,"KAISER [10500]",Kaiser,,3726.14,67,,,,,0,646.79,4727.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Coxsackie Abs",PX-302000119,CDM,86658,CPT,0302,RC,,,both,,,306.80,92.04,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,260.78,"per diem",
"HC Reptilase Test",PX-305000060,CDM,85635,CPT,0305,RC,,,both,,,195.00,58.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8.87,,,,,,,0.01,165.75,"fee schedule",
"CANN PERFUSION FEMUR STD INSRT KIT BIO-MEDICUS",SUP-96550,CDM,S27200284,LOCAL,0272,RC,,,both,,,429.69,128.91,"UHC [10700]","United Healthcare",,271.99,63.3,,,,,0,49.97,365.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC OP Surgery Center or Time Half Hour",PX-360000055,CDM,360000055,LOCAL,0360,RC,,,both,,,410.94,123.28,"FIRST HEALTH [10303]","First Health",,328.75,80,,,,,0,47.79,349.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 MO-4 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP701D,CDM,S27200284,LOCAL,0272,RC,,,both,,,169.32,50.8,"AETNA [10100]","Aetna HMO/PPO",,134.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.69,143.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sensor Flo Trac Vigileo",PX-E27200200,CDM,E27200200,LOCAL,0272,RC,,,both,,,1268.30,380.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,582.15,45.9,,,,,0,147.5,1078.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 120CM 9MM VASCULAR METAL ILIAC ARTERY SELF",SUP-H74939200094020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"MULTIPLAN [10600]",Multiplan,,3519,85,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 4-0 PC-3 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J845G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKAGED RADIAL STEM 7MM X -2MM",SUP-ALN-RST-07M2,CDM,C1776,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"UHC [10700]","United Healthcare",,9001.83,63.3,,8601.07,8395.67,8601.07,"1 through 10",1653.89,12087.77,"percent of total billed charges",
"DEVICE V-LOC 180 3-0 CV-23 .5 CIRCLE 12IN 17MM CLSR TAPER",SUP-VLOCL0814,CDM,S27200284,LOCAL,0272,RC,,,both,,,426.30,127.89,"PHCS [10601]",PHCS,,298.41,70,,,,,0,49.58,362.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAFLEX 15CM 66CM 9FR .025IN IAB CARDIOTHANE II",SUP-IAB-06850-U,CDM,S27200284,LOCAL,0272,RC,,,both,,,12385.50,3715.65,"CIGNA [10200]","Cigna Open Access",,7047.35,56.9,,,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 30MM 7MM .035IN BALLOON DILATATION NYBAX",SUP-39171-07034,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLARED SECUR-FIT HYDROXYAPATITE 6 HIP",SUP-S-2337-HF06,CDM,C1776,HCPCS,0278,RC,,,both,,,16482.96,4944.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1916.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1916.97,14010.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONE IRRIGATION VISI-FLOW STOMA",SUP-022736,CDM,S27000186,LOCAL,0270,RC,,,both,,,44.02,13.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.12,37.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 105MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.443,CDM,C1713,HCPCS,0278,RC,,,both,,,1384.13,415.24,"BLUE CROSS [10001]","Blue Cross HMO",,542.58,39.2,,957.42,156.86,7483.26,51,160.97,1176.51,"percent of total billed charges",
"CANN ARTHROSCOPIC 5.75MM QUICKPASS SUTURELASSO CRESCENT",SUP-AR-6068C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"AETNA [10100]","Aetna HMO/PPO",,1081.84,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL 45MM ATTUNE KNEE POROCOAT REVISION PARTIAL COA",SUP-151111103,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,11781,68,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 20MM TI",SUP-MTC-37200-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"PHCS [10601]",PHCS,,873.18,70,,,,,0,145.07,1060.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 3MM CEREPAK XL HELIFORM DETACHABLE",SUP-SHD180312,CDM,S27800098,LOCAL,0278,RC,,,both,,,13884.25,4165.27,"BLUE CROSS [10001]","Blue Cross PPO",,5442.63,39.2,,,,,0,1614.74,11801.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X5MM ENDOSKELETON TC 6D 12MM SMALL TITANIUM",SUP-5146-1205-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7038,68,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM VERTEX MAX TITANIUM SPINE THORACIC",SUP-6958728,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"PHCS [10601]",PHCS,,2940,70,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL WEIL-BLAKESLEY 45D UP 0 3.5MM 4.5IN SINUS",SUP-3711040,CDM,S27200284,LOCAL,0272,RC,,,both,,,3720.68,1116.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2530.06,68,,,,,0,432.72,3162.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVOLUTION 4CM 10MM 11MM BILIARY PLATINUM RADIOPACITY",SUP-G23127,CDM,C1876,HCPCS,0278,RC,,,both,,,8820.00,2646,"NOVANET [10819]",Novanet,,6615,75,,,,,0,1025.77,7497,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 28CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006155244180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71-75X11MM VANGUARD VIVACIT-E KNEE CRUCIATE RETAIN",SUP-VE183441,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"KAISER [10500]",Kaiser,,8678.3,67,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Study Ext Artery > 2 Lvls Bi",PX-920000004,CDM,93923,CPT,0921,RC,,,both,,,1568.21,470.46,"CIGNA [10200]","Cigna Open Access",,892.31,56.9,,,,,0,182.38,1332.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Study Ext Artery > 2 Lvls Bi",PX-920000004,CDM,93923,CPT,0921,RC,,,both,,,1568.21,470.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,719.81,45.9,,,,,0,182.38,1332.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL BIT SCR BIO-TENODESIS 4MM",SUP-AR-1204D,CDM,C1713,HCPCS,0278,RC,,,both,,,978.08,293.42,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,115.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,113.75,831.37,"percent of total billed charges",
"LENS IOL 5 D +18.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-LI61AOR1850,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 7.5CM 8.25MM EXPANULA ROTATOR CUFF OBTR",SUP-AR-6569,CDM,S27200284,LOCAL,0272,RC,,,both,,,356.27,106.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,163.53,45.9,,,,,0,41.43,302.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cors&Graft Angio W Lt Hrt Cath",PX-481000027,CDM,93459,CPT,0481,RC,,,both,,,20792.02,6237.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2463.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1566.32,17673.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 80MM 80CM 7MM 8FR STRAIGHT VASCULAR",SUP-AVSM07080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4932.9,27,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Not Feeynolm 12.6-20cm",PX-450000022,CDM,12005,CPT,0361,RC,,,both,,,1625.00,487.5,"CIGNA [10200]","Cigna Local Plus",,1625,,"Case rate ($2,587). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,188.99,1625,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 4965-15  LEAD-UNI EPI STEROID 15CM",SUP-4965-15,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"AETNA [10100]","Aetna HMO/PPO",,4457.57,79.5,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 24MM 8MM STAINLESS STEEL LONG THREAD FOOT HAND",SUP-02.226.124,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"FIRST HEALTH [10303]","First Health",,1316.16,80,,,,,0,191.34,1398.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 4FR MERIT MAK COAXIAL PAIR MINI ACCESS",SUP-MAK4F-10,CDM,C1894,HCPCS,0272,RC,,,both,,,152.25,45.67,"AETNA [10100]","Aetna HMO/PPO",,121.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.71,129.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 18MM 135CM 5MM 3.3-2.9FR VASCULAR COCR",SUP-1011493-18,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"BLUE CROSS [10001]","Blue Cross HMO",,2469.6,39.2,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL CERVICAL C-ACS 6 DEGREE 14MM X 16MM",SUP-4W7610,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"BLUE CROSS [10001]","Blue Cross HMO",,2704.8,39.2,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 6MM GRAFTECH LARGE LORDOTIC CORTICAL",SUP-4421406,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT SCORPION SUREFIRE ROTATOR CUFF",SUP-AR-13991N,CDM,S27000186,LOCAL,0270,RC,,,both,,,1190.70,357.21,"AETNA [10100]","Aetna HMO/PPO",,946.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,138.48,1012.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 135CM 4CM 5FR 9MM 7.5MM BALLOON DILATATION",SUP-4209040X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Screen Group B Strep",PX-306000057,CDM,87081,CPT,0306,RC,,,both,,,419.90,125.97,"PHCS [10601]",PHCS,,293.93,70,,,,,0,0.01,356.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 55MM 13MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113613,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"PHCS [10601]",PHCS,,8820,70,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT GLAUCOMA ISTENT RIGHT STERILE LATEX FREE DISPOSABLE",SUP-GTS100R,CDM,C1783,HCPCS,0278,RC,,,both,,,10695.00,3208.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1267.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1243.83,9090.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ORTHOLOC FULL THREAD CANCELLOUS ANKLE FOOT",SUP-58934012,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,220.23,28.62,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIASSIST 24IN 36IN DRUG DELIVERY 60ML GAS",SUP-AA0608,CDM,S27000186,LOCAL,0270,RC,,,both,,,769.50,230.85,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,523.26,68,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 135CM 4CM 4MM BALLOON DILATATION",SUP-DR13544,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"KAISER [10500]",Kaiser,,922.59,67,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE DIAMONDTOUCH 35 ATM INFLATION 30ML DIGITAL SYR BARREL",SUP-IN9135,CDM,S27200284,LOCAL,0272,RC,,,both,,,456.19,136.86,"NOVANET [10819]",Novanet,,342.14,75,,,,,0,53.05,387.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 54MM 36MM ALTRX HIP",SUP-122136454,CDM,C1776,HCPCS,0278,RC,,,both,,,6814.08,2044.22,"FIRST HEALTH [10303]","First Health",,5451.26,80,,,,,0,792.48,5791.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP6PL,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"NOVANET [10819]",Novanet,,16126.43,75,,,,,0,2500.67,18276.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE AUGMENTATION 14MM CORTICAL INTERSPINOUS PROCESS",SUP-4578114,CDM,S27800098,LOCAL,0278,RC,,,both,,,19921.48,5976.44,"NOVANET [10819]",Novanet,,14941.11,75,,,,,0,2316.87,16933.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X7MM FORGE CERVICAL",SUP-865.307S,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FABRIC CARDIOVASCULAR 12X12CM PRECLUDE THK.1MM PERICARDIUM",SUP-1PCM102,CDM,S27800098,LOCAL,0278,RC,,,both,,,5830.50,1749.15,"AETNA [10100]","Aetna HMO/PPO",,4635.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.09,4955.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 8MM 4MM BALLOON DILATATION DURATRAC",SUP-NCEUP4008X,CDM,C1725,HCPCS,0272,RC,,,both,,,550.80,165.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,64.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.06,468.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 18MM 4MM CORONARY STENT EVEROLIMUS",SUP-1550400-18,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 40MM 125CM 6MM 5FR .018IN VASCULAR NITINOL",SUP-G43771,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"NOVANET [10819]",Novanet,,3134.25,75,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 29MM RESTORATION +0MM STD HIP MODULAR REVISION",SUP-6276-1-029,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"FIRST HEALTH [10303]","First Health",,17803.8,80,,,,,0,2588.23,18916.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR LAPAROSCOPIC ENDOWRIST DA VINCI S/SI 2 BLADE",SUP-420249,CDM,S27000186,LOCAL,0270,RC,,,both,,,2212.50,663.75,"PHCS [10601]",PHCS,,1548.75,70,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR SYMMETRY UNIVERSAL RING HORIZONTAL BAR SURGICAL",SUP-58-0004,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL TORIC UV ABSORBENT CLAREON",SUP-CCW0T6,CDM,V2787,HCPCS,0276,RC,,,both,,,355.00,106.5,"FIRST HEALTH [10303]","First Health",,284,80,,,,,0,41.29,301.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 0D E HIP CROSSFIRE TRIDENT",SUP-621-10-36E,CDM,C1776,HCPCS,0278,RC,,,both,,,5690.16,1707.05,"CIGNA [10200]","Cigna Local Plus",,3044.24,53.5,,5372.07,4581.20,7242.98,23,661.77,4836.64,"percent of total billed charges",
"CATH TORCON NB ADVANTAGE BEACON TIP 80CM 5FR CHG-B CURVE",SUP-G13560,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Drng Vacuum Bottle Pleurx",PX-HHE27200401,CDM,C1729,LOCAL,0272,RC,,,outpatient,,,422.00,126.6,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 6X250 80CM SL",SUP-48006025N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 7FR .092IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1007,CDM,C1894,HCPCS,0272,RC,,,both,,,255.78,76.73,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TAKERU 8MM 3.25MM BALLOON DILATATION PTCA",SUP-DC-RZ3208UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TORCON NB ADVANTAGE 90CM 5FR RBT CURVE ANGIOGRAPHIC",SUP-G47159,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH STERLING 150CM 40MM 3.5MM BALLOON DILATATION PEBAX",SUP-H74939032350410,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Phenytoin Free",PX-301000050,CDM,80186,CPT,0301,RC,,,both,,,211.90,63.57,"CIGNA [10200]","Cigna Local Plus",,30.27,,,,,,,0.01,180.12,"fee schedule",
"AUG FEMORAL 4MM ATTUNE 5 KNEE POSTERIOR CEMENT REVISION",SUP-154905001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"PHCS [10601]",PHCS,,4250.4,70,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT TKR 93 CAP EXTRA",SUP-98000200197,CDM,C1776,HCPCS,0278,RC,,,both,,,25830.00,7749,"CIGNA [10200]","Cigna Open Access",,8653.05,33.5,,5302.19,4377.88,6578.61,27,3004.03,21955.5,"percent of total billed charges",
"CATH ACUITY CUT-AWAY 74CM 6FR 90D GUIDING INNER",SUP-7038,CDM,C1887,HCPCS,0272,RC,,,both,,,1579.50,473.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,183.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 6 12MM KNEE AOX REVISION CRUCIATE SUBSTITUTE R",SUP-151710612,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1720.5,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 32CM 14.5FR STRAIGHT DURATHANE EVENMORE BASIC",SUP-H787103035035,CDM,C1750,HCPCS,0278,RC,,,both,,,1385.10,415.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,164.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Albumin Other Source",PX-301000089,CDM,82042,CPT,0301,RC,,,both,,,184.30,55.29,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7,,,,,,,0.01,156.66,"fee schedule",
"BEARING 79/83MMX16MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183566,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"BLUE CROSS [10001]","Blue Cross HMO",,5077.45,39.2,,5311.50,4717.44,5388.59,31,1506.4,11009.78,"percent of total billed charges",
"KIT BIOPSY 10CM 18GA BARD MARQUEE CORE DISPOSABLE",SUP-MQK1810,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.20,174.96,"CIGNA [10200]",Cigna,,396.58,68,,,,,0,67.83,495.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 56MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.756,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"CIGNA [10200]",Cigna,,764.07,68,,1831.33,1831.33,1831.33,16,130.68,955.09,"percent of total billed charges",
"CATH GUIDER SOFTIP XF 90CM 5FR MP CURVE GUIDING DURAFORM",SUP-M003100630,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"KAISER [10500]",Kaiser,,1677.1,67,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT BIORAPTOR SHOULDER KNOTLESS INNER LOCK PLUG",SUP-72202403,CDM,C1713,HCPCS,0278,RC,,,both,,,2212.88,663.86,"CIGNA [10200]","Cigna Open Access",,1259.13,56.9,,1144.80,304.56,2275.09,66,257.36,1880.95,"percent of total billed charges",
"BASEPLT TIBIAL TRIATHLON 5 LEFT MEDIAL RIGHT LATERAL PARTIAL",SUP-5620-B-501,CDM,C1776,HCPCS,0278,RC,,,both,,,6899.26,2069.78,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3166.76,45.9,,,,,0,802.38,5864.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATH NUVISION NAV 10FR ULTRASOUND STERILE LATEX FREE",SUP-FG11656,CDM,C1759,HCPCS,0272,RC,,,both,,,0.01,,"FIRST HEALTH [10303]","First Health",,0.01,80,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL MULTIPASS 4-0 PC-5 18IN BRAID COATED UNDYED",SUP-J823G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]",Cigna,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VENTRALIGHT ST SEPRA ECHO PS 6IN MONOFILAMENT",SUP-5955600,CDM,C1781,HCPCS,0278,RC,,,both,,,3360.00,1008,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,390.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,390.77,2856,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 8.5FR 2.5IN RIC ARROW-FLEX 13 1/8IN .025IN STRAIGHT",SUP-RC-09850,CDM,C1876,HCPCS,0278,RC,,,both,,,93.26,27.98,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.85,79.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM STD",SUP-M7-025,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5953.5,27,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOBRAMYCIN 40 MG/ML INJECTION SOLUTION",RX-97790,CDM,J3260,HCPCS,0636,RC,67457-0428-00,NDC,both,30,ML,197.28,59.18,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,60.6,,,,,,,36.47,167.69,"fee schedule",
"SPACER ALLOGRAFT 12.5X15X9MM PRECISION 7D TRAPEZOID SPINE",SUP-7409,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 5.5MM TITANIUM CURVE CIRCLE INTRALUMINAL",SUP-CDH33A,CDM,S27200284,LOCAL,0272,RC,,,both,,,5683.28,1704.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3864.63,68,,,,,0,660.97,4830.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REINFORCEMENT STAPLE LINE BIOABSORBABLE STERILE SEAMGUARD",SUP-12BSGEC45,CDM,S27200284,LOCAL,0272,RC,,,both,,,1242.00,372.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,570.08,45.9,,,,,0,144.44,1055.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 6FR 4MM 4FR BALLOON",SUP-H74939031404010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 24MM 12/10/8/8MM HEMASHIELD PLATINUM",SUP-M00202175724AP0,CDM,L8670,HCPCS,0278,RC,,,both,,,12405.37,3721.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5098.61,41.1,,,,,0,427.53,10544.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 30MMX4.8MM PI TITANIUM LARGE THICK TISSUE",SUP-4908T,CDM,S27200284,LOCAL,0272,RC,,,both,,,392.20,117.66,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,180.02,45.9,,,,,0,45.61,333.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 74.9X49.3X25MM MBT 4+ MM KNEE CEMENTED REVISION",SUP-129435425,CDM,C1776,HCPCS,0278,RC,,,both,,,35980.56,10794.17,"CIGNA [10200]",Cigna,,14392.22,40,,5873.17,5873.17,5873.17,"1 through 10",4184.54,30583.48,"percent of total billed charges",
"CATH ULTRAVERSE CHECKER 130CM 15CM 5MM BALLOON DILATATION",SUP-U8130515,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RED 128CM REPERFUSION RED 62 KIT PENUMBRA ASPIRATION",SUP-RED62SKIT,CDM,C1757,HCPCS,0272,RC,,,both,,,17608.50,5282.55,"NOVANET [10819]",Novanet,,13206.38,75,,,,,0,2047.87,14967.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cr Cytogenetics 100-300 Cells",PX-300000043,CDM,88275,CPT,0310,RC,,,both,,,474.50,142.35,"PHCS [10601]",PHCS,,332.15,70,,,,,0,0.01,403.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 21MM +20MM HIP MODULAR REVISION BOLT",SUP-6276-1-221,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4140.4,28.62,,,,,0,1682.49,12296.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 5.5IN CASTROVIEJO DELICATE LOCK NDL STRAIGHT WIDE",SUP-60-1918,CDM,S27200284,LOCAL,0272,RC,,,both,,,1175.88,352.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,483.29,41.1,,,,,0,136.75,999.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 80MM 135CM 7MM VASCULAR OTW SELF EXPAND",SUP-1012535-80,CDM,C1876,HCPCS,0278,RC,,,both,,,8799.00,2639.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5983.32,68,,,,,0,1023.32,7479.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRGMR NEROSTIMLTR ACTIVA PATIENT ANTENNA DETERMINED DEEP",SUP-37092,CDM,C1787,HCPCS,0270,RC,,,both,,,607.50,182.25,"MULTIPLAN [10600]",Multiplan,,516.38,85,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 20FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0167SI20,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.45,32.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,49.32,45.9,,,,,0,12.5,91.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) SYSTEM TRUFILL EMBOLIC 1GM KIT LIQUID",SUP-631500,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 250MM 3.5MM BALLOON DILATATION",SUP-48003525S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"FIRST HEALTH [10303]","First Health",,1101.6,80,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOPIRAMATE 25 MG TABLET",RX-18920,CDM,,,0637,RC,68084-0342-11,NDC,both,1,UN,10.56,3.17,"CIGNA [10200]",Cigna,,7.18,68,,,,,0,1.23,8.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL NATRELLE HIGH PROFILE STYLE 20 RESTERILIZABLE GEL",SUP-MSZ20550,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 85MM STAINLESS STEEL 3.5MM SCREWS SMALL FRAGMENT SET 3",SUP-241.061,CDM,C1713,HCPCS,0278,RC,,,both,,,2429.70,728.91,"BLUE CROSS [10001]","Blue Cross PPO",,952.44,39.2,,957.42,570.23,957.42,28,282.57,2065.25,"percent of total billed charges",
"ROD SPINAL 35MM 4.75MM CD HORIZON SOLERA COCRMO CAP",SUP-641003035,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"INTRO ENDOSCOPIC 8.5FR 5FR 195CM 1 ACTION RADIOPAQUE GUIDE",SUP-G31526,CDM,S27200284,LOCAL,0272,RC,,,both,,,1085.40,325.62,"FIRST HEALTH [10303]","First Health",,868.32,80,,,,,0,126.23,922.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 41MM ADJUSTABLE FULL FLEXIBLE RADIOPAQUE",SUP-AFR-41,CDM,S27800098,LOCAL,0278,RC,,,both,,,16909.83,5072.95,"FIRST HEALTH [10303]","First Health",,13527.86,80,,,,,0,1966.61,14373.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eval Swallow Func",PX-444000006,CDM,92610,CPT,0444,RC,,,both,,,592.51,177.75,"KAISER [10500]",Kaiser,,396.98,67,,,,,0,68.91,503.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH TOOL MIS HARDWARE STERILE",SUP-P65-001-0002-SK,CDM,S27200284,LOCAL,0272,RC,,,both,,,14683.20,4404.96,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET 35CM 22FR MALECOT NEPHRSTMY CATH STYLET RETENTION DISK",SUP-G14437,CDM,C1729,HCPCS,0272,RC,,,both,,,836.73,251.02,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cr Cytogenetics 100-300 Cells",PX-300000043,CDM,88275,CPT,0310,RC,,,both,,,474.50,142.35,"FIRST HEALTH [10303]","First Health",,379.6,80,,,,,0,0.01,403.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Head/Brain WO Cntrst",PX-351000002,CDM,70450,CPT,0351,RC,,,both,,,2782.72,834.82,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,742,,,,,,,261.88,2365.31,"per diem",
"SNARE VASCULAR 47IN .47-.79IN 6FR EN SNARE STD 3 LOOP",SUP-EN2006020,CDM,C1773,HCPCS,0272,RC,,,both,,,2520.00,756,"AETNA [10100]","Aetna HMO/PPO",,2003.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,293.08,2142,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY",RX-16071,CDM,,,0250,RC,60505-0827-01,NDC,both,15,ML,602.05,180.61,"AETNA [10100]","Aetna HMO/PPO",,478.63,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.02,511.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 10 5MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151641005,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PHCS [10601]",PHCS,,7877.73,70,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 70-79CM SAPHENOUS VEIN","SUP-V010 70-79",CDM,C1768,HCPCS,0278,RC,,,both,,,59585.40,17875.62,"BLUE CROSS [10001]","Blue Cross HMO",,23357.48,39.2,,,,,0,6929.78,50647.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 24CM 3CM 5FR .035IN",SUP-M006192122190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,162.27,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,162.27,1185.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAC 120CM 6.3FR .07IN GUIDING DISTAL ACCESS STERILE",SUP-90771,CDM,S27200284,LOCAL,0272,RC,,,both,,,9066.95,2720.08,"CIGNA [10200]","Cigna Local Plus",,4850.82,53.5,,,,,0,1054.49,7706.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SENTAI HORNET 10 VASCULAR 190CM 15CM .008IN STAINLESS",SUP-H749393041902,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sars Cov-2 Antibody Qn",PX-302000239,CDM,86413,CPT,0302,RC,,,both,,,228.00,68.4,"CIGNA [10200]","Cigna Open Access",,129.73,56.9,,,,,0,13.35,193.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SECONDARY DELIVERY CATHETER, DISTAL",SUP-4850-03,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL F KNEE RIGHT LPS-FLEX GENDER SOLUTIONS OPT",SUP-00576401652,CDM,C1776,HCPCS,0278,RC,,,both,,,21833.28,6549.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2539.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2539.21,18558.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZINC OXIDE 20 % TOPICAL OINTMENT",RX-8874,CDM,,,0250,RC,75834-0170-01,NDC,both,28.4,GR,41.27,12.38,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PUSHER STENT ADVANIX PANCREATIC RAPID EXCHANGE 4FR 5FR",SUP-M00535010,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE ELECTROSURGICAL 3MM OPES 90D LOW PROFILE ASPIRATE",SUP-AR-9703A-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPN NC 15MM 4MM 35 ATM BALLOON DILATATION THIN WALL LOW",SUP-400-015-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN OPHTHALMIC CONSTELLATION TOTAL PLUS PAK 7500 CPM",SUP-8065751617,CDM,S27200284,LOCAL,0272,RC,,,both,,,4568.84,1370.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1877.79,41.1,,,,,0,531.36,3883.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cystatin C",PX-301000460,CDM,82610,CPT,0301,RC,,,both,,,487.35,146.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,57.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,414.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cta Abdomen W/WO Cntrst",PX-352000027,CDM,74175,CPT,0352,RC,,,both,,,4140.04,1242.01,"PHCS [10601]",PHCS,,2898.03,70,,,,,0,405,3519.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SHARPOINT MET 9-0 DRM5 13CM MONOFILAMENT BLACK",SUP-AA-0112,CDM,S27200284,LOCAL,0272,RC,,,both,,,460.45,138.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,54.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.55,391.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 100MM 125CM 7MM 6FR BILIARY NITINOL",SUP-G50168,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"BLUE CROSS [10001]","Blue Cross HMO",,2387.28,39.2,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28MMX10MM X-PAC PARALLEL",SUP-EI2500P,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 75MM 5.5MM EXPEDIUM PREBENT TITANIUM LINE",SUP-179771075,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 22CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175261190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"CIGNA [10200]","Cigna Local Plus",,676.98,,,,,,,147.16,1075.57,"percent of total billed charges",
"KIT SNARE AMPLATZ GOOSENECK 90D MICRO 175CM 2.3-3FR 2MM CATH",SUP-SK200,CDM,C1773,HCPCS,0272,RC,,,both,,,4140.00,1242,"AETNA [10100]","Aetna HMO/PPO",,3291.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183462,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,929.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) INTREPID TRANSFEMORAL SUPPORT PLATE",SUP-INTPDTFSPG,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mgmt Diabetes Indv per 30min",PX-942000007,CDM,G0108,HCPCS,0942,RC,,,both,,,131.07,39.32,"PHCS [10601]",PHCS,,91.75,70,,,,,0,15.24,131.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 3MM CORONARY STENT",SUP-1125300-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"MULTIPLAN [10600]",Multiplan,,4962.3,85,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 5.5IN 12GA AORTIC ROOT ADULT ANTEGRADE INTRO",SUP-20012,CDM,S27200284,LOCAL,0272,RC,,,both,,,196.65,58.99,"FIRST HEALTH [10303]","First Health",,157.32,80,,,,,0,22.87,167.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERFLEX P3 110CM 2CM 5FR 12MM 7.5MM BALLOON",SUP-4202020L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH X-FORCE U30 4CM 6FR 6MM BALLOON DILATATION TUNGSTEN",SUP-997604,CDM,C1726,HCPCS,0272,RC,,,both,,,1909.58,572.87,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1298.51,68,,,,,0,222.08,1623.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CAP AEQ RVS FX (INC RVS FX STM,RVS FX INSERT,RVS I OR II",SUP-CAP10102,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5375.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,5275.37,38556,"percent of total billed charges",
"CATH IMPULSE 100CM 6FR FL4.5 CURVE ANGIOGRAPHIC FEMORAL 2",SUP-H74916599230,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,31.47,41.1,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN",RX-30510,CDM,,,0250,RC,00487-0201-01,NDC,both,3,ML,13.89,4.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.62,11.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US BPP W Nonstress Test",PX-402000023,CDM,76818,CPT,0402,RC,,,both,,,1663.12,498.94,"FIRST HEALTH [10303]","First Health",,1330.5,80,,,,,0,108.79,1413.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 8MM TITANIUM T4 HAND SELF TAP VARIABLE ANGLE",SUP-04.130.208,CDM,C1713,HCPCS,0278,RC,,,both,,,925.34,277.6,"FIRST HEALTH [10303]","First Health",,740.27,80,,,,,0,107.62,786.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 9MM 140CM 3.5MM CORONARY",SUP-RSINT35009UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"FIRST HEALTH [10303]","First Health",,4435.2,80,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nasal Smear for Eosinophils",PX-309000106,CDM,89190,CPT,0309,RC,,,both,,,108.00,32.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16.85,,,,,,,0.01,91.8,"fee schedule",
"COIL EMBOLIZATION 4CM 2MM DELTAXSFT 10 COIL",SUP-DLX100204,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"BLUE CROSS [10001]","Blue Cross HMO",,3548.7,39.2,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 65MM AXSOS STAINLESS STEEL FEMUR HUMERUS TIBIA",SUP-371565,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"CIGNA [10200]","Cigna Local Plus",,476.69,53.5,,3978.14,359.25,3978.14,24,103.62,757.35,"percent of total billed charges",
"GRAFT VASCULAR 40CM 7MM GORE INTERING THIN WALL PTFE RADIAL",SUP-IRST07040040L,CDM,C1768,HCPCS,0278,RC,,,both,,,6348.00,1904.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,752.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,738.27,5395.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 10CM 75CM 8MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR081001A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"CIGNA [10200]","Cigna Local Plus",,6699.67,31.5,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RISPERIDONE 0.25 MG TABLET",RX-25519,CDM,,,0637,RC,68084-0270-01,NDC,both,1,UN,19.58,5.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.28,16.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 15MM 2.75MM BALLOON DILATATION PEBAX",SUP-1012406-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 5 UNIVERSAL KNEE TOTAL STABILIZED",SUP-5521-B-500,CDM,C1776,HCPCS,0278,RC,,,both,,,10384.92,3115.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7061.75,68,,,,,0,1207.77,8827.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1CM 1MM PRESTIGE PLUS HELICAL EXTRA PACK",SUP-PRES0103CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLGRAFT 30MM 90CM 7MM 9FR 116CM",SUP-M001705730,CDM,C1874,HCPCS,0278,RC,,,both,,,15566.40,4669.92,"AETNA [10100]","Aetna HMO/PPO",,12375.29,79.5,,,,,0,1810.37,13231.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL CUSHING STRAIGHT 8IN THORACIC CARDIOVASCULAR",SUP-130445,CDM,S27200284,LOCAL,0272,RC,,,both,,,222.55,66.76,"CIGNA [10200]","Cigna Local Plus",,119.06,53.5,,,,,0,25.88,189.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP GLOBAL UNITE REVER",SUP-OSC379179,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"UHC [10700]","United Healthcare",,28712.88,63.3,,8601.07,8395.67,8601.07,"1 through 10",5275.37,38556,"percent of total billed charges",
"CMPNT FEMORAL 1 RIGHT KNEE POSTERIOR STABILIZED CEMENTED",SUP-5515F102,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1163,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL INSUFFLATION 150MM 13GA VERRES PNEUMOPERITONEUM STERILE",SUP-C2202,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.10,33.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,46.48,41.1,,,,,0,13.15,96.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 6MM FLIXENE SLIDER GRADUATED WALL",SUP-25125,CDM,C1768,HCPCS,0278,RC,,,both,,,7174.62,2152.39,"BLUE CROSS [10001]","Blue Cross PPO",,2812.45,39.2,,,,,0,834.41,6098.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX 30MM 135CM 9MM VASCULAR NITINOL CAROTID",SUP-PC0930RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,9418.50,2825.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1116.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1095.37,8005.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO 1000093011 OPTISEAL GLBL9FR25CM",SUP-1000093011,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ICD-DR DDMB1D4 EVERA MRI XT IS-1/DF4 US",SUP-DDMB1D4,CDM,C1721,HCPCS,0278,RC,,,both,,,40560.00,12168,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4806.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4717.13,34476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 4.5MM CANNULATED",SUP-AR-1204.5L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1564.92,469.48,"CIGNA [10200]",Cigna,,1064.15,68,,,,,0,182,1330.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 20MM 5MM BASE TITANIUM FIX ANGLE NONSTERILE",SUP-6955201,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Local Plus",,866.7,53.5,,3978.14,359.25,3978.14,24,188.41,1377,"percent of total billed charges",
"TUBE VENTILATION 1.02MM PAPARELLA EAR STERILE",SUP-24441,CDM,S27800098,LOCAL,0278,RC,,,both,,,242.64,72.79,"CIGNA [10200]","Cigna Open Access",,138.06,56.9,,,,,0,28.22,206.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8-6.5MM 40MM CREO SPINE 2 OUTER DIAMETER",SUP-5119.2242,CDM,C1713,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 20MM 5MM BASE TITANIUM FIX ANGLE NONSTERILE",SUP-6955201,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross PPO",,635.04,39.2,,957.42,570.23,957.42,28,188.41,1377,"percent of total billed charges",
"STENT ONYX FRONTIER 22MM 3MM CORONARY RAPID EXCHANGE STERILE",SUP-ONYXNG30022UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2700.00,810,"CIGNA [10200]","Cigna Open Access",,1536.3,56.9,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 16.5IN 15FR 18GA .038IN PTFE NEXTSTEP SMARTSEAL",SUP-CS-15422-SFX,CDM,C1750,HCPCS,0278,RC,,,both,,,2062.50,618.75,"BLUE CROSS [10001]","Blue Cross PPO",,808.5,39.2,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +0MM 22MM HIP C TAPER COCR LFIT",SUP-06-2200,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"KAISER [10500]",Kaiser,,2095.56,67,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPR LD 14CM BP CNCT TO BP",SUP-501206,CDM,C1883,HCPCS,0278,RC,,,both,,,1830.00,549,"CIGNA [10200]",Cigna,,1244.4,68,,,,,0,212.83,1555.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPERCROSS 130CM 80CM 2.4-3.2FR .017-.018IN 90D MICRO",SUP-5304,CDM,C1887,HCPCS,0272,RC,,,both,,,3740.00,1122,"UHC [10700]","United Healthcare",,2367.42,63.3,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 8-11 E-F",SUP-42-5121-008-11,CDM,C1776,HCPCS,0278,RC,,,both,,,9466.80,2840.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2709.4,28.62,,,,,0,1100.99,8046.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIBRILLATOR 65CM 8FR OPTISURE ENDOCARDIUM 2 COIL DF1",SUP-LDA220-65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4636.44,27,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 11MM UNIVERS APEX OPTIFIT",SUP-AR-9100-11M,CDM,C1776,HCPCS,0278,RC,,,both,,,26302.50,7890.75,"KAISER [10500]",Kaiser,,17622.68,67,,,,,0,3058.98,22357.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE POSTERIOR STABILIZED TRIATHLON",SUP-5532P211,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2391.46,28.62,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CELEROMARK 12GA BREAST BIOPSY INTRO","SUP-CELERO INTRO-12",CDM,S27200284,LOCAL,0272,RC,,,both,,,177.22,53.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.61,150.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT LAPAROSCOPIC ROTATION DIAL ERGONOMIC HANDLE CURVE JAW",SUP-CY010,CDM,S27200284,LOCAL,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TFNT40 PANOPTIX TORIC",SUP-TFNT40,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,387.86,45.9,,,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3IN HEADLESS",SUP-6541-4-003,CDM,C1713,HCPCS,0278,RC,,,both,,,1683.75,505.12,"MULTIPLAN [10600]",Multiplan,,1431.19,85,,,,,0,195.82,1431.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 14MM TITANIUM FULL THREAD T10 HEXALOBE FOREFOOT",SUP-AR-8933L-14,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,141.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",141.3,1032.75,"percent of total billed charges",
"SUT FIBERWIRE 5 T-5 CCS-1 38IN BRAID TIES MULTISTRAND LOWER",SUP-AR-7213,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"FIRST HEALTH [10303]","First Health",,292.32,80,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRA-THIN/SDS 75CM 20MM 5.3FR 6MM STD LOW PROFILE",SUP-M001176160,CDM,C1725,HCPCS,0272,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 90MM CD HORIZON SPINE MULTIAXIAL CANNULATED",SUP-25840017590,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH ARTHROSCOPIC 4.5 MM CORKSCREW 4.5 MM PUSHLOCK FULL",SUP-AR-1922P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1615.95,484.78,"KAISER [10500]",Kaiser,,1082.69,67,,,,,0,187.93,1373.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VIATRAC 14 PLUS 135CM 15MM 3.3-3.6FR 4.5MM BALLOON",SUP-1008191-15,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"MULTIPLAN [10600]",Multiplan,,1204.88,85,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 24CM 18FR AXILLARY AORTA SUBCLAVIAN 3/8IN",SUP-OPTI18,CDM,S27200284,LOCAL,0272,RC,,,both,,,2550.00,765,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1734,68,,,,,0,296.57,2167.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 LEFT KNEE CRUCIATE RETAINING CEMENTED",SUP-5510-F-501,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"AETNA [10100]","Aetna HMO/PPO",,13036.29,79.5,,10981.53,8986.79,12413.38,12,1907.07,13938.17,"percent of total billed charges",
"CATH CPS DIRECT PL SITEMARK 58CM 54CM 9FR 7FR WIDE CURVE",SUP-410184,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"KAISER [10500]",Kaiser,,2487.38,67,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 9MM APTUS TITANIUM 6MM HEAD HAND CORTICAL LOCK",SUP-A-5400.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"PHCS [10601]",PHCS,,884.52,70,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (MR)  2.00MM X 6MM",SUP-H74939401062000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"KAISER [10500]",Kaiser,,3629.06,67,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INNATE IMPLANT 3.6MM X 40MM",SUP-EXINN923640,CDM,C1713,HCPCS,0278,RC,,,both,,,5347.50,1604.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3636.3,68,,,,,0,621.91,4545.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 140MM 10-14MM 13FR 10FR TRIVASCULAR OVATION",SUP-TV-IL1410140-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3956.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS LARGE BLOCK 20X20MM",SUP-800101,CDM,S27800098,LOCAL,0278,RC,,,both,,,5255.04,1576.51,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,622.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,611.16,4466.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLUE FLEXTIP 8IN 7FR CENTRAL VENOUS POLYURETHANE 2",SUP-ML-00702,CDM,C1751,HCPCS,0272,RC,,,both,,,241.86,72.56,"UHC [10700]","United Healthcare",,153.1,63.3,,,,,0,28.13,205.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25X10X10MM VERTE-STACK CRESCENT 6D",SUP-9192510,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4471.2,27,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH LONG 105CM .079IN 10.7FR INTRO RADIAL",SUP-107F-079-105,CDM,C1894,HCPCS,0272,RC,,,both,,,8093.70,2428.11,"PHCS [10601]",PHCS,,5665.59,70,,,,,0,941.3,6879.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 7-8 11MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934388,CDM,C1776,HCPCS,0278,RC,,,both,,,18947.25,5684.17,"CIGNA [10200]","Cigna Open Access",,6347.33,33.5,,5302.19,4377.88,6578.61,27,2203.57,16105.16,"percent of total billed charges",
"CAGE SPINAL 55MMX16MM CLYDESDALE 6D PEEK RADIOPAQUE HOLLOW",SUP-2968655,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 15MM KNEE AOX STABILIZE ROTATE PLATFORM SIGMA",SUP-196192143,CDM,C1776,HCPCS,0278,RC,,,both,,,13386.00,4015.8,"MULTIPLAN [10600]",Multiplan,,11378.1,85,,,,,0,1556.79,11378.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE TITANIUM 6 HOLE STAR LOCKING BONE STERNAL NONSTERILE",SUP-460.035,CDM,C1713,HCPCS,0278,RC,,,both,,,7471.87,2241.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2138.45,28.62,,,,,0,868.98,6351.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHAMFERED SCREW 4.0MM X 42MM",SUP-FX-CS-4142,CDM,C1713,HCPCS,0278,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross HMO",,3245.76,39.2,,957.42,156.86,7483.26,51,962.96,7038,"percent of total billed charges",
"COIL EMBOLIZATION 7-3MM TORNADO MICROCOIL PLATINUM FIBER",SUP-G47420,CDM,S27800098,LOCAL,0278,RC,,,both,,,931.42,279.43,"FIRST HEALTH [10303]","First Health",,745.14,80,,,,,0,108.32,791.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 18FR URETHRAL BACTI-GUARD RUBBER HYDROGEL 5CC",SUP-0102SI18,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.46,38.84,"KAISER [10500]",Kaiser,,86.74,67,,,,,0,15.06,110.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Orbit/Ear/Fossa WO Cntrst",PX-351000005,CDM,70480,CPT,0351,RC,,,both,,,3044.68,913.4,"UHC [10700]","United Healthcare",,261.88,,,,,,,261.88,2587.98,"fee schedule",
"CATH EZ STEER DS REDEL 115CM 8MM 7FR 1-7-4MM SPACE J-J CURVE",SUP-BD7TCJJ8L,CDM,C1733,HCPCS,0272,RC,,,both,,,8700.90,2610.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1031.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1011.91,7395.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL PEDIATRIC 1.5-2IN PATRIOT PROCARE SPINE 1",SUP-79-83130,CDM,S27000186,LOCAL,0270,RC,,,both,,,51.33,15.4,"PHCS [10601]",PHCS,,35.93,70,,,,,0,5.97,43.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 14.7MM 21MM 26MM 19.4MM ON-X 21 STD CYLINDRICAL",SUP-ONXAE-21,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10818.36,28.62,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL ARTHREX UNIVERS REVERS 6 SHOULDER STERILE",SUP-AR-9501-06P,CDM,C1776,HCPCS,0278,RC,,,both,,,10557.00,3167.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1227.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1227.78,8973.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 24MM LCP TITANIUM DISTAL VOLAR RADIUS LOCKING",SUP-04.210.124,CDM,C1713,HCPCS,0278,RC,,,both,,,1063.69,319.11,"CIGNA [10200]",Cigna,,723.31,68,,1831.33,1831.33,1831.33,16,123.71,904.14,"percent of total billed charges",
"PLATE 93MM 3.5MM SCR 4 HOLE LCP BONE TIBIA LEFT PROXIMAL",SUP-239.955S,CDM,C1713,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"UHC [10700]","United Healthcare",,5503.3,63.3,,5023.51,2672.93,6679.78,18,1011.11,7389.9,"percent of total billed charges",
"SCR BONE 5MM 34MM RSP SHOULDER LOCK GLENOID BASEPLT",SUP-506-03-134,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"CIGNA [10200]",Cigna,,1057.88,68,,1831.33,1831.33,1831.33,16,180.93,1322.35,"percent of total billed charges",
"CMPNT FEMORAL XS KNEE AVON",SUP-6430-0-050,CDM,C1776,HCPCS,0278,RC,,,both,,,22635.90,6790.77,"CIGNA [10200]","Cigna Local Plus",,7130.31,31.5,,5372.07,4581.20,7242.98,23,2632.56,19240.52,"percent of total billed charges",
"INSRT ACETABULAR 54MM 28MM HIP ANATOMIC DUAL MOBILITY X3",SUP-1236-2-854,CDM,C1776,HCPCS,0278,RC,,,both,,,7518.42,2255.53,"NOVANET [10819]",Novanet,,5638.82,75,,,,,0,874.39,6390.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION AVENIR STERILE LATEX FREE DISPOSABLE",SUP-10USC02506,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5374.03,41.1,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT EVO 15MM 3.5MM BALLOON DILATATION",SUP-2200-3515-B,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"KAISER [10500]",Kaiser,,3929.55,67,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 11MM KNEE X3 CONDYLAR STABILIZED PRIMARY",SUP-5531G411,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3849.46,41.1,,6417.48,6417.48,6417.48,"1 through 10",1089.28,7961.17,"percent of total billed charges",
"STEM EXT 60MM 16MM ATTUNE KNEE PRESS FIT REVISION STERILE",SUP-151316060,CDM,C1776,HCPCS,0278,RC,,,both,,,8266.20,2479.86,"KAISER [10500]",Kaiser,,5538.35,67,,,,,0,961.36,7026.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION DETACHABLE PLATE TEMPORARY NONSTERILE",SUP-389.873,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM STAINLESS STEEL SMALL FRAGMENT SET 4 HOLE 1/3",SUP-241.341,CDM,C1713,HCPCS,0278,RC,,,both,,,1149.80,344.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,329.07,28.62,,,,,0,133.72,977.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 3.0/30",SUP-401768,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE PIN KIT",SUP-AR-9507S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2940.00,882,"KAISER [10500]",Kaiser,,1969.8,67,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 9MM KNEE RIGHT MEDIAL LEFT LATERAL X3 PARTIAL",SUP-5630-G-629,CDM,C1776,HCPCS,0278,RC,,,both,,,5309.55,1592.86,"AETNA [10100]","Aetna HMO/PPO",,4221.09,79.5,,10981.53,8986.79,12413.38,12,617.5,4513.12,"percent of total billed charges",
"WEDGE TIBIAL 13MM PFC SIGMA 20D 2 HEMI KNEE TITANIUM MODULAR",SUP-860172,CDM,C1776,HCPCS,0278,RC,,,both,,,8260.68,2478.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2364.21,28.62,,,,,0,960.72,7021.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 9MM KNEE RIGHT MEDIAL LEFT LATERAL X3 PARTIAL",SUP-5630-G-629,CDM,C1776,HCPCS,0278,RC,,,both,,,5309.55,1592.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1519.59,28.62,,,,,0,617.5,4513.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM .02IN 16MM PENUMBRA COIL 400 RUBY",SUP-RBY4C1650,CDM,S27800098,LOCAL,0278,RC,,,both,,,7098.00,2129.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3257.98,45.9,,,,,0,825.5,6033.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 10CM 4FR 21GA MERIT MAK .018IN STAINLESS STEEL",SUP-MAK405-E,CDM,C1894,HCPCS,0272,RC,,,both,,,225.77,67.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.26,191.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 10CM 8.5FR BILIARY FLEXIMA PLASTIC TEMPORARY DELIVERY",SUP-M00539270,CDM,C2625,HCPCS,0278,RC,,,both,,,755.24,226.57,"BLUE CROSS [10001]","Blue Cross PPO",,296.05,39.2,,,,,0,87.83,641.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 65CM 5FR SIMMONS 2 CURVE",SUP-G08625,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE JEJUNOSTOMY 57.9CM 18FR TUNGSTEN SILICONE MIC SECUR-LOK",SUP-8210-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RAPIDCROSS 170CM 60MM 2MM .014IN BALLOON DILATATION",SUP-A14BX020060170,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC",084,MS-DRG,,,,,,,inpatient,,,40985.78,12295.73,"UHC [10700]","United Healthcare",,,,"Fee schedule rate ($0). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,,,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC",829,MS-DRG,,,,,,,inpatient,,,127470.32,38241.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,,"Stop loss applied when total billed charges minus excluded charges exceed the threshold of $119,403. The stop loss is calculated as the total billed charges minus excluded charges multiplied by 37.7%. Includes an add-on of 27% of RC 0274 if total amount is above $23,637, 27% of RC 0275 if total amount is above $23,637, 27% of RC 0001-0999 if total amount is above $23,637, 27% of RC 0276 if total amount is above $23,637, 43.9% of RC 0636 if total amount is above $6,952.",,,,0,,,other,"IP STOP LOSS - 1ST DOLLAR Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 360D 7MM TREPHINE RADIAL VACUUM BARRON STAINLESS STEEL",SUP-K20-2054,CDM,S27200284,LOCAL,0272,RC,,,both,,,599.40,179.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,275.12,45.9,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Acquisition Liver Live Donor",PX-811000002,CDM,811000002,LOCAL,0811,RC,,,both,,,133855.00,40156.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,15861.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,133.86,113776.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIATHLON CR X3 TIBIAL INSERT",SUP-5530-G-319,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CIGNA [10200]",Cigna,,7760.57,68,,5873.17,5873.17,5873.17,"1 through 10",1327.29,9700.71,"percent of total billed charges",
"SYSTEM ELUNIR THK90UM 28MM 140CM 3.5MM CORONARY STENT",SUP-LUN350R28US,CDM,C1874,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 140MM 3.2MM BONE STERILE LATEX FREE",SUP-213527,CDM,S27200284,LOCAL,0272,RC,,,both,,,505.44,151.63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,59.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.78,429.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS AIM 59MM 2.46MM 8FR UNIVERSAL GUIDE II SLITTABLE",SUP-DS2N102-59,CDM,C1893,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL LEGION 6 L 5DX5P KNEE SCR",SUP-71421751,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,2014.9,14726.25,"percent of total billed charges",
"LENS IOL +6 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-PCB0000060,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 20CM 20MM STD WALL GORE-TEX RING 20CM STERILE",SUP-R20020020,CDM,C1768,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"FIRST HEALTH [10303]","First Health",,4692,80,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL LEGION 6 L 5DX5P KNEE SCR",SUP-71421751,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,1521.93,481.35,16760.95,30,2014.9,14726.25,"percent of total billed charges",
"CANSTR WOUND DRNG PREVENA 45ML INCISION MANAGEMENT SYSTEM",SUP-PRE1095,CDM,S27200284,LOCAL,0272,RC,,,both,,,194.36,58.31,"MULTIPLAN [10600]",Multiplan,,165.21,85,,,,,0,22.6,165.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 111MM 24MM ZENITH FLEX Z-TRAK 2 BRANCH",SUP-G48409,CDM,C1874,HCPCS,0278,RC,,,both,,,48686.90,14606.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5769.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5662.29,41383.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH CONE LONG HANDLE 5MM 2 CUT EDGE SHARP STERILE",SUP-APU550,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.97,86.99,"CIGNA [10200]","Cigna Open Access",,164.99,56.9,,,,,0,33.72,246.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 13MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530G213,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1012.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOAMP CORTICAL CANCELLOUS 5CC 2MM ALLOGRAFT",SUP-12600401,CDM,C1713,HCPCS,0278,RC,,,both,,,7458.76,2237.63,"NOVANET [10819]",Novanet,,5594.07,75,,,,,0,867.45,6339.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 48MM T10 FULL THREAD STARDRIVE NONSTERILE",SUP-657448,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"CIGNA [10200]","Cigna Local Plus",,432.65,53.5,,3978.14,359.25,3978.14,24,94.05,687.4,"percent of total billed charges",
"STAPLE BONE 25X20X20MM JAWS GREAT WHITE STRAIGHT NITINOL KIT",SUP-P72-025-2020-S,CDM,C1713,HCPCS,0278,RC,,,both,,,12311.33,3693.4,"AETNA [10100]","Aetna HMO/PPO",,9787.51,79.5,,1521.93,481.35,16760.95,30,1431.81,10464.63,"percent of total billed charges",
"CUSHION BK MOLDED DISTAL",SUP-L5668,CDM,L5668,HCPCS,0274,RC,,,both,,,884.20,265.26,"CIGNA [10200]","Cigna Local Plus",,473.05,53.5,,,,,0,88.22,751.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 158MM STAINLESS STEEL 3.5MM SCREWS 6 HOLE LCP BONE",SUP-02.104.026S,CDM,C1713,HCPCS,0278,RC,,,both,,,9414.08,2824.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4321.06,45.9,,,,,0,1094.86,8001.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHARTIS PRECISION 145CM 13MM PULMONARY ARTERY STERILE",SUP-CHR-CA-15.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,8176.50,2452.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3360.54,41.1,,,,,0,950.93,6950.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SUCTION 20MM TUBE NEXUS SONICONE SONICVAC STERILE LATEX",SUP-120-31-13C2,CDM,S27200284,LOCAL,0272,RC,,,both,,,4684.62,1405.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3185.54,68,,,,,0,544.82,3981.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) BRIOVAD PATIENT SUPPORT KIT",SUP-490023,CDM,Q0508,HCPCS,0624,RC,,,both,,,114837.90,34451.37,"NOVANET [10819]",Novanet,,86128.43,75,,,,,0,13355.65,97612.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1.5 X 2 HELICAL PICO COIL",SUP-10USH01502,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1363.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIREXION 155CM 2.4-3FR .021IN MICRO INFUSION NITINOL",SUP-M001195350,CDM,C1887,HCPCS,0272,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 16X14X9MM SPINE CERVICAL",SUP-6940964,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 30.5X6.5X1.02MM STERNUM",SUP-6207-097-101,CDM,S27200284,LOCAL,0272,RC,,,both,,,239.08,71.72,"CIGNA [10200]",Cigna,,162.57,68,,,,,0,27.81,203.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR Y ADPTR IRRIGATION DECOMPRESSION CORLOCK",SUP-50-6120,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.55,40.36,"NOVANET [10819]",Novanet,,100.91,75,,,,,0,15.65,114.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 100D L 2.4MM SCR 4 HOLE LOW PROFILE 2 SIDE STERNALOCK",SUP-73-2643,CDM,C1713,HCPCS,0278,RC,,,both,,,3330.00,999,"KAISER [10500]",Kaiser,,2231.1,67,,,,,0,387.28,2830.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND 24CM REGULAR 2 BALLOON AIR INJECTION PORT TRANSPARENT",SUP-TRB24-REG,CDM,S27000186,LOCAL,0270,RC,,,both,,,252.30,75.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,115.81,45.9,,,,,0,29.34,214.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 12MM 144CM 2.5MM CORONARY STENT",SUP-H7493941812250,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL E LEFT KNEE CEMENTED POSTERIOR STABILIZED",SUP-00596401551,CDM,C1776,HCPCS,0278,RC,,,both,,,15346.80,4604.04,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6138.72,40,,,,,0,1784.83,13044.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD MOP FOAM WITH LAMINATED POLYESTER FABRIC FOR QUICKLEAN",SUP-TASK0100,CDM,C1776,HCPCS,0278,RC,,,both,,,47.58,14.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.53,40.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 2 STD KNEE RIGHT KEEL NONPOROUS",SUP-ETPKN2SR,CDM,C1776,HCPCS,0278,RC,,,both,,,15193.80,4558.14,"CIGNA [10200]","Cigna Local Plus",,4786.05,31.5,,5372.07,4581.20,7242.98,23,1767.04,12914.73,"percent of total billed charges",
"BIT DRILL 125MM 4MM TWIST STERILE",SUP-KM166-00-06,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.04,24.01,"KAISER [10500]",Kaiser,,53.63,67,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NORIAN SRS 10CM 10GA BONE CEMENT DELIVERY NDL STERILE",SUP-DLS-7103-01S,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 8MM 6FR 3.75MM .07IN BALLOON",SUP-H7493918908370,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myotomy Lwr Esophgl Transoral",PX-750000220,CDM,43497,CPT,0750,RC,,,both,,,6450.00,1935,"BLUE CROSS [10001]","Blue Cross PPO",,4431.65,,"Case rate ($4,431.65). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,750.14,6450,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16015545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"MULTIPLAN [10600]",Multiplan,,8114.82,85,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FUSION TITAN 190CM 4CM 24FR 8MM .035IN BALLOON",SUP-G49221,CDM,C1726,HCPCS,0272,RC,,,both,,,2452.50,735.75,"FIRST HEALTH [10303]","First Health",,1962,80,,,,,0,285.23,2084.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Pulse Gen W Exst Mult Lead",PX-480000025,CDM,33231,CPT,0481,RC,,,both,,,6640.00,1992,"MULTIPLAN [10600]",Multiplan,,5644,85,,,,,0,772.23,6640,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Swallowing Study W Video",PX-320000098,CDM,74230,CPT,0320,RC,,,both,,,837.92,251.38,"AETNA [10100]","Aetna HMO/PPO",,666.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.45,712.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 50MM ARCOS A HIGH OFFSET HIP FEMUR PROXIMAL PPS",SUP-11-301310,CDM,C1776,HCPCS,0278,RC,,,both,,,39453.12,11835.94,"FIRST HEALTH [10303]","First Health",,31562.5,80,,,,,0,4588.4,33535.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 14MM 4.25MM EMBOLIZATION NEUROVASCULAR",SUP-PED-425-14,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"CIGNA [10200]",Cigna,,30780,40,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esoph Imped Func Test>1hr",PX-750000152,CDM,91038,CPT,0750,RC,,,both,,,7093.00,2127.9,"MULTIPLAN [10600]",Multiplan,,6029.05,85,,,,,0,824.92,6029.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 13CM 6FR CHECK-FLO PERFORMER RADIOPAQUE TIP",SUP-G07919,CDM,C1894,HCPCS,0272,RC,,,both,,,218.89,65.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,25.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,25.46,186.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 55CM 14FR STRAIGHT TRINIFLEX SPLIT CATH III BASIC",SUP-ASPC55-3,CDM,C1750,HCPCS,0278,RC,,,both,,,2437.50,731.25,"KAISER [10500]",Kaiser,,1633.13,67,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 135CM 6MM 8MM 7FR .035IN",SUP-BXA062902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA [10200]","Cigna Open Access",,6534.11,33.5,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 36MM PERFORM THK+0MM .5IN SHOULDER STERILE",SUP-DWP3360,CDM,C1776,HCPCS,0278,RC,,,both,,,17388.00,5216.4,"BLUE CROSS [10001]","Blue Cross HMO",,6816.1,39.2,,5311.50,4717.44,5388.59,31,2022.22,14779.8,"percent of total billed charges",
"SCR BONE 6.5MM 35MM TRILOGY TIVANIUM HIP CORTICAL ACETABULAR",SUP-00625006535,CDM,C1713,HCPCS,0278,RC,,,both,,,691.60,207.48,"FIRST HEALTH [10303]","First Health",,553.28,80,,,,,0,80.43,587.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 6MM ENDOWRIST SP NONSTERILE LATEX FREE REUSABLE",SUP-430006,CDM,S27000186,LOCAL,0270,RC,,,both,,,2324.70,697.41,"PHCS [10601]",PHCS,,1627.29,70,,,,,0,270.36,1976,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRIED 60X14-18MM",SUP-400730,CDM,S27800098,LOCAL,0278,RC,,,both,,,4264.20,1279.26,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,495.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,495.93,3624.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC",918,MS-DRG,,,,,,,inpatient,,,19632.20,5889.66,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,5476.14,,"Case rate ($5,316.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,936.86, add-ons for qualifying new technology services are included. If operating cost exceeds $37,976.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,755.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,943.39. The transfer operating threshold is the transfer adjustment factor * $4,936.86 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.25. The transfer capital threshold is the transfer adjustment factor * $373.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,5316.64,19632.2,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 25MM 3.3MM STERILE DISPOSABLE",SUP-7005-3325S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 75MM 12MM UNIVERSAL FLUTE KNEE PRESS FIT",SUP-86-7412,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"KAISER [10500]",Kaiser,,5427.4,67,,,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD DEFIB ADULT 42IN PREATTACHED WIRE RADIOTRANSPARENT",SUP-22550R,CDM,S27200284,LOCAL,0272,RC,,,both,,,86.77,26.03,"CIGNA [10200]","Cigna Open Access",,49.37,56.9,,,,,0,10.09,73.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS 115CM 4MM 7FR 2-5-2MM SPACING D CURVE ABLATION",SUP-D7BTCDL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"AETNA [10100]","Aetna HMO/PPO",,3944.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT EXTERNAL DRNG LUMBAR XMAS TREE ADPTR TUOHY NDL 910121",SUP-SP0224,CDM,C1729,HCPCS,0272,RC,,,both,,,3270.00,981,"UHC [10700]","United Healthcare",,2069.91,63.3,,,,,0,380.3,2779.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 22MM 140CM 2.25MM 2.1-2.7FR CORONARY",SUP-RONYX22522UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1704.04,45.9,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 RIGHT REVISION TRIATHLON",SUP-5612-F-202,CDM,C1776,HCPCS,0278,RC,,,both,,,48062.70,14418.81,"MULTIPLAN [10600]",Multiplan,,40853.3,85,,,,,0,5589.69,40853.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TYSHAK II 100CM 5CM 8FR 18MM BALLOON DILATATION",SUP-611929,CDM,C1725,HCPCS,0272,RC,,,both,,,3801.21,1140.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1562.3,41.1,,,,,0,442.08,3231.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 66MM 32MM 10D HIP CROSSFIRE OMNIFIT STERILE",SUP-2041C-3266,CDM,C1776,HCPCS,0278,RC,,,both,,,7038.00,2111.4,"CIGNA [10200]","Cigna Local Plus",,3765.33,53.5,,5372.07,4581.20,7242.98,23,818.52,5982.3,"percent of total billed charges",
"CANN SUCTION 4MM 5.6MM 30CM PORT FLARED MERCEDES TIP",SUP-PAL-408LL,CDM,S27200284,LOCAL,0272,RC,,,both,,,680.40,204.12,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,79.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,79.13,578.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 20FTX3IN ROLL 15 LAYER REINFORCE OPEN CELL",SUP-SR315,CDM,S27000186,LOCAL,0270,RC,,,both,,,449.15,134.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,305.42,68,,,,,0,52.24,381.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 70X12.5X1MM LONG RECIPROCATING 2 SIDED OFFSET",SUP-0277096278,CDM,S27200284,LOCAL,0272,RC,,,both,,,328.25,98.47,"CIGNA [10200]","Cigna Open Access",,186.77,56.9,,,,,0,38.18,279.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION AVENIR STERILE LATEX FREE DISPOSABLE",SUP-10CFN03504,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3165.24,27,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 24MM 140CM 4MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927424400,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Train for Caregiver Add 15 (Gn)",PX-440000026,CDM,G0540,HCPCS,0440,RC,,,both,,,37.00,11.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,37,,"Per diem ($426).",,,,0,0.04,37,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 3MM 3 STRAIGHT CONE RING 9IN SURGICAL STAINLESS STEEL",SUP-23-1015,CDM,S27200284,LOCAL,0272,RC,,,both,,,784.32,235.3,"FIRST HEALTH [10303]","First Health",,627.46,80,,,,,0,91.22,666.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"5F DECA 5-5-5-24-4-4-4-4-4 MPA 120CM",SUP-901586,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1217.59,41.1,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL INSUFFLATION 120MM 14GA ENDOPATH ULTRA VERESS",SUP-UV120,CDM,S27200284,LOCAL,0272,RC,,,both,,,316.18,94.85,"AETNA [10100]","Aetna HMO/PPO",,251.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.77,268.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 10CM 5FR 2 PIGTAIL CURVE TAPER BILIARY",SUP-G22122,CDM,C2625,HCPCS,0278,RC,,,both,,,1328.40,398.52,"BLUE CROSS [10001]","Blue Cross PPO",,520.73,39.2,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3.5MM 16MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.816,CDM,C1713,HCPCS,0278,RC,,,both,,,397.07,119.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,47.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",46.18,337.51,"percent of total billed charges",
"INSRT CLAMP 45MM SOFT/TRACTION STERILE LATEX FREE DISPOSABLE",SUP-G-4500,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]","Cigna Open Access",,128.71,56.9,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEEDING SET 20FR ENDOVIVE ENFIT Y PORT",SUP-M00501261,CDM,S27000186,LOCAL,0270,RC,,,both,,,65.25,19.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,26.82,41.1,,,,,0,7.59,55.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 26CM 7FR .035",SUP-M006192143090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,176.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION",RX-95812,CDM,,,0250,RC,00409-7037-01,NDC,both,10,ML,64.86,19.46,"AETNA [10100]","Aetna HMO/PPO",,51.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.54,55.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS FIRSTCHOICE 10 MEQ POTASSIUM CHLORIDE 5%",SUP-07993-09,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"PHCS [10601]",PHCS,,56.7,70,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOJET ULTRA CROSS-STREAM SPIROFLEX VG 60ML/MIN",SUP-106608-001,CDM,C1757,HCPCS,0272,RC,,,both,,,12891.96,3867.59,"AETNA [10100]","Aetna HMO/PPO",,10249.11,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1499.33,10958.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENDO STITCH V-LOC 180 2-0 4IN CLSR ABSORBABLE RELOAD",SUP-VLOCA204L,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.84,83.65,"KAISER [10500]",Kaiser,,186.82,67,,,,,0,32.43,237.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 167MM 15MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-215,CDM,C1776,HCPCS,0278,RC,,,both,,,19885.95,5965.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2356.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2312.74,16903.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 HEALIX ADVANCE BR ORTHOCORD STERILE LATEX",SUP-222295,CDM,C1713,HCPCS,0278,RC,,,both,,,2977.50,893.25,"CIGNA [10200]","Cigna Local Plus",,1592.96,53.5,,3978.14,359.25,3978.14,24,346.28,2530.88,"percent of total billed charges",
"RING ANNULOPLASTY 34MM 41.6MM 34MM MITRAL TRICUSPID FLEXIBLE",SUP-460034MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"KAISER [10500]",Kaiser,,7627.95,67,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cardiolipin Ab Ea Ig Class",PX-302000017,CDM,86147,CPT,0302,RC,,,both,,,313.50,94.05,"KAISER [10500]",Kaiser,,210.05,67,,,,,0,0.01,266.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 6 KNEE CEMENTED ROTATE PLATFORM",SUP-150610006,CDM,C1776,HCPCS,0278,RC,,,both,,,16694.55,5008.36,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4777.98,28.62,,,,,0,1941.58,14190.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL COLOR CODED O RING ADPTR SOFT PRONG KINK",SUP-N4903,CDM,S27000186,LOCAL,0270,RC,,,both,,,97.44,29.23,"CIGNA [10200]","Cigna Local Plus",,52.13,53.5,,,,,0,11.33,82.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 700ML GEL SMOOTH MEMORYGEL SILICONE P5.8CM HIGH","SUP-3507004 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1735.02,45.9,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY EPIDURAL 3.5IN 18GA 20GA PERIFIX HUSTEAD TUOHY PVC DEHP",SUP-332084,CDM,S27200284,LOCAL,0272,RC,,,both,,,175.97,52.79,"MULTIPLAN [10600]",Multiplan,,149.57,85,,,,,0,20.47,149.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM G7 ACTIVE ARTICULATION THR E1 CERAMIC POROUS HIP",SUP-98000100159,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"MULTIPLAN [10600]",Multiplan,,24633,85,,,,,0,3370.37,24633,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE 25CM 2.5CM 6FR INTRO STAINLESS STEEL",SUP-RSS605,CDM,C1894,HCPCS,0272,RC,,,both,,,178.35,53.5,"FIRST HEALTH [10303]","First Health",,142.68,80,,,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTR ORTHOPEDIC 23MM LONG BRIDGE POST NONSTERILE LATEX FREE",SUP-323.1033,CDM,C1713,HCPCS,0278,RC,,,both,,,25389.00,7616.7,"FIRST HEALTH [10303]","First Health",,20311.2,80,,,,,0,2952.74,21580.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SPINAL 3.5IN 20GA LUMBAR PUNCTURE",SUP-26-LP1CO,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.75,30.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.95,87.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 14MM STAINLESS STEEL T15 CORTEX SELF TAP LOW",SUP-02.206.214S,CDM,C1713,HCPCS,0278,RC,,,both,,,725.76,217.73,"BLUE CROSS [10001]","Blue Cross PPO",,284.5,39.2,,957.42,570.23,957.42,28,84.41,616.9,"percent of total billed charges",
"FORCEPS SURGICAL L4.75IN TISSUE 1X2 SERRATED STRAIGHT REUSAB",SUP-77950,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.15,14.14,"NOVANET [10819]",Novanet,,35.36,75,,,,,0,5.48,40.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TRAK BACK II 2IN 2.8X4.5IN ULTRASOUND 183GM CATH",SUP-91003,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"PHCS [10601]",PHCS,,425.25,70,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)CORONARY IVL CATHETER, 3.0MM X 12MM, RX IDE",SUP-501050-002,CDM,C1761,HCPCS,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 18CM 3.5MM SKIMMER 15D 2 CURVED ANGLED TIP LOW",SUP-1883525,CDM,S27200284,LOCAL,0272,RC,,,both,,,4140.00,1242,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21 DIOPTER MONOFOCAL UV ABSORBENT CLAREON",SUP-CC60WF.210,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 14X12.9CM 520ML STYLE 410 NATRELLE SILICONE P6.5",SUP-MX-410520,CDM,C1789,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",647.21,4730.25,"percent of total billed charges",
"CATH DRNG 23CM 4FR STD VENTRICULAR BARIUM IMPREGNATED SHUNT",SUP-41101,CDM,C1729,HCPCS,0272,RC,,,both,,,1143.07,342.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,469.8,41.1,,,,,0,132.94,971.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 18MM 140CM 3MM CORONARY",SUP-RSINT30018UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2544.7,45.9,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR SENZA CHRG NONSTERILE LATEX FREE REUSABLE",SUP-CHGR1000,CDM,C1822,HCPCS,0278,RC,,,both,,,6900.00,2070,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1974.78,28.62,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 28X10X12MM SIGNATURE SMALL PEEK TLIF",SUP-368.212,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"AETNA [10100]","Aetna HMO/PPO",,13165.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NAVITOR LARGE LOADING STENT GUIDE LEAFLET LOADING",SUP-NVTR-LS-LG,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"FIRST HEALTH [10303]","First Health",,3000,80,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 12/14 TAPER 36MM HIP OXINIUM",SUP-71343612,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6214.14,40,,,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14CM NATRELLE INSPIRA P5.8CM FULL PROFILE ROUND",SUP-MSZ-F605,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 35CM MYOCARDIUM VENTRICLE IS-1 CNCT SCR FIXATION",SUP-4058,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross HMO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INSTR GUIDE SPEAR STEP DRILL TROCAR DISPOSABLE STERILE 3",SUP-AR-1934DS-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,158.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PLATINUM PLUS VASCULAR STRAIGHT 180CM .018IN STAINLESS",SUP-H74917531,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 80MM 5FR 4MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-04081,CDM,C1725,HCPCS,0272,RC,,,both,,,972.00,291.6,"PHCS [10601]",PHCS,,680.4,70,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INDIGO LIGHTNING CAT12 HTORQ 115CM THROMBECTOMY",SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,0272,RC,,,both,,,42147.00,12644.1,"UHC [10700]","United Healthcare",,26679.05,63.3,,,,,0,4901.7,35824.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 20 % IN WATER (D20W) INTRAVENOUS SOLUTION",RX-2359,CDM,J3490,HCPCS,0258,RC,08888-8879-95,NDC,both,250,ML,100.65,30.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CEMENTED EXETER V40 4 37.5MM OFFSET HIP",SUP-0580-1-374,CDM,C1776,HCPCS,0278,RC,,,both,,,17001.60,5100.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1977.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1977.29,14451.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL CEMENTED EXETER V40 4 37.5MM OFFSET HIP",SUP-0580-1-374,CDM,C1776,HCPCS,0278,RC,,,both,,,17001.60,5100.48,"CIGNA [10200]","Cigna Local Plus",,5355.5,31.5,,5372.07,4581.20,7242.98,23,1977.29,14451.36,"percent of total billed charges",
"KIT NEROSTIMLTR NEVRO REMOTE NONSTERILE LATEX FREE REUSABLE",SUP-PTRC1000,CDM,C1787,HCPCS,0270,RC,,,both,,,6900.00,2070,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2835.9,41.1,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH INTRDCR FR12 - EACH",SUP-667119-001,CDM,C1892,HCPCS,0272,RC,,,both,,,607.50,182.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,249.68,41.1,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 75CM 2CM 8MM 6FR BALLOON DILATATION PERIPHERAL",SUP-CQ7582,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"AETNA [10100]","Aetna HMO/PPO",,1062.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 22MM STAINLESS STEEL FULL THREAD LONG BONE",SUP-214.722,CDM,C1713,HCPCS,0278,RC,,,both,,,1123.63,337.09,"FIRST HEALTH [10303]","First Health",,898.9,80,,,,,0,130.68,955.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT NEROSTIMLTR 35CM SPINAL CORD PHASE III",SUP-SC-3138-35,CDM,C1883,HCPCS,0278,RC,,,both,,,3525.00,1057.5,"BLUE CROSS [10001]","Blue Cross HMO",,1381.8,39.2,,6399.74,6399.74,6399.74,"1 through 10",409.96,2996.25,"percent of total billed charges",
"NDL ASPIRATION 1400MM 2.6MM 19GA WITHOUT SIDEHOLE 80MM",SUP-NA-U200H-8019,CDM,S27200284,LOCAL,0272,RC,,,both,,,2173.50,652.05,"PHCS [10601]",PHCS,,1521.45,70,,,,,0,252.78,1847.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BACLOFEN 5 MG/ML ORAL SUSPENSION",RX-408875,CDM,,,0637,RC,08888-8885-91,NDC,both,30,ML,233.23,69.97,"FIRST HEALTH [10303]","First Health",,186.58,80,,,,,0,27.12,198.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT SHUNT ACCU-FLO CSF RIGHT ANGLE BEVELED END GROOVED",SUP-821507,CDM,S27800098,LOCAL,0278,RC,,,both,,,1201.39,360.42,"PHCS [10601]",PHCS,,840.97,70,,,,,0,139.72,1021.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH OTOLOGIC 2.5X2.5CM EPIFILM EAR LAMINA FILM RESORBABLE",SUP-1417000,CDM,C1763,HCPCS,0278,RC,,,both,,,1581.53,474.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,187.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.93,1344.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION",RX-7556,CDM,J2865,HCPCS,0636,RC,00703-9514-01,NDC,both,10,ML,113.63,34.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12.8,,,,,,,9.32,96.59,"fee schedule",
"ANCHOR SUT 5MM HEALICOIL PK KNOTLESS",SUP-72205137,CDM,C1713,HCPCS,0278,RC,,,both,,,3368.25,1010.47,"AETNA [10100]","Aetna HMO/PPO",,2677.76,79.5,,1521.93,481.35,16760.95,30,391.73,2863.01,"percent of total billed charges",
"HC Block Cmplx",PX-333000019,CDM,77334,CPT,0333,RC,,,both,,,2389.62,716.89,"KAISER [10500]",Kaiser,,1601.05,67,,,,,0,277.91,2389.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 190CM 2.5CM 1.5MM GALAXY G3 MINI STRETCH",SUP-GLM915025,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"BLUE CROSS [10001]","Blue Cross PPO",,4657.67,39.2,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK12MM 51X63MM GALLANT IMPLANTABLE 2 CHMBR DF",SUP-CDDRA500Q,CDM,C1721,HCPCS,0278,RC,,,both,,,58275.00,17482.5,"MULTIPLAN [10600]",Multiplan,,49533.75,85,,,,,0,6777.38,49533.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 3.5MM X 36MM TI",SUP-SPL-35360-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM SUPRALAMINA LUMBAR TITANIUM",SUP-7541153,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",348.9,2550,"percent of total billed charges",
"INTRO CATH 13CM 16.5FR AIRGUARD VALVED HEMODIALYSIS",SUP-5513165,CDM,C1894,HCPCS,0272,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD HEMOSTATIC 4X4CM CLO-SUR PAD VASCULAR POLYPROLATE",SUP-SCV22P-AB,CDM,S27200284,LOCAL,0272,RC,,,both,,,278.40,83.52,"CIGNA [10200]","Cigna Open Access",,158.41,56.9,,,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ELECTROPHYSIOLOGY BLACK 110CM 5FR 5MM SPACE F CURVE",SUP-F5QF005CTR,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"NOVANET [10819]",Novanet,,234.9,75,,,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXCATH CONTOUR 12FR STEERABLE SHEATH - 20MM TIP LENGTH",SUP-12FCC20,CDM,C1766,HCPCS,0272,RC,,,both,,,7590.00,2277,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,899.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2.9MM SHORT PUSHLOCK HIP BIOCOMPOSITE 12.5MM",SUP-AR-2923BCH,CDM,C1713,HCPCS,0278,RC,,,both,,,3307.50,992.25,"CIGNA [10200]","Cigna Local Plus",,1769.51,53.5,,3978.14,359.25,3978.14,24,384.66,2811.38,"percent of total billed charges",
"PACKAGED RADIAL STEM 12MM X -2MM",SUP-ALN-RST-12M2,CDM,C1776,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"MULTIPLAN [10600]",Multiplan,,12087.77,85,,,,,0,1653.89,12087.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 4.75MM CD HORIZON COCRMO CAP",SUP-641003045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"HALOPERIDOL 1 MG TABLET",RX-3579,CDM,,,0637,RC,70756-0002-11,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVEIR VR PACER SYSTEM",SUP-VR-SYSTEM-AVEIR,CDM,C1786,HCPCS,0275,RC,,,both,,,58905.00,17671.5,"PHCS [10601]",PHCS,,41233.5,70,,,,,0,6850.65,50069.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 5CM 7FR BILIARY PLASTIC RAPID EXCHANGE TEMPORARY TAPER",SUP-4555,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1604.72,28.62,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20.7CM 12MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR181220,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"BLUE CROSS [10001]","Blue Cross HMO",,4657.67,39.2,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 12X18X50MM 10DEG POROUS EXTREME LATERAL LORDOTIC",SUP-1181250P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Local Plus",,8930.25,31.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 40MM PROFILE 3D STERILE LATEX FREE",SUP-680R40,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5388.21,41.1,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 150CM 60MM 4MM BALLOON DILATATION JETCOAT OTW 2",SUP-1013466-060,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"FIRST HEALTH [10303]","First Health",,1004.4,80,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION MRI SLIMPORT POLYURETHANE 6FR 1",SUP-605640,CDM,C1788,HCPCS,0278,RC,,,both,,,1417.50,425.25,"CIGNA [10200]","Cigna Open Access",,806.56,56.9,,2042.80,1340.96,2042.80,"1 through 10",164.86,1204.88,"percent of total billed charges",
"KIT INTRO 10CM 5FR 21GA MERIT S-MAK .018IN STIFFENED DIL",SUP-S-MAK505,CDM,C1894,HCPCS,0272,RC,,,both,,,334.78,100.43,"MULTIPLAN [10600]",Multiplan,,284.56,85,,,,,0,38.93,284.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER VENA 40MM 80CM 10MM BILIARY VENOUS DELIVERY",SUP-G57428,CDM,C1876,HCPCS,0278,RC,,,both,,,12771.83,3831.55,"CIGNA [10200]","Cigna Local Plus",,4023.13,31.5,,,,,0,1485.36,10856.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 24MM 5MM CORONARY STENT PLATINUM",SUP-H7493926024500,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6334.2,68,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X8MM PARALLEL SPINE",SUP-17308,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E FEMUR PATELLA TIBIA CEMENT",SUP-98000200232,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"NOVANET [10819]",Novanet,,21735,75,,,,,0,3370.37,24633,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEARTMATE 3 LVAD IMPLANT KIT INCLUDES 1 HEARTMATE 3 LVAD CON",SUP-106524US,CDM,S27800098,LOCAL,0278,RC,,,both,,,579590.93,173877.28,"CIGNA [10200]",Cigna,,231836.37,40,,,,,0,67406.43,492652.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 80MM 5MM BALLOON DILATATION RAPID EXCHANGE",SUP-47550080L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEQUALIS PERFORM GLENOID (CORTILOC)- S30",SUP-DWE401,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"CIGNA [10200]","Cigna Open Access",,5300.8,56.9,,5302.19,4377.88,6578.61,27,1083.45,7918.6,"percent of total billed charges",
"INSRT TIBIAL 2 20MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158101120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"BLUE CROSS [10001]","Blue Cross HMO",,4380.42,39.2,,5311.50,4717.44,5388.59,31,1299.6,9498.37,"percent of total billed charges",
"SOL MAGNESIUM SULFATE WATER 20GM PER 500ML 500ML INJECTION",SUP-06729-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA [10200]","Cigna Local Plus",,43.34,53.5,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"X3 HUMERAL INSERT - 40MM X 4 CONSTRAINED",SUP-5571-C-4004,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"NOVANET [10819]",Novanet,,7560,75,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THERAPEUTIC CABLES, 3 FT.  M004653S0",SUP-MS4653S0,CDM,S27200284,LOCAL,0272,RC,,,both,,,2537.63,761.29,"FIRST HEALTH [10303]","First Health",,2030.1,80,,,,,0,295.13,2156.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 14.5IN 18FR PHILLIPS 1/56IN HOLLOW PLASTIC 1",SUP-346118,CDM,S27200284,LOCAL,0272,RC,,,both,,,146.16,43.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 24CM 3CM 7FR .035IN PIGTAIL CURVE",SUP-M006180232180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"MULTIPLAN [10600]",Multiplan,,1241.09,85,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM MASTERS HP STD MECHANICAL CUFF",SUP-19AHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 1.5MM PRESTIGE PLUS COMPLEX XTRA PACK",SUP-PRES0153CXPPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 16MM 43MM SHOULDER SIMPLICITI",SUP-7122870,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1187.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1165.21,8516.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP 3 HOLE QUADRANT GROUP C BIOFOAM",SUP-DBFPGC50,CDM,C1776,HCPCS,0278,RC,,,both,,,18194.40,5458.32,"BLUE CROSS [10001]","Blue Cross HMO",,7132.2,39.2,,5311.50,4717.44,5388.59,31,2116.01,15465.24,"percent of total billed charges",
"LUTONIX 035 130CM6X40MM 1/EACH",SUP-LX35130640,CDM,C1725,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"NOVANET [10819]",Novanet,,8538.75,75,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 9MM AXIUM 3D FRAME V01",SUP-FC-9-20-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6610.2,40,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 120MM 5MM .014IN BALLOON DILATATION",SUP-AB14W050120150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.87,68,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK15MM 51X66MM PROTECTA XT CRT-D ATRIUM",SUP-D314TRM,CDM,C1882,HCPCS,0278,RC,,,both,,,85500.00,25650,"BLUE CROSS [10001]","Blue Cross HMO",,33516,39.2,,,,,0,9943.65,72675,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 36X28X15MM CHESAPEAKE 15D LORDOTIC",SUP-2013-21536L15,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"PHCS [10601]",PHCS,,23992.92,70,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X3CM AMINOFIX",SUP-AAS-5330,CDM,Q4433,HCPCS,0636,RC,,,both,,,7396.80,2219.04,"NOVANET [10819]",Novanet,,5547.6,75,,,,,0,247.92,6287.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE EMERALD VASCULAR BENSTON LLT CURVE 150CM 20CM .035IN",SUP-502560,CDM,C1769,HCPCS,0272,RC,,,both,,,95.70,28.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.13,81.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 28X10X12MM SIGNATURE SMALL PEEK TLIF",SUP-368.212,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS [10001]","Blue Cross HMO",,6491.52,39.2,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 58MM 40MM ALTRX HIP",SUP-122140458,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5521.38,40,,,,,0,1605.34,11732.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 45MM 14MM 13FR 10FR TRIVASCULAR OVATION PRIME",SUP-TV-EX141445-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"AETNA [10100]","Aetna HMO/PPO",,26545.05,79.5,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXERCISER HAND ROLYAN BLACK RUBBER ERGONOMIC LATEX FREE",SUP-A3481,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.33,13.6,"NOVANET [10819]",Novanet,,34,75,,,,,0,5.27,38.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH SURGICAL 7.5MM BARRON CORNEA VACCUM DONOR CORNEA",SUP-K20-2076,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,219.72,41.1,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE EXPLANT HIP TRUNCATE OSTEOTOM 46MM HEMISPHERE",SUP-705304610,CDM,S27200284,LOCAL,0272,RC,,,both,,,4526.40,1357.92,"CIGNA [10200]","Cigna Open Access",,2575.52,56.9,,,,,0,526.42,3847.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM BOVINE PERICARDIUM LEAFLET COBALT CHROMIUM",SUP-11400M25,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"FIRST HEALTH [10303]","First Health",,36288,80,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12MM 1MM CORTICAL CRANIOFACIAL TITANIUM SELF",SUP-400.532,CDM,C1713,HCPCS,0278,RC,,,both,,,526.18,157.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,62.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",61.19,447.25,"percent of total billed charges",
"XIENCE SKYPOINT DES 3.50 X 12 RX US",SUP-1804350-12,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO S1 LOW PROFILE QUICK CONNECT GLIDESCOPE",SUP-0270-1151,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.26,129.98,"CIGNA [10200]","Cigna Open Access",,246.52,56.9,,,,,0,50.39,368.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ATLANTIS TITANIUM SPINAL SELF TAPPING",SUP-876-710,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA EXTRA FULL PROFILE SOFT TOUCH",SUP-SSX-750,CDM,C1789,HCPCS,0278,RC,,,both,,,8004.00,2401.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,948.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",930.87,6803.4,"percent of total billed charges",
"STENT WALLSTENT RP UNISTEP PLUS 45MM 75CM 6MM 100CM",SUP-M001711100,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1001.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 20X10CM GENTRIX THICK PORCINE",SUP-PSMT1020,CDM,C1781,HCPCS,0278,RC,,,both,,,35721.00,10716.3,"MULTIPLAN [10600]",Multiplan,,30362.85,85,,,,,0,4154.35,30362.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATLAS 120CM 4CM 14MM BALLOON DILATATION PERIPHERAL",SUP-AT120144,CDM,C1725,HCPCS,0272,RC,,,both,,,2062.50,618.75,"FIRST HEALTH [10303]","First Health",,1650,80,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION",RX-88010,CDM,Q2009,HCPCS,0636,RC,63323-0403-04,NDC,both,10,ML,232.39,69.72,"CIGNA [10200]","Cigna Local Plus",,124.33,53.5,,,,,0,26.1,197.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 14CM 23MM 18.5-21.5MM EXCLUDER",SUP-PLC231400,CDM,C1874,HCPCS,0278,RC,,,both,,,27997.20,8399.16,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11198.88,40,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR CATH GATEWAY PLUS Y",SUP-M001153223,CDM,S27200284,LOCAL,0272,RC,,,both,,,346.83,104.05,"PHCS [10601]",PHCS,,242.78,70,,,,,0,40.34,294.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICONAZOLE NITRATE 2 % TOPICAL OINTMENT",RX-13651,CDM,,,0250,RC,84389-0135-51,NDC,both,71,GR,364.42,109.33,"KAISER [10500]",Kaiser,,244.16,67,,,,,0,42.38,309.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 19MM 80CM 7MM 11MM 7FR .035IN",SUP-BXA071901A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC",803,MS-DRG,,,,,,,inpatient,,,76982.80,23094.84,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,11876.8,,"Case rate ($11,530.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,707.19, add-ons for qualifying new technology services are included. If operating cost exceeds $43,746.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,191.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $10,721.35. The transfer operating threshold is the transfer adjustment factor * $10,707.19 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.52. The transfer capital threshold is the transfer adjustment factor * $809.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,54272.44,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +15.5 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.155,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,197.05,28.62,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.113,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"KAISER [10500]",Kaiser,,574.39,67,,,,,0,99.7,728.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 2.75MM CORONARY STENT",SUP-1145275-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 419688 88CM HF",SUP-419688,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,652.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY 5MM SPACING CRD2 CURVE 5FR 120CM",SUP-401860,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 100MM 11MM NEXGEN OFFSET KNEE FEMUR 145MM STERILE",SUP-00598802011,CDM,C1776,HCPCS,0278,RC,,,both,,,10435.56,3130.67,"BLUE CROSS [10001]","Blue Cross PPO",,4090.74,39.2,,3949.44,3949.44,3949.44,"1 through 10",1213.66,8870.23,"percent of total billed charges",
"SCREW NON-LOCKING 1.2MM X 6MM COCR",SUP-VAN-12006-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1296.00,388.8,"MULTIPLAN [10600]",Multiplan,,1101.6,85,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2.5MM DELTAXSFT 10 COIL",SUP-DLX100256,CDM,S27800098,LOCAL,0278,RC,,,both,,,9052.80,2715.84,"FIRST HEALTH [10303]","First Health",,7242.24,80,,,,,0,1052.84,7694.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 55MM 2.1MM SHANNON STAINLESS STEEL J NOTCH",SUP-16-S1401,CDM,S27200284,LOCAL,0272,RC,,,both,,,133.55,40.06,"CIGNA [10200]",Cigna,,90.81,68,,,,,0,15.53,113.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 42MM STAINLESS STEEL 2.4MM SCR 6 HEAD 2 SHAFT HOLES 2",SUP-02.111.521,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,,1521.93,481.35,16760.95,30,434.96,3179,"percent of total billed charges",
"SCR BONE 1.5MM 16MM ALPS COCR SQUARE HAND CORTICAL LOCK SELF",SUP-131220416,CDM,C1713,HCPCS,0278,RC,,,both,,,1032.75,309.82,"BLUE CROSS [10001]","Blue Cross PPO",,404.84,39.2,,957.42,570.23,957.42,28,120.11,877.84,"percent of total billed charges",
"SMOOTH PEG LOCKING 6.0MM X 30MM TI",SUP-SPL-60300-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1101.6,68,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD LINER MP7 ORANGE/BRN 36MM",SUP-932-36-252,CDM,C1776,HCPCS,0278,RC,,,both,,,12462.02,3738.61,"NOVANET [10819]",Novanet,,9346.52,75,,,,,0,1449.33,10592.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 8MM VERTEX CORTICAL",SUP-7750508,CDM,C1713,HCPCS,0278,RC,,,both,,,1931.70,579.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,886.65,45.9,,,,,0,224.66,1641.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL ANTERIOR CHMBR",SUP-MTA5UO,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 26FR LOOP WOLF RESECTOSCOPE",SUP-M0068802441,CDM,S27200284,LOCAL,0272,RC,,,both,,,478.22,143.47,"CIGNA [10200]","Cigna Local Plus",,255.85,53.5,,,,,0,55.62,406.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 44MM 6.5MM REUNION FOOT ANKLE CENTER STERILE",SUP-5573-6544,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"BLUE CROSS [10001]","Blue Cross HMO",,609.83,39.2,,957.42,156.86,7483.26,51,180.93,1322.35,"percent of total billed charges",
"STENT COVERA 30MM 80CM 9MM 8FR STRAIGHT VASCULAR",SUP-AVSM09030,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS [10001]","Blue Cross HMO",,7161.84,39.2,,9776.84,9776.84,9776.84,"1 through 10",2124.8,15529.5,"percent of total billed charges",
"PLATE 14MM LEVEL 1 EXTEND BONE SPINE CERVICAL ANTERIOR",SUP-161.114,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"AETNA [10100]","Aetna HMO/PPO",,3339,79.5,,1521.93,481.35,16760.95,30,488.46,3570,"percent of total billed charges",
"INSRT TIBIAL 6 CURVE 15MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962063,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"CIGNA [10200]","Cigna Local Plus",,4948.46,53.5,,5372.07,4581.20,7242.98,23,1075.71,7862.03,"percent of total billed charges",
"COIL EMBOLIZATION 40CM 20MM INTERLOCK FIBERED IDC 35 COIL",SUP-M001363830,CDM,S27800098,LOCAL,0278,RC,,,both,,,5181.90,1554.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,614.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,602.65,4404.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOFT TISSUE PROCEDURES WITH CC",501,MS-DRG,,,,,,,inpatient,,,54587.06,16376.12,"PHCS [10601]",PHCS,,7561,,,,,,,7561,51037.53,"per diem","Estimated amount calculated based on 5 day length of stay."
"STENT ABRE 60MM 20MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U20060090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"NOVANET [10819]",Novanet,,7762.5,75,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL LIGHT GREEN 28X36X8.4-10.5MM SYNFIX 6D MEDIUM",SUP-08.815.201S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"KAISER [10500]",Kaiser,,18994.5,67,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 108MM 6MM MONOBLOCK RSP",SUP-510-00-006,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Local Plus",,3969,31.5,,5372.07,4581.20,7242.98,23,1465.38,10710,"percent of total billed charges",
"SUT ETHIBOND EXCEL SUTUPAK 2-0 75CM BRAID 12 STRAND PRECUT",SUP-X305H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRYOPRESERVED SKIN 115.52 SQ CM 7.6CM X 15.2CM CRYOPRESER",SUP-104TSXLR,CDM,Q4121,HCPCS,0636,RC,,,both,,,21690.90,6507.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,14099.09,65,,,,,0,141.84,18437.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7- KNEE RIGHT PRESS FIT EMPOWR KNEE STERILE BP",SUP-353-04-107,CDM,C1776,HCPCS,0278,RC,,,both,,,15979.64,4793.89,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1893.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1858.43,13582.69,"percent of total billed charges",
"SHOE SMALL PATIENT POSTOPERATIVE SHORT WEDGE HEELWEDGE",SUP-92732602,CDM,S27000186,LOCAL,0270,RC,,,both,,,256.65,76.99,"PHCS [10601]",PHCS,,179.66,70,,,,,0,29.85,218.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 240CC NATRELLE INSPIRA COHESIVE STERILE LATEX",SUP-SCM-240,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"NOVANET [10819]",Novanet,,5666.63,75,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +17.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030175,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"PHCS [10601]",PHCS,,822.15,70,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 15MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-55840014515,CDM,C1713,HCPCS,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Open Access",,3926.1,56.9,,1144.80,304.56,2275.09,66,802.47,5865,"percent of total billed charges",
"CMPNT GLENOID MEDIUM 4MM BASE MODULAR COMPREHENSIVE HYBRID",SUP-113954,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1085.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1065.77,7789.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR BLUE 56MM 28MM SELF-CENTERING HIP FEMUR STERILE",SUP-103556000,CDM,C1776,HCPCS,0278,RC,,,both,,,6372.15,1911.64,"CIGNA [10200]","Cigna Open Access",,3625.75,56.9,,5302.19,4377.88,6578.61,27,741.08,5416.33,"percent of total billed charges",
"SHELL ACETABULAR 48MM 49.8MM HIP 3 SCR HOLE CLUSTER RIM",SUP-542-11-48D,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,824.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,809.18,5914.06,"percent of total billed charges",
"HC Rmvl Pcmkr Gen Only",PX-480000026,CDM,33233,CPT,0481,RC,,,both,,,8960.18,2688.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1061.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1042.07,8960.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bag Infusor Pressure",PX-E27000046,CDM,E27000046,LOCAL,0270,RC,,,both,,,157.30,47.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.29,133.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL MICRORAPTOR SHOULDER KNOTLESS",SUP-72205022,CDM,S27200284,LOCAL,0272,RC,,,both,,,1450.71,435.21,"AMERIGROUP MEDICAID [20100]",Amerigroup,,171.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,168.72,1233.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN EXTRA BACKUP LEFT 3.5 CURVE",SUP-LA7EBU35,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PHCS [10601]",PHCS,,274.05,70,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Onc Lung Mrna Quan Pcr 11&3",PX-310000011,CDM,0288U,CPT,0310,RC,,,both,,,18282.00,5484.6,"CIGNA [10200]","Cigna Local Plus",,8520.6,,,,,,,2166.42,15539.7,"fee schedule",
"CATH SOFT-VU 100CM 5FR SIDEWINDER 3 CURVE ANGIOGRAPHIC",SUP-H787107090085,CDM,C1887,HCPCS,0272,RC,,,both,,,190.36,57.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.14,161.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 46CM KIT J TIP ATRIAL",SUP-DS06001/46,CDM,S27500001,LOCAL,0275,RC,,,both,,,486.00,145.8,"BLUE CROSS [10001]","Blue Cross PPO",,190.51,39.2,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK PHACOEMULSIFICATION .9MM 45D ABS TIP FLUID MANAGEMENT",SUP-8065752201,CDM,S27200284,LOCAL,0272,RC,,,both,,,833.00,249.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,96.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,96.88,708.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 57CM .02IN 24MM PENUMBRA COIL 400 RUBY",SUP-RBY2C2457,CDM,S27800098,LOCAL,0278,RC,,,both,,,7098.00,2129.4,"KAISER [10500]",Kaiser,,4755.66,67,,,,,0,825.5,6033.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR STD JR4ST CURVE",SUP-534527T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"CIGNA [10200]","Cigna Open Access",,53.22,56.9,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 190CM 22MM 3.7MM 4 WIRE C HOOK",SUP-FGV432P,CDM,S27200284,LOCAL,0272,RC,,,both,,,1089.29,326.79,"AETNA [10100]","Aetna HMO/PPO",,865.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,126.68,925.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 420MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.162S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5103.94,41.1,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 45CM 7.2FR J ATRIUM BIPOLAR ACTIVE FIXATION SCR",SUP-5568-45,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"FIRST HEALTH [10303]","First Health",,4485.6,80,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 3CM 8FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145382010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"MULTIPLAN [10600]",Multiplan,,821.87,85,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Hip Uni 1v",PX-320000075,CDM,73501,CPT,0320,RC,,,both,,,496.99,149.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,59.95,,,,,,,37.66,422.44,"fee schedule",
"SYSTEM DYONICS 25 FLUID MANAGEMENT SUCTION INFLOW OUTFLOW",SUP-7211005,CDM,S27000186,LOCAL,0270,RC,,,both,,,451.98,135.59,"PHCS [10601]",PHCS,,316.39,70,,,,,0,52.57,384.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 22MM 2.75MM CORONARY STENT FULCRUM COCR",SUP-INT27522UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,286.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE BARD NICORE ENDOSCOPIC 150CM .035IN NITINOL",SUP-150NFS35,CDM,C1769,HCPCS,0272,RC,,,both,,,301.63,90.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,205.11,68,,,,,0,35.08,256.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESPIRATORY NEOPLASMS WITHOUT CC/MCC",182,MS-DRG,,,,,,,inpatient,,,61119.45,18335.83,"BLUE CROSS [10001]","Blue Cross PPO",,18609.1,,,,,,,4675.87,18799.02,"case rate",
"SPONGE HEMSTAT CLLGN ABSRB INSTAT 1 GR",SUP-1985,CDM,S27200284,LOCAL,0272,RC,,,both,,,1046.94,314.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,124.06,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.76,889.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE NEUROSCOUT VASCULAR XL SOFT .014IN",SUP-601415,CDM,C1769,HCPCS,0272,RC,,,both,,,5010.44,1503.13,"PHCS [10601]",PHCS,,3507.31,70,,,,,0,582.71,4258.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +6.5 DIOPTER MODIFY C CONVEXOPLANO 13.5MM 5.5MM",SUP-MTA5U0.065,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"FIRST HEALTH [10303]","First Health",,550.8,80,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 60X.64X6.27MM SHORT RECIPROCATE NONSTERILE",SUP-277-96-250,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.85,90.25,"CIGNA [10200]","Cigna Local Plus",,160.95,53.5,,,,,0,34.99,255.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8MM 55MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1 INNIE",SUP-179712855,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 60CM 6.7FR 10MM SPACE ATRIUM ENDOCARDIUM",SUP-4137,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1604.72,28.62,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PT GRAPHIX VASCULAR STRAIGHT INTERMEDIATE 300CM .014IN",SUP-H74914914011,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 12MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656312,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"BLUE CROSS [10001]","Blue Cross HMO",,523.4,39.2,,957.42,156.86,7483.26,51,155.28,1134.92,"percent of total billed charges",
"CATH IMAGER II 100CM 5FR SIMMONS 2 CURVE STRAIGHT",SUP-M001314351,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"CIGNA [10200]",Cigna,,79.27,68,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG SURGICAL 2X1.6IN GROIN NONABSORBABLE TAPER MARLEX",SUP-0112980,CDM,C1781,HCPCS,0278,RC,,,both,,,851.76,255.53,"KAISER [10500]",Kaiser,,570.68,67,,,,,0,99.06,724,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 45MM AXSOS STAINLESS STEEL 2.5MM FULL THREAD",SUP-345445,CDM,C1713,HCPCS,0278,RC,,,both,,,211.93,63.58,"CIGNA [10200]","Cigna Open Access",,120.59,56.9,,1144.80,304.56,2275.09,66,24.65,180.14,"percent of total billed charges",
"BULKING AGNT DEXTRNMR GLS SYR VESCURTRL REFLX DEFLUX 1ML",SUP-365649922039,CDM,L8603,HCPCS,0278,RC,,,both,,,20018.00,6005.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5729.15,28.62,,,,,0,336.83,17015.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PENTARAY 7FR 4-4-4MM D CURVE ELECTROPHYSIOLOGY",SUP-D128210,CDM,C1732,HCPCS,0272,RC,,,both,,,13634.40,4090.32,"UHC [10700]","United Healthcare",,8630.58,63.3,,,,,0,1585.68,11589.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAPER POST, 11MM O X 21.5MM LG, PFXL CE",SUP-PX11-0218-W,CDM,C1776,HCPCS,0278,RC,,,both,,,3600.00,1080,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,426.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,418.68,3060,"percent of total billed charges",
"DEVICE WECK EFX SHIELD CLSR FASCIAL UNIFORM SUT RETRIEVAL",SUP-EFX002,CDM,S27200284,LOCAL,0272,RC,,,both,,,944.46,283.34,"UHC [10700]","United Healthcare",,597.84,63.3,,,,,0,109.84,802.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150190,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Local Plus",,184.58,53.5,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC",742,MS-DRG,,,,,,,inpatient,,,90441.84,27132.55,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,24469.95,,"Case rate ($11,381.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $10,568.38, add-ons for qualifying new technology services are included. If operating cost exceeds $43,608.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,181.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,582.35. The transfer operating threshold is the transfer adjustment factor * $10,568.38 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.02. The transfer capital threshold is the transfer adjustment factor * $799.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,53568.82,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Unlisted Molec Path",PX-309000117,CDM,81479,CPT,0310,RC,,,both,,,2947.10,884.13,"NOVANET [10819]",Novanet,,2210.33,75,,,,,0,0.01,2505.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Egd W Inj Varices",PX-750000032,CDM,43243,CPT,0750,RC,,,both,,,3736.00,1120.8,"NOVANET [10819]",Novanet,,2802,75,,,,,0,3.74,3736,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 9-0 BV130-3 5IN MONOFILAMENT BLACK NONABSORBABLE",SUP-2819G,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.45,53.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.64,150.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STALIF L FLX 18MM 8FR THROMBECTOMY SHEATH INTRILL",SUP-53-101,CDM,C1894,HCPCS,0272,RC,,,both,,,12420.00,3726,"UHC [10700]","United Healthcare",,7861.86,63.3,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 150CM 1.7-2.4FR .017IN",SUP-M003C1715450,CDM,S27200284,LOCAL,0272,RC,,,both,,,7719.24,2315.77,"CIGNA [10200]","Cigna Local Plus",,4129.79,53.5,,,,,0,897.75,6561.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE RIGHT PROXIMAL TIBIAL 118MM STAINLESS STEEL 4.5MM SCR",SUP-240.038,CDM,C1713,HCPCS,0278,RC,,,both,,,8699.80,2609.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3575.62,41.1,,,,,0,1011.79,7394.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURESIGHT BLADE HYPERANGULATED SIZE 3",SUP-390231000,CDM,S27000186,LOCAL,0270,RC,,,both,,,321.90,96.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Tee Img Acqusit I&R",PX-483000011,CDM,93314,CPT,0483,RC,,,both,,,243.00,72.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,111.54,45.9,,,,,0,28.26,243,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPRESS 65CM 4FR .040IN .038IN KA2 CURVE ANGIOGRAPHIC",SUP-46538KA2,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"UHC [10700]","United Healthcare",,68.84,63.3,,,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9.5MM 100MM CD HORIZON SPINE MULTIAXIAL CANNULATED",SUP-25630019510,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER 1628-017M MERIT MED VRT",SUP-1628-017M,CDM,C1887,HCPCS,0272,RC,,,both,,,1044.90,313.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,121.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,121.52,888.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM VIPER 2 LORDOTIC",SUP-186788055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rf Ablt Nrv Si Joint",PX-510000536,CDM,64625,CPT,0761,RC,,,both,,,4688.00,1406.4,"CIGNA [10200]","Cigna Local Plus",,2051,,"Per diem ($2,051).",,,,0,545.21,3984.8,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X20X5.8MM TITAN NANOLOCK 12D 10MM ANTERALIGN",SUP-46221050,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4982.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 100CM 5FR RACKET CURVE ANGIOGRAPHIC RADIOPAQUE",SUP-H787107095065,CDM,C1887,HCPCS,0272,RC,,,both,,,190.36,57.11,"NOVANET [10819]",Novanet,,142.77,75,,,,,0,22.14,161.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 20MM 3FR SEGURA HEMISPHERE",SUP-M0063801100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"KAISER [10500]",Kaiser,,991.3,67,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 38MM NCB PROTASUL-64 3.5MM SELF TAP 2 LEAD",SUP-0203150038,CDM,C1713,HCPCS,0278,RC,,,both,,,1856.25,556.87,"NOVANET [10819]",Novanet,,1392.19,75,,,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 0D H HIP X3 TRIDENT",SUP-623-00-36H,CDM,C1776,HCPCS,0278,RC,,,both,,,6879.60,2063.88,"FIRST HEALTH [10303]","First Health",,5503.68,80,,,,,0,800.1,5847.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 2.5/15",SUP-434887,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"MULTIPLAN [10600]",Multiplan,,16787.93,85,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC",726,MS-DRG,,,,,,,inpatient,,,26295.44,7888.63,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,9119.35,,"Case rate ($4,478.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,158.69, add-ons for qualifying new technology services are included. If operating cost exceeds $37,198.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,696.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,164.19. The transfer operating threshold is the transfer adjustment factor * $4,158.69 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.42. The transfer capital threshold is the transfer adjustment factor * $314.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,4478.61,18005.96,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dressing Wound Drawtex",PX-E27200249,CDM,E27200249,LOCAL,0272,RC,,,both,,,79.18,23.75,"MULTIPLAN [10600]",Multiplan,,67.3,85,,,,,0,9.21,67.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - TIBIAL KIT (CR) - SIZE 8",SUP-5555-2328,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PISTON OTOLOGY 3.75MM .5MM SMART INCUS STAPES NITINOL",SUP-7014-5920,CDM,L8613,HCPCS,0278,RC,,,both,,,1801.20,540.36,"FIRST HEALTH [10303]","First Health",,1440.96,80,,,,,0,209.48,1531.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rplc Cvc Nontunl Complt",PX-450000227,CDM,36580,CPT,0361,RC,,,both,,,6710.01,2013,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1550,,"Case rate ($1,550). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,780.37,6710.01,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 15MM 21MM 26MM 20MM CARPENTIER-EDWARDS",SUP-3000TFX21MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"CIGNA [10200]","Cigna Open Access",,10753,33.5,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET IRRIGATION CLEARVISION II TUBE STERILE DISPOSABLE",SUP-031229-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,234.98,70.49,"UHC [10700]","United Healthcare",,148.74,63.3,,,,,0,27.33,199.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 120MM 6MM BALLOON DILATATION RAPID",SUP-47560120L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"AETNA [10100]","Aetna HMO/PPO",,1294.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CALCANEUS THK13-15MM ALLOGRAFT FREEZE DRIED CROSS",SUP-400482,CDM,S27800098,LOCAL,0278,RC,,,both,,,4765.14,1429.54,"AETNA [10100]","Aetna HMO/PPO",,3788.29,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,554.19,4050.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 32.26CM 8MM DA VINCI ENDOWRIST SPAT",SUP-470184,CDM,S27000186,LOCAL,0270,RC,,,both,,,1020.60,306.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,468.46,45.9,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD 25CM 8FR PIGTAIL CURVE DRNG GLIDEX PERCUFLEX METAL",SUP-M001245071,CDM,C1729,HCPCS,0272,RC,,,both,,,850.50,255.15,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUT ARTHREX FIBERTAK ROTATOR CUFF TAPE 3 LOAD STERILE",SUP-AR-3633,CDM,C1713,HCPCS,0278,RC,,,both,,,3031.88,909.56,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,867.72,28.62,,,,,0,352.61,2577.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.225 CLAREON",SUP-SY60WF.225,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PHCS [10601]",PHCS,,844.83,70,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER 1628-017M MERIT MED VRT",SUP-1628-017M,CDM,C1887,HCPCS,0272,RC,,,both,,,1044.90,313.47,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,429.45,41.1,,,,,0,121.52,888.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR SMALL DIAMETER SHORT 30MM SIGNIA VASCULAR CURVE",SUP-SIGSDS30CTV,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"FIRST HEALTH [10303]","First Health",,2992,80,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX79MM 8FR 135CMCATH HEPARIN",SUP-BXB097902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"KAISER [10500]",Kaiser,,14342.96,67,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 32X21X2MM TITANIUM 1 LEVEL CLOVERLEAF CAUDAL HOLE LOCK",SUP-450.124,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 2CM 4CM 2MM RAPID EXCHANGE LITHO",SUP-M00510870,CDM,S27200284,LOCAL,0272,RC,,,both,,,2036.93,611.08,"CIGNA [10200]",Cigna,,1385.11,68,,,,,0,236.89,1731.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC LOW PROFILE 100MM 5MM KII 2 PACK OPTICAL",SUP-CTR12,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"MULTIPLAN [10600]",Multiplan,,184.88,85,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 2MM .76MM MORETZ TYTAN EAR TAB TITANIUM",SUP-1066108,CDM,S27800098,LOCAL,0278,RC,,,both,,,179.42,53.83,"CIGNA [10200]",Cigna,,122.01,68,,,,,0,20.87,152.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 55MM VIPER 2 LORDOTIC",SUP-186788055,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"CATH IMPRESS 65CM 4FR .040IN .038IN KA2 CURVE ANGIOGRAPHIC",SUP-46538KA2,CDM,S27200284,LOCAL,0272,RC,,,both,,,108.75,32.62,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.65,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.65,92.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 1.5CC 1-2MM GRANULE MAGNETOS EASYPACK PUTTY",SUP-703-048-US,CDM,C1713,HCPCS,0278,RC,,,both,,,3881.25,1164.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,459.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",451.39,3299.06,"percent of total billed charges",
"TRIAL HIP 22MM 34MM OR3O 2 MOBILITY LINER STERILE LATEX FREE",SUP-71358254,CDM,C1776,HCPCS,0278,RC,,,both,,,10743.30,3222.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3074.73,28.62,,,,,0,1249.45,9131.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM PFC SIGMA TC3 2 KNEE LEFT TITANIUM CEMENTED",SUP-960822,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,608,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,596.72,4361.21,"percent of total billed charges",
"NDL 71CM 18GA STYLET PROC TRANSSEPTAL BRK ADULT",SUP-407200,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"CIGNA [10200]","Cigna Local Plus",,758.36,53.5,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIDOVUDINE 10 MG/ML ORAL SYRUP",RX-11693,CDM,,,0250,RC,65862-0048-24,NDC,both,240,ML,354.76,106.43,"AMERIGROUP MEDICAID [20100]",Amerigroup,,42.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.26,301.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE CONDYLAR CEMENT CONSTRAIN PERSONA",SUP-42504606201,CDM,C1776,HCPCS,0278,RC,,,both,,,42373.80,12712.14,"BLUE CROSS [10001]","Blue Cross PPO",,16610.53,39.2,,3949.44,3949.44,3949.44,"1 through 10",4928.07,36017.73,"percent of total billed charges",
"CATH SAPPHIRE II PRO 10MM 2.5MM BALLOON DILATATION STERILE",SUP-225-103-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER RELOAD 30MM GRAY",SUP-AESR30G,CDM,S27200284,LOCAL,0272,RC,,,both,,,1336.50,400.95,"KAISER [10500]",Kaiser,,895.46,67,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 1-2 15MM KNEE POSTERIOR STABILIZE HIGH",SUP-71421504,CDM,C1776,HCPCS,0278,RC,,,both,,,10774.35,3232.3,"CIGNA [10200]","Cigna Open Access",,6130.61,56.9,,5302.19,4377.88,6578.61,27,1253.06,9158.2,"percent of total billed charges",
"STENT ORSIRO MISSION 35MM 140CM 2.75MM CORONARY STERILE",SUP-453969,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,441.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHEATHLESS EAUCATH 100CM 7.5FR .081IN AL1 CURVE GUIDING",SUP-G7AL10-0-L100,CDM,C1887,HCPCS,0272,RC,,,both,,,1053.00,315.9,"PHCS [10601]",PHCS,,737.1,70,,,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.50 X 18 MM  RX FDA",SUP-1203350-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII ALLOGRAFT 18MM 23MM",SUP-401218A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE VISI-BLACK 5-0 C-1 24IN 2 ARM MONOFILAMENT BLUE",SUP-8325H,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.30,53.19,"CIGNA [10200]","Cigna Local Plus",,94.86,53.5,,,,,0,20.62,150.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC 54-66IN SMARTVEST 2XL HIGH FREQUENCY CHEST",SUP-SW-54/66-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"CIGNA [10200]","Cigna Local Plus",,232.73,53.5,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL L HOOK 44CM 5MM UNIVERSAL PLUS",SUP-60-5274-144,CDM,S27200284,LOCAL,0272,RC,,,both,,,212.28,63.68,"CIGNA [10200]","Cigna Open Access",,120.79,56.9,,,,,0,24.69,180.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE 25CM 2.5CM 7FR INTRO STAINLESS STEEL",SUP-RSS706,CDM,C1894,HCPCS,0272,RC,,,both,,,156.60,46.98,"KAISER [10500]",Kaiser,,104.92,67,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ENTEER VASCULAR 28D STD 300CM 1.5MM .014IN HYDROPHILIC",SUP-ENW-SD-014-300,CDM,C1769,HCPCS,0272,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX RADIANZ 190CM 30MM 8MM .018IN BALLOON DILATATION",SUP-R51008003L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 2MM CANNULATED AO",SUP-AR-8933-20C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM VEIN DISTENTION GRAFT TUNNELING",SUP-26050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1278.75,383.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS MULTIPASS 4-0 PS-2 27IN BRAID COATED UNDYED",SUP-VCP426H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR",518,MS-DRG,,,,,,,inpatient,,,105427.95,31628.38,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,,,"Fee schedule rate ($0). Wage-adjusted base payment rate plus any adjustments related to capital costs, indirect medical education (IME), disproportionate share hospital (DSH) adjustors, new technology, hemophilia, sole community hospital (SCH) and Medicare Dependent Hospital (MDH) adjustors, transfers, and outliers.",,,,0,,,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KNIFE URETHROTOME CORRUGATE",SUP-A3557,CDM,S27200284,LOCAL,0272,RC,,,both,,,2004.75,601.42,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE FEMORAL 35MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-151101203,CDM,C1776,HCPCS,0278,RC,,,both,,,16151.52,4845.46,"CIGNA [10200]",Cigna,,6460.61,40,,5873.17,5873.17,5873.17,"1 through 10",1878.42,13728.79,"percent of total billed charges",
"HEAD FEMORAL +12MM 26MM HIP PRIMARY TAPER OFFSET COCR LFIT V",SUP-6260-9-426,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,895.15,28.62,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X120 80CM SL",SUP-48007012N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"UHC [10700]","United Healthcare",,658.96,63.3,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ADMIN 126IN 15 GTT/ML INTRAVENOUS STERILE LATEX FREE",SUP-490283,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.83,25.45,"PHCS [10601]",PHCS,,59.38,70,,,,,0,9.87,72.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9 % IVPB-ADDV/MBP",RX-120160,CDM,J3490,HCPCS,0258,RC,00338-0553-18,NDC,both,100,ML,100.65,30.19,"CIGNA [10200]",Cigna,,68.44,68,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 7MMX79MM 7FR 80CMCATH HEPARIN",SUP-BXB077901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"CIGNA [10200]","Cigna Local Plus",,6743.33,31.5,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNAP(R) DRESSING KIT WITH FOAM -10 KIT CASE",SUP-SKTF15X15,CDM,S27200284,LOCAL,0272,RC,,,both,,,410.64,123.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,47.76,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.76,349.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KT INTRO 13CM 10FR SFSHTH",SUP-6268,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"FIRST HEALTH [10303]","First Health",,69.6,80,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR LOW DOME 7MM 25MM ADVANCE ALL POLY KNEE",SUP-KPRC25LO,CDM,C1776,HCPCS,0278,RC,,,both,,,3322.50,996.75,"BLUE CROSS [10001]","Blue Cross PPO",,1302.42,39.2,,3949.44,3949.44,3949.44,"1 through 10",386.41,2824.13,"percent of total billed charges",
"NDL NERVE BLOCK 100MM 21GA SONOPLEX II FACET S TIP INJECTION",SUP-001287-77,CDM,C9812,HCPCS,0272,RC,,,both,,,153.12,45.94,"UHC [10700]","United Healthcare",,96.92,63.3,,,,,0,17.81,130.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Cfx Rad/Ulnar Shaft W Manip",PX-450000110,CDM,25565,CPT,0450,RC,,,both,,,3198.00,959.4,"BLUE CROSS [10001]","Blue Cross PPO",,3198,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,67.13,3198,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 8MM CUFFED HOODED MURPHY EYE LOW PRESSURE",SUP-8229508,CDM,S27200284,LOCAL,0272,RC,,,both,,,3487.50,1046.25,"MULTIPLAN [10600]",Multiplan,,2964.38,85,,,,,0,405.6,2964.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL COCHLEAR 6MM 4MM DERMALOCK BAHA TITANIUM HA 1 STAGE",SUP-93329,CDM,L8690,HCPCS,0278,RC,,,both,,,21042.00,6312.6,"BLUE CROSS [10001]","Blue Cross HMO",,8248.46,39.2,,,,,0,2447.18,17885.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
SHEATHS,SUP-FCL20102,CDM,C1893,HCPCS,0272,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 4MM BALL DISSECTING DIAMOND",SUP-MR8-9BA40D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.17,412.25,"CIGNA [10200]","Cigna Local Plus",,735.18,53.5,,,,,0,159.82,1168.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Lumb/Sac Sngl WO Img",PX-510000205,CDM,62322,CPT,0761,RC,,,both,,,4263.00,1278.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1793,,"Per diem ($1,793).",,,,0,495.79,3623.55,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cortisol Blood Total",PX-301000158,CDM,82533,CPT,0301,RC,,,both,,,341.90,102.57,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.44,,"Fee schedule rate ($17.44). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",24.55,24.55,24.55,"1 through 10",0.01,290.62,"fee schedule",
"FILLER BONE VOID 30ML .5-5MM 80% CORTICAL 20% CANCELLOUS",SUP-450776,CDM,C1713,HCPCS,0278,RC,,,both,,,3184.88,955.46,"MULTIPLAN [10600]",Multiplan,,2707.15,85,,,,,0,370.4,2707.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -2.7MM 28MM HIP HEMISPHERICAL CERAMIC TRITANIUM",SUP-6570-0-328,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CIGNA [10200]","Cigna Open Access",,5690,56.9,,5302.19,4377.88,6578.61,27,1163,8500,"percent of total billed charges",
"SPLINT ORTHOPEDIC THK1/8IN LARGE 4.5IN HAND LEFT WRIST",SUP-A311305,CDM,S27000186,LOCAL,0270,RC,,,both,,,260.13,78.04,"NOVANET [10819]",Novanet,,195.1,75,,,,,0,30.25,221.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.6MM 16MM SPINE SELF DRILLING VARIABLE ANGLE",SUP-184.156,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"CIGNA [10200]",Cigna,,639.2,68,,1831.33,1831.33,1831.33,16,109.32,799,"percent of total billed charges",
"CURET 3MM 1 STRAIGHT 5.75IN BUCK EAR SHARP SURGICAL",SUP-380202,CDM,S27200284,LOCAL,0272,RC,,,both,,,134.07,40.22,"AETNA [10100]","Aetna HMO/PPO",,106.59,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.59,113.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 14MM 3FR GEMINI HELICAL",SUP-M0063302100,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1006.09,68,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMAKER CARDIAC THK6MM SMALL 50X46MM ENDURITY 2 CHAMBER IS",SUP-PM2160,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"UHC [10700]","United Healthcare",,26332.8,63.3,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POLYMYXIN B SULFATE 500,000 UNITS/5ML (WET SOLR VIAL)",RX-4156393,CDM,,,0250,RC,70860-0124-41,NDC,both,1,UN,49.38,14.81,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER HEMOSTASIS TEAR AWAY 6FR SAFESHEATH",SUP-6263,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CASSETTE INFUSION PUMP TEMPORARY BLOOD PUMP STERILE LATEX",SUP-0052-0002,CDM,S27200284,LOCAL,0272,RC,,,both,,,4830.00,1449,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG BURN INCISION PATCH STRIP 20CM PREVENA",SUP-PRE1055US.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2091.15,627.34,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM INSPIRA AIR 40MM 10MM BALLOON DILATATION HIGH",SUP-BC1040A,CDM,C1726,HCPCS,0272,RC,,,both,,,4795.50,1438.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FRCP GRASPING ALLIGATOR JAW AUTOCLAVABLE RETRIEVAL BASKET",SUP-FG-49L-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3433.88,1030.16,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 4MM 40MM SOLERA CD HORIZON OSTEOGRIP TITANIUM COCR",SUP-54840004040,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"FIRST HEALTH [10303]","First Health",,7637.48,80,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vad Cable Sys Mon to Pwr Mod",PX-E27400013,CDM,Q0486,HCPCS,0274,RC,,,both,,,2916.00,874.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,345.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,339.13,2478.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WATCHMAN FLX PROCEDURE  TRUSEAL ACCESS SYSTEM",SUP-WMFLXTRUACCPERPROC,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"FIRST HEALTH [10303]","First Health",,5520,80,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT 5-13CM ALEXIS ATRAUMATIC FLEXIBLE RETRACTION RING",SUP-HR104,CDM,S27200284,LOCAL,0272,RC,,,both,,,1800.00,540,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,739.8,41.1,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 15MM 140CM .91-1.12MM 2.25MM CORONARY",SUP-RONYX22515W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,392.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 4.5MM 24MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.524.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,170.71,28.62,,,,,0,69.37,507.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELINE-O SCREW, 5.5X30MM TRACTION POLY",SUP-13115530,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA [10200]","Cigna Local Plus",,5107.56,53.5,,3978.14,359.25,3978.14,24,1110.3,8114.82,"percent of total billed charges",
"GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR",RX-37648,CDM,,,0637,RC,60687-0768-11,NDC,both,1,UN,9.63,2.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4.42,45.9,,,,,0,1.12,8.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE 5-14FR SECUREMENT","SUP-680ME 5F-14F",CDM,S27200284,LOCAL,0272,RC,,,both,,,81.43,24.43,"PHCS [10601]",PHCS,,57,70,,,,,0,9.47,69.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 12MM 144CM 3.5MM CORONARY STENT",SUP-H7493941812350,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,858.6,28.62,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 85MM 2-6MM VORTX 18 COIL PLATINUM FIBER",SUP-M0013812061,CDM,S27800098,LOCAL,0278,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY PINK 10CM 18GA 17GA BARD MISSION TRUGUIDE 10MM 20",SUP-1810MSK,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"MULTIPLAN [10600]",Multiplan,,347.57,85,,,,,0,47.56,347.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 52MM TAN X25 LOCK STERILE LIGHT GREEN 4.2MM",SUP-04.045.052TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 1.5 X 2 COMPLEX FINISHING COIL",SUP-10CFN-01502,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]",Cigna,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL XS UNIVERSAL 18MM KNEE COCR POLYETHYLENE",SUP-198727118,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"CIGNA [10200]","Cigna Local Plus",,9307.11,31.5,,5372.07,4581.20,7242.98,23,3436.24,25114.41,"percent of total billed charges",
"CATH SUPER TORQUE 100CM 5FR .0395IN SIDEWINDER SIMMONS",SUP-532503,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"UHC [10700]","United Healthcare",,66.09,63.3,,,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FUROSEMIDE 20 MG TABLET",RX-3294,CDM,,,0637,RC,00054-8297-25,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 4MM CORONARY STENT EVEROLIMUS",SUP-H7493926132400,CDM,C1874,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3544.88,41.1,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 4MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035424150,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"MULTIPLAN [10600]",Multiplan,,11997.44,85,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC LARGE HUMERUS ADJUSTABLE HOOK LOOP CLSR",SUP-FB1000-14,CDM,S27000186,LOCAL,0270,RC,,,both,,,411.68,123.5,"AETNA [10100]","Aetna HMO/PPO",,327.29,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.88,349.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 3-0 CT-2 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8410H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 80CM .018IN STAINLESS STEEL MANDRELL SS TIP",SUP-06507210,CDM,C1769,HCPCS,0272,RC,,,both,,,200.54,60.16,"NOVANET [10819]",Novanet,,150.41,75,,,,,0,23.32,170.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARTEMIS NEURO EVACUATION DEVICE 1.5",SUP-AP15,CDM,S27200284,LOCAL,0272,RC,,,both,,,45328.50,13598.55,"FIRST HEALTH [10303]","First Health",,36262.8,80,,,,,0,5271.7,38529.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 8FR 8MM ENDOPROSTHESIS HEPARIN",SUP-VBHR080502A,CDM,C1874,HCPCS,0278,RC,,,both,,,18761.40,5628.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5065.58,27,,,,,0,2181.95,15947.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SAFIRE TX COMFORTGRIP 110CM 8MM 7FR 2-5-2MM SPACING 1MM",SUP-402842,CDM,C1733,HCPCS,0272,RC,,,both,,,6555.00,1966.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,776.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3522,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"KAISER [10500]",Kaiser,,1004,67,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pacu Cc Add 30 Min",PX-710000008,CDM,9999178,LOCAL,0710,RC,,,both,,,843.44,253.03,"CIGNA [10200]",Cigna,,573.54,68,,,,,0,98.09,716.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SMOOTH SHELL",SUP-SCM-330,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS [10001]","Blue Cross PPO",,2961.76,39.2,,16595.83,16595.83,16595.83,"1 through 10",878.7,6422.18,"percent of total billed charges",
"CMPNT FEMORAL 6D XS 66X58MM KNEE LEFT ROTATE HINGE PIN",SUP-623421L,CDM,C1776,HCPCS,0278,RC,,,both,,,30350.88,9105.26,"FIRST HEALTH [10303]","First Health",,24280.7,80,,,,,0,3529.81,25798.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 FLEXOR 30MM 125CM 7MM 5FR LOW PROFILE",SUP-G43775,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1918.16,45.9,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZENITH ALPHA THORACIC ENDOVASCULAR GRAFT PROXIMAL COMPONENTS",SUP-G35343,CDM,C1874,HCPCS,0278,RC,,,both,,,96672.00,29001.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11455.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11242.95,82171.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET SPINE MULTIAXIAL EXT LATERAL CNCT VERTEX",SUP-7753520,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,159.73,45.9,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 CURVE PLUS 15MM KNEE XLK FIX BEARING SIGMA",SUP-970433,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UHC [10700]","United Healthcare",,7073.49,63.3,,8601.07,8395.67,8601.07,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"SCR BONE 3.5MM 13MM ZEVO TITANIUM SPINE CERVICAL ANTERIOR",SUP-7723513,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",117.75,860.63,"percent of total billed charges",
"SPACER SPINAL 16X6MM COLONIAL 7D LORDOTIC 14MM XL TITANIUM",SUP-365.806CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Open Access",,3140.88,56.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM STAINLESS STEEL T8 CORTEX TUBE STARDRIVE",SUP-201.768TS,CDM,C1713,HCPCS,0278,RC,,,both,,,476.28,142.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,218.61,45.9,,,,,0,55.39,404.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE SYNTHETIC CALCIUM SULFATE 5ML OSTEOSET RESORBABLE",SUP-84000611,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"FIRST HEALTH [10303]","First Health",,3450,80,,,,,0,501.54,3665.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION",RX-10224,CDM,J1171,HCPCS,0636,RC,00409-2634-10,NDC,both,1,ML,497.10,149.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,58.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.66,422.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 34FR VENOUS STAINLESS STEEL",SUP-66134,CDM,S27200284,LOCAL,0272,RC,,,both,,,285.63,85.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,194.23,68,,,,,0,33.22,242.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transcath Intraop Microinf",PX-361000641,CDM,C9759,HCPCS,0361,RC,,,both,,,5464.00,1639.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1249,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,635.46,4644.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR AVENIR COMPLETE 6 STD HIP STERILE LATEX",SUP-574201060,CDM,C1776,HCPCS,0278,RC,,,both,,,23461.20,7038.36,"BLUE CROSS [10001]","Blue Cross PPO",,9196.79,39.2,,3949.44,3949.44,3949.44,"1 through 10",2728.54,19942.02,"percent of total billed charges",
"HC Fna Bx W/US Gdn 1st Les",PX-361000477,CDM,10005,CPT,0361,RC,,,both,,,2651.08,795.32,"AETNA [10100]","Aetna HMO/PPO",,2107.61,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,308.32,2651.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT FEMORAL 30MM GMRS KNEE COCR",SUP-6495-6-030,CDM,C1776,HCPCS,0278,RC,,,both,,,16025.25,4807.57,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4326.82,27,,,,,0,1863.74,13621.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 62MM STAINLESS STEEL 3.5MM SCR 3 HOLE SHARP HOOK LOW",SUP-02.113.103S,CDM,C1713,HCPCS,0278,RC,,,both,,,3724.88,1117.46,"AMERIGROUP MEDICAID [20100]",Amerigroup,,441.4,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",433.2,3166.15,"percent of total billed charges",
"BODY CONE 31MM RESTORATION +10MM HIP PROXIMAL MODULAR",SUP-6276-1-131,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"CIGNA [10200]","Cigna Open Access",,7455.34,33.5,,5302.19,4377.88,6578.61,27,2588.23,18916.54,"percent of total billed charges",
"SCR BONE 7.5MM 40MM PRECEPT SPINE POLYAXIAL NONSTERILE",SUP-8807540A,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VISIGI 3D 36FR GASTRIC LAVAGE",SUP-5236,CDM,S27000186,LOCAL,0270,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL STEALTH LATIS 6MM LOW PROFILE 30MM .5 SPRING",SUP-A1601,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 28MM 145CM 4MM CORONARY STENT",SUP-1125400-28,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"CIGNA [10200]","Cigna Open Access",,3321.82,56.9,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND COMPRESSION SHORT SMALL PLASTIC R-BAND DUAL BALLOON",SUP-3521,CDM,S27000186,LOCAL,0270,RC,,,both,,,165.30,49.59,"NOVANET [10819]",Novanet,,123.98,75,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 16MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P216,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Open Access",,4754.51,56.9,,5302.19,4377.88,6578.61,27,971.79,7102.52,"percent of total billed charges",
"NEROSTIMLTR IMPLANTABLE CHRONIC PAIN RS2",SUP-97715,CDM,C1820,HCPCS,0278,RC,,,both,,,85500.00,25650,"FIRST HEALTH [10303]","First Health",,68400,80,,,,,0,9943.65,72675,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER FLEXIVA 1000UM FLEXSHIELD HIGH POWER POLISH",SUP-M0068403940,CDM,S27200284,LOCAL,0272,RC,,,both,,,4633.07,1389.92,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,549.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,538.83,3938.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 12X11CM BREAST 400CC STYLE 133S SMOOTH 3 SUT TAB",SUP-133S-MX-12-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"AETNA [10100]","Aetna HMO/PPO",,7405.43,79.5,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 52MM 32MM MARATHON HIP",SUP-121932052,CDM,C1776,HCPCS,0278,RC,,,both,,,7234.65,2170.39,"CIGNA [10200]","Cigna Local Plus",,3870.54,53.5,,5372.07,4581.20,7242.98,23,841.39,6149.45,"percent of total billed charges",
"SYSTEM GRAFTMASTER 16MM 4.8MM CORONARY STENT STAINLESS STEEL",SUP-1012584-16,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1958.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP SOLID BACK METAL HA TRIDENT F",SUP-500-11-56F,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.85,2973.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4549.54,45.9,,,,,0,1152.75,8425.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 250MM 4MM BALLOON DILATATION RAPID EXCHANGE",SUP-47540250S,CDM,C1725,HCPCS,0272,RC,,,both,,,2025.00,607.5,"PHCS [10601]",PHCS,,1417.5,70,,,,,0,235.51,1721.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 25MM MITROFLOW BOVINE PERICARDIUM",SUP-LXA25,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT UNDYED VICRYL 2-0 CT-1 18IN CONTROL RELEASE BRAID 8",SUP-J839D,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.65,37.69,"MULTIPLAN [10600]",Multiplan,,106.8,85,,,,,0,14.61,106.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX PDS PLUS 1 OS-6 24IN VIOLET ABSORBABLE",SUP-SXPP1A203,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,28.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PRECISION CORTICAL RING ALLOGRAFT FREEZE DRIED 26",SUP-439010,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"3.3/4F DECA 2-10-2 S 120CM",SUP-903221,CDM,C1730,HCPCS,0272,RC,,,both,,,6210.00,1863,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,722.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 32MM PERIPHERAL STERILE",SUP-AR-9562-32NL,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"BLUE CROSS [10001]","Blue Cross PPO",,234.17,39.2,,957.42,570.23,957.42,28,69.48,507.77,"percent of total billed charges",
"GRAFT SOFT TISSUE ACHILLES TENDON FROZEN STRUT",SUP-02B002-55,CDM,C1762,HCPCS,0278,RC,,,both,,,10563.90,3169.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1228.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1228.58,8979.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 71MM REGENEREX KNEE PRIMARY CRUCIATE RETAIN",SUP-141273,CDM,C1776,HCPCS,0278,RC,,,both,,,11964.60,3589.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3230.44,27,,,,,0,1391.48,10169.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS 90CM 4MM 8FR 2-5-2MM SPACE B CURVE ABLATION 10",SUP-D8BTCBL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"AETNA [10100]","Aetna HMO/PPO",,3944.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR IM CURVE ANGIOGRAPHIC CORONARY 2 WIRE",SUP-H749165992012,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]","Cigna Local Plus",,40.97,53.5,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 13MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P413,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]",Cigna,,5682.01,68,,5873.17,5873.17,5873.17,"1 through 10",971.79,7102.52,"percent of total billed charges",
"SYSTEM PORTICO FLEXNAV 107CM 6.3MM DELIVERY",SUP-FNAV-DS-LG,CDM,S27200284,LOCAL,0272,RC,,,both,,,10350.00,3105,"PHCS [10601]",PHCS,,7245,70,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE L 32MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 2X3",SUP-249.688,CDM,C1713,HCPCS,0278,RC,,,both,,,2305.80,691.74,"BLUE CROSS [10001]","Blue Cross HMO",,903.87,39.2,,957.42,156.86,7483.26,51,268.16,1959.93,"percent of total billed charges",
"CATH ADVANCE 18LP 80CM 4CM 4FR 5MM .018IN BALLOON DILATATION",SUP-G50236,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP REVISION TRITANIUM F",SUP-509-02-60F,CDM,C1776,HCPCS,0278,RC,,,both,,,11232.00,3369.6,"MULTIPLAN [10600]",Multiplan,,9547.2,85,,,,,0,1306.28,9547.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 16MM GORILLA R3CON LOCK PLATE SYSTEM",SUP-P50-353-2716,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",155.43,1136.03,"percent of total billed charges",
"DRAIN INCISION 4MM CLOT STOP FACIAL 2 LUMEN FILTER STERILE",SUP-410AT,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.44,90.43,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,138.36,45.9,,,,,0,35.06,256.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM TAPER 32MM HIP MODULAR TYPE 1 BIOLOX DELTA",SUP-12-115116,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"BLUE CROSS [10001]","Blue Cross HMO",,3448.62,39.2,,5311.50,4717.44,5388.59,31,1023.15,7477.88,"percent of total billed charges",
"SCR BONE 3MM 36MM DART-FIRE TITANIUM SMALL PARTIAL THREAD",SUP-D2N30032,CDM,C1713,HCPCS,0278,RC,,,both,,,1657.50,497.25,"CIGNA [10200]","Cigna Open Access",,943.12,56.9,,1144.80,304.56,2275.09,66,192.77,1408.88,"percent of total billed charges",
"TERAZOSIN 5 MG CAPSULE",RX-14553,CDM,,,0637,RC,50268-0766-11,NDC,both,1,UN,8.08,2.42,"AETNA [10100]","Aetna HMO/PPO",,6.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.94,6.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG VARIABLE ANGLE LOCKING 1.8MM X 12MM",SUP-SPLS-18120-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"NOVANET [10819]",Novanet,,1069.2,75,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 20MM 135CM 4MM .018IN BILIARY STAINLESS",SUP-G56620,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"PHCS [10601]",PHCS,,3528,70,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X7MM HEDRON C 7D 14MM STERILE LATEX FREE",SUP-1211.4617S,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1777.3,28.62,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 32.77CM 8MM DA VINCI XI ENDOWRIST 75D",SUP-470207,CDM,S27000186,LOCAL,0270,RC,,,both,,,1732.50,519.75,"UHC [10700]","United Healthcare",,1096.67,63.3,,,,,0,201.49,1472.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP BIOPSY PRESHAPE RADIAL TIP 50CM 2.2MM BIPAL INTERNAL",SUP-502402B,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"FIRST HEALTH [10303]","First Health",,1500,80,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 50MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0319,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross HMO",,371.5,39.2,,957.42,156.86,7483.26,51,110.22,805.55,"percent of total billed charges",
"LENS IOL ANTERIOR ASPHERIC SURFACE ABERRATION FREE ADVANCED",SUP-LI61AOR1350,CDM,V2632,HCPCS,0276,RC,,,both,,,1012.50,303.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 20MM 3.75MM BALLOON DILATATION",SUP-H7493912420370,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"UHC [10700]","United Healthcare",,410.18,63.3,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION",RX-8878,CDM,,,0250,RC,00517-6101-25,NDC,both,10,ML,278.14,83.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 214MM 16MM CANNULATED HOLLOW LARGE QUICK COUPLING",SUP-03.037.004S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4978.76,1493.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH SENTRANT .035IN 64CM 16FR INTRO HYDROPHILIC",SUP-SENSH1664W,CDM,C1894,HCPCS,0272,RC,,,both,,,3180.00,954,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NANOCROSS 150CM 60MM 3.5MM .014IN BALLOON DILATATION",SUP-AB14W035060150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE 10CM 2.5CM 7FR INTRO STAINLESS STEEL",SUP-RSS702,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE POWERTURN FLEX VASCULAR STRAIGHT 300CM 3CM",SUP-1044593,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRNQT SURGICAL YELLOW TOURNI-COT SMALL RING FINGER TOE",SUP-TCS,CDM,S27200284,LOCAL,0272,RC,,,both,,,776.30,232.89,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE ORTHOPEDIC THK1/8IN MEDIUM 13IN NEOPRENE KNEE EXTRA",SUP-79-82005,CDM,S27200284,LOCAL,0272,RC,,,both,,,56.72,17.02,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"END CAP SPINAL 14X4MM COLOSSEUM 3.5D 12MM NONSTERILE LATEX",SUP-156.264,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"CIGNA [10200]","Cigna Local Plus",,1841.74,53.5,,,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAMINAR IMPLANT SIZE (16MM)",SUP-FG-6032,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 21MM MASTERS HP STD MECHANICAL CUFF ROTATABLE",SUP-21AHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"CIGNA [10200]","Cigna Local Plus",,9172.56,31.5,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM INTERLOCK IDC OCCLUSION SYSTEM",SUP-M0013613100,CDM,S27800098,LOCAL,0278,RC,,,both,,,3795.00,1138.5,"FIRST HEALTH [10303]","First Health",,3036,80,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOLDER 5.5IN CASTROVIEJO SERRATE INSRT LOCK NDL TUNGSTEN",SUP-32-441,CDM,S27200284,LOCAL,0272,RC,,,both,,,1540.46,462.14,"CIGNA [10200]","Cigna Open Access",,876.52,56.9,,,,,0,179.16,1309.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE NERVE STIM RIGHT LATERAL MECHANOMYOGRAPHIC",SUP-286202208,CDM,S27000186,LOCAL,0270,RC,,,both,,,6727.50,2018.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3087.92,45.9,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 12.5CM 3MM IBUR DISTAL BEND MATCH HEAD",SUP-8431-107-530,CDM,S27200284,LOCAL,0272,RC,,,both,,,3045.45,913.63,"AMERIGROUP MEDICAID [20100]",Amerigroup,,360.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,354.19,2588.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 10% DEXTROSE EXCEL 500ML LATEX FREE",SUP-L5201,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"NOVANET [10819]",Novanet,,60.75,75,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM 22-26-28-32-36MM HIP 3 HOLE POROUS",SUP-71336058,CDM,C1776,HCPCS,0278,RC,,,both,,,22160.25,6648.07,"NOVANET [10819]",Novanet,,16620.19,75,,,,,0,2577.24,18836.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BIOPSY 15CM 11GA OSTEO-SITE 30D SIDE BEVEL DIAMOND BONE",SUP-G12374,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"AETNA [10100]","Aetna HMO/PPO",,371.89,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.4,397.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 100MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035100S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"FIRST HEALTH [10303]","First Health",,1146.96,80,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 13.35IN 18FR HEYMAN PLASTIC DILATION CATH",SUP-021118,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.15,65.14,"CIGNA [10200]",Cigna,,147.66,68,,,,,0,25.25,184.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MOBILE POWER UNIT INC. AC POWER CABLE",SUP-107754,CDM,Q0479,HCPCS,0274,RC,,,both,,,48988.80,14696.64,"BLUE CROSS [10001]","Blue Cross HMO",,19203.61,39.2,,,,,0,5697.4,41640.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM PRESTIGE PLUS HELICAL COMPLEX",SUP-PRES1030CPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3008.75,45.9,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 9MM 33MM SYMMETRIC TRIATHLON X3 KNEE SUPERIOR",SUP-5550L339,CDM,C1776,HCPCS,0278,RC,,,both,,,4478.10,1343.43,"CIGNA [10200]",Cigna,,3045.11,68,,5873.17,5873.17,5873.17,"1 through 10",520.8,3806.39,"percent of total billed charges",
"CATH METACROSS RX 135CM 120MM 5.7-3.9FR 6MM BALLOON",SUP-BD-L60120CR,CDM,C1725,HCPCS,0272,RC,,,both,,,959.85,287.95,"FIRST HEALTH [10303]","First Health",,767.88,80,,,,,0,111.63,815.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY ALWAYS-ON TIP TRACKED",SUP-INS-0352,CDM,S27200284,LOCAL,0272,RC,,,both,,,3912.30,1173.69,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1607.96,41.1,,,,,0,455,3325.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SMART 120MM 150CM 8MM LONG BILIARY NITINOL SELF",SUP-C08120MB,CDM,C1876,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"BLUE CROSS [10001]","Blue Cross PPO",,3042.9,39.2,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061755810,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]","Cigna Open Access",,513.34,,,,,,,104.92,766.85,"percent of total billed charges",
"MORPHINE 10 MG/ML INJECTION SUPERORDERABLE",RX-4085168,CDM,J2270,HCPCS,0636,RC,00641-6127-01,NDC,both,1,ML,48.27,14.48,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8.15,,,,,,,2.54,41.03,"fee schedule",
"HC Enteroscopy W Rmvl FB",PX-750000228,CDM,44363,CPT,0750,RC,,,both,,,3196.00,958.8,"UHC [10700]","United Healthcare",,3196,,"Case rate ($3,833). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,371.69,3196,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 5 KNEE LEFT CRUCIATE RETAINING PFC SIGMA P",SUP-940015,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,10640.73,41.1,,6417.48,6417.48,6417.48,"1 through 10",3010.99,22006.37,"percent of total billed charges",
"TRAY DRNG 10FR FLEXIBLE REVOLUTION SECUREMENT DEVICE RESOLVE",SUP-RLC-NV-10-REV,CDM,C1729,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PHCS [10601]",PHCS,,878.85,70,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ACCUDRAIN EXTERNAL DRNG CSF GRADUATE BURETTE",SUP-INS8401,CDM,C1729,HCPCS,0272,RC,,,both,,,3587.18,1076.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1474.33,41.1,,,,,0,417.19,3049.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION 2MM .76MM MORETZ TYTAN EAR TAB TITANIUM",SUP-1066108,CDM,S27800098,LOCAL,0278,RC,,,both,,,179.42,53.83,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,82.35,45.9,,,,,0,20.87,152.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 30MM SUREFORM STERILE 8MM LATEX FREE DISPOSABLE",SUP-48230W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR SL4 CURVE GUIDING CORONARY LATEX",SUP-LA8SL40,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"MULTIPLAN [10600]",Multiplan,,310.59,85,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP PHACOEMULSIFICATION 1.1MM ABS 30D FLARE STERILE",SUP-8065740806,CDM,S27200284,LOCAL,0272,RC,,,both,,,568.30,170.49,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EZ STEER THERMOCOOL 115CM 3.5MM 7.5FR 2-5-2MM SPACE F-F",SUP-BDI75TCFFRT,CDM,C2630,HCPCS,0272,RC,,,both,,,10626.00,3187.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL MEMORYSHAPE MEDIUM HEIGHT MODERATE PLUS PROFILE",SUP-RSZ-1105S,CDM,S27200284,LOCAL,0272,RC,,,both,,,230.55,69.16,"KAISER [10500]",Kaiser,,154.47,67,,,,,0,26.81,195.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC .75CM 13.2CU CM 4.45X4.81CM ESSENTIO",SUP-L100,CDM,C1786,HCPCS,0275,RC,,,both,,,24840.00,7452,"NOVANET [10819]",Novanet,,18630,75,,,,,0,2888.89,21114,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.0MM X 18.0MM",SUP-493001812,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"FIRST HEALTH [10303]","First Health",,648,80,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cann Eopa Blunt Nonvent 22f",PX-E27200343,CDM,E27200343,LOCAL,0272,RC,,,both,,,342.10,102.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,157.02,45.9,,,,,0,39.79,290.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.453,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"AETNA [10100]","Aetna HMO/PPO",,3849.87,79.5,,1521.93,481.35,16760.95,30,563.19,4116.21,"percent of total billed charges",
"SYSTEM PROMUS ELEMENT PLUS 8MM 144CM 2.5MM CORONARY STENT",SUP-H7493911408250,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"UHC [10700]","United Healthcare",,5787.2,63.3,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM 37.1MM 30.9MM MITRAL HOLDER",SUP-4450M32,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"MULTIPLAN [10600]",Multiplan,,9677.25,85,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 28CM 8FR 2.1FR POLARIS ULTRA NAUTILUS .035IN 2",SUP-M006192154050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS [10001]","Blue Cross PPO",,470.63,39.2,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ 190CM 250MM 2MM .018IN BALLOON",SUP-R51002025L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"KAISER [10500]",Kaiser,,1669.56,67,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 24F LARGE HIP PROXIMAL",SUP-550568,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4996.1,45.9,,,,,0,1265.9,9252.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 5FR 2-5-2MM SPACE A CURVE",SUP-F5SQA252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,274.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 22.5MM PRECISION THK.015IN RECIPROCATING TAPERED",SUP-5100137133,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.38,176.51,"PHCS [10601]",PHCS,,411.87,70,,,,,0,68.43,500.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30MM 4MM VORTX 35 COIL PUSHABLE 4MM",SUP-M0013732041,CDM,S27800098,LOCAL,0278,RC,,,both,,,769.50,230.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,353.2,45.9,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 8MM CONCERTO DETACHABLE",SUP-NV-8-30-HELIX,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"KAISER [10500]",Kaiser,,3004.95,67,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.5/13",SUP-401736,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE FEEDING ORANGE 40CM 5FR NUTRIO TWISTLOK ENTERAL",SUP-ENSI4050,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.36,32.21,"KAISER [10500]",Kaiser,,71.93,67,,,,,0,12.49,91.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.834,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,28.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,27.52,201.14,"percent of total billed charges",
"CATH SABER 150CM 100MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,169.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 2-0 GS-22 6IN CLSR ABSORBABLE GREEN",SUP-VLOCL2105,CDM,S27200284,LOCAL,0272,RC,,,both,,,195.84,58.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC TREK NEO 145CM 12MM 2MM BALLOON DILATATION PEBAX",SUP-1400200-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE OXYGEN SAMPLE BODY BOX SAMPLE LINE ASSEMBLY FOR V62J AN",SUP-769525,CDM,S27200284,LOCAL,0272,RC,,,both,,,792.02,237.61,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABERX RADIANZ 5MM3CM 190",SUP-R51005003L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMPRESS 65CM 5FR CB2 CURVE ANGIOGRAPHIC LEGATO",SUP-56538CB2-H,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.30,101.79,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SMOOTH PEG VARIABLE ANGLE LOCKING 1.8MM X 12MM",SUP-SPLS-18120-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",165.8,1211.76,"percent of total billed charges",
"STENT VISI-PRO 57MM 135CM 5MM 60MM BILIARY STAINLESS STEEL",SUP-PXB35-05-57-135,CDM,C1877,HCPCS,0278,RC,,,both,,,4367.00,1310.1,"CIGNA [10200]",Cigna,,2969.56,68,,,,,0,507.88,3711.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASE TIB STEM #1 LEFT PEGLESS",SUP-2585-0-0001,CDM,C1776,HCPCS,0278,RC,,,both,,,5939.00,1781.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4038.52,68,,,,,0,690.71,5048.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET TPR FIX FRM 70CM",SUP-6769,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,170.52,39.2,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 18MM RETRACTA DETACHABLE .035IN",SUP-G34203,CDM,S27800098,LOCAL,0278,RC,,,both,,,4674.68,1402.4,"PHCS [10601]",PHCS,,3272.28,70,,,,,0,543.67,3973.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERTAPE TIGERWIRE 2 2MM 8IN BLUE 24IN NONABSORBABLE",SUP-AR-7275T,CDM,S27200284,LOCAL,0272,RC,,,both,,,595.35,178.6,"UHC [10700]","United Healthcare",,376.86,63.3,,,,,0,69.24,506.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC THK7.5MM 5MM 6MM 47.9X50.3MM MVP ADAPTA DR",SUP-ADDR06,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16640,40,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL SUBST.75X10MM RT",SUP-2142-1-3410,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]",Cigna,,2422.5,68,,5873.17,5873.17,5873.17,"1 through 10",414.32,3028.13,"percent of total billed charges",
"STENT SUPERA 30MM 120CM 4.5MM 6FR VASCULAR NITINOL",SUP-S-45-030-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"UHC [10700]","United Healthcare",,6369.25,63.3,,,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE COALITION AGX 7D ALLOGRAFT 10X16X8MM",SUP-8128.1478S,CDM,S27800098,LOCAL,0278,RC,,,both,,,5002.50,1500.75,"CIGNA [10200]",Cigna,,3401.7,68,,,,,0,581.79,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 4MM NESTER 11.1 LOOP SOFT RADIOPACITY",SUP-G26988,CDM,S27800098,LOCAL,0278,RC,,,both,,,696.60,208.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,81.01,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN AL3 CURVE GUIDING CORONARY",SUP-LA7AL30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,45.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE NUCEL MEDIUM HUMAN AMNIOTIC PLACENTAL MEMB",SUP-NC-1001,CDM,S27800098,LOCAL,0278,RC,,,both,,,13593.00,4077.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3890.32,28.62,,,,,0,1580.87,11554.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lyme Disease Dna Ampl Probe",PX-306000119,CDM,87476,CPT,0306,RC,,,both,,,2196.00,658.8,"NOVANET [10819]",Novanet,,1647,75,,,,,0,0.01,1866.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 74X46X14MM NEXGEN LCCK 5-6 C-D STD KNEE",SUP-00599404114,CDM,C1776,HCPCS,0278,RC,,,both,,,16256.40,4876.92,"CIGNA [10200]","Cigna Local Plus",,5120.77,31.5,,5372.07,4581.20,7242.98,23,1890.62,13817.94,"percent of total billed charges",
"HC Legion Pneumophilia Ag If",PX-306000097,CDM,87278,CPT,0306,RC,,,both,,,215.00,64.5,"PHCS [10601]",PHCS,,150.5,70,,,,,0,0.01,182.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.453,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"PHCS [10601]",PHCS,,3389.82,70,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AUROUS BEACON TIP 100CM 5FR .035IN VCF CURVE",SUP-G31221,CDM,S27200284,LOCAL,0272,RC,,,both,,,1137.22,341.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,132.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,132.26,966.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BN 2MM 16MM LEIBINGER UNV 2",SUP-5020416,CDM,C1713,HCPCS,0278,RC,,,both,,,458.02,137.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,54.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",53.27,389.32,"percent of total billed charges",
"STENT VENOVO 80MM 80CM 12MM 3MM VASCULAR ILIOFEMORAL VEIN",SUP-VENUM12080,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6310.71,28.62,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,inpatient,,,250756.63,75226.99,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,56227.04,,"Case rate ($26,152.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $24,284, add-ons for qualifying new technology services are included. If operating cost exceeds $57,323.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,218.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $24,316.12. The transfer operating threshold is the transfer adjustment factor * $24,284.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,835.99. The transfer capital threshold is the transfer adjustment factor * $1,835.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,10994,123090.34,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 7MM 210MM HUMERAL EXPERT INTRAMEDULLARY ROUND",SUP-04.001.222S,CDM,C1713,HCPCS,0278,RC,,,both,,,9598.18,2879.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6526.76,68,,,,,0,1116.27,8158.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUBE DEMINERALIZED BONE 13MM Q-PACK CONFORM",SUP-4W0013,CDM,S27800098,LOCAL,0278,RC,,,both,,,4462.92,1338.88,"KAISER [10500]",Kaiser,,2990.16,67,,,,,0,519.04,3793.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LEMAITRE 80CM 3FR 8MM EMBOLECTOMY .20ML STERILE LATEX",SUP-E1601-38,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,71.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 7MM 210MM HUMERAL EXPERT INTRAMEDULLARY ROUND",SUP-04.001.222S,CDM,C1713,HCPCS,0278,RC,,,both,,,9598.18,2879.45,"CIGNA [10200]",Cigna,,6526.76,68,,1831.33,1831.33,1831.33,16,1116.27,8158.45,"percent of total billed charges",
"INTRO SHEATH 6FR 40CM CONTRALATERAL RADIOPAQUE BAND MAXIMUM",SUP-G10406,CDM,C1894,HCPCS,0272,RC,,,both,,,1547.10,464.13,"UHC [10700]","United Healthcare",,979.31,63.3,,,,,0,179.93,1315.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 11CM MINI GWIRE NO OBTR HEXCUSPID VALVE",SUP-504607X,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,32.18,41.1,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 220MM 2.8MM",SUP-03.333.004,CDM,C1769,HCPCS,0272,RC,,,both,,,745.20,223.56,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INPACT 80CM 80MM 9MM BALLOON TRANSLUMINAL PACLITAXEL",SUP-IAV09008008P,CDM,C2623,HCPCS,0272,RC,,,both,,,10281.00,3084.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ROTALINK 135CM .58IN 1.75MM ATHERECTOMY PTFE INTRO",SUP-H802227680040,CDM,C1724,HCPCS,0272,RC,,,both,,,6641.25,1992.37,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 4.5MM HUDSON CANNULATED",SUP-AR-8945-45C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 90CM 8FR XB4 CURVE GUIDING CORONARY SIDEHOLE",SUP-LA8EBU40SHD,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INQUIRY 110CM 1MM 4FR 2-5-2MM SPACE MEDIUM CURVE",SUP-81531,CDM,C1730,HCPCS,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Smoke/Tobacco Asymp >10",PX-510000213,CDM,99407,CPT,0942,RC,,,both,,,85.00,25.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE TRACH 15MM 13.8MM 9.5MM 9MM SHILEY ADULT FLEXIBLE CUFF",SUP-10CN10A,CDM,S27200284,LOCAL,0272,RC,,,both,,,366.97,110.09,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 2MM PRECISION ROUND EXTEND",SUP-5540009320,CDM,S27200284,LOCAL,0272,RC,,,both,,,1777.20,533.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 18X5.5MM THK.38MM THK.43MM THIN SMALL BONE",SUP-KM3-412,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.65,24.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.38,68.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Umbilical Neonate",PX-E27200076,CDM,E27200076,LOCAL,0272,RC,,,both,,,359.70,107.91,"CIGNA [10200]","Cigna Open Access",,204.67,56.9,,,,,0,41.83,305.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +14.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.145,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 11MM 40MM ASYMMETRIC TRIATHLON X3 KNEE",SUP-5551-G-401,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,511.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,502.16,3670.1,"percent of total billed charges",
"SUT ETHILON 9-0 BV100-4 5IN MONOFILAMENT BLACK NONABSORBABLE",SUP-2829G,CDM,S27200284,LOCAL,0272,RC,,,both,,,253.80,76.14,"MULTIPLAN [10600]",Multiplan,,215.73,85,,,,,0,29.52,215.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC MICROFIBRILLAR CLLGN SPONGE AVITENE",SUP-1050050,CDM,S27200284,LOCAL,0272,RC,,,both,,,395.42,118.63,"FIRST HEALTH [10303]","First Health",,316.34,80,,,,,0,45.99,336.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20MM 3MM 35 COIL PUSHABLE 2D HELICAL",SUP-M0013723021,CDM,S27800098,LOCAL,0278,RC,,,both,,,769.50,230.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL OSS LONG KNEE NONMODULAR 71MM STERILE",SUP-161043,CDM,C1776,HCPCS,0278,RC,,,both,,,23169.51,6950.85,"AETNA [10100]","Aetna HMO/PPO",,18419.76,79.5,,10981.53,8986.79,12413.38,12,2694.61,19694.08,"percent of total billed charges",
"INTERLOCK II DRILL BIT 2.25X12MM",SUP-6770080,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE SP 33C",SUP-TENDV-SP-33C-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"AETNA [10100]","Aetna HMO/PPO",,135945,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC",417,MS-DRG,,,,,,,inpatient,,,77914.60,23374.38,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,38048.12,,,,,,,7561,69673.33,"case rate",
"SCR BONE 3.5MM 20MM VARIAX NONSTERILE",SUP-657420,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,371.19,45.9,,,,,0,94.05,687.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 65MM STERILE",SUP-74013480,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.02,64.21,"FIRST HEALTH [10303]","First Health",,171.22,80,,,,,0,24.89,181.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 140CM 10MM 7FR .08IN .014IN GUIDING COMPATIBILITY",SUP-T2R7SA4A,CDM,C1757,HCPCS,0272,RC,,,both,,,2437.50,731.25,"FIRST HEALTH [10303]","First Health",,1950,80,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION",RX-10529,CDM,J0670,HCPCS,0636,RC,63323-0293-01,NDC,both,30,ML,136.81,41.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,13.81,,,,,,,3.88,116.29,"fee schedule",
"ATTACH TOOL LARGE NONSTERILE",SUP-359.212,CDM,S27200284,LOCAL,0272,RC,,,both,,,7113.21,2133.96,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4836.98,68,,,,,0,827.27,6046.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHLORHEXIDINE GLUCONATE 2 % TOWELETTE",RX-88296,CDM,,,0250,RC,53462-0705-23,NDC,both,1,UN,27.62,8.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.21,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.21,23.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRGMR NEROSTIMLTR 22X10X4CM INTERSTIM 5L SACRAL",SUP-3037,CDM,C1787,HCPCS,0270,RC,,,both,,,13455.00,4036.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1594.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1564.82,11436.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN FEMORAL LEFT 3.5 CURVE",SUP-H74908641212,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,31.47,41.1,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM ATTUNE 8 KNEE POSTERIOR CEMENT REVISION",SUP-1549-08-001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"NOVANET [10819]",Novanet,,4554,75,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL GREGORY XS 4 7/8IN PROFUNDA",SUP-55-6090,CDM,S27200284,LOCAL,0272,RC,,,both,,,1349.06,404.72,"KAISER [10500]",Kaiser,,903.87,67,,,,,0,156.9,1146.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 36MM 22MM DHS/DCS STAINLESS STEEL CONDYLE",SUP-280.990S,CDM,C1713,HCPCS,0278,RC,,,both,,,650.67,195.2,"CIGNA [10200]","Cigna Open Access",,370.23,56.9,,1144.80,304.56,2275.09,66,75.67,553.07,"percent of total billed charges",
"HC Orthopoxvirus Amp Prb Each",PX-306000244,CDM,87593,CPT,0306,RC,,,both,,,122.20,36.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,83.1,68,,,,,0,0.12,103.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla I Typing 1 Antigen Lr",PX-309000083,CDM,81374,CPT,0310,RC,,,both,,,1243.55,373.06,"CIGNA [10200]","Cigna Local Plus",,163.53,,,,,,,66.2,1057.02,"fee schedule",
"HC Hla I Typing 1 Antigen Lr",PX-309000083,CDM,81374,CPT,0310,RC,,,both,,,1243.55,373.06,"MULTIPLAN [10600]",Multiplan,,1057.02,85,,,,,0,66.2,1057.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colposcopy Cervix/Vagina",PX-361000429,CDM,57452,CPT,0361,RC,,,both,,,1855.26,556.58,"CIGNA [10200]","Cigna Open Access",,1855.26,,"Case rate ($2,090). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,215.77,1855.26,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 35MM SJM TAILOR SILICONE FLEXIBLE SURE",SUP-TAB-35,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4975.73,41.1,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Sacroiliac Joint>=3v",PX-320000051,CDM,72202,CPT,0320,RC,,,both,,,603.85,181.15,"UHC [10700]","United Healthcare",,261.88,,,,,,,44.96,513.27,"fee schedule",
"HC Xr Sacroiliac Joint>=3v",PX-320000051,CDM,72202,CPT,0320,RC,,,both,,,603.85,181.15,"AETNA [10100]","Aetna HMO/PPO",,480.06,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.96,513.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC or Add 15 Min",PX-360000005,CDM,9999157,LOCAL,0360,RC,,,both,,,2241.14,672.34,"KAISER [10500]",Kaiser,,1501.56,67,,,,,0,260.64,1904.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 4 X 6 COMPLEX PICO COIL",SUP-10USC04006,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1549.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION",RX-31432,CDM,J1162,HCPCS,0636,RC,50633-0120-11,NDC,both,1,UN,30023.06,9006.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6023.57,,,,,,,567.33,25519.6,"fee schedule",
"SHELL ACETABULAR 56MM HIP CLUSTER HOLE SNAP FIT INTEGRATED",SUP-00875705601,CDM,C1776,HCPCS,0278,RC,,,both,,,9319.80,2795.94,"BLUE CROSS [10001]","Blue Cross PPO",,3653.36,39.2,,3949.44,3949.44,3949.44,"1 through 10",1083.89,7921.83,"percent of total billed charges",
"METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION",RX-4996,CDM,J1010,HCPCS,0636,RC,70121-1574-01,NDC,both,1,ML,147.83,44.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.52,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",17.52,17.52,17.52,"1 through 10",11.19,125.66,"percent of total billed charges",
"RELOAD STPLR 30MM SUREFORM STERILE 8MM LATEX FREE DISPOSABLE",SUP-48230W,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SWAN NECK BETA-CAP 112.8CM 60.3CM 15FR 180D",SUP-8888414011,CDM,C1750,HCPCS,0278,RC,,,both,,,3740.00,1122,"MULTIPLAN [10600]",Multiplan,,3179,85,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 20CM 7FR .038IN URETERAL PERCUFLEX HYDROPLUS",SUP-M0061856170,CDM,C2617,HCPCS,0278,RC,,,both,,,1096.66,329,"BLUE CROSS [10001]","Blue Cross PPO",,429.89,39.2,,,,,0,127.54,932.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEUCOVORIN CALCIUM 5 MG TABLET",RX-4398,CDM,,,0637,RC,00555-0484-02,NDC,both,1,UN,11.83,3.55,"FIRST HEALTH [10303]","First Health",,9.46,80,,,,,0,1.38,10.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNR STD SNS PLPCTM CRSNT STF",SUP-6033,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPEL APD TWIST-LOC 25CM 14FR LOOP PIGTAIL CURVE DRNG",SUP-H7493931114250,CDM,C1729,HCPCS,0272,RC,,,both,,,777.60,233.28,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE SERTERA 14GA BREAST BIOPSY PERCUTANEOUS SPRING LOAD",SUP-SERTERA-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,746.42,223.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEXTROSE 22.5 % IN WATER(IV)",RX-410565,CDM,,,0258,RC,08888-8879-96,NDC,both,250,ML,100.65,30.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FILTER GRAFT PLUNGER GRADUATED 100ML REAMER IRR ASPIR",SUP-352.229S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2310.60,693.18,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 150CM 150MM 2.5MM BALLOON DILATATION RAPID",SUP-47525150M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DARUNAVIR 600 MG TABLET",RX-92851,CDM,,,0637,RC,59651-0085-60,NDC,both,1,UN,142.56,42.77,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GARM COMPRESSION STD FOOT SCD ANTIEMBOLISM FLOWTRON",SUP-MIC-FG200R,CDM,S27000186,LOCAL,0270,RC,,,both,,,94.05,28.21,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cath Intro Vascular Kit",PX-E27200304,CDM,E27200304,LOCAL,0272,RC,,,both,,,1090.52,327.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUT 8MM SWIVELOCK TENODESIS SHOULDER BICEPS FORK",SUP-AR-1662BC-8,CDM,C1713,HCPCS,0272,RC,,,both,,,3425.63,1027.69,"UHC [10700]","United Healthcare",,2168.42,63.3,,5023.51,2672.93,6679.78,18,1407.93,2168.42,"percent of total billed charges",
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,inpatient,,,303597.46,91079.24,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,75317.96,,"Case rate ($36,989.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $34,347.23, add-ons for qualifying new technology services are included. If operating cost exceeds $67,386.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,978.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $34,392.65. The transfer operating threshold is the transfer adjustment factor * $34,347.23 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,596.82. The transfer capital threshold is the transfer adjustment factor * $2,596.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,174098.67,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SUCTION SMART THERMAL DRAPE PISTON HEAT DEVICE",SUP-7013-1013,CDM,S27200284,LOCAL,0272,RC,,,both,,,246.28,73.88,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,101.22,41.1,,,,,0,28.64,209.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 26MM 12MM 22-23MM 10-11MM GORE",SUP-RLT261212,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16929,27,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 6-0 P-3 18IN MONOFILAMENT GREEN NONABSORBABLE",SUP-G696G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]",Cigna,,17,68,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL HEALICOIL REGENESORB PEEK-OPTIMA HIGH TORSIONAL",SUP-72203951,CDM,C1713,HCPCS,0278,RC,,,both,,,1494.45,448.33,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,427.71,28.62,,,,,0,173.8,1270.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ VASCULAR J CURVE 260CM 3MM .032IN STAINLESS",SUP-G03750,CDM,C1769,HCPCS,0272,RC,,,both,,,200.01,60,"NOVANET [10819]",Novanet,,150.01,75,,,,,0,23.26,170.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 11.5X5.5MM THK.38MM THK.43MM SMALL BONE OSCILLATE",SUP-KM3-410,CDM,S27200284,LOCAL,0272,RC,,,both,,,557.28,167.18,"AETNA [10100]","Aetna HMO/PPO",,443.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.81,473.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE EXTRA S-PORT VASCULAR J 190CM 3CM .014IN",SUP-22225MJ,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE RELINE L50 MM OD5.5 MM SPINE POLYAXIAL 2 FULL CAN",SUP-16215550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 3.5 MM SCREWS 1 HOLE LOW PROFILE",SUP-02.100.301S,CDM,C1713,HCPCS,0278,RC,,,both,,,2629.20,788.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,305.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",305.78,2234.82,"percent of total billed charges",
"STENT XACT 30MM 10MM STRAIGHT VASCULAR NITINOL CAROTID",SUP-82098-01,CDM,C1876,HCPCS,0278,RC,,,both,,,9360.00,2808,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2678.83,28.62,,,,,0,1088.57,7956,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COPE MAC-LOC 20CM 8.5FR PIGTAIL CURVE",SUP-G48170,CDM,C2617,HCPCS,0278,RC,,,both,,,980.02,294.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,449.83,45.9,,,,,0,113.98,833.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 35MM 5/6-5.5MM LATERAL SPINE SIDE LOAD STERILE",SUP-5554235,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PHCS [10601]",PHCS,,2493.75,70,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THREAD PILOT DRILL",SUP-214-00-013,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,218.06,1593.75,"percent of total billed charges",
"BLADE ARTHROSCOPIC LARGE HUB STERLING GREAT WHITE 2500-6000",SUP-9399A,CDM,S27200284,LOCAL,0272,RC,,,both,,,503.82,151.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CORDELLA SYSTEM (CHFS) KIT",SUP-100171-00,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 6.5FR UMBILICAL SILICONE RADIOPAQUE 1 LUMEN INTEGRAL",SUP-S1UVC-6540,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.20,41.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LINE MNTR ETCO2 SAMPLE LOW FLOW 15FT DISPOSABLE BLUE",SUP-989803152541,CDM,S27000186,LOCAL,0270,RC,,,both,,,190.01,57,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 2.5IN 3MM VESSEL 3MM BLUNT TIP 1 WAY VALVE",SUP-30001,CDM,S27200284,LOCAL,0272,RC,,,both,,,59.60,17.88,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH HI-FLO RENEGADE FATHOM 180CM 150CM 2.8-3FR 10CM MICRO",SUP-M001184560,CDM,C1887,HCPCS,0272,RC,,,both,,,3750.00,1125,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CMPNT FEMORAL 1.5 KNEE RIGHT CEMENT POSTERIOR STABILIZE",SUP-196050150,CDM,C1776,HCPCS,0278,RC,,,both,,,18018.00,5405.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7207.2,40,,,,,0,2095.49,15315.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 8MM GORE-TEX THIN WALL PTFE THIN WALLED",SUP-SRRT08070080L,CDM,C1768,HCPCS,0278,RC,,,both,,,11267.70,3380.31,"PHCS [10601]",PHCS,,7887.39,70,,,,,0,1310.43,9577.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY ALWAYS-ON TIP TRACKED",SUP-INS-0352,CDM,S27200284,LOCAL,0272,RC,,,both,,,3912.30,1173.69,"PHCS [10601]",PHCS,,2738.61,70,,,,,0,455,3325.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 120MM 32MM STAINLESS STEEL ORTHOPEDIC",SUP-209.92,CDM,C1713,HCPCS,0278,RC,,,both,,,1574.24,472.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,183.08,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",183.08,1338.1,"percent of total billed charges",
"CLIP VESOLOCK LARGE",SUP-61114V,CDM,S27200284,LOCAL,0272,RC,,,both,,,273.43,82.03,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,125.5,45.9,,,,,0,31.8,232.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 44MM HIP CLUSTER 3 SCR HOLE METAL HA",SUP-502-11-44B,CDM,C1776,HCPCS,0278,RC,,,both,,,9525.45,2857.63,"PHCS [10601]",PHCS,,6667.82,70,,,,,0,1107.81,8096.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 3CM 7FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175270010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,124.53,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 8MM GORE-TEX THIN WALL PTFE THIN WALLED",SUP-SRRT08070080L,CDM,C1768,HCPCS,0278,RC,,,both,,,11267.70,3380.31,"BLUE CROSS [10001]","Blue Cross PPO",,4416.94,39.2,,,,,0,1310.43,9577.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ADVANIX NAVIFLEX 18CM 2.3MM DUODENAL BEND BILIARY",SUP-M00534250,CDM,C2625,HCPCS,0278,RC,,,both,,,1089.45,326.83,"PHCS [10601]",PHCS,,762.62,70,,,,,0,126.7,926.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 40MM 125CM 8MM 6FR .035IN VASCULAR NITINOL",SUP-G43831,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross PPO",,1481.76,39.2,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 9-0 BV100-4 5IN MONOFILAMENT BLACK NONABSORBABLE",SUP-2829G,CDM,S27200284,LOCAL,0272,RC,,,both,,,253.80,76.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,172.58,68,,,,,0,29.52,215.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRANSITION VENTILATOR NASAL INTERFACE HIGH FLOW XSM OPTI",SUP-OJR410VT,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 4MM ROUND BALL DIAMOND STERILE",SUP-ZB-164,CDM,S27200284,LOCAL,0272,RC,,,both,,,455.06,136.52,"CIGNA [10200]","Cigna Local Plus",,243.46,53.5,,,,,0,52.92,386.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL HEALICOIL REGENESORB PEEK-OPTIMA HIGH TORSIONAL",SUP-72203951,CDM,C1713,HCPCS,0278,RC,,,both,,,1494.45,448.33,"PHCS [10601]",PHCS,,1046.12,70,,,,,0,173.8,1270.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII POSTERIOR STABILIZED OXI",SUP-71704570,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"FIRST HEALTH [10303]","First Health",,17640,80,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SUCTION 20MM UNILATERAL SERRATE BLADE TUBE NEXUS BONE",SUP-110-31-1121,CDM,S27200284,LOCAL,0272,RC,,,both,,,4021.71,1206.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1652.92,41.1,,,,,0,467.72,3418.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 9-0 BV100-4 5IN MONOFILAMENT BLACK NONABSORBABLE",SUP-2829G,CDM,S27200284,LOCAL,0272,RC,,,both,,,253.80,76.14,"CIGNA [10200]","Cigna Local Plus",,135.78,53.5,,,,,0,29.52,215.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INPACT 80CM 80MM 9MM BALLOON TRANSLUMINAL PACLITAXEL",SUP-IAV09008008P,CDM,C2623,HCPCS,0272,RC,,,both,,,10281.00,3084.3,"UHC [10700]","United Healthcare",,6507.87,63.3,,,,,0,1195.68,8738.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP GLIDESCOPE SPECTRUM 2.5 DISPOSABLE",SUP-0270-0962,CDM,S27200284,LOCAL,0272,RC,,,both,,,445.50,133.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NUT EXTERNAL FIXATION 10MM TRUELOK STAINLESS STEEL",SUP-50-1008M,CDM,C1713,HCPCS,0278,RC,,,both,,,246.30,73.89,"CIGNA [10200]","Cigna Open Access",,140.14,56.9,,1144.80,304.56,2275.09,66,28.64,209.36,"percent of total billed charges",
"STYLET TPR FIX FRM 70CM",SUP-6769,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRONCHOSCOPE FLEXIBLE 600MM 3.8MM 1.2MM AMBU ASCOPE 3 SLIM",SUP-402001000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"CIGNA [10200]",Cigna,,1326,68,,,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 36MM 22MM DHS/DCS STAINLESS STEEL CONDYLE",SUP-280.990S,CDM,C1713,HCPCS,0278,RC,,,both,,,650.67,195.2,"CIGNA [10200]",Cigna,,442.46,68,,1831.33,1831.33,1831.33,16,75.67,553.07,"percent of total billed charges",
"CATH LAUNCHER 100CM 5FR RBU3.5 CURVE GUIDING NYLON CORONARY",SUP-LA5RBU35,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"FIRST HEALTH [10303]","First Health",,292.32,80,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE? NC PLUS BALLOON NON-COMPLIANT 3.75 MM X 18 MM",SUP-237-183-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"KAISER [10500]",Kaiser,,542.7,67,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit Level 4",PX-450000317,CDM,99284,CPT,0450,RC,,,both,,,2129.58,638.87,"NOVANET [10819]",Novanet,,1597.19,75,,,,,0,419.55,2129.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit Level 4",PX-450000317,CDM,99284,CPT,0450,RC,,,both,,,2129.58,638.87,"BLUE CROSS [10001]","Blue Cross PPO",,1876.79,,,,,,,419.55,2129.58,"case rate",
"HC ED Visit Level 4",PX-450000317,CDM,99284,CPT,0450,RC,,,both,,,2129.58,638.87,"CIGNA [10200]",Cigna,,1833,,,,,,,419.55,2129.58,"case rate",
"SUT MONOCRYL MULTIPASS 4-0 PS-1 27IN MONOFILAMENT UNDYED",SUP-Y935H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM TOTAL HIP PROS PUREFIX HYDROXYAPATITE",SUP-542-11-52E,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4731.25,68,,,,,0,809.18,5914.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM TRILOGY TIVANIUM ALLOY HIP CORTICAL",SUP-00625006540,CDM,C1713,HCPCS,0278,RC,,,both,,,691.60,207.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,470.29,68,,,,,0,80.43,587.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 26CM 7FR URETERAL FIRM",SUP-M0061456520,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,178.94,28.62,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 3CM 6FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175265010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"BLUE CROSS [10001]","Blue Cross HMO",,419.73,39.2,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER WEDGE FRA ANTERIOR BROAD LORDOTIC 12 DEGREE",SUP-012411,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABRE 150MM 18MM VASCULAR NITINOL ILIOFEMORAL VEIN SELF",SUP-AB9U18150090,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"CIGNA [10200]","Cigna Open Access",,3929.55,33.5,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT PRESS FIT EMPOWR 3D KNEE STERILE",SUP-243-01-106,CDM,C1776,HCPCS,0278,RC,,,both,,,27824.45,8347.33,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11435.85,41.1,,6417.48,6417.48,6417.48,"1 through 10",3235.98,23650.78,"percent of total billed charges",
"INSRT TIBIAL 4 8MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650408,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"KAISER [10500]",Kaiser,,8795.26,67,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE UNICORTICAL DOWEL ALLOGRAFT FREEZE DRIED 16-40MM",SUP-400230,CDM,S27800098,LOCAL,0278,RC,,,both,,,4413.24,1323.97,"CIGNA [10200]","Cigna Local Plus",,2361.08,53.5,,,,,0,513.26,3751.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 0 UR-6 27IN MONOFILAMENT ABSORBABLE",SUP-N879H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +10.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.105,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER CHOCOLATE 150CM 120MM 3MM .014IN BALLOON DILATATION",SUP-CB1415030120OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"UHC [10700]","United Healthcare",,3625.19,63.3,,,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 92CM 4MM 6FR 2-5-2MM SPACE D CURVE",SUP-D6TCDL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3373.55,68,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 13MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532-G-613,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"KAISER [10500]",Kaiser,,5834.1,67,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC .75CM 4.45X5.88CM ESSENTIO EL RA IS-1 RV",SUP-L121,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11232,27,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTILUME 5CM 24FR BALLOON PACLITAXEL",SUP-OPTBDL7003B,CDM,C1726,HCPCS,0272,RC,,,both,,,14455.50,4336.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1712.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1681.17,12287.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SPINAL NIM-SPINE NDL PEDICLE",SUP-9450020,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,inpatient,,,55488.36,16646.51,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,23096.01,,"Fee schedule rate ($23,096.01). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,35533.09,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE COMPRESSION MEDIUM THIGH HIGH SCD EXPRESS",SUP-9530,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.33,61.9,"FIRST HEALTH [10303]","First Health",,165.06,80,,,,,0,24,175.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL STAND OFFSET SZ10",SUP-425-98-010,CDM,C1776,HCPCS,0278,RC,,,both,,,38695.80,11608.74,"BLUE CROSS [10001]","Blue Cross HMO",,15168.75,39.2,,5311.50,4717.44,5388.59,31,4500.32,32891.43,"percent of total billed charges",
"GRAFT BONE CORNERSTONE L-ASCR CORTICAL LORDOTIC ALLOGRAFT 14",SUP-341241,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 3.5 MM SCREWS 6 HOLE CURVED",SUP-245.3,CDM,C1713,HCPCS,0278,RC,,,both,,,5022.37,1506.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,584.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",584.1,4269.01,"percent of total billed charges",
"CANN ARTHROSCOPIC 9CM 8.25MM GEMINI SR8 LOW PROFILE SELF",SUP-AR-6572,CDM,S27200284,LOCAL,0272,RC,,,both,,,292.32,87.7,"MULTIPLAN [10600]",Multiplan,,248.47,85,,,,,0,34,248.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 650ML P5.7CM HIGH PROFILE HIGH PROJECTION ROUND",SUP-350-6504BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5244.00,1573.2,"CIGNA [10200]",Cigna,,3565.92,68,,,,,0,609.88,4457.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.5MM TRA",SUP-58850025,CDM,S27000186,LOCAL,0270,RC,,,both,,,1069.20,320.76,"CIGNA [10200]",Cigna,,727.06,68,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MERCI 95CM 8FR GUIDING SILICONE BALLOON STERILE LATEX",SUP-90073,CDM,C1725,HCPCS,0272,RC,,,both,,,9696.36,2908.91,"KAISER [10500]",Kaiser,,6496.56,67,,,,,0,1127.69,8241.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SURGICAL 7.25IN MALIS 3MM BLUNT NERVE TITANIUM HANDLE",SUP-58-6065,CDM,S27200284,LOCAL,0272,RC,,,both,,,548.45,164.53,"CIGNA [10200]","Cigna Local Plus",,293.42,53.5,,,,,0,63.78,466.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUTTY THERAPY SAMMONS PRESTON TAN SUPER SOFT RESISTANCE",SUP-506503,CDM,S27000186,LOCAL,0270,RC,,,both,,,338.52,101.56,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,230.19,68,,,,,0,39.37,287.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 170MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT SET 6",SUP-222.656,CDM,C1713,HCPCS,0278,RC,,,both,,,9026.30,2707.89,"UHC [10700]","United Healthcare",,5713.65,63.3,,5023.51,2672.93,6679.78,18,1049.76,7672.36,"percent of total billed charges",
"SCR BONE 3.5MM 14MM CORTICAL RAYHACK GENERATION II",SUP-40100914,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.40,228.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,349.48,45.9,,,,,0,88.55,647.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM RADIAL 7MM 0MM ELBOW",SUP-TR-S0700-S,CDM,C1776,HCPCS,0278,RC,,,both,,,15145.50,4543.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1794.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1761.42,12873.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 85MM 5.5MM CREO LATERAL HEAD RIGHT NONSTERILE",SUP-1175.5522,CDM,C1713,HCPCS,0278,RC,,,both,,,12061.20,3618.36,"AETNA [10100]","Aetna HMO/PPO",,9588.65,79.5,,1521.93,481.35,16760.95,30,1402.72,10252.02,"percent of total billed charges",
"DEVICE CRE STERI-FLATE INFLATION DISPOSABLE",SUP-M00550630,CDM,S27200284,LOCAL,0272,RC,,,both,,,340.52,102.16,"PHCS [10601]",PHCS,,238.36,70,,,,,0,39.6,289.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Yo Immunoreactivity",PX-301000283,CDM,86255,CPT,0301,RC,,,both,,,258.70,77.61,"UHC [10700]","United Healthcare",,10.85,,,,,,,0.26,219.9,"fee schedule",
"INSRT TIBIAL 5 11MM KNEE X3 POSTERIOR STABILIZED BEARING",SUP-5532-G-511,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"AETNA [10100]","Aetna HMO/PPO",,6922.55,79.5,,10981.53,8986.79,12413.38,12,1012.7,7401.47,"percent of total billed charges",
"RTRCTR/ELEV LAPAROSCOPIC 34MM VCARE PLUS CUP CERVICAL",SUP-60-6085-201A,CDM,S27200284,LOCAL,0272,RC,,,both,,,522.45,156.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,214.73,41.1,,,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM CREO CREO AMP SPINE MODULAR",SUP-1067.1640,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"MULTIPLAN [10600]",Multiplan,,8114.82,85,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINIARC PRECISE",SUP-720191-01,CDM,C1771,HCPCS,0278,RC,,,both,,,10350.00,3105,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1226.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +14 DIOPTER +3 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT300140,CDM,V2787,HCPCS,0276,RC,,,both,,,495.00,148.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,141.67,28.62,,,,,0,57.57,420.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE WHISPER LS VASCULAR STRAIGHT 190CM 3CM .014",SUP-1005351H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW PROPHECY INBONE MICROAIRE NARROW HALL/LINVATEC",SUP-200138103S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1109.70,332.91,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SAW 75X13X1.27MM SAGITTAL",SUP-6113127075,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SABERX 200CM 20MM 3.5MM BALLOON DILATATION RAPID",SUP-47535020L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CORD ELECTROSURGICAL MONOPOLAR ACTIVE BOVIE STERILE REUSABLE",SUP-C650-129A,CDM,S27200284,LOCAL,0272,RC,,,both,,,1273.89,382.17,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INTRO SHEATH 8FR 180CM 63CM HEMOSTASIS VALVE SUPER STIFF",SUP-406948,CDM,C1893,HCPCS,0272,RC,,,both,,,1255.50,376.65,"MULTIPLAN [10600]",Multiplan,,1067.18,85,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TAKERU 21MM 2MM BALLOON DILATATION RAPID EXCHANGE PTCA",SUP-DC-RZ2021UA2,CDM,C1725,HCPCS,0272,RC,,,both,,,988.20,296.46,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,117.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.93,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM ORTHOLOC FULL THREAD CORTEX ANKLE FOOT 3",SUP-58813528,CDM,C1713,HCPCS,0278,RC,,,both,,,769.50,230.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",89.49,654.08,"percent of total billed charges",
"SUT SILK PERMA-HAND 4-0 P-3 18IN BRAID BLACK NONABSORBABLE",SUP-641G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 20X16CM RESORBABLE GRID 1",SUP-F10256-1620G,CDM,C1781,HCPCS,0278,RC,,,both,,,31570.56,9471.17,"MULTIPLAN [10600]",Multiplan,,26834.98,85,,,,,0,3671.66,26834.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CONTROL CHEMISTRY 1ML LEVEL 1 ASSAYED LIQUID HUMAN WHOLE",SUP-171,CDM,C1895,HCPCS,0278,RC,,,both,,,362.79,108.84,"NOVANET [10819]",Novanet,,272.09,75,,,,,0,42.19,308.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 19CM 5MM COOLCUT 8 FLUTE CONCAVE CURVE HIP",SUP-AR-6500VBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,859.01,257.7,"PHCS [10601]",PHCS,,601.31,70,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 19GA 15CM 9CM ADJUSTABLE COAXIAL TEMNO",SUP-ACT2015,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 23CM 9MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-09023,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"PHCS [10601]",PHCS,,8206.17,70,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUTNER 70CM 4FR 8FR UNIVERSAL URETERAL ADULT WEDGE",SUP-G14056,CDM,C1758,HCPCS,0272,RC,,,both,,,117.45,35.23,"FIRST HEALTH [10303]","First Health",,93.96,80,,,,,0,13.66,99.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Absc Fgr Cmplx",PX-450000120,CDM,26011,CPT,0361,RC,,,both,,,6380.13,1914.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1718,,"Case rate ($1,718). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,6.38,5469,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAUT OPHTHALMIC 2IN ACCU-TEMP 1205C FINE TIP HIGH",SUP-8445000,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.14,53.74,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,82.23,45.9,,,,,0,20.83,152.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Perq Trancath Clsr Mitr/Aort Addl",PX-481000115,CDM,93592,CPT,0481,RC,,,both,,,29534.00,8860.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3499.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1249,25103.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML ORAL SOLUTION SUPERORDERABLE (FROM INJ)",RX-411456,CDM,J1100,HCPCS,0636,RC,67457-0419-00,NDC,both,1,ML,12.54,3.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8.53,68,,,,,0,0.42,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHALANX CORONAL TRANSFIXION SCREW 1.5MM X 8.0MM COCR",SUP-PTS-15008-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.90,337.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,130.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",130.94,957.02,"percent of total billed charges",
"SPACER HUMERAL 39MM UNIVERS REVERS +6MM SHOULDER TITANIUM",SUP-AR-9505-06,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"CIGNA [10200]","Cigna Open Access",,1672.86,56.9,,5302.19,4377.88,6578.61,27,341.92,2499,"percent of total billed charges",
"SYSTEM ION 24MM 144CM 2.5MM CORONARY STENT TRANSLUTE",SUP-H7493902424250,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1083.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Influenza Virus Ab",PX-302000150,CDM,86710,CPT,0302,RC,,,both,,,393.30,117.99,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,334.31,"per diem",
"GWIRE ORTHOPEDIC 300MM 2.8MM THREAD",SUP-03.333.015,CDM,S27200284,LOCAL,0272,RC,,,both,,,1125.33,337.6,"NOVANET [10819]",Novanet,,844,75,,,,,0,130.88,956.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 220MM 3MM BALLOON DILATATION NYBAX",SUP-H74939186302210,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mastotomy W Explr/Drainage",PX-450000061,CDM,19020,CPT,0361,RC,,,both,,,11998.00,3599.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3279,,"Case rate ($3,279). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1395.37,11998,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 3-0 8IN ENDO STITCH V-LOC POLYBUTESTER LOAD",SUP-VLOCN308L,CDM,S27200284,LOCAL,0272,RC,,,both,,,432.39,129.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,177.71,41.1,,,,,0,50.29,367.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOEHENDRA 200CM 3CM 8.5-5FR .035IN BALLOON DILATATION",SUP-G22062,CDM,S27200284,LOCAL,0272,RC,,,both,,,712.80,213.84,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,327.18,45.9,,,,,0,82.9,605.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 3.5MM STAINLESS STEEL CERCLAGE THREADED STERILE",SUP-298.838S,CDM,S27800098,LOCAL,0278,RC,,,both,,,1149.88,344.96,"BLUE CROSS [10001]","Blue Cross HMO",,450.75,39.2,,,,,0,133.73,977.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 4CM 5.8FR 30FR BALLOON",SUP-M0062251050,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1164.49,68,,,,,0,199.16,1455.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 75MM LCP STAINLESS STEEL MEDIAL PROXIMAL",SUP-212.224,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,103.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",101.55,742.2,"percent of total billed charges",
"STENT DYNAMIC 110X11MM 25/40X8MM Y TRACHEOBRONCHIAL SILICONE",SUP-M00570670,CDM,C1875,HCPCS,0278,RC,,,both,,,22226.40,6667.92,"CIGNA [10200]","Cigna Open Access",,7445.84,33.5,,,,,0,2584.93,18892.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Relocation Skin Pocket Implanted Ccm-D Pg",PX-481000420,CDM,0925T,CPT,0481,RC,,,both,,,2818.00,845.4,"BLUE CROSS [10001]","Blue Cross PPO",,2818,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,327.73,2818,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRNSDUC PRESSURE 48IN MERITRANS NONWING HOUSING MALE SWIVEL",SUP-K11-00137B,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.44,26.23,"AETNA [10100]","Aetna HMO/PPO",,69.51,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.17,74.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plasma Solvent/Detergent Tx",PX-390000008,CDM,P9023,HCPCS,0390,RC,,,both,,,622.00,186.6,"CIGNA [10200]","Cigna Open Access",,353.92,56.9,,,,,0,72.34,528.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PCP040250090 PLUS US D4L250UL900",SUP-PCP040250090,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,521.84,41.1,,,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII CRUCIATE RETAINING POROU",SUP-71704545,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9324,40,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT STRETCH VL 22-30CM 6FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M0061851560,CDM,C2617,HCPCS,0278,RC,,,both,,,973.30,291.99,"CIGNA [10200]",Cigna,,661.84,68,,,,,0,113.19,827.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ENDOSCOPIC T TYPE I JET MULTIFUNCTIONAL PROBE",SUP-20150-260,CDM,C1889,HCPCS,0272,RC,,,both,,,3857.10,1157.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2622.83,68,,,,,0,448.58,3278.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT QUILL SRS 0 VIOLET ABSORBABLE",SUP-RA-1029Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,176.84,53.05,"CIGNA [10200]","Cigna Open Access",,100.62,56.9,,,,,0,20.57,150.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHLORPROMAZINE 25 MG TABLET",RX-1656,CDM,Q0161,HCPCS,0636,RC,00527-2962-37,NDC,both,1,UN,28.88,8.66,"KAISER [10500]",Kaiser,,19.35,67,,,,,0,1.92,24.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 10MM TITANIUM T8 FULL THREAD CORTEX",SUP-AR-8724-10,CDM,C1713,HCPCS,0278,RC,,,both,,,891.00,267.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,105.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",103.62,757.35,"percent of total billed charges",
"CANN NASAL MASK NEONATE PROSOFT NONSTERILE LATEX FREE",SUP-PROSOFT-PRE,CDM,S27000186,LOCAL,0270,RC,,,both,,,112.06,33.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,76.2,68,,,,,0,13.03,95.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 114MM 7.5MM PRIMARY M/L TAPER TIVANIUM POROUS",SUP-00771100740,CDM,C1776,HCPCS,0278,RC,,,both,,,20899.62,6269.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2476.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2430.63,17764.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 60MM 130CM 7MM 6FR .035IN VASCULAR NITINOL",SUP-EX070603CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"BLUE CROSS [10001]","Blue Cross HMO",,4598.16,39.2,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1.5 X 2.5 COMPLEX PICO COIL",SUP-10USC0152H,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"CIGNA [10200]","Cigna Local Plus",,4118.78,31.5,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HUMAN TISSUE L150MM DIA4-5.5MM SEMITENDINOSUS FROZEN R",SUP-FROPE,CDM,S27800098,LOCAL,0278,RC,,,both,,,6128.93,1838.68,"FIRST HEALTH [10303]","First Health",,4903.14,80,,,,,0,712.79,5209.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC 47X13IN UNIVERSAL SHOULDER FOAM COLD HOT",SUP-9381-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,216.11,64.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,146.95,68,,,,,0,25.13,183.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 38MM 144CM 3.5MM CORONARY STENT",SUP-H7493941838350,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 14.5FR 3.1ML PALINDROME SYMMETRIC TIP",SUP-8888145018,CDM,C1750,HCPCS,0278,RC,,,both,,,2935.50,880.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,347.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,341.4,2495.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 7FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752730,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,104.92,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 50MM LCP STAINLESS STEEL CORTEX FOREFOOT",SUP-202.967,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,92.73,28.62,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 6.75IN 8FR FRAZIER ANGLE 5-9CM CALIBRATE",SUP-63-7558,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM SOLERA SPINAL MULTIAXIAL CANNULATED",SUP-54840045545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"AETNA [10100]","Aetna HMO/PPO",,7589.75,79.5,,1521.93,481.35,16760.95,30,1110.3,8114.82,"percent of total billed charges",
"GRAFT ENDOVASCULAR 109MM 28MM HANDL-B ONE-SHOT ZENITH",SUP-G32537,CDM,C1874,HCPCS,0278,RC,,,both,,,62551.57,18765.47,"BLUE CROSS [10001]","Blue Cross PPO",,24520.22,39.2,,,,,0,7274.75,53168.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 83MM 5MM COMPREHENSIVE POROUS MINI SHOULDER",SUP-113625,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"NOVANET [10819]",Novanet,,9450,75,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DAC 125CM 3.9FR .038IN GUIDING DISTAL ACCESS STERILE",SUP-90720,CDM,S27200284,LOCAL,0272,RC,,,both,,,9626.67,2888,"AETNA [10100]","Aetna HMO/PPO",,7653.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1119.58,8182.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 3CM 7FR ZIMMON .035IN POLYETHYLENE TAPER",SUP-G22439,CDM,C2625,HCPCS,0278,RC,,,both,,,1328.40,398.52,"PHCS [10601]",PHCS,,929.88,70,,,,,0,154.49,1129.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 3-0 CT-1 36IN BRAID COATED VIOLET ABSORBABLE",SUP-J344H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS BEVEL 360 135CM 200MM 3MM .035IN BALLOON",SUP-AB35W03200135,CDM,C1725,HCPCS,0272,RC,,,both,,,1061.91,318.57,"PHCS [10601]",PHCS,,743.34,70,,,,,0,123.5,902.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP ASPIR 25KHZ UNIVERSAL ULTRASONIC LARGE DIAMETER SOFT",SUP-5450800306,CDM,S27200284,LOCAL,0272,RC,,,both,,,4359.43,1307.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2964.41,68,,,,,0,507,3705.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 100MM 75CM 8MM VASCULAR SELF EXPAND RADIOPAQUE",SUP-H74939293081070,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]","Cigna Open Access",,2748.27,56.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASAHI PROWATERFLEX PTCA GUIDE WIRE 180 CM",SUP-AGH147000,CDM,C1769,HCPCS,0272,RC,,,both,,,769.50,230.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7-8 9MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71934438,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"AETNA [10100]","Aetna HMO/PPO",,9676.42,79.5,,10981.53,8986.79,12413.38,12,1415.56,10345.86,"percent of total billed charges",
"CMPNT GLENOID XL VAULTLOCK ARTHREX UNIVERS STERILE",SUP-AR-9106-04,CDM,C1776,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]","Cigna Open Access",,4907.63,56.9,,5302.19,4377.88,6578.61,27,1003.09,7331.25,"percent of total billed charges",
"ANCHOR SUT 5.5MM FULL THREAD 1.3MM CORKSCREW SUTURETAPE",SUP-AR-1927BCT,CDM,C1713,HCPCS,0278,RC,,,both,,,2795.63,838.69,"BLUE CROSS [10001]","Blue Cross PPO",,1095.89,39.2,,957.42,570.23,957.42,28,325.13,2376.29,"percent of total billed charges",
"GWIRE WALLSTENT VASCULAR TAPER 500CM .035IN SUPER STIFF",SUP-H965180011,CDM,C1769,HCPCS,0272,RC,,,both,,,924.91,277.47,"FIRST HEALTH [10303]","First Health",,739.93,80,,,,,0,107.57,786.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 C 32MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30103203,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6971.37,68,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROSA PIN LONG PIN 3.20MM","SUP-GS910.110.032 STE",CDM,S27200284,LOCAL,0272,RC,,,both,,,972.00,291.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,113.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SEEKER 135CM 5FR .035IN GUIDING CROSSING SPRT FULLY",SUP-SK13535M,CDM,C1887,HCPCS,0272,RC,,,both,,,1498.50,449.55,"AETNA [10100]","Aetna HMO/PPO",,1191.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM HIP LIMIT HOLE COLOR CODED POROUS G7 B",SUP-010000660,CDM,C1776,HCPCS,0278,RC,,,both,,,10120.92,3036.28,"AETNA [10100]","Aetna HMO/PPO",,8046.13,79.5,,10981.53,8986.79,12413.38,12,1177.06,8602.78,"percent of total billed charges",
"KIT SNARE ATRIEVE VASCULAR SNARE 100CM 12-20MM 6FR 3 LOOP",SUP-382006020,CDM,C1773,HCPCS,0272,RC,,,both,,,2925.00,877.5,"NOVANET [10819]",Novanet,,2193.75,75,,,,,0,340.18,2486.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +13.5 DIOPTER UV ABSORBENT CLAREON AUTONOME",SUP-CCA0T0.135,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 10 12MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151621012,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"NOVANET [10819]",Novanet,,8440.43,75,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PREP AVAPREP PATIENT SAFETY HYPODERMIC NDL PREVENTION",SUP-VPK9001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1296.00,388.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,594.86,45.9,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Human Milk Process/Stor/Dist per Oz",PX-220000001,CDM,T2101,HCPCS,0220,RC,,,both,,,10.02,3.01,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4.6,45.9,,,,,0,0.01,8.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 2.9X.98IN SYSTEM 6 THK.035IN BEVEL HEAVY DUTY",SUP-6125089075,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM .0115IN AXIUM PRIME HELIX",SUP-APB-4-6-HX-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,7169.10,2150.73,"CIGNA [10200]","Cigna Local Plus",,3835.47,53.5,,,,,0,833.77,6093.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SURGICAL 45D ILLUMISITE STERILE REUSABLE 1070MM 2.7MM",SUP-ILS-0450-KT,CDM,S27200284,LOCAL,0272,RC,,,both,,,11895.60,3568.68,"NOVANET [10819]",Novanet,,8921.7,75,,,,,0,1383.46,10111.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE CARDIOFORM ASD OCCLUDER 27MM 10FR",SUP-00733132636488,CDM,C1817,HCPCS,0278,RC,,,both,,,52321.50,15696.45,"FIRST HEALTH [10303]","First Health",,41857.2,80,,,,,0,6084.99,44473.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 2-0 30IN BRAID TIE 12 STRAND PRECUT",SUP-A305H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SURGICAL CLP XWIDE RECHARGEABLE PIVOT HEAD LIGHTWEIGHT",SUP-9690,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.34,19.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,26.85,41.1,,,,,0,7.6,55.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD CURVE .6MM MIDFACE 6 HOLE BAR 1.7MM SCR BONE",SUP-5505188,CDM,C1713,HCPCS,0278,RC,,,both,,,1721.95,516.58,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,204.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,200.26,1463.66,"percent of total billed charges",
"SUT PDS II 0 CT-1 36IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z346H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CAROTID SUNDT CONE 30CM TEMPORARY EXTERNAL LOOP FULLY",SUP-NL8505072,CDM,S27800098,LOCAL,0278,RC,,,both,,,4600.44,1380.13,"CIGNA [10200]",Cigna,,3128.3,68,,,,,0,535.03,3910.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP SUCTION/IRRIGATION INTREPID 35D POLYMER BENT IA",SUP-8065751511,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.79,32.34,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.54,91.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DURASEAL EXACT SPINE SEALANT SYSTEM 3ML US BOX OF 5",SUP-206320,CDM,S27200284,LOCAL,0272,RC,,,both,,,6092.29,1827.69,"CIGNA [10200]","Cigna Local Plus",,3259.38,53.5,,,,,0,708.53,5178.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 48MM 28MM ALTRX HIP STERI",SUP-122128148,CDM,C1776,HCPCS,0278,RC,,,both,,,9128.70,2738.61,"PHCS [10601]",PHCS,,6390.09,70,,,,,0,1061.67,7759.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insulin-Like Growth Ftr-1",PX-301000400,CDM,84305,CPT,0301,RC,,,both,,,269.00,80.7,"CIGNA [10200]","Cigna Open Access",,46.77,,,,,,,0.27,228.65,"fee schedule",
"BIOCLEANSE POSTERIOR TIBIALIS TENDON GREATER THAN OR EQUAL T",SUP-453016,CDM,C1762,HCPCS,0278,RC,,,both,,,13800.00,4140,"BLUE CROSS [10001]","Blue Cross PPO",,5409.6,39.2,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 50MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.150,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,519.91,45.9,,,,,0,131.73,962.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC",583,MS-DRG,,,,,,,inpatient,,,208387.21,62516.16,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,11017.46,,"Case rate ($10,696.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,932.48, add-ons for qualifying new technology services are included. If operating cost exceeds $42,972.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,132.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $9,945.61. The transfer operating threshold is the transfer adjustment factor * $9,932.48 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $750.94. The transfer capital threshold is the transfer adjustment factor * $750.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,10696.56,50345.58,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 16MM 43MM SHOULDER SIMPLICITI",SUP-7122870,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6812.92,68,,,,,0,1165.21,8516.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SPINAL NONSTERILE FOR 5/6MM ROD VERSATIE",SUP-8610260,CDM,C1713,HCPCS,0278,RC,,,both,,,6827.62,2048.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,794.05,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",794.05,5803.48,"percent of total billed charges",
"STEM FEMORAL 195MM 17MM MODULAR RESTORATION BOWED CONICAL",SUP-6276-7-217,CDM,C1776,HCPCS,0278,RC,,,both,,,11695.32,3508.6,"AETNA [10100]","Aetna HMO/PPO",,9297.78,79.5,,10981.53,8986.79,12413.38,12,1360.17,9941.02,"percent of total billed charges",
"OCCL CARDIOVASCULAR 25MM 18MM PATENT FORAMEN OVALE 2 DISK",SUP-9-PFO-025,CDM,C1817,HCPCS,0278,RC,,,both,,,56668.50,17000.55,"CIGNA [10200]","Cigna Local Plus",,17850.58,31.5,,,,,0,6590.55,48168.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 F 36MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30103606,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2934.13,28.62,,,,,0,1192.31,8714.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DENTAL AND ORAL DISEASES WITH CC",158,MS-DRG,,,,,,,inpatient,,,28872.17,8661.65,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,5897.5,,"Case rate ($5,643.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,240.41, add-ons for qualifying new technology services are included. If operating cost exceeds $38,280.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,778.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,247.34. The transfer operating threshold is the transfer adjustment factor * $5,240.41 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $396.20. The transfer capital threshold is the transfer adjustment factor * $396.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,5643.54,22689.5,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 62MM HIP 5 SCR HOLE CLUSTER TRITANIUM",SUP-702-04-62G,CDM,C1776,HCPCS,0278,RC,,,both,,,12551.10,3765.33,"KAISER [10500]",Kaiser,,8409.24,67,,,,,0,1459.69,10668.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN NASAL HIGH FLOW PEDIATRIC HFNC VAPOTHERM 2000I SYSTEM",SUP-MI1300,CDM,S27000186,LOCAL,0270,RC,,,both,,,60.20,18.06,"CIGNA [10200]","Cigna Local Plus",,32.21,53.5,,,,,0,7,51.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 22MM MODULAR RESTORATION STRAIGHT CONE",SUP-6276-7-122,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"SUT SUTURETAPE 2-0 .9MM NONABSORBABLE",SUP-AR-7521,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"IRBESARTAN 150 MG TABLET",RX-21848,CDM,,,0637,RC,00024-5851-30,NDC,both,1,UN,34.72,10.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.04,29.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 10MM LOOP ROUND 10MM MEGADYNE",SUP-0450,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.20,28.86,"UHC [10700]","United Healthcare",,60.89,63.3,,,,,0,11.19,81.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE COROLENE 5-0 3/8X13 MM",SUP-20S10Z,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"UHC [10700]","United Healthcare",,44.06,63.3,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM LUMBAR SPINE STERILE",SUP-2140135,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1101.6,68,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 25MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-125,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]","Cigna Local Plus",,5457.38,31.5,,5372.07,4581.20,7242.98,23,2014.9,14726.25,"percent of total billed charges",
"CATH SUPREME 120CM 4FR 5MM SPACING CRD CURVE",SUP-401891,CDM,C1730,HCPCS,0272,RC,,,both,,,1239.30,371.79,"KAISER [10500]",Kaiser,,830.33,67,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL 2-0 TE SKS-3 24IN 2 ARM BRAID DARK BLUE",SUP-TPW80,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.87,53.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,73.93,41.1,,,,,0,20.92,152.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE URETHROTOME SEMICIRCLE",SUP-A3558,CDM,S27200284,LOCAL,0272,RC,,,both,,,1892.55,567.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,868.68,45.9,,,,,0,220.1,1608.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT AGILE 102MM 14MM ESOPHAGEAL FULL COVER STERILE LATEX",SUP-M00517410,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]",Cigna,,7308,40,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BULLET ALLOGRAFT REVISION DOWEL PREHYDRATE",SUP-PCD13,CDM,C1713,HCPCS,0278,RC,,,both,,,6744.75,2023.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3095.84,45.9,,,,,0,784.41,5733.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 130MM 12MM KII BALLOON BLUNT TIP LATEX",SUP-C0R50,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,124.24,68,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 72.5MM KNEE LEFT CRUCIATE RETAINING CEMENTED",SUP-183033,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"UHC [10700]","United Healthcare",,12714.22,63.3,,8601.07,8395.67,8601.07,"1 through 10",2335.96,17072.81,"percent of total billed charges",
"TIP PHACOEMULSIFICATION 1.1MM ABS 30D FLARE STERILE",SUP-8065740806,CDM,S27200284,LOCAL,0272,RC,,,both,,,568.30,170.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,67.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,66.09,483.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RED 43 REPERFUSION CATHETER 138 CM",SUP-RED43138,CDM,C1757,HCPCS,0272,RC,,,both,,,16767.00,5030.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6891.24,41.1,,,,,0,1950,14251.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 80MM 12MM 6FR BILIARY NITINOL SELF",SUP-G36231,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1081.84,28.62,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM ATLANTIS TITANIUM ANTERIOR CERVICAL SPINE",SUP-876-715,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"REUNION TSA - CEMENTED HUMERAL STEM 8MM",SUP-5569-C-2008,CDM,C1776,HCPCS,0278,RC,,,both,,,10440.00,3132,"PHCS [10601]",PHCS,,7308,70,,,,,0,1214.17,8874,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE PT GRAPHIX VASCULAR STRAIGHT 182CM .014IN POLYMER",SUP-H74914902011,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,385.56,68,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PROCEED 6X4IN HERNIA TISSUE SEPARATING",SUP-PCDN1,CDM,C1781,HCPCS,0278,RC,,,both,,,2882.42,864.73,"PHCS [10601]",PHCS,,2017.69,70,,,,,0,335.23,2450.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 35CM .02IN 4MM PENUMBRA COIL 400 RUBY",SUP-RBY2C0435,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.00,2003.4,"CIGNA [10200]",Cigna,,4541.04,68,,,,,0,776.65,5676.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIABAHN BX BALLOON EXP ENDO 9MMX39MM 8FR 135CMCATH HEPARIN",SUP-BXB093902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5266.3,27,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 30MM 2-3MM AVANCE NERVE ALLOGRAFT MULTIPLE",SUP-211230,CDM,C1762,HCPCS,0278,RC,,,both,,,29288.70,8786.61,"CIGNA [10200]",Cigna,,11715.48,40,,,,,0,3406.28,24895.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.3MM 250MM KIRSCHNER STAINLESS STEEL THREADED",SUP-44182523,CDM,C1713,HCPCS,0278,RC,,,both,,,191.40,57.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,87.85,45.9,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 80CM 7MM DISTAL PERIPHERAL PERIPHERAL",SUP-DF8007SC,CDM,C1768,HCPCS,0278,RC,,,both,,,9401.24,2820.37,"CIGNA [10200]","Cigna Local Plus",,5029.66,53.5,,,,,0,1093.36,7991.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR ITOTAL IPOLY XE CRUCIATE RETAIN PATIENT SPECIFIC",SUP-TCR1111111,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"BLUE CROSS [10001]","Blue Cross PPO",,10495.8,39.2,,3949.44,3949.44,3949.44,"1 through 10",3113.93,22758.75,"percent of total billed charges",
"STENT SUPERA 60MM 120CM 5MM 6FR VASCULAR PERIPHERAL",SUP-S-50-060-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4135.48,41.1,,,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL PENCIL 15FT EDGE BUTTON SWITCH CORD",SUP-E2450HDBNSB,CDM,S27200284,LOCAL,0272,RC,,,both,,,4.71,1.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.16,45.9,,,,,0,0.55,4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 155CM 6MM 120CM VASCULAR NITINOL ILIAC",SUP-H74939200064020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"BLUE CROSS [10001]","Blue Cross PPO",,1622.88,39.2,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT HUMERAL STANDARD OD32 MM GLENOSPHERE",SUP-1230-7512-001,CDM,C1776,HCPCS,0278,RC,,,both,,,16684.20,5005.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1977.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1940.37,14181.57,"percent of total billed charges",
"STENT BENTSON 26CM 15CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175273060,CDM,C2617,HCPCS,0278,RC,,,both,,,997.43,299.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,457.82,45.9,,,,,0,116,847.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 30MM 80CM 6MM VASCULAR NITINOL PERIPHERAL",SUP-1012528-30,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]","Cigna Local Plus",,2214.9,53.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 16MM X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G816,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1163,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASE TIB STEM #4 RIGHT PEGLESS",SUP-2586-0-0004,CDM,C1776,HCPCS,0278,RC,,,both,,,6210.00,1863,"PHCS [10601]",PHCS,,4347,70,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENDYNE MITRAL VALVE SP 33B",SUP-TENDV-SP-33B-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,171000.00,51300,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20263.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AMPLATZ ANCHOR MALECOT 30CM 12FR DRNG PERCUFLEX METAL",SUP-M001221020,CDM,C1729,HCPCS,0272,RC,,,both,,,729.00,218.7,"FIRST HEALTH [10303]","First Health",,583.2,80,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 11.5X9MM TPS SHORT MEDIUM OSCILLATING SAGITTAL",SUP-2296-033-411,CDM,S27200284,LOCAL,0272,RC,,,both,,,300.50,90.15,"FIRST HEALTH [10303]","First Health",,240.4,80,,,,,0,34.95,255.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 3MM .017IN",SUP-H7493926708300,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AETNA [10100]","Aetna HMO/PPO",,450.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +11 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200110,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"MULTIPLAN [10600]",Multiplan,,867.51,85,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORCEPS SURGICAL DISPOSABLE LONG SMOOTH",SUP-NF07,CDM,S27200284,LOCAL,0272,RC,,,both,,,200.10,60.03,"CIGNA [10200]","Cigna Local Plus",,107.05,53.5,,,,,0,23.27,170.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 50MM X25 LOCK LOW PROFILE STERILE",SUP-04.045.350S,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"BLUE CROSS [10001]","Blue Cross HMO",,733,39.2,,957.42,156.86,7483.26,51,217.47,1589.42,"percent of total billed charges",
"CABLE PACING 12IN LONG TEMPORARY EXT DISPOSABLE",SUP-4051L,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"UHC [10700]","United Healthcare",,165.21,63.3,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 7CM MR8 4MM BALL XCOARSE GRIT DISSECTING DIAMOND",SUP-MR8-UBA40DX,CDM,S27200284,LOCAL,0272,RC,,,both,,,1142.51,342.75,"PHCS [10601]",PHCS,,799.76,70,,,,,0,132.87,971.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PALACOS MV+G PRO 80",SUP-5081291,CDM,C1713,HCPCS,0278,RC,,,both,,,3829.50,1148.85,"CIGNA [10200]",Cigna,,2604.06,68,,1831.33,1831.33,1831.33,16,445.37,3255.08,"percent of total billed charges",
"HC Rmvl FB Ear Canal Extrnl",PX-450000303,CDM,69200,CPT,0361,RC,,,both,,,909.00,272.7,"BLUE CROSS [10001]","Blue Cross PPO",,909,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,105.72,909,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mlh1 Gene Full Seq",PX-309000052,CDM,81292,CPT,0310,RC,,,both,,,2420.00,726,"UHC [10700]","United Healthcare",,607.86,,,,,,,2.42,2057,"fee schedule",
"APPL INTERNAL CLIP TITANIUM ENDOSCOPIC LIGATING LAPRA-TY",SUP-KA200,CDM,S27200284,LOCAL,0272,RC,,,both,,,15669.90,4700.97,"CIGNA [10200]",Cigna,,10655.53,68,,,,,0,1822.41,13319.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X10MM 6D SPINE CERVICAL ANTERIOR",SUP-4W7010,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"NOVANET [10819]",Novanet,,5175,75,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
ULTRASERT,SUP-AU00T0,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross PPO",,473.1,39.2,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND EXCEL THK1.5MM 2-0 V-5 30IN 2 ARM BRAID 8",SUP-SXX50,CDM,S27200284,LOCAL,0272,RC,,,both,,,583.71,175.11,"FIRST HEALTH [10303]","First Health",,466.97,80,,,,,0,67.89,496.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PACING 58CM 4 STRAIGHT STYLET 1J 1 UNIVERSAL CLIP TOOL",SUP-4090/58,CDM,C1898,HCPCS,0275,RC,,,both,,,453.60,136.08,"MULTIPLAN [10600]",Multiplan,,385.56,85,,,,,0,52.75,385.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD 10CM OSCOR UNIVERSAL IMPLANTABLE BIPOLAR IS-1","SUP-355 914",CDM,S27200284,LOCAL,0272,RC,,,both,,,4947.30,1484.19,"UHC [10700]","United Healthcare",,3131.64,63.3,,,,,0,575.37,4205.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"URETHRAL STRICTURE",697,MS-DRG,,,,,,,inpatient,,,52373.15,15711.94,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-5 TTC-13 36IN 2 ARM MONOFILAMENT UNDYED",SUP-5N02A,CDM,S27200284,LOCAL,0272,RC,,,both,,,303.78,91.13,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GASTROINTESTINAL HEMORRHAGE WITH CC",378,MS-DRG,,,,,,,inpatient,,,37226.65,11167.99,"CIGNA [10200]",Cigna,,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 3-0 KS 30IN MONOFILAMENT BLACK NONABSORBABLE",SUP-627H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH Z-MED-X 100CM 12X6CM 9FR 28MM .035IN BALLOON DILATATION",SUP-618451,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ARTHROSCOPIC .034IN TROCAR TIP LASER LINE",SUP-AR-8737-39,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.40,57.42,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH REDDICK 50CM 4FR CHOLANGIOGRAM 3ML CYSTIC DUCT SCOOP",SUP-E2401-52,CDM,S27200284,LOCAL,0272,RC,,,both,,,1153.93,346.18,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EUPHORA 142CM 20MM 3.5MM BALLOON DILATATION DURATRAC",SUP-NCEUP3520X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUTURE SURGIPRO CV-15 48",SUP-VP583X-2,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.74,49.72,"CIGNA [10200]","Cigna Open Access",,94.31,56.9,,,,,0,19.28,140.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 60MM HIP GRIPTION PINNACLE STERILE LATEX",SUP-121731060,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1921.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1886.21,13785.68,"percent of total billed charges",
"GRAFT BONE BIO DBM PUTTY DEMINERALIZED BONE MATRIX 5CC",SUP-7775005,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,436.13,3187.5,"percent of total billed charges",
"HC Splint Leg Full Pneu Prefb Ots",PX-E27400061,CDM,L4370,HCPCS,0274,RC,,,both,,,1683.00,504.9,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1144.44,68,,,,,0,138.46,1430.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enteroscopy W Rmvl Snare",PX-750000229,CDM,44364,CPT,0750,RC,,,both,,,3196.00,958.8,"CIGNA [10200]",Cigna,,3196,,"Case rate ($3,287). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,371.69,3196,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION",RX-9080,CDM,,,0250,RC,59651-0026-75,NDC,both,75,ML,407.12,122.14,"PHCS [10601]",PHCS,,284.98,70,,,,,0,47.35,346.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 10CM TRU-CORE II COAXIAL OPTIONAL AUTOMATIC",SUP-763120100X,CDM,S27200284,LOCAL,0272,RC,,,both,,,289.54,86.86,"KAISER [10500]",Kaiser,,193.99,67,,,,,0,33.67,246.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 2MM 14MM 4MM STAINLESS STEEL 1.1MM SHORT THREAD",SUP-02.226.014,CDM,C1713,HCPCS,0278,RC,,,both,,,1645.20,493.56,"CIGNA [10200]","Cigna Open Access",,936.12,56.9,,1144.80,304.56,2275.09,66,191.34,1398.42,"percent of total billed charges",
"PIN FIXATION HEXAGON KIT",SUP-531-78-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LACTATED RINGERS IV BOLUS",RX-400296,CDM,J3490,HCPCS,0258,RC,00338-0117-04,NDC,both,1000,ML,100.65,30.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT POSTERIOR STABILIZE GENESIS II",SUP-71421213,CDM,C1776,HCPCS,0278,RC,,,both,,,29077.65,8723.29,"UHC [10700]","United Healthcare",,18406.15,63.3,,8601.07,8395.67,8601.07,"1 through 10",3381.73,24716,"percent of total billed charges",
"EXPANDER TISSUE BREAST 850CC STYLE 133S SMOOTH 3 SUTURE TAB",SUP-133S-MX-16-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"KAISER [10500]",Kaiser,,6241.05,67,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 35X10X.1MM HALL STERNUM OSCILLATING STERILE",SUP-5059-032,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.18,30.65,"MULTIPLAN [10600]",Multiplan,,86.85,85,,,,,0,11.88,86.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II VASCULAR",SUP-1009667,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 F 36MM E1 HIP HIGH WALL",SUP-010000936,CDM,C1776,HCPCS,0278,RC,,,both,,,12282.00,3684.6,"PHCS [10601]",PHCS,,8597.4,70,,,,,0,1428.4,10439.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION .035IN 5.5IN KIRSCHNER STAINLESS STEEL SMOOTH",SUP-1600-021,CDM,C1713,HCPCS,0278,RC,,,both,,,63.19,18.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",7.35,53.71,"percent of total billed charges",
"STENT OMNILINK ELITE 29MM 80CM 10MM THIN VASCULAR COCR",SUP-1012626-29,CDM,C1876,HCPCS,0278,RC,,,both,,,8400.00,2520,"MULTIPLAN [10600]",Multiplan,,7140,85,,,,,0,976.92,7140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 24MM 144CM 3.5MM CORONARY STENT",SUP-H7493952824350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"FIRST HEALTH [10303]","First Health",,4452,80,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.2MM 12MM APTUS TITANIUM HAND CORTICAL HEXADRIVE 4",SUP-A-5100.12/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"UHC [10700]","United Healthcare",,799.86,63.3,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +27 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.270,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,197.05,28.62,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 45MM 10MM ZENITH ILIAC BRANCH 58MM",SUP-G60341,CDM,C1874,HCPCS,0278,RC,,,both,,,68399.94,20519.98,"NOVANET [10819]",Novanet,,51299.96,75,,,,,0,7954.91,58139.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL INTUITIVE DA VINCI XI BLUE GREEN 60",SUP-1BSGXI60GB,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADHSV SKIN CLSR 2 OCTYL CYANOACRYLATE DERMABOND MINI LIQUID",SUP-DHVM12,CDM,S27200284,LOCAL,0272,RC,,,both,,,308.17,92.45,"CIGNA [10200]","Cigna Local Plus",,164.87,53.5,,,,,0,35.84,261.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTERLOCK II DRILL BIT 2.25X12MM",SUP-6770080,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 11MM KNEE X3 BEARING CRUCIATE RETAIN",SUP-5530-G-711-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1327.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE TAG THORACIC BRANCH ENDOPROSTHESIS 28MMX8MMX10CM 22FR",SUP-TAC082810A,CDM,C1874,HCPCS,0278,RC,,,both,,,182400.00,54720,"BLUE CROSS [10001]","Blue Cross PPO",,71500.8,39.2,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 14MM LCP STAINLESS STEEL CORTICAL FOREFOOT",SUP-202.874,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,92.73,28.62,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 90CM 5MM 8FR 2-5-2MM SPACE D CURVE",SUP-D8BTD5L252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"PHCS [10601]",PHCS,,3472.77,70,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ETHOSUXIMIDE 250 MG CAPSULE",RX-9989,CDM,,,0637,RC,69452-0152-20,NDC,both,1,UN,10.78,3.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.25,9.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BONE CORT CANC BLK PARA CRNRSTN ASR 6X14X11MM",SUP-245641,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]",Cigna,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH METACROSS 65CM 20MM 5.4FR 3MM BALLOON DILATATION 2",SUP-BD-L30020SW,CDM,C1725,HCPCS,0272,RC,,,both,,,923.40,277.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,379.52,41.1,,,,,0,107.39,784.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 65CM STREAMLINE MOND RIGHT VENTRICULAR OUTFLOW",SUP-4140/65,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"CIGNA [10200]",Cigna,,391.07,68,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 150MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-593515022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,908.82,68,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LIVEWIRE 95CM 2MM 7FR 2-8-2MM SPACING ELECTROPHYSIOLOGY",SUP-401932,CDM,C1731,HCPCS,0272,RC,,,both,,,6796.50,2038.95,"KAISER [10500]",Kaiser,,4553.66,67,,,,,0,790.43,5777.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IUD - BERLEX MIRENA",SUP-50419042301,CDM,J7298,HCPCS,0636,RC,,,both,,,8604.23,2581.27,"PHCS [10601]",PHCS,,6022.96,70,,,,,0,1019.6,7313.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +12 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0120,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"PHCS [10601]",PHCS,,935.55,70,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC I&D Abscess Peritonsillar",PX-450000257,CDM,42700,CPT,0361,RC,,,both,,,1361.43,408.43,"PHCS [10601]",PHCS,,1361.43,,"Case rate ($4,710). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,158.33,1361.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 55MM TSRH-3D TITANIUM SPINE PEDICLE POSTERIOR",SUP-837-755,CDM,C1713,HCPCS,0278,RC,,,both,,,2361.60,708.48,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1605.89,68,,,,,0,274.65,2007.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (0-0.5 MCI)",RX-184865,CDM,A9520,HCPCS,0343,RC,08888-8878-35,NDC,both,1,UN,4614.97,1384.49,"PHCS [10601]",PHCS,,3230.48,70,,,,,0,536.72,3922.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LEFT OFFSET STAINLESS STEEL 3.2MM SCR 6 HOLE HOOK",SUP-OHOOKL-6,CDM,C1713,HCPCS,0278,RC,,,both,,,5761.50,1728.45,"CIGNA [10200]","Cigna Open Access",,3278.29,56.9,,1144.80,304.56,2275.09,66,670.06,4897.28,"percent of total billed charges",
"STENT COVERA 100MM 80CM 7MM 8FR STRAIGHT VASCULAR",SUP-AVSM07100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2124.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 150ML SMOOTH ROUND MEMORYGEL SILICONE P3.7CM","SUP-3501504 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"KAISER [10500]",Kaiser,,2532.6,67,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC VIVA S CRT-D PHYSIOCURVE CARDIOSYNC SMARTSHOCK",SUP-DTBB1D4,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6839.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 246MM STAINLESS STEEL 3.5MM SCR 14 HOLE WITHOUT TAB",SUP-238.710,CDM,C1713,HCPCS,0278,RC,,,both,,,7615.53,2284.66,"KAISER [10500]",Kaiser,,5102.41,67,,,,,0,885.69,6473.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 80CM 20MM 6FR 10MM .035IN BALLOON DILATATION",SUP-B1100-020,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,89.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CS3 STAINLESS STEEL 2.7MM SCR VARIABLE ANGLE LCP BONE",SUP-02.112.624S,CDM,C1713,HCPCS,0278,RC,,,both,,,6722.53,2016.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,796.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,781.83,5714.15,"percent of total billed charges",
"SPHERE GLENOID 10D TILTED",SUP-DWD191,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1444.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1418.05,10364.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SRGITLG LP SRGDAC 2/0 21""3""LP",SUP-ED-21-L,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"UHC [10700]","United Healthcare",,91.25,63.3,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 19CM 4.2MM EXCALIBUR COOLCUT CURVE HIP LENGTH",SUP-AR-6420CEX,CDM,S27200284,LOCAL,0272,RC,,,both,,,654.89,196.47,"KAISER [10500]",Kaiser,,438.78,67,,,,,0,76.16,556.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 230MM HUMERAL EXPERT INTRAMEDULLARY CANNULATED",SUP-04.001.426S,CDM,C1713,HCPCS,0278,RC,,,both,,,9216.74,2765.02,"BLUE CROSS [10001]","Blue Cross HMO",,3612.96,39.2,,957.42,156.86,7483.26,51,1071.91,7834.23,"percent of total billed charges",
"CAGE SPINAL 17X6MM DIVERGENCE 14MM LORDOTIC NUCLEUS PULPOSUS",SUP-G6626746,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"FIRST HEALTH [10303]","First Health",,9936,80,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 2IN 18GA E-CATH SAFERSONIC CONTINUOUS",SUP-TDL133,CDM,S27200284,LOCAL,0272,RC,,,both,,,595.35,178.6,"CIGNA [10200]",Cigna,,404.84,68,,,,,0,69.24,506.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM 12/14 TAPER 28MM HIP COCR SPECTRON EF",SUP-71302812,CDM,C1776,HCPCS,0278,RC,,,both,,,7431.30,2229.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,880.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,864.26,6316.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION L4 1/8IN OD18GA STRAIGHT WITH OBTURATOR HOUSE",SUP-68-1007,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prolact+4 20ml Qtr Btl",PX-E27000207,CDM,E27000207,LOCAL,0270,RC,,,both,,,179.30,53.79,"CIGNA [10200]","Cigna Local Plus",,95.93,53.5,,,,,0,20.85,152.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12CM 7MM AXIUM 3D NEUROVASCULAR FRAME V01",SUP-FC-7-12-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,13765.50,4129.65,"MULTIPLAN [10600]",Multiplan,,11700.68,85,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 177CM 12MM EMBOLD PLATINUM TUNGSTUN",SUP-M001394240120300,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"AETNA [10100]","Aetna HMO/PPO",,6851.39,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 47MM CATHCART BALL HIP FEMUR MODULAR STERILE",SUP-136347000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"PHCS [10601]",PHCS,,2618,70,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 122MM 2.4MM AO FIT OVER NONSTERILE",SUP-703696,CDM,S27200284,LOCAL,0272,RC,,,both,,,1068.23,320.47,"MULTIPLAN [10600]",Multiplan,,908,85,,,,,0,124.24,908,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE FIAPC 1.5MM 9.8FT SIDEFR",SUP-20132-219,CDM,S27200284,LOCAL,0272,RC,,,both,,,2092.50,627.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,243.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,243.36,1778.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachythrpy Grid",PX-E27200042,CDM,E27200042,LOCAL,0272,RC,,,both,,,363.00,108.9,"CIGNA [10200]","Cigna Open Access",,206.55,56.9,,,,,0,42.22,308.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 48MM 32MM ALTRX HIP",SUP-122132048,CDM,C1776,HCPCS,0278,RC,,,both,,,5307.67,1592.3,"CIGNA [10200]","Cigna Open Access",,3020.06,56.9,,5302.19,4377.88,6578.61,27,617.28,4511.52,"percent of total billed charges",
"HEAD FEMORAL 50MM HIP RESURFACE COCR BIRMINGHAM STERILE",SUP-74121150,CDM,C1776,HCPCS,0278,RC,,,both,,,27319.95,8195.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7818.97,28.62,,,,,0,3177.31,23221.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REAMER SURGICAL 9MM CANNULATED ACL LOW PROFILE STERILE",SUP-AR-1409LP,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"MULTIPLAN [10600]",Multiplan,,1383.8,85,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR EXTERNAL FIXATION 250MM 5MM SCHANZ STAINLESS STEEL HA",SUP-294.788SHA,CDM,C1713,HCPCS,0278,RC,,,both,,,1933.73,580.12,"BLUE CROSS [10001]","Blue Cross PPO",,758.02,39.2,,957.42,570.23,957.42,28,224.89,1643.67,"percent of total billed charges",
"STENT ZILVER 635 30MM 125CM 8MM 6FR .035IN VASCULAR NITINOL",SUP-G43830,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"NOVANET [10819]",Novanet,,2835,75,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 36MM ORTHOLOC TITANIUM CORTICAL SELF TAP",SUP-59225536,CDM,C1713,HCPCS,0278,RC,,,both,,,996.30,298.89,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,285.14,28.62,,,,,0,115.87,846.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Bn/Jnt Img Wb",PX-341000023,CDM,78306,CPT,0341,RC,,,both,,,3278.75,983.62,"UHC [10700]","United Healthcare",,982.43,,,,,,,360.48,2786.94,"fee schedule",
"SUT FIBERWIRE 5 T-5 CCS-1 38IN BRAID TIES MULTISTRAND LOWER",SUP-AR-7213,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"CIGNA [10200]",Cigna,,248.47,68,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM HIP SOLID BACK METAL HA TRIDENT C",SUP-500-11-46C,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.85,2973.55,"NOVANET [10819]",Novanet,,7433.89,75,,,,,0,1152.75,8425.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 33MM 2.25MM CORONARY STENT EVEROLIMUS",SUP-1550225-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 20MM 1.5MM BALLOON DILATATION RAPID",SUP-47515020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1085.08,68,,,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT 15MM CURVE BALLON CRTDG 10GA",SUP-1031-015-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11781,68,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 5MM STRAIGHT 84MM NARROW SHAFT SICKLE EDGE BEAVER",SUP-377300,CDM,S27200284,LOCAL,0272,RC,,,both,,,545.45,163.63,"CIGNA [10200]","Cigna Local Plus",,291.82,53.5,,,,,0,63.44,463.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +32 DIOPTER POSTERIOR CHMBR FOLDABLE APODIZE",SUP-SA25T0,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"CIGNA [10200]","Cigna Local Plus",,398.58,53.5,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE EXTERNAL FIXATION WRISTJACK AGEE RADIUS DISTAL",SUP-CFD-147,CDM,S27000186,LOCAL,0270,RC,,,both,,,10350.00,3105,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1226.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 225MM 6MM STEINMANN STAINLESS STEEL",SUP-294.950,CDM,C1713,HCPCS,0278,RC,,,both,,,793.80,238.14,"FIRST HEALTH [10303]","First Health",,635.04,80,,,,,0,92.32,674.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 90MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.890,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,630.85,45.9,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM STD ENDOCARDIUM 1 COIL ACTIVE DF4 TERMINAL",SUP-0293,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"PHCS [10601]",PHCS,,12020.4,70,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 80CM 20CM 4MM BALLOON DILATATION OTW LOW",SUP-G30897,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +7.5 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.075,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 22FR MEDIUM ROUND URETHRAL SILASTIC 30ML 2 WAY 2",SUP-33422,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.11,15.03,"CIGNA [10200]","Cigna Local Plus",,26.81,53.5,,,,,0,5.83,42.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 19GA 10.2CM SUPERCORE COAXIAL INTRO ECHOGENIC TIP",SUP-MCXS2015LY,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.64,44.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,17.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.4,127.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE LEGACY DBM 2.5CC ALLOGRAFT NONSTERILE LATEX FREE",SUP-420802,CDM,C1713,HCPCS,0278,RC,,,both,,,1875.00,562.5,"NOVANET [10819]",Novanet,,1406.25,75,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 3MM MATCH HEAD DISSECTING",SUP-MR8-9MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1184.63,355.39,"AMERIGROUP MEDICAID [20100]",Amerigroup,,140.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,137.77,1006.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 CURVE 12.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962012,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"CIGNA [10200]","Cigna Open Access",,5262.94,56.9,,5302.19,4377.88,6578.61,27,1075.71,7862.03,"percent of total billed charges",
"SET STENT 30CM 8FR 2.1FR POLARIS ULTRA NAUTILUS .035IN 2",SUP-M006192155050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,139.63,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER GUIDING 150CM .84-.61FR FINECROSS CORONARY",SUP-M3-1450,CDM,C1887,HCPCS,0272,RC,,,both,,,3645.00,1093.5,"AETNA [10100]","Aetna HMO/PPO",,2897.78,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,423.91,3098.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER SURGICAL 24-38MM GRAFT",SUP-M002363200211,CDM,S27200284,LOCAL,0272,RC,,,both,,,90.75,27.22,"CIGNA [10200]","Cigna Open Access",,51.64,56.9,,,,,0,10.55,77.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X16X5MM CERVICAL ANATOMIC",SUP-6940564,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 STD 10MM KNEE LEFT GUR 1020 CRUCIATE SUB",SUP-EIS7S10L,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1208.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FINALE LONG 12IN COMPRESSION RADIAL ARTERY BAND",SUP-FCD200,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.05,30.01,"CIGNA [10200]",Cigna,,68.03,68,,,,,0,11.64,85.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 12CM 6MM .035IN BILIARY SELF EXPAND GWIRE",SUP-G23812,CDM,C1876,HCPCS,0278,RC,,,both,,,13275.60,3982.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1573.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1543.95,11284.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cryoprecipitate Ea Unit",PX-390000003,CDM,P9012,HCPCS,0390,RC,,,both,,,399.85,119.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES,EXTREME",815,APR-DRG,,,,,,,inpatient,,,87334.08,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $9,954.80. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($101,776.48) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR 9FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G00992,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) LAMINAR IMPLANT SIZE (16MM)",SUP-FG-6032,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LUTONIX 035 GEOALIGN 130CM 150MM 7MM BALLOON DILATATION",SUP-LX3513071505F,CDM,C2623,HCPCS,0272,RC,,,both,,,8452.50,2535.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEVICE VENTRICULAR ASSIST 17.4X13.8IN IMPELLA CP 9.3IN 10-40",SUP-0048-0003,CDM,S27800098,LOCAL,0278,RC,,,both,,,153900.00,46170,"FIRST HEALTH [10303]","First Health",,123120,80,,,,,0,17898.57,130815,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 20CM 150CM 5FR .038IN 3CM BLADDER LOOP",SUP-M006155220170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,168.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 20CM 150CM 5FR .038IN 3CM BLADDER LOOP",SUP-M006155220170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,965.83,68,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 3-5 C-D KNEE RIGHT TIBIA",SUP-42521400412,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"CIGNA [10200]",Cigna,,5491.52,68,,5873.17,5873.17,5873.17,"1 through 10",939.21,6864.4,"percent of total billed charges",
"SCR BONE 4MM 40MM LCP STAINLESS STEEL SHORT THREAD",SUP-207.640,CDM,C1713,HCPCS,0278,RC,,,both,,,1040.04,312.01,"CIGNA [10200]",Cigna,,707.23,68,,1831.33,1831.33,1831.33,16,120.96,884.03,"percent of total billed charges",
"HC Electron Micro Dx",PX-312000044,CDM,88348,CPT,0312,RC,,,both,,,1164.80,349.44,"MULTIPLAN [10600]",Multiplan,,990.08,85,,,,,0,0.01,990.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO 6207BTK-5  LEAD INTRODUCER  7 FR",SUP-6207BTK-5,CDM,C1894,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 38MM 140CM .91-1.12MM 2.5MM CORONARY",SUP-RONYX25038W,CDM,C1874,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"AETNA [10100]","Aetna HMO/PPO",,2683.13,79.5,,,,,0,392.51,2868.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM LOW PROFILE SCREWS TITANIUM VARIABLE",SUP-AR-8724V-18,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]","Cigna Open Access",,921.78,56.9,,1144.80,304.56,2275.09,66,188.41,1377,"percent of total billed charges",
"CAGE SPINAL 26X9X11MM COROENT 4D PEEK LARGE IMPACT",SUP-6711926,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA [10200]","Cigna Open Access",,5547.6,33.5,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 32MM STAINLESS STEEL 2.7MM SCR MINI FRAGMENT SET 2X4",SUP-249.697,CDM,C1713,HCPCS,0278,RC,,,both,,,3883.32,1165,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2640.66,68,,,,,0,451.63,3300.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB CONGRU 10MM LFT 1-2",SUP-2041-0-1210,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"KAISER [10500]",Kaiser,,2386.88,67,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tc99m Sulfr Colloid Up to 20mci",PX-343000028,CDM,A9541,HCPCS,0343,RC,,,both,,,610.00,183,"PHCS [10601]",PHCS,,427,70,,,,,0,70.94,610,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW METAPHYSEAL COMPRESSION 3.7MM X 46MM TI",SUP-MTC-37460-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1247.40,374.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,147.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,145.07,1060.29,"percent of total billed charges",
"CATH MUSTANG 40CM 40MM 8MM .035IN BALLOON DILATATION NYBAX",SUP-39171-08044,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,136.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SPINAL SPACER W14.5XH8XL12MM 7DEG CERVICAL LORDOSIS PR",SUP-VG1C-T68P,CDM,S27800098,LOCAL,0278,RC,,,both,,,5865.00,1759.5,"CIGNA [10200]","Cigna Local Plus",,3137.78,53.5,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM NEXGEN LPS-FLEX 3-4 C-D KNEE PROLONG",SUP-596203010,CDM,C1776,HCPCS,0278,RC,,,both,,,7918.44,2375.53,"CIGNA [10200]","Cigna Local Plus",,4236.37,53.5,,5372.07,4581.20,7242.98,23,920.91,6730.67,"percent of total billed charges",
"ENDOSCOPIC DISSECTOR STICK, BULLET, 5MM X 400MM",SUP-698.135S,CDM,S27200284,LOCAL,0272,RC,,,both,,,4112.40,1233.72,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,487.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,478.27,3495.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 25.5X9.5X.6MM THIN OSCILLATING SAGITTAL STERILE",SUP-KM-3101C,CDM,S27200284,LOCAL,0272,RC,,,both,,,61.77,18.53,"CIGNA [10200]",Cigna,,42,68,,,,,0,7.18,52.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOMATRIX+ POROUS ALLOGRAFT STERILE",SUP-OMP-09,CDM,C1713,HCPCS,0278,RC,,,both,,,9522.00,2856.6,"BLUE CROSS [10001]","Blue Cross HMO",,3732.62,39.2,,957.42,156.86,7483.26,51,1107.41,8093.7,"percent of total billed charges",
"HC Lipoprotein A",PX-301000299,CDM,83695,CPT,0301,RC,,,both,,,164.75,49.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,15.04,,"Fee schedule rate ($15.04). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.16,140.04,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL SY60WF.130 CLAREON",SUP-SY60WF.130,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,553.97,45.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER PTX 100MM 125CM 8MM VASCULAR PERIPHERAL OTW",SUP-G38523,CDM,C1874,HCPCS,0278,RC,,,both,,,12392.33,3717.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5093.25,41.1,,,,,0,1441.23,10533.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 3CM 7FR .035IN PIGTAIL CURVE STRAIGHT LOW PROFILE",SUP-M006145374050,CDM,C2617,HCPCS,0278,RC,,,both,,,940.57,282.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,111.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,109.39,799.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +11 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.110,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,345.41,28.62,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURBOHAWK MEC 113CM 9CM 3.5-7MM LOW PROFILE ATHERECTOMY",SUP-TH-LX-M,CDM,C1714,HCPCS,0272,RC,,,both,,,20128.50,6038.55,"MULTIPLAN [10600]",Multiplan,,17109.23,85,,,,,0,2340.94,17109.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC",699,MS-DRG,,,,,,,inpatient,,,31433.45,9430.03,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MALECOT 52CM 20FR 8FR NEPHRSTMY PERCUFLEX STENTING",SUP-M001224200,CDM,C1729,HCPCS,0272,RC,,,both,,,599.40,179.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH INFINITI THRULUMEN 100CM 4FR .042IN 1200 PSI AMPLATZ",SUP-538447,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAMP SURGICAL DIETHRICH ANGLE MICRO 8MM CORONARY BULLDOG",SUP-55-4038,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.19,161.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRSG ALGINATE 16X16IN ACTICOAT POLYETHYLENE NANOCRYSTALLINE",SUP-20401,CDM,S27200284,LOCAL,0272,RC,,,both,,,506.28,151.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOLDER PLATE BB-TAK LARGE TITANIUM",SUP-AR-8970-09,CDM,S27000186,LOCAL,0270,RC,,,both,,,1093.50,328.05,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 40MM 3MM BALLOON",SUP-U357534,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NDL NERVE BLOCK 150MM 18GA 20GA SONOLONG SONOLONG SONO",SUP-511187-31C,CDM,C9814,HCPCS,0272,RC,,,both,,,518.40,155.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,60.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.29,440.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 12MM .0145IN AXIUM PRIME 3D FRAME",SUP-FC-12-30-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"PHCS [10601]",PHCS,,11567.85,70,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD REAMER 13.5MM DEEP FLUTE STAINLESS STEEL CONICAL TIP",SUP-352.253S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2560.05,768.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,297.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,297.73,2176.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 25MM TITANIUM 1 LEVEL ZEVO BONE SPINE CERVICAL",SUP-3001025,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Local Plus",,2399.48,53.5,,3978.14,359.25,3978.14,24,521.61,3812.25,"percent of total billed charges",
"CATH IMPULSE 125CM 5FR .045IN VENTRICULAR PIGTAIL CURVE",SUP-H749163912152,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"UHC [10700]","United Healthcare",,48.48,63.3,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEMLESS SHOULDER : HUMERAL HEAD, INSETGLENOID, STEMLESS",SUP-SI-TSA-SLA,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION .25IN .25IN BARD SILICONE 4 FREE FLOW CHANNEL",SUP-072231,CDM,S27200284,LOCAL,0272,RC,,,both,,,125.37,37.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,51.53,41.1,,,,,0,14.58,106.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 13X3IN RIBBON 2 END MALLEABLE STAINLESS STEEL SPINE",SUP-22-0257,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.13,26.44,"KAISER [10500]",Kaiser,,59.05,67,,,,,0,10.25,74.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PK PAPYRUS 4.5/20",SUP-434897,CDM,C1874,HCPCS,0278,RC,,,both,,,19750.50,5925.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5332.64,27,,,,,0,2296.98,16787.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 3CM 7FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175274110,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,354.71,28.62,,,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MIDAS BURR",SUP-F3/9TA30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1168.83,350.65,"CIGNA [10200]","Cigna Local Plus",,625.32,53.5,,,,,0,135.93,993.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB PCL SUBS 1-2X12MM L",SUP-2141-1-1212,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross HMO",,1396.5,39.2,,5311.50,4717.44,5388.59,31,414.32,3028.13,"percent of total billed charges",
"CLIP MEDIUM CHEVRON HEART INTERNAL WECK HEM-O-LOK POLYMER",SUP-544220,CDM,S27200284,LOCAL,0272,RC,,,both,,,439.14,131.74,"CIGNA [10200]","Cigna Open Access",,249.87,56.9,,,,,0,51.07,373.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 150CM 7FR .038IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145369170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,323.39,28.62,,,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,inpatient,,,99303.02,29790.91,"CIGNA [10200]","Cigna Local Plus",,14485.81,,"Fee schedule rate ($14,485.81). Includes an add-on of 31.5% of RC 0274 if total amount is above $24,380, 31.5% of RC 0275 if total amount is above $24,380, 31.5% of RC 0001-0999 if total amount is above $24,380, 31.5% of RC 0276 if total amount is above $24,380, 51.2% of RC 0636 if total amount is above $7,171.",,,,0,8707.87,35009.37,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 14CM 4MM NESTER MICROCOIL PLATINUM ACCEPTS",SUP-G47327,CDM,S27800098,LOCAL,0278,RC,,,both,,,890.92,267.28,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,254.98,28.62,,,,,0,103.61,757.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCK AUGMENTATION NEXGEN 6 HALF 5MM KNEE TIBIA PRECOAT",SUP-598800626,CDM,C1776,HCPCS,0278,RC,,,both,,,7158.06,2147.42,"MULTIPLAN [10600]",Multiplan,,6084.35,85,,,,,0,832.48,6084.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OLYMPUS 4MM 40 DEG ROTATABLE SHAVER",SUP-SB4040RS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1523.61,457.08,"UHC [10700]","United Healthcare",,964.45,63.3,,,,,0,177.2,1295.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 9MM KNEE XLPE DISHED LEGION",SUP-71453277,CDM,C1776,HCPCS,0278,RC,,,both,,,16373.70,4912.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4686.15,28.62,,,,,0,1904.26,13917.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 10MM 3MM",SUP-SPL30010X,CDM,C1725,HCPCS,0272,RC,,,both,,,607.50,182.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,71.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT HEMODIALYSIS HERO VENOUS",SUP-HEROALLY,CDM,C1768,HCPCS,0278,RC,,,both,,,7935.00,2380.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5395.8,68,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT SOCKET RSP DJO SURGICAL STD HUMERAL HXE+ STERILE",SUP-509-00-036,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"BLUE CROSS [10001]","Blue Cross HMO",,3538.87,39.2,,5311.50,4717.44,5388.59,31,1049.92,7673.56,"percent of total billed charges",
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 40MM 190CM 2.5",SUP-R51002504L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"MULTIPLAN [10600]",Multiplan,,1675.99,85,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 13MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G613,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"UHC [10700]","United Healthcare",,5928.73,63.3,,8601.07,8395.67,8601.07,"1 through 10",1089.28,7961.17,"percent of total billed charges",
"CATH NANOCROSS ELITE 150CM 20MM 2MM .014IN BALLOON",SUP-AB14W020020150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"FIRST HEALTH [10303]","First Health",,1108.08,80,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM THK5-30MM ALLOGRAFT STRIP",SUP-400500,CDM,S27800098,LOCAL,0278,RC,,,both,,,9940.14,2982.04,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2844.87,28.62,,,,,0,1156.04,8449.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 35X10X.1MM HALL STERNUM OSCILLATING STERILE",SUP-5059-032,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.18,30.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42,41.1,,,,,0,11.88,86.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 62X56MM KNEE LEFT POSTERIOR STABILIZE",SUP-81-4405L,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6665.78,41.1,,6417.48,6417.48,6417.48,"1 through 10",1886.21,13785.68,"percent of total billed charges",
"STEM FEMORAL 171MM CEMENT AVENIR PROTASUL-S30 8 43.66MM STD",SUP-01.06010.208,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,10981.53,8986.79,12413.38,12,2014.9,14726.25,"percent of total billed charges",
"SCR BONE 2.7MM 18MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656318,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"CIGNA [10200]","Cigna Open Access",,759.73,56.9,,1144.80,304.56,2275.09,66,155.28,1134.92,"percent of total billed charges",
"SUT CHROMIC SUTUPAK 0 18IN MONOFILAMENT 12 STRAND PRECUT",SUP-SG14T,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.11,53.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,81.29,45.9,,,,,0,20.6,150.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 44-41MM COMPREHENSIVE STD SHOULDER E1",SUP-EP-115396,CDM,C1776,HCPCS,0278,RC,,,both,,,8854.00,2656.2,"CIGNA [10200]","Cigna Local Plus",,4736.89,53.5,,5372.07,4581.20,7242.98,23,1029.72,7525.9,"percent of total billed charges",
"STEM FEMORAL 105MM COLLAR ACTIS DUOFIX 5 12/14 HIGH OFFSET",SUP-101012050,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"NOVANET [10819]",Novanet,,22857.19,75,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 65CM 5FR .052IN .035IN PIGTAIL ANGIOGRAPHIC",SUP-7602-41,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.18,30.95,"PHCS [10601]",PHCS,,72.23,70,,,,,0,12,87.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EZ STEER THERMOCOOL 115CM 3.5MM 7.5FR 2-5-2MM SPACE F-F",SUP-BDI75TCFFRT,CDM,C2630,HCPCS,0272,RC,,,both,,,10626.00,3187.8,"AETNA [10100]","Aetna HMO/PPO",,8447.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1235.8,9032.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 26MM SAPIEN 3 ULTRA RESILIA",SUP-S3URCM26A,CDM,S27800098,LOCAL,0278,RC,,,both,,,193800.00,58140,"CIGNA [10200]","Cigna Local Plus",,61047,31.5,,,,,0,22538.94,164730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CLLGN FIBERTAPE FIBERWIRE 2 TAPER 7INX2MM BRAID BLUE",SUP-AR-7237-7B,CDM,S27200284,LOCAL,0272,RC,,,both,,,637.88,191.36,"FIRST HEALTH [10303]","First Health",,510.3,80,,,,,0,74.19,542.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 8 HOLE STRAIGHT BONE LEFT CLAVICLE",SUP-70-0298,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,783.31,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,768.77,5618.67,"percent of total billed charges",
"CAGE SPINAL 60X10MM STD XL PEEK PLATE FUSION",SUP-7861060,CDM,C1889,HCPCS,0278,RC,,,both,,,34275.60,10282.68,"FIRST HEALTH [10303]","First Health",,27420.48,80,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 48MM PEG REUNION X3 STERILE LATEX FREE TOTAL",SUP-5542-P-0048,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"KAISER [10500]",Kaiser,,6048.57,67,,,,,0,1049.92,7673.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 9MM APTUS TRILOCK TITANIUM PHALANGEAL HAND",SUP-A-5250.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"UHC [10700]","United Healthcare",,1020.33,63.3,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +26.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200265,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"NOVANET [10819]",Novanet,,765.45,75,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 29MM 80CM 6MM 8MM 7FR .035IN",SUP-BXA062901A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"FIRST HEALTH [10303]","First Health",,15603.84,80,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL 220CM 2.3MM FIAPC FLEXIBLE STRAIGHT",SUP-20132-214,CDM,S27200284,LOCAL,0272,RC,,,both,,,1900.50,570.15,"CIGNA [10200]","Cigna Open Access",,1081.38,56.9,,,,,0,221.03,1615.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND MULTIPASS 2-0 PS-2 18IN BRAID BLACK",SUP-583H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH TIGHTRAIL SUB-C .145IN DIL ROTATE STERILE LATEX FREE",SUP-560-011,CDM,C1773,HCPCS,0272,RC,,,both,,,12385.50,3715.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8422.14,68,,,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 20MM LOCK PERIPHERAL STERILE",SUP-AR-9563-20,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"CIGNA [10200]","Cigna Open Access",,339.91,56.9,,1144.80,304.56,2275.09,66,69.48,507.77,"percent of total billed charges",
"VALVE MITRAL 21MM 18.6MM MASTERS HP MECHANICAL ROTATABLE STD",SUP-21MHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK ULTRA 18MM 5MM CORONARY STENT XCELON",SUP-1003382-18,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) DORAYA DEVICE",SUP-40-0002,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 72MM TAN X25 LOCK STERILE LIGHT GREEN 4.2MM",SUP-04.045.072TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,189.34,1383.8,"percent of total billed charges",
"CATH SABER 90CM 80MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050080S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"NOVANET [10819]",Novanet,,1075.28,75,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HIWIRE SAFE-T-J VASCULAR CURVE TAPER 145CM 3CM .035IN",SUP-G00561,CDM,C1769,HCPCS,0272,RC,,,both,,,121.71,36.51,"NOVANET [10819]",Novanet,,91.28,75,,,,,0,14.15,103.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +20.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZA90030205,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA ARTHROSCOPIC L90 MM OD5.5 MM THREAD STERILE CLEAR",SUP-214110,CDM,S27200284,LOCAL,0272,RC,,,both,,,759.78,227.93,"MULTIPLAN [10600]",Multiplan,,645.81,85,,,,,0,88.36,645.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHOE POSTOPERATIVE MEDIUM XLONG MALE NAVY BLUE PATENT",SUP-100344-030,CDM,S27000186,LOCAL,0270,RC,,,both,,,54.55,16.36,"AETNA [10100]","Aetna HMO/PPO",,43.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.34,46.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR 50CM LINEAR PERCUTANEOUS 3-6 LEAD TRIAL SUT",SUP-SC-2366-50E,CDM,C1778,HCPCS,0278,RC,,,both,,,5520.00,1656,"MULTIPLAN [10600]",Multiplan,,4692,85,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +13 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.130,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"KAISER [10500]",Kaiser,,808.62,67,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GASTROINTESTINAL OBSTRUCTION WITH MCC",388,MS-DRG,,,,,,,inpatient,,,28005.88,8401.76,"BLUE CROSS [10001]","Blue Cross PPO",,28005.88,,,,,,,7561,28005.88,"case rate",
"COIL EMBOLIZATION 10CM 3MM AZUR .018IN",SUP-45-480310,CDM,S27800098,LOCAL,0278,RC,,,both,,,5678.70,1703.61,"CIGNA [10200]","Cigna Local Plus",,3038.1,53.5,,,,,0,660.43,4826.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 38-41MM TITANIUM 4.75MM SCR MULTISPAN XLNK BONE SPINE",SUP-5442138,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"PHCS [10601]",PHCS,,3381,70,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 51MM 26MM UHR UNIVERSAL ACETABULAR HIP COCR",SUP-UH1-51-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"NOVANET [10819]",Novanet,,3238.33,75,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER LIME GREEN 17MM 4.5MM INCISOR DYONICS CURVED",SUP-7205332,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,143.03,41.1,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC PERCLOT STANDARD L9 CM 1 GM STERILE LATEX F",SUP-PCUS001,CDM,A6250,HCPCS,0272,RC,,,both,,,715.83,214.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,486.76,68,,,,,0,83.25,608.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 15MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158106115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]",Cigna,,7598.69,68,,5873.17,5873.17,5873.17,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"SCREW METAPHYSEAL LOCKING 3.7MM X 58MM TI",SUP-MTLS-37580-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLONAZEPAM 0.5 MG TABLET",RX-9637,CDM,,,0637,RC,50268-0173-11,NDC,both,1,UN,12.54,3.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 4MM BALL DISSECTING DIAMOND",SUP-MR8-14BA40D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.17,412.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,162.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,159.82,1168.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 91CM 80CM SHUNT STAINLESS STEEL SILICONE",SUP-903330A,CDM,C1729,HCPCS,0272,RC,,,both,,,9242.76,2772.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CHRG 75CM 20MM 5FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206060270,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ASAHI GAIA NEXT 2 VASCULAR 190CM .014IN STERILE LATEX",SUP-AH14R020P,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MEPILEX BORDER HEEL 22X23CM 8.7X9.1IN",SUP-282790,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.30,24.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH RANGER 135CM 100MM 6MM BALLOON DILATATION PACLITAXEL",SUP-H74939419601010,CDM,C2623,HCPCS,0272,RC,,,both,,,8625.00,2587.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SIZER IMPL 12.25CM NATRELLE INSPIRA P3.2CM LOW PLUS PROFILE",SUP-MSZ-LP265,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BIOPSY 60CM 7FR 19GA TLAB STRAIGHT CURVE METAL 4 SWAB",SUP-TL-19,CDM,S27200284,LOCAL,0272,RC,,,both,,,3875.04,1162.51,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT FIBERTAPE FIBERWIRE 0 8INX1.7MM TAPER END BLUE 30IN",SUP-AR-7273-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.2MM 16MM STD COALITION",SUP-184.056,CDM,C1713,HCPCS,0278,RC,,,both,,,940.00,282,"BLUE CROSS [10001]","Blue Cross PPO",,368.48,39.2,,957.42,570.23,957.42,28,109.32,799,"percent of total billed charges",
"INTRO SHEATH 6FR 50CM 23CM GREEN HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-6F-23-038,CDM,C1894,HCPCS,0272,RC,,,both,,,117.45,35.23,"UHC [10700]","United Healthcare",,74.35,63.3,,,,,0,13.66,99.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MORPHINE 30 MG/30 ML (1 MG/ML) IN 0.9 % SODIUM CHLORIDE IV PCA SUPERORDERABLE - BASAL RATE ONLY",RX-411636,CDM,J2270,HCPCS,0636,RC,70092-1519-48,NDC,both,30,ML,102.20,30.66,"NOVANET [10819]",Novanet,,76.65,75,,,,,0,7.62,86.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE RELINE L40 MM OD6.5 MM SPINE POLYAXIAL 2 FULL CAN",SUP-16216540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 30CM 32MM HEMASHIELD PLATINUM STRAIGHT TUBE",SUP-M00202175432P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3797.28,1139.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,449.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,441.62,3227.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII CRUCIATE RETAINING OXINI",SUP-71704560,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5953.5,27,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NELATON 16IN 14FR URETHRAL RUBBER INTERMITTENT STERILE",SUP-402140-000140,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.47,18.74,"KAISER [10500]",Kaiser,,41.85,67,,,,,0,7.27,53.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 32MM C HIP X3 TRIDENT",SUP-623-00-32C,CDM,C1776,HCPCS,0278,RC,,,both,,,6242.04,1872.61,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,725.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,725.95,5305.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 60MM 32MM XLPE HIP STERILE",SUP-71339560,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1318.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1293.98,9457.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 80CM 5FR SOS OMNI 3 CURVE ANGIOGRAPHIC VISCERAL",SUP-H787107204065,CDM,C1887,HCPCS,0272,RC,,,both,,,217.50,65.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,147.9,68,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC",803,MS-DRG,,,,,,,inpatient,,,76982.80,23094.84,"CIGNA [10200]","Cigna Open Access",,20399.57,,"Fee schedule rate ($20,399.57). Includes an add-on of 33.5% of RC 0274 if total amount is above $24,380, 33.5% of RC 0275 if total amount is above $24,380, 33.5% of RC 0001-0999 if total amount is above $24,380, 33.5% of RC 0276 if total amount is above $24,380, 54.4% of RC 0636 if total amount is above $7,171.",,,,0,7561,54272.44,other,"IP DRG - Acute Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DECA 2-2-2 MPA 120CM",SUP-901537,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"AETNA [10100]","Aetna HMO/PPO",,2355.19,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Fetal Addl Gestation",PX-610000054,CDM,74713,CPT,0610,RC,,,both,,,1846.00,553.8,"KAISER [10500]",Kaiser,,1236.82,67,,,,,0,214.69,1846,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MERSILENE SABRELOC 5-0 S-24 18IN 2 ARM BRAIDED GREEN",SUP-1761G,CDM,S27200284,LOCAL,0272,RC,,,both,,,161.20,48.36,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,19.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.75,137.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 1.5% DEXTROSE 2000ML 3000ML BAG LUER CNTNR DIANEAL",SUP-L5B4825,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.48,34.04,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,13.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.2,96.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 4-0 RB-1 18IN 2 ARM MONOFILAMENT BLUE",SUP-8757H,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.08,18.62,"CIGNA [10200]","Cigna Local Plus",,33.21,53.5,,,,,0,7.22,52.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 80MM 80CM 16MM .035IN 3MM VASCULAR VENOUS 3",SUP-VENUM16080,CDM,C1876,HCPCS,0278,RC,,,both,,,22050.00,6615,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2612.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPEL TWIST-LOC 12CM 6FR SHORT LENGTH URETERAL",SUP-H7493936106120,CDM,C2617,HCPCS,0278,RC,,,both,,,1142.10,342.63,"PHCS [10601]",PHCS,,799.47,70,,,,,0,132.83,970.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT FIBERWIRE 2 STRAIGHT 26IN BRAID MULTISTRAND CLOSED LOOP",SUP-AR-7204,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"KAISER [10500]",Kaiser,,341.9,67,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP VIDEO S00 LOW PROFILE QUICK CONNECT GLIDESCOPE",SUP-0270-1153,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.26,129.98,"CIGNA [10200]","Cigna Local Plus",,231.79,53.5,,,,,0,50.39,368.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 27MM MOSAIC BIOPROSTHESIS HOLDER",SUP-31002701,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross PPO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 8 79MM 12.2MM SHILEY CUFF REUSABLE INNER CANN",SUP-8CN85R,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.92,161.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,365.79,68,,,,,0,62.56,457.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENT BUR 2.0MMDIA FINE DIAMOND SS 70MM LONG SHORT EXTENDED AN",SUP-SA-DB2L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1725.00,517.5,"CIGNA [10200]","Cigna Open Access",,981.53,56.9,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING STEROID ELUTING SILICONE 65CM 7FR ENDOCARDIAL DF",SUP-7120/65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]","Cigna Local Plus",,5409.18,31.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOCLEANSE POSTERIOR TIBIALIS TENDON GREATER THAN OR EQUAL T",SUP-453016,CDM,C1762,HCPCS,0278,RC,,,both,,,13800.00,4140,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5671.8,41.1,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR GREEN 44MM 28MM RINGLOC ECCENTRIC HIP",SUP-11-165212,CDM,C1776,HCPCS,0278,RC,,,both,,,6659.88,1997.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,774.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,774.54,5660.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 518 FLEXOR 30MM 125CM 6MM 5FR LOW PROFILE",SUP-G43770,CDM,C1876,HCPCS,0278,RC,,,both,,,4179.00,1253.7,"AETNA [10100]","Aetna HMO/PPO",,3322.31,79.5,,,,,0,486.02,3552.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON SUT 12MM",SUP-AR-8922,CDM,C1713,HCPCS,0278,RC,,,both,,,850.50,255.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,98.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",98.91,722.93,"percent of total billed charges",
"GRAFT VASCULAR 30CM 18MM HEMASHIELD PLATINUM THORACIC CLLGN",SUP-M00202175418P0,CDM,C1768,HCPCS,0278,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17.8MM 25MM 32MM 23.4MM ON-X 25 STD CYLINDRICAL",SUP-ONXAE-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"MULTIPLAN [10600]",Multiplan,,32130,85,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 13MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P113,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5682.01,68,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DAILY (INPATIENT) DRIVELINE KIT",SUP-EBSI1564B,CDM,S27200284,LOCAL,0272,RC,,,both,,,112.00,33.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.03,95.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 14-13.8CM NATRELLE P6.1-6.9CM HIGH PROFILE ROUND",SUP-SZHP68750,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"UHC [10700]","United Healthcare",,192.75,63.3,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 5MM 16MM LCP TITANIUM FULL THREAD DISTAL",SUP-402.816,CDM,C1713,HCPCS,0278,RC,,,both,,,380.02,114.01,"AMERIGROUP MEDICAID [20100]",Amerigroup,,45.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",44.2,323.02,"percent of total billed charges",
"PLATE 71MM TITANIUM LEVEL 4 ZEVO BONE SPINE CERVICAL",SUP-3004071,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,3978.14,359.25,3978.14,24,641.98,4692,"percent of total billed charges",
"STENT INLAY OPTIMA 24CM 6FR URETERAL PHREECOAT POLYMER",SUP-788624,CDM,C2617,HCPCS,0278,RC,,,both,,,834.30,250.29,"CIGNA [10200]",Cigna,,567.32,68,,,,,0,97.03,709.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X9MM ENDOSKELETON TC 6D 12MM SMALL CERVICAL",SUP-5146-1209-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,10350.00,3105,"CIGNA [10200]","Cigna Open Access",,5889.15,56.9,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MACH1 100CM 8FR AR2 CURVE GUIDING PTFE FEMORAL",SUP-H74934358180,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AETNA [10100]","Aetna HMO/PPO",,291.32,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPN NC 20MM 1.5MM BALLOON DILATATION PLATINUM IRIDIUM",SUP-150-020-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"AMERIGROUP MEDICAID [20100]",Amerigroup,,981.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 40MM 125CM 5MM BILIARY NITINOL ILIAC",SUP-G32032,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"PHCS [10601]",PHCS,,2646,70,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH DESTINO SURESEAL FLEXSTEER 17MM BEND STANDARD 55CM 73",SUP-PSS0855517,CDM,C1887,HCPCS,0272,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 800ML GEL SMOOTH MEMORYGEL SILICONE P5.1CM","SUP-3508001 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"PHCS [10601]",PHCS,,2572.5,70,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 25MM COMPREHENSIVE 3.5MM SHOULDER FIX ANGLE",SUP-180552,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,184.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",180.96,1322.6,"percent of total billed charges",
"SLEEVE LAPAROSCOPIC 5MM 150MM KII ADVANCE FIXATION",SUP-CFS01,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.60,20.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,47.33,68,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX9MM FRA 8D 30D LORDOTIC NARROW",SUP-209,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"KAISER [10500]",Kaiser,,12663,67,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 24CM 3CM 5FR .038IN STRAIGHT URETERAL",SUP-M006155222010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"KAISER [10500]",Kaiser,,824.74,67,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN FULL LENGTH AMPLATZ RIGHT 2 CURVE",SUP-H74908641862,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BUTTON 1CM 12FR RADIOPAQUE LOW PROFILE TAPER DISTAL TIP",SUP-0120-12-1.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPHINTOM 30MM 450CM 4.4FR JAGTOME RX 44 BILIARY PANCREAS",SUP-M00573070,CDM,S27200284,LOCAL,0272,RC,,,both,,,2337.98,701.39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SILK PERMA-HAND 1 MH 30IN BRAID BLACK NONABSORBABLE",SUP-K845H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR SURGICAL 26CM 20GA SNAP LOCK FIBRIN SEAL LATEX FREE",SUP-0601137,CDM,S27200284,LOCAL,0272,RC,,,both,,,535.91,160.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,245.98,45.9,,,,,0,62.33,455.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 60MM 3.5MM LORDOSIS TITANIUM",SUP-102063060,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECTRUM LOPRO S4 DISPOSABLE BLADES",SUP-0270-1079,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,40.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2.5 X 3 COMPLEX PICO COIL",SUP-10USC02503,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"KAISER [10500]",Kaiser,,8760.59,67,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SYNCHRO-14 VASCULAR 200CM 35CM .014IN NITINOL",SUP-M00313410,CDM,C1769,HCPCS,0272,RC,,,both,,,4568.90,1370.67,"PHCS [10601]",PHCS,,3198.23,70,,,,,0,531.36,3883.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 22MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0331,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,644.44,68,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHALANX CORONAL TRANSFIXION SCREW 1.5MM X 18.0MM COCR",SUP-PTS-15018-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.90,337.77,"CIGNA [10200]",Cigna,,765.61,68,,1831.33,1831.33,1831.33,16,130.94,957.02,"percent of total billed charges",
"INTRO SHEATH 8FR 60CM HEMOSTASIS VALVE J TIP SUPER STIFF",SUP-406871,CDM,C1893,HCPCS,0272,RC,,,both,,,1215.00,364.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,499.37,41.1,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL SUT 4 .5 CIRCLE TROCAR POINT MAYO CATGUT STERILE LATEX",SUP-1826-4DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 14X14.5CM 600CC STYLE 133S SMOOTH SUT TAB",SUP-133S-FV-14-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"FIRST HEALTH [10303]","First Health",,7452,80,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS02004,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Open Access",,3927.24,33.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sporanox",PX-301000080,CDM,80299,CPT,0301,RC,,,both,,,373.00,111.9,"CIGNA [10200]","Cigna Local Plus",,41.01,,,,,,,0.01,317.05,"fee schedule",
"COIL EMBOLIZATION 7CM 20MM RETRACTA DETACHABLE .035IN",SUP-G34195,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"BLUE CROSS [10001]","Blue Cross HMO",,1663.45,39.2,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR 50CM NEVRO 5MM SPACING TRAIL LEAD STERILE",SUP-TLEAD1058-50B,CDM,C1897,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]",Cigna,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 14CM 23MM 12MM 19-21MM 10-11MM GORE",SUP-RLT231214,CDM,S27800098,LOCAL,0278,RC,,,both,,,62700.00,18810,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,16929,27,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL REVISION CORAIL TITANIUM HA 14 STD TRAPEZOID",SUP-L98014,CDM,C1776,HCPCS,0278,RC,,,both,,,41850.00,12555,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4959.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4867.16,35572.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 36MM 22.2MM ACTIVE ARTICULATION E1 B G7 2",SUP-010000991,CDM,C1776,HCPCS,0278,RC,,,both,,,2700.00,810,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,772.74,28.62,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13CM NATRELLE INSPIRA P2.6CM LOW PROFILE ROUND",SUP-MSZ-L290,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.69,42.81,"UHC [10700]","United Healthcare",,90.32,63.3,,,,,0,16.59,121.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 65CM PROTEGO S 1 COIL",SUP-379969,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS [10001]","Blue Cross HMO",,6731.42,39.2,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WORD 5CM 10FR DRNG 5CC BARTHOLIN GLAND 2 WAY FOLEY",SUP-564000,CDM,C1729,HCPCS,0272,RC,,,both,,,229.52,68.86,"KAISER [10500]",Kaiser,,153.78,67,,,,,0,26.69,195.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 15MM 41MM SHOULDER SIMPLICITI",SUP-7122869,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2867.44,28.62,,,,,0,1165.21,8516.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 40MM 7MM BALLOON",SUP-U357574,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"NOVANET [10819]",Novanet,,516.38,75,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH POWERPICC SOLO 2 SHERLOCK 3CG 55CM 5FR CENTRAL VENOUS",SUP-1395108QD,CDM,C1751,HCPCS,0272,RC,,,both,,,2090.55,627.16,"MULTIPLAN [10600]",Multiplan,,1776.97,85,,,,,0,243.13,1776.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 28CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006180234010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,306.45,28.62,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 48MM 2MM E9000 FINE ROUND DIAMOND STERILE",SUP-E6220,CDM,S27200284,LOCAL,0272,RC,,,both,,,463.08,138.92,"KAISER [10500]",Kaiser,,310.26,67,,,,,0,53.86,393.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 135CM 11MM 16SQ MM 8FR .035IN",SUP-BXA117902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5780,27,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 12CM MR8 3MM MATCH HEAD DISSECTING",SUP-MR8-12MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1089.86,326.96,"CIGNA [10200]",Cigna,,741.1,68,,,,,0,126.75,926.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17CM 5MM PRESTIGE PLUS HELICAL ULTRA",SUP-PRES0517CPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3008.75,45.9,,,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 40MM 12MM 10FR FLUENCY PLUS FLARE ENDOVASCULAR",SUP-FEM12040,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5228.87,28.62,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 38MM 22.2MM D HIP X3 STERILE LATEX FREE MDM",SUP-7236-2-244,CDM,C1776,HCPCS,0278,RC,,,both,,,8711.25,2613.37,"BLUE CROSS [10001]","Blue Cross PPO",,3414.81,39.2,,3949.44,3949.44,3949.44,"1 through 10",1013.12,7404.56,"percent of total billed charges",
"NAIL 7MM 9.5MM 225MM HUMERAL RIGHT MULTILOC INTRAMEDULLARY",SUP-04.016.225S,CDM,C1713,HCPCS,0278,RC,,,both,,,11172.76,3351.83,"BLUE CROSS [10001]","Blue Cross PPO",,4379.72,39.2,,957.42,570.23,957.42,28,1299.39,9496.85,"percent of total billed charges",
"BRONCHOSCOPE EXAMINATION BFLEX ULTRASLIM 2.8 SINGLE USE X2",SUP-0570-0447,CDM,S27200284,LOCAL,0272,RC,,,both,,,2295.00,688.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,271.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,266.91,1950.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 250MM 5MM BALLOON DILATATION",SUP-PCU050250130,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"UHC [10700]","United Healthcare",,803.71,63.3,,,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MEDIUM UNIVERSAL 25MM STAINLESS STEEL 2.7/3.5MM SCR 4",SUP-40240425,CDM,C1713,HCPCS,0278,RC,,,both,,,15000.60,4500.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1777.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1744.57,12750.51,"percent of total billed charges",
"MITRACLIP G4 CDS NT REPAIR-MR CLINICAL",SUP-CDS0704-NT,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]",Cigna,,68400,40,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MITRACLIP G4 CDS NT REPAIR-MR CLINICAL",SUP-CDS0704-NT,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20263.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.9H 40MM 2 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18009240,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"FIRST HEALTH [10303]","First Health",,3588,80,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 6CM 5.8FR 18FR BALLOON",SUP-M0062251080,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,202.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,199.16,1455.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L14MM DIA3.5MM CORTICAL STAINLESS STEEL SELF TAPP",SUP-02.206.014,CDM,C1713,HCPCS,0278,RC,,,both,,,321.55,96.46,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,147.59,45.9,,,,,0,37.4,273.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BIOLOGICAL 5X5CM CYTAL PORCINE EXTRACELLULAR MATRIX",SUP-BMM0505,CDM,Q4166,HCPCS,0636,RC,,,both,,,5991.96,1797.59,"MULTIPLAN [10600]",Multiplan,,5093.17,85,,,,,0,53.69,5093.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 8.2MM 150MM 32MM STAINLESS STEEL LARGE BONE",SUP-209.950,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,162.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",159.84,1168.25,"percent of total billed charges",
"PEG FIXATION 2MM 24MM FOSSA RADIUS DISTAL VOLAR SMOOTH LOCK",SUP-SPLS-20240-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,639.90,191.97,"BLUE CROSS [10001]","Blue Cross PPO",,250.84,39.2,,957.42,570.23,957.42,28,74.42,543.92,"percent of total billed charges",
"BIT DRILL 24MM 2MM ORTHOLOC",SUP-58850020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1069.20,320.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,126.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PLASTIBELL 1.1CM CIRCUMCISION PLASTIC PEDIATRIC",SUP-HL9211,CDM,S27200284,LOCAL,0272,RC,,,both,,,51.82,15.55,"NOVANET [10819]",Novanet,,38.87,75,,,,,0,6.03,44.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 10MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640510,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"MULTIPLAN [10600]",Multiplan,,9565.82,85,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP MEDIUM 23.8CM MULTIPLE OPEN LIGATE",SUP-MSM20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1092.07,327.62,"AETNA [10100]","Aetna HMO/PPO",,868.2,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.01,928.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ZEBRA 6F  115CM ACCESS SYSTEM SIM2",SUP-AC6074-115-20,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"UHC [10700]","United Healthcare",,5656.17,63.3,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL GREEN 11CM SAFE-T-GAUGE ROUND LOOP",SUP-DLP-M11,CDM,S27200284,LOCAL,0272,RC,,,both,,,140.07,42.02,"PHCS [10601]",PHCS,,98.05,70,,,,,0,16.29,119.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT CLEARVUE AIRGUARD",SUP-1608362,CDM,C1788,HCPCS,0278,RC,,,both,,,2887.50,866.25,"BLUE CROSS [10001]","Blue Cross PPO",,1131.9,39.2,,,,,0,335.82,2454.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT",RX-2888,CDM,,,0250,RC,00574-4024-11,NDC,both,1,GR,54.70,16.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,6.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.36,46.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 SOFT 3MM X 10CM",SUP-M0035473100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"FIRST HEALTH [10303]","First Health",,11291.71,80,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT IMPLANTABLE INFUSION POWERPORT ISP MRI AIRGUARD",SUP-1809661,CDM,C1788,HCPCS,0278,RC,,,both,,,1471.10,441.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,171.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,171.09,1250.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 40MM 130CM 7MM LONG VASCULAR NITINOL ILIAC",SUP-SC740LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"FIRST HEALTH [10303]","First Health",,5796,80,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT PROSERIES 170MM 80MM 5MM 5FR .014-.035IN",SUP-5F051701CS,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"BLUE CROSS [10001]","Blue Cross PPO",,8137.33,39.2,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 60MM 130CM 8MM VASCULAR METAL SUPERFICIAL",SUP-H74939293086030,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"MULTIPLAN [10600]",Multiplan,,4105.5,85,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 80MM 120CM 5.5MM 6FR BILIARY NITINOL PERIPHERAL",SUP-S-55-080-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1192.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1063.27,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 12MM 4MM CORONARY STENT FULCRUM COCR RAPID",SUP-INT40012UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"CIGNA [10200]",Cigna,,1642.2,68,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 20MM 80CM 10MM VASCULAR NITINOL OTW",SUP-1012532-20,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 20MM 80CM 10MM VASCULAR NITINOL OTW",SUP-1012532-20,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"KAISER [10500]",Kaiser,,2773.8,67,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 15MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDS32515,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"UHC [10700]","United Healthcare",,52554.65,63.3,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) INTREPID MITRAL VALVE 48MM RECOVERABLE CLINICAL IMPLA",SUP-INTPD-V4-48A,CDM,S62400003,LOCAL,0624,RC,,,both,,,256500.00,76950,"MULTIPLAN [10600]",Multiplan,,218025,85,,,,,0,29830.95,218025,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Emg Anal/Urethral Ndl",PX-750000109,CDM,51785,CPT,0750,RC,,,both,,,3331.00,999.3,"CIGNA [10200]",Cigna,,2497,,"Case rate ($2,497). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,387.4,3331,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS CARDIOBAND FIT ANCHOR DRIVE",SUP-25200AD,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Aorta Ivc Ltd",PX-921000016,CDM,93979,CPT,0921,RC,,,both,,,1081.48,324.44,"CIGNA [10200]","Cigna Open Access",,615.36,56.9,,,,,0,125.78,919.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)SAPIEN M3 VALVE EPTFE 29MM",SUP-9880TFX29M,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"CIGNA [10200]","Cigna Open Access",,113515.5,56.9,,,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 67MM 135CM 7MM 160CM",SUP-M001712150,CDM,C1876,HCPCS,0278,RC,,,both,,,13323.90,3997.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3597.45,27,,,,,0,1549.57,11325.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 67MM 135CM 7MM 160CM",SUP-M001712150,CDM,C1876,HCPCS,0278,RC,,,both,,,13323.90,3997.17,"NOVANET [10819]",Novanet,,9992.93,75,,,,,0,1549.57,11325.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 120MM 135CM 6MM 5FR VASCULAR NITINOL LOW",SUP-5F061203CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EVAL INFLATION DEVICE GLOBAL",SUP-INTPDIDCG,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAPLACE TTVR DELIVERY SYSTEM",SUP-TTVR-DS-2673,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 5.0 MM X 120 MM X 130 CM",SUP-IPU05012013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"NOVANET [10819]",Novanet,,6054.75,75,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) OPTIMIZER SMART MINI IPG INCLUDING PATIENT CHARGER",SUP-10-B501-2-XX,CDM,S62400003,LOCAL,0624,RC,,,both,,,148200.00,44460,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17235.66,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17235.66,125970,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ELECTROPHYSIOLOGY 2-5-2MM SPACING MEDIUM CURVE 4FR 110",SUP-81531R,CDM,C1730,HCPCS,0272,RC,,,both,,,1875.00,562.5,"NOVANET [10819]",Novanet,,1406.25,75,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Epidural",PX-E27200163,CDM,E27200163,LOCAL,0272,RC,,,both,,,179.30,53.79,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,121.92,68,,,,,0,20.85,152.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +7 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR CHMBR",SUP-MTA3U0.070,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WEBSTER CS L 115CM 7FR 2-8-2MM SPACE FJ CURVE MAPPING",SUP-BD710FJ282RTS,CDM,C1730,HCPCS,0272,RC,,,both,,,2142.00,642.6,"MULTIPLAN [10600]",Multiplan,,1820.7,85,,,,,0,249.11,1820.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL MEDIUM PARTIAL KNEE UNICOMPARTMENTAL PHASE 3",SUP-161469,CDM,C1776,HCPCS,0278,RC,,,both,,,16754.58,5026.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6886.13,41.1,,6417.48,6417.48,6417.48,"1 through 10",1948.56,14241.39,"percent of total billed charges",
"CATH LASSO REDEL 115CM 7FR 20MM 6MM SPACE ELECTROPHYSIOLOGY",SUP-D7L1020RT,CDM,C1730,HCPCS,0272,RC,,,both,,,7507.20,2252.16,"MULTIPLAN [10600]",Multiplan,,6381.12,85,,,,,0,873.09,6381.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 7FR 2-5-2MM SPACE REGULAR D CURVE",SUP-D7DR252CT,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"PHCS [10601]",PHCS,,1622.25,70,,,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 8.6FR HELIX VENTRICLE 1 COIL ACTIVE",SUP-693552,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]",Cigna,,6868.8,40,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ADMIN 12IN PERITONEAL CATH LUER LOCK STERILE SAFE-LOCK",SUP-050-95004,CDM,S27200284,LOCAL,0272,RC,,,both,,,314.24,94.27,"MULTIPLAN [10600]",Multiplan,,267.1,85,,,,,0,36.55,267.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POLYMYXIN B SULFATE 500,000 UNITS/5ML (WET SOLR VIAL)",RX-4156393,CDM,,,0250,RC,70860-0124-41,NDC,both,1,UN,49.38,14.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,22.67,45.9,,,,,0,5.74,41.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO BLUE 11CM 8FR BRITE TIP CANN INTERVENTIONAL",SUP-401811M,CDM,C1894,HCPCS,0272,RC,,,both,,,60.90,18.27,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC",988,MS-DRG,,,,,,,inpatient,,,78216.37,23464.91,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,10654.14,,"Case rate ($10,195.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,467.07, add-ons for qualifying new technology services are included. If operating cost exceeds $42,506.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,097.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,479.59. The transfer operating threshold is the transfer adjustment factor * $9,467.07 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $715.76. The transfer capital threshold is the transfer adjustment factor * $715.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,47986.55,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT PROSERIES GEOALIGN 120MM 80CM 5MM 5FR",SUP-5F051201CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS [10001]","Blue Cross PPO",,5950.56,39.2,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR 85CM HEMOSTASIS GWIRE CATH LOCK FAST-CATH",SUP-406787,CDM,C1894,HCPCS,0272,RC,,,both,,,1239.30,371.79,"KAISER [10500]",Kaiser,,830.33,67,,,,,0,144.13,1053.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Caffeine",PX-301000064,CDM,80155,CPT,0301,RC,,,both,,,133.00,39.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.13,.1,,,,,0,0.13,113.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 16CM 6FR .087IN .082IN GLIDESHEATH .035IN SPRING J",SUP-RM*BF6M16MA,CDM,C1894,HCPCS,0272,RC,,,both,,,368.01,110.4,"MULTIPLAN [10600]",Multiplan,,312.81,85,,,,,0,42.8,312.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIB 65CM LINOX SMART 18CM",SUP-359067,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS [10001]","Blue Cross HMO",,6731.42,39.2,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE 25CM 2.5CM 6FR INTRO STAINLESS STEEL",SUP-RSS605,CDM,C1894,HCPCS,0272,RC,,,both,,,178.35,53.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 5MM 85MM 32MM NCB TITANIUM ALUMINUM VANADIUM",SUP-203152085,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,56.9,,1144.80,304.56,2275.09,66,189.34,1383.8,"percent of total billed charges",
"CATH SUPERTORQUE 100CM 5FR SIDEWINDER SIMMONS TECHNIQUE I I",SUP-532502,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 9MM PRECISION THK.51MM 31MM MEDIUM LONG STAINLESS",SUP-2296-033-125,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.84,87.25,"NOVANET [10819]",Novanet,,218.13,75,,,,,0,33.82,247.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 4FR .042IN MULTIPURPOSE A 2",SUP-538442,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"FIRST HEALTH [10303]","First Health",,71.62,80,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYPROPYLENE PROLENE 5-0 C-1 36IN 2 ARM MONOFILAMENT",SUP-8321H,CDM,S27200284,LOCAL,0272,RC,,,both,,,176.54,52.96,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,72.56,41.1,,,,,0,20.53,150.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOLVAPTAN 15 MG TABLET",RX-97893,CDM,,,0637,RC,49884-0768-52,NDC,both,1,UN,2123.53,637.06,"NOVANET [10819]",Novanet,,1592.65,75,,,,,0,246.97,1805,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ORTHOPAT INTEGRATED PROCESSING AUTOTRANSFUSION TUBING",SUP-1150H-00,CDM,S27200284,LOCAL,0272,RC,,,both,,,3668.40,1100.52,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1507.71,41.1,,,,,0,426.63,3118.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 3.5MM MAGILL CURVE NASAL ORAL CUFF",SUP-86443,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.13,18.94,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,25.95,41.1,,,,,0,7.34,53.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUPREME EXTENSION CABLE BLUE  150 CM",SUP-401981,CDM,S27200284,LOCAL,0272,RC,,,both,,,248.00,74.4,"KAISER [10500]",Kaiser,,166.16,67,,,,,0,28.84,215.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 1.5% DEXTROSE 132 MEQ/L SODIUM 95 MEQ/L CHLORIDE 2.5",SUP-044-30321,CDM,S27200284,LOCAL,0272,RC,,,both,,,53.07,15.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,36.09,68,,,,,0,6.17,45.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 5MM CANNULATED",SUP-03.333.113S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3784.37,1135.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2573.37,68,,,,,0,440.12,3216.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE 90MM 3.5MM SERFAS ENDOSCOPIC LATEX FREE",SUP-0279351400,CDM,S27200284,LOCAL,0272,RC,,,both,,,1174.50,352.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,539.1,45.9,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB BEACON 65CM 5FR MPA CURVE ANGIOGRAPHIC",SUP-G11195,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,97.61,41.1,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRACTOR ABDOMINAL RIBBON TISSUE HAND HELD MALLEABLE 8IN LE",SUP-22-0017,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.04,24.61,"MULTIPLAN [10600]",Multiplan,,69.73,85,,,,,0,9.54,69.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ULTRAGLIDE 9-0 CS160-6 6IN MONOFILAMENT BLUE",SUP-J2625N,CDM,S27200284,LOCAL,0272,RC,,,both,,,235.62,70.69,"CIGNA [10200]","Cigna Open Access",,134.07,56.9,,,,,0,27.4,200.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL KNIFE 24FR TUIP OLYMPUS OES PRO",SUP-M0068802671,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,60.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PROC 1 TRIATHLON CR DISPOSABLE FEMORAL",SUP-5555-2201,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"FIRST HEALTH [10303]","First Health",,1134,80,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VLVTOM 1.8MM 110CM EXPANDABLE ANGIOSCOPIC",SUP-1000-90,CDM,S27200284,LOCAL,0272,RC,,,both,,,12965.10,3889.53,"MULTIPLAN [10600]",Multiplan,,11020.34,85,,,,,0,1507.84,11020.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIOGRAPHY 5FR L125CM DIA0.045IN FEMORAL RIGHT 4 I",SUP-H749163912252,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]","Cigna Open Access",,43.57,56.9,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLONAZEPAM 0.5 MG DISINTEGRATING TABLET",RX-35627,CDM,,,0637,RC,49884-0308-52,NDC,both,1,UN,12.90,3.87,"CIGNA [10200]",Cigna,,8.77,68,,,,,0,1.5,10.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 OS-4 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP694H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"CIGNA [10200]","Cigna Open Access",,14.23,56.9,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS 9FR DOUBLEPLAY 2Y METAL SILICONE",SUP-MAP221,CDM,S27200284,LOCAL,0272,RC,,,both,,,168.43,50.53,"KAISER [10500]",Kaiser,,112.85,67,,,,,0,19.59,143.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAPTOPRIL 12.5 MG TABLET",RX-9401,CDM,,,0637,RC,60687-0304-11,NDC,both,1,UN,8.54,2.56,"CIGNA [10200]",Cigna,,5.81,68,,,,,0,0.99,7.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPER TORQUE 100CM 6FR LEFT CORONARY BYPASS CURVE",SUP-532672,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"KAISER [10500]",Kaiser,,55.38,67,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT RAINS 48MM 38MM 4MM 3.2MM STD NASAL FRONTAL SINUS",SUP-7089-0932,CDM,S27200284,LOCAL,0272,RC,,,both,,,372.04,111.61,"CIGNA [10200]","Cigna Local Plus",,199.04,53.5,,,,,0,43.27,316.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF ENHANCR II 110CM 4MM 7FR 2-5-2MM SPACE 55MM MEDIUM",SUP-FND-019-03,CDM,S27200284,LOCAL,0272,RC,,,both,,,1360.80,408.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,161.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,158.26,1156.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOME LAMBOTTE MINI SWISS PATTERN 5 1/8IN 12MM",SUP-27-5712,CDM,S27200284,LOCAL,0272,RC,,,both,,,131.89,39.57,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,54.21,41.1,,,,,0,15.34,112.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP LIGATION RESOLUTION 360 ULTRA 235CM BRAID ROTATION",SUP-M00521400,CDM,S27200284,LOCAL,0272,RC,,,both,,,2000.78,600.23,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,822.32,41.1,,,,,0,232.69,1700.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRAP ANKLE FOOT DSRCTOR SURGICAL STERILE LATEX FREE",SUP-014407,CDM,S27200284,LOCAL,0272,RC,,,both,,,337.91,101.37,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.3,287.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER 1628-Y8M MERIT MED STD",SUP-1628-Y8M,CDM,S27200284,LOCAL,0272,RC,,,both,,,1044.90,313.47,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,479.61,45.9,,,,,0,121.52,888.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INFLATION 1 STPCOCK STERILE VBS",SUP-03.804.413S,CDM,S27200284,LOCAL,0272,RC,,,both,,,668.25,200.47,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,274.65,41.1,,,,,0,77.72,568.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Iabp",PX-E27200059,CDM,E27200059,LOCAL,0272,RC,,,both,,,4138.20,1241.46,"PHCS [10601]",PHCS,,2896.74,70,,,,,0,481.27,3517.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD THK14MM 40J 40X73MM","SUP-CD1357-40C CELL",CDM,C1722,HCPCS,0278,RC,,,both,,,35964.00,10789.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,14385.6,40,,,,,0,4182.61,30569.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC 2 ACTION SERRATE JAW WIDE SPREAD MONOPOLAR",SUP-600126,CDM,S27100035,LOCAL,0271,RC,,,both,,,3457.50,1037.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,409.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,402.11,2938.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablt Perc Liver Tmr Rf",PX-361000179,CDM,47382,CPT,0361,RC,,,both,,,7662.58,2298.77,"KAISER [10500]",Kaiser,,5133.93,67,,,,,0,891.16,7662.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis B Virus Surf Abs Qt",PX-302000062,CDM,86317,CPT,0302,RC,,,both,,,237.50,71.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.13,,,,,,,0.24,201.88,"fee schedule",
"HC Dressing Driveline W Closure 6x6",PX-E27200437,CDM,E27200437,LOCAL,0272,RC,,,both,,,43.97,13.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,29.9,68,,,,,0,5.11,37.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 55CM RIGHT VENTRICLE DF-4 TRIPOLAR SCR DEFIB",SUP-6935M55,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"FIRST HEALTH [10303]","First Health",,13737.6,80,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 4MM COOLCUT 8 FLUTE OVAL STERILE DISPOSABLE",SUP-AR-8400OBE,CDM,S27200284,LOCAL,0272,RC,,,both,,,501.80,150.54,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,58.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,58.36,426.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM ACCOLADE HFX 127D 3 43MM OFFSET HIP",SUP-6077-0335,CDM,C1776,HCPCS,0278,RC,,,both,,,8983.80,2695.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3692.34,41.1,,6417.48,6417.48,6417.48,"1 through 10",1044.82,7636.23,"percent of total billed charges",
"INSERT TIBIAL 6 13MM KNEE POSTERIOR STABILIZED BEARING TRIAT",SUP-5532P613,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3835.36,45.9,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM CD HORIZON REDUCTION MULTIAXIAL",SUP-55890007550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2533.68,45.9,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 85MM ANTIROTATE STERILE FEMORAL NECK SYSTEM",SUP-04.168.485S,CDM,C1713,HCPCS,0278,RC,,,both,,,1642.20,492.66,"CIGNA [10200]","Cigna Local Plus",,878.58,53.5,,3978.14,359.25,3978.14,24,190.99,1395.87,"percent of total billed charges",
"HC Xr Frac Assess Dual Energy",PX-320000219,CDM,77086,CPT,0320,RC,,,both,,,256.13,76.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,30.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.79,217.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (PS) - SIZE 7",SUP-5555-2257,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"AETNA [10100]","Aetna HMO/PPO",,1126.91,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cholinesterase Serum",PX-301000146,CDM,82480,CPT,0301,RC,,,both,,,289.75,86.92,"FIRST HEALTH [10303]","First Health",,231.8,80,,,,,0,0.01,246.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cholinesterase Serum",PX-301000146,CDM,82480,CPT,0301,RC,,,both,,,289.75,86.92,"KAISER [10500]",Kaiser,,194.13,67,,,,,0,0.01,246.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aquaporin-4 Antb Cba Each",PX-302000251,CDM,86052,CPT,0302,RC,,,both,,,751.45,225.43,"CIGNA [10200]",Cigna,,26.51,,,,,,,0.01,638.73,"fee schedule",
"CAP KIT REPLACEMENT SHOULDER HUMERAL GLENOID TRABECULAR META",SUP-98000972001,CDM,C1776,HCPCS,0278,RC,,,both,,,33075.00,9922.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13230,40,,,,,0,3846.62,28113.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 185X70MM D OSCILLATING",SUP-KM33-114,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.65,24.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,54.84,68,,,,,0,9.38,68.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD RADIAL 10MM 24MM EXPLOR ELBOW MODULAR",SUP-11-210041,CDM,C1776,HCPCS,0278,RC,,,both,,,14214.00,4264.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5685.6,40,,,,,0,1653.09,12081.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 120MM 3MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171031210,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,482.72,41.1,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 15MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50015,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"KAISER [10500]",Kaiser,,55626.56,67,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +30.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-PCB0000305,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"MULTIPLAN [10600]",Multiplan,,1032.75,85,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET TUBING DUALWAVE CASSETTE OUTFLOW ARTHROSCOPY PUMP",SUP-AR-6430,CDM,S27200284,LOCAL,0272,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 375MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.455S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"FIRST HEALTH [10303]","First Health",,6649.94,80,,,,,0,966.74,7065.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE LEFT CRUCIATE RETAIN SIGMA STERILE",SUP-940013,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3010.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3010.99,22006.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 15X12X7MM MODULUS 7D CERVICAL STERILE LATEX FREE",SUP-67940002P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"PHCS [10601]",PHCS,,4347,70,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 500MM 11MM CARBON FIBER LARGE EXTERNAL",SUP-394.89,CDM,C1713,HCPCS,0278,RC,,,both,,,1581.53,474.46,"NOVANET [10819]",Novanet,,1186.15,75,,,,,0,183.93,1344.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC AVALUS 23MM 400 SERIES LATEX FREE",SUP-40023,CDM,S27800098,LOCAL,0278,RC,,,both,,,33390.00,10017,"PHCS [10601]",PHCS,,23373,70,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 9 STD KNEE RIGHT CRUCIATE RETAIN PERSONA PPS",SUP-42508606602,CDM,C1776,HCPCS,0278,RC,,,both,,,29326.50,8797.95,"MULTIPLAN [10600]",Multiplan,,24927.53,85,,,,,0,3410.67,24927.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 24CM 6FR .038IN PIGTAIL CURVE",SUP-M006180222120,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"MULTIPLAN [10600]",Multiplan,,1130.72,85,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT TKR 92 CAP EXTRA",SUP-98000200196,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"CIGNA [10200]","Cigna Local Plus",,7739.55,31.5,,5372.07,4581.20,7242.98,23,2857.49,20884.5,"percent of total billed charges",
"CANN RADIOFREQUENCY 150MM 20GA 10MM",SUP-AC0012,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION",RX-1224,CDM,J0665,HCPCS,0636,RC,63323-0472-37,NDC,both,30,ML,74.29,22.29,"MULTIPLAN [10600]",Multiplan,,63.15,85,,,,,0,5.24,63.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Amylase",PX-301000105,CDM,82150,CPT,0301,RC,,,both,,,255.55,76.66,"MULTIPLAN [10600]",Multiplan,,217.22,85,,,,,0,0.26,217.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT BALLOON DILATATION SPACEMAKER PLUS BTT 65X3FT",SUP-SMBTTRND,CDM,C1727,HCPCS,0272,RC,,,both,,,3258.30,977.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,386.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,378.94,2769.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTAINSTABILITY QUADPOLE LEAD",SUP-479878,CDM,C1900,HCPCS,0278,RC,,,both,,,11626.50,3487.95,"FIRST HEALTH [10303]","First Health",,9301.2,80,,,,,0,1352.16,9882.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP BIOFOAM DYNASTY",SUP-DSBFGB48,CDM,C1776,HCPCS,0278,RC,,,both,,,18918.90,5675.67,"FIRST HEALTH [10303]","First Health",,15135.12,80,,,,,0,2200.27,16081.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL SHALLCROSS FULL CURVE 8IN CYSTIC DUCT",SUP-SU10510,CDM,S27200284,LOCAL,0272,RC,,,both,,,466.97,140.09,"NOVANET [10819]",Novanet,,350.23,75,,,,,0,54.31,396.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY CUT-AWAY 8FR GUIDING INNER",SUP-7041,CDM,C1887,HCPCS,0272,RC,,,both,,,1579.50,473.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,187.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 465CC",SUP-SMPX465,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"CIGNA [10200]",Cigna,,5067.36,68,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 72MM STAINLESS STEEL 2.4MM SCR 6X5 HOLES 2",SUP-02.111.551,CDM,C1713,HCPCS,0278,RC,,,both,,,4196.93,1259.08,"MULTIPLAN [10600]",Multiplan,,3567.39,85,,,,,0,488.1,3567.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Factor XII",PX-305000026,CDM,85280,CPT,0305,RC,,,both,,,529.00,158.7,"CIGNA [10200]",Cigna,,42.57,,,,,,,0.01,449.65,"fee schedule",
"STEM FEMORAL TAPERFILL 6 STD OFFSET HIP STERILE LATEX FREE",SUP-425-96-006,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1635.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1604.94,11730,"percent of total billed charges",
"STENT SUPERA 30MM 120CM 6.5MM 6FR VASCULAR NITINOL",SUP-S-65-030-120-P6,CDM,C1874,HCPCS,0278,RC,,,both,,,12385.50,3715.65,"FIRST HEALTH [10303]","First Health",,9908.4,80,,,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE ES 143CM 20MM 3MM .014IN BALLOON DILATATION OTW",SUP-39134-30201,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"FIRST HEALTH [10303]","First Health",,1036.8,80,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL 5IN 2.8MM ACU-LOC 2 QUICK RELEASE",SUP-80-0387,CDM,S27200284,LOCAL,0272,RC,,,both,,,704.70,211.41,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,289.63,41.1,,,,,0,81.96,599,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 8MM 72MM STAINLESS STEEL CORTICAL SELF TAP",SUP-214.872,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"CIGNA [10200]","Cigna Local Plus",,134.24,53.5,,3978.14,359.25,3978.14,24,29.18,213.27,"percent of total billed charges",
"STEM FEMORAL 135D 41.5MM STD OFFSET 38.5MM 155MM 13MM COLLAR",SUP-3L92503,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"BLUE CROSS [10001]","Blue Cross HMO",,6208.15,39.2,,5311.50,4717.44,5388.59,31,1841.86,13461.55,"percent of total billed charges",
"BRACE ORTHOPEDIC SMALL KNEE OPEN BACK AIRMESH ROADRUNNER",SUP-14142,CDM,S27000186,LOCAL,0270,RC,,,both,,,614.55,184.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,72.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,71.47,522.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CERVICAL SPINAL FUSION WITHOUT CC/MCC",473,MS-DRG,,,,,,,inpatient,,,100396.23,30118.87,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,30835.28,,"Case rate ($15,143.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $14,061.80, add-ons for qualifying new technology services are included. If operating cost exceeds $47,101.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,445.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $14,080.39. The transfer operating threshold is the transfer adjustment factor * $14,061.80 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,063.14. The transfer capital threshold is the transfer adjustment factor * $1,063.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,71276.19,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR SKIN 4.8X3.4MM 35 WIDE STAPLE 360D ROTATE HEAD STERILE",SUP-059037,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.80,36.54,"MULTIPLAN [10600]",Multiplan,,103.53,85,,,,,0,14.17,103.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ext Ecg>48hr<7d Recording",PX-731000005,CDM,93242,CPT,0731,RC,,,both,,,383.00,114.9,"NOVANET [10819]",Novanet,,287.25,75,,,,,0,30.87,383,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 60MM 36MM ALTRX HIP",SUP-122136160,CDM,C1776,HCPCS,0278,RC,,,both,,,6814.08,2044.22,"PHCS [10601]",PHCS,,4769.86,70,,,,,0,792.48,5791.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TREVO NXT 4X41+TRAK21 2-PACK - US",SUP-91314,CDM,S27200284,LOCAL,0272,RC,,,both,,,24624.97,7387.49,"AETNA [10100]","Aetna HMO/PPO",,19576.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2863.88,20931.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 17MM ZEVO TITANIUM SPINE CERVICAL ANTERIOR",SUP-7713517,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,688.5,68,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Assay Anti-Mullerian Horm",PX-301000690,CDM,82166,CPT,0301,RC,,,both,,,354.35,106.3,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,301.2,"per diem",
"(EVAL) BOOSTER AND SUPPORT PLATE (BOOSTER KIT)",SUP-VSU05803,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 1.5MM X 14MM COCR",SUP-VAL-15140-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,168.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",165.8,1211.76,"percent of total billed charges",
"BEARING 87/91MMX10MM VANGUARD E1 KNEE CRUCIATE RETAINING",SUP-EP183480,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"KAISER [10500]",Kaiser,,8678.3,67,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 50MM 7MM TITANIUM FOOT HEADLESS",SUP-DC001650,CDM,C1713,HCPCS,0278,RC,,,both,,,4629.90,1388.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,548.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,538.46,3935.42,"percent of total billed charges",
"CAGE SPINAL 55X18X8MM COHERE 10D XL STERILE LATEX FREE",SUP-8180855P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS [10001]","Blue Cross HMO",,11113.2,39.2,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 45MM 16MM CHARLOTTE STAINLESS STEEL SHORT",SUP-44174516,CDM,C1713,HCPCS,0278,RC,,,both,,,4961.10,1488.33,"PHCS [10601]",PHCS,,3472.77,70,,,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 38MM PROFILE 3D",SUP-680R38,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5244,40,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 155CM 100MM 2.5MM RECTANGLE HELIX",SUP-2216-25100,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"AETNA [10100]","Aetna HMO/PPO",,6582.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OXIMETER PULSE BLACK ONYX 9590 FINGERTIP LATEX FREE",SUP-P7100,CDM,S27000186,LOCAL,0270,RC,,,both,,,1820.63,546.19,"MULTIPLAN [10600]",Multiplan,,1547.54,85,,,,,0,211.74,1547.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9.5MM 80MM RELINE-O 2S SPINE ILIAC POLYAXIAL",SUP-13019580,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SENTAI SAMURAI RC VASCULAR 300CM SPECIALITY CROSS",SUP-H749393063002,CDM,C1769,HCPCS,0272,RC,,,both,,,972.00,291.6,"KAISER [10500]",Kaiser,,651.24,67,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 50MM 36MM XLPE HIP STERILE LATEX FREE",SUP-71935848,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.90,3024.27,"BLUE CROSS [10001]","Blue Cross PPO",,3951.71,39.2,,3949.44,3949.44,3949.44,"1 through 10",1172.41,8568.77,"percent of total billed charges",
"SCR BONE 5.5MM 32MM ORTHOLOC ANKLE 3DI TECHNOLOGY LOCKING",SUP-59215532,CDM,C1713,HCPCS,0278,RC,,,both,,,2197.50,659.25,"CIGNA [10200]","Cigna Local Plus",,1175.66,53.5,,3978.14,359.25,3978.14,24,255.57,1867.88,"percent of total billed charges",
"HC Interluken 288 Polymorph Geno",PX-309000114,CDM,81400,CPT,0310,RC,,,both,,,1773.65,532.09,"CIGNA [10200]","Cigna Local Plus",,140.71,,,,,,,0.01,1507.6,"fee schedule",
"SPACER SPINAL 45X22X7MM RISE-L NONSTERILE",SUP-193.403,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"MULTIPLAN [10600]",Multiplan,,29184.75,85,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SILVERHAWK 135CM 2.6CM 1.5-2MM .073IN ATHERECTOMY",SUP-P4028,CDM,C1714,HCPCS,0272,RC,,,both,,,18238.50,5471.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2121.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2121.14,15502.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"O.R. PROCEDURES FOR OBESITY WITH MCC",619,MS-DRG,,,,,,,inpatient,,,114444.88,34333.46,"CLEAR SPRING HEALTH CARE [30192]","Clear Spring Medicare Advantage",,18985.37,,"Case rate ($17,910.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $16,631.32, add-ons for qualifying new technology services are included. If operating cost exceeds $49,671.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,639.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $16,653.31. The transfer operating threshold is the transfer adjustment factor * $16,631.32 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,257.41. The transfer capital threshold is the transfer adjustment factor * $1,257.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,10994,84300.53,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +6MM OFFSET 28MM HIP TYPE 1 COCR G7",SUP-163638,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"CIGNA [10200]",Cigna,,3298.48,68,,5873.17,5873.17,5873.17,"1 through 10",564.14,4123.1,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 12MM 145CM 3.25MM CORONARY STENT",SUP-1145325-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3969.84,68,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 0 XLH 24IN MONOFILAMENT 3 STRAND BLUE",SUP-3844G,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.85,29.95,"KAISER [10500]",Kaiser,,66.9,67,,,,,0,11.61,84.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 18CM 3CM 5FR .035IN",SUP-M006192115190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CIGNA [10200]","Cigna Local Plus",,746.45,,,,,,,162.27,1185.95,"percent of total billed charges",
"CMPNT PATELLAR 29MM PERSONA ALL POLY KNEE LATEX FREE",SUP-42540000029,CDM,C1776,HCPCS,0278,RC,,,both,,,4667.16,1400.15,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2142.23,45.9,,,,,0,542.79,3967.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT NERVE 3MM AXOGUARD NERVE CAP SIS MATRIX END TAB",SUP-AGT315,CDM,C1763,HCPCS,0278,RC,,,both,,,15304.20,4591.26,"AETNA [10100]","Aetna HMO/PPO",,12166.84,79.5,,,,,0,1779.88,13008.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISECT BALLOON DILATATION SPACEMAKER PLUS BTT 65X3FT",SUP-SMBTTRND,CDM,C1727,HCPCS,0272,RC,,,both,,,3258.30,977.49,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2215.64,68,,,,,0,378.94,2769.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 14.5IN 28FR PHILLIPS 1/56IN PLASTIC 1 EYE MALE",SUP-346128,CDM,S27200284,LOCAL,0272,RC,,,both,,,151.38,45.41,"NOVANET [10819]",Novanet,,113.54,75,,,,,0,17.61,128.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TRICLIP NTW DELIVERY 4TH GENERATION TEER",SUP-TCDS0301-NTW,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM LCP TITANIUM DISTAL HUMERAL CORTICAL",SUP-401.768,CDM,C1713,HCPCS,0278,RC,,,both,,,455.87,136.76,"KAISER [10500]",Kaiser,,305.43,67,,,,,0,53.02,387.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTREAM 58MM 135CM 7MM VASCULAR BALLOON EXPAND LOW",SUP-LSMU1350758,CDM,C1874,HCPCS,0278,RC,,,both,,,15870.00,4761,"UHC [10700]","United Healthcare",,10045.71,63.3,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 25MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G425,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"CIGNA [10200]",Cigna,,6368.93,68,,5873.17,5873.17,5873.17,"1 through 10",1089.28,7961.17,"percent of total billed charges",
"SCREW BONE RELINE L40 MM OD6.5 MM SPINE POLYAXIAL 2 FULL CAN",SUP-16216540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1579.82,28.62,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOSCOPIC INSTR 165CM 10.5-12MM OTSC 6MM NITINOL GC",SUP-100.27,CDM,C1760,HCPCS,0278,RC,,,both,,,4547.10,1364.13,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1301.38,28.62,,,,,0,528.83,3865.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW MEDIUM 2 CUT TEETH LATEX FREE",SUP-2108-107-004S1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1085.40,325.62,"KAISER [10500]",Kaiser,,727.22,67,,,,,0,126.23,922.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE",RX-10897,CDM,J0561,HCPCS,0636,RC,60793-0700-01,NDC,both,1,ML,1414.74,424.42,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,515.74,,,,,,,167.65,1202.53,"fee schedule",
"COIL EMBOLIZATION 6CM 4MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035424060,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"BLUE CROSS [10001]","Blue Cross HMO",,5532.94,39.2,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC ILESTO VR-T DX",SUP-383594,CDM,C1722,HCPCS,0278,RC,,,both,,,63000.00,18900,"UHC [10700]","United Healthcare",,39879,63.3,,,,,0,7326.9,53550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 7-0 BV175-8 24IN 2 ARM MONOFILAMENT",SUP-8747H,CDM,S27200284,LOCAL,0272,RC,,,both,,,258.69,77.61,"CIGNA [10200]","Cigna Open Access",,147.19,56.9,,,,,0,30.09,219.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 17.5MM KNEE XLK POSTERIOR LIPPED FIX",SUP-158102117,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4592.74,41.1,,6417.48,6417.48,6417.48,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"CATH EMERGE MONORAIL 144CM 20MM 6FR 3.75MM .07IN BALLOON",SUP-H7493918920370,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"UHC [10700]","United Healthcare",,358.91,63.3,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 58MM TI",SUP-SPL-60580-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"KAISER [10500]",Kaiser,,1085.4,67,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 67MM STAINLESS STEEL 3.5MM SCREWS 3X5 HOLES T RIGHT",SUP-241.151,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"CIGNA [10200]","Cigna Open Access",,1194.9,56.9,,1144.80,304.56,2275.09,66,244.23,1785,"percent of total billed charges",
"CATH MACH 1 55CM 6FR .07IN HOCKEY STICK CURVE GUIDING PTFE",SUP-M001196000,CDM,C1887,HCPCS,0272,RC,,,both,,,597.13,179.14,"PHCS [10601]",PHCS,,417.99,70,,,,,0,69.45,507.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Similac Probiotic Tri-Blend",PX-E27000265,CDM,E27000265,LOCAL,0270,RC,,,both,,,63.40,19.02,"AETNA [10100]","Aetna HMO/PPO",,50.4,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.37,53.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tube Endotrach Holder",PX-E27000178,CDM,E27000178,LOCAL,0270,RC,,,both,,,50.51,15.15,"AETNA [10100]","Aetna HMO/PPO",,40.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.87,42.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch W Valve Rmvl Ea Add",PX-750000147,CDM,31649,CPT,0750,RC,,,both,,,5006.00,1501.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4617,,"Case rate ($4,617). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,5.01,4617,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Shield Eye Phototherapy",PX-E27000154,CDM,E27000154,LOCAL,0270,RC,,,both,,,27.50,8.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.2,23.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CORONARY 3MM 16MM .014IN OTW BALLOON EXPANDING",SUP-12744-16,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"FIRST HEALTH [10303]","First Health",,13220.4,80,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GAR047 CO2 SOURCE TUBING",SUP-K10037012,CDM,S27200284,LOCAL,0272,RC,,,both,,,67.08,20.12,"FIRST HEALTH [10303]","First Health",,53.66,80,,,,,0,7.8,57.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT 8X16CM ALLOGRAFT DERMIS CORTIVA",SUP-DH0816,CDM,S27800098,LOCAL,0278,RC,,,both,,,20932.88,6279.86,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2480.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2434.49,17792.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 37.5MM TITANIUM LOCK TRANSLATIONAL ATLANTIS BONE SPINE",SUP-6190037,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"MULTIPLAN [10600]",Multiplan,,3748.5,85,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDEZILLA II 150CM 6FR .057IN GUIDING Z-GLIDE EXT",SUP-H7493933515060,CDM,C1769,HCPCS,0272,RC,,,both,,,2956.88,887.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,350.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,343.89,2513.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACKING COILS XL 70CM",SUP-RBYPCXL70,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"PHCS [10601]",PHCS,,13185.9,70,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 G NEUTRAL 40MM E1 HIP",SUP-010000865,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"AETNA [10100]","Aetna HMO/PPO",,8150.36,79.5,,10981.53,8986.79,12413.38,12,1192.31,8714.22,"percent of total billed charges",
"SCR BONE 6.5MM 35MM SPINAL POLYAXIAL",SUP-8806535,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4382,45.9,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPIFIX MESH 3.5X3.5 CM",SUP-ES-3300,CDM,Q4186,HCPCS,0636,RC,,,both,,,8618.10,2585.43,"PHCS [10601]",PHCS,,6032.67,70,,,,,0,406.44,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00195,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"KAISER [10500]",Kaiser,,732.65,67,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 90CM 6FR AR1 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H74938969170,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"KAISER [10500]",Kaiser,,245.51,67,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Aerob Presump ID Cath Tip",PX-306000019,CDM,87070,CPT,0306,RC,,,both,,,282.00,84.6,"FIRST HEALTH [10303]","First Health",,225.6,80,,,,,0,0.01,239.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE LASR CANCELLOUS CORTICAL BLOCK SPACER",SUP-340744,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS AIM SL 68CM 65CM 7FR 5FR 90D GUIDING PEBAX",SUP-DS2N022-65,CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4.5MM DYONICS INCISOR PLUS PLATINUM STRAIGHT",SUP-72203013,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.81,194.64,"AETNA [10100]","Aetna HMO/PPO",,515.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.46,551.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"**DO NOT REUSE ITEM # - PS GO LIVE ISSUE**TROCAR ENDOSCOPIC",SUP-CTF33,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,83.86,45.9,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 52MM STAINLESS STEEL 2.4MM SCR MINI FRAGMENT SET 6",SUP-249.676,CDM,C1713,HCPCS,0278,RC,,,both,,,2299.50,689.85,"MULTIPLAN [10600]",Multiplan,,1954.58,85,,,,,0,267.43,1954.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GRAFT HARVEST 7MM LONG SHORT DEPTH STOP SAGITTAL SAW",SUP-AR-1821S,CDM,S27200284,LOCAL,0272,RC,,,both,,,790.97,237.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,537.86,68,,,,,0,91.99,672.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCPL SURGICAL MICRO POINT 128164M",SUP-28164MC-S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1500.85,450.25,"PHCS [10601]",PHCS,,1050.6,70,,,,,0,174.55,1275.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENUCLEATOR MICROSURGERY 9.5IN HARDY SYMMETRY 3.4MM STD ANGLE",SUP-58-7558,CDM,S27000186,LOCAL,0270,RC,,,both,,,680.72,204.22,"FIRST HEALTH [10303]","First Health",,544.58,80,,,,,0,79.17,578.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840007545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 0 MO-5 18IN CONTROL RELEASE BRAID 8 STRAND COATED",SUP-J801D,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.39,52.32,"AETNA [10100]","Aetna HMO/PPO",,138.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.28,148.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 4MM UNIVERSAL NEURO III CRANIOMAXILLOFACIAL",SUP-56-15034,CDM,C1713,HCPCS,0278,RC,,,both,,,584.37,175.31,"BLUE CROSS [10001]","Blue Cross HMO",,229.07,39.2,,957.42,156.86,7483.26,51,67.96,496.71,"percent of total billed charges",
"COIL EMBOLIZATION 2CM 1MM AXIUM PRIME HELIX DETACHABLE EXTRA",SUP-APB-1-2-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1039.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM I HIP ELEVATE RIM X3 TRIDENT",SUP-643-00-36I,CDM,C1776,HCPCS,0278,RC,,,both,,,9915.30,2974.59,"CIGNA [10200]","Cigna Open Access",,5641.81,56.9,,5302.19,4377.88,6578.61,27,1153.15,8428.01,"percent of total billed charges",
"ROD SPINAL 85MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000085,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"KAISER [10500]",Kaiser,,1085.4,67,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 120MM 2MM BALLOON DILATATION RAPID",SUP-47520120L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 550ML P4.5CM MODERATE PLUS PROFILE HIGH",SUP-350-5501BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-6 TTC-13 24IN 2 ARM MONOFILAMENT WHITE",SUP-6K04A,CDM,S27200284,LOCAL,0272,RC,,,both,,,267.53,80.26,"UHC [10700]","United Healthcare",,169.35,63.3,,,,,0,31.11,227.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 7CM 10FR DUODENAL BEND BILIARY PLASTIC TEMPORARY RAPID",SUP-M00545610,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"FIRST HEALTH [10303]","First Health",,682.22,80,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG REPAIR ASPIRA PLEURAL EFFUSION",SUP-4992306,CDM,S27000186,LOCAL,0270,RC,,,both,,,200.97,60.29,"CIGNA [10200]","Cigna Local Plus",,107.52,53.5,,,,,0,23.37,170.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X9MM COALITION AGX 7D 8MM NONSTERILE LATEX",SUP-3128.1279,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"Y-KNOT RC ALL-SUTURE ANCHOR, WITH THREE #2 (5 METRIC) HI-FI",SUP-YRC03,CDM,C1713,HCPCS,0278,RC,,,both,,,4626.31,1387.89,"MULTIPLAN [10600]",Multiplan,,3932.36,85,,,,,0,538.04,3932.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ACUITY CUT-AWAY 8FR GUIDING INNER",SUP-7041,CDM,C1887,HCPCS,0272,RC,,,both,,,1579.50,473.85,"MULTIPLAN [10600]",Multiplan,,1342.58,85,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 145CM 8MM 2MM BALLOON DILATATION PEBAX",SUP-1400200-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ortho Mgmt/Train Ea 15min (Go)",PX-430000030,CDM,97760,CPT,0430,RC,,,both,,,205.82,61.75,"CIGNA [10200]",Cigna,,205.82,,"Per diem ($369).",,,,0,23.94,205.82,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMIKACIN 1,000 MG/4 ML VIAL",RX-123478,CDM,J0278,HCPCS,0636,RC,23155-0290-32,NDC,both,4,ML,129.56,38.87,"CIGNA [10200]","Cigna Open Access",,16.82,,,,,,,6.34,110.13,"fee schedule",
"GRAFT BONE CORNERSTONE ASR CORTICAL FREEZE DRIED BLOCK",SUP-340841,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 140MM 12-14MM 13FR 10FR TRIVASCULAR OVATION",SUP-TV-IL1412140-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,13356,40,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 59CM ENDOCARDIAL 2 COIL STD DF4 TERMINAL CNCT",SUP-0295,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"UHC [10700]","United Healthcare",,10869.88,63.3,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 2.8MM 36MM ORTHOLOC FULL THREAD MIDFOOT",SUP-58803536,CDM,S27200284,LOCAL,0272,RC,,,both,,,1506.60,451.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,691.53,45.9,,,,,0,175.22,1280.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Orbit/Ear/Fossa W Cntrst",PX-351000006,CDM,70481,CPT,0351,RC,,,both,,,3533.18,1059.95,"FIRST HEALTH [10303]","First Health",,2826.54,80,,,,,0,405,3003.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Stent & Ather Sf Ea Add",PX-361000734,CDM,37293,CPT,0361,RC,,,both,,,12161.75,3648.52,"KAISER [10500]",Kaiser,,8148.37,67,,,,,0,12.16,10337.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg WO Vid 2-12 Hr Unmntr",PX-740000040,CDM,95705,CPT,0740,RC,,,both,,,4168.00,1250.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2834.24,68,,,,,0,4.17,3542.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Perq Tcat Ther Rx Dlvr Ntrac Rx Balo 1 Maj C Art",PX-481000408,CDM,0913T,CPT,0481,RC,,,both,,,8782.00,2634.6,"CIGNA [10200]","Cigna Local Plus",,8782,,"Case rate ($20,211). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1021.35,8782,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Perq Tcat Ther Rx Dlvr Ntrac Rx Balo 1 Maj C Art",PX-481000408,CDM,0913T,CPT,0481,RC,,,both,,,8782.00,2634.6,"AETNA [10100]","Aetna HMO/PPO",,6981.69,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1021.35,8782,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Perq Tcat Ther Rx Dlvr Ntrac Rx Balo 1 Maj C Art",PX-481000408,CDM,0913T,CPT,0481,RC,,,both,,,8782.00,2634.6,"NOVANET [10819]",Novanet,,6586.5,75,,,,,0,1021.35,8782,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +32 DIOPTER POSTERIOR CHMBR FOLDABLE APODIZE",SUP-SA25T0,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"KAISER [10500]",Kaiser,,499.15,67,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.75MM CROSSFT KNOTLESS BIOCOMPOSITE STERILE",SUP-CFKB-475S,CDM,C1713,HCPCS,0278,RC,,,both,,,4385.23,1315.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1255.05,28.62,,,,,0,510,3727.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 28CM 3CM 5FR .035IN STRAIGHT URETERAL",SUP-M006155224050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"BLUE CROSS [10001]","Blue Cross PPO",,482.54,39.2,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 100MM 2.5MM BALLOON DILATATION STERILE LATEX",SUP-582510022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR VL 22-30CM 6FR PIGTAIL CURVE URETERAL",SUP-M0061801560,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS [10001]","Blue Cross PPO",,353.65,39.2,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 2-0 P-14 24IN CLSR ABSORBABLE PREMIUM",SUP-VLOCL0135,CDM,S27200284,LOCAL,0272,RC,,,both,,,262.83,78.85,"UHC [10700]","United Healthcare",,166.37,63.3,,,,,0,30.57,223.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Copper Cu-64 Dotatate Dx Inj per Mci",PX-343000040,CDM,A9592,HCPCS,0343,RC,,,both,,,6292.00,1887.6,"CIGNA [10200]",Cigna,,1155,,"Per diem ($1,155). Each quantity on the visit service is paid its own per diem rate. Each eligible service on a given day will be paid its own per diem rate.",,,,0,731.76,5348.2,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 30MM 9.6MM CONDYLAR STABILIZED NECK OMNIFIT EON",SUP-6098-0630,CDM,C1776,HCPCS,0278,RC,,,both,,,10292.40,3087.72,"KAISER [10500]",Kaiser,,6895.91,67,,,,,0,1197.01,8748.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ZIPWIRE UROLOGICAL STRAIGHT 150CM 3CM .032IN NITINOL",SUP-M0066802121,CDM,C1769,HCPCS,0272,RC,,,both,,,320.58,96.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,37.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.28,272.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.838,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"FIRST HEALTH [10303]","First Health",,189.31,80,,,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Srs Linear 1 Session",PX-333000054,CDM,77372,CPT,0333,RC,,,both,,,43469.79,13040.94,"KAISER [10500]",Kaiser,,29124.76,67,,,,,0,5055.54,43469.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER 365UM",SUP-TFL-FBX365S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2690.57,807.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,312.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,312.91,2286.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bag Autotransfusion",PX-E27200032,CDM,E27200032,LOCAL,0272,RC,,,both,,,554.40,166.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,65.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.48,471.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM RELINE 2C SPINE POLYAXIAL NONSTERILE MAS",SUP-16017545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"FIRST HEALTH [10303]","First Health",,7637.48,80,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 5CM 20GA ACCURIAN CURVE SHARP 10MM",SUP-AC0008,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,12.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROPAFENONE 150 MG TABLET, IMMEDIATE RELEASE",RX-11146,CDM,,,0250,RC,59651-0256-01,NDC,both,1,UN,8.23,2.47,"CIGNA [10200]",Cigna,,5.6,68,,,,,0,0.96,7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT KNEE LEGION G2 PS POROUS FEMUR HI DEMAND INSER",SUP-71704651,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"MULTIPLAN [10600]",Multiplan,,19813.5,85,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 100MMX4.5MM PROXIMATE TITANIUM THICK TISSUE 4",SUP-TRT10,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.51,675.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN PERFUSION 30FR RIGHT VENT DLP STERILE LATEX FREE",SUP-67530,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.59,90.48,"PHCS [10601]",PHCS,,211.11,70,,,,,0,35.07,256.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Eeg WO Vid 2-12hr Intmt Mntr",PX-740000041,CDM,95706,CPT,0740,RC,,,both,,,5043.88,1513.16,"BLUE CROSS [10001]","Blue Cross HMO",,5.04,.1,,,,,0,5.04,4287.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Analysis Dev Subq Icd Sys",PX-481000107,CDM,93261,CPT,0480,RC,,,both,,,438.70,131.61,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,298.32,68,,,,,0,51.02,438.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 45MM 16MM CHARLOTTE STAINLESS STEEL SHORT",SUP-44174516,CDM,C1713,HCPCS,0278,RC,,,both,,,4961.10,1488.33,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,587.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,576.98,4216.94,"percent of total billed charges",
"CANN ENDOSCOPIC 210CM ULTRA TAPPERED TIP GWIRE ERCP CONTOUR",SUP-M00530870,CDM,C1769,HCPCS,0272,RC,,,both,,,407.60,122.28,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,277.17,68,,,,,0,47.4,346.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 2-0 CT-2 SPIRAL 30CM SUT",SUP-SXMP1B416,CDM,S27200284,LOCAL,0272,RC,,,both,,,223.56,67.07,"AETNA [10100]","Aetna HMO/PPO",,177.73,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26,190.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL/LINER BIPOLAR 48MM 28MM TANDEM HIP COCR UHMWPE SHELL",SUP-71322048,CDM,C1776,HCPCS,0278,RC,,,both,,,7003.50,2101.05,"CIGNA [10200]","Cigna Open Access",,3984.99,56.9,,5302.19,4377.88,6578.61,27,814.51,5952.98,"percent of total billed charges",
"GRAFT VASCULAR 80CM 10MM THIN WALL GORE-TEX REMOVABLE RING",SUP-RRT10070080L,CDM,C1768,HCPCS,0278,RC,,,both,,,10108.50,3032.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1175.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1175.62,8592.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 3.5MM RELINE-C PRE BENT TITANIUM NONSTERILE",SUP-3943080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 45MM SOLERA CD HORIZON COCR SPINE MULTIAXIAL",SUP-55840007545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP SOLID BACK METAL HA TRIDENT D",SUP-500-11-48D,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.85,2973.55,"BLUE CROSS [10001]","Blue Cross PPO",,3885.45,39.2,,3949.44,3949.44,3949.44,"1 through 10",1152.75,8425.07,"percent of total billed charges",
"CATH CORDIS SABER 90CM 150MM 2MM BALLOON DILATATION DURALYN",SUP-48002015S,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM NARROW BLADE",SUP-7541123,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"AMERIGROUP MEDICAID [20100]",Amerigroup,,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",348.9,2550,"percent of total billed charges",
"VALVE MITRAL 37MM 26.1MM MASTERS PYROLYTIC CARBON MECHANICAL",SUP-37MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"MULTIPLAN [10600]",Multiplan,,24751.35,85,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL GOLD 60MM 3.5MM SYNAPSE CURVE TITANIUM PREBENT",SUP-04.614.760,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"SLEEVE TIBIAL 29X26X40MM MBT KNEE METAPHYSEAL POROUS",SUP-129454000,CDM,C1776,HCPCS,0278,RC,,,both,,,15133.08,4539.92,"AETNA [10100]","Aetna HMO/PPO",,12030.8,79.5,,10981.53,8986.79,12413.38,12,1759.98,12863.12,"percent of total billed charges",
"BRUSH CLEANING ALWAYS-ON TIP TRACKED 3 NDL",SUP-INS-5300,CDM,S27200284,LOCAL,0272,RC,,,both,,,5868.45,1760.53,"AMERIGROUP MEDICAID [20100]",Amerigroup,,695.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.5,4988.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUNTSINK DRILL 2.7 MM CORTICAL SCR NONSTERILE",SUP-310.87,CDM,S27200284,LOCAL,0272,RC,,,both,,,1828.50,548.55,"CIGNA [10200]","Cigna Open Access",,1040.42,56.9,,,,,0,212.65,1554.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE KORE FIBER CORTICAL BONE FIBER 1CC ALLOGRAFT",SUP-423201,CDM,C1713,HCPCS,0278,RC,,,both,,,1725.00,517.5,"BLUE CROSS [10001]","Blue Cross PPO",,676.2,39.2,,957.42,570.23,957.42,28,200.62,1466.25,"percent of total billed charges",
"SURFACE ARTICULAR 13MM PERSONA 3-7 C-D KNEE RIGHT TIBIA",SUP-42521200413,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"CIGNA [10200]",Cigna,,5491.52,68,,5873.17,5873.17,5873.17,"1 through 10",939.21,6864.4,"percent of total billed charges",
"HC CT Abd&Pelvis W/WO Cntrst 1+ Reg",PX-352000030,CDM,74178,CPT,0352,RC,,,both,,,6666.64,1999.99,"AMERIGROUP MEDICAID [20100]",Amerigroup,,790,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",820.10,820.10,820.10,"1 through 10",405,5666.64,"percent of total billed charges",
"LENS IOL +32 DIOPTER POSTERIOR CHMBR FOLDABLE APODIZE",SUP-SA25T0,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,88.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 45MM 6MM EGG STERILE",SUP-1607002003,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PHCS [10601]",PHCS,,304.5,70,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTREPIDTM TMVR CRIMPER",SUP-ASM-0014,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Open Access",,0.01,56.9,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-6 TTC-13 24IN 2 ARM MONOFILAMENT WHITE",SUP-6K04A,CDM,S27200284,LOCAL,0272,RC,,,both,,,267.53,80.26,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,31.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,31.11,227.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 6FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175262010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,306.45,28.62,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ACETABULAR 24MM HIP LOCK STERILE",SUP-105424,CDM,C1776,HCPCS,0278,RC,,,both,,,1211.68,363.5,"BLUE CROSS [10001]","Blue Cross HMO",,474.98,39.2,,5311.50,4717.44,5388.59,31,140.92,1029.93,"percent of total billed charges",
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,inpatient,,,55488.36,16646.51,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,19001.96,,"Case rate ($8,838.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,206.79, add-ons for qualifying new technology services are included. If operating cost exceeds $41,246.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,002.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,217.65. The transfer operating threshold is the transfer adjustment factor * $8,206.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.47. The transfer capital threshold is the transfer adjustment factor * $620.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,35533.09,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP BASEPLT TIBIAL ATTUNE FIX BEARING CEMENTLESS",SUP-OSC381865,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"FIRST HEALTH [10303]","First Health",,18648,80,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC New Eval Visit Level 5",PX-510000175,CDM,99205,CPT,0761,RC,,,both,,,553.58,166.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,227.52,41.1,,,,,0,0.55,553.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 140MM 5MM LEGEND LONG CYL STERILE",SUP-14CY50L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1237.28,371.18,"CIGNA [10200]","Cigna Open Access",,704.01,56.9,,,,,0,143.9,1051.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 36MM BIOLOX",SUP-400-03-362,CDM,C1776,HCPCS,0278,RC,,,both,,,16953.92,5086.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2009.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1971.74,14410.83,"percent of total billed charges",
"SCREW BONE 6MM 45MM VIPER PRIME SPINE CORTICAL FIX ANGLE FEN",SUP-186760445,CDM,C1713,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"KAISER [10500]",Kaiser,,4854.15,67,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32MM TITANIUM CORTICAL 2 LEAD THREAD SELF TAP",SUP-14-405032,CDM,C1713,HCPCS,0278,RC,,,both,,,2475.00,742.5,"KAISER [10500]",Kaiser,,1658.25,67,,,,,0,287.84,2103.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE CRYOABLATION 11IN OD 10MM ATRICURE PROBE W/ 10MM BALL",SUP-CRYOSMAX,CDM,C9808,HCPCS,0272,RC,,,both,,,17640.00,5292,"KAISER [10500]",Kaiser,,11818.8,67,,,,,0,2051.53,14994,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 10MM 11FR ENDOPROSTHESIS HEPARIN",SUP-VBH100502,CDM,C1874,HCPCS,0278,RC,,,both,,,22087.80,6626.34,"KAISER [10500]",Kaiser,,14798.83,67,,,,,0,2568.81,18774.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 30.0",SUP-DIB00U0300,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,155.43,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL UTERINE HEGAR 2 END 11/12MM",SUP-52-3511,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.18,83.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,32.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.47,237.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COMPLETE SE 80MM 130CM 6MM LONG VASCULAR NITINOL ILIAC",SUP-SC680LV,CDM,C1876,HCPCS,0278,RC,,,both,,,7245.00,2173.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2073.52,28.62,,,,,0,842.59,6158.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 19MM 150CM 7MM BILIARY STAINLESS",SUP-37912-71915,CDM,C1876,HCPCS,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS [10001]","Blue Cross HMO",,2434.32,39.2,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM LOW PROFILE SCREWS STAINLESS STEEL FOOT",SUP-AR-8827-18,CDM,C1713,HCPCS,0278,RC,,,both,,,522.45,156.73,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,355.27,68,,,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM FEMORAL CERAMIC",SUP-OSC371173,CDM,C1776,HCPCS,0278,RC,,,both,,,15870.00,4761,"CIGNA [10200]",Cigna,,6348,40,,5873.17,5873.17,5873.17,"1 through 10",1845.68,13489.5,"percent of total billed charges",
"CATH X-FORCE U30 4CM 6FR 4MM BALLOON DILATATION PERCUTANEOUS",SUP-997404,CDM,C1726,HCPCS,0272,RC,,,both,,,1529.38,458.81,"PHCS [10601]",PHCS,,1070.57,70,,,,,0,177.87,1299.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOBOOST SELECT BONE VOID FILLER - 10CC KIT",SUP-OB-10D,CDM,C1713,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]","Cigna Local Plus",,4614.38,53.5,,3978.14,359.25,3978.14,24,1003.09,7331.25,"percent of total billed charges",
"TUBE 10.5IN 24FR SILICONE Y PORT GRADUATE SHAFT OPEN DISTAL",SUP-8884720247,CDM,S27200284,LOCAL,0272,RC,,,both,,,181.27,54.38,"UHC [10700]","United Healthcare",,114.74,63.3,,,,,0,21.08,154.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 4MM ATTUNE 5 KNEE POSTERIOR CEMENT REVISION",SUP-1549-05-001,CDM,C1776,HCPCS,0278,RC,,,both,,,6072.00,1821.6,"FIRST HEALTH [10303]","First Health",,4857.6,80,,,,,0,706.17,5161.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM 5MM S-ROM ZTT 18D LARGE HIP POROUS",SUP-550524,CDM,C1776,HCPCS,0278,RC,,,both,,,6466.32,1939.9,"FIRST HEALTH [10303]","First Health",,5173.06,80,,,,,0,752.03,5496.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLITTER SURGICAL FACIAL UNIVERSITY BLADE DISPOSABLE",SUP-8801279,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"MULTIPLAN [10600]",Multiplan,,3187.5,85,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM FEMORAL CERAMIC",SUP-OSC371173,CDM,C1776,HCPCS,0278,RC,,,both,,,15870.00,4761,"PHCS [10601]",PHCS,,11109,70,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veno Svc W Si",PX-320000132,CDM,75827,CPT,0320,RC,,,both,,,3762.17,1128.65,"AETNA [10100]","Aetna HMO/PPO",,2990.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.44,3762.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 4MM AVENIR 10 HELICAL FINISH STERILE",SUP-10HFN-04006,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"CIGNA [10200]",Cigna,,7033.31,68,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 0 KS 30IN BRAID BLACK NONABSORBABLE",SUP-624H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SPEEDBRIDGE SWIVELOCK FIBERTAPE 4.75MM FIXATION 2",SUP-AR-2600SBS-8,CDM,C1713,HCPCS,0278,RC,,,both,,,13179.00,3953.7,"UHC [10700]","United Healthcare",,8342.31,63.3,,5023.51,2672.93,6679.78,18,1532.72,11202.15,"percent of total billed charges",
"LENS IOL +32 DIOPTER POSTERIOR CHMBR FOLDABLE APODIZE",SUP-SA25T0,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"BLUE CROSS [10001]","Blue Cross HMO",,292.04,39.2,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 2-0 P-14 24IN CLSR ABSORBABLE PREMIUM",SUP-VLOCL0135,CDM,S27200284,LOCAL,0272,RC,,,both,,,262.83,78.85,"FIRST HEALTH [10303]","First Health",,210.26,80,,,,,0,30.57,223.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 28MM 144CM 2.75MM CORONARY STENT",SUP-H7493952828270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"FIRST HEALTH [10303]","First Health",,4452,80,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-05041,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 12MM 2.5MM CORONARY STENT COCR",SUP-1007823-12,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Repo Impl Elect Subq Icd",PX-481000105,CDM,33273,CPT,0481,RC,,,both,,,6653.00,1995.9,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4752,,"Case rate ($4,752). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,773.74,6653,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 65MM CONDYLAR VARIABLE ANGLE CANNULATED LOCK",SUP-42.231.665,CDM,C1713,HCPCS,0278,RC,,,both,,,1693.95,508.18,"NOVANET [10819]",Novanet,,1270.46,75,,,,,0,197.01,1439.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP PARTIAL ANTHOLOGY AFIT WITH OXINIUM HEAD A",SUP-71703320,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"BLUE CROSS [10001]","Blue Cross PPO",,9384.48,39.2,,3949.44,3949.44,3949.44,"1 through 10",2784.22,20349,"percent of total billed charges",
"SUT PDS II 1 CTXB 36IN MONOFILAMENT VIOLET ABSORBABLE",SUP-ZB371,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Open Access",,14.79,56.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 3.00 X 38 MM",SUP-1212300-38,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross PPO",,6762,39.2,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE FATHOM VASCULAR ANGLE 200CM 10CM .014IN PERIPHERAL",SUP-M001508110,CDM,C1769,HCPCS,0272,RC,,,both,,,1815.00,544.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,215.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,211.08,1542.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 20MM TITANIUM DISTAL RADIAL WRIST HAND",SUP-CO-N2320,CDM,C1713,HCPCS,0278,RC,,,both,,,720.90,216.27,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,330.89,45.9,,,,,0,83.84,612.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 20MM 10MM BALLOON",SUP-U35130102,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUBSTITUTE BONE GRAFT 5X2.5CM GRAFTON DEMINERALIZED BONE MAT",SUP-T42110,CDM,S27800098,LOCAL,0278,RC,,,both,,,4912.11,1473.63,"BLUE CROSS [10001]","Blue Cross PPO",,1925.55,39.2,,,,,0,571.28,4175.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SMARTTOUCH THERMOCOOL SF D-D CURVE ABLATION",SUP-D134801,CDM,C1732,HCPCS,0272,RC,,,both,,,21312.90,6393.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2525.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2478.69,18115.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 8X18X50MM 10DEG LORDOTIC MODULUS XL",SUP-1181850P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE HOLDING SMALL HEXAGON SCRDRVR NONSTERILE",SUP-314.06,CDM,S27000186,LOCAL,0270,RC,,,both,,,1728.45,518.53,"NOVANET [10819]",Novanet,,1296.34,75,,,,,0,201.02,1469.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 42MM FLEXIBLE LUMEN SIMUPLUS STERILE LATEX",SUP-7700FR42,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"FIRST HEALTH [10303]","First Health",,10488,80,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HURRICANE 180CM 2CM 5.8FR 4MM 12 ATM BALLOON DILATATION",SUP-M00545890,CDM,C1726,HCPCS,0272,RC,,,both,,,1849.50,554.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,219.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,215.1,1572.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1.5 X 1 HELICAL PICO COIL",SUP-10USH01501,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"UHC [10700]","United Healthcare",,7420.72,63.3,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL 15X15CM 10MM RESORBABLE PLA POLYPROPYLENE",SUP-PP1515G,CDM,C1781,HCPCS,0278,RC,,,both,,,3217.95,965.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1477.04,45.9,,,,,0,374.25,2735.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM PRESTIGE PLUS HELICAL COMPLEX XTRA",SUP-PRES0204CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3519,68,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH VASCULAR 8X1CM BOVINE PERICARDIAL",SUP-DP1X6,CDM,C1768,HCPCS,0278,RC,,,both,,,1263.68,379.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,146.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.97,1074.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 62MM 36MM MARATHON",SUP-121936462,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"FIRST HEALTH [10303]","First Health",,7874.28,80,,,,,0,1144.72,8366.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTA PRO 110CM 10CM 5FR 4MM 7.5MM BALLOON DILATATION",SUP-4194000L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC Z THREAD 150MM 5MM KII 2 PACK BALLOON",SUP-CTR10,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"KAISER [10500]",Kaiser,,145.73,67,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 4MM FRMLA FLUTE HOLLOW 12 ARTHROSCOPIC STERILE",SUP-375940012,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"PHCS [10601]",PHCS,,225.33,70,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-512-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"FIRST HEALTH [10303]","First Health",,9130.08,80,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR .071IN SHEPHERDS CROOK RIGHT 3.5 CURVE",SUP-LA6SCR35,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,266.22,68,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 6.5MM REINFORCE CUFF MURPHY EYE LOW",SUP-DYNJAARC65,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.86,46.46,"FIRST HEALTH [10303]","First Health",,123.89,80,,,,,0,18.01,131.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP GRASPING ALLIGATOR JAW AUTOCLAVABLE RETRIEVAL BASKET",SUP-FG-49L-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,3433.88,1030.16,"AETNA [10100]","Aetna HMO/PPO",,2729.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,399.36,2918.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE 8 KNEE CEMENTED ROTATE PLATFORM",SUP-150610008,CDM,C1776,HCPCS,0278,RC,,,both,,,16694.55,5008.36,"FIRST HEALTH [10303]","First Health",,13355.64,80,,,,,0,1941.58,14190.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP INTERNAL LAPRO-CLIP KIT 2 HANDLE",SUP-2LCH8812,CDM,S27200284,LOCAL,0272,RC,,,both,,,18345.60,5503.68,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2173.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2133.59,15593.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 13MM 57SQ CM 51X71MM COBALT SURESCAN TITANIUM",SUP-DTPA2D1,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,31626.45,41.1,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE UNICORTICAL DOWEL ALLOGRAFT FREEZE DRIED 14-40MM",SUP-400211,CDM,S27800098,LOCAL,0278,RC,,,both,,,4413.24,1323.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2025.68,45.9,,,,,0,513.26,3751.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 34MM TRI-AD 2 ADAM TRICUSPID VALVE MODEL",SUP-900SFC234,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3539.7,27,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAP 3MM 0-50MM STD THREAD SURGICAL SYMPHONY NONSTERILE LATEX",SUP-202033330,CDM,S27200284,LOCAL,0272,RC,,,both,,,1856.25,556.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,215.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,215.88,1577.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 16MM 144CM 4MM CORONARY STENT",SUP-H7493941816400,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PULMONARY AERO OTW FULLY COVERED TRACHEOBRONCHIAL STENT 14MM",SUP-90129-215,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7089.75,41.1,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 50MM 5.5MM RELINE LORDOTIC TITANIUM MAS",SUP-11355050,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RENAL FAILURE WITH MCC",682,MS-DRG,,,,,,,inpatient,,,41481.05,12444.31,"PHCS [10601]",PHCS,,7561,,,,,,,7561,36934.66,"per diem","Estimated amount calculated based on 5 day length of stay."
"SCR BONE 6MM 50MM VIPER EXPEDIUM TITANIUM SPINE CORTICAL",SUP-186731650,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"PHCS [10601]",PHCS,,3864,70,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL TSRH-3D TITANIUM SPINE FLUSH BREAK",SUP-8351500,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"FIRST HEALTH [10303]","First Health",,278.4,80,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ATLANTIS TITANIUM SPINE CERVICAL ANTERIOR",SUP-3120512,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,464.74,45.9,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET NAVIGATION 2 COIL STERILE LATEX FREE DISPOSABLE",SUP-9735428,CDM,S27200284,LOCAL,0272,RC,,,both,,,3919.20,1175.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1610.79,41.1,,,,,0,455.8,3331.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRIMARY DELIVERY CATHETER",SUP-4840-03,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CIGNA [10200]","Cigna Local Plus",,0.01,53.5,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4.5MM DYONICS BONECUTTER PLATINUM BLADE FULL",SUP-72202531,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"AETNA [10100]","Aetna HMO/PPO",,386.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 4MM 9MM 3MM DUCT TYPE II SELF EXPANDING",SUP-9-PDA2-03-04,CDM,C1817,HCPCS,0278,RC,,,both,,,15444.00,4633.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4169.88,27,,,,,0,1796.14,13127.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICS BALL BURR",SUP-110135,CDM,S27200284,LOCAL,0272,RC,,,both,,,578.34,173.5,"KAISER [10500]",Kaiser,,387.49,67,,,,,0,67.26,491.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 92CM 1MM 6FR 12MM SPACE ISMUS CATH CURVE",SUP-D6R20P12RT,CDM,C1731,HCPCS,0272,RC,,,both,,,7086.30,2125.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2912.47,41.1,,,,,0,824.14,6023.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Emg 1 Ext",PX-922000001,CDM,95860,CPT,0922,RC,,,both,,,1218.00,365.4,"FIRST HEALTH [10303]","First Health",,974.4,80,,,,,0,141.65,1035.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 12CM MR8 2.5MM MATCH HEAD TELESCOPE DISSECTING",SUP-MR8-T12MH25,CDM,S27200284,LOCAL,0272,RC,,,both,,,1134.41,340.32,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,520.69,45.9,,,,,0,131.93,964.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 38MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25038UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,305.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL LEGION GENESIS II 7 KNEE RIGHT CEMENTED MALE",SUP-71420190,CDM,C1776,HCPCS,0278,RC,,,both,,,14593.50,4378.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1697.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1697.22,12404.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LIVEWIRE 115CM 2MM 6FR 2-8-2MM SPACING",SUP-401926,CDM,C1730,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3167.1,68,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG SURGICAL 2X1.4IN MONOFILAMENT FULL RESORBABLE PATCH",SUP-1190603,CDM,C1781,HCPCS,0272,RC,,,both,,,3720.75,1116.22,"UHC [10700]","United Healthcare",,2355.23,63.3,,,,,0,1529.23,2355.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG 8X8IN ABSORBENT PAD ANTIMICROBIAL SILICONE STERILE",SUP-287400,CDM,S27200284,LOCAL,0272,RC,,,both,,,205.15,61.54,"UHC [10700]","United Healthcare",,129.86,63.3,,,,,0,23.86,174.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RAPIDCROSS 170CM 60MM 2MM .014IN BALLOON DILATATION",SUP-A14BX020060170,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,161.09,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Bx Pleura Perc Ndl",PX-361000051,CDM,32400,CPT,0361,RC,,,both,,,2839.44,851.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2292.95,,"Case rate ($2,292.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,330.23,2839.44,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Guidance Radiation Tx Sd",PX-333000061,CDM,77387,CPT,0333,RC,,,both,,,3171.03,951.31,"BLUE CROSS [10001]","Blue Cross PPO",,617.85,,"Per diem ($617.85).",,,,0,368.79,3171.03,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insrt/Pl Neurostim Gen Spinal",PX-361000476,CDM,63685,CPT,0361,RC,,,both,,,10158.00,3047.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2262,,"Case rate ($2,262). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1181.38,10158,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trichrome Stain O&P",PX-306000087,CDM,87209,CPT,0306,RC,,,both,,,224.20,67.26,"UHC [10700]","United Healthcare",,16.18,,,,,,,0.01,190.57,"fee schedule",
"SUT TIGERTAPE FIBERWIRE 0 8INX1.7MM TAPER END BLACK WHITE 30",SUP-AR-7273-8T,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHAVER MACRO HOOK BONESCALPEL SURGICAL STERILE LATEX FREE",SUP-MXB-S2,CDM,S27200284,LOCAL,0272,RC,,,both,,,3362.07,1008.62,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2286.21,68,,,,,0,391.01,2857.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pt Eval Mod Complex 30 Min",PX-420000154,CDM,97162,CPT,0424,RC,,,both,,,454.45,136.33,"BLUE CROSS [10001]","Blue Cross HMO",,344.92,,"Per diem ($344.92).",,,,0,52.85,426,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 3CM 2MM NESTER MICROCOIL PLATINUM .018IN",SUP-G47331,CDM,S27800098,LOCAL,0278,RC,,,both,,,842.32,252.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,386.62,45.9,,,,,0,97.96,715.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE MANDIBULAR 12 HOLE STRAIGHT 2 MM SCR BONE TITANIUM",SUP-447.032,CDM,S27800098,LOCAL,0278,RC,,,both,,,2347.80,704.34,"BLUE CROSS [10001]","Blue Cross HMO",,920.34,39.2,,,,,0,273.05,1995.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL LARGE KNEE RIGHT CEMENT LCS COMPLETE COCR",SUP-129401060,CDM,C1776,HCPCS,0278,RC,,,both,,,20635.65,6190.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8254.26,40,,,,,0,2399.93,17540.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo Dplr Color Flow Map",PX-483000014,CDM,93325,CPT,0483,RC,,,both,,,984.64,295.39,"BLUE CROSS [10001]","Blue Cross PPO",,75.01,,"Fee schedule rate ($75.01).",,,,0,52.29,836.94,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy W Stent Plc",PX-750000174,CDM,45389,CPT,0750,RC,,,both,,,4000.72,1200.22,"BLUE CROSS [10001]","Blue Cross PPO",,4000.72,,"Case rate ($5,379.15). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,465.28,4000.72,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR PERSONA 4-5 E-F KNEE RIGHT TIBIA FIX",SUP-42522100610,CDM,C1776,HCPCS,0278,RC,,,both,,,9466.80,2840.04,"CIGNA [10200]","Cigna Open Access",,5386.61,56.9,,5302.19,4377.88,6578.61,27,1100.99,8046.78,"percent of total billed charges",
"SIZER IMPL 11.5CM NATRELLE INSPIRA P3CM LOW PLUS PROFILE",SUP-MSZ-LP220,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"AETNA [10100]","Aetna HMO/PPO",,125.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 135D STD BARREL DHS/DCP HIP STERILE 46MM STAINLESS",SUP-281.102S,CDM,C1713,HCPCS,0278,RC,,,both,,,3765.33,1129.6,"CIGNA [10200]","Cigna Open Access",,2142.47,56.9,,1144.80,304.56,2275.09,66,437.91,3200.53,"percent of total billed charges",
"SCR BONE X-CORE TITANIUM SPINE LOCK NONSTERILE",SUP-7162000,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.93,488.68,"BLUE CROSS [10001]","Blue Cross PPO",,638.54,39.2,,957.42,570.23,957.42,28,189.44,1384.59,"percent of total billed charges",
"GWIRE SYNCHRO SELECT VASCULAR STRAIGHT STD 300CM .014IN",SUP-SSTD300STR,CDM,C1769,HCPCS,0272,RC,,,both,,,5686.57,1705.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,661.35,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,661.35,4833.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 37X27X16MM 12D MEDIUM",SUP-7968216,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"BLUE CROSS [10001]","Blue Cross PPO",,13436.04,39.2,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR EMPHASYS 48MM 36MM AOX ELEVATE",SUP-472248236,CDM,C1776,HCPCS,0278,RC,,,both,,,14038.05,4211.41,"UHC [10700]","United Healthcare",,8886.09,63.3,,8601.07,8395.67,8601.07,"1 through 10",1632.63,11932.34,"percent of total billed charges",
"STENT INNOVA 80MM 130CM 7MM VASCULAR METAL SUPERFICIAL",SUP-H74939293078030,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2216.97,45.9,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 1.5MM AXIUM PRIME HELIX DETACHABLE",SUP-APB-1.5-2-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"KAISER [10500]",Kaiser,,5986.79,67,,,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 40MM 3.5MM BALLOON DILATATION DURALYN",SUP-48003504S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"AETNA [10100]","Aetna HMO/PPO",,998.12,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VXSK-180P RF WIRE 63CM/90DEG/D0 SHEATH",SUP-VXSK0125,CDM,S27200284,LOCAL,0272,RC,,,both,,,6175.50,1852.65,"KAISER [10500]",Kaiser,,4137.59,67,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +9 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.090,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27X24-32X13MM FRA 8D SPINE THORACOLUMBAR",SUP-10513,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2239.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 800ML GEL SMOOTH MEMORYGEL SILICONE P5.1CM","SUP-3508001 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1051.79,28.62,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 8MM 4MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012278-08,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 4.8FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175252050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,126.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 30-34MM TITANIUM 5.5MM ROD LOW PROFILE LEGACY",SUP-8115530,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2422.5,68,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RUBY XL COIL 40CMX70CM",SUP-RBYXL4070,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"CIGNA [10200]","Cigna Local Plus",,5933.66,31.5,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL BLUE GOLD 330MM 3.2MM EXPERT 3 FLUTE QUICK",SUP-03.010.060S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1808.10,542.43,"CIGNA [10200]",Cigna,,1229.51,68,,,,,0,210.28,1536.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1MM 0.0110IN AVENIR HELICAL 10 COIL FINISH",SUP-10HFN01001,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"KAISER [10500]",Kaiser,,6929.88,67,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 18CM PUMP SET INFLATABLE FLUID FILL SOFT",SUP-ES8918,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"AETNA [10100]","Aetna HMO/PPO",,49846.5,79.5,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS ELITE 50MM 5.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE52550,CDM,C1876,HCPCS,0278,RC,,,both,,,90839.19,27251.76,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10764.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10564.6,77213.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK VISION 15MM 3.5MM CORONARY STENT COCR",SUP-1007849-15,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Local Plus",,1605,53.5,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 175X30MM ONETRAC LX 2 SMOKE EVACUATION CHANNEL",SUP-C100220,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-38,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 7MM ADVANTA SST SLIDER STRAIGHT HP3 PTFE",SUP-25019,CDM,C1768,HCPCS,0278,RC,,,both,,,9948.28,2984.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1178.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1156.98,8456.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL CLIP 31.75CM DA VINCI XI ENDOWRIST 8MM SMALL WIDE",SUP-470401,CDM,S27000186,LOCAL,0270,RC,,,both,,,1400.82,420.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLIP SURGICAL STEALTH LATIS 6MM LOW PROFILE 30MM .5 SPRING",SUP-A1601,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"POSACONAZOLE 100 MG TABLET,DELAYED RELEASE",RX-164981,CDM,,,0250,RC,00527-2133-35,NDC,both,1,UN,279.75,83.92,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 3MM SPAT TIP VARIABLE LENGTH SHAFT COAGULATION CAP",SUP-PS210-030P,CDM,S27200284,LOCAL,0272,RC,,,both,,,3150.90,945.27,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC",279,MS-DRG,,,,,,,inpatient,,,156972.67,47091.8,"KAISER [10500]",Kaiser,,,67,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 1.8MM BUTTRESS VARIABLE ANGLE LOCKING T8",SUP-04.210.084,CDM,C1713,HCPCS,0278,RC,,,both,,,872.78,261.83,"KAISER [10500]",Kaiser,,584.76,67,,,,,0,101.5,741.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 80MM 15MM FLEXIPATH FLEXIBLE SLEEVE",SUP-FP015,CDM,S27200284,LOCAL,0272,RC,,,both,,,677.30,203.19,"PHCS [10601]",PHCS,,474.11,70,,,,,0,78.77,575.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11CM NATRELLE INSPIRA P5.4CM EXTRA FULL PROFILE",SUP-MSZ-X340,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,72.6,45.9,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 340MM FEMORAL RIGHT PROXIMAL TFN-ADVANCED LATERAL",SUP-04.037.154S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1471.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1444.25,10555.59,"percent of total billed charges",
"RASP SURGICAL CORE TPS STAINLESS STEEL SMALL L11 MM X W5 MM",SUP-5100-037-115,CDM,S27200284,LOCAL,0272,RC,,,both,,,928.26,278.48,"CIGNA [10200]","Cigna Local Plus",,496.62,53.5,,,,,0,107.96,789.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 107.5MM 11MM PRESS FIT TAPERLOC MICROPLASTY PPS",SUP-51-107110,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"BLUE CROSS [10001]","Blue Cross PPO",,10754.61,39.2,,3949.44,3949.44,3949.44,"1 through 10",3190.72,23319.95,"percent of total billed charges",
"30.0MM, STANDARD ACUTRAK 2 BONE SCREW",SUP-AT2-S30-S,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"CIGNA [10200]","Cigna Local Plus",,1705.31,53.5,,3978.14,359.25,3978.14,24,370.71,2709.38,"percent of total billed charges",
"PIN FIXATION DETACHABLE PLATE TEMPORARY NONSTERILE",SUP-389.873,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,170.52,39.2,,957.42,570.23,957.42,28,50.59,369.75,"percent of total billed charges",
"GRAFT BONE CORNERSTONE SR CORTICAL BLOCK 14X11X9MM CERVICAL",SUP-200941,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AETNA [10100]","Aetna HMO/PPO",,4114.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 26X9X10MM COROENT 4D PEEK LARGE IMPACT",SUP-6710926,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4739.47,28.62,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 255CC P2.9CM MODERATE CLASSIC PROFILE STD",SUP-350-7255MC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross HMO",,2028.6,39.2,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL H+12MM 36MM AEQUALIS SHOULDER RETENTIVE",SUP-DWD972,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"CIGNA [10200]",Cigna,,6139.04,68,,5873.17,5873.17,5873.17,"1 through 10",1049.96,7673.8,"percent of total billed charges",
"BUTTON 1.7CM 20FR LOW PROFILE APPLE BALLOON EXTERNAL BOLST",SUP-M1-5-2017,CDM,S27200284,LOCAL,0272,RC,,,both,,,1069.20,320.76,"UHC [10700]","United Healthcare",,676.8,63.3,,,,,0,124.35,908.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 245741FZ ASR 7X14X11 FZ SRVCFEE",SUP-245741FZ,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Paravrt Jt C/T 2 Lvl Bi",PX-510000135,CDM,64491,CPT,0761,RC,,,both,,,3365.42,1009.63,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2288.49,68,,,,,0,391.4,2860.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUTURE COROLENE 5-0 RB",SUP-20S10Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.82,14.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,33.2,68,,,,,0,5.68,41.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 18MM 80CM 7MM 3.3-3.5FR VASCULAR COCR",SUP-1011504-18,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"CIGNA [10200]",Cigna,,4284,68,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE PACING 135CM 2.4FR CHANDLER V AMC THROMBOSHIELD",SUP-D98100H,CDM,S27200284,LOCAL,0272,RC,,,both,,,917.73,275.32,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,377.19,41.1,,,,,0,106.73,780.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER FOREST GREEN 17MM 4.5MM SYNOVATOR CURVED",SUP-7205334,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,143.03,41.1,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON ETHILON 3-0 PS-2 18IN MONOFILAMENT BLACK",SUP-1669H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"NOVANET [10819]",Novanet,,19.5,75,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE TIGRIS 80MM 120CM 5MM VASCULAR CBAS NITINOL",SUP-PHA050802A,CDM,C1874,HCPCS,0278,RC,,,both,,,10315.50,3094.65,"UHC [10700]","United Healthcare",,6529.71,63.3,,,,,0,1199.69,8768.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 28MMX3.5MM TITANIUM XL CIRCULAR LINEAR CUTTER",SUP-EEAXL2835,CDM,S27200284,LOCAL,0272,RC,,,both,,,2399.55,719.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1101.39,45.9,,,,,0,279.07,2039.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL BICRUCIATE RETAINING ITOTAL IDENTITY IPOLY XE",SUP-TCR-023-060A,CDM,C1776,HCPCS,0278,RC,,,both,,,2130.00,639,"BLUE CROSS [10001]","Blue Cross PPO",,834.96,39.2,,3949.44,3949.44,3949.44,"1 through 10",247.72,1810.5,"percent of total billed charges",
"LENS IOL +22.5 DIOPTER HAPTIC C BICONVEX STERILE LATEX FREE",SUP-PCB0000225,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 3.5MM PRECUT",SUP-3603740,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 40MM 125CM 5MM BILIARY NITINOL ILIAC",SUP-G32032,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Open Access",,2150.82,56.9,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL RED YELLOW 3.6MM VARIAX AO FIT 3.5MM SCR",SUP-4535020,CDM,S27200284,LOCAL,0272,RC,,,both,,,898.13,269.44,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,412.24,45.9,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 11.5IN YANKAUER SATIN FINISH",SUP-170120,CDM,S27000186,LOCAL,0270,RC,,,both,,,205.49,61.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.9,174.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC 142CM 10MM 1.25MM BALLOON",SUP-SPL12510WL,CDM,C1725,HCPCS,0272,RC,,,both,,,577.13,173.14,"KAISER [10500]",Kaiser,,386.68,67,,,,,0,67.12,490.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 10MM 29MM PRIMARY NEXGEN POLYETHYLENE POROUS",SUP-587806529,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.16,2973.35,"MULTIPLAN [10600]",Multiplan,,8424.49,85,,,,,0,1152.67,8424.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 4MM AZUR .018IN",SUP-45-480415,CDM,S27800098,LOCAL,0278,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,405.69,28.62,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 120MM 3.5MM .014IN BALLOON DILATATION",SUP-AB14W035120150,CDM,C1725,HCPCS,0272,RC,,,both,,,1385.10,415.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,164.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE-SR ALLOGRAFT FREEZE DRIED BLOCK 14X14",SUP-200744,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA [10200]","Cigna Local Plus",,2768.63,53.5,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM .0115IN AXIUM PRIME LATTICEFX 3D",SUP-APB-4-10-3D-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,10074.00,3022.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1171.61,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1171.61,8562.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.7MM 16MM VARIAX TITANIUM LOW PROFILE HAND WRIST",SUP-53-17016E,CDM,C1713,HCPCS,0278,RC,,,both,,,734.83,220.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,87.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",85.46,624.61,"percent of total billed charges",
"STEM FEMORAL 217MM 13MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-413,CDM,C1776,HCPCS,0278,RC,,,both,,,19885.95,5965.78,"PHCS [10601]",PHCS,,13920.17,70,,,,,0,2312.74,16903.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 95MM 11MM 6MM CUFFLESS DISTAL EXT EXTEND LENGTH SOFT",SUP-60XLTUD,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.27,145.58,"KAISER [10500]",Kaiser,,325.13,67,,,,,0,56.44,412.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 158MM STAINLESS STEEL 3.5MM SCR 6 HOLE LCP BONE LEFT",SUP-02.104.026,CDM,C1713,HCPCS,0278,RC,,,both,,,8557.10,2567.13,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1014.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,995.19,7273.54,"percent of total billed charges",
"CLIP LARGE CHEVRON INTERNAL WECK HORIZON TITANIUM LIGATE",SUP-4200,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.11,36.93,"MULTIPLAN [10600]",Multiplan,,104.64,85,,,,,0,14.32,104.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ VASCULAR STRAIGHT 260CM .025IN PTFE STAINLESS",SUP-G04047,CDM,C1769,HCPCS,0272,RC,,,both,,,165.21,49.56,"FIRST HEALTH [10303]","First Health",,132.17,80,,,,,0,19.21,140.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Whole Blood, Transf, per Unit",PX-390000029,CDM,P9010,HCPCS,0390,RC,,,both,,,960.00,288,"KAISER [10500]",Kaiser,,643.2,67,,,,,0,111.65,816,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCORTISONE 1 % TOPICAL CREAM",RX-3726,CDM,,,0250,RC,45802-0438-03,NDC,both,28,GR,25.19,7.56,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.56,45.9,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI TREK 145CM 20MM 1.2MM ULTRA LOW PROFILE BALLOON",SUP-1012268-20U,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,76.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM CEMENTED OMNIFIT HFX 132D 9 35MM HIP",SUP-6070-0935A,CDM,C1776,HCPCS,0278,RC,,,both,,,7894.95,2368.48,"CIGNA [10200]","Cigna Open Access",,4492.23,56.9,,5302.19,4377.88,6578.61,27,918.18,6710.71,"percent of total billed charges",
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 20MM 190CM 2MM",SUP-R51002002L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"KAISER [10500]",Kaiser,,1321.07,67,,,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG FIXATION 2MM 23MM FOSSA RADIUS DISTAL VOLAR SMOOTH LOCK",SUP-SPLS-20230-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,639.90,191.97,"MULTIPLAN [10600]",Multiplan,,543.92,85,,,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mycoplasma Ab",PX-302000155,CDM,86738,CPT,0302,RC,,,both,,,481.65,144.49,"BLUE CROSS [10001]","Blue Cross PPO",,16.92,,"Fee schedule rate ($16.92).",,,,0,0.01,409.4,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"ABRE VENOUS SELF-EXPADING STENT16X150X90",SUP-AB9T16150090,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,355.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 220MM 6MM BALLOON DILATATION PEBAX",SUP-H74939032602210,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX14MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183544,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2243.75,28.62,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT GASTRIC LAVAGE TUM-E-VAC SOL BAG PREASSEMBLE CLOSED",SUP-2055,CDM,S27000186,LOCAL,0270,RC,,,both,,,240.94,72.28,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,99.03,41.1,,,,,0,28.02,204.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TIGHTROPE FIXATION MPFL RECONSTRUCTION",SUP-AR-1360TR-BC,CDM,C1713,HCPCS,0278,RC,,,both,,,14453.78,4336.13,"CIGNA [10200]","Cigna Open Access",,4842.02,33.5,,1144.80,304.56,2275.09,66,1680.97,12285.71,"percent of total billed charges",
"SYSTEM XIENCE ALPINE 12MM 145CM 3.25MM CORONARY STENT",SUP-1125325-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3969.84,68,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 80MM 5MM BALLOON DILATATION OTW STERILE",SUP-47050080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"AMERIGROUP MEDICAID [20100]",Amerigroup,,169.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABAHN 79MM 80CM 11MM 16SQ MM 8FR .035IN",SUP-BXA117901A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"AETNA [10100]","Aetna HMO/PPO",,17018.88,79.5,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE AXIOFILL HUMAN PLACENTAL EXTRACELLULAR MATRIX",SUP-PCM-1000,CDM,Q4433,HCPCS,0636,RC,,,both,,,15807.90,4742.37,"MULTIPLAN [10600]",Multiplan,,13436.72,85,,,,,0,247.92,13436.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM GLOBAL ADVANTAGE ARTHROPLASTY TOTAL",SUP-OSC13793,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"MULTIPLAN [10600]",Multiplan,,22758.75,85,,,,,0,3113.93,22758.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC",239,MS-DRG,,,,,,,inpatient,,,141174.97,42352.49,"AMBETTER EXCHANGE  [11102]",Ambetter,,30529.61,,"Case rate ($30,529.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $28,348.81, add-ons for qualifying new technology services are included. If operating cost exceeds $61,388.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,525.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $28,386.30. The transfer operating threshold is the transfer adjustment factor * $28,348.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,143.31. The transfer capital threshold is the transfer adjustment factor * $2,143.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,10994,141174.97,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 75CM 8CM 6FR 8MM .035IN BALLOON DILATATION",SUP-CQ7588,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"AETNA [10100]","Aetna HMO/PPO",,1062.52,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 6MM 2 VELOUR KNITTED STRAIGHT TUBE",SUP-M002020954060,CDM,C1768,HCPCS,0278,RC,,,both,,,3431.40,1029.42,"KAISER [10500]",Kaiser,,2299.04,67,,,,,0,399.07,2916.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BELT SPRT MEDTRONIC SMALL",SUP-FP9000S,CDM,S27000186,LOCAL,0270,RC,,,both,,,408.90,122.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE UROLOGICAL 150CM .038IN LUBRIGLIDE STRAIGHT TIP",SUP-M0066001000,CDM,C1769,HCPCS,0272,RC,,,both,,,247.43,74.23,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEALER TISSUE 25CM ENSEAL X1 CURVE JAW SHAFT STERILE LATEX",SUP-NSLX125C,CDM,S27200284,LOCAL,0272,RC,,,both,,,3109.07,932.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ASTHMA,EXTREME",141,APR-DRG,,,,,,,inpatient,,,44458.22,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $8,088.64. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($33,911.41) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY,MODERATE",564,APR-DRG,,,,,,,inpatient,,,21513.39,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $3,112.39. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MAXI 8-11.5IN OSTOMY FISTULA 2 LAYER 2 SPOUT OUTLET",SUP-14070,CDM,S27200284,LOCAL,0272,RC,,,both,,,303.20,90.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RTRCTR ROUND 7CM GELPOINT VAGINAL",SUP-C2A15,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL RAPIDE MULTIPASS 5-0 PC-1 18IN BRAID COATED",SUP-VR834,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.27,21.68,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATE 20MM DEGENERATIVE DISC 1 LEVEL ARCHON BONE SPINE",SUP-8787120,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"FIRST HEALTH [10303]","First Health",,3360,80,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 2.5MM 13CM SMALL VALVE RADIOPAQUE FLEXOR",SUP-G11211,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Inj Tap Block Unil Abdom Cont",PX-361000493,CDM,64487,CPT,0361,RC,,,both,,,2556.00,766.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE V-18 CONTROLWIRE VASCULAR STRAIGHT 300CM 12CM .018IN",SUP-M001468600,CDM,C1769,HCPCS,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DIL URETERAL HYDROPLUS 70CM 10FR STERILE",SUP-M0062401120,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.52,130.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 8MM 2.25MM .017IN",SUP-H7493926708220,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SOL DIALYSATE BGK2/3.5 POLYOLEFIN 5000ML NONPVC 2",SUP-110243,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.07,91.22,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Central Line Dressing Tray",PX-E27000196,CDM,E27000196,LOCAL,0270,RC,,,both,,,80.28,24.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH HAKIM 14CM 2.7MM 1.4MM DRNG CSF STYLET INTRO RIGHT",SUP-823041,CDM,C1729,HCPCS,0272,RC,,,both,,,2285.10,685.53,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PAD INSULATION CARDIAC ADULT",SUP-ACIP,CDM,S27200284,LOCAL,0272,RC,,,both,,,148.38,44.51,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH PACIFIC PLUS 130CM 40MM 4FR 6MM .018IN BALLOON",SUP-PCP060040130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AETNA [10100]","Aetna HMO/PPO",,978.8,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN LIGAPAK 0 54IN MONOFILAMENT DISPENSE REEL UNDYED",SUP-L104G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 7.9MM 2.9MM 90MM 16MM TITANIUM PARTIAL THREAD",SUP-408.413,CDM,C1713,HCPCS,0278,RC,,,both,,,1520.21,456.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,180.14,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",176.8,1292.18,"percent of total billed charges",
"NDL LOCALIZATION 10CM 20GA HAWKINS I CENTIMETER MARK",SUP-251100,CDM,A4648,HCPCS,0278,RC,,,both,,,378.21,113.46,"CIGNA [10200]",Cigna,,257.18,68,,,,,0,43.99,321.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STELLAREX 135CM 40MM 4MM BALLOON DILATATION ENDURACOAT",SUP-AB35SX040040135,CDM,C2623,HCPCS,0272,RC,,,both,,,9315.00,2794.5,"KAISER [10500]",Kaiser,,6241.05,67,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 3MM J 145CM .018IN STAINLESS STEEL PTFE",SUP-0684-00-0254-16,CDM,C1769,HCPCS,0272,RC,,,both,,,360.28,108.08,"FIRST HEALTH [10303]","First Health",,288.22,80,,,,,0,41.9,306.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +10.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.105,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CIGNA [10200]","Cigna Open Access",,686.73,56.9,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPIFIX 2X2 CM ""Q"" CODED",SUP-GS-5220,CDM,Q4186,HCPCS,0636,RC,,,both,,,6803.40,2041.02,"AETNA [10100]","Aetna HMO/PPO",,5408.7,79.5,,,,,0,406.44,5782.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON 1CM 16FR RADIOPAQUE LOW PROFILE TAPER DISTAL TIP",SUP-0120-16-1.0,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,357.59,45.9,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH VERSACROSS 1 LARGE CURVE 72CM 230CM GUIDING CNCT",SUP-VSTK0020,CDM,C1766,HCPCS,0272,RC,,,both,,,11212.50,3363.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7624.5,68,,,,,0,1304.01,9530.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT CORTICAL CANCELLOUS 7D ALLOGRAFT 14MM",SUP-3W5214,CDM,S27800098,LOCAL,0278,RC,,,both,,,21094.92,6328.48,"BLUE CROSS [10001]","Blue Cross HMO",,8269.21,39.2,,,,,0,2453.34,17930.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD EEG CERIBELL MEDIUM HEADBAND NONSTERILE LATEX FREE",SUP-C152,CDM,S27200284,LOCAL,0272,RC,,,both,,,4167.60,1250.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,493.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,484.69,3542.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC",739,MS-DRG,,,,,,,inpatient,,,103309.50,30992.85,"AMBETTER EXCHANGE  [11102]",Ambetter,,22224.33,,"Case rate ($22,224.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $20,636.79, add-ons for qualifying new technology services are included. If operating cost exceeds $53,676.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,942.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $20,664.08. The transfer operating threshold is the transfer adjustment factor * $20,636.79 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,560.24. The transfer capital threshold is the transfer adjustment factor * $1,560.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,103309.5,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 7FR L28CM FIRM TRI LAYER DESIGN RAW COLORANT",SUP-M0061902340,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Open Access",,926.33,,,,,,,189.34,1383.8,"percent of total billed charges",
"6.0MM X 13MM TECNIS EYHANCE INTRAOCULAR LENS, 1-PIECE, 08.5",SUP-DIB00U0085,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 12MM",SUP-650.112,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUMP INTRACARDIAC SUCTION ADULT .25IN SLIP CNCT 15IN 20FR",SUP-12012,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.06,38.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,53.04,41.1,,,,,0,15.01,109.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE UROLOGICAL 150CM 5CM .025IN PTFE STIFF BODY STRAIGHT",SUP-M0066201080,CDM,C1769,HCPCS,0272,RC,,,both,,,100.40,30.12,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.68,85.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 20MM 6FR 4.5MM",SUP-H7493926720450,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"NOVANET [10819]",Novanet,,425.25,75,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8MM 12/14 TAPER 28MM HIP OXINIUM ECHELON",SUP-71342808,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"MULTIPLAN [10600]",Multiplan,,13205.05,85,,,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 15MM 1.5MM BALLOON DILATATION OTW STERILE",SUP-47015015S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"FIRST HEALTH [10303]","First Health",,1146.96,80,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 32MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.032S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,1831.33,1831.33,1831.33,16,189.34,1383.8,"percent of total billed charges",
"LINER ACETABULAR PINNACLE NEUTRAL 62MM 36MM ALTRX HIP",SUP-122136062,CDM,C1776,HCPCS,0278,RC,,,both,,,6186.60,1855.98,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1770.6,28.62,,,,,0,719.5,5258.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TITAN 18CM TOUCH NARROW BASE PENOSCROTAL NARROW",SUP-EN2918,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"KAISER [10500]",Kaiser,,42009,67,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT 20MM 12MM 75CM ENDOPROSTHESIS ELGILOY VENOUS",SUP-H74912044122070,CDM,C1876,HCPCS,0278,RC,,,both,,,8625.00,2587.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2468.48,28.62,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOOT CAST NYLON 3-5 XS ROCKER BOTTOM STRETCHABLE UPPER",SUP-79-98432,CDM,S27000186,LOCAL,0270,RC,,,both,,,94.83,28.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,11.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.03,80.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10D MODIFY C BICONVEX 13MM 6MM POSTERIOR CHMBR",SUP-MA60AC,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"FIRST HEALTH [10303]","First Health",,965.52,80,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR HEAD TITANIUM +2MM STD SMR TAPER ECCENTRICAL REVISION",SUP-1330.15.272,CDM,C1776,HCPCS,0278,RC,,,both,,,1555.70,466.71,"CIGNA [10200]",Cigna,,1057.88,68,,5873.17,5873.17,5873.17,"1 through 10",180.93,1322.35,"percent of total billed charges",
"STEM HUMERAL 60MM 13MM CEMENTLESS SMR TITANIUM MINI",SUP-1304.15.130,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2266.7,28.62,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 9MM 2MM DCP SMALL BONE STAINLESS STEEL SELF TAPPING",SUP-201.879,CDM,C1713,HCPCS,0278,RC,,,both,,,705.35,211.6,"CIGNA [10200]","Cigna Open Access",,401.34,56.9,,1144.80,304.56,2275.09,66,82.03,599.55,"percent of total billed charges",
"VALVE AORTIC 31MM 26.1MM MASTERS SERIES 85D PYROLYTIC CARBON",SUP-31AECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"BLUE CROSS [10001]","Blue Cross HMO",,11414.74,39.2,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 32MM 144CM 3MM CORONARY STENT EVEROLIMUS",SUP-H7493926132300,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ATTAIN COMMAND SUREVALVE 45CM 9FR 7.2FR .035IN",SUP-6250V-MPR,CDM,C1887,HCPCS,0272,RC,,,both,,,2602.50,780.75,"UHC [10700]","United Healthcare",,1647.38,63.3,,,,,0,302.67,2212.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LARYNSCP INTUB 4 PREASSEMBLE BLADE STD HANDLE LED LIGHT",SUP-040-04-0140U,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.42,18.73,"NOVANET [10819]",Novanet,,46.82,75,,,,,0,7.26,53.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 6 PACK KOBYGARD SURGICAL STERILE DISPOSABLE",SUP-380-0006,CDM,S27200284,LOCAL,0272,RC,,,both,,,6844.80,2053.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,811.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,796.05,5818.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC 13MM 57SQ CM 51X71MM COBALT SURESCAN TITANIUM",SUP-DTPA2D1,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9118.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 1.5IN RICHARDSON 1.5IN LOOP HANDLE SURGICAL",SUP-202-157,CDM,S27000186,LOCAL,0270,RC,,,both,,,197.32,59.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,81.1,41.1,,,,,0,22.95,167.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESPONSE 65CM 6FR 2MM 1MM 2-8-2MM SPACE CSL CURVE",SUP-401353,CDM,C1730,HCPCS,0272,RC,,,both,,,2437.50,731.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,283.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT XL 155CM 100MM 2MM RECTANGLE HELIX BALLOON",SUP-2216-20100,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"FIRST HEALTH [10303]","First Health",,6624,80,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC",345,MS-DRG,,,,,,,inpatient,,,56562.03,16968.61,"AMBETTER EXCHANGE  [11102]",Ambetter,,9333.75,,"Case rate ($9,333.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,667.02, add-ons for qualifying new technology services are included. If operating cost exceeds $41,706.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,037.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,678.48. The transfer operating threshold is the transfer adjustment factor * $8,667.02 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.27. The transfer capital threshold is the transfer adjustment factor * $655.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,7561,43931.22,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 17IN 17FR PERCUTANEOUS FEMORAL ARTERIAL ADULT",SUP-96530-017,CDM,S27200284,LOCAL,0272,RC,,,both,,,1903.58,571.07,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,782.37,41.1,,,,,0,221.39,1618.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 217MM 38MM 33-34MM ZENITH ALPHA FLEXOR",SUP-G35360,CDM,C1874,HCPCS,0278,RC,,,both,,,88350.00,26505,"MULTIPLAN [10600]",Multiplan,,75097.5,85,,,,,0,10275.11,75097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR ANGLE 80CM .035IN HYDROPHILIC FIX CORE",SUP-H2OSTFA3580,CDM,C1769,HCPCS,0272,RC,,,both,,,278.40,83.52,"KAISER [10500]",Kaiser,,186.53,67,,,,,0,32.38,236.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL ADULT MEDIUM O2 RESVR BAG MASK SPUR II 10FT","SUP-520 211 010",CDM,S27000186,LOCAL,0270,RC,,,both,,,68.73,20.62,"UHC [10700]","United Healthcare",,43.51,63.3,,,,,0,7.99,58.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESPIRATORY SIGNS AND SYMPTOMS",204,MS-DRG,,,,,,,inpatient,,,33982.74,10194.82,"UHC [10700]","United Healthcare",,20135.75,,"Fee schedule rate ($20,135.75). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,5008.35,20135.75,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK",RX-11074,CDM,J3480,HCPCS,0636,RC,00990-7074-26,NDC,both,100,ML,100.65,30.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.64,,,,,,,0.12,85.55,"fee schedule",
"STOPPER EXTERNAL FIXATION TRUELOK RUBBER WIRE",SUP-54-1133,CDM,C1713,HCPCS,0278,RC,,,both,,,54.20,16.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,36.86,68,,,,,0,6.3,46.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW QUARTEX 3.5X18MM",SUP-1149.3518,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"KAISER [10500]",Kaiser,,2814,67,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,inpatient,,,141472.34,42441.7,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,47322.08,,"Case rate ($23,240.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $21,580.28, add-ons for qualifying new technology services are included. If operating cost exceeds $54,619.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $3,013.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $21,608.81. The transfer operating threshold is the transfer adjustment factor * $21,580.28 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,631.57. The transfer capital threshold is the transfer adjustment factor * $1,631.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,109385.73,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM EMBOLIC PROTECTION SHEATH INTRO PERMANENT FILTER",SUP-466P306AV,CDM,C1880,HCPCS,0278,RC,,,both,,,6175.50,1852.65,"CIGNA [10200]","Cigna Open Access",,3513.86,56.9,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 26MM 140CM 4.5MM 2.1-2.7FR CORONARY",SUP-RONYX45026UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5754.00,1726.2,"NOVANET [10819]",Novanet,,4315.5,75,,,,,0,669.19,4890.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 154MM 17MM PRESS FIT REDUCE DISTAL TAPERLOC PPS",SUP-51-103170,CDM,C1776,HCPCS,0278,RC,,,both,,,24203.34,7261,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2868.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2814.85,20572.84,"percent of total billed charges",
"SPACER SPINAL 60X22X10MM RISE-L 10D NONSTERILE",SUP-193.436,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14111.69,41.1,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH ENDOSCP 2MM 12.1MM ROUND EDGE STERILE LATEX FREE",SUP-D-201-11802,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.26,63.08,"UHC [10700]","United Healthcare",,133.09,63.3,,,,,0,24.45,178.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL IDENTITY IMPRINT 3 H6 MM KNEE POSTERIOR STABIL",SUP-TPS-020-063S,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"PHCS [10601]",PHCS,,4115.16,70,,,,,0,683.7,4996.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 113MMX2.6MM STAINLESS STEEL 2.7MM SCR 12 HOLE LC-DCP",SUP-242.222,CDM,C1713,HCPCS,0278,RC,,,both,,,2429.70,728.91,"NOVANET [10819]",Novanet,,1822.28,75,,,,,0,282.57,2065.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 155X11X3.3MM STAINLESS STEEL 3.5MM SCR SMALL FRAGMENT",SUP-223.62,CDM,C1713,HCPCS,0278,RC,,,both,,,2532.60,759.78,"CIGNA [10200]","Cigna Local Plus",,1354.94,53.5,,3978.14,359.25,3978.14,24,294.54,2152.71,"percent of total billed charges",
"SCR BONE 3.5MM 12MM LOW PROFILE SCREWS STAINLESS STEEL T15",SUP-AR-8835-12,CDM,C1713,HCPCS,0278,RC,,,both,,,304.50,91.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,36.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,35.41,258.83,"percent of total billed charges",
"IMPL BREAST 545CC NATRELLE INSPIRA COHESIVE STERILE",SUP-SCX-545,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5137.74,68,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Noninvas Ffr Analysis Cta",PX-480000105,CDM,75580,CPT,0350,RC,,,both,,,2831.81,849.54,"UHC [10700]","United Healthcare",,2490.45,,,,,,,329.34,2730.34,"fee schedule",
"CAP CONSTRUCT TOTAL KNEE JOURNEY II CRUCIAT RETAINING OXI VE",SUP-71701650,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8820,40,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 10MM NATURAL LORDOTIC CORTICOCANCELLOUS",SUP-18410,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 3MM OXFORD ARCOM KNEE LEFT MENISCAL PHASE 3",SUP-159554,CDM,C1776,HCPCS,0278,RC,,,both,,,5270.22,1581.07,"CIGNA [10200]",Cigna,,3583.75,68,,5873.17,5873.17,5873.17,"1 through 10",612.93,4479.69,"percent of total billed charges",
"CATH DXTERITY 100CM 6FR .056IN AMPLATZ LEFT 1 CURVE",SUP-DXT6AL10,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"KAISER [10500]",Kaiser,,55.38,67,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHALANX CORONAL TRANSFIXION SCREW 1.5MM X 14.0MM COCR",SUP-PTS-15014-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.90,337.77,"NOVANET [10819]",Novanet,,844.43,75,,,,,0,130.94,957.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ELECTROPHYSIOLOGY 115CM 7FR 2-12-2MM SPACING ISMUS",SUP-D7R-20-P14-RTR,CDM,C1731,HCPCS,0272,RC,,,both,,,2100.00,630,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,248.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT RETRIEVER 20MM 4MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0033PK43022001,CDM,S27200284,LOCAL,0272,RC,,,both,,,20045.55,6013.66,"CIGNA [10200]","Cigna Open Access",,11405.92,56.9,,,,,0,2331.3,17038.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AGENT 12MM 2.25MM BALLOON DILATATION PACLITAXEL",SUP-H7493960812220,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4609.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO 17FR LUMEN CATH",SUP-S17-45,CDM,C1894,HCPCS,0272,RC,,,both,,,3112.50,933.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,361.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE FATHOM VASCULAR 10CM STRAIGHT 215CM 25CM .016IN",SUP-M001509300,CDM,C1769,HCPCS,0272,RC,,,both,,,1815.00,544.5,"PHCS [10601]",PHCS,,1270.5,70,,,,,0,211.08,1542.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE MDII ALLOGRAFT 16MM 20MM",SUP-401116A,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 75CM 40MM 7MM BALLOON DILATATION DRUG COATED",SUP-LX3575740V,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"MULTIPLAN [10600]",Multiplan,,5718.38,85,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 480-575ML TEXTURED LOW POLE PLUS LATERAL EXT",SUP-LPP-FH14,CDM,C1789,HCPCS,0278,RC,,,both,,,8349.00,2504.7,"PHCS [10601]",PHCS,,5844.3,70,,,,,0,970.99,7096.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOL URETHRAL 36CM 26FR PHILLIPS PLASTIC NATURAL RUBBER CATH",SUP-346126,CDM,S27200284,LOCAL,0272,RC,,,both,,,146.16,43.85,"FIRST HEALTH [10303]","First Health",,116.93,80,,,,,0,17,124.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 130MM 12MM REVERSE TIVANIUM TRABECULAR METAL",SUP-00434901213,CDM,C1776,HCPCS,0278,RC,,,both,,,17863.20,5358.96,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5112.45,28.62,,,,,0,2077.49,15183.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 26CM 3CM 8FR .035IN STRAIGHT URETERAL",SUP-M006175283180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"FIRST HEALTH [10303]","First Health",,1168.09,80,,,,,0,169.81,1241.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE RIGHT CONSTRAIN LEGION OXINIUM",SUP-71421175,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"UHC [10700]","United Healthcare",,36608.92,63.3,,8601.07,8395.67,8601.07,"1 through 10",6726.09,49158.9,"percent of total billed charges",
"GRAFT BONE COALITION AGX 7D ALLOGRAFT 8X14X8MM",SUP-8128.1278S,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross HMO",,2163.84,39.2,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 26CM 6FR .038",SUP-M006192133120,CDM,C2617,HCPCS,0278,RC,,,both,,,1528.96,458.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,437.59,28.62,,,,,0,177.82,1299.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 14MM 140CM 2.5MM",SUP-RSINT25014UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"BLUE CROSS [10001]","Blue Cross HMO",,2173.25,39.2,,9776.84,9776.84,9776.84,"1 through 10",644.77,4712.4,"percent of total billed charges",
"STENT VIABAHN 5CM 120CM 8MM 7FR ENDOPROSTHESIS HEPARIN",SUP-VBJR080502A,CDM,C1874,HCPCS,0278,RC,,,both,,,19895.40,5968.62,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2357.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2313.84,16911.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 4MM RELINE-C PRE BENT TITANIUM NONSTERILE",SUP-3944120,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 10IN 13.5MM REDUCE NECK SOL SYSTEM POROUS 12/14",SUP-157211136,CDM,C1776,HCPCS,0278,RC,,,both,,,39412.80,11823.84,"UHC [10700]","United Healthcare",,24948.3,63.3,,8601.07,8395.67,8601.07,"1 through 10",4583.71,33500.88,"percent of total billed charges",
"STENT WALLFLEX 80MM 3.2MM 10MM 8FR BILIARY PLATINOL METAL",SUP-M00570650,CDM,C1876,HCPCS,0278,RC,,,both,,,11927.41,3578.22,"KAISER [10500]",Kaiser,,7991.36,67,,,,,0,1387.16,10138.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Cath Thorac Ea 3rd Ord",PX-361000085,CDM,36217,CPT,0361,RC,,,both,,,1496.43,448.93,"KAISER [10500]",Kaiser,,1002.61,67,,,,,0,174.03,1496.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE JAWS STAPLE SYSTEM 12MM 12X12 STRAIGHT",SUP-P71-012-1212-S,CDM,C1713,HCPCS,0278,RC,,,both,,,8330.03,2499.01,"CIGNA [10200]",Cigna,,5664.42,68,,1831.33,1831.33,1831.33,16,968.78,7080.53,"percent of total billed charges",
"CATH LAUNCHER 5FR .058IN JUDKINS LEFT 3 CURVE GUIDING NYLON",SUP-LA5JL30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE INTEGRITY 12MM 140CM 3.5MM CORONARY STENT",SUP-RSINT35012W,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,656.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM TPS ELITE ROUND FLUTE AGGRESSIVE",SUP-5820010230,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"MULTIPLAN [10600]",Multiplan,,930.72,85,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT RETRIEVER 20MM 4MM STROKE FAST PACK STERILE LATEX FREE",SUP-M0032PK42010001,CDM,S27200284,LOCAL,0272,RC,,,both,,,29495.34,8848.6,"MULTIPLAN [10600]",Multiplan,,25071.04,85,,,,,0,3430.31,25071.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL MEDIUM PEDICLE 5.5/6MM ROD",SUP-5541103,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"PHCS [10601]",PHCS,,2100,70,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THROMBIN (BOVINE) 5,000 UNIT TOPICAL SOLUTION",RX-121612,CDM,,,0250,RC,60793-0215-05,NDC,both,1,UN,457.43,137.23,"AMERIGROUP MEDICAID [20100]",Amerigroup,,54.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,53.2,388.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 20X45X11MM ORACLE 0D SPINE LUMBAR FREEZE",SUP-14541,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9839.34,41.1,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 135MM 11MM REINFORCEMENT SPACER STAGEONE",SUP-431191,CDM,C1776,HCPCS,0278,RC,,,both,,,9954.63,2986.39,"CIGNA [10200]","Cigna Local Plus",,5325.73,53.5,,5372.07,4581.20,7242.98,23,1157.72,8461.44,"percent of total billed charges",
"DIL VASCULAR 10FR 20CM RADIOPAQUE STERILE DISPOSABLE VESSEL",SUP-G00993,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 65MM KNEE LEFT CRUCIATE RETAINING CEMENTED",SUP-183028,CDM,C1776,HCPCS,0278,RC,,,both,,,20085.66,6025.7,"UHC [10700]","United Healthcare",,12714.22,63.3,,8601.07,8395.67,8601.07,"1 through 10",2335.96,17072.81,"percent of total billed charges",
"COIL EMBOLIZATION 10CM 8MM .021IN AZUR DETACHABLE .018IN",SUP-45-480810,CDM,S27800098,LOCAL,0278,RC,,,both,,,5678.70,1703.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1625.24,28.62,,,,,0,660.43,4826.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE FEMORAL 35MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-1511-01-203,CDM,C1776,HCPCS,0278,RC,,,both,,,16151.52,4845.46,"PHCS [10601]",PHCS,,11306.06,70,,,,,0,1878.42,13728.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 2 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRN2PR,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,8601.07,8395.67,8601.07,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"GRAFT STENT 15CM 28MM TAG THORACIC ACTIVE CONTROL",SUP-TGM282815,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,46388.88,40,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE CARDIOFORM SEPTAL OCCLUDER 25MM 10FR",SUP-00733132631025,CDM,C1817,HCPCS,0278,RC,,,both,,,60826.50,18247.95,"PHCS [10601]",PHCS,,42578.55,70,,,,,0,7074.12,51702.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC UNIVERSAL 10IN FOREARM RIGHT WRIST D RING",SUP-5066-80,CDM,S27000186,LOCAL,0270,RC,,,both,,,72.91,21.87,"UHC [10700]","United Healthcare",,46.15,63.3,,,,,0,8.48,61.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 20MM 7FR 3 ELECTROPHYSIOLOGY 20 POLE DEFLECTABLE CARTO",SUP-D7L2020CT,CDM,C1731,HCPCS,0272,RC,,,both,,,10950.30,3285.09,"UHC [10700]","United Healthcare",,6931.54,63.3,,,,,0,1273.52,9307.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"V.A.C. VERAFLO CLEANSE CHOICE DRESSING, MEDIUM",SUP-ULTVCC05MD,CDM,A6550,HCPCS,0272,RC,,,both,,,1061.91,318.57,"KAISER [10500]",Kaiser,,711.48,67,,,,,0,26.26,902.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN HOCKEY STICK 1 CURVE GUIDING",SUP-LA7HSISH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"UHC [10700]","United Healthcare",,231.3,63.3,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 8MM 2.25MM CORONARY STENT COCR",SUP-1007822-08,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]","Cigna Open Access",,1707,56.9,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL 64X43MM PFC SIGMA 2 KNEE CEMENT MODULAR PLUS FIX",SUP-860122,CDM,C1776,HCPCS,0278,RC,,,both,,,16046.64,4813.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6595.17,41.1,,6417.48,6417.48,6417.48,"1 through 10",1866.22,13639.64,"percent of total billed charges",
"INSRT TIBIAL 7 7MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640707,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1308.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mlh1 Gene",PX-309000128,CDM,81288,CPT,0310,RC,,,both,,,1210.75,363.22,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,1029.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 20MM 4.5MM INTRACRANIAL BARE METAL FLOW",SUP-FDS45020,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"FIRST HEALTH [10303]","First Health",,66419.78,80,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC",485,MS-DRG,,,,,,,inpatient,,,119941.43,35982.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,64061.16,,"Fee schedule rate ($64,061.16). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,94218.41,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC",843,MS-DRG,,,,,,,inpatient,,,69733.13,20919.94,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,13116.29,,"Case rate ($12,373.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $11,489.97, add-ons for qualifying new technology services are included. If operating cost exceeds $44,529.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,250.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $11,505.17. The transfer operating threshold is the transfer adjustment factor * $11,489.97 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $868.70. The transfer capital threshold is the transfer adjustment factor * $868.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,49748.32,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXTOME 142CM 10MM 2MM BALLOON DILATATION NYLON",SUP-H749CBM3200100,CDM,C1725,HCPCS,0272,RC,,,both,,,5395.80,1618.74,"KAISER [10500]",Kaiser,,3615.19,67,,,,,0,627.53,4586.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 62MM STAINLESS STEEL 3.5MM SCR 3 HOLE SHARP HOOK LOW",SUP-02.113.103,CDM,C1713,HCPCS,0278,RC,,,both,,,3386.25,1015.87,"CIGNA [10200]","Cigna Open Access",,1926.78,56.9,,1144.80,304.56,2275.09,66,393.82,2878.31,"percent of total billed charges",
"CMPNT FEMORAL 5 KNEE RIGHT TOTAL STBL TRIATHLON COCR",SUP-5512-F-502,CDM,C1776,HCPCS,0278,RC,,,both,,,20599.49,6179.85,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8466.39,41.1,,6417.48,6417.48,6417.48,"1 through 10",2395.72,17509.57,"percent of total billed charges",
"SPACER ALLOGRAFT 21-26X27-32X19MM LUMINARY CC BICONVEX SPINE",SUP-16819,CDM,S27800098,LOCAL,0278,RC,,,both,,,33264.00,9979.2,"CIGNA [10200]","Cigna Local Plus",,10478.16,31.5,,,,,0,3868.6,28274.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEIZURES WITH MCC",100,MS-DRG,,,,,,,inpatient,,,37993.84,11398.15,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,37993.84,,"Fee schedule rate ($38,447.42). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,37993.84,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug/Sbst Def Qual or Quan",PX-301000566,CDM,80377,CPT,0301,RC,,,both,,,363.85,109.15,"CIGNA [10200]","Cigna Local Plus",,251.75,,,,,,,0.01,309.27,"fee schedule",
"SCR BONE 2.5MM 22MM QUICKFIX TITANIUM 1.5MM MICRO FULL",SUP-AR-8725-22H,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"AETNA [10100]","Aetna HMO/PPO",,2086.88,79.5,,1521.93,481.35,16760.95,30,305.29,2231.25,"percent of total billed charges",
"FILLER BONE VOID STIMUBLAST DEMINERALIZED BONE MATRIX GEL",SUP-ABS-2002-10,CDM,C1713,HCPCS,0278,RC,,,both,,,8280.00,2484,"KAISER [10500]",Kaiser,,5547.6,67,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 1.8MM BUTTRESS VARIABLE ANGLE LOCKING T8",SUP-04.210.096,CDM,C1713,HCPCS,0278,RC,,,both,,,872.78,261.83,"MULTIPLAN [10600]",Multiplan,,741.86,85,,,,,0,101.5,741.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 20MM STARDRIVE STAINLESS STEEL PROXIMAL FEMORAL",SUP-212.204,CDM,C1713,HCPCS,0278,RC,,,both,,,873.18,261.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,593.76,68,,,,,0,101.55,742.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,inpatient,,,46575.25,13972.57,"BLUE CROSS [10001]","Blue Cross PPO",,26854.57,,,,,,,6747.69,27128.64,"case rate",
"SCR BONE 4.5MM 34MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.534,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 22MM STAINLESS STEEL T15 SELF TAP LOCK",SUP-02.127.122,CDM,C1713,HCPCS,0278,RC,,,both,,,1132.70,339.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,134.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",131.73,962.8,"percent of total billed charges",
"SCR BONE 1.5MM 14MM TITANIUM CORTEX SELF TAPPING CRUCIFORM",SUP-400.014,CDM,C1713,HCPCS,0278,RC,,,both,,,330.34,99.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,94.54,28.62,,,,,0,38.42,280.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM QUADLINK 100MM IMPL ALL INSIE",SUP-AR-1288QAI-100,CDM,C1713,HCPCS,0278,RC,,,both,,,19785.15,5935.54,"UHC [10700]","United Healthcare",,12524,63.3,,5023.51,2672.93,6679.78,18,2301.01,16817.38,"percent of total billed charges",
"GRAFT SKIN 8X3CM AMNIOBAND 24SQ CM ALLOGRAFT",SUP-WC3038,CDM,Q4151,HCPCS,0636,RC,,,both,,,19348.88,5804.66,"MULTIPLAN [10600]",Multiplan,,16446.55,85,,,,,0,362.66,16446.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 14MM AMNIOBAND PLACENTAL ALLOGRAFT",SUP-WC3014,CDM,Q4151,HCPCS,0636,RC,,,both,,,1667.10,500.13,"MULTIPLAN [10600]",Multiplan,,1417.04,85,,,,,0,197.55,1417.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE DURASPHERE EXP STD 25CM 12MM SUTURING TRANSVAGINAL",SUP-M0068311251,CDM,C2631,HCPCS,0278,RC,,,both,,,4633.57,1390.07,"CIGNA [10200]","Cigna Open Access",,2636.5,56.9,,,,,0,538.88,3938.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) DEVICE CELT ACD 5FR CLSR VASCULAR STERILE LATEX FREE",SUP-KCLT-05,CDM,C1760,HCPCS,0278,RC,,,both,,,1539.00,461.7,"CIGNA [10200]",Cigna,,1046.52,68,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFTTOUCH",SUP-SSM-140,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS [10001]","Blue Cross PPO",,2961.76,39.2,,16595.83,16595.83,16595.83,"1 through 10",878.7,6422.18,"percent of total billed charges",
"SCR BONE 4.5MM 50MM LOW PROFILE SCREWS TITANIUM FULL THREAD",SUP-AR-8945-50FT,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"KAISER [10500]",Kaiser,,949.73,67,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA XFULL PROFILE SOFT TOUCH SMOOTH",SUP-SSX-470,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"MULTIPLAN [10600]",Multiplan,,6422.18,85,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 150CC P2.9CM MODERATE PLUS PROFILE ROUND GEL",SUP-350-1501BC,CDM,C1789,HCPCS,0278,RC,,,both,,,4823.10,1446.93,"NOVANET [10819]",Novanet,,3617.33,75,,,,,0,560.93,4099.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 685CC NATRELLE INSPIRA COHESIVE STERILE",SUP-TCM-685,CDM,C1789,HCPCS,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]","Cigna Local Plus",,4429.8,,,,,,,962.96,7038,"percent of total billed charges",
"SHEATH 27FR ENDOSCOPIC OUTER 2 STPCOCK ROTATE NONSTERILE",SUP-A22021A,CDM,C1894,HCPCS,0272,RC,,,both,,,10209.17,3062.75,"KAISER [10500]",Kaiser,,6840.14,67,,,,,0,1187.33,8677.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Kit Paracentesis",PX-E27200175,CDM,E27200175,LOCAL,0272,RC,,,both,,,423.50,127.05,"CIGNA [10200]",Cigna,,287.98,68,,,,,0,49.25,359.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 13FR 71CM STEERABLE AGILIS NXT DUAL-REACH",SUP-SI-1371-S,CDM,C1766,HCPCS,0272,RC,,,both,,,8970.00,2691,"KAISER [10500]",Kaiser,,6009.9,67,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,inpatient,,,22247.05,6674.11,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,5872.27,,"Case rate ($5,701.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,293.98, add-ons for qualifying new technology services are included. If operating cost exceeds $38,333.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,782.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,300.98. The transfer operating threshold is the transfer adjustment factor * $5,293.98 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.25. The transfer capital threshold is the transfer adjustment factor * $400.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,5701.23,22247.05,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC",981,MS-DRG,,,,,,,inpatient,,,173901.28,52170.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,93136.92,,"Fee schedule rate ($93,136.92). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,10994,136981.79,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANSURETHRAL PROCEDURES WITH MCC",668,MS-DRG,,,,,,,inpatient,,,88844.31,26653.29,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,18928.02,,"Case rate ($18,112.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $16,819.09, add-ons for qualifying new technology services are included. If operating cost exceeds $49,858.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,653.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $16,841.33. The transfer operating threshold is the transfer adjustment factor * $16,819.09 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,271.61. The transfer capital threshold is the transfer adjustment factor * $1,271.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7561,85252.32,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR HEAD AND NECK PROCEDURES WITH MCC",140,MS-DRG,,,,,,,inpatient,,,172534.24,51760.27,"PHCS [10601]",PHCS,,7561,,,,,,,7561,124529.7,"per diem","Estimated amount calculated based on 6 day length of stay."
"STRATTICE LAPAROSCOPIC 16CM X 20CM",SUP-1620005,CDM,Q4130,HCPCS,0636,RC,,,both,,,48900.60,14670.18,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5794.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5794.72,41565.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Short Somatosensory Test Upr",PX-922000008,CDM,95925,CPT,0922,RC,,,both,,,1542.00,462.6,"KAISER [10500]",Kaiser,,1033.14,67,,,,,0,179.33,1310.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD EMG I-PAS III DIAMOND DISPOSABLE NONSTERILE LATEX",SUP-2010028,CDM,S27000186,LOCAL,0270,RC,,,both,,,1650.00,495,"KAISER [10500]",Kaiser,,1105.5,67,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM INDEPENDENCE SPINE SELF DRILL VARIABLE",SUP-176.740,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross HMO",,635.04,39.2,,957.42,156.86,7483.26,51,188.41,1377,"percent of total billed charges",
"CAP CMPNT GLENOID REVERSE SHOULDER",SUP-98B00901601,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"AETNA [10100]","Aetna HMO/PPO",,38565.45,79.5,,10981.53,8986.79,12413.38,12,5641.71,41233.5,"percent of total billed charges",
"PEG FIXATION 2.5MM 14MM FULL THREAD FOOT LOCKING SCR F3",SUP-FP14,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,312.96,28.62,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN AMPLATZ LEFT .75 CURVE",SUP-LA6AL75,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE RIGHT OBLIQUE 3 HOLE HEAD 8 HOLE SHAFT T 107MM",SUP-241.081,CDM,C1713,HCPCS,0278,RC,,,both,,,2673.30,801.99,"KAISER [10500]",Kaiser,,1791.11,67,,,,,0,310.9,2272.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 17MM 46MM SHOULDER AEQUALIS ASCEND FLEX COCR 4",SUP-DWF146,CDM,C1776,HCPCS,0278,RC,,,both,,,10004.00,3001.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1163.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1163.47,8503.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Cytp Oth Xtn / Add on 88162",PX-311000085,CDM,0834T,CPT,0311,RC,,,both,,,104.00,31.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,70.72,68,,,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla Class I High Def Qual",PX-302000218,CDM,86832,CPT,0302,RC,,,both,,,1024.40,307.32,"FIRST HEALTH [10303]","First Health",,819.52,80,,,,,0,1.02,930.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Ankle 2v",PX-320000087,CDM,73600,CPT,0320,RC,,,both,,,598.76,179.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,38.7,,,,,,,38.7,508.95,"fee schedule",
"7F DECA 7-7-7 PV24 110CM",SUP-901645,CDM,C1730,HCPCS,0272,RC,,,both,,,5692.50,1707.75,"PHCS [10601]",PHCS,,3984.75,70,,,,,0,662.04,4838.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) DEVICE CELT ACD 7FR CLSR VASCULAR STERILE LATEX FREE",SUP-KCLT-07,CDM,C1760,HCPCS,0272,RC,,,both,,,1875.00,562.5,"UHC [10700]","United Healthcare",,1186.88,63.3,,,,,0,770.63,1186.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 590ML GEL SMOOTH MEMORYGEL COHESIVE I P6.3CM","SUP-3505590 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3885.00,1165.5,"KAISER [10500]",Kaiser,,2602.95,67,,,,,0,451.83,3302.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE SIERRA 33MM 2.5MM CORONARY STENT EVEROLIMUS",SUP-1550250-33,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]","Cigna Local Plus",,2030.33,53.5,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 700CC STERILE ARTOURA ULTRA HIGH PROFILE ROUND",SUP-TEXP135RUH,CDM,C1789,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"UHC [10700]","United Healthcare",,8713.56,63.3,,,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 375ML GEL ROUND SMOOTH COHESIVE I SILICONE P4CM","SUP-3503751 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"KAISER [10500]",Kaiser,,2462.25,67,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 30MM TITANIUM FULL THREAD LOCK STERILE T2 NAIL",SUP-1896-5030S,CDM,C1713,HCPCS,0278,RC,,,both,,,1279.15,383.74,"BLUE CROSS [10001]","Blue Cross PPO",,501.43,39.2,,957.42,570.23,957.42,28,148.77,1087.28,"percent of total billed charges",
"HC Inj Sacroiliac Jt",PX-510000069,CDM,27096,CPT,0361,RC,,,both,,,5417.97,1625.39,"UHC [10700]","United Healthcare",,1922,,"Case rate ($1,922). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,1249,1922,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 250ML P3.4CM MODERATE PLUS PROFILE HIGH",SUP-350-2501BC,CDM,C1789,HCPCS,0278,RC,,,both,,,5175.00,1552.5,"FIRST HEALTH [10303]","First Health",,4140,80,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 255CC P4.7CM MODERATE PLUS PROFILE MEDIUM HEIGHT",SUP-334-1105,CDM,C1789,HCPCS,0278,RC,,,both,,,8107.50,2432.25,"AETNA [10100]","Aetna HMO/PPO",,6445.46,79.5,,,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 265ML STYLE 15 SMOOTH NATRELLE SILICONE P3.7CM",SUP-15-265,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1638.63,45.9,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FOOT PROCEDURES WITH CC",504,MS-DRG,,,,,,,inpatient,,,77462.59,23238.78,"PHCS [10601]",PHCS,,7561,,,,,,,7561,7561,"per diem","Estimated amount calculated based on 9 day length of stay."
"SMOOTH MODERATE HIGH-PROFILE BOOST, 700CC",SUP-SMHB700,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,903.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",886.73,6480.83,"percent of total billed charges",
"IMPL BREAST 525ML GEL ROUND SMOOTH MEMORYGEL SILICONE P4.4CM","SUP-3505251 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3675.00,1102.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2499,68,,,,,0,427.4,3123.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 605CC SMOOTH SHELL SURFACE COHESIVE GEL 1 LUMEN",SUP-SRF-605,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"BLUE CROSS [10001]","Blue Cross HMO",,2150.32,39.2,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOCARNITINE 20 MG/ML INTRAVENOUS SOLUTION (NICU)",RX-408341,CDM,J1955,HCPCS,0636,RC,08888-8887-98,NDC,both,1,ML,66.63,19.99,"NOVANET [10819]",Novanet,,49.97,75,,,,,0,8.03,62.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Fungi Pres ID Hair/Sk/Na",PX-306000065,CDM,87101,CPT,0306,RC,,,both,,,164.00,49.2,"PHCS [10601]",PHCS,,114.8,70,,,,,0,0.01,139.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRIMONIDINE 0.1 % EYE DROPS",RX-70262,CDM,,,0250,RC,00023-9321-05,NDC,both,5,ML,1173.65,352.09,"NOVANET [10819]",Novanet,,880.24,75,,,,,0,136.5,997.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Amino Acids Ql Single",PX-301000578,CDM,82127,CPT,0301,RC,,,both,,,130.00,39,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,110.5,"per diem",
"HC Asay of Interleukin-6",PX-301000685,CDM,83529,CPT,0301,RC,,,both,,,349.60,104.88,"CIGNA [10200]","Cigna Local Plus",,37.99,,,,,,,0.01,297.16,"fee schedule",
"PRECISION MICROWAVE ABLATION PROBE, 17 GUAGE, 20 CM",SUP-PR20,CDM,C2618,HCPCS,0272,RC,,,both,,,14524.50,4357.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1721.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1689.2,12345.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 40CM 7FR VENTRICLE BIPOLAR PASSIVE FIXATION",SUP-1646T/40,CDM,C1898,HCPCS,0275,RC,,,both,,,1786.00,535.8,"FIRST HEALTH [10303]","First Health",,1428.8,80,,,,,0,207.71,1518.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE EMBOLIZATION RED EMBOZENE 500UM POLYZENE-F HYDROGEL",SUP-15020-S1,CDM,S27800098,LOCAL,0278,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,405.69,28.62,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR IDENTITY ADX SR IMPLANTABLE 1 CHMBR RATE RESPONSIVE",SUP-5180,CDM,C1786,HCPCS,0275,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENROUTE UBER FLEX 40MM 57CM 9MM .078IN VASCULAR",SUP-SR-0940-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VICI VENOUS STENT 120MM 100MM 16MM ENDOPROSTHESIS",SUP-H74916120100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Local Plus",,4129.65,31.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insitu Hybrid Ea Probe Manual",PX-312000049,CDM,88368,CPT,0312,RC,,,both,,,1041.20,312.36,"NOVANET [10819]",Novanet,,780.9,75,,,,,0,0.01,885.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 30MM 125CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-G43820,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]",Cigna,,2570.4,68,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEROSTIMLTR NEVRO REMOTE NONSTERILE LATEX FREE REUSABLE",SUP-PTRC1000,CDM,C1787,HCPCS,0270,RC,,,both,,,6900.00,2070,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,817.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR NEROSTIMLTR 2.63INX1.98IN PROCLAIM ELITE THK.53IN 7",SUP-3662,CDM,C1820,HCPCS,0278,RC,,,both,,,88207.50,26462.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,25244.99,28.62,,,,,0,10258.53,74976.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 8MM 70MM VIPER EXPEDIUM TITANIUM SPINE POLYAXIAL",SUP-179704870,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3753.6,68,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 10MM 36MM SYMMETRIC TRIATHLON X3 KNEE",SUP-5550L360,CDM,C1776,HCPCS,0278,RC,,,both,,,4478.10,1343.43,"BLUE CROSS [10001]","Blue Cross HMO",,1755.42,39.2,,5311.50,4717.44,5388.59,31,520.8,3806.39,"percent of total billed charges",
"STENT E-LUMINEXX SAFE PERFORMAXX 20MM 80CM 7MM 6FR .035IN",SUP-ZBM07020,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"UHC [10700]","United Healthcare",,6333.17,63.3,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 28CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155234180,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESUS MANUAL ADULT MEDIUM TUBE RESVR MASK PEEP VALVE LATEX",SUP-521611001,CDM,S27000186,LOCAL,0270,RC,,,both,,,71.56,21.47,"AETNA [10100]","Aetna HMO/PPO",,56.89,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.32,60.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 151MM STAINLESS STEEL 2.7/3.5MM SCR 9 HOLE LCP BONE",SUP-02.112.148,CDM,C1713,HCPCS,0278,RC,,,both,,,3365.25,1009.57,"CIGNA [10200]",Cigna,,2288.37,68,,1831.33,1831.33,1831.33,16,391.38,2860.46,"percent of total billed charges",
"HC Prolact Rtf26 Qtr Btl",PX-E27000213,CDM,E27000213,LOCAL,0270,RC,,,both,,,300.30,90.09,"PHCS [10601]",PHCS,,210.21,70,,,,,0,34.92,255.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.0MM X 16MM COCR",SUP-VAL-20160-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,408.01,28.62,,,,,0,165.8,1211.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL GERALD 9.25IN TISSUE SERRATE DRSG",SUP-55-9004,CDM,S27200284,LOCAL,0272,RC,,,both,,,339.91,101.97,"AMERIGROUP MEDICAID [20100]",Amerigroup,,40.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.53,288.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 25X15CM OVITEX LPR 3MM 25MM ELLIPSE OVINE",SUP-F10244-1525L,CDM,C1781,HCPCS,0278,RC,,,both,,,30724.60,9217.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8295.64,27,,,,,0,3573.27,26115.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Idh1 Common Variants",PX-309000120,CDM,81120,CPT,0310,RC,,,both,,,544.00,163.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,173.93,,,,,,,0.54,544,"fee schedule",
"STENT ABSOLUTE PRO 60MM 80CM 6MM VASCULAR PERIPHERAL SELF",SUP-1012528-60,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]",Cigna,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE FIBULA SHAFT ALLOGRAFT FREEZE DRY 40X12-13MM",SUP-400721,CDM,S27800098,LOCAL,0278,RC,,,both,,,3978.54,1193.56,"NOVANET [10819]",Novanet,,2983.91,75,,,,,0,462.7,3381.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD PLEXA PROMRI S 65",SUP-402266,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"AETNA [10100]","Aetna HMO/PPO",,13651.74,79.5,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 29MM TITANIUM INTRALUMINAL ENDOSCOPIC LINEAR",SUP-CDH29A,CDM,S27200284,LOCAL,0272,RC,,,both,,,5683.28,1704.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3864.63,68,,,,,0,660.97,4830.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLINDAMYCIN 900 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK",RX-178949,CDM,J0737,HCPCS,0636,RC,00338-9553-50,NDC,both,50,ML,100.65,30.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13.74,,,,,,,7.73,85.55,"fee schedule",
"SOL OPHTHALMIC ADATO SIL-OL 5000 SILICONE SYR VISCOUS FLUID","SUP-ES 5000 S",CDM,C1814,HCPCS,0278,RC,,,both,,,3449.63,1034.89,"MULTIPLAN [10600]",Multiplan,,2932.19,85,,,,,0,401.19,2932.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,J7507,HCPCS,0636,RC,51079-0818-01,NDC,both,1,UN,22.43,6.73,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,0.39,,,,,,,0.2,19.07,"fee schedule",
"HC Prolact+8 Qtr Btl",PX-E27000209,CDM,E27000209,LOCAL,0270,RC,,,both,,,323.40,97.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,38.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,37.61,274.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Pta Sf Init",PX-361000721,CDM,37280,CPT,0361,RC,,,both,,,14777.16,4433.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1751.09,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1718.58,12560.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Sclp/Limb 1.1-2.5cm Cmplx",PX-450000049,CDM,13120,CPT,0450,RC,,,both,,,1861.00,558.3,"CIGNA [10200]",Cigna,,1833,,,,,,,1.86,1861,"case rate",
"HC Neisseria Gonorr Dna Dir",PX-306000141,CDM,87590,CPT,0306,RC,,,both,,,290.00,87,"BLUE CROSS [10001]","Blue Cross PPO",,34.34,,"Fee schedule rate ($34.34).",,,,0,0.01,246.5,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Myotomy Lwr Esophgl Transoral",PX-750000220,CDM,43497,CPT,0750,RC,,,both,,,6450.00,1935,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,750.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,750.14,6450,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Anlys Pain Pump W/Prog/Refi",PX-761000046,CDM,62370,CPT,0761,RC,,,both,,,1715.00,514.5,"AETNA [10100]","Aetna HMO/PPO",,1363.43,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,199.45,1715,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bk Virus Dna",PX-306000151,CDM,87799,CPT,0306,RC,,,both,,,986.10,295.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,116.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.99,838.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Lumb Spine W Cntrst",PX-612000006,CDM,72149,CPT,0612,RC,,,both,,,4838.41,1451.52,"PHCS [10601]",PHCS,,3386.89,70,,,,,0,529.95,4112.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Fx Fib Shft Prox W/Man Clsd",PX-450000390,CDM,27781,CPT,0450,RC,,,both,,,3313.76,994.13,"BLUE CROSS [10001]","Blue Cross PPO",,3313.76,,"Case rate ($3,634.70). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,67.13,3313.76,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tx Fx Fib Shft Prox W/Man Clsd",PX-450000390,CDM,27781,CPT,0450,RC,,,both,,,3313.76,994.13,"CIGNA [10200]","Cigna Local Plus",,1442,,,,,,,67.13,3313.76,"case rate",
"FIBER VENA CURE EVLT NEVERTOUCH LASER",SUP-H78711403002,CDM,C1888,HCPCS,0272,RC,,,both,,,8024.70,2407.41,"AETNA [10100]","Aetna HMO/PPO",,6379.64,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,933.27,6821,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endotracheal Tube (Ett) Exchange-Larynx Surg",PX-410000027,CDM,31599,CPT,0410,RC,,,both,,,1506.33,451.9,"CIGNA [10200]","Cigna Open Access",,309,,"Per diem ($309).",,,,0,1.51,1280.38,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pulm Rhb WO Cont Oximetry Mntr",PX-948000002,CDM,94625,CPT,0948,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,435,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 4.5MM X 12.0MM",SUP-494501212,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Complement Total (Ch50)",PX-302000033,CDM,86162,CPT,0302,RC,,,both,,,345.83,103.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,31.96,,,,,,,0.01,293.96,"fee schedule",
"6.0MM X 13MM SENSAR INTRAOCULAR LENS, BICONVEX, 15.5 DIOPTER",SUP-AR40E00155,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"FIRST HEALTH [10303]","First Health",,745.2,80,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Assembly Suct Anticoag Line",PX-E27200355,CDM,E27200355,LOCAL,0272,RC,,,both,,,82.50,24.75,"CIGNA [10200]",Cigna,,56.1,68,,,,,0,9.59,70.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH METAL HEAD + OSS LH + VE",SUP-98000500315,CDM,C1776,HCPCS,0278,RC,,,both,,,28980.00,8694,"CIGNA [10200]","Cigna Open Access",,9708.3,33.5,,5302.19,4377.88,6578.61,27,3370.37,24633,"percent of total billed charges",
"BEARING HUMERAL 40MM COMPREHENSIVE +3MM SHOULDER VIVACIT-E",SUP-110031428,CDM,C1776,HCPCS,0278,RC,,,both,,,7286.40,2185.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2085.37,28.62,,,,,0,847.41,6193.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL HIP H2D I.E. PROPRIETARY TECHNOLOGY/STRYKER - X3 W/TRI",SUP-CAP-H-2D,CDM,C1776,HCPCS,0278,RC,,,both,,,34650.00,10395,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4106.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,4029.8,29452.5,"percent of total billed charges",
"HEAD HUMERAL 16MM 43MM SHOULDER SIMPLICITI",SUP-7122870,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"MULTIPLAN [10600]",Multiplan,,8516.15,85,,,,,0,1165.21,8516.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROCKET IPC LOCKABLE DRAIN LINE WITH WIDE-BORE CONNECTOR",SUP-R54410-WB-DLH,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,124.24,68,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 9MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530-G-709,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"KAISER [10500]",Kaiser,,5834.1,67,,,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 13MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-613,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"CIGNA [10200]","Cigna Open Access",,5593.57,56.9,,5302.19,4377.88,6578.61,27,1143.29,8355.94,"percent of total billed charges",
"MESH SURGICAL OVITEX TELA BIO 20X16IN PERMANENT REINFORCE 6",SUP-F10246-1620P,CDM,C1781,HCPCS,0278,RC,,,both,,,31570.56,9471.17,"AETNA [10100]","Aetna HMO/PPO",,25098.6,79.5,,,,,0,3671.66,26834.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP CEMENTED FEMUR WITH CERAMIC HEAD XLPE LINE",SUP-71701016,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9839.34,41.1,,6417.48,6417.48,6417.48,"1 through 10",2784.22,20349,"percent of total billed charges",
"INSRT TIBIAL 9MM INFINITY 3+ ANKLE POLY",SUP-33654309,CDM,C1776,HCPCS,0278,RC,,,both,,,11143.50,3343.05,"KAISER [10500]",Kaiser,,7466.15,67,,,,,0,1295.99,9471.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 36MM 22.2MM ACTIVE ARTICULATION E1 B G7 2",SUP-010000991,CDM,C1776,HCPCS,0278,RC,,,both,,,2700.00,810,"MULTIPLAN [10600]",Multiplan,,2295,85,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +28 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-AR40E00280,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"NOVANET [10819]",Novanet,,698.63,75,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Ext Vein Bi",PX-921000011,CDM,93970,CPT,0921,RC,,,both,,,1775.67,532.7,"KAISER [10500]",Kaiser,,1189.7,67,,,,,0,206.51,1509.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 8IN 15MM MODULAR SOL SYSTEM POROUS 12/14 LARGE",SUP-157202150,CDM,C1776,HCPCS,0278,RC,,,both,,,38107.44,11432.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15242.98,40,,,,,0,4431.9,32391.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL TRIATHLON X3 2 H10 MM KNEE POSTERIOR STABILIZE",SUP-5532-G-210-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3266.29,28.62,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 64MM 36MM ALTRX HIP",SUP-122136164,CDM,C1776,HCPCS,0278,RC,,,both,,,11405.70,3421.71,"CIGNA [10200]","Cigna Open Access",,6489.84,56.9,,5302.19,4377.88,6578.61,27,1326.48,9694.85,"percent of total billed charges",
"SPACER FEMORAL CATHCART ARTICUL/EZE +5MM 12/14 TAPER HIP",SUP-136312000,CDM,C1776,HCPCS,0278,RC,,,both,,,1650.00,495,"AMERIGROUP MEDICAID [20100]",Amerigroup,,195.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 36MM +8 ECCENTRIC",SUP-550536108,CDM,C1776,HCPCS,0278,RC,,,both,,,12450.36,3735.11,"FIRST HEALTH [10303]","First Health",,9960.29,80,,,,,0,1447.98,10582.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Paste Karaya",PX-E27100019,CDM,E27100019,LOCAL,0271,RC,,,both,,,40.70,12.21,"CIGNA [10200]","Cigna Open Access",,23.16,56.9,,,,,0,4.73,34.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Paste Karaya",PX-E27100019,CDM,E27100019,LOCAL,0271,RC,,,both,,,40.70,12.21,"CIGNA [10200]",Cigna,,27.68,68,,,,,0,4.73,34.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US OB 1st Trimst Txabd Sngl",PX-402000014,CDM,76801,CPT,0402,RC,,,both,,,1106.77,332.03,"CIGNA [10200]","Cigna Open Access",,155.61,,,,,,,111.26,940.75,"fee schedule",
"LENS IOL SY60WF.255 CLAREON",SUP-SY60WF.255,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,820.69,68,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 13MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-013,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3221.23,68,,,,,0,550.92,4026.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HUMERAL 36MM COMPREHENSIVE STD SHOULDER PROLONG",SUP-110031418,CDM,C1776,HCPCS,0278,RC,,,both,,,5188.80,1556.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2381.66,45.9,,,,,0,603.46,4410.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 20X20IN RESORBABLE REINFORCE",SUP-F10254-2020G,CDM,C1781,HCPCS,0278,RC,,,both,,,20664.00,6199.2,"NOVANET [10819]",Novanet,,15498,75,,,,,0,2403.22,17564.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AR40E +10.5 D 3 PIECE LENS",SUP-AR40E00105,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,108.33,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +29.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000295,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 74MM PRESS FIT AEQUALIS ASCEND FLEX PTC 137.5D",SUP-DWF603C,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA [10200]","Cigna Local Plus",,3969,31.5,,5372.07,4581.20,7242.98,23,1465.38,10710,"percent of total billed charges",
"CMPNT FEMORAL 6 LEFT KNEE CEMENTED CRUCIATE RETAINING",SUP-5510F601,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1943.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1907.07,13938.17,"percent of total billed charges",
"INSRT TIBIAL 3 13MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530-G-313,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1031.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1012.7,7401.47,"percent of total billed charges",
"TRIAL SURGICAL 32MM LFIT C-TAPER -5MM HIP COCR HEAD",SUP-06-3299,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,370.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,363.75,2658.55,"percent of total billed charges",
"STEM HUMERAL 74MM PRESS FIT AEQUALIS ASCEND FLEX PTC 132.5D",SUP-DWF603B,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"FIRST HEALTH [10303]","First Health",,10080,80,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HIP CONSTRUCT 1",SUP-CAP-Z-H-1,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9321.48,41.1,,6417.48,6417.48,6417.48,"1 through 10",2637.68,19278,"percent of total billed charges",
"INSRT TIBIAL 2.5 15MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158122115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"KAISER [10500]",Kaiser,,7486.95,67,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 11MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-511-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1399.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL FEMORAL IDENTITY IMPRINT 4 NARROW KNEE POSTERIOR",SUP-TPS-101-F04N,CDM,C1776,HCPCS,0278,RC,,,both,,,11716.20,3514.86,"KAISER [10500]",Kaiser,,7849.85,67,,,,,0,1362.59,9958.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP 5 SCR HOLE CLUSTER TRITANIUM",SUP-702-04-56F,CDM,C1776,HCPCS,0278,RC,,,both,,,12551.10,3765.33,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5020.44,40,,,,,0,1459.69,10668.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 66MM HIP POROCOAT PINNACLE 300 SERIES",SUP-121703066,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"PHCS [10601]",PHCS,,7945.35,70,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL RESTORIS 2 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-180602,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"BLUE CROSS [10001]","Blue Cross PPO",,2597.96,39.2,,3949.44,3949.44,3949.44,"1 through 10",770.77,5633.33,"percent of total billed charges",
"INSRT TIBIAL 5 10MM KNEE LEFT MEDIAL RIGHT LATERAL X3",SUP-5630-G-510,CDM,C1776,HCPCS,0278,RC,,,both,,,5309.55,1592.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2437.08,45.9,,,,,0,617.5,4513.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 39MM 24MM +4MM LATERALIZE GLENOSPHERE ARTHREX",SUP-AR-9564-2439-LAT,CDM,C1776,HCPCS,0278,RC,,,both,,,9763.50,2929.05,"PHCS [10601]",PHCS,,6834.45,70,,,,,0,1135.5,8298.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -5MM 36MM HIP C TAPER HIGH PERFORMANCE OFFSET",SUP-18-36-5,CDM,C1776,HCPCS,0278,RC,,,both,,,7340.76,2202.23,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2100.93,28.62,,,,,0,853.73,6239.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT CONGR SZ 1/2 RH 16MM",SUP-2042-0-1216,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"NOVANET [10819]",Novanet,,2671.88,75,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 13MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G413,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"CIGNA [10200]",Cigna,,6368.93,68,,5873.17,5873.17,5873.17,"1 through 10",1089.28,7961.17,"percent of total billed charges",
"STEM FEMORAL 167MM 18MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-218,CDM,C1776,HCPCS,0278,RC,,,both,,,19885.95,5965.78,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2356.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2312.74,16903.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL UNITY KNEE 6 KNEE FIX BEARING",SUP-112.040.12,CDM,C1776,HCPCS,0278,RC,,,both,,,5865.00,1759.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,682.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12IN 24FR ARTERIAL ADULT 3/8IN CNCT VENTED",SUP-77624,CDM,C1769,HCPCS,0272,RC,,,both,,,541.37,162.41,"NOVANET [10819]",Novanet,,406.03,75,,,,,0,62.96,460.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALENDRONATE 70 MG TABLET",RX-29048,CDM,,,0637,RC,16714-0633-01,NDC,both,1,UN,77.16,23.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,31.71,41.1,,,,,0,8.97,65.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION",RX-9892,CDM,J1250,HCPCS,0636,RC,00409-2344-01,NDC,both,20,ML,53.45,16.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,15.64,,,,,,,6.7,45.43,"fee schedule",
"HC Inj Anes Trigmnl Nrv Ea Brn",PX-450000291,CDM,64400,CPT,0361,RC,,,both,,,1348.48,404.54,"AETNA [10100]","Aetna HMO/PPO",,1072.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,156.83,1348.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp B1 Marow Smr",PX-305000088,CDM,0855T,CPT,0312,RC,,,both,,,104.00,31.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.32,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.32,88.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 21.5X10.7CM ALLODERM SELECT THK2-2.8MM CONTOUR",SUP-CL1519P,CDM,Q4116,HCPCS,0636,RC,,,both,,,31380.30,9414.09,"FIRST HEALTH [10303]","First Health",,25104.24,80,,,,,0,247.92,26673.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ALLIS 9IN 5X6 TEETH",SUP-50-0223,CDM,S27200284,LOCAL,0272,RC,,,both,,,178.18,53.45,"CIGNA [10200]","Cigna Open Access",,101.38,56.9,,,,,0,20.72,151.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STIM 3 OUTPUT SETTING LOC LED NEURO PULSE NERVE LATEX RED",SUP-0003EA,CDM,S27200284,LOCAL,0272,RC,,,both,,,409.51,122.85,"AETNA [10100]","Aetna HMO/PPO",,325.56,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.63,348.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM QUADLINK 9MM IMPL DISPOSABLE",SUP-AR-1288QAI-90,CDM,C1713,HCPCS,0278,RC,,,both,,,19785.15,5935.54,"MULTIPLAN [10600]",Multiplan,,16817.38,85,,,,,0,2301.01,16817.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF CONDUCTR 110CM 7FR 2-5-2MM SPACING 55-75MM REACH",SUP-07857544,CDM,C1733,HCPCS,0272,RC,,,both,,,4554.00,1366.2,"MULTIPLAN [10600]",Multiplan,,3870.9,85,,,,,0,529.63,3870.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GS SPECTRUM QC, MILLER S00, BOX-10",SUP-0270-1139,CDM,S27200284,LOCAL,0272,RC,,,both,,,433.26,129.98,"AETNA [10100]","Aetna HMO/PPO",,344.44,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.39,368.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROTCT 2.8-8CM ALEXIS ATRAUMATIC FLEXIBLE RETRACTION RING",SUP-HR105,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"AETNA [10100]","Aetna HMO/PPO",,1550.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,226.79,1657.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY JAMSHIDI SAFE-T PLUS BONE MARROW STERILE",SUP-BCTM3411SP,CDM,S27200284,LOCAL,0272,RC,,,both,,,386.91,116.07,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,263.1,68,,,,,0,45,328.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ACCLARENT 2 BALLOON INFLATION TYVEK 30ML HIGH",SUP-SM-ID-S3040H-TB,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .047IN LEFT CORONARY",SUP-534572T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS 115CM 5MM 7FR 2-5-2MM SPACE G CURVE ABLATION 10",SUP-D7BTG5L,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,576.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BENZTROPINE 1 MG TABLET",RX-999,CDM,,,0637,RC,68084-0388-11,NDC,both,1,UN,6.27,1.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 12MM 144CM 2.25MM",SUP-H7493941212220,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"NOVANET [10819]",Novanet,,5821.88,75,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 6X6CM TUTOPLAST THK.3-.5MM PERICARDIUM",SUP-938266,CDM,C1762,HCPCS,0278,RC,,,both,,,16263.30,4878.99,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6684.22,41.1,,,,,0,1891.42,13823.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT TACK 8MM 135 CM 6FR VASCULAR NITINOL RADIOPAQUE OTW 6",SUP-154150042,CDM,C1876,HCPCS,0278,RC,,,both,,,18238.50,5471.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4924.4,27,,,,,0,2121.14,15502.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Group (Gp)",PX-423000001,CDM,97150,CPT,0423,RC,,,both,,,172.00,51.6,"FIRST HEALTH [10303]","First Health",,137.6,80,,,,,0,20,172,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 6X250 80CM SL",SUP-48006025N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"FIRST HEALTH [10303]","First Health",,832.81,80,,,,,0,121.07,884.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL 71CM 21GA 18GA PROC CURVE STERILE BROCKENBROUGH ADULT",SUP-04122JM,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 4FR .042IN AMPLATZ LEFT 1",SUP-538445,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"FIRST HEALTH [10303]","First Health",,71.62,80,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 36CM FEMUR LEFT PROXIMAL TALON DISTALFIX",SUP-SLN-125-36L,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"MULTIPLAN [10600]",Multiplan,,13706.51,85,,,,,0,1875.37,13706.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 7X2CM SUSPEND TUTOPLAST FASCIA LATA",SUP-937227,CDM,C1762,HCPCS,0278,RC,,,both,,,6934.50,2080.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,821.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,806.48,5894.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIMETHICONE 80 MG CHEWABLE TABLET",RX-7227,CDM,,,0637,RC,77333-0812-25,NDC,both,1,UN,6.27,1.88,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,0.73,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIMETHICONE 80 MG CHEWABLE TABLET",RX-7227,CDM,,,0637,RC,77333-0812-25,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Pacing Temp Extrnl",PX-450000308,CDM,92953,CPT,0361,RC,,,both,,,2428.00,728.4,"MULTIPLAN [10600]",Multiplan,,2063.8,85,,,,,0,282.38,2385,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LONG STD ACU-LOC 2 BONE LEFT DISTAL VOLAR RADIAL",SUP-70-0368,CDM,C1713,HCPCS,0278,RC,,,both,,,6654.91,1996.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,788.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",773.97,5656.67,"percent of total billed charges",
"CATH MARINER 65CM 5FR COBRA 2 CURVE ANGIOGRAPHIC DURATION",SUP-11719708,CDM,C1887,HCPCS,0272,RC,,,both,,,418.82,125.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,49.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,48.71,356,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM TWINFIX ULTRA COBRAID TITANIUM STERILE BLUE",SUP-72202893,CDM,C1713,HCPCS,0278,RC,,,both,,,2370.60,711.18,"KAISER [10500]",Kaiser,,1588.3,67,,,,,0,275.7,2015.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 22CM 6FR URETERAL",SUP-M0061456120,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,72.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 STD 10MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS8S10R,CDM,C1776,HCPCS,0278,RC,,,both,,,7569.30,2270.79,"AETNA [10100]","Aetna HMO/PPO",,6017.59,79.5,,10981.53,8986.79,12413.38,12,880.31,6433.91,"percent of total billed charges",
"GWIRE HI-TORQUE BALANCE HEAVYWEIGHT VASCULAR STRAIGHT RIBBON",SUP-1000463H,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT HUMERAL REUNION X3 H4 MM OD36 MM SHOULDER STERILE LAT",SUP-5571-S-3604-E,CDM,C1776,HCPCS,0278,RC,,,both,,,8119.92,2435.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3727.04,45.9,,,,,0,944.35,6901.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 4.5CM 36MM 30-32MM EXCLUDER GORE-TEX",SUP-PLA360400,CDM,S27800098,LOCAL,0278,RC,,,both,,,19725.30,5917.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,5645.38,28.62,,,,,0,2294.05,16766.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC 12IN 30- IN KNEE 3 PANEL TERRYCLOTH",SUP-VP40106-005,CDM,L1830,HCPCS,0274,RC,,,both,,,152.42,45.73,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,69.96,45.9,,,,,0,17.73,129.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS FIRSTCHOICE 20 MEQ POTASSIUM CHLORIDE 0.9%",SUP-711509,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.42,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Albumin",PX-301000088,CDM,82040,CPT,0301,RC,,,both,,,119.70,35.91,"CIGNA [10200]","Cigna Open Access",,10.89,,,,,,,0.12,101.75,"fee schedule",
"HC Ekg Holter Scan/Report",PX-731000002,CDM,93226,CPT,0731,RC,,,both,,,986.00,295.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,116.84,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.67,838.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Breast Local Dev Mammo",PX-361000312,CDM,19281,CPT,0361,RC,,,both,,,1681.32,504.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1681.32,,"Case rate ($1,729.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,195.54,1681.32,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 300MM 5MM 2.9MM CANNULATED LARGE QUICK COUPLING",SUP-310.63S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2534.40,760.32,"CIGNA [10200]","Cigna Open Access",,1442.07,56.9,,,,,0,294.75,2154.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO BLUE RHINO G2 PERCUTANEOUS MULTI",SUP-G57682,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION SUPERORDERABLE",RX-408849,CDM,J2003,HCPCS,0636,RC,00143-9595-01,NDC,both,5,ML,18.92,5.68,"UHC [10700]","United Healthcare",,5,,,,,,,0.58,16.08,"fee schedule",
"ADPR LD 5MM UNPLR IS-1",SUP-343610,CDM,C1883,HCPCS,0278,RC,,,both,,,1882.50,564.75,"MULTIPLAN [10600]",Multiplan,,1600.13,85,,,,,0,218.93,1600.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL 15CM 17GA ABLATION",SUP-LN15,CDM,C2618,HCPCS,0272,RC,,,both,,,14524.50,4357.35,"MULTIPLAN [10600]",Multiplan,,12345.83,85,,,,,0,1689.2,12345.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION 0-30 MCI",RX-187201,CDM,A9560,HCPCS,0343,RC,08888-8878-31,NDC,both,1,UN,882.80,264.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,104.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,102.67,750.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cementoplasty Femur or Knee",PX-361000667,CDM,27599,CPT,0361,RC,,,both,,,668.00,200.4,"PHCS [10601]",PHCS,,467.6,70,,,,,0,0.67,668,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 6FR AR1 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916599842,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 45MM STAINLESS STEEL INSTR SURGIDAC SUT",SUP-020730,CDM,S27200284,LOCAL,0272,RC,,,both,,,544.40,163.32,"MULTIPLAN [10600]",Multiplan,,462.74,85,,,,,0,63.31,462.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 80MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520080M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAPPHIRE NC PLUS 12MM 4MM BALLOON DILATATION STERILE",SUP-240-123-2U,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SAFESHEATH INTRDCR FR9 LONG - EACH",SUP-668002-001,CDM,C1892,HCPCS,0272,RC,,,both,,,1174.50,352.35,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BURR SURGICAL 38MM 6.5MM CUT",SUP-E8165LSO,CDM,S27200284,LOCAL,0272,RC,,,both,,,453.28,135.98,"NOVANET [10819]",Novanet,,339.96,75,,,,,0,52.72,385.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETERIZATION 12FR 18GA 6IN .035IN MULTILUMEN LARGE",SUP-CDC-22123-1A,CDM,C1751,HCPCS,0272,RC,,,both,,,1106.46,331.94,"UHC [10700]","United Healthcare",,700.39,63.3,,,,,0,128.68,940.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 31MM MASTERS ROTATABLE HEMASHIELD TECHNOLOGY",SUP-23AECJ-502,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8333.92,28.62,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS RMT REDEL 125CM 4MM 7FR 2-5-2MM SPACE ABLATION",SUP-CR7TCSIRT,CDM,C2630,HCPCS,0272,RC,,,both,,,15014.40,4504.32,"KAISER [10500]",Kaiser,,10059.65,67,,,,,0,1746.17,12762.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 4MM RETRACTA 5.6 LOOP DETACHABLE",SUP-G34187,CDM,S27800098,LOCAL,0278,RC,,,both,,,4308.98,1292.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1233.23,28.62,,,,,0,501.13,3662.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 9MM CATALYFT PL SHORT",SUP-6068093,CDM,S27800098,LOCAL,0278,RC,,,both,,,39060.00,11718,"NOVANET [10819]",Novanet,,29295,75,,,,,0,4542.68,33201,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 15MM TRIATHLON 5 KNEE LEFT TOTAL STABILIZE",SUP-5542-A-501,CDM,C1776,HCPCS,0278,RC,,,both,,,7027.65,2108.29,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4778.8,68,,,,,0,817.32,5973.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 1 CT 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8435H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA MEDIAL CONGRUENT 6-7 C-D KNEE",SUP-42512100413,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"BLUE CROSS [10001]","Blue Cross PPO",,4224.36,39.2,,3949.44,3949.44,3949.44,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"STEM FEMORAL 11MM PRESS FIT ECHO PF TITANIUM STD OFFSET HIP",SUP-12-150311,CDM,C1776,HCPCS,0278,RC,,,both,,,8336.51,2500.95,"CIGNA [10200]","Cigna Local Plus",,4460.03,53.5,,5372.07,4581.20,7242.98,23,969.54,7086.03,"percent of total billed charges",
"INSRT TIBIAL 9 6MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620906,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1308.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PSN TIB NP 0 DEG KEL D LT",SUP-42-5360-067-01,CDM,C1776,HCPCS,0278,RC,,,both,,,10619.10,3185.73,"CIGNA [10200]","Cigna Local Plus",,5681.22,53.5,,5372.07,4581.20,7242.98,23,1235,9026.24,"percent of total billed charges",
"BEARING 16MM OSS UHMWPE KNEE TIBIAL STD STERILE",SUP-150412,CDM,C1776,HCPCS,0278,RC,,,both,,,8317.26,2495.18,"KAISER [10500]",Kaiser,,5572.56,67,,,,,0,967.3,7069.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR DYNASTY A-CLASS STD 28MM POLY BIOFOAM HIP",SUP-DLXPGB28,CDM,C1776,HCPCS,0278,RC,,,both,,,7507.20,2252.16,"CIGNA [10200]","Cigna Local Plus",,4016.35,53.5,,5372.07,4581.20,7242.98,23,873.09,6381.12,"percent of total billed charges",
"HEAD FEMORAL +3MM 11/13 STD TAPER 32MM HIP MODULAR ULTAMET",SUP-875955,CDM,C1776,HCPCS,0278,RC,,,both,,,2882.88,864.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,825.08,28.62,,,,,0,335.28,2450.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 6 KNEE 4 CRUCIFORM PEG KEEL",SUP-5536-B-600,CDM,C1776,HCPCS,0278,RC,,,both,,,10139.04,3041.71,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1201.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1179.17,8618.18,"percent of total billed charges",
"HEAD FEMORAL +3MM 11/13 STD TAPER 32MM HIP MODULAR ULTAMET",SUP-875955,CDM,C1776,HCPCS,0278,RC,,,both,,,2882.88,864.86,"BLUE CROSS [10001]","Blue Cross HMO",,1130.09,39.2,,5311.50,4717.44,5388.59,31,335.28,2450.45,"percent of total billed charges",
"STEM FEMORAL 153MM CEMENT AVENIR PROTASUL-S30 5 40.91MM STD",SUP-01.06010.205,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"AETNA [10100]","Aetna HMO/PPO",,13773.38,79.5,,10981.53,8986.79,12413.38,12,2014.9,14726.25,"percent of total billed charges",
"KIT DRNG 25CM 8FR .018IN FLEXITHANE HYDROPHILIC LOCK LOOP",SUP-H749393110825K1,CDM,C1729,HCPCS,0272,RC,,,both,,,1474.20,442.26,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET INTRO 65CM 5.5FR PEEL-AWAY MICROPUNCTURE ECHOTIP",SUP-G11567,CDM,C1892,HCPCS,0272,RC,,,both,,,629.53,188.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM MULTI-LINK MINI VISION 28MM 2.5MM CORONARY STENT COCR",SUP-1007823-28,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,348.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 FLEXOR 140MM 125CM 8MM 6FR BILIARY",SUP-G50173,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"MULTIPLAN [10600]",Multiplan,,5176.5,85,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 60MM 75CM 16MM 9FR 100CM",SUP-40332,CDM,C1876,HCPCS,0278,RC,,,both,,,6727.50,2018.25,"NOVANET [10819]",Novanet,,5045.63,75,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 18MM 2.25MM CORONARY STENT",SUP-1007822-18,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 48MM PERIPHERAL",SUP-5572-4548,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.70,466.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,184.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",180.93,1322.35,"percent of total billed charges",
"STENT CONTOUR SENSOR DUAL-FLEX 24CM 7FR .038IN PIGTAIL CURVE",SUP-M006180232120,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"CIGNA [10200]","Cigna Local Plus",,711.69,,,,,,,154.71,1130.72,"percent of total billed charges",
"1ST MCP FUSION PLATE, RIGHT",SUP-PL-MCPR,CDM,C1713,HCPCS,0278,RC,,,both,,,5444.10,1633.23,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2498.84,45.9,,,,,0,633.15,4627.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 35MM INDEPENDENCE SPINE SELF DRILL VARIABLE",SUP-176.735,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"MULTIPLAN [10600]",Multiplan,,2499,85,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 65MM LOCK STERILE",SUP-2361-5065S,CDM,C1713,HCPCS,0278,RC,,,both,,,1687.05,506.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,196.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",196.2,1433.99,"percent of total billed charges",
"LENS 17.0 DIOPTER",SUP-MTA3UO170,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 67MM 135CM 7MM 160CM",SUP-M001712150,CDM,C1876,HCPCS,0278,RC,,,both,,,13323.90,3997.17,"KAISER [10500]",Kaiser,,8927.01,67,,,,,0,1549.57,11325.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 40MM 80CM 8MM 6FR .035IN BILIARY NITINOL",SUP-EX080401CD,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1390.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX 20MM 135CM 6MM VASCULAR NITINOL CAROTID",SUP-PC0620RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"BLUE CROSS [10001]","Blue Cross PPO",,2975.28,39.2,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 90MM 230CM 22MM 10FR",SUP-M00565590,CDM,C1876,HCPCS,0278,RC,,,both,,,12152.97,3645.89,"UHC [10700]","United Healthcare",,7692.83,63.3,,,,,0,1413.39,10330.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PRECISE PRO RX 20MM 135CM 6MM VASCULAR NITINOL CAROTID",SUP-PC0620RXC,CDM,C1876,HCPCS,0278,RC,,,both,,,7590.00,2277,"FIRST HEALTH [10303]","First Health",,6072,80,,,,,0,882.72,6451.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT R2P MISAGO 60MM 200CM 6MM 6FR VASCULAR PERIPHERAL",SUP-SXR06060R,CDM,C1876,HCPCS,0278,RC,,,both,,,6099.60,1829.88,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,722.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,709.38,5184.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENROUTE TRANSCAROTID STENT SYSTEM 10 X 30",SUP-SR-1030-CS,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION",RX-11023,CDM,J3430,HCPCS,0636,RC,00409-9158-31,NDC,both,1,ML,369.61,110.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,251.33,68,,,,,0,31.82,314.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 57MM 135CM 10MM 60MM",SUP-H74938047160130,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"KAISER [10500]",Kaiser,,2773.8,67,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX SAFE PERFORMAXX 40MM 80CM 7MM 6FR .035IN",SUP-ZBM07040,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"BLUE CROSS [10001]","Blue Cross PPO",,3921.96,39.2,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 12MM",SUP-200-24-012,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"CIGNA [10200]",Cigna,,771.12,68,,1831.33,1831.33,1831.33,16,131.88,963.9,"percent of total billed charges",
"SCR BONE 3.5MM 44MM GORILLA R3CON LOCK",SUP-P50-353-3544,CDM,C1713,HCPCS,0278,RC,,,both,,,1470.15,441.04,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,674.8,45.9,,,,,0,170.98,1249.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X12X8MM COHERE 7D LORDOSIS CERVICAL INTERBODY",SUP-1000-00-0814,CDM,C1889,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]",Cigna,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADMIRAL XTREME 130CM 80MM 4MM BALLOON DILATATION",SUP-ADM040080130,CDM,C1725,HCPCS,0272,RC,,,both,,,1134.00,340.2,"NOVANET [10819]",Novanet,,850.5,75,,,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 37X27X14MM SOVEREIGN 12D",SUP-7968214,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"NOVANET [10819]",Novanet,,25706.7,75,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 96L/4D PLA 30MM 8MM FEMUR ACL",SUP-238025M5,CDM,C1713,HCPCS,0278,RC,,,both,,,2563.58,769.07,"CIGNA [10200]","Cigna Open Access",,1458.68,56.9,,1144.80,304.56,2275.09,66,298.14,2179.04,"percent of total billed charges",
"FILLER BONE VOID 20CC 50CC CALCIUM SULFATE STIMULAN RAPID",SUP-620-020,CDM,C1713,HCPCS,0278,RC,,,both,,,10080.00,3024,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4626.72,45.9,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 20X16IN RESORBABLE GRID 2",SUP-F10258-1620G,CDM,C1781,HCPCS,0278,RC,,,both,,,41126.40,12337.92,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,11770.38,28.62,,,,,0,4783,34957.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 74MM HIP MULTIHOLE RIM TRITANIUM X3 MDM",SUP-509-02-74J,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"HC Tiss Cult Lymphocyte",PX-311000025,CDM,88230,CPT,0311,RC,,,both,,,1281.00,384.3,"UHC [10700]","United Healthcare",,104.84,,,,,,,0.01,1088.85,"fee schedule",
"STENT ABSOLUTE PRO 30MM 80CM 10MM VASCULAR PERIPHERAL SELF",SUP-1012532-30,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,481.48,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE TIGHTROPE FIBERTAG FIXATION",SUP-AR-1588RTT2-IB,CDM,C1713,HCPCS,0278,RC,,,both,,,5252.63,1575.79,"AMERIGROUP MEDICAID [20100]",Amerigroup,,622.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",610.88,4464.74,"percent of total billed charges",
"INTRO SHEATH 4.5FR 11CM RED HUB TUBING ROTATING SUT RING",SUP-PSI-4F-11ACT,CDM,C1894,HCPCS,0272,RC,,,both,,,80.04,24.01,"PHCS [10601]",PHCS,,56.03,70,,,,,0,9.31,68.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.5CM NATRELLE INSPIRA P4.5CM MODERATE PROFILE",SUP-MSZ-M445,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 12MM PERSONA 10-11 E-F KNEE RIGHT TIBIA",SUP-42522400812,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1277.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1253.3,9159.96,"percent of total billed charges",
"HC Legion Pneumophilia Ag If",PX-306000097,CDM,87278,CPT,0306,RC,,,both,,,215.00,64.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14.04,,,,,,,0.01,182.75,"fee schedule",
"SHEATH PINNACLE 25CM 2.5CM 7FR INTRO STAINLESS STEEL",SUP-RSS705,CDM,C1894,HCPCS,0272,RC,,,both,,,178.35,53.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,21.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.74,151.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +23 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MA60AC.230,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 25MM TITANIUM 1 LEVEL PRELORDOSED BEND GROOVE VECTRA",SUP-04.613.016,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,521.61,3812.25,"percent of total billed charges",
"SCR BONE 5MM 34MM STAINLESS STEEL T25 SELF TAP LOCK VARIABLE",SUP-02.231.234,CDM,C1713,HCPCS,0278,RC,,,both,,,1307.83,392.35,"CIGNA [10200]",Cigna,,889.32,68,,1831.33,1831.33,1831.33,16,152.1,1111.66,"percent of total billed charges",
"SCR BONE 6.5MM 15MM REFLECTION R3 CONTOUR HIP ACETABULAR",SUP-71332515,CDM,C1713,HCPCS,0278,RC,,,both,,,1287.90,386.37,"BLUE CROSS [10001]","Blue Cross PPO",,504.86,39.2,,957.42,570.23,957.42,28,149.78,1094.72,"percent of total billed charges",
"LENS IOL +21 DIOPTER +1.5 CYL MODIFIED C BICONVEX 13MM 6MM",SUP-ZCT150210,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Local Plus",,184.58,53.5,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 8MM ITOTAL IPOLY XE POSTERIOR STABILIZE INSRT",SUP-RPS0200800,CDM,C1776,HCPCS,0278,RC,,,both,,,6254.85,1876.45,"KAISER [10500]",Kaiser,,4190.75,67,,,,,0,727.44,5316.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 20MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-39206-08027,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,75.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER UMBILICAL VENOUS SINGLE LUMEN PEDIATRIC 3.5FR 15IN",SUP-8888160424,CDM,S27200284,LOCAL,0272,RC,,,both,,,475.71,142.71,"UHC [10700]","United Healthcare",,301.12,63.3,,,,,0,55.33,404.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM PRIMARY ANTHOLOGY HA POROUS PLUS 131D 11",SUP-71357111,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"UHC [10700]","United Healthcare",,20978.35,63.3,,8601.07,8395.67,8601.07,"1 through 10",3854.32,28169.98,"percent of total billed charges",
"CATH 65CM 15CM 5FR .035IN DRUG DELIVERY 2 CHECK VALVE 30",SUP-G06420,CDM,C1751,HCPCS,0272,RC,,,both,,,1020.52,306.16,"AETNA [10100]","Aetna HMO/PPO",,811.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.69,867.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 3CM 7FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175274050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"CIGNA [10200]","Cigna Open Access",,609.25,,,,,,,124.53,910.13,"percent of total billed charges",
"KIT CATH 20GA 8CM POWERGLIDE PRO REINFORCE TIP BASIC STERILE",SUP-F120080T,CDM,C1751,HCPCS,0272,RC,,,both,,,558.98,167.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,380.11,68,,,,,0,65.01,475.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER SLIMLINE 1000UM 1 INCISION SLING",SUP-M0068409260,CDM,S27200284,LOCAL,0272,RC,,,both,,,6863.64,2059.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,813.34,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,798.24,5834.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +16.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM POST",SUP-ZA90030165,CDM,V2632,HCPCS,0276,RC,,,both,,,1174.50,352.35,"CIGNA [10200]","Cigna Local Plus",,628.36,53.5,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE TRUE-LOCK PLUG",SUP-9471S,CDM,C1813,HCPCS,0278,RC,,,both,,,1150.20,345.06,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,329.19,28.62,,,,,0,133.77,977.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ANCHOR DRIVE WITH TORQUE LIMITER",SUP-25100AD,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PLATFORM ACCESS 10MM 12MM GELPOINT MINI ADVANCED GELSEAL CAP",SUP-CNGL3,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SELUTION SLR PTCA DEB 4.5X20MM",SUP-SCA14U-450020D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) VITALYST INTRODUCER SET",SUP-H749396790010,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH AMULET 75CM 14FR CATH STEERABLE DELIVERY STERILE",SUP-STRBL-14F-075,CDM,S27200284,LOCAL,0272,RC,,,both,,,6900.00,2070,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 5.5MM 40MM CD HORIZON SOLERA TITANIUM COCR SPINE",SUP-55890005540,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"SURFACE ARTICULAR 10MM PERSONA MEDIAL CONGRUENT 12 J KNEE",SUP-42-5121-011-10,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"KAISER [10500]",Kaiser,,7220.2,67,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE VITRECTOMY 20GA ULTRAVIT CONSTELLATION ANTERIOR CURVED",SUP-8065751020,CDM,S27200284,LOCAL,0272,RC,,,both,,,1716.68,515,"AETNA [10100]","Aetna HMO/PPO",,1364.76,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,199.65,1459.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 1.5 KNEE LEFT CRUCIATE RETAIN SIGMA STERILE",SUP-940017,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"NOVANET [10819]",Novanet,,19417.39,75,,,,,0,3010.99,22006.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC 12IN 30- IN KNEE 3 PANEL TERRYCLOTH",SUP-VP40106-005,CDM,L1830,HCPCS,0274,RC,,,both,,,152.42,45.73,"BLUE CROSS [10001]","Blue Cross PPO",,59.75,39.2,,,,,0,17.73,129.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Everolimus Assay",PX-301000457,CDM,80169,CPT,0301,RC,,,both,,,394.25,118.27,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,48.77,,,,,,,0.01,335.11,"fee schedule",
"HC Everolimus Assay",PX-301000457,CDM,80169,CPT,0301,RC,,,both,,,394.25,118.27,"CIGNA [10200]","Cigna Open Access",,30.21,,,,,,,0.01,335.11,"fee schedule",
"SEALING ADAPTOR - EXTENDED WINGS",SUP-SSSA-EW-09,CDM,C1892,HCPCS,0272,RC,,,both,,,445.50,133.65,"UHC [10700]","United Healthcare",,282,63.3,,,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 9FR .118IN 25CM ROBUST VALVE SPLITTABLE WITHOUT",SUP-PLSX-2509,CDM,C1892,HCPCS,0272,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 40MM 75CM 8MM 8FR .035IN BILIARY METAL",SUP-M00574620,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross HMO",,6791.4,39.2,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLFLEX 12CM 22MM DUODENAL NITINOL SOFT ANCHOR LOCK",SUP-M00555880,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 40MM 75CM 14MM 100CM",SUP-40311,CDM,C1876,HCPCS,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1777.3,28.62,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 60MM 80CM 5MM 6FR .035IN BILIARY NITINOL",SUP-G32009,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]",Cigna,,2570.4,68,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK ULTRA 13MM 4.5MM CORONARY STENT XCELON",SUP-1003381-13,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"KAISER [10500]",Kaiser,,2010,67,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TACK ORTHOPEDIC CLAW II 3DSI FOOT ANKLE PLATE POLYAXIAL",SUP-40250010,CDM,C1713,HCPCS,0278,RC,,,both,,,696.60,208.98,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,319.74,45.9,,,,,0,81.01,592.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 120MM 130CM 7MM 6FR .035IN VASCULAR NITINOL",SUP-EX071203CS,CDM,C1876,HCPCS,0278,RC,,,both,,,15180.00,4554,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1798.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VENOVO 160MM 16MM 3MM VASCULAR VENOUS ILIOFEMORAL VEIN",SUP-VENUM16160,CDM,C1876,HCPCS,0278,RC,,,both,,,23310.00,6993,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6671.32,28.62,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PALMAZ GENESIS AVIATOR FLEXSEGMENT 15MM 135CM 6MM 20MM",SUP-H739PG1860BAX3,CDM,C1876,HCPCS,0278,RC,,,both,,,6554.03,1966.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1875.76,28.62,,,,,0,762.23,5570.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Paravrt Jt C/T 1 Lvl Bi",PX-510000133,CDM,64490,CPT,0761,RC,,,both,,,6156.44,1846.93,"BLUE CROSS [10001]","Blue Cross PPO",,2740.57,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,715.99,5232.97,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X14X8MM ENDOSKELETON TC 6D MEDIUM LORDOTIC",SUP-5166-1408,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"FIRST HEALTH [10303]","First Health",,5342.74,80,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Est Eval Visit Level 2",PX-510000177,CDM,99212,CPT,0761,RC,,,both,,,323.05,96.91,"CIGNA [10200]","Cigna Local Plus",,323.05,,"Per diem ($2,051).",,,,0,0.32,323.05,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTR STONE 115CM 1.7FR 11MM NGAGE KIDNEY URETER NITINOL",SUP-G48295,CDM,S27200284,LOCAL,0272,RC,,,both,,,2063.25,618.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,244.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.96,1753.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM FREESTYLE SUBCORONARY PORCINE",SUP-995CS23,CDM,S27800098,LOCAL,0278,RC,,,both,,,38430.00,11529,"PHCS [10601]",PHCS,,26901,70,,,,,0,4469.41,32665.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EFS SIEGEL TAVR TRANSCATHETER AORTIC VALVE - 23MM","SUP-30-1-0123 -EFS",CDM,S62400003,LOCAL,0624,RC,,,both,,,182400.00,54720,"CIGNA [10200]","Cigna Local Plus",,97584,53.5,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 30MM MESENTERY THIN TISSUE ARTICULATE CURVE TIP",SUP-SIG30CTAV,CDM,S27200284,LOCAL,0272,RC,,,both,,,1461.81,438.54,"UHC [10700]","United Healthcare",,925.33,63.3,,,,,0,170.01,1242.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC C-Reactive Protein",PX-302000014,CDM,86140,CPT,0302,RC,,,both,,,292.60,87.78,"FIRST HEALTH [10303]","First Health",,234.08,80,,,,,0,0.29,248.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 67MM STAINLESS STEEL 3.5MM SCREWS 3X5 HOLES T RIGHT",SUP-241.15,CDM,C1713,HCPCS,0278,RC,,,both,,,2627.25,788.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,311.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",305.55,2233.16,"percent of total billed charges",
"ROD SPINAL L40MM OD5MM COCR LORDOTIC RELINE-O",SUP-14450040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"NOVANET [10819]",Novanet,,911.25,75,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 24CM 3CM 8FR .035IN BLADDER LOOP STRAIGHT LOW",SUP-M006155252050,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,145.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX 30MM 120CM 8MM VASCULAR PERIPHERAL SELF",SUP-PRB35-08-030-120,CDM,C1876,HCPCS,0278,RC,,,both,,,4347.00,1304.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,515.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,505.56,3694.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLEXCATH CROSS TRANSSEPTAL SOLUTION ? FCC 65CM, 10F",SUP-900310,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 8MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650908,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1555.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1526.7,11158.16,"percent of total billed charges",
"HEAD FEMORAL -3MM 12/14 TAPER 32MM HIP OXINIUM ECHELON",SUP-71343203,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6214.14,40,,,,,0,1806.76,13205.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE EXTRA SPORT VASCULAR STRAIGHT 175CM 3CM .014",SUP-22225M-175,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SHAVER 13CM 3.6MM RAD55 CURVE 30K",SUP-1883655BRC,CDM,S27200284,LOCAL,0272,RC,,,both,,,3898.50,1169.55,"MULTIPLAN [10600]",Multiplan,,3313.73,85,,,,,0,453.4,3313.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 3.5MM TRAUMAONE LORENZ TITANIUM MIDFACE SELF",SUP-916103,CDM,C1713,HCPCS,0278,RC,,,both,,,391.50,117.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",45.53,332.78,"percent of total billed charges",
"INSRT TIBIAL 3 22MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-322,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1143.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK ULTRA 13MM 4.5MM CORONARY STENT XCELON",SUP-1003381-13,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,858.6,28.62,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 4MM AZUR HYDROCOIL DETACHABLE .018IN",SUP-45-480420,CDM,S27800098,LOCAL,0278,RC,,,both,,,1504.17,451.25,"CIGNA [10200]","Cigna Open Access",,855.87,56.9,,,,,0,174.93,1278.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 40MMX10MM CLYDESDALE 6D PEEK-OPTIMA RADIOPAQUE",SUP-2968040,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +27.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-ZMA00U0275,CDM,V2632,HCPCS,0276,RC,,,both,,,6175.50,1852.65,"KAISER [10500]",Kaiser,,4137.59,67,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN CPAP 12FR NEONATAL INFANT COMPLETE SET T ADPTR STAY",SUP-44-2712,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.21,63.06,"AMERIGROUP MEDICAID [20100]",Amerigroup,,24.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.45,178.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION",RX-108061,CDM,J3262,HCPCS,0636,RC,50242-0135-01,NDC,both,4,ML,3206.08,961.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1206.12,,,,,,,379.92,2725.17,"fee schedule",
"CATH SAVVY 150CM 10CM 3.5-3FR 2MM BALLOON DILATATION DURALYN",SUP-435200X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 6MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0615CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,776.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 12D 16D BAND STD 24FR PLASMABAND",SUP-WA22721S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3215.54,964.66,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1321.59,41.1,,,,,0,373.97,2733.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 750CC SMOOTH SHELL SURFACE NATRELLE INSPIRA",SUP-SRX-750,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1135.93,28.62,,,,,0,461.59,3373.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 18GA 8CM POWERGLIDE PRO GUARDIVA REINFORCE TIP",SUP-F118088PT,CDM,C1751,HCPCS,0272,RC,,,both,,,909.39,272.82,"PHCS [10601]",PHCS,,636.57,70,,,,,0,105.76,772.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 38MM 140CM .91-1.12MM 3.5MM CORONARY",SUP-RONYX35038W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"BLUE CROSS [10001]","Blue Cross HMO",,2132.09,39.2,,9776.84,9776.84,9776.84,"1 through 10",632.56,4623.15,"percent of total billed charges",
"BISACODYL 5 MG TABLET,DELAYED RELEASE",RX-1079,CDM,,,0637,RC,00904-6407-61,NDC,both,1,UN,6.27,1.88,"PHCS [10601]",PHCS,,4.39,70,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE COMPRESSION MEDIUM KNEE LENGTH KENDALL SCD EXPRESS",SUP-9529,CDM,S27000186,LOCAL,0270,RC,,,both,,,100.00,30,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68,68,,,,,0,11.63,85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,inpatient,,,99303.02,29790.91,"AMBETTER EXCHANGE  [11102]",Ambetter,,8707.87,,"Case rate ($8,707.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,085.84, add-ons for qualifying new technology services are included. If operating cost exceeds $41,125.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,993.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,096.53. The transfer operating threshold is the transfer adjustment factor * $8,085.84 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.33. The transfer capital threshold is the transfer adjustment factor * $611.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,8707.87,35009.37,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"BLOCK AUGMENTATION NEXGEN 6 HALF 5MM KNEE TIBIA PRECOAT",SUP-598800626,CDM,C1776,HCPCS,0278,RC,,,both,,,7158.06,2147.42,"PHCS [10601]",PHCS,,5010.64,70,,,,,0,832.48,6084.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 15CM 37MM TAG THORACIC ACTIVE CONTROL",SUP-TGMR373715,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,46388.88,40,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM 14FR DELIVERY LOAD",SUP-L-ENVPRO-14-US,CDM,S27800098,LOCAL,0278,RC,,,both,,,2925.00,877.5,"NOVANET [10819]",Novanet,,2193.75,75,,,,,0,340.18,2486.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC",229,MS-DRG,,,,,,,inpatient,,,185247.33,55574.2,"CARESOURCE MEDICARE ADVANTAGE [30186]","Caresource Medicare Advantage",,20904.1,,"Case rate ($19,536.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $18,141, add-ons for qualifying new technology services are included. If operating cost exceeds $51,180.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,753.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $18,164.99. The transfer operating threshold is the transfer adjustment factor * $18,141.00 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,371.55. The transfer capital threshold is the transfer adjustment factor * $1,371.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,19536.54,91952.8,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY XD MONORAIL 32MM 144CM 4MM CORONARY STENT",SUP-H7493941832400,CDM,C1874,HCPCS,0278,RC,,,both,,,3000.00,900,"NOVANET [10819]",Novanet,,2250,75,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 4-0 SH-1 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCP771D,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCUIT HUMD HVT PATIENT 2.0 NONSTERILE LATEX FREE",SUP-HVT-DPC,CDM,S27000186,LOCAL,0270,RC,,,both,,,1033.56,310.07,"CIGNA [10200]",Cigna,,702.82,68,,,,,0,120.2,878.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Barbiturate Confirmation",PX-301000508,CDM,80345,CPT,0301,RC,,,both,,,176.00,52.8,"MULTIPLAN [10600]",Multiplan,,149.6,85,,,,,0,0.01,176,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 1.5CM 2MM GALAXY G3 XTRASOFT NEUROVASCULAR",SUP-GLX120201,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3208.09,27,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAFESHEATH II SSL11",SUP-398359,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"MULTIPLAN [10600]",Multiplan,,447.53,85,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL SIZE 7 HIGH OFFSET CEMENTLESS HA TITANIUM ALLOY",SUP-611202070,CDM,C1776,HCPCS,0278,RC,,,both,,,28967.40,8690.22,"NOVANET [10819]",Novanet,,21725.55,75,,,,,0,3368.91,24622.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLF TORIC AUTONOME",SUP-CNA0T6,CDM,V2787,HCPCS,0276,RC,,,both,,,370.00,111,"BLUE CROSS [10001]","Blue Cross HMO",,145.04,39.2,,,,,0,43.03,314.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 16CM 12FR MAHURKAR 3 LUMEN CURVE EXT HIGH PRESSURE",SUP-8888101002HP,CDM,C1752,HCPCS,0272,RC,,,both,,,995.43,298.63,"CIGNA [10200]","Cigna Open Access",,566.4,56.9,,,,,0,115.77,846.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ENDOSCOPIC 2 ACTION SERRATE JAW WIDE SPREAD MONOPOLAR",SUP-600126,CDM,S27100035,LOCAL,0271,RC,,,both,,,3457.50,1037.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,402.11,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,402.11,2938.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 26X10X10-17MM RISE 15D",SUP-193.142,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8113.77,28.62,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 70MMX12.5MM STAINLESS STEEL RECIPROCATING 2 SIDED",SUP-0277096277,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.41,87.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,34.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,33.77,246.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 50CM",SUP-LEAD3005-50B,CDM,C1778,HCPCS,0278,RC,,,both,,,8970.00,2691,"BLUE CROSS [10001]","Blue Cross PPO",,3516.24,39.2,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STARTER VASCULAR 3MM RADIUS J CURVE TAPER 260CM 10CM",SUP-M001491211,CDM,C1769,HCPCS,0272,RC,,,both,,,126.12,37.84,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,85.76,68,,,,,0,14.67,107.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SCR CD HORIZON SPIRE M4 BREAKOFF",SUP-9240150,CDM,C1713,HCPCS,0278,RC,,,both,,,2406.60,721.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1636.49,68,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM PFC SIGMA 5 KNEE POSTERIOR TITANIUM CEMENT",SUP-960908,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"CIGNA [10200]","Cigna Open Access",,2919.45,56.9,,5302.19,4377.88,6578.61,27,596.72,4361.21,"percent of total billed charges",
"BIT DRILL 112MM 3.5MM STAINLESS STEEL QUICK CONNECT 86MM",SUP-KM166-310-35,CDM,S27200284,LOCAL,0272,RC,,,both,,,198.53,59.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,23.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,23.09,168.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RENEGADE HI-FLO 150CM 10CM 3-2.8FR .027IN MICRO",SUP-M001182900,CDM,C1887,HCPCS,0272,RC,,,both,,,2100.00,630,"AETNA [10100]","Aetna HMO/PPO",,1669.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,244.23,1785,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC App Splint Long Leg",PX-450000202,CDM,29505,CPT,0361,RC,,,both,,,1115.10,334.53,"BLUE CROSS [10001]","Blue Cross PPO",,1115.1,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,129.69,1115.1,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE PERFORM REVERSE LAT/AUG BP",SUP-CAP-T-1153,CDM,C1776,HCPCS,0278,RC,,,both,,,3750.00,1125,"KAISER [10500]",Kaiser,,2512.5,67,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cleanser Wound Vashe 16oz",PX-E27000248,CDM,E27000248,LOCAL,0270,RC,,,both,,,226.60,67.98,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.35,192.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS STREAMLINE 25MM 4MM INTRACRANIAL FLOW DIVERTER",SUP-M003SFD040250,CDM,C1874,HCPCS,0278,RC,,,both,,,85681.49,25704.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,10153.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9964.76,72829.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 22MM LCP",SUP-02.211.022,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"BLUE CROSS [10001]","Blue Cross PPO",,352.07,39.2,,957.42,570.23,957.42,28,104.45,763.41,"percent of total billed charges",
"PLATE STAINLESS STEEL MINI FRAGMENT SET 4 HOLE .25 TUBULAR",SUP-242.04,CDM,C1713,HCPCS,0278,RC,,,both,,,1104.52,331.36,"CIGNA [10200]","Cigna Open Access",,628.47,56.9,,1144.80,304.56,2275.09,66,128.46,938.84,"percent of total billed charges",
"STENT BILIARY 7MM 4-6FR 24MM 135CM .014IN BALLOON EXPANDABLE",SUP-H739PG2470BAX3,CDM,C1876,HCPCS,0278,RC,,,both,,,6554.03,1966.21,"AETNA [10100]","Aetna HMO/PPO",,5210.45,79.5,,,,,0,762.23,5570.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 17MM SPINE CERVICAL ANTERIOR SELF DRILL",SUP-18008117,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"MULTIPLAN [10600]",Multiplan,,860.63,85,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT GORE-TEX CV-0 THX-36 36IN MONOFILAMENT UNDYED",SUP-0N07B,CDM,S27200284,LOCAL,0272,RC,,,both,,,227.65,68.29,"CIGNA [10200]","Cigna Local Plus",,121.79,53.5,,,,,0,26.48,193.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 4.50 X 20MM",SUP-H7493942820450,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"KAISER [10500]",Kaiser,,4160.7,67,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC",832,MS-DRG,,,,,,,inpatient,,,22420.49,6726.15,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,9623.68,,"Case rate ($4,476.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,156.39, add-ons for qualifying new technology services are included. If operating cost exceeds $37,196.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,696.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $4,161.89. The transfer operating threshold is the transfer adjustment factor * $4,156.39 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.24. The transfer capital threshold is the transfer adjustment factor * $314.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,4476.13,17995.98,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Critical Care Add 30min",PX-450000323,CDM,99292,CPT,0450,RC,,,both,,,3116.00,934.8,"UHC [10700]","United Healthcare",,2260,,"Per diem ($2,260).",,,,0,559.4,2648.6,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Critical Care Add 30min",PX-450000323,CDM,99292,CPT,0450,RC,,,both,,,3116.00,934.8,"AETNA [10100]","Aetna HMO/PPO",,2477.22,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,559.4,2648.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH X-FORCE U30 4CM 6FR 6MM BALLOON DILATATION PERCUTANEOUS",SUP-998604,CDM,C1726,HCPCS,0272,RC,,,both,,,1854.00,556.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1260.72,68,,,,,0,215.62,1575.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cftr Gene Full Sequence",PX-309000018,CDM,81223,CPT,0310,RC,,,both,,,5423.00,1626.9,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,4609.55,"per diem",
"CATH NAVICROSS 135CM 30D 12MM SPRT STAINLESS STEEL",SUP-NC35131,CDM,C1887,HCPCS,0272,RC,,,both,,,1462.05,438.61,"KAISER [10500]",Kaiser,,979.57,67,,,,,0,170.04,1242.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCISSORS LAPAROSCOPIC 31.75CM 8MM DA VINCI XI HOT SHEARS",SUP-470179,CDM,S27000186,LOCAL,0270,RC,,,both,,,2520.00,756,"MULTIPLAN [10600]",Multiplan,,2142,85,,,,,0,293.08,2142,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL VENTRALIGHT ST ECHO 2 25X20CM ELLIPSE",SUP-5992025,CDM,C1781,HCPCS,0278,RC,,,both,,,13069.29,3920.79,"PHCS [10601]",PHCS,,9148.5,70,,,,,0,1519.96,11108.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 1.4MM OLIVE",SUP-P99-200-1406,CDM,C1713,HCPCS,0278,RC,,,both,,,550.80,165.24,"BLUE CROSS [10001]","Blue Cross PPO",,215.91,39.2,,957.42,570.23,957.42,28,64.06,468.18,"percent of total billed charges",
"KNIFE OPHTHALMIC 2.4MM INTREPID ANGLE BEVEL STAB MICRO",SUP-8065992445,CDM,S27200284,LOCAL,0272,RC,,,both,,,288.75,86.62,"FIRST HEALTH [10303]","First Health",,231,80,,,,,0,33.58,245.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 45X18X12MM CLYDESDALE PTC 6D PEEK TITANIUM",SUP-4986245,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"FIRST HEALTH [10303]","First Health",,22680,80,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Airway Nasopharyngeal",PX-E27000038,CDM,E27000038,LOCAL,0270,RC,,,both,,,35.48,10.64,"PHCS [10601]",PHCS,,24.84,70,,,,,0,4.13,30.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CAPSTONE ALLOGRAFT 26MMX8MM SPINE",SUP-9440826,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"MULTIPLAN [10600]",Multiplan,,14662.5,85,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +19.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000195,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 7FR .1IN 70CM ANL0 CURVE STRAIGHT TIP ANSEL",SUP-G56222,CDM,C1894,HCPCS,0272,RC,,,both,,,558.09,167.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,229.37,41.1,,,,,0,64.91,474.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR HD 46CM 12-14FR ACCESS STAINLESS STEEL",SUP-M0062502260,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,116.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,114.05,833.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 16MM KNEE X3 TOTAL STABILIZE PLUS TRIATHLON",SUP-5537-G-116,CDM,C1776,HCPCS,0278,RC,,,both,,,13458.45,4037.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1565.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1565.22,11439.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 6MM 2.25MM .017IN",SUP-H7493926706220,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"KAISER [10500]",Kaiser,,379.89,67,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Paravrt Jt C/T 2 Lvl",PX-510000134,CDM,64491,CPT,0761,RC,,,both,,,3361.00,1008.3,"NOVANET [10819]",Novanet,,2520.75,75,,,,,0,390.88,2856.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 13MM DVR TITANIUM CORTICAL ANATOMIC VOLAR",SUP-CS13000,CDM,C1713,HCPCS,0278,RC,,,both,,,1093.50,328.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,129.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",127.17,929.48,"percent of total billed charges",
"HC Homogenization Tiss for Cult",PX-306000078,CDM,87176,CPT,0306,RC,,,both,,,125.00,37.5,"KAISER [10500]",Kaiser,,83.75,67,,,,,0,0.01,106.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 4.75MM CD HORIZON COCRMO CAP",SUP-641003045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"KAISER [10500]",Kaiser,,814.05,67,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN JUDKINS LEFT 5 CURVE GUIDING",SUP-LA6JL50SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ab Elution RBC",PX-302000183,CDM,86860,CPT,0302,RC,,,both,,,538.20,161.46,"BLUE CROSS [10001]","Blue Cross PPO",,39.32,,"Fee schedule rate ($39.32).",,,,0,0.01,457.47,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 35CM 14.5FR STD STRAIGHT POLYURETHANE PTFE HEMOSTAR",SUP-5833350,CDM,C1750,HCPCS,0278,RC,,,both,,,1633.80,490.14,"PHCS [10601]",PHCS,,1143.66,70,,,,,0,190.01,1388.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 1.3MM FLEXIBLE SUT ANCHOR SYSTEM DISPOSABLE",SUP-Y13D,CDM,S27200284,LOCAL,0272,RC,,,both,,,733.54,220.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,85.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,85.31,623.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 18MM IMPL CANNULATED",SUP-200-30-018,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"CIGNA [10200]",Cigna,,771.12,68,,1831.33,1831.33,1831.33,16,131.88,963.9,"percent of total billed charges",
"BURR SURGICAL 4MM ROUND FLUTE",SUP-5220010040,CDM,S27200284,LOCAL,0272,RC,,,both,,,668.25,200.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,454.41,68,,,,,0,77.72,568.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 44MM UNITRAX FEMORAL HIP MODULAR",SUP-6942-5-044,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1435.61,45.9,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 15MM 145CM 4MM BALLOON DILATATION HYDROCOAT",SUP-1400400-15,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BIOPSY 15CM 14GA QUICK-CORE SOFT TISSUE NDL COAXIAL",SUP-G10149,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 100MM 3MM BALLOON DILATATION OTW STERILE",SUP-47030100S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UHC [10700]","United Healthcare",,907.53,63.3,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BIPOLAR CORD INTEGRATE TUBE ROTARY MALIS IRRIGATION",SUP-6790-100-003,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 6MM 4.5MM .017IN",SUP-H7493926706450,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"AETNA [10100]","Aetna HMO/PPO",,450.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ca Ionized POC",PX-301000125,CDM,82330,CPT,0301,RC,,,both,,,202.95,60.88,"BLUE CROSS [10001]","Blue Cross HMO",,0.2,.1,,,,,0,0.2,172.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 2.9MM 75MM LCP STAINLESS STEEL CONE PARTIAL",SUP-212.427,CDM,C1713,HCPCS,0278,RC,,,both,,,1125.25,337.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,322.05,28.62,,,,,0,130.87,956.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC SMALL 32-36IN 32-36IN SHOULDER ELASTIC RIB",SUP-79-84033,CDM,S27000186,LOCAL,0270,RC,,,both,,,49.42,14.83,"PHCS [10601]",PHCS,,34.59,70,,,,,0,5.75,42.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP SMALL 9IN TITANIUM ENDOSCOPIC LIGATING",SUP-133650,CDM,S27200284,LOCAL,0272,RC,,,both,,,379.23,113.77,"AETNA [10100]","Aetna HMO/PPO",,301.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,44.1,322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemo IV Inf > 8hr W/Pump",PX-335000003,CDM,96416,CPT,0335,RC,,,both,,,986.03,295.81,"UHC [10700]","United Healthcare",,986.03,,"Per diem ($1,277).",,,,0,114.68,986.03,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"PEG BONE 22MM 2.3MM ACU-LOC CORTICAL SMOOTH LOCKING",SUP-CO-S2322,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA [10200]","Cigna Open Access",,433.24,56.9,,1144.80,304.56,2275.09,66,88.55,647.19,"percent of total billed charges",
"SCR BONE 4.5MM 8MM 95MM LCP STAINLESS STEEL CORTEX CONDYLE",SUP-214.895,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,199.67,45.9,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH MOD + PROF XTRA 490CC",SUP-SMPX490,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"CIGNA [10200]","Cigna Open Access",,4240.19,56.9,,5166.00,5166.00,5166.00,"1 through 10",866.67,6334.2,"percent of total billed charges",
"HC Cholesterol Ldl",PX-301000549,CDM,83721,CPT,0301,RC,,,both,,,116.00,34.8,"CIGNA [10200]","Cigna Local Plus",,23.1,,,,,,,0.01,98.6,"fee schedule",
"LINE ANGIOGRAPHY 60IN .142IN .071IN 1200 PSI FEMALE LUER",SUP-91051602,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.25,26.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,60.01,68,,,,,0,10.26,75.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Bilat Knee Stand Ap",PX-320000084,CDM,73565,CPT,0320,RC,,,both,,,522.43,156.73,"BLUE CROSS [10001]","Blue Cross HMO",,103.01,,"Fee schedule rate ($103.01).",,,,0,50.18,444.07,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 56MM COCR",SUP-VAL-35560-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"BLUE CROSS [10001]","Blue Cross PPO",,823.2,39.2,,957.42,570.23,957.42,28,244.23,1785,"percent of total billed charges",
"CMPNT FEMORAL 7 KNEE RIGHT MEDIAL LEFT LATERAL",SUP-71422357,CDM,C1776,HCPCS,0278,RC,,,both,,,29030.40,8709.12,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7838.21,27,,,,,0,3376.24,24675.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 75CM 120MM 3MM BALLOON",SUP-U3575312,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 65CM 7FR ENDOCARDIUM TRUE BIPOLAR ACTIVE",SUP-7171Q/65,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"BLUE CROSS [10001]","Blue Cross PPO",,6731.42,39.2,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL LARGE 4.25IN NECK 2 PIECE SEMIRIGID",SUP-11344,CDM,S27000186,LOCAL,0270,RC,,,both,,,129.54,38.86,"CIGNA [10200]","Cigna Local Plus",,69.3,53.5,,,,,0,15.07,110.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ENDOSCOPIC 75MM 8MM DRI-LOK THREAD STERILE",SUP-3910075800,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"MULTIPLAN [10600]",Multiplan,,147.9,85,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 12X4CM GENTRIX PORCINE URINARY BLADDER",SUP-PSM0412,CDM,C1781,HCPCS,0278,RC,,,both,,,3894.91,1168.47,"BLUE CROSS [10001]","Blue Cross HMO",,1526.8,39.2,,,,,0,452.98,3310.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 40MM 5FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206060470,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ivus/Oct Hrt Ea Vssl Init",PX-480000068,CDM,92978,CPT,0481,RC,,,both,,,11421.36,3426.41,"MULTIPLAN [10600]",Multiplan,,9708.16,85,,,,,0,1249,9708.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 37MM 135CM 6MM 40MM",SUP-38047-64013,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"NOVANET [10819]",Novanet,,3105,75,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11MM NATURAL LORDOTIC CORTICOCANCELLOUS",SUP-18411,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET SUPERORDERABLE",RX-409435,CDM,,,0637,RC,37000-0024-10,NDC,both,1,UN,12.54,3.76,"MULTIPLAN [10600]",Multiplan,,10.66,85,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM 20.4MM MASTERS PYROLYTIC CARBON PTFE",SUP-25MTJ-503,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3450.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR ZIPWIRE 26CM 3CM 8FR .038IN PIGTAIL CURVE",SUP-M006180543170,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"PHCS [10601]",PHCS,,861.67,70,,,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 18MM CRANIOFACIAL TITANIUM 6 HOLE 2Y LOW PROFILE",SUP-421.516,CDM,C1713,HCPCS,0278,RC,,,both,,,3788.10,1136.43,"CIGNA [10200]","Cigna Local Plus",,2026.63,53.5,,3978.14,359.25,3978.14,24,440.56,3219.89,"percent of total billed charges",
"SYSTEM PINNACLE PRECISION ACCESS SYSTEM 45CM 10CM 5FR 21-19",SUP-70-5165,CDM,C1894,HCPCS,0272,RC,,,both,,,304.50,91.35,"FIRST HEALTH [10303]","First Health",,243.6,80,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE S-101 - EACH",SUP-666697-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,30.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 28MM MEDLINE UNITE FOOT ANKLE LOCK",SUP-MPSL3528,CDM,C1713,HCPCS,0278,RC,,,both,,,1498.50,449.55,"PHCS [10601]",PHCS,,1048.95,70,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 8FR 18GA 20CM .032IN 2 LUMEN INDWELL CATH GWIRE NDL",SUP-CDC-45802-XP1A,CDM,C1752,HCPCS,0272,RC,,,both,,,1028.70,308.61,"MULTIPLAN [10600]",Multiplan,,874.4,85,,,,,0,119.64,874.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFEPIME HCL 2 G/12.5ML IJ (WET SOLR VIAL)",RX-41516371,CDM,J0692,HCPCS,0636,RC,00409-9735-01,NDC,both,1,UN,91.05,27.31,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6.8,,,,,,,5.69,77.39,"fee schedule",
"PLATE NARROW 51MM STAINLESS STEEL 2.4MM SCR 6X3 HOLE 2",SUP-02.111.530,CDM,C1713,HCPCS,0278,RC,,,both,,,3834.68,1150.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,454.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,445.97,3259.48,"percent of total billed charges",
"LEAD ICD PLEXA PROMRI RIGHT VENTRICULAR DF-1 S DX 65/15",SUP-414005,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"FIRST HEALTH [10303]","First Health",,13737.6,80,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 15MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158125115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3017.13,27,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GENRTR PULSE IMPLANTABLE",SUP-SC-1160,CDM,C1820,HCPCS,0278,RC,,,both,,,99750.00,29925,"PHCS [10601]",PHCS,,69825,70,,,,,0,11600.93,84787.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM 12-14MM POD",SUP-RBYPOD14,CDM,S27800098,LOCAL,0278,RC,,,both,,,11661.00,3498.3,"KAISER [10500]",Kaiser,,7812.87,67,,,,,0,1356.17,9911.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM ENDOSCOPIC 7MM 5FR MICROKNIFE XL BILIARY PANCREAS 3",SUP-M00532810,CDM,S27200284,LOCAL,0272,RC,,,both,,,1159.68,347.9,"CIGNA [10200]","Cigna Open Access",,659.86,56.9,,,,,0,134.87,985.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 6MM TITANIUM SPINE CORTEX SELF TAP STARDRIVE",SUP-401.356.99,CDM,C1713,HCPCS,0278,RC,,,both,,,526.50,157.95,"FIRST HEALTH [10303]","First Health",,421.2,80,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNTRLZR STEM 9MM INVIS HIP FEMUR PMMA RECONSTRUCTION",SUP-71313209,CDM,C1776,HCPCS,0278,RC,,,both,,,972.00,291.6,"MULTIPLAN [10600]",Multiplan,,826.2,85,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM 12/14 TAPER 36MM HIP OXINIUM ECHELON",SUP-71343603,CDM,C1776,HCPCS,0278,RC,,,both,,,15535.35,4660.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1840.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1806.76,13205.05,"percent of total billed charges",
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 22CM 8FR .035",SUP-M006192151090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"CIGNA [10200]","Cigna Local Plus",,798.45,,,,,,,173.57,1268.57,"percent of total billed charges",
"GRAFT VASCULAR 50CM 7MM GORE THIN WALL HEPARIN PROPATEN PTFE",SUP-HT074050A,CDM,C1768,HCPCS,0278,RC,,,both,,,12978.90,3893.67,"CIGNA [10200]","Cigna Local Plus",,4088.35,31.5,,,,,0,1509.45,11032.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP5PR,CDM,C1776,HCPCS,0278,RC,,,both,,,17146.50,5143.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2031.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1994.14,14574.53,"percent of total billed charges",
"BEARING 63/67MMX10MM VANGUARD ARCOM KNEE CRUCIATE RETAINING",SUP-183420,CDM,C1776,HCPCS,0278,RC,,,both,,,7565.85,2269.75,"FIRST HEALTH [10303]","First Health",,6052.68,80,,,,,0,879.91,6430.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 STD KNEE RIGHT POSTERIOR STABILIZE CEMENT",SUP-42500606402,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"NOVANET [10819]",Novanet,,17147.03,75,,,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANSTR WOUND DRNG ABTHERA 1X LARGE NEGATIVE PRESSURE",SUP-370620.S,CDM,S27000186,LOCAL,0270,RC,,,both,,,87.00,26.1,"FIRST HEALTH [10303]","First Health",,69.6,80,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL KNEE 9MM TRIATHLON 4 TIBIAL INSRT TOTAL STABILIZE PLUS",SUP-5537-T-409,CDM,C1776,HCPCS,0278,RC,,,both,,,656.10,196.83,"FIRST HEALTH [10303]","First Health",,524.88,80,,,,,0,76.3,557.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Enteroscopy W Rmvl Snare",PX-750000229,CDM,44364,CPT,0750,RC,,,both,,,3196.00,958.8,"NOVANET [10819]",Novanet,,2397,75,,,,,0,371.69,3196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 74MM 4 LEVEL HELIX R BONE SPINE NONSTERILE",SUP-7800474,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"CAGE SPINAL 14X20MM BENGAL 12MM STD LORDOTIC THORACOLUMBAR",SUP-177306120,CDM,S27800098,LOCAL,0278,RC,,,both,,,15950.04,4785.01,"PHCS [10601]",PHCS,,11165.03,70,,,,,0,1854.99,13557.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TACTIFLEX SE UNID CURVE D UNIFIED",SUP-A-TFSE-D-X,CDM,C2630,HCPCS,0272,RC,,,both,,,25061.40,7518.42,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;; standard_charge|negotiated_dollar=0;"
"CATH FOXCROSS 135CM 40MM 8MM BALLOON DILATATION JETCOAT",SUP-10338-40,CDM,C1725,HCPCS,0272,RC,,,both,,,1539.00,461.7,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MARINR 80CM 5FR 2-5-2MM SPACING 65MM REACH ABLATION",SUP-76586,CDM,C1733,HCPCS,0272,RC,,,both,,,3562.50,1068.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STEM HUMERAL 12MM UNIVERS APEX OPTIFIT",SUP-AR-9100-12M,CDM,C1776,HCPCS,0278,RC,,,both,,,26302.50,7890.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10521,40,,,,,0,3058.98,22357.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EDM 35CM 15CM 2.8MM 1.5MM EXTERNAL DRNG STAINLESS STEEL",SUP-46118,CDM,C1729,HCPCS,0272,RC,,,both,,,1576.99,473.1,"FIRST HEALTH [10303]","First Health",,1261.59,80,,,,,0,183.4,1340.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 150MM 120CM 6MM 6FR VASCULAR PERIPHERAL",SUP-S-60-150-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10782.00,3234.6,"PHCS [10601]",PHCS,,7547.4,70,,,,,0,1253.95,9164.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0225,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOUND 20FR URETHRAL CURVE VAN BUREN 10.75IN",SUP-51-6320,CDM,S27200284,LOCAL,0272,RC,,,both,,,320.33,96.1,"MULTIPLAN [10600]",Multiplan,,272.28,85,,,,,0,37.25,272.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL MICROPOINT 8-0 TG160-8 8IN 2 ARM BRAID COATED",SUP-J574G,CDM,S27200284,LOCAL,0272,RC,,,both,,,161.34,48.4,"CIGNA [10200]","Cigna Open Access",,91.8,56.9,,,,,0,18.76,137.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +24 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CC60WF.240,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,140.36,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 9CM MR8 3MM MATCH HEAD DISSECTING",SUP-MR8-9MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1184.63,355.39,"PHCS [10601]",PHCS,,829.24,70,,,,,0,137.77,1006.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BASEPLT 20MM 4.5MM AEQUALIS REVERSED GLENOID TITANIUM",SUP-VDV220,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"PHCS [10601]",PHCS,,1089.2,70,,,,,0,180.96,1322.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +8.5 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-Z900200085,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"PHCS [10601]",PHCS,,714.42,70,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 27CM 14.5FR STD STRAIGHT POLYURETHANE GLIDEPATH",SUP-5393270R,CDM,C1750,HCPCS,0278,RC,,,both,,,2062.50,618.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,244.41,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM TRIATHLON 4 RIGHT MEDIAL LEFT LATERAL TOTAL",SUP-5545-A-402,CDM,C1776,HCPCS,0278,RC,,,both,,,4327.60,1298.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1986.37,45.9,,,,,0,503.3,3678.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL COMPOSIX L/P 10.2X8.2IN ELLIPSE ECHO",SUP-0144810,CDM,C1781,HCPCS,0278,RC,,,both,,,7203.84,2161.15,"BLUE CROSS [10001]","Blue Cross HMO",,2823.91,39.2,,,,,0,837.81,6123.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BUTTON 12MM 4CM PASSPORT BUTTON SILICONE CURVE HIP 1",SUP-AR-6592-12-40,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"CIGNA [10200]","Cigna Open Access",,290.36,56.9,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 2.5MM 26MM AXSOS STAINLESS STEEL FULL THREAD",SUP-338626,CDM,C1713,HCPCS,0278,RC,,,both,,,230.20,69.06,"BLUE CROSS [10001]","Blue Cross PPO",,90.24,39.2,,957.42,570.23,957.42,28,26.77,195.67,"percent of total billed charges",
"DEVICE CADENCE PRECISION INFLATION 1ML SYR INJECTOR THREAD",SUP-103-0304,CDM,S27200284,LOCAL,0272,RC,,,both,,,3592.50,1077.75,"FIRST HEALTH [10303]","First Health",,2874,80,,,,,0,417.81,3053.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.5MM OASYS SPINE TETHER 3.5MM SCR STERILE",SUP-48560323,CDM,S27200284,LOCAL,0272,RC,,,both,,,3956.40,1186.92,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1626.08,41.1,,,,,0,460.13,3362.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW LAPIPLASTY",SUP-ZMS-4011,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"CIGNA [10200]","Cigna Local Plus",,325.01,53.5,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hepatitis B Virus Surf Abs Qt",PX-302000062,CDM,86317,CPT,0302,RC,,,both,,,237.50,71.25,"CIGNA [10200]","Cigna Open Access",,32.98,,,,,,,0.24,201.88,"fee schedule",
"HEAD UNIPOLAR 47MM UNITRAX HIP MODULAR ENDOPROSTHESIS",SUP-6942-5-047,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2126.84,68,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28X10X9MM COALESCE LORDOTIC STRAIGHT STERILE",SUP-2000-00-100908,CDM,C1889,HCPCS,0278,RC,,,both,,,21420.00,6426,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8568,40,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 3 KNEE RIGHT BICRUCIATE STABILIZE",SUP-74022213,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"BLUE CROSS [10001]","Blue Cross HMO",,6515.86,39.2,,5311.50,4717.44,5388.59,31,1933.15,14128.79,"percent of total billed charges",
"GRAFT STENT 10CM 37MM GORE TAG THORACIC ACTIVE CONTROL",SUP-TGMR373710,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"PHCS [10601]",PHCS,,81180.54,70,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 80MM 80CM 9MM 8FR STRAIGHT VASCULAR",SUP-AVSM09080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2124.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 60MM 2.5MM BALLOON DILATATION PEBAX",SUP-H74939032250610,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 6MM 2.25MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP22506X,CDM,C1725,HCPCS,0272,RC,,,both,,,510.30,153.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,60.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 27MM OPEN PIVOT STD HEART ANNULUS TISSUE",SUP-500FA27,CDM,S27800098,LOCAL,0278,RC,,,both,,,25011.00,7503.3,"CIGNA [10200]",Cigna,,10004.4,40,,,,,0,2908.78,21259.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROGESTERONE MICRONIZED 100 MG CAPSULE",RX-23122,CDM,,,0637,RC,70700-0162-01,NDC,both,1,UN,25.19,7.56,"KAISER [10500]",Kaiser,,16.88,67,,,,,0,2.93,21.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cntrst Bath Ea 15min (Gp)",PX-420000019,CDM,97034,CPT,0420,RC,,,both,,,151.00,45.3,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,17.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.56,151,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 26CM 10FR .038IN LARGE REGULAR PIGTAIL CURVE URETERAL",SUP-M001274080,CDM,C2617,HCPCS,0278,RC,,,both,,,1053.00,315.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,122.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,122.46,895.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 40MM 5FR 7MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206070470,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYPROPYLENE PROLENE 0 CTX 30IN MONOFILAMENT BLUE",SUP-8454H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC",122,MS-DRG,,,,,,,inpatient,,,26678.69,8003.61,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,5020.6,,"Case rate ($4,874.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,526.18, add-ons for qualifying new technology services are included. If operating cost exceeds $37,565.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,724.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $4,532.16. The transfer operating threshold is the transfer adjustment factor * $4,526.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.20. The transfer capital threshold is the transfer adjustment factor * $342.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,4874.37,19597.07,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC",122,MS-DRG,,,,,,,inpatient,,,26678.69,8003.61,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,5215.58,,"Case rate ($4,874.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $4,526.18, add-ons for qualifying new technology services are included. If operating cost exceeds $37,565.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,724.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $4,532.16. The transfer operating threshold is the transfer adjustment factor * $4,526.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $342.20. The transfer capital threshold is the transfer adjustment factor * $342.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,4874.37,19597.07,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 2 X 1 HELICAL FINISHING COIL",SUP-10HFN-02001,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"MULTIPLAN [10600]",Multiplan,,8791.64,85,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 33.58CM 8MM DA VINCI XI ENDOWRIST 42D",SUP-470405,CDM,S27000186,LOCAL,0270,RC,,,both,,,2115.00,634.5,"PHCS [10601]",PHCS,,1480.5,70,,,,,0,245.97,1797.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BONE 105MM INTERTAN 105MMX100MM TROCHANTERIC TITANIUM",SUP-7167-7105,CDM,S27200284,LOCAL,0272,RC,,,both,,,6986.94,2096.08,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,827.95,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,812.58,5938.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR SENSOR DUAL-FLEX 22CM 3CM 6FR .035IN PIGTAIL",SUP-M006180221090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,380.72,28.62,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CARDIOXYL PLEDGET TD18M",SUP-73P30CN,CDM,S27200284,LOCAL,0272,RC,,,both,,,922.73,276.82,"NOVANET [10819]",Novanet,,692.05,75,,,,,0,107.31,784.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SOLYX ADVANTAGE 9CM URETHRAL SPRT POLYPROPYLENE",SUP-M0068507001,CDM,C1771,HCPCS,0278,RC,,,both,,,15346.98,4604.09,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4392.31,28.62,,,,,0,1784.85,13044.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION KIRSCHNER SPINAL THREADED",SUP-8801068,CDM,C1713,HCPCS,0278,RC,,,both,,,3326.40,997.92,"CIGNA [10200]","Cigna Open Access",,1892.72,56.9,,1144.80,304.56,2275.09,66,386.86,2827.44,"percent of total billed charges",
"HC Immunoassay Nos",PX-301000270,CDM,83520,CPT,0301,RC,,,both,,,319.75,95.92,"CIGNA [10200]","Cigna Local Plus",,37.99,,,,,,,0.32,271.79,"fee schedule",
"CIRCAID ARM REDUCTION KIT- STANDARD, WIDE",SUP-25402117,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"KAISER [10500]",Kaiser,,841.19,67,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 16CM 5FR .035",SUP-M006192114090,CDM,C2617,HCPCS,0278,RC,,,both,,,1492.43,447.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,176.85,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.57,1268.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX16MM VANGUARD POROUS KNEE POSTERIOR",SUP-183746,CDM,C1776,HCPCS,0278,RC,,,both,,,8757.48,2627.24,"UHC [10700]","United Healthcare",,5543.48,63.3,,8601.07,8395.67,8601.07,"1 through 10",1018.49,7443.86,"percent of total billed charges",
"PREDNISONE 2.5 MG TABLET",RX-6495,CDM,J7512,HCPCS,0636,RC,59651-0485-01,NDC,both,1,UN,6.27,1.88,"FIRST HEALTH [10303]","First Health",,5.02,80,,,,,0,0.03,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE UNICORTICAL DOWEL ALLOGRAFT FREEZE DRIED 14-40MM",SUP-400211,CDM,S27800098,LOCAL,0278,RC,,,both,,,4413.24,1323.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1263.07,28.62,,,,,0,513.26,3751.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 34X12-16MM MAGNIFY-S 8D LORDOTIC 26MM EXPAND",SUP-1126.1112,CDM,S27800098,LOCAL,0278,RC,,,both,,,42840.00,12852,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5076.54,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4982.29,36414,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR SILICONE RADIOPAQUE EXTERNAL RETENTION RING",SUP-8150-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,592.52,177.76,"NOVANET [10819]",Novanet,,444.39,75,,,,,0,68.91,503.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +18 DIOPTER MODIFIED C BICONVEX 13.5MM 6.5MM",SUP-MC50BD.180,CDM,V2632,HCPCS,0276,RC,,,both,,,810.00,243,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 ULTRA 5MM X 10CM",SUP-M0035425100,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"MULTIPLAN [10600]",Multiplan,,11997.44,85,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 28.5X5.5X.4MM HALL MICROPOWER MICRO100 THK.6MM",SUP-5023-164,CDM,S27200284,LOCAL,0272,RC,,,both,,,232.99,69.9,"UHC [10700]","United Healthcare",,147.48,63.3,,,,,0,27.1,198.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL GORE 20X15CM PREPERITONEAL KNIT WEB SYNECOR",SUP-GKWV1520,CDM,C1781,HCPCS,0278,RC,,,both,,,10108.50,3032.55,"BLUE CROSS [10001]","Blue Cross PPO",,3962.53,39.2,,,,,0,1175.62,8592.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 131MM STAINLESS STEEL 2.7/3.5MM SCR 6 HOLE VARIABLE",SUP-02.107.506,CDM,C1713,HCPCS,0278,RC,,,both,,,6717.56,2015.27,"BLUE CROSS [10001]","Blue Cross HMO",,2633.28,39.2,,957.42,156.86,7483.26,51,781.25,5709.93,"percent of total billed charges",
"PASSER SPECTRUM II 45D ANGLE RIGHT HOOK LOCK HANDLE SUT",SUP-C6380,CDM,S27200284,LOCAL,0272,RC,,,both,,,685.50,205.65,"MULTIPLAN [10600]",Multiplan,,582.68,85,,,,,0,79.72,582.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS 26CM 8FR .038IN URETERAL HYDROPLUS LUBRIGLIDE",SUP-M0061251530,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"CIGNA [10200]","Cigna Open Access",,700.42,,,,,,,143.16,1046.32,"percent of total billed charges",
"INSERT TIBIAL 5 9MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530-G-509,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1012.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1012.7,7401.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATFORM ACCESS GELPOINT INSUFFLATION STABILIZATION BAG",SUP-CNB11,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"KAISER [10500]",Kaiser,,4045.13,67,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE FEMORAL 5MM LEGION 5 KNEE SCR",SUP-71421664,CDM,C1776,HCPCS,0278,RC,,,both,,,11995.65,3598.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3238.83,27,,,,,0,1395.09,10196.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION",RX-6393,CDM,,,0250,RC,70860-0124-41,NDC,both,1,UN,49.38,14.81,"AETNA [10100]","Aetna HMO/PPO",,39.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.74,41.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 51MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-51-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"CIGNA [10200]",Cigna,,3847.44,68,,5873.17,5873.17,5873.17,"1 through 10",658.03,4809.3,"percent of total billed charges",
"VALVE MITRAL 25MM 22.5MM MASTERS HP MECHANICAL ROTATABLE STD",SUP-25MHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"BLUE CROSS [10001]","Blue Cross HMO",,11414.74,39.2,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 8 NARROW KNEE LEFT POSTERIOR STABILIZE PERSONA",SUP-42500206401,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8269.91,28.62,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Iliac W Pta Init",PX-361000148,CDM,37220,CPT,0361,RC,,,both,,,10816.36,3244.91,"CIGNA [10200]","Cigna Local Plus",,6044,,"Case rate ($6,044). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1257.94,9193.91,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"LUTONIX 035 130CM 4X40MM1/EACH",SUP-LX35130440,CDM,C1725,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"PHCS [10601]",PHCS,,7969.5,70,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 40MM 120CM 6MM 6FR VASCULAR PERIPHERAL",SUP-S-60-040-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"CIGNA [10200]","Cigna Local Plus",,5383.17,53.5,,,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT R2P MISAGO 60MM 200CM 6MM 6FR VASCULAR PERIPHERAL",SUP-SXR06060R,CDM,C1876,HCPCS,0278,RC,,,both,,,6099.60,1829.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4147.73,68,,,,,0,709.38,5184.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INNOVA 20MM 75CM 7MM VASCULAR RADIOPAQUE SELF EXPAND",SUP-H74939293070270,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]","Cigna Local Plus",,2584.05,53.5,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER II XP 110CM 10MM 7FR 8FR 2.5MM SPACE STD CURVE",SUP-M0044790TH0,CDM,C1733,HCPCS,0272,RC,,,both,,,12199.20,3659.76,"AETNA [10100]","Aetna HMO/PPO",,9698.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1418.77,10369.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT ELECTROSURGICAL 25CM CURVED TIP ENSEAL TRIO 3MM",SUP-ETRIO325H,CDM,S27200284,LOCAL,0272,RC,,,both,,,3157.44,947.23,"NOVANET [10819]",Novanet,,2368.08,75,,,,,0,367.21,2683.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 20MM 135CM 5MM .018IN BILIARY STAINLESS",SUP-G56624,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1442.45,28.62,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 6-9 G-H KNEE LEFT VIVACIT-E",SUP-42512400910,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"NOVANET [10819]",Novanet,,8082.32,75,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemoglobin Chromatography",PX-301000224,CDM,83021,CPT,0301,RC,,,both,,,118.00,35.4,"AETNA [10100]","Aetna HMO/PPO",,93.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,100.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP POROCOAT PINNACLE 100 SERIES",SUP-121701052,CDM,C1776,HCPCS,0278,RC,,,both,,,11350.50,3405.15,"MULTIPLAN [10600]",Multiplan,,9647.93,85,,,,,0,1320.06,9647.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 31CM 3.3MM PRUITT F3 OUTLYING PORT",SUP-E2011-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,9446.10,2833.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1119.36,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1098.58,8029.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Battery Elec/Combo Vad, Rep",PX-E27400023,CDM,Q0496,HCPCS,0274,RC,,,both,,,543.40,163.02,"NOVANET [10819]",Novanet,,407.55,75,,,,,0,63.2,461.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Parvovirus Ab",PX-302000156,CDM,86747,CPT,0302,RC,,,both,,,414.20,124.26,"CIGNA [10200]","Cigna Local Plus",,33.07,,,,,,,0.01,352.07,"fee schedule",
"GRAFT SOFT TISSUE 3X2CM CYGNUS DUAL THK.2MM 6SQ CM AMNION",SUP-585-001,CDM,Q4282,HCPCS,0636,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,247.92,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATHETER THE RINGER PERFUSION 20MM OD 3MM PERFUSION P",SUP-5884,CDM,C1725,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sr89 Strontium per Mci",PX-344000006,CDM,A9600,HCPCS,0344,RC,,,both,,,10293.00,3087.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1214.03,,,,,,,1197.08,8749.05,"fee schedule",
"IDENTITY IMPRINT PS TIBIAL INSERT TRIAL SIZE 3 10MM",SUP-TPS-030-103S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,332.91,41.1,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ca Total",PX-301000123,CDM,82310,CPT,0301,RC,,,both,,,98.86,29.66,"NOVANET [10819]",Novanet,,74.15,75,,,,,0,0.01,84.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Y90 Spheres per Source",PX-E27800021,CDM,C2616,HCPCS,0278,RC,,,both,,,89579.60,26873.88,"UHC [10700]","United Healthcare",,56703.89,63.3,,,,,0,10418.11,76142.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Cath Cv Tunlw/O Port<5yrs",PX-361000498,CDM,36557,CPT,0361,RC,,,both,,,8549.00,2564.7,"NOVANET [10819]",Novanet,,6411.75,75,,,,,0,994.25,8549,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF CONTACTR 110CM 5MM 7FR 2-5-2MM SPACING ABLATION",SUP-07856044,CDM,C1733,HCPCS,0272,RC,,,both,,,4554.00,1366.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH CELSIUS RMT REDEL 125CM 4MM 7FR 2-5-2MM SPACE ABLATION",SUP-CR7TCS4RTU,CDM,C1733,HCPCS,0272,RC,,,both,,,8142.00,2442.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH SAFIRE TX COMFORTGRIP 110CM 8MM 7FR 2-5-2MM SPACING 1MM",SUP-402842,CDM,C1733,HCPCS,0272,RC,,,both,,,6555.00,1966.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH EUPHORA 142CM 25MM 3.25MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP32525X,CDM,C1725,HCPCS,0272,RC,,,both,,,522.45,156.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cann Fem Art Perc Bio-Med 17f",PX-E27200395,CDM,E27200395,LOCAL,0272,RC,,,both,,,1442.10,432.63,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,661.92,45.9,,,,,0,167.72,1225.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lipoprotein(Lp-Pla2) Assay",PX-301000300,CDM,83698,CPT,0301,RC,,,both,,,1383.20,414.96,"FIRST HEALTH [10303]","First Health",,1106.56,80,,,,,0,0.01,1175.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rlcj Pg Wcs Lv Trnsmtr Only",PX-481000396,CDM,0863T,CPT,0481,RC,,,both,,,2793.00,837.9,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,324.83,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,324.83,2793,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 10CM 10FR DUODENAL BEND BILIARY PLASTIC TEMPORARY",SUP-M00545620,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,101.05,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VICI VENOUS STENT 90MM 100MM 14MM ENDOPROSTHESIS",SUP-H74914090100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"PHCS [10601]",PHCS,,9177,70,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ENDOFLATOR (22MM AND 26MM) 25ML",SUP-30-10-8025,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MENTOR MEMORYSHAPE BREAST IMPLANT TALL HEIGHT HIGH PROFILE S",SUP-334-1204,CDM,C1789,HCPCS,0278,RC,,,both,,,7583.10,2274.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5156.51,68,,,,,0,881.91,6445.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EDWARDS EVOQUE VALVE (EVOQUE VALVE) 44 MM",SUP-9850EV44,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN SUCTION/IRRIGATION UNIVERSAL PLUS 5MM 32CM SPAT STEALTH",SUP-60-5274-032,CDM,S27200284,LOCAL,0272,RC,,,both,,,212.28,63.68,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CARBAMIDE PEROXIDE 6.5 % EAR DROPS",RX-1359,CDM,,,0250,RC,70677-1154-01,NDC,both,15,ML,19.34,5.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LENS IOL 0 D +7.5 DIOPTER MODIFY L BICONVEX 13MM 6MM",SUP-CCA0T0.075,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE HISTOLOGY ACCU-EDGE STAINLESS STEEL BLUNT AND BLUNT",SUP-4797,CDM,S27200284,LOCAL,0272,RC,,,both,,,245.34,73.6,"MULTIPLAN [10600]",Multiplan,,208.54,85,,,,,0,28.53,208.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE RIGHT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F602,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"FIRST HEALTH [10303]","First Health",,13712.02,80,,,,,0,1993.39,14569.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO 2.75/15",SUP-401743,CDM,C1874,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,531.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE ASR CANCELLOUS CORTICAL BLOCK 14X11X8",SUP-245841,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 110MM 32MM LCP STAINLESS STEEL CANCELLOUS",SUP-217.110,CDM,C1713,HCPCS,0278,RC,,,both,,,302.06,90.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,35.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,35.13,256.75,"percent of total billed charges",
"IMPL FEMORAL IDENTITY IMPRINT 5 KNEE POSTERIOR STABILIZE",SUP-TPS-101-F05S,CDM,C1776,HCPCS,0278,RC,,,both,,,11716.20,3514.86,"UHC [10700]","United Healthcare",,7416.35,63.3,,8601.07,8395.67,8601.07,"1 through 10",1362.59,9958.77,"percent of total billed charges",
"STENT ONYX FRONTIER 15MM 2.25MM CORONARY RAPID EXCHANGE",SUP-ONYXNG22515UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"PHCS [10601]",PHCS,,1837.5,70,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 30X11X8MM MODULUS 8D TLIF-A STERILE LATEX FREE",SUP-1081308P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3359.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK EMBOLECTOMY 60CM 2FR FOGARTY SILICONE STAINLESS STEEL",SUP-NL2EMB60,CDM,C1757,HCPCS,0272,RC,,,both,,,798.98,239.69,"KAISER [10500]",Kaiser,,535.32,67,,,,,0,92.92,679.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC",797,MS-DRG,,,,,,,inpatient,,,50780.54,15234.16,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,6391.73,,"Case rate ($6,205.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,762.27, add-ons for qualifying new technology services are included. If operating cost exceeds $38,801.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,817.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $5,769.89. The transfer operating threshold is the transfer adjustment factor * $5,762.27 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $435.66. The transfer capital threshold is the transfer adjustment factor * $435.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,5018,13341.95,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 130CM 120MM 4FR 6MM .018IN BALLOON",SUP-PCP060120130,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 14X11X8MM ALLOGRAFT",SUP-6940841,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 6IN VENTRAL RESORBABLE COMPOSITE",SUP-PCO15X,CDM,C1781,HCPCS,0278,RC,,,both,,,3452.00,1035.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1584.47,45.9,,,,,0,401.47,2934.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 100MM 2MM QUICK COUPLING CANNULATED NONSTERILE",SUP-310.19,CDM,S27000186,LOCAL,0270,RC,,,both,,,329.00,98.7,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,223.72,68,,,,,0,38.26,279.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DOVER 16IN 22FR URETHRAL HYDROGEL 5CC FOLEY 3 WAY LATEX",SUP-2722,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.35,43.6,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,59.74,41.1,,,,,0,16.9,123.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 75CM 20MM 6FR 8MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206080270,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST EXTERNAL FIXATION TRUELOK 2 HOLE NONSTERILE LATEX FREE",SUP-54-11610,CDM,C1713,HCPCS,0278,RC,,,both,,,1165.10,349.53,"BLUE CROSS [10001]","Blue Cross PPO",,456.72,39.2,,957.42,570.23,957.42,28,135.5,990.34,"percent of total billed charges",
"LINER ACETABULAR PINNACLE 10D +4MM 60MM 36MM MARATHON HIP",SUP-121936160,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1166.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1144.72,8366.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEIZURES WITH MCC",100,MS-DRG,,,,,,,inpatient,,,37993.84,11398.15,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 8X80 40CM SL",SUP-48008008P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2.4MM 10MM TITANIUM LOW PROFILE FOOT HAND ANKLE",SUP-AR-8724V-10,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"KAISER [10500]",Kaiser,,1085.4,67,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 13.6CM 8MM CEREPAK XL UNIFORM DETACHABLE",SUP-FCX180813,CDM,S27800098,LOCAL,0278,RC,,,both,,,15872.28,4761.68,"UHC [10700]","United Healthcare",,10047.15,63.3,,,,,0,1845.95,13491.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17MM 27MM 25MM EPIC LINX SUPRA BIOPROSTHESIS",SUP-E100-27A-00,CDM,S27800098,LOCAL,0278,RC,,,both,,,36722.70,11016.81,"PHCS [10601]",PHCS,,25705.89,70,,,,,0,4270.85,31214.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 685CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCM-685,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS [10001]","Blue Cross HMO",,2961.76,39.2,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 NARROW KNEE RIGHT CRUCIATE RETAIN CEMENTLESS",SUP-150401224,CDM,C1776,HCPCS,0278,RC,,,both,,,28775.25,8632.57,"AETNA [10100]","Aetna HMO/PPO",,22876.32,79.5,,10981.53,8986.79,12413.38,12,3346.56,24458.96,"percent of total billed charges",
"CLAMP SURGICAL .4-1MM ARTERY BLACK",SUP-B-1AB,CDM,S27200284,LOCAL,0272,RC,,,both,,,558.82,167.65,"KAISER [10500]",Kaiser,,374.41,67,,,,,0,64.99,475,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC",957,MS-DRG,,,,,,,inpatient,,,299460.93,89838.28,"UHC [10700]","United Healthcare",,222470.6,,"Fee schedule rate ($222,470.60). Includes an add-on of $12,519 when RC 0681-0682 total amount is above $1, $10,516 when RC 0683 total amount is above $1. Includes an add-on of 37.9% of RC 0274 if total amount is above $13,257, 37.9% of RC 0275 if total amount is above $13,257, 37.9% of RC 0276 if total amount is above $13,257, 37.9% of RC 0001-0999 if total amount is above $13,257, 63.3% of RC 0636 if total amount is above $13,257, 63.3% of RC 0343 if total amount is above $13,257, 63.3% of RC 0344 if total amount is above $13,257.",,,,0,7561,222470.6,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC 8- CM 25GA 1.83MM NITINOL 2.8MM BEVEL 1 WAY",SUP-M00555520,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"UHC [10700]","United Healthcare",,1030.52,63.3,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 54MM 26MM UHR UNIVERSAL ACETABULAR HIP COCR",SUP-UH1-54-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,511.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS MULTIPASS 4-0 PS-1 18IN BRAID ANTIBACTERIAL",SUP-VCP682G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHROMIC 2-0 CT 27IN MONOFILAMENT ABSORBABLE",SUP-801H,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,12.39,45.9,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UMBILI-CATH 34CM 5FR UMBILICAL POLYURETHANE NEONATE 1",SUP-4185005,CDM,S27200284,LOCAL,0272,RC,,,both,,,103.36,31.01,"MULTIPLAN [10600]",Multiplan,,87.86,85,,,,,0,12.02,87.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SINGLE USE INSTRUMENTS - FEMORAL KIT (CR) - SIZE 5",SUP-5555-2205,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 STD 17MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS4S17R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"BLUE CROSS [10001]","Blue Cross HMO",,4073.43,39.2,,5311.50,4717.44,5388.59,31,1208.52,8832.69,"percent of total billed charges",
"VEST 1 FRONT ZIP ADJUSTABLE SHOULDER STRAP CUP POSTOPERATIVE",SUP-111901,CDM,S27000186,LOCAL,0270,RC,,,both,,,945.03,283.51,"UHC [10700]","United Healthcare",,598.2,63.3,,,,,0,109.91,803.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RED 68 132CM THROMBECTOMY REPERFUSION CATH PENUMBRA",SUP-RED68KIT,CDM,C1757,HCPCS,0272,RC,,,both,,,17608.50,5282.55,"PHCS [10601]",PHCS,,12325.95,70,,,,,0,2047.87,14967.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL HAND 11GA OPTABLATE STERILE LATEX FREE DISPOSABLE",SUP-9700-811-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2970.62,891.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,352.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,345.48,2525.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMDESIVIR 100 MG/20ML IV (WET SOLR VIAL)",RX-415225383,CDM,J0248,HCPCS,0636,RC,61958-2901-02,NDC,both,1,UN,2615.60,784.68,"PHCS [10601]",PHCS,,1830.92,70,,,,,0,622.5,2223.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Proc Nfrosgrm Urtrgrm Exist",PX-361000413,CDM,50431,CPT,0361,RC,,,both,,,2165.97,649.79,"UHC [10700]","United Healthcare",,2165.97,,"Case rate ($2,385). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,251.9,2165.97,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"FENTANYL 100 MCG/HR TRANSDERMAL PATCH",RX-27908,CDM,,,0250,RC,47781-0428-11,NDC,both,1,UN,408.46,122.54,"UHC [10700]","United Healthcare",,258.56,63.3,,,,,0,47.5,347.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR .074IN 55CM ANL0 CURVE STRAIGHT TIP ANSEL",SUP-G56230,CDM,C1894,HCPCS,0272,RC,,,both,,,472.23,141.67,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,55.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,54.92,401.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 40MM 150CM 8MM VASCULAR NICKEL",SUP-EVD35-08-040-150,CDM,C1876,HCPCS,0278,RC,,,both,,,6285.00,1885.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2884.82,45.9,,,,,0,730.95,5342.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE EXTERNAL FIXATION 400MM 2MM SMOOTH MR CONDITIONAL",SUP-03.311.033,CDM,C1713,HCPCS,0278,RC,,,both,,,550.64,165.19,"CIGNA [10200]","Cigna Local Plus",,294.59,53.5,,3978.14,359.25,3978.14,24,64.04,468.04,"percent of total billed charges",
"TUBE 50MM 11.1MM 6.4MM UNCUFFED LARYNGECTOMY SHILEY TRACH 6",SUP-6LGT,CDM,S27200284,LOCAL,0272,RC,,,both,,,346.09,103.83,"AETNA [10100]","Aetna HMO/PPO",,275.14,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,40.25,294.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH APD FADER TIP 19CM 10FR DRNG PERCUFLEX LOCK PIGTAIL",SUP-M0064102030,CDM,C1729,HCPCS,0272,RC,,,both,,,713.85,214.15,"AETNA [10100]","Aetna HMO/PPO",,567.51,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,83.02,606.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DORADO CHECKER 80CM 8CM 7MM BALLOON DILATATION",SUP-DR8078,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,160.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 38MM ALPS T15 TIBIA CORTICAL DISTAL LOCK SELF",SUP-816135038,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",189.34,1383.8,"percent of total billed charges",
"SPHINTOM 200CM 30MM 5.5FR ULTRATOME XL BILIARY PANCREAS 3",SUP-M00535920,CDM,S27200284,LOCAL,0272,RC,,,both,,,999.05,299.71,"NOVANET [10819]",Novanet,,749.29,75,,,,,0,116.19,849.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 8MM KNEE XLK POSTERIOR LIPPED FIX BEARING PFC",SUP-158104108,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA [10200]","Cigna Local Plus",,5978.38,53.5,,5372.07,4581.20,7242.98,23,1299.6,9498.37,"percent of total billed charges",
"SYSTEM RESOLUTE ONYX 30MM 140CM .91-1.12MM 4MM CORONARY",SUP-RONYX40030W,CDM,C1874,HCPCS,0278,RC,,,both,,,5439.00,1631.7,"MULTIPLAN [10600]",Multiplan,,4623.15,85,,,,,0,632.56,4623.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rapid Infusion Reservoir Belmon",PX-E27000197,CDM,E27000197,LOCAL,0270,RC,,,both,,,653.18,195.95,"MULTIPLAN [10600]",Multiplan,,555.2,85,,,,,0,75.96,555.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sponge Wound Vac",PX-E27200211,CDM,E27200211,LOCAL,0272,RC,,,both,,,298.10,89.43,"FIRST HEALTH [10303]","First Health",,238.48,80,,,,,0,34.67,253.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE OSTEOSPONGE CANCELLOUS DEMINERALIZED BONE MATRIX",SUP-109609,CDM,C1713,HCPCS,0278,RC,,,both,,,8004.00,2401.2,"FIRST HEALTH [10303]","First Health",,6403.2,80,,,,,0,930.87,6803.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR .105IN 13CM ROBUST VALVE SPLITTABLE WITHOUT",SUP-PLSX-1008,CDM,C1892,HCPCS,0272,RC,,,both,,,304.50,91.35,"NOVANET [10819]",Novanet,,228.38,75,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 15CM 8MM GALAXY G3 NEUROVASCULAR 12 COIL",SUP-GLY120815,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4883.42,41.1,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 48MM HIP 3 HOLE POLY POROUS R3 STD STERILE",SUP-71335548,CDM,C1776,HCPCS,0278,RC,,,both,,,14345.10,4303.53,"MULTIPLAN [10600]",Multiplan,,12193.34,85,,,,,0,1668.34,12193.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PERICARDIOCENTESIS 40CM 8FR PIGTAIL CURVE CATH",SUP-PC801,CDM,C1729,HCPCS,0272,RC,,,both,,,1036.80,311.04,"NOVANET [10819]",Novanet,,777.6,75,,,,,0,120.58,881.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 18 25 X 50 COMPLEX FRAMING COIL",SUP-18CFR-25050,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"AETNA [10100]","Aetna HMO/PPO",,10395.02,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"XIENCE SKYPOINT DES 2.75 X 38 RX US",SUP-1804275-38,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIBIAL 7 5MM KNEE AOX CRUCIATE RETAIN ROTATE PLATFORM",SUP-151630705,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1526.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENT BONE SIMPLEX P RADIOPAQUE HALF DOSE",SUP-6188-1-010,CDM,S27800098,LOCAL,0278,RC,,,both,,,460.73,138.22,"NOVANET [10819]",Novanet,,345.55,75,,,,,0,53.58,391.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM PRESTIGE PLUS HELICAL HELICAL",SUP-PRES0620HPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,6555.00,1966.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,776.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,762.35,5571.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE POLY L LACTIC ACID 15MM 6.25MM ACL PCL",SUP-AR-1562BC,CDM,C1713,HCPCS,0278,RC,,,both,,,2716.88,815.06,"KAISER [10500]",Kaiser,,1820.31,67,,,,,0,315.97,2309.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT 16CM X 20CM CORTIVA DERMIS",SUP-DH1620,CDM,S27800098,LOCAL,0278,RC,,,both,,,52332.15,15699.64,"KAISER [10500]",Kaiser,,35062.54,67,,,,,0,6086.23,44482.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION",RX-98312,CDM,Q0138,HCPCS,0636,RC,59338-0775-01,NDC,both,17,ML,7204.65,2161.39,"CIGNA [10200]","Cigna Local Plus",,494.19,,,,,,,190.21,6123.95,"fee schedule",
"CLAREON UVA VIVITY TORIC AUTONOME",SUP-CCAET6,CDM,V2787,HCPCS,0276,RC,,,both,,,880.00,264,"MULTIPLAN [10600]",Multiplan,,748,85,,,,,0,102.34,748,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASSURANT 30MM 80CM 8MM 6FR .035IN BILIARY COBALT 2",SUP-ASC830SV,CDM,C1876,HCPCS,0278,RC,,,both,,,6444.60,1933.38,"AETNA [10100]","Aetna HMO/PPO",,5123.46,79.5,,,,,0,749.51,5477.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 32MM 2MM LCP CORTICAL STAINLESS STEEL SELF TAPPING",SUP-201.378.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"BLUE CROSS [10001]","Blue Cross PPO",,162.34,39.2,,957.42,570.23,957.42,28,48.16,352,"percent of total billed charges",
"SET DRNG 2.19FC AUTO EFFLUENT 12.6IN 22.44IN 13.39IN 4.83LB",SUP-115370,CDM,S27200284,LOCAL,0272,RC,,,both,,,579.90,173.97,"FIRST HEALTH [10303]","First Health",,463.92,80,,,,,0,67.44,492.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Biliary Duct via Tract",PX-361000190,CDM,47553,CPT,0361,RC,,,both,,,5081.43,1524.43,"BLUE CROSS [10001]","Blue Cross HMO",,4025.22,,"Case rate ($4,025.22). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,590.97,5081.43,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Biliary Duct via Tract",PX-361000190,CDM,47553,CPT,0361,RC,,,both,,,5081.43,1524.43,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,590.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,590.97,5081.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Stent Sf Ea Add",PX-361000709,CDM,37268,CPT,0361,RC,,,both,,,13927.30,4178.19,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1249,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,13.93,11838.21,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Stent Sf Ea Add",PX-361000709,CDM,37268,CPT,0361,RC,,,both,,,13927.30,4178.19,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1650.39,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.93,11838.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Fem/Pop W Stent Sf Ea Add",PX-361000709,CDM,37268,CPT,0361,RC,,,both,,,13927.30,4178.19,"NOVANET [10819]",Novanet,,10445.48,75,,,,,0,13.93,11838.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT WALLSTENT UNISTEP PLUS 70MM 75CM 24MM 100CM",SUP-H965405120,CDM,C1876,HCPCS,0278,RC,,,both,,,14331.30,4299.39,"CIGNA [10200]","Cigna Open Access",,4800.99,33.5,,,,,0,1666.73,12181.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 64MM HIP 5 SCR HOLE CLUSTER METAL HA",SUP-502-11-64H,CDM,C1776,HCPCS,0278,RC,,,both,,,9525.45,2857.63,"UHC [10700]","United Healthcare",,6029.61,63.3,,8601.07,8395.67,8601.07,"1 through 10",1107.81,8096.63,"percent of total billed charges",
"GUIDE DRILL TAN 3.2MM SURESHOT PIN",SUP-71631436,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,747.25,45.9,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANNULA PERFUSION ADULT 20FR L10IN ARTERIAL 3/8IN CONNECTOR",SUP-81120R,CDM,S27200284,LOCAL,0272,RC,,,both,,,162.60,48.78,"CIGNA [10200]",Cigna,,110.57,68,,,,,0,18.91,138.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 195MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-410-195,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"BLUE CROSS [10001]","Blue Cross PPO",,6791.4,39.2,,957.42,570.23,957.42,28,2014.9,14726.25,"percent of total billed charges",
"CATH QUICK-CROSS 90CM 1.8FR .03-.044IN 15MM SPACE SPRT",SUP-518-033,CDM,C1887,HCPCS,0272,RC,,,both,,,972.00,291.6,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,115.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 2-0 STP-10 27IN 2 ARM BRAID GREEN NONABSORBABLE",SUP-X997G,CDM,S27200284,LOCAL,0272,RC,,,both,,,191.76,57.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.72,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.3,163,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Entire Spine 6v>",PX-320000203,CDM,72084,CPT,0320,RC,,,both,,,892.00,267.6,"PHCS [10601]",PHCS,,624.4,70,,,,,0,103.74,758.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AEQUALIS PERFORM ORTHOPEDIC 220MM 2.5MM GLENOID",SUP-DWD017,CDM,C1776,HCPCS,0278,RC,,,both,,,1556.00,466.8,"BLUE CROSS [10001]","Blue Cross PPO",,609.95,39.2,,3949.44,3949.44,3949.44,"1 through 10",180.96,1322.6,"percent of total billed charges",
"EXERCISER HAND JUX-A-CISOR 60INX12.5IN STEEL ARM 25 BEND PAD",SUP-5288,CDM,S27000186,LOCAL,0270,RC,,,both,,,327.99,98.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,38.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,38.15,278.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 300MM 2.8MM THREAD STERILE",SUP-03.333.015S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1178.79,353.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,541.06,45.9,,,,,0,137.09,1001.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CRE 240CM 5.5CM 7.5FR 12-13.5-15MM ESOPHAGUS",SUP-M00558690,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1121.34,68,,,,,0,191.78,1401.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 75CM 7FR ENDOCARDIAL TRUE BIPOLAR ACTIVE",SUP-7121/75,CDM,C1895,HCPCS,0278,RC,,,both,,,21892.50,6567.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6265.63,28.62,,,,,0,2546.1,18608.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 34MM LOW PROFILE LOCK TUBE STERILE RFN-ADVANCED",SUP-04.045.334TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1869.90,560.97,"BLUE CROSS [10001]","Blue Cross HMO",,733,39.2,,957.42,156.86,7483.26,51,217.47,1589.42,"percent of total billed charges",
"INTRO SHEATH 5FR 12CM WIRE MANDREL HEMOSTASIS VALVE MICRO",SUP-CLI-101-15,CDM,C1894,HCPCS,0272,RC,,,both,,,295.80,88.74,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"3.0 X 18MM ESPRIT BTK IDE",SUP-1202300-18,CDM,C1874,HCPCS,0624,RC,,,both,,,0.01,,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,,45.9,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CABLE CATH ACHIEVE MAPPING",SUP-990066,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATHETER TORQR 65CM 5FR 2-5-2MM SPACING CORONARY SINUS CURVE",SUP-041565CSR,CDM,C1730,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) TRANS-FEMORAL DELIVERY SYSTEM",SUP-TTVR-DS-26113,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE UROLOGICAL L150CM DIA0.035IN 3CM TAPERED NITINOL H",SUP-M0066802231,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CNCT SHUNT ACCU-FLO STRAIGHT CSF RADIOPAQUE CATH PLASTIC",SUP-45103,CDM,S27800098,LOCAL,0278,RC,,,both,,,755.57,226.67,"MULTIPLAN [10600]",Multiplan,,642.23,85,,,,,0,87.87,642.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PHASIX UMBILICAL LARGE CIRCLE W/ STRAP (8.0CM)",SUP-1230009,CDM,C1781,HCPCS,0278,RC,,,both,,,12144.00,3643.2,"CIGNA [10200]","Cigna Open Access",,4068.24,33.5,,11235.02,819.42,11235.02,"1 through 10",1412.35,10322.4,"percent of total billed charges",
"LENS IOL 5 D +27 DIOPTER MODIFY C BICONVEX 13MM 6MM",SUP-AR40E00270,CDM,V2632,HCPCS,0276,RC,,,both,,,931.50,279.45,"BLUE CROSS [10001]","Blue Cross HMO",,365.15,39.2,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 3-0 CV-23 .5 CIRCLE 9IN 17MM CLSR SURGALLOY",SUP-VLOCL0844,CDM,S27200284,LOCAL,0272,RC,,,both,,,405.94,121.78,"CIGNA [10200]","Cigna Open Access",,230.98,56.9,,,,,0,47.21,345.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC 56.6CM 5MM DA VINCI S/SI ENDOWRIST",SUP-420139,CDM,S27000186,LOCAL,0270,RC,,,both,,,27090.00,8127,"NOVANET [10819]",Novanet,,20317.5,75,,,,,0,3150.57,23026.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BIOPSY 15CM 11GA OSTEO-SITE 30D SIDE BEVEL DIAMOND BONE",SUP-G12374,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET ENDOTRACHEAL 10MM 4MM VIVASIGHT 2 LUMEN NONSTERILE LATEX",SUP-412351000,CDM,S27200284,LOCAL,0272,RC,,,both,,,1950.00,585,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TORCON NB ADVANTAGE BEACON 80CM 5FR C2 CURVE",SUP-G11202,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET EPIDURAL 3 2/3IN 21GA 18GA SONOPLEX CORNERSTONE 20GA",SUP-211285-40E,CDM,C9812,HCPCS,0272,RC,,,both,,,321.90,96.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CUFF TOURNIQUET W4.125XL24IN SINGLE PORT SINGLE BLADDER CYLI",SUP-60-7075-104R,CDM,S27200284,LOCAL,0272,RC,,,both,,,180.73,54.22,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER 4MM 40D CURVE 2 SERRATE DISPOSABLE",SUP-SSB-12440-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Prolact Cr Qtr Btl",PX-E27000211,CDM,E27000211,LOCAL,0270,RC,,,both,,,57.20,17.16,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"AIMING GUIDE 2.4MM",SUP-PDG-AIM-24,CDM,S27000186,LOCAL,0270,RC,,,both,,,2392.50,717.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH 45CM 14FR .038IN DRNG ULTRATHANE HYDROPHILIC 6 SIDEPORT",SUP-G09768,CDM,C1729,HCPCS,0272,RC,,,both,,,769.42,230.83,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL 12-30D LOOP NDL RESECTASCOPE",SUP-WA22655S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2941.82,882.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SURESIGHT BLADE HYPERANGULATED SIZE 3 CHANNELED",SUP-390531000,CDM,S27000186,LOCAL,0270,RC,,,both,,,321.90,96.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION",RX-8878,CDM,,,0250,RC,00517-6101-25,NDC,both,10,ML,278.14,83.44,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL DISSECTING 8CM 1.5MM LEGEND TAPERED STERILE",SUP-F1/8TA15,CDM,S27200284,LOCAL,0272,RC,,,both,,,974.03,292.21,"CIGNA [10200]",Cigna,,662.34,68,,,,,0,113.28,827.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 60MM 3MM BALLOON DILATATION OTW STERILE",SUP-593006022,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH COYOTE 150CM 100MM 3MM .014IN BALLOON DILATATION NYBAX",SUP-39186-30101,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,532.66,41.1,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 11.9-11.7CM NATRELLE BIOCELL P5-5.9CM HIGH",SUP-SZHP68400,CDM,S27200284,LOCAL,0272,RC,,,both,,,304.50,91.35,"UHC [10700]","United Healthcare",,192.75,63.3,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 90X30MM EIKON LT SMOOTH SURGICAL",SUP-C90,CDM,S27200284,LOCAL,0272,RC,,,both,,,7832.88,2349.86,"UHC [10700]","United Healthcare",,4958.21,63.3,,,,,0,910.96,6657.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Excsn Lesn Tr/Ext 2.1-3.0cm",PX-510000029,CDM,11403,CPT,0761,RC,,,both,,,4138.00,1241.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1700.72,41.1,,,,,0,481.25,3517.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR AMPLATZ LEFT 2 CURVE",SUP-534646T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"PHCS [10601]",PHCS,,60.9,70,,,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 18MM 52MM SHOULDER SOFT TISSUE BALANCE",SUP-7122887,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CIGNA [10200]","Cigna Local Plus",,4237.2,53.5,,5372.07,4581.20,7242.98,23,921.1,6732,"percent of total billed charges",
"STENT VIABAHN 10CM 75CM 7MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBHR071001A,CDM,C1874,HCPCS,0278,RC,,,both,,,21268.80,6380.64,"FIRST HEALTH [10303]","First Health",,17015.04,80,,,,,0,2473.56,18078.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC XL 24IN 22-26IN KNEE LOOP LOCK CLSR",SUP-79-80038,CDM,S27000186,LOCAL,0270,RC,,,both,,,117.10,35.13,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.62,99.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC",417,MS-DRG,,,,,,,inpatient,,,77914.60,23374.38,"CARESOURCE MARKETPLACE  [11106]","Caresource Marketplace",,31826.41,,"Case rate ($14,802.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $13,745.57, add-ons for qualifying new technology services are included. If operating cost exceeds $46,785.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,421.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,763.75. The transfer operating threshold is the transfer adjustment factor * $13,745.57 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,039.23. The transfer capital threshold is the transfer adjustment factor * $1,039.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 215%.",,,,0,7561,69673.33,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM 22-26-28-32-36MM HIP 3 HOLE POROUS",SUP-71336058,CDM,C1776,HCPCS,0278,RC,,,both,,,22160.25,6648.07,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2625.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2577.24,18836.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 2MM LARGE 160MM VITALLIUM 2 CABLE GRIP DALL-MILES BONE",SUP-6704-3-092,CDM,C1713,HCPCS,0278,RC,,,both,,,7154.78,2146.43,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4865.25,68,,,,,0,832.1,6081.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUTNER 70CM 5FR 14FR UNIVERSAL URETERAL ADULT WEDGE",SUP-G14057,CDM,C1758,HCPCS,0272,RC,,,both,,,115.01,34.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,47.27,41.1,,,,,0,13.38,97.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 300MM 5MM 2.9MM CANNULATED LARGE QUICK COUPLING",SUP-310.63S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2534.40,760.32,"FIRST HEALTH [10303]","First Health",,2027.52,80,,,,,0,294.75,2154.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UNI-FUSE FLOW-THRU HUB 90CM 2CM 5FR THROMBECTOMY",SUP-H787124018415,CDM,C1757,HCPCS,0272,RC,,,both,,,1417.50,425.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,582.59,41.1,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 85MM 32MM LCP STAINLESS STEEL CANCELLOUS LONG",SUP-217.085,CDM,C1713,HCPCS,0278,RC,,,both,,,485.35,145.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,57.51,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",56.45,412.55,"percent of total billed charges",
"CATH SABERX 90CM 40MM 3MM BALLOON DILATATION RAPID EXCHANGE",SUP-47530040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"AETNA [10100]","Aetna HMO/PPO",,1268.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 130MM 5.5MM STRAIGHT",SUP-7571130,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,826.2,68,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PERSONA TKR VIVACIT-E FEMUR PATELLA TIBIA CEMENT",SUP-98000241100,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6671.32,28.62,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 8MM PFC SIGMA 2.5 KNEE POSTERIOR TITANIUM CEMENT",SUP-96-0848,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"CIGNA [10200]","Cigna Local Plus",,2745,53.5,,5372.07,4581.20,7242.98,23,596.72,4361.21,"percent of total billed charges",
"STEM FEMORAL 113MM TRI-LOCK BPS GRIPTION 9 12/14 HIGH OFFSET",SUP-101214090,CDM,C1776,HCPCS,0278,RC,,,both,,,29153.25,8745.97,"CIGNA [10200]","Cigna Local Plus",,9183.27,31.5,,5372.07,4581.20,7242.98,23,3390.52,24780.26,"percent of total billed charges",
"STENT POLARIS ZIPWIRE 20CM 150CM 8FR .038IN 3CM 2 PIGTAIL",SUP-M006155250170,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,165.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 50MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0250,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross PPO",,371.5,39.2,,957.42,570.23,957.42,28,110.22,805.55,"percent of total billed charges",
"LENS IOL ASPHERIC OPTIC 1 PIECE FOLDABLE UV BLUE LIGHT",SUP-SN6AT5.285,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27X24-32X17MM FRA 8D SPINE THORACOLUMBAR",SUP-10517,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7560,40,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX 75CM 60MM 7MM BALLOON DILATATION DRUG COATED",SUP-LX3575760V,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"MULTIPLAN [10600]",Multiplan,,5718.38,85,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE CATH BLACK 150CM RESPONSE ELECTROPHYSIOLOGY HEXAPOLAR",SUP-401972R,CDM,C1769,HCPCS,0272,RC,,,both,,,287.10,86.13,"KAISER [10500]",Kaiser,,192.36,67,,,,,0,33.39,244.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 9CM 3MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036123090,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 80MM TITANIUM SHORT THREAD CANNULATED STERILE",SUP-04.353.780S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"CIGNA [10200]",Cigna,,1672.39,68,,1831.33,1831.33,1831.33,16,286.03,2090.49,"percent of total billed charges",
"CLAMP SURGICAL BECK COOLEY LARGE MEDIUM CURVE STRAIGHT 6IN",SUP-55-5037,CDM,S27200284,LOCAL,0272,RC,,,both,,,1191.92,357.58,"PHCS [10601]",PHCS,,834.34,70,,,,,0,138.62,1013.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRIVER NDL 1.4CM MEGA SUT CUT ENDOWRIST 0-35D VERY HIGH",SUP-471309,CDM,S27000186,LOCAL,0270,RC,,,both,,,1488.78,446.63,"KAISER [10500]",Kaiser,,997.48,67,,,,,0,173.15,1265.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 100MMX4.5MM PROXIMATE TITANIUM THICK TISSUE 4",SUP-TRT10,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.51,675.15,"FIRST HEALTH [10303]","First Health",,1800.41,80,,,,,0,261.73,1912.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN EXTRA BACKUP LEFT 3 CURVE",SUP-LA7EBU30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTAPRO ATHERECTOMY PRECONNECT EXCHANGEABLE BURR",SUP-H749394671250,CDM,C1724,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 28X10X12MM CASCADIA CONVEX TITANIUM POROUS",SUP-6101-2102812NC-G2,CDM,S27800098,LOCAL,0278,RC,,,both,,,22050.00,6615,"FIRST HEALTH [10303]","First Health",,17640,80,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 5MM25CM 190",SUP-R51005025L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,295.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATHETERIZATION 18FR SURESTEP BARDEX IC COMPLETE CARE",SUP-A300318A,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.29,41.79,"AETNA [10100]","Aetna HMO/PPO",,110.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.2,118.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC UNIVERSAL LSO LOW PROFILE CUSTOMIZE XIPHOID",SUP-993735,CDM,S27000186,LOCAL,0270,RC,,,both,,,1442.12,432.64,"CIGNA [10200]",Cigna,,980.64,68,,,,,0,167.72,1225.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE MARKER 3 X 4 BIOZORB",SUP-F0304,CDM,A4648,HCPCS,0278,RC,,,both,,,8383.50,2515.05,"UHC [10700]","United Healthcare",,5306.76,63.3,,,,,0,975,7125.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 9MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530P509,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"UHC [10700]","United Healthcare",,5289.28,63.3,,8601.07,8395.67,8601.07,"1 through 10",971.79,7102.52,"percent of total billed charges",
"APPLR SURGICAL SPRAY TIP STERILE DISPOSABLE FIBRIJET",SUP-SA-3671,CDM,S27200284,LOCAL,0272,RC,,,both,,,73.60,22.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,33.78,45.9,,,,,0,8.56,62.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 14X8MM REDUCE PROFILE COALITION AGX BONE SPINE",SUP-1128.2208,CDM,C1713,HCPCS,0278,RC,,,both,,,9660.00,2898,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1144.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,1123.46,8211,"percent of total billed charges",
"CATH CHRG 135CM 40MM 5FR 5MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206050410,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC XL 4IN FINGER SPRING EXT ASSIST WIRE-FOAM",SUP-501D,CDM,S27000186,LOCAL,0270,RC,,,both,,,85.87,25.76,"CIGNA [10200]","Cigna Local Plus",,45.94,53.5,,,,,0,9.99,72.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM 2 FULL THREAD HEALICOIL ULTRABRAID SHOULDER",SUP-72203706,CDM,C1713,HCPCS,0278,RC,,,both,,,2283.75,685.12,"BLUE CROSS [10001]","Blue Cross HMO",,895.23,39.2,,957.42,156.86,7483.26,51,265.6,1941.19,"percent of total billed charges",
"SCREW BONE L50MM DIA5MM CARBURIZED VARIABLE ANGLE LOCKING SE",SUP-42.231.250,CDM,C1713,HCPCS,0278,RC,,,both,,,1352.54,405.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,919.73,68,,,,,0,157.3,1149.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 27CM 10MM AVENIR 10 COIL FRAME COMPLEX",SUP-10CFR-10027,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1363.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL CRUCIATE STABILIZE CEMENTED PFC SIGMA TC3 2 60",SUP-960087,CDM,C1776,HCPCS,0278,RC,,,both,,,27588.96,8276.69,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7449.02,27,,,,,0,3208.6,23450.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL BECK COOLEY LARGE MEDIUM CURVE STRAIGHT 6IN",SUP-55-5037,CDM,S27200284,LOCAL,0272,RC,,,both,,,1191.92,357.58,"UHC [10700]","United Healthcare",,754.49,63.3,,,,,0,138.62,1013.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AIMING GUIDE 2.4MM",SUP-PDG-AIM-24,CDM,S27000186,LOCAL,0270,RC,,,both,,,2392.50,717.75,"AETNA [10100]","Aetna HMO/PPO",,1902.04,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,278.25,2033.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 12MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS45012,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA [10200]","Cigna Open Access",,27813.28,33.5,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 8X40 40CM SL",SUP-48008004P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,667.85,68,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE LIGHT GREEN 64MM 5MM NAIL-EX FEMORAL TIBIAL",SUP-04.005.554,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,786.54,68,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Prolact Cr Qtr Btl",PX-E27000211,CDM,E27000211,LOCAL,0270,RC,,,both,,,57.20,17.16,"FIRST HEALTH [10303]","First Health",,45.76,80,,,,,0,6.65,48.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 7CM 7FR PANCREATIC POLYETHYLENE POSITION SLEEVE",SUP-G21479,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,143.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 65MM STERILE",SUP-74013480,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.02,64.21,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.89,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.89,181.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER ANGIO LCB CRV 6FR 100CM",SUP-H749165991952,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]",Cigna,,52.07,68,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2-0 FS 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8685H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"UHC [10700]","United Healthcare",,16.46,63.3,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ARTHROSCOPIC NANOSCOPE",SUP-AR-10100N,CDM,S27200284,LOCAL,0272,RC,,,both,,,1318.28,395.48,"AETNA [10100]","Aetna HMO/PPO",,1048.03,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,153.32,1120.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC XL 24IN 22-26IN KNEE LOOP LOCK CLSR",SUP-79-80038,CDM,S27000186,LOCAL,0270,RC,,,both,,,117.10,35.13,"AETNA [10100]","Aetna HMO/PPO",,93.09,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.62,99.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 34X24X8MM MODULUS 15D ALIF STERILE LATEX FREE",SUP-1921006P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"AETNA [10100]","Aetna HMO/PPO",,27546.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30MMX13MM VERTE-STACK CRESCENT LUMBAR",SUP-293013,CDM,S27800098,LOCAL,0278,RC,,,both,,,24290.28,7287.08,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6951.88,28.62,,,,,0,2824.96,20646.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 60MM 7MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171070610,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,482.72,41.1,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC BREAST BIOPSY 13CM 9GA 3.7MM EVIVA 20MM SITE LOCALIZER","SUP-EVIVA 0913-20",CDM,S27200284,LOCAL,0272,RC,,,both,,,2000.63,600.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,237.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,232.67,1700.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE OPHTHALMIC 11.0X1.6X5.9MM LASEREDGE 15D FULL HANDLE ST",SUP-LP7515,CDM,S27200284,LOCAL,0272,RC,,,both,,,54.81,16.44,"NOVANET [10819]",Novanet,,41.11,75,,,,,0,6.37,46.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL IRRIGATION SORBITOL MANNITOL FLEXIBLE CNTNR 3L LATEX",SUP-07981-08,CDM,S27200284,LOCAL,0272,RC,,,both,,,112.93,33.88,"CIGNA [10200]","Cigna Local Plus",,60.42,53.5,,,,,0,13.13,95.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 10MM YUKON SPINE OCCIPITOCERVICOTHORACIC",SUP-7601-03510,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"KAISER [10500]",Kaiser,,3004.95,67,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Group (Gp)",PX-423000001,CDM,97150,CPT,0423,RC,,,both,,,172.00,51.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,20.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20,172,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2 TP-1 27IN BRAID 2 STRAND ANTIBACTERIAL",SUP-VCP849G,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.55,24.16,"MULTIPLAN [10600]",Multiplan,,68.47,85,,,,,0,9.37,68.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GEENEN 7CM 7FR PANCREATIC POLYETHYLENE POSITION SLEEVE",SUP-G21479,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,837.22,68,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BIOPSY 60CM 7FR 18GA TLAB STRAIGHT CURVE METAL 4 SWAB",SUP-TL-18C,CDM,S27200284,LOCAL,0272,RC,,,both,,,3875.04,1162.51,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE OXYGEN SAMPLE BODY BOX SAMPLE LINE ASSEMBLY FOR V62J AN",SUP-769525,CDM,S27200284,LOCAL,0272,RC,,,both,,,792.02,237.61,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT POLYESTER ETHIBOND 0 MO-6 18IN CONTROL RELEASE BRAID 8",SUP-CX45D,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.15,44.74,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH FLEXIMA 70CM 8FR URETERAL 1 LUMEN INJECTION HUB",SUP-M0064002041,CDM,C1758,HCPCS,0272,RC,,,both,,,80.01,24,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 8CM 4.5MM AVENIR COMPLEX 10 COIL FINISH",SUP-10CFN04508,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]","Cigna Open Access",,3927.24,33.5,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Creatine Kinase Total",PX-301000163,CDM,82550,CPT,0301,RC,,,both,,,171.23,51.37,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,6.97,,"Fee schedule rate ($6.97). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",7.60,7.60,7.60,"1 through 10",0.17,145.55,"fee schedule",
"BIT DRILL 2MM CANNULATED NONSTERILE LATEX REUSABLE",SUP-MSN10002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest Hemorrhoid Thermal Energy",PX-750000215,CDM,46930,CPT,0750,RC,,,both,,,3525.00,1057.5,"BLUE CROSS [10001]","Blue Cross HMO",,3301.54,,"Case rate ($3,301.54). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,409.96,3525,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL JOURNEY 6 KNEE LEFT BICRUCIATE STABILIZE",SUP-74022226,CDM,C1776,HCPCS,0278,RC,,,both,,,16622.10,4986.63,"CIGNA [10200]","Cigna Local Plus",,5235.96,31.5,,5372.07,4581.20,7242.98,23,1933.15,14128.79,"percent of total billed charges",
"PANTOPRAZOLE SODIUM 40 MG/10ML IV (WET SOLR VIAL)",RX-41526226,CDM,J2470,HCPCS,0636,RC,72603-0128-01,NDC,both,1,UN,52.92,15.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,25.72,48.6,,,,,0,2.2,44.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mech Thromb Secndry Artl Add",PX-361000133,CDM,37186,CPT,0361,RC,,,both,,,5304.87,1591.46,"KAISER [10500]",Kaiser,,3554.26,67,,,,,0,616.96,5304.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mech Thromb Secndry Artl Add",PX-361000133,CDM,37186,CPT,0361,RC,,,both,,,5304.87,1591.46,"AETNA [10100]","Aetna HMO/PPO",,4217.37,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,616.96,5304.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mech Thromb Secndry Artl Add",PX-361000133,CDM,37186,CPT,0361,RC,,,both,,,5304.87,1591.46,"MULTIPLAN [10600]",Multiplan,,4509.14,85,,,,,0,616.96,5304.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Mech Thromb Secndry Artl Add",PX-361000133,CDM,37186,CPT,0361,RC,,,both,,,5304.87,1591.46,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5304.87,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,616.96,5304.87,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ER Laryngoscopy Direct Dx (Exc",PX-450000372,CDM,31525,CPT,0450,RC,,,both,,,3057.00,917.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,725,,,,,,,67.13,3057,"case rate",
"STENT ZILVER PTX 140MM 5MM VASCULAR DRUG ELUTE ACCEPTS .035",SUP-G38416,CDM,C1874,HCPCS,0278,RC,,,both,,,15906.62,4771.99,"BLUE CROSS [10001]","Blue Cross PPO",,6235.4,39.2,,,,,0,1849.94,13520.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 140MM 14MM 13FR 10FR TRIVASCULAR OVATION PRIME",SUP-TV-IL1414140-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"PHCS [10601]",PHCS,,23373,70,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X11MM VERTE-STACK CORNERSTONE PSR",SUP-6240141,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"AETNA [10100]","Aetna HMO/PPO",,5309.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 135D STD BARREL 78MM STAINLESS STEEL 1 STEP SYSTEM 4",SUP-281.140,CDM,C1713,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Local Plus",,2000.9,53.5,,3978.14,359.25,3978.14,24,434.96,3179,"percent of total billed charges",
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 8 STD OFFSET HIP",SUP-71935568,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"CIGNA [10200]",Cigna,,14613.48,40,,5873.17,5873.17,5873.17,"1 through 10",4248.87,31053.65,"percent of total billed charges",
"STENT EVERFLEX 100MM 120CM 8MM VASCULAR PERIPHERAL SELF",SUP-PRB35-08-100-120,CDM,C1876,HCPCS,0278,RC,,,both,,,7098.00,2129.4,"KAISER [10500]",Kaiser,,4755.66,67,,,,,0,825.5,6033.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE LARYNSCP MACINTOSH 4 STAINLESS STEEL FIBER OPTIC",SUP-040-914U,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 4FR 2-5-2MM SPACE STD A CURVE ELECTROPHYSIOLOGY FIX",SUP-112449S,CDM,C1730,HCPCS,0272,RC,,,both,,,2317.50,695.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,274.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,269.53,1969.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 150MM 5MM KII FIOS FIRST ENTRY ADVANCED",SUP-CFF01,CDM,S27200284,LOCAL,0272,RC,,,both,,,143.55,43.06,"PHCS [10601]",PHCS,,100.49,70,,,,,0,16.69,122.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 3CM 6FR .038IN PIGTAIL CURVE STRAIGHT URETERAL",SUP-M006145364010,CDM,C2617,HCPCS,0278,RC,,,both,,,966.90,290.07,"KAISER [10500]",Kaiser,,647.82,67,,,,,0,112.45,821.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLUG LEAD IMAGEREADY IS4 DS4 PORT",SUP-7148,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Open Access",,691.34,56.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPONGE ABSORBABLE 4X3IN HELISTAT HEMOSTATIC AGENT 5ML",SUP-3410ZX,CDM,S27200284,LOCAL,0272,RC,,,both,,,1551.97,465.59,"CIGNA [10200]",Cigna,,1055.34,68,,,,,0,180.49,1319.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHLORTHALIDONE 25 MG TABLET",RX-1661,CDM,,,0637,RC,51079-0058-01,NDC,both,1,UN,11.54,3.46,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.34,9.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS ZIPWIRE 20CM 3CM 5FR .035IN",SUP-M006192120190,CDM,C2617,HCPCS,0278,RC,,,both,,,1395.23,418.57,"CIGNA [10200]","Cigna Local Plus",,746.45,,,,,,,162.27,1185.95,"percent of total billed charges",
"AGENT HEMOSTATIC MICROFIBRILLAR CLLGN SPONGE AVITENE",SUP-1050050,CDM,S27200284,LOCAL,0272,RC,,,both,,,395.42,118.63,"NOVANET [10819]",Novanet,,296.57,75,,,,,0,45.99,336.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 9-0 BV100-4 5IN MONOFILAMENT BLACK NONABSORBABLE",SUP-2829G,CDM,S27200284,LOCAL,0272,RC,,,both,,,253.80,76.14,"CIGNA [10200]",Cigna,,172.58,68,,,,,0,29.52,215.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GA-68-GOZETOTIDE INTRAVENOUS SOLUTION (4 MCI)",RX-411539,CDM,A9596,HCPCS,0343,RC,08888-8878-70,NDC,both,1,UN,24796.80,7439.04,"NOVANET [10819]",Novanet,,18597.6,75,,,,,0,1181,21077.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB BONE GRAFT BTCP CLLGN 5ML VITOSS VOID FILLER FOAM PACK",SUP-2102-1605,CDM,C1713,HCPCS,0278,RC,,,both,,,4312.50,1293.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,511.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",501.54,3665.63,"percent of total billed charges",
"OCCL CARDIOVASCULAR 7MM 6MM MUSCLE 2 DISK SELF EXPANDABLE",SUP-9-VSD-MUSC-006,CDM,C1817,HCPCS,0278,RC,,,both,,,62700.00,18810,"KAISER [10500]",Kaiser,,42009,67,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COVER PROBE ULTRACOVER 244X12CM FOLD INTRAOPERATIVE TAPE",SUP-PC3787,CDM,S27200284,LOCAL,0272,RC,,,both,,,50.73,15.22,"AETNA [10100]","Aetna HMO/PPO",,40.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.9,43.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OBTR ENDOSCOPIC 19.8FR OES PRO CYSTOURETHROSCOPE VISUAL",SUP-A20922A,CDM,S27200284,LOCAL,0272,RC,,,both,,,4573.32,1372,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,531.88,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,531.88,3887.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lactate Dehydrogenase",PX-301000292,CDM,83615,CPT,0301,RC,,,both,,,141.70,42.51,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,6.34,,"Fee schedule rate ($6.34). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",6.35,6.35,6.35,"1 through 10",0.14,120.45,"fee schedule",
"ESPRIT BTK 2.50 X 18 MM RX FDA",SUP-1203250-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2006.18,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 60.5X18.5X.64MM SAGITTAL REPROCESSED STERILE LATEX",SUP-2108-120,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.83,30.85,"CIGNA [10200]","Cigna Local Plus",,55.01,53.5,,,,,0,11.96,87.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 15CM 45MM GORE TAG THORACIC ACTIVE CONTROL",SUP-TGM454515,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"CIGNA [10200]","Cigna Open Access",,38850.69,33.5,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 48MM 32MM ALTRX HIP",SUP-122132048,CDM,C1776,HCPCS,0278,RC,,,both,,,5307.67,1592.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2436.22,45.9,,,,,0,617.28,4511.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .018IN 5FR 6MM 120CM 10CM PTA OTW",SUP-435600L,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UHC [10700]","United Healthcare",,794.73,63.3,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC",417,MS-DRG,,,,,,,inpatient,,,77914.60,23374.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,47372.43,,"Fee schedule rate ($47,372.43). Includes an add-on of 40% of RC 0274 if total amount is above $41,867, 40% of RC 0275 if total amount is above $41,867, 40% of RC 0001-0999 if total amount is above $41,867, 65% of RC 0343 if total amount is above $7,218, 65% of RC 0344 if total amount is above $7,218, 65% of RC 0636 if total amount is above $7,218.",,,,0,7561,69673.33,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE SURGICAL ERBELIFT 260CM 1.3MM FLEXIBLE CONNECT HUB",SUP-20350-220,CDM,S27200284,LOCAL,0272,RC,,,both,,,485.60,145.68,"FIRST HEALTH [10303]","First Health",,388.48,80,,,,,0,56.48,412.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 8FR .09IN EXTRA BACKUP 3.75 LEFT CURVE",SUP-LA8EBU375D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,160.91,41.1,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X6MM GRAFTECH 7D 11MM CERVICAL CANCELLOUS",SUP-A80056,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,601.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT HAND ACCESS LOW PROFILE OBTR AUTOMATIC VENT BLADELESS",SUP-IAS8-100LP,CDM,S27200284,LOCAL,0272,RC,,,both,,,723.29,216.99,"FIRST HEALTH [10303]","First Health",,578.63,80,,,,,0,84.12,614.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR 1.8MM STRAIGHT FLUSH CURVE",SUP-H787107086035,CDM,C1887,HCPCS,0272,RC,,,both,,,190.36,57.11,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,22.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,22.14,161.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 3-0 RB-1 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP215H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TUBE FEEDING ORANGE 40CM 5FR NUTRIO TWISTLOK ENTERAL",SUP-ENSI4050,CDM,S27200284,LOCAL,0272,RC,,,both,,,107.36,32.21,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH ULTRAVERSE 035 GEOALIGN 75CM 60MM 12MM BALLOON",SUP-U3575126,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,282.97,41.1,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 10MM KNEE N2VAC POSTERIOR STABILIZE BEARING",SUP-82-3-0710,CDM,C1776,HCPCS,0278,RC,,,both,,,7890.15,2367.04,"AETNA [10100]","Aetna HMO/PPO",,6272.67,79.5,,10981.53,8986.79,12413.38,12,917.62,6706.63,"percent of total billed charges",
"HC Dna Ab Native/Double Strand",PX-302000036,CDM,86225,CPT,0302,RC,,,both,,,427.50,128.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,363.38,"per diem",
"BLADE 1 SMALL REVERSE CURVE 12MM ADENOTOME LAFORCE SHAMBAUGH",SUP-71-1061,CDM,S27200284,LOCAL,0272,RC,,,both,,,165.74,49.72,"CIGNA [10200]","Cigna Open Access",,94.31,56.9,,,,,0,19.28,140.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER ETHIBOND 0 MO-6 18IN CONTROL RELEASE BRAID 8",SUP-CX45D,CDM,S27200284,LOCAL,0272,RC,,,both,,,149.15,44.74,"KAISER [10500]",Kaiser,,99.93,67,,,,,0,17.35,126.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL ATTUNE S+ 4 KNEE CEMENT FIX BEARING",SUP-150670004,CDM,C1776,HCPCS,0278,RC,,,both,,,15487.05,4646.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4432.39,28.62,,,,,0,1801.14,13163.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX LUBRICATH 26FR STD URETHRAL NATURAL RUBBER",SUP-0119L26,CDM,C1726,HCPCS,0272,RC,,,both,,,77.52,23.26,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,52.71,68,,,,,0,9.02,65.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT TIGERTAPE TIGERWIRE 2 2MM 8IN BLUE 24IN NONABSORBABLE",SUP-AR-7275T,CDM,S27200284,LOCAL,0272,RC,,,both,,,595.35,178.6,"CIGNA [10200]",Cigna,,404.84,68,,,,,0,69.24,506.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE 2O VASCULAR ANGLE 80CM .018IN HYDROPHILIC FIX CORE",SUP-H2OSTDA1880,CDM,C1769,HCPCS,0272,RC,,,both,,,408.47,122.54,"UHC [10700]","United Healthcare",,258.56,63.3,,,,,0,47.51,347.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 68MM STAINLESS STEEL 2.4MM SCR 7 HOLE HEAD 4 HOLE",SUP-02.111.740S,CDM,C1713,HCPCS,0278,RC,,,both,,,4450.50,1335.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,527.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",517.59,3782.93,"percent of total billed charges",
"SUT VICRYL PLUS 3-0 RB-1 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP215H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM TIBIAL 75MM 20MM UNIVERSAL KNEE FLUTED",SUP-867419,CDM,C1776,HCPCS,0278,RC,,,both,,,8100.60,2430.18,"MULTIPLAN [10600]",Multiplan,,6885.51,85,,,,,0,942.1,6885.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 6MM REINFORCED PROTECTED LEADS NIM EMG",SUP-8229306,CDM,S27200284,LOCAL,0272,RC,,,both,,,3435.00,1030.5,"KAISER [10500]",Kaiser,,2301.45,67,,,,,0,399.49,2919.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 8MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650908,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UHC [10700]","United Healthcare",,8309.55,63.3,,8601.07,8395.67,8601.07,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"KIT TKR 14MM ITOTAL IPOLY XE POSTERIOR STABILIZE INSRT",SUP-RPS0201400,CDM,C1776,HCPCS,0278,RC,,,both,,,6254.85,1876.45,"AETNA [10100]","Aetna HMO/PPO",,4972.61,79.5,,10981.53,8986.79,12413.38,12,727.44,5316.62,"percent of total billed charges",
"STENT CONTOUR ZIPWIRE 28CM 3CM 7FR .035IN PIGTAIL CURVE",SUP-M006180234180,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA [10200]","Cigna Open Access",,830.8,,,,,,,169.81,1241.09,"percent of total billed charges",
"INSRT ARTICULAR 3-9 CD 14MM KNEE LEFT CRUCIATE RETAINING",SUP-42512000414,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]","Cigna Open Access",,6131.78,56.9,,5302.19,4377.88,6578.61,27,1253.3,9159.96,"percent of total billed charges",
"LENS IOL 10 D +10.5 DIOPTER MODIFIED C BICONVEX 13MM 6MM",SUP-MN60AC.105,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"NOVANET [10819]",Novanet,,905.18,75,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOTRACHEAL 7.5MM REINFORCE CUFF MURPHY EYE LOW",SUP-DYNJAARC75,CDM,S27200284,LOCAL,0272,RC,,,both,,,266.04,79.81,"PHCS [10601]",PHCS,,186.23,70,,,,,0,30.94,226.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 6MM FLIXENE SLIDER GRADUATED WALL",SUP-25058,CDM,C1768,HCPCS,0278,RC,,,both,,,8102.19,2430.66,"MULTIPLAN [10600]",Multiplan,,6886.86,85,,,,,0,942.28,6886.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG 600ML TRU-CLOSE GRAVITY TUBE 20IN",SUP-TC600,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"KAISER [10500]",Kaiser,,52.46,67,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 9MM TARGET 360D PLATINUM DETACHABLE",SUP-M0035479300,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5645.86,40,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 26MM ACUTRAK 2 TITANIUM MINI SMALL BONE STERILE",SUP-AT2-M26-S,CDM,C1713,HCPCS,0278,RC,,,both,,,3187.50,956.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,370.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",370.71,2709.38,"percent of total billed charges",
"STENT GORE VIABAHN 79MM 135CM 10MM 13MM 8FR .035IN",SUP-BXA107902A,CDM,C1874,HCPCS,0278,RC,,,both,,,21407.40,6422.22,"KAISER [10500]",Kaiser,,14342.96,67,,,,,0,2489.68,18196.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILTER GRAFT PLUNGER GRADUATED 100ML REAMER IRR ASPIR",SUP-352.229S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2310.60,693.18,"MULTIPLAN [10600]",Multiplan,,1964.01,85,,,,,0,268.72,1964.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM ENDOSCOPIC CLEVERCUT3V PRELOAD STERILE LATEX FREE",SUP-KDV631M07201A,CDM,S27200284,LOCAL,0272,RC,,,both,,,2433.53,730.06,"MULTIPLAN [10600]",Multiplan,,2068.5,85,,,,,0,283.02,2068.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 10MM2CM 190",SUP-R51010002L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1388.22,68,,,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dna Ab Native/Double Strand",PX-302000036,CDM,86225,CPT,0302,RC,,,both,,,427.50,128.25,"UHC [10700]","United Healthcare",,12.37,,,,,,,0.01,363.38,"fee schedule",
"BASE TIB STEM #1 LEFT PEGLESS",SUP-2585-0-0001,CDM,C1776,HCPCS,0278,RC,,,both,,,5939.00,1781.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,690.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,690.71,5048.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM ENDOSCOPIC CLEVERCUT3V PRELOAD STERILE LATEX FREE",SUP-KDV631M07201A,CDM,S27200284,LOCAL,0272,RC,,,both,,,2433.53,730.06,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,283.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,283.02,2068.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SWAN-GANZ CCOMBO VIP 110CM 8FR STD PULMONARY ARTERY",SUP-746F8,CDM,C1751,HCPCS,0272,RC,,,both,,,1782.30,534.69,"KAISER [10500]",Kaiser,,1194.14,67,,,,,0,207.28,1514.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP MEDIUM 2.3MM TITANIUM 35 CLIP BKLT",SUP-4010-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,6893.10,2067.93,"CIGNA [10200]",Cigna,,4687.31,68,,,,,0,801.67,5859.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET BUNDLE CATH PUMP + COMPANTION SHEATH IMPELLA BLOOD PUMP",SUP-4000021,CDM,S27800098,LOCAL,0278,RC,,,both,,,153900.00,46170,"UHC [10700]","United Healthcare",,97418.7,63.3,,,,,0,17898.57,130815,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 14CM 3MM MIDAS REX LEGEND 3 FLUTE PROXIMAL",SUP-SP14MH30T,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"AMERIGROUP MEDICAID [20100]",Amerigroup,,326.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 8MM 5MM BALLOON DILATATION DURATRAC",SUP-NCEUP5008X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,61.23,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONCIERGE 100CM 8FR SBS4.5 MOD CURVE GUIDING STAINLESS",SUP-CGC8100SBS45SH-M,CDM,C1887,HCPCS,0272,RC,,,both,,,445.50,133.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,51.81,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 35MM SJM TAILOR SILICONE FLEXIBLE SURE",SUP-TAB-35,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"UHC [10700]","United Healthcare",,7663.35,63.3,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 24CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006175262090,CDM,C2617,HCPCS,0278,RC,,,both,,,1330.26,399.08,"FIRST HEALTH [10303]","First Health",,1064.21,80,,,,,0,154.71,1130.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE TIBIAL 10MM PFC 2 KNEE MODULAR PLUS CEMENT STERILE",SUP-860173,CDM,S27200284,LOCAL,0272,RC,,,both,,,8260.68,2478.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5617.26,68,,,,,0,960.72,7021.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 100MM 80CM 10MM 9FR STRAIGHT VASCULAR",SUP-AVSM10100,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2165,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 60MM 6MM 8FR FLUENCY PLUS ENDOVASCULAR EPTFE",SUP-FEM06060,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"CIGNA [10200]","Cigna Local Plus",,5755.05,31.5,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DISC INTERVERTEBRAL 16MM 6MM PRESTIGE LP CERVICAL SPINE",SUP-6972660,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11340,40,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STBL SURGICAL OCTOPUS 4.3 16 LANG CARDIAC",SUP-29403,CDM,S27200284,LOCAL,0272,RC,,,both,,,7915.68,2374.7,"AETNA [10100]","Aetna HMO/PPO",,6292.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,920.59,6728.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC",371,MS-DRG,,,,,,,inpatient,,,34126.49,10237.95,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION",RX-17405,CDM,J1815,HCPCS,0637,RC,00024-5926-05,NDC,both,3,ML,355.45,106.63,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE VASCULAR ANGLE 180CM .014IN",SUP-GA1418,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Mod Sedat Add 15min",PX-371000009,CDM,99153,CPT,0371,RC,,,both,,,387.75,116.32,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"FORMULA TOMCAT CUTTER,(RED/WHITE)4MM ARTHROSCOPIC SHAVER ART",SUP-0375545000,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.94,39.28,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INJECTOR BONE CEMENT 5-5.8MM TRANSFER TUBE",SUP-0909-400-500,CDM,S27200284,LOCAL,0272,RC,,,both,,,529.74,158.92,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BALLOON DILATATION .035IN 5FR 5MM 135CM 4CM PERIPHERAL",SUP-4195040X,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE RADIUS ULNA SHAFT ALLOGRAFT FREEZE DRIED 40X15-18",SUP-400800,CDM,S27800098,LOCAL,0278,RC,,,both,,,4351.14,1305.34,"CIGNA [10200]","Cigna Open Access",,2475.8,56.9,,,,,0,506.04,3698.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 60MM MATRIX TITANIUM SPINE THREADED POLYAXIAL",SUP-04.606.760,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"AETNA [10100]","Aetna HMO/PPO",,4388.4,79.5,,1521.93,481.35,16760.95,30,641.98,4692,"percent of total billed charges",
"SCR BONE 6.5MM 40MM PRECEPT SPINE SHANK MODULAR NONSTERILE",SUP-8896540,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"CIGNA [10200]",Cigna,,2040,68,,1831.33,1831.33,1831.33,16,348.9,2550,"percent of total billed charges",
"STPLR INTERNAL 25MM TITANIUM CIRCLE LINEAR CUTTER SQUEEZE",SUP-EEAORVIL25,CDM,S27200284,LOCAL,0272,RC,,,both,,,637.79,191.34,"UHC [10700]","United Healthcare",,403.72,63.3,,,,,0,74.17,542.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELITE MONORAIL THK.003IN 20MM 144CM 2.75MM",SUP-H7493941220270,CDM,C1874,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5278.5,68,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +21.5 DIOPTER MODIFY C 13MM 6MM POSTERIOR CHMBR 1",SUP-DIB00U0215,CDM,V2632,HCPCS,0276,RC,,,both,,,1336.50,400.95,"CIGNA [10200]","Cigna Open Access",,760.47,56.9,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT VIABAHN 5CM 120CM 5MM ENDOPROSTHESIS HEPARIN NITINOL",SUP-VBJR050502A,CDM,C1874,HCPCS,0278,RC,,,both,,,19895.40,5968.62,"PHCS [10601]",PHCS,,13926.78,70,,,,,0,2313.84,16911.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 3MM I-KNIFE II SATINSLIT ANGLE SCR IN TIP",SUP-8065992962,CDM,S27200284,LOCAL,0272,RC,,,both,,,153.38,46.01,"AETNA [10100]","Aetna HMO/PPO",,121.94,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.84,130.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT NYLON 6 ETHILON MULTIPASS 5-0 PS-2 18IN MONOFILAMENT",SUP-G666G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR ANGLE 180CM .014IN",SUP-GA1418,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,669.11,41.1,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 150CM 6FR .035IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145364190,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,131.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDER 20MM 2.5MM BALLOON DILATATION LOW PROFILE PTCA",SUP-4100A-3004,CDM,C1725,HCPCS,0272,RC,,,both,,,2212.50,663.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,262.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 6FR .071IN SHEPHERDS CROOK RIGHT 4 CURVE",SUP-LA6SCR40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 10 HIGH OFFSET HIP",SUP-71935582,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"CIGNA [10200]","Cigna Open Access",,12238.79,33.5,,5302.19,4377.88,6578.61,27,4248.87,31053.65,"percent of total billed charges",
"GRAFT BONE ARTHROCELL 5CC",SUP-ABS-2009-05,CDM,C1734,HCPCS,0278,RC,,,both,,,22050.00,6615,"KAISER [10500]",Kaiser,,14773.5,67,,,,,0,2564.42,18742.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP CLUSTER HOLE SNAP FIT INTEGRATED",SUP-00875705201,CDM,C1776,HCPCS,0278,RC,,,both,,,11012.40,3303.72,"FIRST HEALTH [10303]","First Health",,8809.92,80,,,,,0,1280.74,9360.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.75CM NATRELLE INSPIRA P5.3CM FULL PROFILE",SUP-MSZ-F450,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.4,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STD 49MM 2.3MM SCR ACU-LOC 2 BONE LEFT PROXIMAL DISTAL",SUP-70-0350,CDM,C1713,HCPCS,0278,RC,,,both,,,6651.60,1995.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,773.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",773.58,5653.86,"percent of total billed charges",
"SOL IV 0.9% SODIUM CHLORIDE 500ML PVC FREE DEHP FREE VISIV",SUP-7983-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"CIGNA [10200]",Cigna,,55.08,68,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 114MM PRIMARY ANTHOLOGY POROUS 131D 8 HIGH",SUP-71356108,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"NOVANET [10819]",Novanet,,24855.86,75,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 6FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752640,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"CIGNA [10200]","Cigna Local Plus",,482.67,,,,,,,104.92,766.85,"percent of total billed charges",
"AIRWAY LARYNGEAL MASK ADULT SIZE 5 40ML PVC CUFF STRAIGHT DI",SUP-ALAA050SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,52.20,15.66,"AETNA [10100]","Aetna HMO/PPO",,41.5,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.07,44.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REUNION TSA - CEMENTED HUMERAL STEM 8MM",SUP-5569-C-2008,CDM,C1776,HCPCS,0278,RC,,,both,,,10440.00,3132,"KAISER [10500]",Kaiser,,6994.8,67,,,,,0,1214.17,8874,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 345CC SMOOTH SHELL SURFACE NATRELLE INSPIRA FULL",SUP-SRF-345,CDM,C1789,HCPCS,0278,RC,,,both,,,3969.00,1190.7,"CIGNA [10200]","Cigna Local Plus",,2123.42,,,,,,,461.59,3373.65,"percent of total billed charges",
"CATH COYOTE 150CM 60MM 2MM BALLOON DILATATION NYBAX BIOSLIDE",SUP-H74939186200610,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 26MM 140CM 2.5MM CORONARY STERILE LATEX",SUP-453956,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,9776.84,9776.84,9776.84,"1 through 10",441.36,3225.75,"percent of total billed charges",
"CANNULA TRACHEOSTOMY DIA8MM INNER SPARE SHILEY",SUP-8SIC,CDM,S27200284,LOCAL,0272,RC,,,both,,,62.12,18.64,"CIGNA [10200]",Cigna,,42.24,68,,,,,0,7.22,52.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOLOIST 110CM 6FR 5MM SPACING JSN FLEX1 CURVE",SUP-44516JF,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LARGE 116MM TITANIUM 4 HOLE SHAFT 2 COMPRESSION SLOT",SUP-59202030,CDM,C1713,HCPCS,0278,RC,,,both,,,14993.70,4498.11,"AETNA [10100]","Aetna HMO/PPO",,11919.99,79.5,,1521.93,481.35,16760.95,30,1743.77,12744.65,"percent of total billed charges",
"LEAD PACING 46CM 7FR 10MM SPACING VENTRICLE BIPOLAR PASSIVE",SUP-1948/46,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1024.72,45.9,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CARVEDILOL 12.5 MG TABLET, IMMEDIATE RELEASE",RX-15749,CDM,,,0637,RC,00904-7307-61,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]","Cigna Open Access",,3.57,56.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FUSION ZILVER 6CM 208CM 10MM 7FR .035IN BILIARY",SUP-G31560,CDM,C1876,HCPCS,0278,RC,,,both,,,9597.90,2879.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4405.44,45.9,,,,,0,1116.24,8158.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL BIT ASSY, CARBIDE, HUDSON END, 2 MM, SINGLE USE",SUP-SBT001,CDM,S27000186,LOCAL,0270,RC,,,both,,,2212.50,663.75,"CIGNA [10200]","Cigna Open Access",,1258.91,56.9,,,,,0,257.31,1880.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG BIOLOGICAL 10X7CM CYTAL PORCINE EXTRACELLULAR MATRIX 1",SUP-WS0710,CDM,Q4166,HCPCS,0636,RC,,,both,,,2160.00,648,"NOVANET [10819]",Novanet,,1620,75,,,,,0,53.69,1836,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE REPLACEMENT PRISMASOL BGK 4/0/1.2 LATEX FREE",SUP-110241,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"NOVANET [10819]",Novanet,,169.65,75,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BN 3MM 4MM 1.2MM 26MM 12MM SS",SUP-202.726,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"CIGNA [10200]","Cigna Open Access",,631.6,56.9,,1144.80,304.56,2275.09,66,129.1,943.52,"percent of total billed charges",
"HC Belt Gait 72x2in Delrin Polyur",PX-HHE27100028,CDM,HHE27100028,LOCAL,0271,RC,,,outpatient,,,195.00,58.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,132.6,68,,,,,0,22.68,165.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trnscth Rnl Symp Dnrv Perc Bi",PX-481000145,CDM,0339T,CPT,0481,RC,,,both,,,9752.00,2925.6,"CIGNA [10200]",Cigna,,9752,,"Case rate ($10,015). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1134.16,9752,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAPESTRY BIOINTEGRATIVE IMPLANT WITH INSERTION SLEEVE 50X40X",SUP-TS-5040-02,CDM,C1781,HCPCS,0278,RC,,,both,,,17633.70,5290.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7247.45,41.1,,,,,0,2050.8,14988.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronchl Alveolar Lav Mini",PX-410000026,CDM,31899,CPT,0410,RC,,,both,,,1137.30,341.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,426,,"Per diem ($426).",,,,0,132.27,1137.3,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 3MM 11MM TITANIUM CORTEX HAND SELF TAPPING",SUP-400.811.96,CDM,C1713,HCPCS,0278,RC,,,both,,,323.99,97.2,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,148.71,45.9,,,,,0,37.68,275.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUTNER 22CM 30CM 12FR 14FR SUPRAPUBIC STAINLESS STEEL",SUP-G15261,CDM,C2627,HCPCS,0272,RC,,,both,,,516.05,154.81,"AETNA [10100]","Aetna HMO/PPO",,410.26,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,60.02,438.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFT TOUCH",SUP-SSM-240,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",878.7,6422.18,"percent of total billed charges",
"OVITEX LOW PROFILE REINFORCED TISSUE MATRIX, LONG-TERM RESOR",SUP-F10264-1520L,CDM,C1781,HCPCS,0278,RC,,,both,,,24580.84,7374.25,"CIGNA [10200]","Cigna Local Plus",,7742.96,31.5,,3096.73,1.00,3096.73,"1 through 10",2858.75,20893.71,"percent of total billed charges",
"SERTRALINE 50 MG TABLET",RX-11351,CDM,,,0637,RC,16714-0612-06,NDC,both,1,UN,14.02,4.21,"CIGNA [10200]","Cigna Open Access",,7.98,56.9,,,,,0,1.63,11.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 74MM 24MM 16FR ZENITH SPIRAL-Z Z-TRAK",SUP-G55246,CDM,C1874,HCPCS,0278,RC,,,both,,,21174.30,6352.29,"CIGNA [10200]","Cigna Local Plus",,6669.9,31.5,,,,,0,2462.57,17998.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM CHLORIDE 100 MG/ML (10 %) IV VIAL",RX-113687,CDM,J0618,HCPCS,0636,RC,00517-6710-01,NDC,both,10,ML,183.16,54.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,21.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.48,155.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION",RX-9892,CDM,J1250,HCPCS,0636,RC,00409-2344-01,NDC,both,20,ML,53.45,16.03,"BLUE CROSS [10001]","Blue Cross HMO",,8.25,,,,,,,6.7,45.43,"fee schedule",
"HC Plc Cath Thorac Ea 1st Ord",PX-361000083,CDM,36215,CPT,0361,RC,,,both,,,3218.39,965.52,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3218.39,,"Case rate ($7,883). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,374.3,3218.39,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRESSING FOAM ANTIMICROBIAL WITH SILVER MEPILEX BORDER POST-",SUP-498100,CDM,S27200284,LOCAL,0272,RC,,,both,,,63.20,18.96,"CIGNA [10200]","Cigna Local Plus",,33.81,53.5,,,,,0,7.35,53.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dgtz Gls Mcrscp Sl Imm Ea M / Add on 88344",PX-312000099,CDM,0762T,CPT,0312,RC,,,both,,,100.00,30,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,41.1,41.1,,,,,0,11.85,85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 13MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P513,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS [10001]","Blue Cross HMO",,3275.51,39.2,,5311.50,4717.44,5388.59,31,971.79,7102.52,"percent of total billed charges",
"SYSTEM RESOLUTE INTEGRITY MICROTRAC 12MM 140CM 2.75MM",SUP-RSINT27512UX,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"KAISER [10500]",Kaiser,,3714.48,67,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 40MM 5.5MM CURVE CHROMALOY PLUS",SUP-1556001040,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross HMO",,476.28,39.2,,957.42,156.86,7483.26,51,141.3,1032.75,"percent of total billed charges",
"SHEATH FARADRIVE INTRO STEERABLE STERILE LATEX FREE",SUP-M004PF21M402,CDM,C1766,HCPCS,0272,RC,,,both,,,8970.00,2691,"PHCS [10601]",PHCS,,6279,70,,,,,0,1043.21,7624.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EUPHORA 142CM 12MM 4MM BALLOON DILATATION DURATRAC",SUP-NCEUP4012X,CDM,C1725,HCPCS,0272,RC,,,both,,,526.50,157.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION",RX-7301,CDM,,,0250,RC,00409-7299-83,NDC,both,20,ML,112.50,33.75,"MULTIPLAN [10600]",Multiplan,,95.63,85,,,,,0,13.08,95.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED + VE/",SUP-98000200464,CDM,C1776,HCPCS,0278,RC,,,both,,,25830.00,7749,"FIRST HEALTH [10303]","First Health",,20664,80,,,,,0,3004.03,21955.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASTATO 30 VASCULAR 180CM 15CM .33-.45MM SLIP-COAT PTFE",SUP-PAGH18M071,CDM,C1769,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE (PF) 20 MG/ML (2%) INJECTION AMP/VIAL SUPERORDERABLE",RX-408650,CDM,J2003,HCPCS,0636,RC,63323-0208-01,NDC,both,5,ML,33.98,10.19,"BLUE CROSS [10001]","Blue Cross PPO",,1.17,,,,,,,1.17,28.88,"fee schedule",
"SHEATH AMPLATZ 17CM 24FR ACCESS PTFE RENAL FIRM TAPER TIP",SUP-M0062601510,CDM,C1894,HCPCS,0272,RC,,,both,,,334.60,100.38,"UHC [10700]","United Healthcare",,211.8,63.3,,,,,0,38.91,284.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT E-LUMINEXX 30MM 80CM 10MM 6FR .035IN BILIARY CATH",SUP-ZBM10030,CDM,C1876,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2863.43,28.62,,,,,0,1163.58,8504.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BUTTON FIXATION 12MM RETROBUTTON CORTICAL TITANIUM UHMWPE",SUP-AR-1588-20,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"BLUE CROSS [10001]","Blue Cross PPO",,725.45,39.2,,957.42,570.23,957.42,28,215.23,1573.04,"percent of total billed charges",
"MESH HERNIA POLYPROPYLENE 12X10CM PERMANENT GRID 1 SMOOTH",SUP-F10246-1012P,CDM,C1781,HCPCS,0278,RC,,,both,,,12966.48,3889.94,"MULTIPLAN [10600]",Multiplan,,11021.51,85,,,,,0,1508,11021.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 28CM 3CM 7FR .035IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175274050,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,728.1,68,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 8MM 29MM SYMMETRIC TRIATHLON X3 TOTAL KNEE",SUP-5550-G-298,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"FIRST HEALTH [10303]","First Health",,3454.22,80,,,,,0,502.16,3670.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIGUARD HDH TRIGUARD CEREBRAL PROTECTION DEVICE",SUP-FG00003,CDM,C1786,HCPCS,0624,RC,,,both,,,0.01,,"KAISER [10500]",Kaiser,,0.01,67,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 5 LEFT MEDIAL RIGHT LATERAL PARTIAL",SUP-5620-B-501,CDM,C1776,HCPCS,0278,RC,,,both,,,6899.26,2069.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,802.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.38,5864.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP STEM HUMERAL CEMENT DELTA XTEND SHOULDER",SUP-OSC368289,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,18642.96,41.1,,6417.48,6417.48,6417.48,"1 through 10",5275.37,38556,"percent of total billed charges",
"FRCP SURGICAL ST CLAIR 7.25IN ADENOID RING JAW 10X5MM",SUP-71-5018,CDM,S27200284,LOCAL,0272,RC,,,both,,,1750.20,525.06,"KAISER [10500]",Kaiser,,1172.63,67,,,,,0,203.55,1487.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 7FR .081IN SHORT AMPLATZ LEFT 1 CURVE GUIDING",SUP-LA7SAL10,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"KAISER [10500]",Kaiser,,262.31,67,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ENDOPROSTHESIS 5CM 6MM HEPARIN NITINOL EPTFE VIABAHN",SUP-VBHR030501A,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR LFIT D 3.9MM 36MM X3 EXPANDED",SUP-623-00-36D,CDM,C1776,HCPCS,0278,RC,,,both,,,6242.04,1872.61,"PHCS [10601]",PHCS,,4369.43,70,,,,,0,725.95,5305.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAC-LOC 40CM 12FR DRNG ULTRATHANE HYDROPHILIC BILIARY",SUP-G09499,CDM,C1729,HCPCS,0272,RC,,,both,,,801.82,240.55,"PHCS [10601]",PHCS,,561.27,70,,,,,0,93.25,681.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X3.1-6MM ROI-C VERTEBRIDGE 7D 12MM LORDOTIC","SUP-MC 1442 P",CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"CIGNA [10200]","Cigna Local Plus",,5670,31.5,,,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7.5CM 3.5MM GALAXY G3 XTRASOFT",SUP-GLX123575,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1407.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE IRRIGATION ELITE 12CM",SUP-5407-010-470,CDM,S27200284,LOCAL,0272,RC,,,both,,,585.74,175.72,"FIRST HEALTH [10303]","First Health",,468.59,80,,,,,0,68.12,497.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 23IN 32FR ANGLE RIGHT TAPER DRNG PVC THORAX 5 EYELET",SUP-8132,CDM,C1729,HCPCS,0272,RC,,,both,,,89.63,26.89,"AMERIGROUP MEDICAID [20100]",Amerigroup,,10.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.42,76.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 55MM T10 FULL THREAD STARDRIVE NONSTERILE",SUP-657455,CDM,C1713,HCPCS,0278,RC,,,both,,,808.70,242.61,"CIGNA [10200]","Cigna Open Access",,460.15,56.9,,1144.80,304.56,2275.09,66,94.05,687.4,"percent of total billed charges",
"SCR BONE 5.5MM 55MM INTERCONTINENTAL HA SPINE VARIABLE ANGLE",SUP-187.255S,CDM,C1713,HCPCS,0278,RC,,,both,,,2625.00,787.5,"MULTIPLAN [10600]",Multiplan,,2231.25,85,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOGRAPHY 48IN DISPOSAL DEPOT BAG LARGE BORE TUBING",SUP-MDD520H,CDM,S27000186,LOCAL,0270,RC,,,both,,,82.74,24.82,"AETNA [10100]","Aetna HMO/PPO",,65.78,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.62,70.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 16MM 80CM 7MM .018IN BILIARY STAINLESS STEEL",SUP-G56616,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"CIGNA [10200]","Cigna Local Plus",,2696.4,53.5,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE HEMOSTASIS 9FR FLO 30 LEAKPROOF SEAL CAP STOP",SUP-FLO30,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.31,30.69,"AMERIGROUP MEDICAID [20100]",Amerigroup,,12.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.9,86.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHOCOLATE 135CM 120MM 4MM 5FR BALLOON DILATATION",SUP-CB1413540120OTW,CDM,C1725,HCPCS,0272,RC,,,both,,,5727.00,1718.1,"AMERIGROUP MEDICAID [20100]",Amerigroup,,678.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,666.05,4867.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 8X6CM SUSPEND TUTOPLAST FASCIA LATA",SUP-937268,CDM,C1762,HCPCS,0278,RC,,,both,,,3238.30,971.49,"AMERIGROUP MEDICAID [20100]",Amerigroup,,383.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,376.61,2752.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 FLEXOR 60MM 125CM 7MM 6FR VASCULAR NITINOL",SUP-G43827,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,447.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 54MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-54-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"PHCS [10601]",PHCS,,3960.6,70,,,,,0,658.03,4809.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC QUANTUM APEX 143CM 12MM 3.25MM BALLOON DILATATION",SUP-H7493912412320,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 30MM SOLERA COCR SPINE MULTIAXIAL CANNULATED",SUP-54840005530,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2732.31,28.62,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK ARTHROSCOPIC MULTIUSE ACL RETROCONSTRUCTION ACL GUIDE",SUP-AR-1510M,CDM,S27200284,LOCAL,0272,RC,,,both,,,3268.13,980.44,"PHCS [10601]",PHCS,,2287.69,70,,,,,0,380.08,2777.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Chlamydia Any Source",PX-306000071,CDM,87110,CPT,0306,RC,,,both,,,289.26,86.78,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.58,,"Fee schedule rate ($20.58). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.29,245.87,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"STRIP SCLERAL 100MM SILICONE STRIP TYPE 220 BOX OF 3 STERILE",SUP-S5.2200,CDM,S27800098,LOCAL,0278,RC,,,both,,,174.00,52.2,"BLUE CROSS [10001]","Blue Cross PPO",,68.21,39.2,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 87/91MMX10MM VANGUARD E1 KNEE CRUCIATE RETAINING",SUP-EP183480,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1534.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-FLO RENEGADE FATHOM VASCULAR 105CM 10CM .016IN",SUP-M001184500,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"FIRST HEALTH [10303]","First Health",,3000,80,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 35 135CM 100MM 4MM .035IN LOW PROFILE BALLOON",SUP-B2040-100,CDM,C1725,HCPCS,0272,RC,,,both,,,769.50,230.85,"FIRST HEALTH [10303]","First Health",,615.6,80,,,,,0,89.49,654.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 16FR SILICONE MIC-KEY SECUR-LOK ENFIT BOLUS",SUP-8200-16,CDM,S27200284,LOCAL,0272,RC,,,both,,,1099.58,329.87,"CIGNA [10200]","Cigna Local Plus",,588.28,53.5,,,,,0,127.88,934.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LITHIUM CARBONATE 150 MG CAPSULE, IMMEDIATE RELEASE",RX-4528,CDM,,,0637,RC,00054-8526-25,NDC,both,1,UN,6.27,1.88,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2.88,45.9,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC GREEN 1.9MM MAXTORQUE STAINLESS STEEL",SUP-CSS04019,CDM,C1769,HCPCS,0272,RC,,,both,,,139.20,41.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,57.21,41.1,,,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 28MM 8MM BLUNT FULL THREAD",SUP-AR-1380TC,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"CIGNA [10200]","Cigna Local Plus",,990.09,53.5,,3978.14,359.25,3978.14,24,215.23,1573.04,"percent of total billed charges",
"DIL SHEATH 20FR PEEL-AWAY ENTERAL ACCESS SYSTEM SERIAL",SUP-98704,CDM,S27200284,LOCAL,0272,RC,,,both,,,814.29,244.29,"AETNA [10100]","Aetna HMO/PPO",,647.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.7,692.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SLIP-CATH BEACON 125CM 6FR HEADHUNTER 1 CURVE",SUP-G31134,CDM,S27200284,LOCAL,0272,RC,,,both,,,708.75,212.62,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SEPTIC ARTHRITIS WITHOUT CC/MCC",550,MS-DRG,,,,,,,inpatient,,,22873.73,6862.12,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 6FR STD AMPLATZ LEFT 1 CURVE",SUP-534645T,CDM,S27200284,LOCAL,0272,RC,,,both,,,87.00,26.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPTICROSS 6 6FR ULTRASOUND INTRAVASCULAR",SUP-H7495181160,CDM,C1753,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 2MM 9MM APTUS TITANIUM 6MM WRIST CORTICAL 2",SUP-A-5450.09/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Revasc Cto Cor Art/Br/Grf Sngl Ant&Rtrgr",PX-481000430,CDM,92945,CPT,0481,RC,,,both,,,29518.12,8855.44,"CIGNA [10200]","Cigna Open Access",,16795.81,56.9,,,,,0,3432.96,25090.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 5 1/8IN 5FR BARON REGULAR THUMB PLATE CUT OFF 3",SUP-62-2215,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.94,39.28,"FIRST HEALTH [10303]","First Health",,104.75,80,,,,,0,15.23,111.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL COLLAR AVENIR COMPLETE 3 STD HIP STERILE LATEX",SUP-5742011030,CDM,C1776,HCPCS,0278,RC,,,both,,,18002.25,5400.67,"UHC [10700]","United Healthcare",,11395.42,63.3,,8601.07,8395.67,8601.07,"1 through 10",2093.66,15301.91,"percent of total billed charges",
"SYSTEM RESOLUTE INTEGRITY 12MM 140CM 3.5MM CORONARY STENT",SUP-RSINT35012W,CDM,C1874,HCPCS,0278,RC,,,both,,,5544.00,1663.2,"BLUE CROSS [10001]","Blue Cross PPO",,2173.25,39.2,,,,,0,644.77,4712.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 1026X60MM 10",SUP-6210160,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2784.22,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablt Av Node",PX-481000062,CDM,93650,CPT,0481,RC,,,both,,,18205.31,5461.59,"NOVANET [10819]",Novanet,,13653.98,75,,,,,0,2117.28,18205.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +15 DIOPTER MODIFIED L BICONVEX 13MM 6MM",SUP-SN60WF.150,CDM,V2632,HCPCS,0276,RC,,,both,,,1206.90,362.07,"MULTIPLAN [10600]",Multiplan,,1025.87,85,,,,,0,140.36,1025.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 15MM APTUS TITANIUM HAND CORTICAL HEXADRIVE 4",SUP-A-5200.15/1,CDM,S27200284,LOCAL,0272,RC,,,both,,,1263.60,379.08,"PHCS [10601]",PHCS,,884.52,70,,,,,0,146.96,1074.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 26MM GORILLA R3CON LOCK",SUP-P50-353-3526,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,382.51,28.62,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE 11CMX20MM FLAT OSTEOTOM NONSTERILE DISPOSABLE",SUP-SBLDFLAT-8-SUP5,CDM,S27000186,LOCAL,0270,RC,,,both,,,1458.00,437.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,172.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM TRANSITION HA SPINE PEDICLE POLYAXIAL",SUP-152.765S,CDM,C1713,HCPCS,0278,RC,,,both,,,10791.60,3237.48,"KAISER [10500]",Kaiser,,7230.37,67,,,,,0,1255.06,9172.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEXTROSE 40 % ORAL GEL",RX-27466,CDM,,,0637,RC,00574-0070-30,NDC,both,37.5,GR,24.77,7.43,"PHCS [10601]",PHCS,,17.34,70,,,,,0,2.88,21.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 52CM RVOT KIT MOND STAINLESS STEEL WIDE",SUP-4151/52,CDM,S27500001,LOCAL,0275,RC,,,both,,,575.10,172.53,"BLUE CROSS [10001]","Blue Cross PPO",,225.44,39.2,,,,,0,66.88,488.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 16MM 41MM SHOULDER ECLIPSE STERILE ARTHROPLASTY",SUP-AR-9341-16,CDM,C1776,HCPCS,0278,RC,,,both,,,4105.50,1231.65,"BLUE CROSS [10001]","Blue Cross HMO",,1609.36,39.2,,5311.50,4717.44,5388.59,31,477.47,3489.68,"percent of total billed charges",
"ROD SPINAL 70MM 5.5MM CREO CURVE TITANIUM NONSTERILE",SUP-1119.7070,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,347.73,28.62,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP",RX-22120,CDM,90675,HCPCS,0636,RC,50632-0010-01,NDC,both,1,UN,2623.30,786.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,375.61,,"Fee schedule rate ($375.61). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,178.05,2229.81,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 45MM CENTERPULSE LEGACY 12/14 TAPER HIP FEMUR",SUP-451000045,CDM,C1776,HCPCS,0278,RC,,,both,,,2328.75,698.62,"MULTIPLAN [10600]",Multiplan,,1979.44,85,,,,,0,270.83,1979.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METHADONE 10 MG TABLET",RX-4953,CDM,,,0637,RC,00406-5771-23,NDC,both,1,UN,12.54,3.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1.49,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KNIFE ENDOSCOPIC T TYPE I JET MULTIFUNCTIONAL PROBE",SUP-20150-260,CDM,C1889,HCPCS,0272,RC,,,both,,,3857.10,1157.13,"CIGNA [10200]",Cigna,,2622.83,68,,,,,0,448.58,3278.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Parva B19 Qpcr Plasma 1500",PX-306000162,CDM,87799,CPT,0306,RC,,,both,,,907.25,272.17,"CIGNA [10200]","Cigna Open Access",,94.25,,,,,,,0.91,771.16,"fee schedule",
"STENT POLARIS 22CM 3CM 7FR .038IN STRAIGHT URETERAL",SUP-M006155241010,CDM,C2617,HCPCS,0278,RC,,,both,,,1230.96,369.29,"AMERIGROUP MEDICAID [20100]",Amerigroup,,145.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.16,1046.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL RED YELLOW 3.6MM VARIAX AO FIT 3.5MM SCR",SUP-4535020,CDM,S27200284,LOCAL,0272,RC,,,both,,,898.13,269.44,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,369.13,41.1,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOTHYROXINE 25 MCG/ML ORAL SUSPENSION",RX-408880,CDM,,,0637,RC,08888-8885-96,NDC,both,8,ML,12.54,3.76,"UHC [10700]","United Healthcare",,7.94,63.3,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TAMP 15MM INFLATABLE BONE EXACT 3MM SURGICAL",SUP-K17B,CDM,S27200284,LOCAL,0272,RC,,,both,,,6587.78,1976.33,"MULTIPLAN [10600]",Multiplan,,5599.61,85,,,,,0,766.16,5599.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VASCBAND 29 CM",SUP-3529,CDM,S27000186,LOCAL,0270,RC,,,both,,,165.30,49.59,"AETNA [10100]","Aetna HMO/PPO",,131.41,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES",769,MS-DRG,,,,,,,inpatient,,,68348.04,20504.41,"CLOVER HEALTH MEDICARE ADVANTAGE [30162]","Clover Health Medicare Advantage",,11110.85,,"Case rate ($10,481.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $9,733.18, add-ons for qualifying new technology services are included. If operating cost exceeds $42,772.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,117.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,746.06. The transfer operating threshold is the transfer adjustment factor * $9,733.18 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $735.88. The transfer capital threshold is the transfer adjustment factor * $735.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 106%.",,,,0,7561,49335.4,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARMADA 14 150CM 60MM 4MM TAPER BALLOON DILATATION JET",SUP-A2040-060,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"AMERIGROUP MEDICAID [20100]",Amerigroup,,158.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PSN MC VE ASF L 14MM 6-7/EF",SUP-42-5121-007-14,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"CIGNA [10200]",Cigna,,7327.97,68,,5873.17,5873.17,5873.17,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"STENT ABSOLUTE PRO 40MM 80CM 6MM VASCULAR PERIPHERAL SELF",SUP-1012528-40,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"FIRST HEALTH [10303]","First Health",,3312,80,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PROPEL 370 MCG NASAL MOMETASONE FUROATE",SUP-70011,CDM,C2625,HCPCS,0278,RC,,,both,,,6679.20,2003.76,"CIGNA [10200]",Cigna,,4541.86,68,,,,,0,776.79,5677.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR EXTRICATION PURPLE 1.75IN PROCARE LOW FLAT CONTOUR",SUP-79-83028,CDM,S27000186,LOCAL,0270,RC,,,both,,,58.12,17.44,"KAISER [10500]",Kaiser,,38.94,67,,,,,0,6.76,49.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM H HIP ELEVATE RIM X3 TRIDENT",SUP-643-00-36H,CDM,C1776,HCPCS,0278,RC,,,both,,,9915.30,2974.59,"BLUE CROSS [10001]","Blue Cross HMO",,3886.8,39.2,,5311.50,4717.44,5388.59,31,1153.15,8428.01,"percent of total billed charges",
"FORMULA TOMCAT CUTTER,(RED/WHITE)4MM ARTHROSCOPIC SHAVER ART",SUP-0375545000,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.94,39.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,60.1,45.9,,,,,0,15.23,111.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.5MM CALIBRATE GRADUATE 3.5MM LOCK CORTICAL SCR",SUP-AR-8916-06,CDM,S27200284,LOCAL,0272,RC,,,both,,,550.80,165.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,64.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,64.06,468.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MAC-LOC 40CM 10.2FR DRNG ULTRATHANE HYDROPHILIC BILIARY",SUP-G09498,CDM,C1729,HCPCS,0272,RC,,,both,,,801.82,240.55,"PHCS [10601]",PHCS,,561.27,70,,,,,0,93.25,681.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 19MM 150CM 7MM BILIARY STAINLESS",SUP-H74937912719150,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"CIGNA [10200]","Cigna Local Plus",,2670.72,53.5,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Finger(S)>=2v",PX-320000074,CDM,73140,CPT,0320,RC,,,both,,,507.16,152.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,60.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,49.66,431.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 6MM 65MM LC-DCP STAINLESS STEEL CORTEX PELVIC",SUP-204.665,CDM,C1713,HCPCS,0278,RC,,,both,,,275.27,82.58,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,126.35,45.9,,,,,0,32.01,233.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INQUIRY 5FR 2MM SPACE MEDIUM CURVE ELECTROPHYSIOLOGY",SUP-D7R20P14RT,CDM,C1731,HCPCS,0272,RC,,,both,,,7086.30,2125.89,"PHCS [10601]",PHCS,,4960.41,70,,,,,0,824.14,6023.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 16MM SECUR-FIT PLUS 12 HIP STERILE",SUP-6054-1216S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"CIGNA [10200]","Cigna Local Plus",,5092.11,31.5,,5372.07,4581.20,7242.98,23,1880.04,13740.62,"percent of total billed charges",
"CATH VIATRAC 14 PLUS 135CM 15MM 3.3-3.6FR 6MM BALLOON",SUP-1008197-15,CDM,C1725,HCPCS,0272,RC,,,both,,,1417.50,425.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA 32-35IN SMALL HOOK LOOP CLSR WIDE ADJUSTABLE SHOULDER",SUP-M5001-S,CDM,S27000186,LOCAL,0270,RC,,,both,,,161.39,48.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,19.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.77,137.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 90CM 6FR AR2 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H74938969180,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,42.62,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL 4 KNEE LEFT CRUCIATE RETAINING PFC SIGMA P",SUP-940014,CDM,C1776,HCPCS,0278,RC,,,both,,,25889.85,7766.95,"BLUE CROSS [10001]","Blue Cross HMO",,10148.82,39.2,,5311.50,4717.44,5388.59,31,3010.99,22006.37,"percent of total billed charges",
"ROD SPINAL 25MM 4MM LORDOSIS TITANIUM",SUP-102064025,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,141.3,1032.75,"percent of total billed charges",
"TRAY SURGICAL PROCEDURE FOR PORT ACCESS",SUP-DT20610A,CDM,S27200284,LOCAL,0272,RC,,,both,,,340.42,102.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,39.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,39.59,289.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE 5MM 68MM NAIL-EX TITANIUM FEMORAL TIBIAL LOCKING",SUP-04.005.558,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"KAISER [10500]",Kaiser,,774.98,67,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK OTW 2.50 X 18 MM",SUP-1212250-18,CDM,C1874,HCPCS,0278,RC,,,both,,,17250.00,5175,"CIGNA [10200]","Cigna Local Plus",,5433.75,31.5,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 5FR 10MM SPACE D CURVE",SUP-F5QD010RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"NOVANET [10819]",Novanet,,680.4,75,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE3.5MM 32.5MM MAXLOCK EXTREME ANKLE FOOT NONLOCKING",SUP-MFT01135325,CDM,C1713,HCPCS,0278,RC,,,both,,,1239.30,371.79,"BLUE CROSS [10001]","Blue Cross HMO",,485.81,39.2,,957.42,156.86,7483.26,51,144.13,1053.41,"percent of total billed charges",
"CMPNT FEMORAL 3 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRN3PR,CDM,C1776,HCPCS,0278,RC,,,both,,,13075.50,3922.65,"FIRST HEALTH [10303]","First Health",,10460.4,80,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 40MM 6MM BALLOON DILATATION HYDROPHILIC",SUP-606004022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"KAISER [10500]",Kaiser,,488.43,67,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 20MM 6MM BALLOON",SUP-U3513062,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"AETNA [10100]","Aetna HMO/PPO",,547.36,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 120CM 9MM VASCULAR METAL ILIAC ARTERY SELF",SUP-H74939200094020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]",Cigna,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25X10X7MM VERTE-STACK CRESCENT 6D",SUP-9192507,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"NOVANET [10819]",Novanet,,12420,75,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EMERGE MONORAIL 144CM 30MM 6FR 3MM .07IN BALLOON",SUP-H7493918930300,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BIT DRILL 9IN 8.5MM SENTINEL ROUNDED ECCENTRIC MONO FLUTED",SUP-S8580,CDM,S27200284,LOCAL,0272,RC,,,both,,,1593.51,478.05,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"INSRT TIBIAL 3+ 10MM KNEE RIGHT GUR 1020 CRUCIATE SUB",SUP-EIS3P10R,CDM,C1776,HCPCS,0278,RC,,,both,,,10391.40,3117.42,"NOVANET [10819]",Novanet,,7793.55,75,,,,,0,1208.52,8832.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLODERM (RTU) CONTOUR LARGE PERFORATED - THIN",SUP-CL1516P,CDM,Q4116,HCPCS,0636,RC,,,both,,,31380.30,9414.09,"KAISER [10500]",Kaiser,,21024.8,67,,,,,0,247.92,26673.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINE ANGIOGRAPHY 60IN .142IN .071IN 1200 PSI FEMALE LUER",SUP-91051602,CDM,S27200284,LOCAL,0272,RC,,,both,,,88.25,26.47,"CIGNA [10200]","Cigna Local Plus",,47.21,53.5,,,,,0,10.26,75.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 15MM 48MM SHOULDER REUNION STD RADIUS STERILE",SUP-5552-S-4815,CDM,C1776,HCPCS,0278,RC,,,both,,,9088.80,2726.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2601.21,28.62,,,,,0,1057.03,7725.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENDO CLOSE 10MM SUTURING TROCAR SITE SPRING LOAD",SUP-173022,CDM,S27200284,LOCAL,0272,RC,,,both,,,634.55,190.36,"KAISER [10500]",Kaiser,,425.15,67,,,,,0,73.8,539.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DULOXETINE 30 MG CAPSULE,DELAYED RELEASE",RX-39276,CDM,,,0637,RC,51991-0747-90,NDC,both,1,UN,28.51,8.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.32,24.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 9CM 10FR ZIMMON .035IN 2 PIGTAIL CURVE",SUP-G21862,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"UHC [10700]","United Healthcare",,779.35,63.3,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FORMULA BARREL BUR 12-FLUTE,(RED/RED)4MM ARTHROSCOPIC SHAVER",SUP-0375941012,CDM,S27200284,LOCAL,0272,RC,,,both,,,493.39,148.02,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,58.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,57.38,419.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 12MM 145CM 3.25MM CORONARY STENT",SUP-1125325-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS [10001]","Blue Cross HMO",,2288.5,39.2,,9776.84,9776.84,9776.84,"1 through 10",678.96,4962.3,"percent of total billed charges",
"FILLER BONE VOID 30CC 1-5MM CANCELLOUS ALLOGRAFT CHIPS",SUP-400120,CDM,C1713,HCPCS,0278,RC,,,both,,,3060.75,918.22,"MULTIPLAN [10600]",Multiplan,,2601.64,85,,,,,0,355.97,2601.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 8MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650808,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UHC [10700]","United Healthcare",,7975.8,63.3,,8601.07,8395.67,8601.07,"1 through 10",1465.38,10710,"percent of total billed charges",
"GWIRE ASAHI CHIKAI VASCULAR STRAIGHT 200CM 9CM .2/.26MM",SUP-WAIN-CKI-008-200,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"KAISER [10500]",Kaiser,,2512.5,67,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH LEAD EXTRACTION STEADYSHEATH EVOLUTION 36.5CM 13FR",SUP-LR-TSS-13.0,CDM,C1773,HCPCS,0272,RC,,,both,,,1875.00,562.5,"FIRST HEALTH [10303]","First Health",,1500,80,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 5FR .058IN JUDKINS RIGHT 5 CURVE GUIDING NYLON",SUP-LA5JR50,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"FIRST HEALTH [10303]","First Health",,313.2,80,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER MAMMOMARK CORMARK TISSUE BREAST BIOPSY BOWTIE CLLGN",SUP-MRM4002,CDM,A4648,HCPCS,0278,RC,,,both,,,701.57,210.47,"BLUE CROSS [10001]","Blue Cross HMO",,275.02,39.2,,,,,0,81.59,596.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 23MM NAVITOR TRANSCATHETER SELF EXPAND INTRA",SUP-NVTR-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,136800.00,41040,"AETNA [10100]","Aetna HMO/PPO",,108756,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15909.84,116280,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 40CM 16MM .0145IN AXIUM PRIME 3D FRAME",SUP-FC-16-40-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,16525.50,4957.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6791.98,41.1,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS 2-0 UR-6 27IN MONOFILAMENT ANTIBACTERIAL",SUP-MCP605H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 7MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650407,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1526.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 9IN NERVE RETRACTION BLUNT ADSON STAINLESS STEEL 5MM",SUP-285230,CDM,S27200284,LOCAL,0272,RC,,,both,,,189.57,56.87,"FIRST HEALTH [10303]","First Health",,151.66,80,,,,,0,22.05,161.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PEG 20FR XYLOCAINE SILICONE PULL METHOD AMPULE TROCAR",SUP-M00566461,CDM,S27200284,LOCAL,0272,RC,,,both,,,1470.15,441.04,"MULTIPLAN [10600]",Multiplan,,1249.63,85,,,,,0,170.98,1249.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION 4.5MM 8MM CORONARY OSTIUM",SUP-OCB4508BA,CDM,C1725,HCPCS,0272,RC,,,both,,,6900.00,2070,"UHC [10700]","United Healthcare",,4367.7,63.3,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PLLA HYDROXYAPATITE 20MM 9MM ANTERIOR",SUP-7209013,CDM,C1713,HCPCS,0278,RC,,,both,,,1839.23,551.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,213.9,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",213.9,1563.35,"percent of total billed charges",
"4.5MM TI CERV SELF-RETAIN SCR SLF-DRLG/VARIABLE ANGLE 14MM",SUP-04.613.564,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,117.75,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",117.75,860.63,"percent of total billed charges",
"CATH MUSTANG 135CM 200MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171082010,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"NOVANET [10819]",Novanet,,880.88,75,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X12X7MM COHERE 7D LORDOSIS SCORIA PEEK LOW",SUP-1000-00-0714,CDM,C1889,HCPCS,0278,RC,,,both,,,6210.00,1863,"AETNA [10100]","Aetna HMO/PPO",,4936.95,79.5,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET STONE RETRIEVAL 120CM 11MM 2.4FR GEMINI HELICAL",SUP-M0063303070,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"CIGNA [10200]","Cigna Open Access",,841.86,56.9,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC ZONENAVIGATOR LEFT POSTERIOR MIDDLE",SUP-AR-7910L,CDM,S27200284,LOCAL,0272,RC,,,both,,,1275.75,382.72,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH COYOTE 150CM 220MM 2MM .014IN BALLOON DILATATION NYBAX",SUP-39186-20221,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHEATH AMPLATZER TORQVUE 2 120CM 5FR INTRO POLYMER PTFE",SUP-9-TV2-05F120,CDM,S27200284,LOCAL,0272,RC,,,both,,,5754.60,1726.38,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH OPN NC 20MM 2MM BALLOON DILATATION PLATINUM IRIDIUM",SUP-200-020-004,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ALLERGIC REACTIONS WITH MCC",915,MS-DRG,,,,,,,inpatient,,,59678.23,17903.47,"CIGNA [10200]",Cigna,,,100,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"4F QUAD 10-10-10 MPA 120CM",SUP-901470,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ADJUSTMENT DISORDERS,MINOR",755,APR-DRG,,,,,,,inpatient,,,15674.12,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $3,360.83. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brain Mapping Add Hr",PX-740000025,CDM,95962,CPT,0740,RC,,,both,,,1167.00,350.1,"MULTIPLAN [10600]",Multiplan,,991.95,85,,,,,0,135.72,1167,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER HUMERAL ARTHREX XS LINER 33+6MM STERILE",SUP-AR-9503XS-06,CDM,C1776,HCPCS,0278,RC,,,both,,,4305.60,1291.68,"BLUE CROSS [10001]","Blue Cross PPO",,1687.8,39.2,,3949.44,3949.44,3949.44,"1 through 10",500.74,3659.76,"percent of total billed charges",
"HC Rv Tib/Prneal W Pta Sf Ea Add",PX-361000722,CDM,37281,CPT,0361,RC,,,both,,,6735.46,2020.64,"BLUE CROSS [10001]","Blue Cross HMO",,6.74,.1,,,,,0,6.74,6735.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 2.5X15/16IN V MUELLER HILL-FERGUSON MIRROR SATIN",SUP-SU181,CDM,S27200284,LOCAL,0272,RC,,,both,,,1070.09,321.03,"NOVANET [10819]",Novanet,,802.57,75,,,,,0,124.45,909.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 17CM 31MM 14.5MM EXCLUDER C3 TRUNK",SUP-RLT311417,CDM,C1874,HCPCS,0278,RC,,,both,,,62700.00,18810,"PHCS [10601]",PHCS,,43890,70,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN JUDKINS LEFT 4 CURVE GUIDING",SUP-LA7JL40SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 8MM 105MM 22MM DHS/DCS STAINLESS STEEL",SUP-280.05,CDM,C1713,HCPCS,0278,RC,,,both,,,2264.18,679.25,"AETNA [10100]","Aetna HMO/PPO",,1800.02,79.5,,1521.93,481.35,16760.95,30,263.32,1924.55,"percent of total billed charges",
"NAIL 11MM 36CM RIGHT TROCHANTERIC INTRAMEDULLARY 125D",SUP-456.396S,CDM,C1713,HCPCS,0278,RC,,,both,,,12838.83,3851.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1493.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",1493.16,10913.01,"percent of total billed charges",
"DISC INTERVERTEBRAL PRESTIGE SPINE",SUP-6972650,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"NOVANET [10819]",Novanet,,21262.5,75,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS INTRALIPID 20% FAT EMULSION PLASTIC BAG 250",SUP-2B6022,CDM,S27200284,LOCAL,0272,RC,,,both,,,389.43,116.83,"FIRST HEALTH [10303]","First Health",,311.54,80,,,,,0,45.29,331.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM OFFSET 28MM HIP TYPE 1 COCR G7",SUP-163661,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"FIRST HEALTH [10303]","First Health",,3880.56,80,,,,,0,564.14,4123.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 40CM 5FR 12MM .035IN EMBOLECTOMY NOVASIL 1.5ML OTW",SUP-1651-84,CDM,C1757,HCPCS,0272,RC,,,both,,,963.90,289.17,"NOVANET [10819]",Novanet,,722.93,75,,,,,0,112.1,819.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 26CM 3CM 6FR .035IN STRAIGHT URETERAL",SUP-M006155233190,CDM,C2617,HCPCS,0278,RC,,,both,,,1460.11,438.03,"CIGNA [10200]","Cigna Local Plus",,781.16,,,,,,,169.81,1241.09,"percent of total billed charges",
"PLATE 8 HOLE STRAIGHT LOW PROFILE BONE CLAVICLE",SUP-70-0286,CDM,C1713,HCPCS,0278,RC,,,both,,,6610.20,1983.06,"BLUE CROSS [10001]","Blue Cross PPO",,2591.2,39.2,,957.42,570.23,957.42,28,768.77,5618.67,"percent of total billed charges",
"SYSTEM AXIUM PRIME LATTICEFX HELIX 20CM 5MM .0115IN",SUP-APB-5-20-HX-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,7169.10,2150.73,"CIGNA [10200]","Cigna Local Plus",,3835.47,53.5,,,,,0,833.77,6093.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 90CM 7FR .081IN AL1 CURVE GUIDING CORONARY",SUP-LA7AL10D,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"AETNA [10100]","Aetna HMO/PPO",,311.24,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE DEMINERALIZED BONE MATRIX 10ML PUTTY PRETREATED",SUP-T43110,CDM,C1713,HCPCS,0278,RC,,,both,,,4185.00,1255.5,"KAISER [10500]",Kaiser,,2803.95,67,,,,,0,486.72,3557.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRUSH CYTOLOGY 1.9MM 115MM 3 NDL SUPERDIMENSION 15MM",SUP-SDTNB1500,CDM,S27200284,LOCAL,0272,RC,,,both,,,1549.53,464.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,711.23,45.9,,,,,0,180.21,1317.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 00 8IN EPSTEIN SURGICAL",SUP-57-4621,CDM,S27200284,LOCAL,0272,RC,,,both,,,349.74,104.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,237.82,68,,,,,0,40.67,297.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NANOCROSS 150CM 20MM 2.5MM .014IN BALLOON DILATATION",SUP-AB14W050150150,CDM,C1725,HCPCS,0272,RC,,,both,,,1577.48,473.24,"AMERIGROUP MEDICAID [20100]",Amerigroup,,186.93,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,183.46,1340.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IDENTITY IMPRINT PS INSERT SIZE 4, 7MM",SUP-TPS-020-074S,CDM,C1776,HCPCS,0278,RC,,,both,,,5878.80,1763.64,"BLUE CROSS [10001]","Blue Cross HMO",,2304.49,39.2,,5311.50,4717.44,5388.59,31,683.7,4996.98,"percent of total billed charges",
"LENS IOL +7 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR CHMBR",SUP-MTA5U0.070,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 78MM PRESS FIT AEQUALIS ASCEND FLEX PTC 127.5D",SUP-DWF604A,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"NOVANET [10819]",Novanet,,9450,75,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 12.5CM 10-4MM TORNADO PLATINUM ACCEPTS",SUP-G10428,CDM,S27800098,LOCAL,0278,RC,,,both,,,853.50,256.05,"KAISER [10500]",Kaiser,,571.85,67,,,,,0,99.26,725.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intra Cor Ffr W 3d Func Map",PX-480000080,CDM,0523T,CPT,0480,RC,,,both,,,3348.00,1004.4,"CIGNA [10200]",Cigna,,3348,,"Case rate ($7,680). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,389.37,3348,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC General Health Panel",PX-301000563,CDM,80050,CPT,0301,RC,,,both,,,789.45,236.83,"UHC [10700]","United Healthcare",,35.66,,,,,,,0.01,671.03,"fee schedule",
"KIT STENT 20CM 8FR .038IN PIGTAIL CURVE TAPER URETER GLIDEX",SUP-M001245620,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"CIGNA [10200]","Cigna Local Plus",,922.88,,,,,,,200.62,1466.25,"percent of total billed charges",
"STEM HUMERAL ALTIVATE NEUTRAL SHOULDER STERILE REVERSE",SUP-508-07-000,CDM,C1776,HCPCS,0278,RC,,,both,,,15316.76,4595.03,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1815.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1781.34,13019.25,"percent of total billed charges",
"GRAFT VASCULAR 40CM 6MM FLIXENE SLIDER GRADUATED WALL",SUP-25061,CDM,C1768,HCPCS,0278,RC,,,both,,,7430.33,2229.1,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2126.56,28.62,,,,,0,864.15,6315.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CRE 240CM 5.5CM 6-7-8MM 7.5FR 2.8MM 3.2MM BALLOON",SUP-M00558660,CDM,C1726,HCPCS,0272,RC,,,both,,,1649.03,494.71,"NOVANET [10819]",Novanet,,1236.77,75,,,,,0,1236.77,1236.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ORSIRO MISSION 15MM 140CM 2.5MM CORONARY STERILE LATEX",SUP-453938,CDM,C1874,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA [10200]",Cigna,,2580.6,68,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Gastric Emptying W Sm Bowel",PX-341000068,CDM,78265,CPT,0341,RC,,,both,,,2606.75,782.02,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,982.43,,,,,,,303.17,2215.74,"fee schedule",
"PORT IMPLANTABLE INFUSION SURECUFF METAL 14.3FR 2 POWER",SUP-0603000,CDM,C1788,HCPCS,0278,RC,,,both,,,1038.70,311.61,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,297.28,28.62,,,,,0,120.8,882.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS CROSSTEC 80CM 40MM 10MM .035IN BALLOON",SUP-AB35W10040080,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,278.31,41.1,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 3.5MM 2 CORKSCREW ROTATOR CUFF BIOABSORBABLE SELF",SUP-AR-1915S,CDM,C1713,HCPCS,0278,RC,,,both,,,936.00,280.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,636.48,68,,,,,0,108.86,795.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Occipital Bi",PX-510000116,CDM,64405,CPT,0761,RC,,,both,,,3761.00,1128.3,"FIRST HEALTH [10303]","First Health",,3008.8,80,,,,,0,437.4,3196.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.3MM 3MM 20MM 2.3MM SMALL HEADLESS SCR CANNULATED",SUP-L2320,CDM,C1713,HCPCS,0278,RC,,,both,,,2700.00,810,"PHCS [10601]",PHCS,,1890,70,,,,,0,314.01,2295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL KNIFE SHORT LENGTH 230CM 1.7MM .9MM",SUP-KD-612U,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AETNA [10100]","Aetna HMO/PPO",,2973.3,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SHOCKWAVE E8 150CM 80MM 3.5MM LITHOTRIPSY PERIPHERAL",SUP-E8IVL035080,CDM,C1725,HCPCS,0272,RC,,,both,,,29610.00,8883,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12169.71,41.1,,,,,0,3443.64,25168.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE ESC 10D +4MM 50MM 28MM GVF",SUP-121828750,CDM,C1776,HCPCS,0278,RC,,,both,,,19449.36,5834.81,"AETNA [10100]","Aetna HMO/PPO",,15462.24,79.5,,10981.53,8986.79,12413.38,12,2261.96,16531.96,"percent of total billed charges",
"HEAD FEMORAL S-ROM +0MM 11/13 TAPER 36MM HIP M SPECIFICATION",SUP-136531000,CDM,C1776,HCPCS,0278,RC,,,both,,,4087.44,1226.23,"CIGNA [10200]",Cigna,,2779.46,68,,5873.17,5873.17,5873.17,"1 through 10",475.37,3474.32,"percent of total billed charges",
"PICK SURGICAL 6.5IN 90D .50MM MEDIUM HOUSE MALLEABLE SHAFT",SUP-61-0374,CDM,S27200284,LOCAL,0272,RC,,,both,,,367.84,110.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,168.84,45.9,,,,,0,42.78,312.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 52MM HIP MULTIHOLE R3 STD STERILE",SUP-71338665,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"CIGNA [10200]","Cigna Open Access",,5322.23,33.5,,5302.19,4377.88,6578.61,27,1847.69,13504.16,"percent of total billed charges",
"SURFACE ARTICULAR PERSONA 4-5 E-F KNEE RIGHT TIBIA FIX",SUP-42522100616,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"UHC [10700]","United Healthcare",,6821.47,63.3,,8601.07,8395.67,8601.07,"1 through 10",1253.3,9159.96,"percent of total billed charges",
"CATH CORDIS SABER 150CM 250MM 2.5MM BALLOON DILATATION",SUP-48002525X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,881.28,68,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 3.5MM 11MM TITANIUM CORTEX HAND SELF TAPPING",SUP-401.811.96,CDM,C1713,HCPCS,0278,RC,,,both,,,319.12,95.74,"BLUE CROSS [10001]","Blue Cross PPO",,125.1,39.2,,957.42,570.23,957.42,28,37.11,271.25,"percent of total billed charges",
"CABLE ORTHOPEDIC VITALLIUM 1.6MM HIP HOMOGENOUS GRIP",SUP-6704-0-110,CDM,C1713,HCPCS,0278,RC,,,both,,,3832.92,1149.88,"KAISER [10500]",Kaiser,,2568.06,67,,,,,0,445.77,3257.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X8MM ALEUTIAN LORDOTIC",SUP-403-21408L,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"KAISER [10500]",Kaiser,,4474.54,67,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +13 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00130,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,127.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRONG CPAP CURVE INFANT SEPTUM CUT AWAY SOFT SILICONE NASAL",SUP-BC4540-10,CDM,S27000186,LOCAL,0270,RC,,,both,,,68.73,20.62,"UHC [10700]","United Healthcare",,43.51,63.3,,,,,0,7.99,58.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FUSION QUATTRO 200CM 6.6FR 8.5-15MM SPECIMEN RETRIEVAL",SUP-G48225,CDM,S27800098,LOCAL,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER MARINR 90CM 7FR 2-2-2MM SPACING CORONARY SINUS CURV",SUP-043302M,CDM,C1730,HCPCS,0272,RC,,,both,,,1012.50,303.75,"PHCS [10601]",PHCS,,708.75,70,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE SAFE-T-J VASCULAR 3MM RADIUS 2.5CM J TAPER 260CM 7CM",SUP-G00471,CDM,C1769,HCPCS,0272,RC,,,both,,,156.51,46.95,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,18.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.2,133.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 3.937X.709IN THK.05IN 2 CUT HIGH PERFORMANCE",SUP-4118127100,CDM,S27200284,LOCAL,0272,RC,,,both,,,382.02,114.61,"PHCS [10601]",PHCS,,267.41,70,,,,,0,44.43,324.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM",RX-9175,CDM,,,0250,RC,45802-0376-35,NDC,both,15,GR,12.54,3.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8.53,68,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 320MM VASCULAR TISSUE POWER ADVANCE PLACEMENT",SUP-PVE35A,CDM,S27200284,LOCAL,0272,RC,,,both,,,6740.84,2022.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2770.49,41.1,,,,,0,783.96,5729.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML IV SUPERORDERABLE",RX-408117332,CDM,J1642,HCPCS,0636,RC,64253-0333-35,NDC,both,5,ML,28.01,8.4,"UHC [10700]","United Healthcare",,2,,,,,,,1.17,23.81,"fee schedule",
"LENS IOL +22.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.225,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,80.07,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 235CC P3.1CM ROUND LOW PLUS PROFILE SMOOTH GEL",SUP-SSLP-235,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2162.38,28.62,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT GLENOID 29MM AEQUALIS PERFORM 35D SHOULDER HALF",SUP-DWJ514,CDM,C1776,HCPCS,0278,RC,,,both,,,11340.00,3402,"BLUE CROSS [10001]","Blue Cross PPO",,4445.28,39.2,,3949.44,3949.44,3949.44,"1 through 10",1318.84,9639,"percent of total billed charges",
"CATH KOALA INTRAUTERINE PRESSURE SENSOR TIP LUMEN LATEX FREE",SUP-IPC-5000E,CDM,S27200284,LOCAL,0272,RC,,,both,,,252.30,75.69,"CIGNA [10200]","Cigna Open Access",,143.56,56.9,,,,,0,29.34,214.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 0D 50MM 32MM XLPE HIP STERILE",SUP-71339550,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"BLUE CROSS [10001]","Blue Cross HMO",,4361.49,39.2,,5311.50,4717.44,5388.59,31,1293.98,9457.31,"percent of total billed charges",
"CANN PERFUSION 17IN 17FR PERCUTANEOUS FEMORAL ARTERIAL ADULT",SUP-96530-017,CDM,S27200284,LOCAL,0272,RC,,,both,,,1903.58,571.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,873.74,45.9,,,,,0,221.39,1618.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BALL TIPPED GUIDE ROD 3.0 X 550MM PHANTOM? HINDFOOT NAIL",SUP-P31-955-1550,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"FIRST HEALTH [10303]","First Health",,1166.4,80,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER FLEXIVA ID 200UM FLEXSHIELD HIGH POWER NONTAPER",SUP-M006R8403911,CDM,S27200284,LOCAL,0272,RC,,,both,,,2720.04,816.01,"AETNA [10100]","Aetna HMO/PPO",,2162.43,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,316.34,2312.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 64CM 9FR ENDOCARDIUM 2 COIL ACTIVE FIXATION",SUP-0185,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1997.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TORSEMIDE 20 MG TABLET",RX-18293,CDM,,,0637,RC,50268-0756-11,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ENTEER 150CM 20X2.75X1MM .066IN BALLOON OCCLUSION",SUP-ENB-275-20-150,CDM,C1887,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1404.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 80MM 6MM BALLOON DILATATION DURALYN",SUP-48006008X,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UHC [10700]","United Healthcare",,794.73,63.3,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM ATRIUM RIGHT VENTRICLE TRANSVENOUS 4 TINE",SUP-407452,CDM,C1898,HCPCS,0275,RC,,,both,,,2250.00,675,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1032.75,45.9,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 20X16CM GENTRIX THICK PORCINE",SUP-PSMT1620,CDM,C1781,HCPCS,0278,RC,,,both,,,57153.60,17146.08,"FIRST HEALTH [10303]","First Health",,45722.88,80,,,,,0,6646.96,48580.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 12MM 145CM 2.5MM CORONARY STENT",SUP-1145250-12,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1670.84,28.62,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACURATE NE02TM AORTIC VALVE S - CLINICAL",SUP-SYM-SV23-006-C,CDM,S62400003,LOCAL,0624,RC,,,both,,,159600.00,47880,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,108528,68,,,,,0,18561.48,135660,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Epidrm Autograft a/T/L Add 100scm",PX-761000022,CDM,15111,CPT,0761,RC,,,both,,,1247.00,374.1,"MULTIPLAN [10600]",Multiplan,,1059.95,85,,,,,0,1.25,1247,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rv Tib/Prneal W Ather Cmplx Init",PX-361000731,CDM,37290,CPT,0361,RC,,,both,,,23403.71,7021.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5284,,"Case rate ($5,284). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,23.4,19893.15,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM DCP LC-DCP STAINLESS STEEL DISTAL",SUP-204.834,CDM,C1713,HCPCS,0278,RC,,,both,,,236.64,70.99,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,27.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",27.52,201.14,"percent of total billed charges",
"INTRODUCER SHEATH 10CM 6FR 22GA",SUP-506610P22G,CDM,C1894,HCPCS,0272,RC,,,both,,,567.00,170.1,"PHCS [10601]",PHCS,,396.9,70,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2.5 CURVE PLUS 15MM KNEE XLK FIX BEARING SIGMA",SUP-970443,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"NOVANET [10819]",Novanet,,8380.91,75,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tau Phosphorylated Ea",PX-301000699,CDM,84393,CPT,0301,RC,,,both,,,1050.00,315,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,892.5,"per diem",
"PROS PENILE TITAN COLOPLAST LOCK-OUT 11CM INFLATABLE NARROW",SUP-EN8911,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"BLUE CROSS [10001]","Blue Cross PPO",,24578.4,39.2,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS SENSOR DUAL-FLEX 26CM 5FR .038",SUP-M006192123120,CDM,C2617,HCPCS,0278,RC,,,both,,,1528.96,458.69,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1039.69,68,,,,,0,177.82,1299.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN RIGHT CORONARY BYPASS CURVE",SUP-DXT6RCB,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"FIRST HEALTH [10303]","First Health",,66.12,80,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 1.5MM X 6MM COCR",SUP-VAL-15060-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,165.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",165.8,1211.76,"percent of total billed charges",
"BLADE SHAVER NAVY BLUE 4.5MM TURBOWHISKER DYONICS STRAIGHT",SUP-7205316,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,159.73,45.9,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ENDOBRONCHIAL ARNDT PEDIATRIC 65CM 7FR STD 1 LUMEN CATH",SUP-G44114,CDM,S27200284,LOCAL,0272,RC,,,both,,,1942.50,582.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1320.9,68,,,,,0,225.91,1651.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 11MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532-P-811,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3835.36,45.9,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN JUDKINS",SUP-77801400,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"KAISER [10500]",Kaiser,,291.45,67,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEEDLE GUIDE AND COVER DISPOSABLE ULTRPRO3",SUP-610-901,CDM,S27200284,LOCAL,0272,RC,,,both,,,167.62,50.29,"CIGNA [10200]",Cigna,,113.98,68,,,,,0,19.49,142.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE LOW PROFILE STAINLESS STEEL 4 HOLE LOCK MODULAR BONE",SUP-AR-8943BL-04,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"PHCS [10601]",PHCS,,2656.5,70,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT NEEDLE GUIDE AND COVER DISPOSABLE ULTRPRO3",SUP-610-901,CDM,S27200284,LOCAL,0272,RC,,,both,,,167.62,50.29,"KAISER [10500]",Kaiser,,112.31,67,,,,,0,19.49,142.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17.5MM 25MM HANCOCK II ULTRA CINCH PORCINE",SUP-T505U225,CDM,S27800098,LOCAL,0278,RC,,,both,,,21420.00,6426,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8568,40,,,,,0,2491.15,18207,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 7FR .078IN SHORT",SUP-77809000,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 180MM HUMERAL TALON DISTALFIX INTRAMEDULLARY",SUP-HTN-409-180,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2053.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,2014.9,14726.25,"percent of total billed charges",
"STENT ONYX FRONTIER 12MM 2.5MM CORONARY RAPID EXCHANGE",SUP-ONYXNG25012UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,305.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 20MM COCR",SUP-VAL-25200-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]",Cigna,,969.41,68,,1831.33,1831.33,1831.33,16,165.8,1211.76,"percent of total billed charges",
"INSRT TIBIAL 10MM IPOLY XE POSTERIOR STABILIZE ITOTAL",SUP-TPS-020-1000,CDM,C1776,HCPCS,0278,RC,,,both,,,2130.00,639,"BLUE CROSS [10001]","Blue Cross HMO",,834.96,39.2,,5311.50,4717.44,5388.59,31,247.72,1810.5,"percent of total billed charges",
"SCR BONE 12.7MM 8.2MM 130MM 22MM DHS/DCS STAINLESS STEEL",SUP-280.3,CDM,C1713,HCPCS,0278,RC,,,both,,,1818.38,545.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,834.64,45.9,,,,,0,211.48,1545.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER 6287641 PSR LAT PORTS 6X14X11",SUP-6287641,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"FIRST HEALTH [10303]","First Health",,5342.74,80,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE MICRO 150CM 10CM 2.5MM BALLOON DILATATION",SUP-G26678,CDM,C1725,HCPCS,0272,RC,,,both,,,3112.43,933.73,"AMERIGROUP MEDICAID [20100]",Amerigroup,,368.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,361.98,2645.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 12MM 420MM FEMORAL PROXIMAL TFN-ADVANCED INTRAMEDULLARY",SUP-04.037.262S,CDM,C1713,HCPCS,0278,RC,,,both,,,12418.34,3725.5,"FIRST HEALTH [10303]","First Health",,9934.67,80,,,,,0,1444.25,10555.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 12MM TITANIUM CORTICAL HAND SELF TAPPING",SUP-400.812,CDM,C1713,HCPCS,0278,RC,,,both,,,401.94,120.58,"NOVANET [10819]",Novanet,,301.46,75,,,,,0,46.75,341.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING HIP 44MM 28MM F VIVACIT-E LUMEN STERILE LATEX FREE",SUP-110031012,CDM,C1776,HCPCS,0278,RC,,,both,,,10356.90,3107.07,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1227.29,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1204.51,8803.37,"percent of total billed charges",
"SUT VICRYL RAPIDE MULTIPASS 5-0 PC-3 18IN BRAID",SUP-VR844,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.27,21.68,"CIGNA [10200]","Cigna Open Access",,41.12,56.9,,,,,0,8.41,61.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC XTREME 130CM 250MM 4MM BALLOON DILATATION",SUP-PCU040250130,CDM,C1725,HCPCS,0272,RC,,,both,,,1269.68,380.9,"AMERIGROUP MEDICAID [20100]",Amerigroup,,150.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.66,1079.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PROC 7 TRIATHLON CR DISPOSABLE FEMORAL",SUP-5555-2207,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) BATWIRE IMPLANT KIT MODEL 1100",SUP-100066-102,CDM,C1769,HCPCS,0624,RC,,,both,,,0.01,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE VISIGLIDE 2 UROLOGICAL 4500MM 70MM .025IN HYDROPHILIC",SUP-G-260-2545S,CDM,C1769,HCPCS,0272,RC,,,both,,,1288.95,386.68,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE NOVAGOLD ENDOSCOPIC 260CM 6CM .018IN TRITON BILIARY",SUP-M00552001,CDM,C1769,HCPCS,0272,RC,,,both,,,1460.03,438.01,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL VASCULAR J",SUP-1009663J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYNCOPE AND COLLAPSE",312,MS-DRG,,,,,,,inpatient,,,29947.86,8984.36,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPERANCE CATHETER KIT 5F 131CM",SUP-ASP5F131KIT,CDM,C1757,HCPCS,0272,RC,,,both,,,15145.50,4543.65,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Trcran Dplr Intrcr Complt",PX-921000003,CDM,93886,CPT,0921,RC,,,both,,,1764.05,529.21,"PHCS [10601]",PHCS,,1234.84,70,,,,,0,205.16,1499.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE VERSACORE VASCULAR MODIFIED J 175CM .035IN",SUP-1012068-05,CDM,C1769,HCPCS,0272,RC,,,both,,,631.80,189.54,"KAISER [10500]",Kaiser,,423.31,67,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX MONOCRYL PLUS 4-0 PS-2 SPIRAL 14CM SUT",SUP-SXMP2B407,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.59,68.58,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,26.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.59,194.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY CATH 16CM 12FR .035IN MAHURKAR 3 LUMEN CURVED EXT HIGH",SUP-8888101002,CDM,C1752,HCPCS,0272,RC,,,both,,,1573.52,472.06,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CONTROL WIRE V-14 0.014 X 300CM",SUP-H74939216730010,CDM,C1769,HCPCS,0272,RC,,,both,,,2295.00,688.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MASK CPAP LARGE 4 POINT HEADGEAR LEAK 1",SUP-73-1061735,CDM,S27000186,LOCAL,0270,RC,,,both,,,206.58,61.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE SYNCHRO VASCULAR STD 215CM .014IN HYDROPHILIC SOFT",SUP-SSTD215PRE,CDM,C1769,HCPCS,0272,RC,,,both,,,4186.64,1255.99,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ROTAWIRE WIRECLIP TORQUER VASCULAR 330CM 2.8CM .014IN",SUP-H802232390012,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE TALON ORTHOPEDIC 600MM 3MM TROCAR TIP",SUP-SLN-T35,CDM,C1769,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"METRONIDAZOLE 5 MG/ML IVPB",RX-40840043,CDM,J1836,HCPCS,0636,RC,00338-1055-48,NDC,both,100,ML,100.65,30.19,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,68.44,68,,,,,0,1.75,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183462,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5331.05,68,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 20MM  COCR",SUP-VAL-35200-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"CIGNA [10200]","Cigna Local Plus",,1123.5,53.5,,3978.14,359.25,3978.14,24,244.23,1785,"percent of total billed charges",
"DRILL SURGICAL CANNULATED 3.5MM FIFTH METATARSAL FRACTURE",SUP-AR-8956C-35PD,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"CIGNA [10200]","Cigna Open Access",,1066.88,56.9,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 90MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.890,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"BLUE CROSS [10001]","Blue Cross PPO",,538.77,39.2,,957.42,570.23,957.42,28,159.84,1168.25,"percent of total billed charges",
"STENT VICI VENOUS STENT 120MM 100MM 14MM ENDOPROSTHESIS",SUP-H74914120100,CDM,C1876,HCPCS,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3752.08,28.62,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT VASCULAR STRAIGHT",SUP-1001782,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL CARDIO-GRIP DEBAKEY ANGLED 7IN PERIPHERAL",SUP-320250,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.00,228.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,517.48,68,,,,,0,88.5,646.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X8MM LORDOTIC SPINE CERVICAL CORTICAL",SUP-17008,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cleanser Wound Vashe 16oz",PX-E27000248,CDM,E27000248,LOCAL,0270,RC,,,both,,,226.60,67.98,"MULTIPLAN [10600]",Multiplan,,192.61,85,,,,,0,26.35,192.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT BONE CEMENT CEMEX FEMORAL PREP",SUP-KIT-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1435.89,430.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,166.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.99,1220.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM MULTI-LINK MINI VISION 12MM 2.5MM CORONARY STENT COCR",SUP-1007823-12,CDM,C1876,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,858.6,28.62,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TORQVUE SHEATH 14F 080CM 45X45 PKG STER",SUP-9-TV45X45-14F-080-CLINICAL,CDM,S62400003,LOCAL,0624,RC,,,both,,,5989.20,1796.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,696.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,696.54,5090.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION",RX-234450,CDM,A9573,HCPCS,0636,RC,00270-7025-40,NDC,both,7.5,ML,225.00,67.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,153,68,,,,,0,26.66,191.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 30CM 8FR 2.1FR POLARIS ULTRA NAUTILUS .038IN 2",SUP-M006192155010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"PHCS [10601]",PHCS,,840.41,70,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO 10CM 7FR PINNACLE 45CM PERIPHERAL SMOOTH",SUP-RSS701,CDM,C1894,HCPCS,0272,RC,,,both,,,78.30,23.49,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Aqmbf Spect Xers/Strs & Rest",PX-341000093,CDM,0742T,HCPCS,0341,RC,,,both,,,720.11,216.03,"AMERIGROUP MEDICAID [20100]",Amerigroup,,85.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,83.75,612.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +17 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR CHMBR",SUP-MTA4U0.170,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,316.02,45.9,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM PINNACLE D THR HIP MODULAR",SUP-OSC378823,CDM,C1776,HCPCS,0278,RC,,,both,,,30240.00,9072,"CIGNA [10200]","Cigna Local Plus",,9525.6,31.5,,5372.07,4581.20,7242.98,23,3516.91,25704,"percent of total billed charges",
"CAP SYSTEM PINNACLE D THR HIP MODULAR",SUP-OSC378823,CDM,C1776,HCPCS,0278,RC,,,both,,,30240.00,9072,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3583.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3516.91,25704,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cath Cervical Balloon Dilatation",PX-E27200255,CDM,C1726,HCPCS,0272,RC,,,both,,,309.10,92.73,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE LUGE VASCULAR 182CM .014IN ICE STAINLESS STEEL POLYMER",SUP-H74912130010,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE TRANSEND VASCULAR 182CM 2CM .014IN ICE SCITANIUM STD",SUP-M001468050,CDM,C1769,HCPCS,0272,RC,,,both,,,3942.52,1182.76,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ROADRUNNER UNIGLIDE VASCULAR ANGLE TAPER 260CM 14CM",SUP-G30492,CDM,C1769,HCPCS,0272,RC,,,both,,,327.10,98.13,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRO 10CM 4FR 21GA MERIT MAK .018IN STAINLESS STEEL",SUP-MAK401-PED,CDM,C1894,HCPCS,0272,RC,,,both,,,197.06,59.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Iep Serum",PX-302000070,CDM,86334,CPT,0302,RC,,,both,,,541.50,162.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,460.28,"per diem",
"HC Iep Serum",PX-302000070,CDM,86334,CPT,0302,RC,,,both,,,541.50,162.45,"BLUE CROSS [10001]","Blue Cross PPO",,28.54,,"Fee schedule rate ($28.54).",,,,0,0.01,460.28,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 75MM LCP STAINLESS STEEL PROXIMAL MEDIAL",SUP-212.127,CDM,C1713,HCPCS,0278,RC,,,both,,,857.30,257.19,"BLUE CROSS [10001]","Blue Cross HMO",,336.06,39.2,,957.42,156.86,7483.26,51,99.7,728.71,"percent of total billed charges",
"HC Temp Pacing Catheter/Intro Kit",PX-E27200289,CDM,E27200289,LOCAL,0278,RC,,,both,,,950.40,285.12,"FIRST HEALTH [10303]","First Health",,760.32,80,,,,,0,110.53,807.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Trypsin Fecal Qual",PX-301000427,CDM,84311,CPT,0301,RC,,,both,,,338.00,101.4,"FIRST HEALTH [10303]","First Health",,270.4,80,,,,,0,0.01,287.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Immunofluor Antb Addl Stain",PX-312000065,CDM,88350,CPT,0312,RC,,,both,,,245.70,73.71,"KAISER [10500]",Kaiser,,164.62,67,,,,,0,0.01,208.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOVIVE PLUS 1.0CC",SUP-203201,CDM,C1713,HCPCS,0278,RC,,,both,,,2437.50,731.25,"NOVANET [10819]",Novanet,,1828.13,75,,,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 55MM TITANIUM REGULAR GASTROINTESTINAL",SUP-TLC55,CDM,S27200284,LOCAL,0272,RC,,,both,,,1876.45,562.93,"CIGNA [10200]","Cigna Local Plus",,1003.9,53.5,,,,,0,218.23,1594.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PACIFIC PLUS 150MM 150CM 4MM BALLOON DILATATION",SUP-PCP040150150,CDM,C1725,HCPCS,0272,RC,,,both,,,1231.20,369.36,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,143.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION",RX-7556,CDM,J2865,HCPCS,0636,RC,00703-9514-01,NDC,both,10,ML,113.63,34.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.32,96.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ACUITY WHISPERVIEW VASCULAR CS J CURVE 190CM CORONARY",SUP-4648,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 9MM 370MM TIBIA T2 INTRAMEDULLARY STD LOCK TITANIUM",SUP-1822-0937S,CDM,C1713,HCPCS,0278,RC,,,both,,,14406.10,4321.83,"NOVANET [10819]",Novanet,,10804.58,75,,,,,0,1675.43,12245.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 42MM X25 LOCK STERILE INTRAMEDULLARY NAIL",SUP-04.045.042S,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,465.93,28.62,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plc Transperi Pros Inters",PX-361000240,CDM,55875,CPT,0361,RC,,,both,,,7679.62,2303.89,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,893.14,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,893.14,7679.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CNCT ROD 12MM 5.5-6MM 5.5-6.35MM CREO SPINE 1 HEAD OPEN",SUP-1175.9214,CDM,C1713,HCPCS,0278,RC,,,both,,,10005.00,3001.5,"UHC [10700]","United Healthcare",,6333.17,63.3,,5023.51,2672.93,6679.78,18,1163.58,8504.25,"percent of total billed charges",
"CELECOXIB 200 MG CAPSULE",RX-24501,CDM,,,0637,RC,50268-0169-11,NDC,both,1,UN,12.21,3.66,"CIGNA [10200]","Cigna Open Access",,6.95,56.9,,,,,0,1.42,10.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 1.5MM FAST MINI QUICK CONNECT ALPS HAND FRACTURE",SUP-231220203,CDM,S27200284,LOCAL,0272,RC,,,both,,,668.25,200.47,"MULTIPLAN [10600]",Multiplan,,568.01,85,,,,,0,77.72,568.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT GORE VIABIL 40MM 200CM 8MM ENDOPROSTHESIS METAL NO",SUP-VSWVN0804,CDM,C1874,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"NOVANET [10819]",Novanet,,12993.75,75,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NEROSTIMLTR IMPLANTABLE AXONICS SNM SYSTEM STERILE LATEX",SUP-4101,CDM,C1767,HCPCS,0278,RC,,,both,,,64615.20,19384.56,"KAISER [10500]",Kaiser,,43292.18,67,,,,,0,7514.75,54922.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT ELITE VASCULAR J CURVE",SUP-1011880J,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE GLIDE TECHNOLOGY VASCULAR STD ANGLE 260CM 3CM",SUP-GS3509,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT FOR THE PREP OF TC-99M-TILMANOCEPT SOLUTION FOR INJECTION (2.5-3 MCI)",RX-411874,CDM,A9520,HCPCS,0343,RC,08888-8876-08,NDC,both,1,UN,4614.97,1384.49,"PHCS [10601]",PHCS,,3230.48,70,,,,,0,536.72,4614.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LPT ANGLED GREAT TOE SIZE 2",SUP-487A002,CDM,C1776,HCPCS,0278,RC,,,both,,,11585.10,3475.53,"UHC [10700]","United Healthcare",,7333.37,63.3,,8601.07,8395.67,8601.07,"1 through 10",1347.35,9847.34,"percent of total billed charges",
"BEARING 79/83MMX10MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183560,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2243.75,28.62,,,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3.5MM 12/14 SMALL 36MM HIP ACETABULAR BIOLOX",SUP-00877503601,CDM,C1776,HCPCS,0278,RC,,,both,,,9858.72,2957.62,"PHCS [10601]",PHCS,,6901.1,70,,,,,0,1146.57,8379.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 56MM HIP MULTIHOLE R3 STD STERILE",SUP-71338667,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"CIGNA [10200]","Cigna Local Plus",,5004.48,31.5,,5372.07,4581.20,7242.98,23,1847.69,13504.16,"percent of total billed charges",
"CMPNT TIBIAL PERSONA 0D G KNEE LEFT OSSEOTI KEEL",SUP-42535007901,CDM,C1776,HCPCS,0278,RC,,,both,,,13765.50,4129.65,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1600.93,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1600.93,11700.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX10MM VANGUARD ARCOM KNEE CRUCIATE RETAIN",SUP-183560,CDM,C1776,HCPCS,0278,RC,,,both,,,7839.78,2351.93,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,911.77,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,911.77,6663.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 19.5+ CMX10-20MM ACHILLES TENDON CALCANEUS",SUP-430201,CDM,C1762,HCPCS,0278,RC,,,both,,,14314.74,4294.42,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1696.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1664.8,12167.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 11 STD KNEE LEFT CRUCIATE RETAIN PERSONA",SUP-42508607001,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3109.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,3051.51,22302.5,"percent of total billed charges",
"CMPNT FEMORAL 11 STD KNEE LEFT CRUCIATE RETAIN PERSONA",SUP-42508607001,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"CIGNA [10200]","Cigna Local Plus",,8265.05,31.5,,5372.07,4581.20,7242.98,23,3051.51,22302.5,"percent of total billed charges",
"INSRT TIBIAL 3 13MM CONDYLAR STABILIZE BEARING TRIATHLON",SUP-5531-G-313-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"CIGNA [10200]","Cigna Local Plus",,3790.58,31.5,,5372.07,4581.20,7242.98,23,1399.51,10228.56,"percent of total billed charges",
"CMPNT FEMORAL 7 STD KNEE LEFT CRUCIATE RETAIN PERSONA PPS",SUP-42508606201,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3051.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER FEMORAL 15MM ACCOLADE C RING MEDIUM HIP CEMENT 4 5",SUP-1059-4515,CDM,C1776,HCPCS,0278,RC,,,both,,,810.00,243,"CIGNA [10200]","Cigna Open Access",,460.89,56.9,,5302.19,4377.88,6578.61,27,94.2,688.5,"percent of total billed charges",
"BASEPLT TIBIAL LEGION 1 KNEE LEFT JOURNEY LOCK",SUP-71933567,CDM,C1776,HCPCS,0278,RC,,,both,,,26148.15,7844.44,"CIGNA [10200]","Cigna Local Plus",,8236.67,31.5,,5372.07,4581.20,7242.98,23,3041.03,22225.93,"percent of total billed charges",
"INSRT TIBIAL 4 CURVE 12.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962042,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2647.19,28.62,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP SYSTEM VANGUARD TKR E1 FEMUR PATELLA TIBIA CEMENT INSRT",SUP-98B00200138,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"PHCS [10601]",PHCS,,17199,70,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL TAPERFILL 13 STD OFFSET HIP STERILE LATEX FREE",SUP-425-96-013,CDM,C1776,HCPCS,0278,RC,,,both,,,13800.00,4140,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5671.8,41.1,,6417.48,6417.48,6417.48,"1 through 10",1604.94,11730,"percent of total billed charges",
"GWIRE SHEPHERD ANGIOGRAPHIC STRAIGHT .014IN 4GM PERIPHERAL",SUP-PSP14S-30004,CDM,C1769,HCPCS,0272,RC,,,both,,,1012.50,303.75,"KAISER [10500]",Kaiser,,678.38,67,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ABSORBATACK 5MM FIXATION POLYESTER 15 TACK ABSORBABLE",SUP-ABSTACK15,CDM,S27200284,LOCAL,0272,RC,,,both,,,2795.85,838.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,325.16,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,325.16,2376.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 20GA 15CM SUPERCORE COAXIAL INTRO ADJUSTABLE",SUP-701120150,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.65,103.09,"FIRST HEALTH [10303]","First Health",,274.92,80,,,,,0,39.97,292.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT CEMENTED CRUCIATE RETAINING ATTUNE",SUP-150400106,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"CIGNA [10200]","Cigna Open Access",,7501.77,33.5,,5302.19,4377.88,6578.61,27,2604.35,19034.35,"percent of total billed charges",
"STENT URETERAL 4.8FR L14CM FIRM WITHOUT GUIDEWIRE TRIA",SUP-M0061902070,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,,,,,,,189.34,1383.8,"percent of total billed charges",
"SUT ETHIBOND 0 SH 36IN 2 ARM BRAID GREEN NONABSORBABLE",SUP-X524H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"KAISER [10500]",Kaiser,,17.42,67,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH UROMAX ULTRA QUADRA-FOLD 75CM 10CM 5.8FR 12FR BALLOON",SUP-M0062251150,CDM,C1726,HCPCS,0272,RC,,,both,,,1712.48,513.74,"PHCS [10601]",PHCS,,1198.74,70,,,,,0,199.16,1455.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX TISSUE 5X7CM GENTRIX PLUS EXTRACELLULAR",SUP-MSPL0507,CDM,C1781,HCPCS,0278,RC,,,both,,,6846.53,2053.96,"BLUE CROSS [10001]","Blue Cross HMO",,2683.84,39.2,,,,,0,796.25,5819.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION",RX-27737,CDM,Q9967,HCPCS,0255,RC,00270-1315-35,NDC,both,100,ML,200.00,60,"AMERIGROUP MEDICAID [20100]",Amerigroup,,23.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",25.87,23.70,25.87,400,23.26,170,"percent of total billed charges",
"GWIRE VASCULAR STRAIGHT 145CM .014IN CORONARY TIP",SUP-TFC14145S,CDM,C1769,HCPCS,0272,RC,,,both,,,2250.00,675,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1530,68,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vrtplsty Cerv/Thorac W Img",PX-361000375,CDM,22510,CPT,0361,RC,,,both,,,9476.00,2842.8,"FIRST HEALTH [10303]","First Health",,7580.8,80,,,,,0,1102.06,9476,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Inj Anes Nerve Suprascapular",PX-761000048,CDM,64418,CPT,0761,RC,,,both,,,3959.74,1187.92,"PHCS [10601]",PHCS,,2771.82,70,,,,,0,460.52,3365.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD SUT ASSISTANT 2-0 ES-9 7IN COATED ENDO STITCH BRALON",SUP-170011,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"MULTIPLAN [10600]",Multiplan,,122.54,85,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER SUT REMOVAL NOVOCUT MANAGER",SUP-CTXC001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1093.50,328.05,"MULTIPLAN [10600]",Multiplan,,929.48,85,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"27 MM LOTUS EDGE AORTIC VALVE SYSTEM AND LARGE LOTUS INTRODU",SUP-B0M27EDGELGIS,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"CIGNA [10200]","Cigna Local Plus",,58353.75,31.5,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM POLYCARBOPHIL 625 MG TABLET",RX-11046,CDM,,,0637,RC,00904-2500-91,NDC,both,1,UN,6.27,1.88,"CIGNA [10200]",Cigna,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SKATER CHOICE LOCK 35CM 14FR NEPHRSTMY METAL PIGTAIL",SUP-756614035,CDM,C1729,HCPCS,0272,RC,,,both,,,651.24,195.37,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,442.84,68,,,,,0,75.74,553.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 24CM 3CM 8FR .038IN STRAIGHT URETERAL PERCUFLEX PLUS",SUP-M006175282110,CDM,C2617,HCPCS,0278,RC,,,both,,,1239.38,371.81,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,146.87,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,144.14,1053.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CLOTTRIEVER 16FR THROMBECTOMY",SUP-51-101,CDM,C1894,HCPCS,0272,RC,,,both,,,13800.00,4140,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1635.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.55-1.75IN TITANIUM 5.5MM ROD LOW PROFILE BAR FIX",SUP-811-321,CDM,C1713,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"CIGNA [10200]","Cigna Local Plus",,1905.94,53.5,,3978.14,359.25,3978.14,24,414.32,3028.13,"percent of total billed charges",
"SUT PDS II 5-0 RB-1 30IN 2 ARM MONOFILAMENT VIOLET",SUP-Z320H,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.00,19.8,"NOVANET [10819]",Novanet,,49.5,75,,,,,0,7.68,56.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Abd Pelv Complt",PX-921000013,CDM,93975,CPT,0921,RC,,,both,,,1504.64,451.39,"KAISER [10500]",Kaiser,,1008.11,67,,,,,0,174.99,1278.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL BLADE 24FR INCISION STORZ 1 STEM",SUP-M0068805011,CDM,S27200284,LOCAL,0272,RC,,,both,,,516.48,154.94,"KAISER [10500]",Kaiser,,346.04,67,,,,,0,60.07,439.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.6CM MEMORYGEL P3.3CM MODERATE CLASSIC PROFILE",SUP-RSZ-7360MC,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.23,46.27,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,63.39,41.1,,,,,0,17.94,131.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"S MEGATRON US MR 4.00 X 32MM",SUP-H7493942832400,CDM,C1874,HCPCS,0278,RC,,,both,,,6210.00,1863,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1777.3,28.62,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN EXTRA BACKUP 3 LEFT CURVE",SUP-LA6EBU30,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENICILLIN VK DESENSITIZATION ORAL (5 MG/ML)",RX-411687,CDM,,,0250,RC,08888-8877-43,NDC,both,20,ML,12.54,3.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5.76,45.9,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CALCIUM GLUCONATE 10% TOPICAL",RX-411652,CDM,J0612,HCPCS,0636,RC,63323-0360-01,NDC,both,10,ML,75.61,22.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,51.41,68,,,,,0,3.52,64.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SPINAL MAXCESS 4 ACCESS",SUP-3241000,CDM,S27200284,LOCAL,0272,RC,,,both,,,11730.00,3519,"CIGNA [10200]","Cigna Open Access",,6674.37,56.9,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE RIGHT CONSTRAIN LEGION OXINIUM",SUP-71421173,CDM,C1776,HCPCS,0278,RC,,,both,,,57834.00,17350.2,"BLUE CROSS [10001]","Blue Cross HMO",,22670.93,39.2,,5311.50,4717.44,5388.59,31,6726.09,49158.9,"percent of total billed charges",
"KIT TKR ITOTAL IPOLY XE CRUCIATE RETAIN PATIENT SPECIFIC",SUP-TCR1111111,CDM,C1776,HCPCS,0278,RC,,,both,,,26775.00,8032.5,"CIGNA [10200]","Cigna Local Plus",,8434.13,31.5,,5372.07,4581.20,7242.98,23,3113.93,22758.75,"percent of total billed charges",
"CATH SABERX RADIANZ 190CM 100MM 8MM .018IN BALLOON",SUP-R51008010L,CDM,C1725,HCPCS,0272,RC,,,both,,,2041.50,612.45,"AETNA [10100]","Aetna HMO/PPO",,1622.99,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,237.43,1735.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X9MM SABLE 22D STERILE LATEX FREE",SUP-1172.2033S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"NOVANET [10819]",Novanet,,25987.5,75,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Analysis Electr Pump W Reprog",PX-510000113,CDM,62368,CPT,0761,RC,,,both,,,2899.73,869.92,"UHC [10700]","United Healthcare",,1835.53,63.3,,,,,0,337.24,2740.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST 405CC 11.2CM 5.6CM PROJECTION HIGH PROFILE SM",SUP-SHPB405,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"CIGNA [10200]",Cigna,,5184.66,68,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC",098,MS-DRG,,,,,,,inpatient,,,88819.60,26645.88,"BLUE CROSS [10001]","Blue Cross HMO",,52683.54,,,,,,,7561,57232.51,"case rate",
"TUBE ENDOTRACHEAL 4.5MM CUFF MURPHY EYE RADIOPAQUE VITAL",SUP-8045RTC,CDM,S27200284,LOCAL,0272,RC,,,both,,,47.28,14.18,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,21.7,45.9,,,,,0,5.5,40.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE ROUND 240CM 2.4MM 2.8MM CAPTIVATOR COLD STIFF",SUP-M00561102,CDM,S27200284,LOCAL,0272,RC,,,both,,,130.50,39.15,"CIGNA [10200]","Cigna Open Access",,74.25,56.9,,,,,0,15.18,110.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hemoglobin A1c",PX-301000228,CDM,83036,CPT,0301,RC,,,both,,,179.50,53.85,"BLUE CROSS [10001]","Blue Cross PPO",,0.18,.1,,12.40,11.85,179.50,"1 through 10",0.18,152.58,"percent of total billed charges",
"SCR BONE 3.5MM 26MM SECUR-FIT X-TRA TITANIUM T15 CORTICAL",SUP-131218026,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"KAISER [10500]",Kaiser,,529.13,67,,,,,0,91.85,671.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM 40MM HIP MODULAR TYPE 1 COCR SELEX",SUP-S031140,CDM,C1776,HCPCS,0278,RC,,,both,,,4574.70,1372.41,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3110.8,68,,,,,0,532.04,3888.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE CONNECT 250T VASCULAR 195CM .018IN DURASTEEL",SUP-1012594,CDM,C1769,HCPCS,0272,RC,,,both,,,1417.50,425.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,164.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE AMPLATZ SUPER STIFF VASCULAR STRAIGHT 260CM 7CM .035IN",SUP-M001465261,CDM,C1769,HCPCS,0272,RC,,,both,,,494.10,148.23,"KAISER [10500]",Kaiser,,331.05,67,,,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 80CM 32MM 13-20MM GORE CARDIOFORM ATRIAL",SUP-ASD32A,CDM,C1817,HCPCS,0278,RC,,,both,,,54495.00,16348.5,"PHCS [10601]",PHCS,,38146.5,70,,,,,0,6337.77,46320.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RESOLVE 40CM 11CM 10FR 2CM PIGTAIL CURVE DRNG",SUP-RBDC-10-038,CDM,C1729,HCPCS,0272,RC,,,both,,,558.90,167.67,"PHCS [10601]",PHCS,,391.23,70,,,,,0,65,475.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENROUTE ENFLATE TRANSCAROTID RX BALLOON DILATATION CATHETER",SUP-SR-4035-BC,CDM,C1725,HCPCS,0272,RC,,,both,,,2625.00,787.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,305.29,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE STARTER BENTSON VASCULAR STD TAPER 260CM 15CM .035IN",SUP-M001491481,CDM,C1769,HCPCS,0272,RC,,,both,,,304.50,91.35,"FIRST HEALTH [10303]","First Health",,243.6,80,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE NITREX VASCULAR 45D 260CM 15CM .035IN NITINOL TUNGSTEN",SUP-N352601,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN HALF 70MM 5MM JET-X LONG ORTHOPEDIC TITANIUM NITRIDE",SUP-71065709,CDM,C1887,HCPCS,0272,RC,,,both,,,2085.00,625.5,"UHC [10700]","United Healthcare",,1319.81,63.3,,,,,0,242.49,1772.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 55X22X12MM COROENT WIDE XL 100",SUP-6921255,CDM,C1889,HCPCS,0278,RC,,,both,,,23760.00,7128,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9504,40,,,,,0,2763.29,20196,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Endo US-Guide Hep Porto Grad",PX-750000216,CDM,C9768,HCPCS,0750,RC,,,both,,,6251.00,1875.3,"PHCS [10601]",PHCS,,4375.7,70,,,,,0,726.99,5313.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM NAVITOR SMALL LOADING",SUP-NVTR-LS-SM,CDM,S27200284,LOCAL,0272,RC,,,both,,,3750.00,1125,"AETNA [10100]","Aetna HMO/PPO",,2981.25,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8.5MM 12/14 TAPER 36MM CERAMIC ARTICUL/EZE",SUP-473436085,CDM,C1776,HCPCS,0278,RC,,,both,,,14072.55,4221.76,"UHC [10700]","United Healthcare",,8907.92,63.3,,8601.07,8395.67,8601.07,"1 through 10",1636.64,11961.67,"percent of total billed charges",
"SCR BONE 5.5MM 45MM SOLERA SPINAL MULTIAXIAL CANNULATED",SUP-54840045545,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS [10001]","Blue Cross HMO",,3742.37,39.2,,957.42,156.86,7483.26,51,1110.3,8114.82,"percent of total billed charges",
"CBL PCNG CNCT DF4 MDTRNC SYS",SUP-4161,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"FIRST HEALTH [10303]","First Health",,174,80,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 20CMX.49MM 20MM HEMAGARD STRAIGHT POLYESTER",SUP-HGK0020-20,CDM,C1768,HCPCS,0278,RC,,,both,,,1926.00,577.8,"BLUE CROSS [10001]","Blue Cross HMO",,754.99,39.2,,,,,0,223.99,1637.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLI KIT SSL6 SAFESHEATH II 6FR 23CM",SUP-SSL6,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 400MM 3.2MM TIBIAL THREAD NONSTERILE",SUP-357.399,CDM,C1769,HCPCS,0272,RC,,,both,,,616.90,185.07,"NOVANET [10819]",Novanet,,462.68,75,,,,,0,71.75,524.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE T2 ORTHOPEDIC 800MM 3MM TITANIUM TIBIA BALL TIP",SUP-1806-0090S,CDM,C1769,HCPCS,0272,RC,,,both,,,1275.75,382.72,"MULTIPLAN [10600]",Multiplan,,1084.39,85,,,,,0,148.37,1084.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) AGENT DCB MR 3.00MM X 30MM",SUP-H74939436303010,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 180MM HIP AFFIXUS INTRAMEDULLARY SHORT",SUP-814511180,CDM,C1713,HCPCS,0278,RC,,,both,,,16044.57,4813.37,"BLUE CROSS [10001]","Blue Cross HMO",,6289.47,39.2,,957.42,156.86,7483.26,51,1865.98,13637.88,"percent of total billed charges",
"HC Topical Skin Adhesive",PX-E27200218,CDM,E27200218,LOCAL,0272,RC,,,both,,,222.42,66.73,"PHCS [10601]",PHCS,,155.69,70,,,,,0,25.87,189.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HEMOSPRAY 220CM 10FR ENDOSCOPIC HEMOSTAT 3.7MM MINIMUM",SUP-G21049,CDM,C1052,HCPCS,0272,RC,,,both,,,17250.00,5175,"NOVANET [10819]",Novanet,,12937.5,75,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC .75CM 4.45X5.02CM ESSENTIO PACESAFE",SUP-L111,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"PHCS [10601]",PHCS,,29120,70,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.0MM X 7MM TI",SUP-VAN-20070-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]",Cigna,,660.96,68,,1831.33,1831.33,1831.33,16,113.04,826.2,"percent of total billed charges",
"CAGE SPINAL 14X22MM BENGAL 12MM STD LORDOTIC THORACOLUMBAR",SUP-177306122,CDM,S27800098,LOCAL,0278,RC,,,both,,,15950.04,4785.01,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6555.47,41.1,,,,,0,1854.99,13557.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERIPHERAL CUTTING BALLOON 90CM 20MM 8MM BALLOON",SUP-PCB802090,CDM,C1725,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"NOVANET [10819]",Novanet,,3493.13,75,,,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE TURNTRAC FLEX VASCULAR STRAIGHT 300CM 3CM",SUP-1020012,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 NARROW KNEE RIGHT CRUCIATE RETAIN PERSONA",SUP-42508005802,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"FIRST HEALTH [10303]","First Health",,20990.59,80,,,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 635 80MM 80CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-G43848,CDM,C1876,HCPCS,0278,RC,,,both,,,3780.00,1134,"CIGNA [10200]","Cigna Local Plus",,2022.3,53.5,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CS1 STAINLESS STEEL 2.7MM SCR VARIABLE ANGLE LCP BONE",SUP-02.112.620,CDM,C1713,HCPCS,0278,RC,,,both,,,6189.30,1856.79,"NOVANET [10819]",Novanet,,4641.98,75,,,,,0,719.82,5260.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT HUMERAL 42MM AEQUALIS SHOULDER METAPHYSIS REVERSE",SUP-DWB961,CDM,C1776,HCPCS,0278,RC,,,both,,,10080.00,3024,"KAISER [10500]",Kaiser,,6753.6,67,,,,,0,1172.3,8568,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JAGWIRE JAGTOME AUTOTOME ENDOSCOPIC STRAIGHT 20MM 5MM",SUP-M00584260,CDM,C1769,HCPCS,0272,RC,,,both,,,3112.43,933.73,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,361.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,361.98,2645.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 595CC",SUP-RSZ-SHPX-595S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PLUS PROFILE SILICONE",SUP-SCLP-235,CDM,C1789,HCPCS,0278,RC,,,both,,,8004.00,2401.2,"KAISER [10500]",Kaiser,,5362.68,67,,,,,0,930.87,6803.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ASAHI GRAND SLAM VASCULAR STRAIGHT 180CM .014IN",SUP-AG141002,CDM,C1769,HCPCS,0272,RC,,,both,,,1093.50,328.05,"AMERIGROUP MEDICAID [20100]",Amerigroup,,129.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ROTAWIRE WIRECLIP TORQUER VASCULAR 330CM 2.8CM .014IN",SUP-H802232390012,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM TRIATHLON 2 LEFT MEDIAL RIGHT LATERAL TOTAL",SUP-5545-A-201,CDM,C1776,HCPCS,0278,RC,,,both,,,4327.60,1298.28,"FIRST HEALTH [10303]","First Health",,3462.08,80,,,,,0,503.3,3678.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 5MM TRIATHLON 2 LEFT MEDIAL RIGHT LATERAL TOTAL",SUP-5545-A-201,CDM,C1776,HCPCS,0278,RC,,,both,,,4327.60,1298.28,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1986.37,45.9,,,,,0,503.3,3678.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 120MM 3MM BALLOON DILATATION OTW",SUP-H74939206031210,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +22.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-ZCB00225,CDM,V2632,HCPCS,0276,RC,,,both,,,1093.50,328.05,"CIGNA [10200]","Cigna Open Access",,622.2,56.9,,,,,0,127.17,929.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL VASCULAR ACCEPTS .038IN GWIRE 7FR 20CM RADIOPAQUE",SUP-G00973,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.33,14.8,"CIGNA [10200]","Cigna Open Access",,28.07,56.9,,,,,0,5.74,41.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 32MM 144CM 2.75MM CORONARY STENT",SUP-H7493911432270,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"CIGNA [10200]",Cigna,,6216.9,68,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATALYST HUMERAL STEM SHORT - 36MM X8MM",SUP-1230-7523-001,CDM,C1776,HCPCS,0278,RC,,,both,,,27713.70,8314.11,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3223.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3223.1,23556.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 45MM KNEE CUSTOM SEG LPS STERILE LIMB",SUP-198707045,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA [10200]",Cigna,,6930,40,,5873.17,5873.17,5873.17,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"CAP CONSTRUCT TOTAL HIP SMF WITH COBALT CHROME HEAD AND R3 H",SUP-71705511,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"KAISER [10500]",Kaiser,,16039.8,67,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 10 D +16 DIOPTER MODIFIED C BICONVEX TECNIS CL",SUP-Z9002160,CDM,V2632,HCPCS,0276,RC,,,both,,,1020.60,306.18,"NOVANET [10819]",Novanet,,765.45,75,,,,,0,118.7,867.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX MONOCRYL PLUS 3-0 SH SPIRAL 70CM KNOTLESS",SUP-SXMP1B428,CDM,S27200284,LOCAL,0272,RC,,,both,,,213.90,64.17,"AETNA [10100]","Aetna HMO/PPO",,170.05,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.88,181.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR G7 E 36MM VIVACIT-E HIP STERILE LUMEN LATEX",SUP-30123605,CDM,C1776,HCPCS,0278,RC,,,both,,,10252.02,3075.61,"CIGNA [10200]",Cigna,,6971.37,68,,5873.17,5873.17,5873.17,"1 through 10",1192.31,8714.22,"percent of total billed charges",
"CAP CONSTRUCT TOTAL KNEE LEGION GII CRUCIATE RETAINING HYBRI",SUP-71704525,CDM,C1776,HCPCS,0278,RC,,,both,,,22050.00,6615,"UHC [10700]","United Healthcare",,13957.65,63.3,,8601.07,8395.67,8601.07,"1 through 10",2564.42,18742.5,"percent of total billed charges",
"STEM FEMORAL 235MM 24MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-324,CDM,C1776,HCPCS,0278,RC,,,both,,,18758.25,5627.47,"BLUE CROSS [10001]","Blue Cross HMO",,7353.23,39.2,,5311.50,4717.44,5388.59,31,2181.58,15944.51,"percent of total billed charges",
"AUG TIBIAL 5MM TRIATHLON 4 LEFT MEDIAL RIGHT LATERAL TOTAL",SUP-5545-A-401,CDM,C1776,HCPCS,0278,RC,,,both,,,4327.60,1298.28,"CIGNA [10200]",Cigna,,2942.77,68,,5873.17,5873.17,5873.17,"1 through 10",503.3,3678.46,"percent of total billed charges",
"HEAD FEMORAL +8MM 44MM HIP BIOLOX DELTA FMP",SUP-400-03-444,CDM,C1776,HCPCS,0278,RC,,,both,,,16953.92,5086.18,"BLUE CROSS [10001]","Blue Cross HMO",,6645.94,39.2,,5311.50,4717.44,5388.59,31,1971.74,14410.83,"percent of total billed charges",
"CMPNT FEMORAL 5 KNEE RIGHT CEMENT REVISION CONSTRAIN ATTUNE",SUP-1504-40-205,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3502.26,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3502.26,25596.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 10MM KNEE X3 CONDYLAR STABILIZE BEARING",SUP-5531-G-310-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1425.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1399.51,10228.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 3 STD KNEE RIGHT KEEL NONPOROUS",SUP-ETPKN3SR,CDM,C1776,HCPCS,0278,RC,,,both,,,15193.80,4558.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6077.52,40,,,,,0,1767.04,12914.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 32MM 2MM LCP CORTICAL STAINLESS STEEL SELF TAPPING",SUP-201.378.97,CDM,C1713,HCPCS,0278,RC,,,both,,,414.12,124.24,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,190.08,45.9,,,,,0,48.16,352,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMPONENT FEMORAL F KNEE LEFT LPS-FLEX GENDER SOLUTIONS NEXG",SUP-00576201651,CDM,C1776,HCPCS,0278,RC,,,both,,,20412.00,6123.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8164.8,40,,,,,0,2373.92,17350.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 35D MEDIUM AUG CORTILOC SHOULDER RIGHT",SUP-DWK404RA35S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"UHC [10700]","United Healthcare",,6646.5,63.3,,8601.07,8395.67,8601.07,"1 through 10",1221.15,8925,"percent of total billed charges",
"CMPNT FEMORAL 10 STD KNEE RIGHT CRUCIATE RETAINING PERSONA",SUP-42502806802,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"AETNA [10100]","Aetna HMO/PPO",,22971.99,79.5,,10981.53,8986.79,12413.38,12,3360.56,24561.24,"percent of total billed charges",
"CMPNT GLENOID 35D MEDIUM AUG CORTILOC SHOULDER RIGHT",SUP-DWK404RA35S,CDM,C1776,HCPCS,0278,RC,,,both,,,10500.00,3150,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1244.25,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1221.15,8925,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 155MM 20MM MODULAR RESTORATION HA STRAIGHT CONE",SUP-6276-7-020,CDM,C1776,HCPCS,0278,RC,,,both,,,10468.22,3140.47,"NOVANET [10819]",Novanet,,7851.17,75,,,,,0,1217.45,8897.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530G211,CDM,C1776,HCPCS,0278,RC,,,both,,,8707.61,2612.28,"CIGNA [10200]",Cigna,,5921.17,68,,5873.17,5873.17,5873.17,"1 through 10",1012.7,7401.47,"percent of total billed charges",
"REMIMAZOLAM 20 MG INTRAVENOUS SOLUTION",RX-227979,CDM,J2249,HCPCS,0636,RC,71390-0011-00,NDC,both,1,UN,355.94,106.78,"NOVANET [10819]",Novanet,,266.96,75,,,,,0,42.18,302.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 160MM 20MM PRESS FIT LEGION KNEE",SUP-71424053,CDM,C1776,HCPCS,0278,RC,,,both,,,12181.95,3654.58,"FIRST HEALTH [10303]","First Health",,9745.56,80,,,,,0,1416.76,10354.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEMENTLESS KNEE SYSTEM",SUP-55500012,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"MULTIPLAN [10600]",Multiplan,,19813.5,85,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COUPLER 4.0MM",SUP-GEM2756,CDM,S27200284,LOCAL,0272,RC,,,both,,,2962.50,888.75,"FIRST HEALTH [10303]","First Health",,2370,80,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 10MM TRIATHLON 3 RIGHT DISTAL KNEE TOTAL",SUP-5541-A-302,CDM,C1776,HCPCS,0278,RC,,,both,,,4770.99,1431.3,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2189.88,45.9,,,,,0,554.87,4055.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL IDENTITY IMPRINT 4 KNEE POSTERIOR STABILIZE",SUP-TPS-301-T04S,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"FIRST HEALTH [10303]","First Health",,7038,80,,,,,0,1023.15,7477.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR 275X4.2X4.2CM .035IN STREAMLINE DEVICE (EVAL)",SUP-H74939406S1,CDM,C1769,HCPCS,0272,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ca Ionized POC",PX-301000125,CDM,82330,CPT,0301,RC,,,both,,,202.95,60.88,"CIGNA [10200]","Cigna Open Access",,30.1,,,,,,,0.2,172.51,"fee schedule",
"HC Paste Stomahesive",PX-E27100020,CDM,E27100020,LOCAL,0271,RC,,,both,,,58.30,17.49,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,26.76,45.9,,,,,0,6.78,49.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Flexhd/Allopatchhd/Sq Cm",PX-E63600049,CDM,Q4128,HCPCS,0636,RC,,,both,,,674.30,202.29,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,247.92,,,,,,,79.9,573.16,"fee schedule",
"KIT THROMBECTOMY REPERFUSION CATHETER 0.06INX160CM LUMEN 0.0",SUP-RED43KIT160,CDM,C1757,HCPCS,0272,RC,,,both,,,17608.50,5282.55,"FIRST HEALTH [10303]","First Health",,14086.8,80,,,,,0,2047.87,14967.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELLIPSE NEXT GENERATION VR 36",SUP-CD1411-36C,CDM,C1722,HCPCS,0278,RC,,,both,,,39000.00,11700,"FIRST HEALTH [10303]","First Health",,31200,80,,,,,0,4535.7,33150,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE 0.5%-EPI 1:100,000 BUFFERED W/SOD BICARB 8.4% SYRINGE 10 ML",RX-411236,CDM,,,0250,RC,08888-8879-62,NDC,both,10,ML,18.92,5.68,"FIRST HEALTH [10303]","First Health",,15.14,80,,,,,0,2.2,16.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insulin-Like Growth Ftr Bp-3",PX-301000140,CDM,82397,CPT,0301,RC,,,both,,,121.80,36.54,"FIRST HEALTH [10303]","First Health",,97.44,80,,,,,0,0.01,103.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 325ML GEL ROUND SMOOTH SILTEX SILICONE P4.6CM","SUP-3503254 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross HMO",,1481.76,39.2,,,,,0,439.61,3213,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PERITONEAL DIALYSIS SOLN 2.5% DEXTROSE CA 3.5 MEQ/L-MAG 0.5 MEQ/L",RX-27801,CDM,,,0250,RC,00941-0427-52,NDC,both,2000,ML,241.44,72.43,"FIRST HEALTH [10303]","First Health",,193.15,80,,,,,0,28.08,205.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST SMOOTH HIGH PROFILE XTRA 465CC",SUP-SHPX465,CDM,C1789,HCPCS,0278,RC,,,both,,,7452.00,2235.6,"PHCS [10601]",PHCS,,5216.4,70,,,,,0,866.67,6334.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUORESCEIN 1 MG EYE STRIPS",RX-27663,CDM,,,0250,RC,51801-0009-01,NDC,both,1,UN,12.54,3.76,"FIRST HEALTH [10303]","First Health",,10.03,80,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION",RX-10427,CDM,J2004,HCPCS,0636,RC,63323-0482-01,NDC,both,10,ML,35.86,10.76,"BLUE CROSS [10001]","Blue Cross HMO",,1.17,,,,,,,1.17,30.48,"fee schedule",
"HC T Cell Total Count",PX-302000080,CDM,86359,CPT,0302,RC,,,both,,,244.56,73.37,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33.96,,,,,,,0.01,207.88,"fee schedule",
"DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN",RX-163725,CDM,,,0250,RC,00942-0641-04,NDC,both,1000,ML,100.65,30.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46.2,45.9,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 11MM KII Z THREAD SLEEVE NONBLADE",SUP-CTR33,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,111.81,45.9,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER BEIGE 7CM 3.5MM DYONICS FULL RADIUS RESECTOR",SUP-7205305,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.00,84.9,"CIGNA [10200]","Cigna Local Plus",,151.41,53.5,,,,,0,32.91,240.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL 15CM NANOKNIFE 1 ELECTRD IRE GENRTR",SUP-20400101,CDM,S27200284,LOCAL,0272,RC,,,both,,,16573.80,4972.14,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11270.18,68,,,,,0,1927.53,14087.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUFF BLOOD PRESSURE CRITIKON DURA-CUF DINACLICK ADULT LONG",SUP-DUR-A2-2A-L-5S,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.18,26.75,"CIGNA [10200]","Cigna Open Access",,50.74,56.9,,,,,0,10.37,75.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE ELECTROSURGICAL STRAIGHT BIPOLAR TAPERED BLUNT POINT",SUP-221266,CDM,S27200284,LOCAL,0272,RC,,,both,,,566.25,169.87,"CIGNA [10200]",Cigna,,385.05,68,,,,,0,65.85,481.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 3.4MM STAINLESS STEEL .51MM 35 STAPLE SQUEEZE",SUP-059036,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.62,34.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,46.7,41.1,,,,,0,13.21,96.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 20FR 12CM INTRO TROCAR NDL GWIRE SUPRAPUBIC OBRIEN",SUP-G16121,CDM,S27200284,LOCAL,0272,RC,,,both,,,908.82,272.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,107.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.7,772.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BARDEX IC 14FR URETHRAL BACTI-GUARD NATURAL RUBBER",SUP-0165SI14,CDM,S27200284,LOCAL,0272,RC,,,both,,,64.82,19.45,"CIGNA [10200]",Cigna,,44.08,68,,,,,0,7.54,55.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLARIFIX CANISTER CFX II",SUP-CFX-2002,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MULA AGGRESSIVE BARREL BUR,6 FLUTES (TAN/TAN)5.5MM ARTHROSCO",SUP-0375951000,CDM,S27200284,LOCAL,0272,RC,,,both,,,321.90,96.57,"MULTIPLAN [10600]",Multiplan,,273.62,85,,,,,0,37.44,273.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HNDPC BREAST BIOPSY 14CM 9GA ATEC 20MM STD MRI DISPOSABLE","SUP-ATEC 0914-20MR",CDM,S27200284,LOCAL,0272,RC,,,both,,,2619.00,785.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,310.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,304.59,2226.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT 17GA 150MM COOL RADIOFREQUENCY PROBE ELECTROTHERAPY",SUP-CRK-17-150-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL 1.5 MEQ DEXTROSE 132 MEQ SODIUM CHLORIDE 2.5 MEQ CALCIUM",SUP-5B9757,CDM,S27200284,LOCAL,0272,RC,,,both,,,337.03,101.11,"CIGNA [10200]","Cigna Open Access",,191.77,56.9,,,,,0,39.2,286.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 57.9CM 26FR TUNGSTEN SILICONE MIC SECUR-LOK",SUP-8210-26,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"AETNA [10100]","Aetna HMO/PPO",,1147.07,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP 5MM 11IN TITANIUM ENDOSCOPIC PISTOL GRIP",SUP-176630,CDM,S27200284,LOCAL,0272,RC,,,both,,,891.00,267.3,"CIGNA [10200]","Cigna Open Access",,506.98,56.9,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL LOOP 24FR POWERBALL STORZ 1 STEM",SUP-M0068802011,CDM,S27200284,LOCAL,0272,RC,,,both,,,956.45,286.93,"NOVANET [10819]",Novanet,,717.34,75,,,,,0,111.24,812.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UNIT ELECTROSURGICAL PROC SET GENESYS HTA",SUP-58021,CDM,S27200284,LOCAL,0272,RC,,,both,,,12385.50,3715.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1467.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1440.43,10527.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPROXIMATOR SURGICAL 5.75IN BAILEY RIB SHARP TEETH",SUP-54-2530,CDM,S27200284,LOCAL,0272,RC,,,both,,,1265.71,379.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,149.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,147.2,1075.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC 8MM TRANSPORT 7 POLYMER PROXIMAL",SUP-CAT00224,CDM,S27200284,LOCAL,0272,RC,,,both,,,743.90,223.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,86.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,86.52,632.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM MR8 4MM MATCH HEAD DISSECTING",SUP-MR8-14MH40,CDM,S27200284,LOCAL,0272,RC,,,both,,,1416.29,424.89,"MULTIPLAN [10600]",Multiplan,,1203.85,85,,,,,0,164.71,1203.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT PRESSURE MNTR 1 LINE TRNSDUC 1 VAMP 1 WAY VALVE STERILE",SUP-PXVP0566,CDM,S27200284,LOCAL,0272,RC,,,both,,,242.90,72.87,"FIRST HEALTH [10303]","First Health",,194.32,80,,,,,0,28.25,206.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 42MM 6.5MM 4.5MM CUFFLESS SOFT FLANGE ROUND TIP OBTR","SUP-4.5 PED",CDM,S27200284,LOCAL,0272,RC,,,both,,,279.53,83.86,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,32.51,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.51,237.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR LAPAROSCOPIC 35CM VISTASEAL DUAL APPLR RIGID",SUP-VSTL35,CDM,S27200284,LOCAL,0272,RC,,,both,,,839.46,251.84,"UHC [10700]","United Healthcare",,531.38,63.3,,,,,0,97.63,713.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPLR LAPAROSCOPIC 35CM VISTASEAL DUAL APPLR RIGID",SUP-VSTL35,CDM,S27200284,LOCAL,0272,RC,,,both,,,839.46,251.84,"CIGNA [10200]","Cigna Local Plus",,449.11,53.5,,,,,0,97.63,713.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 5.5IN 5MM ROUND",SUP-KM-AM35U,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 125CM 5FR LARGE JR4 CURVE",SUP-SRD6604,CDM,S27200284,LOCAL,0272,RC,,,both,,,314.24,94.27,"KAISER [10500]",Kaiser,,210.54,67,,,,,0,36.55,267.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLIP SURGICAL STEALTH 6MM ATRAUMATIC OCCLUSION FIBRA SPRING",SUP-G-6050,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"PHCS [10601]",PHCS,,158.34,70,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL STD 5 1/8IN TISSUE 1X2 TEETH",SUP-BD555R,CDM,S27200284,LOCAL,0272,RC,,,both,,,105.36,31.61,"FIRST HEALTH [10303]","First Health",,84.29,80,,,,,0,12.25,89.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP FOGARTY HYDRAGRIP 61MM SOFTJAW SET ATRAUMATIC",SUP-SOFT61,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.35,28,"CIGNA [10200]",Cigna,,63.48,68,,,,,0,10.86,79.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RELOAD STPLR 60X4.8MM GIA TITANIUM THICK TISSUE ENDOSCOPIC",SUP-GIA6048L,CDM,S27200284,LOCAL,0272,RC,,,both,,,354.61,106.38,"AMERIGROUP MEDICAID [20100]",Amerigroup,,42.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,41.24,301.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT NASAL C-FLEX DOYLE BIVALVE SET",SUP-1524075,CDM,S27200284,LOCAL,0272,RC,,,both,,,247.95,74.38,"PHCS [10601]",PHCS,,173.57,70,,,,,0,28.84,210.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP MEDIUM 33CM TITANIUM LIGATE PISTOL GRIP",SUP-176619,CDM,S27200284,LOCAL,0272,RC,,,both,,,679.10,203.73,"NOVANET [10819]",Novanet,,509.33,75,,,,,0,78.98,577.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Nephleometry",PX-301000322,CDM,83883,CPT,0301,RC,,,both,,,414.00,124.2,"NOVANET [10819]",Novanet,,310.5,75,,,,,0,0.01,351.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 90CM 3FR 11MM STONE 3 WIRE HELICAL",SUP-M0063301050,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"FIRST HEALTH [10303]","First Health",,1183.64,80,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13CM NATRELLE INSPIRA P6.2CM EXTRA FULL PROFILE",SUP-MSZ-X545,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,72.6,45.9,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PLAIN LIGAPAK 3-0 54IN MONOFILAMENT REEL YELLOWISH TAN",SUP-L102G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 65MM 9.4MM 5MM CUFF INNER CANN SMOOTH OBTR INTEGRAL",SUP-4LPC,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COLLAR CERVICAL ADULT REGULAR CONTOUR 3IN ATLAS PROCARE 2",SUP-79-83285,CDM,S27000186,LOCAL,0270,RC,,,both,,,245.69,73.71,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER CARDIOTHORACIC AND THORACIC CIRCULATORY PROCEDURES,EXTREME",167,APR-DRG,,,,,,,inpatient,,,368711.33,,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $40,152.59. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 105%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($261,290.85) where the difference is multiplied by the percent of outlier that is reimbursed (104.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2205).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL BIOPSY 21GA 20CM CHIBA SOFT TISSUE STERILE DISPOSABLE",SUP-G00895,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.31,31.29,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SCR BONE 3.5MM 16MM SECUR-FIT X-TRA ALPS TITANIUM T15 ELBOW",SUP-131218016,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,537.03,68,,,,,0,91.85,671.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 200MM 7FR 5MM 5FR BALLOON DILATATION",SUP-H74939032502110,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 80CM 6FR STRAIGHT URETERAL PERCUFLEX HYDROPLUS CLOSED",SUP-M0061602250,CDM,C2617,HCPCS,0278,RC,,,both,,,1537.95,461.38,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,705.92,45.9,,,,,0,178.86,1307.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 250MM 2MM BALLOON DILATATION RAPID",SUP-47520250L,CDM,C1725,HCPCS,0272,RC,,,both,,,1740.00,522,"NOVANET [10819]",Novanet,,1305,75,,,,,0,202.36,1479,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tracheostomy Tube Collar/Holder",PX-E27000257,CDM,A7524,HCPCS,0270,RC,,,both,,,53.66,16.1,"KAISER [10500]",Kaiser,,35.95,67,,,,,0,6.24,53.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BROAD 10IN STAINLESS STEEL 4.5MM SCREWS 9 HOLE 10",SUP-3704-3-120,CDM,C1713,HCPCS,0278,RC,,,both,,,2250.00,675,"CIGNA [10200]","Cigna Open Access",,1280.25,56.9,,1144.80,304.56,2275.09,66,261.68,1912.5,"percent of total billed charges",
"CMPNT FEMORAL 7+ KNEE CONDYLAR CEMENT CONSTRAIN PERSONA COCR",SUP-42504606211,CDM,C1776,HCPCS,0278,RC,,,both,,,49172.76,14751.83,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,14073.24,28.62,,,,,0,5718.79,41796.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 100MM 120CM 5MM 6FR VASCULAR PERIPHERAL",SUP-S-50-100-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10062.00,3018.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1192.35,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1170.21,8552.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 20FR SILICONE INTERNAL RETENTION BALLOON RECESS DISTAL",SUP-8100-20,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"FIRST HEALTH [10303]","First Health",,223.9,80,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAG DRNG 18OZ MEDIUM CNCT EXT TUBE PLEAT SIDE DRAIN VALVE",SUP-9348,CDM,S27000186,LOCAL,0270,RC,,,both,,,45.04,13.51,"AETNA [10100]","Aetna HMO/PPO",,35.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.24,38.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6F DECA 5-5-5-24-4-4-4-4-4 MPA 120CM",SUP-901830,CDM,C1730,HCPCS,0272,RC,,,both,,,2962.50,888.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,344.54,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH HEARTSPAN MP18 CURVE 60CM 8.5FR GUIDING TRANSSEPTAL",SUP-FCB8560MP18,CDM,C1894,HCPCS,0272,RC,,,both,,,1432.08,429.62,"NOVANET [10819]",Novanet,,1074.06,75,,,,,0,166.55,1217.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 6MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620806,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS [10001]","Blue Cross HMO",,4411.53,39.2,,5311.50,4717.44,5388.59,31,1308.83,9565.82,"percent of total billed charges",
"SCR INTERFERENCE BIOCOMPOSITE 28MM 9MM BLUNT FULL THREAD",SUP-AR-1390TC,CDM,C1713,HCPCS,0278,RC,,,both,,,1850.63,555.19,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,219.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,215.23,1573.04,"percent of total billed charges",
"CANN OPHTHALMIC 5MM 28MM POLYTIP .12MM .6MM",SUP-3233,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET TITANIUM 5.5-6MM SPINE NONBREAK OFF CD HORIZON",SUP-5540130,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,41.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,40.47,295.8,"percent of total billed charges",
"BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER",RX-81454,CDM,,,0250,RC,00186-0370-28,NDC,both,6,GR,960.93,288.28,"UHC [10700]","United Healthcare",,608.27,63.3,,,,,0,111.76,816.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 18GA 50CM 11CM GRAY HUB DIL GWIRE",SUP-PSI-5F-11-035-18G,CDM,C1894,HCPCS,0272,RC,,,both,,,102.23,30.67,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,42.02,41.1,,,,,0,11.89,86.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA FULL PROFILE SOFT TOUCH SMOOTH",SUP-SSF-325,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS [10001]","Blue Cross HMO",,2961.76,39.2,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MTRL STRAPPING PILE LOOP FABRIC NYLON TRICOT THK1/8IN STD 10",SUP-A8097,CDM,S27000186,LOCAL,0270,RC,,,both,,,168.61,50.58,"CIGNA [10200]",Cigna,,114.65,68,,,,,0,19.61,143.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLIDESHEATH SLENDER SS KIT, 0.021 GW, 7 FR, 10CM",SUP-80-1070,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"AETNA [10100]","Aetna HMO/PPO",,354.17,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 12MM 4.5MM EMBOLIZATION NEUROVASCULAR",SUP-PED-450-12,CDM,S27800098,LOCAL,0278,RC,,,both,,,76950.00,23085,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,30780,40,,,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET EXT 3.5CM 14FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-14-3.5,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"NOVANET [10819]",Novanet,,584.3,75,,,,,0,90.6,662.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 8MM 140CM 3MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927408300,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]",Cigna,,2550,68,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CGUARD PRIME CAROTID STENT SYSTEM 135CM 08MM LENGTH 40MM",SUP-CND0840,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"CIGNA [10200]",Cigna,,8303.4,40,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 75CM 100MM 4MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171041070,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,139.18,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 300MM 2MM BALLOON DILATATION RAPID",SUP-47520300L,CDM,C1725,HCPCS,0272,RC,,,both,,,1740.00,522,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1183.2,68,,,,,0,202.36,1479,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC LARGE 20IN 18-20IN KNEE T BAR CONTOUR",SUP-A142007,CDM,L1830,HCPCS,0274,RC,,,both,,,117.71,35.31,"BLUE CROSS [10001]","Blue Cross HMO",,46.14,39.2,,,,,0,13.69,100.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 16X14X8MM SPINE CERVICAL",SUP-6940864,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"MULTIPLAN [10600]",Multiplan,,4398.75,85,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER CEREBROVASCULAR 135CM EXCELSIOR XT-27 1 TIP",SUP-M003XT2735920,CDM,S27200284,LOCAL,0272,RC,,,both,,,8474.58,2542.37,"KAISER [10500]",Kaiser,,5677.97,67,,,,,0,985.59,7203.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +16 DIOPTER HAPTIC C BICONVEX 13MM 6MM POSTERIOR",SUP-ZXR00U0160,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"NOVANET [10819]",Novanet,,558.75,75,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RAMIPRIL 10 MG CAPSULE",RX-11259,CDM,,,0637,RC,57237-0225-01,NDC,both,1,UN,11.15,3.34,"NOVANET [10819]",Novanet,,8.36,75,,,,,0,1.3,9.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 14MM QUICKFIX TITANIUM T8 PARTIAL THREAD",SUP-AR-8724-14,CDM,C1713,HCPCS,0278,RC,,,both,,,1028.70,308.61,"FIRST HEALTH [10303]","First Health",,822.96,80,,,,,0,119.64,874.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLOSED WOUND DRAIN FLAT 4MM SILICONE WITH CLOTSTOP",SUP-410ATSX,CDM,S27200284,LOCAL,0272,RC,,,both,,,392.34,117.7,"NOVANET [10819]",Novanet,,294.26,75,,,,,0,45.63,333.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET",RX-2516,CDM,,,0637,RC,00406-1236-01,NDC,both,1,UN,12.54,3.76,"KAISER [10500]",Kaiser,,8.4,67,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TENSIONER SURGICAL CUTTER 2-0/0 FIBERWIRE SUT",SUP-AR-5815,CDM,S27200284,LOCAL,0272,RC,,,both,,,1488.38,446.51,"AMERIGROUP MEDICAID [20100]",Amerigroup,,176.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,173.1,1265.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER HUMERAL 20MM 13MM AEQUALIS FLEX REVIVE SHOULDER",SUP-ARS342003,CDM,C1776,HCPCS,0278,RC,,,both,,,11135.00,3340.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1319.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1295,9464.75,"percent of total billed charges",
"FRCP SURGICAL JANSEN-MIDDLETON 8.25IN",SUP-OK405R,CDM,S27200284,LOCAL,0272,RC,,,both,,,1917.83,575.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,227.26,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,223.04,1630.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 46CM 7FR 10MM SPACING VENTRICLE BIPOLAR PASSIVE",SUP-1948/46,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"BLUE CROSS [10001]","Blue Cross HMO",,875.14,39.2,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVETIRACETAM 500 MG TABLET, IMMEDIATE RELEASE",RX-26817,CDM,,,0637,RC,51079-0821-01,NDC,both,1,UN,17.68,5.3,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2.06,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.06,15.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 41MM 5.9MM 4MM CUFFLESS SOFT FLANGE ROUND TIP OBTR","SUP-4.0 PED",CDM,S27200284,LOCAL,0272,RC,,,both,,,279.53,83.86,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,128.3,45.9,,,,,0,32.51,237.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 0 D +24 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.240,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]","Cigna Open Access",,196.31,56.9,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SURGIDAC SURGIWIP 0 V-20 48IN BRAID COATED GREEN",SUP-EDW-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,144.16,43.25,"PHCS [10601]",PHCS,,100.91,70,,,,,0,16.77,122.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 38MM TITANIUM LEVEL 2 ASSURE BONE SPINE CERVICAL",SUP-110.238,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"BLUE CROSS [10001]","Blue Cross PPO",,1728.72,39.2,,957.42,570.23,957.42,28,512.88,3748.5,"percent of total billed charges",
"LEAD PACING 92CM LEFT VENTRICULAR QUARTET",SUP-1456Q/75,CDM,C1900,HCPCS,0278,RC,,,both,,,5607.00,1682.1,"KAISER [10500]",Kaiser,,3756.69,67,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.75CM NATRELLE INSPIRA P3.3CM LOW PLUS PROFILE",SUP-MSZ-LP300,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,72.6,45.9,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.3MM 2.4MM 6MM TITANIUM CORTEX HAND SELF TAPPING",SUP-400.686,CDM,C1713,HCPCS,0278,RC,,,both,,,650.92,195.28,"BLUE CROSS [10001]","Blue Cross HMO",,255.16,39.2,,957.42,156.86,7483.26,51,75.7,553.28,"percent of total billed charges",
"SABER .035 6X200 135CM SL",SUP-48006020R,CDM,C1725,HCPCS,0272,RC,,,both,,,997.11,299.13,"FIRST HEALTH [10303]","First Health",,797.69,80,,,,,0,115.96,847.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 20MM 120CM 7MM VASCULAR NITINOL ILIAC ARTERY SELF",SUP-H74939200072020,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"CIGNA [10200]",Cigna,,2815.2,68,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 70MM 32MM STAINLESS STEEL FEMORAL CANNULATED",SUP-209.870,CDM,C1713,HCPCS,0278,RC,,,both,,,1510.49,453.15,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,175.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",175.67,1283.92,"percent of total billed charges",
"CATH NC TREK NEO 145CM 12MM 2.25MM BALLOON DILATATION PEBAX",SUP-1400225-12,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 4 HIGH OFFSET HIP",SUP-71935576,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9864.1,27,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WEDGE TIBIAL 10MM LEGION 5-6 FULL KNEE SCR STEP",SUP-71423059,CDM,C1776,HCPCS,0278,RC,,,both,,,16601.40,4980.42,"CIGNA [10200]","Cigna Open Access",,5561.47,33.5,,5302.19,4377.88,6578.61,27,1930.74,14111.19,"percent of total billed charges",
"GRAFT BONE CANCELLOUS THK15MM ALLOGRAFT BLOCK FREEZE DRIED",SUP-400280,CDM,S27800098,LOCAL,0278,RC,,,both,,,6371.46,1911.44,"PHCS [10601]",PHCS,,4460.02,70,,,,,0,741,5415.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 14X11X7MM 7D PEEK LUMBAR INTERBODY FUSION",SUP-21411-707,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"AETNA [10100]","Aetna HMO/PPO",,5309.34,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3-4 9MM KNEE POSTERIOR STABILIZE HIGH FLEXION",SUP-71934436,CDM,C1776,HCPCS,0278,RC,,,both,,,12171.60,3651.48,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1415.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1415.56,10345.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 58CM 1.7MM ATRIUM ENDOCARDIUM VENTRICLE BIPOLAR",SUP-4471,CDM,C1898,HCPCS,0275,RC,,,both,,,5607.00,1682.1,"BLUE CROSS [10001]","Blue Cross HMO",,2197.94,39.2,,,,,0,652.09,4765.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT WLSTNT 60MM 194CM 8MM 8FR",SUP-6962,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 93MM 3.5MM SCR 4 HOLE LCP BONE TIBIA LEFT PROXIMAL",SUP-239.955S,CDM,C1713,HCPCS,0278,RC,,,both,,,8694.00,2608.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5911.92,68,,,,,0,1011.11,7389.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 7-0 CC 24IN 2 ARM BLUE NONABSORBABLE",SUP-EP8704H,CDM,S27200284,LOCAL,0272,RC,,,both,,,248.18,74.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,168.76,68,,,,,0,28.86,210.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POD XL 14MMX55CM",SUP-RBYPODXL1455,CDM,S27800098,LOCAL,0278,RC,,,both,,,18837.00,5651.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7534.8,40,,,,,0,2190.74,16011.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 9IN .054IN KIRSCHNER STAINLESS STEEL TROCAR",SUP-160132000,CDM,C1713,HCPCS,0278,RC,,,both,,,417.60,125.28,"FIRST HEALTH [10303]","First Health",,334.08,80,,,,,0,48.57,354.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH SENTRANT .035IN 64CM 16FR INTRO HYDROPHILIC",SUP-SENSH1664W,CDM,C1894,HCPCS,0272,RC,,,both,,,3180.00,954,"UHC [10700]","United Healthcare",,2012.94,63.3,,,,,0,369.83,2703,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 605CC COHESIVE NATRELLE INSPIRA STERILE LATEX",SUP-SCF-605,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"MULTIPLAN [10600]",Multiplan,,6422.18,85,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH RAPID RELEASE PARALLEL FLEXOR 35CM 12FR ACCESS",SUP-G56435,CDM,C1894,HCPCS,0272,RC,,,both,,,1396.44,418.93,"NOVANET [10819]",Novanet,,1047.33,75,,,,,0,162.41,1186.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 450-480ML STYLE 68 SMOOTH ANTERIOR DIAPH VALVE",SUP-68-450,CDM,C1789,HCPCS,0278,RC,,,both,,,2250.00,675,"BLUE CROSS [10001]","Blue Cross HMO",,882,39.2,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 32MM MITRAL 3D REDUCED CURVATURE SEWING","SUP-4100 M32",CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2044.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VASCULAR ANGLED 180CM .014IN CORONARY TIP",SUP-TFC14180A,CDM,C1769,HCPCS,0272,RC,,,both,,,2250.00,675,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,266.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLS-2508 CLASSICSHEATH LONG",SUP-398724,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 12.5X11CM 400CC AEROFORM P8CM SMALL",SUP-BR125-400,CDM,C1789,HCPCS,0278,RC,,,both,,,16118.40,4835.52,"NOVANET [10819]",Novanet,,12088.8,75,,,,,0,1874.57,13700.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THOMASMEDICAL INTRDCR FR10 - EACH",SUP-666268-001,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 4.8CM 375ML GEL ROUND SMOOTH SILICONE","SUP-3503754 BC",CDM,C1789,HCPCS,0278,RC,,,both,,,3780.00,1134,"BLUE CROSS [10001]","Blue Cross PPO",,1481.76,39.2,,16595.83,16595.83,16595.83,"1 through 10",439.61,3213,"percent of total billed charges",
"COIL EMBOLIZATION 9.5CM 8-4MM TORNADO MICROCOILS PRELOAD",SUP-G47421,CDM,S27800098,LOCAL,0278,RC,,,both,,,931.42,279.43,"CIGNA [10200]","Cigna Open Access",,529.98,56.9,,,,,0,108.32,791.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HUMERAL EQUINOXE +0MM ADPTR +0MM STERILE LATEX FREE",SUP-322-10-00,CDM,C1776,HCPCS,0278,RC,,,both,,,10695.00,3208.5,"MULTIPLAN [10600]",Multiplan,,9090.75,85,,,,,0,1243.83,9090.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACC INTRDCR VALV FR7",SUP-7461,CDM,C1894,HCPCS,0272,RC,,,both,,,87.00,26.1,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,10.12,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,10.12,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 120MM 4MM BALLOON DILATATION RAPID",SUP-47540120L,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIMMON 4CM 5FR PIGTAIL CURVE PANCREATIC POLYETHYLENE",SUP-G22358,CDM,C2617,HCPCS,0272,RC,,,both,,,631.80,189.54,"NOVANET [10819]",Novanet,,473.85,75,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 46MM HIP SOLID BACK METAL HA TRIDENT C",SUP-500-11-46C,CDM,C1776,HCPCS,0278,RC,,,both,,,9911.85,2973.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1174.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1152.75,8425.07,"percent of total billed charges",
"IMPL BREAST 700ML STYLE 20 GEL SMOOTH NATRELLE SILICONE P6.2",SUP-20-700,CDM,C1789,HCPCS,0278,RC,,,both,,,3570.00,1071,"FIRST HEALTH [10303]","First Health",,2856,80,,,,,0,415.19,3034.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT EXTERNAL FIXATION HOFFMANN STRUT CONNECTION LIMB",SUP-4933-1-702,CDM,C1713,HCPCS,0278,RC,,,both,,,234.90,70.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,27.32,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",27.32,199.67,"percent of total billed charges",
"SHEATH HEARTSPAN MR0 CURVE 63CM 8.5FR GUIDING PEBAX STEEL",SUP-FCB8563MR0,CDM,C1894,HCPCS,0272,RC,,,both,,,1432.08,429.62,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,169.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,166.55,1217.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 45CM 6FR 20GA .061IN GLIDESHEATH HYDROPHILIC",SUP-30-1065,CDM,C1894,HCPCS,0272,RC,,,both,,,664.20,199.26,"KAISER [10500]",Kaiser,,445.01,67,,,,,0,77.25,564.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INTRO 4 1/8IN 8.5FR 7-7.5FR ARROWG+ARD BLUE ARROW-FLEX",SUP-AK-29803-CDC,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO 17FR LUMEN CATH",SUP-S17-45,CDM,C1894,HCPCS,0272,RC,,,both,,,3112.50,933.75,"PHCS [10601]",PHCS,,2178.75,70,,,,,0,361.98,2645.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 125CC P2.8CM MODERATE PLUS PROFILE ROUND GEL",SUP-350-1251BC,CDM,C1789,HCPCS,0278,RC,,,both,,,4823.10,1446.93,"BLUE CROSS [10001]","Blue Cross HMO",,1890.66,39.2,,,,,0,560.93,4099.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 4MM CLOT STOP FACIAL 2 LUMEN FILTER STERILE",SUP-410AT,CDM,S27200284,LOCAL,0272,RC,,,both,,,301.44,90.43,"PHCS [10601]",PHCS,,211.01,70,,,,,0,35.06,256.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY INTRO KYPHOPAK XPANDER FIRST FRACTURE TROCAR INFLATABLE",SUP-KPT1505,CDM,C1894,HCPCS,0272,RC,,,both,,,11021.40,3306.42,"NOVANET [10819]",Novanet,,8266.05,75,,,,,0,1281.79,9368.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 14X13.2CM 620CC GEL TEXTURE ORIENTATION MARK",SUP-3341402,CDM,C1789,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"BLUE CROSS [10001]","Blue Cross HMO",,3583.86,39.2,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PLUS PROFILE SOFTTOUCH",SUP-SSLP-360,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2162.38,28.62,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA XFULL PROFILE SOFTTOUCH SMOOTH",SUP-SSX-420,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"CIGNA [10200]","Cigna Local Plus",,4042.19,,,,,,,878.7,6422.18,"percent of total billed charges",
"HC Ph Study Mcus Tele",PX-750000113,CDM,91035,CPT,0750,RC,,,both,,,6579.56,1973.87,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,765.2,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,765.2,5592.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Esophagosc W/Submucosal Inj",PX-750000198,CDM,43201,CPT,0750,RC,,,both,,,2077.85,623.35,"AMERIGROUP MEDICAID [20100]",Amerigroup,,246.23,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,241.65,2077.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP 30MM STEALTH 1 LATIS STERILE LATEX FREE",SUP-A0C01,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]","Cigna Local Plus",,121.02,53.5,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXPANDER TISSUE BREAST 700CC STYLE 133S SMOOTH 3 SUTURE TAB",SUP-133S-MX-15-T,CDM,C1789,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"AETNA [10100]","Aetna HMO/PPO",,7405.43,79.5,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA MODERATE PROFILE SOFT TOUCH",SUP-SSM-600,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,895.33,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION",RX-5751,CDM,,,0250,RC,00904-7276-41,NDC,both,5,ML,12.54,3.76,"AETNA [10100]","Aetna HMO/PPO",,9.97,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST NATRELLE INSPIRA LOW PLUS PROFILE SILICONE",SUP-SCLP-190,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"FIRST HEALTH [10303]","First Health",,6044.4,80,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 25MM TRIDENT II LOW PROFILE HEXAGONAL STERILE",SUP-7030-6525,CDM,C1713,HCPCS,0278,RC,,,both,,,761.40,228.42,"CIGNA [10200]","Cigna Open Access",,433.24,56.9,,1144.80,304.56,2275.09,66,88.55,647.19,"percent of total billed charges",
"SYSTEM PICO 7 25X25CM NEGATIVE PRESSURE STERILE LATEX FREE",SUP-66022009,CDM,S27200284,LOCAL,0272,RC,,,both,,,2130.00,639,"KAISER [10500]",Kaiser,,1427.1,67,,,,,0,247.72,1810.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 8X34X24MM 20 DEGREE",SUP-1921010P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9355.5,27,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTED TOTAL KNEE SYSTEM INCLUDING CONSTRAINED",SUP-98000200261,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"UHC [10700]","United Healthcare",,11963.7,63.3,,8601.07,8395.67,8601.07,"1 through 10",2198.07,16065,"percent of total billed charges",
"PROPARACAINE 0.5 % EYE DROPS",RX-6644,CDM,,,0250,RC,70069-0601-01,NDC,both,15,ML,275.22,82.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ARMSLING, (ULTRASLING) MED.",SUP-11-0138-3-13130,CDM,S27000186,LOCAL,0270,RC,,,both,,,373.06,111.92,"CIGNA [10200]","Cigna Local Plus",,199.59,53.5,,,,,0,43.39,317.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAREON UVA VIVITY AUTONOME",SUP-CCAET0,CDM,V2788,HCPCS,0276,RC,,,both,,,880.00,264,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,251.86,28.62,,,,,0,102.34,748,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RETRIEVER ENDOSCOPIC 25MM 6MM TREVO XP PROVUE STERILE LATEX",SUP-90186,CDM,S27200284,LOCAL,0272,RC,,,both,,,47273.94,14182.18,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5601.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5497.96,40182.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VISTA BRITE TIP 100CM 8FR JL4.5 CURVE GUIDING STAINLESS",SUP-588852,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EDWARDS EVOQUE VALVE52 MM",SUP-9850EV52,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTREPID MITRAL PRE-CRIMP TOOL CLINICAL",SUP-ASM-0039,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TACTIFLEX ABLATION CATHETER, SENSOR ENABLED",SUP-A-TFSE-JJ-CLIN,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"MULTIPLAN [10600]",Multiplan,,0.01,85,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 4MM PRESTIGE PLUS HELICAL COMPLEX",SUP-PRES0410CPKPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 6FR .071IN RIGHT BACKUP 3.5 CURVE",SUP-LA6RBU35SH,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"KAISER [10500]",Kaiser,,262.31,67,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STRATAFIX PDS PLUS 1 CTX SPIRAL 14IN ABSORBABLE",SUP-SXPP2B405,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.66,64.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,24.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.96,182.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD ICD 59CM ENDOTAK RELIANCE ENDOCARDIUM 4 SITE 2 COIL",SUP-265,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"BLUE CROSS [10001]","Blue Cross PPO",,5950.56,39.2,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6MM 40MM EXPEDIUM TITANIUM SPINE CORTICAL FIX 5.5MM",SUP-186731640,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"KAISER [10500]",Kaiser,,3698.4,67,,,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE QUILL 3-0 3/8 CIRCLE 14X14CM 18MM CLSR MONODERM 2 ARM",SUP-YA-1016Q,CDM,S27200284,LOCAL,0272,RC,,,both,,,159.70,47.91,"MULTIPLAN [10600]",Multiplan,,135.75,85,,,,,0,18.57,135.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ACETABULAR 36MM 10D H HIP X3 TRIDENT 11.2MM",SUP-723-10-36H,CDM,C1776,HCPCS,0278,RC,,,both,,,9332.25,2799.67,"CIGNA [10200]","Cigna Open Access",,5310.05,56.9,,5302.19,4377.88,6578.61,27,1085.34,7932.41,"percent of total billed charges",
"KIT CATHETERIZATION 14GA 18GA 8IN SHARPSAWAY 2.5IN .032IN",SUP-AK-04700,CDM,C1751,HCPCS,0272,RC,,,both,,,161.82,48.55,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,66.51,41.1,,,,,0,18.82,137.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 23MM 145CM 2.75MM CORONARY STENT",SUP-1125275-23,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3969.84,68,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ASCERTA 20CM 7FR URETERAL",SUP-M0061456170,CDM,C2617,HCPCS,0278,RC,,,both,,,625.24,187.57,"NOVANET [10819]",Novanet,,468.93,75,,,,,0,72.72,531.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OCCL CARDIOVASCULAR 25MM SEPTAL SELF EXPANDING 2 DISC",SUP-9-ASD-MF-025,CDM,C1817,HCPCS,0278,RC,,,both,,,21250.80,6375.24,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2518.22,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2471.47,18063.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 85MM ANTIROTATE STERILE FEMORAL NECK SYSTEM",SUP-04.168.485S,CDM,C1713,HCPCS,0278,RC,,,both,,,1642.20,492.66,"KAISER [10500]",Kaiser,,1100.27,67,,,,,0,190.99,1395.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 8MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650408,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"BLUE CROSS [10001]","Blue Cross HMO",,5145.88,39.2,,5311.50,4717.44,5388.59,31,1526.7,11158.16,"percent of total billed charges",
"STEM HUMERAL 70MM PRESS FIT AEQUALIS ASCEND FLEX PTC 137.5D",SUP-DWF602C,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1493.1,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 5 STD KNEE RIGHT CRUCIATE RETAIN PERSONA PPS",SUP-42508605802,CDM,C1776,HCPCS,0278,RC,,,both,,,29326.50,8797.95,"MULTIPLAN [10600]",Multiplan,,24927.53,85,,,,,0,3410.67,24927.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 41MM CEMENTED MEDIALIZE ATTUNE AOX KNEE",SUP-151810041,CDM,C1776,HCPCS,0278,RC,,,both,,,7176.00,2152.8,"MULTIPLAN [10600]",Multiplan,,6099.6,85,,,,,0,834.57,6099.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL OSS LONG KNEE NONMODULAR 71MM STERILE",SUP-161043,CDM,C1776,HCPCS,0278,RC,,,both,,,23169.51,6950.85,"FIRST HEALTH [10303]","First Health",,18535.61,80,,,,,0,2694.61,19694.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +12MM OFFSET TAPER 40MM HIP PRIMARY ANATOMIC",SUP-6260-9-440,CDM,C1776,HCPCS,0278,RC,,,both,,,7469.28,2240.78,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,885.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,868.68,6348.89,"percent of total billed charges",
"CAP AEQRVS II SHD (RVS STEM,METP,RVS II INSERT,RVS II BPLATE",SUP-CAP1013,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"BLUE CROSS [10001]","Blue Cross PPO",,17781.12,39.2,,3949.44,3949.44,3949.44,"1 through 10",5275.37,38556,"percent of total billed charges",
"CMPNT FEMORAL 2 RIGHT KNEE POSTERIOR STABILIZED CEMENTED",SUP-5515F202,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1163,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 235MM 20MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-320,CDM,C1776,HCPCS,0278,RC,,,both,,,18758.25,5627.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7503.3,40,,,,,0,2181.58,15944.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL 36MM UNIVERS REVERS +6MM SMALL SHOULDER",SUP-AR-9503S-06,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,348.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,341.92,2499,"percent of total billed charges",
"INSRT TIBIAL 8 6MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620806,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3220.87,28.62,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 11FR .144IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLSX-1011,CDM,C1892,HCPCS,0272,RC,,,both,,,304.50,91.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,35.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR SL4.5ST CURVE GUIDING CORONARY",SUP-LA7SL45,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"AETNA [10100]","Aetna HMO/PPO",,290.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE AUG 3CC ALLOGRAFT AUG INJECTABLE KIT",SUP-K30003010,CDM,C1734,HCPCS,0278,RC,,,both,,,23052.69,6915.81,"FIRST HEALTH [10303]","First Health",,18442.15,80,,,,,0,2681.03,19594.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 20CM 150CM 7FR .038IN STD STRAIGHT URETERAL PERCUFLEX",SUP-M006145369170,CDM,C2617,HCPCS,0278,RC,,,both,,,1129.95,338.98,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,131.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.41,960.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 13X11CM BREAST 400ML STYLE 133SV TEXTURED SUT TAB",SUP-133SX-13-T,CDM,C1789,HCPCS,0278,RC,,,both,,,6510.00,1953,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1863.16,28.62,,,,,0,757.11,5533.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 16FR 30CM RADIOPAQUE DRNG TRANSITIONLESS",SUP-G08322,CDM,C1892,HCPCS,0272,RC,,,both,,,526.42,157.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,216.36,41.1,,,,,0,61.22,447.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 40MM SMALL PEG PERFORM SHOULDER ALL POLY",SUP-DWE303,CDM,C1776,HCPCS,0278,RC,,,both,,,9316.00,2794.8,"BLUE CROSS [10001]","Blue Cross PPO",,3651.87,39.2,,3949.44,3949.44,3949.44,"1 through 10",1083.45,7918.6,"percent of total billed charges",
"BIT DRILL 220MM 2.6MM AO SCALE",SUP-703901,CDM,S27200284,LOCAL,0272,RC,,,both,,,1207.71,362.31,"PHCS [10601]",PHCS,,845.4,70,,,,,0,140.46,1026.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC De Revasc Bypss Grft Sngl Vess",PX-481000084,CDM,C9604,HCPCS,0481,RC,,,both,,,27922.64,8376.79,"BLUE CROSS [10001]","Blue Cross PPO",,21224.89,,"Case rate ($21,224.89). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,2795,25681,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE INFINITY 200CM 3MM ENDOSCOPIC NITINOL DRIVE WIRE",SUP-00711652,CDM,S27200284,LOCAL,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL PLUS 0 CT-2 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP334H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AETNA [10100]","Aetna HMO/PPO",,19.88,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cult Fungi Pres ID Hair/Sk/Na",PX-306000065,CDM,87101,CPT,0306,RC,,,both,,,164.00,49.2,"CIGNA [10200]","Cigna Open Access",,16.96,,,,,,,0.01,139.4,"fee schedule",
"BIT DRILL 2.2MM STRAIGHT CANNULATED 2.5MM COMPRESSION FT SCR",SUP-AR-8737-58,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"CIGNA [10200]","Cigna Local Plus",,845.03,53.5,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON MEDIUM TITANIUM WIDE BLADE TRANSVERSE",SUP-7541113,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2040,68,,,,,0,348.9,2550,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER CORD CLAMP UMBILICAL SERRATE",SUP-53-2312,CDM,S27200284,LOCAL,0272,RC,,,both,,,111.97,33.59,"AMERIGROUP MEDICAID [20100]",Amerigroup,,13.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.02,95.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ASPIRATION 130CM 20GA 1.8MM EXCELON TRANSBRONCHIAL",SUP-M00564111,CDM,S27200284,LOCAL,0272,RC,,,both,,,664.10,199.23,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,451.59,68,,,,,0,77.23,564.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 150MM 120CM 6MM VASCULAR NICKEL",SUP-EVD35-06-150-120,CDM,C1876,HCPCS,0278,RC,,,both,,,8085.00,2425.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,958.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,940.29,6872.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 120MM 4MM BALLOON DILATATION STERILE LATEX",SUP-584012022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"AETNA [10100]","Aetna HMO/PPO",,1191.31,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) CATHETER TURNPIKE 150CM 2.2-2.9FR 1.6FR GUIDING LOW P",SUP-5639,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE ENDO STITCH V-LOC 180 0 4IN CLSR ABSORBABLE RELOAD",SUP-VLOCA004L,CDM,S27200284,LOCAL,0272,RC,,,both,,,282.40,84.72,"KAISER [10500]",Kaiser,,189.21,67,,,,,0,32.84,240.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PHASIX SEPRA 8IN MONOFILAMENT RESORBABLE",SUP-1200008,CDM,C1781,HCPCS,0278,RC,,,both,,,10904.07,3271.22,"BLUE CROSS [10001]","Blue Cross PPO",,4274.4,39.2,,,,,0,1268.14,9268.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO PEEL-AWAY SAFE-T-J PERCUTANEOUS STAINLESS STEEL 2",SUP-G04496,CDM,C1892,HCPCS,0272,RC,,,both,,,777.60,233.28,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH IMAGER II 65CM 5FR JB1 CURVE URETERAL STAINLESS STEEL",SUP-M0064003041,CDM,C1758,HCPCS,0272,RC,,,both,,,149.15,44.74,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 12CM 4MM CONCERTO 3D",SUP-PV-4-12-3D,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"NOVANET [10819]",Novanet,,3363.75,75,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 35MM 5.5MM RELINE LORDOTIC TITANIUM MULTIAXIAL",SUP-11355035,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"BURR SURGICAL 4MM MEDIUM BARREL",SUP-5120017040,CDM,S27200284,LOCAL,0272,RC,,,both,,,765.94,229.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RECTAL RESECTION WITHOUT CC/MCC",334,MS-DRG,,,,,,,inpatient,,,90693.67,27208.1,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM",RX-16299,CDM,,,0637,RC,00904-5354-31,NDC,both,28,GR,27.30,8.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC US Guide Compression Rpr Arty",PX-402000036,CDM,76936,CPT,0402,RC,,,both,,,1394.00,418.2,"MULTIPLAN [10600]",Multiplan,,1184.9,85,,,,,0,162.12,1184.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAUT BTTRY 5IN BOVIE HIGH TEMPERATURE LOOP TIP EXTEND SHAFT",SUP-AA09,CDM,S27200284,LOCAL,0272,RC,,,both,,,120.79,36.24,"CIGNA [10200]","Cigna Open Access",,68.73,56.9,,,,,0,14.05,102.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE JAGWIRE DREAM TIP ENDOSCOPIC 450CM 5CM .035IN BILIARY",SUP-M00556581,CDM,C1769,HCPCS,0272,RC,,,both,,,932.72,279.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Admin Hepatitis B Vacc",PX-771000006,CDM,G0010,HCPCS,0771,RC,,,both,,,159.60,47.88,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT PACING NEURX DPS",SUP-22-0035,CDM,C1767,HCPCS,0278,RC,,,both,,,197505.00,59251.5,"AETNA [10100]","Aetna HMO/PPO",,157016.48,79.5,,,,,0,22969.83,167879.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 100MM 17MM CEMENTLESS TOTAL STABILIZED",SUP-5565-S-017,CDM,C1776,HCPCS,0278,RC,,,both,,,4737.10,1421.13,"NOVANET [10819]",Novanet,,3552.83,75,,,,,0,550.92,4026.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 7MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-151630507,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UHC [10700]","United Healthcare",,8309.55,63.3,,8601.07,8395.67,8601.07,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"SHELL ACETABULAR 52MM 3 HOLE BIOFOAM DYNASTY",SUP-DBFPGD52,CDM,C1776,HCPCS,0278,RC,,,both,,,18194.40,5458.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2156.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2116.01,15465.24,"percent of total billed charges",
"STEM HUMERAL 108MM ALTIVATE DJO SURGICAL 10 STD SHOULDER",SUP-530-10-108,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS [10001]","Blue Cross PPO",,4939.2,39.2,,3949.44,3949.44,3949.44,"1 through 10",1465.38,10710,"percent of total billed charges",
"CMPNT FEMORAL ATTUNE STERILE 7 KNEE LEFT CEMENTED POSTERIOR",SUP-150410107,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2653.61,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM 40MM HIP SOLID MODULAR COCR SELEX",SUP-S331140,CDM,C1776,HCPCS,0278,RC,,,both,,,4574.70,1372.41,"NOVANET [10819]",Novanet,,3431.03,75,,,,,0,532.04,3888.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL EVOLUTION MP 3 STD KNEE RIGHT KEEL NONPOROUS",SUP-ETPKN3SR,CDM,C1776,HCPCS,0278,RC,,,both,,,15193.80,4558.14,"CIGNA [10200]","Cigna Local Plus",,4786.05,31.5,,5372.07,4581.20,7242.98,23,1767.04,12914.73,"percent of total billed charges",
"SCR BASEPLT 35MM 6.5MM AEQUALIS PERFORM REVERSED GLENOID",SUP-DWJ135,CDM,C1776,HCPCS,0278,RC,,,both,,,9028.00,2708.4,"BLUE CROSS [10001]","Blue Cross PPO",,3538.98,39.2,,3949.44,3949.44,3949.44,"1 through 10",1049.96,7673.8,"percent of total billed charges",
"SCR BONE 2.7MM 12MM LCP STAINLESS STEEL SMALL BONE SELF",SUP-02.211.012,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,106.43,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",104.45,763.41,"percent of total billed charges",
"PROS PENILE AMS 700 MS PUMP CONCEAL INFLATABLE RESVR",SUP-720185-01,CDM,C1813,HCPCS,0278,RC,,,both,,,21609.00,6482.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2513.13,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2513.13,18367.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 71/75MMX14MM VANGUARD E1 KNEE POSTERIOR STABILIZE",SUP-EP-183744,CDM,C1776,HCPCS,0278,RC,,,both,,,13241.10,3972.33,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1539.94,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1539.94,11254.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 114MM PRIMARY ANTHOLOGY POROUS 131D 8 HIGH",SUP-71356108,CDM,C1776,HCPCS,0278,RC,,,both,,,33141.15,9942.34,"PHCS [10601]",PHCS,,23198.81,70,,,,,0,3854.32,28169.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP REVERSE INHANCE",SUP-OSC382090,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"BLUE CROSS [10001]","Blue Cross HMO",,17781.12,39.2,,5311.50,4717.44,5388.59,31,5275.37,38556,"percent of total billed charges",
"INSRT TIBIAL XS UNIVERSAL 16MM KNEE COCR POLYETHYLENE",SUP-198727116,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11818.55,40,,,,,0,3436.24,25114.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 56MM 40MM ALTRX HIP",SUP-122140056,CDM,C1776,HCPCS,0278,RC,,,both,,,13803.45,4141.03,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5673.22,41.1,,6417.48,6417.48,6417.48,"1 through 10",1605.34,11732.93,"percent of total billed charges",
"CAP CONSTRUCT TOTAL KNEE JOURNEY II BCS COCR FEMUR WITH ASMD",SUP-71709022,CDM,C1776,HCPCS,0278,RC,,,both,,,18900.00,5670,"CIGNA [10200]","Cigna Open Access",,6331.5,33.5,,5302.19,4377.88,6578.61,27,2198.07,16065,"percent of total billed charges",
"STEM EXT 70MM 10MM GENESIS II LONG KNEE STERILE",SUP-71928199,CDM,C1776,HCPCS,0278,RC,,,both,,,14676.30,4402.89,"BLUE CROSS [10001]","Blue Cross HMO",,5753.11,39.2,,5311.50,4717.44,5388.59,31,1706.85,12474.86,"percent of total billed charges",
"BASE TIB STEM #3 RIGHT PEGLESS",SUP-2586-0-0003,CDM,C1776,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Open Access",,3533.49,56.9,,5302.19,4377.88,6578.61,27,722.22,5278.5,"percent of total billed charges",
"CATH RELIANCE XK AIRGUARD DUALATOR 24CM 19CM 16FR 16.5FR",SUP-5323190,CDM,C1750,HCPCS,0278,RC,,,both,,,1498.50,449.55,"CIGNA [10200]","Cigna Local Plus",,801.7,53.5,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 60MM CATHCART BALL HIP FEMORAL ORTHOCHROME",SUP-136360000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1070.39,28.62,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 8MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650708,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1526.7,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 60MM CATHCART BALL HIP FEMORAL ORTHOCHROME",SUP-136360000,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,434.96,3179,"percent of total billed charges",
"STEM FEMORAL +8MM 40MM STD LATERAL OFFSET 165MM 20MM 15MM",SUP-523420,CDM,C1776,HCPCS,0278,RC,,,both,,,11104.56,3331.37,"FIRST HEALTH [10303]","First Health",,8883.65,80,,,,,0,1291.46,9438.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, ALL-POLY PEGGED GLENOID, SIZE 46, E-PLUS",SUP-521-07-246,CDM,C1776,HCPCS,0278,RC,,,both,,,9164.40,2749.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1085.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1065.82,7789.74,"percent of total billed charges",
"OXF UNI TIB TRAY SZ E LM PMA",SUP-154726,CDM,C1776,HCPCS,0278,RC,,,both,,,11195.94,3358.78,"FIRST HEALTH [10303]","First Health",,8956.75,80,,,,,0,1302.09,9516.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"UPCHARGE REVERSED FX STEM",SUP-CAP-T-1058,CDM,C1776,HCPCS,0278,RC,,,both,,,3750.00,1125,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,444.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,436.13,3187.5,"percent of total billed charges",
"STEM HUMERAL 83MM 8MM COMPREHENSIVE POROUS MINI SHOULDER",SUP-113628,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"NOVANET [10819]",Novanet,,9450,75,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 44MM 28MM MARATHON HIP",SUP-121928044,CDM,C1776,HCPCS,0278,RC,,,both,,,8328.30,2498.49,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3422.93,41.1,,6417.48,6417.48,6417.48,"1 through 10",968.58,7079.06,"percent of total billed charges",
"CMPNT TALAR INBONE 2 DOME ANKLE SULCUS",SUP-220220902,CDM,C1776,HCPCS,0278,RC,,,both,,,23719.50,7115.85,"CIGNA [10200]","Cigna Local Plus",,7471.64,31.5,,5372.07,4581.20,7242.98,23,2758.58,20161.58,"percent of total billed charges",
"GRAFT PORCINE 11.8X9.8IN XENMATRIX AB RECTANGLE PORCINE",SUP-1152530,CDM,C1781,HCPCS,0278,RC,,,both,,,110903.19,33270.96,"BLUE CROSS [10001]","Blue Cross HMO",,43474.05,39.2,,,,,0,12898.04,94267.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH HERNIA POLYGLYCOLIC ACID 10X6IN RESORBABLE REINFORCE",SUP-F10254-0610G,CDM,C1781,HCPCS,0278,RC,,,both,,,3690.00,1107,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1693.71,45.9,,,,,0,429.15,3136.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 14MM KNEE AOX ROTATE PLATFORM CRUCIATE SUB",SUP-151710414,CDM,C1776,HCPCS,0278,RC,,,both,,,14793.60,4438.08,"MULTIPLAN [10600]",Multiplan,,12574.56,85,,,,,0,1720.5,12574.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ACCOLADE II 3 132D",SUP-6720-0330,CDM,C1776,HCPCS,0278,RC,,,both,,,23962.05,7188.61,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2839.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2786.79,20367.74,"percent of total billed charges",
"KIT TKR 12MM ITOTAL IPOLY XE POSTERIOR STABILIZE INSRT",SUP-RPS0201200,CDM,C1776,HCPCS,0278,RC,,,both,,,6254.85,1876.45,"CIGNA [10200]","Cigna Open Access",,3559.01,56.9,,5302.19,4377.88,6578.61,27,727.44,5316.62,"percent of total billed charges",
"STEM FEMORAL 140MM 10MM COLLARLESS CEMENTLESS LOW PROFILE",SUP-L20310,CDM,C1776,HCPCS,0278,RC,,,both,,,15837.12,4751.14,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1876.7,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1841.86,13461.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP NON POROUS TM REV SHLDRSTD GLEND AND INST",SUP-98000965000,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"BLUE CROSS [10001]","Blue Cross PPO",,17781.12,39.2,,3949.44,3949.44,3949.44,"1 through 10",5275.37,38556,"percent of total billed charges",
"INSRT TIBIAL 2 22.5MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA",SUP-962326,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"PHCS [10601]",PHCS,,10152.66,70,,,,,0,1686.79,12328.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 19MM KNEE X3 POSTERIOR STABILIZE BEARING",SUP-5532-G-519,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"KAISER [10500]",Kaiser,,7646.44,67,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 RIGHT KNEE TOTAL STABILIZED TRIATHLON COCR",SUP-5512-F-602,CDM,C1776,HCPCS,0278,RC,,,both,,,20599.49,6179.85,"NOVANET [10819]",Novanet,,15449.62,75,,,,,0,2395.72,17509.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 50MM 28MM UHR UNIVERSAL HIP UHMWPE PRIMARY",SUP-UH1-50-28,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"BLUE CROSS [10001]","Blue Cross PPO",,1692.57,39.2,,3949.44,3949.44,3949.44,"1 through 10",502.16,3670.1,"percent of total billed charges",
"KIT TKR 12MM ITOTAL IPOLY XE POSTERIOR STABILIZE INSRT",SUP-RPS0201200,CDM,C1776,HCPCS,0278,RC,,,both,,,6254.85,1876.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,741.2,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,727.44,5316.62,"percent of total billed charges",
"INSRT TIBIAL 6 12MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650612,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1555.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1526.7,11158.16,"percent of total billed charges",
"STEM FEMORAL 195MM 17MM MODULAR RESTORATION BOWED CONICAL",SUP-6276-7-217,CDM,C1776,HCPCS,0278,RC,,,both,,,11695.32,3508.6,"UHC [10700]","United Healthcare",,7403.14,63.3,,8601.07,8395.67,8601.07,"1 through 10",1360.17,9941.02,"percent of total billed charges",
"ADPTR HEAD TITANIUM +4MM STD SMR TAPER ECCENTRICAL REVISION",SUP-1330.15.274,CDM,C1776,HCPCS,0278,RC,,,both,,,1555.70,466.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1057.88,68,,,,,0,180.93,1322.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM PRESS FIT BASIC SUMMIT 6 12/14 TAPER HIP",SUP-157005120,CDM,C1776,HCPCS,0278,RC,,,both,,,9090.75,2727.22,"NOVANET [10819]",Novanet,,6818.06,75,,,,,0,1057.25,7727.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ACETABULAR 58MM DURALOC DYNAMIC HIP LOCK STERILE LATEX",SUP-124958000,CDM,C1776,HCPCS,0278,RC,,,both,,,1878.00,563.4,"PHCS [10601]",PHCS,,1314.6,70,,,,,0,218.41,1596.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REVERSE SHOULDER STANDARD CAP",SUP-RSA1,CDM,C1776,HCPCS,0278,RC,,,both,,,45360.00,13608,"CIGNA [10200]","Cigna Local Plus",,14288.4,31.5,,5372.07,4581.20,7242.98,23,5275.37,38556,"percent of total billed charges",
"STEM FEMORAL 15MM SECUR-FIT PLUS 11 HIP STERILE",SUP-6054-1115S,CDM,C1776,HCPCS,0278,RC,,,both,,,16165.44,4849.63,"BLUE CROSS [10001]","Blue Cross PPO",,6336.85,39.2,,3949.44,3949.44,3949.44,"1 through 10",1880.04,13740.62,"percent of total billed charges",
"SLEEVE CENTERING 9.5MM 5MM S-ROM ZTT 18D SMALL HIP POROUS",SUP-550523,CDM,C1776,HCPCS,0278,RC,,,both,,,6466.32,1939.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2968.04,45.9,,,,,0,752.03,5496.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GLENOSPHERE - 36MM DIA X 6MM THK CONCENTRIC",SUP-5573-C-3606,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.20,3657.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1444.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1418.07,10364.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 11MM KNEE CRUCIATE RETAINING TRIATHLON",SUP-5530P811,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3835.36,45.9,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 15MM KNEE GVF UHMWPE ROTATE PLATFORM SIGMA TC",SUP-962363,CDM,C1776,HCPCS,0278,RC,,,both,,,14503.80,4351.14,"CIGNA [10200]","Cigna Open Access",,4858.77,33.5,,5302.19,4377.88,6578.61,27,1686.79,12328.23,"percent of total billed charges",
"KIT TKR 18MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0101800,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"BLUE CROSS [10001]","Blue Cross HMO",,1992.09,39.2,,5311.50,4717.44,5388.59,31,591.02,4319.57,"percent of total billed charges",
"KIT TKR 18MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0101800,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"KAISER [10500]",Kaiser,,3404.84,67,,,,,0,591.02,4319.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 CURVE 17.5MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962064,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6289.63,68,,,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 13MM PERSONA 6-9 E-F KNEE LEFT",SUP-42511400713,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"CIGNA [10200]",Cigna,,5491.52,68,,5873.17,5873.17,5873.17,"1 through 10",939.21,6864.4,"percent of total billed charges",
"STEM RADIAL 10MM 0MM STERILE",SUP-TR-S1000-S,CDM,C1776,HCPCS,0278,RC,,,both,,,15145.50,4543.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1794.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1761.42,12873.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIPOLAR HIP WITH PRESS FIT STEM",SUP-55500031,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1123.46,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 10MM KNEE AOX ROTATE PLATFORM CRUCIATE RETAIN",SUP-1516-30-710,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"KAISER [10500]",Kaiser,,8795.26,67,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 9MM KNEE X3 CONDYLAR STABILIZED TRIATHLON",SUP-5531G109,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"UHC [10700]","United Healthcare",,6330,63.3,,8601.07,8395.67,8601.07,"1 through 10",1163,8500,"percent of total billed charges",
"STENT PROTEGE GPS 30MM 80CM 8MM BILIARY ACCEPTS .035IN GWIRE",SUP-SERB65-08-30-80,CDM,C1876,HCPCS,0278,RC,,,both,,,6037.50,1811.25,"FIRST HEALTH [10303]","First Health",,4830,80,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BLAZER II HTD 110CM 4MM 7FR 2.5MM SPACE ASYMMETRIC 4",SUP-M0045031THN40,CDM,C1733,HCPCS,0272,RC,,,both,,,8107.50,2432.25,"KAISER [10500]",Kaiser,,5432.03,67,,,,,0,942.9,6891.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR 57MM MULTIPOLAR HIP METAL STERILE",SUP-500105700,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 8MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-608,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"NOVANET [10819]",Novanet,,9845.44,75,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 RIGHT KNEE POSTERIOR STABILIZED CEMENTED",SUP-5515-F-602,CDM,C1776,HCPCS,0278,RC,,,both,,,16566.90,4970.07,"UHC [10700]","United Healthcare",,10486.85,63.3,,8601.07,8395.67,8601.07,"1 through 10",1926.73,14081.87,"percent of total billed charges",
"INSERT TIB CONGRUENT 3/4 LF 14",SUP-2041-0-3414,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,422.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,414.32,3028.13,"percent of total billed charges",
"CATH MARINR 90CM 7FR 2-5-2MM SPACING 65MM REACH MC CURVE",SUP-072322M,CDM,C1730,HCPCS,0272,RC,,,both,,,2437.50,731.25,"AETNA [10100]","Aetna HMO/PPO",,1937.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,283.48,2071.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM HIP LIMIT HOLE TITANIUM POROUS",SUP-PT-116058,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1186.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1186.85,8674.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR DYNASTY A-CLASS STD 36MM POLY BIOFOAM HIP",SUP-DLXPGD36,CDM,C1776,HCPCS,0278,RC,,,both,,,7507.20,2252.16,"KAISER [10500]",Kaiser,,5029.82,67,,,,,0,873.09,6381.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD UNIPOLAR 51MM UNITRAX HIP MODULAR ENDOPROSTHESIS",SUP-6942-5-051,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"KAISER [10500]",Kaiser,,2095.56,67,,,,,0,363.75,2658.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED + VE",SUP-98000200252,CDM,C1776,HCPCS,0278,RC,,,both,,,24570.00,7371,"MULTIPLAN [10600]",Multiplan,,20884.5,85,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 KNEE LEFT CEMENT REVISION CONSTRAIN ATTUNE",SUP-150440107,CDM,C1776,HCPCS,0278,RC,,,both,,,30114.00,9034.2,"CIGNA [10200]","Cigna Local Plus",,9485.91,31.5,,5372.07,4581.20,7242.98,23,3502.26,25596.9,"percent of total billed charges",
"CMPNT FEMORAL 6 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRP6PR,CDM,C1776,HCPCS,0278,RC,,,both,,,21501.90,6450.57,"UHC [10700]","United Healthcare",,13610.7,63.3,,8601.07,8395.67,8601.07,"1 through 10",2500.67,18276.62,"percent of total billed charges",
"STEM FEMORAL 105MM TYPE 1 TAPERLOC MICROPLASTY PPS 133D 10",SUP-51106100,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"AETNA [10100]","Aetna HMO/PPO",,21811.02,79.5,,10981.53,8986.79,12413.38,12,3190.72,23319.95,"percent of total billed charges",
"SCR BONE 6.5MM 35MM REFLECTION R3 CONTOUR HIP ACETABULAR",SUP-71332535,CDM,C1713,HCPCS,0278,RC,,,both,,,1287.90,386.37,"CIGNA [10200]","Cigna Local Plus",,689.03,53.5,,3978.14,359.25,3978.14,24,149.78,1094.72,"percent of total billed charges",
"LINER HUMERAL SMR UHMWPE +3 MM OD36 MM SHOULDER REVISION REV",SUP-1360.50.815,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,841.43,28.62,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER HUMERAL SMR UHMWPE +3 MM OD36 MM SHOULDER REVISION REV",SUP-1360.50.815,CDM,C1776,HCPCS,0278,RC,,,both,,,2940.00,882,"PHCS [10601]",PHCS,,2058,70,,,,,0,341.92,2499,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 10IN 18MM REDUCE NECK SOL SYSTEM POROUS 12/14",SUP-157210180,CDM,C1776,HCPCS,0278,RC,,,both,,,39412.80,11823.84,"BLUE CROSS [10001]","Blue Cross HMO",,15449.82,39.2,,5311.50,4717.44,5388.59,31,4583.71,33500.88,"percent of total billed charges",
"STEM FEMORAL 120MM 8MM PRESS FIT REDUCE PROXIMAL PROFILE",SUP-192408,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"CIGNA [10200]","Cigna Local Plus",,7480.77,31.5,,5372.07,4581.20,7242.98,23,2761.95,20186.21,"percent of total billed charges",
"SHELL ACETABULAR 48MM HIP GRIPTION PINNACLE STERILE LATEX",SUP-121731048,CDM,C1776,HCPCS,0278,RC,,,both,,,16218.45,4865.53,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6665.78,41.1,,6417.48,6417.48,6417.48,"1 through 10",1886.21,13785.68,"percent of total billed charges",
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 52MM 36MM MARATHON",SUP-121936452,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"BLUE CROSS [10001]","Blue Cross HMO",,3858.4,39.2,,5311.50,4717.44,5388.59,31,1144.72,8366.42,"percent of total billed charges",
"CMPNT HUMERAL 46MM 42MM OVOMOTION STERILE LATEX FREE",SUP-8HM2-4642-A,CDM,C1776,HCPCS,0278,RC,,,both,,,18585.00,5575.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7638.44,41.1,,6417.48,6417.48,6417.48,"1 through 10",2161.44,15797.25,"percent of total billed charges",
"CMPNT FEMORAL 3 KNEE LEFT POSTERIOR STABILIZE CEMENT LEGION",SUP-71423223,CDM,C1776,HCPCS,0278,RC,,,both,,,21886.20,6565.86,"MULTIPLAN [10600]",Multiplan,,18603.27,85,,,,,0,2545.37,18603.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX LOW PROFILE REINFORCED TISSUE MATRIX, LONG-TERM RESOR",SUP-F10264-0909L,CDM,C1781,HCPCS,0278,RC,,,both,,,7268.46,2180.54,"CIGNA [10200]","Cigna Local Plus",,3888.63,53.5,,3096.73,1.00,3096.73,"1 through 10",845.32,6178.19,"percent of total billed charges",
"EXT STEM 80MM 10MM 1 AXIS PRESS FIT CEMENTED KNEE VITALLIUM",SUP-6478-6-395,CDM,C1776,HCPCS,0278,RC,,,both,,,3364.45,1009.33,"FIRST HEALTH [10303]","First Health",,2691.56,80,,,,,0,391.29,2859.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 4 10MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650410,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"KAISER [10500]",Kaiser,,8442,67,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 20MM KNEE XLK STABILIZE FIX BEARING PFC SIGMA",SUP-158121120,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4592.74,41.1,,6417.48,6417.48,6417.48,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"STEM FEMORAL 8IN 13.5MM MODULAR SOL SYSTEM POROUS 12/14",SUP-157201136,CDM,C1776,HCPCS,0278,RC,,,both,,,38107.44,11432.23,"CIGNA [10200]","Cigna Local Plus",,12003.84,31.5,,5372.07,4581.20,7242.98,23,4431.9,32391.32,"percent of total billed charges",
"HEAD FEMORAL +5MM 12/14 TAPER 36MM HIP SLEEVE TOTAL",SUP-136536720,CDM,C1776,HCPCS,0278,RC,,,both,,,13002.36,3900.71,"CIGNA [10200]","Cigna Local Plus",,4095.74,31.5,,5372.07,4581.20,7242.98,23,1512.17,11052.01,"percent of total billed charges",
"CMPNT FEMORAL 7 NARROW KNEE RIGHT CRUCIATE RETAINING PERSONA",SUP-42502206202,CDM,C1776,HCPCS,0278,RC,,,both,,,28895.58,8668.67,"PHCS [10601]",PHCS,,20226.91,70,,,,,0,3360.56,24561.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 120MM PRIMARY CEMENT DISTAL BULLET TIP SYNERGY",SUP-71316211,CDM,C1776,HCPCS,0278,RC,,,both,,,21262.50,6378.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8738.89,41.1,,6417.48,6417.48,6417.48,"1 through 10",2472.83,18073.13,"percent of total billed charges",
"INSRT TIBIAL 2 CURVE 15MM KNEE GVF UHMWPE ROTATE PLATFORM",SUP-962013,CDM,C1776,HCPCS,0278,RC,,,both,,,9249.45,2774.83,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1075.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1075.71,7862.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR 10MM 35MM ASYMMETRIC TRIATHLON X3 KNEE",SUP-5551-G-350-E,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"CIGNA [10200]",Cigna,,3847.44,68,,5873.17,5873.17,5873.17,"1 through 10",658.03,4809.3,"percent of total billed charges",
"TRIAL KNEE TRIATHLON 0D HINGE BUMPER STERILE LATEX FREE",SUP-5612-4-000,CDM,C1776,HCPCS,0278,RC,,,both,,,6003.00,1800.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1718.06,28.62,,,,,0,698.15,5102.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 10MM PERSONA 6-9 E-F KNEE LEFT",SUP-42511400710,CDM,C1776,HCPCS,0278,RC,,,both,,,8075.76,2422.73,"PHCS [10601]",PHCS,,5653.03,70,,,,,0,939.21,6864.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 127MM 19MM REVISION MODULAR PLASMA RESTORATION",SUP-6276-5-019,CDM,C1776,HCPCS,0278,RC,,,both,,,17520.30,5256.09,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2076.16,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2037.61,14892.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 58MM 3 HOLE POLY R3 STD",SUP-71335558,CDM,C1776,HCPCS,0278,RC,,,both,,,14345.10,4303.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1699.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1668.34,12193.34,"percent of total billed charges",
"CMPNT FEMORAL 3 KNEE RIGHT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F302,CDM,C1776,HCPCS,0278,RC,,,both,,,29995.06,8998.52,"PHCS [10601]",PHCS,,20996.54,70,,,,,0,3488.43,25495.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 19MM 52MM SHOULDER SIMPLICITI",SUP-7122875,CDM,C1776,HCPCS,0278,RC,,,both,,,10019.00,3005.7,"FIRST HEALTH [10303]","First Health",,8015.2,80,,,,,0,1165.21,8516.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 30MM SECUR-FIT MAX 7 STERILE",SUP-6051-0730S,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6431.82,41.1,,6417.48,6417.48,6417.48,"1 through 10",1820,13301.82,"percent of total billed charges",
"CAP CONSTRUCT TOTAL HIP POROUS FEMUR COBALT CHROME HEAD R3 H",SUP-71705313,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Local Plus",,7541.1,31.5,,5372.07,4581.20,7242.98,23,2784.22,20349,"percent of total billed charges",
"BASEPLT GLENOID 24MM 20D OBLIQUE FULL AUG STERILE LATEX FREE",SUP-AR-9580-2420,CDM,C1776,HCPCS,0278,RC,,,both,,,11571.30,3471.39,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1345.74,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1345.74,9835.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 30MM SECUR-FIT MAX 7 STERILE",SUP-6051-0730S,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"NOVANET [10819]",Novanet,,11736.9,75,,,,,0,1820,13301.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 22MM KNEE X3 CRUCIATE SUBSTITUTING TRIATHLON",SUP-5531G722,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6800,68,,,,,0,1163,8500,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 13.5MM S-ROM ZTT 20F LARGE HIP PROXIMAL",SUP-550728,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"CIGNA [10200]",Cigna,,7401.63,68,,5873.17,5873.17,5873.17,"1 through 10",1265.9,9252.04,"percent of total billed charges",
"DISC INTERVERTEBRAL 5MM PRESTIGE LP 14MM SPINE STERILE LATEX",SUP-6972450,CDM,C1776,HCPCS,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Open Access",,9497.25,33.5,,5302.19,4377.88,6578.61,27,3297.11,24097.5,"percent of total billed charges",
"INSRT TIBIAL XS S1 S2 SMALL 10MM DISTAL BEARING MODULAR",SUP-64813210,CDM,C1776,HCPCS,0278,RC,,,both,,,4114.66,1234.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,487.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,478.53,3497.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 96MM 12MM PRESS FIT REUNION SHOULDER",SUP-5567-P-3012,CDM,C1776,HCPCS,0278,RC,,,both,,,17250.00,5175,"BLUE CROSS [10001]","Blue Cross PPO",,6762,39.2,,3949.44,3949.44,3949.44,"1 through 10",2006.18,14662.5,"percent of total billed charges",
"CMPNT FEMORAL 7 KNEE LEFT CRUCIATE RETAIN BEAD TRIATHLON PA",SUP-5517F701,CDM,C1776,HCPCS,0278,RC,,,both,,,17140.03,5142.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1993.39,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1993.39,14569.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 12MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-512,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3544.36,27,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP NANO HUMERUS/AUGMENTED GLENOID/VERSADIAL HEAD",SUP-98000900234,CDM,C1776,HCPCS,0278,RC,,,both,,,34650.00,10395,"KAISER [10500]",Kaiser,,23215.5,67,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Colonoscopy Stoma W Hot Bx",PX-750000072,CDM,44392,CPT,0750,RC,,,both,,,2060.19,618.06,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,244.13,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.6,2060.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +3MM 22MM HIP PRIMARY TAPER OFFSET ION",SUP-6260-9-222,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA [10200]",Cigna,,2126.84,68,,5873.17,5873.17,5873.17,"1 through 10",363.75,2658.55,"percent of total billed charges",
"SHELL ACETABULAR 46MM CLUSTER HOLE PRIMARY HEMISPHERICAL",SUP-502-03-46B,CDM,C1776,HCPCS,0278,RC,,,both,,,10466.82,3140.05,"PHCS [10601]",PHCS,,7326.77,70,,,,,0,1217.29,8896.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR ROUND 7.5MM 32MM RESURFACE JOURNEY",SUP-71932912,CDM,C1776,HCPCS,0278,RC,,,both,,,6768.90,2030.67,"KAISER [10500]",Kaiser,,4535.16,67,,,,,0,787.22,5753.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PRIMARY METAL BACK GLENOID TOTAL SHOULDER (CONVERITIBLE)",SUP-SMRMBTS,CDM,C1776,HCPCS,0278,RC,,,both,,,33232.50,9969.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,8972.78,27,,,,,0,3864.94,28247.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 115MM TYPE 1 TAPERLOC MICROPLASTY PPS 133D 15",SUP-51106150,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,7851.97,28.62,,,,,0,3190.72,23319.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 109MM 13MM FULL PROXIMAL PROFILE ECHO BI-METRIC",SUP-19-3013,CDM,C1776,HCPCS,0278,RC,,,both,,,27578.88,8273.66,"FIRST HEALTH [10303]","First Health",,22063.1,80,,,,,0,3207.42,23442.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 58MM 28MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-58-28,CDM,C1776,HCPCS,0278,RC,,,both,,,5658.00,1697.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,670.47,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,658.03,4809.3,"percent of total billed charges",
"ATTUNE RP CEMENTED",SUP-CAP-DS-K-2A,CDM,C1776,HCPCS,0278,RC,,,both,,,20790.00,6237,"UHC [10700]","United Healthcare",,13160.07,63.3,,8601.07,8395.67,8601.07,"1 through 10",2417.88,17671.5,"percent of total billed charges",
"INSERT TIB SUBPCL #3/4X14MM RT",SUP-2142-1-3414,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1019.59,28.62,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 14MM PRESS FIT REDUCE PROXIMAL PROFILE",SUP-192414,CDM,C1776,HCPCS,0278,RC,,,both,,,23748.48,7124.54,"BLUE CROSS [10001]","Blue Cross PPO",,9309.4,39.2,,3949.44,3949.44,3949.44,"1 through 10",2761.95,20186.21,"percent of total billed charges",
"INSRT TIBIAL 2 10MM KNEE XLK POSTERIOR LIPPED FIX BEARING",SUP-158101110,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"UHC [10700]","United Healthcare",,7073.49,63.3,,8601.07,8395.67,8601.07,"1 through 10",1299.6,9498.37,"percent of total billed charges",
"INSRT TIBIAL 5 14MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650514,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"BLUE CROSS [10001]","Blue Cross PPO",,5145.88,39.2,,3949.44,3949.44,3949.44,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"CAP CEMENTLESS TOTAL KNEE SYSTEM INCLUDING CONSTRAINED",SUP-98000200468,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,2710.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP POROUS STEM WITH BIOLOX DELTA HEAD R3 MH C",SUP-71705326,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"AETNA [10100]","Aetna HMO/PPO",,19032.3,79.5,,10981.53,8986.79,12413.38,12,2784.22,20349,"percent of total billed charges",
"STEM FEMORAL COLLAR ACTIS DUOFIX 12 HIGH OFFSET HIP STERILE",SUP-101012120,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"FIRST HEALTH [10303]","First Health",,24381,80,,,,,0,3544.39,25904.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT TIB 7 13MM KN BRNG POST STAB",SUP-5532-G-713-E,CDM,C1776,HCPCS,0278,RC,,,both,,,11412.60,3423.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7760.57,68,,,,,0,1327.29,9700.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 KNEE RIGHT POSTERIOR STABILIZE LEGION",SUP-71421203,CDM,C1776,HCPCS,0278,RC,,,both,,,28813.05,8643.91,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11842.16,41.1,,6417.48,6417.48,6417.48,"1 through 10",3350.96,24491.09,"percent of total billed charges",
"CAP CONSTRUCT TOTAL HIP CEMENTED FEMUR COBALT CHROME HEAD R3",SUP-71705312,CDM,C1776,HCPCS,0278,RC,,,both,,,23940.00,7182,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 1.5MM 3MM 9MM TITANIUM CORTEX HAND SELF TAPPING",SUP-400.809,CDM,C1713,HCPCS,0278,RC,,,both,,,421.52,126.46,"KAISER [10500]",Kaiser,,282.42,67,,,,,0,49.02,358.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 22MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532-P-222,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"CIGNA [10200]","Cigna Open Access",,4754.51,56.9,,5302.19,4377.88,6578.61,27,971.79,7102.52,"percent of total billed charges",
"CAP CONSTRUCT HIP BIPOLAR PRIMARY CEMENTED POLARSTEM WITH OX",SUP-71703544,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"BLUE CROSS [10001]","Blue Cross PPO",,3786.72,39.2,,3949.44,3949.44,3949.44,"1 through 10",1123.46,8211,"percent of total billed charges",
"SHELL ACETABULAR 52MM HIP MULTIHOLE R3 STD STERILE",SUP-71338665,CDM,C1776,HCPCS,0278,RC,,,both,,,15887.25,4766.17,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6354.9,40,,,,,0,1847.69,13504.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL ANTHOLOGY HA POROUS PLUS 14 STD OFFSET HIP",SUP-71935574,CDM,C1776,HCPCS,0278,RC,,,both,,,36533.70,10960.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10455.94,28.62,,,,,0,4248.87,31053.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT HIP BIPOLAR PRIMARY CEMENTED POLARSTEM WITH OX",SUP-71703544,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"CIGNA [10200]",Cigna,,6568.8,68,,5873.17,5873.17,5873.17,"1 through 10",1123.46,8211,"percent of total billed charges",
"CMPNT GLENOID 2 4 PEG MODULAR ALLIANCE SHOULDER STERILE",SUP-SAGL2042,CDM,C1776,HCPCS,0278,RC,,,both,,,7396.80,2219.04,"BLUE CROSS [10001]","Blue Cross HMO",,2899.55,39.2,,5311.50,4717.44,5388.59,31,860.25,6287.28,"percent of total billed charges",
"INSERT TIB CONGR SZ3/4X10MM RT",SUP-2042-0-3410,CDM,C1776,HCPCS,0278,RC,,,both,,,3562.50,1068.75,"PHCS [10601]",PHCS,,2493.75,70,,,,,0,414.32,3028.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1 16MM KNEE POLYETHYLENE POSTERIOR STABILIZE",SUP-5532-P-116,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"MULTIPLAN [10600]",Multiplan,,7102.52,85,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 39MM CEMENTLESS OFFSET SECUR-FIT MAX 127D",SUP-6052-0730S,CDM,C1776,HCPCS,0278,RC,,,both,,,15649.20,4694.76,"FIRST HEALTH [10303]","First Health",,12519.36,80,,,,,0,1820,13301.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 7MM KNEE AOX FIX BEARING CRUCIATE RETAIN",SUP-151620207,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"FIRST HEALTH [10303]","First Health",,9003.12,80,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 21MM 52MM SHOULDER SOFT TISSUE BALANCE",SUP-7122888,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"CIGNA [10200]",Cigna,,5385.6,68,,5873.17,5873.17,5873.17,"1 through 10",921.1,6732,"percent of total billed charges",
"SHELL ACETABULAR 56MM HIP 5 SCR HOLE CLUSTER METAL HA",SUP-502-11-56F,CDM,C1776,HCPCS,0278,RC,,,both,,,9525.45,2857.63,"NOVANET [10819]",Novanet,,7144.09,75,,,,,0,1107.81,8096.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 2 11MM KNEE FIX BEARING CRUCIATE SUB TRIATHLON",SUP-5531-G-211-E,CDM,C1776,HCPCS,0278,RC,,,both,,,12033.60,3610.08,"BLUE CROSS [10001]","Blue Cross PPO",,4717.17,39.2,,3949.44,3949.44,3949.44,"1 through 10",1399.51,10228.56,"percent of total billed charges",
"INSRT TIBIAL 3 19MM KNEE X3 CONDYLAR STABILIZED PRIMARY",SUP-5531G319,CDM,C1776,HCPCS,0278,RC,,,both,,,9366.08,2809.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4299.03,45.9,,,,,0,1089.28,7961.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 115MM 6MM PRIMARY TURON",SUP-520-01-006,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"PHCS [10601]",PHCS,,5544,70,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED DUAL MOBILITY HIP SYSTEM + CER HD",SUP-98000500322,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,11088,40,,,,,0,3223.84,23562,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 46MM 28MM MARATHON HIP",SUP-121928046,CDM,C1776,HCPCS,0278,RC,,,both,,,8328.30,2498.49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2383.56,28.62,,,,,0,968.58,7079.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPREME 120CM 5FR 2-5-2MM SPACING JSN CURVE",SUP-401450,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH WOLVERINE CUTTING BALLOON MONORAIL 10CM 2.5MM BALLOON",SUP-H74939401102500,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,2226.18,41.1,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT SWIVE TENDON 7X19.1",SUP-AR-1662BCC-7,CDM,C1713,HCPCS,0278,RC,,,both,,,3425.63,1027.69,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,405.94,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,398.4,2911.79,"percent of total billed charges",
"SCR BONE 2.4MM 26MM LCP STAINLESS STEEL DISTAL RADIUS",SUP-02.210.126,CDM,C1713,HCPCS,0278,RC,,,both,,,959.36,287.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,113.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",111.57,815.46,"percent of total billed charges",
"HC Bordetella Ab",PX-302000100,CDM,86615,CPT,0302,RC,,,both,,,175.00,52.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,8.94,,,,,,,0.01,148.75,"fee schedule",
"INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC",728,MS-DRG,,,,,,,inpatient,,,23237.50,6971.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,13149.55,,"Fee schedule rate ($13,149.55). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,5031.92,20230.52,other,"IP MEDICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION (HIE THERAPY ONLY)",RX-411797,CDM,J1815,HCPCS,0637,RC,00002-7533-01,NDC,both,3,ML,180.45,54.13,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,20.99,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,15.51,153.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC US OB Ltd Txabd >=1 Fetus",PX-402000020,CDM,76815,CPT,0402,RC,,,both,,,528.37,158.51,"AETNA [10100]","Aetna HMO/PPO",,420.05,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,61.45,449.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM CABLE 121X23MM CABLE-READY LONG 4 INTEGRAL GREATER",SUP-00223200205,CDM,C1713,HCPCS,0278,RC,,,both,,,22018.50,6605.55,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,8807.4,40,,,,,0,2560.75,18715.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X12X6MM ENDOSKELETON TC 6D SMALL INTERBODY",SUP-5146-1206,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1911.36,28.62,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC SAMURAI FULL RADIUS CAPSULAR TISSUE",SUP-CAT00227,CDM,S27200284,LOCAL,0272,RC,,,both,,,1635.00,490.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,190.15,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,190.15,1389.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE GLDEWIRE GLIDE TECHNOLOGY VASCULAR STD STRAIGHT 260CM",SUP-GS3504,CDM,C1769,HCPCS,0272,RC,,,both,,,435.00,130.5,"UHC [10700]","United Healthcare",,275.36,63.3,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK 5MM RETRACTION SHARP ELASTIC STAY LONE STAR STAINLESS",SUP-3311-1G,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.05,27.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,61.91,68,,,,,0,10.59,77.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ELECTROSURGICAL 50MM 17GA MULTICOOL RADIOFREQUENCY",SUP-MCKA2-17-50-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,9177.00,2753.1,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"STPLR INTERNAL STERILE LATEX FREE DISPOSABLE SUREFORM 45 14",SUP-480445,CDM,S27200284,LOCAL,0272,RC,,,both,,,3622.50,1086.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CANN BONE CEMENT 15CM 18GA NDL ACCESS CHIBA",SUP-K12-08326,CDM,S27200284,LOCAL,0272,RC,,,both,,,113.10,33.93,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ASAHI SION VASCULAR 190CM .014IN STERILE LATEX FREE",SUP-AHW14R101S,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HOOK 2 6.5IN SKIN RETRACTION 5MM KLEINERT-KUTZ",SUP-410136,CDM,S27200284,LOCAL,0272,RC,,,both,,,197.32,59.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE STARTER VASCULAR 3MM RADIUS J CURVE STRAIGHT 150CM",SUP-M001491701,CDM,C1769,HCPCS,0272,RC,,,both,,,92.19,27.66,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SPACER SPINAL 30X12X6MM SABLE 8D",SUP-1172.4210S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA [10200]","Cigna Open Access",,11607.75,33.5,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Microsomal Ab Ea",PX-302000083,CDM,86376,CPT,0302,RC,,,both,,,307.80,92.34,"CIGNA [10200]","Cigna Open Access",,32.01,,,,,,,0.31,261.63,"fee schedule",
"CATH COYOTE ES 142CM 20MM 6FR 2MM BALLOON DILATATION OTW LOW",SUP-H74939134202010,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC",421,MS-DRG,,,,,,,inpatient,,,84505.46,25351.64,"MULTIPLAN [10600]",Multiplan,,,85,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE VITRECTOMY 25+ GA CONSTELLATION TROCAR PLUG SET",SUP-8065751443,CDM,S27200284,LOCAL,0272,RC,,,both,,,439.26,131.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH JADE 150CM 80MM 2MM BALLOON DILATATION STERILE LATEX",SUP-582008022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM EVOLUT FX DELIVERY 34 MM",SUP-D-EVOLUTFX-34,CDM,S27200284,LOCAL,0272,RC,,,both,,,14559.00,4367.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5983.75,41.1,,,,,0,1693.21,12375.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE? II PRO SZ PTCA BALLOON SEMI-COMPLIANT 1.25 MM X 5",SUP-212-053-5UU,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"NOVANET [10819]",Novanet,,607.5,75,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 40MM 8MM BALLOON DILATATION DURALYN",SUP-48008004S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Culture CSF",PX-306000036,CDM,87070,CPT,0306,RC,,,both,,,437.00,131.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9.22,,"Fee schedule rate ($9.22). If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,371.45,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC So Gsap Cl Fr Cpy Nmbr&Mcrst",PX-310000021,CDM,81463,CPT,0310,RC,,,both,,,5525.00,1657.5,"FIRST HEALTH [10303]","First Health",,4420,80,,,,,0,5.53,4696.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM STRAIGHT STD CLOS",SUP-SB4000SC,CDM,S27200284,LOCAL,0272,RC,,,both,,,893.85,268.15,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,105.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.95,759.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE",RX-12933,CDM,J7507,HCPCS,0636,RC,51079-0818-01,NDC,both,1,UN,22.43,6.73,"CIGNA [10200]","Cigna Open Access",,0.54,,,,,,,0.2,19.07,"fee schedule",
"BIT DRILL 4.3MM CANNULATED",SUP-AR-8610DB-65C,CDM,S27200284,LOCAL,0272,RC,,,both,,,1417.50,425.25,"MULTIPLAN [10600]",Multiplan,,1204.88,85,,,,,0,164.86,1204.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2 TP-1 27IN BRAID 2 STRAND ANTIBACTERIAL",SUP-VCP849G,CDM,S27200284,LOCAL,0272,RC,,,both,,,80.55,24.16,"CIGNA [10200]","Cigna Open Access",,45.83,56.9,,,,,0,9.37,68.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2-0 FS 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8685H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]",Cigna,,17.68,68,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 2-0 FS 18IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8685H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH SURGICAL 6.5MM CORNEAL TREPHINE RADIAL VACUUM BAR",SUP-K20-2052,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"FIRST HEALTH [10303]","First Health",,427.68,80,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION KIRSCHNER PACK LUMBAR SPINE STERILE",SUP-675.399S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3326.40,997.92,"MULTIPLAN [10600]",Multiplan,,2827.44,85,,,,,0,386.86,2827.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DESARA SL SLING SYSTEM SHORT LENGTH STERILE SINGLE USE 5/BOX",SUP-CAL-DS01SL,CDM,C1771,HCPCS,0278,RC,,,both,,,7893.60,2368.08,"AMERIGROUP MEDICAID [20100]",Amerigroup,,935.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,918.03,6709.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Picc With S&I < 5 Yr",PX-361000485,CDM,36572,CPT,0361,RC,,,both,,,5574.10,1672.23,"KAISER [10500]",Kaiser,,3734.65,67,,,,,0,5.57,4737.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPR LD 14CM BP CNCT TO BP",SUP-501206,CDM,C1883,HCPCS,0278,RC,,,both,,,1830.00,549,"FIRST HEALTH [10303]","First Health",,1464,80,,,,,0,212.83,1555.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hfo W/Joint(S) Cf",PX-E27400035,CDM,L3921,HCPCS,0274,RC,,,both,,,815.10,244.53,"CIGNA [10200]","Cigna Local Plus",,436.08,53.5,,,,,0,94.8,692.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hfo W/Joint(S) Cf",PX-E27400035,CDM,L3921,HCPCS,0274,RC,,,both,,,815.10,244.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,96.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.8,692.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.4MM",SUP-AR-4160-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,1579.50,473.85,"FIRST HEALTH [10303]","First Health",,1263.6,80,,,,,0,183.7,1342.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Hla II Type 1 Ag Equivalent Lr",PX-309000086,CDM,81377,CPT,0310,RC,,,both,,,424.00,127.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,50.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.99,360.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Veni Other <3 Yr W Phys",PX-300000007,CDM,36406,CPT,0300,RC,,,both,,,87.00,26.1,"KAISER [10500]",Kaiser,,58.29,67,,,,,0,10.31,73.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 180 SURGALLOY 3-0 V-20 6IN CLSR ABSORBABLE",SUP-VLOCL0604,CDM,S27200284,LOCAL,0272,RC,,,both,,,406.03,121.81,"MULTIPLAN [10600]",Multiplan,,345.13,85,,,,,0,47.22,345.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIAGNOSTIC ELECTROPHYSIOLOGY CABLE 6F FEMORAL ONLY SINGLE US",SUP-DEX-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,1875.00,562.5,"MULTIPLAN [10600]",Multiplan,,1593.75,85,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 4FR .042IN AMPLATZ LEFT 1",SUP-538445,CDM,S27200284,LOCAL,0272,RC,,,both,,,89.52,26.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,36.79,41.1,,,,,0,10.41,76.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRIAL TIBIAL IDENTITY IMPRINT 5 THK8MM INSRT POSTERIOR",SUP-TPS-030-085S,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"MULTIPLAN [10600]",Multiplan,,688.5,85,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 5-0 RB-1 27IN BRAID ANTIBACTERIAL COATED",SUP-VCP213H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"FIRST HEALTH [10303]","First Health",,20,80,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 200CM 200MM 5MM BALLOON DILATATION RAPID",SUP-47550200L,CDM,C1725,HCPCS,0272,RC,,,both,,,1890.00,567,"NOVANET [10819]",Novanet,,1417.5,75,,,,,0,219.81,1606.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 122MM 2.7MM AO OVER",SUP-703897,CDM,S27200284,LOCAL,0272,RC,,,both,,,1068.23,320.47,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,124.24,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,124.24,908,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX RADIANZ RADIAL PERIPHERAL SYSTEM 60MM 190CM 3.5",SUP-R51003506L,CDM,C1725,HCPCS,0272,RC,,,both,,,1971.75,591.52,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,229.31,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.31,1675.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT 137CM 10MM 3.5MM RECTANGLE HELIX TAPER",SUP-2200-3510,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"MULTIPLAN [10600]",Multiplan,,4985.25,85,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 018 130CM 2CM 4MM BALLOON DILATATION",SUP-U813042,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE PLIAFORM STARCAST 80CM 14CM 12MM BALLOON",SUP-G52383,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"KAISER [10500]",Kaiser,,643.05,67,,,,,0,111.62,815.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE ARTHROSCOPIC GREAT WHITE STERLING 13CM 4.2MM",SUP-9299A,CDM,S27200284,LOCAL,0272,RC,,,both,,,490.21,147.06,"UHC [10700]","United Healthcare",,310.3,63.3,,,,,0,57.01,416.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 135CM 80MM 3.8FR 7MM BALLOON DILATATION PEBAX",SUP-H74939032708010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH VASCUTRAK 140CM 15CM 5MM BALLOON DILATATION HYDROPHILIC",SUP-V1850150,CDM,C1725,HCPCS,0272,RC,,,both,,,5485.50,1645.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3730.14,68,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE 100 MEQ SODIUM 3 MEQ POTASSIUM 2.25 MEQ",SUP-08-3231-1,CDM,S27200284,LOCAL,0272,RC,,,both,,,44.59,13.38,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,30.32,68,,,,,0,5.19,37.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 40CM 40MM 10MM .035IN BALLOON DILATATION NYBAX",SUP-39171-10044,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"MULTIPLAN [10600]",Multiplan,,998.33,85,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 150CM 2CM 6MM BALLOON DILATATION ILIAC",SUP-G34333,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRODE BIPOLAR CUTTING LOOP THICK 26 FR SQUARE FITTING",SUP-MV2S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2250.00,675,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,261.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 1.5MM X 14MM TI",SUP-VAN-15140-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"CIGNA [10200]","Cigna Open Access",,553.07,56.9,,1144.80,304.56,2275.09,66,113.04,826.2,"percent of total billed charges",
"CATH STERLING 80CM 40MM 3.8FR 4MM BALLOON DILATATION OTW",SUP-39032-40408,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,174.28,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 135CM 80MM 4MM BALLOON DILATATION HYDROPHILIC",SUP-604008022,CDM,C1725,HCPCS,0272,RC,,,both,,,729.00,218.7,"NOVANET [10819]",Novanet,,546.75,75,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE 035 GEOALIGN 130CM 80MM 9MM BALLOON",SUP-U3513098,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"UHC [10700]","United Healthcare",,435.82,63.3,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDDICK 50CM 4FR CHOLANGIOGRAM CYSTIC DUCT SCOOP TIP",SUP-E2400-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,897.97,269.39,"KAISER [10500]",Kaiser,,601.64,67,,,,,0,104.43,763.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 100MM 5FR 6MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206061010,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"NOVANET [10819]",Novanet,,486,75,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"2/0 CARDIOXYL NO PLEDGET 25MM",SUP-73P30AH,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.78,140.33,"KAISER [10500]",Kaiser,,313.41,67,,,,,0,54.4,397.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 0 CT-2 27IN MONOFILAMENT VIOLET ABSORBABLE",SUP-Z334H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA [10200]","Cigna Local Plus",,13.91,53.5,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CARDIOXYL PLEDGET TD3X7",SUP-73P30F,CDM,S27200284,LOCAL,0272,RC,,,both,,,922.73,276.82,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,423.53,45.9,,,,,0,107.31,784.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MUSTANG 135CM 60MM 8MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171080610,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"MULTIPLAN [10600]",Multiplan,,998.33,85,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 250MM 2.5MM BALLOON DILATATION",SUP-48002525S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,565.95,41.1,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH Z-MED II 100CM 6CM 25MM .035IN BALLOON DILATATION",SUP-611479,CDM,C1725,HCPCS,0272,RC,,,both,,,5318.04,1595.41,"KAISER [10500]",Kaiser,,3563.09,67,,,,,0,618.49,4520.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) TF (-T) LOADING SYSTEM INTPD-TF-LS",SUP-INTPD-TF-LS,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 20MM 2MM BALLOON DILATATION OTW STERILE",SUP-582002022,CDM,C1725,HCPCS,0272,RC,,,both,,,1498.50,449.55,"UHC [10700]","United Healthcare",,948.55,63.3,,,,,0,174.28,1273.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 4FR 100CM TRIFORCE FLEXOR PEEL-AWAY STRAIGHT CURVE",SUP-G56418,CDM,S27200284,LOCAL,0272,RC,,,both,,,2711.18,813.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1114.29,41.1,,,,,0,315.31,2304.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ASPIRATION ANTICOAGULATION LINE ELECTA ESSENTIAL CONCEPT",SUP-AAL,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"PHCS [10601]",PHCS,,158.34,70,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PENCIL SMOKE EVAC 70MM NEPTUNE ROCKER SWITCH COATED SUCTION",SUP-0703-047-000,CDM,S27200284,LOCAL,0272,RC,,,both,,,243.60,73.08,"PHCS [10601]",PHCS,,170.52,70,,,,,0,28.33,207.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 THK7MM NARROW KNEE LEFT RIGHT POSTERIOR",SUP-TPS-030-073N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,550.8,68,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRASCORE GEOALIGN 130CM 150MM 6MM BALLOON DILATATION",SUP-US35130615,CDM,C1725,HCPCS,0272,RC,,,both,,,8280.00,2484,"UHC [10700]","United Healthcare",,5241.24,63.3,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 6MM 3.25MM ULTRA LOW PROFILE BALLOON",SUP-1012275-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"PHCS [10601]",PHCS,,453.6,70,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 28MM RIGID SADDLE SUT CUFF TITANIUM",SUP-RSAR-28,CDM,S27800098,LOCAL,0278,RC,,,both,,,14801.54,4440.46,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6083.43,41.1,,,,,0,1721.42,12581.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC EVOLUT FX 29MM",SUP-EVOLUTFX-29,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CIGNA [10200]",Cigna,,68400,40,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TRUE FLOW 110CM 3.5CM 18MM 11FR PERFUSION VALVULOPLASTY",SUP-TF0183511,CDM,C1725,HCPCS,0272,RC,,,both,,,11730.00,3519,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7976.4,68,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AGENT HEMOSTATIC 2 POUCH PACK 1 LAPAROSCOPIC TIP PVC DEHP",SUP-PCET038,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.44,52.33,"MULTIPLAN [10600]",Multiplan,,148.27,85,,,,,0,20.29,148.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.75MM 15MM COMPREHENSIVE 3.5MM SHOULDER VARIABLE",SUP-180557,CDM,C1713,HCPCS,0278,RC,,,both,,,1556.00,466.8,"BLUE CROSS [10001]","Blue Cross PPO",,609.95,39.2,,957.42,570.23,957.42,28,180.96,1322.6,"percent of total billed charges",
"SPECLM OPHTHALMIC 1.5IN DULL FINISH BARRAQUER 14MM ADULT",SUP-E4106,CDM,S27200284,LOCAL,0272,RC,,,both,,,252.91,75.87,"AETNA [10100]","Aetna HMO/PPO",,201.06,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,29.41,214.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC THK12MM 51X74MM GALLANT HF IS-1 IS-4 DF-4 CNCT",SUP-CDHFA500Q,CDM,C1882,HCPCS,0278,RC,,,both,,,76950.00,23085,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,9118.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8949.29,65407.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 13CM MIDAS REX MR8 3MM MATCH HEAD DISSECTING ND STERILE",SUP-MR8-ND13MH30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"UHC [10700]","United Healthcare",,1746.61,63.3,,,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 19MM 90CM 5MM BILIARY STAINLESS",SUP-H74937912519900,CDM,C1876,HCPCS,0278,RC,,,both,,,3967.50,1190.25,"KAISER [10500]",Kaiser,,2658.23,67,,,,,0,461.42,3372.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT ARTICULAR 5-6 11MM KNEE CONSTRAIN LOCK GENESIS II",SUP-71934385,CDM,C1776,HCPCS,0278,RC,,,both,,,19429.20,5828.76,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5245.88,27,,,,,0,2259.62,16514.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS",RX-15981,CDM,J1250,HCPCS,0636,RC,00409-2346-31,NDC,both,250,ML,157.30,47.19,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8.25,,,,,,,6.7,133.71,"fee schedule",
"VITOSS BIMODAL FOAM PACK 10CC",SUP-2102-1910,CDM,C1713,HCPCS,0278,RC,,,both,,,21154.77,6346.43,"NOVANET [10819]",Novanet,,15866.08,75,,,,,0,2460.3,17981.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 32CM 10MM .021-.027IN AZUR CX HYDROCOIL",SUP-45-781032,CDM,S27800098,LOCAL,0278,RC,,,both,,,5278.50,1583.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,625.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,613.89,4486.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS",870,MS-DRG,,,,,,,inpatient,,,172930.99,51879.3,"BLUE CROSS [10001]","Blue Cross PPO",,170631.95,,,,,,,10994,172373.38,"case rate",
"WEDGE TIBIAL 10MM LEGION 3-4 HEMI KNEE LEFT MEDIAL RIGHT",SUP-71423034,CDM,C1776,HCPCS,0278,RC,,,both,,,15245.55,4573.66,"AETNA [10100]","Aetna HMO/PPO",,12120.21,79.5,,10981.53,8986.79,12413.38,12,1773.06,12958.72,"percent of total billed charges",
"PACK SUT 1.5MM BROADBAND TAPE BLACK BLUE",SUP-CM0322,CDM,S27200284,LOCAL,0272,RC,,,both,,,631.80,189.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,429.62,68,,,,,0,73.48,537.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYPROPYLENE CAPIO TAPERCUT 0 36IN 2 ARM MONOFILAMENT",SUP-M0068331241,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"AETNA [10100]","Aetna HMO/PPO",,345.83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 30CM 4.8FR PIGTAIL CURVE URETERAL PERCUFLEX PLUS",SUP-M0061752550,CDM,C2617,HCPCS,0278,RC,,,both,,,902.18,270.65,"BLUE CROSS [10001]","Blue Cross PPO",,353.65,39.2,,,,,0,104.92,766.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 60MM STARDRIVE STAINLESS STEEL T8 METAPHYSEAL",SUP-02.118.560,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"CIGNA [10200]",Cigna,,356.26,68,,1831.33,1831.33,1831.33,16,60.93,445.32,"percent of total billed charges",
"SABER .035 4X80 135CM SL",SUP-48004008R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"KAISER [10500]",Kaiser,,575.54,67,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 63MM STAINLESS STEEL 2.4MM SCR 6X4 HOLES 2",SUP-02.111.540,CDM,C1713,HCPCS,0278,RC,,,both,,,4041.68,1212.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1156.73,28.62,,,,,0,470.05,3435.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 20MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDS32520,CDM,C1874,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"BLUE CROSS [10001]","Blue Cross PPO",,32545.69,39.2,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CELSIUS REDEL 115CM 4MM 7FR 2-5-2MM SPACE B CURVE",SUP-D7BTCBL252RT,CDM,C1733,HCPCS,0272,RC,,,both,,,4961.10,1488.33,"AMERIGROUP MEDICAID [20100]",Amerigroup,,587.89,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,576.98,4216.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 CURVE PLUS 17.5MM KNEE XLK FIX BEARING",SUP-970424,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7598.69,68,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET ADMIN 120IN 60 GTT/ML 25ML INTRAVENOUS ULTRASITE SPIN",SUP-375040,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.36,18.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,24.81,41.1,,,,,0,7.02,51.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 55MMX2.59MM TITANIUM THIN VASCULAR TISSUE 4",SUP-TVC55,CDM,S27200284,LOCAL,0272,RC,,,both,,,2010.80,603.24,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,233.86,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,233.86,1709.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 10X80 135CM SL",SUP-48010008R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"KAISER [10500]",Kaiser,,575.54,67,,,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX PROGRIP 5.5X3.5IN RIGHT FLAP SELF FIX",SUP-TEM1409GR,CDM,C1781,HCPCS,0278,RC,,,both,,,1948.20,584.46,"BLUE CROSS [10001]","Blue Cross PPO",,763.69,39.2,,,,,0,226.58,1655.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EVERCROSS 135CM 100MM 7MM .035IN BALLOON DILATATION",SUP-AB35W07100135,CDM,C1725,HCPCS,0272,RC,,,both,,,677.16,203.15,"KAISER [10500]",Kaiser,,453.7,67,,,,,0,78.75,575.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ADVANCE 35LP 80CM 10CM 6FR 8MM .035IN BALLOON",SUP-G52362,CDM,C1725,HCPCS,0272,RC,,,both,,,959.77,287.93,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) SELUTION DEB 2.50X40",SUP-SCA14U-250040D,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MINI TREK 145CM 25MM 2MM ULTRA LOW PROFILE BALLOON",SUP-1012270-25,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"VIABAHN BX BALLOON EXP ENDO 8MMX39MM 7FR 135CMCATH HEPARIN",SUP-BXBL083902A,CDM,C1874,HCPCS,0278,RC,,,both,,,19504.80,5851.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7801.92,40,,,,,0,2268.41,16579.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12.5X15X9MM ADVANCED PARALLEL TRAPEZOIDAL",SUP-7609,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"AETNA [10100]","Aetna HMO/PPO",,6582.6,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL H+6/33MM 36MM ARTHREX SHOULDER COMBO STERILE",SUP-AR-9503-3633-6,CDM,C1776,HCPCS,0278,RC,,,both,,,4305.60,1291.68,"AMERIGROUP MEDICAID [20100]",Amerigroup,,510.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,500.74,3659.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 30MM TRI-AD 2 ADAM TRICUSPID VALVE MODEL",SUP-900SFC230,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"FIRST HEALTH [10303]","First Health",,10488,80,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BODY CONE 23MM 23MM RESTORATION +0MM STD HIP MODULAR",SUP-6276-1-023,CDM,C1776,HCPCS,0278,RC,,,both,,,22254.75,6676.42,"AETNA [10100]","Aetna HMO/PPO",,17692.53,79.5,,10981.53,8986.79,12413.38,12,2588.23,18916.54,"percent of total billed charges",
"BUR SURGICAL DIA4MM STAINLESS STEEL EGG 10 FLUTE",SUP-1607002035,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD EXTERNAL FIXATION 400MM 11MM HOFFMANN 3 VECTRAN CARBON",SUP-4922-8-400,CDM,C1713,HCPCS,0278,RC,,,both,,,3401.70,1020.51,"BLUE CROSS [10001]","Blue Cross HMO",,1333.47,39.2,,957.42,156.86,7483.26,51,395.62,2891.45,"percent of total billed charges",
"DEVICE ATRICLIP 45D 45MM 6CM CLSR NITINOL TITANIUM POLYESTER",SUP-ACH245,CDM,S27800098,LOCAL,0278,RC,,,both,,,8245.50,2473.65,"FIRST HEALTH [10303]","First Health",,6596.4,80,,,,,0,958.95,7008.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +28 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.280,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GYNECARE TVT OBTURATOR SYSTEM (SINGLE USE DEVICE)",SUP-810081,CDM,C1771,HCPCS,0278,RC,,,both,,,8539.72,2561.92,"BLUE CROSS [10001]","Blue Cross PPO",,3347.57,39.2,,,,,0,993.17,7258.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COENZYME Q10  50 MG CAPSULE",RX-35228,CDM,,,0637,RC,40093-0102-32,NDC,both,1,UN,6.27,1.88,"AETNA [10100]","Aetna HMO/PPO",,4.98,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 35MM RELINE-O SPINE POLYAXIAL TRACTION",SUP-13117535,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,3978.14,359.25,3978.14,24,641.98,4692,"percent of total billed charges",
"GRAFT SOFT TISSUE 5X4IN DURAGEN CRANIUM BOVINE CLLGN MATRIX",SUP-ID4501,CDM,,,0278,RC,,,both,,,10871.57,3261.47,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,10.87,.1,,,,,0,10.87,9240.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 3.5 X 6 HELICAL PICO COIL",SUP-10USH03506,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"CIGNA [10200]",Cigna,,4689.24,40,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE CONNECTING 30CM Y FLEXIBLE KINK RESISTANT FEMALE LUER",SUP-M0067401020,CDM,S27200284,LOCAL,0272,RC,,,both,,,139.37,41.81,"NOVANET [10819]",Novanet,,104.53,75,,,,,0,16.21,118.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SPEAKING AQUA 22MM 15MM PMV LOW PROFILE TRACHEA RUBBER",SUP-PMV007,CDM,S27000186,LOCAL,0270,RC,,,both,,,909.87,272.96,"CIGNA [10200]","Cigna Open Access",,517.72,56.9,,,,,0,105.82,773.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309011,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"UHC [10700]","United Healthcare",,23903.47,63.3,,8601.07,8395.67,8601.07,"1 through 10",4391.74,32097.87,"percent of total billed charges",
"AVENIR 10, 3.5 X 6 HELICAL PICO COIL",SUP-10USH03506,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3355.15,28.62,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 1MM CEREPAK MINI FREEFORM DETACHABLE",SUP-MCR091040,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA [10200]","Cigna Local Plus",,4166.14,31.5,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STNT WALLFLEX 6CM 230CM 22-27",SUP-6501,CDM,S27000186,LOCAL,0270,RC,,,both,,,348.00,104.4,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,159.73,45.9,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUDEOXYGLUCOSE F-18 20 MCI TO 300 MCI/ML INTRAVENOUS SOLUTION",RX-164696,CDM,A9552,HCPCS,0343,RC,08888-8878-25,NDC,both,1,UN,755.00,226.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,755,,,,,,,87.81,755,"fee schedule",
"CATH LUTONIX ULTRAVERSE 130CM 220MM 7MM BALLOON DILATATION",SUP-LX1813072205F,CDM,C2623,HCPCS,0272,RC,,,both,,,12075.00,3622.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4962.83,41.1,,,,,0,1404.32,10263.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 194MM 12MM COMPREHENSIVE POROUS SHOULDER",SUP-113672,CDM,C1776,HCPCS,0278,RC,,,both,,,17863.20,5358.96,"CIGNA [10200]","Cigna Open Access",,5984.17,33.5,,5302.19,4377.88,6578.61,27,2077.49,15183.72,"percent of total billed charges",
"PRIMARY REVERSE SHOULDER CONSTRUCT",SUP-CAP-D-CONALTIVATESHOULDER,CDM,C1776,HCPCS,0278,RC,,,both,,,49140.00,14742,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,19656,40,,,,,0,5714.98,41769,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL LEGION GENESIS II 7 KNEE RIGHT CEMENTED MALE",SUP-71420190,CDM,C1776,HCPCS,0278,RC,,,both,,,14593.50,4378.05,"FIRST HEALTH [10303]","First Health",,11674.8,80,,,,,0,1697.22,12404.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WIRE FIXATION 2.8MM 200MM 25MM LCP ANKLE COMPRESSION THREAD",SUP-03.118.025,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"FIRST HEALTH [10303]","First Health",,348,80,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 55MM 16MM STAINLESS STEEL FEMORAL CANNULATED",SUP-208.855,CDM,C1713,HCPCS,0278,RC,,,both,,,1374.41,412.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,393.36,28.62,,,,,0,159.84,1168.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ZIDOVUDINE 10 MG/ML ORAL SYRUP",RX-11693,CDM,,,0250,RC,08888-8883-21,NDC,both,10,ML,14.78,4.43,"CIGNA [10200]","Cigna Local Plus",,7.91,53.5,,,,,0,1.72,12.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 40MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520040S,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,185.58,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 3.5MM X 15.0MM",SUP-493501512,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"UHC [10700]","United Healthcare",,512.73,63.3,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2.5CM 2.5MM CEREPAK XTRASOFT FREEFORM",SUP-XCR122525,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"MULTIPLAN [10600]",Multiplan,,11241.97,85,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TRANSITION VENTILATOR NASAL INTERFACE HIGH FLOW XL OPTIF",SUP-OJR418VT,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"NOVANET [10819]",Novanet,,326.25,75,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 12MM 5MM INTRACRANIAL FLOW DIVERTER",SUP-FDS50012,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"CIGNA [10200]","Cigna Open Access",,27813.28,33.5,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 9CM 10FR PROXIMAL BEND BILIARY 2 LAYER STERILE",SUP-PBD-421-1009,CDM,C1876,HCPCS,0278,RC,,,both,,,1387.85,416.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,164.46,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,161.41,1179.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GUIDER SOFTIP XF 90CM 8FR MP CURVE GUIDING DURAFORM",SUP-H965100480,CDM,S27200284,LOCAL,0272,RC,,,both,,,2503.13,750.94,"UHC [10700]","United Healthcare",,1584.48,63.3,,,,,0,291.11,2127.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 2 SWIVELOCK C KNOTLESS CLOSED EYELET TWIST IN",SUP-AR-2323KBCC,CDM,C1713,HCPCS,0278,RC,,,both,,,3622.50,1086.75,"PHCS [10601]",PHCS,,2535.75,70,,,,,0,421.3,3079.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS DIRECT PL SITEMARK 51CM 47CM 9FR 7FR 135D GUIDING",SUP-410173,CDM,C1887,HCPCS,0272,RC,,,both,,,3712.50,1113.75,"AETNA [10100]","Aetna HMO/PPO",,2951.44,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN BUTTON 12MM 5CM PASSPORT BUTTON SILICONE CURVE HIP 1",SUP-AR-6592-12-50,CDM,S27200284,LOCAL,0272,RC,,,both,,,510.30,153.09,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,209.73,41.1,,,,,0,59.35,433.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STAPLE BONE 10X10MM FUSEFORCE 2MM FOREFOOT MIDFOOT REARFOOT",SUP-FFS1010,CDM,C1713,HCPCS,0278,RC,,,both,,,5582.10,1674.63,"CIGNA [10200]","Cigna Local Plus",,2986.42,53.5,,3978.14,359.25,3978.14,24,649.2,4744.79,"percent of total billed charges",
"REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION",RX-225383,CDM,J0248,HCPCS,0636,RC,61958-2901-02,NDC,both,1,UN,2615.60,784.68,"BLUE CROSS [10001]","Blue Cross HMO",,784.38,,,,,,,622.5,2223.26,"fee schedule",
"INTRO SHEATH 12.5FR .164IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1012.5,CDM,C1892,HCPCS,0272,RC,,,both,,,304.50,91.35,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,35.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PORT STRAIGHT RETRACTION 40MM MARS 26MM",SUP-632.464S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2880.00,864,"NOVANET [10819]",Novanet,,2160,75,,,,,0,334.94,2448,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE TIBIAL 29MM ATTUNE KNEE POROCOAT REVISION FULL COAT",SUP-1511-11-201,CDM,C1776,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,8601.07,8395.67,8601.07,"1 through 10",2014.9,14726.25,"percent of total billed charges",
"BODY CONE 19MM RESTORATION +30MM HIP MODULAR",SUP-6276-1-319,CDM,C1776,HCPCS,0278,RC,,,both,,,14466.82,4340.05,"CIGNA [10200]","Cigna Local Plus",,4557.05,31.5,,5372.07,4581.20,7242.98,23,1682.49,12296.8,"percent of total billed charges",
"SOL INTRAVENOUS 500ML 20% MANNITOL PLASTIC FLEXIBLE CNTNR",SUP-771503,CDM,S27200284,LOCAL,0272,RC,,,both,,,145.55,43.66,"CIGNA [10200]",Cigna,,98.97,68,,,,,0,16.93,123.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 28CM 3CM 8FR .038IN STRAIGHT URETERAL",SUP-M006180244010,CDM,C2617,HCPCS,0278,RC,,,both,,,1070.74,321.22,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,306.45,28.62,,,,,0,124.53,910.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 2MM SPACE A CURVE ELECTROPHYSIOLOGY",SUP-1086259RT,CDM,C1730,HCPCS,0272,RC,,,both,,,1458.00,437.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,169.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) OPTIMAP CATHETER GEN 1B",SUP-OPTI-CATH-60,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL ULTRA MICRO RING ROUND HANDLE 8.25IN",SUP-55-9056T,CDM,S27200284,LOCAL,0272,RC,,,both,,,2741.85,822.55,"CIGNA [10200]","Cigna Local Plus",,1466.89,53.5,,,,,0,318.88,2330.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE TRANSEND VASCULAR 190CM 2CM .014IN SCITANIUM ICE",SUP-M001468010,CDM,C1769,HCPCS,0272,RC,,,both,,,2062.50,618.75,"KAISER [10500]",Kaiser,,1381.88,67,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cmv Dna Ampl Prob Igm/Igg",PX-306000125,CDM,87496,CPT,0306,RC,,,both,,,877.50,263.25,"CIGNA [10200]",Cigna,,77.2,,,,,,,0.01,745.88,"fee schedule",
"SCR BONE 3.5MM 12MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0257,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"AMERIGROUP MEDICAID [20100]",Amerigroup,,112.3,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",110.22,805.55,"percent of total billed charges",
"TFAT00 AS UVA PANOPTIX",SUP-TFAT00,CDM,V2788,HCPCS,0276,RC,,,both,,,845.00,253.5,"CIGNA [10200]","Cigna Open Access",,480.81,56.9,,,,,0,98.27,718.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Barbiturate Confirmation",PX-301000508,CDM,80345,CPT,0301,RC,,,both,,,176.00,52.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,176,,,,,,,0.01,176,"fee schedule",
"NDL BIOPSY 18GA 20CM SUPERCORE COAXIAL SEMIAUTOMATIC",SUP-701118200,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.65,103.09,"CIGNA [10200]","Cigna Local Plus",,183.85,53.5,,,,,0,39.97,292.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +29.5 DIOPTER MODIFY C BICONVEX 13MM 6MM 1 PIECE",SUP-DCB0000295,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,557.69,45.9,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 28MM REVISION MODULAR RESTORATION PUREFIX",SUP-6276-7-228,CDM,C1776,HCPCS,0278,RC,,,both,,,17822.70,5346.81,"CIGNA [10200]","Cigna Local Plus",,5614.15,31.5,,5372.07,4581.20,7242.98,23,2072.78,15149.3,"percent of total billed charges",
"CATH URETHRAL BARDEX IC 22FR FOLEY 2 WAY COUNCIL TIP 2",SUP-0196SI22,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.25,42.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,16.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.54,120.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL SMALL 65X55MM KNEE LEFT MODULAR ROTATE HINGE",SUP-64811110,CDM,C1776,HCPCS,0278,RC,,,both,,,25203.15,7560.94,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6804.85,27,,,,,0,2931.13,21422.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE NEUTRAL 46MM 28MM MARATHON HIP",SUP-121928046,CDM,C1776,HCPCS,0278,RC,,,both,,,8328.30,2498.49,"UHC [10700]","United Healthcare",,5271.81,63.3,,8601.07,8395.67,8601.07,"1 through 10",968.58,7079.06,"percent of total billed charges",
"TISSUE REGENEATION GRAFT 2CM X 3CM",SUP-GS-5230,CDM,Q4186,HCPCS,0636,RC,,,both,,,8252.40,2475.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,406.44,,,,,,,406.44,7014.54,"fee schedule",
"VALVE BIOPSY 7MM BRONCHIAL",SUP-HU-VS-7,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"FIRST HEALTH [10303]","First Health",,13860,80,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 NARROW KNEE RIGHT CRUCIATE RETAIN PERSONA",SUP-42508006002,CDM,C1776,HCPCS,0278,RC,,,both,,,26238.24,7871.47,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,10495.3,40,,,,,0,3051.51,22302.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOTHYROXINE 88 MCG TABLET",RX-10403,CDM,,,0637,RC,60687-0486-11,NDC,both,1,UN,6.27,1.88,"KAISER [10500]",Kaiser,,4.2,67,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM EXT 30MM 15MM NEXGEN FEMORAL KNEE TIVANIUM ALLOY",SUP-00598801215,CDM,C1776,HCPCS,0278,RC,,,both,,,4909.80,1472.94,"NOVANET [10819]",Novanet,,3682.35,75,,,,,0,571.01,4173.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 45MM REVERE TITANIUM SPINE PEDICLE POLYAXIAL",SUP-124.465,CDM,C1713,HCPCS,0278,RC,,,both,,,4842.60,1452.78,"FIRST HEALTH [10303]","First Health",,3874.08,80,,,,,0,563.19,4116.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 74MM PRESS FIT AEQUALIS ASCEND FLEX PTC 127.5D",SUP-DWF603A,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"MULTIPLAN [10600]",Multiplan,,10710,85,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL STD 32MM HIP MODULAR BIOLOX DELTA",SUP-12-115115,CDM,C1776,HCPCS,0278,RC,,,both,,,34083.00,10224.9,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9754.55,28.62,,,,,0,3963.85,28970.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 3X3CM AMINOFIX",SUP-AAS-5330,CDM,Q4433,HCPCS,0636,RC,,,both,,,7396.80,2219.04,"AETNA [10100]","Aetna HMO/PPO",,5880.46,79.5,,,,,0,247.92,6287.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 18.5X10MM MICRO 100 MICROPOWER THK.4MM STRAIGHT",SUP-502316300,CDM,S27200284,LOCAL,0272,RC,,,both,,,177.65,53.29,"CIGNA [10200]","Cigna Open Access",,101.08,56.9,,,,,0,20.66,151,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS BLOCK ALLOGRAFT 8MM",SUP-290841,CDM,S27800098,LOCAL,0278,RC,,,both,,,3839.85,1151.95,"MULTIPLAN [10600]",Multiplan,,3263.87,85,,,,,0,446.57,3263.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 75CM 8.6FR HELIX VENTRICLE 1 COIL ACTIVE",SUP-693575,CDM,C1777,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"KAISER [10500]",Kaiser,,11505.24,67,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 12X15MM FORTIFY 0D 12MM NO SPIKE NONSTERILE",SUP-151.001,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"CIGNA [10200]",Cigna,,12839.4,40,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE COALITION AGX 7D ALLOGRAFT 8X14X7MM",SUP-8128.1277S,CDM,S27800098,LOCAL,0278,RC,,,both,,,5520.00,1656,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,654.12,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,641.98,4692,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PUNCH SURGICAL 8.5MM BARRON CORNEA VACCUM DONOR CORNEA",SUP-K20-2080,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,62.17,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 18MM TITANIUM STERNAL SELF DRILLING NONSTERILE",SUP-04.501.118.01,CDM,C1713,HCPCS,0278,RC,,,both,,,1833.00,549.9,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,841.35,45.9,,,,,0,213.18,1558.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"APPL INTERNAL CLIP MEDIUM 23.8CM MULTIPLE OPEN LIGATE",SUP-MSM20,CDM,S27200284,LOCAL,0272,RC,,,both,,,1092.07,327.62,"CIGNA [10200]","Cigna Local Plus",,584.26,53.5,,,,,0,127.01,928.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 113MM TYPE 1 TAPERLOC MICROPLASTY PPS 133D 14",SUP-51106140,CDM,C1776,HCPCS,0278,RC,,,both,,,27435.24,8230.57,"BLUE CROSS [10001]","Blue Cross HMO",,10754.61,39.2,,5311.50,4717.44,5388.59,31,3190.72,23319.95,"percent of total billed charges",
"VALVE MITRAL 27MM 24.2MM MECHANICAL ROTATABLE STD CUFF",SUP-27MHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"BLUE CROSS [10001]","Blue Cross PPO",,11414.74,39.2,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 11MM KNEE X3 TOTAL STABILIZED PLUS TRIATHLON",SUP-5537-G-511,CDM,C1776,HCPCS,0278,RC,,,both,,,9830.52,2949.16,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2813.49,28.62,,,,,0,1143.29,8355.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 30CM 8MM THORACIC AORTA WOVEN EXCLUSIVE",SUP-IGW0008-30,CDM,C1768,HCPCS,0278,RC,,,both,,,2830.73,849.22,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,335.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,329.21,2406.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Coll Cap Blood Specimen",PX-300000011,CDM,36416,CPT,0300,RC,,,both,,,28.60,8.58,"UHC [10700]","United Healthcare",,7.96,,,,,,,0.01,24.31,"fee schedule",
"FRCP LAPAROSCOPIC 2 ACTION ROTATE RATCHET HANDLE 32CM 5MM",SUP-97-1089RC,CDM,S27200284,LOCAL,0272,RC,,,both,,,3597.53,1079.26,"CIGNA [10200]","Cigna Local Plus",,1924.68,53.5,,,,,0,418.39,3057.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10 5 X 10 COMPLEX FINISHING COIL",SUP-10CFN-05010,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"MULTIPLAN [10600]",Multiplan,,9964.64,85,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL XS UNIVERSAL 16MM KNEE COCR POLYETHYLENE",SUP-198727116,CDM,C1776,HCPCS,0278,RC,,,both,,,29546.37,8863.91,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,12143.56,41.1,,6417.48,6417.48,6417.48,"1 through 10",3436.24,25114.41,"percent of total billed charges",
"GWIRE PT GRAPHIX VASCULAR STRAIGHT INTERMEDIATE 300CM .014IN",SUP-H74914914011,CDM,C1769,HCPCS,0272,RC,,,both,,,567.00,170.1,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,233.04,41.1,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X3.1-6MM ROI-C VERTEBRIDGE 7D 12MM LORDOTIC","SUP-MC 1442 P",CDM,S27800098,LOCAL,0278,RC,,,both,,,18000.00,5400,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2133,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2093.4,15300,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION",RX-20954,CDM,J1955,HCPCS,0636,RC,00517-1045-01,NDC,both,5,ML,323.18,96.95,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,45.38,,,,,,,8.03,274.7,"fee schedule",
"COIL EMBOLIZATION 10CM 5MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR180510,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA [10200]","Cigna Open Access",,3980.4,33.5,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 20MM REVISION 20 GRIT BLAST SURFACE",SUP-197620140,CDM,C1776,HCPCS,0278,RC,,,both,,,17952.48,5385.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2127.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,2087.87,15259.61,"percent of total billed charges",
"SENSOR FLOW CALIBRATION ADPTR CNCT 188CM 15MM 22MM",SUP-281637,CDM,S27000186,LOCAL,0270,RC,,,both,,,121.81,36.54,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,82.83,68,,,,,0,14.17,103.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SAPPHIRE NC24 NON-COMPLIANT RX PTCA BALLOON 5.0MM X 10.0MM",SUP-495001012,CDM,C1725,HCPCS,0272,RC,,,both,,,810.00,243,"AMERIGROUP MEDICAID [20100]",Amerigroup,,95.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Excsn Skin Lesn Tr/Ext 1.1-2cm",PX-510000028,CDM,11402,CPT,0761,RC,,,both,,,4138.00,1241.4,"KAISER [10500]",Kaiser,,2772.46,67,,,,,0,481.25,3517.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ivus/Oct Hrt Ea Vssl Addl",PX-480000069,CDM,92979,CPT,0481,RC,,,both,,,9804.04,2941.21,"FIRST HEALTH [10303]","First Health",,7843.23,80,,,,,0,1140.21,8333.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION",RX-225383,CDM,J0248,HCPCS,0636,RC,61958-2901-02,NDC,both,1,UN,2615.60,784.68,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1778.61,68,,,,,0,622.5,2223.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EPISTAXIS WITH MCC",150,MS-DRG,,,,,,,inpatient,,,48475.86,14542.76,"BLUE CROSS [10001]","Blue Cross PPO",,32870.81,,,,,,,7561,33206.28,"case rate",
"MESH HERNIA POLYPROPYLENE 30X25CM PERMANENT 8 LAYER DEVICE 2",SUP-F10248-2530P,CDM,C1781,HCPCS,0278,RC,,,both,,,68172.00,20451.6,"AETNA [10100]","Aetna HMO/PPO",,54196.74,79.5,,,,,0,7928.4,57946.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTON PLUS DEMINERALIZED BONE MATRIX 10ML PASTE",SUP-T45010,CDM,C1713,HCPCS,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]","Cigna Open Access",,3533.49,56.9,,1144.80,304.56,2275.09,66,722.22,5278.5,"percent of total billed charges",
"CATH COYOTE 150CM 150MM 2.5MM BALLOON DILATATION NYBAX",SUP-H74939186251510,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 12FR FEEDING REPLACEMENT STRAIGHT BOLST GASTRO ENDOVIVE",SUP-M00509881,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.82,72.25,"MULTIPLAN [10600]",Multiplan,,204.7,85,,,,,0,28.01,204.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR",SUP-SSR10-01,CDM,A4648,HCPCS,0278,RC,,,both,,,3740.00,1122,"BLUE CROSS [10001]","Blue Cross HMO",,1466.08,39.2,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 11CM 24MM 33MM 21.4MM GELWEAVE VALSALVA ON-X",SUP-ONXAAP-23,CDM,S27800098,LOCAL,0278,RC,,,both,,,51187.50,15356.25,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13820.63,27,,,,,0,5953.11,43509.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPYSCOPE DSII DIGITAL ACCESS",SUP-M00546610,CDM,S27200284,LOCAL,0272,RC,,,both,,,16905.00,5071.5,"PHCS [10601]",PHCS,,11833.5,70,,,,,0,1966.05,14369.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT 22CM 10FR PIGTAIL CURVE NEPHROURETERAL PERCUFLEX METAL",SUP-M001221400,CDM,C2617,HCPCS,0278,RC,,,both,,,891.00,267.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,255,28.62,,,,,0,103.62,757.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIPHENHYDRAMINE 25 MG TABLET",RX-2505,CDM,,,0637,RC,68094-0018-59,NDC,both,1,UN,6.27,1.88,"MULTIPLAN [10600]",Multiplan,,5.33,85,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 145MM PRIMARY DISTAL BULLET TIP SYNERGY",SUP-71309111,CDM,C1776,HCPCS,0278,RC,,,both,,,37762.20,11328.66,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,15104.88,40,,,,,0,4391.74,32097.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ewho Rigid W/O Jnts Cf",PX-E27400104,CDM,L3763,HCPCS,0274,RC,,,both,,,2009.70,602.91,"AMERIGROUP MEDICAID [20100]",Amerigroup,,238.15,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,233.73,1708.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +1.5MM 12/14 TAPER 36MM HIP M SPECIFICATION",SUP-1365-51-000,CDM,C1776,HCPCS,0278,RC,,,both,,,6720.60,2016.18,"KAISER [10500]",Kaiser,,4502.8,67,,,,,0,781.61,5712.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 8MM 145CM 4MM CORONARY STENT EVEROLIMUS",SUP-1145400-08,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1670.84,28.62,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER MAMMARY SALINE 375-450ML ROUND MODERATE PLUS PROFILE",SUP-351-2375SZ,CDM,S27200284,LOCAL,0272,RC,,,both,,,850.50,255.15,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRAIN SILICONE POLYMER INCISION FULL PERFORATED FLAT WOUND",SUP-00256900010,CDM,S27200284,LOCAL,0272,RC,,,both,,,121.80,36.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET EXT 1.7CM 24FR MIC-KEY SECUR-LOK ENFIT SILICONE",SUP-8140-24-1.7,CDM,S27200284,LOCAL,0272,RC,,,both,,,779.06,233.72,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE JAGWIRE ENDOSCOPIC ANGLE 450CM .035IN HIGH PERFORMANCE",SUP-M00556591,CDM,C1769,HCPCS,0272,RC,,,both,,,932.72,279.82,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Test Car Seat/Bed + 30 Min",PX-920000006,CDM,94781,CPT,0920,RC,,,both,,,230.11,69.03,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"OTHER CARDIOTHORACIC PROCEDURES WITH MCC",228,MS-DRG,,,,,,,inpatient,,,237640.85,71292.25,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 125CM 5FR FL4 CURVE ANGIOGRAPHIC FEMORAL 2 WIRE",SUP-H749163912202,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LAUNCHER 100CM 6FR AL2.5 CURVE GUIDING NYLON CORONARY",SUP-LA6AL25,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Kit Cath Drain Thoracentesis",PX-E27200149,CDM,C1729,HCPCS,0272,RC,,,both,,,363.00,108.9,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH TEMPO 65CM 4FR UNIVERSAL ANGIOGRAPHIC NEON SLX NYLON 5",SUP-451404V5,CDM,S27200284,LOCAL,0272,RC,,,both,,,104.40,31.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ATHEROSCLEROSIS WITH MCC",302,MS-DRG,,,,,,,inpatient,,,43825.96,13147.79,"FIRST HEALTH [10303]","First Health",,,80,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SPINAL 3.5IN 20GA LUMBAR PUNCTURE",SUP-26-LP1CO,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.75,30.82,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUT 2.2MM 4-0 3/8 CIRCLE MICRO FULL THREAD TAPER",SUP-AR-1318FT-40,CDM,C1713,HCPCS,0278,RC,,,both,,,2244.38,673.31,"MULTIPLAN [10600]",Multiplan,,1907.72,85,,,,,0,261.02,1907.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD HUMERAL 19MM 50MM SHOULDER AEQUALIS ASCEND FLEX COCR 4",SUP-DWF151,CDM,C1776,HCPCS,0278,RC,,,both,,,10004.00,3001.2,"MULTIPLAN [10600]",Multiplan,,8503.4,85,,,,,0,1163.47,8503.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COMP FEM N/POROUS SIZE 5 LEFT",SUP-2153-0-0005,CDM,C1776,HCPCS,0278,RC,,,both,,,8280.00,2484,"BLUE CROSS [10001]","Blue Cross HMO",,3245.76,39.2,,5311.50,4717.44,5388.59,31,962.96,7038,"percent of total billed charges",
"TROCAR SURGICAL FALLER DIALYSIS CATH",SUP-FT-1100,CDM,S27200284,LOCAL,0272,RC,,,both,,,607.50,182.25,"MULTIPLAN [10600]",Multiplan,,516.38,85,,,,,0,70.65,516.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 7MM LCP STAINLESS STEEL DISTAL RADIUS T8",SUP-212.807,CDM,C1713,HCPCS,0278,RC,,,both,,,802.87,240.86,"CIGNA [10200]","Cigna Local Plus",,429.54,53.5,,3978.14,359.25,3978.14,24,93.37,682.44,"percent of total billed charges",
"SCR BONE 4.5MM 40MM PERIPHERAL STERILE",SUP-AR-9562-40NL,CDM,C1713,HCPCS,0278,RC,,,both,,,597.38,179.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,170.97,28.62,,,,,0,69.48,507.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 40MM PRECEPT SPINE POLYAXIAL NONSTERILE",SUP-8806540A,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,641.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",641.98,4692,"percent of total billed charges",
"SCREW BONE 2.4MM 8MM TITANIUM CORTICAL HAND SELF TAPPING NON",SUP-401.508.96,CDM,C1713,HCPCS,0278,RC,,,both,,,596.48,178.94,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,170.71,28.62,,,,,0,69.37,507.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD MONOPOLAR LINA ENDOSCOPIC LOOP",SUP-EL-200-8,CDM,S27200284,LOCAL,0272,RC,,,both,,,2756.25,826.87,"AMERIGROUP MEDICAID [20100]",Amerigroup,,326.62,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,320.55,2342.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TIP APPLR 29CM PROGEL SPRAYER EXTENDED",SUP-PGEN00511,CDM,S27200284,LOCAL,0272,RC,,,both,,,2195.01,658.5,"MULTIPLAN [10600]",Multiplan,,1865.76,85,,,,,0,255.28,1865.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 10MM STAINLESS STEEL T8 ELBOW METAPHYSEAL",SUP-02.118.510,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,60.93,445.32,"percent of total billed charges",
"CAP SYSTEM PERSONA STD TKR POLYETHYLENE KNEE FEMUR PATELLA T",SUP-98000200165,CDM,C1776,HCPCS,0278,RC,,,both,,,22680.00,6804,"FIRST HEALTH [10303]","First Health",,18144,80,,,,,0,2637.68,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 23MM CHORDAL GUIDE DURAN ANCORE LATEX FREE",SUP-620RG23,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"PHCS [10601]",PHCS,,9177,70,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 9MM KNEE X3 CRUCIATE RETAINING TRIATHLON",SUP-5530P309,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"BLUE CROSS [10001]","Blue Cross PPO",,3275.51,39.2,,3949.44,3949.44,3949.44,"1 through 10",971.79,7102.52,"percent of total billed charges",
"STENT EVERFLEX ENTRUST 120MM 150CM 8MM VASCULAR NICKEL",SUP-EVD35-08-120-150,CDM,C1876,HCPCS,0278,RC,,,both,,,7665.00,2299.5,"KAISER [10500]",Kaiser,,5135.55,67,,,,,0,891.44,6515.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DICLOFENAC 1 % TOPICAL GEL",RX-100611,CDM,,,0250,RC,00067-8152-03,NDC,both,100,GR,157.25,47.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.29,133.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE 14MM 5MM EMBOLIZATION",SUP-PED2-500-14,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,33207.77,41.1,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 12X8CM AXIS TUTOPLAST DERMIS ALLOGRAFT",SUP-939812,CDM,C1762,HCPCS,0278,RC,,,both,,,21892.50,6567.75,"BLUE CROSS [10001]","Blue Cross PPO",,8581.86,39.2,,,,,0,2546.1,18608.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 32MM 5MM CORONARY STENT PLATINUM",SUP-H7493926032500,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"BLUE CROSS [10001]","Blue Cross PPO",,3651.48,39.2,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION 12IN 22FR ARTERIAL ADULT 3/8IN CNCT BLUNT TIP",SUP-77522,CDM,S27200284,LOCAL,0272,RC,,,both,,,448.00,134.4,"CIGNA [10200]",Cigna,,304.64,68,,,,,0,52.1,380.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 10IN 18MM REDUCE NECK SOL SYSTEM POROUS 12/14",SUP-157210180,CDM,C1776,HCPCS,0278,RC,,,both,,,39412.80,11823.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,4583.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4583.71,33500.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 40MM 3.5MM BALLOON DILATATION DURALYN",SUP-48003504S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"MULTIPLAN [10600]",Multiplan,,1067.18,85,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 25MM SYNFIX EVOLUTION SPINAL FINE TIP STERILE",SUP-04.835.125.02S,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"AMERIGROUP MEDICAID [20100]",Amerigroup,,191.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",188.41,1377,"percent of total billed charges",
"HC Herpes Simplex Dna Ampl Probe",PX-306000135,CDM,87529,CPT,0306,RC,,,both,,,443.65,133.09,"UHC [10700]","United Healthcare",,31.58,,,,,,,0.01,377.1,"fee schedule",
"BIT DRILL 2MM CANNULATED NONSTERILE LATEX REUSABLE",SUP-MSN10002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"NOVANET [10819]",Novanet,,1221,75,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE INSUFLOW ENDOSCOPIC GAS CONDITION PORT STERILE LATEX",SUP-6198,CDM,S27200284,LOCAL,0272,RC,,,both,,,486.00,145.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,56.52,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 45D COOLCUT STERILE ABLATOR",SUP-AR-9802M-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,931.50,279.45,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,633.42,68,,,,,0,108.33,791.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 140MM 15MM PRIMARY VERSYS TIVANIUM FIBER METAL",SUP-786201500,CDM,C1776,HCPCS,0278,RC,,,both,,,26645.22,7993.57,"CIGNA [10200]",Cigna,,10658.09,40,,5873.17,5873.17,5873.17,"1 through 10",3098.84,22648.44,"percent of total billed charges",
"GWIRE ACROBAT ENDOSCOPIC 260CM 4CM .035IN HYDROPHILIC",SUP-G34265,CDM,C1769,HCPCS,0272,RC,,,both,,,1628.00,488.4,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,189.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM 2 TWINFIX ULTRA ULTRABRAID PRELOAD COBRAID",SUP-72202613,CDM,C1713,HCPCS,0278,RC,,,both,,,2039.63,611.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,936.19,45.9,,,,,0,237.21,1733.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL MULTIPASS 3-0 PS-2 27IN MONOFILAMENT UNDYED",SUP-Y427H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,3.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD THERAPEUTIC 23X14X12.5IN COLD WRAP ON REGULAR HOSE",SUP-11-1334-9-00000,CDM,S27000187,LOCAL,0270,RC,,,both,,,224.20,67.26,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,26.57,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,26.07,190.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Drug Scrn Quan Mycophenolate",PX-301000309,CDM,80180,CPT,0301,RC,,,both,,,222.30,66.69,"NOVANET [10819]",Novanet,,166.73,75,,,,,0,0.01,188.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRSG MEDIUM CLNSR VERAFLO VAC FOAM",SUP-ULTVCL05MD.S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1015.74,304.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,417.47,41.1,,,,,0,118.13,863.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 7MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-151650907,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5395.3,41.1,,6417.48,6417.48,6417.48,"1 through 10",1526.7,11158.16,"percent of total billed charges",
"KIT CATH 7FR 65CM HICKMAN PEEL-APART 2 LUMEN LOW PROFILE",SUP-0600570,CDM,C1751,HCPCS,0272,RC,,,both,,,1385.10,415.53,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,941.87,68,,,,,0,161.09,1177.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRANSURETHRAL PROCEDURES WITHOUT CC/MCC",670,MS-DRG,,,,,,,inpatient,,,37883.74,11365.12,"PRUITT HEALTH PREMIER MEDICARE [30134]","Pruitt Health Medicare Advantage",,6244.13,,"Case rate ($6,062.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $5,629.21, add-ons for qualifying new technology services are included. If operating cost exceeds $38,668.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,807.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,636.66. The transfer operating threshold is the transfer adjustment factor * $5,629.21 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $425.60. The transfer capital threshold is the transfer adjustment factor * $425.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,6062.26,28533.25,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 90CM 300MM 2MM BALLOON DILATATION RAPID EXCHANGE",SUP-47520300S,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP POROUS COATED HIP SYSTEM WITH CERAMIC HEAD + OSS LH",SUP-98000500314,CDM,C1776,HCPCS,0278,RC,,,both,,,27720.00,8316,"AETNA [10100]","Aetna HMO/PPO",,22037.4,79.5,,10981.53,8986.79,12413.38,12,3223.84,23562,"percent of total billed charges",
"SCR BONE 4MM 34MM NAIL-EX TITANIUM FULL THREAD HUMERUS TIBIA",SUP-04.005.424,CDM,C1713,HCPCS,0278,RC,,,both,,,1156.68,347,"NOVANET [10819]",Novanet,,867.51,75,,,,,0,134.52,983.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SKIN 5X5CM ALLOPATCH HD THK.8-1.7MM THICK ACELLULAR",SUP-371505,CDM,Q4128,HCPCS,0636,RC,,,both,,,9894.26,2968.28,"PHCS [10601]",PHCS,,6925.98,70,,,,,0,80.43,8410.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE RIGHT CRUCIATE RETAIN CRUCIATE SUB",SUP-EFSRN4PR,CDM,C1776,HCPCS,0278,RC,,,both,,,13075.50,3922.65,"CIGNA [10200]","Cigna Local Plus",,4118.78,31.5,,5372.07,4581.20,7242.98,23,1520.68,11114.18,"percent of total billed charges",
"COLLAR CERVICAL PEDIATRIC 5 37-48IN",SUP-100281-000,CDM,S27000186,LOCAL,0270,RC,,,both,,,307.63,92.29,"UHC [10700]","United Healthcare",,194.73,63.3,,,,,0,35.78,261.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE CLSR 14GA 15CM SUT 1 HND",SUP-RSG-14F-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.80,52.44,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,20.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,20.33,148.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NEPHROMAX AMPLATZ 55CM 15CM 7FR 30FR 20CM BALLOON",SUP-M0062101440,CDM,C1726,HCPCS,0272,RC,,,both,,,1802.55,540.76,"AMERIGROUP MEDICAID [20100]",Amerigroup,,213.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,209.64,1532.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 5X5CM SOLID SHEET NONSTERILE LATEX FREE",SUP-PAC25,CDM,Q4201,HCPCS,0636,RC,,,both,,,7521.00,2256.3,"PHCS [10601]",PHCS,,5264.7,70,,,,,0,204.57,6392.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH 60CM 2FR 4.5MM EMBOLECTOMY .5ML 1 LUMEN BALLOON LATEX",SUP-E1601-26,CDM,C1757,HCPCS,0272,RC,,,both,,,599.40,179.82,"PHCS [10601]",PHCS,,419.58,70,,,,,0,69.71,509.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT TIBIAL PERSONA 0D G KNEE RIGHT CEMENT KEEL",SUP-42536007902,CDM,C1776,HCPCS,0278,RC,,,both,,,10619.10,3185.73,"BLUE CROSS [10001]","Blue Cross HMO",,4162.69,39.2,,5311.50,4717.44,5388.59,31,1235,9026.24,"percent of total billed charges",
"GWIRE AMPLATZ SUPER STIFF VASCULAR SHORT TAPER 260CM 1CM",SUP-M001465091,CDM,C1769,HCPCS,0272,RC,,,both,,,494.10,148.23,"FIRST HEALTH [10303]","First Health",,395.28,80,,,,,0,57.46,419.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X18X8-15MM RISE-L 6D",SUP-193.323,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CIGNA [10200]","Cigna Local Plus",,10815.53,31.5,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL 5 D +21.5 DIOPTER 13MM 6MM 3 PIECE TECNIS ACRYLIC",SUP-ZMA00U0215,CDM,V2632,HCPCS,0276,RC,,,both,,,6175.50,1852.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4199.34,68,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL EPIDURAL 20GA 3.5IN PERIFIX TUOHY BISPHENOL A WING HUB",SUP-332168,CDM,S27200284,LOCAL,0272,RC,,,both,,,51.38,15.41,"AETNA [10100]","Aetna HMO/PPO",,40.85,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.98,43.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TURNPIKE 135CM 2.9FR SPIRAL GUIDING MULTILAYER SHAFT",SUP-5640,CDM,C1887,HCPCS,0272,RC,,,both,,,4140.00,1242,"AMERIGROUP MEDICAID [20100]",Amerigroup,,490.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CRTDG PULSED LAVAGE ERBEJET 2 PUMP STERILE DISPOSABLE",SUP-20150-300,CDM,S27200284,LOCAL,0272,RC,,,both,,,1206.90,362.07,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYR GRAFT DELIVERY STERILE",SUP-03.950.001S,CDM,S27200284,LOCAL,0272,RC,,,both,,,974.59,292.38,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH",RX-27863,CDM,,,0250,RC,43598-0448-71,NDC,both,1,UN,12.54,3.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT ETHILON 2-0 FSLX 75CM MONOFILAMENT BLACK NONABSORBABLE",SUP-1674BH,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,MODERATE",810,APR-DRG,,,,,,,inpatient,,,43212.35,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $3,512.78. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-2 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,MAJOR",625,APR-DRG,,,,,,,inpatient,,,109877.01,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $14,976.12. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to (Final Base Payment plus Newborn Screen Add-on Amount $63.00) multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($81,066.34) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-3 Newborn; Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC",673,MS-DRG,,,,,,,inpatient,,,136196.19,40858.86,"NOVANET [10819]",Novanet,,,75,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER MENTAL HEALTH CONDITIONS AND DISORDERS,MINOR",760,APR-DRG,,,,,,,inpatient,,,15135.59,,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $2,158.51. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($30,000) where the difference is multiplied by the percent of outlier that is reimbursed (106.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.2247).",,,,0,,,other,"SOI-1 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES,EXTREME",815,APR-DRG,,,,,,,inpatient,,,87334.08,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $9,954.80. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($101,776.48) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-4 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"OTHER NERVOUS SYSTEM AND RELATED PROCEDURES,MAJOR",026,APR-DRG,,,,,,,inpatient,,,160863.39,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,,"Bed Charges are equal to the sum of charges with RC 0000. Covered Charges are equal to Total Charges minus Bed Charges. Base Payment is equal to the Covered Charges multiplied by the Cost to Charge Ratio 1. DRG Reimbursement is equal to $14,007.21. Final Base Payment is equal to the lesser of the Base Payment and the DRG Reimbursement. Total Payment is equal to Final Base Payment multiplied by [1 plus (11.88 divided by 100)]. Final payment is multiplied by 107%. The outlier payment amount is calculated as the estimated cost amount minus the DRG reimbursement amount ($88,770.19) where the difference is multiplied by the percent of outlier that is reimbursed (99.9%). If the calculated outlier amount is greater than 0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (0.20).",,,,0,,,other,"SOI-3 ALL other APRDRG; Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Vrtplsty Cerv/Thor Lumb/Sac W Img Add",PX-361000377,CDM,22512,CPT,0361,RC,,,both,,,8890.00,2667,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"RELOAD STPLR 60X4.8MM DST SERIES TA TITANIUM THICK TISSUE",SUP-TA6048L,CDM,S27200284,LOCAL,0272,RC,,,both,,,310.07,93.02,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE SHAVER 110MM 3.5MM RAD 90 90D FRONTAL SINUS RADIAL",SUP-1883519HR,CDM,S27200284,LOCAL,0272,RC,,,both,,,2615.00,784.5,"MULTIPLAN [10600]",Multiplan,,2222.75,85,,,,,0,304.12,2222.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE VITRECTOMY 25GA GRIESHABER 30D DSP POINTED TIP",SUP-339.21,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS 14CM 5FR URETERAL PERCUFLEX HYDROPLUS 2",SUP-M0061552130,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"PHCS [10601]",PHCS,,840.41,70,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X13MM LUMINARY 10/11MM SPINE",SUP-4713,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"BLUE CROSS [10001]","Blue Cross HMO",,12348,39.2,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Irr Nacl 9% 1000ml",PX-E27200202,CDM,E27200202,LOCAL,0272,RC,,,both,,,35.75,10.72,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14.69,41.1,,,,,0,4.16,30.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP KIT REPLACEMENT SHOULDER E1 REVERSE INSRT AB",SUP-98000900118,CDM,C1776,HCPCS,0278,RC,,,both,,,48510.00,14553,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,5748.44,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,5641.71,41233.5,"percent of total billed charges",
"STEM FEMORAL 111MM COLLAR ACTIS DUOFIX 8 12/14 STANDARD OFFS",SUP-101011080,CDM,C1776,HCPCS,0278,RC,,,both,,,30476.25,9142.87,"CIGNA [10200]","Cigna Local Plus",,9600.02,31.5,,5372.07,4581.20,7242.98,23,3544.39,25904.81,"percent of total billed charges",
"STENT EPIC 60MM 112CM 9MM 75CM VASCULAR NITINOL ILIAC ARTERY",SUP-H74939200096070,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"AETNA [10100]","Aetna HMO/PPO",,3291.3,79.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE PEEK-OPTIMA 15MM 8MM BIOSURE BICEPTOR",SUP-72202284,CDM,C1713,HCPCS,0278,RC,,,both,,,2054.03,616.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,587.86,28.62,,,,,0,238.88,1745.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.3MM 24MM AEQUALIS TITANIUM HUMERAL DISTAL",SUP-7424524,CDM,C1713,HCPCS,0278,RC,,,both,,,955.80,286.74,"KAISER [10500]",Kaiser,,640.39,67,,,,,0,111.16,812.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH PEG LOCKING 6.0MM X 30MM TI",SUP-SPL-60300-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"BLUE CROSS [10001]","Blue Cross PPO",,635.04,39.2,,957.42,570.23,957.42,28,188.41,1377,"percent of total billed charges",
"CATH STERLING SL 150CM 80MM 3.8FR 2MM BALLOON DILATATION OTW",SUP-H74939148208010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC ED Visit B Level 4",PX-450000331,CDM,G0383,HCPCS,0450,RC,,,both,,,1807.00,542.1,"AETNA [10100]","Aetna HMO/PPO",,1436.57,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,67.13,1807,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CANCELLOUS BLOCK ALLOGRAFT 10MM",SUP-291041,CDM,S27800098,LOCAL,0278,RC,,,both,,,3839.85,1151.95,"BLUE CROSS [10001]","Blue Cross PPO",,1505.22,39.2,,,,,0,446.57,3263.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE MYNX CONTROL 6-12FR CLSR HYDROPHILIC PEG VASCULAR",SUP-MX61260,CDM,C1760,HCPCS,0278,RC,,,both,,,1650.00,495,"NOVANET [10819]",Novanet,,1237.5,75,,,,,0,191.9,1402.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AMPLATZ ANCHOR MALECOT 30CM 10FR DRNG PERCUFLEX METAL",SUP-M001221010,CDM,C1729,HCPCS,0272,RC,,,both,,,729.00,218.7,"NOVANET [10819]",Novanet,,546.75,75,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) ZEBRA 7F 95CM ACCESS SYSTEM SIM2",SUP-AC7087-095-20-S,CDM,C1887,HCPCS,0272,RC,,,both,,,8935.50,2680.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1058.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABERX RADIANZ 5MM25CM 190",SUP-R51005025L,CDM,C1725,HCPCS,0272,RC,,,both,,,2491.88,747.56,"KAISER [10500]",Kaiser,,1669.56,67,,,,,0,289.81,2118.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 80CM 8MM GORE-TEX THIN WALL PTFE THIN WALLED",SUP-SRRT08070080L,CDM,C1768,HCPCS,0278,RC,,,both,,,11267.70,3380.31,"MULTIPLAN [10600]",Multiplan,,9577.55,85,,,,,0,1310.43,9577.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 8 5MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620805,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"PHCS [10601]",PHCS,,7877.73,70,,,,,0,1308.83,9565.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 22.5MM PRECISION THK.015IN RECIPROCATING TAPERED",SUP-5100137133,CDM,S27200284,LOCAL,0272,RC,,,both,,,588.38,176.51,"UHC [10700]","United Healthcare",,372.44,63.3,,,,,0,68.43,500.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 3 LEFT KNEE CRUCIATE RETAINING CEMENTED",SUP-5510-F-301,CDM,C1776,HCPCS,0278,RC,,,both,,,16397.85,4919.35,"NOVANET [10819]",Novanet,,12298.39,75,,,,,0,1907.07,13938.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 50MM CREO CREO AMP SPINAL MODULAR NONSTERILE",SUP-1067.1650,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"BLUE CROSS [10001]","Blue Cross HMO",,3742.37,39.2,,957.42,156.86,7483.26,51,1110.3,8114.82,"percent of total billed charges",
"GRAFT VASCULAR 80CM 8MM GORE-TEX THIN WALL PTFE THIN WALLED",SUP-SRRT08070080L,CDM,C1768,HCPCS,0278,RC,,,both,,,11267.70,3380.31,"CIGNA [10200]","Cigna Open Access",,6411.32,56.9,,,,,0,1310.43,9577.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR 18MM 1MM FLO-THRU INTRALUMINAL",SUP-FT12100,CDM,S27200284,LOCAL,0272,RC,,,both,,,741.67,222.5,"UHC [10700]","United Healthcare",,469.48,63.3,,,,,0,86.26,630.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH BALLOON DILATATION .035IN 5FR 12MM 110CM 4CM PTA 2",SUP-4202040L,CDM,C1725,HCPCS,0272,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 32CM FEMUR LEFT PROXIMAL TALON DISTALFIX",SUP-SLN-125-32L,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4615.06,28.62,,,,,0,1875.37,13706.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bx Tissue Neck/Thorax",PX-360000051,CDM,21550,CPT,0360,RC,,,both,,,4427.78,1328.33,"PHCS [10601]",PHCS,,3099.45,70,,,,,0,514.95,4427.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BOLT SPINAL 50MM 5.5MM DECADE LARGE PLATE EXTREME LATERAL",SUP-7145550,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"FIRST HEALTH [10303]","First Health",,1296,80,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KWIRE 0.9MM X 127MM DOUBLE TROCAR",SUP-KWIR-DT-09127,CDM,S27000186,LOCAL,0270,RC,,,both,,,234.90,70.47,"CIGNA [10200]","Cigna Local Plus",,125.67,53.5,,,,,0,27.32,199.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Calcaneous 1v",PX-320000194,CDM,73650,CPT,0320,RC,,,both,,,464.00,139.2,"UHC [10700]","United Healthcare",,216.45,,,,,,,32.95,394.4,"fee schedule",
"HC Xr Calcaneous 1v",PX-320000194,CDM,73650,CPT,0320,RC,,,both,,,464.00,139.2,"CIGNA [10200]",Cigna,,46.09,,,,,,,32.95,394.4,"fee schedule",
"SLDFR FLUID 20L UROLOGY FLUIDRAIN LSS DISPOSABLE",SUP-337220,CDM,S27200284,LOCAL,0272,RC,,,both,,,261.00,78.3,"PHCS [10601]",PHCS,,182.7,70,,,,,0,30.35,221.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 25MM SOLERA CD HORIZON OSTEOGRIP TITANIUM",SUP-54840004525,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6491.86,68,,,,,0,1110.3,8114.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BIOABSORBABLE PLLA HA 25MM 10MM 1.5MM ACL PCL CANNULATED",SUP-7209016,CDM,C1713,HCPCS,0278,RC,,,both,,,1882.13,564.64,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,538.67,28.62,,,,,0,218.89,1599.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OLYMPUS 4MM 90 DEG ROTATABLE SHAVER",SUP-SB4090RS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1541.46,462.44,"AMERIGROUP MEDICAID [20100]",Amerigroup,,182.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,179.27,1310.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT DRNG 12IN 3/16IN PVC 3 SPRING EVAC TROCAR Y CNCT TUBE",SUP-0043630,CDM,S27200284,LOCAL,0272,RC,,,both,,,66.12,19.84,"MULTIPLAN [10600]",Multiplan,,56.2,85,,,,,0,7.69,56.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Tmj",PX-610000002,CDM,70336,CPT,0610,RC,,,both,,,3403.00,1020.9,"CIGNA [10200]",Cigna,,955,,"Per diem ($955). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,395.77,2892.55,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 5MM LEIBINGER UNIVERSAL 2 TITANIUM",SUP-5020405,CDM,C1713,HCPCS,0278,RC,,,both,,,458.02,137.41,"AMERIGROUP MEDICAID [20100]",Amerigroup,,54.28,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",53.27,389.32,"percent of total billed charges",
"PLATE 72.5MM ATLANTIS VISION ELITE BONE SPINAL",SUP-7200072,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3598.56,68,,,,,0,615.46,4498.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sigmoid Flex W Dil",PX-750000084,CDM,45340,CPT,0750,RC,,,both,,,2362.42,708.73,"PHCS [10601]",PHCS,,2362.42,,"Case rate ($4,710). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.",,,,0,274.75,2362.42,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"VASCBAND 29 CM",SUP-3529,CDM,S27000186,LOCAL,0270,RC,,,both,,,165.30,49.59,"CIGNA [10200]","Cigna Open Access",,94.06,56.9,,,,,0,19.22,140.51,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT INFUSION PORT WITHOUT Y SITE ACCESS 20GA POWERLOC .75IN",SUP-2652034,CDM,C1788,HCPCS,0278,RC,,,both,,,97.79,29.34,"CIGNA [10200]","Cigna Local Plus",,52.32,53.5,,,,,0,11.37,83.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Steth Esophageal Tapscope",PX-E27000220,CDM,E27000220,LOCAL,0270,RC,,,both,,,1003.20,300.96,"AETNA [10100]","Aetna HMO/PPO",,797.54,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.67,852.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATHETER 14.5FR L40CM INSERTION L23CM POLYURETHANE DOUBL",SUP-8888145040P,CDM,C1750,HCPCS,0278,RC,,,both,,,2876.79,863.04,"CIGNA [10200]","Cigna Local Plus",,1539.08,53.5,,,,,0,334.57,2445.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM 13MM PRIMARY VERSYS TIVANIUM FIBER METAL",SUP-786201300,CDM,C1776,HCPCS,0278,RC,,,both,,,26645.22,7993.57,"KAISER [10500]",Kaiser,,17852.3,67,,,,,0,3098.84,22648.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE NASOGASTRIC 43IN 12FR FEED RIGID PORT DEHP FREE STYLET",SUP-8884711253,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.98,21.89,"FIRST HEALTH [10303]","First Health",,58.38,80,,,,,0,8.49,62.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 4FR 80CM 23CM RED HUB GWIRE HEMOSTASIS VALVE",SUP-PSI-4F-23-035,CDM,C1894,HCPCS,0272,RC,,,both,,,117.45,35.23,"MULTIPLAN [10600]",Multiplan,,99.83,85,,,,,0,13.66,99.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.7MM CANNULATED STERILE",SUP-03.333.102S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3129.15,938.74,"AMERIGROUP MEDICAID [20100]",Amerigroup,,370.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,363.92,2659.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 5MM 44MM 7.3MM SHILEY PEDIATRIC UNCUFF TAPE TIE",SUP-5.0PEF,CDM,S27200284,LOCAL,0272,RC,,,both,,,395.85,118.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,46.91,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,46.04,336.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 13.6CM NATRELLE BIOCELL P3.8CM MODERATE PROFILE",SUP-MSZ10390,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION AZUR DETACHMENT CTRL",SUP-45-4001,CDM,S27200284,LOCAL,0272,RC,,,both,,,1405.35,421.6,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,645.06,45.9,,,,,0,163.44,1194.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET SUCTION CRTDG TUBE CUSA QUICK CONNECT",SUP-C7300,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"CIGNA [10200]","Cigna Open Access",,2128.06,56.9,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZIPWIRE 30CM 3CM 7FR .035IN STRAIGHT URETERAL",SUP-M006175275190,CDM,C2617,HCPCS,0278,RC,,,both,,,1265.38,379.61,"NOVANET [10819]",Novanet,,949.04,75,,,,,0,147.16,1075.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 16MM GORILLA R3CON LOCK",SUP-P50-353-3516,CDM,C1713,HCPCS,0278,RC,,,both,,,1336.50,400.95,"MULTIPLAN [10600]",Multiplan,,1136.03,85,,,,,0,155.43,1136.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC TREK NEO 20MM 145CM 4MM BALLOON DILATATION HYDROCOAT",SUP-1400400-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 69MM COLONIAL 2XL PEEK ANTERIOR CERVICAL",SUP-365.069,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,791.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTICROSS 6 6FR ULTRASOUND INTRAVASCULAR",SUP-H7495181160,CDM,C1753,HCPCS,0272,RC,,,both,,,4657.50,1397.25,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,541.67,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,541.67,3958.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 16MM MODULAR REVISION RESTORATION BOW",SUP-6276-7-216,CDM,C1776,HCPCS,0278,RC,,,both,,,11695.32,3508.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4678.13,40,,,,,0,1360.17,9941.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL LARGE 15MM KNEE GVF ROTATE PLATFORM LCS",SUP-129405615,CDM,C1776,HCPCS,0278,RC,,,both,,,9663.45,2899.03,"PHCS [10601]",PHCS,,6764.42,70,,,,,0,1123.86,8213.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOXCROSS 135CM 40MM 8MM BALLOON DILATATION JETCOAT",SUP-10338-40,CDM,C1725,HCPCS,0272,RC,,,both,,,1539.00,461.7,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,632.53,41.1,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OVITEX PRS LONG-TERM RESORBABLE, 25X30 CM OVAL",SUP-P20363-2530G,CDM,C1781,HCPCS,0278,RC,,,both,,,86776.80,26033.04,"PHCS [10601]",PHCS,,60743.76,70,,,,,0,10092.14,73760.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAA - AMPLATZ CARDIAC PLUG 2-IDE-028",SUP-9-ACP2-IDE-028,CDM,S62400003,LOCAL,0624,RC,,,both,,,63452.40,19035.72,"CIGNA [10200]","Cigna Local Plus",,33947.03,53.5,,,,,0,7379.51,53934.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT MARDIS ZIPWIRE 28CM 3CM 7FR .035IN PIGTAIL CURVE",SUP-M0061265840,CDM,C2617,HCPCS,0278,RC,,,both,,,1483.43,445.03,"KAISER [10500]",Kaiser,,993.9,67,,,,,0,172.52,1260.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8FR 11CM GWIRE PRELUDE .035IN STERILE BLUE",SUP-PRO-8F-11,CDM,C1894,HCPCS,0272,RC,,,both,,,75.69,22.71,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,51.47,68,,,,,0,8.8,64.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER 60MM 120CM 12MM BILIARY VENA CAVA OTW DELIVERY",SUP-G57441,CDM,C1876,HCPCS,0278,RC,,,both,,,13800.00,4140,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3726,27,,,,,0,1604.94,11730,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW BONE L15 MM OD3.5 MM SPINE CERVICAL ANTERIOR SELF TAP",SUP-18008415,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"BLUE CROSS [10001]","Blue Cross PPO",,396.9,39.2,,957.42,570.23,957.42,28,117.75,860.63,"percent of total billed charges",
"HYDROMORPHONE 0.2 MG/ML IN 0.9 % NACL IV PCA SUPERORDERABLE - BASAL RATE ONLY",RX-411637,CDM,J1171,HCPCS,0636,RC,70004-0300-16,NDC,both,30,ML,100.39,30.12,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,6.99,85.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 2.7MM 2.7/3MM SCR ANKLE FRACTURE MANAGEMENT SYSTEM",SUP-AR-8827D-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"CIGNA [10200]",Cigna,,468.18,68,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 12.75CM NATRELLE INSPIRA P4.2CM MODERATE PROFILE",SUP-SRM-360,CDM,C1789,HCPCS,0278,RC,,,both,,,5485.50,1645.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3730.14,68,,,,,0,637.96,4662.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASSEMB TUBE 520MM REAMER IRR ASPIR DRIVE SHAFT",SUP-314.746S,CDM,S27200284,LOCAL,0272,RC,,,both,,,3089.55,926.86,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1269.81,41.1,,,,,0,359.31,2626.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT DOUBLE-J 26CM 100CM 7FR .028IN URETERAL SILICONE PTFE",SUP-5204100,CDM,C2625,HCPCS,0278,RC,,,both,,,1212.57,363.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,556.57,45.9,,,,,0,141.02,1030.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 14X11X6MM PEEK TITANIUM COMPOSITE ANATOMIC",SUP-5030641,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3065.39,45.9,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 45MM SPINE VARIABLE ANGLE",SUP-5485545,CDM,C1713,HCPCS,0278,RC,,,both,,,2940.00,882,"AMERIGROUP MEDICAID [20100]",Amerigroup,,348.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",341.92,2499,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL BALL 4IN 5MM NONHEX",SUP-E15644,CDM,S27200284,LOCAL,0272,RC,,,both,,,100.49,30.15,"AETNA [10100]","Aetna HMO/PPO",,79.89,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11.69,85.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP LAPAROSCOPIC 33.53CM 8MM DA VINCI XI PROGRASP ENDOWRIST",SUP-471093,CDM,S27000186,LOCAL,0270,RC,,,both,,,1275.75,382.72,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,148.37,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,148.37,1084.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 20MM NESTER MICROCOIL PLATINUM .035IN",SUP-G47361,CDM,S27800098,LOCAL,0278,RC,,,both,,,1113.67,334.1,"PHCS [10601]",PHCS,,779.57,70,,,,,0,129.52,946.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 14CM 5FR 2 PIGTAIL CURVE",SUP-M0061921130,CDM,C2617,HCPCS,0278,RC,,,both,,,1135.62,340.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,325.01,28.62,,,,,0,132.07,965.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 170MM STAINLESS STEEL 4.5MM SCR LARGE FRAGMENT SET 6",SUP-222.657,CDM,C1713,HCPCS,0278,RC,,,both,,,9026.30,2707.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4143.07,45.9,,,,,0,1049.76,7672.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE VENTILATION ACTIVENT SHEEHY",SUP-1026145,CDM,S27800098,LOCAL,0278,RC,,,both,,,194.76,58.43,"BLUE CROSS [10001]","Blue Cross PPO",,76.35,39.2,,,,,0,22.65,165.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT STENT 28CM 8FR .038IN LARGE REGULAR PIGTAIL CURVE URETER",SUP-M001274190,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"CIGNA [10200]",Cigna,,1107.04,68,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.6V 30MM 2 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18006230,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1283.61,28.62,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +7.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-PCB0000075,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,143.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE 10D +4MM 60MM 36MM MARATHON HIP",SUP-121936160,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1166.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,1144.72,8366.42,"percent of total billed charges",
"STENT RX BILIARY SYSTEM 15CM 10FR BILIARY PLASTIC RAPID",SUP-M00545640,CDM,C2625,HCPCS,0278,RC,,,both,,,852.77,255.83,"FIRST HEALTH [10303]","First Health",,682.22,80,,,,,0,99.18,724.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 37X27X16MM SOVEREIGN 8D MEDIUM",SUP-7968816,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"PHCS [10601]",PHCS,,23992.92,70,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SELECTRA 45CM 8.7FR 7.3FR STRAIGHT GUIDING PEBAX","SUP-375 537",CDM,C1887,HCPCS,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 120MM 3.5MM MOUNTAINEER TITANIUM PREBENT",SUP-188363200,CDM,C1713,HCPCS,0278,RC,,,both,,,10350.00,3105,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2962.17,28.62,,,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 235CC P3.6CM MODERATE PLUS PROFILE COHESIVE GEL",SUP-SMPB235,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"MULTIPLAN [10600]",Multiplan,,6480.83,85,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM STRAIGHT 2 SERRATE ENTELLUS MEDICAL HNDPC",SUP-SSB-12400-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,239.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL MULTIPASS 6-0 PS-3 18IN BRAID COATED UNDYED",SUP-J499G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ARCHON SCREW, 4.0X14MM SELF-DRILL VAR",SUP-8780214,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"NOVANET [10819]",Novanet,,1057.5,75,,,,,0,163.98,1198.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP ELECTROSURGICAL 7.5INX1.5MM HARDY IRRIGATE 3.5IN LATEX",SUP-US416SU,CDM,S27200284,LOCAL,0272,RC,,,both,,,2487.93,746.38,"PHCS [10601]",PHCS,,1741.55,70,,,,,0,289.35,2114.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NC EMERGE BI-SEG SLOPE MONORAIL 143CM 30MM 6FR 3.25MM",SUP-H7493926730320,CDM,C1725,HCPCS,0272,RC,,,both,,,567.00,170.1,"MULTIPLAN [10600]",Multiplan,,481.95,85,,,,,0,65.94,481.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) PACKAGED DELIVERY SYSTEM",SUP-ES0200,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE FUSION LOCKING BILE PANCREATIC GWIRE STERILE",SUP-G31522,CDM,C1769,HCPCS,0272,RC,,,both,,,149.64,44.89,"MULTIPLAN [10600]",Multiplan,,127.19,85,,,,,0,17.4,127.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 100MM 4MM ELBOW",SUP-840004410,CDM,C1776,HCPCS,0278,RC,,,both,,,36662.85,10998.85,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9898.97,27,,,,,0,4263.89,31163.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP CONSTRUCT TOTAL KNEE LEGION GII CRUCIATE RETAINING POROU",SUP-71704545,CDM,C1776,HCPCS,0278,RC,,,both,,,23310.00,6993,"PHCS [10601]",PHCS,,16317,70,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 20MM PINNACLE GRIPTION TF DOME 4 POINT CUT",SUP-121720500,CDM,C1713,HCPCS,0278,RC,,,both,,,1146.15,343.84,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,135.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,133.3,974.23,"percent of total billed charges",
"COIL EMBOLIZATION 6.6CM 3.5MM MICRUSFRAME 10 COIL",SUP-MFR100356,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"NOVANET [10819]",Novanet,,8911.35,75,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 6X34X24MM 20 DEGREE",SUP-1921009P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"KAISER [10500]",Kaiser,,23215.5,67,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER YELLOW 4.5MM DYONICS STRAIGHT FULL RADIUS",SUP-7205306,CDM,S27200284,LOCAL,0272,RC,,,both,,,283.00,84.9,"MULTIPLAN [10600]",Multiplan,,240.55,85,,,,,0,32.91,240.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Shave S/N/H/F/G Lesn 0.6-1.0cm",PX-510000023,CDM,11306,CPT,0761,RC,,,both,,,712.00,213.6,"UHC [10700]","United Healthcare",,450.7,63.3,,,,,0,82.81,712,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PDS II 2-0 CT-1 18IN CONTROL RELEASE MONOFILAMENT 8",SUP-Z739D,CDM,S27200284,LOCAL,0272,RC,,,both,,,218.94,65.68,"NOVANET [10819]",Novanet,,164.21,75,,,,,0,25.46,186.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW NON-LOCKING 2.0MM X 8MM TI",SUP-VAN-20080-TS,CDM,C1713,HCPCS,0278,RC,,,both,,,972.00,291.6,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,660.96,68,,,,,0,113.04,826.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT CARDIOVASCULAR 40CM 22/11MM BIFURCATED KNITTED SOFT",SUP-M002020852210,CDM,C1768,HCPCS,0278,RC,,,both,,,4673.51,1402.05,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,553.81,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,543.53,3972.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN RADIOFREQUENCY 169.9MM 18GA 1.25MM VENOM CURVE 150MM",SUP-0406-860-225,CDM,S27200284,LOCAL,0272,RC,,,both,,,348.00,104.4,"FIRST HEALTH [10303]","First Health",,278.4,80,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 18FR SILICONE RADIOPAQUE BOLUS ENTERAL FEED INTERNAL",SUP-0110-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"KAISER [10500]",Kaiser,,187.52,67,,,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIGTR ORTHOPEDIC 25YDX3IN COTTON BLACK",SUP-55119103,CDM,S27000186,LOCAL,0270,RC,,,both,,,243.51,73.05,"FIRST HEALTH [10303]","First Health",,194.81,80,,,,,0,28.32,206.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHEST PAIN",313,MS-DRG,,,,,,,inpatient,,,23187.34,6956.2,"BLUE CROSS [10001]","Blue Cross PPO",,17774.68,,,,,,,4466.2,17956.08,"case rate",
"SET DRNG 29CM 9FR 18GA STAINLESS STEEL VINYL PTFE THORACIC 1",SUP-G03301,CDM,C1729,HCPCS,0272,RC,,,both,,,1931.25,579.37,"FIRST HEALTH [10303]","First Health",,1545,80,,,,,0,224.6,1641.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL FOERSTER CURVE 7IN SERRATE SPONGE",SUP-19-5118,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.19,36.96,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,14.6,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,14.33,104.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD THERAPEUTIC 12X11.34IN COLD WRAP ON REGULAR HOSE XL",SUP-11-0681-9-00000,CDM,S27000187,LOCAL,0270,RC,,,both,,,157.38,47.21,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,18.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,18.3,133.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT AMNIOTIC 4.0 X 3.0 CM",SUP-NX-10-4030,CDM,Q4148,HCPCS,0636,RC,,,both,,,16767.00,5030.1,"CIGNA [10200]",Cigna,,332.85,,,,,,,332.85,14251.95,"fee schedule",
"TUBE CALIBRATION ENDOLUMIK 36FR GASTRIC CALIBRATION TUBE M",SUP-EGCT36M,CDM,S27000186,LOCAL,0270,RC,,,both,,,1950.00,585,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HEAD REAMER 13MM IRR ASPIR STERILE DISPOSABLE",SUP-352.252S,CDM,S27200284,LOCAL,0272,RC,,,both,,,2560.05,768.01,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Cath Umbilical",PX-E27200075,CDM,E27200075,LOCAL,0272,RC,,,both,,,242.00,72.6,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MITRACLIP G4 SYSTEM ONE (1) STEERABLE GUIDE CATHETER SGC0701",SUP-CDS0706-XTW,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"BLUE CROSS [10001]","Blue Cross HMO",,,39.2,,,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Atrasump",PX-E27200350,CDM,E27200350,LOCAL,0272,RC,,,both,,,111.10,33.33,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DEFIB CARDIAC 71X40X14IN FORTIFY 2.5V 500OHM 60 PPM TITANIUM",SUP-CD1231-40Q,CDM,C1722,HCPCS,0278,RC,,,both,,,35000.00,10500,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,14385,41.1,,,,,0,4070.5,29750,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEFIB CARDIAC IPERIA 7 PROMRI DF-1 IMPLANTABLE",SUP-393007,CDM,C1882,HCPCS,0278,RC,,,both,,,57720.00,17316,"PHCS [10601]",PHCS,,40404,70,,,,,0,6712.84,49062,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"120MM EXTRA-THOR PRBNT PLT",SUP-323.412,CDM,C1713,HCPCS,0278,RC,,,both,,,31040.10,9312.03,"KAISER [10500]",Kaiser,,20796.87,67,,,,,0,3609.96,26384.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR FMP EPLUS 36",SUP-932-36-752,CDM,C1776,HCPCS,0278,RC,,,both,,,5638.37,1691.51,"AETNA [10100]","Aetna HMO/PPO",,4482.5,79.5,,10981.53,8986.79,12413.38,12,655.74,4792.61,"percent of total billed charges",
"GRAFT SOFT TISSUE 4X4CM ACTISHIELD AMNIOTIC BARR MEMB",SUP-AM204X04,CDM,V2790,HCPCS,0278,RC,,,both,,,12420.00,3726,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1471.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ARGYLE SENTINEL LINE SENTINEL EYE 20IN 12FR STRAIGHT",SUP-8888570507,CDM,C1729,HCPCS,0272,RC,,,both,,,83.25,24.97,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,34.22,41.1,,,,,0,9.68,70.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 50X22X10MM COHERE XLW 15D STERILE LATEX FREE",SUP-8151050P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,29925.00,8977.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8564.54,28.62,,,,,0,3480.28,25436.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR 47MM MULTIPOLAR HIP METAL STERILE",SUP-00500104700,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"CIGNA [10200]",Cigna,,2543.2,68,,5873.17,5873.17,5873.17,"1 through 10",434.96,3179,"percent of total billed charges",
"SCR BONE 6MM 1.5MM CRANIOFACIAL TITANIUM SELF DRILLING LOW",SUP-400.836,CDM,C1713,HCPCS,0278,RC,,,both,,,708.75,212.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,202.84,28.62,,,,,0,82.43,602.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN AL1 CURVE ANGIOGRAPHIC",SUP-H74908641962,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,8.91,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EVERFLEX ENTRUST 150MM 150CM 8MM VASCULAR NICKEL",SUP-EVD35-08-150-150,CDM,C1876,HCPCS,0278,RC,,,both,,,8295.00,2488.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3807.41,45.9,,,,,0,964.71,7050.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2CM 2MM INTERLOCK IDC 18 COIL SOFT 2D",SUP-M0033612020,CDM,S27800098,LOCAL,0278,RC,,,both,,,3795.00,1138.5,"MULTIPLAN [10600]",Multiplan,,3225.75,85,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALVIMOPAN 12 MG CAPSULE",RX-91870,CDM,,,0637,RC,00591-2312-45,NDC,both,1,UN,783.59,235.08,"NOVANET [10819]",Novanet,,587.69,75,,,,,0,91.13,666.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM ACUMED TITANIUM CORTICAL ELBOW",SUP-CO-2718,CDM,C1713,HCPCS,0278,RC,,,both,,,696.60,208.98,"CIGNA [10200]","Cigna Local Plus",,372.68,53.5,,3978.14,359.25,3978.14,24,81.01,592.11,"percent of total billed charges",
"HC Chlamydia Trach Dna Ampl Prb",PX-306000122,CDM,87491,CPT,0306,RC,,,both,,,292.56,87.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,55.2,,,,,,,0.01,248.68,"fee schedule",
"HC Chlamydia Trach Dna Ampl Prb",PX-306000122,CDM,87491,CPT,0306,RC,,,both,,,292.56,87.77,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,28.98,,"Fee schedule rate ($28.98). If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,248.68,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG TIBIAL 10MM TRIATHLON 1 RIGHT MEDIAL LEFT LATERAL TOTAL",SUP-5546-A-102,CDM,C1776,HCPCS,0278,RC,,,both,,,5971.95,1791.58,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,707.68,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,694.54,5076.16,"percent of total billed charges",
"PK 7.5CM ANTERIOR POSTERIOR SINUS NASAL RAPID RHINO ADULT",SUP-RR750,CDM,S27200284,LOCAL,0272,RC,,,both,,,361.92,108.58,"CIGNA [10200]","Cigna Local Plus",,193.63,53.5,,,,,0,42.09,307.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 115CM 1MM 6FR 5MM SPACE F CURVE ELECTROPHYSIOLOGY",SUP-F6QRF005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"AMERIGROUP MEDICAID [20100]",Amerigroup,,107.5,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL TRIATHLON 3 KNEE REVISION",SUP-5612-B-300,CDM,C1776,HCPCS,0278,RC,,,both,,,26089.56,7826.87,"CIGNA [10200]","Cigna Local Plus",,8218.21,31.5,,5372.07,4581.20,7242.98,23,3034.22,22176.13,"percent of total billed charges",
"ELECTRD DEFIB ADULT 6.25X4.5IN MULTIFUNCTION ADHSV",SUP-22660R-,CDM,S27200284,LOCAL,0272,RC,,,both,,,154.30,46.29,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,17.95,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,17.95,131.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dup Scan Ext Vein Uni",PX-921000012,CDM,93971,CPT,0921,RC,,,both,,,1421.25,426.37,"PHCS [10601]",PHCS,,994.88,70,,,,,0,165.29,1208.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 1.6V 30MM 2 LEVEL BONE SPINE CERVICAL ANTERIOR",SUP-18006230,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2058.62,45.9,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM ULNAR SIZE 6 L90MM LEFT CEMENTED CONSTRAINED NEXEL",SUP-840001609,CDM,C1776,HCPCS,0278,RC,,,both,,,31971.49,9591.45,"FIRST HEALTH [10303]","First Health",,25577.19,80,,,,,0,3718.28,27175.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 26MM ELBOW NONLOCKING HEXALOBE NONSTERILE",SUP-30-0310,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,434.99,45.9,,,,,0,110.22,805.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 25MM 3.5MM VERTEX SELECT PRECUT",SUP-7753725,CDM,C1713,HCPCS,0278,RC,,,both,,,1410.00,423,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,163.98,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",163.98,1198.5,"percent of total billed charges",
"BURR SURGICAL 47.8MM 5.5MM MEDIUM OVAL CARBIDE OSCILLATING",SUP-5300010903,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.08,49.82,"PHCS [10601]",PHCS,,116.26,70,,,,,0,19.32,141.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR REFLECTION 20D E 50-52MM 32MM XLPE HIP",SUP-71333334,CDM,C1776,HCPCS,0278,RC,,,both,,,20487.60,6146.28,"UHC [10700]","United Healthcare",,12968.65,63.3,,8601.07,8395.67,8601.07,"1 through 10",2382.71,17414.46,"percent of total billed charges",
"LENS IOL +16 DIOPTER CONVEXOPLANO 12.5MM 5.5MM ANTERIOR",SUP-MTA3U0.160,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"CIGNA [10200]","Cigna Local Plus",,368.35,53.5,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE STAINLESS STEEL 3.5 MM SCREWS 2 HOLE LOW PROFILE",SUP-02.100.302S,CDM,C1713,HCPCS,0278,RC,,,both,,,1800.00,540,"FIRST HEALTH [10303]","First Health",,1440,80,,,,,0,209.34,1530,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC NM Parathy Planar Img Spect",PX-341000062,CDM,78071,CPT,0341,RC,,,both,,,5425.30,1627.59,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,415.89,,,,,,,415.89,4611.51,"fee schedule",
"LINER ACETABULAR PINNACLE 52MM 45MM HIP 2 MOBILITY",SUP-121852045,CDM,C1776,HCPCS,0278,RC,,,both,,,15870.00,4761,"AETNA [10100]","Aetna HMO/PPO",,12616.65,79.5,,10981.53,8986.79,12413.38,12,1845.68,13489.5,"percent of total billed charges",
"DRILL SURGICAL 24MM FUSION ACUTRAK 2.4MM 24MM SCR",SUP-ATF-024,CDM,S27200284,LOCAL,0272,RC,,,both,,,1657.50,497.25,"CIGNA [10200]",Cigna,,1127.1,68,,,,,0,192.77,1408.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REVOLVE BREAST BIOPSY STERILE DISPOSABLE",SUP-RV0002,CDM,S27200284,LOCAL,0272,RC,,,both,,,6147.90,1844.37,"FIRST HEALTH [10303]","First Health",,4918.32,80,,,,,0,715,5225.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE BEACON TIP 80CM 5FR ANGLE",SUP-G09312,CDM,S27200284,LOCAL,0272,RC,,,both,,,237.49,71.25,"CIGNA [10200]",Cigna,,161.49,68,,,,,0,27.62,201.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CGUARD PRIME CAROTID STENT SYSTEM 135CM 9MM LENGTH  40MM",SUP-CND0940,CDM,C1876,HCPCS,0278,RC,,,both,,,20758.50,6227.55,"BLUE CROSS [10001]","Blue Cross HMO",,8137.33,39.2,,,,,0,2414.21,17644.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 15MM SPINE CERVICAL ANTERIOR SELF DRILL",SUP-7741115,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR LEAD 15CM BRADY 5.38MM IS-1 UNIPOLAR CNCT EXT LOW",SUP-6161,CDM,C1883,HCPCS,0278,RC,,,both,,,1875.00,562.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,222.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 20MM TITANIUM FOOT VARIABLE ANGLE LOCK",SUP-AR-8933V-20,CDM,C1713,HCPCS,0278,RC,,,both,,,1417.50,425.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,167.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",164.86,1204.88,"percent of total billed charges",
"CATH LAUNCHER 100CM 8FR SL4 CURVE GUIDING CORONARY LATEX",SUP-LA8SL40,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"KAISER [10500]",Kaiser,,244.82,67,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VASCADE 6/7FR COMPRESSION CLLGN VASCULAR",SUP-700-580I-05U,CDM,C1760,HCPCS,0278,RC,,,both,,,1539.00,461.7,"CIGNA [10200]","Cigna Local Plus",,823.37,53.5,,,,,0,178.99,1308.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL ACETABULAR 50MM HIP CLUSTER HOLE HA TRIDENT D",SUP-502-11-50D,CDM,C1776,HCPCS,0278,RC,,,both,,,6957.72,2087.32,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4731.25,68,,,,,0,809.18,5914.06,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 11X14X10MM PARALLEL SPINE CERVICAL ANTERIOR",SUP-4W7310,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CIGNA [10200]","Cigna Open Access",,3926.1,56.9,,,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 110CM 7FR .081IN JL5 CURVE GUIDING CORONARY",SUP-LA7JL50SH,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"NOVANET [10819]",Novanet,,274.05,75,,,,,0,42.5,310.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 60MM TSRH OSTEOGRIP THINLINE LONG SPINAL",SUP-83565609,CDM,C1713,HCPCS,0278,RC,,,both,,,9546.85,2864.05,"UHC [10700]","United Healthcare",,6043.16,63.3,,5023.51,2672.93,6679.78,18,1110.3,8114.82,"percent of total billed charges",
"CATH MUSTANG 135CM 80MM 12MM BALLOON DILATATION NYBAX HIGH",SUP-H74939171120810,CDM,C1725,HCPCS,0272,RC,,,both,,,1174.50,352.35,"MULTIPLAN [10600]",Multiplan,,998.33,85,,,,,0,136.59,998.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 22MM SPINE PLY NONSTERILE 4MM ROD",SUP-102040122,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"SUT STAINLESS STEEL 4-0 FS-2 18IN MONOFILAMENT NONABSORBABLE",SUP-603G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"MULTIPLAN [10600]",Multiplan,,22.1,85,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 1.7MM GRADUATE 2.4MM SCR",SUP-AR-8916-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,639.90,191.97,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,75.83,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.42,543.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 7 STD KNEE RIGHT CRUCIATE RETAIN CEMENT",SUP-42502606202,CDM,C1776,HCPCS,0278,RC,,,both,,,22862.70,6858.81,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2709.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2658.93,19433.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT CHORD-X 2-0 .5 CIRCLE 18MM 2 ARM LOOP PLEDG 3 CHORDAL 24",SUP-CXL-20-1812-24,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"AMERIGROUP MEDICAID [20100]",Amerigroup,,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTICLES EMBOLIZATION TRUFILL N-BCA LIQUID EMBOLIC SYSTEM 2",SUP-631400,CDM,S27800098,LOCAL,0278,RC,,,both,,,43065.16,12919.55,"MULTIPLAN [10600]",Multiplan,,36605.39,85,,,,,0,5008.48,36605.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT AORTIC VALVE 14FR COMMANDER SAPIEN 3 20MM TRANSCATHETER",SUP-9600CM20A,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"BLUE CROSS [10001]","Blue Cross HMO",,72618,39.2,,,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 12MM ATLANTIS TITANIUM SPINE CERVICAL ANTERIOR",SUP-3120412,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",117.75,860.63,"percent of total billed charges",
"PACKAGED RADIAL STEM 6MM X -2MM",SUP-ALN-RST-06M2,CDM,C1776,HCPCS,0278,RC,,,both,,,14220.90,4266.27,"KAISER [10500]",Kaiser,,9528,67,,,,,0,1653.89,12087.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH INTRO 11CM 5FR SSHTH SHRT",SUP-H7491603505B1,CDM,C1894,HCPCS,0272,RC,,,both,,,79.31,23.79,"UHC [10700]","United Healthcare",,50.2,63.3,,,,,0,9.22,67.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACK HEATING 24X15IN THERMAL-PAK OVER COTTON CANVAS NYLON",SUP-561728,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 32X23X10MM SOVEREIGN 8D SMALL",SUP-7967810,CDM,S27800098,LOCAL,0278,RC,,,both,,,34275.60,10282.68,"CIGNA [10200]","Cigna Open Access",,11482.33,33.5,,,,,0,3986.25,29134.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT COVERA 80MM 80CM 8MM 8FR FLARE VASCULAR ARTERIOVENOUS",SUP-AVFM08080,CDM,C1874,HCPCS,0278,RC,,,both,,,18270.00,5481,"KAISER [10500]",Kaiser,,12240.9,67,,,,,0,2124.8,15529.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH WOLVERINE CUTTING BALLOON (OTW)  4.00MM X 15MM",SUP-H74939402154000,CDM,C1725,HCPCS,0272,RC,,,both,,,5416.50,1624.95,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,3683.22,68,,,,,0,629.94,4604.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 50MM CD HORIZON REDUCTION MULTIAXIAL",SUP-55890007550,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"LENS IOL +7.5 DIOPTER C HAPTIC BICONVEX 13MM 6MM POSTERIOR",SUP-PCB0000075,CDM,V2632,HCPCS,0276,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HARVESTER 10MM GRAFT QUADPRO",SUP-AR-2386-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,3346.88,1004.06,"PHCS [10601]",PHCS,,2342.82,70,,,,,0,389.24,2844.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PERFORMA 100CM 3.3CM 4FR .042IN .038IN IMA CURVE",SUP-7706-10,CDM,S27200284,LOCAL,0272,RC,,,both,,,99.96,29.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL CURVE SPAT 45CM CLEANCOAT",SUP-E3771-45C,CDM,S27200284,LOCAL,0272,RC,,,both,,,316.07,94.82,"AETNA [10100]","Aetna HMO/PPO",,251.28,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.76,268.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CUTTER ENDOSCOPIC RESECTOR SHAVER BLADE 125MM STERILE LATEX",SUP-0375532000,CDM,S27200284,LOCAL,0272,RC,,,both,,,174.00,52.2,"FIRST HEALTH [10303]","First Health",,139.2,80,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT HERCULINK ELITE 15MM 135CM 5.5MM 3.3-2.9FR 6FR LOW",SUP-1011496-15,CDM,C1876,HCPCS,0278,RC,,,both,,,6300.00,1890,"BLUE CROSS [10001]","Blue Cross HMO",,2469.6,39.2,,,,,0,732.69,5355,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AUG FEMORAL 16MM PFC SIGMA 5 KNEE RIGHT TITANIUM COMBO",SUP-960912,CDM,C1776,HCPCS,0278,RC,,,both,,,5130.84,1539.25,"AETNA [10100]","Aetna HMO/PPO",,4079.02,79.5,,10981.53,8986.79,12413.38,12,596.72,4361.21,"percent of total billed charges",
"SCR BONE 4.5MM 45MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75444545,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"KIT JEJUNOSTOMY 30CM 16FR TUNGSTEN SILICONE 2CM MIC-KEY",SUP-0270-16-2.0-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1082.08,41.1,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 50CM 5FR 21GA MICROPUNCTURE .018IN LONG NDL WIRE",SUP-G49471,CDM,C1894,HCPCS,0272,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",477,MS-DRG,,,,,,,inpatient,,,125782.25,37734.67,"WELLCARE MEDICARE [30113]","Wellcare Medicare Advantage",,22071.96,,"Case rate ($21,429.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $19,898.37, add-ons for qualifying new technology services are included. If operating cost exceeds $52,938.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,886.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,924.68. The transfer operating threshold is the transfer adjustment factor * $19,898.37 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,504.41. The transfer capital threshold is the transfer adjustment factor * $1,504.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,100860.5,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE",325,MS-DRG,,,,,,,inpatient,,,199674.97,59902.49,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,20511.73,,"Case rate ($19,914.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $18,491.78, add-ons for qualifying new technology services are included. If operating cost exceeds $51,531.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,780.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $18,516.24. The transfer operating threshold is the transfer adjustment factor * $18,491.78 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,398.07. The transfer capital threshold is the transfer adjustment factor * $1,398.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,19914.3,93730.84,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 130MM LOW PROFILE NECK VERTICAL GROOVE CORAIL2",SUP-L20309,CDM,C1776,HCPCS,0278,RC,,,both,,,28658.70,8597.61,"UHC [10700]","United Healthcare",,18140.96,63.3,,8601.07,8395.67,8601.07,"1 through 10",3333.01,24359.9,"percent of total billed charges",
"LENS IOL 0 D +24.5 DIOPTER +1.5 CYL BICONVEX 13MM 6MM",SUP-SN6AT3.245,CDM,V2787,HCPCS,0276,RC,,,both,,,345.00,103.5,"CIGNA [10200]",Cigna,,234.6,68,,,,,0,40.12,293.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ROADRUNNER NIMBLE VASCULAR ANGLE TAPER 145CM 9CM .035",SUP-G07914,CDM,C1769,HCPCS,0272,RC,,,both,,,313.11,93.93,"FIRST HEALTH [10303]","First Health",,250.49,80,,,,,0,36.41,266.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE V-LOC 90 2-0 GS-22 .5 CIRCLE 9IN 27MM CLSR TAPER",SUP-VLOCM2245,CDM,S27200284,LOCAL,0272,RC,,,both,,,405.94,121.78,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,276.04,68,,,,,0,47.21,345.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABERX 150CM 100MM 2MM BALLOON DILATATION RAPID",SUP-47520100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"AMERIGROUP MEDICAID [20100]",Amerigroup,,189.09,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 22MM MODULAR RESTORATION BOWED CONICAL",SUP-6276-7-222,CDM,C1776,HCPCS,0278,RC,,,both,,,11695.32,3508.6,"PHCS [10601]",PHCS,,8186.72,70,,,,,0,1360.17,9941.02,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM SELF TAPPING VARIABLE",SUP-130.642,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPLANT BREAST GEL , TEXTURED, SHAPED, OVAL BASE, HIGH, 550C",SUP-20645-550HP,CDM,C1789,HCPCS,0278,RC,,,both,,,6555.00,1966.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,776.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",804.81,804.81,804.81,"1 through 10",762.35,5571.75,"percent of total billed charges",
"HC Up Ext Fx Orthos Humeral Nos",PX-E27400038,CDM,L3980,HCPCS,0274,RC,,,both,,,699.60,209.88,"BLUE CROSS [10001]","Blue Cross PPO",,274.24,39.2,,,,,0,81.36,594.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT INLAY OPTIMA 28CM 4.7FR TAPER URETERAL POLYMER",SUP-788428,CDM,C2625,HCPCS,0278,RC,,,both,,,729.00,218.7,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,334.61,45.9,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 70MM PRESS FIT AEQUALIS ASCEND FLEX PTC 132.5D",SUP-DWF602B,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"NOVANET [10819]",Novanet,,9450,75,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHINTOM ENDOSCOPIC 20MM 3.9FR TRUETOME CENTER LUMEN TAPER",SUP-M00583080,CDM,S27200284,LOCAL,0272,RC,,,both,,,2190.68,657.2,"AETNA [10100]","Aetna HMO/PPO",,1741.59,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,254.78,1862.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROPYLTHIOURACIL 50 MG TABLET",RX-6662,CDM,,,0637,RC,68084-0964-95,NDC,both,1,UN,16.90,5.07,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1.97,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1.97,14.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESCITALOPRAM 10 MG TABLET",RX-33512,CDM,,,0637,RC,00904-6426-61,NDC,both,1,UN,22.04,6.61,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,9.06,41.1,,,,,0,2.56,18.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM STRAIGHT 2 SERRATE ENTELLUS MEDICAL HNDPC",SUP-SSB-12400-5,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"CIGNA [10200]","Cigna Open Access",,1173.56,56.9,,,,,0,239.87,1753.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM INTEGRITY 12MM 2.5MM CORONARY STENT FULCRUM COCR",SUP-INT25012UX,CDM,C1876,HCPCS,0278,RC,,,both,,,2415.00,724.5,"FIRST HEALTH [10303]","First Health",,1932,80,,,,,0,280.86,2052.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE MULTIPASS 6-0 PS-3 18IN MONOFILAMENT BLUE",SUP-8680G,CDM,S27200284,LOCAL,0272,RC,,,both,,,65.80,19.74,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,7.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.65,55.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 130-260ML 2 CHMBR TEXTURED SURFACE INTEGRATED",SUP-20799-390ACX,CDM,S27800098,LOCAL,0278,RC,,,both,,,8625.00,2587.5,"FIRST HEALTH [10303]","First Health",,6900,80,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROPYLTHIOURACIL 50 MG TABLET",RX-6662,CDM,,,0637,RC,68084-0964-95,NDC,both,1,UN,16.90,5.07,"CIGNA [10200]",Cigna,,11.49,68,,,,,0,1.97,14.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Home Mgmt Train Ea 15min (Gp)",PX-420000029,CDM,97535,CPT,0420,RC,,,both,,,207.28,62.18,"BLUE CROSS [10001]","Blue Cross HMO",,207.28,,"Per diem ($344.92).",,,,0,24.11,207.28,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL CARDIO-GRIP DEBAKEY ANGLED 7IN PERIPHERAL",SUP-320250,CDM,S27200284,LOCAL,0272,RC,,,both,,,761.00,228.3,"NOVANET [10819]",Novanet,,570.75,75,,,,,0,88.5,646.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3MM 36MM HIP MODULAR BIOLOX DELTA",SUP-12-115120,CDM,C1776,HCPCS,0278,RC,,,both,,,8797.50,2639.25,"BLUE CROSS [10001]","Blue Cross PPO",,3448.62,39.2,,3949.44,3949.44,3949.44,"1 through 10",1023.15,7477.88,"percent of total billed charges",
"SHIELD WOUND IRRIGATION ROUND FISH SKIN SILICONE CONTACT",SUP-50215I52B0D,CDM,A2019,HCPCS,0636,RC,,,both,,,37195.20,11158.56,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4407.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,247.92,31615.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 60MM ELBOW LOCKING HEXALOBE NONSTERILE",SUP-30-0297,CDM,C1713,HCPCS,0278,RC,,,both,,,947.70,284.31,"BLUE CROSS [10001]","Blue Cross PPO",,371.5,39.2,,957.42,570.23,957.42,28,110.22,805.55,"percent of total billed charges",
"ELECTRD ELECTROSURGICAL BLADE PENCIL 15FT EDGE STERILE",SUP-E2350H-DB,CDM,S27200284,LOCAL,0272,RC,,,both,,,49.42,14.83,"FIRST HEALTH [10303]","First Health",,39.54,80,,,,,0,5.75,42.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PENTARAY 115CM 7FR 3FR 1MM 1-8-1MM SPACING F CURVE STAR",SUP-D128203,CDM,C1732,HCPCS,0272,RC,,,both,,,13634.40,4090.32,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1585.68,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1585.68,11589.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 48MM M/G STAINLESS STEEL KNEE HEADLESS",SUP-00579104100,CDM,C1713,HCPCS,0278,RC,,,both,,,530.96,159.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,151.96,28.62,,,,,0,61.75,451.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE THE MAGNET GWIRE EXCHANGE ACCEPTS 182 CM GWIRE",SUP-H74908966011,CDM,C1769,HCPCS,0272,RC,,,both,,,946.08,283.82,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,110.03,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,110.03,804.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25X10X10MM VERTE-STACK CRESCENT 6D",SUP-9192510,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,6806.16,41.1,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE BONE 1.6V L42 MM SPINE CERVICAL ANTERIOR 2 LEVEL NONST",SUP-18006242,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"KAISER [10500]",Kaiser,,3004.95,67,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CONQUEST 50CM 4CM 7MM BALLOON DILATATION PERIPHERAL",SUP-CQ5074,CDM,C1725,HCPCS,0272,RC,,,both,,,1336.50,400.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"COUNTSINK DRILL 4.5 MM HEADLESS SCR",SUP-P20-915-4500,CDM,S27200284,LOCAL,0272,RC,,,both,,,1004.40,301.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,119.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,116.81,853.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 80MM 2.8MM QUICK CONNECT STERILE",SUP-03.133.107S,CDM,S27200284,LOCAL,0272,RC,,,both,,,1013.80,304.14,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,416.67,41.1,,,,,0,117.9,861.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 54MM TITANIUM 3 LEVEL ASSURE BONE SPINE CERVICAL",SUP-110.354,CDM,C1713,HCPCS,0278,RC,,,both,,,5292.00,1587.6,"BLUE CROSS [10001]","Blue Cross HMO",,2074.46,39.2,,957.42,156.86,7483.26,51,615.46,4498.2,"percent of total billed charges",
"BURR SURGICAL 5MM MICROPOWER MICRO100 MEDIUM CARBIDE ROUND",SUP-5091-230,CDM,S27000186,LOCAL,0270,RC,,,both,,,269.79,80.94,"FIRST HEALTH [10303]","First Health",,215.83,80,,,,,0,31.38,229.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MD DOUBLE ARTERIAL CLAMP","SUP-GEM TKM-2",CDM,S27200284,LOCAL,0272,RC,,,both,,,582.39,174.72,"FIRST HEALTH [10303]","First Health",,465.91,80,,,,,0,67.73,495.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 8X9X6MM ARCH 7.5D SPINE FREEZE DRY NOTCH",SUP-15208,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"KAISER [10500]",Kaiser,,3467.25,67,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Sol Irr Nacl 9% 1000ml",PX-E27200202,CDM,E27200202,LOCAL,0272,RC,,,both,,,35.75,10.72,"AETNA [10100]","Aetna HMO/PPO",,28.42,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4.16,30.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 130-260ML 2 CHMBR TEXTURED SURFACE INTEGRATED",SUP-20799-390ACX,CDM,S27800098,LOCAL,0278,RC,,,both,,,8625.00,2587.5,"CIGNA [10200]","Cigna Open Access",,4907.63,56.9,,,,,0,1003.09,7331.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENV ABSORBABLE LARGE 3.35X3IN POLYARYLATE MINOCYCLINE",SUP-NMRM6133,CDM,S27800098,LOCAL,0278,RC,,,both,,,6175.50,1852.65,"CIGNA [10200]",Cigna,,4199.34,68,,,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HANDLE LAPSCP BRITEPRO SOLO MACINTOSH 4 METAL BLADE FIBER",SUP-040-334U,CDM,S27200284,LOCAL,0272,RC,,,both,,,72.63,21.79,"AETNA [10100]","Aetna HMO/PPO",,57.74,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.45,61.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL 0 CT-1 27IN CONTROL RELEASE MONOFILAMENT 4",SUP-YY31G,CDM,S27200284,LOCAL,0272,RC,,,both,,,91.36,27.41,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,41.93,45.9,,,,,0,10.63,77.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SMOOTH MODERATE HIGH-PROFILE BOOST, 500CC",SUP-SMHB500,CDM,C1789,HCPCS,0278,RC,,,both,,,7624.50,2287.35,"AETNA [10100]","Aetna HMO/PPO",,6061.48,79.5,,,,,0,886.73,6480.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 122MM 8MM COMPREHENSIVE PPS SHOULDER",SUP-12-113558,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3606.12,28.62,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV",RX-9801,CDM,J3480,HCPCS,0258,RC,00264-7635-00,NDC,both,1000,ML,100.65,30.19,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,11.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.02,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH NAVIGATOR HD 46CM 11-13FR ACCESS STAINLESS STEEL",SUP-M0062502230,CDM,C1894,HCPCS,0272,RC,,,both,,,980.67,294.2,"NOVANET [10819]",Novanet,,735.5,75,,,,,0,114.05,833.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 6-0 C-1 30IN 2 ARM MONOFILAMENT 4 STRAND BLUE",SUP-M8706,CDM,S27200284,LOCAL,0272,RC,,,both,,,562.13,168.64,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BARDEX IC 6FT 18FR URETHRAL BACTI-GUARD HYDROGEL 5CC",SUP-129418,CDM,S27200284,LOCAL,0272,RC,,,both,,,142.68,42.8,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"ELECTRD ELECTROSURGICAL 10MM LOOP ROUND 10MM MEGADYNE",SUP-0450,CDM,S27200284,LOCAL,0272,RC,,,both,,,96.20,28.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE AMPLATZ VASCULAR 3CM STRAIGHT TAPER 180CM 7CM .035IN",SUP-G03330,CDM,C1769,HCPCS,0272,RC,,,both,,,308.76,92.63,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CLAMP SURGICAL ROCHESTER-PEAN 8IN STRAIGHT",SUP-BH446R,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.10,57.63,"PHCS [10601]",PHCS,,134.47,70,,,,,0,22.34,163.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ULTRA NAUTILUS 20CM 3CM 8FR .038IN 2 PIGTAIL",SUP-M006192150010,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"BLUE CROSS [10001]","Blue Cross HMO",,470.63,39.2,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ZILVER FLEX 35 100MM 125CM 7MM 6FR BILIARY NITINOL",SUP-G50168,CDM,C1876,HCPCS,0278,RC,,,both,,,6090.00,1827,"CIGNA [10200]",Cigna,,4141.2,68,,,,,0,708.27,5176.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR INTERFERENCE BIOCOMPOSITE 30MM 11MM KNEE FASTTHREAD",SUP-AR-4030C-11,CDM,C1713,HCPCS,0278,RC,,,both,,,2323.13,696.94,"CIGNA [10200]",Cigna,,1579.73,68,,1831.33,1831.33,1831.33,16,270.18,1974.66,"percent of total billed charges",
"DEVICE ATRICLIP FLEX-MINI 40MM CLSR POLYESTER LOW PROFILE",SUP-ACHM40,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"AETNA [10100]","Aetna HMO/PPO",,12342.38,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL BREAST 180CC SMOOTH SHELL SURFACE HIGHLY COHESIVE GEL",SUP-SCF-200,CDM,C1789,HCPCS,0278,RC,,,both,,,7555.50,2266.65,"NOVANET [10819]",Novanet,,5666.63,75,,,,,0,878.7,6422.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 280MM 11MM LARGE QUICK COUPLING CANNULATED TAPERED",SUP-357.404,CDM,S27200284,LOCAL,0272,RC,,,both,,,2883.30,864.99,"CIGNA [10200]",Cigna,,1960.64,68,,,,,0,335.33,2450.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MATRIX WOUND 24SQ CM 2.4X1.6IN CLLGN SILICONE PORCINE TENDON",SUP-TG-M4060,CDM,A2008,HCPCS,0636,RC,,,both,,,14436.87,4331.06,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,247.92,,,,,,,247.92,12271.34,"fee schedule",
"BAND ANNULOPLASTY 40MM SIMULUS ANNULUS POSTERIOR POLYESTER",SUP-800SC40,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"BLUE CROSS [10001]","Blue Cross HMO",,5139.12,39.2,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM VANGUARD E1 KNEE CRUCIATE RETAIN LIPPED",SUP-EP-183562,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3707.06,28.62,,,,,0,1506.4,11009.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 25MM 20.4MM MASTERS-SERIES 85D STD PYROLYTIC",SUP-25MJ-501,CDM,S27800098,LOCAL,0278,RC,,,both,,,29119.23,8735.77,"UHC [10700]","United Healthcare",,18432.47,63.3,,,,,0,3386.57,24751.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT UNISTEP PLUS WALLSTENT RP 59MM 135CM 6MM 160CM",SUP-M001712070,CDM,C1876,HCPCS,0278,RC,,,both,,,8452.50,2535.75,"CIGNA [10200]",Cigna,,5747.7,68,,,,,0,983.03,7184.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 6.5MM 65MM CD HORIZON LEGACY TITANIUM SPINE",SUP-75446565,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1741.91,45.9,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 16X9MM COALITION MIS 7D LORDOTIC 14MM STERILE",SUP-3136.2109,CDM,S27800098,LOCAL,0278,RC,,,both,,,17250.00,5175,"AETNA [10100]","Aetna HMO/PPO",,13713.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROPYLTHIOURACIL 50 MG TABLET",RX-6662,CDM,,,0637,RC,68084-0964-95,NDC,both,1,UN,16.90,5.07,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH MALECOT 40FR NEPHRSTMY NATURAL RUBBER 4 WING DRAIN",SUP-086040,CDM,C1729,HCPCS,0272,RC,,,both,,,105.62,31.69,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BLADE 12MM BIOMET STAINLESS STEEL QUICK RELEASE COUPLING",SUP-430054,CDM,S27200284,LOCAL,0272,RC,,,both,,,2062.50,618.75,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"KIT BIOPSY 10CM 20GA 19GA MISSION TRUGUIDE 10MM 20MM BLUNT",SUP-2010MSK,CDM,S27200284,LOCAL,0272,RC,,,both,,,408.90,122.67,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY CATH 7FR 15CM CENTRAL VENOUS SPECTRUM 3 LUMEN CURVE NDL",SUP-G44126,CDM,C1751,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SABER .035 7X120 80CM SL",SUP-48007012N,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT VICRYL RAPIDE MULTIPASS 5-0 P-3 18IN BRAID COATED UNDYED",SUP-VR493,CDM,S27200284,LOCAL,0272,RC,,,both,,,69.98,20.99,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TRAY PERF W/FEET SM 1/2 242X252X110MM",SUP-920300,CDM,S27000186,LOCAL,0270,RC,,,both,,,838.03,251.41,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"(EVAL) TF (-T) CRADLE ASSEMBLY LHR-0078",SUP-LHR-0078,CDM,S27200284,LOCAL,0272,RC,,,both,,,0.01,,"PHCS [10601]",PHCS,,0.01,70,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM 30.7MM 24.9MM MITRAL FLEXIBLE HOLDER",SUP-4450M26,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"CIGNA [10200]",Cigna,,7741.8,68,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS HIGHFLOW 100CM 7FR MPA2 CURVE ANGIOGRAPHIC DUCOR",SUP-527742,CDM,C1887,HCPCS,0272,RC,,,both,,,137.11,41.13,"KAISER [10500]",Kaiser,,91.86,67,,,,,0,15.95,116.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2MM 13MM STAINLESS STEEL T6 SELF TAP LOCK VARIABLE",SUP-02.130.313,CDM,C1713,HCPCS,0278,RC,,,both,,,841.43,252.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,99.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,97.86,715.22,"percent of total billed charges",
"HC Colonoscopy W Decomprsn",PX-750000168,CDM,44408,CPT,0750,RC,,,both,,,3679.00,1103.7,"AETNA [10100]","Aetna HMO/PPO",,2924.81,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,427.87,3679,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LIGHTED SIGMOIDOSCOPE KIT LATEX FREE 1 LIGHTED SCOPE RECTO M",SUP-ASDSK02,CDM,S27200284,LOCAL,0272,RC,,,both,,,688.50,206.55,"MULTIPLAN [10600]",Multiplan,,585.23,85,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Tomosynthesis Breast Dgtl Dx Uni",PX-401000008,CDM,77061,CPT,0401,RC,,,both,,,310.40,93.12,"AETNA [10100]","Aetna HMO/PPO",,246.77,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.1,275,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ACUITY WHISPER VIEW DS CS-J - EACH",SUP-664643-001,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,131.88,963.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 3.5MM X 34MM COCR",SUP-VAL-35340-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,2100.00,630,"BLUE CROSS [10001]","Blue Cross PPO",,823.2,39.2,,957.42,570.23,957.42,28,244.23,1785,"percent of total billed charges",
"SYSTEM IVAS ELITE 20MM 10GA DIAGNOSTIC CATH STERILE LATEX",SUP-0808-020-800,CDM,S27200284,LOCAL,0272,RC,,,both,,,17325.00,5197.5,"KAISER [10500]",Kaiser,,11607.75,67,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MESH SURGICAL PARIETEX 6X4IN HERNIA 2D FLAT SHEET RIGID",SUP-VTX1510,CDM,C1781,HCPCS,0278,RC,,,both,,,702.51,210.75,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,322.45,45.9,,,,,0,81.7,597.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP END 5MM TIBIA STARDRIVE",SUP-04.004.001S,CDM,C1713,HCPCS,0278,RC,,,both,,,1688.40,506.52,"CIGNA [10200]","Cigna Local Plus",,903.29,53.5,,3978.14,359.25,3978.14,24,196.36,1435.14,"percent of total billed charges",
"ROD SPINAL 85MM 5.5MM MOSS MIAMI SI TITANIUM PREBENT",SUP-179772085,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"MULTIPLAN [10600]",Multiplan,,3748.5,85,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablt Liver Tmr Cryo",PX-361000370,CDM,47383,CPT,0361,RC,,,both,,,12701.00,3810.3,"MULTIPLAN [10600]",Multiplan,,10795.85,85,,,,,0,1477.13,10795.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC LARGE 13X3.5-3.75IN RIGHT WRIST HAND",SUP-81096080,CDM,L3807,HCPCS,0274,RC,,,both,,,460.89,138.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,179.46,,,,,,,53.6,391.76,"fee schedule",
"PORT ENDOSCOPIC 8.5MM SINGLE-SITE",SUP-428065,CDM,S27200284,LOCAL,0272,RC,,,both,,,1154.25,346.27,"UHC [10700]","United Healthcare",,730.64,63.3,,,,,0,134.24,981.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSTRUMENT CLAMP EM UNIVERSAL  - MAXIMUM 10 USES",SUP-8000060021,CDM,S27200284,LOCAL,0272,RC,,,both,,,16242.60,4872.78,"FIRST HEALTH [10303]","First Health",,12994.08,80,,,,,0,1889.01,13806.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CORTICAL SCREW 4MM X 42MM",SUP-HTN-U-4-42,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.20,466.56,"FIRST HEALTH [10303]","First Health",,1244.16,80,,,,,0,180.87,1321.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR Q-CURVE 3.5 GUIDING PTFE FEMORAL LARGE",SUP-H749389692930,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,249.18,68,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PASSER FIRSTPASS MINI PRELOAD NDL SUT DISPOSABLE",SUP-72290128,CDM,S27200284,LOCAL,0272,RC,,,both,,,1611.90,483.57,"FIRST HEALTH [10303]","First Health",,1289.52,80,,,,,0,187.46,1370.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING 150CM 150MM 7MM BALLOON DILATATION PEBAX",SUP-H74939032701510,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"AETNA [10100]","Aetna HMO/PPO",,965.93,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STPLR INTERNAL 30MM TITANIUM STD ENDOSCOPIC LINEAR CUTTER",SUP-TL30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1963.88,589.16,"NOVANET [10819]",Novanet,,1472.91,75,,,,,0,228.4,1669.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL DIALYSATE BGK0/2.5 POLYOLEFIN 5000ML NONPVC 2",SUP-110240,CDM,S27200284,LOCAL,0272,RC,,,both,,,332.60,99.78,"UHC [10700]","United Healthcare",,210.54,63.3,,,,,0,38.68,282.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASKET SPECIMEN RETRIEVAL 90CM 3FR 13MM STONE FLATWIRE 0 TIP",SUP-039790,CDM,S27200284,LOCAL,0272,RC,,,both,,,1016.51,304.95,"UHC [10700]","United Healthcare",,643.45,63.3,,,,,0,118.22,864.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 35X15MM CONTINENTAL 15D 24MM MEDIUM PEEK",SUP-364.615CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]",Cigna,,9576,40,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EUPHORA 142CM 6MM 3.75MM BALLOON DILATATION ULTRA-SLIM",SUP-EUP37506X,CDM,C1725,HCPCS,0272,RC,,,both,,,538.65,161.59,"MULTIPLAN [10600]",Multiplan,,457.85,85,,,,,0,62.64,457.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CHOLANGIOGRAM RAPID EXCHANGE",SUP-7565,CDM,S27200284,LOCAL,0272,RC,,,both,,,217.50,65.25,"FIRST HEALTH [10303]","First Health",,174,80,,,,,0,25.3,184.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Lyme Western Blot",PX-302000101,CDM,86617,CPT,0302,RC,,,both,,,486.40,145.92,"PHCS [10601]",PHCS,,340.48,70,,,,,0,0.01,413.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR ROSCH 2 CURVE ANGIOGRAPHIC VISCERA",SUP-M001314861,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,53.51,45.9,,,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 90MM 6MM XIA 3 TITANIUM RADIOLUCENT",SUP-48238090,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 8MM AZUR HYDROCOIL 18 COILS",SUP-45-480820,CDM,S27800098,LOCAL,0278,RC,,,both,,,6406.65,1921.99,"NOVANET [10819]",Novanet,,4804.99,75,,,,,0,745.09,5445.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 10IN 18MM REDUCE NECK SOL SYSTEM POROUS 12/14",SUP-157210180,CDM,C1776,HCPCS,0278,RC,,,both,,,39412.80,11823.84,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,11279.94,28.62,,,,,0,4583.71,33500.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Metanephrines Fract Plasma",PX-301000314,CDM,83835,CPT,0301,RC,,,both,,,424.03,127.21,"BLUE CROSS [10001]","Blue Cross HMO",,0.01,,,,,,,0.01,360.43,"per diem",
"HC Plt Lr Ea Unit",PX-390000022,CDM,P9031,HCPCS,0390,RC,,,both,,,1023.00,306.9,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,121.23,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,118.97,869.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT PALMAZ GENESIS AVIATOR FLEXSEGMENT 15MM 135CM 6MM 20MM",SUP-H739PG1860BAX3,CDM,C1876,HCPCS,0278,RC,,,both,,,6554.03,1966.21,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3008.3,45.9,,,,,0,762.23,5570.93,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 3MM AZUR CX HYDROCOIL DETACHABLE LOOP",SUP-45-780308,CDM,S27800098,LOCAL,0278,RC,,,both,,,5275.05,1582.51,"CIGNA [10200]","Cigna Open Access",,3001.5,56.9,,,,,0,613.49,4483.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 20MM 120CM 7MM 6FR VASCULAR NITINOL PERIPHERAL",SUP-S-70-020-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"MULTIPLAN [10600]",Multiplan,,7771.13,85,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY",RX-11143,CDM,,,0250,RC,45802-0758-00,NDC,both,1,UN,66.93,20.08,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,7.78,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.78,56.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SENSOR LNCS NEO-3 3FT ASSORTED OXIMETER LOW NOISE CABLED SOL",SUP-2320,CDM,S27000186,LOCAL,0270,RC,,,both,,,4.95,1.48,"AMERIGROUP MEDICAID [20100]",Amerigroup,,0.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.58,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD DEFIBRILLATOR 65CM 8FR OPTISURE ENDOCARDIUM 2 COIL DF4",SUP-LDA230Q-65,CDM,C1895,HCPCS,0278,RC,,,both,,,15180.00,4554,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4098.6,27,,,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 8CM 4MM CEREPAK XTRASOFT FREEFORM",SUP-XCR120408,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,5290.34,40,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 3.9MM 50MM MULTILOC TITANIUM NIOBIUM ALUMINUM",SUP-04.019.050S,CDM,C1713,HCPCS,0278,RC,,,both,,,1747.20,524.16,"NOVANET [10819]",Novanet,,1310.4,75,,,,,0,203.2,1485.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PACEMKR CARDIAC PROMRI 2 CHMBR ELUNA DR-T",SUP-394969,CDM,C1785,HCPCS,0275,RC,,,both,,,41600.00,12480,"KAISER [10500]",Kaiser,,27872,67,,,,,0,4838.08,35360,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD BIPOLAR 52MM 26MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-52-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"CIGNA [10200]",Cigna,,2936.08,68,,5873.17,5873.17,5873.17,"1 through 10",502.16,3670.1,"percent of total billed charges",
"BASEPLT GLENOID H+3MM 36MM INSET 0MM STD SHOULDER REVERSE",SUP-2R1GLC0336,CDM,C1776,HCPCS,0278,RC,,,both,,,12816.75,3845.02,"CIGNA [10200]","Cigna Open Access",,4293.61,33.5,,5302.19,4377.88,6578.61,27,1490.59,10894.24,"percent of total billed charges",
"VALVE AORTIC KONECT 27MM RESILIA AORTIC VALVED CONDUIT",SUP-11060A27,CDM,S27800098,LOCAL,0278,RC,,,both,,,79800.00,23940,"FIRST HEALTH [10303]","First Health",,63840,80,,,,,0,9280.74,67830,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SURPASS EVOLVE 17MM 3.25MM INTRACRANIAL FLOW DIVERTER",SUP-FDS32517,CDM,C1876,HCPCS,0278,RC,,,both,,,83024.72,24907.42,"MULTIPLAN [10600]",Multiplan,,70571.01,85,,,,,0,9655.77,70571.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH OPTITORQUE 100CM 5FR 4MM SARAH RADIAL CURVE",SUP-40-5022,CDM,C1887,HCPCS,0272,RC,,,both,,,313.20,93.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 CURVE PLUS 17.5MM KNEE XLK FIX BEARING",SUP-970424,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"KAISER [10500]",Kaiser,,7486.95,67,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE COSTAL CARTILAGE SEG THK3-20MM ALLOGRAFT FROZEN",SUP-450030,CDM,S27800098,LOCAL,0278,RC,,,both,,,4350.73,1305.22,"BLUE CROSS [10001]","Blue Cross PPO",,1705.49,39.2,,,,,0,505.99,3698.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 15CM POLYURETHANE POWER-TRIALYSIS 3 LUMEN POWER",SUP-5603150,CDM,C1752,HCPCS,0272,RC,,,both,,,1245.78,373.73,"KAISER [10500]",Kaiser,,834.67,67,,,,,0,144.88,1058.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM VISIGI 3D 36FR GASTRIC LAVAGE BULB",SUP-5236B,CDM,S27000186,LOCAL,0270,RC,,,both,,,1792.50,537.75,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1218.9,68,,,,,0,208.47,1523.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 90X25X1.47MM SAGITTAL SYSTEM 6",SUP-6125147090,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,178.79,41.1,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER FLO CHECK14FR 38X45",SUP-RCFW-14.0-38-45-RB,CDM,C1894,HCPCS,0272,RC,,,both,,,1173.69,352.11,"MULTIPLAN [10600]",Multiplan,,997.64,85,,,,,0,136.5,997.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 18MM LCP STAINLESS STEEL SMALL BONE SELF",SUP-202.218,CDM,C1713,HCPCS,0278,RC,,,both,,,748.44,224.53,"CIGNA [10200]","Cigna Open Access",,425.86,56.9,,1144.80,304.56,2275.09,66,87.04,636.17,"percent of total billed charges",
"APPL INTERNAL CLIP LARGE 17.75IN HEM-O-LOK 10MM ENDOSCOPIC",SUP-544995L,CDM,S27200284,LOCAL,0272,RC,,,both,,,18893.70,5668.11,"UHC [10700]","United Healthcare",,11959.71,63.3,,,,,0,2197.34,16059.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL F KNEE LEFT CEMENT LPS-FLEX NEXGEN TIVANIUM",SUP-596801651,CDM,C1776,HCPCS,0278,RC,,,both,,,26214.30,7864.29,"CIGNA [10200]","Cigna Local Plus",,8257.5,31.5,,5372.07,4581.20,7242.98,23,3048.72,22282.16,"percent of total billed charges",
"HC Inj Retro Ucg",PX-361000234,CDM,51610,CPT,0361,RC,,,both,,,855.96,256.79,"AETNA [10100]","Aetna HMO/PPO",,680.49,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.55,855.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC",839,MS-DRG,,,,,,,inpatient,,,35275.95,10582.78,"ALLIANT SOLOCARE  [11101]","Alliant Solocare",,18237.43,,"Case rate ($8,956.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $8,316.81, add-ons for qualifying new technology services are included. If operating cost exceeds $41,356.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $2,010.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $8,327.81. The transfer operating threshold is the transfer adjustment factor * $8,316.81 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.79. The transfer capital threshold is the transfer adjustment factor * $628.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.62%.",,,,0,7561,35275.95,other,"IP DRGS Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SAW 31X9X.51MM TPS MICRO OSCILLATING SAGITTAL STERILE",SUP-2296033519,CDM,S27200284,LOCAL,0272,RC,,,both,,,290.84,87.25,"CIGNA [10200]","Cigna Local Plus",,155.6,53.5,,,,,0,33.82,247.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SPINAL 14MM 4MM CODA SPINE SELF TAP VARIABLE ANGLE",SUP-102254014,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GUIDE 22MM HELI-FX 16FR",SUP-SA-64,CDM,S27200284,LOCAL,0272,RC,,,both,,,9775.02,2932.51,"MULTIPLAN [10600]",Multiplan,,8308.77,85,,,,,0,1136.83,8308.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 38MM 145CM 3.25MM CORONARY STENT",SUP-1145325-38,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,691.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 9-0 V100-3 5IN MONOFILAMENT BLACK NONABSORBABLE",SUP-2894G,CDM,S27200284,LOCAL,0272,RC,,,both,,,238.83,71.65,"AETNA [10100]","Aetna HMO/PPO",,189.87,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.78,203.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT POLYESTER ETHIBOND 2-0 SH 30IN 2 ARM BRAID GREEN",SUP-X563H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,3.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LINEAR 6IN 7.5FR .025IN IAB DURATHANE 40ML INSRT KIT",SUP-0684-00-0480-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,5588.79,1676.64,"MULTIPLAN [10600]",Multiplan,,4750.47,85,,,,,0,649.98,4750.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ablation Renal Tumors Bi Cryo",PX-361000353,CDM,50593,CPT,0361,RC,,,both,,,16134.00,4840.2,"KAISER [10500]",Kaiser,,10809.78,67,,,,,0,1876.38,13713.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN NAVIGATION 150MM 3MM PRECISION NAVIGATION SYSTEM KNEE",SUP-6007-003-150,CDM,S27200284,LOCAL,0272,RC,,,both,,,669.22,200.77,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,455.07,68,,,,,0,77.83,568.84,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR RAABE 70CM 5FR 1.9MM GUIDING AQ CHECK-FLO",SUP-G13091,CDM,C1894,HCPCS,0272,RC,,,both,,,445.50,133.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,52.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,51.81,378.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GAG MOUTH 3 BLADE TONGUE GUARD MCIVOR",SUP-45-5320X,CDM,S27000186,LOCAL,0270,RC,,,both,,,88.65,26.59,"FIRST HEALTH [10303]","First Health",,70.92,80,,,,,0,10.31,75.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 8.5FR 71CM STEERABLE SMALL CURL DUAL REACH",SUP-408309,CDM,C1766,HCPCS,0272,RC,,,both,,,3754.80,1126.44,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2553.26,68,,,,,0,436.68,3191.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 138MM 13MM PRIMARY PRESS FIT TIVANIUM 12/14 45",SUP-786401320,CDM,C1776,HCPCS,0278,RC,,,both,,,30164.40,9049.32,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3574.48,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3508.12,25639.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7MM 45MM MATRIX TITANIUM T25 SPINE PEDICLE",SUP-04.639.745,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross PPO",,1487.64,39.2,,957.42,570.23,957.42,28,441.36,3225.75,"percent of total billed charges",
"HEAD BIPOLAR 42MM 26MM UHR UNIVERSAL HIP COCR UHMWPE",SUP-UH1-42-26,CDM,C1776,HCPCS,0278,RC,,,both,,,4317.77,1295.33,"AETNA [10100]","Aetna HMO/PPO",,3432.63,79.5,,10981.53,8986.79,12413.38,12,502.16,3670.1,"percent of total billed charges",
"HC Selct Plc Cath Extrnl Cartd",PX-361000293,CDM,36227,CPT,0361,RC,,,both,,,3629.33,1088.8,"PHCS [10601]",PHCS,,2540.53,70,,,,,0,422.09,3629.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS PENILE AMS SPECTRA 3CM 12/14MM CONCEALABLE REAR TIP EXT",SUP-72404323,CDM,C2622,HCPCS,0278,RC,,,both,,,0.01,,"CIGNA [10200]",Cigna,,0.01,68,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SPECIMEN RETRIEVAL 90CM 3FR HOOK PRONG GRASP RETRACT",SUP-M0063701140,CDM,S27200284,LOCAL,0272,RC,,,both,,,1376.11,412.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,565.58,41.1,,,,,0,160.04,1169.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II VASCULAR",SUP-1009665,CDM,C1769,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION",RX-10059,CDM,,,0250,RC,14789-0122-07,NDC,both,5,ML,2226.66,668,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,915.16,41.1,,,,,0,258.96,1892.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL DARK BLUE 15MM SYNFIX 18D MEDIUM EVOLUTION 6.9",SUP-08.815.264S,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,7654.5,27,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FLEXABILITY SENSOR ENABLED ENSITE PRECISION MEDIGUIDE",SUP-A-FASE-FJ,CDM,S27200284,LOCAL,0272,RC,,,both,,,12765.00,3829.5,"PHCS [10601]",PHCS,,8935.5,70,,,,,0,1484.57,10850.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD NEROSTIMLTR 30CM PRECISION PERCUTANEOUS PHASE III",SUP-SC-2158-30,CDM,C1778,HCPCS,0278,RC,,,both,,,8914.80,2674.44,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2551.42,28.62,,,,,0,1036.79,7577.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VIA MATRIX (4 X 4) 16 SQ CM",SUP-585-006,CDM,Q4309,HCPCS,0636,RC,,,both,,,114000.00,34200,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2366.1,,,,,,,247.92,96900,"fee schedule",
"TOOL 7CM MR8 3MM BALL COARSE GRIT DISSECTING DIAMOND",SUP-MR8-7BA30DC,CDM,S27200284,LOCAL,0272,RC,,,both,,,1142.51,342.75,"AMERIGROUP MEDICAID [20100]",Amerigroup,,135.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,132.87,971.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 100CM 6FR .056IN FULL LENGTH AMPLATZ RIGHT 2 CURVE",SUP-H74908641862,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,35.15,45.9,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN OPHTHALMIC 5MM 27GA AIR INJECTION",SUP-60-1148,CDM,S27200284,LOCAL,0272,RC,,,both,,,75.08,22.52,"NOVANET [10819]",Novanet,,56.31,75,,,,,0,8.73,63.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DORZOLAMIDE 2 % EYE DROPS",RX-14471,CDM,,,0250,RC,42571-0141-26,NDC,both,10,ML,420.17,126.05,"CIGNA [10200]","Cigna Local Plus",,224.79,53.5,,,,,0,48.87,357.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT CONTOUR 26CM 3CM 6FR .035IN PIGTAIL CURVE STRAIGHT",SUP-M006180223050,CDM,C2617,HCPCS,0278,RC,,,both,,,1041.58,312.47,"KAISER [10500]",Kaiser,,697.86,67,,,,,0,121.14,885.34,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE T COMPRESSION SLOT FUSION ORTHOLOC 3DI BONE MIDFOOT",SUP-5818001L,CDM,C1713,HCPCS,0278,RC,,,both,,,9308.10,2792.43,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,3825.63,41.1,,,,,0,1082.53,7911.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC MRI Upr Ext Nonjnt WO Cntrst",PX-610000024,CDM,73218,CPT,0610,RC,,,both,,,3640.89,1092.27,"FIRST HEALTH [10303]","First Health",,2912.71,80,,,,,0,423.44,3094.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 34MM VERTEX MAX TITANIUM SPINE MULTIAXIAL",SUP-6958734,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 82MM 24MM 7.1MM 18FR ZENITH FLEX Z-TRAK 2",SUP-G48407,CDM,C1874,HCPCS,0278,RC,,,both,,,48686.90,14606.07,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,13145.46,27,,,,,0,5662.29,41383.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR/ELEV LAPAROSCOPIC 34MM VCARE PLUS CUP CERVICAL",SUP-60-6085-201A,CDM,S27200284,LOCAL,0272,RC,,,both,,,522.45,156.73,"CIGNA [10200]",Cigna,,355.27,68,,,,,0,60.76,444.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Out of or Bedside Procedure",PX-361000431,CDM,361000431,LOCAL,0361,RC,,,both,,,5325.22,1597.57,"FIRST HEALTH [10303]","First Health",,4260.18,80,,,,,0,619.32,4526.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ptt Mixng Studies",PX-305000065,CDM,85730,CPT,0305,RC,,,both,,,182.40,54.72,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9.45,,,,,,,0.18,155.04,"fee schedule",
"FILLER BONE VOID 20CC DBX ALLOGRAFT FREEZE DRY MIX",SUP-58200,CDM,S27800098,LOCAL,0278,RC,,,both,,,15525.00,4657.5,"MULTIPLAN [10600]",Multiplan,,13196.25,85,,,,,0,1805.56,13196.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Insitu Hybridization Quant Cad",PX-312000057,CDM,88367,CPT,0312,RC,,,both,,,1242.00,372.6,"MULTIPLAN [10600]",Multiplan,,1055.7,85,,,,,0,0.01,1055.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Neisseria Gonorr Dna Dir",PX-306000141,CDM,87590,CPT,0306,RC,,,both,,,290.00,87,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,34.37,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,246.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Echo 2d WO Spect/Color Complt W Contr",PX-483000005,CDM,93307,CPT,0483,RC,,,both,,,2274.00,682.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,934.61,41.1,,,,,0,240.91,1932.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DIAMONDBACK 360 145CM 10MM .063- MM 1.5MM .014IN",SUP-DBP-CART-150SOL145,CDM,C1724,HCPCS,0272,RC,,,both,,,17250.00,5175,"FIRST HEALTH [10303]","First Health",,13800,80,,,,,0,2006.18,14662.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTALINK 135CM 1.25MM ATHERECTOMY BURR EXCHANGE",SUP-H749393001250,CDM,C1724,HCPCS,0272,RC,,,both,,,17325.00,5197.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,7120.58,41.1,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Xr Chest 3v",PX-324000011,CDM,71047,CPT,0324,RC,,,both,,,426.52,127.96,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,46.01,,,,,,,46.01,362.54,"fee schedule",
"STEM FEMORAL 127MM 11MM MRS KNEE",SUP-6485-3-111,CDM,C1776,HCPCS,0278,RC,,,both,,,14800.50,4440.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1753.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1721.3,12580.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY BIOPSY BIOSEAL BONE FLAP AUTOLOGOUS SKULL STERILE LATEX",SUP-BIEBBF00710,CDM,S27200284,LOCAL,0272,RC,,,both,,,356.10,106.83,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,146.36,41.1,,,,,0,41.41,302.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT VASCULAR 50CM 8/10/30MM HEMASHIELD PLATINUM 4 BRANCH",SUP-M00202175930P0,CDM,C1768,HCPCS,0278,RC,,,both,,,11611.73,3483.52,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3135.17,27,,,,,0,1350.44,9869.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH FLEXOR CHECK-FLO BALKIN CURVE 40CM 8FR 2.9MM GUIDING",SUP-G10385,CDM,C1894,HCPCS,0272,RC,,,both,,,405.25,121.57,"AMERIGROUP MEDICAID [20100]",Amerigroup,,48.02,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,47.13,344.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 0 MO-4 27IN CONTROL RELEASE BRAID 8 STRAND",SUP-VCPP71D,CDM,S27200284,LOCAL,0272,RC,,,both,,,179.65,53.89,"NOVANET [10819]",Novanet,,134.74,75,,,,,0,20.89,152.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chromosome Karyotype Study Addl",PX-311000069,CDM,88280,CPT,0311,RC,,,both,,,598.50,179.55,"CIGNA [10200]","Cigna Open Access",,73.63,,,,,,,0.01,508.73,"fee schedule",
"PHENOBARBITAL SODIUM 130 MG/ML VIAL FOR IM USE",RX-411684,CDM,J2560,HCPCS,0636,RC,00641-0477-21,NDC,both,1,ML,372.40,111.72,"CIGNA [10200]","Cigna Open Access",,156.35,,,,,,,7.76,316.54,"fee schedule",
"CATH SABERX 150CM 100MM 6MM BALLOON DILATATION RAPID",SUP-47560100M,CDM,C1725,HCPCS,0272,RC,,,both,,,1595.70,478.71,"AETNA [10100]","Aetna HMO/PPO",,1268.58,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,185.58,1356.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Dest Rectal Tmr Trnsanal",PX-750000157,CDM,45190,CPT,0750,RC,,,both,,,12954.00,3886.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1535.05,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1506.55,11010.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 45MM 5.5MM ES2 RADIUS TITANIUM HEXAGONAL",SUP-482806045,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]",Cigna,,826.2,68,,1831.33,1831.33,1831.33,16,141.3,1032.75,"percent of total billed charges",
"CATH VISTA BRITE TIP TRUELUMEN 100CM .1IN 8FR .088IN HOCKEY",SUP-588850,CDM,C1887,HCPCS,0272,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH BALLOON DILATATION .018IN 4FR 5MM 135CM 4CM PTA LOW",SUP-G50237,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC US Abd Ltd",PX-402000009,CDM,76705,CPT,0402,RC,,,both,,,1183.10,354.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure count. Procedure 1, Fee schedule rate ($136.31). Procedures 2 - 999, Fee schedule rate ($68.15).",136.30,136.30,136.30,"1 through 10",,,"fee schedule",
"CATH LAUNCHER 110CM 5FR .058IN EBU4 CURVE GUIDING CORONARY",SUP-LA5EBU40A,CDM,C1887,HCPCS,0272,RC,,,both,,,365.40,109.62,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"DRILL TWIST 30MM 2MM SPEEDGUIDE AO",SUP-703891,CDM,S27200284,LOCAL,0272,RC,,,both,,,1374.41,412.32,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"PROBE LITHO 120CM 5FR ELECTROHYDRAULIC STERILE AEH2 3",SUP-E-5F,CDM,S27200284,LOCAL,0272,RC,,,both,,,1180.28,354.08,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE GUIDERIGHT VASCULAR J 180CM 3CM .032IN SUPER STIFF",SUP-404560,CDM,C1769,HCPCS,0272,RC,,,both,,,174.00,52.2,"KAISER [10500]",Kaiser,,116.58,67,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DTECT CARBON DIOXIDE END TIDAL COLORIMETRIC LATEX FREE","SUP-PEDICAP 6",CDM,S27200284,LOCAL,0272,RC,,,both,,,82.22,24.67,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,9.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,9.56,69.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 125CM 6FR Q-CURVE 4.5 GUIDING PTFE FEMORAL LARGE",SUP-H749389692950,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,43.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 5CM 5.5MM TSRH SILO STD PEDICLE TITANIUM PREBENT",SUP-8370050,CDM,C1713,HCPCS,0278,RC,,,both,,,4410.00,1323,"PHCS [10601]",PHCS,,3087,70,,,,,0,512.88,3748.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 63CM VERSACROSS 45D TRANSSEPTAL PIGTAIL RF WIRE 1",SUP-VXSK0022,CDM,C1893,HCPCS,0272,RC,,,both,,,6175.50,1852.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,731.8,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,718.21,5249.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 17MM HELIX R SPINE SELF TAP VARIABLE ANGLE",SUP-7805117,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM AVENIR HELICAL 10 COIL FINISH",SUP-10HFN-02006,CDM,S27800098,LOCAL,0278,RC,,,both,,,10343.10,3102.93,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4251.01,41.1,,,,,0,1202.9,8791.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL 45D BALL COOLCUT STERILE SMALL JOINT",SUP-AR-9808SJ-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,978.08,293.42,"KAISER [10500]",Kaiser,,655.31,67,,,,,0,113.75,831.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT 20CM 6FR 2.1FR POLARIS ULTRA NAUTILUS .035IN 2",SUP-M006192130050,CDM,C2617,HCPCS,0278,RC,,,both,,,1200.58,360.17,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,551.07,45.9,,,,,0,139.63,1020.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 55X18X8-15MM RISE-L 6D",SUP-193.325,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9270.45,27,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRACE ORTHOPEDIC XL THERMOPLASTIC PREFABRICATE LIGHWEIGHT",SUP-FB1000-16,CDM,S27000186,LOCAL,0270,RC,,,both,,,435.00,130.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,51.55,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SOL INTRAVENOUS 10% DEXTROSE EXCEL 500ML LATEX FREE",SUP-L5201,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.00,24.3,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,55.08,68,,,,,0,9.42,68.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 14X6MM GRAFTECH 7D 11MM CERVICAL CANCELLOUS",SUP-A80056,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE 4MM SHUTT GREEN ENDOSCOPIC LAPAROSCOPIC STRAIGHT",SUP-21.1002,CDM,S27200284,LOCAL,0272,RC,,,both,,,1026.19,307.86,"UHC [10700]","United Healthcare",,649.58,63.3,,,,,0,119.35,872.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMAGER II 65CM 5FR CONTRALATERAL CURVE ANGIOGRAPHIC",SUP-M001315281,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.04,22.81,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,34.9,45.9,,,,,0,8.84,64.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 8X60 135CM SL",SUP-48008006R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,101.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) LAA - AMPLATZ CARDIAC PLUG 2-IDE-028",SUP-9-ACP2-IDE-028,CDM,S62400003,LOCAL,0624,RC,,,both,,,63452.40,19035.72,"FIRST HEALTH [10303]","First Health",,50761.92,80,,,,,0,7379.51,53934.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT FRMLA 418 16MM 135CM 5MM .018IN BILIARY STAINLESS",SUP-G56623,CDM,C1876,HCPCS,0278,RC,,,both,,,5040.00,1512,"BLUE CROSS [10001]","Blue Cross HMO",,1975.68,39.2,,,,,0,586.15,4284,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 8FR L20CM SOFT WITHOUT GUIDEWIRE TRIA",SUP-M0061903400,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 30MM TIGER CANNULATED",SUP-200-30-030,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"CIGNA [10200]","Cigna Local Plus",,606.69,53.5,,3978.14,359.25,3978.14,24,131.88,963.9,"percent of total billed charges",
"KIT CATH 135CM 2.8FR RENEGADE HI-FLO TRANSEND-18 165CM 38CM",SUP-M001183020,CDM,C1887,HCPCS,0272,RC,,,both,,,4726.50,1417.95,"NOVANET [10819]",Novanet,,3544.88,75,,,,,0,549.69,4017.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH GLIDECATH GLIDE TECHNOLOGY 100CM 15CM 4FR .041IN ANGLE",SUP-CG416,CDM,S27200284,LOCAL,0272,RC,,,both,,,435.00,130.5,"MULTIPLAN [10600]",Multiplan,,369.75,85,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT URETERAL 7FR L22CM SOFT WITHOUT GUIDEWIRE TRIA",SUP-M0061903310,CDM,C2617,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross HMO",,638.18,39.2,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY MONORAIL 24MM 5MM CORONARY STENT PLATINUM",SUP-H7493926024500,CDM,C1874,HCPCS,0278,RC,,,both,,,9315.00,2794.5,"NOVANET [10819]",Novanet,,6986.25,75,,,,,0,1083.33,7917.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMPL ORBITAL ROUND MEDPOR POLYETHYLENE 18MM",SUP-6327,CDM,S27800098,LOCAL,0278,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2.5MM AXIUM PRIME 3D EXTRA SOFT",SUP-APB-2.5-6-3D-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,11695.50,3508.65,"CIGNA [10200]","Cigna Open Access",,3917.99,33.5,,,,,0,1360.19,9941.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1 X 1 COMPLEX PICO COIL",SUP-10USC01001,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"KAISER [10500]",Kaiser,,8760.59,67,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC PERI 23MM (PERI)",SUP-3300TFX23MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,40887.00,12266.1,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,16354.8,40,,,,,0,4755.16,34753.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE BICORTICAL ILIUM ALLOGRAFT STRIP FREEZE DRIED",SUP-P00257,CDM,S27800098,LOCAL,0278,RC,,,both,,,5197.08,1559.12,"AETNA [10100]","Aetna HMO/PPO",,4131.68,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,604.42,4417.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Asp Cyst Invert Disc/Paravert",PX-361000450,CDM,62267,CPT,0361,RC,,,both,,,3631.00,1089.3,"BLUE CROSS [10001]","Blue Cross HMO",,2490.09,,"Case rate ($2,490.09). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,422.29,3086.35,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 12X19MM FORTIFY 12MM NONSTERILE LATEX FREE",SUP-151.051,CDM,S27800098,LOCAL,0278,RC,,,both,,,32098.50,9629.55,"UHC [10700]","United Healthcare",,20318.35,63.3,,,,,0,3733.06,27283.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 22MM 31MM 41MM 28MM MOSAIC CINCH RING HEART",SUP-310C31,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"BLUE CROSS [10001]","Blue Cross HMO",,10742.76,39.2,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X60 40CM SL",SUP-48007006P,CDM,C1725,HCPCS,0272,RC,,,both,,,982.13,294.64,"NOVANET [10819]",Novanet,,736.6,75,,,,,0,114.22,834.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 10X38X28MM 15DEG",SUP-1921047P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,4106.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL ALIF 3DP INTERFIXATED 10X38X28MM 15DEG",SUP-1921047P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,9355.5,27,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT STRATAMR II ADJUSTABLE",SUP-42955MR,CDM,S27800098,LOCAL,0278,RC,,,both,,,42777.00,12833.1,"UHC [10700]","United Healthcare",,27077.84,63.3,,,,,0,4974.97,36360.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 8MM MREYE 4 LOOP .035IN PLATINUM",SUP-G20452,CDM,S27800098,LOCAL,0278,RC,,,both,,,834.22,250.27,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,97.02,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,97.02,709.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"POST EXTERNAL FIXATION 11MM 11MM 30D OUTRIGGER NONSTERILE",SUP-390.012,CDM,S27800098,LOCAL,0278,RC,,,both,,,737.10,221.13,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,338.33,45.9,,,,,0,85.72,626.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 6CM 2MM AXIUM PRIME HELIX EXTRA SOFT",SUP-APB-2-6-HX-ES,CDM,S27800098,LOCAL,0278,RC,,,both,,,8935.50,2680.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1058.86,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1039.2,7595.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM LARGE ALLOGRAFT BLOCK FREEZE",SUP-T00220,CDM,S27800098,LOCAL,0278,RC,,,both,,,6109.95,1832.98,"PHCS [10601]",PHCS,,4276.97,70,,,,,0,710.59,5193.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 11CM 26MM 36MM 23.4MM GELWEAVE VALSALVA ON-X",SUP-ONXAAP-27/29,CDM,S27800098,LOCAL,0278,RC,,,both,,,51187.50,15356.25,"CIGNA [10200]",Cigna,,20475,40,,,,,0,5953.11,43509.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM BIRMINGHAM BICEPS FIXATION STERILE LATEX FREE",SUP-AR-1662S-1,CDM,C1713,HCPCS,0278,RC,,,both,,,5071.50,1521.45,"AMERIGROUP MEDICAID [20100]",Amerigroup,,600.97,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",589.82,4310.78,"percent of total billed charges",
"COIL EMBOLIZATION 8CM 3.5MM PRESTIGE PLUS HELICAL ULTRA",SUP-PRES0358CXPPL,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1481.09,28.62,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 16.1CM 8MM .01IN MICRUSFRAME .015IN MICRO",SUP-MFR100816,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3208.09,27,,,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17.8MM 25MM 32MM 23.4MM ON-X 25 STD CYLINDRICAL",SUP-ONXAE-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,37800.00,11340,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10206,27,,,,,0,4396.14,32130,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE SHUNT RICKHAM 70MM 2O PRECISION NO CATH PROGRAMMABLE",SUP-NS0567,CDM,S27800098,LOCAL,0278,RC,,,both,,,6819.27,2045.78,"CIGNA [10200]","Cigna Open Access",,3880.16,56.9,,,,,0,793.08,5796.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COROENT XL-XW, 14X26X55MM",SUP-6214055,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,6463.8,27,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 45X22X7MM RISE-L NONSTERILE",SUP-193.403,CDM,S27800098,LOCAL,0278,RC,,,both,,,34335.00,10300.5,"CIGNA [10200]",Cigna,,13734,40,,,,,0,3993.16,29184.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TARGET 360 STANDARD 3MMX8CM",SUP-M0035463080,CDM,S27800098,LOCAL,0278,RC,,,both,,,14114.64,4234.39,"FIRST HEALTH [10303]","First Health",,11291.71,80,,,,,0,1641.53,11997.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABLE, 12X30MM, 7-14MM, 15%C2%B0",SUP-1172.4221S,CDM,S27800098,LOCAL,0278,RC,,,both,,,34650.00,10395,"CIGNA [10200]","Cigna Open Access",,11607.75,33.5,,,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 330711 ACSR 7X11X11 SRVC FEE",SUP-330711,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"NOVANET [10819]",Novanet,,3881.25,75,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRODUCER PACING LEAD ACUITY 8FR LONG",SUP-667471-001,CDM,C1894,HCPCS,0272,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ACCUSTICK II 6FR INTRO STERILE DISPOSABLE",SUP-M001207050,CDM,C1894,HCPCS,0272,RC,,,both,,,526.50,157.95,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SET CLAMP FOGARTY HYDRAGRIP HYDRAJAW TRACTIONJAW 61MM",SUP-HYDRA61,CDM,S27200284,LOCAL,0272,RC,,,both,,,281.27,84.38,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT SUTURETAPE .5 CIRCLE 40INX1.3MM TAPER END REVERSE CUT",SUP-AR-7502,CDM,S27200284,LOCAL,0272,RC,,,both,,,319.73,95.92,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,146.76,45.9,,,,,0,37.18,271.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP SURGICAL FOGARTY 8MM 2 SOFTJAW ATRAUMATIC OCCLUSION",SUP-HCDSOFT8,CDM,S27200284,LOCAL,0272,RC,,,both,,,78.30,23.49,"KAISER [10500]",Kaiser,,52.46,67,,,,,0,9.11,66.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHILON 10-0 BV130-3 5IN MONOFILAMENT BLACK",SUP-2820G,CDM,S27200284,LOCAL,0272,RC,,,both,,,192.81,57.84,"UHC [10700]","United Healthcare",,122.05,63.3,,,,,0,22.42,163.89,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WATCHMAN FLX PROCEDURE  TRUSEAL ACCESS SYSTEM",SUP-WMFLXTRUACCPERPROC,CDM,S27800098,LOCAL,0278,RC,,,both,,,6900.00,2070,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,802.47,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,802.47,5865,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PATCH DURAL 7X5IN THK3.5MM CRANIOMAXILLOFACIAL",SUP-DMOP57,CDM,S27800098,LOCAL,0278,RC,,,both,,,15989.99,4797,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4576.34,28.62,,,,,0,1859.64,13591.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2.5CM 2.5MM CEREPAK XTRASOFT FREEFORM",SUP-XCR122525,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"FIRST HEALTH [10303]","First Health",,10580.68,80,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 15MM MASTERS HP SERIES LATEX FREE",SUP-15MHPJ-505,CDM,S27800098,LOCAL,0278,RC,,,both,,,60064.20,18019.26,"MULTIPLAN [10600]",Multiplan,,51054.57,85,,,,,0,6985.47,51054.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 39MM SIMULUS C FULL FLEXIBLE STERILE",SUP-700FC39,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"PHCS [10601]",PHCS,,9177,70,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 6MM PRESTIGE PLUS COMPLEX PACK ULTRA",SUP-PRES0650CPKPLT,CDM,S27800098,LOCAL,0278,RC,,,both,,,7935.00,2380.5,"NOVANET [10819]",Novanet,,5951.25,75,,,,,0,922.84,6744.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 2.5CM 2.5MM CEREPAK XTRASOFT FREEFORM",SUP-XCR122525,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"CIGNA [10200]","Cigna Local Plus",,4166.14,31.5,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 16CM 10MM .0135IN MICRUSFRAME MICRO",SUP-MFR141016,CDM,S27800098,LOCAL,0278,RC,,,both,,,11881.80,3564.54,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1407.99,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1381.85,10099.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PIPELINE FLEX 14MM 3.25MM EMBOLIZATION",SUP-PED2-325-14,CDM,S27800098,LOCAL,0278,RC,,,both,,,80797.50,24239.25,"UHC [10700]","United Healthcare",,51144.82,63.3,,,,,0,9396.75,68677.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXT AORTIC 4.5CM 26MM EXCLUDER CONFORMABLE ACTIVE CONTROL",SUP-CXA260005,CDM,C1874,HCPCS,0278,RC,,,both,,,27612.90,8283.87,"BLUE CROSS [10001]","Blue Cross HMO",,10824.26,39.2,,9776.84,9776.84,9776.84,"1 through 10",3211.38,23470.97,"percent of total billed charges",
"BAND SCLERAL 100X2.5X.6MM SILICONE TYPE 240 BUCKLE ELASTIC",SUP-S5.2000,CDM,S27800098,LOCAL,0278,RC,,,both,,,174.00,52.2,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,49.8,28.62,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CORNERSTONE SELECT CORTICAL FIBULA WEDGE 7MM",SUP-210700,CDM,S27800098,LOCAL,0278,RC,,,both,,,3018.75,905.62,"NOVANET [10819]",Novanet,,2264.06,75,,,,,0,351.08,2565.94,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 10CM 3MM AZUR .018IN",SUP-45-480310,CDM,S27800098,LOCAL,0278,RC,,,both,,,5678.70,1703.61,"CIGNA [10200]","Cigna Open Access",,3231.18,56.9,,,,,0,660.43,4826.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 34MM 2 MARKER SEMIRIGID WIRE STIFFENER",SUP-800SR34,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,5388.21,41.1,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHUNT CARDIOVASCULAR CLEARVIEW SILICONE L14 MM OD2 MM INTRAC",SUP-31200,CDM,S27800098,LOCAL,0278,RC,,,both,,,632.53,189.76,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,181.03,28.62,,,,,0,73.56,537.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE CENTERPIECE ALLOGRAFT STRUT 14MM",SUP-853914,CDM,S27800098,LOCAL,0278,RC,,,both,,,3412.50,1023.75,"BLUE CROSS [10001]","Blue Cross HMO",,1337.7,39.2,,,,,0,396.87,2900.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30MMX12MM CRESCENT LORDOTIC",SUP-293012,CDM,S27800098,LOCAL,0278,RC,,,both,,,24290.28,7287.08,"PHCS [10601]",PHCS,,17003.2,70,,,,,0,2824.96,20646.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT CATH 135CM 2.7FR DRAGONFLY OPTIS 20MM HYDROPHILIC",SUP-C408646,CDM,S27800098,LOCAL,0278,RC,,,both,,,4485.00,1345.5,"MULTIPLAN [10600]",Multiplan,,3812.25,85,,,,,0,521.61,3812.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 23-27MMX13MM FRA 12D LORDOTIC NARROW SPINE",SUP-2313,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"FIRST HEALTH [10303]","First Health",,15120,80,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EDWARDS PASCAL ACE PRECISION IMPLANT SYSTEM (5MM)",SUP-20000ISM,CDM,S62400003,LOCAL,0624,RC,,,both,,,199500.00,59850,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,135660,68,,,,,0,23201.85,169575,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH THERMOCOOL SF 115CM 8FR D CURVE ABLATION",SUP-D131602,CDM,C1732,HCPCS,0272,RC,,,both,,,10149.90,3044.97,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6901.93,68,,,,,0,1180.43,8627.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ABSOLUTE PRO 30MM 135CM 6MM VASCULAR NITINOL",SUP-1012534-30,CDM,C1876,HCPCS,0278,RC,,,both,,,4140.00,1242,"AETNA [10100]","Aetna HMO/PPO",,3291.3,79.5,,,,,0,481.48,3519,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE GRAFTECH DOWEL ALLOGRAFT 11MM CERVICAL",SUP-4411211,CDM,S27800098,LOCAL,0278,RC,,,both,,,12335.82,3700.75,"KAISER [10500]",Kaiser,,8265,67,,,,,0,1434.66,10485.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 360MM TIBIA NAIL-EX INTRAMEDULLARY CANNULATED",SUP-04.034.452S,CDM,C1713,HCPCS,0278,RC,,,both,,,8166.56,2449.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3748.45,45.9,,,,,0,949.77,6941.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 0 CT-2 SPIRAL 12IN CLSR ABSORBABLE",SUP-SXPP1B405,CDM,S27200284,LOCAL,0272,RC,,,both,,,224.03,67.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH NAVISTAR 115CM 4MM 7FR 1-7-4MM SPACING B CURVE ABLATION",SUP-NS7TCBL174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,13731.00,4119.3,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GRAFT SKIN READIGRAFT CRYOSKIN 500SQ CM FIBROBLAST",SUP-SK-H,CDM,Q4433,HCPCS,0636,RC,,,both,,,8843.25,2652.97,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM RELIEVA SPINPLUS 16MM 6MM DILATION MAXILLARY FRONTAL",SUP-RSP0616MFSN,CDM,C1726,HCPCS,0272,RC,,,both,,,15007.50,4502.25,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SUT STRATAFIX PDS PLUS 1 CTX SPIRAL 14IN ABSORBABLE",SUP-SXPP2B405,CDM,S27200284,LOCAL,0272,RC,,,both,,,214.66,64.4,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MITRACLIP G4 SYSTEM ONE (1) STEERABLE GUIDE CATHETER SGC0701",SUP-CDS0706-XT,CDM,S27800098,LOCAL,0278,RC,,,both,,,0.01,,"AMERIGROUP MEDICAID [20100]",Amerigroup,,,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"MASK CPAP MEDIUM FULL 2 FLAP FOREHEAD SPRT HEADSTRAP CLIP",SUP-1012624,CDM,S27000186,LOCAL,0270,RC,,,both,,,1822.88,546.86,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"HC Sr89 Strontium per Mci",PX-344000006,CDM,A9600,HCPCS,0344,RC,,,both,,,10293.00,3087.9,"PHCS [10601]",PHCS,,7205.1,70,,,,,0,1197.08,8749.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IMMOB ORTHOPEDIC UNIVERSAL 24IN 12-24IN KNEE 3 PANEL T BAR",SUP-7091-52,CDM,L1830,HCPCS,0274,RC,,,both,,,264.57,79.37,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,121.44,45.9,,,,,0,30.77,224.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"THOMASMEDICAL INTRDCR FR10 LONG",SUP-6276,CDM,C1894,HCPCS,0272,RC,,,both,,,139.20,41.76,"FIRST HEALTH [10303]","First Health",,111.36,80,,,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 6 KNEE LEFT CEMENTED CRUCIATE RETAINING ATTUNE",SUP-150400106,CDM,C1776,HCPCS,0278,RC,,,both,,,22393.35,6718,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,6408.98,28.62,,,,,0,2604.35,19034.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 4CM 2MM RUBY LP STERILE LATEX FREE",SUP-RBYLP0204,CDM,S27800098,LOCAL,0278,RC,,,both,,,5451.00,1635.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1560.08,28.62,,,,,0,633.95,4633.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH PENTARAY 7FR 2-6-2MM D CURVE ELECTROPHYSIOLOGY",SUP-D128211,CDM,C1732,HCPCS,0272,RC,,,both,,,13634.40,4090.32,"NOVANET [10819]",Novanet,,10225.8,75,,,,,0,1585.68,11589.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH ENDO-SCRUB 2 30D 4MM ENDOSCOPIC CLEANING STERILE",SUP-1912051,CDM,S27200284,LOCAL,0272,RC,,,both,,,537.84,161.35,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,365.73,68,,,,,0,62.55,457.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 7X250 135CM SL",SUP-48007025R,CDM,C1725,HCPCS,0272,RC,,,both,,,1041.01,312.3,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"GWIRE ASAHI CONFIANZA PRO 9 VASCULAR 180CM 20CM .009IN",SUP-AGH143090,CDM,C1769,HCPCS,0272,RC,,,both,,,1134.00,340.2,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"TOOL 9CM MR8 4MM BALL SYMMETRIC DISSECTING",SUP-MR8-9BA40T,CDM,S27200284,LOCAL,0272,RC,,,both,,,1495.26,448.58,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"SHELL ACETABULAR 54MM HIP LIMIT HOLE TITANIUM POROUS",SUP-PT-116054,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"UHC [10700]","United Healthcare",,6459.83,63.3,,8601.07,8395.67,8601.07,"1 through 10",1186.85,8674.34,"percent of total billed charges",
"SCR BONE 5MM 60MM NAIL-EX TITANIUM FULL THREAD TIBIAL SELF",SUP-04.015.550,CDM,C1713,HCPCS,0278,RC,,,both,,,1313.17,393.95,"NOVANET [10819]",Novanet,,984.88,75,,,,,0,152.72,1116.19,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 3MM POD",SUP-RBYPOD3,CDM,S27800098,LOCAL,0278,RC,,,both,,,11661.00,3498.3,"CIGNA [10200]",Cigna,,4664.4,40,,,,,0,1356.17,9911.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 3MM POD",SUP-RBYPOD3,CDM,S27800098,LOCAL,0278,RC,,,both,,,11661.00,3498.3,"KAISER [10500]",Kaiser,,7812.87,67,,,,,0,1356.17,9911.85,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 25CM 15MM INTERLOCK FIBERED IDC 35 COIL",SUP-M001363810,CDM,S27800098,LOCAL,0278,RC,,,both,,,3891.60,1167.48,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1113.78,28.62,,,,,0,452.59,3307.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +10.5 DIOPTER CONVEXOPLANO 13MM 5.5MM ANTERIOR",SUP-MTA4U0.105,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"BLUE CROSS [10001]","Blue Cross HMO",,269.89,39.2,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 24MM 140CM 4MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927424400,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"CIGNA [10200]","Cigna Open Access",,2133.75,56.9,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM REBEL 24MM 140CM 4MM CORONARY STENT PLATINUM CHROMIUM",SUP-H7493927424400,CDM,C1876,HCPCS,0278,RC,,,both,,,3750.00,1125,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1073.25,28.62,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RESVR SHUNT BURRHOLE PROGAV 2 PEDIATRIC",SUP-FX445T,CDM,S27800098,LOCAL,0278,RC,,,both,,,18201.71,5460.51,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7280.68,40,,,,,0,2116.86,15471.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 2-0 CT-2 18IN CONTROL RELEASE BRAID 8 STRAND",SUP-J726D,CDM,S27200284,LOCAL,0272,RC,,,both,,,124.95,37.48,"KAISER [10500]",Kaiser,,83.72,67,,,,,0,14.53,106.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 30CM 14MM AVENIR COMPLEX 10 COIL SOFT",SUP-10CFS13030,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"AETNA [10100]","Aetna HMO/PPO",,9319.86,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 2 X 6 COMPLEX PICO COIL",SUP-10USC02006,CDM,S27800098,LOCAL,0278,RC,,,both,,,13075.50,3922.65,"FIRST HEALTH [10303]","First Health",,10460.4,80,,,,,0,1520.68,11114.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH STERLING MONORAIL 135CM 40MM 3.8-3.4FR 5MM LOW PROFILE",SUP-H74939031504010,CDM,C1725,HCPCS,0272,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL ENDOSCOPIC CLEANGUIDE ESOPHAGEAL OTW PHTHALATE FREE",SUP-CG-17-3,CDM,S27200284,LOCAL,0272,RC,,,both,,,526.50,157.95,"CIGNA [10200]","Cigna Open Access",,299.58,56.9,,,,,0,61.23,447.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSPIRE 14 X 12 X 07MM 7° 3D TRABECULAR PEEK HA FUSE CERVI",SUP-C234-141207-7,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"KAISER [10500]",Kaiser,,4160.7,67,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 18MM RETRACTA DETACHABLE .035IN",SUP-G34194,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"BLUE CROSS [10001]","Blue Cross PPO",,1663.45,39.2,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 7CM 18MM RETRACTA DETACHABLE .035IN",SUP-G34194,CDM,S27800098,LOCAL,0278,RC,,,both,,,4243.50,1273.05,"MULTIPLAN [10600]",Multiplan,,3606.98,85,,,,,0,493.52,3606.98,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 95MM 5MM XLONG CARBIDE ROUND 8 FLUTED LINVATEC",SUP-5300030513,CDM,S27200284,LOCAL,0272,RC,,,both,,,271.18,81.35,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,111.45,41.1,,,,,0,31.54,230.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +7.5MM 36MM HIP C TAPER BIOLOX DELTA",SUP-183675,CDM,C1776,HCPCS,0278,RC,,,both,,,7340.76,2202.23,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,869.88,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",214.80,23.78,386.72,13,853.73,6239.65,"percent of total billed charges",
"PLATE CS2 STAINLESS STEEL 2.7MM SCR VARIABLE ANGLE LCP BONE",SUP-02.112.622,CDM,C1713,HCPCS,0278,RC,,,both,,,6005.21,1801.56,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,698.41,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",698.41,5104.43,"percent of total billed charges",
"SET PLATE 14MM 2.7MM TARSAL METATARSAL LOW PROFILE S1 PLATE",SUP-SK28,CDM,C1713,HCPCS,0278,RC,,,both,,,11730.00,3519,"AETNA [10100]","Aetna HMO/PPO",,9325.35,79.5,,1521.93,481.35,16760.95,30,1364.2,9970.5,"percent of total billed charges",
"STAPLE BONE MEDIUM REGULAR SPIKED FIXATION 23.22X11.11MM",SUP-128694,CDM,C1713,HCPCS,0278,RC,,,both,,,2300.10,690.03,"CIGNA [10200]","Cigna Local Plus",,1230.55,53.5,,3978.14,359.25,3978.14,24,267.5,1955.09,"percent of total billed charges",
"STENT ABRE 120MM 12MM VASCULAR NITINOL VENOUS SELF EXPAND 3",SUP-AB9U12120090,CDM,C1876,HCPCS,0278,RC,,,both,,,10350.00,3105,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1203.71,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1203.71,8797.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ADVANCE COOL RADIOFREQUENCY ELECTROTHERAPY COOLIEF",SUP-CRKA-17-75-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,5175.00,1552.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2375.33,45.9,,,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AMNIOFIX INJECTABLE 40MG",SUP-AI-5050,CDM,Q4433,HCPCS,0636,RC,,,both,,,5002.50,1500.75,"AETNA [10100]","Aetna HMO/PPO",,3976.99,79.5,,,,,0,247.92,4252.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH HALO360+ 4CM 3CM 25MM 360D ABLATION ESOPHAGUS HALOFLEX",SUP-32041-25,CDM,S27200284,LOCAL,0272,RC,,,both,,,11712.34,3513.7,"CIGNA [10200]","Cigna Local Plus",,6266.1,53.5,,,,,0,1362.15,9955.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 31X13MM MONUMENT 8D 25MM SMALL NONSTERILE",SUP-3108.0113,CDM,S27800098,LOCAL,0278,RC,,,both,,,39123.00,11736.9,"CIGNA [10200]","Cigna Open Access",,13106.21,33.5,,,,,0,4550,33254.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE HEMI PELVIS 1/3 ALLOGRAFT",SUP-450417,CDM,S27800098,LOCAL,0278,RC,,,both,,,17724.42,5317.33,"PHCS [10601]",PHCS,,12407.09,70,,,,,0,2061.35,15065.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 10MM ZERO-P PEEK CERVICAL INTERBODY FUSION",SUP-04.617.120S,CDM,S27800098,LOCAL,0278,RC,,,both,,,12420.00,3726,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3554.6,28.62,,,,,0,1444.45,10557,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 60CM 32MM EMBOLD NITINOL FIBER DETACHABLE",SUP-M001394240320600,CDM,S27800098,LOCAL,0278,RC,,,both,,,8618.10,2585.43,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1021.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1002.29,7325.39,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE HEMI PELVIS 1/3 ALLOGRAFT",SUP-450417,CDM,S27800098,LOCAL,0278,RC,,,both,,,17724.42,5317.33,"FIRST HEALTH [10303]","First Health",,14179.54,80,,,,,0,2061.35,15065.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL PLUS 2-0 SH 27IN CONTROL RELEASE BRAIDED 8 STRAND",SUP-VCP785D,CDM,S27200284,LOCAL,0272,RC,,,both,,,129.21,38.76,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,87.86,68,,,,,0,15.03,109.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 0 18IN BRAID TIE 6 STRAND PRECUT BLACK",SUP-A186H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,11.93,45.9,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH BRITE TIP 35CM 5FR INTRO KINK RESISTANT CANN",SUP-401535M,CDM,C1894,HCPCS,0272,RC,,,both,,,104.40,31.32,"AETNA [10100]","Aetna HMO/PPO",,83,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.14,88.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT STAINLESS STEEL ETHI-PACK 5 18IN MONOFILAMENT 12 STRAND",SUP-DS20,CDM,S27200284,LOCAL,0272,RC,,,both,,,70.85,21.25,"AETNA [10100]","Aetna HMO/PPO",,56.33,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,8.24,60.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY SURGICAL PROC 13CM TRU-CLOSE PNEUMOTHORAX SELF CONTAIN",SUP-TV11-13,CDM,S27200284,LOCAL,0272,RC,,,both,,,1710.00,513,"CIGNA [10200]","Cigna Open Access",,972.99,56.9,,,,,0,198.87,1453.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAROTID ARTERY STENT PROCEDURES WITH MCC",034,MS-DRG,,,,,,,inpatient,,,166453.99,49936.2,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,73454.27,,"Fee schedule rate ($73,454.27). Includes an add-on of $8,137 when RC 0681-0682 total amount is above $1, $6,835 when RC 0683 total amount is above $1. Includes an add-on of 24.6% of RC 0274 if total amount is above $13,257, 24.6% of RC 0275 if total amount is above $13,257, 24.6% of RC 0276 if total amount is above $13,257, 24.6% of RC 0001-0999 if total amount is above $13,257, 41.1% of RC 0636 if total amount is above $13,257, 41.1% of RC 0343 if total amount is above $13,257, 41.1% of RC 0344 if total amount is above $13,257.",,,,0,7561,113008.96,other,"IP SURGICAL DRGS EXCLD OB, NEWBORN Zero final payments for the item or service in the 15 months prior to posting the file."
"CLAMP EXTERNAL FIXATION JET-X FREEDOM 10.5-5MM BAR TO PIN MR",SUP-71064001,CDM,C1713,HCPCS,0278,RC,,,both,,,7563.78,2269.13,"PHCS [10601]",PHCS,,5294.65,70,,,,,0,879.67,6429.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SOFT-VU 65CM 5FR ROSCH INFERIOR MESENTRIC CURVE",SUP-10733301,CDM,C1887,HCPCS,0272,RC,,,both,,,236.64,70.99,"AETNA [10100]","Aetna HMO/PPO",,188.13,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,27.52,201.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SHEATH 24FR PEEL-AWAY BUILT IN MIC MIC-KEY 20FR FEEDING",SUP-98706,CDM,S27200284,LOCAL,0272,RC,,,both,,,814.29,244.29,"UHC [10700]","United Healthcare",,515.45,63.3,,,,,0,94.7,692.15,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR VENTRICULAR ASSIST THORATEC HEARTMATE 3 TUNNEL STERILE",SUP-106534US,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,2543.2,68,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FRCP SURGICAL WEIL-BLAKESLEY PEDIATRIC 45D UP 00 6.25IN",SUP-63-7424,CDM,S27200284,LOCAL,0272,RC,,,both,,,1913.63,574.09,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,878.36,45.9,,,,,0,222.56,1626.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 70X23MM SMITH-BUIE SWIVEL BLADE SELF RETAINING SPREAD",SUP-50-7420,CDM,S27200284,LOCAL,0272,RC,,,both,,,1909.50,572.85,"NOVANET [10819]",Novanet,,1432.13,75,,,,,0,222.07,1623.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 70X23MM SMITH-BUIE SWIVEL BLADE SELF RETAINING SPREAD",SUP-50-7420,CDM,S27200284,LOCAL,0272,RC,,,both,,,1909.50,572.85,"CIGNA [10200]",Cigna,,1298.46,68,,,,,0,222.07,1623.08,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR VENTRICULAR ASSIST THORATEC HEARTMATE 3 TUNNEL STERILE",SUP-106534US,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,443.19,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.25CM NATRELLE INSPIRA P3.2CM LOW PLUS PROFILE",SUP-MSZ-LP265,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"KAISER [10500]",Kaiser,,105.98,67,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE CRESCENT 165CM 2MM 25MM SNAREMASTER 2 WIRE ENDOSCOPIC",SUP-SD-221L-25,CDM,S27200284,LOCAL,0272,RC,,,both,,,172.82,51.85,"CIGNA [10200]",Cigna,,117.52,68,,,,,0,20.1,146.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SIZER IMPL 12.25CM NATRELLE INSPIRA P3.2CM LOW PLUS PROFILE",SUP-MSZ-LP265,CDM,S27200284,LOCAL,0272,RC,,,both,,,158.18,47.45,"FIRST HEALTH [10303]","First Health",,126.54,80,,,,,0,18.4,134.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOTOM 5.5IN HOKE SPINE SURGICAL CURVE .25IN",SUP-28-4956,CDM,S27200284,LOCAL,0272,RC,,,both,,,197.40,59.22,"FIRST HEALTH [10303]","First Health",,157.92,80,,,,,0,22.96,167.79,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 6.75IN BECKMAN-WIETLANER SHARP HINGED ARM 3X4 PRONG",SUP-SU3195,CDM,S27200284,LOCAL,0272,RC,,,both,,,1223.67,367.1,"AETNA [10100]","Aetna HMO/PPO",,972.82,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,142.31,1040.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE OPHTHALMIC 9MM TANNE UNIVERSAL TREPHINE STERILE","SUP-E3050 9.00",CDM,S27200284,LOCAL,0272,RC,,,both,,,552.83,165.85,"NOVANET [10819]",Novanet,,414.62,75,,,,,0,64.29,469.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL ENDOSCOPIC SUCTION 22GA EAR",SUP-230087,CDM,S27200284,LOCAL,0272,RC,,,both,,,613.90,184.17,"PHCS [10601]",PHCS,,429.73,70,,,,,0,71.4,521.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RTRCTR 6.7IN SEWALL HANDHELD SURGICAL 70X13MM",SUP-N3324,CDM,S27200284,LOCAL,0272,RC,,,both,,,1357.80,407.34,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,558.06,41.1,,,,,0,157.91,1154.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"25 MM LOTUS EDGE AORTIC VALVE SYSTEM AND LARGE LOTUS INTRODU",SUP-H749LVSUS250,CDM,S27800098,LOCAL,0278,RC,,,both,,,185250.00,55575,"AETNA [10100]","Aetna HMO/PPO",,147273.75,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,21544.58,157462.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BAND ANNULOPLASTY 25MM SJM TAILOR SILICONE FLEXIBLE SURE",SUP-TAB-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,12106.40,3631.92,"MULTIPLAN [10600]",Multiplan,,10290.44,85,,,,,0,1407.97,10290.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAP LOCKING MERCURY CLASSIC THREAD NONSTERILE",SUP-62000-000,CDM,S27800098,LOCAL,0278,RC,,,both,,,2406.60,721.98,"CIGNA [10200]","Cigna Local Plus",,1287.53,53.5,,,,,0,279.89,2045.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY TIBIAL INFINITY 2 STD",SUP-33650002,CDM,S27200284,LOCAL,0272,RC,,,both,,,29049.30,8714.79,"CIGNA [10200]","Cigna Open Access",,16529.05,56.9,,,,,0,3378.43,24691.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 356MM 5MM 126MM 3 FLUTED QUICK COUPLING CALIBRATED",SUP-03.008.008,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"CIGNA [10200]","Cigna Local Plus",,870.98,53.5,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL MINI 2.75MM CANNULATED OPEN REPAIR .066IN",SUP-AR-7000-14,CDM,S27200284,LOCAL,0272,RC,,,both,,,2756.25,826.87,"KAISER [10500]",Kaiser,,1846.69,67,,,,,0,320.55,2342.81,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ATTACH ENDOSCP 4MM 11.8MM ROUND EDGE STERILE LATEX FREE",SUP-D-201-11304,CDM,S27200284,LOCAL,0272,RC,,,both,,,210.26,63.08,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,142.98,68,,,,,0,24.45,178.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AEON ENDOSTAPLER SHORT TIP RELOAD 60MM PURPLE",SUP-ASR60PS,CDM,S27200284,LOCAL,0272,RC,,,both,,,1458.00,437.4,"MULTIPLAN [10600]",Multiplan,,1239.3,85,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN ARTHROSCOPIC PUSHLOCK LOW PROFILE SHOULDER OBTR THREAD",SUP-AR-6548,CDM,S27200284,LOCAL,0272,RC,,,both,,,228.38,68.51,"KAISER [10500]",Kaiser,,153.01,67,,,,,0,26.56,194.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CURET 4-0 STD ANGLE MICRO 9IN HOLLOW HANDLE SURGICAL 3X2.1MM",SUP-RN0987,CDM,S27200284,LOCAL,0272,RC,,,both,,,842.56,252.77,"KAISER [10500]",Kaiser,,564.52,67,,,,,0,97.99,716.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 30X10MM LUMINARY 10/11MM SPINE",SUP-4710,CDM,S27800098,LOCAL,0278,RC,,,both,,,31500.00,9450,"UHC [10700]","United Healthcare",,19939.5,63.3,,,,,0,3663.45,26775,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING ANNULOPLASTY 26MM 33.6MM 25.9MM MITRAL TRICUSPID",SUP-460026MM,CDM,S27800098,LOCAL,0278,RC,,,both,,,11385.00,3415.5,"NOVANET [10819]",Novanet,,8538.75,75,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT BARD INLAY 26CM 6FR 2 PIGTAIL CURVE URETERAL",SUP-778626,CDM,C2625,HCPCS,0278,RC,,,both,,,625.73,187.72,"BLUE CROSS [10001]","Blue Cross HMO",,245.29,39.2,,,,,0,72.77,531.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE PRESET 30MM 48MM 6MM THROMBECTOMY CLOSED RING HELICAL",SUP-PRE-6-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,34650.00,10395,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4106.03,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4029.8,29452.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"END CAP SPINAL 14X2MM COLOSSEUM 0D 12MM NONSTERILE LATEX",SUP-156.252,CDM,S27800098,LOCAL,0278,RC,,,both,,,3442.50,1032.75,"AETNA [10100]","Aetna HMO/PPO",,2736.79,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,400.36,2926.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 10X22X50MM 5DEG LORDOTIC MODULUS XLW",SUP-1223050P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"PHCS [10601]",PHCS,,19845,70,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CPSL PH BRAVO CALIBRATION FREE REFLUX DELIVERY SYSTEM",SUP-FGS-0635,CDM,S27200284,LOCAL,0272,RC,,,both,,,2244.00,673.2,"CIGNA [10200]","Cigna Local Plus",,1200.54,53.5,,,,,0,260.98,1907.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 12.7MM 36MM 22MM DHS/DCS STAINLESS STEEL CONDYLE",SUP-280.990S,CDM,C1713,HCPCS,0278,RC,,,both,,,650.67,195.2,"BLUE CROSS [10001]","Blue Cross HMO",,255.06,39.2,,957.42,156.86,7483.26,51,75.67,553.07,"percent of total billed charges",
"HC Chng Tube Nephro/Pyelostomy",PX-361000225,CDM,50435,CPT,0361,RC,,,both,,,3817.84,1145.35,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2719,,"Case rate ($2,719). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,444.01,3817.84,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC CT Neck/Soft Tiss W Cntrst",PX-351000012,CDM,70491,CPT,0351,RC,,,both,,,2714.77,814.43,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure count. Procedure 1, Per diem ($536.40). Procedures 2 - 999, Per diem ($268.20).",,,,0,,,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ULTRAVERSE CHECKER 130CM 15CM 5MM BALLOON DILATATION",SUP-U8130515,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,153.58,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"REMIFENTANIL 1 MG INTRAVENOUS SOLUTION",RX-18398,CDM,,,0250,RC,00143-9391-01,NDC,both,1,UN,487.51,146.25,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,57.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,56.7,414.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH IMPULSE 100CM 5FR AR2 CURVE ANGIOGRAPHIC PERIPHERAL 2",SUP-H74916391862,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"KAISER [10500]",Kaiser,,51.31,67,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) OCCLUDER CARDIOVASCULAR 25MM CARDIAC PLUG AMPLATZER S",SUP-9-ACP2-010-025,CDM,C1817,HCPCS,0278,RC,,,both,,,96900.00,29070,"CIGNA [10200]","Cigna Open Access",,32461.5,33.5,,,,,0,11269.47,82365,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLEEVE CENTERING 9.5MM S-ROM ZTT 20D SMALL HIP PROXIMAL",SUP-550533,CDM,C1776,HCPCS,0278,RC,,,both,,,10884.75,3265.42,"BLUE CROSS [10001]","Blue Cross HMO",,4266.82,39.2,,5311.50,4717.44,5388.59,31,1265.9,9252.04,"percent of total billed charges",
"SIZER IMPL SMOOTH HIGH PROFILE XTRA 535CC",SUP-RSZ-SHPX-535S,CDM,S27200284,LOCAL,0272,RC,,,both,,,166.09,49.83,"CIGNA [10200]",Cigna,,112.94,68,,,,,0,19.32,141.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 3.7MM MERLIN GREAT WHITE 15D PREBENT BENDABLE",SUP-37GRW-ME-PB,CDM,S27200284,LOCAL,0272,RC,,,both,,,749.25,224.77,"CIGNA [10200]","Cigna Local Plus",,400.85,53.5,,,,,0,87.14,636.86,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(COMM) OCCLUDER CARDIOVASCULAR 7.5X11-13MM 16MM 22MM HEMOSTA",SUP-9-ACP2-007-016,CDM,C1817,HCPCS,0278,RC,,,both,,,96900.00,29070,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11482.65,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,11269.47,82365,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR SET SPINE FLAT CNCT INFINITY NONSTERILE LATEX FREE",SUP-3602615,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"NOVANET [10819]",Novanet,,261,75,,,,,0,40.47,295.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intro Cath Aorta",PX-361000081,CDM,36200,CPT,0361,RC,,,both,,,4155.54,1246.66,"KAISER [10500]",Kaiser,,2784.21,67,,,,,0,483.29,4155.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 19MM EDWARDS INTUITY ELITE STERILE LATEX FREE",SUP-8300KITB19A,CDM,S27800098,LOCAL,0278,RC,,,both,,,68400.00,20520,"NOVANET [10819]",Novanet,,51300,75,,,,,0,7954.92,58140,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 16X14X10MM ENDOSKELETON TCS 6D LORDOTIC MEDIUM",SUP-5366-1410-N,CDM,S27800098,LOCAL,0278,RC,,,both,,,23310.00,6993,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,9324,40,,,,,0,2710.95,19813.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 240MM 2MM BALLOON DILATATION STERILE LATEX",SUP-592024022,CDM,C1725,HCPCS,0272,RC,,,both,,,1458.00,437.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,991.44,68,,,,,0,169.57,1239.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT SEROSAFUSE IMPLANTABLE FASTNER",SUP-R2275,CDM,S27800098,LOCAL,0278,RC,,,both,,,34618.50,10385.55,"KAISER [10500]",Kaiser,,23194.4,67,,,,,0,4026.13,29425.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 20X50X17-14.2MM ORACLE 8D SPINE FREEZE",SUP-15017,CDM,S27800098,LOCAL,0278,RC,,,both,,,23940.00,7182,"CIGNA [10200]","Cigna Local Plus",,7541.1,31.5,,,,,0,2784.22,20349,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 18MM 25MM MOSAIC CINCH PORCINE BIOPROSTHESIS",SUP-310-25,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"UHC [10700]","United Healthcare",,17945.55,63.3,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE NARROW 8 HOLE LOW PROFILE STRAIGHT BONE RIGHT CLAVICLE",SUP-70-0299,CDM,S27800098,LOCAL,0278,RC,,,both,,,6610.20,1983.06,"CIGNA [10200]",Cigna,,4494.94,68,,,,,0,768.77,5618.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL 27MM BOVINE PERICARDIUM LEAFLET COBALT CHROMIUM",SUP-11400M27,CDM,S27800098,LOCAL,0278,RC,,,both,,,45360.00,13608,"CIGNA [10200]",Cigna,,18144,40,,,,,0,5275.37,38556,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE PRIME HD DBM 5CC ALLOGRAFT LATEX FREE",SUP-421050,CDM,C1713,HCPCS,0278,RC,,,both,,,3750.00,1125,"NOVANET [10819]",Novanet,,2812.5,75,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 22X10X8MM SUSTAIN SMALL OBLIQUE PEEK TITANIUM",SUP-304.088CS,CDM,S27800098,LOCAL,0278,RC,,,both,,,18207.00,5462.1,"NOVANET [10819]",Novanet,,13655.25,75,,,,,0,2117.47,15475.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 26X9X12MM 8D EIT PLIF STERILE LATEX FREE",SUP-PUI81206,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,8113.77,28.62,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TISSUE 171226 IMP WG 12X26 SRVC FEE FD",SUP-171226,CDM,S27800098,LOCAL,0278,RC,,,both,,,12572.49,3771.75,"FIRST HEALTH [10303]","First Health",,10057.99,80,,,,,0,1462.18,10686.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER 3992612 26MM X 12MM",SUP-3992612,CDM,S27800098,LOCAL,0278,RC,,,both,,,21225.60,6367.68,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,8723.72,41.1,,,,,0,2468.54,18041.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID DBX ALLOGRAFT FREEZE DRIED MIX 10CC",SUP-058100,CDM,S27800098,LOCAL,0278,RC,,,both,,,8280.00,2484,"CIGNA [10200]",Cigna,,5630.4,68,,,,,0,962.96,7038,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW VARIABLE ANGLE LOCKING 2.5MM X 8MM COCR",SUP-VAL-25080-CC,CDM,C1713,HCPCS,0278,RC,,,both,,,1425.60,427.68,"CIGNA [10200]","Cigna Open Access",,811.17,56.9,,1144.80,304.56,2275.09,66,165.8,1211.76,"percent of total billed charges",
"DFBR CRD 40J UNIFY ASR VNTRC","SUP-CD3357-40C CELL",CDM,C1882,HCPCS,0278,RC,,,both,,,44764.00,13429.2,"NOVANET [10819]",Novanet,,33573,75,,,,,0,5206.05,38049.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH NAVISTAR 115CM 8MM 7FR 1-7-4MM SPACE LARGE F CURVE",SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,0272,RC,,,both,,,15870.00,4761,"FIRST HEALTH [10303]","First Health",,12696,80,,,,,0,1845.68,13489.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 45MM STAINLESS STEEL SMALL FRAGMENT SET 4 HOLE 1/3",SUP-241.341,CDM,C1713,HCPCS,0278,RC,,,both,,,1149.80,344.94,"KAISER [10500]",Kaiser,,770.37,67,,,,,0,133.72,977.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rpr Feeynolm 12.6-20cm",PX-450000029,CDM,12016,CPT,0450,RC,,,both,,,1347.00,404.1,"CIGNA [10200]","Cigna Open Access",,1347,,,,,,,67.13,1347,"case rate",
"ADPTR FEEDING SET MIC FEED ACCESS",SUP-0301-60,CDM,S27200284,LOCAL,0272,RC,,,both,,,81.69,24.51,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,37.5,45.9,,,,,0,9.5,69.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 20MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036122050,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"MULTIPLAN [10600]",Multiplan,,14726.25,85,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +10.5MM 12/14 TAPER 28MM HIP ZIMALOY VERSYS",SUP-00801802805,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1388.27,28.62,,,,,0,564.14,4123.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 55MM 9MM COMPREHENSIVE POROUS MICRO SHOULDER",SUP-113609,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"UHC [10700]","United Healthcare",,7975.8,63.3,,8601.07,8395.67,8601.07,"1 through 10",1465.38,10710,"percent of total billed charges",
"CNCT ROD 29-33MM REVERE TRANSVERSE ADJUSTABLE TITANIUM SPINE",SUP-124.912,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]","Cigna Local Plus",,2584.05,53.5,,3978.14,359.25,3978.14,24,561.73,4105.5,"percent of total billed charges",
"PROSTATECTOMY WITHOUT CC/MCC",667,MS-DRG,,,,,,,inpatient,,,56410.72,16923.22,"AMBETTER EXCHANGE  [11102]",Ambetter,,6861.82,,"Case rate ($6,861.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,371.67, add-ons for qualifying new technology services are included. If operating cost exceeds $39,411.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,863.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,380.10. The transfer operating threshold is the transfer adjustment factor * $6,371.67 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.73. The transfer capital threshold is the transfer adjustment factor * $481.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 203.4%. Includes a variable per diem for the first 99999 days: RC 0111:0219 @ $0.",,,,0,6861.82,32296.62,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT 137CM 6MM 2.5MM RECTANGLE HELIX TAPER",SUP-2200-2506,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,695,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 23CM 6FR CHECK-FLO FLEXOR .018IN RADIAL ARTERY",SUP-G11605,CDM,C1894,HCPCS,0272,RC,,,both,,,312.33,93.7,"FIRST HEALTH [10303]","First Health",,249.86,80,,,,,0,36.32,265.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Fna W CT Init",PX-361000481,CDM,10009,CPT,0361,RC,,,both,,,3291.17,987.35,"BLUE CROSS [10001]","Blue Cross PPO",,2740.57,,"Case rate ($2,740.57). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,382.76,2797.49,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 5 5MM KNEE AOX POSTERIOR STABILIZE ROTATE",SUP-1516-50-505,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"PHCS [10601]",PHCS,,9189.08,70,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR R3 20D 54MM 32MM XLPE HIP",SUP-71337654,CDM,C1776,HCPCS,0278,RC,,,both,,,11126.25,3337.87,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4572.89,41.1,,6417.48,6417.48,6417.48,"1 through 10",1293.98,9457.31,"percent of total billed charges",
"GWIRE GLDEWIRE ADVANTAGE VASCULAR ANGLE 260CM 5CM .035IN",SUP-GA3502,CDM,C1769,HCPCS,0272,RC,,,both,,,1510.65,453.19,"FIRST HEALTH [10303]","First Health",,1208.52,80,,,,,0,175.69,1284.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER 10GA HYDROMARK BREAST BIOPSY OPEN COIL TITANIUM",SUP-4010-05-10-T3,CDM,A4648,HCPCS,0278,RC,,,both,,,640.49,192.15,"AMERIGROUP MEDICAID [20100]",Amerigroup,,75.9,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.49,544.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Amino Acids 2-5 Acids Qn",PX-301000580,CDM,82136,CPT,0301,RC,,,both,,,590.00,177,"AMERIGROUP MEDICAID [20100]",Amerigroup,,11.43,,,,,,,0.01,501.5,"fee schedule",
"HC Rpr Feeynolm 7.6-12.5cm",PX-450000028,CDM,12015,CPT,0361,RC,,,both,,,909.00,272.7,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,105.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,105.72,909,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 24MM LCP",SUP-02.211.024,CDM,C1713,HCPCS,0278,RC,,,both,,,898.13,269.44,"FIRST HEALTH [10303]","First Health",,718.5,80,,,,,0,104.45,763.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LANTHANUM 500 MG CHEWABLE TABLET",RX-39975,CDM,,,0637,RC,66993-0422-47,NDC,both,1,UN,48.96,14.69,"FIRST HEALTH [10303]","First Health",,39.17,80,,,,,0,5.69,41.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4.5MM DYONICS INCISOR PLUS PLATINUM STRAIGHT",SUP-72203013,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.81,194.64,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,297.8,45.9,,,,,0,75.46,551.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH JADE 150CM 240MM 3.5MM BALLOON DILATATION STERILE LATEX",SUP-583524022,CDM,C1725,HCPCS,0272,RC,,,both,,,1628.00,488.4,"PHCS [10601]",PHCS,,1139.6,70,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET LEADWIRE 10 LEAD PLUG AHA BANANA NEONATAL CABLE",SUP-2016032-001,CDM,S27200284,LOCAL,0272,RC,,,both,,,2167.50,650.25,"CIGNA [10200]",Cigna,,1473.9,68,,,,,0,252.08,1842.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET CATH 4FR 100CM TRIFORCE FLEXOR PEEL-AWAY STRAIGHT CURVE",SUP-G56417,CDM,S27200284,LOCAL,0272,RC,,,both,,,2711.18,813.35,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,321.27,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,315.31,2304.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 11MM KNEE POSTERIOR STABILIZED BEARING",SUP-5532P311,CDM,C1776,HCPCS,0278,RC,,,both,,,8355.90,2506.77,"NOVANET [10819]",Novanet,,6266.93,75,,,,,0,971.79,7102.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 375MM TIBIA EXPERT INTRAMEDULLARY UNIVERSAL",SUP-04.004.455S,CDM,C1713,HCPCS,0278,RC,,,both,,,8312.43,2493.73,"CIGNA [10200]",Cigna,,5652.45,68,,1831.33,1831.33,1831.33,16,966.74,7065.57,"percent of total billed charges",
"VENTURA INTERATRIAL SHUNT",SUP-VIS-01-5.0-14F,CDM,S62400003,LOCAL,0624,RC,,,both,,,0.01,,"NOVANET [10819]",Novanet,,0.01,75,,,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT HUMERAL H+6/33MM 36MM ARTHREX SHOULDER COMBO STERILE",SUP-AR-9503-3633-6,CDM,C1776,HCPCS,0278,RC,,,both,,,4305.60,1291.68,"BLUE CROSS [10001]","Blue Cross PPO",,1687.8,39.2,,3949.44,3949.44,3949.44,"1 through 10",500.74,3659.76,"percent of total billed charges",
"CATH DORADO CHECKER 80CM 4CM 10MM BALLOON DILATATION",SUP-DR80104,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,163.17,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL LIGAPAK 3-0 54IN BRAID REEL COATED UNDYED",SUP-J285G,CDM,S27200284,LOCAL,0272,RC,,,both,,,27.00,8.1,"CIGNA [10200]",Cigna,,18.36,68,,,,,0,3.14,22.95,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Selenium",PX-301000393,CDM,84255,CPT,0301,RC,,,both,,,262.60,78.78,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.26,.1,,,,,0,0.26,223.21,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30MMX14MM VERTE-STACK CRESCENT LUMBAR",SUP-293014,CDM,S27800098,LOCAL,0278,RC,,,both,,,24290.28,7287.08,"PHCS [10601]",PHCS,,17003.2,70,,,,,0,2824.96,20646.74,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING INGEVITY+ STEROID STAINLESS STEEL SILICONE RUBBE",SUP-7840,CDM,C1898,HCPCS,0275,RC,,,both,,,2250.00,675,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1530,68,,,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT LEAD SPLICE 6.1FR 8.3FR CAPSURE 10.7FR TRANSVENOUS",SUP-5867-5,CDM,S27000186,LOCAL,0270,RC,,,both,,,174.00,52.2,"PHCS [10601]",PHCS,,121.8,70,,,,,0,20.24,147.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 12CM 33MM MASTERS HEMASHIELD CLLGN MECHANICAL","SUP-33CAVGJ-514  00",CDM,S27800098,LOCAL,0278,RC,,,both,,,25533.90,7660.17,"AMERIGROUP MEDICAID [20100]",Amerigroup,,3025.77,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2969.59,21703.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM SYNERGY 8MM 144CM 3.5MM CORONARY STENT PEBAX",SUP-H7493926008350,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,659.45,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY HEMODIALYSIS CATHETER 12.5FR X 24CM PASS ACUTE STRAIGHT",SUP-8888231424,CDM,C1752,HCPCS,0272,RC,,,both,,,1178.06,353.42,"UHC [10700]","United Healthcare",,745.71,63.3,,,,,0,137.01,1001.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 8FR .09IN JUDKINS LEFT 4 CURVE GUIDING",SUP-LA8JL40,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"NOVANET [10819]",Novanet,,293.63,75,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"OSTEOCEL PRO CELLULAR BONE MATRIX, MED",SUP-5016005,CDM,C1713,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,5023.51,2672.93,6679.78,18,2014.9,14726.25,"percent of total billed charges",
"IRR SUCTION 5MM DA VINCI SI SINGLE-SITE",SUP-428054,CDM,S27000186,LOCAL,0270,RC,,,both,,,2137.50,641.25,"CIGNA [10200]","Cigna Local Plus",,1143.56,53.5,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)VALVE AORTIC 23MM SAPIEN RETROFLEX 3 HEART COCR BOVINE",SUP-9600TFX23,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,19887.3,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MANIP OCCL BALLOON AUDIO INDCTR ALERT ELECTROSURGERY DEVICE",SUP-KC-ARCH-30,CDM,S27200284,LOCAL,0272,RC,,,both,,,1145.84,343.75,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,470.94,41.1,,,,,0,133.26,973.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE SUCTION 3MM FRAZIER ELECTROMAGNETIC MALLEABLE 10 TIME",SUP-8000050005,CDM,S27200284,LOCAL,0272,RC,,,both,,,15180.00,4554,"AETNA [10100]","Aetna HMO/PPO",,12068.1,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1765.43,12903,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 60MM 130CM 5MM 6FR .035IN VASCULAR NITINOL",SUP-EX050603CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"CIGNA [10200]","Cigna Local Plus",,3694.95,31.5,,,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD PACING 52CM 6.2FR 2MM 10MM SPACE SMALL STRAIGHT ATRIUM",SUP-5076-52,CDM,C1898,HCPCS,0275,RC,,,both,,,2232.50,669.75,"BLUE CROSS [10001]","Blue Cross HMO",,875.14,39.2,,,,,0,259.64,1897.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH INFINITI THRULUMEN 100CM 5FR .047IN MULTIPURPOSE A 2",SUP-534542T,CDM,S27200284,LOCAL,0272,RC,,,both,,,93.53,28.06,"CIGNA [10200]","Cigna Local Plus",,50.04,53.5,,,,,0,10.88,79.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP TRACTION MCCONNELL LARGE HAND ARM HOLDER TRACTION STRAP",SUP-12-401,CDM,S27000186,LOCAL,0270,RC,,,both,,,304.50,91.35,"KAISER [10500]",Kaiser,,204.02,67,,,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 80MM 4MM BALLOON DILATATION DURALYN",SUP-48004008S,CDM,C1725,HCPCS,0272,RC,,,both,,,1255.50,376.65,"MULTIPLAN [10600]",Multiplan,,1067.18,85,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE SUPERCORE ECHOGENIC 9CM 3.9CM 18GA 17GA BIOPSY",SUP-701218090,CDM,S27200284,LOCAL,0272,RC,,,both,,,467.53,140.26,"UHC [10700]","United Healthcare",,295.95,63.3,,,,,0,54.37,397.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 22MM TIGER CANNULATED SCR SYSTEM",SUP-200-30-022,CDM,C1713,HCPCS,0278,RC,,,both,,,1134.00,340.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,134.38,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",131.88,963.9,"percent of total billed charges",
"ROD SPINAL 30MM 4.75MM PERCUTANEOUS CCM",SUP-641000030,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"PHCS [10601]",PHCS,,850.5,70,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STYLET LEAD 52CM .014IN BRADY SOFT GREEN KNOB RED CAP ATRIUM",SUP-6054,CDM,S27500001,LOCAL,0275,RC,,,both,,,435.00,130.5,"BLUE CROSS [10001]","Blue Cross PPO",,170.52,39.2,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Obstetric Panel",PX-301000512,CDM,80055,CPT,0301,RC,,,both,,,414.00,124.2,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,169.71,,,,,,,0.41,351.9,"fee schedule",
"STEM HUMERAL 122MM 10MM COMPREHENSIVE PPS SHOULDER",SUP-12-113560,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1465.38,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER FIDUCIAL 5MM .018IN LUMICOIL FIGURE 8 PLATINUM",SUP-M00553841,CDM,A4648,HCPCS,0278,RC,,,both,,,1387.72,416.32,"NOVANET [10819]",Novanet,,1040.79,75,,,,,0,161.39,1179.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION SIGMA HIGH PERFORMANCE QUICK DRILL",SUP-950502072,CDM,C1713,HCPCS,0278,RC,,,both,,,1526.85,458.05,"MULTIPLAN [10600]",Multiplan,,1297.82,85,,,,,0,177.57,1297.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM HUMERAL 78MM PRESS FIT AEQUALIS ASCEND FLEX PTC 132.5D",SUP-DWF604B,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3402,27,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 27MM 75CM 7MM 30MM",SUP-38046-73075,CDM,C1876,HCPCS,0278,RC,,,both,,,4830.00,1449,"CIGNA [10200]","Cigna Local Plus",,2584.05,53.5,,,,,0,561.73,4105.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LAUNCHER 100CM 7FR .081IN AMPLATZ LEFT1.5 CURVE GUIDING",SUP-LA7AL15,CDM,C1887,HCPCS,0272,RC,,,both,,,391.50,117.45,"MULTIPLAN [10600]",Multiplan,,332.78,85,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE VISIGLIDE 2 ENDOSCOPIC 4500MM 70MM .035IN FLUORINE",SUP-G-260-3545S,CDM,C1769,HCPCS,0272,RC,,,both,,,1288.95,386.68,"NOVANET [10819]",Novanet,,966.71,75,,,,,0,149.9,1095.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE ORTHOPEDIC 290MM 3.2MM NONSTERILE",SUP-03.010.115,CDM,C1769,HCPCS,0272,RC,,,both,,,601.02,180.31,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,408.69,68,,,,,0,69.9,510.87,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GORE CARDIOFORM ASD OCCLUDER 44MM 12FR",SUP-00733132636518,CDM,C1817,HCPCS,0278,RC,,,both,,,52321.50,15696.45,"BLUE CROSS [10001]","Blue Cross PPO",,20510.03,39.2,,,,,0,6084.99,44473.28,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl Impacted Cerumen",PX-450000304,CDM,69210,CPT,0361,RC,,,both,,,1527.04,458.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,1527.04,,"Case rate ($1,729.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 25 procedures at 0%.",,,,0,177.59,1527.04,other,"OP SURGERY Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE 16FR SILICONE INTERNAL RETENTION BALLOON RECESS DISTAL",SUP-8100-16LV,CDM,S27200284,LOCAL,0272,RC,,,both,,,279.88,83.96,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,32.55,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,32.55,237.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH EXPO 110CM 5FR PIGTAIL 155 CURVE ANGIOGRAPHIC",SUP-08526-42,CDM,S27200284,LOCAL,0272,RC,,,both,,,76.58,22.97,"CIGNA [10200]","Cigna Local Plus",,40.97,53.5,,,,,0,8.91,65.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BASEPLT TIBIAL RESTORIS 5 KNEE LEFT MEDIAL RIGHT LATERAL",SUP-180605,CDM,C1776,HCPCS,0278,RC,,,both,,,6627.45,1988.23,"AETNA [10100]","Aetna HMO/PPO",,5268.82,79.5,,10981.53,8986.79,12413.38,12,770.77,5633.33,"percent of total billed charges",
"WEDGE TIBIAL 5MM LEGION 3-4 HEMI KNEE LEFT MEDIAL RIGHT",SUP-71421142,CDM,C1776,HCPCS,0278,RC,,,both,,,15369.75,4610.92,"PHCS [10601]",PHCS,,10758.83,70,,,,,0,1787.5,13064.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FILLER BONE VOID 20CC 50CC CALCIUM SULFATE STIMULAN RAPID",SUP-620-020,CDM,C1713,HCPCS,0278,RC,,,both,,,10080.00,3024,"CIGNA [10200]","Cigna Open Access",,5735.52,56.9,,1144.80,304.56,2275.09,66,1172.3,8568,"percent of total billed charges",
"TRAY CATHETERIZATION SURESTEP LUBRI-SIL STATLOCK PERI-CARE",SUP-A947318,CDM,S27200284,LOCAL,0272,RC,,,both,,,106.14,31.84,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,12.34,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,12.34,90.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS",870,MS-DRG,,,,,,,inpatient,,,172930.99,51879.3,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,45875.52,,"Case rate ($42,874.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $39,811.71, add-ons for qualifying new technology services are included. If operating cost exceeds $72,851.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $4,391.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $39,864.36. The transfer operating threshold is the transfer adjustment factor * $39,811.71 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,009.96. The transfer capital threshold is the transfer adjustment factor * $3,009.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,10994,172373.38,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"FORMULA BARREL BUR 12-FLUTE,(RED/RED)4MM ARTHROSCOPIC SHAVER",SUP-0375941012,CDM,S27200284,LOCAL,0272,RC,,,both,,,493.39,148.02,"CIGNA [10200]","Cigna Local Plus",,263.96,53.5,,,,,0,57.38,419.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH REDEL 110CM 1MM 5FR 2-5-2MM SPACE F CURVE",SUP-F5QRF252RT,CDM,C1730,HCPCS,0272,RC,,,both,,,907.20,272.16,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,372.86,41.1,,,,,0,105.51,771.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WAND ELECTROSURGICAL 3MM ARTHROWAND 45D BEVEL KNEE SHOULDER",SUP-AC2430-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,1255.50,376.65,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,148.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LUTONIX 035 130CM 6X60MM1/EACH",SUP-LX35130660,CDM,C1725,HCPCS,0272,RC,,,both,,,11385.00,3415.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,4679.24,41.1,,,,,0,1324.08,9677.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHELL BIPOLAR 46MM MULTIPOLAR HIP METAL STERILE",SUP-500104600,CDM,C1776,HCPCS,0278,RC,,,both,,,3740.00,1122,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,434.96,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS PREMIER 28MM 144CM 2.75MM CORONARY STENT",SUP-H7493952828270,CDM,C1874,HCPCS,0278,RC,,,both,,,5565.00,1669.5,"CIGNA [10200]",Cigna,,3784.2,68,,,,,0,647.21,4730.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATFORM ACCESS 4X4CM GELPOINT GELSEAL INSUFFLATION",SUP-CNB10,CDM,S27200284,LOCAL,0272,RC,,,both,,,6037.50,1811.25,"FIRST HEALTH [10303]","First Health",,4830,80,,,,,0,702.16,5131.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 110MM 1.8MM QUICK COUPLING DEPTH MARK NONSTERILE",SUP-310.509,CDM,S27000186,LOCAL,0270,RC,,,both,,,945.76,283.73,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,112.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,109.99,803.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH X-FORCE U30 4CM 6FR 4MM BALLOON DILATATION PERCUTANEOUS",SUP-997404,CDM,C1726,HCPCS,0272,RC,,,both,,,1529.38,458.81,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,177.87,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,177.87,1299.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM XIENCE ALPINE 33MM 145CM 3.25MM CORONARY STENT",SUP-1145325-33,CDM,C1874,HCPCS,0278,RC,,,both,,,5838.00,1751.4,"PHCS [10601]",PHCS,,4086.6,70,,,,,0,678.96,4962.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRSP LAPAROSCOPIC 32.77CM 8MM DA VINCI XI ENDOWRIST 60D TIP",SUP-470347,CDM,S27000186,LOCAL,0270,RC,,,both,,,1732.50,519.75,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,201.49,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,201.49,1472.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE TRACH 7.5MM PORTEX BLUSELECT CUFF STERILE LATEX FREE",SUP-101/815/075,CDM,S27200284,LOCAL,0272,RC,,,both,,,343.48,103.04,"CIGNA [10200]","Cigna Local Plus",,183.76,53.5,,,,,0,39.95,291.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"1.1MM X 425MM TRILOGY PROBE KIT",SUP-M0068403470,CDM,S27200284,LOCAL,0272,RC,,,both,,,5531.45,1659.43,"CIGNA [10200]","Cigna Open Access",,3147.4,56.9,,,,,0,643.31,4701.73,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 20MM ORTHOLOC CLAW II STAINLESS STEEL CORTEX",SUP-40233520,CDM,C1713,HCPCS,0278,RC,,,both,,,1474.20,442.26,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,676.66,45.9,,,,,0,171.45,1253.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN DRILL PATHWAY PACK QUICK",SUP-217842010,CDM,S27200284,LOCAL,0272,RC,,,both,,,1526.85,458.05,"NOVANET [10819]",Novanet,,1145.14,75,,,,,0,177.57,1297.82,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CERES-C 7MM INTERBODY PLATE",SUP-SK-08-170-07,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"CIGNA [10200]",Cigna,,4222.8,68,,,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 10MM 360MM RIGHT TROCHANTERIC INTRAMEDULLARY 130D LONG",SUP-456.356S,CDM,C1713,HCPCS,0278,RC,,,both,,,13670.42,4101.13,"CIGNA [10200]","Cigna Open Access",,4579.59,33.5,,1144.80,304.56,2275.09,66,1589.87,11619.86,"percent of total billed charges",
"BLADE SAW PRECISION FALCON OSCILLATE TIP CRTDG",SUP-6720-127-105,CDM,S27200284,LOCAL,0272,RC,,,both,,,2580.23,774.07,"CIGNA [10200]","Cigna Local Plus",,1380.42,53.5,,,,,0,300.08,2193.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT PATELLAR BICONVEX 26MM GENESIS II KNEE",SUP-71420568,CDM,C1776,HCPCS,0278,RC,,,both,,,6344.55,1903.36,"CIGNA [10200]",Cigna,,4314.29,68,,5873.17,5873.17,5873.17,"1 through 10",737.87,5392.87,"percent of total billed charges",
"DRILL SURGICAL 40MM 2.5MM GEMINUS SOLID SIDE CUT NONSTERILE",SUP-DRLL-SSC-25040,CDM,S27200284,LOCAL,0272,RC,,,both,,,753.30,225.99,"CIGNA [10200]","Cigna Open Access",,428.63,56.9,,,,,0,87.61,640.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCREW SPINAL CERVICAL THORACIC MA 55MM X 30MM RELINE-C",SUP-3935530,CDM,C1713,HCPCS,0278,RC,,,both,,,4485.00,1345.5,"CIGNA [10200]","Cigna Open Access",,2551.97,56.9,,1144.80,304.56,2275.09,66,521.61,3812.25,"percent of total billed charges",
"SINGLE USE INSTRUMENTS - TIBIAL KIT (PS) - SIZE 3",SUP-5555-2363,CDM,S27200284,LOCAL,0272,RC,,,both,,,1012.50,303.75,"FIRST HEALTH [10303]","First Health",,810,80,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET PHLEBOTOMY PVC 600 ML",SUP-VSL7000YD,CDM,S27200284,LOCAL,0272,RC,,,both,,,224.90,67.47,"MULTIPLAN [10600]",Multiplan,,191.17,85,,,,,0,26.16,191.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PIN FIXATION 22.9CM 2MM STEINMANN ORTHOPEDIC STAINLESS STEEL",SUP-00018700159,CDM,C1713,HCPCS,0278,RC,,,both,,,152.25,45.67,"AMERIGROUP MEDICAID [20100]",Amerigroup,,18.04,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",17.71,129.41,"percent of total billed charges",
"HC Veno Svc W Si",PX-320000132,CDM,75827,CPT,0320,RC,,,both,,,3762.17,1128.65,"AMERIGROUP MEDICAID [20100]",Amerigroup,,445.82,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,103.44,3762.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.5MM 18MM MICRONAIL TITANIUM BUTTRESS RADIUS",SUP-59412518,CDM,C1713,HCPCS,0278,RC,,,both,,,1328.40,398.52,"CIGNA [10200]","Cigna Local Plus",,710.69,53.5,,3978.14,359.25,3978.14,24,154.49,1129.14,"percent of total billed charges",
"WIRE FIXATION 9IN .062IN KIRSCHNER 2 END TROCAR POINT THREAD",SUP-163840000,CDM,C1713,HCPCS,0278,RC,,,both,,,185.60,55.68,"NOVANET [10819]",Novanet,,139.2,75,,,,,0,21.59,839.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES",213,MS-DRG,,,,,,,inpatient,,,268163.70,80449.11,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,90989.27,,"Fee schedule rate ($90,989.27). The outlier threshold amount is ($224,410.00),  the outlier percentage is (46.51%).  The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1). Includes an add-on of $2,243.60 when RC 0681-0684 total amount is above $1.",,,,0,7561,140886.53,other,"IP STOPLOSS Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT ETHIBOND 3-0 SH 36IN 2 ARM BRAID GREEN NONABSORBABLE",SUP-X522H,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"MULTIPLAN [10600]",Multiplan,,21.25,85,,,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAPROXEN 250 MG TABLET, IMMEDIATE RELEASE",RX-5391,CDM,,,0637,RC,65162-0188-10,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ins Artery Line Perc",PX-450000236,CDM,36620,CPT,0361,RC,,,both,,,773.31,231.99,"MULTIPLAN [10600]",Multiplan,,657.31,85,,,,,0,89.94,773.31,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.7MM 30MM LCP STAINLESS STEEL T8 ELBOW METAPHYSEAL",SUP-02.118.530,CDM,C1713,HCPCS,0278,RC,,,both,,,523.91,157.17,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,62.08,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",89.95,62.76,129.33,34,60.93,445.32,"percent of total billed charges",
"MATRIX TISSUE AXIOFILL HUMAN PLACENTAL EXTRACELLULAR MATRIX",SUP-PCM-0250,CDM,Q4433,HCPCS,0636,RC,,,both,,,3946.80,1184.04,"NOVANET [10819]",Novanet,,2960.1,75,,,,,0,247.92,3354.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM ANGIOGRAPHY 48IN DISPOSAL DEPOT BAG LARGE BORE TUBING",SUP-MDD520H,CDM,S27000186,LOCAL,0270,RC,,,both,,,82.74,24.82,"FIRST HEALTH [10303]","First Health",,66.19,80,,,,,0,9.62,70.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IN.PACT 018 5.0 MM X 40 MM X 130 CM",SUP-IPU05004013P,CDM,C2623,HCPCS,0272,RC,,,both,,,8073.00,2421.9,"FIRST HEALTH [10303]","First Health",,6458.4,80,,,,,0,938.89,6862.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 30MMX11MM VERTE-STACK CRESCENT THORACOLUMBAR",SUP-9193011,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,6624,40,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 9 6MM KNEE AOX POSTERIOR STABILIZE FIX BEARING",SUP-151640906,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"CIGNA [10200]","Cigna Open Access",,6403.47,56.9,,5302.19,4377.88,6578.61,27,1308.83,9565.82,"percent of total billed charges",
"HC Grad Compression Thigh 30-40",PX-E27100013,CDM,A6534,HCPCS,0292,RC,,,both,,,191.40,57.42,"KAISER [10500]",Kaiser,,128.24,67,,,,,0,22.26,162.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT FINGER SWANSON 4 METACARPOPHALANGEAL GROMMET HIGH",SUP-G4700004,CDM,C1776,HCPCS,0278,RC,,,both,,,4170.60,1251.18,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,485.04,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,485.04,3545.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE ANATOMIC, SHORT HUMERAL STEM, 8MM",SUP-520-08-000,CDM,C1776,HCPCS,0278,RC,,,both,,,7920.00,2376,"FIRST HEALTH [10303]","First Health",,6336,80,,,,,0,921.1,6732,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 15CM 40MM TAG THORACIC ACTIVE CONTROL",SUP-TGMR404015,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"CIGNA [10200]",Cigna,,46388.88,40,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 5.5MM MULTIFIX S ULTRA KNOTLESS PEEK",SUP-72290001,CDM,C1713,HCPCS,0278,RC,,,both,,,3138.75,941.62,"BLUE CROSS [10001]","Blue Cross HMO",,1230.39,39.2,,957.42,156.86,7483.26,51,365.04,2667.94,"percent of total billed charges",
"HIV WITH MAJOR RELATED CONDITION WITH CC",975,MS-DRG,,,,,,,inpatient,,,47370.52,14211.16,"KAISER MEDICARE [30106]","Kaiser Medicare Advantage",,8273.96,,"Case rate ($8,032.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $7,459.15, add-ons for qualifying new technology services are included. If operating cost exceeds $40,498.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,945.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $7,469.02. The transfer operating threshold is the transfer adjustment factor * $7,459.15 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.95. The transfer capital threshold is the transfer adjustment factor * $563.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.",,,,0,7561,32296.01,other,"INPATIENT DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL 0MM 12/14 MEDIUM TAPER 28MM HIP MODULAR BIOLOX",SUP-104.2805,CDM,C1776,HCPCS,0278,RC,,,both,,,3375.00,1012.5,"CIGNA [10200]","Cigna Local Plus",,1805.63,53.5,,5372.07,4581.20,7242.98,23,392.51,2868.75,"percent of total billed charges",
"SCR BONE 4.5MM 8MM 24MM DHS/DCS STAINLESS STEEL STD CORTICAL",SUP-214.024,CDM,C1713,HCPCS,0278,RC,,,both,,,435.00,130.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,50.59,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",50.59,369.75,"percent of total billed charges",
"DIL ENDOSCOPIC ELATION 100CM 3CM 10-11-12MM PULMONARY 3",SUP-P10L30,CDM,C1726,HCPCS,0272,RC,,,both,,,2137.50,641.25,"MULTIPLAN [10600]",Multiplan,,1816.88,85,,,,,0,248.59,1816.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 50CM 4CM GRAY HUB STAINLESS STEEL GWIRE NDL",SUP-PSS-5F-4-035MT,CDM,C1894,HCPCS,0272,RC,,,both,,,208.80,62.64,"KAISER [10500]",Kaiser,,139.9,67,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT POLARIS ZIPWIRE 24CM 3CM 5FR .035IN STRAIGHT URETERAL",SUP-M006155222190,CDM,C2617,HCPCS,0278,RC,,,both,,,1420.34,426.1,"MULTIPLAN [10600]",Multiplan,,1207.29,85,,,,,0,165.19,1207.29,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 32X21MM ENDOSKELETON TAS 7D 11MM STD TITANIUM",SUP-2307-0111,CDM,S27800098,LOCAL,0278,RC,,,both,,,28350.00,8505,"CIGNA [10200]","Cigna Local Plus",,8930.25,31.5,,,,,0,3297.11,24097.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Cpap Init & Mgmt Rpeat",PX-410000010,CDM,94660,CPT,0410,RC,,,both,,,1484.41,445.32,"BLUE CROSS [10001]","Blue Cross HMO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $15,625, 68.6% of billed. Billed Amounts $15,625.01 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"LEAD PACING 59CM ENDOCARDIAL 2 COIL STD DF4 TERMINAL CNCT",SUP-0295,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"MULTIPLAN [10600]",Multiplan,,14596.2,85,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR PINNACLE +4MM NEUTRAL 62MM 36MM MARATHON",SUP-121936462,CDM,C1776,HCPCS,0278,RC,,,both,,,9842.85,2952.85,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1144.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1144.72,8366.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT SOFT TISSUE 19.5+ CMX10-20MM ACHILLES TENDON CALCANEUS",SUP-430201,CDM,C1762,HCPCS,0278,RC,,,both,,,14314.74,4294.42,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1664.8,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1664.8,12167.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Bronch W Dest Tumor Laser/Cryo",PX-750000018,CDM,31641,CPT,0750,RC,,,both,,,6667.30,2000.19,"BLUE CROSS [10001]","Blue Cross PPO",,4431.65,,"Case rate ($4,431.65). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,775.41,6667.3,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Intravasc Litho Iliac",PX-361000703,CDM,37262,CPT,0361,RC,,,both,,,6377.03,1913.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1249,,"Case rate ($1,249). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.",,,,0,6.38,6377.03,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER SPINAL 25MMX9MM CRESCENT PEEK-OPTIMA VERTEBRAL BODY",SUP-9392509,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"CIGNA [10200]","Cigna Open Access",,5547.6,33.5,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE 80% CANCELLOUS 20% CORTICAL 90CC 1-4MM LATEX FREE",SUP-800122,CDM,S27800098,LOCAL,0278,RC,,,both,,,6365.94,1909.78,"AETNA [10100]","Aetna HMO/PPO",,5060.92,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,740.36,5411.05,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Impl Cardiac Event Record",PX-361000058,CDM,33285,CPT,0361,RC,,,both,,,15025.48,4507.64,"BLUE CROSS [10001]","Blue Cross PPO",,9549.81,,"Case rate ($9,549.81). The procedures on each service date are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 999 procedures at 25%.",,,,0,1747.46,12771.66,"fee schedule","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Resp Virus 6-11 Targets",PX-306000231,CDM,87632,CPT,0306,RC,,,both,,,4400.40,1320.12,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,0.01,,,,,,,0.01,3740.34,"per diem",
"HC Amino Acids 2-5 Acids Qn",PX-301000580,CDM,82136,CPT,0301,RC,,,both,,,590.00,177,"MULTIPLAN [10600]",Multiplan,,501.5,85,,,,,0,0.01,501.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Chemo IV Inf 1st Hr",PX-335000001,CDM,96413,CPT,0335,RC,,,both,,,987.65,296.29,"UHC [10700]","United Healthcare",,987.65,,"Per diem ($1,277).",,,,0,114.86,987.65,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"7F DUO-DECA 2-8-2-..-60-..-2-8-2 MPD-H 100CM",SUP-901684,CDM,C1731,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"PHCS [10601]",PHCS,,4709.25,70,,,,,0,782.41,5718.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 3 THK7MM NARROW KNEE LEFT RIGHT POSTERIOR",SUP-TPS-030-073N,CDM,S27200284,LOCAL,0272,RC,,,both,,,810.00,243,"CIGNA [10200]","Cigna Local Plus",,433.35,53.5,,,,,0,94.2,688.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 40MM 22GA SONOPLEX II FACET SPECIAL TIP",SUP-001287-70,CDM,C9812,HCPCS,0272,RC,,,both,,,119.63,35.89,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,49.17,41.1,,,,,0,13.91,101.69,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CPS LOC MEDIUM CARDIAC PERCUTANEOUS 3D STERILE",SUP-DS2C200-42,CDM,C1893,HCPCS,0272,RC,,,both,,,2250.00,675,"AMERIGROUP MEDICAID [20100]",Amerigroup,,266.63,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,261.68,1912.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 24MM SECUR-FIT X-TRA TITANIUM T15 CORTICAL",SUP-131218024,CDM,C1713,HCPCS,0278,RC,,,both,,,789.75,236.92,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,91.85,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",91.85,671.29,"percent of total billed charges",
"SUT PROLENE 5-0 V-5 36IN 2 ARM MONOFILAMENT BLUE",SUP-8934H,CDM,S27200284,LOCAL,0272,RC,,,both,,,84.98,25.49,"CIGNA [10200]",Cigna,,57.79,68,,,,,0,9.88,72.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT JEJUNOSTOMY 45CM 18FR TUNGSTEN SILICONE 3.5CM MIC-KEY",SUP-8270-18-3.5-45,CDM,S27200284,LOCAL,0272,RC,,,both,,,2632.80,789.84,"FIRST HEALTH [10303]","First Health",,2106.24,80,,,,,0,306.19,2237.88,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM PROMUS ELEMENT PLUS 32MM 144CM 2.5MM CORONARY STENT",SUP-H7493911432250,CDM,C1874,HCPCS,0278,RC,,,both,,,9142.50,2742.75,"PHCS [10601]",PHCS,,6399.75,70,,,,,0,1063.27,7771.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ANCHOR SUT 4.5MM HEALIX ADVANCE CORD PEEK-OPTIMA",SUP-222303,CDM,C1713,HCPCS,0278,RC,,,both,,,2977.50,893.25,"CIGNA [10200]","Cigna Local Plus",,1592.96,53.5,,3978.14,359.25,3978.14,24,346.28,2530.88,"percent of total billed charges",
"CLAREON PANOPTIX TORIC",SUP-CNWTT3,CDM,V2788,HCPCS,0276,RC,,,both,,,865.00,259.5,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,100.6,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,100.6,735.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOTAL KNEE 1 -  STANDARD",SUP-CAP-DJO-K-1,CDM,C1776,HCPCS,0278,RC,,,both,,,17640.00,5292,"UHC [10700]","United Healthcare",,11166.12,63.3,,8601.07,8395.67,8601.07,"1 through 10",2051.53,14994,"percent of total billed charges",
"BLADE SHAVER 8CM 2.9MM STERLING GATOR 6000 RPM SMALL JOINT",SUP-C9961A,CDM,S27200284,LOCAL,0272,RC,,,both,,,638.28,191.48,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,75.64,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,74.23,542.54,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TRAY NERVE BLOCK 3.25IN 18GA 20GA PAJUNK E-CATH 21GA",SUP-TDL112,CDM,S27200284,LOCAL,0272,RC,,,both,,,534.60,160.38,"KAISER [10500]",Kaiser,,358.18,67,,,,,0,62.17,454.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SPRINTER LEGEND FASTRAC MICRO-BRITE 142CM 12MM 3MM",SUP-SPL30012X,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"KAISER [10500]",Kaiser,,434.16,67,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SNARE STD OVAL 5.5CM 2.5CM 7FR ACUSNARE 1 PIECE ENDOSCOPIC",SUP-G22629,CDM,S27200284,LOCAL,0272,RC,,,both,,,164.43,49.33,"AETNA [10100]","Aetna HMO/PPO",,130.72,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,19.12,139.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXP TISSUE 11X10CM BREAST 300ML STYLE 133MX-T TEXTURED TAB",SUP-133MX-11-T,CDM,C1789,HCPCS,0278,RC,,,both,,,6510.00,1953,"PHCS [10601]",PHCS,,4557,70,,,,,0,757.11,5533.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT SUPERA 150MM 120CM 6MM 6FR VASCULAR PERIPHERAL",SUP-S-60-150-120-P6,CDM,C1876,HCPCS,0278,RC,,,both,,,10782.00,3234.6,"KAISER [10500]",Kaiser,,7223.94,67,,,,,0,1253.95,9164.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"IRON DEXTRAN 50 MG/ML INJECTION SOLUTION",RX-183103,CDM,J1750,HCPCS,0636,RC,00023-6082-01,NDC,both,2,ML,337.79,101.34,"NOVANET [10819]",Novanet,,253.34,75,,,,,0,40.03,287.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachythrpy Stranded I-125",PX-E27800013,CDM,C2638,HCPCS,0278,RC,,,both,,,363.00,108.9,"CIGNA [10200]","Cigna Open Access",,206.55,56.9,,,,,0,42.22,308.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MONOCRYL PLUS MULTIPASS 6-0 P-3 18IN MONOFILAMENT",SUP-MCP492G,CDM,S27200284,LOCAL,0272,RC,,,both,,,25.00,7.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,2.96,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2.91,21.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 6FR 50CM 4CM 2 ENDED GWIRE PRELUDE STAINLESS",SUP-PSS-6F-4-038MT,CDM,C1894,HCPCS,0272,RC,,,both,,,208.80,62.64,"MULTIPLAN [10600]",Multiplan,,177.48,85,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR",RX-27333,CDM,,,0637,RC,00904-7208-06,NDC,both,1,UN,6.27,1.88,"NOVANET [10819]",Novanet,,4.7,75,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE TRICORTICAL ILIUM FREEZE DRIED STRIPS 50-80X9X15",SUP-40A003,CDM,S27800098,LOCAL,0278,RC,,,both,,,7741.80,2322.54,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,2215.7,28.62,,,,,0,900.37,6580.53,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ESPRIT BTK 3.00 X 18 MM  RX FDA",SUP-1203300-18,CDM,C1874,HCPCS,0272,RC,,,both,,,17250.00,5175,"UHC [10700]","United Healthcare",,10919.25,63.3,,,,,0,7089.75,10919.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT LIFESTENT 40MM 130CM 6MM 6FR .035IN VASCULAR NITINOL",SUP-EX060403CS,CDM,C1876,HCPCS,0278,RC,,,both,,,11730.00,3519,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,1390.01,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1364.2,9970.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 50CM 20MM TARGET XL 360D LARGE DETACHABLE",SUP-M0036122050,CDM,S27800098,LOCAL,0278,RC,,,both,,,17325.00,5197.5,"UHC [10700]","United Healthcare",,10966.73,63.3,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"AVENIR 10, 1.5 X 3 HELICAL PICO COIL",SUP-10USH01503,CDM,S27800098,LOCAL,0278,RC,,,both,,,11723.10,3516.93,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3355.15,28.62,,,,,0,1363.4,9964.64,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE V-18 CONTROLWIRE VASCULAR STRAIGHT 150CM 8CM .018IN",SUP-46-850,CDM,C1769,HCPCS,0272,RC,,,both,,,602.64,180.79,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,247.69,41.1,,,,,0,70.09,512.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 7 10MM KNEE POSTERIOR STABILIZE ROTATE PLATFORM",SUP-151650710,CDM,C1776,HCPCS,0278,RC,,,both,,,13127.25,3938.17,"KAISER [10500]",Kaiser,,8795.26,67,,,,,0,1526.7,11158.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT GLENOID 36MM STD GLENOSPHERE COMPREHENSIVE VERSA-DIAL",SUP-TI-115310,CDM,C1776,HCPCS,0278,RC,,,both,,,12193.00,3657.9,"CIGNA [10200]",Cigna,,4877.2,40,,5873.17,5873.17,5873.17,"1 through 10",1418.05,10364.05,"percent of total billed charges",
"CATH IMAGER II 100CM 5FR SIMMONS 2 CURVE ANGIOGRAPHIC BRAID",SUP-M001314341,CDM,S27200284,LOCAL,0272,RC,,,both,,,116.58,34.97,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,13.56,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,13.56,99.09,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FARAPOINT PFA CATHETER F-F CURVE",SUP-M004PF81M310,CDM,C1733,HCPCS,0272,RC,,,both,,,24570.00,7371,"MULTIPLAN [10600]",Multiplan,,20884.5,85,,,,,0,2857.49,20884.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE VERTIGRAFT CERVICAL LARGE PARALLEL 14X14.5X9MM",SUP-VG2C-DR9P,CDM,S27800098,LOCAL,0278,RC,,,both,,,6077.73,1823.32,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,720.21,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,706.84,5166.07,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL 14CM LEGEND 9MM BALL DIAMOND DISSECTING",SUP-14BA90D,CDM,S27200284,LOCAL,0272,RC,,,both,,,1468.94,440.68,"CIGNA [10200]","Cigna Open Access",,835.83,56.9,,,,,0,170.84,1248.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -3.5MM 12/14 TAPER UNIVERSAL 28MM HIP COCR",SUP-802202801,CDM,C1776,HCPCS,0278,RC,,,both,,,4850.70,1455.21,"PHCS [10601]",PHCS,,3395.49,70,,,,,0,564.14,4123.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRILL SURGICAL FREEHAND HINDFOOT VALOR 4.3MM SCR IMPL KIT",SUP-415S002350,CDM,S27200284,LOCAL,0272,RC,,,both,,,1972.50,591.75,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,233.74,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,229.4,1676.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 102MM 2.7MM STAINLESS STEEL QUICK CONNECT 76MM",SUP-KM166-310-26,CDM,S27200284,LOCAL,0272,RC,,,both,,,198.53,59.56,"NOVANET [10819]",Novanet,,148.9,75,,,,,0,23.09,168.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH FOX SV 150CM 60MM 4FR 5MM .018IN LARGE CRESCENT LOW",SUP-83175-02,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"PHCS [10601]",PHCS,,1312.5,70,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GWIRE HI-FLO RENEGADE FATHOM VASCULAR 105CM 20CM .016IN",SUP-M001184510,CDM,C1769,HCPCS,0272,RC,,,both,,,3750.00,1125,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,1541.25,41.1,,,,,0,436.13,3187.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 6MM 3.25MM ULTRA LOW PROFILE BALLOON",SUP-1012275-06,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"MULTIPLAN [10600]",Multiplan,,550.8,85,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rheumatoid Factor Qual",PX-302000090,CDM,86430,CPT,0302,RC,,,both,,,236.00,70.8,"PHCS [10601]",PHCS,,165.2,70,,,,,0,0.01,200.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 65MM LCP STAINLESS STEEL PARTIAL THREAD",SUP-02.207.465,CDM,C1713,HCPCS,0278,RC,,,both,,,1555.85,466.75,"MULTIPLAN [10600]",Multiplan,,1322.47,85,,,,,0,180.95,1322.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT CLAMP STEALTH SMALL FIBRA SIDE BITE STERILE LATEX FREE",SUP-A0G05,CDM,S27200284,LOCAL,0272,RC,,,both,,,226.20,67.86,"CIGNA [10200]","Cigna Local Plus",,121.02,53.5,,,,,0,26.31,192.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM TACKING L160CM ENDOSCOPIC HELIX DISPOSABLE X-TACK",SUP-M00505500,CDM,S27200284,LOCAL,0272,RC,,,both,,,5706.30,1711.89,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,2619.19,45.9,,,,,0,663.64,4850.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUB SKIN 16X10CM STRATTICE PORCINE DERMAL MATRIX FIRM PATCH",SUP-1016002,CDM,Q4130,HCPCS,0636,RC,,,both,,,24450.30,7335.09,"CIGNA [10200]","Cigna Open Access",,13912.22,56.9,,,,,0,2897.36,20782.76,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 2.4MM 18MM VARIAX T8 FULL THREAD LOCK NONSTERILE",SUP-656018,CDM,C1713,HCPCS,0278,RC,,,both,,,1335.20,400.56,"MULTIPLAN [10600]",Multiplan,,1134.92,85,,,,,0,155.28,1134.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROS OSSICULAR 2X133MM GOLDENBERG EAR HA FOOTPLATE SHOE",SUP-140914,CDM,L8613,HCPCS,0278,RC,,,both,,,1710.08,513.02,"BLUE CROSS [10001]","Blue Cross PPO",,670.35,39.2,,,,,0,198.88,1453.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL KNIFE 1650MM 2.8MM STERILE 4.5MM",SUP-KD-640L,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"UHC [10700]","United Healthcare",,2367.42,63.3,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS LD TANDEM ARCHITECTURE 17MM 135CM 5MM 20MM",SUP-H74938047520130,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"FIRST HEALTH [10303]","First Health",,3993.6,80,,,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 55MM EXPEDIUM TITANIUM SPINE POLYAXIAL 1",SUP-179712055,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"NOVANET [10819]",Novanet,,2846.25,75,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE AORTIC 17.5MM 25MM MOSAIC ULTRA CINCH PORCINE",SUP-305U225,CDM,S27800098,LOCAL,0278,RC,,,both,,,27405.00,8221.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,11263.46,41.1,,,,,0,3187.2,23294.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH DXTERITY 100CM 6FR .056IN JUDKINS RIGHT 6 CURVE",SUP-DXT6JR60,CDM,S27200284,LOCAL,0272,RC,,,both,,,82.65,24.79,"MULTIPLAN [10600]",Multiplan,,70.25,85,,,,,0,9.61,70.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 6 8MM KNEE AOX CRUCIATE RETAINING FIX BEARING",SUP-151620608,CDM,C1776,HCPCS,0278,RC,,,both,,,11253.90,3376.17,"BLUE CROSS [10001]","Blue Cross HMO",,4411.53,39.2,,5311.50,4717.44,5388.59,31,1308.83,9565.82,"percent of total billed charges",
"LENS IOL +16 DIOPTER CONVEXOPLANO 13.5MM 5.5MM ANTERIOR",SUP-MTA5U0.160,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"KAISER [10500]",Kaiser,,461.3,67,,,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.5MM 55MM RELINE-O SPINE POLYAXIAL TRACTION",SUP-13117555,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"BLUE CROSS [10001]","Blue Cross PPO",,2163.84,39.2,,957.42,570.23,957.42,28,641.98,4692,"percent of total billed charges",
"SCR BONE 1.5MM 12MM STAINLESS STEEL T4 CORTEX SELF TAP",SUP-02.214.112,CDM,C1713,HCPCS,0278,RC,,,both,,,418.99,125.7,"MULTIPLAN [10600]",Multiplan,,356.14,85,,,,,0,48.73,356.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Ptt Mixng Studies",PX-305000065,CDM,85730,CPT,0305,RC,,,both,,,182.40,54.72,"PHCS [10601]",PHCS,,127.68,70,,,,,0,0.18,155.04,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Brachythrpy Stranded I-125",PX-E27800013,CDM,C2638,HCPCS,0278,RC,,,both,,,363.00,108.9,"NOVANET [10819]",Novanet,,272.25,75,,,,,0,42.22,308.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 80MM 16-14MM 14MM 11FR TRIVASCULAR OVATION PRIME",SUP-TV-IL141680-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,9556.22,28.62,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TORCON NB ADVANTAGE 100CM 7FR .038IN SHORT MONT-1 CURVE",SUP-G08943,CDM,S27200284,LOCAL,0272,RC,,,both,,,156.60,46.98,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,106.49,68,,,,,0,18.21,133.11,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH MINI-TREK II 6MM 5FR 2MM BALLOON DILATATION HYDROCOAT",SUP-1012403-06A,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"AETNA [10100]","Aetna HMO/PPO",,515.16,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CHRG 135CM 40MM 5FR 7MM BALLOON DILATATION OTW 2 LUMEN",SUP-H74939206070410,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,440.64,68,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEATH PINNACLE DESTINATION MULTIPURPOSE CURVE 45CM 5CM 7FR",SUP-RSR06,CDM,C1894,HCPCS,0272,RC,,,both,,,672.30,201.69,"AETNA [10100]","Aetna HMO/PPO",,534.48,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,78.19,571.46,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 20CM 6MM .0115IN AXIUM PRIME 3D",SUP-APB-6-20-3D-SS,CDM,S27800098,LOCAL,0278,RC,,,both,,,9591.00,2877.3,"AMERIGROUP MEDICAID [20100]",Amerigroup,,1136.53,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1115.43,8152.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH TREK 145CM 20MM 3MM BALLOON DILATATION PEBAX HYDROCOAT",SUP-1012407-20,CDM,C1725,HCPCS,0272,RC,,,both,,,648.00,194.4,"FIRST HEALTH [10303]","First Health",,518.4,80,,,,,0,75.36,550.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET",RX-28384,CDM,,,0250,RC,27808-0037-01,NDC,both,1,UN,12.54,3.76,"MULTIPLAN [10600]",Multiplan,,10.66,85,,,,,0,1.46,10.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 80MM 5.5MM MATRIX 100MM RADIUS CURVE BULLET NOSE",SUP-04.651.080,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"CIGNA [10200]","Cigna Local Plus",,650.03,53.5,,3978.14,359.25,3978.14,24,141.3,1032.75,"percent of total billed charges",
"CATH ULTRAVERSE 018 150CM 30CM 4MM BALLOON DILATATION",SUP-U8150430,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,150.72,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL EMBOLIZATION 17CM 5MM CEREPAK MICRO UNIFORM DETACHABLE",SUP-FCX100517,CDM,S27800098,LOCAL,0278,RC,,,both,,,13225.85,3967.75,"BLUE CROSS [10001]","Blue Cross HMO",,5184.53,39.2,,,,,0,1538.17,11241.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SURFACE ARTICULAR 11MM PERSONA MEDIAL CONGRUENT 12 G-H KNEE",SUP-42512101011,CDM,C1776,HCPCS,0278,RC,,,both,,,10776.42,3232.93,"MULTIPLAN [10600]",Multiplan,,9159.96,85,,,,,0,1253.3,9159.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE STRATAFIX PDS PLUS 1 CTX 45CM SUT ABSORBABLE KNOTLESS",SUP-SXPP1A400,CDM,S27200284,LOCAL,0272,RC,,,both,,,240.30,72.09,"CIGNA [10200]","Cigna Open Access",,136.73,56.9,,,,,0,27.95,204.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROLL EXERCISE TUMBLE FORMS 2 24INX4IN VINYL PEDIATRIC STRAP",SUP-2794A,CDM,S27000186,LOCAL,0270,RC,,,both,,,581.66,174.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,395.53,68,,,,,0,67.65,494.41,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MARKER RADIOLOGY 5X4IN 2MM GUIDELINES NECK BIOPSY GRID CT",SUP-117,CDM,S27200284,LOCAL,0272,RC,,,both,,,48.50,14.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,5.75,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,5.64,41.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC 100MM 12MM KII OPTICAL ACCESS SYSTEM",SUP-CFR74,CDM,S27200284,LOCAL,0272,RC,,,both,,,182.70,54.81,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,75.09,41.1,,,,,0,21.25,155.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE ENDOBRONCHIAL 35FR ANGLE 2 LEFT",SUP-M125135,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TROCAR LAPAROSCOPIC CLEAR 5MM SPACEMAKER PRO BLUNT TIP OVAL",SUP-SMBTTOVLX,CDM,C1727,HCPCS,0272,RC,,,both,,,3323.48,997.04,"MULTIPLAN [10600]",Multiplan,,2824.96,85,,,,,0,386.52,2824.96,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE SHAVER 4MM FRMLA TOMCAT LONG HIP STERILE",SUP-385545000,CDM,S27200284,LOCAL,0272,RC,,,both,,,2287.50,686.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,271.07,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,266.04,1944.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PROBE BREAST BIOPSY 145MM 11GA MAMMOTOME MR LONG BLADELESS",SUP-MRP11X,CDM,S27200284,LOCAL,0272,RC,,,both,,,2043.23,612.97,"PHCS [10601]",PHCS,,1430.26,70,,,,,0,237.63,1736.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALLOGRAFT SPACER SPINAL LUMBAR ALIF ANTERIOR CONVEX 12 DEGRE",SUP-12419,CDM,S27800098,LOCAL,0278,RC,,,both,,,18900.00,5670,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,5103,27,,,,,0,2198.07,16065,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3MM 4MM 1.2MM 25MM 10MM STAINLESS STEEL LONG THREAD",SUP-202.725,CDM,C1713,HCPCS,0278,RC,,,both,,,1110.02,333.01,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,129.1,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",380.36,380.36,380.36,"1 through 10",129.1,943.52,"percent of total billed charges",
"TRNSDUC PRESSURE 12IN MERITRANS WINGED HOUSING MALE SWIVEL",SUP-K11-00096B,CDM,S27200284,LOCAL,0272,RC,,,both,,,94.13,28.24,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,64.01,68,,,,,0,10.95,80.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE RELINE C SPINE OPEN LOCK NONSTERILE LATEX FREE",SUP-3900240,CDM,C1713,HCPCS,0278,RC,,,both,,,348.00,104.4,"CIGNA [10200]","Cigna Open Access",,198.01,56.9,,1144.80,304.56,2275.09,66,40.47,295.8,"percent of total billed charges",
"CATH REDEL 92CM 1MM 6FR 5MM SPACE STD F CURVE",SUP-D610FR005RT,CDM,C1730,HCPCS,0272,RC,,,both,,,3727.50,1118.25,"FIRST HEALTH [10303]","First Health",,2982,80,,,,,0,433.51,3168.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Plmt Uret Stnt New Acc Sep Cath",PX-361000419,CDM,50695,CPT,0361,RC,,,both,,,7552.00,2265.6,"AMERIGROUP MEDICAID [20100]",Amerigroup,,894.91,11.85,"11.85% of billed. For each date, the first unit reimbursed at 100%, unit 2 reimbursed at 50%, units 3 to 999 reimbursed at 25%. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,878.3,7552,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SUPREME 120CM 6FR 2-5-2MM SPACING JSN CURVE",SUP-401451,CDM,C1730,HCPCS,0272,RC,,,both,,,729.00,218.7,"NOVANET [10819]",Novanet,,546.75,75,,,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEET TRANSFER 1960X760MM 480MM MAXITUBE FLITES PREMIUM TUBE",SUP-NPA0700,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.89,30.57,"UHC [10700]","United Healthcare",,64.5,63.3,,,,,0,11.85,86.61,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPHERE GLENOID 22.3MM 36MM EQUINOXE SHOULDER SMALL REVERSE",SUP-320-31-36,CDM,C1776,HCPCS,0278,RC,,,both,,,7762.50,2328.75,"FIRST HEALTH [10303]","First Health",,6210,80,,,,,0,902.78,6598.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 35MM OMNIFIT 10 C TAPER HIP STERILE LATEX FREE",SUP-6076-1035A,CDM,C1776,HCPCS,0278,RC,,,both,,,8076.45,2422.93,"AETNA [10100]","Aetna HMO/PPO",,6420.78,79.5,,10981.53,8986.79,12413.38,12,939.29,6864.98,"percent of total billed charges",
"BUTTON SUT 12MM 2.6MM BICEPS TITANIUM STERILE",SUP-AR-2261,CDM,C1713,HCPCS,0278,RC,,,both,,,2323.13,696.94,"CIGNA [10200]",Cigna,,1579.73,68,,1831.33,1831.33,1831.33,16,270.18,1974.66,"percent of total billed charges",
"SUT CARDIOXYL PLEDGET TD3X7",SUP-73P30F,CDM,S27200284,LOCAL,0272,RC,,,both,,,922.73,276.82,"NOVANET [10819]",Novanet,,692.05,75,,,,,0,107.31,784.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -5MM 36MM HIP DELTA V40",SUP-6570-0-036,CDM,C1776,HCPCS,0278,RC,,,both,,,10000.00,3000,"BLUE CROSS [10001]","Blue Cross PPO",,3920,39.2,,3949.44,3949.44,3949.44,"1 through 10",1163,8500,"percent of total billed charges",
"STENT WALLFLEX 60MM 75CM 10MM 8FR .035IN BILIARY METAL",SUP-M00574670,CDM,C1876,HCPCS,0278,RC,,,both,,,17325.00,5197.5,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,4677.75,27,,,,,0,2014.9,14726.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO CATH 13CM 7FR PEEL-APART SHEATH LONG T HANDLE LOCK",SUP-0601170,CDM,C1894,HCPCS,0272,RC,,,both,,,729.00,218.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL L HOOK 45CM CLEANCOAT WIRE COATED",SUP-E3773-45C,CDM,S27200284,LOCAL,0272,RC,,,both,,,316.07,94.82,"CIGNA [10200]","Cigna Local Plus",,169.1,53.5,,,,,0,36.76,268.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +8.5MM 12/14 TAPER 36MM CERAMIC ARTICUL/EZE",SUP-473436085,CDM,C1776,HCPCS,0278,RC,,,both,,,14072.55,4221.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,1636.64,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,1636.64,11961.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SABER .035 8X100 135CM SL",SUP-48008010R,CDM,C1725,HCPCS,0272,RC,,,both,,,859.01,257.7,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,101.79,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,99.9,730.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TUBE JEJUNOSTOMY 57.9CM 18FR TUNGSTEN SILICONE MIC SECUR-LOK",SUP-8210-18,CDM,S27200284,LOCAL,0272,RC,,,both,,,1442.85,432.85,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,170.98,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,167.8,1226.42,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET NDL 25MM 15GA ARROW EZ-IO EZ-CONNECT NDL VISE WRIST BAND",SUP-9001P-VC-005,CDM,S27200284,LOCAL,0272,RC,,,both,,,1138.86,341.66,"UHC [10700]","United Healthcare",,720.9,63.3,,,,,0,132.45,968.03,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CEFTAROLINE FOSAMIL 600 MG VIAL",RX-107671,CDM,J0712,HCPCS,0636,RC,00456-0600-01,NDC,both,1,UN,1554.03,466.21,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,496.2,,,,,,,184.15,1320.93,"fee schedule",
"TRAY DRNG 10FR FLEXIBLE STAYFIX SMALL SECUREMENT DEVICE",SUP-RLC-NV-10-SFX,CDM,C1729,HCPCS,0272,RC,,,both,,,1255.50,376.65,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,516.01,41.1,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CIRCAID ARM REDUCTION KIT- STANDARD, REGULAR",SUP-25401117,CDM,S27000186,LOCAL,0270,RC,,,both,,,1255.50,376.65,"NOVANET [10819]",Novanet,,941.63,75,,,,,0,146.01,1067.18,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Card MRI W Stress Img & Dye",PX-614000004,CDM,75563,CPT,0614,RC,,,both,,,5382.89,1614.87,"CIGNA [10200]",Cigna,,955,,"Per diem ($955). Each unique revenue code and service date combination is paid its own per diem rate.",,,,0,626.03,4575.46,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 150MM 23MM PRESS FIT TRIATHLON TITANIUM KNEE",SUP-5566-S-023,CDM,C1776,HCPCS,0278,RC,,,both,,,7345.05,2203.51,"CIGNA [10200]","Cigna Local Plus",,3929.6,53.5,,5372.07,4581.20,7242.98,23,854.23,6243.29,"percent of total billed charges",
"BLADE LARYNSCP MILLER 1 STRAIGHT STAINLESS STEEL FIBER OPTIC",SUP-040-851U,CDM,S27200284,LOCAL,0272,RC,,,both,,,265.18,79.55,"CIGNA [10200]","Cigna Local Plus",,141.87,53.5,,,,,0,30.84,225.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PICK SURGICAL 6IN STRAIGHT HOUGH MALLEABLE HEAVY SHAFT",SUP-61-0349,CDM,S27200284,LOCAL,0272,RC,,,both,,,421.34,126.4,"PHCS [10601]",PHCS,,294.94,70,,,,,0,49,358.14,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +32 DIOPTER POSTERIOR CHMBR FOLDABLE APODIZE",SUP-SA25T0,CDM,V2788,HCPCS,0276,RC,,,both,,,745.00,223.5,"FIRST HEALTH [10303]","First Health",,596,80,,,,,0,86.64,633.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSERT - 42 MM X 6 MM",SUP-DWD966,CDM,C1776,HCPCS,0278,RC,,,both,,,9027.72,2708.32,"KAISER [10500]",Kaiser,,6048.57,67,,,,,0,1049.92,7673.56,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SODIUM CHLORIDE 0.9 % IV BOLUS 500 ML",RX-400291,CDM,,,0258,RC,00990-7983-55,NDC,both,500,ML,100.65,30.19,"UHC [10700]","United Healthcare",,63.71,63.3,,,,,0,11.71,85.55,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 85MM 5.5MM CD HORIZON SOLERA PERCUTANEOUS COCRMO",SUP-651000085,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"FIRST HEALTH [10303]","First Health",,1296,80,,,,,0,188.41,1377,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"WRAP THERAPEUTIC 28 LB BACK COMPRESSION 2 PLUS HOUR GEL NONS",SUP-B-24-6-NP,CDM,S27000186,LOCAL,0270,RC,,,both,,,401.59,120.48,"CIGNA [10200]",Cigna,,273.08,68,,,,,0,46.7,341.35,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN LAPAROSCOPIC 100MM Z THREADED KII STERILE 5MM LATEX",SUP-CTS02,CDM,S27200284,LOCAL,0272,RC,,,both,,,68.00,20.4,"FIRST HEALTH [10303]","First Health",,54.4,80,,,,,0,7.91,57.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL -4 36MM HIP BIOLOX DELTA FMP SYSTEM",SUP-400-03-361,CDM,C1776,HCPCS,0278,RC,,,both,,,16953.92,5086.18,"CIGNA [10200]",Cigna,,6781.57,40,,5873.17,5873.17,5873.17,"1 through 10",1971.74,14410.83,"percent of total billed charges",
"SPLINT ORTHOPEDIC XL 4IN FINGER SPRING EXT ASSIST WIRE-FOAM",SUP-501D,CDM,S27000186,LOCAL,0270,RC,,,both,,,85.87,25.76,"FIRST HEALTH [10303]","First Health",,68.7,80,,,,,0,9.99,72.99,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TOOL DISSECTING 14CM 3MM MIDAS REX LEGEND 3 FLUTE PROXIMAL",SUP-SP14MH30T,CDM,S27200284,LOCAL,0272,RC,,,both,,,2759.25,827.77,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,1266.5,45.9,,,,,0,320.9,2345.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BURR SURGICAL 3MM ELITE ROUND COARSE DIAMOND 5 STEP NOTCH",SUP-5820-013-030,CDM,S27200284,LOCAL,0272,RC,,,both,,,1094.96,328.49,"PHCS [10601]",PHCS,,766.47,70,,,,,0,127.34,930.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT STENT 160MM 22-14MM 14FR 12FR TRIVASCULAR OVATION",SUP-TV-IL1422160-J,CDM,C1874,HCPCS,0278,RC,,,both,,,33390.00,10017,"MULTIPLAN [10600]",Multiplan,,28381.5,85,,,,,0,3883.26,28381.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MINOCYCLINE HCL 100 MG/5ML IV (WET SOLR VIAL)",RX-41510612,CDM,,,0250,RC,70842-0160-01,NDC,both,1,UN,1560.31,468.09,"UHC [10700]","United Healthcare",,987.68,63.3,,,,,0,181.46,1326.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"METOPROLOL TARTRATE 50 MG TABLET",RX-5009,CDM,,,0637,RC,65862-0063-01,NDC,both,1,UN,6.27,1.88,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,4.26,68,,,,,0,0.73,5.33,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DRAIN INCISION 12FR 12IN DEAVER NATURAL RUBBER 5IN T TUBE",SUP-0099810,CDM,S27200284,LOCAL,0272,RC,,,both,,,60.29,18.09,"PHCS [10601]",PHCS,,42.2,70,,,,,0,7.01,51.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPLINT ORTHOPEDIC 35X3IN SAFETY PRECUT FIBERGLASS",SUP-SS-335PC,CDM,S27000186,LOCAL,0270,RC,,,both,,,74.55,22.36,"CIGNA [10200]","Cigna Open Access",,42.42,56.9,,,,,0,8.67,63.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM RESOLUTE ONYX 34MM 140CM 2.75MM 2.1-2.7FR CORONARY",SUP-RONYX27534UX,CDM,C1874,HCPCS,0278,RC,,,both,,,3712.50,1113.75,"BLUE CROSS [10001]","Blue Cross PPO",,1455.3,39.2,,,,,0,431.76,3155.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EXPRESS SD MONORAIL 19MM 150CM 7MM BILIARY STAINLESS",SUP-H74937912719150,CDM,C1876,HCPCS,0278,RC,,,both,,,4992.00,1497.6,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,580.57,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,580.57,4243.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 26MM LC-DCP DHS/DCS STAINLESS STEEL CORTICAL",SUP-214.826,CDM,C1713,HCPCS,0278,RC,,,both,,,250.91,75.27,"CIGNA [10200]",Cigna,,170.62,68,,1831.33,1831.33,1831.33,16,29.18,213.27,"percent of total billed charges",
"CNCT ROD XLNK MEDIUM SPINE",SUP-7752536,CDM,C1713,HCPCS,0278,RC,,,both,,,4830.00,1449,"AETNA [10100]","Aetna HMO/PPO",,3839.85,79.5,,1521.93,481.35,16760.95,30,561.73,4105.5,"percent of total billed charges",
"BAND ANNULOPLASTY 28MM SIMULUS ANNULUS POSTERIOR POLYESTER",SUP-800SC28,CDM,S27800098,LOCAL,0278,RC,,,both,,,13110.00,3933,"CIGNA [10200]","Cigna Open Access",,4391.85,33.5,,,,,0,1524.69,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Progr Dev Eval Icd Dual Lead",PX-480000054,CDM,93283,CPT,0480,RC,,,both,,,409.40,122.82,"UHC [10700]","United Healthcare",,409.4,,"Per diem ($3,140).",,,,0,47.61,409.4,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"CMPNT FEMORAL 4 KNEE LEFT POSTERIOR STABILIZE CEMENT LEGION",SUP-71423224,CDM,C1776,HCPCS,0278,RC,,,both,,,21886.20,6565.86,"KAISER [10500]",Kaiser,,14663.75,67,,,,,0,2545.37,18603.27,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SLING PATIENT LARGE SOLO HIGHBACK 25",SUP-P3525916-2,CDM,S27000186,LOCAL,0270,RC,,,both,,,308.50,92.55,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,36.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.88,262.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELEV SURGICAL 7.5X1IN SLIGHT CURVE KEY",SUP-26-5625,CDM,S27200284,LOCAL,0272,RC,,,both,,,282.23,84.67,"CIGNA [10200]","Cigna Open Access",,160.59,56.9,,,,,0,32.82,239.9,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HEAD FEMORAL +10MM 28MM HIP COCR UHMWPE PCA",SUP-6280-0-328,CDM,C1776,HCPCS,0278,RC,,,both,,,3127.70,938.31,"CIGNA [10200]","Cigna Open Access",,1779.66,56.9,,5302.19,4377.88,6578.61,27,363.75,2658.55,"percent of total billed charges",
"KIT STENT 22CM 6FR .038IN PIGTAIL CURVE TAPER URETER GLIDEX",SUP-M001245730,CDM,C2617,HCPCS,0272,RC,,,both,,,1725.00,517.5,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,708.98,41.1,,,,,0,200.62,1466.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PAD THERAPEUTIC 11.34X10.85IN WRAP ON EXTEND HOSE CONTINUOUS",SUP-11-0680-9-00000,CDM,S27000187,LOCAL,0270,RC,,,both,,,157.38,47.21,"CIGNA [10200]","Cigna Local Plus",,84.2,53.5,,,,,0,18.3,133.77,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BRA 46IN AUGMENTATION HEAVIER ADJUSTABLE STRAP FRONT ZIPPER",SUP-2-8124C-46,CDM,S27000186,LOCAL,0270,RC,,,both,,,391.50,117.45,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,179.7,45.9,,,,,0,45.53,332.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 0 CT-2 18IN CONTROL RELEASE BRAID 8",SUP-C027D,CDM,S27200284,LOCAL,0272,RC,,,both,,,102.49,30.75,"MULTIPLAN [10600]",Multiplan,,87.12,85,,,,,0,11.92,87.12,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.5MM 12MM INFINITY SPINE MULTIAXIAL NONSTERILE",SUP-3603512,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"KAISER [10500]",Kaiser,,2542.65,67,,,,,0,441.36,3225.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Thrpy Massage Ea 15min (Gp)",PX-420000025,CDM,97124,CPT,0420,RC,,,both,,,163.34,49,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,163.34,,"Per diem ($239.55).",,,,0,19,163.34,"per diem","Zero final payments for the item or service in the 15 months prior to posting the file."
"LENS IOL +10 DIOPTER MODIFIED C CONVEXOPLANO 13.5MM 5.5MM",SUP-MTA5U0.100,CDM,V2630,HCPCS,0276,RC,,,both,,,688.50,206.55,"AMERIGROUP MEDICAID [20100]",Amerigroup,,81.59,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,80.07,585.23,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH LUTONIX ULTRAVERSE 130CM 80MM 7MM BALLOON DILATATION",SUP-LX181307805F,CDM,C2623,HCPCS,0272,RC,,,both,,,6727.50,2018.25,"PHCS [10601]",PHCS,,4709.25,70,,,,,0,782.41,11143.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VANCOMYCIN 750 MG VIAL",RX-97371,CDM,J3373,HCPCS,0636,RC,00409-6531-11,NDC,both,1,UN,60.53,18.16,"CIGNA [10200]",Cigna,,6.41,,,,,,,2.62,51.45,"fee schedule",
"SPACER SPINAL 14X11X10MM ALEUTIAN SMALL LORDOTIC ANTERIOR",SUP-403-21410L,CDM,S27800098,LOCAL,0278,RC,,,both,,,6678.42,2003.53,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3065.39,45.9,,,,,0,776.7,5676.66,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE 65X21X2MM TITANIUM 3 LEVEL CLOVERLEAF CAUDAL HOLE LOCK",SUP-450.357,CDM,C1713,HCPCS,0278,RC,,,both,,,5520.00,1656,"CIGNA [10200]","Cigna Local Plus",,2953.2,53.5,,3978.14,359.25,3978.14,24,641.98,4692,"percent of total billed charges",
"INTRO SHEATH 12FR .158IN 13CM ROBUST VALVE SPLITTABLE",SUP-PLS-1012,CDM,C1894,HCPCS,0272,RC,,,both,,,304.50,91.35,"AETNA [10100]","Aetna HMO/PPO",,242.08,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,35.41,258.83,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ROTAREX 110CM 6FR ATHERECTOMY SET GWIRE ROTATIONAL",SUP-80236,CDM,C1724,HCPCS,0272,RC,,,both,,,23625.00,7087.5,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,2799.56,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,2747.59,20081.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT SILK PERMA-HAND 4-0 RB-1 24IN 2 ARM BRAID BLACK",SUP-K571H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"PHCS [10601]",PHCS,,18.2,70,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT ENDOVASCULAR 12CM 12MM EXCLUDER GORE CONTRALATERAL LEG",SUP-PLC121200,CDM,S27800098,LOCAL,0278,RC,,,both,,,27997.20,8399.16,"UHC [10700]","United Healthcare",,17722.23,63.3,,,,,0,3256.07,23797.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STEM FEMORAL 195MM 15MM MODULAR RESTORATION BOW CONE HIP",SUP-6276-7-215,CDM,C1776,HCPCS,0278,RC,,,both,,,17822.70,5346.81,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,7129.08,40,,,,,0,2072.78,15149.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT VICRYL 4-0 PS-2 18IN BRAID COATED UNDYED ABSORBABLE",SUP-J496G,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"FIRST HEALTH [10303]","First Health",,20.8,80,,,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL) EFS SIEGEL TAVR TRANSCATHETER AORTIC VALVE - 23MM","SUP-30-1-0123 -EFS",CDM,S62400003,LOCAL,0624,RC,,,both,,,182400.00,54720,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,83721.6,45.9,,,,,0,21213.12,155040,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"RING FIXATION 13MM FINE-THORNTON SWIVEL",SUP-60-7065,CDM,S27200284,LOCAL,0272,RC,,,both,,,1628.00,488.4,"FIRST HEALTH [10303]","First Health",,1302.4,80,,,,,0,189.34,1383.8,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 90CM 150MM 4MM BALLOON DILATATION OTW STERILE",SUP-47040150S,CDM,C1725,HCPCS,0272,RC,,,both,,,1433.70,430.11,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,589.25,41.1,,,,,0,166.74,1218.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"VALVE MITRAL MITRACLIP BUNDLE 1 SGC0301 1 CDS0601 NTR 2",SUP-MBR0303,CDM,S27800098,LOCAL,0278,RC,,,both,,,171000.00,51300,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,70281,41.1,,,,,0,19887.3,145350,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PARTIAL HIP CONSTRUCT 2",SUP-CAP-SN-PH-2,CDM,C1776,HCPCS,0278,RC,,,both,,,9660.00,2898,"PHCS [10601]",PHCS,,6762,70,,,,,0,1123.46,8211,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LINER ACETABULAR 0D D 7.9MM 28MM X3 HIP",SUP-623-00-28D,CDM,C1776,HCPCS,0278,RC,,,both,,,8545.65,2563.69,"BLUE CROSS [10001]","Blue Cross HMO",,3349.89,39.2,,5311.50,4717.44,5388.59,31,993.86,7263.8,"percent of total billed charges",
"CATH AGENT 15MM 2.25MM BALLOON DILATATION PACLITAXEL",SUP-H7493960815220,CDM,C9610,HCPCS,0272,RC,,,both,,,38902.50,11670.75,"UHC [10700]","United Healthcare",,24625.28,63.3,,,,,0,4524.36,33067.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH ANGIOSCULPT 137CM 10MM 2.5MM RECTANGLE HELIX TAPER",SUP-2200-2510,CDM,C1725,HCPCS,0272,RC,,,both,,,5865.00,1759.5,"NOVANET [10819]",Novanet,,4398.75,75,,,,,0,682.1,4985.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT TKR 6MM ITOTAL POSTERIOR STABILIZE INSRT STERILE LATEX",SUP-RPS0100600,CDM,C1776,HCPCS,0278,RC,,,both,,,5081.85,1524.55,"MULTIPLAN [10600]",Multiplan,,4319.57,85,,,,,0,591.02,4319.57,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"FIBER LASER SOLTIVE 150UM THULIUM BALL TIP DISPOSABLE",SUP-TFL-FBX150BS,CDM,S27200284,LOCAL,0272,RC,,,both,,,3740.00,1122,"UHC [10700]","United Healthcare",,2367.42,63.3,,,,,0,434.96,3179,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ALTIVATE REVERSE REVISION HUMERAL STEM, SZ 6X175MM",SUP-530-06-175,CDM,C1776,HCPCS,0278,RC,,,both,,,12600.00,3780,"FIRST HEALTH [10303]","First Health",,10080,80,,,,,0,1465.38,10710,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH AMPLATZ ANCHOR MALECOT 30CM 10FR DRNG PERCUFLEX METAL",SUP-M001221010,CDM,C1729,HCPCS,0272,RC,,,both,,,729.00,218.7,"AMERIGROUP MEDICAID [20100]",Amerigroup,,86.39,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,84.78,619.65,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"EXTRACTOR, STRIPPED SCREW, 6 MM, 6"" LONG, SINGLE USE",SUP-SXT013-ST3,CDM,S27000186,LOCAL,0270,RC,,,both,,,2962.50,888.75,"KAISER [10500]",Kaiser,,1984.88,67,,,,,0,344.54,2518.13,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"(EVAL)CORONARY IVL CATHETER, 4.0MM X 20MM, RX IDE",SUP-501050-008,CDM,C1761,HCPCS,0624,RC,,,both,,,0.01,,"AETNA [10100]","Aetna HMO/PPO",,0.01,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,0.01,0.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ROD SPINAL 75MM 5.5MM EXPEDIUM PREBENT TITANIUM LINE",SUP-179771075,CDM,C1713,HCPCS,0278,RC,,,both,,,1215.00,364.5,"FIRST HEALTH [10303]","First Health",,972,80,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BEARING 79/83MMX12MM VANGUARD E1 KNEE CRUCIATE RETAINING",SUP-EP183462,CDM,C1776,HCPCS,0278,RC,,,both,,,12952.68,3885.8,"AETNA [10100]","Aetna HMO/PPO",,10297.38,79.5,,10981.53,8986.79,12413.38,12,1506.4,11009.78,"percent of total billed charges",
"SYSTEM 1 SMALL HYPERINFLATION PEDIATRIC .5L 2 PLEAT BAG 1",SUP-HS4151,CDM,S27000186,LOCAL,0270,RC,,,both,,,101.88,30.56,"CIGNA [10200]","Cigna Local Plus",,54.51,53.5,,,,,0,11.85,86.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 150CM 250MM 6MM BALLOON DILATATION DURALYN",SUP-48006025X,CDM,C1725,HCPCS,0272,RC,,,both,,,1296.00,388.8,"PHCS [10601]",PHCS,,907.2,70,,,,,0,150.72,1101.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4.5MM 38MM TITANIUM TIBIA CORTICAL OPENING WEDGE",SUP-AR-13380-38,CDM,C1713,HCPCS,0278,RC,,,both,,,1968.75,590.62,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,903.66,45.9,,,,,0,228.97,1673.44,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SYSTEM GRAFTMASTER 26MM 2.8MM CORONARY STENT STAINLESS STEEL",SUP-1012580-26,CDM,C1874,HCPCS,0278,RC,,,both,,,16525.50,4957.65,"KAISER [10500]",Kaiser,,11072.09,67,,,,,0,1921.92,14046.68,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LEAD 6946M62 DUAL COIL PSSV DF4 QUATTRO",SUP-6946M62,CDM,C1895,HCPCS,0278,RC,,,both,,,17172.00,5151.6,"CIGNA [10200]",Cigna,,6868.8,40,,,,,0,1997.1,14596.2,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 50MM REFLECTION HIP SPHERICAL HEAD",SUP-71332550,CDM,C1713,HCPCS,0278,RC,,,both,,,1287.90,386.37,"PHCS [10601]",PHCS,,901.53,70,,,,,0,149.78,1094.72,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"MICROCATHETER INFUSION 130CM 2.9FR .025IN TRINAV LV EXPANDAB",SUP-XPS-25130-35,CDM,C1982,HCPCS,0272,RC,,,both,,,50292.90,15087.87,"FIRST HEALTH [10303]","First Health",,40234.32,80,,,,,0,5849.06,42748.97,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DIL SURGICAL AMPLATZ PTFE COAXIAL STYLET SAFETY WIRE INTRO",SUP-M0062601200,CDM,C1894,HCPCS,0272,RC,,,both,,,365.49,109.65,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,248.53,68,,,,,0,42.51,310.67,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RF ENHANCR II 90CM 4MM 7FR 2-5-2MM SPACE 55MM MEDIUM",SUP-39745533,CDM,C1733,HCPCS,0272,RC,,,both,,,3375.00,1012.5,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $14,864.78, 50.08% of billed. Billed Amounts $14,864.79 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"CATH LASSO NAVISTAR 7FR 20MM D CURVE ELECTROPHYSIOLOGY 22",SUP-D134904,CDM,C1732,HCPCS,0272,RC,,,both,,,12889.20,3866.76,"BLUE CROSS [10001]","Blue Cross PPO",,,,"Payment is accumulated by procedure billed amount. Billed Amounts $0 - $16,593.67, 68.6% of billed. Billed Amounts $16,593.68 - $99,999,999, 0% of billed.",,,,0,,,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;"
"BOOT PATIENT BLACK APB SMALL METASHANK SQUARE TOE",SUP-199649,CDM,S27000186,LOCAL,0270,RC,,,both,,,214.02,64.21,"AETNA [10100]","Aetna HMO/PPO",,170.15,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,24.89,181.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC",822,MS-DRG,,,,,,,inpatient,,,99189.17,29756.75,"GEORGIA HEALTH ADVANTAGE [30143]","Georgia Health Medicare Advantage",,7991.28,,"Case rate ($7,468.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,934.99, add-ons for qualifying new technology services are included. If operating cost exceeds $39,974.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,906.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $6,944.17. The transfer operating threshold is the transfer adjustment factor * $6,934.99 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $524.32. The transfer capital threshold is the transfer adjustment factor * $524.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 107%.",,,,0,7468.49,35151.98,other,"IP DRGs Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT C-FLEX 10CM 10FR 2 PIGTAIL CURVE BILIARY PLASTIC",SUP-M00532050,CDM,C2617,HCPCS,0272,RC,,,both,,,435.00,130.5,"CIGNA [10200]",Cigna,,295.8,68,,,,,0,50.59,369.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"TITAN ZERO DEGREE - INFRAPUBIC  ZERO ANGLE CYLINDER/PUMP SE",SUP-ES8824,CDM,C1813,HCPCS,0278,RC,,,both,,,62700.00,18810,"NOVANET [10819]",Novanet,,47025,75,,,,,0,7292.01,53295,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5.5MM 40MM INDEPENDENCE SPINE VARIABLE ANGLE",SUP-176.240,CDM,C1713,HCPCS,0278,RC,,,both,,,1620.00,486,"CIGNA [10200]",Cigna,,1101.6,68,,1831.33,1831.33,1831.33,16,188.41,1377,"percent of total billed charges",
"STENT SURPASS ELITE 17MM 4.5MM INTRACRANIAL FLOW DIVERTER",SUP-FDSE45017,CDM,C1876,HCPCS,0278,RC,,,both,,,83664.60,25099.38,"CIGNA [10200]","Cigna Local Plus",,26354.35,31.5,,,,,0,9730.19,71114.91,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPECLM EAR 7.5MM ROUND EBONY FINISH STAINLESS STEEL",SUP-130675,CDM,S27200284,LOCAL,0272,RC,,,both,,,535.98,160.79,"PHCS [10601]",PHCS,,375.19,70,,,,,0,62.33,455.58,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 15.5-11MM 36CM FEMUR RIGHT PROXIMAL TALON DISTALFIX",SUP-SLN-125-36R,CDM,C1713,HCPCS,0278,RC,,,both,,,16125.30,4837.59,"CIGNA [10200]","Cigna Open Access",,5401.98,33.5,,1144.80,304.56,2275.09,66,1875.37,13706.51,"percent of total billed charges",
"SCR BONE 4MM 13MM VENTURE TITANIUM LOW PROFILE SPINE",SUP-9790313,CDM,C1713,HCPCS,0278,RC,,,both,,,1012.50,303.75,"NOVANET [10819]",Novanet,,759.38,75,,,,,0,117.75,860.63,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SHEILD SPIRAL, 80 MM DIAMETER",SUP-50215L54B0D,CDM,A2019,HCPCS,0636,RC,,,both,,,130900.50,39270.15,"CIGNA [10200]","Cigna Local Plus",,70031.77,53.5,,,,,0,247.92,111265.43,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"GRAFT BONE ALLOQUENT 7D ALLOGRAFT MONOLITHIC 10MM PLIF",SUP-3W3110,CDM,S27800098,LOCAL,0278,RC,,,both,,,12487.62,3746.29,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,3573.96,28.62,,,,,0,1452.31,10614.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATHETER SOLOIST 110CM 6FR 5MM SPACING JSN CURVE ELECTROPHYS",SUP-44516J,CDM,C1730,HCPCS,0272,RC,,,both,,,313.20,93.96,"AMERIGROUP MEDICAID [20100]",Amerigroup,,37.11,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,36.43,266.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DEVICE NAKAO SPIDER-NET STD 230CM 5.5X2.5CM SPECIMEN",SUP-00230A,CDM,S27000186,LOCAL,0270,RC,,,both,,,486.00,145.8,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,330.48,68,,,,,0,56.52,413.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ADPTR FEEDING SET 20FR PONSKY-GAUDERER SILICONE 2 PORT PEG",SUP-000333,CDM,S27000186,LOCAL,0270,RC,,,both,,,208.80,62.64,"PHCS [10601]",PHCS,,146.16,70,,,,,0,24.28,177.48,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NAIL 11MM 34CM LEFT DISTAL TROCHANTERIC INTRAMEDULLARY 125D",SUP-456.395S,CDM,C1713,HCPCS,0278,RC,,,both,,,12838.83,3851.65,"NOVANET [10819]",Novanet,,9629.12,75,,,,,0,1493.16,10913.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PLATE CURVE TITANIUM 5 HOLE POLYAXIAL LOCK LOW PROFILE",SUP-40-15012,CDM,C1713,HCPCS,0278,RC,,,both,,,4614.17,1384.25,"AMERIGROUP MEDICAID [20100]",Amerigroup,,546.78,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",536.63,3922.04,"percent of total billed charges",
"CATH IMAGER II 65CM 5FR STRAIGHT URETERAL STAINLESS STEEL",SUP-M0064003021,CDM,C1758,HCPCS,0272,RC,,,both,,,149.15,44.74,"UNITED HEALTHCARE EXCHANGE  [11110]","United Healthcare Exchange",,61.3,41.1,,,,,0,17.35,126.78,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT EPIC 40MM 75CM 10MM 110CM VASCULAR NITINOL ILIAC",SUP-H74939200104070,CDM,C1876,HCPCS,0278,RC,,,both,,,4515.00,1354.5,"NOVANET [10819]",Novanet,,3386.25,75,,,,,0,525.09,3837.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HOOK SPINAL CD HORIZON TITANIUM RIGHT OFFSET 5.5 MM ROD",SUP-7541198,CDM,C1713,HCPCS,0278,RC,,,both,,,3000.00,900,"BLUE CROSS [10001]","Blue Cross PPO",,1176,39.2,,957.42,570.23,957.42,28,348.9,2550,"percent of total billed charges",
"INSRT TIBIAL 1.5 15MM KNEE XLK STABILIZE FIX BEARING PFC",SUP-158120115,CDM,C1776,HCPCS,0278,RC,,,both,,,11174.55,3352.36,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,3017.13,27,,,,,0,1299.6,9498.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Gtt Add Specimens",PX-301000209,CDM,82952,CPT,0301,RC,,,both,,,89.30,26.79,"CIGNA [10200]","Cigna Open Access",,8.62,,,,,,,0.01,75.91,"fee schedule",
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,inpatient,,,36356.65,10906.99,"UHC MEDICARE [30111]","United Healthcare Medicare Advantage",,7407.21,,"Case rate ($7,088.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.163, exceeds $6,581.91, add-ons for qualifying new technology services are included. If operating cost exceeds $39,621.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.007, exceeds $1,879.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $6,590.61. The transfer operating threshold is the transfer adjustment factor * $6,581.91 If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $497.62. The transfer capital threshold is the transfer adjustment factor * $497.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 104.5%.",,,,0,7088.24,28497.8,other,"IP DRG Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Gammaglobulin Ige",PX-301000195,CDM,82785,CPT,0301,RC,,,both,,,170.30,51.09,"CIGNA [10200]",Cigna,,36.21,,,,,,,0.17,144.76,"fee schedule",
"GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION",RX-234450,CDM,A9573,HCPCS,0636,RC,00270-7025-40,NDC,both,7.5,ML,225.00,67.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,26.66,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",29.10,29.10,29.10,30,26.66,191.25,"percent of total billed charges",
"GRSP LAPAROSCOPIC RATCHET HANDLE INSULATED SHAFT ROTATION",SUP-5BB,CDM,S27200284,LOCAL,0272,RC,,,both,,,702.00,210.6,"MULTIPLAN [10600]",Multiplan,,596.7,85,,,,,0,81.64,596.7,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Transducer Tru Wave Kit 2-3w",PX-E27200341,CDM,E27200341,LOCAL,0272,RC,,,both,,,64.90,19.47,"AMERIGROUP MEDICAID [20100]",Amerigroup,,7.69,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,7.55,55.17,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SPACER ALLOGRAFT 12X14X9MM OVAL PARALLEL SPINE CORTICAL",SUP-17109,CDM,S27800098,LOCAL,0278,RC,,,both,,,5175.00,1552.5,"AMERIGROUP MEDICAID [20100]",Amerigroup,,613.24,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,601.85,4398.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HC Rmvl FB Ft Sq",PX-450000172,CDM,28190,CPT,0361,RC,,,both,,,3198.00,959.4,"NOVANET [10819]",Novanet,,2398.5,75,,,,,0,371.93,3198,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INTRO SHEATH 5FR 150CM 12CM 2 DISTAL GWIRE HEMOSTATIS VALVE",SUP-406100,CDM,C1894,HCPCS,0272,RC,,,both,,,69.60,20.88,"MULTIPLAN [10600]",Multiplan,,59.16,85,,,,,0,8.09,59.16,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BLADE URETHROTOME MACRO PREPARATION KNIVE 10IN",SUP-5010,CDM,S27200284,LOCAL,0272,RC,,,both,,,114.67,34.4,"FIRST HEALTH [10303]","First Health",,91.74,80,,,,,0,13.34,97.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"COIL HELICAL FIBER.PLAT.4MX30M",SUP-312043,CDM,S27800098,LOCAL,0278,RC,,,both,,,664.23,199.27,"AMERIGROUP MEDICAID [20100]",Amerigroup,,78.71,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,77.25,564.6,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 90CM 6FR AR2 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H74938969180,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"FIRST HEALTH [10303]","First Health",,293.15,80,,,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL 25X9X15MM CONCORDE 10D THORACOLUMBAR CFRP INLINE",SUP-187855215,CDM,S27800098,LOCAL,0278,RC,,,both,,,16560.00,4968,"BLUE CROSS ANTHEM PATHWAY GEORGIA  [11103]","Anthem Pathway",,4739.47,28.62,,,,,0,1925.93,14076,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"STENT ONYX FRONTIER 30MM 2.25MM CORONARY RAPID EXCHANGE",SUP-ONYXNG22530UX,CDM,C1874,HCPCS,0278,RC,,,both,,,2625.00,787.5,"CIGNA [10200]","Cigna Local Plus",,1404.38,53.5,,,,,0,305.29,2231.25,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"BIT DRILL 50MM 1.6MM 7MM STOP TWIST 7MM STERILE",SUP-6016007,CDM,S27200284,LOCAL,0272,RC,,,both,,,1073.25,321.97,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,492.62,45.9,,,,,0,124.82,912.26,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"PELVIC STABILIZATION DEVICE",SUP-T-PODR,CDM,S27200284,LOCAL,0272,RC,,,both,,,1077.30,323.19,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,494.48,45.9,,,,,0,125.29,915.71,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"NDL NERVE BLOCK 80MM 22GA SONOPLEX II FACET S TIP INJECTION",SUP-001287-71,CDM,C9812,HCPCS,0272,RC,,,both,,,139.20,41.76,"CARESOURCE MEDICAID [20104]","Caresource Medicaid",,16.19,11.63,"11.63% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,787.18, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,16.19,118.32,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ELECTRD ELECTROSURGICAL NDL 4IN 3/32IN EDGE SAFETY SLEEVE",SUP-E1465B-4,CDM,S27200284,LOCAL,0272,RC,,,both,,,54.81,16.44,"KAISER [10500]",Kaiser,,36.72,67,,,,,0,6.37,46.59,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CANN PERFUSION FEMUR STD INSRT KIT BIO-MEDICUS",SUP-96550,CDM,S27200284,LOCAL,0272,RC,,,both,,,429.69,128.91,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,292.19,68,,,,,0,49.97,365.24,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CABLE NAVIGATION EXT",SUP-8000050011,CDM,S27200284,LOCAL,0272,RC,,,both,,,7038.00,2111.4,"PEACH STATE MEDICAID [20101]","Peach State Medicaid",,834,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,818.52,5982.3,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"DFBR CRD ELLIPSE DR VNTRC 2","SUP-CD2411-36C CELL",CDM,C1721,HCPCS,0278,RC,,,both,,,35964.00,10789.2,"AMERIGROUP MEDICAID [20100]",Amerigroup,,4261.73,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,4182.61,30569.4,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT PROLENE 1 CT-1 30IN MONOFILAMENT BLUE NONABSORBABLE",SUP-8425H,CDM,S27200284,LOCAL,0272,RC,,,both,,,26.00,7.8,"AETNA [10100]","Aetna HMO/PPO",,20.67,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,3.02,22.1,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH CORDIS SABER 90CM 200MM 6MM BALLOON DILATATION DURALYN",SUP-48006020S,CDM,C1725,HCPCS,0272,RC,,,both,,,1377.00,413.1,"KAISER [10500]",Kaiser,,922.59,67,,,,,0,160.15,1170.45,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 7.3MM 80MM LCP STAINLESS STEEL FULL THREAD CONDYLAR",SUP-02.207.080,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"AMERIGROUP MEDICAID [20100]",Amerigroup,,192.92,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",8.18,8.18,8.18,"1 through 10",189.34,1383.8,"percent of total billed charges",
"SCR INTERFERENCE PEEK-OPTIMA 25MM 7MM BIOSURE",SUP-72202263,CDM,C1713,HCPCS,0278,RC,,,both,,,1628.00,488.4,"BLUE CROSS [10001]","Blue Cross PPO",,638.18,39.2,,957.42,570.23,957.42,28,189.34,1383.8,"percent of total billed charges",
"NEEDLE CHIBA 18 GA X 20CM",SUP-MCN1808,CDM,S27200284,LOCAL,0272,RC,,,both,,,123.54,37.06,"CIGNA [10200]",Cigna,,84.01,68,,,,,0,14.37,105.01,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"6.0MM TI CURVED SOFT ROD 75MM",SUP-498.142,CDM,S27800098,LOCAL,0278,RC,,,both,,,1215.00,364.5,"BLUE CROSS [10001]","Blue Cross PPO",,476.28,39.2,,,,,0,141.3,1032.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 4MM 22MM ELLIPSE TITANIUM SPINE POLYAXIAL",SUP-182.422,CDM,C1713,HCPCS,0278,RC,,,both,,,4200.00,1260,"FIRST HEALTH [10303]","First Health",,3360,80,,,,,0,488.46,3570,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"KIT ABLATION STAR POWERCURVE SHORT BLISTER TRAY TUMOR",SUP-RF-0510S-01,CDM,S27200284,LOCAL,0272,RC,,,both,,,22680.00,6804,"CIGNA GEORGIA CIGNA CONNECT  [11107]","Cigna Connect",,10410.12,45.9,,,,,0,2637.68,19278,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"JOINT FINGER SWANSON 9 METACARPOPHALANGEAL SILICONE FLEXIBLE",SUP-G4700009,CDM,C1776,HCPCS,0278,RC,,,both,,,4170.60,1251.18,"BLUE CROSS [10001]","Blue Cross PPO",,1634.88,39.2,,3949.44,3949.44,3949.44,"1 through 10",485.04,3545.01,"percent of total billed charges",
"GRAFT STENT 10CM 21-26MM GORE TAG THORACIC ACTIVE CONTROL",SUP-TGM262110,CDM,C1874,HCPCS,0278,RC,,,both,,,115972.20,34791.66,"BLUE CROSS [10001]","Blue Cross PPO",,45461.1,39.2,,,,,0,13487.57,98576.37,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 3.2MM 16MM CORTICAL HEXAGONAL HEAD",SUP-HEX3.2-16,CDM,C1713,HCPCS,0278,RC,,,both,,,729.00,218.7,"BLUE CROSS [10001]","Blue Cross HMO",,285.77,39.2,,957.42,156.86,7483.26,51,84.78,619.65,"percent of total billed charges",
"SCR BONE 6.5MM 90MM TITANIUM LONG THREAD CANNULATED STERILE",SUP-04.354.790S,CDM,C1713,HCPCS,0278,RC,,,both,,,2459.40,737.82,"CIGNA [10200]",Cigna,,1672.39,68,,1831.33,1831.33,1831.33,16,286.03,2090.49,"percent of total billed charges",
"STENT ADVANIX 4CM 4FR PIGTAIL PANCREATIC POLYMER RADIOPAQUE",SUP-M00536880,CDM,C2617,HCPCS,0278,RC,,,both,,,639.25,191.77,"CIGNA [10200]",Cigna,,434.69,68,,,,,0,74.34,543.36,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SUT MICRORAPTOR MINITAPE COBRAID KNOTLESS WHITE",SUP-72205129,CDM,S27200284,LOCAL,0272,RC,,,both,,,648.81,194.64,"CIGNA [10200]","Cigna Local Plus",,347.11,53.5,,,,,0,75.46,551.49,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SCR BONE 5MM 40MM RELINE-O 2S SPINE POLYAXIAL NONSTERILE",SUP-13015040,CDM,C1713,HCPCS,0278,RC,,,both,,,3795.00,1138.5,"BLUE CROSS [10001]","Blue Cross HMO",,1487.64,39.2,,957.42,156.86,7483.26,51,441.36,3225.75,"percent of total billed charges",
"BASKET STONE RETRIEVAL 120CM 11MM 3FR GEMINI HELICAL",SUP-M0063301150,CDM,S27200284,LOCAL,0272,RC,,,both,,,1479.55,443.86,"CIGNA [10200]","Cigna Open Access",,841.86,56.9,,,,,0,172.07,1257.62,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CAGE SPINAL MODULUS 7 D L17 MM X W14 MM X H8 MM CERVICAL STE",SUP-67940038P2,CDM,S27800098,LOCAL,0278,RC,,,both,,,6210.00,1863,"AETNA [10100]","Aetna HMO/PPO",,4936.95,79.5,"79.5% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for claim lines that do not have RC 0274-0276, 0278, 0343-0344, 0350-0352, 0359, 0404, 0610-0612, 0614-0616, 0619, 0636, 0680-0689, plus the current reimbursement is less than a reimbursement limit defined as $18,626, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,722.22,5278.5,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH RUNWAY 100CM 6FR ART4 CURVE GUIDING PTFE FEMORAL LARGE",SUP-H749389695000,CDM,C1887,HCPCS,0272,RC,,,both,,,366.44,109.93,"AMERIGROUP MEDICAID [20100]",Amerigroup,,43.42,11.85,"11.85% of billed. If the accumulated reimbursement, defined as the sum of reimbursement for non-excluded claim lines that have certain procedure codes, plus the current reimbursement is less than a reimbursement limit defined as $6,916.46, reimbursement remains unchanged. Otherwise, calculate the remaining allowable amount as the reimbursement limit minus the accumulated reimbursement. If the remaining allowable amount is less than zero, reimbursement equals zero. Otherwise, reimbursement equals the remaining allowable amount.",,,,0,42.62,311.47,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"CATH SABER 150CM 250MM 3.5MM BALLOON DILATATION OTW STERILE",SUP-47035250M,CDM,C1725,HCPCS,0272,RC,,,both,,,1875.00,562.5,"ALLIANT HEALTH PLANS OF GEORGIA [10952]",Alliant,,1275,68,,,,,0,218.06,1593.75,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"HYDROMORPHONE 1 MG/ML INJECTION SUPERORDERABLE",RX-408113497,CDM,J1171,HCPCS,0636,RC,00409-1283-03,NDC,both,1,ML,48.74,14.62,"BLUE CROSS [10001]","Blue Cross PPO",,1.17,,,,,,,1.17,41.43,"fee schedule",
"APPL CLIP 8IN OPEN LIGATE SMALL CURVE WIDE HORIZON",SUP-137082,CDM,S27200284,LOCAL,0272,RC,,,both,,,1687.50,506.25,"CIGNA [10200]",Cigna,,1147.5,68,,,,,0,196.26,1434.38,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"INSRT TIBIAL 1.5 10MM KNEE GVF UHMWPE STABILIZE ROTATE",SUP-972101,CDM,C1776,HCPCS,0278,RC,,,both,,,10205.10,3061.53,"AETNA [10100]","Aetna HMO/PPO",,8113.05,79.5,,10981.53,8986.79,12413.38,12,1186.85,8674.34,"percent of total billed charges",
"TRAY HUMERAL COMPREHENSIVE +5MM STD SHOULDER REVERSE",SUP-110031400,CDM,C1776,HCPCS,0278,RC,,,both,,,8473.20,2541.96,"FIRST HEALTH [10303]","First Health",,6778.56,80,,,,,0,985.43,7202.22,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET STENT PURPLE 9CM 10FR ZIMMON .035IN 2 PIGTAIL CURVE",SUP-G21862,CDM,C2625,HCPCS,0272,RC,,,both,,,1231.20,369.36,"KAISER [10500]",Kaiser,,824.9,67,,,,,0,143.19,1046.52,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"SET INTRO 13CM 8FR CHECK-FLO PERFORMER SIDEARM FITTING SIDE",SUP-G07432,CDM,C1894,HCPCS,0272,RC,,,both,,,139.90,41.97,"MULTIPLAN [10600]",Multiplan,,118.92,85,,,,,0,16.27,118.92,"percent of total billed charges","Zero final payments for the item or service in the 15 months prior to posting the file."
"ASCOPE 5 BROCHNO 2.7/ 1.2 ULTRA THIN",SUP-624001000US,CDM,S27200284,LOCAL,0272,RC,,,both,,,2362.50,708.75,"CIGNA [10200]",Cigna,,1606.5,68,,,,,0,274.76,2008.13,"percent of total billed char